ENT: Ear Problems 2 Flashcards

Question

Discuss the management of vertigo (brief overview)

Answer 1

* May need **further investigations** to establish underlying cause * **Symptom control** in peripheral vertigo: * Prochlorperazine * Antihistamines (e.g. cyclizine, cinnirazine) * **Treat underlying cause**: * Ménière’s disease: betahistine to reduce attacks * BPPV: Epley manouevre * Vestibular migraine: avoid triggers, triptans for acute symptoms, betablockers/amitriptyline/topiramate for prophylaxis * MS: medications * Tumours: surgical removal

Answer 2

Benign paroxysmal positional vertigo Get **recurrent** episodes of **sudden onset vertigo** triggered by **head movement**

Answer 3

* **Otoconia** (crystals of calcium carbonate) are usually found in **utricle & saccule above the stereocili**a; they are displaced in response to movement and cause depolarisation of hair cells- which is perceived as movement * In BPPV, otoconia get into the **semicircular canals** (most commonly in the posterior semicircular canal) * Displacement/movement into semicircular canals may be caused by viral infection, head trauma, ageing or idiopathically * Crystals **disrupt normal flow of endolymph in canals**; they can continue to stimulate hair cells even after head movement has ceased leading to vertigo

Answer 4

Average age of onset is 55yrs: * Vertigo triggered by head movements (commonly by turning over in bed or looking up) * Episodes last 10-20 seconds * Associated nausea

Answer 5

_Dix-Hallpike test_ Head movements move the endolymph through semicircular canals and triggers vertigo in pts with BPPV. * The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear) * Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees * Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch * Watch the eyes closely for 30-60 seconds, looking for nystagmus * Repeat the test with the head turned 45 degrees in the other direction In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).

Answer 6

Usually **resolves spontaneously within a few weeks to months** hence pt has option of waiting; however, there are a couple options to relieve symptoms: * **Epley manoeuvre** (sucessful in ~80%) * **Brandt-Daroff exercises**

Answer 7

Idea is to move otoconia in the semicircular canals to a position that doesn't cause symptoms. Maintain each head position for at least 30 seconds and wait for any nystagmus or vertigo to settle * Start with the person sitting upright with their head turned 45 degrees to the affected side, then lie them back (with their head still turned 45 degrees) until the head is dependent 30 degrees over the edge of the couch (as if performing the Dix-Hallpike manoeuvre) * With the face upwards, but still tilted backwards by 30 degrees, rotate the head through 90 degrees to the opposite side. * Hold the head in this position for about 20 seconds and ask the person to roll onto the same side as they are facing. * Rotate the person's head so that they are facing obliquely downward with their nose 45 degrees below the horizontal. * Sit the person up sideways while the head remains rotated and tilted to the side. * Rotate the head to the central position and move the chin downwards by 45 degrees.

Answer 8

Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.

Answer 9

* Usually resolves spontaneously after few weeks to months * ~50% get recurrence 3-5yrs later

Answer 10

**Inflammation of the vestibular nerve**- usually due to a **viral infection**. Inflammation of the nerve distorts signals travelling from vestibular system to the brain resulting in episodes of vertigo.

Answer 11

* Hx of recent viral URTI * Acute onset of vertigo * Most severe in first few days (may be constant at first but then reduce to being triggered by head movement) * Associated nausea and vomiting (can be severe)

Answer 12

* Treatments for symptom relief- can be used for up to 3 days: * **Prochlorperazine** *(can be given IM or buccal in severe, PO in mild)* * **Antihistamines** (e.g. cyclizine, cinnirazine, promethazine) * **Admit pts if they are becoming dehydrated** due to severe nausea & vomiting * **Refer to ENT if symptoms not improved after 1/52 or resolved after 6/52** *(may need further investigation or vestibular rehabilitation therapy which involves tailored exercises specific to pt)*

Answer 13

* Symptoms most severe in first few days; **usually resolves within 6 weeks** * **Recurrence is rare**

Answer 14

* **Inflammation of inner ear** (semicircular canals, vestibule [utricle & saccule] and cochlea) * Usually caused by **viral URTI** however can be rarely caused by bacterial infection (usually secondary to otitis media or meningitis)

Answer 15

* Hx of viral URTI * Acute onset vertigo * Hearing loss * Tinnitus * Nausea and vomiting

Answer 16

*Management similar to vestibular neuronitis & like vestibular neuronitis it usually resolves in a few weeks* * Treatments for symptom relief- can be used for up to 3 days: * **Prochlorperazine** *(can be given IM or buccal in severe, PO in mild)* * **Antihistamines** (e.g. cyclizine, cinnirazine, promethazine) * If chronic, refer to ENT as may benefit from **vestibular rehabilitation therapy**

Answer 17

* Vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment * Labyrinthitis is used when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment.

Answer 18

* Meniere's disease is a **long term** disorder affecting the **inner ear**, of **unknown cause**, which can affect **balance and hearing**. * It is a clinical syndrome characterized by episodes of **vertigo, fluctuating hearing loss, and tinnitus** and is associated with a feeling of fullness in the affected ear.

Answer 19

* **Excess endolymph** within **labyrinth of inner ear** * Causes **increased pressures** *(increased pressure of endolymph called endolymphatic hydrops)* * Which

Answer 20

Typically a **40-50yr** old patient with: _Classic triad_ * **Vertigo** *(episodes last 20mins-hours. Can come in clusters and then be followed by prolonged periods without symptoms. Not triggered by movement or posture)* * **Unilateral hearing loss** *(typically fluctuates at first but then gradually becomes more permanent, low frequencies affected first, may become gradual over time)* * **Unilateral tinnitus** *(usually occurs with vertigo episodes before becoming permanent, may become gradual over time)* _Other symptoms_ * Sensation of fullness in ear * Unexplained falls (drop attacks) without loss of consciousness * Imbalance can persist after vertigo * Unilateral nystagmus during an attack

Answer 21

* **Clinical diagnosis made by ENT** *(hence need to refer to ENT in primary care)* * **Audiometry** needed to assess hearing

Answer 22

* Symptomatic relief during attack: * Prochlorperazine * Antihistamines (cyclizine, cinnarizine, promethazine) * Prophylaxis: * Betahistine * If symptoms are severe enough, people may require hospital admission for intravenous (IV) labyrinthine sedatives and fluids to maintain hydration and nutrition

Answer 23

* Must not drive on presentation and must notify DVLA. When satisfactory control of symptoms has been achieved, relicensing may be considered for restoration of the ’til 70 licence.

Answer 24

Infection of middle ear Often preceded by viral URTI

Answer 25

Children \<4yrs *(especially those who are subject to passive smoking, attend daycare or nursery, are formula-fed, or have craniofacial abnormalities)*

Answer 26

Although often preceded by viral URTI, acute otitis media usually caused by bacterial infection. * Most common= **Streptococcus pneumoniae** * Others: * Haemophilus influenza * Moraxella catarrhalis * Staphylococcus aureus

Answer 27

* **Ear pain** * Reduced hearing in affected ear * Feeling generally unwell (e.g. fever) * Hx of or current symptoms or URTI (cough, coryzal symptoms, sore throat) * Discharge from ear if tympanic perforation

Answer 28

* Bulging, red tympanic membrane (like a doughnut) * May see perforation in tympanic membrane

Answer 29

_Antibiotics_ Most cases resolve without abx in around 3-7 days. Hence, antibiotics are not always needed. Antibiotics can be given as an immediate or delayed prescription. **Indications for immediate antibiotics include:** * People who are systemically very unwell * People who have symptoms and signs of a more serious illness or condition * People who have a high risk of complications **Indications for delayed antibiotics (to be used after 3 days) include:** * No improvement or worsening of symptoms * More likely to benefit (e.g. \<2yrs with bilateral symptoms, otorrhea) * Helpful strategy in pts pressing for abx **Antibiotic choice:** * First line= amoxicillin 5-7 days * If penicillin allergy= clarithromycin * If penicillin allergic & pregnant= erythromycin _Other aspects of management:_ * Safety netting * Simple analgesia

Answer 30

**Admit for immediate specialist assessment:** * People with a **severe systemic infection** * People with **suspected acute complications** of acute otitis media (AOM), such as meningitis, mastoiditis, intracranial abscess, sinus thrombosis, or facial nerve paralysis * Children **younger than 3 months of age with a temperature of 38°C or more**

Answer 31

* 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)

Answer 32

**Inflammation of external ear canal**; may also involve tympanic membrane and pinna

Answer 33

* **Acute otitis externa** is inflammation of **less than 6 weeks** duration, typically caused by bacterial infection with *Pseudomonas aeruginosa* or *Staphylococcus aureus*. * **Chronic otitis externa** is inflammation which has lasted **longer than 3 months**, and may be caused by fungal infection with *Aspergillus* species or *Candida albicans*.

Answer 34

* Swimming *(often called swimmers ear)* * Trauma *(e.g. from cotton buds or earplugs)* * Removal of ear wax *(ear wax is protective)* * Eczema * Seborrheic dermatitis * Psoriasis * Contact dermatitis

Answer 35

* **Pseudomonas aeruginosa** * **Staphylococcus aureus** *TOM TIP: It is worth remembering Pseudomonas aeruginosa. It is a gram-negative aerobic rod-shaped bacteria. It likes to grow in moist, oxygenated environments. Other than causing otitis externa, an important exam-related point to remember is that it can colonise the lungs in patients with cystic fibrosis, significantly increasing their morbidity and mortality. It is naturally resistant to many antibiotics, making it very difficult to treat in children with cystic fibrosis. It can be treated with aminoglycosides (e.g., gentamicin) or quinolones (e.g., ciprofloxacin).*

Answer 36

* **Ear pain** * **Discharge** * **Itchiness** * Conductive hearing loss (if the ear becomes blocked) * Tenderness when press tragus

Answer 37

* Red, swollen canal * Eczematous canal

Answer 38

* **Clinical diagnosis** * Ear swab _not usually required_

Answer 39

Main aspects of management: * Advice to all: keep ear clean & dry, aural toilet, simple analgesia * _Mild otitis externa_: **acetic acid 2%** *(can buy OTC. Has antifungal & antibacterial effects)* * _Moderate otitis externa:_ **topical abx (usually aminoglycosides or quinolones) & steroid for 7-14 days** * E.g. neomycin, dexamethasone & acetic acid (Otomize spray) * Other combinations of: gentamicin, ciprofloxacin, hydrocortisone, betamethasone * Aminoglycosides: neomycin, gentamicin * Quinolines: ciprofloxacin * _Severe or systemic symptoms or immunocompromised:_ **oral abx (**e.g. flucloxacillin or clarithromycin) Other aspects of management: * Fungal infections: can use clotrimazole drops * Ear wick may be used if canal is very swollen and treatment with drops or sprays will be difficult *(w**icks are inserted into the ear canal and left there for a period of time (e.g., 48 hours). Contain topical treatments. As the swelling and inflammation settle, the ear wick can be removed, and treatment can continue with drops or spray)*

Answer 40

Do not use if tympanic perforation (hence MUST exclude before prescribing); can cause hearing loss.

Answer 41

* Symptoms **persist** despite optimal management in primary care * There is **external ear canal occlusion** due to ear discharge, swelling, or debris which is stopping topical treatment working effectively * Specialist 'aural toilet' including microsuction, ear wick insertion, or use of systemic antibiotics may be needed. * **Cellulitis extending beyond the external ear canal** which cannot be managed in primary care

Answer 42

Potentially **life-threatening** **progressive infection of the external ear canal** causing o**steomyelitis of the temporal bone** and adjacent structures.

Answer 43

Malignant otitis externa is usually related to underlying risk factors for severe infection, such as: * Diabetes * Immunosuppressant medications (e.g., chemotherapy) * HIV

Answer 44

* Similar, but more severe, to those of otitis externa with additional features such as headache, severe pain, fever * Granulation tissue at junction between bone & cartilage in ear canal (~ ½ way along)= key finding

Answer 45

**Emergency admission to hospital under ENT** for: * **IV abx** *(that cover pseudomonas)* * Imaging (CT or MRI head) to assess extent infection

Answer 46

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

Answer 47

Cerumen + discarded/dead skin cells

Answer 48

Ear wax can build up and become impacted and stuck to the tympanic membrane. This can result in: * Conductive hearing loss * Discomfort in the ear * A feeling of fullness * Pain * Tinnitus

Answer 49

Most cases doesn't require treatment. Pts should be advised to avoid inserting cotton buds into ear. Methods to remove ear wax include: * Ear drops: *olive oil or sodium bicarbonate* * Ear irrigation: *squirting water into ear to clean wax away. Perforation is a contraindication.* * Microsuction

Answer 50

* Also called otitis media with effusion; **collection of fluid in middle ear without signs of acute inflammation** (hence NOT an infection) * Most common in **winter** in children aged **6 months to 4 years** * It is the _most common cause of hearing impairment in children_

Answer 51

* Negative pressure builds up inside ear, often due to dysfunction of Eustachian tube, causing build up of fluid in middle ear * Decreases motility of tympanic membrane and ossicles hence decreases hearing

Answer 52

* **Recent acute otitis media** *(50% follow on from AOM)* * Parental smoking * Siblings with OME * Allergy * Reflux disease * Other conditions: * Down's syndrome * Primary ciliary dyskinesia * Cystic fibrosis * Allergic rhinitis

Answer 53

* Hearing loss is usually presenting feature * May see secondary problems such as speech & language delay, behavioural problems, balance problems

Answer 54

_Non-surgical_ * **Active observation for 3 months** *(should have audiology assessments and assess impact on life)* * **Auto inflation using nasal balloon or Valsalva manoeuvre** *(useful in older children- may do in the active observation period)* * **Hearing aids** *(if surgery not suitable or acceptable)* _Surgical_ * **Grommets:** *allow air to pass into middle ear and hence do the job normally done by Eustachian tube. Majority stop functioning after 10 months & fall out on their own in time* * **Adenoidectomy:** *if adenoids obstructing Eustachian tube*

Answer 55

* **Chronic inflammation of the middle ear and mastoid cavity,** which presents with **recurrent ear discharge** (otorrhoea) **through a tympanic perforation**. *(WHO says after 2/52 of discharge but some experts say \>6/62 discharge)* * Presentation: * Ottorhea \>2/6 weeks _without_ pain or fever * Hearing loss * Hx of AOM, trauma, grommet insertion, OME * Otoscopy findings: perforated tympanic membrane * Refer to ENT *(don't swab or initiate treatment)*

Answer 56

* Peripheral **facial nerve palsy** accompanied by an **erythematous vesicular rash** on the ear (zoster oticus) or in the mouth * Also called herpes zoster oticus * Caused by **reactivation of varicella zoster virus in the geniculate ganglion of CNVII** * Features: * **Auricular pain** * **Facial nerve palsy** * **Vesicular rash around ear on affected side** *(can extend to anterior ⅔ of tongue and hard palate)* * Vertigo * Tinnitus * Management: * **PO aciclovir and corticosteroids** * **Lubricating eydrops**

Answer 57

* Infection of perichondrium (tissue that covers cartilage) in ear * Presentation: * Erythema * Pain * Swelling * Management: * Antibiotics & corticosteroids * If abscess, incision & drainage * Simple analgesia * Complications: * Cauliflower ear

Answer 58

* Acute otitis media (most common) * Glue ear * Other infections e.g. mumps, meningitis * Ear wax blockage * Foreign body * Genetics

ENT: Ear Problems 2 Flashcards

(82 cards)