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1
Q

In whom is acute otitis media common?

A
  • young children

- 1/2 have 3 or more episodes by 3yo

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2
Q

Pathophysiology of acute otitis media:

A
  • viral URTIs typically precede
  • most secondary to bacteria esp. streptococcus pneumonia, haemophilus influenza and moraxella catarrhalis
  • disturb normal nasopharyngeal microbiome, allowing bacteria to infect middle ear via Eustachian tube
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3
Q

Features of acute otitis media:

A
  • otalgia
  • fever 50%
  • hearing loss
  • recent viral URTI symptoms
  • ear discharge if tympanic membrane perforated
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4
Q

Otoscopy findings acute otitis media:

A
  • bulging tympanic membrane - loss of light reflex
  • opacification or erythema of tympanic membrane
  • perforation with purulent otorrhoea
  • decreased mobility if using pneumatic otoscope
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5
Q

Criteria to diagnose otitis media:

A
  • acute onset
  • presence of middle ear effusion (bulging membrane, otorrhoea or decreased mobility of pneumatic otoscope)
  • inflammation of tympanic membrane
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6
Q

Management otitis media:

A
  • generally self-limiting
  • analgesia to relieve otalgia
  • antibiotics: 5-7 days amoxicillin (erythromycin/clarithromycin)
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7
Q

When should antibiotics be prescribed for otitis media?

A
  • symptoms more than 4 days or not improving
  • systemically unwell not requiring admission
  • immunocompromised or high risk complications secondary to significant heart, lung, kidney, liver or neuromuscular disease
  • younger than 2 years with bilateral otitis media
  • otitis media with perforation and/or discharge in canal
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8
Q

Common sequelae acute otitis media:

A
  • perforation of tympanic membrane - otorrhoea
  • unresolved with perforation may develop into chronic suppurative otitis media (CSOM)
  • CSOM - perforation with otorrhoea > 6 weeks
  • hearing loss
  • labyrinthitis
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9
Q

Complications otitis media:

A
  • mastoiditis
  • meningitis
  • brain abscess
  • facial nerve paralysis
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10
Q

What is acute sinusitis?

A
  • inflammation of mucous membrane of paranasal sinuses

- most common: streptococcus pneumonia, haemophilus influenzae and rhinoviruses

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11
Q

Predisposing factors acute sinusitis:

A
  • nasal obstruction e.g. septal deviation or nasal polyps
  • recent local infection e.g. rhinitis or dental extraction
  • swimming/diving
  • smoking
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12
Q

Features acute sinusitis:

A
  • facial pain
  • typically frontal pressure pain which is worse on bending forward
  • nasal discharge: thick and purulent
  • nasal obstruction
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13
Q

Management acute sinusitis:

A
  • analgesia
  • intranasal decongestants or nasal saline
  • intranasal corticosteroids if symptoms more than 10 days
  • oral antibiotics not normally required
  • only phenoxymehylpenicillin or co-amoxiclav if systemically unwell and serious
  • double sicking - viral sinusitis worsening due to secondary bacterial infection
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14
Q

Features of acute tonsillitis:

A
  • pharyngitis, fever, malaise and lymphadenopathy
  • over half are bacterial: streptococcus pyogenes
  • tonsils oedematous and yellow or white pustules
  • infectious mononucleosis mimics
  • may cause local abscess formation (quinsy)
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15
Q

Treatment acute tonsillitis:

A

penicillins

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16
Q

What is allergic rhinitis?

A
  • inflammatory disorder of nose
  • sensitised to allergens e.g. house dust mites, grass, tree, pollens
  • seasonal, perennial or occupational
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17
Q

Features of acute rhinitis:

A
  • sneezing
  • bilateral nasal obstruction
  • clear nasal discharge
  • post-nasal drip
  • nasal pruritus
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18
Q

Management acute rhinitis:

A
  • allergen avoidance
  • mild-to-moderate, intermittent or mild symptoms: oral or intranasal antihistamines
  • moderate-to-severe, persistent or initial drug ineffective: intranasal corticosteroids
  • short courses of topical nasal decongestants e.g. oxymetazoline - not prolonged as tachyphylaxis and rebound hypertrophy of nasal mucosa (rhinitis medicamentosa) upon withdrawal
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19
Q

Above what dB on audiogram is normal?

A

20dB

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20
Q

What conduction is impaired in sensorineural hearing loss?

A

air and bone

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21
Q

What conduction is impaired in conductive hearing loss?

A

air only

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22
Q

What conduction is lost in mixed hearing loss?

A

both with air being worse than bone

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23
Q

What is an auricular haematoma?

A
  • common in rugby players and wrestlers

- cauliflower ear formation

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24
Q

management of auricular haematomas?

A
  • same day assessment ENT

- incision and drainage superior to needle aspiration

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25
Average age of onset benign paroxysmal position vertigo:
55yo
26
Features of benign paroxysmal position vertigo:
- triggered by change in head position - nausea - 10-20 seconds - positive Dix-Hallpike manoeuvre
27
Symptomatic relief benign paroxysmal position vertigo:
- Epley manoeuvre (80%) - vestibular rehabilitation e.g. Brandt-Daroff exercises - medication e.g. betahistine limited value
28
What is black hairy tongue?
- defective desquamation of filiform papillae | - tongue brown, green, pink or another colour
29
Predisposing factors black hairy tongue:
- poor oral hygiene - antibiotics - head and neck radiation - HI - IV drug use
30
Investigations and management black hairy tongue:
- swab to exclude candida - tongue scraping - topical antifungals if candida
31
What is a branchial cyst?
- benign developmental defect of branchial arches - filled with acellular fluid with cholesterol crystals and encapsulated by stratified squamous epithelium - may have fistula so prone to infection - may enlarge following a respiratory tract infection
32
When do branchial cysts present?
- late childhood/early adulthood - asymptomatic neck lateral lumps - usually anterior to sternocleidomastoid muscles - slight male predisposition
33
Typical features branchial cyst:
- unilateral typically left - lateral, anterior to SCM - slowly enlarging - smooth, soft, fluctuant - non-tender - fistula may be seen - no movement on swallowing - no transillumination
34
Differential diagnosis of congenital neck lump in children:
- branchial cyst - thyroglossal cyst - dermoid cyst - vascular malformation
35
Differential diagnosis of inflammatory neck lump in children:
- reactive lymphadenopathy | - lymphadenitis
36
Differential diagnosis of neoplastic neck lump in children:
- lymphoma - thyroid tumour - salivary gland tumour
37
Diagnosis, investigations and treatment of branchial cysts:
- consider and exclude other malignancy - US - referral to ENT - fine-needle aspiration - treat conservatively or excise surgically - antibiotics acute infections
38
What is a cholesteatoma?
- non-cancerous growth of squamous epithelium - trapped in skull base causing local destruction - most common 10-20yo
39
What increases risk of cholesteateoma?
cleft palate x100
40
Features cholesteatoma:
- main: foul smelling, non-resolving discharge and hearing loss - vertigo - facial nerve palsy - cerebelopontine angle syndrome
41
Otoscopic findings cholesteatoma:
attic crust (uppermost ear drum)
42
Management cholesteatoma:
refer to ENT for surgical removal
43
What is chronic rhinosinusitis?
- 1 in 10 people - inflammatory disorder of paranasal sinuses - 12 weeks of longer
44
Predisposing factors chronic rhinosinusitis?
- atopy: hay fever, asthma - nasal obsturciton e.g. septal deviation or nasal polyps - recent local infection e.g. rhinitis or dental extraction - swimming/diving - smoking
45
Features chronic rhinosinusitis:
- facial pain: frontal pressure pain worse with bending forwards - nasal discharge: clear if allergic or vasomotor, thick/purulent suggests secondary infection - nasal obstruction - post-nasa drip - may have chronic cough
46
Management of chronic rhinosinusitis:
- avoid allergen - intranasal corticosteroids - nasal irrigation with saline solution
47
Red flag symptoms chronic rhinosinusitis:
- unilateral symptoms - persistent symptoms despite compliance with 2 months treatment - epistaxis
48
How is cochlear implant suitability determined?
- children: audiological assessment and/or difficulty developing basic auditory skills - adults: complete trial of appropriate hearing aids for at least 3 months (no benefit or limited)
49
Causes of severe-to-profound hearing loss in children:
- genetic (50%) - congenital e.g. maternal CMV, rubella or varicella - idiopathic (30% childhood deafness) - infectious e.g. post meningitis
50
Causes of severe-to-profound hearing loss in adults:
- viral induced hearing loss - ototoxicity e.g. following administration of aminoglycoside antibiotics or loop diuretics - otosclerosis - meniere disease - truma
51
What is required for ensuring the success of the cochlear implant?
surviving spiral ganglion neurons | assess anatomy by otolaryngologist/skull base surgeon
52
What can complicate cochlear surgical implantation?
- infection - facial paralysis due to nerve injury intra-operatively - CSF leakage - meningitis
53
What vaccinations should one have before cochlear implant surgery?
streptococcus and haemophilus
54
How long after surgery should patients return for a post-op device stimulation?
3-5 weeks
55
Contraindications to cochlear implant:
- lesions of cranial nerve VIII or in brain stem causing deafness - chronic infective otitis media, mastoid vacuity or tympanic membrane perforation - cochlear aplasia
56
Relative contraindications cochlear implant:
- chronic infective otitis media or mastoid cavity infections - tympanic membrane perforation
57
Most common causes of hearing loss:
- ear wax - otitis media - otitis externa
58
Features of presbycusis:
- age related - sensorineural - difficulty following conversations - audiometry: bilateral high frequency hearing loss
59
Features of otosclerosis:
- autosomal dominant - replacement of bone with vascular spongy bone - onset 20-40 years - conductive deafness - tinnitus - tympanic membrane - 10% flamingo tinge caused by hyperaemia - positive family history
60
What is glue ear?
- otitis media with effusion - peaks at 2yo - hearing loss presenting features - secondary: speech delay, behaviour or balance problems
61
What is Meniere's disease?
- middle aged adults - recurrent episodes vertigo, tinnitus and hearing loss - sensorineural - vertigo most prominent - sensation of aural fullness - nystagmus and positive Romberg test - episodes minutes to hours
62
What causes drug ototoxicity?
e.g. aminoglycosides (gentamicin), furosemide, aspirin, cytotoxics
63
What frequencies are lost with noise damage?
3000-6000Hz
64
What are acoustic neuromas?
-vestibular schwannomas -CN VIII: hearing loss, vertigo, tinnitus -CN V: absent corneal reflex -CN VII: facial palsy bilateral in neurofibromatosis type 2
65
Impacted ear wax symptoms:
- pain - conductive hearing loss - tinnitus - veritgo
66
Treatment ear wax:
- olive oil - sodium bicarbonate - almond oil
67
Whom should not be given ear drops to treat ear wax?
- perforation | - grommets
68
Where does anterior epistaxis originate?
Kiesselbach's plexus
69
In whom do posterior nosebleeds typically occur?
older patients - higher risk aspiration and airway compromise
70
What can nosebleeds indicate apart from trauma?
- platelet function disorders: thrombocytopenia, splenomegaly, leukaemia, Waldenstrom's macroglobulinaemia and ITP - juvenile angiofibroma - drug use - abrasion and atrophy - elderly: haemorrhage telangiectasia - Wegener's, pyogenic granuloma
71
Management epistaxis:
- pinching, leaning forwards etc. - topical antiseptic e.g. naseptin (chlorhexdine and neomycin) to reduce crusting and risk of vetibulitis - mupicorin - if not after 10-15 minutes: cautery or packing
72
How is cautery carried out for epistaxis?
- topical local anaesthetic spray e.g. co-phenylcaine and wait 3-4 minutes - silver nitrate stick to bleeding point 3-10 min - dab area with cotton bud and apply naseptin or mupicorin
73
How is packing carried out for epistaxis?
- anaesthetise with topical LA spray e.g. co-phenylcaine and wait 3-4 minutes - pack nose
74
Characteristic exam features of sinusitis:
- facial fullness and tenderness - nasal discharge - pyrexia or post-nasal drip leading to cough
75
Characteristic exam features of trigeminal neuralgia:
- unilateral facial pain - brief electric shocks - abrupt onset and temrination - triggered by light touch and emotion
76
Drug causes of gingival hyperplasia:
- phenytoin - ciclosporin - calcium channel blockers
77
Other cause of gingival hyperplasia:
acute myeloid leukaemia
78
What is gingivitis usually secondary to and presentation?
- poor dental hygiene | - simple gingivitis or necrotising ulcerative gingivitis
79
Management gingivitis:
- simple gingivitis: dentist | - refer to dentist and oral metronidazole 3 days, chlorhexidine or hydrogen peroxide mouth wash, analgesia

ENT (3 decks)

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