ENT infectious (ear & nose) Flashcards
What are the 5 D’s which are signs of ear disease ?
- Deafness
- Discomfort
- Discharge
- Dizziness
- Din Din – tinnitus
What is tinnitus ?
Often described as rinning in your ears (basically hearing sound that comes from inside your body rather than outside)
Can also be described as:
- Buzzing
- Humming
- Grinding
- Hissing
- Whistling
What nerve is the most common caue of ear discomfort and why?
- CN IX
- Due to referred pain from the throat as its the main nerve which supplies there but it also supplies some of the ear
What are the 2 main causes of infections of the middle ear ?
Viral (most common) and bacterial
What are the common causative organisms of bacterial infections of the middle ear ?
Haemophilus influenzae, Streptococcus pneumoniae and Streptococcus pyogenes.
What type of discharge indicates external ear inflammation i.e. otitis externa?
Scanty watery discharge
What type of ear discharge is almost always due to middle ear disease ?
Mucous discharge (& if offensive think specifically cholesteatoma)
Define what CSF ottorhoea is
CSF otorrhoea is defined as leakage of cerebrospinal fluid (CSF) from the subarachnoid space into the middle ear cavity
What ear discharge would suggest CSF ottorhoea ?
CSF leaks following trauma - halo sign on filter paper, or discharge has increased glucose or Beta-2-transferrin present
What are the 2 types of otitis media & define them ?
- Acute = Acute inflammation of the middle ear
- Chronic = It is essentially inflammation with middle ear fluid of several months duration
Who is most commonly affected by middle ear infections ?
Infants and children
What are the symptoms of acute otitis media ?
Acute (middle ear inflammation):
- Rapid onset ear pain
- Fever +/- irritability
- Anorexia &/or vomiting
- Often occurs after preceding URTI (due to link between eustachian tube upper resp infections usually cause otitis media)
- Bluging tympanic membrane ==> if ruptures then purulent discharge (often settles in 48hrs)
- Slight hearing loss
How is a middle ear infection (otitis media) diagnosed ?
- No initial test - based on clinical evidence
- Only swab if tympanic membrane ruptures
When would you consider antibiotics for a middle ear infection ?
- Symptoms lasting > 4 days or not improving
- Systemically unwell but not requiring admission
- Immunocompromise or high risk of complications (secondary to significant heart, lung, kidney, liver, or neuromuscular disease)
- < 2 years with BOM
- Otitis media with perforation and/or discharge in the canal
What is the treatment of acute otitis media if Abx’s are given (note most resolve without in a few days with symptomatic treatment) ?
- 1st line - amoxicillin
- 2nd line - clarithromycin or erythromycin
What are the potential complications of Acute otitis media ?
- Mastoiditis (although rare)
- Even rarer = petrositis, labyrinthitis, facial palsy, meningitis & intracranial abscess
What is mastoiditis ?
- This is where middle ear inflammation leads to destruction of air cells in the mastoid bone +/- abscess formation
- Beware of intracranial extension
What are the signs of mastoiditis ?
- Fever
- Tender mastoid
- Protudring auricle (external ear) due to swelling/ bulging of mastoid area
What investigations and treatment should be done in someone with mastoiditis ?
- Ix = CT
- Tx = IV Abx + myringotomy +/- definitive mastoidectomy
What are the 2 types of chronic otitis media ?
- Glue ear/OME (otitis media with effusion)
- Chronic suppurative otitis media (with or without cholesteatoma)
What is OME/glue ear caused by?
Dysfunction of the eustacian tubes resulting in a build up of fluid in the middle ear due to fluid not being able to drain out of the eustacian tube. It is associated with URTI, oversized adenoids & narrow nasopharyngeal dimensions
What are some of the causes of OME ?
- Upper resp tract infections
- Overised adenoids
Who is OME most common in ?
Children:
- Boys
- Downs syndrome
- Winter season
- Atopy
- Children of smokers
- Primary ciliary dyskinesia
What is the chief cause of hearing loss of young children?
OME
What are the clinical features of OME?
Symptoms:
- Little pain
- Hearing loss noticed by parents
- Conductive hearing loss - can lead to poor speech & listening, laungage delay, inattention etc
Signs:
- Retracted or bulging tympanic membrane
- Dull, grey or yellow tympanic memrane
- Mya be bubbles or a fluid level at drum
- Decreased drum motility
W|hat investigations should be done in someone with OME and why?
- Audiometry - to look for conductive defect
- Tympanometry - assesses the ability of the eardrum to react to sound, and may be used to improve the accuracy of a diagnosis of otitis media with effusion (OME).
What is the treatment of OME ?
- 1st line = Explanation & reasurrance that most resolve + 3 month review
- 2nd line (if persistent bilateral OME + hearing level in better ear < 25-30dBHL confirmed over 3 months OR hearing loss less severe but learning difficulties prominent) = surgery with Myringotomy, and insertion of grommets +/- adenoidectomy
- 2nd line (if surgery unacceptable and have persistent bilateral OME + hearing loss) = hearing aids
What are the features of chronic supperative otitis media ?
- Intermittent discharge (because tympanic membrane has rupture & not fully healed) - non offensive if no cholesteatoma but if cholesteatoma then foul smelling
- Conductive hearing loss
- Usually little pain if not associated with cholesteatoma
What is a cholesteatoma ?
The presence of keratinising squamous epithelium within the middle ear, or in other pneumatised areas of the temporal bone.
What are the 2 main serious complications of a cholesteatoma ?
Meningitis & cerebral abscess
If chronic supperative otitis media is caused by a cholesteatoma what additions signs might be present and what does there presence indicate ?
- Headache, Pain, Facial paralysis, tinnitus & vertigo indicate impending CNS complications (cerebral abscess or meningitis)
- Ototscopy - any crusting or wax at the attic of the ear drum is a cholesteatoma until proven otherwise
How is a cholesteatoma diagnosed ?
CT + audiogram
What is the treatment of chronic supperative otitis media ?
- If without cholesteatoma tx = managed non operatively or a myringoplasty considered if symptoms troublesome.
- If presence of cholesteatoma tx = Mastoid surgery (needed to completely remove the disease)
Define what sinuisitis is
- Sinusitis is an inflammation of the membranous lining of one or more of the sinuses.
- Sinusitis is also referred to as rhinosinusitis because inflammation of the nasal mucosa generally accompanies sinusitis.
What are the main 2 classifications of sinusitis ?
- Acute = a bacterial or viral infection of the sinuses lasting fewer than four weeks and resolving completely with the appropriate management.
- Chronic: symptoms persist for >90 days (these may be caused by irreversible changes in the mucosal lining of the sinuses), with or without acute exacerbations.
What are episodes of acute sinusitis usually preceeded by ?
Most commonly preceeded by a non-resolving cold
How is acute sinusitis diagnosed ?
Clinical diagnosis based on if there is:
- Facial discomfort (fullness/pressure, often worse on bending forward) or pain over affected sinus
- Nasal obstruction or (purulent) nasal discharge or postnasal drip
- Decreased or absent sense of smell
List some of the additional signs/symptoms of acute sinusitis which may be present
- Headache.
- Halitosis.
- Fatigue.
- Dental pain.
- Cough.
- A feeling of pressure or fullness in the ears.
Describe the key differences between viral and bacterial sinusitis
- Viral = Mild discomfort over frontal or maxillary sinuses due to congestion
- Bacterial = severe pain and tenderness with purulent nasal discharge
What is the cause of most cases acute sinusitis ?
- Viral ==> self limiting
- But some are bacterial in origin ==> requiring antibiotics
What is the mainstay treatment of acute sinusitis ?
People presenting with symptoms for around 10 days or fewer should not be offered an antibiotic prescription. Supportive measures which can be used include:
- Paracetamol/ibuprofen for pain/fever.
- Intranasal decongestant Oxymetazoline (oral is not recommended for sinusitis) for a maximum of a week.
- Nasal irrigation with warm saline solution.
- Warm face packs, which may provide localised pain relief.
- Adequate fluids and rest.
- Intra-nasal corticosteroids may be considered if symptoms present > 10days
When antibiotics are required what is the treatment of bacterial sinusitis ?
- 1st line - penicillin V
- 2nd line - doxycycline
What are the potential causes of chronic sinusitis?
- Chronic sinusitis is multifactorial in nature and can include infectious, inflammatory, or structural factors.
- Thus, other aetiologies such as allergic rhinitis (dust mites, molds), exposures (airborne irritants, cigarette smoke or other toxins), structural causes (nasal polyps, deviated nasal septum), ciliary dysfunction, immunodeficiencies, and fungal infections should be considered
What are the signs/symptoms of chronic sinusitis ?
Same as acute sinusitis, just may be less florid
What is the treatment of chronic sinusitis ?
Refer to ENT specialist, tx may include:
- avoid allergen
- intranasal corticosteroids
- nasal irrigation with saline solution
What are the red flag symptoms for someone presenting with chronic sinusitis ?
- unilateral symptoms
- persistent symptoms despite compliance with 3 months of treatment
- epistaxis
(risk is that this is caused by nasopharyngeal carcinoma)
Who should tetracycline not be given to ?
Tetracyclines causes staining and occasionally dental hypoplasia, and they should not be given to children under 12 years, or to pregnant or breast-feeding women.
What is otitis externa ?
A condition that causes inflammation (redness and swelling) of the external ear canal
What are the 3 main causes of ottitis externa ?
- Infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
- Seborrhoeic dermatitis
- Contact dermatitis (allergic and irritant)
What are the fungal causes of otitis externa ?
- Aspergillus niger
- Candida albicans
Who does ottitis externa often affect ?
Swimmers as the ears are often wet increasing chances of bacterial infection
What are the presenting features of otitis externa ?
- Ear pain & tragal tenderness
- Itch
- Discharge (serous or purulent)
- Otoscopy: red, swollen, or eczematous canal
- May have temporary hearing loss (conductive)
What is the management of otitis externa ?
- If mild 1st line = acetic acid
- If moderate give 1st line = otomize or sofradex
- +/- for either can do aural toilet if lots of canal debris
If this doesn’t resolve take a swab for cultures then treated with topical which include corticosteroid based on results:
- For fungal use clomitrazole
- For bacterial - 1st gentamicin, 2nd ciprofloxacin (1st if tympanic membrane perforated)
Note acetic acid, otomize etc include antibiotic + corticosteroid
What features make otitis externa considered to be more severe i.e. mod-severe tx needed not mild
- a red, oedematous ear canal which is narrowed and obscured by debris
- conductive hearing loss
- discharge
- regional lymphadenopathy
- cellulitis spreading beyond the ear
- fever
If someone develops facial cellulitis due to spreading otitis externa what treatment needs to be given?
PO Flucloxacillin
What is malignant ottits externa ?
- Otitis externa infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal. It then Progresses to temporal bone osteomyelitis
- Malignant otitis, without treatment, is fatal.
- Osteomyelitis will progressively involve the skull and meninges
What is the usual cause of malignant ottitis ?
Pseudomonas aeruginosa
Who is malignant otitis externa most common in ?
Mainly found in immunocompromised individuals (90% cases found in diabetics)
What are the symptoms/signs of malignant otitis externa ?
- Diabetes (90%) or immunosuppression (illness or treatment-related)
- Severe, unrelenting, deep-seated otalgia
- Temporal headaches
- Exposed bone in the ear canal.
- Purulent otorrhea
- Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
How is malignant otitis externa diagnosed ?
CT
What is the treatment of malignant otitis externa ?
- Non-resolving otitis externa with worsening pain should be referred urgently to ENT (suspect malignant otitis externa)
- Tx requires IV Abx’s that cover pseudomonal infections
Ear wax is a normal physiological substance which helps protect the ear canal, however it can very commonly become impacted. What clinical features can impacted ear wax result in ?
- pain
- conductive hearing loss
- tinnitus
- vertigo
What is the treatment of impacted ear wax?
1st line = ear drops or irrigation (‘ear syringing’).
The following drops may be used:
- olive oil
- sodium bicarbonate 5%
- almond oil
When should treatment of impacted ear wax not be given?
If a perforation is suspected or the patient has grommets.
What are the causes of perforated ear drums ?
- Most commonly infection
- Barotrauma
- Direct trauma
What may a perforated tympanic membrane lead to ?
Hearing loss depending on the size
What is the management of a perforated tympanic membrane ?
- 1st line = no treatment, review as usually heals in 6-8 weeks, avoid getting ear wet.
- 2nd line = myringoplasty
