1
Q
HX of ear pain
A
- Use Socrates
- Ask about quality of pain
- Any preceding trauma- may indicate CSF leak
- Any itching?
- Any discharge?- mucus or blood stain will tell us there’s an infection.
- hearing loss?
- Experiencing tinnitus?- subjective sensation of sound
2
Q
What are the 2 distinct causes of hearing loss?
A
- Conductive
- Sensorineural
3
Q
What causes conductive hearing loss?
A
- When sound gets blocked in the external or middle ear.
- Any process which disrupts the conduction of sound from outside of the ear to the tympanic membrane and vesicular chain to the inner ear.
Causes: - Wax
- Foreign body
- Scar tissue or adhesions
4
Q
What is sensironeural hearing loss?
A
- An impairment that develops with damage to the organ for hearing/ 8th cranial nerve.
- Hearing is impaired
Causes:
- infection- Rubella, influenza, herpes
- Head trauma
- Ototoxic drugs
- Loud noises
- Age related
- Congenital
5
Q
What’s vertigo?
A
- The sensation of whirling and loss of balance especially from looking down at great height.
- Duration and frequency is important to know
- Is it associated with fullness- think minnieres disease
- Was there a recent neurological event?
- Headaches?
- Head injury
- Red flag with vertigo is when pt has drowsiness, LOC, inability to stand or walk, new onset of headache, hearing loss.
6
Q
What’s nystagmus?
A
- A condition where the eyes move rapidly and uncontrollably.
7
Q
Physical examination of the ear:
A
INSPECTION:
- Pinna
- Skin around the ear, the size, shape, position, any scars, any hearing aids.
PALPATION:
- Gently pull on the pinna and push the tragus
- palpate over mastoid bone for pain and swelling
- Perform hearing tests & otoscopy
8
Q
What is a tuning fork?
A
- An acoustic resonator that vibrates at a set frequency after being struck on the heel of the hand.
- It assesses vibratory sensation and hearing- air conduction & bone conduction.
- 512 hz
9
Q
What are 3 ways to test hearing?
A
- Whispered voice test- whisper a number close to pts ear and again slightly away.
- Webers test- Bang tuning fork then place against pts forehead and ask if they can hear it in both ears.
* This detects unilateral conductive hearing loss/middle ear hearing loss and unilateral sensorineural hearing loss/ inner ear hearing loss. - Rinne’s test: Differentiates sound transmitted through air conduction from those transmitted through bone conduction. Air conduction is better than bone conduction so in a normal ear, the tuning fork is louder in the front of the ear.
10
Q
Otoscopy
A
- Inspect the ear for signs of swelling, infection, wax & foreign body.
- The tympanic membrane should be pearly white and translucent.
11
Q
Auricular haematoma
A
- Collection of blood underneath the perichondrium of the ear.
- Occurs often due to a sporting incident.
- Referral to minor injuries unit as they require drainage in 7-10 days.
- There’s a tender fluctuating mass
12
Q
Mastoiditis
A
- Infection & inflammation of the mastoid air cells.
- Behind the ear
- May cause bone necrosis
- Pus formation
Common s&s: - Redness, tenderness and pain behind the ear, swelling, discharge behind ear, pyrexia, headache, hearing loss on the affected side.
- Treatment: antibiotics, may require surgery to drain the ear and remove part of the mastoid bone.
- Complications: Meningitis, facial paralysis, abscess formation.
13
Q
Cerumen
A
- External auditory canal
- Related to pts attempt to remove ear wax with a cotton bud or finger
- Conductive hearing loss as an impact on the ear wax can lead to a reduction in the sound travelling to the external ear canal.
- Treatment is wax softener
14
Q
Otitis external
A
- Inflammation of the pinna and external auditory canal
- Caused by swimming & infections or hypersensitivity to shampoos
- S&S: Pain, itching & discharge
- Treatment: if no pus in the early canal, it can be treated with ear drops, if there’s pus it needs to be swabbed, drained.
- Complications: meningitis, Bell’s palsy
15
Q
Tympanic membrane rupture:
A
- Caused by trauma, blast injuries, blows to side of the head
- Often self healing
- Advice: avoid entry of water or foreign body.
16
Q
What are anatomical differences of the ear in a child & adult?
A
- In paeds, the eustachian tube is at a more of a horizontal angle, making them more susceptible to middle ear infections.
17
Q
Otitis media
A
- Inflammation of the middle ear associated with an effusion.
- More common in kids
- Caused by viruses or bacteria
S&S: Pain, pyrexia, malaise, headache, n&v, tinnitus, reduction in hearing - Treatment: Antibiotics, Pain relief, antipyretics
- If left untreated or if they experience it numerous times, it can cause literacy problems and educational development issues.
18
Q
Labrynthitis
A
- infection of the inner ear
- May be secondary to a virus/illness
S&S: dizziness, n&v, loss of hearing, vertigo, loss of balance, tinnitus - Treatment: Anti emetics (stemetil), ENT referral if symptoms not resolving within 4-6wks!
19
Q
Temporal bone fracture
A
- Trauma can cause hearing loss
- significant intercranial injury is likely with this
- Battle sign, bloody discharge from ears, dizziness, altered eye movement, facial muscle paralysis
- Treatment: initial treatment for head injury, managing s&s
20
Q
Acoustic neuroma
A
- Slow growing tumour pressing on hearing & balance nerves.
- Beingn
S&S: Persistent headaches, blurred vision, ataxia, voice changes
21
Q
BELLS PALSY
A
- Inability to raise eyebrows!
- Drooping eyelid, inability to close eyes, inability to puff cheeks, asymmetrical smile, drooping corner of mouth
- Acute unilateral facial nerve caused by swelling of the facial nerve
- Often a sudden onset and will resolve after weeks/months
S&S: Sharp pain in inner ear, impaired/altered sense of taste, sensitivity to loud noise, inability to close eye on affected side, dysphasia. - Managment: Referral, eye care, potentially steroids.
22
Q
Function of the nose
A
- To warm , moisten and filter inhaled air
- To detect olfactory stimuli CNI
23
Q
HX for nose complaints
A
- SOCRATES
Common nose pc: nasal obstruction- ask if bi/unilateral, nasal discharge- colour?, epistaxis (nosebleed)- trauma related?, sneezing- associated factor?. Disturbance of smell?, nasal & facial pain- any deformity? - PMHX, DHX, SHX, FHX
24
Q
Physical examination of the nose
A
Inspection:
- Any deviation of septum?, look externally, periorbital swelling/bruising?, any nasal swelling?
PALPATION:
- Feel nasal bones facial swelling, block each nostril
25
Fractures nose
- Need early ENT referral
* Complications: Septal haematoma- can become an abscess and spread to sinuses & the brain.
26
Foreign body nose
- Common in paeds
- Can be resolved with the mothers kiss- instruct pts mother to cover unaffected nose and blow into their mouth and the object should come out!
27
Epistaxis
- Nose bleed
- Is it unilateral or bilateral?
- Are they on anticoagulants?
- Hypertensive pts are likely to get it!
- What caused it- is it trauma related?
- What have they done since, any blood clots?
- Put pressure on the tip of their nose and squeeze, get them to lean forward as they do this
28
Sinsitis
- Often get infected after UPRTI
- Inflammation of the lining of the sinuses often after a common cold.
- Mainly viral in origin
- Bacterial in less than 10%
RED FLAGS:
- High fever, double/ loss of vision, neck stiffness, confusion/drowsiness, swelling/puffiness around one or both eyes- orbital cellulitis
* THINK SEPSIS
29
Mouth
- oropharyx contains the tonsils
- The role of the tonsils is to participate in the fight against inhaled or ingested foreign substances.
30
HX of mouth issues
- SOCRATES
- Ask if they have got a sore throat/mouth
- Any stridor?
- What does their voice sound like- any changes?
- Are they able to eat as normal?
- Any enlarged lymph nodes?
31
Physical examination of the mouth
Inspection:
- Look at the face first, any drooling, obvious discomfort?
- Are the lips dry?
- Inspect the mouth
- Can they swallow?
- Any dryness
- Ask pt to say aaaa, assessing CNXII
PALPATION: Lymph nodes
32
Red flags for foreign body
- Any compromise to the airway
- Stridor, drooling, change of voice
- Signs of oesophageal perforation- chest pain, features of sepsis or surgical emphysema
- HX of button battery ingestion
33
Glandular fever (MONO)
- Infectious disease caused by Epistein virus
- AKA as the kissing disease as the virus is spread through saliva and commonly affects young adults.
- Symptoms typically appear 4-8wks after being infected
-S&S: sore throat, enlarged lymph nodes, fever, tiredness, swollen tonsils, headache, muscle aches
*COMPLICATIONS: Anemia, heart problems, meningitis, encephalitis, ruptured spleen- avoid contact sport from 3 months
34
Pharyngitis:
- Inflammation of the mucous membranes of the oropharynx
- Acute onset of sore throat, no cough, nasal congestion or discharge
* Consider group A streptococcus pharyngitis
- Usually self limiting, resolves in 2-12 weeks.
35
Strep A
- Can be carried in the throat & skin.
- Most serious infection linked to GAS
- Treated with antibiotics if +ve
36
Rheumatic fever
- Step A left untreated can result in rheumatic fever
- Rare complication, not contagious
- Occurs 1-5weeks after infection
- S&S: Malaise (generally unwell), rash, pyrexia, skin lesions, prolonged PR interval in ECG
- Jane’s criteria can diagnose rheumatic fever.
37
Tonsilitis
- More common in children
- Viral infections more common
- S&S: sore throat, dysphagia, earache, temperature
* severe tonsillitis need admittance
38
Quinsy
- May folllow recent sore throat
- Colection of pus that develops between tonsillar capsule and superior constrictor muscle
- Drooling, foul smelling breath, dehydrated, severe sore throat, pyrexia, trismus, uvula deviation
* Red flag- severe sore throat, aphasia of rapid onset due to impeding airway disaster
- require admittance to recieve antibiotics
39
Post tonsillectomy bleed
- Risk of bleed, occurs in 2-5%
- usually self limiting but may need surgery to resolve heamorrhage
- paeds can compensate well, so be cautious
- consider airway management
- get them to spit the blood out, fluid &TXA
40
Epiglottits
- Inflammation of the epiglottis
- S&S: High resp rate, DIB, inspiratory stridor, inability to swallow secretions, sore throat, pyrexia
*RED FLAG: severe sore throat with aphagia, severe dysphagia, hoarse or no voice
41
Ludwigs angina
- Life threatening cellulitis of soft tissue involving the floor of the mouth and neck
- Often caused by tounge piercings or dental infection
- As the condition progresses so does airway compromise
* RED FLAG- hot potato voice, restricted tounge mobility, fever, mouth opening restriction, swallowing difficulty.
42
Angioedema
1. IGE
2. Bradykinin angioedema
Hereditary angioedema- very rare. Low level of C1 inhibitor or it doesn’t function.
- Bradykinin is a peptide that promotes inflammation.
* Pts who do not have C1 inhibitor, when they have a stressor, bradykinin is produced and the inflammatory process is disregulated leading to angioedema.
- Angioedema is seen in the face and throat, they present as though the are having an allergic reaction.
* Adrenaline does not really do much, do not respond to antihistamines or steroids.
* TXA works
43
Carotid blowout
- Rupture of the caraotid artery
- Rare
- Causes: radiotherapy, pts who have sustained trauma, direct trauma invasion
- Occurs when a damaged arterial wall cannot sustain its integrity against the pts blood pressure.
PMMH
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