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Med School Finals Series The Ear Lavandan Jegatheeswaran Ear, Nose and Throat Surgery Core Surgical Trainee 1Social Medias Case 1 Question Label the different structures of the pinna: A G B F E C DCase 1 Answer A G B F E C DStructure of the Ear Case 2 Question Label the different structures seen through the tympanic membrane:Case 2 Answer A B C D G E F Case 3 Question You are asked to see a 3 year old boy brought in by his mother. She reports that the child has had recent cold like symptoms. In the last 4 days, she reports the child being more irritable than usual and is constantly tugging on their right ear. Clinically he appears distressed and says “ear hurts mummy”. Mother reports that he has been off his food and having on and off fevers. E/ What is your primary diagnosis? A/ Patent B/ A. Acute sinusitis Sats 99% OA B. Cholesteatoma RR 22 C. Acute Otitis Media C/ HRBP 110/70larAlert but irritable D. Acute Otitis Externa CRT <2 PEARL Enlarged E. Don’t know seconds Temp 38.0 lymphadenopathy on HS I + II + 0 R side Case 3 Answer What is the most likely cause? The acute presentation of the child’s A. Otitis Media with Effusion symptoms, alongside the recent viral illness B. Cholesteatoma and clinical features of ear pain and C. Acute Otitis Media erythematous tympanic membrane points D. Acute Otitis Externa towards an infective cause of the middle E. Don’t know ear. • The acute nature of the child’s presentation rules out otitis media with effusion and cholesteatoma, both of which usually are chronic in nature and painless. • Acute Otitis Externa involves the ear canal +/- the pinna and tends to be associated with ear discharge and pain. Case 3 Explanation • 2nd most common paeds ENT presentation • Acute inflammation of middle ear and may be caused by bacteria or viruses • Haemophilus influenza • Strep pneumoniae • Moraxella catarrhalis • Strep pyogenes • RSV • Rhinovirus • Complication of URTI Case 4 Question You have diagnosed the 3 year old child with acute otitis media. They are currently in Paediatric A+E. After being given some analgesia in ED, they have been able to eat and drink. You have been asked by your senior for a management plan. How would you manage this patient? A/ Patent E/ A. Analgesia and home with no antibiotics B/ B. Analgesia and admit for pain relief Sats 99% OA RR 22 C. Analgesia and antibiotics and C/ admit HR 95 Regular D/ BP 110/70 Alert D. Analgesia and antibiotics and CRT <2 PEARL Enlarged home seconds Temp 37.5 lymphadenopathy on HS I + II + 0 R side E. Don’t know Case 4 Answer How would you manage this patient? Given the fact that the child is now able to eat A. Analgesia and home with no and drink, with normal observations and the antibiotics pain is controlled with simple analgesia, the B. Analgesia and admit for pain reliefhild can be deemed safe for discharge. C. Analgesia and antibiotics and admit D. Analgesia and antibiotics and homeAntibiotic usage is controversial but in this case E. Don’t know as there has been no resolution within 3 days, it is worth thinking about. Most patients with acute otitis media do not need admitting, unless they are very young, unable to tolerate anything orally or have complications of acute otitis media. Case 4 Explanation • Acute Otitis Media tends to resolve within 3 days, but can take up to 1 week to resolve • Antibiotics guided by clinical picture of patient • Complications • Mastoiditis • Sepsis • Meningitis • Brain Abscesses • Chronic perforations Case 5 Question You are asked to see a 35 year old man who presented with 3 day history of left ear pain. He states the pain to be unbearable. He reports persistent yellow discharge – trying to stem discharge by using cotton wool buds. Reports hearing being slightly muffled in his left ear. He also reports that he was at the seaside few days prior on holiday. A/ Patent E/ A. Perichondritis B/ B. Acute Otitis Externa Sats 99% OA RR 17 C. Acute Otitis Media D. Cholesteatoma C/ D/ HRBP 120/70lar GCS 15 E. Don’t know CRT <2 BM 8.0 seconds PEARL HS I + II + 0 Temp 37.0 Case 5 Answer What is the most likely cause? The acute nature of the presentation, A. Perichondritis alongside risk factors such as cotton wool B. Acute Otitis Externa bud usage and recent history of swimming C. Acute Otitis Media in untreated water points towards Acute D. Cholesteatoma Otitis Externa. E. Don’t know Severe otitis externa can affect the pinna and cause perichondritis in severe cases however this is not evident from the patient’s current condition. Acute Otitis Media can cause otorrhoea but that is usually after the tympanic membrane perforates – the pain also reduces once this happens. Cholesteatoma causes painless otorrhoea. Case 5 Explanation • Also known as swimmers ear, affects the ear canal and pinna • Affects middle aged people • Symptoms: • Otalgia • Otorrhoea • Itchiness in the ear canal • Temporary hearing loss • Diabetics or immunosuppressed people at high risk of developing malignant otitis externa – causes facial nerve palsy after invasion of the temporal bone Case 5 Management • Usually a course of topical ear drops – otomize, sofradex, ciladex, gentisone • If persistent otorrhoea +/- ear canal stenosis – will need referral to ENT emergency clinic for microsuctioning +/- pope wick removal • Good analgesia required • Ear swab also useful • Prevention is cure – avoid exposure to water Case 6 Question You are asked to see a 4 year old who has presented with hearing loss. An audiogram is performed. What type of hearing loss is present? A. Bilateral conductive hearing loss B. Left conductive hearing loss C. Right sensorineural hearing loss D. Normal hearing E. Don’t know Case 6 Answer What is the most likely cause? There is an upsloping bilateral conductive A. Bilateral conductive hearing loshearing loss (air bone gap >10dB). Hearing is B. Left conductive hearing loss worse than 20dB hearing loss across all C. Right sensorineural hearing lossspectrums D. Normal hearing E. Don’t know Case 6 Explanation • Normally air conduction > bone conduction • Conductive hearing loss: air-bone gap of >10dB is considered significant when averaged over 0.5, 1 and 2 kHz • Sensorineural hearing loss: no air-bone gap present Case 7 Question You are asked to see a 4 year old who is brought in by their mother as she is concerned by his development. The teachers in school report that they have to raise their voice for him to hear and that his speech and language skills seem to be affected. PMH – recurrent tonsillitis. Mother also worried about his breathing as he seems to snore at night. A. Obstructive Sleep Apnoea B. Otitis Media with Effusion C. Cholesteatoma D. Chronic Suppurative Otitis Media E. Don’t know Case 7 Answer What is the most likely cause? The history of poor speech development, A. Obstructive Sleep Apnoea B. Otitis Media with Effusion confounded by hearing loss points towards a C. Cholesteatoma diagnosis of OME. Children in this age tend D. Chronic Suppurative Otitis Mediato have large adenoids and tonsils, which E. Don’t know can prevent fluid being drained from the middle ear, thus leading to glue ear. This child is struggling with OSA from the history, however this is a spectrum of diseases caused by the child having large adenoids and tonsils. Cholesteatomas can cause hearing loss however is not present in the otoscopy image provided. Chronic Suppurative Otitis Media tends to be associated with chronic discharge from the ear which the child and mother do not report. Case 7 Explanation • AKA glue ear – most common cause of hearing impairment in childhood • > 50% of cases follow an episode of AOM, especially in children under 3 years of age • Persistence of OME may be caused by one or more of the following: • Impaired eustachian tube function causing poor aeration of the middle ear • Low-grade viral or bacterial infection • Persistent local inflammatory reaction • Adenoidal infection or hypertrophy • Management • No evidence of antibiotics in this patient cohort • Watch and wait 3 months – sometimes spontaneous resolution • If nil improvement after 6 months or affect speech and language, then referral to ENT for grommet insertion Case 8 Question You are asked to see a 50 year old woman who reports a unilateral deafness with tinnitus in the right ear. Nil vertigo symptoms. An audiogram is performed: Predominantly, what type of hearing loss is present? A. Right conductive hearing loss B. Left conductive hearing loss C. Right sensorineural hearing loss D. Left sensorineural hearing loss E. Don’t know Case 8 Answer What is the most likely cause? There is a hearing loss noted predominantly A. Right conductive hearing loss on the right side with nil air bone gap thus B. Left conductive hearing loss implying a right sensorineural hearing loss. C. Right sensorineural hearing loss D. Left sensorineural hearing loss E. Don’t know Case 8 Acoustic Neuroma • Benign tumours that arise from CN VIII and represent ~80% of cerebellopontine angle (CPA) masses • Bilateral vestibular schwannomas are strongly suggestive of neurofibromatosis type 2 (NF2) • MRI with gadolinium enhanced contrast used to delineate anatomy • Discussed in MDT – stereotactic gamma knife removal, microsurgery or watch and wait Case 9 Question You are asked to see a 7 year old who has painless discharge from their left ear. They also report hearing loss in the left ear, which is confirmed on the audiogram as left conductive hearing loss. Patient does not report any fevers. What is the diagnosis? A. Chronic tympanic membrane perforation B. Cholesteatoma C. Chronic Suppurative Otitis Media D. Otitis Externa E. Don’t know Case 9 Answer What is the most likely cause? A history of painless discharge with hearing A. Chronic tympanic membrane perforation loss should always warrant concerns for a B. Cholesteatoma cholesteatoma D. Otitis Externaative Otitis Media E. Don’t know A chronic tympanic membrane perforation can cause discharge (if infection present) and hearing loss however is not visible on otoscopy. Otitis Externa can cause discharge but is associated with an acute presentation and pain. Case 9 Explanation • Abnormal collection of keratinizing squamous epithelium growing just posterior to TM • Persistent foul smelling discharge with associated hearing loss • Usually seen as crusting in attic of tympanic membrane – can also be associated with perforation of tympanic membrane • Management • Referral to ENT if suspected cholesteatoma • CT temporal bones • Surgery to remove disease – there is small risk of recurrence and future surgery • Emergency admission • Facial nerve palsy or vertigo with cholesteatoma • Neurological features caused by direct invasion of cholesteatomaThank you Lavandan.Jegatheeswaran@nhs.net O O F Feedback & Instagram + 3C N O Please complete feedback to receive CF slides and cheat sheet!Follow our Instagram page for MCQs! NH O Cl CH 3 CH OH CH 3 3 CH OH 3 3HC CH3 HC O 3