ENT Flashcards

Question

Describe the appearance of otitis externa on otoscopy

Answer 1

Ear canal appears **erythematous and swollen**- may be so much so that you cannot see tympanic membrane and may also see **discharge**

Answer 2

* **Mainly a clinical diagnosis** * If persists/doesn't respond to treatment consider a **swab of external ear canal for MC&S** * Consider **diabetes screening** if suspect immunosupression * **Urgent CT head required if necrotising/malignant otitis externa suspected** to assess extent of infection

Answer 3

* **Aural toileting** * **Analgesia** * **Topical antbiotics +/- steroid** (7-14 days) *e.g. ciprofloxacin & dexamethasone* * **Manage aggravating & precipitating factors** *e.g. keep ear dry, avoid cotton buds* * **Can give oral antibiotics (alongside topical) if refractory to initial treatment or immunocompromised** e.g. ciprofloxacin * Insertion of **ear wick** to keep ear canal open and help topical preparations take effect * **ENT referral**

Answer 4

* Considerable swelling & discharge * Sufficient ear wax or debris to obsruct application of topical medication * Extreme pain or discomfort * Signs of malignant otitis externa

Answer 5

* Peri-auricular cellulitis * Malignant/necrotising otitis externa

Answer 6

* Otitis externa infection has spread to temporal bone and caused osteomyelitis * Common in immunocompromised, particularly diabetics * Symptoms: * Severe pain * Headaches * Yellow or green foul smelling ottorhea * Fever * Itchign in ear canal * Swollen, erythematous skin aroud ear * Pain when press mastoid * Otalgia with radiation to TMJ * Facial palsy * Management: * Urgent Ct scan * Urgent debridement * IV antibiotics *(abx against pseudomonas e.g. ciprofloxacin and anaerobes e.g. metronidazole)*

Answer 7

* Hearing loss due to damage to stereocilia due to excessive noise; can be a single loud event or damage over a period of time (generally sounds \>85dB) * Risk factors: * Occupational e.g. construction worker * Recreational e.g. loud music * Accidental e.g. blast injury, gunfire * Not wearing appropriate ear defenders * Diagnoses to exclude/other reasons for hearing loss: * Impacted wax * Acute ear infection * Otitis media with effusion * Symptoms/presentation: * **Bilateral** hearing loss * No features suggestive of infection, impaction, effusion etc... * **Muffled speech** * **Sensorineural** hearing loss * Often accompanied by **high pitched tinnitus** * **Hyperacusis** * **Risk factors** present * Investigations: * Otoscopy: rule out other causes * Weber's & Rinne's * Audiometry * Management: * Irreversible therefore about trying to improve hearing and preventing further damage: * Hearing aids * Nosie protection e.g. foam ear plugs * Education about how to protect ears * Early detection

Answer 8

Boiler's notch

Answer 9

* **Too much endolymph** in inner ear which causes an increase in pressure and results in hearing loss/dullness. As pressure eases, hearing comes back; however, if increased pressure has damaged the ear hearing won't come back. Consequenlty **hearing may deteriorate over time and then may get acute worsening of hearing during episodes. May also get persistent tinnitus as disease progresses.** * Risk factors: * Autoimmunity * FH * Head trauma * Viral infection * Association with migraines (vascular factors) * Symptoms, may last from 30 mins up to 24 hours, triad of: * **Vertigo** * **Tinnitus** * **Hearing loss (sensorineural)** * .... with associated aural fullness

Answer 10

* Investigations (refer to ENT for investigations): * **Pure tone audiometry** (with air & bone conduction & masking) * Others may be done to exclude other issues e.g. CT or MRI to rule out issues with brain, MS etc.. * Managment: * Limiting caffeine, alcohol, stress and smoking cessation as these can trigger an attack * Low salt diet & diuretics to decrease endolymphatic pressure * Antihistamines (help with vertigo) * Tinnitus masksers (help with tinnitus) * Vestibular & balance rehabilitation therapy * Hearing aids * Intratympanic therpay e.g. steroids, gentamycin * Meniett device

Answer 11

Presbyacusis

Answer 12

* Pathophysiology thought to be multifactorial e.g. neuronal loss, damage to sterocilia, metabolic & systemic disease e.g. diabetes * Risk factors: * **Age** * Ototoxic medications e.g. aminoglycosides, loop diuretics etc... * Hypertension * Diabetes * Smoking * Family history

Answer 13

* Bilateral, gradual hearing loss *(however, be aware that someone might think it has come on quite suddenly if their hearing has just crossed threshold of what is impacting their life)* * Sensorineural * Struggle to conversate with people with background noise * High pitch sounds are muffled * Struggle to understand what words people are saying- can hear them talking but can't distinguish between certain words * Some sounds appear overly loud "annoying sounds"

Answer 14

* Otoscopy: rule out other causes * Gross hearing assessment (whisper word in ear) * Weber's & Rinnes * Pure tone audiometry

Answer 15

* Hearing aids * Learning to lip read * Use of assistive listening devices e.g. flashing light alarms, loud doorbell, phone with loud ring tone, subtitles on TV etc... * Cochlear implants considered in severe cases where pt is young and hearing aids have not been beneficial * **Reassurance** that they will not go completely deaf

Answer 16

* Presence of inflammation in the middle ear, associated with an effusion, and accompanied by the rapid onset of symptoms and signs of an ear infection **(infection of middle ear)** * Common causes: * Most commonly viral * Can be bacterial *e.g. S.Pneumoniae, H.Influenza* * More common in infants & children \<4yrs * Symptoms: * Otalgia * Fever * Malaise * Rhinorrhoea * Child may rub or hold ear, cry, poor feeding * Decreased hearing * Often history of URT

Answer 17

* Bulging tympanic membrane with classic "doughnut" or "bagel" appearance * Erythematous tympanic membrane * May aslo see prurulent discharge in external ear canal

Answer 18

* First line= analgesia e.g. paracetamol, ibruprofen * Second line= delayed antibiotic therapy *(wait 2-3 days for any improvement)* * **Amoxicillin 5-7 days * Clarithromycin or erythromycin if penicillin allergic

Answer 19

* People with a severe systemic infection. * People with suspected complications of AOM, such as meningitis, mastoiditis, intracranial abscess, sinus thrombosis, or facial nerve paralysis. * Children younger than 3 months of age with a temperature of 38°C or more.

Answer 20

* Tympanic membrane perforation (and hence chronic suppartive otitis media) * Labyrinthitis * Rarely: * Mastoiditis * Meningitis * Sinus thrombosis * Intracranial abcess * Facial nerve paralysis

Answer 21

**Chronic inflammation** of the **middle ear and mastoid cavity**, which presents with **recurrent otorrhoea through a tympanic perforation.** *World Health Organization definition states that AOM is considered to be CSOM after at least 2 weeks of discharge, whereas some experts suggest that more than 6 weeks of discharge is the cut-off point.*

Answer 22

_Symptoms_ * Otorrhoea \>2 weeks _without_ pain or fever * Hearing loss * History of acute otitis media, trauma, grommet insertion, otitis media with effusion _Examination & Otoscopy_ * Painless ear examination (unlike in AOM) * Perforated tympanic membrane

Answer 23

Assessment should include: * Checking for anything that requires admission: * postauricular swelling & tenderness * facial paralysis * vertigo * signs or symptoms of intracranial infection * Asking about hearing loss and effect on everyday activities (and speech development in child) * Excluding alternative causes for persistent ear discharge e.g. otitis externa, a foreign body impacted ear wax, and neoplasm (ear canal swelling that bleeds on contact).

Answer 24

If CSOM is suspected, **referral to an ear, nose, and throat specialist** (for diagnosis, treatment, and follow-up) should be made: * Ears should **not** be swabbed * Treatment should **not** be initiated * **Reassurance** should be given that any hearing loss will usually return when the perforation heals, but that a hearing test may be carried out in secondary care

Answer 25

* Hearing loss * Tinnitus * Ottorhea (WET ONLY) * Sudden sharp otalgia or sudden decrease in otalgia * Facial palsy * Vertigo

Answer 26

* Acute otitis media * Barotrauma *(imbalance of middle ear pressure and atmospheric pressure e.g. following scuba diving)* * Foreign objects * Severe head trauma * Acoustic trauma *e.g. explosion or gunshot*

Answer 27

No specific investigations required. * Otoscopy: *should be able to see perforation. Micro-otoscopy may be required but this would require referral*

Answer 28

* Keep ear dry (sue cotton wool smeared with vaseline in bath/shower) * Usually repair by themselves in a 6-8 weeks, but sometimes may need patch or surgical repair to heal. If peforation not healing, refer to ENT * If infected, may require antibiotic ear drops (only use ones that are safe for perforations e.g. * Increased risk of developing acute otitis media, if this does develop treat as normal

Answer 29

* Mastoiditis= infection of mastoid air cells in the mastoid bone (osteomyelitis of mastoid bone) * Risk factors: * Immunosupression * Acute otitis media * Caused by spread of middle ear infection into mastoid air cells *(spread through mastoid aditus into mastoid antrum)* * Symptoms & signs: * Erythema behind ear * Tenderness on pressing mastoid bone * Swelling behind ear * Other signs of acute otitis media e.g. hearing loss, otalgia, ottorhea * Fever * Headache

Answer 30

*\*emergency admission for all of the following* _Investigations_ * Blood test: *FBC, ESR, CRP, blood culture* * Swab of discharge for MC&S * CT head to check extent _Management_ * IV antibiotics e.g. IV ceftriaxone & IV metronidazole * Can also consider adidng topical antibiotics aswell (avoid topical aminoglycosides in perforation) * Analgesia * Surgery to drain middle ear and/or remove part of mastoid bone

Answer 31

* Abnormal sac of **keratinizing squamous epithelium and accumulation of keratin** within the **middle ear** **or mastoid air cell spaces** which **can become infected and also erode neighbouring structures** * Pathophysiology: mostly due to **Eustachain tube dysfunction** this creates -ve pressures in the middle ear cavity and retracts pars flacida which forms the retraction pocket. Risk factors e.g. ototlogial surgery can promote depostion of keratin & epithelial cells in retraction pocket. * Not common * Risk factors: * Middle ear disease e.g. otitis media * Chronic Eustachain tube dysfunction * Otological surgery * Trauma * Congential abnormalities associated with Eustachain tube dysfunction e.g. Down syndrome, cleft palate

Answer 32

_Symptoms_ * **Persistent, foul smelling otorrhoea** * Hearing loss * Tinnitus * Less commonly: vertigo, otalgia, CNVII involvement e.g. facial palsy, altered taste _Signs/otoscopic findings_ * Discharge * Deep retraction pocket in tympanic membrane- with or without skin debris & granulation tissue * Crust or keratin in upper part of tympanic membrane * Tympanic perforation *\*NOTE: congential cholesteatomas may present as white mass behind tympanic membrane*

Answer 33

In primary care setting it is a clinical diagnosis however secondary care investigations include: * **Pure tone audiogram:** *assess hearing* * **CT scan of petrous temporal bone:***asess for mastoid pathology complications e.g. cochlear, semicircular canal or intracranial pathology*

Answer 34

* **Referral to ENT:** * Semi-urgent referral if suspected cholesteatoma but no serious complications * Emergency admission if have vertigo, facial nerve involvement or other neurological symptoms that could be due to intracranial pathology e.g. abscess, meningitis etc... * **Pre-surgery topical antibiotics e.g. ciprofloxacin/dexamethasone** *(quinolones are effective)* * **Pre-surgery ear care:** *e.g. aural cleaning, ear wick if necesary* * **Surgery to remove** (followed by second look surgery to check all gone)

Answer 35

* Extensive disease casuing facial palsy, veritgo, meningitis, intracranial abscess * Conductive hearing loss * Labrinthyine fistula

Answer 36

Remember, ear is innervated by 6 nerves: two branches from cervical plexus derived from nerve roots C2 and C3, and four cranial nerves: trigeminal (CNV), facial (CNVII), glossopharyngeal (CNIX) and vagus (CNX). Hence, stimulation of any branch of these nerves by any of the structures sending sensory information via these nerves can cause ear pain. Examples include: * TMJ syndrome * Sore throat * Malignancy * Sinusitis * Tonsilitis * Laryngitis * GORD

Answer 37

Investigations are centred around ruling out otalgia caused by ear issues and finding alternative cause; investigations may include: * Otoscopy * Throat/oropharynx examination * Head and neck examination * Cranial nerve examination * Flexible endoscopy (if indicated)

Answer 38

* **Collection of fluid** within the **middle ear** space **without signs of acute inflammation** due to **negative pressure** in middle ear causing collection of fluid *(remember: mucous membranes of middle ear continuously reabsorb air causing negative pressure to develop. Usually, Eustachain tube allows equilibration of pressure)* * Common in **children** (2-5yrs)- presents commonly in **winter months** * Risk factors: * Acute otitis media (50% OME develop after AOM) * Congenital abnormalities associated with Eustachain tube dysfunction e.g. Down's syndrome, cleft palate etc... * Household smoking * Frequent URT infections

Answer 39

_Symptoms_ * Hearing loss: *commonly presents as child having difficulty communicating, asking for things to be repeated, needing TV loud* * Mild intermittent otalgia * Aural fullness with popping * Recurrent ear infections, URT infections or nasal obstruction _Signs_ * Tympanic membrane looks **abnormal colour** e.g. yellow, amber or blue (as effusion can be purulent, mucoid or serous) * **No signs of inflammation** * **Retracted** ear drum *(rarely causes bulging- hence learn that is is retracted in OME and bulgin in AOM)* *\*Ensure to examine nose & throat to assess for factors that may predispose ot OME*

Answer 40

* **Tympanometry** *(put device in external auditory canal- forming an ear tight seal- uses pressure to try and move the tympanic membrane. If not movement then it must be being 'braced' by fluid in middle ear hence flat line supports diagnosis)* * **Audiometry** (visual if under 2.5yrs, conventional for \>4yrs)

Answer 41

* **Active observe for 6-12 weeks as most spontaenously recover** *(be sure to re-evaluate during this time to check for any complications. Ideally have two hearing tests)* * **If persists after active observation, refer to ENT** *(NOTE: refer children with Down's syndrome or cleft palate straight away to ENT)* * **Grommet (tympanostomy tubes)** insertion to equilibrate pressures

Answer 42

X axis= frequecy Y axis= decibels

Answer 43

Degree of hearing loss is expressed by the **difference between a person’s threshold and the average threshold for people with normal sensitivity** *(therefore smaller number=better hearing)* * = 20dB: normal * 21-40dB: mild hearing loss * 41-70dB: moderate hearing loss * 71-90dB: severe hearing loss * \>90dB: profound hearing loss

Answer 44

* Frequency: 20 to 20000Hz * Decibles: 0 to 180dB

Answer 45

Presbyacusis

Answer 46

* Inflammation of inner ear due to infection * Normally viral cause * Symptoms (often resolve in few days): * Tinnitus * Vertigo * Hearing loss * Nausea & vomitting * Otalgia * Nystagmus * Positive head impulse test * Normal otoscopic findings * Management: * Antiemetic e.g. prochlorperazine * Anithistaminies e.g. cyclizine * Analgesia * Reassurance * Regard on safety e.g. driving, working if vertigo

Answer 47

* Acute labyrinthitis is inflammation of inner ear due to infection- usually viral cause. Has both ear and balance related symptoms. * Vestibular neuronitis is inflammation of the cochlear component of the vestibular component of the vestibulocochlear nerve (CNVIII) usually following viral infection. ONLY HAS BALANCE related symptoms e.g. vertigo, nausea/vomitting, unsteadiness

Answer 48

* Spontaneous onset of vertigo, nausea, vomiting, and unsteadiness. Hearing loss and tinnitus are not present, and there are no focal neurological symptoms. * Management similar to acute labyrinthitis: * Reassurance * Advise on alcohol, tiredness in relation to increased impact on balance * Advise on safety e.g. driving * Anti-emetic e.g. prochlorperazine * Antihistamine e.g. cyclizine * Consider referral to secondary care if dehydration risk, symptoms persist after 6 weeks or other neurological signs

Answer 49

* Hearing loss present from birth/at time of birth * Potential causes: * Syndromic: e.g. Down's syndrome, Alport syndrome, Treacher Collins syndrome * Non-syndromic e.g. infection (rubella, syphillis), teratogenic drugs (thalidomide) * Symptoms: * No startled by loud sounds * Not trying to make babbling noises by 4 months * Not turning towards sounds by 6 months * Not saying simple words by 1 year

Answer 50

* **Newborn hearing screening (automated otoacoustic emission test)**: *a miniature earphone and microphone are placed in the ear, sounds are played and a response is measured. If a baby hears normally, an echo is reflected back into the ear canal and this is picked up by the microphone* * when a baby has a hearing loss, no echo can be measured on the OAE test* * **Auditory brainstem response** *(sound waves played to baby and electrodes placed on head to detect brain's response to sounds)*

Answer 51

* Hearing aids * Cochlear implants * Learning special skills such as BSL * Speech therapy * Surgery * Support groups