ENT 2 Flashcards
What are the causes of otitis externa?
infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
seborrhoeic dermatitis
contact dermatitis (allergic and irritant)
recent swimming is a common trigger of otitis externa
How does otitis externa present? Mx?
ear pain, itch, discharge
otoscopy: red, swollen, or eczematous canal
Mx:
topical antibiotic / combined topical antibiotic with a steroid
if the canal is extensively swollen then an ear wick is sometimes inserted
Second-line:
oral antibiotics (flucloxacillin) if the infection is spreading
swab inside the ear canal
Malignant otitis externa is an uncommon type of otitis externa that is found in immunocompromised individuals.
Which patient group are commonly affected?
Diabetic patients
What causes malignant otitis externa?
most commonly caused by Pseudomonas aeruginosa
Infection starts in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal
Progresses to temporal bone osteomyelitis
How does malignant otitis externa present?
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
How is malignant otitis externa investigated and managed?
Dx: CT scan is typically done
Managment:
non-resolving otitis externa with worsening pain should be referred urgently to ENT
Intravenous antibiotics that cover pseudomonal infections
Otosclerosis is an autosomal dominant condition that causes progressive conductive deafness in young adults.
How can it be managed?
hearing aid
stapedectomy - removal of the stapes bone
What are the most common location of salivary gland tumours?
What patient population do they largely effect?
80% of all salivary gland tumours occur in the parotid gland (and 80% of these are benign)
middle aged patients, with the exception of Warthins tumours, they are commoner in women than men
List the key benign parotid neoplasms
Benign pleomorphic adenoma or benign mixed tumor
Warthin tumor
Monomorphic adenoma
Haemangioma
What is the most common parotid neoplasm?
Outline its key features :
Benign pleomorphic adenoma
Slow growing, lobular, and not well encapsulated
Malignant degeneration occurring in 2-10%
What is a Warthin tumor?
Second most common benign parotid tumor
Most common bilateral benign neoplasm of the parotid
Occurs later in life
Presents as a lymphocytic infiltrate and cystic epithelial proliferation
What are the associations of Warthin tumours?
strongly associated with smoking
Marked male predominance
What is a Monomorphic adenoma of the parotid?
Slow growing benign tumour of the parotid gland
Consist of only one morphological cell type (hence term mono)
Outline the key features of a parotid Haemangioma
Accounts for 90% of parotid tumours in children less than 1 year of age
Hypervascular on imaging
Spontaneous regression may occur
List the key malignant parotid neoplasms
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Mixed tumours
Adenocarcinoma
Lymphoma
How may parotid tumours be investigated?
Plain x-rays to exclude calculi
Sialography to delineate ductal anatomy
FNAC is used in most cases
Superficial parotidectomy may be diagnostic/ therapeutic
CT/ MRI may be used in cases of malignancy for staging primary disease
Lymphoepithelial cysts associated with HIV occur almost exclusively in which gland?
the parotid
Typically presents as bilateral, multicystic, symmetrical swelling
Risk of malignant transformation is low and management usually conservative
What is Sjogren’s syndrome?
How does it present with regards to the parotid gland?
How is this managed?
Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca
Bilateral, non tender enlargement of the gland is usual
Tx is supportive, there is risk of subsequent lymphoma
Parotid involvement occurs in 6% of patients with sarcoid. How does this present?
Bilateral in most cases
Gland is not tender
Xerostomia may occur
Management of isolated parotid disease is usually conservative
What is the most common cause of a perforated tympanic membrane?
Infection
other causes include barotrauma or direct trauma.
What is the risk of a perforated tympanic membrane? How can it be managed?
may lead to hearing loss depending on the size and also increase the risk of otitis media
will usually heal spontaneously after 6-8 weeks
avoid getting water in the ear during this time
prescribe antibiotics for perforations which occur following an episode of acute otitis media
A peritonsillar abscess (quinsy) typically develops as a complication of bacterial tonsillitis.
How may it present?
severe throat pain, which lateralises to one side
deviation of the uvula to the unaffected side
trismus (difficulty opening the mouth)
reduced neck mobility
How should quinsy be managed?
urgent review by an ENT specialist
needle aspiration or incision & drainage + intravenous antibiotics
tonsillectomy should be considered to prevent recurrence
Pleomorphic adenoma (also known as a benign mixed tumour) is a benign tumour of the parotid gland. It is the most common tumour of the parotid gland and typically appears at the age of 40-60 years.
How does it appear on examination?
What is the prognosis?
gradual onset, painless unilateral swelling of the parotid gland
typically movable on examination rather than fixed
recurrence rate of 1-5% with appropriate excision (parotidectomy)
malignant transformation if not removed
What are the main post operative complications of tonsillectomy?
Pain - may increase for 6 days post surgery
Haemorrhage
How may post tonsillectomy haemorrhage be managed?
All should be reviewed by ENT
Primary:
6-8 hours following surgery
immediate return to theatre
Secondary:
5 - 10 days after surgery
often associated with a wound infection
admission and antibiotics
Presbycusis is a type of sensorineural hearing loss (typically bilateral high frequency hearing loss) that affects elderly individuals.
What can cause it?
Arteriosclerosis: diminished perfusion and oxygenation of the cochlea
Diabetes: Acceleration of arteriosclerosis
Accumulated exposure to noise
Drug exposure (Salicylates, chemotherapy agents etc.)
Stress
Genetics
How may presbycusis present?
Speech becoming difficult to understand
Need for increased volume on the television or radio
Difficulty using the telephone
Loss of directionality of sound
Worsening of symptoms in noisy environments
How can presbycusis be investigated?
Otoscopy: Normal - to rule out otosclerosis, cholesteatoma and conductive hearing loss (Foreign body, impacted wax)
Tympanometry: Normal middle ear function with hearing loss (Type A)
Audiometry: Bilateral sensorineural pattern hearing loss
Blood tests including inflammatory markers and specific antibodies: Normal.
Outline Rinne’s test
tuning fork is placed over the mastoid process until the sound is no longer heard, followed by repositioning just over external acoustic meatus
‘positive test’: air conduction (AC) is normally better than bone conduction (BC)
‘negative test’: if BC > AC then conductive deafness
Outline Weber’s test
tuning fork is placed in the middle of the forehead equidistant from the patient’s ears
the patient is then asked which side is loudest
in unilateral sensorineural deafness, sound is localised to the unaffected side
in unilateral conductive deafness, sound is localised to the affected side
How does conductive hearing loss present on Weber’s and Rinne’s tests?
Rinne’s:
Bone conduction > air conduction in affected ear
Air conduction > bone conduction in unaffected ear
Weber’s:
Lateralises to affected ear
How does sensorineural hearing loss present on Weber’s and Rinne’s tests?
Rinne’s:
Air conduction > bone conduction bilaterally
Weber’s:
Lateralises to unaffected ear
What are the 3 pairs of salivary glands?
parotid (serous) - most tumours
submandibular (mixed) - most stones
sublingual (mucous)
What are the key features of salivary gland tumours?
How about malignant salivary gland tumours?
tumours: ‘80% parotid, 80% of these = pleomorphic adenomas, 80% superficial lobe
malignant rare: short hx, painful, hot skin, hard, fixation, CN VII involvement
What is the main risk with superficial parotidectomy?
CN VII (facial nerve) damage
How do salivary gland stones present?
How should they be investigated and managed?
recurrent unilateral pain & swelling on eating
may become infected → Ludwig’s angina
80% are submandibular
Ix: plain x-rays; sialography
Mx: surgical removal
Other than stones and tumours, what may cause salivary gland enlargement?
acute viral infection e.g. mumps
acute bacterial infection
sicca syndrome and Sjogren’s (e.g. RA)
What are the Centor criteria for requirement of abx for tonsillitis?
3 of the following should be present to warrant abx for suspected tonsilitis:
C – Cough absent
E – Exudate
N – Nodes
T – temperature (fever)
(OR – young OR old modifier)
What are the fever PAIN criteria for requirement of abx for tonsilitis?
Fever over 38°C
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (3 days or less)
Inflamed tonsils (severe)
No cough or coryza
What abx can be given for tonsillitis?
phenoxymethylpenicillin or clarithromycin (if the patient is penicillin-allergic) for 7 or 10 days
Give some complications of tonsillitis
otitis media
quinsy - peritonsillar abscess
rheumatic fever and glomerulonephritis very rarely
When is tonsillectomy indicated for patients with persistent sore throat?
sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
the person has five or more episodes of sore throat per year
the episodes of sore throat are disabling and prevent normal functioning
80% of all salivary gland calculi occur in the submandibular gland.
How are these composed?
How do they present?
70% of these calculi are radio-opaque
Stones are usually composed of calcium phosphate or calcium carbonate
Patients typically develop colicky pain and post prandial swelling of the gland
What are the key features of submandibular gland sialadenitis?
Usually occurs as a result of Staphylococcus aureus infection
Pus may be seen leaking from the duct, erythema may also be noted
Development of a sub mandibular abscess is a serious complication as it may spread through the other deep fascial spaces and occlude the airway
Sudden onset sensorineural hearing loss (SSNHL) =
urgent referral to ENT for high dose steroids
usually idiopathic
How should SSNHL be investigated and managed?
An MRI scan is usually performed to exclude a vestibular schwannoma.
High-dose oral corticosteroids are used by ENT for all cases of SSNHL.
What are the main complications of thyroid surgery?
recurrent laryngeal nerve damage.
bleeding - haematomas may rapidly lead to respiratory compromise (laryngeal oedema)
damage to the parathyroid glands = hypocalcaemia
Tinnitus is the perception of sounds in the ears or head that do not come from an outside source.
What may cause it?
Idiopathic
Meniere’s Disease
Otosclerosis
Acoustic neuroma
Hearing loss
Drugs
Impacted ear wax
What drugs can cause tinnitus?
Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine
How should tinnitus be investigated?
audiological assessment to detect underlying hearing loss
imaging:
not all patients will require imaging
pulsatile tinnitus generally requires imaging as there may be an underlying vascular cause. Magnetic resonance angiography (MRA) is often used
How should tinnitus be managed?
investigate and treat any underlying cause
amplification devices (more beneficial if associated hearing loss)
psychological therapy (CBT and tinnitus support groups)
Spot diagnosis:
Recent viral infection e.g URTI
Sudden onset
Vertigo
Nausea and vomiting
Hearing may be affected
Viral labyrinthitis
Spot diagnosis:
Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss or tinnitus
Vestibular neuronitis
(Acute Labyrinthitis has ALl the symptoms whereas Vestibular neuronitis only has Vertigo)
Spot diagnosis:
Vertigo
Gradual onset
Triggered by change in head position
Each episode lasts 10-20 seconds
Benign paroxysmal positional vertigo
BPPV
spot diagnosis:
vertigo associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears
Meniere’s disease
Spot diagnosis:
Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2
Acoustic neuroma
give 4 less common causes of vertigo
posterior circulation stroke
trauma
multiple sclerosis
ototoxicity e.g. gentamicin
Vestibular neuronitis is a cause of vertigo that often develops following a viral infection.
How does it present?
recurrent vertigo attacks lasting hours or days
nausea and vomiting may be present
horizontal nystagmus is usually present
no hearing loss or tinnitus
How can vestibular neuronitis be differentiated from a posterior circulation stroke?
the HiNTS exam
How can vestibular neuronitis be managed?
a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine)
vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms
What is the main difference between labyrinthitis and vestibular neuritis?
Vestibular neuritis = only the vestibular nerve is involved, hence there is no hearing impairment
Labyrinthitis = both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo AND hearing impairment.
Patients with acute labyrinthitis typically present with an acute onset of:
vertigo: not triggered by movement but exacerbated by movement
nausea and vomiting
hearing loss: may be unilateral or bilateral, with varying severity
tinnitus
preceding or concurrent symptoms of upper respiratory tract infection
What are the signs of labyrinthitis on examination?
spontaneous unidirectional horizontal nystagmus towards the unaffected side
sensorineural hearing loss: shown by Rinne’s test and Weber test
abnormal head impulse test: signifies an impaired vestibulo-ocular reflex
gait disturbance: the patient may fall towards the affected side
How can acute labyrinthitis be managed?
episodes are usually self-limiting
prochlorperazine or antihistamines may help reduce the sensation of dizziness
Non-resolving otitis externa with worsening pain despite strong analgesia =
urgent ENT referral
suggestive of malignant (necrotising) otitis externa
Tx for otitis externa in diabetics?
ciprofloxacin for pseudomonas cover
