Miscellaneous

Question 1

Otitis Externa

Answer 1

Risk factors (Swimming, eczema, psoriasis, irritants such as hair dye, trauma due to cleaning)
Symptoms (Itching. Pain in ear.)
Management
- Suspected bacterial (Otodex 3 drops affected ear TDS.x 7 days)
- NO aminoglycoside due to perforation? Consider Ciprofloxacin + Hydrocortisone iii BD x 7 days.
- Fungal?
- Aural toilet _(dry mopping, suction clearance under microscopy, irrigation)
- Kenacomb (3 TDS x 7 days.

PO needed (Consider Diclox/Fluclox + Ciprofloxacin 750mg PO BD x 7-10 days. )
- Need coverage for s.aureus and p. aeruginosa, Hence combination of penicillin + ciprofloxacin.

Long-term prevention
- Keep ear dry (Use earplugs or bathing cap during showering/swimming)
- Ascetic acid + Isopropyl alcohol drops into ears following exposure to water

Question 2

Management of Sialolithiasis

Answer 2

Clinical diagnosis based on history of swelling and pain associated with eating or in anticipation of eating.

Conservative management
- Keep well-hydrated
- Apply moist heat to involved area
- Massage the parotid gland
- Milk the duct
- Suck on a tart or anything very sour
- Analgesia - NSAIDS
- Discontinue anti-cholinergics if suspected contributor.
- Secondary infection? Dicloxacillin or Cephalexin x 7-10 days.

Nil improvement within 1 week, consider referral to otolaryngologist for removal of sialolith.

Question 3

Eustachian Tube Dysfunction

Answer 3

Location of ET - Originates in anterior wall of middle ear cavity and opens into nasopharynx.

Roles of ET
- Equalization of pressure of TM
- Protection of middle ear from infection and reflux of nasopharyngeal contents
- Clearance of middle ear secretions

Spectrum of ET dysfunction

• Obstructive
  
  • ET is obstructed
  • Large proportion of otitis media and chronic ear disease
  • Underlying causes - Rhinosinusitis, rhinitis, laryngopharyngeal reflux, obstructing mass or lesion
  • Rx treat underlying cause.
    
    • Can use intermittent balloon insufflation.
  • Note: Empirical use of PO antihistamines, systemic glucocoritcoids, nasal steroid sprays not recommended. Not enough evidence to support use.
• Patulous
  
  • ET remains patent
  • Rx - Adequate hydration
    
    • > 6/52 symptoms, use nasal saline drops which cause localised inflammation and oedema to help close patulous ET.

Question 4

Presbycusis

Answer 4

Age-related sensorineural hearing loss.
- Noted to have worsening sensorineural hearing loss at high frequencies on audiogram.

Question 5

Menieres disease

Answer 5

Idiopathic endolymphatic hydrops of labyrinthine system of inner ear

Clinical picture
- (Episode vertigo, tinnitus, hearing loss)

Diagnosis - Nil definitive investigation. Clinical diagnosis based upon following criteria
- 2+ Spontaneous episodes of vertigo lasting 20mins - 12 hours
- Audiometry showing low to mid frequency sensorineural hearing loss in affected ear.
- Fluctuating aural symptoms (Reduced or distorted hearing, tinnitus, fullness)
- Symptoms not better accounted for by another vestibular diagnosis.

Management
- Salt restriction < 3g per day
- Limit caffeine intake to 1 beverage daily
- Limit alcohol intake to 1 beverage daily
- Avoid other identified triggers including nicotine, stress, MSG

Refractory to above?
- Betahistine 16mg PO OD
- 2nd line - Hydrochlorothiazide 25mg PO OD.

• Differentials to exclude
  
  • Vestibular schwannoma, multiplesclerosis, TIA, vestibular migraine, BPPV

Question 6

Vestibular Neuritis

Answer 6

Acute vestibular syndrome that is common cause for spontaneous vertigo
- many cases are due to HSV1 reactivation

Diagnosis
- History of acute onset severe rotatory vertigo, nausea, postural imbalance without hearing loss.
- Unidirectional mixed horizontal and torsional nystagmus with positive head impulse test.

Usually self-limiting improving over hours to days.

Treatment
- Prednisolone 1mg/kg up to 75mg PO OD x 5 days then taper dose over 15 days then stop.

Question 7

Injected tympanic membrane

Answer 7

• Pink or red TM
• Often seen with fever, ETD or viral URTI
• TM remains transparent
• Handle of malleus is well seen and more horizontal.

Question 8

Otosclerosis

Answer 8

Bony overgrowth that involved the footplate of the stapes. Inhibits stapes ability to work as a piston
- Progressive hearing loss until maximal conductive hearing loss of 60dB is reached.

Clinical features
- Progressive disease
- Age - 20-30yo
- Autosomal dominant inheritance
- F > M
- Bilateral or unilateral
- Conductive hearing loss
- Begins in lower frequencies and progresses to higher frequencies.
- May be associated with Meniere disease

Rx
- Hearing amplification
- Surgical replacement of stapes with prosthesis.