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Phase 3a General Practice and Community > GP ENT > Flashcards

GP ENT Flashcards

1
Q

What is otitis externa?

A

AKA Swimmers ear
Otitis externa = inflammation of the skin in the external ear canal

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2
Q

How does otitis externa present?

A

Localised or diffuse
It can spread to the external ear (pinna)
* Acute (less than 3 weeks)
* Chronic (more than 3 weeks)

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3
Q

What can a person to do to increase their risk of developing otitis externa?

A
  • Swimming = exposure to water whilst swimming can lead to inflammation in the ear canal
  • Trauma (cotton buds or earplugs)
  • Ear wax (cerumen) = protective against infection → removal of ear wax increasing infection risk
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4
Q

What can the inflammation in otitis externa be caused by?

A
  • Bacterial infection
  • Fungal infection (e.g., aspergillus or candida)
  • Eczema
  • Contact dermatitis
  • Seborrhoeic dermatitis

Antibiotics kill ‘friendly bacteria’ that are protective against fungal infections: Abx → Fungal infection

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5
Q

Tom Tip

A

Think about fungal infection in patients that have had multiple courses of topical antibiotics. Antibiotics kill the “friendly bacteria” that have a protective effect against fungal infections. This is similar to how oral antibiotics can predispose people to develop oral or vaginal candidiasis (thrush).

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6
Q

What are the 2 most common bacterial causes of otitis externa?

A
  • Pseudomonas aeruginosa
  • Staphylococcus aureus
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7
Q

What type of bacteria is pseudomonas aeruginosa?

A

Gram-negative aerobic rod-shapd bacteria
(Likes to grow in moist oxygenated environments → hence colonises lungs of CF patients - increasing morbidity + mortality)

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8
Q

Tom Tip

A

TOM TIP: It is worth remembering Pseudomonas aeruginosa. It is a gram-negative aerobic rod-shaped bacteria. It likes to grow in moist, oxygenated environments. Other than causing otitis externa, an important exam-related point to remember is that it can colonise the lungs in patients with cystic fibrosis, significantly increasing their morbidity and mortality. It is naturally resistant to many antibiotics, making it very difficult to treat in children with cystic fibrosis. It can be treated with aminoglycosides (e.g., gentamicin) or quinolones (e.g., ciprofloxacin).

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9
Q

A patient who is a keen swimmer presents with:

  • Ear pain
  • Discharge
  • Itchiness
  • Conductive hearing loss (if the ear becomes blocked)

Possible diagnosis?

A

Otitis externa

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10
Q

What are the examination findings of a patient with otitis externa?

A
  • Erythema + swelling + tenderness in the ear canal
  • Pus or discharge in the ear canal
  • Lymphadenopathy in the neck or around the ear
  • Tympanic membrane may be obstructed by wax or discharge - may be red if extends to the tympanic membrane → if ruptured - the discharge in the ear canal might be from otitis media rather than otitis externa
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11
Q

What Ix/diagnosis for Otitis externa?

A
  • Clinical diagnosis → examination of the ear canal (otoscopy)
  • Ear swab → used to identify causative oragnism (not usually required)
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12
Q

What is the management of mild otitis externa?

A

Acetic acid 2% (OTC EarCalm)
(Has an antifungal + antibacterial effect)
(Can be used prophylactically before and after swimmin in patients that are prone to otitis externa)

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13
Q

What is the management for moderate otitis externa?

A

Topical antibiotic + steroid

E.g:
* Neomycin + dexamethasone + acetic acid (e.g., Otomize spray)
* Neomycin and betamethasone
* Gentamicin and hydrocortisone
* Ciprofloxacin and dexamethasone

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14
Q

What is main concern of using aminoglycosides (e.g. gentamicin and neomycin) to treat otitis externa?

A

Potentially ototoxic (rarely causing hearing loss if they get past the tympanic membrane)

Therefore essential to exclude a perforated tympanic membrane before using topical aminoglycosides in the ear. This can be difficult if the patient has discharge, swelling or wax blocking the ear canal → refer to ENT for microsuction to remove debris and visualise tympanic membrane better

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15
Q

What is the management for severe otitis externa or those presenting with systemic symptoms?

A

Oral antibiotics (flucloxacillin or clarithromycin)
Maybe IV (admission)

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16
Q

If a patient with otitis externa has a very swollen ear canal, what else can be used to settle the inflammation for treatment to be useful?

A

An ear wick
= sponge or gauze containing topical treatement (antibiotics + steroids) + left for 48 hours

As the swelling and inflammation settle, the ear wick can be removed, and treatment can continue with drops or sprays.

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17
Q

What is used to otitis media (fungal causative organsim)?

A

Cloterimazole ear drops

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18
Q

What is the main drug to remember for otitis externa treatment?

A

Otomize ear spray (acetic acid)

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19
Q

What is malignant otitis externa?

A

Severe and potentially life-threatening form of otitis externa
Infection = spreads to the bones surrounding the ear canal + skull → progresses to osteomyelitis of the temporal bone of the skull

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20
Q

Which individuals are most at risk of developing otitis externa?

A

Immunocompromised individuals:
* Diabetes
* Immunosuppressant medications (e.g. chemotherapy)
* HIV

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21
Q

How does severe otitis externa present?

A

Symptoms are generally more severe than otitis externa, with persistent headache, severe pain and fever.

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22
Q

What is the key finding that indicates malignant otitis externa?

A

Granulation tissue at the junction between the bone + cartilage in the ear canal (about halfway along)

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23
Q

What is the management of malignant otitis externa?

A

Emergency management:
* Admission under ENT team
* IV antibiotics
* Imaging (CT or MRI head) to assess extent of infection

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24
Q

What are the complications of otitis externa?

A
  • Facial nerve damage + palsy
  • Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves)
  • Meningitis
  • Intracranial thrombosis
  • Death
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25
Q

What is the conjunctivitis?

A

Conjunctivitis = inflammation of the conjunctiva (covers the eyelid + sclera)

Maybe:
* Bacterial, viral, allergic
* Unilateral or bilateral

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26
Q

How does conjuctivitis present?

A
  • Red bloodshot eye
  • Itchy or gritty sensation
  • Discharge

NO pain, photophobia or reduced visual acuity (discharge covering the eye may cause blurry vision - but should return to normal when discharge is cleared)

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27
Q

How does bacterial conjunctivitis present?

A
  • Purulent discharge
  • Typically worse in the morning → eyes stick together
  • Usually starts in one eye + can spread to the other
  • Highly contagious
  • Red bloodshot eye
  • Itchy or gritty sensation
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28
Q

How does viral conjunctivitis present?

A
  • Usually clear discharge
  • Often associated with other viral symptoms (e.g. dry cough, sore throat, blocked nose)
  • Maybe tender pre-auricular lymph nodes (in front of the ear)
  • Contagious
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29
Q

Management of conjunctivitis

A
  • Usually resolves in 1-2 weeks w/o treatment (even bacterial)
  • Hygiene measures (spreading), cooled boiled water + cotton wool to clear discharge
  • Chloramphenicol or fusidic acid eye drops (bacterial)
  • Neonates (under 1 month) → urgent ophthalamology; neonatal conjunctivitis may be caused by gonococcal infection → serious complications (e.g. permanent vision loss)
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30
Q

Drug treatment for bacterial conjunctivitis?

A

Chloramphenicol or fusidic acid eye drops

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31
Q

What is allergic conjunctivitis?

A
  • Allergic conjunctivitis = caused by contact with allergens
  • Causes swelling of the conjunctivital sac + eyelid + itching + watery discharge
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32
Q

Patient presents with swelling of the conjunctival sac and eyelide, its itchy and there is a watery discharge. Possible diagnosis?

A

Allergic conjunctivitis

Think of hayever (and Thelma)

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33
Q

What is allergic conjunctivitis?

A

Antihistamines (oral or topical)

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34
Q

What can be used in patinets with chronic seasonal symptoms of allergic conjunctivitis ?

A

Topical mast cell stabilisers
(They prevent mast cells from released histamine)
(Require several weeks of use before they show any benefit)

35
Q

What is benign paroxysmal positional vertigo (BPPV)?

A
  • BPPV = Common cause of recurrent episodes of vertigo → triggered by head movement
  • BPPV = a peripheral cause of vertigo (problem is located in the inner ear - rather than the brain)
36
Q

What triggers benign paroxysaml positional vertigo (BPPV)?

A
  • Variety of head movements = can trigger attacks of vertigo
  • Common trigger = turning over in bed
37
Q

How can benign paroxysaml positional vertigo (BPPV) present?

A
  • Symptoms settle after around 20-60 seconds
  • Patients = asymptomatic between attacks
  • Often episodes occur over several weeks and then resolve but can reoccur weeks or months late

BPPV does not cause hearing loss or tinnitus.

38
Q

What is the pathophysiology underlying benign paroxysmal positional vertigo (BPPV)?

A
  • BPPV = caused by crystal of calcium carbonate called otoconia → become displaced into the semicircular canals (most often in the posterior semicircular canal)
  • The crystals = disrupt the normal flow of endolymph through the canals → confusing the vestibular system
  • Head movement = creates flow of endolymph in the canals → triggering episodes of vertigo
39
Q

What can cause displacement of the otoconia causing BPPV?

A
  • Viral infection
  • Head trauma
  • Ageing
  • Without a clear cause
40
Q

Why is the Dix-Hallpike Manoeuvre used in BPPV?

A

Diagnose BPPV
* Moving the pts head in a way that moves endolyph through the semicircular canals triggering vertigo in BPPV patients
* Will trigger rotational nystagmus + symptoms of vertigo
* (The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV))

Dix = Dx

41
Q

Why is the Epley manoeuvre performed in a patient with BPPV?

A

To treat BPPV
* Moves the crystals in the semicircular canal into a position that does not disrupt endolymph flow

42
Q

When are Brandt-Daroff exercises peformed?

A

Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV

These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.

43
Q

What is the most common cause of tonsillitis?

A

Viral
(Obvs don’t need Abx)

44
Q

What is the most common cause of bacterial tonsillitis?

A

Group A streptococcus (streptococcus pyogenes)

45
Q

What is the treatment for Group A streptococcal tonsillitis (most common bacterial tonsillitis)?

A

Penicillin V
(Phenoxymethylpenicillin)

46
Q

What is the most common alternative cause of tonsillitis (not Group A strep)?

A

Streptococcus pneumoniae

47
Q

What bacteria is the most common cause of otitis media, rhinosinusitis and most conmon alternative bacterial cause of tonsillitis?

A

Streptococcus pneumoniae

48
Q

Name other causes of tonsillitis than group A streptococcus

A
  • Streptococcus pneumoniae
  • Haemophilus influenzae
  • Staphylococcus aureus
  • Morazella catarrhalis
49
Q

Which tonsils are usually infected and enlarged in tonsillitis?

A

Palantine tonsils

50
Q

What are the six areas of lymphoid tissue in the pharynx that make up Waldeyer’s tonsillar ring?

A

6 in total:
* Adenoid
* Tubal tonsils
* Palantine tonsils
* Lingual tonsil

51
Q

What is the typical presentation of tonsillitis?

A
  • Fever
  • Sore throat
  • Painful swallowing
52
Q

At what ages does tonsillitis usually occur?

A

Peaks at:
5-10
15-20

53
Q

How does tonsillitis present in younger children?

A

More non-specific symptoms:
* Fever
* Poor oral intake
* Headache
* Vomitting
* Abdominal pain (maybe)

54
Q

What will you find on examination of the tonsils in a patient with tonsillitis?

A

Tonsils:
Red, inflamed, enlarged tonsils with or without exudates (small white patches of pus on the tonsils)

55
Q

When a patient presents with tonsillitis, apart from the tonsils, what else must you exam?

A
  • Ears (visualise tympanic membrane)
  • Cervical lymphadenopathy (palpate)
56
Q

What criteria do you use to estimate that tonsillitis is due to a bacterial infection?….and will benefit from antibiotics

A

Centor criteria

57
Q

What score in the centor criteria will deem it appropriate to offer antibiotics?

A

Score of 3 (40-60%)

58
Q

What is the criteria for the Centor criteria (for tonsillitis)?

A

FETA:
* Fever over 38ºC
* Tonsillar exudates
* Tender anterior cervical lymph nodes (lymphadenopathy)
* Absence of cough

59
Q

What is the FeverPAIN score?

A

Gives you the probability of tonsilitis being bacterial
* 2-3 → 3-4-40%
* 4-5 → 62-65%

60
Q

What is the criteria for the FeverPAIN score?

A
  • Fever during previous 24 hours
  • P – Purulence (pus on tonsils)
  • A – Attended within 3 days of the onset of symptoms
  • I – Inflamed tonsils (severely inflamed)
  • N – No cough or coryza
61
Q

What serious pathology must you exclude when a patient presents with likely tonsillitis?

A
  • Meningitis
  • Epiglottis
  • Peritonsillar abscess
62
Q

What is the management for tonsillitis?

A
  • Viral → educate, simple analgesia (pain + fever)
  • Pt advised to return if pain not settled after 3 days or fever rises above 38.3C → consider antibiotics or alternative diagnosis
  • Antibiotics: phenoxymethylpenicillin (Penicillin V) or clarithromycin (10 days)
63
Q

When do you prescribe Abx (Pen V or clarithromycin) for tonsillitis?

A
  • Centor score ≥ 3 or the FeverPAIN score ≥ 4
  • At infection risk: Infants, immunocompromised patients, Hx of rheumatic fever
64
Q

If you are unsure whether a patient has a viral pharyngitis or bacterial tonsillitis, what can you do in terms of prescribing?

A

Delayed prescription
(They can pick them up in a couple of days if it doesn’t improve or worsens)

65
Q

When should you consider admission for someone with tonsillitis?

A
  • Immunocompromised
  • Systemically unwell
  • Dehydrated

Has:
* Stridor
* Respiratory distress
* Evidence of peritonsillar abscess or cellulitis

66
Q

What are some complications of tonsillitis?

A
  • Chronic tonsillitis
  • Peritonsillar abscess, also known as quinsy
  • Otitis media if the infection spreads to the inner ear
  • Scarlet fever
  • Rheumatic fever
  • Post-streptococcal glomerulonephritis
  • Post-streptococcal reactive arthritis
67
Q
A
67
Q
A
68
Q
A
69
Q

What is sinusitis?

A

Inflammation of the paranasal sinuses in the face

Usually accompanied by inflammation of the nasal cavity = rhinosinusitis

70
Q

What is the difference between acute and chronic sinusitis?

A

Acute (less than 12 weeks)
Chronic (more than 12 weeks)

71
Q

What do paranasal sinuses do?

A
  • Paranasal sinuses = hollow spaces within the bones of the face - arranged symmetrically around the nasal cavity.
  • They produce mucous and drain into the nasal cavities via holes called ostia.
  • Blockage of the ostia prevents drainage of the sinuses → resulting in sinusitis.
72
Q

What are the 4 paranasal sinuses?

A
  • Frontal sinuses (above the eyebrows)
  • Maxillary sinuses (either side of the nose below the eyes)
  • Ethmoid sinuses (in the ethmoid bone in the middle of the nasal cavity)
  • Sphenoid sinuses (in the sphenoid bone at the back of the nasal cavity)
73
Q

What are the causes of inflammed sinuses?

A
  • Infection → particularly following viral upper respiratory tract infections
  • Allergies → such as hayfever (with allergic rhinitis)
  • Obstruction of drainage →e.g due to a foreign body, trauma or polyps
  • Smoking
74
Q

People with what condition are more likely to develop sinusitis?

A

People with asthma

74
Q

What is the typical presentation of acute sinusitis?

A

Some presenting with a recent viral upper respiratory tract infection and:
* Nasal congestion
* Nasal discharge
* Facial pain or headache
* Facial pressure
* Facial swelling over the affected areas
* Loss of smell

75
Q

What may examination of a patient with sinusitis show?

A
  • Tenderness to palpation of the affected areas
  • Inflammation and oedema of the nasal mucosa
  • Discharge
  • Fever
  • Other signs of systemic infection (e.g., tachycardia)
76
Q

What is chronic sinusitis associated with?

A

Nasal polyps
(Growths of the nasal mucosa)

77
Q

What are the investigations for sinusitis?

Usually doesn’t require Ix, only if unresponsive to treatment

A
  • Nasal endoscopy
  • CT scan
78
Q

What is the management for acute sinusitus?

A
  • Symptoms less than 10 days → nothing probs viral

Not improving after 10 days
* High dose steroid nasal spray for 14 days (e.g.,** mometasone 200 mcg twice daily)
* A delayed antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin** = first-line)

79
Q

What is the management for chronic sinusitis?

A
  • Saline nasal irrigation
  • Steroid nasal sprays or drops (e.g.,** mometasone** or fluticasone)
  • Functional endoscopic sinus surgery (FESS)
80
Q

What is functional endoscopy sinus surgery (FESS) used fo ?

A
  • Used to remove or correct any obstructions to the sinuses
  • Obstruction may be caused by swollen mucosa, bone, polyps or a deviated septum (surgery to correct a deviated septum is call septoplasty).
  • Balloons may be inflated to dilate the opening of the sinuses.

Patients need a CT scan before the procedure to confirm the diagnosis and assess the structures.

81
Q
A

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