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EOY4 > Ear, Nose and Throat > Flashcards

Ear, Nose and Throat Flashcards

1
Q

What is otitis externa and its most likely causative organisms?

A

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)

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2
Q

What can precipitate otitis externa?

A

Ear trauma

Excessive moisture e.g. swimming for a long time

Dermatitis

Hearing aids

Narrower canal

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3
Q

How does otitis externa normally present?

A

Otalgia + can refer + pinna and tragus tenderness

Otorrhoea - creamy and nasty smelling

Itching

Feeling of fullness

Onset over about 48 hours

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4
Q

How does the ear canal look in otitis externa?

A

Erythematous

Mild = normal diameter, mod = reduced diameter, severe = occluded

Creamy discharge

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5
Q

How does the tympanic membrane look in otitis externa?

A

In tact

Might not be able to see

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6
Q

What is the management for otitis externa?

A

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

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7
Q

What are the complications of otitis externa?

A

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

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8
Q

What is cauliflower ear?

A

A haematoma of the perichondrium within the pinna

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9
Q

How is cauliflower ear managed? What are the complications?

A

Drainage

Abx

Wear a scrum cap or something (this is a bad card)

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10
Q

What are the symptoms of a tympanic membrane perforation?

A

PAIN

? conductive hearing loss

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11
Q

What is the management of a tympanic membrane perforation?

A

Manage conservatively - watch and wait as should heal itself and keep dry

Doesn’t heal after 6 months = myringoplasty (repair it)

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12
Q

Why can the middle ear be counted as a continuation of the upper respiratory tract? Why is this significant?

A

Has the same epithelium (pseudostratified columnar)

Means they’re susceptible to the same organisms e.g. strep pneumoniae, h influenzae etc

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13
Q

Dysfunction of which structure is acute otitis media associated with?

A

Eustachian tube dysfunction

muffled hearing, pain, tinnitus, reduced hearing, a feeling of fullness in the ear or problems with balance may occur.

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14
Q

What are the risk factors for acute otitis media?

A

non-modifiable = More common in 1-4 year olds, craniofacial abnormality e.g. cleft palate

modifiable = passive smoking, nursery, formula feeding

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15
Q

How does acute otitis media normally present?

A

Rapid onset otalgia (often ear pulling in children)

Mucousy discharge from the ear

Fever +/- irritability

Often following a URTI

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16
Q

How will the tympanic membrane look in acute otitis media?

A

Erythematous

Bulging of the pars flaccida

Dilated vessels

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17
Q

What are the intracranial complications of acute otitis media?

A

Intracranial abscess

Meningitis

Sinus thrombosis

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18
Q

How should acute otitis media be managed?

A

Analgesia

Amoxicillin PO or Clarithromycin PO

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19
Q

What are the intra-temporal bone complications of acute otitis media?

A

Mastoiditis

Facial Nerve paralysis

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20
Q

What are the complications of acute otitis media relating to the ear?

A

Recurrence/ persistence with effusion

Labrynthitis

TM perforation

Conductive hearing loss (temporary)

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21
Q

Describe the intracranial route of the facial nerve

A

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

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22
Q

What is the function of the greater petrosal nerve? What happens if there’s a lesion

A

Parasympathetic fibres to mucous glands and lacrimal gland

Reduced tear production on ipsilateral side

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23
Q

What is the function of the nerve to stapedius? What happens if there’s a lesion?

A

Motor fibres to stapedius muscle of the middle ear

Lesion = ipsilateral hyperacusis

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24
Q

What is the function the chordae tympani? What happens if there’s a lesion?

A

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

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25
Q

Describe the extra cranial route of the facial nerve

A

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
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26
Q

What are the 5 branches of the facial nerve?

A

To Zanzibar By Motor Car!

Temporal 
Zygomatic
Buccal
Marginal mandibular
Cervical

They innervate muscles of facial expression

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27
Q

How does otitis media with effusion differ to otitis media?

A

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)

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28
Q

How does the tympanic membrane look on examination in OME?

A

Abnormal colour of the drum e.g. yellow

Loss of light reflex

More opaque

Air bubbles

Retracted or concave

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29
Q

What are the risk factors for developing OME?

A

Non-modifiable = congenital abnormalities e.g. down’s, CF, cleft palate

Modifiable = low socioeconomic group, parental smoking, frequent URTIs

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30
Q

What are the investigations to diagnose OME?

A

Tympanogram - Flat tracing with normal canal volume

Pure tone audiogram - Conductive hearing loss

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31
Q

How should OME be managed?

A

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

32
Q

What are 4 complications of grommets?

A

Otorrhoea

Infection +/- bleeding

Tympanosclerosis

Perforation

33
Q

What is chronic otitis media? How can you categorise it?

A

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

34
Q

What is the difference between active and inactive squamous COM?

A

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

35
Q

What is the difference between active and inactive mucosal COM?

A

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

36
Q

How should COM be managed?

A

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)

37
Q

What are the complications of COM?

A

Cholesteatoma

38
Q

What are the complications of mastoid surgery?

A

Facial nerve palsy

Altered taste from damage to the chorda typani,

CSF leak

Tinnitus

Vertigo

39
Q

What is a cholesteatoma?

A

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

40
Q

Why is a cholesteatoma bad?

A

Locally destructive
Around the pars flaccida
Due to the release of lytic enzymes

41
Q

How does a cholesteatoma normally present?

A

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)

42
Q

What is the management of a cholesteatoma?

A

Mastoidectomy

43
Q

What hearing loss is associated with a cholesteatoma?

A

Conductive

44
Q

What are the components that allow balance?

A

Peripheral and Central vestibular system

Proprioception

Sensation

Eyes/ Visual system

45
Q

What makes up the peripheral vestibular system? Give 3 examples of diseases affecting

A

Semicircular Canals (Superior and Lateral)

Otolith organs

46
Q

What makes up the central vestibular system? Give 4 examples of conditions affecting

A

Vestibular Nerve

Migraine
Cardiovascular disease
Multiple Sclerosis
Tumour (compresses)

47
Q

What do the semicircular canals and otolith organs each detect?

A

SSCs = rotational movement

Otolith organs = linear movement

48
Q

What is the definition of Benign Paroxysmal Positional Vertigo?

A

ACUTE, ROTATORY vertigo lasting SECONDS and triggered by CERTAIN HEAD MOVEMENTS

49
Q

What is the supposed pathophysiology of BPPV?

A

Displacement of otoliths causes stimulation of the semicircular canals

50
Q

How is BPPV diagnosed?

A

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

51
Q

Describe the nystagmus associated with BPPV

A

Latency - comes on within 2-20 seconds
Duration - lasts for 20-40 seconds
Direction - Rotary or horizontal BUT NOT VERTICAL

52
Q

What are the important negatives to distinguish in a patient with suspected BPPV?

A
  • Not prolonged periods of vertigo
  • No speech/sensory/motor/visual deficits
  • NO TINNITUS
  • NOT VERTICAL NYSTAGMUS
53
Q

What is the management of BPPV?

A

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

54
Q

What are 3 absolute contraindications to the Hall-Pike test?

A

Recent neck trauma/ cervical fracture

Fracture of the odontoid peg

Cervical disc prolapse

55
Q

What are 4 relative contraindications to the Hall-Pike test/

A

Morbidly obese

Recent stroke

Carotid Sinus syncope

Cardio bypass surgery in the past 3/12

56
Q

What advice should be given to a patient with BPPV?

A

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)

57
Q

What is the endolymphatic compartment?

A

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

58
Q

What is the pathophysiology behind Menieres disease?

A

Increased fluid in the endolymphatic compartment

59
Q

How does menieres disease normally present?

A

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

60
Q

How should Menieres disease be diagnosed?

A

Clinical diagnosis but should send for audiometry to confirm sensorineural hearing loss

61
Q

What is the management of Menieres disease?

A

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

62
Q

Define vestibular neuritis

A

Inflammation of the vestibular nerve and ganglion, usually preceded by an URTI/viral infection

63
Q

How does vestibular neuritis present?

A

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)

64
Q

What is the management of vestibular neuritis?

A

Supportive

Acute = prochlorperazine (vestibular sedative)

65
Q

What is Ludwig’s angina?

A

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

66
Q

In which group of patient’s is Ludwig’s angina common?

A

Immunocompromised e.g. HIV, IVDU

Those with poor dentition - pericoronitis (inflammation surrounding a partially erupted wisdom tooth) can predispose

67
Q

Which neural pathways can cause referred otalgia?

A

CN V

CN VII

CN IX

CN X

C2, C3

68
Q

In which circumstance is otalgia a red flag?

A

In the absence of any ear signs is a red flag for head and neck malignancy

69
Q

What is allergic rhinitis?

A

An inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens

70
Q

How can allergic rhinitis be classified?

A

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!!

71
Q

What is the clinical presentation of allergic rhinitis?

A

Sneezy

Bilateral nasal obstruction

Post nasal drip

Clear snot

Nasal pruritus

72
Q

What is the conservative management of allergic rhinitis?

A

Allergen avoidance

73
Q

What is the medical management of allergic rhinitis?

A

1) mild to mod = oral/intranasal antihistamines
2) mod to severe or persistent = intranasal steroids

Topical nasal decongestants e.g. oxymetazoline

74
Q

What are 2 problems with topical nasal decongestants?

A

Tachyphylaxis - if used for a long time then more is needed to achieve the same effect

Rebound hypertrophy of nasal mucosal upon withdrawal

75
Q

What are the 2 main complications of tonsillectomies?

A

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

76
Q

When should someone be urgently referred to investigate laryngeal cancer?

A

> 45

Persistent unexplained hoarseness

Unexplained neck lump

77
Q

What are the typical features of labynthitis?

A

Recent viral infection

Sudden onset

N&V

Hearing might be affected

EOY4 (22 decks)

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