ENT Flashcards
Describe the composition of the outer ear
Outer 1/3 of ear canal is elastic cartilage (as a continuation of the pinna)
The canal is self cleansing via the epithelial escalator
Describe the composition of Ear Wax and 3 of it’s roles
Composed of epithelial cells, lysozymes and oily secretions
Cleaning, Acidic coating prevents microbial growth, Hydrophobic coat prevents water from reaching canal skin
Give 3 risk factors for Otitis Externa
Hot & Humid Climates
Swimming
Insufficient/Excess Wax
90% of Otitis Externa infections are bacterial, state two common organisms
Staphylococcus Aureus
Pseudomonas Auerginosa
What happens if the infective organism is Herpes Zoster Virus?
Ramsay Hunt Syndrome
Reactivates in ganglion causing facial paralysis, loss of taste, vestibulocochlear dysfuncton and ear pain
Give 3 non infective causes of Otitis Externa
Acne
Psoriasis
Hearing Aids
Give three classical symptoms of Otitis Externa
Pain
Itching
Hearing loss
What is Necrotising/Malignant Otitis Externa
Extension of the infection into mastoid and temporal bones, often in the immunocompromised
Headahce of great intensity
Facial nerve paralysis
When do you need to investigate Otitis Externa? And how would you?
Only if atypical/treatment failure
Ear swab from medial ear canal
How can you test the integrity of the Tympanic Membrane?
Can they taste something put in the ear?
Can they blow air out of their ears when nose is pinched?
How would you manage Otitis Externa?
Remove any debris if relevant
Mild - Acetic Acid
Moderate - Antibiotics (not aminoglycosides - OTOTOXIC) +/- steroids
Oral Fluclox if systemically unwell
Give three risk factors for Otitis Media
Smoking
Eustacian Tube Dysfunction
URTI
Give two causative organisms for Otitis Media
most commonly viral
Haemophilus Influenza
Streptococcus Pneumoniae
Give a classical triad of Otitis Media
Otalgia
Hearing Loss
Fever
How would you manage Otitis Media?
Paracetamol/NSAIDs
Try to delay abx (unless systemic symptoms of complications - 5 days Amoxicillin)
If recurrent refer to ENT
delayed prescription for strep pneumoniae
What would make you suspect Nasopharyngeal Cancer?
Peristent Symptoms
Persistent Cervical Lymphadenopathy
Unilateral Epistaxis
What is Otitis Media with Effusion?
A subtype of Otitis Media resulting from either unresolved Otitis Media or non infective obstruction of eustacian tube
Give 3 risk factors for Otitis Media with Effusion
Chronic Allergy
Deviated Septum
Enlarged Tonsils
How does Otitis Media with Effusion present
Rarely Otalgia
Fullness
Pressure Popping
Imapired hearing
How would the tympanic membrane appear in Otitis Media with Effusion?
Retracted and Straw Coloured
How would you temporarily relieve ‘blocked ear’ from Otitis Media with Effusion
Valsalva
Normally resolves in 6-12 weeks
How would you surgically treat Acute Otitis Media? Give 3 options
Adenoidectomy
Grommets
Laser Myringotomy (creating a hole in membrane allows fluid to drain)
Describe the pathophysiology of Cholesteotomas
Negative pressure pulls the superior part of the tympanic membrane (pars flaccida) backwards allowing epithelial cells to become trapped and proliferate
Normally due to eustacian tube dysfunction
Osteolytic enzyme release can cause bony destruction
What is a congenital cholesterotoma?
Squamous epithelium is trapped in temporal bone during embryogenesis
Usually presents between 6 months and 5 years
Otoscopy shows pearly white mass behind tympanic membrane
Describe Primary and Secondary Acquired Cholesteotomas
Primary - 80% of cases
Secondary - Insult to tympanic membrane (as a result of surgery/trauma/otitis media)
Give four clinical features of Cholesteatomas
Progressive hearing loss
Enzymatic bony destruction (headache, facial nerve palsy)
Foul smelling painless otorrhoea
Pus filled canal with granulation tissue
The management of CHolesteotomas is surgical, describe the options
General anaesthetic followed by incision behind the ear to remove the Cholesteotoma
Can be open (tymapnomastoidectomy) or closed (tympanoplasty)
What is the difference between Vestibular Neuritis and Labyrinthitis?
Labyrinthitis - affects labyrinth and vestibular nerve, causes hearing loss
Vestibular Neuritis - affects vestibular nerve only, does not cause hearing loss
What is a common cause of Vestibular Neuritis?
Reactivation of laent HSV1 infection in vestibular ganglion
Commonly preceded by URTI
What is the cause of Labyrinthitis?
Inflammation f membranous labryinth
Usually viral in origin (bacterial is more dangerous)
What are the common clincial features of Labyrinthitis and VN?
Sudden spontaneous veritgo (not necessaeily triggered by movement)
Nausea and Vomiting
What extra features does Labyrinthitis have?
Hearing Loss
Tinnitus
What would Nystagmus look like Labyrinthitis and VN?
Consistent and Unidirectional
How would you manage Labyrinthitis/VN?
If sudden unilateral hearing loss - A&E
Reassurance and mobile as soon as possible
Medication - Prochlorperazine or Antihistamines
What is Meniere’s Disease?
Distension of membranous labyrinth due to excess endolymph
Give 3 risk factors for Meniere’s Disease
Allergy
Autoimmunity
Genetic Succeptibility
Give 4 clinical features of Meniere’s
Vetigo (2 x 20mins is diagnostic)
Tinnitus
Aural Pressure
Fluctuating hearing loss
There is no cure for Meniere’s (and requires DVLA notification), what would you give in an acute attack?
Prochlorperazine
Cyclizine
IM Steroid Injection (and tapered oral)
Give two conservative and two pharmacological prophylactic managements of Meniere’s
Conservative - Low Salt, Low Caffiene
Pharmacological - Trial of Betahistine, Diuretics
Give two surgical managements of Meniere’s
Endolymphatic Sac Decompression
Labyrinthectomy (causes hearing loss)
BPPV is the most common cause of vertigo, describe the pathophysiology
Hair cells are embedded in otoliths and stimulated by movement of endolymph
If Otoliths become detached there will still be movement
Causes are generally idiopathic
Give three presenting features of BPPV
Vertigo promoted by head movement (lasting 20-30 seconds)
Nausea
Usually worse in mornings
The Dix-Hallpike examination can be used in BPPV. Describe it.
Sit patient up on the bed, hold there head at a 45 degree angle and then suddenly drop the patient so their head is off the bed
Observe for Nystagmus (vertical and rotary suggests posterior canal, horizontal suggests horizontal canal)
BPPV is self limiting, describe three conservative managements
Get out of bed slowly
Reduced head movements
Epley’s manouvre
Describe the Epley’s manouvre
Aims to reposition the otoliths
Do the Dix-Hallpike movement, wait for nystagmus to cease before turning the patient’s head 90 degrees, then asking patient to slowly roll over and sit up
What is an Acoustic Neuroma? Name two risk factors
Tumour (often benign and slow growing) arising from the schwann cells of the vestibulocochlear nerve
Risk Factors - Neurofibromatoses, High Dose Ionising Radiation in H&N
Describe three presenting features of Acoustic Neuroma
Unilateral hearing loss/tinnitus
Impaired Facial Sensation
Balance Problems
After investigating with MRI, how could you surgically treat an Acoustic Neuroma?
Sterotactic Radiosurgery
Microsurgery
What is Otosclerosis?
Slowly progressing conductive hearing loss due to increased bone turnover (and subsequent ossicle fusion
Genetic element (Autosomal Dominant) and environmental element (such as lack of Fluoride)
Describe three managements of Otosclerosis (post audiological assessment)
Bilateral Hearing Aids
Bisphosphonates/NaF
Stapedectomy/Stapedotomy
Describe the two types of Tinnitus
Objective (Pulsatile - Carotid Stenosis, Muscular - Tympanic Muscle Spasm)
Subjective (Drug related - salicyclates, aminoglycosides, NSAIDs)
What should you NOT give if you suspect Glandular Fever?
Amoxicillin (can cause secondary rash)
