ENT – Fast HY Review

For ENT Infections (OM/OE/Mastoiditis), Refer to ID from Here.

Emergencies 🚨🚑

	Ludwig Angina
features	Abscess in the floor of the mouth, Can be life-threatening It involves 2 compartments: sublingual and submaxillary space bilaterally. MCC is 2˚ to dental disease in the lower molars, 90% of cases
S/S	Ludwig’s angina starts as cellulitis of the submandibular region and rapidly progress to cause airway obstruction. neck swelling, neck pain, odynophagia, and dysphagia PEx: fever, submandibular swelling and tenderness, swelling to the floor of the mouth, tenderness to the involved teeth, stiff neck, edema in the upper part of the neck, and crepitus. No LN Complications: The most life-threatening complication of Ludwig’s angina is airway obstruction.
Dx	Clx
Tx	1˚: Make sure AW is safe. Early airway management is critical to the treatment of Ludwig’s angina as the most common cause of death is sudden asphyxiation from airway obstruction. Flexible fiberoptic nasal intubation is clinicians’ favored method of intubation. If the patient is not able to be intubated, the next step would be an emergency tracheotomy. 2˚: Tx the Infxn I/D IV broad spectrum Abx

Facial n. injuries 2˚ to trauma:	If paralysis immediately after trauma –> result of trauma If paralysis later after trauma –> swelling that will resolve spontaneously
Cavernous sinus thrombosis	Suspects in pt who has sinusitis and suddenly develops diplopia + fever Dx: MRI Tx: Hospitalize Tx w/ aggressive IV Abx for 3-4 weeks Drain the inflammed sinus

Peds

Foreign bodies are the cause of unilateral ENT problens in toddlers. A 2-year-old with milateral

earache, tmilateral rhinorrhea, or tmilateral wheezing has a little toy truck (substitute for your favorite

toy if you wish) in his ear canal, up his nose, or into a bronchus. The appropriate endoscopy under

anesthesia will allow extraction.

Just do endoscopy w/ anesthesia & get it out.

Thyroglossal duct cysts	Midline, at hyoid bone level, moves w/ tongue. Tx: Surgery.
Brachial cleft	Along anterior border of SCM muscle
Cystic hygroma

Chronic otitis media

This implies that the eardrum has perforated, the perforation has failed to heal and there is ongoing infection.
Why it happens? 1- not adequate tx to AOM 2-Sepsis 3- general weak state
Complications: invasive infection – cholesteotoma – permenant deafness
Tx:
- If bony → aural toilet (تنظف المكان)
Dry perforation → nothing
permenant perforation → Maryngoplasty → using temporalis fascia

🔴 COMPLICATIONS 🔴

can be classified into: ear / cranial complications

1️⃣Ear complications

Acute mastoiditis
- FEVER + pain (over mastoid) + pus + swelling post-auricular
- Tx: IMMEDIATE IV ABx → Surgery (if abscess of slow response to ABx)
CN7 Palsy
- If w/ AOM → treat AOM
if w/ choleostotoma → Surgery
Cholesteotoma`
- squamous epithelium within the middle ear. It results in accumulation of keratotic debris.
- It expands and damages vital structures, such as dura, the facial nerve and the semicircular canals
- Cholesteatoma is destructive and potentially lethal if untreated.
- Tx: surgery (mastoidectomy)

Otitis media w/ effusion

Because some fluid in the middle ear is normal for up to several weeks after an episode of AOM, the term OME requires that the fluid be persistent for at least 3 months.
What are the indications or myringotomy and PE tube placement?

Persistent middle ear effusion over 3 months
Debilitated or immunocompromised patient
More than three episodes over 6 months (especially if bilateral)

Complications:
- Acute mastoiditis
  - perform CT scan of temporal bone.
  - myringotomy and IV antibiotics
- Cholestotoma
  - tympanomastoid surgery

	Epistaxis
features	The MC site of bleeding is an area on the nasal septum called Little’s region The most common causes of epistaxis include nose picking, a foreign body in the nasal cavity, and a dry nose. There’re other systematic causes.
S/S	Epistaxis
Dx	Clx
Tx	Immediate measures IVF if hemodynamically unstable Bend forward & pinch the nostril for 5-10 m Apply cold packs and sustained Apply topical vasoconstrictors (e.g., oxymetazoline, phenylephrine) If epistaxis continues after 10–15 minutes First-line: cauterization of the bleeding vessel using silver nitrate or electrocautery. Second-line: nasal packing using gauze impregnated with paraffin and antibiotics (covering for Staphylococcus aureus). Anterior epistaxis: anterior nasal packing Posterior epistaxis: posterior nasal packing If epistaxis persists: arterial embolization or endoscopic ligation of the bleeding vessel Anterior ethmoidal artery for anterior epistaxis Sphenopalatine artery for posterior epistaxis
📝	Packing > 24 –> toxic shock syn

types of epistaxis	Anterior epistaxis	Posterior epistaxis
Clx	Bleeding through the anterior nasal aperture	Bleeding through the posterior nasal aperture Bleeding is therefore not obvious but can be identified by examining the posterior pharyngeal wall, which appears blood-stained. The patient may swallow large amounts of blood and present with hematemesis.
Relative frequency	90% of cases	10% of cases
Peak incidence	More common among children and young adults	More common among elderly individuals
Most common site of bleeding	Little’s region	Lateral and posterior walls of the nasal cavity (Woodruffs plexus)

Choanal Atresia

- Best initial test? Insert a catheter
- How to confirm dx? CT Scan
- It can be part of CHARGE
  - Colobomas (A coloboma is a hole in one of the structures of the eye, such as the iris, retina, choroid, or optic disc)
  - Heart
  - Atresia
  - Retardation
  - GU abnormalities
  - Ear abnormal

	Choanal atresia
Clx	Unilateral (most common) o Chronic nasal discharge o Symptomatic during childhood Bilateral o Cyanosis that worsens with feeding & improves with crying o Noisy breathing (stertor) o Symptomatic shortly after birth May be associated with CHARGE syndrome
Dx	Inability to pass catheter past nasopharynx Confirmation with CT scan or nasal endoscopy
Tx	Oral airway Surgical repair

CHARGE = Coloboma, Heart defects, Atresia choanae, growth Retardation, Genital and Ear abnormalities.

Otosclerosis

Bony growth of stapes that causes CONDUCTIVE hearing loss
Autosomal Dominant
Px will be in 20s w/ hearing loss & +ve FHx
Tx: hearing aids or surgery (romoval of stapes + putting prosthesis)

Hearing Loss

Before 6 m → Brainstem response
When 6 m → Visual reinforcement audiometry

Nose:

Nasal polyps

What is it? pedunculated epithelial growth.
Why it happens? Nobody knows exactly why, but in general, they are associated with: allergic rhinitis, asthma (aspirin), CF, and chronic sinusitis.
Sx? obstruction sx (mouth breath, snoaring) & recurrent infections.
Dx? Visualization (otoscope). CT can be done.
Tx: Intranasal steroids → if steroid didn’t do the job, pt have multiple polyps or deformity → surgery (شيلهم وريح راسك)

Epistaxis

Causes: trauma (nose picking by kids), dryness (in winter), COCAINE
Tx: Compress and lean forward → drugs (topical: oxymetazonolone – phenylphrine) → Anterior nasal picking
if bleeding site identified → Cautery.

Foreign body

Unilateral + purulent maladorous mucus
Tx: just remove it

Allergic rhinitis

Management:

Educate pt about the condtition
Avoid triggers
Antihistamine
Local corticosteroids (nansonex)
If severe → oral corticosteroids

Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor that tends to bleed and occurs in the nasopharynx of prepubertal and adolescent males. Symptoms include Nasal obstruction (80-90%), epistaxis (45-60%) – mostly unilateral and recurrent, headache (25%).

Throat

Tonsillitis
- Sx: Sore throat + dysphagia (children will refuse to eat), +/- drooling
- PEx: hyperemic tonsills + cervical LN
- Dx:
- Tx: ABx

Tumors:

Salivary gland
- MC → Parotid (mostly benign) / Others (highly malignant)
- Benign
  - Pleomorphic adenoma (mc tumor)
  - Warthin → associated w/ smoking + bilateral
  - Dx: FNA
  - Tx: Surgery (Gland excision w/ margin)
- Malignant
  - Adenoid cystic carcinoma → pulmonary metastasis
- Mucoepidermoid carcinoma (MC in children) → if epidermoid (poor prognosis) if mucoid (good prognosis)
- Squ cell car → very aggressive (r/o metastasis to parotid LN)
- Dx: FNA
- Tx: 1* surgery → radiation
Thyroid
- you know it: Papillary, Follicular, Medullary and anaplastic
- papillary prognosis in thyroid is related to size
- U/S most sensitive
- FNA for all (except follicular)
- Tx: Lobectomy if small (<1.5 papillary / <4 follicular) except with FAMILIAL MEDULLARY.
Oral cavity
- High risk for malignancy
- MCC → SCC
- Dx: 1* line CT w/ contrast
- Tx: SURGERY
  - +bone → chemo
Laryngeal (HPV16)
- if arise from TRUE vocal cords → glottic → hoarseness
- if arise from FALSE vocal cords → suppra-glottic → muffled sound
- supraglottic: otolgia, dysphagia. hemoptysis

Airway dz

laryngomalacia → improves when prone
Laryngeal papilloma → true vocal cords → hoarseness
conginertal subglottic stenosis
Croup → barking cough (parainfluenza)
- Tx: Adrenaline inhalation + steroids
- steeple sign on x-ray
Bacterial tracheitis
- Sx: cough (barky) – stridor – sore throat – cold sx
- PEx: Sick Sick – resp distress – FEVER
- Dx: no response to recemic epinephrine (you thought it was croup) – GOLD STANDARD: Bronchoscopy
- on x-ray: irregular trachea (membranes are formed)
- Tx: 1) secure Airway (intubation may be needed) 2) Abx
Retropharyngeal abscess:
- Sx of sore throat
- neck stiffness
- Stridor
- on Neck x-ray ➡️ increase paravertebral space
- Tx Intravenous broad-spectrum antibiotic / O2 or intubation
Grading:
- 1: only inspiratory obstruction
- 2: inspiratory + passive expiratory
- 3: inspiratory + active expiratory + pulsus paradoxicus

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Notes:

Rhinitis medicamentosa (RM), also known as rebound rhinitis, is a condition characterized by nasal congestion that is triggered by the overuse of topical vasoconstrictive medications, most notably intranasal decongestants.
Quinsy Triad (Peritonsillar Abscess)

Trismus (due to irritation and reflex spasm of the medial pterygoid) is the most reliable indicator of peritonsillar abscess
Uvular deviation
Dysphonia (“hot potato voice”)

lesion raised from fossa of Rosenmüller → nasopharyngeal carcinoma
Juvenile nasopharyngeal angiofibroma (JNA) is a benign tumor that tends to bleed and occurs in the nasopharynx of prepubertal and adolescent males.
In practice: Before biopsy → DO IMAGING FIRST
Overall, prior nasal septal surgery (septoplasty) is the most common cause of septal perforations

All pictures in this blog are (c) to UWorld (hope they don’t catch me 🤭)

	Otitis Externa
RF	· Water exposure · Trauma (Cotton swabs, ear candling) · Foreign material (Hearing aid. headphones) · Dermatology (Eczema. contact dermatitis)
👾	1st: Pseudomonas aeruginosa → Staphylococcus aureus
Clx	· Otalgia, pruritis, discharge, hearing loss · Pain with auricle manipulation · Ear canal erythema edema, debris · ⓝ TM (clear, not inflamed, no middle ear fluid)
Tx	Topical Abx (Fq) topical GCS Systemic (oral) for immunocompromised pts (DM/HIV)

· An infection of the external ear canal caused by excessive moisture

· Sub category of otitis externa known as necrotizing (or malignant) otitis externa

o DM

o Pseudomonas aeruginosa is MCC

o EMERGENCY: Can cause osteomyelitis

o Tx is IV ciprofloxacin

· Dx: Clx

o In DM –> CT to r/o osteomyelitis

· Tx: ABx drops, If DM (Admission + IV ABx)

	Necrotizing (malignant) OE
RF	Elderly (age >60) / Diabetes mellitus
👾	Pseudomonas aeruginosa
Clx	· Severe, unremitting ear pain (worse at night & with chewing) · Granulation tissue in the external auditory canal · ↑ ESR
Tx	· IV antipseudomonal Abx (ciprofloxacin) · May consider surgical debridement

	Otitis Media
features	RF: · Down syn · 2nd-hand smoking · previous ear infxn · precipitated by URTI
S/S	Sx · ear tugging · fever · hearing loss · irritability · feeding difficulties · vomiting PEx · bulging or fullness of the tympanic membrane (TM) · erythema of the TM · possible perforation with otorrhea · possibe absence of light reflex
Dx	Pneumatic otoscopy · for visualization of the TM and also important in assessing mobility of the TM
Tx	Medical · 1˚: Amoxicillin/Claculanic acid – 10 days. · if penicillin allergy? cephalosporin · if both penicillin & cephalosporin allergy? Macrolides Surgical · myringotomy with t-tube insertion for recurrent cases

	Acute OM
👾	· S.pneumoniae · H. influenzae · Moraxe/la catarrhalis
Clx	Middle ear effusion + Bulging TM
Tx	1˚ Amoxicillin 2˚ Amoxicillin-clavulanic acid – <6 months: Oral Amoxicillin >6 months + ⓑ AMO + High fever: Oral Amoxicillin >6 w/ mild features: Supportive.
Comp	*Conductive* hearing loss Mastoiditis-Meningitis

Complications of AOM

Bollous Maryngitis

bulla on TM

Cholesteatoma

pearly white mass

Conductive Hearing loss

ⓝ TM

Chronic supporative OM

>6 weeks

Pus (otorreha)

Hearing loss

OM w/ effusion

no fever

Can lead to hearing loss

TM effusion

PEx

	OM w/ Effusion
features	Rx OM
S/S	Asx
Tx	Otitis media with effusion if the child does not have risk for speech and language development or other learning disabilities, observation may be appropriate Steroids, decongestants and antihistamines do not completely resolve effusion

	Mastoiditis
features	A complication of OM
S/S	Persistant fever + pain Painful mastoid process >3 weeks dischare
Dx	CT + Otoscope
Tx	IV Abx + Maryngotomy · What Abx? o Vanco –> if no hx of recurrent AOM o Vanco + either ceftazidime / pip-tazo –> if they have recieved abx or have hx of AOM · Maryngotomy + T-Tube insertion If SEVERE & DO NOT IMPROVE ON THE ABOVE CHOICES –> Mastoidectomy

	Mastoiditis
Path	· Complication of acute otitis media · Most commonly due to Streptococcus pneumoniae
Clx	· Fever & otalgia · Inflammation of mastoid · Deviation of ear · 1˚ Opacification of mastoid air cells on CT scan or MRI
Tx	· Intravenous antibiotics · Drainage of purulent material

Preseptal vs Orbital cellulitis
	Preseptal	Orbital
Clx	· Eyelid erythema & swelling · Chemosis	· Symptoms of preseptal cellulitis PLUS · Pain with EOM, proptosis &/or · ophthalmoplegia with diplopia
Tx	Oral Abx	IV antibiotics

	Orbital cellulitis
RF	· Local infection (eg, sinusitis, dental · infection, skin infection) · Orbital trauma
Clx	· Painful eye movements · Ophthalmoplegia · Proptosis · Visual changes
Dx	· Can be a clinical · CT scan if diagnosis is uncertain
Tx	· IV antibiotics · Surgical drainage for abscess

	Acute Bacterial Rhinosinusitis
Clx	· S.pneumonia / H.influenza / Maroxilla catarrahlis · Cough, · Nasal discharge · Fever · Face pain/headache
Dx	· ∆ l of 3: · ≥10 days without improvement · Fever ≥39 C [102.2 F] + drainage ≥ 3 days · Worsening sx following initial improvement
Tx	· Abx (Amoxicillin ± clavulanate)

	Rhino-orbital-cerebral mucormycosis*
RF	· Diabetes mellitus (ketoacidosis) · Hematologic malignancy · Solid organ or stem cell transplant
S/S	· Acute/aggressive · Fever, nasal congestion, purulent nasal · discharge, headache, sinus pain · Necrotic invasion of palate, orbit, brain
Dx	Sinus endoscopy with biopsy & culture
Tx	· Surgical debridement · Liposomal amphotericin B · Elimination of risk factors (eg, inc glucose, acidosis)

	Bell palsy
Involve	CN7: facial nerve
Clx	· ⓤ mouth drooping, disappearance of the nasolabial fold, and, importantly, involvement of the upper face weakness in closing the eye or raising the eyebrow). · hyperacusis / lacrimation / taste sensation
Path	Reactivation of a neurotrophic virus → HSV
Tx	Glucocorticoids

Emergencies 🚨🚑

Facial n. injuries 2˚ to trauma:

Cavernous sinus thrombosis

Peds

Choanal Atresia