ENT - Level 2 Flashcards
1
Q
Definition of otitis externa?
A
- Inflammation of external ear canal
o Localised = folliculitis that can progress to become boil in canal
o Diffuse = inflammation of skin and sub-dermis in canal and tympanic membrane - Acute (<3 weeks), chronic (>3 months)
2
Q
Defintion of malignant otitis externa?
A
o Aggressive infection affecting immunocompromised or DM or elderly which spreads to bone surrounding ear canal
3
Q
Epidemiology of otitis externa?
A
- Prevalence increases at end of summer
- Common >1% diagnosed per year
- Women > Men
4
Q
Causative organisms of otitis externa?
A
- Bacterial o S.Aureus o Pseudomonas sp. - Fungal o Aspergillus o Candida Albicans
5
Q
Other causes of otitis externa?
A
- Seborrhoeic Dermatitis
- Contact dermatitis (irritant or allergen)
- Trauma (scratching, aggressive, ear syringing, foreign objects, cotton buds)
- Swimming
- High humidity
- Narrow ear canal
- Hearing aids
6
Q
Symptoms of otitis externa?
A
- Minimal discharge
- Itch
- Pain – made worse by moving pinna
- Hearing Loss
- Tender regional lymphadenitis
7
Q
Signs of otitis externa?
A
- Otoscopy o Red canal with swelling, shedding of scaly skin o White or yellow pus in canal o Struggle to see tympanic membrane - Lymphadenopathy of pre-auricular nodes - Pyrexia
8
Q
Symptoms of chronic otitis externa?
A
- Lack of earwax
- Dry hypertrophic skin, partial stenosis of canal
- Pain on manipulation of external ear canal
- Constant itch and discomfort
9
Q
Symptoms of malignant otitis externa?
A
- Granulation tissue at bone-cartilage junction of ear canal
- Facial nerve palsy
- Temperature >39
- Severe pain and headache
- Vertigo
- Profound hearing loss
10
Q
Diagnosis of otitis externa?
A
- Clinical Diagnosis
11
Q
When to swab ear in otitis externa?
A
o Treatment fails, recurrent or chronic
o Infection spread or severe enough for oral antibiotics
12
Q
Management of otitis externa - general measures?
A
Self-Care Advice • Avoid swimming, cotton buds, foreign objects down ear • Keep ears clean and dry Paracetamol and ibuprofen PRN Local heat with warm flannel
13
Q
Management of otitis externa - medical therapy?
A
Acetic Acid 2%
• For mild cases
Topical antibiotic with/without topical corticosteroid
• Gentamicin, neomycin or Chloramphenicol with steroid (Otomize, Betnesol)
• 7-14 days
Oral antibiotics if cellulitis beyond ear canal to pinna, fever, systemic signs of infection, DM or immunocompromised:
• 7-day course of flucloxacillin (or clarithrymycin)
14
Q
Management of otitis externa - when to ear swab?
A
Treatment failure Recurrent or chronic Topical treatment cannot be delivered Infection spread beyond EAC Need oral antibiotics
15
Q
Management of otitis externa - when to refer?
A
Symptoms not improved despite treatment
Cellulitis extensive
Pain extreme
Micro-suction or ear wick insertion required
Requiring incision and drainage of furuncle
16
Q
Management of otitis externa - when to refer urgently?
A
o Referral urgently if malignant otitis externa suspected:
Unremitting pain, otorrhoea, fever or malaise
Granulation tissue at bone-cartilage joint of ear canal
Facial nerve paralysed
Temperature >39
17
Q
Management of chronic otitis externa - if fungal nfection suspected?
A
Topical clotrimazole 1% solution/acetic acid 2% spray/
Seek specialist advice if inadequate response
18
Q
Management of chronic otitis externa - if irritant or allergic dermatitis?
A
Advise person to avoid contact with irritant or allergen
Give topical corticosteroid
19
Q
Management of chronic otitis externa - if seborrheoic dermatitis?
A
Topical antifungal/corticosteroid combination
20
Q
Management of chronic otitis externa - if no evident cause?
A
7 days topical corticosteroid with acetic acid spray
21
Q
Management of chronic otitis externa - when to refer?
A
Does not respond to treatment
Contact sensitivity suspected
Ear canal occluded
Malignant otitis is suspected
22
Q
Complications of otitis externa?
A
- Abscess
- Chronic otitis externa
- Fibrosis
- Myringitis
- Tympanic membrane perforation
23
Q
Prognosis of otitis externa?
A
- Symptoms usually improve within 48-72 hours of initiation of treatment
- Resolves within 7-10 days
24
Q
What is ear wax?
A
- Ear wax = normal physiological substance that protects ear canal
- Combination of sheets of desquamated keratin squames (dead, flattened cells on outer layer of skin), cerumen (wax-like substance produced by ceruminous glands), sebum and foreign substances
25
Function of ear wax?
o Aids removal of keratin
o Cleans, lubricates and protects lining of ear canal – trapping dirt and repelling water
o Antibacterial properties
26
Epidemiology of ear wax?
- Most common ENT procedure in primary care – ear wax removal
- Dry wax is dry, flaky and golden-yellow and common in Asian people
27
Risk factors of ear wax?
```
o Narrow or deformed ear canal
o Hairs in ear canal
o Osteomata
o Dermatological disease in peri-auricular area
o Elderly
o Recurrent otitis externa
o Cotton wool bud use/Hearing aids
```
28
Symptoms of ear wax?
- Mainly asymptomatic
- Symptoms include:
o Blocked ears
o Ear discomfort
o Feeling of fullness in ear
o Tinnitus
o Itchiness
o Vertigo
29
Signs of ear wax?
- Signs on otoscopy
| o Wax in ear canal (may occlude whole canal)
30
Management of ear wax - when to remove?
o Totally occluding canal and symptoms present
o If tympanic membrane is obscured by needs to be viewed to establish diagnosis
o If hearing aid impression needing to be fit
31
Management of ear wax - general advice?
o Do not insert anything into ear as can damage structures
| o Ear candles has no benefit in management
32
Management of ear wax - safety net?
o If develop earache, itching, discharge from ear, swelling of ear canal come back
33
Management of ear wax - how to remove ear wax?
o Ear drops (olive oil 3-4 times a day for 3-5 days) to soften wax
o Ear irrigation
• Electronic ear irrigator
• Angle so flow is along top of posterior wall
34
Management of ear wax - contraindications of removing ear wax?
* Hx of previous problem
* Current perforation or in last 12 months
* Grommets in place
* Hx of ear surgery
* Mucous discharge from ear
* Middle ear infection in previous 6 weeks
* Acute otitis externa
35
Management of ear wax - complications of removing ear wax?
• Failure, otitis externa, perforation, pain, vertigo
36
Management of ear wax - if irrigation unsuccessful?
o Use drops for further 3-5 days and return for repeat irrigation
o Instil water into ear – then irrigate after 15 minutes
o Refer to ENT specialist
37
Management of ear wax - when to refer?
o Before irrigation if – chronic perforation, history of ear surgery, foreign body
o If irrigation unsuccessful
o Severe pain, deafness or vertigo
o Infection present
38
Management of ear wax - recurrent ear wax?
o Ear drops regularly (sodium bicarbonate, sodium chloride, olive oil, almond oil)
o Irrigation or referral for manual extraction if needed
39
Complications of ear wax?
o Conductive hearing loss
| o Discomfort
40
Categories of hearing loss?
o Conductive – occurs due to abnormalities of outer or middle ear which impairs conduction of sound waves from external ear (pinna, ear canal or tympanic membrane) through ossicles to cochlear
o Sensorineural – abnormalities in cochlear, auditory nerve or structures in neural pathway leading to auditory cortex
o Mixed
41
Severity of hearing loss?
o Mild – 25-39dB
o Moderate 40-69dB
o Severe – 70-94dB
o Profound - >95dB
42
Epidemiology of hearing loss?
- Prevalence increases with age
| - Most common is age related hearing loss
43
Causes of conductive hearing loss?
Impacted earwax
Foreign Bodies
Tympanic membrane perforation
Infection (otitis media and externa)
Middle ear effusion
Cholesteatoma
Otosclerosis (abnormal bone growth affecting ossicles)
Neoplasms (SCC of external ear, vascular glomus tumour)
Exostoses (hard, bony growths in ear canal)
44
Causes of sensorineural hearing loss?
Age-related (presbycusis) – most common
Noise exposure
Sudden sensorineural hearing loss (within 72 hours)
Meniere’s disease
Ototoxic substances (gentamicin, bumetanide, furosemide, NSAIDs, aspirin, quinine, chloroquine, cisplatin, bleomycin, cigarettes, mercury, lead)
Labyrinthitis
Vestibular Schwannoma (Acoustic Neuroma)
MS, stroke
Malignancy (intracranial or nasopharyngeal)
Infections (CMV, toxoplasmosis, syphilis, meningitis, HIV, Lyme disease HZV)
Autoimmune (RA, SLE, sarcoidosis, Wegeners granulomatosis)
Hereditary (Alports syndrome)
45
Symptoms of prebycusis?
o Bilateral high-frequency hearing loss after 50 years old
| o May be unaware and need TV higher or cannot hear people
46
Symptoms of noise-related hearing loss?
o Hx of exposure to persistent high levels of noise
| o Associated with tinnitus
47
Symptoms of sensorineural hearing loss?
o Bilateral hearing loss within 72 hours
| o May have tinnitus, sensation of fullness in ear and vertigo
48
Symptoms of labyrinthitis?
o Tinnitus and vertigo common
49
Symptoms of acoustic neuroma?
o Gradual onset, unilateral hearing loss associated with tinnitus and vertigo
50
Assessment of hearing loss?
```
o History
o Examination
o Otoscopy
o Weber Test
o Rinne’s Test
o Cranial Nerve and Cerebellar tests
```
51
Weber test used in hearing loss? what is positive test?
512Hz tuning fork, strike one side on padded surface or ball of hand
Place vibrating tuning fork on person’s forehead for 4 seconds
Ask person where tone is heard – centrally, left or right
• If centrally – suggests symmetrical hearing loss
• In poorer ear – suggests asymmetrical conductive hearing loss
• In better ear – suggests asymmetrical sensorineural hearing loss
52
Rinne's test used in hearing loss? What is positive test?
512Hz tuning fork, strike one side on padded surface or ball of hand
Hold tuning fork 2.5cm from entrance to ear canal for 2s then press footplate firmly over mastoid and hold for 2s
Ask person if tone is louder next to ear or behind ear
• If better/louder by air conduction (next to ear) – Rinne’s positive and suggests sensorineural hearing loss or normal hearing
• If better/louder by bone conduction (held on mastoid) – Rinne’s negative and suggests conductive hearing loss in that ear
53
Further investigations in hearing loss?
o Audiology assessment if underlying systemic condition
54
Management of hearing loss - when to refer immediately?
o Sudden onset (<72 hours) unilateral or bilateral hearing loss within 30 days and not explained by external or middle ear causes
o Unilateral hearing loss associated with focal neurology
o Hearing loss with head/neck injury
o Necrotising otitis externa or Ramsay Hunt Syndrome
55
Management of hearing loss - when to refer within 2 weeks?
o Sudden onset (<72 hours) unilateral or bilateral hearing loss over 30 days ago and not explained by external or middle ear causes
o Rapidly progressive hearing loss not explained by external or middle ear cause
o Suspected head and neck malignancy
56
Management of hearing loss - when to refer routinely?
o Unilateral or asymmetric gradual onset hearing loss
o Fluctuating hearing loss not with URTI
o Hearing loss associated with hyperacusis
o Hearing loss associated with persistent tinnitus which is:
Unilateral – acoustic neuroma, Meniere’s disease, otosclerosis
Pulsatile – intracranial vascular tumours, aneurysms, carotid atherosclerosis
Changed significantly
Causing distress
o Hearing loss with persistent or recurrent vertigo
o Hearing loss not age related
57
Management of hearing loss in primary care - initial management?
Exclude/treat ear wax, acute ear infection, middle ear effusion due to URTI
```
Audiological Assessment
If sensorineural confirmed and no underlying causes requiring further investigation by ENT
• Hearing aids
• Assisted listening devices (ALDs)
• Cochlear implants
Follow up 6-12 weeks
```
Refer for diagnostic assessment
58
Management of hearing loss in primary care - general measures?
Reduce competing noises
Soft furnishings improve sound quality if hearing aid used
Ensure adequate lighting to help with communicating
59
Management of hearing loss in secondary care - investigations?
MRI to adults with hearing loss and localising symptoms or signs (facial nerve weakness) indicating vestibular schwannoma
Audiology assessment
• Bloods – FBC, ESR, CRP, U&E, LFT, TSH, autoimmune profile, clotting, glucose
• Audiometry and brainstem responses
• High-dose steroids
60
Management of hearing loss in secondary care - non-induced hearing loss?
* Reduced occupational risk
| * Tinnitus retraining therapy
61
Management of hearing loss in secondary care - otosclerosis?
* Hearing aid
| * Surgery – stapedectomy, stapedotomy
62
Management of hearing loss in audiological services - what hearing devices are available?
Hearing Aids
• If hearing loss affects ability to communicate and hear
• Offer 2 if both ears affected
Assisted Listening Devices
• Personal loops, personal communicators, TV amplifiers, telephones devices, smoke alarms, doorbell sensors
Implantable Devices
• Cochlear Implants
63
Follow up in audiological services?
6-12 weeks after hearing aids fitted
64
Definition of acoustic neuroma?
- Tumour of vestibulocochlear nerve (CN8) arising from Schwann cells of nerve sheath
- Typically benign and slow-growing
65
Risk factors of acoustic neuroma?
o Neurofibromatosis
| o High-dose ionising radiation
66
Presentation of acoustic neuroma?
o Unilateral sensorineural hearing loss – considered acoustic neuroma until proven otherwise
Progressive onset
o Impaired facial sensation
o Balance problems
o Large tumours give cerebellar signs or raised ICP
67
Investigations of acoustic neuroma?
o Audiology assessment
| o MRI scan – for all with unilateral hearing loss
68
Management of acoustic neuroma - observation?
Small neuromas and good preserved hearing
| Annual scans to monitor growth – if detected then active management
69
Management of acoustic neuroma - surgery?
Microsurgery – removal of tumour
| Stereotactic radiosurgery – single large dose of radiation using high-energy X rays or gamma rays
70
What are the most common causes of vertigo?
BPPV, Meniere's and vestibular neuronitis
71
Definition of vertigo?
- Vertigo is false sensation of movement (spinning or rotating) of the person or their surroundings in absence any actual physical movement
72
Peripheral causes of vertigo?
```
BPPV
Labryrinthitis
Meniere’s Disease
Perilymphatic fistula
Ototoxicity
Syphilis
```
73
Central causes of vertigo?
Migraine
| Stroke
74
Tests to perform in vertigo?
- Romberg’s test
- Dix-Hallpike manoeuvre
- Head impulse test
- Unterberger’s test
75
What is Romberg's test in vertigo?
o Stand up straight with feet together and shut their eyes
o If person cannot maintain balance when eyes closed, test if positive
o Problem with proprioception or vestibular function
76
What is Dix-Hallpipe manoeuvre in vertigo?
o Caution if neck/back problems, carotid sinus syncope
o Keep eyes open and look straight ahead
o Sit upright on couch and head turned 45o to one side
o From this position, lie person down rapidly supporting head and neck until head is extended 20-30 degrees over end of couch and maintain for 30 seconds
o Observe eyes closely for 30 seconds for nystagmus
o If Dix-Hallpipe positive with vertigo and torsional upbeating nystagmus - BBPV
77
What is Head impulse test in vertigo?
o Sit upright and fix gaze on examiner
o Rapidly turn head 10-20o to one side and watch person’s eyes
o Normal = eyes stay fixed
o Abnormal = eyes are dragged off target by head turn, corrective abnormal movement (saccade) – positive test
78
What is Unterberger's test in vertigo?
o March on spot with eyes closed
| o Person will rotate to side of affected labyrinth
79
Common features of peripheral vertigo?
Prolonged, severe vertigo
New-onset headache or recent trauma
CV risk factors
80
Common features of central vertigo?
Normal neurological examination
Severe N&V
Hearing loss
81
Management of central vertigo?
o Admit or urgently refer to ENT
| o Prochlorprazine, cyclizine, promethazine whilst awaiting referral
82
Management of peripheral vertigo?
o Admit urgently if severe N&V, central neurological symptoms
o Refer to ENT if undetermined cause
o Prochlorprazine, cyclizine, promethazine whilst awaiting referral for no longer than 1 week
83
Description of acute vestibular syndrome?
```
Acute onset dizziness and/or vertigo
Intolerance of head movement
Continuous dizziness of 24 hours to several weeks duration
Nystagmus
Unsteady gait
Nausea and/or vomiting
```
84
Definition of BPPV?
- Disorder of inner ear characterised by repeated episodes of positional vertigo and positional nystagmus on performing diagnostic manoeuvres
85
Epidemiology of BPPV?
- Most common cause of vertigo
- Women more commonly
- Posterior semi-circular canal most commonly affected 85-90%
86
Risk Factors of BPPV?
o Head injury
o Prolonged recumbent position (vet, hairdresser)
o Ear surgery
o Ear pathology (labyrinthitis, Meniere’s)
87
Pathology of BPPV?
o Loose calcium carbonate debris (otoconia) in semi-circular canals of inner ear (canalithiasis)
o When head moves, otoconia move into semi-circular canals causing motion of fluid of inner ear (endolymph) which induces symptoms
88
Symptoms of BPPV?
- Vertigo
o Brought on by movements (lying down, turning over in bed, looking upwards, bending over)
o Lasts <1 minute, preceded by position change
o Asymptomatic between attacks
- Nausea and vomiting
- Hearing and tinnitus NOT affected
89
Classical vetigo symptoms in BPPV?
o Brought on by movements (lying down, turning over in bed, looking upwards, bending over)
o Lasts <1 minute, preceded by position change
o Asymptomatic between attacks
90
Tests in BPPV?
- Dix-Hallpipe manoeuvre
o Diagnose posterior BPPV if torsional upbeating nystagmus (left ear = clockwise, right ear = anticlockwise)
o Latent period 5-20s until symptoms and increase in intensity and then decline
o If negative – repeat in one week
91
Management of BPPV - general advice?
o Most people recover over several weeks, but may last or recur
o Get out of bed slowly and avoid tasks looking upwards
o Do not drive when dizzy and inform DVLA if ‘sudden unprovoked or unprecipitated episodes of disabling dizziness’
92
Management of BPPV - if mild?
o Watchful waiting
93
Management of BPPV - moderate/severe?
o Epley Maneouvre
If symptoms do not settle after 1 week – return for repeat
o Brandt-Daroff exercises if Epley manoeuvre not performed
Sit on edge of couch with eyes closed
Lie down sideways on one side with head looking up at ceiling
Rest for 30 seconds, keep eyes closed and then sit upright
Repeat 3-4 times until symptoms free and 3-4 times a day
o Follow up in 4 weeks if not resolved
94
Management of BPPV - when to admit?
o If severe N&V unable to tolerate oral fluids
95
Management of BPPV - when to refer to ENT?
o Epley manoeuvre not available in primary care
o Epley manoeuvre not worked
o Symptoms not resolved in 4 weeks
96
Complications of BPPV?
- Falls
| - Difficulty performing ADLs
97
Prognosis of BPPV?
- Relapsing and remitting pattern
| - Recurrence is common (about 15%)
98
Definition of vestibular neuronitis?
- Acute, isolated, prolonged vertigo of peripheral origin
| Inflammation of vestibular nerve and no hearing loss and may occur after viral infection
99
Definition of labyrinthitis?
inflammation of labyrinth, hearing loss a feature
100
Epidemiology of vestibular neuronitis?
- 30-60
- Spring or early summer most likely
- 2nd most common cause of vertigo
101
Symptoms of vestibular neuronitis?
o Preceded by viral illness
o Rotational vertigo occurs spontaneously
Sudden, on waking and may worsen over course of day
Exacerbated by head position but initially constant
o Nausea and vomiting
o Malaise
o Balance affected
o HEARING LOSS AND TINNITUS IN LABYRINTHITIS ONLY
102
Signs of vestibular neuronitis? What test can be performed?
o Nystagmus – fine horizontal
o Head impulse test positive
Sit upright and fix gaze on examiner
Rapidly turn head 10-20o to one side and watch person’s eyes
Normal = eyes stay fixed
Abnormal = eyes are dragged off target by head turn, corrective abnormal movement (saccade) – positive test
103
Diagnosis of vestibular neuronitis?
- Clinical diagnosis
104
Management of vestibular neuronitis - general advice?
o Symptoms will settle over 2-6 weeks, even with no treatment
o Avoid alcohol, tiredness, illness which worsen it
o Bed rest during acute phase
o Do not drive when dizzy and inform DVLA if ‘sudden unprovoked or unprecipitated episodes of disabling dizziness’
105
Management of vestibular neuronitis - symptomatic management?
o Rapidly relieve severe N&V – buccal prochlorperazine
o Alleviate N&V and vertigo
3-day oral course of prochlorperazine or antihistamine (cinnarizine, cyclizine, promethazine)
o Return if symptoms worsen or not resolved after 1 week
106
Management of vestibular neuronitis - when to admit?
o If severe N&V who cannot tolerate oral fluids
107
Management of vestibular neuronitis - when to refer to ENT?
o Symptoms not typical (neurological symptoms)
o Symptoms persist without improvement for >1 week despite treatment
o Symptoms persist >6 weeks
108
Complications of vestibular neuronitis?
- BPPV can develop after Vestibular neuronitis in 10%
- Risk of falls
- Worse ADLs and QoL
109
Prognosis of vestibular neuronitis?
- Severe initial symptoms usually last 2-3 days, and recover gradually over weeks (by 6)
- Recurrence is possible but rare and consider vestibular migraine or BPPV
110
Definition of Meniere's Disease?
- Disorder of inner ear which can affect balance and hearing
- Clinical syndrome characterised by episodes of vertigo, fluctuating hearing loss and tinnitus
- Associated with feeling of fullness in ear
111
Epidemiology of Meniere's Disease?
- Uncommon
| - Women, 30-60
112
Risk factors of Meniere's Disease?
```
o Autoimmune
o FHx
o Metabolic disturbances – sodium, potassium
o Viral infection
o Head trauma
```
113
Pathology of Meniere's Disease?
o Abnormal endolymph production and/or absorption
o Volume of endolymph in membranous labyrinth increases and volume of perilymph filling bony labyrinth decreases
o Swelling of vestibular system lead to classic symptoms
114
Classic symptoms of Meniere's Disease?
o Vertigo
Spontaneous, with or without nausea and vomiting
Unsteadiness can persist for several days after acute attack
o Tinnitus
‘Roaring’, may become permanent
o Sensorineural hearing loss
Fluctuating, initially low frequencies and then permanent
o Aural Fullness (sensation of pressure in ear)
115
Acute attacks of Meniere's Disease?
o Preceded by change in tinnitus, increased hearing loss or aural fullness before vertigo for few hours
o Vertigo and symptoms for 20 minutes to a few hours
116
Other problems in Meniere's Disease?
o Otholitic crises of Tumarkin – drop attack without LoC without warning and normal activity resumed immediately
o Gait problems
o Postural instability
117
Diagnosis of Meniere's Disease?
- Diagnosis is clinical and need the following criteria:
o Vertigo – 2 or more spontaneous episodes lasting 20 minutes to 12 hours
o Fluctuating hearing loss, tinnitus and/or perception to aural fullness in affected ear
o Hearing loss confirmed by audiometry as sensorineural, low-to-mid frequency
118
When is Meniere's Disease the probable diagnosis?
- Probable diagnosis if all of above without audiometry
119
Management of Meniere's Disease - when to admit?
o If severe symptoms for IV labyrinthine sedatives and fluids
120
Management of Meniere's Disease - when to refer to ENT?
o To confirm diagnosis
121
Management of Meniere's Disease - when to refer to audiology?
o If signs suggestive of hearing loss
122
Management of Meniere's Disease - general advice?
o Long-term condition but vertigo usually improves
o Acute attack usually settle within 24 hours
o Do not drive when dizzy and inform DVLA if ‘sudden unprovoked or unprecipitated episodes of disabling dizziness’
123
Management of Meniere's Disease - symptomatic treatment of acute attacks?
o Severe – admission for IV labyrinthine sedatives
o Rapidly relieved severe N&V – buccal prochlorperazine
o Alleviate N&V and vertigo
7 days (14 days if required before) of prochlorperazine or antihistamine (cyclizine, promethazine, cinnarizine)
If symptoms don’t improve within 5-7 days – reassess
124
Management of Meniere's Disease - prevention of recurrent attacks??
```
o Oral Betahistine
o Specialist management:
Vestibular rehabilitation
Diuretics
Intratympanic gentamicin or steroids
Endolymphatic shunts or sac surgery
Labyrinthectomy
```
125
Prognosis of Meniere's Disease?
- Symptoms can initially fluctuate, resolving completely between episodes
- Later in course, hearing loss progresses and tinnitus becomes persistent
- After years, vertigo is no longer experienced
126
Definition of epistaxis?
- Bleeding from the nose
127
Epidemiology of epistaxis?
- Up to 60% have nosebleeds but rarely do people need medical attention
- Common in children
- Posterior epistaxis more common in elderly
128
Patholgoy of epistaxis?
o 80-90% originate from Little’s area on anterior nasal septum, contains Kiesselbach plexus of vessels
o Less commonly from branches of sphenopalatine artery in posterior nasal cavity
129
Causes of epistaxis?
o Trauma – nose-picking, nasal fractures, septal ulcers, foreign body, blunt trauma
o Inflammation – infection, allergic rhinosinusitis, nasal polyps
o Topical drugs – cocaine, decongestants, corticosteroids
o Vascular – Wegener’s granulomatosis
o Post-operative bleeding
o Tumours – benign (angiofibroma) or malignant (SCC)
o Nasal oxygen therapy
o Clotting disorders – thrombocytopenia, platelet dysfunction, von Willebrand disease, leukaemia, haemophilia
o Drugs – anticoagulants, antiplatelet drugs
o Excessive alcohol consumption
130
Symptoms of epistaxis?
- Nosebleed
131
Assessment of epistaxis?
- Assess how much blood, any temporary measures performed, previous epistaxis and treatment
- Examine – both nasal passages (with nasal speculum)
o Look for bleeding point
132
When to suspect posterior epistaxis?
o Profuse, from both nostrils, bleeding site not identified and goes down throat
133
Investigations if secondary cause suspected in epistaxis?
o FBC (if heavy or recurrent), coagulation (if clotting disease suspected)
134
Management of epistaxis - when to transfer immediately to A&E?
o Haemodynamic compromise
135
Management of epistaxis - when to admit to hospital?
o Posterior bleed - Bleeding profuse, from both nostrils and site cannot be identified
o Children <2
o Underlying cause (bleeding predisposition, haemophilia, leukaemia)
136
Management of epistaxis - acute management - first aid measures?
Sit with upper body tilted forward and mouth open – avoid lying down
Pinch cartilaginous (soft) part of nose firmly and hold for 10-15 minutes without releasing pressure, breathe through mouth
137
Management of epistaxis - acute management - if stops with first aid?
Topical antiseptic (Naseptin cream QDS for 10 days)
138
Management of epistaxis - acute management - if does not stop in 10-15 minutes?
Either admit to hospital (A&E) or perform in primary care if possible:
Nasal Cautery – if site identified
• Topical LA spray (Co-phenylcaine), wait 3-4 minutes and apply silver nitrate stick to bleeding point for 3-10 seconds until grey
• Need Naseptin after
Nasal packing – if cautery ineffective
• Topical LA spray (Co-phenylcaine), wait 3-4 minutes
• Options: Nasal tampons (Merocel), inflatable packs (Rapid-Rhino)
• Need admission to ENT afterwards
139
Management of epistaxis - general measures after nosebleed?
Avoid blowing nose, picking nose, heavy lifting, strenuous exercise, lying flat, drinking alcohol
140
Management of epistaxis - secondary care of severe epistaxis?
Resuscitate if BP low, dizzy on sitting
Apply pressure for 20 minutes, sit forward and breathe through mouth
Cautery – encourage patient to blow out clots
• LA soaked for 2 minutes
• Apply cautery on bleeding point – moving in a circle
• Never cauterise both sides of septum
If continues:
• Anterior nasal pack – Rapid Rhino, Merocel
• Posterior nasal pack – Foley urinary catheter and inflate balloon
141
Management of epistaxis - secondary care treatments?
```
Resuscitation if needed
Formal packing
Endoscopic assessment and electrocautery
EUA
Arterial ligation/embolisation
IV transexamic acid
```
142
Management of epistaxis - recurrent epistaxis?
o First aid measures when bleeds
o Avoid blowing/picking nose, heavy lifting, strenuous exercise and lying flat for 24 hours after
o Determine underlying cause:
FBC, clotting
o Referral to ENT if recurrent with signs of underlying conditions such as:
Angiofibroma (nasal obstruction, severe epistaxis)
Cancer (nasal obstruction, facial pain, hearing loss, eye symptoms)
Telangiectasia (red spots on fingertips, lips, lining of nose)
143
Complications of epistaxis?
o Hypovolaemia, anaemia, aspiration
o Nasal packing treatment – sinusitis, septal haematoma, pressure necrosis, toxic shock syndrome
o Nasal cautery treatment – septal perforation
144
How common is nasal injury?
o Nasal bone most commonly fractured bones of face
| o Seen in 15-30
145
Causes of nasal injury?
```
o Motor vehicle
o Sports
o Falls
o Abuse
o Punches, clash of heads
```
146
Symptoms and signs of nasal injury?
o Usually high-impact injury
o Swelling becomes apparent
o CSF Rhinorrhoea
CSF contains glucose and B2 tau transferrin
If traumatic – 7-10 bed rest, lumbar drain, avoid coughing/sneezing, antibiotic cover
o Epistaxis
o Septal deviation/haematoma
147
When to refer nasal injury to ENT immediately?
```
o Marked deviation
o Epistaxis not settling
o Septal haematoma
o CSF rhinorrhoea
o Widening intercanthal distance
o Facial anaesthesia
```
148
Management of nasal injury?
```
o If significant swelling:
Ice, simple analgesia
Review in 5 days by GP
o Usually heal within 2-3 weeks
o Manipulation under anaesthetic (MUA) performed within 5-10 days in adults
```
149
Common causes of nasal foreign body?
```
o Beads
o Buttons
o Sweets
o Nuts
o Seeds
o Peas
```
150
Presentation of nasal foreign body?
o Self-inserted and often observed
o May produce nasal obstruction
o Purulent unilateral discharge suggests organic material
151
When to refer to ENT a nasal foreign body?
o If prolonged unilateral nasal discharge
o FB in posterior position
o Patient agitated
o Not experienced
152
Management of nasal foreign body?
o Topical anaesthetic and vasoconstrictor spray
o Ask child to blow nose
o Ask parent to blow sharply though patients mouth whilst obstructing unaffected nostril (success rate >70%)
o Nasal speculum and thin forceps to hold object (avoid pushing deeper)
o Refer to ENT if two unsuccessful attempts
153
Definition of allergic rhinitis?
- IgE mediated inflammatory disorder of nose
| - Due to nasal mucosa sensitised to allergens, triggers histamine release to produce symptoms
154
Epidemiology of allergic rhinitis?
- Prevalence increasing
| ¼ of adults
155
Classifications of allergic rhinitis?
o Seasonal – occur at same time each year (hayfever)
o Perennial – throughout year, typically due to house dust mites, animal dander
o Intermittent - <4 days a week or <4 consecutive weeks
o Persistent - >4 days a week and >4 consecutive weeks
156
Causes of allergic rhinitis?
```
o FHx
o House dust mites
o Grass, tree and weed pollen
o Mould
o Animal dander (cats and dogs most common)
o Occupational
```
157
Symptoms of allergic rhinitis?
o Sneezing
o Nasal Itching
o Nasal discharge (rhinorrhoea)
o Nasal congestion
o Eye itching, redness, tearing
o Bilateral and usually develop within minutes of exposure to allergen
o Other – postnasal drip, cough, mouth breathing
158
Signs of allergic rhinitis?
o Nasal voice
o Darkened eye shadows
o Horizontal nasal crease
o Discharge – usually clear
159
Management of allergic rhinitis - general measures?
o Nasal irrigation with saline – OTC
o Allergen avoidance
Grass pollen allergy – avoid grassy, open spaces, particularly early in morning or late at night, avoid drying washing outdoors, keep windows shut
House dust mite – synthetic pillows, keep furry toys off bed, wash bedding frequently, wooden floors preferable
Animal allergy – Restrict areas of house animal can go, wash animal regularly
Occupational – reduce exposure, adequately ventilated work environment
160
Management of allergic rhinitis - drug treatment for mild-to-moderate?
PRN intranasal antihistamines (azelastine) OR
PRN oral antihistamines (loratadine or certirizine)
• If antihistamines CI or not tolerated – PRN intranasal sodium cromoglicate
161
Management of allergic rhinitis - drug treatment for moderate-to-severe?
Regular intranasal corticosteroid during periods of exposure (mometasone, fluticasone)
162
Management of allergic rhinitis - other treatments?
If nasal congestion – short-term intranasal decongestant (ephedrine)
If watery rhinorrhoea – intranasal anticholinergic (ipratropium bromide)
If itching or sneezing – regular antihistamine
163
Management of allergic rhinitis - severe symptoms or uncontrolled?
Oral prednisolone for 5-10 days
164
Management of allergic rhinitis - follow up?
o Review after 2-4 weeks of treatments
165
Management of allergic rhinitis - when to refer to ENT?
o Red flag features – unilateral, blood stained mucous, nasal pain, recurrent epistaxis – 2-week wait
o Nasal obstruction/structural abnormality which makes intranasal treatment difficult
o Persistent symptoms despite ongoing management
Allergy Testing – skin prick or IgE levels to allergens
Immunotherapy
166
Complications of allergic rhinitis?
o Impaired QoL
o Asthma
o Sinusitis
o Nasal Polyps
167
Definition of sinusitis?
- Inflammation of paranasal sinuses
| o Frontal, maxillary, sphenoid, ethmoidal
168
Classifications of sinusitis?
- Acute – resolves within 12 weeks
- Recurrent – 4 or more annual episodes of sinusitis with persistent symptoms in intervening periods
- Chronic – symptoms lasting >12 weeks
169
Epidemiology of sinusitis?
- Acute – common in adults
| - Chronic – increases with age, women, asthma/COPD
170
Causes of acute sinusitis?
Viral URTI which can be followed by bacterial infection
• S.pneumoniae, H,influenza, Moraxella catarrhalis and S.aureus
Also associated with asthma, allergic rhinitis, smoking, anatomical variation, seasonal variation, CF
171
Causes of chronic sinusitis?
Multifactorial
Usually S.aureus, enterobacteriaeceae
Predisposing conditions: atopy, asthma, CF, aspirin sensitivity, immunocompromise, smoking
172
Symptoms and signs of acute sinusitis?
```
o Usually follows viral illness
o Diagnostic with (<12 weeks):
Nasal obstruction/congestion
Nasal discharge (anterior, posterior)
Facial pain/pressure
Reduced/Loss of smell
o Altered speech, tender cheekbones, cough
```
173
When to suspect bacterial sinusitis?
o >10 days
o Discoloured or purulent nasal discharge
o Severe local pain
o Fever >38
174
Symptoms and signs of chronic sinusitis?
- Chronic Sinusitis (>12 weeks):
o Nasal obstruction/congestion
o Nasal discharge (anterior, posterior)
o Facial pain/pressure
175
Examination performed in sinusitis?
o Inspect and palpate maxillofacial area to elicit swelling/tenderness
o Perform anterior rhinoscopy to identify:
Nasal inflammation, mucosal oedema, purulent nasal discharge, nasal polyps
o Pulse rate, blood pressure, temperature
176
Management of sinusitis - when to refer to ENT?
```
o If not typical or diagnosis in doubt
o Frequent recurrent episodes
o Treatment failure
o Anatomical defect
o Immunocompromise
o Nasal polyps
```
177
Management of sinusitis - when to refer urgently?
o Systemically unwell, intra/periorbital complications, intracranial complications
178
Management of sinusitis - acute sinusitis - if symptoms <10 days?
Usually caused by virus and should take 2-3 weeks, most people will get better without antibiotics
PRN paracetamol + ibuprofen
Nasal saline or nasal decongestants
Seek medical advice if symptoms worsen or do not improve after 3 weeks
179
Management of sinusitis - acute sinusitis - if symptoms >10 days with no improvement?
High-dose nasal corticosteorids for 14 days (mometasone 200mcg BDS)
Backup prescription used if no improvement after 7 days
• Phenoxymethylpenicillin 500mg QDS for 5 days (doxycycline)
• 2nd line if not working – Co-amoxiclav
180
Management of sinusitis - chronic sinusitis?
o Avoid allergic triggers
o Stop smoking
o Good dental hygiene
o Avoid underwater diving
o Nasal irrigation with saline solution
o Intranasal steroids (mometasone/fluticasone) for up to 3 months
o Seek specialist advice on long-term antibiotics
181
Complications of sinusitis?
```
o Acute (rare) – orbital cellulitis/abscess, meningitis, encephalitis, osteomyelitis
o Chronic – sleep problems, depression, impact on work, reduced QoL
```
182
Definition of viral croup?
Mucosal inflammation affecting the nose to the LRT
| Due to parainfluenza, influenza and RSV in children aged 6 months – 6 years
183
Definition of spasmodic or recurrent croup?
Barking cough and hyperreactive upper airways
| No respiratory tract symptoms
184
Definition of acute epiglottitis?
Life-threatening swelling of the epiglottis and septicaemia due to H. Influenzae type B infection
Now rare due to Hib immunization
185
How common is viral croup?
- Viral croup= 95% of the laryngotracheal infections
- Most common in autumn
- Peak at 2yrs old, in children aged 6M-6yrs
186
How common is acute epiglottitis?
most commonly in ages 1 – 6 years, rare due to Hib immunisation
187
Causative organisms in viral croup?
o MOST COMMONLY due to parainfluenza
| o Others include Influenza and RSV
188
Causative organisms in acute epiglottitis?
o H. Influenzae type B infection
189
Symptoms of croup?
o Barking cough
o Harsh stridor
o Hoarseness preceded by fever & coryza
190
Symptoms of acute epiglottitis?
```
o High fever, toxic-looking child
o Intensely painful throat
Stops swallowing or speaking
o Saliva drooling
o Respiratory difficulty
o Child sitting immobile, upright, with open mouth
```
191
Examination in croup/epiglottitis?
DO NOT EXAMINE THE THROAT---assess severity:
o Degree of stridor and subcostal recession
o RR
o HR
o LOC (drowsy?), tired, exhausted
o Pulse oximetry
192
Diagnosis of acute epiglottitis?
- Anaesthetist makes diagnosis by laryngoscopy – cherry-red swollen epiglottis
- Electively intubate before obstruction occurs
193
Scoring system used in croup?
- Westley Croup Score
o Assesses stridor, retractions, air entry, SpO2 and level of consciousness
o Those with moderate – severe >2 need admission
194
Initial management of croup/epiglottitis?
- LEAVE CHILD ALONE - DO NOT DISTRESS (especially in epiglottitis)
- Immediate Management:
o Differentiate between croup and acute epiglottitis
o Stabilise child, give oxygen and keep airway open
195
Management of mild croup?
o Mild illness can be managed at home
Usually resolves after 48hours
Take paracetamol/ibuprofen PRN
o If there is recession and stridor at rest, then return to hospital
196
Management of severe croup?
Moist or humidified air
• Ease breathing
Steroids
• Oral dexamethasone (0.15mg/kg stat dose) or oral prednisolone (1-2mg/kg stat) or nebulised budesonide (2mg stat dose)
Nebulised adrenaline (epinephrine)
• Transient relief of Sx (airway obs)
• Driven by 8L/O2
My need endotracheal intubation
197
Management of epiglottits?
o Nebulised adrenaline may buy time
o Manage in ICU after endotracheal intubation
o Once procedure completed take blood cultures and start IV Abx
Cefotaxime IV for 7-10 days
o Rifampicin prophylaxis to close contacts
