ENT Flashcards
Otitis media
A group of complex infective and inflammatory conditions affecting the middle ear.
Types: AOM, Otitis media with effusion (glue ear), chronic suppurative otitis media, mastoiditis and cholesteatoma.
C: Bacterial (usually Haemophilus influenzae and Streptococcus pneumoniae), viral (Rhinoviruses and respiratory syncytial viruses). Enters via the nasopharynx.
S: Hearing loss, otalgia, fever, also in children malaise, restlessness, pulling at the ear, poor feeding, crying, coryza/rhinorrhoea. May have red, yellow or cloudy, or bulging tympanic membrane. May have discharge if perforation.
D: Ear exam, culture of discharge, Tympanocentesis, CT/MRI.
T: Analgesia, antipyretics, warm compress. Usually no or delayed antibiotics (4 days). 5 day course of amoxicillin (or erythromycin or clarithromycin). Admit if there are complications. Refer to ENT if recurrent.
Cerumen impaction
A build-up of earwax that becomes wedged in, blocking the ear canal.
C: Ear is unable to clear the ear due to hardening, patient has put objects to push the wax deeper. May be associated with a bony blockage, otitis externa, skin disease, autoimmune disease, narrowed ear canal, overproduction of earwax.
S: Itchy ear, pain in the ear, ringing in the ear, hearing loss, hearing aid feedback or malfunction.
D: Hearing test, ear examination.
T: Ceruminolytic agents to soften the earwax for removal. Cerumen removed by curette, suction, flushing.
Labyrinthitis
Inflammation of the membranous labyrinth causing damage to the vestibular and auditory end organs.
C: Usually viral and precedes URTI, bacterial (enter through anatomical connections), asssociated with vertebrobasilar ischaemia, meningitis, Ménière’s disease and medication.
S: Severe and debilitating vertigo, nausea and vomiting, hearing loss, tinnitus, falling to the affected side, spontaneous nystagmus.
D: Ear examination, CN examination, gait assessment, hearing test, HINTS examination.
T: Prochlorperazine or antihistamines for symptomatic relief. May need buccal or deep intramuscular injection of prochorperazine. Vestibular rehabilitation, consisting of physical manoeuvres and exercise regimes. Surgery.
Otitis externa
Inflammation of the auricle, external auditory canal or outer surface of the eardrum.
C: Infection which is usually bacterial (Staphylococcus aureus and/or P. aeruginosa) or fungal (Aspergillus spp. or Candida spp.). Foreign bodies, water in the ear, chemicals, hearing aids. Associated with eczema, acne, SLE, psoriasis.
S: Pain, itching, erythema, oedema, discharge, hearing loss, regional lymphadenopathy, fever.
D: Ear examination, ear swab for bacterial and fungal microscopy and culture, check for perforation (if the patient can taste medication placed in the ear or can blow air out of the ear when the nose is pinched).
T: Topical drops (acetic acid) or topical antibiotics (neomycin or clioquinol). Removal of debris (gentle syringing or microsuction). Oral antibiotics are rarely needed - but if they are 7 day course of flucloxacillin, or clarithromycin. Patients with systemic symptoms need same-day ENT review. Remove aggravating factors.
Vertigo
A type of dizziness and refers to a false sensation that oneself or the surroundings are moving or spinning.
C: Labyrinthitis, BPPV, Eustachian tube dysfunction, Ménière’s disease, chronic otitis media, epilepsy, drugs: salicylates, quinine, aminoglycosides, head injury, acoustic neuroma.
S: rotatory or spinning symptoms
D: Ear exam, neuro exam, eye exam, Romberg’s test (arms outstretched), head impulse test (rapid turn of the head), hearing tests, CT/MRI.
T: Treat underlying cause. Avoid driving and include occupational advice. Consider offering symptomatic drug treatment with prochlorperazine, cinnarizine, cyclizine or promethazine for max 1 week. Vestibular rehabilitation programmes.
Chronic otitis media
A chronic inflammation of the middle ear and mastoid cavity (with perforation of tympanic membrane).
C: Ongoing cycle of inflammation, ulceration, infection and granulation. Increased risk with craniofacial abnormalities, multiple episodes of AOM, crowded living, large family.
S: Chronically draining ear (>2 weeks), hearing loss, discharge varies from fetid, purulent and cheese-like to clear and serous, visible granulation.
D: Hearing tests, CT/MRI.
T: Refer to ENT - microsuction the exudate. Topical steroids and antibiotics, IV antibiotics if there is failure to respond to the topical therapy, surgery.
Acute sinusitis
A bacterial or viral infection of the sinuses lasting fewer than four weeks.
C: Commonly Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.
S: Non-resolving cold (>1 week or worsening symptoms over 4-5 days), facial discomfort, pyrexia, purulent nasal discharge ± decreased or absent smell, erythema and oedema of the nasal mucosa may also be found.
D: Clinical diagnosis, if uncertain ESR, CRP, plain X-ray films, ultrasonography, nasendoscopy, CT/MRI.
T: Supportive - paracetamol, intranasal decongestant, nasal irrigation with warm saline solution, warm face packs, adequate fluids and rest. If the patient has been unwell for over 10 days, high-dose nasal corticosteroid for 14 days. If antibiotics, first-line is phenoxymethylpenicillin (very rarely given).
Allergic rhinitis
Inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mould or flakes of skin from certain animals.
Types: Seasonal allergic rhinitis/hay fever, Perennial rhinitis, Occupational rhinitis.
C: IgE mediated inflammation reaction of the nasal mucosa mediated by an allergen. Increase in epithelial permeability and this prompts migration of inflammatory cells to the area. Genetic and environmental factors.
Associated with atophy, conjunctivitis, sinusitis, nasal polyps.
S: Sneezing, rhinorrhoea, nasal congestion, itchy nose/palate, worse on waking, watering, itching, redness or swelling of the eyes.
D: Skin prick testing, radioallergosorbent test (RAST) or enzyme-linked immunosorbent assay (ELISA) of the blood, CT scan.
T: Allergen avoidance, topical nasal antihistamines, oral antihistamines such as cetirizine, loratadine or fexofenadine, topical intranasal steroids for when there is nasal blockage, short courses of oral steroids, surgery.
Epistaxis
Nosebleed - bleeding usually occurs when the mucosa is eroded and vessels become exposed and subsequently break.
C: Spontaneous, trauma to the nose, disorders of platelet function, aspirin and anticoagulants, elderly arteriosclerotic vessels, cocaine use, malignancy of the nose.
S: Blood running out of the nose - one nostril (usually anterior), both nostrils and into the throat (usually posterior), facial pain.
D: FBC, coagulation studies and blood typing. CT scanning and/or nasopharyngoscopy if malignancy is suspected.
T: Get the patient to sit upright and squeeze the bottom part of the nose for 10-20 minutes. If the bleeding has not stopped, cautery using silver nitrate or electrocautry is used to stop the bleeding points. If there are no particular bleeding points, you’ll need to use a rapidrhino. Or if this doesn’t work ligate the arteries or perform endovascular embolisation.
Chronic sinusitis
An inflammation of the membranous lining of one or more of the sinuses that lasts more than 12 weeks.
C: Allergic rhinitis (dust mites, molds), exposures (airborne irritants, cigarette smoke or other toxins), structural causes (nasal polyps, deviated nasal septum), ciliary dysfunction, immunodeficiencies, bacterial and fungal infections.
S: Dull ache on palpation, nasal purulence, loss of smell, may come in acute exacerbations.
D: Ear exam, neuro exam, assessment for polyps, presence of a foreign body.
T: Antihistamines if there is an allergic component, nasal steroids for max 8-12 weeks, if no change a short course of oral steroids can be considered. Avoid antibiotics if possible. Endoscopic sinus surgery.
Nasal polyps
Lesions arising from the nasal mucosa, occurring at any site in the nasal cavity or paranasal sinuses but most frequently seen in the clefts of the middle meatus.
C: Unknown. Linked to the presence of inflammation and oedema. Superantigens produced by Staphylococcus aureus may play a role. Associated with asthma, aspirin sensitivity, Churg-Strauss syndrome, CF, allergic fungal sinusitis.
S: Nasal airway obstruction, nasal discharge, dull headaches, snoring and obstructive sleeping symptoms, decreased smell and taste, yellowish-grey colour.
D: Nose examination, rigid or flexible endoscopy, CT scan.
T: Refer to ENT if unilateral. Topical nasal corticosteroids. Wash with saline. Short-course of oral steroids. Leukotriene receptor antagonists may be beneficial for some patients. Endoscopic sinus surgery.
Acute Pharyngitis
Inflammation of the pharynx, which is in the back of the throat. AKA a sore throat.
C: Commonly viral (adenovirus, influenza, or mononucleosis), can be bacterial (group A streptococcus), also associated with measles, chickenpox, croup, whooping cough.
S: Sneezing, runny nose, headache, cough, fatigue, body aches, fever.
D: Throat examination - white or gray patches, swelling, and redness. Throat culture if strep throat is suspected
Blood tests.
T: Lots of fluids, gargling with salt water, dehumidifier, rest, analgesia. Throat lozenges to soothe.
Antibiotics if caused by a bacterial infection - amoxicillin and penicillin for strep throat.
Acute tonsillitis
Inflammation due to infection of the tonsils.
C: Usually viral infection (influenza), can be bacterial (usually group A streptococcus bacteria).
Risk factors - immunodeficiency, family history, atopy
S: Severe throat pain, may radiate to ears, headache, loss or change in voice, fever, throat is reddened, the tonsils are swollen and may be coated or have white flecks of pus on them. May have abdo pain.
D: Clinical diagnosis. Throat swab - Rapid antigen test for Group A strep. Paul-Bunnell or equivalent blood test to rule out glandular fever.
T: Reassurance, watchful waiting.
Antipyretic analgesics.
If no better in 3-5 days or if symptoms worsen - 5-10 day course of phenoxymethylpenicillin (or clarithromycin or erythromycin).
If glandular fever, may need hospital admission and corticosteroids.
Tonsillectomy for recurrent episodes.
Aphthous ulcers
Common ulcer that usually form on soft areas of the mouth such as the inside of the lips, the cheeks or the underside of the tongue.
C: Unknown. Triggered by emotional stress, cuts, burns or bites, family history, coffee, chocolate, eggs and cheese, acidic or spicy foods, zinc, B-12, folate and iron deficiency, tobacco products, pregnancy, immunodeficiency.
S: Round, soft, shallow ulcers. Usually pale, but may be red. Difficulty drinking, eating or talking. Lymph node swelling. Fever and fatgiue.
D: Rule out coeliac disease, IBD, HIV/AIDS which might cause a weakened immune system.
T: Should resolve on their own. Avoid hard or irritative substances. Topical lidocaine or benzocaine. Topical anti-inflammatory pastes. Antiseptic mouthwash e.g. containing chlorhexidine, twice per day. If bacterially infected, tetracycline or minocycline in mouth wash form.
Laryngitis
Inflammation of the mucosa lining the vocal folds and larynx. Chronic is more than 3 weeks.
C: Viral (rhinovirus, adenovirus, influenza, parainfluenza, herpes virus, HIV, coxsackievirus), bacterial (Haemophilus influenzae type B, streptococcus pneumoniae, staphylococcus aureus, group B beta-haemolytic streptococci, moraxella catarrhalis, klebsiella pneumoniae), fungal (candidiasis), trauma due to voice misuse.
S: Hoarseness, pain in the neck, symptoms of URTI, dysphagia, globus pharyngeus (lump), myalgia, fever, fatigue, malaise.
D: Swab for microbiological analysis. If chronic, bloods, sputum culture, serology for autoimmune markers, laryngoscopy, CXR, barium swallow, CT/MRI.
T: Hoarse voice/change to the voice for three weeks should be referred to ENT.
Acute - rest the voice, avoid smoking and alcohol, humidification, hydration, reduce caffeine.
Chronic - voice therapy, SALT, treat underlying condition.
Oral candidiasis
Fungal infection of the mouth.
C: Multiplication of commensal candida caused by antibiotic use, inhaled corticosteroid medication, ill-fitting dentures, poor oral hygiene, dry mouth, smoking, chemo.
S: White patches that can be wiped, often leave it red and bleeding, loss of taste, redness, cracks at the corner of the mouth, painful, burning sensation in the mouth.
D: Physical examination, blood tests to look for conditions such as diabetes and nutritional deficiencies.
T: Topical antifungal gel for 7 days. First-line is miconazole oral gel. If unsuitable, nystatin suspension. If severe, oral fluconazole 50 mg a day for 7 days. Advice on good dental hygiene, smoking cessation, good inhaler technique, disinfect dentures with chlorhexidine or hexetidine. If recurrent, refer to an oral surgeon.
Parotitis
Inflammation of one or both of the parotid glands.
C: Bacterial infection (Staph aureus, Strep viridans, E. coli), viral (mumps), HIV, TB, blockage of saliva flow.
S: Sudden pain and swelling that worsens with eating, redness, pus that may drain into the mouth.
D: Physical examination, swabs, blood cultures, fluid sample from the parotid gland, may need imaging - ultrasound, sialography, X-rays, CT, MRI.
T: Warm water rinses and good oral hygiene. If bacterial, usually antistaphylococcal antibiotic (nafcillin, oxacillin, cefazolin). Anti-inflammatories to manage pain and swelling. Surgery to remove anything that may be blocking saliva flow.
Mastoiditis
Suppurative infection extends from a middle ear affected by otitis media to the mastoid air cells. Causes inflammation and may lead to bony destruction.
C: Strep. pneumoniae, strep. pyogenes, staphylococcus spp, pseudomonas aeruginosa.
S: Acute or recurrent episodes of otitis media, ear pain, fever, swelling, redness or a boggy, tender mass behind the ear, ear discharge may be present, tymphanic membrane bulges and is erythematous.
D: FBC, ESR, blood cultures, fluid extracted by tympanocentesis, CT/MRI, LP.
T: Admit to hospital. High-dose, broad-spectrum intravenous (IV) antibiotics, given for at least 1-2 days.
Oral antibiotics are usually used after this, starting on IV treatment after 48 hours without fever and continuing for at least 1-2 weeks. Paracetamol and ibruprofen. Myringotomy ± tympanostomy tube insertion may be performed. Immediate mastoidectomy if also has a subperiosteal abscess.
Ménière’s Disease
Disorder of the inner ear caused by a change in fluid volume in the labyrinth.
C: Unknown. Risk factors include: allergy, autoimmunity, SLE, RA, APA, genetics, metabolic disturbances, viral infection.
S: Vertigo, tinnitus and fluctuating hearing loss with a sensation of aural pressure. Episodic pattern. Acute attacks last mins-hours. Usually unilateral, but can progress to bilateral. May have imbalance or unexplained falls.
D: ENT exam, cardio exam, neuro exam, blood tests to exclude systemic illness - FBC, ESR, thyroid function, syphilis screen, fasting glucose, renal function, lipids, audiometry, electronystagmography.
T: Vertigo and nausea can be alleviated by prochlorperazine, cinnarizine, cyclizine, or promethazine. May need to be IM or buccal.
Low-salt diet and avoiding caffeine, chocolate, alcohol and tobacco are often advised.
If symptoms are severe, IV labyrinthine sedatives and fluids to maintain hydration, and nutrition. Advise about risks. Trial of betahistine to reduce the frequency and severity of attacks of hearing loss, tinnitus, and vertigo.
Barotrauma
The eardrum becomes stretched and tense due to unequal pressures that develop either side of the eardrum.
C: Usually occurs during plane travel, scuba diving, diving to the bottom of a swimming pool, or rapidly descending in a lift.
Risk factors - narrow Eustachian tube, colds, throat infections, hay fever.
S: Ear pain
D: Clinical diagnosis
T: Encourage airflow in the Eustachian tube by swallowing, yawning or chewing.
The Valsalva manoeuvre - breathe out and pinch nose.
Decongestant nasal spray, air pressure-regulating ear plugs.
Conductive hearing loss
The movement of sound is blocked or does not pass into the inner ear due to a problem in the ear canal or middle ear.
C: earwax, foreign bodies, ottitis externa, ottitis media, perforated eardrum, cholesteatoma, otosclerosis, eustachian tube dysfunction.
S: Sudden or unexpected hearing loss in one or both ears, sound is muffled, pain, clear or yellow drainage.
D: Whispering in the patient’s ear, Weber’s test (if conductive, the sound will be heard best in the affected ear) Rinne’s test (bone conduction is better than air conduction, and the sound is not heard when the tuning fork is placed adjacent to the canal). Formal audiography.
T: Removing ear wax with ear drops, irrigation, microsuction. Surgery if congenital defect or tumours. Conventional hearing aid, bone-conduction hearing aid, or a surgically implanted, osseointegrated device. Antibiotic or antifungal medications are used to treat chronic ear infections, or chronic middle fluid.
Sensorineural hearing loss
The hair cells in the cochlea or the auditory nerve is not functioning correctly so some or all of the sounds are not being sent to the brain.
C: Age, noise damage, severe head injury, measles, mumps, meningitis, TB, VZV, Gentamycin, Meniere’s disease, MS, encephalitis, acoustic neuroma, stroke.
S: Can be mild, moderate or profound and affect one or both ears.
D: Whispering in the patient’s ear, Weber’s test (if sensorineural, the sound will be heard best in the unaffected ear) Rinne’s test (air conduction is better than bone conduction, so the sound is heard for longer when the tuning fork is placed adjacent to the canal). Formal audiography.
T: Cannot be treated with surgery or medicine. Conventional hearing aids or cochlear implants.
Tympanic membrane perforation
A perforated eardrum is a hole or tear that has developed in the eardrum, the extent of hearing loss can vary greatly.
C: Otitis media, direct injury, sudden loud noise, barotrauma, grommets.
S: Asymptomatic, slightly muffled hearing to significant loss, tinnitus, aching or pain, itching, discharge, high temp.
D: Otoscope
T: Should heal within 6-8 weeks. Ofloxacin otic solution if otitis media or otitis externa are present. Myringoplasty or a tympanoplasty if it has not healed within 3 months.
Quinsy
Peritonsillar abcess - pus trapped between the tonsillar capsule and the lateral pharyngeal wall.
Complication of tonsilitis.
C: Streptococcus pyogene, Staphylococcus aureus, Haemophilus influenzae, anaerobic organisms including Prevotella spp., Porphyromonas spp., Fusobacterium spp. and Peptostreptococcus spp.
S: Severe throat pain, fever, drooling of saliva, foul-smelling breath, trismus (difficulty opening the mouth), altered voice quality, earache, neck stiffness, headache, lymph node swelling.
D: Clinical diagnosis. CT scan.
T: IV fluids for dehydration, analgesia, IV antibiotics - Penicillin, cephalosporins, amoxicillin + clavulanic acid, needle aspiration, incision and drainage and quinsy tonsillectomy.
