If a child has otorrhea from the myringotomy tubes, what should you do?

Topical antibiotic eardrops have high efficacy, although unusual organisms are more common for kids with tubes than for those without

How can you remember which test is the Rinne , and which is the Weber ?

WEBER has two “Es” so it’s between the ears

(the tuning fork is held at the vertex of the forehead – should hear it equally)

How is the Rinne test performed?

Tuning fork on the mastoid, then beside the ear, in the air –

Air should be heard better

(still heard after the mastoid is silent)

“Sudden” hearing loss is defined as loss of hearing that occurs over 3 days or less. What are four conduction problems that can cause sudden hearing loss?

1. Cerumen impaction (most common)

2. Foreign body

3. TM or ossicle problems

4. Middle ear fluid

When performing a hearing exam, how does bilateral sensorineural hearing loss present?

Bilaterally decreased hearing

  with

normal Weber & Rinne

`

Which medical conditions predispose the patient to sudden sensorineural hearing loss?

(4)

1. DM

2. Hyperlipidemia

3. Vascular hypercoagulable states

4. Meniere

What is a typical environmental cause of sudden sensorineural hearing loss?

Noise

What is a likely infectious cause of sudden sensorineural hearing loss (general category)?

Viruses

(especially mumps, in unimmunized kids)

What is a likely cause of sudden sensorineural hearing loss in a hospitalized patient?

Medication

Do tumors cause sudden sensorineural hearing loss?

Yes –

Especially if there is a small associated hemorrhage

Which medications are most notorious for causing sensorineural hearing loss?

 (5 categories)

1. Loop diuretics (especially ethacrynic acid)

2. NSAIDs

3. Salicylates

4. Certain antibiotics (e.g., gentamicin)

5. Chemo regimens

It’s sad if you lose your hearing. How can the mnemonic “SAD” help you remember the drugs most likely to cause this problem?

SAD CHEMicals

Salicylates (& NSAIDs)

Antibiotics (& alcohol)

Diuretics (loop)

CHEMicals (reminds you of chemo regimens)

When a patient complains of headache or ear pain, what source of the pain should always be considered?

Tooth pain

Why is perichondritis a worrisome infection?

The infection rapidly damages the underlying cartilage –

Cosmetic result is bad

Where is perichondritis most often seen?

Pinna of the ear

What unusual infectious agents must you watch for perichondritis?

(2)

Pseudomonas

  &

Proteus

Which bacterium is most often identified in otitis externa?

Pseudomonas (60 %)

Is a TM perforation an ENT emergency?

No –

Follow-up with ENT later that week

What percentage of TM perforations heals spontaneously?

90 %

What are the most typical or widely cited causes for TM perforation?

(4)

1. Noise

2. Barotrauma

3. Blunt or penetrating trauma

4. Lightning strike (especially if the patient is found undressed or in arrest)

What is the hallmark of otitis externa on exam?

Pain with movement of the pinna

What is a feared complication of otitis externa?

Malignant otitis externa

Which patients are likely to develop malignant otitis externa?

Diabetics – 90 % of patients are diabetic

(other immunodeficient patients are also at increased risk)

What is the “triad” of Meniere disease ?

1. Vertigo

2. Tinnitus

3. Sensorineural hearing loss

(to reduce recurrences low-salt diet & hydrochlorothiazide may be helpful)

What other patient group presents similarly to Meniere patients?

CPA tumor

(cerebellopontine angle)

What is the natural history of Meniere disease?

Intermittent recurring attacks that last weeks to years (treatment doesn’t work well, but is improving)

Most treatments for Meniere disease focus on what aspect of the auditory system?

Reducing pressure in the endolymphatic portion of the affected ear

What differentiates labyrinthitis from vestibular neuronitis ?

Labyrinthitis includes hearing loss!

(not just vertigo or tinnitus)

What is the most common cause of peripheral vertigo?

Benign positional vertigo

(BPV)

What are the typical features of BPV, in terms of the patients’ movement or position?

• Worse in certain positions

• Worse with head motion

What is the typical onset for BPV?

Gradual

What is the natural course of BPV?

Spontaneous resolution

What “key” should you find on physical exam, if you are able to elicit the vertigo of BPV?

Fatiguing (horizontal) nystagmus

(fatiguing means that it decreases, then stops, on its own)

What are the most concerning complications of sinusitis?

(4)

1. Cavernous sinus thrombosis

2. Pott’s puffy tumor (skull osteomyelitis on the forehead)

3. Orbital cellulitis

4. Brain abscess

Sinusitis has the same typical bacterial pathogens as which other ENT infection?

What are the pathogens?

• Otitis media

• Strep pneumo

• H. flu (non-typeable)

• M. catarrhalis

• Anaerobes (especially with chronic infection)

( S. pyogenes is also a common cause of otitis media, but not common in sinusitis)

What is “ring sign” supposed to tell you?

Whether fluid dripping from the nose is snot or CSF

(a ring should form around a droplet on filter paper if it’s CSF – but it’s very unreliable in reality)

Why is a septal hematoma (in the nose) a big deal?

Because without rapid treatment the pressure causes septal necrosis –

“saddle nose” deformity results

Where do most nosebleeds come from?

(give two names for it)

Anterior veins of the nose (along the septum)

  Or

Kiesselbach’s plexus

(same thing)

Patients with posterior epistaxis make up what percentage of epistaxis patients overall?

5 %

(fortunately)

What is the biggest risk factor for posterior epistaxis?

Arteriosclerosis

What are the main risks involved in posterior epistaxis?

(2)

1. Hypovolemia

2. Aspiration

How is posterior epistaxis treated?

Posterior nasal pack

What must you watch out for with patients who have a posterior nasal pack?

(4)

1. Hypoxia & CO ₂ retention (due to airway obstruction)

2. Bradycardia (vagal response)

3. Sinusitis/OM

4. Coronary ischemia (due to stress and hypovolemia, in a patient at risk for ischemia)

What is the correct disposition for a patient with posterior epistaxis who has had a posterior pack placed?

Admit to ICU for observation under ENT’s supervision

In cavernous sinus thrombosis , which cranial nerves are likely to be affected?

Ipsilateral 3, 4, 5, & 6 –

CN6 is usually the FIRST affected, because it is not well anchored compared to the other two, so it is most easily stretched by the increasing pressure

Which infections are likely to produce cavernous sinus thrombosis?

Midface infections –

Sinusitis, periorbital cellulitis, dental

Who was LeFort ?

A guy who dropped cadavers from heights to find out how their faces would fracture

How did LeFort classify facial fractures?

Three groups:

LeFort 1 – the maxilla moves freely

LeFort 2 – the maxilla & nose move freely

LeFort 3 – the maxilla, nose, & cheeks (to the orbits) move freely

(in other words, the whole midface is mobile as a unit)

Why is a LeFort facial fracture concerning?

(3)

1. Risk of airway compromise (teeth or bleeding in airway)

2. Risk of basilar skull fracture or associated c-spine injury

3. Risk of brain injury

4. Risk of tooth malocclusion if not properly repaired

What is the most common complication of outpatient ENT surgery?

Post-op hemorrhage

Historically, what was the most common cause of epiglottitis?

H. flu

Which vessel is the most common culprit in posterior epistaxis?

The lateral nasal branch of the sphenopalatine artery

How does chronic otitis media spread to other locations?

It erodes nearby bone

What is the most common cause of sialadenitis worldwide?

Mumps

Excruciating stabbing or electric shock-type pain to the cheek with sudden onset, that waxes & wanes, typically in a female patient =

Tic Douloureux

(trigeminal neuralgia)

If there is a hematoma on the pinna, how should it be treated and why?

• It must be aspirated (evacuated) then dressed with a pressure dressing to prevent it from refilling

• Without treatment the cartilage deforms and causes cauliflower ear

A hard, rounded swelling of the hard palate or posterior mandible that is not tender is likely to be what diagnosis?

Torus palatinus/torus mandibularis

What is trench mouth , and what organism causes it?

• Acute necrotizing ulcerative gingivitis

• Treponema vincentii

Mnemonic:

Think of Vincent van Gogh with bad teeth to remember the organism

How is trench mouth treated?

Metronidazole

  &

Penicillin

(surgical debridement may also be needed)

What is the typical age group for croup?

6 months to 6 years

(typically <3 years)

What is the other name for croup ?

Laryngotracheobronchitis

What infection produces “ lumpy jaw syndrome ?”

Actinomycosis

(the one with “sulphur-colored crystals”)

(Remember that a single lump on the jaw of an African child is usually Burkitt’s lymphoma)

What are the most important risk factors for rhinocerebral mucormycosis ?

Neutropenia

  &

Diabetic ketoacidosis

A child presents with ear pain and fluid-filled blisters on the tympanic membrane. What is the most likely diagnosis and its associated organism?

• Bullous myringitis

• Mycoplasma is most associated in the literature BUT the typical otitis media pathogens are actually more common

What diagnosis and related organism should always be considered in a child who seems to have bullous myringitis?

• Ramsay-Hunt

• Herpes

The main treatment for rhinocerebral mucormycosis is . . .?

Surgical debridement

(+ antifungals IV)

High mortality!

Where do preauricular sinus tracts come from?

Failure of the first & second branchial arches to fuse properly

Why must nasal packing be removed promptly (24–48 h) after placement?

Toxic shock syndrome can develop!

(The antibiotics prescribed to prevent sinusitis while the packing is in are somewhat preventative)

Which laryngeal ring is essential in airway patency?

The cricoid

(goes the whole way around)

Which sinuses are present at birth?

Sphenoid

Ethmoid (one or two cells)

Maxillary

(sources differ on the ethmoid – some say it is present, others dispute that)

What is the diagnostic test of choice for neck masses?

FNA

(fine-needle aspiration)

Does anticoagulant therapy improve outcome in patients with cavernous sinus thrombosis?

No

What study is preferred to diagnose cavernous sinus thrombosis ?

CT or MRI

What is the most common organism found in retropharyngeal abscesses?

β-Hemolytic strep

At what age does retropharyngeal abscess typically occur?

6 months to 3 years

How does retropharyngeal abscess present?

Fever

Ill to toxic appearing

Stridor

Dysphagia

+/− Drooling

Refusal to eat

Little movement (it hurts)

What is the most feared complication of lateral pharyngeal space infections?

Septic thrombophlebitis of the jugular vein

(Lemierre’s syndrome)

What is the usual bacterial agent in Lemierre’s syndrome ?

Fusobacterium

(others are possible, and is often polymicrobial)

A teenager presents with a sore throat, but seems genuinely ill, with fever & rigors. What serious disorder should you consider?

Lemierre’s syndrome

What is the most common congenital laryngeal disorder?

Laryngomalacia

If a mandibular tumor has a “soap-bubble” appearance on X-ray, what is it?

Ameloblastoma

What three signs should you look for on physical exam when evaluating for basilar skull fracture?

1. Blood behind the TM (hemotympanum)

2. Raccoon eyes

3. Battle’s sign (bruising over the mastoid)

What two presenting complaints are most common with acoustic neuromas?

1. Hearing loss

2. Tinnitus

What is the most common laryngeal tumor of children?

Laryngeal papillomas

Which major artery runs through the cavernous sinus?

The internal carotid

Adolescent male +

nose bleed +

nasal obstruction =

Juvenile nasopharyngeal angiofibroma

What is the most characteristic finding on physical exam of a patient with malignant otitis externa?

Granulation tissue in the external auditory meatus

Diplopia after facial trauma suggests what diagnosis?

Orbital floor fracture

A patient presents with fever, malaise, and a dark red raised lesion – painful to touch – on his face. The lesion is expanding over time. What is the likely diagnosis?

Erysipelas

Only one muscle abducts the vocal cords. Which one?

Posterior cricoarytenoid

Infection and edema spreading from the lower part of the oral cavity into the neck is called . . .?

Ludwig’s angina –

Neck is usually described as having “brawny edema”

What usually gets Ludwig’s angina started?

Dental work

Technically, what is Ludwig’s angina, and why is it called “angina?”

• Bilateral submandibular cellulitis

• “Angina” just means “pain” (not specific to the heart)

What types of organisms are usually involved in Ludwig’s angina?

Mixed aerobic & anaerobic

If an item mentions “brawny edema” of the anterior neck, what diagnosis should you be thinking of?

Ludwig’s angina

(Brawny just refers to the skin color deepening due to underlying infection)

What is the most common cause of death in Ludwig’s angina?

Airway obstruction

Can a dermoid cyst be found in the mouth?

Yes –

Along the floor of the mouth

What is the diagnostic test of choice for acoustic neuromas?

MRI with gadolinium contrast

In general, how can you differentiate viral sialadenitis from bacterial sialadenitis?