ENT 18/5/2020 Flashcards
causes of referred otalgia
- dental pathology
- TMJ dysfunction
- infection of pharynx
- Ramsey Hunt syndrome
- oropharyngeal malignancy (posterior 1/3rd tongue)
otological causes of otalgia
- acute otitis media
- otitis externa
- furunculosis
- necrotising otitis externa
common causative organisms of otitis externa
- Pseudomonas aeruginosa
- Strep epidermidis
- S. aureus
- Aspergillus (fungal)
features of otitis externa
- progressive ear pain
- purulent discharge
- erythematous/swollen ear canal
- itchy EAM
- may cause mild hearing loss
management of otitis externa
- water precautions
- acetic acid
- microsuction
- topical antibiotic (often with steroid) = gentamicin/ciprofloxacin
- for fungal = clotrimazole 1% for 14 days+
features of a furuncle
- staphylococcal abscess on hair follicle in ear canal
- very tender
- dry ear
- sometimes visible abscess, often too tender for exam
treatment of furunculosis
- irrigation and debridement
- oral flucloxacillin
what is necrotising otitis externa
- osteomyelitis of the EAM and bony tympanic membrane, which can spread along skull base
- usually caused by Pseudomonas aeruginosa
- typically affects elderly diabetics
- exacerbated by antibiotic resistance
features of necrotising OE
- severe otalgia
- purulent discharge
- granulations visible
- may be visible bone
causes of acute otitis media
- viral (RSV, rhinovirus, parainfluenza)
- bacterial (S. pneumoniae, H. influenzae, Moraxella catarrhalis)
features of acute otitis media
- middle ear inflam (bulging, red ear drum)
- rapid onset earache (rapidly relieved pain with discharge suggests perforated eardrum)
- preceding URTI
acute otitis media management
- avoid antibiotics if possible - only if child very unwell/not improving after 72 hrs
- delayed prescription role
- 5 day course amoxicillin if prescribed
- grommet may be used in recurrent
- in perforation, stick to water precautions and should heal within 3 months
complications of otitis media
- hearing loss
- perforated tympanic membrane
- mastoiditis (can lead to meningitis/intracranial abscess)
- cholesteatoma (can lead to facial palsy, vertigo)
otitis media with effusion (glue ear)
chronic mucoid/serous effusion in the tympanic cavity in absence of infection lasting for > 3 months
- conductive hearing loss (pure tone audiometry and tympanometry should be organised)
- feeling of pressure without pain in ear
- intact tympanic membrane (may see fluid level)
chronic suppurative otitis media
persistent drainage from the middle ear through a PERFORATED tympanic membrane lasting >6 weeks
- bacterial infection following perforation
- recurrent ear discharge
- absence of fever or ear pain
- conductive hearing loss (pure tone audiometry and tympanometry should be organised if language problems)
- check for cholesteatoma
management of chronic suppurative otitis media
referral to ENT where they will do:
- ear rinse
- topical antibiotic (ciprofloxacin) and steroid drops (dexamethasone)
- surgery may be required
management of otitis media with effusion (glue ear)
watchful waiting (50% cases resolve within 3 months), ENT referral if language problems or non-resolving
- non surgical = hearing aid, autoinflation (older children)
- surgical = myringotomy and/or grommet
Meniere’s disease features
usually middle aged adults - triad of > vertigo > tinnitus > sensorineural hearing loss - sensation of aural fulness common - episodes last minutes to hours
management of Meniere’s
ENT referral
acute: buccal or intramuscular prochlorperazine
prevention: betahistine and vestibular rehabilitation exercises, salt restriction
features of vestibular schwannoma/acoustic neuroma
CN8 - vertigo - unilateral sensorineural hearing loss - unilateral tinnitus CN5 - absent corneal reflex CN7 - facial palsy
bilateral seen in NF2
vestibular schwannoma/acoustic neuroma management
investigation with MRI of cerebellopontine angle
- surgery
- radiotherapy
- observation
features of benign paroxysmal positional vertigo
average age = 55yrs
- vertigo triggered by change in head position (often when rolling over in bed or looking upwards)
- episode lasts 10-20s
- positive Dix-Hallpike manoeuvre (rotary nystagmus)
management of benign paroxysmal positional vertigo
commonly self-resolving after few weeks to months
- epley manoeuvre can relieve symptoms
- vestibular rehabilitation lessons for patient to do at home (eg. Brandt-Daroff exercises)
labyrinthitis vs vestibular neuritis
labyrinthitis
- vestibular nerve AND labyrinth affected
- vertigo exacerbated by movement
- hearing loss
- tinnitus
vestibular neuronitis
- vestibular nerve only
- only vertigo (no hearing loss) and lasts hours/days
BOTH
- usually viral so may be preceded by URTI symptoms + may have N+V
- often horizontal nystagmus towards the unaffected side
FeverPAIN criteria
Fever in last 24hrs Purulent tonsils ABSENCE of cough/coryza Inflammation of tonsils = severe oNset of symptoms ≤3 days
4+ points = consider immediate pen V/erythromycin
infectious mononucleosis (glandular fever) symptoms
triad of:
- fever
- lymphadenopathy (ant/post triangles of neck)
- sore throat
may have splenomegaly or lymphocytosis
diagnostic test for glandular fever
Monospot test/heterophil antibody test (should be tested in 2nd week of illness)
Also check LFTs for viral hepatitis
management of glandular fever
- supportive
- usually subsides after 2-4 wks
- avoid contact sport for 8wks after recovery to prevent splenic rupture
- as it is viral, treatment with amoxicillin/co-amox leads to a pruritic rash in 99%
peritonsillar abscess (quinsy) symptoms
- severe throat pain on one side (hot potato voice)
- deviated uvula away from quinsy
- difficulty opening mouth
needs draining
epistaxis management
ABC
- 20 mins pinching nose
- ant/post rhinoscopy - identify bleeding point
- nasal cautery (silver nitrate)
- nasal packing
- surgery could be necessary (sphenopalatine artery tie)
RFs for epistaxis
- trauma
- dry air, rhinitis
- warfarin, aspirin
- hereditary haemorrhagic telangiectasia
- coagulopathy
- neoplastic: SCC, adenocarcinoma
> MULTIPLE UNILATERAL BLEEDS = 2WW ENT referral
features of nasal polyposis
- nasal congestion
- anosmia
- snoring
- postnasal drip
management of nasal polyposis
unilateral = 2WW to ENT
bilateral = routine to ENT
- flexible endoscopic sinus surgery + polypectomy
management of nasal trauma
- septal haematomas need urgent drainage + IV abx
> they may compress cartilage causing necrosis, they can collapse and cause saddle deformity - fractures need moving back within 21 days otherwise will need rhinoplasty
indications for tonsillectomy in recurrent tonsillitis
- 7 episodes of bacterial tonsillitis in the last year
- 5 episodes per year in last 2 years (5 and 5)
- 3 episodes in the last 3 years (3 and 3 and 3)
- 2 peritonsillar abscesses (quinsy)
- Suspected malignancy (asymmetrical tonsils)
- Sleep disordered breathing (snoring)
features of cholesteatoma
- hearing loss
- chronic foul smelling ear discharge, abscess formation
- vertigo
- attic crust on otoscopy
management of cholesteatoma
- keep ear dry
- ENT referral
> tympanoplasty/tympanomastoidectomy