Hearing Loss and Common ENT Presentations Flashcards
1
Q
What are the differential diagnoses for ear discharge?
A
- Acute otitis media or otitis externa
- Both very painful, with reduction in pain if TM perforates
- Chronic suppurative otitis media
- Painless and smelly
- Acute infection usually indicated by bloody / whitish / pus discharge.
- Cholesteatoma usually produces a smelly discharge.
2
Q
Why it otitis media more common in children?
A
Because they have shorter and flatter Eustachian tubes.
3
Q
What are the systemic symptoms commonly caused by acute otitis media?
How is otitis media treated?
A
- Acute otitis media can cause fever and malaise.
- It is usually treated with oral ABx, or drops if the patient is well and the TM has perforated.
4
Q
How is otitis externa treated?
A
- Topical treatment is most effective in treating otitis externa.
- The patient is usually systemically well.
- If ear canal is almost swollen shut patient needs urgent ENT referal for otowicks.
5
Q
How are chronic suppurative otitis media and cholesteatoma managed?
A
- The patient is well but the discharge usually does not settle with oral or topical ABx.
- TM will be persistently abnormal.
- Outpatient ENT referral is required.
6
Q
What are the complications of acute otitis media?
A
- Spread of infection around the middle ear and via perforating vessels into the brain.
- Mastoiditis / subperitoneal abscess
- Meningitis
- Cerebral abscess / empyema
- Facial nerve palsy
- IJV thrombosis
7
Q
What are the complications of otitis externa?
A
- Spreading cellulitis on face and neck.
- Osteomyelitis.
8
Q
What are the complications of chronic suppurative otitis media?
A
- Facial nerve palsy
- Lateral semicircular canal fistula resulting in vertigo
- Conductive hearing loss
- Complete sensorineural hearing loss
- Meningitis
- CSF leak
9
Q
Describe vertigo.
What should be elicited in the history of a patient with ?vertigo?
A
- Vertigo is a sensation of motion of either subject or their surroundings in the absence of movement.
- In inner ear pathology this is often rotatory.
- Dizziness, giddiness, light-headedness are very non-specific symptoms.
- History is key:
- Exact sensation, duration, precipitating factors e.g. certain head movements, episodic or regular, associated symptoms e.g. hearing loss, ear fullness, tinnitus, nausea / vomiting, headache.
10
Q
What are the different causes of dizziness?
A
- Cardiac
- Neurological
- Pharmacological
- Sight-related
- Postural
- ENT
11
Q
What are the common ENT-related causes of dizziness?
A
- Benign paroxysmal positional vertigo
- Acute vestibular neuronitis (labyrinthitis)
- Vestibular migraine
- Secondary to AOM or CSOM
- Meniere’s disease (mich less common than the rest)
12
Q
What is epistaxis and why does it happen?
A
- Nosebleeding - common ENT emergency.
- Causes in children:
- Nose picking
- Anterior nasal infections
- Settles with topical ABx cream. Occasionally need cautery.
- Causes in adults:
- Post traumatic
- Secondary to hypertension
- Digital manipulation
- Idiopathic
- Most commonly troublesome in the anticoagulated (DVT / PE / cardiac) or thrombocytopaenic population (e.g. cancer / haematology patients).
13
Q
How is epistaxis managed?
A
- First aid measures - pressure to the cartilaginous part of the nose for 10 minutes, ice over forehead, head forward.
- If persisting and profuse needs A&E / ENT management, cautery, nasal packing if source is not clear.
- If multiple regular, short bleeds, ABx cream, advice to avoid picking and rationalise anticoagulation if possible.
- Refer to ENT clinic if above is unsuccessful.
- Haematological derangement requires haematology input as topical measures do not work in the absence of intact clotting mechanisms.
14
Q
What are the causes of nasal blockage?
A
- Due to mechanical or functional obstruction.
-
Mechanical obstruction:
- Septal cartilage deviation (possibly post-injury)
- Nasal polyps
- Foreign body
- Tumours
- Choanal atresia
-
Functional obstruction:
- Allergic rhinitis
- URTI
- Rhinitis medicamentosa
- Drugs
- Nasal polyps are associated with rhinitis and asthma, but not everyone with rhinitis will develop them, indeed only a minority.
15
Q
Describe sinusitis:
- Duration
- Symptoms and associated features
- Treatment
A
- Acute or chronic.
- Chronic can be with or without nasal polyps.
- Acute sinusitis duration <3/12, usually following URTI.
- Symptoms:
- Painful
- Purulent discharge
- Blockage
- Dull headache
-
Not painful around face / eyes
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16
Q
What is chronic rhinosinusitis?
How is it managed?
A
- Chronic rhinosinusitis (CRS) is defined as persistent symptomatic inflammation of the nasal and sinus mucosa.
- Needs referral to ENT for confirmation of diagnosis and management.
- Management:
- Topical +/- oral steroids, long course of macrolide ABx, if not responsive, CT sinuses and surgery for drainage / opening of sinuses to allow deeper penetration of topical treatment.
- Surgery does not cure the underlying rhinitis / mucosal dysfunction that leads to CRS.
17
Q
Describe these CT images of the sinuses.
A
-
A
- Normal
- Black and therefore full of air
-
B
- Full of secretions, nasal thickenings and polyps
19
Q
Describe bacterial tonsilitis and how you would treat.
A
- High temperature
- Difficulty swallowing
- Treatment:
- Oral ABx - penicillin unless allergic.
- Plenty fluid and rest.
- Symptoms should resolve in 7-10 days.
- If unable to take fluids / ABx orally, may need hospital admission.
- Multiple recurrent episodes - consider referral for tonsilectomy.
20
Q
Describe glandular fever and how you would treat.
A
- Commonest type of viral tonsilitis.
- Systemic malaise
- Fatigue
- Lymphadenopathy (bilateral neck nodes, +/- axillary and inguinal nodes with hepatosplenomegaly)
- Mild pyrexia
- Usually huge, spotty tonsils.
- Conservative measures unless secondary bacterial infection.
- Avoid alcohol / contact sports.
- Can take 3-4/52 for symptoms to settle and lead to severe fatigue.
21
Q
Describe quinsy and how you would treat.
A
- Peri-tonsillar abscess:
- Pyrexia
- Difficulty swallowing
- Symptoms more unilateral and swelling ++ in throat
- Emergency ENT referral for drainage.
- Usually require 24-48 hrs of IV ABx.
- If drainage is unsuccessful, may need emergency tonsilectomy.
22
Q
Describe supra- / epiglottitis and how you would treat.
What is the most common causative organism?
A
- Most common causative organism is H. influenza.
- Severe sore throat and fever with almost complete dysphagia.
- May be drooling / having difficulty breathing.
- Throat looks normal or slightly red.
- ENT emergency - needs urgent attention to the airway as can obstruct very quickly.
- Avoid examination in child if suspected as upset can precipitate airway obstruction.
- Commonest in 2-6 years and >60s.
- Most common in >60s because they have not been immunised against H. influenza.
23
Q
Describe laryngitis and how you would treat.
A
- Usually viral.
- Hoarse / voice loss but no difficulty breathing and normal or near normal swallow.
- Clinical diagnosis: acute onset of loss of voice, painless or slight sore throat and malaise.
- Conservative management, consider referral to ENT if persisting over 4/52.
31
Q
Describe a normal audiogram.
A
- If you have normal hearing you should be at the very top of this scale at all the different frequencies.
- Within 20 is the lower limit of normal hearing.
35
Q
What is otosclerosis? What does it cause?
A
- CHL caused by excessive ossification around the footplate of the stapes, where it transmits sound into the oval window.
- Usually the only symptom is hearing loss which is progressive and conductive. TM appearance is normal.
37
Q
Describe noise-induced hearing loss.
How should it be managed?
A
- Either due to a sudden ‘impulse’ sound (e.g. explosion), or more commonly, to prolonged, repeated exposure over time (e.g. loud concerts, headphones, occupational, shooting).
- Caused by the permanent damage and loss of the hair cells in the cochlea over time.
- Best approach is prevention; there is no treatment available once it has occurred except hearing aids.
41
Q
What are the surgical options in managing hearing loss?
A
- It is only possible to correct CHL or improve it by using implantable bone conducting hearing aids.
- The only surgical option for SNHL is a cochlear implant, for which there are very strict criteria for patients that are getting little benefit from conventional hearing aids.
- Grommets help to correct CHL caused by OME (pictured).
- Middle ear fluid is aspirated and long term middle ear ventilation occurs through the TM rather than relying on the eustachian tube.
- Designed to stay in place for ~1 year then fall out.
-
Stapedectomy for otosclerosis aims to disconnect the otosclerotic stapes footplate from the oval window and allow insertion of a prosthesis. The prosthesis is between the incus and the footplate to allow normal mobility once again.
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