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Otorhinolaryngology Flashcards

Flashcards for the Ear, Nose and Throat Surgery rotation at the University of Stellenbosch for undergraduate MB.ChB (Bachelors of Medicine and Bachelors of Surgery) students. Note that decks are always a work in progress and are liable to factual, grammatical and spelling errors. (306 cards)

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1
Q

Parts of the Ear

A
  1. External ear
  2. Middle ear
  3. Inner ear
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2
Q

Parts of External Ear

A
  1. Pinna
  2. External Auditory Meatus
  3. Tympanic Membrane
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3
Q

Tissues of the External Ear

A
  • skin (including hair, wax)
  • cartilege (perichondrium)
  • bone
  • membrane
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4
Q

Functions of the External Ear

A
  1. Seals off middle ear: protection
  2. Desquamation
  3. Migration
  4. Expulsion
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5
Q

Broad Parts of the Middle Ear

A
  1. Middle Ear per se
  2. Eustachian Tubes
  3. Mastoid Air Cell System
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6
Q

Contents of the Middle Ear

A
  • Tympanic membrane
  • Ossicles
  • Oval window
  • Round window
  • Facial nerve
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7
Q

Components that aerate the middle ear

A

a. Eustachian tubes

b. Mastoid air cell reservoir

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8
Q

Components that amplify sound in the middle ear

A

a. Tympanic membrane

b. Ossicles

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9
Q

Parts of the Inner Ear

A
  1. Cochlea
  2. Vestibule
  3. Vestibulocochlear nerve
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10
Q

Compartments of the Cochlea

A
  • scala tympani
  • scala media
  • scala vestibuli
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11
Q

Types of Tuning Fork Tests

A
  1. Rinne
  2. Weber
    [3. Loock - starting off by asking patient to listen on each side]
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12
Q

Subjective Audiometry Tests

A

Pure tone audiograms

Speech audiometry

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13
Q

Objective Audiometry Tests

A

Impedance Audiometry/ Tympanometry
Evoked Response Audiometry
Cochlear Echo Measurement

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14
Q

Normal human hearing range (dB)

A

0-130

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15
Q

Populations where ERA is useful

A
  1. Babies
  2. Handicapped
  3. Malingerers
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16
Q

Frequency at which noise-induced hearing loss starts

A

4000Hz

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17
Q

Parts of the Vestibule

A
  1. Utricle
  2. Saccule
  3. Semicircular canals
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18
Q

Vestibular tests

A
  • positional test
  • fistula test
  • caloric test
  • rotation tests
  • electronystagmography
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19
Q

Layers of the tympanic membrane

A
  1. skin
  2. fibrous tissue
  3. mucosa
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20
Q

Name the nasal turbinates and what they drain

A 
SUPERIOR TURBINATE:
posterior ethmoid sinus
sphenoid sinus
MIDDLE TURBINATE:
anterior and middle ethmoid sinus
frontal sinus
maxillary sinus
INFERIOR TURBINATE:
nasolacrimal duct
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21
Q

Briefly explain the arterial supply of the nose

A

a. trigeminal branches of external and internal carotid arteries
b. anterior and posterior ethmoidal branches supply structures superior to middle turbinate
c. sphenopalatine arteries, palatine arteries and labial arteries supply other structures

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22
Q

Briefly explain the venous drainage of the nose

A

a. facial veins and ophthalmic veins

b. drain through the cavernous sinus

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23
Q

Briefly explain the innervation of the nose

A
  1. sensory: maxillary division of CNV (Trigeminal Nerve)
  2. secretory: Vidian nerve
  3. vessels: sympathetic constrict, parasympathetic dilate
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24
Q

Functions of the Nose

A
  1. Filtration of air and protection
  2. Humidification and warming of air
  3. Olfaction
  4. Vocal resonance
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25
Name the paranasal sinuses
frontal sinus maxillary sinus ethmoid sinus sphenoid sinus
26
Anatomical relations to the maxillary sinus
orbit teeth cheek nasal cavity
27
Important boundaries of the frontal sinus
orbit | anterior cranial fossa
28
Important adjacent structures to sphenoid sinus
internal carotid artery optic nerve cavernous sinus
29
Contents of the cavernous sinus
oculomotor nerve trochlear nerve abducens nerve 1st and 2nd divisions of trigeminal nerve
30
Possible functions of paranasal sinuses
1. aid vocal resonance 2. reduce skull weight 3. protect eye from trauma 4. protect vital intracranial structures
31
Parts of the Pharynx
Nasopharynx Oropharynx Hypopharynx
32
Functions of the larynx
protect tracheobronchial tree | voice production
33
Innervation of the larynx
1. Recurrent Laryngeal Nerve - laryngeal muscles except cricothyroid - glottis - subglottis 2. Superior Laryngeal Nerve - cricothyroid muscle - supraglottis
34
Predisposing factors for otitis externa
a. environmental (heat, humidity, swimming) b. trauma (cotton buds, fingernails) c. physical (narrow canals, eczematous skin)
35
Clinical features of otitis externa
``` otalgia pruritis erythema of skin oedema of skin/canal debris in canal hearing loss can occur due to oedema ```
36
Most important aspect of managing otitis externa
Aural toilet
37
Common pathogens for otitis externa
- staph pyogenes - pseudomonas pyocyanea - diphtheroids - proteus vulgaris - e. coli - aspergillus niger - candida albicans
38
define otitis externa
inflammation of the skin of the external auditory meatus
39
constituents of quadriderm cream
Betamethasone Gentamicin Clioquinol Tolnaflate
40
Good treatment for very mild otitis externa
1. Aural toilet 2. Topical drops: acetic acid weak povidone-iodine solution ichthammol glycerin thiomersal tincture
41
Appearance of fungal otitis externa
"soggy newspaper"
42
Define localised otitis externa
furuncle of a hair-bearing area of the external auditory meatus
43
Define malignant otitis externa
otitis externa that progresses to an osteomyelitis
44
Common sites of malignant OE spread
tympanic plate skull base petrous bone
45
Main pathogen of malignant OE
Pseudomonas Aeruginosa
46
Complications of Malignant OE
1. CN 7-12 palsies 2. meningitis 3. sigmoid sinus thrombosis 4. brain abscess 5. death
47
Clinical features of malignant OE
1. constant deep otalgia 2. granulation tissue deep in the EAM 3. failure to resolve on conventional treatment
48
Management of malignant OE
1. hospitalise 2. IV antibiotics - prolonged - aminoglycosides - B-lactams - fluoroquinolones 3. surgery is debated and should only take place in the form of debridement if at all
49
Define Acute Otitis Media
infection of the mucous membrane of the entire middle-ear cleft
50
Risk factors for AOM
- recent URTI - Eustachian tube dysfunction - 2nd hand smoke inhalation - bottle feeding - immunosuppression - low socioeconomic status - allergies - craniofacial abnormalities - neuromuscular abnormalities
51
Common pathogens of AOM
``` BACTERIAL - Strep Pneumoniae - H. Influenzae - Moraxella Catarrhalis VIRAL - RSV - Influenza - Rhinovirus ```
52
Complications of AOM
Mastoiditis | CN VII palsy
53
Complications of Mastoiditis
``` intracranial abscess meningitis labyrinthitis sigmoid sinus thrombosis petrositis ```
54
Symptoms of AOM
1. otalgia 2. fever 3. irritability/ poor feeding 4. hearing loss
55
Signs of the TM in AOM
1. loss of lustre/ decreased light reflex 2. redness/ hypervascularity 3. bulging/ fullness 4. reduced mobility 5. perforation 6. mucoid discharge (only if perforated)
56
Treatment: AOM
1. Antibiotics 2. Analgesia 3. Nasal decongestants 4. Follow-up
57
Antibiotics in AOM
co-amoxiclav | cefuroxime
58
Causes of non-resolving AOM
1. sinusitis 2. inefficient antibiotic choice 3. low grade mastoid air cell infection
59
Causes of recurrent AOM
IgA deficiency | hypogammaglobulinaemia
60
Define acute mastoiditis
inflammation of mastoid air cells, usually follows AOM
61
Symptoms: Acute Mastoiditis
otalgia | acutely ill patient
62
Signs: Acute Mastoiditis
1. pyrexia 2. auricle protrusion 3. acute hearing loss 4. pinna displacement down and out 5. otorrhoea 6. leukocytosis
63
Treatment: Acute Mastoiditis
1. IV antibiotics 2. Analgesia 3. Antipyretcis 4. Mastoidectomy
64
Classify Chronic Otitis Media
A. Chronic Otitis Media with Effusion (OME) B. Chronic Suppurative Otitis Media (CSOM) - mucosal type - bony type (with cholesteatoma)
65
Define OME
fluid collection behind an in tact TM, usually in children
66
Causes: OME
1. post AOM 2. Eustachian abnormality/dysfunction 3. idiopathic
67
Symptoms: OME
1. may have none 2. moderate hearing loss picked up by parents 3. speech/language difficulties 4. aural fullness
68
Signs: OME
1. may have none 2. bulging or retracted TM 3. discoloured TM 4. fluid/ air-fluid level visualised 5. pneumatic otoscopy changes 6. type B tympanogram
69
Management: OME
1. Watchful waiting 2. Steroids (debatable) 3. Behavioural changes (parents stop smoking etc) 4. Surgery e.g. grommets if persists >3 months
70
Causes: CSOM
1. AOM with perforation 2. TB 3. Cholesteatoma
71
Common organisms: CSOM
Pseudomonas Aeruginosa Staph Aureus Anaerobes Fungi
72
Symptoms: CSOM
1. otorrhoea 2. hearing loss 3. painless
73
Signs: CSOM without cholesteatoma
1. central perforation | 2. wet purulent discharge
74
Signs: CSOM with cholesteatoma
1. abnormal keratinising squamous epithelium in middle ear 2. bony destruction 3. marked hearing loss 4. granulations 5. sentinel polyps
75
Treatment: CSOM without cholesteatoma
1. keep ear dry 2. syringe/dry mopping 3. antibiotic drops 4. steroid drops 5. myringoplasty/tympanoplasty 6. hearing aid if needed after resolution
76
Treatment: CSOM with cholesteatoma
1. keep ear dry 2. aural/suction toilet 3. mastoid surgery
77
Diagnoses to consider in runny ear
1. TB 2. foreign body 3. neoplasia
78
Features of Atopic Syndrome
1. infantile eczema 2. allergic asthma 3. nasal and conjunctival allergy
79
Signs of Allergic Rhinitis
1. oedematous nasal mucosa 2. pale/violet nasal mucosa 3. copious clear mucous in nose 4. "allergic salute"
80
History of Allergic Rhinitis
1. seasonal/perennial - association with exposure 2. family history of atopy 3. rhinorrhoea 4. nasal irritation and sneezing 5. itchy/watery eyes 6. previous dermatitis/eczema 7. symptoms of nasal obstruction e.g. hyposmia
81
Nasal complications of Allergic Rhinitis
nasal septal deviation turbinate hypertrophy sinus disease
82
Management of Allergic Rhinitis
1. Avoidance 2. Oral/intranasal antihistamines 3. Topical steroid nasal sprays 4. Depot IM steroids (only when symptoms interfere with special events) 5. Topical anticholinergics 6. Sodium chromoglycate 7. Desensitisation 8. Surgery for turbinate hypertrophy
83
Define Sinusitis
inflammation of the mucosa of the paranasal sinuses
84
Aetiology of Sinusitis
a. rhinogenic b. dental c. traumatic d. neoplastic
85
Common pathogens of acute sinusitis
strep. pneumoniae h. influenzae moraxella catarrhalis staph pyogenes anaerobes (in dental origins)
86
Signs of acute sinusitis
1. pyrexia 2. tenderness over sinus/es 3. mucopus in nose/nasopharynx 4. imaging: opacity or fluid-level in sinus
87
Treatment of acute sinusitis
1. bed rest 2. systemic antibiotics e.g. augmentin 3. nasal decongestants e.g. illiadin drops 4. analgesia 5. steam/menthol inhalation 6. antral wash-outs (only in certain cases)
88
Associations with chronic sinusitis
- polyposis - allergy - immune deficits - Wegener's granulomatosis - Churg-Strauss - sarcoidosis - cystic fibrosis
89
Common pathogens: chronic sinusitis
staph aureus | strep viridans
90
Treatment: chronic sinusitis
1. prevent acute episodes 2. nasal douche 3. nasal steroids 4. systemic steroids (only if obstructive polyps) 5. antibiotics (short course) 6. surgery (if medical mx fails)
91
DDX for sinusitis
``` viral rhinitis allergic rhinitis migraine TMJ pain dental pathology sinus tumour ```
92
Diagnosis of sinusitis is clinical. What can you use as adjuncts?
1. endoscopy 2. bloods 3. microscopy 4. imaging
93
Complications of Sinusitis
- meningitis - dental abscess - intracranial abscess - osteomyelitis of the frontal bone (Pott's puffy tumour) - cavernous sinus thrombosis - orbital cellulitis
94
Indications for sinus surgery
failure of medical treatment >6 weeks obstructed osteomiatal complex large obstructive polyps
95
Surgical options for sinus surgery
functional endoscopic sinus surgery | open sinus surgery
96
Management: complicated sinusitis
1. drain complication 2. address problematic sinus 3. maxillary sinus washout 4. drains in sinus/es and irrigate til clear 5. broad spectrum antibiotics, adjust after MCS 6. nasal decongestants 7. long-term intranasal steroids
97
Principles for safe use of systemic steroid in allergic rhinitis
1. short term (<2weeks) 2. not more than every fourth month 3. not instead of, but in addition to other medication 4. not for: children, pregnant women, insulin dependent DM
98
Orbital complications of acute sinusitis
1. preseptal oedema 2. orbital cellulitis 3. subperiostial abscess 4. orbital abscess 5. cavernous sinus thrombosis
99
Aetiology: Sore throat in children
``` acute pharyngitis acute tonsilitis infectious mononucleosis blood dyscrasias diphtheria ```
100
Aetiology: Acute sore throat in adults
tonsillitis pharyngitis quinsy candidiasis
101
Aetiology: Chronic sore throat in adults
tonsillitis pharyngitis GORD eagle syndrome
102
Symptoms: tonsillitis
``` sore throat dysphagia otalgia headache malaise ```
103
Signs: tonsillitis
1. pyrexia 2. tonsils enlarged and hyperaemic 3. inflamed pharyngeal mucosa 4. hallitosis 5. tender cervical lymphadenopathy
104
Treatment: Tonsillitis
1. Bed rest 2. Analgesia, Antipyretics 3. Hydration 4. Antibiotics - penicillin 5. Surgery when earned
105
Complications: Tonsillitis
1. acute otitis media 2. peritonsillar abscess 3. pulmonary infection 4. IgA nephropathy 5. Acute rheumatism
106
Chronic Tonsillitis symptoms and signs
malaise halitosis sore throat small tonsils
107
Chronic tonsillitis treatment
surgery | long-term antibiotics
108
Symptoms: Quinsy
severe unilateral sore throat dysphagia/odynophagia otalgia
109
Signs: Quinsy
1. deviating tonsil and uvula 2. trismus 3. cervical lymphadenopathy 4. halitosis
110
Treatment: Quinsy
1. Aspirate 2. Penicillin IVI 3. Fluids 4. Surgery if earned
111
Causes: acute pharyngitis
viral | candidiasis
112
Causes: chronic pharyngitis
1. post nasal drip 2. tobacco smoke 3. gastro-oesophageal reflux disease (GORD) 4. mouth breathing 5. chronic sinusitis 6. industrial fumes 7. antiseptic throat lozenges
113
Important to exclude with sore throat
1. post-nasal drip 2. reflux disease 3. tedonitis 4. sinister causes
114
What is Eagle Syndrome
stylohyoid ligament calcification
115
Formal name of croup
Laryngotracheobronchitis
116
Causes of croup
Parainfluenza virus Respiratory syncytial virus Bacterial superinfection
117
Clinical features: croup
1. pyrexia 2. cough: painful, barking 3. gross mucosal oedema of lower resp tract 4. stridor: inspiratory, later biphasic 5. later complete airway obstruction
118
Management: Croup
1. admit 2. humidifier 3. oxygen 4. intubate if indicated 5. tracheostomy if indicated 6. regular saline suction 7. physiotherapy
119
Difference between croup and epiglottitis
1. croup has no drooling | 2. croup does not have constant forward leaning
120
Stridor Grading Scale
I. Inspiratory stridor II. Expiratory stridor III. Inspiratory and Expiratory stridor with pulsus paradoxus IV. Respiratory arrest
121
Causes: Stridor in adults
1. malignancy 2. laryngeal trauma 3. acute laryngitis 4. supra/epiglottitis
122
Causes: stridor in children
1. croup 2. epiglottitis 3. foreign body 4. trauma 5. retropharyngeal abscess 6. laryngeal papillomata
123
Benign Laryngeal Tumours
1. Haemangiomata of childhood 2. Respiratory Papillomatosis 3. Benign cartilaginous tumours 4. Granular cell myoblastoma 5. Paragangliomas
124
Malignant Laryngeal Tumours
1. SCC 2. Adenocarcinoma 3. Adenoid cyst carcinoma 4. Sarcoma 5. Lymphoma 6. Verrucous carcinoma
125
Risk factors: laryngeal carcinoma
tobacco smoking | heavy alcohol use
126
T-grading of larynx carcinoma
``` T1S: Carcinoma in Situ T1: Carcinoma in on region T2: carcinoma in two regions, but with mobile vocal cords T3: fixation of vocal cords T4: carcinoma beyond the larynx ```
127
Anatomical spread of laryngeal carcinoma
thyroid tongue hypopharynx
128
Types of Laryngeal Carcinom
1. Carcinoma in Situ 2. Supraglottic Laryngeal Carcinoma 3. Glottic Laryngeal Carcinoma 4. Subglottic Laryngeal Carcinoma 5. Transglottic Laryngeal Carcinom
129
Treatment option for laryngeal carcinoma and when you would use them
A. Excision/Laser of affected surfaces: Carcinoma in Situ B. Supraglottic Laryngectomy: supraglottic laryngeal carcinoma with no nodal involvement or spread, this conserves the voice C. Radiotherapy: all laryngeal carcinomas with nodal and/or neck involvement D. Total laryngectomy: residual or recurrent disease after radiotherapy
130
Why do UMN lesions of CNVII usually spare the forehead, while LMN lesions do not?
Upper Motor Neuron innvervation of the forehead is bilateral. The pons is supplied by the contralateral hemisphere, but ipsilateral fibres also supply the portion of the nucleus which innervates the forehead.
131
Components of the Facial Nerve
1. Motor 2. Sensory (N. Intermedius) 3. Secretomotor (parasympathetic)
132
Structures found in the internal auditory canal
1. CNVII 2. Vestibulocochlear nerve 3. Nervus Intermedius 4. Internal auditory artery and vein
133
Acquired Causes of Facial Palsy
A. Malignancies B. Infective C. Trauma D. Miscellaneous
134
Malignancies causing facial palsy
acoustic neuroma brain stem tumour parotid tumours schwannoma
135
Infective causes of facial palsy
Herpes Zoster Oticus | Bell's Palsy (query HSV)
136
Traumatic causes of facial palsy
Base of skull fracture Penetrating injury Surgery
137
Miscellaneous causes of facial palsy
Sarcoidosis Polyneuritis CVA
138
Congenital Causes of Facial Palsy
A. Traumatic (difficult delivery, forceps, big infant) B. Inherited (myotonic dystrophy) C. Developmental (Moebius Syndrom, Charge Syndrome)
139
Potential features of CNVII palsy
1. History of otalgia, otalgia, injury, surgery 2. Tissue masses in region of parotid 3. Middle ear mass 4. Taste alteration 5. Dry eyes 6. Facial weakness/assymetry 7. Hyperacusis
140
Examining CNVII
1. Inspection (forehead spared?) 2. Schirmer test (lacrimation) 3. Audiometric evaluation (stapedius reflex) 4. Taste testing (chorda tympani) 5. Electrodiagnosis
141
Facial branches of CNVII
1. Temporal 2. Zygomatic 3. Buccal 4. Mandibular 5. Cervical
142
Signs that CNVII palsy may be due to malignant cause
1. slowly evolving paresis 2. facial twitching 3. middle ear mass 4. conductive deafness (as opposed to sensorineural)
143
Management: Bell's Palsy
1. Exclude other causes of palsy 2. Reassure and educate patient 3. Eye protection if necessary 4. Systemic steroids 5. Acyclovir (debated) 6. Re-evaluate after five days, continue steroids if necessary 7. ENT/opthalmology referral, depending
144
Systems used to grade palsy
A. House-Brackmann Score | B. Sunderland Score
145
Methods of Eye-Protection in Palsies
1. Eyedrops/Ointments 2. Spectacles with side protector 3. Insertion of gold weights in upper lid (NOT in South Africa!) 4. Temporary suturing of eyelids 5. Canthoplasty 6. Lower lid augmentation
146
Congenital causes: nasal obstruction
1. choanal atresia 2. repaired cleft palata 3. tumours
147
Congenital tumours that may cause nasal obstruction
meningo-encephalocoele | nasal glioma
148
Acquired causes: nasal obstruction without discharge
A. Trauma B. Polyps C. Neoplasia D. Post Nasal Masses
149
Traumatic conditions that cause nasal obstruction
septal deviation | septal haematoma
150
Neoplasia that cause nasal obstruction
inverted papilloma juvenile angiofibroma malignancies
151
Post nasal space masses that cause nasal obstruction
adenoids carcinoma/lymphoma angiofibroma
152
Acquired causes: nasal obstruction with discharge
``` viral bacterial chemical allergic foreign body ```
153
Features of nasal foreign body
child usually calm unilateral nasal discharge foul smelling discharge skin excoriation of upper lip, nasal vestibulum
154
Define: rhinolith
large foreign body in the nose of an adult, composed of calcium and magnesium, forming around a nidus of gauze or dried blood
155
How to differentiate a nasal turbinate from a polyp
1. a polyp is mobile 2. a polyp is paler 3. a polyp has reduced sensation 4. polyp bleeds less
156
Causes of nasal polyps
infection idiopathic neoplastic other disease
157
Diseases with an association for polyps
nasal allergy asthma cystic fibrosis bronchiectasis
158
Management of nasal polyps
1. steroids (intranasal or systemic, usually for small polyps) 2. pernasal removal 3. ethmoidectomy (severe, recurring) 4. treat underlying allergies/sinusitis/asthma 5. post-op steroids to reduce recurrence
159
Clinical features of septal deviation
- nasal obstruction, usually unilateral - crusting or discharge - epistaxis - facial pain - compensatory hypertrophy of inferior turbinate - external deformity
160
Management: septal deviation
A. watchful waiting B. submucous resection C. Septoplasty
161
Management: septal haematoma
1. Emergency when acute 2. Drainage: aspiration, or incision and evacuation 3. Nasal packing 4. Antibiotics
162
Types of Hearing Loss
Conductive Sensorineural Mixed
163
Important History points in hearing loss
1. Onset and progression 2. Pain/discharge 3. Tinnitus 4. Imbalance 5. Noise exposure 6. Drug history 7. Chronic disease 8. Recent URTIs 9. Family history
164
Causes: conductive hearing loss in adults
``` A. External Auditory Canal - wax - exostoses B. Tympanic Membrane - perforation - chronic supurative otitis media C. Middle Ear - otitis media with effusion - ostosclerosis ```
165
Causes: sensorineural hearing loss in adults
i. age ii. noise iii. ototoxicity iv. syphilis v. acoustic neuroma vi. vascular vii. labyrinthitis viii. perilymph fistula ix. genetic
166
Causes: wax impaction
narrow canal wax consistency elderly earbud use
167
What are exostoses?
bony projections into the external auditory canal, found commonly in surfers and swimmers
168
Complications: exostoses
obstruction hearing loss infections
169
Causes: otitis media with effusion in adults
U/LRTI chronic sinusitis nasopharyngeal carcinoma
170
Management: otosclerosis
A. hearing aid | B. stapedectomy
171
Characteristics: Presbyacusis
1. loss of high frequency hearing 2. decreased speech discrimination 3. reduced dynamic range
172
Management: noise-induced hearing loss
1. avoid further noise exposure 2. hearing aids 3. compensation from employer
173
Causes: sudden-onset sensorineural hearing loss
1. vascular 2. infective 3. trauma 4. neoplastic 5. ototoxic 6. immunologic
174
Define sudden hearing loss
Loss of 30dB or more in 3 adjacent frequencies over 72 hours or less
175
Treatment of non-traumatic, non-malignant sudden sensorineural hearing loss
1. Vasodilators e.g. Betahistine | 2. Prednisone
176
Ototoxic drugs
``` Aminoglycosides Streptomycin Cytotoxic drugs Salicylates Quinine ```
177
Which ototoxic drug damage is reversible
Salicylates | Quinine
178
Suspect hearing loss in these children:
1. Birth factors 2. Failed distraction test 3. Parental suspicion of HL 4. Abnormal speech/language development 5. Parental or sibling hearing loss
179
Birth factors predisposing to HL
1. prematurity 2. very low birth weight 3. intraventricular haemorrhage 4. neonatal jaundice 5. aminoglycoside administration
180
Types of congenital conductive HL
atresia/aplasia of EAM | ossicular abnormalities
181
Types of congenital sensorineural HL
``` A. Hereditary B. Intrauterine events - infections - ototoxic drugs - metabolic disease - perinatal events ```
182
Symptoms associated with otalgia
1. hearing loss 2. otorrhoea 3. systemic symptoms 4. dermatological changes 5. odynophagia/dysphagia
183
Causes of referred otalgia
1. TMJ 2. parotid 3. teeth/dentures 4. tongue 5. oropharynx 6. nose/ sinuses 7. larynx/ hypopharynx 8. oesophagus 9. C-spine
184
Contraindications to syringing an ear
1. base of skull fracture 2. organic foreign body 3. traumatic perforation 4. dry perforation
185
Causes: Otalgia of the external ear
1. otitis externa 2. Ramsay-Hunt syndrome 3. Meatal furunculosis 4. cellulitis/erysipelas 5. myringitis bullosa 6. perichondritis 7. neoplasia
186
Treatment: Myringitis Bullosa
1. analgesia 2. topical steroids 3. antibiotic drops
187
Treatment: EAM furunculosis
incision and drainage | antibiotics
188
Treatment: pinna perichondritis
1. local astringents (magnesium sulphate) | 2. systemic antibiotics
189
Classify: Neoplasia of the Ear
``` A. Auricular - squamous cell carcinoma - basal cell carcinoma - malignant melanoma - keratoacanthoma B. Ear canal - squamous cell carcinoma - ceruminoma C. Middle Ear - squamous cell carcinoma D. Glomus tumours ```
190
Define ceruminoma
term for all benign and malignant tumours of the ceruminous glands of the external auditory meatus, the most common being adenoid cystic carcinoma
191
Treatment: Auricular neoplasm
a. wedge excision b. total auriculectomy c. nodal and neck dissection
192
Treatment: SCC of the EAM
1. mastoidectomy 2. removal of parotid gland 3. removal of TMJ 4. post-op radiotherapy
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Treatment: Ceruminoma
1. wide excision | 2. post-operative radiotherapy
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Treatment: SCC of the middle ear
1. radical mastoidectomy 2. petrosectomy 3. post-op radiotherapy
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Complications: petrosectomy
CSF leak meningitis facial paralysis damage to lower cranial nerves
196
Define dysphonia
Alteration in the quality of the voice as a result of turbulent airflow over the larynx and irregularities of the vocal cord's vibrations
197
Classification: Dysphonia
``` A. Congenital B. Inflammatory C. Trauma D. Neoplasia E. Neurological F. Systemic G. Non-organic ```
198
Congenital causes of dysphonia
laryngomalacia nerve palsies haemangioma laryngocoele
199
Inflammatory causes of dysphonia
acute laryngitis chronic laryngitis reflux disease
200
Systemic causes of dysphonia
rheumatic arthritis hypothyroidism angioneurotic oedema
201
Neurological causes of dysphonia
1. myasthenia gravis 2. cancer of the lung/oesophagus/breast 3. post-thyroidectomy 4. spasmodic dysphonia 5. aortic arch aneurysm 6. cortical/subcortical lesions 7. glossopharyngeus 8. vagus 9. hypoglossal
202
Traumatic causes of dysphonia
``` iatrogenic (surgery, intubation) inhalation (chemicals, fumes) blunt trauma penetrating trauma foreign body aspiration ```
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Non-organic causes of dysphonia
``` A. habitual dysphonia - acute non-infective laryngitis - chronic non-infective laryngitis - vocal cord nodules - vocal cord oedema/polyps - contact ulcers B. psychogenic dysphonia - musculoskeletal tension - ventricular dysphonia - conversion disorder - mutational falsetto ```
204
Management: Organic dysphonia
1. treat underlying cause 2. watchful waiting 3. medialisation procedures
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Medialisation techniques
1. injection of silicone/collagen/fat | 2. placement of tissue
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Always biopsy these dysphonic features:
polyps unilateral ulcers non-healing/recurring ulcers hyperkeratosis
207
Symptoms associated with noisy breathing
1. signs of respiratory distress 2. cough 3. dysphonia 4. poor feeding (especially in babies)
208
define stertor
rough, unmusical sound caused by vibration in the tissues of the nasopharynx, oropharynx and soft palate
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define stridor
musical sound of obstruction in the larynx, trachea or bronchi
210
Sites and causes of respiratory obstruction
``` A. Nose/Nasopharynx - nasal polyps - severely deviated septum - adenoids B. Oropharynx/Velopharynx - macroglossia - soft palate - tonsils C. Laryngotrachea - tumours/ cysts - inflammation ```
211
Causes: noisy breathing in adults
1. malignancy 2. largyngeal trauma 3. acute laryngitis 4. supraglottitis/epiglottitis
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Causes: noisy breathing in children
1. laryngotracheobronchitis 2. epiglottitis 3. foreign body 4. trauma 5. retropharyngeal abscess 6. laryngeal papillomata
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Causes: noisy breathing in neonates
1. laryngomalacia 2. congenital cysts 3. webs 4. subglottic stenosis 5. vocal cord paralysis
214
define apnoea
cessation of airflow at the nostrils for 10 seconds or longer
215
define sleep apnoea syndrome
five or more episodes of apnoea in an hour of sleep
216
Sleep apnoea types
1. central 2. obstructive 3. mixed
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Risk factors: Obstructive Sleep Apnoea Syndrome (OSAS)
``` obesity older males anatomical facial abnormalities family history sedative/alcohol use smoking ```
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Clinical features: OSAS
``` sleep fragmentation daytime fatigue/somnolence morning headaches poor job performance depression and family discord ```
219
Complications: OSAS
``` A. Cardiac - systemic hypertension - pulmonary hypertension - cor pulmonale - polycythemia - cardiac dysrhythmias B. CNS - hypersomnolence - fatigue - reduced concentration and memory C. Other (in children) - failure to thrive - Sudden Infant Death Syndrome ```
220
Special investigations: OSAS
1. polysomnography 2. lateral X-ray of the neck 3. CXR 4. ECG 5. nasal endoscopy 6. elective intubation
221
Treatment: OSAS
``` A. Conservative - weight loss B. Medical - nasopharyngeal airway - continuous positive airway pressure C. Surgical - adenotonsillectomy - uvulopharyngopalatoplasty - tracheostomy ```
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Signs: Epiglottitis
1. pyrexia 2. severe sore throat 3. stridor 4. dribbling 5. breathing with raised chin and open mouth 6. cherry red epiglottis
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Treatment: Epiglottitis
1. IVI antibiotics | 2. intubation
224
Define tinnitus
the perception of sound in the absence of external stimuli or hallucinations
225
Causes: objective tinnitus
1. AV malformations 2. Glomus jugulare 3. Glomus tympanum 4. Atherosclerosis 5. Cardiac murmurs 6. Persistent stapedial artery 7. Increased cardiac output 8. Palatal myoclonus 9. Patulous Eustachian tube 10. Carotid body tumour 11. TMJ pathology
226
Causes: subjective tinnitus
1. Presbyacusis 2. Noise exposure 3. Meniere Disease 4. Otosclerosis 5. Head trauma 6. Acoustic neuroma 7. Drugs 8. Middle ear effusion 9. Depression 10. Meningitis 11. Syphilis
227
Places to listen for bruits when patient has tinnitus
``` Orbit Mastoid process Skull Neck Heart ```
228
Drugs causing tinnitus
``` Aminoglycosides Antidepressants Aspirin Quinine Loop diuretics Cytotoxics ```
229
Management of Tinnitus
1. Avoid dietary stimulants 2. Smoking cessation 3. Avoid drugs causing tinnitus 4. Reassurance 5. White noise machine 6. Hearing aids 7. Tinnitus retraining therapy 8. Cochlear implants 9. Surgery for vascular causes
230
Classification: Head, Neck and Facial Pain
``` A. Rhinological B. Dental C. Vascular D. Tension-Type E. Neurological F. Tumours G. Atypical Facial Pain ```
231
Important points on history of headaches
1. Site and radiation 2. Duration 3. Character 4. What relieves the pain 5. Effect on quality of life
232
Features: pain due to TMJ dysfunction
1. periauricular or deep otalgia 2. unilateral pain 3. pain worsens when chewing 4. crepitus felt over TMJ 5. pain ellicited over TMJ in palpation
233
Treatment: pain due to TMJ dysfunction
1. correct bite | 2. muscle relaxants
234
Features: Migraine
1. visual disturbance (scotoma, photophobia) 2. pain: throbbing, unilateral 3. nausea 4. triggers are usually identifiable
235
Treatment: Migraine
1. avoid triggers 2. headache diary 3. NSAIDs for acute 4. anti-emetics for acute 5. triptans for acute 6. prophylaxis: Beta-blockers
236
Treatment: post-herpetic neuralgia
1. tricyclic antidepressants | 2. carbamazepine
237
Features: tension-type headache
1. duration: hours to days 2. pain: "band around head" 3. pain present on waking 4. pain not worse with activity 5. no or little interference with quality of life 6. hyperaesthesia of skin of forehead
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Treatment: Tension-type headaches
1. lifestyle changes | 2. amitryptyline 10-20mg nocte for six weeks
239
Features: cluster headaches
1. pain unilateral, forehead and eye 2. pain very severe and debilitating 3. lacrimation and redness of eye 4. rhinorrhoea and nasal obstruction 5. pain wakes patient 6. episodes occur in clusters
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Treatment: cluster headaches
1. avoid alcohol during the cluster period | 2. triptans
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Features: atypical facial pain
1. diagnosis of exclusion 2. pain: severe and generalised 3. multiple trigger points 4. history of depression
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Treatment: atypical facial pain
1. amitryptyline | 2. psychiatry/psychology referral
243
Define otorrhoea
aural discharge
244
Causes of Otorrhoea
``` Acute Otitis Externa Chronic Otitis Externa Furunculosis Eczema of EAM Acute otitis media CSOM with cholesteatoma CSOM without cholesteatoma Discharging mastoid cavities Fracture of Temporal Bone ```
245
Types of Otorrhoea and what causes them
``` WATERY: - CSF - eczema of EAM BLOODY: - Trauma PURULENT: - acute otitis externa - furunculosis MUCOPURULENT: - acute otitis media - neoplasia of the ear FOUL-SMELLING - CSOM with cholesteatoma ```
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Causes: persistently discharging mastoid cavities (after mastoid surgery e.g. for CSOM with cholesteatoma)
1. small external opening 2. infection 3. residual cholesteatoma 4. allergy to topical drops 5. high posterior canal wall 6. neoplasia
247
Define vertigo
The illusion of rotary movement, which is worsened by closing the eyes or being in the dark
248
Important history question in patient with balance disorder
1. details of first episode 2. onset and duration 3. associated hearing loss or tinnitus 4. relation to activities 5. effect of darkness 6. co-morbidities 7. medication history 8. alcohol use 9. anxiety
249
Otological causes of balance disorders
1. middle ear disease 2. trauma (perilymph fistula) 3. BPPV 4. Meniere's disease 5. labyrinthitis 6. otosclerosis 7. syphilis 8. ototoxic drugs
250
Non-otological causes of balance disorders
``` A. CNS disease B. CVS factors C. cervical spondylosis D. ageing E. psychogenic ```
251
Features: Benign Paroxysmal Positional Vertigo
1. episodic vertigo 2. positional association 3. may have had recent URTI or trauma 4. lasts seconds to minutes 5. positive Dix Hallpike manoevre
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Features: Labyrinthitis
1. history of otitis media or meningitis 2. acute onset vertigo 3. nystagmus 4. hearing loss
253
Features: Meniere's Disease
1. True vertigo 2. Hearing loss 3. Tinnitus 4. Aural fullness
254
Treatment: Meniere's Disease
``` A. CONSERVATIVE - reassurance - cease smoking, salt, caffeine B. MEDICAL - Betahistine - Diuretics C. SURGICAL - drainage of endolymphatic sac - disconnection of labyrinth - labyrinthectomy ```
255
When should one refer a patient with balance disorder?
1. auditory associations e.g. tinnitus, hearing loss 2. signs of supurative middle ear disease 3. symptoms triggered by an increase in pressure
256
Warning signs in a patient with dysphagia
1. loss of weight 2. neck mass 3. regurgitation 4. respiratory symptoms 5. otalgia 6. dysphonia
257
Medications that may cause dysphagia
1. anti-histamines 2. anticholinergics 3. antidepressants 4. antihypertensives
258
Causes: Acute dysphagia
1. tonsillitis 2. aphthous ulceration 3. foreign body 4. caustic ingestion 5. tracheostomy
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Causes: Chronic dysphagia
``` A. Neurologic/Neuromuscular disorders B. Intrinsic features of the GIT C. Extrinsic features D. Autoimmune disorders E. Ageing F. Psychosomatic (Globus) ```
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Extrinsic causes of dysphagia
1. thyroid 2. aortic aneurysm 3. aberrant right sublavian artery
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Neurological causes of dysphagia
1. stroke 2. amyotropic lateral sclerosis 3. multiple sclerosis 4. parkinson's disease 5. muscular dystrophy 6. myasthenia gravis 7. diffuse oesophageal spasm
262
Intrinsic GIT features causing dysphagia
1. neoplasia 2. pharyngeal pouch 3. oesophageal stricture 4. oesophageal achalasia
263
Treatment: Globus
1. Exclude true dysphagia 2. 2 week treatment with - iron rich diet/supplements - reflux medication - amitryptyline nocte 3. stress management 4. if no improvement, contrast swallow
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Imaging available for dysphagia
CXR contrast swallow manometry endoscopic evaluation of swallowing
265
Autoimmune causes of dysphagia
1. systemic sclerosis 2. SLE 3. dermatomyositis 4. mixed connective tissue disease 5. Sjogren's syndrome 6. Rheumatoid Arthritis
266
How does rheumatoid arthritis cause dysphagia?
causes cricoarytenoid joint fixation
267
Surgeries for achalasia
a. bougie dilation | b. cardiomyotomy (Heller's operation)
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Treatment: Auricular haematoma
1. aspiration OR incision&drainage 2. irrigation 3. oral antibiotics 4. pressure dressings 5. re-assess in 24h, re-aspirate if necessary
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Treatment: auricular keloids
a. silicone gel clip b. steroid injections c. excision and local radiotherapy
270
Which mechanisms protect the tympanic membrane from trauma?
1. narrow isthmus | 2. Eustachian tubes
271
Causes: otic barotrauma
flying diving slap/box to ear
272
Prophylaxis: otic barotrauma
1. repeated valsalva manoevre 2. nasal decongestants (topical or systemic) 3. myringotomy and grommets
273
Complications: otic barotrauma
1. Tympanic membrane rupture 2. Cochlear damage - SNHL - tinnitus 3. Vestibular damage - balance disorders
274
Management: Tympanic membrane rupture
1. most will resolve spontaneously in six week to three months 2. Water precautions - do not get fluid in ear 3. topical antibiotics and steroids if infected 4. audiogram if hearing loss suspected 5. myringoplasty if not healed by 3 months
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Management: Ossicular chain dislocation
a. ossiculoplasty | b. hearing aids
276
Signs: Temporal bone fracture
1. hearing loss - conductive in longitudenal, sensorineural in transverse 2. nausea and vomiting 3. vertigo 4. nystagmus 5. battle sign 6. racoon eyes 7. CSF rhinorrhoea/otorrhoea 8. facial nerve palsy - delayed in longitudenal, immediate in transvers
277
Symptoms and signs: perilymph fistula
1. vertigo: episodic, worse with loud noise 2. tinnitus 3. hearing loss - sensorineural, fluctuating 4. headache 5. progresses during the day 6. symptoms worse with valsalva
278
Important assessments after naso-facial trauma
1. nasal airway patency and respiratory status 2. ocular movement and function 3. cranial nerve V function/sensation 4. dental occlusion 5. circulation status 6. C-spine integrity
279
Management: nasal soft tissue injury
1. clean wounds 2. anti-tetanus injection if appropriate 3. antibiotics if appropriate 4. abrasions cleaned and left open 5. small lacerations: steristrips 6. large lacerations: suture with fine microfilament
280
How to distinguish CSF rhinorrhoea from normal fluid rhinorrhoea
1. CSF has glucose 2. CSF has positive B-transferrin assay testing 3. CSF leaves a halo on a white cloth when mixed with blood 4. CSF will stain with fluorescein after fluroescein lumbar puncture
281
Complications of nasal trauma
1. respiratory obstruction 2. haemorrhage 3. inhalation/aspiration 4. sensory loss 5. CSF rhinorrhoea 6. cavernous sinous thrombosis 7. physical deformity
282
Management: CSF rhinorrhoea
1. conservative: nurse in upright position, many will abate by itself 2. surgical repair - endoscopically - craniotomy
283
Classify epistaxis
``` A. LOCAL - digital trauma - direct trauma - viral nasal infection - neoplasia - foreign bodies B. GENERAL - hypertension - clotting defects - drugs - hereditary haemorrhagic telangiectasia ```
284
Management: Epistaxis
1. initial first-aid measures 2. assess blood loss 3. evaluate cause 4. procedures to stop the bleeding
285
Trotter's measure for initial epistaxis management
1. pinch nostril (NOT bony pyramid) together 2. place container under chin 3. sit upright 4. lean forward (NOT backward)
286
Options to control bleeding in epistaxis
a. vessel cautery (with silver nitrate sticks of electrocautery) b. anterior or posterior nasal packing c. examination under anaesthesia d. endoscopic diathermy e. arterial ligation (sphenopalatine, maxillary, external carotid)
287
Minimum investigations in a neck mass - before considering FNA!
1. full blood count 2. erythrocyte sedimentation rate 3. chest x-ray
288
Causes of midline neck masses in children
1. thyroglossal duct cysts 2. dermoid cysts 3. chondromas 4. thyroid masses
289
Causes of lateral neck masses in children
a. infective b. congenital c. neoplastic
290
Infective causes of lateral neck masses in children
1. mumps 2. lymphadenitis 3. tuberculosis
291
congenital causes of lateral neck masses in children
1. branchial cysts 2. cystic hygroma 3. haemangioma 4. chemodectomas
292
neoplastic causes of lateral neck masses in children
- lymphoma - neurblastoma - parotid malignancy - rhabdomyosarcoma - metastases
293
Causes of midline neck masses in adults
1. thyroid masses 2. thyroid cancers 3. untreated congenital masses
294
causes of lateral neck masses in adults
- neoplasia - glandular fever - parotitis - TB lymphadenitis - Sjogren's syndrome - sarcoidosis - HIV - normal variants
295
characteristics of Sjogren's syndrome
1. xerostomia 2. keratoconjuncitivitis sicca 3. systemic autoimmune condition e.g. RA
296
Levels of the neck
``` I. submental and submandibular II. upper jugular III. mid jugular IV. lower jugular V. posterior triangle VI. anterior compartment ```
297
Signs: laryngotracheal injury
1. stridor 2. haemoptysis 3. dysphonia 4. dysphagia 5. surgical emphysema 6. laryngeal tenderness/echymoses/oedema 7. loss of thyroid cartilage prominence 8. associated injuries - vascular/c-spine/oesophageal
298
Causes: laryngotracheal trauma
BLUNT - MVA, sports PENETRATING - gunshots, knives MISCELLANEOUS - corrosive ingestion, smoke inhalation, intubation
299
Principles of managing laryngotracheal injury
1. secure airway 2. control haemorrhage 3. drain laryngeal haematomas 4. laryngeal exploration 5. laryngeal reconstruction
300
Causes of chronic laryngotracheal stenosis
1. subglottic/tracheal stenosis 2. bilateral vocal cord palsies 3. glottic webs
301
Causes: subglottic/tracheal stenosis
- traumatic endotracheal intubation - too large endotracheal tube/cuff - GERD - infection - delay in changing to tracheostomy - incorrectly sited tracheostomy
302
Treatment: subglottic stenosis
a. cruciate cuts using knife/laser b. temporary stenting c. topical mitomycin c d. anterior augmentation e. tracheal resection and end-to-end anastomosis
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Treatment: bilateral vocal cord palsy
a. intubation/tracheostomy b. lateralisation of cords c. airway lasering
304
Treatment: glottic webs
a. surgical division b. mitomycin c c. silasitc sheet in anterior commisure
305
Management: Caustic ingestion
1. identify substance 2. do not induce emesis 3. do not dilute 4. airway control 5. do not give activated charcoal 6. do not perform gastric lavage 7. IV resuscitation and blood products if necessary 8. Surgical consult for complications 9. ENT consult for complications especially stenosis 10. psychiatry consult
306
Complications: Caustic ingestion
1. oesophageal stenosis 2. laryngotracheal trauma 3. mediastinitis 4. oesophageal perforation 5. peritonitis

Otorhinolaryngology (1 decks)

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