ENT COPY Flashcards
What are the 3 bones in the middle ear called?
Malleus
Inucus
Stapes
What are the 2 muscles in the middle ear called?
Stapedius muscle
Tensor tympanic muscle
What are the 2 functions of the inner ear?
To convert mechanical signals from the middle ear into electrical signals for conduction via nerve
To maintain balance by detecting position and motion
How can you tell the difference between conductive and sensorineural hearing loss?
Weber’s test - Vibrating 256Hz tubing fork. Louder in the abnormal hear in conductive hearing loss and in the normal ear in sensorineural hearing loss.
Rinne’s test - Vibrating 256Hz tubing fork. Normally louder when held at external acoustic meatus than on mastoid bone. Opposite in conductive hearing loss.
What are the most common bacterial causes of acute otitis media?
haemophilus influenzae
streptococcus pneumoniae
moraxella catarrhalis
streptococcus pyogenes
How does acute otitis media present?
Pain
Fever
Irritability
Discharge from affected ear (if perforated)
TM appearance for acute otitis media?
Red, bulging, oedematous
Pus seen behind TM
Treatment for acute otitis media?
Analgesia
Watchful waiting
Delayed prescription of amoxicillin 5 days
What are the risk factors for otitis media with effusion (glue ear)?
Age 1-6 years Older sibling Male Parental smoking Day care attendance Immune deficiency Allergy
Location in which part of the tympanic membrane is most likely to lead to mastoiditis?
Periphery, specifically upper ear drum
How does glue ear present?
(Otitis media with effusion)
Ear pain Hearing loss (mispronouncing words, speech delay)
TM appearance for otitis media with effusion?
Opaque ear drum
Loss of light reflex
Indrawn/retracted TM
What is the management of otitis media with effusion?
Watch and wait for 3 months as most resolve
Surgery (grommets) is:
- persistent bilateral OME >3 months
- hearing loss >25dB in best ear
- language, educational, social developmental delay
Adenoidectomy if recurrent
What is chronic suppurative otitis media?
Ear with tympanic membrane perforation in setting of recurrent or chronic infections
Recurrent infections -> ulceration and oedema -> breakdown of epithelial lining
Risk factors for chronic suppurative otitis media?
Multiple AOM episodes
Living in crowded environment
Day care
Congenital abnormality eg cleft lip/palate, down’s syndrome
How does chronic suppurative otitis media present?
> 2 weeks ear discharge (bloody)
Hearing loss
Ear pain
Ear fullness
What is the management of chronic suppurative otitis media?
Keep dry
Aural cleaning
topical quinalone: ciprofloxacin
What are the complications of chronic suppurative otitis media?
Cholesteatoma Chronic hearing loss Mastoiditis Labyrinthitis Abscess formation Facial paralysis
Common causative pathogens of otitis external?
Pseudomonas
Escherichia coli
Staphylococci
Risk factors for otitis externa?
Swimming/Water sports Humidity Trauma Cotton bud use Diabetes Immunosuppression
What is the presentation of otitis externa?
Ear pain Itching Purulent discharge Pre-auricular lymphadenopthy \+/- hearing loss \+/- fever
Investigation for otitis externa
Swab discharge for MC+S
Management of otitis externa
All: aural cleaning
mild: hydrocortisone cream on pinna, ear calm spray (2% acetic acid ) as anti-fungal
mod: topical Abx and steroid drops (otosporin)
Severe: ear wick
Referral to ENT for diagnosis and exclusion of complications
Complications of otitis externa
Temporary hearing loss
Chronic otitis externa
Necrotising OE
Cellulitis
Causes of referred ear pain
Tonsillitis
Cervical arthritis
TMJ disorders
What score’s are used to determine if a patient needs antibiotics for tonsillitis?
Centor score or FeverPAIN
What factors are taken into consideration on the centor score?
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- History of fever (over 38°C)
- Absence of cough
What is the 1st choice antibiotic for tonsillitis?
Pen V (phenoxymethylpenicillin)
What is the first 1st line antibiotic for tonsillitis in a penicillin allergic patient?
Erythromycin or clarithromycin
How might you treat a patient systematically unwell with tonsillitis?
IV Benzylpenicillin stat
Steroids
IV Fluids
What is Ramsay Hunt Syndrome?
Herpes zoster oticus
Acute peripheral facial neuropathy associated with erythematous vesicular rash of the skin of the ear canal.
Infection of the facial nerve (CNVII)
What pathogen causes Ramsay Hunt Syndrome?
Varicella Zoster Virus
Symptoms of Ramsay Hunt Syndrome?
PURPLE acronym
P - Pain in face, head, ear or mouth
U - Unsteady (vertigo/dizziness)
R - Red rash, vesicles in mouth, ear, throat, hairline
P - Palsy (LMN facial palsy, forehead not spared)
L - Loss of hearing, tinnitus
E - Exception, there is not always a rash)
Treatment of Ramsay Hunt Syndrome?
Acyclovir
Steroids
Analgesia
Complications of Ramsay Hunt Syndrome?
Lasting neurological damage in approx 30%.
Investigations for Ramsay Hunt Syndrome?
Bloods: Antibodies for VZV
Saliva: PCR for VZV
MRI: Inflammation of facial nerve
What is mastoiditis?
Inflammation of the mastoid lining of the mastoid antrum and mastoid air system inside the mastoid process of the temporal bone.
What organisms are the most common cause of mastoiditis?
streptococcus pneumoniae
streptococcus pyogenes
staphylococcus aureus
moraxella catarrhalis
What is the clinical presentation of mastoiditis?
Red, painful, swollen mastoid process
Fever
Ear pain
Headache
Investigation for mastoiditis
Blood cultures
MRI - to confirm diagnosis and look for extra cranial complications
Fluid from middle ear due to perforated drums or by intervention (tympanocentesis) for MC+S
LP - if intracranial spread is suspected
Management of mastoiditis
IV broad spec antibiotics eg ceftriaxone
Analgesia
Surgery (myringotomy +/- tympanostomy) to drain pus from middle ear
Complications of mastoiditis
Hearing loss due to labyrinthitis, facial nerve palsy, abscess formation, meningitis, epidural or brain abscess
Through what 2 anatomical connections can bacteria gain access to the membranous labyrinth?
Between CNS and subarachnoid space via internal auditory canal and cochlear aqueductThrough congenital or acquired defects of the bony labyrinth
How does labyrinthitis present?
Sudden, spontaneous, severe and incapacitating vertigo. Not triggered by movement but can be exacerbated by movement.
N+V
Hearing loss
Tinnitus
What investigations would you do for labyrinthitis?
MC+S if ear discharge
CT of temporal bone
Management of labyrinthitis
Antiemetics eg prochlorperazine (buccal or deep intramuscular injection if severe)
Surgery: Myringotomy
Complications of labyrinthitis
Falls
Unilateral hearing loss
BPPV
What condition is associated with acoustic neuromas?
Neurofibromatosis type 2
What is the inheritance of neurofibromatosis type 2?
Autosomal dominance
What cell type to acoustic neuromas arise from?
Schwaan cells
How would an acoustic neuroma present?
Progressive tinnitus ± sensorineural deafness
Larger tumours - increased ICP symptoms
Any trigeminal involvement - numb face
+ear ache, balance changes
Investigations for acoustic neuroma?
Audiogram
MRI
What types of drugs can cause hearing loss?
Aminoglyosides (gentamycin, streptomycin, neomycin)
NSAIDS
Loop diuretics
Quinine
What is the most common bacterial cause of pharyngitis?
Group A streptococcus
What investigations can be done for patients with suspected pharyngitis?
Rapid antigen test for GAS
Throat swab for MMC+S
What is the antibiotic of choice for confirmed group a strep pharyngitis?
Phenoxymethylpenicillin
Presentation of quinsy
general: fever, malaise
mouth: saliva drooling, bad breath, trismus,
Pain: throat, swallowing, ear, head
What symptom indicates pharyngitis over tonsillitis?
Trismus
What is the management of quinsy?
Same day referral to ENT IV fluids Analgesia IV antibiotics Needle aspiration, incision and drainage
What condition is characterised by the triad of vertigo, tinnitus and hearing loss?
Meniere’s disease
What is the most common salivary gland tumour?
Pleomorphic adenoma
Benign, slow-growing, rubbery
2 most common locations for epistaxis to occur
Ant bleed: Kiesselbach’s plexus (Littles area) - ant/post ethmoid arteries, superior labial art and greater palatine art.
Post bleed: sphenopalatine artery - underlying pathologies like HTN
What are the 5 parts of the temporal bone?
Mastoid Styloid process Tympanic bone Squamous part Petrous part
Differentials for parotid swelling
Pleomorphic ademoma Parotid abscess Lymphoma Adenocarcinoma of the parotid Parotid adenitis
What is taken into account in the FeverPAIN score?
Fever >38 Purulent exudate Acute Inflamed tonsils (severely) No cough
Nerves responsible for referred ear pain
CN V: dental disease and TMJ dysfunction
CN VII: geniculate herpes
CN IX/X: posterior 1/3rd of tongue, pyriform fossa, larynx, throat (tonsillitis)
C2 C3: neck soft tissue injury and cervical spondylosis/arthritis
What is a cholesteatoma and how is it managed?
Ingrowth of skin of eardrum in sac form
Skin in middle/outer ear meant to be respiratory but becomes squamous
Treatment: Mastoidectomy
What is osteosclerosis?
new bone growth causes fusion of stapes footplate to oval window
How would you manage osteosclerosis?
hearing aid
surgery: stapedectomy or stapedotomy
How would you manage Menieres disease
prochlorperazine for acute attacks
Betahistine prophylaxis
Grommet.
Why would you avoid prescribing amoxicillin in a patient with tonsillitis?
Causes pathognomonic rash in anyone whos illness due to EBV
21 year old female with several week hx of malaise and fatigue now has a sore throat, OE you also notice a macular non pruritic rash on her back, what is your suspected diagnosis?
Infective mono nucleosis
What is the most common organism to cause mononucleosis
EBV
How does mononucleosis present?
Fever, fatigue, malaise (can last several months)
Sore throat: enlarged tonsils, exudative
Macular non pruritic rash
Lymphadenopathy
Nausea and anorexia
Later signs: hepato/splenomegaly, jaundice
mononucleosis investigations
- Monospot test and Paul-Bunnell test: detects heterophile antibodies, positivity increases during first 6 weeks (could be -ve early)
- If -ve for heterophile antibodies after 6 weeks but have symptoms = heterophile negative IM - test for EBV specific antibodies
how would you manage mononucleosis?
Avoid contact sports for 3 weeks incase splenic rupture Avoid alcohol Paracetamol IV fluids steroids if tonsils super big
why would you not prescribe amoxicillin in mono?
Causes pathognomonic rash- EBV
