1
Q
Definition of otitis media?
A
- Middle ear inflammation
2
Q
Definition of recurrent otitis media with effusion?
A
- Recurrent ear infections – secretory otitis media (Glue ear)
Middle ear effusion without the symptoms of acute otitis media
3
Q
How common is otitis media?
A
o Bacterial (most commonly)
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes
o Viral
RSV, rhinovirus, adenovirus, influenza and parainfluenza
4
Q
Causative organisms of otitis media?
A
o Bacterial (most commonly)
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, streptococcus pyogenes
o Viral
RSV, rhinovirus, adenovirus, influenza and parainfluenza
5
Q
Symptoms of otitis media?
A
- May follow URTI
- Symptoms
o Rapid onset pain in the ear
o Fever
o Irritability
o Vomiting
o Deafness
6
Q
Signs of otitis media?
A
o Bright red and bulging with loss of normal light reflection
o Occasional acute perforation with pus in ear canal
o Look for swelling over mastoid – mastoiditis secondary
7
Q
Diagnosis of acute otitis media?
A
o Acute onset – earache, holding, tugging ear or non-specific symptoms
o Otoscopy – red, tallow or cloudy tympanic membrane with bulging and loss of normal landmarks, air fluid level behind tympanic membrane or perforation
8
Q
When to admit of otitis media for specialist assessment from primary care?
A
o Severe systemic infection
o Acute complications of otitis media (meningitis, mastoiditis, incracranial abscess, sinus thrombosis, facial nerve paralysis)
o Child <3 months with temperature >38
9
Q
Management of otitis media - general advice?
A
o Analgesia (regular paracetamol and ibuprofen) o Most cases resolve spontaneously within 3 days but can be up to 1 week
10
Q
Management of otitis media - antibiotics?
A
o If very unwell, have symptoms and signs of illness or high risk:
Immediate antibiotic
o For those who may benefit from antibiotics, consider delayed prescription, no prescription or immediate
Amoxicillin for 5-7 days
Can give clarithromycin or erythromycin if penicillin allergic
11
Q
Management of otitis media - if perforation?
A
o Follow up with ENT and do not swim
12
Q
Management of otitis media - if treatment failure?
A
o If not taken antibiotic – give prescription
Amoxicillin for 5-7 days
Can give clarithromycin or erythromycin if penicillin allergic
o If taken first-line antibiotics, give co-amoxiclav for 5-7 days
o If symptoms persist despite two courses of antibiotics – refer to ENT
13
Q
Management of otitis media if persistent symptoms - hearing loss with no pain or fever?
A
Active observation for 6-12 weeks
Two hearing tests using pure tone audiometry >3 months apart
14
Q
Management of otitis media if persistent symptoms - hearing loss with no pain or fever - when to refer?
A
o Hearing loss impacting child development
o Hearing loss >61dB
o Significant hearing loss on two occasions
o Tympanic membrane abnormal
o Foul-smelling discharge (cholesteatoma)
o Down’s syndrome or cleft palate
15
Q
Management of otitis media if persistent symptoms - hearing loss with no pain or fever - non-surgical and surgical management?
A
o Active observation for 3 months with regular audiology follow up
o Hearing aids
o Autoinflation
o Myringotomy with Grommet insertion, with or without adenoidectomy
If persistent bilateral OME over 3 months with hearing in better ear <25-30dB averaged at 0.5, 1, 2 and 4 kHz or if affecting development
Adenoidectomy only if frequent URTIs
Follow up until grommets extruded and eardrum healed
16
Q
Management of otitis media if persistent symptoms - discharge from ear canal for 2 weeks?
A
Refer to ENT assessment – given steroids and antibiotics and intensive cleaning of ear
17
Q
Complications of otitis media?
A
- Mastoiditis
- Meningitis
18
Q
Definition of pharyngitis?
A
local inflammation of oropharynx with enlarged and tender lymph nodes
19
Q
Definition of tonsilitis?
A
form of pharyngitis where there is intense inflammation of the tonsils, often with purulent exudate
20
Q
Definition of influenza?
A
acute respiratory illness caused by RNA Orthomyxoviridae viruses
21
Q
Epidemiology of URTIs?
A
- Highest incidence in children and young adults
- More common in winter
- URTI are 80% of respiratory infections
22
Q
Causative organisms of common cold (coryza)?
A
Rhinovirus, coronaviruses, influenza virus, parainfluenza and RSV (however RSV usually causes acute bronchiolitis)
Lasts 1 ½ weeks
Common – adults 2-3x colds per year, children 5-6x colds per year
23
Q
Causative organisms of Pharyngitis/tonsilits?
A
Adenoviruses, enteroviruses, rhinoviruses, influenza types A and B, parainfluenza, group A B-haemolytic streptococcus, HSV-1, EBV, Candida
Non-infectious – physical irritation, hayfever, GORD, Kawasaki’s disease, oral mucositis
Lasts 1 week
24
Q
Causative organisms of epiglottitis?
A
Hib
25
Causative organisms of influenza?
Type A – frequent and more virulent, local outbreaks and epidemics
Type B – co-circulates with A during yearly outbreaks, less severe
Type C – mild/asymptomatic infection similar to common cold
Peak during winter months
26
Symptoms of tonsillitis/pharyngitis?
```
o Fever (+/- febrile convulsions)
o Painful throat
o Exudate present in bacterial tonsillitis
o Earache and nasal discharge
o Difficulty feeding and drinking
```
27
Symptoms of common cold?
o Sore throat
o Nasal irritation, congestion, nasal discharge and sneezing
o Cough
o Hoarse voice
o General malaise
o Fever, myalgia and headache less common
28
Symptoms of uncomplicated influenza?
Coryza, cough, fever, Diarrhoea, headache, myalgia, malaise, sore throat, photophobia, conjunctivitis
29
Symptoms of complicated influenza?
Signs and symptoms requiring hospital admission, LRTIs, CNS involvement, exacerbation of underlying medical condition
30
Assessment of tonsillitis/pharyngitis?
o Clinical examination – pus on tonsils indicates bacterial infection
o Neck – think bacterial infection if tender lymphadenopathy
o FeverPAIN score
o Centor Criteria
31
What is FeverPain score in tonsillitis?
```
Fever >38
Purulent (exudate on tonsils/pharyngeal)
Attend rapidly (<3 days)
Inflamed tonsils
No cough/coryza
• Score 4 or 5 - Abx
```
32
What is Centor Criteria in tonsillitis?
```
Tonsilllar exudate
Tender anterior cervical lymphadenopathy
Fever
Absence of cough
• 3 or 4 needs Abx
```
33
Investigations in influenza?
o Laboratory diagnosis for complicated influenza (in hospital)
o Viral PCR
o Alternatives – serology and culture
34
Management of tonsillitis - hospital admission needed when?
Breathing difficulty
Dehydration
Peri-tonsillar abscess or cellulitis
Sepsis
35
Management of tonsillitis - if on DMARDs, carbimazole, chemotherapy, HIV, asplenia?
Seek immediate advice
| FBC urgently
36
Management of tonsillitis - general advice?
Majority caused by viral infections
40% of symptoms resolve within 3 day and 85% within 1 week
Symptomatic relief
• Keep hydrated
• Paracetamol and ibuprofen
• Avoid hot drinks – worsen pain
Children return to school after fever resolved and no longer feel unwell or after 24h of Abx
37
Management of tonsillitis - Antibiotics?
If positive culture or Centor criteria 3 or 4 or FeverPAIN 4 or 5
If FeverPAIN 2 or 3 – consider delayed prescription
Prescribe penicillin V (phenoxymethylpenicillin 500mg QDS) for 10 days
Alternatives: erythromycin or clarithromycin for 5 days
AVOID AMOXICILLIN AS CAUSES RASH IN EBV
38
Management of tonsillitis - recurrent tonsillitis?
o If recurrent tonsillitis (>7 episodes per year for one year, >5 episodes per year for 2 years or >3 episodes per year for 3 years)
Refer to ENT for tonsillectomy advice
39
Criteria for referral to ENT for tonsillectomy?
>7 episodes per year for one year
>5 episodes per year for 2 years
>3 episodes per year for 3 years
40
Management of common cold - general advice?
o Self-limiting and symptoms peak around 2-3 days then decrease up to 1 week or 2 weeks for young children, cough may last for 3 weeks
41
Management of common cold - symptomatic relief?
* Keep hydrated
* Paracetamol and ibuprofen
* Avoid hot drinks – worsen pain
* Steam inhalation relieves congestion (or sitting in hot shower)
* Intranasal decongestants, cough medicine available OTC
42
Management of common cold - hygiene methods?
* Washing hands frequently with soap and water
| * Avoid sharing towels
43
Management of common cold - follow up?
Come back if symptoms worsen or persist longer than 7/14 days
44
Management of influenza - prevention with seasonal vaccine - when to give?
• All people >65 (trivalent)
• All people 6m-65y if in following groups (quadrivalent):
o Chronic respiratory illness
COPD, bronchiectasis, CF, ILD, pneumoconiosis, BPD, asthma needed ICS
o Chronic heart disease
CHD, hypertension with cardiac complications, HF, regular medication for IHD
o CKD (Stage 3-5), nephrotic syndrome, transplant
o Chronic liver disease – cirrhosis, biliary atresia, chronic hepatitis
o Neurological
Stroke/TIA, at risk of co-morbidity exacerbated by flu (CP, LD, PD, MS, MND, degenerative disease, polio)
o DM type 1 and 2 needing OHA/insulin
o Immunosuppressed
Chemotherapy, bone marrow transplant, HIV, systemic steroids (>1m of 20mg daily), myeloma, asplenia, or SCD
o Pregnant women
o BMI>40
45
Management of influenza - symptomatic relief?
* Keep hydrated
* Paracetamol and ibuprofen
* Rest in bed
* Stay off work/school until feel able to attend
46
Management of influenza - antiviral therapy criteria?
o Antiviral (oral oseltamivir or inhaled zanamivir) if all of following apply:
National surveillance scheme indicate influenza circulating
Person at ‘high risk’ group
• Aged >65, <6m or pregnant women
• People with following conditions:
• Asplenia, COPD, bronchiectasis, CF, ILD, pneumoconiosis, Asthma needing inhaled corticosteroids
• HF, CHD, IHD
• CKD (Stage 3-5), chronic liver disease
• Stroke/TIA
• DM
• Immunosuppressed – chemotherapy, bone marrow transplant, HIV, systemic steroids (>1m of 20mg daily), myeloma
• BMI >40
Person can start treatment within 48 hours of onset of symptoms (36 with zanamivir with children)
47
Management of influenza - follow up?
Within 1 weeks if >65 or <6m to confirm improving
| After 1 week if not improving
48
Management of influenza - admission to hospital if?
Complication – pneumonia
High risk of complications
<2 years and at risk group
Febrile seizure
49
Management of influenza - post-exposure prophylaxis given when and what?
• National surveillance scheme indicates influenza circulating
• Person exposed (in same household or residential setting)
• At risk group and:
o Not vaccinated since previous season
o Vaccination not well-matched to circulating scheme
o <14 days between vaccination and date of contact
• Person can start treatment within 48 hours of onset of symptoms (36 with zanamivir with children)
Oral oseltamivir or inhaled zanamivir for 10 days
50
Complications of tonsilitis/cold?
o Otitis Media
o Sinusitis
o Peritonsillar abscess (quinsy)
o Para-pharyngeal abscess
51
Complications of influenza?
```
o Bronchitis
o Exacerbation of asthma or COPD
o Otitis media
o Pneumonia
o Sinusitis
o Myocarditis, pericarditis
o Febrile convulsions
o Myalgia, rhabdomyolysis
o GBS
o In pregnancy – preterm labour and low birth weight
```
52
Neck lumps - key features of reactive lymphadenopathy?
Most common cause
History of localised infection or generalised viral illness
53
Neck lumps - key features of lymphoma?
Rubbery, painless lymphadenopathy
Pain whilst drinking alcohol (rare)
Night sweats and splenomegaly
54
Neck lumps - key features of thyroid goitres/lumps
Symptomatic hypo/hyperthyroid
Moves upward on swallowing
55
Neck lumps - key features of thyroglossal cyst
Common in patients <20
Midline between thyroid isthmus and hyoid bone
Moves upwards with tongue protrusion
Painful if infected
56
Neck lumps - key features of pharyngeal pouch
Older men
Posteromedial herniation between thyropharyngeal and cricopharyngeus muscles
If large midline lump in neck that gurgles on palpation
Symptoms - dysphagia, regurgitation, aspiration, chronic cough
57
Neck lumps - key features of cystic hydroma?
Congenital lymphatic lesion
Left side neck
Most evident at birth but 90% by 2
58
Neck lumps - key features of branchial cyst
Oval mobile cystic mass between sternocleidomastoid muscle and pharynx
Presents in early adulthood
59
Key features of salivary gland stones (sialolithiasis)
primarily affect the submandibular glands but are also seen in the parotid and sublingual glands
Age 50-60
Majority calcium phosphate stones
Symptoms - Pain and swelling of gland on eating or chewing. Resolve after mealtimes
Management - conservative management -well hydrated, NSAIDs for pain
If recurrent then refer to ENT
60
Definition of otitis externa?
- Inflammation of external ear canal
o Localised = folliculitis that can progress to become boil in canal
o Diffuse = inflammation of skin and sub-dermis in canal and tympanic membrane
- Acute (<3 weeks), chronic (>3 months)
61
Defintion of malignant otitis externa?
o Aggressive infection affecting immunocompromised or DM or elderly which spreads to bone surrounding ear canal
62
Epidemiology of otitis externa?
- Prevalence increases at end of summer
- Common >1% diagnosed per year
- Women > Men
63
Causative organisms of otitis externa?
```
- Bacterial
o S.Aureus
o Pseudomonas sp.
- Fungal
o Aspergillus
o Candida Albicans
```
64
Other causes of otitis externa?
- Seborrhoeic Dermatitis
- Contact dermatitis (irritant or allergen)
- Trauma (scratching, aggressive, ear syringing, foreign objects, cotton buds)
- Swimming
- High humidity
- Narrow ear canal
- Hearing aids
65
Symptoms of otitis externa?
- Minimal discharge
- Itch
- Pain – made worse by moving pinna
- Hearing Loss
- Tender regional lymphadenitis
66
Signs of otitis externa?
```
- Otoscopy
o Red canal with swelling, shedding of scaly skin
o White or yellow pus in canal
o Struggle to see tympanic membrane
- Lymphadenopathy of pre-auricular nodes
- Pyrexia
```
67
Symptoms of chronic otitis externa?
- Lack of earwax
- Dry hypertrophic skin, partial stenosis of canal
- Pain on manipulation of external ear canal
- Constant itch and discomfort
68
Symptoms of malignant otitis externa?
- Granulation tissue at bone-cartilage junction of ear canal
- Facial nerve palsy
- Temperature >39
- Severe pain and headache
- Vertigo
- Profound hearing loss
69
Diagnosis of otitis externa?
- Clinical Diagnosis
70
When to swab ear in otitis externa?
o Treatment fails, recurrent or chronic
| o Infection spread or severe enough for oral antibiotics
71
Management of otitis externa - general measures?
```
Self-Care Advice
• Avoid swimming, cotton buds, foreign objects down ear
• Keep ears clean and dry
Paracetamol and ibuprofen PRN
Local heat with warm flannel
```
72
Management of otitis externa - medical therapy?
Acetic Acid 2%
• For mild cases
Topical antibiotic with/without topical corticosteroid
• Gentamicin, neomycin or Chloramphenicol with steroid (Otomize, Betnesol)
• 7-14 days
Oral antibiotics if cellulitis beyond ear canal to pinna, fever, systemic signs of infection, DM or immunocompromised:
• 7-day course of flucloxacillin (or clarithrymycin)
73
Management of otitis externa - when to ear swab?
```
Treatment failure
Recurrent or chronic
Topical treatment cannot be delivered
Infection spread beyond EAC
Need oral antibiotics
```
74
Management of otitis externa - when to refer?
Symptoms not improved despite treatment
Cellulitis extensive
Pain extreme
Micro-suction or ear wick insertion required
Requiring incision and drainage of furuncle
75
Management of otitis externa - when to refer urgently?
o Referral urgently if malignant otitis externa suspected:
Unremitting pain, otorrhoea, fever or malaise
Granulation tissue at bone-cartilage joint of ear canal
Facial nerve paralysed
Temperature >39
76
Management of chronic otitis externa - if fungal nfection suspected?
Topical clotrimazole 1% solution/acetic acid 2% spray/
| Seek specialist advice if inadequate response
77
Management of chronic otitis externa - if irritant or allergic dermatitis?
Advise person to avoid contact with irritant or allergen
| Give topical corticosteroid
78
Management of chronic otitis externa - if seborrheoic dermatitis?
Topical antifungal/corticosteroid combination
79
Management of chronic otitis externa - if no evident cause?
7 days topical corticosteroid with acetic acid spray
80
Management of chronic otitis externa - when to refer?
Does not respond to treatment
Contact sensitivity suspected
Ear canal occluded
Malignant otitis is suspected
81
Complications of otitis externa?
- Abscess
- Chronic otitis externa
- Fibrosis
- Myringitis
- Tympanic membrane perforation
82
Prognosis of otitis externa?
- Symptoms usually improve within 48-72 hours of initiation of treatment
- Resolves within 7-10 days
83
What is ear wax?
- Ear wax = normal physiological substance that protects ear canal
- Combination of sheets of desquamated keratin squames (dead, flattened cells on outer layer of skin), cerumen (wax-like substance produced by ceruminous glands), sebum and foreign substances
84
Function of ear wax?
o Aids removal of keratin
o Cleans, lubricates and protects lining of ear canal – trapping dirt and repelling water
o Antibacterial properties
85
Epidemiology of ear wax?
- Most common ENT procedure in primary care – ear wax removal
- Dry wax is dry, flaky and golden-yellow and common in Asian people
86
Risk factors of ear wax?
```
o Narrow or deformed ear canal
o Hairs in ear canal
o Osteomata
o Dermatological disease in peri-auricular area
o Elderly
o Recurrent otitis externa
o Cotton wool bud use/Hearing aids
```
87
Symptoms of ear wax?
- Mainly asymptomatic
- Symptoms include:
o Blocked ears
o Ear discomfort
o Feeling of fullness in ear
o Tinnitus
o Itchiness
o Vertigo
88
Signs of ear wax?
- Signs on otoscopy
| o Wax in ear canal (may occlude whole canal)
89
Management of ear wax - when to remove?
o Totally occluding canal and symptoms present
o If tympanic membrane is obscured by needs to be viewed to establish diagnosis
o If hearing aid impression needing to be fit
90
Management of ear wax - general advice?
o Do not insert anything into ear as can damage structures
| o Ear candles has no benefit in management
91
Management of ear wax - safety net?
o If develop earache, itching, discharge from ear, swelling of ear canal come back
92
Management of ear wax - how to remove ear wax?
o Ear drops (olive oil 3-4 times a day for 3-5 days) to soften wax
o Ear irrigation
• Electronic ear irrigator
• Angle so flow is along top of posterior wall
93
Management of ear wax - contraindications of removing ear wax?
* Hx of previous problem
* Current perforation or in last 12 months
* Grommets in place
* Hx of ear surgery
* Mucous discharge from ear
* Middle ear infection in previous 6 weeks
* Acute otitis externa
94
Management of ear wax - complications of removing ear wax?
• Failure, otitis externa, perforation, pain, vertigo
95
Management of ear wax - if irrigation unsuccessful?
o Use drops for further 3-5 days and return for repeat irrigation
o Instil water into ear – then irrigate after 15 minutes
o Refer to ENT specialist
96
Management of ear wax - when to refer?
o Before irrigation if – chronic perforation, history of ear surgery, foreign body
o If irrigation unsuccessful
o Severe pain, deafness or vertigo
o Infection present
97
Management of ear wax - recurrent ear wax?
o Ear drops regularly (sodium bicarbonate, sodium chloride, olive oil, almond oil)
o Irrigation or referral for manual extraction if needed
98
Complications of ear wax?
o Conductive hearing loss
| o Discomfort
99
Categories of hearing loss?
o Conductive – occurs due to abnormalities of outer or middle ear which impairs conduction of sound waves from external ear (pinna, ear canal or tympanic membrane) through ossicles to cochlear
o Sensorineural – abnormalities in cochlear, auditory nerve or structures in neural pathway leading to auditory cortex
o Mixed
100
Severity of hearing loss?
o Mild – 25-39dB
o Moderate 40-69dB
o Severe – 70-94dB
o Profound - >95dB
101
Epidemiology of hearing loss?
- Prevalence increases with age
| - Most common is age related hearing loss
102
Causes of conductive hearing loss?
Impacted earwax
Foreign Bodies
Tympanic membrane perforation
Infection (otitis media and externa)
Middle ear effusion
Cholesteatoma
Otosclerosis (abnormal bone growth affecting ossicles)
Neoplasms (SCC of external ear, vascular glomus tumour)
Exostoses (hard, bony growths in ear canal)
103
Causes of sensorineural hearing loss?
Age-related (presbycusis) – most common
Noise exposure
Sudden sensorineural hearing loss (within 72 hours)
Meniere’s disease
Ototoxic substances (gentamicin, bumetanide, furosemide, NSAIDs, aspirin, quinine, chloroquine, cisplatin, bleomycin, cigarettes, mercury, lead)
Labyrinthitis
Vestibular Schwannoma (Acoustic Neuroma)
MS, stroke
Malignancy (intracranial or nasopharyngeal)
Infections (CMV, toxoplasmosis, syphilis, meningitis, HIV, Lyme disease HZV)
Autoimmune (RA, SLE, sarcoidosis, Wegeners granulomatosis)
Hereditary (Alports syndrome)
104
Symptoms of prebycusis?
o Bilateral high-frequency hearing loss after 50 years old
| o May be unaware and need TV higher or cannot hear people
105
Symptoms of noise-related hearing loss?
o Hx of exposure to persistent high levels of noise
| o Associated with tinnitus
106
Symptoms of sensorineural hearing loss?
o Bilateral hearing loss within 72 hours
| o May have tinnitus, sensation of fullness in ear and vertigo
107
Symptoms of labyrinthitis?
o Tinnitus and vertigo common
108
Symptoms of acoustic neuroma?
o Gradual onset, unilateral hearing loss associated with tinnitus and vertigo
109
Assessment of hearing loss?
```
o History
o Examination
o Otoscopy
o Weber Test
o Rinne’s Test
o Cranial Nerve and Cerebellar tests
```
110
Weber test used in hearing loss? what is positive test?
512Hz tuning fork, strike one side on padded surface or ball of hand
Place vibrating tuning fork on person’s forehead for 4 seconds
Ask person where tone is heard – centrally, left or right
• If centrally – suggests symmetrical hearing loss
• In poorer ear – suggests asymmetrical conductive hearing loss
• In better ear – suggests asymmetrical sensorineural hearing loss
111
Rinne's test used in hearing loss? What is positive test?
512Hz tuning fork, strike one side on padded surface or ball of hand
Hold tuning fork 2.5cm from entrance to ear canal for 2s then press footplate firmly over mastoid and hold for 2s
Ask person if tone is louder next to ear or behind ear
• If better/louder by air conduction (next to ear) – Rinne’s positive and suggests sensorineural hearing loss or normal hearing
• If better/louder by bone conduction (held on mastoid) – Rinne’s negative and suggests conductive hearing loss in that ear
112
Further investigations in hearing loss?
o Audiology assessment if underlying systemic condition
113
Management of hearing loss - when to refer immediately?
o Sudden onset (<72 hours) unilateral or bilateral hearing loss within 30 days and not explained by external or middle ear causes
o Unilateral hearing loss associated with focal neurology
o Hearing loss with head/neck injury
o Necrotising otitis externa or Ramsay Hunt Syndrome
114
Management of hearing loss - when to refer within 2 weeks?
o Sudden onset (<72 hours) unilateral or bilateral hearing loss over 30 days ago and not explained by external or middle ear causes
o Rapidly progressive hearing loss not explained by external or middle ear cause
o Suspected head and neck malignancy
115
Management of hearing loss - when to refer routinely?
o Unilateral or asymmetric gradual onset hearing loss
o Fluctuating hearing loss not with URTI
o Hearing loss associated with hyperacusis
o Hearing loss associated with persistent tinnitus which is:
Unilateral – acoustic neuroma, Meniere’s disease, otosclerosis
Pulsatile – intracranial vascular tumours, aneurysms, carotid atherosclerosis
Changed significantly
Causing distress
o Hearing loss with persistent or recurrent vertigo
o Hearing loss not age related
116
Management of hearing loss in primary care - initial management?
Exclude/treat ear wax, acute ear infection, middle ear effusion due to URTI
```
Audiological Assessment
If sensorineural confirmed and no underlying causes requiring further investigation by ENT
• Hearing aids
• Assisted listening devices (ALDs)
• Cochlear implants
Follow up 6-12 weeks
```
Refer for diagnostic assessment
117
Management of hearing loss in primary care - general measures?
Reduce competing noises
Soft furnishings improve sound quality if hearing aid used
Ensure adequate lighting to help with communicating
118
Management of hearing loss in secondary care - investigations?
MRI to adults with hearing loss and localising symptoms or signs (facial nerve weakness) indicating vestibular schwannoma
Audiology assessment
• Bloods – FBC, ESR, CRP, U&E, LFT, TSH, autoimmune profile, clotting, glucose
• Audiometry and brainstem responses
• High-dose steroids
119
Management of hearing loss in secondary care - non-induced hearing loss?
* Reduced occupational risk
| * Tinnitus retraining therapy
120
Management of hearing loss in secondary care - otosclerosis?
* Hearing aid
| * Surgery – stapedectomy, stapedotomy
121
Management of hearing loss in audiological services - what hearing devices are available?
Hearing Aids
• If hearing loss affects ability to communicate and hear
• Offer 2 if both ears affected
Assisted Listening Devices
• Personal loops, personal communicators, TV amplifiers, telephones devices, smoke alarms, doorbell sensors
Implantable Devices
• Cochlear Implants
122
Follow up in audiological services?
6-12 weeks after hearing aids fitted
123
Definition of acoustic neuroma?
- Tumour of vestibulocochlear nerve (CN8) arising from Schwann cells of nerve sheath
- Typically benign and slow-growing
124
Risk factors of acoustic neuroma?
o Neurofibromatosis
| o High-dose ionising radiation
125
Presentation of acoustic neuroma?
o Unilateral sensorineural hearing loss – considered acoustic neuroma until proven otherwise
Progressive onset
o Impaired facial sensation
o Balance problems
o Large tumours give cerebellar signs or raised ICP
126
Investigations of acoustic neuroma?
o Audiology assessment
| o MRI scan – for all with unilateral hearing loss
127
Management of acoustic neuroma - observation?
Small neuromas and good preserved hearing
| Annual scans to monitor growth – if detected then active management
128
Management of acoustic neuroma - surgery?
Microsurgery – removal of tumour
| Stereotactic radiosurgery – single large dose of radiation using high-energy X rays or gamma rays
129
What are the most common causes of vertigo?
BPPV, Meniere's and vestibular neuronitis
130
Definition of vertigo?
- Vertigo is false sensation of movement (spinning or rotating) of the person or their surroundings in absence any actual physical movement
131
Peripheral causes of vertigo?
```
BPPV
Labryrinthitis
Meniere’s Disease
Perilymphatic fistula
Ototoxicity
Syphilis
```
132
Central causes of vertigo?
Migraine
| Stroke
133
Tests to perform in vertigo?
- Romberg’s test
- Dix-Hallpike manoeuvre
- Head impulse test
- Unterberger’s test
134
What is Romberg's test in vertigo?
o Stand up straight with feet together and shut their eyes
o If person cannot maintain balance when eyes closed, test if positive
o Problem with proprioception or vestibular function
135
What is Dix-Hallpipe manoeuvre in vertigo?
o Caution if neck/back problems, carotid sinus syncope
o Keep eyes open and look straight ahead
o Sit upright on couch and head turned 45o to one side
o From this position, lie person down rapidly supporting head and neck until head is extended 20-30 degrees over end of couch and maintain for 30 seconds
o Observe eyes closely for 30 seconds for nystagmus
o If Dix-Hallpipe positive with vertigo and torsional upbeating nystagmus - BBPV
136
What is Head impulse test in vertigo?
o Sit upright and fix gaze on examiner
o Rapidly turn head 10-20o to one side and watch person’s eyes
o Normal = eyes stay fixed
o Abnormal = eyes are dragged off target by head turn, corrective abnormal movement (saccade) – positive test
137
What is Unterberger's test in vertigo?
o March on spot with eyes closed
| o Person will rotate to side of affected labyrinth
138
Common features of peripheral vertigo?
Prolonged, severe vertigo
New-onset headache or recent trauma
CV risk factors
139
Common features of central vertigo?
Normal neurological examination
Severe N&V
Hearing loss
140
Management of central vertigo?
o Admit or urgently refer to ENT
| o Prochlorprazine, cyclizine, promethazine whilst awaiting referral
141
Management of peripheral vertigo?
o Admit urgently if severe N&V, central neurological symptoms
o Refer to ENT if undetermined cause
o Prochlorprazine, cyclizine, promethazine whilst awaiting referral for no longer than 1 week
142
Description of acute vestibular syndrome?
```
Acute onset dizziness and/or vertigo
Intolerance of head movement
Continuous dizziness of 24 hours to several weeks duration
Nystagmus
Unsteady gait
Nausea and/or vomiting
```
143
Definition of BPPV?
- Disorder of inner ear characterised by repeated episodes of positional vertigo and positional nystagmus on performing diagnostic manoeuvres
144
Epidemiology of BPPV?
- Most common cause of vertigo
- Women more commonly
- Posterior semi-circular canal most commonly affected 85-90%
145
Risk Factors of BPPV?
o Head injury
o Prolonged recumbent position (vet, hairdresser)
o Ear surgery
o Ear pathology (labyrinthitis, Meniere’s)
146
Pathology of BPPV?
o Loose calcium carbonate debris (otoconia) in semi-circular canals of inner ear (canalithiasis)
o When head moves, otoconia move into semi-circular canals causing motion of fluid of inner ear (endolymph) which induces symptoms
147
Symptoms of BPPV?
- Vertigo
o Brought on by movements (lying down, turning over in bed, looking upwards, bending over)
o Lasts <1 minute, preceded by position change
o Asymptomatic between attacks
- Nausea and vomiting
- Hearing and tinnitus NOT affected
148
Classical vetigo symptoms in BPPV?
o Brought on by movements (lying down, turning over in bed, looking upwards, bending over)
o Lasts <1 minute, preceded by position change
o Asymptomatic between attacks
149
Tests in BPPV?
- Dix-Hallpipe manoeuvre
o Diagnose posterior BPPV if torsional upbeating nystagmus (left ear = clockwise, right ear = anticlockwise)
o Latent period 5-20s until symptoms and increase in intensity and then decline
o If negative – repeat in one week
150
Management of BPPV - general advice?
o Most people recover over several weeks, but may last or recur
o Get out of bed slowly and avoid tasks looking upwards
o Do not drive when dizzy and inform DVLA if ‘sudden unprovoked or unprecipitated episodes of disabling dizziness’
151
Management of BPPV - if mild?
o Watchful waiting
152
Management of BPPV - moderate/severe?
o Epley Maneouvre
If symptoms do not settle after 1 week – return for repeat
o Brandt-Daroff exercises if Epley manoeuvre not performed
Sit on edge of couch with eyes closed
Lie down sideways on one side with head looking up at ceiling
Rest for 30 seconds, keep eyes closed and then sit upright
Repeat 3-4 times until symptoms free and 3-4 times a day
o Follow up in 4 weeks if not resolved
153
Management of BPPV - when to admit?
o If severe N&V unable to tolerate oral fluids
154
Management of BPPV - when to refer to ENT?
o Epley manoeuvre not available in primary care
o Epley manoeuvre not worked
o Symptoms not resolved in 4 weeks
155
Complications of BPPV?
- Falls
| - Difficulty performing ADLs
156
Prognosis of BPPV?
- Relapsing and remitting pattern
| - Recurrence is common (about 15%)
157
Definition of vestibular neuronitis?
- Acute, isolated, prolonged vertigo of peripheral origin
| Inflammation of vestibular nerve and no hearing loss and may occur after viral infection
158
Definition of labyrinthitis?
inflammation of labyrinth, hearing loss a feature
159
Epidemiology of vestibular neuronitis?
- 30-60
- Spring or early summer most likely
- 2nd most common cause of vertigo
160
Symptoms of vestibular neuronitis?
o Preceded by viral illness
o Rotational vertigo occurs spontaneously
Sudden, on waking and may worsen over course of day
Exacerbated by head position but initially constant
o Nausea and vomiting
o Malaise
o Balance affected
o HEARING LOSS AND TINNITUS IN LABYRINTHITIS ONLY
161
Signs of vestibular neuronitis? What test can be performed?
o Nystagmus – fine horizontal
o Head impulse test positive
Sit upright and fix gaze on examiner
Rapidly turn head 10-20o to one side and watch person’s eyes
Normal = eyes stay fixed
Abnormal = eyes are dragged off target by head turn, corrective abnormal movement (saccade) – positive test
162
Diagnosis of vestibular neuronitis?
- Clinical diagnosis
163
Management of vestibular neuronitis - general advice?
o Symptoms will settle over 2-6 weeks, even with no treatment
o Avoid alcohol, tiredness, illness which worsen it
o Bed rest during acute phase
o Do not drive when dizzy and inform DVLA if ‘sudden unprovoked or unprecipitated episodes of disabling dizziness’
164
Management of vestibular neuronitis - symptomatic management?
o Rapidly relieve severe N&V – buccal prochlorperazine
o Alleviate N&V and vertigo
3-day oral course of prochlorperazine or antihistamine (cinnarizine, cyclizine, promethazine)
o Return if symptoms worsen or not resolved after 1 week
165
Management of vestibular neuronitis - when to admit?
o If severe N&V who cannot tolerate oral fluids
166
Management of vestibular neuronitis - when to refer to ENT?
o Symptoms not typical (neurological symptoms)
o Symptoms persist without improvement for >1 week despite treatment
o Symptoms persist >6 weeks
167
Complications of vestibular neuronitis?
- BPPV can develop after Vestibular neuronitis in 10%
- Risk of falls
- Worse ADLs and QoL
168
Prognosis of vestibular neuronitis?
- Severe initial symptoms usually last 2-3 days, and recover gradually over weeks (by 6)
- Recurrence is possible but rare and consider vestibular migraine or BPPV
169
Definition of Meniere's Disease?
- Disorder of inner ear which can affect balance and hearing
- Clinical syndrome characterised by episodes of vertigo, fluctuating hearing loss and tinnitus
- Associated with feeling of fullness in ear
170
Epidemiology of Meniere's Disease?
- Uncommon
| - Women, 30-60
171
Risk factors of Meniere's Disease?
```
o Autoimmune
o FHx
o Metabolic disturbances – sodium, potassium
o Viral infection
o Head trauma
```
172
Pathology of Meniere's Disease?
o Abnormal endolymph production and/or absorption
o Volume of endolymph in membranous labyrinth increases and volume of perilymph filling bony labyrinth decreases
o Swelling of vestibular system lead to classic symptoms
173
Classic symptoms of Meniere's Disease?
o Vertigo
Spontaneous, with or without nausea and vomiting
Unsteadiness can persist for several days after acute attack
o Tinnitus
‘Roaring’, may become permanent
o Sensorineural hearing loss
Fluctuating, initially low frequencies and then permanent
o Aural Fullness (sensation of pressure in ear)
174
Acute attacks of Meniere's Disease?
o Preceded by change in tinnitus, increased hearing loss or aural fullness before vertigo for few hours
o Vertigo and symptoms for 20 minutes to a few hours
175
Other problems in Meniere's Disease?
o Otholitic crises of Tumarkin – drop attack without LoC without warning and normal activity resumed immediately
o Gait problems
o Postural instability
176
Diagnosis of Meniere's Disease?
- Diagnosis is clinical and need the following criteria:
o Vertigo – 2 or more spontaneous episodes lasting 20 minutes to 12 hours
o Fluctuating hearing loss, tinnitus and/or perception to aural fullness in affected ear
o Hearing loss confirmed by audiometry as sensorineural, low-to-mid frequency
177
When is Meniere's Disease the probable diagnosis?
- Probable diagnosis if all of above without audiometry
178
Management of Meniere's Disease - when to admit?
o If severe symptoms for IV labyrinthine sedatives and fluids
179
Management of Meniere's Disease - when to refer to ENT?
o To confirm diagnosis
180
Management of Meniere's Disease - when to refer to audiology?
o If signs suggestive of hearing loss
181
Management of Meniere's Disease - general advice?
o Long-term condition but vertigo usually improves
o Acute attack usually settle within 24 hours
o Do not drive when dizzy and inform DVLA if ‘sudden unprovoked or unprecipitated episodes of disabling dizziness’
182
Management of Meniere's Disease - symptomatic treatment of acute attacks?
o Severe – admission for IV labyrinthine sedatives
o Rapidly relieved severe N&V – buccal prochlorperazine
o Alleviate N&V and vertigo
7 days (14 days if required before) of prochlorperazine or antihistamine (cyclizine, promethazine, cinnarizine)
If symptoms don’t improve within 5-7 days – reassess
183
Management of Meniere's Disease - prevention of recurrent attacks??
```
o Oral Betahistine
o Specialist management:
Vestibular rehabilitation
Diuretics
Intratympanic gentamicin or steroids
Endolymphatic shunts or sac surgery
Labyrinthectomy
```
184
Prognosis of Meniere's Disease?
- Symptoms can initially fluctuate, resolving completely between episodes
- Later in course, hearing loss progresses and tinnitus becomes persistent
- After years, vertigo is no longer experienced
185
Definition of epistaxis?
- Bleeding from the nose
186
Epidemiology of epistaxis?
- Up to 60% have nosebleeds but rarely do people need medical attention
- Common in children
- Posterior epistaxis more common in elderly
187
Patholgoy of epistaxis?
o 80-90% originate from Little’s area on anterior nasal septum, contains Kiesselbach plexus of vessels
o Less commonly from branches of sphenopalatine artery in posterior nasal cavity
188
Causes of epistaxis?
o Trauma – nose-picking, nasal fractures, septal ulcers, foreign body, blunt trauma
o Inflammation – infection, allergic rhinosinusitis, nasal polyps
o Topical drugs – cocaine, decongestants, corticosteroids
o Vascular – Wegener’s granulomatosis
o Post-operative bleeding
o Tumours – benign (angiofibroma) or malignant (SCC)
o Nasal oxygen therapy
o Clotting disorders – thrombocytopenia, platelet dysfunction, von Willebrand disease, leukaemia, haemophilia
o Drugs – anticoagulants, antiplatelet drugs
o Excessive alcohol consumption
189
Symptoms of epistaxis?
- Nosebleed
190
Assessment of epistaxis?
- Assess how much blood, any temporary measures performed, previous epistaxis and treatment
- Examine – both nasal passages (with nasal speculum)
o Look for bleeding point
191
When to suspect posterior epistaxis?
o Profuse, from both nostrils, bleeding site not identified and goes down throat
192
Investigations if secondary cause suspected in epistaxis?
o FBC (if heavy or recurrent), coagulation (if clotting disease suspected)
193
Management of epistaxis - when to transfer immediately to A&E?
o Haemodynamic compromise
194
Management of epistaxis - when to admit to hospital?
o Posterior bleed - Bleeding profuse, from both nostrils and site cannot be identified
o Children <2
o Underlying cause (bleeding predisposition, haemophilia, leukaemia)
195
Management of epistaxis - acute management - first aid measures?
Sit with upper body tilted forward and mouth open – avoid lying down
Pinch cartilaginous (soft) part of nose firmly and hold for 10-15 minutes without releasing pressure, breathe through mouth
196
Management of epistaxis - acute management - if stops with first aid?
Topical antiseptic (Naseptin cream QDS for 10 days)
197
Management of epistaxis - acute management - if does not stop in 10-15 minutes?
Either admit to hospital (A&E) or perform in primary care if possible:
Nasal Cautery – if site identified
• Topical LA spray (Co-phenylcaine), wait 3-4 minutes and apply silver nitrate stick to bleeding point for 3-10 seconds until grey
• Need Naseptin after
Nasal packing – if cautery ineffective
• Topical LA spray (Co-phenylcaine), wait 3-4 minutes
• Options: Nasal tampons (Merocel), inflatable packs (Rapid-Rhino)
• Need admission to ENT afterwards
198
Management of epistaxis - general measures after nosebleed?
Avoid blowing nose, picking nose, heavy lifting, strenuous exercise, lying flat, drinking alcohol
199
Management of epistaxis - secondary care of severe epistaxis?
Resuscitate if BP low, dizzy on sitting
Apply pressure for 20 minutes, sit forward and breathe through mouth
Cautery – encourage patient to blow out clots
• LA soaked for 2 minutes
• Apply cautery on bleeding point – moving in a circle
• Never cauterise both sides of septum
If continues:
• Anterior nasal pack – Rapid Rhino, Merocel
• Posterior nasal pack – Foley urinary catheter and inflate balloon
200
Management of epistaxis - secondary care treatments?
```
Resuscitation if needed
Formal packing
Endoscopic assessment and electrocautery
EUA
Arterial ligation/embolisation
IV transexamic acid
```
201
Management of epistaxis - recurrent epistaxis?
o First aid measures when bleeds
o Avoid blowing/picking nose, heavy lifting, strenuous exercise and lying flat for 24 hours after
o Determine underlying cause:
FBC, clotting
o Referral to ENT if recurrent with signs of underlying conditions such as:
Angiofibroma (nasal obstruction, severe epistaxis)
Cancer (nasal obstruction, facial pain, hearing loss, eye symptoms)
Telangiectasia (red spots on fingertips, lips, lining of nose)
202
Complications of epistaxis?
o Hypovolaemia, anaemia, aspiration
o Nasal packing treatment – sinusitis, septal haematoma, pressure necrosis, toxic shock syndrome
o Nasal cautery treatment – septal perforation
203
How common is nasal injury?
o Nasal bone most commonly fractured bones of face
| o Seen in 15-30
204
Causes of nasal injury?
```
o Motor vehicle
o Sports
o Falls
o Abuse
o Punches, clash of heads
```
205
Symptoms and signs of nasal injury?
o Usually high-impact injury
o Swelling becomes apparent
o CSF Rhinorrhoea
CSF contains glucose and B2 tau transferrin
If traumatic – 7-10 bed rest, lumbar drain, avoid coughing/sneezing, antibiotic cover
o Epistaxis
o Septal deviation/haematoma
206
When to refer nasal injury to ENT immediately?
```
o Marked deviation
o Epistaxis not settling
o Septal haematoma
o CSF rhinorrhoea
o Widening intercanthal distance
o Facial anaesthesia
```
207
Management of nasal injury?
```
o If significant swelling:
Ice, simple analgesia
Review in 5 days by GP
o Usually heal within 2-3 weeks
o Manipulation under anaesthetic (MUA) performed within 5-10 days in adults
```
208
Common causes of nasal foreign body?
```
o Beads
o Buttons
o Sweets
o Nuts
o Seeds
o Peas
```
209
Presentation of nasal foreign body?
o Self-inserted and often observed
o May produce nasal obstruction
o Purulent unilateral discharge suggests organic material
210
When to refer to ENT a nasal foreign body?
o If prolonged unilateral nasal discharge
o FB in posterior position
o Patient agitated
o Not experienced
211
Management of nasal foreign body?
o Topical anaesthetic and vasoconstrictor spray
o Ask child to blow nose
o Ask parent to blow sharply though patients mouth whilst obstructing unaffected nostril (success rate >70%)
o Nasal speculum and thin forceps to hold object (avoid pushing deeper)
o Refer to ENT if two unsuccessful attempts
212
Definition of allergic rhinitis?
- IgE mediated inflammatory disorder of nose
| - Due to nasal mucosa sensitised to allergens, triggers histamine release to produce symptoms
213
Epidemiology of allergic rhinitis?
- Prevalence increasing
| ¼ of adults
214
Classifications of allergic rhinitis?
o Seasonal – occur at same time each year (hayfever)
o Perennial – throughout year, typically due to house dust mites, animal dander
o Intermittent - <4 days a week or <4 consecutive weeks
o Persistent - >4 days a week and >4 consecutive weeks
215
Causes of allergic rhinitis?
```
o FHx
o House dust mites
o Grass, tree and weed pollen
o Mould
o Animal dander (cats and dogs most common)
o Occupational
```
216
Symptoms of allergic rhinitis?
o Sneezing
o Nasal Itching
o Nasal discharge (rhinorrhoea)
o Nasal congestion
o Eye itching, redness, tearing
o Bilateral and usually develop within minutes of exposure to allergen
o Other – postnasal drip, cough, mouth breathing
217
Signs of allergic rhinitis?
o Nasal voice
o Darkened eye shadows
o Horizontal nasal crease
o Discharge – usually clear
218
Management of allergic rhinitis - general measures?
o Nasal irrigation with saline – OTC
o Allergen avoidance
Grass pollen allergy – avoid grassy, open spaces, particularly early in morning or late at night, avoid drying washing outdoors, keep windows shut
House dust mite – synthetic pillows, keep furry toys off bed, wash bedding frequently, wooden floors preferable
Animal allergy – Restrict areas of house animal can go, wash animal regularly
Occupational – reduce exposure, adequately ventilated work environment
219
Management of allergic rhinitis - drug treatment for mild-to-moderate?
PRN intranasal antihistamines (azelastine) OR
PRN oral antihistamines (loratadine or certirizine)
• If antihistamines CI or not tolerated – PRN intranasal sodium cromoglicate
220
Management of allergic rhinitis - drug treatment for moderate-to-severe?
Regular intranasal corticosteroid during periods of exposure (mometasone, fluticasone)
221
Management of allergic rhinitis - other treatments?
If nasal congestion – short-term intranasal decongestant (ephedrine)
If watery rhinorrhoea – intranasal anticholinergic (ipratropium bromide)
If itching or sneezing – regular antihistamine
222
Management of allergic rhinitis - severe symptoms or uncontrolled?
Oral prednisolone for 5-10 days
223
Management of allergic rhinitis - follow up?
o Review after 2-4 weeks of treatments
224
Management of allergic rhinitis - when to refer to ENT?
o Red flag features – unilateral, blood stained mucous, nasal pain, recurrent epistaxis – 2-week wait
o Nasal obstruction/structural abnormality which makes intranasal treatment difficult
o Persistent symptoms despite ongoing management
Allergy Testing – skin prick or IgE levels to allergens
Immunotherapy
225
Complications of allergic rhinitis?
o Impaired QoL
o Asthma
o Sinusitis
o Nasal Polyps
226
Definition of sinusitis?
- Inflammation of paranasal sinuses
| o Frontal, maxillary, sphenoid, ethmoidal
227
Classifications of sinusitis?
- Acute – resolves within 12 weeks
- Recurrent – 4 or more annual episodes of sinusitis with persistent symptoms in intervening periods
- Chronic – symptoms lasting >12 weeks
228
Epidemiology of sinusitis?
- Acute – common in adults
| - Chronic – increases with age, women, asthma/COPD
229
Causes of acute sinusitis?
Viral URTI which can be followed by bacterial infection
• S.pneumoniae, H,influenza, Moraxella catarrhalis and S.aureus
Also associated with asthma, allergic rhinitis, smoking, anatomical variation, seasonal variation, CF
230
Causes of chronic sinusitis?
Multifactorial
Usually S.aureus, enterobacteriaeceae
Predisposing conditions: atopy, asthma, CF, aspirin sensitivity, immunocompromise, smoking
231
Symptoms and signs of acute sinusitis?
```
o Usually follows viral illness
o Diagnostic with (<12 weeks):
Nasal obstruction/congestion
Nasal discharge (anterior, posterior)
Facial pain/pressure
Reduced/Loss of smell
o Altered speech, tender cheekbones, cough
```
232
When to suspect bacterial sinusitis?
o >10 days
o Discoloured or purulent nasal discharge
o Severe local pain
o Fever >38
233
Symptoms and signs of chronic sinusitis?
- Chronic Sinusitis (>12 weeks):
o Nasal obstruction/congestion
o Nasal discharge (anterior, posterior)
o Facial pain/pressure
234
Examination performed in sinusitis?
o Inspect and palpate maxillofacial area to elicit swelling/tenderness
o Perform anterior rhinoscopy to identify:
Nasal inflammation, mucosal oedema, purulent nasal discharge, nasal polyps
o Pulse rate, blood pressure, temperature
235
Management of sinusitis - when to refer to ENT?
```
o If not typical or diagnosis in doubt
o Frequent recurrent episodes
o Treatment failure
o Anatomical defect
o Immunocompromise
o Nasal polyps
```
236
Management of sinusitis - when to refer urgently?
o Systemically unwell, intra/periorbital complications, intracranial complications
237
Management of sinusitis - acute sinusitis - if symptoms <10 days?
Usually caused by virus and should take 2-3 weeks, most people will get better without antibiotics
PRN paracetamol + ibuprofen
Nasal saline or nasal decongestants
Seek medical advice if symptoms worsen or do not improve after 3 weeks
238
Management of sinusitis - acute sinusitis - if symptoms >10 days with no improvement?
High-dose nasal corticosteorids for 14 days (mometasone 200mcg BDS)
Backup prescription used if no improvement after 7 days
• Phenoxymethylpenicillin 500mg QDS for 5 days (doxycycline)
• 2nd line if not working – Co-amoxiclav
239
Management of sinusitis - chronic sinusitis?
o Avoid allergic triggers
o Stop smoking
o Good dental hygiene
o Avoid underwater diving
o Nasal irrigation with saline solution
o Intranasal steroids (mometasone/fluticasone) for up to 3 months
o Seek specialist advice on long-term antibiotics
240
Complications of sinusitis?
```
o Acute (rare) – orbital cellulitis/abscess, meningitis, encephalitis, osteomyelitis
o Chronic – sleep problems, depression, impact on work, reduced QoL
```
241
Definition of viral croup?
Mucosal inflammation affecting the nose to the LRT
| Due to parainfluenza, influenza and RSV in children aged 6 months – 6 years
242
Definition of spasmodic or recurrent croup?
Barking cough and hyperreactive upper airways
| No respiratory tract symptoms
243
Definition of acute epiglottitis?
Life-threatening swelling of the epiglottis and septicaemia due to H. Influenzae type B infection
Now rare due to Hib immunization
244
How common is viral croup?
- Viral croup= 95% of the laryngotracheal infections
- Most common in autumn
- Peak at 2yrs old, in children aged 6M-6yrs
245
How common is acute epiglottitis?
most commonly in ages 1 – 6 years, rare due to Hib immunisation
246
Causative organisms in viral croup?
o MOST COMMONLY due to parainfluenza
| o Others include Influenza and RSV
247
Causative organisms in acute epiglottitis?
o H. Influenzae type B infection
248
Symptoms of croup?
o Barking cough
o Harsh stridor
o Hoarseness preceded by fever & coryza
249
Symptoms of acute epiglottitis?
```
o High fever, toxic-looking child
o Intensely painful throat
Stops swallowing or speaking
o Saliva drooling
o Respiratory difficulty
o Child sitting immobile, upright, with open mouth
```
250
Examination in croup/epiglottitis?
DO NOT EXAMINE THE THROAT---assess severity:
o Degree of stridor and subcostal recession
o RR
o HR
o LOC (drowsy?), tired, exhausted
o Pulse oximetry
251
Diagnosis of acute epiglottitis?
- Anaesthetist makes diagnosis by laryngoscopy – cherry-red swollen epiglottis
- Electively intubate before obstruction occurs
252
Scoring system used in croup?
- Westley Croup Score
o Assesses stridor, retractions, air entry, SpO2 and level of consciousness
o Those with moderate – severe >2 need admission
253
Initial management of croup/epiglottitis?
- LEAVE CHILD ALONE - DO NOT DISTRESS (especially in epiglottitis)
- Immediate Management:
o Differentiate between croup and acute epiglottitis
o Stabilise child, give oxygen and keep airway open
254
Management of mild croup?
o Mild illness can be managed at home
Usually resolves after 48hours
Take paracetamol/ibuprofen PRN
o If there is recession and stridor at rest, then return to hospital
255
Management of severe croup?
Moist or humidified air
• Ease breathing
Steroids
• Oral dexamethasone (0.15mg/kg stat dose) or oral prednisolone (1-2mg/kg stat) or nebulised budesonide (2mg stat dose)
Nebulised adrenaline (epinephrine)
• Transient relief of Sx (airway obs)
• Driven by 8L/O2
My need endotracheal intubation
256
Management of epiglottits?
o Nebulised adrenaline may buy time
o Manage in ICU after endotracheal intubation
o Once procedure completed take blood cultures and start IV Abx
Cefotaxime IV for 7-10 days
o Rifampicin prophylaxis to close contacts
257
Definition of cholesteatoma?
- Abnormal accumulation of squamous epithelium and keratinocytes within middle ear
- Active squamous chronic otitis media
- Keratinising squamous epithelia (of the skin) within middle ear with foul-smelling otorrhoea
- Can be locally invasive
- Bone erosion occurs mainly by pressure and release of osteolytic enzymes
258
Epidemiology of cholesteatoma?
- Young children
- 1 in 10000
- Peak Age: 5-15 years
- Males
259
Risk factors of cholesteatoma?
o Ear trauma
o Insertion of Grommets
o Otitis media
260
Classifications of cholesteatoma - congenital?
Squamous epithelium becomes trapped within temporal bone during embryogenesis
It expands, resulting in conducting hearing loss
261
Classifications of cholesteatoma - primary acquired?
Most common type
Chronic negative middle ear pressure
Dysfunctional Eustachian tube causes erosion of tympanic membrane and defect
262
Classifications of cholesteatoma - secondary acquired?
Insult to tympanic membrane (perforation or trauma)
| Squamous epithelium implanted by insult
263
Symptoms of cholesteatoma?
```
o Foul-smelling otorrhoea
o Deafness
o Headache
o Ear pain
o Facial paralysis
```
264
Signs of cholesteatoma?
o Ear discharge
o Deep retraction pocket in tympanic membrane, with or without granulation tissue
o Crust or keratin in upper tympanic membrane
265
Assessment of cholesteatoma?
- If ear drum cannot be seen:
o Treat infection if present
o Refer to ENT
- CT imaging
266
Management of cholesteatoma - all people?
arrange semi-urgent referral to ENT specialist
| o For audiology and CT scan
267
Management of cholesteatoma - emergency referral?
o Facial paralysis, pain, signs of meningitis
268
Management of cholesteatoma - medical therapy?
- Medical therapy (only if unfit/refuse for surgery/prior to surgery)
o Regular ear cleaning with topical antibiotics
269
Management of cholesteatoma - surgical therapy?
- Mastoid surgery to remove disease
o Mastoidectomy and tympanoplasty
Second procedure after 9-12 months
o Myringoplasty – repair of tympanic membrane
270
Complications of cholesteatoma?
```
o Meningitis
o Cerebral Abscess
o Conductive Hearing Loss
o Mastoiditis
o Facial Nerve Dysfunction
```
271
Definition of acoustic neuroma?
- Indolent, histologically benign slow-growing subarachnoid tumours
- Causes problems by local pressure and behave as space-occupying lesions
- Tumour of vestibulocochlear nerve - arise from superior vestibular nerve Schwann cell layer
272
Location of acoustic neuroma?
o Internal auditory canal or cerebellopontine angle
273
Causes of acoustic neuroma?
o 40% a defect in long arm of chromosome 22
o Neurofibromatosis Type-2 – particularly bilateral
o High-dose ionising radiation
274
Symptoms and signs of acoustic neuroma?
Progressive ipsilateral tinnitus +/- sensorineural deafness (cochlear nerve compression)
o Any unilateral sensorineural hearing loss suspicious
Impaired facial sensation
Balance problems
Large tumours – ipsilateral cerebellar or raised ICP symptoms
275
Management of acoustic neuroma - referral?
- Refer urgently ENT for:
o Audiological assessment
o MRI for all those with unilateral tinnitus/deafness
276
Management of acoustic neuroma - conservative?
o Small neuromas and good hearing
| o Watch and wait – annual scans to monitor growth
277
Management of acoustic neuroma - surgical?
o Microsurgery
| Risks include – death, CSF leak, meningitis, cerebellar injury, stroke
278
Management of acoustic neuroma - radiotherapy?
- Stereotactic Radiosurgery
| o Single large dose of radiation to control growth of tumour
279
Definition of nasal polyps?
- Lesions arising from nasal mucosa, occurring at any site in nasal cavity or paranasal sinuses
- Most commonly in clefts of middle meatus
280
Pathology of nasal polyps?
o Sac-like entities with eosinophil rich oedematous wall
| o Poor blood supply
281
Epidemiology of nasal polyps?
- Males more than females
282
Causes of nasal polyps?
- Linked with chronic inflammation – chronic rhinosinusitis and vasculitis
283
Symptoms and signs of nasal polyps?
- Recurring acute or chronic sinusitis
- Symptoms
o Nasal airway obstruction
o Nasal discharge – watery, sneezing, postnasal drainage
o Dull headaches
o Snoring
o Decreased smell/taste
- Examination with nasal speculum
o Visualise polyp – often bilateral
284
Investigations of nasal polyps?
o Rigid or flexible endoscopy (rhinoscopy)
285
Management of nasal polyps - referral to ENT?
o Unilateral polyp
| o Children – risk of cystic fibrosis
286
Management of nasal polyps - medical management (1st line)?
```
o Topical corticosteroids – nasal sprays
Betnesol spray
o Nasal douche – saline
o Antihistamines (if allergic rhinitis present)
Beconase spray
```
287
Management of nasal polyps - surgical management?
Functional endoscopic sinus surgery (FESS)
| Used when medical management fails
288
Complications of nasal polyps?
o Acute bacterial sinusitis
o Sleep disruption
o Structural abnormalities
289
Prognosis of nasal polyps?
o Recurrence is common
290
Most common form of H&N cancer?
- SCC represent >90% of H&NC
| - 6th most common cancer
291
Risk factors for H&N cancer?
```
o Smoking
o Alcohol
o Poor dentition
o Poor diet
o GORD
o HPV Type 16 (oropharyngeal)
```
292
Types of H&N cancer?
o Oral cavity cancers (buccal mucosa, alveolus, hard palate, anterior 2/3rd of tongue, floor of mouth, lip)
o Cancer of pharynx
o Cancer of larynx
o Salivary gland, nose, sinus, middle ear
293
Symptoms of oral cavity H&N cancer?
o Mass, painless and felt on inner lip/tongue/floor of mouth/hard palate
o Bleeding
- Erythroleukoplakia
294
Symptoms of pharyngeal H&N cancer?
o Odynophagia, dysphagia, otalgia
295
Symptoms of laryngeal H&N cancer?
o Horse voice, stridor, dysphagia, persistent cough, referred otalgia
296
Referral H&N cancers - laryngeal cancer?
Aged 45 and over with:
• Persistent unexplained hoarseness or
• Unexplained lump in the neck
297
Referral H&N cancers - laryngeal cancer?
Unexplained ulceration in oral cavity for >3 weeks or
Persistent and unexplained lump in neck
Consider to dentist if lump on lip, red/white patch consistent with erythroplakia, erythroleukoplakia
298
Investigations in H&N cancers?
o Clinical examination
o Endoscopy
o Fine-needle aspiration
o CT/MRI for staging
299
Management of H&N cancers - early stage?
o Surgery
o Radiotherapy
o Neoadjuvant chemotherapy
300
Management of H&N cancers - advanced stage?
o Radiotherapy + Surgery
301
Definition of trigeminal neuralgia?
- Severe, episodic facial pain in distribution of 1 or more branches of 5th cranial nerve
- Typically, maxillary or mandibular branches
- Frequency from a couple of times a year – hundred of times a day
302
How common is trigeminal neuralgia?
- Rare
| - 3% cases bilateral
303
Causes of trigeminal neuralgia?
o 95% caused by vascular compression of trigeminal nerve, leading to demyelination of nerve root entry zone
o Other causes – MS, tumours, skull base abnormalities
304
Risk factors of trigeminal neuralgia?
```
o MS
o Advancing age
o Females
o FHx
o Hypertension and stroke
```
305
Triggers of trigeminal neuralgia?
```
o Touching face
o Talking
o Cold wind
o Vibration
o Cleaning teeth
o Shaving
```
306
Symptoms of trigeminal neuralgia?
o Pain in distribution of trigeminal nerve that is:
Severe, unilateral, short-lived, recurrent, episodic
Often described like sharp ‘electric shocks’
Provoked by factors like light touch, eating, talking or exposure to cold air
o Preceding symptoms – tingling/numbness
307
Red flag symptoms of trigeminal neuralgia?
```
o Sensory changes
o Deafness
o Pain in eye socket
o Optic neuritis
o FHx of MS
o Age <40
```
308
Diagnosis of trigeminal neuralgia?
- Clinical diagnosis
- Rule out dental causes of pain
- Specialist tests:
o MRI to exclude causes
309
Management of trigeminal neuralgia - if red flag symptoms?
- Refer urgently for specialist assessment if red flag symptoms
310
Management of trigeminal neuralgia - if severe pain?
- Refer to neurologist or specialist pain service
311
Management of trigeminal neuralgia - if no red flag symptoms?
o Carbamazepine 100mg BDS and titrate up every 2 weeks in 100-200mg until pain relieved
o If contraindicated/ineffective then refer to specialist
o Early follow-up to assess progress
312
Management of trigeminal neuralgia - specialist treatments?
o Lamotrigine, phenytoin or gabapentin
o Microvascular decompression surgery
o Stereotactic radiosurgery (gamma knife)
313
Prognosis of trigeminal neuralgia?
- Attacks can occur daily for time or can be remission
o 50% experience remissions of >6 months
- 10% will not respond to neuropathic pain drug therapy
AKT Flashcards
flashcards
Decks in class (37)
# Cards
-
Last Minute . com146
-
DVLA Advice63
-
Statistics86
-
Organisation and Management152
-
Developmental Milestones44
-
School Exclusion Illnesses11
-
Immunisation Programme44
-
2-Week Cancer Pathways34
-
Questions I Got Wrong243
-
Learning Points from Questions96
-
Notifiable Diseases5
-
BP & Diabetes Targets9
-
CYP450 DRUGS5
-
DRUGS IN PREGNANCY AND BREASTFEEDING3
-
Haematology273
-
Cardiovascular516
-
Endocrine454
-
ENT313
-
Gastrointestinal 1402
-
Gastrointestinal 2513
-
Infectious Diseases335
-
MSK370
-
Neurology 1250
-
Neurology 2242
-
Ophthalmology & Skin353
-
Psychiatry345
-
Reproductive System 1232
-
Reproductive System 2280
-
Respiratory411
-
Urinary System368
-
Gynaecology357
-
Fertility72
-
Antenatal Obstetrics399
-
Postnatal Obstetrics75
-
Contraception Drugs212
-
General Paediatrics424
-
General Paediatrics 2530
