Ear nose and throat Flashcards
Conductive hearing loss
- usually external and middle ear
- many causes curable by surgery
- Rhinne negative, so bone conduction better than air conduction
Causes
- wax (ceruminosis) - soften with olive oil drops then syringe with warm water
- otosclerosis
- otitis media
- glue ear
Sensorineural hearing loss
- affecting inner ear or auditory nerve/auditory pathway
- often permanent as hair cells have limited repair capabilities
- Weber test, sound localises to opposite side than affected
Causes of chronic
- accumulated environmental noise toxicity
- presbyacusis (age - high frequency lost first)
- inherited disorders
Causes of sudden
- needs URGENT ENT opinion, steroids may cure
- noise exposure
- gentamicin/toxin
- mumps
- acoustic neuroma
- MS
- stroke
- vasculitis
- TB
Tinnitus
- common, can be distressing -> depression and insomnia
- onset age 40-50, equal in M and F
- caused by inner ear damage and hearing loss (so then auditory cortex hyper-excitability), also wax, excess noise, head injury, otitis media, Menieres, anaemia, drugs eg aspirin, loop diuretics, aminoglycosides
Treatment
- 1st exclude serious causes eg acoustic neuroma (unilateral)
- cognitive therapy
- drugs limited effects
- masking with white noise generator
- hearing aids
- cochlear nerve section can resolve but at the cost of deafness
Benign paroxysmal positional vertigo
- vertigo lasting seconds, after head movement
- associated nausea and lightheadedness
- normal hearing!
- due to disruption of debris in semicircular canal of ears (canolithiasis)
- more common as older, female, head trauma
50% primary/idiopathic
50% secondary to head trauma, labyrinthitis, vestibular neuritis, Meniere’s
Hallpike manouvre - see nystagmus to diagnose
Epley manouvre to treat
Meniere’s disease
- vertigo that lasts minutes-hours in recurrent attacks
- also with sensorineural hearing loss, aural fullness and tinnitus
- due to increased pressure in endolymphatic system of inner ear, so vestibular membrane ruptures then reforms many times (each time baseline hearing and balance worsens)
- see positive Romberg’s test, test with audiometry
- manage with bed rest and reassurance in acute attacks, antihistamine if prolonged
- diuretics and low salt diet may help
Causes of vertigo by time
BPPV - seconds Meniere's - minutes-hours Labyrinthitis - days Vestibular migraine (aura then vertigo, no headache) Vestibular neuritis Post-traumatic vertigo
Acoustic neuroma
Should be called vestibular schwannoma!
- presents with unilateral sensorineural hearing loss, and vertigo later
- progressive episodes of dizziness
- slow growth rate, monitor with serial MRIs
- also ipsilateral CNV, VI, IX, X affected, then cerebellar
- signs of ICP rise late, indicate large tumour
Head and neck cancer
- alcohol and smoking always increase risk (+ genetics, diet, HPV)
- usually from squamous epithelium, agressive and locally destructive with mets to lymph
- 2x more in men
Presentation
- painless lump with nil else usually
- red flags - hoarse voice, dysphagia, unilateral tonsil enlargement, nose bleed or glue ear, unexplained pain, isolated cranial nerve palsy
Investigations
- fine needle aspiration (?SCC)
- core biopsy (?lymphoma)
- PET-CT (to find primary)
- dermatoscope (BCC vs SCC)
Central airway obstruction
- SOB, cough, haemoptysis, wheeze, stridor, ?hypoxia
Malignant causes
- primary intraluminal tumour
- airway invasion of tumour
- metastatic tumour
- compression from nearby tumour
Non-malignant causes
- lymphadenopathy - sarcoidosis, TB
- vascular - vascular ring, dilated aorta, aortic aneurysm
- excessive granulation tissue - after intubation / tracheotomy / lung transplant anastamosis
- benign tumours
- trauma - burns / smoke, airway haematoma
- infectious - TB, epiglottitis
- other - thyroid cyst/goitre, mucus plug, vocal cord paralysis
Ix
- CXR
- bronchoscopy
- CT chest
- MRI
- spirometry
Acute otitis media
= infection of middle ear
- common complication of viral respiratory illness, so common in children (>80% have by age 2)
Presentation
- ostalgia (pain)
- irritability, sleep disturbance
- fever
- URT symptoms
- on otoscopy - bulging tympanic membrane, with opacification/redness
Causes
- resp viruses - influenza, RSV, parainfluenza, adenovirus
- or URT bacteria - strep pneumoniae, h influenzae, moraxella catarrhalis
Management
- paracetamol/ibuprofen (self limiting usually)
- if no improvement by 3 days, co-amoxiclav
- beware complications - perforated tympanic membrane, mastoiditis, seventh cranial nerve palsy, sigmoid sinus thrombosis
Otitis externa
= inflammation/infection of ear canal
- is essentially eczema of ear canal - cellulitis of skin
- caused by Pseudomonas aeruginosa or Staph aureus (or trauma, chemical irritant, skin disease)
- common in age 7-12
- RFs - obstruction, humid environment, swimming, trauma, allergy, diabetes
Presentation
- ear pain
- tragal tenderness
- ear canal swelling and erythema on otoscopy
- itching
- decreased hearing
Management
- fluoroquinolone (ciprofloxacin, ofloxacin) ear drops
- analgesia paracetamol or ibuprofen
Stridor
Inspiratory - obstruction above vocal cords
(Expiratory - intrathoracic obstruction
Biphasic - subglottic or tracheal)
Obstruction from
- intra-lumen - foreign body, tumour, bilateral vocal cord palsy
- within wall - oedema from anaphylaxis, laryngospasm, tumour, croup, acute epiglottitis, amyloidosis
- extrinsic - goitre, oesophagus, lymphadenopathy, post-op
EMERGENCY if gas exchange compromised
Labyrinthitis
= inflammation of labyrinth in cochlea, usually from viral infection
Presentation
- rotational vertigo (room spin), dizziness
- nausea and vomiting
- sensorineural hearing loss, tinnitus
- nystagmus
- flu like symptoms
- preceding URTI common (so influenza, VZV, cytomegalovirus, MMR, HIV)
- bacterial rare, associated with chronic otitis media/meningitis
Management
- standard viral - vestibular suppressant (diazepam), antiemetic (promethazine, metoclopromide)
- bacterial otitis media (as above + topical abx)
Cholesteatoma
= accumulation of squamous epithelium and keratin debris involving the middle ear (skin cyst, but then locally erodes)
- benign, but may enlarge and invade and destroy adjacent ossicles ± mastoid
Presentation
- hearing loss, tinnitus
- ear discharge resistant to abx
- ostalgia
- facial nerve weakness / change in taste
- attic crust in retraction pocket on otoscope
RFs - middle ear disease, trauma, surgery, congenital abnormalities
Ix - CT scan of temporal bones, audiography
Mx - surgery to remove
Bell’s palsy
= acute unilateral palsy of facial nerve, with otherwise normal history and examination (diagnosis of exclusion)
- usually complete recovery in 6mo if untreated
Presentation
- single episode - ptosis, facial droop/paralysis
+ maybe dry eyes, pain, change in sense of taste, hearing sensitivity
- usually due to reactivation of HSV1 -> infection of Schwann cells, demyelination and neural inflammation
- in age 15-45 usually, high risk in late pregnancy
Mx
- prednisolone
- eye protection (glasses, artificial tears, tape eyes shut at night)
