ENT Flashcards
What is epistaxis?
Nosebleeds
Where does bleeding usually originate in epistaxis?
From Kiesselbach’s plexus, which is located in Little’s area. This is an area of the nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels. When the mucosa is disrupted and the blood vessels are exposed, they become prone to bleeding.
What is the most likely location of the nose bleeding?
Little’s area
Epistaxis tiggers
-nose picking
-colds
-sinusitis
-vigorous nose-blowing
-trauma
-changes in weather
-coagulation disorders (e.g., thrombocytopenia or Von Williebrand disease)
-Anticoagulant medication (e.g. aspirin, DOACs or warfarin)
-Snorting cocaine
-Tumours (e.g., squamous cell carcinoma)
Bleeding is usually unilateral. Bleeding from both nostrils may indicate bleeding posteriorly in the nose. Posterior bleeding presents a higher risk of … of blood.
aspiration
You may have to advise patients on how to manage a nosebleed in an exam:
Sit up and tilt the head forwards (tilting the head backwards is not advised as blood will flow towards the airway)
Squeeze the soft part of the nostrils together for 10 – 15 minutes
Spit out any blood in the mouth, rather than swallowing
When bleeding does not stop after 10 – 15 minutes, the nosebleed is severe, bleeding is from both nostrils, or haemodynamically unstable, patients may require hospital admission. Treatment options are:
Nasal packing using nasal tampons or inflatable packs
Nasal cautery using silver nitrate sticks
After treating an acute nosebleed, consider prescribing Naseptin nasal cream (chlorhexidine and neomycin) four times daily for 10 days to reduce any crusting, inflammation and infection. This is contraindicated in peanut or soya allergy.
What is otitis media?
Infection in the middle ear
What is the middle ear and what is found here?
The space that sits between the tympanic membrane (ear drum) and the inner ear.
This is where the cochlea, vestibular apparatus and nerves are found.
A bacterial infection of the middle ear is often preceded by a …
viral upper respiratory tract infection
Otitis media may be caused by bacteria, which can enter from the back of the throat through the …
eustachian tube
What is the most common bacterial cause of otitis media and also rhino-sinusitis and tonsilitis?
streptococcus pneumoniae
Apart from streptococcus pneumoniae, name other common causes of otitis media
-Haemophilus influenzae
-Moraxella catarrhalis
-Staphylococcus aureus
Presentation of otitis media
-ear pain, reduced hearing
-general symptoms of upper respiratory infection such as fever, cough, coryzal symptoms, sore throat, and feeling generally unwell.
-when the infection affects the vestibular system it can cause balance issues and vertigo.
-when the tympanic membrane has perforated there may be discharge from the ear
-symptoms in children can be very non-specific such as fever, vomiting, irritability, lethargy or poor feeding.
How should the tympanic membrane look in normal children?
pearly-grey, translucent and slightly shiny
What does cone of light in an ear mean?
The cone of light or light reflex is a visible phenomenon which occurs upon examination of the tympanic membrane with an otoscope. Shining light of the tympanic membrane causes a cone-shaped refection of light to appear in the anterior inferior quadrant.
How does otitis media look?
Otitis media will give a bulging, red, inflamed looking membrane. When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane.
What is otorrhoea?
Ear discharge
Most cases of otitis media resolve within 3 days without antibiotics but what is the first line choice of antibiotics?
-Amoxicillin for 5 days
-Alternatives= erythromycin and clarithromycin
Complications of otitis media
-otitis media with effusion
-hearing loss )usually temporary
-perforated eardrum (tympanic membrane
-recurrent infection
-mastoiditis (rare)
-abscess (rare)
what is the medical name for eardrum?
Tympanic membrane
What are acoustic neuromas?
Benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear.
AKA vestibular scheannomas
What are Schwann cells?
Schwann cells are found in the peripheral nervous system and provide the myelin sheath around neurones.
Where do acoustic neuromas occur?
At the cerebellopontine angle and are sometimes referred to as cerebellopontine angle tumours.
What are bilateral acoustic neuromas associated with/indicate?
Neurofibromatosis type II (a genetic condition that causes tumours to grow along your nerves).
Typical presentation of acoustic neuromas?
Aged 40-60 with gradual onset of:
-unilateral sensorineural hearing loss
-unilateral tinnitus
-dizziness or imbalance
-a sensation of fullness in the ear
-can also be associated with facial nerve palsy if the tumour grows large enough to compress the facial nerve
What is used to assess hearing loss?
Audiometry
What pattern of hearing loss is seen in acoustic neuromas?
Sensorineural
What is the difference between sensorineural and conductive hearing loss?
-Sensorineural hearing loss results from damage to the hair cells within the inner ear, the vestibulocochlear nerve, or the brain’s central processing centres.
-Conductive hearing loss results from the inability of sound waves to reach the inner ear e.g. wax, fluid, otitis media, benign tumours
Name the notable risks associated with treatment of acoustic neuromas
-Vestibulocochlear nerve injury with permanent hearing loss or dizziness
-Facial nerve injury, with facial weakness
What is benign paroxysmal positional vertigo (BPPV)?
It is a common cause of recurrent episodes of vertigo triggered by head movement. It is a peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain. It is more common in older adults.
What is the presentation of benign paroxysmal positional vertigo?
-a variety of head movements can trigger attacks of vertigo e.g. turning over in bed
-symptoms settle after around 20-60 seconds, and patients are asymptomatic between attacks.
-often episodes occur over several weeks and then resolve but can reoccur weeks or months later
-BPPV does not cause hearing loss or tinnitis
Pathophysiology of benign paroxysmal positional vertigo?
BPPV is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals.
This occurs most often in the posterior semicircular canal.
They may be displaced by a viral infection, head trauma, ageing or without a clear cause.
The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.
Name the 3 manoeuvres/exercises associated with BPPV
-Dix-Hallpike Manoeuvre (for diagnosis)
-Epley Manoeuvre (to treat)
-Brandt-Daroff Exercises (to improve symptoms)
What is Meniere’s disease?
A long-term inner ear disorder that causes recurrent attacks of vertigo, and symptoms of hearing loss, tinnitus and a feeling of fullness in the ear.
What is the typical triad of Meniere’s disease?
-Hearing loss
-Vertigo
-Tinnitus
Pathophysiology of Meniere’s disease
Meniere’s disease is associated with the excessive build up of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals. This increased pressure of the endolymph is called endolymphatic hydrops.
Presentation of Meniere’s disease
-typical patient is 40-50 years old, presenting with unilateral episodes of vertigo, hearing loss (sensorineural and unilateral) and tinnitus
-other symptoms=a sensation of fullness in the ear, unexplained falls (“drop attacks”) without loss of consciousness, imbalance
-spontaneous nystagmus (involuntary movement of the eyes) may be seen during an acute attack, usually unidirectional.
Management of Meniere’s disease
For acute attacks to manage symptoms:
-Prochlorperazine
-Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
Prophylaxis is with:
-Betahistine
What is otitis extrena?
Inflammation of the skin in the external ear canal. The infection can be localised or diffuse. It can spread to the external ear (pinna). It can be acute (less than 3 weeks) or chronic.
Risk factors and protective factor of otitis externa
Risk factors:
-Otitis externa is sometimes called swimmers ear, as exposure to water can lead to inflammation in the ear canal.
-Trauma in the ear canal (e.g., from cotton buds or ear plugs)
Protective factor:
Ear wax (cerumen)
Causes of inflammation in otitis externa
-bacterial infection (pseudomonas aeruginsoa and staphylococcus aureus)
-fungal infection (e.g., aspergillus or candida)
-eczema
-seborrhoeic dermatitis
-contact dermatitis
What bacteria can colonise the lungs in patients with cystic fibrosis
Pseudomonas aeruginosa
Presentation of otitis externa
ear pain, itchiness, discharge, conductive hearing loss (if the ear becomes blocked)
What does examination show in otitis externa?
-erythema and swelling in the ear canal
-tenderness of the ear canal
-pus or discharge in the ear canal
-lymphadenopathy
-the tympanic membrane may be obstructed by wax or discharge
Treatment for mild otitis externa
Acetic acid 2% (EarCalm over the counter)
Acetic acid has an antifungal and antibacterial effect.
This can also be used prophylactically before and after swimming in patients that are prone to otitis externa
How is moderate otitis externa treated?
Topical antibiotic and steroid:
-Neomycin, dexamethasone and acetic acid (e.g., Otomize spray)
How is otitis externa treated in patients with severe or systemic symptoms?
Oral antibiotics e.g. flucloxacillin or clarithromycin
If the canal is very swollen, an ear wick may be used
Otitis externa caused by a fungal infection can be treated with…
Clotrimazole ear drops
Most common treatment of otitis externa
Otomize ear spray (antibacterial, steroidal)
Aminoglycosides (e.g., gentamicin and neomycin) are potentially … , rarely causing hearing loss if they get past the tympanic membrane. Therefore, it is essential to exclude a perforated tympanic membrane before using topical aminoglycosides in the ear.
Ototoxic
What is malignant otitis externa?
A severe and potentially life-threatening form of otitis externa, The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull.
Malignant otitis externa is usually related to underlying risk factors for severe infection, such as:
Diabetes
Immunosuppressant medications (e.g., chemotherapy)
HIV
Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along) is a key finding that indicates…
malignant otitis externa
malignant otitis externa requires emergency treatment with:
-admission to hospital under the ENT team
-IV antibiotics
-Imaging (CT or MRI head) to assess the extent of the infection
Complications of malignant otitis externa
-facial nerve damage and palsy
-other cranial nerve involvement
-meningitis
-intracranial thrombosis
-death
What is sinusitis?
Sinusitis refers to the inflammation of the paranasal sinuses in the face. This is usually accompanied by inflammation of the nasal cavity and can be referred to as rhinosinusitis.
Rhinosinusitis is the preferred term because inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa
