ENT

Question 1

What causes sinusitis?

Answer 1

• Infection → viral URTI
• Allergies → allergic rhinitis
• Obstruction of drainage → polyps, foreign body, trauma
• Smoking → impairs normal mucociliary clearance

Question 2

How does sinusitis present?

Answer 2

• Nasal congestion & discharge
• Facial pain, headache, pressure
• Facial swelling over affected areas
• Loss of smell
• Tenderness on palpation of affected areas

Question 3

How is acute sinusitis managed?

Answer 3

<10 days:

• Do not offer antibiotics → most cases are viral & will clear up within 2-3 weeks
• Paracetamol for pain

If symptoms haven’t improved after 10 days:

• High-dose steroid nasal spray for 14 days (mometsone)
• Delayed abx prescription, used if worsening or not improving within 7 days → phenoxymethylpenicillin

Question 4

How is chronic sinusitis managed?

Answer 4

• Saline nasal irrigation
• Steroid nasal sprays or drops
• Functional endoscopic sinus surgery → clear any obstructions to the sinuses.

Question 4

What is otitis externa, and what are the risk factors?

Answer 4

= inflammation of the skin in the external ear canal.
Risk Factors:

• Swimming → often referred to as ‘swimmers ear’
• Trauma to the ear canal → cotton buds or ear plugs
• Removal of ear wax
• Highest incidence in 7-12 year olds → however can affect all ages
• Hot & humid climates
• Dermatological issues

Question 5

What are the common causes of otitis externa?

Answer 5

• Bacterial (90% cases): pseudomonas aeruginosa, s.aureus
• Fungal: aspergillis, candida, especially if extensive topical abx or steroid use
• atopic dermatitis
• Psoriasis

Question 6

How does otitis externa present?

Answer 6

• Significant ear pain → progressive. The inflammation & swelling in the ear canal causing a rising pressure.
• Itch
• Discharge
  
  • If fungal → Looks like wet newspaper, can see spores
• Sometimes conductive hearing loss → can present without hearing loss, helpful to differentiate between OE & AOM.

Question 7

How is otitis externa managed?

Answer 7

Supportive:

• Keep the ear dry → can roll a ball of cotton in vaseline & gentle place in the eye when bathing. Very important to advise this!
• Avoid itching or using cotton buds.

Medical:

• Mild OE → acetic acid 2% (EarCalm OTC), which has an antibacterial & antifungal effects.
• Moderate → topical antibiotic & steroid
  
  • Otomize spray → neomycin, dexamethasone, acetic acid
  • If the tympanic membrane is perforated, then avoid these drops & others with aminoglycosides → if unable to visualise the TM then refer to ENT for microsuction.
• Severe/systemic symptoms → oral antibiotics (flucloxacillin) and potential admission.

Question 8

What is malignant otitis externa? How does it present?

Answer 8

= a severe & life-threatening form of OE, where the infection has spread beyond the soft tissue, resulting in osteomyelitis of the temporal bone & skull base.

Presentation:

• Non-resolving OE despite adequate topical treatment
• Persistent headache
• Severe pain
• Fever

Question 9

What is the most common cause of Acute Otitis Media?

Answer 9

Streptococcus pneumoniae

Question 10

How does Acute Otitis Media present?

Answer 10

• Recent onset ear pain → irritability & ear pulling noted in non-verbal children.
• Fever, cough, coryzal symptoms, sore throat, anorexia
• Aural fullness, hearing loss
• Discharge from the ear → when the tympanic membrane has perforated.
• Balance issues & vertigo

Question 11

How is Acute Otitis Media managed?

Answer 11

AOM is a self-limiting disease lasting 3 days-1 week & often does not require antibiotics.

Systemically Well:

• Reassurance & safety-netting
• Analgesia & antipyretic agents → paracetamol or ibuprofen
• If failure to improve within 48hrs, consider antibiotics (delayed prescription)

Unwell Child:

• Consider hospital admission (rare)
• Antibiotics → 5-7 days amoxicillin, then co-amoxiclav if worsening symptoms or first choice taken for 2-3 days without benefit.

Question 12

What antibiotics are given for tonsillitis if they are required?

Answer 12

Phenoxymethylpenicillin for 10 days, or clarithromycin if there is a penicillin allergy.

Question 13

What are the indications for tonsillectomy?

Answer 13

• If recurrent episodes, refer for tonsillectomy if the following criteria has been met:
  
  • > 7 documented, adequately treated, sore throat episodes in 1 year
  • > 5 episodes per year for 2 years
  • > 3 episodes per year for 3 years
• Other indications:
  
  • Recurrent tonsillar abscesses (2 episodes)
  • Enlarged tonsils causing difficulty breathing, swallowing, or snoring

Question 14

What are the causes of central & peripheral vertigo?

Answer 14

• Peripheral
  
  • Benign Paroxysmal Positional Vertigo → most common
  • Meniere’s disease
  • Vestibular Neuronitis
  • Labyrinthitis
• Central → uncommon
  
  • Vestibular migraine → most common
  • Posterior circulation infarct
  • Tumour
  • MS

Question 15

What are some differing features of peripheral vs central vertigo presentation?

Answer 15

Peripheral:
- sudden onset
- short duration (seconds, minutes)
- hearing loss or tinnitus often present
- coordination intact
- severe nausea

Central:
- gradual onset (except stroke)
- persistent
- usually no tinnitus or hearing loss
- impaired coordination
- mild nausea

Question 16

When is a Dix-Hallpike Test performed, and what are the findings if this is positive?

Answer 16

Indicated in someone with paroxysmal vertigo in who BPPV is considered

If positive:
- pt will feel the vertigo & nausea
- you will observe nystagmus directly

Typical findings in BPPV:
- up to 20s latent period followed by onset of torsional (rotary) or horizontal nystagmus

Question 17

What is Meniere’s disease, and how does it present?

Answer 17

= a long-term inner ear disorder that causes peripheral vertigo.
- Exact aetiology/physiology is not fully understood.
- Associated with the excessive build-up of endolymph in the labyrinth of the inner ear

Triad of symptoms:

• Hearing loss → progressive, fluctuating. Sensorineural, unilateral, affects low frequencies first.
• Vertigo → recurrent, spontaneous episodes. 20 minutes→ several hours. Not triggered by movement or posture.
• Tinnitus → initially occurs with episodes of vertigo, before eventually becoming more permanent.

Other symptoms:

• Aural fullness
• Unexplained falls (”drop attacks”) without LOC
• Imbalance, which can persist after episodes of vertigo resolve.

Question 18

How is meniere’s disease managed?

Answer 18

Acute Attacks:

• Prochlorperazine
• Antihistamines → cyclizine

Prophylaxis:

• Betahistine

Question 19

What is BPPV? Why does it occur?

Answer 19

= an inner ear disorder, characterised by recurrent brief attacks of positional vertigo.
- Canalolithiasis is most commonly accepted theory → there is displacement of free-floating otoconia particles from the macula that then become trapped in the posterior canal.
- The detached otoconial debris, in addition to the endolymph may continue to stimulate hair cells even after head movements have ceased.
- This leads to abnormal sensation of vertigo & nystagmus when the head moves in the plane of the affected semi-circular canal.

Question 20

How does BPPV present?

Answer 20

• Brief episodes of vertigo → 30s - 1 minute
• Symptoms provoked by head movements → turning over in bed, gazing upwards, bending forwards.
• No hearing loss of tinnitus

Dix-Hallpike Test:

• Used to diagnose BPPV
• It involves moving the patient’s head in a way that moves endolymph through the semi-circular canals, and triggers vertigo in patients with BPPV.
• Check the patient has no neck pain or pathology beforehand.

Question 21

How is BPPV managed?

Answer 21

Conservative:

• Often self-limiting, & symptoms may subside within 6 months of onset.
• Patients should be advised to:
  
  • Avoid positions that may provoke vertigo symptoms
  • Counsel that symptoms may re-occur.
• Do not drive when they feel dizzy or if this provokes episodes & inform their employer if there is an occupational hazard

Medical:

• If symptoms persist, vestibular rehabilitation should be performed.
• Repositioning techniques
• Medications:
  
  • Anti-emetics → prochlorperazine, cyclizine
  • Vestibular sedatives → betahistine

Question 22

What is an acoustic neuroma? How do they present?

Answer 22

= benign tumours of the schwann cells surrounding the vestibulocochlear nerve

The typical patient is aged 40-60 years presenting with a gradual onset of:

-Unilateral sensorineural hearing loss (often the first symptom)
-Unilateral tinnitus
-Dizziness or imbalance
-A sensation of fullness in the ear

They can also be associated with a facial nerve palsy if the tumour grows large enough to compress the facial nerve.

Question 23

How is acoustic neuroma managed?

Answer 23

Conservative- monitoring if no symptoms or unable to treat

Surgery -> partial or total removal

Radiotherapy - to reduce growth

Question 24

What is a cholesteatoma? How does it present?

Answer 24

= an abnormal collection of squamous epithelial cells & keratinocytes within the middle ear or mastoid air spaces.

• It is non-cancerous, but can invade local tissues, bones, and nerves, and predisposes the person to significant infections
• Foul discharge from the ear → recurrent or chronic
• Unilateral conductive hearing loss
• Unilateral tinnitus
• Advanced disease:
  
  • Infection
  • Pain (otalgia)
  • Vertigo
  • Facial nerve palsy

Examination:

• Abnormal build-up of whitish debris or crust in the upper tympanic membrane
• Ear discharge/wax
• There may be a perforated TM