ENT Flashcards
A 50 year old swimming presented with a 3/7 history of pruritus around the ear after a surfing session. He woke up today with pain worse when moving the pinna and fullness in his ear. On further questioning, the patient has a history of diabetes.
Otitis Externa
What are the common bacterial and fungal causes for Otitis externa?
Pseudomonas, E.coli, S. aureus, proteus, Klebsiella
Fungal: Candida, aspergillus
Pale cream “wet blotting paper” debris in the ear?
Candida Albicans
Black spores in the ear canal…
Aspergillus Nigra
Management of otitis externa?
- Aural toilet
- Dressing (dry)?
3a. Analgesia - Topical antimicrobes - Sofradex (bacteria) or Kenacomb (fungi)
- Lifestyle things - prevent scratching, neomycin sulfate, gramicidn and nystatin
What is surfer’s ear?
Narrowing of the ear canal - due to bone overgrowth caused by water retention in the ear.
A 23-year-old comes to the GP with a painful left ear. On examination, pulling the auricle elicited pain and otoscopy revealed a raised white pustule with surrounding erythema
Furunculosis or Boil
What is the cause of a boil/Furunculosis?
Staph infection of the hair follicle in the outer ear canal.
How to manage Boil which has lead to surround cellulitis of the ear canal?
Dicloxacillin
A 34 year old female attends her GP complaining of worsening unilateral ear pain following an ear piercing. She has removed the ear piercing.
Perichondritis
What organism causes Perichondritis and hence what is the management?
Caused by P. pyocyaneus and hence treat with ciprofloxacin
Julia an 8 month old girl attends with her father who states that she has recently had a runny nose and was sneezing but had been improving. Last night she was crying inconsolably and pulling her right ear.
Acute Otitis Media
Cause of Acute Otitis Media?
Eustacian tube dysfinction leading to stasis of fluid in the inner ear. This can lead to a secondary bacterial or viral infection.
Main diagnostic feature of AOM is __________ of the TM
Redness and bulging of Tympanic membrane
Indications for antibiotics in AOM? (7)
Children 48hrs
Toxic
Aboriginal
Red-Yellow bulging TM
How do you manage AOM with antibiotics?
Analgesics (Panadol/ibuprofen)
Adequate rest in a warm room
Nasal decongestants for nasal congestion
- Abx: Amoxycillin for 5-7 days
Complications of AOM?
Middle ear effusion
Acute Mastoiditis
Serous otitis Media
Pain, swelling and tenderness behind the ear?
Acute Mastoiditis
Antibiotic prevention of acute otitis media is indicated if it occurs more often than every other month or for _____ or more episodes in _______ months
How do you manage recurrent AOM
Antibiotic prevention of acute otitis media is indicated if it occurs more often than every other month or for three or more episodes in 6 months
Use amoxicillin for abut 4months
and if Child over 18mo then consider pneumococcus vaccine
Avoid smoke/cigarrette exposure
Consider r/v by ENT?
Two forms of Chronic suppurative otitis media they both present with ______ and ______ without ______
Both present with deafness and discharge without pain
Discharge in Cholesteatoma has ____ odour, is _____ in amount and is {Purulent or mucopurulent}?
Foul odour, Usually scant in amount and Purulent
Discharge in Safe chronic otitis media has ____ odour, is _____ in amount and is {Purulent or mucopurulent}?
Inoffensive odour, Can be profuse in amount and is mucopurulent
How to monitor Chronic otitis media (safe)
- monitor closely
- auraldischarge persists for >6 weeks after course of abx
- treatment can be with topical steroid and abx combo following ear toilet
- if persistent - referral to exclude cholesteatoma or chronic osteitis
Cholesteatoma is Presence of accumulated _______epithelium in the middle ear (Attic perforation contains such material, safe perforations do not)
Presence of accumulated squamous epithelium in the middle ear (Attic perforation contains such material, safe perforations do not)
Cholesteatoma can erode the ______ ear bones and damage the TM and cochlear leading to ________
Erode bones of the temporal and middle ear leading to SNHL
Cholesteatoma can erode the ______ ear bones and damage the TM and cochlear leading to ________
Erode bones of the temporal and middle ear leading to SNHL!
“Small white pearl” behind an intact tympanic membrane
Congenital Cholesteatoma (Thought to be due to ectopic migration of external canal ectoderm to conductive hearing loss)
Treatment of Cholesteatoma?
Referral to ENT –> Audiogram, CT scan, surgical removal is necessary within a few weeks
Common cause of discomfort; Typically due to disorders that cause oedema in the tubal lining such as viral URTI or allergy?
Eustachian tube dysfucntion
How does Eustachian tube dysfunction present as?
It presents as fullness in the ear, pain of various levels and impairment of hearing.
When only partially blocked -swallowing and yawning may elicit a crackling or popping sound
Retraction of TM and decreased mobility on pneumatic otoscopy points to?
Eustachian tube dysfunction
What is Otic Barotrauma?
Rapid changes in pressure in the presence of an occluded Eustachian tube
Causes of conductive hearing loss? (5)
Impacted cerumen (wax) - most common Eustachian tube dysfunction Perforated tympanic membrane Cholesteatoma Otosclerosis (commonly stapes)
Causes of Sensorineural hearing loss? (5)
Noise induced deafness (most common) Age related presbycusis Acoustin neuroma (unilateral) Meniere's disease Sudden Sensorineural hearing loss
How do you investigate hearing loss?
Audiometry - Pure tone vs Impednace tympanometry
Electrical response audiometry
24 year old woman from home with husband has come to the GP clinic asking about poor hearing over the past few years. She states that her mother had bilateral cochlear implants by the age of 35.
Otosclerosis
What is the most common cause of conductive hearing loss in the adult with a normal tympanic membrane?
Otosclerosis
Normal middle ear bone is replaced by vascular spongy none that becomes sclerotic in _______-
Otosclerosis
How does Otosclerosis present?
Progressive disease starts in 20’s/30’s with family history. F >M
Affects the foot plates of the stapes or the junction of the incus and stapes.
May progress rapidly during pregnancy
May have mild sensorineural loss alongside the conductive loss and may be associated with Meniere’s syndrome
30 year old truck driver and rock concert goer comes in complaining of long-term hearing loss and tinnitus. Ear examination was normal. Audiogram results showed:
Noise induced hearing loss
Audiometry shows decreased hearing ability for certain sounds at about 4000 (for both sensory and conductive)…. is indicative of
Noise induced hearing loss
What are the clinical features of noise-induced hearing loss?
- Onset of tinnitus after work in excessive noise
- Speech seems muffled soon after work
- Temporary loss initially but becomes permanent if noise exposure continues
- High frequency loss of audiogram
40 year old male comes to the GP complaining of rapidly progressive sudden hearing loss in his right ear. Otoscopic examination reveal no wax or abnormalities with the tympanic membrane. Hearing test was organised and the results are:
Sudden Sensorineural hearing loss!
SSNHL occurs suddenly or over a period of ____ hrs.
72
Causes of SSNHL include:
Trauma, Post-operative, Viral infections,Ototoxic drugs, tumours, Miniere disease, Cochlear otosclerosis
How to treat SSNHL?
High dose steroids early; Medical Emergency
Are hearing aids more helpful in conductive or SNHL deafness?
Conductive. They help with amplification.
In who are cochlear impants used?
Is used in adults and children over 2 years with severe hearing loss unresponsive to powerful hearing aids
Difference between Dizziness and Vertigo?
Dizziness - General term described as impairment in spatial perception and stabiltiy
Vertigo - An illusion of rotary movement due to disturbed oreintation of the body in space. The sufferer may sense that the environment is moving. Vertigo may result form disease of labyrinth, vestibular nerve or their central connectuons.
Vertigo happening for few seconds after waking up with no hearing loss, tinnitus or other features.
Benign Paroxysmal Positional Vertigo
Vertigo happening from minutes to hours preceding an attack, Usually fluctuating and affecting one ear with associated tinnitus and pressure in the ear?
Meniere’s disease
vertigo lasting for hours to days which doesn’t present with any other major symtpoms?
Vestibular neuritis
Vertigo presenting for days in one ear, with an associated ongoing whistling sound in the ear. Recent history of acute Otitis media
Labyrinthitis
Chronic Vertigo, with progressive hearing loss and tinnitus. Alongside ataxia and CN VII palsy
Acoustic neuroma
Acute attacks of transient rotatory vertigo lasting seconds to minutes initiated by changing head position
Benign Paroxysm Positional Vertigo
How do you diagnose BPV?
Hallpike manoever - hold the patients head and observe for torsional vertigo and nystagmus
How do you treat Benign Paroxysmal Vertigo?
Generally tends to recover spontaneously. Can use Epley manoevre and antiemetics
Vertigo + Hearing Loss + tinnitus =
Meniere’s disease!
Why does Meniere’s disease occur?
Becaus eof inadequate absorption of endolymph –> this leads to accumulation of endolymph which distorts the membranous labyrinth
How do you treat meniere’s disease?
- An acute attack
An acute attack should be treated with bed rest and diazepam +/- Stemetil (Prochlorperazine)
Long term Mx of Meniere’s disease?
Low Salt diet, avoid triggers, alleviate anxiety
Meds - Stemetil (e.g. when ear feels full
A 60 year old acupuncturist presented with a 3 day history of vertigo, double vision, nausea and vomiting that has been constant and has caused him to be off work
Vestibular Neuronitis
What is vestibular neuronitis
Post viral inflammatory condition of the vestibular nerve.
What must be ruled out for Vestibular Neuronitis
Stroke - through a CT scan
How do you treat Vestibular Neuronitis?
- Bed rest and supportive care
- Diazepam(reduced brainstem response to vestibular stimuli)
- Corticosteroids - promotes recovery
- can use stemetil too
What is Labyrithitis?
Acute infection of the inner ear resulting in vertigo and hearing loss
A 14 year old girl presents with a 1 year history of worsening dizziness and vertigo which has resulted in her being away from school for extended period of times. On history, her father suffered from similar symptoms before passing away at the age of 28 from a fall.
Acoustic Neuroma
What is an acoustic Neuroma?
It is a benign tumour of the Schwann cells of the vetsibular nerve
Risk factors for Acoustic Neuroma?
Exposure to loud sounds, childhood exposure to low dose radiation, Hx of parathyroid adenoma, Type II Neurofibromatosis
How does Type II Neurofibromatosis present?
Bilateral acoustic neuroma + cafe aut lait skin lesions + multiple intracranial lesions
Is Acoustic neuroma generally with bilateral or unilateral hearing loos and tinnitus?
It presents with unilateral hearing loss and tinnitus
Work up for Acoustic neuroma?
Audiogram to confirm assymetrical sensorineural hearing loss
MRI scan - ENT referral
What is Rhinitis?
Inflammation of the mucosa of the nasal cavity
What is pain in trigeminal neuralgia evoked by?
Light touch, washign, shaving, talking, eating and brushing teeth (trigger)
How do you treat Trigeminal neuralgia?
Carbamazapine
3 common complications of Tonsillitis?
- otitis media
- Quinsy : peritonsillar abscess
- Rheumatic fever and GN (rarely)
A newborn baby is noted to have a large swelling on the left-side of the neck. On examination a soft, fluctuant and highly transilluminable lump is noted just beneath the skin.
Cystic Hygroma
A 75-year-old man presents with dysphagia and halitosis. On the left side of the neck is a small, fluctuant swelling which gurgles when palpated.
Pharyngeal pouch
Very common neck swelling - generally present during local infection or a generalised viral illness
Reactive lymphadenopathy
Painless neck swelling - associated with night sweats and splenomegaly?
Lymphoma
Does Thyroid swelling move upwards on swallowing?
Yes
Does a thyroglossal cyst move downwards on protrusion of tongue?
NO. It moves upwards
A thyroglossal cyst is generally located between the ______ of the thyroid and the _____ bone
Isthmus of the thyroid and hyoid bone
A pharyngeal pouch represents a posteromedial herniation between the _______ and ______ muscles
thyropharyngeus and cricopharyngus muscles
Typical symptoms of a pharyngeal pouch:
Presents in an elderly man - usually not large but if large then gurgles on palpation.
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough.
Branchial cyst: Develop due to failure of obliteration of the _____ branchial cleft in embryonic development
Second
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Branchial cyst
Pulsatile lateral neck mass which doesn’t move on swallowing
carotid aneurysm
Inability to move many facial muscles, pain in the ear, taste loss on the front of the tongue, dry eyes and mouth, and a vesicular rash.
Ramsay Hunt syndrome
What is Ramsay hunt Syndrome (type II)?
Disorder that is caused by the reactivation fo varicella zoster virus in the geniculate ganglion - nerve cell bundle of the facial nerve.
How to treat bells palsy?
Prednisolone
How to treat ramsay hunt syndrome?
Aciclovir + oral Steroids
5 top features of allergic rhinitis ?
Sneezing, Bilateral nasal obstruction, clear nasal discharge, post-nasal drip and nasal pruritis
5 mx points for Allergic Rhinitis
- Allergen avoidance
- Antihistamines
(Nasal Decongestant) - Intranasal corticosteroids
- Possible oral steroids in exacerbation
- Allergen immunotherapy
Nasal polyps are sensitive to which medication?
Aspirin
What is Samter’s triad?
The association of asthma, aspirin sensitivity and nasal polyposis
What are common associations with nasal polyps?
Asthma, aspirin sensivitiy, Infective sinusitis, CF, Kartagener’s syndrome
‘attic crust’ - seen in the uppermost part of the ear drum
Choleastatoma
Air and bone conduction are impaired in _____
Sensorineural hearing loss
In conductive hearing loss only _______ is imapired
Air conduction
In mixed hearing loss both air and bone conduction is impaired, with _____ being worse than_____
Air conduction being worse than bone
Offensive ear discharge
Choleastatoma
Air conduction is worse than bone conduction means _______ hearing loss
Conductive hearing loss
