ENT Flashcards
(137 cards)
1
Q
what is the external acoustic metatus made up of
A
outer 1/3 = cartilage
inner 2/3 = temporal bone
2
Q
2 parts of the external ear
A
auricle/pinna
external acoustic meatus
3
Q
which muscles contract in response to loud noise
A
tensor tympani and strapedius
inhibit vibrations of malleus, incus and stapes
4
Q
how to position ear to straighten canal in adults vs children
A
adults = posteriorly and superiorly
children = posteriorly and inferiorly
5
Q
tuning fork Hertz for rinne’s test
A
512 Hz
6
Q
Utenberger’s test
A
patient marches on the spot with closed eye
if vestibular dysfunction will turn towards the lesion
7
Q
decibels that a patient can hear at different distances
A
whisper at arm’s length (60cm) = >30 decibels
whisper at 15cm or conversational voice at 60 then can hear between 30-70 dB
8
Q
Rinne negative
A
if sound is louder on the mastoid process
= conductive deafness
9
Q
normal hearing
A
Normal = between 0-20dB in all frequencies - 20 and 20,000Hz
10
Q
audiometry
A
present a pure tone at an audible level
decrease by 10 till can’t hear
then increase by 5 till they hear
To check for accuracy, should decrease 10 dB one more time to check for no response, then increase by 5 dB increments until the patient responds again to the signal
both a bone conduction threshold and air conduction is tested
11
Q
presbycusis on an audiometry graph
A
Presbycusis usually affects the high frequencies more than the low
will show tailing off of both air and bone conduction at higher frequencies
12
Q
Noise induced hearing loss on an audiometry graph
A
shows a sharp dropping off as you reach higher frequencies
if a hearing loss is noise induced you would expect that the sounds have to be made louder before they are heard at 4KHz than at any other frequency. This leads to a dip in the graph
13
Q
symmetrical hearing loss
A
We consider a hearing loss to be symmetrical if the points for each ear occur within 10dB of each other
14
Q
what does impedance audiometry encompass
A
tympanometry - measures pressure in the middle ear
measuring the reflex of the strapedius
eustachian tube funciton test
15
Q
cause of a flat line on tympanometry waveform
A
middle ear effusion - EAC volume is normal
tympanic membrane
perforation or patent gromet- EAC volume >1cm3
16
Q
peak on tympanometry occurs at negative pressure causes
A
eustacian tube dysfunction
17
Q
uses of impedence audimetry
A
Is mainly used to determine the cause for conductive hearing loss
- presence of infectious fluids in the middle ear
- otitis media with effusion – glue ear
- checking the patency of a grommet
- to check for microscopic perforation of tympanic membrane
- hypertrophy of adenoids or tonsils
- Eustachian tube dysfunction
- otosclerosis
- ossicular chain fracture
- facial palsy
18
Q
external ear causes of ear pain
A
chondritis (inflammation of the cartilage of the pinna - typically occuring after trauma/a cut - Psueodomans, staph or strep) pericondritis (inflammation of the pericondrium - a layer of CT which surrounds the cartilage) otitis externa foreign body trauma herpes zoster neoplasm impacted cerumen (earwax)
19
Q
referred causes of otalgia
A
salivary glands - calculi or infection
temporal arteritis
cranial nerve referred pain e.g. with trigeminal neuralgia (5) or Ramsay Hunt syndrome (7)
TMJ dysfunction
20
Q
management of cerumen impaction
A
flush it out with a syringe filled with water or saline (the wax can be softened first with oil or bicarbonate drops - give for 2-3 days then put in water then suck all out)
or manual removal e.g. with alligator forceps
21
Q
treatment of chrondritis or perichondritis
A
drain pus from an abscess if present
antibiotics like levofloxacin
22
Q
external ear otorrhea
A
e.g. otitis externa
will only produce a small amount of discharge compared to middle or inner because there are no mucinous glands
23
Q
types of discharge with middle ear otorrhea
A
serosanguinous suggests a granular mucosa of chronic otitis media
offensive discharge = choleastoma
24
Q
inner ear otorrhea
A
CSF otorrhea may follow discharge
suspect if you see the halo sign on filter paper
25
conductive hearing loss causes
- Wax production
- Eardrum perforation
- Middle ear effusion
- Nasopharyngeal tumours blocking the Eustachian tube
- Otosclerosis
26
pysiology of presbycusis
o Progressive loss of hair cells in the cochlea
| o Start losing higher frequencies first as outer hair cells are most exposed to damage
27
sensorineural causes of hearing loss
```
presbycusis
sudden (idiopathic) hearing loss - thought to be ischaemia or viral
noise exposure
ototoxicity with drugs
acoustic tumour
dysacusis
inflammatory diseases - measles, mumps, meningitis, syphilis, chronic middle ear infection
perilymph fistula
```
28
what decibels require protection against
>90
29
dysacusis
despite having normal hearing, some patients are unable to hear well in noisy environemnts
presumed due to a choclear abnormality
30
ototoxic drugs
aminoglycosides e.g. gentamicin
loop diuretics
spironolactone
aspirin
31
character of tinnitus
Ringing, hissing or buzzing sounds suggest an inner ear or central cause.
Popping or clicking suggests an external or middle ear cause or the palate
32
subjective vs objective tinnitus
Subjective if the sound can only be heard by the affected individual. Most commonly caused by things causing sensorineural hearing loss e.g. presbycusis. Ototoxic drugs cause bilateral tinnitus with associated hearing loss.
Objective if the sound can also be heard by the examiner. This is rare and occurs due to rare things, like rare vascular disorders, carotid pathology, or in high output cardiac states.
33
subjective unilateral tinnitus and sensorineural hearing loss
Meniere's disease - episodes of tinnitus associated with hearing loss + vertigo lasting 15 mins -->24 hours
acoustic neruoma - especially if associated with unilateral hearing loss
34
subjective bilateral tinnitus and sensorineural hearing loss
age-related hearing loss
noise-induced hearing loss
drug-induced ototoxicity (aspirin, NSAIDs, Abx, loop diuretics, cytotoxic drugs)
35
subjective unilatearl or bilateral tinnitus and conductive hearing loss
impacted wax, otitis media, cholesteatoma
otosclerosis - especially if there is a family hisotry
36
secondary causes of tinnitus
secondary to head or neck injury, multiple sclerosis, diabetes, or thyroid disease
37
acoustic neruoma
a benign intracranial tumour
| are misnomers as they most commonly arise from the vestibular nerve Schwann cells - a schwannoma
38
symptoms of acoustic neuroma
progressive ipsilateral tinnitus +/- sensorineural deafness (cochlear nerve compression)
dizziness
any patient presenting with unilateral tinnitus = acoustic neuroma until proven otherwise
other: large tumours might give unilateral cerebellar signs or raised ICP signs. balance problems and unsteadiness. if compresses trigeminal nerve then may cause a numb face or tingling
39
management options for tinnitus
Try having continuous, low-level, unobtrusive sound in the background
Hearing aids. If hearing loss >35Db, a hearing aid that improves perception of background noise makes tinnitus less apparent.
Psychological support
CBT
Relaxation techniques may also be useful
40
diagnosis of acoustic neuroma
audiogram - will show a sensorinureal pattern of hearing loss
MRI
41
treatment of acoustic neuroma
observation if there is no tumour growth
focused radiation (stereotactic radiotherapy) or surgery
42
vertigo define
vertigo is a symptom - it is the illusion of movement of the patient's surroundings, typically rotatory
vertigo is always worsened by dizziness
```
associated symptoms:
o Difficulty walking or standing (pt may even fall)
o Nystagmus – principle sign
o Relief on lying or sitting still
o Nausea/vomiting/pallor/sweating
```
43
2 divisions of causes of vertigo
peripheral/vestibular - i.e. affecting the vestibular nerve or semi-circular canals
central - rare. affecting the visual-vestibular centres of the brainstem e.g. infarct or drugs. acoustic neuroma could be a central cause
44
benign paroxysmal vertigo (BPPV) symptoms
most common cause of peripheral vertigo
attacks of sudden rotational vertigo >30 seconds that is provoked by head turning
nausea is often associated
45
cause of benign paroxysmal vertigo (BPPV)
Most cases are primary/idiopathic:
canalolithiasis (canalith particles)
debris in the semi-circular canal which are disturbed by head movements, resettles and causes vertigo for a few seconds after the movement
or can be secondary to head trauma, viral labyrinthitis, Meniere’s disease, migraine, ear surgery
46
diagnosis of benign paroxysmal positional vertigo
nystagmus when performing the Dix-Hallpike manoevre is diagnostic
turn head to side. patients are lowered quickly to a supine position with the neck extended around 30 degrees below horizontal (hanging off the bed) - will experience vertigo and see nystagmus
47
treatment of benign paroxysmal positional vertigo
epley manoervures
- clears the debris form the semi-circular canals
generally is self- limiting and treatment is only necessary if persistant
48
Meniere's disease symptoms and definition
dilation of the endolymphatic spaces by hydrops (excess fluid) - causes distension and rupture of Reissner's membrane --> release of endolymph into perilymphatic space and causes injury to the sensory and neural elements of the inner ear
typically one ear affected but over time both
causing recurrent attakcs of vertigo lasting >20 mins +/- episodes of N+V
flutuating sensorineural loss and tinnitus
associated fullness of the ear
49
epidemiology of Meniere's disease
can affect any age
40s and 50s more likely to experience it
considered to be chronic
50
acute labyrinthitis vs vestibular neuronitis
o Vestibular neuronitis is thought to be due to inflammation of the vestibular nerve and often occurs after a viral infection.
o Labyrinthitis is a different diagnosis that involves inflammation of the labyrinth.
Hearing loss is a feature of labyrinthitis, but hearing is not affected in vestibular neuronitis
51
5 vestibular causes of vertigo
benign paroxysmal positional vertigo - seconds -minutes
meniere's disease - 30 mins - 30 hours
acute labyrinthisis or vestibular neuronitis - 30h-week
trauma
ototoxicty by aminoglycosides or loop diuretics
52
cholesteatoma
a destructive and expanding growth consisting of keratinizing sqamous epithelium in the middle ear and/or mastoid process
the keratinizing epithelium exhibits independent growth leading to expansion and resporption of underlying bone
are not classified as tumours or cancers
53
symptoms of cholesteatoma
```
foul smelling discharge
may have conductive hearing loss
tinnitus may be present
headache
pain
```
- facial paralysis and vertigo indicate central CNS complications.
54
management of vestibular neuronitis / acute labyrinthitis
o Reassure the person that symptoms will usually settle over several weeks – even if no treatment is given
o Advise that factors such as alcohol, tiredness, or intercurrent illness may have a greater than usual effect on their balance
o Advise that bed rest may be necessary but that activity should be resumed as soon as possible (even if vertigo becomes more prominent during movement).
o Advise the person not to drive when they are dizzy, or if they are likely to experience an episode of vertigo while driving.
o the person should inform their employer if their vertigo poses a risk in the workplace
o offer person written information
o if symptoms are severe, offer short-term symptomatic drug treatment
vestibular suppressant medications (for example antihistamines and antiemetics)
55
management of cholesteatoma
1st line is surgery - a type of mastoidectomy
56
malignant otitis externa
spread of otitis externa into the bone surrounding the ear canal
57
diffuse vs localised otitis externa
diffuse = widespread inflammation of the skin and subdermis of the ear canal
localised = infection of a hair follicle that can progress to become a boil in the ear canal
58
causes of otitis externa
most commonly bacterial - pseudomonas aeruginosa and staph aureaus
precipitating facotrs include ear trauma, excessive moisture or dermatitis
59
diagnosis of acute otitis externa
based on examination and symptoms
ear pain (made worse when the tragus or pinaa is moved or when an otoscope is inserted), itch, discharge, hearing loss
swelling of the ear canal or redness
this can progress to the swelling containing a white or yellow filled centre
60
appearance of chronic otitis externa
lack of earwax, dry hypertrophic skin, pain, constant itch
61
appearance of malignant otitiis externa
granulation tissue at bone-cartilage junction of ear canal ; exposed bone in the ear canal
facial nerve palsy
temp >39 degrees
hearing loss, vertigo, pain
62
differentials for otitis externa
acute otitis media - otitis externa can be secondary to otorrhea from otitis media
foreign body
impacted earwax
cholesteatoma - causes discharge
neoplasm - if there is a swelling in the ear canal that bleeds easily on contact
63
management of localised otitis externa
treat with analgesia and application of local heat
oral Abx are rarely indicated
can drain pus if necessary but again this is rarely required
64
management of diffuse otitis externa
investigations are rarely needed - tympanometry can show that the tympanic membrane is intact if unsure
consider taking an ear swab to determine the causative organism if treatment fails or otitis externa is recurrent or chronic
analgesia
consider prescribing a topical Abx with or without a topical csteroid - consider cleaning canal of debris and wax if it blocks medication getting in
oral Abx rarely indicated
consider inserting an ear wick soaked in the treatment if there is extensive swelling of the canal
65
prognosis of malignant otitis externa
Without treatment, this can be a fatal condition — osteomyelitis will progressively involve the mastoid, temporal, and basal skull bones, and the infection will spread to cerebrospinal fluid causing meningitis.
With treatment, the mortality rate is less than 15%
66
main cause of malignant (aka necrotrizing) otitis externa
pseudomonas aeruginosa = 95%
67
otitis media vs otitis media with effusion
otitis medial with effusion is characterised by fluid in the middle ear but is not associated with symptoms and signs of an acute ear infection aka glue ear
whereas otitis media is inflammation with an effusion AND symptoms and signs of an ear infection
68
causes of otitis media
bacterial - Haemophilus influenzae, strep pnuemoniae, streptococcus pyogenes…
viral – respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza, parainfluenza virus
69
presentation of otitis media
earache - due to pressure on the TM. if perforation occurs, the pain lessens and hearing improves
tympanic membrane will be red yellow or cloudy and may be bulging. may be an air-fluid level behind the tympanic membrane
younger children may hold or rub their ear or have more non-specific symptoms like fever, crying, restlessness
70
management of otitis media
Pain and fever managed with paracetamol or ibuprofen
Advise that the usual course of acute otitis media is about 3 days, but can be up to 1 week
Many people will not require Abx because symptoms usually resolve spontaneously within a few days
Abx are required when:
oSystemically very unwell
oHigh risk of complications
5-7-day course of amoxicillin is recommended first-line
Can give back-up prescription if symptoms do not start to improve within 3 days or worsen significantly or rapidly at any time
Take account of evidence that acute complications such as mastoiditis are rare with or without antibiotics, and the possible adverse effects of antibiotics
71
complications of otitis media
- Recurrence of infection
- Hearing loss
- Tympanic membrane perforation
- Rarely – mastoiditis, meningitis, intracranial abscess, sinus thrombosis and facial nerve paralysis
Mastoiditis - the mastoid air cells will be filled with pus. Boggy red swelling observable behind the ear. This pus pushes the ear outwards
72
glue ear cause
uncertain but over 50% of cases are thought to follow an episode of acute otitis media
persistence of OME may be caused by impaired eustachian tube function, low-grade viral or bacterial infection, local inflammaotry reaction, adenoidal infection
73
presentation and diagnosis of glue ear
may be associated with significant hearing loss - usually resolves over several weeks or months
mild ear pain with fullness or popping may occur
diagnosis is based on suspected hearing loss - there are usually no signs on examination other than effusion
refer to audiometry and tympanometry where appropriate if uncertain
74
management of glue ear
- Spontaneous resolution of OME is common, so for most children a period of active observation over 6–12 weeks is appropriate
- During this period, it is essential to re-evaluate signs and symptoms of the effusion and concerns regarding the child's hearing or language development
75
symptoms of a perforated eardrum
may feel a sharp pain or an earache that you've had for a while may suddenly go away
conductive hearing loss - usually temporary
other symptoms may include tinnitus, vertigo, otorrhoea
76
causes of a perforated eardrum
otitis media - pressure builds up and pushes against the eardrum
foreign object - cotton swab or pin
less commonly: loud noise or surgery
77
treatment of perforated eardrum
may heal in a few weeks or may take up to a few months
| some require intervention e.g. a paper patch to promote healing or surgery (tympanoplasty)
78
facial nerve - muscle supplied and taste supplied
facial nerve supplies stapedius – paralysis results in hyperacusis
supplies taste sensation to the anterior two-thirds of the tongue
79
causes of facial nerve damage
Between the brainstem and middle ear
o Tumours – meningioma or astrocytoma
o Temporal bone trauma
o Acoustic neuroma
In the middle ear
o AOM – acute otitis media (oedema pressing on)
o Cholesteatoma
Neck or face
o Parotid tumours
o Facial lacerations
Global
o Ramsay hunt (herpes zoster of facial nerve)
o Lyme disease (Borrelia bacterium which is spread by ticks --> erythema migrans appears at site of tick bite)
o Bell’s palsy (15% undergo Wallerian degeneration of nerve (regrowth is 1mm per day, takes about 3 months to return to function)
80
score to assess the degree of facial nerve damage
House-brachman score
- I – normal
- II – slight-mild weakness. Only on close inspection
- III – moderate – facial asymmetry and weakness but eye closes. Asymmetrical mouth, may not be able to lift eyebrow
- IV – moderately severe – total facial asymmetry and weakness with incomplete closure of the eye and inability to lift brow
- V – severe – barely detectable movement. Slight movement of corner of mouth
- VI – total – no facial function. Loss of tone
81
UMN vs LMN facial nerve damage
UMN damage = forehead is spared
LMN = whole side is affected
82
what structures open into the nasal cavity
paranasal sinuses
nasolacrimal duct - drains tears
eustachian tube - equalises pressure
83
isolated nasal bone fracutre diagnosis
is clinical - will not need an X ray
84
septal haematoma
causes - broken nose, injury, surgery
presents with pain, nasal obstruction with a boggy swelling
septal cartilage has no blood supply and recieves all nutrients from perichondrium so an untreated septal haematoma may lead to necrosis and a saddle nose deformity
treatment is incision and drainage
85
window of opportunity for manipulation with a nasal fracture
swelling often interferes with adequate examination so patients should be reassesed after 5-7 days (so after initial A+E appointment then book in an OPD ENT appointment - in meanwhile advise ice pack and painkillers)
at 3 weeks nasal bones heals and fixate so manipulation would be near impossible
so around 7-21- day window
86
how is nasal reduction performed followed nasal fracture
Manual reduction under anaesthesia
- But if patient is happy to live with a minor deformity then nothing further needs to be done
- is done under LA or GA
or referral for rhinoplasty in 3-6 months:
o Septoplasty
Or surgery can be done to straight both the bone and cartilage
o Septorhinoplasty
87
nose blood supply
the internal carotid (via the ethmoidal arteries) supplies the region above the middle turbinate - remaining areas are supplied by branches of the external carotid
L- superior labial artery
E - anterior ethmoidal
G- greater palatine artery
S - sphenopalatine artery
88
recommended antibiotic for otitis media
5-day course of amoxicillin is first line if given (not always needed)
89
if the tympanic membrane, how does this impact Abx treatment for otitis media
If the tympanic membrane is perforated, aminoglycosides are traditionally not used
90
causes of epistaxis
trauma - e.g. nose picking of foreign body
inflammation - chronic sinusitus, allergic rhinosinusitis or nasal polyps
topical drugs - cocaine, steroids, decongestants
vascular - hereditary haemorrhagic telangiectasia or Wegener's granulomatosis
poster-op bleeding
tumour - angiofibroma (benign) or SCC
nasal oxygen therapy
more general causes - HTN, atherosclerosis, increased venous pressure form mitral stenosis, haematological disorders
91
site of majority of epistaxis
Little's area on the anterior nasal septum, which contains the Kiesselbach plexus of vessels
Less commonly, epistaxis originates from branches of the sphenopalatine artery in the posterior nasal cavity.
o Posterior nosebleeds usually occur in older people, are more profuse, result in bleeding from both nostrils, and the bleeding site cannot be identified on examination
92
assessment of epistaxis
A-E
if haemoydnamically unstable then try quantify the amount of blood loss via rough cups
ask if a temporary pack has been used before seeking help - this could push up foreign bodies further
examine both nasal passages with good lighting and a speculum
look for a small red dot when doing this - this will be the bleeding point
Suspect a posterior bleed if bleeding is profuse, from both nostrils, the bleeding site cannot be identified on speculum examination, and/or if bleeding first started down the throat
93
general first aid measures for epistaxis
sit with their body tilted forward and mouth open to decrease swallowing of blood - avoid lying down unless feeling faint
pinch the cartilaginous part of the nose firmly for 10-15 mins without releasing pressure
94
if epistaxis stops with first aid measures alone then consider applying....
a topical antiseptic (naseptin (chlorehxidine + neomycin) to reduce crusting and vestibulitits
naseptin (chlorhexidine and neomycin) cream to be applied to the nostrils 4x daily for 10 days
95
what to do if epistaxis does not stop
nasal cautery if the bleeding point can be seen and the procedure can be tolerated
- use a local anaesthetic spray preferably with a vasoconstrictor like lidocaine with phenylephrine then wait 3-4 mins. apply silver nitrate stick to bleeding point for 3-10 secs. then apply a topical antiseptic to area (naseptin (chlorhexidine + neomycin)
nasal packing if cautery is ineffective or bleeding point cannot be seen
- first anaesthetise (same as above)
- admit to hospital if nasal pack has been inserted in primary care
96
nasal packing options
nasal tampons e.g. Merocel
inflatable packs e.g. rapid-rhino - may be easier and more comfortable to insert and remove
ribbon gauze impregnated with vaseline - if left in for >48 hours then Abx should be started to prevent toxic shock syndrome
97
secondary care measures for epistaxis
resuscitation - this may include transfusion to replace blood volume
formal packing - may be under GA
endoscopic assessmnet and electrocautery
examination under anaesthesia and surgical intervention (such as diathermy, septal surgery, arterial ligation + laser)
radiological arterial embolization
IV or oral tranexamic acid
98
management of episatxis from posterior area
admit to hostpial
may require either balloon insertion (foley catheter or Brighton balloon) or a formal posterior pack (usually done under GA)
99
rhinosinusitis define
inflammation of the nose and paranasal sinuses with >2 symptoms - one of which must be
- nasal blockage/obstruction/congestion
- nasal discharge
- +/- facial pain or pressure
- reduction or loss of smell
- and either endoscopic or CT signs
NB the term rhinosinusitis is preferred over sinusitis because inflammation of the sinuses is almost always accompanied by inflammation of the nasal cavities
100
acute vs chronic rhinosinusitis
acute <12 weeks
chronic >12 weeks
if chronic, patient may develop polyps due to inflammatory environment
101
diagnosis of acute rhinosinusitis
diagnosed by presence of nasal blockage or discharge with facial pain/pressure and/or reduction of sense of smell
palpate the maxiofacial area to elict swelling or tenderness
perform anterior rhinoscopy to look for nasal inflammation, mucosal oedema and purulent nasal discharge
record pulse, BP and temp if person is systemicall unwell
102
treatment of acute rhinosinusitis
refer to hospital if unwell of complications like periorbital oedema or cellulitis, reduced visual acuity, double vision, signs of meningitis...
offer written advice
analgesia
some people may want to do a trial of nasal saline or decongestants (although evidence is lacking to support their use)
adivise that is s usually caused by a virus and is only complicated by bacterial infection in about 2 in 100 cases. It takes 2–3 weeks to resolve, and most people will get better without antibiotics
103
treatment of acute rhinosinusitis that persists >10 days
consider a high-dose nasal corticosteriod for 14 days
consider antibioitc prescription keeping in mind that evidence has shown they make little difference to how long symptoms last + withoulding is unlikely to lead to complications
104
when should you suspect acute bacterial rhinosinusitis
symptoms >10 days
purulent discharge with unilateral predominance
severe local pain with unilateral predominance
fever >38 degrees C
A marked deterioration after an initial milder form of the illness (so-called 'double-sickening').
Elevated ESR/CRP
105
causes of acute bacterial rhinosinusitis
s pneumoniae
h influenza
s aureus
106
investigations for acute bacterial rhinosinusitus
diagnosis is clinical, by examining the nose and looking for mucosal inflammation, oedema, discharge etc.
In recurrent rhinosinusitis, a CT can be performed to assess for anatomical variation
107
antibiotic treatment for acute bacterial rhinosinusitis
amoxicillin or doxycyline
108
complications from bacterial rhinosinusitis
orbital cellulitis can occur, which is severe and life/sight threatening.
We can also see spread, leading to encephalomeningitis. In the same way, we can see osteomyelitis.
Mucocoeles (esp. frontal sinus) – we see pus filling the frontal cavity.
109
types of allergic rhinitis
- Can be seasonal
- Perennial (occurring throughout the year, typically due to allergens from the house like dust mites)
- Intermittent (<4 days a week or less than 4 consecutive weeks)
- Persistent (more than 4 days a week AND >4 consecutive weeks)
- Occupational
110
management of allergic rhinitis
- Sources of information and support.
- Possible use of nasal irrigation with saline.
- Allergen avoidance
- The use of an as-needed intranasal antihistamine or non-sedating oral antihistamine, or an intranasal chromone,
- The use of a regular intranasal corticosteroid during periods of allergen exposure for moderate-to-severe persistent symptoms, or if initial drug treatment is ineffective.
111
chronic rhinosinusitis with nasal polyps symptoms + investigations
watery anterior rhinorrhoea, sneezing, purulent postnasal drip, nasal obstruction, sinusitis, mouth-breathing, snoring, headaches
investigate with anterior rhinoscopy or nasal endoscopy - polyps are pale, mobile and insensitive to gentle palpation
112
treatment of chronic rhinosinusitis with polyps
medical polypectomy - topical steroids shrink the polyps e.g. betamethasone or a course of 5 days 40mg prednisolone. consider adding long term Abx. this process is known as a medical polypectomy. douching with saline also helps
endoscopic sinus surgery (ESS)/ endoscopic nasal polypectomy - consider if max medical treatment fails + ongoing severe symptoms
always important to rule out neoplams - if unilateral single polyp then refer to ENT
113
CSF rhinorrhea
occurs when there is a fistula between the dura and skull base
due to basilar skull fracture or pituitary adenoma, ethmoid fracture or tumour
other signs of this include CSF otorrhea (drainage of CSF through the ear)
114
investigations for CSF rhinorrhea
nasal CSF discharge test - positive for glucose
| and nasal CSF uniquely containts beta-2 (tau) transferrin = gold standard diagnostic test
115
management of CSF rhinorrhea
If traumatic, conservative management has high spontaneous resolution: 7-10 days bedrest (head elevated at 15-30 degrees) + lumbar drain
Leaks often stop spontaneously
If this does not occur, then neurosurgical closure is necessary to prevent the spread of infection to the meninges
CSF fistulae persisting for > 7 days had a significantly increased risk of developing meningitis
Avoid coughing, sneezing, nose blowing etc.
Cover with antibiotics and pneumococcal vaccine
116
management of foreign body in child's nose
Ask the child to blow their nose or ask parent to perform a ‘parental kiss’ – make the parent blow into the child’s mouth while occluding other nostril. 70% success rate.
Crocodile forceps may be used if the child is cooperative
117
management of septal perforation
if aymptomatic can be managed with observation (although none will spontaneously close)
saline nasal irrigation, petroleum jelly applied to the edge of the perforation to promote healing
surgical closure via placement of a septal prosthesis - but only half of patients find this tolerable (can be botherseom)
118
presentation of nasopharyngeal cancer
lymphadenopathy (main symptom is neck lump; 90%)
blocked nose
epistaxis
tinnitus
deafness
cranial nerve involvement due to base of skull extensions
119
investigations for nasopharyngeal cancer
endoscopy + biopsy
| MRI for staging
120
when to suspect cancer of the paranasal sinuses
when chronic sinusitis presents for the first time later in life
blood-stained nasal discharge and nasal obstruction /masses
121
histology of paranasal sinuses and investigations
50% squamous cell, 10% lymphoma, adenocarcinoma
investigate with MRI/CT + biopsy
122
tonsils
pharyngeal/adenoi at the top
then 2 tubal tonsils
then 2 palatine tonsils
then one lingual at the bottom (posterior 1/3 of the tongue)
123
salivary glands
parotid - serous - most tumours (mostly pleomorphic adenomas)
submandibular - mixed - most sontes
sublingual - mucous
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types of stridor
inspiratory - larynx
expiratory - lower respiratory tract i.e. asthma
biphasic - trachea
125
2 clinical descriptions of acute sore throat
acute pharyngitis = inflammation of the part of the throat behind the soft palate (oropharynx)
tonsillitis = inflammation of the tonsils
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causes of sore throat
usually viral or bacterial
e.g. common cold, influexa, strep, infectious mononucleosis
acute herpetic pharyngitis - suggested by vesicles and shallow ulcers on the palate
physical irritation from GORD
chronic cigarette smoke
hayfever
oral mucositis secondary to radiotherapy or chemo
leukaemia - ulceration and haemorrhage of the mucus membrane of the pharynx may occur
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scores to determine the liklihood of strep infection (and therefore the need for Abx)
FeverPAIN score and centor criteria
strep infection is suggested by fever >38.5, exudate on the pharynx/tonsils, anterior neck lymphadenopathy and absence of cough
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FeverPAIN score
* Fever over 38°C.
* Purulence (pharyngeal/tonsillar exudate).
* Attend rapidly (3 days or less)
* Severely Inflamed tonsils
* No cough or coryza
max score = 5 points
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simple advice for sore throat
o Regular use of paracetamol or ibuprofen to relieve pain and fever
o Adequate fluid intake to avoid dehydration until the discomfort and swelling subside
o Salt water gargling, medicated lozenges (containing a local anaesthetic and NSAID or an antiseptic agent) may provide temporary relief from throat pain
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first line antibiotic for strep pharyngitis
phenoxymethylpenicillin
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who might benefit from tonseillectomy
a frequency of more than 7 episodes per year for one year, 5 per year for 2 years, or 3 per year for 3 years
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complications of acute pharyngitis
scarlet fever - due to group A strep
otitis media - most common
peri-tonsillar abscess (quinsy) - risk of airway comprimse
parapharyngeal abscess
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most common organism to cause acute bacterial tonsillitis
strep pyogenes - over half
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acute tonsillitis symptoms
the tonsils will often meet in the midline and may be covered in a membrane
pharyngitis, fever, malaise and lymphadenopathy
tonsils are typically oedematous and yellow or white pustules may be present
135
treatment of acute bacterial tonsillits if due to group A beta-haemolytic strep
with penicillin type antibiotics
phenoxymethylpenicillin or benzylpenicillin or amoxicillin
136
when should quinsy be suspected (peri-tonsillar abscess)
with unilateral swelling and fever – surgical drainage usually produces prompt resolution of symptoms
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causes of odynophagia
infection of mouth, tonsils, throat, epilgottis or oesophagus e.g. URTI, cadidiasis, HIV, EBV
foreign object
non-infectious e.g. sores, ulcers, tumours, oesophageal disorders, acid reflux, injury
oesophageal cancer
