ENT

Question 1

What is otitis media

Answer 1

Infection in the middle ear

Question 2

Most common bacterial cause of otitis media

Answer 2

The most common bacterial cause of otitis media is streptococcus pneumoniae. This also commonly causes other ENT infections such as rhino-sinusitis and tonsillitis.

Question 3

Presentation of otitis media

Answer 3

Ear pain is the primary presenting feature of otitis media in adults.

It may also present with:

Reduced hearing in the affected ear
Feeling generally unwell, for example with fever
Symptoms of an upper airway infection such as cough, coryzal symptoms and sore throat

Question 4

Why does otitis media sometimes cause balance issues and vertigo

Answer 4

Can infect and affect the vestibular system

Question 5

Otoscope examination - otitis media

Answer 5

Bulging, red, inflamed looking membrane.

When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane.

Question 6

Management of otitis media

Answer 6

Most resolve without abx within around 3 days

Simple analgesia for pain and fever

Question 7

When should you consider immediate antibiotics for otitis media

Answer 7

Consider immediate antibiotics at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised.

Question 8

When should you consider a delayed prescription for otitis media

Answer 8

Consider a delayed prescription that can be collected and used after three days if symptoms have not improved or have worsened at any time. This can be a helpful strategy in patients pressing for antibiotics or where you suspect the symptoms might worsen.

Question 9

Appropriate antibiotics for otitis media

Answer 9

Amoxicillin for 5-7 days first-line
Clarithromycin (in pencillin allergy)
Erythromycin (in pregnant women allergic to penicillin)

Always safety-net, offering education and advice to patients on when to seek further medical attention.

Question 10

Complications of otitis media

Answer 10

Otitis media with effusion
Hearing loss (usually temporary)
Perforated tympanic membrane (with pain, reduced hearing and discharge)
Labyrinthitis (causing dizziness or vertigo)
Mastoiditis (rare)
Abscess (rare)
Facial nerve palsy (rare)
Meningitis (rare)

Question 11

What is mastoiditis

Answer 11

Mastoiditis is inflammation of the mastoid antrum and the lining of the mastoid air cells.

Question 12

Most common aetiology of mastoiditis

Answer 12

Children of school age following an untreated episode of acute otitis media or recurrent episodes

Question 13

Risk factors for developing mastoiditis

Answer 13

Immunosuppression.
Diabetes mellitus.
Congenital defects of the middle and outer ear.
Recurrent episodes of acute otitis media
Cholesteatoma.

Question 14

Clinical features of mastoiditis

Answer 14

Recent or concurrent acute otitis media in around 50% of cases.
Deep otalgia on the affected side in nearly all cases.
Recent loss of hearing (progressive) on affected side.
Generally unwell with young children often not eating or drinking as normal.

Question 15

Key findings on examination in mastoiditis

Answer 15

Fever.

Usually bulging tympanic membrane with clear fluid level or perforation with purulent discharge from the ear.

Erythema and swelling over mastoid process behind the ear in up to 75% of cases.

Mastoid tenderness.

Cervical lymphadenopathy on affected side.

External ear may protrude forwards

Question 16

Key IX for mastoiditis

Answer 16

CT scanning is quick and will demonstrate the extent of mastoid air cell opacification.

A CT scan with contrast can also identify intracranial infection and the extent of this.

MRI imaging is better for identifying intracranial infection and will give better detail of the soft tissues but struggles to see the bone in as much detail.

Question 17

Antibiotic for mastoiditis

Answer 17

Ceftriaxone

Question 18

How can mastoiditis cause facial nerve damage

Answer 18

If the infection enters the facial canal within the bone it can result in facial nerve damage and ipsilateral facial weakness (without forehead sparing due to the lower motor neurones being affected).

Question 19

Most serious complication of mastoiditis

Answer 19

Meningitis.
Formation of a subdural empyema.
Intracerebral abscess formation.

Question 20

Most common bacterial causes of otitis external

Answer 20

Pseudomonas aeurginosa

Staphylococcus aureus

Question 21

Causes of inflammation in otitis externa

Answer 21

Bacterial infection
Fungal infection (e.g., aspergillus or candida)
Eczema
Seborrhoeic dermatitis
Contact dermatitis

Question 22

Symptoms of otitis externa

Answer 22

Ear pain
Discharge
Itchiness
Conductive hearing loss if blocked

Question 23

Examination findings in otitis externa

Answer 23

Erythema and swelling in the ear canal
Tenderness of the ear canal
Pus or discharge in the ear canal
Lymphadenopathy (swollen lymph nodes) in the neck or around the ear

Question 24

Diagnosis of otitis externa

Answer 24

Otoscopy

Question 25

Mx of mild otitis externa

Answer 25

Acetic acid 2% OTC (EarCalm)

Question 26

Self-care measures for acute otitis externa

Answer 26

Avoid ear buds Avoid swimming Keep shampoo, soap, and water out of the ear when bathing and showering

Question 27

Management of moderate otitis externa

Answer 27

Moderate otitis externa is usually treated with a topical antibiotic and steroid

Question 28

Mx of fungal otitis externa

Answer 28

Clotrimazole ear drops

Question 29

What is malignant otitis externa

Answer 29

Severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull.

Question 30

Risk factors for malignant otitis externa

Answer 30

Diabetes Immunosuppressant meds(chemo) HIV

Question 31

What is a key finding in malignant otitis externa

Answer 31

Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along) is a key finding that indicates malignant otitis externa.

Question 32

Mx of malignant otitis externa

Answer 32

Admission to hospital under the ENT team IV antibiotics Imaging (e.g., CT or MRI head) to assess the extent of the infection

Question 33

Complications of malignant otitis externa

Answer 33

``` Facial nerve damage and palsy Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves) Meningitis Intracranial thrombosis Death ```

Question 34

When should follow up for otitis externa be arranged

Answer 34

Symptoms have not fully resolved after 2 weeks of starting initial treatment. Symptoms are severe and/or there is cellulitis spreading beyond the external ear canal The person is immunocompromised and at risk of severe infection, depending on clinical judgement.

Question 35

When does hearing impairment require thorough assessment immediately

Answer 35

Sudden onset hearing loss (over less than 72 hours) requires a thorough assessment to establish the cause.

Question 36

Weber's test result that indicates sensorineural hearing loss

Answer 36

In sensorineural hearing loss, the sound will be louder in the normal ear (quieter in the affected ear). The normal ear is better at sensing the sound.

Question 37

Weber's test result that indicates conductive hearing loss

Answer 37

In conductive hearing loss, the sound will be louder in the affected ear. This is because the affected ear “turns up the volume” and becomes more sensitive, as sound has not been reaching that side as well due to the conduction problem. When the tuning fork’s vibration is transmitted directly to the cochlea, rather than having to be conducted, the increased sensitivity makes it sound louder in the affected ear.

Question 38

What is a normal rinne test result

Answer 38

A normal result is when the patient can hear the sound again when bone conduction ceases and the tuning fork is moved next to the ear rather than on the mastoid process. It is normal for air conduction to be better (more sensitive) than bone conduction. This is referred to as “Rinne’s positive”.

Question 39

Rinne test result that indicates conductive hearing loss

Answer 39

An abnormal result (Rinne’s negative) is when bone conduction is better than air conduction. The sound is not heard after removing the tuning fork from the mastoid process and holding it near the ear canal.

Question 40

Causes of sensorineural hearing loss

Answer 40

``` Presbycusis (age-related) Noise exposure Ménière’s disease Labyrinthitis Acoustic neuroma Neurological conditions (e.g., stroke, multiple sclerosis or brain tumours) Infections ```

Question 41

Medications associated with sensorineural hearing loss

Answer 41

``` Loop diuretics (e.g., furosemide) Aminoglycoside antibiotics (e.g., gentamicin) Chemotherapy drugs (e.g., cisplatin) ```

Question 42

Causes of conductive hearing loss

Answer 42

``` Ear wax Infection Effusion Eustachian tube dysfunction Perforated tympanic membrane Otosclerosis Cholesteatoma Exostoses ```

Question 43

What is presbyacusis

Answer 43

It is a type of sensorineural hearing loss that occurs as people get older. It tends to affect high-pitched sounds first and more notably than lower-pitched sounds. The hearing loss occurs gradually and symmetrically.

Question 44

Risk factors for presbyacusis

Answer 44

``` Age Male gender Family history Loud noise exposure Diabetes Hypertension Ototoxic medications Smoking ```

Question 45

What are patients with hearing loss more likely to develop

Answer 45

patients with hearing loss are more likely to develop dementia, and treating the hearing loss (e.g., a hearing aid) may reduce the risk.

Question 46

Mx of presbyacusis

Answer 46

Optimising the environment, for example, reducing the ambient noise during conversations Hearing aids Cochlear implants (in patients where hearing aids are not sufficient)

Question 47

Conductive causes of rapid-onset hearing loss

Answer 47

Ear wax (or something else blocking the canal) Infection (e.g., otitis media or otitis externa) Fluid in the middle ear (effusion) Eustachian tube dysfunction Perforated tympanic membrane

Question 48

Causes of SSNHL

Answer 48

``` Idiopathic(90%) Meniere's disease Otoxic meds MS Migraine Stroke Acoustic neuroma ```

Question 49

Diagnosis of SSNHL

Answer 49

Audiometry is required to establish the diagnosis. A diagnosis of SSNHL requires a loss of at least 30 decibels in three consecutive frequencies on an audiogram.

Question 50

Mx of SSNHL

Answer 50

immediate referral to ENT for assessment within 24 hours for patients presenting with sudden sensorineural hearing loss presenting within 30 days of onset. Idiopathic SSNHL may be treated with steroids

Question 51

Purpose of Eustachian tube

Answer 51

The Eustachian tube is present mainly to equalise the air pressure in the middle ear and drain fluid from the middle ear.

Question 52

What might Eustachian tube dysfunction may be related to

Answer 52

Eustachian tube dysfunction may be related to a viral upper respiratory tract infection (URTI), allergies (e.g., hayfever) or smoking

Question 53

Presentation of Eustachian tube dysfunction

Answer 53

``` Reduced or altered hearing Popping noises or sensations in the ear A fullness sensation in the ear Pain or discomfort Tinnitus ``` Symptoms tend to get worse when external pressure changes and middle ear pressure cannot equalise to the outside pressure

Question 54

IX for Eustachian tube dysfunction

Answer 54

May not be required if URTI/hayfever aetiology Tympanometry Audiometry Nasopharyngoscopy CT scan

Question 55

Mx of eustachian tube dysfunction

Answer 55

No rx if URTI Valsalva manoeuvre Decongestant nasal sprays(short term only) Antihistamines and a steroid nasal spray Surgery Otovent

Question 56

Surgical options for mx of Eustachian tube dysfunction

Answer 56

Treating any other pathology that might be causing symptoms, for example, adenoidectomy (removal of the adenoids) Grommets Balloon dilatation Eustachian tuboplasty

Question 57

What is otosclerosis

Answer 57

There is remodelling of the small bones in the middle ear, leading to conductive hearing loss

Question 58

Otosclerosis aetiology

Answer 58

Combination of environmental and genetic factors, although the exact mechanism is not understood. It can be inherited in an autosomal dominant pattern.

Question 59

Presentation of otosclerosis

Answer 59

Age < 40 - hearing loss and tinnitus Affects hearing of lower-pitched sounds more Patient can experience their voice as being loud compared to the environment (due to bone conduction of their voice)

Question 60

Mx of otosclerosis

Answer 60

Conservative, with use of hearing aids Surgical(stapectomy or stapedotomy)

Question 61

Main methods for removing excessive ear wax

Answer 61

Ear drops – usually olive oil or sodium bicarbonate 5% Ear irrigation – squirting water in the ears to clean away the wax Microsuction – using a tiny suction device to suck out the wax

Question 62

Systemic conditions associated with tinnitus

Answer 62

Anaemia Diabetes Hypothyroidism or hyperthyroidism Hyperlipidaemia

Question 63

What is objective tinnitus

Answer 63

Refers to when the patient can objectively hear an extra sound within their head

Question 64

Causes of objective tinnitus

Answer 64

``` Carotid artery stenosis (pulsatile carotid bruit) Aortic stenosis (radiating pulsatile murmur sounds) Arteriovenous malformations (pulsatile) Eustachian tube dysfunction (popping or clicking noises) ```

Question 65

Red flags in tinnitus assessment

Answer 65

``` Unilateral tinnitus Pulsatile tinnitus Hyperacusis (hypersensitivity, pain or distress with environmental sounds) Associated unilateral hearing loss Associated sudden onset hearing loss Associated vertigo or dizziness Headaches or visual symptoms ```

Question 66

General mx of tinnitus

Answer 66

Tends to improve or resolve over time Treat underlying causes Hearing aids Sound therapy (adding background noise to mask the tinnitus) Cognitive behavioural therapy

Question 67

Most common peripheral causes of vertigo

Answer 67

Benign paroxysmal positional vertigo Ménière’s disease Vestibular neuronitis Labyrinthitis

Question 68

BPPV pathophys

Answer 68

caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals

Question 69

Causes of BPPV

Answer 69

They may be displaced by a viral infection, head trauma, ageing or without a clear cause

Question 70

Diagnosis of BPPV

Answer 70

Dix-Hallpike manoeuvre

Question 71

Pathophys of meneiere's disease

Answer 71

caused by an excessive buildup of endolymph in the semicircular canals, causing a higher pressure than normal, disrupting the sensory signals

Question 72

Central causes of vertigo

Answer 72

Posterior circulation infarction (stroke) Tumour Multiple sclerosis Vestibular migraine

Question 73

Peripheral vs central vertigo presentation

Answer 73

Peripheral more sudden, shorter, tinnitus often present, coordination intact and nausea more severe

Question 74

What is HINTS

Answer 74

HI – Head Impulse N – Nystagmus TS – Test of Skew To distinguish between central and peripheral vertigo

Question 75

Mx of peripheral vertigo

Answer 75

Prochlorperazine Antihistamines (e.g., cyclizine, cinnarizine and promethazine) Betahistine may reduce attacks in meneiere's disease

Question 76

Antibiotics in otitis externa

Answer 76

Topical Ciproflox/dexamethasone 0.3%/0.1% ear drops

Question 77

What are renal transplant patients matched based on

Answer 77

human leukocyte antigen (HLA) type A, B and C on chromosome 6. They don’t have to fully match. Recipients can receive treatment to desensitise them to the donor HLA when there is a living donor.

Question 78

Incision associated with renal transplant

Answer 78

Hockey stick incision

Question 79

Immunosuppressant regime for patients post renal transplant

Answer 79

Tacrolimus Mycophenolate Prednisolone

Question 80

Complications relating to renal transplant

Answer 80

Transplant rejection (hyperacute, acute and chronic) Transplant failure Electrolyte imbalances

Question 81

Complications relating to immunosuppression in renal transplantation

Answer 81

Ischaemic heart disease Type 2 diabetes (steroids) Infections are more likely and more severe Unusual infections can occur (PCP, CMV, PJP and TB) Non-Hodgkin lymphoma Skin cancer (particularly squamous cell carcinoma)