Week 4 - ENT and Dermatology Flashcards
Outline the findings on an otoscope view in the following ear conditions
- Otitis externa
- Otitis media
- Otitis media with effusion
- Cholesteatoma
Otitis externa
- Oedematous/swollen external canal
- Surrounding erythema
- Often unable to see the tympanic membrane due to proximal swelling
Otitis media
- Bulging tympanic membrane
- Surrounding erythema
- May have perforated tympanic membrane
Otitis media with effusion
- Straw coloured fluid
- Retraction of tympanic membrane
- May have presence of air bubbles
Cholesteatoma
- Erythema / waxy mass in pars flaccid region of tympanic membrane
- Associated smelly otorrhoea
List some common differentials for hearing loss
- Presbycusis (age-related hearing loss)
- Noise-related hearing loss (acute or chronic)
- Waxy / foreign body obstruction
- Otitis media +/- effusion / otitis externa / cholesteatoma
- Perforated tympanic membrane
- Otosclerosis
- Meniere’s disease
- Exostoses and osteomas (benign bony growths)
- Autoimmune hearing loss
- Acoustic neuroma
Briefly outline the difference between acute and chronic sinusitis
Acute sinusitis
- Generally resolves within 7-10 days
- Considered acute if lasts less than 4 weeks
Chronic sinusitis
- Lasts more than 12 weeks
- Continues despite medical treatment
Acute sinusitis - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Symptomatic inflammation of the mucosal lining of the paranasal sinuses and nasal cavity
- Majority of cases are of viral aetiology
- However, suspect bacterial cause if duration of symptoms more than 10 days OR symptoms worsen after an initial improvement
Presentation:
- Recent URTI
- Yellow/green nasal drainage
- Blocked nose
- Pyrexia
- Facial pain/pressure/fullness, worse on leaning forwards
Management:
- Generally self-limiting within 2.5 weeks
- Antipyretics, analgesia, nasal irrigation and steam inhalation
- If unresolving, give high dose nasal corticosteroids
If bacteria suspected: leave for 10 days, unless immunocompromised then give immediate antibiotics (Phenoxymethylpenicillin)
Acute sinusitis - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Symptomatic inflammation of the mucosal lining of the paranasal sinuses and nasal cavity
- Majority of cases are of viral aetiology
- However, suspect bacterial cause if duration of symptoms more than 10 days OR symptoms worsen after an initial improvement
Presentation:
- Recent URTI
- Yellow/green nasal drainage
- Blocked nose
- Pyrexia
- Facial pain/pressure/fullness, worse on leaning forwards
Management:
- Generally self-limiting
- Antipyretics, analgesia and steam inhalation
- Safety net to come back if it doesn’t resolve within 10 days (may require antibiotics if bacterial cause)
If bacteria suspected: leave for 10 days, unless immunocompromised then give immediate antibiotics
Chronic sinusitis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Symptomatic inflammation of the mucosal lining of the paranasal sinuses and nasal cavity
- Lasts longer than 12 weeks (3 months) or unresolving to regular treatment
- Either with or without polyps
Presentation:
- General malaise
- Yellow/green nasal drainage
- Blocked nose
- Pyrexia
- Facial pain/pressure/fullness, worse on leaning forwards
Investigations:
Diagnosis is initially clinical
- Anterior rhinoscopy
- Nasal endoscopy
May need to consider
- Sinus CT/MRI
- Sinus cultures
- Allergy testing
Management:
- Nasal saline irrigation
- Intranasal corticosteroids e.g. nasal Budesonide
- May consider antibiotics
Acute otitis media - state the following:
- Pathophysiology
- Presentation
- Otoscope findings
- Management
Pathophysiology:
- Infection of the middle ear space
- Common complication of viral respiratory illnesses
- Primarily affects children
Presentation:
- Otalgia (tugging at ear)
- Aural fullness
- Preceding upper respiratory symptoms
- Crying / generally unwell
- Fever
Otoscope findings:
- Bulging tympanic membrane
- Surrounding erythema
- May have perforated tympanic membrane
Management:
- Supportive therapy mainly e.g. analgesics
- Observe for 2-3 days, then if not improved may require antibiotics e.g. Amoxicillin
Otitis media with effusion - state the following:
- Pathophysiology
- Presentation
- Otoscope findings
- Management
Pathophysiology:
- ‘Glue ear’
- Fluid accumulation within the middle ear space, in absence of signs of acute inflammation
- Commonly affects children 6 months - 4 years, especially in winter
- Generally occur due to impaired/blockage eustachian tube
Presentation:
- Hearing loss/difficulties
- Otalgia (tugging at one or both ears)
- Loss of balance
- Delayed speech development
Otoscope findings:
- Straw coloured fluid
- Retraction of tympanic membrane
- May have presence of air bubbles
- May consider pneumatic otoscopy or tympanometry
Management:
- Watchful waiting for 3 months, mostly resolve
- May consider grommets if chronic dysfunction of eustachian tube is suspected
Otitis externa - state the following:
- Pathophysiology
- Presentation
- Otoscope findings
- Management
Pathophysiology:
- Form of cellulitis, involving diffuse inflammation of the external ear canal
- Most commonly caused by Pseudomonas aeruginosa and Staph aureus
- Risk of malignant otitis externa
Presentation:
- Otalgia
- Tenderness to pinna/tragus
- Itching
- Aural fullness
- Hearing loss
- Localised erythema or oedema
Otoscope findings:
- Oedematous/swollen external canal
- Surrounding erythema
- Often unable to see the tympanic membrane due to proximal swelling
Management:
- Supportive treatment e.g. analgesia
- Consider OTC Acetic acid 2% ear drops
- Consider topical antibiotics +/- topical steroids if appropriate
- Symptoms should resolve within 48-72 hours
- Consider anti-fungals if suspect fungal infection
Tinnitus - state the following:
- Pathophysiology
- Common causes
- Presentation
- Investigations
- Management
Pathophysiology:
- Perception of sound in the absence of any external auditory stimulus
Common causes:
- Meniere’s disease
- Acute labyrinthitis
- Ototoxic medications
- Multiple sclerosis
- Head injury
- Depression/anxiety
- Vitamin B12 deficiency
Presentation:
- Perception of ringing, humming, buzzing, hissing, clicking, or pulsing (intermittently or constantly)
- May have associated hearing loss, vertigo or N&V
- Relevant medication history
Investigations:
- Audiometry testing
- May consider other investigations if cause unclear
Management:
- If cause known, treat underlying cause
- Hearing aids can help to reduce tinnitus
- May require psychological support or education to cope with chronic tinnitus
Meniere’s disease - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Episodic auditory and vestibular disease, with a triad of: vertigo, tinnitus and hearing loss
- Cause is unknown, may be due to incorrect endolymph production in inner ear
Presentation:
Acute onset of the triad of:
- Vertigo (longer-lasting, up to 24 hrs)
- Tinnitus
- Hearing loss
Plus a feeling of aural fullness
Investigations:
- Audiometry
- Tympanometry
Management:
- Dietary changes and lifestyle modification e.g. reduce salt intake, alcohol intake, smoking cessation
- Prochlorpenazine / antihistamines for vertigo and N&V
- May require hearing aids
- Some surgical interventions
- Betahistine can be used to prevent further attacks
Benign paroxysmal positional vertigo (BPPV) - state the following:
- Pathophysiology
- Presentation
- Special test for testing for BPPV
- Special test for resolving BPPV
- Management
Pathophysiology:
- Peripheral vestibular disorder
- Manifests as sudden, short-lived episodes of vertigo elicited by specific head movements
- One of the most common causes of vertigo
- Mostly caused by endolymph crystals affecting fluid movement in inner ear
Presentation:
- Brief duration of episodes of vertigo, only lasting seconds with description that the room is spinning around them
- Specific provoking positions e.g. bending down
Special test for testing for BPPV:
- Dix-Hallpike manoeuvre
Special test for resolving for BPPV:
- Epley manouvre
Management:
- Patient education and reassurance, most cases resolving after manoeuvre
- Spontaneous remission in 1/3 patients at 3 weeks (and majority of patients by 6 months)
- If persistent, may require surgery
Outline some risk factors that may result in developing Benign paroxysmal positional vertigo (BPPV)
- Aging
- Recent viral infection
- Head trauma
Also can be idiopathic
Otosclerosis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Abnormal bone remodeling in the middle ear, fusing the bones and reducing sound wave conduction
- Often begins in young adults
Presentation:
- Mainly hearing loss
- May also have tinnitus, vertigo or balance issues
Investigations:
- Audiogram
- Tympanometry
Management:
- Mild can be treated with hearing aids
- Surgery is often required, involving stapedectomy
Presbycusis (age-related hearing loss) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Age-related hearing loss, caused by hearing
- Likely to be due to a gradual loss of stereocilia as well as loss of neurones
Presentation:
- Gradual onset of bilateral hearing loss, mainly of higher pitched sounds (makes it difficult to understand speech)
- May have associated tinnitus,
Investigations:
- Audiometry
Management:
Supportive management (no cure)
- Improving sound environments
- Hearing aids
- Cochlear implants
Outline how the vertigo attacks differ in the following conditions, including what causes it, what triggers attacks, how long they last for
- BPPV
- Meniere’s disease
- Vestibular neuronitis
BPPV:
Cause: crystals forming in the semicircular canals
Trigger: movement or position changes e.g. bending down
Attacks: last around 1 minute
Meniere’s disease
Cause: excessive endolymph
Trigger: no trigger (not associated with movement)
Attacks: last for several hours
Vestibular neuronitis:
Cause: viral infection, inflammation of nerve causes a mismatch to signalling (also trauma, tumours, otosclerosis, Ramsey-Hunt syndrome)
Trigger: movement or position changes e.g. bending down
- Attacks: acute onset, lasts for weeks
Outline the anatomy of the eustachian tube and it’s role
The eustachian tube is a collagen tube that connects the nasopharynx with the middle ear space (air filled)
Role:
Upon swallowing, the tube equilibrates the pressure between the middle ear and the nasopharynx to reduce pressure build up in the middle ear
It also helps to drain fluid from the middle ear, preventing infection from ascending there
Dysfunction:
Mucus continues to resorb the air, whilst eustachian tube dysfunction leads to negative pressure
Chronic eustachian tube dysfunction = otitis media with effusion
Solution: grommets
Briefly outline the 3 main types of skin cancers and where they originate from
Basal cell carcinoma (BCC)
- Originates from basal cells in the deep epidermis (stratum basale)
Squamous cell carcinoma (SCC)
- Originates from keratinocytes in the middle epidermis (stratum spinosum)
Melanoma
- Originates from melanocytes in the deep epidermis
Basal cell carcinoma (BCC) - state the following:
- Originating layer and area found
- Typical appearance
- Diagnosis method
- Prognosis
- Type of referral and management
- Safety netting advice
Originating layer and area found:
- Originates from basal cells in the deep epidermis (stratum basale)
- Found in UV exposed areas e.g. face, ears
Typical appearance:
Appearance can vary greatly
- Often a waxy, pink appearance
- Can seem to be a scab that doesn’t heal
- Can be a pearl-like appearance
Diagnosis:
- Take a skin biopsy
Prognosis:
- Extremely good, very slow growing and rarely malignant
- However, can return
Type of referral and management:
- Non-urgent referral
- Remove cancer with surgery
- Reduce recurrence with good skin protection
Safety netting advice:
- Notice any further unusual areas, present to the GP for further investigation as can come back
- Any issues with vision or headaches
- Future prevention e.g. sun cream use, smoking cessation
Squamous cell carcinoma (SCC) - state the following:
- Originating layer and area found
- Typical appearance
- Diagnosis method
- Prognosis
- Type of referral and management
- Safety netting advice
Originating layer and area found:
- Originates from keratinocytes in the middle epidermis (stratum spinosum)
- Found in UV exposed areas e.g. face, ears
- Also damaged by chemical burns and chronic ulcers
Typical appearance:
Appearance can vary
- Mostly a crust/scale appearance, raised and rough
- Can be sore or tender
Diagnosis:
- Take a skin biopsy
Prognosis:
- Good, most are are low risk skin cancers
- However, a small amount can metastasise or return locally
Type of referral and management:
- 2 week wait referral
- Remove cancer with surgery
- May require some radiotherapy
Safety netting advice:
- Notice any further unusual areas, present to the GP for further investigation as can come back
- Future prevention e.g. sun cream use, don’t use sunbeds
Melanoma - state the following:
- Originating layer and area found
- Typical appearance
- Diagnosis method
- Prognosis
- Type of referral and management
- Safety netting advice
Originating layer and area found:
- Originates from melanocytes in the deep epidermis
- Found in UV exposed areas e.g. face, ears
Typical appearance:
- Generally a darker colour (due to melanin production) like a mole
- Use ABCDE assessment method to assess for risk of melanoma
Diagnosis:
- May use a dermascopy
- Take a skin biopsy
Prognosis:
- Worse of the 3, however 75% of patients who have a melanoma removed will have no further problems
Type of referral and management:
- 2 week wait referral
- Remove cancer with surgery, depending on stage of cancer
- May require radiotherapy or immunotherapy for stage 4 melanoma
Safety netting advice:
- Notice any further unusual areas, present to the GP for further investigation as can come back
- Future prevention e.g. sun cream use, don’t use sunbeds
Outline the ACBDE approach to assessing melanomas
Asymmetry – whether two halves of the area differ in their shape
Border – are the edges of the area irregular or blurred?
Colour – can different shades of black, brown and pink be seen?
Diameter – is the lesion > 6mm diameter?
Evolving - has the mole changed recently or is it a new mole?
List the 4 components of the Centor criteria for tonsillitis management
Centor Criteria:
- Fever
- Exudates
- No cough
- Cervical lymphadenopathy (tender)
Cholesteatoma - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Abnormal collection of squamous epithelial cells in the middle ear caused by eustachian tube dysfunction
- Non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear
Presentation:
- Foul discharge from the ear
- Unilateral conductive hearing loss
- Generally painless
Investigations:
- Otoscope
- Audiogram
- CT scan temporal bone
Management:
- Referral to secondary care
- Canal wall up mastoidectomy (surgery)
- May need topical antibiotics prior to surgical treatment
Noise related hearing loss - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Gradual or sudden deterioration in hearing (temporary or permanent)
- Results from damage stereocilia and damage to the synapses between the stereocilia and the auditory nerve
Presentation:
Unilateral or bilateral
- Decrease in volume of sound
- Loss of clarity of sound
If trauma: tinnitus, otalgia, hyperacusis, vertigo
Investigations:
- Audiogram, see a decrease hearing sensitivity in the higher frequencies
Management:
- Prevention is key
- If already damaged: hearing amplification and counselling
Tympanic perforation - state the following:
- Common causes
- Presentation
- Investigations
- Management
Common causes:
- Acute otitis media
- Trauma
- Sudden changes in air pressure e.g. explosions
Presentation:
- Sudden otalgia
- Otorrhea
- Tinnitus
- Vertigo
Investigations:
- Usually just an otoscope
- Definitive diagnosis: otomicroscopy or middle ear impedance studies
Management:
- Generally self-resolving
- Keep ear dry to aid healing
State the difference between wet and dry tympanic perforation
Wet perforation: perforation with the presence of endogenous bloody or watery exudates, but not purulent otorrhea or signs of infection in the middle ear (perforations associated with serum or plasma exudates)
Dry perforation: perforation without the presence of secondary bloody and watery substances and purulent otorrhea on the ruptured membrane and at perforation edges
Mastoiditis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Infection of the mastoid air cell
- Generally occurs secondary to an untreated otitis media
Presentation:
- Otalgia / tugging at ear
- Pinna pushed anteriorly
- Localised postauricular erythema
- Fever
- Headache
- Brown otorrhoea
Investigations:
- Mainly clinical
- Can do MRI scan (or CT scan)
Management:
- Broad spectrum antibiotics e.g. Ceftriaxone, tailored after cultures
- Requires long term antibiotics for full resolution
- May require myringotomy if no improvement
List some common causititve organisms for mastoiditis
- Staphylococcus aureus
- Haemophilus influenzae
- Streptococcus pneumoniae
- Streptococcus pyogenes
- Moraxella catarrhalis
List some complications of mastoiditis, if left untreated
- Hearing loss
- Labyrinthitis / vertigo
- Bell’s palsy
- Meningitis
- Epidural or brain abscess
- Dural venous thrombophlebitis
List some causes of congenital hearing loss in newborns
- Drug / alcohol use during pregnancy
- Infections e.g. rubella or herpes simplex
- Premature birth / low birth weight
- Birth injuries
- Jaundice and Rh factor problems
- Maternal diabetes
- Preeclampsia
- Genetics e.g. Treacher Collins syndrome
