Hearing Loss and Common ENT Presentations Flashcards
(42 cards)
1
Q
What are the differential diagnoses for ear discharge?
A
- Acute otitis media or otitis externa
- Both very painful, with reduction in pain if TM perforates
- Chronic suppurative otitis media
- Painless and smelly
- Acute infection usually indicated by bloody / whitish / pus discharge.
- Cholesteatoma usually produces a smelly discharge.
2
Q
Why it otitis media more common in children?
A
Because they have shorter and flatter Eustachian tubes.
3
Q
What are the systemic symptoms commonly caused by acute otitis media?
How is otitis media treated?
A
- Acute otitis media can cause fever and malaise.
- It is usually treated with oral ABx, or drops if the patient is well and the TM has perforated.
4
Q
How is otitis externa treated?
A
- Topical treatment is most effective in treating otitis externa.
- The patient is usually systemically well.
- If ear canal is almost swollen shut patient needs urgent ENT referal for otowicks.
5
Q
How are chronic suppurative otitis media and cholesteatoma managed?
A
- The patient is well but the discharge usually does not settle with oral or topical ABx.
- TM will be persistently abnormal.
- Outpatient ENT referral is required.
6
Q
What are the complications of acute otitis media?
A
- Spread of infection around the middle ear and via perforating vessels into the brain.
- Mastoiditis / subperitoneal abscess
- Meningitis
- Cerebral abscess / empyema
- Facial nerve palsy
- IJV thrombosis
7
Q
What are the complications of otitis externa?
A
- Spreading cellulitis on face and neck.
- Osteomyelitis.
8
Q
What are the complications of chronic suppurative otitis media?
A
- Facial nerve palsy
- Lateral semicircular canal fistula resulting in vertigo
- Conductive hearing loss
- Complete sensorineural hearing loss
- Meningitis
- CSF leak
9
Q
Describe vertigo.
What should be elicited in the history of a patient with ?vertigo?
A
- Vertigo is a sensation of motion of either subject or their surroundings in the absence of movement.
- In inner ear pathology this is often rotatory.
- Dizziness, giddiness, light-headedness are very non-specific symptoms.
- History is key:
- Exact sensation, duration, precipitating factors e.g. certain head movements, episodic or regular, associated symptoms e.g. hearing loss, ear fullness, tinnitus, nausea / vomiting, headache.
10
Q
What are the different causes of dizziness?
A
- Cardiac
- Neurological
- Pharmacological
- Sight-related
- Postural
- ENT
11
Q
What are the common ENT-related causes of dizziness?
A
- Benign paroxysmal positional vertigo
- Acute vestibular neuronitis (labyrinthitis)
- Vestibular migraine
- Secondary to AOM or CSOM
- Meniere’s disease (mich less common than the rest)
12
Q
What is epistaxis and why does it happen?
A
- Nosebleeding - common ENT emergency.
- Causes in children:
- Nose picking
- Anterior nasal infections
- Settles with topical ABx cream. Occasionally need cautery.
- Causes in adults:
- Post traumatic
- Secondary to hypertension
- Digital manipulation
- Idiopathic
- Most commonly troublesome in the anticoagulated (DVT / PE / cardiac) or thrombocytopaenic population (e.g. cancer / haematology patients).
13
Q
How is epistaxis managed?
A
- First aid measures - pressure to the cartilaginous part of the nose for 10 minutes, ice over forehead, head forward.
- If persisting and profuse needs A&E / ENT management, cautery, nasal packing if source is not clear.
- If multiple regular, short bleeds, ABx cream, advice to avoid picking and rationalise anticoagulation if possible.
- Refer to ENT clinic if above is unsuccessful.
- Haematological derangement requires haematology input as topical measures do not work in the absence of intact clotting mechanisms.
14
Q
What are the causes of nasal blockage?
A
- Due to mechanical or functional obstruction.
-
Mechanical obstruction:
- Septal cartilage deviation (possibly post-injury)
- Nasal polyps
- Foreign body
- Tumours
- Choanal atresia
-
Functional obstruction:
- Allergic rhinitis
- URTI
- Rhinitis medicamentosa
- Drugs
- Nasal polyps are associated with rhinitis and asthma, but not everyone with rhinitis will develop them, indeed only a minority.
15
Q
Describe sinusitis:
- Duration
- Symptoms and associated features
- Treatment
A
- Acute or chronic.
- Chronic can be with or without nasal polyps.
- Acute sinusitis duration <3/12, usually following URTI.
- Symptoms:
- Painful
- Purulent discharge
- Blockage
- Dull headache
-
Not painful around face / eyes
*
16
Q
What is chronic rhinosinusitis?
How is it managed?
A
- Chronic rhinosinusitis (CRS) is defined as persistent symptomatic inflammation of the nasal and sinus mucosa.
- Needs referral to ENT for confirmation of diagnosis and management.
- Management:
- Topical +/- oral steroids, long course of macrolide ABx, if not responsive, CT sinuses and surgery for drainage / opening of sinuses to allow deeper penetration of topical treatment.
- Surgery does not cure the underlying rhinitis / mucosal dysfunction that leads to CRS.
17
Q
Describe these CT images of the sinuses.
A
-
A
- Normal
- Black and therefore full of air
-
B
- Full of secretions, nasal thickenings and polyps
18
Q
How can nasal foreign body present?
How should you manage this?
A
- Mostly children, occasionally adults (learning difficulties).
- Either witnessed and present acutely or unilateral smelly nasal discharge for weeks.
- Can be visualised using an otoscope gently in the nostril, sometimes only pus can be seen if there for some time.
- Attempt to remove if clearly visible, otherwise refer to ENT rapid access clinic.
- Button batteries: emergency ENT referral.
19
Q
Describe bacterial tonsilitis and how you would treat.
A
- High temperature
- Difficulty swallowing
- Treatment:
- Oral ABx - penicillin unless allergic.
- Plenty fluid and rest.
- Symptoms should resolve in 7-10 days.
- If unable to take fluids / ABx orally, may need hospital admission.
- Multiple recurrent episodes - consider referral for tonsilectomy.
20
Q
Describe glandular fever and how you would treat.
A
- Commonest type of viral tonsilitis.
- Systemic malaise
- Fatigue
- Lymphadenopathy (bilateral neck nodes, +/- axillary and inguinal nodes with hepatosplenomegaly)
- Mild pyrexia
- Usually huge, spotty tonsils.
- Conservative measures unless secondary bacterial infection.
- Avoid alcohol / contact sports.
- Can take 3-4/52 for symptoms to settle and lead to severe fatigue.
21
Q
Describe quinsy and how you would treat.
A
- Peri-tonsillar abscess:
- Pyrexia
- Difficulty swallowing
- Symptoms more unilateral and swelling ++ in throat
- Emergency ENT referral for drainage.
- Usually require 24-48 hrs of IV ABx.
- If drainage is unsuccessful, may need emergency tonsilectomy.
22
Q
Describe supra- / epiglottitis and how you would treat.
What is the most common causative organism?
A
- Most common causative organism is H. influenza.
- Severe sore throat and fever with almost complete dysphagia.
- May be drooling / having difficulty breathing.
- Throat looks normal or slightly red.
- ENT emergency - needs urgent attention to the airway as can obstruct very quickly.
- Avoid examination in child if suspected as upset can precipitate airway obstruction.
- Commonest in 2-6 years and >60s.
- Most common in >60s because they have not been immunised against H. influenza.
23
Q
Describe laryngitis and how you would treat.
A
- Usually viral.
- Hoarse / voice loss but no difficulty breathing and normal or near normal swallow.
- Clinical diagnosis: acute onset of loss of voice, painless or slight sore throat and malaise.
- Conservative management, consider referral to ENT if persisting over 4/52.
24
Q
How should neck lumps be managed in the:
- Acute setting?
- Chronic setting?
A
- Acute presentation of painful lumps can be treated with oral ABx and early review (24-48hrs). Refer to ENT emergently if not settling / worse.
- Subacute / chronic lumps: refer urgently to ENT clinic for further assessment. USS can help differentiate benign / malignant, but interpretation of results is better done in light of specialist review.
25
What are the common types of foreign bodies presenting in the throat?
Describe the management.
* Fishbones: 'jaggy' sensation after eating fish. Patient can usually pinpoint on their throat / neck. Refer to ENT, usually seen within 12-24 hours.
* Swallowed: if below the level of the cricoid cartilage refer to gastro, otherwise ENT. Emergency referral.
* Inhaled: emergency ENT referal. Commonest in children (coins, peanuts, button batteries).
26
How would an airway foreign body present?
* Usually children.
* Witnessed choking episode, which may settle completely.
* Worsening cough / audible wheeze raises the possibility of persistent FB.
* Choking episode leading to acute respiratory distress.
* FB not always visible on XR, unilateral wheeze, cough, loss of lung volume on XR and good Hx should trigger urgent referral to ENT for consideration of rigid bronchoscopy.
27
Describe the different types of hearing loss.
* **Conductive hearing loss (CHL)**
* ****Inner ear and pathways to auditory brainstem are intact but the sound cannot get to the inner ear.
* **Sensorineural (SNHL)**
* ****The ear apparatus is transmitting sound normally to the cochlea, but the sound is not getting to the auditory brainstem. Usually cochlear problem but less frequently a failure of transmission along the auditory nerve / pathways.
* **Both CHL and SNHL** can be congenital or acquired.
28
What are the congenital and acquired causes of CHL and SNHL?
* Congenital causes include:
* Malformation of the ossicles, cochlear agenesis or dysplasia, aplasia of the VIIIth nerve, genetic / hereditary syndromes, prenatal infections (congenital rubella / toxoplasmosis).
* Acquired causes include:
* Noise damage, advancing age, trauma, inner ear infections, vascular events and tumours.
29
What are the commonest causes of CHL?
1. Otitis media with effusion
2. Wax / FB impaction
3. CSOM / cholesteatoma
4. Otosclerosis
30
What are the commonest causes of SNHL?
1. Noise-induced hearing loss (NIHL)
2. Presbyacusis (hearing loss of older age)
3. Congenital (of various causes)
31
Describe a normal audiogram.
* If you have normal hearing you should be at the very top of this scale at all the different frequencies.
* Within 20 is the lower limit of normal hearing.
32
What effect can otitis media with effusion have on hearing?
Who is most commonly affected by this and how should it be managed?
* Fluid accumulation in the middle ear space secondary to eustachian tube dysfunction.
* Commonest in ages 2-6.
* Can cause a CHL up to 30dB.
* Treatment:
* Common after URTI but only requires treatment if persistent \>3/52.
* Decongestants, nasal steroid spray, oto-inflation / valsalva.
* If none of the above are successful, consider grommet insertion.
33
Describe the effect wax impaction has on hearing.
How is this managed?
* CHL up to 20-30dB.
* Tympanometry is likely to be flat (type B) as per OME.
* Management
* Needs softening with oil drops before attempt to syringe or suction.
* Usually immediate improvement in hearing unless there is a second cause of hearing loss.
34
Describe the effect CSOM / cholesteatoma have on hearing.
How does this present and how is it managed?
* Can cause erosion of ossicles and chronic discharge affecting hearing (CHL) but in rarer cases, if untreated for many years, can cause a complete SNHL due to erosion into the cochlea.
* Abnormal appearance of TM, chronic smelly discharge and hearing loss needs referral to ENT for further investigation.
35
What is otosclerosis? What does it cause?
* CHL caused by excessive ossification around the footplate of the stapes, where it transmits sound into the oval window.
* Usually the only symptom is hearing loss which is progressive and conductive. TM appearance is normal.
36
Who is affected by otosclerosis and when does it develop?
* 50% genetic.
* Most start to develop symptoms in their 20s and 30s.
* Pregnancy can accelerate the process.
* Slight female preponderance.
37
Describe noise-induced hearing loss.
How should it be managed?
* Either due to a sudden 'impulse' sound (e.g. explosion), or more commonly, to prolonged, repeated exposure over time (e.g. loud concerts, headphones, occupational, shooting).
* Caused by the permanent damage and loss of the hair cells in the cochlea over time.
* Best approach is prevention; there is no treatment available once it has occurred except hearing aids.
38
Describe presbyacusis.
* Age-related reduction in hearing due to progressive death of the hair cells in the cochlea.
* High frequencies happen first as they are mapped in the basal turn of the cochlea and hence the hair cells and stereocilia in that area get the maximum movement from the acoustic travelling wave from the oval window.
* Presbyacusis is commonly associated with the high frequency tinnitus that older patients experience due to the loss of hearing at those frequencies. Wearing hearing aids can help reduce this.
39
How is presbyacusis managed?
* Hearing aids are the commonest treatment.
* New digital hearing aids can selectively enhance the specific frequencies that the patient has lost.
* The hearing aid can help reduce the associated high frequency tinnitus due to loss of hearing at these frequencies.
40
When is congenital hearing loss normally picked up?
How can it be managed?
* Either picked up at neonatal hearing screen, or hearing loss starting in childhood / young adulthood.
* Can be static or progressive.
* Need follow-up to see if progressing, however, there is normally no way of preventing further deterioration except to make sure to limit noise exposure to prevent additional NIHL.
41
What are the surgical options in managing hearing loss?
* It is only possible to **correct** CHL or improve it by using implantable bone conducting hearing aids.
* The only surgical option for SNHL is a cochlear implant, for which there are very strict criteria for patients that are getting little benefit from conventional hearing aids.
* Grommets help to correct CHL caused by OME (pictured).
* Middle ear fluid is aspirated and long term middle ear ventilation occurs through the TM rather than relying on the eustachian tube.
* Designed to stay in place for ~1 year then fall out.
* **Stapedectomy** for otosclerosis aims to disconnect the otosclerotic stapes footplate from the oval window and allow insertion of a prosthesis. The prosthesis is between the incus and the footplate to allow normal mobility once again.
*
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