ENT Flashcards
Risk factors for otitis externa
Mechanical injury to the skin - cleaning, foreign objects (hearing aids, earplugs), itching Increased moisture - swimming Skin disease DM Prolonged use of topical antibiotics
Clinical features of otitis externa
Otalgia - particularly at night Otorrhea Tender tragus Moving auricle causes pain Conductive hearing loss Diffuse oedema and erythema Purulent debris Peri-auricular lymphadenopathy
Possible complications of acute otitis externa
Perichondritis (infection of the cartilage)
Cellulitis
Malignant otitis externa
Otomycosis (fungal ear infection usually following use of topical abx)
Late: canal stenosis, hearing loss
What is malignant/necrotising otitis externa
When otitis externa spreads and causes osteomyelitis of the temporal bone
Causative organisms of otitis externa
Staph aureus
Pseudomonas aeruginosa (swimming, abx drop resistance)
Aspergillus niger - itching > otorrhea, looks like cotton wool speckled with black dots
Herpes zoster
Influenza viruses
Management of otitis externa
Keep ear dry
Oral analgesia
Topical drops - antibiotic + steroid: Sofradex, Gentisone, Otomise
What features would make you think of perichondritis rather than otitis externa
Symptoms worsening or not responding to treatment
Pyrexial
Tachycardic
Hearing loss
Features of malignant otitis externa
Severe pain Granulation tissue - at junction of cartilage and bony part of ear canal Red/swollen periauricular tissue Otorrhea Conductive hearing loss
Possible complications of malignant otitis externa
Facial nerve palsy
Osetomyelitis of skull base which in turn can cause extradural abscess, venous sinus thrombosis, paralysis of other cranial nerves
Who gets malignant otitis externa
The immunocompromised
Management of malignant otitis externa
Continue with topical antibiotics PLUS 6 weeks of IV antibiotics (Ciprofloxacin) CT head to identify bone destruction MRI to identify intracranial extension
Most common causative organism of acute otitis media
Streptococcus pneumoniae
Presentation of acute otitis media
Acute onset of earpain, usually with a throbbing character Fever Loss of appetite Bulging TM Red TM Purulent discharge if ruptured TM Conductive hearing loss
Risk factors for acute otitis media
Bottle/formula feeding Pacifier use Passive cigarette smoking Day care Poor socioeconomic status
What is the definition of recurrent acute otitis media
More than 4 episodes in a 6 month period
How does otitis media happen
Eustachian tube dysfunction –> negative middle ear pressure –> retracted TM
Accumulation of middle ear secretions –> bacterial superinfection –> bulging TM
Predisposing factors for eustachian tube obstruction
ET mucosal inflammation - viral URTI, allergic rhinitis
Enlarged adenoids
Nasal polyps
Cleft palae
Young - the ET of infants is short, wide and horizontal so nasopharyngeal secretions easily reflux into the ET and so infants are more prone to developing acute otitis media
Management of acute otitis media
Paracetamol and ibuprophen
Antibiotics if: bilateral/lasted over 2 days/systemic illness
Antibiotic of choice in acute otitis media
Amoxicillin
What is chronic otitis media
Inflammation of the middle ear for >3 months
Most common causative organisms of chronic otitis media
Pseudomonas aeruginosa
Staph aureus
What is chronic suppurative otitis media
Persistent drainage from the middle ear through a perforated tympanic membrane lasting >6-12 weeks
How does chronic suppurative otitis media present
Painless recurrent otorrhea that is odourless and mucoid/serous
Conductive hearing loss
May develop concurrent cholesteatoma
Management of chronic suppurative otitis media
Topical antibiotics and steroids
Consider tympanoplasty or graft insertion
What is otitis media with effusion (glue ear)
Chronic mucoid or serous effusion in the middle ear, in the absence of infection, lasting for >3 months
What is thought to cause otitis media with effusion
Eustachian tube dysfunction
Otoscopy findings of otitis media with effusion
Opaque/yellow TM
Air-fluid level behind TM
Management of otitis media with effusion
Tympanostomy tubes
Possible complications of chronic otitis media a) intra-temporal, b) extra-temporal
Intra-temporal complications of COM = vertigo (inflammation spreads to labyrinth + vestibular system), hearing loss (conductive due to ossicle/membrane damage, sensorineural due to cochlear inflammation), acute otitis externa (due to discharge irritating skin), facial weakness (erosion of middle ear bony canal exposes facial nerve, gets inflamed)
Extra-temporal complications = meningitis/subdural abscess/temporal lobe abscess (erodes through tegmen and expose dura), sigmoid sinus thrombosis (direct infective process or retrograde venous spread)
Possible complications of inner ear surgery
Infection
Bleeding
No improvement in hearing
Complete loss of hearing if inner ear damaged
Tinnitus
Vertigo
Facial nerve injury
Altered taste - chorda tympani nerve damange
Recurrence of disease and need for further surgery
What is cholesteatoma
A form of chronic otitis media in which keratinizing squamous epithelium grows from the tympanic membrane or the auditory canal into the middle ear mucosa. Deep retraction of the tympanic membrane, keratin accumulation (originates from skin cells that line the outer surface of the normal tympanic membrane – usually migrate out of ear canal with wax but if there is a deep retraction the keratin cant escape the pocket and develops into a keratin cyst
Potential complications of cholesteatoma
Middle ear invasion and ossicle erosion
Erosion of temporal bone –> extradural abscess, meningitis, sigmoid sinus thrombosis
Facial nerve paralysis
Clinical features of cholesteatoma
May be asymptomatic
Painless otorrhea
Scant, foul smelling discharge
Conductive hearing loss
Primary vs secondary causes of acquired cholesteatoma
Primary acquired - eutsachian tube dysfunction and formation of a retraction pocket
Secondary acquired - epithelium migrates inwards through a perforated tympanic membrane
Appearance of primary acquired cholesteatoma Vs appearance of congenital and secondary acquired cholesteatoma
Primary acquired: retraction pocket with squamous epithelium and debris that often appears as a brownish, irregular mass.
Congenital and secondary acquired: white or pearly mass behind the tympanic membrane
Imaging options for cholesteatomy
XR mastoid process
CT temporal bone
MRI is suspected intracranial extension
What is the definitive treatment of cholesteatoma
Mastoidectomy - open mastoid air cells, remove cholesteatoma from middle ear, reconstruct ossicles and tympanic membrane
What is a glomus jugulare
A vascular tumour in the middle ear. Usually benign but can be locally destructive
Symptoms of glomus jugulare
Hearing loss
Pulsatile tinnitus
Vertigo
Otorrhoea
Management of perichondritis
Gentle microsuction
Insert an aural wick
Continue topical drops
If systemically unwell then admit for IV antibiotics
Why are oral antibiotics not really used for treating perichondritis
The cartilage has a relatively poor blood supply
Causes of tympanic membrane perforation
Trauma - NAI, foreign body, ear irrigation
Infection - otitis media
Barotrauma - slap, diving, explosion
Iatrogenic - grommet insertion
Signs/symptoms of tympanic membrane perforation
Whistling sounds when sneezing.blowing nose
Decreased hearing
Tendency to infection
Purulent discharge
Pain usually only if concurrent infection
Management of tympanic membrane perforation
Water precautions - no swimming, ear plugs or vaseline on cotton balls when showering
Topical abx + steroid drops if infection also present (e.g. Sofradex, Gentisone)
If recurrent/persitent then consider myringoplasty
Differentials for otorrhea
Otitis externa Chronic suppurative otitis media Acute otitis media with TM perforation CSF otorrhea External or middle ear tumours Granulomatous disease - granulomatosis with polyangitis (Wegeners) Perichondritis Cholesteatoma
Differentials for otorrhea + facial pain
Malignant otitis externa Chronic suppurative otitis media Cholesteatoma Malignancy Ramsay Hunt Syndrome Skull base fracture
Neck lumps red flags
Persistent sore throat Hoarseness Dysphagia Odynophagia Horner's syndrome SVC obstruction Weight loss Fevers Night sweats History of radiation to the neck Rapidly enlarging painless mass Stridor
Differentials for a midline neck lump
Thyroid nodule - adenoma, cyst, carcinoma Goitre Lipoma Thyroglossal cyst Dermoid cyst Cervical lymphadenopathy
What are the 2 main investigations use to assess neck lumps
USS
FNAC
What is meant by a ‘functioning’ thyroid nodule
A thyroid nodule that is associated with hyperthyroidism
When assessing for thyroid cancer, what do the ‘U’ and ‘TH’ grades refer to
U = USS TH = FNAC
Both are graded 1-5
Differentials for a solitary thyroid nodule
Benign;
- Follicular adenoma
- Hyperplastic nodule
- Thyroid cyst
Malignant;
- Papillary carcinoma
- Follicular carcinoma
- Medullary carcinoma
- Anaplastic carcinoma
Differentials for a generalised thyroid swelling/goitre
Physiological - Pregnancy, puberty
Multinodular goitre
Hashimotos thyroiditis
Graves disease
Risk factors for head and neck SCC
HPV EBV (nasopharyngeal carcinoma) Betel nut chewing (oropharyngeal) Alcohol Smoking
What does a panendoscopy look at
The upper aerodigestive tract - pharynx, larynx, upper trachea and oesophagus
Differentials for dysphonia/hoarseness
Overuse (e.g. singers) Acute laryngitis Chronic laryngitis secondary to reflux Inhalers Smoking SCC of the larynx Vocal cord paralysis Recurrent laryngeal nerve damage (e.g. in surgery)
Differentials for vocal cord lesions
Vocal cord polyp - result from overuse
SCC of the larynx
GORD
Reinke’s oedema - common in female smokers, oedema and accumulation of gelatinous material
Dysphonia - indications for urgent referral
Hoarsness lasting >6 weeks Oral swellings lasting >3 weeks Dysphagia lasting >3 weeks Unilateral nasal obstruction Neck mass lasting >3 weeks Cranial neuropathies Orbital masses
Neck lump - rubbery, painless lymphadenopathy, may be night sweats and splenomegaly
Lymphoma
Neck lump - common in patients <20 years old, midline, moves upwards with tongue protrusion, may be painful if infected
Thyroglossal cyst
Neck lump - common in older men, midline lump if large, gurgles on palpation. Typical symptoms are dysphagia, regurgitation, aspiration, chronic cough
Pharyngeal pouch
Neck lump - congenital lymphatic lesion, classically on the left side of the neck, most present at birth/before age 2
Cystic hygroma
Neck lump - oval, mobile, cystic mass between SCM and pharynx, usually presents in early adulthood
Branchial cyst
Neck lump - pulsatile lateral neck mass that doesn’t move on swallowing
Carotid aneurysm
What conditions/lumps are only really found in the anterior triangle of the neck
Salivary gland swelling
Carotid artery aneurysm
Laryngocele
What conditions/lumps are only really found in the posterior triangle of the neck
Pharyngeal pouch
Cystic hygroma
What happens to a) thyroid mass b) thyroglossal cyst if you get a patient to swallow
Both will rise
What happens to a) thyroid mass b) thyroglossal cyst if you get a patient to stick their tongue out
a) thyroid mass won’t move
b) thyroglossal cyst will rise
When is rhinosinusitis classed as chronic
If it’s >12 weeks without complete resolution of symptoms
Risk factors for rhinosinusitis
URTI Polyps Allergies Granulomatosis with polyangitis Septal deviation
What are the main symptoms of rhinosinusitis
Purulent rhinorrhea Facial pain - worse when leaning forwards Nasal blockage/congestion/obstruction Reduced sense of smell With or without polyps
What kind of test can you do if someone has allergic rhinosinusitis
RAST testing - blood test for specific allergens
Management of allergic rhinosinusitis
Avoid allergen triggers
Saline nasal irrigation
Nasal steroid spray (e.g. Flixonase)
Antihistamines
Management for rhinosinusitis with polyps
Topical nasal steroid - drops if severe but usually spray
Functional endoscopic sinus surgery (FESS) to remove polyps
Risks of FESS (functional endoscopic sinus surgery)
Recurrence Orbital damage Damage to optic nerve CSF leak if skull base breached, carries risk of meningitis Synechiae (adhesions in nasal cavity) Bleeding Change in sense of smell Damage to nasolacrimal duct can cause watery eye Infection
What do you advise patients regarding their nasal steroid spray after having polyp surgery
Keep on using it even if the symptoms are better.
It can be explained by thinking of the surgery as a method of opening up the sinus drainage & creating a route of access for the steroids.
Antibiotic of choice if you suspect infected rhinosinusitis
Clarithromycin
Nasal steroid sprays
Fluticasone (Flixonase)
Beclomethasone (Beconase)
Mometasone (Nasonex)
Risk factors for nasal polyps
Chronic rhinosinusitis
Cystic fibrosis
Aspirin induced respiratory disease
Clinical features/symptoms of nasal polyps
Long history (years) Bilateral nasal obstruction Post nasal drip Hyposmia/anosmia Worse around allergens No preceding symptoms Rhinorrhea No nasal sprays work May have associated cheek pain
Which vasculitis commonly affects the nose
Granulomatosis with polyangitis (Wegeners)
Effects of granulomatosis with polyangitis on the nose
Inflammation of nasal mucosa
Large amounts of crusting
Can cause septal perforation and nasal dorsal collapse
Causes of nasal septal deviation
Congenital
Infective
Inflammatory - GPA, sarcoidosis
Trauma
Symptoms of septal deviation
Difficulty breathing through one nostril Nasal congestion Snoring Headaches Facial pain Epistaxis
What test can be used to assess nasal mucocilliary function
Saccharine test
A common cause of nasal obstruction in children
Large adenoids
Two ways of visualising the nose properly
Anterior rhinoscopy
Nasal endoscopy
What happens if patients use nasal decongestant too much
You get rebound congestion
Most nose bleeds come from which anatomical region
Little’s area - located in the anterior nasal septum
What is the name of the plexus of vessels in Little’s area
Kiesselbach’s plexus
Which 3 blood vessels form Kiesselbach’s plexus
Anterior ethmoid artery
Sphenopalatine artery
Greater palatine artery
Name of the plexus of vessels that causes posterior epistaxis
Woodruf’s plexus
Causes of epistaxis
Trauma Inflammatory - Granulomatosis with polyangitis, sarcoidosis Acute/chronic rhinosinusitis Anticoagulation Hypertension Haematological disorder - ITP Neoplasia of nasal cavity - SCC, adenocarcinoma, papilloma, juvenile angiofibroma Iatrogenic - recent surgery
Management of epistaxis
Naseptin ointment - for 1-2 weeks, caution peanut allergy
General advice regarding nose bleeds
Silver nitrate cautery
What general advice can you give to patients about nose bleeds
Try not to blow your nose for a week
Don’t try and clean the node
Avoid hot baths and showers
Don’t drink/eat anything really hot for 72 hours
Try to avoid strenuous exercise for a week
Avoid picking the nose
Apply firm pressure for 15 minutes - if this fails to work then attend A+E
Acute management of epistaxis lasting >15 minutes or that is profuse
ABCDE approach
IV access with cannula
PPE - gloves, eye shield, apron
Use headlight + Thuddicums speculum - if you can see the vessel cauterise it, if not then apply pressure and pack
Order FBC, coagulation profile, group and save
Admit to ENT ward
Anterior nasal packing - if continuing to bleed or spitting out blood then need posterior pack (often using foley catheter)
Posterior packs should stay in for 48hours, consider prophylactic abx
If continuing to bleed may need artery ligation
What are the CENTOR criteria
Used to see how likely it is that tonsillitis is caused by streptococcal bacteria Absence of cough Exudate Nodes Temp (38)
Vertigo - recent viral infection, sudden onset, nausea and vomiting, hearing may be affected
Viral labyrinthitis
Vertigo - recent viral infection, recurrent attacks lasting hours or days, no hearing loss
Vestibular neuronitis
Vertigo - gradual onset, triggered by change in head position, each episode lasts 10-20 seconds
Benign paroxysmal positional vertigo (BPPV)
Vertigo - associated with hearing loss, tinnitus, and a sensation of fullness/pressure in one or both ears
Meniere’s disease
Vertigo - elderly patient, dizziness on extension of the neck
Vertebrobasilar ischaemia
Vertigo - hearing loss, vertigo, tinnitus, absent corneal reflex, may also have NF type 2
Acoustic neuroma
