SLA 5 - ENT (A)

Question 1

What are the two main physiological functions of the ear?

Answer 1

1. Hearing
2. Balance

Question 2

What is an auricular haematoma?

Answer 2

A collection of blood between the cartilage of the ear and the overlying perichondrium, usually occurring as a result of trauma (ie. in contact sports).

The accumulation of blood can disrupt the blood supply to the cartilage, resulting in avascular necrosis (AVN). AVN of the auricular cartilage can result in ‘cauliflower ear’ deformity.

Question 3

How does hearing happen in terms of sound waves, vibrational and electrical energy?

Answer 3

1. Sound waves are focused and projected along the external auditory meatus onto the tympanic membrane.
2. Vibrations of the tympanic membrane translates onto the ossicles of the middle ear.
3. The ossicles project vibrations onto the oval window of the cochlea, resulting in vibrations in the fluid in the cochlea.
4. The cochlear nerve transmits sound was via to the primary auditory cortex, where the listener becomes aware of sound.

Question 4

What is the difference between conductive and sensorineural hearing loss?

Answer 4

A conductive hearing loss occurs when sound cannot reach the inner ear, usually due to obstruction, deformity or trauma in the outer or middle ear (e.g. wax impaction).

A sensorineural hearing loss occurs when there is a problem occurring in the inner ear or the auditory nerve (e.g. presbycusis).

Question 5

Give the findings of Weber’s test in the following scenarios:

a) left sided conductive hearing loss

b) right sided conductive hearing loss

c) left sided sensorineural hearing loss

d) right sided sensorineural hearing loss

e) bilateral conductive deafness

f) bilateral sensorineural deafness

Answer 5

a) lateralises to the left ear

b) lateralises to the right hear

c) lateralises to the right ear

d) lateralises to the left hear

e) normal in both ears

f) normal in both ears

Question 6

Give the findings of Rinne’s test in the following scenarios:

a) left sided conductive hearing loss

b) right sided conductive hearing loss

c) left sided sensorineural hearing loss

d) right sided sensorineural hearing loss

Answer 6

a) BC > AC in left ear (Rinne’s negative)

b) BC > AC in right ear (Rinne’s negative)

c) AC > BC in left ear (Rinne’s false positive)

d) AC > BC in right ear (Rinne’s false positive)

Question 7

What is otitis externa?

Answer 7

Inflammation of the outer ear (ie. auricle, external auditory meatus, outer surface of eardrum).

Question 8

What are the risk factors of otitis externa?

Answer 8

• hot and humid climates
• swimming
• older age
• immunocompromised
• narrow external auditory meatus
• trauma to ear canal

Question 9

What is the most common cause of otitis externa?

Answer 9

Bacterial (90%) by Staphylococcus aureus or Pseudomonas aeruginosa.

Approx. 10% are due to fungal infection.

Question 10

Presentation of acute otitis externa.

Answer 10

• hearing loss
• discharge
• regional lymphadenopathy
• pain
• temperature

Question 11

Give the otoscopy findings of acute otitis externa.

Answer 11

• ear canal with erythema, oedema and exudate
• mobile tympanic membrane
• pain with movement of tragus or auricle
• pre-auricular lymphadenopathy

Question 12

Give some possible causes of chronic otitis externa.

Answer 12

• fungal infection
• prolonged use of abx eardrops

Question 13

What is a major complication of acute otitis externa that can occur in immunocompromised patients?

Answer 13

Necrotising otitis external is a life-threatening extension of otitis externa into the mastoid and temporal bones.

Presentation as below:
- facial nerve palsy
- pain
- oedema
- exudate
- headache

Note pain and headache of greater intensity than clinical signs would suggest is a red flag.

Question 14

Management of acute otitis externa.

Answer 14

Acetic acid drops (abx/steroid) 1/52

Question 15

What is acute otitis media (AOM)?

Answer 15

The presence of inflammation in the middle ear, associated with an effusion and accompanied by the rapid onset of symptoms and signs of an ear infection.

Question 16

Give some risk factors for AOM.

Answer 16

• young age
• male sex
• smoking / passive smoking
• frequent contact with other children (e.g. daycare, nursery)
• craniofacial abnormalities (e.g. cleft palate)

Question 17

Presentation of AOM.

Answer 17

• earache

Upon otoscopy:
- red, yellow or cloudy tympanic membrane
- bulging of tympanic membrane
- perforation of tympanic membrane
- discharge in external auditory canal

Note in young children, earache may present as holding, tugging or rubbing the ear.

Question 18

What is the initial management of AOM?

Answer 18

• advise the usual course of AOM is 3/7
• regular doses of paracetamol or ibuprofen for pain
• no evidence to support the use of decongestants or antihistamines

Question 19

Give 3 scenarios in which antibiotics may be considered in the management of AOM.

Answer 19

1. pts presenting with otorrhoea
2. age <2yo
3. systemically very unwell

Question 20

Outline the pathophysiology of otitis media with effusion (OME).

Answer 20

The Eustachian tube becomes blocked, restricting the middle ears ability to equilibrate pressure. Middle ear pressure decreases, causing the tympanic membrane to become retracted.

Note Eustachian tube may be blocked due to:
- congenital abnormality
- adenoids
- inflammatory exudate

Question 21

Presentation of OME.

Answer 21

• hearing loss
• ear pain
• feeling of fullness or popping
• aural discharge

Otoscopy findings:
- loss of light reflex
- opacification of ear drum
- retracted tympanic membrane
- air bubbles at tympanic membrane

Question 22

How can the severity of OME be assessed?

Answer 22

Assess the severity of the hearing loss and the impact on the child’s life and developmental status by asking about the following:
- fluctuations in hearing
- lack of concentration or attention, or being socially withdrawn
- changes in behaviour
- listening skills and progress at school or nursery
- speech or language development
- balance problems and clumsiness

Question 23

Outline the management of OME.

Answer 23

1. Watchful waiting for 3/12 (usually spontaneous resolution)
2. Referral to ENT after 3/12 months

Note antibiotics and corticosteroids are not recommended for treating OME, as there is no evidence to support their use.

Question 24

What is chronic suppurative otitis media (CSOM)?

Answer 24

The chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges through a tympanic perforation.

CSOM is assumed to be a complication of acute otitis media.

Question 25

Presentation of CSOM.

Answer 25

- ear discharge persisting for more than 2/52 - no ear pain or fever - hearing loss in affected ear - history of AOM, ear trauma, OME or grommet insertion - tinnitus - pressure Otoscopy: - tympanic membrane perforation

Question 26

What is the management of CSOM?

Answer 26

Refer to ENT for assessment. Do NOT swab the ear or initiate treatment without specialist advice.

Question 27

Give some red flag symptoms which can indicate serious complications in a person with CSOM.

Answer 27

- headache - nystagmus - vertigo - fever - labyrinthitis - facial paralysis - swelling / tenderness behind the ear These are signs of mastoiditis and/or intracranial infection.

Question 28

What is mastoiditis?

Answer 28

The spread of suppurative infection to the mastoid air cells, causing inflammation of the mastoid and surrounding tissues (may lead to bony destruction).

Question 29

Presentation of mastoiditis.

Answer 29

- systemic illness - fever - marked hearing loss - mastoid tenderness / swelling

Question 30

Management of mastoiditis.

Answer 30

Urgent hospital admission / ENT referral

Question 31

Pathophysiology of cholesteatoma.

Answer 31

A chronically negative middle ear pressure causes the tympanic membrane to retract, forming a retraction pocket. The retraction pocket is lined by squamous, non-keratinising epithelial tissue and releases osteolytic enzymes, allowing the cholesteatoma to grow independently. The osteolytic enzymes can cause local bone erosion, allowing the cholesteatoma to be locally invasive and destructive.

Question 32

Give some risk factors for a cholesteatoma.

Answer 32

- age <5yo - chronic OME - cleft palate deformities (ie. correlation with Eustachian tube deformity) - ear trauma

Question 33

Presentation of cholesteatoma (signs / symptoms)

Answer 33

Symptoms: - vertigo - hearing loss - headache - facial nerve palsy Signs: - conductive hearing loss (progressive) - otorrhoea - otoscopic findings (see image)

Question 34

Management of cholesteatoma.

Answer 34

Refer to ENT

Question 35

Pathophysiology of Meniere's disease.

Answer 35

The volume of endolymph within the membranous labyrinth increases, causing swelling. This leads to the characteristic symptoms of Meniere's disease. Note if a cause is identified it is referred to an Meniere's syndrome.

Question 36

Presentation of Meniere's disease.

Answer 36

- episodic vertigo (ie. spinning or rocking) - tinnitus (roaring) - sensorineural hearing loss - aural fullness - balance or gait problems Meniere's disease is episodic and symptoms can occur in clusters over a few weeks, although months or years of remission can also occur.

Question 36

Presentation of Meniere's disease.

Answer 36

- episodic vertigo (ie. spinning or rocking) - tinnitus (roaring) - sensorineural hearing loss - aural fullness - balance or gait problems Meniere's disease is episodic and symptoms can occur in clusters over a few weeks, although months or years of remission can also occur.

Question 37

Management of Meniere's disease.

Answer 37

Refer to ENT services

Question 38

What self-care advice can be given to someone with Meniere's disease.

Answer 38

- Reassure that Meniere's disease is a long-term condition, but vertigo significant improves with treatment - advise not to drive when feeling dizzy

Question 39

Give the symptomatic treatment for an acute attack of Meniere's disease in the following scenarios: a) severe symptoms b) severe nausea / vomiting / vertigo c) mild / moderate nausea / vomiting / vertigo

Answer 39

a) hospital admission for IV labyrinthine sedatives and fluids b) buccal / IM prochlorperazine c) prescribe short course prochlorperazine or antihistamine

Question 40

What medication can be prescribed in attempt to prevent recurrent attacks of Meniere's diseae?

Answer 40

Prescribing a trial of betahistine to reduce the frequency and severity of attacks of hearing loss, tinnitus and vertigo.