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UCPEX > ORL > Flashcards

ORL Flashcards

1
Q

Microorganisms causing acute otitis media

A

Respiratory viruses, Strep pneumoniae, H influenzae, Moraxella catarrhalis

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2
Q

Examination findings in acute otitis media

cf otitis media with effusion

A

Red, bulging tympanic membrane
Loss of normal contours
Loss of translucency
Air-fluid level
Discharge from grommet or perforation

OME
Dull, retracted tympanic membrane
Middle ear effusion
No symptoms of infection
Persists up to 12 weeks after AOM
GP to refer for tympanometry if persisting

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3
Q

Complications of acute otitis media

A

Perforation of TM
Mastoiditis
Facial nerve palsy
Intracranial spread

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4
Q

Criteria for antibiotics for acute otitis media

Abx treatment:

A

Age <6 months
Age <2 years with bilateral infection
Not improving after 48 hours
Recurrent infection >3 in 6 months/>4 in 12 months

Amoxicillin 15mg/kg tds 5 days (30mg/kg 7 days in severe)
Augmentin if no response to high dose
OR
Erythromycin 10-12.5mg/kg QID 5-7 days
OR
Cotrimoxazole 24mg/kg BD 5-7 days

80% resolve in 3 days without abx

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5
Q

Causes of otitis externa and treatment

A

Sweating, swimming, high humidity
Local trauma

  • Gentle irrigation unless canal swollen ++
  • Microsuction
  • Mild: - 2% acetic acid + 1% hydrocortisone drops 5 drops tds until resolve

Bacterial
- Swelling, fever, severe discomfort, lymphadenopathy, scant white discharge, bloody discharge if chronic
- Sofradex 5 drops tds, 3-5 days after symptoms resolve

Fungal
- **Profuse discharge, itch, fullness, tinnitus
- Clean ear canal
- Locarten Vioform 5 drops QID 5-7/7

Atopic dermatitis
- Itch, red, thick, crusty, hyper pigmented skin, eczema elsewhere

Psoriasis
- Itch, red lesion, thick white scale, scalp involvement

Allergic contact dermatitis
- Rapid, red, swollen, itchy, exudative lesions, outer lobe/ear involvement

Irritant contact dermatitis
- Slow onset, patches of thickened, hardened skin, outer lobe/ear involvement

Prevention advice:
No swimming 14 days
Dry ears after shower/swimming
Acetic acid drops in ear after swimming
Avoid FB in ear

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6
Q

Features of cholesteatoma
Symptoms
Examination finding
Risk factors
Complications

A

Lesion of keratinising stratified squamous epithelial cells, from lateral epithelium of tympanic membrane

Sx: Conductive hearing loss
Intermittent foul smelling ear discharge

Exam: Retracted pocket in attic or postero-superior quadrant, granular polyp in ear canal

Risk - Eustachian tube dysfunction, recurrent childhood AOM, cleft palate, Down Syndrome

Complications: Facial nerve weakness
Inner ear invasion - loss of balance
Labyrinthitis
Intracranial infection, meningitis, brain abscess
Mastoiditis

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7
Q

Bacteria in mastoiditis

A

Pneumococcus
Strep pyogenes
H influenzae
Staph aureus

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8
Q

Spread of mastoiditis

A

Extension of acute otitis media - days to weeks

Osteitis of septae + coalescence of air cells
>lateral mastoid cortex = post auricular subperiosteal abscess
>central extension = temporal lobe abscess or septic thrombosis of lateral sinus
>zygoma = zygomatic mastoiditis
>tip of mastoid into neck = Bezold abscess

IV flulcox + ceftriaxone
Urgent ENT referral, NBM

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9
Q

Symptoms of mastoiditis

A

Mastoid swelling + tenderness
Pinna pushed down + forward
Fever >38
Conductive hearing loss
Nausea/vomiting
Ear discharge

Beware of masked mastoiditis - partially treated, milder symptoms

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10
Q

Incidence and causes of sudden sensorineural hearing loss

A

Peak 50s and 60s, usually unilateral
Bilateral more common in younger age groups

Idiopathic
Possible infective, vascular, immunological, traumatic, deficiencies
NSAIDs (especially aspirin)

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11
Q

Management of sudden sensorineural hearing loss

A

ENT referral - Urgent audiometry and bone conduction tests within 48 hrs
High dose steroids - 40-60mg prednisone OD 5-7 days
Repeat audiometry
Slow taper if no improvement, discuss with ENT if improvement
50% patients have full recovery in 2 weeks

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12
Q

Tinnitus that requires urgent investigation:

A

Unilateral and lower hearing threshold - MRI to r/o acoustic neuroma

Conductive hearing loss - CT to r/o otosclerosis or cholesteatoma

Pulsatile tinnitus - MRA/CTA to r/o vascular abnormality

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13
Q

Arteries contributing to Little’s area

Arteries for posterior bleed

A

90% of epistaxis

Internal carotid:
Anterior ethmoid, posterior ethmoid

External carotid:
Sphenopalatine, greater palatine, superior labial

Posterior bleed:
Posterior septum or lateral nasal wall
internal maxillary, sphenopalatine, descending palatine, posterior ethmoid

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14
Q

Causes of epistaxis

A

Trauma - nasal trauma/picking
Sinusitis/URTI
HTN
Coagulopathy, anticoagulants, haemophilia
Nasal steroids
Cocaine
Post-op
Nasal tumours/polyps

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15
Q

Complications of nasal trauma

A

Full thickness lacerations
Open fracture
Septal haematoma - saddle deformity
Septal abscess -> meningitis, intracranial abscess, venous sinus thrombosis
Postural CSF leak -> fracture of cribriform plate

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16
Q

Microbial causes of tonsillitis

A

90% viral
EBV/CMV
COVID
Group A streptococcus (7-37% depending on community)

17
Q

Antibiotic indication in sore throat

A

Family hx rheumatic fever
OR 2 of:
Maori/Pacific
Low SES or crowded circumstance
Ages 3-24, especially 4-19

Local suppurative complication (peritonsillar cellulitis, quinsy), scarlet fever or immunocompromised

Penicillin V 250mg (<20kg)/500mg (>20kg) 2-3 times/day, 10 days
Amoxicillin 50mg/kg or 1g OD, or 25mg/kg or 500mg BD 10 days
Benzathine penicillin 450mg IM stat (<30kg), 900mg IM stat (>30kg)

Erythromycin 40mg/kg/day 10 days
800mg BD 10 days
Roxithromycin 300mg OD 10 days or 150mg BD 10 days

18
Q

Microbial causes of acute rhinosinusitis

A

98% viral
COVID 19
Bacterial - Strep pneumoniae, Haemophilus influenzae, Moraxella catarrhalis

19
Q

Signs of bacterial rhinosinusitis

Complications

A

Fever >39 deg
Purulent nasal discharge
Severe unilateral maxillary pain with percussion tenderness

Cavernous sinus thrombosis
Meningitis
Cerebral abscess
Orbital cellulitis/abscess

20
Q

At risk groups for rhinosinusitis

A

Polyps, deviated septum, turbinate deformity, enlarged tonsils/adenoids, nasal FB, tumour
Atopy
Smoking
Rhinitis medicamentosa - chronic decongestant use
Allergic/non-allergic rhinitis
Pregnancy, immunodeficiency, hypothyroid, CF, migraine, vascular headache

21
Q

Management of rhinosinusitis

Acute viral
Acute bacterial
Chronic

A

Acute viral - nasal decongestants <7 days, sinus rinses, analgesia
- Nasal steroid if symptoms >10 days.
- Post-viral symptoms may persist for 12 weeks.

Acute bacterial - nasal decongestant, sinus rinse, analgesia, nasal steroid
- Abx if severe illness >3 days, symptoms >10 days, worsening after initial improvement
- Amoxicillin 15-30mg/kg, 500mg tds 7 days
OR Doxycycline 200mg day 1, 100mg OD further 6 days
OR augmentin if symptoms persist

Chronic - Long term nasal saline irrigation and nasal steroid
- No improvement in 4 weeks - 3 weeks of weaning steroids
- If nasal polyps add 3 weeks roxithromycin/doxycycline
- No improvement - CT sinus and ENT referral

22
Q

Risk groups for dental infections

A

Poverty
Poor diet
Poor dental hygiene
Drugs (meth mouth)
Immunocompromised
Sjogren’s disease - reduced saliva

23
Q

Complications of dental infections

Red flag symptoms

A

Trismus
Swelling floor of mouth
Airway compromise
Severe facial swelling

Ludgwig’s angina - spread of infection for lower 2nd, 3rd molars to sublingual, submandibular, submittal space.
- Trismus, resp distress, dysphagia, dysphonia, preference to sit upright

Paediatric dental infections
> retropharygeal space > retropharyngeal abscess
> parapharyngeal space > parapharyngeal abscess

Bacteraemia, endocarditis (in valvular disease)

24
Q

Dental trauma management:
Avulsed tooth
Fractured tooth
Mobile tooth

A

Emergency referral for all:

Avulsed
- Leave primary teeth
- avoid touching root
- brief wash under cold water (<10 s)
- place in socket, in mouth between cheek and molars, or in glass of milk

Fractured
- Keep tooth fragment

25
Q

Antibiotics for dental infection if delay to see dentist

A

Amoxicillin 5/7
OR Cefalexin 500mg QID 5/7
OR Metronidazole 400mg tds 5/7

26
Q

Temporomandibular dysfunction:
Aetiology
Frequency
At risk groups

A

Muscular disorder - Stress related MSK dysfunction, bruxism, teeth grinding, poor posture, anxiety
TMJ disorder - osteoarthritis, subluxation, dislocation (usually anterior and bilateral)

70% population have signs
5-12% symptomatic
Peak incidence age 20-40
Women 4x more than men

27
Q

Signs and symptoms of temporomandibular dysfunction

Management

A

***Pain with jaw movement
Clicking, crepitus
Headache, neck pain
Poor sleep, reported teeth grinding
Normal jaw opening 35-45mm

Jaw splints
Psychosocial support
Sleep hygiene
Simple analgesia +/- amitriptyline. Avoid opioids/benzos

TMJ dislocation
- inability to close mouth, garbled speech, drooling

  • Syringe technique
  • Gag reflex
  • Manual reduction - intraoral/wrist pivot/extraoral
  • Soft food for 1 week, avoid extreme mouth opening
28
Q

Neck lump pertinent hx

A

Size, progression over time, pain, affecting eating
Voice changes
Recent infection of nearby structures
Fever
Smoker
Travel
Past cancer
Symptoms of systemic illness

29
Q

Ddx for lateral neck lumps

A

Hodgkin’s lymphoma
- Young adults
- Painless progressive submittal swelling

Metastatic ca
- Submental/submandibular, upper neck/tail of parotid
- SCC, melanoma

Primary oral cancer
- HPV oropharyngeal ca, level 2 jugulodigastric node, age 40-60 male, smoker, ETOH
- Nasopharyngeal ca, TB - Asian

Submandibular duct obstructing stone
- acute, associated with eating

Submandibular tumour
- Painless progressive swelling of submandibular gland
- 50% malignant

Parotid gland
- Mumps, bacterial inf secondary to salivary obstruction
- Tumour - painless progressive swelling. Primary usually benign. Secondary from melanoma, SCC

Branchial cyst
- Children and young adults
- Usually cystic (sometimes solid) jugulodigastric region
- Can present acutely with inflammation
- Refer for removal

Inflammatory lymphadenopathy
- Jugulodigastric or posterior triangle
- Acute bacterial/viral infection

Plunging ranula
- Mucoid saliva from sublingual gland herniates through myohyoid
- Soft, ill defined swelling in submental/submandibular area
- Swelling in floor of mouth
- Refer for removal sublingual gland

Carotid body tumour
Nerve sheath tumour
Lipoma
Hyoid bone, carotid bulb (normal variants)

30
Q

Ddx for lower midline neck lumps

A

Thyroid nodules
- Elevate with swallowing
- Usually on either side of midline
- High risk of malignancy if >4cm solitary nodule in men or children

Thyroglossal cyst
- Age <20 years
- 80% under hyoid bone
- Moves with tongue protrusion
- If infected, large and painful
- Refer for removal

Dermoid cyst
- Anywhere from chin to jugular notch
- Usually young children
- Congenital, benign, filled with caseous material

Refer for FNA if neck lump persists >3 weeks

UCPEX (13 decks)

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