Ear, Nose and Throat Flashcards
what is pure tone audiometry used for?
key hearing test used to identify hearing threshold levels of an individual, enabling determination of the degree, type and configuration of a hearing loss
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?
Pure tone audiometry
what is tympanometry used for?
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.
tympanogram results showing a flat line suggests?
middle ear fluid or perforation
what is evoked response audiometry?
used for neonatal screening
auditory stimulus w measurement of elicited brain response by surface electrode
what is otitis externa?
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
causes of otitis externa?
moisture e.g. swimming
trauma e.g. fingernails
absence of wax
hearing aid
what are the main organisms leading to otitis externa?
mainly pseudomonas
staph aureus
mx of acute diffuse otitis externa?
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
what is malignant otitis externa?
Life-threatening infection which can → skull osteomyelitis
90% of pts. are diabetic (or other immune compromise)
features of malignant otitis externa?
severe otalgia worse at night
copious otorrhoea
granulation tissue in the canal
mx of malignant otitis externa?
surgical debridement
systemic abx
what is bullous myringitis?
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
what is TMJ (temporomandibular joint) dysfunction?
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
sign of TMJ dysfunction?
Joint tenderness exacerbated by lateral movements of an open jaw.
ix of TMJ dysfunction
MRI
Mx of TMJ Dysfunction?
NSAIDS
stabilising orthodontic occlusal prostheses
acute vs chronic otitis media?
acute: acute phase
vs
chronic: effusion > 3mo if bilat or > 6 mo if unilat
what organisms may be responsible for otitis media/
viral
pneumococcus
haemophilus
moraxella
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
acute otitis media
mx of acute otitis media?
paracetamol
amoxicillin (abx)
complications of acute otitis media?
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
what is otitis media with effusion?
ie. glue ear
effusion after symptom regression (acute phase)
features of Otitis media with effusion?
inattention at school
hearing impairment
poor speech development
examination findings of otitis media with effusion?
retracted dull Tympanic membrane
fluid level
ix of otitis media with effusion?
audiometry: flat tympanogram
mx of otitis media with effusion?
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
what is chronic suppurative Otitis media?
Ear discharge w hearing loss and evidence of central drum perforation.
features of mastoiditis?
fever
mastoid tenderness
protruding auricle
what is mastoiditis?
middle ear inflammation -> destruction of mastoid air cells and abscess formation
ix of mastoiditis?
CT
mx of mastoiditis?
IV abx
myringotomy (surgical incision into the eardrum, to relieve pressure or drain fluid.) +/- mastoidectomy (removes diseased mastoid air cells)
features of chronic suppurative otitis media
painless discharge and hearing loss
examination findings of chronic suppurative otitis media?
tympanic membrane perforation
mx of chronic suppurative otitis media?
aural toilet
abx/ steroid ear drops
what is a cholesteatoma?
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)
presentation of cholesteatoma?
foul smelling white discharge
headache, pain
CN involvement: vertigo, deafness, facial paralysis
examination findings of cholesteatoma?
appears pearly white w surrounding inflammation
complications of cholesteatoma?
deafness (ossicle destruction)
meningitis
cerebral abscess
mx of cholesteatoma?
surgery
what is tinnitus?
sensation of sound w/o external sound stimulation
ix of tinnitus?
audiometry and tympanogram
MRI if unilateral to exclude acoustic neuroma
examinations for tinnitus?
otoscopy
tuning fork tests
pulse and BP
general systemic causes of tinnitus?
High BP
low Hb
unilateral tinnitus suggests?
+ vertigo/ deafness
acoustic neuroma
FH of tinnitus +ve?
otosclerosis
tinnitus, vertigo, deafness triad?
Meniere’s disease
mx of tinnitus
treat any underlying cause e.g. noise, drugs, head injury
psych support: tinnitus retraining therapy
hypnotics at night may help
definition of vertigo?
illusion of movement
drugs that may cause vertigo?
gentamicin
loop diuretics
metronidazole
co-trimoxazole
examination and tests to do with vertigo as symptom?
hearing test
cranial nerves
cerebellum and gait
hallpike manouevre
romberg’s +ve = vestibular or proprioception
audiometry, calorimetry, LP, MRI
what is the pathology behind meniere’s disease?
dilatation of endolymph spaces of membranous labyrinth
(endolymphatic oedema)
features of meniere’s disease?
attacks occur in clusters and last up to 12h
progressive sensorineural hearing loss
vertigo and N+V
tinnitus
aural fullness
ix of meniere’s disease?
audiometry
- shows low frequency sensorineural hearing loss which fluctuates
ultimately clinical diagnosis
medical mx of meniere’s disease
to rapidly relieve N+V: prochlorperazine /cyclizine
betahistine:
local vasodilation and increased permeability, which helps to reverse the underlying problem of endolymphatic hydrops
surgical mx of meniere’s disease should medications fail?
vestibular rehabilitation
intratympanic gentamicin or corticosteroids
endolymphatic shunts or sac surgery
labyrinthectomy or vestibular nerve section
features of viral labyrinthitis?
follows febrile illness e.g. URTI
sudden vomiting
severe vertigo exacerbated by head movements
mx of viral labyrinthitis?
cyclizine
improvement in days
features of benign paroxysmal positional vertigo?
episodes of sudden rotational vertigo provoked by changing position of the head
nystagmus
pathology behind benign paroxysmal positional vertigo?
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
diagnosis of BPPV?
Hallpike manouevre - +ve if nystagmus
mx of BPPV?
self limiting
Epley manouevre
Betahistine: histamine analogue
what is conductive hearing loss?
impaired conduction anywhere between auricle and round window
causes of conductive hearing loss?
external canal obstruction:
wax, pus, foreign body
TM perforation: trauma, infection
Ossicle defects: otosclerosis, infection, trauma
Inadequate eustachian tube ventilation of middle ear
what is sensorineural hearing loss?
defects of inner ear (cochlea), auditory nerve or brain
causes of sensorineural hearing loss?
drugs: aminoglycosides, vancomycin
post-infective:
meningitis, measles, mumps, herpes
Meniere’s, Trauma, MS, Acoustic neuroma, B12 deficiency
what is an acoustic neuroma/ vestibular schwannoma?
Benign, slow-growing tumour of superior vestibular N.
acts as SOL -> cerebellopontine angle syndrome
assoc w Neurofibromatosis 2
what is acoustic neuroma/ vestibular schwannoma assoc w ?
neurofibromatosis type 2
Ix of acoustic neuroma?
MRI of cerebellopontine angle
(MRI of all pts w unilateral tinnitus/ deafness)
hearing test: sensorineural?
features of acoustic neuroma?
slow onset, unilateral sensorineural hearing loss, tinnitus +/- vertigo
headache (raised ICP)
CN palsies: 5, 7, 8
cerebellar signs
mx of acoustic neuroma?
gamma knife radiosurgery
surgery
what is otosclerosis?
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
features of otosclerosis?
Begins in early adult life
(AD condition)
Bilateral conductive deafness + tinnitus
HL improved in noisy places: Willis’ paracousis
Worsened by pregnancy/ menstruation/ menopause
Ix of otosclerosis
Pure tone audiometry: shows Dip (Cahart’s notch) @ 2kHz
Mx of otosclerosis?
hearing aid
or stapes implant
what is presbyacussis?
age related hearing loss
features of presbyacussis?
>65 yo
bilateral
slow onset
+/- tinnitus
ix of presbyacussis?
pure tone audiometry
mx of presbyacussis?
hearing aid
sensorineural hearing loss, heterochromia + telecanthus (increased distance between the medial canthi of the eyes)
Waardenburgs
autosomal recessive condition with sensorineural hearing loss, heamaturia + eye abnormalities?
Alport’s syndrome
long QT syndrome associated with severe, bilateral sensorineural hearing loss
Jervell and Lange-Nielsen syndrome
mx of pinna haematoma?
aspiration + firm packing to auricle contour
complication of pinna haematoma?
blunt trauma -> subperichondrial haematoma
can lead to ischaemic necrosis of cartilage and subsequent fibrosis to cauliflower ears
causes of Tympanic membrane perforation?
otitis media
foreign body
barotrauma
trauma
mx of wax accumulation/ impaction in ear?
suction under direct vision w microscope
syringing after 1 wk softening w olive oil
what is exostoses of the ear?
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
features of exostoses of the ear canal?
asymptomatic unless narrowing occludes the ear canal -> conductive deafness
mx of exostoses of the ear?
Conservative
or surgical widening
symptoms of allergic rhinitis?
sneezing
rhinorrhoea
pruritus
pathology of allergic rhinitis?
T1 hypersensitivity IgE-mediated inflammation from allergen exposure -> mediator release from mast cells
allergens: pollen (seasonal), house dust mites (perennial)
signs of allergic rhinitis?
swollen, pale and boggy turbinates
w pale, bluish gray mucosa
nasal polyps
ix of allergic rhinitis?
skin prick testing to find allergen
RAST tests
1st line mx of allergic rhinitis?
allergen avoidance
anti-histamines e.g. cetrizine
or steroid nasal spray e.g. beclometasone
2nd line: intranasal steroids + anti histamines
features of sinusitis?
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
ix of sinusitis?
nasendoscopy +/- CT
mx of acute sinusitis?
bed rest, decongestants, analgesia
nasal douching and topical steroids
abx of uncertain benefit
e.g. of nasal decongestant?
pseudoephedrine
mx of chronic/ recurrent sinusitis?
usually a structural or drainage problem e.g. PCD
stop smoking + fluticasone nasal spray
functional endoscopy sinus surgery if failed medical tx
complications of sinusitis?
mucoceles -> pyoceles
orbital cellulitis/ abscess
osteomyelitis -> e.g. staph in frontal bone
intracranial infection: meningitis, encephalitis, abscess, cavernous sinus thrombosis
What is Bell’s Palsy?
inflammatory oedema from entrapment of CN VII in narrow facial canal
LMN Palsy
75% of facial palsy
probably of viral origin HSV1
features of Bell’s Palsy?
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
ix of bell’s palsy
serology: Borrelia or VZV abs
MRI: SOL, stroke, MS
LP
mx of Bell’s Palsy?
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
prognosis of Bell’s Palsy?
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.
complications of Bell’s Palsy?
aberrant neural connections
synkinesis: e.g. blinking causes up turning of mouth
crocodile tears: eating stimulates unilateral lacrimation not salivation
What is Ramsay Hunt syndrome?
reactivationg of VZV in geniculate ganglion in CNVII
features of Ramsay Hunt syndrome?
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
mx of ramsay hunt syndrome?
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
UMN vs LMN facial palsy?
UMN forehead sparing of frontalis and orbicularis oculi
what is laryngomalacia?
seen in infants
Immature and floppy aryepiglottic folds and glottis →laryngeal collapse on inspiration
features of laryngomalacia?
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.
mx of laryngomalacia?
usually no tx required but serious cases may warrant surgery
main organism responsible for acute epiglottitis?
haemophilus influenzae type b
symptoms of epiglotittis
sudden onset, continuous stridot
toxic looking child
drooling
mx of acute epiglottitis?
Don’t examine throat
Consult anaesthetists and ENT surgeons
O2 + nebulised adrenaline
IV dexamethasone
Cefotaxime
Take to theatre to secure airway by intubation
Ix of foreign body inhalation?
bronchoscopy
causes of subglottic stenosis?
subglottis is the narrowest part of respiratory tract in children
causes:
prolonged intubation
congenital abnormalities
features of subglottic stenosis?
stridor
FTT
mx of subglottic stenosis?
mild: conservative
severe: tracheostomy or partial tracheal resection
functions of the larynx?
phonation
positive thoracic pressure: inc auto-PEEP
respiration
prevention of aspiration
features of laryngitis?
pain, hoarseness and fever
O/E findings of laryngitis?
redness and swelling of the vocal cords
mx of laryngitis?
supportive
pen V if necessary
what is laryngeal papilloma?
usually occur in children
pedunculated vocal cord swellings caused by HPV
present with hoarseness
mx of laryngeal papilloma?
laser removal
recurrent laryngeal nerve supplies?
Supplies all intrinsic muscles of the larynx except for cricothyroideus.
Responsible for ab- and ad-uction of vocal folds
features of recurrent laryngeal n palsy?
hoarseness
breathy voice w bovine cough
repeated coughing from aspiration (decreased supraglottic sensation)
exertional dyspnoea (narrow glottis)
causes of recurrent laryngeal n palsy?
30% are cancers: larynx, thyroid, oesophagus,
hypopharynx, bronchus
25% iatrogenic: para- / thyroidectomy, carotid
endarterectomy
Other: aortic aneurysm, bulbar / pseudobulbar palsy
laryngeal SCC risk factors?
smoking
Alcohol
features of laryngeal SCC?
Male smoker
Progressive hoarseness → stridor
Dys-/odono-phagia (difficulty & pain when swallowing)
Wt. loss
Ix of laryngeal SCC?
laryngoscopy + biopsy incl nodes
MRI staging
Mx of laryngeal SCC
based on stage
radiotx
laryngectomy
features of tonsillitis?
sore throat, fever, malaise
lymphadenopathy
inflamed tonsils and oropharynx
exudates
organisms responsible for tonsillitis?
viruses most common (consider EBV)
Group A strep: pyogenes
Mx of tonsillitis?
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
what is the Centor Criteria?
Guideline for admin of Abx in acute sore throat / tonsillitis / pharyngitis
what does the centor criteria consist of?
1 Point for Each of
- Hx of fever
- Tonsillar exudates
- Tender anterior cervical adenopathy
- No cough
0-1: no Abx (risk of strep infection <10%)
2: consider rapid Ag test + Rx if +ve
≥3: Abx
indications for tonsillectomy?
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
strep throat complications
Quinsy: peritonsillar abscess
retropharyngeal abscess
Lemierre’s Syndrome
Scarlet fever
Rheumatic fever
Post-strep glomerulonephritis
features of Quinsy (peritonsillar abscess)?
trismus (reduced opening of the jaws)
odonophagia: unable to swallow saliva
halitosis
tonsillitis
unilateral tonsillar enlargement
contralateral uvula displacement
cervical lymphadenopathy
mx of quinsy (peritonsillar abscess)?
admit
iv abx
incision and drainage under LA ->
wound is left open to heal by secondary intent
if v severe -> tonsillectomy under GA
features of retropharyngeal abscess?
unwell child w stiff, extended neck who refuses to eat or drink
fails to improve w IV abx
unilateral swelling of tonsil and neck
ix of retropharyngeal abscess?
lateral neck xrays show soft tissue swelling
CT from skull base to diaphragm
mx of retropharyngeal abscess?
IV abx
incision and drainage
features of rheumatic fever
carditis
arthritis
subcutaneous nodules
erythema marginatum
sydenham’s chorea
features of scarlet fever?
strawberry tongue
sandpaper like rash on chest, axillae or behind ears 12-48h after pharyngotonsillitis
circumoral pallor
mx of scarlet fever?
start Pen V/G and notify HPA
what is Lemierre’s Syndrome?
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
causes of epistaxis?
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
initial Mx of epistaxis?
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
anterior epistaxis pathology?
usually septal haemorrhage: Little’s area/ Kisselbach’s plexus
- Ant ethmoidal artery
- sphenopalatine artery
- facial artery
mx of anterior epistaxis?
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
mx of posterior/ major epistaxis?
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
features of Hereditary haemorrhagic telangiectasia?
(aka Osler-Weber-Rendu)
auto dominant
telangiectasias in mucosae -> recurrent spontaneous epistaxis, painless GI bleeds
internal telangiectasias and AVMS:
lungs
liver
brain
septal haematoma features?
boggy swelling and nasal obstruction
complications of septal haematoma?
septal necrosis + nasal collapse if untreated
- cartilage blood supply comes from mucosa
mx of septal haematoma?
needs evacuation under GA w packing and suturing
nasal polyps in children assoc w?
Cystic fibrosis
neoplasms
single unilateral nasal polyp
sign of?
could be rare but sinister pathology
e.g. nasopharyngeal ca, glioma, lymphoma, neuroblastoma, sarcoma
Do CT and get histology!
mx of nasal polyps in children?
drugs: betamethasone drops for 2/7
short course of oral steroids
endoscopic polypectomy
mx of pt > 45 yo
w persistent unexplained hoarseness or
An unexplained lump in the neck?
referral to ENT specialist
(suspect laryngeal Ca)
+ chest xray to exclude apical lung ca
anterior vs posterior epistaxis?
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.
mx If bleeding does not stop after 10-15 minutes of continuous pressure on the nose?
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.
what does cautery of epistaxis involve?
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
Weber Test?
in unilateral sensorineural deafness, sound is localised to the unaffected side
in unilateral conductive deafness, sound is localised to the affected side
what does packing of epistaxis involve?
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
Rinne’s test?
air conduction (AC) is normally better than bone conduction (BC)
if BC > AC then conductive deafness
neck lump
Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly
Lymphoma
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
thyroglossal cyst
neck lump
May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
thyroid swelling
neck lump
Pulsatile lateral neck mass which doesn’t move on swallowing
carotid aneurysm
neck lump
More common in adult females
Around 10% develop thoracic outlet syndrome
cervical rib
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
Branchial cyst
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
cystic hygroma
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
pharyngeal pouch
how to interpret an audiogram?
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
mx of acute sinusitis?
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’
Mx of recurrent or chronic sinusitis?
treat any acute element
intranasal corticosteroids are often beneficial
referral to ENT may be appropriate
drugs that may cause tinnitus?
aspirin
aminoglycosides (Kanamycin, Gentamicin)
Loop diuretics
quinine
what is Ludwig’s Angina?
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
what is the most common type of salivary gland tumour?
80% parotid glands
80% of these - pleomorphic adenoma
risk of pleomorphic adenoma?
CNVII damage
features of Warthin’s tumour?
papillary cystadenoma
benign
strong assoc with smoking
softer, more mobile and fluctuant than pleomorphic adenoma
which salivary glands are stones most likely to be found in?
submandibular
features of salivary stones?
recurrent unilateral pain & swelling on eating
may become infected → Ludwig’s angina
80% are submandibular
Ix of salivary stones?
Xray
Sialography
mx of salivary stones?
surgical removal
mx of perforated tympanic membrane?
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
audiometry of presbyacusis?
bilateral high-frequency sensorineural hearing loss
Whartons duct drains?
submandibular gland
Stensen’s duct drains?
parotid gland
complications following thyroid surgery?
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
mx of acute necrotizing ulcerative gingivitis
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
mx of malignant otitis externa?
usually pseudomonas
so abx to tx pseudomonas - e.g. ciprofloxacin
mx of thyroglossal cyst?
Sistrunk’s procedure
unilateral foul smelling discharge and deafness?
on examination there is no wax but a crust on the upper part of the tympanic membrane
cholesteatoma
Drug causes of gingival hyperplasia?
phenytoin
ciclosporin
calcium channel blockers (especially nifedipine)
most common parotid tumour in child < 1yo?
Haemangioma
- Hypervascular on imaging
Spontaneous regression may occur and malignant transformation is almost unheard of
Post-operative complications of tonsillectomy?
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.
pt with unilateral nasal polyp and bleeding mx?
Refer to ENT for a full examination
to rule out malignancy
Samter’s triad?
asthma, aspirin sensitivity and nasal polyposis
mx If small bilateral nasal polyps are seen?
saline nasal douche and intranasal steroids
why does the thyroglossal cyst move on tongue protrusion?
connection with the foramen caecum
Management of acute sinusitis
?
analgesia
intranasal decongestants or nasal saline may be considered
intranasal corticosteroids if the symptoms > 10 days
severe presentation: phenoxymethylpenicillin first-line
Management of recurrent or chronic sinusitis
treat any acute element
intranasal corticosteroids are often beneficial
referral to ENT may be appropriate
initial management of otitis externa?
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
features of otitis externa on otoscopy?
red, swollen, or eczematous canal
what pt group is at biggest risk of malignant otitis externa?
diabetes
(Infective organism is usually Pseudomonas aeruginosa)
diagnosis of malignant otitis externa?
CT
Mx of malignant otitis externa?
Intravenous antibiotics that cover pseudomonal infections
Hyperbaric oxygen is sometimes used in refractory cases
what does malignant otitis externa cause?
temporal bone osteomyelitis
abx for strep throat?
phenoxymethylpenicillin or erythromycin (if the patient is penicillin allergic)
7 or 10 day course
features of acoustic neuroma?
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
painful blue red lesions on anterior shins?
erythema nodosum
3Ss: sarcoid, strep, sulfonamides
also: OCP, IBD, TB, Behcet’s
infections that cause erythema multiforme?
HSV 70%
Mycoplasma
tx of pyoderma gangrenosum?
High dose systemic steroids
what is Rhinitis medicamentosa?
rebound nasal congestion brought on by extended use of topical decongestants
Treatment of rhinitis medicamentosa involves withdrawal of the offending nasal spray (cold turkey).
What are the most common bacterial causes of otitis media?
Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis.
If abx indicated for acute otitis media, what is normally given?
1st line: 5-day course of amoxicillin
penicillin allergy-> erythromycin or clarithromycin
Why is Little’s area the most common area for anterior nasal bleed?
Little’s area in the anterior nasal septum is the site of Kiesselbach’s plexus, supplied by 4 arteries.
Causes of epistaxis?
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
What does cautery of a bleeding vessel causing epistaxis involve?
- 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
What does packing of an anterior bleed in epistaxis involve?
- 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
Self care advice to reduce risk of re bleeding after tx of epistaxis?
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
posterior packing
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.
Predisposing factors of black hairy tongue?
poor oral hygiene
antibiotics
head and neck radiation
HIV
intravenous drug use
Ix of Black hairy tongue?
The tongue should be swabbed to exclude Candida
Management of black hairy tongue?
tongue scraping
topical antifungals if Candida
features of cluster headaches?
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
Presenting features of nasopharyngeal carcinoma?
Otalgia, unilateral serous otitis media, nasal obstruction, discharge, bleeding
Cranial n palsies III-VI
Cervical lymphadenopathy - early spread
Treatment of nasopharyngeal ca?
Radiotherapy is first line therapy.
Imaging of nasopharyngeal ca?
Combined CT and MRI.
what is nasopharyngeal carcinoma?
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
what infection is assoc w nasopharyngeal ca?
EBV
Mx of Otitis externa if infection is spreading?
oral antibiotics (flucloxacillin)
features of nasal septal haematoma?
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.
Management of nasal septal haematoma?
refer straight to ENT
- emergency
surgical drainage
intravenous antibiotics
complications of nasal septal haematoma?
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
What is the main side-effect of using topical decongestants for prolonged periods?
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
Parotid gland involvement in Sarcoidosis?
6% of patients with sarcoid
Bilateral in most cases
not tender
Xerostomia (dry mouth) may occur
Management of isolated parotid disease is usually conservative
Ix of parotid mass?
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
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
7 days of a topical antibiotic with or without a topical steroid.
Facial nerves major branches?
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)
facial nerve course through middle ear?
facial nerve runs through the tympanic cavity, medial to the incus.
Frey’s syndrome?
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
in Frey’s syndrome, what nerve may be damaged?
auriculotemporal nerve
Mx of Frey’s syndrome?
injection of botulinum toxin A
ointment of anticholinergic e.g. scopolamine
what is the most useful prognostic factor in thyroid ca?
pt’s age at time of diagnosis
the younger the pt, the better the prognosis
mx of thyroid storm?
Seek senior help - propranolol, carbimazole and steroids are mainstays of tx
+ IV fluids, sedation and antiarrhythmic drugs e.g. digoxin if needed
Most common organism causing acute otitis media?
Strep pneumoniae
Posterior nose bleed- which artery is most commonly ligated in theatre?
sphenopalatine artery
which abx can cause a itchy maculopapular rash when given in pts suffering w glandular fever?
Amoxicillin
(e.g. co-amoxiclav too)
Mx of Ludwig’s Angina?
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
