1
Q
Otoscopy findings in acute otitis media?
A
- bulging tympanic membrane → loss of light reflex
- opacification or erythema of the tympanic membrane
- perforation with purulent otorrhoea
- decreased mobility if using a pneumatic otoscope
2
Q
Management of acute otitis media?
A
> > Usually self-limiting
> > 5-7d amoxicillin, if:
- Symptoms > 4 days / not improving
- Systemically unwell but not requiring admission
- Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
- Younger than 2 years with bilateral otitis media
- Otitis media with perforation and/or discharge in the canal
3
Q
Complications of acute otitis media?
A
Common:
- unresolved perforation may develop into chronic suppurative otitis media (perforation of tympanic membrane with otorrhoea for >6 weeks)
- hearing loss
- labyrinthitis
Other:
- mastoiditis
- meningitis
- brain abscess
- facial nerve paralysis
4
Q
Glue ear?
A
// Chronic otitis media with effusion
Build up of fluid behind an intact TM for >3 months
5
Q
Management of glue ear?
A
> > Observation in primary care 6-12w + pure tone audiometry
If referred to secondary care:
- Hearing aids - patients with persistent bilateral symptoms
- Eustachian tube autoinflation
- Surgical; myringotomy with grommet insertion - temporary measure lasting around 12 months
6
Q
Management auricular haematomas?
A
- same-day assessment by ENT
- incision and drainage
7
Q
Clinical features of Bell’s Palsy?
A
> > Unilateral facial paralysis
- Acute onset (within 72 hours)
- Involves forehead and lower parts of face
- Upper facial signs include inability to wrinkle forehead and close eye fully on affected side
- Lower facial signs include loss of nasolabial labial fold, and drooping of mouth, which is more pronounced when patient tries to smile
- Pain in ear and surrounding area
- Loss of taste in anterior tongue
- Hyperacusis (increased sensitivity to noise)
- post-auricular pain (may precede paralysis)
- dry eyes
8
Q
Management of Bell’s Palsy?
A
- <72hrs of symptom onset = prednisolone
- Antivirals considered as adjunct (if severe)
- Artificial tears or ocular lubricants to prevent dry eyes
- Using tape (e.g.micropore) to close the eye overnight
- Wearing sunglasses and avoiding irritants to the eye such as dust
- Supporting nutrition by using straws and a soft diet
> > If eye pain or irritation - referred to ophthalmology for RV (risk of corneal ulceration)
If no signs of recovery seen after 3 weeks of initial symptoms - referral to secondary care
9
Q
Clinical features of a branchial cyst?
A
- unilateral, typically on the left side
- lateral, anterior to the sternocleidomastoid muscle
- slowly enlarging
- smooth, soft, fluctuant
- non-tender
- fistula may be seen
- no movement on swallowing
- no transillumination
10
Q
Management of a branchial cyst?
A
- ultrasound / fine-needle aspiration
- referral to ENT
- Can be treated conservatively or surgically excised
- Antibiotics required for acute infections
11
Q
RF for Cholesteatoma?
A
Cleft palate
12
Q
Clinical features of choleseatoma?
A
- foul-smelling, non-resolving discharge
- hearing loss
- otoscopy - ‘attic crust’ seen in the uppermost part of the ear drum
> > Referred to ENT for consideration of surgical removal
13
Q
Clinical features of chronic rhinosinusitis?
A
- facial pain: typically frontal pressure pain which is worse on bending forward
- nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection
- nasal obstruction: e.g. ‘mouth breathing’
- post-nasal drip: may produce chronic cough
- lasts 12 weeks or longer
14
Q
Management of chronic rhinosinusitis?
A
- avoid allergen
- intranasal corticosteroids
- nasal irrigation with saline solution
15
Q
Management of epistaxis?
A
Initial:
- Ask patient to sit with their torso forward and their mouth open, and breathe through their mouth
- Pinch the cartilaginous (soft) area of the nose firmly for at least 20 minutes
Cautery:
- used initially if source of bleed visible and cautery is tolerated
- use topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
- identify bleeding point and apply silver nitrate stick for 3-10 seconds until it becomes grey-white
- avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.
- dab area clean with cotton bud and apply Naseptin or Muciprocin
Packing:
- used if cautery is not viable or bleeding point cannot be visualised
- anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes
- pack patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions
- examine patient’s mouth and throat for any continuing bleeding, and consider packing other nostril as this increases pressure on septum and offending vessel
- patients should be admitted for observation and review, and to ENT if available
> > Epistaxis that has failed all emergency management
may require sphenopalatine ligation in theatre
16
Q
Management of acute necrotizing ulcerative gingivitis?
A
- refer to dentist, meanwhile:
- oral metronidazole for 3 days
- chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash
- simple analgesia
17
Q
Clinical features of Ludwig’s angina?
A
- neck swelling
- dysphagia
- fever
> > Life-threatening emergency as airway obstruction can occur rapidly as a result
Mx = airway management and IV abx
18
Q
Most common cause of malignant otitis externa?
A
Pseudomonas aeruginosa
19
Q
Diagnosis of malignant otitis externa?
A
CT
20
Q
Management of malignant otitis externa?
A
non-resolving otitis externa with worsening pain should be referred urgently to ENT
Intravenous antibiotics that cover pseudomonal infections
21
Q
Management of mastoiditis?
A
- IV abx - ceftriaxone
- If persistent - surgery to drain the infection (e.g. myringotomy, mastoidectomy)
22
Q
Complications of mastoiditis?
A
- facial nerve palsy
- hearing loss
- meningitis
23
Q
Clinical features of Meniere’s?
A
- recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural)
- a sensation of aural fullness or pressure
- other features include nystagmus and a positive Romberg test
- episodes last minutes to hours
- typically symptoms are unilateral but bilateral symptoms may develop after a number of years
24
Q
Management of Meniere’s?
A
- ENT assessment required to confirm diagnosis
- Patients should inform the DVLA - current advice is to cease driving until satisfactory control of symptoms is achieved
- Acute attacks = buccal or IM prochlorperazine. Admission is sometimes required
- Prevention = betahistine and vestibular rehabilitation exercises
25
Samter's triad?
- asthma
- aspirin sensitivity
- nasal polyposis
26
Management of nasal polyps?
- all patients with suspected nasal polyps should be referred to ENT for a full examination
- topical corticosteroids shrink polyp size
27
Management for nasopharyngeal carcinoma?
Radiotherapy first line
28
Clinical features of nasopharyngeal carcinoma?
- Squamous cell carcinoma of the nasopharynx
- Rare in most parts of the world, apart from individuals from Southern China
- Associated with Epstein Barr virus infection
- Cervical lymphadenopathy
- Otalgia
- Unilateral serous otitis media
- Nasal obstruction, discharge and/ or epistaxis
- Cranial nerve palsies e.g. III-VI
29
Management of otitis externa?
*Initial management:*
- topical antibiotic or a combined topical antibiotic with a steroid
- if tympanic membrane perforated aminoglycosides are traditionally not used*
- if there is canal debris then consider removal
- if the canal is extensively swollen then an ear wick is sometimes inserted
*Second-line options:*
- consider contact dermatitis secondary to neomycin
- oral antibiotics (flucloxacillin) if the infection is spreading
- taking a swab inside the ear canal
- empirical use of an antifungal agent
>>If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.
30
Clinical features of osteosclerosis?
- Progressive conductive deafness
- Autosomal dominant, typically affects young adults
- tinnitus
- majority of patients will have a normal tympanic membrane
10% of patients may have a 'flamingo tinge', caused by hyperaemia
- positive family history
>> Management - hearing aid, stapedectomy
31
Most common tumour of the parotid gland?
Pleomorphic adenoma
32
Clinical features of pleomorphic adenoma?
- Gradual onset, painless unilateral swelling of the parotid gland
- Typically movable on examination rather than fixed
- Management = surgical excision
33
Haemorrhage following tonsillectomy?
>>All post-tonsillectomy haemorrhages should be assessed by ENT.
- Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.
- Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery.
34
Clinical features of Ramsey-Hunt syndrome?
- auricular pain is often the first feature
- facial nerve palsy
- vesicular rash around the ear
- other features include vertigo and tinnitus
- otoscopy - vesicles on tympanic membrane
>>oral aciclovir and corticosteroids
35
Causes of Gingival hyperplasia?
phenytoin, ciclosporin, CCBs and AML
36
Clinical features of vestibular neuritis?
- vertigo
- imbalance
- nystagmus
- NO hearing loss / tinnitus
37
Management of vestibular neurotos?
- buccal or IM prochlorperazine to provide rapid relief for severe cases
- short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) for less severe cases
- vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms (>1wk)
38
Clinical features of viral labyrinthitis?
- vertigo
- hearing loss
- tinnitus
- spontaneous unidirectional horizontal nystagmus towards the unaffected side
39
Management of viral labyrinthitis?
- episodes are usually self-limiting
- prochlorperazine or antihistamines may help reduce the sensation of dizziness
40
Management of SSNHL?
>>Urgent referral to ENT
High dose oral corticosteroids
41
YEAR 6
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