ENT Flashcards
Why is otitis externa sometimes referred to as “swimmers ear”
Because repeated exposure to water can make the ear canal more vulnerable to infection
What are the symptoms of otitis externa?
Ear pain Swelling of ear canal Itchiness Discharge Temporary hearing loss Swollen pre and post auricular lymph nodes
How can you differentiate between otitis externa and otitis media?
Both will present with ear pain and discharge
With otitis media there is usually systemic illnesss
The ear canal will not look inflamed in otitis media
What are the main bacteria that cause otitis media?
Staph Aureus (main one) Pseudomonas aeriguinosa (not as common but is a common cause of antibiotic drop resistant infection)
What is the known fungal infection to cause otitis media?
How does this present differently?
Asperilligus niger
Tends to cause more itching than otalgia (ear pain)
Discharge is rare
Can occur as a result of prolonged topical antibiotic use
Looks like ball of cotton wool in ear speckled with black fungal spots
What are the risk factors for developing otitis media?
Trauma to skin
Water exposure
Use of cotton buds - these cause trauma to the ear canal
Underlying medical conditions - eczema, asthma, allergic rhinitis
What are the complications of otitis media?
Facial cellulitis - if infection spreads to skin surrounding ear
Perichondriitits - infection spread to cartilage/pinna (if untreated can cause necrosis of pinna and cauliflower ear)
Osteomyelitis of temporal bone - if infection spreads to underlying bone
What is malignant otitis externa?
Another name for osteomyelitis of the temporal bone
Complication of otitis externa - more common in diabetic patients
Can cause inflammation of facial nerve
If untreated can lead to sensorineural deafness
Which patients are more susceptible to the complications of otitis externa including osteomyelitis of the temporal bone?
Diabetic patients
Immunocompromised patients
What bacterial infection that causes otitis externa is most likely to cause osteomyelitis of the temporal bone?
Pseudomas aeruginosa
How is osteomyelitis of the temporal bone managed?
IV antibiotics - given for 6 weeks minimum (can be done in community with indwelling canula)
Continue topical antibiotics also
Monitor bloods - CRP, ESR
Monitor MRI of skull to see progress
How would you examine a patient presenting with otitis externa symptoms?
Audoscope in both ears
Cranial nerve exam - to check for malignant otitis externa
How is otitis externa managed?
Conservative - keep ear dry
Analgesia for symptom management
Topical antibiotics + steroids in form of ear drops
What topical antibiotics are usually used to managed otitis externa?
Sofradex (framyceitn, Dexamethasone, gramicidin)
Gentinsone H/C (gentamicin, hydrocortisone)
Optimise (dexamethasone, neomycin, acetic acid)
What further management is available for complications of otitis externa?
Micro suction of ear - to remove infected debris
Aural wick (otowick) (otoligical tampons) - to sent the ear canal to get topical treatment into the ear
IV antibiotics - if systemic illness is present
Why is otitis media more common in infants?
The Eustachian tube is smaller - they are more easily blocked
The adenoids are larger - large adenoid tonsils can block the Eustachian tube
What are the symptoms of otitis media?
Ear pain (otalgia) Fluid in ear Systemic symptoms Hearing loss Perforated ear drum
What are the signs of otitis media in young children?
Pulling, tugging or rubbing at ear Irritability, poor feeding Coughing or runny nose Unresponsive to noise Loss of balance
What are the risk factors for otitis media?
Previous viral infection e.g, cold - mucus can block Eustachian tube
Younger children - due to enlarged adenoids and thinner Eustachian tube
Certain conditions - Down’s syndrome, cleft palate
What are the different types of otitis media?
Acute otitis media - acute inflammation with systemic upset
Otitis media with effusion (glue ear) - inflammatory condition of middle ear, and development of middle ear effusion. This is not an infection but can follow infection
Chronic otitis media - inflammation in middle ear for >3 months, resulting in tympanic membrane perforation
What kind of hearing loss can otitis media with effusion lead to?
Conductive hearing loss
Can also caused tinnitus
What is recurrent acute otitis media?
Where you get more than 4 episodes of acute otitis media in a 6 month period
How is acute otitis media managed?
If viral in origin (following cold) - should settle by itself within 72 hours
If not settled after 72 hours then antibiotic course is given - amoxicillin
What is the pathophysiology of otitis media with effusion (glue ear)?
Dysfunction of the Eustachian tube
Gas is trapped in middle ear and leads to negative pressure in the middle ear
This causes fluid from the surrounding tissue to be sucked into the middle ear cavity, causing effusion
This fluid is usually sterile, but may become infected by bacteria or viruses
How is otitis media with effusion managed?
Often clears up on its own within 3 months
If fluid becomes infected, then antibiotics can be used
Grommets can be used (small tubes in the tympanic membrane) - these take over Eustachian tube function to drain away excess fluid
In chronic otitis media, which part of the tympanic membrane usually perforates?
Pars tensa
What are the complications of chronic otitis media?
Infection spreading and causing osteomyelitis of the:
- mastoid bone
- tegmental tympani bone
Cholesteatoma - accumulation of keratin cyst in middle ear
Vertigo - if infection spreads to the labyrinth
Hearing loss
Facial weakness - if inflammation affects the facial nerve
What are the two types of chronic otitis media?
Mucosal - occurs in presence of perforated tympanic membrane (pars tensa). Active disease is in presence of infection, inactive is a dry perforation
Squamous - results from cholesteatoma formation (pars flaccida). Active disease is where cholesteatoma is present, inactive is where the membrane is retracted
How is chronic otitis media managed?
Topical antibiotic and steroid drops (7-10 days) - when active infection is present
Referral to ENT
Surgical managed
Myringoplasy - operation to repair the eardrum
What is a cholestaetoma?
Chronic Eustachian tube dysfunction causes negative pressure in the middle ear leading to a retraction pocket in the tympanic membrane (usually within the pars flaccida - this is more prone to retraction)
This deep retraction then accumulates keratin, which develops into a keratin cyst in the middle ear
How is cholesteatoma managed?
Mastoidectomy
- surgery involving opening up mastoid air cells to remove the cholesteatoma from the middle ear
- followed by reconstruction of ossicles and tympanic membrane
What is a Globus jugulare?
How does it present?
A vascular tumour that presents as a red pulsating mass behind an intact tympanic membrane
Presents with a pulsatile tinnitus
What are the red flag symptoms for a neck lump?
Hoarse voice persisting more than 6 weeks Dysphagia persisting more than 3 weeks Odynophagia (pain on swallowing) Weight loss Fever Night sweats
If you are suspicious about a neck lump, what 1st line investigations would you do?
Fine needle aspiration cytology (FNAC)
USS (can also have USS guided FNAC)
CT - to examine surrounding areas
What are the risk factors for squamous cell carcinoma of the head and neck?
Betel nut chewing - carcinogenic (chewed in Indian, Asia and pacific) HPV EBV Smoking Alcohol
What are the red flag symptoms for a thyroid mass?
Rapidly enlarging and painless Enlarged cervical lymph nodes Stridor Unexplained hoarseness Thyroid nodule in a child
When examining a neck lump, what other anatomical areas should you examine?
Larynx and nasopharynx - can be examined using fibre optic endoscopes in ENT clinic
Oropharynx and oral cavity - using light and tongue depressor
What is reactive lymphadenopathy?
When lymph glads respond to infection by becoming swollen
What is reinke’s oedema?
Condition where the vocal folds become very edema to us with accumulation of gelatinous material in the vocal fold
Commonly occurs in females and usually in smokers
What is panedoscopy?
Using a rigid endoscope to examine the upper aero digestive tract and oesophagus to assess any potential carcinoma
The oral cavity, nasopharynx, Oropharynx, hypopharynx, larynx and upper Oesophagus are all examined
Where is th most common site of head and neck squamous carcinoma in adults?
Oral cavity
What are the main causes of deviated septum?
Congenital
Trauma
Inflammation
Infection
How are deviated septum’s managed?
majority don’t cause bother and can be left alone
If causing bother then a Septoplasty - operation to correct deviation can be done
What are the risks of Septoplasty?
Septal peroration Bleeding Infection Numbness or upper teeth and nose - due to nerve damage Altered appearance Anosmia/hyposmia - rare complication
What is Rhinosinusitis?
Inflammation of the sinuses and nasal cavity
What is the most common cause of nasal obstruction?
Rhinosinusitis
What are the different types of Rhinosinusitis?
Acute - <4 weeks
Subacute - 4-12 weeks
Chronic - >12 weeks
Recurrent - >4 episodes per year
What are the symptoms of Rhinosinusitis?
Runny nose Post-nasal drip Nasal congestion Sinus pain/pressure Headache Loss of smell Nasal polyps can be seen on examination
What are the risk factors for Rhinosinusitis?
Smoking Asthma Dental issues Swimming Changes in air pressure - e.g, air travel, scuba diving
What are the two main causes of Rhinosinusitis?
Infective
Allergic
How is Rhinosinusitis investigated?
RAST (radioallergosorbent test) - blood test to identify any allergies to specific allergens
When would you do a CT scan in the context of a patient with Rhinosinusitis?
In patients who you think may need surgery to treat disease e.g patients with chronic Rhinosinusitis
CT allows a road map for surgery
How is Rhinosinusitis managed?
Topical nasal steroid spray e.g, flixonase
Saline nasal irrigation e.g, sterimar
If nasal polyps are present then consider short course of prednisolone
Antibiotics (only when evidence of infective cause)
Antihistamines (only used when evidence of allergic cause)
Sinus surgery - reserved for those with chronic cases
What are nasal polyps?
Small painless soft growths inside of the nose
Are nasal polyps usually unilateral or bilateral?
Bilateral
If unilateral then this is a red flag and should be referred urgently to ENT
What are the symptoms of a nasal polyp?
Cold like symptoms - blocked, runny nose
Symptoms of sinusitis
Epistaxis
Snoring
What are the risk factors for developing nasal polyps?
Asthma
Aspirin sensitivity
Chronic Rhinosinusitis
Cystic fibrosis
How are nasal polyps managed?
Topical nasal steroid (shrink polyps in 80% of cases)
- nasal drops (short course for severe cases)
- nasal sprays (long term maintenance for less severe disease)
Oral steroids (prednisolone) - for patients with larger polyps Sinus surgery - if medical management doesn’t work
What type of surgery is used to treat nasal polyps and how does it work?
Functional endoscopic sinus surgery
Performed through the nostrils using endoscopes and a de rider is used to suck the polyps and cut them away
The surgery is called functional, as it is to persevere function of the airway
What are the risks of sinus surgery to remove polyps?
Infection
Bleeding
Recurrence of polyps
Hyposmia/anosmia (must warn patients this may worsen after operation)
What are the key questions to ask in a blocked nose history?
Unilateral or bilateral Duration of blockage Is blockage intermittent or constant History of trauma History of nasal surgery Hyposmia or anosmia? Other symptoms e.g, sneezing, rhinorrhoea, facial pain, post nasal drip, epistaxis
After patients have had functional endoscopic sinus surgery to remove polyps, what medication will they need to be on?
Maintainance topic steroids - this is to reduce reccurnace of polyps
What is the most common area of epistaxis in the nose and why?
Kiesselbach’s plexus (where 3 arteries come together: anterior ethmoid, sphenopalatine, greater palatine)
Situated in anterior portion of nasal septum and relatively exposed
How do you manage a small nose bleed?
Pinch soft part of nose for 15 mins
Lean head forward
How would you manage a large nose bleed?
Investigate - FBC, Coagulation profile, G+S if v heavy
Check for source of bleeding for cauterisation
Obtain IV assess - for maintaining circulation
Admit to ENT ward for nasal packing
What are the two types of nasal packing?
Anterior nasal packing - if bleeding doesn’t stop with basic compression
Posterior nasal packing - if anterior packing doesn’t work
How is recurrent epistaxis managed?
Naseptin ointment - prescribed for 1-2 weeks to prevent nasal crusting
Silver nitrate cautery - applied to affected side (naseptin ointment should be used alongside afterwards to keep area moist and prevent crusts
What must you check before prescribing naseptin ointment?
For peanut allergy
As it contains peanuts
Why must you never cauterise both sides of the nasal septum at the same time?
Can damage blood supply and cause septal perforation
What advice would you give to someone after they have had a large nose bleed?
Don’t blow nose for a week - this could dislodge clot and restart bleeding
Avoid hot baths/showers
Avoid hot/spicy food (also avoid hot drinks in first 72 hours)
Don’t pick nose
No strenuous exercise for 2 weeks - this can cause rise in BP which can blow off any clots
When sneezing, sneeze with mouth open to avoid rush of air through the nose
Which medications can cause epistaxis?
Any anticoagulants e.g, clopidogrel, warfarin
Aspirin
What medical equipment do you need to perform an anterior rhinoscopy?
Thuddicm’s speculum
If this is not available you can use an otoscope
What is the difference between a rigid and flexible endoscopy for a posterior rhinoscopy examination?
Rigid - higher quality picture, unable to examine pharynx and larynx. Easier to control in one hand
Flexible - lower quality, allows further examination of pharynx and larynx
What are the common causes of hearing loss?
Ear wax
Otitis media/otitis externa
Presbycusis (age related sensorineural hearing loss)
Otosclerosis (autosomal dominant condition causing conductive deafness)
Meinere’s disease (vertigo, tinnitus and sensorineural hearing loss)
Drug Ototoxicity (gentamicin, quinine, furosemide, aspirin)
What medications can cause ototoxicity?
Gentamicin Quinine Furosemide Aspirin/NSAIDs Some chemotherapy agents
What is a vestibular schwannoma?
Also known as acoustic neuroma
Benign tumour that develops in the vestibular system
They grow on the vestibular cochlear nerve so can affect hearing and balance
Can affect the facial nerve
Which genetic condition predisposes you to a vestibular scwannoma?
Neurofibromatosis type 2 (NF2)
How do you determine what type of hearing loss is present from an audiogram?
In sensorineural hearing loss - both air and bone conduction are impaired (<20dB)
In conductive hearing loss - only air conduction is impaired
In mixed hearing loss - both air and bone are impaired, with air conduction often worse
What is the management of a perforated ear drum?
Tympanic membrane will heal by itself in 6-8 weeks
Advise to avoid water getting into the ear as this can impair healing and increase risk of infection
Prescribe antibiotics in the context of an episode of acute otitis media
Myringoplasy may be performed if tympanic membrane doesn’t heal by itself
