ENT Flashcards
Otitis media
Infection of ear metween tympanic membrane + cochlea/vestibular apparatus.
Common site of infection in children as bacteria from back of throat can enter through eustachian tube.
Oft preceeded by viral URTI.
Bacterial causes of otitis media
STREP PNEUMONIA = most common (commonly causes rhino-sinusitis, tonsillitis)
Others:
- Haem influenza
- Moraxella catarrhalis
- Staph aureus
Otitis media presentation
- EAR PAIN + REDUCED HEARING (usually unilateral)
Fever, cough, coryza, sore throat, malaise
- very non-specific Sx esp in young kids
Can cause BALANCE ISSUES + VERTIGO if affecting vestibular system
If typanic membrane perforates - may get DISCHARGE
Examination findings from otoscopy in healthy ear
Tympanic membrane - ‘Pearly-grey’, translucent + slightly shiny
- cone of reflected light
- should be able to see malleus through membrane
Examination findings in otitis media
Red, bulging, inflamed membrane if acute
may see discharge + hole
Otitis media management
Usually self resolving -> SIMPLE ANALGESIA for pain/fever
Antibiotics oft not recommended, but consider if:
- SIGNIFICANT CO-MORB (systemically unwell, immunocompromised)
- Kids < 2 YEAR with BILATERAL infection
- OTORRHOEA (discharge)
Consider after 3 days if not improving/worsening without antibiotics.
1st line = AMOXICILLIN for 5 DAYS
2nd = macrolides (erythro/clarithro)
SAFTY NET
When is specialist referal required for pediatric otitis media
Refer for specialist assessment/admission in INFANTS:
- < 3 MONTHS with FEVER > 38 DEGREES
- 3-6 months with temp > 39 DEGREES
Complications
- Otitis medial with effusion
- Hearing loss (usually temporary)
- Perforated eardrum
- Recurrent infection
- Mastoiditis - inflam of mastoid process (rare)
- Abscess (rare)
Glue ear
AKA otitis media with effusion
FLUID builds up due to eustachian tube blokage
-> HEARING LOSS (most common cause in kids)
Usually caused by ear infection. Can also lead to ear infection.
Appearance of glue ear on otoscopy
DULL tympanic membrane with AIR BUBBLES or VISBLE FLUID LEVEL.
Can look normal.
Glue ear RFx
- Childhood
- URTI; acute otitis media
- Cranio facial anomalies; Eustachian tube dysfunction
- Genetic predisposition
- Daycare attendance
- Adenoiditis/hyperplasia blocking eustachian tubes
Weak:
Allergic rhinitis, tobacco smoke, nasopharyngeal malig, GORD, low socioeconomic status, male sex
Glue ear Sx
- Aural fullness/signs of ear discomfort
- HEARING LOSS; failed hearing screen;
- slow progress at school; speech delay
HEaring problems/balance problems uncommonly.
Glue ear investigations
PNEUMATIC OTOSCOPY
Tympanometry if difficult to diagnose
Audiology if CHRONIC or an AT-RISK CHILD
If chronic/recurrent consider nasopharyngeal endoscopy
Which children are at risk of developmental sequelae as a result of glue ear
- Permanent non-OME related hearing loss
- Speech and language delay or disorder
- Autism-spectrum disorder
- Genetic syndromes or craniofacial disorders associated with cognitive or language delays
- Blindness or uncorrectable visual impairment
- Cleft palate
- Developmental delay
- Intellectual disability, learning disorders or attention deficit/hyperactivity disorder.
Glue ear Tx
Usually self resolves WITHIN 3 MONTHS - usually just watchful waiting
If risk of developmental sequelae or hearing loss:
- Grommet +/- adenoidectomy
May need hearing aid if co-morbid something affecting ear structure
Grommets
Tiny tubes inserted into tympanic membrane -> allows drainage; mainly for ventilation to help depressurise
Usually geneeral anaesthetic + day case procedure
Few complications. Usually fall out within a year. 1 in 3 require further grommets from chronic/recurrent.
Causes of hearing loss
Congenital:
- Maternal Antenatal RUBELLA or CMV
- GENETIC
- Associated with syndromes e.g. DOWN’S
Aquired:
Perinatal:
- Premmie
- Hypoxia
Postnatal:
- Jaundice
- Mening/encephalitis
- Otitis media / Glue ear
- Chemo
Presentation of Hearing loss/deafness
- Congenital = oft picked up during NEWBORN HEARING SCREENING PROGRAM (since 2006)
- picks up if v profound loss; typically in high risk kids (prem, v ill, FHx)
- can give hearing aids/cochlear implants to help the kid learn speech + language (otherwise will not develop SAL) - Parental concerns about behaviour problems/changes
- Ignoring calls; bad behaviour, Poor salt; Poor school performance
- SCHOOL SCREENING PROGRAMME when starting school
How is hearing loss tested
Audiometry
- < 3 y/o = basic response to sound
- > 3 y/o = headphones with specific tones + volumes
Hearing loss epidemiology
- 1 in 6 people
- Usually takes around 10 years before treated
- 1 in every 100 babies spending > 48 HRS in ICU (norm only 1 in 1000)
Which groups are high risk for hearing loss
- CYSTIC FIBROSIS
- DOWN’S
- Head TRAUMA
- Cleft lip/palate
- CMV
- CHEMO
These groups are monitored more closely
Aims of hearing test
- Measure threshold
- Frequency specific
- DIfferentiate which type of hearing loss: conductive, sensorineural or mixed
- Compare aided + unaided response (check if aids helping)
- Monitor if fluctuating / progressive
Audiogram
Docment volume at which patients can hear diff tones.
- Frequency (Hz) on x-axis (high pitched at right);
- volume (dB) on y-axis (quiet at top)
ie lower on chart = louder volume required = worse hearing
Symbol meanings on audiogram
X – Left sided air conduction
] – Left sided bone conduction
O – Right sided air conduction
[ – Right sided bone conduction
What is normal range of volume needed for hearing
Between 0-20 dB (decibals)
Conductive vs sensorineural hearing loss on audiogram
Sensorineural - both air + bone conduction will be charted > 20 dB
Conductive - bone conductions in normal range (0-20 dB); air conduction > 20 dB
If mixed: both will be > 20 dB but bone conduction will be >15 dB better than air
Severity of Hearing loss
- Mild = 20-40 dBHL
- Mod = 41-70
- Severe = 71-95
- Profound = > 96
Causes of conductive hearing loss
- Glue ear
- Ear wax
- Middle ear infection
- Perforated eardrum
- Abnormality of the outer ear
- Eustachian tube dysfunction
Conductive hearing loss Tx
- Oft self-resolving
- Grommets
- Hearing aid if persistent + don’t want surgery
- Bone Anchored Hearing Aid if permanent
Sensorineural hearing loss Tx
Usually permanent so HEARING AIDS
- aim to make speech audible
Chochlear implants if profoundly deaf
Hearing loss Ix
Subjective (kid has to respond):
- Distraction test (6-18 M)
- Visual Reinforcement Audiometry (6-30 M)
- Performance Testing (> 24 M)
- Pure Tone Audiometry (>3 yrs)
Objective (no response needed - just need to be still + quiet environment)
- Otoacoustic Emissions (in newborn screening)
- Auditory Brainstem Response (more detailed; 2ndary)
Tympanometry - measures middle ear pressure
- abnormal = conductive
Herpes zoster ophthalmicus definition + Px
Shingles reactivation in distribution of ophthalmic branch of trigeminal nerve
Px:
- Painful red eye
- Fever, malaise, headache
- Erythematous vesicular rash over ophthalmic area
HUTCHINSON’S SIGN = lesion on nose - very indicative of ocular involvement
Herpes zoster ophthalmicus Tx
Hospital admission + IV ACICLOVIR
Analgesia = NSAIDs (1st) then things for nerve pain if 1st doesn’t work (Amytriptyline, Duloxetine, Gabapentin/pregabalin)
Avoid contact with anyone immunocompromised (including preg ppl + babies) till all lesions crusted over
NB: hospital admission only needed if severe, ophthalmic involvement or suspicion of CNS infection
- mod/severe rash / pain or non-truncal (or mild in immunocomp) = oral aciclovir
- Normally, truncal shingles in healthy person self resolves without meds
When is the shingles vaccine recommended to be taken
Within the 70s age range
Complications of herpes zoster ophthalmicus
- Corneal ulcers, scarring / blindness
- 2ndry bacterial infection of skin lesions
- Post herpetic neuralgia
