1
Q
What is otitis media and who does it commonly affect?
A
- Infection of the middle ear
- Usually affects children
2
Q
What are the common causative organisms for acute otitis media?
A
- Pneumococcus
- Haemophilus influenzae
- Moraxella catarrhalis
- Other strep and staph spp
3
Q
What are the risk factors for otitis media?
A
- URTI
- Bottle feeding
- Passive smoking
- Use of dummy
- Presence of adenoids
- Asthma
- Malformation ie cleft palate
- In adults: GORD, ^BMI
4
Q
What are the clinical features of acute otitis media?
A
- Rapid onset ear pain
- Fever
- Irritability
- Anorexia
- Vomiting
- Preceding viral URTI - secondary bacterial infection is common
- Hearing loss
- Discharge from ear.
5
Q
How is otitis media investigated and what are some clinical signs you’d see?
A
- Otoscopy: bulging tympanic membrane/purulent discharge if ear drum has perforated
- Light reflection moves in otoscopy because of the bulge
6
Q
Management of acute otitis media?
A
-Analgesia
-Most resolve in 24hrs with abx
-Decongestants
*consider abx if systemically unwell, immunocomprimised, no improvement >4/7
>Amoxicillin for 5/7
7
Q
What are the complications of acute otitis media?
A
-Intracranial: >Meningitis >Intra-cranial abscess >Petrositis >Labyrithitis -Extracranial >Mastoiditis >Facial nerve palsy >Tympanic membrane perforation
8
Q
What is otitis media with effusion?
A
-GLUE EAR
>an effusion is present after the regression of the symptoms of acute OM
-Main cause of hearing loss in children
9
Q
What are the causes/associations of otitis media with effusion in children?
A
- URTI
- Oversized adenoids
- Narrow nasopharyngeal dimensions
- Bacterial biofilms on adenoids
10
Q
What is an important cause of OME to exclude in adults?
A
-Post-nasal space tumour
11
Q
What are some risk factors for OME?
A
- Male
- Down’s syndrome
- Cleft palate
- Winter season
- Atopy
- Children of smokers
- Primary ciliary dyskinesia
12
Q
What are the clinical features of otitis media with effusion?
A
-Hearing impairment
>Often leads to behavioural/developmental issues
-Can have no ear pain, can go unnoticed for a long time
13
Q
What investigations need to be performed for OME?
A
- Otoscopy
- Hearing assessment
- Audiograms (conductive deafness)
- Tympanometry
14
Q
What signs would be seen on otoscopy for OME?
A
- Fluid level or bubbles behind the ear drum
- Retracted drum
- Bulging drum
- Dull, grey or yellow drum
15
Q
How is OME treated?
A
- Usually mild and resolves spontaneously
- Observe for 3/12 to maximise child’s hearing
- Auto-inflation of Eustachian tube (popping ears)
- Surgery: Grommets
- Hearing aid (if surgery not an option, and bilateral hearing loss)
16
Q
What advice would you give to parents to help maximise child’s hearing if they have OME?
A
- Reduce background noise
- Sit at child’s level
- Short, simple instructions
17
Q
What’s the definition of chronic otitis media?
A
-Defined as chronic infections plus a perforated tympanic membrane
18
Q
What are the symptoms of chronic otitis media?
A
- Hearing loss
- Otorrhoea
- Feeling of fullness in the ear
- Otalgia
19
Q
What is the treatment for chonic otitis media?
A
- Topical/systemic abx
- Aural cleaning
- Water precautions
- May require surgery: myringoplasty/mastoidectomy
20
Q
What are the complications of chronic otitis media?
A
-Cholesteatoma
21
Q
What is cholesteatoma and the pathology behind it?
A
- Abnormal skin growth that develops in the middle ear behind the ear drum
- Develops as a cyst
- Prolonged low middle ear pressure allows development of retraction picket in ear drum which enlarges allowing squamous epithelium to build up and no longer escape the neck of the sack
22
Q
What are the symptoms of cholesteatoma?
A
- Foul discharge +/- deafness
- Headache
- Pain
- Facial paralysis
- Vertigo
23
Q
Treatment for cholesteatoma?
A
-Mastoid surgery
24
Q
What are some serious but rare complications of cholesteatoma?
A
- Meningitis
- Cerebral abscess
- Hearing loss
- Mastoiditis
- Facial nerve dysfunction
25
What is mastoiditis?
-Infection of the mastoid bone
>often follows ear infection
-Middle ear inflammation leads to destruction of air cells in the mastoid bone +/- abscess formation
26
What causes mastoiditis?
-Follows otitis media infection
27
What are the clinical features of mastoiditis?
- Recent URTI
- Ear discharge
- Blunting of postural sulcus
- Fluctuant tender swelling
- Pyrexia
- Ear looks pushed forwards from the front - protruding auricle
- Facial nerve palsy
- Tragal tenderness
- Swelling and redness behind the pinna
28
Management for mastoiditis?
- Systemic antibiotics (IV - needs admitting)
- Analgesia
- Urgent ENT for ?surgical drainage
29
What are the complications of mastoiditis?
- Intracranial extension
| - Meningitis
30
What is otitis externa?
-Infection of the outer ear canal
>Swimmer's ear
-DDx: contact dermatitis
31
What causes otitis externa?
- Excess canal moisture ie swimming, going on holiday
- Trauma ie itching with fingernails of eczema etc
- High humidity
- Absence of wax from self cleaning
- Narrow ear canal
- Hearing aids
32
What are common infecting organisms in otitis externa?
- Usually pseudomonas
| - Staph. aureus and E.coli
33
What are some risk factors of otitis externa?
-Eczema/dermatitis
-Frequent swimming
-Cotton buds
-Diabetics/immune suppressed
>at risk of malignant/necrotising otitis externa
34
What are the symptoms of otitis externa?
- Discharge
- Itch
- Pain
- Tragal tenderness
35
What investigations would you do on someone with otitis externa?
- Otoscopy
| - Swab for microscopy if moderate/severe
36
What signs may be seen on otoscopy in someone with otitis externa?
- Mild: scaly skin with some erythema, External Auditory Canal normal diameter
- Moderate: painful ear, narrow EAC with smelly, creamy discharge
- Severe: EAC completely occluded
37
How do you treat mild otitis externa?
- Clear the external auditory canal
- Keep ears free of water during treatment
- Hydrocortisone cream
- 'Ear calm' spray: antifungal and antibacterial
38
How do you treat moderate otitis externa?
-Clear EAC
-Keep ears free from water
-Topical abx: gentamycin
> +/- steroid drops
39
How do you treat severe otitis externa?
- Clear EAC
- Ears kept free of water during treatment
- Ear wick with aluminium acetate
- ENT referral
- After few days, meatus open up enough for micro suction or careful cleansing
40
What needs to be done with otitis externa which is resistant to treatment?
Biopsy
| >May be at risk of SCC
41
Why is it important to refer otitis externa to ENT?
- Non-responsive treatment
- Oedematous canal
- Can't get drops down
- Suspicious of malignant OE
42
What is malignant OE?
-Necrotising otitis externa
>invasive
-Aggressive, life threatening infection of the external ear
43
What are some risk factors for necrotising otitis externa?
- Diabetes
- Elderly
- Immunosuppression
44
What are the most common causative organisms of necrotising otitis externa?
- Most common: pseudomona aeruginosa
- Proteus
- Klebsiella
45
What are the clincical features of necrotising otitis externa?
- Disproportionately severe pain >opioid dependent pain killers required
- Granulomatous polypoid otitis externa
- CN involvement
46
What cranial nerves may be involved in necrotising otitis externa?
- CN VII: facial nerve
- CN IX: glossopharyngeal nerve
- CN X: vagus nerve
- CN XI: accessory nerve
- CN XII: hypoglossal nerve
47
What are some complications of necrotising otitis externa?
- Can lead to temporal bone destruction
- Base of skill osteomyelitis
- Bone infiltration
- Sepsis
- Death
48
What investigations need to be done for necrotising otitis externa?
- Monitor CRP
- Monitor pain levels
- BM for diabetics
49
How is necrotising otitis externa treated?
- Admit to hospital
- Topical abx
- Aural toilet
- IV abx: 6/52 (pseudomal cover)
- Opioid analgesia
- Surgical debridement
- Specific immunoglobulins
50
What is Ramsay-Hunt syndrome?
- aka Herpes zoster oticus
| - Herpes zoster infection of the facial nerve
51
Which group of pts is Ramsay Hunt syndrome common in?
- Elderly
| - Immunocompromised
52
What are the clinical features of Ramsay Hunt syndrome?
- Severe otalgia
- 7th Nerve palsy
- Herpes zoster vesicles (in and around the ear)
- Sometimes: vertigo, tinnitus, deafness
53
Which other cranial nerves may be sometimes involved in Ramsay Hunt syndrome?
- V
- VI
- VII
- XI
54
How is Ramsay Hunt syndrome treated?
-Acyclovir and prednisolone
55
Define furunculosis?
-Very painful abscess arising from a hair follicle within the ear canal
56
What is the most common causative organism of furunculosis?
-Staph
57
What is the most common predisposing factor for furunculosis?
-Diabetes mellitus
58
How is furunculosis managed?
- Consider lancing (cut open to releive abscess)
| - Cellulitis of the pinna: oral abx ie flucloxacillin
59
What is peri-chondrial cellulitis and how is it managed?
- Cellulitis of the pinna of the ear
| - Treat with systemic abx: flucloxacillin
60
What is sub-perichondrial haematoma and who does it commonly affect?
- Blood underneath the pinna of the ear
| - Perichondrium lifted and bleeds usually caused by sheer force trauma ie rugby players
61
How is sub-perichondrial haematoma treated and why is it important to treat?
-Needs draining
>to avoid cauliflower ear
-If left untreated: heamatoma turns to fibrous tissue and doesn't break down properly
62
How do you attempt to removea foreign body from ear?
- Ask for help if not sure
- Syrginge with warm water
- If living object: drown in olive oil/water -> syringe
63
What are some causes of referred ear pain?
- Dental disease
- Ramsay Hunt syndrome: sensory branch of facial nerve
- Primary glossopharyngeal neuralgia: CN9, induced by talking/swallowing
- Throat/laryngeal cancer: CN9/10
- Tonsilitis or quinsy: CN 9/10
- Post tonsillectomy
- Cervical spondylosis/arthritis or soft tissue injury of the neck: CN 2/3
64
What is conductive deafness?
-Deafness which is caused by anything which may obstruct the sound entering the ear
65
What is the most common cause of conductive deafness in children?
-Otitis media with effusion
66
What is the most common cause of conductive deafness in adults?
-Otosclerosis (ossicles of the ear becoming spongy with age)
67
What are some genetic causes of conductive deafness?
- Congenital structural abnormalities on the pinna, external ear canal, ear drum, ossicles
- Treacher-Collins syndrome
- Pierre Robin syndrome
- Goldenhar syndrome
68
What investigations are performed for conductive deafness?
- Neonatal hearing tests within 1st few weeks of life > otoacoustic emissions test
- Subjective hearing tests in older children ie distraction testing
- Adults: audiometry
69
How is conductive deafness managed?
- Children with glue ear: grommets
- Watch and wait: conductive problem may self resolve
- Mild otosclerosis: hearing aid
- Moderate to severe otosclerosis: surgery
70
What is a stapdectomy procedure and what is it used to treat?
- A prosthetic device inserted into a middle ear to bypass the abdormal bone and permited sound waves to travel into the inner ear
- Used for moderate-severe otosclerosis
71
What is sensorineural deafness?
-hearing loss associated with damage or abnormality to the vestibulocochlear nerve
72
Name some causes of bilateral sensorineural hearnig loss
- Drug use: ototoxic abx, chemo
- Infection: measles, meningitis, mumps
- Noise exposure
- Head trauma
73
Name some unilateral causes of sensoirneural hearing loss
-Meniere's disease
-Acoustic neuroma/vestibular schwannoma
>require MRI
74
Name some causes of sudden sensorineural hearing loss?
- Trauma
| - Viral infections
75
Name some genetic causes of sensorineural hearing loss
- AD: Waardenburg syndrome
- AR: Pendred syndrome
- X lined: Alport syndrome, Turner's syndrome
76
Name some non-genetic causes of sensorineural hearing loss
- Intrauterine TORCH infections
- Perinatal causes
- Infections
- Ototoxic drugs
- Acoustic or cranial trauma
77
What are the different TORCH infections?
- Toxoplasmosis
- Other (syphilis, HIV)
- Rubella
- CMV
- Herpes
78
What are the perinatal causes of sensorinerual hearing loss?
- Prematurity
- Hypoxia
- IVH
- Kernicterus
- Infection
79
What are the infective causes of sensorineural hearing loss?
- Meningitis
- Encephalitis
- Measles
- Mumps
80
How is sensorinerual deafness treated?
- Hearing aids
| - Cochlear implants (usually before 1)
81
Define tinnitus?
-Perception of sound in the absence of auditory stimulation
82
How can the character of tinnitus help identify the cause?
- Unilateral
- Bilateral
- Pulsatile
- Non-pulsatile
- Ringing, hissing, buzzing (inner ear or central cause)
- Popping or clicking (external ear, middle ear or palate
83
What is the difference between objective and subjective tinnitus?
- Objective: audible to examiner
| - Subjective: audible only to pt
84
What are the causes of objective tinnitus?
- Vascular disorders (AV malformations, carotid pathology)
- High output cardiac states (Pagets, hyperthyroidism, anaemia)
- Myoclonus or palatal or strapedius/tensor tympanic muscles
- Patulous Eustacian tube
85
What are the causes of subjective tinnitus?
-Commonly associated with disorders that cause SNHL
>Presbyacusis (age-related hearing loss)
>Noise induced hearing loss
>Meniere's disease
-Ototoxic drugs (cause bilateral tinnitus with associated hearing loss)
>cisplatin, aminoglycosides
>aspirin, NSAIDs, quinine, macrolides, loop diuretics
86
What investigations should be performed for tinnitus?
- Audiometry
- Tympanogram
- Investigate unilateral tinnitus to exclude acoustic neuroma - MRI
87
How is tinnitus managed?
- Treat underlying cause
- Take time to explain tinnitus
- Psych support
88
What is acoustic neuroma?
- Histological benign subarachnoid tumour
- Causes problems by local pressure
- Arise from superior vestibular Schwanna cell layer
89
Which age group is affected by acoustic neuroma?
Adults aged 30-60
90
What cause acoustic neuroma?
- Though to be malfunctioning gene on chromosome 22
- Normally this gene produces a tumour suppressor protein that helps control the growth of Schwann cells covering the nerves
91
Name a risk factor for acoustic neuroma
-Neurofibromatosis type 2
92
What are the clinical features of acoustic neuroma?
-Progressive ipsilateral tinnitus
>+/- sensorinueral deafness (cochlear nerve compression)
-Large tumours may have ipsilateral cerebella signs or signs of raised ICP
-Giddiness common
-Numb face (trigeminal compression above the tumour)
93
What investigations should be done for suspected acoustic neuroma?
-MRI for unilateral hearing loss/tinnitus
94
How is acoustic neuroma managed?
- Leave alone and monitor yearly (slow growing)
- Scan sooner if symptoms getting worse
- Surgery if necc. but not normally
- Stereotactic radiosurgery
95
Risk factors for noise induced hearing loss?
- Occupations with loud noises: builder, carpenter, armed forces
- Repeated loud noise exposure ie DJs
96
Explain the process of noise induced hearing loss
- Exposure to loud noise will cause damage to inner ear
- One-time exposure to an intense sound
- More commonly occupational: continuous exposure to loud sounds causes hearing loss
97
What are the clinical features of noise-induced hearing loss?
- Bilateral symmetrical sensorineural hearing loss
| - +/- tinnitus
98
How is noise-induced hearing loss managed?
- Reduce risk of occupational exposure
| - Hearing aids
99
Define vertigo
-Sensation that the person or the world around them is moving or spinning
100
What is vestibular vertigo?
```
-Most common kind of vertigo
>severe
>may be accompanied by loss of balance
>Nausea
>Vomiting
>Decreased hearing
>Tinnitus
>Nystagmus (horizontal)
>Diaphoresis (massive sweating)
```
101
What is central vertigo?
- Hearing loss and tinnitus is less common with vertigo symptoms
- Nystagmus can be horizontal or vertical
102
What are some causes of peripheral (vestibular) vertigo?-
- Meniere's disease
- BPPV
- Vestibular failure
- Labrinthitis
- Superior semi-circular canal dehiscence (rupture)
103
What are some causes of ventral vertigo?
- Acoustic neuroma
- MS
- Head injury
- Migraine associated dizziness
- Vertobrobasilar insufficiency
104
If vertigo symptoms last seconds to minutes, what's the most likely cause?
-BPPV
105
If vertigo symptoms last 30mins-30hrs, what's the most likely cause?
- Meniere's
| - Migraine
106
If vertigo symptoms last 30hrs-tweeks, what's the most likely cause?
-Acute vestibular failure
107
What is an important question to ask when someone reports dizziness?
- Did the world seem to spin like getting off a playground roundabout?
- Which direction are you spinning in? (people with vertigo always know which way, if no idea: further investigation required)
108
What symptoms could point towards another diagnosis?
-Light headedness +/- sense of collapse
| >can be vascular, ocular, MSK, metabolic, claustrophobic
109
What examination should be done for someone with vertigo?
- CNS exam and ears
- Cerebellar function and reflexes
- Assess: nystagmus, gait, Romberg's test
- Audiometry and MRI if unsure
110
How is Romberg's test useful in vertigo?
-+ve if balance is worse when eyes are shut
| >defective proprioception or vestibular input
111
Which specific provocation test can be used to diagnose BPPV?
-Dix-Hallpike maoeuvre
112
How is vertigo treated?
-Treat underlying cause
113
What is BPPV?
-Benign paroxysmal positional vertigo (most common type of peripheral vertigo)
114
What causes BPPV?
-Displacement of otoliths stimulating the semi-circular canals
>can be idiopathic or post head injury
115
What are the clinical features of BPPV?
- Attacks of sudden rotational vertigo lasting >30 seconds
- Provoked by head turning
- Complain of vertigo when rolling over in bed
116
What are some important 'negative symptoms' to establish if a pt presents with suspected BPPV?
- No persistent vertigo
- No speech, visual, motor or sensory problems
- No tinnitus, headaches, ataxia, facial numbness or dysphagia
- No vertical nystagmus
117
How do you investigate suspected BPPV?
-Dix-Hallpike manouever test is positive
118
How is BPPV treated?
- Usually self limiting
- Persistent: Epley manoeuvre
- Home repositioning manoeuvres
119
What are the quadrad of symptoms that makes up Meniere's disease?
- Vertigo
- Tinnitus
- Hearing loss
- Feeling of fullness in the ears
120
What causes Meniere's disease?
-Unknown
-Pathology:
>dilatation of the endolymphatic spaces of the membranous labyrinth causes sudden attacks of vertigo lasting 2-4hrs
121
What are the clinical features of Meniere's disease?
- Suddent attacks of vertigo lasting 2-4 hrs
- Nystagmus always present
- Increasing fullness in the ears +/- tinnitus and vertigo
- Bilateral symptoms
- Fluctuating SNHL and can become permanent
122
What investigations should be done for Meniere's disease?
- Electro-cochleography
| - Posterior fossa MRI
123
What is the acute treatment for Meniere's disease?
-Prochlorperazine (short term vestibular sedative)
124
What medication can be used as prophylaxis for Meniere's disease?
-Betahistine
125
What are some surgical approaches that can be used as treatment for persistent symptoms of Meniere's disease?
-Instilation of gentamicin via grommet
-Labyrinthectomy
(causes ipsilateral deafness)
-Vestibular neurectomy
126
What is acute vestibular failure?
- AKA labyrinthitis
| - Inflammation of the labyrinth (cochlear and semi-circular canals)
127
What are the symptoms of labyrinthitis/acute we failure?
- Sudden attacks of unilateral vertigo and vomiting in previously well person
- Often follows a recent URTI
- Lasts 1-2 days
- Improves over a week
128
What clinical signs wouold be seen in labyrinthitis?
-Nystagmus
| >away from the affected side
129
How is labyrinthitis diagnosed?
- Clinical diagnosis
| - Audiogram if there is hearing loss
130
How is labyrinthitis treated?
- Usually self resolves within 1-2 weeks
| - Vestibular suppressants for symptomatic relief: prochloperazine
131
How is rhinosinusitis defined?
-Inflammation of the nose and paransal sinuses with >2 of:
>nasal blockage/obstruction/congestion/nasal discharge
>+/- facial pressure
>Reduction or loss of smell
-Endoscopic or CT signs
132
How can rhinosinusitis be classified?
- Mild, moderate or severe
- Acute (ARS)
- Chronic (CRS) > if lasting >12/52
133
What are some risk factors for rhinosinusitis?
- Family history
- Hay fever
- More common in children
134
Causes of rhinosinusitis?
- Acute rhinosinusitis (common cold)
- Acute post-viral sinusitis
- Chronic rhinosinusitis +/- nasal polyps
- Allergic rhinosinusitis
135
What are some causes of chonic rhinorrhoea?
- Foreign body
- CSF leak post head injury
- Bacteria (TB)
- HIV
- Cystic fibrosis
- Age
- Pregnancy
- Decongestant overdose
- Antibody deficiency
136
What are some causes of nasal congestion in children?
- Large adenoids
- Choanal atresia (congenital blockage of one or both nasal passages by bone or tissue)
- Post-nasal space tumour
- Foreign body
137
What are some causes of nasal congestion in adults?
- Deviated/defected nasal septum
- Granuloma (TB, syphilis, granulomatosis, leprosy)
- Topical vasoconstrictors
- TCAs
138
Which other symptoms are a cause for urgent referral in someone with nasal congestion?
- Numbness
- Tooth loss
- Bleeding
- Unilateral obstructing mass
139
What are the symptoms of rhinosinusitis?
- Watery anterior rhinorrhoea
- Sneezing
- Purulent post-nasal drip
- Nasal obstruction
- Mouth breathing
- Snoring
- Headaches (worse when leaning forwards)
140
What are they symptoms of allergic rhinosinusitis?
-May be seasonal (hay fever)
-May be chronic
-Sneezing
-Pruritus
-Nasal discharge
-Bilateral red and itchy eyes
>caused by IgE medicated inflammation from allergen exposure
141
What are some signs of allergic rhinosinusitis on examination?
- Swollen turbinates
- Pale/mauve mucosa
- Nasal polyps
142
What investigations should be done for someone with chronic rhinosinusitis with nasal polyps?
-Anterior rhinoscopy
-Nasal endoscopy
>a single unilateral polyp needs biopsy to exclude rare intranasal pathology
-Consider allergy testing
143
What investigations should be done for allergic rhinosinusitis?
- Allergy testing
| - Test for eczema
144
How can chronic rhinosinusitis with nasal polyps be treated medically?
- Topical steroid drops to shrink plyps for 2/52 (beclomethasone)
- Fluticasone for 3/12
- Long term abx ie doxycyclline
145
How can chronic rhinosinusitis with nasal polyps be treated surgically?
- Endoscopic sinus surgery
| - Consider when max medical Rx fails
146
How is chronic rhinosinusitis (without polyps) treated?
- Intranasal corticosteroids
- Nasal saline irrigation
- If no improvement after 4 weeks – microbiological cultures, long term (>12 weeks) Abx if IgE is not elevated
- Perform CT scan if poor response to treatment, consider surgery
147
How is allergic rhinosinusitis treated?
- Allergen/irritant avoidance
- Nasal saline irrigation
- Antihistamines ie loratadine
- Intranasal corticosteroid sprays ie fluticasone
- Short course prednisolone
- Immunotherapy
148
What is acute bacterial rhinosinusitis?
-Infection of the paranasal sinuses
149
What causes acute bacterial rhinosinusitis?
-Obstruction impairs drainage and occurs due to:
>anatomical problems: septal deviation, polyps, mechanical ventilation and Ng tubes
>mucosal problems: viruses causing mucosal oedema and decreased ciliary action
150
What is the main cause of acute bacterial rhinosinusitis?
-Viral infection
151
What are the common infecting organisms in acute bacterial sinusitis?
- Strep. pneumonia
- H. influenzae
- S. aureus
- Moraxella catarrhalis
- Fungi
152
What are the clinical features of acute bacterial sinusitis?
- Discoloured discharge and purulent secretions in nasal cavity
- Severe local pain
- Fever >38
- Elevated ESR/CRP
- Double sickening (deterioration after initial milder phase of illness)
- Headaches
- Pain worse on leaning forwards
153
What are some red flag symptoms which would make you suspect cancer of the paranasal sinuses?
- Onset for the first time later in life
- Blood stained nasal discharge and nasal obstruction
- Cheek swelling
154
What are some differential diagnoses for acute bacterial sinusitis?
- Migraine
- TMJ dysfunction
- Dental pain
- Neuropathic pain
- Temporal arteritis
- Herpes zoster
155
Investigations for acute bacterial sinusitis?
- Clinical diagnosis
| - Recurrent/chronic sinusitis: CT paranasal sinuses and nasal endoscopy
156
What is the treatment for an acute/single episode of sinusitis?
- Mainly viral so self limiting
- Simple analgesia
- Nasal saline irrigations
- Intranasal decongestants (ephidrine)
- Abx if bacterial infection suspected
157
What are some possible complications of bacterial sinusitis?
- Orbital cellulits/abscess *EMERGENCY*
- Intracranial involvement ie meningitis
- Mucocele infections
- Osteomyelitis (staph) of frontal bone
- Pott's puffy tumour
158
What are some important features to exclude in someone presenting with a nasal fracture?
- Head or c-spine injury
| - Septal haematoma
159
What is the most common cause of nasal fracture and how do they normally present?
-Direct trauma
| >often presents with obvious deformity or epistaxis
160
How is a nasal fracture treated?
- Treat epistaxis
- Advise on analgesia/using ice
- Close skin injury
- Reassess 5-7/7 post injury
- Ensure no septal heamatoma
- MUA 10-14/7 after injury before nasal bones set if required
161
What causes CSF rhinorrhoea?
-Ethmoidal fracture
>usually follows head trauma: frontobasal skull fracture or intracranial surgery
-If not associated with trauma: look for tumour
162
How should CSF rhinorrhoea be investigated?
- X ray skull(fractures)
| - Nasal CSF testing: +ve for glucose
163
How should CSF rhinorrhoea be managed?
-Traumatic: conservative management
>7-10/7 bed rest and head elevation
>avoid coughing/nose blowing
-Cover with abx and pneumococcal vaccine
164
How should a foreign body in the nose be treated?
- Ask child to blow nose if possible
- Be wary of using forceps to pull things out
- refer to ENT if failed attempt/ uncoopertive pt
165
What are the causes of nasal septal perforation
- Most common: septal surgery
- Trauma: nose picking, foreign body, laceration
- Inhalants: nasal steroids/decongestant sprays, cocaine abuse
- Infection: TB. syphilis, HIV
- Inflammation/malignancies: SSC, churg strauss, vasculitis
166
What are the symptoms of nasal septal perforation?
- Irritation
- Whistling
- Crusting
- Bleeding
167
How is nasal septal perforation treated?
-Symptom relief:
>nasal saline irrigation
>petroleum jelly at the edge of perforation
-Surgical closure
168
What is the most common ENT emergency?
-Epistaxis
>anterior easily seen with rhinoscopy, easier to treat/less severe
>posterior
169
What causes epistaxis?
- Local trauma ie nose picking
- Facial trauma
- Dry/cold weather
- Haemophillia and other bleeding disorders
- Septal perforation
170
How should epistaxis be managed?
- Nasal packing
- Balloons
- Catheterise and compression
171
How is a septal haematoma managed?
-Draining in theatre
>can become infected and damage the nasal cartilage
>pus can drain backwards to the brain due to venous drainage into the cavernous sinus
172
What is tonsilitis?
-Inflammation of the tonsils
>viral or bacterial
>causes an acute sore throat
173
What are the most common viral causes of tonisillitis?
- Common cold: rhinovirus, parainfluenza, coronavirus
- Influenza A&B
- Adenovirus
- HSV
- EBV (glandular fever)
174
What are some bacterial causes of tonisilitis?
- Group A beta haemolytic strep (pyogenes)
| - Rarer: H,influenza B
175
Which criteria should be used for tonsilitis and it's treatment?
- Feverpain score
| - Used to be centor criteria
176
What are the centor criteria?
- Tonsillar exudate
- Tender anterior cervical lymphadenopathy
- History of fever
- Absence of cough
* 3/4 suggest staph infection
177
What are the feverpain criteria?
- Fever in past 24hrs
- Absence of cough/coryza
- Symptom onset <3 days
- Purulent tonsils
- Severe tonsil inflammation
178
How should tonsilitis be managed?
- Symptomatic relief
- Abx if score suggests it
- If immunosuppressed: seek urgent specialist advice
- If on DMARDS or carbimazole: check FBC urgently
179
Why should FBC be checked urgently in someone that is on DMARDS/carbimazole with a sore throat?
-Causes agranulocytosis
180
Which abx should be used for tonsilitis ?
-Penicillin V for 10/7
181
What abx should be used if allergic to penicillin for tonsilitis?
-Clarithromycin or erythromycin for 5/7
182
What abx is important to avoid in tonsilitis?
-Amoxicillin
| >if tonsilitis is due to EBV, amox will cause widespread maculopapular rash
183
Indications for tonsilectomy?
-Certainty that recurrent sore throat is due to tonsillitis
-Episodes of sore throat must be disabling
>7 documented cases in 1 year
-OSA
-Quinsy
-Suspicion of malignancy
184
Complications of tonsillectomy?
-Primary and secondary haemorrhage
185
Complications of tonsillitis?
- Ottiis media
- Sinusitis
- Peritonsillar abscess (quinsy)
- Pharyngeal abscess
- Lemierre syndrome (acute septicaemia and jugular vein thrombosis)
186
What is a peritonsillar abscess or quinsy?
- Sore throat
- dysphagia
- peritonsillar bulge
- trismus
- muffled voice
- Needs abx and aspiration
187
Define stridor
-High pitched inspiratory noise from partial obstruction of the larynx or large airways
188
Define stertor
- Inspiratory snoring noise: obstruction of the pharynx
| - Heard in post-ictal phase of Tonic clonic seizure
189
Why is stridor more obvious in children than in adults?
-Children's airways are narrower than adults so obstruction happens faster and more dramatically
190
Name the most common congenital cause of stridor?
-Laryngomalacia (soft immature cartilage of the upper larynx collapses inwards during inhalation)
191
Name some inflammatory causes of stridor?
- Laryngitis
- Epiglottitis
- Croup
- Anaphylaxis
192
Name some tumours that can cause stridor?
- Haemangiomas
- Papillomas
- Oesophagela cancer
- Any cancer of the throat
193
Name some traumatic causes of stridor
- Thermal/chemical burns
| - Intubation
194
Name some infetive causes of stridor
- Laryngotrachobronchitis (croup)
| - Acute epiglottitis
195
What are the clinical features of stridor/impending obstruction?
- Audible inspiratory sounds
- Swalloing difficulty/drooling
- Pallor/cyanosis
- Use of accessory muscles of respiration
- Downward plunging of the trachea with respiration (tracheal tug)
196
What are the clinical features of laryngomalacia?
- Excessive collapse and indrawing of the supraglottic airways during inspiration = stridor
- Commonly seen in new borns
- Breathing and feeding difficulties
- Usually resolves by 2 years and no treatment is needed
197
How should acute airway obstruction be managed in adults?
- Help
- ABCDE
- O2
- Nebulised adrenaline
- Call oncall ENT/anaesthetist
- ET intubation
- Emergency needle criothyroidotomy
- Surgical cricothyroidotomy
198
Deifine dysphonia?
-Hoarseness of voice
199
Causes of dysphonia?
- Viral URTI
- Laryngeal carcinoma
- VOice overuse
- Vocal cord palsy
- Reflux laryngitis
- Reinke's oedema
- Vocal cord nodules
- Muscle tension/spasm
- Children with functional speech disorders
200
What is Reinke's oedema?
-Chronic cord irritation from smoking +/- chronic voice abuse causing gelatinous fusiform enlargement of the cords = deep gruff voice
201
What are the clinical features of dystonia?
- Vocal cord palsy: weak, breathy voice
- Laryngitis: pain on speaing, fever
- Reflux laryngitis: GORD symptoms
- Vocal cord nodules: variable, husky voice
202
Why is it important to investigate hoarseness of voice?
- dysphonia is the main and often only presenting compliant of laryngeal carcinoma
- Especially important to check in smokers
- >any hoarseness that lasts >3 weeks
203
How should someone with a hoarse voice be assessed?
- SALT assessment
- Head and neck examination
- Neurological examination
- Respiratory examination
- Voice handicap index
- Reflux symptoms index
- Laryngoscopy
- CT/MRI head neck larynx chest
- Biopsy
204
How should hoarseness caused by laryngitis be treated?
- Supportive
| - Phenoxymethylpenicillin if necessary
205
How should hoarseness caused by reflux laryngitis be treated?
- PPI
- Diet/lifestyle alterations
- Weight loss
- Surgical fundoplication
206
How should hoarseness caused by Reinke's oedema be treated?
- Smoking cessation
- SALT
- Laser therapy
207
How should hoarseness caused by vocal cord nodules be treated?
-Speech therapy and surgical excision
208
How should hoarseness caused by spasmodic dysphonia be treated?
-Botox injections into laryngeal muscles
209
How should hoarseness caused by muscle tension dysphoniabe treated?
- Reassure and explanation
| - Speech therapy
210
How should hoarseness caused by cancer be treated?
- Surgery
- Radio
- Chemo
211
What 'vocal hygiene' advice would you give to someone with dysphonia?
- Drink plenty
- Sleep well
- Take adequate breaths whilst speaking
- Steam inhalations to hydrate the coval cords
- Avoid shouting or whispering
- Rest voice if feel tired
- Avoid excess throat clearing
- Avoid irritants ie spicy food, tobacco, smoke, dust, alcohol
- Avoid late night eating
- Avoid throar lozenges
212
What is laryngeal nerve palsy?
-Paralysis or the recurrent laryngeal nerve
>supplies the intrinsic muscles of the larynx (apart from the cricothyroid)
>abduction and adduction of the vocal fold
>originates from the vagus nerve
213
What causes laryngeal nerve palsy?
```
-Cancer of the:
> larynx, thyroid, oesophagus, hypopharynx, bronchus
-Iatrogenic (surgery)
-CNS disease
>polio, syringomyelia
-TB
-Aortic aneurysm
-Idiopathic (post viral neuropathy)
```
214
What are the clinical features of laryngeal nerve palsy?
- Weak 'breathy' voice
- Weak cough
- Repeated coughing/aspiration
- Exertional dyspnoea
215
What investigations should be done for someone with larygneal nerve palsy?
- CXR
| - if CXR normal: CT +/- USS thyroid +/- OGD
216
How should larygneal nerve palsy be managed?
-Malignant: treat underlying cancer
-Non-malignant:
>unilateral palsies: compensation by contralateral cord: injections and thyroplasty
>Reinnervation techniques
217
Describe the course of the facial nerve?
- Arises in the medulla oblongata
- Emerges between the pons and the medulla
- Passes through the posterior fossa
- Runs through the middle ears
- Emerges from the stylomastoid foramen into the parotid
218
What are the intracranial branches of the facial nerve?
- Greater superficial petrosal nerve: lacrimation
- Branch to strapedius: (lesions above causes hyperacusis)
- Chorda tympani: supples taste to the anterior 2/3 of tongue
219
What is hyperacusis?
-Increased sensitivity to certain volumes/frequencies of sounds
220
What are the extracranial branches of the facial nerve?
- Temporal
- Zygomatic
- Buccal
- Marginal mandibular
- Cervical
- Posterior auricular nerve
221
Where do the extracranial brnaches of the facial nerve emerge from? What type of nerves are they?
- Stylomastoid foramen
| - Motor fibres
222
Where does the facial nerve branch into the 5 major branches to control facial expression?
-Parotid
223
What is the name for idiopathic facial palsy?
-Bell's palsy
224
What are some intracranial causes for facial nerve palsy?
- Brainstem tumours
- Stroke
- Polio
- MS
- Cerebellopontine angle lesions ie acoustic neuroma, meningitis
225
What are some intratemporal causes of facial nerve palsy?
- Otitis media
- Ramsay hunt syndrome (shingles of the facial nerve)
- Cholesteatoma
226
What are some infratemporal causes of facial nerve palsy?
- Parotid tumours
| - Trauma leading to complete palsy
227
What are some other causes of facial nerve palsy?
- Lyme's disease
- Sarcoidosis
- Diabetes
- Bell's palsy
- MS
228
Name some risk factors for Bell's palsy?
- Pregnancy
| - Diabetes
229
What is the difference between an UMN and LMN facial nerve palsy on clinical examination?
- LMN lesions: paralysed all of one side of the face
| - UMN lesions: forehead muscles spared due to bilateral innervation
230
What are the symptoms of Bell's palsy?
- Abrupt onset
- Complete weakness at 24-72hrs
- Mouth sagging/drooping
- Dribbling
- Watering or dry eyes
- Impaired brow wrinkling
- Impaired whistling
- Impaired eye-lid closure
- Impaired cheek pouting
- Impaired speech/taste
231
What investigations should be done for a facial nerve palsy?
- ESR
- Glucose
- Lyme disease serology
- Parotid gland examination
- Examine ears: cholesteatoma, Ramsy Hunt
- History: head trauma
- CT/MRI brain if suspicious of CVA, MS, fracture
232
How is facial nerve palsy treated?
-Prednisolone
-Protection of the eye (lubricating drops)
-Referral for:
>recurrent, bilateral palsy, no sign of improvement after 1m)
233
What referral pathway should be followed for any ? malignant neck lumps?
- 2WW
| - Urgent ENT referral
234
What are some causes of midline neck lumps?
- Dermoid cyst
- Thyroglossal cyst (moves up on protruding the tongue)
- Thyroid mass
- Chondroma (bony and hard on paplation - benign cartilaginous tumour)
235
What are the causes for neck lumps in the submandibular triangle?
- Reactive lymphadenopathy
- Malignant lymphadenopathy ie ass. w/ B symptoms
- TB
- Submandibular salivary stone
- Tumour
- Sialadenitis (inflammation of the salivary glands)
236
What are the causes of neck lumps found in the anterior triangle?
- Lymphadenopathy
- Branchial cysts
- Partoid tumour
- Laryngoceles
- Carotid artery aneurysm
- Tortuous carotid artery
- Carotid body tumour
237
What are some causes of neck lumps in the posterior triangle?
- Cervical rib
- Pharyngeal pouches
- Cystic hygromas
- Lymphoma (if lymphadenopathy and B symptoms are present)
238
Investigations for neck lumps?
- Uss (shows lump architecture and vascularity)
- CT (defines mass in relation to anatomical structures)
- Virology ie EBV
- Mantoux test
- CXR (malignancy or BHL in sarcoidosis)
239
How should neck lumps be managed ?
- Treat underlying cause
| - Urgent ENT referral if ?malignancy
240
What are the names of the 3 major pairs of salivary glands?
- Parotid
- Submandibular
- Sublingual
241
How should the salivary glands be examined?
- Look for external swellings
- Paplate for stones
- Test faical nerve function
- Assess mass: size, mobility, fixed
- Assess surrounding skin
242
Define sialadenitis?
-Actue infection of the submandibular or parotid glands
-Usually in elderly or debilitated pts
>dehydrated, poor oral hygiene
243
What are the symptoms of sialedenitis?
- Painful diffuse swelling of the gland
- Fever
- Pressure applied over the gland = pus leakage
- Pain and swelling on eating
- Chronic infections can be caused by strictures from previous infection or salivary gland stones
244
How is sialadenitis treated?
- ABX and good oral hygiene
- Sialogogues to stimulate salivation ie pineapple
- Surgical drainage
245
Define sialotithiasis
-Salivary gland stones
| >usually affects the submandibular gland
246
What are the clinical features of salivary gland stones?
- Pain
- Tense swelling of the gland during/after meals
- Stone may be palpable in floor of mouth
247
What management should be done for suspected salivary gland stones?
- Small stones may pass spontabneously
- Sialogogues
- Larger stones may need surgical removal
248
Name some inflammatory conditions which affect the salivary glands?
- Sjorgren's syndrome
- Viral infections
- Granulomatous disease ie TB sarcoidosis
249
Which salivary gland is most commonly affected by tumours?
-Parotid
250
What are the risk factors for salivary gland malignancy?
- Radiation to the neck
| - Smoking
251
What are they symptoms of salivary gland malignancy?
- Hard fixed mass +/- pain
- Overlying skin ulceration
- Local LN enlargement
- Doesn't vary in size when eating (like in inflammation or stones)
- Ass. facial nerve palsy
252
How should salivary gland malignancy be managed?
- Urgent ENT referral
- USS/MRI
- CT guided biopsy
- Surgery, radiotherapy
253
Define xerostomia
-Dry mouth
254
What are the causes of dry mouth?
-Hypnotics and tricyclics
-Antipsychotics
-Beta blockers
-Mouth breathing
-Diuretics
-Dehydration
-ENT radiotherapy
-Sjogren's syndrome
-SLE and scleroderma
-Sarcoidosis
HIV/AIDs
-Parotid stones
255
What are the clinical signs of dry mouth?
- Dry atrophic fissured oral mucosa
- Discomfort (difficulty eating, speaking etc)
- No saliva pooling in the floor of mouth
- Difficulty in expressing saliva from major ducts
256
What are the complications of a chronic dry mouth?
- Dental caries
- Candida infection
- Ulceration/sores
257
How is dry mouth treated?
- Increased oral fluid intake
- Good dental hygiene
- No acidic drinks or foods
- Saliva substitutes ie biotene
258
When should an oral ulcer be referred for secialist assessmeent?
- When it has not healed for 3 weeks
| - Needs biopsy to exclude malignancy
259
What are the main causes of facial pain?
- Tooth pathology
- Sinusitis
- TMJ dysfunction
- Salivary gland pathology
- Migraine
- Trigeminal neuralgia
- Atypical facial pain
- Trauma
- Angina
- Cluster headache
- Frontal bone osteomyelitis (post sinusitis)
- ENT tumours
260
What is the main histological type of cancer found in the head and neck?
-Squamous cell carcinoma
261
Where can oropharyngeal neoplasms occur?
- Oral cavity
- Oropharynx
- Hypopharynx
- Larynx
- Trachea
262
Risk factors for oropharyngeal neoplams?
- Smoking
- Alcohol
- Vitamin A&C deficiency
- HPV
- GORD
- Socioeconomic deprivation
263
Clinical features of oropharyngeal cancers?
- Neck pain/lump
- Hoarse voice/sore throat >6 weeks
- Mouth bleeding/numbness
- Sore tongue
- Painless ulcers
- Patches in the mouth
- Earache/effusion
- Lumps
- Speech change
- Dysphagia
264
What ar ethe clinical features of oral cavity and tongue cancer?
- Uncommon in the UK
- Painful persistent ulcers
- White or red patches on tongue, gums, mucosa
- Otalgia
- Odonophagia (pain with swallowing)
- Lymphadenopathy
265
Clinical features of oropharyngeal carcinoma?
- Older pt
| - smoker with sore throat or sensation of lump and complaining of otalgia
266
Describe the typical pt for larygneal cancer
- Older
- Male smoker with progressive hoarseness > stridor.
- Difficulty/pain on swallowing
- Haemoptysis
- Ear pain
- IF younger, usually HPV +VE
267
How should suspected oropharyngeal cancer be investigated?
- Pts with suspicious symptoms
- Endoscopy
- Fine Needle Aspiration or biopsy of masses
- CT/MRI of primary tumour site
- TNM staging
268
How is oropharyngeal cancer managed?
- MDT
- Radiotherapy
- Surgery
269
What is TMJ syndrome?
- Temporomandibular joint dysfunction
| - Biopsychosocial disorder = can become a chronic pain syndrome
270
Symtpoms of TMJ syndrome?
- Earache
- Facial pain
- Joint clicking/popping related to teeth grinding or joint derangement
- Stress
271
Signs of TMJ dysfunction?
- Joint tenderness exacerbated by lateral movement of the open jaw
- trigger points in the pterygoids (chewing muscle)
272
How it TMJ syndrome treated?
- Usually self limiting
- Simple analgesia
- Soecialist treatment: oral splinting, physiotherapy
- CBT
273
What are the clinical signs of basal skull fracture?
- Peri-orbital haematoma (panda eyes)
- Battle sign (significant bruise behind the ear)
- Cranial nerve palsies
274
What investigations should be uone for a suspected basal skull fracture?
- X ray skull
| - Examination of the cranial nerves
275
Management of a basal skull fracture?
-Admit under head injury team for neuro obs
-Non-urgent ENT referral
-CNVII - ENT emergency
>drill into ear to relieve pressure
276
What investigations should be done for someone with a nasal fracture and how should it be treated?
- Exclude other max-fax fractures
- Exclude CSF rhinorrhoea
- Routine referral if there is a deformity
- Urgent referral if obvious deformity
- Analgesia
- Repair
277
What is orbital cellulitis and how is it managed?
- Cellulitis of the orbit
- Children: systemic abx ie cefuroxime, met, fluclox
- Otrivine (reduces nasal congestion symptoms)
- analgesia
278
What are clincial features of cavernous sinus thrombosis
- Chemosis
| - Ophthalmoplegia
279
What is the difference between primary and secondary haemorrhage post-tonsillectomy
- Primary: reactive (occurs within 24 hours after tonsillectomy)
- Secondary: occurs >24hrs after tonisllectomy
280
How should a primary haemorrhage post tonsillectomy be managed?
-Requires immediate return to theatre due to risk of further extensive bleeding
281
How should a secondary haemorrhage post tonsillectomy be managed?
-More likely to be due to infection so treat with abx
282
Where is the most likely area for bleeding to occur from in the nose?
-Anterior nasal septum (little's area)
| >an area of 4 confluencing arteries
283
What is a branchial cyst?
- A mobile cystic mass
- Develops between the sternocleidomastoid and the pharynx
- Develops due to failure of obliteration of the second branchial cleft in embryonic development
284
Which drugs can cause gingical hyperplasia (overgrowth of gums)?
- Phenyotin
- Ciclosporin
- Calcium channel blockers
285
How is quinsy managed?
- Iv abx
| - Surgical drainage
286
What is the main side effect of using topical decongestants fro prolonged periods?
-Tachyphylaxis
| >increasing the doses is needed to proivde the same effect
