Minimum criteria

Symptoms and clinical features of diffuse otitis externa

Symptoms:

• earache, ear itching, ear discharge, feeling of ear blockage, possible moderate hearing loss.

• There is usually no fever. Good general condition, tragus usually sensitive to pressure

Clinical picture:

• swelling and hiperemia of the skin of the ear canal, serous or purulent or crumbly discharge.

• Tympanic membrane appears to be normal.

Symptoms and clinical features of acute otitis media (AOM) – suppurative form

Symptoms:

• earache, fever, hearing loss, otorrhoea in case of perforation, loss of appetite, malaise

Clinical picture:

• moderately wide ear canal, initially free of secretions, with secretions in case of perforation.

• Vascularized, blood-filled tympanic membrane, later bulging.

• The tympanic membrane may spontaneously perforate.

Causes of acute hearing loss

Conductive:

• cerumen plug, foreign body, otitis media (serous or purulent type), trauma (e.g. perforation of the tympanic membrane)

Sensorineural:

• acute noise, viral infection, vascular causes, toxical damage (medication, chemicals), traumas.

What is to be done in case of acute sensorineural hearing loss?

• immediate oral or intravenous steroid bolus treatment

• if necessary with hospitalization

• meanwhile detailed investigation is required to be carried out to clarify the etiology.

• The earlier the treatment is started, the better the outcome is.

Recognition of hearing loss in childhood, newborn hearing screening

Signs of hearing loss in childhood:

• the newborn doesn’t react to sounds

• tone of crying is unusual

• visual orientation is dominant

• speech development is delated

• tone, pitch, intensity, melody and rhythm of speech is pathologic

• articulation disorders

• worse reading and writing skills

Infant hearing screening:

• with objective testing methods in first few days after birth

  • BERA, may be OAE

• Mandatory examination in all infant care facilities

• further examination in centres if hearing loss

Causes of ear pain

Primary:

• otitis externa, otitis media, tumours of ear

Referred ear pain:

• tumors and inflammations of the larynx, pharynx, tonsils, base of the tongue;

• neuralgic pain (n. IX, n. X, n. V/1, C/II-III, n. VII);

• dental inflammations, temporomandibular joint syndrome.

Complications of acute otitis media AOM

Extracranial:

• intratemporal

  • acute mastoiditis, zygomaticitis, petrositis, facial nerve palsy, labyrinthitis

• extratemporal

  • abscess: subperiosteal, preauricular, suboccipital

  • Bezold’s abscess

Intracranial

• extradural abscess, sinus phlebitis- sinus thrombosis, subdural abscess, meningitis, encephalitis, brain abscess

General: sepsis

Clinical symptoms and recognition of acute mastoiditis

Associated with, or following acute otitis media:

• the pinna is pushed forward

• retroauricular pain, erythema

• the posterior wall of external ear canal is swollen, seems to be lowered

• pulsating, severe pain

• pulsating otorrhea

• fever

• symptoms may be milder with antibiotic pretreatment

• covered mastoid cavity based on imaging (CT, possibly MR)

Causes of unilateral otitis media with effusion (OME) in adults and childhood

• Chronic dysfunction of the Eustachian tube

  • (adenoid vegetation or nasopharyngeal tumor).

• In adults, the possibility of a nasopharyngeal tumor must not be left out of consideration!

How to diagnose vertigo caused by vestibular disorders

Patient history:

• type of vertigo (sensation of spinning or falling), vegetative symptoms, nausea, vomiting.

Examination:

• deviation, tilting.

• Patient has spontaneous nystagmus or nystagmus provoked by head movements.

• Brief description of head-impulse test.

Causes of peripherial facial palsy

• Bell’s palsy

• Herpes zoster oticus

• other viral or bacterial infections (HSV, EBV, Lyme);

• acute and chronic middle ear diseases (acute and chronic middle ear infections, cholesteatoma, rarely tumors);

• tumors of the pontocerebellar angle, vestibular schwannoma;

• cranial traumas (pyramid bone fractures),

• extratemporal traumas;

• malignant tumors of parotid gland.

Differential diagnosis of central and peripheral facial nerve palsy

Peripheral facial paralysis:

• function of all nerve branches distal to underlying cause is affected

• In case of involvement of main branch of facial nerve- full ipsilateral facial motor function is lost

Central paralysis

• function of frowning and the muscles around eyes is preserved on the affected side due to bilateral innervation of the affected muscles

• Motor function of lower part of the face are list

• often associated with other neurological symtpoms- slurred speech, limb weakness or sensory disturbances

Primary management of epistaxis/nosebleeding (at home/ambulance/by GP)

• The patient should lean forward with open mouth, firm digital pressure should be applied to both nasal alae for 10 minutes;

• Ephedrine/nasal drop/vasocontrictor solution-imbibed cotton or spongostan should be applied in nasal cavity;

• Cold compress should be applied to the nape of the neck and to the nasal dorsum;

• Blood pressure-measurement, antihypertensive treatment if needed.

Management of epistaxis/nosebleeding (anterior, posterior) by ENT professionals

• Blood pressure-measurement, antihypertensive treatment - if needed.

• Visible bleeding source:

  • chemical cauterization (trichloroacetate, silver nitrate) or coagulation (bipolar electrocoagulation).

• Anterior nasal bleeding:

  • anterior nasal packing.

• Posterior nose bleeding:

  • Bellocq tamponade and anterior nasal packing, possibly balloon catheter. Endoscopic electrocoagulation.

Management and complications of nasal folliculitis and furuncles

• The infection is usually caused by Staphylococcus aureus.

• Circumscript folliculitis:

  • local therapy with antibiotic and steroid containing creams, vapor coverage.

    • The patient should be told not to pick or squeeze the lesions.

• For furunculosis and/or phlegmonous reaction

  • parenteral antibiotics should be administered, along with vapor coverage, initiation of anticoagulant treatment.

• Possible complications:

  • facial phlegmone, angular vein thrombophlebitis, cavernous sinus thrombosis.

Types of rhinitis (list)

• common infections: simple acute rhinitis, purulent rhinitis;

• allergic rhinitis

• specific forms of rhinitis: TB, syphilis, sarcoidosis;

• atrophic rhinitis (oezena)

• rhinitis sicca anterior.

• other causes:

  • idiopathic, vasomotoric, hormonal, drug-induced, rhinitis medicamentosa, occupational (caused by irritants) foodstuffs.

    • (3 causes are required from the “other” group)

Clinical features and management of angioedema (Quincke-edema)

Symptoms and clinical features:

• urticaria, edema in the head and neck region;

• dysphagia, globus feeling or visible swelling in the throat, choking.

• In a severe form: anaphylaxis.

Treatment:

• antihistamines, corticosteroids, adrenaline,

• maintaining free airways: cricothyrotomy/tracheotomy – if needed.

Complications of paranasal sinus infections (list)

Extracranial complications:

• periorbital cellulitis

• subperiosteal abscess

• orbital phlegmone/ abscess

• osteomyelitis

• sepsis

Intracranial complications:

• meningitis

• epi/subdural or brain abscess, encephalitis

• cavernous sinus thrombosis

Where does the patient localize the pain in cases of frontal, maxillary, ethmoidal or sphenoidal sinusitis?

• frontal sinusitis – forehead;

• maxillary sinusitis – face;

• ethmoidal sinusitis –periorbitally, between the eyes;

• sphenoid sinusitis – crown of the head, referring to the occipital area;

• all forms of sinusitis can cause diffuse headache.

Causes of unilateral nasal obstruction and discharge in childhood and in adulthood

Childhood:

• foreign body, sinusitis, nasopharyngeal angiofibroma,

• congenital malformation: choanal atresia, meningoencephalocele

Adulthood:

• nasopharyngeal tumours

• deviation of the nasal septum

• hypertrophy of turbinates

• tumours of blocking the nasal cavity eg polyp, benign or malignant tumour

• trauma and its late consequences

ENT diseases causing headache

• viral infection of the upper airways;

• inflammation of nasal sinuses: (acute and chronic);

• benign and malignant tumors of nasal sinuses;

• cervical: cervical vertebra disorders, spondylosis, myalgia;

• complications of otitis and sinusitis: mastoiditis, meningitis, brain abscess, inflammation of the petrous pyramid;

• neuralgias;

• pain of temporomandibular joint.

Most frequent causes of dysphagia

• GERD

• inflammation in the mesopharyngeal, hypopharyngeal and laryngeal region;

• tumors in the mesopharyngeal, hypopharyngeal and laryngeal region;

• neuralgia (n. IX, n. X);

• sensorial and motor innervation disorders: sensorial disorders in supraglottical region;

• foreign bodies in the hypopharynx and oesophagus;

• esophageal motility disorders, achalasia;

• diverticulum (e.g. Zenker);

• esophageal, hypopharyngeal stenoses;

• processus styloideus elongatus,

• globus feeling, psichogenic disorders,

Indications of tonsillectomy (absolute and relative)

Absolute indications:

• rheumatic fever, peritonsillar abscess, tonsillogenic sepsis

Relative indications:

• chronic tonsillitis, recurrent T, tonsillogenic or posttonsillitis focal symtpoms, marked hypertrophy of the tonsils causing mechanical obstruction

• if tonsilar tumour is suspected

• mycosis tonsillae

• OSAS, or other obstructive sleep related breathing disorders

• severe orofacial/ dental disorders causing narrow upper airways

Clinical features and symptoms of peritonsillar abscess

Symptoms:

• throat pain (unilateral), referred ear pain,

• difficulty in swallowing, trismus,

• the speech is thick and indistinct, oral fetor,

• fever, insomnia, loss of appetite.

Clinical signs:

• swelling, redness and protrusion of the tonsil,

• faucial arch, palate and uvula;

• the uvula is pushed towards the healthy side.

Peritonsillar abscess – treatment

Drainage of the abscess:

• puncture, incision, daily opening of the abscess cavity, tonsillectomy 6 weeks after recovery („á froid”);

• abscess-tonsillectomy („á chaud”).

• Antibiotics, decreasing edema, analgesics, administration of fluids.

Clinical features, symptoms and complications of para- and retropharyngeal abscesses

Symptoms:

• throat and neck pain, foreign-body sensation,

• fever, difficulty in swallowing, trismus,

• torticollis, swelling of the lateral or posterior pharyngeal wall,

• thick speech, laryngeal/oropharyngeal edema.

Complications:

• Oropharyngeal and laryngeal edema, septicemia, mediastinitis, choking.

Pathogens of tonsillitis and pharyngitis, indication of antibiotic treatment

• Viral: 80-90%

  • adenovirus, rhinovirus, EBV- infectious mononucleosis

• Bacterial

  • s, pyogenes- follocular tonsillitis

  • group c and G streptococci

  • mycoplasma, chlamydia, neisseria subspecies

  • pneumococci, haemophilus influenzae, moraxella catarrhalis, staph, subspecies

• Antibiotic therapy indications

  • only in bacterial infection- centor criteria

  • physical findings, lab findings- BC, CRP, ESR, rapid bacteriological test

  • types of complaints (acute or chrronic) based on antibiogram, presence of immunosuppression

Causes of chronic hoarseness (why is it necessary to visit an ENT specialist after 3 weeks of hoarseness?)x

• acute and chronic inflammations of the larynx;

• benign laryngeal lesions (cysts, granulation, Reinke edema, polyps, papillomatosis);

• malignant laryngeal lesions;

• recurrent laryngeal nerve paresis,

  • (which can be caused by: hypopharyngeal, thyroid gland, esophageal, pulmonary, mediastinal cancer, intracranial diseases);

• GERD;

• It is exceptionally important to diagnose a malignant lesion as soon as we can.

Symptoms of head and neck tumors

• Hoarseness,

• dyspnea,

• dysphagia,

• referred ear pain,

• globus feeling,

• hemoptoe,

• foetor ex ore,

• loss of body weight,

• neck lump,

• visible mucosal leukoplakia,

• erythroplakia.

Swollen neck lymph nodes – causes

• Non-specific inflammations

  • (e.g. upper respiratory tract infections);

• Specific inflammations:

  • Bacterial: TB, syphilis, cat scratch disease, tularemia, •

  • Protozoal: toxoplasmosis,

  • Viral: HIV-infection,

  • Non-infectious: sarcoidosis;

• Lymphomas

• Metastases of head and neck cancer

Evaluation of neck lumps – diagnostic steps

1. Correct, accurate registration of patient history:

   1. e.g. duration of symptoms, upper respiratory tract infections, dysphagia, hoarseness;

2. Careful ENT examination –

   1. special attention should be paid to the examination of the neck: localization, consistency, sensibility of the lump, its relation to the surrounding structures;

3. Blood tests: inflammation markers, serology;

4. Imaging modalities: ultrasound, CT/MRI;

5. US guided Fine Needle Aspiration Biopsy;

6. For lymphadenomegaly, excision of the node is carried out only if the evaluation of the FNAB reveals lymphoma (or, if it is needed by the pathologist).

   1. Reason: it is necessary to avoid the removal of the metastasis of a hidden primary tumor before examination, or isolated metastasectomy.

Causes of dyspnea in the upper respiratory tract

• upper respiratory tract infections (tonsillitis, epiglottitis, laryngitis),

• lumps in the upper respiratory tract: abscess, granulation tissue, malignancies,

• non-specific reactions of the upper respiratory mucosa:

  • allergy, Reinke edema, hereditary angioneurotic edema,

• foreign body,

• crico-tracheal stenosis,

• recurrent laryngeal nerve palsy (one or both side).

Middle-aged, smoker patient presents with unilateral ear pain, but the examination of the ear does not reveal any disorders. What may be the cause, and what is obligatory to be examined?

• Unilateral, referred ear pain is a typical finding in patients with hypopharyngeal (less commonly supraglottic and oropharyngeal) malignancies.

• This symptom and the tobacco use in the patient history make the examination of the oral cavity, oropharynx/hypopharynx, larynx and the neck obligatory.

Management of choking patients – if intubation cannot be carried out

1- Cricothyrotomy

• in the lack of time and appropriate tools: we find the cricothyroid ligament above the cricoid cartilage (using fingers)

• , and after carrying out a transversal incision on the skin,

• we pierce the ligament with any instrument at hand,

• and insert a holed tool (e.g. outer tube of a pen).

2- Tracheotomy

• After incising the skin and the platysma,

• we find (and if necessary - ligate) the isthmus of the thyroid gland,

• and - at the 2nd or 3rd tracheal cartilage -

• we make an incision on the anterior wall of trachea (in childhood) or remove a part of the cartilage (in adults).

• We insert a tube/cannula in order to maintain the free airway.