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surgery - ENT EAR Flashcards

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1
Q

what is acute otitis media (AOM) characterised by?

A

days to weeks

young children

severe otalgia and visible inflammation of the tympanic membrane

fever + malaise

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2
Q

pathophysiology of AOM?

A

Bacterial infection of the middle ear results from nasopharyngeal organisms migrating into the middle ear cavity via the eustachian tube.

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3
Q

why are younger children more affected by AOM?

A

shorter and more horizontal ET tube

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4
Q

most common causative organisms of AOM?

A

S. pneumoniae (most common), H. influenza, M. catarrhalis, and S. pyogenes

RSV + rhinovirus

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5
Q

RF for AOM?

A

age (peak age 6-15 months), gender (more common in boys), passive (parenteral) smoking, bottle feeding, and craniofacial abnormalities

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6
Q

who is recurrent AOM seen in?
ie >5 episodes in a year

A

seen more commonly with the use of pacifiers, who are typically fed supine, or their first episode of AOM occurred <6months

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7
Q

features of AOM?

A

pain, malaise, fever, and coryzal symptoms
tug at or cradle the ear that hurts
tympanic membrane (TM) will look erythematous + bulging
small tear visible with purulent discharge
conductive hearing loss or a cervical lymphadenopathy.

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8
Q

what is it important to check in AOM?

A

function of the facial nerve (due to its anatomical course through the middle ear)

checking for any intracranial complications, cervical lymphadenopathy, and signs of infection in the throat and oral cavity.

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9
Q

ix of AOM?

A

diagnosed clinically
FBC, U&Es, and CRP
discharge from the ear should be sent for fluid MC&S

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10
Q

mx for AOM?

A

resolve spontaneously within 24 hours, nearly all within 3 days
simple analgesics
‘watch and wait’ approach

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11
Q

how do you treat recurrent AOM>

A

Grommets

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12
Q

when are abx considered for AOM?

A
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13
Q

when is inpatient considered for AOM?

A

Inpatient admission should be considered for all children under 3 months with a temperature >38c, or aged 3-6 months with a temperature >39c, for further assessment.

evidence of an AOM complication or the systemically unwell child

Patients with a cochlear implant

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14
Q

complications of AOM?
intra-temporal, extra-temporal and intracranial

A
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15
Q

what is mastoiditis?

A

inflammation within the air cells progresses to necrosis and subperiosteal abscess

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16
Q

mx of mastoiditis?

A

admitted for intravenous antibiotics and investigated further via CT head if no improvement is seen after 24 hours of intravenous antibiotics.

mastoidectomy with grommet insertion = DEFINITIVE

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17
Q

presentation of mastoiditis?

A

boggy, erythematous swelling behind the ear, which if left untreated causes anterior protrusion of the pinna

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18
Q

what is the risk assoc with mastoiditis?

A

intracranial spread and meningitis,

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19
Q

what is chronic otitis media?

A

inflammatory disorder of the middle ear. It is characterised by persistent or recurrent ear discharge.

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20
Q

what are the subtypes of COM?

A
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21
Q

what is the pathophysiology of mucosal COM?

A

chronic inflammation of the middle ear mucosa secondary to a perforation in the tympanic membrane as that allows bacteria to enter the sterile middle ear

mastoid air cells are continuous with the middle ear cavity and may also be affected in this disease, which may result in more significant otorrhoea

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22
Q

aetiology of mucosal COM?

A

previous traumatic perforation of the TM, insertion of grommets, and craniofacial abnormalities

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23
Q

features of mucosal COM?

A

chronically discharging ear ie >6wks
absence of fever or otalgia
perforation in the tympanic membrane
history of recurrent AOM, previous ear surgery, or trauma to the ear

Hearing loss can occur, which is nearly always conductive hearing loss

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24
Q

ix for mucosal COM?

A

Audiograms and tympanometry
Microbiological swabs for culture and antibiotic sensitivities

any suspicion of cholesteatoma warrants a CT scan of the petrous temporal bone

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25
mx of mucosal COM?
aural toileting and topical/oral antibiotic or steroid treatments keep ear dry and Clea
26
when is mucosal COM referred for surgery?
referral for surgical management may be required, if there is significant conductive hearing loss or recurrent acute otitis media.
27
what is the surgical mx for mucosal COM?
close the perforation in the tympanic membrane
28
what is squamous COM?
congenital* or acquired acquired = from chronic negative middle ear pressure from Eustachian tube dysfunction.
29
pathophysiology of squamous COM?
Due to negative middle ear pressure, the tympanic membrane is retracted inwards. This results in a retraction pocket These pockets are initially self-cleansing, but some may narrow and trap keratinised squamous cell debris which accumlates with time, leading to the formation of a cyst-like structure which may evolve into a cholesteatoma
30
how may cholesteatoma cause local destruction?
nduce an inflammatory process in the adjacent temporal bone local destruction of the ossicles (resulting in a conductive hearing loss), semicircular canals (leading to vertigo), cochlea (sensorineural hearing loss), and facial canal (facial nerve palsy).
31
RF of squamous COM?
ecurrent acute otitis media, Eustachian tube dysfunction, and prior otological surgery are all known risk factors for cholesteatoma.
32
features of cholesteatoma?
conductive hearing loss painless and persistent purulent ear discharge Any bony destruction of the cochlea may present with a sensorineural component tinnitus, vertigo, or facial nerve palsy pearly, keratinized, or waxy mass in the attic region is seen on otoscopy
33
ix for cholesteatoma?
pure-tone audiogram CT scan of the petrous temporal bone
34
mx of cholesteatoma?
surgery, aiming to remove the entire cholesteatoma as otherwise it will recur - mastoidectomy ossicles can be reconstructed
35
what is a pinna haematoma?
occurs from shearing forces applied to the auricle, most commonly seen amongst rugby players and boxers.
36
how does pinna haematoma form?
Following initial trauma, the perichondrial blood vessels tear, resulting in haematoma forming between the auricular cartilage and the overlying perichondrium the blood supply to the underlying cartilage from the perichondrium can become impaired
37
what happens if pinna haematoma untreated?
avascular necrosis of the pinna can occur due to disrupted blood supply subsequent fibrocartilage overgrowth can lead to a structural deformity of the auricle, colloquially termed “cauliflower ear”
38
mx of Pina haematoma?
draining of the haematoma, and pressure dressing after to prevent re-accumulation gauze padding should be placed over the ear and a tight headband applied
39
how is pinna haematoma drained?
appropriate aseptic field local anaesthetic - NO ADRENALINE 1. incision along the inside of the helical rim 2. evacuation of the haematoma 3. dental roll either side of the auricle and secure these in place using tight mattress sutures around the rolls and through the pinna
40
how is pinna laceration managed?
thorough wound cleaning under local anaesthetic; consider tetanus boosters and antibiotic prophylaxis if required auricular cartilage should be covered by skin
41
what is temporal bone fracture? classifications
42
signs of temporal bone fracture?
facial nerve injury/palsy Post-auricular ecchymosis (termed “Battle’s sign”) Haemotymanum CSF otorrhoea or rhinnorhoea Hearing loss, either conductive or sensori-neural
43
mx for temporal bone fracture?
A to E assessment admitted for neuro-observation CT imaging of the temporal bones
44
what is TM perforation?
as a result of blunt trauma, penetrating trauma, or barotrauma
45
what can make TM perforation more complicated?
substantial volumes of blood in the canal/middle ear
46
how is uncomplicated TM perforation managed?
heal spontaneously after 2-3 months. strict ear water precautions
47
how to mx non-healing TM perforation?
surgical repair (commonly a myringoplasty).
48
what is otitis externa?
an infection of the external ear,
49
pathophysiology of otitis externa?
affects the external auditory canal Any interruption in wax formation (e.g. repeated water exposure), trauma to the canal (e.g. cotton buds), or blockage (e.g. debris) can disrupt the external auditory canal’s protective mechanisms and lead to pathogen overgrowth and inflammation. The skin becomes erythematous, swollen, tender, and warm, leading to debris and discharge accumulation. The narrowing of the canal, in combination with the accumulation of debris, leads to further entrapment of pathogens and propagating the infective process.
50
causative organisms of OE?
Pseudomonas Aeruginosa S. Epidermidis S. Aureus anaerobes rare = fungal infection (typically Aspergillus spp. or Candida).
51
RF for OE?
52
features of OE?
progressive ear pain with a purulent discharge fever or malaise hearing loss, tinnitus, or vertigo. external ear canal will appear swollen and erythematous pinna may be swollen and the tragus is usually tender on palpation
53
ix of OE?
clinical diagnosis swabs of the discharge glucose levels for diabetes mellitus High Resolution CT scan (HRCT) of the mastoid and temporal bones
54
risk scoring in OE?
55
mx of OE?
topical antibiotics, Steroid drops discharge micro-suctioned pope ear wick for 2 days if extremely swollen
56
prevention of OE?
avoid exacerbating factors, such as swimming, and advising the patient to keep their ears dry. underlying eczema or polyps should be managed as required recurrent otitis externa secondary to using a standard hearing aid, they should consider a bone-anchored hearing aid instead, as this allows the external ear canal to ventilate better and prevent accumulation of debris and wax.
57
what is otitis media with effusion?
caused by the build-up of a viscous inflammatory fluid within the middle ear cavity, which may or may not result in conductive hearing impairment.
58
aetiology of OME?
Blocked ET leads to impaired middle ear ventilation. Mucosal cells lining the cavity produce fluid due to negative pressures within the middle ear cavity, and subsequent mucosal inflammation increases the likelihood of middle ear infection (acute otitis media).
59
what is role of eustachian tube?
connects the middle ear cavity to the nasal cavity equilibriate the pressure within the middle ear with atmospheric pressure, allowing optimisation of sound conduction within the cavity
60
RF for OME?
61
features of OME?
difficulty hearing sensation of pressure disequilibrium and vertigo tympanic membrane will appear dull with a yellowish tinge, indicating fluid in the middle ear. bubble or fluid-level seen behind the TM
62
ix for OME?
pure tone audiometry and tympanometry reveal a conductive hearing loss and reduced membrane compliance flexible nasoendoscopy (to exclude a post-nasal space mass).
63
mx of OME?
usually resolve within 3 months - ‘active surveillance’ If no resolution is seen after 3 months, the management options can be divided into surgical and non-surgical: Non-surgical – hearing aid insertion Surgical – myringotomy and grommet insertion
64
if persistent after multiple grommet insertion, whats done for OME?
adenoidectomy
65
what is this phenomenon? Mrs HW, aged 29 has been troubled by increasing bilateral deafness for the past five years of so. She has two children and noted that she became more deaf during her pregnancies. She has no other ear symptoms and in particular has never had discharging ears. She is quite definite that she heard normally until her early twenties. She also mentioned that she seems to hear quite well when she is in noisy surroundings.
paracusis where individuals with hearing loss hear better in noisier environments than quiet ones
66
what kind of deafness is paracusis?
conductive
67
What would the Rinne and Weber tests show in the case of conductive hearing loss affecting both ears equally?
Rinne Negative (Bone conduction louder than air conduction) Weber does not lateralise to either side
68
what is otosclerosis?
the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window.
69
how is otosclerosis inherited?
autosomal dominant
70
who does otosclerosis affect?
affects young adults 20-40yrs
71
features of otosclerosis?
conductive deafness tinnitus tympanic membrane the majority of patients will have a normal tympanic membrane 10% of patients may have a 'flamingo tinge', caused by hyperaemia positive family history
72
mx of otosclerosis?
hearing aid stapedectomy
73
what method of cautery is usually used in outpatients?
silver nitrate
74
what are examples of commonly used nasal packs or material?
BIPP - Bismuth Iodoform Paraffin Paste Alginates (e.g. Kaltostat) Rapid Rhino Merocel
75
how does Alginates (e.g. Kaltostat) - work?
calcium alginate. It helps the body make a clot by reacting with the sodium that is in the blood. It also jellifies. This lets you take it out of the nose without disturbing the clot that has formed
76
how does rapid rhino work?
- form a cushioning hydrocolloid gel when activated with water. This gel creates a moist environment to support healing, minimizes recurrent bleeding
77
how does merocel work?
- nasal tampon. nasal tampon swells and fills the nasal cavity and applies pressure over the bleeding point
78
which blood vessel supplies the area back below the middle turbinate?
sphenopalatine artery
79
what are the pharmacological names of the otrivine nasal drops and Sudafed tablets?
otrivine nasal drops - Xylometazoline Sudafed tablets- Pseudoephrine
80
side effects from Otrivine nasal drops and Sudafed tablets?
tachycardia anxiety insomnia urinary retention
81
what is a common examination finding in acute sinusitis?
inflammation of nasal mucosa, nasal discharge visible generally arises from middle meatus
82
how do you differentiate between nasal polyp or hypertrophies inferior turbinate?
Nasal polyps are insensate whereas turbinates are not
83
what worsens rhinitis?
smoking
84
what does it mean if Rinne test positive?
air > bone
85
what could help with tinnitus at night?
sound generating devices eg music or pillow maskers
86
explain degrees of hearing loss in decibels? Normal Hearing mild moderate moderate severe severe profound
Normal Hearing 0-25dB (adult) 0-15dB (infant) Mild 20-40dB – difficult to hear in noisy environments Moderate 41-55dB – difficult to hear quiet conversation Moderate Severe 56-70dB – difficult to hear normal conversation Severe 71-90dB – can understand speech if speaker is very close Profound 90dB+ - cannot understand speech, able to hear loud stimuli such as passing traffic
87
chromosomal causes of sensorineural hearing loss?
Connexin 26 GJB2 deafness (most common) Most common dominant syndromic Waardenburg’s Stickler Most common recessive syndromic Ushers Pendred’s
88
congenital causes of sensorineural hearing loss>?
Maternal infection Rubella Varicella zoster (chicken pox) HIV CMV Streptococcus Drug/alcohol misuse during pregnancy
89
acquired causes of sensorinerual hearing loss?
presbyacusis noise induced inflammatory eg meningitis, viral, mumps, measles, syphilis trauma autoimmune eg RA, PGA, sarcoid vestibular schwannoma meningioma menieres drugs eg ahminoglycosides, platinum based chemo
90
causes of tinnitus?
Sensorineural hearing loss neuro eg MS Foreign body in ear/wax impaction Eustachian tube dysfunction Drug induced Ototoxic medication, benzodiazepine withdrawal, salicylate, chemotherapy, loop diuretics, chloroquine, antidepressants Transmitted noise Jaw clicking, head/shoulder movement, valvular heart disease (murmurs) Vestibular schwannoma Thyroid disease, iron deficiency anaemia, B12 deficiency, hyperlipidaemia Depression and anxiety
91
result in tympanometry when there is fluid in ear
low less return/ounce back
92
result in tympanometry when there is hole in TM
peak no return
93
how long does it take for TM perforation to heal?
6wks keep dry with cotton wool and vaseline

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