Ear, Nose and Throat Flashcards

Question

Examining otosclerosis

Answer 1

Otoscopy is normal. Weber’s test is normal if the otosclerosis is bilateral, meaning that when the tuning fork is applied to the centre of the forehead, they will hear the sound equally in both ears. If the otosclerosis is unilateral or affects one ear more than the other, the sound will be louder in the more affected ear. Rinne’s test will show conductive hearing loss. The sound will be easily heard when the tuning fork is applied to the mastoid process (bone conduction). When the patient stops being able to hear the sound during bone conduction, and the tuning fork is removed from the mastoid process and held close to the ear canal, they will still not hear the sound (air conduction is worse than bone conduction).

Answer 2

Audiometry is the initial investigation of choice. Otosclerosis will show a conductive hearing loss pattern. Bone conduction readings will be normal (between 0 and 20 dB). However, air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart. Hearing loss tends to be greater at lower frequencies. Tympanometry will show generally reduced admittance (absorption) of sound. The tympanic membrane is stiff and non-compliant and does not absorb sound, reflecting most of it back. High-resolution CT scans can detect boney changes associated with otosclerosis, although they are not always required.

Answer 3

The options for management are: Conservative, with the use of hearing aids Surgical (stapedectomy or stapedotomy) Surgical management is generally successful and can potentially restore hearing to normal. It involves lifting the tympanic membrane and some of the surrounding skin out of the way to access the middle ear through the ear canal. Stapedectomy involves removing the entire stapes bone and replacing it with a prosthesis. The prosthesis attaches to the oval window and hooks around the incus, transmitting the sound from the incus to the cochlea in the same way the stapes normally would. Stapedotomy involves removing part of the stapes bone and leaving the base of the stapes (the footplate) attached to the oval window. A small hole is made in the base of the stapes for the prosthesis to enter. A prosthesis is added to transmit sound from the incus to the cochlea.

Answer 4

Otitis media is the name given to an infection in the middle ear. The middle ear is the space that sits between the tympanic membrane (eardrum) and the inner ear. This is where the cochlea, vestibular apparatus and nerves are found. Bacteria enter from the back of the throat through the eustachian tube. A viral upper respiratory tract infection often precedes bacterial infection of the middle ear.

Answer 5

The most common bacterial cause of otitis media is streptococcus pneumoniae. This also commonly causes other ENT infections such as rhino-sinusitis and tonsillitis. Other common causes include: Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus

Answer 6

Ear pain is the primary presenting feature of otitis media in adults. It may also present with: Reduced hearing in the affected ear Feeling generally unwell, for example with fever Symptoms of an upper airway infection such as cough, coryzal symptoms and sore throat When the infection affects the vestibular system, it can cause balance issues and vertigo. When the tympanic membrane has perforated, there may be discharge from the ear.

Answer 7

An otoscope is used to visualise the tympanic membrane whilst gently pulling the pinna up and backwards. It may be challenging to visualise the tympanic membrane if there is significant discharge or wax in the ear canal. A normal tympanic membrane is “pearly-grey”, translucent and slightly shiny. You should be able to visualise the malleus through the membrane. Look for a cone of light reflecting the light of the otoscope. Otitis media will give a bulging, red, inflamed looking membrane. When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane.

Answer 8

Most otitis media cases will resolve without antibiotics within around three days, sometimes up to a week. Antibiotics make little difference to symptoms or complications. Complications (mainly mastoiditis) are rare. Simple analgesia (e.g., paracetamol or ibuprofen) can be used for pain and fever. There are three options for prescribing antibiotics: Immediate antibiotics Delayed prescription No antibiotics Consider immediate antibiotics at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised. Consider a delayed prescription that can be collected and used after three days if symptoms have not improved or have worsened at any time. This can be a helpful strategy in patients pressing for antibiotics or where you suspect the symptoms might worsen. The NICE clinical knowledge summaries (updated January 2021) suggest: Amoxicillin for 5-7 days first-line Clarithromycin (in pencillin allergy) Erythromycin (in pregnant women allergic to penicillin) Always safety-net, offering education and advice to patients on when to seek further medical attention.

Answer 9

Otitis media with effusion Hearing loss (usually temporary) Perforated tympanic membrane (with pain, reduced hearing and discharge) Labyrinthitis (causing dizziness or vertigo) Mastoiditis (rare) Abscess (rare) Facial nerve palsy (rare) Meningitis (rare)

Answer 10

Otitis externa is inflammation of the skin in the external ear canal. Oto- refers to ear, -itis refers to inflammation, and externa refers to the external ear canal. The infection can be localised or diffuse. It can spread to the external ear (pinna). It can be acute (less than three weeks) or chronic (more than three weeks). Otitis externa is sometimes called “swimmers ear”, as exposure to water whilst swimming can lead to inflammation in the ear canal. Trauma from the ear canal (e.g., from cotton buds or earplugs) is another predisposing factor. Ear wax (cerumen) has a protective effect against infection, and the removal of ear wax can increase the chances of infection. The inflammation in otitis externa may be caused by: Bacterial infection Fungal infection (e.g., aspergillus or candida) Eczema Seborrhoeic dermatitis Contact dermatitis TOM TIP: Think about fungal infection in patients that have had multiple courses of topical antibiotics. Antibiotics kill the “friendly bacteria” that have a protective effect against fungal infections. This is similar to how oral antibiotics can predispose people to develop oral or vaginal candidiasis (thrush).

Answer 11

The two most common bacterial causes of otitis externa are: Pseudomonas aeruginosa Staphylococcus aureus TOM TIP: It is worth remembering Pseudomonas aeruginosa. It is a gram-negative aerobic rod-shaped bacteria. It likes to grow in moist, oxygenated environments. Other than causing otitis externa, an important exam-related point to remember is that it can colonise the lungs in patients with cystic fibrosis, significantly increasing their morbidity and mortality. It is naturally resistant to many antibiotics, making it very difficult to treat in children with cystic fibrosis. It can be treated with aminoglycosides (e.g., gentamicin) or quinolones (e.g., ciprofloxacin).

Answer 12

The typical symptoms of otitis externa are: Ear pain Discharge Itchiness Conductive hearing loss (if the ear becomes blocked) Examination can show: Erythema and swelling in the ear canal Tenderness of the ear canal Pus or discharge in the ear canal Lymphadenopathy (swollen lymph nodes) in the neck or around the ear The tympanic membrane may be obstructed by wax or discharge. It may be red if the otitis externa extends to the tympanic membrane. If it is ruptured, the discharge in the ear canal might be from otitis media rather than otitis externa.

Answer 13

The diagnosis can be made clinically with an examination of the ear canal (otoscopy). An ear swab can be used to identify the causative organism but is not usually required.

Answer 14

Mild otitis externa may be treated with acetic acid 2% (available over the counter as EarCalm). Acetic acid has an antifungal and antibacterial effect. This can also be used prophylactically before and after swimming in patients that are prone to otitis externa. Moderate otitis externa is usually treated with a topical antibiotic and steroid, for example: Neomycin, dexamethasone and acetic acid (e.g., Otomize spray) Neomycin and betamethasone Gentamicin and hydrocortisone Ciprofloxacin and dexamethasone Aminoglycosides (e.g., gentamicin and neomycin) are potentially ototoxic, rarely causing hearing loss if they get past the tympanic membrane. Therefore, it is essential to exclude a perforated tympanic membrane before using topical aminoglycosides in the ear. This can be difficult if the patient has discharge, swelling or wax blocking the ear canal. Patients with a blocked ear canal may need to be seen by ENT to microsuction the debris from the canal and visualise the tympanic membrane. They will also require a referral if the canal is so blocked or swollen that topical treatments cannot reach the site of infection. Patients with severe or systemic symptoms may need oral antibiotics (e.g., flucloxacillin or clarithromycin) or discussion with ENT for admission and IV antibiotics. An ear wick may be used if the canal is very swollen, and treatment with ear drops or sprays will be difficult. An ear wick is made of sponge or gauze. They contain topical treatment for otitis externa (e.g., antibiotics and steroids). Wicks are inserted into the ear canal and left there for a period of time (e.g., 48 hours). As the swelling and inflammation settle, the ear wick can be removed, and treatment can continue with drops or sprays. Fungal infections can be treated with clotrimazole ear drops. TOM TIP: The treatment for otitis externa I have seen used most often is Otomize ear spray, so this is probably the one to remember. Always check the local antibiotic guidelines when prescribing antibiotics, as they will vary in different hospitals and areas.

Answer 15

Malignant otitis externa is a severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull. Malignant otitis externa is usually related to underlying risk factors for severe infection, such as: Diabetes Immunosuppressant medications (e.g., chemotherapy) HIV Symptoms are generally more severe than otitis externa, with persistent headache, severe pain and fever. Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along) is a key finding that indicates malignant otitis externa. Malignant otitis externa requires emergency management, with: Admission to hospital under the ENT team IV antibiotics Imaging (e.g., CT or MRI head) to assess the extent of the infection It can lead to complications of: Facial nerve damage and palsy Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves) Meningitis Intracranial thrombosis Death

Answer 16

Ear wax is also called cerumen. It is normally produced in small amounts in the external ear canal. It is created from a combination of secretions, dead skin cells and any substances that enter the ear. Ear wax has a protective effect, helping to prevent infection in the ear canal. In most people, ear wax does not cause any problems.

Answer 17

Ear wax can build up and become impacted and stuck to the tympanic membrane. This can result in: Conductive hearing loss Discomfort in the ear A feeling of fullness Pain Tinnitus Ear wax can be seen on examination with an otoscope. It may completely cover the tympanic membrane, preventing assessment of the tympanic membrane and inner ear.

Answer 18

In most cases, ear wax does not require any interventions. The ears should naturally regulate the amount of wax in the ear canal without any issues. Inserting cotton buds into the ear should be avoided, as this can press the wax in further and cause impaction. There are three main methods for removing ear wax: Ear drops – usually olive oil or sodium bicarbonate 5% Ear irrigation – squirting water in the ears to clean away the wax Microsuction – using a tiny suction device to suck out the wax Ear drops may be enough to clear the ears. If not, ear irrigation can often be performed in primary care. Where there are contraindications to ear irrigation (e.g., perforated tympanic membrane or infection), microsuction can be performed by specialist ear, nose and throat services.

Answer 19

Tinnitus refers to a persistent addition sound that is heard but is not present in the surrounding environment. It may be described as a “ringing in the ears”, but it can also be a buzzing, hissing or humming noise. The additional noise experienced with tinnitus is thought to be the result of a background sensory signal produced by the cochlea that is not effectively filtered out by the central auditory system. In a quiet enough environment, almost everyone will experience some background noise (tinnitus). This becomes more prominent the more attention it is given.

Answer 20

Primary tinnitus has no identifiable cause and often occurs with sensorineural hearing loss. Secondary tinnitus refers to tinnitus with an identifiable cause. Causes include: Impacted ear wax Ear infection Ménière’s disease Noise exposure Medications (e.g., loop diuretics, gentamicin and chemotherapy drugs such as cisplatin) Acoustic neuroma Multiple sclerosis Trauma Depression Tinnitus may also be associated with systemic conditions: Anaemia Diabetes Hypothyroidism or hyperthyroidism Hyperlipidaemia Objective tinnitus refers to when the patient can objectively hear an extra sound within their head. This sound can also be observable on examination by auscultating with a stethoscope around the ear. Actual additional sounds may be caused by: Carotid artery stenosis (pulsatile carotid bruit) Aortic stenosis (radiating pulsatile murmur sounds) Arteriovenous malformations (pulsatile) Eustachian tube dysfunction (popping or clicking noises) TOM TIP: I think of primary tinnitus as the ears trying to “turn up the volume” when they cannot hear the surrounding noises as well. This is a helpful way of explaining it to patients who have tinnitus associated with hearing loss. Using hearing aids allows the ears to pick up noises better and “turn the volume down”, improving the tinnitus. The actual cause of tinnitus is not entirely understood, so this is not entirely accurate, but it is a helpful analogy.

Answer 21

The NICE clinical knowledge summaries (updated March 2020) suggest considering blood tests for possible underlying causes: Full blood count (anaemia) Glucose (diabetes) TSH (thyroid disorders) Lipids (hyperlipidaemia) Audiology can be used to assess the hearing in detail and help establish the underlying cause. Imaging (e.g., CT or MRI) may be rarely required to investigate for underlying causes such as vascular malformations or acoustic neuromas.

Answer 22

Red flags that could indicate a serious underlying cause and the need for specialist assessment include: Unilateral tinnitus Pulsatile tinnitus Hyperacusis (hypersensitivity, pain or distress with environmental sounds) Associated unilateral hearing loss Associated sudden onset hearing loss Associated vertigo or dizziness Headaches or visual symptoms Associated neurological symptoms or signs (e.g., facial nerve palsy or signs of stroke) Suicidal ideation related to the tinnitus

Answer 23

Tinnitus tends to improve or resolve over time without any interventions. Underlying causes of tinnitus can be treated, such as impacted ear wax or infection. Several measures can be used to help improve and manage symptoms: Hearing aids Sound therapy (adding background noise to mask the tinnitus) Cognitive behavioural therapy

Answer 24

Vertigo is a descriptive term for a sensation that there is movement between the patient and their environment. They may feel they are moving or that the room is moving. Often this is a horizontal spinning sensation, similar to how you feel after turning in circles then stopping abruptly. Vertigo is often associated with nausea, vomiting, sweating and feeling generally unwell.

Answer 25

The sensory inputs that are responsible for maintaining balance and posture are: Vision Proprioception Signals from the vestibular system Vertigo is caused by a mismatch between these sensory inputs. The vestibular system is the most important sensory system to understand when learning about vertigo. The vestibular apparatus is located in the inner ear. It consists of three loops called the semicircular canals that are filled with a fluid called endolymph. These semicircular canals are oriented in different directions to detect various movements of the head. As the head turns, the fluid shifts inside the canals. This fluid shift is detected by tiny hairs called stereocilia found in a section of the canal called the ampulla. This sensory input of shifting fluid is transmitted to the brain by the vestibular nerve and lets the brain know that the head is moving in a particular direction. The vestibular nerve carries signals from the vestibular apparatus to the vestibular nucleus in the brainstem and the cerebellum. The vestibular nucleus then sends signals to the oculomotor, trochlear and abducens nuclei that control eye movements and the thalamus, spinal cord and cerebellum. The cerebellum is responsible for coordinating movement throughout the body. Therefore, the vestibular signals help the central nervous system coordinate eye movements and other movements throughout the body. Vertigo can be caused by either a: Peripheral problem, usually affecting the vestibular system Central problem, usually involving the brainstem or the cerebellum

Answer 26

There are several peripheral (vestibular) causes of vertigo. The four most common causes to be familiar with are: Benign paroxysmal positional vertigo Ménière’s disease Vestibular neuronitis Labyrinthitis

Answer 27

Benign paroxysmal positional vertigo (BPPV) is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. They may be displaced by a viral infection, head trauma, ageing or without a clear cause. The crystals disrupt the normal flow through the canals and therefore disrupt the function of the system. The symptoms are usually positional, because movement is required to confuse the system. Therefore, attacks of vertigo are triggered by movement and can last around a minute before the symptoms settle. Often symptoms occur over several weeks and then resolve, then can reoccur weeks or months later. A special test called the Dix-Hallpike manoeuvre can be used to diagnose BPPV.

Answer 28

Ménière’s disease is caused by an excessive buildup of endolymph in the semicircular canals, causing a higher pressure than normal, disrupting the sensory signals. It causes attacks of hearing loss, tinnitus, vertigo and a sensation of fullness in the ear. These attacks typically last several hours before settling. It most often occurs in middle-aged adults and is not associated with movement. The symptoms are not positional. Patients will have spontaneous nystagmus during attacks (nystagmus is discussed in more detail later). Over time, the patient’s hearing will gradually deteriorate.

Answer 29

Acute vestibular neuronitis describes inflammation of the vestibular nerve. This is usually attributed to a viral infection. Typically, the history is of acute onset of vertigo that improves within a few weeks.

Answer 30

Labyrinthitis describes inflammation of the structures of the inner ear. This is usually attributed to a viral infection. Usually the history is of acute onset of vertigo that improves within a few weeks. Labyrinthitis can cause hearing loss, which distinguishes it from vestibular neuronitis.

Answer 31

There are several other peripheral causes of vertigo. These are: Trauma to the vestibular nerve Vestibular nerve tumours (acoustic neuromas) Otosclerosis Hyperviscosity syndromes Varicella zoster infection (often with facial nerve weakness and vesicles around the ear – Ramsay Hunt syndrome)

Answer 32

Pathology that affects the cerebellum or the brainstem disrupt the signals from the vestibular system and cause vertigo. The most common pathology that results in a central cause of vertigo are: Posterior circulation infarction (stroke) Tumour Multiple sclerosis Vestibular migraine All the central causes of vertigo will cause sustained, non-positional vertigo. Posterior circulation infarction will have a sudden onset and may be associated with other symptoms, such as ataxia, diplopia, cranial nerve defects or limb symptoms. Tumours in the cerebellum or brainstem will have a gradual onset with associated symptoms of cerebellar or brainstem dysfunction. Multiple sclerosis may cause relapsing and remitting symptoms, with other associated features of multiple sclerosis, such as optic neuritis or transverse myelitis. Vestibular migraine will cause symptoms lasting minutes to hours, often associated with visual aura and headache. Attacks may be triggered by: Stress Bright lights Strong smells Certain foods (e.g. chocolate, cheese and caffeine) Dehydration Menstruation Abnormal sleep patterns

Answer 33

When a patient presents with “dizziness’, it is important to first distinguish between vertigo and lightheadedness. Ask whether the “room is moving” (vertigo) or whether they feel more of a lightheadedness. Ask about symptoms that will help you differentiate between central and peripheral vertigo. The table below gives a general idea of the distinguishing features: Peripheral Vertigo Central Vertigo Onset Sudden onset Gradual onset (except stroke) Duration Short (seconds or minutes) Persistent Hearing loss or tinnitus Often present (except BPPV) Usually not Coordination Intact Impaired Nausea More severe Mild Key features that may point to a specific cause are: Recent viral illness (labyrinthitis or vestibular neuronitis) Headache (vestibular migraine, cerebrovascular accident or brain tumour) Typical triggers (vestibular migraine) Ear symptoms, such as pain or discharge (infection) Acute onset neurological symptoms (stroke)

Answer 34

There are four things to examine when assessing a patient presenting with vertigo: Ear examination to look for signs of infection or other pathology Neurological examination to assess for central causes of vertigo (e.g., stroke or multiple sclerosis) Cardiovascular examination to assess for cardiovascular causes of dizziness (e.g., arrhythmias or valve disease) Special tests (see below) Cerebellar examination is an important part of a full neurological examination in patients with vertigo. The components can be remembered with the DANISH mnemonic: D – Dysdiadochokinesia A – Ataxic gait (ask the patient to walk heel-to-toe) N – Nystagmus (see below for more detail) I – Intention tremor S – Speech (slurred) H – Heel-shin test Special tests that may be helpful in patients with dizziness or vertigo include: Romberg’s test (screens for problems with proprioception or vestibular function) Dix-Hallpike manoeuvre (to diagnose BPPV) HINTS examination (to distinguish between central and peripheral vertigo)

Answer 35

The HINTS examination can be used to distinguish between central and peripheral vertigo. It stands for: HI – Head Impulse N – Nystagmus TS – Test of Skew Head Impulse Test The head impulse test involves the patient sitting upright and fixing their gaze on the examiner’s nose. The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose. The head is moved slowly back to the centre before repeating in the opposite direction. Ensure they have no neck pain or pathology before performing the test. A patient with a normally functioning vestibular system will keep their eyes fixed on the examiner’s nose. In a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis), the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner. The head impulse test helps diagnose a peripheral cause of vertigo but will be normal if the patient has no current symptoms or a central cause of vertigo. Nystagmus Nystagmus can be demonstrated by having the patient look left and right. The eyes rapidly saccade or oscillate, meaning they shake side to side as they try to settle into place. A few beats can be normal. Unilateral horizontal nystagmus is more likely to be a peripheral cause. Bilateral or vertical nystagmus suggests a central cause. Test of Skew The test of skew (also called the alternate cover test) involves the patient sitting upright and fixing their gaze on the examiner’s nose. The examiner covers one eye at a time, alternating between covering either eye. The eyes should remain fixed on the examiner’s nose with no deviation. If there is a vertical correction when an eye is uncovered (the eye has drifted up or down and needs to move vertically to fix on the nose when uncovered), this indicates a central cause of vertigo.

Answer 36

Patients with suspected central vertigo need referral for further investigation (e.g., CT or MRI head) to establish the cause. For peripheral vertigo, short-term options for managing symptoms include: Prochlorperazine Antihistamines (e.g., cyclizine, cinnarizine and promethazine) Betahistine may be used to help reduce the attacks in patients diagnosed with Ménière’s disease. Epley manoeuvre can be effective in treating BPPV. Vestibular migraine is usually managed by avoiding triggers and lifestyle changes (e.g., getting enough sleep and staying hydrated). Medical management is similar to migraines, with triptans for the acute symptoms and propranolol, topiramate or amitriptyline to prevent attacks. The DVLA guide for medical professionals (updated March 2021) states that patients must not drive and must inform the DVLA if they are liable to “sudden and unprovoked or unprecipitated episodes of disabling dizziness”.

Answer 37

Benign paroxysmal positional vertigo (BPPV) is a common cause of recurrent episodes of vertigo triggered by head movement. It is a peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain. It is more common in older adults.

Answer 38

A variety of head movements can trigger attacks of vertigo. A common trigger is turning over in bed. Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks. Often episodes occur over several weeks and then resolve but can reoccur weeks or months later. BPPV does not cause hearing loss or tinnitus.

Answer 39

BPPV is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. This occurs most often in the posterior semicircular canal. They may be displaced by a viral infection, head trauma, ageing or without a clear cause. The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.

Answer 40

The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis). It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV. Check the patient can do the manoeuvre safely before performing it, for example, ensuring they have no neck pain or pathology. To perform the manoeuvre: The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear) Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch Watch the eyes closely for 30-60 seconds, looking for nystagmus Repeat the test with the head turned 45 degrees in the other direction In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).

Answer 41

The Epley manoeuvre can be used to treat BPPV. The idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow. To perform the manoeuvre: Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees Rotate the patient’s head 90 degrees past the central position Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction Have the patient sit up sideways with the legs off the side of the couch Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle TOM TIP: Watch videos of the Dix-Hallpike and Epley manoeuvres and practice performing them on your friends. It is worth remembering the names, indications and interpretation, which may be tested in your MCQ exams. I would be surprised if you are asked to perform the manoeuvres in your OSCEs. However, it is worth learning how to perform them as they are not too difficult, and you can impress patients, friends, relatives or seniors if you can perform them at will.

Answer 42

Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.

Answer 43

Vestibular neuronitis describes inflammation of the vestibular nerve. This is usually attributed to a viral infection.

Answer 44

The inner ear contains the bony labyrinth, a complex bony structure containing fluids (perilymph and endolymph). The inner ear is comprised of three parts: Semicircular canals Vestibule (middle section) Cochlea The semicircular canals and otolith organs within the vestibule (the utricle and saccule) are responsible for detecting movement of the head. Together they form the vestibular system: The semicircular canals detect rotation of the head The otolith organs detect gravity and linear acceleration The cochlea is responsible for hearing. The vestibular nerve transmits signals from the vestibular system (the semicircular canals and vestibule) to the brain to help with balance. The cochlear nerve transmits signals from the cochlea to provide hearing. Together they form the vestibulocochlear nerve (the 8th cranial nerve). Vestibular neuronitis refers to inflammation of the vestibular nerve. A viral infection may trigger this inflammation. It distorts the signals travelling from the vestibular system to the brain, confusing the signal required to sense movements of the head. This results in episodes of vertigo, where the brain thinks the head is moving when it is not.

Answer 45

Typically, the history involves the acute onset of vertigo. In addition, there may be a history of a recent viral upper respiratory tract infection. Symptoms are most severe for the first few days. Initially, vertigo may be constant, after which it is triggered or worsened by head movement. It is often associated with: Nausea and vomiting (may be severe) Balance problems It is essential to differentiate between peripheral (inner ear) and central (brain) causes when a patient presents with vertigo. Any neurological signs or symptoms should make you consider a central cause of vertigo rather than vestibular neuronitis. This may require urgent management, particularly if posterior circulation infarction (stroke) is suspected. TOM TIP: Tinnitus and hearing loss are not features of vestibular neuronitis, as the cochlea and cochlear nerve are not affected. If tinnitus and hearing loss are also present, consider labyrinthitis or Ménière’s disease as differential diagnoses. You can remember this with: Labyrinthitis – Loss of hearing Neuronitis – No loss of hearing

Answer 46

The head impulse test can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g., vestibular neuronitis or labyrinthitis). The head impulse test involves the patient sitting upright and fixing their gaze on the examiner’s nose. The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose. The head is slowly moved back to the centre before repeating in the opposite direction. Ensure they have no neck pain or pathology before performing the test. A patient with a normally functioning vestibular system will keep their eyes fixed on the examiner’s nose. In a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis), the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner. The head impulse test helps diagnose a peripheral cause of vertigo but will be normal if the patient has no current symptoms or a central cause of vertigo.

Answer 47

The management here is adapted from the NICE clinical knowledge summaries (updated 2017). Always check local and national guidelines when treating patients. Patients may need admission if they are becoming dehydrated due to severe nausea and vomiting. For peripheral vertigo, short-term options for managing symptoms include: Prochlorperazine Antihistamines (e.g., cyclizine, cinnarizine and promethazine) NICE advise that symptomatic treatment can be used for up to 3 days. More extended use may slow down the recovery. NICE also recommend referral if the symptoms do not improve after 1 week or resolve after 6 weeks, as they may require further investigation or vestibular rehabilitation therapy (VRT).

Answer 48

Symptoms are most severe for the first few days, after which they gradually resolve over the following 2-6 weeks. Benign paroxysmal positional vertigo (BPPV) may develop after vestibular neuronitis.

Answer 49

Labyrinthitis refers to inflammation of the bony labyrinth of the inner ear, including the semicircular canals, vestibule (middle section) and cochlea. The inflammation is usually attributed to a viral upper respiratory tract infection. Rarely labyrinthitis can be caused by a bacterial infection. This may be an inflammatory response to a nearby infection or the result of bacteria or bacterial toxins entering the labyrinth. It is usually secondary to otitis media or meningitis.

Answer 50

Labyrinthitis presents with acute onset vertigo, similarly to vestibular neuronitis. Unlike vestibular neuronitis, labyrinthitis can also be associated with: Hearing loss Tinnitus Patients may have symptoms associated with the causative virus, such as a cough, sore throat and blocked nose.

Answer 51

A clinical diagnosis is based on history and examination findings. It is important to exclude a central cause of the vertigo. The head impulse test can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g., vestibular neuronitis or labyrinthitis).

Answer 52

Management is the same as with vestibular neuronitis, with supportive care and short-term use (up to 3 days) of medication to suppress the symptoms. Options for managing symptoms are: Prochlorperazine Antihistamines (e.g., cyclizine, cinnarizine and promethazine) Antibiotics are used to treat bacterial labyrinthitis. The underlying infection (e.g., otitis media or meningitis) needs appropriate treatment. Patients rarely have lasting symptoms, including permanent hearing impairment. This is more common after bacterial labyrinthitis, particularly associated with meningitis. TOM TIP: Remember hearing loss as a key complication of meningitis. All patients with meningitis are offered audiology assessment as soon as they are recovered to assess for hearing impairment. This complication comes up often in exams and is worth remembering.

Answer 53

Ménière’s disease is a long-term inner ear disorder that causes recurrent attacks of vertigo, and symptoms of hearing loss, tinnitus and a feeling of fullness in the ear. TOM TIP: Remember the typical triad of symptoms in Ménière’s disease, as this is commonly tested in exams: Hearing loss Vertigo Tinnitus

Answer 54

Ménière’s disease is associated with the excessive buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals. This increased pressure of the endolymph is called endolymphatic hydrops.

Answer 55

The typical patient is 40-50 years old, presenting with unilateral episodes of vertigo, hearing loss, and tinnitus. Vertigo in Ménière’s disease comes in episodes. These last for 20 minutes to several hours before settling. These episodes can come in clusters over several weeks, followed by prolonged periods (often months) without vertigo symptoms. Vertigo is not triggered by movement or posture. Hearing loss in Ménière’s disease typically fluctuates at first, associated with vertigo attacks, then gradually becomes more permanent. It is sensorineural hearing loss, generally unilateral and affects low frequencies first. Tinnitus initially occurs with episodes of vertigo before eventually becoming more permanent. It is usually unilateral. Other symptoms can include: A sensation of fullness in the ear Unexplained falls (“drop attacks”) without loss of consciousness Imbalance, which can persist after episodes of vertigo resolve Spontaneous nystagmus may be seen during an acute attack. This is usually in one direction (unidirectional).

Answer 56

Diagnosis of Ménière’s disease is clinical, based on the signs and symptoms. It will be made by an ear, nose and throat (ENT) specialist. Patients will need an audiology assessment to evaluate hearing loss.

Answer 57

Management involves: Managing symptoms during an acute attack Prophylactic medication to reduce the frequency of attacks For acute attacks, short-term options for managing symptoms include: Prochlorperazine Antihistamines (e.g., cyclizine, cinnarizine and promethazine) Prophylaxis is with: Betahistine

Answer 58

Acoustic neuromas are benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear. They are also called vestibular schwannomas, as they originate from the Schwann cells. Schwann cells are found in the peripheral nervous system and provide the myelin sheath around neurones. They occur at the cerebellopontine angle and are sometimes referred to as cerebellopontine angle tumours. Acoustic neuromas are usually unilateral. Bilateral acoustic neuromas are associated with neurofibromatosis type II. TOM TIP: Bilateral acoustic neuromas almost certainly indicate neurofibromatosis type II. This is a popular association in exams, so worth remembering.

Answer 59

The typical patient is aged 40-60 years presenting with a gradual onset of: Unilateral sensorineural hearing loss (often the first symptom) Unilateral tinnitus Dizziness or imbalance A sensation of fullness in the ear They can also be associated with a facial nerve palsy if the tumour grows large enough to compress the facial nerve.

Answer 60

Audiometry is used to assess hearing loss. There will be a sensorineural pattern of hearing loss. Brain imaging (MRI or CT) is used to establish the diagnosis and features of the tumour. MRI provides more detail than CT.

Answer 61

ENT specialist management options include: Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate Surgery to remove the tumour (partial or total removal) Radiotherapy to reduce the growth Notable risks associated with treatment are: Vestibulocochlear nerve injury, with permanent hearing loss or dizziness Facial nerve injury, with facial weakness

Answer 62

Cholesteatoma is an abnormal collection of squamous epithelial cells in the middle ear. It is non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear. It can predispose to significant infections. Confusingly, cholesteatoma has nothing to do with cholesterol or a tumour.

Answer 63

The pathophysiology is not fully understood. Squamous epithelial cells originate from the outer surface of the tympanic membrane. The main theory is that negative pressure in the middle ear, caused by Eustachian tube dysfunction, causes a pocket of the tympanic membrane to retract into the middle ear. Essentially, a small area of the tympanic membrane gets sucked inwards. The squamous epithelial cells of this pocket continue to proliferate and grow into the surrounding space, bones and tissues. It can damage the ossicles (the tiny bones of the middle ear involved in hearing), resulting in permanent hearing loss.

Answer 64

The typical presenting symptoms are: Foul discharge from the ear Unilateral conductive hearing loss As the cholesteatoma continues to expand into the surrounding spaces and tissues, further symptoms may develop, including: Infection Pain Vertigo Facial nerve palsy Otoscopy can show an abnormal build-up of whitish debris or crust in the upper tympanic membrane. However, it may not be possible to visualise the eardrum if discharge or wax are blocking the canal.

Answer 65

A CT head can be used to confirm the diagnosis and plan for surgery. MRI may help assess invasion and damage to local soft tissues. Treatment involves surgical removal of the cholesteatoma.

Answer 66

Facial nerve palsy refers to isolated dysfunction of the facial nerve. This typically presents with a unilateral facial weakness. It is important to understand some basics about the pathway and function of the facial nerve.

Answer 67

The facial nerve exits the brainstem at the cerebellopontine angle. On its journey to the face, it passes through the temporal bone and parotid gland. It then divides into five branches that supply different areas of the face: Temporal Zygomatic Buccal Marginal mandibular Cervical

Answer 68

There are three functions of the facial nerve: motor, sensory and parasympathetic. Motor It supplies the muscles of facial expression, the stapedius in the inner ear and the posterior digastric, stylohyoid and platysma muscles in the neck. Sensory It carries taste from the anterior 2/3 of the tongue. Parasympathetic It provides the parasympathetic supply to the: Submandibular and sublingual salivary glands Lacrimal gland (stimulating tear production)

Answer 69

A common exam task is to distinguish between an upper motor neurone and lower motor neurone facial nerve palsy. It is essential to make this distinction because, in a patient with a new-onset upper motor neurone facial nerve palsy, you should be referring immediately with a suspected stroke. In contrast, patients with a lower motor neurone facial nerve palsy can be managed with less urgency. Each side of the forehead has upper motor neurone innervation by both sides of the brain. However, each side of the forehead only has lower motor neurone innervation from one side of the brain. In an upper motor neurone lesion, the forehead will be spared, and the patient can move their forehead on the affected side. In a lower motor neurone lesion, the forehead will NOT be spared, and the patient cannot move their forehead on the affected side. You can differentiate between an upper and lower motor neurone lesion by asking the patient to raise their eyebrows. If they can raise both eyebrows and wrinkle both sides of the forehead, the patient has an upper motor neurone lesion. If the eyebrow on the affected side cannot be raised and the forehead remains smooth, the patient has a lower motor neurone lesion.

Answer 70

Unilateral upper motor neurone lesions occur in: Cerebrovascular accidents (strokes) Tumours Bilateral upper motor neurone lesions are rare. They may occur in: Pseudobulbar palsies Motor neurone disease

Answer 71

Bell’s palsy is a relatively common condition. It is idiopathic, meaning there is no apparent cause. It presents as a unilateral lower motor neurone facial nerve palsy. The majority of patients fully recover over several weeks, but recovery may take up to 12 months. A third are left with some residual weakness. If patients present within 72 hours of developing symptoms, NICE clinical knowledge summaries (updated 2019) recommend considering prednisolone as treatment, either: 50mg for 10 days 60mg for 5 days followed by a 5-day reducing regime of 10mg a day Patients also require lubricating eye drops to prevent the eye on the affected side from drying out and being damaged. If they develop pain in the eye, they need an ophthalmology review for exposure keratopathy. The eye can be taped closed at night.

Answer 72

Ramsay-Hunt syndrome is caused by the varicella zoster virus (VZV). It presents as a unilateral lower motor neurone facial nerve palsy. Patients stereotypically have a painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side. This rash can extend to the anterior two-thirds of the tongue and hard palate. Treatment should ideally be initiated within 72 hours. Treatment is with: Prednisolone Aciclovir Patients also require lubricating eye drops. TOM TIP: Ramsay-Hunt syndrome is a very popular presentation in your MCQ exams. Look out for that patient with a facial nerve palsy and vesicular rash around their ear.

Answer 73

Infection: Otitis media Malignant otitis externa HIV Lyme’s disease Systemic disease: Diabetes Sarcoidosis Leukaemia Multiple sclerosis Guillain–Barré syndrome Tumours: Acoustic neuroma Parotid tumours Cholesteatomas Trauma: Direct nerve trauma Damage during surgery Base of skull fractures

Answer 74

Nosebleeds are also known as epistaxis. Bleeding usually originates from Kiesselbach’s plexus, which is located in Little’s area. This is an area of the nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels. When the mucosa is disrupted and the blood vessels are exposed, they become prone to bleeding. TOM TIP: Little’s area (the area most affected by Little fingers picking noses) is a popular topic in exams. Remember the name of this area as examiners like to ask, “what is the most likely location of the bleeding?”

Answer 75

Nosebleeds are common in young children and older adults. They can be triggered by: Nose picking Colds Sinusitis Vigorous nose-blowing Trauma Changes in the weather Coagulation disorders (e.g., thrombocytopenia or Von Willebrand disease) Anticoagulant medication (e.g., aspirin, DOACs or warfarin) Snorting cocaine Tumours (e.g., squamous cell carcinoma) When a patient swallows blood during a nosebleed, they may present with vomiting blood. Bleeding is usually unilateral. Bleeding from both nostrils may indicate bleeding posteriorly in the nose. Posterior bleeding presents a higher risk of aspiration of blood.

Answer 76

Nosebleeds will usually resolve without needing any medical assistance. Recurrent and significant nosebleeds might require further investigation to look for an underlying cause, such as thrombocytopenia or clotting disorders. You may have to advise patients on how to manage a nosebleed in an exam: Sit up and tilt the head forwards (tilting the head backwards is not advised as blood will flow towards the airway) Squeeze the soft part of the nostrils together for 10 – 15 minutes Spit out any blood in the mouth, rather than swallowing When bleeding does not stop after 10 – 15 minutes, the nosebleed is severe, bleeding is from both nostrils, or haemodynamically unstable, patients may require hospital admission. Treatment options are: Nasal packing using nasal tampons or inflatable packs Nasal cautery using silver nitrate sticks After treating an acute nosebleed, consider prescribing Naseptin nasal cream (chlorhexidine and neomycin) four times daily for 10 days to reduce any crusting, inflammation and infection. This is contraindicated in peanut or soya allergy.

Answer 77

Sinusitis refers to inflammation of the paranasal sinuses in the face. This is usually accompanied by inflammation of the nasal cavity and can be referred to as rhinosinusitis. It is very common. Sinusitis can be: Acute (less than 12 weeks) Chronic (more than 12 weeks)

Answer 78

The paranasal sinuses are hollow spaces within the bones of the face, arranged symmetrically around the nasal cavity. They produce mucous and drain into the nasal cavities via holes called ostia. Blockage of the ostia prevents drainage of the sinuses, resulting in sinusitis. There are four sets of paranasal sinuses: Frontal sinuses (above the eyebrows) Maxillary sinuses (either side of the nose below the eyes) Ethmoid sinuses (in the ethmoid bone in the middle of the nasal cavity) Sphenoid sinuses (in the sphenoid bone at the back of the nasal cavity)

Answer 79

nflammation of the sinuses can be caused by: Infection, particularly following viral upper respiratory tract infections Allergies, such as hayfever (with allergic rhinitis) Obstruction of drainage, for example, due to a foreign body, trauma or polyps Smoking Patients with asthma are more likely to suffer from sinusitis.

Answer 80

The typical presentation of acute sinusitis is someone with a recent viral upper respiratory tract infection presenting with: Nasal congestion Nasal discharge Facial pain or headache Facial pressure Facial swelling over the affected areas Loss of smell Examination may reveal: Tenderness to palpation of the affected areas Inflammation and oedema of the nasal mucosa Discharge Fever Other signs of systemic infection (e.g., tachycardia) Chronic sinusitis involves a similar presentation but with a duration of more than 12 weeks. Chronic sinusitis may be associated with nasal polyps, which are growths of the nasal mucosa.

Answer 81

In most cases, investigations are not necessary. In patients with persistent symptoms despite treatment, investigations include: Nasal endoscopy CT scan

Answer 82

This section is a brief outline based on the NICE clinical knowledge summaries (updated March 2021). Always check the full local and national guidelines when treating patients. Patients with systemic infection or sepsis require admission to hospital for emergency management. NICE recommend not offering antibiotics to patients with symptoms for up to 10 days. Most cases are caused by a viral infection and resolve within 2-3 weeks. NICE recommend for patients with symptoms that are not improving after 10 days, the options of: High dose steroid nasal spray for 14 days (e.g., mometasone 200 mcg twice daily) A delayed antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin first-line) Options for chronic sinusitis are: Saline nasal irrigation Steroid nasal sprays or drops (e.g., mometasone or fluticasone) Functional endoscopic sinus surgery (FESS)

Answer 83

Steroid nasal sprays are often misused, which means they will not be as effective. A good question to ask is, “do you taste the spray at the back of your throat after using it?” Tasting the spray means it has gone past the nasal mucosa and will not be as effective. The technique involves: Tilting the head slightly forward Using the left hand to spray into the right nostril, and vice versa (this directs the spray slightly away from the septum) NOT sniffing hard during the spray Very gently inhaling through the nose after the spray TOM TIP: It is worth learning and practising how to explain the use of a steroid nasal spray. You may be asked to explain how to use a steroid nasal spray in your OSCEs. I probably explain the technique several times a month in general practice.

Answer 84

Functional endoscopic sinus surgery (FESS) involves using a small endoscope inserted through the nostrils and sinuses. Instruments are used to remove or correct any obstructions to the sinuses. Obstruction may be caused by swollen mucosa, bone, polyps or a deviated septum (surgery to correct a deviated septum is call septoplasty). Balloons may be inflated to dilate the opening of the sinuses. Patients need a CT scan before the procedure to confirm the diagnosis and assess the structures.

Answer 85

Nasal polyps are growths of the nasal mucosa that can occur in the nasal cavity or sinuses. They are often associated with inflammation, particularly with chronic rhinitis. They grow slowly and gradually obstruct the nasal passage. Polyps are usually bilateral. Unilateral nasal polyps are a red flag and should raise suspicions of tumours. TOM TIP: If you remember one thing about nasal polyps, remember that unilateral polyps are concerning for malignancy and require a specialist referral for assessment.

Answer 86

Nasal polyps are associated with several conditions: Chronic rhinitis or sinusitis Asthma Samter’s triad (nasal polyps, asthma and aspirin intolerance/allergy) Cystic fibrosis Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

Answer 87

Nasal polyps may be found on examination in patients presenting with: Chronic rhinosinusitis Difficulty breathing through the nose Snoring Nasal discharge Loss of sense of smell (anosmia) You can examine the nose with a nasal speculum, which holds the nostrils open. Alternatively, you can use an otoscope with a large speculum attached. A specialist can perform nasal endoscopy to visualise the nasal cavity in detail to assess any polyps. Nasal polyps appear as round pale grey/yellow growths on the mucosal wall.

Answer 88

Unilateral polyps should be referred for specialist assessment to exclude malignancy. Medical management involves intranasal topical steroid drops or spray. Surgical management is used where medical treatment fails. This involves removing the polyps: Intranasal polypectomy is used where the polyps are visible close to the nostrils Endoscopic nasal polypectomy is used where the polyps are further in the nose or the sinuses

Answer 89

Obstructive sleep apnoea is caused by collapse of the pharyngeal airway. It is characterised by episodes of apnoea during sleep, where the person stops breathing periodically for up to a few minutes. The partner usually reports this happening, and the patient is unaware of the episodes.

Answer 90

Middle age Male Obesity Alcohol Smoking

Answer 91

Episodes of apnoea during sleep (reported by their partner) Snoring Morning headache Waking up unrefreshed from sleep Daytime sleepiness Concentration problems Reduced oxygen saturation during sleep Severe cases can cause hypertension, heart failure and can increase the risk of myocardial infarction and stroke.

Answer 92

The Epworth Sleepiness Scale is used to assess symptoms of sleepiness associated with obstructive sleep apnoea. TOM TIP: If interviewing someone you suspect has obstructive sleep apnoea, ask about daytime sleepiness and occupation. Daytime sleepiness is a crucial feature that should make you suspect obstructive sleep apnoea. Patients that need to be fully alert for work, for example, heavy goods vehicle operators, require an urgent referral and may need amended work duties whilst awaiting assessment and treatment.

Answer 93

Patients with obstructive sleep apnoea require referral to an ENT specialist or a specialist sleep clinic to perform sleep studies. This involves the patient sleeping in a laboratory whilst staff monitor their oxygen saturation, heart rate, respiratory rate and breathing to establish any episodes of apnoea and the extent of their snoring. The first step in management is to correct reversible risk factors by advising them to stop drinking alcohol, stop smoking and lose weight. The next step is to use a continuous positive airway pressure (CPAP) machine that provides continuous pressure to maintain the patency of the airway. Surgery is another option. This involves quite significant surgical reconstruction of the soft palate and jaw. The most common procedure is called uvulopalatopharyngoplasty (UPPP).

Answer 94

Tonsillitis refers to inflammation of the tonsils. The most common cause of tonsillitis is a viral infection. Viral infections do not require or respond to antibiotics. The most common cause of bacterial tonsillitis is group A streptococcus (Streptococcus pyogenes). This can be effectively treated with penicillin V (phenoxymethylpenicillin). The second most common bacterial cause of tonsillitis is Streptococcus pneumoniae. Other causes: Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus

Answer 95

In the pharynx, at the back of the throat, there is a ring of lymphoid tissue. There are six areas of lymphoid tissue in Waldeyer’s ring, comprising of the adenoids, tubal tonsils, palatine tonsils and the lingual tonsil. The palatine tonsils are the ones typically infected and enlarged in tonsillitis. These are the tonsils on either side at the back of the throat.

Answer 96

A typical presentation of acute tonsillitis is with: Sore throat Fever (above 38°C) Pain on swallowing Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. Exudates are small white patches of pus on the tonsils. There may be anterior cervical lymphadenopathy, which refers to swollen, tender lymph nodes in the anterior triangle of the neck (anterior to the sternocleidomastoid muscle and below the mandible). The tonsillar lymph nodes are just behind the angle of the mandible (jawbone).

Answer 97

The Centor criteria can be used to estimate the probability that tonsillitis is due to bacterial infection and will benefit from antibiotics. A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics. A point is given if each of the following features are present: Fever over 38ºC Tonsillar exudates Absence of cough Tender anterior cervical lymph nodes (lymphadenopathy)

Answer 98

The FeverPAIN score is an alternative to the Centor criteria. A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis: Fever during previous 24 hours P – Purulence (pus on tonsils) A – Attended within 3 days of the onset of symptoms I – Inflamed tonsils (severely inflamed) N – No cough or coryza

Answer 99

Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis. When tonsillitis is the most likely diagnosis, calculate the Centor criteria or FeverPAIN score. Educate patients with likely viral tonsillitis and give safety net advice about when to seek medical advice. Advise simple analgesia with paracetamol and ibuprofen to control pain and fever. NICE clinical knowledge summaries suggest advising patients to return if the pain has not settled after 3 days or the fever rises above 38.3ºC. Starting antibiotics or an alternative diagnosis should be considered. Consider prescribing antibiotics if the Centor score is ≥ 3, or the FeverPAIN score is ≥ 4. Also, consider antibiotics if they are at risk of more severe infections, such as young infants, immunocompromised patients or those with significant co-morbidity, or a history of rheumatic fever. Delayed prescriptions can be considered. This involves educating patients or parents about the likely viral nature of the sore throat and providing a prescription to be collected only if the symptoms worsen or do not improve in the next 2 – 3 days.

Answer 100

Penicillin V (also called phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes. Clarithromycin is the usual first-line choice in true penicillin allergy.

Answer 101

Peritonsillar abscess, also known as quinsy Otitis media, if the infection spreads to the inner ear Scarlet fever Rheumatic fever Post-streptococcal glomerulonephritis Post-streptococcal reactive arthritis

Answer 102

Quinsy is the common name for a peritonsillar abscess. Peritonsillar abscess arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils. Peritonsillar abscess is a complication of untreated or partially treated tonsillitis, although it can arise without tonsillitis. Quinsy can occur just as frequently in teenagers and adults as it does in children, unlike tonsillitis which is much more common in children.

Answer 103

Patients present with similar symptoms to tonsillitis: Sore throat Painful swallowing Fever Neck pain Referred ear pain Swollen tender lymph nodes Additional symptoms that can indicate a peritonsillar abscess include: Trismus, which refers to when the patient is unable to open their mouth Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice” Swelling and erythema in the area beside the tonsils

Answer 104

Quinsy is usually due to a bacterial infection. The most common organism is streptococcus pyogenes (group A strep), but it is also commonly caused by staphylococcus aureus and haemophilus influenzae.

Answer 105

Patients should be referred to the hospital under the ENT team’s care for needle aspiration or surgical incision and drainage to remove the pus from the abscess. Quinsy typically has an underlying bacterial cause. Therefore, antibiotics are appropriate before and after surgery. A broad-spectrum antibiotic such as co-amoxiclav would be an appropriate choice to cover the common causes, but local guidelines will guide antibiotic selection according to local bacterial resistance. Some ENT surgeons give steroids (i.e. dexamethasone) to settle inflammation and help recovery, although this is not universal.

Answer 106

Tonsillectomy is the name for the surgical removal of the tonsils. Removing the tonsils prevents further episodes of tonsillitis, although patients can still get a sore throat from other causes (e.g., pharyngitis). The procedure is performed under a general anaesthetic as a day case. Patients can usually go home the same day after a period of observation.

Answer 107

The SIGN guidelines (2010) give the indications for tonsillectomy. The number of episodes of acute sore throat they specify for a tonsillectomy are: 7 or more in 1 year 5 per year for 2 years 3 per year for 3 years Other indications are: Recurrent tonsillar abscesses (2 episodes) Enlarged tonsils causing difficulty breathing, swallowing or snoring

Answer 108

Sore throat where the tonsillar tissue has been removed (this can last 2 weeks) Damage to teeth Infection Post-tonsillectomy bleeding Risks associated with a general anaesthetic

Answer 109

Post tonsillectomy bleeding is the main significant complication after a tonsillectomy. Significant bleeding can occur in up to 5% of patients who have had a tonsillectomy requiring urgent management. This can happen up to 2 weeks after the operation. Bleeding can be severe and, in rare cases, life-threatening due to aspiration of blood.

Answer 110

Call the ENT registrar and get them involved early Get IV access and send bloods including an FBC, clotting screen, group and save and crossmatch Keep the patient calm and give adequate analgesia Sit them up and encourage them to spit out the blood rather than swallowing Make the patient nil by mouth in case an anaesthetic and operation is required IV fluids for maintenance and resuscitation, if required If there is severe bleeding or airway compromise, call an anaesthetist. Intubation may be required. Before going back to theatre there are two options for stopping less severe bleeds: Hydrogen peroxide gargle Adrenalin soaked swab applied topically

Answer 111

There are three descriptions to note the location of a neck lump: Anterior triangle Posterior triangle Midline (vertically along the centre of the neck) These two triangles are on either side of the sternocleidomastoid muscle. The borders of the anterior triangle are: Mandible forms the superior border Midline of the neck forms the medial border Sternocleidomastoid forms the lateral border The borders of the posterior triangle are: Clavicle forms the inferior border Trapezius forms the posterior border Sternocleidomastoid forms the lateral border

Answer 112

In adults Normal structures (e.g., bony prominence) Skin abscess Lymphadenopathy (enlarged lymph nodes) Tumour (e.g., squamous cell carcinoma or sarcoma) Lipoma Goitre (swollen thyroid gland) or thyroid nodules Salivary gland stones or infection Carotid body tumour Haematoma (a collection of blood after trauma) Thyroglossal cysts Branchial cysts Neck lumps in young children may also be caused by: Cystic hygromas Dermoid cysts Haemangiomas Venous malformation TOM TIP: It is not uncommon for patients to present worried about a normal bony prominence in the neck. Common areas of concern are the hyoid bone, mastoid process and transverse processes of C1.

Answer 113

The purpose of taking a history is to gain: General information about the symptoms (e.g., when the lump first appeared and how quickly it has grown) Features that suggest or exclude a particular diagnosis (e.g., night sweats indicating lymphoma) Risk factors for that condition (e.g., family history, age and smoking status) General fitness for further investigations and treatment (e.g., co-morbidities and medications such as anticoagulants) Examination When examining a neck lump, the things to establish are: Location (anterior triangle, posterior triangle or midline) Size Shape (oval, round or irregular) Consistency (hard, soft or rubbery) Mobile or tethered to the skin or underlying tissues Skin changes (erythema, tethering or ulceration) Warmth (e.g., infection) Tenderness (e.g., infection) Pulsatile (e.g., carotid body tumours) Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts) Transilluminates with light (e.g., cystic hygroma – usually in young children) A general examination can be used to look for signs of the underlying cause, such as: 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 114

The NICE guidelines on suspected cancer (updated January 2021) suggest a referral for two week wait referral for: An unexplained neck lump in someone aged 45 or above A persistent unexplained neck lump at any age They recommend considering an urgent ultrasound scan in patients with a lump that is growing in size. This should be within 2 weeks in patients 25 and older and within 48 hours in patients under 25. They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma. TOM TIP: Patients presenting to primary care with symptoms and signs that are suspicious of cancer require either urgent direct-access investigations or a two week wait referral. The NICE guidelines on “suspected cancer: recognition and referral” set out their recommendations by either the site or the symptom, making it really easy to quickly look up the referral criteria. There is also a section for non-specific symptoms, such as unexplained weight loss, appetite loss and deep vein thrombosis.

Answer 115

Blood tests may be helpful depending on the suspected cause of the neck lumps. Not everyone with a neck lump will require blood tests. The choice of test will depend on the suspected cause: FBC and blood film for leukaemia and infection HIV test Monospot test or EBV antibodies for infectious mononucleosis Thyroid function tests for goitre or thyroid nodules Antinuclear antibodies for systemic lupus erythematosus Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma Imaging may involve: Ultrasound is often the first-line investigation for neck lumps CT or MRI scans Nuclear medicine scan (e.g., for toxic thyroid nodules or PET scans for metastatic cancer) Biopsy may be required to gain a tissue sample (histology) to establish the exact cause. This may be with: Fine needle aspiration cytology – aspirating cells from the lump using a needle Core biopsy – taking a sample of tissue with a thicker needle Incision biopsy – cutting out a tissue sample with a scalpel Removal of the lump – the entire lump can be removed and examined

Answer 116

Lymphadenopathy refers to enlarged lymph nodes. There are a long list of causes of enlarged lymph nodes, which can be generally grouped into: Reactive lymph nodes (e.g., swelling caused by viral upper respiratory tract infections, dental infection or tonsillitis) Infected lymph nodes (e.g., tuberculosis, HIV or infectious mononucleosis) Inflammatory conditions (e.g., systemic lupus erythematosus or sarcoidosis) Malignancy (e.g., lymphoma, leukaemia or metastasis) Enlarged supraclavicular nodes are the most concerning for malignancy of the cervical lymph nodes. They may be caused by malignancy in the chest or abdomen and require further investigation. Features that suggest malignancy are: Unexplained (e.g., not associated with an infection) Persistently enlarged (particularly over 3cm in diameter) Abnormal shape (normally oval shaped where the length is more than double the width) Hard or “rubbery” Non-tender Tethered or fixed to the skin or underlying tissues Associated symptoms, such as night sweats, weight loss, fatigue or fevers

Answer 117

Infectious mononucleosis is a cause of lymphadenopathy. It is caused by infection with the Epstein Barr virus (EBV) and most often affects teenagers and young adults. It is found in the saliva of infected individuals and may be spread by kissing or sharing cups, toothbrushes and other equipment that transmits saliva. It presents with Fever Sore throat Fatigue Lymphadenopathy Mononucleosis can present with an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins. The first-line investigation is the Monospot test. It is also possible to test for IgM (acute infection) and IgG (immunity) to the Epstein Barr virus. Management is supportive. Patients should avoid alcohol (risk of liver impairment) and contact sports (risk of splenic rupture).

Answer 118

Lymphomas are a group of cancers that affect the lymphocytes inside the lymphatic system. These cancerous cells proliferate within the lymph nodes and cause the lymph nodes to become abnormally large (lymphadenopathy). There are two categories of lymphoma: Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. Hodgkin’s lymphoma is a specific disease and non-Hodgkins lymphoma encompasses all the other lymphomas. Hodgkin’s lymphoma is the most likely specific type of lymphoma to appear in your exams. Overall, 1 in 5 lymphomas are Hodgkin’s lymphoma. It is caused by proliferation of lymphocytes. There is a bimodal age distribution with peaks around aged 20 and 75 years. Lymphadenopathy is the key presenting symptom. The enlarged lymph node or nodes might be in the neck, axilla (armpit) or inguinal (groin) region. They are characteristically non-tender and feel “rubbery”. Some patients will experience pain in the lymph nodes when they drink alcohol. B symptoms are the systemic symptoms of lymphoma: Fever Weight loss Night sweats The Reed-Sternberg cell is the key finding from lymph node biopsy in patients with Hodgkin’s lymphoma. The Ann Arbor staging system is used for both Hodgkins and non-Hodgkins lymphoma.

Answer 119

Leukaemia is the name for cancer of a particular line of the stem cells in the bone marrow. This causes the unregulated production of certain types of blood cells. They can be classified depending on how rapidly they progress (chronic is slow and acute is fast) and the cell line that is affected (myeloid or lymphoid) to make four main types: Acute myeloid leukaemia Acute lymphoblastic leukaemia Chronic myeloid leukaemia Chronic lymphocytic leukaemia The presentation of leukaemia is quite non-specific. If leukaemia appears on your list of differentials then get an urgent full blood count. Some typical features are: Fatigue Fever Pallor due to anaemia Petechiae and abnormal bruising due to thrombocytopenia Abnormal bleeding Lymphadenopathy Hepatosplenomegaly

Answer 120

A goitre refers to generalised swelling of the thyroid gland. A goitre can be caused by: Graves disease (hyperthyroidism) Toxic multinodular goitre (hyperthyroidism) Hashimoto’s thyroiditis (hypothyroidism) Iodine deficiency Lithium Individual lumps can occur in the thyroid due to: Benign hyperplastic nodules Thyroid cysts Thyroid adenomas (benign tumours the can release excessive thyroid hormone) Thyroid cancer (papillary or follicular) Parathyroid tumour

Answer 121

The three salivary gland locations are the: Parotid glands Submandibular glands Sublingual glands These can enlarge for three main reasons: Stones blocking the drainage of the glands through the ducts (sialolithiasis) Infection Tumours (benign or malignant)

Answer 122

The carotid body is a structure located just above the carotid bifurcation (where the common carotid splits into the internal and external carotids). It contains glomus cells, which are chemoreceptors that detect the blood’s oxygen, carbon dioxide, and pH. Groups of these glomus cells are called paraganglia. Carotid body tumours are formed by excessive growth of the glomus cells. They are also called paragangliomas. Most are benign. They present with a slow-growing lump that is: In the upper anterior triangle of the neck (near the angle of the mandible) Painless Pulsatile Associated with a bruit on auscultation Mobile side-to-side but not up and down Carotid body tumours may compress the glossopharyngeal (IX), vagus (X), accessory (XI) or hypoglossal (XII) nerves. Pressure on the sympathetic nerves may result in Horner syndrome, with a triad of: Ptosis Miosis Anhidrosis (loss of sweating) A characteristic finding on imaging investigations is splaying (separating) of the internal and external carotid arteries (lyre sign). They are mostly treated with surgical removal.

Answer 123

Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue. On examination, lipomas are typically: Soft Painless Mobile Do not cause skin changes They are typically treated conservatively with reassurance (after excluding other pathology). Alternatively, they can be surgically removed.

Answer 124

During fetal development, the thyroid gland starts at the base of the tongue. From here, it gradually travels down the neck to the final position in front of the trachea, beneath the larynx. It leaves a track behind called the thyroglossal duct, which then disappears. When part of the thyroglossal duct persists, it can give rise to a fluid-filled cyst. This is called a thyroglossal cyst. Ectopic thyroid tissue is a key differential diagnosis, as this commonly occurs at a similar location. Thyroglossal cysts occur in the midline of the neck. They are: Mobile Non-tender Soft Fluctuant Thyroglossal cysts move up and down with movement of the tongue. This is a key feature that demonstrates a midline neck lump is a thyroglossal cyst. This occurs due to the connection between the thyroglossal duct and the base of the tongue. Ultrasound or CT scan can confirm the diagnosis. Thyroglossal cysts are usually surgically removed to provide confirmation of the diagnosis on histology and prevent infections. The cyst can reoccur after surgery unless the entire thyroglossal duct is removed. The main complication is infection of the cyst, causing a hot, tender and painful lump. TOM TIP: Remember the key feature of thyroglossal cysts moving with movement of the tongue. This is a unique fact that examiners like to use to test your knowledge. Look out for a thyroglossal cyst as a differential of a neck lump in your MCQ exam. If you come across a midline neck lump in a child in your OSCEs, ask them to stick their tongue out and look for the lump moving upwards.

Answer 125

A branchial cyst is a congenital abnormality that arises when the second branchial cleft fails to form properly during fetal development. This leaves a space surrounded by epithelial tissue in the lateral aspect of the neck. This space can fill with fluid. This fluid-filled lump is called a branchial cyst. Branchial cysts arising from the first, third and fourth branchial clefts are possible, although they are much rarer. Branchial cysts present as a round, soft, cystic swelling between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck. Branchial cysts tend to present after the age of 10 years, most commonly in young adulthood when the cyst becomes noticeable or infected. Management of a branchial cyst is either: Conservative, without any active intervention, where it is not causing problems Surgical excision where recurrent infections are occurring, there is diagnostic doubt, or it is causing other problems TOM TIP: Branchial cysts may appear in exams as a differential of neck lumps in teenagers or as part of a neck examination in an OSCE. Remembering the key features will help you differentiate them in your exams. They are just anterior to the sternocleidomastoid muscle, round, soft and non-tender. They might ask you where it was most likely to originate, and the answer would be the second branchial cleft.

Answer 126

Head and neck cancers can affect a variety of locations. They are usually squamous cell carcinomas arising from the squamous cells of the mucosa. Locations The potential areas of head and neck cancers are: Nasal cavity Paranasal sinuses Mouth Salivary glands Pharynx (throat) Larynx (epiglottis, supraglottis, vocal cords, glottis and subglottis) Head and neck cancers usually spread to the lymph nodes first. Squamous cell carcinoma cells may be found in an enlarged, abnormal lymph node (lymphadenopathy), and the original tumour cannot be found. This is called cancer of unknown primary.

Answer 127

Smoking Chewing tobacco Chewing betel quid (a habit in south-east Asia) Alcohol Human papillomavirus (HPV), particularly strain 16 Epstein–Barr virus (EBV) infection HPV also causes cervical cancer. The HPV vaccine (Gardasil) protects against strains 6, 11, 16 and 18.

Answer 128

Presenting symptoms and signs that may indicate head and neck cancer are: Lump in the mouth or on the lip Unexplained ulceration in the mouth lasting more than 3 weeks Erythroplakia or erythroleukoplakia Persistent neck lump Unexplained hoarseness of voice Unexplained thyroid lump

Answer 129

Management will be guided by the multidisciplinary team (MDT). It will be dependent on the location, stage and individual patient factors. Staging usually involves the TNM staging system, grading the tumour, node involvement and metastases. Treatment may involve any combination of: Chemotherapy Radiotherapy Surgery Targeted cancer drugs (i.e., monoclonal antibodies) Palliative care Cetuximab is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck. It may also be used to treat bowel cancer. It targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.

Answer 130

Glossitis refers to an inflamed tongue. The tongue becomes red, sore and swollen. The papillae of the tongue atrophy (shrink), giving the tongue a smooth appearance. It is sometimes described as “beefy”.

Answer 131

Iron deficiency anaemia B12 deficiency Folate deficiency Coeliac disease Injury or irritant exposure Management involves correcting the underlying cause.

Answer 132

Angioedema refers to fluid accumulating in the tissues, resulting in swelling. It can affect a number of areas, such as the limbs, face and lips. It can affect the tongue, causing the tongue to swell.

Answer 133

Allergic reactions ACE inhibitors C1 esterase inhibitor deficiency (hereditary angioedema)

Answer 134

Oral candidiasis is also called oral thrush. It refers to an overgrowth of candida, a type of fungus, in the mouth. This results in white spots or patches that coat the surface of the tongue and palate.

Answer 135

Inhaled corticosteroids (particularly with poor technique, not using a spacer and not rinsing with water afterwards) Antibiotics (disrupt the normal bacterial flora giving candida a chance to thrive) Diabetes Immunodeficiency (consider HIV) Smoking

Answer 136

Miconazole gel Nystatin suspension Fluconazole tablets (in severe or recurrent cases)

Answer 137

Geographic tongue is an inflammatory condition where patches of the tongue’s surface lose the epithelium and papillae. The patches form irregular shapes on the tongue, resembling a map, with countries and oceans bordering each other. The condition tends to relapse and remit, with episodes of the abnormal tongue appearance that can last days to weeks before resolving or changing. The cause of these changes is not known. Geographic tongue often occurs without any associations. However, it can be related to: Stress and mental illness Psoriasis Atopy (asthma, hayfever and eczema) Diabetes Geographic tongue is a benign condition and does not cause any harmful effects. It does not usually require any treatment. Symptoms such as discomfort or burning are sometimes treated with topical steroids or antihistamines.

Answer 138

A strawberry tongue appearance occurs when the tongue becomes swollen and red, and the papillae become enlarged, white and prominent. The two key causes of a strawberry tongue to remember are: Scarlet fever Kawasaki disease

Answer 139

Black hairy tongue results from decreased shedding (exfoliation) of keratin from the tongue’s surface. The papillae elongate and take on the appearance of hairs. Bacteria and food cause the dark pigmentation. This gives the appearance of black hair on the tongue. Patients may also report sticky saliva and a metallic taste. Black hairy tongue may be due to dehydration, a dry mouth, poor oral hygiene and smoking. Management involves ensuring adequate hydration, gentle brushing of the tongue and stopping smoking.

Answer 140

Leukoplakia is characterised by white patches in the mouth, often on the tongue or insides of the cheeks (buccal mucosa). It is a precancerous condition, meaning it increases the risk of squamous cell carcinoma of the mouth. The patches are asymptomatic, irregular and slightly raised. They are fixed in place, meaning they cannot be scraped off. They may require a biopsy to exclude abnormal cells (dysplasia) or cancer. Management involves stopping smoking, reducing alcohol intake, close monitoring and potentially laser removal or surgical excision.

Answer 141

Erythroplakia is similar to leukoplakia, except the lesions are red. Erythroleukoplakia refers to lesions that are a mixture of red and white. Both erythroplakia and erythroleukoplakia are associated with a high risk of squamous cell carcinoma and should be referred urgently to exclude cancer.

Answer 142

Lichen planus is an autoimmune condition that causes localised chronic inflammation of the skin. The skin has shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae. It usually occurs in patients over 45 and is more common in women. Lichen planus can also affect the mucosal membranes, including the mouth. Often it only affects the mouth. In the mouth, it can take three patterns: Reticular Erosive Plaque A reticular pattern involves a net-like web of white lines called Wickham’s striae. Erosive lesions are where the surface layer of the mucosa is eroded, leaving bright red and sore areas of mucosa. Plaques are larger continuous areas of white mucosa. Management involves good oral hygiene, stopping smoking and topical steroids.

Answer 143

Gingivitis refers to inflammation of the gums. This can present with swollen gums, bleeding after brushing, painful gums and bad breath (halitosis). Gingivitis can lead to periodontitis if not adequately managed. Periodontitis refers to severe and chronic inflammation of the gums and the tissues that support the teeth. This often leads to loss of teeth. Acute necrotising ulcerative gingivitis is a rapid onset of more severe inflammation in the gums. It presents similarly to gingivitis, however, it is painful. Anaerobic bacteria usually cause this. The risk factors for gingivitis are: Plaque build-up on the teeth (inadequate brushing) Smoking Diabetes Malnutrition Stress Bacteria live in plaque, damaging the teeth and gums. Hardened plaque is called tartar. Patients with gingivitis will be managed by a dentist. Treatment involves: Good oral hygiene Stopping smoking Dental hygienist treatment to remove plaque and tartar Chlorhexidine mouth wash Antibiotics for acute necrotising ulcerative gingivitis (e.g., metronidazole) Dental surgery if required

Answer 144

Gingival hyperplasia refers to abnormal growth of the gums. The gums are notably enlarged around the teeth. Possible causes of gingival hyperplasia include: Gingivitis Pregnancy Vitamin C deficiency (scurvy) Acute myeloid leukaemia Medications, particularly calcium channel blockers, phenytoin and ciclosporin

Answer 145

Aphthous ulcers are very common, small, painful ulcers of the mucosa in the mouth. They have a well-circumscribed, punched-out, white appearance. Aphthous ulcers commonly occur in otherwise healthy people, with no underlying cause. They may be triggered by emotional or physical stress, trauma to the mucosa or particular foods. They may also be an indication of underlying conditions, notably: Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) Coeliac disease Behçet disease Vitamin deficiency (e.g., iron, B12, folate and vitamin D) HIV Aphthous ulcers usually heal within 2 weeks. Manageable ulcers do not require any intervention. Topical treatments can be used to treat symptoms, including: Choline salicylate (e.g., Bonjela) Benzydamine (e.g., Difflam spray) Lidocaine Topical corticosteroids can be used in more severe ulcers. These may reduce the duration and severity of symptoms. Options include: Hydrocortisone buccal tablets applied to the lesion Betamethasone soluble tablets applied to the lesion Beclomethasone inhaler sprayed directly onto the lesion The NICE guidelines on suspected cancer (updated January 2021) recommend a two week wait referral in patients with “unexplained ulceration” lasting over 3 weeks.