12 - ENT Flashcards
Label the tympanic membrane
- Pars flaccida at the top
- Pars tensa at the bottom
- Umbo is the tip of the malleus
How do you perform an ear examination?
https: //geekymedics.com/hearing-ear-examination-osce-guide/
- General inspection
- Basic hearing assessment with rubbing tragus
- Weber’s and Rinne’s with 512 Hz
- Palpate the pinna, mastoid process, preauricular area
- Otoscopy with normal ear first and ask about any pain
How is pure tone audiometry performed?
- Wearing headphones they measure what is the quietest sound you can hear 50% of the time at different pitches
- AC measured with headphones, BC measured with headband
- Pure tone threshold is the lowest decibel that the patient hears the pure tone 50% of the time
- May mask the patients other ear by playing a noise into it to stop the cross over problem
How do you read an audiogram?
Red line = right ear
Blue line = left
Why may someone with high frequency hearing loss struggle to comprehend speech?
How may impacted ear wax present and how is it treated?
- Conductive hearing loss, blocked ears or a feeling of fullness, earache, tinnitus, itchiness, vertigo
`- Remove if symptomatic, need to view tympanic membrane or someone needs a mould for a hearing aid
Mx:
- Do not use cotton buds as may become foreign body
- Ear drops for 3-5 days to soften e.g olive/almond oil, NaHCO3 5% (not if ear drum perforation)
- If persists try ear irrigation
- Refer to ENT if after 2 attempts of irrigation and drops no change
How may otitis externa present? (caused by P.Aeruginosa/S.Aureus)
- Acute <3weeks, Chronic >3months
- Diffuse when widespread inflammation of the skin and subdermis
- Localised when infected hair follicle that can become a boil in the ear canal
- Malignant when spreads to surrounding bones e.g mastoid, temporal bones
Symptoms: pain, itch, discharge, hearing loss, red oedematous ear canal, will be painful when touching pinna
How is otitis externa treated?
- Provide patient leaflet
- Treat pain with analgesic (codeine if severe)
- Warm compress
- Topical acetic acid 2% spray for 7-14 days or topical corticosteroid e.g dexamethasone spray (OTOMIZE)
- If needed oral flucloxacillin for 7 days
- Tell patient to keep ear dry and clean, avoid cotton buds, use hairdryer after swimming or shower
How does acute otitis media present? (Hib, S.Pneumoniae, M.Cattarhalis) and what are some complication?
- Most common in children, may hold or rub their ear, or fever, crying, poor feeding, restlessness, cough, rhinorrhoea
- Bulging red, yellow TM with no cone of light
- Risks: second hand smoke, nursery, facial deformities e.g cleft pallate
Complications: recurrence, hearing loss, TM perforation, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysi
How should acute otitis media be managed?
- Check for intracranial complications that need emergency admission e.g mastoid tenderness
- Advise analgesia and explain self limiting 3-7 days
- Delayed or immediate prescription if systemically unwell, amoxicillin or clarithromycin 5-7 days
- Safety net
What are the different ways that you can describe an ear drum perforation?
- Dry or Wet - A dry perforation was defined as a perforation without the presence of secondary bloody and watery substances and purulent otorrhea on the ruptured membrane and at perforation edges, whereas a wet perforation was defined as a perforation with the presence of those substances.
- Central: if in pars tensa. safer
- Attic/Peripheral: if in pars flaccida. less safe as not under tension
May present with sudden hearing loss, tinnutus, fluid leaking from ear, itchy
How do we manage a tympanic membrane perforation?
- Keep ear very dry and do not put anything in there whilst healing
- Analgesia and warm compress
- Don’t blow nose too hard
- If not healing /chronic supparative after 6-8 weeks refer to ENT for topical steroids, antibiotics and possible surgical tympanoplasty
How does choleasteatoma present and how do we manage it in primary care?
Sac of keratinising squamous epithelium in the pars flaccida that can errode into the middle ear structures
Often asymptomatic to start then foul smelling blood stained discharge. May have retraction pocket with crust/granulation tissue/pearly white/keratin material in upper part of TM
Semi-urgent referral to ENT for audiology assessment and CT. Topical antibiotics before surgical removal
What is this presentation of the eardrum and what is it caused by?
Calcification/scarring of the ear drum due to previous ear infections
Nothing to manage, no symptoms
How does otitis media with effusion (glue ear) present and what are some risk factors for this condition?
- Hearing loss/dulled sounds with occassional ear pain and popping
- May have speech and developmental issues
- Abnormal colour TM (e.g yellow), loss of light reflex, air bubbles, retracted concave TM
Risk Factors: large adenoids, cleft pallate, household smoking, allergic rhinitis, ET dysfunction, Down’s
How is otitis media with effusion managed?
- Observe over 6-12 weeks as may spontaneously resolve with at least two pure tone audiometry tests in this time as well as tympanometry
- Refer to ENT if hearing loss in these tests or symptoms persist after observation period
- ENT may give nasal balloon, hearing aids or do myringotomy and grommet insertion
What is the purpose of the eustachian tube and how can it be blocked?
From the middle ear into post nasal space allowing mucus to clear and equillibriation of pressure when open
Cone of light on TM due to concave TM due to the pressure changes
Blocks: sinusitis, large adenoids, persistent rhinitis, smoking related changes to nasal mucosa
How may otosclerosis present and how is it managed in primary care?
Symptoms: usually bilateral conductive hearing loss, speaking softly, hearing better in noisy surroundings, hearing sounds from within your body, dizziness and balance problems
- Due to abnormal bone growth, especially around stapes and the ossicles may fuse together
Refer for hearing tests and for CT. ENT may give hearing aids or stapedectomy
How does noise related hearing loss present and what does an audiogram of this show?
- May have gradual onset and present with tinnitus, saying ‘what’ a lot, turning up volume on TV
- When exposed to loud noises for too long, e.g working with lawnmowers, stereocilia are damaged
- Permanent!!!! Cannot be reversed, need to prevent by moving away from loud sounds, wearing earmuffs, using noise cancelling earphones
How does Meniere’s disease present and what are some risk factors for this disease?
- Episodes of vertigo, fluctuating sensorineural hearing loss, feeling of fullness in the ear, nystagmus and tinnitus lasting 20 mins-12 hours
- Risks: endolymphatic hydrops, autoimmunity, genetic susceptibility, metabolic disturbances, migraines, viral infection, head trauma
- Will have low to middle frequency sensorineural hearing loss on an audiogram
How can we manage Meniere’s disease in primary care before official diagnose by ENT?
- Admit to hopsital if severe symptoms for IV labyrinth sedatives and fluids
Advice: reassure will clear up in 24 hours but to return if continues for 5-7 days, inform DVLA, don’t operate machinery when dizzy, tell patients to keep their meds always available
N+V: prescribe prochlorperazine or antihistamine/vestibular sedative (cinnarizine, cyclizine, or promethazine teoclate) for 7 days
Prevention: betahistine to reduce frequency and severity of attacks
How does presbyacusis present and how does it show up on audiogram?
Bilateral sensorineural hearing loss often slow onset and in noisy environments at first. Often noticed by other people
Can get tinnitus if gets progressive
Diagnosis of exclusion
How can presbyacusis be managed in primary care after pure tone audiometry?
- Reassure patient it is part of natural aging process
- Communication and environment manipulation e.g speaking face to face
- Hearing aids
- Assistive hearing devices e.g light for doorbell
- Prevent by eating antioxidants, good CVS health, good diabetic control, limiting noise exposure
What is the definition of chronic supparative otitis media?
Chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges through a tympanic perforation
Do not swab the ear, refer for ENT assessment
Explain that the hearing loss will return when the perforation has healed
How is mastoiditis diagnosed and then managed?
If tympanic membrane is normal it is not mastoiditis as usually follows on from Otitis media
Refer for urgent admission if acute otitis media with mastoid tenderness. Antibiotics or mastoidectomy if abx not working
What hearing loss on an audiogram would a tympanic perforation show?
What can cause referred pain to the ear?
Ear exam normal then examine TMJ, throat, dental hygeine, cervical lymph nodes, general head and neck exam
Take into consideration red flags and risk factors e.g weight loss, voice changes, smoking, chronic alcohol, diabetes
Refer for nasal endoscopy if high suspicion
How do we test for congenital deafness and what are some causes of this?
- Newborn hearing screening AOAE or AABR
- Causes: infections e.g HSV and rubella, maternal diabetes, low birth weight, preeclampsia, low birth weight, premature birth, alcohol use whilst pregnant
How is congenital deafness managed?
- Audiology clinic within 4 weeks
- Intervention before 6 months
- Hearing aids from 1 month, cochlear implants from 12 months
- Consider communication method e.g sign language