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ENT > Lesson 4 > Flashcards

Lesson 4 Flashcards

1
Q

Classification of otitis externa according to localisation.

A

Local = circumscribed/ furuncle, diffuse.

General = 1° otological, 1° dermatological

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2
Q

Classification of otitis externa according to aetiology.

A
  1. Infective = bacterial, fungal, viral.
  2. Reactive / allergies
  3. Mixed
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3
Q

Incidence of otitis externa.

A

Tropical countries with high humidity.

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4
Q

Aetiology of otitis externa.

A
  1. Pathogenesis organism through contaminated scratching,dirty instruments, trauma, ear syringing, unclean hearing aid earpieces.
  2. Allergy through cosmetics, antibiotics, psychological and mental stress.
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5
Q

Stages of diffuse otitis externa.

A
  1. Acute = exfoliative and exudative

2. Chronic = granular and proliferation.

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6
Q

Acute clinical picture of diffuse otitis externa.

A

Early = heat then pain of the ear, pain during jaw movement, thin serous discharge.

Late = thick purulent foul smelling discharge, inflamed swollen tender tissue, conductive deafness, enlarged periauricular nodes, oedema with displaced auricle, absence of wax.

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7
Q

Bacteriology of otitis externa.

A
  1. Staphylococcus albus
  2. Staphylococcus aureus
  3. Non haemolytic streptococcus
  4. Pseudomonas pyocanea
  5. Proteus vulgaris
  6. E.coli
  7. Mixed
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8
Q

Furunculosis/ boils main features.

A

It is a staph infection of the hair follicle/ sebaceous gland on the skin of the outer cartilaginous part of the external meatus.

Can be superficial or deep.

Single or multiple.

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9
Q

Clinical picture of furunculosis.

A

Typical = pain, tenderness of the meatus, swelling of the meatal walls, deafness, fever

Superficial = red, circumscribed, tender.
Deep = more diffuse, tender on pressure.

Anterior/inferior wall = pain increases during chewing, swelling of the lower eyelid

Posterior wall = auricle protrusion, obliteration of the postaurocular sulcus due to oedema.

Spreading = anterior to auricle, below to the tip of the mastoid process.

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10
Q

Treatment of furunculosis.

A
  1. Daily metal packing with gauze soaked in 10% ichthammol glycerin solution, boric acid solution, hydrocortisone / unguents/ emulsion + ab/ steroids.
  2. Removal of discharge; dry mopping, continue with ichthammol glycerin wicks
  3. After treatment keep the external meatus clean with 1% solution of dioxydion.
  4. Pain relief = antibiotic penicillin for S. aureus for 5 day’s.
  5. Incision = when there is a clean point on the skin.
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11
Q

Chronic clinical picture of diffuse otitis externa.

A

Constant discharge and irritation, severe scratching at night, lumen narrowing, oedema, desquamation, superficial ulceration of the skin, congested and granular surface of the drum head, intermittent deafness.

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12
Q

Treatment of diffuse otitis externa ( general/ both stages)

A
  1. Cleansing of the external meatus
  2. Keep ear dry
  3. Avoid scratching trauma
  4. Personal hygiene
  5. Associate with skin treatment
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13
Q

Treatment of diffuse otitis externa acute stage.

A
  1. Gentle irrigation of meatus with isotonic saline with dry mopping, see drumhead, clean anterior meatal recess, regular meatus toilets g with ear drops.
  2. Anti inflammatory drugs and ABs; sefamicin dexamethasone 2xd
  3. Gauze packing with corticosteroids + AB cream,repeat on alternate days.
  4. Antibiotic drops and ointments to be used on circumstance to avoid sensitisation or 2° fungus infection.
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14
Q

Treatment of diffuse otitis externa chronic stage.

A
  1. Meatus toileting
  2. Reduce swelling with gauze soaked in 10% ichthammol glycerin.
  3. Control irritation with AB/hydrocortisone cream, use gauze then wool tipped applicator.
  4. Nocturnal itching relief with sedatives.
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15
Q

Causes of treatment failure in diffuse otitis externa.

A

Underlying middle ear infection, skin sensitisation to AB, 2° fungal infection.

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16
Q

Main features of otomycosis.

A

It is the mycotic infection of the EAM. Increased incidence in tropical and subtropical climates with increased use of ABs.

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17
Q

Aetiology of otomycosis.

A

Aspergillus niger, Candida albicans

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18
Q

Clinical picture of otomycosis.

A

Usually due to treatment failure of diffuse otitis externa, irritation of the ear, reformation of mass debris in meatus after cleaning.

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19
Q

Diagnosis of otomycosis.

A

Black speck in epithelial debris, microscopic smear, culture and sensitivity test of fungal mycelium.

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20
Q

Treatment of otomycosis.

A
  1. Cleansing and dry mopping
  2. Nystatin powder or ointment
  3. Amphotericin (Candida cream)
  4. 2% salicylic acid in alcohol

Regime for 3-4 weeks.

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21
Q

What is impacted wax?

A

Secretions from the ceruminous glands.

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22
Q

Clinical picture of impacted wax.

A

Solid hard mass that causes deafness, autophony, ear discomfort, tinnitus, balance disturbance (due to wax pressure), cough reflex due to vagus stimulation.

Deafness characteristics = appear suddenly after bath/shower.

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23
Q

Diagnosis of impacted wax.

A

Otoscopic exam shows brown/yellow mass or plug, Black/grey desquamated epithelium, obstructed drumhead.

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24
Q

Treatment of impacted wax.

A

Removal of wax using hook /syringe.
Technique = patient is sitting with head inclined to the same side, pull auricle up and back, inject fluid into meatus, remove wax, if not possible, soften wax with syringe. Inspect if any remaining and dry the meatus with cottonwool mops.

Softening wax with olive oil, almond oil or lukewarm sodium bicarbonate.

Before syringing, ask patient if she/he has previous ear diseases, and perforated drum/ healed with thin scarring to avoid activation of otitis media.

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25
Q

Symptoms of acute suppurative otitis media phase 1.

A

Phase 1 = exudative inflammation (preperforative)

1-2 days with 39- 40° fever, rigours, meningismus (esp in children), pulsating pain worse at night, muffled noise in sync with pulse, deafness, Astrid process sensitive to pressure.

26
Q

Symptoms of acute suppurative otitis media phase 2

A

Phase 2 = resistance and demarcation (perforative)

3-8 days, pain and fever subside, pus and exudate discharge, deafness, phase can be prevented with the use of ABs.

27
Q

Symptoms of acute suppurative otitis media phase 3.

A

Phase 3 = healing

2-4 weeks. Drying of discharge, normal hearing.

28
Q

Pathogenesis of acute suppurative otitis media.

A

Route of infection = tubal (most common), haematogenous (in measles, scarlet fever, typhus,septicaemia), exogenous infection (TM rupture or perforation, dirty irrigation, incorrect removal of FB)

Types of organisms = monomicrobial, streptococci, pneumococci, haemophilus influenza, staphylococci, coliforms, viral.

29
Q

Diagnosis acute suppurative otitis media otoscopy.

A

1st Phase

  • hyperemia
  • moist infiltration
  • opacity of TM surface
  • Disappear handle & short process of malleus contour

Influenzal Otitis

  • Hemorrhagic bullae on EAM & TM
  • Conductive deafness

Peak of Exudative Phase

  • TM bulging
  • Pulsation
  • Tender mastoid process to pressure

2nd Phase

  • Pinhole size fistula
  • Pulsating, thin, fluid, colorless pus

3rd Phase

  • resolving of inflammation and thickening of TM
  • disappear pulsation
  • mucoid discharge later gone
  • fine scar of perforation
  • normal hearing
30
Q

Diagnosis of acute suppurative otitis media radiography.

A

2nd Phase

  • Schueller’s view: clouding of cell system with osteolysis
  • Sharp bony septa

3rd Phase
- Gradual clearing of cell system

31
Q

Differential diagnosis of acute suppurative otitis media.

A

Otitis externa

  • pain on pressure on tragus
  • non pulsating exudates
  • non mucoid exudates
  • no deafness
  • normal cell system on x-ray
32
Q

Treatment of acute suppurative otitis media.

A 
1st Stage
1. Systemic AB
2. Local decongestants
3. Nasal drops
4. Paracentesis
2nd Stage
1. Systemic AB
2. Culture & sensitivity test
3. Local AB
4. Irrigation of tympanic cavity with antiseptics
5. Local decongestants
6. nasal drops

AfterCare

  • Open Eustachian tube if clpse b catheterization / politzerization
  • Check paranasal sinuses & nasoppharynx
  • Adenoidectomy
33
Q

Course and prognosis of acute suppurative otitis media.

A

1st Phase

  • otogenic complication
  • bacterial infection

2nd Phase

  • rare complication
  • latent otitis media & conseqent occult mastoiditis

3rd Phase
- complete heal

34
Q

Types and causes of chronic suppurative otitis media.

A

Types

  1. Tubotympanic type
  2. Tympanomastoid type\

TUBOTYMPANIC TYPE / MESOTYMPANITIS

  • Central perforation of eardrum due to acute otitis media
  • Perforation edges covered by squamous epithelium.
  • So, risk for discharge 2° infection.

Cause

  1. Upper respiratory tract infection
  2. Perforation of external meatus
35
Q

Classification of chronic suppurative otitis media.

A
  1. Anterior
  2. Posterior
  3. Kidney shaped
  4. Subtotal
36
Q

Clinical picture of chronic suppurative otitis media.

A

Intermittent / persistent mucopurulent discharge

  • Deafness 40dB
  • Central perforation
  • Otitis externa
37
Q

Diagnosis of chronic suppurative otitis media.

A
  1. Ear examination
    - Infected in tonsils, adenoids sinusitis in ascending infection
  2. Tuning fork test
    - conductive deafness
  3. Pure tone audiometry
    - conductive deafness
  4. X-Ray
    - To exclude sinusitis
    - cellular mastoid
    - sclerotic mastoid if prolong infection
  5. Ear swab for bacterial investigation
38
Q

Complications of chronic suppurative otitis media.

A
  • Polypus
  • Otitis externa
  • Fixation of ossicles by fibrosis
  • Broken ossicular chain deafness
39
Q

Treatment and preventive measures for chronic suppurative otitis media.

A
  1. Elimination of upper respiratory tract infection
    - removal of adenoids / tonsils
    - treatment of sinusitis
  2. Cleaning of ear
  3. Local AB w or w/o hydrocortisone
    - Gentamycin
    - Neomycin
  4. Systemic AB
  5. Myringoplasty closure
    - if recurring discharge
    - disability of deafness

Preventive Measures

  • Don’t get water into ears when washing / swimming
  • Don’t blow nose
40
Q

What is tympanomastoid/epitympanitis?

A
  • Infection of attic bone, antrum, mastoid process, mucosa of middle ear cleft
  • Granulations / polyps indicates bone involvement
  • Attic type or posterosuperior segment of TM is most dangerous.
41
Q

Clinical features of epitympanitis.

A
  • Purulent / mucopurlent foul smelling ear discharge
  • Deafness
  • Bleeding (if granulation/ polyp)
  • Cholesatoma
42
Q

What is cholesteatoma? And what are it’s causes?

A

It is grayish substance which project from attic or marginal perforation.

Cause
- problems of Eustachian tube function leading to secretory otitis media

43
Q

Theories of formation of cholesteostoma.

A
  1. Congenital
    - fr embryogenic cell rest in cranial bones
  2. Cell Rest
    - from cell rest of squamous epithelium in middle ear mucosa
  3. Metaplasia
    - metaplasisa of mucous membrane
  4. Squamous epithelium
    - growth through TM perforation
  5. Retraction Pocket
    - Blockage of retraction pocket of Eustachian tube
    - Retraction of TM to posterosuperior segment & attic region (here thin pars flaccida)
    - Dead epithelium pass into meatus to the exterior
    - Process continue and more retraction pocket
    - Forming of sac with a narrow neck
    - Dead squames cant escape
    - Cholesteatoma formed and grow.
  6. Cholesterol Granuloma
    - cholesterol crystal surrounded by giant cell and granular tissue granuloma
44
Q

Complications of cholestema.

A

Long process of incus, Fallopian canal, horizontal semicircular canal

  1. Erosion of tegmen and expose middle fossa dura / posterior fossa dura
  2. Erosion of sigmoid sinus and sinus thrombosis
45
Q

Investigations of cholestema.

A
  1. Hearing test – tuning fork test & puretone audiometry.
  2. X – ray
    - sclerotic mastoid
    - cholesteatoma sac
  3. Ear swab
    - Bacteriological study.
46
Q

Treatment of cholestema.

A
  1. Assess nature and degree of process
  2. Examine ear using operating microscope
  3. Remove aural poly or granulation to adequately see drum
  4. If there is no cholesteaoma treat as in for safe type otitis media.
  5. If has cholesteatoma surgery.
47
Q

Delayed treatment risk of cholestema.

A
  1. Sudden loss of hearing esp if long process of incus is eroded
  2. Facial paralysis
  3. Labyrinth complication
  4. Intracranial complication
48
Q

Aim of surgical treatment of chronic otitis media.

A

To produce a safe dry ear, restore or improve hearing.

49
Q

What is myringoplasty?

A
  • Closing of central perofration in TM in tubotympanic otitis media
  • This operation can be combined with operation to reconstruct ossicular chain
50
Q

Indications and requirements for myringoplasty.

A

Indication

  • Recurring discharge and deafness
  • Central perforation of ear drums

Requirement
- Dry and non infection ear for months

51
Q

Material and technique of myringoplasty.

A

Material
- Fascia of superficial surface of temporalis mm (strong & very thin)

Technique
Onlay
1. Remove squamous epithelium on the the eardrum outer surface or turned the epithelium forward as flap
2. Apply temporalis fascia
3. Replace flap

Underlay

  1. Separate mucosa from inner surface of drum
  2. Apply graft on inner aspect
52
Q

Good and bad outcomes of myringoplasty.

A

Good Outcome

  • Improved hearing
  • Reduce ascending infection of middle ear

Bad Outcome

  • Deterioration of hearing due to thick and immobile ear drum
  • Severe sensorineural deafness
53
Q

What is radial mastoidectomy?

A
  • To treat chronic suppurative otitis media of dangerous type associated with granulations or cholestoma
  • Complete removal of mastoid air cells + posterior meatal wall + outer attic + TM + ossicles
  • 1 cavity = external meatus + mastoid air cells
  • Curation of Eustachian tube
54
Q

Disadvantages of radial mastoidectomy.

A
  1. Deafness

2. Recurrent ascending infection from Eustachian tube

55
Q

What is modified radial mastoidectomy? Technique and advantage.

A
  • For chronic suppurative otitis media dangerous type

Technique

  • Removal of outer wallof attic + posterior meatal wall.
  • 1 cavity = meatus, attic, mastoid cells
  • Remove ossicles of involve choelstgeatoma

Advantage
- Hearing retained

56
Q

What is meastoplasty?

A
  • enlarge external auditory meatus
  • good for dressing
  • allow air to enter to it can be lined by squamous epithelium to achieve dry ear.
57
Q

What is tympanoplasty? Technique.

A
  • Reconstruction of ossicular chain using patient’s own incus or homograft incus.

Mobile malleus & stapes, Lost structure of stapes
- Incus is used to bridge gap between handle of malleus and stapes footplate.

Immobile stapes à stapedectomy.

Fixed malleus / incus to attic

  • Remove head of malleus to mobilize malleolar handle
  • Reconstruct drum like if malleus is intact
58
Q

Complications and outcomes of tympanoplasty.

A

Complication

  • Absorption of replaced ossicles causing refixation of ossicles
  • Obliteration of middle ear by adhesion. (Use silastic sheet to prevent)

Outcome
Excellent hearing results

59
Q

Ossicular reconstruction; indications and obstacles.

A

Indication
- Disruption of ossicular chain in chronic otitis media

Obstacles

  • perforate eardrum
  • ossicle damage
  • loss normal mucosa of middle ear
60
Q

Technique and principles of ossicular reconstruction.

A

Principle Of Reconstruction

  • Remove infection
  • Repair eardrum by myringoplasty
  • Reconstruction of ossicles can overcome ossicle disruption

How?

  • Reshape incus
  • Transplant it between malleus and stapes head
61
Q

What is homografting?

A

If ptts incus too diseased, use homograft.

Homograft eardrum can be used if ptts eardrum is too damage.

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