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:
-
HPV Association:
- Oropharyngeal squamous cell carcinomas (OPSCC) in the head and neck are often linked to HPV.
-
EBV Suspected:
- Epstein-Barr virus is also a potential factor.
-
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.
-
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:
-
Ear Toileting:
-
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.
-
Purpose: Ear toileting, or aural toilet, involves cleaning the ear canal to remove discharge, debris, and infected material. This is crucial in CSOM to:
-
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.
-
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.
-
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.
-
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.
-
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)
Parotid gland tumour investigation
Tumor !!!
CT head & neck
Midline neck swelling which moves with tongue protrusion. Treatment
Thyroglossal cyst
Treatment
• Painless, firm, midline neck mass that elevates with swallowing and tongue protrusion
• Usualy located near the hyoid bone
• May cause dysphagia or neck/throat pain fi the cyst enlarges • Diagnostics
• Neck and thyroid examination
Ultrasound of the neck to evaluate the cyst and confirm the location of the thyroid
•
• Patients with thyroglossal duct cysts can have an ectopic thyroid gland. 141
• In the absence of ectopy, ti is important to assess the anatomical relation of the cyst to the thyroid for preoperative planning.
Contrast-enhanced TC of the neck: preferred imaging modality
Thyroglossal duct cysts are demonstrated as wel-
•
•
ISH levels
If an infection is suspected, fine needle aspiration should be performed for Gram stain and culture (including AFB and mycobacterial culture).
Elective surgical excision (Sistrunk procedure) to prevent infection: includes removal of the cyst, a portion of the hyoid bone, and excision of tissue comprising the path of descent from the foramen cecum
defined lesions with homogenous fluid attenuation and surrounding rim ernancernent, typically close to the hyoid
bone.
Alows for assessment of ar atomical location, relation, and extent of the cyst as weil as its relation to
normal orthotopic thyroid tissue.
•
Treatment of any active infection with antibiotics before surgery • Complications
• Infection of the cyst with possible abscess formation
• Sinus tract formation with persistent drainage
• Ectopicthroidtisanaakram436@gmail.com
Painless neck lumps in adults
Painless- tumour
- Malignant unless proven otherwise
- FNAC and CT investigations of choice first
-Excisional biopsy after CT
Lateral neck swelling which doesn’t move with tongue protrusion
Branchial cysts
Sleep apnoea features
– Excessive daytime sleepiness.
– Fatigue.
– Snoring at night.
– Choking or gasping while asleep.
– Morning headaches.
– Moodiness, irritability or depression
- Impaired vigilance
- Depression
- Narcolepsy
Difference between obstructive sleep apnoea and central sleep apnoea
- sleep maintenance insomnia (experiencing a lot of prolonged
awakenings during the night or one long wakeful period associated with daytime tiredness)
The main difference between obstructive sleep apnea (OSA) and central sleep apnea (CSA) lies in the underlying cause of the breathing pauses during sleep:
-
Obstructive Sleep Apnea (OSA):
- Cause: In OSA, the airway becomes partially or completely blocked during sleep, leading to breathing pauses.
- Mechanism: The obstruction typically occurs due to relaxation of the muscles in the throat, tongue, or soft palate, which collapse and block the airway.
- Symptoms: Common symptoms include loud snoring, gasping or choking during sleep, excessive daytime sleepiness, and fatigue.
- Risk Factors: Risk factors for OSA include obesity, enlarged tonsils or adenoids, a narrow airway, and anatomical abnormalities in the upper airway.
-
Central Sleep Apnea (CSA):
- Cause: In CSA, the brain fails to send the appropriate signals to the muscles that control breathing, resulting in breathing pauses.
- Mechanism: Unlike OSA, there is no physical obstruction in the airway. Instead, CSA occurs due to instability in the respiratory control center of the brainstem.
- Symptoms: CSA is often associated with medical conditions such as heart failure, stroke, or certain neurological disorders. Symptoms may include difficulty breathing during sleep, frequent awakenings, and poor sleep quality.
- Risk Factors: Risk factors for CSA include heart failure, stroke, opioid use, and certain neurological conditions affecting the brainstem.
In summary, while both OSA and CSA involve breathing pauses during sleep, OSA is primarily due to airway obstruction, whereas CSA results from a failure of the brain to properly regulate breathing.
Sleep apnoea treatment
Continuous positive airway pressure (CPAP)
- sleep studies & respiratory specialist referral for diagnosis confirmation of the
Sleep apnoea most important risk factor
Before obesity
Congestive cardiac failure (most important)
- obesity (50%)
- myotonic dystrophy
- Ehlers-Danlos syndrome
- smoking
Sleep apnoea stroke mechanisms
- Large swings in blood pressure
- Increased coagulopathy
- Development of atrial fibrillation
- Local vibrational damage to the carotid artery bifurcation
- Paradoxical emboli through the asymptomatic patent foramen ovale opening during transient sleep-related hypoxia with pulmonary hypertension.
Anterior triangle of the neck mass
BCC
- Branchial cyst
- Carotid body tumour
- Carotid aneurysm
Branchial Cyst
- 20 – 40 y/o
- Location: inferior to the EAM and
anterior to the sternomastoid muscle - diagnosis: Mainly clinical
- management: Excision
Carotid body tumour
- 40 – 60 y/o
- Location: opposite thyroid cartilage
- Pulsatile mass that moves laterally
- Management: referral for excision
Posterior triangle of the neck mass
CPP
- Cystic hygroma
- Cervical rib
- Pancoast tumour
- (Naso/oropharyngeal squamous cell carcinomas)
Cystic hygroma
Paediatric condition (developmental
remnant)
* Transluminal mass
Treatment:
* refer Surgery
* Sclerosis
Pancoast tumour
-Tumour of lung APEX
- non-small cell cancer.
- Unilateral or bilateral
Pancoast tumour Complications
Mainly compression of:
- Subclavian artery: subclavian syndrome
- Brachial plexus: painful paraesthesia
- Sympathetic ganglion: Horner’s syndrome
- brachiocephalic vein compression
- phrenic nerve: cough
- recurrent laryngeal nerve: hoarseness
Pancoast tumour treatment
- Surgery
- Radiotherapy if life-threatening (subclavian syndrome)
- Chemotherapy if surgery too difficult
Horner’s Syndrome
- Anhidrosis
– pseudo enophthalmos - Ptosis
- Miosis
Midline of the neck mass
**TTD **
- Thyroid nodule
- Thyroglossal cyst
- Dermoid cyst
Thyroglossal cyst
Paeds remnant
- most common cause of midline
neck masses
- will move upwards with protrusion of the tongue
Dermoid cyst
-
teratoma that contains an array of
developmentally mature, solid tissues - Management: imaging (CT) and
surgical resection
Epistaxis management
- Sitting forward to prevent blood dripping down the throat.
- Compress the cartilaginous portion of nose for 5 -10 minutes
without interruption
Most common cause of epistaxis
Local incidental trauma
Recurrent epistaxis in a sleep apnoeic patient
CPAP use
- recommend warming & humidification of CPAP
- nasal saline irrigation
Painless swelling in front of the ear and slight drooping of mouth
Parotid gland carcinoma Parotid gland carcinoma
Ramsay Hunt syndrome
- Also termed herpes zoster oticus (reactivation of varicella-zoster virus)
- acute peripheral facial neuropathy
Triad of symptoms:
1. ipsilateral facial paralysis (lower motor neuron cranial nerve 7)
palsy
2. ear pain
3. erythematous vesicular rash of the skin of the ear canal, auricle, and mucous membrane of the oropharynx. - may be a loss of taste at anterior two-thirds of the tongue and hyperacusis
-
Ipsilateral Facial Paralysis:
- Lower motor neuron palsy affecting cranial nerve VII (facial nerve), leading to paralysis on one side of the face.
-
Ear Pain:
- Pain in the ear on the same side as the facial paralysis.
-
Erythematous Vesicular Rash:
- Red, blister-like rash on the skin of the ear canal, auricle, and mucous membranes of the oropharynx.
This condition often indicates a viral infection, such as herpes zoster oticus (Ramsay Hunt syndrome).
Ramsay Hunt syndrome treatment
- antiviral therapy and corticosteroid
within 72 hours of presentation (rash onset). - Oral Acyclovir (800 mg five times per day), valaciclovir (1 g three times per day for 7–10 days) and famciclovir (250 mg three times per day)
- valaciclovir and famciclovir have replaced acyclovir as drug of choice
- oral corticosteroids combined with antivirals (eg, 40 mg prednisolone daily for 7 days, tapering to 5 mg daily over the next 2 weeks – total of 14 days)
- Start antiviral therapy and corticosteroids within 72 hours of symptom onset (rash appearance).
-
Antiviral Options:
- Valaciclovir: 1 g three times a day for 7–10 days.
- Famciclovir: 250 mg three times a day for 7–10 days.
- Note: Valaciclovir and famciclovir are now preferred over acyclovir.
-
Corticosteroids:
- Combine with antivirals for better effectiveness.
- Prednisolone: 40 mg daily for 7 days, then taper to 5 mg daily over the next 2 weeks, for a total of 14 days.
This combined approach helps reduce inflammation and viral activity, improving recovery outcomes.
Cancer of the oral cavity
- > 50 years
- Heavy smoker
-Heavy drinker
If no ulcerations or lesions present, follow up in 12 months
Rinne test
Weber test
The Weber test is a quick screening test for hearing that can help to differentiate between conductive and sensorineural hearing loss. Here’s how it works and what the results indicate:
- Preparation: Use a tuning fork (usually 512 Hz).
- Activation: Strike the tuning fork to make it vibrate.
- Placement: Place the base of the vibrating tuning fork on the midline of the patient’s forehead or the top of their head (the vertex).
- Patient Response: Ask the patient where they hear the sound best – in the left ear, the right ear, or equally in both ears.
-
Normal Hearing:
- Sound Perception: The sound is heard equally in both ears.
-
Conductive Hearing Loss:
- Sound Perception: The sound is heard louder in the affected ear.
- Reason: In conductive hearing loss, the affected ear picks up the sound through bone conduction better than through air conduction, leading to a perception of louder sound in the affected ear.
-
Sensorineural Hearing Loss:
- Sound Perception: The sound is heard louder in the unaffected ear.
- Reason: In sensorineural hearing loss, the damaged ear has reduced ability to perceive sound through both air and bone conduction. Thus, the unaffected ear perceives the sound as louder.
- Normal: Sound is equal in both ears.
- Conductive Hearing Loss: Sound is louder in the affected ear.
- Sensorineural Hearing Loss: Sound is louder in the unaffected ear.
The Weber test is often used in conjunction with the Rinne test for a more comprehensive evaluation of hearing loss.
Diseases of the middle ear
OO
Otitis media
Otosclerosis
Types of sensorineural hearing loss
- Meniere’s
- Labyrinthitis
- Vestibular neuritis
Sensorineural deafness diseases are all found in
Which part if ear?
Outer or inner?
inner ear
Types of conductive hearing loss
- Otitis media
- Otosclerosis
- Cholesteatoma
- TM perforation
- Head trauma
Under normal circumstances, bone conduction is ________ than air conduction
worse
Under the Weber test, sensorineural loss localises to
the good ear, therefore the bad ear won’t be able to hear it as well
Ménière’s syndrome diagnosis
vertigo + vomiting + tinnitus + aural fullness + sensorineural deafness
Abrupt onset. Attacks
last 30 minutes to
several hours.
Ménière’s syndrome. Acute severe attack TREATMENT
Diazepam ±
Prochlorperazine, or if
episodic, a thiazide
diuretic
IF Anticipation of
attack (Aural fullness,
tinnitus) : Prochlorperazine
Ménière’s syndrome: Prophylaxis
Fluid problem
Hydrochlorothiazide or
Triamterene
+
amiloride (K+ sparing
diuretic) combination
Labyrinthitis diagnosis
acute onset vertigo provoked with changes in head position + tinnitus + hearing loss + URTI
URTI + vertigo + loss of balance + nystagmus + change in head position + reduced caloric test
Vestibular neuritis
Vestibular neuritis cause
Herpes Zoster URTI
Investigation of choice in a patient suspected with hearing loss + tinnitus + vertigo
Pure tone audiometry (audiogram)
BPPV investigation
Hallpike manoeuvre
BPPV treatment
Epley manoeuvre
Red flags for
dizziness/vertigo
– Neurological signs
– Ataxia out of proportion to vertigo
– Nystagmus out of proportion to vertigo
– Central nystagmus
– Central eye movement abnormalities
Vestibular Neuronitis
VS
Labyrinthitis
Vestibular Neuronitis:
Acute vertigo
Nausea
Vomiting
Labyrinthitis: PLUS
Hearing loss ± Tinnitus
Vestibular Neuronitis and Labyrinthitis MANAGEMENT
❌❌❌❌
The management of Vestibular Neuronitis and Labyrinthitis according to RACGP involves:
- Symptomatic Treatment: Use of antiemetics (e.g., prochlorperazine) and vestibular suppressants (e.g., meclizine) for short-term relief of nausea and dizziness.
- Vestibular Rehabilitation: Physical therapy exercises to help the brain compensate for the balance deficit.
- Steroids: Sometimes prescribed early in the course for vestibular neuronitis.
- Antibiotics: Indicated only if there is a bacterial infection (more relevant for labyrinthitis).
For more details, refer to the RACGP guidelines.
Bed rest
Prochlorperazine
or
Ondansetron
or
Promethazine
or
Diazepam
for the first 2 days
Vestibular Neuronitis and Labyrinthitis are inner ear conditions that can cause vertigo, dizziness, and imbalance. Their management according to RACGP (Royal Australian College of General Practitioners) guidelines typically involves symptom relief and supportive care, as the conditions are often self-limiting.
Vestibular Neuronitis primarily involves inflammation of the vestibular nerve without hearing loss. The management focuses on symptom control and vestibular rehabilitation.
-
Symptomatic Treatment:
-
Vestibular Suppressants:
- Medications such as prochlorperazine or promethazine can be used to control severe vertigo. These should be used for a short period (1-3 days) as they can delay vestibular compensation.
-
Antiemetics:
- Medications like ondansetron can help manage nausea and vomiting associated with vertigo.
-
Vestibular Suppressants:
-
Vestibular Rehabilitation:
-
Physical Therapy:
- Vestibular rehabilitation exercises, such as the Epley maneuver, Brandt-Daroff exercises, or other balance exercises, can help promote central compensation and improve recovery.
-
Physical Therapy:
-
Education and Reassurance:
- Inform the patient about the typically self-limiting nature of the condition and the expected gradual improvement over several weeks.
Labyrinthitis involves inflammation of both the vestibular nerve and the labyrinth, often leading to vertigo with associated hearing loss. Management includes symptom relief, possible use of antiviral or antibiotic therapy if an infection is suspected, and vestibular rehabilitation.
-
Symptomatic Treatment:
-
Vestibular Suppressants:
- As with vestibular neuronitis, short-term use of medications such as prochlorperazine or promethazine can help control severe vertigo.
-
Antiemetics:
- Ondansetron or similar medications can be used to control nausea and vomiting.
-
Vestibular Suppressants:
-
Hearing Assessment:
-
Audiometry:
- Conduct a hearing test to assess the extent of hearing loss. This helps differentiate between viral and bacterial causes and guides further treatment.
-
Audiometry:
-
Antiviral or Antibiotic Therapy:
-
If an Infection is Suspected:
- If bacterial labyrinthitis is suspected (usually indicated by severe symptoms, systemic illness, or middle ear infection), antibiotics such as amoxicillin may be prescribed.
- If a viral cause is suspected, antiviral medications might be considered, although evidence of efficacy is limited.
-
If an Infection is Suspected:
-
Vestibular Rehabilitation:
- Similar to vestibular neuronitis, vestibular rehabilitation exercises can help in recovery and reducing symptoms.
-
Education and Reassurance:
- Educate the patient about the condition, its self-limiting nature, and the importance of gradual activity to aid vestibular compensation.
Both conditions often require symptomatic treatment to manage vertigo and nausea, short-term use of vestibular suppressants, and vestibular rehabilitation exercises. Labyrinthitis may additionally require hearing assessment and specific treatments if an infection is suspected. Reassurance and education about the conditions’ typically self-limiting nature are also crucial.
For exact and specific management recommendations, always refer to the latest RACGP guidelines or consult with a healthcare professional.
