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Surgery > Ear, Nose and Throat > Flashcards

Ear, Nose and Throat Flashcards

1
Q

what is pure tone audiometry used for?

A

key hearing test used to identify hearing threshold levels of an individual, enabling determination of the degree, type and configuration of a hearing loss

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2
Q

Headphones deliver tones at different frequencies and strengths in a sound-proofed room.

Pt. indicates when sound appears and disappears.

Mastoid vibrator → bone conduction threshold.

Threshold at different frequencies are plotted to give an audiogram.

what test is this?

A

Pure tone audiometry

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3
Q

what is tympanometry used for?

A

an examination used to test the condition of the middle ear and mobility of the eardrum (tympanic membrane)

not a hearing test, but rather a measure of energy transmission through the middle ear.

tympanometry permits a distinction between sensorineural and conductive hearing loss, when evaluation is not apparent via Weber and Rinne testing.

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4
Q

tympanogram results showing a flat line suggests?

A

middle ear fluid or perforation

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5
Q

what is evoked response audiometry?

A

used for neonatal screening

auditory stimulus w measurement of elicited brain response by surface electrode

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6
Q

what is otitis externa?

A

inflammation (redness and swelling) of the external ear canal

ear pain, which can be severe

itchiness in the ear canal

a discharge of liquid or pus from the ear

some degree of temporary hearing loss

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7
Q

causes of otitis externa?

A

moisture e.g. swimming

trauma e.g. fingernails

absence of wax

hearing aid

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8
Q

what are the main organisms leading to otitis externa?

A

mainly pseudomonas

staph aureus

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9
Q

mx of acute diffuse otitis externa?

A

Manage any aggravating or precipitating factors.

Consider cleaning the external auditory ear canal if earwax or debris obstructs the application of topical medication

analgesia if required

topical antibiotic +/- topical corticosteroid

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10
Q

what is malignant otitis externa?

A

Life-threatening infection which can → skull osteomyelitis

90% of pts. are diabetic (or other immune compromise)

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11
Q

features of malignant otitis externa?

A

severe otalgia worse at night

copious otorrhoea

granulation tissue in the canal

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12
Q

mx of malignant otitis externa?

A

surgical debridement

systemic abx

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13
Q

what is bullous myringitis?

A

Painful haemorrhagic blisters on deep meatal skin and TM.

ear infection in which small, fluid-filled blisters form on the eardrum.

cause pain

assoc with influenza URTI

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14
Q

what is TMJ (temporomandibular joint) dysfunction?

A

condition affecting the movement of the jaw

Earache (referred pain from auriculotemporal N.)

pain around your jaw, ear and temple

clicking, popping or grinding noises when you move your jaw

a headache around your temples

difficulty opening your mouth fully

your jaw locking when you open your mouth

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15
Q

sign of TMJ dysfunction?

A

Joint tenderness exacerbated by lateral movements of an open jaw.

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16
Q

ix of TMJ dysfunction

A

MRI

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17
Q

Mx of TMJ Dysfunction?

A

NSAIDS

stabilising orthodontic occlusal prostheses

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18
Q

acute vs chronic otitis media?

A

acute: acute phase

vs

chronic: effusion > 3mo if bilat or > 6 mo if unilat

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19
Q

what organisms may be responsible for otitis media/

A

viral

pneumococcus

haemophilus

moraxella

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20
Q

Child post-viral URTI

rapid onset ear pain, tugging at ear

irritability, anorexia, vomiting

purulent discharge if drum perforates

O/E bulging, red TM, fever

A

acute otitis media

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21
Q

mx of acute otitis media?

A

paracetamol

amoxicillin (abx)

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22
Q

complications of acute otitis media?

A

intratemporal:

otitis media with effusion

perforation of TM

mastoiditis

facial n palsy

intracranial:

meningitis/ encephalitis

brain abscess

sub/epidural abscess

systemic:

bacteraemia

septic arthritis

IE

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23
Q

what is otitis media with effusion?

ie. glue ear

A

effusion after symptom regression (acute phase)

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24
Q

features of Otitis media with effusion?

A

inattention at school

hearing impairment

poor speech development

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25
Q

examination findings of otitis media with effusion?

A

retracted dull Tympanic membrane

fluid level

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26
Q

ix of otitis media with effusion?

A

audiometry: flat tympanogram

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27
Q

mx of otitis media with effusion?

A

usually resolves spontaneously

consider grommets if persistent hearing loss

autoinflation:

e.g.

blowing up a special balloon using one nostril at a time

swallowing while holding the nostrils closed

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28
Q

what is chronic suppurative Otitis media?

A

Ear discharge w hearing loss and evidence of central drum perforation.

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29
Q

features of mastoiditis?

A

fever

mastoid tenderness

protruding auricle

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30
Q

what is mastoiditis?

A

middle ear inflammation -> destruction of mastoid air cells and abscess formation

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31
Q

ix of mastoiditis?

A

CT

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32
Q

mx of mastoiditis?

A

IV abx

myringotomy (surgical incision into the eardrum, to relieve pressure or drain fluid.) +/- mastoidectomy (removes diseased mastoid air cells)

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33
Q

features of chronic suppurative otitis media

A

painless discharge and hearing loss

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34
Q

examination findings of chronic suppurative otitis media?

A

tympanic membrane perforation

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35
Q

mx of chronic suppurative otitis media?

A

aural toilet

abx/ steroid ear drops

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36
Q

what is a cholesteatoma?

A

cholesteatoma is an abnormal, noncancerous skin growth that can develop in the middle section of your ear, behind the eardrum

locally destructive expansion of stratified squamous epithelium within the middle ear.

can be congenital.

most commonly caused by repeated middle ear infections (ie. chronic suppurative OM)

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37
Q

presentation of cholesteatoma?

A

foul smelling white discharge

headache, pain

CN involvement: vertigo, deafness, facial paralysis

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38
Q

examination findings of cholesteatoma?

A

appears pearly white w surrounding inflammation

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39
Q

complications of cholesteatoma?

A

deafness (ossicle destruction)

meningitis

cerebral abscess

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40
Q

mx of cholesteatoma?

A

surgery

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41
Q

what is tinnitus?

A

sensation of sound w/o external sound stimulation

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42
Q

ix of tinnitus?

A

audiometry and tympanogram

MRI if unilateral to exclude acoustic neuroma

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43
Q

examinations for tinnitus?

A

otoscopy

tuning fork tests

pulse and BP

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44
Q

general systemic causes of tinnitus?

A

High BP

low Hb

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45
Q

unilateral tinnitus suggests?

+ vertigo/ deafness

A

acoustic neuroma

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46
Q

FH of tinnitus +ve?

A

otosclerosis

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47
Q

tinnitus, vertigo, deafness triad?

A

Meniere’s disease

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48
Q

mx of tinnitus

A

treat any underlying cause e.g. noise, drugs, head injury

psych support: tinnitus retraining therapy

hypnotics at night may help

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49
Q

definition of vertigo?

A

illusion of movement

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50
Q

drugs that may cause vertigo?

A

gentamicin

loop diuretics

metronidazole

co-trimoxazole

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51
Q

examination and tests to do with vertigo as symptom?

A

hearing test

cranial nerves

cerebellum and gait

hallpike manouevre

romberg’s +ve = vestibular or proprioception

audiometry, calorimetry, LP, MRI

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52
Q

what is the pathology behind meniere’s disease?

A

dilatation of endolymph spaces of membranous labyrinth

(endolymphatic oedema)

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53
Q

features of meniere’s disease?

A

attacks occur in clusters and last up to 12h

progressive sensorineural hearing loss

vertigo and N+V

tinnitus

aural fullness

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54
Q

ix of meniere’s disease?

A

audiometry

  • shows low frequency sensorineural hearing loss which fluctuates

ultimately clinical diagnosis

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55
Q

medical mx of meniere’s disease

A

to rapidly relieve N+V: prochlorperazine /cyclizine

betahistine:

local vasodilation and increased permeability, which helps to reverse the underlying problem of endolymphatic hydrops

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56
Q

surgical mx of meniere’s disease should medications fail?

A

vestibular rehabilitation

intratympanic gentamicin or corticosteroids

endolymphatic shunts or sac surgery

labyrinthectomy or vestibular nerve section

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57
Q

features of viral labyrinthitis?

A

follows febrile illness e.g. URTI

sudden vomiting

severe vertigo exacerbated by head movements

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58
Q

mx of viral labyrinthitis?

A

cyclizine

improvement in days

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59
Q

features of benign paroxysmal positional vertigo?

A

episodes of sudden rotational vertigo provoked by changing position of the head

nystagmus

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60
Q

pathology behind benign paroxysmal positional vertigo?

A

underlying mechanism involves a small calcified otolith (Crystals) moving around loose in the inner ear -> stimulating the hair cells

can result from head injury or idiopathic

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61
Q

diagnosis of BPPV?

A

Hallpike manouevre - +ve if nystagmus

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62
Q

mx of BPPV?

A

self limiting

Epley manouevre

Betahistine: histamine analogue

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63
Q

what is conductive hearing loss?

A

impaired conduction anywhere between auricle and round window

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64
Q

causes of conductive hearing loss?

A

external canal obstruction:

wax, pus, foreign body

TM perforation: trauma, infection

Ossicle defects: otosclerosis, infection, trauma

Inadequate eustachian tube ventilation of middle ear

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65
Q

what is sensorineural hearing loss?

A

defects of inner ear (cochlea), auditory nerve or brain

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66
Q

causes of sensorineural hearing loss?

A

drugs: aminoglycosides, vancomycin

post-infective:

meningitis, measles, mumps, herpes

Meniere’s, Trauma, MS, Acoustic neuroma, B12 deficiency

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67
Q

what is an acoustic neuroma/ vestibular schwannoma?

A

Benign, slow-growing tumour of superior vestibular N.

acts as SOL -> cerebellopontine angle syndrome

assoc w Neurofibromatosis 2

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68
Q

what is acoustic neuroma/ vestibular schwannoma assoc w ?

A

neurofibromatosis type 2

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69
Q

Ix of acoustic neuroma?

A

MRI of cerebellopontine angle

(MRI of all pts w unilateral tinnitus/ deafness)

hearing test: sensorineural?

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70
Q

features of acoustic neuroma?

A

slow onset, unilateral sensorineural hearing loss, tinnitus +/- vertigo

headache (raised ICP)

CN palsies: 5, 7, 8

cerebellar signs

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71
Q

mx of acoustic neuroma?

A

gamma knife radiosurgery

surgery

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72
Q

what is otosclerosis?

A

aka otospongiosis

fixation of the stapes footplate to the oval window of the cochlea. This greatly impairs movement of the stapes and therefore transmission of sound into the inner ear

F>M 2:1

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73
Q

features of otosclerosis?

A

Begins in early adult life

(AD condition)

Bilateral conductive deafness + tinnitus

HL improved in noisy places: Willis’ paracousis

Worsened by pregnancy/ menstruation/ menopause

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74
Q

Ix of otosclerosis

A

Pure tone audiometry: shows Dip (Cahart’s notch) @ 2kHz

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75
Q

Mx of otosclerosis?

A

hearing aid

or stapes implant

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76
Q

what is presbyacussis?

A

age related hearing loss

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77
Q

features of presbyacussis?

A

>65 yo

bilateral

slow onset

+/- tinnitus

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78
Q

ix of presbyacussis?

A

pure tone audiometry

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79
Q

mx of presbyacussis?

A

hearing aid

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80
Q

sensorineural hearing loss, heterochromia + telecanthus (increased distance between the medial canthi of the eyes)

A

Waardenburgs

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81
Q

autosomal recessive condition with sensorineural hearing loss, heamaturia + eye abnormalities?

A

Alport’s syndrome

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82
Q

long QT syndrome associated with severe, bilateral sensorineural hearing loss

A

Jervell and Lange-Nielsen syndrome

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83
Q

mx of pinna haematoma?

A

aspiration + firm packing to auricle contour

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84
Q

complication of pinna haematoma?

A

blunt trauma -> subperichondrial haematoma

can lead to ischaemic necrosis of cartilage and subsequent fibrosis to cauliflower ears

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85
Q

causes of Tympanic membrane perforation?

A

otitis media

foreign body

barotrauma

trauma

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86
Q

mx of wax accumulation/ impaction in ear?

A

suction under direct vision w microscope

syringing after 1 wk softening w olive oil

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87
Q

what is exostoses of the ear?

A

bone surrounding the ear canal develop lumps of new bony growth which constrict the ear canal

bone hypertrophy due to cold exposure

e.g. from swimming/ surfing

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88
Q

features of exostoses of the ear canal?

A

asymptomatic unless narrowing occludes the ear canal -> conductive deafness

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89
Q

mx of exostoses of the ear?

A

Conservative

or surgical widening

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90
Q

symptoms of allergic rhinitis?

A

sneezing

rhinorrhoea

pruritus

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91
Q

pathology of allergic rhinitis?

A

T1 hypersensitivity IgE-mediated inflammation from allergen exposure -> mediator release from mast cells

allergens: pollen (seasonal), house dust mites (perennial)

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92
Q

signs of allergic rhinitis?

A

swollen, pale and boggy turbinates

w pale, bluish gray mucosa

nasal polyps

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93
Q

ix of allergic rhinitis?

A

skin prick testing to find allergen

RAST tests

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94
Q

1st line mx of allergic rhinitis?

A

allergen avoidance

anti-histamines e.g. cetrizine

or steroid nasal spray e.g. beclometasone

2nd line: intranasal steroids + anti histamines

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95
Q

features of sinusitis?

A

maxillary pain/ ethmoidal pain (between eyes)

which may increase on bending/ straining

discharge from nose

nasal obstruction/ congestion

anosmia or cacosmia (bad smell w/o external source)

systemic symptoms e.g. fever

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96
Q

ix of sinusitis?

A

nasendoscopy +/- CT

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97
Q

mx of acute sinusitis?

A

bed rest, decongestants, analgesia

nasal douching and topical steroids

abx of uncertain benefit

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98
Q

e.g. of nasal decongestant?

A

pseudoephedrine

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99
Q

mx of chronic/ recurrent sinusitis?

A

usually a structural or drainage problem e.g. PCD

stop smoking + fluticasone nasal spray

functional endoscopy sinus surgery if failed medical tx

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100
Q

complications of sinusitis?

A

mucoceles -> pyoceles

orbital cellulitis/ abscess

osteomyelitis -> e.g. staph in frontal bone

intracranial infection: meningitis, encephalitis, abscess, cavernous sinus thrombosis

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101
Q

What is Bell’s Palsy?

A

inflammatory oedema from entrapment of CN VII in narrow facial canal

LMN Palsy

75% of facial palsy

probably of viral origin HSV1

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102
Q

features of Bell’s Palsy?

A

sudden onset e.g. overnight

complete, unilateral facial weakness in 24-72h

  • failure of eye closure (bells sign) -> dryness and conjunctivitis
  • drooling, speech difficulty

numbness or pain around ear

decreased taste

hyperacusis: stapedius palsy

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103
Q

ix of bell’s palsy

A

serology: Borrelia or VZV abs

MRI: SOL, stroke, MS

LP

104
Q

mx of Bell’s Palsy?

A

protect eye: dark glasses, artificial tears, tape close eyes @ night

give prednisolone within 72h

(60mg/ d PO for 5/7 followed by tapering)

valaciclovir if zoster suspected

plastic surgery may help if no recovery

105
Q

prognosis of Bell’s Palsy?

A

Incomplete paralysis usually recovers completely w/i wks.

With complete lesions, 80% get full recovery but the remainder have delayed recovery or permanent neurological / cosmetic abnormalities.

106
Q

complications of Bell’s Palsy?

A

aberrant neural connections

synkinesis: e.g. blinking causes up turning of mouth

crocodile tears: eating stimulates unilateral lacrimation not salivation

107
Q

What is Ramsay Hunt syndrome?

A

reactivationg of VZV in geniculate ganglion in CNVII

108
Q

features of Ramsay Hunt syndrome?

A

preceding ear pain or stiff neck

vesicular rash in auditory canal +/- Tm, pinna, tongue, hard palate

ipsilateral facial weakness, ageusia (decreased taste) and hyperacusis

may affect CN8 -> vertigo, tinnitus and deafness

109
Q

mx of ramsay hunt syndrome?

A

if dx suspected, give valaciclovir and prednisolone within first 72h

Prognosis

Rxed w/i 72h: 75% recovery
Otherwise: 1/3 full recovery, 1/3 partial, 1/3 poor

110
Q

UMN vs LMN facial palsy?

A

UMN forehead sparing of frontalis and orbicularis oculi

111
Q

what is laryngomalacia?

A

seen in infants

Immature and floppy aryepiglottic folds and glottis →laryngeal collapse on inspiration

112
Q

features of laryngomalacia?

A

Stridor: commonest cause in children

Presents w/i first wks of life.

Noticeable @ certain times:

Lying on back, Feeding, Excited/upset

Problems can occur w concurrent laryngeal infections

or w feeding.

113
Q

mx of laryngomalacia?

A

usually no tx required but serious cases may warrant surgery

114
Q

main organism responsible for acute epiglottitis?

A

haemophilus influenzae type b

115
Q

symptoms of epiglotittis

A

sudden onset, continuous stridot

toxic looking child

drooling

116
Q

mx of acute epiglottitis?

A

Don’t examine throat

Consult anaesthetists and ENT surgeons

O2 + nebulised adrenaline

IV dexamethasone

Cefotaxime

Take to theatre to secure airway by intubation

117
Q

Ix of foreign body inhalation?

A

bronchoscopy

118
Q

causes of subglottic stenosis?

A

subglottis is the narrowest part of respiratory tract in children

causes:

prolonged intubation

congenital abnormalities

119
Q

features of subglottic stenosis?

A

stridor

FTT

120
Q

mx of subglottic stenosis?

A

mild: conservative
severe: tracheostomy or partial tracheal resection

121
Q

functions of the larynx?

A

phonation

positive thoracic pressure: inc auto-PEEP

respiration

prevention of aspiration

122
Q

features of laryngitis?

A

pain, hoarseness and fever

123
Q

O/E findings of laryngitis?

A

redness and swelling of the vocal cords

124
Q

mx of laryngitis?

A

supportive

pen V if necessary

125
Q

what is laryngeal papilloma?

A

usually occur in children

pedunculated vocal cord swellings caused by HPV

present with hoarseness

126
Q

mx of laryngeal papilloma?

A

laser removal

127
Q

recurrent laryngeal nerve supplies?

A

Supplies all intrinsic muscles of the larynx except for cricothyroideus.

Responsible for ab- and ad-uction of vocal folds

128
Q

features of recurrent laryngeal n palsy?

A

hoarseness

breathy voice w bovine cough

repeated coughing from aspiration (decreased supraglottic sensation)

exertional dyspnoea (narrow glottis)

129
Q

causes of recurrent laryngeal n palsy?

A

30% are cancers: larynx, thyroid, oesophagus,

hypopharynx, bronchus

25% iatrogenic: para- / thyroidectomy, carotid

endarterectomy

Other: aortic aneurysm, bulbar / pseudobulbar palsy

130
Q

laryngeal SCC risk factors?

A

smoking

Alcohol

131
Q

features of laryngeal SCC?

A

Male smoker

Progressive hoarseness → stridor

Dys-/odono-phagia (difficulty & pain when swallowing)

Wt. loss

132
Q

Ix of laryngeal SCC?

A

laryngoscopy + biopsy incl nodes

MRI staging

133
Q

Mx of laryngeal SCC

A

based on stage

radiotx

laryngectomy

134
Q

features of tonsillitis?

A

sore throat, fever, malaise

lymphadenopathy

inflamed tonsils and oropharynx

exudates

135
Q

organisms responsible for tonsillitis?

A

viruses most common (consider EBV)

Group A strep: pyogenes

136
Q

Mx of tonsillitis?

A

Swabbing superficial bacteria is irrelevant and can →overdiagnosis.

Analgesia: Ibuprofen / Paracetamol ± Difflam gargle

Consider Abx only if ill: use Centor Criteria

Pen V 250mg PO QDS (125mg TDS in children) or erythromycin for 5/7

NOT AMOXICILLIN → MACPAP RASH IN EBV

137
Q

what is the Centor Criteria?

A

Guideline for admin of Abx in acute sore throat / tonsillitis / pharyngitis

138
Q

what does the centor criteria consist of?

A

1 Point for Each of

  1. Hx of fever
  2. Tonsillar exudates
  3. Tender anterior cervical adenopathy
  4. No cough

0-1: no Abx (risk of strep infection <10%)

2: consider rapid Ag test + Rx if +ve

≥3: Abx

139
Q

indications for tonsillectomy?

A

Recurrent tonsillitis if all the below criteria are met:

  • Caused by tonsillitis
  • 5+ episodes/yr
  • Symptoms for >1yr
  • Episodes are disabling and prevent normal functioning

Airway obstruction: e.g. OSA in children

Quinsy

Suspicion of Ca: unilateral enlargement or ulceration

140
Q

strep throat complications

A

Quinsy: peritonsillar abscess

retropharyngeal abscess

Lemierre’s Syndrome

Scarlet fever

Rheumatic fever

Post-strep glomerulonephritis

141
Q

features of Quinsy (peritonsillar abscess)?

A

trismus (reduced opening of the jaws)

odonophagia: unable to swallow saliva

halitosis

tonsillitis

unilateral tonsillar enlargement

contralateral uvula displacement

cervical lymphadenopathy

142
Q

mx of quinsy (peritonsillar abscess)?

A

admit

iv abx

incision and drainage under LA ->

wound is left open to heal by secondary intent

if v severe -> tonsillectomy under GA

143
Q

features of retropharyngeal abscess?

A

unwell child w stiff, extended neck who refuses to eat or drink

fails to improve w IV abx

unilateral swelling of tonsil and neck

144
Q

ix of retropharyngeal abscess?

A

lateral neck xrays show soft tissue swelling

CT from skull base to diaphragm

145
Q

mx of retropharyngeal abscess?

A

IV abx

incision and drainage

146
Q

features of rheumatic fever

A

carditis

arthritis

subcutaneous nodules

erythema marginatum

sydenham’s chorea

147
Q

features of scarlet fever?

A

strawberry tongue

sandpaper like rash on chest, axillae or behind ears 12-48h after pharyngotonsillitis

circumoral pallor

148
Q

mx of scarlet fever?

A

start Pen V/G and notify HPA

149
Q

what is Lemierre’s Syndrome?

A

infectious thrombophlebitis of the internal jugular vein

-> septic embolic affecting lungs/ sepsis

due to bacterial sore throat e.g. fusobacterium necrophorum

mx: IV ABx- pen G, clindamycin, metronidazole

150
Q

causes of epistaxis?

A

80% unknown

Trauma: nose-picking / #s

Local infection: URTI

Pyogenic granuloma

Overgrowth of tissue on Little’s area due to irritation or hormonal factors.

Osler-Weber-Rendu / HHT

Coagulopathy: Warfarin, NSAIDs, haemophilia, ↓plats, vWD, ↑EtOH

Neoplasm

151
Q

initial Mx of epistaxis?

A

assess for shock and manage accordingly

if not shocked: sit up, head tilted down

compress nasal cartilage for 15 min

if bleeding not controlled, remove clots w suction or by blowing and try to visualise bleed by rhinoscopy

152
Q

anterior epistaxis pathology?

A

usually septal haemorrhage: Little’s area/ Kisselbach’s plexus

  • Ant ethmoidal artery
  • sphenopalatine artery
  • facial artery
153
Q

mx of anterior epistaxis?

A

insert gauze soaked in vasoconstrictor + LA

  • xylometazoline + 2% lignocaine for 5 min

bleeds can be cauterised with silver nitrate sticks

persistent bleeds should be packed with Mericel pack

  • refer to ENT if this fails or if you cant visualise the bleeding point
  • ENT may insert a posterior pack or take pt to theatre for endoscopic control
154
Q

mx of posterior/ major epistaxis?

A

posterior packing (+ anterior pack)

  • pass 18/18G Foley catheter through the nose into nasopharynx, inflate w 10ml water and pull forward until it lodges
  • admit pt and leaveg pack for 48h

gold standard = endoscopic visualisation and direct control e.g. by cautery/ ligation

155
Q

features of Hereditary haemorrhagic telangiectasia?

(aka Osler-Weber-Rendu)

A

auto dominant

telangiectasias in mucosae -> recurrent spontaneous epistaxis, painless GI bleeds

internal telangiectasias and AVMS:

lungs

liver

brain

156
Q

septal haematoma features?

A

boggy swelling and nasal obstruction

157
Q

complications of septal haematoma?

A

septal necrosis + nasal collapse if untreated

  • cartilage blood supply comes from mucosa
158
Q

mx of septal haematoma?

A

needs evacuation under GA w packing and suturing

159
Q

nasal polyps in children assoc w?

A

Cystic fibrosis

neoplasms

160
Q

single unilateral nasal polyp

sign of?

A

could be rare but sinister pathology

e.g. nasopharyngeal ca, glioma, lymphoma, neuroblastoma, sarcoma

Do CT and get histology!

161
Q

mx of nasal polyps in children?

A

drugs: betamethasone drops for 2/7

short course of oral steroids

endoscopic polypectomy

162
Q

mx of pt > 45 yo

w persistent unexplained hoarseness or

An unexplained lump in the neck?

A

referral to ENT specialist

(suspect laryngeal Ca)

+ chest xray to exclude apical lung ca

163
Q

anterior vs posterior epistaxis?

A

the former often has a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s Plexus.

Posterior haemorrhages, on the other hand, tend to be more profuse and originate from deeper structures. They occur more frequently in older patients and confer a higher risk of aspiration and airway compromise.

164
Q

mx If bleeding does not stop after 10-15 minutes of continuous pressure on the nose?

A

consider cautery or packing

Cautery should be used if the source of the bleed is visible and cautery is tolerated- it is not so well tolerated in younger children!

Packing may be used if cautery is not viable or the bleeding point cannot be visualised.

165
Q

what does cautery of epistaxis involve?

A

Ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume

Use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect

Identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.

Dab the area clean with a cotton bud and apply Naseptin or Muciprocin

166
Q

Weber Test?

A

in unilateral sensorineural deafness, sound is localised to the unaffected side

in unilateral conductive deafness, sound is localised to the affected side

167
Q

what does packing of epistaxis involve?

A

Anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes

Pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions

Pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack.

Examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel.

Patients should be admitted to hospital for observation and review, and to ENT if available

168
Q

Rinne’s test?

A

air conduction (AC) is normally better than bone conduction (BC)

if BC > AC then conductive deafness

169
Q

neck lump

Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly

A

Lymphoma

170
Q

neck lump

More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected

A

thyroglossal cyst

171
Q

neck lump

May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing

A

thyroid swelling

172
Q

neck lump

Pulsatile lateral neck mass which doesn’t move on swallowing

A

carotid aneurysm

173
Q

neck lump

More common in adult females
Around 10% develop thoracic outlet syndrome

A

cervical rib

174
Q

neck lump

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx (Anterior triangle)
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood

painless, fluctuant mass

A

Branchial cyst

175
Q

neck lump

A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age

Posterior triangle usually

A

cystic hygroma

176
Q

neck lump

More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

A

pharyngeal pouch

177
Q

how to interpret an audiogram?

A

anything above the 20dB line is essentially normal (marked in red on the blank audiogram below)

in sensorineural hearing loss both air and bone conduction are impaired

in conductive hearing loss only air conduction is impaired

in mixed hearing loss both air and bone conduction are impaired, with air conduction often being ‘worse’ than bone

178
Q

mx of acute sinusitis?

A

analgesia

intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited

NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for >10 days

oral antibiotics are not normally required but may be given for severe presentations. BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’

179
Q

Mx of recurrent or chronic sinusitis?

A

treat any acute element

intranasal corticosteroids are often beneficial

referral to ENT may be appropriate

180
Q

drugs that may cause tinnitus?

A

aspirin

aminoglycosides (Kanamycin, Gentamicin)

Loop diuretics

quinine

181
Q

what is Ludwig’s Angina?

A

cellulitis which occurs on the floor of the mouth

deadly, as it spreads in the fascial spaces of the head and neck

swelling that ensues from the inflammation begins to push the floor of the mouth upwards and blocks air entry -> airway compromise

risk factors: poor dentition, immunocompromised

182
Q

what is the most common type of salivary gland tumour?

A

80% parotid glands

80% of these - pleomorphic adenoma

183
Q

risk of pleomorphic adenoma?

A

CNVII damage

184
Q

features of Warthin’s tumour?

A

papillary cystadenoma

benign

strong assoc with smoking

softer, more mobile and fluctuant than pleomorphic adenoma

185
Q

which salivary glands are stones most likely to be found in?

A

submandibular

186
Q

features of salivary stones?

A

recurrent unilateral pain & swelling on eating

may become infected → Ludwig’s angina

80% are submandibular

187
Q

Ix of salivary stones?

A

Xray

Sialography

188
Q

mx of salivary stones?

A

surgical removal

189
Q

mx of perforated tympanic membrane?

A

no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. avoid getting water in the ear during this time

it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media.

myringoplasty may be performed if TM does not heal by itself

190
Q

audiometry of presbyacusis?

A

bilateral high-frequency sensorineural hearing loss

191
Q

Whartons duct drains?

A

submandibular gland

192
Q

Stensen’s duct drains?

A

parotid gland

193
Q

complications following thyroid surgery?

A

Anatomical such as recurrent laryngeal nerve damage.

Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.

Damage to the parathyroid glands resulting in hypocalcaemia.

Thyroid storm

194
Q

mx of acute necrotizing ulcerative gingivitis

A

refer the patient to a dentist +

oral metronidazole* for 3 days

chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash

simple analgesia

195
Q

mx of malignant otitis externa?

A

usually pseudomonas

so abx to tx pseudomonas - e.g. ciprofloxacin

196
Q

mx of thyroglossal cyst?

A

Sistrunk’s procedure

197
Q

unilateral foul smelling discharge and deafness?

on examination there is no wax but a crust on the upper part of the tympanic membrane

A

cholesteatoma

198
Q

Drug causes of gingival hyperplasia?

A

phenytoin

ciclosporin

calcium channel blockers (especially nifedipine)

199
Q

most common parotid tumour in child < 1yo?

A

Haemangioma

  • Hypervascular on imaging
    Spontaneous regression may occur and malignant transformation is almost unheard of
200
Q

Post-operative complications of tonsillectomy?

A

pain: may increase for up to 6 days following a tonsillectomy.

Haemorrhage:

primary haemorrhage managed by immediate return to theatre

Secondary haemorrhage occurs 5 - 10 days after surgery, assoc with a wound infection. Treatment: admission and antibiotics. Severe bleeding may require surgery.

201
Q

pt with unilateral nasal polyp and bleeding mx?

A

Refer to ENT for a full examination

to rule out malignancy

202
Q

Samter’s triad?

A

asthma, aspirin sensitivity and nasal polyposis

203
Q

mx If small bilateral nasal polyps are seen?

A

saline nasal douche and intranasal steroids

204
Q

why does the thyroglossal cyst move on tongue protrusion?

A

connection with the foramen caecum

205
Q

Management of acute sinusitis
?

A

analgesia

intranasal decongestants or nasal saline may be considered

intranasal corticosteroids if the symptoms > 10 days

severe presentation: phenoxymethylpenicillin first-line

206
Q

Management of recurrent or chronic sinusitis

A

treat any acute element

intranasal corticosteroids are often beneficial

referral to ENT may be appropriate

207
Q

initial management of otitis externa?

A

topical antibiotic or a combined topical antibiotic with steroid

if there is canal debris then consider removal

if the canal is extensively swollen then an ear wick is sometimes inserted

208
Q

features of otitis externa on otoscopy?

A

red, swollen, or eczematous canal

209
Q

what pt group is at biggest risk of malignant otitis externa?

A

diabetes

(Infective organism is usually Pseudomonas aeruginosa)

210
Q

diagnosis of malignant otitis externa?

A

CT

211
Q

Mx of malignant otitis externa?

A

Intravenous antibiotics that cover pseudomonal infections

Hyperbaric oxygen is sometimes used in refractory cases

212
Q

what does malignant otitis externa cause?

A

temporal bone osteomyelitis

213
Q

abx for strep throat?

A

phenoxymethylpenicillin or erythromycin (if the patient is penicillin allergic)

7 or 10 day course

214
Q

features of acoustic neuroma?

A

Features can be predicted by the affected cranial nerves

cranial nerve VIII: hearing loss, vertigo, tinnitus

cranial nerve V: absent corneal reflex

cranial nerve VII: facial palsy

215
Q

painful blue red lesions on anterior shins?

A

erythema nodosum

3Ss: sarcoid, strep, sulfonamides

also: OCP, IBD, TB, Behcet’s

216
Q

infections that cause erythema multiforme?

A

HSV 70%

Mycoplasma

217
Q

tx of pyoderma gangrenosum?

A

High dose systemic steroids

218
Q

what is Rhinitis medicamentosa?

A

rebound nasal congestion brought on by extended use of topical decongestants

Treatment of rhinitis medicamentosa involves withdrawal of the offending nasal spray (cold turkey).

219
Q

What are the most common bacterial causes of otitis media?

A

Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis.

220
Q

If abx indicated for acute otitis media, what is normally given?

A

1st line: 5-day course of amoxicillin

penicillin allergy-> erythromycin or clarithromycin

221
Q

Why is Little’s area the most common area for anterior nasal bleed?

A

Little’s area in the anterior nasal septum is the site of Kiesselbach’s plexus, supplied by 4 arteries.

222
Q

Causes of epistaxis?

A

most common cause = trauma e.g. insertion of foreign bodies, nose picking and nose blowing.

Coagulopathies: low Pl, splenomegaly, leukaemia, Waldenstrom’s macroglobulinaemia and ITP.

Drugs: cocaine use

Neoplasia:

Juvenile angiofibroma, nasopharyngeal ca

HHT

Vasculitis: wegeners

223
Q

What does cautery of a bleeding vessel causing epistaxis involve?

A
  • Ask pt to blow their nose to remove any clots.
  • Use a topical LA spray (e.g. Co-phenylcaine) and wait 3-4 minutes
  • Identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require tx, and only cauterise one side of the septum as there is a risk of perforation.
  • Dab the area clean with a cotton bud and apply Naseptin or Muciprocin- topical antiseptics that reduce crusting and risk of vestibulitis
224
Q

What does packing of an anterior bleed in epistaxis involve?

A
  • Anaesthetise with topical LA spray (e.g. Co-phenylcaine) and wait for 3-4 minutes
  • Pack the pt’s nose while they are sitting with their head forward
  • Pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack.
  • Examine the mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel.
  • Patients should be admitted to hospital for observation and review, and to ENT if available
225
Q

Self care advice to reduce risk of re bleeding after tx of epistaxis?

A

Avoid blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks. -> any strain on the nostril may induce a re-bleed

226
Q
A

posterior packing

227
Q
A

Black hairy tongue

Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour.

228
Q

Predisposing factors of black hairy tongue?

A

poor oral hygiene

antibiotics

head and neck radiation

HIV

intravenous drug use

229
Q

Ix of Black hairy tongue?

A

The tongue should be swabbed to exclude Candida

230
Q

Management of black hairy tongue?

A

tongue scraping

topical antifungals if Candida

231
Q

features of cluster headaches?

A

Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
Clusters typically last 4-12 weeks
Intense pain around one eye
Accompanied by redness, lacrimation, lid swelling, nasal stuffines

232
Q

Presenting features of nasopharyngeal carcinoma?

A

Otalgia, unilateral serous otitis media, nasal obstruction, discharge, bleeding

Cranial n palsies III-VI

Cervical lymphadenopathy - early spread

233
Q

Treatment of nasopharyngeal ca?

A

Radiotherapy is first line therapy.

234
Q

Imaging of nasopharyngeal ca?

A

Combined CT and MRI.

235
Q

what is nasopharyngeal carcinoma?

A

Squamous cell carcinoma of the nasopharynx

Rare in most parts of the world, apart from individuals from Southern China

Associated with Epstein Barr virus infection

236
Q

what infection is assoc w nasopharyngeal ca?

A

EBV

237
Q

Mx of Otitis externa if infection is spreading?

A

oral antibiotics (flucloxacillin)

238
Q

features of nasal septal haematoma?

A

may be precipitated by relatively minor trauma

the sensation of nasal obstruction is the most common symptom

pain and rhinorrhoea are also seen

on examination, classically a bilateral, red swelling arising from the nasal septum

this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm

*impt complication of nasal trauma-

development of a haematoma between the septal cartilage and the overlying perichondrium.

239
Q

Management of nasal septal haematoma?

A

refer straight to ENT

  • emergency

surgical drainage

intravenous antibiotics

240
Q

complications of nasal septal haematoma?

A

If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis.

-> ‘saddle-nose’ deformity

241
Q
A
242
Q

What is the main side-effect of using topical decongestants for prolonged periods?

A

should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa may occur upon withdrawal

243
Q

Parotid gland involvement in Sarcoidosis?

A

6% of patients with sarcoid

Bilateral in most cases

not tender

Xerostomia (dry mouth) may occur

Management of isolated parotid disease is usually conservative

244
Q

Ix of parotid mass?

A

Plain x-rays: exclude calculi

Sialography: delineate ductal anatomy

FNAC is used in most cases

Superficial parotidectomy: diagnostic or therapeutic

Where malignancy is suspected the primary approach should be definitive resection rather than excisional biopsy

CT/ MRI may be used in cases of malignancy for staging primary disease

245
Q

mx otitis externa when features of severe inflammation are present?

ie.

a red, oedematous ear canal which is narrowed and obscured by debris

conductive hearing loss

discharge

regional lymphadenopathy

cellulitis spreading beyond the ear

fever

A

7 days of a topical antibiotic with or without a topical steroid.

246
Q

Facial nerves major branches?

A

The facial nerve passes through the parotid gland, which it does not innervate, to form the parotid plexus, which splits into 5 branches innervating the muscles of facial expression

(temporal, zygomatic, buccal, marginal mandibular, cervical)

247
Q

facial nerve course through middle ear?

A

facial nerve runs through the tympanic cavity, medial to the incus.

248
Q

Frey’s syndrome?

A

erythema (redness/flushing) and sweating in the cutaneous distribution of the auriculotemporal nerve, usually in response to gustatory stimuli.

“gustatory neuralgia”

side effect of surgeries of or near the parotid gland or due to injury to the auriculotemporal nerve

249
Q

in Frey’s syndrome, what nerve may be damaged?

A

auriculotemporal nerve

250
Q

Mx of Frey’s syndrome?

A

injection of botulinum toxin A

ointment of anticholinergic e.g. scopolamine

251
Q

what is the most useful prognostic factor in thyroid ca?

A

pt’s age at time of diagnosis

the younger the pt, the better the prognosis

252
Q

mx of thyroid storm?

A

Seek senior help - propranolol, carbimazole and steroids are mainstays of tx

+ IV fluids, sedation and antiarrhythmic drugs e.g. digoxin if needed

253
Q

Most common organism causing acute otitis media?

A

Strep pneumoniae

254
Q

Posterior nose bleed- which artery is most commonly ligated in theatre?

A

sphenopalatine artery

255
Q

which abx can cause a itchy maculopapular rash when given in pts suffering w glandular fever?

A

Amoxicillin

(e.g. co-amoxiclav too)

256
Q

Mx of Ludwig’s Angina?

A

Ludwigs angina = bilateral submandibular and sunlingual space infection

surgical emergency

refer to Maxillofacial team

IV Abx + Incision and drainage of abscess

usually urgent intubation w oropharyngeal tube

if advanced to stage of significantly elevating tongue -> cricothyroidotomy/ tracheostomy

Surgery (17 decks)

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