Ear nose and throat Flashcards
Define vestibular schwannoma
BENIGN SLOW GROWING TUMOUR OF THE SUPERIOR VESTIBULAR NERVE
Benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear.
What are Schwann cells?
found in the peripheral nervous system and provide the myelin sheath around neurones.
Risk factors for vestibular schwannomas
Neurofibromatosis type II
Other names for vestibular schwannomas
acoustic neuroma
Cerebellopontine angle tumour
Symptoms of vestibular schwannomas
- Asymmetric hearing loss – unilateral (slow onset)
o If bilateral hearing loss = neurofibromatosis type II - Facial numbness
- Progressive episodes of dizziness
- Tinnitus (unilateral) +/- vertigo
- Sensation of fullness in the ear
- Difficulty localising sounds
- CN palsies – 5, 7 and 8 (forehead is not spared as it’s a LMN lesion)
- Cerebellar signs
Ix for vestibular schwannomas
- MRI of cerebellopontine angle
o Need to MRI all patients with unilateral tinnitus and deafness - Audiometry = sensorineural pattern of hearing loss
Mx for vestibular schwannomas
- Conservative – monitoring id there are no symptoms/tx is inappropriate
- Surgery – to remove the tumour
- Radiotherapy – to reduce tumour growth
Define benign paroxysmal positional vertigo (BPPV)
common cause of recurrent episodes of vertigo triggered by head movement. Is a peripheral cause of vertigo (problem in the inner ear, not the brain).
What causes BPPV
displacement of otoconia (crystals of calcium carbonate) in semi-circular canals. Happens due to: - Head injury - Idiopathic / ageing - Otosclerosis - Post viral
Symptoms of BPPV
- Sudden rotational vertigo for <30 seconds, provoked by head turning
o E.g., turning over in bed - Nystagmus
- Often occurs over several weeks, resolves and then reoccurs weeks/months later
- DOES NOT CAUSE hearing loss / tinnitus
diagnosis of BPPV
Dix-Hallpike manoeuvre
Treatment of BPPV
- Epley manoeuvre: moves the crystals in the semi-circular canals into a position that doesn’t disrupt endolymph flow
- Brandt-Daroff exercises – done at home to improve symptoms
- Beta-histamine
Define epiglottitis
paediatric condition. Cellulitis (inflammation and swelling) of the supraglottis (epiglottis) caused by infection, with the potential to cause airway compromise, surgical emergency. Classic symptoms: tripod position, drooling, high fever and a toxic appearance.
Common cause of epiglottitis
haemophilus influenza type B
[Vaccinated against, therefore epiglottitis is now rare. Be aware of children who have not had vaccines]
Symptoms of epiglottitis
- Sudden onset
- Continuous stridor
- Drooling
- Toxic – septic unwell appearance
- Sore throat / difficulty and painful swallowing
- Tripod position – sat forwards with hand on each knee
- High fever
- Muffled voice
- Scared / quiet child
Ix for epiglottitis
- Don’t perform if patient acutely unwell
- Lateral x-ray of neck = thumb sign / thumb print sign. Caused by the oedematous and swollen epiglottis. Neck x-rays also useful for excluding foreign body.
Mx for epiglottitis
- Do not distress the child
- Get senior paediatrician and anaesthetist
- Be prepared for intubation
- May require tracheostomy and ICU
- IV abx – ceftriaxone
- Steroids – dexamethasone
Where does the blood come from in epistaxis?
bleeding usually originates from Kiesselbach’s plexus, which is in Little’s area in the nose. This is an area of nasal mucosa at the front of the nasal cavity that contains lots of blood vessels. When the mucosa is disrupted and the blood vessels are exposed, they become prone to bleeding.
Management of acute epistaxis
- To manage an acute nosebleed
o Sit up and tilt head forwards
o Squeeze the soft part of the nostrils together for 10-15 mins
o Spit out any blood in the mount, don’t swallow - If bleeding doesn’t stop after 10-15 minutes
o Nasal packing using nasal tampons or inflatable packs
o Nasal cautery using silver nitrate sticks
What to prescribe after an acute nosebleed
o Naseptin nasal cream (chlorhexidine and neomycin) QDS, 10 days to reduce crusting, inflammation and infection (CI in peanut/soya allergy)
What is infectious mononucleosis
Caused by Epstein barr virus.
Also known as glandular fever, is a condition caused by infection with EBV.
Most people are infected with EBV as children, when it causes very few symptoms. When infection occurs in teenagers/young adults, it causes more severe symptoms.
Symptoms of infectious mononucleosis
- Fever
- Sore throat
- Fatigue
- Lymphadenopathy
- Tonsillar enlargement
- Splenomegaly (and splenic rupture rarely)
- Pharyngitis (sore throat)
- Petechiae in soft palate
- Rash – in response to amoxicillin or cephalosporins. Itchy rash.
- Signs of hepatitis – hepatomegaly / jaundice
Ix for infectious mononucleosis
- FBC – lymphocytosis
- LFTs – elevated
- Heterophile antibodies – takes up to 6 weeks for the antibodies to be produced. Not specific to EBV. Testa re 100% specific for infectious mononucleosis but not everyone produces heterophile antibodies and can take 6 weeks for them to be produced. To test for antibodies:
a. Monospot test – patient’s blood + blood from horses. Heterophile antibodies if present will react to the horse RBCs and give a positive result
b. Paul-Bunnell test – RBCs from sheep - EBV antibodies tests – target viral capsid antigen (VCA). IgM in acute infection, IgG suggest immunity developed.
Mx for infectious mononucleosis
- Self-limiting illness (2-3 weeks) – paracetamol and ibuprofen
- Avoid alcohol
- Avoid contact sports (risk of splenic rupture)
- Emergency surgery for splenic rupture
Complications of infectious mononucleosis
- Splenic rupture
- Glomerulonephritis
- Haemolytic anaemia
- Thrombocytopenia
- Chronic fatigue (can be fatigued for several months once infection cleared)
- Burkitt’s lymphoma (associated with EBV)
What is Ménière’s disease?
long term inner ear disorder that causes recurrent attacks of vertigo and symptoms of hearing loss, tinnitus, and a feeling of fullness in the ear.
Pathology for Meniere’s disease?
= excessive build up of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory glands. Increased pressure of endolymph = endolymphatic hydrops.
Presentation of Ménière’s disease
- Unilateral episodes of vertigo, hearing loss and tinnitus
- Vertigo
o Episodes that last for 20 mins to several hours
o Episodes happen in clusters over several weeks, followed by prolonged periods without vertigo
o Not triggered by movement or posture - Hearing loss
o Fluctuates at first associated with vertigo attacks
o Gradually becomes permanent
o Sensorineural hearing loss
o Unilateral
o Affects low frequencies first - Tinnitus
o Initially with episodes of vertigo before becoming permanent
o Unilateral - Fullness in the ear
- Unexplained falls without LOC – ‘Drop attacks’
- Imbalance
- Spontaneous nystagmus during acute attack – unidirectional
Diagnosis of Ménière’s disease
- Audiometry – low frequency sensorineural hearing loss which fluctuates
- Clinical diagnosis
Mx for Ménière’s disease
- For acute attacks = cyclizine / prochlorperazine
- Prophylaxis - betahistine
- Surgical = endolymphatic sac decompression
What is otitis externa?
= inflammation of the skin in the external ear canal. The infection can be localised or diffuse. Can spread to the external ear (pinna) and the tympanic membrane. Can be acute (<3 weeks) or chronic (>3 weeks).
Causes of otitis externa
Causative bacteria:
- Pseudomonas aeruginosa (gram -ve aerobic rod-shaped bacteria)
- Staph aureus
Other causes:
- Fungal – aspergillus or candida
- Eczema
- Seborrheic dermatitis
- Contact dermatitis
risk factors for otitis externa
Swimming
Trauma to ear canal - ear buds / earplugs
Ear wax removal
Symptoms of otitis externa
- Erythema and swelling in the ear canal
- Tenderness of the ear canal – pain on palpating the tragus or by pulling on the pinna
- Pus or discharge in the ear canal
- Lymphadenopathy in the neck / around ear
Management for otitis externa
- Mild = acetic acid 2% (ear calm)
- Moderate = topical abx and steroid (Neomycin, dexamethasone and acetic acid = otomize spray)
- Severe = oral abx (flucloxacillin/clarithromycin)
- Ear wick (sponge/gauze that contain topical treatments) – used if the canal is very swollen, left in for 48 hours
- Fungal = clotrimazole ear drops
What is malignant otitis externa
- Severe and life threatening form of otitis externa
- Infection spreads along bones surrounding ear canal and skull = osteomyelitis of the temporal bone of the skull
- Increased risk: DM, immunosuppressant medications, HIV
Presentation of malignant otitis externa
persistent headache, severe pain, fever, granulation tissue at the junction between the bone and cartilage in the ear canal
Management for malignant otitis externa
admit to hospital, IV abx, CT/MRI brain
Complications of malignant otitis externa
facial nerve damage, meningitis, intracranial thrombosis, death
Define otitis media
infection in the middle ear (between tympanic membrane and inner ear where the cochlear, vestibular apparatus and the nerves are found). Bacteria enters the middle ear via the back of the throat through the eustachian tube. Bacterial otitis media often preceded by viral URTI.
Classification of otitis media
- Acute – acute phase inflammation of middle ear
- Glue ear / otitis media with effusion (OME) – effusion after symptom regression
- Chronic – effusion >3 months if bilateral or >6 months if unilateral
- Chronic suppurative otitis media – painless ear discharge with hearing loss and evidence of tympanic membrane perforation on otoscopy. Abx and steroid ear drops. Complications = cholesteatoma.
Causative organisms of otitis media
- Streptococcus pneumoniae
- Haemophillus influenzae
- Viral
- Moraxella catarrhalis
- Staphylococcus aureus
Symptoms of acute otitis media
- Presentation
o Ear pain
o Reduced hearing in affected ear
o Generally unwell, fever
o Viral URTI – cough, coryzal symptoms, sore throat - O/e - Otoscopy – bulging red tympanic membrane
Mx of acute otitis media
o Paracetamol o Amoxicillin (clarithromycin if allergic) (can do delayed prescription – to collect after 3 days if symptoms haven’t improved)
Complications of acute otitis media
o Intra-temporal Otitis media with effusion Perforation of tympanic membrane – pain, reduced hearing and discharge Mastoiditis Facial nerve palsy o Intracranial Meningitis / encephalitis Brain abscess Sub or epi dural abscess o Systemic Bacteraemia Septic arthritis Infective endocarditis
Findings on examination of otitis media with effusion
Otoscopy - retracted dull tympanic membrane with fluid level
Causes of rhino sinusitis (sinusitis)
- Majority are bacterial infection secondary to viral infection
- Dental root infections
- Diving / swimming in infected water
- Deviated septum
- Polyps
- Systemic disease – primary ciliary dyskinesia, Kartagener’s, immunodeficiency
- Allergies – allergic rhinitis
- Obstruction of drainage – foreign body, trauma, polyps
- Smoking
Symptoms of acute sinusitis (<12 weeks)
o Recent viral URTI o Nasal congestion o Nasal discharge o Facial pain or headache o Facial pressure o Facial swelling over the affected areas o Loss of smell o O/e – tenderness to palpation of affected areas, inflammation of nasal mucosa, discharge, fever
Mx for rhinosinusitis
- No tx if symptoms last for up to 10 days
- If symptoms not improving after 10 days:
o High dose steroid nasal spray (mometasone)
o Delayed abx prescription (phenoxymethylpenicillin) - Chronic sinusitis
o Saline nasal irrigation
o Steroid nasal spray or drops (mometasone)
o Functional endoscopic sinus surgery – endoscope inserted through nostrils and any obstructions removed
Causes of tonsillitis
- Viruses (most common)
- Bacterial:
a. Group A streptococcus – streptococcus pyogenes (most common bacteria)
b. Streptococcus pneumoniae
c. Haemophilus influenzae
d. Moraxella catarrhalis
e. Staphylococcus aureus
Symptoms of tonsillitis
- Sore throat and pain on swallowing
- Fever
- Malaise
- Lymphadenopathy – anterior cervical lymphadenopathy (anterior triangle of neck) and tonsillar lymph nodes (behind the angle of the mandible)
- Inflamed tonsils and oropharynx
- Exudates – small white patches of pus on the tonsils
What part of the tonsils are affected by tonsillitis?
In waldeyer’s ring (ring of lymphoid tissue), there’s 6 areas. The area most effected is the palatine tonsils.
What criteria can be used to decide if tonsillitis is bacterial (and therefore requires abx)?
Centor criteria
FeverPAIN score
What is the centor criteria?
- Used to estimate the probability that tonsillitis is due to bacterial infection
- Score of 3+ = 40 to 60% probability of bacterial tonsillitis = give abx
- Point for each of the following:
o Fever over 38
o Tonsillar exudates
o Absence of cough
o Tender anterior cervical lymph nodes
What is the feverPAIN score?
- Alternative to centor criteria.
- A score of 2-3 gives a 34-40% of bacterial tonsilitis and a score of 4-5 gives a 62-65% chance
- Fever PAIN score:
o Fever – during previous 24 hours
o P = purulence (pus on tonsils)
o A = attended within 3 days of onset of symptoms
o I = inflamed tonsils
o N = no cough or coryza
Mx for tonsillitis
- Analgesia – NSAIDs, paracetamol, difflam
- Abx (if meeting centor >3 / FeverPAIN score >4)
a. Penicillin V (phenoxymethylpenicillin)
b. Clarithromycin if penicillin allergy - Tonsillectomy indications:
a. If recurrent tonsillitis
b. 5+ episodes / year
c. Symptoms for >1 year
d. Episodes are disabling and prevent normal functioning
e. Airway obstruction e.g., OSA in children
f. Quinsy
g. Suspicion of Ca
Complications of tonsillitis
Peritonsillar abscess (Quinsy) Retropharyngeal abscess Lemierre's syndrome Otitis media scarlet fever Rheumatic fever Post streptococcal glomerulonephritis Post streptococcal reactive arthritis
What is Quinsy? What are the symptoms, findings o/e and management?
- Peritonsillar abscess (Quinsy)
a. Typically occurs in adults
b. Symptoms = Trismus (restriction in ROM of jaw), odonophagia (unable to swallow saliva), halitosis
c. O/E - Unilateral tonsillar enlargement, contralateral uvula displacement, cervical lymphadenopathy
d. Mx: admit, IV abx, tonsillectomy
