ENT Flashcards
what is a cholesteatoma?
an abnormal accumulation of stratifies keratinising squamous epithelium growing in middle ear
what are the symptoms of a cholesteatoma?
- purulent otorrhea
- hearing loss
- headache
- vertigo (red flag)
- possible facial nerve palsy (red flag)
what causes a cholesteatoma/
- eustachian tube dysfunction = chronic negative pressure in middle ear
what are the signs of a cholesteatoma?
- ear discharge
- perforation of the tympanic membrane
- on otoscopy (yellow pus + keratin behind pars flaccida and lack of landmarks e.g. handle of malleus)
what is the main complication of a cholesteatoma?
- a facial nerve palsy
- bone erosion
- meningitis
- cerebral abcesses
what is the management of a cholesteatoma?
- canal wall up mastoidectomy (surgery)
why does the pars flaccida invert in early signs of a cholesteatoma?
due to pressure differences tympanic membrane is pulled and pars flaccida is weakest part of tympanic membrane
what is the presentation of acute sinusitis?
nasal blockage or nasal discharge with facial pain/pressure (or headache) and/or reduction of the sense of smell
*persistence of symptoms beyond 10 days, but less than 12 weeks.
how would you examine a patient to confirm a diagnosis of sinusitis?
inspect and palpate maxillofacial area to elicit swelling and tenderness
perform anterior rhinoscopy (=nasal inflammation, mucosal oedema, and purulent nasal discharge OR nasal polyps / septal deviaton )
Recording pulse rate, BP, and temp if person is systemically unwell.
how woudl you if acute sinusitis is bacterial or viral?
bacterial:
- symptoms last mroe than 10 days
- Discoloured or purulent nasal discharge
- Severe local pain
- A fever greater than 38°C.
- A marked deterioration after an initial milder form of the illness .
- Elevated ESR/CRP
what are the normal causes of referred pain to the ear?
- TMJ pain
- temporal arteritis
- dental pain
- pharyngitis, tonsilitis
- ramsay hunt syndrome (shingles)
- malignant otitis externa (osteomyelitis of the bone)
- bells palsy
- cellulitis / perichondritis
what can cause congenital deafness?
- preeclampsia
- gestational diabetes
- infections e.g. rubella, herpes simplex
- premature birth/low birth weight
- drug and alcohol use while pregannt
- genetic cuases e.g. down syndrome, Treacher Collins syndrome, Waardenburg syndrome
what treatment is given for congenital deafness?
Hearing aids
Cochlear implants – electrically stimulates the cochlear nerve
Grommets
If hearing can’t be improved, families and their children are taught to use sign language
what is menieres disease?
disorder affectign inner ear which can affect balance and hearing
what are the signs and symptoms of menieres disease
- fluctuating hearing loss
- episodes of vertigo
- tinnitus
- fullness in ear
- headach e
- dizziness
- N+V
what are the causes of menieres diseasE?
poor fluid drainage in your ear an autoimmune disease allergies a viral infection, such as meningitis a family history of Ménière's disease a head injury migraines
how do you diagnose menieres disease based on symptoms?
a least 2 sponteaneous episodes of vertigo lasting 20mins -12 hours
fluctuating hearing loss, tinnitus and feeling of fullness in affected ear
sensorineural hearign loss determined by audiometry
must refer to ENT to confirm diagnosis
what investigations are doen to diagnose menieres disease?
Head adn neck examination audiogram Rombergs and unterbergers balance tests MRI Bloods - FBC,U&E's, TFT's, Lipid profile, Syphilis screen
what is the management of menieres disease?
to alleviate N+V and vertigo give prochlorperazine
avoid possible triggers (high salt diets, caffeine, excessive fatigue, stress, allergies, chocolate and alcohol)
medical ablation
for severe symptoms - IV labyrinthine sedatives + hydration
surgery - labyrinthectomy (only if have very little hearing left in affected ear)
what is presbycusis
age related hearing loss
usually bilateral, sensorineural hearing loss
what are the signs of presbycusis?
- diffuculty hearing others
- frequently asking people to repeat thigns
- listenign to music / tv at v high volume
= difficulty hearing on phone - finding it hard to keep up in convos
- feeling tired/ stressed havign to concnetrate in a convo
what investigatiosn need to be done to be diagnose menieres disease?
- webers and rinnes (sensorineural hearing loss)
- audiometry
- otoscope
what is the management of presbycusis?
- treat other causes (impacted wax, middle ear infection or effusion)
- hearing aids
- assisted hearign devies
- implantable devices
- learning to lip read
- emotional support
what is noise related hearing loss (NRHL)
cell death and damage to sterocilia in cochlear due to loud noises (repeated or one loud noise)
what are teh clinical features of NRHL?
- feelign of fullness in affected ear
- reduced hearing is affected ear
- tinnitus
what would webers and rinnes test show in people with NRHL?
webers - sensorineural hearing loss (sound lateralises to normal ear)
rinnes test is normal
what is the managemetn of NRHL?
protect ears from loud noise e.g. wear earplugs/headphones
hearing aids
possibly cochlear implants if v bad
what is otitis externa?
infection of the outer ear canal
what are the symptoms of otitis externa?
- itch in ear canal
- ear pain
- hearing loss due to external canal occlusion
- ear discharge
waht are teh signs of otitis externa on otoscope?
ear canal = red and oedematous
tympanic membrane erythema (usually hard to see as blocked by oedema dn discharge in ear canal)
conductive hearing loss (slight)
what is the managemtn for otitis externa?
- avoid damage to ears + keep them clean and dry
- paracetamol/ibuprofen
- acetic acid spray 2% or otimize
- consider topical ABX (gentamicin) with/wihtout topicl corticosteorid fro 7-14 days
- if immunocomprimised then consider prescribing oral ABX
what is acute otitis media?
acute otitis media is a middle ear ifnecton that most commonly affects children
what are teh signs an symptoms of acute otitis mediia?
Ear pain
Temperature
hearing loss slightly
Erythematous, bulging tympanic membrane seen on otoscope
Perforated tympanic membrane in some (feelign of releives pressure and pain and discharge occurs after)
management of acute otitis media?
mostly viral so patients will get better within 3 days to a week
ABX can be given if symptoms worseing over 24-48 hrs or patient severly unwell or has infection in both ears (5-7 days amoxicillin)
pain relief !!
what is mastoiditis?
a serioud bacteral infection that affects teh mastoid bone - usually a complication from otitis media
what are teh signs and symptoms of mastoiditis?
redness, tenderness and pain behind ear swellign behind ear makes ear stick out disahcrge from ear high temp and hearign loss recurrent ear infection facial weakness Erythematous, bulging, cloudy appearance, of tympanic membrane – sometimes perforated
what is the managment of mastoiditis in primary care?
urgent referral to ENT and hospital admission -> reciveve IV ABX
what is chronic suppurative otitis media?
it is a chronic infalmmaation fo middle ear and mastoid bone due to complcation of acute otitis media
what are teh clinical features of chronic suppurative otitis media?
recurrent discharge without pain or fever
possible hearign loss
history of acute otitis media with tympanc perforation
what assessment need to be done is suspected chronic suppurative otitis media
checking for tenderness, facial paralysis, vertigo ,signs and symptoms of intracranial infection
id chronic suppurative otitis media is supected, what do you do?
refer to ENT specialist immedietely
if sign of infection beyonf ear then admit
what are the causes of a dry tymapnic perforation?
- unknown
- q tip trauma
- infection
what are teh symptoms of a dry perforate tympanic membrane?
sudden hearing loss (conductive) itching in ear otalgia / ear ache high temperature tinnitus
what is teh managemnt for a dry perforated tympanic membrane?
- shoudl heal with treatment in a few weeks
- may need ABX if sign of infection
+ keep ear dry, refraining from cleaning ears, avoid blowing nose
ear patch or surgery needed if perforation doesnt heal by itself
what are teh symptoms of acute otitis media?
- hearign loss
- otalgia with fullness or popping may occur
- aural dischrge
what are teh signs of otitis media with effusion on otoscopy?
usually no signs of inflammation or discharge
Abnormal colour of the drum, such as yellow,
Air bubbles or an air/fluid level.
A retracted tympanic membrane
waht is teh managment fo otitis media with effusion
Active observation for 3 months is appropriate for most children, as spontaneous resolution is common - if signs and sympotms persist then refer to ENT
autoinflation equilibrating the middel ear pressure and draining fluid
possible hearign aids
grommets
what is acute sinusitis
short term inflamamtion of the nasal membrnaes and sinuses
= difficulty drianing mucus from your nose and sinuses
what are the clinical features of sinusitis?
- nasal blockage or nasal discharge
- facial pain and/or loss of smell
whats the examination of a person with sinusitis?
- inspect/palpate maxillofacial areas for swelling/tenderness
- anterior rhinoscopy to identify nasal inflammation, mucosal oedema and pruluent nasal discharge
when would you suspect acute bacterial sinusitis over viral sinusitis?
- sympotms for more than 10 days
- disccoloured or prurulent discharge
- sevre local pain
- fever
what is the management of acute sinusitis?
viral (takes 2-3 weeks to resolve)
steroid nasal sprays
antihistamines
what is acute labyrinthitis?
inflammation fo teh inner ear usually following an infection
what are teh clinical features of acute labyrinthitis?
- dizziness/vertigo
- poor balance
- nausea or vomiting
- hearing loss
- tinnitus
what investgations need to be doen to diagnose labyrinthtis?
head impulse test - nystagmus
what is teh managment of acute labyrinthtitis?
cause is usually viral
- bed rest
- anithistaminea
- short course antiemetics (metoclopramide)
- vestibular rehab (physio)
what is chronic sinusitis?
long term inflammation of nasal membranes and sinuses lasting for longer than 12 weeks without resolution
what is the management of chronic sinusitis?
- inform the person than chronic sinusitis may last several months
- consider nasal irrigation
- ocnsider intranasal corticosteroids for up to 3 months
- adivce on avoiding allrgic triggers, stop smoking, good dental hygeine, avoid udnerwater diving
what are the clinical featues of a thyroid nodule?
- solid or fluid filled lump
- smooth margin
- ovoid or flat shape
- difficulty swallowing
- hoarseness or other voice changes
- pain in neck
what investigations need to be done to diagnose a thyroid nodule?
- arrange TFTs
- routien endorcrinology referral
what is the management for a thyroid nodule?
monitor in primary care if:
- Hx of longstanding unchanging thyroid nodule, no red flags, no cervical lymphadenopathy
- non palpable, asympotmatic thyroid nodule less than 2cm in dimater w/ no red flags or cervical lymphadenopathy
what is allergic rhinitis?
Allergic rhinitis is inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mould or flakes of skin from certain animals
what are the clinical features for allergic rhiniits?
- sneezing
- nasal itching
- nasal discharge
- nasal congestion
- presence of allergens
- hisotry of atopy/eczema/asthma
what is the managemnt of allergic rhinitis?
- nasal irrigation
- allergen avoidance
- intranasal antihistamine or intranasal chromone
- if more severe: intranasal corticosteroid (and sevre uncontrolled = oral corticosteroid)
*could do allergy tested or immunotherapy treatment
what is BPPV (benign paroxysmal positional vertigo)?
BPPV is a disorder of the inner ear characterised by repeated episodes of positional vertigo
whatc auses BPPV? (physiology)
cuased by loose calcium carbonate debris (otoconia) in the semi circular canasl of the inner ear (canalithiasis) which move in semi circular canals when teh head moves = symptoms of vertigo
what can precipitate BPPV?
- head injury
- prolonged recumbent position
- ear surgery
- episode of inner ear patholgoy (vestibular neruonitis, labryrinthitis, menieres disease)
what are teh symptoms of BPPV?
- vertigo brought on by lying down, turning over in bed, looking upwards, bending over
- vertigo occurs in transient episodes (last less than a minute)
- N+V may occur
- light headedness
hwo do you examine a patient for BPPV?
Examine the person to elicit signs suggestive of a diagnosis of BPPV:
- Dix-Hallpike manouevre (if promotes vertigo and torsional upbeating nystagmus then BPPV)
what is the management of BPPV?
- can be self limitng and resolve within week s
- Epley manoeuvre (if symptoms do not settle after 1 week then repeat Epley)
- Brandt-Daroff exercises
- Semont manoeuvre
when shoudl you admit or refer a patient with BPPV?
- severe N+V
- symptoms still present after performing and repeating a canalith repositioning manoeuvre
- symptoms and signs ahve not resolved within 4 wks
- 3 or more periods that the pt. has expericned vertigo
what are some complications of BPPV?
falls
difficulty performing daily activites
- adverse effects on QOL
- increased likelihood of depression
what symptoms would point to central vertigo, over peripheral vertigo?
- prolonged, severe vertigo
- new onset headache or recent trauma
- CVS risk factors
what symptoms woudl point to peripheral vertigo over central vertigo?
- normla neurological exmaintion
- severe N+V
- hearing loss
what is the presentation of a nasal fracture?
- swollen, painful, bleeding nose
- crunching, crackling when touched,
- difficulty breathign throuhg nose
- nose deformity
- Hx of trauma
what are some red flag symptoms for a nasal fracture?
- evidence of septal heamotoma
- evidence of skull fracture (panda eyes, battel sign, CSF out of nose)
- severe epistaxis
what is the managemnt of a nasal fracture?
- analgesia and ice pack to reuce swelling
- refer to ENT fro 7-10 dyas if manipulation needed
what symptoms can a deviated septum cause?
- repeated isnus infection s
- sleep apnoea
- snoring
- reduced / loss of sense of smll
- sneezing
what can cause a deviated septum?
- history of trauma
- congenital conditions e.g. marfans, ehlers-danlos
what is teh treatment for a deviated septum?
- decongestants, antihistamiines, corticosteroids
- septoplasty (done wiht a laser)
what is a vestibular migraine?
vertigo, dizziness, or balance problems w migraine
what are teh clinical features of a vestibualr migraine?
- n+V
- visual disorders and occpital pressure
- sensitivity to mvoemebt and vertigo
- photophobia and phonophobia
- ataxia
lasts 5-72 mins
what is the managment of a vestibualr migraine?
- preventative meds e.g. amitriptylline, candesatran, flunarizine
- acute headache attack - triptans or NSAIDs
- acute vertigo attack - prochorperazine
- greater occipital nerve block
what is vestibulopathy?
disorder of the middle ear causing vertigo symptoms (cna be central or peripheral)
what are nasal polyps?
fleshy, benign swellings of nasal mucosa
usually bilateral, common in >40yo
pale or yellow in apperance (fleshy and reddened)
what are the symptoms when having nasal polyps?
- blocked nose and watery rhinorrhoea
- post nasal drip
- decreased small and reduced taste
what is a major red flags with polyps?
unilateral polyp +/- blood tinged secretion may suggest tumour
what is cervical lymphadenopathy?
enlagrment of the lymph nodes in teh head and neck
what are teh potentials causes fo cervical lymphadenopathy?
- infection or inflammation of nearby structures
- common cold
- bronchitis
- dental decay
- conjuctivitis
- ear infection
- salivary gland infection
- cance r
- autoimmune disease
- chronic infection
