Otitis externa; ostosclerosis; Quincy Flashcards
(23 cards)
Describe what is meant by otitis externa [1]
Otitis externa is inflammation of the skin in the external ear canal. Oto- refers to ear, -itis refers to inflammation, and externa refers to the external ear canal. The infection can be localised or diffuse. It can spread to the external ear (pinna). It can be acute (less than three weeks) or chronic (more than three weeks).
Risk factors for otitis externa? [5]
Risk factors include
* water exposure (e.g. frequent swimming)
* high humidity
* trauma to the auditory canal (e.g. cotton swab use)
* narrow ear canals
* immunosuppression
What are the causes of otitis externa? [4]
Causes of otitis externa include:
infection
- bacterial: Staphylococcus aureus, Pseudomonas aeruginosa
fungal: primarily caused by Aspergillus species and Candida albicans, are more prevalent in chronic cases
seborrhoeic dermatitis
contact dermatitis (allergic and irritant)
Features of otitis externa? [+]
Features
* ear pain
* ear itch
* ear discharge
* Conductive hearing loss (if the ear becomes blocked)
Otoscopy findings:
* view may be limited secondary to discharge, debris or swelling
* red, swollen, or eczematous canal
Mx of otitis externa?
Mild otitis externa may be treated with acetic acid 2% (available over the counter as EarCalm). Acetic acid has an antifungal and antibacterial effect. This can also be used prophylactically before and after swimming in patients that are prone to otitis externa.
Moderate otitis externa is usually treated with a topical antibiotic and steroid
An ear wick may be used if the canal is very swollen, and treatment with ear drops or sprays will be difficult
- An ear wick is made of sponge or gauze. They contain topical treatment for otitis externa (e.g., antibiotics and steroids). Wicks are inserted into the ear canal and left there for a period of time (e.g., 48 hours). As the swelling and inflammation settle, the ear wick can be removed, and treatment can continue with drops or sprays.
Fungal infections can be treated with clotrimazole ear drops.
Which drugs do you not use if tympanic membrane is perforated? [1]
if the tympanic membrane is perforated aminoglycosides are traditionally not used
- Aminoglycosides (e.g., gentamicin and neomycin) are potentially ototoxic, rarely causing hearing loss if they get past the tympanic membrane. Therefore, it is essential to exclude a perforated tympanic membrane before using topical aminoglycosides in the ear.
Describe what is meant by osteosclerosis [2]
Describe the pathophysiology [2]
Otosclerosis is a condition where there is remodelling of the small bones in the middle ear, leading to conductive hearing loss
Pathophysiology
* The auditory ossicles are the tiny bones in the middle ear that transmit sound vibrations from the tympanic membrane to the cochlea.
* They are the malleus, incus and stapes.
* The stapes is connected to the oval window (fenestra ovalis) of the cochlea, where it transmits vibrations into the cochlea, which converts them into sensory signals.
In patients with otosclerosis, these tiny bones in the middle are affected by abnormal bone remodelling and formation. This mainly affects the base of the stapes, where it attaches to the oval window, causing stiffening and fixation and preventing it from transmitting sound effectively.
It causes conductive hearing loss.
Describe the typical presentation of otosclerosis
The typical presentation is a patient under 40 years presenting with unilateral or bilateral:
* Hearing loss
* Tinnitus
It tends to affect the hearing of lower-pitched sounds more than higher-pitched sounds. Female speech may be easier to hear than male speech (due to the generally higher pitch). This is the reverse of the pattern seen in presbycusis.
Due to conductive hearing loss with intact sensory hearing, the patient can experience their voice as being loud compared to the environment (due to bone conduction of their voice). This can lead to them talking quietly.
How would Webers and Rinne’s test present with otosclero
Weber’s test is normal if the otosclerosis is bilateral, meaning that when the tuning fork is applied to the centre of the forehead, they will hear the sound equally in both ears. If the otosclerosis is unilateral or affects one ear more than the other, the sound will be louder in the more affected ear.
Rinne’s test will show conductive hearing loss.
- The sound will be easily heard when the tuning fork is applied to the mastoid process (bone conduction).
- When the patient stops being able to hear the sound during bone conduction, and the tuning fork is removed from the mastoid process and held close to the ear canal, they will still not hear the sound (air conduction is worse than bone conduction).
Describe the audiometry results for otosclerosis? [2]
What other investigations would you do? [2]
Audiometry is the initial investigation of choice.
- Otosclerosis will show a conductive hearing loss pattern.
- Bone conduction readings will be normal (between 0 and 20 dB).
- However, air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart.
- Hearing loss tends to be greater at lower frequencies.
Tympanometry will show generally reduced admittance (absorption) of sound. The tympanic membrane is stiff and non-compliant and does not absorb sound, reflecting most of it back.
High-resolution CT scans can detect boney changes associated with otosclerosis, although they are not always required.
Mx for otosclerosis? [3]
The options for management are:
Conservative, with the use of hearing aids
Surgical (stapedectomy or stapedotomy):
* Stapedectomy involves removing the entire stapes bone and replacing it with a prosthesis. The prosthesis attaches to the oval window and hooks around the incus, transmitting the sound from the incus to the cochlea in the same way the stapes normally would.
* Stapedotomy involves removing part of the stapes bone and leaving the base of the stapes (the footplate) attached to the oval window. A small hole is made in the base of the stapes for the prosthesis to enter. A prosthesis is added to transmit sound from the incus to the cochlea.
How do you distinguish otosclerosis from menieres? [1]
Audiometric testing in Meniere’s disease usually reveals low-frequency sensorineural hearing loss initially, which distinguishes it from the conductive or mixed type seen in otosclerosis.
What is quincy? [1]
What is it normally caused by? [1]
Quinsy is the common name for a peritonsillar abscess. Peritonsillar abscess arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils.
- Peritonsillar abscess is a complication of untreated or partially treated tonsillitis, although it can arise without tonsillitis.
Features of quinsy? [+]
Patients present with similar symptoms to tonsillitis:
Sore throat
Painful swallowing
Fever
Neck pain
**Referred ear pain **
Swollen tender lymph nodes
Additional symptoms that can indicate a peritonsillar abscess include:
* Trismus, which refers to when the patient is unable to open their mouth
* Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
* Swelling and erythema in the area beside the tonsils
Mx for quinsy? [+]
Antibiotic therapy:
- Empirical antibiotics are initiated before culture results are available.
- The first-line treatment typically includes a penicillin combined with a beta-lactamase inhibitor.
Analgesia:
- Pain management is crucial due to severe sore throat associated with quinsy. Non-steroidal anti-inflammatory drugs (NSAIDs) or paracetamol can be used for this purpose.
Steroids:
- While not universally agreed upon, some clinicians advocate for the use of steroids to reduce inflammation and potentially expedite recovery.
Surgical Management
- Needle aspiration: This is often the first line surgical intervention, especially if there is significant trismus preventing oral examination.
- Intraoral incision and drainage: This procedure may be performed if needle aspiration fails or if the abscess is large.
* Quinsy tonsillectomy: This is a more radical approach and is usually reserved for recurrent cases or if other interventions fail. The procedure involves removal of the tonsil along with the abscess.
Quinsy is usually due to a bacterial infection. The most common organism is [], but it is also commonly caused by [2]
Quinsy is usually due to a bacterial infection.
- The most common organism is streptococcus pyogenes (group A strep), but it is also commonly caused by staphylococcus aureus and haemophilus influenzae.
Describe what is meant by a pharyngeal pouch [+]
A pharyngeal pouch is formed when pharyngeal mucosa herniates through a weak area of the posterior pharyngeal wall
- This area is known as the Killian’s dehiscence and is located between the cricopharyngeus and thyropharyngeus muscles
- Over time, excessive pressure within the lower pharynx, caused by swallowing, can result in ballooning of the pharyngeal mucosa through Killian’s dissidence, forming a pharyngeal pouch
A pharyngeal pouch may be asymptomatic, however, patients typically present with: [+]
Dysphagia (85%)
Regurgitation of food (40%)
Cough and aspiration (35%)
Halitosis
Neck swelling
Gurgling sound when swallowing
Weight loss due to eating difficulties
Describe what is meant by Boyce’s sign [1]
A neck swelling which gurgles on palpation (Boyce’s sign)
Ix for pharyngeal pouch? [2]
Patients presenting with dysphagia are referred for an oesophagoduodenoscopy (OGD) as an initial investigation
A barium swallow test is the gold standard investigation to confirm the presence of a pharyngeal pouch
- The barium will pool in the pharyngeal pouch and not move between films, as a food bolus would
Mx for pharyngeal pouch? [2]
The mainstay management of a pharyngeal pouch is surgery, however, in patients with **mild symptoms **or those unable to have surgery, a ‘watch-and-wait’ approach may be more appropriate.
Endoscopic techniques using rigid endoscopes are now preferred to open surgery as they are quicker, less invasive, more cost-effective and tend to have a shorter recovery time. During endoscopic surgery, the pharyngeal pouch may be treated using a diathermy laser or stapling technique
- open surgery should only be performed after 2 failed endoscopic surgeries, or if patients have any contraindications to endoscopic surgery, such as poor mobility of the cervical spine due to osteoarthritis
Possible complicationsof pharyngeal pouch? [2]
Aspiration pneumonia
Up to 12% of patients with a pharyngeal pouch may develop an aspiration pneumonia
Small increased risk of squamous cell carcinoma within the pouch
