ENT Flashcards
The adenoids and tonsils produce what immune cells?
B cells (IgG and IgA)
In which paediatric age group is the peak incidence of OSA?
3-6 yrs
What are the three most common causes of hearing loss in children?
- Acute otitis media
- Otitis media with effusion (glue ear).
- Tympanic membrane perforation.
What are the most common bacterial causes of AOM?
- Streptococcus pneumonaie
- Haemophilus influenzae
- Moraxella catarrhalis
How would glue ear present on an audiogram?
Bone conduction normal, air conduction poor in the affected ear.
“Bone air gap”
How would glue ear present on an tympanogram?
Flat trace
Cholesteatoma is made of what cells?
Keratinising squamous epithelium.
What is the treatment for cholesteatoma?
Surgical - mastoidectomy
Complications of mastoidectomy for cholesteatoma?
Surgery risks further hearing loss or imbalance, injury to facial nerve (less concern is chorda tympani).
Main features of cholesteatoma:
- foul-smelling, non-resolving discharge
- hearing loss
What is the most common cause of bacterial tonsilitis?
Group A strep (strep pyogenes)
What is the centor criteria?
- No cough
- Fever
- Tonsilar exudates
- Lymphadenopathy
What is the antibiotic given for tonsilitis and how long for?
Penicillin V(also called phenoxymethylpenicillin) for a10-day course is typically first-line.
Treatment for quinsy?
Needle aspiration / surgical incision and drainage. Broad spec antibiotics after surgery.
What is a complication of rhinosinusitis?
Nasal polyps
What is the first line treatment for nasal polyps?
Topical steroid drops (to shrink the polyps).
Symptoms of nasal polyps:
Symptoms include watery anterior rhinorrhoea, purulent post-nasal drip, snoring, mouth-breathing and headaches.
Diagnosis of nasal polyps?
Diagnosis is confirmed by anterior rhinoscopy or nasal endoscopy.
What is the treatment for Meniere’s disease?
Betahistine to reduce the frequency of attacks.
Prochloroperazine for acute flare.
What is the name of the sleep study used to assess OSA?
Polysomnography
Is stridor inspiratory or expiratory?
Inspiratory
Most common cause of congenital stridor?
Laryngomalacia
Croup vs Epiglottitis
Pathogen?
Common age group?
- Croup = parainfluenza virus, 4 months -2 years, barking cough
- Epiglottitis = haemophilus influenza, 2-5years, drooling
Congenital hearing loss causes - autosomal dominant? (20% of cases)
Syndromic =Waardenburg, Branchio-oto-renal
Congenital hearing loss causes - autosomal recessive? (75% of cases)
Syndromic = Ushers, Pendreds; non-syndromic
=GJB2 mutation around 50% of all severe or profound hearing
X-linked causes of congenital hearing loss?
Alport’s
Albanism
Infective causes of acquired hearing loss in children?
TORCH infection
Other infections: meningitis, measles, encephalitis,
chicken pox, head injury, ototoxic drugs
TORCH infection causes what?
fetal death, prematurity, IUGR
IUGR
Intrauterine growth restriction
TORCH infections are what?
Toxoplasmosis, rubella, CMV, herpes simplex
What is the most common and concerning infective organism for otitis externa?
Pseudomonas aeruginosa
also common Staph a.
E.coli / candidiasis / aspergillus
What are non-infective causes of otitis externa?
Eczema and psoriasis
Where does cholesteatoma arise from?
Pars flaccida
Important complication of otitis externa?
Benign necrotising otitis externa - osteomyelitis of the skull base. Patient is very unwell and in severe pain.
Complications of cholesteatoma if untreated?
- Deafness due to ossicular damage or inner ear damage
- Dizziness due to semicircular canal damage
- Facial palsy due to bony erosion of the facial canal
- Meningitis or other intracranial infection due to erosion of the tegmen
Treatment for chronic infective suppurative otitis media?
Ciprofloxacin drops. Gentamicin + hydrocortisone drops.
Define vertigo
Hallucination of movement
Summarise the symptoms of menieres:
- recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
- a sensation of aural fullness or pressure is now recognised as being common
- other features include nystagmus and a positive Romberg test
- episodes last minutes to hours
- typically symptoms are unilateral but bilateral symptoms may develop after a number of years
Classic BPPV history (1 line)
I roll over in bed and go dizzy for about 30 seconds.
What test confirms BPPV?
- what is a positive test?
Dix Hallpike
- observe for torsional nystagmus.
How is BPPV treated?
Epley manoeuvre
Long term complication of menieres?
Sensorineural hearing loss.
What are the key treatments for Menieres?
Transtympanic steroids
Chemical labyrinthectomy (gentamicin ablation)
What is vestibular neuritis?
Inflammation or infection, usually viral, of vestibular nerve
Presentation of vestibular neuronitis?
Vertigo is the only otological symptom - lasts days to weeks.
Often may follow a URTI.
Labyrinthitis
Inflammation or infection, usually viral, of the labyrinth structures:
semicircular canals, saccule, utricle
Symptoms of Labyrinthitis?
Vertigo + deafness and tinnitus lasts days to weeks.
Treatment for vestibular neuritis and labyrinthitis?
IM or oral prochlorperazine
- only given for first week as in order to recover brain needs to develop compensation.
Cooksey-Cawthorne exercises.
Causes of bilateral facial nerve palsy?
- sarcoidosis
- Guillain-Barre syndrome
- Lyme disease
- bilateral acoustic neuromas (as in neurofibromatosis type 2)
- as Bell’s palsy is relatively common it accounts for up to 25% of cases f bilateral palsy, but this represents only 1% of total Bell’s palsy cases
What is the only UMN cause of a unilateral facial nerve palsy?
Stroke
Causes of unilateral facial nerve palsy (LMN).
- Bell’s palsy
- Ramsay-Hunt syndrome (due to herpes zoster)
- acoustic neuroma
- parotid tumours
- HIV
- multiple sclerosis*
- diabetes mellitus
Key feature in identifying an UMN facial palsy?
FOREHEAD SPARING
Is Bell’s palsy forehead sparing?
No it’s LMN - therefore affects all facial muscles.
What is the cause of Bell’s palsy?
Idiopathic if there is a known cause it’s not Bell’s palsy.
Sensory innervation of the facial nerve.
- Sensory– asmall area around the concha of the external ear.
- Special Sensory– provides special taste sensation to the anterior 2/3 of the tongue via the chorda tympani.
Intracranial causes of a facial nerve palsy?
Infection - if no cause found then termed Bell’s Palsy
Extracranial causes of a facial nerve palsy:
- Parotid gland pathology – e.g a tumour, parotitis, surgery.
- Infection of the nerve– particularly by the herpes virus.
- Compression during forceps delivery – the neonatal mastoid process is not fully developed and does not provide complete protection of the nerve.
- Idiopathic– If no definitive cause can be found then the disease is termed Bell’s palsy.
How is a facial palsy graded?
House-Brackmann
*1 – Normal
*6 – Complete palsy
*2 – A bit weak
*5 – A bit of movement
*3+4 – everything else: 3 = eye closure, 4 = unable to close eye (however oculomotor nerve also controls eye closure!)
Vesicles + a facial nerve palsy = what?
Ramsay hunt syndrome - varicella zoster.
Management of facial nerve palsy?
- Prednisolone 1mg/kg (up to 60mg) daily 1/52, taper by 10mg every
3 days thereafter - PPI cover as needed
- Viscotears or similar in the day
- Lacrilube or similar for night-time use
- Antivirals e.g. valacyclovir for Ramsey-Hunt
Treatment for Ramsay Hunt?
Prednisolone + PPI
Antiviral - Valacyclovir, absorbed much better orally that aciclovir.
In Weber’s test is conductive hearing loss is heard where?
The same ear
In Weber’s test is sensorineural hearing loss is heard where?
The opposite ear
Rinne’s test
BC > AC
Abnormal - conductive hearing loss
Rinne’s test
BC < AC
Normal for air conduction to be better.
What is a normal result for an audiogram?
20dB or better at all frequencies in both ears
AC > BC = ‘normal’
BC > AC = conductive hearing loss
AC > BC = ‘normal’
BC > AC = conductive hearing loss
How to identify sensorineural hearing loss on a pure tone audiogram?
f BC > 20dB there is sensorineural loss at that frequency, otherwise there is
not
How many dB to diagnose a conductive hearing loss?
If AC worse than BC by >10dB there is a conductive loss at that frequency, otherwise there is not.
Mixed loss on a pure tone audiogram:
If BC > 20dB and AC worse than BC by >10dB there is a mixed loss at that
frequency
How does presbycusis present on an audiogram?
Loss of hearing at higher frequencies.
How does noise damage hearing loss present on an audiogram?
Noise damage over long periods will cause a sensori- neural dip in hearing at 3, 4 or 6 kHz with improving thresholds at higher frequencies.
Respiratory problems associated with chronic rhinosinusitis.
- Asthmatics have 80% chance of CRS.
- COPD patients have 88% chance of CRS.
- Patients with poorly controlled CRS have a 50% chance of developing asthma.
- Patients with well-controlled CRS have a 7% chance of developing asthma.
Initial management of rhinosinusitis?
- Saline nasal douching bd
- Intranasal corticosteroid spray
Treatment of rhinosinusitis if initial management isn’t effective:
- without nasal polyps
*Maximal medical therapy - CRS without nasal polyps
* Saline nasal douching bd
* Fluticasone propionate nasules 400mcg
½ nasule each nostril bd 3/12
* Clarithromycin 250mg bd 3/12?
Treatment of rhinosinusitis if initial management isn’t effective:
- with nasal polyps
*Maximal medical therapy
*CRS with nasal polyps
* Prednisolone 0.5mg/kg ~ 30 – 40 mg od 1/52
* Saline nasal douching bd
* Fluticasone propionate nasules 400mcg
½ nasule each nostril bd 3/12
* Doxycycline 100mg od 3/52?
Important differential to consider for chronic rhinosinusitis:
- Unilateral – may be inverted papilloma, malignancy etc.
- Excessive crusting/bleeding – may be vasculitis e.g. granulomatosis with polyangiitis.
When to admit for chronic rhinosinusitis:
- Orbital infections e.g. cellulitis or abscess
- Intracranial infection e.g. meningitis or intracerebral absess
When to operate for chronic rhinosinusitis?
Surgical management aims to unblock normal sinus drainage pathways to facilitate future medical management
Considered after failure of maximal medical therapy
Frequently needed to manage orbital or intracranial complications
Useful in unilateral problems to obtain biopsy or remove disease.
What is the classic otoscopic finding in otosclerosis?
Schwartze’s sign [red vascular blush over the promontory and oval window].
Children presenting with glue ear with a background of Down’s syndrome or cleft palate should be managed how?
Children presenting with glue ear with a background of Down’s syndrome or cleft palate should be referred to ENT
Symptoms of acute labyrinthitis:
Sudden onset horizontal nystagmus, hearing disturbances, nausea, vomiting and vertigo.
Oral antibiotics should be given in acute otitis media with perforation
Oral antibiotics should be given in acute otitis media with perforation
What type of nystagmus do you get in vestibular neuronitis?
Horizontal nystagmus
What type of nystagmus do you get in BBPV.
Rotatory
What distinguishes labyrinthitis from vestibular neuronitis?
Hearing loss which occurs only in labyrinthitis.
What type of nystagmus is indicative of a positive Dix-Hallpike manoeuvre?
Rotatory nystagmus
Sudden onset HORIZONTAL NYSTAGMUS, hearing disturbances, nausea, vomiting and vertigo = what?
Acute viral labrynthitis
Acute management for menieres?
Prochlorperazine
Prophylaxis for menieres?
Beta histine
Describe vestibular neuronitis:
Vestibular neuronitis isinflammation of the vestibular nerve, resulting in vertigo thatlasts for days.Most cases are due to a viral infection, therefore a URTI precedes around half of the cases.
What are Cawthorne-Cooksey exercises used for?
Longer-term vestibular rehabilitation via Cawthorne-Cooksey exercises e.g for patients with balance issues following vestibular neuronitits.
What are the central causes of vertigo?
Multiple sclerosis
Posterior stroke
Migraine
Intracranial space-occupying lesion
1st line treatment for persistent otitis media?
Amoxicillin
1st line treatment for impacted ear wax that is causing a conductive hearing loss?
Olive oil drops followed by ear syringing is commonly used as a first-line treatment for impacted ear wax.
Acoustic neuromas are best visualised where?
Acoustic neuromas are best visualized by MRI of the cerebellopontine angle.
What triad do acoustic neuromas present with?
Unilateral sensorineural hearing loss
Tinnitus
Vertigo
Treatment for Ramsay Hunt syndrome?
Oral aciclovir for 7 days and oral prednisolone for 5 days.
When should you treat otitis media?
• Systemically unwell
• Immunocompromised
• Perforation/discharge
• < 2 years old with bilateral otitis media
When to admit a child with otitis media?
< 3 months old
Under 6 months with temperature 39°C
Suspected complications
Mastoiditis
BC > AC what result on Rinne’s test is this?
Negative Rinnes test!
What cranial nerves are affected by a vestibular schwanoma?
Vertigo and unilateral hearing loss indicating CN VIII involvement.
Absent corneal reflex indicating CN V involvement.
Unilateral facial numbness indicating CN VII involvement
Dysphagia to both food and liquids from the start
Achalasia
Investigation for achalasia
Oesophageal manometry testing
Loop diuretics may cause ototoxicity
Loop diuretics may cause ototoxicity
Ix for pharyngeal pouch
Barium swallow combined with dynamic video fluoroscopy is the investigation of choice for a suspected pharyngeal pouch
Presbycusis findings on an audiogram:
Bilateral high frequency hearing loss.
AC>BC.
Treatment of Ramsay Hunt syndrome
Oral aciclovir and corticosteroids.
Explain the medical management of vestibular neuronitis
Prochlorperazine may be useful in the acute phase of vestibular neuronitis, but should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms.
After the acute phase, mobilisation should be encouraged as well as twice daily vestibular rehabilitation exercises.
Treatment of mild otitis externa:
Acetic acid (available OTC as ear calm).
Treatment of moderate otitis externa:
Moderate otitis externa is usually treated with a topical antibiotic and steroid, for example:
- Neomycin, dexamethasone and acetic acid (e.g., Otomize spray)
- Neomycin and betamethasone
- Gentamicin and hydrocortisone
- Ciprofloxacin and dexamethasone
Treatment of severe otitis externa:
Patients with severe orsystemic symptoms may needoral antibiotics(e.g., flucloxacillin or clarithromycin) or a discussion with ENT for admission and IV antibiotics.
What are the ENT cancer referral guidelines for laryngeal cancer?
A suspected cancer pathway referral to an ENT specialist should be considered for people aged 45 and over with:
Persistent unexplained hoarseness or
An unexplained lump in the neck.
Glue ear in children affects development how?
- management?
Delayed speech is a sign of glue ear as they can’t hear people talk to learn themselves - combined with recurrent otitis media will likely need grommet insertion.
Hearing loss + off balance + LOSS OF CORNEAL REFLEX
Loss of corneal reflex - think acoustic neuroma
Causes of pulsatile tinitus:
- Vascular abnormalities, such as arteriovenous malformations, aneurysms, or stenosis
- High blood pressure or turbulent blood flow
- Glomus tumours
How should sudden sensorineural hearing loss be managed?
When a patient presents with sudden onset hearing loss it is important to examine them carefully to differentiate between conductive and sensorineural hearing loss → sudden-onset sensorineural hearing loss (SSNHL) requiresurgent referral to ENT.
An MRI scan is usually performed to exclude a vestibular schwannoma.
High-doseoral corticosteroids are used by ENT for all cases of SSNHL.
What is the most common cause of sudden sensorineural hearing loss?
The majority of SSNHL cases areidiopathic.
Tonsillitis 1st line and 2nd line abx’s:
1st = PenV
2nd (if penicillin allergic) = Clarithromycin
What gene is strongly associated with congenital hearing loss?
GJB2
