ENT Flashcards
What is epistaxis?
Bleeding from the nose
Types of epistaxis?
Anterior bleeds 90% - in Little’s area where there is an anastomosis of 5 arteries (so is highly vascularised)
Posterior bleeds 10% - deeper structures of the nose, occurs in older individuals, have a greater risk of obstructing the airway
Important things for epistaxis history?
Recent trauma (picking, foreign body) Co-morbidities Drugs (clotting) Facial pain (nasopharyngeal tumour) FHx/PHx of clotting disorders Otalgia Systemic symptoms
Management of epistaxis
Sat up, sat forward (to protect airway)
Resus if necessary
Nose peg applied for 20 minutes
Ice to back of neck/bridge of nose to promote vasoconstriction
Investigating epistaxis
Adrenaline soaked gauze can cause vasoconstriction and help to visualise the septum
Examine the oropharynx if no bleeding point identified
What is nasal packing used for?
Pack the nose with a nasal tampon to attempt to control the bleeding if no bleeding point found
Posterior packing with a Foley catheter can be used if bleeding into oropharynx
When do we consider surgery in epistaxis?
When nasal packing has been unsuccessful we can ligate surgically or embolise radiologically.
Arteries in Little’s area
Ant./post. ethmoidal
Sphenopalatine artery
Greater palatine artery
Superior labial artery
If we can visualise the point of bleeding in epistaxis, what can we do?
Cauterise using silver nitrate
What is a nasal septal haematoma?
An important complication of nasal trauma in which there is a haematoma between septal cartilage and perichondrium
Symptoms of nasal septal haematoma?
Sensation of nasal obstruction Pain Rhinorrhoea (runny nose) Bilateral red swelling from nasal septum Boggy to palpate (as opposed to deviated septums which are firm)
Management of nasal septal haematoma
Surgical drainage
IV abx
Features of nasal polyps?
Nasal obstruction
Poor sense of smell
Rhinorrhoea/sneezing
Management of nasal polyps?
Corticosteroids shrink 80%
ENT referral
What is the most common cause of tonsillitis?
Viral infections
Bact. infection (1/3) - s. pyogenes/S. aureus
Features of tonsillitis
Difficult/painful swallowing
Pyrexia
Halitosis
Erythematous/swollen tonsils
What is the centor criteria?
Used to assess likelihood of bacterial tonsillitis. Abx if >2
Hx of pyrexia
Tonsillar exudate
No cough
Tender anterior cervical lymphadenopathy
Important differentials of tonsillitis?
EBV (infectious mononucleosis) Head and neck malignancy Leukaemia Scarlett fever Abscess formation
Management of tonsillitis
Symptomatic
Hydration
Abx - penicillin 5 or benzylpenicillin
Why don’t we give amoxicillin in tonsillitis?
If it’s caused by EBV it’ll result in a maculopapular rash
Indication for tonsillectomy?
>7 episodes in the last year >5 episodes in each of the last 2 years >3 episodes in each of the last 3 years Suspected malignancy Sleep apnoea Peritonsillar abscess formation
What is quinsy?
Quinsy is a peritonsillar abscess, a common complication of bacterial tonsillitis
What are the symptoms of quinsy?
Sore throat Difficulty swallowing Trismus (reduced ROM of jaw - lockjaw) Pyrexia Peri-tonsillar swelling and a deviated uvula
How do we treat quinsy?
Needle aspiration with topical anaesthetic
Incision and drainage
Following drainage, abx cover - typically metronidazole and penicillin regime
What causes hoarse voice?
Benign laryngeal conditions
Laryngitis/epiglottitis
Neurological conditions
What is the first line investigation for most cases of hoarseness?
Flexible nasal endoscopy
What are vocal cord nodules secondary to?
Chronic phonotrauma
Treat with SALT involvement
What is stridor?
Noise made by air being forced through narrow upper airways
What are acute causes of stridor?
Foreign body inhalation Laryngitis Epiglottitis Croup Anaphylaxis
What are chronic causes of stridor?
Laryngomalacia Subglottic stenosis (usually from prolonged intubation) Vocal cord paralysis Subglottic haemangioma Malignancy
Where is the obstruction if it is an inspiratory stridor?
Laryngeal
What is the obstruction if it is an expiratory stridor?
Tracheobronchial
Where is the obstruction if it is a biphasic stridor?
Subglottic/glottic
How do we investigate stridor?
Fibreoptic nasal endoscopy (if non-emergency) CT scan (for malignancies etc.)
How to treat stridor acutely?
Stabilise High-flow oxygen Alert senior Suction Adrenaline/steroids Bloods/ABG
If emergency, could be a cricothyroidotomy or intubation
What causes epiglottitis?
H. influenzae type B infections
Features of epiglottitis
Sore throat Fever Dyspnoea Absence of a cough Tripod position (later presentation)
Investigation/management in epiglottitis?
Neb. adrenaline, IV dexamethasone
IV abx
Blood/throat cultures
IV fluids
What is otitis externa?
An infection that typically affects the external auditory canal of the ear
What is the skin like in otitis externa?
Erythematous
Swollen
Tender
Warm
What causes otitis externa?
Pseudomonas aeruginosa (40%)
S. epidermidis
S. aureus
Rarely aspergillus spp.
What are the main risk factors for otitis externa?
Frequent water contact Humid environments Presence of ear polyps/foreign bodies Narrow ear canals Local trauma Eczema/psoriasis
What are the clinical features of otitis externa?
Progressive ear pain
Purulent discharge
Itchiness
Ear fullness
Less common:
Hearing loss
Tinnitus
Swollen ear
Colour of discharge in otitis externa and type of infection?
White-yellow - bacterial
Thick white grey - fungal
Clear grey - otitis media
What is the Brighton Grading scheme for otitis externa?
A scoring system to quantify the severity of otitis externa
What does Brighton Grade I mean?
Localised canal inflammation with mild pain, tympanic membrane visible
What does Brighton Grade II mean?
Debris in ear canal (not entirely occluded)
Erythematous
Tympanic membrane partially obscured
What does Brighton Grade III mean?
The ear canal is oedematous
Erythematous
Occluded
Tympanic membrane cannot be seen
What does Brighton Grade IV mean?
Tympanic membrane is obscured
Perichondritis
Pinna cellulitis
Signs of systemic involvement
Management of otitis externa?
Prevention Aural toileting Topical abx Simple analgesia Steroid drops
What is malignant otitis externa?
A complication of otitis externa in which you get mastoid and temporal bone involvement
Who is most likely to get malignant otitis externa?
Elderly
Diabetics
Immunocompromised in general
Presentation of malignant otitis externa?
Severe pain and headaches + OE symptoms
Treatment of malignant otitis externa?
Urgent CT
Debridement
IV abx
Which nerve is often involved in malignant otitis externa?
CN VII
What is acute otitis media?
It is an infection of the middle ear resulting from nasopharyngeal organisms migrating up the eustachian tube
Why do younger children tend to get otitis media more often?
The eustachian tube starts off quite horizontal and is less likely to close when coughing/sneezing (during periods of increased pressure)
This changes as you get older and then it is more likely to close from these pressures, stopping organisms migrating upward
What are common causes of otitis media?
Viral:
Respiratory syncytial virus
Rhinovirus
Bacteria: H. influenzae Strep. pneumoniae Moraxella Strep pyogenes
Features of acute otitis media?
Pain
Malaise
Fever
Coryzal symptoms
What do you see on otoscopy in otitis media?
Erythematous tympanic membrane, may be bulging
Potentially a small tear in the tympanic membrane
Purulent discharge
What else should you check after otoscopy of the ear?
Check function of the facial nerve - VII (due to its course in the middle ear)
Also check for intracranial complications
Signs of infection in the throat/oral cavity
How do we treat acute otitis media?
Usually self-resolves within 24 hours (vast majority gone within 3 days)
Simple analgesia
When do you give abx in otitis media?
If significant deterioration seen Systemically unwell Known risk factors (cong. heart disease, immunosuppression) Unwell for >4 days Discharge
When should someone be admitted for otitis media?
Children under 3 months with a temperature above 38 degrees
Children 3-6 months with a temperature above 39
What are complications of AOM?
Mastoiditis
Meningitis
Facial nerve paresis
Chronic otitis media
What does mastoiditis present as?
Boggy, erythematous swelling behind the ear
How do we treat mastoiditis?
Admission for IV abx
CT head if no improvement after 24 hours
What are the two different aetiologies of chronic otitis media?
Mucosal COM
Chronic inflammation secondary to a perforation
Squamous COM
Discharge due to a cholestatoma
What are causes of COM?
Recurrent AOM
Traumatic perforation of the tympanic membrane
Insertion of grommets
Features of COM
Chronically discharging ear >6 weeks
Absence of fever
Absence of otalgia
Perforation of tympanic membrane
What should you always test in COM?
Facial nerve function
Hearing (conductive hearing loss common - use Rinne’s)
Investigations for COM?
Audiograms and tympanometry
Swabs
If cholesteatoma suspicion, CT
What is the treatment for COM?
Aural toileting
Topical abx
Steroid treatments
ENT referral
What are the surgical options for COM?
Myringoplasty - closure of perforation in pars tensa
Tympanoplasty - myringoplasty combined with reconstruction of ossicular chain
If the external ear canal and drum are normal, but there is pain in the ear, what could be causing it?
Referred ear pain:
CN V
CN VII - Ramsay Hunt syndrome
CN IX and X
^ damage to any of these innervations
What is a cholesteatoma?
Ectopic epithelium which grows in the attic of the middle ear causing a collection of epithelial tissue
Clinical features of cholesteatoma
Conductive hearing loss
Background of COM
Otoscopy finding in cholesteatoma
Pearly, keratinized, or waxy mass in the attic region of the tympanic membrane
Management of cholesteatoma
Surgery
What nerves are potentially affected in acoustic neuroma (vestibular schwannoma)?
Cranial nerve VIII - causing vertigo, sensorineural unilateral hearing loss and tinnitus
Cranial nerve VII - facial palsy
Cranial nerve V - absent corneal reflex
When might you see bilateral vestibular schwannomas?
Neurofibromatosis type II
What investigations should be performed in vestibular schwannomas?
MRI of the cerebellopontine angle
Audiometry - 5% will be normal though
Management of acoustic neuroma?
ENT referral for surgery/radiotherapy
What is a vestibular schwannoma?
A cerebellopontine angle tumour, they make up 5% of intracranial tumours
What is labyrinthitis?
An inflammatory disorder of the membraneous labyrinth affecting both the cochlear and vestibular ends
What is vestibular neuronitis?
A cause of vertigo following a viral infection
How do differentiate between vestibular neuronitis and labyrinthitis?
As only the vestibular nerve is involved in vestibular neuronitis, there is no hearing impairment.
In labyrinthitis, there is inflammation of both the nerve and the labyrinth and so there is vertigo AND hearing impairment.
Features of labyrinthitis?
Usually viral Vertigo, not triggered by movement (though can be exacerbated by it) Nausea and vomiting Hearing loss Tinnitus Often a preceding URTI
Investigations in labyrinthitis?
Usually clinical diagnosis
Hypoglycaemia important to rule out
Is hearing loss conductive or sensorineural in labyrinthitis?
Sensorineural
Signs of labyrinthitis?
Nystagmus toward unaffected side
Sensorineural hearing loss
Gait disturbance
Management of labyrinthitis?
Lie still in a dark room if you feel dizzy
Avoid noise/bright lights
Sleep
Try to start walking again
Focus on one object when walking
ENT referral if it doesn’t go away after a few days
What are features of vestibular neuronitis?
Vertigo following a viral infection
Nausea/vomiting
Horizontal nystagmus
NO hearing loss/tinnitus
Management of vestibular neuronitis?
If chronic symptoms:
Vestibular rehabilitation exercises
Buccal/IM prochlorperazine if severe
Short course of prochlorperazine to alleviate less severe cases
What is Meniere’s disease?
A disease of the inner ear in which you get excessive pressure and progressive dilation of the endolymphatic system
What are the features of Meniere’s disease?
Vertigo (lasts for hours) Tinnitus Sensorineural hearing loss Aural fullness/pressure Nystagmus Positive Romberg test Typically unilateral
Management of Meniere’s disease?
ENT referral to confirm Inform the DVLA Prochlorperazine for acute attacks Betahistine to prevent attacks Vestibular rehabilitation exercises
Prognosis of Meniere’s disease?
Usually resolves within 5-10 years
Majority of patients will experiences some degree of hearing loss
Pyschological distress common
What is benign paroxysmal positional vertigo?
A disorder in which vertigo is triggered by changes in head position
What are the features of BPPV?
Vertigo lasting 10-20 seconds
Associated with head movement
May be associated with nausea
Positive Dix-hallpike manoeuvre
What is a Dix-hallpike maneouvre?
Patient sits up
You turn their head 45 degrees
Lie them down with their head off the end of the bed
Can repeat on contralateral side
Should reproduce vertigo symptoms if caused by BPPV
How can we relieve symptoms of BPPV?
Epley maneouvre
Betahistine is also often prescribed but has limited benefit
Prognosis of BPPV?
Symptom recurrence within 3-5 years for almost half of patients
