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Y2 ENT > Otalgia, Ear discharge, Hearing loss > Flashcards

Otalgia, Ear discharge, Hearing loss Flashcards

1
Q

What is otitis externa

A

Inflammation of the outer ear canal
Aka swimmer’s ear

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2
Q

Causes of otitis externa

A

Bacterial infections (S aureus, Proteus spp, pseudomonas aeruginosa)
Fungal infections (aspergillus, candida)
Triggers (water, cotton buds, skin conditions)

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3
Q

What are the bacterial causes of otitis externa

A

S aureus
Proteus spp.
Pseudomonas aeruginosa

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4
Q

What are the fungal causes of otitis externa

A

Aspergillus
Candida

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5
Q

Common causative pathogens of otitis externa

A

Pseudomonas
S aureus

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6
Q

What are the common triggers of otitis externa

A

Water
Cotton buds
Soap, shampoo
Skin conditions - eczema, seborrheic dermatitis, psoriasis

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7
Q

Symptoms of otitis externa

A

Redness, swelling of outer ear canal
May be itchy
May become sore and painful
May have discharge
Hearing loss if canal is blocked by discharge / swelling

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8
Q

Management of mild otitis externa

A

Topical acetic acid
Keep ear dry

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9
Q

Management for severe otitis externa

A

Topical antibiotics or anti fungal +/- steroids drops if more severe

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10
Q

Which topical antibiotic drop to use for bacterial cause of severe otitis externa

A

Topical gentamicin
Add steroids if cellulitis develops

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11
Q

Which topical anti fungal drop is used for fungal causes of severe otitis externa

A

Topical clotrimazole
Add steroids if cellulitis develops

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12
Q

management of otitis externa caused by eczema

A

Topical steroid drops

Avoid topical antibiotics because it can cause local sensitivity

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13
Q

Management of otitis externa when there is significant swelling

A

Use pope wick to apply topical antibiotics - pope wick ensures that the antibiotic ear drops are in constant contact with the inflamed ear canal

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14
Q

When is oral antibiotics indicated in otitis externa

A

Cellulitis beyond ear canal
Very significant swelling hence Wick cannot be inserted
Immunocompromised
Diabetics

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15
Q

What is acute otitis media

A

Inflammation of the middle ear due to infection

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16
Q

Who does acute otitis media commonly affect

A

Infants and children after viral URTI

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17
Q

How does a viral URTI cause acute otitis media

A

The infection travels up to the ear via Eustachian tube

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18
Q

Why are children more susceptible to acute otitis media after viral URTI

A

Children’s Eustachian tube is shorter and less angled, making it easier for pathogens to enter the middle ear cavity

Children have immature immune system

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19
Q

Causes of acute otitis media

A

Bacterial
Viral

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20
Q

Bacterial causes of acute otitis media

A

Strep pneumoniae (most common)
H. influenza

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21
Q

Viral causes of acute otitis media

A

RSV
Rhinovirus
Adenovirus
Influenza virus

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22
Q

Symptoms of otitis media in children

A

Fever
Irritability
Difficulty feeding
Holding / tugging ear

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23
Q

Symptoms of otitis media in adults

A

Fever
Otalgia
Hearing loss

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24
Q

Clinical signs of otitis media

A

Middle ear effusion
Feeling of aural fullness -> discharge and relief of pain when tympanic membrane perforates
Diffuse erythema
May have Bulging of tympanic membrane

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25
Q

Investigations for acute otitis media

A

Clinical
Swab if tympanic membrane perforates

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26
Q

Management of acute otitis media

A

Admit any children under 3 months with a temperature of 38 or more

Paracetamol, ibuprofen

Most resolve without antibiotics

Delayed antibiotic prescribing strategy - if symptoms don’t improve after 4 days

Immediate antibiotic prescription to children who are unwell but do not need admission / perforated TM

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27
Q

When should you admit a patient with acute otitis media

A

Children under 3 months with a temperature of >38
Children with suspected complications of acute otitis media

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28
Q

When are antibiotics used in otitis media

A

Delayed - if symptoms do not improve after 3-4 days
Immediate

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29
Q

When is immediate antibiotic prescription indicated for otitis media

A

Symptoms not improving after 4 days
Unwell but does not need admission
Immunocompromised
Children under 2 with bilateral AOM
Otitis media with perforation

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30
Q

Complications of acute otitis media

A

Facial palsy
Mastoiditis
Petrositis
Labrynthitis
Vertigo
Brain abscess
Meningitis
Sigmoid sinus thrombosis

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31
Q

What is mastoiditis

A

When the infection (otitis media) spreads into the mastoid air spaces of temporal bone

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32
Q

Why can otitis media cause mastoiditis

A

Because infection can spread to mastoid air cells via aditus to mastoid antrum (an opening at posterior wall of middle ear cavity)

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33
Q

Signs of mastoiditis

A

Erythematous Swelling behind the ear, pushing the auricle outwards and forwards

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34
Q

Investigations for mastoiditis

A

CT
MRI

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35
Q

Management of mastoiditis

A

IV antibiotics
Surgical drainage

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36
Q

Mastoiditis secondary to otitis media can further lead to

A

Meningitis

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37
Q

What is petrositis

A

When the infection spreads into the apex of petrous temporal bone

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38
Q

Petrositis secondary to otitis media can develop into a serious syndrome. What is the clinical triad of this syndrome

A

Gradenigo syndrome
Otitis media + Facial pain + Diplopia (due to abducens nerve (CN VI) palsy

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39
Q

Why can otitis media cause petrositis

A

Due to petrous part of temporal bone being the roof of middle ear cavity

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40
Q

Clinical signs of meningitis

A

High fever
Non-blanching rash
Photophobia
Neck stiffness
Headache
Vomiting

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41
Q

What is labrynthitis

A

Inflammation of the semicircular canals in inner ear cavity

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42
Q

Symptoms of labrynthitis

A

Vertigo
Nausea
Imbalance
Vomiting

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43
Q

What is sigmoid sinus thrombosis

A

When infection from the adjacent mastoid spreads into the venous wall and forms a thrombus

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44
Q

Symptoms of sigmoid sinus thrombosis

A

Swinging pyrexia
Meningitis
Sepsis

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45
Q

What is malignant otitis externa

A

Invasive infection of the bone surrounding the outer ear canal - mastoid and temporal bones

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46
Q

Most common cause of malignant otitis externa

A

Pseudomonas aeruginosa

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47
Q

Risk factors for malignant otitis externa

A

Diabetes
Radiotherapy to head and neck

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48
Q

Symptoms and signs of malignant otitis externa

A

Severe pain, headache
Pain on chewing
Facial nerve palsy - weakness in muscles of face
Exposed bone in ear canal
Granulation tissue in external canal

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49
Q

What does granulation tissue in malignant otitis externa look like

A

red/purple fleshy tissue
Usually on the floor of ear canal

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50
Q

Investigations for malignant otitis externa

A

Bloods - CRP, plasma viscosity
Imaging
Biopsy and culture

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51
Q

Management of malignant otitis externa

A

Refer to ENT
Topical ciprofloxacin

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52
Q

Describe the sensory innervation of the auricle

A

Auriculotemporal branch of trigeminal CN V3
- medial superior part of concha
Greater auricular nerves C2 C3
- Lateral and anterior surface of helix
Lesser auricular nerves C2 C3
- Posterior surface of helix
Facial nerve
- small parts of concha

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53
Q

Describe the sensory innervation of the external ear canal

A

Auriculotemporal branch of trigeminal nerve
- superior and anterior
Auricular branch of vagus nerve
- inferior and posterior

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54
Q

Describe the sensory innervation of the external surface of tympanic membrane

A

Auricular branch of vagus CN X
- posteroinferior of tympanic membrane
Facial nerve
-posterosuperior of tympanic membrane
Auriculotemporal branch of CN V3
- anterior of tympanic membrane

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55
Q

Describe the sensory innervation of the internal surface of tympanic membrane

A

Tympanic branch of glossopharyngeal nerve

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56
Q

Describe the sensory innervation of the middle ear cavity

A

Tympanic branch of Glossopharyngeal nerve CN XI

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57
Q

Nerves that causes referred otalgia

A

Trigeminal CN V3 (auriculotemporal)
Vagus CN X
Sensory branch of Facial nerve CN VII
Glossopharyngeal CN IX
Spinal nerves C2 C3

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58
Q

Glossopharyngeal nerve provides general sensory innervation to

A

Middle ear cavity
Internal surface of tympanic membrane
Eustachian tube
Oropharynx
Nasopharynx
Posterior 1/3 of tongue

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59
Q

What pathologies can cause referred otalgia due to glossopharyngeal nerve

A

Tonsillitis
Post-tonsillectomy
Pharyngitis
Carcinoma at posterior 1/3 of tongue

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60
Q

Mandibular division of trigeminal nerve CN V3 provides general sensory innervation to

A

External ear canal and area above concha
External surface of tympanic membrane
Lower lip
Chin
Anterior 2/3 of tongue
Lower molar, incisor, canine teeth and gingiva
Parotid gland

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61
Q

Which nerve provides special sensory innervation to the tongue

A

Anterior 2/3 - lingual nerve (branch of facial nerve)
Posterior 1/3 - glossopharyngeal (provides both general sensory and special sensory)

62
Q

What pathologies can cause referred otalgia due to auriculotemporal trigeminal nerve CN V3

A

Dental abscess
Dental caries
Infection / piercing of anterior 2/3 of tongue
Infection of salivary glands

63
Q

Facial nerve gives sensory innervation to

A

External ear
External surface of tympanic membrane
Ethmoid sinus
Maxillary sinus
Nasal mucosa

64
Q

Pathologies that can cause referred otalgia due to facial nerve

A

Sinusitis
Nasal pathology - foreign Bodies

65
Q

Vagus nerve provides sensory innervation to

A

Laryngopharynx and larynx
External ear and surface of TM

66
Q

Pathologies that causes referred otalgia due to vagus nerve

A

Foreign bodies in piriform fossa
Carcinoma of piriform fossa
Carcinoma of larynx
Piriform abscess

67
Q

What is chronic otitis media

A

A group of conditions that causes inflammation of the middle ear cavity for 3 months or more

68
Q

Conditions consisted in chronic otitis media

A

Benign chronic otitis media
Chronic secretory otits media (glue ear)
Chronic suppurative otitis media

69
Q

What is benign chronic otitis media

A

Dry tympanic membrane perforation without chronic infection

70
Q

What is chronic secretory otitis media (glue ear)

A

Inflammation of the middle ear + accumulation of fluid without symptoms and signs of acute inflammation (often asymptomatic)

71
Q

What is chronic suppurative otitis media

A

Persistent purulent drainage through the perforated tympanic membrane

72
Q

Complications of chronic otitis media

A

Hearing loss
Perforation
Cholesteatoma
Mastoiditis
Meningitis
Labrynthitis

73
Q

What is cholesteatoma

A

Growth of keratinising squamous epithelium cells in middle ear that can erode into mastoid air cells

74
Q

Cholesteatoma commonly occurs in

A

young patients 5-15 years old

75
Q

Cholesteatoma can be acquired or congenital. What are the causes of each

A

Acquired - due to chronic otitis media or perforated tympanic membrane

Congenital - proliferation of fragment embryonic tissue that has been retained

76
Q

Histology of cholesteatoma will show

A

Squamous epithelium with a lot of keratin production
Inflammatory infiltrates

77
Q

Symptoms of cholesteatoma

A

May be asymptomatic
Foul smelling discharge
Headache
Otalgia
Conductive hearing loss

78
Q

otoscope findings for cholesteatoma

A

Otoscopy
- visible retraction before development of cholesteatoma
- defect in tympanic membrane full of cheesy white material at the top

79
Q

Management for cholesteatoma

A

Mastoid surgery

80
Q

Complication of mastoidectomy

A

Facial nerve palsy

81
Q

Complications of cholesteatoma

A

Facial nerve palsy
Vertigo
Meningitis
Intracranial abscess
Sigmoid sinus thrombosis

82
Q

Risk factors for otitis media with effusion (glue ear)

A

Day care
Older siblings
Smoking household
Recurrent URTI
Craniofacial abnormalities (Down syndrome)
Prematurity
Immunodeficiency

83
Q

Otitis media with effusion most commonly occurs in

A

Children 2-8 years old , but can occur at any age

84
Q

Cause of otitis media with effusion

A

Eustachian tube dysfunction - fluid builds up due to blocked Eustachian tube unable to drain it from middle ear cavity to the nasal cavity

85
Q

Cause of otitis media with effusion in adults

A

Rhinosinusitis
Nasopharyngeal carcinoma or lymphoma (causes Eustachian tube dysfunction)

86
Q

How does nasopharyngeal carcinoma cause Eustachian tube dysfunction

A

Block / narrow the Eustachian tube

87
Q

Otitis media with effusion is often preceded by

A

Recurrent URTI
Recurrent otitis media
Frequent nasal obstruction

88
Q

Is otitis media with effusion an infection

A

No, it is not but it can be a consequence of an infection

89
Q

Symptoms of otitis media with effusion in children

A

Often asymptomatic
No otalgia
Hearing loss can lead to poor school performance, behavioural problems, speech delay, impact on balance

90
Q

Hearing loss in children can have a huge impact on them. What are the consequence of hearing loss in children

A

Poor school performance
Delayed speech development
Behavioural problems
Poor balance

91
Q

Investigations for otitis media with effusion

A

Otoscopy
Tuning fork tets
Audiometry
Tympanometry

92
Q

What would otoscope show in a patient with otitis media with effusion

A

Visible fluid / bubbles = effusion
Retraction of tympanic membrane - due to Eustachian tube dysfunction causing decreased pressure in ear
Altered tympanic membrane color
Reduced mobility of tympanic membrane

93
Q

What does tympanometry measure

A

How well the tympanic membrane moves

94
Q

What pattern would tympanometry show in a patient with otitis media with effusion

A

Flat tracing = stiff tympanic membrane

95
Q

What pattern would audiometry show for otitis media with effusion

A

Conductive hearing loss

96
Q

What is conductive hearing loss

A

Hearing loss due to obstruction of sound waves at any point in the outer ear and foot plate of stapes in the middle ear

97
Q

What pattern does conductive hearing loss cause on audiometry

A

Difference between bone conduction and air conduction at least 10db
Bone conduction > air conduction

98
Q

Management of otitis media with effusion

A

Generally self limiting - resolves after 3 months
Review at 3 months (otoscope, hearing assessment)
Refer Down syndrome patients w OME to ENT
Surgery if indicated

99
Q

When is surgery indicated for otitis media with effusion

A

Persistent glue ear (over 3 months)
Conductive hearing loss > 25dB
Speech / language problems
Developmental / behavioural problems

100
Q

Surgical management for Otitis media with effusion

A

Grommets
Grommets + adenoidectomy

101
Q

Complications of grommets

A

Infection
Early extraction
Retention
Persistent perforation

102
Q

Causes of conductive hearing loss

A

Otitis media with effusion
Ear wax
Perforation of tympanic membrane
Chronic suppurative otitis media
Ear infections
Otosclerosis
Cholesteatoma

103
Q

What is otosclerosis

A

Hereditary disorder in which new bony deposits occur within the stapes footplate and the cochlear

104
Q

Otosclerosis causes a distinct pattern on audiometry. What is the pattern

A

Conductive hearing loss pattern
+ Carhart’s notch at 2000Hz - an apparent loss of bone conduction at 2000Hz

105
Q

Risk factors of otosclerosis

A

Female
Pregnancy
Family history

106
Q

Why is otosclerosis more common in females

A

Linked to high oestrogen level

107
Q

Effect of pregnancy on otosclerosis

A

Can be triggered / deteriorate rapidly during pregnancy

108
Q

Symptoms of otosclerosis

A

Gradual hearing loss

109
Q

Investigations for otosclerosis

A

Audiometry - conductive hearing loss pattern + Carhart’s notch at 2000Hz

110
Q

Management for otosclerosis

A

Hearing aids
Stapedectomy

111
Q

Perforated tympanic membrane is most commonly seen in

A

Young patients with acute otitis media

112
Q

Causes of perforated tympanic membrane

A

Otitis media
Sudden negative pressure - scuba diving
Insertion of foreign objects
Acoustic trauma - exposure to loud noises
Trauma

113
Q

Symptoms of perforated tympanic membrane

A

Sudden severe pain
Followed by bleeding, hearing loss, tinnitus

114
Q

Investigations for perforated tympanic membrane

A

Otoscope
Audiometry

115
Q

Perforated tympanic membrane causes what pattern on audiometry

A

Conductive hearing loss

116
Q

Management of perforated tympanic membrane

A

Usually self limiting
Surgery if patient is symptomatic with recurrent discharge

117
Q

What is sensorineural hearing loss

A

Hearing loss due to malfunction / disease within the cochlea or auditory nerve (inner ear)

118
Q

What is the auditory nerve that is usually affected in sensorineural hearing loss

A

Vestibulocochlear nerve CN VIII

119
Q

Function of vestibulocochlear nerve

A

Transmit sound information from the cochlea to the brain

Balance and equilibrium

120
Q

Causes of sensorineural hearing loss

A

Presbycusis
Noise-induced hearing loss
Congenital infections
Kernicterus (brain damage due to hyperbilirubinaemia)
Meningitis
Drugs
Vasculopathy

121
Q

What are the congenital infections that can cause sensorineural hearing loss

A

Rubella
CMV

122
Q

What are the drugs that cause sensorineural hearing loss

A

Gentamicin - aminoglycosides
Overdose NSAID
Cisplatin (chemo)
Vincristine (chemo)

123
Q

What vasculopathy can cause sensorineural hearing loss

A

Stroke
TIA

124
Q

What is the pattern shown on audiometry for sensorineural hearing loss

A

Significant hearing loss
No difference in bone / air conduction

125
Q

Most common cause of sensorineural hearing loss

A

Presbycusis

126
Q

What is presbycusis

A

Degenerative disorder of cochlea

127
Q

how does presbycusis cause sensorineural hearing loss

A

Loss of outer hair cells
Loss of ganglion cells
Atrophy of stria vascularis

128
Q

What is stria vascularis

A

Region in cochlea for blood supply, production of endolymph and maintenance of ion composition

129
Q

Describe how do we hear sounds

A
  1. Sound waves causes vibration of tympanic membrane
  2. The vibrations are transferred through the ossicles in middle ear
  3. Then to the footplate of stapes which vibrates in oval window of cochlea
  4. This causes vibration and movement of perilymph
  5. The movement of perilymph causes vibration in the cochlear duct which activates the organ of corti
  6. organ of corti converts that mechanical stimuli into neural stimuli (action potentials) -> cochlear nerve -> vestibulocochlear nerve
  7. Vibrations are dampened at round window
130
Q

Describe the anatomical course of vestibulocochlear nerve

A

Exit the cranium via internal acoustic meatus then splits into 2 parts -> cochlear and vestibular nerves
The vestibular nerve innervates the vestibular system
The cochlear nerve innervates the cochlea

131
Q

Function of vestibulocochlear nerve

A

Hearing
Balance (because it innervates the vestibular system)

132
Q

Describe how do we coordinate balance

A

Utricle and saccule detect linear movement change of the head
3 semicircular canals detect rotational movements of the head
As your head moves, the endolymph fluid in the vestibular system moves and triggers the hair cells in ampulla -> trigger APs to vestibular nerve -> vestibulocochlear nerve back to brain

133
Q

what are the 3 semicircular canals

A

Horizontal
Superior
Posterior

134
Q

Movement detected by each semicircular canal

A

Horizontal - head rotation in transverse plane ; head from side to side

Superior - head rotation in sagittal plane ; nodding head

Posterior - head rotation in coronal plane ; moves head to touch shoulder / doing a cartwheel

135
Q

What is vestibulo-ocular reflex

A

Reflex that allows images to be stabilised when the head is turning by moving eyes in the opposite direction

136
Q

Vestibulo-ocular reflex is regulated by

A

Vestibular system - vestibular nerve, semicircular canals and otoliths (utricle and saccule)

137
Q

Where is the perilymph of cochlea located at

A

Scala vestibuli
Scala tympani

138
Q

How does the organ of corti detect stimuli

A

Receptor hair cells at the basilar membrane of cochlear duct

139
Q

Another name for cochlear duct

A

scala media

140
Q

Presentation of presbycusis

A

Gradual hearing loss

141
Q

Features on audiometry for presbycusis

A
  • sensorineural hearing loss
  • higher frequencies affected the most
142
Q

Management for presbycusis

A

High-frequency specific hearing aid

143
Q

Causes of noise induced hearing loss

A

Damage to the cochlea due to
- Shooting without ear protectors
- Industrial noise

144
Q

Features on audiometry for noise induced hearing loss

A

Sensorineural hearing loss
Dip at 4000Hz

145
Q

What is vestibular schwannoma

A

Benign tumour of vestibulocochlear nerve CN VIII nerve sheath that arises in internal auditory meatus

146
Q

What structures pass through the internal auditory meatus

A

Vestibulocochlear nerve
Facial nerve
Labyrinthine artery and vein

147
Q

What is labyrinthine artery

A

Branch of artery from the circle of Willis

148
Q

Causes of vestibulocochlear schwannoma

A

Extensive exposure to excessively loud noise
Neurofibromatosis type 2

149
Q

Clinical presentation of vestibulocochlear schwannoma

A

Gradual unilateral hearing loss
Imbalance
Facial nerve palsy

150
Q

Investigations for vestibulocochlear schwannoma

A

Audiometry - sensorineural
MRI

151
Q

Management for vestibulocochlear schwannoma

A

Surgery
Small lesions may be monitored in 6 months interval

152
Q

Most common tumour of the ear

A

Squamous cell carcinoma

Y2 ENT (7 decks)

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