ENT

Otitis media with effusion

➢ Also known as glue ear, persistent build-up of fluid in the middle ear
➢ History of recurrent OM
➢ Issue stems from a dysfunction of the Eustachian tubes
Presentation
• Hearing diminished or lost (usually bilateral) → glue ear is the commonest cause of CHL in childhood
- Listening to the TV at excessively high volumes
- Needs things to be repeated
- Lack of concentration
- Withdrawal especially in school
• 2ry problems such as speech and language delay or behavioral problems
• Rarely complains of ear pain
• May have a prior history of infections (URTIs) or oversized adenoids
• Balance problems
• Peaks at 2 years of age
Signs (by otoscope)
• Retracted (more common) or bulging (less common) drum
• Dull, grey, or yellow tympanic membrane, there may be bubbles or a fluid level
Diagnosis
• Audiograms → conductive defects
• Tympanometry → assesses the ability of the eardrum to react to sound
Treatment
• <3 months → Reassure and review in 3 months
• >3 months → Surgery (insert grommets)
• If surgery is rejected → Hearing aids

- An important risk factor for OME is “parental smoking” → Always encourage parents of patients to stop smoking

- The light reflex (cone of light) is seen as a cone-shaped reflection in the anterior inferior quadrant of the TM
- Absence of the cone of light indicates distortion of the shape of the TM such as bulging due to an increase of
inner ear pressure seen in otitis media

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Acute otitis media in children
➢ Acute inflammation of the middle ear and may be caused by bacteria or viruses
Features
• Rapid onset of pain (younger children may pull at the ear)
• Fever
Treatment of perforated OM
• Irritability
• Amoxicillin (5-days course)
• Coryza (rhinitis) • If penicillin-allergic → Erythromycin or clarithromycin
• Vomiting
• Often after a viral upper respiratory infection
• A red, yellow or cloudy tympanic membrane or bulging of the tympanic membrane
• An air-fluid level behind the tympanic membrane
• Discharge in the auditory canal secondary to perforation of the tympanic membrane
• Perforation of the eardrum often relieves pain. This is because bulging of the tympanic membrane causes
the pain

• Furuncles can be
found in diabetics or
low immunity
• Also called “boils”
• They’re infected hair
follicles
• MC organism →
Staph
• Red, hard, tender
• Self-limiting or
requires flucloxacillin

- Tenderness in movement of the tragus → Otitis externa

- If you’re treating otitis externa but suspect there may be a tympanic membrane perforation → aminoglycosides
ear drops are NOT the best choice as it’s toxic → use Ciprofloxacin drops

- Otitis externa with Pseudomonas (pus in the external canal) → topical gentamicin only or with topical
gentamicin with hydrocortisone (Gentisate HC)
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Acoustic neuroma
➢ Also called “vestibular schwannomas”, accounts for 5% of intracranial tumors and 90% of cerebellopontine
angle
➢ Bilateral acoustic neuromas are seen in neurofibromatosis type II
Features
• Cranial nerve V → Absent corneal reflex
• Unilateral SNHL should be considered as caused by an
• Cranial nerve VII → Facial palsy acoustic neuroma until proven otherwise
• Cranial nerve VIII → SNHL, vertigo, tinnitus
Investigation
• MRI of the internal auditory meatus → to view the cerebellopontine angle
• MRI brain → for further evaluation

DVT = Deafness, Vertigo, Tinnitus

DVT + CN palsy = Acoustic neuroma
DVT + aural heaviness = Meniere’s disease

Meniere’s disease
Presentation
• Deafness, vertigo, tinnitus (DVT) + fullness in the ear (could be experienced with AN)
• Note: Vertigo → is usually the prominent symptom
• Episodes last minutes to hours
• MRI is normal
• Usually a female → male; 20-60 years old
• Typically, symptoms are unilateral but bilateral symptoms may develop after a number of years
Treatment
• Acute attacks → buccal or intramuscular prochlorperazine or cyclizine
• Admission is sometimes required

Vestibular schwannoma → high frequency SNHL, MRI is diagnostic, will have CN involvement
Meniere’s disease → low frequency SNHL
Otosclerosis → CHL + young age + patient reports better hearing in noisy places + precipitating factors like pregnancy

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 ENT
Otosclerosis
• Abnormal growth of bones of the middle ear preventing structures within the ear from working properly
• Most common cause of progressive deafness in young adults (CHL) (15-45 years)
• Tinnitus and vertigo
• Positive family history (50%) • Could be mixed hearing loss if cochlea is involved
• Usually bilateral (80%)
• Women + pregnant
Management
• Stapedectomy or stapedotomy, with the insertion of a prosthesis
• If surgery is rejected → Hearing aids

Peritonsillar abscess (Quinsy)

➢ Swelling of the soft palate and tissues lateral to the tonsils
➢ It’s a complication of acute tonsillitis
➢ Pus is trapped between the tonsillar capsule and the lateral pharyngeal wall
➢ Typically preceded by a sore throat for several days
Presentation
• Sore throat
• Dysphagia
• Pain localized to one side of the throat
• Peritonsillar bulge
• Uvular deviation (bulging tonsils push the uvula away from the affected side)
• Fever
• Trismus (difficulty opening the mouth)
• Fetor
• Drooling
• Altered voice quality (hot potato voice) due to pharyngeal edema and trismus
Management
• Antibiotics → IV benzylpenicillin
• Needle aspiration, incision and drainage

Tonsillar carcinoma → SCC, Lump in the neck

- RF: smoking, regular alcohol intake and HPV infection
- Direct spread often involves pharyngeal space and mandible
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Hearing screening
➢ It’s offered to all babies within 4-5 weeks of birth
➢ Healthy born babies are normally given a hearing test before discharge otherwise it’ll be done during this
timeframe
2 types of tests
1. Automated otoacoustic emission (AOE)
- Soft-tipped earpiece is placed inside the ear to detect vibration of hair cells
2. Automated auditory brainstem response (AABR)
- Brain waves are measured by electrodes
- Can detect auditory neuropathy in children

Below 6 months → AOE or AABR

6 months – 18 months → Distraction test
2 years – 5 years → Conditioned response audiometry OR Speech discrimination
>5 years → Pure tone audiogram

Rinne’s and Weber’s

Rinne’s test
• A tuning fork is placed over the mastoid process until the sound is no longer heard, followed by repositioning
just over external acoustic meatus
• AC is normally better than BC → Positive Rinne's test (normal)
• If BC > AC, then the patient has conductive deafness → Negative Rinne’s test (Abnormal Rinne’s test)

Weber's test [CSSO]

• A tuning fork is placed in the middle of the forehead equidistant from the patient's ears. The patient is then
asked which side is loudest
• If sound is localized to the unaffected side → Unilateral SNHL
• If sound is localized to the affected side → Unilateral CHL
• SNHL = localized to the normal ear

Example
If Weber’s test localizes to the right side. It can either be right CHL or left SNHL, a Rinne’s test would be able to
confirm if it’s a right CHL

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Candida vs LP vs Leukoplakia

Leukoplakia should be biopsied as it’s premalignant

Leukoplakia occurs primarily in HIV-positive individuals
For oral candidiasis → Nystatin suspension can be used
Leukoplakia may present with dysplasia of the vocal cords
- White patches over the vocal cord + hoarseness of voice
- Management → cessation of smoking and observation, as it might turn malignant
Difference between oral thrush (oral candidiasis) and Leukoplakia → Leukoplakia CANNOT be removed by rubbing
Ludwig’s angina
- Severe cellulitis involving the floor of the mouth
- Early, the floor of the mouth is raised and there’s difficulty swallowing saliva which might be drooling
- Usually following a dental infection
Dysphagia + Odynophagia + radiates to the back → Esophageal candidiasis, caused by candida albicans

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Cholesteatoma
➢ Destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear and/or
mastoid process
➢ Uncommon abnormal collection of skin in the ear that left untreated can continue to grow and damage the
bones of the middle ear (ossicles)
➢ Small lesions → CHL, Large lesions → CHL + vertigo + headache + facial nerve palsy
Acquired
• Following repeated ear infections, they’re usually responsive to antibiotics
• Frequent painless otorrhea which may be foul-smelling
• Progressive, unilateral CHL
• TM perforation (90%) or retracted tympanum
• Otoscopy:
- Retraction pocket in attic or posterosuperior quadrant of TM
- Granular tissue
- White mass behind eardrum
- Purulent drainage
Congenital
• Present 6 months – 5 years, sometimes later in adulthood
• Often NO history of recurrent suppurative ear disease, previous ear surgery or TM perforation
• May be incidental finding on routine otoscopy of an asymptomatic child
• Otoscopy → Spherical pearly white mass behind intact membrane

Vestibular neuritis
➢ Inflammation of the vestibulocochlear nerve (CN VIII), but the etiology is thought to be a vestibular
neuropathy
Features
• Abrupt onset
• Recurrent vertigo (lasting hours-days)
• Unsteadiness, nausea and vomiting (feel as if the room is rotating)
• Symptoms are aggravated by head movement
• History of viral infection (runny nose, cough, fever)

Vestibular neuritis → commonly present with a history of viral infection + lasts hours-days
BPPV → lasts seconds
Labyrinthitis
- Vestibular nerve and labyrinth are affected
- Same as vestibular neuritis + Hearing loss (SNHL) ± tinnitus
Vertebrobasilar insufficiency (VBI)
- Very old male
- Most common cause → atherosclerosis
- RF: DM, HTN, smoking and dyslipidemia

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Temporomandibular disorders (TMDs)
• A group of disorders affecting tempomandibular joint (TMJ), masticatory muscles and associated structures
• Associated with muscle overactivity which include bruxism (grinding of teeth)
• Symptoms → Facial pain, restricted jaw function and joint noise
• Pain is around the temporomandibular joint but is often referred to the head, neck and ear
• Managed by ice packs, NSAIDs, dental splits or Botox injections

Pleomorphic adenoma
• The most common tumor of the parotid gland
• They’re benign tumors which appear as a lump just behind the angle of mandible
• Benign with the capacity to turn malignant
Features
• Slow-growing and asymptomatic
• Firm
• Painless
• Mobile
Management
• Superficial parotidectomy or enucleation
- Tender and painful mass at the angle of the mandible, especially when eating → Parotiditis
- Mobile, soft, cystic and tender mass → Adenolymphoma (Warthin’s tumor)
- Mandibular and tonsillar tumors are NOT mobile

Sialadenitis
➢ Inflammation of salivary gland and may be acute or chronic, infective or autoimmune
Features
• Unilateral redness, swelling and pain
• May enlarge to reach a size of an orange
• Mild odynophagia, usually common before and during meals
• Fluctuation test positive if it’s filled with swelling
• Foul taste in the mouth
• Decreased mobility in the jaw
• Dry mouth, skin changes, weight loss, shortness of breath, keratitis, dental pain, skin changes and
lymphadenopathy
• Fever with rigors and chills along with malaise and generalized weakness as a result of septicemia
• In severe cases → pus can often be secreted from the duct by compressing the affected gland
• Duct orifice is reddened with reduced flow, there may be a visible or palpable stone
Acute sialadenitis
- Typically, present with erythema over the area, pain, tenderness on palpation and swelling
- Infection often occurs as a result of dehydration with overgrowth of oral flora (e.g. postoperative
dehydration)
- Purulent material may be observed
Chronic sialadenitis
- Less painful + gland enlargement (often following meals) WITHOUT erythema
- Associated with decreased salivary flow due to stones rather than dehydration

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Nasal polyps
• Lesions arising from the nasal mucosa, occurring at any site in the nasal cavity or paranasal sinuses
• Nasal polyps tend to be bilateral
• Associated with → Asthma, Aspirin sensitivity (Samter’s triad)
Presentation [RAN]
• Rhinorrhea
• Anosmia (loss of smell)
• Nasal obstruction

Laryngeal cancer
Presentation
• Progressive hoarseness of voice → most common early symptom
• Later, Stridor, dysphagia and odynophagia
• If the pharynx is involved → Hemoptysis and ear pain • HPV → RF for tonsillar, oropharyngeal and
Risk factors laryngeal cancer
• Smoking → 1 st

• Occupational exposures (asbestos, formaldehyde, nickel, isopropyl alcohol and sulphuric acid mist)
• Insufficient fruit and vegetables intake
• HPV 16

Nasopharyngeal carcinoma
• Painless swelling or lump in the upper neck, often due to a swollen LN
• Nasal obstruction, epistaxis and otitis media from eustachian tube obstruction
• Unilateral CHL + tinnitus
• Other cranial nerves involvements
Risk factors EBV is associated with:
• Smoking, Alcohol • Hodgkin’s lymphoma
• Infection with EBV • Nasopharyngeal carcinoma

• South Asian, male

Nasopharyngeal carcinoma → Ear symptoms

Paranasal sinus tumors → Prominent ocular symptoms (e.g. epiphora, double vision)
Oropharyngeal cancer (tonsillar cancer)
- At the base of tongue, tonsils, soft palate and walls of the pharynx
- Associated with ear pain
- Often involves pharyngeal space and mandible
Malignant otitis externa
- An aggressive infection rather than a malignancy
- CHL + foul-smelling purulent otorrhea + facial nerve palsy
- Black skin around the ear
- RF: DM, weakened immune system
- Urgent refer to an ENT specialist is usually needed

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Acute tonsillitis
Symptoms
• Sore throat
• Pain referred to the ear
Signs
• Throat is reddened
• Tonsils are swollen and may be coated or have white flecks of pus on them
• Fever
• Swollen regional LNs
• Examination shows intense erythema of tonsils and pharynx, yellow exudate and tender, enlarged anterior
cervical glands

3 or 4 of the Centor Criteria → Bacterial tonsillitis → Antibiotics (Penicillin V)

• Fever >38
• Tonsillar exudates
• No cough
• Tender anterior cervical
lymphadenopathy

Infectious mononucleosis
- Affects teenagers more often
- Very large purulent tonsils and long-
lasting lethargy
- Splenomegaly

Tonsillectomy
• Aim → Reducing the incidence if recurrent infections
• Indications → children with no other explanation for recurrent symptoms + frequency of symptoms
- >7 episodes per year for one year
- >5 episodes for 2 years
- >3 episodes for 3 years
• Complications
- Primary hemorrhage → may require a return to theatre
- Secondary hemorrhage → antibiotics and antiseptic mouthwashes

Otherwise, tonsillitis is treated with Analgesics (paracetamol and ibuprofen)

If tonsillitis + exudates + cervical lymphadenopathy + fever >38 → Antibiotics

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Presbycusis
➢ Also known as age-related SNHL → most common cause of hearing impairment in elderly patients
➢ Etiology → degenerative changes in the inner ear (hair cells inside the cochlea)
Features
• Progressive high-frequency hearing loss
• Bilateral
• Usually occurs after age 50
• Difficulty understanding speech, especially in noisy environments
• Usually brought in by the family to clinics as the patient would not think his/her hearing is impaired
Management
• Hearing aids, to increase the high-frequency sound

The graph shows that hearing threshold level goes down as the frequency increases which is a feature seen in
presbycusis

Functional dysphonia
➢ Disturbance of voice in the absence of any structural abnormality of the larynx or any cord paralysis
➢ Diagnosed by exclusion
➢ There may be various interacting causes such as overuse of the voice, poor vocal technique and stress
➢ May occur after treatment of acute respiratory infection (if prior ttt of infection → Laryngitis)
Features
• Vocal fatigue (voice becoming worse with use) and laryngeal discomfort

Noise-induced hearing loss (NIHL)

• Hearing impairment resulting from exposure to loud sound
• Usually bilateral high frequency SNLH

- Acoustic trauma such as gun shooting or bomb explosion and barotrauma (such as sudden changes in pressure
like driving) → TM perforation → CHL
- Acoustic trauma → Sudden
- NIHL → Chronic

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Management of ear wax buildup
1. Ear wax softeners
- Sodium bicarbonate, sodium chloride, olive oil can be used
- Prescribe for 2-3 days initially
2. If symptoms persist → Ear irrigation
3. If irrigation is unsuccessful
- Ear drops are advised for further 3-4 days and then return for further irrigation
- Instill water into the ear, after 15 mins → irrigate the ear
- Refer to ENT specialist

Management of epistaxis
1. Lean forward, open mouth, press soft nose for 10-15 minutes
2. Nasal cautery with silver nitrate
3. Nasal packing

After stopping the bleeding, if unstable → transfer to A&E

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Notes
• An insect buzzing and stuck in the external ear → 2% Lidocaine, to kill it then remove it by Olive oil
• Soft objects, organic matter or seeds stuck in the ear → Suction with a small catheter
• Large clearly visible foreign bodies in adults or older children → Bayonet forceps
• Styrofoam or chewing gum → Acetone
• Superglue → Manual removal, in 1-2days after desquamation, or referral to the ENT specialist
• Batteries → Urgent ENT referral, removed within 24h
• Ear wax → Olive oil, to loosen the hard wax
• Any spherical object → Hook, can’t be grasped by forceps
• An intellectually-disabled patient with a foreign object in the ear → Removal under general anesthesia
• Indications for ENT referral:
- Uncooperative patient
- Requiring sedation
- Perforated ear drum
- An adhesive in contact with the eardrum
- Difficulty removing the foreign body
• Ear trauma with bleeding, tinnitus and CHL, possible nausea and vomiting initial investigation → Otoscopy
• RTA with bleeding and CSF leakage from the ear (a possible basilar fracture) → CT scan
• Small perforation the TM → Reassure
• Large perforation of the TM → Refer to a specialist
• Flamingo pink (Schwartz sign) → Otosclerosis
• Cartwheel appearance of the TM → Acute suppurative otitis media
• Chalky white patches on the TM → Tympanosclerosis
• Sudden vertigo + vomiting + preceding URTI → Labyrinthitis
• Difficulty hearing in noisy environment → Presbycusis
• Difficulty hearing in quiet environment → Otosclerosis
• Form of acute OM where vesicles develop on the TM, pain occurs suddenly and persists for 24h-48h, hearing
loss and fever suggest a bacterial origin → Myringitis
• Any salivary gland mass for more than 1 month → FNAC
• Paget’s disease + OI → Mixed hearing loss
• Headache worsens when bending forward + NO nausea or vomiting → Chronic sinusitis
• Headache worsens when bending forward + nausea, vomiting, photosensitivity → Migraine
• Swelling that moves up on swallowing → Goiter
• Moves up on swallowing and tongue protrusion → Thyroglossal cyst
• Fluctuant and transluminate → Cystic hygroma, a fluid-filled sac due to a blockage in the lymphatic system
• Pain at the cheeks preceded by URTIs + upper jaw pain/toothache → Maxillary sinusitis
• Same but pain at the nose bridge → Ethmoidal sinusitis
• Same but pain above the orbit → Frontal sinusitis
• Causes of SNHL:
- Acoustic neuroma
- Meniere’s disease
- Presbycusis → Bilateral
- Labyrinthitis
• Blunt trauma to the ear pinna with only redness → Oral analgesia
• Blunt trauma to the pinna with hematoma (bluish discoloration) → Incision and drainage + Oral antibiotics
• If left untreated, it will lead to → Cauliflower ear
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