Surgery: ENT Flashcards
What’s Presbycusis?
- age-related hearing loss
- bilateral
- progressive
- high frequency
Which inflammatory diseases may lead to sensorineural hearing loss?
- measles
- mumps
- meningitis
- syphillis
What drug classes (2) may cause ototoxicity and lead to sensorineural hearing loss?
- aminoglycosides
- cytotoxic agents
(2) causes of conductive hearing loss re to external ear
- otitis externa
- wax
Cause of conductive hearing loss related to the tympanic membrane
perforation
Causes of conductive hearing loss related to middle ear
- ossicular discontinuity
- otosclerosis
- cholesteatoma
- otitis media with effusion (OME) (beware unilateral)
- Mixed - chronic suppurative otitis media (CSOM)
What to ask in HPC re to hearing loss?
What to ask in PMH and Med Hx re to hearing loss?
Anatomy of tympanic membrane
What’s the importance of the wax in the attic?
It could be cholesteatoma
Pathophysiology of cholesteatoma
- non-cancerous growth of squamous epithelium that is ‘trapped’ within the skull base → local destruction
Risk factors for cholesteatoma (2)
- most common in patients aged 10-20 years
- cleft palate increases the risk of cholesteatoma around 100 fold
Symptoms of cholesteatoma
Main features
- foul-smelling, non-resolving discharge
- hearing loss
Other features are determined by local invasion:
- vertigo
- facial nerve palsy
- cerebellopontine angle syndrome
What’s seen on otoscopy in cholesteatoma?
‘attic crust’ - seen in the uppermost part of the ear drum
Principles of tuning fork tests
Management of sudden SN hearing loss
Steroids
Ix and management of asymmetrical SN hearing loss
- MRI
- hearing aids
Management of symmetrical SN hearing loss
hearing aids
Management of Conductive Hearing Loss
- hearing aids
- surgery
What may hearing loss in children lead to?
Management of Cholesteatoma
patients are referred to ENT for consideration of surgical removal
Congenital causes of hearing loss (4)
- genetic
- prenatal infections e.g. Rubella
- prenatal toxins exposure
- hypoxic injury
What does Newborn Hearing Screening Programme consist of?
- otoacoustic emissions → performed within days of birth until up to 3 months
If the unclear response on otoacoustic emissions test → auditory brainstem response
Pathophysiology and management of glue ear
Risk factors for glue ear
- male
- attending daycare
- older siblings
- parental smoking
- winter season
- atopy
- recurrent URTIs
- refux
Indications for immediate prescription of antibiotics in otitis media
- Symptoms lasting more than 4 days or not improving
- Systemically unwell but not requiring admission
- Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
- Younger than 2 years with bilateral otitis media
- Otitis media with perforation and/or discharge in the canal
If indicated, what antibiotics and how long for do we prescribe in otitis media?
- 5-day course of amoxicillin
- if penicillin allergy → erythromycin or clarithromycin should be given
Symptoms and management of Acute Otitis Media
Symptoms and management of ear wax
Management of Foreign Body in the ear
What extra questions to ask while taking hearing loss Hx in children?
How to differentiate between: BPPV, Vestibular Neuronitis/ Labirynthitis and Menieres disease
Consider:
- duration of vertigo episodes
- associated auditory symptoms
Causes of Tinnitus
Other causes include
- impacted ear wax
- chronic suppurative otitis media
What drugs may cause tinnitus? (4)
- Aspirin
- Aminoglycosides
- Loop diuretics
- Quinine
What’s that? What’s its association?
10% of patients may have a ‘flamingo tinge’, caused by hyperaemia (excess of blood vessels)
What’s the classical history of vestibular schwannoma?
The classical history of vestibular schwannoma includes: a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex
Features of vestibular schwannoma in relation to affected cranial nerves (VIII, V and VII)
Features can be predicted by the affected cranial nerves:
- cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
- cranial nerve V: absent corneal reflex
- cranial nerve VII: facial palsy
In which patients we can see bilateral vestibular schwannoma?
Bilateral vestibular schwannomas are seen in neurofibromatosis type 2
Investigations for vestibular schwannoma
- MRI of the cerebellopontine angle
- Audiometry
Management of vestibular schwannoma
- if suspected → urgent ENT referral
(It should be noted though that the tumours are often slow growing, benign and often observed initially)
Management is with either of:
- surgery
- radiotherapy
- observation
Pathophysiology of otosclerosis
Otosclerosis
- the replacement of normal bone by vascular spongy bone → a progressive conductive deafness due to fixation of the stapes at the oval window
- Otosclerosis is autosomal dominant and typically affects young adults
Features of otosclerosis
Onset is usually at 20-40 years
- conductive deafness
- tinnitus
- normal tympanic membrane
- positive family history
Management of otosclerosis
- hearing aid
- stapedectomy
What type of hearing loss does he have and in which ear?
Conductive hearing loss (air conduction better than bone conduction)
Why should xylomethazoline only be used for 1 week?
Xylomethazoline → direct acting sympathomimetic adrenergic alpha-agonist used to induce systemic vasoconstriction, thereby decreasing nasal congestion.
Excess use can cause rhinitis medicamentosa - a drug-induced swelling of the lining of the nasal cavity (mucosal hypertrophy) which causes rebound nasal congestion.
Why are topical nasal steroids and decongestants often used to try to treat otitis media with effusion in adults?
Inflammation and oedema of the nasal cavity and postnasal space → congestion of the medial aspect of the eustachian tubes (present in the postnasal space) → reduced ventilation of the middle ear cleft and resultant glue ear formation
What is the likely diagnosis from the postnasal space biopsy?
- lymphoid hyperplasia of the adenoidal tissue → the most likely diagnosis
- increased risk of nasopharyngeal carcinoma in ethnic Chinese (in China 2-3 per 100, 000)
Management of (2) likely diagnoses
Most likely diagnosis:
- Lymphoid Hyperplasia of Adenoidal Tissue
- possibly Nasopharyngeal carcinoma
Management:
- left grommet insertion and biopsy of postnasal space to establish the diagnosis
- If nasopharyngeal carcinoma is diagnosed → oncology MDT (usually chemoradiotherapy)
* Surgery is not a usual treatment
What is the diagnosis?
Sudden idiopathic sensorineural hearing loss
Diagnosis: Idiopathic SN hearing loss
How soon the steroids should be started?
Within 24 hours
Dx: Sudden idiopathic sensorineural hearing loss
If she was a poorly controlled diabetic, with peptic ulcer disease, can you think of another method of trying to treat her hearing loss with steroids other than orally?
Intratympanic steroid injection
Why was the MRI requested?
To exclude other rare causes of sensorineural hearing loss such as vestibular schwannoma
What treatment can be given for her persisted right hearing loss and tinnitus?
- hearing loss → hearing aid
- tinnitus → tinnitus rehabilitation therapy,
a masker or even a hearing can reduce tinnitus
What’s the most likely diagnosis?
Otosclerosis
What are the treatment options available to improve this patient’s hearing?
Dx: otosclerosis
Mx: A trial of hearing aid initially or stapedectomy surgery
She asks if it is likely to happen to her other ear. What do you tell her?
Otosclerosis is likely to affect both ears
List some causes of this condition
- Adenotonsillar hypertrophy cause sleep-disordered breathing and Obstructive Sleep Apnoea (OSA)
- recurrent otalgia is likely to be due to recurrent middle ear infections (acute otitis media) or eustachian tube dysfunction
What other symptoms may that patient have?
- Ear may discharge with blood or pus if the tympanic membrane ruptures with infection
- if the child has OSA he may have restless sleep, enuresis, wakes up tired and irritable
*In extreme cases of OSA the child may struggle to gain weight
What do you expect to find an examination?
Diagnosis: Adenosinal hypertrophy possibly leading to OSA
- bilateral glue ear
- a reduced bilateral nasal airway
- enlarged tonsils
What treatment options are available?
- For recurrent AOM: treat each ear infection with appropriate antibiotics if unwell for more than 24 hours, consider prophylactic antibiotics (the history is certainly too short to consider grommet insertion)
- OSA could be monitored with a pulse oximetry test. If this showed normal or mild symptoms monitoring would be appropriate as the history is short and many resolve. If there is moderate or worse desaturation on pulse oximetry or the parents feel that the child is struggling to even eat and breathe at the same time due to nasal obstruction → adeno-tonsillectomy
What needs to be assessed before surgical options are considered?
- The amount of difficulty that the child is experiencing with nasal obstruction symptoms and possible OSA by pulse oximetry
- The hearing would have to be assessed by pure tone audiometry and tympanometry
What’s the likely diagnosis?
Meniere’s disease
What are the other causes of vertigo (other than Menier’s)?
- Benign paroxysmal positional vertigo or BPPV (typically seconds duration when lying down)
- Labyrinthitis (acute vertigo especially when moving for a few days gradually improves, hearing may be affected)
- vestibular neuronitis (due to inflammation of the vestibular nerve probably due to viral infection which results in vertigo typically for a couple of days but no hearing symptoms)
What is the drug in buccastem? How does it work?
Management of Mennier’s disease/ other vestibular problems
Buccastem is Prochlorperazine
- a dopamine receptor antagonist.
- MoA: antiemetic and is also classed as a vestibular sedative which reduces the overactivity of the labyrinth
How is betahistine thought to exert its effect?
Betahistine - for Mennier’s prophylaxis
- strong antagonist for histamine H3 receptors and weak agonist for histamine H1 receptors
- (H1 agonist) → histamine like effect is thought to stimulate inner ear H1 resulting in vasodilatation and increased permeability in blood vessels which reduces endolymphatic pressure
What’s Mennier’s implications on the occupation?
- Meniere’s is chronic but can present with acute episodes which are incapacitating
- Construction and driving occupations place the patient at risk if a sudden acute episode was to occur
- ‘Sudden and disabling attacks of vertigo’ should prevent driving → DVLA should be informed if the driver suffers from vertigo with particular emphasis on the acute
What lifestyles modification (in addition to medical treatment) can be tried in patient’s suffering from Meniere’s Disease?
- avoid eating foods with a high salt content as these foods can result in a fluctuation of inner ear pressure and provoke symptoms
- Salt intake should be consistent and avoid processed foods
- Other labyrinthine stimulants include alcohol and caffeine which should be avoided
- Stress, fatigue, overwork and additional illnesses can exacerbate Meniere’s
Treatment options available for Mennier’s disease
- avoiding or managing stress
- Buccastem during acute events
- regular Betahistine
- Vestibular rehabilitation therapy
- Hearing aids for hearing loss
- Intratympanic injections of gentamicin which is ototoxic can reduce balance sensitivity but result in additional hearing loss
- Intra-tympanic steroids have been tried but are less effective than gentamicin but less risk of hearing loss
- More complex surgery for difficult to manage case include; endolymphatic sac procedure (sac is decompressed), labyrinthectomy (destruction of part of vestibular system) and vestibular nerve section (cutting the nerve to reduce signals to the brain)
What’s the diagnosis?
Benign Paroxysmal Positional Vertigo (BPPV)
How is Benign - Paroxysmal Positional Vertigo (BPPV) diagnosed?
Dix-Hallpike testing:
- lies the patient down quickly as the eyes are observed → nystagmus will occur on the side tested
- there will be a brief delay then nystagmus will occur for less than one minute
- . Repeating the manoeuvre shows the effect is weaker with subsequent attempts
How is BPPV treated?
Epley’s manoeuvre
- a repositioning technique
- It can be done on either left or right side
- The manoeuvre is commenced on the side of greatest nystagmus when Dix-Hallpike testing→ placing the head into different positions will allow movement of free-floating canaliths to fall into the utricle
What do you suspect is the histology?
Squamous cell carcinoma
(most common malignancy of the head and neck)
Why did the patient present with the ear pain if that’s squamous cell carcinoma of head and neck?
- The tonsil area is supplied by the glossopharyngeal nerve
- Irritation of this nerve can result in pain being referred via the Jacobson’s nerve (tympanic branch of the glossopharyngeal nerve) to the ear
What are the other (rather than SCC of head and neck) causes of referred otalgia?
- the ear receives sensory supply from six sources, cranial nerves V, VII, IX, and X and cervical spinal nerves C2 and C3.
- irritation of any of these can cause referred otalgia
- common causes include: dental pathology, pharyngitis, temporomandibular joint pathology, sinusitis, cervical spine pathology, and mumps of the parotid gland, retro and parapharyngeal abscess
How can infection lead to permanent hearing changes? (pathophysiology)
infection → increased pressure (swelling, inflammation, discharge) → reduced blood supply to the tissue (due to compression of blood vessels) → bone may die (erosion of the bones)
What’s hearing ‘threshold’?
The quietest sound we can hear with given frequency
Possible causes of sudden hearing loss
- trauma
- chemotherapy drugs
- gentamycin
- stroke → vascular
- viral infection → mononeuropathy (common cause of sudden hearing loss)
Sudden hearing loss:
- 60% of patients get better
- prescribe steroids ASAP
Management of sudden hearing loss
Give steroids ASAP (within 48 hours)
60 mg Prednisolone daily for 10 days
*this will reduce the inflammation and pressure within the ear and nerve → so less risk for the blood supply to be reduced
What’s ‘whisper’ test?
Whisper Test
- The examiner exhales and whispers a combination of numbers and letters (example 4-K-2).
- Whispering at the end of exhalation is to ensure as quiet and as standardized voice as possible.
- If the patient responds correctly, hearing is considered normal and no further screening is necessary on that ear
*cover the other (not tested ear) to be able to assess the one at a time only
Why its so crucial to be able to identify hearing problems in a child below 3 years old?
neuroplasticity until age of 3 → if a child’s hearing is affected before they would not be able to speak properly for the rest of their life
*as soon after e.g. meningitis a child should have hearing test → cochlear implant may be a treatment and prevent disability for the rest of their lives
What do we do if a patient presents with unilateral sensorineural deafness?
Need to see ENT → possible vestibular schwannoma → need to have MRI
What could be a calcification on TM result of?
- trauma
- perforation
- grommet
*it does not usually interfere with hearing
How and when to advise the patients to get water out of their ears?
- do after any water contact (if out for 10-15 minutes)
- Technique: lean forward → head turned to the side → wiggle your fingers till the water is out
*this is to prevent ear canal to be wet and bacteria growth
What ‘keratin trapped inside the sack’ may mean?
Cholesteatoma → lump of keratin/dead skin that cannot get out (is trapped in the skin)
What’s a connection between cholesteatoma and mental health illness?
- Cholesteatoma may grow and irritate temporal lobe → visual hallucinations
*similarly may grow posteriorly into the cerebellum → ataxia
- 25% of patients with mental health issues may habe persistent ‘runny ear’ → refer to ENT
Appearance of the tympanic membrane with chronic otitis media
- yellow ‘straw’ colour of TM
- retracted TM
Can children with grommets swim?
Yes, research have proven that this is safe (due to small size of a hole in TM)
No ear protection needed
What factors may predispose to nasopharyngeal carcinoma?
- Hong-Kong population genetics
- chromium exposure
- soot /sadza/ exposure
What type of tumour most common head and neck cancers are?
Squamous Cell Carcinomas
*some may come from adenoid (adenocarcinomas)
How autoimmune diseases may destroy hearing?
Clumps of antibodies and antigen complexes → block the vessels/blood supply to the ear bones/nerves
What’s characteristic, on an audiogram, for otosclerosis?
Carhart’s notch
What type of hearing loss is there in chronic otitis media?
Management of the problem
- conductive → due to increased fluid (effusion) behind tympanic membrane (so sound cannot get through)
*grommets if a child cannot cope
* hearing only affected badly if both ears affected - su usually grommets are considered only in bilateral causes
Triad if Meniere’s disease
- dizzness
- tinnitus
- deafness
Why we may use Buccastem as a drug in acute episodes of Mennier’s?
- it contains Prochlorperazine (dopamine antagonist with anti-emetic properties)
- if a patient is vomiting, they would not be able to absorb oral Prochlorperazine
- Buccastem is absorbed through buccal mucosa quickly and therefore an effective way to administer medication
What’s the role of ototoxicity of Gentamycin in management of Meniere’s disease?
We can give Gentamycin injections into the ear → this will poison the affected cochlea and reduce dizziness (while not significantly worsening of the hearing)
*We need to monitor the hearing before new injections
This is due to small risk of hearing changes
