ENT Flashcards
Old age hearing loss name
Presbycusis
Hearing loss history questions
- Onset & progression
- Symptoms: otorrhoea, otalgia
- Vertigo, tinnitus or disequilibrium
- Headaches (acoustic neuroma)
- Exposure to loud noise
- Head trauma, ear trauma, barotrauma
- Ear surgery
- Recurrent ear infections, major infections
- Family history
- Ototoxic medications: frusemide, gentamicin
- Systemic symptoms; eg thyrotoxicosis (late stage)
Examination for hearing loss
- Otoscopy
- Pneumatic otoscopy
- Weber & Rinne test
- Cranial nerve exam
Conductive hearing loss causes
OUTER EAR
- Otitis externa
- trauma
- Wax
- Exostotsis
- Osteoma
- Congenital atresia
MIDDLE EAR
- Otitis media
- Cholesteatoma
- Otosclerosis
- TM perforation
- Temporal bone trauma
- Congenital atresia
Sensorineural hearing loss causes
- Presbycusis (age related sensorineural HL)
- Hereditary hearing loss
- Accoustic neuroma
- Menier’s
- Ototoxic drugs
- Noise exposure
- CVA
- Barotrauma
- Meningitis
- Thyrotoxicosis
History questions for Ear ache
- Fever
- Otorrhoea
- Hearing loss
- URTI /coryzal symptoms (most AOM, OME follow on from nasal congestion/infection)
- Swimming (OE) (barotrauma)
- ATSI
- Trauma
- Speech issues
- Attention /behaviour /school issues
- Balance issues
- Second hand smoke exposure
- Air travel (barotrauma)
Indications for antibiotics in acute otitis media
- <6m
- Bilateral <2
- Systemically unwell
- ATSI
- Otorrhoea (perforation)
- Immunocompromised
- Cochlear implant
Analgesia in AOM
Paracetemol 15mg/kg
Lignociane 2% 1-2 drops to INTACT TM
Ibuprofen 10mg/kg
Acute otitis media NON Aboriginal no red flags
- Analgesia
- Review 48 hours –> can give abx then
- Review 3 months to ensure effusion resolved
Persistent otitis media with effusion AKA
Glue ear
Features of chronic suppurative OM
Infection of middle ear
Perforated TM
Discharge
TIME COURSE: > 6 weeks
Treatment for Chronic suppurative OM
- Dry Aural Toilet 6hourly
- Ciprofloxacin 0.3% 5 drops BD until no d/c for 3days
OME (otitis media with effusion) Definition
Middle ear effusion without:
- Bulging membrane,
- fever
Looks like
- Loss of lucency
- Grey/white fluid
- Immobile TM with dilated vessels
OME referral for grommets (tympanostomy)
<3 months of OME
BUT with hearing loss and or learning/speech problems
> 3 months
Bilateral hearing loss
ATSI persistent otitis media with effusion (glue ear) for >3 months
- Refer for hearing assessment
- Consider 2-4 weeks of abx (amox 50mg/kg/day)
- Referral to ENT if OME> 3 months OR DB>20 loss in better ear
ATSI Acute Otitis Media with poor compliance antibiotics
Azithromycin 30mg/kg stat day 1 and 7
ATSI AOMwiP (with perforation) management
= Small hole (difficult to see) but with discharge
Amox 50-90mg/kg/day for 14 days
OR
Single dose azithromycin 30mg/kg
Review at day 7
If no better then 90mg/kg amox or second dose azithro
ATSI Recurrent AOM (rAOM)
Prophylactic not routine
but consider
Amox 50/mg on time per day for 3-6 months
??seems like a massive dose. (if child is <2)
ATSI chronic suppurative OM (CSOM)
= visible perf and discharge
- Clean pus
- Cipro 0.3% ear drops 5 drops BD
- Add amox 50-90mg/kg/day if perf not readily visible
- Continue for at least 3 days after ear becomes dry3
Tinnitis - causes
External ear:
- wax
- OE
Middle ear:
- OM
- Otosclerosis
- Cholesteatoma
Inner ear
- Schwannoma
- Menniers
- Ototoxicity
- nueritis
Non Auditory cuases
- Vascular anomalies
- Nasopharyngeal carcinoma
Imaging for tinnitis - when is it reasonable?
Pulsatile
- Vascular cause- get CT angio
Unilateral
- Focal lesion
Asymmetrical hearing loss
- MRI
Risk factors for head and neck cancers
- Smoking
- etOH
- > 40
- Previous neck malignancy
RED flags for head and neck masses
- Mass <2 weeks
- Voice change
- Dysphagia, odynophagia
- Otaliga, epistaxis, nasal obstruction (ipsilateral)
- Weight loss, loss of apetite
Investigation of neck mass
CT with contrast
FNA
Oral /mucosal ulcer: time course for suspicion?
> 2 weeks
(as cell turnover <10 days)
Leukoplakia & erythroplakia- what to do?
Biopsy is mandatory
NOTE: white plaques vs red plaques
Jaw swelling first line investigation
OPG
Otitis media step wise approach (no red flags)
1.Analgesia and review 48 hours
2. Amoxicillin 15mg/kg TDS for 5 days
3. If not improving at 48 hours: Augmentin DF (22.5/3.2mg/kg) BD 5 days
Intranasal antihistamine example
Azelastine 1mg/ml 1 spray each nostril BD
Allergic rhinitis intranasal cortisteroid
Mometasone 100microg daily 4 weeks then 50microg (2 spray to 1 spray)
= Nasonex
Allergic rhinitis combination therapy
Azelastine + fluticasone propionate 125+50mcg 1 spray BD
Olopatadine & mometasone 665+25mcg 2 sprays BD
Allergic rhinitis severe: intranasal atrovent
Ipatropium 44 mcg (2 sprays each nostril up to TDS
Caution with intranasal decongestants
Rhinitis medicamentosa (rebound congestion)
What type of hearing loss (specific)
Presbyacusis
Type of hearing loss pattern?
Sensorineural
Type of hearing loss pattern?
Conductive
Type of hearing loss pattern?
Noise induced hearing loss (sensorineural)
Otosclerosis features & managment
- Conductive hearing loss
- Develops 20s-30s
- Family hx (autosomal dominant)
- Lower frequencies then progresses
REFERRAL TO ENT (consider stapedectomy)
Symptomatic relief of acute rhino-sinusitis
- Simple analgesia
- Saline nasal preparations
- Intranasal corticosteroid
- Intranasal decongestant (short term)
- Intranasal ipatropium
Acute rhino-sinusitis- antibiotic regime & step wise
Shared decision making
Amoxicillin 15mg/kg (up to 500mg) TDS 5 days
Review in 5 days
Step up to Augmentin DF (22.5/3.2 mg/kg) BD 5 days
Middle ear effusion (OME) time course for referral
Persistent >3 months –> ENT REFERRAL
Cervical lymphadenitis Abx
Cephalexin 12.5mg (up to 500mg) 6hourly for 7 days
Persistent Cervical Lymphadenopathy (2-6 weeks) paeds investigations
- FBC, blood film
- CRP, ESR
- LDH
- LFT
- Serology; EBV/CMV/HIV
- Toxoplasmosis/Bartonella Henselae
- TB
- CXR
- Neck USS
- biopsy (excisional is gold standard, FNA less helpful)
Persistent Cervical Lymphadenopathy (2-6 weeks) paeds investigations
- FBC, blood film
- CRP, ESR
- LDH
- LFT
- Serology; EBV/CMV/HIV
- Toxoplasmosis/Bartonella Henselae
- TB
- CXR
- Neck USS
- biopsy (excisional is gold standard, FNA less helpful)
What is the cause of 90% of unilateral hearing loss?
Idiopathic
Treatment of idiopathic SNHL
Prednisolone 1mg/kg up to 60mg for 7-14 days
Menier’s disease management
- Hydrochlorothiazide 25mg daily
- Betahistine
- Vestibular rehabilitation
AOM with perforation antibiotics
Amoxicillin 15mg/kg TDS for 5 days
ADD
Ciprofloxacin drops
weber test: Lateralising to one side. 2 options
Sensorineural hearing loss in the other ear
Conductive in that ear
Menniers non- pharmacological advice
Sodium <2g /day
Limit caffeine
Limit etOH
Referral to audiologist for hearing aid
Referral to AEP for vestibular rehab
Menniers pharmacological management
Hydrochlorothiazide 25mg daily
Sore throat: RED flag populations necessitating antibiotics
- ABORIGINAL
- Maori/ pacific islanders
- RF or RHD
- Family history of RHD or RF
- Immunosuppressed
Dose of Phenoxymethylpenicillin for Strep Pharyngitis (and alternative for non compliance)
PMP
15mg/kg up to 500mg 12hourly for 10 days
Benzathine benzylpenicillin IM stat dose
Tympanostomy Tube Otorrhoea (TTO)
Dry mopping
Topical ciprofloxacin 5drops BD 7 days
Sudden onset (idiopathic) sensorineural hearing loss treatment
Prednisone 60mg 7-14 days
Mometasone dose for a child
50 microg each nostril daily
Mennier’s pharmacotherapy
HCT 25mg daily
Vestibular Neuritis Pharmacology
Prednisolone 1mg/kg (up to 75mg) daily for 5 days
Examination for hearing loss (what are your three key exams)
Otoscopy
Weber and rinnes
Cranial nerve exam
