ENT Flashcards
When should a patient with foreign object in the ear be referred to second care?
- if they require sedation
- if dificulty in removing the foreign body
- if they are uncooperative
- if the tympanic membrane has been perforated
- if an adhesive is in contact with the tympanic membrane
- after one failed attempt by physicial in a child
Batteries and insects must be taken out of the ear canal on the same day.
Organic matters (like peas) can be taken out on the same day or over the next few days, and these may expand if come in touch with olive oil, so don’t use it.
Insects should be killed prior to removal, using 2% lidocaine. Olive oil can also be used to float the insect out.
What are the different features and treatment of otitis externa and otitis media?
Otitis externa
- serous discharge
- starts with itch followed by pain
- tragal and pinna tenderness
- tt: topical acetic acid, aminoglycoside and corticosteroids
Otitis media
- bulging tympanic membrane without discharge
- purulent discharge with rupture tympanic membrane
- follows and upper respiratory tract infection
- tt: usually conservative since majority are viral; amoxicillin if bacterial suspected
How to manage acute and recurrent epistaxis?
ACUTE
- unstable patient: transfer to AE + first aid measures (lean forward, open mouth, pinch cartilaginous part of the nose for 10-15 minutes without releasing pressure)
- stable patient: first aid as above. If bleeding doesn’t stop after 15 minutes, do nasal cautery with silver nitrate of bleeding is small and visible, or nasal packing if it isn’t
Only perform nasal cautery if the bleeding point can be seen and the procedure can be tolerated.
Anterior nasal packs are reserved for refractory bleeds where the bleeding point cannot be seen or if a prior cautery was ineffective.
RECURRENT
- topical naseptin (chlorexidine and neomycin) cream or nasal cautery (more uncomfortable)
Avoid performing nasal cautery of both sides of the septum because of risk of perforation
If there is bilateral active bleed that fails to stop with first aid measurements, perform anterior packing rather than cauterise.
Never compress the bridge of the nose, only the cartilaginous part.
How to differentiate between Meniere’s disease, benign paroxysmal positional vertigo, and vestibular neuritis?
- Find the duration of episodes
- seconds to minutes - BPPV
- minutes to hours - Meniere’s
- hours to days - vestibular neuritis - Position change as a trigger
- triggered by movement - BPPV
- not triggered, but exacerbated by movement - vestibular neuritis
- not provoked by movement - Meniere’s - Other features
- feeling of aural fullness + tinnitus - Meniere’s
- hearing loss - Meniere’s or neuritis (not BPPV)
- recent onset of URTI - vestibular neuritis
If there’s vertigo + tinnitus + hearing loss + pressure in the ear, suspect acoustic neuroma
What is the commonest cause of conductive hearing loss in childhood, and how to treat it? What findings should be expected on an otoscopy?
Otitis media with effusion, which presents as hearing loss without ear pain, usually associated with complaints of listening to the TV at high volumes or symptoms of that sort.
Treatment
- observation first because it may resolve; monitor every 3 months (this should only be done after an audiometry has taken place). Audiometry should be done to assess if it’s indeed a conductive hearing loss, which is consistent with OME. It is also required to quantify how much hearing is affected. If hearing loss is not severe, observe for 3 months and repeat the audiogram to compare.
- referral to ENT + surgery if persistent bilateral OME after 3 months - insert grommets (tiny plastic tubes inserted in the tympanic membrane to let air in and out of the middle ear, they usually come out by themselves after 6-12 months)
- hearing aids are reserved for persistent bilateral OME and hearing loss, if surgery is contraindicated
An important risk factor for OME is parental smoking.
Findings: bluish grey timpanic membrane with an air-fluid level, retracted or bulging tympanic membrane
How does Meniere’s disease present?
Dizziness, tinnitus, deafness, increased feeling of pressure in the ear
What is the likely diagnosis?
bone conduction better than air conduction in left year
sound localised towards left side on Weber’s test
bone conduction better than air conduction in left year = conductive deafness
sound localised towards left side on Weber’s test = sound is localised to the affected side, then this is unilateral left conductive deafness
What are the differences between Rinne’s and Weber’s test?
Rinne’s test - measures air conduction
- tuning fork is placed over the mastoid process until sound os no longer hear, followed by repositioning just over external acoustic meatus
- air conduction > bone conduction = positive Rinne’s test = normal
- bone conduction > air conduction = negative Rinne’s test = conductive deafness
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Weber’s test - measures bone conduction
- tuning fork is placed in the middle of the forehead equidistant from the patient’s ears, the patient is then asked which side is loudest
- sound localising to left side = right sensorineural deafness OR left conductive deafness
- sounds localising to right side = left sensorineural deafness OR right conductive deafness
How should a pinna haematoma be managed?
Incision and drainage + oral antibiotics
If pinna haematomas are not drained early, they can compromise the viability of the auricular cartilage which leads to avascular necrosis. This results in a deformity called “cauliflower ear” which is no longer reversible
Which are the most common sensorineural and conductive causes of hearing loss?
Sensorineural (air > bone)
- acoustic neuroma
- presbycusis
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Conductive (bone > air)
- otosclerosis (adults + pregnancy)
- glue ear / otitis media with effusion (children)
- wax obstruction (negative rinne’s test + no lateralization on weber’s test)
Obstructive sleep apnea and DVLA
If suspected, advise patient to stop driving until further investigations.
If confirmed and moderate/severe OSAS or mild OSAS with excessive daytime sleepiness not controlled within 3 months, advise patient to inform DVLA.
What should be suspected in any patient who smokes and has hoarseness for more than 3 weeks?
Laryngeal cancer.
Features
- chronic hoarseness
- pain
- dysphagia
- lump in the neck
- sore throat
- persistent cough
