Conditions

Question 1

Otitis Externa

Cause?
Symptoms/Signs?
Investigations?
Management?

Answer 1

Inflammation of the external ear, ‘swimmers ear’

Bacterial infections (S.aureus), fungal infections (p.aerugeniosa), swimming, warm weather, eczema or psoriasis, excessive earwax, ear syringing, middle ear infections

Itching, ear discharge, dulled hearing, pain, aural fulness

Otoscopy - erythema, oedema, exudate, pain with movement of tragus, pre-auricular lymphadenopathy.

Ear drops/spray - flumetasone and clioquinol (ciprofloxacij and dexamethasone).
If unsuccessful, consider ear wicks, ear canal cleaning, oral antibiotics.

Question 2

Noise induced hearing loss

Cause?

Answer 2

Hair cells are damaged and are unable to grow back. Vital for converting sound to electrical energy.

Question 3

Ménière’s Disease

Cause?
Symptoms?
Investigations?
Management?

Answer 3

Build up of fluid in the labyrinth

Average 2-4hrs for an attack
Dulled hearing, vertigo, tinnitus, aural pressure

Audiometry will show low frequency loss in one ear.

Short course of prochlorperazine to ease dizziness and vomiting,best taken when aura is felt.
Betahistine improves blood flow around the inner ear.
Limited research supporting improvements in diet and lifestyle e.g exercise and stopping smoking

Question 4

Acute Otitis Media

Cause?
Symptoms?
Treatment?

Children?

Answer 4

Presence of inflammation in the middle ear associated with an effusion

Middle ear becomes filled with mucus which then becomes infected by germs.

Otalgia, dulled hearing, fever, nausea, malaise, bulging of TM
If perforation of eardrum, pain relief suddenly.

Analgesia, E+D as normal, antibiotics NOT usually required as infection clears within 3 days. nasal/oral steroids may be offered if persistent in adults.
If antibiotic required, amoxicillin/erythromycin 5/7.

Children are vulnerable as the angle between the Eustachian tube and the wall of the pharynx is less acute so infected material can be transferred from the nasopharynx to the middle ear. H.influenzae, S.pneumoniae.
Admission if <3mnths with >38degrees OR if suspected complications like meningitis, mastoiditis, facial nerve paralysis

Question 5

Chronic Suppurative Otitis Media

Symptoms?
Treatment?

Answer 5

Chronic inflammation of the middle ear and mastoid cavity

Otorrhoea without otalgia or fever, conductive hearing loss. Severe: headache, vertigo, nystagmus, fever

Referral to ENT, advise to keep dry, don;t swab
Topical antibitoics, topical steroids

Question 6

Otitis Media with Effusion

Cause?
Symptoms?
Investigations?
Management?

Answer 6

‘glue ear’

Eustachian tube dysfunction. Fluid and negative pressure in the middle ear decreases mobility of TM and ossicles affecting hearing

Hearing loss, aural discharge, recurrent ear infections

Otoscopy- retracted and evidence of fluid within middle ear cavity, abnormal colour of TM

Spontaneous resolution is common after 2-3 months so active observation. Explore concerns regarding hearing or language development.
Autoinflation
Grommets - should stop functioning after 10 months.

Question 7

Dry Tympanic Perforations

Symptoms?
Investigations?
Management?

Answer 7

Perforation without secondary watery/bloody/ purulent ottorhea

Sudden hearing loss, earache, pain

Audiogram shows conductive hearing loss

Small perforations heal on their own, larger may require invasive surgical patching (myringoplasty).

Question 8

Mastoiditis

Symptoms?
Investigations?
Management?

Answer 8

Infection of mastoid air cells usually caused by acute otitis media.

Otalgia, swelling in mastoid region, ottorhoea, fever, headaches, irritability

Otoscopy- red and bulging tympanic membrane

IV antibiotics, myringotomy and mastoidectomy

Question 9

Cholesteatoma

Symptoms?
Investigations?
Management?

Answer 9

Secondary to ET dysfunction,

Painless, smelly ottorhoea, hearing impairment, recurrent otitis, tympanic membrane perforation, deep retraction pocket in the TM

If congenital, may be found incidentally on otoscopy - , or due to hearing loss.

CT imaging or MRI to consider soft tissue involvement

Mainstay is surgery - open is tympanomastoidectomy and closed is tympanoplasty.

Question 10

Referred pain to the ear

Answer 10

Nose & Sinuses - trigeminal nerve (Vb) e.g. sinus infection

Teeth and TMJ - trigeminal nerve (Vc)
e.g. tooth abscesses, cavities, impacted molars, TMJ dysfunction

Parotid Gland - trigeminal nerve (Vc) e.g. parotiditis

Tongue and Oropharynx - trigeminal nerve (Vc) and glossopharyngeal nerve
e.g. tonsillitis, pharyngitis, tumours of the oropharynx

Larynx and Laryngopharynx - vagus nerve
e.g. goitre, thyroid tumours, vocal cord cancers

Oesophagus - vagus nerve (X) e.g. GORDs

Cervical Spine - C2 and C3 spinal nerves
e.g. osteoarthritis, disc herniation, spinal stenosis

Question 11

Congenital Deafness

Causes ?
Symptoms?
Screening ?
Management?

Answer 11

CMV, alcoholism in mother, teratogenic drugs, Down’s, Alport’s

Not startled by loud noises, selective hearing, unresponsive to verbal cues, haven’t started to say recognisable words by 15 months.

AOAE - automated otoacoustic emission. Newborn hearing tests done when discharged. Earpiece with clicking sounds.

Hearing aids, cochlear implants, patient education, family support

Question 12

What further issues might arise when hearing loss happens in certain groups?

Answer 12

Childhood (e.g. congenital deafness or glue ear) –think about behaviour and educational issues.
In older age with dementia –think about difficulties in diagnosis and impact on confusion.
With visual impairment –think about communication

Question 13

Deviated Nasal Septum?

What is it?
Cause?
Symptoms?
Management?

Answer 13

Displacement of the nasal septum, making one of the nasal passages smaller. If this is severe, it can block a side of the nose making it difficult to breathe

Can be congenital but occurs often due to injury to the nose

Nasal obstruction, nosebleeds, facial pain, noisy breathing during sleep

Decongestants and antihistamines
Nasal dilators can also be used to prevent snoring, improving sleep
Surgery is required to correct a deviated septum

Question 14

Nasal Fracture

Cause?
Symptoms?
Management?

Answer 14

Trauma
Deviation of the nose, instability and crepitus, nasal obstruction, swelling or bruising, nosebleeds, nasal discharge

Need to ensure there is no haematoma or active bleeding
Use ice packs and take regular painkillers
Fracture usually heals within 2-3 weeks

Question 15

Vestibular Migraine
What is it?
Symptoms?
Management?

Answer 15

Nervous system disorder that causes repeated dizziness (or vertigo) in people who have a history of migraine symptoms. No known cause F>M

Headaches (not always present), dizziness (few mins) and balance problem, motion sensitivity, sensitivity to sound

MRI and hearing and balance tests to rule out other dx (menieres and stroke)
Abortive therapy to prevent attacks as they occur.
Triptans
Vestibular suppressants (lorazepam, promethazine, antihistamines)
Avoid triggers (alcohol, MSG common)

Question 16

Vestibulopathy
What? 
Cause? 
Symptoms? 
Management?

Answer 16

Bilateral vestibulopathy occurs when the balance portions of both inner ears are damaged

Mostly idiopathic (~50%) but next biggest cause is ototoxic drugs, such as gentamicin.

Symptoms include imbalance (worse in dark or uneven terrain) and visual disturbance- termed oscillopsia (only when head is moving). Vertigo is rare

Treat cause if possible but rare to find. Avoid vestibular suppressants and ototoxins. Vestibular rehabilitation speeds recovery. No sensory substitution devices are presently practical.
Vestibular suppressants include antihistamines, nsaids, antidepressants, benzos and verapamil

Question 17

Allergic Rhinitis
Symptoms?
Investigations?
Management?

Answer 17

Sneezing, rhinorrhoea/nasal congestion, itchy nose/palate, eyes – watery, itchy, red

History and examination usually sufficient but can use a skin prick test or a blood assay

Topical nasal antihistamines, oral antihistamines, topical intranasal steroids

Question 18

Nasal Polyps
What is it?
Cause?
Symptoms? 
Investigations?
Management?

Answer 18

Benign flesh swellings often found at the middle meatus (sometimes in sinuses). Ongoing inflammation in the nose can cause oedema of the nasal mucosa. Gravity causes the swelling to hang down.

Asthma, allergy to aspirin, cystic fibrosis and rare conditions of the nose

Nasal airway obstruction, nasal discharge – watery, green, blood tinged, post nasal drip, dull headaches, snoring and obstructive sleep symptoms, hyposmia or anosmia and reduced taste

Nasal Speculum, rhinoscopy, CT scans- severe

Management
Unilateral – malignancy? 2WW
Children – tested for CF

Functional endoscopic sinus surgery – gold standard -10 weeks.
Recurrence is common
Topical corticosteroids – nasal drops to shrink and nasal sprays daily to prevent recurrence

Question 19

Lymphadenopathy
Causes?
Investigations?
Management?

Answer 19

Infection (Most common): Tender & Mobile
Cancer: Hard, matted, non-tender

Investigations: FBC, Chest X-ray/CT, Biopsy

Infection: Antibiotics
Cancer: Surgery/Radio/Chemo

Question 20

BPPV
What is it?
Diagnosis?
Management?

Answer 20

Benign paroxysmal positional vertigo(BPPV) is an inner-eardisorder that is the most common cause of vertigo

Your doctor will look for nystagmus. They may ask you to lie on your back on a table with your head tilted back off it.This helps to see eye movements
Your doctor also will look to see if symptoms of dizziness happen when your eyesor head moves in a certain direction, and if doing so makes you dizzy for less than a minute - Dix-Hallpike

Epley Manouver
Canalith repositioning.You hold four positions for about 30 seconds, or until the symptoms go away.

Rare: Surgery

Question 21

Acute sinusitis

What is it?
Symptoms?
Management?

Answer 21

Follows a common cold, and is defined as an increase in symptoms after 5 days, or persistence of symptoms beyond 10 days, but less than 12 weeks. Sinusitis is defined as symptomatic inflammation of the paranasal sinuses.

Nasal blockage, nasal discharge (anterior/posterior nasal drip), facial pain/pressure (or headache) and/or reduction (or loss) of the sense of smell.
Other features suggestive (but not diagnostic) of acute sinusitis include:
Altered speech indicating nasal obstruction.
Tenderness, swelling, or redness over the cheekbone or periorbital areas.
Cough

Refer if other complications present e.g systemically unwell, periorbital complications etc. If admission unlikely, prescribe antibiotics (phenoxymethylpenicillin 500 mg, 4 times a day if not life threatening, co-amoxiclav 500/125 mg three times a day for 5 days if severe. If allergic to penicillin, erythromycin)
Don’t offer antibiotics if 10 days or less as likely to be viral cause, not bacterial commonly
If more than 10 days, high nasal corticosteroid - mometasone

Question 22

Chronic sinusitis

What is it?
Symptoms?
Investigations?
Management?

Answer 22

Refers to sinusitis that causes symptoms that last for more than 12 weeks.

Presence of nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip) with facial pain/pressure (or headache) and/or reduction (or loss) of the sense of smell, lasting for longer than 12 weeks without complete resolution.

Anterior rhinoscopy

Admission if severe or systemic infection. Consider nasal irrigation with saline solution to relieve congestion and nasal discharge. Consider a course of intranasal corticosteroids -mometasone or fluticasone - for up to 3 months, especially if there is suspicion of an allergic cause.

Question 23

Thyroid nodules

Causes?
Symptoms?
Management?

Answer 23

Overgrowth of normal thyroid tissue, thyroid cyst, chronic inflammation of the thyroid, multinodular goiter, thyroid cancer

Arrange an urgent referral to a thyroid surgeon or endocrinologist if there is:
An unexplained thyroid lump.
A thyroid mass associated with unexplained hoarseness or voice change.
A thyroid mass associated with cervical lymphadenopathy or supraclavicular lymphadenopathy.
Sudden onset of a rapidly expanding painless thyroid mass, significantly increasing in size over days and weeks.
A suspected thyroid nodule with other red flags or risk factors for malignancy.
A suspected thyroid nodule with associated compressive symptoms, such as breathlessness or dysphagia.

If not urgent referral, bloods. Do not arrange for neck scan as this could delay diagnosis.

Question 24

Meniere’s disease

What is it?
Symptoms?
Management?

Answer 24

Meniere’s disease is a disorder affecting the inner ear which can affect balance and hearing

Vertigo — at least two spontaneous episodes lasting 20 minutes to 12 hours.
Fluctuating hearing, tinnitus, and/or perception of aural fullness in the affected ear.
Hearing loss confirmed by audiometry to be sensorineural, low-to-mid frequency, and defining the affected ear on one or more occasions before, during, or after an episode of vertigo.

Advise that an acute attack of vertigo will normally settle within 24 hours in most people.
Advise people experiencing sudden attacks of vertigo to:
Keep medication readily accessible.
Consider the risks before undertaking activities such as operating dangerous machinery, using ladders or scaffolding, or going swimming.
Advise the person not to drive when they are dizzy, or if they might experience an episode of vertigo while driving.