Ear, Nose and Throat Flashcards
What does the outer ear consist of?
- Auricle-> cartilage (helix, tragus, concha) + lobule to capture + direct sound
- External auditory canal-> concha to tympanic membrane, outer 1/3 cartilage + produces wax, inner 2/3 bone
What is cauliflower ear?
- Blood accumulates between cartilage and perichondrium
- Disrupts blood supply
- Avascular necrosis
What is the tympanic membrane?
- Boundary between external + middle ear
- Umbo meets lateral process of malleus bone
- Pars flaccida (weak) + pars tensa
- Light reflex-> at 5’oclock (right ear) or 7 oclock (left)
What does the middle ear consist of?
- 1 nerve-> facial (CNVII)
- 2 muscles-> tensor tympani + stapedius (restrict ossicle movement + protect from loud noise)
- 3 bones/ossicles-> malleus + incus + stapes (from tympanic membranes to oval window + pass vibrations to inner ear)
- Mastoid process
- Eustachian tube
What is the mastoid process?
- Area of temporal bone behind ear
- Air cells protect ear + equalise air pressure
What is the role of the Eustachian tube?
- Middle ear has no direct contact with the atmosphere
- Pressure differences between outer + middle ear
- ET-> opens + allow equalisation
What does the inner ear consist of?
- Vestibular-> 3 semi-circular canals, utricle + saccule, messages to CNVIII
- Cochlear-> oval window, scala media + tympani + vestibuli (transmit into signals via organ of Corti)
How do the semicircular canals work?
- Endolymph + sensory hair cells
- Detect direction + flow when move
- Sends messages to CNVIII
What are the functions of the nose?
- Ventilation
- Humidify air
- Smell via olfactory nerve
- Protect airway from pathogens-> mucous + hairs
- Drainage from sinuses + tear ducts
- Middle ear ventilation via Eustachian tube
What is the anatomy of the nose?
- Cartilage, septum + bone
- Cavity-> vestibule to nasopharynx with CNI on superior aspect
- Superior, middle + inferior turbinates-> on lateral walls to increase surface area + improve humidity
What is the arterial blood source of nose?
- Little’s area-> Keisselbach’s plexus, anterior, source of epistaxis
- Woodruff’s plexus-> cause posterior nose bleeds
Who is at risk of posterior nose bleeds?
Older, HTN, atherosclerosis
Where do anterior nose bleeds usually come from?
Little’s area-> Keisselbach’s plexus
Where do posterior nose bleeds come from?
Woodruff’s plexus
What is the anterior triangle of the neck?
- Mandible (superior)
- Midline of neck (medial)
- Sternocleidomastoid (lateral)
What structures are in the anterior triangle of the neck?
- Thyroid + parathyroid
- CNs IX, X and XII
- Carotid artery
- Internal jugular vein
- Salivary glands
What is the posterior triangle of the neck?
- Sternocleidomastoid (anterior)
- Clavicle (inferior)
- Trapezius (posterior)
What structures are in the posterior triangle of the neck?
- Subclavian artery and vein
- External jugular vein
- CN XI
- Brachial plexus
Where are branchial cysts usually located?
Anterior triangle of the neck
Where are cystic hygromas usually located?
Posterior triangle of the neck
What anatomical structures are in the throat?
Hard + soft palate, uvula, palatine tonsils, tongue
Where are salivary tumours usually located?
Parotid gland
What runs through the parotid gland?
CN VII (facial nerve)
What is Stensen’s duct and where can it be found?
- Where saliva secreted from the parotid gland
- Feel as bulge on cheek opposite the second molar
What gland produces the most saliva when not eating?
Submandibular gland
What salivary gland produces the most mucous secretions and why?
Sublingual-> allow smooth food passage down oesophagus
What pathology is common in the sublingual glands?
Mucoceles
Where is the lymphatic drainage (including nodes) of the head and neck?
- Submental
- Submandibular
- Tonsillar
- Parotid
- Preauricular
- Deep cervical
- Superior + posterior cervical
- Supraclavicular
- Post auricular
- Occipital
What is conductive hearing loss?
Sound not conducted at ear canal to inner ear-> due to external or middle ear problem
What can cause conductive hearing loss?
Fluid, foreign object, allergies, ruptured tympanic membrane, impacted earwax
What is sensorineural hearing loss?
Sound is received at the inner ear but sensory problem-> due to cochlear or CNVIII problem
What causes sensorineural hearing loss?
Age related, noise damage, drug side effects, auditory tumours, blast/explosions
What can caused mixed hearing loss?
Genetics, infection, head trauma
What Rinne’s and Weber’s test results do you get in normal hearing?
- Weber-> equal on both sides
- Rinne’s-> air conduction>bone (ie louder when next to ear)
What Rinne’s and Weber’s test results do you get in sensorineural loss?
- Rinne’s-> air>bone conduction
- Weber’s-> lateralise to unaffected ear
What Rinne’s and Weber’s test results do you get in conductive loss?
- Rinne’s-> bone conduction>air
- Weber’s-> lateralised to affected ear
What causes otitis externa?
- External canal’s protective mechanism disrupted + bacteria trapped
- EG due to water, humidity, cotton buds, hearing aids, immunocompromised
- Pseudomonas aeruginosa
What pathogens usually cause otitis externa?
Pseudomonas aeruginosa, staph aureus, candida
How does otitis externa present?
Otalgia, otorrhoea, swollen + red ear, itching, tender pinna
How is otitis externa managed?
- Topical antibiotics + steroids
- Aural toilet
- Microsuction
What is necrotising/malignant otitis externa?
- Infection spreads to mastoid and temporal bones-> skull base osteomyelitis
- Can cause CN palsies and death if untreated
How is necrotising/malignant otitis externa managed?
Prolonged antibiotics
What is the pathophysiology of acute otitis media?
- URTIs migrate to eustachian tube into middle ear
- Kids-> shorter tube + easier transmission
- Viral-> RSV, rhinovirus, enterovirus
- Bacterial-> s.pneumoniae
What pathogens cause acute otitis media?
- Viral-> RSV, rhinovirus, enterovirus
- Bacterial-> s.pneumoniae
How does acute otitis media present?
Otalgia, inflamed tympanic membrane, malaise
How is acute otitis media managed?
- Self resolving with analgesia
- Amoxicillin if unwell
- Grommets-> in recurrent
What are the complications of acute otitis media?
- Perforated tympanic membrane-> discharge + sudden pain relief
- Hearing loss
- Mastoiditis
- CNVII palsy
- Intracranial infection
What is otitis media with effusion?
- Glue ear
- Non infective fluid in middle ear
What causes otitis media with effusion?
- Eustachian tube dysfunction-> wider + shorter in kids
- Congenital structural malformations eg cleft palate
- Allergies
- Adults-> consider malignant (obstruction of tube)
What are the symptoms and signs of otitis media with effusion?
- Hearing loss, speech delay in kids
- Exam-> dull tympanic membrane, upward reflecting/absent light reflex
How is otitis media with effusion managed?
- 50% resolve in 3 months
- Hearing aids
- Grommets
What is the pathophysiology of chronic otitis media?
- Tympanic membrane perforations after recurrent OM
- Non infective-> trauma or iatrogenic (eg grommets)
How does chronic otitis media present?
6+ weeks of hearing loss + ottorhoea-> not infection
How is chronic otitis media managed?
- Aural toilet
- Topical antibiotics + steroids-> allow healing
- Surgery-> myringoplasty using tragus to fill hole
What are the complications of chronic otitis media?
Hearing loss, mastoiditis, CNVII palsy, intracranial
What is a cholesteatoma?
- Destructive hyperproliferating growth of keratinising squamous epithelial cells
- In the middle ear
What is the pathophysiology of cholesteatoma?
- Destructive hyperproliferating growth of keratinising squamous epithelial cells
- In the middle ear
- Retraction pocket-> space behind tympanic membrane prone to trapping epithelium
- Expansile-> can erode to other structures
What are the risk factors for developing cholesteatoma?
Recurrent acute OM, Eustachian tube dysfunction, previous ear surgery
What are the symptoms of cholesteatoma?
- Chronic otorrhoea-> brown, no otalgia or fever
- Hearing loss-> conductive (ossicle damage) or sensorineural (cochlea invasion)
- Dizziness (semicircular canals)
- CNVII palsy
How is cholesteatoma managed?
- CT head of temporal bone to confirm
- Otoscopy-> pearly grey/white + painless brown discharge
- Complete surgical removal
What are the complications of cholesteatoma?
Intracranial invasion + infection
What is true vertigo?
Inappropriate sensation of movement of surroundings (eg room spinning)
What can cause true vertigo?
BPPV, stroke, MS, migraine
What is benign positional paroxysmal vertigo?
Non-malignant temporary vertigo from moving head
What is the pathophysiology of benign positional paroxysmal vertigo?
- Crystals (canaliths) in semicircular canals (utricle)
- Dislodge due to age, infection, injury, DM
- Abnormal endolymph movement in canals-> few seconds of vertigo
How is benign positional paroxysmal vertigo investigated?
Dix-Hallpike test-> sit up with head at 45 degrees, lie down overhanging the bed, look for nystagmus
How is benign positional paroxysmal vertigo treated
Epley manoeuvre
- Sit with head at 45 degrees + lie down with head overhanging bed
- Stay for 1-2 minutes
- Rotate head 90 degrees and stay for 1-2 minutes
- Roll onto shoulder + rotate head 90 degrees (ie at downward 45 degree angle) for 1-2 minutes
- Slowly sit up with 45 degree head angle for 30 second
What is Meniere’s disease?
Increased endolymphatic pressure in the semicircular canals
What are the symptoms of Meniere’s disease?
Vertigo, tinnitus, sensorineural hearing loss-> lasts minutes to hours
How is Meniere’s disease managed?
- Self resolves
- Reduce salt + caffiene
- Intratympanic steroid/antibiotic injection if persistent
What is vestibular neuronitis?
Inflammation of the vestibular nerve due to viral infection
What are the symptoms of vestibular neuronitis?
Severe vertigo + viral symptoms for a few days
How is vestibular neuronitis managed?
- Self resolves
- Anti-emetics
- Fluids if vomiting
- Long term damage-> rehab exercises
What might cause referred ear pain?
- CNV-> teeth, TMJ (excess grinding), prarotid
- CNVII-> herpes zoster, Bell’s palsy
- CNXI-> throat (tonsillitis), oropharyngeal malignancy
- Cervical nerves-> arthritis
What causes rhinosinusitis?
- Inflammation of mucosal lining of nose + paranasal sinuses
- Viral infection-> rhinovirus, RSV, parainfluenza
- Bacterial infection-> s.pneumoniae, H.influenzae
- Allergies-> IgE mediated type I hypersensitivity, hay fever
- Other-> smoking, environment (cold + dry air), pollution, exercise
What are the symptoms of rhinosinusitis?
Rhinorrhoea, nasal congestion, reduced sense of smell, facial pain, headache
How is rhinosinusitis managed?
- Self resolves
- Avoid triggers
- Nasal decongestants + antibiotics or steroids if severe
What are the complications of rhinosinusitis?
Intracranial infection, osteomyelitis, periorbital or orbital abscess
What is the most common facial bone fracture?
Nasal
What is septal haematoma and how might is present?
- Can happen after nasal fractures
- Collection of blood within septum
- Cuts off blood flow to cartilage
- Can cause saddle nose deformity-> (avascular necrosis of septal cartilage)
When are nasal fractures corrected?
1 week after injury when swelling gone down
What pathogens cause tonsillitis?
- Viral (70%)-> adenovirus, influenza, rhinovirus, parainfluenza
- Bacterial (30%)-> group A beta-haemolytic strep (eg s.pyogenes)
What are the symptoms of tonsillitis?
Pain, fever, dysphagia
What are the Centor criteria for tonsillitis?
- Pyrexia, exudates on tonsil, absence of cough, tender cervical LNs
- Consider antibiotics if 2+
What are the criteria for receiving a tonsillectomy?
- 7 episodes in last 1 year
- 5 episodes in each of last 2 years
- 3 episodes in each of last 3 years
- Swelling affecting function
What is a quincy?
Peritonsillar abscess-> rare + severe complication of bacterial tonsillitis
What are the signs and symptoms of quincy?
- Severe tonsillitis
- Trismus (can’t open jaw)
- Unilateral symptoms
- Hot potato voice
- Deviated uvula (away)
How is quinsy managed?
Admission, IV antibiotics (eg metronidazole), drainage (needle or incision)
What can happen if a quinsy isn’t treated?
Deep neck infection or upper airway obstruction
What type of cancers most commonly affect the head and neck?
Squamous cell cancers (90%)
Who are nasopharynx cancers common in?
- Asians
- EBV infection
What are the reg flag symptoms of nasopharynx cancer?
Otalgia, hearing loss, smell change
What are the risk factors for oral cavity cancers?
- Recurrent dental infection
- Sun exposure (lips)
What are the symptoms of oral cavity cancers?
- Ulcer for 3+ weeks
- Jaw swelling
What can cause pharynx cancers?
HPV
What are the symptoms of a pharynx cancer?
- Peristent neck lump
- Dysphagia
- Otalgia
What is the biggest risk factor for laryngeal cancer?
Smoking
What are the symptoms of laryngeal cancer?
Hoarse voice, persistent lump, dysphagia, stridor
How are head and neck cancers managed?
- Fine needle aspiration
- Chemo, radiotherapy, surgery
What might cause secondary hyperthyroidism?
TSH-secreting pituitary adenoma
What might cause secondary hypothyroidism?
Pituitary adenoma
What is the most common type of thyroid cancer?
Papillary
What are the types of thyroid cancer?
- Papillary
- Follicular
- Medullary
- Anaplastic
Which is the most aggressive type of thyroid cancer?
Anaplastic
How does thyroid cancer present?
Neck lump + not typically any thyroid symptoms
How is thyroid cancer managed?
- Thyroidectomy
- Radioactive iodine if advanced
When is foreign body in the ear considered an emergency?
- Bugs
- Button battery-> can burn + damage tissues
How might foreign body in the ear present?
pain, hearing loss, discharge
How are foreign bodies in the ear removed?
- Crocodile forceps
- Microsuction
What can cause epistaxis?
Spontaneous, trauma, hypertension, blood thinners
How is epistaxis managed?
- ABCDE
- Pinch cartilage + lean forward for 20 minutes
- Cauterise with silver nitrate
- Pack (anterior/posterior)
- May need surgical ligation
What can cause airway obstruction?
- Cancers-> oropharynx, laryngeal, tongue
- Epiglottitis
- Deep neck space infections
- Foreign bodies
What are the red flag symptoms/features of airway obstruction?
Stridor, cyanosis, agitation, respiratory distress, wheeze, decreased breath sounds
How might airway obstruction be managed?
- ABCDE
- Oxygen
- Salbutamol/adrenaline nebs
- Tracheostomy
What is epiglottitis?
-Infection of the supraglottic tissue
What usually causes epiglottitis?
H.influenzae type B
What are the symptoms and signs of epiglottitis?
- Drooling, distress, dysphagia
- Swollen epiglottis
- Thumb print sign on lateral C-spine X ray
How is epiglottitis managed?
Intubation + IV antibiotics
What is a lump that moves when the patient sticks out their tongue likely to be?
Thyroglossal cyst
What is periorbital cellulitis?
- A complication of acute rhinosinusitis
- Graded depending on location
What are the grades of periorbital cellulitis?
- Preseptal
- Post septal
- Subperiosteal or orbital
- Cavernous sinus thrombosis
What are the potential complications of periorbital cellulitis?
Vision impairment or loss, Horner’s syndrome (CNIII)
How is periorbital cellulitis managed?
- Preseptal-> medical
- Post septal-> medical
- Subperiosteal or orbital-> surgical
- Cavernous sinus thrombosis-> neurosurgery
What are the red flag symptoms of periorbital cellulitis?
- Chemosis (oedema of sclera)
- Proptosis
- Ophthalmoplegia
Why are amoxicillin and co-amoxiclav contraindicated in tonsillitis?
If glandular fever not ruled out may cause Steven-Johnson syndrome
Why are amoxicillin and co-amoxiclav contraindicated in glandular fever?
Can cause Steven-Johnson syndrome
What causes glandular fever?
EBV
What are the symptoms of glandular fever?
High fever, lethargy, bulky lymphadenopathy, splenomegaly
What blood results will be apparent in glandular fever?
- Lymphocytosis
- Deranged LFTs
How is glandular fever managed?
No contact sports for 3 months
