content Flashcards
3 pathologies of outer ear
otitis externa
pinna haematoma
perichondritis
definition of otitis externa
inflammation of outer ear
history of otitis externa
- itchy, painful ear canal
- foul smelling discharge
tx for otitis externa
- microsuction
- steroid/abx drops (gentamicin + hydrocortisone)
- pope wicks
complications of otitis externa
necrotising/malignant otitis externa
perichondritis
epidemiology of necrotising otitis externa
older, male, diabetic
chronic otitis externa
tx of necrotising otitis externa
admit with IV long course (ceftriaxone)
common causative organism in necrotising otitis externa
pseudomonas
aetiology of pinna haematoma
shear force trauma
management of pinna haematoma
must be drained before it solidifies - haematoma separates the perichondrium from the underlying cartilage therefore can destroy cartilage
features of perichondritis vs pinna cellulitis
perichondritis = inflammation of cartilage in ear therefore lobe sparing
pinna cellulitis does not have lobe sparing and may have inflammation in pre-auricular area
complications of otitis media
mastoiditis
complication of mastoiditis
sigmoid sinus thrombosis
definition of cholesteatoma
build up of dead skin cells behind the tympanic membrane - trapped in that area and can affect nearby nerve
tx of cholesteatoma
urgent tympanoplasty
main cause of sudden onset sensorineural hearing loss
viral infection
tx of sudden onset sensorineural hearing loss
steroids (60mg pred PO) + PPI
?intratympanic steroid injections
causes of facial nerve palsy
Bell’s palsy (if no underlying disorder found)
parotid disease
varicella zoster
ear infection
tx of Bell’s palsy
steroids and aciclovir
tape down eyelid at night if can’t close it -> can get corneal ulceration
differentials for vertigo
stroke BPPV Meniere's vestibular neuritis viral labyrinthitis
presentation of BPPV
feeling of ‘vertigo’ on head movements
presentation of Meniere’s
‘vertigo’ and ear fullness and change in hearing
pathophysiology of BPPV
crystal build up in semicircular canals
tx of Meniere’s
prochlorperazine (acute)
beta-histidine (longer-term)
difference between vestibular neuritis and viral labyrinthitis
VN = inflammation of nerve, hearing not affected VL = inflammation of labyrinth, hearing affected
questions to ask in epistaxis
which nostril how long how often anticoagulation how they feel how much blood loss
management of epistaxis
- sit forward and pinch fleshy bit of nose ~20mins
- if still trickling => co-phenylcaine cotton wool +/- cautery if anterior
- if hosing or posterior, pack with rapid rhino
- then surgery
what to be concerned about in nasal fracture
septal haematoma
features of septal haematoma
blueberry/grape in nostril on septum
tx of septal haematoma
co-phenylcaine + drain with green needle
causes of peri-orbital cellulitis
pre-septal - insect bites - ENT procedures post-septal - sinus causes
examinations for peri-orbital cellulitis
- eye exam
- CN exam
- colour vision
- nasal exam
- flexi-nasoendoscopy
triangles of the neck
anterior: - submandibular - submental - carotid - muscular posterior: - supraclavicular - occipital
questions for throat history
difficulty swallowing pain on swallowing voice changes weight loss, night sweats bleeding from back of throat ear and nose symptoms chest pain
differentials for hoarse voice
benign:
- vocal cord nodules (bilateral)
- vocal cord polyps (unilateral)
- papillomas (HPV)
- muscle tension dysphonia
- reflux
- Reinke’s oedema
infectious:
- supraglottitis
- epiglottitis
neuro:
- recurrent laryngeal nerve palsy (trauma, MS, thyroid cancer, lung cancer)
malignant:
- SCC
benign causes of hoarse voice
- vocal cord nodules (bilateral)
- vocal cord polyps (unilateral)
- papillomas (HPV)
- muscle tension dysphonia
- reflux
- Reinke’s oedema
infectious causes of hoarse voice
- epiglottitis
- supraglottitis
neuro cause of hoarse voice
recurrent laryngeal nerve palsy
malignant cause of hoarse voice
squamous cell carcinoma
tx of tonsillitis
IV abx (ben pen) IV steroid one off
investigation to do in tonsillitis and why
LFTs
common cause is infectious mononucleosis (glandular fever)
what is a quinsy
peritonsillar abscess
tx of pinna cellulitis
flucloxacillin
questions for ear hx
pain (otalgia)
discharge (otorrhoea)
hearing loss
added sounds (tinnitus)
most common cause of bacterial tonsillitis
group a strep (strep pyogenes)
tx of tonsillitis from group a strep
penicillin v
most common cause of otitis media
strep pneumoniae
most common cause of rhinosinusitis
strep pneumoniae
causes of bacterial tonsillitis
- strep pyogenes
- strep pneumoniae
- haemophilus influenzae
- morazella catarrhalis
- staph aureus
6 areas of lymphoid tissue in the pharynx
- adenoid
- 2x tubal tonsils
- 2x palatine tonsils
- lingual tonsils
which tonsils are infected and enlarged in tonsillitis
palatine
peak ages of incidence of tonsillitis
age 5-10
age 15-20
examination in suspected tonsillitis
- throat exam looking for red, inflamed and enlarged tonsils +/- exudate
- otoscopy (ears) to visualise tympanic membrane
- palpate for cervical lymphadenopathy
what scores are used to determine the likely cause of tonsillitis
centor criteria
feverPAIN score
centor criteria in tonsillitis
score of 3+ indicates likely bacterial tonsillitis (give abx)
- fever >38
- tonsillar exudates
- absence of cough
- tender anterior cervical lymphadenopathy
feverPAIN score in tonsillitis
- fever during previous 24hrs
- pus on tonsils
- attended within 3 days of onset of symptoms
- inflamed tonsils
- no cough or coryza
mx of viral tonsillitis
- reassurance
- advise simple analgesia
- safety net: return if pain not settled after 3 days or fever above 38.3
when to prescribe abx in tonsillitis
centor = 3+
feverPAIN = 4+
consider in young infants, immunocompromised patients, those with significant comorbidity or hx of rheumatic fever
abx choice in tonsillitis
penicillin v - 10 day course
if penicillin allergic: clarithromycin
complications of tonsillitis
- chronic tonsillitis
- peritonsillar abscess (quinsy)
- otitis media
- scarlet fever
- rheumatic fever
- post-strep glomerulonephritis
- post-strep reactive arthritis
definition of a quinsy
peritonsillar abscess formed when bacterial infection traps pus and forms an abscess
usually after untreated/partially treated tonsillitis
presentation of quinsy
- sore throat
- painful swallowing
- fever
- neck pain
- referred ear pain
- swollen tender lymph nodes
- trismus (unable to open mouth)
- change in voice
common cause of quinsy
bacteria: strep pyogenes, staph aureus, haemophilus influenzae
mx of quinsy
refer to ENT for incision and drainage of abscess under GA
abx (co-amoxiclav)
may give dexamethasone
requirement for tonsillectomy
- 7+ episodes in 1 year
- 5 episodes per year for 2 years
- 3 episodes per year for 3 years
- recurrent quinsy (2x)
- enlarged tonsils causing difficulty breathing, swallowing or snoring
complications of tonsillectomy
- pain
- damage to teeth
- infection
- post-tonsillectomy bleeding (can be significant)
- risks of GA
what is found in the middle ear
bones: malleus, incus and stapes
what is found in the inner ear
cochlea
vestibular apparatus
nerves
pathophysiology of otitis media
bacterial infection of the throat/URT
bacteria enter the middle ear from the back of the throat through the eustachian tube
common causes of otitis media
strep pneumoniae
also: haemophilus influenzae, moraxella catarrhalis, staph aureus
presentation of otitis media
- ear pain
- reduced hearing
- symptoms of URTI: fever, cough, coryzal symptoms, sore throat, generally unwell
signs of otitis media on otoscopy
bulging, red, inflamed tympanic membrane
discharge in ear canal and hole in membrane if perforated
mx of otitis media
most will resolve in 3 days without abx
consider abx in children under 2 with bilateral otitis media, those with otorrhoea, immunocompromised or comorbid or systemically unwell
abx choice in otitis media
amoxicillin for 5 days
alternatives: erythromycin, clarithromycin
complications of otitis media
- otitis media with effusion
- hearing loss (temporary)
- perforation
- recurrent infection
- mastoiditis
- abscess
conditions associated with nasal polyps
asthma aspirin sensitivity infective sinusitis cystic fibrosis Kartagener's syndrome Churg-Strauss syndrome
presentation of nasal polyps
nasal obstruction
rhinorrhoea
sneezing
poor sense of taste or smell
mx of nasal polyps
referral to ENT for full examination
topical corticosteroids e.g. drops/nasal spray
explanation of Weber and Rinne test
Weber = tuning fork in middle of forehead, ask if it is louder on one side
- lateralizes to one side = conductive hearing loss in ipsilateral side or sensorineural hearing loss in contralateral side
Rinne = tuning fork against mastoid then air in front of ear
- air conduction should be louder than bone -> if bone conduction louder, conductive hearing loss
what is the result of a Weber test lateralizing to the right and Rinne’s test showing bone conduction louder on RHS
conductive hearing loss in right ear
- > lateralizing to RHS = conductive loss in RHS or sensorineural loss in LHS
- > bone conduction louder in RHS = conductive loss in RHS
mx of sudden onset sensorineural hearing loss
urgent referral to ENT
causes of sudden onset sensorineural hearing loss
idiopathic
vestibular schwannoma
contraindications for cochlear implant
- lesions of CN VIII or in brainstem causing deafness
- chronic infective otitis media, mastoid cavity or tympanic membrane perforation
- cochlear aplasia
mx of post-tonsillectomy haemorrhage
all cases need ENT assessment
- primary/reactionary (6-8hrs post-op) = immediate return to theatre
- secondary (5-10 days post-op) associated with wound infection = admission + abx
causes of gingival hyperplasia
- phenytoin
- ciclosporin
- calcium channel blockers
- AML
definition of chronic rhinosinusitis
inflammatory disorder of the paranasal sinuses and linings of the nasal passages lasting 12 weeks or longer
predisposing factors for chronic rhinosinusitis
- atopy
- nasal obstruction e.g. septal deviation, nasal polyps
- recent local infection
- swimming, diving
- smoking
presentation of rhinosinusitis
- facial pain: frontal pressure worse on bending forwards
- nasal discharge usually clear
- nasal obstruction: mouth breathing
- post-nasal drip
mx of chronic sinusitis
avoid allergen trigger
intranasal corticosteroids
nasal irrigation with saline
red flags of chronic sinusitis
unilateral symptoms
persistent symptoms despite compliance with 3 months of tx
epistaxis
features of thyroglossal cyst
- more common in <20yo
- midline, between isthmus of thyroid and hyoid bone
- moves upwards with tongue protrusion
- may be painful if infected
features of pharyngeal pouch
- commonly older men
- posteromedial herniation between thyropharyngeus and cricopharyngeus muscles, not usually seen
- if large, midline lump which gurgles on palpation
- dysphagia, regurgitation, aspiration, chronic cough, halitosis
differentials for neck lumps
- reactive lymphadenopathy
- lymphoma
- thyroid swelling
- thyroglossal cyst
- pharyngeal pouch
- cystic hygroma
- branchial cyst
- cervical rib
- carotid aneurysm
features of vestibular neuronitis
- recurrent vertigo attacks lasting hours or days
- nausea and vomiting
- horizontal nystagmus
- no hearing loss or tinnitus
- develops after viral infection
mx of vestibular neuronitis
- vestibular rehabilitation exercises for chronic symptoms
- buccal/IM prochlorperazine for rapid relief of severe symptoms
- short course oral prochlorperazine or antihistamine for milder
definition of sialadenitis
inflammation of the salivary gland likely secondary to obstruction by stone impacted in the duct
most common cause of malignant otitis externa
pseudomonas aeruginosa
risk factors for malignant otitis externa
- diabetes (90% of cases)
- immunosuppression
presentation of malignant otitis externa
- diabetic or immunocompromised
- severe, unrelenting, deep-seated otalgia
- temporal headaches
- purulent otorrhoea
- dysphagia, hoarseness +/- CN VII dysfunction
mx of malignant otitis externa
urgent referral to ENT
IV abx which cover pseudomonas
mx of tympanic membrane perforation
- should usually heal spontaneously in 6-8 weeks (avoid getting ear wet)
- common to prescribe abx if perforation follows acute otitis media
- myringoplasty if doesn’t spontaneously heal
definition of meniere’s disease
excessive pressure and progressive dilation of the endolymphatic system
features of meniere’s disease
- recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural)
- aural fullness or pressure
- nystagmus
- typically symptoms are unilateral but may become bilateral
prognosis of meniere’s disease
symptoms resolve in majority of pt after 5-10 years
majority are left with degree of hearing loss
mx of meniere’s disease
- ENT assessment to confirm dx
- inform DVLA
- acute attacks: buccal/IM prochlorperazine
- prevention: betahistine and vestibular rehab
definition of acoustic neuroma
tumour of the vestibulocochlear nerve, arising from the Schwann cells of the nerve sheath
bilateral acoustic neuroma is associated with
neurofibromatosis type 2
symptoms of acoustic neuroma and why
compression of local structures and associated symptoms:
- vestibular nerve = hearing loss and balance disturbance
- trigeminal and facial nerve = altered facial sensation and muscle movements
- cerebellum and brainstem
risk factors for acoustic neuroma
- high-dose ionising radiation to head and neck
- NF2
typical presentation of acoustic neuroma
- unilateral sensorineural hearing loss (normally progressive) +/- tinnitus
- dizziness and disequilibrium
- facial pain, numbness
- facial weakness
- headaches, nausea and vomiting
results of rinne and weber test in acoustic neuroma
- AC>BC bilaterally
- weber lateralises to unaffected ear
investigations in suspected acoustic neuroma
- hearing test including weber and rinne
- cranial nerve exam
- pure-tone audiometry
- MRI brain
mx of acoustic neuroma
- conservative - active observation
- microsurgery - rectosigmoid, translabyrinthine or middle fossa approach
- stereotactic radiosurgery
complications of acoustic neuroma
- hearing loss
- facial paralysis
- hydrocephalus
- compression of cerebellar peduncles, cerebellum, brainstem and CN IX-XI
causes of BPPV
- idiopathic
- head injury
- vestibular neuronitis
- labyrinthitis
- complications of mastoid/stapes surgery
risk factors for BPPV
- older age
- female
- meniere’s disease
- patients with migraines or anxiety disorders
causes of secondary epistaxis
- trauma
- intranasal drugs (decongestants, steroids, illicit)
- weather
- anatomical variants
- systemic causes
- tumours
step-wise approach to mx of epistaxis
- basic first aid: pinch soft cartilaginous portion of nose for ~20 mins
- rhinoscopy/endoscopy to localise source
- silver nitrate cautery
- anterior packing
- posterior packing (1st line for posterior bleeds)
- surgery: ligation of sphenopalatine, internal maxillary or anterior ethmoid arteries
- angiographic embolisation
