Ear, Nose & Throat (ENT) Flashcards
List some ototoxic medications.
Loop diuretics (e.g. furosemide)
Aminoglycosides (e.g. gentamicin)
NSAIDs (e.g. ibuprofen)
Salicylates (e.g. aspirin)
Platinum agents (e.g. cisplatin)
Antimalarials (e.g. quinine)
Rinne’s and Weber’s test results in conductive hearing loss?
Rinne’s = BC > AC in affected ear (“negative”)
Weber’s = sound localises to affected ear
Rinne’s and Weber’s test results in sensorineural hearing loss?
Rinne’s = AC > BC in both ears (“positive”)
Weber’s = sound localises to unaffected ear
Hearing threshold considered normal in audiometry?
0-20dB
Features of a sensorineural vs conductive hearing loss audiogram?
Sensorineural = AC and BC impaired
Conductive = AC impaired and “air-bone gap”
Top 3 bacterial causes of acute otitis media?
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella cataharrlis
Clinical and otoscopy features and management of acute otitis media?
Otalgia
Recent/current URTI
Otorrhoea (if perforation)
Otoscopy = bulging/red TM, loss of light reflex
Management = self-limiting, consider antibiotics if ≥4 days, perforation, systemically unwell, immunocompromised, bilateral OM in child
Antibiotic options for otitis media (if required)?
1st line = amoxicillin
2nd line = clarithromycin
Timescale for perforated tympanic membrane to heal and management if unresolved?
6-8 weeks
Myringoplasty
Clinical and otoscopy features and management of glue ear (otitis media with effusion)?
Hearing loss
Behavioural issues
Speech and language delay
Otoscopy = indrawn TM, bubbles, visible fluid level, loss of light reflex
Management = self-limiting, grommets if persistent
Chalky white tympanic membrane in patient with history of glue ear/grommet insertion?
Tympanosclerosis
Features of malignant otitis media and associated pathogen?
Immunocompromised patient (90% in diabetics)
SEVERE otalgia
Headache
Ottorhoea
Associated pathogen = pseudomonas
Complication of malignant otitis media?
Temporal bone osteomyelitis
Causes of otitis externa?
Staphyloccocus aureus
Pseudomonas aeruginosa
Fungal infection
Dermatitis (contact or seborrheic)
Clinical and otoscopy features and management of otitis externa?
Otalgia
Pruritus
Otorrhoea
Otoscopy = red/swollen/flaky ear canal
Management = aural toilet + topical antibiotic/steroid, ear wick if canal very swollen
Clinical and otoscopy features and management of cholesteatoma?
Foul-smelling otorrhoea
Otoscopy = attic crust
Management = surgical removal
Antibiotics used for otitis externa?
Ciprofloxacin
Neomycin
Gentamicin
Management for otitis externa not responding to topical treatment or worsening pain?
Take a swab
Refer to ENT
Features and management of mastoiditis?
Swollen/red mastoid process
Affected ear protruding forwards
Management = admission + IV antibiotics
Management of pinna haematoma and complication if untreated?
Drainage within 24 hours
Avascular necrosis leading to “cauliflower ear”
Clinical and otoscopy features and management of otosclerosis?
Hearing loss
Tinnitus
Strong family history (AD)
Worse during pregnancy
Otoscopy = flamingo flush/Schwartze (~10%)
Management = hearing aids, stapedectomy or stapedotomy
Key audiogram sign of otosclerosis?
Impaired BC at 2000Hz
Most common hearing loss in elderly, audiogram feature and management?
Presbycusis
Bilateral loss of high-frequency hearing
Hearing aids
Management options for ear wax?
Ear syringing
Softeners (e.g. olive oil, sodium bicarbonate 5%)
Microsuction
Pathology of benign paroxysmal positional vertigo (BPPV)?
Otoconia dislodge and float around semi-circular canals, stimulating hair cells in the Organ of Corti
Features of benign paroxysmal positional vertigo (BPPV)?
Sudden onset vertigo
Triggered by position
No auditory symptoms
Episodes last for secs to mins
+ve Dix Hallpike (vertigo and rotatory nystagmus)
Management of benign paroxysmal positional vertigo (BPPV)?
Epley manoeuvre (80% success)
Brandt-Daroff exercises
Pathology of Meniere’s disease?
Excess fluid in the endolymph (endolymphatic hydrops)
Features of Meniere’s disease?
Sudden onset vertigo
Tinnitus, hearing loss, fullness
Nausea and vomiting
Episodes last hours
Management of Meniere’s disease?
Acute attack = prochloperazine
Prophylaxis = betahistine
Features of vestibular labyrinthitis?
Sudden onset vertigo
Tinnitus, hearing loss
Nausea and vomiting
Horizontal nystagmus
Episodes lasting weeks
Recent/current URTI
Rule of 3 for vestibular labyrinthitis?
3 bed days
3 weeks off work
3 months off balance
Difference between vestibular neuritis and labyrinthitis?
Neuritis = CN VIII involvement with no hearing impairment (just vertigo)
Labyrinthitis = CN VIII + labyrinth involvement with hearing impairment
Test to differentiate central (e.g. stroke) from peripheral (e.g. vestibular neuritis) cause of vertigo?
HINTS exam:
Head Impulse, Nystagmus, Test of Skew
Type of nystagmus seen in vestibular neuritis vs. stroke?
Neuritis = horizontal unidirectional
Stroke = horizontal bidirectional
Classic features of Ramsay-Hunt syndrome (CN VII palsy) and management?
Otalgia
Facial paralysis
Vesicular rash around ear
Management = oral aciclovir + steroid
Most common cause of sudden sensorineural hearing loss (SSHL), audiometry criteria, other investigation and treatment?
Idiopathic (90%)
Loss of ≥30 dB in 3 consecutive frequencies
MRI/CT head
1st line = high-dose oral steroids
2nd line = intra-tympanic steroids
Features and management of vestibular schwannoma?
Unilateral hearing loss
Vertigo, tinnitus
Absent corneal reflex
<40mm = 6 monthly MRI
>40mm = surgery
Bilateral vestibular schwannomas?
Neurofibromatosis type II
Most common bone affected in a basal skull fracture?
Temporal bone
Classic features of a basal skull fracture fracture?
Battle’s sign (mastoid bruise)
Raccoon eyes
Haemotympanum
CSF rhinorrhoea
Cranial nerve palsy
What does “sore throat” cover?
Pharyngitis
Laryngitis
Tonsilitis
Centor criteria aim, features and score indicating antibiotic is needed?
Screens for GAS pharyngitis
Fever, tonsillar exudate, tender anterior cervical nodes, absence of cough
≥3 needs antibiotic
Antibiotic management (if needed) for pharyngitis, laryngitis and tonsillitis?
1st line = phenoxymethylpenicillin (penicillin V)
2nd line = clarithromycin
Complications of GAS throat infection?
Otitis media
Peritonsillar abscess (quinsy)
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis
Post-streptococcal reactive arthritis
Most common cause of bacterial tonsillitis?
Streptoccoccus pyogenes (GAS)
Indications for tonsillectomy?
≥7 episodes in the same year OR
≥5 episodes in previous 2 years OR
≥3 episodes in previous 3 years
Management of post-tonsillectomy primary vs secondary haemorrhage?
Primary (<24 hours) = urgent return to theatre
Secondary (>24 hours) = admission + antibiotics
Features and management of a peritonsillar abscess (quinsy)?
Throat pain (worse on affected side)
Odynophagia
Drooling
Trismus
Deviated uvula
Management = aspiration + IV antibiotics
What is Lemierre’s syndrome, risk factor and complications?
Thrombophlebitis of internal jugular vein
Peritonsillar abscess
Septic emboli/sepsis
Cause of rheumatic fever and scarlet fever?
GAS (strep pyogenes) infection
Features and management of rheumatic fever?
Generally unwell (e.g. fever)
Polyarthritis (migratory)
Pancarditis and valve disease
Erythema marginatum
Subcutaenous nodules
Sydenham’s chorea
Management = NSAID + oral penicillin V
Cells seen in rheumatic heart disease?
Aschoff bodies
Features and management of scarlet fever?
Generally unwell (e.g. fever)
Strawberry tongue
Sandpaper texture rash
Desquamation
Manament = penicillin V
School exclusion for children with scarlet fever?
24 hours after starting antibiotics
Features of mononucleosis (glandular fever)?
Sore throat
Exudative tonsilitis
Lymphadenopathy
Palatal petechiae
Hepatosplenomegaly
Haematological manifestations of EBV infection?
Lymphocytosis with atypical lymphocytes
Haemolytic anaemia (cold agglutins/IgM)
Key test for mononucleosis (glandular fever)?
Heterophil antibody (Monospot test)
School exclusion for children with glandular fever?
No need to stay off if well
Classic reaction to ampicillin or amoxicillin in patient with mononucleosis (glandular fever)?
Pruritic, maculopapular rash
Virus associated with nasopharyngeal cancer and B cell lymphomas?
Epstein-Barr virus (EBV)
Red flags for nasopharyngeal carcinoma?
Eustachian tube dysfunction
Bloody nasal discharge
Persistent epistaxis
Unilateral nasal mass e.g. polyp
Virus associated with oropharyngeal cancer?
HPV 16
Red flags for oral cancer?
Lump in the mouth or lip
Ulcer lasting >3 weeks
Erythroplakia or erythroleukoplakia
Timescale for head and neck symptoms to be urgently referred (2 week pathway)?
Persistent for >3 weeks
Risk factors for Reinke’s oedema (vocal cord oedema)?
Smoking (most cases)
Hypothyroidism
Voice overuse
Laryngopharyngeal reflux
Risk factors for head and neck cancer?
Smoking tobacco
Alcohol
Age > 40
HPV (16) and EBV
UV exposure
Poor dental hygiene
Most common type of head and neck cancer?
Squamous cell carcinoma
Midline neck lump which moves upwards on swallowing and tongue protrusion?
Thyroglossal cyst
Midline neck lump that gurgles on palpation?
Pharyngeal pouch
Neck lump between angle of jaw and sternocleidomastoid?
Branchial cyst
Most common branchial cleft to form a cyst?
Second
Lateral neck lump present at birth?
Cystic hygroma
Neck lump associated with thoracic outlet syndrome?
Cervical rib
What do salivary gland tumours cover?
Parotid (most common)
Sublingual
Submandibular
Most common parotid gland tumour?
Pleomorphic adenoma
Most common bilateral parotid gland tumour?
Warthin’s tumour
Most common malignant parotid gland tumour?
Mucoepidermoid carcinoma
Parotid tumour associated with perineural invasion?
Adenoid cystic carcinoma
Systemic causes of bilateral parotid disease?
Mumps
HIV infection
Lymphoma
Sarcoidosis
Tuberculosis
Sjögren’s syndrome
Rule of 80 for parotid tumours?
80% benign
80% pleomorphic adenomas
80% superficial lobe
Most common location of sialolithiasis?
Wharton’s duct of the submandibular gland
What is Ludwig’s angina and list some causes?
Cellulitis involving the floor of the mouth
Dental abscess
Sialolithiasis
What does sinusitis vs rhinosinusitis involve?
Sinusitis = paranasal sinuses
Rhinosinusitis = paranasal sinuses + nasal cavity
Most common causes of acute sinusitis?
Streptococcus pneumoniae
Haemophilus influenzae
Rhinovirus
Features and management of acute sinusitis?
Recent/current URTI
Facial pain (worse bending forward)
Purulent nasal discharge
Loss of smell and taste
Management = self-limiting, intranasal steroid + antibiotic if > 10 days
Timescale of acute vs chronic sinusitis?
Acute = <12 weeks
Chronic = >12 weeks
Management of chronic sinusitis?
Nasal irrigation with saline solution
Intranasal steroid
Features of allergic rhinitis?
Sneezing
Nasal pruritus
History of atopy
Clear nasal discharge
Associated allergic conjunctivitis
Drug options for allergic rhinitis?
1st line = oral or intranasal antihistamine (1st gen)
2nd line = intranasal steroid
3rd line = oral steroid
N.B. nasal decongestants can also be used
Nasal decongestant examples and side effects with prolonged use?
Oxymetazoline, phenylephrine, pseudoephedrine
Side effects = tachyphylaxis, rhinitis medicamentosa
Antihistamine mechanism of action and 1st gen vs 2nd gen examples?
H1 receptor antagonist
1st gen = chlorphenamine, promethazine
2nd gen = cetirizine, loratadine, fexofenadine
Which generation of antihitamines has a higher risk of sedation and anticholingergic side effects?
1st gen e.g. cyclizine
Samter’s triad?
Aspirin sensitivity
Asthma
Nasal polyps
Management of nasal polyps?
Topical steroid
Surgery if persistent
Management of a nasal septal haematoma and complication if untreated?
Drainage within 24 hours
Avascular necrosis leading to “saddle-nose” deformity
Management of epistaxis?
1st line = first aid (10-15 mins)
2nd line = cautery via silver nitrate sticks (if bleed source visible)
3rd line = nasal packing (if cautery fails or bleed source not visible)
4th line = sphenopalatine ligation
Naseptin for 10 days to reduce crusting and vestibulitis
Drug options for oral candidasis?
1st line = miconazole gel or nystatin suspension
2nd line = oral fluconazole
Management of acute necrotising ulcerative gingivitis?
Urgent dental referral
Analgesia (e.g. NSAIDs)
Oral metronidazole + chlorhexidine mouthwash
Drugs which cause gingival hyperplasia?
Phenytoin
Ciclosporin
Calcium channel blockers (especially nifedipine)
