Surgery: ENT Flashcards
1
Q
What’s Presbycusis?
A
- age-related hearing loss
- bilateral
- progressive
- high frequency
2
Q
Which inflammatory diseases may lead to sensorineural hearing loss?
A
- measles
- mumps
- meningitis
- syphillis
3
Q
What drug classes (2) may cause ototoxicity and lead to sensorineural hearing loss?
A
- aminoglycosides
- cytotoxic agents
4
Q
(2) causes of conductive hearing loss re to external ear
A
- otitis externa
- wax
5
Q
Cause of conductive hearing loss related to the tympanic membrane
A
perforation
6
Q
Causes of conductive hearing loss related to middle ear
A
- ossicular discontinuity
- otosclerosis
- cholesteatoma
- otitis media with effusion (OME) (beware unilateral)
- Mixed - chronic suppurative otitis media (CSOM)
7
Q
What to ask in HPC re to hearing loss?
A
8
Q
What to ask in PMH and Med Hx re to hearing loss?
A
9
Q
Anatomy of tympanic membrane
A
10
Q
What’s the importance of the wax in the attic?
A
It could be cholesteatoma
11
Q
Pathophysiology of cholesteatoma
A
- non-cancerous growth of squamous epithelium that is ‘trapped’ within the skull base → local destruction
12
Q
Risk factors for cholesteatoma (2)
A
- most common in patients aged 10-20 years
- cleft palate increases the risk of cholesteatoma around 100 fold
13
Q
Symptoms of cholesteatoma
A
Main features
- foul-smelling, non-resolving discharge
- hearing loss
Other features are determined by local invasion:
- vertigo
- facial nerve palsy
- cerebellopontine angle syndrome
14
Q
What’s seen on otoscopy in cholesteatoma?
A
‘attic crust’ - seen in the uppermost part of the ear drum
15
Q
Principles of tuning fork tests
A
16
Q
Management of sudden SN hearing loss
A
Steroids
17
Q
Ix and management of asymmetrical SN hearing loss
A
- MRI
- hearing aids
18
Q
Management of symmetrical SN hearing loss
A
hearing aids
19
Q
Management of Conductive Hearing Loss
A
- hearing aids
- surgery
20
Q
What may hearing loss in children lead to?
A
21
Q
Management of Cholesteatoma
A
patients are referred to ENT for consideration of surgical removal
22
Q
Congenital causes of hearing loss (4)
A
- genetic
- prenatal infections e.g. Rubella
- prenatal toxins exposure
- hypoxic injury
23
Q
What does Newborn Hearing Screening Programme consist of?
A
- otoacoustic emissions → performed within days of birth until up to 3 months
If the unclear response on otoacoustic emissions test → auditory brainstem response
24
Q
Pathophysiology and management of glue ear
A
25
Risk factors for **glue ear**
* male
* attending daycare
* older siblings
* parental smoking
* winter season
* atopy
* recurrent URTIs
* refux
26
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
27
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
28
Symptoms and management of **Acute Otitis Media**
29
Symptoms and management of ear wax
30
Management of Foreign Body in the ear
31
What extra questions to ask while taking hearing loss Hx in children?
32
How to differentiate between: BPPV, Vestibular Neuronitis/ Labirynthitis and Menieres disease
Consider:
**- duration of vertigo episodes**
**- associated auditory symptoms**
33
Causes of Tinnitus
Other causes include
* impacted ear wax
* chronic suppurative otitis media
34
What drugs may cause tinnitus? (4)
* Aspirin
* Aminoglycosides
* Loop diuretics
* Quinine
35
What's that? What's its association?
10% of patients may have a '***flamingo tinge***', caused by hyperaemia (excess of blood vessels)
36
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**
37
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
38
In which patients we can see **bilateral** vestibular schwannoma?
Bilateral vestibular schwannomas are seen in **neurofibromatosis type 2**
39
Investigations for **vestibular schwannoma**
* **MRI of the cerebellopontine angle**
* Audiometry
40
Management of **vestibular schwannoma**
* if suspected → urgent ENT referral
## Footnote
(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
41
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
42
Features of ***otosclerosis***
Onset is usually at **20-40 years**
* conductive deafness
* tinnitus
* normal tympanic membrane
* positive family history
43
Management of ***otosclerosis***
* hearing aid
* stapedectomy
44
What type of hearing loss does he have and in which ear?
Conductive hearing loss (air conduction better than bone conduction)
45
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.
46
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
47
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)
48
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
49
What is the diagnosis?
***Sudden idiopathic sensorineural hearing loss***
50
Diagnosis: Idiopathic SN hearing loss
**How soon the steroids should be started?**
Within 24 hours
51
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
52
Why was the MRI requested?
To exclude other rare causes of sensorineural hearing loss such as vestibular schwannoma
53
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
54
What's the most likely diagnosis?
Otosclerosis
55
What are the treatment options available to improve this patient's hearing?
Dx: otosclerosis
Mx: A trial of hearing aid initially or stapedectomy surgery
56
## Footnote
**She asks if it is likely to happen to her other ear. What do you tell her?**
Otosclerosis is likely to affect both ears
57
List some causes of this condition
* **Adenotonsillar hypertrophy** cause sleep-disordered breathing and O**bstructive Sleep Apnoea (OSA)**
* recurrent otalgia is likely to be due to recurrent middle ear infections (**acute otitis media**) or **eustachian tube dysfunction**
58
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
59
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
60
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**
61
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**
62
What's the likely diagnosis?
Meniere's disease
63
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)
64
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
65
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
66
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
67
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
68
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)
69
What's the diagnosis?
Benign Paroxysmal Positional Vertigo (BPPV)
70
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
71
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
72
What do you suspect is the histology?
***Squamous cell carcinoma***
(most common malignancy of the head and neck)
73
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
74
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
75
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)
76
What's hearing 'threshold'?
The quietest sound we can hear with given frequency
77
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
78
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
79
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
80
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
81
What do we do if a patient presents with **unilateral sensorineural** deafness?
Need to see ENT → possible vestibular schwannoma → need to have MRI
82
What could be a calcification on TM result of?
* trauma
* perforation
* grommet
\*it does not usually interfere with hearing
83
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
84
What 'keratin trapped inside the sack' may mean?
***Cholesteatoma*** → lump of keratin/dead skin that cannot get out (is trapped in the skin)
85
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
86
Appearance of the tympanic membrane with **chronic otitis media**
* yellow 'straw' colour of TM
* retracted TM
87
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
88
What factors may predispose to nasopharyngeal carcinoma?
* Hong-Kong population genetics
* chromium exposure
* soot /sadza/ exposure
89
What type of tumour most common head and neck cancers are?
**Squamous Cell Carcinomas**
\*some may come from adenoid (adenocarcinomas)
90
How autoimmune diseases may destroy hearing?
Clumps of antibodies and antigen complexes → block the vessels/blood supply to the ear bones/nerves
91
What's characteristic, on an **audiogram**, for **otosclerosis**?
Carhart's notch
92
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
93
Triad if ***Meniere's*** disease
* dizzness
* tinnitus
* deafness
94
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
95
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
