ENT AS Flashcards
What types of audiometry are there?
Pure tone audiometry (PTA)
Tympanometry
Evoked response audiometry
What is pure tone audiometry?
Headphones deliver tones at different frequencies and strengths in a sound-proofed room.
Patient indicates when sound appears and disappears.
What is tympanometry?
Measures stiffness of ear drum
- Evaluates middle ear function
Flat tympanogram: mid ear fluid or perforation
Shifted tympanogram: +/- mid ear pressure
What is an evoked response audiometry?
- Auditory stimulus with measurements of elicited brain response by surface electrodes
- Used for neonatal screening (if otoacoustic emission testing negative).
What is otitis externa presentation?
Watery discharge
Itch
Pain and tragal tenderness - acute main on moving the pinna.
Conductive hearing loss if lesion is large.
Inflammation is more likely to be severe if there is:
- a red, oedematous ear canal which is narrowed and obscured by debris
- conductive hearing loss
- Discharge
- Regional lymphadenopathy
- Cellulits
- Fever
Chronic otitis externa
- Chronic discharge from affected ear, hearing loss, and severe pain.
What are the risk factors of otitis externa ?
Moisture: e.g swimming
Trauma: e.g fingernails
Absence of wax
Hearing aid
What are the most common organisms for otitis externa?
Mainly pseudomonas
Staph Aureus
Management of otitis externa?
Mild cases (no deafness no discharg) topical acetic acid.
Aural toilet with drops
- Betamethasone for non-infected eczematous OE
- Betamethasone with neomycin
- Hydrocortisone with gentamicin
- Acidifying drops
Use flucloxacillin for uncomplicated otitis externa if systemic therapy was warranted.
If not responsive do a swab.
If they fail to respond refer to ENT urgently. This is despite strong analgesia therefore suggests malignant otitis externa
Poor response to topical antibiotics should be referred to ENT. This is for microsuction and insertion of a pope wick.
What is malignant otitis externa?
- Life-threatening infection which can –> skull osteomyelitis
- 90% of pts are diabetic (or other immune compromise)
Common in diabetics with pseudomonas infection.
Therefore need ciprofloxacin.
Presentation
- Severe otalgia which is worse @ night
- Copious otorrhoea
- Granulation tissue in the canal
Management
- Surgical debridement
- Systemic antibiotics
What is bullous myringitis ?
- Painful haemorrhagic blisters on deep meatal skin and TM
- Associated with influenza infection
What are the symptoms of TMJ dysfunction?
temporomandibular joint
- Earache (referred pain from auriculotemporal N)
- Facial pain
- Joint clicking/popping
- Teeth grinding (bruxism)
Signs
- Joint tenderness exacerbated by lateral movements of an open jaw
Investigations of TMJ dysfunction?
MRI
Management of TMJ dysfunction?
NSAIDS
Stabilising orthodontic occlusal prostheses.
What is the classification of otitis media?
Acute: Acute phase
Glue ear/OME: effusion after symptom regression
Chronic: effusion >3 months if bilateral or >6 months if unilateral
Chronic suppurative OM: Ear discharge with hearing loss and evidence of central drum perforation
What are the organisms for otitis media?
Viral
Strep Pneumococcus
Haemophilus influenza
Moraxella catarrhalis
Acute OM presentation?
Usually children post viral URTI
Secondary to eustacian tube dysfunction.
Rapid onset ear pain, tugging @ ear
Irritability, anorexia, vomiting
Purulent discharge if drum perforates. Green discharge more likely to be mucinous and OE.
O/E
- Bulging, red TM
- Fever
Management of Acute OM?
Paracetamol: 15mg/kg
Give antibiotics if:
- Symptoms lasting more than 4 days or not improving
- Immunocompromised
- Younger than 2 with bilateral otitis media
- Otitis media with perforation.
Amoxicillin: may use delayed prescription
What are the complications of otitis media?
Complications - Intratemporal OME Perforation of TM Mastoiditis Facial nerve palsy
- Intracranial
Meningitis/encephalitis
Brain abscess
Sub/epidural abscess
Systemic
- Bacteraemia
- Septic Arthritis
- IE
OME presentation?
Inattention at school
Poor speech development
Hearing impaired
o/e
- retracted dull TM
- Fluid level
Investigations for OME?
Audiometry: flat tympanogram
Management of OME?
Usually resolves spontaneously
- Consider grommets if persistent hearing loss
SE: infections and tympanosclerosis
Chronic suppurative OM?
Presents with painless discharge and hearing loss
o/e - TM perforation
Management
- Aural toilet
- Abx/Steroid ear drops
Complications
- Cholesteatoma. Those with cholesteatoma have a perforation of the pars tensa. Complain of intermittent discharge. IMpaired hearing and foul smelling discharge.
Mastoiditis presentation and management?
Middle-ear inflammation –> destruction of mastoid air cells and abscess formation.
Presents with
- Fever
- Mastoid tenderness
- Protruding auricle
- Bogguness of the space behind ear.
Imaging
- CT
Management
- IV abx
- Myringotomy ± mastoidectomy
What is a cholesteatoma?
Locally destructive expansion of stratified squamous epithelium within the middle ear.
Form in early childhood - repeated ear infection weakening the ear drum leading to it collapsing inwards. Developing into a cyst.
Classification
- Congenital
- Acquired: 2ndry to attic perforation in chronic suppurative OM.
Presentation of cholesteatoma?
**Foul smelling white discharge** Headache, pain CN involvement - Vertigo - Deafness - Facial paralysis
o/e of cholesteatoma?
Appears pearly white with surrounding inflammation.
Any crusting or ear wax obscuring the attic is a cholesteatoma until proven otherwise.
The attic is extremely important to visualise to see attic crust.
Never trust an attic crust.
Complications of cholesteatoma?
Deafness –> ossicle destruction
Meningitis
Cerebral abscess
Management of cholesteatoma?
Surgery
What is tinnitus?
Sensation of sound without external sound stimulation
Causes of tinnitus?
Specific
- Meniere’s
- Acoustic neuroma (hearing loss, vertigo, tinnutis, Absent corneal reflex). NF2.
- Otosclerosis (20-40yrs, conductive deafness, tinnitus, normal tympanic membrane)
- Noise-induced - typically high range (3,000-6,000)
- head injury
- Hearing loss - presbyacusis
General
- Increased BP
- decreased Hb
Ototoxicity is my FAV.Q&A Furosemide Aminoglycoside (gentamicin, neomycin) Vancomycin Quinine Aspirin
History of tinnitus?
Character: constant, pulsatile
Unilateral: acoustic neuroma
FH: otosclerosis
Alleviating/exacerbating factors: worse @ night
Associations
- Vertigo: Meniere’s, acoustic neuroma
- Deafness: Meniere’s, acoustic neuroma
Cause: head injury, noise, drugs, FH
Examination of tinnitus?
Otoscope
Tuning fork tests
Pulse and BP
Investigation of tinnitus?
Audiometry and tympanogram
MRI if unilateral to exclude acoustic neuroma
Management of tinnitus?
Treat any underlying causes
Psych support: tinnitus retraining therapy
Hypnotics @ night may help.
What is vertigo?
The illusion of movement
Causes of peripheral/vestibular vertigo?
Peripheral/Vestibular?
Meniere’s = Hearing loss, tinnitus, sensation of fullness or pressure in one or both ears. >30 mins but lasts few hours.
BPPV = Gradual onset, triggers by change in head position. Each episodes lasts 10-20 s.
Viral Labyrinthitis = Recent viral infection. Sudden onset, N+V. Hearing may be affected. = Days.
Vestibular neuronitis (No Hearing loss) = Recent viral infection, recurrent vertigo attacks lasting hours or days. No hearing loss.
Central causes of vertigo?
- Acoustic neuroma
- MS
- Vertebrobasilar insufficiency/stroke
- Inner ear syphilis
Drugs
- Gentamicin
- Loop diuretics
- Metronidazole
- Co-trimoxazole
History of vertigo?
Is it true vertigo or just light-headedness - Which way are things moving
Timespan
Associated symptoms: n/v, hearing loss, tinnitus, nystagmus
Examination of vertigo and tests?
- Hearing
- Cranial nerves
- Cerebellum and gait
- Rombergs +ve = vestibular or proprioception
- Hallpike manoeuvre
- Audiometry, calorimetry, LP, MRI.
Meniere’s Disease?
Dilatation of endolymph space of membranous labyrinth (endolymphatic oedema)
Presents with
- Attacks occur in clusters up to 12hrs
- Progressive SNHL (sensorineural hearing loss)
- vertigo and n/v
- Tinnitus
- Aural fullness
- Romberg’s test +ve.
- Lasts minutes to hours
Ix
- Audiometry shows low-freq SNHL which fluctuates
Management
- Medical = Vertigo: Cyclizine, betahistine
acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required
prevention: betahistine and vestibular rehabilitation exercises may be of benefit
- Surgical = Gentamicin instillation via grommets, saccus decompression.
What is vestibular neuronitis
/viral labyrinthis?
Vestibular neuritis = only vestibular nerve so no hearing impairment
Labyrinthitis = vestibular nerve and labyrinth are involved.
Both
- Follows febrile illness
- Sudden vomiting
- Horizontal nystagmus
- No hearing loss of tinnitus
- Severe vertigo exacerbated by head movement
DDx
- Viral labyrinthitis (includes hearing loss)
/posterior circulation stroke (HiNTs exam helps to tell apart)
Management
- Vestibular rehabilitation exercises are preferred treatment for patients who experience chronic symptoms
- A short oral course of prochlorperazine or an antihistamine (cinnarize, cyclizine, promethazine) may be used to alleviate less severe cases.
- Buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases. FOR THE ACUTE PHASE. Delays recovery.
What is BPPV?
Displacement of otoliths in semicircular canals
Common after head injury
Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients.
Features
- vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
may be associated with nausea
- each episode typically lasts 10-20 seconds
- positive Dix-Hallpike manoeuvre
Management
- Epley manoeuvre
- Teaching patient exercises they can do themselves.
Presentation of BPPV
Sudden rotational vertigo for <30s
- Provoked by head turning
Nystagmus
Causes by: idiopathic, head injury, otosclerosis, post-viral
Diagnosis
- Hallpike manoeuvre –> Upbeat-torsional nystagmus
Management
- Self-limiting
- Epley manoeuvre
- Betahistine: histamine analogue
What is conductive hearing loss?
Impaired conduction anywhere between auricle and round window
What is conductive hearing loss caused by?
External canal obstruction
- Wax, pus, foreign body
TM perforation
- trauma, infection
Ossicle defects
- Otosclerosis
- Infection
- Trauma
Sensorineural adult hearing loss?
Defects in the cochlea, cohlear nerve or brain.
Drugs
- Aminoglycosides
- Vancomycin
Post-infective
- Meningitis
- Measles
- Mumps
- Herpes
Misc
- Meniere’s
- Trauma
- MS
- CPA lesion (acoustic neuroma)
- Decreased B12
What is an acoustic neuroma?
Benign, slow-growing tumour of superior vestibular nerve
Acts as SOL –> CPA
- Associated with NF2
What is the presentation of acoustic neuroma?
Should also be considered in patients with unilateral sensorineural deafness or tinnitus.
- Slow onset, unilateral SNHL, tinnitus ± vertigo. Absent corneal reflex.
- Headache (Increased ICP)
- CN palsies:
5, = Absent corneal reflex
7, = Facial palsy
8. = vertigo, unilateral sensorineural hearing loss, unilateral tinnitius. - Cerebellar signs
Investigations
- MRI of cerebellopontine angles (Gadolinium-enhanced)
- MRI all patients with unilateral tinnitus/deafness
PTA (pure tone audiometry)
Differential
- Meningioma
- Cerebellar astrocytoma
- Mets
Management
Refer urgently to ENT.
- Gamma knife
- Surgery (risk of hearing loss)
Otosclerosis?
AD condition characterised by fixation of stapes at the oval window
F>M = 2:1
Presentation of otosclerosis?
Begins in early adult life
Bilateral conductive deafness + tinnitus. Key is bilateral.
HL improved in noisy places: Willis’ paracousis
Worsened by pregnancy/menstruation/menopause
Investigations of otosclerosis?
PTA shows dip (Caharts notch) @ 2kHz
