ENT Flashcards
Describe epistaxis
Common
Anterior epistaxis accounts for 90% of all nosebleeds and usually involves Kiesselbach’s plexus. Usually unilateral and can be controlled with packing
10% are posterior and usually arise from a posterior branch of the spheopalatine artery, posterior epistaxis differs from anterior bleeding in that it is more severe and occurs mostly in adults with multiple co-morbidities
List causes of epistaxis
Local:
- Nasal or facial trauma
- URTI
- Nose picking
- allergies
- low home humidity
- nasal polyps
- foreign body in the nose
- environemental irritants
- nasopharyngeal mucormycosis
- traumatic internal carotid arteyr aneurysm
- chlamydial rhitis neonatorum
- neoplasm
- septal deviation
- surgery
Idiopathic
- habitual
- familial
Systeic
- Atherosclerosis of nasal blood vessels
- anticoagulants
- pregnancy
- barotrauma
- hereditary telangiectasai
- blood dyscrasis
- hepatic disease
- rupture of the internal carotid artery aneurysms
- DM
- alcholism
- chemo
- cocain
Discuss examination in epistaxis
- Identifying the source of the bleeding can be difficult
- patient should blow clots out of nose as a start
- 10-15 minutes of compression of the cartilagenous area of the nose with head tilited foward
- Nasal speculum opened vertically so as not to obscure the septum
Discuss management of epistaxis
Anterior -direct pressure -adrenaline or TXA soaked gauze -cophenylcaine spray -silver nitrate - do not use bilaterally -Nasal tampons -Rapid rhino Packing is uncomfortable and patient may require opiate medication to have procedure completed -- do not need prophylactic ABs - should not be left for more than 48 horus. - if bilateral pack should be admitted -elderly, resp distress, multiple comorbidities and unliteral packing should be admitted
Posterior: Suggested when bleeding continues despite appropriately plaed anterior nasal packing.
- Can use foley catheter - place 5-7 mls of water into the balloon once the foley has been passed into the posterior pharynx (should be able to visualise the catheter in the throat) than pull anterior ( do not use saline as it can crystalise)
- Double balloon - insert the device as far back into the airway as possible - inflate the posteior balloon, pull back anteriorly and inlfate the anterior balloon
Discuss Perichondritis
Presents as painful swelling and redness of the pinna with sparing of the lobules.
It may occur after
- minor trauma
- high chondral piercings
- Subperichondrial haematoma
- severe OM
It can lead to liquefaction necrosis of the cartilage and cause severe cosmetic deformity to the ear. The primary organisms is pseudomonas.
Urgent evaluation by ENT + ciprofloxacin 750mg BD for 1 week or if severe IV ticarcillin/clavulanate 3.1g IV Q6hourly
Swelling and redness of the pinna involving the lobule suggest pinna cellulitis and should be treated with fluclox
Discuss Perichondritis
Presents as painful swelling and redness of the pinna with sparing of the lobules.
It may occur after
- minor trauma
- high chondral piercings
- Subperichondrial haematoma
- severe OM
It can lead to liquefaction necrosis of the cartilage and cause severe cosmetic deformity to the ear. The primary organisms is pseudomonas.
Urgent evaluation by ENT + ciprofloxacin 750mg BD for 1 week or if severe IV ticarcillin/clavulanate 3.1g IV Q6hourly
Swelling and redness of the pinna involving the lobule suggest pinna cellulitis and should be treated with fluclox
Describe Ottits externa
Infection of the external auditory canal often caused by swimming, ear syringing or the use of cotton buds or hearing aids.
Bacterial OE is often caused by pseudomonas or staph. In about 10% of cases it is fungal such as aspergillus or candida
Clinical features
- severe otalagia
- discharge
- pain on traction of the pinna (this helps distinguish from OM)
- canal debris
- canal oedema
Suspect fungal in patients without water exposures or those who have used anti bacterial ototopicals and in those with recurrent OM (specifically t2dm)
Discuss treatment of OE
1) Removal of debri from the canal
- tissue spears
- suction under direct vision
2) assess whether the TM is intact
- fungal OE and cause TM rupture
- if TM not intact and voluminous purulent discharge suspect an acute or chornic supportive OM.
3) Antibiotic or antifungal drops
- If TM intact use sofradex (framycetin, dexamethasone, gramicidin)
- If fungal suspected use flumetasone + clioquinol 0.02%+1% drops x3 instilled into the affected ear for 7 days
- if marked swelling an otowic can be inserted.
Discuss DDX of OE
In diabetics, the elderly or immunocompromised patient with a discharging ear, consider malignent OE (skull base osteomyelitis) which can be fatal
Presentation includes
- dull earache especially at night
- pain on chewing
- persistent ear discharge
- treatment failure
The pathognomonic sign is granulation tissue in the floor of the ear canal. There may be associated CN palsies (7,9,12)
Describe OM
Presentation is with symptoms of an UTRI, severe otalgia and blocked sensation. It is clinically defined as a red bulging TM.
There will be no mobility of the tm on pneumatic otoscopy.
A TM perf may occur with otorrhoea
TUning fork demonstrates a conductive hearing loss with Weber lateralising to the affected ear.
MANAGEMENT
Initially manage with simple analgesia
Commence AB if bilateral or severe infection after 48 hours of observation or high risk groups or only hearing ear
If Abs are required give amoxacillin 500mg TDS for 5 days. If response inadequate uprgrade to augmentin duo forte.
If unresolving despite upgrade consider ENT for a grommet.
Describe OM
Presentation is with symptoms of an UTRI, severe otalgia and blocked sensation. It is clinically defined as a red bulging TM.
There will be no mobility of the tm on pneumatic otoscopy.
A TM perf may occur with otorrhoea
TUning fork demonstrates a conductive hearing loss with Weber lateralising to the affected ear.
MANAGEMENT
Initially manage with simple analgesia
Commence AB if bilateral or severe infection after 48 hours of observation or high risk groups or only hearing ear
If Abs are required give amoxacillin 500mg TDS for 5 days. If response inadequate uprgrade to augmentin duo forte.
If unresolving despite upgrade consider ENT for a grommet.
Discuss complications of OM
1) TM perf
2) suppurative labryinthitis
3) Mastoiditis with subperiosteal abcess
- present with swelling redness and tenderness over the mastoid with the pinna pushed foward
- refer to ENT for CT and IV ABs +- surgery
4) menigitis
5) Facial nerve palsy
6) otic hydrocephalous
7) petrous apicitis
8) cerebral abscess
9) venous sinus thrombosis
Discuss idiopathic sudden sensorineural hearing loss
Otologic emergency
The patient may wake and notice a sudden hearing loss or may present with a blocked ear unaware of hearing losee. THere is often associated tinnitus and mild disequilibrium.
Cause is unknown but may be vascular, viral or autoimmune. Consider Zoster otticus if there is otalgia or vesciles are seen on the pinna or in the canal
If tuning fork consistent with sudden sensorineural hearing loss the patient is commenced on emperically oral predinsolone 1mg/kg up to 60mg for 7 days then tapering. Urgent audiogram and ENT follow-up for the same or following day.
OPD MRI
60% of patient with SSNHL regain some hearing over time
List causes of LMN 7th palsy
Bells Ramsay hunt AOM Cholesteatoma Trauma (temporal bone fracture) Autoimmune conditions vascular conditions infections such as HIV, EBV and syphilis.
The following can cause sudden CN 7 palsy if there is a bleed into the mass-
- Parotid tumor
- Metastatic peruneural invasion
- facial schwannoma
Briefly discuss BOS fracture
Clinical signs include battles sign, racoon eyes and clear or bloody otorrhoea or rhinorrhoea with a halo sign on the bed sheet.
Anterior fractures mainly involve the cribriform plate. If there is also a dural tear this wull present with CSF rhinorrhoea. Do not insert NGT in this situation
Lateral fractures involve the temporal bone. Fractures that spare the otic capsule are more common and can include the ear canal, perforate the eardrum and disrupt the ossicles.
Otic capsule involving fractures are more likley to cause facial palsy, CSF otorrhoea, perilymphatic fistula and sensorineural hearing loss.
Complete facial nerve palsy after trauma of immediate onset requires urgent ENT decompression.
