ENT Flashcards
random management questions
Manage AOM
Admission, if:
severe systemic infection
*
complications: meningitis, mastoiditis, intracranial abscess, sinus thrombosis, facial nerve palsy
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children under 3 months or if Temp > 39°C and under 6 months
supportive:
simple analgesia (regular paracetamol or ibuprofen)
Management of discharge:
antibiotic/steroid ear drops
back-up antibiotic may be given: take if symptoms do not start to improve within 3 days or worsen significantly or rapidly at any time; and seeking medical help if symptoms worsen rapidly or significantly
If very unwell without systematic infection, or <6/12 old:
offer immediate antibiotic prescription
5-7 days of Amoxicillin (if allergic to Penicillin, use Erythromycin)
drops usually better than PO
ENT referral if:
failure of resolution
persistent discharge
complication (facial palsy, mastoiditis, intracranial sepsis)
Advise:
usually lasts 3 days, but can be 1 week
there is no evidence for decongestants or antihistamines. Seek medical attention urgently if symptoms worsen rapidly
Manage CSOM
topical/systemic abx (based on swab results), aural cleaning, water precautions, careful F/U (risk of cholesteatoma), may require surgery – myringoplasty, mastoidectomy
OME management, after 3 months of Watch and Wait with no resolution and impact on school performance
Grommets
Surgically inserted tubes which allow fluid to drain.
Ok to swim afterwards, but not dive. Also important not to get shampoo into ears.
Complications:
infection, scarring of eardrum (tympanosclerosis)
They normally come out in 3-12 months. Follow up.
tinnitus treatment
explanation (common and usually improves with time – via habituation), address patients concerns, manage comorbid depression, anxiety or insomnia, treatment aimed at reduction in symptoms: hearing aids (if hearing loss >35dB – improves perception of background noise to make tinnitis less apparent), psych support (psychoeducation and sound therapy – using background noise e.g. from fan or radio to mask tinnitis), CBT (and tinnitus retraining therapy)
BPPV advise
BENIGN NATURE.
For many patients, the vertigo may go away on it’s own within over several weeks. May take longer.
Usually gets better within 12-18 months.
Get out of bed slowly and avoid tasks that involve looking upwards.
DRIVING
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do not drive if dizzy or if they might experience dizziness
*
DVLA says that if they have a liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness, then STOP driving
Medications DON’T help
Meniere’s management
Acute: prochlorperazine (buccastem bucally short-term as a vestibular sedative)
Prophylaxis: betahistine
Surgical approaches taken if symptoms persistent
MDT (ENT, physitherapist, audiologist, counsellor, psychologist)
Spontaneously resolves in 70% of cases.
If it is very severe and you are vomiting a lot, call a hospital.
Consider the risk before going swimming, climbing a ladder etc.
If you don’t have warning signs and the attacks of vertigo come on suddenly then you need to inform the DVLA.
Vestibular neuronitis
Can be managed in GP. Should start improving in few days
Refer to audiology and audiometry if hearing loss.
Can take buccastem tablets for acute management.
DO:
drink plenty of water
Rest
DON’T
drive, or work with heavy machinery
Safety Net:
if it hasn’t resolved in a week
Difference between vestibular neuronitis and labyrinthitis
labyrinthitis presents with additional SNHL
Facial palsy differentials
Intracranial: brainstem tumour, stroke, MS
intratemporal: Otitis media, cholesteatoma
infratemporal: Parotid gland tumour, Trauma, Bell’s Palsy
Bell’s palsy management and red flags
RED flags:
Ear infection or discharge
Parotid mass
Suspected CVA
Investigations:
Otoscopy
Parotid gland examination
Potentially an MRI head
Management:
Resolves on its own.
Eye lubrication and maybe tape at night
If within first 48 hours, can give oral prednisolone.
Refer to ENT if bilateral, recurrent or >1month
Prognosis: only 5% have remaining facial weakness, most recover within months. There are surgical options
Allergic rhinosinusitis history and management
History
- check for asthma
- seasonal
- itchy eyes, pruritus, discharge, sneezing
Management
- examine nose
- allergen avoidance
- steroid spray (betamethasone)
- if very severe, can try oral prednisolone (very short term)
- nasal douching
- non-sedating antihistamines
- Review in 4 weeks
Nose fracture history
Head trauma? LOC, amnesia, N+V
Nose blockage? Change in appearance
CSF leak
Base of skull fracture: facial numbness, diplopia
Nose fracture immediate management
No imaging is required.
Need to drain septal haematoma if present.
Refer to clinic in 5-7 days: assess when the swelling has gone down.
Nose can be manipulated up to 3 weeks after injury. Under LA or GA. Afterwards a rhinoplasty is required.
Epistaxis management (apart from history of trauma, risk factors and severity)
Advise to pinch fleshy part of nose and lean forward.
Spit any clots out. Let the blood flow into a bucket.
- Spray with local anaesthetic. Cautery with silver nitrate for 2s if you can see where the bleeding points are. Otherwise refer to ENT
- nasal packing for 24h. Try anteriorly first.
- If still bleeding, can try posterior packing
dysphonia differentials
Muscle tension dysphonia (benign, reassure and SALT)
Vocal cord nodules (overuse, SALT and voice hygiene. This may suffice, but there is also surgery)
Reinke’s oedema (from smoking, SALT, laser therapy 2nd line)
Laryngeal cancer…
OSA management
Refer for an overnight sleep study: look at ECG, oxygen sats, BP, pulse and number of apnoeic episodes
Lifestyle. Including avoidance of sleeping tablets
If mild - mandibular advancement devices
Moderate-severe: CPAP (covered by NHS)
- most get used to it fairly quickly, and the benefit is great
- noisy
- strange at first
- may cause runny nose
- may cause headaches
Sleep apnoea trust for support.
Potentially psych support.
