Lecture 16: Ear and throat Clinical management Flashcards
1
Q
What are the important features in the outer ear?
A
- Ear canal: tube that carries sound to the eardrum. Site for conditions like otitis externa, excessive ear wax
- Tympanic membrane (ear drum): A thin membrane that vibrates in response to sound and transmits to middle ear
2
Q
What are the important features in the middle ear?
A
- Malleus (hammer):
- Incus (anvil)
- Stapes (stirrup)
- Eustachian tube
3
Q
What is the Stapes?
A
- Stapes (stirrup) smallest, has a base that fits into oval window of inner ear. Transmits vibrations from the incus to window of cochlea. Converts mechanical vibrations into waves -> sound perception prevents excessive vibrations that damage ear
4
Q
What is the incus?
A
between malleus and stapes. Acts as a bridge, passing vibrations and amplifies sound
5
Q
What is the malleus?
A
Largest of 3, attached to tympanic membrane and incus, receives sound vibrations from ear drum and transfers to incus
6
Q
What is the Eustachian tube?
A
- Connects to throat and back of nose
- It drains fluid and equalises pressure
7
Q
What are the important features of the inner ear?
A
- Vestibular nerve: Balance, co-ordination of eye movements. Sensory info from inner ear -> brain
- Cochlea: Spiral shaped, has hair cells that convert sound waves -> nerve signals
8
Q
What are the features of the Tympanic membrane?
A
- Light reflex: cone of light, bright reflection when examined w/ otoscope
- Umbo (central point)
- Annulus: Thickened edge (ring)
- Handle of malleus and lateral process of malleus
9
Q
What are some outer ear infections?
A
- Otitis externa
- Wax build up
- Dermatitis/ seborrheic dermatitis (fungal infection)
- Tumour (basal and squamous cells)
- Cauliflower ear (trauma)
10
Q
What is Otitis Externa and what are the symptoms?
A
- Swimmers ear
- Inflammation in the external ear canal triggered by bacterial infection
- Usually 1 ear affected
- Symptoms: Itching, discharge, pain, redness, inflammation, odour
11
Q
What do you expect to see about Otitis Externa on an Otoscope?
A
- Light - coloured discharge
- Redness, inflammation
- Possibly an odour
12
Q
What is the treatment for Otitis Externa?
A
- Self limiting may take weeks to resolve
- OTC: ear calm acetic acid, acts as an astringent by reducing pH and reduces bacterial and fungal cell growth, efficacy reduced after a week
- If recurrent/OTC fail: give anti-infective w/ without corticosteroid for 1/2 wks (Otomize)
- Refer after
13
Q
What is some self care advice for Otitis Externa?
A
- Avoid getting the ear wet
- Avoid swimming
- Remove leaking discharge with cotton bud (dont stick in ear)
- Consider analgesia for pain/discomfort
14
Q
What is impacted wax made of and when is it a problem?
A
- Wax is produced to protect against water and infection, made of sebum and dead skin cells
- Wax builds up quicker than body can remove
- Problem when wax starts causing irritation, discomfort or hearing loss
15
Q
What are some risk factors for impacted wax?
A
- Older patients
- Narrowed ear canal - injury, inflammation
- Skin issues
- Benign bony growths blocking ear canal
- Hearing aids
16
Q
What are some things a patient may say they feel when they have impacted wax?
A
- Feeling of pressure that can radiate to jaw
- A feeling of ‘full’, ‘blocked’ or ‘being underwater’
- Cracking/popping sounds
- Itching
- Ringing
- Feel off balance
17
Q
What are some key questions to ask when discussing impacted wax?
A
- Constant dizziness? unlikely to be associated with ear wax
- Inner ear pain?, infection?
- Cotton bud user
- History of perforation - avoid drops unless advised by GP
18
Q
What is the treatment for impacted wax?
A
- Cerumenolytics to soften ear wax, has side effects of local irritation, 7-10 days to work, might feel worse before better
- oil based: olive oil, 2-3 drops BD/TDS
- peroxide based products: otex. mild temp effervescence as oxygen bubbles produced
- Microsuction: vaccum in private, must use drops before
19
Q
What are the middle ear conditions?
A
- Blocked eustachian tube: from viral infection
- Otitis media
- Otitis media w/ efflusion
- Otomycosis
- Cholesteatoma
- Osteomas
- Perforation
- Grommets
- Tympanosclerosis (scarring): result from infection/surgery
20
Q
What is acute otitis media?
A
- Inflammation in middle ear with rapid onset and symptoms of an ear infection
- More common in children than adults by viruses or bacteria
21
Q
What are the symptoms of acute otitis media?
A
- Pain in ear
- Fever
- Irritability
- Restlessness at night
- Cough
- Rhinorrhoea (runny nose)
22
Q
What is the management like for acute otitis media?
A
- Self limiting
- Often resolves within 3-7 days (1 week) without antibiotics
- Advise self care with analgesics: paracetamol/ ibuprofen
- If child = systemically very unwell antibacterial considered: amoxicillin 5 day course
23
Q
What is Otitis media with effusion (glue ear)?
A
- Collection of fluid in middle ear without signs of inflammation or infection
- More freq in children 6mnths-4yrs
- More prevalent in kids with Downs Syndrome, Cleft palate, allergic rhinitis, CF
- In children without hearing loss: self limiting
- Children w/ hearing loss = refer
24
Q
What are the differences between acute otitis media and otitis media effusion?
A
- AOM: infective, significant pain, tympanic membrane buldging due to infected fluid, ear = red, inflamed
- OME: Non-infective, full feeling and dullness in ear, presents as bubbles behind membrane, sometimes associated w/ hearing loss
25
What are the symptoms otomycosis (fungal infection)?
- Presents similar to otitis externa
- Symptoms: white, soggy discharge
- Itching in ear canal
- Black fungal spores
26
What is the treatment for otomycosis?
- Should refer patient - treat with anti-fungal ear drops
- Clotrimazole 1% drops
27
What is Cholesteatoma?
- Retraction of the tympanic membrane
- As dead skin migrates away from the membrane, it gets trapped in the pocket
- Over time the skin gets infected causing corrosion of the membrane, ossicles, mastoid bone
- Not have symptoms until latter stages when will have hearing loss
28
What are Osteomas?
- Slow growing, benign bony growths in ear canal
- Doesnt usually cause pain or hearing difficulties - unaware
- Associated with chronic-cold water exposure
- Seen in swimmers or surfers
29
What is perforation?
- Old healed perforation in tympanic membrane
- Borders are smooth, clear and rounded, no signs of inflammation
- A new perforation will have jagged edge, caused by trauma, injury, loud noises
- Resolves on own, antibiotics may be necessary
- Avoid ear drops
30
What are Grommets?
- Very small tube implanted into tympanic membrane to allow fluid to drain from middle ear
- Commonly seen in younger patients when children cant hear
- Always refer to ENT
- They will drop out on their own - dont need to be removed
31
What are some red flags for ear?
- Redness/inflammation: if caused by OM treated under PGD
- Bulging of TM
- Severe unexplained pain
- Perforation/Grommets
- Discharge
- Marked hearing loss
- Mastoid tenderness
32
What are conditions of the inner ear?
- Disruption of hearing and balance
- Tinnitus and Vertigo
- Menieres disease
33
What is Vertigo?
- It is a symptom not diagnosis
- False sense of movement (spinning or rotation) and absence of movement
- Can last few seconds to hours
- Associated symptoms: hearing loss, ear discharge, headache, visual disturbances
34
What are the causes of Vertigo?
- Peripheral or central cause
- Peripheral: more common inner ear problem of the labyrinth or vestibular nerve: benign paroxysmal positional vertigo (BPPV) specific head movements
- Central: Pathology in brainstem e.g. stroke, MS, TIA
35
How do you manage vertigo?
- Management dependent on type of vertigo
- Urgent referral for severe cases of peripheral vertigo
- Advise adequate hydration
- More slower and avoid head movements if trigger
- Prochlorperazine, cyclizine, promethazine teoclate, cinnarizine
36
What is Tinnitus?
- Symptom not disease
- Perception of sound in the absence of external stimuli
- Described as ringing, buzzing, clicking
- May resolve on own
37
What are the causes of Tinnitus?
- Unknown
- Hearing loss
- Trauma/ exposure to loud sounds
- Menieres disease
- Medicines (chemo/NSAIDs)
38
How do you manage Tinnitus?
- Urgent referral for severe cases
- Very urgent referral w/ tinnitus developed suddenly over 3 days
- Should resolve on its own
- Address underlying causes
- Stress management
- Treat hearing loss if necessary
39
What is Menieres disease?
- Disorder of inner ear characterised by episodes of vertigo (lasting hrs), fluctuating hearing loss, feeling of fullness, N+V
- Associated tinnitus and hearing loss that resolves between attacks
40
What is the cause of Menieres Disease?
- Pathophysiology is unknown
- Caused by raised pressure of membrane of labyrinth of inner ear
41
How do you manage Menieres disease?
- Menieres is long term, vertigo usually improves with treatment
- Vertigo managed with oral meds
- Acute attacks settle in 24hrs
- ENT should be involved as part of management
- Betahistine (analogue of histamine) considered for long prophylaxis
42
What are some common causes of a sore throat related to throat conditions?
- Laryngitis: Inflammation of larynx
- Acute Pharyngitis: Inflammation of pharynx
- Tonsilitis
- Glandular fever: a viral infection, usually caused by the Epstein-Barr virus (EBV)
43
What is acute tonsilitis and what are the symptoms?
- Inflammation of the tonsils
- Associated with viral and less bacterial
- Sore throat and pain when swallowing
- Fever
- Swollen glands
- More common in children than adults
- Usually 3-4 days
44
What are some complications of acute tonsilitis?
- Quinsy: absess forms between 1 of the tonsils and walls of the throat
- Can block airways
- May need absess to be drained
45
What is the fever pain score?
- Prediction tool to determine likelihood of streptococcal infection and need for antibiotics
46
What are the 5 pain criteria for the fever pain score?
- Fever (during previous 24hr)
- Purulence (pus on tonsils)
- Attend rapidly (within 3 days of onset)
- Severely inflamed tonsils
- No cough
47
What are the symptoms of a strep throat (streptococcus A)?
- Flu like symptoms (high temp, swollen glands)
- Usually mild and easily treated
- Children more commonly affected
- Sore throat, white patches on tonsils, petechiae (tiny spots of bleeding under the skin) on roof of mouth, strawberry tongue
- Refer if antibiotic treatment needed
48
What are the symptoms of Glandular fever (Epstein Barr)?
- Symptoms persist for several months
- Swollen lymph glands
- General malaise, fatigue, muscle aches, possible rash, fever, loss of appetite, headache
49
What does glandular fever present as?
- Severe sore throat following 1-2 weeks of malaise (general feeling of discomfort)
- Inflamed throat with exudate
- swollen lymph nodes
- Age 15-25yrs old
50
How do you treat glandular fever?
- rest
- hydration
- over-the-counter pain relievers like paracetamol or ibuprofen.
51
What are some red flags or throat referral points?
- Persistent sore throat over 1 week
- Difficulty swallowing (dysphagia)
- Severe pain
- Displaced uvula
- Persistent unexplained hoarseness
- Signs of airway obstruction
- Certain meds: methotrexate
- Clinical dehydration
52
How do you manage sore throats?
- Most are self-limiting resolve within a week with/out antibiotics
- Self care advice and safety netting
- Analgesia: Oral OTC paracetamol/ibuprofen
- Lozenges and pastilles = soothing effect
- Anaesthetic throat sprays/rinse
- Fluid intake
- Refer recurrent tonsilitis
- Children to school after 24hrs of taking antibiotics or once fever resolved
