Otorhinolaryngology (ENT) Flashcards
Ear: - Sensorineural & Conductive hearing loss - Tumours of ear Nose: -Rhinitis
NasoOropharyngeal squamous cell carcinomas (OPSCC)
- In the head and neck, OPSCC are associated with HPV
-Ebstein Barr virus (suspect 2nd) - Arise in the soft palate, tonsils, base of
tongue, pharyngeal wall, and vallecula, the fold located between the base of tongue
and the epiglottis. Often present with neck masses - Classic symptoms of odynophagia and otalgia (usually no other clinical complaints)
Key Points:
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HPV Association:
- Oropharyngeal squamous cell carcinomas (OPSCC) in the head and neck are often linked to HPV.
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EBV Suspected:
- Epstein-Barr virus is also a potential factor.
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Common Sites:
- OPSCC typically arises in the soft palate, tonsils, base of tongue, pharyngeal wall, and vallecula (the fold between the base of the tongue and the epiglottis).
- These cancers often present with neck masses.
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Classic Symptoms:
- Patients usually experience painful swallowing (odynophagia) and ear pain (otalgia) without other major clinical complaints.
Squamous cell carcinomas risk factors
- smoking & drinking (strongest)
Oropharyngeal squamous cell carcinomas (OPSCC) differentials
- Branchial cleft cyst carcinomas (exceptionally rare and its diagnosis should be one of exclusion rather than presumption)
Oropharyngeal squamous cell carcinomas (OPSCC) diagnosis
-Test for HPV
- CT head & neck (assessing the degree of local infiltration, involvement of regional
lymph nodes, and presence of distant metastases or second primary tumours)
1st line treatment for moderate to severe rhinitis?
Intranasal corticosteroid glucocorticoid (fluticasone)
-include antihistamines, leukotriene-receptor blockers, and topical glucocorticoids
Types of Rhinitis
- Allergic
- vasomotor (perennial and
is not associated with itching) - infectious (nasal turbinates red and inflamed)
Allergic rhinitis
- Caused by allergens that trigger a local hypersensitivity reaction (Specific IgE antibodies attach to circulating mast cells or basophils)
- Rhinorrhoea and pruritus
- nasal turbinates appear pale and
boggy
If all conservative approaches to rhinitis have been unsuccessful, what the next step?
Immunotherapy:
- requires identification of specific antigen by dermal or serum testing
- 3-to-5-year course (treatment duration of less than a year is ineffective)
Pleomorphic adenoma diagnosis
- CT to assess for deep lo be involvement
Pleomorphic adenoma management
- If there’s no deep lobe involvement: superficial parotidectomy (treatment of choice for most cases)
- If there’s deep lobe involvement: Total parotidectomy
clinical features of otitis media
- one-week history of unwellness with URTI
- unilateral earache
- tympanic membrane red and bulging
Acute Otitis media risk factors
ALDS
- Age (6-18 months)
- Lack of breastfeeding
- Day care attendance
- Smoke exposure
Pathogens that give arise to acute otitis media
- Streptococcus pneumoniae
- Nontypeable (?) Haemophilus influenzae
- Moraxella catarrhali
Chronic Suppurative Otitis Media treatment
Ear toileting + ciprofloxacin ear drops
For Chronic Suppurative Otitis Media (CSOM), the recommended treatment often includes ear toileting and the use of ciprofloxacin ear drops. The reasons for this management approach, as per RACGP guidelines, are as follows:
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Ear Toileting:
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Purpose: Ear toileting, or aural toilet, involves cleaning the ear canal to remove discharge, debris, and infected material. This is crucial in CSOM to:
- Reduce the bacterial load in the ear canal.
- Improve the efficacy of topical treatments by allowing better penetration of the ear drops.
- Prevent the accumulation of discharge that can foster bacterial growth and perpetuate the infection.
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Purpose: Ear toileting, or aural toilet, involves cleaning the ear canal to remove discharge, debris, and infected material. This is crucial in CSOM to:
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Ciprofloxacin Ear Drops:
- Antibacterial Effect: Ciprofloxacin is a broad-spectrum fluoroquinolone antibiotic that is effective against the common pathogens associated with CSOM, including Pseudomonas aeruginosa and Staphylococcus aureus.
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Topical Application: Topical antibiotics are preferred over systemic antibiotics in uncomplicated CSOM because:
- They deliver high concentrations of the drug directly to the site of infection.
- They minimize the risk of systemic side effects and antibiotic resistance.
- Efficacy and Safety: Ciprofloxacin ear drops are generally well-tolerated and have a good safety profile, with minimal ototoxicity compared to other antibiotics.
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Effectiveness:
- Combining ear toileting with ciprofloxacin ear drops addresses both the removal of infectious material and the application of a potent antibiotic directly to the site of infection.
- Studies have shown that this combination is effective in resolving infection and controlling symptoms in CSOM.
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Preventing Complications:
- Effective treatment of CSOM is essential to prevent complications such as hearing loss, mastoiditis, and intracranial infections.
- By reducing the bacterial load and inflammation, this approach helps to preserve the integrity of the ear structures and improve patient outcomes.
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Guideline Recommendations:
- RACGP and other clinical guidelines support this management strategy because it is based on evidence of efficacy and safety.
- The use of ear drops like ciprofloxacin, which have minimal ototoxic effects, is particularly important in treating infections involving the middle ear and mastoid cavity.
In summary, the RACGP recommends ear toileting and ciprofloxacin ear drops for the treatment of CSOM because this combination effectively reduces bacterial load, addresses the infection at the site, prevents complications, and is supported by clinical evidence for its safety and efficacy. This approach ensures a comprehensive management strategy that improves patient outcomes while minimizing potential risks.
Complications of Otitis media
Acute mastoiditis
Acute mastoiditis initial treatment
sample from the ear discharge should be taken for culture DONE BY ENT
flucloxacillin + a third-generation cephalosporin
Acute otitis media treatment
- Amoxicillin 1st choice (used for 1 week)
- 2nd line: amoxicillin-clavulanate
Acute otitis media px that’s allergic to penicillin
- clindamycin
- azithromycin
Aboriginal px with otitis media management
Antibiotics straight away
Chronic suppurative otitis media treatment
Assess if tympanic membrane intact or perforated:
If intact: ciprofloxacin ear drops to treat on going infection
If perforated: initial treatment ear toilet with povidone-iodine solution, followed by
dry mopping with rolled toilet papers2 to 3 times a day using 20ml syringe with plastic tubing. In addition, ciprofloxacin ear drops
Untreated a tympanic membrane perforation secondary to chronic otitis media
- Marginal perforation with discharge
- Perforation that is surrounded by granulation tissue
- Continuously discharging central perforation
- Perforation associated with a cholesteatoma
Benign growth of the squamous epithelium squamous epithelium and
accumulation of keratin debris within the middle ear
Cholesteatoma
Cholesteatoma risk factors
- history of recurrent acute otitis media
- chronic middle ear effusion
- tympanostomy tube placement
- history of cleft palate
Cholesteatoma features
- pearly white mass in the anterosuperior quadrant of the TM
- chronic otorrhea (runny ear)
- conductive hearing loss
Cholesteatoma treatment
surgical excision
Chronic sinusitis
Symptoms improve beyond?
Symptoms improve with therapy?
- Symptoms that persist beyond 3 months (symptoms that improve with therapy
then reoccur)
Chronic sinusitis treatment
- 2-3 weeks amoxicillin/clavulanate or fluoroquinolones
- if above are unsuccessful, high-dose
amoxicillin or a cephalosporin for 14 to 21 days
Chronic sialadenitis features
- recurrent jaw pain
- swelling of the affected salivary gland
- minimal saliva expression
Salivary duct calculi are composed predominantly of
calcium salts
Chronic sialadenitis investigation
-
Intraoral plain X-ray (80% stones are
radio-opaque) - CT
- US (best used for parotid glands)
Parotid gland tumour features
- painless firm and mobile mass (same side)
- facial nerve dysfunction (same side)