ENT Flashcards
Webers test
How to: Strike tuning fork and place on centre of forehead.
Results;
* Normal = patient hears sound equally in both ears
* Sensorineural hearing loss = Sound is quieter in affected ear
* Conductive hearing loss = Sound is **louder **in affected ear
Rhinne’s test
How to: Strike tuning fork and place it flat on the mastoid process. Ask the pt to tell you when they stop hearing it and then remove it and hover it 1cm away from the ear.
Results;
* Normal = pt can hear the sound again once placed next to the ear
* Conductive hearing loss = Bone conduction is better than air conduction.
Causes of Sensorineural hearing loss
Sudden sensorineural hearing loss
Presbycusis
Noise exposure
Meniere’s disease
Labrynthitis
Acoustic neuroma
Neurological conditions
Infections (e.g meningitis)
Medications
Which medications cause sensorineural hearing loss
Loop diuretics
Gentamicin (&other aminoglycosides)
Cisplatin
Causes of conductive hearing loss
Ear wax / blockage
Infection - otitis media / otitis externa
Fluid in middle ear
Eustachian tube dysfunction
Perforated tympanic membrane
Otosclerosis
Cholesteatoma
Exostoses
Tumours
Presbycusis
Age related hearing loss - due to a loss of hair cells & neurons in the cochlea & atrophy of the stria vascularis
RF = old age / male / loud noise exposure / diabetes / HTN / ototoxic meds / smoking
Presentation;
* Typically affects **high pitched sounds first **
* Occurs gradually and symmetrically
* Often noticed by friends & family before patient
* **Tinnitus **
Invx = Gold standard = Audiometry which shows a sensorineural hearing loss pattern (worse at higher frequencies).
Management = optimise environment, give hearing aids or cochlea implants
Sudden sensorineural hearing loss (SSNHL)
Hearing loss over <72hours, unexlpained by other causes - an Otological emergency.
Causes;
* 90% idiopathic
* Infection e.g meningitis, mumps, HIV
* Meniere’s disease / MS / Migraine / Stroke
* Acoustic neuroma
* Ototoxic meds
* Gogan’s syndrome (rare autoimmune condition causing inflammation of eyes + inner ear)
Invx = Audiometry (loss of 30db in 3 consecutive frequencies)
MRI head / CT head to rule out stroke/acoustic neuroma/MS
management = immediate ENT referal (<24hrs) +/- steroids.
A loss of 30 decibels in 3 consecutive frequencies on audiometry testing is diagnostic of what condition?
Sudden sensorineural hearing loss
Labrynthitis
Inflammation of bony labrynth - including semicircular canals, vestibule + cochlea.
Usually attributed to a recently viral URTI.
Sx;
* Acute onset vertigo
* Hearing loss
* Tinnitus
* May have associated coryzal symptoms
Diagnosis = exclusion of other causes. Can do head impulse test (confirms peripheral cause of vertigo e.g labrynthitis)
Management = supportive care + short term symptomatic relief with Prochlorperazine/antihistamines
Meniere’s disease
Long term inner ear disorder caused by excess endolymph in the labrynth (endolymphatic hydrops) distrupting the sensory signals.
Sx;
* Typically age 40-50yrs
* Unilateral hearing loss - fluctuates at first then becomes permanent. Typically low pitched sounds first
* Vertigo - episodes lasting 20mins-hours. Not positional
* Tinnitus
* Unidirectional nystagmus may be seen during an acute attack
Diagnosis = Made by ENT specialist. Need audiology assesment.
Management;
- Prochlorperazine & Antihistamines
- Prophylaxis = betahistine (anti-vertigo)
Main difference between labrynthitis + vestibular neuritis
Both present with vertigo however vestibular Neuritis has No loss of hearing
Benign tumour of schwaan cells around the vestibulocochlear nerve
Acoustic neuroma (Vestibular schwwanoma)
Tumours typically occur at the cerebellopontine angle.
Features;
* Usually unilateral - if its bilateral then associated with neurofibromatosis type 2
* Hearing loss
* tinnitus
* Dizziness/imbalance
* Feeling of fullness in the ear
* Facial nerve palsy - if the tumour is large enough to compress the facial nerve - forehead is NOT spared as its a LMN lesion
Investigations - Audiometry confirms sensorineural hearing loss. MRI/CT can detect the tumour.
Management = Conservative. Surgery can be done to remove it / Radiotherapy to reduce growth
*Risks = Vestibulocochlear nerve injury / facial nerve injury
Eustachian tube dysfunction
Often related to viral URTI, Allergies or smoking.
Sx;
* Altered hearing
* Popping sensation in the ear
* sensation of fullness in the ear
* pain
* tinnitus
Symptoms typically get worse when the external air pressure changes e.g flying
Investigations = Otoscopy (to rule out other causes).
Tympanometry + audiometry can be of use.
Management = conservative manage
Valsalva manoevre (to inflate eustachian tube)
Decongestant nasal sprays / Otovent
Antihistamines / steroid nasal sprays if allergies
Surgical options = Adenoiectomy / grommets / Balloon dilation eustachian tuboplasty
Otosclerosis
= remodelling of the small bones in the inner ear leading to conductive hearing loss = autosomal dominant inheritence. Mainly affects the base of the stapes.
Sx;
* Usually presents <40yrs
* Hearing loss - affects low pitched sounds first
* Tinnitus
* pts may hear their voice sounding really loud compared to the environment
Invx = audiometry confirms conductive loss. Tympanometry shows reduced admittance of sound. High res CT can be done.
Management = hearing aids +/- Stapedectomy
Acute otitis media
Infection of the middle ear
Streptococcus pneumoniae most common
Sx;
* Ear pain
* Hearing loss in affected ear
* fever
* Coryzal symptoms
* May cause balance issues/vertigo
If the tympanic membrane perforates = discharge from ear (purulent otorrhoea)
Investigations;
* Otosopy shows a bulging tympanic membrane causing loss of light reflex. Also see opacification/erythema of the membrane.
Management = generally self limiting.
Antibiotics if indicated
Diagnostic criteria of acute otitis media
- acute onset of symptoms (otalgia/ear tugging)
- Presence of a middle ear effusion (bulging membrane, ottohorea)
- inflammation of the tympanic membrane
Indications for anitbiotics in otitis media
Symptoms lasting >4days or no improvement
Systemically unwell
immunocomprimised
Age <2yrs with bilateral otitis media
Perforation/discharge
Give 5-7 days amoxicillin (or clarith if pen allergic / erythromycin in pregnant allergic)
Complications of otitis media
Perforation
Chronic suppurative otitis media
Hearing loss
labrynthitis
mastoiditis
Meningitis
brain abscess
facial nerve palsy
Otitis externa
Inflammation of the skin in the external ear. A.K.A swimmers ear
Causes;
1. pseudomonas auerginosa (treat with gentamicin or ciprofloxcain)
2. Staph aureas
3. fungus - suspect this in pts with multiple recent Abx
Features = ear pain + discharge + itchiness + hearing loss. Otoscopy shows erythema of canal
Management;
1. Mild = Treat with acetic acid 2% (available OTC - use before and after swimming for prophylaxis)
2. Moderate = Topical antibiotic + steroid (e.g Neomycin + dexamethasone or Gentamicin + hydrocort) - *note these are ototoxic so do not give if perforation - refer to ENT *
3. Severe = Oral antibiotics (fluxoc or clarith) or admit to ENT
Malignant otitis externa
A severe life threatening form of otitis externa where the infection spreads to the bones surrounding the ear canal + skull, progressing to osteomyelitis of the temporal bone.
Usually due to underlying risk factors e.g immunosupression.
Sx = more severe + persisten headache + fever
Invx = The presence of granulation tissue is diagnostic.
Management = Admit to ENT for IV antibiotics + imaging
Cholesteatoma
Abnormal collection of squamous epithelial cells in the middle ear - it is benign but may invade local structures / erode bones of the middle ear.
Sx;
* Foul discharge from the ear
* Unilateral conductive hearing loss
*as it expands you may develop infection, pain, vertigo and facial nerve palsy
Diagnosis = otoscopy shows an abnormal build up of white-ish debris / “attic crust” in the upper tympanic membrane
Mangement = CT head confirms diagnosis. MRI helps to assess invasion to local tissue.
Surgery is definitive
Causes of Vertigo
Peripheral;
* BPPV
* Meniere’s disease
* Vestibular neuronitis
* Labrynthitis
* Ramsay-hunt syndrome
* Acoustic neuromas
* Trauma to the vestibular nerve
Central vertigo;
* Posterior stroke
* Tumour
* MS
* Vestibular migraine
Main differences between peripheral & central vertigo
Peripheral vertigo = Sudden onset & short duration. Hearing loss is common. Coordination will be intact & Nausea will be severe
Unlike central causes which tend to be a gradual onset but persistent Sx. Hearing loss and nausea are less common but Coordiantion is likely to be impaired.
Examination for vertigo
- HINTS exam;
* Head impulse test
* Nystagmus
* Test of skew - Romberg’s test - identifies problems with proprioception (dorsal columns) or Vestibular function
- Dix-hallpike manoeuvre - can diagnose BPPV.
BPPV
= Caused by crystals of calcium carbonate (otoconia) being displaced into the semicircular canals (mainly posterior) therefore distrupting the flow of endolymph.
Features;
* Vertigo - this is triggered by head movements, classically when turning over in bed
* Symptoms tend to resolve within 20-60 seconds
* Asymptomatic between attacks
*Does not cause hearing loss or tinnitus (if this is present consider labrynthitis)
Management;
–> Dix-hallpike (geotropic nystagmus confirms diangosis) followed by epley manouevre
Brandt-daroff exercises can be performed at home.
Vestibular neuronitis
Inflammation of the vestibular nerve
Essentially presents the same as Labrynthitis with vertio following a recent URTI - however in this there is NO loss of hearing.
*The vertigo is typically triggered by head movement + is associated with balance problems & N&V.
Diagnosis = Head impulse test
Management = Prochlorperazine + Antihistamines for 3 days. If symptoms do not improve within 1 week or resolve after 6 weeks refer to vestibular rehab.
*increases risk of BPPV.
Vertebrobasilar ischemia
Typically an older patient with vertigo triggered by neck extension
Nasal polyps
Associations = Cystic fibrosis / Kartagners syndrome / Churg strauss / Sinusitis / Asthma / Aspirin sensitivity
*Samter’s triad = aspirin sensitivity + asthma + nasal polyps
Features = Anosmia / loss of taste + Nasal obstruction + Rhinorrhoea
Management = refer to ENT for full examination. Topical corticosteroids can be used to shrink them.
Most common causative organism in tonsilitis
Group A streptococcus (e.g strep pyogenes)
Which tonsils are typically affected in tonsilitis
Palatine tonsils.
CENTOR criteria - tonsilitis
= used to estimate the probability of tonsilitis being bacterial (therefore benefiting from antibiotics). A score of 3+ means 40-60% chance its bacterial.
- Fever >38
- Tonsilar exudates
- Absence of cough
- Lymphadenopathy
FeverPAIN score is an alternative.
Indications for hospital admission in tonsilitis
- Immunocomprimised
- Systemically unwell
- dehydrated
- Stridor
- Respiratory distress
- Evidence of peritonsilar abscess or cellulitis
Management of tonsilitis
If viral : advise analgesia + tell the patient to return if no better in 3 days or fever >38.3
If bacterial: (Centor score >3 or feverpain score >4) or if they are immunocomprimsied / history of rheumatic fever give Phenyoxymethylpenecillin for 10 days
(or clarithromycin if allergic)
Complications of tonsilitis
- Peritonsilar abscess (quincy)
- Otitis media
- Scarlet fever
- Rheumatic fever
- Post streptococcal GN
- Post streptococcal Reactive arthritis
Quinst features + management
Sx;
* Sore throat + painful swallowing
* fever
* neck + ear pain
* lymphadenopathy
* change in voice
* Trismus (unable to open mouth)
* Swelling + erythema of tonsils (crossing midline)
Management;
Refer to ENT for needle aspiration or surgical incision and drainage. Give antibiotics (co-amox) +/- dexamethasone to settle inflammation
Tonsillectomy referal guidelines
7 or more episodes in past yr OR
5 per year for 2 years OR
3 per year for 3 years
OR
Recurrent tonsilar abscesses (2 episodes)
Enlagred tonsils causing difficulty breathing, swallowing or snoing
Unilateral tonsilar enlargement
Common Causes of neck lumps in children
Cystic hygromas
Dermoid cysts
Haemangiomas
Venous malformation
Carotid body tumors
Carotid body is located just above the carotid bifurcation. Tumours here are caused by excess growth of glomus cells (paragangliomas) most being benign.
Sx;
* Slow growing lump located in the anterior triangle
* Painless, pulsatiles + has a bruit on auscultation
* mobile side-side but not up and down
Can compress IX, X (horners) and XII nerves
Investigations = Lyre’s sign: Splaying of the internal + external carotids
Management = surgery
Mobile, non-tender soft lump located in the neck midline (between thyroid + hyoid) in a 18 year old. The lump moves upwards with protrusion of the tongue
Thyroglossal cyst
Brachial cyst
An oval mobile mass between the sternocleidomastoid muscle and pharynx
Forms due to a failure of obliteration of the second brachial cleft in embryological development
Geographic tongue
Inflammatory condition where patches of the tongues surface lose the epithelium + papillae forming irregular shapes on the tongue.
Causes = stress / psoriasis / atopy / diabetes
Management of oral candidiasis
Miconazole gel
Nystatin suspension
Oral fluconazole
Management of otitis media + perforation
7 days amoxicillin
Otalgia + Protruding ear + Post-auricular tenderness = ?
Mastoiditis
Management of mastoiditis
Immediate referal to ENT for IV antibiotics
*Can lead to meningitis, facial nerve palsies and hearing loss
Main differentiation between Meniere’s disease + Labrynthitis
labrynthitis tends to be continuous vertigo whereas meniere’s is more typically episodic lasting 20mins - 1hour. Both are associated with recent viral URTI.
Lemierre’s syndrome
An infective thrombophlebitis which can occur from untreated bacterial throat infections in otherwise healthy adults - can lead to septic emboli & bacteremia.
Typically presents with tonsilitis symptoms + painful swelling in neck + USS shows clot in the jugular vein
Heriditary haemorrhagic telangiectasia
rare autosomal dominant syndrome characterised by telangiectasias on the oral mucosa, lips and GI tract.
Typically presents with recurrent epistaxis which is hard to stop
What antibiotic should be given to a diabetic with otitis externa
Ciprofloxacin - to cover pseudomonas
