Ent Key Flashcards
(206 cards)
1
Q
A
2
Q
Points on Epistaxis Management
◙ If the patient is hemodynamically compromised:
• Immediate transfer to the Accident and Emergency Department (A&E).
• Use the first aid measures to control bleeding:
Lean forward – Open mouth – Pinch the SOFT cartilaginous part of the nose
firmly for 10-15 minutes (sometime a
WRONG option is given, which is: pinch the
nasal bridge, be careful!). You can provide cold fomentation with an ice-pack on
the bridge of nose, not compressing it!
A
◙ If the patient is hemodynamically stable:
• Use the first aid measures (mentioned above).
• If still bleeding:
√ If the bleeding is small and the bleeding can point can be seen
→ Nasal cautery (with silver nitrate).
√ If cautery failed or the bleeding is massive or the bleeding point is invisible:
→ Anterior nasal packing.
3
Q
Examples:
◙ Case (1):
• Recurrent episodes of Epistaxis +
• Visible blood vessels are seen on the anteroinferior part of the nasal septum
bilaterally +
• No active bleeding (or small bleeding) at the time of presentation.
→ Nasal Cautery at one side of the septum initially.
Note, another valid answer if no active bleeding i
→ Topical treatment with Naseptin “Chlorhexidine and Neomycin cream”.
if the bleeding is bilaterally, both sides will eventually need cautery. However,
A
we cannot do cautery of both sides at the same time for risk of septal
perforation.
Important:
Cautery (with silver nitrate) should be avoided if there is massive active bleeding
(as the silver nitrate would be washed out if there is active bleeding).
However, if
the active bleeding is small and the point of bleeding can be located, start with
nasal cautery with silver nitrate (if first aids had failed).
4
Q
• Recurrent episodes of Epistaxis +
• Visible blood vessels are seen on the anteroinferior part of the nasal septum
bilaterally +
• There is still massive active bleeding at the time of presentation:
→ Anterior Nasal Packing Bilaterally.
(Even if bleeding point is not visible and he is still bleeding heavily, we do anterior
nasal packing).
However, if minimal bleeding → nasal cautery.
A
Cautery (with silver nitrate) should be avoided if there is heavy active bleeding
(as the silver nitrate would be washed out if there is active bleeding).
The packing is done bilaterally as the bleeding is bilaterally, and the patient is
encouraged to breath per mouth.
“Typically left in for 24-48 hours”
5
Q
A child with recurrent bleeding especially when he picks his nose.
• Presented to the ER.
• There is still active bleeding for 30 minutes. However, the active bleeding is
minimal (only after picking his nose or sometimes after coughing).
• Rhinoscopy could locate the bleeding point (in the little area)
• First aids have failed to stop bleeding
→ Nasal cautery with silver nitrate.
Note: if cautery is not in the options:
A
Pick → Topical Naseptin “Chlorhexidine and Neomycin cream”.
(As the bleeding point can be seen and the bleeding is minimal – after nose
picking, silver nitrate cautery is tried first.
If failed, or of heavy bleeding, or if the
bleeding point cannot be seen → nasal packing).
6
Q
Important Last note:
If the bleeding is posterior (from both mouth and nose). For example: nonstop
bleeding from both nose and mouth after adenoidectomy
A
→ Re-explore under general anaesthesia.
7
Q
Oral Thrush (Oral Candidiasis).
◙ RFx →
√ Immunosuppression (e.g., DM, recent Hx of treatment with antibiotics, long-term
steroids intake).
√ smoking.
√ elderly.
◙ Features →
- Thick white marks ± Inflamed mouth/ tongue.
- Note that Plaques might enlarge and become painful and cause discomfort while
A
eating and swallowing.
- The white lesions Can be rubbed out (removed).
- It might also present with red inflamed painful sore mouth angles.
◙ Rx of oral thrush →
- Stop Smoking.
- Good inhaler techniques, spacer device, rinse mouth with water after use.
- Oral Fluconazole 50 mg OD for 7 days or Fluconazole oral suspension.
- If the infection is mild and localized → Miconazole gel “first line”.
In those using Inhaled Steroids such as asthmatics and COPD patients, to avoid oral
thrush “Oral Candidiasis”:
√ Rinse mouth with “water” after use.
√ Check adequate spacer techniques.
8
Q
Leukoplakia
- Hx of Smoking.
- Raised edges, bright white patches, sharply well defined.
- The white lesions Cannot be rubbed out (cannot be removed).
- Rx → Stop Smoking + take biopsy (as Leukoplakia is premalignant).
A
√ Oral Candidiasis → Thick white marks + Can be rubbed out ± Inflamed mouth.
√ Leukoplakia → White marks, cannot be rubbed out, sharply defined.
√ Pregnancy → weak immunity → Candida albicans can grow (oral thrush =
candidiasis).
√ Smoking is a precipitating factor in both Oral Candidiasis and Leukoplakia.
9
Q
Oral Lichen Planus
- Lace like appearance on oral cavity.
- With purple, pruritic (itchy), polygonal, papular rash on flexor surfaces. (4P + F).
A
◙ Rx:
√ Topical steroids → the mainstay of treatment.
√ benzydamine mouthwash or spray is recommended for oral lichen planus.
√ Extensive lichen planus may require oral steroids or immunosuppression.
10
Q
Removal of Ear Foreign Body
◙ Insect
√ First: Kill insect with Lidocaine 2% or Olive oil or Mineral oil or Alcohol drops.
√ Then: Syringe it out by water irrigation or olive oil
A
Seed (eg, beans, pea)
→ “Rapid access” not urgent referral to ENT to remove it by Suction with a
catheter or by a hook.
NEVER Irrigate or instil oil in the case of an organic matter (eg, seed, bean, pea)
as it would swell causing more discomfort and difficulty to remove.
◙ Super Glue
√ It could be removed manually in 1-2 days (after desquamation).
√ Or: refer to ENT if ear drum is involved.
◙ Earwax build up → A few drops of olive oil Or (sodium chloride drops) to
soften hard wax. Other methods → Irrigation/ Microsuction.
◙ Batteries → Refer to ENT as they should be taken out within 24 hours!
◙ Any spherical object
→ (eg, pencil rubber) → remove by a Hook.
If any FB in the ear of an intellectually disabled person (eg, autistic child)
→ Remove under General Anaesthesia by ENT.
11
Q
If any FB in the ear of a child who is
A
in severe pain ▐ extremely restless ▐ agitated ▐ difficult to examine
→ Remove under General Anaesthesia by ENT. (Safer and better).
12
Q
◙ Referral to ENT in the following situations:
A
- If the patient requires sedation.
- If there is any difficulty in removing the FB.
- If the patient is uncooperative. (e.g., a person with autism, mental
retardation, very young child to be cooperative). - If the tympanic membrane is perforated.
- If an adhesive (e.g., super glue) is in contact with tympanic membrane.
13
Q
• Example 1:
An autistic child with beans stuck into his right ear
➔ Remove under GA.
• Example 2:
A 5 YO boy has a pea stuck inside his right ear while eating dinner. His TM is
intact with a wax covering it.
A
There was not an option with (suction with a catheter) or (remove by hook)
In this case, pick
→ Routine referral to ENT. “Not urgent referral”.
• Example 3:
A child presents with a pencil rubber stuck in his right ear.
→ Remove by a hook.
• Example 4:
A child with a piece of toy stuck in his ear. It is difficult to examine using
otoscopy, the child is in pain, crying, restless.
→ Remove under general anaesthesia.
14
Q
A child with this otoscope image has decreased hearing on his left ear. He has
no fever and no ear discharge.
→ Ear wax. It needs ear drops first to soften the wax.
(eg, olive oil drops, NaCl 0.9% drops, almond oil drops),
→ Other methods (if ear drops not in options) → irrigation or microsuction.
A
Rx → Ear drops Notes:
• Hearing test would be rejected if there is significant wax.
• Microsuction is safer and more preferred over irrigation (syringing).
• Never use cotton pads in wax as they may worsen wax impaction.
15
Q
Nasopharyngeal Carcinoma
• Swollen cervical LNs → a painless swelling or lump in the upper neck.
• Eustachian tube obstruction → Otitis media, Epistaxis “recurrent nose
bleeds”, Nasal obstruction.
• Others: Conductive hearing loss, Tinnitus.
• RFx: EBV (specific), Smoking, Alcohol
A
.
N.B: EBV → Hodgkin’s lymphoma, Nasopharyngeal carcinoma.
16
Q
Tonsil Carcinoma
• Persistent sore throat (over weeks).
• Progressive Hoarseness of voice.
• Dysphagia and painful swallowing.
• Feeling of a persistent lump in the throat.
• Palpable lump on the anterolateral portion of the neck
A
• N.B. the absence of weight loss does not exclude the tonsil cancer!
• Tonsillar cancer spreads to → Mandible (important)
→ Pain in the throat + Trismus (spasm of the jaw muscles, causing the
mouth to remain tightly closed).
17
Q
Quinsy (Peritonsillar abscess)
Peritonsillar abscess usually presents after a Hx of tonsillitis or sore throat for
several days.
◘ Quinsy “Peritonsillar abscess” presents with:
√ Severe trismus (which is lockjaw = spasm of jaw muscles),
√ Sore throat (of several days),
√ Drippling of saliva,
√ Otalgia (as CN IX glossopharyngeal nerve supplies both the ears and tonsils),
√ Hot potato voice,
√ uvular deviation.
√ Inflamed bulge on one side of a tonsil + painful swallowing.
→ Amit for IV antibiotics, incision and drainage.
Another answer → Urgent admission to the hospital.
A
Recently asked): What if both answers were given:
A) IV antibiotics (IV benzyl penicillin/ Phenoxymethylpenicillin). OR:
B) Incision and drainage.
Look at the question phrase:
• If it asks about the (initial) step → • If it asks about the (most appropriate) Rx → IV antibiotics.
incision and drainage.
18
Q
Acute Sinusitis in Points
◙ Presenting features:
• There is usually a Hx of upper respiratory tract infection in the last few days.
• Nasal blockage ± discharge
• Facial pain or pressure (e.g., cheekbone or periorbital pain ± redness)
• ↓ smell, headache.
◙ The vast majority of acute sinusitis cases are due to viral infections (98%).
◙ So, they are mostly self-limiting:
- Symptom’s relief is what’s needed
A
Nasal decongestant containing ephedrine. (and/or nasal saline)
→ Paracetamol/ibuprofen for fever and facial pain relief.
- Nasal steroids can be considered if symptoms last > 10 days without a
significant improvement.
◙ It is rarely bacterial. Thus, no need to start antibiotics unless necessary.
• Notes:
√ Acute sinusitis → Oral paracetamol/Ibuprofen.
√ If 10 or more days without improvement → Nasal corticosteroids.
√ Antibiotics are rarely used.
19
Q
Plummer Vinson Syndrome:
√ Iron Deficiency Anemia (IDA),
√ Glossitis,
√ Dysphagia (due to post-cricoid oesophageal web).
A
is a risk factor for oropharyngeal carcinoma
It is common in postmenopausal women.
20
Q
Pns Tumour
A
Paranasal sinus tumour
• Pressure / pain / Tenderness / Swelling in the cheek, upper teeth.
• Blood seen in the nasal discharge.
• Nasal Obstruction.
• Hx of chronic sinusitis.
• If the orbit is involved → Epiphora (excessive watering of the eye),
Diplopia.
21
Q
Otitis Media (OM)
• Earache (otalgia) = ie, ear pain.
• Usually follows viral URTI (eg, tonsillitis).
• ± Fever, Vomiting, Irritability.
• Tympanic membrane: might be Red, Yellow, or Cloudy.
It might also be bulging, or perforated, with or without purulent discharge.
• Ruptured tympanic membrane alleviates the pain
A
.
analgesics supportive ◙ Management of Acute Otitis Media in Short ◙
◘ OM is usually viral (requires Ie, if mild symptoms → and
◘ If signs of bacterial (e.g. High fever, cervical lymphadenopathy)
treatment only).
No treatment required (only supportive). √
→ Oral Amoxicillin.
Reassure and review in 6 weeks
√ If the tympanic membrane ruptured and a discharge came out →
this would
relieve the ear pain. What is next? → (
Reassure and review in 6 weeks
as the
membrane heals on its own within 6 weeks).
√ If it does heal in 6 weeks → Consider (TM repair).tympanoplasty
(Note: if it is suspected to be bacterial eg, purulent foul-smelling discharge,
fever, or persistent pain after discharge → Consider oral antibiotics.
22
Q
Otitis Externa
• Hx of swimming, High humidity, travel
+ Painful ear
+ pus or serous fluid inside the ear canal.
• Serous discharge.
• Tragal Tenderness.
• Starts with itching → then pain in the ear.
• Rx:
A combination of Acetic Acid + Aminoglycoside + Topical Corticosteroids
A
N.B. Avoid Aminoglycoside (e.g. gentamicin) if there is tympanic membrane
perforation as it is ototoxic.
Ciprofloxacin drops could be used instead.
- The treatment in the exam is usually (Topical Gentamicin)
or (Topical Gentamicin + Hydrocortisone). - It these were not in the choices, pick (Acetic Acid 2%).
23
Q
A
24
Q
Trauma to the ear
(e.g., during fight, Slap to the ear)
→ intense otalgia, bleeding per ear, ringing inside the ear (tinnitus), temporary
decreased hearing (Conductive).
A
• The first investigation is → Otoscopy (suspected perforated eardrum).
25
Hx of travel, presents with earache and pus in the ear canal. Management?
→ (Acetic Acid 2%). (Otitis Externa).
Or (Topical gentamicin).
Or (Topical Gentamicin + Hydrocortisone).
England’s guidelines recommend the following for OE “Otitis Externa”:
√ Acetic acid 2% 1 spray TID for 7 days (First line).
√ Neomycin sulphate + Corticosteroids 3 drops TID for 7 to 14 days. (2nd line).
26
Tonsillar carcinoma usually metastasizes to the
Mandible
27
URTI can be followed by Acute Otitis Media (Sever pain in the ear).
28
Mandible or salivary gland mass investigation
Mandibular lumps and any salivary gland masses need to be investigated by:
→ U/S Guided Fine Needle Aspiration (FNAC).
◙ Example:
Free and mobile submandibular mass that grows rapidly with skin induration
→ FNAC.
29
◙ Features:
√ Swelling in the submandibular region which can become enormously
enlarged.
√ The swelling is more painful and prominent on chewing (This indicates
obstruction due to salivary stones).
√ Tenderness and redness.
√ Sour taste in the mouth (No saliva), dry mouth (no saliva).
√ Decreased mobility of the jaw.
• If got infected → fever and rigors (may cause septicaemia).
Chronic Sialadenitis:
Inflammation of the salivary glands
Chronic Sialadenitis → often 2ry to Sialolithiasis (Salivary stones) which leads
to decreased salivary outflow.
30
Mikulicz syndrome → a triad of:
√ Symmetrical enlargement of all salivary glands.
√ Narrowing of the palpebral fissures due to enlargement of the lacrimal
glands.
√ Parchment-like dryness of the mouth.
• It may occur 2ry to sarcoidosis, tuberculosis (TB) or lymphoma.
31
In a patient with epistaxis with normal labs (normal Hb, Platelets, PT, APTT)
The likely cause → Anatomical defect or Trauma.
N.B. Trauma to the nose is the most common cause of epistaxis, it includes
nose picking, excessive nose blowing, FB insertion
32
Webers rinne
Rinne and Weber tests using tuning fork.
(SNHL vs CHL)
What are Rinne and Weber tests?
√ Rinne and Weber tests are exams that test for hearing loss.
√ They help determine whether a patient may have conductive or
sensorineural hearing loss.
• A Rinne test evaluates hearing loss by comparing air conduction to bone
conduction. Air conduction (AC) hearing occurs through air near the ear, and it
involves the ear canal and eardrum.
Bone conduction (BC) hearing occurs
through vibrations picked up by the ear’s specialised nervous system.
• A Weber test is another way to evaluate conductive and sensorineural
hearing losses.
◙ Conductive hearing loss (CHL) occurs when sound waves are unable to
pass through the middle ear to the inner ear. This can be caused by problems
in the ear canal, eardrum, or middle ear.
◙ Sensorineural hearing loss (SNHL) occurs when there’s damage to any
part of the specialised nervous system of the ear. This includes the auditory
nerve, hair cells in the inner ear, and other parts of the cochlea.
Ongoing exposure to loud noises and aging are common reasons for this type
of hearing loss.
33
Causes of Hearing Loss in Older Adults
SITE/TYPE OF
BLOCKAGE EXAMPLES OF ETIOLOGY
❤️Conductive hearing loss (CHL)
Obstruction of
Cerumen (Wax obstruction); foreign body; debris from
external
otitis externa; large exostoses, osteomas
auditory canal
Impairment of
Perforated tympanic membrane; tympanosclerosis
tympanic
membrane
function
Middle ear
Otitis media with effusion; otosclerosis; cholesteatoma;
conditions
disarticulation of ossicular chain; glomus tumours
❤️Sensorineural hearing loss (SNHL)
No site/types Age-related hearing loss (Presbycusis);
noise trauma;
medications;
autoimmune disease;
mechanical trauma
(e.g., temporal bone fracture);
Meniere disease
; infection
(e.g., meningitis, labyrinthitis);
neoplasm (e.g., acoustic
neuroma)
NOTE: Causes are in approximate order of most to least common within each
category.
34
Causes of Hearing Loss in Older Adults
SITE/TYPE OF
BLOCKAGE EXAMPLES OF ETIOLOGY
❤️Conductive hearing loss (CHL)
Obstruction of
Cerumen (Wax obstruction); foreign body; debris from
external
otitis externa; large exostoses, osteomas
auditory canal
Impairment of
Perforated tympanic membrane; tympanosclerosis
tympanic
membrane
function
Middle ear
Otitis media with effusion; otosclerosis; cholesteatoma;
conditions
disarticulation of ossicular chain; glomus tumours
❤️Sensorineural hearing loss (SNHL)
No site/types Age-related hearing loss (Presbycusis);
noise trauma;
medications;
autoimmune disease;
mechanical trauma
(e.g., temporal bone fracture);
Meniere disease
; infection
(e.g., meningitis, labyrinthitis);
neoplasm (e.g., acoustic
neuroma)
NOTE: Causes are in approximate order of most to least common within each
category.
35
What are the results of Rinne and Weber tests?
How to conduct Rinne and Weber tests?
Rinne and Weber tests both use 512-Hz tuning forks to test how a patient
responds to sounds and vibrations near your ears.
Rinne test
• The doctor strikes a tuning fork and places it on the mastoid bone behind
one ear.
• When the patient can no longer hear the sound, he signals to the doctor.
• Then, the doctor moves the tuning fork next to the patient’s ear canal.
• When the patient can no longer hear that sound, the patient once again
signals the doctor.
• The doctor records the length of time the patient hears each sound.
Weber test
• The doctor strikes a tuning fork and places it on the middle of the patient’s
head.
• The patient notes where the sound is best heard: the left ear, the right ear,
or both equally.
36
What are the results of Rinne and Weber tests?
Rinne Test results
• Normal hearing will show an air conduction time that is twice as long as the
bone conduction time (i.e. AC > BC).
• In other words, a patient will hear the sound next to his ear twice as long as
he will hear the sound behind his ear over the mastoid bone.
• If the patient has conductive hearing loss, the bone conduction is heard
longer than the air conduction sound (i.e. BC > AC).
• If the patient has sensorineural hearing loss, air conduction is heard longer
than bone conduction, but may not be twice as long.
Weber Test results
• Normal hearing will produce equal sound in both ears.
• Conductive loss will cause the sound to be heard best in the abnormal ear.
• Sensorineural loss will cause the sound to be heard best in the normal ear.
37
Webers rinnes
short,
- BC>AC → CHL ‘’Conductive hearing loss’’ in the SAME side
- AC>BC (normal) and Weber’s test lateralises to one side → SNHL in the
OTHER side.
- e.g., if Weber lateralises to the right → it is either right conductive
(confirmed by Rinne’s) OR Left Sensorineural hearing loss.
38
◙ Example (1):
√ BC > AC on the right side.
√ Weber’s best heard on the right ear.
→ Right Conductive Hearing Loss.
◙ Example (2):
√ AC > BC bilaterally.
√ Weber’s best heard on the right ear.
→ Left Sensorineural Hearing Loss.
◙ Example (3):
√ AC > BC bilaterally.
√ Weber’s: equal sounds on both ears (does not lateralise to either side).
No hearing loss
39
40
Meniere’s Disease: DVT + Fullness
- D: Deafness (Usually Unilateral – SNHL)
- V: Vertigo
- T: Tinnitus
- Fullness (feeing of fullness or pressure in the affected ear).
- +/- Nausea and Vomiting,
- Lasts from minutes to hours.
- Management: “careful for the question words, both can be asked”!
• To terminate the acute attack Prochlorperazine (Buccal or IM)
or: Promethazine, Cyclizine, Cinnarizine.
• To prevent further attacks (↓ the frequency of the episodes) → Betahistine.
Note, the feeling of pressure inside an ear may not always be given.
Important Note:
Feeling of fullness or pressure in the affected ear is more classic for Meniere’s
disease.
HOWEVER, if there are other symptoms of cranial nerve involvement
e.g. diplopia, facial drooping, facial sensation loss, the likely diagnosis will be
acoustic neuroma despite having the pressure sensation.
B. MRI is normal (which excludes Acoustic Neuroma).
N.B. Labyrinthitis is usually preceded by Viral URTI. (Sudden Vertigo and
Vomiting + hearing loss/ tinnitus after URTI).
41
Normal finding ear
AC > BC Bilaterally → Not Conductive hearing loss
Weber’s does not lateralize → Normal
42
Snhl
Investigation?
AC > BC Bilaterally → Not Conductive hearing loss
Weber’s lateralizes to Left → Right SNHL
SNHL means a defect in cochlea, hair cells in the inner ear, cochlear nerve or
brain stem:
→ Do MRI scan. (Careful! Not otoscopy!)
So, if a patient presents with hearing loss and found to have SNHL on Rinne’s
and Weber’s: (AC > BC bilaterally) +
Weber’s lateralizes to one side:
→ Order MRI.
43
Normal finding ear
AC > BC Bilaterally → Not Conductive hearing loss
Weber’s does not lateralize → Normal
43
Conductive hearing loss
√ If AC > BC → It is either Normal or SNHL (Not conductive).
√ If BC > AC → Conductive hearing loss on the same side of lateralization.
Weber lateralizes to the intact ear in SNHL and to the affected air in
Conductive HL.
44
In summary:
- Viral URTI followed by attacks of vertigo +/- Nystagmus, Vomiting
→ Vestibular neuritis.
Give → Prochlorperazine
- Viral URTI followed by Vertigo + Hearing loss/Tinnitus
→ Labyrinthitis.
N.B. Vestibular neuritis attack lasts hours or days whereas Benign paroxysmal
Positional Vertigo (BPPV) lasts a few minutes.
Vestibular neuritis VS Labyrinthitis
◙ Vestibular neuritis: inflammation of vestibular nerve “vestibular
neuropathy”
.
3 Vs: Vertigo, Vomiting, Viral URTI.
Rx to relieve symptoms → Prochlorperazine.
◙ Labyrinthitis: inflammation of vestibular nerve and labyrinth.
• Both have attacks of vertigo, nausea and vomiting that are aggravated by
moving the head and both are proceeded by URTI (runny nose, cough, fever).
• However, vestibular neuritis does not have hearing loss or tinnitus
• While labyrinthitis has SNHL ± Tinnitus.
“imp √”.
45
◙ Injury to ear pinna with INTACT tympanic membrane
(self-limiting).
→ No further investigations needed ◙
1.If Painful →
2. ◙ If hematoma →
give analgesics.
refer to ENT
46
Otitis Media with Effusion (OME) or Glue Ear
(Eustachian Tubes Dysfunction)
• It is the commonest cause of conductive hearing loss in children
(peaks at 2 Y/O). usually mild bilateral CHL.
• ± Hx of Recurrent OM URTIs oversized adenoids.
• Tympanic membrane is either Retracted “more common” or Bulging.
• It might be bluish grey, dull or yellow ± with an air-fluid level.
• Presents usually with hearing loss ‘’Conductive’’.
• Common Examples in PLAB 1:
√ A child raises the TV volume up.
√ A child is doing poorly in school.
√ A child lacks concentration and is socially withdrawn.
→ Refer them for hearing loss more commonly bilaterally”
47
Glue ear
Treatment:
• If first visit or recently diagnosed with OME (BUT NO OBVIOUS HEARING
LOSS YET)
→ Reassurance and review in 3 months (as it can resolve spontaneously
But if obvious hearing loss (eg, he raises TV volume up)
→ Pure tone audiometry from the start.
→ Grommet insertion • If persists over 3 months and bilateral:
“i.e. surgery”.
“Insertion of a small plastic or metal tube into the tympanic membrane to
relieve pressure in the middle ear. It is used in the management of otitis media
with effusion and in recurrent acute otitis media”.
• If surgery is contraindicated or rejected by the patient:
→ ear aids.
48
More clarification on Rx of OME (Important):
◙ Note that if is it is obvious that the child is having hearing loss (eg, he gets
close to the TV, he raises the TV volume) then there is a concern for hearing
loss.
Therefore, pure tone audiometry is needed (without a delay for 3
months). We need audiometry to determine the severity of the CHL.
• If the conductive hearing loss (CHL) is not severe (based on the audiometry
results) → then 3 months is given and then review with another audiogram.
• After 3 months, review with another audiometry:
If spontaneous resolve occurs, then that’s good. But f hearing loss becomes
more severe, then refer to ENT for consideration of grommets insertion.
Always encourage the parents to factor for their children’s glue ear.
stop smoking as it is an important risk
• Thus, sometimes, the answer would be ➔ Parental smoking is a risk factor for OME.
So, encourage them to stop
smoking and review the child in 3 months.
Advise parents to quit smoking.
49
Remember that:
Otosclerosis is the commonest cause of progressive conductive hearing loss in
Young adults (15-45 Y/O).
• Note: Children with down syndrome are specifically susceptible to
OME and they need yearly hearing checks using pure tone audiometry
Note: Pregnancy accelerates the progression of otosclerosis
50
Otoscopy findings in some ear conditions:
Otoscopy findings in some ear conditions:
• Bluish grey, or yellow TM with an air fluid level:
→ Otitis media with effusion (glue ear).
• Flamingo pink blush TM (Schwartz sign) → Otosclerosis.
• Inflamed TM with Cartwheel appearance of vessels
→ Acute suppurative OM.
51
• The commonest cause of progressive conductive hearing loss in the Young
adults (15-45 Y/O).
• ↑ stapes bony growth “turnover”.
• Family Hx: 50% is genetic.
• Bilateral in 80%.
• Other symptoms: Tinnitus and Vertigo (not always).
• More in females (2:1).
• Conductive hearing loss (Low tone loss).
• Difficulty hearing in a quiet environment (e.g., on the phone) (Low frequency
hearing loss), i.e., the patient hears better in a noisy environment.
• Pregnancy accelerates the progression of otosclerosis.
• No curative treatment.
• Management: Stapedectomy Or Stapedotomy with Prosthesis insertion.
• If not fit for surgery → Bilateral hearing aids.
52
53
Tympanosclerosis
Tympanosclerosis
√ CHL “Conductive hearing loss”.
√ Look for Chalky white patches over the eardrum.
54
Acquired Cholesteatoma
• Collections of keratinizing squamous epithelium in the middle ear that is
able to expand, erode and destroy the adjacent structures, causing TM
perforation and ossicles damage.
• It is neither a cholesterol nor a tumour.
• Pearly white mass BEHIND the tympanic membrane.
(Remember → white chalky mass ON the TM → Tympanosclerosis)
• Chronic Foul-smelling purulent discharge (otorrhea).
• Otoscopy may reveal canal filled with pus/mucus/granulation tissue.
• Hx of recurrent Otitis Media.
• (Cholesteatoma is poorly responsive to antibiotics).
• It causes Conductive hearing loss.
In Congenital Cholesteatoma:
- The same but the presenting patient is a child (6 months – 5 years).
- Usually there are neither Hx of recurrent OM nor TM perforation.
N.B. Because of the ability of Cholesteatoma to erode and damage the
adjacent structures, the presenting symptoms may include facial paralysis,
vertigo, headache besides deafness and earache.
55
a patient present to the GP with cholesteatoma
→ URGENT referral to ENT. Important.
Cholesteatoma: Pearly white mass BEHIND the TM
◙ Management of cholesteatoma:
→ Patients are referred to ENT (urgent) for consideration of surgical removal
N.B. Because of the ability of Cholesteatoma to erode and damage the
adjacent structures, the presenting symptoms may include facial paralysis,
vertigo, headache besides deafness and earache.
56
57
Acoustic Neuroma (Vestibular Schwannoma)
“Pressure effect on cranial nerves”:
• Vestibular nerve CN VIII (8th) → DVT (Deafness, Vertigo, Tinnitus).
• Facial nerve CN VII (7th) → Facial Palsy/ Facial drooping.
• Abducens nerve CN VI (6th) → Diplopia to the same side.
• Trigeminal nerve CN V (5th) → Loss of corneal reflex and facial sensation.
• ± Intracranial Pressure manifestations (e.g. Headache) as it is a space-
occupying lesion.
• Feeling of “fullness” in the affected ear.
Important Note:
Feeling of fullness or pressure in the affected ear is more classic for Meniere’s
disease.
HOWEVER, if there is other cranial nerve involvement e.g., diplopia,
facial drooping,
facial sensation loss, the likely diagnosis will be acoustic
neuroma despite having the pressure sensation.
Important Note:
Acoustic neuroma (vestibular schwannoma) is usually commonly associated
with neurofibromatosis type 2.
Remember this association:
Acoustic neuroma WITH Neurofibromatosis
58
Example:
A man with bilateral sensorineural hearing loss + Vertigo + Tinnitus + Hs of
neurofibromatosis type 2
→ Acoustic neuroma → do MRI cerebellopontine angle (or MRI brain).
Dx → MRI of the cerebellopontine angle
(or MRI of the internal auditory meatus) then MRI Brain.
Note:
- DVT (Deafness, Vertigo, Tinnitus) + heaviness/pressure/fullness in ear
→ Meniere’s disease.
- DVT (Deafness, Vertigo, Tinnitus) + CN Palsy
→ Acoustic Neuroma.
Remember that: MRI in Meniere’s disease is NORMAL.
N.B. Bilateral Acoustic Neuromas are seen in Neurofibromatosis type 2
(autosomal dominant).
59
Malignant Otitis Externa
• Not Malignancy or Cancer, but called so as it is an aggressive infection that
can spread to the bones of the face and jaw and deeper into the ear.
• It is usually caused by pseudomonal infection of the auditory canal which can
cause gangrene/necrosis → near or within the ear canal.
• When this necrosis extends deeper to the facial nerve
(in 50% of the patients).
black coloured skin → Facial palsy • Severe pain in the ear, Purulent foul discharge, conductive hearing loss.
◙ Need urgent ENT referral as it can be fatal! (50% death if left untreated).
◙ Important Risk Factors → Immunocompromised patients e.g., DM. √
◙ Diagnosis → CT scan is typically done.
“CT scan of the temporal bones”.
◙ Treatment:
√ Non-resolving otitis externa with worsening pain should be referred
urgently to ENT.
√ IV antibiotics that cover pseudomonal infections e.g., ciprofloxacin.
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Sensorineural Hearing loss + Dizziness ± others such as Tinnitus
➔ Suspect Acoustic Neuroma/ Meniere’s?
➔ Request MRI of the internal auditory canal.
(benign mass in the cerebellopontine angle if acoustic neuroma).
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Earache (painful ear) that resolves when a pus discharge per ear occurs
➔ Acute Otitis Media with tympanic membrane perforation which releases
the pressure and thus alleviates the pain
➔ Give 5-day course of Oral Amoxicillin.
- If a child who is allergic to penicillin → erythromycin or clarithromycin.
- The commonest organisms in OM
→ RSV ▐ H. Influenza ▐ Strept. Pneumoniae ▐ Strept. Pyogenes.
- N.B. Most cases are viral and self-limiting.
- The commonest viral OM → RSV (Respiratory Syncytial Virus) and Rhinovirus.
Summary:
• Perforated OM → Oral Amoxicillin
• If Allergic to Penicillin → Erythromycin or Clarithromycin.
• Otitis Externa → Topical Aminoglycoside (Gentamicin) + Topical Acetic Acid
+ Topical Corticosteroids.
• If perforated TM → Avoid Gentamicin as it is ototoxic. (Ciprofloxacin drops
could be used instead)
62
Oesophageal candidiasis
Candida Albicans can cause Oesophageal Candidiasis which presents with
→ Dysphagia +
→ Odynophagia (pain and burning sensation on swallowing food or fluid).
63
Painless, mobile lump in the anterior midline neck that moves up with tongue
protrusion
➔ Thyroglossal Cyst.
Notes:
* it is the commonest neck congenital anomaly.
* it can become painful if infected.
* a thyroglossal cyst moves up with tongue protrusion because it is attached to
the thyroglossal tract which attaches to the larynx by the peritracheal fascia.
- A lump that moves up with swallowing → Goitre? Large Thyroid nodule?
- A fluctuant lump and transilluminate in the neck → Cystic hygroma?
64
65
Benign Paroxysmal Positional Vertigo [BPPV]
- Sudden onset of vertigo that is aggravated by a change in head position and
lasts a few seconds to a few minutes ± Nausea.
“It is important to remember that it lasts only a few seconds – a few minutes”
- Occurs usually during turning over in bed or lying down.
- Kindly note that nystagmus can be seen in BPPV as well.
- Dx → Hallpike’s Manoeuvre.
- Rx → Epley’s Manoeuvre = repositioning technique.
“Apply Epley for Treatment”
- N.B. mostly resolves spontaneously.
Benign paroxysmal positioning vertigo (BPPV) is a peripheral vestibular
disorder involving the semicircular canal usually but not exclusively the
posterior semi-circular canal (PSCC). Imp √√
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Bone conduction is normal, Air conduction is reduced symmetrically bilaterally
(this means BC>AC → webers does not lateralize (as the conductive deafness is symmetrical and bilateral).
+ Child
+ does not hear the teacher well in class
Think of OME (Otitis media with effusion) = (Glue ear).
67
Removal of Ear Foreign Body
Lidocaine 2% or Olive oil or • Insect:
- 1st: Kill it with - 2nd: Syringe it out by water irrigation or olive oil.
Mineral oil.
“any is a valid answer”
• Seed (e.g., beans) → Suction with a catheter, or Removal by a hook.
√ NEVER Irrigate it as it would swell causing more discomfort and difficulty to
remove.
√ Sometime, a “rapid access” not urgent referral to ENT is made so the ENT
specialist removes the pea by a hook or a catheter suction in a few days. (imp √)
• Super Glue
- It could be removed manually in 1-2 days (after desquamation).
- Or: refer to ENT if ear drum is involved.
• Earwax build-up → a few drops of olive oil or NaCl 0.9% or sodium
bicarbonate 5% or almond oil to soften hard wax.
If not in the options → Microsuction or irrigation (syringing).
• Batteries → Refer to ENT as they should be taken out within 24 hours.
• Any spherical object → Remove by a Hook.
• If any object from these is in an intellectually disabled person (e.g., Autistic
child) → Remove under General Anaesthesia.
• If any object from these is in a person who is in severe pain, extremely
agitated and difficult to examine→ Remove under General Anaesthesia.
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◙ Referral to ENT is done in the following situations:
- If the patient requires sedation.
- If there is any difficulty in removing the FB.
- If the patient is uncooperative.
- If the TM is perforated.
- If an adhesive (e.g., super glue) is in contact with TM.
Scenario: an autistic child with beans stuck into his ear
➔ Remove under GA.
69
Sialadenitis = infection of salivary glands
• Acute Sialadenitis → often due to Dehydration (e.g., post-op) (dehydration
leads to overgrowth of oral flora and presents with erythema, pain,
tenderness).
• Chronic Sialadenitis → often 2ry to Sialolithiasis (Salivary stones) which
leads to decreased salivary outflow.
Scenario: A patient presents with pain and swelling in the submandibular area
that have been present for weeks. The area is tender on palpation.
The pain is
unilateral and MORE PROMINENT on chewing (During eating).
➔ Chronic Sialadenitis.
70
5years
Pure time audiometry
71
2 to 4 years
Speech discrimination and conditioned response audiometry
72
6months- 18months
Disctraction testing
73
Below 6 months
Otoacoustic emission
Audiologic brainstem response
74
Ear Furuncle (Boil)
• Infected hear follicle.
• Red, painful, tender, hard nodule on the skin of the ear canal.
• The commonest causing organism → Staph Aureus.
• RFs → DM, Immunocompromised patients.
• Rx →
√ Mostly resolves spontaneously.
√ Some may need Flucloxacillin.
√ A very few cases grow larger and thus require incision and drainage.
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The answer would always be → Arrange or refer for hearing assessment in
any of the following conditions:
• Any parental concern about hearing loss at any time (Despite previously
normal hearing tests). imp √√
• Professional (Doctor’s) Concern.
• Temporal bone fracture.
• Bacterial Meningitis.
• Sever Unconjugated “indirect” Hyperbilirubinemia.
• Delayed speech and language milestones.
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Itching in the ear, pain in the ear and serous discharge in the auditory canal,
Tender tragus esp. with movement (difficult to examine the ear)
→ Otitis Externa.
- Additional supportive clinchers:
• The severe tenderness makes it difficult to examine the ear (tenderness
when moving or touching the tragus).
• Hx of Swimming, Traveling or High Humidity.
- How to treat?
A combination of topical: Acetic acid + Gentamicin + Corticosteroids.
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AC > BC bilaterally (Normal)
Weber’s test lateralizes to the left
Right Sensorineural Hearing Loss.
AC > BC bilaterally (Normal)
Weber’s test lateralizes to the left
Right Sensorineural Hearing Loss.
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Super Glue is stuck into a child’s ear and it is in contact with the ear drum
(tympanic membrane)
→ Refer to ENT specialist.
- Super glue may be removed manually within 1-2 days once desquamation
has occurred.
- Referral to ENT is required if the adhesive is in contact with the tympanic
membrane.
79
A seed has been stuck into a child’s ear → Never irrigate seeds, soft objects or organic matters.
Suction with a small catheter.
If the child is uncooperative, mentally retarded or autistic → refer to ENT to
remove the FB under GA.
If suction with a catheter/ remove by a hook are not in the options, pick
→ Rapid access ENT clinic referral to be seen in a few days.
“rapid access = semi-urgent” but not urgent.
This is done in the UK for seed (e.g. beans/ pea).
Remember, the urgent removal needed in cases of batteries, insects.
80
Attacks of Vertigo, Dizziness that occurs when moving the head specially
while
in bed, and last for a few seconds or minutes ± a feeling that the room is
spinning
→ Benign Paroxysmal Positional Vertigo
Diagnosis? ➔ Dix-Hallpike’s manoeuvre. (it provokes Nystagmus).
Treatment? ➔ Apply Epley’s manoeuvre for treatment.
81
82
A child fell on his nose and presented later on with nasal pain and tenderness,
general malaise and fever
Think → (nasal septal abscess)
due to nasal hematoma that has been infected)
This is why nasal septal hematoma needs to be incised and drained in order to
prevent bacterial infection and abscess formation on top of this hematoma.
So, the answer is NOT HEMATOMA as hematoma does not cause general
malaise and fever!
83
A child who is inattentive at school and sits close to the TV and with bilateral
conductive progressive hearing loss
over a 12-month period presented to his
GP and after 3 months he did not show improvement.
Q) What is next?
➔ Grommet insertion
(Otitis Media with effusion = Glue ear)
If this was his first visit and the symptoms are new
→ Reassure and review in 3 months.
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Headache that worsens on bending the head forwards and in the early
morning WITHOUT Nausea or vomiting
(due to chronic sinusitis).
➔ Sinus headache N.B. Both Sinus
headache and Migraine worsen when bending the head
forward;
however, migraine is more intense and tends to be associated with
other symptoms such as Nausea, Vomiting and Photosensitivity.
85
Weak and altered voice in some occupations where there is voice overuse
(e.g. teachers, actors, singers, commentators …etc)
→ Think of Functional Dysphonia.
• Functional Dysphonia: Voice disturbance in the absence of any structural
abnormality of the larynx and the cords.
• Do not be tricked by a Hx of a previous respiratory infection.
• If this weakness of voice occurs DURING the respiratory infection, the cause
might be Laryngitis.
86
Presbycusis
• Inability to hear HIGH-frequency sounds. (Raising the voice would not
improve hearing). (Inability to hear sound in noisy environment).
• Affects the elderly patients.
• Bilateral SNHL (bilateral sensorineural hearing loss)
• It is difficult to understand the speech and follow conversations.
• The patients usually do not recognize they have hearing loss “Don’t shout I
am not Deaf!”, thus, usually presented to a clinic by their family.
• Poor hearing especially in noisy environment.
• Rx → bilateral digital hearing aids that increase the high-frequency sounds.
Remember:
In Otosclerosis:
• Conductive hearing loss.
• (Inability to hear Low frequency sounds). Therefore, raising the speaker’s
voice would allow the patient to hear better.
• Also, it affects people at a younger age (15-45).
Another important point is that patients with otosclerosis usually hear
better while in a noisy environment.
87
Epistaxis (Bleeding per nose)
◙ First aid measures “initial”:
• Lean forward, open mouth.
• Pinch the cartilaginous (soft) part of the nose firmly and hold for 10-15
minutes while the patient is breathing per mouth.
If the patient is haemodynamically compromised (Unstable) ➔ Send to A&E.
• Recurrent episodes of Epistaxis +
• Visible blood vessels are seen on the anteroinferior part of the nasal septum
bilaterally +
• No active bleeding at the time of presentation to a GP surgery.
Rx → Nasal Cautery at one side of the septum initially.
Naseptin “Chlorhexidine and Neomycin cream”.
Note, another valid answer if no active bleeding is
→ Topical treatment with As the bleeding is bilateral, both sides will eventually need cautery. However
88
• Recurrent episodes of Epistaxis +
• Visible blood vessels are seen on the anteroinferior part of the nasal septum
bilaterally +
• There is still active bleeding at the time of presentation to a GP surgery.
→ Anterior Nasal Packing Bilaterally.
Cautery (with silver nitrate) should be avoided if there is active bleeding (as
the silver nitrate would be washed out if there is active bleeding).
The packing is done bilaterally as the bleeding is bilateral, and the patient is
encouraged to breath per mouth. “typically left in for 24-48 hours
we cannot do cautery of both sides at the same time for risk of septal
perforation.
Cautery (with silver nitrate) should be avoided if there is active bleeding (as
the silver nitrate would be washed out if there is active bleeding
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Acute Tonsillitis
• Painful sore throat for more than 2 days.
• Earache (as the pain may refer to the ears).
• Tonsils are reddened, swollen, congested and ± pus or exudates.
• Mostly viral but can be bacterial.
Centor criteria
They are used to help differentiate either it is a viral or bacterial tonsillitis.
The presence of 3 out of the following 4 Centor criteria raise the suspicion of
Bacterial – Streptococcal tonsillitis:
1) Fever > 38.
2) Tender and Enlarged Anterior cervical LNs.
3) Tonsillar exudates/pus.
4) No associated cough. (Associated cough is more towards viral).
• If <3 → Viral (most cases) → Supportive management (eg, paracetamol).
• if ≥3 → Bacterial we give Antibiotics (Phenoxymethylpenicillin = Penicillin V).
◙ Management of acute tonsillitis:
If Viral (most cases) → Supportive (eg, If bacterial → First line → Take care of the question!
90
Acute tonsillitis
Collection:
1st line in bacterial Otitis Media → Amoxicillin.
1st line in bacterial tonsillitis → Phenoxymethylpenicillin “penicillin V”.
1st line in bacterial sinusitis →
Phenoxymethylpenicillin “penicillin V”
91
• Oral steroids can weaken the immunity and cause candidiasis (fungal
infection).
• One of the possible candidiasis sites is
Laryngeal candidiasis
→ patient presents with Hoarseness of Voice
• A Scenario of an Asthmatic patient on long term oral steroid therapy for
his asthma presents with hoarseness of voice
→ Think of Laryngeal candidiasis 2ry to prolonged steroid intake.
92
Benign Parotid tumour
• The most common type is → (or = Benign Pleomorphic Adenoma
Benign Mixed Tumour).
• Asymptomatic,
• Solitary,
• Painless,
• Firm,
• MOBILE mass/swelling at the angle of the mandible that
• Grows slowly.
√
• Rx → Superficial Parotidectomy or Enucleation.
• There is a 2-10% risk of malignant transformation.
93
Sjögren’s syndrome
• Autoimmune disorder characterised by parotid enlargement, xerostomia
(dry mouth) and keratoconjunctivitis sicca.
• 90% of cases occur in females.
• Second most common connective tissue disorder.
• Bilateral, non-tender enlargement of the gland is usual.
• Treatment is supportive.
• There is an increased risk of subsequent lymphoma.
94
Mumps
• Mumps is an acute, contagious, self-limited, systemic viral illness
characterized by the swelling of one or more of the salivary glands, typically
the parotid glands.
• Mumps is a caused by RNA paramyxovirus and tends to occur in winter and
spring.
• Spread:
√ by droplets
√ respiratory tract epithelial cells → parotid glands → other tissues
√ infective 7 days before and 9 days after parotid swelling starts
√ incubation period = 14-21 days
95
• Clinical features of mumps:
√ fever
√ malaise
√ muscular pain
√ parotitis (‘earache’
,
bilateral in 70%
‘pain on eating’): unilateral initially then becomes
• Prevention:
MMR vaccine: the efficacy is around 80%
• Management of mumps:
√ rest
√ paracetamol for high fever/discomfort
√ notifiable disease
• Complications
√ Orchitis – (testicular inflammation) uncommon in pre-pubertal males but
occurs in around 25-35% of post-pubertal males. Typically occurs four or five
days after the start of parotitis
√ hearing loss – usually unilateral and transient
√ meningoencephalitis
√ pancreatitis
96
Dd of mumps
Other Differential Diagnoses:
- Parotitis → Painful, Tender.
- Mandible or Tonsillar cancer → NOT Mobile.
- Sjogren’s Syndrome → There should be associated dry eyes and/or mouth.
97
Bone Conduction is better than Air Conduction in the Left ear, Weber’s test
lateralises to the Left ear ➔
Left Conductive Deafness.
98
The initial step for Epistaxis in a haemodynamically stable patient →
Lean forward, Open mouth, Pinch the soft (Cartilaginous) part of the nose
firmly for 10-15 minutes.
If haemodynamically unstable → Send to A&E.
99
• Dizziness/Vertigo on Moving head lasts for seconds to minutes ➔ BPPV.
• If + Hx of Viral URTI ➔ Vestibular Neuritis.
• If + Hx of Viral URTI + Hearing loss/Tinnitus ➔ Labyrinthitis.
• Vertigo + Hx of Common cold → Vestibular neuritis.
• Vertigo + Hx of Common cold + Hearing loss/Tinnitus → Labyrinthitis.
• Vertigo on moving head that lasts for seconds WITHOUT Hx of Common
cold → Benign Paroxysmal Positional Vertigo.
• DVT + Fullness (Deafness, Vertigo, Tinnitus) + Pressure or Fullness in one
ear → Meniere’s disease (MRI is normal).
• DVT + Cranial Nerve Palsy (e.g. Facial palsy, Loss of Corneal reflex, Loss of facial
sensation) → Acoustic Neuroma (Do MRI of the cerebellopontine angle).
100
Insect in the ear →
• Initially: Kill it by 2% Lidocaine.
• Then: Remove it by pouring olive oil into the ear or water irrigation.
Insect in the ear →
• Initially: Kill it by 2% Lidocaine.
• Then: Remove it by pouring olive oil into the ear or water irrigation.
101
Unilateral SNHL + Facial Drooping + Dizziness and Headache → Think of
and request MRI of the Cerebellopontine angle.
(Or: Vestibular Schwannoma) →
Remember: Acoustic Neuroma - DVT (Deafness, Vertigo, Tinnitus) +
- Cranial Nerve Palsy (e.g. Facial Drooping) +
- Intracranial Pressure manifestations (e.g. Headache). It is a space-occupying
lesion.
102
Pain in an ear, cheek, mandible that increases on chewing + Bruxism (grinding
of the teeth)
Think of: Temporomandibular joint disorder.
103
Q) How to Deal with Earwax Build-up?
- Firstly → Earwax softening ear drops (e.g. Olive oil, Almond oil, Normal
Saline, Sodium Bicarb…etc.) for 3-5 days
to soften wax and ease its removal.
- If persists → Ear Irrigation.
If these two lines have been tried but the symptoms (e.g., ↓ hearing) persist,
what should be done?
→ In this case, one of the following 3 options is attempted:
√ Another course of 3-5 days ear drops (e.g. olive oil, normal saline).
√ Instill water into the ear and irrigate after 15 minutes.
√ Refer to an ENT specialist.
104
Noise-induced hearing loss
• It is the second most common form of sensorineural hearing deficit, after
presbycusis (which is age-related hearing loss).
- It occurs due to exposure to a loud sound.
- It can occur due to occupational noise (e.g. working in a shipyard, army,
factories…etc.)
→ Occupational hearing loss.
- The form of this type is → Bilateral Sensorineural Hearing Loss
(Bilat. SNHL).
- The patient cannot hear well in a large room when a number of people are
taking simultaneously.
He also cannot understand the speech well while
on the phone.
He feels that the sound is muffled.
- Mixed hearing loss can be seen in Paget’s disease and Osteogenesis
imperfecta.
105
An insect (e.g. a fly) is stuck inside an ear.
- Initial step? → Kill it with 2% lidocaine OR alcohol.
- Then? → instil oil (olive oil/Mineral oil) to make the insect float and thus
facilitate its removal.
• If it asks about (the the answer would be → (Lidocaine / alcohol).
• If it asks about the answer would be
→ instilling the method to get the insect removed,
mineral or olive oil into the ear.
106
Red and inflamed bulge (or) swelling beside the tonsil (above and lateral to a
tonsil) + Hx of Dysphagia and Sore throat +/- hot potato voice.
➔ Think of Peritonsillar Abscess (= Quinsy).
→ Amit for IV antibiotics, incision and drainage.
Another answer → Urgent admission to the hospita
l.
• The antibiotic is → IV Benzylpenicillin.
• It is a complication of acute tonsillitis.
• Other features → Trismus, Drooling of Saliva, Fever, deviation of the uvula,
Hot potato voice (due to pharyngeal oedema).
107
Elderly + Smoker + Dysphagia + unilateral ear pain + unilateral red lesion with
central ulcer that bleeds on touch
→ Tonsillar Cancer.
Oropharyngeal cancer includes: the base of the tongue, the tonsils, the soft
palate, the walls of the pharynx
108
A child, raises the TV volume to a high level, does not hear her parents well,
bilaterally reduced air conduction
➔
OME (Otitis Media with Effusion) = Glue Ear.
N.B. Bilaterally BA>AC ➔ Bilateral Conductive hearing loss (that is seen in
OME).
109
In a case of Tonsillitis:
Q1) When to Give Antibiotics?
Q2) When is the Tonsillectomy indicated?
Q3) If neither Antibiotics nor Tonsillectomy is indicated, how to manage?
A1) According to Centor criteria (3 of the following 4 raise the suspicion of
Bacterial – Streptococcal tonsillitis →
we give Antibiotics
(Phenoxymethylpenicillin = Penicillin V))
• Fever > 38
• Tender Anterior cervical Lymphadenopathy
• Tonsillar exudates/pus
• No associated cough
If 3 out of 4 are present, we give Antibiotics.
A2) Tonsillectomy is indicated in any of the following:
• > 7 episodes of tonsillitis per year for 1 year.
• > 5 episodes per year for 2 years.
• > 3 episodes per year for 3 years.
110
• An additional important indication for tonsillectomy is
→ Sleep Apnea
(If the enlarged tonsils affect sleeping. Eg, are making the child struggle with
breathing while sleeping).
A3) Paracetamol. (Reassure).
If not bacterial tonsillitis, and tonsillectomy is not indicated, we manage
using antipyretic analgesic such as Paracetamol or Ibuprofen “Supportive”.
Example: a child with fever, sore throat, cough, no cervical LNs, tonsils are red
but without exudates or pus → pmol
111
The appropriate test for deafness in neonates:
→ ABR (auditory brainstem response)
112
BPPV (Benign Paroxysmal Positional Vertigo)
• Attacks of Dizziness, Vomiting, Anxiety that last for a few seconds to minutes.
• “The room is Spinning”
• They occur when changing posture (Head movement).
• No Hx of viral URTI.
Benign paroxysmal positioning vertigo (BPPV) is a peripheral vestibular
disorder involving the semicircular canal usually but not exclusively the
posterior semi-circular canal (PSCC). Imp √√
113
Red, Bulging Tympanic membrane + Otalgia ➔ Acute OM.
N.B. The absence of light reflex on the TM
→ means that the TM is Bulging (Any distortion of the TM would prevent light
reflex).
114
Meniers
Acoustic neuroma
- DVT (Deafness, Vertigo, Tinnitus) + Fullness/Pressure in one ear + No cranial
nerve involvement.
➔ Meniere’s disease
- If the above are present + Cranial Nerve Problem ± Headache
➔ Acoustic Neuroma.
- Examples of CN palsies that can occur with Acoustic Neuroma:
• Facial nerve CN VII → Facial Palsy/ Facial drooping.
• Abducens nerve CN VI → Diplopia to the same side.
• Trigeminal nerve CN V → Loss of corneal reflex and facial sensation.
115
Important Scenarios on Hearing Loss Causes:
• Presbycusis: elderly, Sensorineural, difficulty hearing in a noisy
environment. (High frequency hearing loss).
• Otosclerosis: Young Adult, Conductive, Difficulty hearing in a quiet
environment (e.g., on the phone) (Low frequency hearing loss), i.e., the patient
hears better in a noisy environment. ± Family Hx
116
Always suspect Laryngeal cancer in a patient with Hx of smoking and presents
Hoarseness of voice.
- Risk factors of Laryngeal cancer:
- Risk factors of Laryngeal cancer:
• Smoking (The main avoidable RF and the number one cause of laryngeal
cancer in the UK).
• Asbestos, formaldehyde.
• Poor fruit and vegetable diet.
• Human Papilloma Virus (HPV 16) → Oral, Pharyngeal, Laryngeal cancer.
117
Meniere’s disease could present without the feeling of fullness or pressure on
the affected ear.
It can simply present with several yearly attacks of vertigo
that last from minutes to hours.
Pick Meniere’s as long as there is no cranial nerve involvement (e.g. facial
drooping, diplopia, loss of corneal reflex etc.) and there is no Hx of viral URT
I.
- If CN involvement → Acoustic neuroma.
- If Hx of Common cold (URTI) → Vestibular neuritis
- If Hx of Common cold (URTI) + Hearing loss or Tinnitus → Labyrinthitis.
Prochlorperazine, Cyclizine •
The treatment of Meniere’s disease is some drugs to alleviate vertigo and
nausea such as buccal or IM (Zine family).
• The MRI in Meniere’s disease is NORMAL.
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Acute Otitis Media
• Earache (otalgia).
• Usually follows viral URTI (e.g. tonsillitis).
• Fever, Vomiting, Irritability.
• Tympanic membrane: might be Red, Yellow or Cloudy. It might also be
bulging, or perforated with or without purulent discharge.
.
• Ruptured tympanic membrane alleviates the pain.
• Usually viral (requires analgesics and supportive treatment only).
• If signs of bacterial (e.g. High fever, cervical lymphadenopathy) → Oral
Amoxicillin.
119
Again, a child who raises the TV volume to a high level → Think of Otitis
media with effusion
Again, a child who raises the TV volume to a high level → Think of Otitis
media with effusion.
The TM might be either retracted or Bulging.
Rx: Review in 3 months → not resolved? → Insert Grommets.
120
Hx of URTI (Common cold) + unilateral pain at the upper jaw, cheek and
infraorbital region ± fever.
Maxillary sinusitis. (Acute sinusitis).
“contain ephedrine”.
• Viral URTI is an important precipitating factor of sinusitis.
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Asthma + Nasal Obstruction + Rhinorrhoea + Anosmia (inability to smell)
Think ➔ Nasal Polyps.
First-line treatment ➔ Intranasal corticosteroids. Then: Oral corticosteroids.
Samter’s Triad: Asthma, Aspirin Sensitivity, Nasal Polyps
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Paranasal sinus tumour
• Pressure / pain / Tenderness / Swelling in the cheek, upper teeth.
• Blood seen in the nasal discharge.
• Nasal Obstruction.
• Hx of chronic sinusitis.
• If the orbit is involved → Epiphora (excessive watering of the eye),
Diplopia.
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Obstructive Sleep Apnea Syndrome OSA
Features of OSA
√ Snoring loudly while sleeping and having headaches in the morning.
√ Occasional apnea episodes while sleeping.
√ Somnolence (dozing off), sleepiness, fatigue and tiredness during daytime.
√ Associated with: Obesity, Hypertension, DM, Alcoholism.
Diagnosis
Polysomnography (sleep study).
- Initial → Pulse oximetry, overnight study of breathing pattern.
- Gold standard (Diagnostic) → Polysomnography is also called a sleep study, is a comprehensive test used to
diagnose sleep disorders.
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Obstructive Sleep Apnea Syndrome OSA
Features of OSA
√ Snoring loudly while sleeping and having headaches in the morning.
√ Occasional apnea episodes while sleeping.
√ Somnolence (dozing off), sleepiness, fatigue and tiredness during daytime.
√ Associated with: Obesity, Hypertension, DM, Alcoholism.
Polysomnography records brain waves, oxygen level in blood, heart rate and
breathing, as well as eye and leg movements during the study.
Treatment
- Conservative: e.g. weight reduction, reduce alcohol intake.
- CPAP “Continuous Positive Airway Pressure” → first line for moderate or
severe OSA.
- Rarely Surgery (e.g. Tonsillectomy, Adenoidectomy) to alleviate pharyngeal
obstruction.
Driving Advice for Obstructive Sleep Apnea (OSA) Patients Especially
Those with Excessive Daytime Sleepiness:
→ Advise the patient to stop driving • If the diagnosis is suspected but has not yet been confirmed
(until the diagnosis is confirmed).
(No need to inform DVLA yet neither by the patient nor by the doctor).
• After the diagnosis of OSA has been confirmed (by polysomnography):
→ Advise the patient to inform DVLA themselves.
• If they refused to inform DVLA
→ Inform DVLA on their behalf.
125
Tonsillectomy Complications
1ry Bleeding (within the first 24 hours) → Return to the theatre may be
required. Usually due to inadequate haemostasis, displacement of a tie,
loss of eschar.
• 2ry or Reactive Bleeding (occurs more than 24 hours post-op = 1-10 days
post op, and usually after discharge)
Usually due to wound infection that leads to vessel erosion; thus,
→ Admit the patient and give IV Antibiotics. √ imp.
(Antibiotics and Antiseptic mouthwashes are also indicated)
126
Tonsillectomy Complications
In short:
◙ Primary (first 24 hrs) → Call ENT surgeon “may require to return to the
theatre”
.
◙ Secondary “or reactive” (> 24 hrs after discharge) → Admit and give IV
antibiotics.
127
Call ent surgeon
f a patient bleeds (hematemesis) within the first 24 hours post-tonsillectomy
as the patient may require a return to theatre.
128
Mild Squamous Dysplasia of the larynx
• Hoarseness, White patch “Leukoplakia” over the Vocal cords.
STOP SMOKING
- What to do Next?
- Advice the patient to + Observe and F/U (Risk of Malignancy).
129
Mild Squamous Dysplasia of the larynx
• Hoarseness, White patch “Leukoplakia” over the Vocal cords.
STOP SMOKING
- What to do Next?
- Advice the patient to + Observe and F/U (Risk of Malignancy).
Mild squamous dysplasia of the larynx
Hoarseness + white patches on the vocal cord
→ advice patient to stop smoking and follow up
130
◙ In otitis media with effusion (Glue ear). Sometimes, the answer would be
Advice parents to quit smoking.
Parental smoking is a risk factor for OME. So, encourage them to stop
smoking and review the child in 3 months
131
Tonsillar Carcinoma
• Persistent sore throat (over weeks).
• Progressive Hoarseness of voice.
• Dysphagia and painful swallowing.
• Feeling of a persistent lump in the throat.
• Palpable lump on the anterolateral portion of the neck.
- The most common type → Squamous Cell Carcinoma.
- Lateral Direct Local Spread → involves Spread to Mandible
→ Pain in the throat + Trismus (spasm of the jaw muscles, causing the
mouth to remain tightly closed)
132
◙ One important complication of tonsillitis is
→ Peritonsillar abscess (Quinsy).
In peritonsillar abscess, there is usually high temperature, swelling on the soft
palate or beside tonsils often with exudates. The pain is usually worse on one
side of the throat.
- Others: Sore throat, Dysphagia, uvular deviation, Drooling, altered
voice “Hot Potato Voice”.
- There is usually a Hx of sore throat for several days.
Amit for IV antibiotics, incision and drainage.
Rx → Another answer → This is to be given (IV Benzylpenicillin) + Aspiration or Incision and Drainage.
Urgent admission to the hospital
So, ADMISSION is a must.
√ Remember, first line antibiotic for bacterial tonsillitis
→ Penicillin-V (Phenoxymethylpenicillin)
133
◙ Large hematoma of the pinna (of the ear)
Management? ➔
Incision and drainage +
Prophylactic Oral Antibiotics (Co-amoxicillin) for 1 week
Large pinna hematoma “needs incision and drainage + Abx”
Note that if left untreated (not drained early),
necrosis may develop and affect
the auricular cartilage leading to a persistent deformity “Cauliflower ear”.
134
135
◙ Injury to ear pinna with INTACT tympanic membrane with no large
hematoma
→ No further investigations (self-limiting).
If Painful → give analgesics.
❤️Hx of smoking, Hoarseness, Dysphagia, Hemoptysis
→ think of Laryngeal Cancer.
❤️A boy who had tonsillectomy returned after 8 hours as he vomited
blood. His temperature is 36.7. What to do?
→ inform the ENT surgeon immediately.
136
Tonsillectomy Complications
Tonsillectomy Complications
• 1ry Bleeding (within the first 24 hours) → Return to the theatre may
be required. Usually due to inadequate haemostasis, displacement of a
tie, loss of eschar.
• 2ry or Reactive Bleeding (occurs more than 24 hours post-op = 1-10
days post op, and usually after discharge). Usually due to wound
infection that leads to vessel erosion; thus,
→ Admit the patient and give IV Antibiotics.
(Antibiotics and Antiseptic mouthwashes are also indicated).
137
A Smoker presents with white patch on vocal folds with mild dysplasia.
→ Stop smoking
Mild Squamous Dysplasia of the larynx
• Hoarseness, White patch over the Vocal cord.
- What to do Next?
- Advice the patient to + Observe and F/U (Risk of Malignancy).
Buccal Ulcer with palpable cervical nodes
Think → Squamous Cell Carcinoma.
138
A 22 YO male was hit on his right ear while playing rugby.
He complains
of intense ear pain.
The right pinna is red and tender but without
swelling. His tympanic membrane is intact. What is the management?
As there is no swelling → discharge on oral analgesics (to relieve the pain).
What if the pinna shows swelling (hematoma)?
→ refer to otolaryngologist for incision and drainage.
139
• Recurrent episodes of Epistaxis +
• Visible blood vessels are seen on the anteroinferior part of the nasal septum
bilaterally +
• No active bleeding at the time of presentation to a GP surgery.
→ Nasal Cautery at one side of the septum initially.
Note, another valid answer if no active bleeding is
→ Topical treatment with Naseptin “Chlorhexidine and Neomycin cream”.
As the bleeding is bilaterally, both sides will eventually need cautery.
However, we cannot do cautery of both sides at the same time for risk of
septal perforation.
Cautery (with silver nitrate) should be avoided if there is active bleeding (as
the silver nitrate would be washed out if there is active bleeding).
140
• Recurrent episodes of Epistaxis +
• Visible blood vessels are seen on the anteroinferior part of the nasal septum
bilaterally +
• No active bleeding at the time of presentation to a GP surgery
• Recurrent episodes of Epistaxis +
• Visible blood vessels are seen on the anteroinferior part of the nasal septum
bilaterally +
• There is still active bleeding at the time of presentation to a GP surgery.
→ Anterior Nasal Packing Bilaterally.
Cautery (with silver nitrate) should be avoided if there is active bleeding (as
the silver nitrate would be washed out if there is active bleeding).
The packing is done bilaterally as the bleeding is bilaterally, and the patient is
encouraged to breath per mouth. “typically left in for 24-48 hours”
141
A 60-year-old man presents to the Ear, nose and throat clinic with complaints
of gradual hearing loss in the left ear. There is a history of occasional vertigo
and tinnitus.
The external auditory meatus and tympanic membrane appear
normal. Audiology reveals left ear hearing loss.
What is the most appropriate
investigation to lead to a diagnosis?
A. Brain stem evoked response
B. C. Speech Audiogram
D. Tinnitus matching
E. Vestibular Tests
Acoustic Neuroma (Vestibular Schwannoma)
Pressure effect on cranial nerves:
• Vestibular nerve CN VIII → DVT (Deafness, Vertigo, Tinnitus).
• Facial nerve CN VII → Facial Palsy/ Facial drooping.
• Abducens nerve CN VI → Diplopia to the same side.
• Trigeminal nerve CN V → Loss of corneal reflex and facial sensation.
• Dx → MRI of the cerebellopontine angle (or to internal auditory meatus)
then MRI Brain.
N.B.
- DVT (Deafness, Vertigo, Tinnitus) + heaviness/pressure/fullness in ear
(without cranial nerve involvement)
→ Meniere’s disease.
- DVT (Deafness, Vertigo, Tinnitus) + CN Palsy ± pressure sensation in the
affected ear
→ Acoustic Neuroma.
Remember that: MRI in Meniere’s disease is NORMAL.
N.B. Bilateral Acoustic Neuromas are seen in Neurofibromatosis type 2
Important Summary:
• Vertigo + Hx of Common cold → Vestibular neuritis.
• Vertigo + Hx of Common cold + Hearing loss/Tinnitus → Labyrinthitis.
• Vertigo on moving head that lasts for seconds WITHOUT Hx of Common
cold → Benign Paroxysmal Positional Vertigo.
• DVT + Fullness (Deafness, Vertigo, Tinnitus) + Pressure or Fullness in one
ear → Meniere’s disease (MRI is normal).
• DVT + Cranial Nerve Palsy (e.g. Facial palsy, Loss of Corneal reflex, Loss of
facial sensation) → Acoustic Neuroma (Do MRI of the cerebellopontine
angle).
142
• Pearly white mass BEHIND the Tympanic membrane.
• Chronic Foul-smelling purulent discharge (otorrhea).
• Otoscopy may reveal canal filled with pus/mucus/granulation tissue.
• Hx of recurrent Otitis Media. (poorly responsive to antibiotics).
• It causes Conductive hearing loss
The likely Dx → Cholesteatoma.
143
It is important to note that Vertigo in Meniere’s disease can sometimes last for
several hours, while in BPPV, it only lasts for a few seconds-minute
144
A patient came back after 7 days of adeno-tonsillectomy with the complaint
of vomiting blood. Temp is 38.5. What is the most appropriate step?
A.admit for iv antibiotics
B. Admit for FFP and Vit k
C. Discharge home with oral antibiotics
D. urgent surgical exploration of wound site
Tonsillectomy Complications
• 1ry Bleeding (within the first 24 hours) → Return to the theatre may
be required. Usually due to inadequate haemostasis, displacement of a
tie, loss of eschar.
• 2ry or Reactive Bleeding (occurs more than 24 hours post-op = 1-10
days post op, and usually after discharge)
Usually due to wound infection that leads to vessel erosion; thus,
Admit the patient and give IV Antibiotics.
(Antibiotics and Antiseptic mouthwashes are also indicated).
145
A 23 yr old with recurrent vertigo of 4 weeks lasting for a few seconds,
What is the site of the anatomical defect?
Post semi-circular canal
A. B. Cochlea
C. Spiral ganglion
D. Temporal lobe of brain
E. Vestibular nucleus
Benign paroxysmal positioning vertigo (BPPV) is a peripheral vestibular
disorder involving the semicircular canal usually but not exclusively the
posterior semi-circular canal (PSCC).
146
147
148
Conductive hearing loss
◙ CHL “Conductive hearing loss”:
√ Otosclerosis,
√ Tympanosclerosis,
√ OME “Glue ear”,
√ Malignant otitis externa,
√ Cholesteatoma
149
Snhl
◙ SNHL “Sensorineural hearing loss”:
√ Meniere’s disease,
√ Acoustic neuroma,
√ Presbycusis,
√ Noise-induced hearing loss
150
Suspected laryngeal cancer [referral guidelines]
A suspected cancer pathway referral (for an appointment within 2 weeks) to
an ENT specialist should be considered for people aged 45 and over with:
√ Persistent unexplained hoarseness of voice (for > 3 weeks) or:
√ An unexplained lump in the neck.
• Smoking is the main avoidable risk factor for laryngeal cancer.
• Chronic hoarseness is the most common early symptom of laryngeal cancer.
• Other features may develop with time and include:
Stridor ▐ difficulty or painful swallowing ▐ hemoptysis ▐ neck lump ▐ cough
151
While having dinner, a 5-year-old child inserted a pea inside his ear
and is brough to the paediatric emergency.
Otoscopy reveals the
stuck pea and wax. What should be done?
A) Reassure and review in 2 weeks.
B) Antibiotics ear drops.
C) Olive oil air drops.
D) Urgent referral to ENT clinic to be seen immediately.
E) Rapid access ENT clinic referral to be seen in a few days.
If suction with a catheter/ remove by a hook are not in the options, pick
→ Rapid access ENT clinic referral to be seen in a few days.
“rapid access = semi-urgent” but not urgent.
This is done in the UK for seed (e.g. beans/ pea) and usually the child is seen in
1-2 days.
Remember, the urgent removal needed in cases of batteries, insects.
152
A 60 YO man has developed intense pain in his right auricle 2 weeks
ago. He was treated with flucloxacillin. However, the pain and swelling of the right pinna are progressively worsening with no
improvement. There is no Hx of trauma and no hearing loss. He has
fever. What is the most likely causative organism?
→ Pseudomonas aeruginosa.
◙ Perichondritis Treatment:
√ Prompt oral antibiotic therapy, typically a fluoroquinolone, sometimes with
an aminoglycoside plus a semisynthetic penicillin
√ For an abscess, prompt incision and drainage.
For knowledge: The Fluoroquinolone antibiotics include:
Ciprofloxacin (Cipro),
Gemifloxacin (Fictive),
Levofloxacin (Levaquin),
Moxifloxacin (Avelox),
and Ofloxacin (Floxin)
153
A patient with a suspected Obstructive Sleep Apnea presents to his GP.
What should be done?
1)
2) Advise the patient not to drive cars or lorries.
Urgent referral to a sleep clinic “for Dx -polysomnography- and Rx”.
◙ When should Driver and Vehicle Licensing Agency (DVLA) be informed?
√ If already diagnosed with moderate to severe OSAS, or:
√ If diagnosed with mild OSAS with excessive sleepiness not controlled within 3
months.
154
mother is concerned about her 6 YO son as he has had 3 episodes of
tonsillitis within the past 6 months. What should be done
→ Reassure and continue observation.
He does not meet the SIGN criteria for tonsillectomy.
Remember:
Tonsillectomy is indicated in any of the following:
• > 7 episodes of tonsillitis per year for 1 year.
• > 5 episodes per year for 2 years.
• > 3 episodes per year for 3 years.
155
√ Short course of oral Prochlorperazine.
√ If rapid intervention is required → IV or IM Prochlorperazine or Cyclizine.
Dizziness/Vertigo on Moving head lasts for seconds to minutes
➔ BPPV “Benign Paroxysmal Positional Vertigo”.
• If + Hx of Viral URTI (without tinnitus or hearing loss)
➔ Vestibular Neuritis.
• If + Hx of Viral URTI with Hearing loss/Tinnitus
➔ Labyrinthitis.
◙ To relieve vertigo, give → Prochlorperazine
156
A boy was punched in his face and had nose bleeds for 1 hour.
He
presented to the A&E and found to be vitally stable with no active
bleeding.
There is no CSF leakage. The skin over his nose is intact.
However, by inspection, it is seen that there is nose deviation to the
right side
.
The next appropriate step → Speculum examination of the nasal cavity.
This can show: nasal hematoma, site of bleeding, septal deviation, septal
perforation.
The diagnosis of nasal fracture is generally made on clinical grounds and
imaging is usually unnecessary during the initial assessment.
The Royal College
of Radiologists guidelines state the following: “X-rays are unreliable in the
diagnosis of nasal fractures and even when positive do not usually affect
patient management.
XR or further imaging could be considered only after
ENT/maxillofacial assessment, depending on local policy.”
157
Toddler age (1-3 YO)
+ Unilateral nasal discharge (later on becomes foul-smelling)
+ No cough or facial pain
Think → Foreign body in the nasal cavity
In chronic sinusitis, there is usually cough, facial pain, and the nasal discharge.
158
Hoarseness of voice for > 3 weeks
→ ENT referral Hoarseness of voice for > 3 weeks
within 2 weeks (suspected laryngeal cancer)
Especially if there is Hx of alcohol +/- smoking.
159
Allergic rhinitis (nasal congestion, sneezing, rhinorrhea)
→ Xylometazoline intranasally.
However, this medication SHOULD NOT be used for > 7 days.
If used for > 7 days, it can cause rebound nasal congestion.
Therefore, if the congestion still exists in a patient who have used
Xylometazoline for > 7 days, the first step is to →
Advise the patient to stop the medication and to have a medicine-free interval
160
Erythematous bulging tympanic membrane, think → acute otitis media.
Note that acute OM could be a complication of URTI such as pharyngitis.
161
Headache, Facial pain, Foul smelling nasal discharge, loss of smell,
supraorbital pain
→ Sinusitis ± complications of sinusitis (e.g. periorbital abscess, cellulitis).
The most appropriate investigation
→ CT of head and sinuses.
162
Acute Sinusitis in Points
◙ Presenting features:
• There is usually a Hx of upper respiratory tract infection in the last few days.
• Nasal blockage ± discharge
• Facial pain or pressure (e.g., cheekbone or periorbital pain ± tenderness,
redness, swelling over the affected area).
• ↓ smell, headache.
◙ The vast majority of acute sinusitis cases are due to viral infections (98%).
◙ So, they are mostly self-limiting:
- Symptom’s relief is what’s needed:
→ Nasal decongestant containing ephedrine. (and/or Nasal saline).
→ Paracetamol/ibuprofen for fever and facial pain relief.
“Note that as per NICE, Oral decongestants are always invalid answer”
- However, if the symptoms last for > 10 days without a significant
improvement → Nasal Steroids can be considered.
◙ It is rarely bacterial (2%). Thus, no need to start antibiotics unless necessary.
163
164
Q) When to suspect that it is bacterial and commence antibiotics? (
reading)
- Complicated sinusitis (e.g., systemically unwell patients with features such
as periorbital edema or cellulitis or displaced eyeball or diplopia).
- Symptoms that last for > 10 days nasal discharge
No improvement
+ Fever > 38 C + purulent or discoloured
+ unilateral pain with rapid deterioration instead of
◙ If Antibiotics are indicated, prescribe the first line is as follows:
• Phenoxymethylpenicillin.
• If very unwell → co-amoxiclav.
• If penicillin allergic → doxycycline or clarithromycin
165
30 YO man presents with nasal blockage, headache and cheekbone pain.
He has had fever and cough a week ago. His temp. is 37.5. He is penicillin
allergic.
Acute sinusitis.
• The likely Dx → sinusitis (acute)
• The most appropriate Rx →
• Another valid answer for Rx →
Nasal decongestants “contains ephedrine”.
Nasal saline.
• Don’t get tricked by “he is penicillin allergic” and pick clarithromycin or
doxycycline.
• As mentioned above, acute sinusitis is mostly viral “also in this stem, he has
had a fever and cough a week ago, which means likely viral URTI”.
• This patient needs symptoms relievers as nasal decongestants and
analgesics.
• The symptoms have been there for → nasal steroids is wrong.
• If there are indications for bacterial infections (mentioned above), we would
go for an antibiotic.
166
Example (2):
A 30 YO woman presents with nasal blockage, frontal headache and facial
pressure for the past 2 weeks. She also has reduced sense of smell. Her nasal
discharge is clear. Her temp. is 37.8.
• The most appropriate Rx → Nasal steroids.
> 10 days • The symptoms have been there for improvement → consider nasal steroids.
• The given features are not yet sufficient to commence an antibiotic.
Remember: to think bacterial sinusitis:
> 10 days and without a significant
+ fever > 38 + purulent nasal discharge + unilateral pain
167
Episodes of Vertigo, Tinnitus, fluctuating Hearing loss, Ear pressure
± nausea and vomiting
→ Meniere’s disease.
◙ Management: “careful for the question words, both can be asked”!
• To terminate the acute attack (Rx during the episodes) → (Buccal or IM) or: Promethazine, Cyclizine, Cinnarizine.
• To prevent further attacks (↓ the frequency of the episodes) → Prochlorperazine
Betahistine.
168
Itching in the ear, pain in the ear and serous discharge in the auditory canal,
Tender tragus esp. with movement (difficult to examine the ear)
→ Otitis Externa.
169
One of the important indications for Adeno-tonsillectomy “referral to ENT
surgery” is
→ “Sleep Apnea “effect on sleep”
If a child is having recurrent episodes of sore throats, enlarged tonsils/
adenoids, temporary cessation of breathing during sleep
If a child is having recurrent episodes of sore throats, enlarged tonsils/
adenoids, temporary cessation of breathing during sleep
→ Refer to ENT surgery for further assessment for adeno-tonsillectomy.
170
A child with a piece of toy stuck in his ear. It is difficult to examine using
otoscopy, the child is in pain, crying, restless
→ Remove under general anaesthesia.
171
It is more common in women > 60 years old.
• It is different from psychiatric auditory hallucination in the fact that the patient
does not hear voices or people talking.
• It is often associated with tinnitus and hearing loss.
• The exact cause is unknown, but we first investigate for and assess hearing loss
by pure-tone audiometry as it is thought that the brain fills the gaps of hearing
loss with these musical sounds.
• Investigations involves pure-tone audiometry to assess hearing loss.
Musical Ear Syndrome (MES)
[NON-psychiatric musical auditory hallucination]
• Hearing music/ sounds without external source, ie, no one is playing music
around. It is not a form of psychosis.
• MES is a form of auditory hallucination often linked to hearing loss, particularly
in older adults. Pure tone audiometry helps assess the extent of hearing loss,
which is crucial because hearing impairment is a significant risk factor for
auditory hallucinations like MES.
• Pure tone audiometry provides quantitative data on the patient's hearing
thresholds at various frequencies, which can guide further management. For
instance, if the patient is found to have significant hearing loss, interventions
such as hearing aids might reduce the symptoms of MES by improving overall
hearing function.
• In contrast, an MRI, while useful for ruling out central nervous system
pathologies, is not the first-line investigation for suspected MES where the
primary concern is peripheral hearing loss. Hence, pure tone audiometry is more
appropriate in this context.
• There is no cure for MES (and since hearing loss is often present, we start by
audiometry to assess and try to treat hearing loss).
172
patient with a few months left ear discharge that is foul smelling
+ Decreased hearing (a feeling of blocked left ear) + Recurrent OM.
+ He used topical and oral antibiotics but without improvements.
Otoscope shows:
Think → cholesteatoma
Rx → urgent referral to ent( for surgical removal)
• Cholesteatoma is a collection of keratinizing squamous epithelium in the
middle ear that is able to expand, erode and destroy the adjacent structures,
causing TM perforation and ossicles damage.
It is neither a cholesterol nor a
tumour.
It is sown as a Pearly white mass BEHIND the tympanic membrane.
• (Cholesteatoma is poorly responsive to antibiotics
Cholesteatoma.
Urgent referral to ENT (for consideration of surgical removal).
173
174
Benign Paroxysmal Positional Vertigo [BPPV]
- Sudden onset of vertigo that is aggravated by a change in head position and
lasts a few seconds to a few minutes ± Nausea.
“It is important to remember that it lasts only a few seconds – a few minutes”
- Occurs usually during turning over in bed or lying down.
- Kindly note that nystagmus can be seen in BPPV as well.
- Dx → Hallpike’s Manoeuvre.
- Rx → Epley’s Manoeuvre = repositioning technique.
“Apply Epley for Treatment”
- N.B. mostly resolves spontaneously.
Benign paroxysmal positioning vertigo (BPPV) is a peripheral vestibular
disorder involving the semicircular canal usually but not exclusively the
posterior semi-circular canal (PSCC).
Imp √√
Important DDx:
• Dizziness/Vertigo on Moving head lasts for seconds to minutes ➔ BPPV.
• If + Hx of Viral URTI ➔ Vestibular Neuritis.
• If + Hx of Viral URTI + Hearing loss/Tinnitus ➔ Labyrinthitis.
175
Dvt
Another Summary:
• Vertigo + Hx of Common cold → Vestibular neuritis.
• Vertigo + Hx of Common cold + Hearing loss/Tinnitus → Labyrinthitis.
• Vertigo on moving head that lasts for seconds WITHOUT Hx of Common
cold → Benign Paroxysmal Positional Vertigo.
• DVT + Fullness (Deafness, Vertigo, Tinnitus) + Pressure or Fullness in one
ear → Meniere’s disease (MRI is normal).
• DVT + Cranial Nerve Palsy (e.g. Facial palsy, Loss of Corneal reflex, Loss of facial
sensation) → Acoustic Neuroma (Do MRI of the cerebellopontine angle).
176
Down Syndrome and Otitis Media with Effusion [OME]
• Children with down syndrome are susceptible to OME (or glue ear).
• Some of the features:
√ diffuse light reflex on tympanic membranes (or sometimes absent light
reflex).
√ Sits close to the TV.
√ They lack response when people talk to them (not hearing very well).
• Children with down syndrome need yearly hearing check using:
→ Pure tone audiometry.
This is because they have a higher risk of middle ear pathology and early onset
hearing loss.
Remember:
More clarification on Rx of OME (Important):
◙ Note that if is it is obvious that the child is having hearing loss (eg, he gets
close to the TV, he raises the TV volume) then there is a concern for hearing
loss. Therefore, pure tone audiometry is needed (without a delay for 3
months). We need audiometry to determine the severity of the CHL.
• If the conductive hearing loss (CHL) is not severe (based on the audiometry
results) → then 3 months is given and then review with another audiogram
177
Glue ear
After 3 months, review with another audiometry:
If spontaneous resolve occurs, then that’s good. But f hearing loss becomes
more severe, then refer to ENT for consideration of grommets insertion.
• Always encourage the parents to factor for their children’s glue ear.
stop smoking as it is an important risk
178
Old
+ Inability to hear sound in a noisy environment
+ Difficulty to comprehend speech as they sound muffled
+ bilateral sensorineural hearing loss (SNHL
)
Think → Presbycusis.
179
After adenoidectomy, a child is bleeding heavily from mouth and nose for 12
hours now:
→ Re-explore under general anaesthesia.
Nasal cautery and anterior nasal tampons are not beneficial here as the
bleeding is posterior (not from anterior visible nasal vessels).
180
Surgical bleeding types
❤️Primary
hemorrhage
Bleeding at the time of
surgery.
Rx: Replacing Blood or
return to theatre if severe.
❤️Reactionary
hemorrhage
Bleeding within 24 hours
after surgery/ Trauma.
e.g., a patient bleeding
and hypotensive while in
the recovery room.
Usually due to slipping of
ligatures, dislodgement of
clots, warming up post-op
leading to vasodilatation and
rising of BP to normal.
Rx: Replacing blood, wound
re-exploration.
❤️Secondary
hemorrhage
1 to 2 weeks post-op Usually due to necrosis of
blood vessels related to the
previous repair, and
precipitated by wound
INFECTION.
The patient may require
admission and IV antibiotics.
181
• A child with recurrent bleeding especially when he picks his nose.
• Presented to the ER.
• There is still active bleeding for 30 minutes. However, the active bleeding is
minimal (only after picking his nose or sometimes after coughing).
• Rhinoscopy could locate the bleeding point (in the little area)
• First aids have failed to stop bleeding
→ Nasal cautery with silver nitrate
.
(As the bleeding point can be seen and the bleeding is minimal – after nose
picking, silver nitrate cautery is tried first.
If failed, or of heavy bleeding, or if the
bleeding point cannot be seen → nasal packing).
182
Nasal Polyps
• They may cause → ↓ smell sense, difficult breathing through nostrils.
• Management:
√ Nasal steroids (can be used to shrink nasal polyps). (important).
√ If fails → Oral steroids, nasal polypectomy.
183
Acute Mastoiditis
• Post-auricular “behind ear” severe pain, swelling and edema.
• ± Loss of post-auricular sulcus.
• Ear problem (on the affected side) → • General → ↓ hearing, foul discharge, pain.
Fever, headache.
◙ Management:
→ IV antibiotics • If ear discharge is present → take swabs.
• Then → the most appropriate initial step to do is to start
(not oral!). (important). “IV antibiotics and admit for observation”.
• If no response to IV antibiotics after 24 hours, or if abscess is suspected
→ CT scan of petrous bone and brain.
184
Example:
A 54-year-old man who is on corticosteroids for renal transplant presents
complaining of left ear pain, hearing reduction, and foul discharge that started a
few days ago. He also has headache and a fever of 38.6.
On examination, there is
post-auricular swelling and edema and a loss of post-auricular sulcus. What is the
most appropriate management?
→ IV antibiotics.
(This is a case of acute mastoiditis. Take swabs of the ear discharge and
commence IV antibiotics.
CT scan of petrous bone is done if abscess is suspected
or if there is no response to IV antibiotics after 24 hours).
185
Acute mastitis
Vs malignant melanoma
The presentation of acute mastoiditis is similar to malignant otitis externa.
However, in malignant otitis externa, there is no post-auricular swelling and
erythema.
And, there is no loss of post-auricular sulcus.
The remaining features
can be seen (ear pain, foul discharge, ↓hearing, fever).
• If the case is malignant otitis externa → Refer urgently to ENT.
Also, we do CT scan of temporal bones first, then we initiate IV antibiotics
186
Important Scenarios on Hearing Loss Causes
• Presbycusis: elderly, Sensorineural, difficulty hearing in a noisy
Remember that:
• OME (glue ear) → bilat. Conductive HL, occurs in children.
• Otosclerosis → Conductive HL, occurs in young adults.
• Wax buildup → Conductive HL
• Presbycusis → SNHL, seen in the elderly.
• Acoustic Neuroma → SNHL + Other manifestations (eg, Vertigo, facial
palsy, diplopia, loss of corneal reflex).
• Meniere’s disease → SNHL + Other manifestations (eg, Vertigo, feeling of
fullness or pressure in the involved ear).
Remember:
Rennie’s test that shows:
√ Bone conduction better than air conduction → Conductive HL.
√ Air conduction better than bone conduction → Sensorineural HL.
187
A 35-year-old man presents to the ENT clinic complaining of persistent left-sided
nasal discharge, which he describes as yellow-greenish and foul-smelling. The
symptoms have been intermittent for the past four months.
He has noticed
temporary relief after completing several courses of antibiotics, but the discharge
returns shortly after.
Upon examination, the left nasal passage shows swelling
and erythema.
What is the most appropriate next step in managing this patient’s
condition?
The correct answer is D) Nasendoscopy.
Explanations:
• Nasendoscopy (or: Nasal Endoscopy) is the most appropriate step because it
allows direct examination of the nasal passages, sinuses, and other
surrounding structures. This helps identify structural issues, such as polyps,
masses, or obstructions, which could be causing recurrent infections. It also
allows for biopsy if needed.
• CT head is primarily used for brain and skull pathology (e.g., trauma). It is
incorrect here because the issue is likely sinus-related. If imaging is required, a
CT scan of the sinuses (CT PNS) is preferred, as it focuses on the paranasal
sinuses and nasal structures.
It is the ideal method for assessing sinus disease
and anatomical abnormalities.
• MRI head is mainly used to examine the brain and central nervous system
structures. It does not specifically focus on the sinuses or nasal passages, so it
is not the best choice for this case.
• Nasal swabs can identify infection-causing pathogens, but in cases of recurring
symptoms after antibiotic use, structural issues are more likely.
Swabs alone
will not reveal the underlying cause if the problem is more chronic or
structural.
X-rays are not used for chronic sinusitis because they lack the detail required
to evaluate sinus pathology, unlike CT scans, which provide a clearer picture of
sinus issues.
188
Recurrent unilateral nasal discharge:
When a patient has recurrent nasal discharge on one side, it is important to
think about possible causes like nasal polyps or a tumour.
The best way to
investigate this is by performing → a nasendoscopy (nasal endoscopy), which
allows the doctor to directly look at the nasal passages and sinuses for any
abnormalities.
◙ Recurrent rhinosinusitis:
In cases of recurrent rhinosinusitis (chronic sinus inflammation or infection), the
most appropriate imaging test is a CT scan of the paranasal sinuses (CT PNS).
This scan gives a detailed view of the sinuses, helping to identify blockages,
polyps, or structural issues causing the recurring symptoms.
◙ Acoustic neuroma:
If there is a suspicion of an acoustic neuroma (a benign tumour on the nerve
responsible for hearing and balance), the best test is an MRI of the
cerebellopontine angle (MRI CPA).
This type of MRI is focused on the area where
these tumours typically develop, providing a clear and detailed view for
diagnosis.
189
Acute Sinusitis
◙ The most frequent symptoms of acute sinusitis are:
Nasal congestion/ blockage - Facial pain and pressure eg, cheekbones pain -
Clear or yellow or green nasal discharge - Reduced sense of smell - Headache -
Low-grade fever - A history of a recent upper respiratory tract infection.
◙ Key Points on Acute Sinusitis Management:
√ First-line → Oral paracetamol or Ibuprofen. √ (To alleviate pain and fever).
Other additional lines for symptomatic relief: Nasal Decongestants (used short-
term, eg, nasal pseudoephedrine, oxymetazoline). Saline Nasal Irrigation.
√ If the episode lasted ≥ 10 days without improvement → Nasal steroids.
An example of nasal corticosteroid → Fluticasone nasal spray.
√ Antibiotics are rarely used. (The vast majority of cases are viral).
◙ When to use antibiotics in acute sinusitis? (rare).
• Antibiotics are used in acute sinusitis if it is bacterial “rare”,
suggested by the
long duration of symptoms (>10 days) + initial improvement followed by
worsening of symptom (ie, double-sickening) + severe fever and purulent thick
nasal discharge.
In viral, the discharge is usually clear thin.
190
Quick Notes:
• Patients suspected of having obstructive sleep apnea (OSA) should be:
→ Advised to stop “cease” car and lorry driving until an assessment is made.
• If diagnosed of having obstructive sleep apnea OSA “by polysomnography”
→ Advise the patient to inform DVLA (Driver and Vehicle Licensing Agency).
If they refused → Inform DVLA on their behalf.
191
Chronic long-lasting hoarseness
→ Refer to ENT “otolaryngologist”.
This is to rule out laryngeal pathology such as laryngeal cancer, particularly if
there is a history of smoking.
192
Quick Scenario on a Previous Topic:
A 44-year-old woman presents to the A&E with:
• Severe persistent pain behind her right ear that has been present for 2 weeks.
• The symptoms started with a sore throat and a feeling of fullness in her right
ear that initially improved with oral antibiotics.
• Over the last few days, she has developed a fever, the pain has intensified, with
some ear discharge.
• There is redness, swelling, and tenderness behind her right ear.
• The tympanic membrane is not visible due to edema of the external auditory
canal.
What is the most appropriate next step in management?
√ This is likely a case of mastoiditis.
√ Mastoiditis is a severe infection. Its complications can include meningitis, brain
abscess, lateral sinus thrombosis. Therefore, IV antibiotics are important initially.
√ So, the answer is:
→ Give intravenous “not oral” antibiotics and admit the patient for observation.
√ If no response within 24 hrs, or abscess → CT scan of petrous bone. “Not MRI”.
√ Do not confuse acute mastoiditis with malignant -necrotising- otitis externa. In
malignant otitis externa → refer urgently to ENT and CT of the temporal bones.
193
Malignant otitis externa
Acute mastoiditis
◙ Important comparison notes:
• The presentation of acute mastoiditis is similar to malignant otitis externa.
However, in malignant otitis externa, there is no post-auricular swelling and
erythema. And, there is no loss of post-auricular sulcus.
The remaining features
can be seen (ear pain, foul discharge, ↓hearing, fever).
• If the case is malignant otitis externa → Refer urgently to ENT.
Also, we do CT scan of temporal bones first, then we initiate IV antibiotics.
194
Chronic long-lasting hoarseness
→ Refer to ENT “otolaryngologist”.
This is to rule out laryngeal pathology such as laryngeal cancer, particularly if
there is a history of smoking.
Quick Notes:
• Patients suspected of having obstructive sleep apnea (OSA) should be:
→ Advised to stop “cease” car and lorry driving until an assessment is made.
• If diagnosed of having obstructive sleep apnea OSA “by polysomnography”
→ Advise the patient to inform DVLA (Driver and Vehicle Licensing Agency).
If they refused → Inform DVLA on their behalf.
195
196
197
Important comparison notes:
• The presentation of acute mastoiditis is similar to malignant otitis externa.
However, in malignant otitis externa, there is no post-auricular swelling and
erythema. And, there is no loss of post-auricular sulcus.
The remaining features
can be seen (ear pain, foul discharge, ↓hearing, fever).
• If the case is malignant otitis externa → Refer urgently to ENT.
Also, we do CT scan of temporal bones first, then we initiate IV antibiotics.
198
A 44-year-old woman presents to the A&E with:
• Severe persistent pain behind her right ear that has been present for 2 weeks.
• The symptoms started with a sore throat and a feeling of fullness in her right
ear that initially improved with oral antibiotics.
• Over the last few days, she has developed a fever, the pain has intensified, with
some ear discharge.
• There is redness, swelling, and tenderness behind her right ear.
• The tympanic membrane is not visible due to edema of the external auditory
canal.
What is the most appropriate next step in management?
√ This is likely a case of mastoiditis.
√ Mastoiditis is a severe infection. Its complications can include meningitis, brain
abscess, lateral sinus thrombosis. Therefore, IV antibiotics are important initially.
√ So, the answer is:
→ Give intravenous “not oral” antibiotics and admit the patient for observation.
√ If no response within 24 hrs, or abscess → CT scan of petrous bone. “Not MRI”.
√ Do not confuse acute mastoiditis with malignant -necrotising- otitis externa. In
malignant otitis externa → refer urgently to ENT and CT of the temporal bones.
199
Remember that:
• Ear wax (cerumen impaction) can cause → unilateral conductive hearing loss.
• In conductive hearing loss (CHL):
√ Rinne’s test (when placing the vibrating fork over the mastoid bone and then
around 1 cm from the ear).
→ Bone conduction (BC) is greater than air conduction (AC) in the affected side.
√ Weber’s Test (when placing the fork on the middle of the forehead):
→ The sound lateralizes to the affected side (the abnormal air).
200
Important Note on hearing loss caused by prolonged exposure
to a loud noisy environment (eg, working in a loud machinery plant)
→ Noise-induced hearing loss is a sensorineural hearing loss (SNHL), and it
typically affects both ears not one.
201
Ear wax (cerumen impaction) can cause → unilateral conductive hearing loss.
• In conductive hearing loss (CHL):
√ Rinne’s test (when placing the vibrating fork over the mastoid bone and then
around 1 cm from the ear).
→ Bone conduction (BC) is greater than air conduction (AC) in the affected side.
√ Weber’s Test (when placing the fork on the middle of the forehead):
→ The sound lateralizes to the affected side (the abnormal air).
202
Owe
Hearing Tests in Babies < 6 months:
• OAE (Otoacoustic emission) test.
• ABR (Auditory brainstem response) test.
Note: If a baby tested normal for OAE but his family still has concerns (eg, for the
presence of family history of hearing loss)
→ Go for ABR as well.
203
Quick Points on Management:
◙ Acute Mastoiditis (Swelling behind ear, tenderness over mastoid process,
protruded pinna, otalgia, fever).
(not oral; it is severe and can lead to intracranial complications).
→ IV antibiotics ◙
Malignant otitis externa (Severe pain in the ear, purulent foul discharge,
conductive hearing loss).
→ Urgent ENT referral and CT scan of temporal bone.
◙ Acute sinusitis (Nasal congestion, facial pain and pressure, reduced smell,
fever, ± tenderness over frontal, maxillary sinuses). (Mostly Viral).
→ Oral paracetamol. (Supportive: for fever, pain, inflammation).
If persists 10 or more days without improvement → Nasal corticosteroids.
204
TM perforations have multiple origins such as a complication of infection (acute
otitis media or otitis externa secondary to Aspergillus Niger),
barotrauma from
explosions, scuba diving, or air travel, sudden negative pressure, head trauma,
noise trauma, insertion of objects into the ear, or iatrogenic from attempting
foreign body or cerumen removal.
• One may feel a pain in his ear for a few days (before rupture).
• Once tympanic membrane rupture occurs, the pain is relieved, and a small
amount of discharge may come out.
• After rupture → ↓ hearing.
• Management (important):
√ Reassure and review in 6 weeks (as it usually heals on its own in 6 weeks).
√ If bacterial infection is suspected → prescribe antibiotics.
√ If it does not heal by itself → Tympanoplasty (TM repair procedure).
205
A 24-year-old pregnant woman (31 weeks gestation) has been having gradual
hearing loss over the past month.
Her eardrums look normal on otoscopy.
Hearing tests show bone conduction (BC) is better than air conduction (AC) in
both ears.
What is the most likely cause of her gradual hearing loss?
A) Early-onset presbycusis.
B) Meniere’s disease.
C) Otitis media.
D) Tympanosclerosis.
E) Otosclerosis.
◙ Since BC > AC in both ears
→ Bilateral conductive hearing loss (CHL).
• Both options A and B (Presbycusis and Meniere’s) are causes of sensorineural
not conductive hearing loss → wrong.
• The remaining options are causes of conductive hearing loss, let’s see:
√ Otitis media: there is no features of infection in the stem. Also, eardrums are
normal → wrong.
√ Tympanosclerosis → it is characterized by Chalky white patches over the
eardrum. Here, the eardrums are normal → wrong.
√ Otosclerosis: it is the only option left, it is a cause of conductive hearing loss, it
is accelerated by pregnancy (given as a hint) → Right answer.
So, the answer is → E (Otosclerosis).
