ENT Flashcards
Spot diagnosis:
Recent viral infection e.g URTI
Sudden onset
Vertigo
Nausea and vomiting
Hearing may be affected
Viral labyrinthitis
Spot diagnosis:
Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss or tinnitus
Vestibular neuronitis
Spot diagnosis:
Vertigo
Gradual onset
Triggered by change in head position
Each episode lasts 10-20 seconds
Benign paroxysmal positional vertigo
BPPV
spot diagnosis:
vertigo associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears
Meniere’s disease
Spot diagnosis:
Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2
Acoustic neuroma
give 4 less common causes of vertigo
posterior circulation stroke
trauma
multiple sclerosis
ototoxicity e.g. gentamicin
The most common causes of hearing loss are ear wax, otitis media and otitis externa.
Give 6 other causes
Presbycusis
Noise damage
Otosclerosis
Otitis media with effusion (glue ear)
Meniere’s disease
Drug ototoxicity
How does presbycusis present?
age-related sensorineural hearing loss
patients may describe difficulty following conversations
Audiometry shows bilateral high-frequency hearing loss
How does otosclerosis present?
Autosomal dominant replacement of normal bone by vascular spongy bone
onset at 20-40 years
conductive deafness
tinnitus
tympanic membrane - 10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
positive family history
how does glue ear present?
peaks at 2 years of age
hearing loss (commonest cause of conductive hearing loss childhood)
secondary problems such as speech and language delay, behavioural or balance problems may also be seen
how does Meniere’s disease present?
Multiple episodes last Minutes to hours
recurrent episodes of vertigo, tinnitus and sensorineural hearing loss
sensation of aural fullness or pressure
other features include nystagmus and a positive Romberg test
causes of drug induced ototoxicity?
aminoglycosides (e.g. Gentamicin), furosemide, aspirin and a number of cytotoxic agents
how do acoustic neuromas present?
cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
Complications of thyroid surgery?
recurrent laryngeal nerve damage.
bleeding - haematomas may rapidly lead to respiratory compromise (laryngeal oedema)
damage to the parathyroid glands = hypocalcaemia
3 of the following should be present to warrant abx for suspected tonsilitis:
(Centor criteria)
C – Cough absent
E – Exudate
N – Nodes
T – temperature (fever)
(OR – young OR old modifier)
Causes of otitis externa?
infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
seborrhoeic dermatitis
contact dermatitis (allergic and irritant)
recent swimming is a common trigger of otitis externa
Presentation of otitis externa? Mx?
ear pain, itch, discharge
otoscopy: red, swollen, or eczematous canal
Mx:
topical antibiotic / combined topical antibiotic with a steroid
if the canal is extensively swollen then an ear wick is sometimes inserted
Second-line:
oral antibiotics (flucloxacillin) if the infection is spreading
swab inside the ear canal
Give 4 causes of facial pain and outline how they present
Sinusitis:
Facial ‘fullness’ and tenderness
Nasal discharge, pyrexia or post-nasal drip leading to cough
Trigeminal neuralgia:
Unilateral facial pain, brief electric shock-like pains, abrupt in onset and termination
May be triggered by light touch, emotion
Cluster headache:
Pain occurs once or twice a day, each episode lasting 15 mins - 2 hours
Clusters typically last 4-12 weeks
Intense pain around one eye
Accompanied by redness, lacrimation, lid swelling, nasal stuffiness
Temporal arteritis:
Tender around temples
Raised ESR
Features of peritonsillar abscess (Quinsy)?
Mx?
severe throat pain, which lateralises to one side
deviation of the uvula to the unaffected side
trismus (difficulty opening the mouth)
reduced neck mobility
Mx: urgent ENT review
incision & drainage + intravenous antibiotics
How should post-tonsillectomy haemorrhage be managed?
All should be reviewed by ENT
Primary:
6-8 hours following surgery
immediate return to theatre
Secondary:
5 - 10 days after surgery
often associated with a wound infection
admission and antibiotics
Methods to achieve symptomatic relief in BPPV?
Epley manoeuvre
teaching the patient exercises they can do themselves at home - vestibular rehabilitation e.g. Brandt-Daroff exercises
Acute otitis media is extremely common in young children, with around half of children having three or more episodes by the age of 3 years.
What commonly causes it?
preceding URTI
Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
Presentation of otitis media?
otalgia (children may tug or rub their ear)
fever
hearing loss
recent viral URTI symptoms are common (e.g. coryza)
ear discharge may occur if the tympanic membrane perforates
Findings on otoscopy for otitis media?
bulging tympanic membrane → loss of light reflex
opacification or erythema of the tympanic membrane
perforation with purulent otorrhoea
decreased mobility if using a pneumatic otoscope
Mx of acute otitis media?
generally a self-limiting condition that does not require an antibiotic prescription
analgesia for otalgia
Abx if:
Symptoms lasting >4 days
Systemically unwell
Immunocompromise / high risk of complications
< 2 years with bilateral otitis media
perforation and/or discharge in the canal
5-7 day course of amoxicillin is first-line
Complications of otitis media?
mastoiditis
meningitis
brain abscess
facial nerve paralysis
Causes of acute sinusitis?
Mx?
Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses
Predisposing factors include:
nasal obstruction e.g. septal deviation or nasal polyps
recent local infection e.g. rhinitis or dental extraction
swimming/diving
smoking
Mx:
analgesia
intranasal decongestants or nasal saline
intranasal corticosteroids if the symptoms have been present for > 10 days
oral antibiotics for severe presentations - phenoxymethylpenicillin first-line
What is the ‘double-sickening’?
sometimes seen in acute sinusitis where an initial viral sinusitis worsens due to secondary bacterial infection
Mx of sudden onset unilateral sensorineural hearing loss?
Refer urgently to ENT and start high dose oral steroids
usually idiopathic
Vestibular neuronitis is a cause of vertigo that often develops following a viral infection.
How can it be treated medically?
a short oral course of prochlorperazine
Non-resolving otitis externa with worsening pain despite strong analgesia =
urgent ENT referral
suggestive of malignant (necrotising) otitis externa
Malignant otitis externa is a type of otitis externa that is found in immunocompromised individuals, most commonly caused by Pseudomonas aeruginosa. It can progress into temporal bone osteomyelitis.
What key features would you expect in the hx?
How do you diagnose?
Diabetes or immunosuppression
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Dx is with CT head
Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
How does it present? Tx?
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus
Tx: oral aciclovir and corticosteroids
What drugs can cause tinnitus?
Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine
Mastoiditis typically develops when an infection spreads from the middle to the mastoid air spaces of the temporal bone.
How does it present?
Ix? Mx?
otalgia: severe, classically behind the ear
swelling, erythema and tenderness over the mastoid process
the external ear may protrude forwards (proptosis)
ear discharge may be present if eardrum has perforated
CT head and IV abx
tx for otitis externa in diabetics?
ciprofloxacin for pseudomonas cover
how can Meniere’s disease be managed?
ENT assessment required to confirm dx
patients should inform the DVLA and cease driving until satisfactory control of symptoms is achieved
acute attacks: prochlorperazine
prevention: betahistine and vestibular rehabilitation exercises
