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
