Ear, Nose and Throat Flashcards
Define otitis media
Describes infection of the middle ear (Space between tympanic membrane and inner ear)
What often precedes otitis media?
Viral Upper Respiratory tract infections
What is the most common bacterial cause of otitis media? Give 2 other causes
Streptococcus pneumoniae (most common)
Other;
Haemophilus influenzae
Moraxella catarrhalis
Give 4 clinical features of otitis media
Otalgia (ear pain) (children may tug/rub ear)
Fever (50% of cases)
Hearing loss
Symptoms of upper airway infection (cough, coryza, sore throat)
Give 1 complication of otitis media
Tympanic membrane perforation (discharge from ear)
What investigation is used to diagnose otitis media? Give 3 possible findings
Otoscopy
Possible findings;
Bulging red tympanic membrane > Loss of light reflex
Opacification or erythema of tympanic membrane
Perforation with purulent otorrhoea
Give 3 features required for diagnosis of otitis media
Acute onset of symptoms (ear pain)
Presence of middle ear effusion (bulging, otorrhoea)
Inflammation of tympanic membrane (erythema)
When should antibiotics be prescribed in a case of otitis media?
If;
Symptoms last >4 days and are not improving
Systemically unwell (but not requiring admission)
Immunocompromise or high risk for complications
Younger than 2 with bilateral otitis media
Otitis media with perforation and/or discharge in canal
What antibiotic is given to treat otitis media? (plus penicillin allergy)
Amoxicillin (for 5-7 days)
Erythromycin/clarythromycin (if pen allergy or pregnant)
Give 4 possible complications of otitis media
Mastoiditis
Meningitis
Brain abscess
Facial nerve paralysis
Give 4 causes of otitis externa
Swimming (aka swimmers ear)
Infection - Staph aureus, pseudomonas aeuroginosa)
Seborrheic dermatitis
Contact dermatitis
Give 2 common bacterial causes of otitis externa
Staphylococcus aureus
Pseudomonas aeruginosa
Give 4 clinical features of otitis externa
Ear pain
Discharge
Itchiness
Conductive hearing loss (if ear becomes blocked)
Give 4 examination findings (otoscopy) for otitis externa
Erythema and swelling in the ear canal
Tenderness in ear canal
Pus or discharge in ear canal
Lymphadenopathy around neck/ear
Give 2 investigations useful to conduct in a patient with otitis externa
Otoscopy (direct examination)
Ear swab (identify causative organism)
How is mild otitis media treated?
Acetic acid 2% (EarCalm)
How is moderate otitis media managed?
Topical antibiotic + Steroid (Otomize spray)
Spray includes; Neomycin + Dexamethasone + Acetic acid
What is it essential to exclude before prescribing aminoglycosides (gentamycin and neomycin) when treating otitis externa? and why?
Exclude perforated tympanic membrane.
As aminoglycosides are ototoxic
How is otitis externa managed in patients with severe or systemic symptoms?
Oral flucloxacillin or clarithromycin
Define malignant otitis externa
A severe and life-threatening form of otitis media.
Infection spreads to bones of ear canal and skull, progressing to osteomyelitis of the temporal bone.
Give 3 risk factors for malignant otitis externa
Diabetes
Immunosuppressant medications (chemo)
HIV
What key feature indicates malignant otitis externa?
Granulation tissue at junction between bone and cartilage in the ear canal
How is malignant otitis externa managed? (3)
Admission under ENT team
IV antibiotics
CT/MRI head to assess extent of infection
Define vertigo
A false sensation that the body or environment is moving
Give 5 possible causes of vertigo
Viral labyrinthitis
Vestibular neuronitis
Benign paroxysmal positional vertigo
Meniere’s disease
Acoustic neuroma
How is benign paroxysmal positional vertigo characterised?
Sudden onset of dizziness and vertigo triggered by changes in head position.
What is the average age of onset for BPPV?
55
Give 2 presenting features of BPPV
Vertigo triggered by change in head position (turning over in bed)
Episodes lasting 10-20 seconds
Describe the pathophysiology of BPPV
Caused by calcium carbonate crystals being displaced into the semi-circular canals (most commonly the posterior semi-circular canal)
Crystals disrupt the normal flow of endolymph through these canals, causing vertigo.
What test is used to diagnose BPPV?
Dix-Hallpike manoeuvre
Involves moving pt’s head to trigger vertigo.
What can be used to treat BPPV?
Epley manoeuvre
What is vestibular neuronitis?
Describes inflammation of the vestibular nerve, usually due to viral infection
Name the 3 parts of the inner ear
Semi circular canals
Vestibule (middle section)
Cochlea
Give 4 clinical features of vestibular neuronitis
Recent history of viral upper resp infection
Recurrent vertigo attacks lasting hours/days
Nausea and vomiting
Horizontal nystagmus
What can be used to distinguish vestibular neuronitis from a posterior circulation stroke?
HiNTs exam
(Head Impulse, Nystagmus, Test of Skew exam)
How is vestibular neuronitis managed? (3)
Oral Prochlorperazine or Antihistamine (cyclazine or promethazine) (for mild cases)
Buccal or IM prochlorperazine (for rapid relief in severe cases)
Vestibular rehabilitation exercises (for chronic symptoms - sx dont improve after 1 week or resolve after 6 weeks)
Describe Meniere’s disease
Describes a disorder of the inner ear, characterised by excessive pressure and progressive dilation of the endolymphatic system (endolymphatic hydrops).
Causes recurrent attacks of vertigo, hearing loss, tinnitus and a feeling of fullness in the ear
What triad of symptoms is seen in Meniere’s disease?
Hearing loss (sensorineural)
Vertigo
Tinnitus
(Unilateral episodes)
What is the typical age of onset for Meniere’s disease?
40-50 years old
What type of hearing loss is seen in Meniere’s disease?
Sensorineural hearing loss (unilateral)
Give 4 clinical features of Meniere’s disease (inc triad)
Triad; Hearing loss, Vertigo, Tinnitus
Aural fullness
Nystagmus + Positive Romberg test
Episodes last minutes to hours
Give 3 history features of meniere’s disease
Symptoms resolve after 5-10 years
Majority of patients are left with a degree of hearing loss
Psychological distress is common
How is Meniere’s disease managed? (4)
ENT assessment required to confirm diagnosis
Patient should inform DVLA and cease driving until symptoms are controlled.
Acute attacks - Buccal/IM prochlorperazine
Prevention - Betahistine or vestibular rehabilitation exercises
Describe acoustic neuroma
Benign tumour of the Schwann cells surrounding the auditory nerve (vestibulocochlear) that innervates the inner ear
What nervous system are schwann cells found in? What is their function?
Peripheral Nervous System
Function; provide the myelin sheath around neurones
Where do acoustic neuroma’s commonly occur?
Cerebellopontine angle
Acoustic neuromas are usually unilateral. Bilateral acoustic neuromas indicate what?
Neurofibromatosis type II
Give 4 clinical features of acoustic neuroma
Unilateral sensorineural hearing loss
Unilateral tinnitus
Absent corneal reflex (CN V)
Dizziness or imbalance
If an acoustic neuroma is affecting CN VIII (vestibulocochlear), what symptoms will the patient likely have? (3)
Vertigo
Unilateral Sensorineural Hearing Loss
Unilateral Tinnitus
If an acoustic neuroma is affecting CN V (Trigeminal), what symptoms will the patient likely have?
Absent corneal reflex
If an acoustic neuroma is affecting CN VII (Facial), what symptoms will the patient likely have?
Facial palsy
What is the investigation(s) of choice used to diagnose acoustic neuroma? (2)
MRI of cerebellopontine angle
Audiometry (to assess hearing loss)
Describe Presbycusis
Age related hearing loss.
Describes a type of sensorineural hearing loss. Tends to affect high-pitched sounds first.
Hearing loss occurs gradually and symmetrically
Give 4 risk factors for Presbycusis
Increasing age
Family history
Loud noise exposure
Smoking
Define Quinsy
Peritonsillar abscess that develops as a complication of bacterial tonsillitis
Give 4 features of a Quinsy
Severe throat pain, which lateralises to one side
Deviation of uvula to the unaffected side
Trismus (difficulty opening mouth)
Reduced neck mobility
What bacteria most commonly causes Quinsy?
Streptococcus pyogenes (group A strep)
Why does Quinsy cause trismus? (Pain on opening mouth)
Due to inflammation of the pterygoid muscles
How is Quinsy managed? (3)
Urgent review by ENT specialist
Needle aspiration/incision and drainage
IV antibiotics (co-amoxiclav)
What lymph node is commonly affected in quinsy
Jugulodigastric lymoh nodes
What is considered to prevent recurrence of Quinsy?
Tonsillectomy
How many episodes of acute sore throat qualify a patient for tonsillectomy? (3)
7 or more in 1 year
5 per year for 2 years
3 per year for 3 years
Give 2 other indications for tonsillectomy (other than number of acute episodes)
Recurrent tonsillar abscesses (2 episodes)
Enlarged tonsils causing difficulty breathing, swallowing or snoring
Give 4 complications of tonsillectomy
Sore throat (where tonsillar tissue is removed, can last 2 weeks)
Damage to teeth
Post-tonsillectomy bleeding
Infection
Define labyrinthitis
Describes inflammation of the bony labyrinth of the inner ear, including the semi-circular canals, vestibule (middle section) and cochlear.
Inflammation is usually due to a viral upper resp infection.
Give 3 clinical features of Labyrinthitis
Acute onset vertigo
Hearing loss
Tinnitus
Give 1 feature seen in both labyrinthitis and vestibular neuronitis
Acute onset vertigo
Give 2 features seen in labyrinthitis but not in vestibular neuronitis
Hearing loss
Vertigo
Give 4 complications of tonsillitis
Otitis media
Quinsy (peritonsillar abscess)
Scarlet fever
Post streptococcal glomerulonephritis
What is the most common cause of tonsillitis?
Viral infection
What is the most common bacterial cause of tonsillitis?
Group A Streptococcus Pyogenes
Which tonsils are typically affected in tonsillitis?
Palatine tonsils
What is it important to examine in children presenting with tonsillitis? (2)
Ears - Otoscopy (tympanic membranes)
Cervical lymphadenopathy
Describe the Fever PAIN score for used to estimate whether tonsillitis is due to a bacterial cause
Fever - During last 24 hours
P - Pus on tonsils
A - Attended within 3 days of onset of symptoms
I - Inflamed tonsils
N - No cough/coryza
What Fever PAIN score warrants prescription with antibiotics?
Score >=4
What are the 1st and 2nd line antibiotics for bacterial tonsillitis?
1st - Penicillin V for 10 days (may be syrup in child)
2nd - Clarithromycin (if pen allergy)
What causes Ramsay Hunt Syndrome? How does it present?
Varicella Zoster Virus.
Presents as unilateral Lower Motor Neurone facial nerve palsy with a painful/tender vesicular rash in the ear canal, pinna and round the ear.
How is Ramsay Hunt Syndrome managed?
Acyclovir + Prednisolone + Lubricating eye drops
What is the most likely location of bleeding for a patient presenting with nosebleeds?
Little’s area (Kiesselbach’s plexus)
Give 5 common causes of nosebleeds
Nose picking
Colds/Sinusitis
Vigorous nose-blowing
Coagulation disorders (thrombocytopenia/Von willebrand disease)
Anticoagulant medications (Aspirin, DOAC, warfarin)
Name 3 medications that could increase the risk of nosebleeds
DOAC
Aspirin
Warfarin
Describe the acute non-pharmacological/surgical management of nosebleeds (3)
Sit up and tilt head forwards (avoids blood flowing towards airway)
Squeeze the soft part of the nostrils together for 10-15 mins
Spit out any blood in the mouth, rather than swallowing
If a nosebleed does not stop after 10-15 minutes, the nosebleed is severe, is bleeding from both nostrils or they are harmodynamically unstable, what are the treatment options? (2)
Hospital admission;
Nasal packing with nasal tampons or inflatable packs
Nasal cautery using silver nitrate sticks
What is it useful to prescribe after treating an acute nosebleed? and why?
Naseptin nasal cream (Chlorhexidine and neomycin) 4x per day for 10 days.
Reduces crusting, inflammation and infection
In whom is Naseptin nasal cream (chorohexidine and neomycin) contraindicated?
Patients with a peanut or soya allergy
What causes infectious mononucleosis (glandular fever)?
Epstein-Barr virus
What triad of symptoms is seen in infectious mononucleosis?
Sore throat
Lymphadenopathy (anterior and posterior triangles of neck)
Pyrexia
Give 4 clinical features of infectious mononucleosis (inc triad as 1)
Triad; Sore throat, Lymphadenopathy, Pyrexia
Splenomegaly
Malaise, anorexia, headacke
Hepatitis
Taking what can cause patients with infectious mononucleosis to present with a maculopapular, pruritic rash?
Taking amoxicillin/ampicillin
What test is used to diagnose infectious mononucleosis?
Monospot test (Heterophil antibody test)
NICE - Suggest FBC and Monospot test in 2nd week of illness to confirm diagnosis
Describe the management of infectious mononucleosis (3)
Rest during early stages, fluids and avoid alcohol
Simple analgesia for aches or pains
Avoid contact sports for 4 weeks after having glandular fever, to reduce risk of splenic rupture.
Define obstructive sleep apnea
Describes episodes of apnoea during sleep caused by collapse of the pharyngeal airway.
Give 4 risk factors of obstructive sleep apnoea
Male
Obesity
Alcohol
Smoking
Give 5 clinical features of obstructive sleep apnoea
Episodes of apnoea during sleep (reported by their partner)
Snoring
Morning headache
Daytime sleepiness/waking unrefreshed from sleep
Concentration problems
Severe cases of obstructive sleep apnoea can cause what? (2)
Hypertension
Heart failure
What scale is used to assess symptoms of sleepiness associated with obstructive sleep apnoea?
Epworth Sleepiness Scale
How is obstructive sleep apnoea managed? (4)
ENT referral/Specialist sleep clinic (sleep studies)
Lifestyle advice (stop alcohol/smoking, lose weight)
CPAP
Surgery - Uvulopalatopharyngoplasty (UPPP)
