ENT Flashcards
Describe a normal tympanic membrane
Thin, transluminal membrane with a cone of light
What is otitis externa?
Infection of the skin of the external auditory canal
Sx of otitis externa?
Irritable child
Worsening otalgia (ear pain)
Otorrhoea (discharge)
Itchiness
Ear fullness / hearing loss
Tinnitus
What is the prevalence of otitis externa?
1% of children
List 8 risk factors of otitis externa
Younger children
Females
Frequent water contact
Obstruction of ear canal
Ear trauma
Foreign body in ear
Skin conditions: eczema, psoriasis
Immunocompromised patients
List otoscopic features of bacterial otitis externa
Narrow, swollen & red ear canal
Tympanic membrane not visible
Yellow / white crusted discharge
List otoscopic features of fungal otitis externa
Narrow, swollen & red ear canal
Tympanic membrane not visible
Thick white / grey spores
What is the difference in fungal / bacterial otitis externa Tx?
Fungal Tx is used for 6 weeks but bacterial Tx is used less
What pathogens cause otitis externa ?
Pseudomonas aeruginosa (40%)
S. epidermis
S. aureus
Anaerobes
Fungal infection eso aspergillus
List otitis externa Mx?
Patient education - no cotton buds, keep ear moisturised
Take a swab
Ear microsuction
Ear drops - antibiotic / steroid / antifungals
What is otitis media ?
Acute inflammation of the middle ear cavity
What is the prevalence of otitis media ?
30% of age 3s
What is peak incidence of otitis media ?
6 to 15 months
List risk factors of otitis media ?
Young children - nursery age
Male
Passive smoking
Bottle feeding
Cleft palate / Downs - craniofacial abnormalities
Large adenoids
List common organisms causing otitis media
Respiratory syncytial virus and rhinovirus
Step pneumoniae (40%)
Hameophillius influenza (25%)
Why are kids more likely to get otitis media vs adults?
Thinner, flatter eustachian tube is more prone to blockage
Outline the course of otitis media ?
Child has URTI / cold
Becomes irritable
EITHER:
- tympanic membrane perforation
- mastoiditis
List Sx of otitis media
Irritable child
Otalgia
Ear fullness
Fever
Unilateral hearing loss
List Sx of tympanic membrane perforation
Purulent ear discharge
Child becomes happier (relieved fullness of otitis media)
Unilateral hearing loss
List Sx of mastoiditis?
Bulging, opaque tympanic membrane (red/yellow/pink) with evidence of effusion posteriorly
Unwell child
Protruding ear with red, hot, tender mass over mastoid
Describe Mx of mastoiditis?
ENT EMERGENCY
IV antibiotics
List Mx of otitis media
80% self limiting - resolves in 3 days
Oral Abx if systemically unwell
List complications of otitis media
Tympanic membrane perforation
Otitis media with effusion (glue ear)
Intracranial complications eg meningitis / abscess
List causes of tympanic membrane perforation
Loud sounds
Head trauma
Infection
Foreign body in ear
Iatrogenic
Cholesteatoma
List Sx of tympanic membrane perforation
Sudden unilateral hearing loss
Tinnitus
Otalgia
Otorrhoea
List Mx of tympanic membrane perforation
Depends on cause:
- small perforations: watch & wait
- treat infection
- cholesteatoma: urgent ENT referral
- chronic large perforation: refer for surgical repair if affecting QoL
What is cholesteatoma?
Migration of middle ear mucosa to outer ear causing gradual erosion
What is glue ear?
- time period diagnosis for glue ear
Otitis media with effusion
Presence of fluid in middle ear for 3 months or more
What is the prevalence of glue ear?
80% children have it before age of 10
What is peak age incidence of glue ear?
2-5 years
When is glue ear more common?
Winter
What causes glue ear?
Chronic eustachian tube dysfunction leading to difficulty ventilating middle ear
List complications of glue ear
Hearing loss
Delay in speech development
Poor performance in school
List risk factors of glue ear
Male
Under 7
Immunocompromised
Bottle fed
Passive smoking
Downs / Cleft palette
CF
List Sx glue ear
Mainly asymptomatic
Unilateral hearing loss - behaviour issues, poor attention and speech
Mild otalgia
Describe Ix of glue ear
Examination of ear
Otoscopy
Hearing test
Tympanogram
What will tympanic membrane look like in glue ear?
Dull or opaque
Fluid bubbles behind drum
List tympanogram findings of glue ear
Type B - flat trace with normal volume
Type C - negative peak (eustachian tube dysfunction)
List Mx of glue ear
Active monitoring - self resolving in 3 months
+/- Rhinitis Tx / otovent balloon
+/- Hearing aids
+/- Grommets
What are the types of hearing loss?
Conductive and sensorineural
What is conductive hearing loss?
Damage to outer and middle ear causing interference with sound travelling
What is sensorineural hearing loss?
Interference with AP conduction in inner ear
Is glue ear conductive or sensorineural?
Conductive - prevents tympanic membrane movement
What is mastoiditis?
Infection of mastoid air cells spreading from ear
List risk factors of mastoiditis
<2 years old
Immunocompromised
Pre existing cholesteatoma
Communication difficulties - can’t vocalise the pain
List Sx of acute mastoiditis
Acute / recurrent otitis media
Otalgia
Fever
Irritable child
Muffled hearing
List signs of acute mastoiditis
VERY UNWELL
red, tender swelling over mastoid
protrusion of external ear forward
bulging and erythematous tympanic membrane
List Sx of chronic mastoiditis
recurrent otitis media, headaches, otalgia
List signs of chronic mastoiditis
no perimastoid inflammation
+/- tympanic membrane affected
Ix of mastoiditis?
EARLY & PROMPT
FBC, U&E, CRP, blood cultures
Ear swab
+/- CT petrous bone / brain - complications
Mx of mastoiditis?
IV Abx
topical Abx ear drops
+/- cortical mastoidectomy
+/- grommet
What is a cholesteatoma?
Squamous epitheleium (skin) migrates in the middle ear and gradually erodes the bone / soft tissues
Sx of cholesteatoma?
persistent smelly discharge
progressive / severe hearing loss
dizziness
acute mastoiditis
facial palsy
Ix & Mx of cholesteatoma
Diffusion weighted MRI aids diagnosis
Surgery - mastoidectomy
List risks of cholesteatoma
Permenant hearing loss
Spread of infection into brain / facial nerve
Mx of foreign body in ear?
Diagnosis = Hx & evidence on otoscopy
EXAMINE BOTH EARS
1st attempt is best attempt to remove it
If unsuccessful - use GA
What foreign bodies need to be removed straight away?
Corrosive materials or evidence of infections
What foreign bodies need to be removed same day?
Organic material - food or bugs
What foreign bodies need to be removed at the next appt?
Inorganic material - eg beads / cotton buds
Sx of pinna haematoma?
Boggy, blueish swelling of pinna
(cauliflower ear - chronic)
Causes of pinna haematoma?
blunt ear injury
infection - secondary to piercing
Mx of pinna haematoma?
Urgent drainage under GA
Pressure dressing
Abx
Describe the new born hearing screening
Usually during first few weeks, before 3 months
AOAE - Automated otoacoustic emission test
- clicking sound in ear, with echo measured by microphone
ABR - auditory brainstem response test
- electrodes on head detects brain waves in response to clicking sound
Describe prevalence of epistaxis
60% population have them
Less common under 2
6% need admission
Risk factors for epistaxis?
Male
Winter months
Nasal allergies
Previous episodes
Coagulation disorders
Nasal trauma
Where is the most common place for a nose bleed and why?
Kiesselbach’s plexus / Little’s area
where major arteries in the nose anastamose
What is Mx of epistaxis?
ABCDE
A - lean child forward and pinch nose for 15 minutes (prevent congealing of blood at back of nose)
–> 90% resolve at this point
Topical lidocaine / tranexamic acid / adrenaline
Cauterisation with silver nitrate stick
Packing if a posterior bleed eg with Foley’s catheter or rapid rhino or naseptin cream
Why is adenoidal hypertrophy a problem?
Persistent mouth breathing
Hyponasal speech
OSA
Glue ear
When are adnenoids the biggest?
5-7 years old, then regress
Indications for adenoidectomy?
Airway obstruction eg OSA
Glue ear
What must be done post adenoidectomy for best results?
Good analgesia
Start eating / drinking ASAP
What type of allergy is allergic rhinitis?
Type 1 sensitivity
List allergens causing allergic rhinitis
Hay, pollen, dust, animal hair, mold spores
What causes T1HR?
Lack of exposure to siblings / animals
Sx of allergic rhinitis?
Related to excess fluid in facial tissues
- sneezing
- red itchy swollen eyes
- nasal congestion
- affects concentration / sleep / attendance
How is allergic rhinitis diagnosed?
Skin prick test or patch test
Mx of allergic rhinitis?
Avoid allergen
Antihistamines eg cetirizine
Nasal toileting - flush water up and down nose
Desensitisation if very severe - gradual exposure to allergen
What is rhinosinusitis?
Acute inflammation of nose and paranasal sinuses from viral infection and inadequate drainage of paranasal sinuses
Causes of rhinosinusitis?
Rhino virus or coronavirus
2% strep
Risk factors of rhinosinusitis?
Air pollution, damp housing, winter months, smoke
Sx of rhinosinusitis?
Headache
Hyposmia
Nasal obstruction
Rhinorrhoea & post nasal drip
Facial pain
fever
Mx of rhinosinusitis?
Resolve spontaneously in 7 days
Abx if fever or prolonged Sx
Nasal steroids
CT sinus is persistent
What is periorbital cellulitis?
ENT EMERGENCY
Infection from nasal sinuses, eyes or skin extend to surround eyes
List categories of periorbital cellulitis
Pre-septal - infection from conjunctiva / lids
Post-septal - infection from frontal / ethmoid sinuses
Mx of periorbital cellulitis
Keep monitoring eye movements of child
Nasal decongestants
IV Abx
+/- surgical drainage
Sx of periorbital cellulitis
Prodrome of URTI
Acute swelling of eye
Proptosis
Restricted eye movements
Complications of periorbital cellulitis
Cavernous sinus thrombosis
Erosion into orbital bones
Brain abcess
Meningitis
What is the peak age of nasal foreign bodies?
1-4 years old
Sx of nasal foreign bodies
Unilateral nasal discharge
Offensive smelling discharge
Excoriation around nostril with foreign body
Mx of nasal foreign bodies
Check BOTH nostrils
Remove object on SAME DAY - risk of inhalation to lungs
- can be done under GA
Ways to remove:
- positive pressure technique “magic kiss”: close empty nostril, ask parent to blow air through mouth and hopefully will dislodge object
Jobson Horn / St Barts Wax Hook / Foley Catheter - hook or drag it out
Crocodile forceps - pinch and pull it out
Name 3 parts of the throat and their boundaries
Nasopharynx - end of inferior turbinate to end of soft pallate
Oropharynx - end of soft pallate to laryngeal vestibule
Laryngopharynx - laryngeal vestibule to division of trachea/oesophagus
List Sx of tonsillitis
Sore throat
Odynophagia
Fever
Malaise
Enlarged red tonsils +/- exudate
Cervical lymphadenopathy
What is the duration of tonsillitis?
3-7 days
List responsible organisms of tonsillitis?
Resp viruses
Haemophilius influenza
Pneumococcus
Haemolytic strep
DDx of tonsilitis?
Mono
Agranulocytosis
Scarlet fever
Diptheria
Ix of tonsilitis?
FBC
U&E
Glandular fever screen - mono spot / EBV serology
Mx of tonsilitis
Pain killers
Fluids & keep eating
Abx if no improvement after 5 days
When would you refer tonsilitis to ENT?
Recurrent debilitating tonsilitis
Asymmetrical tonsils / unilateral enlargement
Sleep disordered breathing in children
Complications of acute tonsilitis
Quinsy
Retropharangeal abcess if under 5 years old or parapharyngeal abcess
Rheumatic fever
Glomerulonephritis
Septicaemia
What causes pharyngitis?
Viral disease - flu / measles
EBV
Scarlet fever
Thyphoid fever
Coxsackie infection
Diptheria
What does EBV pharyngitis look like?
White membrane
What does diptheria pharyngitis look like?
Gray film
Complications of pharyngitis?
Peritonsilar abcess
Uvulitis
Sx of pharyngitis
Sore throat
Malaise
Fever
Erythema
Mx of pharyngitis
90% resolve spontaneously in 7 days
Good analgesia - difflam mouthwash, ibuprofen etc
Only give ABx if FeverPain score appropriate
Mx of post tonsillectomy bleed
ENT EMERGENCY
Majority are self limiting but must admit as they have sudden severe harmorrhage risk
ABCDE
A- lean head forward
Stop bleeding - hydrogen peroxide gargles, NBM, tranexamic acid, silver nitrate cautery sticks
Sx of foreign body inhalation
Short, sudden episode of respiratory distress, cyanosis, coughing and gagging
Then the child will appear well
Stridor
Unilateral wheeze
Persistent recurrent cough
Mx of foreign body inhalation
AIRWAY EMERGENCY
Removal must be same day
Complications of foreign body inhalation
Airway obstruction
Cardiac arrest
Choking
Lung abcess
Fistula
What is the difference between stridor or stertor?
Stridor = upper airway obstruction sound
Stertor = doesn’t mean airway is at risk, is just a snoring nose. Much longer duration
How are stridor and stertor similar?
Both inspiratory sounds
When do you hear wheeze?
Expiratory sound
What is laryngomalacia?
When a child’s larynx is soft / floppy / malformed
What is the main clinical sign of laryngomalacia?
Stridor - the most common cause for stridor
When is laryngomalacia present?
Birth or 1st month of life
Mx of laryngomalacia?
90% cases resolve by 20 months
Mx of GORD
Surgery
Sx of laryngomalacia?
Stridor - worse when laying on back or crying
Struggling to breathe
Poor oral intake / choking when eating
Failure to thrive
When do you refer laryngomalacia
Life threatening apnea
Significant cyanosis episode
failure to thrive
Chest / neck retractions
secondary heart or lung disease
When do you get cervical lymphadenitis?
URTI viral infection
Bacterial infections
Cancer
Immunological response
What is cervical lymphadenitis linked with?
Eczema
Mx of cervical lymphadenitis?
ABx
USS neck
Surgery for drainage collection
Sx of cervical lymphadenitis?
Tired child, off their food and not sleeping well
Enlarging neck lump
Tender, red, hot lump
What does a fluctuant cervical lymphadenitis lump indicate?
Abscess formed
