Yr4 ENT - Lectures Flashcards
- What additional history features would you like to elicit?
- What symptoms would support a diagnosis other than presbyacusis?
- What 4 systemic conditions can accelerate presbyacusis?
What systemic conditions can accelerate presbyacusis?
1. Diabetes mellitus
2. Cerebrovascular disease
3. Smoking
4. Hypertension
How would you classify hearing loss? Causes of each?
How would you differentiate between these types on clinical examination?
- What are the typical audiometry findings of presbyacusis?
- What advice would you give to the family for best communicating with the patient?
Audiometry: High tone (4000-8000Hz) bilateral loss of about 40-80 dB ( i.e.moderate to severe)
Advice:
1. Speak within 2 metres of the patient
2. Speak directly to the patient
3. Use a steady frequency of voice without marked inflections
4. Speak slowly and clearly
5. Speak so the patient can see the mouth of the person who is speaking; face the light and avoid covering the mouth with the hand.
6. Be patient
How can insects in the ear be removed?
What are the requirements to safely remove a foreign body from the ear without sedation?
Insects should be killed before removal. The child’s distress in this case is likely due to the fluttering noise made by the insect’s wings. Drowning the insect in olive oil (ideally warmed first by placing the bottle in warm water) or topical lignocaine is the quickest way.
What about nasal foreign bodies – how can they present and how are they best removed?
- What causes otitis externa?
- Why are Aboriginal children more susceptible and in this case how do swimming pools affect rate of disease?
- What types of organisms are responsible?
- Are swabs usually helpful with treatment?
- What is the usual first line treatment?
- Should Thomas stop his swimming?
What causes otitis externa?
Trauma - irritation of skin in ear from scratching, using ear buds and dirty water left in ear with difficulty draining. So to prevent otitis externa, stop scratching and don’t use ear buds.
Why are Aboriginal children more susceptible and in this case how do swimming pools affect rate of disease?
Issues of general hygiene, not blowing nose, prevalence of flies in communities and chronic perforated ear drums due to chronic suppurative otitis media. Allowing bath water to chronically get in ears as babies (smaller canals with poor drainage as babies). Community swimming pools decrease incidence due to improved nose washing and cleanliness.
- What preventative treatment options are there and what are their costs?
- Are oral antibiotics indicated?Why or why not?
- What is cholesteatoma and mastoiditis? How common is this in a Perth type population?
Outline your Initial Assessment of an Upper Airway Obstruction.
- What should you first determine and how?
- What is the 2nd thing you need to determine & how?
Outline how you might manage a patient with an upper airway obstruction.
- 4 Initial?
- 3 Relative contraindications for oral intubation?
What is the difference between Stridor & Stertor?
- Pitch?
- Level of obstruction?
- Inspiratory vs. Expiratory?
- Emergency?
- Stridor = obstruction at the level of the vocal cords - always an emergency
List 8 Causes of Infection/obstruction of the Airway.
- How would you manage angiodema causing obstruction of the airway?
- Angioedema
- Vincent’s Angina
- Tonsillitis
- Quincy
- Epiglottitis
- Croup
- Foreign body aspiration
- Tracheostomy blockage
What is Ludwig’s Angina?
- Usual cause?
- Management?
- Pathophysiology?
- 7 Risk factors?
Ludwig angina is a rapidly progressive gangrenous bilateral cellulitis of the submandibular space with risk of life-threatening airway compromise.
Ludwig’s Angina
- Causes?
- Risk Factors?
- Complications?
- Signs & Symptoms?
- Diagnosis?
- Treatment: Medical, Surgical?
Ludwig’s Angina
- 14 Clinical features?
- 10 features on CT neck & face?
- Prognosis?
- Management?
PROGNOSIS
- high mortality untreated
- mortality ~8% with appropriate therapy
Epiglottitis
- What is it?
- Risk factors?
Epiglottitis = Supra glottitis = above vocal cords
- Usually bacterial infection of epiglottis ( H influenza)
- Airway emergency
- Children- stridor/drooling/shallow breathing/sitting up /head sniffing position. Ill
- Adults – severe throat pain and almost complete dysphagia for liquids
- High index of suspicion
- Lateral x-ray, Thumbprint sign
- Careful examination, fibre optic endoscopy
Epiglottitis
- Pathophysiology?
- 10 Clinical features?
- What sign are you looking for on xray?
Pathophysiology
Bacteria invades tissue (directly or through hematogenous spreading) of the epiglottis and/or surrounding supraglottic structures (i.e., arytenoids, aryepiglottic folds, and vallecula) → supraglottic inflammation and edema → narrowing of the airway → airway obstruction (partial or complete).
Diagnosis of Epiglottitis
- Approach?
- Visualisation of the epiglottis?
Epiglottitis
- Treatment?
Remember - if an adult comes with a sore throat complaining they can’t swallow own saliva as too painful - need to send to ED!
Croup
- What is it?
- Epidemiology?
- Aetiology?
- Pathophysiology?
Croup
* Laryngotacheobronchitis
* Stridor/barking cough/hoarseness
* Viral
* 6months-6 years- 15% children
* Mild-severe- worse at night
* Subglottic (immediately beneath the vocal cords) swelling in cricoid
area ( complete cartilage ring)
* Xray- AP view= Steeple sign
* Humidification/racemic adrenalin nebs/steroids
Croup
- Clinical features?
- Diagnosis?
- Management?
Diagnostics
General principles
- Croup is most commonly diagnosed based on the presence of characteristic clinical features of croup.
- Diagnostic studies are not routinely required; do not delay treatment in unstable patients to obtain studies.
- Indications for diagnostic studies include: Atypical presentation or diagnostic uncertainty, to rule out differential diagnoses of stridor, Severe disease, Recurrent episodes of croup
Imaging - X-ray chest and neck (anteroposterior and lateral)
- May identify subglottic narrowing on anteroposterior view (steeple sign)
- May show concurrent lower airway involvement
- Steeple sign - not specific to croup; it may also be present with bacterial tracheitis, epiglottitis, and noninfectious etiologies such as thermal injuries and neoplasms.
What is the diagnosis in these images?
Croup
- Causes?
- Risk factors?
- Complications?
- Signs & Symptoms?
- Diagnosis?
- Wesley scoring?
ENT Emergencies - Foreign Body Aspiration
- History?
- Exam?
- Imaging?
ENT Emergencies - Esophageal Foreign Body
- Child vs. Adult?
- Investigations?
ENT Emergencies - Caustic Ingestion
- Child vs. Adult?
- Exam?
- Investigations?
ENT Emergencies - Penetrating Neck Trauma
- Main concerns?
- Investigations?
- Management?
Outline your approach to emergency tracheostomy management?
When a patient presents saying they feel “dizzy” - what do you need to clarify?
“Doc, I am feeling dizzy”
Differentiate Dizziness
1. Vertigo- sensation of spinning or rotation
OR
2. Disequilibrium
3. Lightheadness
4. Pre syncope/faintheaded
Explain the Anatomy of Balance: Which structures are involved?
Anatomy of Balance
- Eyes
- Ears: vestibulocochlear nerve, hair cells & fluid in semicircular canals
- Joints: stretch & proprioceptors
What are your differentials for a patient presenting with dizziness described as disequilibrium?
What are your differentials for a patient presenting with dizziness described as pre-syncope?
What are your differentials for a patient presenting with dizziness described as lightheadedness?
What is Vertigo?
- 5 Causes?
-
Vertigo = A false sense of motion or spinning.
1. Benign Paroxysmal Positional Vertigo (BPPV)
2. Vestibular Neuronitis or Labyrinthitis (Vestibular neuronitis = vertigo only vs. Labyrnthitis = hearing loss & vertigo - both nerves out)
3. Meniere’s Disease
4. Vestibular Migraine
5. Cerebrovascular Disease (TIA or stroke)
BPPV: Benign Positional Paroxysmal Vertigo
- What is it?
- Definition?
- Classification?
Definition: Episodic vertigo triggered by certain changes in the position of the head.
- Paroxysmal = at its peak at onset then subsides
BPPV: Benign Positional Paroxysmal Vertigo
- Epidemiology: prevalence, sex, age?
- Aetiology?
- Risk factors?
- Pathophysiology?
Epidemiology
- Prevalence: BPPV is the most common type of peripheral vestibular vertigo with a prevalence of ∼ 2%. BPPV is the underlying cause in approx. 40% of geriatric patients presenting with dizziness.
- Sex: ♀ > ♂
- Age: peak incidence between 50–60 years
BPPV: Benign Positional Paroxysmal Vertigo
- Clinical features?
Classic Symptoms
1. Looking up, High shelf, Washing line
2. Bending down, Washing machine/bowls
3. Lasts 20-30 seconds
4. Paroxysmal vertigo
5. Lying down/turning over/Sitting up
BPPV: Benign Positional Paroxysmal Vertigo
- Medical treatment?
BPPV: Benign Positional Paroxysmal Vertigo
- Manoeuvre for diagnosis?
- Manoeuvre for treatment?
BPPV
- Treat on site with canalith repositioning manoeuvre
- Modified Epley– posterior / superior
- BBQ roll – horizontal
- Patients may need to remain upright for 24 hours post procedure to prevent recurrence
- 80% success rate with Epley Manoeuvre first time, 100% success rate with repeated treatments
- Recurrence rate is about 15% per year
Differentials for Vertigo: Vestibular Neuronitis
- What is it?
- Definition?
Vestibular Neuronitis
* Thought to be viral
* Sudden onset
* Early hours of morning
* Awake vertigo/vomiting
* Days to weeks to recover gradually
* Initial Rx symptomatic
* Later avoid vestibular suppressants
* Vestibular rehabilitation
Differentials for Vertigo: Vestibular Neuronitis
- Clinical features?
- Epidemiology?
- Aetiology?
Epidemiology
- Second most common cause of vertigo (after BPPV)
- Age: peak incidence at 30–50 years of age
- Sex: ♀ = ♂
Aetiology
- Idiopathic inflammation of the vestibular nerve
- Tends to occur more often after upper airway infections
Differentials for Vertigo:
Labyrinthitis
- What is it?
- Pathology & Causes?
- Risk factors?
- Complications?
- Signs & Symptoms?
- Management?
Labyrinthitis
- Definition: inflammation of the inner ear, notably the membranous labyrinth
- Epidemiology: Peak incidence = 30–50 years of age, ♀ > ♂ (1,5:1)
Aetiology
- Infectious: viruses, bacteria, fungi
- Viral labyrinthitis - Congenital: rubella, cytomegalovirus
- Acquired: mumps, measles, herpes simplex virus, influenza, HIV, varicella zoster virus (see “Herpes zoster oticus”)
- Bacterial labyrinthitis: typically a complication of acute otitis media, meningitis, mastoiditis, syphilis, or cholesteatoma
- Autoimmune systemic diseases (e.g., due to vasculitis)
- Other: head trauma, vascular ischemia, ototoxic drugs (e.g., aminoglycosides)
Differentials for Vertigo: Meniere’s disease
- Causes?
- Clinical features?
- 3 Stages?
- Treatment?
Meniere’s disease- diagnosis of exclusion
* Unknown aetiology
* Endolymphatic hydrops
* Sudden attacks with nausea/vomiting
* Last minutes to hours, then balance returns but may experience
cluster of attacks over days
* Reasonably well in between attacks but “washed out”
* Typical attacks Tinnitus/fluctuating hearing loss/vertigo/fullness in
ears ( unilateral in most cases)
* Precipitated by stress/anxiety/diet
3 stages of Meniere’s disease
- Stage 1: Severe vertigo and vomiting- tinnitus and fullness ears not always so noticeable
- Stage 2: Typical symptoms
- Stage 3: Burnt out Meniere’s, Permanent hearing loss, tinnitus, balance loss – disequilibrium, but
fewer vertigo attacks
Differentials for Vertigo
- Vestibular migraine/migraine associated vertigo?
- TIA’s and CVAs?
TIA’s and CVA’s
* Involving vertebrobasilar system
* Sudden onset and sudden recovery vertigo- TIA
* CVA- vertigo/ataxia
What is the definition of “dizziness”?
- Outline the balance control systems.
Dizziness means many different things to each patient ranging from disequilibrium, light-headedness, feeling off balance, woozy, shaky, ‘not quite right’ or ‘not myself’ to a vertigo
sensation of gentle swaying and ground moving upwards, the world spinning around or violent incapacitating rotatory vortex feelings.
Outline the history and examination you would obtain from a patient presenting with “dizziness”.
Examination
This will exclude systemic, cardiovascular and neurologic, ophthalmic and vestibulospinal examination. Otoscopy, tuning fork and basic balance tests like the Dix Hallpike (For BBPV), Romberg’s and Unterbergers will confirm or exclude otologic causes.
Where are the 3 tonsils in the human body?
- Pharyngeal
- Lingual
- Nasopharynx- post nasal space- ADENOID
What does the image show?
Normal lingual tonsils
Tonsillitis
- 3 Types?
- What is it?
- Most common pathogen? Age?
- What does the image show?
Tonsillitis
* Acute, recurrent, chronic
* Mainly viral under 3 years
* Bacterial 5-15 years
* The herpes simplex virus, Streptococcus pyogenes (GABHS), Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis.
* Bacteria cause 15-30% of pharyngotonsillitis cases; GABHS is
the cause for most bacterial tonsillitis. (i.e., “strep throat”).
- Look for symmetry
- Enlarged: infection/abscess, tumour (squamous cell carcinoma, lymphoma), congenital asymmetry
- Most common = group A beta haemolytic streptococcus
Image = Acute follicular tonsillitis (not a Quincy as that is usually unilateral) - cannot tell if viral or bacterial
What is the diagnosis in the image?
- What is trismus?
Image = Infectious mononucleosis (Epstein Barr virus) glandular fever = kissing disease = look for raised WCC - then specifically for monocytes (bacterial = neutrophils vs. viral = lymphocytes) - mono spot test = not that reliable (lots of false positives) - can do EBV serology & white cell differentiation instead
Trismus = inability to open jaw 2 fingers width (pts fingers)
Acute tonsillitis and pharyngitis
- Summary?
- Epidemiology: Peak incidence? Peak season?
- Aetiology?
Epidemiology
Peak incidence
- Acute viral tonsillopharyngitis: children < 5 years and young adults
- Acute GAS tonsillopharyngitis: children aged 5–15 years; rare in children aged < 2 years
- Peak season: Acute GAS tonsillopharyngitis most commonly occurs in winter and spring.
What are the clinical features of acute bacterial vs. acute viral tonsillopharyngitis?
- 8 Reg flags for tonsillopharyngitis?
Acute viral tonsillopharyngitis
1. Cough
Coryza
Rhinorrhea
Oral ulcers, anterior stomatitis
Conjunctivitis
Diarrhea
Absence of fever
Outline an approach to the diagnosis of acute tonsillitis.
- Routine testing for GAS is not recommended for children < 3 years old, as their prevalence of GAS pharyngitis and risk of developing subsequent acute rheumatic fever are both low. Consider testing only if specific risk factors (e.g., close household contact) are present.
- Testing for GAS infection is not recommended in patients with clinical features that strongly suggest acute viral tonsillopharyngitis.
Diagnosis of Acute Tonsillitis
- Rapid Strep Test?
- Throat culture?
- Additional laboratory tests?
- Imaging?
Outline a Clinical Scoring System used to estimate the likelihood of acute bacterial pharyngitis based on clinical features alone.
Modified Centor Score
- Rationale: Estimate the likelihood of acute bacterial pharyngitis based on clinical features alone.
- Clinical applications: Identifying patients with a low likelihood of GAS infection, thereby minimizing unnecessary diagnostic tests and antibiotic therapy. The use of scoring systems to identify patients with a high likelihood of bacterial pharyngitis in order to treat empirically without testing is controversial.
Treatment of Acute Tonsillitis
- Approach?
- Supportive care? (4)
- Antibiotic choice?
Supportive care
1. Ensure adequate hydration.
2. Consider household remedies such as salt-water gargles.
3. Consider oral topical local anesthetics: e.g., benzocaine lozenges, phenol throat sprays, compounded mouthwash.
4. Analgesics and antipyretics [2]
NOTE:
- Avoid aspirin in children due to the risk of Reye syndrome.
- Amoxicillin therapy in patients with infectious mononucleosis can trigger a maculopapular and/or morbilliform rash. Reserve antibiotics for patients with confirmed bacterial tonsillopharyngitis (e.g., positive rapid strep test or throat culture), whenever possible.
Tonsillectomy
- 6 Indications?
- 2 Types of procedures?
- 6 Complications?
Tonsillitis - Indications for surgery
Take into account natural history of tonsillitis in children
1. Unilateral enlarged tonsil/Cancer
2. Recurrent infection
3. 7 episodes/year 5 episodes/2 years 3 episodes/3 years
4. Airway obstruction/sleep apnoea
5. Quincy > 2
6. Complicated tonsillitis- rheumatic fever
Tonsillectomy complications
1. Pain
2. Dehydration
3. Bleeding Primary and secondary - Mx: get patient to gargle ice cold water, then if it hasn’t stopped get topical LA/adrenaline or cophenylcaine spray, or adrenaline soaked gauze applied pressure, sitting up but not leaning forwards
4. Infection
5. Taste
6. Referred otalgia
List 7 Suppurative complications & 3 Non-suppurative complications of tonsillitis.
- Antibiotic therapy for GAS pharyngitis can decrease the risk of rheumatic fever but does not affect the risk of PSGN.
- Streptococcus “ph”yogenes is the most common cause of bacterial pharyngitis, which can result in rheumatic “phever” and poststreptococcal glomerulonephritis.
Quinsy/Peritonsillar abscess
- What is it?
- Epidemiology?
- Aetiology?
- Clinical features?
- Diagnostics?
Peritonsillar abscess, also known as quinsy, is the most common deep neck infection.
- Definition: Peritonsillar cellulitis/abscess (= SWELLING NEXT TO TONSIL)
- Presentation: Fever, hot potato voice, unilateral enlarged tonsil shifted to midline. Uvula displaced, trismus, drooling saliva
- Treatment: I.V. fluid hydration, analgesia, antibiotics, steroids, needle aspiration/incision and drainage
- Indications for tonsillectomy > 2 episodes or bilateral with airway obstruction
Quinsy/Peritonsillar abscess
- Treatment?
- Complications?
What is the diagnosis?
Quinsy on LHS
What is the diagnosis?
- Benign tonsillar pathology = calcified food & debris = tonsillar stone/lith
- Benign Tonsillar Pathology
tonsil stones- tonsilloliths = halitosis
What grade are these tonsils?
- Image 5 = upper airway obstruction = touching - grade 4
- Grade 0 = not visible
- Grade 1 = tonsils fill 25% of airway
- Grade 2 = 50%
- Grade 3 = 75%
- Grade 4 = Kissing tonsils that meet in the midline
- Grade is only important if the patient is getting symptoms
Clinical features of an upper airway obstruction - OSA?
Upper airway obstruction
* Anatomically multi level
* Nose-post nasal space– tongue pharynx- neck
* Snoring
* Sleep apnoea/daytime somnolence/poor concentration
* Children- growth delays/enuresis
* Signs of sleep apnoea in a child (Adenoids/enlarged tonsils: snoring loudly, mouth breathing, decreased growth, poor quality of sleep, enuresis, behaviour issues & learning/concentration at schoool
* Growth delays in children with OSA as growth hormone is secreted in the very deep phases of sleep
* Commonly due to enlarged adenoids/tonsils in kids
If you saw this post-tonsillectomy, would you be concerned?
= NO - Post-operative slough - not an infection, just a normal post-operative appearance - can give Abx but it would be empirical - 1st = fluids & analgesia so pt can eat/swallow
Head & Neck Cancers
- How common worldwide?
- Incidence in Australia?
- Impact of smoking?
- Aetiology?
- Prevention?
Head and Neck cancers
* 6th commonest cancer worldwide
* Over 3000 new cases in Australia 2011
* Smoking has decreased 20-30% worldwide- incidence of H&N cancer
remained same- some groups have increased
* Trebling incidence oropharynx Cancer (base of tongue/tonsils)
* HPV types 16 and 18 (same as cervical cancer)
* Orogenital contact
* Gardasil vaccination
Retromolar trigone (coffins corner)
SCC R lateral border tongue - SCC - >3-4 weeks non-healing ulcer = sinister pathologies
SCC of R palatine tonsil - tonsillar malignancy - unilateral mass should always concern you = squamous cell carcinoma
Lymphoma
- Head and Neck tumours: Friedland’s Rule of 80’s?
- Head and Neck Cancers: Causes FRIEDLANDS 6 ‘S’?
How has the paradigm of head & neck cancer shifted?
- Diagnosis approach?
- Classification?
Diagnosis
- History (risk factors/associated symptoms)
- Examination (full head and neck and systemic exam)
- Investigations
1. FNA of neck nodes (Do not perform biopsy neck glands unless FNA unhelpful or suggestive Lymphoma)
2. CT scan/MRI/PET
3. Biopsy aero digestive tract
4. Check HPV status p16
Head & Neck Cancers
- Treatment/Management?
- Who is involved in the MDT?
Treatment/Management
- MDT
- GOAL - Organ preservation
- Counselling patient/family/informed consent
- Radiotherapy
- Surgery
- Chemo
- Palliation
Why is Snoring a concern?
- 2 Screening Questionnaries?
- Management?
- Surgery?
Snoring
* Obstructive sleep apnoea syndrome (OSAS) = repetitive apnoea’s and symptoms of sleep disturbance
* Important public health issue- cardiovascular complications/road
traffic accidents
* Common in adults and children
* Apnoea= 10 seconds or > of no oxygen airflow
* Hypopnoea = lesser reduction in airflow
* AHI index 0-5 (normal), 5-15(mild), 15-25 (moderate), >25 (severe)
What is the clinical relevance of smell?
Clinical relevance of Smell
- Pathway to olfaction - olfactory nose exits brain via cribriform plate at base of skull
- “Doc I cannot smell”
- Causes of anosmia /hyposmia /phantosmia - The olfactory loss may be complete (anosmia) or partial (hyposmia). It may be associated with perceived odour distortions (dysosmia) that are related to actual environmental odorant stimulation (parosmia) or occur spontaneously (phantosmia).
- Dangers
- Taste
- NOTE: Covid attacks angiontension converting enzyme receptor 2 in lungs, throat & ACE receptors in the nose (especially cribriform plate)
Epistaxis
- Aetiology: Local factors?
- What are Friedland’s Rule of 80’s in regards to Epistaxis?
- Aetiology: Systemic factors?
Friedland’s Rule of 80’s for Epistaxis
- 80% people have had at least one episode in their lifetime
- 80% of nose bleeds are anterior
- 80% people do not seek medical attention
- 80% managed as outpatient
- 80% of epistaxis presenting to hospital are in teh elderly
- 80% poorly managed
- 80% trauma/coagulopathy related
Disclaimer: ABOVE FACTS ACCURATE 80% of the time
- Causes of epistaxis - cocaine stiffing = septal perforation
Epistaxis
- Why do we have nosebleeds?
- Explain the Vasculature?
Why bleeding from the nose?
- Vascular organ secondary to incredible heating/humidification
- Vasculature runs just under mucosa (not squamous)
- Arterial to venous anastomoses
- ICA and ECA blood flow
Case study: Epistaxis Management in the ED
- 72 year old man
- Hypertensive on Clopidrigel and Warfarin
- Chronic renal failure
- Bleeding for 4 hours mainly left side nose and spitting up blood
ABCDE Approach or Hx/Exam etc if stable
- Chronic renal failure = increased bleeding risk (hypertensive and ↑ Bleeding tendency caused by abnormal platelet adhesion and aggregation)
Nasal Fracture
- Diagnosis?
- Exam - what must you exclude?
- Management?
A patient has sustained facial trauma and is suspected to have a nasal fracture - what must you exclude before sending them home?
With any nasal fracture - Look inside the nose to make sure there is not a septal haematoma - this will become an abscess and erode through the septum causing perforation if left.
What is the diagnosis & how should she be managed?
Allergic Rhinitis
* Extremely common
* Children & adults
* Seasonal (Intermittent) or Permanent (all year)
* Inhaled allergies- grass/tree pollens/dust mites/animal dander
* Ingested(food allergies) milk/gluten/wheat/peanuts
* Sensitivities to smoke/perfume/deoderants
Clinical vignette - the lady has atopia (allergic rhinitis & allergic lungs/asthma) - when you treat the nose, you also need to treat the lungs
Allergic Rhinitis
- Aetiology & Risk Factors?
- Epidemiology?
- Clinical features?
Allergic Rhinitis
Epidemiology
- Most common form of rhinitis (affects 1 in 6 Americans)
- ♂ > ♀ in patients ≤ 21 years
- ♀ > ♂ in patients > 21 years
Allergic Rhinitis
- 6 Symptoms?
- 6 Clinical signs?
Allergic rhinitis symptoms (Blocker or a Runner)
1. Itchy nose/eyes
2. Sneezing (hay fever)
3. Watery nose – rhinorrhoea or post nasal drip
4. Blocked nose, nasal speech, decreased smell
5. Headache
6. Fatigue
- Allergic shiners = black rings under eyes & Allergic crease from rubbing nose
What is this?
= Enlarged edamatous turbinate in allergic rhinitis
Allergic Rhinitis - Diagnosis
- Approach?
- Allergen testing?
- Bloods?
Allergic rhinitis Management - Diagnosis
* History/examination
* Investigations
1. Skin prick allergen testing
2. RAST inhaled screen
3. IgE
Blood tests
Indications
1. Presence of contraindications for skin tests
2. Patient preference
Method: immunoassays to identifiy allergen-specific IgE in the serum (allergen-specific IgE test).
- Blood tests for allergen sensitization are preferred if there is concern for anaphylaxis with skin testing.
- In asymptomatic individuals, a positive skin or blood test for a particular allergen is not diagnostic of an allergy to that allergen.
Allergic Rhinitis - Treatment
- Pharmacotherapy?
- Environmental modifications?
- Allergen immunotherapy?
- Surgery?
- 3 Differential diagnoses?
Treatment
1. Topical nasal steroids/saline douches/non sedating antihistamines - oral & nasal sprays
2. Desensitisation/ avoidance/ environmental control
3. SCIT = specific cutaneous immunotherapy or SLIT = specific sublingual immunotherapy
NOTE - - Nasonex nasal spray = 10-14 days before it starts to work - need to continue for 4-6 weeks
Differential diagnoses
1. Nonallergic rhinitis -
2. Sinusitis
3. Other causes of nasal congestion (e.g., nasal polyps, adenoid hypertrophy)
Sinusitis
- 5 Causes?
- Risk factors?
- Complications?
- Signs & Symptoms?
- Diagnosis?
- Treatment?
Sinusitis - Causes
* Infection: viral/bacterial/fungal
* Allergy
* Inflammatory
* Neoplastic
* Traumatic
Sinusitis
- How many sinuses do we have?
- 4 Classifications by duration?
Classification of Sinusitis by
Duration of Disease
- Acute– up to 4 weeks
- Recurrent (acute) – at least 4 episodes per year, with complete resolution between episodes
- Chronic– ≥12 weeks
- Acute exacerbations of chronic – sudden worsening of chronic, return to baseline after treatment
Sinusitis
- Epidemiology?
- Clinical presentation?
- Pathophysiology?
- Aetiology & Risk factors?
Pathophysiology
- Sinusitis is triggered by three factors: obstruction of sinus drainage pathways (sinus ostia) due to mucosal edema, ciliary impairment, and altered mucus quantity and quality → stasis of secretions inside the sinuses → proliferation of various pathogens → sinusitis
- Recurrent, untreated/complicated acute sinusitis may lead to chronic sinusitis.
Sinusitis
- How can you differentiate between viral and bacterial?
- Outline the management of Sinusitis?
- List 10 complications of sinusitis?
Complications of Sinusitis
Sinus - Pain, pressure, anosmia, nasal obstruction
Extra sinus- Eye/Brain
Eye - cellulitis/ chemosis/ abscess/ proptosis/ blindness
Brain - Meningitis/extradural abscess/brain abscess/cavernous sinus thrombosis
Guidelines definitions of:
- Acute rhinosinusitis?
- Chronic rhinosinusitis?
- Recurrent acute rhinosinusitis?
Sinusitis - Clinical Features
- Acute?
- Acute subtypes: Viral vs. Bacterial?
- Chronic?
- Chronic subtypes?
Acute - Subtypes
Acute viral rhinosinusitis
- May occur with acute otitis media
- May manifest with other symptoms of URTI (e.g., sore throat, cough)
Acute bacterial rhinosinusitis
- Severe symptoms (including fever > 39°C, facial pain, purulent nasal discharge)
- Symptoms typically remain stable or improve for 5–6 days and then worsen (double worsening).
Diagnosis of Sinusitis
- General principles?
- Direct visualisation?
- Imaging?
Direct visualization
- Indications: evaluation of complicated rhinosinusitis, recurrent ARS, or CRS
- Modalities: Nasal endoscopy (preferred) + Anterior rhinoscopy
Findings
- Signs of rhinosinusitis: mucosal erythema, edema, osteomeatal blockage with purulent drainage, Detection of structural abnormalities or masses, if present
- Signs of fungal rhinosinusitis: necrosis, Pale or dark necrotic mucosa with crusting or ulcers indicates acute invasive fungal rhinosinusitis, which is a medical emergency.
Treatment of Sinusitis
- Approach?
- Symptomatic treatment? (4)
- Antibiotics?
Symptomatic treatment - The following options may be offered to all patients with rhinosinusitis.
1. Nasal saline irrigation
2. Oral analgesics, e.g., ibuprofen or acetaminophen
3. Intranasal steroids, e.g., mometasone
4. Decongestants, e.g., oxymetazoline
Treatment of Sinusitis
- Antibiotic regime in Antibiotic treatment in acute bacterial rhinosinusitis (ABRS)?
- Indications for surgery? (3)
- Objectives of surgery? (4)
Surgery
Indications
1. Evidence of structural abnormalities: e.g., polyps, masses, or anatomical obstructions
2. Treatment failure or complications of rhinosinusitis
3. Acute invasive fungal rhinosinusitis
Objective
1. Improving aeration through sinus opening and drainage
2. Debridement of necrotic tissue or abscess drainage
3. Correction/removal of anatomic obstructions
4. Obtaining intraoperative cultures and biopsy for histopathology if the diagnosis remains unclear
Complications of Sinusitis
- Local spread?
- Spread to the orbit?
- Intracranial spread?
- Systemic complications?
Orbital and intracranial necrotic spread is especially common in invasive fungal sinusitis.
Nasal polyps
- Definition?
- 3 Risk factors?
- 4 Clinical features?
- Choanal polyp?
- Diagnostics?
- 1 Differential?
- Treatment?
Fungal Rhinosinusitis
- Definition?
- Classified by?
- 2 Risk factors?
- Clinical features?
- Diagnostics?
- Management?
Outline the anatomy of the ear/hearing.
- Degrees of Hearing loss?
Degrees of Hearing Loss
- Normal: 0 - 25 hearing range for frequency
- Mild: 25-50
- Moderate: 50-70
- Severe: 70-90
- Profound: 90-110
Where do familiar sounds sit on the audiogram?
List 6 causes of Conductive Hearing Loss?
- Visualisation on audiogram?
Conductive (Air conduction)
* Ext ear canal
1. Wax/otitis externa
* Middle ear-
2. Perforation
3. Fluid
4. Ossicular dislocation/fixation
5. Otosclerosis
6. Cholesteatoma
List 7 Causes of Sensorineural hearing loss?
- How does it appear on an audiogram?
Sensorineural hearing loss
1. Aging, i.e., presbycusis
2. Idiopathic (e.g., Meniere disease)
3. Infectious (e.g., viral cochleitis, meningitis, otosyphillis)
4. Traumatic: (e.g., noise-induced hearing loss, head injury, inner ear barotrauma)
5. Neurologic (e.g., acoustic neuroma, stroke, multiple sclerosis)
6. Autoimmune (e.g., vasculitis)
7. Ototoxic drugs (e.g., aminoglycosides, loop diuretics)
The differential diagnoses listed here are not exhaustive.
Sensorineural Hearing Loss
- What are the 2 most common causes of Sensorineural Hearing loss (bone conduction)?
- When is noise too loud?
- 9 Common Medications that can cause Sensorineural HL?
- 1 type of tumour? Clinical red flag?
- What is Menieres?
Noise exposure
- 2015 WHO stats -1.1 billion teenagers/young adults at risk due to unsafe – audio devices/sound levels at gyms/sports events/concerts/bars etc
- 1/3rd worlds population has a degree of hearing loss
- Orchestral brass band- jet engine
- Occupational
When is noise too loud ??
- When you need to shout to be heard
- When you can hear audio/music from their ear buds
- When you can hear music from outside their car
- When you get a “threshold shift”- blocked ear after loud noise/music
exposure
Sudden Sensorineural hearing loss (SSNHL)
- Should you be concerned?
- Epidemiology?
- Aetiology?
- Clinical features?
- Diagnostics?
- Treatment?
- Prognosis
Sudden Sensorineural hearing loss (SSNHL)
an ent emergency !!!
- 1 in 10 000 people
- Aetiology unknown- thought to be HSV/vascular .
- Asymptomatic- complain of a blocked ear or tinnitus/ringing in ear
- May be permanent
- 30-50% may recover spontaneously
- Immediate steroids 1mg/kg/day for 14 days (50mg prednisolone) Orally.
- Some trans tympanic injection if no response
- Antiviral agents debatable
Explain the Impact of Hearing Loss on Speech Understanding?
- 7 Signs of Hearing Loss?
- 5 Effects of Untreated Hearing Loss?
Signs of Hearing Loss
1. People around you seem to mumble
2. You often ask others to repeat themselves
3. You can hear but cannot understand
4. Difficulty following conversations in background noise or when in groups
5. Children and women’s voices are difficult to hear
6. Need to turn up the TV or radio louder
7. Cannot hear high pitched sounds such as birds, crickets and bells
List 8 reasons why people don’t get help for their hearing loss?
- Explain the link between cognition and hearing loss?
- Explain how hearing loss often develops?
Why Doesn’t Everyone Get Help?
1. Unaware of hearing loss
2. Denial/blame others for hearing loss
3. Lack of desire to interface with others
4. Negative stories
5. Vanity
6. Prior problems with other hearing aids
7. Misinformed – can’t be helped because of “nerve loss”
8. Cost $$
How is hearing loss managed? (7)
- If there is hearing loss in both ears, you should wear two hearing aids. Why? (4)
- List 3 Current Current Government Funding Initiatives and Programs for hearing loss management?
Management of hearing loss
1. Recognition
2. Testing
3. Treat reversible causes e.g. wax/OME/ perforated ear drum
4. Behavioural strategies
5. Noise protection strategies
6. Hearing aid trials
7. Surgery
If there is hearing loss in both ears, you should wear two hearing aids. Why?
1. Better sound sensitivity – “Stereo” quality
2. Improved ability to locate sound
3. Easier to understand speech in noise
4. Risk of “auditory deprivation” is reduced
Treatment of Hearing Loss
- Hearing Aids?
- Cochlear Implants?
- Surgery: Middle ear? Mastoid bone? Cochlear?
Treatment of Hearing Loss
- Treatment depends on the underlying etiology of the hearing loss.
- For irreversible causes, hearing devices such as hearing aids (for conductive hearing loss) or cochlear implants (for cochlear dysfunction) can be considered.
Interpret this audiogram?
Possible causes?
= Conductive hearing loss
The diagram shows a difference of 30dB between air and bone conduction in the right ear versus the left ear. These findings are indicative of middle or external ear pathologies, such as otitis media or tympanic membrane perforation.
Diagnosis of Hearing Loss
- 4 Initial Tests?
- 3 Further diagnostic tests?
Initial diagnostic tests
1. Whispered voice test and finger rub test: screening to determine the extent of hearing loss
2. Rinne test and Weber test: to classify hearing loss as conductive or sensorineural
3. Otoscopy: allows for visual assessment of the external ear and tympanic membrane
4. Pneumatic otoscopy: evaluates the mobility of the tympanic membrane (esp. for conductive hearing loss)
Diagnosis of Hearing Loss: Subjective Audiometry
- 2 Types?
- Audiogram: Procedure? Interpretation?
- Speech Audiometry: Procedure? Interpretation?
Speech audiometry
- Procedure: The patient is played increasingly loud words, which should be repeated by the patient. The speech reception threshold is calculated from the level at which a patient can correctly repeat 50% of words.
- Interpretation: Increasing loudness eventually leads to a speech comprehension of 100% in patients with conductive hearing loss, but not in patients with sensorineural hearing loss. Loss of word comprehension is referred to as discrimination loss.
Interpret the audiogram?
= Sensorineural hearing loss
Both ears show a parallel decrease of air and bone conduction in the higher frequencies. This finding indicates cochlear or retrocochlear damage (often seen in presbycusis).
Interpret the Audiogram? Diagnosis?
= Otosclerosis audiogram
- Audiogram of a patient with otosclerosis in the right ear.
- Air conduction is reduced in the affected ear by approx. 35dB. Bone conduction shows a characteristic notched hearing loss at 2000Hz (Carhart notch). These are characteristic findings of otosclerosis, a condition that causes conductive hearing loss due to the fixation of the stapes to the oval window.
Interpret the Audiogram?
Audiogram in presbycusis
Frequency-dependent auditory threshold, measured via air and bone conduction: In presbycusis, patients struggle to hear the higher frequencies in both air and bone conduction.
Interpret the audiogram?
Audiogram in noise-induced hearing loss
- Frequency-dependent auditory threshold, measured via air and bone conduction
- In noise-induced hearing loss, hearing is most impaired at frequencies of 4000 Hz in both bone and air conduction.
Diagnosis of Hearing Loss: Objective audiometry
- Tympanometry: Description? Procedure? Interpretation?
- Otoacoustic emissions (OAE): Description? 2 Types? Measurement?
How does Tympanometry work?
Tympanometry
- Tympanometry is an objective hearing test that measures the compliance of the tympanic membrane.
- The probe creates an air-tight seal between the external auditory canal and the environment. A tone is generated and the sound reflected from the tympanic membrane is measured. Middle ear pathology results in changes to the compliance of the tympanic membrane and, thus, changes in the reflected sound. A pressure pump varies the pressure inside the sealed-off external auditory canal during testing, allowing measurement of how compliance varies with pressure.
Interpret the 3 Typanograms?
Type A: normal tympanogram with a clear compliance peak near 0 daPa
Type B: flattened compliance curve with no clear peak; most commonly found in otitis media with effusion
Type C: compliance peak is shifted to the negative pressure range, indicating negative pressure in the middle ear (matching negative pressure in the external auditory canal during the test increases compliance)
How are the causes of a blocked ear categorised?
The causes of a blocked ear may be divided into three broad categories:
i) Arising from the ear (Otologic)
ii) arising from other adjacent head and neck structures (Non Otologic)
iii) idiopathic
Otologic Causes of a Blocked Ear
- How are they described?
- 4 Common causes?
- What is otitis externa usually caused by? Why does it cause the sensation of a blocked ear?
- How can trauma lead to a blocked ear?
- What are 5 types of middle ear fluid?
- What is the most significant cause of a blocked ear sensation?
- Symptoms associated with SSNHL?
- Otoscopic findings in SSNHL?
A perforation of the ear drum, barotrauma or haemotympanum due to trauma, sudden shock waves or inadequate equalisation often leads to a blocked ear. A further cause of a conductive hearing loss is ossicular chain disruption following trauma. Middle ear fluid maybe serous, mucoid, glue like, purulent in acute and chronic otitis media and even CSF (following trauma). These conditions leading to a conductive hearing loss are more than often treatable and reversible.
Otologic Causes of a Blocked Ear
- When should treatment for SSNHL be initiated? What is the treatment?Level of evidence?
- Role of anti-virals in SSNHL?
- What is Carbogen? Does it work?
- 3 ototoxic medications?
- Ototoxic medications for example, chemotherapeutic agents (e.g.Cisplatin), anti-inflammatory, and Aminoglycoside antibiotics will affect hearing.
- Rarer causes of sensorineural hearing loss are tumours of the 8th cranial nerve (acoustic neuromas) and brain tumours.
Non-Otologic Causes of a Blocked Ear
- Which joint lies immediately anterior and adjacent to the external ear canal?
- 6 Non-otologic causes of a blocked ear?
- What are the two tiniest ligaments in the body?
- When the ear drum and otologic examination appears normal and the patient is surprisingly
well, what should you be highly suspicious of? Mx?
Summary
When the ear drum and otologic examination appears normal and the patient is surprisingly well, you should have a very index of suspicion of a SSNHL. If you are unable to use tuning forks, refer to an audiologist for an urgent hearing test. You will have a very grateful and relieved patient if you confirm your early diagnosis and institute immediate treatment.
