ENT Flashcards
What are the 3 important nerves in temporal bone?
- Vestibularcocular nerve
- Hearing & balance - Facial nerve
- In Bell’s palsy - this nerve is overacting = hyperacusis (noisy)
- If you have facial weakness, loss of taste & loud noise = Bell’s palsy - Trigeminal nerve (3 branches)
- Falmic
- Maxillary (goes through piteous part of temporal bone
- Mandular
Minor illness: ear
Ear Wax (Carenum impaction) - Caused by irritation or agitation of the skin
Otitis Externa (outer ear)
- Irritation or localised infection of ear canal (bacterial or fungal ear canal)
- Becomes congested with discharge or debris
- Otorrhoea - fluid form ear
- Treatments
- Topical antibiotics e.g. gentamicin (can cause damage to ear)
- Other antibiotics used are usually gram + Staphylococcus aureus can produce beta lactase. Flucoxacillin & augmentin used for skin infections (beta lactamase resistant)
Otitis media/sinusitis
- Infection of middle ear, around tragus
- Sinusitis presents as headache & feeling of pressure in face
- Caused by upper respiratory tract infection, blocking drainage from airspace’s within the head
- Viral or bacterial
- Superimposed infection - goes away and comes back again (bacterial infection)
Tympanic membrane perforation
- direct trauma, infection or pressure changes
- Don’t want it getting wet
Comensils (natural bacteria on the skin) if irritation occurs = infection
What are the RED FLAGS with EARS???
MASTOIDITIS
- Infection of mastoid bone of the skull which presents with headache, pain, fever, 10-14 days purulent discharge, systemic upset + erythema over the mastoid area
- Infection spreading from the ear into the base of skull. Patients will be very ill with severe ear ache and fever.
- Look behind the ear
MALIGNANT OTITIS EXTERNA
- Tends to occur in vulnerable pts e.g. diabetic, altered immune state
- Symptoms; severe headache, tenderness over temporal bone, systemic illness, unilateral ear discharge, unilateral deafness, facial nerve palsy = facial droop
CHOLESTEATOMA
- A begin tumour of the skin in the middle but will invade/destroy the adjacent structures, caused by growth of trapped squamous epithelium.
- Can present with pus coming form the ear
- Fowl smelling discharge
What is vertigo?
- Caused by conflicting sensory information from ears, eyes and joints. Usually due to peripheral (sensory) problems e.g. ear infection rather than central (brain) ones e.g. Stroke
Peripheral causes involves inner ear;
- Labyrinth
- Vestibular nerve
Benign paroxysmal positional vertigo
- Dizziness on sudden movement. Last very short time
- Caused by disturbing debri in the semi circle canals
Labyrinthitis
- Infection causing severe dizziness and hearing loss
- Usually viral
- Can last 6-7 weeks
Meniere’s disease
- Unknown cause of intermittent dizziness and hearing loss
Vestibular neuritis
- inflammation of the vestibular nerve causing prolonged dizziness & associated symptoms.
- Often caused by infection.
Treatment
- Control symptoms e.g. antiemetics
What are the RED FLAG symptoms of vertigo?
Central - Involves the brainstem and cerebellum
TIA – posterior circulation
- Unlikely unless vertigo is associated with other neurological brain stem symptoms or signs e.g. ataxia, dysarthria, diplopia & headache
CVA
- posterior circulation
Cerebellar tumours
- Nystagmus & headache & sudden onset
- Testing cerebellum, promator drift either up or down
What is the Unterberger’s Test?
Wal on spot with eyes closed, keeping arm + index finger pointing at examinator
- if turns towards hypoactive side = peripheral lesion
- if shows instability = central lesion
Minor Illness: Nose/Sinus
Nasal vestibulitis
- Infection of skin of nasal vestibule
Rhinitis
- Inflammation or infection of the nasal mucosa.
- Causes excess mucus production- dripping/blocked nose
- Can be allergic rhinitis, infective rhinitis or non-allergic rhinitis
Sinusitis
- Inflammation or infection of the facial sinuses.
- Causes excess mucus production
- Clear mucus probs inflammatory
- If green probs bacterial
Minor injuries: Nose
Nose bleeds
- Causes mostly minor trauma but also from dry/infected mucosa
- Most bleeds from venous plexi in anterior part of nose (little area)
- Mostly elderly have bleeding from posterior part of nasal cavity (check about warfarin & antiplatelet drugs e.g. Aspirin & clopidogrel & hypertension
Nasal Fractures
- Effects the bone and septum. Patient concerns include appearance and blocked airways
DON’T MISS - NOSE
Septal haematoma (swelling from the medial side of a fractured nose)
- (see by looking up nostril) = clot = breakdown cartilage
- Causes pressure on the septal cartilage from blood in the subperichondrial space
- Requires urgent drainage to prevent avascular necrosis of the cartilage
What are the 3 glands in the eyelids?
- 2 lacrimal glands - produces tears, module mucin + oil = lubricates eyelids + cornea
- meibomian glands
- glands of Moll – modified sweat glands that also open into the eyelash follicles.
What occurrence might you see bleeding on the retina?
shaking baby syndrome
Minor Illness: Eyes
Conjunctivitis
- Inflammation /infection of the conjunctivae
- Red eyes with watery discharge, usually bilateral & associated with normal visual acuity
- Viral, will settle down
- Advice how to stop it spreading
Stye/hordeolum
- Infection of the upper or lower eyelid
Meibomian cyst/chalazion
- Chronic, inflammatory eyelid caused by a foreign body within the meibomian gland (sweat gland in eyelid)
Subconjunctival haemorrhage
- Caused by rupture of subconjunctional vein & spread of blood below the conjunctiva
- No treatment necessary unless occured as a result of head injury = indicates skull base fracture.
RED FLAGS in EYE
Orbital Cellulitis
- spreading infection from skin or surrounding structures
- Can get bulging eye
- Swelling
- Can be superficial or affect eye socket
- Compartment syndrome of eye
- Can get dilated pupil & altered vision = due to compression (parasympathetic nervous system)
Painful red eye
- Think Glaucoma, Scleritis and Uveitis
Ophthalmic Shingles
- Herpes Zoster infection involving the eye
- Can affect cornea (clear)
Central retinal artery occlusion
- Causes sudden painless loss of vision, except for red spot
- Causes; emboli, atherosclerosis, giant cell arteritis
TIA
- Described as a curtain coming down on their vision
What questions should be asked for someone with a red eye?
- do you wear contacts? = corneal ulceration
- is it painful when you move your eyes? = iritis or scleritis
- Are the lids stuck together in the morning? = conjunctivitis
- have you had an injury or worked with dust, metal grinders or welding equipment? = injury, FB or flash burn
- Have you had arthritis or rashes? = vasculitis
Minor injurers: Eye
Foreign body
- Multiple causes. Can be penetrating or not
- Check for foreign body
- Need x-ray
Arc Eye
- From bright light from welder arc.
- Can occur in bight sunlight – snow eye
- Burning of the eye
- Severe bilateral pain & redness develops several hours later
- Can’t have local anaesthetic (prevents/delays heeling)
Corneal abrasion
- Normal superficial but will need to exclude infective causes
- Scratching cornea
- If contact wearers - opthormology
Orbital fractures
- can involve any of the bony walls. Most common of orbital floor
- Check for upward gaze palsy (cannot gaze upward)
- Refer to max fax
Retinal detachment
- Gradual visual deterioration, floaters, flashes or field defects
Minor Illness: Mouth and Throat
Tonsillitis
- Viral or bacterial infection involving the tonsillar / lymphatic tissue.
- Penicillin V most commonly given
- Strep throat needs to keep away from newborn & pregnant women
Herpes Simplex (cold sores)
- Virals infection.
- Can effect any where in Trigeminal distribution leading to sever infections/sequela
Dental abscess
- Can be from the gum or the root tip. Secondary to bacterial infection
- Metrocidosol (bacteria) which targets anaerobic bacteria
- Bleeding socket - get them to bite down on swab to maintain pressure
Candida infection
- Fungal infection.
- Secondary to immunosuppression. Can be debilitating
- Use topical creams
- Alberkins (White)
Dislocated jaw
- Associated by TMJ (temporal mandibular joint) dysfunction, acute trauma (e.g over jawning, oral sex) & contributing habits.
RED FLAGS with MOUTH + THROAT
Epiglottitis – life threatening infection
- Can cause upper airway obstruction
- Stridor
- Hoarse voice
- Drooling - too painful to swallow
- Normally unwell with high fever
- Sitting forward normally to aid breathing
- PRE ALERT
- Senior anethetist
- Max fax/ ent
Ludwig’s Angina
- Severe dental infection / abscess causing oedema obstructing the airway
- Excessive oedema
- Mouth inside will be hard to touch
- Progresses over hours
Peritonsillar abscess/ quinsy
- Causes painful, asymmetrically swollen throat with difficulty opening the mouth or swallowing and a plummy voice
- Uvular moved to one side
- Airway narrowed
Mouth electrical issues
- Biting into electrical wires causes initial hyperaemia, but swelling of surrounding tissues occurs after several hours
Minor Injuries: Maxilla/Mandible/Teeth/Face
Maxilla
- Fractures of Zygomas (cheekbone) or whole maxilla
- Don’t blow nose (can cause surgical emphysema-blow air into tissue)
- Bruising top of mouth
- Can fall back onto pharynx = airway issue
- Bleed
- Thump to roof of mouth & compress
- Have to come to hospital
Facial fractures
- Assess stability of upper teeth & mandible & facial sensation
- Assess eye movements for fractures of orbital floor
Mandible
- Fractures at weakest points in the bone
- Tongue attached to mandible so tongue can fall back & occlude airway
Teeth
- Can fracture in the crown or root or be avulse
- Aspirin best for dental pain
Facial Laceration
- Need to consider underlying structure; Lip laceration involving the vermillion border needs expert closure
- Check sensation
Foreign body in throat
- If there is pain on every swallow - object still likely to be in situ
- Often move with combination of glucagon (which relaxes the lower oesophageal sphincter) and fizzy drink
How to calculate AOM score - paediatrics otitis media
- fever
- tugging ears
- crying
- irritability
- difficulty sleeping
- less playful
- eating less
Score
0 = no symtoms
1 = mild symptom
2 = severe symptom
What is distant complications of an ear infection?
Meningitis
What is distant complications of a throat infection e.g. quinsy?
Bacteria can travel from throat to other parts of the body e.g.
- ear = otitis media
- lungs = pneumonia
- brain = meningitis
- heart = rheumatic fever + bacteria endocarditis
- kidneys = glomerulonephritis
- skin = scarlet fever
RED FLAGS with sinusitis
- blood + pus from nose or post nasal drip
- fever
- systemic symptoms
- eye pain
- facial pain
- tingling over cheekbone
