ENT Flashcards
What is otitis media?
Infection in the middle ear
What are the most common causes of otitis media?
- streptococcus pneumoniae
- haemophilus influenzae
- moraxella catarrhalis
Presentation of otitis media
- otalgia ear pain
- fever
- hearing loss
- recent viral URTI symtpoms
- ear discharge may occur if the eardrum has perforated
Otitis media on otoscopy
- Bulging tympanic membrane leading to loss of the light reflex
- opacification or erythema of the tympanic membrane
- otorrhoea
- inflammation of the tympanic membrane
What is the management of otitis media?
- normally self limiting within 3 days to a week
- analgesia
- advised to seek help if not resloved within 3 days
When should you prescribe antibiotics immediately for otitis media?
- symptoms lasting 4 days or not improving
- systemically unwell
- immunocompromised
- younger than 2 with bilateral otitis media
- otits media with perforation and/or discharge in the canal
Which antibiotic for otitis media?
Amoxicillin for 5-7 days, clarithromycin if penicillin allergy
Complications of otitis media
- perforation of the tympanic membrane
- hearing loss
- labyrinthitis (causing dizziness/vertigo)
- mastoiditis
- meningitis
- brain abscess
- facial nerve paralysis
What is chronic suppurative otits media?
Perforation of the tympanic membrane with otorrhoea for > 6 weeks
Where do nosebleeds normally originate?
Kisselbach’s plexus in littles area (at the front of the nasal cavity)
How can you categorise nosebleeds?
Anterior (normally kisselbach’s plexus) and posterior bleeds
What are the causes of epistaxis?
- nose picking or nose blowing
- trauma
- foreign body
- bleeding disorders e.g. thrombocytopenia or von willebrand
- snorting cocaine
- granulomatosis with polyangiitis
What is bleeding from both nostrils a sign of?
Posterior nose bleed
Management of mild epistaxis
- Sit patient up with head tilting forwards and mouth open
- squeeze the soft cartilaginous area of the nose firmly for 20 minutes (breath through mouth)
- if successful then consider naseptin (topical antiseptic) to reduce crusting
- follow up if comorbid cause suspected, or under 2
- avoid blowing or picking nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks
What should you do if epistaxis continues despite 10-15 minutes of continuous pressure on the nose
- cautery if source of bleed is visible, use topical anaestheic spray then silver nitrate stick for 3-10 seconds (only cauterise one side of the septum), dab area with naseptin
- Packing if cautery not viable usign nasal tampons or inflatable pack
When is naseptin contraindicated?
Peanut or soya allergy
Management of epistaxis which has failed all emergency management
sphenopalatine ligation in theatre
What is nasal septum haematoma?
Complication of nasal trauma, development of haematoma between the septal cartilage and overlying perichondrium
Features of nasal septum haematoma
- may be caused by relatively minor trauma
- sentation of nasal obstruction
- pain
- rhinorrhoea
- bilateral red swelling arising from the nasal septum
- feel boggy (a deviated septum will feel firm)
What is the management of septal haematoma?
- surgical drianage
- intravenous antibiotics
Complication of septal haematoma
- septal necrosis may develop after 3-4 days
- saddle nose deformity
Differential diagnoses of facial pain
- trigeminal neuralgia: sever pain along distribution of trigeminal nerve
- sinusitis: nasal discharge or congestion
- dental problems
- tension type headache: band like
- migraine: unilateral throb
- giant cell arteritis
Explain Weber’s test
- tuning fork in centre of forehead
- normal = both ears equal
- senorineural: louder in normal ear
- conductive: louder in affected ear (ear becomes more sensitive to try to hear and when transmitted directly to the cochlea it is heard as louder)
Explain Rinne’s test
- mastoid process then 1cm from ear
- air conduction better than bone = normal
- in conductive, the sound is not heard when moved from the mastoid process to the ear canal
Causes of sensorineural hearing loss
- presbycusis
- noise exposure
- menieres disease
- labyrinthitis
- acoustic neuroma
- neurological conditions
- infection
- loop diuretics, aminoglycosides, chemotherapy
What medications cause sensorineural hearing loss?
- aminoglycosides
- loop diuretics
- chemotherapy
What are the causes of conductive hearing loss?
- ear wax
- infection
- fluid in the ears
- eustachian tube
- perforated tympanic membrane
- otosclerosis
- cholesteatoma
- tumor
What is presbycusis?
Age related sensori-neural hearing loss
What is otosclerosis?
- autosomal dominant
- replacement of the normal bone by vascular spongy bone
- onset usually age 20-40
Features of otosclerosis
- conductive deafness
- tinnitus
- positive family history
What is glue ear
Otitis media with effusion
What is vertigo?
Movement between the patient and their environment
What are the two categories of causes of vertigo?
- peripheral problems affecting the vestibular system
- central problem involving the brainstem or the cerebellum
What are the causes of peripheral vertigo?
- benign paroxysmal positional vertigo
- menieres disease
- vestibular neuronitis
- labyrinthitis
What are the causes of central vertigo?
- posterior circulation infarction: sudden
- tumour: gradual
- multiple sclerosis
- vestibular migraine
Features of benign paroxysmal positional vertigo
- vertigo triggered by change in the head position
- associated with nausea
- each episode lasts 10-20 seconds
- positive dix hallpike manoeuvre
Management of BBPV
- usually resolves spontaneously
- epley manoeuvre
- teaching the patient Brandt-Daroff exercise
Dix hallpike manoeuvre
- rapidly lower the patient to the supine position with their head at 45 degrees to the right or left, until extended at 30 degrees
- rotatory nystagmus and patient reports vertigo
What is rhinosinusitis?
Inflammation of the paranasal sinuses. Can either be acute or chronic (12 weeks+)
What are the sinuses?
- frontal
- maxillary
- ehtmoid
- sphenoid
Presentation of sinustitis
- nasal congestion
- nasal discharge
- facial pain or headache
- facial pressure
- facual swelling over the affected areas
- loss of smell
- tenderness on palpation of affected areas
Association of sinusitis
nasal polyps
Management of sinusitis
- most cases are viral and resolve in 2-3 weeks
- if symptoms persist over 10 days then high dose nasal spray for 14 days, delayed antibiotic prescription
Management of chronic sinusitis
- saline nasal irrigation
- steroid nasal spray or drops
- functional endoscopic sinus surgery
Causes of otitis externa
- infection: staph aureus, pseudomonas aeruginosa, fungal
- seborrhoeic dermatitis
- contact dermatitis
- recent swimming
Features of otitis externa
- ear pain
- itch
- discharge
- otoscopy: red, swollen, eczematous canal
Management of otitis externa
- topical antibiotics or combined antibiotic and steroid
- if the canal is perforated then no aminoglycosides
- if canal debris you can consider removal
- if continuing infection can condider: oral antibiotics if spreading, swab, antifungal agent
Malignant otitis externa
More common in elderly diabetic, extension of infection into the bony ear canal and soft tissues deep to the bony canal. IV antibiotics
Treatment of glue ear
- active observation: 3 months
- grommet insertion
- adenoidectomy
Management of perforated tympanic membrane
- usually heals after 6-8 weeks, avoid getting water in the ear during this time
- Antibiotics if perforation occurs after an episode of acute otitis media
- myringoplasty if doesnt heal by itself
What is cholesteatoma?
Non cancerous growth of squamous epithelium in the middle ear
Features of cholesteatoma
- foul smelling, non-resolving discharge
- hearing loss
- As it expands: vertigo, facial nerve palsy, infection, pain
Otoscopy of cholesteatoma
Attic crust (build up of debris in the upper tympanic membrane)
Management of cholesteatoma
ENT for surgical removal
What are the branches of the facial nerve?
- temporal
- zygomatic
- buccal
- marginal mandibular
- cervical
What is the function of the facial nerve?
- Motor: facial expression
- sensory: taste from the anterior 2/3 of the tongue
- Parasympathetic supply to the submandibular and sublingual salivary glans aand lacrimal gland
How to distinguish between UMN and LMN lesion of the facial nerve
if they can wrinkle their forehead then its upper
Unilateral UMN lesion of the facial nerve causes
- stroke
- tumour
Bilateral UMN lesion of the facial nerve
- pseudobulbar palsies
- motor neurone disease
Management of bells palsy
- if presents within 72 hours then prednisolone 50mg for 10 days then 60 for 5 then 10 for 5
- lubricating eye drops
Ramsay hunt syndrome
- varicella zoster virus
- unilateral lower motor neurone facial nerve palsy
- painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side
Management of ramsay hunt syndrome
-Initiate treatment within 72 hours
- prednisolone
- aciclovir
- lubricating eye drops
What is vestibular neuronitis?
Inflammation of the vestibular nerve. Often following a viral infection
Features of vestibular neuronitis
- recurrent vertigo attacks lasting days or hours
- may have nausea/vomiting
- horizontal nystagmus
- no hearing loss or tinnitus
How can you distinguish between vestibular neuronitis and posterior circulation stroke
HiNTs
Management of vestibular neuronitis
- procholrperazine (buccal or IM for severe, oral for less severe)
- Antihistamines
Treatment should last for 3 days
- Vestibular rehabilitation exercises if chronic symptoms
Features of menieres
- triad of vertigo, tinnitus and hearing loss
- sensation of aural fullness
- other features e.g. nystagmus or positive romberg
- vertigo episodes lasting 20 minutes to hours
Causes of neck swelling
- reactive lymphadenopathy
- lymphoma
- thyroid swelling
- thyroglossal cyst
- pharyngeal pouch
- cystic hygroma
- branchial cyst
- cervical rib
- carotid aneurysm
Lymphoma - neck palpation
rubbery, painless lymphadenopathy
thyroid swelling exam
Moves up on swallowing
Thyroglossal cyst exam
midline, moves upwards with protrusion of the tongue
Symptoms of pharyngeal pouch
- dysphagia
- regurgitation
- aspiration
- chronic cough
Cystic hygroma
- congenital lymphatic lesion, classically on the left
Branchial cyst
Oval, mobile cyst that develops between the sternocleidomastoid and pharynx
Carotid aneurysm exam
pulsatile lateral neck mass which doesnt move on swallowing
Complications of tonsillitis
- otitis media
- quinsy
- rheumatic fever and glomerulonephritis
Indication for tonsillectomy
- sore throats are due to tonsillitis
- 7 or more episodes of sore throat per year, 5 or more for 2 years, 3 per year for 3 years
- symptoms occurring for more than one year
- episodes are disabling and prevent normal function
Features of quinsy
- severe throat pain, lateralises to one side
- deviation of the uvula to one side
- trismus (difficulty opening the mouth)
- reduced neck motility
Management of quinsy
- needle aspiration or incision and drainage
- intravenous antibiotics
- consider tonsillectomy (2 episodes)
What types of cancers do head and neck cancers tend to be?
squamous cell carcinoma
Where do head and neck cancers spread first?
Lymph nodes
Risk factors head and neck cancer
- smoking, chewing tobacco
- alcohol
- HPV
- EBV
Red flags head and neck cancer
- lump in the mouth or the lip
- unexplained ulceration in the mouth lasting more than 3 weeks
- erythroplakia or erythroleukoplakia
- unexplained hoarseness of voice
- unexplained thyroid lump
monoclonal antibody used to treat squamous cell head and neck cancers
Cetuximab (epidermal growth factor receptor)
2 week wait laryngeal cancer
- aged 45+
- persistent unexplained hoarseness or unexplained neck lump
Oral cancer 2 week wait
- ulcer 3+ weeks or unexplained lump in neck
- lump in the lip or oral cavity, red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
What are the types of allergic rhintis?
- seasonal
- perennial: symptoms throughout the year
- occupational
Features of allergic rhinitis
- sneezing
- bilateral nasal obstruction
- clear nasal discharge
- post nasal drip
- nasal pruritis
Management of allergic rhinitis
- allergen avoidance
- if mild to moderate then oral or intranasal antihistamine
- if moderate to severe or antihistamine ineffective then intranasal corticosteroids
Nasal deocngestants
- dont use for long periods
- rebound hypertrophy of the nasal mucosa may occur upon withdrawal
Auricular haematoma
- treatment promt to avodid cauliflower ear
- same day assessment by ENT
- incision and drainage
What is a branchial cyst?
- developmental defect of the branchial arches
- cyst is filled with acellular fluid with cholesterol crystals, encapsulated by stratified squamous epithelium
Management of branchial cyst
- consdier and exclude malignancy
- USS
- refer to ENT
- fine needle aspiration
Red flags of rhinosinusitis
- unilateral pain
- persistent symptoms despite 3 months of treatment
- epistaxis
What are the contraindications to a cochlear implant?
- lesion of cranial nerve VIII or brain stem causing deafness
- chronic infective otitis media , mastoid cavity or tympanic membrane perforation
- cochlear aplasia
How long do adults have to try hearing aids for before consideration of a cochlear implant?
3 months
Management simple gingivitis
Routine regular review by dentist
What is ludwigs angina
Cellulitis that invades the floor of the mouth and soft tissues of the neck
bacteria malignant otitis externa
Pseudomaonas aeruginosa
Samter’s triad
- asthma
- aspirin sensitivity
- nasal polyposis
Management of nasal polyps
- ENT for exam
- topical corticosteroids
Features of nasal polyps
- nasal obstruction
- rhinorrhoea, sneezing
- poor sense of taste and smell
association of secondary haemorrhage post tonsillectomy
wound infection
Management of primary haemorrhage after tonsillectomy
Immediate return to theatre
What can be given to prevent episodes in menieres?
Betahistine
Labyrinthitis presentation
- vertigo
- nausea and vomiting
- hearing loss
- after viral infection
