ENT

Question 1

Otitis media

Answer 1

Infection of ear metween tympanic membrane + cochlea/vestibular apparatus.

Common site of infection in children as bacteria from back of throat can enter through eustachian tube.

Oft preceeded by viral URTI.

Question 2

Bacterial causes of otitis media

Answer 2

STREP PNEUMONIA = most common (commonly causes rhino-sinusitis, tonsillitis)

Others:

• Haem influenza
• Moraxella catarrhalis
• Staph aureus

Question 3

Otitis media presentation

Answer 3

• EAR PAIN + REDUCED HEARING (usually unilateral)

Fever, cough, coryza, sore throat, malaise
- very non-specific Sx esp in young kids

Can cause BALANCE ISSUES + VERTIGO if affecting vestibular system

If typanic membrane perforates - may get DISCHARGE

Question 4

Examination findings from otoscopy in healthy ear

Answer 4

Tympanic membrane - ‘Pearly-grey’, translucent + slightly shiny
- cone of reflected light
- should be able to see malleus through membrane

Question 5

Examination findings in otitis media

Answer 5

Red, bulging, inflamed membrane if acute

may see discharge + hole

Question 6

Otitis media management

Answer 6

Usually self resolving -> SIMPLE ANALGESIA for pain/fever

Antibiotics oft not recommended, but consider if:

• SIGNIFICANT CO-MORB (systemically unwell, immunocompromised)
• Kids < 2 YEAR with BILATERAL infection
• OTORRHOEA (discharge)

Consider after 3 days if not improving/worsening without antibiotics.

1st line = AMOXICILLIN for 5 DAYS
2nd = macrolides (erythro/clarithro)

SAFTY NET

Question 7

When is specialist referal required for pediatric otitis media

Answer 7

Refer for specialist assessment/admission in INFANTS:

• < 3 MONTHS with FEVER > 38 DEGREES
• 3-6 months with temp > 39 DEGREES

Question 8

Complications

Answer 8

• Otitis medial with effusion
• Hearing loss (usually temporary)
• Perforated eardrum
• Recurrent infection
• Mastoiditis - inflam of mastoid process (rare)
• Abscess (rare)

Question 9

Glue ear

Answer 9

AKA otitis media with effusion

FLUID builds up due to eustachian tube blokage

-> HEARING LOSS (most common cause in kids)

Usually caused by ear infection. Can also lead to ear infection.

Question 10

Appearance of glue ear on otoscopy

Answer 10

DULL tympanic membrane with AIR BUBBLES or VISBLE FLUID LEVEL.

Can look normal.

Question 11

Glue ear RFx

Answer 11

• Childhood
• URTI; acute otitis media
• Cranio facial anomalies; Eustachian tube dysfunction
• Genetic predisposition
• Daycare attendance
• Adenoiditis/hyperplasia blocking eustachian tubes

Weak:
Allergic rhinitis, tobacco smoke, nasopharyngeal malig, GORD, low socioeconomic status, male sex

Question 12

Glue ear Sx

Answer 12

• Aural fullness/signs of ear discomfort
• HEARING LOSS; failed hearing screen;
• slow progress at school; speech delay

HEaring problems/balance problems uncommonly.

Question 13

Glue ear investigations

Answer 13

PNEUMATIC OTOSCOPY

Tympanometry if difficult to diagnose

Audiology if CHRONIC or an AT-RISK CHILD

If chronic/recurrent consider nasopharyngeal endoscopy

Question 14

Which children are at risk of developmental sequelae as a result of glue ear

Answer 14

• Permanent non-OME related hearing loss
• Speech and language delay or disorder
• Autism-spectrum disorder
• Genetic syndromes or craniofacial disorders associated with cognitive or language delays
• Blindness or uncorrectable visual impairment
• Cleft palate
• Developmental delay
• Intellectual disability, learning disorders or attention deficit/hyperactivity disorder.

Question 15

Glue ear Tx

Answer 15

Usually self resolves WITHIN 3 MONTHS - usually just watchful waiting

If risk of developmental sequelae or hearing loss:
- Grommet +/- adenoidectomy

May need hearing aid if co-morbid something affecting ear structure

Question 16

Grommets

Answer 16

Tiny tubes inserted into tympanic membrane -> allows drainage; mainly for ventilation to help depressurise

Usually geneeral anaesthetic + day case procedure

Few complications. Usually fall out within a year. 1 in 3 require further grommets from chronic/recurrent.

Question 17

Causes of hearing loss

Answer 17

Congenital:

• Maternal Antenatal RUBELLA or CMV
• GENETIC
• Associated with syndromes e.g. DOWN’S

Aquired:

Perinatal:

• Premmie
• Hypoxia

Postnatal:

• Jaundice
• Mening/encephalitis
• Otitis media / Glue ear
• Chemo

Question 18

Presentation of Hearing loss/deafness

Answer 18

• Congenital = oft picked up during NEWBORN HEARING SCREENING PROGRAM (since 2006)
  - picks up if v profound loss; typically in high risk kids (prem, v ill, FHx)
  - can give hearing aids/cochlear implants to help the kid learn speech + language (otherwise will not develop SAL)
• Parental concerns about behaviour problems/changes
  
  • Ignoring calls; bad behaviour, Poor salt; Poor school performance
• SCHOOL SCREENING PROGRAMME when starting school

Question 19

How is hearing loss tested

Answer 19

Audiometry

• < 3 y/o = basic response to sound
• > 3 y/o = headphones with specific tones + volumes

Question 20

Hearing loss epidemiology

Answer 20

• 1 in 6 people
• Usually takes around 10 years before treated
• 1 in every 100 babies spending > 48 HRS in ICU (norm only 1 in 1000)

Question 21

Which groups are high risk for hearing loss

Answer 21

• CYSTIC FIBROSIS
• DOWN’S
• Head TRAUMA
• Cleft lip/palate
• CMV
• CHEMO

These groups are monitored more closely

Question 22

Aims of hearing test

Answer 22

• Measure threshold
• Frequency specific
• DIfferentiate which type of hearing loss: conductive, sensorineural or mixed
• Compare aided + unaided response (check if aids helping)
• Monitor if fluctuating / progressive

Question 23

Audiogram

Answer 23

Docment volume at which patients can hear diff tones.

• Frequency (Hz) on x-axis (high pitched at right);
• volume (dB) on y-axis (quiet at top)

ie lower on chart = louder volume required = worse hearing

Question 24

Symbol meanings on audiogram

Answer 24

X – Left sided air conduction
] – Left sided bone conduction
O – Right sided air conduction
[ – Right sided bone conduction

Question 25

What is normal range of volume needed for hearing

Answer 25

Between 0-20 dB (decibals)

Question 26

Conductive vs sensorineural hearing loss on audiogram

Answer 26

Sensorineural - both air + bone conduction will be charted > 20 dB Conductive - bone conductions in normal range (0-20 dB); air conduction > 20 dB If mixed: both will be > 20 dB but bone conduction will be >15 dB better than air

Question 27

Severity of Hearing loss

Answer 27

- Mild = 20-40 dBHL - Mod = 41-70 - Severe = 71-95 - Profound = > 96

Question 28

Causes of conductive hearing loss

Answer 28

- Glue ear - Ear wax - Middle ear infection - Perforated eardrum - Abnormality of the outer ear - Eustachian tube dysfunction

Question 29

Conductive hearing loss Tx

Answer 29

- Oft self-resolving - Grommets - Hearing aid if persistent + don't want surgery - Bone Anchored Hearing Aid if permanent

Question 30

Sensorineural hearing loss Tx

Answer 30

Usually permanent so HEARING AIDS - aim to make speech audible Chochlear implants if profoundly deaf

Question 31

Hearing loss Ix

Answer 31

Subjective (kid has to respond): - Distraction test (6-18 M) - Visual Reinforcement Audiometry (6-30 M) - Performance Testing (> 24 M) - Pure Tone Audiometry (>3 yrs) Objective (no response needed - just need to be still + quiet environment) - Otoacoustic Emissions (in newborn screening) - Auditory Brainstem Response (more detailed; 2ndary) Tympanometry - measures middle ear pressure - abnormal = conductive

Question 32

Herpes zoster ophthalmicus definition + Px

Answer 32

Shingles reactivation in distribution of ophthalmic branch of trigeminal nerve Px: - Painful red eye - Fever, malaise, headache - Erythematous vesicular rash over ophthalmic area HUTCHINSON'S SIGN = lesion on nose - very indicative of ocular involvement

Question 33

Herpes zoster ophthalmicus Tx

Answer 33

Hospital admission + IV ACICLOVIR Analgesia = NSAIDs (1st) then things for nerve pain if 1st doesn't work (Amytriptyline, Duloxetine, Gabapentin/pregabalin) Avoid contact with anyone immunocompromised (including preg ppl + babies) till all lesions crusted over NB: hospital admission only needed if severe, ophthalmic involvement or suspicion of CNS infection - mod/severe rash / pain or non-truncal (or mild in immunocomp) = oral aciclovir - Normally, truncal shingles in healthy person self resolves without meds

Question 34

When is the shingles vaccine recommended to be taken

Answer 34

Within the 70s age range

Question 35

Complications of herpes zoster ophthalmicus

Answer 35

- Corneal ulcers, scarring / blindness - 2ndry bacterial infection of skin lesions - Post herpetic neuralgia