COMMON INFECTIONS IN ENT/OTOLOGY Flashcards
Sore throat associated with stridor, respiratory difficulty, drooling or unilateral neck swelling?
Epiglotitis: is an acute inflammation in the supraglottic region of the oropharynx, with inflammation of the epiglottis, vallecula, arytenoids, and aryepiglottic folds. A patient in extremis requires immediate airway management.
RED FLAG: absolute indication for emergency referral to hospital
Causes of small painful, shallow, and round/oval lesions of the mucus membranes and gums?
ORAL CAVITY ULCERATION:
- vast majority of mouth ulcers are self -limiting and resolve in 7-10 days.
- More persistent or recurrent ulceration merits further investigation.
Investigations and Treatment for Oral Cavity Ulcertaion?
“I wish to investigate this patient Clinically, hematological, histologically and radiologically”
Imaging: MRI is modality of choice for tongue
Causes of Pharyngitis?
How to Differentiate?
WHEN TO GIVE ANTIBIOTICS?
Pharyngitis is usually infectious:
- 70% viral origin (DO NOT REQUIRE ANTIBIOTICS)
- Most bacterial cases: Group A Streptococci (GAS).
- Mouth-breathing secondary to nasal obstruction (as with a URI): sore throat that is worse in the morning and abates as the day progresses
Signs and symptoms alone cannot be used to rule out or diagnose GAS pharyngitis:
Complications of Bacterial Pharyngitis?
Complications of Group A Strep pharyngitis include rheumatic fever and glomerulonephritis.
- Incidence of rhematic fever is very low
- antibiotics do not prevent glomerulonephritis.
Condition Characterised by:
- Fever
- Bilateral nonpurulent conjunctivitis
- Cervical node enlargement, erythematous oral mucosa, and an inflamed pharynx with a strawberry tongue?
At risk of developing what condition?
Kawasaki Disease (aka. mucocutaneous lymph
node syndrome) is an acute febrile illness of early childhood (<5) characterized by vasculitis of the medium-sized arteries. Given its predilection for the coronary arteries, there is a potential for the development of coronary artery aneurysms (CAAs)=> sudden death.
Diagnosis/Treatment of Pharyngitis?
Rapid streptococcal tests demonstrate a sensitivity of approximately 95%.
- vigorous samples of both tonsils and posterior
pharynx while avoiding the uvula and soft palate as they dilute the sample.
GAS pharyngitis is usually a self-limiting disease, and most signs and symptoms resolve spontaneously in 3-4 days.
- Incidence of rheumatic fever is very low
- antibiotics do not prevent glomerulonephritis.
___________________________ has clinical symptoms consisting of fever, pharyngitis, and adenopathy. It is caused by ________________________ a common cause of viral pharyngitis/tonsillitis. Patients present with a constellation of symptoms including marked fatigue, lymphadenopathy, a maculopapular rash, lymphocytosis and splenomegaly
Treatment?
Infectious Mononucleosis (Glandular Fever) has clinical symptoms consisting of fever, pharyngitis, and adenopathy. It is caused by Epstein Barr Virus (EBV) a common cause of viral pharyngitis/tonsillitis. Patients present with a constellation of symptoms including marked fatigue, lymphadenopathy, a maculopapular rash, lymphocytosis and splenomegaly
Treatment:
- Steroids for impending airway obstruction secondary to grossly enlarged tonsils
- Avoid Penicillin – causes rash
Avoid contact sports for 6 Weeks
A _______________ is a peritonsillar abscess (a collection of pus) which may form as a result of acute tonsillitis. It is more common in ________ and extremely rare in _________. This can be severe with absolute ______________ and referred ___________.
A Quinsy is a peritonsillar abscess (a collection of pus) which may form as a result of acute tonsillitis. It is more common in adults and extremely rare in children. This can be severe with absolute dysphagia and referred otalgia.
What are these Signs/Symptoms indicative of?
Treatment?
Quinsy
Clinical Features of Epiglottitis?
Causative Organisms of Epiglottis
Children vs. Adults?
Children: Haemophilus influenzae type b (Hib)
- Dramatic DECREASE in incidence with widespread adoption of Hib Vaccine
Adults:
- Haemophilus influenzae (25%)
- H parainfluenzae
- Streptococcus pneumoniae
- group A streptococci
Management of Epiglottis?
- Unstable: immediate airway intervention (intubation or tracheostomy)
- Stable: IV steroids, antibiotics, nebulized adrenaline
Conditions to be considered in patients with SEVERE signs of sore throat?
Red Flag for Dysphonia?
Red Flag: the presence of persistent dysphonia >3 weeks requires specialist ENT referral
It is estimated that up to 30% of patients with __________ initially present with laryngeal complications
It is estimated that up to 30% of patients with GORD initially
present with laryngeal complications.
Signs/Treatment of Tonsilitis?
When Tonsillectomy Indicated?
Signs
- Pyrexia ALWAYs present and may be high => febrile convulsions in some infants
- Tonsils enlarged, hyperaemic may exude pus from the crypts– follicular tonsilitis
- Pharyngeal mucosa is inflamed
- Halitosis
- Cervical lymph nodes are enlarged and tender
Treatment
- Bed rest
- Ibuprofen in adults and Paracetamol in children- Ibuprofen can be used in children but with caution in the dehydrated child
- Patient should drink as much as possible – particularly small children who may be susceptible to becoming dehydrated
- Severe cases: penicillin V (amoxicillin can cause rash in glandular fever)
Tonsillectomy indicated if:
- 7 episodes in one year
- 5 episodes per year for two years
- 3 episodes per year for three years
Causes of Acute vs. Chronic Laryngitis
Chronic Laryngitis = Fungal
Acute Laryngitis: Bacterial/Viral
___________________________: Cystic mass lined with keratin producing squamous epithelium filled with layered desquamated debris within the middle ear/mastoid which causes the destruction of local structures and can be accompanied by infection
Types?
CHOLESTEATOMA: Cystic mass lined with keratin producing squamous epithelium filled with layered desquamated debris within the middle ear/mastoid which causes the destruction of local structures and can be accompanied by infection
Presentation of Cholesteatoma?
Otalgia (Earache)
Ottorhea (Discharge from ears)
Deafness
Advanced cholesteatoma: vertigo secondary to a fistula into semicircular canal, facial nerve paralysis, ossicular involvement causing reduced hearing.
Pathology of Cholesteatomas?
Cystic mass lined with keratin producing squamous epithelium filled with layered desquamated debris
Mastoid Bone Erosion by cholesteatoma occurs through a combination of mechanisms including:
- perimatrix-secreting metalloproteinases
- osteoclast activation
- altered pH
- Bacterial Toxins
- Pressure-mediated bone resorption
Superinfection may enhance biologic profile of perimatrix & inflammatory infiltrate thus increasing bone erosion
___________________ increases inflammatory and secretory profile of cholesteatoma. Treatment?
Bacterial superinfection increases inflammatory and secretory profile of cholesteatoma
Treatment options include
o 2nd generation quinolone: ciprofloxacin
o 3rd generation cephalosporin ceftriaxone, cefotaxime
Management of Cholesteatoma?
Intratemporal vs. intracranial complications of Middle Ear Disease due to Infection/Cholesteatoma
What are these Signs/Symptoms Indicative of?
Treatment?
LABYRINTHITIS: Cholesteatoma may erode the labyrinth most often the lateral semicircular canal.
Note: Vestibular neuritis=> Labyrinthitis (herpes simplex virus in the vestibular ganglion). Prior URTI => Acute Labyrinthitis
Condition that presents with:
- Diplopia from lateral rectus palsy
- Trigeminal pain
- Evidence of middle ear infection
PETROSITIS: Infection spreads from the mastoid to temporal bone and finally petrous apex of the temporal bone, from here it involves the 5th cranial nerve.
What are these signs/symptoms indicative of?
Treatment?
SUBDURAL/EXTRADURAL ABSCESS
Management is with IV Antibiotics and if indicated surgical intervention. Options include lateral temporal bone resection or drainage of any intracranial abscess.
Facial Nerve Palsy Red Flag Presentation?
Presentation of facial nerve palsy with a new onset parotid lump
should alert the clinician to the possibility of a tumor – direct ENT referral is indicated
Facial Nerve Palsy: Complete or partial weakness of 7th cranial nerve.
- ____________ motor neuron which spares the forehead
- ____________ motor neuron which causes weakness of the entire hemiface.
- Degree of facial nerve dysfunction is graded using the _______________________________________ where __ is normal and __ is total paralysis.
Facial Nerve Palsy: Complete or partial weakness of 7th cranial nerve.
- Upper motor neuron which spares the forehead
- Lower motor neuron which causes weakness of the entire hemiface.
- Degree of facial nerve dysfunction is graded using the “House Brackman” grading system where 1 is normal and 6 is total paralysis.
Etiology of Facial Nerve Palsy?
Facial Nerve Palsy:
- Progression beyond ________ or lack of improvement beyond _____________suggests a malignant cause
- Presence of infections such as otitis media/externa.
- Hearing loss can occur in _____________ and ______.
Other Potential Causes?
- Progression beyond 3 weeks or lack of improvement beyond 6 months suggests a malignant cause
- Presence of infections such as otitis media/externa.
- Hearing loss can occur in Ramsay Hunt syndrome (Herpes Virus) and Bell’s palsy (Idopathic => 3x Higher in pregnancy)
Other Potential Causes:
- Neurological infections affecting the facial nerve: meningitis, encephalitis, leprosy & tetanus
- Recent polio, rabies, tetanus and influenza Immunization
Grading system for Facial Nerve Palsy?
House Brackman system
Facial Nerve Palsy Treatment?
_________________ - Most common form of OE, often seen in swimmers
Acute diffuse Otitis Exterena - Most common form of OE, often seen in swimmers
_________________- OE Associated with infection of a hair follicle
Acute localized Otitis Exterena (furunculosis) - Associated with infection of a hair follicle
_________________- Commonly seen in swimmers but is of longer duration (>_________)
Chronic Otitis Exterena - Commonly seen in swimmers but is of longer duration (>6 weeks)
_________________ - Encompasses various dermatologic conditions (e.g., atopic dermatitis, psoriasis, systemic lupus erythematosus, and eczema) that may infect the EAC and cause OE
Treatment?
Eczematous (eczematoid) Otitis Exterena - Encompasses various dermatologic conditions (e.g., atopic dermatitis, psoriasis, systemic lupus erythematosus, and eczema) that may infect the EAC and cause OE
Treatment: Antibiotic + topical steroid
______________________ - Infection that extends into the deeper tissues adjacent to the EAC; occurs primarily in immunocompromised adults (e.g., diabetics, patients with AIDS)
Necrotizing (malignant) Otitis Exterena - Infection that extends into the deeper tissues adjacent to the EAC; occurs primarily in immunocompromised adults (e.g., diabetics, patients with AIDS)
____________________ - Infection of the ear canal from a fungal species (e.g., Candida, Aspergillus)
Otomycosis - Infection of the ear canal from a fungal species (e.g., Candida, Aspergillus)
Etiology of Otitis Externa?
- Gram negative organisms e.g., pseudomonas aeruginosa
- Fungi
- Viruses
Diagnosis/Treatment of Otitis Externa?
Treatment:
• Topical Antibiotic Drops– Quinolones
• Aural Packing – Ribbon Gauze/Pope’s Wick
OTITIS EXTERNA Red Flag Signs?
Malignant otitis externa (MOE) is a rare potentially fatal inflammatory disease of the external auditory canal, temporal bone, and skull base. The disease begins in the __________________and then spreads to the skull base through __________________.
Additionally, the disease spreads to the stylomastoid and jugular foramina. It occurs most commonly in patients who are ___________________ or __________________.
Malignant otitis externa (MOE) is a rare potentially fatal inflammatory disease of the external auditory canal, temporal bone, and skull base. The disease begins in the external auditory canal and then spreads to the skull base through Santorini’s fissures.
Additionally, the disease spreads to the stylomastoid and jugular foramina. It occurs most commonly in patients who are immunocompromised or diabetic
Malignant Otitis Externa:
- Clinical Presentation
- Investigations
- Complications
- Management
FURUNCULOSIS of the External Auditory Meatus/ Nasal vestibule
- Etiology?
- Clinical Signs?
- Treatment?
- Complications?
Facial nerve palsy in the presence of a head injury is pathognomonic for a ____________________.
Facial nerve palsy in the presence of a head injury is pathognomonic for a temporal bone fracture
Sudden onset sensorineural hearing loss of _______ decibels or more over _______ frequencies that develops over _______ days or less.
Prognosis?
Sudden onset sensorineural hearing loss:
- 30 decibels or more
- over three frequencies
- develops over three days or less.
RARE: Overwhelming majority of cases are idiopathic.
- 50% spontaneously recover
- Improvement at 1-2 weeks may predict long term prognosis
Benign brain tumor arising from the 8th cranial nerve which occurs when Schwann cells grow too quickly
ACOUSTIC NEUROMA (Acoustic/Vestibular Schwannoma)
ACOUSTIC NEUROMA (Acoustic/Vestibular Schwannoma)
- Risk Factor
- Symptoms
- Treatment
RIsk Factor: Neurofibromatosis 2 (NF2)
Grow slowly, years before signs and symptoms:
- Asymmetrical sensorineural hearing loss – usually gradual, but in some instances can develop suddenly
- Tinnitus – buzzing or other repetitive sounds in the ear
- Vertigo
- Facial numbness (CN V affected)
Treatment
- Conservative – (⅓ do not grow, ⅓ involute, ⅓ grow at 2mm per year)
- Surgery
- Radiation
TINNITUS Red Flag Signs?
Causes of Tinnitus?
The character of Tinnitus indicative of its pathology
Unilateral: ______________
Pulsatile: ________________
Vertigo/Sensory Neural Hearing Loss: _____________
Unilateral: Organic Pathology
Pulsatile: Vascular Pathology
Vertigo/Sensory Neural Hearing Loss: Meniere’s
Central vs. Peripheral Vertigo?
VERTIGO can be central (CNS) or peripheral (labyrinthine)
- Central causes indicate significant pathology requiring urgent treatment.
- Central causes of vertigo may have vertical nystagmus (peripheral vertigo will never have this) along with other focal neurological findings
Causes of vertigo
- Infection of the vestibular apparatus following a viral infection such as a common cold or flu
- Symptom of Meniere’s Disease: a disorder in which excess fluid builds up in the inner ear.
- Benign paroxysmal position vertigo (BPPV): due to particles floating in the semicircular canal. lasts for seconds as opposed to hours in other causes
Investigations for Vertigo
Otoscopy: Middle ear pathology causing vertigo?
Hallpike: Diagnostic of BPPV (Otoconia dislodging in semicircular canals)
Cerebellar Examination: HINTS mnemonic
- Head Impulse: Vestibulo-ocular reflex is normal if NO corrective saccade. If Pt. is dizzy and this reflex remains normal=> CNS is the source of vertigo.
- Nystagmus Test: bidirectional or vertical => central pathology
- Skew: (cover/uncover test) Vertical movement of the eye when uncovered => central cause of vertigo
___________________ symptoms including tinnitus, hearing loss, aural fullness and vertigo. Attacks last hours to days unlike ________________ which lasts seconds. Often has a prodromal warning phase much like a migraine.
- Diagnosis?
- Treatment (Conservative/Medical)?
Meniere’s Disease is a constellation of symptoms including tinnitus, hearing loss, aural fullness and vertigo(THAV). Attacks last hours to days unlike BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) which lasts seconds. Meniere’s is caused by excess fluid buildup in the inner ear and often has a prodromal warning phase much like migraine
Diagnosis:
- Headshake Test– Nystagmus toward side of lesion
- Triad of recurrent vertigo, worsening tinnitus, fluctuation in hearing loss
_______________________is a common disorder of the inner ear. It is caused by otoconia (canaliths) dislodging and migrating into one of the semicircular canals, most commonly the __________ semicircular canal. Here the canalith disrupts the endolymph dynamics and thus triggers vertigo on sudden head movement
Diagnosis??
Treatment?
BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) a common disorder of the inner ear. It is caused by otoconia (canaliths) dislodging and migrating into one of the semicircular canals, most commonly the POSTERIOR semicircular canal. Here the canalith disrupts the endolymph dynamics and thus triggers vertigo on sudden head movement
________________________________: Acute-onset (1-2 days) vertigo, nausea, vomiting, and gait instability in otherwise healthy patients. Mild symptoms persist for months
- Pathogenesis?
- Causes?
Vestibular Neuritis (Labyrinthitis): anifests with acute-onset (1-2 days) vertigo, nausea, vomiting, and gait instability in otherwise healthy patients. Mild symptoms persist for months
- Idiopathic inflammation of the vestibular nerve
- Most likely caused by herpes simplex virus in the vestibular ganglion.
- Prior URTI also common => ACUTE LABRINTHITIS (inflammation of labyrinth rather than nerve)
Vestibular vs. Psychogenic dizziness
- Duration?
- Frequency?
- Head Movement?
- Ataxia?
- Effect of Hyperventilation?
Differences between Sensorineural and Conductive Hearing Loss?
Causes of Each?
Sensirineural
- Loss of intensity
- Loss of clarity
Conductive:
- Loss of intensity
- NO loss of clarity
- Paracusis Willisi: patient hears better w/ background noise
How does Weber’s Test Work?
Weber: Base of the tuning fork (512 Hz) is placed on the center of the forehead. Sound will appear loudest in an ear with conductive deafness. Weber’s test can detect a hearing loss of 5dB
Sensorineural => impacted ear QUITER
Conduction => Impacted ear LOUDER
How does Rinne’s Test Work?
Rinne: Vibrating tuning fork (256 or 512 Hz usually) is placed on the mastoid bone, behind the ear and level with the canal, to assess bone conduction.
To assess air conduction, the fork is then quickly placed close to the ear canal with the “U” of the fork facing forward to maximize the sound for the patient.
Sensorineural: AIR > BONE
Conduction: BONE > AIR
What is this condition called?
Microtia
Ottis Externa
- Microbiology?
- Risks
- Complications
Microbiology of Acute Otitis Media?
Causitive Organisms:
- Strep Pneuomia
- Haemophilus Influenza
- Moraxella Catarrhalis
Management of Recurrent Acute Otitis Media?
Ventilation Tubes (Grommits) => 67% Reduction in Episodes
Indicated if:
- 3 in 6 Months
- 4 in 12 Months
Management of Otitis media with Effusion (OME)
NO BENEFIT TO MEDICAL MANAGEMENT!!
Indications for surgery:
- Bilateral OME and hearing loss should be confirmed over a three month period before referral for intervention is considered
- OME documented over three months with a hearing level in the better ear of 25–30 dBHL or worse => SURGERY
- Impact on developmental, social or educational status => SURGERY
- Adenoidectomy extends the period of hearing benefit from ventilation tube insertion up to two years (NOT recommended in the absence of persistent upper respiratory tract symptoms)
Complications of Anterior Inferior Myringotomy (Ventilation Tube / Grommet)?
Perforation (~2%)
Tympanosclerosis(31%): Hyaline degeneration, with calcium deposition of middle fibrous layer of tympanic membrane.
Tympanosclerosis also Caused by
– Recurrent acute otitis media
– OME
________________: Paragangliomas originating in glomus cells of neural crest
- Characteristics
- Clinical Findings
- Treatment
Glomus Tumors: Paragangliomas originating in glomus cells of neural crest
Etiology:
- 10% Secrete Catacholamines
- 10% Familial (MEN)
- Benign but locally invasive
Clinical Findings:
– Pulsatile Tinnitus
– Conductive Hearing Loss
– Cranial Nerve Palsies (VII – Facial Weakness, X - Hoarseness)
– Red Middle ear mass
Treatment:
- Surgical Resection
- Stereotactic Radiosurgery
