ENT - Lecture Flashcards
Broad aetiology of otalgia
External or middle ear pathology
Referred
- CN5, 7, 9, 10
- C2/3
Why is examination important
Drum condition is a good indicator of middle ear health
Patient is unlikely to have a normal drum with middle ear pathology
Inner ear conditions do not cause otalgia
Normal external ear examination = REFERRED PAIN
Specific aetiology of otalgia
Otological
- Acute OM
- Otitis externa
- Furuncle
- Necrotising otitis externa
Referred otalgia
- Dental pathology
- TMJ dysfunction
- Cervical OA
- Acute infections of the pharynx
- Malignancy of the pharynx and/or larynx
TMJ dysfunction
Causes otalgia as TMJ is close to ear
Causes
- Bruxism - Stress/anxiety
- Malocclusion - Overbite or underbite
Management - Analgesia
Oropharyngeal malignancy red flags
Otalgia
Dysphagia
Dysphonia
Otitis externa aetiology
Bacterial - PSEUDOMONAS
Fungal - Otomycosis
Otitis external signs and symptoms
Pain
Discharge
Associated with eczema/dermatitis
O/E
- Debris - White/creamy
- Oedema
- Stenosis
- Fungal - Green mould or black dots
Otitis externa management
Topical abx - GENTAMICIN or CIPROFLOXACIN
Fungal - CLOTRIMAZOLE
Micro-suction to remove debris
Otits externa prevention
Stop touching
NO COTTON BUDS
Keep ears dry
Treat underlying skin condition
ACETIC ACID
Furuncle
STAPH AUREUS abscess on hair follicles
Pain - Cannot stand examination
Management
- I+D
- FLUCLOXACILLIN
Necrotising malignant otitis externa
Potentially fatal osteomyelitis of the EAM and bony tympanic plate
May spread along inferior surface of skull base
NMOE signs and symptoms
Typically older DM patients
Severe unremitting pain
Purulent discharge
Single or multiple cranial neuropathies - CN7
O/E - Granulations at the isthmus of the EAM
NMOE management and complications
Management - Refer to ENT for debridement
Complications
- Meningitis
- Cerebral abscess
- Dural sinus thrombosis
Acute OM aetiology
Viral
- RSV
- Rhinovirus
- Parainfluenza
Bacterial
- Strep pneumoniae
- Haemophilus influenza
- Moraxella catarrhalis
CHILDREN HAVE SHORTER MORE HORIZONTAL EUSTACHIAN TUBES
Acute OM signs and symptoms
Preceding coryzal illness - Cough and rhinorrhoea
Pain
Deafness
Discharge
Systemic features - Fever and irritability
Acute OM examination findings
Middle ear inflammation
RED BULGING DRUM
Acute OM management
Self limiting - 48-72 hours
Abx do not affect outcome
Prescribe amoxicillin if…
- Systemically unwell
- Increasing pain
- No improvement after 72 hours
- Developing complication
Recurrent infections - Grommet insertion
Acute OM complications
Intracranial
- Meningitis
- Extradural, subdural, intracerebral abscess
- Lateral sinus thrombosis
Extracranial
- Mastoiditis
- Petrositis
- LMN - C7 palsy
- Labyrinthitis
- CHL or SNHL
- TM perforation
Ramsay-Hunt syndrome presentation
HERPES ZOSTER OTICUS
Severe pain
Vesicles on TM/pinna
Facial nerve palsy
Hearing loss
Ramsay-Hunt syndrome investigations
HERPES ZOSTER OTICUS
Check for corneal reflex
PCR for VZV
Pure tone audiogram
Grade the palsy
Ramsay-Hunt syndrome management
Corticosteroids
ACYCLOVIR
Eye protection
Vertigo
Hallucination of movement
Manifestation of inner ear dysfunction
BPPV
Benign positional paroxysmal vertigo
Positional rotational vertigo that lasts seconds
Management - EPLEY MANEUVER
Meniere’s disease
Episodic vertigo lasting minutes or hours
Associated with…
- Hearing loss
- Tinnitus
- Aural fullness
Meniere’s disease management
Salt restriction
Betahistine HCL- SERC
Anti-emetics
Chemical labyrinthectomy
Sinusitis signs and symptoms
Post-coryzal - Nasal congestion
Lasting days - Often recurrent
Dull throbbing pain and pressure - Worse on bending forward
- Forehead
- Cheeks
- Between the eyes
- Occipital
Acute sinusitis management
Analgesia - Sufficient for 80% cases
Intranasal decongestion - After 1 week
Saline irrigation
Consider intranasal steroid therapy if severe or prolonged
Antibiotics if bacterial or co-morbidity
Refer to hospital if suspected cranial involvement
OPD referral to ENT if >3 abx courses in 1 year
Acute sinusitis antibiotics
Amoxicillin
Penicillin
Doxycycline, erythromycin, clarithromycin
No improvement in 48 hours - Consider co-amox or azithromycin
Chronic sinusitis management
Intranasal steroid
Prolonged antibiotic course - Macrolide
Referral to ENT…
- Intranasal polypectomy
- Septal correction
- Functional endoscopic sinus surgery
Atypical facial pain signs and symptoms
Vague history
Changing symptoms
Unresponsive to various medications
History of depression or psychological disturbance
Atypical facial pain management
Amitriptyline
Gabapentin
Pregabalin
Epistaxis aetiology
Idiopathic
Coagulopathy
Rhinitis
Trauma
Neoplastic - Juvenile angiofibroma
Drugs - Aspirin or warfarin
Chronic granulomatous disease
- Wegener’s
- Sarcoid
Epistaxis management
ABC
Anterior and posterior rhinoscopy - Identify bleeding source
Nasal cautery - Silver nitrate
Nasal packing
- Anterior - Merocel or BIPP
- Posterior - Foley catheter
Epistaxis surgical management
Examination under GA - Ligation of artery
Anterior ethmoid
Sphenopalatine
Carotid
Angiography and embolisation
Tonsillitis aetiology
Viral
- Adenovirus
- Rhinovirus
- H. Influenza
- RSV
- EBV - 1-10%
Bacterial
- Strep pyogenes
- Staph aureus
- Strep pneumoniae
- Mycoplasma plenumoniae
- Chlamydia pneumoniae
CENTOR criteria
Cervical lymphadenopathy
Exudate
No cough
Temperature
< 15 (+1 point)
> 44 (-1 point)
0-1 points - No abx or culture
2-3 - Culture ± abx
4-5 - Abx therapy
Fever PAIN score
Fever
Purulence
Attend within 3 days of symptom onset
Inflamed tonsils
No cough or coryza
0-1 points - No abx
2-3 points - Consider delayed prescription
4-5 points - Consider abx
Bacterial tonsillitis management
Analgesia
Penicillin V
Erythromycin or clarithromycin
Rehydration
Admit if severe
Tonsillitis complications
Rheumatic fever Glomerulonephritis Scarlet fever Quinsy Retropharyngeal abscess
Tonsillitis investigations
Throat swab
Monospot test
EBV serology - IgG or IgM
FBC
Tonsillectomy indications
> 7 episodes of bacterial tonsillitis in 12 months
5 episodes in each of last 2 years
3 episodes in each of last 3 years
Peritonsillar abscess
Suspected malignancy
Sleep disordered breathing - Obstructive sleep apnoea
Thyroglossal cyst
More common in patients < 20
Usually midline - Between isthmus of thyroid and hyoid bone
Moves upwards with protrusion of tongue
Painful if infected
Reactive lymphadenopathy
Most common cause of neck swellings
History of local infection or generalised viral illness
Lymphoma
Rubbery painless lymphadenopathy
Night sweats
Splenomegaly
Pain on drinking alcohol - UNCOMMON
Thyroid swelling
May present with thyroid symptoms
Moves upwards on swallowing
Pharyngeal pouch
More common in older men
Posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not visible
May present as a midline lump in the neck that gurgles on palpation
Dysphagia
Regurgitation
Aspiration
Chronic cough
Cystic hygroma
Congenital lesion - Lymphangioma
Classically the left side of the neck
Mostly evident at birth
90% present before 2 years of age
Branchial cyst
Oval mobile cystic mass
Between sternocleidomastoid and pharynx
Failure of obliteration of second branchial cleft
Usually present in early adulthood
Cervical rib
More common in adult females
10% develop thoracic outlet syndrome
Carotid aneurysm
Pulsatile lateral neck mass
Doesn’t move on swallowing
Types of hearing loss
CHL - Disease affecting outer/middle ear
SNHL - Disease affecting cochlea or CN8
Mixed - Disease affecting both
Normal hearing physiology
Sound waves travel through EAC
Stimulate cochlear nerve
Air conduction > Bone conduction
Conductive hearing loss pathophysiology
Decreased transmission of sound to cochlea via air conduction
Sensorineural hearing loss pathophysiology
Sound is transmitted normally to the inner ear
CHL aetiology
Obstruction of EAC
Perforation of TM
Discontinuity of ossicular chain - Infection or trauma
Fixation of ossicular chain - Otosclerosis
Progressive SNHL aetiology
Bilateral
- Presbyacusis
- Drug ototoxicity
- Noise damage
Unilateral
- Meniere’s disease - Endolymphatic hydrops
- Acoustic neuroma
Sudden SNHL aetiology
Trauma
Impaired vascular flow (CVA)
Acoustic neuroma
Barotrauma and leakage of perilymph fluid from inner ear
Viral infections
- Mumps
- Measles
- VZV
