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Y4 special senses, neurology & dermatology > ENT conditions > Flashcards

ENT conditions Flashcards

1
Q

Otitis media with effusion (glue ear)

A

Characterised by a collection of fluid within the middle ear space without signs of acute inflammation

Most common cause of hearing impairment in childhood & most common between 6 months & 4 years

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2
Q

Otitis media with effusion (glue ear) pathophysiology

A

Eustachian tube connects the middle ear to back of the throat → helps drain secretions from the middle ear

When becomes blocked → causes middle ear secretions to build up in the middle ear space

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3
Q

Otitis media with effusion (glue ear) clinical features

A

Hearing loss - main symptom

Mild intermittent ear pain with fullness or ‘popping’ may occur

Tinnitus

Recurrent ENT infections

Otoscopy - dull tympanic membrane with air bubbles/visible fluid level

  • can look normal
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4
Q

Otitis media with effusion (glue ear) mx

A

Referral for audiometry to help establish diagnosis & extent of hearing loss

Usually treated conservatively & resolves without treatment within 3 months

Children with co-morbidities affecting structure of the ear (Down’s syndrome or cleft palate) → may require hearing aids or grommets

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5
Q

Grommets

A

Tiny tubes inserted into the tympanic membrane by an ENT surgeon

Allows fluid from middle ear to drain through the tympanic membrane to the ear canal

Usually fall out within a year & only 1/3 require further grommets to be inserted for persistent glue ear

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6
Q

Otitis media with effusion (glue ear) complications

A

Conductive hearing loss

Speech and language development issues

Chronic damage to tympanic membrane

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7
Q

Childhood hearing loss aetiology

A

Congenital - maternal rubella/CMV infection during pregnancy, genetic deafness, associated syndromes (eg. Down’s syndrome)

Perinatal - prematurity, hypoxia during/after birth

After birth - jaundice, meningitis & encephalitis, otitis media/glue ear, chemotherapy

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8
Q

Childhood hearing loss presentation

A

UK newborn hearing screening programme

Parental concerns about hearing

Behavioural changes associated with not being able to hear:

  • ignoring calls or sounds
  • frustration or bad behaviour
  • poor speech and language development
  • poor school performance
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9
Q

Childhood hearing loss mx

A

Establish diagnosis

MDT support:

  • SALT
  • educational psychology
  • ENT specialist

Hearing aids for children who retain some hearing

Sign language

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10
Q

Allergic rhinitis

A

Caused by an IgE-mediated type 1 hypersensitivity reaction

Environmental allergens cause an allergic inflammatory response in the nasal mucosa

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11
Q

Allergic rhinitis types

A

Seasonal - hay fever

Perennial (year round) - for example house dust mite allergy

Occupational - associated with school or work environment

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11
Q

Allergic rhinitis presentation

A

Runny, blocked and itchy nose

Sneezing

Itchy, red and swollen eyes

Associated with a personal/family history of other allergic conditions (atopy)

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12
Q

Allergic rhinitis mx

A

Avoid the trigger

Hoovering and changing pillows regularly & allowing good ventilation of the home can help with house dust mite allergy

Staying indoors during high pollen counts

Minimise contact with pets

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13
Q

Allergic rhinitis meds

A

Oral antihistamines are taken prior to exposure to reduce allergic symptoms:

  • non-sedating: cetirizine, loratadine & fexofenadine
  • sedating: chlorphenamine & promethazine

Nasal corticosteroid sprays: fluticasone and mometasone → can be taken regularly to suppress local allergic symptoms

Nasal antihistamines: good option for rapid onset symptoms in response to a trigger

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14
Q

Non-allergic rhinitis presentation

A

Stuffy or runny nose

Sneezing

Mucus in throat

Cough

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15
Q

Non-allergic rhinitis triggers

A

Irritants in the air

Weather

Infections

Foods and drinks - hot & spicy

Drugs - aspirin, ibuprofen, high BP medicines, hormone changes, sleep issues

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16
Q

Non-allergic rhinitis mx

A

Saline nose sprays

Antihistamine nasal sprays

Ipratropium nose spray - SE: nosebleeds & dryness

Decongestants

Steroids - SE: dry nose/throat, nosebleeds & headaches

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17
Q

Non-allergic rhinitis complications

A

Nasal polyps

Sinusitis

Trouble with daily life

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18
Q

BPPV

A

Condition characterised by sudden episodes of vertigo, typically following head movement

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19
Q

BPPV pathophysiology

A

Caused by crystals of calcium carbonate called otoconia that become displaced into the semi-circular canals

Occurs most often in the posterior semi-circular canal

May be displaced by a viral infection, head trauma, ageing or without a clear cause

Crystals disrupt the normal flow of endolymph through the canals

Head movement creates the flow of endolymph in the canals → triggers episodes of vertigo

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20
Q

BPPV clinical features

A

Vertigo attacks provoked by specific head movements → turning the head to one side while in bed/looking upwards

Episodes of rotational vertigo lasting between 30 seconds to 1 minute

Absence of auditory symptoms

Recurrent episodes, often resolving naturally over weeks to months

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21
Q

BPPV ix

A

Dix-Hallpike manoeuvre → will trigger rotational nystagmus & symptoms of vertigo

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22
Q

BPPV mx

A

Epley manoeuvre - idea is to move the crystals in the semi-circular canal into a position that does not disrupt endolymph flow

Brandt-Daroff exercises - can be performed by the patient at home to improve the symptoms of BPPV

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23
Q

Meniere’s disease

A

Inner ear disorder caused by increased fluid pressure in the endolymphatic spaces of the membranous labyrinth

Typically presents in individuals between the ages of 30 and 60 & predominantly affects only one ear

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24
Meniere’s disease clinical features
Unilateral episodes of vertigo, hearing loss and tinnitus Vertigo comes in episodes → last for 20 minutes to several hours before settling - episodes can come in clusters over several weeks, followed by prolonged periods without vertigo symptoms Hearing loss fluctuates first → becomes sensorineural, unilateral & affects low frequencies Tinnitus initially occurs with episodes of vertigo before eventually becoming more permanent → usually unilateral Other symptoms - sensation of fullness, unexplained falls without LOC, imbalance
25
Meniere’s disease diagnosis
Typically relies on clinical evaluation and audiometric testing
26
Meniere’s disease mx
Prophylactic use of betahistine to reduce the frequency of attacks Acute use of prochlorperazine to manage symptoms during attacks Diuretics → only prescribed by specialists Low-salt diets can also help prevent attacks, by reducing the volume of endolymphatic fluid
27
Acute labyrinthitis
Inflammation of the bony labyrinth of the inner ear, including the semi-circular canals, vestibule and cochlea Usually attributed to a viral URTI
28
Acute labyrinthitis presentation
Acute onset vertigo Hearing loss Tinnitus May have symptoms associated with the causative virus → cough, sore throat & blocked nose
29
Acute labyrinthitis diagnosis
Clinical diagnosis Head impulse test can be used to diagnose peripheral causes of vertigo
30
Acute labyrinthitis mx
Supportive care and short-term use of medication to suppress the symptoms Medications for managing symptoms: - prochlorperazine - antihistamines - cyclizine, cinnarizine, promethazine Abx - used to treat bacterial labyrinthitis
31
Vestibular neuronitis
Inflammation of the vestibular nerve Usually attributed to a viral infection
32
Vestibular neuronitis presentation
Acute onset of vertigo - recurrent attacks lasting hours/days History of recent viral URTI Horizontal nystagmus N&V Balance problems
33
Vestibular neuronitis mx
Prochlorperazine/antihistamines for managing symptoms → symptomatic treatment can be used for up to 3 days Vestibular rehabilitation therapy (VRT)
34
Rhinosinusitis
Acute = < 4 weeks Chronic = > 12 weeks Inflammation of the nose and paranasal sinuses
35
Rhinosinusitis aetiology
Viral Bacterial Fungal Allergies Auto-immune reactions Deviations/obstructions of the nasal septum
36
Rhinosinusitis clinical features
Nasal blockage/obstruction/congestion Nasal discharge Facial pain or heaviness Reduced olfaction Other symptoms - headache, ear pain, sore throat, cough
37
Rhinosinusitis ix
Nasal endoscopy - visual examination of the internal nasal passages & sinus openings CT - provides detailed images of the sinuses and can reveal evidence of sinus inflammation/obstruction Cultures - useful when bacterial sinusitis is suspected
38
Rhinosinusitis mx
Conservative - nasal saline irrigation, analgesics for pain, intranasal corticosteroids High-dose nasal corticosteroids - if symptoms > 10 days, a 14 day course of high-dose nasal corticosteroids may be considered Antibiotics - severe or persistent cases & guided by culture results
39
Acute otitis media (AOM)
Presents over a course of days to weeks, characterised by severe pain and visible inflammation of the tympanic membrane
40
AOM pathophysiology
Bacterial infection of the middle ear results from nasopharyngeal organisms migrating via the eustachian tube Anatomy of ET in younger children is short, straight & wide → infection is more likely
41
AOM organisms
Bacteria - S. pneumoniae - H. influenza - M. catarrhalis - S. pyogenes Viral - RSV - rhinovirus
42
AOM risk factors
Age (6-15 months) Males Passive smoking Bottle feeding Craniofacial abnormalities
43
AOM clinical features
Pain Malaise Fever Coryzal symptoms O/E - erythematous, bulging tympanic membrane, if fluid pressure has perforated TM → small tear visible with purulent discharge in auditory canal, conductive hearing loss, cervical lymphadenopathy
44
AOM mx
Majority resolve spontaneously within 24 hours Simple analgesics, ‘watch and wait’ approach Abx should be avoided unless significant deterioration or disease progression is seen (amoxicillin 5-7 day course) Inpatient admission for all children < 3 months with temp > 38, aged 3-6 months with a temp > 39 for further assessment, consider for evidence of an AOM complication/systemically unwell child
45
AOM complications
Mastoiditis - any suspected cases should be admitted for IV abx & CT head if no improvement after 24 hours - mastoidectomy if there is no improvement with IV abx Meningitis Facial nerve paresis Intracranial abscess Sigmoid sinus thrombosis Chronic otitis media
46
Cholesteatoma
Abnormal accumulation of skin and squamous epithelium within the middle ear cleft and mastoid air cells
47
Cholesteatoma pathophysiology
Chronic negative middle ear pressure from ET dysfunction Result of this = retraction pocket - initially self-cleansing but some may narrow & trap keratinised squamous cell debris → formation of a cyst-like structure → cholesteatoma Cholesteatomas can induce an inflammatory process in adjacent temporal bone - destruction of ossicles = conductive hearing loss - semi-circular canals = vertigo - cochlea = sensorineural hearing loss - facial canal = facial nerve palsy
48
Cholesteatoma risk factors
Male sex ET dysfunction Prior otological surgery
49
Cholesteatoma presentation
Persistent foul-smelling discharge Headaches Otalgia O/E - pearly, keratinised or waxy mass in the attic region
50
Cholesteatoma ix
Pure tone audiogram CT scan of the petrous temporal bone - guide clinical suspicion & for pre-op surgical planning
51
Cholesteatoma mx
Surgical → remove the entire cholesteatoma
52
Chronic otitis media (mucosal disease)
Inflammatory disorder of the middle ear, characterised by persistent or recurrent ear discharge Active mucosal disease = chronic discharge from the middle ear through a tympanic membrane perforation Inactive mucosal disease = tympanic membrane perforation but no active infection/discharge
53
Chronic otitis media (mucosal disease) pathophysiology
Chronic mucosal otitis media develops due to chronic inflammation secondary to a perforation in the tympanic membrane → cause of initial perforation may be infection, iatrogenic or trauma Associated discharge = chronic suppurative OM (CSOM)
54
COM risk factors
Recurrent acute otitis media Previous traumatic perforation of TM Insertion of grommets Craniofacial abnormalities
55
COM presentation
Discharge > 6 weeks Absence of fever or otalgia O/E: perforation in the tympanic membrane Hearing loss can occur, which is nearly always conductive hearing loss
56
COM ix
Audiograms & tympanometry Microbiological swabs for cultures & abx sensitivities Any suspicion of cholesteatoma → CT scan of petrous temporal bone for further assessment
57
COM mx
Aural toileting & topical abx/steroid treatment until symptoms resolve or reduce Referral to ENT specialist Large perforations → referral for surgical management - myringoplasty (closure of perforation in pars tensa) - tympanoplasty - myringoplasty combined with reconstruction of the ossicular chain
58
Sudden sensorineural hearing loss
Defined as hearing loss < 72 hours, unexplained by other causes Otological emergency & requires an immediate referral to the on-call ENT team Most often unilateral
59
SSHL aetiology
Idiopathic (90%) Infection Meniere’s disease Ototoxic medications MS, migraine, stroke Acoustic neuroma Cogan’s syndrome
60
SSHL ix
Audiometry - a loss of at least 30 decibels in three consecutive frequencies MRI/CT head - stroke/acoustic neuroma are being considered
61
SSHL mx
Immediate referral to ENT for assessment within 24 hours Treatment directed at underlying cause if found Idiopathic - steroids under the guidance of the ENT team - oral - intra-tympanic (via an injection of steroids through the tympanic membrane)
62
Presbycusis
Age-related hearing loss
63
Presbycusis risk factors
Age Male gender Family history Loud noise exposure Diabetes Hypertension Ototoxic medications Smoking
64
Presbycusis presentation
Gradual & insidious hearing loss - tends to affect high-pitched sounds first May be associated tinnitus
65
Presbycusis diagnosis
Audiometry - sensorineural hearing loss pattern with worsening hearing loss at higher frequencies
66
Presbycusis mx
Effects cannot be reversed Optimise the environment - reducing the ambient noise during conversations Hearing aids Cochlear implants - when hearing aids are not sufficient
67
Acoustic neuroma
Benign tumours of the Schwann cells surrounding the auditory nerve (also called vestibular schwannomas) Schwann cell = found in the peripheral nervous system & provide the myelin sheath around neurones Bilateral acoustic neuromas are associated with neurofibromatosis type II
68
Acoustic neuroma presentation
40-60 years old with gradual onset of: - unilateral sensorineural hearing loss - unilateral tinnitus - dizziness/imbalance - sensation of fullness in the ear May be associated with a facial nerve palsy if tumour grows large enough to compress the facial nerve
69
Acoustic neuroma ix
Audiometry - sensorineural pattern of hearing loss Brain imaging (MRI/CT) - used to establish the diagnosis & features of the tumour
70
Acoustic neuroma mx
Conservative management - may be used if there are no symptoms/treatment are inappropriate Surgery to remove the tumour (partial/total removal) Radiotherapy to reduce the growth
71
Acoustic neuroma mx complications
Vestibulocochlear nerve injury - permanent hearing loss/dizziness Facial nerve injury with facial weakness
72
Otosclerosis
Remodelling of the small bones in the middle ear → conductive hearing loss
73
Otosclerosis pathophysiology
Tiny bones in the middle ear are affected by abnormal bone remodelling and formation Mainly affects the base of the stapes, where it attaches to the oval window → stiffening & fixation and preventing it from transmitting sound effectively Conductive hearing loss
74
Otosclerosis presentation
Patient < 40 years w/ unilateral/bilateral: - hearing loss - tinnitus Tends to affect the hearing of lower-pitched sounds more than higher-pitched sounds Can talk quietly → due to bone conduction of their voice
75
Otosclerosis ix
Audiometry - initial investigation of choice - conductive hearing loss pattern - hearing loss tends to be greater at lower frequencies Tympanometry - reduced admittance (absorption) of sound High-resolution CT scan - detect bony changes associated with otosclerosis
76
Otosclerosis mx
Conservative - use of hearing aids Surgical - stapedectomy/stapedotomy - stapedectomy = removing the entire stapes bone & replacing it with a prosthesis - stapedotomy = removing part of the stapes bone & leaving the base of the stapes attached to the oval window
77
Otitis externa
Inflammatory condition affecting the skin of the external auditory meatus, characterised by minimal discharge, itchiness & pain
78
Otitis externa aetiology
Bacterial infection - pseudomonas aeruginosa & staph aureus Fungal infection Eczema Seborrhoeic dermatitis Contact dermatitis
79
Otitis externa presentation
Otalgia Minimal discharge Itchiness Pain due to inflammation Impaired hearing → meatus becomes blocked by swelling or discharge O/E - erythematous, swollen ear canal, pus/discharge, lymphadenopathy
80
Otitis externa mx
Mild - acetic acid 2%, can also be used prophylactically before & after swimming in patients that are prone Moderate - topical abx & steroid Severe - treated using a strip of ribbon gauze known as ‘pope’ wicks → can be used for the application of topical abx (classically gentamicin) enabling deeper penetration Microsuction of pus/debris which enables the drops to get to the source of the infection Oral abx - cellulitis extending beyond the external ear canal, ear canal occluded by swelling & debris, people with diabetes/compromised immunity with severe infection/high risk of severe infection
81
Necrotising otitis externa
Severe and potentially life-threatening form of otitis externa Infection spreads to the bones surrounding the ear canal and skull → progresses to osteomyelitis of the temporal bone of the skin
82
Necrotising otitis externa risk factors
Diabetes Immunosuppressant medications HIV
83
Necrotising otitis externa presentation
Deep seated severe ear pain Chronic ear discharge despite topical treatment Can have cranial nerve palsies (CN VII most common)
84
Necrotising otitis externa mx
Admission to hospital under the ENT team - emergency IV abx & topical treatment for an extended period of time to eradicate infection Imaging to assess the extent of the infection
85
Necrotising otitis externa complications
Facial nerve damage & palsy Other CN involvement - glossopharyngeal, vagus or accessory nerves Meningitis Intracranial thrombosis Death
86
Neck lumps red-flag referral criteria
2WW for: - unexplained neck lump in someone >45 - persistent unexplained neck lump at any age Urgent USS - patients with a lump that is growing in size
87
Neck lumps ix
Blood tests - FBC, blood film, HIV test, monospot test/EBV antibodies, TFTs, antinuclear antibodies, LDH Imaging - USS, CT/MRI, nuclear medicine scan Biopsy - FNA cytology, core biopsy, incision bioopsy, removal of the lump
88
Infectious mononucleosis
Cause of lymphadenopathy Most often affects teenagers & young adults → found in the saliva of infected individuals & may be spread by kissing/sharing cups, toothbrushes & other equipment that transmits saliva Caused by EBV virus Presents with: fever, sore throat, fatigue & lymphadenopathy - can present with an intensely itchy maculopapular rash in response to amoxicillin/cefalosporins Investigations - monospot test Supportive management - avoid alcohol & contact sports
89
Acute sialadenitis
May be viral/bacterial - bacterial - typically due to staphylococcal infection - viral - mumps, coxsackievirus, echovirus, HIV
90
Sialolithiasis
Stones in the salivary duct cause obstruction & subsequently lead to pain & swelling which is worse during meals
91
Sialolithiasis ix
Ultrasound Sialogram
92
Sialolithiasis mx
Conservative - analgesia - hydration - sialogogues Endoscopy Radiological removal Surgery - intraoral removal of palpable stones - removal of salivary gland Complications - sialadenitis - abscess formation
93
Sjogren’s syndrome
Autoimmune disease causing lymphocytic infiltration into the ductal tissue of the secretary glands Increased risk of developing lymphoma Primary - xerostomia & xerophthalmia Secondary - as primary disease, with connective tissue disease, most commonly RA Dx - history, examination, some specific autoantibodies & biopsy of minor salivary glands on the inner lip
94
Carotid body tumours
Formed by excessive growth of the glomus cells Present as a slow-growing lump that is: - upper anterior triangle of the neck - painless - pulsatile - associated with a bruit on auscultation - mobile side-to-side but not up and down Horner’s syndrome due to pressure on the sympathetic nerves Characteristic finding on imaging - splaying of the internal & external carotid arteries (lyre sign) Surgical removal = management
95
Lipoma
Benign tumours of fat tissue O/E - soft, painless, mobile, do not cause skin changes Typically treated conservatively with reassurance but can be surgically removed

Y4 special senses, neurology & dermatology (7 decks)

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