ENT conditions Flashcards
Describe Bell’s palsy
Acute, unilateral facial nerve weakness or paralysis of rapid onset & unknown cause
Most common between 15 and 45 years of age
List the symptoms of Bell’s palsy
Rapid onset (<72 hours)
Facial muscle weakness involving the upper and lower parts of the face
Ear and postauricular region pain on the affected side
Difficulty chewing, dry mouth & changes in taste
List the complications of Bell’s palsy
Eye injury
Facial pain
Dry mouth
Intolerance to loud noises
Abnormal facial muscle contraction during voluntary movements
Describe the diagnosis of Bell’s palsy
Can be made when no other medical condition is found to be causing facial weakness/paralysis
Have the typical symptoms of Bell’s palsy
Atypical features of Bell’s palsy require referral for exclusion of an alternative diagnosis
List differentials of Bell’s palsy
Stroke – forehead will be spared
Brain tumour
Traumatic injury to the facial nerve
Infectious – herpes simplex, Lyme disease, otitis media
Describe the management of Bell’s palsy
Advice: prognosis is good -> most people recover within 3-4 months, keep affected eye lubricated, wear sunglasses when outdoors, tape eye closed if they can’t close it at night
Treatment (people presenting within 72 hours): consider prescribing prednisolone
Refer urgently if there are worrying symptoms
Describe benign paroxysmal positional vertigo (BPPV)
A disorder of the inner ear characterised by repeated episodes of positional vertigo (symptoms occur with changes in the position of the head)
Most common cause of vertigo in clinical practice, most commonly 50-70s females
List symptoms of BPPV
Symptoms are brought on by specific movements & positions of the head relative to gravity
Vertigo occurs in transient episodes (usually last less than one min)
N&V
Hearing NOT affected & tinnitus NOT a feature
Describe the diagnosis of BPPV
Relevant symptoms
Examination – likely to be normal at rest in a sitting position, positive Dix-Hallpike manoeuvre
Investigations not usually required
List differentials of BPPV
Vestibular neuritis
Labyrinthitis
Meniere’s disease
Describe the management of BPPV
Advice: most people recover over several weeks, even without treatment, simple repositioning manoeuvre, advise person not to drive when they are suffering vertigo
Management: offer a particle repositioning manoeuvre (Epley manoeuvre) -> ideally this should be done at the first presentation; consider suggesting Brandt-Daroff exercises which person can do at home
Follow up in 4 weeks if symptoms have not resolved
What is a cholesteatoma?
Abnormal sac of keratinising squamous epithelium & accumulation of keratin within the middle ear/mastoid air cell spaces which can become infected & erode neighbouring structures
List symptoms of a cholesteatoma
Recurrent/chronic purulent aural discharge, may be unresponsive to abx treatment
Hearing loss or tinnitus
Less common – otalgia, vertigo or facial nerve involvement
Describe the diagnosis of cholesteatoma
Relevant symptoms
If suspected, ask the person about any pre-existing ear disease/surgery
Examination (requires clear visualisation of the tympanic membrane) – ear discharge, deep retraction pocket in the tympanic membrane, crust/keratin in the upper part of the tympanic membrane
List differentials of cholesteatoma
Otitis media with effusion
Otitis externa
Tympanosclerosis
Describe the management of cholesteatoma
Arrange urgent referral to ENT – investigations carried out will include an audiology assessment and a CT scan
Prior to surgical treatment, aural discharge may be treated with topical abx (canal wall up mastoidectomy)
Emergency admission – facial nerve palsy/vertigo, other neurological symptoms/signs that could be associated with development of an intracranial abscess/meningitis
What is glandular fever?
Infection most commonly caused by EBV
Spread mainly through contact with saliva eg. kissing or sharing food and drink, spread during sexual contact
Lifelong latent carrier state
Most common aged 15-24 years
Describe the symptoms of glandular fever
Fever
Lymphadenopathy
Sore throat (usually severe)
Prodromal symptoms: lasts for several days & includes general malaise, fatigue, myalgia, chills
Non-specific rash
List complications of glandular fever
Upper airways obstruction
Splenic rupture
Neutropenia
Immunocompromised – may result in malignancies eg. Hodgkin’s lymphoma, nasopharyngeal carcinoma
List differentials of glandular fever
Streptococcal sore throat
Local infection or inflammation
Lymphoma or metastatic solid tumour
Cytomegalovirus primary infection
Describe the management of glandular fever
Use paracetamol and/or ibuprofen
Advice: symptoms usually last 2-4 weeks, exclusion from work/school is not necessary, return to normal activities as soon as possible
Advise the patient to seek urgent medical advice if:
- Develop stridor
- Difficulty swallowing/have signs of dehydration
- Become systemically very unwell
- Develop abdominal pain
What is Meniere’s disease?
Disorder affecting the inner ear which can affect balance and hearing
Clinical syndrome characterised by episodes of vertigo, fluctuating hearing loss & tinnitus, associated with a feeling of fullness in the affected ear
Unknown cause
Describe the diagnosis of Meniere’s disease
No specific diagnostic tests – based on presence of key clinical features
Definitive diagnosis requires all of the following:
1) Vertigo – at least two spontaneous episodes lasting 20 minutes to 12 hours
2) Fluctuating hearing, tinnitus and/or perception of aural fullness in affected ear
3) Hearing loss (sensorineural) confirmed by audiometry
Refer to ENT services to confirm the diagnosis of Meniere’s disease
List differentials of Meniere’s disease
Acoustic neuroma
Multiple sclerosis
Perilymph fistula
Migraine
BPPV
Describe the management of Meniere’s disease
Advice – reassurance that vertigo significantly improves with treatment, acute attack will normally settle within 24 hours, don’t drive whilst dizzy
Acute attack – hospital admission may be required for IV labyrinthine, use buccal/IM injection of prochlorperazine or IM injection of cyclizine to rapidly relieve N&V
Prevention – trial of betahistine, if this does not work, refer to ENT
Describe otitis externa
Diffuse inflammation of the skin and sub-dermis of the external ear canal, which may also involve the pinna or tympanic membrane
Outline the types of otitis externa
1) Acute otitis externa is inflammation (< 6 weeks) typically caused by bacterial infection with Pseudomonas aeruginosa/staphylococcus aureus
2) Chronic otitis externa is inflammation (> 3 months) which may be caused by fungal infection with Aspergillus species or Candida albicans
NB: malignant otitis externa is potentially life-threatening progressive infection of the external ear canal causing osteomyelitis of the temporal bone & adjacent structures
Describe the diagnosis of acute otitis externa
Usually rapid-onset within 48 hours:
-itch of the ear canal
-ear pain & tenderness of the tragus and/or pinna
-ear discharge
-hearing loss due to ear canal occlusion
At least two typical signs: tenderness of tragus and/or pinna, ear canal is red & oedematous, typical membrane erythema, cellulitis of pinna and adjacent skin
Describe the diagnosis of chronic otitis externa
Typical symptoms: constant itch in the ear, mild discomfort or pain
Typical signs: lack of ear wax in the external ear canal, dry scaly skin in the ear canal (often resulting in at least partial canal stenosis), conductive hearing loss
List differentials of otitis externa
Acute otitis media
Foreign body in the ear
Impacted ear wax
Skin conditions – contact dermatitis, eczema, fungal skin infection
Describe the management of acute otitis externa
Self-care measures: avoid damage to external ear canal, keep ears clean and dry, over-the-counter ear drops/spray
Manage underlying causes or risk factors
Consider prescribing a topical antibiotic preparation with/without a topical corticosteroid for 7-14 days
Arrange follow-up if symptoms don’t get better
Describe the management of chronic otitis externa
Analgesics
Arrange ear swab & arrange treatment depending on the result
Consider cleaning the external auditory canal
Consider prescribing a topical ear preparation (if fungal = a topical antifungal preparation/clioquinol/corticosteroid)
What is acute otitis media?
Defined as the presence of inflammation in the middle ear, associated with an effusion & accompanied by the rapid onset of symptoms and signs of an ear infection
Common condition caused by both viruses and bacteria
List complications of acute otitis media
Recurrence of infection
Hearing loss
Tympanic membrane perforation
Rarely: mastoiditis, meningitis
List the symptoms of acute otitis media
Older children & adults: earache
Younger children: holding, tugging & rubbing of ear & other non-specific symptoms eg. crying, fever and poor feeding
List the examination findings of acute otitis media
Tympanic membrane – red, yellow/cloudy tympanic membrane
Moderate to severe bulging of the tympanic membrane, with loss of normal landmarks & an air-fluid level behind the tympanic membrane (middle ear effusion)
Perforation of the tympanic membrane and/or discharge in EAC
List differentials of acute otitis media
Otitis media with effusion (glue ear)
Chronic suppurative otitis media
Myringitis
Describe the management of acute otitis media
Advise the usual course of acute otitis media is about 3 days, but can be up to 1 week
Paracetamol/ibuprofen for pain
What is chronic suppurative otitis media?
Chronic inflammation of the middle ear and mastoid cavity
Presents with recurrent ear discharged through a tympanic perforation for at least 2 weeks
Complication of acute otitis media
Describe the presentation of chronic suppurative otitis media (CSOM)
Ear discharge > 2 weeks, without ear pain or fever
Hearing loss in affected ear
History of AOM, ear trauma, glue ear & grommet insertion
History of allergy, atopy, URTI
Tinnitus and/or sensation of pressure in ear
List red flag symptoms in a person with CSOM
Headache
Nystagmus
Vertigo
Fever
Labyrinthitis
Facial paralysis
Swelling/tenderness behind the ear
List differential diagnoses of CSOM
Otitis externa
ASOM
Otitis media with effusion
Foreign body
Describe the management of suspected CSOM
Any red flag symptoms – urgent assessment by ENT specialist
Others: refer for ENT assessment (likely to involve abx, steroids, intensive cleaning)
Advise to keep affected ear dry & dry mopping the affected ear will help to clean discharge from ear
What is otitis media with effusion?
Also known as ‘glue ear’
Characterised by a collection of fluid within the middle ear space without signs of acute inflammation
Most common cause of hearing impairment in childhood
Describe the presentation of otitis media with effusion
History – hearing loss (mishearing, difficulty communicating in a group, asking for things to be repeated), mild intermittent ear pain with fullness, aural discharge, recurrent ear infections
Examination – can be serous, mucoid or purulent & more likely if one or more of the following are present: abnormal colour of drum, loss of light reflex, opacification of drum, air bubbles or air/fluid level
List differentials diagnoses of otitis media with effusion
Acute otitis media
Mastoiditis
Otitis externa
Describe the management of otitis media with effusion
Active observation for 3 months is appropriate for most children, as spontaneous resolution is common -> during this time, re-evaluate signs and symptoms of the effusion & look for any complications
-includes two hearing tests using pure tone audiometry at least 3 months apart & tympanometry
Describe mastoiditis
Inflammation of the mastoid air cells within the petrous temporal bone
Complication of acute otitis media with infection spreading from the middle ear into the mastoid air cells -> abscess formation -> several life-threatening sequelae
Describe the typical presentation of mastoiditis
Children – ear pulling, ear pain, non-specific symptoms of systemic upset, persistent fever despite oral abx
Adults – severe otalgia, otorrhoea, headache, hearing loss
Examination – post-auricular erythema, tenderness, swelling; proptosed auricle, loss of post-auricular sulcus, evidence of sepsis
List the differential diagnoses of mastoiditis
Acute otitis media
Post-auricular lymphadenopathy
Cellulitis/perichondritis
What is vestibular neuronitis?
Disorder characterised by acute, isolated, spontaneous & prolonged vertigo of peripheral origin
Due to inflammation of the vestibular nerve & often occurs after a viral infection
Describe the symptoms of vestibular neuronitis
Spontaneous onset of vertigo, nausea, vomiting & unsteadiness
NO hearing loss, tinnitus and focal neurological signs
List differential diagnoses of vestibular neuronitis
BPPV
Labyrinthitis (similar, but also involves tinnitus & hearing loss)
Meniere’s disease
Central causes eg. migraine, stroke, cerebellar tumour
Describe the management of vestibular neuronitis
Reassure the person that symptoms will usually settle over several weeks
Advise that bed rest may be necessary if symptoms are particularly severe during the acute phase
Advice on safety issues – not to drive when dizzy, inform employer if affects work, falls at home
