Otology Flashcards
Describe what you see in the picture
What is the most likely diagnosis. Give a brief description of what has occurred
How is this treated?
This is a clinical picture of the left ear showing subcutaneous collection affecting the left pinna especially the area of the antihelix and crura (sup and inf) of the antihelix,
This clinical picture is consistent to an auricular hematoma usually secondary to trauma. Collection of blood formed between cartilage and pericondrium (which supplies blood to cartilage due to shearing of these BV due to trauma) leading to ischemia and necrosis.
Diagnosis: Cauliflower ear typically seen in rugby players
Tx: Urgent incision and drainage before suturing bolster dressing (splinting in book) on pinna to prevent it from re-opening
Auricular haematoma formation is due to the shearing of perichondrial blood vessels supplying the cartilage. What is the main complication of this if it is not treated promptly
Cauliflower ear from avascular necrosis
On otoscopy, you find this clinical picture. The patient has been complaining of pain. On examination this finding is pulsatile. What is the finding in this image?
The finding is a pulsatile (given) red mass behind a normal tympanic membrane
This is actually Globus Tympanicum which is a vascular tumour in the middle ear
You see this patient in the OPD as you clock in to start your shift. What diagnoses come to your head (give 2)
Mastoiditis (from AOM…)
Bat ears (congenital)
In the field of ENT what red flags are you always looking to rule out?
Unilateral symptoms
Presence of eye symptoms
Weight loss
Dysphagia
Chest infection (aspiration)
What is vertigo?
Sensation that the environment around you is spinning
Define Odynophagia
Pain from swallowing referred to the ears via the glossopharyngeal nerve (CNIX)
Define Globus sensation
sensation of a lump in the throat
Define Stridor
High pitched wheeze caused by airway obstruction
Define Torticollis
Whatis the etiology of torticollis in children and adults?
Children: Positional torticollis due to SCM (shorter)
Adult: Spasm or viral infection causing irritation to cervical ligaments or vigorous movement
During inspection in an ENT exam, what are you looking for?
Other than looking at the patient what other actions must be performed? Go crazy with detail for bonus points
Make a show by looking around the patient and raising their hair for the back of their neck esp for scars. You would be looking for scars, asymmetry, swellings, masses erythema, rashes, tophi…
Ask patient to smile for symmetry and facial nerve palsy
Ask patient to swallow for thyroid gland (give glass of water if needed)
Ask patient to stick tongue out for thyroglossal duct cyst
ET function (Valsalva test)
Inspect oral cavity via tongue depressor and otoscope (light) around the tongue looking at Dentition!! and symmetry of structures
Inspect Nasal cavity for polyps, masses, swellings, DNS…
Check eyes for signs of cysts, abscess, eye movements.
Describe the image as you would on your finals
I see two clinical pictures each demonstrating a patients ear, one on each side. The ear looks healthy with no evidence of any obvious asymmetry, swellings, or disease. There appears to be 3 white/skin colored lesions around .5cm diameter along the pinna. This seems to be consistent with tophi which appear peripherally and on extensor surfaces usually including the ear. Colchicine may be used to treat this acutely and allopurinol preventatively to lower uric acid levels in the body
This picture is given to you on an exam. Have at it
How is this managed?
This is a clinical picture of a male paediatrics patient. They appear to have a nice symmetrical face with no obvious signs of weakness. No masses, scars, or swellings are evident. They appear to have prominent ears due to an absent antihelix.
Prominant ears is surgically managed via Pinnaplasty or Otoplasty (cosmetic procedures) !prior to the child commencing school! to prevent bullying and psychological sequelae
This picture is given to you on an exam. The clinical context is a patient in the pediatric outpatient department for a follow up.
What is this finding associated with (not disease or syndrome)
This is a clinical picture of a paediatric patient’s left ear. The external ear itself looks healthy and does not have any evident swelling, erythema, lesions, or masses. The main finding is what appears to be a sinus present pre-auricularly. Pre-auricular sinus. They are associated with deafness and may become easily infected.
Give some congenital ear deformities you may spot on inspection
What would your workup be once you spot any of these deformities including curative treatment
1) Prominent ears (Bat ears): Absent anti-helix! others include deep concha anc protruding lobule
2) Anotia/Microtia
3) Pre-auricular sinus
Workup: Check hearing by obtaining a Pure Tone Audiogram and tympanogram. If hearing not affected, this becomes cosmetic. Pinnaplasty/otoplasty would be the curative surgery.
This picture is given to you on an exam. Have at it
This is a clinical picture of a patient’s right eat. The external ear itself looks healthy apart from a lesion on the pinna. The most common neoplastic lesion is an SCC due to the exposure to sunlight. (may also be a BCC)
When holding an otoscope, it is typically held like a pencil. Why does the doctor typically rest their pinky on the patient’s face?
The otoscope is typically held by the hand that is on the same side as the ear that is being examined (right hand right ear). What does the other hand do?
Once going in make sure you angle it upwards to see the attic or the pars flaccida. What is the pars flaccida?
You see a light, what is that light and where is it located?
For stability especially in the pediatric population who may jerk in any direction suddenly from potential pain
The other hand holds the pinna up and out and back for adults, down and out and back in pediatrics
The pars flaccida is the thinnest portion of the tympanic membrane and hence the weakest => commonest point of perforation and retraction. It is composed of 2 layers as it is missing the third, middle fibrous layer that the pars tensa has
The light is the light reflex, typically located on the anterior inferior part (=> towards front of patient) of the TM. It is missing in disease and grommets (inserted here)
While using an otoscope, this image is what you see. Explain what you see
This is a picture of the external auditory meatus obtained via otoscopy. There appears to be a non-erythematous swelling of the walls of the EAM. This is consistent with Exostosis or Surfer’s ear secondary to chronic exposure to cold weather/water. It is a bony overgrowth that may lead to recurrent infections and wax compaction leading to conductive hearing loss
While using an otoscope, this image is what you see. Explain what you see
Clinical context: 2 year old child presents with severe otalgia, 2 days after going to the community pool for a swim with the family. You conduct otoscopy but cannot move further due to the pain.
How are you expecting the Tympanic membrane to look if you were able to go further?
What is the most likely diagnosis?
This is a picture of the external auditory meatus obtained via otoscopy. There appears to be evidence of extensive swelling of the erythematous wall of the EAM leading to stenosis. There also appears to be a yellow/white cottage cheese discharge. Pressing on the walls of the EAM may lead to more production and can further confirm the likely diagnosis of acute otitis externa.
This is basically a skin infection, the tympanic membrane should be normal
How would you test ET tube function?
(Honours, Contraindications)
Valsalva test (pinch nose, deep breath, close mouth, exhale through nose). This will test if the ET is limited by effusions/discharge or perforation.
Normally the tympanic membrane would just move outwards. If there is a
Hissing sounds -> Perforation
Crackling sound -> Discharge/effusions
Contraindications: Atrophic sclerosis with risk of rupture or presence of infection in nasopharynx (may make it go to middle ear)
The examiner gives you this on the exam. What is the main finding of this image?
Tympanosclerosis (say full thing like its an exam)
While using an otoscope, this image is what you see. Explain what you see
This is an image of the tympanic membrane of the left ear obtained via otoscope. This tympanic membrane appears to be retracted highlighted mainly at the Pars Flaccida. There is a brown/yellow tinge giving evidence of effusions in the middle ear consistent with glue ear or otitis media with effusions. Other differentials would be chronic supporative otitis media with cholesteatoma (complication of glue ear)
While using an otoscope, this image is what you see. Explain what you see
This is an image of the tympanic membrane obtained via otoscopy. There is a red, bulging tympanic membrane (should have reduced movement and a history of conductive hearing loss and severe otalgia until perforation - obs you dont have to be saying that here). There is an absent light reflex in the anterior inferior quadrant and I cannot visualize the handle of the malleus. I suspect the bulging to be as a result of an infective process such as otitis media => filled with pus.
While using an otoscope, this image is what you see. Explain what you see
This is an image of the tympanic membrane of the left ear obtained via otoscopy. The handle of the malleus is evident along with the pars flaccida and pars tensa. There is a small perforation in the location of the light reflex on the anterior inferior margin. It seems to be dry with no evidence of discharge as it would in AOM. Here it may be a more chronic otitis media or trauma or cholesteatoma.
You have conducted the Rinne and Weber test and now want to conduct the Whisper test.
Explain the Whisper test and its escalations
Explain the test to the patient. Start by testing the hearing via normal conversation infront of them and ask them to repeat
Stand arms length (60cm) behind the patient and rub the tragus of the non-tested ear to mask noise. Whisper bisyllabic # (twenty). (12db). If they cannot hear, escalate.
Conversation voice (50db)
Loud (75db)
Move 15 cm closer (=>45cm) and whisper (35db)
Conversational (55db)
What are the 3 ossicles of the ear? Which portion of the ear are they located
Malleus, incus, stapes
Middle ear
The stapes connects indirectly to the inner ear via a structure. What is this structure and what is the other connection between the middle and inner ear?
Oval window closed by stapes footplate
Round window closed by membrane
What is the main function of the Eustachian Tube?
Equalize pressure in the middle ear
Describe the structures of the inner ear.
The inner ear is divided into anterior and posterior parts, the anterior being the cochlear and posterior being the vestibular
The cochlear (hearing) portion is composed of the Scala tympani, Scala vestibuli, and cochlear duct
The vestibular (balance) portion is composed of the utricle, saccule, and 3 semicircular canals
State differentials of the outer ear (as many as you can)
Congenital: Pinna disorders, preauricular sinus
Trauma: e.g. Battle’s sign (post-auricular ecchymosis from basilar skull fracture), temporal bone fracture, Cauliflower ear
Infectious: AOE, Perichondritis, pinna cellulitis, mastoiditis, erysipelas,
Neoplastic: SCC
Wax impaction
CSF leak is a major complication of a temporal bone fracture due to its proximity to the Tegmen in the middle ear. What are the 2 ways a CSF leak may manifest in a patient presenting to the ED with temporal bone trauma?
Otorrhoea => CSF in middle ear through perforated tympanic membrane
Post-nasal drip of CSF from middle ear through ET into post-nasal space (classic bending over)
What is seen in this image? Explain
What is your workup for this patient including
1) What you are looking out for in history and physical exam
2) imaging and its possible findings
What are the main ENT-related complications of this?
This is a clinical picture of a patient’s left ear which appears to have post-auricular ecchymosis consistent with Battle’s sign, basilar skull fracture, temporal bone fracture.
This is considered a head injury and should be worked up as such ABCDE especially if major
1) if you get like 90% its a 5/5 definitely
Main: GCS!!, nausea, vomiting, headache, (increased ICP)
Base of skull fracture => Check for orbital ecchymosis or raccoon eyes
Tympanic perforation => otoscopy
CSF leak (Otorrhoea vs post-nasal drip)
Facial Nerve function
Hearing (tuning fork, rinne, whisper, Pure Tone Audiogram, tympanogram)
Tinnitis
Vertigo
Otalgia
Cuts/lacerations
Auricular hematoma
2) Non-contrast CT brain (contrast later if needed). It will show left temporal bone fracture and air bubbles around fracture medially +/- orbital emphysema. May also show hematoma.
This is handed to you in an exam. Explain what you see
DO the full thing: Must include
Perichondritis. Inflammation of the cartilage. Redness and oedema on pinna but not lobule as lobule has no cartilage
Caused by Pseudomonas Aeruginosa, Staph, strep
This is handed to you in an exam. Explain what you see
Must include:
Pinna cellulitis affecting all of pinna and lobule with a more diffuse border (as opposed to erysipelas)
Caused by Pseudomonas Aeruginosa, Staph, strep
This is handed to you in an exam. Explain what you see
What else would you check for after seeing this finding
Must include:
Erysipelas: Intense redness on entire ear including pinna, lobule, concha and preauricular space. Typically well demarcated and may appear on the face and nose => check
Typically caused by Group A Strep (Pyogenes).
Very tender
Also Check for lymphadenopathy
This is handed to you in an exam. Explain what you see
Must include:
Full introduction of image
Subperiosteal abscess typically resulting from progression of orbital cellulitis which can occur from ethmoidal sinusitis especially in infants suffering from recent URTI (wow if you get all that).
This is handed to you in an exam. Explain what you see
What is it associated with?
What is the treatment for this patient?
Must include
Post-auricular swelling => Mastoiditis. Associated with AOM, subperiosteal abscesses (Ethmoidal sinusitis/sinusitis), Temporal lobe abscess, brain abscesses.
Caused by M. Catarrhalis, S.pneumonia, H. Influenzae (same as AOM and acute sinusitis)
IV antibiotics +/- Mastoidectomy + Grommet insertion
What is the age cutoff for Pure Tone Audiogram testing?
How do you screen for hearing loss in an infant? How does it work? What is the main drawback?
If someone is positive on the screening test, what is the next step (for an infant still)? How does it work? How would you interpret the results.
Infant=> cannot give input => Cannot produce audiogram. Children <4 cannot reliably perform the test
Screening: Otoacoustic Emissions test. It tests for an echo via a small microphone-like device. Inner hair cells receive sound waves from an sound played by examiner. That sends signals to the brain via Cochlear nerve. The brainstem will then reflex by contracting the external hair cells leading to formation of the echo picked up by device.
Drawback? Does not assess function of the vestibulocochlear nerve (CNVIII) . => ABR
After this, Auditory Brainstem reflex which is the reflex to focus on a sound, uses the same concept as above but here, surface electrodes are placed on the scalp to detect electrical signals originating from the brainstem and along CNVIII. Results are obtained in a series of waves. The 5th wave is what is important as its presence signifies that 1,2,3,4 have already passed without issues.
