ENT Flashcards
What are the different forms of audiometry, and outline what they assess and how
Pure tone audiometry
Assesses bone conduction threshold at different sound frequency and volumes
Tympanometry
Evaluates middle ear function by assessing tympanic membrane stiffness
Evoked response audiometry
Used for neonatal screening by measuring brain response to an auditory stimulus
Outline the presentation of otitis externa
Watery discharge
Itch
Pain and tragal tenderness
What are some causes and common infective agents in otitis externa?
Moisture
Trauma
Absence of wax
Hearing aid
Most commonly pseudomonas infection but also Staph aureus
What is the management of otitis externa?
Ear drops - betamethasone + neomycin or gentamycin
What is malignant otitis media and who gets it?
Life threatening infection which may cause skull osteomyelitis presenting in diabetics with severe otalgia esp at night, granulation tissue in the canal and copious otorrhoea
Surgical debridement with IV abx
What is bullous myringitis?
Painful haemorrhagic blisters on deep meatal skin and TM associated with influenza infection
What is the clinical presentation of TMJ dysfunction?
Ear and facial ache
Joint clicking/popping
Bruxism
Jointline tenderness
What are the Ix and Rx for TMJ dysfunction?
MRI
NSAIDs
Stabilising orthodontic occlusional prostheses
What is the classification of otitis media?
Acute
Otitis media with effusion - after symptom regression
Chronic - >3 months
Chronic suppurative OM - discharge with hearing loss and evidence of central drum perforation
Which organisms commonly cause otitis media?
Pneumococcus
Haemophilus
Viral
Moraxella
What is the typical presentation of otitis media?
Children post viral URTI Rapid onset ear pain Irritability, anorexia, vomiting Purulent discharge if perforation Fever
What is the treatment of acute otitis media/
Paracetamol
Amoxicillin
What are the complications of acute otitis media?
Intratemporal - OME, perforation, mastoiditis, facial nerve palsy
Intracranial - menin/encephalitis, brain abscess, sub/epidural abscess
Systemic - bacteraemia, septic arthritis, IE
How does otitis media with effusion typically present?
Inattention at school
Poor speech development
Hearing impairment
O/E
Retracted dull TM with fluid level
What is the investigation and management of otitis media with effusion?
Typanometry
Usually sel limiting but consider grommets if persistent hearing loss
What is the presentation of chronic suppurative OM?
Painless discharge with hearing loss
TM perforation
Management of chronic suppurative OM?
Aural toilet
Abx/steroid drops
Qhat is the main complication of chronic suppurative OM?
Cholesteatoma
What is the pathology and presentation of mastoiditis?
Middle ear inflammation causing destruction of mastoid air cells and abscess formation
Fever
Mastoid tenderness
Protruding auricle
Imaging modality for mastoiditis?
CT
Rx for mastoiditis?
IV Abx
Myringotomy +- mastoidectomy
What is a cholesteatoma, and what are the two types?
A locally destructive expansion of stratified squamous epithelium in the middle ear
Congenital
Acquired (2ary to attic perforation in chronic suppurative OM)
How does a cholesteatoma typically present?
Foul smelling white discharge with headache and CN 5, 7 and 8 involvement
Complications for cholesteatoma?
Deafness
Meningitis
Abscess
What are the causes of tinnitus?
Specific Menieres Acoustic neuroma Otosclerosis Noise induced Injury Presbyacusis
General - HTN, anaemia
Drugs - Aspirin Aminoglycosides Loop diuretics EtOH
How might the history of tinnitus point you to the cause?
Character; constant, pulsatile
Unilateral - ac neuroma
FHx - otosclerosis
Vertigo/deafness - ac neuroma, Meniere’s
Aside from audiometry, what Ix should be done for patients with unilateral vertigo and why?
MRI for CPA malignancy
Rx of tinnitus?
Treat the cause
Psych support
Hypnotics
What are the causes of vertigo?
Vestibular
Menieres, BPPV, labyrinthitis
Central
Neuroma, MS, vertebrobasilar insufficiency, injury, inner ear syphillis
Drugs -
Gentamicin, loops, metronidazole, co-trimoxazole
What investigations would you do in a vertigo patient?
Hearing CN exam Cerebellum and gait Romberg (+ve indicates vestibular or proprioception) Hallpike manouvre Audiometry, calorimetry, LP, MRI
What is the underlying pathology in Meniere’s disease?
Dilatation of endolymph spaces of membranous labyrinth
What is the presentation of Meniere’s disesae?
Attacks of vertigo occuring in clusters lasting up to 12 hours Progressive SNHL Vertigo and N/V Tinnitus Aural fullness
What is the key investigation finding seen in Meniere’s disease?
Audiometry showing low frequency SNHL which fluctuates
Management of Meniere’s disesae?
Medical
Cyclizine, betahistine for vertigo
Surgical
Gentamicin instillation via grommets
Saccus decompression
How does viral labyrinthitis present and how is it managed?
Following febrile URTi with sudden vomiting and severe vertigo exacerbated by head movement
Cyclizine
Whgat is the pathology and presentation of BPPV?
Displaced otoliths in the semicircular canals commonly after head injury.
Presents with sudden rotational vertigo for <30 seconds provoked by head turning, with nystagmus
What is the positive investigation finding in BPPV?
Positive Hallpike manouvre with upbeat torsional nystagmus
How is BPPV treated?
Self limiting
Epley manouvre
Betahistine
What is the site of conductive hearing loss?
Anywhere between the auricle and round window
What are some causes of conductive hearing loss in adults?
Obstruction - wax, pus, FB
TM perf - trauma, infection
Ossicles - otosclerosis, infection, trauma
Inadequate Eustacian tube ventilation of the middle ear
What is the site of SNHL?
Dochlea
Cochlear nerve
Brain
What are some causes of SNHL in adults?
Drugs - Aminoglycosides, vancomycin
Post infective - meningitis, measles, mumps, herpes
Misc - Menieres, trauma, MS, CPA lesion, low b12
With which syndrome is ac neuroma associated/
NF2
How would an acoustic neuroma present?
Slow onset unilateral SNHL with tinnitus and or vertigo
Headache (due to raised ICP)
5,7,8 palsies
Cerebellar signs
What differentials might you have for an ac neuroma?
Meningioma
Cerebellar astrocytoma
Mets
What is the inheritance pattern of otosclerosis?
AD with fixation of the stapes at the oval window
How does otosclerosis present and when?
Begins in early adult life with bilateral conductive deafness and tinnitus
HL improved in noisy places (Willis’ paracousis)
Worsened by pregnancy, menopause and menstruation
What are the congenital causes of conductive hearing loss in children?
Structural anomalies
Congenital cholesteatoma
Pierre-Robin
What are the congenital causes of SNHL in children?
AD - Waardenburgs AD - Alports (+haematuria), Jewel Lange Nielson (+long QT) Xlinked - Alports INfections - CMV, rubella, HSV, toxo Ototoxic drugs
What is the management of a cauliflower ear?
Aspiration + firm packing
What is Exostoses?
Smooth symmetrical bony narrowing of the internal ear canals due to cold exposure, resulting in conductive hearing loss
What is the pathology of allergic rhinosinusitis?
T1HS IgE mediated inflammation from allergen exposure leading to mediator release from mast cells
How would you investigate rhinosinusitis?
Skin prick testing
RAST tests
What is the management of allergic rhinosinusitis?
Allergy avoidance
- Antihistamine or beclometasone nasal spray
- IN steroids + antihistamines
- Zafirlukast
- Immunotherapy
What are the causative agents of acute and chronic sinusitis?
Acute - Pneumococcus, Haemophilus, Moraxella
Chronic - Staph, anaerobes
What are the causes of sinusitis?
Mostly following viral illness Some 2ary to dental root infections Swimming in infected water Anatomical susceptability Systemic disease e.g. Kartageners
What are the clinical features of sinusitis?
Pain Discharge (-> post nasal drip) Nasal obstruction Anosmia ?fever
What is the management of acute sinusitis?
Bed rests decongestants analgesia nasal douching topical steroids Abx generlaly not used
What is the mnagement of chronic/recurrent sinusitis?
Stop smoking
Fluticasone spray
Functional endoscopic sinus surgery
What are the complications of sinusitis?
Mucoceles
Orbital cellulitis
Osteomyelitis
CNS infection
What are the featuers of a nasal polyp?
Watery rhinorrhoea Purulent post nasal drip Nasal obstruction Sinusitis Headaches Snoring
What are some of the associations of nasal polyps?
Rhinitis
CF
Aspirin hypersensitivity
Asthma
What might a single unilateral polyp indicate?
Malignancy
What is the management of nasal polyps?
Betametasone drops
Endoscopic polypectomy
What important checks must be done in a nasal #?
Teeth malocclusion and diplopia
WHat is the management of a fractured nose?
Exclude septal haematoma
Rexamine after 1 week
Reduce under GI with post op splinting within 2 weeks
What is the danger and management of a septal haematoma?
Septal necrosis and nasal collapse if untreated
Boggy swelling and nasal obstruction
Needs evacuation under GA with packing and suturing
What are the common causes of epistaxis?
Unknown Trauma Local infection Pyogenic granuloma (overgrowth of tissue on littles area) Osler Weber Rendu Coagulopathy Neoplasm
What is little’s area/Kiesselbach’s pleuxs?
An area on the anterior nasal septum where ethmoid and other arteries anastamose
Initial management of epistaxis?
Assess for shock
Sit up head tilted down, compress nasal cartilage for 15 minutes
If bleeding not controlled remove clots by suction or blowing to try to visualise the bleed
Management of anterior epistaxis?
Usually at Little’s area
Insert gauze soaked in vasoconstrictor and local anaesthetic for 5 mins
Can use silver nitrate sticks for cautery
Merocel pack for persistent bleeds
Advice for after the bleed
Dont pick nose sit upright and out of sun Avoid bending or lifting Sneeze through mouth No hot food or dtrink Avoid drink and tobacco
What are the features and inheritance pattern of HHT?
AD inheritance
Mucosal telangiectasia
Internal telangiectasiae and AVMs (lungs, liver, brain)
Rarely pulmonary HTN and colon polyps which may progress to cancer.
Where is the jugulodigastric node?
Midway down the anterior border of sternocleidomastoid
What organism must be considered in tonsillitis?
EBV
What are the Centor criteria and how is it interpreted?
1 point each for Absence of cough Fever Tonsillar exudates Tender anterior cervical adenopathy
0-1 no Abx
2 consider rapid Ag test
3 or more - Abx indicated
Why should amoxicillin not be used for tonsilitis?
It causes a severe mac Pap rash in EBV
What are the indications for tonsillectomy?
Recurrent cases
Airway obstruction
Quinsy (peritonsillar abscess)
Ca suspicion
What are the potential complications of a tonsillectomy?
Reactive haemorrhage
Tonsillar gag may damage teeth or TMJ
What are the complications of strep throat?
Quinsy Retropharyngeal abscess Lemierre's syndrome Scarlet fever Rheumatic fever Post strep glomerulonephritis
What are the features of quinsy?
Trismus - lock jaw Odonophagia - unable to swallow saliva Halitosis Tonsillitis - unilateral Contralateral uvula displacement Cervical lymphadenopathy
What is the management of quinsy?
ADMIT
IV Abx
What is Samter’s triad?
Nasal polyps
Asthma
Aspirin hypersensitivity
What is Lemierre’s syndrome?
IJV thrombophlebitis with septic embolization most commonly affecting the lung
Caused by Fusiform necrophorum
What are the functions of the larynx?
Phonation
Positive thoracic pressure
Respiration
Prevention of aspiration
What are the features of laryngitis?
Pain, hoarseness, fever with redness and swelling of the vocal cords
Laryngeal papilloma is secondary to which viral infection, and how does it present?
HPV
Kids with scratchy voices
What are the symptoms of a recurrent laryngeal nerve palsy?
Hoarseness
Breathy voice with bovine cough
Repeated coughing from aspiration
Exertional dyspnoea due to narrowed glottis
What are the causes of laryngeal nerve palsy?
30% local cancers
25% iatrogenic (para-/thyroidectomy, carotid endarterectomy
Aortic aneurysm
Bulbar palsy
What is the classic presntation of laryngeal SCC?
Male smoker and drinker presents with dys/odynophagia and hoarsenss progresisng to stridor with weight loss
What are patients who have had laryngeal SCC left with?
Trachy with speech valve
What is the presentation of laryngomalacia in children?
Floppy aryepiglottic folds and glottis causing laryngeal collapse on inspiration
Stridor early + positional
What agents cause epiglotitis in children and how does it presnet?
GAS
Sudden onset
Continuous stridor
Drooling
Toxic
Treatment of epiglottitis?
Do not examine throat Consult anaesthetics and ENT surgeons 02 + adrenaline nebs IV dex Cefotaxime Intubate IN THEATRE
What are the possible complications following Bell’s palsy?
Synkinesis - blinking causes oral upturning
Crocodile tears - eating stimulates unilateral lacrimation rather than salivation
What is the typical presentation of Ramsay Hunt syndrome?
Preceding ear pain/stiff neck
Vesicular rash in auditory canal
Ipsilateral facial weakness, ageusia, hyperacusis
May affect CN7 as well
Rx of Ramasy Hunt?
Valaciclovir and prednisolone within 72 hours
What are the differentials for a facial nerve palsy?
Bells - non forehead sparing Ramsay Hunt - rash Cholesteatoma - discharge Otitis media Parotid tumour Trauma Peripheral neuropathy
