ENT Flashcards
presentation of menieres
- hearing loss- sensorineural
- tinnitus
- vertigo
feeling of fullness
lasts several hrs
get recurrent attacks
unilateral
horizontal nystagmus
what is menieres
excessive buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals
= endolymphatic hydrops
mx menieres
For acute attacks, short-term options for managing symptoms include:
Bed rest
Prochlorperazine
Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
Prophylaxis is with:
Betahistine
what is Benign paroxysmal positional vertigo (BPPV)
common cause of recurrent episodes of vertigo triggered by head movement
prob is peripheral (in ear) caused by debris in semicircular canals
presentation of BPPV
severe vertigo when moving head
does not cause hearing loss or tinnitus
ix bppv
dix hallpike manouvre = rotatory nystagmus
tx bppv
epley manouvre
what is an acoustic neuroma / vestibular schwannoma
benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear
occur at the cerebellopontine angle - referred to as cerebellopontine angle tumours
usually unilateral
what are Bilateral acoustic neuromas assoc w
neurofibromatosis type II
acoustic neuroma / vestibular schwannoma presentation
hearing loss - Unilateral sensorineural (often first sx)
vertigo - dizzy
tinnitus
absent corneal reflex
facial nerve palsy if large
sx for months
ix for acoustic neuroma / vestibular schwannoma
MRI cerebellopontine angle
audiometry
mx acoustic neuroma / vestibular schwannoma
refer to ENT
what is Vestibular neuronitis
inflam of vestibular nerve usually due to viral infection
It distorts the signals travelling from the vestibular system to the brain, confusing the signal required to sense movements of the head. This results in episodes of vertigo, where the brain thinks the head is moving when it is not.
Vestibular neuronitis presentation
acute onset of vertigo - recurrent attacks lasting hrs or days
history of a recent viral upper respiratory tract infection.
Nausea and vomiting (may be severe)
Balance problems
HORIZONTAL NYSTAGMUS usually seen
NO tinnitus or hearing loss
Symptoms are most severe for the first few days, after which they gradually resolve over the following 2-6 weeks.
how to differentiate between central and peripheral causes of vertigo
head impulse test
mx epistaxis w first aid measures
torso forward + mouth open
pinch catilaginous area 20 mins
topical antiseptic (naseptin)
admission + follow up if suspected underlying cause (or under 2 yrs)
self care advice
mx epistaxis if still bleeding after 10-15 mins pressure
cautery - if source of bleed is visible + it is tolerated (anaesthetic spray then silver nitrate stick)
packing - if cautery not viable of bleeding site not visible
admit for obs + review
mx epistaxis when no emergency measures have worked
sphenopalatine ligation
common trigger for otitis externa
recent swimming
sx otitis externa
ear pain, itch, discharge
otoscopy otitis externa
red, swollen or eczematous canal
otitis externa mx
if v mild (e.g. no deafness or discharge, mild discom/pruritis) = topical acetic acid 2% spray
moderate = topical abx / combined w steroid = otomise spray (neomycin, dexamethazone, acetic acid)
(ensure tympanic membrane is not perforated b4 using aminoglycosides)
failure to respond to topicals = ENT referral
severe/systemic = ENT - oral/IV abx
what is malignant otitis externa
more common in elderly diabetics
extension of infection into the bony ear canal + the soft tissues deep to the bony canal
- have worsening unrelenting pain despite strong analgesia
need IV abx
causes of acute otitis media
usually preceded by viral URTI
which allows bacteria to enter via the eustachian tube: Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
what is an auricular haematoma
collection of blood between cartilage + overlying perichondrium
happens due to trauma
can lead to cauliflower ear
sx of acute otitis media
otalgia - children tugging at ear
fever in 50%
hearing loss
discharge if tympanic membrane perforates
recent URTI sx - eg coryza
otoscopy 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
criteria for otitis media dx
acute onset of symptoms
- otalgia or ear tugging
presence of a middle ear effusion
- bulging of the tympanic membrane, or
- otorrhoea
- decreased mobility on pneumatic otoscopy
inflammation of the tympanic membrane
- i.e. erythema
mx otitis media
self-limiting condition that does not require an antibiotic prescription
analgesia
safety net if sx worsen / no not improve after 3 days
when to prescribe abx for otitis media + which
Sx>4 days / not improving
Systemically unwell
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
<2 years with BILATERAL otitis media
Otitis media with perforation and/or discharge in the canal
5-7 days oral amoxicillin (erythromycin or clarithromycin if allergic)
chronic suppurative otitis media (CSOM) definition
perforation of the tympanic membrane with otorrhoea for > 6 weeks
sinusitis sx
facial pain
- typically frontal pressure pain which is worse on bending forward
nasal discharge: usually thick and purulent
nasal obstruction
mx sinusitis
analgesia
intranasal decongestants or nasal saline??
intranasal corticosteroids may be considered if the sx have been present >10 days
what abx to give in v severe sinusitis
phenoxymethylpenicillin first line
co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications
most common bacteria to cause tonsillitis
strep pyogenes
what is glue ear
otitis media w effusion
risk factors for glue ear
male sex
siblings with glue ear
higher incidence in Winter and Spring
bottle feeding
day care attendance
parental smoking
glue ear features
peaks at 2 yrs old
hearing loss is usually the presenting feature
secondary problems such as speech and language delay, behavioural or balance problems may also be seen
tx glue ear
for first presentation of otitis media with effusion: active observation for 3 mths - no intervention is required
if a background of Down’s / cleft palate -> refer to ENT
grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months
adenoidectomy
features of peritonsillar abscess (quinsy)
severe throat pain, which lateralises to one side
deviation of the uvula to the unaffected side
trismus (difficulty opening the mouth)
reduced neck mobility
tx quinsy
urgent review by an ENT specialist
needle aspiration or incision & drainage + intravenous antibiotics
tonsillectomy should be considered to prevent recurrence
what is mastoiditis
typically develops when an infection spreads from the middle to the mastoid air spaces of the temporal bone.
mastoiditis features
otalgia: severe, classically behind the ear
hx of recurrent otitis media
fever
the patient is typically very unwell
swelling, erythema and tenderness over the mastoid process
the external EAR may PROTRUDE forwards
ear discharge may be present if the eardrum has perforated
tx mastoiditis
urgent same day referral to paeds
IV abx
what is rinne’s test
testing for conductive hearing loss
tuning fork is placed over the mastoid process until the sound is no longer heard, followed by repositioning just over external acoustic meatus
what is a positive rinne’s test i.e. what sld happen normally
air conduction is better than bone conduction
if negative (bone better than air) - they have conductive deafness
(can’t test for sensoineural)
what is weber’s test
to localise hearing loss
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 - sld be same
result of weber’s test in unilateral sensorineural deafness
sound is localised to the unaffected side
result of weber’s test in unilateral conductive deafness
sound is localised to the affected side
what is presbycusis
age-related sensorineural hearing loss
high freq hearing is affected bilaterally
what is otosclerosis
AD
replacement of normal bone by vascular spongy bone in ear.
Onset is usually at 20-40 years
features of otosclerosis
conductive deafness
tinnitus
+ve FHx
what is a nasal septal haematoma
comp of nasal trauma
dev of haematoma between the septal cartilage + the overlying perichondrium
mx nasal septal haematoma
ref to ENT asap
need surgical drainage
IV abx
what happens if nasal septal haematoma is left untreated
irreversible septal necrosis may dev within 3-4 days -> saddle nose
features of nasal septal haematoma
- relatively minor trauma
- sensation of nasal obstruction
- pain + rhinorrhoea on examination
- classically a BILATERAL, RED SWELLING arising from the nasal septum
(differente from a deviated septum by gently probing the swelling. Will be boggy whereas septums will be firm)
what is ramsay hunt syndrome caused by
reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve
ramsay hunt syndrome features
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus
ramsay hunt syndrome tx
oral aciclovir and corticosteroids
causes for gingival hyperplasia (overgrowth of gum tissue)
P - Phenytoin
A - Acute Myeloid Leukaemia
N - Nifedipine (CCBs)
I - Idiopathic
C - Ciclosporin
what to do when someone presents with sudden onset sensorineural hearing loss (SSNHL)
uregent ENT ref
- MRI to exclude vestibular schwannoma
high dose corticosteroids
sx viral labyrinthitis
Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected
what is malignant otitis externa most commonly caused by
Pseudomonas aeruginosa
what conditions are assoc w nasal polyps
asthma (particularly late-onset asthma)
aspirin sensitivity
infective sinusitis
cystic fibrosis
Kartagener’s syndrome
Churg-Strauss syndrome
features of nasal polyps
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
tx nasal polyps
all patients with suspected nasal polyps should be referred to ENT for a full examination
topical corticosteroids shrink polyp size in around 80% of patients
mx perforated tympanic membrane
no tx needed in majority as it will usually heal after 6-8 weeks.
Avoid getting water in the ear during this time
Prescribe antibiotics to perforations which occur following an episode of acute otitis media.
if still perf when reviewed refer to ENT
myringoplasty may be performed if the tympanic membrane does not heal by itself
tonsillitis presentation
Sore throat
Fever (above 38°C)
Pain on swallowing
exam =
red, inflamed and enlarged tonsils, with or without exudates
may be anterior cervical lymphadenopathy
FeverPAIN Score criteria
Fever during previous 24 hours
P – Purulence (pus on tonsils)
A – Attended within 3 days of the onset of symptoms
I – Inflamed tonsils (severely inflamed)
N – No cough or coryza
FeverPAIN Score results
2–3 = 34 – 40% probability, delayed abx
4–5 = 62 – 65% probability, prescribe abx
of bacterial tonsillitis
tx tonsillitis
safety net - return if the pain has not settled after 3 days or the fever rises above 38.3ºC
simple analgesia with paracetamol and ibuprofen
if abx needed
- phenoxymethylpenicillin 10 days
- Clarithromycin if allergy
what is Infectious mononucleosis (glandular fever) caused by
Epstein-Barr virus (EBV, also known as human herpesvirus 4, HHV-4)
triad in Infectious mononucleosis (glandular fever)
sore throat
pyrexia
lymphadenopathy
blood test change in Infectious mononucleosis (glandular fever)
transient rise in ALT due to hepatitis
lymphocytosis
what happens in px who take ampicillin/amoxicillin whilst they have infectious mononucleosis
a maculopapular, pruritic rash develops
dx Infectious mononucleosis (glandular fever)
heterophil antibody test (Monospot test)
mx Infectious mononucleosis (glandular fever)
rest during the early stages, drink plenty of fluid, avoid alcohol
simple analgesia for any aches or pains
avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture
Unilateral glue ear in an adult
needs evaluation for a posterior nasal space tumour -> two weeks-wait referral to ENT
Otalgia in the absence of any ear signs
red flag for head and neck malignancy and must be investigated further
- referred pain
post tonsillectomy comp + what to do
haemorrhage
all need to be assessed by ENT
-> immediate return to theatre if bleeding in first 6-8 hrs (primary)
if 5-10 days after (secondary + rarer) -> admit + abx
3 main structures in inner ear
semi-circular canals
vestibule
cochlea
3 main structures in middle ear
malleus
incus
stapes
what is the external acoustic meatus
sigmoid tube that extends from the deep park of the concha to the tympanic membrane
