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Flashcards in ENT Deck (63):
1

Otitis Externa definition

Inflammation of the eternal ear canal

2

Otitis Externa epidemiology

10% experience in lifeetime

3

Otitis Externa aetiology

-Usually infectious, can be allergic / inflammatory
-Infection: 90% bacterial = S. aureus ± P. aeruginosa, 10% fungal = aspergillus and candida (usually follows prolonged antibiotic treatment)

4

Otitis Externa risk factors

-hot humid climates
-swimming
-immunocompromised, elderly
-DM
-acoustic meatus obstruction
-insufficient or build up of wax
-trauma to ear canal e.g. cotton buds

5

Otitis Externa presentation

Symptoms:
-otalgia
-itching
-hearing loss and otorrhoea if more severe
Signs:
-erythematous ear canal
-oedema
-exudate
-mobile tympanic membrane
-pain on movement of tragus or auricle
-pre-auricular lymphadenopathy

6

Otitis Externa differentials

-otitis media
-foreign body
-impacted wax
-malignancy (swollen ear canal with regular bleeding)
-referred pain from sphenoidal sinus / teeth / neck / throat

7

Otitis Externa investigation

-assess tympanic membrane
-cultures not useful for management

8

Otitis Externa management

Acute:
-antibiotic ear drops
-if systemic symptoms, ENT review and may need IV abx

Chronic:
-remove agravating factors e.g. swimming, scratching

9

Otitis Externa complications:

Necrotising otitis externa: life-threatening extension of infection into mastoid / temporal bones
-especially in elderly / immunocompromised / DM
-can cause facial nerve palsy

10

Otitis Media definition

Infection of middle ear
-acute
-with effusion
-chronic suppurative
(disease continuum)

11

Otitis Media epidemiology

-More common in children
-Occurs more in Winter, associated with cold

12

Otitis Media aetiology

-Bacterial: H. influenzae, S. pneumoniae
-VIral: rhinovirus, RSV
-Suppurative OM means pus is present in middle ear - can lead to TM perforation

13

Otitis Media risk factors

-Smoking
-Eustachian tube dysfunction
-URTI
-Allergies
-Chronic sinusitis
-Craniofacial abnormalities
-Immunosuppression

14

Otitis Media presentation

-Hearing loss, otalgia and fever
-Followed by otorrhoea if TM perforates
-Otitis Media with Effusion: effusion of glue-like fluid behind intact TM with absence of SSx of acute inflammation

15

Otitis Media differentials

-Otitis externa
-URTI
-Referred pain from teeth
-Foreign body
-Trauma
-Giant cell arteritis

16

Otitis Media investigation

-acute phase Ix not helpful
-culture of discharge may be helpful if chronic perforation expected

17

Otitis Media management

-analgesics and antipyretics
-no antibiotics - make little difference to symptoms
-steroids if persistent AOM with allergic background

18

Otitis Media complications

-TM perforation
-Mastoiditis = facial nerve palsy
-Cholesteatoma

19

Cholesteatoma definition

Collection of epidermal and connective tissues within middle ear. Grows independently and can damage bony ossicles.

20

Cholesteatoma aetiology

-Congenital: squamous epithelium trapped within temporal bone during embryogenesis
-Primary acquired: negative middle-ear pressure due to Eustachian tube dysfunction causes TM to be 'sucked back'. This erodes lateral wall which causes pocket lined by squamous non-keratinising epithelium to form.
-Secondary acquired: injury to TM = implantation of squamous epithelium to trigger process of cellular growth

21

Cholesteatoma risk factors

Congenital: cleft palate
Acquired: ear trauma

22

Cholesteatoma presetnation

Varies according to size.
-characteristic is progressive hearing loss and painless otorrhoea
-progressive conductive hearing loss
-vertigo
-headache
-facial nerve palsy
-painless otorrhea, may be foul-smelling
-pus-filled canal with granulation tissue

23

Cholesteatoma differentials

Myringosclerosis
Myospherulosis

24

Cholesteatoma investigation

-CT to assess lesion extent and bony defects
-MRI if soft tissue concern

25

Cholesteatoma management

Surgical removal
Topical antibiotics and potentially steroids if granulation tissue present

26

Cholesteatoma complications

Will continue to grow if left in situ causing all symptoms to worsen

27

Vertigo definition

False sensation that surroundings are spinning, usually accompanied by nausea and loss of balance

28

Vertigo aetiology

Central causes: cerebral cortex, cerebellum, brainstem
-cerebrovascular disease
-migraine
-MS
-acoustic neuroma
-diplopia
-alcohol addiction

Peripheral causes: vestibular labyrinth, semi-circular canals, vestibular nerve
-viral labyrinthitis
-vestibular neuritis
-BPPV
-Meniere's disease
-Motion sickness
-Ototoxicity
-Herpes zoster (ramsay hunt) n

29

Vertigo presentation

Sensation that surroundings are spinning accompanied by nausea and balance loss.
Associated symptoms:
-Ear: hearing loss, otorrhoea, tinnitus
-Neurological: headache, diplopia, paraesthesia, muscle weakness, ataxia
-Autonomic: N+V, sweating palpitations
-Migraine aura

30

Vertigo differentials

-Postural hypotension
-Disequilibrium
-Presyncope
-Panic attacks with hyperventilation

31

Vertigo investigations

-Romberg's test to identify central or peripheral cause
-Dix-Hallpike: to confirm BPPV

32

Vertigo management

-Treat underlying cause
-Symptomatic treatment: prochlorperazine, cinnarizine, cyclizine or promethazine - maximum 1 week
-Rehabilitation: vestibular conditioning for unilateral disorder with at home exercises

33

Vertigo complications

-Increased falls risk
-Confines to home = depression

34

Facial nerve palsy definition

Damage to facial nerve - can be LMN or UMN lesion

35

Facial nerve palsy Aetiology

LMN
-Bell's palsy (idiopathic compression and paralysis of CNVII): pregnancy, DM
-Cerebrovascular disease
-Iatrogenic: local anaesthetic
-Infective: HSV1, Ramsay Hunt (VZV), EBV, CMV, Lyme disease, otitis media / cholesteatoma
-Trauma
-Neurological: Guillain-Barre syndrome, mononeuropathy
-Neoplastic: parotid gland tumours

UMN
-Cerebrovascular disease
-Intracranial tumours
-MS
-Syphillis
-HIV
-Vasculitides

36

Facial nerve palsy presentation

-Weakness of facial expression muscles
-Face sags, drawn across to opposite side on smiling
-Voluntary eye closure not possible

LMN
-Rapid onset unilateral full facial paralysis
-Aching pain below ear / mastoid ear
-Hyperacusis
-Lesions proximal to geniculate ganglion unable to produce teras, loss of taste

UMN:
-Upper facial muscles spared
-Muscle weakness in unilateral lower face
-Usually caused by cerebrovascular event

37

Facial nerve palsy investigation

Serology - lyme, herpes and zoster

38

Facial nerve palsy managment

MDT approach depending on cause
-eye care
-steroids
-antivirals
-surgical e.g. facial decompression

39

Facial nerve palsy complications

-lack of regain of function in facial muscles
-facial asymmetry
-gustatory lacrimaiton
-inadequate lid closure, brow ptosis, drooling, hemifacial spasm

40

Acute rhinosinusitis definition

Inflammation of membranous lining of one or more of sinuses. Lasts 7-30 days.

41

Acute rhinosinusitis aetiology

Viral infection with sinus drainage obstruction followed by secondary bacterial infection.
Bacteria: S. pneumoniae, H. influenzae, M. catarrhalis

42

Acute rhinosinusitis risk factors

-URTI
-Allergy
-Smoking
-Hormonal status e.g. pregnancy
-Nasal dryness
-DM
-Foreign body
-Iatrogenic

43

Acute rhinosinusitis clinical presentation

-Non-resolving cold with biphasic character
-Pain over affected sinus
-Pyrexia
-Purulent nasal discharge
-Poor response to decongestants

Sinusitis diagnosed if:
-facial discomfort
-nasal obstruction or discharge
-decreased / absent sense of smell

44

Acute rhinosinusitis management

-Reassure that viral infection will take 3 weeks to resolve
-Symptomatic relief: pain, nasal decongestant / irrigation, fluids, rest
-Abx only if severe and prolonged

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Chronic rhinosinusitis definition

Lasts over 90 days.
-with polyps
-without polyps
-with associated fungal infection

46

Chronic rhinosinusitis aetiology

-Anaerobes
-GNB
-S. Aureus
-Coagulase -ve staph

-Usually underlying chronic issue

47

Chronic rhinosinusitis risk factors

-URTI
-Allergy
-Smoking
-Hormonal status e.g. pregnancy
-Nasal dryness
-DM
-Foreign body
-Iatrogenic

48

Chronic rhinosinusitis presentation

-Non-resolving cold with biphasic character
-Pain over affected sinus
-Pyrexia
-Purulent nasal discharge
-Poor response to decongestants

Sinusitis diagnosed if:
-facial discomfort
-nasal obstruction or discharge
-decreased / absent sense of smell

49

Chronic rhinosinusitis managment

-Topical nasal steroids / oral steroids
-Good dental hygiene
-Smoking cessation
-No evidence of Abx benefit

50

Chronic rhinosinusitis complications

-Adenoiditis, dacryocystitis and laryngitis
-Orbital complications - cellulitis, abscesses cavernous sinus thrombosis
-Intracranial: meningitis, abscess
-Oteomyelitis
-Mucocele

51

Epistaxis aetiology

-Trauma to nose: picking, foreign body, blowing
-Platelet disorders
-Drugs: aspirin, anti-coagulant, cocaine
-Vessel abnormality
-Malignancy, especially juvenile angiofibroma in males
-Granulomatosis with polyangiitis

52

Epistaxis presentation

Anterior haemorrhage:
-source of bleeding visible, usually from nasal septum, especially Little's area (kiesselbach's plexus)

Posterior haemorrhage
-deeper structures of nose
-more common in elderly
-more profuse

53

Epistaxis management

Treatment ladder:
1. Stem bleed: ask patient to sit forwards and squeeze cartilage
2. Cautery: silver nitrate used to chemically burn vessels to stem bleed
3. Consider packing

54

Acute sore throat definition

Inflammation of URT.
-pharynx
-larynx
-tonsils
-epiglottitis

55

Acute sore throat aetiology

Viral infection: rhinovirus, coronavirus, influenza, parainfluenza, adenovirus

Bacterial infection: group A beta-haemolytic strep

56

Acute sore throat presentation

Symptoms:
-headache
-malaise
-rhinitis
-cough
-hoarse voice

Signs:
-red pharynx / tonsils
-tonsillar enlargement
-exudate, enlarged cervical lymph glands

Epiglottitis:
-drooling, leaning forward, pyrexia

57

Centor criteria for bacterial tonsillitis

-History of fever
-Tonsillar exudate
-Absence of cough
-Tender anterior cervical lymphadenopathy

58

Supraglottitis / Epiglottitis

-Above larynx = supraglottitis
-Below larynx = epiglottitis
-Hoarse voice, odynophagia
-Stridor is late symptom
-Seen in immunocompromised

Causes:
-Adults: H. influenzae, S. pneumoniae, group A strep
-Paeds: H. influnzae, gourp A strep, S. pneumoniae

Management
-Emergency
-ABCDE assessment

Treat with IV cefotaxime

59

Head and neck lumps differentials

Most common cause is reactive lymph nodes:
-Bacterial: beta-haemolytic strep, S. aureus, TB, syphilis
-Viral: URTI viruses, EBV, CMV, HIV, HSV
-Parasitic
-Non-infective: sarcoidosis, connective tissue disease

Other causes
-Malignant lymph nodes
-Skin infections
-Lipomas and other benign tumours
-Thyroid swellings
-Thyroglossal cyst, brachial cyst
Carotid body aneurysm or tumour
-Malignant tumour

60

Head and neck lumps diagnosit tools

-Age: inflammatory more likely than malignancy in young. Branchial cyst present in late teens.
-Onset: inflammatory = sudden, 2-6 weeks resolution, malignant = progressive enlargement over time, transient with eating .= salivary gland.
-Consistency: hard mass = malignant, thyroid gland swellings move with swallowing, fluctuant mass = cystic.
-Location: midline = thyroid, posterior triangle = lymph nodes, bilateral across mandibular angle = mumps

61

Head and neck lumps investigations

-Bloods: FBC, ESR, TFTs
-Viral serology
-Throat swab
-CXR if supraclavicular lymph node swelling
-USS for thyroid swellings
-CT or MRI

62

Meniere's disease triad

Vertigo, tinnitus and hearing loss

(with a feeling of fullness)

63

Ramsay Hunt Characteristic features

Bell's palsy, herpetic rash, deafness, tinnitus, vertigo