ORL Flashcards
Microorganisms causing acute otitis media
Respiratory viruses, Strep pneumoniae, H influenzae, Moraxella catarrhalis
Examination findings in acute otitis media
cf otitis media with effusion
Red, bulging tympanic membrane
Loss of normal contours
Loss of translucency
Air-fluid level
Discharge from grommet or perforation
OME
Dull, retracted tympanic membrane
Middle ear effusion
No symptoms of infection
Persists up to 12 weeks after AOM
GP to refer for tympanometry if persisting
Complications of acute otitis media
Perforation of TM
Mastoiditis
Facial nerve palsy
Intracranial spread
Criteria for antibiotics for acute otitis media
Abx treatment:
Age <6 months
Age <2 years with bilateral infection
Not improving after 48 hours
Recurrent infection >3 in 6 months/>4 in 12 months
Amoxicillin 15mg/kg tds 5 days (30mg/kg 7 days in severe)
Augmentin if no response to high dose
OR
Erythromycin 10-12.5mg/kg QID 5-7 days
OR
Cotrimoxazole 24mg/kg BD 5-7 days
80% resolve in 3 days without abx
Causes of otitis externa and treatment
Sweating, swimming, high humidity
Local trauma
- Gentle irrigation unless canal swollen ++
- Microsuction
- Mild: - 2% acetic acid + 1% hydrocortisone drops 5 drops tds until resolve
Bacterial
- Swelling, fever, severe discomfort, lymphadenopathy, scant white discharge, bloody discharge if chronic
- Sofradex 5 drops tds, 3-5 days after symptoms resolve
Fungal
- **Profuse discharge, itch, fullness, tinnitus
- Clean ear canal
- Locarten Vioform 5 drops QID 5-7/7
Atopic dermatitis
- Itch, red, thick, crusty, hyper pigmented skin, eczema elsewhere
Psoriasis
- Itch, red lesion, thick white scale, scalp involvement
Allergic contact dermatitis
- Rapid, red, swollen, itchy, exudative lesions, outer lobe/ear involvement
Irritant contact dermatitis
- Slow onset, patches of thickened, hardened skin, outer lobe/ear involvement
Prevention advice:
No swimming 14 days
Dry ears after shower/swimming
Acetic acid drops in ear after swimming
Avoid FB in ear
Features of cholesteatoma
Symptoms
Examination finding
Risk factors
Complications
Lesion of keratinising stratified squamous epithelial cells, from lateral epithelium of tympanic membrane
Sx: Conductive hearing loss
Intermittent foul smelling ear discharge
Exam: Retracted pocket in attic or postero-superior quadrant, granular polyp in ear canal
Risk - Eustachian tube dysfunction, recurrent childhood AOM, cleft palate, Down Syndrome
Complications: Facial nerve weakness
Inner ear invasion - loss of balance
Labyrinthitis
Intracranial infection, meningitis, brain abscess
Mastoiditis
Bacteria in mastoiditis
Pneumococcus
Strep pyogenes
H influenzae
Staph aureus
Spread of mastoiditis
Extension of acute otitis media - days to weeks
Osteitis of septae + coalescence of air cells
>lateral mastoid cortex = post auricular subperiosteal abscess
>central extension = temporal lobe abscess or septic thrombosis of lateral sinus
>zygoma = zygomatic mastoiditis
>tip of mastoid into neck = Bezold abscess
IV flulcox + ceftriaxone
Urgent ENT referral, NBM
Symptoms of mastoiditis
Mastoid swelling + tenderness
Pinna pushed down + forward
Fever >38
Conductive hearing loss
Nausea/vomiting
Ear discharge
Beware of masked mastoiditis - partially treated, milder symptoms
Incidence and causes of sudden sensorineural hearing loss
Peak 50s and 60s, usually unilateral
Bilateral more common in younger age groups
Idiopathic
Possible infective, vascular, immunological, traumatic, deficiencies
NSAIDs (especially aspirin)
Management of sudden sensorineural hearing loss
ENT referral - Urgent audiometry and bone conduction tests within 48 hrs
High dose steroids - 40-60mg prednisone OD 5-7 days
Repeat audiometry
Slow taper if no improvement, discuss with ENT if improvement
50% patients have full recovery in 2 weeks
Tinnitus that requires urgent investigation:
Unilateral and lower hearing threshold - MRI to r/o acoustic neuroma
Conductive hearing loss - CT to r/o otosclerosis or cholesteatoma
Pulsatile tinnitus - MRA/CTA to r/o vascular abnormality
Arteries contributing to Little’s area
Arteries for posterior bleed
90% of epistaxis
Internal carotid:
Anterior ethmoid, posterior ethmoid
External carotid:
Sphenopalatine, greater palatine, superior labial
Posterior bleed:
Posterior septum or lateral nasal wall
internal maxillary, sphenopalatine, descending palatine, posterior ethmoid
Causes of epistaxis
Trauma - nasal trauma/picking
Sinusitis/URTI
HTN
Coagulopathy, anticoagulants, haemophilia
Nasal steroids
Cocaine
Post-op
Nasal tumours/polyps
Complications of nasal trauma
Full thickness lacerations
Open fracture
Septal haematoma - saddle deformity
Septal abscess -> meningitis, intracranial abscess, venous sinus thrombosis
Postural CSF leak -> fracture of cribriform plate
Microbial causes of tonsillitis
90% viral
EBV/CMV
COVID
Group A streptococcus (7-37% depending on community)
Antibiotic indication in sore throat
Family hx rheumatic fever
OR 2 of:
Maori/Pacific
Low SES or crowded circumstance
Ages 3-24, especially 4-19
Local suppurative complication (peritonsillar cellulitis, quinsy), scarlet fever or immunocompromised
Penicillin V 250mg (<20kg)/500mg (>20kg) 2-3 times/day, 10 days
Amoxicillin 50mg/kg or 1g OD, or 25mg/kg or 500mg BD 10 days
Benzathine penicillin 450mg IM stat (<30kg), 900mg IM stat (>30kg)
Erythromycin 40mg/kg/day 10 days
800mg BD 10 days
Roxithromycin 300mg OD 10 days or 150mg BD 10 days
Microbial causes of acute rhinosinusitis
98% viral
COVID 19
Bacterial - Strep pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
Signs of bacterial rhinosinusitis
Complications
Fever >39 deg
Purulent nasal discharge
Severe unilateral maxillary pain with percussion tenderness
Cavernous sinus thrombosis
Meningitis
Cerebral abscess
Orbital cellulitis/abscess
At risk groups for rhinosinusitis
Polyps, deviated septum, turbinate deformity, enlarged tonsils/adenoids, nasal FB, tumour
Atopy
Smoking
Rhinitis medicamentosa - chronic decongestant use
Allergic/non-allergic rhinitis
Pregnancy, immunodeficiency, hypothyroid, CF, migraine, vascular headache
Management of rhinosinusitis
Acute viral
Acute bacterial
Chronic
Acute viral - nasal decongestants <7 days, sinus rinses, analgesia
- Nasal steroid if symptoms >10 days.
- Post-viral symptoms may persist for 12 weeks.
Acute bacterial - nasal decongestant, sinus rinse, analgesia, nasal steroid
- Abx if severe illness >3 days, symptoms >10 days, worsening after initial improvement
- Amoxicillin 15-30mg/kg, 500mg tds 7 days
OR Doxycycline 200mg day 1, 100mg OD further 6 days
OR augmentin if symptoms persist
Chronic - Long term nasal saline irrigation and nasal steroid
- No improvement in 4 weeks - 3 weeks of weaning steroids
- If nasal polyps add 3 weeks roxithromycin/doxycycline
- No improvement - CT sinus and ENT referral
Risk groups for dental infections
Poverty
Poor diet
Poor dental hygiene
Drugs (meth mouth)
Immunocompromised
Sjogren’s disease - reduced saliva
Complications of dental infections
Red flag symptoms
Trismus
Swelling floor of mouth
Airway compromise
Severe facial swelling
Ludgwig’s angina - spread of infection for lower 2nd, 3rd molars to sublingual, submandibular, submittal space.
- Trismus, resp distress, dysphagia, dysphonia, preference to sit upright
Paediatric dental infections
> retropharygeal space > retropharyngeal abscess
> parapharyngeal space > parapharyngeal abscess
Bacteraemia, endocarditis (in valvular disease)
Dental trauma management:
Avulsed tooth
Fractured tooth
Mobile tooth
Emergency referral for all:
Avulsed
- Leave primary teeth
- avoid touching root
- brief wash under cold water (<10 s)
- place in socket, in mouth between cheek and molars, or in glass of milk
Fractured
- Keep tooth fragment
Antibiotics for dental infection if delay to see dentist
Amoxicillin 5/7
OR Cefalexin 500mg QID 5/7
OR Metronidazole 400mg tds 5/7
Temporomandibular dysfunction:
Aetiology
Frequency
At risk groups
Muscular disorder - Stress related MSK dysfunction, bruxism, teeth grinding, poor posture, anxiety
TMJ disorder - osteoarthritis, subluxation, dislocation (usually anterior and bilateral)
70% population have signs
5-12% symptomatic
Peak incidence age 20-40
Women 4x more than men
Signs and symptoms of temporomandibular dysfunction
Management
***Pain with jaw movement
Clicking, crepitus
Headache, neck pain
Poor sleep, reported teeth grinding
Normal jaw opening 35-45mm
Jaw splints
Psychosocial support
Sleep hygiene
Simple analgesia +/- amitriptyline. Avoid opioids/benzos
TMJ dislocation
- inability to close mouth, garbled speech, drooling
- Syringe technique
- Gag reflex
- Manual reduction - intraoral/wrist pivot/extraoral
- Soft food for 1 week, avoid extreme mouth opening
Neck lump pertinent hx
Size, progression over time, pain, affecting eating
Voice changes
Recent infection of nearby structures
Fever
Smoker
Travel
Past cancer
Symptoms of systemic illness
Ddx for lateral neck lumps
Hodgkin’s lymphoma
- Young adults
- Painless progressive submittal swelling
Metastatic ca
- Submental/submandibular, upper neck/tail of parotid
- SCC, melanoma
Primary oral cancer
- HPV oropharyngeal ca, level 2 jugulodigastric node, age 40-60 male, smoker, ETOH
- Nasopharyngeal ca, TB - Asian
Submandibular duct obstructing stone
- acute, associated with eating
Submandibular tumour
- Painless progressive swelling of submandibular gland
- 50% malignant
Parotid gland
- Mumps, bacterial inf secondary to salivary obstruction
- Tumour - painless progressive swelling. Primary usually benign. Secondary from melanoma, SCC
Branchial cyst
- Children and young adults
- Usually cystic (sometimes solid) jugulodigastric region
- Can present acutely with inflammation
- Refer for removal
Inflammatory lymphadenopathy
- Jugulodigastric or posterior triangle
- Acute bacterial/viral infection
Plunging ranula
- Mucoid saliva from sublingual gland herniates through myohyoid
- Soft, ill defined swelling in submental/submandibular area
- Swelling in floor of mouth
- Refer for removal sublingual gland
Carotid body tumour
Nerve sheath tumour
Lipoma
Hyoid bone, carotid bulb (normal variants)
Ddx for lower midline neck lumps
Thyroid nodules
- Elevate with swallowing
- Usually on either side of midline
- High risk of malignancy if >4cm solitary nodule in men or children
Thyroglossal cyst
- Age <20 years
- 80% under hyoid bone
- Moves with tongue protrusion
- If infected, large and painful
- Refer for removal
Dermoid cyst
- Anywhere from chin to jugular notch
- Usually young children
- Congenital, benign, filled with caseous material
Refer for FNA if neck lump persists >3 weeks
