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YEAR 3 & 5 CORE CONDITIONS > ENT > Flashcards

ENT Flashcards

1
Q

What is the normal threshold for hearing?

A

-10dB to +15dB

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2
Q

What is the normal hearing range for humans?

A

20 to 20,000 Hz

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3
Q

What are the different severities of hearing loss?

A

Mild = 20-40dB
Moderate = 41-70dB
Severe = 71-95dB
Profound > 95dB

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4
Q

What are the categories of hearing loss?

A

Conductive

Sensorineural

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5
Q

Give examples of what causes a conductive hearing loss

A

Sound conduction is impeded through external ear, middle ear or both

Earwax
Trauma to tympanic membrane
Otitis 
Otosclerosis 
Cholesteatoma
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6
Q

Give examples of what causes a sensorineural hearing loss

A

Problem with the cochlea or the neural pathway to the auditory cortex

Presbyacusis (progressive, irreversible hearing loss of ageing)
MS
Acoustic neuroma
Occupational acoustic trauma
Ototoxicity - aminoglycosides, loop diuretics, quinine
Meniere’s disease

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7
Q

What test identifies the side of the hearing loss?

A

Weber’s test

  • Conductive hearing loss = loudest in affected ear (blocked out background noises)
  • Sensorineural hearing loss = quieter in affected ear
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8
Q

How can you distinguish between whether it is a conductive or sensorineural hearing loss?

A

Rinne’s test - if the tuning fork is perceived louder on the mastoid process, there is a conductive hearing loss

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9
Q

What is glue ear?

A

Otitis media with an effusion

The negative pressure in the Eustachian tube pulls fluid out of the lining of the middle ear

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10
Q

What usually causes otitis media?

A

Viral URTI - adenoid pads enlarge and block off eustachian tube

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11
Q

What is an important complication of otitis media? How does this occur and what is found on examination?

A

Mastoiditis

Infection can spread from the middle ear to form an abcess in the mastoid air spaces of the temporal bone.

This leads to post-auricular swelling pushing the auricle outwards and forwards

Mastoid tenderness will be present..

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12
Q

What is otosclerosis?

A

Autosomal dominant metabolic dysplasia of the ossicles

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13
Q

How does otosclerosis present?

A

Progressive bilateral conductive hearing loss (low frequencies)
Tinnitus
Quiet speech

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14
Q

What is Schwartze’s sign?

A

Red-blue oval window due to hyperaemia in otosclerosis

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15
Q

How do you treat otosclerosis?

A

Hearing aids

Stapedectomy

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16
Q

What usually causes otitis externa?

A

Swimmer’s ear

Trauma from ear buds

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17
Q

How does otitis externa present?

A 
Otalgia (worse at night)
Itchiness 
Lymphadenopathy of preauricular nodes
Minimal discharge 
Tragal tenderness 
Conductive hearing loss if meatus becomes blocked by swelling/discharge
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18
Q

How do you treat otitis externa depending on the severity?

A

Mild to moderate
• Combined antibiotic/steroid drops - Gentamix (gentamicin + dexamethasone)
• Advise to keep ear dry for next 7-10 days

Severe
• Pope wicks - strip of ribbon gauze used for application of topical antibiotics (gentamicin) to enable deeper penetration
• Oral antibiotics if:
○ Cellulitis extending beyond external ear canal
○ If ear canal is so swollen that wick cannot be inserted
○ Immunocompromised patients including diabetics

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19
Q

What is cholesteatoma?

A

Locally erosive collection of epidermal/connective tissue in the middle ear

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20
Q

What causes primary cholesteatoma?

A

Chronic negative pressure due to a poorly functioning eustacian tube leads to dead skin cells getting trapped in the pars flacida

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21
Q

What causes secondary cholesteatoma?

A

Trauma

Chronic otitis media

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22
Q

How does cholesteatoma present?

A

Foul-smelling otorrhoea
Otalgia
Conductive hearing loss
Headache

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23
Q

What are risk factors for cholesteatoma?

A

Chronic otitis media

Trauma

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24
Q

What is the management for cholesteatoma?

A

Mastoid surgery to remove the sac of squamous debris

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25
Q

What do the otolith organs do?

A

Detect tilt and acceleration/deceleration

There are 2 otolith organs (utricle + saccule)

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26
Q

What do the semi-circular canals do?

A

Detect rotation

Control eye movements in the plane of the canal

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27
Q

What does dysfunction of semi-circular canals lead to?

A

Nystagmus

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28
Q

What causes benign paroxysmal positional vertigo?

A

Otolith detachment into semicircular canals (especially posterior ones)
Head movements set the particles in motion which gives spinning sensation until they settle

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29
Q

What investigation can you do for BPPV?

A

Dix-Hallpike test - vertical nystagmus on rapid depression of tilted head

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30
Q

How can you manage BPPV?

A

Usually self limiting
If persistent - Epley’s manehouvre
Rarely surgery eg vestibular nerve section

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31
Q

How can you distinguish between different causes of vertigo depending on how long they last?

A

Seconds to minutes = BPPV
Minutes to hours = Meniere’s disease
Hours to days = vestibular neuronitis

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32
Q

What is Meniere’s disease?

A

Disorder of the endolymph volume (labyrinthine fluid) with progressive distention of the labyrinthe

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33
Q

What is Meniere’s disease associated with?

A

Autoimmune diseases
Allergy
Metabolic disorders
Infection

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34
Q

What are the symptoms of Meniere’s disease?

A

Triad of:

  • Vertigo
  • Tinnitus
  • Hearing loss (sensorineural)

Preceded by aural fullness
Last minutes to hours
+/- nystagmus

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35
Q

How can you treat Meniere’s disease?

A

Acute: Prochlorperazine - Buccastem 3mg/8hr bucally (vestibular sedative)

Prophylaxis:
Betahistine 16mg/8hr po
Limit salt intake

Surgical procedures:
Instillation of gentamicin via grommets
Labyrinthectomy (but causes total ipsilateral deafness)
Vestibular neurectomy

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36
Q

What is vestibular neuronitis/labyrinthitis?

A

aka acute vestibular failure

Isolated vestibular (CNVIII) neuropathy due to viral infection/herpes simplex reactivation

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37
Q

How does vestibular neuronitis/labyrinthitis present?

A 
Sudden and severe vertigo that persists for several days but improves with time
Nausea + vomiting
Worsened with head movements
Often following URTI
Nystagmus away from affected side

Neuronitis - no hearing loss or tinnitus
Labyrinthitis - hearing loss + tinnitus

(NB cochlear + SCC = labyrinth)

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38
Q

How do you manage vestibular neuronitis/labyrinthitis?

A

Vestibular suppressants eg buccastem 3mg TDS po or PO cyclizine 50mg TDS

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39
Q

What does the facial nerve supply?

A

Mostly motor fibres to muscles of facial expression

Sensory fibres from anterior 2/3rd of tongue

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40
Q

What causes weakness of only the lower part of the face?

A

UMN lesion e.g. stroke, MS

Neurones in the CNVII nucleus supplying the upper face receive bilateral supranuclear innervation

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41
Q

What causes ipsilateral weakness of all facial expression muscles?

A

LMN lesion

  • Bell’s palsy
  • Trauma
  • Otitis media
  • Ramsay Hunt syndrome - herpes zoster
  • Parotid tumour
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42
Q

What are the symptoms of Bell’s palsy?

A

Unilateral facial droop
Inability to close eye
Taste impairment
Hyperacusis - increased sensitivity to certain frequencies/volume ranges

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43
Q

How do you treat Bell’s palsy?

A

It is self-limiting
Can give prednisolone
80% make full recovery

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44
Q

What are nasal polyps associated with?

A 
Asthma
Hayfever
Aspirin hypersensitivity 
Cystic fibrosis
Sinusitis
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45
Q

Are nasal polyps usually unilateral or bilateral?

A 
Bilateral = polyps
Unilateral = malignancy
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46
Q

What defines acute and chronic sinusitis?

A 
Acute = <4 weeks
Chronic = >12 weeks
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47
Q

What causes acute and chronic sinusitis?

A

Acute

  • S. pneumoniae
  • H. influenzae type B
  • Moraxella

Chronic

  • Polyps
  • Fungal infections
48
Q

What are some risk factors for sinusitis

A 
URTI
Atopy
Smoking
Diabetes
Swimming
Dental problems
CF
49
Q

What are some complications of sinusitis?

A

Orbital cellulitis
Meningitis
Cerebral abscess
Osteomyelitis

50
Q

How do you treat sinusitis?

A

Usually self limiting and resolve in 2.5 weeks
Nasal decongestants
Inhaled steroids e.g. beclometasone
Co-amoxiclav

51
Q

What most commonly causes bacterial tonsillitis?

A

Beta-haemolytic streptococcus

52
Q

What are the guidelines for when someone can have an elective tonsillectomy?

A

> 7 cases in last year
5 per year for 2 years
3 per year for 3 years

53
Q

How do you treat tonsillitis?

A

Penicillin V if exudate present

54
Q

What should you not give in pharyngitis?

A

Amoxicillin - if it were EBV, would cause a rash

55
Q

What is quinsy?

A

Peritonsillar abscess

56
Q

How does glandular fever present?

A

Cervical lymphadenopathy
Soft palate petechiae (rash on roof of mouth)
Exudative tonsils
Hepatosplenomegaly

57
Q

How does epiglottitis present?

A

Odynophagia
Hoarse voice
Dyspnoea
Stridor

58
Q

How do you manage epiglottitis?

A

Adrenaline nebulisers
IV dexamethasone
Intubate
Cricothyroidostomy

59
Q

What are some causes of reactive lymph nodes?

A

Bacterial - TB, syphilis, s. aureus
Viral - URTI, EBV, CMV, HIV, herpes
Parasites - head lice, toxoplasmosis
Non-infective - sarcoidosis, SLE, amyloidosis
Children - cat scratch disease, Kawasaki disease

60
Q

What malignancies most commonly cause enlarged lymph nodes?

A

Leukaemia - AML, CLL, ALL, (not CML)
Lymphoma
Mets from elsewhere

61
Q

What are some congenital causes of neck lumps?

A 
Thyroglossal cyst
Dermoid cyst
Pharyngeal pouch
Cervical rib
Laryngocoele
62
Q

What is the criteria for 2 week wait referral for head/neck cancer?

A
  • Unexplained ulceration in the oral cavity
  • Persistent unexplained sore throat
  • Persistent unexplained hoarseness
  • Unexplained thyroid lump
63
Q

How does acute otitis media present?

A
  • Otalgia - might be pulling at ear
  • Malaise
  • Crying, poor feeding, restlessness
  • Fever
  • Vomiting •Coryza/rhinorrhoea

Perforation of TM often relieves pain - a child who is screaming and distressed may settle remarkably quickly then ear starts to discharge green pus

64
Q

What causes pain in acute OM and how may this be relieved?

A

Bulging of tympanic membrane causes pain

Eases if drum perforates - associated with purulent discharge

65
Q

What is the management of acute OM?

A

Analgesia

Acute OM resolves in 60% in 24hr with no abx

66
Q

When should abx be considered in acute OM?

A

Immediate abx:
Systemically unwell
Immunocompromised
No improvement in symptoms in >4 days

Immediate or 2 day ‘delayed’ abx:
<3 months old
Perforation / discharge
<2yrs with bilateral OM

67
Q

Which abx and dose are used in acute OM?

A

Amoxicillin 40mg/kg/day in 3 divided doses for 5 days

Erythromycin if penicillin allergic

68
Q

What is chronic otitis media?

A

An ear with a tympanic membrane perforation in the setting of recurrent or chronic infections, associated with:

  • Hearing loss
  • Otorrhoea
  • Fullness
  • Otalgia
69
Q

What are the 3 types of chronic otitis media?

A

1) Benign / inactive COM
2) Chronic serous OM
3) Chronic suppurative otitis media

70
Q

What is benign / inactive COM?

A

Dry tympanic membrane perforation without active infection

71
Q

How does chronic serous OM present?

A

Continuous serous drainage

Typically straw coloured

72
Q

What is chronic suppurative OM?

A

Persistent purulent drainage through a perforated tympanic membrane

73
Q

What is the management of COM?

A 
Topical or systemic abx based on swab results
Aural cleaning
Water precautions
Careful follow up
Surgery
74
Q

When is surgery considered in COM?

A 
Aural cleaning and abx fail
Persistent perforation / discharge
Conductive hearing loss
Chronic mastoiditis
Cholesteatoma formation
75
Q

What are the two surgical procedures offered in COM?

A

Myringoplasty = repair of tympanic membrane alone using a graft

Mastoidectomy = surgical repair of tympanic membrane and ossicles

76
Q

How does a cholestaetoma form following chronic OM?

A

Prolonged low middle ear pressure allows for the development of a retraction pocket of the pars tensa or flaccida. As this enlarges, squamous cell epithelium builds up

77
Q

What are some rare but serious complications of cholesteatoma?

A 
Meningitis
Cerebral abscess
Hearing loss
Mastoiditis
Facial nerve dysfunction
78
Q

Why is cholestatoma a misnomer?

A

It is not made of cholesterol nor is it a tumour

It is locally destructive around and beyond the pars flaccida from the release of lytic enzymes

79
Q

How may a cholesteatoma present?

A 
Foul discharge +/- deafness
Headache
Pain
Facial paralysis 
Vertigo

These symptoms indicate impending CNS complications

80
Q

What is the leading cause of hearing loss in children?

A

OM with effusion (OME) = glue ear

81
Q

What is the management of OME?

A

Usually transient, mild and resolves spontaneously
50% with bilateral will resolve within 3 months

Observation for 3 months then reassess hearing

Auto-inflation of eustation tube via a balloon through the nose can help during this period

Surgery

82
Q

What surgery can be offered in OME?

A

If worse after 3 months of persistent bilateral hearing loss, ventilation tubes can be inserted

Tympanostomy tube / grommets

83
Q

What are some possible complications of grommet insertion?

A

Infections and tympanosclerosis

84
Q

What advise is given regarding grommets?

A

Okay to swim post op but avoid forcing water into the middle ear by diving
Use ear plugs
Grommets extrude after 3-12 months, recheck hearing at this point
Approx 25% need reinsertion
Very rarely, a small perforation remains after grommets come out which may require surgery

85
Q

When is systemic treatment indicated for otitis externa? What may be given?

A

Immunosuppression
DM
Severe OE with cellulitis of face and neck
Topical administartion not possibly eg severe oedema

Oral ciprofloxacin

86
Q

What is necrotising inflammation of the external auditory canal?

A

Malignant otitis externa

Rare life threatening infection of the external ear that can lead to temporal bone destruction and base of skull osteomyelitis

87
Q

What is the causative organism of malignant OE?

A

Pseudomonas aeruginosa (95%)

88
Q

How does malignant OE present?

A

Severe ear pain
Red and swollen periauricular soft tissue
Otorrhea
Conductive hearing loss

89
Q

What are some complications of malignant OE?

A

Facial nerve palsy

Osteomyelitis of skull base leading to extradural abscess, venous sinus thrombosis, paralysis of other cranial nerves

90
Q

How should malignant OE be investigated?

A

CT for bone destruction
MRI for intracranial extension eg venous sinus thrombosis, cranial abscess
Biopsy to distinguish from a tumour

91
Q

What is the management of malignant OE?

A

Prompt IV abx for several weeks
1st line ciprofloxacin
2nd line other antipseudomonals eg piperacillin-taxobactam

Surgical debridement

High mortality

92
Q

What is cerumen?

A

Natural protective wax produced and secreted in outer third of the canal

93
Q

How may excess impacted ear wax present?

A

Dulled hearing
Feeling of fullness
+/- tinnitus

94
Q

How is excess ear wax removed?

A

Ear drops alone can clear the wax - Drops should be inserted 2-3 times each day for 3-7 days

if not…
Suction under direct vision using a microscope
OR
Irrigation (syringing) after softening with olive oil

95
Q

When should an ear not be irrigated?

A

Perforated TM
Grommets in place or within 1.5yrs
Cleft palate
After mastoid surgery

96
Q

Describe the Epley manoeuvre

A

Follow these steps if the problem is with your right ear:

Start by sitting on a bed.
Turn your head 45 degrees to the right.
Quickly lie back, keeping your head turned. Your shoulders should now be on the pillow, and your head should be reclined. Wait 30 seconds.
Turn your head 90 degrees to the left, without raising it. Your head will now be looking 45 degrees to the left. Wait another 30 seconds.
Turn your head and body another 90 degrees to the left, into the bed. Wait another 30 seconds.
Sit up on the left side.

97
Q

How may conductive hearing loss present?

A

Hearing improves in noisy environments
Volume of voice remains normal because inner ear and auditory nerve are intact
Sound is not normally distorted
Features of external auditory canal pathology present eg cerumen impaction

98
Q

How may sensorineural hearing loss present?

A

Hearing worsens in noisy environments
Volume of voice may be loud because nerve transmissions are impaired
Tend to lose higher frequencies preferentially = sound may be distorted
Often associated with tinnitus

99
Q

What is the most common cause of sensorineural hearing loss?

A

Presbycusis

100
Q

What is presbycusis? Which frequency is lost?

A

Progressive bilateral and irreversible damage of the hair cells of the organ of corti that impairs high frequency hearing

101
Q

What is the management of presbycusis?

A

Hearing aids

Cochlear implants

102
Q

How do hearing aids work?

A

Devices that amplify sound to help with conductive and sensorineural hearing loss

103
Q

How do cochlear implants work?

When are they indicated?

A

Prosthetic devices that are surgically implaned and function by electrical stimulation of CN VIII

Indicated if hearing aid treatment was unsuccessful

Auditory nerve and auditory system must be intact

104
Q

What is the most common way to assess hearing?

A

Pure tone audiometry

105
Q

How does pure tone audiometry work?

A

Headphones deliver sounds over frequencies 250-8000 Hz

Initially played above hearing threshold then is decreased in 10dB intervals until no longer heard

Then increase in 5dB until a 50% response rate is obtained

106
Q

What is the most common cause of otalgia (ear pain)?

A

50% non otological

107
Q

List five common causes of otalgia

A 
Barotrauma
Eustachian tube dysfunction
FB
Otits externa
Otitis media
108
Q

What does a pt with otalgia with a recent scuba diving hx?

A

Barotrauma

109
Q

How can barotrauma be prevented?

A

Topical decongestants

Autoinflation

110
Q

List come uncommon causes of otalgia

A 
Cellulitis of auricle eg following insect bite
Cholesteatoma
Wegener granulomatosis - granulomatosis
Malignant OE
Mastoiditis
Ramsay Hunt syndrome - Herpes zoster oticis
Relapsing polychondritis
Trauma
Tumours
Infected cyst
Viral myringitis
111
Q

How may ramsay hunt syndrome present?

A

Pain can be present before lesions develop
+/- hearing loss, vertigo, tinnitis
Vesicular rash on auricle of ear canal with possibly palsy of CNVII

112
Q

How does relapsing polychondritis present? Is the ear lobe involved?

A

Recurrent swelling of the auricle
Hearing loss
Earlobe not involved as it has no carticale

113
Q

How would wegener granulomatosis present?

A 
Arthralgia
Hearing loss
Myalgias
Oral ulcers
Otorrhea
Rhinorrhea
114
Q

What should be tested for in wegeners granulomatosis?

A

Antineutrophil cytoplasmic autoantibodies

115
Q

What are some secondary causes of otaligia?

A 
Bell palsy
Carotidynia
Cervical adenopathy
Tumours
Neuralgias
Sinusitis
TMJ syndrome
116
Q

How may Bell palsy present?

A

Retroauricular pain that is less severe than with Ramsay Hunt syndrome

YEAR 3 & 5 CORE CONDITIONS (30 decks)

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