ENT Flashcards
What is otitis media
Infection in the middle ear
Most common bacterial cause of otitis media
The most common bacterial cause of otitis media is streptococcus pneumoniae. This also commonly causes other ENT infections such as rhino-sinusitis and tonsillitis.
Presentation of otitis media
Ear pain is the primary presenting feature of otitis media in adults.
It may also present with:
Reduced hearing in the affected ear
Feeling generally unwell, for example with fever
Symptoms of an upper airway infection such as cough, coryzal symptoms and sore throat
Why does otitis media sometimes cause balance issues and vertigo
Can infect and affect the vestibular system
Otoscope examination - otitis media
Bulging, red, inflamed looking membrane.
When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane.
Management of otitis media
Most resolve without abx within around 3 days
Simple analgesia for pain and fever
When should you consider immediate antibiotics for otitis media
Consider immediate antibiotics at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised.
When should you consider a delayed prescription for otitis media
Consider a delayed prescription that can be collected and used after three days if symptoms have not improved or have worsened at any time. This can be a helpful strategy in patients pressing for antibiotics or where you suspect the symptoms might worsen.
Appropriate antibiotics for otitis media
Amoxicillin for 5-7 days first-line
Clarithromycin (in pencillin allergy)
Erythromycin (in pregnant women allergic to penicillin)
Always safety-net, offering education and advice to patients on when to seek further medical attention.
Complications of otitis media
Otitis media with effusion Hearing loss (usually temporary) Perforated tympanic membrane (with pain, reduced hearing and discharge) Labyrinthitis (causing dizziness or vertigo) Mastoiditis (rare) Abscess (rare) Facial nerve palsy (rare) Meningitis (rare)
What is mastoiditis
Mastoiditis is inflammation of the mastoid antrum and the lining of the mastoid air cells.
Most common aetiology of mastoiditis
Children of school age following an untreated episode of acute otitis media or recurrent episodes
Risk factors for developing mastoiditis
Immunosuppression. Diabetes mellitus. Congenital defects of the middle and outer ear. Recurrent episodes of acute otitis media Cholesteatoma.
Clinical features of mastoiditis
Recent or concurrent acute otitis media in around 50% of cases.
Deep otalgia on the affected side in nearly all cases.
Recent loss of hearing (progressive) on affected side.
Generally unwell with young children often not eating or drinking as normal.
Key findings on examination in mastoiditis
Fever.
Usually bulging tympanic membrane with clear fluid level or perforation with purulent discharge from the ear.
Erythema and swelling over mastoid process behind the ear in up to 75% of cases.
Mastoid tenderness.
Cervical lymphadenopathy on affected side.
External ear may protrude forwards
Key IX for mastoiditis
CT scanning is quick and will demonstrate the extent of mastoid air cell opacification.
A CT scan with contrast can also identify intracranial infection and the extent of this.
MRI imaging is better for identifying intracranial infection and will give better detail of the soft tissues but struggles to see the bone in as much detail.
Antibiotic for mastoiditis
Ceftriaxone
How can mastoiditis cause facial nerve damage
If the infection enters the facial canal within the bone it can result in facial nerve damage and ipsilateral facial weakness (without forehead sparing due to the lower motor neurones being affected).
Most serious complication of mastoiditis
Meningitis.
Formation of a subdural empyema.
Intracerebral abscess formation.
Most common bacterial causes of otitis external
Pseudomonas aeurginosa
Staphylococcus aureus
Causes of inflammation in otitis externa
Bacterial infection Fungal infection (e.g., aspergillus or candida) Eczema Seborrhoeic dermatitis Contact dermatitis
Symptoms of otitis externa
Ear pain
Discharge
Itchiness
Conductive hearing loss if blocked
Examination findings in otitis externa
Erythema and swelling in the ear canal
Tenderness of the ear canal
Pus or discharge in the ear canal
Lymphadenopathy (swollen lymph nodes) in the neck or around the ear
Diagnosis of otitis externa
Otoscopy
Mx of mild otitis externa
Acetic acid 2% OTC (EarCalm)
Self-care measures for acute otitis externa
Avoid ear buds
Avoid swimming
Keep shampoo, soap, and water out of the ear when bathing and showering
Management of moderate otitis externa
Moderate otitis externa is usually treated with a topical antibiotic and steroid
Mx of fungal otitis externa
Clotrimazole ear drops
What is malignant otitis externa
Severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull.
It progresses to osteomyelitis of the temporal bone of the skull.
Risk factors for malignant otitis externa
Diabetes
Immunosuppressant meds(chemo)
HIV
What is a key finding in malignant otitis externa
Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along) is a key finding that indicates malignant otitis externa.
Mx of malignant otitis externa
Admission to hospital under the ENT team
IV antibiotics
Imaging (e.g., CT or MRI head) to assess the extent of the infection
Complications of malignant otitis externa
Facial nerve damage and palsy Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves) Meningitis Intracranial thrombosis Death
When should follow up for otitis externa be arranged
Symptoms have not fully resolved after 2 weeks of starting initial treatment.
Symptoms are severe and/or there is cellulitis spreading beyond the external ear canal
The person is immunocompromised and at risk of severe infection, depending on clinical judgement.
When does hearing impairment require thorough assessment immediately
Sudden onset hearing loss (over less than 72 hours) requires a thorough assessment to establish the cause.
Weber’s test result that indicates sensorineural hearing loss
In sensorineural hearing loss, the sound will be louder in the normal ear (quieter in the affected ear).
The normal ear is better at sensing the sound.
Weber’s test result that indicates conductive hearing loss
In conductive hearing loss, the sound will be louder in the affected ear.
This is because the affected ear “turns up the volume” and becomes more sensitive, as sound has not been reaching that side as well due to the conduction problem.
When the tuning fork’s vibration is transmitted directly to the cochlea, rather than having to be conducted, the increased sensitivity makes it sound louder in the affected ear.
What is a normal rinne test result
A normal result is when the patient can hear the sound again when bone conduction ceases and the tuning fork is moved next to the ear rather than on the mastoid process.
It is normal for air conduction to be better (more sensitive) than bone conduction. This is referred to as “Rinne’s positive”.
Rinne test result that indicates conductive hearing loss
An abnormal result (Rinne’s negative) is when bone conduction is better than air conduction. The sound is not heard after removing the tuning fork from the mastoid process and holding it near the ear canal.
Causes of sensorineural hearing loss
Presbycusis (age-related) Noise exposure Ménière’s disease Labyrinthitis Acoustic neuroma Neurological conditions (e.g., stroke, multiple sclerosis or brain tumours) Infections
Medications associated with sensorineural hearing loss
Loop diuretics (e.g., furosemide) Aminoglycoside antibiotics (e.g., gentamicin) Chemotherapy drugs (e.g., cisplatin)
Causes of conductive hearing loss
Ear wax Infection Effusion Eustachian tube dysfunction Perforated tympanic membrane Otosclerosis Cholesteatoma Exostoses
What is presbyacusis
It is a type of sensorineural hearing loss that occurs as people get older. It tends to affect high-pitched sounds first and more notably than lower-pitched sounds.
The hearing loss occurs gradually and symmetrically.
Risk factors for presbyacusis
Age Male gender Family history Loud noise exposure Diabetes Hypertension Ototoxic medications Smoking
What are patients with hearing loss more likely to develop
patients with hearing loss are more likely to develop dementia, and treating the hearing loss (e.g., a hearing aid) may reduce the risk.
Mx of presbyacusis
Optimising the environment, for example, reducing the ambient noise during conversations
Hearing aids
Cochlear implants (in patients where hearing aids are not sufficient)
Conductive causes of rapid-onset hearing loss
Ear wax (or something else blocking the canal)
Infection (e.g., otitis media or otitis externa)
Fluid in the middle ear (effusion)
Eustachian tube dysfunction
Perforated tympanic membrane
Causes of SSNHL
Idiopathic(90%) Meniere's disease Otoxic meds MS Migraine Stroke Acoustic neuroma
Diagnosis of SSNHL
Audiometry is required to establish the diagnosis. A diagnosis of SSNHL requires a loss of at least 30 decibels in three consecutive frequencies on an audiogram.
Mx of SSNHL
immediate referral to ENT for assessment within 24 hours for patients presenting with sudden sensorineural hearing loss presenting within 30 days of onset.
Idiopathic SSNHL may be treated with steroids
Purpose of Eustachian tube
The Eustachian tube is present mainly to equalise the air pressure in the middle ear and drain fluid from the middle ear.
What might Eustachian tube dysfunction may be related to
Eustachian tube dysfunction may be related to a viral upper respiratory tract infection (URTI), allergies (e.g., hayfever) or smoking
Presentation of Eustachian tube dysfunction
Reduced or altered hearing Popping noises or sensations in the ear A fullness sensation in the ear Pain or discomfort Tinnitus
Symptoms tend to get worse when external pressure changes and middle ear pressure cannot equalise to the outside pressure
IX for Eustachian tube dysfunction
May not be required if URTI/hayfever aetiology
Tympanometry
Audiometry
Nasopharyngoscopy
CT scan
Mx of eustachian tube dysfunction
No rx if URTI
Valsalva manoeuvre
Decongestant nasal sprays(short term only)
Antihistamines and a steroid nasal spray
Surgery
Otovent
Surgical options for mx of Eustachian tube dysfunction
Treating any other pathology that might be causing symptoms, for example, adenoidectomy (removal of the adenoids)
Grommets
Balloon dilatation Eustachian tuboplasty
What is otosclerosis
There is remodelling of the small bones in the middle ear, leading to conductive hearing loss
Otosclerosis aetiology
Combination of environmental and genetic factors, although the exact mechanism is not understood.
It can be inherited in an autosomal dominant pattern.
Presentation of otosclerosis
Age < 40 - hearing loss and tinnitus
Affects hearing of lower-pitched sounds more
Patient can experience their voice as being loud compared to the environment (due to bone conduction of their voice)
Mx of otosclerosis
Conservative, with use of hearing aids
Surgical(stapectomy or stapedotomy)
Main methods for removing excessive ear wax
Ear drops – usually olive oil or sodium bicarbonate 5%
Ear irrigation – squirting water in the ears to clean away the wax
Microsuction – using a tiny suction device to suck out the wax
Systemic conditions associated with tinnitus
Anaemia
Diabetes
Hypothyroidism or hyperthyroidism
Hyperlipidaemia
What is objective tinnitus
Refers to when the patient can objectively hear an extra sound within their head
Causes of objective tinnitus
Carotid artery stenosis (pulsatile carotid bruit) Aortic stenosis (radiating pulsatile murmur sounds) Arteriovenous malformations (pulsatile) Eustachian tube dysfunction (popping or clicking noises)
Red flags in tinnitus assessment
Unilateral tinnitus Pulsatile tinnitus Hyperacusis (hypersensitivity, pain or distress with environmental sounds) Associated unilateral hearing loss Associated sudden onset hearing loss Associated vertigo or dizziness Headaches or visual symptoms
General mx of tinnitus
Tends to improve or resolve over time
Treat underlying causes
Hearing aids
Sound therapy (adding background noise to mask the tinnitus)
Cognitive behavioural therapy
Most common peripheral causes of vertigo
Benign paroxysmal positional vertigo
Ménière’s disease
Vestibular neuronitis
Labyrinthitis
BPPV pathophys
caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals
Causes of BPPV
They may be displaced by a viral infection, head trauma, ageing or without a clear cause
Diagnosis of BPPV
Dix-Hallpike manoeuvre
Pathophys of meneiere’s disease
caused by an excessive buildup of endolymph in the semicircular canals, causing a higher pressure than normal, disrupting the sensory signals
Central causes of vertigo
Posterior circulation infarction (stroke)
Tumour
Multiple sclerosis
Vestibular migraine
Peripheral vs central vertigo presentation
Peripheral more sudden, shorter, tinnitus often present, coordination intact and nausea more severe
What is HINTS
HI – Head Impulse
N – Nystagmus
TS – Test of Skew
To distinguish between central and peripheral vertigo
Mx of peripheral vertigo
Prochlorperazine
Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
Betahistine may reduce attacks in meneiere’s disease
Antibiotics in otitis externa
Topical Ciproflox/dexamethasone 0.3%/0.1% ear drops
What are renal transplant patients matched based on
human leukocyte antigen (HLA) type A, B and C on chromosome 6. They don’t have to fully match. Recipients can receive treatment to desensitise them to the donor HLA when there is a living donor.
Incision associated with renal transplant
Hockey stick incision
Immunosuppressant regime for patients post renal transplant
Tacrolimus
Mycophenolate
Prednisolone
Complications relating to renal transplant
Transplant rejection (hyperacute, acute and chronic)
Transplant failure
Electrolyte imbalances
Complications relating to immunosuppression in renal transplantation
Ischaemic heart disease
Type 2 diabetes (steroids)
Infections are more likely and more severe
Unusual infections can occur (PCP, CMV, PJP and TB)
Non-Hodgkin lymphoma
Skin cancer (particularly squamous cell carcinoma)
