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Phase 4 > ENT > Flashcards

ENT Flashcards

1
Q

What are the 3 main bones of the middle ear?

A

Malleus - attaches to tympanic membrane, incus, stapes (attaches to oval window of inner ear)

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2
Q

What is the function of the Eustachian tube?

A

Connects middle ear to the nasopharynx and equalises the pressure to that of the external auditory meatus (if dysfunction= negative pressure builds in middle ear)

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3
Q

What makes up the bony labryinth (3) of the inner ear?

A

Semi-circular canals- involved in balance
Cochlear- houses the cochlear duct for hearing
Vestibule - balance

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4
Q

What are some red flag questions to ask in a patient with a neck lump?

A 
Weight loss, night sweats, fever
Hard, fixed lump
Dysphagia 
Otalgia 
Hoarseness
Unilateral nasal congestion 
Epistaxis 
CN palsies
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5
Q

What are 5 causes of neck lumps?

A

Malignancy- Lymphoma, squamous cell carcinoma, thyroid malignancy, carotid body tumours
Infective- reactive lymphadenopathy, abscess
Congenital - thyroglossal cyst (midline), branchial cyst (lateral), dermoid cyst (midline), salivary gland disease
Thyroid goitre - Hashimoto’s, Graves
Inflammatory- TB, sarcoidosis

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6
Q

What type of carcinoma (histology) is most common in head and neck cancers?

A

Squamous cell carcinoma

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7
Q

How would you investigate a SCC of head and neck?

A

Bloods- FBC, U&E, LFTs, CRP
Ultrasound
Flexible nasolaryngoscopy

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8
Q

What are the signs/symptoms of lymphoma?

A

Lymphadenopathy - rubbery nodes + B symptoms- weight loss, night sweats, fever

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9
Q

What are the two types of non-Hodgkin’s lymphoma and which type is more aggressive?

A

Low grade- follicular
High grade- diffuse B cell
High grade is more aggressive but can be cured. Compared to low grade- slow growing but incurable.

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10
Q

What is a carotid body tumour?

A

Tumour of the paraganglionic cells of the carotid body

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11
Q

How does a carotid body tumour present?

A

Painless, pulsatile neck lump with a bruit. Can’t move it up and down but can move it side to side

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12
Q

How do you treat a carotid body tumour?

A

Active monitoring or surgical excision

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13
Q

What is the typical age for a branchial cyst to present in?

A

Around 30s- if older, need to rule out thyroid/oesophageal cancer

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14
Q

What is the branchial cyst?

A

Remnant of the branchial cleft from embyonic development

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15
Q

How does a branchial cyst present?

A

Painless mass on lateral side of neck. no symptoms unless infected.

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16
Q

How do you investigate a branchial cyst?

A

US. Aspirate for cytology- check it’s not metastasis from head and neck ca

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17
Q

How do you treat a branchial cyst?

A

Surgical excision

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18
Q

What is a thyroglossal cyst?

A

Remnant of the thyroglossal tract that should obliterate at birth

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19
Q

What is the typical age group for a thyroglossal cyst to present in?

A

Children- around 5

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20
Q

What are the symptoms and signs of a thyroglossal cyst? What can you ask the patient to do to help confirm a thyroglossal cyst?

A

Painless palpable lump in the midline

Can ask the patient to swallow and stick out their tongue- it will move on swallowing and tongue protrusion

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21
Q

How do you investigate and treat a thyroglossal cyst?

A

TFTs
Ultrasound +/- aspiration
Tx: surgical

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22
Q

A patient comes into your practice with painful lump under her jaw. She says the swelling and pain is particularly noticeable at meal times. The pain is severe but intermitten. What is the likely diagnosis?

A

Stones in salivary gland= sialolithiasis

Lump - submandibular stones are most common. painful mainly at meals.

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23
Q

How do you treat Sialolithiasis?

A

Supportive

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24
Q

What is the most common cause of acute sialadenitis?

A

Staphylcoccus

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25
Q

How does acute sialadenitis present? How would you treat?

A

Pain, swelling, purulent discharge, erythema. Treat with antibiotics.

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26
Q

What is the most common salivary gland tumour?

A

Parotid tumour. Most are benign

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27
Q

What is the most common type of parotid tumour?

A

Pleomorphic adenomas

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28
Q

How does a parotid tumour (plemomorphic adenoma) present?

A

Painless lump behind the angle of the jaw

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29
Q

How does a malignant parotid neoplasm present?

A

Unilateral facial swelling, facial nerve palsy, cervical lymphadenopathy, painful

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30
Q

How would you investigate and treat a salivary gland tumour?

A

Ultrasound, aspiration + MRI (if malignant to stage)

Tx: surgically excise

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31
Q

What is the type of salivary gland tumour common in elderly men (70s) who are smokers?

A

Warthin’s tumour. can be managed conservatively.

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32
Q

What are the functions of the facial nerve?

A

Motor to muscles of facial expression and stapedius
Special sensory- taste to the anterior 2/3 of tongue
Parasympathetic- lacrimal glands, salivary glands

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33
Q

What are some causes of facial nerve palsy?

What type of lesion causes forhead sparing?

A

Bell’s palsy - LMN
Infection of facial nerve
Parotid tumours
Surgery to parotid causing nerve transaction
Temporal bone fracture
Stroke
UMN lesion causes forehead sparing - bilateral innervation

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34
Q

What is the most common cause of tonsilitis?

A

Viral- adenovirus, rhinovirus, influenza, EBV

Bacterial cause - group A haemolytic strep

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35
Q

A 7 year old boy comes into your practice with a 4 day history painful throat. He says it really hurts to swallow and he feels unwell. His mother mentions he’s been suffering from a cough and cold for a few days but not having any fevers. When you look in this throat, you see redness around the tonsils but no white stuff around it. What is the likely diagnosis? How will you decide whether antibiotics are indicated? Are they in this case?

A 
Tonsillitis 
Fever PAIN score  
- Fever
-Purulence
-Attends rapidly within 3 days 
-Inflamed tonsils 
-No cough or coryza 
His fever pain score is 2 (inflamed tonsils, no cough and coryza)- Abx not indicated.
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36
Q

What are the symptoms of tonsilitis?

A

Sore throat
Painful swallowing- odonyphagia, dysphagia
Earache
Malaise and headache

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37
Q

What are the signs of tonsilitis?

A

Bilateral enlarged tonsils with exudate
Bilateral cervical lymphadenopathy
‘Hot potato’/thick voice
Fever

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38
Q

What investigations should you do in a patient presenting with tonsillitis?

A

FBC, U&Es (dehydration), CRP, monospot test (glandular fever screen), blood cultures if pyrexial

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39
Q

How do you treat viral tonsillitis? What antibiotic would you give if you suspected bacterial tonsillitis?

A

Reassure- will clear up in 7 days. Supportive- fluids, analgesia.
Phenoxymethylpenicillin (if penicillin allergic: erythromycin)

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40
Q

What antibiotic do you avoid giving in tonsillitis and glandular fever?

A

Ampicillin based eg. co-amoxiclav= can cause a rash in glandular fever

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41
Q

The same 7 year old patient with viral tonsillitis who you reassured and sent home with analgesia and advice for fluids has come back a week later with worsening sore throat. He says the pain is just on his left side and he is struggling to open his mouth for you to examine him. You eventually do as you see the uvula has been pushed to one side. What is the likely diagnosis and cause?

A

Quinsy- peritonsillar abscess caused by group A strep

Sx: trismus, severe unilateral pain, ‘hot potato’ voice, deviated uvula - pushed away by abscess.

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42
Q

How do you investigate and treat a quinsy?

A

Bloods- FBC, U&Es, CRP.
Aspirate the quinsy and send for MC&S.
May have dexamethasone to reduce any swelling
Antibiotics- benzylpenicillin

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43
Q

What is globus pharyngeus?

A

Sensation of lump/discomfort in the throat with no obvious cause. Usually associated with reflux. Rule out serious pathology with flexible naso-endoscopy and then reassure and treat reflux.

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44
Q

What are common risk factors for tonsillar carcinoma?

A

Smoking, alcohol, HPV 16 and 18

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45
Q

What is the most common histological type of tonsillar carcinoma?

A

Squamous cell carcinoma

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46
Q

What symptoms and signs will you get with a tonsillar carcinoma?

A 
Unilateral tonsillar swelling
Dysphagia
Sore throat
Lump in throat sensation 
Referred otalgia
Cervical lymphadenopathy
Trismus
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47
Q

How will you investigate a suspected tonsillar carcinoma?

A

Bloods
Endoscopy + biopsy
Aspirate lymph nodes
MRI - staging

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48
Q

A 17 year old boy comes into your practice with a 3 day history of sore throat and low grade fever. On looking in his throat you see the tonsils are red and enlarged and there are some spots on his palate. You do a full examination and you notice he has splenomegaly present. What is test needed to diagnose this condition?

A

Monospot test done to diagnose glandular fever (EBV)

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49
Q

What investigations are done in a patient with suspected glandular fever?

A

Monospot
Bloods- FBC, LFTs - deranged, ESR/CRP, U&Es
US- if splenomegaly

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50
Q

What is the treatment for glandular fever?

A

Avoid contact sports and alcohol

Paracetamol/ibuprofen for pain and fever and fluids (IV if can’t swallow/dehydrated)

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51
Q

What complications can you get from glandular fever?

A

Obstruction of airway by very large tonsils
Splenic rupture
Autoimmune haemolytic anaemia- cold type
Pneumonia (infection spread to lungs)

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52
Q

What are the causes of vertigo? central and otologic

A

Central: stroke- posterior/cerebellar (acute onset), brain mets, MS, SOL, migraine
Otologic: BPV, Meniere’s disease, vestibular neuronitis/viral labrynthitis

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53
Q

What is the cause of BPV?

A

Crystals in the semi-circular canals causing abnormal movement of endolymph and vertigo

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54
Q

Who are classically affected by BPV?

A

40-60 years old, elderly, rugby players

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55
Q

What are the classic symptoms and signs of BPV? (sx, onset, hearing loss, symptom duration)

A

Vertigo precipitated the same sudden movement eg moving head in bed, symptoms lasts seconds, nausea and vomiting. No hearing loss.

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56
Q

How can you diagnose BPV?

A

Dix Hallpike maneovre. If +ve= vertigo, nausea, and nystagmus

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57
Q

How can you treat BPV?

A

Epley maneouvre

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58
Q

What are the classic symptoms and signs of Meniere’s disease? (sx, onset, hearing loss, symptom duration)

A

Unilateral sx: severe paroxysmal vertigo, sensorineural hearing loss, tinnitus
Gradual onset, symptoms can last minutes to hours.

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59
Q

What investigations should you do for a patient with Meniere’s?

A

Otoscopy- normal

Pure tone audiometry- sensorineural hearing loss

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60
Q

What is the treatment for Meniere’s disease?

A

Prochlorperazine - acutely
Reduce salt in diet, avoid caffeine
Betahistine hydrochloride
If not controlled= surgery

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61
Q

What is usually the cause of vestibular neuronitis?

A

Viral infection preceeds- URTI

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62
Q

What are the symptoms and signs of vestibular neuronitis? (sx, onset, hearing loss, symptom duration)

A 
Vertigo, nausea and vomiting 
Sudden onset of severe symptoms, can last for days - classically confined to bed. 
Horizontal nystagmus 
No hearing loss
Takes a few weeks to fully resolve
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63
Q

How do you treat vestibular neuronitis?

A

Acutely: supportive- anti-emetics, fluids

Vestibular rehab exercises

64
Q

Do you get change in hearing/hearing loss in labrynthitis?

A

Yes

65
Q

How do you treat viral labrynthitis?

A

Supportive- anti-emetics, prochlorperazine, fluids

66
Q

What are some causes of conductive deafness?

A

Obstruction of ear canal- wax, foreign body, oedema, inflammation
Otitis media with effusion- popping, feeling of pressure
Tympanic membrane perforation- see on otoscopy. middle ear discharge.
Otosclerosis - abnormal remodelling of bone affecting stapes
Cholesteatoma- non-cancerous skin growth in ear- smelly discharge. (need CT)

67
Q

What are some causes of sensorineural deafness? Bilateral and unilateral

A

Bilateral - age (presbyacusis), noise damage (+tinnitus), drugs- gentamicin, furosemide, chemotherapy, aspirin
Unilateral- Meniere’s disease, Acoustic neuroma (asymetrical hearing loss + tinnitus- needs MRI),
Trauma , viral infections, stroke/TIA= sudden onset

68
Q

What investigations would you do for deafness?

A

Pure tone audiometry
Rinne and Weber test
Tympanometry

69
Q

What would be found on Rinne and Weber test in conductive deafness?

A

Normally: Rinne positive = they can hear the sound= air conduction >bone conduction
Rinne test= Rinne negative. bone conduction > air conduction (problem with sound getting through)
Weber test= hear better on the affected side (bad ear)

70
Q

What would be found on Rinne and Weber test in sensorineural deafness?

A

Normally: Rinne positive = they can hear the sound= air conduction >bone conduction
Rinne test: Rinne positive. air conduction > bone conduction (no problems getting in - problem at cochlea)
Weber test= hear better on the good side (unaffected ear)

71
Q

When would you suggest a cochlear implant as a treatment?

A

For profound sensorineural hearing loss

In children with congenital deafness

72
Q

What questions in the history would you like to ask a patient presenting with epistaxis?

A

Onset- when did it start?
How many times has it happened?
Volume- how much blood lost? teaspoon? cupful? Clots?
Which side did it start?
Anterior / posterior- does it run down the front or back of the throat?
Any trauma to nose?
Current medication- anticoagulants? HTN? previous nasal surgery?
Other symptoms- discharge, pain, crusting, weight loss, fever, night sweats

73
Q

What is the most common site for epistaxis to come from?

A

Little’s area- anterior part of septum

74
Q

What are some causes of epistaxis?

A 
Idiopathic 
Trauma- injury, nose picking, surgery 
Coagulopathies
Anticoagulants/antiplatelets
Hypertension 
Cold weather
75
Q

What investigations do you do for a patient with epistaxis?

A

Bloods- FBC, U&Es, clotting, cross-match/group & save, LFTs
May do rhinoscopy

76
Q

How do you treat epistaxis?

A
  1. Nasal pinching- the squish part and keep head forward. Ice cold packs. Adrenaline soaked gauze
  2. Nasal cautery- silver nitrite sticks to Little’s area- if can see the bleeding point
  3. Anterior packing eg. rapid rhino
  4. Posterior packing- using a Foley catheter
  5. Surgical- cautery, emoblisation

(stop and reverse any anticoagulation)

77
Q

What are the 4 sinuses?

A

Frontal
Maxillary
Ethmoid
Sphenoid- posterior, near pituitary gland

78
Q

Patient presents with a headache that he describes as a dull throbbing pain in his forehead that is worse on bending forward. He says he has recently had a cold and a runny nose. What is the likely diagnosis?

A

Sinusitis

79
Q

What are the 4 sinuses?

A

Frontal
Maxillary
Ethmoid
Sphenoid- posterior, near pituitary gland

80
Q

Patient presents with a headache that he describes as a dull throbbing pain in his forehad that is worse on bending forward. He says he has recently had a cold and a runny nose. What is the likely diagnosis?

A

Sinusitis

81
Q

What are some causes of sinusitis?

A

Viral- rhinovirus, parainfluenza
Bacterial - strep pneumoniae, H.influenza
Fungal

82
Q

When would a CT of the sinuses be indicated?

A

Sinusitis >12 weeks with treatment

Complications develop- meningitis, pre-orbital/orbital cellulitis, cavernous sinus thrombosis , abscess

83
Q

How do you treat acute sinusitis?

A 
Analgesia
Saline irrigation 
Intranasal decongestant- for 1 week only
If symptoms last >5 days: intranasal steroids
If bacterial- Amoxicillin or doxycycline
84
Q

When would a CT of the sinuses be indicated?

A

Sinusitis >12 weeks with treatment

Complications develop- meningitis, pre-orbital/orbital cellulitis, cavernous sinus thrombosis

85
Q

Name some other causes of facial pain?

A

Migraine, GCA, trigeminal neuralgia, dental abscess, TMJ dysfunction

86
Q

How do you treat chronic sinusitis (with polyps and without polyps)?

A

Analgesia, decongestant, saline irrigation
Without polyps: NASAL steroids then spray
With polyps: ORAL steroids then nasal
Antibitoics- amoxicillin or doxycycline

87
Q

How do you treat GCA?

A

Prednisolone 30mg

88
Q

How do you treat trigeminal neuralgia?

A

Carbamazepine
If this fails- local nerve blocks
If this fails- surgery

89
Q

What is the presentation of TMJ dysfunction?

A

Pain in jaw, radiating to deep ear, limited jaw movement

Pain is worse on chewing

90
Q

How do you treat TMJ dysfunction?

A

Bite raising appliance- rest the jaw, analgesia, jaw rest

91
Q

What is the best analgesia to give for dental pain?

A

NSAIDs

92
Q

How do you treat a dental abscess?

A

Drainage and Abx

93
Q

What is the innervation to the larynx and vocal cords?

A

Vagus nerve

94
Q

What are the two main branches of vagus nerve that provide innervation to the larynx and vocal cords and what are their functions?

A

Superior laryngeal nerve- motor to cricothyroid, sensory to vocal cords
Recurrent laryngeal nerve- motor to all muscles of larynx except cricothyroid, sensory to laryngeal mucosa

95
Q

What are 5 causes of hoarseness?

A 
Malignancy: laryngeal carcinoma (SCC), thyroid carcinoma, lung cancer- compressing RLN
Benign: vocal cord nodules, cysts, polyps  
Trauma: surgery, intubation 
Iatrogenic: RLN palsy from surgery 
Infection: laryngitis, candida 
Vocal cord palsy
Muscle tension dysphonia 
Hypothyroidism
96
Q

A patient comes in complaining of hoarseness. This is usually at the end of the day or after he’s spent the day shouting in work and being particularly stressed. He has no red flag symptoms including dysphagia, neck mass, weight loss. The hoarseness is not present all the time. You do a flexible naso-endoscopy which shows no abnormalities. You do full blood tests which show no abnormality. What is the next best step in management?

A

Reassure, get SALT team involved.
If reflux related- PPIs
This is muscle tension dysphonia- commonest cause but a diagnosis of exclusion .

97
Q

What is the most common cause of hoarseness in professional singers?

A

Vocal cord nodules secondary to phonotrauma

98
Q

What are the symptoms of vocal cord nodules?

A

Hoarseness, loss of vocal range while singing, voice fatigue

99
Q

How are vocal cord nodules treated?

A

SALT team. If severe= surgery

100
Q

Are vocal cord polpys unilateral or bilateral compared to vocal cord nodules?

A

Vocal cord polyps are unilateral

Vocal cord nodules are bilateral

101
Q

What are the two main risk factors for vocal cord polyps?

A

Smoking

Vocal cord abuse

102
Q

How do you treat vocal cord polyps?

A

They need surgical excision to exclude malignancy

103
Q

A middle aged woman comes into your clinic complaining of hoarseness. You also notice she has quite a deep voice sounding like a man. On asking about her smoking history, she says she smokes 40 a day and has done for 10 years. What is the likely diagnosis and treatment?

A

Reinke’s oedema- oedema of the vocal folds linked to smoking
Tx: smoking cessation and voice therapy

104
Q

What is the causative organism of laryngeal papillomas?

A

herpes simplex virus 6 & 11

105
Q

What is the treatment for laryngeal papillomas?

A

Surgical excision

106
Q

A patient that you’ve seen for sometime now for a long difficult to control history of GORD presents now with hoarseness. He said it started a couple of weeks ago and he is still getting the burning sensation come up his throat. What will you see on flexible naso-endoscopy given the diagnosis?

A

FNE: erythema of the larynx

This is reflux laryngitis due to GORD

107
Q

How do you treat reflux laryngitis?

A

PPI + H.pylori treatment : amoxicillin + clarithromycin/ metronidazole

108
Q

What are some causes of recurrent laryngeal nerve palsy?

A 
Malignancy- thyroid cancer, lung cancer
Iatrogenic- head and neck, cardiothoracic surgery 
Aortic aneurysm 
Stroke 
MS
109
Q

What is the main investigation done if you suspect a RLN palsy?

A

CT skull to diaphragm- assess for pathology

110
Q

What are some risk factors for laryngeal carcinoma?

A

Male, older age, smoking and alcohol, HPV 16 and 18, FMH

111
Q

How do patients with laryngeal carcinoma present?

A

Hoarseness, referred otalgia, cough, cervical lymphadenopathy (lymphatic spread), stridor- if tumour obstructs, B symptoms

112
Q

What is the most common histological type of laryngeal carcinoma?

A

Squamous cell carcinoma

113
Q

How do you investigate laryngeal carcinoma?

A

CT or MRI of thorax- for TNM staging and for mets
Flexible naso-endoscopy and biopsy
Fine needle aspiration under USS for cervical lymph nodes

114
Q

What are the options to treat laryngeal carcinoma?

A

Endoscopic resection- if early stage
Partial laryngectomy- if later stage
Chemo and radio- if later stage

115
Q

What is the innervation to the ear? (4 CN and another) And where in the ear do they innervate?

A

Trigeminal nerve - sensory to all of face and motor to muscles of mastication
Facial nerve - supplies mainly outer- lobes and helix
Glossopharyngeal nerve- sensory to posterior 1/3 of tongue and pharynx including tonsils
Vagus nerve- sensory to larynx and pharynx, motor to vocal cords
Cervical plexus - C2,3

116
Q

Why do you get referred otalgia in dental disease?

A

Trigeminal nerve- supplies sensory innervation to face and motor innervation to muscles of mastication. Since it also supplies teeth- referred pain in dental disease

117
Q

Why do you get referred otalgia in oral disease eg. tonsillitis?

A

Glossopharyngeal nerve (supplying posterior 1/3 of tongue and pharynx) and vagus nerve (supplying pharynx, larynx and vocal cords).

118
Q

Why do you get referred otalgia in degenerative neck disease?

A

Cervical plexus- C2, C3

119
Q

What are some otological causes and referred causes of otalgia?

A

Otological:

  • Acute Otitis media
  • Otitis externa
  • Necrotising otitis externa
  • Furuncle

Referred:

  • TMJ dysfunction
  • Tonsillitis/laryngitis
  • Cervical arthritis
  • Dental pathology
  • Malignancy of pharynx and larynx (will have red flags- dysphagia, hoarseness, dysphonia + otalgia)
120
Q

What questions would you want to ask in the history in a patient presenting with otalgia?

A

When did it start?
Where is the pain? Can they point to it?
What does the pain feel like? Sharp / dull?
Are there any other symptoms that go along with it? - discharge, vertigo, tinnitus, itching, change in hearing?
Is the pain always there or is it intermittent?
Is there anything that triggers the pain ?
Anything that makes it feel better? - any anaglesia?
Is it getting better or worse?
Any problems with dentition?
Any pain/problems with neck?
Recent colds/ illnesses?
Sore throat?

121
Q

Why do you get otalgia in TMJ dysfunction?

A

Due to the proximity of the jaw joint to the ear

122
Q

What are the common causes of TMJ dysfunction?

A

Teeth clenching, malocclusion

123
Q

How can you feel for TMJ dysfunction on examination?

A

Put fingers over the jaw joint and ask them to open/close their mouth- can feel crepitus and pain

124
Q

A patient comes into your practice complaining of ear pain. She says she has noticed some discharge and it is quite itchy. She is a big swimmer and goes every day for an hour. When you look in the ear you see some white debris. What is the most appropriate treatment for this condition?

A

Topical antibiotic - ciprofloxacin + topical steroid

This is otitis externa

125
Q

What is the commonest causative organism of otitis externa?

A

Pseudomonas (others= staph, fungal)

126
Q

How does otitis externa present?

A

Itchy ear, otalgia, discharge

127
Q

What can you see on otoscopy in a patient with otitis externa?

A

Debris in the ear canal- usually white
Oedema of the ear
If fungal- black debris

128
Q

How do you treat otitis externa? (bacterial and fungal)

A

Topical antibiotic + steroid = clarithromycin
If lots of debris- microsuction to remove first
Fungal: clotrimazole

129
Q

What is a furuncle?

A

Staphylcoccus abscess of the hair follicle

130
Q

What are the symptoms of a furuncle?

A

Very tender ear- especially when pulling on the pinna or putting in otoscope

131
Q

Would you see anything on otoscopy in a furuncle?

A

No - the ear is dry. If you see debris- suspect otitis externa

132
Q

How do you treat a furuncle?

A

If the abscess if big- may need incision and drainage

Oral flucloxacillin to treat the staph

133
Q

What is happening in necrotising otitis externa?

A

Osteomyelitis of the temporal bone due to uncleared outer ear infection –> can lead to necrosis

134
Q

What are some risk factors for necrotising otitis externa?

A

Immunocompromised, elderly, diabetic

135
Q

What is the main causative organism of necrotising otitis externa?

A

Pseudomonas auerginosa

136
Q

What are symptoms of necrotising otitis externa?

A

Severe, unremitting ear pain- out of proportion to normal otitis media/externa
Purulent discharge
Night pain
Not responsive to topical antibiotics

137
Q

What can you see on otoscopy in necrotising otitis externa?

A

Granulation tissue, redness and swelling. If severe- bone can be exposed.

138
Q

What complications can occur from necrotising otitis externa?

A

Facial nerve palsy
Spread and cause meningitis
Cerebral abscess

139
Q

How do you investigate and treat necrotising otitis externa?

A

CT temporal bone (or MRI- gold standard)
Admit to hospital
Debridement of osteomyelitic bone
IV antibiotics for 6 weeks

140
Q

A child has come into your GP practice with his mother. She says he has pain in his ear for a few days now and he keeps pulling on his ear. He has not been sleeping well and is irritable. She thinks he may have have a fever but he has had a cold for the last few days too with a runny nose and cough. When you look in the ear, it is red and inflamed and the ear drum is bulging. Given the likely diagnosis, what is the likely treatment?

A

Likely to be a viral cause of acute otitis media therefore reassurance and analgesia.

141
Q

How does acute otitis media present?

A 
Usually in a child 
Pain in the ear
Preceeding coryzal symptoms
Rubbing/tugging of the ear
Discharge - if TM rupture 
Systemic- fever, irritability, poor sleep 
Decreased hearing- if recurrent AOM
142
Q

What are the likely causative pathogens of acute otitis media?

A

Viral- RSV, rhinovirus, parainfluenza

Bacterial- strep pneum, H. influenza

143
Q

When would you give antibiotics for acute otitis media? And what antibiotic would you give?

A

If symptoms not improving over 72 hours, decreased oral intake and increasingly unwell, developed any complications eg. meningitis, mastoiditis, TM perf, abscess
You would give amoxicillin

144
Q

What signs may you get with mastoiditis?

A

Ear protrusion, swelling and redness of ear and mastoid region, systemically unwell

145
Q

How do you treat mastoiditis?

A

Admit to hospital
NBM, IV fluids, analgesia, IV antibiotics
CT temporal bone

146
Q

A little girl aged 4 years old has come into your practice with her mother. Her mother thinks she has noticed her daughter’s hearing changed over the past few days. When you speak to the girl, she says she thinks she can’t hear as well and her ear feels full all the time. You look in the ear and the eardrum is retracted and you can see fluid. What investigations would you do to confirm this diagnosis?

A

This is glue ear/otitis media with effusion
Pure tone audiometry- conductive deafness
Tympanometry - flat trace (ear drum doesnt move because fluid in ear)

147
Q

What are some risk factors for glue ear/otitis media with effusion?

A

Older sibling, male, breastfeeding, day care attendance, parental smoking ,allergy, immune deficiency

148
Q

What is the pathophysiology of glue ear/otitis media with effusion?

A

Adenoidal hypertrophy- obstructs the Eustachian tubes causing poor ventilation and recurrent infections.

149
Q

What additional investigation would you do if it was an adult presenting with glue ear/otitis media with effusion , not a child ?

A

Flexible naso-endoscopy- look for nasopharyngeal tumour

150
Q

How do you treat glue ear/otitis media with effusion in a child?

A

Active surveillance- usually clears up in 3 months

If it doesnt- hearing aids/grommets

151
Q

What are some causes of stridor?

A

Infections- supraglottitis, epiglottitis, croup, abscess
Anaphylaxis
Trauma- vocal cord palsy, laryngeal fracture
Malignancy- tumours of head and neck eg, laryngeal cancer, lymphoma mediastinal tumours compressing
Foreign body inahlation
Congenital- laryngomalacia

152
Q

What questions would you want to ask (ENT specific) in the history in a patient with stridor?

A 
When did it start? 
Getting worse?
Associated symptoms?- drooling, fever, voice changes? 
Any allergies? 
Any medications recently started? 
PMH- malignancy? reflux? 
Red flags- dysphagia, weight loss, night sweats
Recent illnesses- ?abscess
153
Q

How would you initially assess a patient with stridor?

A

A–>E
Airway- can they talk? Sit them forward and give them 15L oxygen.
Breathing- RR, oxygen sats, listen to their breath sounds, chest movements
Circulation- BP, pulse, CRT, heart sounds. Urine output, IV access and get bloods- FBC, U&E, CRP, LFTs, cultures, clotting. IV DEXAMETHASONE and IV ABX
Disability- glucose, AVPU, temperature, pupils.
Everything else- calves, abdo.

154
Q

What imaging may you do after you’ve stabilised the patient?

A

CT neck and chest with contrast- find the cause.

155
Q

What are the treatment options after you’ve done an A-E assessment of the patient?

A
  1. Antibiotics + steroids and monitor
  2. Intubate in theatre
  3. Tracheostomy under local anaesthetic - foreign body, trauma, infection
156
Q

How do you initially manage a patient with peri-orbital cellulitis?

A

ABCDE: airway- can they talk? Breathing- RR, oxygen sats, listen to chest. Circulation- BP, pulse, CRT, heart sounds, urine output. IV access and send off bloods. Disability- glucose, AVPU, temperature, pupils.
Assess for intracranial spread - do full neuro exam
NBM
IV fluids
IV antibiotics
Urgent opthal review
CT scan- IF not improving on Abx, neurological signs, fever >36 hours

157
Q

What are some causes of peri-orbital cellultiis?

A

Infection of tear sac
Sinusitis spread to eye
Skin infection

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