Rosen's 10th > Head & Neck > Flashcards

Head & Neck Flashcards

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1
Q

List 3 most common bacteria causing AOM

A

Streptococcus pneumoniae

Haemophilus influenzae

Moraxella catarrhalis

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2
Q

List clinical features of AOM

A

Ear pain
- most important SYMPTOM

TM bulging
- most important SIGN dx characteristic of AOM

Middle ear effusion
TM erythema
Fever

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3
Q

Name most common suppurative complication of AOM

A

Mastoiditis

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4
Q

Outline tx of Otorrhea associated w/ Tympanostomy tubes

A

Ofloxacin 5drops to affected ear BID x10d

Ciprofloxacin-Dexamethasone 4drops to affected ear BID x7d

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5
Q

List 2 most common pathogens causing otitis externa

A

Pseudomonas aeruginosa

Staphylococcus aureus
- including MRSA

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6
Q

Outline tx of otitis externa w/ intact and perforated TMs

A

Ruptured OR Intact
= Fluoroquinolones
- Ofloxacin 5drops to affected ear BID x10d
- Ciprofloxacin-Dexamethasone 4drops to affected ear BID x7d

Intact ONLY
= Aminoglycosides (b/c ototoxic)
- PolymyxinB/Neomycin/Hydrocortisone 3drops to affected ear TID

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7
Q

List 3 pts at risk for necrotizing (malignant) otitis externa

A

DM
Immunocompromised
Advanced age

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8
Q

Name best initial systemic ABX tx in OE

A

Ciprofloxacin 500mg PO BID
- works against Pseudomonas

Can combo w/ drops

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9
Q

Outline ABX tx in necrotizing OE

A

Ciprofloxacin 400mg IV q12h
- works against Pseudomonas

+/- PipTazo or Cefepime

ENT consult

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10
Q

List clinical features of mastoiditis

A

Postauricular erythema & tenderness

Protrusion of auricle

Abnormal TM

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11
Q

Outline mgmt/tx of mastoiditis

A

CT if suspected intracranial involvement

Vancomycin (15mg/kg) IV

plus Cefepime 2g (50mg/kg) IV q8h
- Pseudomonal coverage if prev abx

Consult ENT

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12
Q

List 7 causes of sudden sensorineural hearing loss (SSNHL)

A

Idiopathic
Infection
Otologic dz
Trauma
Vascular dz
Hematologic d/o
Neoplasm

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13
Q

Outline tx of sudden sensorineural hearing loss (SSNHL)

A

Prednisone 1mg/kg PO OD, tapered over 14d
(max 60mg)

+/- HBOT
+/- Intratympanic steroids

ENT consult + f/u

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14
Q

List 6 risk factors for sialolithiasis

A

Dehydration
Anticholinergic meds
Diuretics
Trauma
Gout
Smoking

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15
Q

Outline tx of sialolithiasis

A

Manual massage of salivary gland

Sialogogues

NSAIDs

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16
Q

Outline tx of sialadentis

A

= Infection of salivary gland

Tx w/ AmoxClav 875/125mg PO BID

or Clindamycin 300mg PO TID

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17
Q

Define recurrent otitis media

A

3+ episodes of AOM in 6mos
or
4 episodes w/in 1yr

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18
Q

List 7 risk factors for otitis media

A

Male
White
Daycare attendance
FmHx of recurrent OM
Parental smoking
Pacifier use
Bottle use

Down syndrome
Cleft palate

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19
Q

List 1 protective factor against otitis media

A

Breastfeeding

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20
Q

List 5 features suggestive of middle ear effusion

A

TM opacification
Bubbles
Air fluid levels
Retraction of TM
Lack of movement w/ pneumatic otoscopy

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21
Q

Name the dx w/ bullae on the TM in AOM

A

Bullous Myringitis

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22
Q

Name most common cause of Otitis-Conjunctivitis syndrome

A

H. influenza

  • purulent conjunctivitis w/ AOM
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23
Q

List 5 intratemporal and intracranial complications of AOM

A

INTRATEMPORAL:
- mastoiditis
- facial nerve paralysis
- conductive & perceptive hearing loss

INTRACRANIAL:
- meningitis
- intracranial abscess

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24
Q

List 6 DDx of AOM

A

Otitis media w/ effusion

Trauma

Otic foreign bodies

Mastoiditis

Otitis externa

Referred pain from teeth, sinuses, throat or TMJ

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25
List guidelines for initial mgmt of uncomplicated AOM in children 6mos-2yr
Age 6mo-2yr: - Observe w/out ABX if unilateral AOM, no otorrhea, temp <39, no mod-sev otalgia >48hr - Tx w/ ABX if bilateral, or otorrhea, or severe symptoms Age >2yr: - Observe w/out ABX if no otorrhea, no severe symptoms - Tx w/ ABX if otorrhea, or severe symptoms Observation appropriate if reliable caregivers and ability to f/u if worsening
26
Outline tx of AOM
FIRST LINE: Amoxicillin 90mg/kg/day PO divided BID x10d (max 4g/d) - PEDS Amoxicillin 500mg PO TID x10d - ADULTS ABX w/in 30d, or RECURRENT DZ, or CONJUNCTIVITIS: Amox 90mg/kg/day PO + Clav 6.4mg/kg/day PO divided BID x10d PEN ALLERGY: Cefuroxime 30mg/kg/day PO divided BID x10d CTX 50mg/kg IV/IM q24h x3d PEN + CEF ALLERGY: Azithromycin 10mg/kg PO on D1, then 5mg/kg on D2-5 Clindamycin 30mg/kg/day PO divided TID x10d
27
Outline duration of tx for AOM based on age
10 DAYS: - Age <2 - TM perforation - chronic or recurrent dz 5 DAYS: - Age >2 w/ 1st time dz - non-severe s/s - intact TM
28
List 3 indications for Tympanostomy tubes
- Persistent OME w/ hearing loss - Structural damage to TM & Middle ear - Risk for speech, language, or hearing problems
29
List clinical features of otitis externa
Ear pain Pruritus Ear fullness Otorrhea Hearing loss Jaw pain Discoloured cerumen Associated: Lymphadenitis Tm erythema Local cellulitis
30
List 2 common pathogens in otomycosis
Aspergillosis Candida
31
List 9 DDx of Otitis Externa
AOM w/ otorrhea Fungal infections of ear canal Auricular cellulitis Furunculosis Eczema Seborrhea Contact dermatitis Herpes zoster oticus - Ramsay Hunt syndrome Necrotizing otitis externa
32
List clinical features of necrotizing otitis externa
*Granulation tissue on floor of ear canal at bony cartilaginous junction Severe otalgia HA Periauricular pain and swelling CN VII palsy = Facial paralysis
33
List 3 complications of necrotizing otitis externa
Meningitis Brain abscess Thrombosis of sigmoid sinus
34
List 5 DDx of Necrotizing External Otitis
Otitis externa Otitis media Mastoiditis Trauma Referred pain
35
List 5 DDx for mastoiditis, other than AOM
Leukemia EBV Mono Temporal bone sarcoma Kawasaki dz Cochlear implant placement
36
List 5 common pathogens causing mastoiditis
S. pneumoniae GAS P. aeruginosa S. aureus Fusobacterium necrophorum
37
List 6 DDx of Mastoiditis
Otitis media Otitis externa Necrotizing external otitis Skull fracture Lymphadenitis Deep space neck infections
38
Define Sudden sensorineural hearing loss (SSNHL)
- idiopathic loss of hearing of 30 dB over 3+ test frequencies - occurring over period of <3 days
39
List 7 DDx of Sudden Sensorineural Hearing Loss
Cerumen impaction Otitis externa Otitis media Tympanic membrane perforation Medication side effects or toxicity Barotrauma Autoimmune disease
40
List 3 arteries that supply the nasal area
Sphenopalatine Artery - Nasopalatine branch Ophthalmic Artery (branch of Internal Carotid Artery) - Anterior & Posterior ethmoidal arteries Facial Artery - Superior labial branch
41
Where do most anterior epistaxis bleeds arise?
Kiesselbach’s plexus
42
Outline sequential mgmt of anterior epistaxis
ABCs Spray 2x 0.05% oxymetazoline into affect naris 2% Lidocaine atomized or soaked gauze Apply nose clip/clamp x10-15min Silver nitrate chemical cautery Topical TXA Topical thrombogenic agents - Gelfoam or Surgicel Tamponade w/ inflatable nasal balloon (Rapid Rhino Rocket) - can then put 2nd one into contralateral side
43
List 15 causes of epistaxis
Nasal or facial trauma URTIs Nose picking Allergies Low home humidity Nasal polyps FB in nose Environmental irritants Neoplasms Surgery (post-op epistaxis) Anticoagulant or antiplatelet tx Barotrauma Hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber disease) Blood dyscrasias Hepatic disease Alcoholism Vitamin K deficiency Folic acid deficiency Chemotherapy Chronic use of nasal vasoconstrictors Cocaine use
44
Outline mgmt of posterior epistaxis
Posterior packing w/ 12Fr Foley balloon - inflate 5cc, then apply traction - inflate additional 5cc - place anterior packing and umbilical clamp to secure Or Dual balloon tamponade catheter Then ENT consult Then possible IR embolization
45
After nasal packing, who should get ABX?
Packing in place >48hr Immunocompromised pts Pts w/ valvular dz
46
List 7 DDx of Sialolithiasis
Salivary gland pathology Lymph node disease Granulomatous process - Sarcoidosis HIV Sjogren's dz Soft tissue masses Neoplasms
47
List 8 risk factors predisposing to ENT malignancies
EtOH use Tobacco use Herpes viruses Genetics Diet Excessive UV sunlight exposure Excessive Dust exposure Chemical exposure
48
List common origins of neck masses in the anterior and posterior triangles
Anterior: - skin - scalp - oral cavity - oropharynx - hypopharynx - larynx - tongue Posterior: - nasopharynx - mets from lungs - mets from GI tract - mets from GU tract
49
List worrisome features of LNs
>1.5cm Hard Decreased mobility
50
List 12 DDx of Inflammatory Neck Masses
Adenitis Bacterial (Strep, Staph) Viral (HIV, EBV, HSV) Fungal (Coccidioidomycosis) Parasitic (Toxoplasmosis) Cat scratch disease Tularemia Local cutaneous infections Sialoadenitis (parotid & submaxillary glands) Thyroiditis Mycobacterium avium-intracellulare Mycobacterium tuberculosis
51
List 8 DDx of Congenital or Developmental Neck Masses
Brachial cleft cyst Thyroglossal duct cyst Dermoid cyst Cystic hygromas Torticollis Thymic masses Teratomas Ranula Lymphangioma Laryngocele
52
List 12 DDx of Neoplastic Neck Masses
BENIGN: Mesenchymal tumours - Lipoma - Fibroma - Neural tumour Salivary gland masses Vascular abnormalities - Hemangioma - AVM - Lymphangioma - Aneurysm MALIGNANT: Primary tumours Sarcoma Salivary gland tumour Thyroid or Parathyroid tumours Lymphoma METASTASIS: From primary head & neck tumours From infraclavicular primary tumours - Lung Ca - Esophageal Ca
53
List 6 indications for ENT referral in adults w/ neck masses
- Mass does NOT resolve <2wks - Enlarging mass - Fixed mass - Matted cervical LNs - Parotid gland mass - Thyroid gland mass
54
List 3 layers of teeth
Enamel Dentin Pulp
55
List DDx of tooth pain
Pulpitis Dental caries Maxillary sinusitis Dysbarism Trigeminal neuralgia GCA Jaw claudication TMJ disorder
56
List types of nerve blocks for dental issues
Supraperiosteal - for individual teeth - Upper > Lower Inferior Alveolar - multiple lower teeth
57
Outline tx for pulpitis 2/2 dental caries
Dental nerve block Ibuprofen 400mg PO q6h SCHEDULED +/- opioids prn F/u w/ Dentist in 1wk
58
Define Periodontitis
Inflammation of supporting structures of teeth (gingiva, alveolar bone, cementum, and periodontal ligament) Can lead to loss of teeth, destruction of alveolar bone
59
List pathogen causes of necrotizing periodontal disease
* Polymicrobial - predominance of Fusobacterium and spirochetes
60
Diagnosis?
Pericoronitis
61
List 4 drug causes of gingival hyperplasia
Phenytoin Cyclosporine Diltiazem Nifedipine
62
Outline triad of necrotizing periodontal disease
Papillary necrosis Gingival bleeding Pain
63
List 5 DDx of mucosal ulcerations
Necrotizing stomatitis Aphthous ulcers Behcet disease HIV HSV gingivostomatitis
64
Outline ABX tx options for Simple Odontogenic Infections, Severe Periodontal Disease, & Severe Pericoronitis
Anti-bacterial mouth rinshes Penicillin V 500mg PO TID x10d AmoxClav 875/125mg PO BID x10d Flagyl 500mg PO BID x10d Clindamycin 300mg PO QID x10d Nystatin 100k units/mL w/ 5mL swish&spit QID x10d - if candida suspected
65
List most common risk factor for gingival disease in HIV(-) pts
SMOKING
66
Diagnosis?
Alveolar osteitis (“dry socket”) - after extraction of tooth and clot dislodges 3-4d later - severe dull aching pain - halitosis
67
What material can be used to cover exposed dentin/pulp of a tooth?
Calcium hydroxide paste/cement OR Skin Glue!
68
Outline mgmt of a bleeding tooth extraction site
Direct pressure w/ dry gauze or TXA soaked gauze Supraperiosteal nerve block w/ lido + epi, then more direct pressure Pack socket w/ Gelfoam or Surgicel Loosely close gingiva w/ 3-0 absorbable suture in figure-8 +/- Anticoagulation reversal
69
List 2 maxillary deep spaces
1. Canine space - flattening of ipsilateral nasolabial fold - can lead to cavernous sinus thrombosis 2. Buccal space - maxillary (or mandibular) molars
70
List 3 mandibular deep spaces
1. Submental - discrete midline swelling - usually mandibular incisors 2. Sublingual - elevates tongue, firmness to floor of mouth 3. Submandibular - from mandibular molars INFECTION OF ALL 3 = Ludwig Angina
71
Describe Lemierre syndrome, and its complications
= Septic thrombophlebitis of the internal jugular vein - caused by Fusobacterium necrophorum Complications of Septic Emboli: - Pleuropulmonary emboli - Pleuropulmonary Abscesses - Pleuropulmonary Empyema - Brian abscess - Meningitis - Septic joints
72
List most common cause of deep neck space infections in adults
Dental infections!
73
Diagnosis?
Periapical abscesses
74
Diagnosis?
Ludwig angina - infection involving submental, sublingual, submandibular spaces
75
List 12 risk factors for facial cellulitis & deep space neck infections
- Recent dental work - Recent trauma - Recent upper airway manipulation or surgery - IVDU - Sinusitis - AOM - Immunosuppression - HIV/AIDS - Cirrhosis - DM - Chemotherapy - Steroid use
76
Irritation of what 2 muscles can lead to trismus?
Pterygoid Masseters = inability to open the mouth because of involuntary muscle spasm
77
Outline ABX tx options for deep space neck infections
PipTazo 3.375g IV q6h + Vancomycin 20mg/kg IV q12h Clindamycin 600mg IV q8h - if pen allergy Meropenem 1g IV q8h + Vancomycin 20mg/kg IV q12h - if immunocompromised
78
List types of dentoalveolar trauma
- Concussed (pain to percussion, minor injury to periodontal ligament) - Subluxated (mobile tooth, normal anatomic position) - Luxated (moved from anatomic position) - Avulsed (out of socket) - Infraction (incomplete fracture) - Fractured
79
Outline general mgmt of dentoalveolar trauma
Analgesia - nerve blocks - NSAIDs Splint mobile teeth Ca Hydroxide paste for fractured teeth (Ellis 2-3) Tetanus booster UTD Liquid to soft diet F/u w/ Dentist or OMFS
80
List 3 types of tooth luxation
Extrusive Intrusive Lateral - can have alveolar bone fracture as well
81
Outline mgmt of luxated teeth
Intrusive luxation - Refer to specialist as not easy ED-based retrieval Extrusive luxation or Lateral luxation - Baby teeth → just take it out - Adult teeth → place into anatomic position and splint
82
Diagnosis?
Alveolar bone fracture
83
Outline Ellis classification for fractured teeth
Ellis I - just enamel Ellis II - dentin showing Ellis III - pulp showing
84
Outline mgmt of fractured teeth
Ellis I → No ER tx, can file down sharp edges Ellis II & III → Cover with Calcium Hydroxide paste ABX: Amoxicillin AmoxClav Chlorhexidine mouth rinse BID x 7 days *Pt should go to dentist within 24hr
85
Outline mgmt of avulsed teeth
Secondary (adult) teeth ONLY - If viable! - Reimplantation of dry tooth may help maintain alveolar bone contour Viability Timeline: - None (dry) = <60min - Milk = 3–8 h - Hank’s balanced salt sol'n = 12–24 h - Oral rehydration solution = 12–24 h - Saliva if nothing else available Handle tooth by crown, avoid root injury Rinse tooth w/ NS Irrigate socket Replace tooth Splint w/ sutures or Coe-Pak ABX: Amoxicillin AmoxClav Chlorhexidine mouth rinse BID x 7 days
86
Outline solutions that an avulsed tooth can be placed in, and the viability timeline for each
Viability Timeline: - None (dry) = <60min - Milk = 3–8 h - Hank’s balanced salt sol'n = 12–24 h - Oral rehydration solution = 12–24 h - Saliva if nothing else available
87
Outline general mgmt of alveolar fractures
Conserve as much bone as possible Loss = cosmetic deformity - Difficult to replace w/ prosthetics, hard to implant into Fracture healing = 4-6 weeks Stabilization of alveolar fracture > ankylosis of a tooth - so re-implant to protect the bone
88
List 5 features of tongue lacerations that require repair/closure
- gaping - have a flap - involves the muscle - cause a bifid or grooved tongue - hemostasis cannot be achieved
89
Which lacerations to buccal mucosa require closure/repair?
>1cm Or if food could get stuck
90
List 5 risk factors for TMJ dislocation
- Anatomic disharmonies - Weak joint capsule & TM ligaments - Torn TM ligaments - Dystonic reactions 2/2 drugs - Previous TMJ dislocations
91
List clinical features of Temporomandibular Joint Disorder
= aching in muscles of mastication, w/ occasional brief severe pain on chewing, w/ restricted jaw movement & clicking or popping sounds - HA - Facial pain - Earache 1. Crepitus or Joint click 2. Limited joint movements w/ pain on assisted max mouth opening 3. Pain anterior to auricular canal
92
Outline mgmt of TMJ disorder
NSAIDS Heat/Cooling Bite guards for bruxism Diazepam TENS Surgery
93
Outline mgmt of TMJ dislocation
CT scan to r/o fracture prn Procedural sedation - Reduction technique Or roll back and forth on syringe btwn molars
94
List 5 structures affected by a Cavernous Sinus Thrombosis
Oculomotor (III) CN Trochlear (IV) CN Trigeminal (V) CN (V1+2) Abducens (VI) CN Internal carotid artery
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