W13 46 ENT and dentistry Flashcards
What are some otological symptoms (symptoms relating to the ear)?
Hearing loss
Otalgia - pain in the ear
Otorrhea - discharge from the ear
Tinnitus - perception of sound coming from the outside world without external stimulus
Vertigo - hallucination of movement
Facial nerve
What different things can cause otalgia?
Ontological causes (from the ear) - pinna, external auditory meatus, middle ear
Referred pain (from other areas) - from nerves that supply the ear, TMJ
What are chondritis and perichondritis?
Bacterial infection of the auricle - mainly caused by pseudomonas, staph or strep
What is chondritis?
Cartilage inflamed eg from piercings, accidents etc
What is perichondritis?
Occurs after inadequately treated cellulitis of the ear. Affects the perichondrium (layer covering the cartilage). Spread of infection usually.
What happens if the blood supply to the cartilage is cut off and why?
Cartilage only has extrinsic blood supply, so if supply is cut off then causes malformation from devascularisation and necrosis.
What’s the treatment for chondritis and perichondritis? (Otalgia from pinna)
Drain pus, IV antbiotics
What might result from severe cartilage damage?
Cauliflower ear
What is sub-perichondrial haematoma? (otalgia from pinna)
Traumatic disruption of perichondrial blood vessels, strips perichondrium from cartilage. Blood usually accumulates only laterally, unless there is a fracture in the cartilage (which is more dangerous to the vitality of the cartilage).
How do you treat sub-perichondrial haematoma?
Drain haematoma to avoid avascular necrosis of cartilage and cauliflower ear.
What is otitis externa? (Otalgia from external auditory meatus)
Often history of trauma or prolonged water exposure. Usually caused by pseudomonas bacteria.
What is treatment for otitis externa?
Clean debris from ear. Antibiotic drops
What is malignant otitis externa?
Severe infection - not cancer. Occurs in diabetics and other immunosuppressed states. Presents as otitis externa but resistant to treatment and much more painful. Patient develops osteomyelitis of the temporal bone facial nerve palsy and other CN palsies (eg 7-12).
What is treatment for malignant otitis externa?
High dose ciprofloxacin 500mg BD for at least 3 months.
How does wax cause Otalgia of the external auditory meatus?
Nor wax is normal but not in ear canal. Pain is caused by impaction of wax from using earbuds.
How do you treat wax?
Sodium bicarbonate ear drops - more effective than olive oil but can dry out the skin of the external auditory canal which can predispose you to otitis externa
Ear syringing - squirting water down ear canal to push it out
Direct vision removal - micro suction
Not by ear buds!
How does trauma to the EAC occur (Otalgia to EAM)?
Usually by cotton buds, foreign bodies in ear. Biological material (eg peas) can cause skin inflammation and need to come out, however blunt object can stay in for a while without causing issues.
What is the management for trauma to the EAC?
Observe - blood will reabsorb slowly
What is acute otitis media (otalgia from middle ear)?
Acute inflammation of the middle ear cleft.
What causes acute otitis media?
Nearly always preceding URTI.
Strep pneumoniae, H inf, Moraxella Cat - usually organisms living in the oral cavity and nose
Does discharge occur from acute otitis media?
Ear pain but no discharge
(Unless ear drum bursts - usually pain resolves though due to the less pressure)
What is the treatment for acute otitis media?
Antibiotics - amoxicillin
What is the most common complication of acute otitis media?
Perforation - most will heal themselves.
Can cause bulging, red eardrum, pus from acute otitis media
What is acute mastoiditis?
Characterised by ear being pushed out and forwards, usually in children. Mastoid cavity full of pus and subperiosteal abscess formation (if brake in the cortex of the bone).
How does acute mastoiditis occur?
If otitis media worsens
How do you treat acute mastoiditis?
Needs admission and IV antibiotics. If no improvement after 24 hours - CT and cortical mastoidectomy and grommet (to stop further fluid accumulation)
What are the complications of acute mastoiditis?
Intracranial - meningitis, intracranial abscess, sigmoid sinus thrombosis
Infratemporal (within temporal bone) - perforation, mastoiditis, facial palsy, SNHL, labyrinthitis)
Extratemporal (outside temporal bone) - Bezold’s, Citelli’s (abscesses)
Otalgia from referred pain can come from nerves which supply the external auditory canal and the middle ear. Which nerves are these?
V (auriculotemporal branch of mandibular) - canal and lateral TM
VII - external canal
IX (tympanic branch) - supplies middle ear via plexus
X (auricular branch of vagus)
What can trigeminal referred pain cause?
Nose and sinuses - infection, neoplasm, septal deformity
Nasopharynx - acute infection, neoplasm
Teeth and jaw - molar impaction, TMJ, malocclusion
Salivary gland - infection, stones
Trigeminal neuralgia
Sphenopalatine neuralgia
What can facial referred pain cause?
Facial nerve neuralgia
What can IX and X cranial nerve cause?
Pharynx - tonsillitis, quinsy, retropharyngeal abscess, neoplasm
Larynx - neoplasm, granulomatous lesion
Tongue - neoplasm, ulcer
Summary of the different forms of Otalgia
Otological:
Pinna - trauma, infections
External ear - infections, foreign body, wax, trauma
Middle ear - infections
Referred:
V - face, mouth pathology
VII - neuralgia
IX, X - pharynx, larynx, tongue
TMJ
Why is epistaxis common?
Nasal bleeds are common because it has a rich blood supply
What are the 2 main arteries that supply blood to the nose?
External carotid artery
Internal carotid artery
What branches of the external carotid artery supply blood to the nose?
Maxillary artery - sphenopalatine and greater palatine
Facial artery - septal branch of superior labial artery, lateral labial artery
What branches of the internal carotid artery supply blood to the nose?
Ophthalmic artery - anterior ethmoidal and posterior ethmoidal arteries
What do the spheno and greater palatine arteries supply? (IMGS PG 453)
Supplies around the sphenopalatine foramen and most of the septum
What does the facial artery supply? (IMGS PG 453)
Lower front area
Littles area overlies Kittlebach’s plexus
What is Little’s area/Kiesselbach’s plexus?
An anastomose of 5 arteries - anterior ethmoidal artery, posterior ethmoidal artery, phenopalatine artery, greater palatine artery, septal branch of superior labial artery
What are some local causes of epistaxis?
Idiopathic - usually Little’s
Trauma - nose picking, foreign body, fracture
Inflammatory - rhinitis, sinusitis
Neoplastic - tumours of nose or sinuses
Environmental - altitude
Iatrogenic - surgery, steroid spray, cocaine abuse
What are some general causes of epistaxis?
Anticoagulants or bleeding disorders
Familial haemorrhagic telangiectasia
Hypertension (not a cause but perpetuant of it, more likely to bleed for longer and more invasive treatment to stop it but doesn’t make it more likely)
What is the initial management for epistaxis?
- Pressure on cartilaginous part of nose (septum), lean forward
- Anterior rhinoscopy with vasoconstriction and local anaesthetic - cauterise
- Anterior nasal packing
- Anterior and posterior nasal packs
(ABC’s, medical history/medication, vital signs - need IV?)
Successful management of nasal injuries depends on assessing 3 areas - inside the nose, outside the nose, and cosmetic deformity. What complications could there be inside the nose and who should you refer to?
Uncontrollable nose bleeding
Septal haematoma
Septal abscess
CSF rhinorrhoea (if cribriform plate crack, or temporal bone trauma)
(Septal dislocation)
Complications need urgent referral to ENT
Successful management of nasal injuries depends on assessing 3 areas - inside the nose, outside the nose, and cosmetic deformity. What complications could there be outside the nose and who should you refer to?
Facial fractures
Orbital floor fractures - ophthalmoplegia
Mandibular fractures
Refer to maxillo-facial surgeons
Successful management of nasal injuries depends on assessing 3 areas - inside the nose, outside the nose, and cosmetic deformity. What should you do if there are cosmetic deformities?
No cosmetically important deviation - discharge
Swollen - see 5 days
Cosmetically important deviation - refer to RNT for ?manipulation
What are some causes of acute sore throat?
Pharyngitis
Tonsillitis and it’s complications
Epiglottis
Foreign body
What is pharyngitis?
Inflammation of posterior pharyngeal wall and tonsils
Usually viral
Supportive care needed
What organisms can cause tonsillitis?
B-haemolytic strep, strep pneumoniae, H influenzae, anaerobes
What should you do with patients with tonsillitis who can eat and drink?
Send home with antibiotics, after checking monospot (kissing disease caused by Epstein-Barre virus)
What should you do with patients with tonsillitis who are unable to eat and drink?
Admit
IV antibiotics
IV fluids
Pain relief
Monospot
What is a monospot?
Test for glandular fever - a viral infection, but need to warn pt about other complications eg risk of contact sports. Ruptures if playing with inflamed spleen.
What are the complications of tonsillitis?
Severe swelling and respiratory obstruction
Abscess formation - quinsy, parapharyngeal, retropharyngeal
Septicaemia
What is quinsy?
A large swelling superior and lateral to the tonsil. Abscess formed lateral to the tonsil. In tonsillitis.
What organisms cause sore throat in the epiglottis?
Haemophilus influenzae type B
B haemolytic strep
(Less common now with vaccine)
What is the management of sore throat from epiglottic causes?
Safeguard airway - ?intubate (as it can cause airway obstruction)
IV antibiotics
Describe foreign body sore throat
Usually give history of foreign body ingestion
If not and unexplained sore throat will need endoscopy and x-rays to exclude
Foreign bodies can usually get stuck in cricopharyngeus (at top of oesophagus) and usually needs GA to remove.
