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SHORT CUT of ENT

MS Ansari

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Index

Sr. Content Page

1.

EAR

1

2. NOSE 51

3. LARYNX & PHARYNX 78

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1

EAR

LONG QUESTIONS-

1) Acute Mastoiditis – aetiology,

clinical features & management.

Inflammation of mucosal lining of

antrum and mastoid air cell system is

an invariable accompaniment of acute

otitis media and forms a part of it

Aetiology- Children are affected more;

usually accompanies or follows acute

suppurative otitis media; Beta-

haemolytic streptococcus is the more

causative organism.

Clinical features-

Symptoms-

i. Pain behind ear- persistence of pain,

increase its intensity or recurrence of

pain (acute otitis media)

ii. Fever- persistence or recurrence of

fever in a case of acute otitis media

iii. Ear discharge- Profuse and

increases in purulence. Any persistence

of discharge beyond 3 weeks, in a case

of acute otitis media, point to

Mastoiditis.

Sign-

i. Mastoid tenderness (important sign)

ii. Ear discharge- Mucopurulent or

purulent discharge, often pulsatile

(light-house effect).

iii. Sagging of posterosuperior meatal

wall.

iv. Perforation of TM.

v. Swelling over the mastoid.

vi. Hearing loss.

vii. General finding- Patient appears ill

and toxic with low grade fever,

(children, high fever with rise in pulse

rate).

Management-

Investigation-

i. Blood count- polymorphonuclear

leukocytosis.

ii. Erythrocyte sedimentation rate-

raised.

iii. X-ray mastoid- clouding of air cells,

bony partitions b/w air cells become

indistinct, but the sinus plate is seen as

a distinct outline. Later stage, cavity

may be seen in mastoid.

Differential Diagnosis-

i. Suppuration of mastoid lymph nodes

ii. Furunculosis of meatus.

iii. Infected sebaceous cyst.

Treatment-

i. Hospitalization of the patient.

ii. Antibiotics- start with amoxicillin or

ampicillin (in the absence of culture

and sensitivity). For anaerobic

organisms (often present),

chloramphenicol or metronidazole is

added. Specific antimicrobial is started

on the receipt of sensitivity report.

iii. Myringotomy- when pus is under

tension.

iv. Cortical mastoidectomy- indicated

when there is

a. Subperiosteal abscess.

b. Sagging of posteriosuperior meatal

wall.

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2

c. Positive reservoir sign, i.e. meatus

immediately fills with pus after it has

been mopped out.

d. No change in condition of patient or

it worsens.

e. Complications, e.g. facial paralysis,

labyrinthitis, intracranial complication,

etc.

2) Acute otitis media (ASOM) -

aetiology, clinical features,

management & complication.

It is acute inflammation of middle ear

by pyogenic organisms.

Aetiology- more common in infants and

children of lower socioeconomic gp.

Follows viral infection of URT, but

soon the pyogenic organism invade the

middle ear.

Route of infection- via eustachian tube,

external ear and blood-borne.

Predisposing factors- recurrent attack

of common cold, URI, infections of

tonsils and adenoids, chronic rhinitis

and sinusitis, tumours of nasopharynx,

packing of nose or nasopharynx for

epistaxis and Cleft palate.

Clinical features-

i. Stage of tubal occlusion-

Symptoms- Deafness and earache (not

marked), no fever

Sign- TM is retracted, Tuning for tests

show conductive deafness.

ii. Stage of presuppuration-

Symptoms- marker earache (throbbing

nature, disturbed sleep), Deafness and

tinnitus also present (complained by

adult), high degree of fever and restless

(in child)

Sign- congestion of pars tensa, leash of

blood vessels appear along the handle

of malleus and at the periphery of TM

(cart-wheel appearance)

iii. Stage of suppuration-

Symptoms- earache become

excruciating, deafness increases. Child

run fever of 102-103℉. May

accompanied by vomiting and

convulsions.

Signs- TM appears red and bulging

with loss of landmarks, A yellow spot

may be seen on the TM where rupture

is imminent.

X-ray of mastoid – clouding of air cells

(exudate).

iv. Stage of resolution-

Symptoms- with evacuation of pus,

earache is relieved, fever comes down

and child feels better.

Signs- External auditory canal may

contains blood-tinged discharge (which

later become Mucopurulent)

v. Stage of complication-

May lead to

a. acute mastoiditis

b. subperiosteal abscess.

c. facial paralysis

d. labyrinthitis

e. Petrositis

f. extradural abscess

g. meningitis

h. brain abscess or lateral sinus

thrombophlebitis.

Treatment-

i. Antibacterial therapy-

S. pneumoniae and H. influenzae (most

common) – ampicillin (50 mg/kg/day

in four divided dose) and amoxicillin

(40 mg/kg/day in three divided dose).

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3

Those allergic to penicillin- cefaclor,

co-trimoxazole or erythromycin.

β-lactamase-producing H. influenzae or

M. catarrhalis – amoxicillin

clavulanate, Augmentin, cefuroxime

axetil or cefixime may be used.

Antibacterial therapy must be

continued for a min. of 10 days.

ii. Decongestant nasal drops-

Ephedrine nose drops (1% in adults and

0.5% in children) or oxymetazoline

(Nasivion) or xylometazoline (Otrivin).

iii. Oral nasal decongestants-

Pseudoephedrine (Sudafed) 30mg

twice daily or a combination of

decongestant and antihistamine

(Triominic).

iv. Analgesics and antipyretics-

Paracetamol

v. Ear toilet

vi. Dry local heat- relieve pain

vii. Myringotomy- indicated when

a. drum is bulging and there is acute

pain

b. incomplete resolution despite

antibiotics (drum remains full with

persistent conductive deafness)

c. there is persistent effusion beyond 12

weeks.

3) Chronic otitis media (CSOM)

- aetiology, clinical features,

management & complication.

CSOM is a long standing infection of a

part or whole of the middle ear cleft

characterized by ear discharge and a

permanent perforation.

Types- 1. Tubotympanic; 2.

Atticoantral

1. Tubotympanic

Aetiology-

i. It is sequelae of acute otitis media

ii. Ascending infection via eustachian

tube

iii. Persistent mucoid otorrhea.

C/F-

i. Ear discharge- nonoffensive, mucoid

or Mucopurulent, constant or

intermittent.

ii. Hearing loss- conductive type;

severity varies but rarely exceed 50dB.

Paradoxical effect i.e. hears better in

the presence of discharge than the ear

dry.( round window shielding effect).

In long standing cases cochlea may

suffer damage due to absorptions of

toxins from the oval and round

windows and hearing loss becomes

mixed type.

iii. Perforation- Always central (lie

anterior, posterior or inferior to the

handle of malleus).

iv. Middle ear mucosa- seen when the

perforation is large. Normally, pale

pink or moist; when inflamed it looks

red, oedematous and swollen.

Management-

Investigations-

i. Examination under microscope-

provide useful information regarding

presence of granulations, in-growth of

squamous ep. From the edges of

perforation, status of ossicular chain,

Tympanosclerosis and adhesion.

ii. Audiogram- degree of HL and its

type.

iii. Culture and sensitivity of ear

discharge.

iv. Mastoid X-ray/CT scan temporal

bone- Mastoid is usually sclerotic but

may be pneumatized with clouding of

air cells.

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Treatment-

i. Aural toilet

ii. Ear drop- Antibiotic ear drops

containing neomycin, polymyxin,

chloromycetin or gentamicin are used

three or four times a day.

Combined with steroids for local anti-

inflammatory effect.

Acid pH helps to eliminate

pseudomonas infection (irrigation with

1.5% acetic acid).

iii. Systemic antibiotics- for acute

exacerbation of chronically infected

ear.

iv. Precautions- keep water out of the

ear, hard nose blowing should be

avoided.

v. Treatment of contributory cause

vi. Surgical treatment- Aural polyp or

granulations, if present, should be

removed before local treatment with

antibiotics. An aural polyp should

never be avulsed.

vii. Reconstructive surgery- Once ear is

dry, myringoplasty with or without

ossicular reconstruction can be done to

restore hearing.

2. Atticoantral type-

Is also called unsafe or dangerous type.

Aetiology- Same as cholesteatoma

C/F-

Symptoms-

i. Ear discharge- usually scanty, but

always foul-smelling due to bone

destruction.

ii. Hearing loss- HL is mostly

conductive but sensorineural element

may be added.

Cholesteatoma hearer.

iii. Bleeding- from granulations or the

polyp when cleaning the ear.

Signs-

i. Perforation- either attic or

posterosuperior marginal type

ii. Retraction pocket- An invagination

of TM is seen in the attic or

posterosuperior area of pars tensa.

Stage -

a. Stage I- TM is retracted but does not

contact the incus

b. Stage II- TM is retracted deep and

contact the incus; middle ear mucosa is

not affected.

c. Stage III- also called middle ear

atelectasis. Middle ear is totally or

partially obliterated but middle ear

mucosa is intact.

d. Stage IV- also called adhesion otitis

media.TM is very thin and wraps the

promontory and ossicles. There is no

middle ear space; mucosa lining of the

middle ear is absent and TM gets

adherent to the promontory.

iii. Cholesteatoma- Pearly white flakes

of cholesteatoma can be sucked form

the retraction pockets.

Management-

Investigation-

i. Examination under microscope-

reveal presence of Cholesteatoma, its

site and extent, evidence of bone

destruction, granulation, condition of

ossicles and pockets of discharge.

ii. Tuning fork tests and audiogram-

essential for preoperative assessment,

to confirm the degree and type of HL.

iii. X-ray mastoid/CT scan temporal

bone- indicate extent of bone

destruction and degree of mastoid

pneumatization.

iv. Culture and sensitivity of ear

discharge.

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