ENT: Otitis Media & Tonsilitis Flashcards
1
Q
What is otitis media?
A
a common infection of the middle ear, that may be bacterial or viral
2
Q
Who is otitis media predominantly seen in?
A
Children <4 y/o
3
Q
What INTRINSIC factors can predispose to otitis media?
A
1) age <4
2) atopic predisposition
3) immunosuppression
4) conditions affecting ciliary motility:
- CF
- Primary ciliary dyskinesia
- Kartagener’s syndrome
4
Q
What EXTRINSIC factors can predispose to otitis media?
A
1) passive smoking
2) not receiving pneumococcal vaccination
3) daycare: the larger the daycare group, the higher the risk.
4) bottle feeding
5) use of a dummy
6) low economic status: poor nutritional status thought to play a role
5
Q
What vaccine can help protect against otitis media?
A
Pneumococcal
6
Q
How can bottle feeding increase the risk of otitis media?
A
1) The strong swallow required to feed from a breast induces a sizeable negative pressure in the infants oral cavity allowing eustachian tube insufflation. Bottle feeding however, relies more on gravity from the bottle, and less negative pressure is required.
2) Breast milk provides maternal antibodies against common OM pathogens.
7
Q
What is the middle ear?
A
The space that sits between the tympanic membrane (ear drum) and the inner ear.
8
Q
Where does infection come from in otitis media?
A
The bacteria enter through the back of the throat through the eustachian tube.
9
Q
What is a bacterial infection of the middle ear often preceded by?
A
A viral URT infection.
10
Q
What is the most common bacterial cause of otitis media?
A
Streptococcus pneumoniae –> this is common cause of other ENT infections such as rhino-sinusitis and tonsilitis.
11
Q
Give the 4 most common bacteria causing otitis media
A
1) Strep. pneumoniae
2) Haemophilus influenzae
3) Moraxella catarrhalis
4) Staph. aureus
12
Q
Pathophysiology in otitis media?
A
1) OM occurs 2ary to oedema and narrowing of the eustachian tube
2) An oedematous eustachian tube prevents the middle ear from draining –> predisposed to colonoisation
13
Q
Purpose of the eustachian tube?
A
The eustachian tube serves to equalise pressure in the middle ear, when the tube is blocked this cannot happen.
14
Q
Why are children predisposed to OM?
A
1) their esutachian tubes are narrower and more prone to blockage
2) their eustachian tubes are more horizontal, inhibiting drainage (why the pinna is pulled down for paediatric examination, and up for adults)
3) children have less developed immune systems are are more prone to upper respiratory tract infections (a common cause of eustachian tube oedema)
15
Q
What can OM be categorised in accordance to?
A
1) Duration: acute or chronic
2) Effusion: present or absent
16
Q
What are the 2 types of acute otitis media?
A
1) Acute otitis media
2) Acute otitis media with effusion
17
Q
What can acute otitis media with effusion progress to?
A
Chronic OM with effusion or chronic suppurative
18
Q
What is the most common cause of hearing impairment in children?
A
otitis media with effusion.
19
Q
What are the 2 types of chronic OM?
A
1) Chronic OM with effusion
2) Chronic suppurative
20
Q
What is chronic OM with effusion characterised by?
A
A build up of fluid behind an intact TM.
21
Q
How long must OM be present for to support a diagnosis of ‘chronic’?
A
> 3 months
22
Q
What is chronic OM with effusion also known as?
A
‘glue ear’
23
Q
Is acute or chronic OM with effusion more common?
A
Acute OM
24
Q
Is acute or chronic OM with effusion more likely to cause hearing impairment?
A
Chronic
25
What is chronic suppurative OM?
Presents with persistent ear discharge through a perforated tympanic membrane (TM).
26
How long must discharge be present for in chronic suppurative OM to support a diagnosis?
>2 weeks
27
Clinical features of OM?
1) ear pain/otalgia (most common): may present with ear tugging
2) reduced hearing in affected ear
3) may have symptoms of URT infection e.g. fever, cough, coryzal symptoms, sore throat
4) ear discharge --> if tympanic membrane rupture
5) if infection affects vestibular system --> vertigo, balance issues
28
How may otitis media present in very young children or infants?
Can be non specific e.g. fever, vomiting, irritability, lethargy, poor feeding.
29
Otoscopy findings in otitis media?
1) bulging tympanic membrnae --> loss of light reflex
2) opacification or erythema of tympanic membrane
3) perforation with purulent otorrhoea
4) decreased mobility if using pneumatic otoscope
5) if perforation --> may see discharge in the ear canal and a hole in the tympanic membrane.
30
How to use otoscope in infants <12 months vs >12 months?
<12 months --> gently pull the outer ear down and back.
>12 months --> pull the outer ear gently up and back
31
What should the tympanic membrane normally look like?
Pearly grey, transulscent & slightly shiny.
32
What should you be able to visualise on a normal TM?
1) You should be able to visualise the malleus through the membrane
2) Should be able to visualise a cone of light reflecting the light of the otoscope.
33
What is it important to exclude in OM?
Systemic infection and serious complications:
1) mastoiditis
2) meningitis
3) intracranial abscess
34
What investigation is useful as an aid for the diagnosis of middle ear conditions?
Tympanometry
35
What is involved in tympanometry?
The procedure involves changing the pressure in the outer ear, playing a tone and analysing the reflected sound waves.
The degree of reflection gives a good proxy measurement for the admittance of the TM (the amount of energy transmitted through the TM).
The admittance will be at its maximal point when the pressures on either side of the TM are equal.
36
What are the 3 most common tympanometry findings?
1) normal waveform: a symmetrical tented 'teepee-like' graph is seen.
2) flat waveform
3) similar shaped graph to normal, but the peak is shifted negatively (to the left).
37
What does a flat waveform finding on tympanometry indicate?
Suggestive of fluid in the middle ear, or rupture of the TM.
38
What does a waveform similar shaped to normal, but the peak is shifted negatively (to the left)?
This indicates a negative pressure in the middle ear.
39
What is often the management of acute OM?
Most cases of OM will self resolve without antibiotics and instead use simple analgesia.
40
When are Abx considered in OM?
A prescription for antibiotics may be given with the advice to take:
a) in 3 days if symptoms do not being to improve
b) or the patient becomes systemically unwell.
41
Which groups is it recommended to prescribe Abx?
1) Children <2 y/o with bilateral OM
2) Children <3 months with a temp >38
3) OM with ear discharge (otorrhoea)
4) Systemically unwell
5) High risk of complications or immunosuppressed
42
1st line Abx in OM?
1st --> amoxicillin (5-7 day course)
2nd --> erythromycin or clarithromycin
43
When should admission be considered in OM?
Consider admission in infants younger than 3 months with a temperature above 38ºC or 3 – 6 months with a temperature higher than 39ºC.
44
What are the three options regarding prescribing antibiotics to patients with otitis media?
1) immediate Abx
2) delayed Abx
3) no Abx
45
Management of acute and chronic otitis media with effusion (glue ear)?
1) Conservative management & observation for 6-12 weeks
2) Pure tone audiometry
3) Referral to 2ary care if:
- There is concern with the child's development
- The hearing loss persists after other symptoms have resolved
- There is severe hearing loss
- The child has Down's syndrome or cleft palate
46
What 2 congenital abnormalities would you refer to 2ary care in chronic OM with glue ear?
1) Down's syndrome
2) Cleft palate
47
Management options in 2ary care of chronic otitis media with effusion (glue ear)?
1) hearing aids --> offered to patients with persistent bilateral symptoms
2) Eustachian tube autoinflation --> blowing up a balloon with the nostrils several times a day
3) Surgical --> myringotomy with grommet insertion
48
What is a grommet?
A grommet is a tube, surgically inserted in the TM, that allows middle ear ventilation and the drainage of excess secretions.
49
How long are grommets usually in for?
They are ordinarily a temporary measure lasting around 12 months.
50
What are some complications of OM?
Common:
1) Chronic OM (8% will progress)
2) Tympanic membrane perforation
3) Hearing loss (more common with recurrent OM)
4) Tinnitus
Uncommon:
1) Mastoiditis
2) Bacterial meningitis
3) Extradural abscess
4) Subdural abscess
5) Labyrinthitis
6) Facial paralysis
51
What advice is given in TM perforation in acute OM?
This is a common occurrence and will ordinarily heal within a few weeks
1) avoid swimming
2) be careful in shower
3) assess site --> monitor for mastoiditis
52
Perforations in what area of TM are more likely to lead to mastoiditis?
Upper portion of drum
53
What is mastoiditis?
Mastoiditis is inflammation of the mastoid antrum and the lining of the mastoid air cells.
54
What is the mastoid process?
The area of bone formed of the petrous temporal and occipital bones which is present posterior and inferior to the external auditory meatus.
55
What is mastoiditis usually the result of?
Infection of the middle ear --> OM
It most commonly occurs in children of school age following an UNTREATED episode of acute otitis media or after RECURRENT episodes of otitis media.
56
What are the most common pathogen causing OM/mastoiditis in young children prior to vaccination?
Haemophilus influenzae
57
What are the most common pathogen causing OM/mastoiditis in children of school age?
Strep. pneumoniae (& strep. pyogenes)
57
What are the most common pathogen causing OM/mastoiditis in adults?
Strep. pneumoniae & Staph. aureus
58
What pathogen can cause OM or mastoiditis in diabetics?
Pseudomonas aeruginosa
59
Clinical features of mastoiditis?
1) Recent or concurrent acute otitis media (50%)
2) Deep otalgia on the affected side in nearly all cases.
3) Recent loss of hearing (progressive) on affected side.
4) Generally unwell with young children often not eating or drinking as normal.
5) Seizures and symptoms of intracranial infection (rarely presenting symptoms)
60
Key exam findings in mastoiditis?
1) fever
2) usually bulging tympanic membrane with clear fluid level or perforation with purulent discharge from the ear.
3) erythema and swelling over mastoid process behind the ear in up to 75% of cases.
4) mastoid tenderness
5) cervical lymphadenopathy on affected side.
61
What are the key imaging investigations in mastoiditis?
1) CT head with contrast:
- will demonstrate the extent of mastoid air cell opacification
- an also identify intracranial infection and the extent of this
2) MRI head:
- better for identifying intracranial infection
- will give better detail of the soft tissues but struggles to see the bone in as much detail.
62
Mainstay of management in mastoiditis?
Early IV Abx
63
Abx of choice in mastoiditis?
1st line --> Cephalosporins e.g. ceftriaxone
If allergic to penicillins / beta-lactams --> vancomycin, gentamicin
64
What has decreased the overall incidence of mastoiditis?
vaccination against Haemophilus influenzae and Streptococcus pneumoniae
65
Surgical options for mastoiditis?
In addition to Abx:
1) Myringotomy and grommet insertion: to help infection drain via the middle ear.
2) Mastoidectomy: to drill out the mastoid bone and allow the infection to drain
66
Complications of mastoiditis?
The complications of untreated mastoiditis are a result of the infection progressing and causing damage to surrounding neurological structures:
1) Conductive hearing loss
2) Sensorineural hearing loss & vertigo
3) If infection enters facial canal --> facial nerve damage, ipsilateral facial weakness
4) If erosion of mastoid into cranial vault:
- meningitis
- formation of subdural empyema
- intracerebral abscess formation
67
What can cause conductive hearing loss in mastoiditis?
Due to a middle ear effusion from co-existing acute otitis media or due to infection causing destruction of the ossicles.
68
What can cause sensorineural hearing loss & vertigo in mastoiditis?
If the inner ear is affected by progressive mastoid destruction.
69
is there forehead sparing in facial nerve damage in mastoiditis?
no (due to the lower motor neurones being affected)
70
What branch of the facial nerve runs through the middle ear?
The corda tympani branch of the facial nerve.
71
What is chronic suppurative OM?
A persistent inflammation of the middle ear that results in the discharge of pus from the ear
72
Risk factors for chronic suppurative OM?
poor hygiene, malnutrition, and exposure to polluted environments.
73
Management of chronic suppurative OM?
antibiotics or antifungal medications, as well as cleaning and drying the ear canal.
74
What is the most common cause of tonsillitis?
Viral infection
75
What tonsils are involved in tonsillitis?
Palatine tonsils
76
What is the most common virus causing viral tonsillitis?
Rhinovirus
77
3 most common viruses causing viral tonsillitis?
1) rhinovirus
2) coronavirus
3) parainfluenza virus
78
What is the most common cause of bacterial tonsillitis?
Group A Strep (Strep. pyogenes)
79
What is the 2nd most common cause of bacterial tonsillitis?
Strep. pneumoniae
80
Give 5 bacterial causes of bacterial tonsillitis?
1) group A streptococcus (Streptococcus pyogenes)
2) strep. pneumoniae
3) H. influenzae
4) Moraxella catarrhalis
5) Staph. aureus
81
What age group is most commonly affected by tonsillitis?
515 y/o
82
Presentation of tonsillitis?
Acute onset of:
1) sore throat (99%)
2) fever >38 degrees (82%)
3) dysphagia/pain on swallowing (66%)
4) nasal congestion, headache, earache, cough (47%)
83
What is the Centor criteria?
can be used to estimate the probability that tonsillitis is due to a bacteria infection, and will benefit from antibiotics.
84
What Centor score indicates a 40 – 60 % probability of bacterial tonsillitis?
A score of 3 or more --> it is appropriate to offer antibiotics.
85
What Centor score indicates that Abx can be offered?
3 or more
86
What 4 aspects make up the centor criteria?
A point is given if each of the following features are present:
1) fever >38
2) tonsillar exudates (if bacterial)
3) absence of cough
4) tender anterior cervical lymph nodes (lymphadenopathy)
87
Does a cough indicate that a viral or bacterial cause of tonsillitis is more likely?
Viral
88
Does nasal congestion, headache, earache, & cough indicate that a viral or bacterial cause of tonsillitis is more likely?
Viral
89
What may examination of the pharynx reveal in tonsilitis?
1) Severely inflamed tonsils (87%)
2) Painfully enlarged anterior cervical lymph nodes (49%)
3) Purulent tonsils (41%)
90
Is pus on the tonsils suggestive of a bacterial or viral cause?
Bacterial
91
Where are the tonsillar lymph nodes located?
just behind the angle of the mandible (jawbone).
92
When should you NOT examine the pharynx in tonsillitis?
If epiglottitis is suspected.
93
What additional features may be suggestive of epiglottitis?
1) young child
2) muffled voice
3) excessive drooling and pooling of saliva
Call for an anaesthetist and an ENT surgeon!
94
How is a diagnosis of tonsillitis usually made?
Usually clinical
95
In which circumstance are investigations done in tonsillitis?
If confirmation of group A streptococcal (GAS) infection is required e.g. immunosuppression, very old/young, severe symptoms
96
When it is indicated, what test is used for the confirmation of group A streptococcal (GAS) infection in tonsillitis?
1) Rapid antigen test for GAS
2) If negative --> throat culture
97
In all other patients (i.e. where rapid antigen test not needed) with tonsillitis, what is done to establish likelihood of GAS aetiology?
Why is it important to establish the likelihood of GAS infection?
What - clinical examination in combination with a clinical prediction score (FeverPAIN or Centor
Why - GAS aetiology requires antibiotic treatment.
98
Differentials for acute tonsillitis?
1) Viral URT infection
2) 1ary herpes labialis (oral herpes)
3) Peritonsilar abscess
4) Infectious mononucleoisis
5) Epiglottitis
99
What is seen in a peritonsillar abscess to help differentiate from tonsillitis?
Can be a complication of tonsillitis.
BUT can have:
- trismus (lockjaw)
- muffled voice
- uvular deviation
- unilateral enlarged
- displaced tonsil
100
What is seen in epiglottitis to help differentiate from tonsillitis?
muffled voice, excessive drooling (in children), possible stridor and breathing difficulty.
101
Management of tonsillitis?
All patients:
1) reassure: symptoms can last for around 1 week, but most people get better within this time without treatment.
2) paracetamol or ibuprofen: for pain and/or fever
3) fluids
Others:
1) Abx if indicated
2) ? single dose of oral steroids
102
What Abx is indicated in tonsillitis caused by group A streptococcus (Streptococcus pyogenes)?
penicillin V (phenoxymethylpenicillin)
103
What is an alternative to the Centor criteria?
FeverPAIN score
A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis.
104
Describe the FeverPAIN score
Fever >38 - during previous 24 hours
P - purulence (pus on tonsils)
A - attended rapidly (within 3 days of onset of symptoms)
I - inflamed tonsils (severely inflamed)
N - no cough or coryza
105
What are the NICE indications for Abx in tonsillitis?
1) features of marked systemic upset secondary to the acute sore throat
2) unilateral peritonsillitis
3) history of rheumatic fever
4) an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
5) patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
106
What FeverPAIN score would you consider prescribing Abx? What Centor score?
FeverPAIN: >/=4
Centor: >/=3
107
What is a 'delayed' prescription in tonsillitis?
This involves educating patients or parents about the likely viral nature of the sore throat and providing a prescription to be collected only if the symptoms worsen or do not improve in the next 2 – 3 days.
108
1st line Abx choice in tonsillitis?
Penicillin V (also called phenoxymethylpenicillin) for a 10-day course.
It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes.
109
1st line Abx in tonsillitis in penicillin allergy?
Clarithromycin
110
Complications of tonsillitis?
1) peritonsillar abscess (quinsy)
2) otitis media (if infection spreads to ear)
3) scarlet fever
4) rheumatic fever
5) post-strep glomerulonephritis
6) post-strep reactive arthritis
111
What is a quinsy?
A peritonsillar abscess --> when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils.
112
What is a peritonsillar abscess a complication of?
Untreated or partially treated tonsillitis (but can arise without tonsillitis)
113
What age can quinsy affect?
Quinsy can occur just as frequently in teenagers and adults as it does in children, unlike tonsillitis which is much more common in children.
114
Presentation of a quinsy?
Patients present with similar symptoms to tonsillitis:
Sore throat
Painful swallowing
Fever
Neck pain
Referred ear pain
Swollen tender lymph nodes
115
What additional symptoms may indicate a quinsy over tonsillitis?
- Trismus: when the patient is unable to open their mouth
- Change in voice: due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
- Swelling & erythema: in area beside tonsils
116
What are the 3 most common causes of quinsy?
Quinsy is usually due to a bacterial infection.
1) streptococcus pyogenes (group A strep) --> most common
2) staph. aureus
3) H. influenzae
117
Management of a quinsy?
1) Refer to hospital under ENT
2) Needle aspiration OR surgical incision & drainage to remove pus
3) Abx before and after surgery
Some ENT surgeons give steroids (i.e. dexamethasone) to settle inflammation and help recovery, although this is not universal.
118
Choice of Abx in quinsy?
Usually co-amoxiclav (broad spectrum)
119
What is the most specific otoscopy finding in OM?
Bulging TM
120
Under what circumstances should Abx be prescribed immediately in acute OM?
1) Symptoms lasting more than 4 days or not improving
2) Systemically unwell but not requiring admission
3) Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
4) Younger than 2 years with bilateral otitis media
5) Otitis media with perforation and/or discharge in the canal
121
what is a cholesteatoma?
A skin cyst in the middle ear and mastoid that may result from chronic OM.
122
How does a cholesteatoma present?
- Recurrent ear discharge that may be foul smelling
- Hearing loss
- Pain (if there is an associated infection)
123
What are 2 post op complications of a tonsillectomy?
1) Pain
2) Haemorrhage
124
How long may pain last following a tonsillectomy?
The pain may increase for up to 6 days following a tonsillectomy.
125
What is a 1ary (or reactionary) haemorrhage post-tonsillectomy?
most commonly occurs in the first 6-8 hours following surgery
126
Management of wound bleeding in the first 6-8 after tonsillectomy?
requires immediate return to theatre (can be life threatening)
127
What is 2ary haemorrhage post-tonsillectomy?
What is it associated with?
Occurs between 5-10 days after surgery.
Often associated with wound infection.
128
Management of 2ary haemorrhage post-tonsillectomy?
Admission & Abx.
Severe bleeding may require surgery.
129
When should a child with recurrent glue ear be referred to ENT?
If they have persisting significant hearing loss on two separate occasions (usually 6-12 weeks apart).
130
What are the causes of otitis externa?
1) infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
2) seborrhoeic dermatitis
3) contact dermatitis (allergic and irritant)
4) recent swimming is a common trigger of otitis externa
131
Features of otitis externa?
- ear pain, itch, discharge
- otoscopy: red, swollen, or eczematous canal
132
management of otitis externa?
topical antibiotic or a combined topical antibiotic with a steroid
133
What are the NICE criteria for the consideration of a tonsillectomy?
Should be considered only if the person meets ALL of the following criteria:
1) sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
2) the person has five or more episodes of sore throat per year
3) symptoms have been occurring for at least a year
4) the episodes of sore throat are disabling and prevent normal functioning
134
Management of acute OM with perforation?
Oral Abx (amoxicillin) for 5-7 days
135
What are 3 key complications of mastoiditis?
1) facial nerve palsy
2) hearing loss
3) meningitis
136
What is otosclerosis?
The replacemnt of normal bone by vascular spongy bone.
137
What type of hearing loss is there in otosclerosis?
progressive conductive deafness due to fixation of the stapes at the oval window
138
Inheritance of otosclerosis?
Autosomal dominant
139
What type of hearing loss is seen with furosemide treatment?
Ototoxicity associated with medications tends to cause sensorineural hearing loss (SNHL).
140
Immediate management of bleeding post-tonsillectomy 5 days ago?
Refer immediately to ENT --> all post-tonsillectomy haemorrhages should be assessed by ENT
141
What does unilateral glue ear in an adult need to be investigated for?
Posterior nasal space tumour.
142
