19 - ENT History, Examination and Presentations Flashcards

Question

What are the borders of the anterior and posterior triangle of the neck?

Answer 1

**- Duration of onset** **- Any recent change in size** **- Associated symptoms** (especially red flag) **- Relevant PMHx:** smoking status, alcohol intake, and known radiation exposure.

Answer 2

- Hard and fixed lump - Associated otalgia, dysphagia, stridor, or hoarse voice - Epistaxis or unilateral nasal congestion - Unexplained weight loss, night sweats, or fever or rigors - Cranial nerve palsies **In children:** presence of a supraclavicular mass, lumps larger than 2cm, and a previous history of malignancy.

Answer 3

**Infective:** reactive lymphadenopathy, sialadenitis (e.g parotitis) **Malignancy:** lymphoma, head and neck malignancy, metastatic spread, lipoma (benign) **Vascular:** carotid body tumour **Inflammatory**: sarcoidosis **Autoimmune**: Grave's **Congenital:** Cystic hygroma, Thyroglossal cyst, Branchial cyst, Dermoid cyst

Answer 4

**Midline**: Dermoid cyst, Thyroglossal cyst, Thyroid mass, Chondroma **Anterior triangle:** Lymphadenopathy, Lymphoma (ask B symptoms), Branchial cyst, Carotid body tumour, Laryngocele, Parotid tumour **Posterior triangle (Behind SCM):** Cystic hygroma, Pharyngeal pouch, Cervical rib, Lymphadenopathy

Answer 5

**_Imaging_** **- 1st line:** US +/- FNA if suspicious features - CT or MRI - Nuclear medicine: PET for metastases or toxic thyroid nodules **_Bloods_** - See image

Answer 6

**_General examination_** - Ear, nose and throat infections (e.g.reactive lymph nodes) - Weight loss (e.g. malignancy or hyperthyroidism) - Skin pallor and bruising (e.g. leukaemia) - Focal chest sounds (e.g lung cancer) - Clubbing (e.g lung cancer) - Hepatosplenomegaly (e.g.leukaemia)

Answer 7

- An unexplained neck lump in someone aged 45 or above - A persistent unexplained neck lump at any age If there is a lump growing in size and urgent US is needed in 48 hours if aged \<25, or 2 weeks if aged \>25

Answer 8

- Reactive e.g tonsillitis - Infected lymph nodes e.g TB, HIV or EBV - Inflammatory conditions e.g SLE or sarcoidosis - Malignancy e.g lymphoma, leukaemia or metastasis

Answer 9

- Unexplained (e.g., not associated with an infection) - Persistently enlarged (\>3cm) - Abnormal shape (normally oval shaped where the length is more than double the width) - Hard or “rubbery” - Non-tender - Tethered - Night sweats, weight loss, fatigue or fevers

Answer 10

- Benign fluid-filled sac caused by a ***malformation of the lymphatic system*** - Usually in ***posterior triangle of neck or axilla*** - Usually diagnosed before 2 as ***soft painless fluctuant masses** that **transilluminate*** - Can be associate with ***Turners Syndrome*** - Can grow large enough to cause ***dysphagia and airway obstruction***

Answer 11

Only treat if symptomatic - Surgical excision - Lymphatic sclerotherapy

Answer 12

**- Benign neuroendocrine tumour (paraganglionoma)** that arise from the paraganglion cells of the carotid body - **Pulsatile painless neck lump,**with **bruit** on auscultation - **Can be moved sided to side** but not up and down **- Slow growing,** but can become large enough to compress cranial nerves so CN palsies (e.g can cause Horners)

Answer 13

On imaging can see separatingof the internal and external carotid arteries (**Lyre sign**). - Monitoring with serial imaging - Surgical excision with ENT and vascular surgeons - Radiotherapy if unresectable

Answer 14

- Congenital fluid filled sac that usually present in childhood - **Painless midline mass** that **moves up and down on tongue protrusion** - If infected can become large and painful

Answer 15

**_Sistrunk Procedure:_** - Remove central body of the hyoid bone - Remove whole thyroglossal tract - If don't remove centre of hyoid high chance of recurrence Rarely patients may develop thyroglossal duct cyst carcinoma from ectopic thyroid tissue in the cyst (papillary carcinoma)

Answer 16

Congenital neck lump. Branchial clefts form ridges known as branchial arches, involved in the formation of a number of structures in the head and neck. **Incomplete obliteration of these clefts** will result in the formation of branchial cysts. **Palpable mass anterior to SCM** If infected can become large and cause **dysphagia, dysphonia, and difficulty breathing**

Answer 17

**_Ix:_** Need to do **ultrasound-guided FNA** as there is a differential of a **cystic metastasis from a H+N SCC** **_Mx:_** **- Surgical excision** **- US guided sclerotherapy**

Answer 18

**Stridor:** High pitched noise heard on inspiration from partial obstruction of the larynx or large airways, EMERGENCY **Stertor:** Inspiratory snoring noise from obstruction of the pharynx Anything from the bronchi onwards will cause a wheeze

Answer 19

**Pouiselle's Law** - Children have smaller airways - Exponential increase in airflow resistance with decrrease in radius e. g 1mm oedema in a neonate’s 4mm airway increases resistance 16–fold

Answer 20

**- Congenital:** Laryngomalacia, web/stenosis, vascular rings * *- Inflammation:** Laryngitis, epiglottitis, croup, anaphylaxis * *- Tumours:** Haemangiomas or papillomas **- Trauma:** Thermal/chemical

Answer 21

**- Inspiratory stridor** suggests a laryngeal obstruction **- Expiratory stridor** suggests tracheobronchial obstruction **- Biphasic stridor** suggests a subglottic or glottic anomaly

Answer 22

**- Volume of the stridor decreases**: patient is becoming tired - Swallowing difficulty/drooling - Torticollis - Trismus (lockjaw) - Cyanosis - Use of accessory muscles of respiration - Poor response to initial management

Answer 23

**Acute:** Diagnosis is clinical, avoid any airway exam due to risk of airway closure from Croup or Epiglottitis **Chronic:** Fibreoptic nasal endoscopy, CT for masses, Bronchoscopy if want to see past vocal cords (supraglottic)

Answer 24

- Start **high-flow oxygen** or **Heliox** as less dense **- Alert suitable senio**r specialists (ENT and Anaesthetics) and move to **HDU setting** - **IV hydrocortisone** 200mg **- Nebulized adrenaline** (1mL of 1:1000 with 1mL saline) - Try to suction secretions or clear any foreign body from airway if obvious or visible - Take bloods, including an ABG or cultures if indicated - In emergency situations, **be prepared to perform or assist with an emergency cricothyroidotomy or intubation**

Answer 25

**- EMERGENCY** as can respiratory arrest from airway obstruction - **Progressive inflammation of the epiglottis due to HiB** (also S.Pneumoniae, HSV, P.Aeruginosa) but declining incidence due to vaccination **- Presentation:** sore throat, fever, dyspnoea, ***absence of a cough,*** drooling, painful swallowing, tripodding

Answer 26

- Do not do anything to distress patient. Clinical diagnosis - **Summon ENT** or anaesthetist and move to **HDU or ITU setting** **- High flow oxygen** **- Nebulised adrenaline** and **IV dexamethasone** **- Broad spectrum IV abx** (Cefotaxime) **- Analgesia** **- IV fluids** - Once initial management started then do **Examination Under Anaesthesia (EUA) and intubation** in theatre - **Chemoprophylaxis**

Answer 27

For anyone that is a contact and is unvaccinated give Rifampicin

Answer 28

Inflammation of the larynx, trachea and bronchus 95% are viral causes e.g parainfluenza, influenza, RSV, rhinovirus

Answer 29

**- Barking cough** and **dyspnea** that were preceded by a URTI **- Stridor** **- Usually worse at night** at gets wose over 48 hours before improve Usually affects 6 months to 2 years

Answer 30

Grade 1: Expiratory Stridor Grade 2: Pulsus Paradoxus Grade 3: Cyanosis or Reduced Cognition

Answer 31

**- Single dose of oral dexamethasone** (0.15mg/kg) **- Paracetamol and Ibuprofen** for fever and pain - Explain to patient it is **self-limiting over 48 hrs** so only admit if moderate and not settling or severe. Come back if severe signs - Explain not to give humidified air - Fluids if dehydration - Supplemental oxygen if needed **- Neb adrenaline and ICS for inpatients**

Answer 32

- Known structural upper airway obstruction - History of severe croup - Immunocompromised - Uncertain diagnosis - An unwell child with inadequate oral intake - Less than 6 months old

Answer 33

Congenitaly abnormality of the larynx. **Tissues above the vocal cords are soft so collapse on inspiration** causing **stridor** and breathing/feeding difficulties Stridor noticable in certain sleeping positions or when excited/upset

Answer 34

**- Reassure most improve by 2 years** and only have complications when laryngeal infection **- Ranitidine for reflux** - If very symptomatic can have **aryepiglottoplasty** surgery

Answer 35

Weak or altered voice **_Investigations_** **- Flexible Nasoendoscopy (FNE)**: to view larynx and the true and false vocal cords **- Microlaryngobronchoscopy (MLB)**: can be done under GA to view bronchi too **- Stroboscopy:** done in special clinc to assess vocal cord movements **- Ask about**: GORD, dysphagia, smoking, stress, singing/shouting

Answer 36

If \>3 weeks could be laryngeal carcinoma! Especially if smoker

Answer 37

- Laryngeal cancer - Vocal Cord Nodules - Muscle tension dysphonia - Vocal cord polyps - Laryngitis (Viral or Reflux) - Laryngeal papilloma - Reinke's oedema - Acute epiglottitis - Recurrent laryngeal nerve palsy

Answer 38

- Secondary to chronic phonotrauma causing hoarse voice - Benign nodules - Usually bilateral at the junction between the anterior and middle folds of the vocal cords **_Mx_**: Speech and Language Therapy (SALT) or surgical excision

Answer 39

Hoarse voice worsening towards the end of the day or following prolonged use. Voice tires easily. Due to abnormal laryngeal muscle tension Associated with stress **_Mx_**: Diagnose with stroboscopy, Reassurance, SALT therapy

Answer 40

**_Vocal Cord Polyps_** - Unilateral so need to be surgical excised to exlude malignancy **_Laryngeal Papilloma_** - Cause hoarse voice, can grow and cause airway obstruction. Due to HPV - Need excision and debulking if growing

Answer 41

**_Reflux Laryngitis_** - Acid reflux irritates larynx - OGD to diagnose - PPIs +/- H.Pylori eradication **_Viral Laryngitis_** - Supportive - Can give Penicillin V if not cleared after a week as may be secondary bacterial infeciton

Answer 42

- Deep gruff voice. Due to chronic cord irritation from smoking ± chronic voice abusse. Causes fusiform enlargement (oedema) of the cords - Usually in females, smokers, elderly **_- Mx:_** smoking cessation, voice therapy, laser therapy

Answer 43

Due to recurrent laryngeal nerve palsy (from vagus nerve) as this innervates muscle that abduct/adduct vocal cords - Weak ‘breathy’ voice - Weak cough - Repeated coughing/aspiration - Exertional dyspnoea (a narrow glottis reduces air flow)

Answer 44

Cancers (larynx, thyroid, oesophagus, lung) Iatrogenic (after parathyroidectomy, oesophageal surgery) MS Stroke Aortic aneurysm

Answer 45

ALWAYS KEEP IN MIND MALIGNANCY - Neck and Cranial Nerve exam - FNE **- 1st investigation:** CXR **- Subsequent investigations:** CT from skull base to hilum, US thyroid, OGD

Answer 46

Two roots come from the **pons**, into the **internal acoustic meatus** (inner ear) then the facial canal. After facial canal goes out through **stylomastoid foramen** and gives off first extracranial branches. Then goes into **parotid** and gives off **TZBMC** **Intracranial branches:** Greater petrosal nerve, Nerve to stapedius, Chorda tympani **Extracranial branches:** posterior auricular nerve, nerve to digastrics, and nerve stylohyoid, in parotid gives off TZBMC

Answer 47

**- Concurrent viral infection:** HSV-1, CMV, EBV - Pregnancy - Diabetes

Answer 48

**- Intracranial:** Brainstem tumours, strokes; polio, MS, cerebellopontine angle lesions (acoustic neuroma, meningitis) **- Intratemporal**: Otitis media, Ramsay Hunt syndrome, cholesteatoma. **- Infratemporal:** Parotid tumours; trauma leading to a complete palsy is an indication for urgent CT **- Others:** Bell’s Palsy, Diabetes BELL’S PALSY IS DIAGNOSIS OF EXCLUSION

Answer 49

Painless unilateral LMN lesion. ACUTE ONSET - Hyperacusis - Inability to close eye - Metallic taste - Reduced lacrimation (greater petrosal nerve) - No forehead wrinkling

Answer 50

Bell’s is LMN lesion so paralyses whole nerve. Stroke is UMN lesion so forehead sparing

Answer 51

**House-Brackmann Classification** Can see if treatment is working by rescoring them

Answer 52

- Usually clinical Can do viral serology but won’t change management **- Look in ear** for choleasteatoma and Ramsey Hunt - Examine parotid for lumps

Answer 53

**- Conservative:** Reassurance will likely resolve fully, ***Eye care*** (eye drops hourly, patch at night - MOST IMPORTANT) **- Medical:** If \<72h since onset give PO Prednisolone +/- Aciclovir for 10 days **- Surgical**: Refer to ENT if bilateral, recurrent or persistent over 1 month. Can refer for botox injections for synkinesis or to Ophthalmology for closure of eye

Answer 54

Majority will make full recover. Risks for incomplete recovery are: - Complete palsy - No signs of recovery within 3 weeks - Age \>60yrs - Associated pain - Ramsay Hunt syndrome - Associated hypertension, diabetes mellitus, or pregnancy

Answer 55

Herpes Zoster Oticus (Reactivation in geniculate nucleus so facial nerve palsy) ## Footnote - Initially moderate to severe ear pain - After a few days there is a facial nerve palsy, ipsilateral vertigo, hyperacusis, and tinnitus. Also develop vesicles on ear, anterior 2/3 tongue and soft palate

Answer 56

- Clinical diagnosis but needs prompt diagnosis as facial nerve palsy can often be permanent if left untreated **- Management**: Prednisolone + Aciclovir as early as possible **- Complications**: tinnitus, vestibular dysfunction

Answer 57

**Nasal Blockage**: sinusitis, septum deviation, foreign body, nasal polyps, influenza, enlarged adenoids, allergies **Epistaxis**: dry air, nose picking, bleeding disorders, anticoagulants, cocaine use, foreign body, tumours, trauma **Rhinitis:** allergies, aspirin, weather changes, environmental irritants

Answer 58

**Deafness:** Acoustic neuroma, Ear wax, TM perforation, Otosclerosis, Presbyacusis, Noise damage **Otalgia:** C-Spine issues, TMJ dysfunction, Tongue cancer, Laryngeal or Oesophageal Cancer **Pain in throat:** Lymphoma, Thyroid pathology, Tonsillitis, Cancer, Acute epiglottis, Croup

Answer 59

**Dysphagia**: Cancers, CN palsies, MS, Stroke, MND, Thyroid disease **Neck Swelling:** Reactive lymphadenopathy, lymphoma, metastases, primary cancer, branchial cyst, thyroid pathology,thyroglossal duct cyst **Facial Pain:** Sinusitis, GCA, TMJ dysfunction, Post-Herpetic Neuralgia, Headaches

Answer 60

**Headaches:** SOL, Meningitis, raised ICP, Benign Intracranial HTN, Migraine, SAH, Head trauma, Encephalitis **Hoarseness:** Cancers, Singers nodules, Reinke’s oedema

Answer 61

**- Acute mastoiditis:** IV co-amoxiclav **- Acute otitis media:** PO amoxicillin **- Otitis externa:** Topical acetic acid spray for 2 days **- Otitis externa with cellulitis/extension:** PO flucloxacillin **- Malignant otitis externa:** IV piperacillin-tazobactam

Answer 62

**- Acute sinusitis uncomplicated:** PO phenoxymethylpenicillin **- Acute sinusitis complicated:** IV ceftriaxone and IV metronidazole **- Chronic sinusitis:** PO co-amoxiclav **- Acute epiglottitis:** IV ceftriaxone

Answer 63

**- Ludwig's Angina:** IV benzylpenicillin and IV metronidazole **- Neck abscess:** IV co-amoxiclav **- Peritonsillar abscess:** IV benzylpenicillin and IV metronidazole **- Sore throat/Pharyngitis/Tonsillitis:** PO phenoxymethylpenicillin **- Facial cellulitis:** IV flucloxacillin

Answer 64

- Can impact wax - Trauma to ear canal - Traumal to TM

Answer 65

- Otoscopy - Pure tone audiometry

Answer 66

When the affected ear is undermost: - Latency - Torsional geotropic nystagmus - Fatigue - Habituation on repeating the test

Answer 67

It causes loss of blood supply to the cartilage of the septum

Answer 68

Anterior ethmoidal and sphenopalatine