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PLABABLE
VERSION 1.2
ENT
Acute Otitis Media
Presentation
● Earache
● fever
● H/o upper resp tract infection
● Pain relief followed by ear discharge - perforation
Otoscopy
● Red or cloudy TM
● Bulging of the TM
● Air-fluid level behind the TM
● Perforation and discharge (late cases)
Management
● Paracetamol or NSAIDs
● Antibiotics for children who are systemically
unwell or if symptoms > 4 days
○ First line - amoxicillin for 5 days
○ Pen allergy - erythromycin or clarithromycin
Complications
● Perforation
● Chronic Suppurative Otitis Media
● Mastoiditis
● Labyrinthitis
● Facial nerve palsy
PLABABLE
Otitis Media with Effusion
Glue ear is a collection of fluid in the middle ear
Presentation
● Hearing loss
● Speech or language delay
● Usually following acute otitis media
● Intermittent ear pain with fullness
● Risk factor: parental smoking
Otoscopy
● Opacification of the eardrum
● Loss of light reflex
● Retracted eardrum
● Decreased mobility of eardrum
● Presence of air bubbles of fluid level
Pure tone audiometry: Conductive hearing loss
Management
● Usually self-limiting so reassure and review in 3
months
● Grommet insertion if persistent bilaterally for 3 >
months
PLABABLE
Otitis Externa (swimmer’s ear)
Presentation
● Pain and itching of the ear
● Discharge
● Conductive hearing loss (Severe cases)
Common organisms
● Staphylococcus aureus
● P. aeruginosa
● Very rarely fungal
Risk factors
● Swimming
● Diabetes
● Immunocompromised patients
Management
● Acetic acid (1st week only) or
● Topical antibiotics
○ Neomycin
○ Clioquinol
PLABABLE
Malignant Otitis Externa
Non-malignant extension of otitis externa into the
mastoid and temporal bones
Presentation
● Severe ear pain and headache
● Purulent foul discharge
● Conductive hearing loss (Severe cases)
Common organisms
● P. aeruginosa
● S. aureus
Risk factors
● Old age
● Diabetes
● Immunocompromised patients
Management
● urgent referral to ENT (high mortality rate)
PLABABLE
Hearing Tests (children)
Below 6 months
1. Otoacoustic Emissions (OAE)
2. Audiological brainstem responses (ABR)
6 months to 18 months
● Distraction testing
6 months to 2.5 years
● Visually reinforced audiometry (VRA)
2 - 5 years
● Speech discrimination
5+ years
● Pure tone audiogram (PTA)
PLABABLE
Hearing Loss
Conductive
● Cerumen (Wax buildup);
● foreign body;
● debris from otitis externa;
● large exostoses,
● Osteomas
● Perforated tympanic membrane
● tympanosclerosis
Sensorineural hearing loss
● Presbycusis
● Noise trauma
● Mechanical trauma
● Meniere disease
● Medications
● Autoimmune disease
● Infection
● Neoplasm
PLABABLE
Osteosclerosis
Features
● Ankylosis of the stapes footplate
● Tinnitus
● Autosomal dominant inheritance
● Seen common between 15 and 35 years of age
Investigation
● Audiometry - Conductive hearing loss
(Commonly bilateral)
Management
● Medical:
○ Hearing aids
○ Sodium fluoride
● Surgical:
○ Stapedectomy
○ Stapedotomy
PLABABLE
Acute Sialadenitis
Acute infection of the salivary gland usually in
dehydrated patients (e.g. elderly, post-surgery).
Presentation
● Painful swelling of gland
● Fever
● Pus leaking from duct on application of pressure
Investigation
● Oral swab (culture and sensitivity)
Management
● Antibiotics
● Good oral hygiene
● Lemon drops
● Surgical drainage
PLABABLE
Chronic Sialadenitis
(Küttner's tumour)
Chronic inflammation of the salivary gland that
progresses with increasing fibrosis and parenchymal
atrophy
Presentation
● Unilateral or bilateral
● Swelling, redness and pain of the salivary gland
● Most commonly submandibular gland is
affected
● Symptoms are more prominent when chewing
food
● Sour taste in the mouth
● Mouth dryness
● Localised lymphadenopathy
Investigation
● USG
● FNAC
Management
● Surgical resection
PLABABLE
Cholesteatoma
Destructive and expanding keratinizing squamous
epithelium in the middle ear or mastoid process
Presentation
● Chronic foul smelling ear discharge
● Progressive unilateral conductive hearing loss
● Erosion can cause facial nerve palsy and vertigo
Otoscopy
● Tympanic membrane perforation
● Retracted tympanic membrane
● White mass behind tympanic membrane
CT scan - Investigation of choice
Management
● Surgery
○ Tympanomastoidectomy (first line)
○ Tympanoplasty
Cholesteatoma
Perforated TM
PLABABLE
Rinne’s and Weber’s Test
Used to differentiate between conductive and
sensorineural hearing loss
Conductive hearing loss in right ear
Rinne’s test Weber’s test
Right ear: Sound is localised to the
Bone conduction better right ear
than air conduction
Left ear:
Air conduction better than
bone conduction
Sensorineural hearing loss in right ear
Rinne’s test Weber’s test
Right ear: Sound is localised to the
Air conduction better than left ear
bone conduction
Left ear:
Air conduction better than
bone conduction
PLABABLE
Thyroglossal Cyst
Presentation
● Painless fluctuant swelling in the midline of the
neck
● Move upwards with swallowing and protrusion of
the tongue
● Rarely cause pain and fever once it gets infected
Management
● Surgical removal
PLABABLE
Nasopharyngeal Carcinoma
Risk factors
● Epstein–Barr virus
● Alcohol
● Smoking
● South Asian background
Presentation
● Painless swollen cervical lymph nodes
● Otitis media, epistaxis, nasal obstruction
● Conductive hearing loss, tinnitus
Management
● Urgent ENT referral (within 2 weeks)
● Biopsy (diagnosis)
● CT (staging)
PLABABLE
Tonsil Carcinoma
Brain trainer:
A 70 year old man presents with progressive
dysphagia and right sided ear pain. His right
palatine tonsil is enlarged. He is a heavy smoker
and drinker. What is the likely diagnosis?
➔ Tonsillar cancer
PLABABLE
Paranasal Sinus Carcinoma
Brain trainer:
A 46 year old man complains of a blocked nose
with occasional blood present on tissues when
blowing. He also complains of pressure in his
upper teeth, recent cheek swelling, and double
vision. What is the most likely diagnosis?
➔ Paranasal sinus carcinoma
PLABABLE
Throat Cancer
Brain trainer:
A 70 year old patient presents with a hoarse
voice which has been ongoing for 3 weeks. He is
a heavy smoker and drinker. What is on the top
of your differential?
➔ Laryngeal cancer
PLABABLE
Nasal Polyp
Brain trainer:
A patient has asthma, rhinorrhoea, bilateral
painless nasal obstruction and anosmia. What
do you suspect?
➔ Nasal polyp
PLABABLE
Chronic Sinusitis
Brain trainer:
A 25 year old man has a headache which
worsens on leaning forward. He denies nausea
or vomiting. What is the most likely diagnosis?
➔ Chronic sinusitis
PLABABLE
Tonsillectomy Bleeding
Brain trainer:
What is the management for bleeding
post-tonsillectomy?
➔ 1° (<24hr) → Return to the theatre
➔ 2° or reactionary (24hr+)
→ Admit + IV ATB
PLABABLE
Nasal Septal Abscess
Brain trainer:
Child presents with nasal pain, tenderness,
malaise and fever. He fell on his nose a few
days ago but was not treated. What is the most
likely diagnosis?
➔ Nasal septal abscess
The fall most likely caused a septal haematoma
which accounts for the temperature and
malaise. The child should have had the
haematoma drained a few days ago.
PLABABLE
Perichondritis
Brain trainer:
Above patient has intense pain in his right
auricle. He denies trauma or hearing loss.
What is the most likely diagnosis, aetiology and
treatment?
➔ Perichondritis
➔ Pseudomonas aeruginosa
➔ Fluoroquinolone
PLABABLE
Foreign Body - Ear
● Insects to be killed with 2% lidocaine before
removal
● Adhesives (super glue) to be removed after 1 to 2
days after desquamation has occurred
● Methods:
○ Hook or forceps
○ Irrigation - contraindicated for soft objects,
organic material or seeds
○ Suction - Small objects
Referral to ENT if
● Patient requires sedation
● Difficulty in removal
● Perforated tympanic membrane
● Adhesive touching TM
● After one failed attempt in a child
PLABABLE
Presbycusis
Features
● Progressive sensorineural hearing loss
● Associated with aging
● Difficulty to understand in a noisy surrounding
Investigation
● Pure tone audiometry
Management
● Hearing aids
● Supportive management
PLABABLE
Furuncle
Brain trainer:
A diabetic woman presents with a painful small,
red, tender mass at the outer third of the right
external ear canal. She denies hearing loss.
There is no discharge. What is the most likely
diagnosis?
➔ Furuncle
PLABABLE
Tympanosclerosis
Brain trainer:
A patient presenting with mild conductive hearing
loss in left ear. Examination reveals chalky white
patches on the eardrum. What is the most likely
diagnosis?
➔ Tympanosclerosis
PLABABLE
Epistaxis
Features
● Either anterior (Little’s area) or posterior
● Trauma is the most common cause followed by
platelet disorder
Management
● Sit upright and leaning forward
● Pinch cartilaginous soft part of the nose for
10-20 min
● Still bleeds then nasal cautery followed by nasal
packing
Important to remember:
● If you cannot visualise the heavy bleeding then
just use nasal packing
● Vitamin K is never the correct choice in a patient
taking warfarin if the INR value is not given
PLABABLE
Nasal Trauma
Brain trainer:
A patient with a punch to the nose with a grossly
deviated nose to the right. What is the most
appropriate step?
➔ Speculum examination of the nasal cavity
PLABABLE
Tonsillitis
Presentation
● Throat pain
● Odynophagia
● Swollen tonsils
● Fever
● Cervical lymphadenopathy
Management
● Symptomatic - Paracetamol and NSAIDs
● Antibiotics (if severe symptoms)
○ Phenoxymethylpenicillin (1st line)
○ Clarithromycin (penicillin allergy)
● Tonsillectomy:
○ > 7 episodes/year for 1 year
○ > 5 episodes/year for 2 years
○ > 3 episodes/year for 3 years
PLABABLE
Peritonsillar Abscess - Quinsy
Features
● Complication of acute tonsillitis
● Swelling of the soft palate and tissues lateral to
the tonsils (peritonsillar bulge)
● Dysphagia
● Uvular deviation
● Fever
● Trismus (Difficulty in opening the mouth)
● Altered voice - Hot potato voice
Management
● Aspiration
● Antibiotics (usually IV benzylpenicillin)
PLABABLE
Benign Paroxysmal Positional
Vertigo (BPPV)
Common cause of vertigo due to otoliths
Presentation
● Vertigo brought out by change in head position
● Sudden in onset
● Lasts 20-30 seconds
● Nausea
● Dix-Hallpike test is used to confirm
Management
● Epley's manoeuvre (reposition the otoliths)
PLABABLE
Vestibular Neuritis and
Labyrinthitis
Presentation
● Sudden onset and severe vertigo
● Not precipitated by head movements
● Hearing loss and tinnitus in Labyrinthitis
● H/o URI
Vertigo H/O URI
PLABABLE
Meniere’s Disease
Presentation
● Vertigo
● Ear fullness
● Tinnitus
● Sensorineural hearing loss
● Episodic (6-11 clusters / year)
Investigations
● Audiometry
● MRI brain (To R/o Vestibular neuroma)
Management
Acute attacks:
● Prochlorperazine or cinnarizine
Prophylaxis:
● Betahistine
PLABABLE
Acoustic Neuroma
Presentation
● Hearing loss (Mostly unilateral)
● Tinnitus
● Facial weakness (Facial nerve compression)
● Facial pain or numbness (Trigeminal nerve)
● Ataxia (Cerebellar compression)
● Bilateral acoustic neuroma occurs in
Neurofibromatosis-type 2
Investigations
● MRI brain
● Audiometry
Management
Acute attacks: prochlorperazine or cinnarizine
Prophylaxis: betahistine
PLABABLE
Pleomorphic Adenoma
Features
● Benign salivary gland tumour
● Most common gland: parotid
● Unilateral slow growing swelling at the angle of
mandible
● On examination: painless, firm, mobile
Investigation
● FNAC
● Core needle biopsy (High sensitivity)
● Ultrasound
Management:
● Surgical resection
PLABABLE
Image Attributions
https://commons.wikimedia.org/wiki/File:Thyroglossal_Cyst.jpg
Bp20151130 CC BY-SA 4.0
https://commons.wikimedia.org/wiki/File:Cholesteatoma_and_large_perforation_left_ear.jpg
Michael Hawke MD CC BY 4.0
https://commons.wikimedia.org/wiki/File:PeritonsilarAbsess.jpg
James Heilman,MD CC BY-SA 3.0
https://en.wikipedia.org/wiki/File:Pos_strep.JPG
James Heilman,MD CC BY-SA 3.0
https://commons.wikimedia.org/wiki/File:Parotisadenom.jpg
Klaus D. Peter, Gummersbach, Germany CC BY 3.0 DE
PLABABLE
