ENT Flashcards
What is otitis externa ?
It is a diffuse inflammation of the skin lining the external auditory meatus.
What is the external auditory meatus ?
External part of the ear that lies between the surrounding environment and middle ear. It is 2cm long and lined with normal skin ending at the tympanic membrane.
What are the clinical features of otitis media ?
Rapid onset
Scanty discharge
Otalgia
Itching
Feeling of fullness
What is seen on examination of the ear in otitis media ?
Meatal tenderness
Narrowed, Oedematous meatus
Erythema and narrowing
Tuning fork may demonstrate mild conductive deafness
What are some causative agents of otitis externa ?
Bacteria - pseudomonas aeruginosa and staph aureus
Fungi - Candida and aspergillus
Allergy
Iatrogenic
What are some risk factors for otitis externa ?
Swimming
Increased humidity
Foreign objects in ear - cotton buds
Trauma to the ear canal
Scratching
Eczema or psoriasis
Diabetes
Previous ear surgery
What is the management of otitis externa ?
Swab ear canal
If pseudomonas give Ciprofloxacin
If not give oral flucloxacillin
Pain relief
What is a complication of otitis externa ?
Malignant otitis externa
What are some causes of noise related hearing loss ?
Occupational - prolonged industrial exposure
Recreational - loud music
Accidental - blast injury or gunfire
What is seen on an audio gram in noise induced hearing loss ?
Notching at 3000,4000 or 6000 Hz with recovery at 8000 Hz
Precise notching depends on the frequency of the noise and the length of the ear canal
What are some clinical features of noise-induced hearing loss ?
Always sensorineural and often accompanied by high-pitched tinnitus
Usually bilateral
Irreversible
What is the management of noise induced hearing loss ?
Cannot be treated as damaged hair cells do not recover
Use of hearing aids
What may be used as a preventative measure for noise related hearing loss ?
Foam - insert earplugs
High usage of noise protection
What is Ménière’s disease ?
A condition of the inner ear which causes sudden attacks of vertigo and tinnitus. It also causes a persons hearing to decrease over time.
What causes Ménière’s disease ?
Not fully understood but could be due to extra fluid in the inner ear called endolymph which could be due to poor drainage.
What symptoms are experienced in Ménière’s disease ?
Tinnitus
Dizziness
Feeling of fullness behind the ear - aural fullness
Nausea and vomiting
Hearing loss
What is the management of Ménière’s disease ?
No cure
Anti-emetics and antihistamines may help reduce the symptoms
What is Presbycusis ?
A progressive condition causing hearing loss that comes on with age. Usually bilaterally and is sensorineural.
What symptoms are present in Presbycusis ?
Hears Slurred or mumbled speech
Struggle to hear higher pitch sounds
Tinnitus
What is the management of Presbycusis ?
Hearing aids may help improve hearing
What is otitis media ?
Inflammation of the middle ear usually associated with a URTI.
What is the management of otitis media ?
Discuss and advise that most infections resolve without antibiotics after 3 days
Pain relief
Decongestants and antihistamines
Consider antibiotics ( amoxicillin 5-7 days )
What are some symptoms of otitis media ?
Ear pain
Ear rubbing
Cloudy eardrums
Bulging ear drums
Redness
What are some complications of otitis media ?
Hearing impairment
Tympanic membrane perforation
Mastoiditis
Meningitis
What is secretory otitis media ?
The accumulation of serous or mucoid fluid in the middle ear cavity without signs and symptoms of an acute infection.
Conductive hearing loss
What are the clinical features of secretory otitis media ?
Hearing impairment
Recurrent infections
Ear fullness or popping
Dull appearance of the tympanic membrane
Retraction of the ear drum
Rinne’s test - negative and Weber’s test is heard more on the deafer ear
What is the management of secretory otitis media ?
Resolves spontaneously within 6 weeks
Decongestants and antibiotics
If recurrent refer to ENT specialist
What is mastoiditis ?
The result of extension of acute otitis media into the mastoid air cells with an accompanying suppuration an bone necrosis which can cause extra dural and subperiosteal abscesses.
What are the clinical features of mastoiditis ?
Earache - persistent and throbbing
Cramp profuse ear discharge
Increasing deafness
Pyrexial and looks ill
Tenderness over the mastoid antrum
Pinna may be pushed down and forward
Red or perforated tympanic membrane
What investigations are performed for mastoiditis ?
FBC - raised neutrophils
Mastoid radiograph - opacity and air coalescence
What is the management of mastoiditis ?
Antibiotics IV
Cortical mastoidectomy is no response to antibiotics or there is a subperiosteal abscess
What are the complications of mastoiditis ?
Masked mastoiditis
Cranial extra dural abscess
What is chronic suppurative otitis media ?
Chronic inflammation and infection of the middle ear and mastoid cavity characterised by ear discharge through the perforated tympanic membrane
When does otitis media become chronic ?
Differs per person
Otorrhoea for more than 2 weeks or 6 weeks
What are some clinical features of chronic otitis media ?
Ear discharge
Hearing loss
What is the management of chronic otitis media ?
Don’t swab the ear if diagnosis suspected
Refer to ENT to confirm diagnosis
What are some complications of chronic otitis media ?
Acute mastoiditis
Meningitis
Extra dural abscess
Brain abscess
Labyrinthitis
Facial nerve paralysis
What is acute sinusitis ?
Inflammation of the paranasal sinuses which completely resolves in 12 weeks
What are some features of acute sinusitis ?
Presence of nasal blockage or nasal discharge Facial pain / pressure
Altered sense of smell
Tenderness or swelling over the cheekbone or periorbital region
Cough
When should acute bacterial sinusitis be suspected ?
Symptoms are longer than 10 days
Discoloured or purulent discharge
Severe local pain
Fever greater than 38
Elevated ESR or CRP
What are some differentials for sinusitis ?
URTI
Allergic rhinitis
Nasal foreign body
Adenoiditis or tonsillitis
Sinonasal tumour
Migraine
GCA
What is the management of acute sinusitis ?
- If symptoms lest than 10 days - don’t offer antibiotics
Advise that it is usually viral and can take 2-3 weeks to resolve.
OTC meds - if symptoms have been longer than 10 days - consider high dose nasal corticosteroids and if antibiotics are required give phenoxymethylpenicillin
When should a referral to ENT be considered for acute sinusitis ?
Frequent recurrrent episodes
Failure of treatment to work
Unusual or resistant bacteria
Immunocompromised
Presence of nasal polyps
What is chronic sinusitis ?
Sinusitis that causes symptoms to last for longer than 12 weeks
What are some causes of sinusitis ?
Asthma
Allergic rhinitis
Smoking
Impaired ciliary motility - CF
What is the management of chronic sinusitis ?
Nasal saline irrigation
Topical intranasal corticosteroids
CT is needed if all other meds fail and functional endoscopic sinus surgery could be an option
What advise should be given to people with chronic sinusitis ?
Avoid allergic triggers
Stop smoking
Avoid underwater diving
What is a thyroid nodule ?
Lumps that may be present in the thyroid gland upon examination.most lumps are adenomatous and there are usually multiple .
What are some causes of thyroid nodules ?
Graves’ disease
Thyroid cancer
Thyroid cyst
Hashimoto’s disease
Iodine deficient
What are some investigations for thyroid nodules ?
TFT’s
USS
Fine needle aspiration
CT or MRI scan if malignancy suspected
If a thyroid lump is suspected on examination what should be done if there is also stridor ?
Arrange emergency hospital admission
When should an urgent referral be made to a thyroid surgeon or endocrinologist if there is a thyroid lump ?
It is unexplained
There is hoarseness of the voice
Associated cervical or supraclavicular lymphadenopathy
Rapidly expanding painless mass
Red flags for malignancy
What should be performed on people with a suspected thyroid lump in primary care ?
Perform TFT’s
Arrange a routine endocrinology referral if severe however manage condition if no red flags
If a thyroid nodule produces extra hormone what symptoms are likely to be present ?
Unexplained weight loss
Increased sweating
Tremor
Anxiety
Tachycardia or arrhythmias
What symptoms would indicate hypothyroidism ?
Increased Sensitivity to cold
Fatigue
Dry skin
Memory problems
Depression
Constipation
What is acute labyrinthitis ?
An inflammatory condition of the otic capsule. Could be caused by an infection of the inner ear.
How does acute labyrinthitis present ?
Sensorineural hearing loss
Vertigo
Problems with balance
What is the difference between serous and suppurative labyrinthitis ?
Suppurative follows direct microbial invasion of the inner ear and usually presents with severe to profound hearing loss and vertigo - usually bacterial .
Serous results from inflammation of the labyrinth only and presents with less severe hearing loss - usually viral
What is seen on examination in acute labyrinthitis ?
Weber’s and Rinne’s test - sensorineural
Head impulse test - vertigo
CT and MRI and possibly audio gram
What is the management of acute labyrinthitis ?
Viral Labyrinthitis is treated with anti-emetics to address the nausea such as Metoclopramide or Ondansetron and vestibular suppressants such as Cyclizine
Suppurative - oral antibiotics and can be supplemented with anti-emetics and vestibular suppressants
What is a deviated septum ?
This happens when the nasal septum is significantly displaced to one side making one of the nasal passages smaller than the other.
If severe one side of the nasal passage can be blocked and reduce air flow causing breathing difficulties.
What are some symptoms of a deviated septum ?
None
Difficulty breathing through the nostril
Nosebleeds due to the nasal septum becoming dry
Facial pain
What are some causes of a deviated septum ?
Condition at birth
Nose injury - trauma
Due to ageing
what are the complications of a deviated septum ?
Dry mouth
Pressure feeling
Disturbed sleep
What is the management of a deviated septum ?
Decongestants to reduce nasal swelling
Antihistamines to prevent allergy symptoms
Nasal steroid spray to reduce swelling
Surgical repair - septoplasty
What are some clinical signs of a nasal fracture ?
Pain
Displaced bone/cartilage
Changes on appearance
Nose bleed
Difficulty breathing
Septal haematoma
Swelling and bruising of the nose and eyelids
What are the causes of a nasal fracture ?
Facial injuries / contact sport / falls
Injuries to the teeth and mouth
What investigations should be done for a nasal fracture ?
X ray
Ct
Otoscope
What is the management of a nasal fracture ?
If the nose is broken but not out of place - treatment may not be needed other than rest, ice and pain relief
Manual realignment - needs to be done before 2 weeks - a splint may be used
Surgery - severe or if longer than 2 weeks
What is a vestibular migraine ?
A type of migraine that mainly presents with dizziness
What can trigger a vestibular migraine ?
Stress
Lack of sleep
Dehydration
Menstruation
Weather changes
What symptoms are present in vestibular migraines ?
Severe, throbbing headache - on one side of the head
Nausea and vomiting
Vertigo
Unsteadiness or loss of balance
Sensitivity to motion
What investigations are performed for vestibular migraines ?
Mainly based upon symptoms of patient
Neurological exam
What is the management of a vestibular migraine ?
There is no specific treatment options for this/
Conventional migraine management
What is vestibulopathy ?
Disorders of the inner ear - umbrella term for vestibular neuritis or labyrinthitis, BPPV, Ménière’s and more
What are the symptoms of vestibulopathy ?
Vertigo
Nausea and vomiting
Decreased balance
Walking and balance difficulties
Blurry vision
Hearing loss - of cochlea involved
What are the investigations for vestibulopathy ?
ENG - electronystagmography
Rotatory chair testing
Romberg test, visual acuity
Ophthalmoscope
What is the management of vestibulopathy ?
Treatment involves finding the cause and treating it however it is usually rare that a cause is identified.
Anti-emetics and balance exercises
What are the types of allergic rhinitis ?
Seasonal - hay fever - caused by grass and tree pollen allergens
Perennial - caused by house dust mites and animals
Occupational - caused by allergens at the workplace eg. Flour
What are some of the clinical features of allergic rhinitis ?
Rhinnorhea
Nasal blockage
Sneezing attacks
Itching of the eyes and nose
Watery eyes
Malaise
Headache
Wheezing
SOB
What other conditions usually coexist with allergic rhinitis ?
Asthma
Eczema
Chronic sinusitis
What are some of the investigations performed for allergic rhinitis ?
History is important - time of the day, what activity, seasonal
Skin prick test assesses IgE bound to cutaneous mast cells
Allergen specific IgE antibody testing ( RAST ) is useful for dust mites, pollen and pet dander.
What is the management of allergic rhinitis ?
Removal of trigger - pets
Antihistamines
Corticosteroids ( nasal, oral or IM )
Leukotriene receptor antagonist - Montelukast
When is surgery contemplated for allergic rhinitis ?
If medical treatment is unsuccessful
Indications -
- nasal polyps
- septal deviation
- inferior turbinate hypertrophy
What is the referral criteria from primary care for perennial rhinitis ?
Severe symptoms that are resistant to treatment - tried for 3 months
Unilateral nasal symptoms
Nasal perforation
Serosangionous discharge
Recurrent cellulitis
What are nasal polyps ?
They are yellowish, grey, pedunculated sacs which usually cause progressive nasal obstruction. Usually bilateral
Why is a unilateral nasal polyp deemed suspicious and what should be done following its finding ?
A unilateral polyp should be assumed to be neoplastic until proven otherwise.
Sent for histological examination
What is the common origin for nasal polyps ?
Ethmoid sinus
What are some clinical features of nasal polyps ?
Progressive nasal obstruction
Rhinorrhoea
Post nasal drip
Anosmia
Sneezing
Hyponasal voice
What are some investigations for nasal polyps ?
Test for allergies
Exclude CF in children
Biopsy unilateral polyps to exclude neoplasia
What is the medical management of nasal polyps ?
Topical steroids such as betamethasone drops
What are some surgical options for nasal polyps ?
Polypectomy - performed through the nostril
Ethmoidectomy - clearing of the ethmoid air cells from which most polyps arise - carried out endoscopically
What can cause cervical lymphadenopathy ?
Lymphomata
Secondary tumour deposit
Local inflammation due to infection
Generalised lymphadenopathy - HIV
Which cancers can cause cervical lymphadenopathy ?
Squamous carcinoma and melanoma of the skin of the neck, face, scalp and ear
Squamous carcinoma of the mouth and tongue, nasopharynx, oropharynx, larynx and paranasal sinuses
Adenocystic carcinoma of the salivary glands
Papillary carcinoma of the thyroid
How can cervical lymphadenopathy be diagnosed ?
Physical examination of the neck region
USS
CT scan or MRI
What is Benign paroxysmal positional vertigo ?
A disorder characterised by brief recurrent attacks of vertigo provoked by certain changes in head position with respect to gravity.
What is the diagnostic criteria of Benign paroxysmal positional vertigo ?
At least 5 attacks of vertigo with one of the following :
. Nystagmus
. Ataxia
. Vomiting
. Pallor
. Fearfulness
Normal neurological examination and audoiometric and vestibular functions between attacks
What is the proposed pathophysiology of BPPV ?
The canalolithiasis hypothesis - small crystals called otocania come loose from their normal location on the utricle. When detached they can flow freely in the fluid filled spaces of the inner ear and cause vertigo.
What are some causes of BPPV ?
Idiopathic
Secondary causes -
. Head trauma
. Mastoid surgery
. Vestibular neuritis
. Labyrinthitis
. Ménière’s disease
What are some clinical features of BPPV ?
Symptoms are precipitated by a change of position of the head
Vertigo
Nausea
Imbalance and lightheadedness
What are some differentials for recurrent vertigo ?
BPPV
Ménière’s disease
Migraines
Panic disorders
Cerebellar disease ( with nystagmus )
What is the management of BPPV ?
Observe and wait as it is usually self-limiting and may subside in 6 months
Medial management
- anti-emetics and vestibular sedatives
- particle repositional manoeuvres - redirect the otoconial particles back to the utricle
Surgery
What can help diagnosis of BPPV ?
Hallpike manoeuvre
Supine roll test
What are the functions of the sinuses ?
Lightening the weight of the head
Supporting immune defence of the nasal cavity
Humidifying inspired air
Increasing resonance of the voice
What are the functions of the nasal cavity ?
.Warms and humidifies the inspired air
.Removes and traps pathogens and particulate matter from inspired air
.responsible for the sense of smell
. Drains and clears the paranasal sinuses and lacrimal ducts
What are the major functions of the oral cavity ?
Digestion
Communication
Breathing
How is Weber’s test performed ?
Strike the tuning fork to make it vibrate and hum
Place it in the centre of the patient’s forehead
Ask them if they can hear the sound and which is the loudest
What indicates a conductive hearing loss when performing Weber’s test ?
The sound will be louder in the affected ear
What indicates sensorineural hearing loss in weber’s test ?
The sound will be louder in the normal ear as it is better at sensing sound.
How is the Rinne’s test performed ?
Strike the tuning fork to make it vibrate and hum
Place the flat end on the mastoid process - testing bone conduction
Ask the patient to tell you when they cant hear the humming noise
When they can no longer hear it hover the tuning fork 1cm from the ear - testing air conduction
Repeat on other ear
What is a normal result in the Rinne’s test ?
When the patient can hear the sound again when bone conduction ceases and the tuning fork has been moved next to the ear.
This shows that air conduction is better than bone conduction.
what is an abnormal result in the Rinne’s test ?
This is when bone conduction is better than air conduction. This is when the tuning fork is not heard when holding it over the ear. This suggests conductive hearing loss
What are some causes of sensorineural hearing loss ?
Presbycusis
Noise exposure
Ménière’s disease
Labyrinthitis
Acoustic neuroma
Infections such as meningitis
Medications
What are some causes of conductive hearing loss ?
Ear wax
Infection
Middle ear effusions
Eustachian tube dysfunction
Otosclerosis
Cholestatoma
What is an audio gram ?
Charts that document the volume at which patients can hear different tones.
The frequency in hertz is plotted on the x axis from low to high pitches and the decibels are plotted on the y axis (loud is lower and quieter is higher )
What is seen in patients with sensorineural hearing loss on an audio gram ?
Both air and bone conduction readings will be more than 20dB. One ear can be affected or both can.
What is seen in conductive hearing loss in an audio gram ?
Bone conduction Readings will be normal
Air conduction readings will be greater than 20dB as sound struggles to travel through the air due to pathology.
What are the risk factors for Presbycusis ?
Age
Male
Family history
Loud noise exposure
Diabetes
Hypertension
Smoking
How is a diagnosis of Presbycusis established ?
Audiometry - worsening hearing at higher frequencies
What is otosclerosis ?
A condition where there is remodelling of the small bones in the middle ear leading to conductive hearing loss.
What is the pathophysiology of otosclerosis ?
The tiny bones in the ear are affected by abnormal bone remodelling and formation. The base of the stapes is usually affected where it attaches to the oval window causing stiffening and fixation. This reduces the transmission of sound
How does otosclerosis present ?
Hearing loss - usually affects the hearing of lower pitched sounds.
Tinnitus
What is seen on examination in otosclerosis ?
Otoscopy is normal
Weber’s test - normal if bilateral, if unilateral the sound will be louder in the affected ear.
Rinne’s test - heard better when placed on mastoid process.
What investigations are performed in otosclerosis ?
Audiometry - hearing loss in lower frequencies, air conduction will be greater than 20dB
Tympanometry will show reduced admittance of sound
CT
What is the management of otosclerosis ?
Hearing aids
Stapedectomy or stapedotomy
What organisms are most likely to cause otitis media ?
Strep pneumoniae
Haemophilus influenzae
Staph aureus
Moraxella catarrhalis
What is seen on examination in otitis media ?
Otoscopy - red bulging inflamed tympanic membrane
What can a build up of ear wax cause ?
Conductive hearing loss
Discomfort in the ear
Feeling of fullness
Pain
Tinnitus
What is tinnitus ?
A persistent additional sound that is heard but not present in the surrounding environment. It may be described as a ringing in the ears or buzzing, hissing or humming noise.
What are some causes of tinnitus ?
Impacted ear wax
Ear infection
Ménière’s disease
Noise exposure
Acoustic neuroma
Trauma
Medications
What is vestibular neuronitis ?
Inflammation of the vestibular nerve usually due to a viral infection. It distorts the signals travelling from the vestibular system to the brain confusing the signal required to sense movement. This results in vertigo.
How does vestibular neuronitis present ?
Vertigo
Nausea and vomiting
Balance problems
what is the management of vestibular neuronitis ?
Short term options - prochlorperzine
Antihistamines
What is a cholesteatoma ?
An abnormal collection of squamous epithelial cells in the middle ear. It is non-cancerous but can invade other local tissues and nerves and erode the bones of the middle ear.
What is the pathophysiology of cholesteatoma ?
Not fully understood
The main theory is that negative pressure in the middle ear caused by Eustachian tube dysfunction causes a pocket of the tympanic membrane to retract into the middle ear. The squamous cells still proliferate and grow into the surrounding space, bones and tissues. It can damage the ossicles resulting in permanent hearing loss.
How does cholesteatoma present ?
Foul discharge
Unilateral conducive hearing loss
Pain
Vertigo
Facial nerve palsy
What is seen on Otoscopy in a cholesteatoma ?
An abnormal build-up of whitish debris or crust in the upper tympanic membrane. However it may not be possible to visualise the ear drum if discharge or wax are blocking the canal.
What is the management of cholesteatoma ?
A CT head can be used to confirm the diagnosis and plan for surgery
MRI may help assess the invasion and damage to local soft tissues.
Treatment involves surgical removal of the cholesteatoma.
What is obstructive sleep apnoea ?
It is caused by the collapse of the pharyngeal airway and characterised by episodes of apnoea during sleep where the person can stop breathing for up to a few minutes. The person is usually unaware of this.
What are some risk factors of obstructive sleep apnoea ?
Middle age
Male
Obesity
Alcohol
Smoking
What are some clinical features of sleep apnoea ?
Episodes of apnoea during sleep
Snoring
Morning headache
Waking up unrefreshed from sleep
Daytime sleepiness
Concentration problems
What is the management of obstructive sleep apnoea ?
ENT referral or specialist sleep clinic to perform sleep studies.
Advise against smoking, stop drinking alcohol and lose weight.
CPAP machines at night
What is tonsillitis ?
Inflammation of the tonsils usually caused by viral infections.
What is the most common causes of bacterial tonsillitis ?
Group A strep ( pyogenes )
Strep pneumoniae
Haemophilus influenza
How does tonsillitis present ?
Sore throat
Fever
Pain when swallowing
What is seen on examination of tonsillitis ?
Red, inflamed and enlarged tonsils
Possible exudate
Swollen lymph nodes
What is used to assess if the tonsillitis is viral or bacterial ?
Centor score
FeverPAIN score
What is the management of tonsillitis ?
If centor score is above 3 and feverPAIN score is above 4 give antibiotics - penicillin 5 also called phenoxymethylpenicillin
What are some potential complications of tonsillitis ?
Peritonsillar abscess
Otitis media
Scarlet fever
What is a peritonsillar abscess ?
It arises when there is a bacterial infection with trapped pus forming an abscess in the region of the tonsils.
How does tonsillitis present ?
Sore throat
Painful swallowing
Fever
Neck pain
Referred ear pain
Swollen lymph nodes
Trismus - unable to open their mouth
Change in voice
Swelling and erythema beside the tonsils
What is the usual cause of a peritonsillar abscess ?
Bacterial infection usually due to streptococcus pyogenes
Can be staph aureus and Haemophilus influenzae
What is the management of a peritonsillar abscess ?
Referral to ENT hospital care for needle aspiration or surgical incision and drainage to removed the pus.
Antibiotics should be given - co-amoxiclav
Possibly give Dexamethasone to settle inflammation and help recovery.
What is glossitis ?
Inflamed tongue - red swollen and sore.
The papillae shrink and give it a smooth appearance
What are some causes of glossitis ?
Iron deficiency anaemia
B12 deficiency
Folate deficiency
Coeliac disease
What is oral candidiasis ?
Refers to the overgrowth of candida in the mouth. This results in white spots or patches that coat the surface of the tongue and palate.
What factors can predispose someone to developing oral candidiasis ?
Inhaled corticosteroids
Antibiotics
Diabetes
Immunodeficiency
Smoking
What are some treatment options for oral candidiasis ?
Miconazole gel
Nystatin suspension
Fluconazole tablets
What conditions cause a strawberry tongue ?
Scarlet fever
Kawasaki disease
