Surgical specialties - ENT Flashcards
Usual infective agents associated with acute otitis externa?
- Strep.
- Staph.
- Pseudomonas.
- Fungi.
How may hearing loss occur with acute otitis externa?
Oedema of the external auditory meatus and accumulation of debris.
Relapse is also often due to residual debris in meatus.
Why should prolonged use of antibiotics/ steroids be avoided in otitis externa?
Promotes secondary fungal otitis e.g. Aspergillus.
How is itching controlled in acute otitis externa?
1% hydrocortisone cream applied with a cotton bud - AFTER infection has been treated.
What is furunculosis?
Infection of a hair follicle in outer ear canal.
AKA severe acute otitis externa.
Symptoms and signs of furunculosis?
- Severe throbbing pain.
- Pyrexia.
- Seropurulent otorrhoea (rupture of abscess).
Describe the pathophysiology of malignant otitis externa?
- Aggressive otitis externa.
- Spreading osteomyelitis of temporal bone due to infection by Pseudomonas pyocyaneus.
- Marked granulations of ear canal.
- Infection spreads, involving middle ear and lower cranial nerves.
Who is typically affected by malignant otitis externa?
Immunocompromised e.g. elderly diabetics.
How is malignant otitis externa investigated?
CT and isotope scanning to determine extent of osteomyelitis.
How is malignant otitis externa treated?
- Local aural toilet.
- Insertion of wicks + anti-pseudomonal + high dose antibiotics.
- Occasionally surgical debridement if progression despite conservative treatment.
What is myringitis bullosa?
Localised otitis externa - blisters form on eardrum and deep meatus.
(pts will complain of excruciating earache).
(treatment is symptomatic).
What is perichondritis?
Infected cartilage following severe otitis externa or trauma, causing a swollen, red and tender pinna.
Signs/ symptoms of perichondritis?
- Swollen, red, tender pinna.
- Oedema may spread to face.
- Enlarged pre-tragal lymph nodes.
How is perichondritis managed?
- Local astringents e.g. magnesium sulphate.
- Systemic antibiotics to prevent permanent cartilage damage and poor cosmesis.
Pathophysiology of acute otitis media.
- Usually due to URTI ascending via eustachian tube.
- Eardrum retracts as eustachian tube is blocked and fluid (inflammatory exudate) fills middle ear.
- Pressure causes pain, eardrum congests and bulges.
Signs/ symptoms of acute otitis media?
- Recent URTI.
- Otalgia.
- Congested, bulging eardrum.
- Fever, tachycardia.
- Eardrum rupture - bloodstained discharge and relief from pain.
When are antibiotics indicated in acute otitis media?
If spontaneous resolution/ improvement of symptoms does not occur with 48 hours.
Management of acute otitis media?
- Analgesia.
- Nasal decongestant.
- Keep ear dry (swab, mop discharge).
- If failure to resolve within 48 hours: broad-spec ABx to cover Haemophilus and Strep.
- Recurrent - myringotomy, grommet insertion, adenoidectomy considered.
What is acute otitic barotrauma?
Occurs during descent in aircrafts.
Causes severe otalgia, sometimes rupture of eardrum with bloody otorrhoea.
What is Ramsay Hunt syndrome (Herpes zoster oticus)?
Facial nerve ganglion becomes infected with shingles.
- Severe pain, vesicles in ear canal and concha, +/- facial palsy.
How is Ramsay Hunt syndrome (Herpes zoster oticus) treated?
- Anti-virals: aciclovir.
Early recognition and treatment may prevent permanent damage to facial nerve.
If examination of pinna, ear canal and eardrum is normal - otalgia will be a referred pain and may originate from which structures?
- Oropharynx and tongue (CN IX, V).
- Larynx and hypopharynx (CN X).
- Cervical spine (C2,3).
- Oesophagus (CNX).
- Nose and sinuses (CN V).
- Teeth, parotid, temporo-mandibular joint (CN V).
What skin conditions are associated with acute otitis externa with otorrhoea?
- Psoriasis.
- Eczema.
- Seborrhoeic dermatitis.
How does chronic otitis externa differ from acute?
- Chronic: usually bilateral, painless, relapsing. Skin of canal is permanently thickened and easily traumatized.
- Acute: otalgia, otorrhoea, ass. with skin conditions e.g. eczema.
Why are antibiotic drops not advised in chronic otitis externa?
- Only if there is acute inflammation.
- May precipitate an allergic reaction or predispose to fungal infection.
Management of chronic otitis externa?
- Remove any debris.
- Keep dry.
- Antibiotic drops only if acute inflammation present.
What are the two forms of chronic otitis media?
Chronic suppurative otitis media:
- Tubotympanic disease (mucosal disease).
- Atticoantral disease (bone loss + serious complications).
Signs/ symptoms of chronic otitis media?
- Otorrhoea.
- Hearing loss.
- Defect of eardrum.
- Rarely otalgia.
What is chronic suppurative otitis media - tubotympanic disease?
Rupture of tympanic membrane in acute otitis media fails to heal > persistent perforation despite aural toilet and topical steroid ear-drops.
Inactive or active depending if discharging or not.
Management of tubotympanic chronic suppurative otitis media?
- ABx ear drops e.g. ofloxacin, ciprofloxacin (not currently licensed in UK).
- Hearing aid.
- Surgery if recurring discharge / swimmer/ impaired hearing.
What is atticoantral chronic suppurative otitis media?
Chronic eustachian tube dysfunction > retractions and perforations of tympanic membrane in attic region or involving the annulus.
Why is atticoantral chronic suppurative otitis media potentially life-threatening?
Associated with cholesteatoma - destructive and ass. with serious complications e.g. unrecognized bone destruction leading to intracranial complications.
What are the eosinophilic associated causes of inflammatory rhinitis?
- Allergic rhinitis.
- NARES.
- Nasal polyps.
- Chronic eosinophilic sinus syndrome.
- Aspirin sensitivity.
What are the neutrophilic associated causes of inflammatory rhinitis?
- Bacterial sinusitis.
- Adenoiditis.
- Cystic fibrosis.
What may cause inflammatory rhinitis not associated with eosinophils or neutrophils?
- Viral rhinitis.
- Granulomatosis with Polyangiitis (Wegener’s).
- Sarcoidosis.
- Midline granuloma.
What are the irritant forms of non-inflammatory rhinitis?
- Vasomotor.
- Irritant.
- Cholinergic hypersecretory.
- Gustatory.
What are the non-irritant forms of non-inflammatory rhinitis?
- Hypothyroid.
- B-blocker.
- Anti-hypertensives.
- Pregnancy.
- Atrophic rhinitis.
Allergic, non-infective rhinitis can be divided into?
- Intermittent rhinitis.
- Persistent rhinitis.
Non-allergic, non-infective rhinitis can be divided into?
- Idiopathic rhinitis (vasomotor).
- Polyps.
How are asthma and rhinitis linked?
- Segmental bronchial allergen provocation leads to inflammation in the nose in allergic rhinitis.
- Nasal provocation leads to increased blood and bronchial.
> Generalised induction of inflammatory mediators.
How is the development of nasal symptoms in allergic asthma and rhinitis prevented during the pollen season?
- Inhaled corticosteroids (topical treatment of lungs).
How do the Th1/2/3 pathways differ from normal in allergic rhinitis?
- Exaggerated Th2 pathway i.e. Eosinophils and B cells (> IgE) - Type I.
- Impaired Th3 pathway.
- Impaired Th2 pathway i.e. macrophages - type IV.
House dust mite faeces bind to mast cells in the nose, causing?
Mast cells produce:
- Histamine.
- Leukotrienes
Name the 5 parts of the temporal bone.
- Mastoid.
- Styloid process.
- Tympanic bone.
- Squamous part.
- Petrous part.
Most common thyroid carcinoma?
Papillary thyroid carcinoma.
Which thyroid carcinoma is associated with “Orphan-Annie” (ground-glass) nuclei with psammoma bodies?
Papillary thyroid carcinoma.
(psammoma bodies are calcified spherical bodies). Be aware that it can also appear as solid balls of neoplastic follicular cells with fibrous stroma.
Describe “orphan-Annie” nuclei.
Hypochromatic empty nuclei devoid of nucleoli.
Histopathologic appearance of follicular thyroid carcinoma?
Usually microfollicular pattern.
- Many uniform, colloid-filled follicles resembling a normal thyroid.
Follicular thyroid carcinoma may have the same appearance as what other pathology on fine needle aspiration?
Follicular adenoma.
Hashimoto’s thyroiditis is associated with increased risk of which thyroid malignancy?
Lymphoma of the thyroid.
Medullary thyroid carcinomas are associated with which endocrine conditions?
MEN 2A and 2B.
Medullary thyroid carcinomas arise from which cells?
Parafollicular C cells.
Medullary thyroid carcinomas secrete what?
Calcitonin.
Microscopic appearance of medullary thyroid carcinoma?
Polygonal to spindle-shaped cells.
- Associated with amyloid deposits derived from abnormal calcitonin molecules.
Microscopic appearance of anaplastic thyroid carcinoma?
Large, pleomorphic giant cells.
Which thyroid cancer has the best prognosis?
Papillary thyroid carcinoma.
Which thyroid cancer has the worst prognosis?
Anaplastic thyroid cancer.
What usually causes death in those with anaplastic thyroid carcinoma?
Aggressive local growth.
Common autosomal dominant disorder of conductive hearing loss which characteristically worsens during pregnancy.
Otosclerosis.
30 y/o F complains of worsening hearing loss in pregnancy. No FHx of hearing loss.
OE - tympanic membrane is intact. Pure tone audiometry shows conductive hearing loss with a Carhart notch.
What is the most likely pathology?
Otosclerosis.
- Fixation of stapes bone.
Why does otosclerosis occasionally skip generations?
Incomplete penetrance.
