9. ENT Flashcards
Consider USOC referral for suspected laryngeal cancer if:
Person aged >45 with:
Persistent unexplained hoarseness
OR
Unexplained lump in neck
Which two cancers increase the risk of specifically head and neck cancer, and why?
Thyroid
Lymphoma
May have had exposure to radiation in the past to the chest and neck.
Someone presents with hoarseness. What 4 things are important to ask about regarding this?
Progressing?
Smoker?
Voice quality normally?
Intermittent or constant?
What is the most common type of laryngeal cancer?
Squamous cell carcinoma
Strong links to alcohol and smoking
Hoarseness is the cardinal symptom
Why can lung primaries cause hoarseness?
Infiltration / compression of the recurrent laryngeal nerve.
RLN supplies most of the instrinsic muscles of larynx except the cricothyroid, so this would cause vocal cord paralysis.
Where does a thyroglossal cyst usually arise, how can it be identified and how can it be managed?
Midline mass due to failure of the thyroglossal duct (which connects tongue and thyroid) to atrophy.
Moves upwards with tongue protrusion, most cases in <20s.
Surgical excision can be done (Sistrunk’s procedure).
Thyroid nodules present as midline masses that move on swallowing. 95% are benign, but it is important to rule out malignancy. Which tests should be done for these patients?
Thyroid function tests
US thyroid
Give 4 benign causes of thyroid nodules.
Multinodular goitre
Thyroid adenoma
Hashimoto’s disease
Cysts
Give 5 malignant causes of thyroid nodules.
Papillary ca
Medullary ca
Follicular ca
Anaplastic ca
Lymphoma
Which specific thyroid function test is best used for monitoring disease and guiding treatment in thyroid disease?
TSH
TSH is more sensitive than T4 levels.
Often an early marker, e.g. TSH is high and T4 is normal in subclinical hypothyroidism.
A goitre can have a variety of causes, including iodine deficiency, Hashimoto’s and Grave’s disease. What is important to test for considering most thyroid disorders are autoimmune?
TFTs
TPO antibodies (90% of patients with Hashimoto’s)
TSH receptor antibodies (80-90% in Grave’s)
Lateral masses are more likely to be malignant than midline ones in the neck. There should be a high index of suspicion if over 35 years old. A full examination and US + FNA/core biopsy is required. Give the 3 types of cancer that could present with a lateral mass.
SCC - likely to arise from head and neck
Adenocarcinoma - pathology more likely to arise below the clavicles
Lymphoma
What is the most common tumour of the parotid gland?
Pleomorphic adenoma
What is the typical age range for a pleomorphic adenoma, and what clinical signs and symptoms may the patient present with?
Age 40-60
Gradual onset, painless, unilateral swelling of the parotid gland.
Slow growing and mobile on examination.
What are the recurrence / transformation rates for a pleomorphic adenoma?
2-5% recur after appropriate surgical excision, maybe due to capsule damage.
2-10% experience malignant transformation.
Which nerve runs through the parotid and can potentially be affected in a malignant parotid lump?
Facial nerve
Facial nerve palsy can be present.
What does the facial nerve supply?
FACE, EAR, TASTE, TEAR
Facial expression muscles
Nerve to stapedius
Anterior 2/3 of tongue
Parasympathetic supply to lacrimal and also salivary glands
LMN vs UMN facial nerve palsy:
UMN spares the forehead.
LMN lesions affect all facial muscles.
Causes of unilateral facial nerve palsy:
Acoustic neuroma
Parotid tumours
Bell’s palsy
Ramsay Hunt syndrome (herpes zoster infection)
HIV
MS
Diabetes
Causes of bilateral facial nerve palsy:
Bilateral acoustic neuroma as in NF2
GBS
Sarcoidosis
Lyme disease
What is a Warthin tumour, and when in life is it most likely to occur?
2nd most common benign parotid tumour - papillary cystadenoma lymphoma.
60s and 70s are most common ages for this to arise.
Lymphocytic infiltrate and cystic epithelioid parotid gland tumour.
A Warthin tumour can be present bilaterally in 10% of people. Does it have a male or female predominance, and what other 1 lifestyle risk factors is heavily implicated?
Male predominance
Smoking is a major risk factor
What is a branchial cyst and who tends to get them?
Benign developmental defect of the branchial arches.
Filled with acellular fluid and cholesterol crystals.
Squamous lined.
Young adults are the most common group, and they tend to enlarge post-infection.
Give some typical examination features of a branchial cyst.
Unilateral lateral neck lump anterior to the sternocleidomastoid.
Smooth, soft and fluctuant.
Non-tender.
May present with a fistula and in these cases infection is more common.
NO movement on swallowing
NO transillumination
How are suspected branchial cysts investigated and managed?
Consider and exclude other malignancies
US
Refer to ENT
Surgical excision
Abx if acute infection
What is important to ask about when a patient presents to you with dysphagia (7)?
Liquid / solid / both / change?
Progression
Regurgitation / halitosis
Constant or variable?
Sudden onset?
Weight loss?
Odonyphagia?
Give 3 criteria that are used to diagnose otitis media.
Acute onset
Presence of middle ear effusion e.g. bulging of membrane or discharge from ear
Inflammation of tympanic membrane e.g. erythema
Which 3 organisms are most likely to be a cause of otitis media.
Strep pneumoniae
H. influenzae
Moraxhella catarrhalis
Give some clinical features of acute otitis media with possible otoscopy findings
Otalgia
Fever in 50%
Hearing loss
Recent viral URTI
Bulging tympanic membrane
Loss of light reflex
Perforation with purulent discharge
Acute otitis media is generally self-limiting and does not usually require antibiotics. However, there are some exceptions. Give 5 situations in which antibiotics should be prescribed immediately, and what the appropriate prescription would be.
Amoxicillin 5-7 days
BITSS:
Bilateral otitis media in <2s
Immunocompromised / severe comorbidity
Tympanic membrane perforation
Symptoms lasting >=4 days / not improving
Systemically unwell
Give 3 common sequelae of acute otitis media.
Perforation - can develop into CSOM (chronic suppurative otitis media, defined as perf of the tympanic membrane with discharge for >6 weeks)
Hearing loss
Labyrinthitis
Give some rarer complications of otitis media to be aware of.
Mastoiditis
Meningitis
Brain abscess
Facial nerve palsy
What does glue ear describe, and what are the common presenting features?
Acute otitis media with effusion
Peak incidence at age 2
Presenting feature is hearing loss (most common cause of conductive hearing loss and elective surgery in children)
2 types of cancer most likely to be associated with hoarseness?
Laryngeal malignancy
Lung esp apical malignancy
Consider USOC referral for suspected oral cancer if:
Unexplained ulceration in oral cavity for > 3 weeks
OR
Persistent, unexplained lump in the neck
Assessment by dentist required for:
Lump on lip or in oral cavity
OR
Red or red and white patch in the oral cavity (erythroplakia / erythroleukoplakia)
Consider USOC referral for suspected thyroid cancer in people with:
Unexplained thyroid lump
Give some risk factors for glue ear:
Males
Winter and spring predominance
Bottle feeding
Nursery attendance
Parental smoking
Siblings with glue ear
Management of glue ear:
- Active observation for 3 months if first episode.
- Potential for grommet insertion - allows air to pass into the middle ear, acting as a Eustachian tube. Stop working after around 10 months.
When should a patient with simple otitis externa be referred to ENT?
No response to topical antibiotics.
Top 2 bacterial agents that cause otitis externa (‘swimmer’s ear’)?
Pseudomonas aeruginosa
Staph aureus
Causes of otitis externa outwith bacterial infection:
Eczema
Seborrheic dermatitis
Contact dermatitis
Fungal (?recent antibiotic use in history)
4 symptoms of otitis externa + examination findings:
Ear pain
Discharge
Itch
Conductive hearing loss if blocked
Examination: erythema and swelling of ear canal, tenderness, pus, lymphadenopathy
Diagnosis of otitis externa is mostly clinical via otoscopy. Discuss management of otitis externa.
Mild: acetic acid
Moderate: topical antibiotic and steroid e.g. neomycin + dexamethasone
Consider removal of ear canal debris
Consider ear wick if canal is extensively swollen
Give 3 underlying risk factors for malignant otitis externa.
Diabetes (90% of patients have diabetes)
Immunocompromised
HIV
What is a key finding in malignant otitis externa compared to non-malignant?
Granulation tissue present at the bony cartilage junction in the ear canal.
Spreading of infection to temporal bone / osteomyelitis.
Management of malignant otitis externa?
Emergency
ENT admission, IV abx for pseudomonas cover
Imaging e.g. CT
State some complications of malignant otitis externa.
Facial nerve palsy and other cranial nerve involvement
Meningitis
Intracranial thrombosis
Death
The most common cause of tonsillitis is a viral infection, but what is the most common cause of bacterial tonsillitis?
Group A strep - Strep pyogenes
Which tonsils are typically affected in tonsillitis?
Palatine tonsils
What are the posterior and anterior borders of the palatine tonsils?
Anterior = palatoglossal arch
Posterior = palatopharyngeal arch
Arterial supply and venous drainage of the palatine tonsils:
Supply: Tonsillar branch of the facial artery
Drainage: External palatine vein into the facial vein
Presentation of tonsillitis vs peritonsillar abscess:
Tonsillitis:
Sore throat
Pain on swallowing
Fever >38
Anterior cervical lympadenopathy
Swollen, erythematous palatine tonsils
Peritonsillar abscess:
Uvula deviated to unaffected side
Severe pain
Trismus; cannot open mouth
Reduced neck mobility
When is the Centor criteria use and what are the 4 components?
Used to predict if sore throat has a bacterial cause.
Score or 3 or 4 = 40-60% change of bacterial, antibiotics can be offered.
- Fever >38
- Absence of cough
- Presented within 3 days of symptom onset
- Tonsillar exudates
What is an alternative score to the Centor criteria that can be used to predict the probability of bacterial tonsillitis as well?
FeverPAIN score
Fever for last 24 hours
Peritonsillar abscess
Attended within 3 days
Inflammation
No cough
When to consider admission for tonsillitis?
Peritonsillar abscess
Immunocompromised
Systemically unwell
Stridor / respiratory distress
Complications of tonsillitis:
Otitis media
Quinsy
RARE: glomerulonephritis, rheumatic fever
Indications for tonsillectomy:
7 episodes in 1 year
5 episodes in 2 years
3 episodes in 3 years
OR
Recurrent tonsillar abscess
Enlarged tonsils causing problems with breathing, swallowing, snoring
Complications of tonsillectomy:
Sore throat ~ 2 weeks
Teeth damage
Infection
Anaesthetic complications
Post-tonsillectomy bleeding; can be life-threatening, cause aspiration of blood etc. Significant in 5%.
Immediate management of post-tonsillectomy bleeding:
ENT reg involved early
IV access + bloods including coag, group and save, crossmatch, FBC,
Analgesia
Sit up, encourage to spit blood out
NBM
2 options for stopping less severe post-tonsillectomy bleeding before going back to theatre:
Hydrogen peroxide gargle
Adrenaline soaked gauze
2 options for management of a peri-tonsillar abscess / quinsy:
Needle aspiration
Incision and drainage
Why must you be certain there is no tympanic membrane perforation before treating otitis externa?
Aminoglycosides are the abx of choice for otitis media due to prevalence of pseudomonas.
Aminoglycosides have potential to be ototoxic if membrane is perforated.
Antibiotic of choice for tonsillitis, and in cases of allergy?
Phenoxymethylpenicillin
Clarithromycin if true penicillin allergy
Describe the pathophysiology of BPPV.
Displaced calcium carbonate crystals in the semicircular canals disrupt flow of endolymph and confuse the vestibular system.
Mostly posterior canal.
Describe the clinical features of BPPV.
Vertigo episodes lasting 20-60 second, sudden onset, accompanied by dizziness.
Triggered by head movement e.g. turning over in bed.
Recurrent episodes, usually lots over a few weeks and then can be episode-free for months.
What test is done to diagnose BPPV?
Dix-Hallpike manoeuvre
Will trigger rotational nystagmus and symptoms of vertigo.
What two treatment options can be done for a patient with BPPV?
Epley manoeuvre
Brandt-Daroff exercises taught to the patient
A Dix-Hallpike manoeuvre is performed on a patient, and rotational nystagmus is triggered. You see that it is clockwise. Which side is affected?
LEFT
Clockwise rotation = left side
Anticlockwise rotation = right side
What is the typical triad of symptoms in Meniere’s disease, and the average ages affected?
Hearing loss
Tinnitus
Vertigo
40-50 year olds
Describe the pathophysiology of Meniere’s disease.
Excessive build up of endolymph in the inner ear labyrinth.
Causes high pressure and interrupts sensory signals.
‘Endolymphatic hydrops’.
Describe the typical presentation and progression of Meniere’s disease, including specific progression and relationship between the hearing loss, tinnitus and vertigo.
Vertigo - episodic, usually lasts 20 minutes to several hours. Clusters over weeks, then months without it. NOT triggered by movement or posture.
Tinnitus; initially occurs with episodes of vertigo before becoming more permanent. UNILATERAL.
Hearing loss; sensorineural, unilateral, affects lower frequencies first. Fluctuates at first, associated with vertigo episodes, then becomes more permanent.
Give 3 extra features of Meniere’s disease out with the classic triad.
Drop attacks, no LOC
Fullness in ear
Imbalance
?Unidirectional nystagmus during attacks
How is a diagnosis of Meniere’s disease made?
Clinically by an ENT specialist
Requires audiology assessment of hearing loss as well
Discuss symptomatic and prophylactic management of Meniere’s disease.
Symptomatic:
Buccal or IM prochlorperazine
Antihistamines
Prophylaxis:
Betahistine
A patient is found to have bilateral acoustic neuromas. What underlying condition are they likely to have?
Neurofibromatosis Type 2
Acoustic neuromas can present with similar symptoms to Meniere’s disease, include vertigo, unilateral tinnitus and sensorineural hearing loss. Outline some other features that would point you towards a diagnosis of an acoustic neuroma.
Constant, progressive symptoms not episodic
Facial nerve palsy
Absent corneal reflex
Which cranial nerves are affected in acoustic neuroma?
V - corneal reflex
VII
VIII
What is the investigation of choice in an acoustic neuroma?
MRI of the cerebellopontine angle
Also audiometry
Structures of the ear from the outside in:
PETE Might Start Cat Vomiting
Pinna
External auditory canal
Tympanic membrane
Eustachian tube
Malleus, incus and stapes
Semicircular canals
Cochlear
Vestibulocochlear nerve
How do you perform Weber’s test?
Place tuning fork in centre of patient’s forehead
Ask if they can hear sound and which ear it is loudest in
How do you perform Rinne’s test?
Place flat end of fork on the mastoid
Ask patient to tell you when they stop hearing the hum
When they say this, move it in front of the ear
Rinne’s positive / normal result = air conduction better than bone conduction.
Sensorineural vs conductive hearing loss results of Weber’s test:
Sensorineural; hear hum loudest in the normal ear.
Conductive; sound is louder in affected ear, and this ear ‘turns up the volume’ and becomes more sensitive as sound has not been reaching that side as well due to the conduction problem.
What does an abnormal Rinne’s test indicate?
Bone conduction is better than air conduction, cannot continue to hear sound when it is removed from the mastoid.
Indicates conductive hearing loss, as the sounds are less able to travel through air, ear canal and tympanic membrane.
Genetic associations of medullary thyroid cancer:
MEN 2a and 2b
FAP
Calcitonin secreting cells
2 biggest risk factors for tonsillar SCC:
Tobacco use
HPV
IV antibiotic of choice for malignant otitis externa?
Ciprofloxacin to cover pseudomonas
Anti diabetic should be given cipro for non-malignant otitis externa due to risk of development
Secondary haemorrhage post tonsillectomy occurs how long after the operation, what is it usually due to and how is it managed?
5-10 DAYS
Usually due to infection
Treatment is with admission and antibiotics
3 drugs that can cause deafness:
Furosemide
Aminoglycosides e.g. gentamicin
Aspirin
What is presbycusis?
Age-related sensorineural hearing loss.
Difficulty following conversation.
Bilateral high-frequency hearing loss, gradually and symmetrically.
What happens in otosclerosis and what is the genetic transmission of it, and the average age of onset?
AD
Normal bone is replaced by vascular spongy bone, causing conductive deafness and tinnitus.
20-40
What is the HiNTS exam used for and what does it involve?
To differentiate between a central and peripheral cause of vertigo.
Head impulse
Nystagmus
Test of Skew
Head Impulse - vestibulo-ocular reflex; eyes will saccade if there is a problem with the VESTIBULAR system.
Nystagmus; bilateral or vertical nystagmus = central cause. Unilateral horizontal = peripheral cause
Test of skew / cover test = vertical correction when eye is uncovered = central cause.
Which virus causes infectious mononucleosis?
EBV (HHV-4)
CMV and HHV-6 are rare causes
Classic triad of infectious mononucleosis symptoms:
Fever
Sore throat
Lymphadenopathy - anterior and posterior triangles, in contrast to tonsillitis where only the upper anterior cervical chain is enlarged.
Other features of infectious mononucleosis, outwith classic triad.
Splenomegaly
Hepatitis, transient ALT rise
Lymphocytosis
Haemolytic anaemia
Palatal petechiae
Patients with infectious mononucleosis react to which drug and what happens to them?
Amoxicillin / ampicillin
Maculopapular, pruritic rash in 99%
How is glandular fever diagnosis confirmed?
Monospot test + FBC in 2nd week of illness
BUT EBV serology gold standard in children / immunocompromised
What should patients who have had glandular fever be advised to avoid?
Contact sports for 4 weeks after due to risk of splenic rupture
Also alcohol, as EBV impacts ability of liver to process it.
Discuss IgM and IgG levels in glandular fever.
IgM antibody rises early and suggests acute infection.
IgG antibody persists after the condition and suggests immunity.
EBV specific antibodies target VCA (viral capsid antigen)
4 sets of paranasal sinuses, and sinus function:
Frontal
Maxillary
Ethmoid
Sphenoid
They produce mucous and drain into the nasal cavities via holes called ostia. Blockage of the ostia = sinusitis.
Patients with asthma are more likely to suffer from sinusitis. Give 4 causes of sinus inflammation.
Smoking
Infection, esp viral URTI
Allergy e.g. allergic rhinitis
Obstruction of drainge e.g. foreign body, polyp, trauma, septal deviation
What time frame must exist for chronic sinusitis to be diagnosed?
12 weeks
Red flags for chronic sinusitis:
Unilateral symptoms
Persistence despite 3 months of treatment (intranasal steroids, nasal irrigation)
Epistaxis
A post-nasal drip can be present in sinusitis. What can this cause?
Chronic cough
You should not offer treatment for acute sinusitis unless symptoms are not improving after 10 days, as most will resolve on its own within 2-3 weeks. For patients who do qualify for treatment, what should be given?
High dose steroid nasal spray 14 days e.g. mometasone
Delayed abx prescription to use if not improving in a further 7 days e.g. phenoxymethylpenicillin
Nasal spray technique:
Should NOT taste the spray - has gone past nasal mucosa and not as effective.
- Tilt head slightly forward
- Using left hand to spray into right nostril etc so angled away from septum
- Do NOT sniff hard during the spray
- Inhale slowly through nose after the spray
Most common infectious agents to cause acute sinusitis:
Rhinovirus
Strep pneumoniae
H.influenzae
Which organism causes epiglottitis, and classic presentation?
Haemophilus influenzae type B
Drooling, tripod position, rapid onset
Risk factors for presbycusis, which is sensorineural and can be associated with tinnitus:
Age
Male
FHx
Exposure to loud noises, chronic
DM
HTN
Ototoxic medications
Smoking
A 15 year old is presenting with foul smelling, non resolving discharge from her ear and hearing loss. What is the most likely diagnosis, and what is this?
Cholesteatoma
Squamous epithelium ‘trapped’ in an area of tympanic membrane retraction. The cells grow into the surrounding space and invade bones and tissues.
Foul smelling discharge and unilateral conductive hearing loss.
Where do anterior nosebleeds most commonly originate from?
Kiesselbach’s plexus
How long should the cartilaginous area of the nose be held for in a nose bleed first aid scenario?
At least 20 minutes
First aid measures are unsuccessful in managing a nosebleed - a topical antiseptic is considered. You go for Naseptin. Who is this cautioned in?
Peanut and soy allergy
Neomycin allergy
Mupirocin is a viable alternative
Bleeding nose does not stop after 10-15 minutes of continuous pressure on the nose - next options?
Silver nitrate cautery (get patient to blow nose to remove any clots)
Packing if cautery not tolerated or if bleeding point not identified
How long does local anaesthetic spray e.g. Co-phenylcaine take for effect?
3-4 mins
Management of allergic conjunctivitis:
Topical or systemic antihistamines (symptom relief)
Topical mast cell stabilisers e.g. sodium cromoglicate, nedocromil sodium
Presentation of a nasopharyngeal carcinoma:
Otalgia
Recurrent epistaxis
Cervical lymphadenopathy
CN palsies III-VI
Southern China very common
EBV infection
1% of adults in the UK have nasal polyps. Give 3 common presenting features, and 2 unusual features which would always require investigation.
Rhinorrhoea, sneezing
Nasal obstruction
Poor taste and smell
Requires further investigation:
Unilateral symptoms
Bleeding
Management of nasal polyps?
All suspected nasal polyps should be referred to ENT for a full examination.
Topical corticosteroids can shrink it in 80% of patients.
What is Samter’s triad?
Asthma
Aspirin sensitivity
Nasal polyposis
Give 6 associations of nasal polyps:
Asthma
Aspirin sensitivity
Infective sinusitis
CF
Kartagener’s (PCD)
EGPA
