ENT Flashcards
What is conductive hearing loss?
Problem with transmission of sound from the environment to the inner ear
What is sensorineural hearing loss?
Problem with the sensory system or the vestibulocochlear nerve
How is Weber’s test performed?
Tuning form is placed in the centre of the forehead
Patient is asked if the sound is louder in either side
How is Weber’s test interpreted?
Normal = Sound heard equally in both sides
Sensorineural hearing loss = sound louder in normal ear
Conductive hearing loss = sound louder in affected ear
How is Rinne’s test performed?
Tuning fork is placed on the mastoid process (bone conduction)
Tuning fork moved to in front of the ear when sound can no longer be heard (air conduction)
How is Rinne’s test interpreted?
Normal = Sound can be heard again once fork is in front of ear (air conduction better than bone)
Abnormal = Sound cannot be heard again (bone better than air)
What are causes of sensorineural hearing loss?
Sudden sensorineural hearing loss
Presbycusis (age-related)
Noise exposure
Meniere’s disease
Labyrinthitis
Acoustic neuroma
Neurological cause e.g., MS, stoke, tumour
Neurological infections e.g., meningitis
Medication e.g., furosemide, gentamycin, chemotherapy
What are the causes of obstructive hearing loss?
Ear wax
Infection e.g., otitis media/externa
Effusion
Eustachian tube dysfunction
Perforated tympanic membrane
Otosclerosis
Cholesteatoma
Exostoses (bony growth into the ear canal)
Local tumours
What is presbycusis?
Age related sensorineural hearing loss
What is the pattern of hearing loss in presbycusis?
High-pitches affected first
Gradual
Symmetrical
What are the risk factors for presbycusis?
Age
Male gender
Family history
Loud noise exposure
Diabetes
Hypertension
Ototoxic medication
Smoking
What is sudden sensorineural hearing loss?
Hearing loss over less than 72 hours with no other explanation
Otological emergency
What is otosclerosis?
Remodelling of the small bones in the ear causing conductive hearing loss
How does otosclerosis present?
Can be unilateral or bilateral
Hearing loss
Tinnitus
Lower-pitch sounds first (opposite of presbycusis)
What is the management for otosclerosis?
Conservative with hearing aids
Surgical (stapedectomy or stapedotomy)
What is an acoustic neuroma?
Benign tumours of the Schwann cells surrounding the vestibulocochlear nerve
How does acoustic neuroma present?
Usually unilateral
Sensorineural hearing loss
Tinnitus
Dizziness/imbalance
Sensation of fullness
Facial nerve palsy if tumour grows and causes compression
What is the management of acoustic neuroma?
Conservative if no symptoms or if surgery is inappropriate
Surgery
Radiotherapy
What are the complications of acoustic neuroma surgery?
Damage to vestibulocochlear nerve –> hearing loss and dizziness
Damage to facial nerve –> palsy
What is a cholesteatoma?
Abnormal collection of squamous epithelial cells in the middle ear
Non-cancerous but can invade local structures
How does cholesteatoma present?
Foul discharge from ear
Unilateral conductive hearing loss
Infection
Pain
Vertigo
Facial nerve palsy
What is the management of cholesteatoma?
Surgical removal
Where does epistaxis originate from?
Kiesselbach’s plexus in Little’s area
What are the causes of epistaxis?
Nose picking
Colds
Sinusitis
Vigorous nose blowing
Trauma
Changes in the weather
Coagulation disorders
Anticoagulation medication
Cocaine use
Tumours
How does epistaxis present?
Usually unilateral bleeding
Bilateral bleeding suggests a posterior bleed with increased risk of aspiration
What is the management of epistaxis?
Usually resolves
Recurrent and significant bleeds may require further investigation for underlying cause
First aid –> cautery –> packing –> ligation
What is classed as a severe nosebleed?
Not stopped after 10-15 minutes
How does eustachian tube dysfunction present?
Reduced or altered hearing
Popping noises/sensations
Sensation of fullness
Pain/discomfort
Tinnitus
Symptoms worsen when external air pressure changes (e.g., flying, mountain climbing, diving)
What is the management of eustachian tube dysfunction?
No treatment and wait for spontaneous resolve if not severe
Valsalva manoeuvre (hold nose and blow)
Decongestant nasal spray
Antihistamines/steroid nasal spray
Surgery if persistent or severe –> adenoidectomy, grommets, balloon dilation
What is the cause of infective mononucleosis?
EBV infection
Spread by saliva of affected individuals by kissing/sharing cups etc
How does infective mononucleosis present?
Teenagers and young adults
Fever
Sore throat
Fatigue
Lymphadenopathy
What investigations are performed for infective mononucleosis?
Monospot test
IgM (acute infection) or IgG (immunity) to EBV
What is the management of infective mononucleosis?
Supportive
What are 2 complications of infective mononucleosis?
Liver impairment –> Avoid alcohol
Increased risk of splenic rupture –> Avoid contact sports
Why should amoxicillin not be given in infectious mononucleosis?
Can cause a macular papular rash
What is obstructive sleep apnoea?
Collapse of the pharyngeal airway causing episodes of apnoea during sleep
What are risk factors for obstructive sleep apnoea?
Middle age
Male
Obesity
Alcohol
Smoking
What are the features of obstructive sleep apnoea?
Episodes of apnoea during sleep –> often reported by partner
Snoring
Morning headache
Waking up unrefreshed
Daytime sleepiness
Concentration problems
Reduced O2 saturation during sleep
What is the management of obstructive sleep apnoea?
Referral to ENT or sleep clinic
Correct reversible risk factors –> lose weight, stop smoking, avoid alcohol
CPAP
Surgical reconstruction of soft palate
What is the most common causative organism of otitis externa?
Pseudomonas aeruginosa
Also staph aureus
How does otitis externa present?
Ear pain
Discharge
Itchiness
Conductive hearing loss if ear becomes blocked
What is the management of otitis externa?
Acetic acid 2% spray if mild
If moderate, topical antibiotic and steroid (neomycin, dexamethasone and acetic acid (otomize spray))
If severe, oral flucloxacillin or clarithromycin
What is a complication of otitis externa?
Malignant otitis externa
Infection spreads to bones in canal and skull
Causes temporal osteomyelitis
What is the most common causative organism of otitis media?
Streptococcus pneumoniae (most common)
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
How does otitis media present?
Ear pain
Reduced hearing
Malaise and fever
Symptoms of URTI
Balance issues/vertigo
Discharge is tympanic membrane ruptured
What is the management for otitis media?
Most resolve without antibiotics in 3-7 days
Analgesia
Monitor for mastoiditis
If indicated, amoxicillin or clarithromycin (penicillin allergy) or erythromycin (penicillin allergy and pregnant)
What pattern of nasal polyps is a red flag?
Unilateral –> suggests tumour
What conditions are associated with nasal polyps?
Chronic rhinitis/sinusitis
Asthma
Cystic fibrosis
Eosinophilic granulomatosis with polyangiitis
How do nasal polyps present?
Chronic rhinosinusitis
Difficult nasal breathing
Snoring
Nasal discharge
Anosmia
What is the management of nasal polyps?
Refer if unilateral
Intranasal topical steroid
Surgery
How does rhinosinusitis present?
Recent viral URTI
Nasal congestion/discharge
Facial tenderness/pressure
Headache
Facial swelling
Anosmia
What is the management of rhinosinusitis?
Most cases are viral and resolve in 2-3 weeks
If symptoms last longer than 10 days, delayed Penicillin V + high dose nasal spray
What is the most common cause of tonsilitis?
Viral
What is the most common bacterial cause of bacterial tonsilitis?
Group A streptococcus (Strep pyogenes) –> Most common
Streptococcus pneumoniae –> 2nd most common
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
How does tonsilitis present?
Sore throat
Fever > 38
Pain on swallowing
Red, inflamed, enlarged tonsils with/without exudate
Anterior cervical lymphadeopathy
What is the Centor criteria?
Score used to determine the probability that tonsilitis is due to a bacterial cause
What scores points in the Centor criteria?
Fever > 38
Tonsillar exudate
Absence of cough
Tender lymphadenopathy
3 or more points = 40-60% chance of bacterial tonsilitis
What scores points in FeverPAIN?
Fever in last 24 hours
Purulence
Attended within 3 days of onset
Inflamed tonsils
No cough or coryza
2-3 = 34-40% probability of bacterial cause
4-5 = 62-65% probability of bacterial cause
What is the management of tonsilitis?
Likely viral = safety net, simple analgesia
If likely bacterial, Penicillin V for 10 days
Admission if systemically unwell, has respiratory distress or evidence of peritonsillar abscess
What are complications of tonsilitis?
Peritonsillar abscess (Quincy)
Otitis media
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis/reactive arthritis
Which vaccine has reduced the prevalence of epiglottitis?
Haemophilus influenzae B
What features suggest possible epiglottitis?
Sore throat and stridor
Drooling
Tripod position
High fever
Difficulty/painful swallowing
Muffled voice
Scared/quiet child
Septic/unwell appearance
What investigations should be performed for epiglottitis?
None - do not want to distress child
Lateral neck xray would show thumb sign
How is epiglottitis managed?
Alert most senior anaesthetist and paediatrician
Leave the child in a comfortable environment as to not distress them
ABCDE –> manage airway
Once airway is secure, IV abx (e.g., ceftriaxone) and dexamethasone
What is difference between central and peripheral vertigo?
Central vertigo affects the brainstem or cerebellum
Peripheral vertigo affects the vestibular system
What is the pathophysiology of BPPV?
Calcium carbonate crystals become displaced in the semi-circular canals when the head is moved
What are the causes of BPPV?
Viral infection
Head trauma
Ageing
Idiopathic
What symptoms are present in BPPV?
Vertigo that is positional –> movement required to confuse the vestibular system
Lasts around 1 minute before symptoms settle
Lasts over several weeks before resolving, but can reoccur
NO hearing loss or tinnitus
What test is used to diagnose BPPV?
Dix-Hallpike manoeuvre
How is the Dix-Hallpike manoeuvre performed?
The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
Watch the eyes closely for 30-60 seconds, looking for nystagmus
Repeat the test with the head turned 45 degrees in the other direction
What manoeuvre is used to treat BPPV?
Epley manoeuvre
How is the Epley manoeuvre performed?
Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
Rotate the patient’s head 90 degrees past the central position
Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
Have the patient sit up sideways with the legs off the side of the couch
Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle
What is the pathophysiology of Meniere’s disease?
Excessive build up of endolymph in the semi-circular canals
How does Meniere’s disease present?
Triad of hearing loss, vertigo and tinnitus
How is Meniere’s disease managed?
Symptom management –> prochlorperazine, antihistamines
Prophylaxis –> Betahistine
What is the presentation of vestibular neuronitis?
Acute onset vertigo –> constant and triggered by head movement
History of recent viral URTI
Nausea and vomiting
Balance problems
NO problems with hearing
WHhat test is used to diagnose vestibular neuronitis or labyrinthitis?
Head impulse test
How is the head impulse test performed?
Patient fixes gaze on doctor’s nose
Doctor jerks patient’s head 10-20° in one direction and slowly returns to midline
Normal should be able to maintain focus
Abnormal patients’ eyes will saccade (rapidly move back and forth) until eventually returning to centre
Will be normal in central vertigo or current absence of symptoms
What is management of vestibular neuronitis?
Prochlorperazine
Antihistamines
Referral if symptoms don’t improve
How does labyrinthitis present?
Acute onset vertigo
Can be associated with hearing loss and tinnitus
Viral illness symptoms
What is the management of labyrinthitis?
(Same as vestibular neuronitis)
Prochlorperazine
Antihistamines
Antibiotics if bacterial cause
What is the difference between the presentations of labyrinthitis and vestibular neuronitis?
Labyrinthitis affects hearing, whereas vestibular neuronitis does not
What are the causes of central vertigo?
Posterior circulation stroke
Tumour
Multiple sclerosis
Vestibular migraine
How does central vertigo present?
Sustained, non-positional vertigo
