ENT Flashcards
Define acute otitis media
Inflammation of middle ear mucosa
Epidemiology of acute otitis media
Common condition especially in children
High morbidity, low mortality
30% <3yrs visit GP with acute otitis media/year
Peak incidence 3-11 months
By age 3, 50-85% of children have had AOM
Incidence decreases by age 7
Aetiology of acute otitis media
Most commonly viral, but can be bacterial or both
Commonly an initial viral infection, complicated by a secondary bacterial infection
Most common bacterial causes of acute otitis media
Strep pneumoniae - 40%
Haemophilus influenzae - 30%
Moraxella catarrhalis - 10%
Risk factors for acute otitis media
Male Daycare Winter Genetics (Down's, cleft palate) Smoking Not being breast fed
Symptoms of acute otitis media
Otalgia (pain) Otorrhoea (discharge if TN perforation) Headache Fever Irritability Loss of appetite D&V Reduced hearing in affected ear Relief on ear tugging
Investigations for acute otitis media
Otoscopy (TM bulging, erythematous, may be perforated)
Examine entire head and neck region
Complications of acute otitis media
Otitis media with effusion Hearing loss (sensorineural, usually temporary) Acute mastoiditis (inflammation of mastoid air cells) Perforated ear drum Facial nerve palsy Subperiosteal abscess Labyrinthitis - dead ear Meningitis Cerebral abscess Sigmoid/lateral sinus thrombosis Recurrent attacks
Treatment of acute otitis media
Most cases improve spontaneously - analgesia, antipyretic
Conservative for 3 days, treat if persistent (>4 days): Otorrhoea TM perforation <2yrs and bilateral Mastoiditis Systemically unwell Antibiotics (amoxicillin/clarithromycin) \+/- myringotomy (surgical incision into eardrum)
Pathophysiology of acute suppurative otitis media
Viral induced middle ear effusions secondary to eustacian tube dysfunction
Epidemiology of acute suppurative otitis media
Most common in children, rare in adults
Signs and symptoms of acute suppurative otitis media
Severe pain
Sometimes fever
+/- discharge (TM rupture)
Management of acute suppurative otitis media
Amoxicillin
Define chronic otitis media
Recurrent otitis media with effusion
Not infective
Chronic inflammation with accumulation of fluid in the middle ear and no sign of infection due to eustachian tube dysfunction
Signs and symptoms of chronic otitis media
Asymptomatic Hearing loss (conductive deafness) Tinnitus Vertigo Otalgia Recurrent infection Impaired development in speech and language Fullness in ears (adults) Commonest cause of acquired hearing loss in children, rare in adults
Investigations for chronic otitis media
Conductive hearing loss
Flat tympanogram
Suspect nasopharyngeal cancer if unilateral OM with effusion in adults
Management of chronic otitis media
Grommets
Hearing aid
Chronic supparative otitis media
Chronic inflammation of middle ear and mastoid cavity
Signs and symptoms of chronic supparative otitis media
Painless otorrhoea (>2 weeks) Conductive hearing loss of variable severity Perforated TM (pars flaccida) Granulation tissue
Management of chronic supparative otitis media
Aural toilet
Topical antibiotics
Possible surgery - myringoplasty or tympanoplasty
Define cholesteatoma
Expanding destructive growth of keratinising squamous epithelium in middle ear cleft
Causes of cholesteatoma
Congenital or acquired
Retraction of TM commonest cause
Ear trauma
Recurrent OM infection
Signs and symptoms of cholesteatoma
Chronic otorrhoea History of otitis media Malodorous discharge Vertigo Conductive hearing loss
Complications of cholesteatoma
Facial nerve palsy
Labyrinthitis
Meningitis
Extra/subdural abscess
Management of cholesteatoma
Surgical: mastoidectomy and tympanoplasty
Pathophysiology of cholesteatoma
Eustachian tube dysfunction -> Negative middle ear pressure -> Retraction of pars flaccida -> Infection -> Erosion and spread
Investigations for cholesteatoma
CT
Biopsy
Define primary otalgia
Pain that originates within ear: External otitis Otitis media Mastoiditis Auricular infections
Define referred otalgia
Pain originating outside of the ear: Dental pathology Sinusitis Neck problems Tonsillitis Pharyngitis
Investigations for earache
Detailed history and exam
Rule out differentials
Management of earache
Identification of causative aetiology often necessary to treat successfully
Define laryngitis
(acute and chronic)
Inflammation of the larynx
Can lead to oedema of the true vocal fold
Acute:
Abrupt onset, usually self-limited
Chronic symptoms:
>3 weeks
Thorough evaluation required as symptoms are similar to laryngeal malignancy
Causes of acute laryngitis
Infectious:
Most often viral and self-limiting
Rhinovirus, parainfluenza, respiratory syncytial virus, influenza, adenoviruses
Bacterial:
Can be life-threatening
H influenzae, Moraxella, Strep pneum, Staph aureus, klebsiella, diptheria, TB
Fungal Non-infectious agents Vocal misuse Reflux laryngitis - caused by GORD Chronic irritant laryngitis Allergic Autoimmune (RA, relapsing polychondritis, Wegener granulomatosis, sarcoidosis)
Signs and symptoms of laryngitis
Hoarseness of voice (gradually over <7d, preceded by viral URTI)
Dysphagia, sore throat
May present with airway distress and high fever
Infective signs - odynophagia, cough, fever, respiratory distress
Investigations for laryngitis
Culture
Laryngoscopy (inflammation seen, biopsy)
Analysis of vocal fold movement (asymmetry)
FBC
PCR for diphtheria rapid antigen detection test (group A strep)
Management of laryngitis
Secure airway
Vocal hygiene
Supportive care (cough suppressant, mucolytic)
Analgesia
Viral:
Voice rest
Hydration (humidified air)
Bacterial:
Antibiotics and supportive measures
Vocal strain - voice therapy and vocal hygiene
Define epiglottitis
Acute inflammation in supraglottic region of oropharynx
With inflammation of the epiglottitis, vallecula, arytenoids, aryepiglottic folds
Airway emergency - especially in children (may be more indolent in adults)
Classically occurs in children 2-6 yrs
Causes of epiglottitis
Infectious Most common organisms: H. influenzae (25%) H. parainfluenzae Strep pneumoniae Group A strep
Can be any other of bacteria/viruses
Candida and aspergillus are important causes in immunocompromised patients Non-infectious Thermal (drug smoking, bottle-feeding) Causitic insults Foreign body ingestion Head and neck chemo
Signs and symptoms of epiglottitis
Rapid onset and progression High fever Sore throat Inability to control secretions Tripod positioning Difficulty breathing/swallowing Muffled voice Preceding URTI symptoms
Complications of epiglottitis
Meningitis Adenitis Vocal granuloma Pneumonia and other lung pathology Pericarditis Septic arthritis Cellulitis Sepsis Death (asphyxia)
Investigations for epiglottitis
Clinical diagnosis (don’t delay securing airway)
Nasopharyngoscopy/laryngoscopy
Radiology (soft tissue lateral neck radiography, USS)
Cultures of systemically unwell
Management of epiglottitis
ABCDE
Airway management, intubate if necessary
(respiratory distress, airway compromise, stridor, dysphagia, drooling, deterioration)
Define acute pharyngitis
Rapid onset sore throat and pharyngeal inflammation
With or without exudate
Pathophysiology includes infection and inflammation of the pharynx
Signs and symptoms of pharyngitis
Acute onset sore throat
Pharyngeal exudates
Cervical adenopathy
Fever
Absence of cough, nasal congestion and discharge suggests bacterial aetiology
Generally self-limited with resolution within 2 wks
Causes of pharyngitis
Group A strep
Viral:
EBV, adenoviruses, enteroviruses, influenza, parainfluenza
Candidal pharyngitis
Diphtheria
Measles
Tularaemia
Sexually transmitted:
Acute HIV, gonorrhoea, chlamydia
Differentials of pharyngitis
Epiglottitis Abscess Infectious mononucleosis (EBV) Diphtheria Lemierre's (thrombophlebitis of the jugular vein) Measles Oropharyngeal cancer
Investigations for pharyngitis
Throat swab
Blood agar
RATD
Management of pharyngitis
Analgesia, LA
Salt water
Antibiotics if proven strep A
Complications of group A strep pharyngitis
Suppurative (pus) Peri-tonsillar abscess Lymphadenitis Sinusitis Otitis media Mastoiditis Invasive infections e.g. toxic shock syndrome, necrotising fasciitis Non-suppurative Acute rheumatic fever Acute glomerulonephritis
Define tonsillitis
Acute infection of the parenchyma of the palatine tonsils
May occur in isolation or as part of generalised pharyngitis
Clinical distinction between tonsilitis and pharyngitis in the literature is unclear, often referred to as “acute sore throat”
Pathophysiology of tonsillitis
Local inflammatory pathways result in oropharyngeal swelling, oedema, erythema and pain
Rarely swelling may progress to soft palate and uvula (uvulitis) or inferiorly to the region of the supraglottis
Causes of tonsillitis
Mostly viral:
Commonly rhinovirus
Then coronavirus & adenovirus, influenza, parainfluenza, enteroviruses, herpes, EBV
Bacterial causes: 10-30% Group A strep (Beta haemolytic) Strep pyogenes Staph aureus H-influenza
Symptoms of tonsillitis
Acute onset fever Throat pain exacerbated by swallowing Headache Malaise Halitosis Odynophagia Tonsils enlarged, red, purulent exudate Cervical lymphadenopathy
Investigations for tonsillitis
Throat culture Rapid strep antigen testing FBC Antibody testing for mononucleosis (EBV) Throat swab/ASO titre +/- MONOSPOT
Management of tonsillitis
Conservative for 7d if pyrexic
Analgesia/anaesthesia
Salt water gurgling
If microbiologically confirmed group A strep: penicillin or macrolide
Tonsillectomy if recurrent
