ENT Flashcards
(32 cards)
What are 5 common causes of epistaxis?
What’s 2 congenital causes?
Whats a drug cause?
dry weather or low humidity, barotrauma, nasal or facial fracture/trauma eg. nosepicking, nasal polyp, nasal irritants eg. dust/smoke
Familial Hereditary Haemorrhagic Telangiectasia, septal deviation
Cocaine, topical nasal drugs eg. nasal corticosteroids
What are the 2 types of epistaxis?
90% are Anterior:
- originates from Kiesselbach’s plexus (vascular anastamosis in Little’s area)
Posterior:
- produce more active bleeding
How would you investigate epistaxis?
FBC, Coagulation studies and INR and prothrombin time
Nasal endoscopy and nasopharyngoscopy to identify source
nasal or sinus Xray to show fracture
How would you initially manage epistaxis? (active bleeding)
- apply pressure to anterior bleeding sites by pinching the lower compressible cartilage of the nose
- applying a vasoconstrictor/decongestant ( eg. oxymetazoline) helps encourage haemaostasis
- topical anaesthetic (eg. lidocaine) can help
Describe the steps you take once the bleeding source has been visualised
- anterior epistaxis = silver nitrate cautery
- ** avoid cautery on same area on either side of septum as it can result in deprivation of blood supply and septal perforation ***
- petroleum jelly after
Describe the steps you take if the cautery fails?
- anterior nasal packing
- give co-amoxi antibiotics as there is impaired sinus drainage = infection risk
if the bleeding persists:
- endoscopy = surgical clip ligation of sphenopalatine artery
- angiography + embolisation with interventional radiology
- open surgery ligation
What if you suspect a posterior bleed?
- posterior packing
- double balloon epistaxis device OR traditional gauze anterior pack with Foley urinary catheter placed posteriorly
- IV analgesia and antiemetics
A man comes in with acute bacterial sinusitis. What part of the history makes you think this?
How would an acute viral sinusitis present?
4 weeks> Symptoms >10 days
** viral sinusitis progresses to bacterial so viral sinusitis will present with <10 days symptoms. Then initial improvement, then secondary bacterial infection **
Symptoms: purulent nasal mucus, nasal congestion, facial pain eg. headache
Virus specific symptoms: myalgia, sore throat, fever
How would you manage acute viral sinusitis?
Analgesia/antipyretic = Paracetamol/ibuprofen
Decongestant = topical Oxymetazoline nasal
saline spray OR Corticosteroids for congestion = Mometasone nasal
Topical anticholinergics for rhinorrhoea = Ipratropium nasal
Mucolytics = Guaifenesin
How would you treat acute bacterial sinusitis?
wait 10 days before antibiotics!!!
- amoxi or co-amoxi or phenomethylpenicillin
- analgesia, decongestant, mucolytics, ipratropium, saline spray, etc as needed.
If immunocompromised:
- high dose co-amoxi
- for penicillin allergy, give clindamycin + cefixime
- for beta lactam allergy, give doxycycline
When do you refer sinusitis to ENT?
Over 4 episodes per year
What is chronic sinusitis and how is it differentiated?
Paranasal sinus inflammation lasting >12 weeks.
There is with and without polyps
How does chronic sinusitis happen?
Usually due to an anatomical obstruction of the osteomeatal complex, resulting in inadequate sinus drainage of mucus.
Acute exacerbation:
1) Inflammation of the sinonasal mucosa occurs due to allergies, viral infections, pollutants.
2) Results in additional swelling in narrow osteomeatal channels.
3) Pooling of mucus means resp cilia cannot clear it. It thickens and microorganisms grow.
How would you manage acute exacerbations?
1st line = co-amoxi or cefuroxime
Nasal saline irrigations
Intranasal corticosteroids eg. budesonide, mometasone, etc
(ensure proper spraying technique or epistaxis risk!)
Decongestants eg. ometazoline nasal spray
Prednisoline oral to shrink polyps
Antihistamines eg. Loratadine, cetrizine, chlorphenamine for allergic rhinitis
Endoscopic sinus surgery last resort
What are common bacterial organisms that cause acute sinusitis?
strep pneumoniae
haem influenzae
moraxella catarrhalis
How would otitis externa present?
What would a diabetic be at risk for?
- Acute onset ear pain, tender on tragus manipulation
- ear canal swelling and erythema
- ottorhoea
- feeling of fullness
- decreased hearing due to swelling
- erythematous tympanic membrane
Malignant or necrotising otitis externa
How would you manage OE
- clean the ear from debris/wax
- Antibacterial otic drops (ciprofloxacin/dexmethasone can be used even in perforated tymp membranes)
- paracetamol/ibuprofen for pain
- add systemic antibiotics for immunocompromised (systemic ciprofloxacin OR amoxi OR co-amoxi)
Explain the pathophysiology of otitis media
What are 3 common bacteria?
Upper resp infections can infect nasal passage –> E tube –> Middle ear, and impair the Eustachian tube’s mucociliary action and ventilator function.
Middle ear effusion occurs and nasopharyngeal bacterial grow.
Pressure against tympanic membrane = perforation = purulent ottorhoea
Common bacteria = strep pneumonia, H influenzae, moraxella catarrhalis
How would otitis media present?
- Hx of exposure to resp viruses eg. healthcare/ daycare worker
- Symptoms of an upper resp infection
- bulging tympanic membrane
- myringitis (erythema of tympanic membrane)
- fever
How would you manage otitis media?
- Analgesia eg. paracetamol/NSAIDs
Antibiotics = amoxicillin OR co-amoxi
Tympanocentesis can relieve pressure in middle ear
How do cholesteatomas occur?
- a retraction pocket is an area of invagination of the tympanic membrane
- gets pulled into the middle ear due to -ve pressure caused by eustachian tube dysfunction
- the pocket can trap squamous cells with keratin accumulation and retentino.
- These cells proliferate
- Bacterial infection of the trapped cells can form a biofilm (commonly pseudomonas aeruginosa)
What damage can result from the bacteria accumulating in the cholesteatoma?
cytokine induced inflammatory changes:
- activates osteoclasts and lysozymes
- bony ossicle destruction = conductive hearing loss
- destruction of semicircular canals = vertigo
- destruction of cochlea = sensorineural hearing loss
- erosion into facial canal = facial palsy
- acute infection of temporal bone = mastoiditis
How do cholesteatomas typically present?
- ear discharge unresponsive to antibiotics
- hearing loss (usually conductive)
attic crust in retraction pocket - white mass behind intact tympanic membrane (congenital)
- tinnitus
- otalgia
- altered taste (facial nerve involvement)
- dizziness (erosion into semicircular canal)
How would you manage a cholesteatoma?
surgery!!! eg. mastoidectomy
- 8mg dexamethasone for post-op nausea
- Topical antibiotics containing quinolone for the discharge (ciprofloxacin, ofloxacin)
- ** can use a wick to deliver ear drops into a really swollen canal ***
- aural cleaning to reduce discharge
