MSRA Content > ENT - Level 2 > Flashcards

ENT - Level 2 Flashcards

(197 cards)

Study These Flashcards
1
Q

Definition of otitis externa?

A
  • 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)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Defintion of malignant otitis externa?

A

o Aggressive infection affecting immunocompromised or DM or elderly which spreads to bone surrounding ear canal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Epidemiology of otitis externa?

A
  • Prevalence increases at end of summer
  • Common >1% diagnosed per year
  • Women > Men
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Causative organisms of otitis externa?

A 
-	Bacterial
o	S.Aureus
o	Pseudomonas sp.
-	Fungal
o	Aspergillus
o	Candida Albicans
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Other causes of otitis externa?

A
  • Seborrhoeic Dermatitis
  • Contact dermatitis (irritant or allergen)
  • Trauma (scratching, aggressive, ear syringing, foreign objects, cotton buds)
  • Swimming
  • High humidity
  • Narrow ear canal
  • Hearing aids
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Symptoms of otitis externa?

A
  • Minimal discharge
  • Itch
  • Pain – made worse by moving pinna
  • Hearing Loss
  • Tender regional lymphadenitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Signs of otitis externa?

A 
-	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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Symptoms of chronic otitis externa?

A
  • Lack of earwax
  • Dry hypertrophic skin, partial stenosis of canal
  • Pain on manipulation of external ear canal
  • Constant itch and discomfort
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Symptoms of malignant otitis externa?

A
  • Granulation tissue at bone-cartilage junction of ear canal
  • Facial nerve palsy
  • Temperature >39
  • Severe pain and headache
  • Vertigo
  • Profound hearing loss
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Diagnosis of otitis externa?

A
  • Clinical Diagnosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

When to swab ear in otitis externa?

A

o Treatment fails, recurrent or chronic

o Infection spread or severe enough for oral antibiotics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Management of otitis externa - general measures?

A 
	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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Management of otitis externa - medical therapy?

A

 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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Management of otitis externa - when to ear swab?

A 
	Treatment failure
	Recurrent or chronic
	Topical treatment cannot be delivered
	Infection spread beyond EAC
	Need oral antibiotics
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Management of otitis externa - when to refer?

A

 Symptoms not improved despite treatment
 Cellulitis extensive
 Pain extreme
 Micro-suction or ear wick insertion required
 Requiring incision and drainage of furuncle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Management of otitis externa - when to refer urgently?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Management of chronic otitis externa - if fungal nfection suspected?

A

 Topical clotrimazole 1% solution/acetic acid 2% spray/

 Seek specialist advice if inadequate response

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Management of chronic otitis externa - if irritant or allergic dermatitis?

A

 Advise person to avoid contact with irritant or allergen

 Give topical corticosteroid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Management of chronic otitis externa - if seborrheoic dermatitis?

A

 Topical antifungal/corticosteroid combination

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Management of chronic otitis externa - if no evident cause?

A

 7 days topical corticosteroid with acetic acid spray

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Management of chronic otitis externa - when to refer?

A

 Does not respond to treatment
 Contact sensitivity suspected
 Ear canal occluded
 Malignant otitis is suspected

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Complications of otitis externa?

A
  • Abscess
  • Chronic otitis externa
  • Fibrosis
  • Myringitis
  • Tympanic membrane perforation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Prognosis of otitis externa?

A
  • Symptoms usually improve within 48-72 hours of initiation of treatment
  • Resolves within 7-10 days
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is ear wax?

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
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
26
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
27
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 ```
28
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
29
Signs of ear wax?
- Signs on otoscopy | o Wax in ear canal (may occlude whole canal)
30
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
31
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
32
Management of ear wax - safety net?
o If develop earache, itching, discharge from ear, swelling of ear canal come back
33
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
34
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
35
Management of ear wax - complications of removing ear wax?
• Failure, otitis externa, perforation, pain, vertigo
36
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
37
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
38
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
39
Complications of ear wax?
o Conductive hearing loss | o Discomfort
40
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
41
Severity of hearing loss?
o Mild – 25-39dB o Moderate 40-69dB o Severe – 70-94dB o Profound - >95dB
42
Epidemiology of hearing loss?
- Prevalence increases with age | - Most common is age related hearing loss
43
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)
44
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)
45
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
46
Symptoms of noise-related hearing loss?
o Hx of exposure to persistent high levels of noise | o Associated with tinnitus
47
Symptoms of sensorineural hearing loss?
o Bilateral hearing loss within 72 hours | o May have tinnitus, sensation of fullness in ear and vertigo
48
Symptoms of labyrinthitis?
o Tinnitus and vertigo common
49
Symptoms of acoustic neuroma?
o Gradual onset, unilateral hearing loss associated with tinnitus and vertigo
50
Assessment of hearing loss?
``` o History o Examination o Otoscopy o Weber Test o Rinne’s Test o Cranial Nerve and Cerebellar tests ```
51
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
52
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
53
Further investigations in hearing loss?
o Audiology assessment if underlying systemic condition
54
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
55
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
56
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
57
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
58
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
59
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
60
Management of hearing loss in secondary care - non-induced hearing loss?
* Reduced occupational risk | * Tinnitus retraining therapy
61
Management of hearing loss in secondary care - otosclerosis?
* Hearing aid | * Surgery – stapedectomy, stapedotomy
62
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
63
Follow up in audiological services?
 6-12 weeks after hearing aids fitted
64
Definition of acoustic neuroma?
- Tumour of vestibulocochlear nerve (CN8) arising from Schwann cells of nerve sheath - Typically benign and slow-growing
65
Risk factors of acoustic neuroma?
o Neurofibromatosis | o High-dose ionising radiation
66
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
67
Investigations of acoustic neuroma?
o Audiology assessment | o MRI scan – for all with unilateral hearing loss
68
Management of acoustic neuroma - observation?
 Small neuromas and good preserved hearing |  Annual scans to monitor growth – if detected then active management
69
Management of acoustic neuroma - surgery?
 Microsurgery – removal of tumour |  Stereotactic radiosurgery – single large dose of radiation using high-energy X rays or gamma rays
70
What are the most common causes of vertigo?
BPPV, Meniere's and vestibular neuronitis
71
Definition of vertigo?
- Vertigo is false sensation of movement (spinning or rotating) of the person or their surroundings in absence any actual physical movement
72
Peripheral causes of vertigo?
```  BPPV  Labryrinthitis  Meniere’s Disease  Perilymphatic fistula  Ototoxicity  Syphilis ```
73
Central causes of vertigo?
 Migraine |  Stroke
74
Tests to perform in vertigo?
- Romberg’s test - Dix-Hallpike manoeuvre - Head impulse test - Unterberger’s test
75
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
76
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
77
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
78
What is Unterberger's test in vertigo?
o March on spot with eyes closed | o Person will rotate to side of affected labyrinth
79
Common features of peripheral vertigo?
 Prolonged, severe vertigo  New-onset headache or recent trauma  CV risk factors
80
Common features of central vertigo?
 Normal neurological examination  Severe N&V  Hearing loss
81
Management of central vertigo?
o Admit or urgently refer to ENT | o Prochlorprazine, cyclizine, promethazine whilst awaiting referral
82
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
83
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 ```
84
Definition of BPPV?
- Disorder of inner ear characterised by repeated episodes of positional vertigo and positional nystagmus on performing diagnostic manoeuvres
85
Epidemiology of BPPV?
- Most common cause of vertigo - Women more commonly - Posterior semi-circular canal most commonly affected 85-90%
86
Risk Factors of BPPV?
o Head injury o Prolonged recumbent position (vet, hairdresser) o Ear surgery o Ear pathology (labyrinthitis, Meniere’s)
87
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
88
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
89
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
90
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
91
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’
92
Management of BPPV - if mild?
o Watchful waiting
93
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
94
Management of BPPV - when to admit?
o If severe N&V unable to tolerate oral fluids
95
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
96
Complications of BPPV?
- Falls | - Difficulty performing ADLs
97
Prognosis of BPPV?
- Relapsing and remitting pattern | - Recurrence is common (about 15%)
98
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
99
Definition of labyrinthitis?
inflammation of labyrinth, hearing loss a feature
100
Epidemiology of vestibular neuronitis?
- 30-60 - Spring or early summer most likely - 2nd most common cause of vertigo
101
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
102
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
103
Diagnosis of vestibular neuronitis?
- Clinical diagnosis
104
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’
105
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
106
Management of vestibular neuronitis - when to admit?
o If severe N&V who cannot tolerate oral fluids
107
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
108
Complications of vestibular neuronitis?
- BPPV can develop after Vestibular neuronitis in 10% - Risk of falls - Worse ADLs and QoL
109
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
110
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
111
Epidemiology of Meniere's Disease?
- Uncommon | - Women, 30-60
112
Risk factors of Meniere's Disease?
``` o Autoimmune o FHx o Metabolic disturbances – sodium, potassium o Viral infection o Head trauma ```
113
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
114
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)
115
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
116
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
117
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
118
When is Meniere's Disease the probable diagnosis?
- Probable diagnosis if all of above without audiometry
119
Management of Meniere's Disease - when to admit?
o If severe symptoms for IV labyrinthine sedatives and fluids
120
Management of Meniere's Disease - when to refer to ENT?
o To confirm diagnosis
121
Management of Meniere's Disease - when to refer to audiology?
o If signs suggestive of hearing loss
122
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’
123
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
124
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 ```
125
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
126
Definition of epistaxis?
- Bleeding from the nose
127
Epidemiology of epistaxis?
- Up to 60% have nosebleeds but rarely do people need medical attention - Common in children - Posterior epistaxis more common in elderly
128
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
129
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
130
Symptoms of epistaxis?
- Nosebleed
131
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
132
When to suspect posterior epistaxis?
o Profuse, from both nostrils, bleeding site not identified and goes down throat
133
Investigations if secondary cause suspected in epistaxis?
o FBC (if heavy or recurrent), coagulation (if clotting disease suspected)
134
Management of epistaxis - when to transfer immediately to A&E?
o Haemodynamic compromise
135
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)
136
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
137
Management of epistaxis - acute management - if stops with first aid?
 Topical antiseptic (Naseptin cream QDS for 10 days)
138
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
139
Management of epistaxis - general measures after nosebleed?
 Avoid blowing nose, picking nose, heavy lifting, strenuous exercise, lying flat, drinking alcohol
140
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
141
Management of epistaxis - secondary care treatments?
```  Resuscitation if needed  Formal packing  Endoscopic assessment and electrocautery  EUA  Arterial ligation/embolisation  IV transexamic acid ```
142
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)
143
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
144
How common is nasal injury?
o Nasal bone most commonly fractured bones of face | o Seen in 15-30
145
Causes of nasal injury?
``` o Motor vehicle o Sports o Falls o Abuse o Punches, clash of heads ```
146
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
147
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 ```
148
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 ```
149
Common causes of nasal foreign body?
``` o Beads o Buttons o Sweets o Nuts o Seeds o Peas ```
150
Presentation of nasal foreign body?
o Self-inserted and often observed o May produce nasal obstruction o Purulent unilateral discharge suggests organic material
151
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
152
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
153
Definition of allergic rhinitis?
- IgE mediated inflammatory disorder of nose | - Due to nasal mucosa sensitised to allergens, triggers histamine release to produce symptoms
154
Epidemiology of allergic rhinitis?
- Prevalence increasing | ¼ of adults
155
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
156
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 ```
157
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
158
Signs of allergic rhinitis?
o Nasal voice o Darkened eye shadows o Horizontal nasal crease o Discharge – usually clear
159
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
160
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
161
Management of allergic rhinitis - drug treatment for moderate-to-severe?
 Regular intranasal corticosteroid during periods of exposure (mometasone, fluticasone)
162
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
163
Management of allergic rhinitis - severe symptoms or uncontrolled?
 Oral prednisolone for 5-10 days
164
Management of allergic rhinitis - follow up?
o Review after 2-4 weeks of treatments
165
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
166
Complications of allergic rhinitis?
o Impaired QoL o Asthma o Sinusitis o Nasal Polyps
167
Definition of sinusitis?
- Inflammation of paranasal sinuses | o Frontal, maxillary, sphenoid, ethmoidal
168
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
169
Epidemiology of sinusitis?
- Acute – common in adults | - Chronic – increases with age, women, asthma/COPD
170
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
171
Causes of chronic sinusitis?
 Multifactorial  Usually S.aureus, enterobacteriaeceae  Predisposing conditions: atopy, asthma, CF, aspirin sensitivity, immunocompromise, smoking
172
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 ```
173
When to suspect bacterial sinusitis?
o >10 days o Discoloured or purulent nasal discharge o Severe local pain o Fever >38
174
Symptoms and signs of chronic sinusitis?
- Chronic Sinusitis (>12 weeks): o Nasal obstruction/congestion o Nasal discharge (anterior, posterior) o Facial pain/pressure
175
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
176
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 ```
177
Management of sinusitis - when to refer urgently?
o Systemically unwell, intra/periorbital complications, intracranial complications
178
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
179
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
180
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
181
Complications of sinusitis?
``` o Acute (rare) – orbital cellulitis/abscess, meningitis, encephalitis, osteomyelitis o Chronic – sleep problems, depression, impact on work, reduced QoL ```
182
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
183
Definition of spasmodic or recurrent croup?
 Barking cough and hyperreactive upper airways |  No respiratory tract symptoms
184
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
185
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
186
How common is acute epiglottitis?
most commonly in ages 1 – 6 years, rare due to Hib immunisation
187
Causative organisms in viral croup?
o MOST COMMONLY due to parainfluenza | o Others include Influenza and RSV
188
Causative organisms in acute epiglottitis?
o H. Influenzae type B infection
189
Symptoms of croup?
o Barking cough o Harsh stridor o Hoarseness preceded by fever & coryza
190
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 ```
191
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
192
Diagnosis of acute epiglottitis?
- Anaesthetist makes diagnosis by laryngoscopy – cherry-red swollen epiglottis - Electively intubate before obstruction occurs
193
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
194
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
195
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
196
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
197
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
MSRA Content
flashcards
Decks in class (88)
# Cards
Brainscape helps you reach your goals faster, through stronger study habits.
© 2026 Bold Learning Solutions. Terms and Conditions