1. Feb 2017. ST1a group. DTV programme
ENT presentation
Feb 2017.
ST1a group. DTV programme

2. I am not an ENT specialist !

3. Otoscopy (1) What is this condition ? How would you treat it ?
Otitis externa.
Often there is ear canal oedema making otoscopy painful and this is the reason for using combined antibiotics/ steroids
Otomize - dexamethasone, neomycin and acetic acid. Used for adults/ children above 2 yrs of age.
- advised not to use if known TM perforation. Use for 2 days beyond sx resolving (up to 2 weeks).

4. Otitis Externa T/F
Otitis externa tends to be more painful rather than itchy and uncomfortable.
Otitis externa should always be swabbed at presentation to exclude fungal infection.
Aminoglycoside (gentamicin, neomycin) ear drops should never be used if there is a known tympanic membrane perforation.
Oral antibiotics are not an effective treatment for otitis externa.
False – tends to itchy with scanty discharge.
False – usually bacterial – pseudomonas or staph
False – can be used safely in the presence of infection for a maximum of 2 weeks (neomycin thought to be better than gentamicin)
True – do not use oral antibiotics except ciprofloxacin (for months) in malignant OE (osteomyelitis, not a cancer !)

5. Otoscopy (2)
What is this condition commonly seen in swimmers and surfers.
Exostosis. Swimmers nodules – nearly always bilateral and asymptomatic.

6. Ear discharge
More likely to see thick purulent ear discharge in acute OM with discharge
2 peak prevalence at 1-2 yrs and 5-6 yrs.
Think of cholesteatoma if foul smelling chronic dx with associated hearing loss. Give topical antibiotics for 2 weeks and refer urgently to ENT. Probably best to use ciprofloxacin (not licensed)

7. Ear discharge T/F
Otitis externa results in a more profuse discharge than otitis media with perforation.
Fungal infection should be considered in resistant OE after multiple antibiotic use.
The presence of ear discharge in acute otitis media is more likely to receive antibiotics.
Chronic suppurative otitis media may represent an underlying cholesteatoma..
False – scanty discharge.
True – especially if dx is fluffy , white and sx are more than you would expect for the clinical appearance.
True – NICE say “consider” immediate antibiotics for children who present with AOM and discharge.
True - usually as a consequence of trauma (grommets) or acute OM with perforation.

8. Otoscopy (3)
What is this a presentation of in a patient with chronic ear discharge.
cholesteatoma

9. Otoscopy (4) What is this condition?
How old is this child likely to be ?
Acute OM is essentially a painful ear but can cause irritability, poor feeding, fever and vomiting in a smaller child (under 2 yrs of age)
Analgesia is more important than antibiotics.

10. Otitis media T/F
All children presenting with red eardrums should receive antibiotics.
Ear pain is the most useful symptom
Antibiotics are more likely to be effective in children aged under 2 yrs old with bilateral otitis media.
Children are generally more settled in acute OM when there is ear discharge present.
False – 60% resolve within 24 hrs and 80% within 3 days. Consider antibiotics if fever or vomiting, especially in a child
But need to treat 3 children to prevent 1 child experiencing pain or fever at 3-7 days. Ear pain resolves in 90% children within 8 days (without antibiotics).
True – usually less than 6 yrs old and often preceded by URTI
False – no but NICE say consider if acute OM with discharge (acute suppurative OM)
True – pain tends to peak at night and the pressure relieved by perforation – not seen due to purulent discharge.

11. Otoscopy (5) What is this a picture of in a pre-school child?
Glue ear (otitis media with effusion)

12. Glue ear (OME) T/F
20 – 50% of children under 10yrs have had at least 1 episode of otitis media with effusion (OME).
OME often co-exists with large adenoids and the child may be a mouth-breather.
OME does not cause speech or delayed language development.
In OME, the TM will always be retracted and yellow with visible bubbles.
True – most common between 1 – 6 yrs of age.
True – linked to ETD, large adenoids, atopy and passive smoking.
False – 90% resolve within 3 months but child should be referred to community audiology if suspected hearing loss or developmental delay
False – TMs not inflamed (no acute infection) but can be dull grey/ amber or red and can be flat/ bulging or retracted.

13. Otoscopy (6) What is this and what part of the TM is affected.
Perforation. Pars flaccida

14. Hearing loss T/F
Impacted wax is unlikely to cause significant hearing loss
A fullness in the ear sensation may be a symptom of ETD.
Asymmetric hearing loss does not need investigation.
A 512 Hz tuning fork test for unilateral sensori- neural deafness (Weber) will lateralise to the affected side (the deaf ear).
False – especially when impacted – should not be in lower ear canal.
True – main sx is muffled or reduced hearing but may also get tinnitus, fullness or even pain.
False – refer as will need MRI scan to exclude acoustic neuroma, especially if other sx such as tinnitus or vertigo.
False – it will lateralise to the hearing ear which is opposite in conductive deafness.

15. Otoscopy (7)
What is this seen in a small child who presents with ear pain.
Grommet (not grommit)

16. It is a clue !

17. Sudden hearing loss T/F
Usually seen in year olds and rare.
Should be referred that day to ENT if hearing loss has developed over less than 72 hrs.
Patients are often given high dose steroids.
50% will recover some or all of their hearing spontaneously over 1-2 weeks.
True - sudden sensorineural hearing loss (SSHL)
True – acute ENT emergency
True – some evidence from steroids to suggest a benefit.
True – yes and 85% over 2-4 weeks. 15% will develop permanent deficit.

18. Otoscopy (8) What is this ? What is this ? Normal eardrum.
Tympanosclerosis – due to scarring – often seen in children who had grommets.
What is this ?
What is this ?

19. Tinnitus.
Tinnitus may present with the patient reporting perception of noises as varied as pure tones, music, speech or random white noise. The site of perception is ascribable to the head generally, or occasionally one ear. The association with intermittent bouts of vertigo and hearing loss direct one to a diagnosis of Meniere's disease.
Although tinnitus is not a psychological disorder, it may cause anxiety concerning its cause, prognosis and the patient may fear of its influence on lifestyle and work (1).
Tinnitus may also produce or exacerbate symptoms such as tension, frustration, loss of concentration, sleep disturbance and depression (1). Otoscopy may disclose impacted wax, a tympanic membrane perforation or middle ear disease.
Patients with unilateral tinnitus should be referred to an ENT specialist to exclude an acoustic neuroma.

20. Tinnitus T/F
Unilateral tinnitus is thought to be safe, with or without associated otological features.
Pulsatile tinnitus should be referred to ENT
Tinnitus can be associated with hearing loss and vertigo.
Addressing hearing loss by removing wax or referring for hearing aids are not helpful.
False – most cases are benign but consider referral for assessment if unilateral and recent onset, especially if unilateral hearing loss or tympanic membrane abnormalities.
True – rhythmical noise of the same rate as heart beat - usually due to heightened awareness. But can be due to altered blood flow through the blood vessels. Can be objective if heard by a steth over the neck/ base of skull.
True – Meniere’s disease
False – addressing hearing loss by removing occlusive wax, referring for hearing aids, treating infection or surgery in otosclerosis can be helpful.

21. Otoscopy (9) What abnormality can you see here ?
What would you do with this ?
Retraction pocket – not a perforation – cannot see middle ear contents and still features of tympanic membrane in the defect.

22. Are you ready to be ENT informed !