ENT History and Management Flashcards
What should you ask in a history of hearing loss?
Onset
Progression
Degree of hearing loss and pitch of loss - difficulty following conversations or hearing TV?
Headaches? Vertigo? Nausea and vomiting? Tinnitus? Pain and discharge from the ear?
Popping/clicking? Fullness?
Recent infection?
IMPACT ON QUALITY OF LIFE
What are the 3 most common causes of hearing loss?
ear wax, otitis media and otitis externa
The most common causes of hearing loss are ear wax, otitis media and otitis externa.
Give 6 other causes
Presbycusis
Otosclerosis
Otitis media with effusion (Glue ear)
Drug ototoxicity
Meniere’s disease
Acoustic neuroma
What should you ask in a history of otalgia?
Where is it?
Does it radiate?
Can you describe the pain? Burning/aching/sapping/pinching?
How severe is it? Does it wake you in the night?
When did it come on? Did it come on gradually or suddenly?
Is it there all the time or is it intermittent? Progression?
Have you had anything like this before?
Does anything make it worse? (e.g. swallowing or jaw movement)
Have they inserted anything into the ear e.g. cotton swabs?
Secondary sxs
What secondary symptoms should you ask about in a history of otalgia?
- Discharge/ bleeding from the ear?
- Itching?
- Change in hearing?
- Headache/sensation of fullness?
- Any other symptoms of infection e.g. runny nose, sore throat, cough
What should you cover in a PMHx of otalgia?
- Recent ear infections or URTI
- Recent trauma
- Dental status (if associated w jaw pain)
What questions should you ask in an ENT history to screen for malignancy?
Screen for ENT malignancy:
New headaches
Problems breathing through your nose / blocked nose
Nosebleeds
Any difficulty swallowing
New neck lumps
Speech
What should you ask in a history of vertigo?
“When did the dizziness first start?”
“Did the dizziness start suddenly (over a few seconds)?”
- identify patients who have experienced a hyper-acute (over a few seconds) onset of their symptoms, which can be a marker of an acute vascular event (e.g. posterior stroke)
Describe the dizziness - world spinning? light-headed?
Any triggers e.g. change in head position?
Other symptoms - N+V? tinnitus? hearing loss? fullness in ears? popping or clicking? headaches? recent infections?
Give some causes of vertigo
Migraine
BPPV
Meniere’s disease
Sudden-onset sensorineural hearing loss
Vestibular neuronitis
Viral labyrinthitis
Ear Wax
Rare: acoustic neuroma
NEVER MISS: TIA/ posterior circulation stroke
How should you take a history of a patient with a new neck lump?
When did it come on? Progression over time? Change in size or shape?
Is the lump painful? Tender to touch?
Been poorly recently? Fever? Sore throat? Anyone else with similar symptoms?
Weight loss? Night sweats?
Chronic cough? Dysphagia? Hoarseness?
Bothered by bad breath?
Give some ddx for a neck lump
congenital: branchial cyst, thyroglossal cyst, dermoid cyst, vascular malformation
inflammatory: reactive lymphadenopathy, lymphadenitis
neoplastic: lymphoma, thyroid tumour, salivary gland tumour
What may you find on otoscopy of acute otitis media?
bulging tympanic membrane → loss of light reflex
opacification or erythema of the tympanic membrane
perforation with purulent otorrhoea
decreased mobility if using a pneumatic otoscope
What is the biggest risk factor for developing a cholesteatoma?
cleft palate (increases risk by 100 fold)
What clinical criteria is commonly used for dx of otitis media?
acute onset of symptoms (otalgia or ear tugging)
presence of a middle ear effusion
inflammation of the tympanic membrane (erythema)
How can acute otitis media be managed?
generally a self-limiting condition that does not require antibiotics
good analgesia
advise to return if worse / not improved after 2 days
When should patients with otitis media receive abx?
Symptoms for > 4 days or not improving
Systemically unwell
Perforation and/or discharge in the canal
Younger than 2 years with bilateral otitis media
Immunocompromise or high risk of complications
What abx can be given for prolonged / complicated otitis media?
5-7 day course of amoxicillin is first-line
erythromycin or clarithromycin if pencillin allergic
What are the potential complications of acute otitis media?
mastoiditis
meningitis
brain abscess
facial nerve paralysis
How may allergic rhinitis present?
sneezing
nasal pruritus
bilateral nasal obstruction
clear nasal discharge
post-nasal drip
How can allergic rhinitis be managed?
allergen avoidance
mild-to-moderate sxs:
oral or intranasal antihistamines
moderate-to-severe sxs:
intranasal corticosteroids
a short course of oral corticosteroids are occasionally needed to cover important life events
Short courses of topical nasal decongestants (e.g. oxymetazoline) can be used to control allergic rhinitis.
Why can longer courses not be prescribed?
increasing doses are required to achieve the same effect (tachyphylaxis)
rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal
How do cholesteatomas present?
foul-smelling, non-resolving otorrhea
hearing loss
local invasion:
vertigo
facial nerve palsy
cerebellopontine angle syndrome
How can cholesteatomas be investigated and managed?
Otoscopy: ‘attic crust’ - seen in the uppermost part of the ear drum
Management: referred to ENT for consideration of surgical removal
What can cause severe hearing loss in children?
Genetic (up to 50% of cases)
idiopathic (up to 30% of childhood deafness)
Infectious e.g. post meningitis
Congenital e.g. maternal CMV, rubella or varicella
What can cause severe hearing loss in adults?
Viral-induced sudden hearing loss
Ototoxicity e.g. aminoglycoside antibiotics or loop diuretics.
Otosclerosis
Meniere disease
Trauma
Give some causes of neck lumps
Reactive lymphadenopathy
Lymphoma
Thyroid swelling
Thyroglossal cyst
Branchial cyst
Pharyngeal pouch
Cystic hygroma
Cervical rib
Carotid aneurysm
How does presbycusis present?
age-related sensorineural hearing loss
patients may describe difficulty following conversations
Audiometry shows bilateral high-frequency hearing loss
How does otosclerosis present?
Autosomal dominant replacement of normal bone by vascular spongy bone
onset at 20-40 years
conductive deafness
tinnitus
tympanic membrane - 10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
positive family history
How does glue ear present?
peaks at 2 years of age
hearing loss (commonest cause of conductive hearing loss childhood)
secondary problems such as speech and language delay, behavioural or balance problems may also be seen
How does Meniere’s disease present?
Multiple episodes last Minutes to hours
recurrent episodes of vertigo, tinnitus and sensorineural hearing loss
sensation of aural fullness or pressure
other features include nystagmus and a positive Romberg test
How do acoustic neuromas present?
cranial nerve V (trigeminal): absent corneal reflex
cranial nerve VII (facial): facial palsy
cranial nerve VIII (vestibulocochlear): hearing loss, vertigo, tinnitus
How can impacted ear wax be managed?
What are the contraindications to the usual first line mx?
ear drops or irrigation (‘ear syringing’)
olive oil
sodium bicarbonate 5%
almond oil
tx should not be given if a perforation is suspected or the patient has grommets
How does otitis media with effusion present?
peaks at 2 years of age
hearing loss (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood)
secondary problems such as speech and language delay, behavioural or balance problems
How can otitis media with effusion be managed?
first presentation of otitis media with effusion is active observation for 3 months - no intervention is required
grommet insertion
adenoidectomy
Give some ddx for a patient presenting with new hoarseness of their voice
voice overuse
smoking
viral illness
hypothyroidism
gastro-oesophageal reflux
laryngeal cancer
lung cancer
Mastoiditis typically develops when an infection spreads from the middle to the mastoid air spaces of the temporal bone.
How does it present?
otalgia: severe, classically behind the ear
fever
may be a history of recurrent otitis media
the patient is typically very unwell
Examination findings for mastoiditis?
swelling, erythema and tenderness over the mastoid process
the external ear may protrude forwards
ear discharge may be present if the eardrum has perforated
How can mastoiditis be investigated and managed? Complications?
Clinical dx / CT if complications suspected
Mx: IV antibiotics
Complications:
facial nerve palsy
hearing loss
meningitis
Meniere’s disease is a disorder of the inner ear characterised by excessive pressure and progressive dilation of the endolymphatic system.
How does it present?
Meniere’s in Middle Age
episodes last Minutes to hours
typically unilateral
recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural)
a sensation of aural fullness
nystagmus and a positive Romberg test
How can Meniere’s disease be managed?
ENT assessment
patients should inform the DVLA
cease driving until satisfactory control of symptoms is achieved
acute attacks: buccal or IM prochlorperazine
prevention: betahistine and vestibular rehabilitation exercises may be of benefit
What are your top differentials for a patient with a new parotid lump? How would you ask about these?
Pleomorphic adenoma
Mumps
Dental Infection
Salivary glands stones
Sjogrens
Recent infection
Problems with teeth/ gums
Painful ? Worse when eating?
Dry mouth? Dry eyes?
Change in sensation in your face? Changes in facial movement? Change in hearing?
