12 - ENT

Question 1

Label the tympanic membrane including the quadrants it is split into.

Answer 1

• Pars flaccida at the top
• Pars tensa at the bottom
• Umbo is the tip of the malleus

Question 2

How do you perform an ear examination?

Answer 2

https: //geekymedics.com/hearing-ear-examination-osce-guide/
- General inspection
- Basic hearing assessment with rubbing tragus
- Weber’s and Rinne’s with 512 Hz
- Palpate the pinna, mastoid process, preauricular area
- Otoscopy with normal ear first and ask about any pain

Question 3

How is pure tone audiometry performed?

Answer 3

• Wearing headphones they measure what is the quietest sound you can hear 50% of the time at different pitches
• AC measured with headphones, BC measured with headband

- Pure tone threshold is the lowest decibel that the patient hears the pure tone 50% of the time

• May mask the patients other ear by playing a noise into it to stop the cross over problem

Question 4

How do you read an audiogram?

Answer 4

Red line = right ear

Blue line = left

Question 5

Why may someone with high frequency hearing loss struggle to comprehend speech?

Answer 5

Question 6

How may impacted ear wax present and how is it treated?

Answer 6

• Conductive hearing loss, blocked ears or a feeling of fullness, earache, tinnitus, itchiness, vertigo

`- Remove if symptomatic, need to view tympanic membrane or someone needs a mould for a hearing aid

Mx:

• Do not use cotton buds as may become foreign body
• Ear drops for 3-5 days to soften e.g olive/almond oil, NaHCO₃ 5% (not if ear drum perforation)
• If persists try ear irrigation
• Refer to ENT if after 2 attempts of irrigation and drops no change

Question 7

How may otitis externa present? (caused by P.Aeruginosa/S.Aureus)

Answer 7

- Acute <3weeks, Chronic >3months

- Diffuse when widespread inflammation of the skin and subdermis

- Localised when infected hair follicle that can become a boil in the ear canal

- Malignant when spreads to surrounding bones e.g mastoid, temporal bones

Symptoms: pain, itch, discharge, hearing loss, red oedematous ear canal, will be painful when touching pinna

Question 8

How is otitis externa treated?

Answer 8

• Treat pain with analgesic (codeine if severe)

- Warm compress

- Topical acetic acid 2% spray for 7-14 days or topical corticosteroid e.g dexamethasone spray (OTOMIZE)

• If needed oral flucloxacillin for 7 days
• Tell patient to keep ear dry and clean, avoid cotton buds, use hairdryer after swimming or shower

Mild otitis externa may be treated with acetic acid 2% (available over the counter as EarCalm)
Moderate otitis externa is usually treated with a topical antibiotic and steroid,

Question 9

How does acute otitis media present? (Hib, S.Pneumoniae, M.Cattarhalis)

Answer 9

• Most common in children, may hold or rub their ear, or fever, crying, poor feeding, restlessness, cough, rhinorrhoea
• Bulging red, yellow TM with no cone of light

- Risks: second hand smoke, nursery, facial deformities e.g cleft pallate

Complications: recurrence, hearing loss, TM perforation, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysi

Question 10

How should acute otitis media be managed?

Answer 10

- Check for intracranial complications that need emergency admission e.g mastoid tenderness

- Advise analgesia and explain self limiting 3-7 days

• Delayed or immediate prescription if systemically unwell, amoxicillin or clarithromycin 5-7 days
• Safety net

Question 11

What are the different ways that you can describe an ear drum perforation?

Answer 11

- Dry or Wet (chronic supparative otitis media)

• Central: if in pars tensa. safer

- Attic/Peripheral: if in pars flaccida. less safe as not under tension

May present with sudden hearing loss, tinnutus, fluid leaking from ear, itchy

Question 12

How do we manage a tympanic membrane perforation?

Answer 12

- Keep ear very dry and do not put anything in there whilst healing

- Analgesia and warm compress

- Don’t blow nose too hard

• If not healing /chronic supparative after 6-8 weeks refer to ENT for topical steroids, antibiotics and possible surgical tympanoplasty

Question 13

How does choleasteatoma present and how do we manage it in primary care?

Answer 13

Sac of keratinising squamous epithelium in the pars flaccida that can errode into the middle ear structures

Often asymptomatic to start then foul smelling blood stained discharge. May have retraction pocket with crust/granulation tissue/pearly white/keratin material in upper part of TM

Semi-urgent referral to ENT for audiology assessment and CT. Topical antibiotics before surgical removal

Question 14

What is this presentation of the eardrum and what is it caused by?

Answer 14

Calcification/scarring of the ear drum due to previous ear infections

Nothing to manage, no symptoms

Question 15

How does otitis media with effusion (glue ear) present and what are some risk factors of this condition?

Answer 15

• Hearing loss/dulled sounds with occassional ear pain and popping
• May have speech and developmental issues

- Abnormal colour TM (e.g yellow), loss of light reflex, air bubbles, retracted concave TM

Risk Factors: large adenoids, cleft pallate, household smoking, allergic rhinitis, ET dysfunction, Down’s

Question 16

How is otitis media with effusion managed?

Answer 16

- Observe over 6-12 weeks as may spontaneously resolve with at least two pure tone audiometry tests in this time as well as tympanometry

- Refer to ENT if hearing loss in these tests or symptoms persist after observation period

• ENT may give nasal balloon, hearing aids or do myringotomy and grommet insertion

Question 17

What is the purpose of the eustachian tube and how can it be blocked?

Answer 17

From the middle ear into post nasal space allowing mucus to clear and equillibriation of pressure when open

Cone of light on TM due to concave TM due to the pressure changes

Blocks: sinusitis, large adenoids, persistent rhinitis, smoking related changes to nasal mucosa

Question 18

How may otosclerosis present and how is it managed in primary care?

Answer 18

Symptoms: usually bilateral conductive hearing loss, speaking softly, hearing better in noisy surroundings, hearing sounds from within your body, dizziness and balance problems

• Due to abnormal bone growth, especially around stapes and the ossicles may fuse together

Refer for hearing tests and for CT. ENT may give hearing aids or stapedectomy

Question 19

How does noise related hearing loss present and what does an audiogram of this show?

Answer 19

• May have gradual onset and present with tinnitus, saying ‘what’ a lot, turning up volume on TV
• When exposed to loud noises for too long, e.g working with lawnmowers, stereocilia are damaged

- Permanent!!!! Cannot be reversed, need to prevent by moving away from loud sounds, wearing earmuffs, using noise cancelling earphones

Question 20

How does Meniere’s disease present and what are some risk factors for this disease?

Answer 20

• Episodes of vertigo, fluctuating sensorineural hearing loss, feeling of fullness in the ear, nystagmus and tinnitus lasting 20 mins-12 hours

- Risks: endolymphatic hydrops, autoimmunity, genetic susceptibility, metabolic disturbances, migraines, viral infection, head trauma

• Will have low to middle frequency sensorineural hearing loss on an audiogram

Question 21

How can we manage Meniere’s disease in primary care before official diagnose by ENT?

Answer 21

• Admit to hopsital if severe symptoms for IV labyrinth sedatives and fluids

Advice: reassure will clear up in 24 hours but to return if continues for 5-7 days, inform DVLA, don’t operate machinery when dizzy, tell patients to keep their meds always available

N+V: prescribe prochlorperazine or antihistamine/vestibular sedative (cinnarizine, cyclizine, or promethazine teoclate) for 7 days

Prevention: betahistine to reduce frequency and severity of attacks

Question 22

How does presbyacusis present and how does it show up on audiogram?

Answer 22

Bilateral sensorineural hearing loss often slow onset and in noisy environments at first. Often noticed by other people

Can get tinnitus if gets progressive

Diagnosis of exclusion

Question 23

How can presbyacusis be managed in primary care after pure tone audiometry?

Answer 23

- Reassure patient it is part of natural aging process

• Communication and environment manipulation e.g speaking face to face

- Hearing aids

- Assistive hearing devices e.g light for doorbell

• Prevent by eating antioxidants, good CVS health, good diabetic control, limiting noise exposure

Question 24

What is the definition of chronic supparative otitis media?

Answer 24

Chronic inflammation of the middle ear and mastoid cavity, which presents with recurrent ear discharges through a tympanic perforation

Do not swab the ear, refer for ENT assessment

Explain that the hearing loss will return when the perforation has healed

Question 25

How is mastoiditis managed?

Answer 25

If tympanic membrane is normal it is not mastoiditis as usually follows on from OM Refer for urgent admission if acute otitis media with mastoid tenderness. Antibiotics or mastoidectomy if abx not working

Question 26

What hearing loss on an audiogram would a tympanic perforation show?

Answer 26

Question 27

What can cause referred pain to the ear?

Answer 27

Ear exam normal then examine **TMJ, throat, dental hygeine, cervical lymph nodes, general head** and **neck** exam Take into consideration red flags and risk factors e.g weight loss, voice changes, smoking, chronic alcohol, diabetes Refer for nasal endoscopy if high suspicion

Question 28

How do we test for congenital deafness and what are some causes of this?

Answer 28

- Newborn hearing screening AOAE or AABR **- Causes:** infections e.g HSV and rubella, maternal diabetes, low birth weight, preeclampsia, low birth weight, premature birth, alcohol use whilst pregnant

Question 29

How is congenital deafness managed?

Answer 29

- Aduiology clinic within 4 weeks - Intervention before 6 months - Hearing aids from 1 month, cochlear implants from 12 months - Consider communication method e.g sign language

Question 30

What can be some difficulties with hearing loss in the following groups: - Childhood - Dementia patients - Visual impairment

Answer 30

- Behaviour and education issues - Diagnoses issues and impact on confusion - Difficulties communicating

Question 31

If a patient presents with the folowing red flags, what do you need to consider: - Unilateral sensorineural hearing loss - Rhinorrhoea - Unilateral pulsatile tinnitus - Recurrent purulent discharge

Answer 31

- Acoustic Neuroma - Basillar skull fracture - Vascular cause e.g carotid stenosis, aneurysm - Choleasteatoma

Question 32

What is Swimmer's ear?

Answer 32

Otitis externa Related to often getting wet

Question 33

What are some complications of acute otitis media?

Answer 33

- Perforation - Labrynthitis - Mastoiditis

Question 34

What antibiotics should you avoid with ENT issues?

Answer 34

- Tobramycin - Gentamicin - Furosemide loop diuretic

Question 35

Where does the ET tube open into?

Answer 35

Question 36

What is the retromolar trigone, and where do the thyroid and cricoid cartilages sit?

Answer 36

- Thyroid is shield more superior - Cricoid sits below

Question 37

How do you examine the nose in clinic?

Answer 37

**- Inspect externally:** look for deformities/deviations, lesions e.g BCC **- Inspect nasal cavity:** shine light in **- Nasal bone and cartilage palpation:** ask about any pain, look for any alignment issues. Look at infraorbital ridges **- Nasal airflow**

Question 38

What are some red flags for a neck lump?

Answer 38

Question 39

How do you do a neck exam?

Answer 39

**- General and Neck Inspection:** e.g dyspnea, neck lumps that move with swallowing or tongue protrusion, systemic signs of thyroid pathology, scars, anterior and posterior triangles **- Palpation of lymph nodes and lumps:** noting consistency, mobility, tenderness **- Inspect thyroid:** see images **- Palpate submandibular gland** **- Assess trachea**

Question 40

How do you do a throat exam?

Answer 40

**- General inspection** e.g swollen lymph nodes **- Lips and gums** e.g ulcers, dental hygeine **- Tongue** e.g glossitis, candida **- Buccal mucosa, cavity floor** and **hard palate** **- Oropharynx** using tongue depressor looking at uvula and tonsils **- Bimanual palpation of glands** **- Suggest further exams** e.g TMJ, ears, neck

Question 41

What are the three inputs of the balance system?

Answer 41

- Proprioception (somatosensory) - Vestibular - Visual Sensory inputs cause changes in eye position and limb and trunk position to maintain balance If any of these are off may feel vertigo (the room spinning)

Question 42

What is nystagmus and what is the slow and fast phase in jerk nystagmus?

Answer 42

Rapid involuntary movements of the eyes Jerk nystagmus usually due to inner ear vestibular issues

Question 43

What are some systems in the body that can cause balance issues?

Answer 43

Question 44

How does acute sinusitis present?

Answer 44

Usually triggered by URTI and lasts less than 12 weeks Presence of ***nasal blockage*** or ***nasal discharge*** with **facial pain/pressure (or headache)** and/or **reduction of the sense of smell** Suspect **acute bacterial sinusitis** when symptoms last **longer than 10 days**, discoloured or **purulent nasal discharge**, severe local pain, **fever \>38ºC**, and deterioration after an initial mild illness

Question 45

How do we diagnose and manage acute sinusitis in primary care?

Answer 45

**_Dx:_** symptoms, tenderness/swelling on palpation of sinuses, anterior rhinoscopy to look for mucosal oedema, polyps, septal deviation **_Mx:_** - If systemically unwell or infraorbital/intracranial admit to hospital - Paracetamol/Ibuprofen ***- Nasal saline*** and ***nasal decongestants*** - If *\>10days* with no improvement ***high-dose nasal corticosteroids*** 14 days e.g Mometasone BD - ***Delayed antibiotic prescription*** if no improvement after 7 days+10, either ***Penicillin V or Co-amoxiclav*** if systemically unwell - Ask pt to return if not improved in 3 weeks or deteriorates. Could be other cause e.g dental infection

Question 46

How does chronic sinusitis present and how do we manage it?

Answer 46

- Same symptoms as acute but longer than 12 weeks - If red flags e.g unilateral blood, neurological/orbital symptoms then refer **_Mx:_** - Inform pt it may last several months and to control any precipitating illnesses e.g allergic rhinitis, asthma ***- Avoid triggers***, stop smoking, good dental hygiene, avoid underwater diving ***- Nasal irrigation with saline solution*** ***- Nasal steroids*** up to 3 months if allergic cause e.g ***fluticasone, mometasone***

Question 47

How do thyroid nodules present and how would you investigate them?

Answer 47

- Solid of fluid filled lumps in the thyroid that are often **asymptomatic** and found incidentally e.g on US - If large may be **palpable/visible** and may compress oesophagus/trachea so **trouble swallowing/breathing** - If **hyperfunctioning will cause hyperthyroidism** e.g weight loss, difficulty sleeping, light periods, anxiety etc **_- Ix:_** TFTs, Thyroid US to see if solid as may be cancerous if solid, fine needle aspiration biopsy, thyroid schintography

Question 48

How can we manage thyroid nodules?

Answer 48

**- Monitor and wait** if colloid or hyperplastic nodules **- Surgical removal** if compressive symptoms or thyroid adenoma **- Fine needle aspiration** if cyst - **Radioactive iodine** to shrink hyperplastic nodules or goitre

Question 49

When should you urgently refer someone down the 2 week wait for a thyroid lump?

Answer 49

Question 50

How does acute labrynthitis present?

Answer 50

- Often occurs after a URTI - Presents with **sudden, severe onset of vertigo, n+v, hearing loss, tinnutus, unsteady gait, nystagmus** - No hearing loss in vestibular neuritis - Movement exacerbates not causes vertigo like BPPV

Question 51

How do we manage acute labrynthitis?

Answer 51

- Assess cranial nerves, gait, nystagmus, hearing **- Urgent referral:** sudden unilateral hearing loss/neurological signs/persistent symptoms \>1month - If nothing on the image helps may need surgery e.g myringotomy with effusion clearance

Question 52

How does allergic rhinitis present and how is it managed?

Answer 52

- Could be seasonal (hayfever), intermittent, occupation **_Mx_** - Allergen avoidance!!!! **Mild to moderate intermittent:** - either ***PRN intranasal antihistamines (azelastine)*** as faster or ***oral non sedating antihistamine (loratadine or cetirizine***) - consider ***intranasal chromone (sodium cromoglicate)*** if above not tolerated **Moderate to severe persistent:** - Regular ***intranasal corticosteroid*** when exposed to allergen (mometasone furoate, fluticasone furoate, or fluticasone propionate) - If nasal congestion ***intranasal decongestant (ephedrine or xylometazoline)*** for up to 5–7 days - If persistent watery rhinorrheoa despite intranasal steroid/oral antihistamine consider ***intranasal anticholinergic (ipratropium bromide)***

Question 53

When should you refer someone with allergic rhinitis to ENT?

Answer 53

**_Red flags:_** unilateral symptoms, blood-stained nasal discharge, recurrent epistaxis, or nasal pain Persistent symptoms Septal deviation or nasal obstruction that makes treatment difficult to apply intranasally

Question 54

How do nasal polpys present?

Answer 54

- Arise from nasal mucosa, usually from middle meatus and are **associated with chronic sinusitis/recurrent acute sinusitis, aspirin sensitivity and asthma** **- Symptoms:** snoring, nasal obstruction, anosmia, watery anterior rhinorrhoea, sneezing, postnasal drainage, dull headaches

Question 55

How are nasal polyps investigated?

Answer 55

**- Nasal exam:** yellow-grey colour, look at misting of the speculum for airflow, can get between them and the side wall of the nose **- Rhinoscopy** - Likely to be bilateral, if unilateral with blood stained discharge suggests cancer or foreign body. More likely cancer in Asians - If in children refer for testing for CF

Question 56

How are nasal polyps managed?

Answer 56

- **Intranasal corticosteroids** e.g mometasone and fluticasone, betamethasone - Oral antihistamines if allergic rhinitis - Nasal saline irrigation - LTRA **- Gold standard:** functional endoscopic sinus surgery

Question 57

What are some causes of cervical lymphadenopathy in primary care?

Answer 57

**- Infective cause:** e.g TB, CMV, EBV, HIV. If persists after 2-4 weeks arrange urgent referral to ENT **- Boils/Abscesses:** from infection **- Malignancy:** lymphoma, leukaemia, metastasis from lung/stomach

Question 58

How would you investigate cervical lymphadenopathy in primary care if you are concerned e.g not an infective cause?

Answer 58

**- Generalised lymphadenopathy:** urgent FBC within 48 hours to look for leukaemia **- Unexplained lymphadenopathy and/or splenomegaly:** refer 2 week wait if over 25, refer 48 hours if child or \<24 to exclude lymphoma - **\>40 with supraclavicular lymphadenopathy:** refer 2 week wait for CXR to exclude lung cancer **- \>45 with lymphadenopathy/hoarse voice:** refer 2 week wait to exclude laryngeal cancer **- Lymphadenopathy and oral ulceration\>3 weeks:** refer 2 week wait to exclude oral cancer

Question 59

How does BPPV present and what is the underlying pathology of this condition?

Answer 59

- Repeated transient episodes of vertigo on positional change e.g turning in bed, bending over - N+V - Loss of balance

Question 60

How is BPPV diagnosed and managed?

Answer 60

**Dx**: Dix-Hallpike manoeuvre showing vertigo and possible nystagmus **Mx:** - Watchful waiting - Epley manoeuvre - Brandt- Daroff exercises - Drug treatment does not help - Return in 4 weeks if not improved

Question 61

How do we perform the Dix Hallpike and Epley manoeuvre?

Answer 61

https://www.youtube.com/watch?v=D6qEdlFVxig

Question 62

What are some symptoms of a deviated nasal septum and what will you see on examination of the nasal cavity?

Answer 62

**- Nasal obstruction** (difficult to breathe from one nostril) **- Snoring** **- Recurrent sinus infections** or **nose bleeds** - May be congenital or acquired e.g nasal injury in contact sport

Question 63

How do we manage a deviated nasal septum?

Answer 63

- Take hisotry asking about trauma, impact on life etc **- Symptomatic relief** to relieve mucosal oedema e.g ***nasal decongestants, antihistamines, nasal corticosteroids*** which take a few weeks to reach maximal effect **- Septoplasty**

Question 64

How does a vestibular migraine present?

Answer 64

- Recurring episodes of vertigo alongside other migraine symptoms lasting 5 minutes to 72 hours. Vertigo is NOT the aura!!!! - Might have migraines before vertigo for years - Can rule out other causes with MRIs but can diagnose once at least 5 episodes of vertigo, at least half of these episodes occur with migraines, migraines in the past

Question 65

How is a vestibular migraine managed?

Answer 65

- Diagnosis of exclusion e.g exclude Meniere's, **_- Mx_** - avoid triggers e.g poor sleep, hunger - usual migraine analgesia e.g ibuprofen and triptans - prevention with amitriptyline

Question 66

How does a nasal fracture present and how would you investigate it?

Answer 66

**- Symptoms:** trauma causing nasal deformity/deviation, bruising, epistaxis, rhinorrhea - Do nasal exam looking for **septal haematoma**, facial xray NOT usually performed as diagnosis clinical

Question 67

How is a nasal fracture managed?

Answer 67

- Analgesia and ice packs - Closed reduction after 5-7 days so as to allow for swelling to decrease - Surgical intervention if more complicated

Question 68

How does vestibulopathy present and what are some of the causes?

Answer 68

Vertigo imbalance, nausea, and vision problems caused by inner ear labyrinth pathology Patients are at risk of frequent falls Treatment can focus on inner ear as the cause of imbalance/falls

Question 69

When an elderly person presents with loss of balance, what are some underlying causes you should consider?

Answer 69

Question 70

What are some post thyroidectomy complications?

Answer 70

**- Hypoparathyroidism**: check Ca levels and check for any tingling around mouth **- Bleeding** and **compartment syndrome** which can block airway

Question 71

What is Samter's triad?

Answer 71

When an individual has **asthma, sinus inflammation with recurring nasal polyps**, and **sensitivity to aspirin** and some other NSAID They have severe reactions to upper and lower respiratory tract infections

Question 72

How can you tell the difference between a hypertrophic turbinate and a polp?

Answer 72

Question 73

What examinations can we do to assess balance?

Answer 73

- Rombergs (loss of proprioception) - Dix-Hallpike - Rotary chair test - Electronystagmography/Videonystagmography

Question 74

Type of hearing loss in Ototsclerosis?

Answer 74

Conductive deafness | from oxford gp handbook

Question 75

Type os hearing loss in Presbycusis?

Answer 75

Sensorineural deafness