ENT Conditions Flashcards
Acute mastoiditis (key points, diagnosis, treatment)
Key point
● Rare but most common compilation of acute otitis media
Diagnosis:
● Post-auricular inflammatory signs (erythema, oedema, tenderness or fluctuance)
● Protruding auricle/external auditory canal oedema and signs of AOM
Treatment:
● IV Abx
● ENT involvement
Allergic rhinitis (classifications, clinical findings, management approach)
Classifications
- Intermittent: <4 days/week or <4 weeks
- Persistent: >4 days/week or >4 weeks
- Mild: sx present but not troublesome
- Mod to severe: present but causing disturbance
Clinical findings
● Nasal mucosa: oedematous and pale.
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Management tips
● Combining oral and intranasal antihistamine has no added benefit
● Advised to trial new treatments for 4 week prior to re-assessing
● Oral and nasal decongestants have no role in allergic rhinitis
Management approach
● Mild - oral or intranasal antihistamin
● Mod to severe - oral or intranasal antihistamine PLUS intranasal corticosteroid
*Continue to with minimum effective treatment as required
Allergic rhinitis (treatment options)
Oral
Less effective than intranasal sprays, consider alternatives in the group if not adequate response.
● Cetirizine 10mg PO daily
● Fexofenadine 120-180mg PO daily
● Loratadine 10mg PO daily
Intranasal
Antihistamine
More effective than the oral agents, have the fastest onset, can be used for intermittent symptoms.
● Azelastine 1mg/mL 1 spray each nostril BD
● Levocabastine 0.5mg/mL 2 sprays each nostril 2-4 times a day
Corticosteroid alone
● Useful in moderate to severe, more effective than oral antihistamines.
Combined
● Dymista (azelastine + fluticasone 125+50mcg, 1 spray each nostril BD)
Other
● Montelukast - used in combination with antihistamine and intranasal corticosteroid, may be first line in
children with asthma
○ ADRs: nightmares, sleep disturbance, agitation, depression and rarely suicidal thinking and
behaviour
● Ipratropium (intranasal) - use for marked rhinorrhoea, has rapid onset with prolonged effect (4-12 hours)
Eye drops
Use with oral antihistamines or intranasal corticosteroids and saline eye drops are effective.
● Antihistamine + mast cell stabiliser: Olopatadine 0.1% 1 drop both eyes BD
● Antihistamine: Levocabastine 0.05% 1 drop both eyes 2-4 times a day
● Mast cell stabiliser: Lodoxamide 0.1% 1 drop both eyes QID.
Allergen immunotherapy
Used in moderate to severe cases, more successful in patients with single sensitivity.
Course is is around 3 years with sublingual and subcutaneous options.
Audiology - patterns
** Refer to page 65-68 of GP Study Notes
Barotrauma (cause, symptoms, clinical findings, natural course)
Cause: Rapid changes in atmospheric pressure in the presence of occluded Eustachian tube
Symptoms: Temporary or persisting pain, deafness, vertigo, tinnitus +/- discharge
Clinical findings: Retraction, erythema, haemorrhage, fluid or blood in middle ear, perforation
Natural course: Spontaneous resolution.
Cholesteatoma (presentation, types)
Presentation: asymptomatic or hearing loss, dizziness and/or otorrhoea
● Hearing loss occurs late
Types:
● Primary - acquired, posterosuperior of TM
● Secondary - e.g. perforation, pearly mass behind ear behind TM
Thyroglossal duct cysts (location, epidemiology, clinical feature, presentation)
Location: Midline at level of thyrohyoid membrane
Epidemiology: Children or adolescents (most), >20 (⅓)
Clinical feature: Painless, moves with swallowing or protrusion of the tongue.
Presentation: Most present when there is a degree of infection or inflammation.
Brachial cleft cyst
Key points
● Present at birth
● Located anterior to sternocleidomastoid muscle
● Generally unrecognised until infected - late childhood or early adulthood
Dacryocystitis (definition, history, type, management)
Definition: Infection of the lacrimal sac secondary to obstruction of the nasolacrimal duct. History: Watery eyes (usually months). Type: ● Acute ● Chronic ○ Recurring episodes which may be associated with nontender mass ○ Can be superimposed with acute infection Management: ● Local hot moist compresses ● Analgesia ● Massage (mild cases) ● Systemic antibiotics (acute cases) ○ Cephalexin 500mg PO 6 hourly ● Surgery (if recurrent)
Dacryocystocele (findings, referral)
Key point
● Usually noted shortly after birth
Findings: Bluish swelling of the skin overlying the lacrimal sac and superior displacement of the medial canthal tendon.
Referral: Urgent review by ophthalmologist because of the risk of infection and/or nasal obstruction.
Dacryostenosis (prognosis, presentation, examination, diagnosis, management, referral indications)
AKA congenital nasolacrimal duct obstruction
Key point
● Most common cause of persistent tearing and ocular discharge in infants and young children.
Prognosis: Spontaneous resolution in more than 90% of cases.
Presentation: Intermittent tearing and debris on the eyelashes.
Examination: Increase in the size of the tear meniscus. Palpation of the lacrimal sac may cause reflux of tears and/or
mucoid discharge onto the eye.
Diagnosis: Clinical.
Management:
● First-line: Lacrimal sac massage and observation.
● If persisting 6-10 months: Lacrimal duct probing.
Indications to refer to ophthalmologist:
● Uncertain diagnosis (concern of infantile glaucoma)
● Symptoms persist past 6 months of age
● Signs and symptoms of acute dacryocystitis
● Clinical findings suggesting dacryocystocele
Ear Images - exotosis, tympanosclerosis, myringosclerosis plaque
** Refer to page 134-135 of GP Study Notes
Otitis externa (cause, aetiology, organism, history, examination, investigations, management, prevention)
AKA Swimmer’s ear
Cause: Decreased cerumen → increased water and debris retention → increased bacterial growth
Aetiology: summer due to increased swimming, secondary to atopic dermatitis, irritation secondary to chemicals e.g.
hair dye, trauma due to cleaning
Organism: Staphylococcus aureus, Pseudomonas and fungi are common.
History: ● Ear pain ● Conductive hearing loss ● Blockage/pressure ● Itchiness ● +/- discharge
Examination:
● Pain when moving tragus + pinna
● Ear canal
○ Common - moist + oedematous, filled with serous or purulent debris
○ Possible - erythema, dry, grey/black fungal plaque
Investigations: Nil required
Management: Analgesia + topical treatment (ear drop)
Prevention: 2% acetic acid drops (Aqua ear)
Otitis externa - management
Short-term
○ Dry aural toileting 6 hourly until external canal is dry (during and at least 2 weeks after)
○ Followed by ear drops (apply gentle pressure on the tragus for 30 seconds). Can insert wick in ear
canal if it is too blocked to help with administration. Consider oral antibiotics if fever, spread to
pinna or folliculitis.
■ Dexamethasone/Framycetin/Gramicidin 0.05%/0.5%/0.005% ear drops, 3 drops in
affected ear TDS for 7 days ** avoid if perforated tympanic membrane → risk inner ear
damage**
○ Analgesia - paracetamol 15mg/kg (max 1g) PO QID PRN
Long-term
○ Keep ear dry - ear plugs or bathing cap during shower/swimming
○ Use acetic acid plus isopropyl alcohol ear drops following exposure to water to prevent recurrent
otitis externa
Otitis media - shared decision making
● Reassure that it is a self-limiting condition and severe complications are rare
● Explain that initial antibiotic therapy is not essential but there can be two approaches:
○ Analgesia alone → follow up → consideration of ABx
○ Analgesia with initial ABx therapy
● Explain symptoms usually lasts for 2-3 days with or without antibiotics
● Discuss limited effect of antibiotic therapy (i.e. does not improve pain in first 24 hours, ABx only shortens by
12 hours)
