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Diseases > Surgery - Ears, Nose and Throat > Flashcards

Surgery - Ears, Nose and Throat Flashcards

1
Q

There are two main categories of hearing loss: What are they?

A

conductive hearing loss and sensorineural hearing loss.

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2
Q

What is conductive hearing loss

A

Conductive hearing loss relates to a problem with sound travelling from the environment to the inner ear. The sensory system may be working correctly, but the sound is not reaching it. Putting earplugs in your ears causes conductive hearing loss.

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3
Q

What is Sensorineural hearing loss

A

Sensorineural hearing loss is caused by a problem with the sensory system or vestibulocochlear nerve in the inner ear.

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4
Q

There are three sections of the ear are:

A

Outer ear
Middle ear
Inner ear

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5
Q

Head and neck cancers can affect a variety of locations. They are usually _____________ ______ _______ arising from the _____________ cells of the mucosa.

A

Head and neck cancers can affect a variety of locations. They are usually squamous cell carcinomas arising from the squamous cells of the mucosa.

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6
Q

The potential areas of head and neck cancers are:

A

Nasal cavity
Paranasal sinuses
Mouth
Salivary glands
Pharynx (throat)
Larynx (epiglottis, supraglottis, vocal cords, glottis and subglottis)

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7
Q

Where does head and neck cancers usually spread to first?

A

lymph nodes

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8
Q

Risk Factors for head and neck cancers?

A

Smoking
Chewing tobacco
Chewing betel quid (a habit in south-east Asia)
Alcohol
Human papillomavirus (HPV), particularly strain 16
Epstein–Barr virus (EBV) infection

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9
Q

The HPV vaccine (Gardasil) protects against which strains

A

6, 11, 16 and 18.

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10
Q

Presenting red flag symptoms and signs that may indicate head and neck cancer are:

A
  • Lump in the mouth or on the lip
  • Unexplained ulceration in the mouth lasting more than 3 weeks
  • Erythroplakia or erythroleukoplakia
  • Persistent neck lump
  • Unexplained hoarseness of voice
  • Unexplained thyroid lump
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11
Q

Management of Head and Neck Cancer?

A

Management will be guided by the multidisciplinary team (MDT). It will be dependent on the location, stage and individual patient factors.
* Chemotherapy
* Radiotherapy
* Surgery
* Targeted cancer drugs (i.e., monoclonal antibodies)
* Palliative care

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12
Q

________________ is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck.

A

Cetuximab is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck.

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13
Q

What can Cetuximab be used to treat also?

A

bowel cancer
It targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.

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14
Q

The basic structures of the ear, from outside in, are:

  • The ________ is the external portion of the ear
  • The ___________ ______ _____ is the tube into the ear
  • The __________ __________ is the eardrum
  • The ___________ _______ connects the middle ear with the throat to equalise pressure
  • The __________ __________ and ________ are the small bones in the middle ear that connect the tympanic membrane to the structures of the inner ear
  • The ___________ _______ are responsible for sensing head movement (the vestibular system)
  • The ________ is responsible for converting the sound vibration into a nervous signal
  • The _______________ _______ transmits nerve signals from the semicircular canals and cochlea to the brain
A

The basic structures, from outside in, are:

  • The pinna is the external portion of the ear
  • The external auditory canal is the tube into the ear
  • The tympanic membrane is the eardrum
  • The Eustachian tube connects the middle ear with the throat to equalise pressure
  • The malleus, incus and stapes are the small bones in the middle ear that connect the tympanic membrane to the structures of the inner ear
  • The semicircular canals are responsible for sensing head movement (the vestibular system)
  • The cochlea is responsible for converting the sound vibration into a nervous signal
  • The vestibulocochlear nerve transmits nerve signals from the semicircular canals and cochlea to the brain
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15
Q

WHat should be done if there is a sudden onet of hearing loss (over less than 72 hours)

A

requires a thorough assessment to establish the cause.

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16
Q

There may be associated symptoms alongside hearing loss, which can give clues about the potential cause. What are these symptoms

A
  • Tinnitus (ringing in the ears)
  • Vertigo (the sensation that the room is spinning)
  • Pain (may indicate infection)
  • Discharge (may indicate an outer or middle ear infection)
  • Neurological symptoms
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17
Q

Patients with hearing loss are more likely to develop?

A

It is worth noting patients with hearing loss are more likely to develop dementia, and treating the hearing loss (e.g., a hearing aid) may reduce the risk

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18
Q

What tests are used to differentiate between used to differentiate between sensorineural and conductive hearing loss?

A

Weber’s test and Rinne’s test

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19
Q

What equipment do you use to conduct Weber’s test and Rinne’s test

A

tuning fork

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20
Q

Explain how you perform a Weber’s test?

A
  • Strike the tuning fork to make it vibrate and hum (use the palm of your hand or your knee – not the patient!)
  • Place it in the centre of the patient’s forehead
  • Ask the patient if they can hear the sound and which ear it is loudest in
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21
Q

Webers test results for normal result, sensorineural hearing loss and conductive hearing loss?

A

A normal result is when the patient hears the sound equally in both ears.

In sensorineural hearing loss, the sound will be louder in the normal ear (quieter in the affected ear). The normal ear is better at sensing the sound.

In conductive hearing loss, the sound will be louder in the affected ear. This is because the affected ear “turns up the volume” and becomes more sensitive, as sound has not been reaching that side as well due to the conduction problem. When the tuning fork’s vibration is transmitted directly to the cochlea, rather than having to be conducted, the increased sensitivity makes it sound louder in the affected ear

TOM TIP: The way I remember which way round these tests are, is to picture Spiderman shooting a web (Weber’s) right in the middle of someone’s face.

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22
Q

Explain how you perform Rinne’s Test

A

To perform Rinne’s test:

  • Strike the tuning fork to make it vibrate and hum
  • Place the flat end on the mastoid process (the boney lump behind the ear) – this tests bone conduction
  • Ask the patient to tell you when they can no longer hear the humming noise
  • When they can no longer hear the noise, remove the tuning fork (still vibrating) and hover it 1cm from the same ear
  • Ask the patient if they can hear the sound now – this tests air conduction
  • Repeat the process on the other side
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23
Q

Explain a normal result and abnormal result of Rinne’s Test?

A

A normal result is when the patient can hear the sound again when bone conduction ceases and the tuning fork is moved next to the ear rather than on the mastoid process. It is normal for air conduction to be **better **(more sensitive) than bone conduction. This is referred to as “Rinne’s positive”.

An abnormal result (Rinne’s negative) is when bone conduction is better than air conduction. The sound is not heard after removing the tuning fork from the mastoid process and holding it near the ear canal. This suggests a conductive cause for the hearing loss. Sound is transmitted through the bones of the skull directly to the cochlea, meaning bone conduction is intact. However, the sound is less able to travel through the air, ear canal, tympanic membrane and middle ear to the cochlea due to a conductive problem

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24
Q

What are the causes of adult-onset sensorineural hearing loss?

A
  • Sudden sensorineural hearing loss (over less than 72 hours)
  • Presbycusis (age-related)
  • Noise exposure
  • Ménière’s disease
  • Labyrinthitis
  • Acoustic neuroma
  • Neurological conditions (e.g., stroke, multiple sclerosis or brain tumours)
  • Infections (e.g., meningitis)
  • Medications
    *
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25
Q

There are a large number of medications that can cause sensorineural hearing loss. Some of the more common to remember are:

A
  • Loop diuretics (e.g., furosemide)
  • Aminoglycoside antibiotics (e.g., gentamicin)
  • Chemotherapy drugs (e.g., cisplatin
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26
Q

What are the causes of adult-onset conductive hearing loss are:

A
  • Ear wax (or something else blocking the canal)
  • Infection (e.g., otitis media or otitis externa)
  • Fluid in the middle ear (effusion)
  • Eustachian tube dysfunction
  • Perforated tympanic membrane
  • Otosclerosis
  • Cholesteatoma
  • Exostoses
  • Tumours
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27
Q

What is Presbycusis?

A

Presbycusis is described as age-related hearing loss. It is a type of sensorineural hearing loss that occurs as people get older. It tends to affect high-pitched sounds first and more notably than lower-pitched sounds. The hearing loss occurs gradually and symmetrically.

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28
Q

Causes of presbycusis

A

There are several different mechanisms, including loss of the hair cells in the cochlea, loss of neurones in the cochlea, atrophy of the stria vascularis and reduced endolymphatic potential.

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29
Q

RF of Presbycusis

A
  • Age
  • Male gender
  • Family history
  • Loud noise exposure
  • Diabetes
  • Hypertension
  • Ototoxic medications
  • Smoking
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30
Q

What is the presentation of Presbycusis

A

Hearing loss in presbycusis is gradual and insidious. The gradual onset may mean patients do not notice the change in their hearing. The loss of high-pitched sounds can make speech difficult to hear and understand, particularly in loud environments. Male voices may be easier to hear than female voices (due to the generally lower pitch). Patients may present after others have noticed they are not paying attention or missing details of conversations. Sometimes patients can present with concerns about dementia, when in fact, the issue is hearing loss.

There may be associated tinnitus (ringing in the ears).

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31
Q

Diagnosis of Presbycusis

A

Audiometry
Presbycusis will give a sensorineural hearing loss pattern, with normal or near-normal hearing at lower frequencies and worsening hearing loss at higher frequencies.

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32
Q

Management of Presbycusis

A

The effects of presbycusis cannot be reversed.

Management involves supporting the person to maintain normal functioning:

  • Optimising the environment, for example, reducing the ambient noise during conversations
  • Hearing aids
  • Cochlear implants (in patients where hearing aids are not sufficient)
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33
Q

What is Otitis Media?

A

Otitis media is the name given to an infection in the middle ear. The middle ear is the space that sits between the tympanic membrane (eardrum) and the inner ear.

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34
Q

What is inside the middle ear?

A

cochlea, vestibular apparatus and nerves

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35
Q

A ____________________ infection often precedes ____________ infection of the middle ear.

A

A viral upper respiratory tract infection often precedes bacterial infection of the middle ear.

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36
Q

What is the most common cause of otitis media?

A

streptococcus pneumoniae

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37
Q

streptococcus pneumoniae also commonly causes ENT infections such as ?

A

rhino-sinusitis and tonsillitis.

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38
Q

What are the other common causes of otitis media?

A

Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus

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39
Q

Presentation of Otitis media in adults?

A

Ear pain is the primary presenting feature of otitis media in adults.

It may also present with:

  • Reduced hearing in the affected ear
  • Feeling generally unwell, for example with fever
  • Symptoms of an upper airway infection such as cough, coryzal symptoms and sore throat

When the infection affects the vestibular system, it can cause balance issues and vertigo. When the tympanic membrane has perforated, there may be discharge from the ear

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40
Q

What do you see on examination for otitis media?

A

Otitis media will give a bulging, red, inflamed looking membrane. When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane..

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41
Q

What does a normal tympanic membrane look like?

A

A normal tympanic membrane is “pearly-grey”, translucent and slightly shiny. You should be able to visualise the malleus through the membrane. Look for a cone of light reflecting the light of the otoscope.

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42
Q

Management for otitis media?

A

Most otitis media cases will resolve** without antibiotics within around three **days, sometimes up to a week
Simple analgesia (e.g., paracetamol or ibuprofen) can be used for pain and fever.

There are three options for prescribing antibiotics:

  • Immediate antibiotics
  • Delayed prescription
  • No antibiotics
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43
Q

When would you consider immediate and delayed prescription for otitis media

A

Consider immediate antibiotics at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised.

Consider a delayed prescription that can be collected and used after three days if symptoms have not improved or have worsened at any time. This can be a helpful strategy in patients pressing for antibiotics or where you suspect the symptoms might worsen

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44
Q

What abx can you use for otitis media?

A
  • Amoxicillin for 5-7 days first-line
  • Clarithromycin (in pencillin allergy)
  • Erythromycin (in pregnant women allergic to penicillin)
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45
Q

What are the complications of otitis media?

A
  • Otitis media with effusion
  • Hearing loss (usually temporary)
  • Perforated tympanic membrane (with pain, reduced hearing and discharge)
  • Labyrinthitis (causing dizziness or vertigo)
  • Mastoiditis (rare)
  • Abscess (rare)
  • Facial nerve palsy (rare)
  • Meningitis (rare)
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46
Q

What is otitis externa?

A

Otitis externa is inflammation of the skin in the external ear canal. Oto- refers to ear, -itis refers to inflammation, and externa refers to the external ear canal. The infection can be localised or diffuse. It can spread to the external ear (pinna). It can be acute (less than three weeks) or chronic (more than three weeks).

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47
Q

What can otitis externa be also referred to as?

A

Otitis externa is sometimes called “swimmers ear”, as exposure to water whilst swimming can lead to inflammation in the ear canal. Trauma from the ear canal (e.g., from cotton buds or earplugs) is another predisposing factor. Ear wax (cerumen) has a protective effect against infection, and the removal of ear wax can increase the chances of infection.

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48
Q

The inflammation in otitis externa may be caused by:

A

Bacterial infection
Fungal infection (e.g., aspergillus or candida)
Eczema
Seborrhoeic dermatitis
Contact dermatitis

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49
Q

The two most common bacterial causes of otitis externa are:

A

Pseudomonas aeruginosa
Staphylococcus aureus

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50
Q

Tell me some facts about Pseudomonas aeruginosa

A
  • gram-negative aerobic rod-shaped bacteria
  • grow in moist, oxygenated environments
  • can colonise the lungs in patients with cystic fibrosis
  • naturally resistant to many antibiotics,
  • It can be treated with aminoglycosides (e.g., gentamicin) or quinolones (e.g., ciprofloxacin).
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51
Q

The typical symptoms of otitis externa are:

A

Ear pain
Discharge
Itchiness
Conductive hearing loss (if the ear becomes blocked)

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51
Q

Examination of otits externa can show:

A
  • Erythema and swelling in the ear canal
  • Tenderness of the ear canal
  • Pus or discharge in the ear canal
  • Lymphadenopathy (swollen lymph nodes) in the neck or around the ear
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52
Q

Diagnosis of otitis externa

A

The diagnosis can be made clinically with an examination of the ear canal (otoscopy).

An ear swab can be used to identify the causative organism but is not usually required

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53
Q

Management of otitis externa?

A

Mild otitis externa may be treated with acetic acid 2% (available over the counter as EarCalm). Acetic acid has an antifungal and antibacterial effect. This can also be used prophylactically before and after swimming in patients that are prone to otitis externa.

Moderate otitis externa is usually treated with a topical antibiotic and steroid, for example:

  • Neomycin, dexamethasone and acetic acid (e.g., Otomize spray)
  • Neomycin and betamethasone
  • Gentamicin and hydrocortisone
  • Ciprofloxacin and dexamethasone
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54
Q

Aminoglycosides (e.g., gentamicin and neomycin) are potentially ____________, rarely causing hearing loss if they get past the tympanic membrane. Therefore, it is essential to exclude a ___________ __________ _________ before using topical aminoglycosides in the ear.

A

Aminoglycosides (e.g., gentamicin and neomycin) are potentially ototoxic, rarely causing hearing loss if they get past the tympanic membrane. Therefore, it is essential to exclude a perforated tympanic membrane before using topical aminoglycosides in the ear.

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55
Q

An ______ ______may be used if the canal is very swollen, and treatment with ear drops or sprays will be difficult

A

An ear wick may be used if the canal is very swollen, and treatment with ear drops or sprays will be difficult

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56
Q

Otitis Externa Fungal infections can be treated with ____________ ear drops.

A

Fungal infections can be treated with clotrimazole ear drops.

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57
Q

What is Malignant Otitis Externa?

A

Malignant otitis externa is a severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull

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58
Q

Malignant otitis externa is usually related to underlying risk factors for severe infection, such as

A

Diabetes
Immunosuppressant medications (e.g., chemotherapy)
HIV

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59
Q

What is a key is a key finding that indicates malignant otitis externa.

A

Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along)

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60
Q

Malignant otitis externa requires emergency management, with:

A

Admission to hospital under the ENT team
IV antibiotics
Imaging (e.g., CT or MRI head) to assess the extent of the infection

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61
Q

Malignant otitis externa can lead to complications of

A
  • Facial nerve damage and palsy
  • Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves)
  • Meningitis
  • Intracranial thrombosis
  • Death
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62
Q

What is tonsillitis?

A

Tonsillitis refers to inflammation of the tonsils.

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63
Q

The most common cause of tonsillitis is

A

viral infection

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64
Q

The most common cause of bacterial tonsillitis is

A

Group A streptococcus (Streptococcus pyogenes).
The second most common bacterial cause of tonsillitis is Streptococcus pneumoniae.

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65
Q

What can you use to treat bacterial tonsilitis?

A

penicillin V (phenoxymethylpenicillin)

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66
Q

What are the tonsils in Waldeyer’s Tonsillar Ring

A

adenoids, tubal tonsils, palatine tonsils and the lingual tonsil

67
Q

Which tonsils are the ones typically infected and enlarged in tonsillitis

A

The palatine tonsils

68
Q

A typical presentation of acute tonsillitis is with:

A

Sore throat
Fever (above 38°C)
Pain on swallowing

69
Q

What would be postive finding from examination from a person with tonsilitis?

A

Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. Exudates are small white patches of pus on the tonsils.

There may be anterior cervical lymphadenopathy, which refers to swollen, tender lymph nodes in the anterior triangle of the neck (anterior to the sternocleidomastoid muscle and below the mandible). The tonsillar lymph nodes are just behind the angle of the mandible (jawbone).

70
Q

What is Centor Criteria?

A

The Centor criteria can be used to estimate the probability that tonsillitis is due to bacterial infection and will benefit from antibiotics.

A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics. A point is given if each of the following features are present:

  • Fever over 38ºC
  • Tonsillar exudates
  • Absence of cough
  • Tender anterior cervical lymph nodes (lymphadenopathy)
71
Q

What is FeverPAIN Score

A

The FeverPAIN score is an alternative to the Centor criteria. A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis:

  • Fever during previous 24 hours
  • P – Purulence (pus on tonsils)
  • A – Attended within 3 days of the onset of symptoms
  • I – Inflamed tonsils (severely inflamed)
  • N – No cough or coryza
72
Q

Management for Tonsilitis?

A
  • Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis.
  • Safety net if it is viral tonsilitis
  • Consider prescribing antibiotics if the Centor score is ≥ 3, or the FeverPAIN score is ≥ 4.
73
Q

What do you safety net about with tonsilitis?

A

Advise simple analgesia with paracetamol and ibuprofen to control pain and fever. NICE clinical knowledge summaries suggest advising patients to return if the pain has not settled after 3 days or the fever rises above 38.3ºC. Starting antibiotics or an alternative diagnosis should be considered.

74
Q

What is the choice of abx tonsilitis and for how long

A

Penicillin V (also called phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes.

Clarithromycin is the usual first-line choice in true penicillin allergy.

75
Q

Complications of tonsilitis?

A
  • Peritonsillar abscess, also known as quinsy
  • Otitis media, if the infection spreads to the inner ear
  • Scarlet fever
  • Rheumatic fever
  • Post-streptococcal glomerulonephritis
  • Post-streptococcal reactive arthritis
76
Q

What is called when you surgical removed tonsils

A

Tonsillectomy

77
Q

What is the indications for tonnsillectomy?

A

The SIGN guidelines (2010) give the indications for tonsillectomy. The number of episodes of acute sore throat they specify for a tonsillectomy are:

  • 7 or more in 1 year
  • 5 per year for 2 years
  • 3 per year for 3 years

Other indications are:

  • Recurrent tonsillar abscesses (2 episodes)
  • Enlarged tonsils causing difficulty breathing, swallowing or snoring
78
Q

Complications of tonsillectomy?

A
  • Sore throat where the tonsillar tissue has been removed (this can last 2 weeks)
  • Damage to teeth
  • Infection
  • Post-tonsillectomy bleeding
  • Risks associated with a general anaesthetic
79
Q

What is the most common complication on tonsilitis?

A

Post tonsillectomy bleeding is the main significant complication after a tonsillectomy. Significant bleeding can occur in up to 5% of patients who have had a tonsillectomy requiring urgent management. This can happen up to 2 weeks after the operation. Bleeding can be severe and, in rare cases, life-threatening due to aspiration of blood

80
Q

What is Management for Post Tonsillectomy Bleeding

A
  • Call the ENT registrar and get them involved early
  • Get IV access and send bloods including an FBC, clotting screen, group and save and crossmatch
  • Keep the patient calm and give adequate analgesia
  • Sit them up and encourage them to spit out the blood rather than swallowing
  • Make the patient nil by mouth in case an anaesthetic and operation is required
  • IV fluids for maintenance and resuscitation, if required

If there is severe bleeding or airway compromise, call an anaesthetist. Intubation may be required.

Before going back to theatre there are two options for stopping less severe bleeds:

  • Hydrogen peroxide gargle
  • Adrenalin soaked swab applied topically
81
Q

What is Cholesteatoma

A

Cholesteatoma is an abnormal collection of squamous epithelial cells in the middle ear. It is non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear. It can predispose to significant infections.

82
Q

Pathophysiology of cholesteatoma?

A

The pathophysiology is not fully understood. Squamous epithelial cells originate from the outer surface of the tympanic membrane. The main theory is that negative pressure in the middle ear, caused by Eustachian tube dysfunction, causes a pocket of the tympanic membrane to retract into the middle ear. Essentially, a small area of the tympanic membrane gets sucked inwards. The squamous epithelial cells of this pocket continue to proliferate and grow into the surrounding space, bones and tissues. It can damage the ossicles (the tiny bones of the middle ear involved in hearing), resulting in permanent hearing loss.

83
Q

Presentation of cholesteatoma?

A

The typical presenting symptoms are:

  • Foul discharge from the ear
  • Unilateral conductive hearing loss
84
Q

As the cholesteatoma continues to expand into the surrounding spaces and tissues, further symptoms may develop, including:

A

Infection
Pain
Vertigo
Facial nerve palsy

85
Q

What can otoscopy show for cholesteatoma?

A

Otoscopy can show an abnormal build-up of whitish debris or crust in the upper tympanic membrane. However, it may not be possible to visualise the eardrum if discharge or wax are blocking the can

86
Q

What is the management for cholesteatoma?

A

A CT head can be used to confirm the diagnosis and plan for surgery. MRI may help assess invasion and damage to local soft tissues.

Treatment involves surgical removal of the cholesteatoma.

87
Q

What is Acoustic Neuroma

A

Acoustic neuromas are benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear.

88
Q

Are acoustic neuromas usually unilateral or bilateral?

A

unilateral

89
Q

What are Bilateral acoustic neuromas are associated with

A

neurofibromatosis type II

TOM TIP: Bilateral acoustic neuromas almost certainly indicate neurofibromatosis type II. This is a popular association in exams, so worth remembering

90
Q

Presentation of acoustic neuroma

A

The typical patient is aged 40-60 years presenting with a gradual onset of:

  • Unilateral sensorineural hearing loss (often the first symptom)
  • Unilateral tinnitus
  • Dizziness or imbalance
  • A sensation of fullness in the ear
91
Q

Acoustic Neuroma is associated with a ________________ if the tumour grows large enough to compress the facial nerve.

A

They can also be associated with a facial nerve palsy if the tumour grows large enough to compress the facial nerve.

92
Q

What are ix for acoustic neuroma?

A

Audiometry is used to assess hearing loss. There will be a sensorineural pattern of hearing loss.

Brain imaging (MRI or CT) is used to establish the diagnosis and features of the tumour. MRI provides more detail than CT.

93
Q

Management of Acoustic Neuroma?

A

ENT specialist management options include:

  • Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate
  • Surgery to remove the tumour (partial or total removal)
  • Radiotherapy to reduce the growth
94
Q

Notable risks associated with treatment for acoustic neuromas are:

A
  • Vestibulocochlear nerve injury, with permanent hearing loss or dizziness
  • Facial nerve injury, with facial weakness
95
Q

What is Ménière’s disease

A

Ménière’s disease is a long-term inner ear disorder that causes recurrent attacks of vertigo, and symptoms of hearing loss, tinnitus and a feeling of fullness in the ear.

96
Q

What is the triad of symptoms in Ménière’s disease?

A

TOM TIP: Remember the typical triad of symptoms in Ménière’s disease, as this is commonly tested in exams:

Hearing loss
Vertigo
Tinnitus

97
Q

Pathophysiology of Ménière’s disease?

A

Ménière’s disease is associated with the excessive buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals. This increased pressure of the endolymph is called endolymphatic hydrops.

98
Q

Presentation of Ménière’s disease

A

The typical patient is 40-50 years old, presenting with unilateral episodes of vertigo, hearing loss, and tinnitus.

Other symptoms can include:

  • A sensation of fullness in the ear
  • Unexplained falls (“drop attacks”) without loss of consciousness
  • Imbalance, which can persist after episodes of vertigo resolve
99
Q

Specifc presentations of vertigo, hearing loss, and tinnitus in Ménière’s disease

A

Vertigo in Ménière’s disease comes in episodes. These last for 20 minutes to several hours before settling. These episodes can come in clusters over several weeks, followed by prolonged periods (often months) without vertigo symptoms. Vertigo is not triggered by movement or posture.

Hearing loss in Ménière’s disease typically fluctuates at first, associated with vertigo attacks, then gradually becomes more permanent. It is sensorineural hearing loss, generally unilateral and affects low frequencies first.

Tinnitus initially occurs with episodes of vertigo before eventually becoming more permanent. It is usually unilateral.

100
Q

Management of Ménière’s disease

A

Management involves:

  • Managing symptoms during an acute attack
  • Prophylactic medication to reduce the frequency of attacks

For acute attacks, short-term options for managing symptoms include:

  • Prochlorperazine
  • **Antihistamines **(e.g., cyclizine, cinnarizine and promethazine)

Prophylaxis is with:

  • Betahistine
101
Q

What is tinnitus?

A

Tinnitus refers to a persistent addition sound that is heard but is not present in the surrounding environment. It may be described as a “ringing in the ears”, but it can also be a buzzing, hissing or humming noise.

102
Q

Causes of
Primary tinnitus

A

Primary tinnitus has no identifiable cause and often occurs with sensorineural hearing loss

103
Q

Causes of Secondary tinnitus

A

Secondary tinnitus refers to tinnitus with an identifiable cause. Causes include:

  • Impacted ear wax
  • Ear infection
  • Ménière’s disease
  • Noise exposure
  • Medications (e.g., loop diuretics, gentamicin and chemotherapy drugs such as cisplatin)
  • Acoustic neuroma
  • Multiple sclerosis
  • Trauma
  • Depression
104
Q

Tinnitus may also be associated with systemic conditions like?

A

Anaemia
Diabetes
Hypothyroidism or hyperthyroidism
Hyperlipidaemia

105
Q

What is Objective tinnitus?

A

Objective tinnitus refers to when the patient can objectively hear an extra sound within their head. This sound can also be observable on examination by auscultating with a stethoscope around the ear

106
Q
A
107
Q

Objective tinnitus: Actual additional sounds may be caused by:

A

Carotid artery stenosis (pulsatile carotid bruit)
Aortic stenosis (radiating pulsatile murmur sounds)
Arteriovenous malformations (pulsatile)
Eustachian tube dysfunction (popping or clicking noises)

108
Q

What is a helpful analogy for primary tinnitus?

A

I think of primary tinnitus as the ears trying to “turn up the volume” when they cannot hear the surrounding noises as well. This is a helpful way of explaining it to patients who have tinnitus associated with hearing loss. Using hearing aids allows the ears to pick up noises better and “turn the volume down”, improving the tinnitus. The actual cause of tinnitus is not entirely understood, so this is not entirely accurate, but it is a helpful analogy

109
Q

Whagt are the questions you ask in a person suspected of tinnitus?

A

Ask about the pattern of symptoms:

  • Unilateral or bilateral
  • Frequency and duration
  • Severity
  • Pulsatile or non-pulsatile (pulsatile may indicate a cardiovascular cause, such as carotid artery stenosis with a bruit)

A focused history and examination can be used to identify any underlying causes, including:

  • Contributing factors, such as hearing loss or noise exposure
  • Associated symptoms (e.g., hearing loss, vertigo, pain or discharge)
  • Stress and anxiety
  • Otoscopy to look for causes such as ear wax or infection
  • Weber’s and Rinne’s tests for hearing loss
110
Q

Investigations for Tinnitus?

A

The NICE clinical knowledge summaries (updated March 2020) suggest considering blood tests for possible underlying causes:

  • Full blood count (anaemia)
  • Glucose (diabetes)
  • TSH (thyroid disorders)
  • Lipids (hyperlipidaemia)

Audiology can be used to assess the hearing in detail and help establish the underlying cause.

Imaging (e.g., CT or MRI) may be rarely required to investigate for underlying causes such as vascular malformations or acoustic neuromas.

111
Q

What are the red flags of tinnitus?

A

Red flags that could indicate a serious underlying cause and the need for specialist assessment include:

  • Unilateral tinnitus
  • Pulsatile tinnitus
  • Hyperacusis (hypersensitivity, pain or distress with environmental sounds)
  • Associated unilateral hearing loss
  • Associated sudden onset hearing loss
  • Associated vertigo or dizziness
  • Headaches or visual symptoms
  • Associated neurological symptoms or signs (e.g., facial nerve palsy or signs of stroke)
  • Suicidal ideation related to the tinnitus
112
Q

Management of Tinnitus?

A

Tinnitus tends to improve or resolve over time without any interventions.

Underlying causes of tinnitus can be treated, such as impacted ear wax or infection.

Several measures can be used to help improve and manage symptoms:

  • Hearing aids
  • Sound therapy (adding background noise to mask the tinnitus)
  • Cognitive behavioural therapy
113
Q

What is Vestibular Neuronitis

A

Vestibular neuronitis describes inflammation of the vestibular nerve. This is usually attributed to a viral infection.

114
Q

The inner ear contains the _______ _______, a complex bony structure containing fluids (________ and ________).

A

The inner ear contains the bony labyrinth, a complex bony structure containing fluids (perilymph and endolymph).

115
Q

The inner ear is comprised of three parts:

A

Semicircular canals
Vestibule (middle section)
Cochlea

116
Q

What is the semicircular canals responsible for

A

The semicircular canals and otolith organs within the vestibule (the utricle and saccule) are responsible for detecting movement of the head. Together they form the vestibular system:

  • The semicircular canals detect rotation of the head
  • The otolith organs detect gravity and linear acceleration
117
Q

The cochlea is responsible for

A

hearing

118
Q

What is the Presentation of Vestibular Neuronitis

A

acute onset of vertigo
history of a recent viral upper respiratory tract infection.
It is often associated with:

  • Nausea and vomiting (may be severe)
  • Balance problems
119
Q

How do you differentiate between peripheral (inner ear) and central (brain) causes when a patient presents with vertigo?

A

It is essential to differentiate between peripheral (inner ear) and central (brain) causes when a patient presents with vertigo. Any neurological signs or symptoms should make you consider a central cause of vertigo rather than vestibular neuronitis. This may require urgent management, particularly if posterior circulation infarction (stroke) is suspected.

120
Q

TRUE OR FALSE

Tinnitus and hearing loss are not features of vestibular neuronitis

A

FALSE
Tinnitus and hearing loss are not features of vestibular neuronitis, as the cochlea and cochlear nerve are not affected. If tinnitus and hearing loss are also present, consider labyrinthitis or Ménière’s disease as differential diagnoses. You can remember this with:

Labyrinthitis – Loss of hearing
Neuronitis – No loss of hearing

121
Q

What is the head impulse test?

A

The head impulse test involves the patient sitting upright and fixing their gaze on the examiner’s nose. The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose. The head is slowly moved back to the centre before repeating in the opposite direction. Ensure they have no neck pain or pathology before performing the test.

A patient with a normally functioning vestibular system will keep their eyes fixed on the examiner’s nose.

In a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis), the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner.

The head impulse test helps diagnose a peripheral cause of vertigo but will be normal if the patient has no current symptoms or a central cause of vertigo.

122
Q

Management of Vestibular neuronitis

A

Patients may need admission if they are becoming dehydrated due to severe nausea and vomiting.

For peripheral vertigo, short-term options for managing symptoms include:

* Prochlorperazine
* Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

NICE advise that symptomatic treatment can be used for up to 3 days. More extended use may slow down the recovery.

NICE also recommend referral if the symptoms do not improve after 1 week or resolve after 6 weeks, as they may require further investigation or vestibular rehabilitation therapy (VRT).

123
Q

What is Labyrinthitis

A

Labyrinthitis refers to inflammation of the bony labyrinth of the inner ear, including the semicircular canals, vestibule (middle section) and cochlea. The inflammation is usually attributed to a viral upper respiratory tract infection.

124
Q

Rarely labyrinthitis can be caused by a bacterial infection. This may be an inflammatory response to a nearby infection or the result of bacteria or bacterial toxins entering the labyrinth. It is usually secondary to

A

otitis media or meningitis.

125
Q

Presentation
Labyrinthitis

A

Labyrinthitis presents with acute onset vertigo, similarly to vestibular neuronitis.

Unlike vestibular neuronitis, labyrinthitis can also be associated with:
**
* Hearing loss
* Tinnitus**

Patients may have symptoms associated with the causative virus, such as a cough, sore throat and blocked nose

126
Q

Diagnosis of labyrinthitis

A

A clinical diagnosis is based on history and examination findings. It is important to exclude a central cause of the vertigo.

The head impulse test can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g., vestibular neuronitis or labyrinthitis).

127
Q

Management for labyrinthitis

A

Management is the same as with vestibular neuronitis, with supportive care and short-term use (up to 3 days) of medication to suppress the symptoms. Options for managing symptoms are:

* Prochlorperazine
* Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

Antibiotics are used to treat bacterial labyrinthitis. The underlying infection (e.g., otitis media or meningitis) needs appropriate treatment.

128
Q

Remember _________ _____ as a key complication of meningitis

A

Remember hearing loss as a key complication of meningitis. All patients with meningitis are offered audiology assessment as soon as they are recovered to assess for hearing impairment. This complication comes up often in exams and is worth remembering

129
Q

What is Benign paroxysmal positional vertigo BPPV

A

Benign paroxysmal positional vertigo (BPPV) is a common cause of recurrent episodes of vertigo triggered by head movement. It is a peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain. It is more common in older adults.

130
Q

Presentation of BPPV

A

A variety of head movements can trigger attacks of vertigo. A common trigger is turning over in bed. Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks. Often episodes occur over several weeks and then resolve but can reoccur weeks or months later.

BPPV does not cause** hearing loss or tinnitus**.

131
Q

Pathophysiology of
BPPV

A

BPPV is caused by** crystals of calcium carbonate** called otoconia that become displaced into the semicircular canals. This occurs most often in the posterior semicircular canal. They may be displaced by a viral infection, head trauma, ageing or without a clear cause.

The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo

132
Q

What is Dix-Hallpike Manoeuvre

A

The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis). It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV. Check the patient can do the manoeuvre safely before performing it, for example, ensuring they have no neck pain or pathology.

133
Q

How do you perform Dix-Hallpike Manoeuvre

A

To perform the manoeuvre:

  • The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
  • Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
  • Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
  • Watch the eyes closely for 30-60 seconds, looking for nystagmus
  • Repeat the test with the head turned 45 degrees in the other direction

In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).

134
Q

What is Epley Manoeuvre

A

The Epley manoeuvre can be used to treat BPPV. The idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow

135
Q

How do you perform Epley Manoeuvre

A

To perform the manoeuvre:

  • Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
  • Rotate the patient’s head 90 degrees past the central position
  • Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
  • Have the patient sit up sideways with the legs off the side of the couch
  • Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
  • At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle
136
Q

What is Brandt-Daroff Exercises

A

Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve

137
Q

What is facial Nerve Palsy?

A

Facial nerve palsy refers to isolated dysfunction of the facial nerve. This typically presents with a unilateral facial weakness. It is important to understand some basics about the pathway and function of the facial nerve

138
Q

What is the Facial Nerve Pathway

A

The facial nerve exits the brainstem at the cerebellopontine angle. On its journey to the face, it passes through the temporal bone and parotid gland.

It then divides into five branches that supply different areas of the face:

  • Temporal
  • Zygomatic
  • Buccal
  • Marginal mandibular
  • Cervical
139
Q

What are the three functions of facial nerve?

A

There are three functions of the facial nerve: motor, sensory and parasympathetic.

140
Q

What is the motor function of facial nerve

A

It supplies the muscles of facial expression, the stapedius in the inner ear and the posterior digastric, stylohyoid and platysma muscles in the neck.

141
Q

What is the sensory function of facial nerve?

A

It carries taste from the anterior 2/3 of the tongue

142
Q

What is the parasympathetc function of facial nerve?

A

It provides the parasympathetic supply to the:

  • Submandibular and sublingual salivary glands
  • Lacrimal gland (stimulating tear production)
143
Q

It is essential to make this distinction because, in a patient with a new-onset upper motor neurone facial nerve palsy, you should be referring immediately with a suspected _______

A

It is essential to make this distinction because, in a patient with a new-onset upper motor neurone facial nerve palsy, you should be referring immediately with a suspected stroke

144
Q

Which lesion needs urgent attention UMN or LMN lesion

A

UMN lesion

145
Q

Explain What happened to the forehead in an UMN or LMN lesion

A

Each side of the forehead has upper motor neurone innervation by both sides of the brain. However, each side of the forehead only has lower motor neurone innervation from one side of the brain.

In an upper motor neurone lesion, the forehead will be spared, and the patient can move their forehead on the affected side.

In a lower motor neurone lesion, the forehead will **NOT be spared, **and the patient cannot move their forehead on the affected side

146
Q

Unilateral upper motor neurone lesions occur in:

A

Cerebrovascular accidents (strokes)
Tumours

147
Q

Bilateral upper motor neurone lesions are rare. They may occur in:

A

Pseudobulbar palsies
Motor neurone disease

148
Q

What type of lesion is Bell’s Palsy

A

unilateral LMN lesion

149
Q

What is recovery like for bell’s palsy

A

The majority of patients fully recover over several weeks, but recovery may take up to 12 months. A third are left with some residual weakness.

150
Q

Bell’s Palsy
If patients present within 72 hours of developing symptoms, NICE clinical knowledge summaries (updated 2019) recommend considering:

A

prednisolone as treatment, either:

  • 50mg for 10 days
  • 60mg for 5 days followed by a 5-day reducing regime of 10mg a day

Patients also require lubricating eye drops to prevent the eye on the affected side from drying out and being damaged. If they develop pain in the eye, they need an ophthalmology review for exposure keratopathy. The eye can be taped closed at night

151
Q

What is Ramsay-Hunt Syndrome

A

Ramsay-Hunt syndrome is caused by the varicella zoster virus (VZV). It presents as a unilateral lower motor neurone facial nerve palsy. Patients stereotypically have a painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side. This rash can extend to the anterior two-thirds of the tongue and hard palate.

152
Q

Ramsay-Hunt Syndrome Treatment

A

Treatment should ideally be initiated within 72 hours. Treatment is with:

  • Prednisolone
  • Aciclovir

Patients also require lubricating eye drops

153
Q

Ramsay-Hunt Syndrome MCQ presentation

A

Ramsay-Hunt syndrome is a very popular presentation in your MCQ exams. Look out for that patient with a facial nerve palsy and vesicular rash around their ear.

154
Q

Other Infectious Causes of Lower Motor Neurone Facial Nerve Palsy

A

Otitis media
Malignant otitis externa
HIV
Lyme’s disease

155
Q

Other Systemic Disease Causes of Lower Motor Neurone Facial Nerve Palsy

A

Diabetes
Sarcoidosis
Leukaemia
Multiple sclerosis
Guillain–Barré syndrome

156
Q

Other Tumour Causes of Lower Motor Neurone Facial Nerve Palsy

A

Acoustic neuroma
Parotid tumours
Cholesteatomas

157
Q

Other Trauma Causes of Lower Motor Neurone Facial Nerve Palsy

A

Direct nerve trauma
Damage during surgery
Base of skull fractures

158
Q

What is Otosclerosis

A

Otosclerosis is a condition where there is remodelling of the small bones in the middle ear, leading to conductive hearing loss. Oto- refers to the ears, and -sclerosis means hardening. It usually presents before the age of 40 years.

159
Q

Otosclerosis can be inherited in what pattern?

A

autosomal dominant

160
Q

Presentation of ostosclerosis?

A

The typical presentation is a patient under 40 years presenting with unilateral or bilateral:

  • Hearing loss
  • Tinnitus

It tends to affect the hearing of lower-pitched sounds more than higher-pitched sounds. Female speech may be easier to hear than male speech (due to the generally higher pitch). This is the reverse of the pattern seen in presbycusis.

161
Q

What can be seen on webers test for ostosclerosis?

A

Weber’s test is normal if the otosclerosis is bilateral, meaning that when the tuning fork is applied to the centre of the forehead, they will hear the sound equally in both ears. If the otosclerosis is unilateral or affects one ear more than the other, the sound will be louder in the more affected ear.

162
Q

What can be seen on Rinne’s test for ostosclerosis?

A

Rinne’s test will show conductive hearing loss. The sound will be easily heard when the tuning fork is applied to the mastoid process (bone conduction). When the patient stops being able to hear the sound during bone conduction, and the tuning fork is removed from the mastoid process and held close to the ear canal, they will still not hear the sound (air conduction is worse than bone conduction).

163
Q

What are the investigations for ostosclerosis?

A

Audiometry is the initial investigation of choice. Otosclerosis will show a conductive hearing loss pattern. Bone conduction readings will be normal (between 0 and 20 dB). However, air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart. Hearing loss tends to be greater at lower frequencies.

Tympanometry will show generally reduced admittance (absorption) of sound. The tympanic membrane is stiff and non-compliant and does not absorb sound, reflecting most of it back.

High-resolution CT scans can detect boney changes associated with otosclerosis, although they are not always required.

164
Q

What is the conservative management for ostosclerosis?

A

use of hearing aids

165
Q

What is

A
166
Q
A

Diseases (40 decks)

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