COMMON INFECTIONS IN ENT/OTOLOGY

Question 1

Sore throat associated with stridor, respiratory difficulty, drooling or unilateral neck swelling?

Answer 1

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

Question 2

Causes of small painful, shallow, and round/oval lesions of the mucus membranes and gums?

Answer 2

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.

Question 3

Investigations and Treatment for Oral Cavity Ulcertaion?

Answer 3

“I wish to investigate this patient Clinically, hematological, histologically and radiologically”

Imaging: MRI is modality of choice for tongue

Question 4

Causes of Pharyngitis?

How to Differentiate?

WHEN TO GIVE ANTIBIOTICS?

Answer 4

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:

Question 5

Complications of Bacterial Pharyngitis?

Answer 5

Complications of Group A Strep pharyngitis include rheumatic fever and glomerulonephritis.

• Incidence of rhematic fever is very low
• antibiotics do not prevent glomerulonephritis.

Question 6

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?

Answer 6

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.

Question 7

Diagnosis/Treatment of Pharyngitis?

Answer 7

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.

Question 8

___________________________ 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?

Answer 8

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

Question 9

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 ___________.

Answer 9

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.

Question 10

What are these Signs/Symptoms indicative of?

Treatment?

Answer 10

Quinsy

Question 11

Clinical Features of Epiglottitis?

Answer 11

Question 12

Causative Organisms of Epiglottis

Children vs. Adults?

Answer 12

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

Question 13

Management of Epiglottis?

Answer 13

• Unstable: immediate airway intervention (intubation or tracheostomy)
• Stable: IV steroids, antibiotics, nebulized adrenaline

Question 14

Conditions to be considered in patients with SEVERE signs of sore throat?

Answer 14

Question 15

Red Flag for Dysphonia?

Answer 15

Red Flag: the presence of persistent dysphonia >3 weeks requires specialist ENT referral

Question 16

It is estimated that up to 30% of patients with __________ initially present with laryngeal complications

Answer 16

It is estimated that up to 30% of patients with GORD initially
present with laryngeal complications.

Question 17

Signs/Treatment of Tonsilitis?

When Tonsillectomy Indicated?

Answer 17

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

Question 18

Causes of Acute vs. Chronic Laryngitis

Answer 18

Chronic Laryngitis = Fungal

Acute Laryngitis: Bacterial/Viral

Question 19

___________________________: 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?

Answer 19

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

Question 20

Presentation of Cholesteatoma?

Answer 20

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.

Question 21

Pathology of Cholesteatomas?

Answer 21

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

Question 22

___________________ increases inflammatory and secretory profile of cholesteatoma. Treatment?

Answer 22

Bacterial superinfection increases inflammatory and secretory profile of cholesteatoma

Treatment options include

o 2nd generation quinolone: ciprofloxacin

o 3rd generation cephalosporin ceftriaxone, cefotaxime

Question 23

Management of Cholesteatoma?

Answer 23

Question 24

Intratemporal vs. intracranial complications of Middle Ear Disease due to Infection/Cholesteatoma

Answer 24

Question 25

What are these Signs/Symptoms Indicative of? Treatment?

Answer 25

**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*

Question 26

Condition that presents with: * Diplopia from lateral rectus palsy * Trigeminal pain * Evidence of middle ear infection

Answer 26

**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.

Question 27

What are these signs/symptoms indicative of? Treatment?

Answer 27

**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.

Question 28

Facial Nerve Palsy Red Flag Presentation?

Answer 28

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

Question 29

**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.

Answer 29

**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.

Question 30

Etiology of Facial Nerve Palsy?

Answer 30

Question 31

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?**

Answer 31

* 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**

Question 32

Grading system for Facial Nerve Palsy?

Answer 32

House Brackman system

Question 33

Facial Nerve Palsy Treatment?

Answer 33

Question 34

_________________ - Most common form of OE, often seen in swimmers

Answer 34

**Acute diffuse Otitis Exterena** - Most common form of OE, often seen in swimmers

Question 35

_________________- OE Associated with infection of a hair follicle

Answer 35

**Acute localized Otitis Exterena (furunculosis)** - Associated with infection of a hair follicle

Question 36

_________________- Commonly seen in swimmers but is of longer duration (>_________)

Answer 36

**Chronic Otitis Exterena** - Commonly seen in swimmers but is of longer duration (>6 weeks)

Question 37

_________________ - Encompasses various dermatologic conditions (e.g., atopic dermatitis, psoriasis, systemic lupus erythematosus, and eczema) that may infect the EAC and cause OE **Treatment**?

Answer 37

**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**

Question 38

______________________ - Infection that extends into the deeper tissues adjacent to the EAC; occurs primarily in immunocompromised adults (e.g., diabetics, patients with AIDS)

Answer 38

**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)

Question 39

____________________ - Infection of the ear canal from a fungal species (e.g., Candida, Aspergillus)

Answer 39

**Otomycosis** - Infection of the ear canal from a fungal species (e.g., Candida, Aspergillus)

Question 40

Etiology of Otitis Externa?

Answer 40

* Gram negative organisms e.g., pseudomonas aeruginosa * Fungi * Viruses

Question 41

Diagnosis/Treatment of Otitis Externa?

Answer 41

Treatment: • Topical Antibiotic Drops– Quinolones • Aural Packing – Ribbon Gauze/Pope’s Wick

Question 42

Answer 42

Question 43

OTITIS EXTERNA Red Flag Signs?

Answer 43

Question 44

**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 __________________.

Answer 44

**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**

Question 45

Malignant Otitis Externa: * Clinical Presentation * Investigations * Complications * Management

Answer 45

Question 46

**FURUNCULOSIS of the External Auditory Meatus**/ **Nasal vestibule** * Etiology? * Clinical Signs? * Treatment? * Complications?

Answer 46

Question 47

Facial nerve palsy in the presence of a head injury is pathognomonic for a ____________________.

Answer 47

Facial nerve palsy in the presence of a head injury is pathognomonic for a **temporal bone fracture**

Question 48

**Sudden onset sensorineural hearing loss** of _______ decibels or more over _______ frequencies that develops over _______ days or less. Prognosis?

Answer 48

**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

Question 49

Benign brain tumor arising from the 8th cranial nerve which occurs when Schwann cells grow too quickly

Answer 49

**ACOUSTIC NEUROMA (Acoustic/Vestibular Schwannoma)**

Question 50

**ACOUSTIC NEUROMA (Acoustic/Vestibular Schwannoma)** * Risk Factor * Symptoms * Treatment

Answer 50

_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

Question 51

TINNITUS Red Flag Signs?

Answer 51

Question 52

Causes of Tinnitus?

Answer 52

Question 53

The character of Tinnitus indicative of its pathology Unilateral: ______________ Pulsatile: ________________ Vertigo/Sensory Neural Hearing Loss: _____________

Answer 53

Unilateral: **Organic Pathology** Pulsatile: **Vascular Pathology** Vertigo/Sensory Neural Hearing Loss: **Meniere's**

Question 54

Central vs. Peripheral Vertigo?

Answer 54

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

Question 55

Causes of vertigo

Answer 55

* **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_

Question 56

Investigations for Vertigo

Answer 56

**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

Question 57

___________________ 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)?

Answer 57

**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**

Question 58

_______________________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?**

Answer 58

**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

Question 59

________________________________: Acute-onset (1-2 days) vertigo, nausea, vomiting, and gait instability in otherwise healthy patients. Mild symptoms persist for months * Pathogenesis? * Causes?

Answer 59

**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)

Question 60

Vestibular vs. Psychogenic dizziness * Duration? * Frequency? * Head Movement? * Ataxia? * Effect of Hyperventilation?

Answer 60

Question 61

Differences between Sensorineural and Conductive Hearing Loss? Causes of Each?

Answer 61

**Sensirineural** * Loss of intensity * Loss of clarity **Conductive**: * Loss of intensity * NO loss of clarity * Paracusis Willisi: patient hears better w/ background noise

Question 62

How does Weber's Test Work?

Answer 62

**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

Question 63

How does Rinne's Test Work?

Answer 63

**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**

Question 64

What is this condition called?

Answer 64

**Microtia**

Question 65

**Ottis Externa** * Microbiology? * Risks * Complications

Answer 65

Question 66

Microbiology of **Acute Otitis Media**?

Answer 66

_Causitive Organisms_: * Strep Pneuomia * Haemophilus Influenza * Moraxella Catarrhalis

Question 67

Management of **Recurrent Acute Otitis Media**?

Answer 67

**Ventilation Tubes (Grommits)** => 67% Reduction in Episodes Indicated if: * 3 in 6 Months * 4 in 12 Months

Question 68

Management of **Otitis media with Effusion (OME)**

Answer 68

**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)

Question 69

Complications of Anterior Inferior Myringotomy (Ventilation Tube / Grommet)?

Answer 69

**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

Question 70

________________: Paragangliomas originating in glomus cells of neural crest * Characteristics * Clinical Findings * Treatment

Answer 70

**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