ENT Flashcards
spot dx: unilateral sensorineural loss of hearing and tinnitus and ataxia
acoustic neuroma
disabling vertigo, hearing loss, tinnitus and nausea and vomiting
meniere’s disease
DDX: sudden acute loss of hearing in the last 72 hours
trauma/post operative: post stapedectomy, head injury, driving, flying
infections: mumps, measles, herpes zoster, syphilis, meningitis, encephalitis
iatrogenic: drug (gentamicin, furosemide)
neoplastic: cerebopontine tumors, cochlear otosclerosis
vascular: polycythemia, diabetic vascular disease
menierre’s
what is the treatment for sudden sensorineural hearing loss in the last 72 hours (monash powerpoint)?
emergency referral and specialist referral
start high dose steroid ASAP (1mg/kg up to 60mg)
DDX: hearing loss in an adult/elderly (Murtagh Model)
probability: prebyascus, otitis media/externa, cerumen (wax impactation)
dangerous conditions: cerebellopontine tumors (acoustic neuroma), infections (meningitis, syphilis, mumps, measles), perforated TM, cholesteatoma, perilymphatic fistula
pitfalls: meniere’s, Foreign body, otosclerosis, temporal bone fracture, baro induced, rare diseases (paget’s, multiple sclerosis, osteogenesis imperfecta)
masquerades; drugs, diabetic, thyroid disease
what does a +ve rinne test mean?
+ve rinne test means air conduction > bone conduction. essentially means it can be either normal or a present sensorineural loss
interpret the permutations of these results:
(1) webber central, rinne positive on the left
(2) webber lateralizes left, rinne negative on the left
(3) webber lateralizes right, rinne positive on the left
(1) normal
(2) conduction loss on the left
(3) sensorineural loss on the left
80 year old man, unable to understand speech, social withdrawal, and speaks quite loudly
presbyacius
20 year old man w/ unilateral ear discharge and hearing loss. otoscopy reveals a growth on the tympanic membrane. what is the treatment?
cholesteatoma (expanding growth of keratinized squamous epithelium in the middle ear)
tx: urgent referral to ENT surgeon, surgical removal
20 year old female presents w/ unilateral conductive hearing loss. this begins in lower frequencies initally, and has now progressed to higher frequencies as well. what is the most likely dx?
otosclerosis
(female, 20 - 30, middle ear bone replaced by spongy vascular bone structures that has become sclerotic, autosomal dominant inheritance, causing conductive hearing loss unilateral that progresses from lower frequencies to high)
tx: referral and stapedectomy
DDX: ear pain (otalgia) in Murtagh’s model
probability: otitis externa/media, TMJ arthraljia, eustachian tube dysfunction
dangerous disorders: perforated TM, FB, acute mastoiditis, cholesteatoma, neoplasia of external ear, Ramsay-hunt syndrome
pitfalls: FB, ear wax impactation, barotrauma, dental causes, referred pain (nose, throat), facial neuralgias (glossopharyngeal), post tonsillectomy
child complaining of ear pain and discharge. otoscopy reveals a opaque red tympanic membrane. what is the treatment?
assess severity of OM. usually OM does not warrant a/b (w/o the presence of systemic symptoms) and r/v in the next 24 - 48 hours if pt is not getting better
symptomatic; rest pt in warm room w adequate humidity, give analgesia, give nasal decongestants if needed
what are the indications for use of a/b in children w/ acute OM
suppurative OM
with systemic features (fever, n/v, lethargy)
for children < 6mths, as long as persistent beyond 24 hours, discharge present, bilateral AOM - give a/b
what antibiotic to use in acute OM if it is indicated/
amoxcillin 15mg/kg up to 500mg oral for 5 days
if inadequate response in the next 48 - 72h, possible inadequate response to amoxycillin therapy and hence use amoxcillin + clauvanate (augmentin)
what are some risk factors for recurrent bacterial OM
smoking group child care allergic rhinitis adenoid disease structural deformities (cleft plate and down syndrome)
what is the definition of chronic supparative OM and what is the treatment for it?
chronic supp OM = infection of middle ear w/ perforated eardrums and discharge for at least 6 weeks
when ear dicharge persists beyond 6 weeks = ciprofloxacin 0.3% ear drops 5 drops into the affected ear, 12 hourly until ear is free of discharge for 3 days
if recent perforation = treat as if acute OM (oral amoxicillin up to 500mg for 5 days) + topical antibiotics as above
what are some of the complications of chronic OM
acute mastoiditis intracranial infections facial palsy (bell's palsy)
what is the treatment for persistent OM with effusion i.e glue ear?
treat w/ course of 3 - 6 months of amoxicllin (oral) and insertion of grommet
optimize learning environment for the child
preventive measures to modify risk factors (smoking environment, allergic rhinitis, child care group) for recurrent bacterial OM
what is an unsafe perforation in the case of chronic suppurative otitis media
site of perforation at attic region (small area of the drum between the lateral process of the maleus and the roof of the external auditory canal immediately above it)
what is the tx for acute diffused otitis externa
preventive treatments; aural toilet (tissue spear) 6 hourly until ear canal is dry, remove discharge from ear, NO syringing. keep ear dry as much as possible
medical care: dexamethasone + framycetin + gramicidin ear drops 3 drops instilled into the affected ear, 3 times daily for up to 3 - 7 days
if fungal = flumethasone + clioquinol 1% ear drops OR triamcinolone acetonide + neomycin + gramicidin + nystatin
what are the organisms involved in acute OM
h influenzae
strep pneumoniae
moraxella catarrhiasis
what is the tx of localized otitis externa
most often than not caused by S aureus from a boil/hair follicle
flucox 500mg or if hypersensitive, use cephalexin 500mg
what prevention can be put in place to prevent recurrent otitis externa
use acetenic acid plus isopropyl alcohol ear drops following exposure to water
use ear plugs while showering and swimming
what is the treatment for a patient when his otitis externa complicates to become a necrotizing OE presneting with high fever, severe persistent pain, visible granulation tissue, progressive cranial neuropathies
urgent referral to ID physician and ENT surgeon
start patient on anti pseudomonas = gentamicin IV + tazocin
DDX to dizziness in the elderly
probability: orthostatic hypotension/drugs induced, BPPV, menierre’s, ear wax impactation
dangerous: cerebellopontine tumors, CVS disease, auditory nerve dysfunction
acute vertigo, hearing loss, ipsilateral facial paralysis, ear pain and vesiclular eruption in the auditory canal and auricle
ramsay hunt syndrome
episodic hearing loss and vertigo induced by sneezing, straining, coughing, lifting heavy things
perilymphatic fistula
often accompanied w/history of concussion, straining, barotrauma
sudden onset of vertigo, n/v in young man. finding of unidirectional mixed horizontal and torsional nystagmus
vestibular neuritis
sudden onset of vertigo, n/v and hearing loss + tinnitus
acute labyrinthinitis
treatment for vestibular neuritis
prednisolone 1mg/mg (up to 100mg) oral, daily in the morning for 5 days, then taper over 15 days
what is the tratment for acute vertigo (etg recommended)?
prochlorperazine 12.5mg IM immediately, followed by oral dose if still require
others: prochlorperazine, promethazie, diazepam
not reccomended for long term treatment as it may potentially cause tardive dyskinesia, drug induced parkinsonism, and dependence
what is the diagnostic test for BPPV. describe it
halls pike manouvre (should be held for at least 20 seconds)
patient lying on the bed supine, take patients head hanging position 20 degrees below the couch (3 x with once head straight, and head rotated to either side) –> this should elicit, rotatory geotropic nystagmus, fatiguable nystagmus, reversal of direction of nystagmus on sitting up, duration of nystagmus 20s
what is the treatment of BPPV
give appropriate reassurance and counselling
Repositioning maneuvers - Epley maneuver, Brandt-Daroff exercises
avoid movements that causes acute attack
Surgery for refractory cases
Anti-emetics if N/V
what is the treatment for menierre’s disease?
acute attack: prochlorperazine chronic attack: low salt diet, avoid excessive salt, tobacco, coffee alleviate stress thiazide diuretic as prophylaxis may use betahistine (vasodilator) oral
what are the side effects of prochloperazine
d2 receptor antagonist s.e include: drug induced parkinsonis, tardive dyskinesia dependence
what is the treatment of ramsay hunt syndrome?
prednisolone 1mg/kg (up to 100mg) oral, daily in the morning for 5 days + famciclovir 250mg oral OR valaciclovir 1g oral OR aciclovir 800mg
what is the treatment of bells palsy?
reassurance and prednisolone oral up to 100mg daily in the morning for 5 days
what is the centor criterion for a/b prescription in sore throat
temperature > 38
no anterior cervical LN
tonsillar exuate
absence of cough
what are high risk patient groups where antibiotics tend to be prescribed?
TI/aboriginal or other communities
chidlren w/ history of existing rheumatic heart disease
patient with scarlet fever
what are some non suppurative complications of S pyogenese infection of the throat/
post strep glomerulonephritis
rheumatic heart fever
what are the indications for tonsillectomy
tend not to be indicated in adults.
indicated in children who are:
repeated attacks of acute tonsillitis at least 5 or more
enlarged tonsils and/or adenoids causing airway obstruction
chronic tonsillitis
more than 1 attack of peritonsillar abscess (quinsy)
biopsy excision for suspected new growth
what antibiotics to give strep throat when antibiotics are indicated?
phenoxymethylpenicillin 500mg oral 12 hourly for 10 days
if resistant strain suspected = azithromycin
what are some common diagnostic features of a streptococcal throat?
- Constitutional features: fever > 38, toxicity
- Tender anterior cervical lymphadenopathy
- Tonsillar swelling and exudate
- Absence of a cough
what are some clinical features of EBV
posterior cervical lymphadenopathy
splenomegaly
jaundice +/- hepatomegaly
peri-orbital oedema
enlarged tonsils w/ or w/o white exudate covering membrane
clinical features usually take up to 7 days to peak in symptoms
what is the clinical diagnosis of EBV
monospot
EBV serology - IgM antibodies
patient from overseas, has tonsils covered with grey green pseudomembranous, enlarged tonsils. mild to moderate fever w/ sore throat and dysphagia
diptheria Treatment: - diptheria antitoxin in hospital - benpen can be given - treat contacts with benpen or erythromycin
Lymphatic drainage of cervical lymph nodes
Suboccipital - posterior scalp
Retroauricular - scalp, temporal region, external auditory meatus, posterior pinna
Parotid-preauricular - external auditory meatus, anterior pinna, soft tissue of frontal and temporal region, root of nose, eyelids, palpebral conjunctiva
Submental - floor of mouth, anterior oral tongue, lower lip
Sumandibular - oral cavity, anterior nasal cavity, soft tissue of mid-face, submandibular gland
Jugular (along SCM) - oral cavity, parotid gland (superior), pharynx, larynx, thyroid (inferior), cervical esophagus (inferior)
Posterior - nasopharynx, oropharynx, cutaneous structure of posterior scalp and neck
Anterior - thyroid gland, larynx, cervical oesophagus
Tetrad of menieres disease
Vertigo - minutes to hours
Sensorineural low frequency hearing loss
Aural fullness
Unilateral tinnitus
