W13 46 ENT and dentistry

Question 1

What are some otological symptoms (symptoms relating to the ear)?

Answer 1

Hearing loss
Otalgia - pain in the ear
Otorrhea - discharge from the ear
Tinnitus - perception of sound coming from the outside world without external stimulus
Vertigo - hallucination of movement
Facial nerve

Question 2

What different things can cause otalgia?

Answer 2

Ontological causes (from the ear) - pinna, external auditory meatus, middle ear
Referred pain (from other areas) - from nerves that supply the ear, TMJ

Question 3

What are chondritis and perichondritis?

Answer 3

Bacterial infection of the auricle - mainly caused by pseudomonas, staph or strep

Question 4

What is chondritis?

Answer 4

Cartilage inflamed eg from piercings, accidents etc

Question 5

What is perichondritis?

Answer 5

Occurs after inadequately treated cellulitis of the ear. Affects the perichondrium (layer covering the cartilage). Spread of infection usually.

Question 6

What happens if the blood supply to the cartilage is cut off and why?

Answer 6

Cartilage only has extrinsic blood supply, so if supply is cut off then causes malformation from devascularisation and necrosis.

Question 7

What’s the treatment for chondritis and perichondritis? (Otalgia from pinna)

Answer 7

Drain pus, IV antbiotics

Question 8

What might result from severe cartilage damage?

Answer 8

Cauliflower ear

Question 9

What is sub-perichondrial haematoma? (otalgia from pinna)

Answer 9

Traumatic disruption of perichondrial blood vessels, strips perichondrium from cartilage. Blood usually accumulates only laterally, unless there is a fracture in the cartilage (which is more dangerous to the vitality of the cartilage).

Question 10

How do you treat sub-perichondrial haematoma?

Answer 10

Drain haematoma to avoid avascular necrosis of cartilage and cauliflower ear.

Question 11

What is otitis externa? (Otalgia from external auditory meatus)

Answer 11

Often history of trauma or prolonged water exposure. Usually caused by pseudomonas bacteria.

Question 12

What is treatment for otitis externa?

Answer 12

Clean debris from ear. Antibiotic drops

Question 13

What is malignant otitis externa?

Answer 13

Severe infection - not cancer. Occurs in diabetics and other immunosuppressed states. Presents as otitis externa but resistant to treatment and much more painful. Patient develops osteomyelitis of the temporal bone facial nerve palsy and other CN palsies (eg 7-12).

Question 14

What is treatment for malignant otitis externa?

Answer 14

High dose ciprofloxacin 500mg BD for at least 3 months.

Question 15

How does wax cause Otalgia of the external auditory meatus?

Answer 15

Nor wax is normal but not in ear canal. Pain is caused by impaction of wax from using earbuds.

Question 16

How do you treat wax?

Answer 16

Sodium bicarbonate ear drops - more effective than olive oil but can dry out the skin of the external auditory canal which can predispose you to otitis externa
Ear syringing - squirting water down ear canal to push it out
Direct vision removal - micro suction
Not by ear buds!

Question 17

How does trauma to the EAC occur (Otalgia to EAM)?

Answer 17

Usually by cotton buds, foreign bodies in ear. Biological material (eg peas) can cause skin inflammation and need to come out, however blunt object can stay in for a while without causing issues.

Question 18

What is the management for trauma to the EAC?

Answer 18

Observe - blood will reabsorb slowly

Question 19

What is acute otitis media (otalgia from middle ear)?

Answer 19

Acute inflammation of the middle ear cleft.

Question 20

What causes acute otitis media?

Answer 20

Nearly always preceding URTI.
Strep pneumoniae, H inf, Moraxella Cat - usually organisms living in the oral cavity and nose

Question 21

Does discharge occur from acute otitis media?

Answer 21

Ear pain but no discharge
(Unless ear drum bursts - usually pain resolves though due to the less pressure)

Question 22

What is the treatment for acute otitis media?

Answer 22

Antibiotics - amoxicillin

Question 23

What is the most common complication of acute otitis media?

Answer 23

Perforation - most will heal themselves.
Can cause bulging, red eardrum, pus from acute otitis media

Question 24

What is acute mastoiditis?

Answer 24

Characterised by ear being pushed out and forwards, usually in children. Mastoid cavity full of pus and subperiosteal abscess formation (if brake in the cortex of the bone).

Question 25

How does acute mastoiditis occur?

Answer 25

If otitis media worsens

Question 26

How do you treat acute mastoiditis?

Answer 26

Needs admission and IV antibiotics. If no improvement after 24 hours - CT and cortical mastoidectomy and grommet (to stop further fluid accumulation)

Question 27

What are the complications of acute mastoiditis?

Answer 27

Intracranial - meningitis, intracranial abscess, sigmoid sinus thrombosis Infratemporal (within temporal bone) - perforation, mastoiditis, facial palsy, SNHL, labyrinthitis) Extratemporal (outside temporal bone) - Bezold’s, Citelli’s (abscesses)

Question 28

Otalgia from referred pain can come from nerves which supply the external auditory canal and the middle ear. Which nerves are these?

Answer 28

V (auriculotemporal branch of mandibular) - canal and lateral TM VII - external canal IX (tympanic branch) - supplies middle ear via plexus X (auricular branch of vagus)

Question 29

What can trigeminal referred pain cause?

Answer 29

Nose and sinuses - infection, neoplasm, septal deformity Nasopharynx - acute infection, neoplasm Teeth and jaw - molar impaction, TMJ, malocclusion Salivary gland - infection, stones Trigeminal neuralgia Sphenopalatine neuralgia

Question 30

What can facial referred pain cause?

Answer 30

Facial nerve neuralgia

Question 31

What can IX and X cranial nerve cause?

Answer 31

Pharynx - tonsillitis, quinsy, retropharyngeal abscess, neoplasm Larynx - neoplasm, granulomatous lesion Tongue - neoplasm, ulcer

Question 32

Summary of the different forms of Otalgia

Answer 32

Otological: Pinna - trauma, infections External ear - infections, foreign body, wax, trauma Middle ear - infections Referred: V - face, mouth pathology VII - neuralgia IX, X - pharynx, larynx, tongue TMJ

Question 33

Why is epistaxis common?

Answer 33

Nasal bleeds are common because it has a rich blood supply

Question 34

What are the 2 main arteries that supply blood to the nose?

Answer 34

External carotid artery Internal carotid artery

Question 35

What branches of the external carotid artery supply blood to the nose?

Answer 35

Maxillary artery - sphenopalatine and greater palatine Facial artery - septal branch of superior labial artery, lateral labial artery

Question 36

What branches of the internal carotid artery supply blood to the nose?

Answer 36

Ophthalmic artery - anterior ethmoidal and posterior ethmoidal arteries

Question 37

What do the spheno and greater palatine arteries supply? (IMGS PG 453)

Answer 37

Supplies around the sphenopalatine foramen and most of the septum

Question 38

What does the facial artery supply? (IMGS PG 453)

Answer 38

Lower front area Littles area overlies Kittlebach’s plexus

Question 39

What is Little’s area/Kiesselbach’s plexus?

Answer 39

An anastomose of 5 arteries - anterior ethmoidal artery, posterior ethmoidal artery, phenopalatine artery, greater palatine artery, septal branch of superior labial artery

Question 40

What are some local causes of epistaxis?

Answer 40

Idiopathic - usually Little’s Trauma - nose picking, foreign body, fracture Inflammatory - rhinitis, sinusitis Neoplastic - tumours of nose or sinuses Environmental - altitude Iatrogenic - surgery, steroid spray, cocaine abuse

Question 41

What are some general causes of epistaxis?

Answer 41

Anticoagulants or bleeding disorders Familial haemorrhagic telangiectasia Hypertension (not a cause but perpetuant of it, more likely to bleed for longer and more invasive treatment to stop it but doesn’t make it more likely)

Question 42

What is the initial management for epistaxis?

Answer 42

1. Pressure on cartilaginous part of nose (septum), lean forward 2. Anterior rhinoscopy with vasoconstriction and local anaesthetic - cauterise 3. Anterior nasal packing 4. Anterior and posterior nasal packs (ABC’s, medical history/medication, vital signs - need IV?)

Question 43

Successful management of nasal injuries depends on assessing 3 areas - inside the nose, outside the nose, and cosmetic deformity. What complications could there be inside the nose and who should you refer to?

Answer 43

Uncontrollable nose bleeding Septal haematoma Septal abscess CSF rhinorrhoea (if cribriform plate crack, or temporal bone trauma) (Septal dislocation) Complications need urgent referral to ENT

Question 44

Successful management of nasal injuries depends on assessing 3 areas - inside the nose, outside the nose, and cosmetic deformity. What complications could there be outside the nose and who should you refer to?

Answer 44

Facial fractures Orbital floor fractures - ophthalmoplegia Mandibular fractures Refer to maxillo-facial surgeons

Question 45

Successful management of nasal injuries depends on assessing 3 areas - inside the nose, outside the nose, and cosmetic deformity. What should you do if there are cosmetic deformities?

Answer 45

No cosmetically important deviation - discharge Swollen - see 5 days Cosmetically important deviation - refer to RNT for ?manipulation

Question 46

What are some causes of acute sore throat?

Answer 46

Pharyngitis Tonsillitis and it’s complications Epiglottis Foreign body

Question 47

What is pharyngitis?

Answer 47

Inflammation of posterior pharyngeal wall and tonsils Usually viral Supportive care needed

Question 48

What organisms can cause tonsillitis?

Answer 48

B-haemolytic strep, strep pneumoniae, H influenzae, anaerobes

Question 49

What should you do with patients with tonsillitis who can eat and drink?

Answer 49

Send home with antibiotics, after checking monospot (kissing disease caused by Epstein-Barre virus)

Question 50

What should you do with patients with tonsillitis who are unable to eat and drink?

Answer 50

Admit IV antibiotics IV fluids Pain relief Monospot

Question 51

What is a monospot?

Answer 51

Test for glandular fever - a viral infection, but need to warn pt about other complications eg risk of contact sports. Ruptures if playing with inflamed spleen.

Question 52

What are the complications of tonsillitis?

Answer 52

Severe swelling and respiratory obstruction Abscess formation - quinsy, parapharyngeal, retropharyngeal Septicaemia

Question 53

What is quinsy?

Answer 53

A large swelling superior and lateral to the tonsil. Abscess formed lateral to the tonsil. In tonsillitis.

Question 54

What organisms cause sore throat in the epiglottis?

Answer 54

Haemophilus influenzae type B B haemolytic strep (Less common now with vaccine)

Question 55

What is the management of sore throat from epiglottic causes?

Answer 55

Safeguard airway - ?intubate (as it can cause airway obstruction) IV antibiotics

Question 56

Describe foreign body sore throat

Answer 56

Usually give history of foreign body ingestion If not and unexplained sore throat will need endoscopy and x-rays to exclude Foreign bodies can usually get stuck in cricopharyngeus (at top of oesophagus) and usually needs GA to remove.