ENT Flashcards
what is cholesteatoma?
abnormal collection on squamous epithelial cells in the middle ear
it is non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear
predisposes to infection
what is the cause of cholesteatoma?
not fully understood
complication of otitis media
squamous epithelial cells originate from outer surface of tympanic membrane
negative pressure in middle ear (Eustacian tube dysfunction) causes a pocket of tympanic membrane to retract to the middle ear
squamous cells continue to proliferate and can damage the ossicles > permanent damage
what is the presentation of cholesteatoma on history and exam?
history: foul discharge from ear, unilateral conductive hearing loss, otalgia, headache; also: vertigo, facial nerve palsy, infection
exam: otoscopy = an area of white debris/ crust in the attic behind the tympanic membrane
what are the investigations for cholesteatoma?
audiology assessment
CT (confirm diagnosis and plan for surgery)
MRI (can help to assess invasion and damage to local soft tissues)
referral to ENT
what is the treatment of cholesteatoma?
surgical removal of cholesteatoma
treat any discharge for infection with Abx
what is matoiditis?
inflammation of mastoid air cells within petrous temporal bone
acute = complication of acute otitis media leading to abscess formation and is life-threatening
most common in children
increased incidence in children with learning disabilities and autism
what is the cause of matoiditis?
acute is usually secondary to bacterial infection: STREP PNEUMONIAE, staph aureus, strep pyogenes, haemophilus influenzae
initially hyperaemia and oedema of mastoid air cell mucosa
inflammation and swelling leads to blockage of drainage > serous then purulent exudate collects in air cells
increased pressure in air system > bone necrosis of tiny bone septae
pus and abscess cavity forms
what are the RF of mastoiditis?
recurrent acute otitis media age learning difficulties immunocompromise anatomical abnormalities e.g. cholesteatoma
what is the history and exam of mastoiditis?
history =
children: ear pulling, ear pain, irritability, persistent fever despite Abx, lethargy, reduced oral intake, diarrhoea
adults: severe otalgia, ottorhoea, headache, hearing loss, persistent fever despite Abx, vertigo
exam =
external: post-auricular erythema, tenderness, swelling and fluctuance, proptosed auricle, loss of post-auricular sulcus, evidence of sepsis
otoscopy: bulging tympanic membrane, bulging/sagging of posterior-superior wall of external auditory canal
what are the complications of mastoiditis?
reduced LOC
facial nerve palsy
abducens nerve palsy
what are the investigations for mastoiditis?
labs: FBC (high WCC), U&E (baseline renal function for Abx), CRP (high), lactate (high in sepsis), blood cultures (for organism and Abx choice)
send purulent middle ear fluid for MC&S
LP if intra-cranial extension
imaging: CT scan of temporal bones (progression) > mastoid air cell and middle ear opacification, loss of wall, haziness/distortion of mastoid outline, abscess formation
what is the management of mastoiditis?
immediate: ABCDE, NBM/fasted for surgery, analgesia
medical: broad-spec IV Abx e.g. IV piperacillin and tazobactam (tazocin), or metronidazole and ciprofloxacin (if penicillin allergy)
surgical: tympanocentesis, myringotomy +/- grommet/tube insertion, cortical mastiodectomy
pure-tone audiometry to exclude persistent conductive hearing loss
what is a Eustachian tube dysfunction?
when the tube between the middle ear and throat is not functioning
Eustachian tube equalises air pressure int he middle ear and drains fluid from the middle ear
what is the cause of Eustachian tube dysfunction?
when the ET is not functioning/blocked, the air pressure cannot equalise and fluid cannot drain
air pressure between the middle ear and environment is not equal
the middle ear can fill with fluid
this can be related to a viral URTI, allergies or rhinitis
what is the presentation of Eustachian tube dysfunction?
reduced hearing, popping noises or sensations in the ear, fullness sensation in the ear, pain or discomfort, tinnitus
symptoms get worse when external air pressure changes and the middle ear pressure cannot equalise
otoscopy: can be normal, but need to exclude signs of otitis media etc.
what are the investigations for Eustachian tube dysfunction?
if clear cause, no need
in persistent/severe symptoms: tympometry (peak admittance and negative pressure), audiometry, nasopharyngoscopy, CT scan to assess structural pathology
what is the management of Eustachian tube dysfunction?
none
valsalva manoeuvre (pop ears with nose)
decongestant nasal sprays
antihistamines and steroid nasal sprays for allergies/rhinitis
otovent device
surgery if severe: 1. adenoidectomy, 2. grommets, 3. balloon dilatation Eustachian tuboplasty
what is vertigo?
the hallucination of rotation due to the abnormal stimulation of hair cells of the vestibular system
what is the pathology of vertigo?
sensory inputs = 1. vision 2. propioception 3. vestibular system signals
vertigo is a mismatch between these sensory inputs
can be peripheral (affects vestibular) or central (involves brainstem/cerebellum)
what are the causes of vertigo?
peripheral: BPPV, Meniere’s disease, vestibular neuronitis, labyrinthitis; trauma, otosclerosis, Ramsey-Hunt
central: posterior circulation infarction (stroke), tumour, MS, vestibular migraine
what is BPPV and what is its presentation?
crystals of calcium carbonate called otoconia that become displaced in semicircular canals
may be displaced by a viral infection, head trauma, ageing or no clear cause
crystals disrupt the normal flow through the canals > disrupt the function of the system
features: induced by change in position, vertigo lasts from seconds to minutes, a/w nausea, torsional nystagmus and can be fatigued
which investigation is used for BPPV?
Dix Hallpike test - will be positive
what is Meniere’s disease and what is the presentation?
caused by excessive build up of endolymph in the semicircular canals, causing a higher pressure than normal, disrupting the sensory signals
features: acute episodes of = loss of hearing, tinnitus, vertigo, sensation of fullness of ear
attacks last several hours before settling
most often occurs in middle aged adults
NOT ASSOCIATED WITH MOVEMENT/POSITION
spontaneous nystagmus during attacks
what is vestibular neuronitis and what is the presentation?
inflammation of the vestibular nerve
usually URTI (viral)
features: sudden onset vertigo, lasts several days to weeks, a/w N/V, NO hearing loss/tinnitus, horizontal nystagmus
what is labyrinthitis and what is the presentation?
inflammation of structures of the inner ear
viral infection
features: acute onset of vertigo that improves after a few weeks, causes hearing loss (different vestibular neuronitis)
what is posterior circulation infarction and what is the presentation?
sudden onset, a/w ataxia, diplopia, cranial nerve defects
what is the presentation of tumours that cause vertigo?
gradual onset, a/w cerebellar/brain dysfunction
what is the presentation of MS with vertigo?
may cause relapsing and remitting symptoms
a/w optic neuritis or transverse myelitis
what is the presentation of vestibular migraine?
symptoms last from mins to 72 hours
a/w stress, bright lights, strong smells, food, dehydration, menstruation, abnormal sleep patterns
which acronym is used for cerebellar signs in vertigo?
DANISH: Dysdiadokinesis Ataxic gait Nystagmus Intention tremor Speech (slurred) Heel to Shin test
what are the investigations for vertigo?
central vertigo: CT scan/MRI for cause
what is the management of vertigo?
peripheral:
short term = prochlorperazine (vestibular sedative) and antihistamine (cyclizine and prometrazine)
Meniere’s = betahistine reduces attacks
vestibular migraine = avoid triggers, medical = triptans, propanolol, topiramate or amitriptyline all prevent
BPPV = Epley’s
what are the salivary gland sections?
parotid, submandibular, sublingual
what is sialedenitis and what are the RF?
inflammation of salivary glands
normally 2nd to stone formation (sialolithiasis)
RF: poor oral hygiene/dehydration, infective (mumps) and autoimmune (sarcoidosis)
what is the management of sialadenitis?
IV Abx, try to express stone, surgery if recurrent, citrus and lime increases salivation
what is sialolithiasis and the presentation?
the presence of calculi in the glands/ducts
typically calcium phosphate and hydroxyapatite
intermittent pain that is worse before and during meals
most involve whorton ducts
what is the pathology and management of salivary tumours?
80% are parotid glands (and submandibular) - most benign
most sublingual tumours are malignant
malignant parotid tumour will cause a facial nerve palsy
if present for over 1 month REMOVE
what does infectious mononucleosis cause?
lymphadenopathy
what are the causes of infectious mononucleosis?
caused by infection of EBV
most affects young adults
found in saliva of infected individuals
may spread by kissing or sharing cups, toothbrushes…