Ear, Nose and Throat Flashcards
What is otitis externa and its most likely causative organisms?
Infection of the outer ear, external auditory meatus etc
Normally caused by pseudomonas aeurginosa or staphylococcus aureus
Can be acute (less than 3 months) or chronic (more than 3 months)
What can precipitate otitis externa?
Ear trauma
Excessive moisture e.g. swimming for a long time
Dermatitis
Hearing aids
Narrower canal
How does otitis externa normally present?
Otalgia + can refer + pinna and tragus tenderness
Otorrhoea - creamy and nasty smelling
Itching
Feeling of fullness
Onset over about 48 hours
How does the ear canal look in otitis externa?
Erythematous
Mild = normal diameter, mod = reduced diameter, severe = occluded
Creamy discharge
How does the tympanic membrane look in otitis externa?
In tact
Might not be able to see
What is the management for otitis externa?
Conservative - don’t get wet - ear plugs and tight swimming cap, blow dry on a low heat, can still fly
Medical - topic abx/anti-fungals +/- steroids
use empirical ones
Microsuction
Can wick if need to and will open up the canal over days
Swab if treatment resistant
What are the complications of otitis externa?
Malignant/necrotising otitis externa
Infection invades adjacent cartilage and bone leading to temporal bone destruction and osteomyelitis at the base of the skull
More common if immunosuppressed or an insulin dependant diabetic
Can also get a facial nerve palsy
Need IV abx in addition to topical
What is cauliflower ear?
A haematoma of the perichondrium within the pinna
How is cauliflower ear managed? What are the complications?
Drainage
Abx
Wear a scrum cap or something (this is a bad card)
What are the symptoms of a tympanic membrane perforation?
PAIN
? conductive hearing loss
What is the management of a tympanic membrane perforation?
Manage conservatively - watch and wait as should heal itself and keep dry
Doesn’t heal after 6 months = myringoplasty (repair it)
Why can the middle ear be counted as a continuation of the upper respiratory tract? Why is this significant?
Has the same epithelium (pseudostratified columnar)
Means they’re susceptible to the same organisms e.g. strep pneumoniae, h influenzae etc
Dysfunction of which structure is acute otitis media associated with?
Eustachian tube dysfunction
muffled hearing, pain, tinnitus, reduced hearing, a feeling of fullness in the ear or problems with balance may occur.
What are the risk factors for acute otitis media?
non-modifiable = More common in 1-4 year olds, craniofacial abnormality e.g. cleft palate
modifiable = passive smoking, nursery, formula feeding
How does acute otitis media normally present?
Rapid onset otalgia (often ear pulling in children)
Mucousy discharge from the ear
Fever +/- irritability
Often following a URTI
How will the tympanic membrane look in acute otitis media?
Erythematous
Bulging of the pars flaccida
Dilated vessels
What are the intracranial complications of acute otitis media?
Intracranial abscess
Meningitis
Sinus thrombosis
How should acute otitis media be managed?
Analgesia
Amoxicillin PO or Clarithromycin PO
What are the intra-temporal bone complications of acute otitis media?
Mastoiditis
Facial Nerve paralysis
What are the complications of acute otitis media relating to the ear?
Recurrence/ persistence with effusion
Labrynthitis
TM perforation
Conductive hearing loss (temporary)
Describe the intracranial route of the facial nerve
Arises from the pons
Internal acoustic meatus
Petrous part of temporal bone
Facial canal
Forms the geniculate ganglion then gives rise to 3 nerves: greater petrosal nerve, nerve to stapedius and Chordae tympani
Exits via the stylomastoid foramen
What is the function of the greater petrosal nerve? What happens if there’s a lesion
Parasympathetic fibres to mucous glands and lacrimal gland
Reduced tear production on ipsilateral side
What is the function of the nerve to stapedius? What happens if there’s a lesion?
Motor fibres to stapedius muscle of the middle ear
Lesion = ipsilateral hyperacusis
What is the function the chordae tympani? What happens if there’s a lesion?
Special sensory fibres to the anterior 2/3 tongue
Parasympathetic fibres to the submandibular and sublingual glands
Lesion = Dry mouth and loss of taste on the ipsilateral 2/3 of the tongue
Describe the extra cranial route of the facial nerve
Travels anteriorly to outer ear
Then through the parotid gland (but doesn’t innervate) where it splits into 5 branches (To Zanzibar By Motor Car)
Temporal Zygomatic Buccal Marginal Mandibular Cervical
What are the 5 branches of the facial nerve?
To Zanzibar By Motor Car!
Temporal Zygomatic Buccal Marginal mandibular Cervical
They innervate muscles of facial expression
How does otitis media with effusion differ to otitis media?
OME = fluid within the middle ear leading to Eustachian tube dysfunction and the tympanic membrane is still in tact
Most commonly presents with HEARING LOSS and no signs of acute inflammation (no pain)
Leads to conductive hearing loss (and ?developmental delay)
How does the tympanic membrane look on examination in OME?
Abnormal colour of the drum e.g. yellow
Loss of light reflex
More opaque
Air bubbles
Retracted or concave
What are the risk factors for developing OME?
Non-modifiable = congenital abnormalities e.g. down’s, CF, cleft palate
Modifiable = low socioeconomic group, parental smoking, frequent URTIs
What are the investigations to diagnose OME?
Tympanogram - Flat tracing with normal canal volume
Pure tone audiogram - Conductive hearing loss
How should OME be managed?
Actively monitor for 6-12 weeks as spontaneous resolution is common
Grommets can be inserted if appropriate. Can swim with them but diving not recommended
Hearing aids can be used if Grommets not appropriate
What are 4 complications of grommets?
Otorrhoea
Infection +/- bleeding
Tympanosclerosis
Perforation
What is chronic otitis media? How can you categorise it?
An ear with a TM perforation in the setting of chronic infections with associated hearing loss, otorrhoea, fullness, otalgia
Can categorise into squamous and mucosal and then into active and inactive
What is the difference between active and inactive squamous COM?
Active squamous disease = cholesteatoma (Develops from introduction of keratinised squamous cells into the middle ear following a perforation or retraction pocket)
Inactive squamous COM = retraction pocket which may develop into active disease
What is the difference between active and inactive mucosal COM?
Active mucosal disease = chronic discharge from the middle ear through a tympanic membrane perforation
Inactive mucosal disease = tympanic membrane perforation but no active infection/discharge
Develops following AOM with a perforation that doesn’t heal properly
How should COM be managed?
1) Medical management (no cholesteatoma, not know if cholesteatoma) - topical abx + aural toilet
2) Surgical - myringoplasty or mastoidectomy if cholesteatoma present (do this first if there is a known cholesteatoma)
What are the complications of COM?
Cholesteatoma
What are the complications of mastoid surgery?
Facial nerve palsy
Altered taste from damage to the chorda typani,
CSF leak
Tinnitus
Vertigo
What is a cholesteatoma?
An abnormal sac of keratinizing squamous epithelium and accumulation of keratin within the middle ear
Can move into the mastoid air cell spaces/surrounding structures
Peak age between 5-15 years old
Why is a cholesteatoma bad?
Locally destructive
Around the pars flaccida
Due to the release of lytic enzymes
How does a cholesteatoma normally present?
Persistent or recurrent discharge from the ear that is often foul smelling
An associated conductive hearing loss may also occur
Can progress to CN VII paralysis and vertigo (this is a sign of CNS involvement)
What is the management of a cholesteatoma?
Mastoidectomy
What hearing loss is associated with a cholesteatoma?
Conductive
What are the components that allow balance?
Peripheral and Central vestibular system
Proprioception
Sensation
Eyes/ Visual system
What makes up the peripheral vestibular system? Give 3 examples of diseases affecting
Semicircular Canals (Superior and Lateral)
Otolith organs
What makes up the central vestibular system? Give 4 examples of conditions affecting
Vestibular Nerve
Migraine
Cardiovascular disease
Multiple Sclerosis
Tumour (compresses)
What do the semicircular canals and otolith organs each detect?
SSCs = rotational movement
Otolith organs = linear movement
What is the definition of Benign Paroxysmal Positional Vertigo?
ACUTE, ROTATORY vertigo lasting SECONDS and triggered by CERTAIN HEAD MOVEMENTS
What is the supposed pathophysiology of BPPV?
Displacement of otoliths causes stimulation of the semicircular canals
How is BPPV diagnosed?
Dix-Hall-Pike Test
\+ve = nystagmus observed (have to watch for 30 seconds) -ve = central cause of vertigo
Important to ask which way things are moving too to differentiate from light headedness
Describe the nystagmus associated with BPPV
Latency - comes on within 2-20 seconds
Duration - lasts for 20-40 seconds
Direction - Rotary or horizontal BUT NOT VERTICAL
What are the important negatives to distinguish in a patient with suspected BPPV?
- Not prolonged periods of vertigo
- No speech/sensory/motor/visual deficits
- NO TINNITUS
- NOT VERTICAL NYSTAGMUS
What is the management of BPPV?
Usually self limiting so watch and wait
If doesn’t resolve within 4 weeks then do an Epley manoeuvre to try and displace the otoliths
Recovery for this can be up to 2 weeks
What are 3 absolute contraindications to the Hall-Pike test?
Recent neck trauma/ cervical fracture
Fracture of the odontoid peg
Cervical disc prolapse
What are 4 relative contraindications to the Hall-Pike test/
Morbidly obese
Recent stroke
Carotid Sinus syncope
Cardio bypass surgery in the past 3/12
What advice should be given to a patient with BPPV?
Don’t drive if you feel dizzy (but don’t usually have to notify the DVLA)
Tell employer if it’s a risk in the workplace e.g. you work on ladders or lots of heavy lifting
Can do home exercises (brandt-daroff)
What is the endolymphatic compartment?
A fluid filled compartment of the inner ear that coordinates balance and hearing
Balance = angular acceleration of fluid in the semicircular canals stimulate vestibular receptors in the endolymph
Hearing = fluid waves stimulate nerves
What is the pathophysiology behind Menieres disease?
Increased fluid in the endolymphatic compartment
How does menieres disease normally present?
Hearing = gradual sensorineural hearing loss that eventually becomes permanent. + unilateral tinnitus
Balance = episodes of vertigo that lasts hours and are no positional. Nystagmus always present during attacks
Other = aural fullness
How should Menieres disease be diagnosed?
Clinical diagnosis but should send for audiometry to confirm sensorineural hearing loss
What is the management of Menieres disease?
C = MDT + reduced salt and caffeine + signpost to Menieres society and NHS choices
M = acute = Prochlorperazine (vestibular sedative) and prophylaxis = Bethahistine (vasodilation of labyrinth) can also use thiazides
S = grommet insertion + gentamicin/dexamethasone OR Endolymphatic compression
Define vestibular neuritis
Inflammation of the vestibular nerve and ganglion, usually preceded by an URTI/viral infection
How does vestibular neuritis present?
Balance = sudden on set episodes of vertigo that last for 3-7 days and resolve gradually
Nystagmus = horizontal/h-torsional that deflects AWAY from the affected ear and reduces when vision fixes on a point
Associated nausea/vomiting/diarrhoea
Hearing is not affected (affected in labrynthitis)
What is the management of vestibular neuritis?
Supportive
Acute = prochlorperazine (vestibular sedative)
What is Ludwig’s angina?
Cellulitis which occurs on the floor of the mouth
Spreads within the fascial layers of the neck
Swelling pushes down on floor of mouth and can compromise airway
In which group of patient’s is Ludwig’s angina common?
Immunocompromised e.g. HIV, IVDU
Those with poor dentition - pericoronitis (inflammation surrounding a partially erupted wisdom tooth) can predispose
Which neural pathways can cause referred otalgia?
CN V
CN VII
CN IX
CN X
C2, C3
In which circumstance is otalgia a red flag?
In the absence of any ear signs is a red flag for head and neck malignancy
What is allergic rhinitis?
An inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens
How can allergic rhinitis be classified?
Seasonal - symptoms occur at the same time each year
Perennial - symptoms throughout the year
Occupational - symptoms follow exposure to work allergens
Remember to ask about triggers/when the symptoms specifically happen!!
What is the clinical presentation of allergic rhinitis?
Sneezy
Bilateral nasal obstruction
Post nasal drip
Clear snot
Nasal pruritus
What is the conservative management of allergic rhinitis?
Allergen avoidance
What is the medical management of allergic rhinitis?
1) mild to mod = oral/intranasal antihistamines
2) mod to severe or persistent = intranasal steroids
Topical nasal decongestants e.g. oxymetazoline
What are 2 problems with topical nasal decongestants?
Tachyphylaxis - if used for a long time then more is needed to achieve the same effect
Rebound hypertrophy of nasal mucosal upon withdrawal
What are the 2 main complications of tonsillectomies?
Pain (up to 6 days after)
Haemorrhage - primary within 6-8 hours (take straight back to theatre) or secondary within 5-10 days after + associated with infection
When should someone be urgently referred to investigate laryngeal cancer?
> 45
Persistent unexplained hoarseness
Unexplained neck lump
What are the typical features of labynthitis?
Recent viral infection
Sudden onset
N&V
Hearing might be affected
