ENT Flashcards
What should you do about this?
(present for 2 weeks)
Advise referral to an oral maxillofacial surgeon for excision of the lesion to send for histopathology
Define Chronic Suppurative Otitis Media
This is when there is an ear infection with a perforation and it has been discharging for greater than 6 weeks
What is the management of Chronic Suppurative Otitis Media?
If < 6 weeks then
Dry Aural Toilet, and if signs of AOM then use topical antibiotics
If > 6 weeks then
1. Dry Aural Toilet can be done every 6 hours until canal is dry
- Instil 5 drops of ciprofloxacin 0.3% ear drops of the right ear twice a day after dry mopping until there has been no discharge for 3 days (1)
- Refer to an Ear Nose and Throat surgeon for assessment to rule out cholesteatoma (or chronic osteitis)
What is the difference between OME and AOM with otorrhea?
In terms of otitis media.
AOM: acute otitis media
AOM= middle ear effusion AND Middle ear inflammation, accompanied by pain
- OME: otitis media with effusion
This is when fluid is present for weeks after the resolution of the AOM (acute otitis media) i.e no middle ear inflammation - AOM with otorrhea. This is when there is discharge ,(but after clearing it up) and there are signs of middle ear inflammation.
What is this?
What is the management?
Otitis Media with effussion.
if < 3 months and no report of hearing difficulties, can reassure most will resolve
(if there are significant hearing difficulties or on exam you see TM retraction or cholesteotoma then refer to ENT)
if > 3 months, then do a formal hearing test. If conductive hearing loss, especially in both ears, or noticeable hearing loss or even behavioural difficulties that have arisen refer to an ENT.
What symptoms make An Acute rhinosinusitis more likely to be bacterial?
Severe localised pain
Unilateral pain
Double sickening. Significantly worse after initial recovery
fevers > 39dC for days in a row
Symptoms over 7 days
Purulent and discoloured discharge
Management for ARS
(7)
Simple analgesia
Saline nasal rinses
Decongestants - intranasal such as phenylepherine
Ipratropium (if rhinorrhea predominant) 44 micrograms/spray, 2 sprays each nostril BD
Intranasal steroids: Fluticasone propionate (adult or child 12 years or older) 100 micrograms into each nostril, daily for 4 weeks, then 50 micrograms daily
Avoid smoking and air pollution
Education
What is post viral sinusitis ?
How to you approach management?
Sinusitis that lasts over 10 days but not quite 12 weeks.
Need Sudden onset of symptoms
AND
any of: nasal blockage, congestion, discharge, obstruction
AND
any: facial pain, pressure or loss of smell
Treatment is the same as ARS
Simple analgesia
Nasal rinses with saline
Nasal decongestants
Nasal steroids
Allergic Rhinitis
Treatments
(4)
Oral or IN antihistamines
Azelastine 1mg/ml. 1 spray into each nostril BD (only in patients 5yo and over)
or certirizine 10mg, orally, daily
IN corticosteroids (not used soley, can be used when combined with IN antihistamine)
Dymista
azelastine+fluticasone propionate 125+50 micrograms per spray, 1 spray into each nostril, twice daily
Montelukast
4-5-10mg orally daily
IN ipratropium
44 micrograms per spray, 2 sprays into each nostril, up to 3 times daily initially, reducing as rhinorrhoea improves
For conjunctivitis (allergic)
azelastine 0.05% eye drops, 1 drop into both eyes, 2 to 4 times daily
Definition of Chronic Rhinosinusitis
Symptoms lasting over 12 weeks
and consists of 2 or more of:
Facial pain or pressure
Mucopurulent discharge
Nasal blockage (congestion or obstruction)
Reduction or loss of sense of smell
Management steps for Chronic Rhinosinusitis?
(5)
- Nasal irrigation
- Similar treatments to ARS
ipratropium, IN steroids, anaglesia, NOT antihistamine, decongestants - If still persistant after 1 month consider
a. RAST testing
b. CT - If NO polyps
Refer to ENT and start on prednisolone 25 mg for 10 days
WITH polyps- refer to ENT
prednisolone 25mg daily PO for 1 week, 12.5mg daily PO for 1 week then 12.5mg alternate days PO for one more week
5- if polyps in children test for CF
If there is somehow bacterial ARS, what can you use?
Amoxicillin 1g PO, 12 hourly (500mg TDS, child 30mg/kg BD or 15mg/kg TDS) for 5 days
(follow up in 5 days)
Or
if immediate hypersensitivity;
Cefuroxime 500mg (child over 3 months 15mg/kg) PO 12 hourly for 5 days
If there is somehow bacterial ARS, what can you use?
Amoxicillin 1g PO, 12 hourly (500mg TDS, child 30mg/kg BD or 15mg/kg TDS) for 5 days
(follow up in 5 days)
Or
if immediate hypersensitivity;
Cefuroxime 500mg (child over 3 months 15mg/kg) PO 12 hourly for 5 days
What would any of these signs/symptoms indicate?
Acute onset confusion
Proptosis
Orbital swelling or oedema
Meningism- stiff neck headache photophobia
Septic shock
diplopia or impaired vision
Complicated Acute Bacterial Rhinosinusitis
If any of these features are present, hospitalisation for intravenous antibiotics and urgent surgical referral are required
What is the treatment for Acute diffuse otitis externa?
Give dosing if required
Firstly what is ADOE?
acute diffuse otitis externa is swimmer’s ear.
its is inflammation of the external ear canal usually following water exposure or ear maceration. Usually presents with ear pain, hearing loss and pruritus. The pinna can be inflammed with cellulitis and enlarged lymph nodes
treatment involves
1. dry aural toilet
2. dexamethasone+framycetin+gramicidin 0.05%+0.5%+0.005% ear drops, 3 drops instilled into the affected ear, 3 times daily for 7 days
If there is a fever, folliculitis or spread of inflammation to the pinna during acute diffuse otitis externa, what is the first line treatment?
(2)
Because of the spread to the pinna and folliculitis you have to ADD to the topical treatment:
dicloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 7 to 10 days
(fluclox and cephalexin can be used at the same dosage)
PLUS
ciprofloxacin 750 mg (child: 20 mg/kg up to 750 mg) orally, 12-hourly for 7 to 10 days
How can you prevent acute diffuse otitis externa?
(4)
Again this is swimmers ear
- Wear ear plugs
- Use a shower cap in the shower
- Use a bathing cap/swimming cap in the water
- Use ear clear (acetic acid plus isopropyl alcohol ear drops, 4 to 6 drops instilled into each ear, after water exposure.)
Acute localised Otitis Externa is not the same as acute diffuse otitis externa. apparently. Though I cannot find a distinct description. Localised would indicate that it is not as bad.
However, how would you treat this?
dosing required.
dicloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 days
or cephalexin or flucloxacillin
Pretty much as a cellulitis suspicious for staph
What should you do for any suspicious oral disease?
Referral to a specialist
Oral cancer can mimic ANY oral mucosal disease, so investigation for full biopsy by specialist is necessary.
Risk factors for oral SCC?
(9)
advanced age
male
smoking or tobacco use
alcohol use
infection by oncogenic viruses (HPV)
fx of SCC on head or neck
history of cancer therapy
prolonged immunosuppression
areca nut (betel nut ) chewing
what is this and what do you do?
This in particular is oral leukoplakia which is just a term for a non removable white lesion.
It can be homogenous like that picture or not (irregular, patchy and colour variation)
Because it can be an SCC or SCC in situ, this needs referral for biopsy
What is oral erythroplakia?
Who does if primarily affect?
and what should be done/
Erythroplakia is a clinical term for a potentially malignant fiery red lesion that cannot be attributed to any particular condition.
Urgent referral to a specialist for biopsy of oral Erythroplakia lesions is essential because approximately 70 to 90% are carcinoma in situ or squamous cell carcinoma upon presentation.
Those who are heavy smokers or abuse alcohol are most at risk.
This is?
HPV related oral lesion
Because HPV is oncogenic. Referral for biopsy and management.
What are these white striations characteristic of?
Oral lichen planus
What should be done for this lesion?
Referral to specialist for biopsy
This is oral lichen planus, but because oral lichen planus is associated with an increased risk of oral squamous cell carcinoma, you should refer.
If a biopsy proven oral lichen planus becomes acutely agitated, what can you use?
betamethasone dipropionate 0.05% cream or ointment topically to the lesions, twice daily after meals, until symptoms resolve
Is this condition benign or malignant or hard to tell?
what should be done?
This is a geographic tongue
Unlike other oral lesions, this one is benign and doesn’t need referral.
The cause is not known. No specific management is needed.
What are red flag features of oral mucosal lesions.
note. there are many.
- oral ulcers > 2 weeks
- Oral ulcers that recur
- non traumatic ulcers in children
- pigmented lesions in the oral mucosa
- Red, or mixed red-white lesions on the oral mucosa of unknown origin or suspicious of malignancy
- facial or oral parasthesia
- persistent oral mucosal discomfort with no obvious cause
- lumps or swellings including lymphadenopathy
- swelling, pain or blockage of salivary gland
- suspected allergy to dental material
- Dry mouth not relieved with artificial lubricants
- Dry mouth from systemic disease
- Lesions in immunocompromised persons
- suspected oral manifestations of systemic disease (IBD, phemigoid, syphillis)
what is a hairy tongue?
excessively long and hyperkeratinised filiform papillae of the tongue become stained by an accumulation of epithelial cells, exogenous material or chromogenic microorganisms
Usually blackened, but can be any colour
What can predispose to hairy tongue?
(3)
use of chlorhexidine mouthwash
antibiotic use
poor/little oral intake (say due to have a PEG feed)
management for this?
This is a hairy tongue
Oral hygiene
Brushing tongue gently with tooth brush
using a sodium bicarb mouth wash
What is the mainstay of oral hygiene?
3 definite things and 2 other
- interdental cleaning, flossing or interdental brushes
- brushing teeth with soft bristle brushes
- using fluoride tooth paste
Other
Mouth wash. not recommended regularly but if someone is post a dental procedure or has gingivitis.
Watch carbohydrate intake. Frequent sugary intake can lead to dental carries. also avoid sugar snacks and drinks before bed, after brushing as saliva is reduced during sleep and sugary things can stick around causing carries.
What type of mouth wash needs to be avoided?
alcohol based ones. linked with oral cancer
What advice do you give someone on how to brush their teeth?
at least for 2 minutes a day, twice a day with a fluoride toothpaste. Ideally mouth should not be rinsed to allow fluoride uptake.
Can brush the tongue but avoid brushing or massaging the gums.
Oral candidiasis is uncommon in most healthy people, what are some risk factors for developing it?
(7)
Denture use
Use of inhaled corticosteroids
salivary gland HYPOfunction
poor oral hygiene
smoking
immune compromise including poorly controlled diabetes
drugs like corticosteroids (oral) and antibiotics
What are the different types of oral candidiasis?
pseudomembranous
erythematous
hyperplastic
angular cheilitis
denture associated
medium rhomboid glossitis.
What is the topical therapy recommended for oral candidiasis (most types) but not for angular cheilitis?
amphotericin B 10 mg lozenge sucked (then swallowed), 4 times daily, after food, for 7 to 14 days; continue treatment for 2 to 3 days after symptoms resolve
miconazole 2% gel 2.5 mL topically (then swallowed), 4 times daily, after food, for 7 to 14 days; continue treatment for at least 7 days after symptoms resolve
second line
nystatin liquid 100 000 units/mL 1 mL topically (then swallowed), 4 times daily, after food, for 7 to 14 days; continue treatment for 2 to 3 days after symptoms resolve
How is this treated?
This is angular cheilitis
clotrimazole 1% cream topically to the angles of the mouth, twice daily for at least 14 days; continue treatment for 14 days after symptoms resolve
What is an aphthous ulcer?
What is recurrent aphthous ulcer disease?
painful punched lesion in the oral (or genital) mucosa that is non traumatic.
the disease means the ulcers recur. this is via an immune mediated reason.
What can you use to try and treat this before it gets worse?
(2)
say this is minor
an aphthous ulcer
hydrocortisone 1% cream or ointment topically to the lesions, 2 to 3 times daily after meals
for analgesia
benzydamine 1% gel topically to the lesions, 2- to 3-hourly as necessary.
When should you refer a presumed aphthous ulcer?
(3)
- if not healing after 2 weeks
- herpetiform aphthous ulceration
- immunocompromised with neutropenic ulceration
What is the treatment for a traumatic oral ulcer?
(3)
Salt water rinse/gargles
Local anaesthetic like benzydamine 1% gel (adult and child 6 years or older) topically to the ulcer, 2- to 3-hourly as necessary.
(if persistent more than2 weeks then refer)
How can you manage sleep bruxism (grinding of teeth during sleep)?
avoiding risk factors,
relaxation techniques,
hypnotherapy,
biofeedback,
cognitive behavioural therapy (CBT) and
improving sleep hygiene.
full coverage splints to protect the teeth
Management of awake bruxism?
Stress management
Recognition and reversal of habit
What is temporomandiblar joint dysfunction (TMD)?
Broadly speaking, TMD commonly refers to pain involving the TMJ and surrounding structures as well as dysfunction of the joint itself.
What is the gold standard investigation for TMD?
MRI as it can assess soft tissue structures, articular disc displacement and the presence of joint effusion with a high degree of specificity and sensitivity
What is the management for TMD?
- patient education and reassurance
- Jaw rest
- Soft diet
- Warm compressors over area
- Short term CBT as cognitive factors lead to this.
- NSAIDs are first line
- Benzodiazepines if the TMD is chronic
8 TCAs can be used in chronic cases
What are red flag features to rule out when presented with a potential temporomandibular joint dysfunction (TMD)?
- persistent or worsening pain
- Trismus
- CN abnormalities
- Other neurology
- Trismus
- Systemic illness
- Weight loss
- asymmetrical swelling in the neck/face
- vestibular dysfunction
- unilateral hearing loss
- unilateral or new onset tinnitus
What is trismus?
inability to open the mouth
How long should you attempt basic treatments for trismus/TMD before you refer?
6-8 weeks
What does the Y axis and X axis represent on an audiogram?
X axis - frequency of the sound
Y axis- the volume needed to hear that sound
What is the purpose of masking in hearing tests?
With air conduction the hearing can be heard by either cochlear if the sound is loud enough. If the difference in thresholds is greater than 40dB the better ear needs to be masked for the true value of hearing loss.
What does this audiogram show?
68 year old man, with known damage to his left ear during childhood, presents after a cold for 5 days, and feels his right ear is blocked.
The only normal finding here is the bone conduction of the right ear i.e. the red ‘[’. As you can see there is a conduction loss of the right ear (the red O’s are below the red ‘[’ ).
There is sensorineural loss of the left ear, with both the ‘X’s and ‘]’o representing left ear air and bone conduction respectively, well below the red ‘[‘-which represents right bone conduction.
What level of sound on the Y axis of an audiogram would count as severe hearing loss?
70-90 Db
Describe what this shows?
Mild to Moderate
neurosensory hearing loss
What is this showing?
Mild conductive hearing loss in BOTH ears.
The cochlear itself is normal.
This might be caused by bilateral otitis media. and effusion. Maybe wax.
What does this show?
mild to moderate MIXED hearing loss. There is still bone conduction loss, but the air conduction is worse.
Differentials for conductive hearing loss?
(4)
Cerumen impaction,
Perforated tympanic membrane
Fluid in the middle ear space
Otosclerosis (bony growth in middle ear)
What is the most common cause of sensorineural hearing loss?
Noise exposure
Frequent exposure over 85 DB usually causes this. And higher frequencies after affected more.
Causes for sensorineural hearing loss?
(7)
1 Medications that are ototoxic: aminoglyclsides, MTX, frusemide, platinum chemotherapeutics
- Infections: mumps, measles, meningitis, syphillis
- Autoimmune
- head trauma
- Neoplastic
- Noise exposure and presbycusis
- Congential malformations
Describe this?
LEFT sensorineural hearing loss
(Oops it’s on the diagram)
Describe this?
bilateral sensorineural hearing loss
When doing a Rinne and Webers test, if the Rinne’s test is negative (i.e. BC is better than AC) which ear will the Weber’s test lateralise to?
For some reason it lateralises to the BAD side (i.e the side where BC>AC).
What is a cholesteotoma?
Clinically defined as an abnormal extension of skin into the middle ear and mastoid air cell spaces.
In pathological terms cholesteatoma is simply benign keratinising squamous epithelium that forms a cyst within the middle ear or mastoid.
Which nerve can be affected with a cholesteotoma?
The facial nerve.
What is the fistula ear test and why would you do it?
The fistula test involves applying positive pressure to the affected ear. It can be performed by placing a finger to the external auditory meatus and creating an air-proof seal, or with the insufflation device built within the otoscope.9 The test is positive if the increased pressure on the tympanic membrane causes either dizziness or nystagmus.
You might do this if someone has a cholesteotoma and you’re suspecting inner ear damage.
What investigations should be done for a suspected cholesteotoma?
(2)
Audiogram
CT of the temporal bone- to assess extent of the disease
what are these examples of?
Cholesteotomas
how might this need to be treated?
This is a cholesteotoma
Referral for Surgical correction. The type of surgery will depend on the extend are part of the TM affected
What is the proposed pathogenesis for a cholesteotoma and which condition can lead to this?
When the middle ear cannot drain properly. There can be a build up of wax and skin.
Eustachian Tube dysfunction can lead to this.
If the eustachian tube is not working properly, the middle ear space does not get ventilated. This creates negative pressure and ultimately causes the weakened eardrum to retract. This retraction collects skin and earwax, which leads to a cholesteatoma. Seasonal allergies, upper respiratory infections (cough/cold), or sinusitis may contribute to eustachian tube dysfunction
What specific questions on history are important to exclude a potentially serious cause of tinnitus?
(5)
Unilateral tinnitus
Asymmetrical hearing loss
Vertigo
Headache
Neurological signs
Pulsatile tinnitus
Medication history of ototoxic drugs
What investigations can you order for tinnitus?
(2)
Pure Tone audiometry
Tympanogram
What are causes of peripheral vertigo?
(5)
Vestibular neuritis
Acute labryinthitis
Vestibular migraine
BPPV
Menieres Disease
What is Meniere Disease?
What is the pathogenesis and how does it present?
(4)
Due to increase of fluid in the endolymph. Pathogenesis is unknown.
usually 10-20 minute episodes
unilateral
usually present with a triad of unilateral progressing hearing loss, tinnitus, and veritigo
can have aural fulness
How can you treat and prevent Menieres Disease?
(3)
Salt restriciton
Caffeine restriction
Can try prophylaxis with HCT or potassium sparing diuretic.
What is the Dix-Halpike and Epley Manoevers?
(2)
These relate to diagnosing and treating Benign Paroxysmal Positional Vertigo
Dix-Halpike to diagnose
Epley OR Semond manoevres to treat
Brand-daroff exercises to use as a home remedy to treat
What specific clues in a patient with vertigo, might point towards benign paroxysmal positional vertigo as the diagnosis?
(4)
Usually occurs when turning the head
Symptoms of vertigo usually last seconds
Sometimes associated with nausea
Doesn’t usually present with hearing loss or aural fullness or post infection
Vestibular neuritis and acute labyrinthitis can be hard to pick and differentiate. Usually VN precedes a viral URTI, whereas in AL, the URTI symptoms occur first. How long do symptoms of vertigo last in each case?
6-8 weeks for both
Acute labyrinthitis may only take days however.
Which other symptom is notoriously confused by patients with, or present with vertigo?
What colloquial and frustrating term do patients use to describe either of the above symptoms?
What history feature might help differentiate it?
- Dizziness. often confused with vertigo.
- “funny turns”
- Internal spinning of the head or feeling faint is likely to be dizziness,
whereas external motion/movement of the environment is likely to be vertigo
Why is it important to differentiate between dizziness and vertigo?
There can be serious systemic causes for dizziness:
-Cardiogenic/perfusion issues
-Metabolic (glucose for example) causes
-Endocrine causes (Thyroid, cushings)
-Psychological (feeling ‘light headed; or disconnected)
-Anaemia
Whereas vertigo is more peripheral (vestibular) or neurological causes.
Drugs/medications can affect either.
Vertigo can be peripheral or central. Central causes can indicate underlying neurological issues. What features on history or exam might heighten suspicion of a central cause?
(8)
gait ataxia out of proportion to extent of vertigo
visual field loss
diplopia
hemisensory loss
limb weakness and ataxia
slurred speech (dysarthria)
difficulty swallowing (dysphagia)
eye movement abnormalities (direction-changing nystagmus, skew deviation)
Which 4 features are more likely to be found with peripheral vertigo?
Aural fulness
Tinnitus
Hearing loss
Positive head impulse test
Central causes of vertigo are rare. The most common being a vestibular migraine. What are 3 other causes?
multiple sclerosis
vertebrobasilar ischaemia
tumour
Despite common belief, what do Acoustic Neuromas NOT present with?
What are you likely to find?
Acoustic neuromas (nor acute otitis media) hardly ever present with vertigo.
Usually presents as sudden onset hearing loss.
If someone presents with sudden onset hearing loss, what investigations can you order or do?
(4)
what is the most important thing to order?
(1)
- Likely sent to ENT for investigation
- Pure tone audiometry
- Tympanometry
- Consider bloods that look for infection and potential autoimmune/rheumatic diseases (quite a broad ordering; FBC, CRP/ESR, EUC, ANA, ANCA, RF, anti-CCP, anti-phospholipid, viral titres: HIV, HCV, HBV, mumps, rubella, HSV)
- The most important thing is likely an MRI with gadolinium contrast of the internal acoustic meatus and brain is essential in unilateral or asymmetrical SNHL (>15 dB) to exclude a vestibular schwannoma.
First line Treatment of acute vertigo or nausea?
(2)
If medications, no dosing required.
1.
If nauseous and not vomiting
prochlorperazine 5 to 10 mg orally, 6- to 8-hourly for up to 2 days
OR
promethazine 25 to 50 mg orally, 8- to 12-hourly for up to 2 days (maximum daily dose 100 mg).
-Use IM formulations if vomiting
- Can start IV fluid therapy
or oral rehydration
If your first line treatments (medical) for acute vertigo are not working, what else can you use ?
diazepam 5 mg orally, 3 times daily for up to 2 days
OR
Ondasenatron 4 to 8 mg orally, 2 to 3 times daily for up to 2 days
What medication MIGHT help hasten recovery from vestibular neuritis, or can be used if the case is severe?
Prednisolone 1mg/kg, oral, daily for 5 days, then taper over 15 days to stop.
