Module 3D ENT - Conditions Flashcards
1
Q
Acute epiglottitis (aka. supraglottitis) - Aetiology + what group is at risk?
A
Usually a bacterial infection (Strep. pneumonia, group A streptococci, and Staph. aureus)
- Epiglottitis is now rare due to the HiB vaccine - be suspicious in unvaccinated children
2
Q
Acute epiglottitis - Clinical features
A
- Sore throat, stridor, and drooling
- Muffled voice (‘hot potato’ voice) - characteristic change
- Respiratory distress - tachypnoea +/- use of accessory muscles
- Tripod position
- High-grade fever (if bacterial)
3
Q
Acute epiglottitis - Investigations
A
Diagnosis is clinical and investigations should only be done once pt is stable:
- Lateral X-ray of neck: ‘thumb sign’
- Blood cultures and throat swabs: causative pathogen (guides antibx therapy)
4
Q
Acute epiglottitis - Management
A
- Keep pt calm and do not examine the throat due to risk of acute airway closure
- Call for senior pediatrician + anaesthesist + ENT surgeon
- Steroids (dexamethasone) +/- oxygen
- Monitor in ICU and intubation/tracheostomy (if need) +/- adrenaline
(5. If bacterial –> IV antibiotics - empiric broad-spectrum (eg. ceftriaxone) –> adjust based on culture + local guidelines)
(6. Vaccination - HiB vaccine to prevent paediatric cases of acute epiglottitis)
5
Q
What is a common complication of epiglottitis?
A
Epiglottic abscess - collection of pus around the epiglottis
6
Q
Tonsillitis - aetiology
A
- Viral (more common) - adenoviruses
OR - Bacterial - Strep. pyogenes
7
Q
In the pharynx, at the back of the throat, there is a ring of lymphoid tissue. There are six areas of lymphoid tissue in Waldeyer’s ring, comprising of the adenoids, tubal tonsils, palatine tonsils and the lingual tonsil.
Which tonsils are typically infected and enlarged in tonsillitis?
A
Palatine tonsils (on either side at back of throat)
8
Q
Tonsillitis - Clinical features
A
Symptoms:
- Sore throat
- Fever (above 38ºC)
- Pain on swallowing
.
Signs:
- Red, inflamed tonsils
- +/- Exudates - small white patches of pus
- +/- Tender and enlarged anterior cervical lymph nodes (anterior triangle)
9
Q
Tonsillitis - what are the 2 criterias used to assess whether the tonsilitis is bacterial and therefore antibiotics should be given
A
CENTOR criteria (≥ 3):
- Fever over 38ºC
- Tonsillar exudates
- Absence of cough
- Tender anterior cervical lymph nodes (lymphadenopathy)
.
FeverPAIN score (≥ 4):
- Fever during previous 24hrs
- P - Purulence (pus on tonsils)
- A - Attended withing 3 days of onset of symptoms
- I - Inflamed tonsils (severely inflamed)
- N - No cough or coryza
10
Q
Tonsillitis - Management
A
- Reassure/safety net - return if fever > 38.3ºC or symptoms persist more than 3 days
- Paracetamol or ibuprofen - to control pain and fever
- Use CENTOR or FeverPAIN (bacterial?) - antibiotics
- (Penicillin V, 10-day course OR erythromycin if penicillin allergy)
- (Delayed prescription - educate pt that it is likely viral, but if symptoms worsen or do not improve in 2-3 days then can pick up antibiotics)
11
Q
Tonsillitis - complcaitions
A
- Peritonsillar abscess (quinsy)
- Otitis media (if infection spreads to the inner ear)
- Scarlet fever
- Rheumatic fever (rare)
- Post-streptococcal glomerulonephritis (very rare)
- Streptococcal toxic shock syndrome (very rare, but life-threatening)
12
Q
What is chronic rhinosinusitis (CRS)?
- include time and the 2 types of CRS
A
- a persistent inflammatory condition affecting the paranasal sinuses and nasal passages
- lasting longer than 12 weeks
1. CRS with nasal polyps
2. CRS without nasal polyps
13
Q
Chronic rhinosinusitis - aetiology/risk factors
A
- Atopy: hay fever, asthma
- Nasal obstruction: eg. septal deviation or nasal polyps
- Recent local infection: eg. rhinitis or dental extraction
- Swimming/diving
- Smoking
14
Q
Chronic rhinosinusitis - Clinical features
A
Symptoms lasting for longer than 12 weeks…
- Cardinal symptoms: Nasal obstruction + facial pain or pressure + purulent nasal discharge
- Other symptoms: fatigue, headache, dental pain, cough, hearing changes
15
Q
Chronic rhinosinusitis - 2 main investigations
A
- Nasal Endoscopy - to assess nasal cavity and sinuses (polyps, mucopurulent discharge, oedema/inflammation)
- CT scan of paranasal sinuses
16
Q
Chronic rhinosinusitis - Management
A
Medical:
1. Nasal saline irrigation (clears nasal secretions and improves mucociliary function)
2. Intranasal steroids
3. Oral corticosteroids (for severe cases)
(4. Antibiotics - if evidence of bacterial infection - Staph. A)
Surgical:
5. Functional endoscopic sinus surgery (FESS)
17
Q
Chronic rhinosinusitis - complications
A
- Mucosal polyp formation - build up of nasal and sinus mucosa can lead to polyp formation (further exacerbates symptoms)
- Orbital cellulitis or abscess - due to close proximity
- Intracranial complications (rare) - eg. meningitis, brain abscess
18
Q
Rhinitis VS Rhinosinusitis - locations affected
A
- Rhintitis - nasal mucosa
- Rhinosinusitis - nasal mucosa + paranasal sinuses
19
Q
Allergic rhinitis - what type of reaction is it?
A
IgE-mediated type 1 hypersensitivity reaction
20
Q
Allergic rhinitis - main triggers
A
- Tree pollen or grass allergy - seasonal symptoms (hay fever)
- House dust mites and pets
- Other allergens
21
Q
Allergic rhinitis - Classification (3 types)
A
- Seasonal - eg. hay fever
- Perennial (year-round) - eg. house dust mite allergy
- Occupational - associated with school/work environment
22
Q
Allergic rhinitis - Clinical features + investigation
A
- Runny (rhinorrhoea), blocked, and itchy (pruritus) nose
- Sneezing
- Itchy, red, and swollen eyes (allergic conjunctivitis)
- associated with a personal or family hx of atopy
- skin prick testing can be useful
23
Q
Allergic rhinitis VS Non-allergic rhinitis vs Infective sinusitis
A
- Non-allergic rhinitis - similar presentation, but lacks the IgE response + doesn’t respond well to antihistamines + no ocular symptoms
- Infective sinusitis - has additional symptoms such as facial pain/pressure + fever + purulent nasal discharge (nasal swab to test)
24
Q
Allergic rhinitis - Management
A
- Allergen avoidance
- Oral/Intranasal antihistamines
- Non-sedating - cetirizine, loratadine, and fexofenadine
- Sedating - chlorphenamine and promethazine - Nasal corticosteroid sprays - eg. fluticasone and mometasone
25
Head and neck cancer - locations affected
- Nasal cavity
- Paranasal sinuses
- Mouth
- Salivary glands
- Pharynx (throat)
- Larynx (epiglottis, supraglottis, vocal cords, glottis and subglottis)
.
- head and neck cancers usually spread to the lymph nodes first
26
Head and neck cancers - what cell type is usually affected?
Squamous cell carcinomas - arising from the squamous cells of the mucosa
27
Head and neck cancer - Risk factors
- Smoking
- Alcohol
- chewing betel quid (a hbit in south-east Asia)
- HPV-16 (strain 16)
- EBV
28
Head and neck cancers - red flags
- Lump in mouth or on lip
- Unexplained ulceration in the mouth lasting more than 3 weeks
- Erythroplakia or erythroleukoplakia (premalignant conditions)
- Persistent neck lump
- Unexplained hoarseness of voice
- Unexplained thyroid lump
29
Referral criteria for laryngeal cancer (2-week wait)
- Persistent unexplained hoarseness
- OR an unexplained lump in the neck
30
Head and neck cancer - Staging + Management
Staging (TNM) or stages 1-4:
- Tumour (size of tumour): 1 = small, 4 = large
- Node involvement (has cancer spread to lymph nodes): 0 = no lymph nodes containing cancer cells, 3 = lots of lymph nodes containing cancer cells
- Metastases (whether cancer has spread to another part of the body): M0 = cancer hasn't spread, M1 = cancer has spread
.
Management:
1. Chemotherapy +/- Radiotherapy
2. Surgery
3. Targeted cancer drugs (ie. monoclonal antibodies - eg. Cetuximab for SCCs)
4. Palliative care
31
How do laryngeal tumours typically present?
1. Glottic tumours
2. Supraglottic tumours
3. Subglottic tumours
- General symptoms
1. Glottic tumours (most common):
- Hoarseness +/- dysphonia +/- stridor (advanced disease)
2. Supraglottic tumours:
- Dysphagia/Odynophagia +/- referred otalgia (ear pain) +/- neck mass
3. Subglottic tumours:
- Dyspnoea/airway obstruction +/- stridor (advanced disease)
- General symptoms: persistent sore throat, weight loss
32
What is leukoplakia?
Precacnerous condition (increases risk of SCC of the mouth)
- characterised by white patches in the mouth, often on the tongue or insides of the cheeks (buccal mucosa) - *won't come off with scraping*
33
Leukoplakia - management
1. Biopsy - to exclude SCC
2. Conservative: smoking cessation + reducing alcohol intake
3. Close monitoring +/- laser removal or surgical excision
34
What is erythroplakia and what is erythroleukoplakia?
- Erythroplakia = similar to leukoplakia, except the lsions are red
- Erythroleukoplakia = refers to lesions that are a mixture of red and white
(both precancerous lesions - high risk of progression to SCC)
35
What is Lichen planus + appearance?
Lichen planus = an autoimmune condition that causes localised chronic inflammation of the skin, hair, nails, and mucous membranes
- Appearance: shiny, purplish, flat-topped raised areas, with white lines across the surface called Wickham's striae
(often it only affects the mouth and can be reticular, erosive, or plaque)
36
Lichen planus - management
1. Good oral hygeine
2. Stopping smoking
3. Topical steroids
37
What is gingivitis?
Gingivitis refers to inflammation of the gums
- can present with swollen gums, bleeding after brushing, painful gums, and bad breath (halitosis)
- can lead to periodontitis (severe and chronic inflammation of the gums and tissues that support the teeth - leads to loss of teeth)
38
Gingival hyerplasia
- abnormal growth of the gums
39
Aphthous ulcers - what are they + management
- Very common, small, painful ulcers of the mucosa in the mouth
- have a well-circumscribed, punched-out, white appearance
- Management (usually heal within 2 weeks on their own)
1.Choline salicylate (eg. Bonjela) OR Benzydamine (eg. Difflam spray)
2. Topical corticosteroids (for severe ulcers)
3. If last more than 3 weeks --> 2 week wait referral
40
What is glossitis?
- Inflamed tongue - red, sore, and swollen
- Papillae of tongue atrophy, giving the tongue a smooth appearance ("beefy")
41
Glossitis - causes
- Iron-deficiency anaemia
- B12 deficiency
- Folate deficiency
- Coeliac disease
- Injury or irritant exposure
42
Angioedema - what is it + top 3 causes
Angioedema = refers to fluid accumulating in the tissues, resulting in swelling (can affect the tongue)
.
- Allergic reactions
- ACE inhibitors
- C1 esterase inhibitor deficiency (hereditary angioedema)
43
Oral candidasis (oral thrush) - what is it + causes + management
Refers to an overgrowth of candida (type of fungus) in the mouth
- results in white spots/patches that coat the surface of the tongue and palate
.
Causes:
- Inhaled corticosteroids (not rinsing mouth afterwards)
- Antibiotics
- Diabetes
- Smoking
.
Management:
1. Miconazole gel
2. Nystatin suspension
44
Strawberry tongue - 2 key causes
- Scarlet fever
- Kawasaki disease
45
Black, hairy tongue
Results from decresed shedding (exfoliation) of keratin from the tongue's surface
- due to dehydration, dry mouth, poor oral hygiene, and smoking
46
What are the key features of laryngitis?
1. Definition
2. Causes
3. Symptoms
4. Management
1. Definition: Inflammation of the larynx, often affecting the vocal cords
2. Causes:
- Acute: Viral infections (most common), bacterial infections, voice strain
- Chronic: Smoking, GORD, chronic irritants (e.g., dust, chemicals)
3. Symptoms:
- Hoarseness or loss of voice.
- Sore throat or discomfort.
- Cough and dysphonia.
4. Management: Rest voice, treat underlying cause (e.g., infections, reflux)
47
What are reactive nodules (vocal cord polyps) and their features?
1. Definition
2. Causes
3. Symptoms
4. Management
1. Definition: Benign growths on the vocal cords due to chronic voice overuse or irritation.
2. Causes:
- Vocal strain (e.g., singers).
- Smoking or chronic irritation.
3. Symptoms:
- Hoarseness or rough voice.
- Loss of vocal range.
- No associated pain.
4. Management:
- Vocal rest, speech therapy.
- Surgery if persistent or large.
48
What are the key features of laryngeal papilloma?
1. Definition
2. Symptoms
3. Age groups
4. Management
1. Definition: Benign tumours caused by human papillomavirus (HPV), commonly types 6 and 11.
2. Symptoms:
- Hoarseness (most common).
- Stridor or airway obstruction (if severe).
- Dysphonia.
3. Age Groups:
- Juvenile onset: Transmitted during childbirth.
- Adult onset: Often linked to HPV exposure.
4. Management:
- Surgery (e.g., laser excision).
- Recurrence common, requiring multiple interventions.
49
Laryngeal dysplasia
1. Definition
2. Causes
3. Symptoms
4. Management
1. Definition: Pre-malignant changes in the laryngeal epithelium.
2. Causes:
- Smoking (major risk factor).
- Alcohol use.
3. Symptoms:
- Hoarseness or voice changes.
- No pain or systemic symptoms.
4. Diagnosis:
- Visualisation via laryngoscopy.
- Biopsy for histopathology (to confirm dysplasia grade)
5. Management:
- Smoking cessation, regular monitoring.
- Surgery or laser excision for severe dysplasia.
50
What are the clinical features and management of squamous cell carcinoma (SCC) of the larynx?
1. Definition
2. Risk factors
3. Symptoms
4. Diagnosis
5. Management
1. Definition: Malignant tumour arising from the squamous epithelium of the larynx.
2. Risk Factors:
- Smoking (strongest risk factor).
- Alcohol, HPV, chronic laryngitis.
3. Symptoms:
- Glottic SCC: Hoarseness (early symptom).
- Supraglottic SCC: Dysphagia, neck mass, odynophagia.
- Subglottic SCC: Dyspnoea, stridor (often advanced).
- Weight loss in late stages.
4. Diagnosis:
- Laryngoscopy with biopsy.
- Imaging (CT/MRI) for staging.
5. Management:
- Early-stage: Surgery or radiotherapy.
- Advanced-stage: Combined chemoradiotherapy or total laryngectomy.
51
Anterior cervical triangle - borders
- Mandible forms the superior border
- Midline of the neck forms the medial border
- Sternocleidomastoid forms the lateral border
52
Posterior cervical triangle - borders
- Clavicle forms the inferior border
- Trapezius forms the posterior border
- Sternocleidomastoid forms the lateral border
53
Neck lump/swellling differentials
- Reactive lymphadenopathy (most common) - hx of infection/virus
- Lymphoma - rubbery, painless lymphadenopathy
- Thyroid swelling (goitre) - moves upwards on swelling
- Thyroglossal cyst
- Cystic hygroma (congenital lymphatic lesion - lymphangioma) - usually presents < 2yrs of age
- Branchial cyst - oval, mobile cystic mass between sternocleidomastoid and pharynx (presents during childhood)
- Carotid aneurysm - pulsatile lateral neck mass which doesn't move on swallowing
- Carotid body tumour
- Salivary gland stones or infection
- lipoma
54
Neck lump red-flag referral criteria
2-week wait referral if:
- unexplained neck lump in > 45yrs
- persistent unexplained neck lump at any age
- USS if growing in size
55
What causes infectious mononucleosis?
Epstein Barr virus (EBV)
56
Infectious mononucleosis - investigations
1. Monospot test - heterophile antibody test
2. IgM (acute infection) and IgG (immunity) to EBV
57
Salivary glands - 3 locations + 3 reasons for enalrgement
- Stones blocking the drainage of the glands through the ducts (sialolithiasis)
- Infection
- Tumours (benign or malignant)
58
Which salivary glands are usually affected in salivary gland stones + symptoms of salivary gland stones?
Submandibular glands
.
Symptoms:
- pain and swelling (usually triggered when salivary flow is stimulated - eg. eating or chewing)
- can be asymptomatic
- can present with a hard, palpable lump within the salivary duct or orifice
59
Salivary gland stones - management
1. Advise pt to remain well hydrated
2. Stop medications (if able to) that impair saliva flow - eg. amitriptyline
3. Encourage saliva flow - suck on citrus fruits/sweets
4. NSAIDs - to relieve pain
60
Epistaxis (nosebleeds) - where does the bleeding usually originate from (anterior) and what about posterior nosebleeds?
Kiesselbach's plexus, located in Little's area
- this is an area of the nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels
.
Posterior epistaxis - arises from branches of sphenopalatine artery (tends to be more severe)
61
Epistaxis - Triggers
Anterior nosebleeds are usually unilateral:
- nose picking
- colds
- sinusitis
- vigorous nose-bloing
- trauma
- changes in weather
- coagulation disorders (eg. Von Willebrand's, thrombocytopenia)
- Anticoagulation (eg. aspirin, DOACS, or warfarin)
- snorting cocaine
- tumours (eg. SCC)
62
How does a posterior nosebleed (epistaxis) present?
- blood can go down throat - causes coughing/vomiting due to swallowed blood
- bilateral bleeding
63
Epistaxis (nose bleeds) - Management
1. First aid measures: sit up and tilt head forwards (to reduce blood in pharynx and prevent aspiration) + squeeze the soft part of the nostrils together for 10-15 mins
2. Topical vasoconstrictor (eg. phenylephrine or oxymetazoline)
(Tranexamic acid - can soak gauze and apply to bleeding site)
3. Nasal packing - using nasal tampons or inflatable packs
4. Nasasl cautery - silver nitrate sticks
(5. Naseptin nasal cream (chlorhexidine and neomycin) QDS for 10 days to reduce any crusting/inflammation/infection)
64
Who should you not give Naseptin nasal cream to?
contradicted in peanut or soya allergy
65
What conditions are nasal polyps associated with?`
- chronic sinusitis/rhinitis
- asthma
- Samter's triad (nasal polyps, asthma, and aspiring intolerance/allergy)
- Cystic fibrosis
- Eosinophilic granulomatosis with polyangiitis
66
Nasal polyps - Presentation
Nasal polyps may be found on examination in pts presenting with:
- chronic rhinosinusitis
- difficulty breathing through nose
- snoring
- nasal discharge
- loss of sense of smell (ansomia)
.
Examination:
- Use a nasal speculum (holds nostrils open) - unilateral polyps are a RED FLAG (tumours)
- Nasal endoscopy - to visualise nasal cavity in detail
67
Nasal polyps - Management
1. Medical management:
- intranasal tpoical steroid drops (to reduce inflammation)
- intranasal saline irrigations (can provide symptomatic relief)
2. Surgical intervention:
- Intranasal polypectomy - used when polyps are visible close to the nostrils
- Endoscopic nasal polypectomy - used where the polyps are further in nose/sinuses
(NOTE: Unilateral polyps - refer to exclude malignancy)
68
What is a peritonsillar abscess (quinsy)?
a serious complication of tonsilitis or can arise on its own
- a collection of pus in the tissue surrounding the tonsils, usually caused by a bacterial infection
69
Peritonsillar abscess (quinsy) - Presentation
Pts present similarly to tonsillitis:
- sore throat
- painful swallowing
- fever
- neck pain
- referred ear pain
- swollen tender lymph nodes
.
Additional symptoms that indicate a peritonsillar abscess include:
- Trismus (unable to open mouth)
- Change in voice - due to pharyngeal swelling ("hot potato" voice)
- Swelling and erythema - in area beside tonsils
- deviation of uvula to unaffected side
70
Peritonsillar abscess (quinsy) - most common causative organism
Strep. pyogenes (group A Strep)
71
Peritonsillar abscess (quinsy) - management
1. Antibiotics - empirical antibiotics (eg. co-amoxiclav)
2. Analgesia - eg. NSAIDs or paracetamol
3. Needle aspiration OR surgical incision and drainage - to remove pus from abscess
(4. Recurrent cases - quinsy tonsillectomy)
72
Indications for tonsillectomy (ie. how many episodes of acute sore throat per year in 1 year/2 years/3 years + other reasons for tonsillectomy)
No. episodes of acute sore throat:
- 7 or more in 1 year
- 5 per year for 2 years
- 3 per year for 3 years
.
Other indications:
- Recurrent tonsillar abscesses (2 episodes)
- Enlarged tonsils causing difficulty breathing, swallowing, or snoring
73
Post-tonsillectomy bleeding is the main significant complication after a tonsillectomy, significant bleeding can occur in up to 5% of pts who have had a tonsillectomy. This can happen up to 2 weeks after the operation. Bleeding can be severe, and in rare cases, life-threatening due to aspiration of blood.
What is the management of a pt who has post-tonsillectomy bleeding?
- Call the ENT registrar and get them involved early
- Get IV access and send bloods including an FBC, clotting screen, group and save and crossmatch
- Keep the patient calm and give adequate analgesia
- Sit them up and encourage them to spit out the blood rather than swallowing
- Make the patient nil by mouth in case an anaesthetic and operation is required
- IV fluids for maintenance and resuscitation, if required
.
- If there is severe bleeding or airway compromise, call an anaesthetist. Intubation may be required.
.
Before going back to theatre there are two options for stopping less severe bleeds:
- Hydrogen peroxide gargle
- Adrenalin-soaked swab applied topically
74
Which side bronchus is an inhaled foreign body more likely to become lodged in?
Right main bronchus
- more vertical orientation
- wider diameter
- shorter length
75
Laryngopharyngeal reflux ("silent reflux") - Clinical features
"Silent" refers to the fact that it doe snot present with typical gastroesophageal reflux symptoms like heartburn:
- 'Globus pahryngeus' - feeling of a lump in the throat
- hoarseness
- chronic cough
- sore throat
76
Laryngopharyngeal reflux - management
1. Lifestyle measures:
- avoid dietary triggers - eg. fatty foods, caffeine, chocolate, and alcohol
2. Proton pump inhibitor - eg. omeprazole
3. Sodium alginate liquids - eg. Gaviscon
77
Ludwig's angina - what is it + aetiology
- Ludwig's angina = a type of progressive cellulitis that invades the floor of the mouth and soft tissues of the neck (life-threatening due to potential airways obstruction)
- Aetiology - usually occurs as a result of dental infections (infected mandibular molars)
78
Ludwig's angina - Clinical features
Symptoms:
- neck swelling often with either dental pain or following a recent dental procedure
- dysphagia
.
Signs O/E:
- bilateral submandibular swelling
- elevated or protruding tongue
- +/- signs of resp. distress
79
Ludwig's angina - Management
1. Airway assessment +/- management
2. Empirical broad-spectrum IV antibiotics
80
What is the most common benign salivary gland tumour?
Pleomoprhic adenomas - usually occur within the parotid gland
81
Pleomorphic adenoma (parotid gland) - Clinical features
- Swelling, erythema, and tenderness within the parotid gland
- free-moving structure - not tethered
- NO facial nerve involvement (this would suggest a malignant cause as the tumour invades local structures)
82
Pleomorphic adenoma (parotid gland) - Investigations
- USS-guided fine needle aspiration/biopsy
- CT/MRI - to assess local invasion
83
Pleomorphic adenoma (parotid gland) - Management
(urgent referral (2 weeks) for unexplained lumps in parotid or submandibular glands)
1. Surgical - pleomorphic adenomas are removed due to their risk of malignant transformation + allow for a biopsy (tissue diagnosis) to be done
84
What is a thyroglossal cyst - pathophysiology
- During fetal development, the thyroid gland starts at the base of the tongue
- From here it gradually travels down the neck to its final position in front of the trachea, beneath the larynx
- It leaves a track behind called the thyroglossal duct, which then disappears
- When part of the thyroglossal duct persists it can give rise to a fluid-filled cyst --> this is called a thyroglossal cyst
85
Thyroglossal cyst - clinical features
- Painless, midline neck mass that moves upwards with swallowing or protrusion of the tongue
86
Thyroglossal cyst - management
1. USS or CT - diagnosis
2. Surgical removal - to provide confirmation of diagnosis (biopsy) + prevent infections
87
What is a branchial cyst?
- a congenital abnormality arising when the second branchial cleft fails to properly form during fetal development
- this leaves a space surrounded by epithelial tissue in the lateral aspect of the neck
- this space can fill with fluid. This fluid-filled lump is called a branchial cyst
88
Branchial cyst - presentation
- round, soft, cystic swelling usually anterior to the sternocleidomastoid muscle (in anterior triangle of the neck)
- non-tender, but can become infected or inflamed
89
What is otitis media?
- Infection in the middle ear (space that sits between the tympanic membrane (eardrum) and the inner ear)
- Bacteria enter from the back of the throat through the eustachian tube
90
Otitis media - most common bacterial cause
Streptococcus pneumoniae (also commonly causes other ENT infection such as rhinosinusitis and tonsillitis)
91
Otitis media - Clinical features (presenting symptoms + O/E)
- Ear pain (otalgia) - main presenting feature
- +/- reduced hearing in affected ear
- +/- malaise and fever
- +/- viral URTI symptoms (eg. coryza)
.
- If tympanic membrane has perforated - discharge from ear
- If infection affects vestibular system - can cause balance issues and vertigo
.
Signs O/E:
- Otoscopy (to visualise tympanic membrane) - bulging, red, inflamed +/- discharge (if perforation)
92
Otitis media - Management
(Most cases will resolve without antibiotics within around 3 days)
1. Simple analgesia (eg. paracetamol or ibuprofen) - for pain and fever
2. Antibiotics (immediate or delayed prescription):
- Amoxicillin 1st-line (5-7 day course)
- (erythromycin or clarithromycin if pen allergy)
93
What is otitis media with effusion (glue ear) + main presenting symptom
Where the middle ear becomes full of fluid
- causing a loss of hearing in that ear
94
Otitis media with effusion (glue ear) - otoscopy findings
- dull tympanic membrane (shows that there is fluid/infection)
- +/- air bubbles +/- visible fluid lvl
95
Otitis media with effusion (glue ear) - management
(Refer for audiometry to establish degree of hearing loss)
1. Usually self-limiting (3 months)
2. Persistent hearing loss or recurrent otitis media with effusion --> myringotomy and grommet insertion (allows for drainage of fluid)
96
What is otitis externa (aka. 'swimmer's ear')?
an inflammatory condition affecting the external auditory canal and pinna
- acute (< 3 weeks) or chronic (> 3 weeks)
97
Otitis externa ('swimmer's ear') - Risk factors/Aetiology
Risk factors:
- Water exposure (eg. frequent swimming)
- High humidity
- Trauma to the auditory canal (eg. cotton swab use) - *ear wax has a protective effect against infection, and removal can increase chances of infection *
- Narrow ear canals
- Immunosuppression
.
Aetiology:
- Bacterial infection: Staph. aureus OR Pseudomonas aeruginosa
- Fungal infection: Aspergillus or Candida albicans
- Seborrhoeic dermatitis
- Contact dermatitis
98
Why does multiple courses of topical antibiotics increase the risk of fungal infections?
- 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)
99
Otitis externa - Clinical features (symptoms and signs O/E)
Symptoms:
- Ear pain (otalgia)
- Ear itch
- Ear discharge
.
Signs O/E:
- Erythema and swelling in ear canal +/- tenderness
- Pus or discharge in ear canal
100
Otitis externa - Management`
1. MILD: acetic acid 2% (aka. EarCalm) - has antifungal and antibacterial effects
2. MODERATE: Topical antibx + Steroid
- eg. Neomycin + dexamethasone + acetic acid (eg. Otomize spray)
3. SEVERE: oral antibx
(4. Ear wick (contains topical treatment, eg. antibxs + steroids) - used if ear canal is very swollen)
(5. Fungal infections - clotrimazole ear drops_
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What is malignant otitis externa and which groups of people are most at risk?
- a severe and potentially life-threatening form of otitis external where the infection spreads to the bones surrounding the ear canal and skull
- it progresses to osteomyelitis of the temporal bone of the skull
.
At risk groups:
- Diabetes (most common)
- Immunosuppressed (eg. chemotherapy or HIV)
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Malignant otitis externa - Symptoms + key finding O/E
- Severe, unrelenting, deep-seated otalgia
- Temporal headaches
- Purulent otorrhea
- Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
- +/- fever
.
- O/E: granulation tissue in the ear canal
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Malignant otitis externa - Management
1. IV antibiotics
2. Imaging (CT or MRI) - to assess extent of infection
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What is vertigo?
the sensation of feeling off balance or experiencing a sense of spinning.
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How does the vestibular system (vestibular apparatus) let the brain know that the head is turning in a particular direction
- Vestibular apparatus is located in the inner ear, consists of 3 loops called the semicircular canals that are filled with endolymph
- These semiciruclar canals are orientated in different direction to detect various movements of the head - as the head turns, the fluid shifts inside the canala
- Stereocilia (tiny hairs) in the ampulla detect the fluid shift and transmit to the brain by the vestibular nerve, which then lets the brain know that the head is moving in a particular direction
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What is the role of the vestibular nerve in helping the CNS coordinate eye movements and other movements throughout the body?
- The vestibular nerve carries signals from the vestibular apparatus to the vestibular nucleus in the brainstem and cerebellum
.
The vestibular nucleus then sends signals to:
- the oculomotor, trochlear, and abducens nuclei - control eye movements (extraocular muscles)
- Spinal cord - maintains posture and balance by adjusting muscle tone and body position
- Thalamus
- Cerebellum - fine-tunes motor responses and coordinates balance and posture
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What are the two types of vertigo?
Peripheral problem (most common type):
- usually affecting the vestibular system
- Causes: BPPV, Meniere's, vestibular neuronitis, labyrinthitis
.
Central problem (more serious):
- usually involving brainstem or the cerebellum
- Causes: stroke (posterior), tumour, MS, vestibular migraine
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Vertigo - Central VS Peripheral CAUSE
When a pt presents with 'dizziness', it is important to first distinguish between vertigo and lightheadedness - ask whether the "room is moving" (vertigo)
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Vertigo - Investigations
1. Ear examination - infection? or other pathology?
2. Neurological examination - assess for central causes
3. Cardiovascular examination - eg. arrhythmias or valve disease
4. Special tests:
- Romberg's test (problems with proprioception or vestibular function)
- Dix-Hallpike manoeuvre (BPPV)
- HINTS examination (central VS peripheral)
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HINTS examination is a bedside tool used to distinguish between central and peripheral causes of vertigo (acute vestibular syndrome) - what does it stand for?
HI - Head Impulse
-
N - Nystagmus
-
TS - Test of Skew
-
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HINTS examination - explain the head impulse, nystagmus, and test of skew components
Head impulse:
- pt sitting upright and fixing their gaze on the examiner's nose 9ensure they have no neck pain before performing)
- examiner holds pts head and rapidly jerks it 20 degrees in one direction while the pt continues looking at the examiner's nose
- head is moved slowly back to the centre before repeating in the opposite direction
.
Nystagmus:
- unilateral --> peripheral cause
- bilateral or vertical --> central cause
.
Test of skew (alternate cover test):
- examiner covers one eye at a time, alternating between covering either eye
- the eyes should remain fixed on the examiner's nose with no deviation
- if there is a vertical correction when an eye is covered (eye has drifted up or down) and needs to move vertically to fix on the nose when uncovered, this indicates a central cause of vertigo
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Vertigo - Management (central + peripheral)
Central:
1. CT or MRI - to establish the cause
(Vestibular migraine - avoid triggers + migraine management)
.
Peripheral:
1. Prochlorperazine +/- Antihistamines
(Prophylaxis of Meniere's disease - Betahistine)
(BPPV - Epley manouvre)
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Benign paroxysmal positional vertigo (BPPV) - clinical features
- Vertigo triggered by a change in head position (eg. rolling over in bed)
- symptoms last 20-60 secs and pts are asymptomatic between attacks
- +ve Dix-Hallpike manouevre
114
BPPV - pathophysiology
- caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals
- this occurs most often in the posterior semicircular canal
- they may be displaced by a viral infection, head trauma, ageing or without a clear cause
- the crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system
- head movement creates the flow of endolymph in the canals, triggering episodes of vertigo
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BPPV - Dix-Hallpike manouevre
Used to diagnose BPPV - it involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV:
- (ensure pt has no neck pain)
1. Pt sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
2. Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
3. Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
4. Watch the eyes closely for 30-60 seconds, looking for nystagmus
Repeat the test with the head turned 45 degrees in the other direction
.
+ve test: triggers rotational nystagmus and 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)
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BPPV - Management
Epley manouevre - *watch a video of this*
- idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow
(Brandt-Daroff exercises can be done at home to improve symptoms of BPPV)
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What is vestibular neuronitis + aetiology
Inflammation of the vestibular nerve
- usually caused by a viral infection
- this distorts the signals traveling from the vestibular system to the brain, confusing the signal required to sense movements of the head - resulting in episodes of vertigo
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What forms the inner ear + vestibular system + which nerves form the vestibulocochlear nerve?
Inner ear (contains the bony labyrinth - bony structure containing perilymph and endolymph):
- semicircular canals
- vestibule (middle section)
- cochlear - responsible for hearing
.
Vestibular system:
- Semicircular canals - detect rotation of the head
- Otolith organs - detect gravity and linear acceleration
.
Vestibulocochlear nerve (CN VIII):
- Vestibular nerve - transmits signals from the vestibular system to the brain to help with balance
- Cochlear nerve - transmits signals from the cochlear to provide hearing
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Vestibular neuronitis - Clinical features
1. Vertigo - sudden onset of severe, persistent vertigo (can last for days to weeks) +/- nausea and vomiting
2. Imbalance
3. Nystagmus - spontaneous, unidirectional, horizontal nystagmus
(No hearing loss OR tinnitus as cochlear NOT involved)
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Vestibular neuronitis - Management
1. Symptomatic: Prochlorperazine OR antihistamines
(symptomatic treatment for up to 3 days)
2. Vestibular rehabilitation therapy (VRT) - for chronic symptoms
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What is labyrinthitis?
inflammation of the bony labyrinth of the inner ear (semicircular canals, vestibule, and cochlear)
- usually caused by a viral infection
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Labyrinthitis - Clinical features
- Acute onset vertigo
- Hearing loss (sensorineural) +/- tinnitus
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Labyrinthitis - Management
1. Symptomatic: Prochlorperazine OR antihistamines
(symptomatic treatment for up to 3 days)
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Meniere's disease - Clinical features
- Vertigo - episodes of 20 mins to several hrs and occurs in clusters (over weeks) followed by period without vertigo, not triggered by movement
- Hearing loss (sensorineural) - usually **unilateral** and affects low frequencies first
- Tinnitus - usually **unilateral**
- a sensation of fullness/pressure in the ear
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Meniere's disease - Management
1. Symptomatic: Prochlorperazine OR antihistamines
(symptomatic treatment for up to 3 days)
2. Prophylaxis - Betahistine
(Inform DVLA and stop driving until symptoms are controlled)
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Tinnitus - management
1. Underlying causes can be treated
2. Hearing aids +/- Sound therapy +/- CBT
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What are some conductive causes of hearing loss?
- Ear wax (or something else blocking the canal)
- Infection (e.g., otitis media or otitis externa)
- Fluid in the middle ear (effusion)
- Eustachian tube dysfunction
- Perforated tympanic membrane
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What is sudden sensorineural hearing loss (SSNHL) defined as?
- hearing loss over less than 72 hours, unexplained by other causes
- this is considered an otological emergency and requires an immediate referral to the on-call ENT team
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Is sudden sensorineural hearing loss (SSNHL) usually unilateral or bilateral?
Unilateral
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Sudden sensorineural hearing loss (SSNHL) - investigations
1. Audiometry (for diagnosis) - requires a loss of at least 30db in 3 consecutive frequencies on an audiogram
(2. MRI or CT head - to rule out stroke or acoustic neuroma)
(3. Otoscopic examination - used to exclude other causes of hearing loss such as cerumen impaction or otitis media)
(4. Blood tests (FBC, renal function, LFTs, and ESR/CRP) - to rule out any systemic conditions that might contribute to the SSNHL)
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Sudden sensorineural hearing loss (SSNHL) - Management
1. Immediate referral to ENT (within 24hrs)
(2. Treat any underlying cause - eg. infection)
3. Idiopathic SSNHL (90%): Steroids (oral or intra-tympanic)
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What is an acoustic neuroma (vestibular schwannoma)?
- Benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear
- also called vestibular schwannomas
- Schwann cells are found in the peripheral NS and provide the myelin sheath around neurones
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Note: Acoustic neuromas (vestibular schwannomas) are a subtype of a broader category which are cerebellopontine angle (CPA) tumours. Acoustic neuromas make up around 85% of CPA tumours
CPA tumours include meningiomas and other types of tumours
134
Acoustic neuromas (vestibular schwannomas) are usually unilateral, what are bilateral acoustic neuromas heavily associated with?
Neurofibromatosis type II
135
Acoustic neuroma (vestibular schwannoma) - Clinical features
- Unilateral + progressive sensorineural hearing loss (often first symptom)
- Unilateral tinnitus
- Vertigo and balance issues
- +/- facial nerve palsy (if tumour grows large enough to compress the facial nerve)
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Acoustic neuroma (vestibular schwannoma) - Investigations
- Audiometry - to asses hearing loss (sensorineural pattern)
- MRI brain - to establish diagnosis and features of tumour
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MRI brain images of acoustic neuromas (vestibular schwannomas)
- Left: vestibular schwannoma at the right cerebellopontine angle
- Right: MRI showing a vestibular schwannoma
138
Acoustic neuroma (vestibular schwannoma) - Management
1. Observation: monitoring
2. Surgery: to remove the tumour (partial or total removal)
3. Radiotherapy: to reduce the growth
(risks of surgery: vestibulocochlear nerve injury (with hearing loss or dizziness) +/- facial nerve injury (with facial weakness))
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Conductive VS Sensorineural hearing loss
- Conductive: relates to a problem with sound travelling from the environment to the inner ear (the sensory system may be working correctly, but the sound is not reaching it)
- Sensorineural: caused by a problem with the sensory system or vestibulocochlear nerve in the inner ear
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Describe the basic structures of the ear (from outside in)
- Pinna - the external portion of the ear
- External auditory canal - the tube into the ear
- Tympanic membrane - the eardrum
- Eustachian tube - connects the middle ear with the throat to equalise pressure
- Malleus, incus and stapes (ossicles) - the small bones in the middle ear that connect the tympanic membrane to the structures of the inner ear
- Semicircular canals - responsible for sensing head movement (the vestibular system)
- Cochlea - responsible for converting the sound vibration into a nervous signal
- Vestibulocochlear nerve - transmits nerve signals from the semicircular canals and cochlea to the brain
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Rinne's and Weber's test - describe how to do these tests + what they are testing for
Rinne's test:
.
Weber's test:
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Describe how to perform Rinne's test
1. Strike the tuning fork to make it vibrate and hum
2. Place the flat end on the mastoid process (boney lump behind ear) - this tests bone conduction
3. Ask the pt to tell you when they can no longer hear the humming noise
4. When they can no longer hear the noise, remove the tuning fork (still vibrating) and hover it 1cm from the same ear
5. Ask the patient if they can hear the sound now – this tests air conduction
(6. Repeat the process on the other side)
.
- Normal result (Rinne's +ve): pt can hear sound again next to ear (it is normal for air conduction to be better than bone conduction)
- Abnormal result (Rinne's -ve): sound not heard next to ear - indicates that bone conduction > air conduction, this suggests a conductive cause for the hearing loss
(When the tuning fork is placed on the mastoid process, sound is transmitted through the bones of the skull directly to the cochlear, meaning bone conduction is intact)
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Describe how to perform Weber's test
1. Strike the tuning fork to make it vibrate and hum (use the palm of your hand or your knee – not the patient!)
2. Place it in the centre of the patient’s forehead
3. Ask the patient if they can hear the sound and which ear it is loudest in
.
- Normal result: pt hears sound equally in both ears
- Sensorineural hearing loss: sound will be louder in the normal ear (quieter in the affected ear) - the normal ear is better at sensing the sound
- Conductive hearing loss: sound will be louder in the affected ear - due to affected ear "turning up the volume" and becomes more sensitive (as sound has not been reaching that side as well due to the conduction problem (When the tuning fork’s vibration is transmitted directly to the cochlea, rather than having to be conducted, the increased sensitivity makes it sound louder in the affected ear)
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Causes of sensorineural hearing loss
- Sudden sensorineural hearing loss (over less than 72 hours)
- Presbycusis (age-related)
- Noise exposure
- Ménière’s disease
- Labyrinthitis
- Acoustic neuroma
- Neurological conditions (e.g., stroke, multiple sclerosis or brain tumours)
- Infections (e.g., meningitis)
- Medications: loop diuretics (eg. furosemide), aminoglycoside antibx (gentamicin), chemotherapy drugs (eg. cisplatin)
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Causes of conductive hearing loss
- Ear wax (or something else blocking the canal)
- Infection (e.g., otitis media or otitis externa)
- Fluid in the middle ear (effusion)
- Eustachian tube dysfunction
- Perforated tympanic membrane
- Otosclerosis
- Cholesteatoma
- Exostoses
- Tumours
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What is audiometry?
- Involves testing a patient’s hearing by playing a variety of tones and volumes using headphones (air conduction) and a bone conduction device (oscillator) that delivers sound directly to the bones of the skull
- Audiometry results are recorded on an audiogram
- Audiograms can help identify and differentiate conductive and sensorineural hearing loss
147
Normal audiogram + details
Normal readings will be between 0 and 20 dB, at the top of the chart
.
Symbols used on audiograms:
- X – Left-sided air conduction
- ] – Left-sided bone conduction
- O – Right-sided air conduction
- [ – Right-sided bone conduction
.
(each ear is tested separately and air and bone conduction are tested separately too)
148
Sensorineural hearing loss audiogram
- both air and bone conduction readings will be more than 20 dB, plotted below the 20 dB line on the chart
- this may affect only one side, one side more than the other or both sides equally
149
Conductive hearing loss audiogram
- bone conduction readings will be normal (between 0 and 20 dB)
- However, air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart
150
What type of hearing loss is presbycusis and which frequencies of sound tend to be affected first?
- Presbycusis = age-related hearing loss
- it is a type of sensorineural hearing loss
- tends to affect high-pitched sounds first
150
Mixed hearing loss audiogram
- Both air and bone conduction readings will be more than 20 dB
- However, there will be a difference of more than 15 dB between the two (bone conduction > air conduction)
(due to BC adding an additional barrier for sound transmitted through the air, increasing the AC thresholds relative to BC)
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Presbycusis - pathophysiology (basics)
Senile degeneration of auditory structures:
- atrophy of sensory cells in the cochlear
- Loss of hair cells of the Organ of Corti (particularly outer hair cells)
- Loss of neurones (spiral ganglion neurons) - transmit signals from hair cells to brainstem
152
Presbycusis - clinical features
Gradual and insidious onset of hearing loss:
- difficulty understanding speech (partially in noisy environments)
- other general hearing loss stuff (eg. increased volume on TV)
153
Presbycusis - Diagnosis and Management
- Audiometry - sensorineural pattern (with worse hearing loss at higher frequencies)
.
1. Hearing aids
2. Cochlear implants (if hearing aids are not sufficient)
(3. Lifestyle adaptations)
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What is eustachian tube dysfunction?
-The Eustachian tube is present mainly to equalise the air pressure in the middle ear and drain fluid from the middle ear.
- When the Eustachian tube is not functioning correctly or becomes blocked, the air pressure cannot equalise properly and fluid cannot drain freely from the middle ear
- The air pressure between the middle ear and the environment can become unequal - the middle ear can fill with fluid.
.
- Eustachian tube dysfunction may be related to a viral upper respiratory tract infection (URTI), allergies (e.g., hayfever) or smoking
155
Eustachian tube dysfunction - Symptoms
- Reduced or altered hearing
- Popping noises or sensations in the ear
- A fullness sensation in the ear
- Pain or discomfort
- Tinnitus
.
- symptoms tend to get worse when the external air pressure changes and the middle ear pressure cannot equalise to the outside pressure, for example, flying, climbing a mountain or scuba diving.
156
What is tympanometry?
1. Inserting a device into the external auditory canal (ear canal)
2. Creating different air pressures in the canal
3. Sending a sound in the direction of the tympanic membrane
4. Measuring the amount of sound reflected back off the tympanic membrane
5. Plotting a tympanogram (graph) of the sound absorbed (admittance) at different air pressures
.
- The amount of sound absorbed by the tympanic membrane and middle ear (not reflected back to the device) is known as the admittance
- Normally, sound is absorbed best when the air pressure in the ear canal matches the ambient air pressure
- The ambient air pressure is equal to the middle ear pressure in healthy ears.
.
- When there is Eustachian tube dysfunction, the air pressure in the middle ear may be lower than the ambient air pressure because new air cannot get in through the tympanic membrane to equalise the pressures
- As a result, the tympanogram will show a peak admittance (most sound absorbed) with negative ear canal pressures
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Eustachian tube dysfunction - Management
1. No treatment, waiting for it to resolve spontaneously (e.g., recovering from the viral URTI)
2. Valsalva manoeuvre (holding the nose and blowing into it to inflate the Eustachian tube)
3. Decongestant nasal sprays (short term only)
(4. Antihistamines and a steroid nasal spray for allergies or rhinitis)
(5. Surgery (if severe) - eg. grommets or balloon dilatation eustachian tuboplasty)
.
(Otovent is an over-the-counter device where the patient blows into a balloon using a single nostril, which can help inflate the Eustachian tube, clear blockages, and equalise pressure)
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What is otosclerosis + what type of hearing loss?
- A condition where there is remodeling of the small bones in the middle ear (malleus, incus, and stapes)
- Normal bone is replaced by vascular spongy bone - mainly affects the base of the stapes, where it attaches to the oval window, causing stiffening and fixation and preventing it from transmitting sound effectively
.
- Leading to conductive hearing loss
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Otosclerosis - Clinical features
- progressive bilateral conductive hearing loss
- affects lower-pitched frequency sounds more (opposite of presbycusis)
.
O/E:
- Otoscpoy is normal
- Rinne's: conductive hearing loss (Rinne's -ve)
- Weber's: if bilateral then normal, if unilateral then sound will be louder in affected ear
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Otosclerosis - Investigations
- Audiometry: conductive hearing loss pattern
- Tympanometry: reduced admittance (absorption) of sound (due to the tympanic membrane is stiff and non-compliant, therefore absorbing less sound)
161
Otosclerosis - Management
1. Conservtaive: hearing aids
2. Surgical: stapedectomy or stapedotomy
.
(Stapedectomy = removing entire stapes bone and replacing with prosthesis)
(Stapedotomy = removing part of the stapes bone and leaving the base of the stapes (the footplate) attached to the oval window)
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Impacted ear wax (cerumen) - Management
(Avoid inserting cotton buds into ear as can press wax in further and cause impaction)
1. Ear drops: olive oil or sodium bicarbonate 5%
2. Ear irrigation: squirting water in ears to clean away wax
(do not irrigate if perforation of tympanic membrane suspected)
3. Microsuction
163
What is a cholesteatoma?
a non-cancerous skin growth (squamous epithelial cells) that develops in the middle ear
- usually caused by Eustachian tube dysfunction
164
Cholesteatoma - Clinical features
- foul-smelling discharge from ear
- unilateral conductive hearing loss
.
If cholesteatoma expands into surrounding spaces and tissues, further symptoms may develop:
- Vertigo
- Facial nerve palsy
.
O/E:
- Otoscopy: crust on tympanic membrane
165
Cholesteatoma - Management
1. Imaging:
- CT head: to confirm diagnosis and plan for surgery
- MRI head: to assess invasion/damage to local soft tissues
2. Surgical removal of the cholesteatoma
166
Mastoiditis - complication + management
- Mastoiditis is usually as a result of a middle ear infection - can progress into an intracranial infection
- Management: IV antibx +/- surgery
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