Ears, Nose, Throat Flashcards
1
Q
Why can a haematoma cause AVN?
A
Perichondrium supplies nutrients to the cartilage. Disruption due to blood accumulation between these two layers causes AVN
2
Q
What are the common causes of tympanic membrane perforation?
A
Infection
Barotrauma
Direct trauma
3
Q
What are features of tympanic membrane perforation?
A
Pain, possible conductive hearing loss, increased risk of otitis media
4
Q
Management of tympanic membrane perforation?
A
Watch and wait - usually heal within 6-8 weeks.
Don’t get water into ear during this time.
Prescribe abx if perforation follows acute otitis media.
If hasn’t healed after 6 months - myringoplasty.
5
Q
Causes of otitis externa?
A
Infection - staph aureus, pseudomonas or fungal. Sebrrhoeic dermatitis Contact dermatitis (allergic and irritant)
6
Q
Features of otitis externa?
A
Ear pain, itch, discharge
Otoscopy - red, swollen, or eczematous canal.
7
Q
Initial management of otitis externa?
A
Topical abx or combined topical abx with steroid.
AVOID aminogylcosides.
If canal debris present, consider removal
If canal extensively swollen then ear wick sometimes inserted.
8
Q
Second line management of otitis externa?
A
Consider contact dermatitis secondary to neomycin.
Oral abx (flucloxacillin) if infection is spreading.
Take swab inside ear canal.
Empirical use of anti fungal agent.
If still fails - refer to ENT.
9
Q
Features of malignant otitis externa?
A
Found in immunocompromised - eg DM.
Most commonly pseudomonas aeruginosa.
Spreads from soft tissue of external auditory meatus to involve soft tissues and into bony ear canal.
Can progress to osteomyelitis.
Severe, unrelenting, deep-seated otalgia.
Temporal headaches.
Purulent otorrhoea
Dysphagia, hoarseness, and/or facial nerve dysfunction
10
Q
How to diagnose malignant otitis externa?
A
CT scan
11
Q
Treatment of malignant otitis externa?
A
Non-resolving with worsening pain referred to ENT urgently.
IV abx eg ceftazidime.
12
Q
What are the muscles of the middle ear that are involved in preventing hyperacusis?
A
Tensor tympani - branch of mandibular nerve
Stapedius muscle - facial nerve
13
Q
What are retraction pockets?
A
Sucked in areas of TM, caused by negative pressure and ET dysfunction.
Most commonly in pars flaccida or attic region.
If deep enough, collects keratinus debris from squamous epithelial cells of TM and ear canal skin - can lead to cholesteatoma.
14
Q
Features of acute otitis media including causes?
A
Most common in children
Causes - strep pneumonia, H. influenza, moraxella, viral.
Ear pain, ear pulling, discharge if TM ruptures. Pain settles with discharge.
Fever
Otoscopy - hyperaemia, suppuration and bulging ear drum.
15
Q
Management of acute otitis media?
A
Conservative
Oral abx (amoxicillin for 5 days/clarithromycin or erythromycin) if:
- symptoms lasting more than 4 days or not improving
- systemically unwell but not requiring admission
- immunocompromised or high risk of complications secondary to significant heart, lung, kidney, liver or neuromuscular disease.
- <2 years of age with bilateral otitis media
- otitis media with perforation and/or discharge in canal.
Surgical - recurrent AOM helped with grommet insertion.
16
Q
Features of glue ear?
A
Otitis media with effusion.
Peaks at 2 years of age.
Conductive hearing loss is usually the presenting feature.
Painless, but if infected leads to acute OM which is painful.
Can have speech delay at school.
Otoscopy - dull grey TM, may look retracted.
17
Q
Investigations of glue ear?
A
Tympanogram - flat type B
Pure tone audiogram - conductive hearing loss.
18
Q
Management of glue ear?
A
Conservative - settle in 3 months.
Hearing aid.
Surgery - grommets and possible adenoidectomy.
19
Q
What are the subdivisions of chronic otitis media? And the features of each?
A
Subdivided into squamous and mucosal disease. And active or inactive depending on if there is discharge or not.
Squamous:
Active - cholesteatoma (pars flaccida perforation.
Inactive - retraction pocket which may develop into cholesteatoma.
Mucosal:
Active - chronic discharge from middle ear through TM perforation.
Inactive - TM perforation but not active infection/discharge
Mucosal develops as consequence of AOM where there is TM rupture and failure to heal.
20
Q
Management of chronic otitis media
A
If cholesteatoma present - radical mastoidectomy
If cholesteatoma not present - topical abx and aural toilet. If ineffective, surgery to repair perforation and ensure good ventilation of middle ear and mastoid bone.
21
Q
What are the risks of mastoid surgery?
A
Facial nerve palsy
Altered taste from damage to chorda tympani
CSF leak
Tinnitus
Vertigo
Complete loss of hearing in operated ear.
22
Q
What is cholesteatoma?
A
Non-cancerous growth of squamous epithelium trapped within skull base causing local destruction.
Peaks at age 10-20.
Being born with cleft palate increases risk 100 fold.
23
Q
Features of cholesteatoma?
A
Foul-smelling, non-resolving discharge.
Hearing loss.
Local invasion -> CNS complications -> vertigo, facial nerve palsy, cerebellopontine angle syndrome.
Otoscopy - attic crust.
24
Q
Investigations of cholesteatoma?
A
Pure tone audiogram - conductive hearing loss.
Microbiology - often pseudomonas.
Fine-cut CT scan of temporal bones.
MRI
25
Management of cholesteatoma?
Early disease - topical abx and micro suction of debris from retraction pockets.
Radical mastoidectomy.
26
What are the complications of cholesteatoma?
```
Meningitis
Cerebral abscess
Hearing loss
Mastoiditis
Facial nerve dysfunction
```
27
Features of mastoiditis?
Middle ear inflammation leads to air cell destruction in mastoid +/- abscess formation.
Otalgia - severe, behind ear
History of recurrent otitis media
Fever
Patient typically very unwell
Swelling, erythema, tenderness over mastoid process
External ear may protrude forwards
Ear discharge may present if eardrum has perforated.
28
Investigations and management of mastoiditis?
CT scan
Admit for IV abx, myringectomy +/- mastoidectomy.
29
What is otosclerosis?
Replacement of normal bone by vascular spongy bone.
Progressive conductive deafness due to fixation of stapes at oval window.
Autosomal dominant and typically affects young adults (20-40 years).
30
Features of otosclerosis?
Conductive deafness.
Tinnitus
Normal tympanic membrane
Positive family history
10% patients have flamingo tinge, caused by hyperaemia
31
Management of otosclerosis?
Conservative - hearing aid.
| Surgery - stapedectomy.
32
Central causes of vertigo?
```
Stroke
Migraine
Neoplasms
MS
Drugs - eg gentamicin
Vertebrobasilar ischaemia
```
33
Peripheral causes of vertigo?
```
Menieres
BPPV
Vestibular neuronitis
Viral labyrinthitis
Acoustic neuroma
```
34
What causes BPPV?
Otoliths (crystals) in semicircular canals causing abnormal stimulation of hair cells giving hallucination of movement.
35
Features of BPPV?
Sudden onset dizziness and vertigo triggered by changes in head position (eg rolling over in bed or gazing upwards)
Associated with nausea
Each episode lasts 10-20 seconds
Positive Dix-Hallpike Manoeuvre
36
Management of BPPV?
Symptomatic relief:
- Epley manoeuvre - successful in 80% of cases
- exercises at home - Brandt-Daroff exercises.
Betahistine medication.
50% of BPPV patients have recurrence of symptoms 3-5 years after diagnosis.
37
What is vestibular neuronitis and what are the features?
Inflammation of inner ear following viral infection commonly.
Recurrent vertigo attacks lasting hours or days
Nausea and vomiting may be present
Horizontal nystagmus usually present
NO HEARING LOSS OR TINNITUS
38
Management of vestibular neuronitis?
Vestibular rehab exercises are preferred treatment for patients who experience chronic symptoms.
Buccal or IM prochlorperazine for severe cases.
Short oral course of prochlorperazine or anti-histamine to alleviate less severe cases.
39
What causes Meniere's disease?
Excessive pressure and progressive dilation of end-lymphatic system.
More common in middle-aged adults.
M = F
40
Features of Meniere's disease?
```
Recurrent episodes of vertigo, tinnitus and sensorineural hearing loss.
Sensation of aural fullness or pressure.
Nystagmus and positive Romberg test
Episodes last minutes to hours.
Typically symptoms are unilateral.
```
Symptoms resolve after 5-10 years.
Patients left with degree of hearing loss.
Psychological distress common.
41
Management of Meniere's disease?
Inform DVLA - cease driving until control of symptoms.
Dietary - reduce salt, chocolate, alcohol, caffeine, chinese food.
Acute attacks - buccal or IM prochlorperazine. May need admission.
Prevention - betahistine and vestibular rehab exercises.
Surgical - grommets, dexamethasone middle ear injections, end-lymphatic sac decompression, vestibular destruction using middle ear injection of gentamicin. Surgery labyrinthectomy.
42
What causes acoustic neuroma?
Cerebellopontine angle tumours
43
Features of acoustic neuroma?
Vertigo, hearing loss, tinnitus, absent corneal reflex.
CN 8 - vertigo, unilateral SNHL, unilateral tinnitus
CN 5 - absent corneal reflex
CN 7 - facial palsy
Bilateral in neurofibromatosis type 2.
44
Investigations and management of acoustic neuroma?
MRI cerebellopontine angle.
Audiometry - 5% will have normal audiogram.
Stereotactic radio surgery or observation if not fit for surgery.
45
Features of viral labyrinthitis?
Disorder of membranous labyrinth, affecting both vestibular and cochlear end organs. Can be viral, bacterial or systemic disease. Viral most common.
```
Vertigo
N + V
Hearing loss: may be unilateral or bilateral, with varying severity
Tinnitus
Preceding or concurrent symptoms or URTI
```
46
Investigations and management of viral labyrinthitis?
History and examination.
Check glucose to exclude hypoglycaemia.
Vestibular suppressants - diazepam
Anti-emetics - promethiazine, metoclopramide, prochlorperazine.
Prednisolone for SNHL.
47
Causes of presbycusis?
SNHL affecting elderly.
High-frequency hearing affected bilaterally.
Slow progression, sensory hair cells and neutrons in cochlea atrophy over time.
48
Features of presbycusis?
```
Speech becoming difficult to understand
Need for increased volume on TV or radio
Difficulty using phone
Loss of directionality of sound
Worsening symptoms in noisy environments
Hyperacusis to certain frequencies - uncommon
Tinnitus - uncommon
```
49
Investigations and management of presbycusis?
Otoscopy - normal
Tympanometry - normal type A
Audiometry - bilateral SNHL
Blood tests - normal
Hearing aids
50
Sudden onset SNHL investigations and management?
Pure tone audiogram
MRI scan - exclude acoustic neuroma
Prednisolone 80mg/24 hours PO for 4 days tapered over 8 days.
Anti-virals
Hyperbaric oxygen, carbogen.
51
What is normal on pure tone audiogram?
Anything above 20dB on graph.
52
What does conductive hearing loss and SNHL look like on pure tone audiogram?
CHL - normal bone conduct and reduced air conduction - air-bone gap
SNHL - reduced bone and air conduction thresholds - no air-bone gap.
53
What types of tympanogram results are there? What causes each one?
Type A - normal, peaks at 0dPa
Type B - flat line. Suggests effusion or perforation. Differentiate by calculating ear canal volume. Normal volume is 1 cm3.
Type C - line peaks less than 0 dPa (negative pressure). Suggests ET dysfunction
54
Causes of epistaxis?
Local - traumatic, idiopathic, iatrogenic, FB, inflammatory neoplastic.
Systemic - HTN, coagulopathies, vasculopathies, ITP, hereditary haemorrhagic telangiectasia.
55
Initial management of epistaxis?
ABCDE
Ask patient to pinch soft part of nose for 20 minutes. Breathe through mouth, head forward and spit out any blood in mouth.
Locate source of bleeding (anterior or posterior)
56
If initial management of epistaxis doesn't work what is the next step?
Place ice pack on dorm of nose.
Cautery or packing.
Cautery -
- If source of bleed visible and cautery tolerated.
- topical local anaesthetic spray and wait 3-4 minutes for it to take effect.
- identify bleeding point and apply silver nitrate stick for 3-10 seconds until becomes grey-white. Then apply Naseptin.
Packing -
- Local anaesthetic spray and wait 3-4 minutes.
- Pack nose while sitting with head forward.
- Pressure on cartilage around nostril can cause cosmetic changes so should be reviewed after inserting pack.
- Examine mouth and throat for any continuing bleeding and consider packing other nostril as this increases pressure on septum and offending vessel.
57
If packing fails in epistaxis management what is next step?
Surgery -
- ligate vessels surgically or embolise radiologically - sphenopalatine artery.
DO NOT embolise anterior ethmoid as it comes from ICA.
External carotid is last resort.
58
What is the self-care advice after epistaxis management?
Avoid blowing or picking nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks.
59
Management of nasal fractures?
ABCDE
Examine for septal haematoma
No x-ray required
Reassess 5-7 days post-injury once swelling has resolved.
If deviated, consider manipulation under anaesthetic within 2 weeks of injury - before nasal bones set.
60
Features of nasal septal haematoma? Also management and complications?
```
From minor trauma.
Sensation of nasal obstruction
Pain and rhinorrhoea
Bilaterally, red swelling arising from nasal septum
Feels boggy.
```
Surgical drainage and pack nose.
IV abx.
If untreated, AVN within 3-4 days. Can result in saddle-nose deformity.
61
CSF rhinorrhoea -
Causes
Investigations
Management
Ethmoid fractures disrupting dura and arachnoid
Tumours
CSF glucose levels +ve
CSF contains beta 2 transferrin (>0.5ml)
If traumatic - bed rest 7-10 days, head elevated to 15-30 degrees +/- lumbar drain.
Avoid coughing or sneezing or nose-blowing.
Cover abx and pneumococcal vaccine.
62
Features and management of septal deviation?
Difficulty breathing, infection of sinuses, sleep apnoea, snoring, repetitive sneezing, facial pain, nose bleeds, inability to smell.
Medical - decongestants, anti-histamines, nasal steroids
Surgical - septoplasy or septorhinoplasty.
63
Risk factors or associations of nasal polyps?
```
Asthma
Aspirin insensitivity (asthma + aspirin insensitivity + nasal polyps = Samter's triad)
Infective sinusitis
Cystic fibrosis
Kartagener's syndrome
Churg-Strauss Syndrome
```
64
Features of nasal polyps?
Nasal obstruction
Rhinorrhoea
Sneezing
Poor sense of taste and smell
65
Investigations of nasal polyps
Skin prick test if allergy suspected.
| CT sinuses if surgery planned or unusual features such as unilateral symptoms or bleeding.
66
Management of nasal polyps
Nasal douching, avoid allergens
Medical - topical corticosteroids to shrink polyps (betamethasone) for 2 weeks followed by fluticasone for 3 months.
Consider abx
Antihistamines
Surgical -
Nasal polypectomy (high rate of recurrence)
FESS to improve ventilation/drainage of sinuses.
67
What is allergic rhinitis classified into?
Features of allergic rhinitis
Seasonal
Perennial
Occupational
```
Sneezing
Bilateral nasal obstruction
Clear nasal discharge
Post-nasal drip
Nasal pruritus
```
68
Investigations and management of allergic rhinitis
Skin prick test for allergens
Allergen avoidance
If mild to moderate intermittent or mild persistent - oral or intranasal antihistamines
If moderate to severe persistent or initial treatment ineffective - intranasal corticosteroids.
Short course of oral corticosteroids needed to cover important life events.
69
Classification of rhinosinusitis?
Acute - <12 weeks
| Chronic - >12 weeks without resolution of symptoms +/- nasal polyps.
70
Causes of acute rhino sinusitis?
Viral - rhinovirus
| Non-viral - if persistent >5 days - strep pneumonia, H. influenza, mortadella catarrhal is.
71
Management of rhino sinusitis?
Analgesia
Intranasal decongestants or nasal saline
Intranasal corticosteroids if symptoms persist for >10 days.
Penicillin V if severe presentations. Co-amoxiclav if systemically unwell.
72
Causes of chronic rhino sinusitis?
```
Allergy
Infections - staph aureus, strep pneumonia
Ciliary impairment - CF
Septal deviation
Immunocompromised
Aspirin hypersensitivity.
Hormonal - pregnancy, hypothyroidism.
Trauma
FB in nose or sinuses
```
73
Management of chronic rhino sinusitis?
Conservative - avoid allergens, nasal douching.
Medical - antihistamines, topical nasal steroids, 1 week oral steroids in severe cases, oral abx.
Surgery - nasal polypectomy if polyps present.
FESS to improve ventilation/drainage of sinuses
Septoplasty
Reduction of inferior turbinates.
74
Features of parotid gland?
| Comment on location, neoplasms and infections.
Serous gland anterior to pinna and lateral to ramus of mandible.
Deep and superficial lobes - separated by facial nerve.
Parotid duct opens opposite second uppler molar teeth.
80% salivary gland tumours are in parotid. 80% are benign.
Infections are 9 times less common.
Malignancies are 9 times more common.
75
Submandibular gland features?
| Comment on location, neoplasms and infections.
Mixed mucous and serous gland. Located inferior to body of mandible and superior to digastric muscle.
Duct opens into mouth close to frenulum of tongue.
80% stones occur in submandibular gland.
Infections 9 times more common compared to parotid.
50% of neoplasms are malignant.
76
Sublingual gland features?
| Comment on location, neoplasms and infections.
Mucous salivary gland.
80% neoplasms are malignant.
Floor of mouth.
77
What are the contents of Waldeyer's ring?
Adenoids
2 tubal tonsils
2 palatine tonsils
Lingual tonsil
78
Location of retropharyngeal space?
Space lies anterior to prevertebral fascia, behind pharynx.
| Space extends from base of skull to mediastinum so potential space for injection/abscess.
79
Features of retropharyngeal abscess?
Commonly in children after URTI
Neck held rigid and upright with reluctance to move
Systemically unwell
Airway compromise
Dysphagia/odynophagia
Widening of retropharyngeal space on lateral x-ray
80
Investigations of retropharyngeal abscess and management?
CT neck to differentiate from cellulitis
Secure airways if concerns.
IV abx -> tazocin.
Surgery -> incision and drainage
81
What is Ludwig's angina?
Infection of space between floor of mouth and mylohyoid. Most commonly associated with dental infections and stones.
82
Features of Ludwig's angina?
Investigations?
Management?
```
Swelling of floor of mouth
Painful mouth
Drooling
Protruding tongue
Airway compromise
```
CT neck and orthopantogram (dental x-ray)
Secure airway if concerns
IV abx
Surgery to drain any collection
83
What is a Parapharyngeal abscess?
The space is potential space posters-lateral to oropharynx and nasopharynx which is divided by styloid process.
Contains carotid sheath -> risk of severe complications.
84
Features and management of parapharyngeal abscess?
```
Similar features to quinsy.
Febrile illness
Trismus
Reduced neck movement
Odynophagia
Swelling in neck around upper part of SCM.
```
Secure airways if concerns
IV abx
Surgical drainage
85
Investigations for neck lumps?
```
Ultrasound guided FNA
CXR - shows malignancy
CT
Virology & mantoux test
FNA cytology of suspicious lymph nodes
```
86
Examples of midline lumps?
Dermoid cyst
Thyroglossal cyst - moves up on protruding tongue
Thyroid mass - moves upwards on swallowing
Chondroma
87
Features of thyroglossal cyst?
Failure of thyroglossal duct to atrophy.
Age <20 years
Usually midline, between isthmus of thyroid and hyoid bone.
Moves upwards with protrusion of tongue.
May be painful if infected.
Manage with surgical excision.
88
Examples of anterior triangle lumps?
Lymphadenopathy
Branchial cyst
Parotid tumour
Pulsatile mass - carotid aneurysm.
89
Features of branchial cyst including diagnosis and management?
Congenital failure of obliteration of 2nd branchial cleft in embryonic development.
May have fistula and therefore prone to infection.
```
Unilateral, typically on left side.
Lateral, anterior to SCM muscle
Slowly enlarging
Smooth, soft, fluctuant.
Non-tender
Fistula may be seen
No movement on swallowing
No transillumination
```
Investigations -
Exclude malignancy - USS, ENT referral, FNA
Surgical excision under GA.
Abx if acute infections.
90
Posterior triangle neck swelling examples?
Cervical rib
Pharyngeal pouch
Cystic hygroma
91
Cervical ribs (C7) features
More common in adult females
10% develop thoracic outlet syndrome
Can cause symptoms by putting pressure on brachial plexus or Raynaud's syndrome by compressing subclavian artery.
92
Pharyngeal pouch features?
More common in older men
Usually not seen but if large enough then a midline lump in neck that gurgles on palpation.
Symptoms - dysphagia, regurgitation, aspiration, chronic cough.
Manage with diverticulotomy.
93
Features of cystic hygroma?
Congenital abnormality due to overgrowth of dilated lymphangiomatous vessels.
Picked up on routine antenatal anomaly scans.
Soft, large, ill-defined, fluctuant mass which transilluminates.
Typically on left side, in posterior triangle.
Manage with surgical excision.
94
Features of adenoidal hypertrophy?
Aged 2-6
May block nasopharynx -> nasal blockage, discharge, snoring, OSA
Can obstruct ET opening -> prevent equalisation of middle ear pressure -> glue ear.
Mouth breathing if chronically enlarged.
95
Diagnosis of adenoidal hypertrophy and management?
Spatula test confirms nasal blockage.
Examination of nasopharynx.
Soft tissue radiographs of post-nasal space if cannot examine.
Medical -> trial of topical steroids before surgery
Surgery -> adenoidectomy
Indications for surgery -
- severe nasal symptoms that don't respond to medical treatment.
- child with OSA
- Otitis media with effusion
- To exclude malignancy in adults.
96
What is pharyngitis, diagnosis and management?
Common cause of sore throat, due to viral URTI
Generalised erythema of entire pharynx and raised lymphoid aggregates on posterior pharyngeal wall.
Manage with symptomatic relief.
97
Causes of bacterial and viral tonsillitis?
Bacterial - beta-haemolytic strep, staph, strep, pneumonia, H. influenza, E.coli
Viral - adenovirus, rhinovirus, enterovirus, EBV.
98
Features and complications of tonsillitis?
```
Pyrexia
Dysphagia
Bilateral odynophagia
Otalgia
Tender cervical lymphadenopathy
Trismus
Swollen tonsils +/- exudate
```
```
Quinsy -> hot potato voice, sore throat localised to one side, requires drainage under LA.
Otitis media
Sinusitis
Rheumatic fever
Parapharyngeal abscess
```
99
Management of tonsillitis?
Analgesia
Abx if centor criteria 3 or 4 -> Penicillin V for 10 days or erythromycin for 5 days.
AVOID amoxicillin - causes maculopapular rash if EBV cause.
Drainage of peritonsillar abscess
Surgical - tonsillectomy.
100
What are the indications for tonsillectomy?
Sore throats are due to tonsillitis
Person has >=5 episodes per year
Symptoms been occurring for at least a year
Episodes of sore throat are disabling and prevent normal functioning.
Also -
Recurrent febrile convulsions secondary to tonsillitis
OSA, stridor, dysphagia
Peritonsillar abscess (quinsy) if unresponsive to standard treatment.
101
Complications of tonsillectomy?
Primary (<24 hours) -> haemorrhage due to inadequate haemostasis, pain
Secondary (24 hours to 10 days) -> haemorrhage due to infection, pain
102
Why don't you get many cases of viral parotitis?
MMR vaccine
103
Risk factors for bacterial parotitis?
Elderly
Dehydration
Immunocompromised
Post-surgical patients with poor dental hygiene.
104
Feature and management of parotitis?
Systemically unwell
Tender enlargement of parotids
Massage gland and look inside mouth opposite second upper molar -> expresses pus.
Adequate rehydration
Oral hygiene
Gland massage
Abx
105
What is sialolithiasis?
Stones in salivary ducts.
| Most common in submandibular gland than parotid because it contains more calcium and phosphate (more alkaline).
106
Features of sialolithiasis?
Middle aged
Pain and swelling in affected gland, worse during meals.
Swelling usually settles spontaneously over hours/days
Acute sialadenitis may follow -> increased pain, redness, pyrexia.
107
Investigations for sialolithiasis and management?
USS
Plain X-ray - doesn't pick up parotid calculi as they are radio-lucent.
Sialogram - inject contrast into duct of gland, very useful but US easier.
Conservative - most settle with analgesia, hydration and sialogogues -> pilocarpine.
Endoscopy
Radiological removal
Surgery -> intraoral removal of palpable stones or removal of salivary glands.
108
Features of salivary gland tumours?
More common in adults
Malignant - rapid growth, pain, nerve involvement
Benign - slow, gradual, painless, no nerve involvement
109
Diagnosis of salivary gland tumours?
Plain x-ray to exclude stones.
Sialography to delineate ductal anatomy
FNAC
Superficial parotidectomy - diagnostic/therapeutic.
Avoid open biopsy of parotid as can damage facial nerve.
CT/MRI for staging
110
Treatment of salivary gland tumours?
Benign -> superficial parotidectomy
| Malignant -> radical or extended radical parotidectomy
111
Complication of salivary gland tumour removal?
Facial nerve palsy
Fray syndrome -> sweating of cheek skin, provoked by food, caused by re-routing of parasympathetic secretomotor supply to gland.
112
What are the most common benign parotid tumours?
Benign pleomorphic adenoma (80%)
Warthin tumour (5%)
Monomorphic adenoma (<5%)
Haemangioma - most common in <1 years of age.
113
What are the main malignant salivary gland tumours?
```
Mucoepidermoid carcinoma (30% of parotid malignancies)
Adenoid cystic carcinoma
Mixed tumours
Acinic cell carcinoma
Adenocarcinoma
Lymphoma
```
114
What is black hair tongue? What predisposes to this? How do you manage this condition?
Results from defective desquamation of filiform papillae.
Can be brown, green, pink or another colour.
Predisposing factors - poor oral hygiene, abx, head and neck radiation, HIV, IVDU
Tongue swabbed to exclude Candida
Manage - tongue scraping, topical antifungals if Candida.
115
Treatment for impacted ear wax?
Primary care - ear syringing.
Can also use drops such as olive oil, sodium bicarbonate, almond oil.
Do not syringe if perforation suspected or patient has grommets.
116
Name 4 conditions that can cause facial pain
Sinusitis
Trigeminal neuralgia
Cluster headache
Temporal arteritis
117
Causes of gingival hyperplasia?
Phenytoin
Ciclosporin
CCB (nifedipine)
AML
118
Investigations for thyroid lumps?
US guided FNA - but can't distinguish follicular carcinoma from follicular adenoma.
If doubt - hemithyroidectomy for definitive histology.
TFTs
Lumpectomy is not done because if malignant, will be unable to gain adequate margins - also puts recurrent laryngeal nerve at risk.
119
Examples of thyroid neoplasms? A fact about each one?
Benign:
Adenoma - mainly follicular
```
Malignant:
Papillary adenocarcinoma (20%) - often in younger patients or irradiation of neck.
```
Follicular carcinoma (20%) - high risk of mets to bones and lungs
Medullary carcinoma (5%) - Seen in MEN.
Anaplastic carcinoma (5%) - typically seen in older patients. Poor prognosis.
120
Management of non-neoplastic thyroid nodules?
Conservative
Surgery - for compressive symptoms, cosmesis, patient preference.
Should aim for hemithyroidectomy rather than total thyroidectomy.
121
Management of thyroid neoplastic nodules?
Adenoma - no further treatment after diagnostic hemithyroidectomy.
Carcinoma - total thyroidectomy for papillary, follicular and medullary carcinoma.
Radio-iodine therapy for papillary and follicular after surgery.
122
Complications of thyroid surgery?
Post-op haemorrhage - due to confined space, haematomas may rapidly lead to respiratory compromise owing to laryngeal oedema.
Airway compromise -> due to haemorrhage or bilateral vocal cord palsy
Vocal cord palsy
Recurrent laryngeal nerve damage
Hypocalcaemia due to damage of parathyroid glands.
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What is Ramsay Hunt Syndrome? Features and management?
Reactivation of VZV in geniculate ganglion of 7th CN.
Auricular pain first features
Facial nerve palsy
Vesicular rash around ear
Vertigo, tinnitus
Manage with oral acyclovir and corticosteroids.
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Causes of OSA?
Obesity
Macroglossia - acromegaly, hypothyroidism, amyloidosis
Large tonsils
Marfan's syndrome
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Features of OSA?
Excessive snoring
Daytime somnolence
Compensated respiratory acidosis
Hypertension
126
Diagnosis of OSA?
Epworth sleepiness scale
Multiple sleep latency test - measures time to fall asleep in dark room.
Sleep studies (polysomnography)
127
Management of OSA?
Weight loss
CPAP first line for moderate to severe.
Intra-oral devices if CPAP not tolerated.
DVLA should be informed.
128
What do head and neck cancers comprise of?
Oral cavity cancers
Cancers of pharynx
Cancers of larynx
129
Features of head and neck cancers?
```
Neck lump
Dysphonia
Dysphagia/odynophagia
Dyspnoea
Persistent sore throat >6 weeks
Persistent mouth ulcer
```
130
Risk factors for head and neck cancers?
```
Male
>50 years of age
Alcohol
Smoking
HPV
GORD
Vit A and C def.
Chinese ethnic origin for nasopharyngeal malignancy.
Chew tobacco or betel nut
```
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Investigations of head and neck cancers?
Biopsy for histological diagnosis.
CT neck/MRI
Ix neck mets -> CT neck, US guided FNA of neck nodes.
Ix distant mets -> CT chest as most common site of mets.
Staging -> TNM staging.
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Management of head and neck cancers?
| Curative and palliative?
Palliation -> prolong life. Chemo and radiotherapy and maybe surgery
Curative -> treat primary site and neck nodes even if no mets to the nodes.
Radiotherapy to primary side and neck +/- chemo
Surgery -> endoscopic or open surgery.
133
Features of oral cavity and tongue cancers?
```
Persistent painful ulcers
White or red patches on tongue, gums or mucosa
Otalgia
Odynophagia
Lymphadenopathy
```
134
Referral guidelines for oral cancer?
Oral cancer suspected pathway (<2 weeks):
-Unexplained ulceration in oral cavity lasting >3 weeks, OR
Persistent and unexplained lump in neck
Oral cancer urgent referral pathway (<2 weeks):
A lump on lip or in oral cavity, OR
Red or red and white patch in oral cavity consistent with erythroplakia or erythroleukoplakia.
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Which location in larynx has best prognosis in laryngeal cancer?
Glottic region as hoarseness comes on earlier.
136
Referral guidelines for laryngeal cancer?
>45 years with:
Persistent unexplained hoarseness, OR
Unexplained lump in neck
137
Treatment of laryngeal cancer?
Radical radiotherapy for small tumours
| Larger tumours treated with partial/total laryngectomy +/- block dissection of neck glands.
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Options for voice restoration after laryngectomy?
Trans-oesophageal puncture (TEP) - one-way valve inserted between trachea and pharynx. Valve activated when patient occludes stoma and breathes out.
Exhaled air modified and shaped with lips and teeth into speech.
Artificial Larynx (Servox) - vibrating larynx held firmly against patients neck, tissues vibrate, producing distinct electronic voice sound.
139
What is the centor criteria?
- Presence of tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- History of fever
- Absence of cough
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Features of quinsy? Management of quinsy?
Severe throat pain, lateralises to one side
Deviation of uvula to unaffected side
Trismus
Reduced neck mobility
Needle aspiration or incision and drainage
IV abx
Tonsillectomy should be considered.
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Features of nasopharyngeal carcinoma?
SCC
Southern china
Associated with EBV
```
Cervical lymphadenopathy
Otalgia
Unilateral serous otitis media
Nasal obstruction, discharge and/or epistaxis
Cranial nerve palsies eg 3-6
```
142
Causes of hoarseness?
```
voice overuse
Smoking
Viral illness
Hypothyroidism
GORD
Laryngeal cancer
Lung cancer
```
143
What is the name of the ducts draining the submandibular and parotid glands?
Submandibular - Whartons duct
| Parotid - Stensens duct
144
What is the consequence of using nasal decongestants for prolonged periods of time?
Tachyphylaxis - increased doses required to achieve same effect
Rhinitis medicamentosa - rebound hypertrophy of nasal mucosa.
