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ENT 1 Flashcards

1
Q

Acute otitis media is extremely common in young children, with around half of children having three or more episodes by the age of 3 years.

What are the common causative agents?

A

(URTIs) typically precede otitis media as they disrupt the nasal microbiome

most infections are bacterial: Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis

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2
Q

How does otitis media present?

A

recent viral URTI
fever
otalgia (children may tug their ear)
hearing loss
ear discharge may occur if the tympanic membrane perforates

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3
Q

What may you find on otoscopy of acute otitis media?

A

bulging tympanic membrane → loss of light reflex
opacification or erythema of the tympanic membrane
perforation with purulent otorrhoea
decreased mobility if using a pneumatic otoscope

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4
Q

What clinical criteria is commonly used for dx of otitis media?

A

acute onset of symptoms (otalgia or ear tugging)
presence of a middle ear effusion
inflammation of the tympanic membrane (erythema)

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5
Q

How can acute otitis media be managed?

A

generally a self-limiting condition that does not require antibiotics
good analgesia
advise to return if worse / not improved after 2 days

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6
Q

When should patients with otitis media receive abx?

A

Symptoms for > 4 days or not improving
Systemically unwell
Perforation and/or discharge in the canal
Younger than 2 years with bilateral otitis media
Immunocompromise or high risk of complications

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7
Q

What abx can be given for prolonged / complicated otitis media?

A

5-7 day course of amoxicillin is first-line
erythromycin or clarithromycin if pencillin allergic

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8
Q

What are the potential complications of acute otitis media?

A

mastoiditis
meningitis
brain abscess
facial nerve paralysis

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9
Q

Sinusitis describes an inflammation of the mucous membranes of the paranasal sinuses.

What are the most common causative agents?

A

Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses

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10
Q

What factors predispose to developing acute sinusitis?

A

nasal obstruction e.g. septal deviation or nasal polyps
recent local infection e.g. rhinitis or dental extraction
swimming/diving
smoking

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11
Q

What features may acute sinusitis present with?

A

facial pain: frontal pressure pain which is worse on bending forward
nasal discharge: usually thick and purulent
nasal obstruction

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12
Q

How can acute sinusitis be managed?

A

analgesia
intranasal decongestants or nasal saline
intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days
oral antibiotics are not normally required

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13
Q

What is the ‘double sickening’?

A

when an initial viral sinusitis worsens due to secondary bacterial infection

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14
Q

Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens.

How may it be classified?

A

seasonal
perennial
occupational

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15
Q

How may allergic rhinitis present?

A

sneezing
nasal pruritus
bilateral nasal obstruction
clear nasal discharge
post-nasal drip

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16
Q

How can allergic rhinitis be managed?

A

allergen avoidance

mild-to-moderate sxs:
oral or intranasal antihistamines

moderate-to-severe sxs:
intranasal corticosteroids

a short course of oral corticosteroids are occasionally needed to cover important life events

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17
Q

Short courses of topical nasal decongestants (e.g. oxymetazoline) can be used to control allergic rhinitis.

Why can longer courses not be prescribed?

A

increasing doses are required to achieve the same effect (tachyphylaxis)

rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal

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18
Q

Audiograms are usually the first-line investigation that is performed when a patient complains of hearing difficulties.

What are the rules for audiogram interpretation?

A

anything above the 20dB line is essentially normal

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

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19
Q

Auricular haematomas are common in rugby players and wrestlers. How should these be managed?

A

prompt tx to avoid cauliflower ear
same-day assessment by ENT
incision and drainage has been shown to be superior to needle aspiration

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20
Q

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo.

What is the usual patient group?

A

average age of onset is 55 years and it is less common in younger patients

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21
Q

How does BPPV present?

A

vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
may be associated with nausea
each episode typically lasts 10-20 seconds

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22
Q

What is the clinical test for BPPV?

A

Dix-Hallpike manoeuvre

rapidly lower the patient to the supine position with an extended neck

a positive test recreates the symptoms of BPPV and induces rotatory nystagmus

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23
Q

BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months.

Symptomatic relief may be gained by:

A

Epley manoeuvre (successful for 80%)

Vestibular rehabilitation exercises to do at home (e.g. Brandt-Daroff exercises)

Betahistine often prescribed but it tends to be of limited value

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24
Q

What does the Epley manoeuvre involve?

A

involves patient turning their head in a series of movements

specifically designed to use gravity to dislodge the crystals from the semi-circular canals

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25
Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. What are the predisposing factors?
poor oral hygiene antibiotics head and neck radiation HIV intravenous drug use
26
How should black hairy tongue be managed?
tongue should be swabbed to exclude Candida, if +ve then use topical antifungals tongue scraping
27
Give some ddx for a neck lump
congenital: branchial cyst, thyroglossal cyst, dermoid cyst, vascular malformation inflammatory: reactive lymphadenopathy, lymphadenitis neoplastic: lymphoma, thyroid tumour, salivary gland tumour
28
Branchial cysts are benign, developmental defects of the branchial arches. How do they present?
present in late childhood or early adulthood asymptomatic lateral neck lumps usually located anterior to the sternocleidomastoid muscle
29
How do branchial cysts present on examination?
slowly enlarging smooth, soft, fluctuant non-tender no transillumination no movement on swallowing a fistula may be seen
30
How can you investigate a branchial cyst?
consider and exclude malignancy ultrasound referral to ENT for fine-needle aspiration
31
What is a cholesteatoma?
a non-cancerous growth of squamous epithelium that is 'trapped' within the skull base causing local destruction most common in patients aged 10-20 years
32
What is the biggest risk factor for developing a cholesteatoma?
cleft palate (increases risk by 100 fold)
33
How do cholesteatomas present?
foul-smelling, non-resolving otorrhea hearing loss local invasion: vertigo facial nerve palsy cerebellopontine angle syndrome
34
How can cholesteatomas be investigated and managed?
Otoscopy: 'attic crust' - seen in the uppermost part of the ear drum Management: referred to ENT for consideration of surgical removal
35
What is chronic rhinosinusitis?
an inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer
36
What factors predispose to developing chronic rhinosinusitis?
atopy: hay fever, asthma nasal obstruction e.g. Septal deviation or nasal polyps recent local infection e.g. Rhinitis or dental extraction swimming/diving smoking
37
How does chronic rhinosinusitis present?
facial pain nasal discharge: clear if allergic or vasomotor, thicker and purulent if secondary bacterial infection nasal obstruction: e.g. 'mouth breathing' post-nasal drip: may produce chronic cough
38
How can chronic rhinosinusitis be managed?
avoid allergen intranasal corticosteroids nasal irrigation with saline solution
39
What are the red flags for recurrent rhinosinusitis?
unilateral symptoms persistent symptoms despite compliance with 3 months of treatment epistaxis
40
A cochlear implant is an electronic device that may be offered to patients with severe-to-profound hearing loss. How can you assess which patients are suitable?
In children, audiological assessment and/or difficulty developing basic auditory skills In adults, patients should have completed a trial of appropriate hearing aids for at least 3 months without success
41
What can cause severe hearing loss in children?
Genetic (up to 50% of cases) idiopathic (up to 30% of childhood deafness) Infectious e.g. post meningitis Congenital e.g. maternal CMV, rubella or varicella
42
What can cause severe hearing loss in adults?
Viral-induced sudden hearing loss Ototoxicity e.g. aminoglycoside antibiotics or loop diuretics. Otosclerosis Meniere disease Trauma
43
What are the potential complications of surgical cochlear implantation?
infection, facial paralysis due to nerve injury , CSF leakage, and meningitis all patients should have up-to-date vaccinations against Streptococcus and Haemophilus
44
Contraindications to consideration for cochlear implant?
Lesions of cranial nerve VIII or in the brain stem causing deafness Chronic infective otitis media, mastoid cavity or tympanic membrane perforation Cochlear aplasia
45
What are the 3 most common causes of hearing loss?
ear wax, otitis media and otitis externa
46
The most common causes of hearing loss are ear wax, otitis media and otitis externa. Give 6 other causes
Presbycusis Otosclerosis Otitis media with effusion (Glue ear) Drug ototoxicity Meniere's disease Acoustic neuroma
47
How does presbycusis present?
age-related sensorineural hearing loss patients may describe difficulty following conversations Audiometry shows bilateral high-frequency hearing loss
48
How does otosclerosis present?
Autosomal dominant replacement of normal bone by vascular spongy bone onset at 20-40 years conductive deafness tinnitus tympanic membrane - 10% of patients may have a 'flamingo tinge', caused by hyperaemia positive family history
49
How does glue ear present?
peaks at 2 years of age hearing loss (commonest cause of conductive hearing loss childhood) secondary problems such as speech and language delay, behavioural or balance problems may also be seen
50
How does Meniere's disease present?
Multiple episodes last Minutes to hours recurrent episodes of vertigo, tinnitus and sensorineural hearing loss sensation of aural fullness or pressure other features include nystagmus and a positive Romberg test
51
Causes of drug induced ototoxicity?
Ototoxicity is my FAV Q&A Furosemide Aminoglycoside (e.g. gentamicin) Vancomycin Quinine Aspirin
52
How does hearing loss due to noise damage present?
Workers in heavy industry are particularly at risk Hearing loss is bilateral and typically is worse at frequencies of 3000-6000 Hz
53
How do acoustic neuromas present?
cranial nerve V (trigeminal): absent corneal reflex cranial nerve VII (facial): facial palsy cranial nerve VIII (vestibulocochlear): hearing loss, vertigo, tinnitus
54
Ramsay Hunt syndrome is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the facial nerve (seventh cranial nerve). How does it present? How can it be managed?
auricular pain is often the first feature vesicular rash around the ear facial nerve palsy other features include vertigo and tinnitus Mx: oral aciclovir and corticosteroids are usually given
55
Impacted ear wax is extremely common and may cause a variety of symptoms including:
pain conductive hearing loss tinnitus vertigo
56
How can impacted ear wax be managed? What are the contraindications to the usual first line mx?
ear drops or irrigation ('ear syringing') olive oil sodium bicarbonate 5% almond oil tx should not be given if a perforation is suspected or the patient has grommets
57
Epistaxis (nose bleeds) is split into anterior and posterior bleeds. How do these present differently?
Anterior: visible source of bleeding usually occurs due to insult to Kiesselbach's plexus (anterior inferior nasal septum) Posterior haemorrhages: more profuse, originate from deeper structures occur more frequently in older patients higher risk of aspiration and airway compromise
58
What can cause epistaxis?
trauma to the nose / insertion of foreign bodies bleeding disorders juvenile angiofibroma (highly vascularised benign tumour, teenage boys) cocaine use hereditary haemorrhagic telangiectasia granulomatosis with polyangiitis
59
If the patient is haemodynamically stable, epistaxis can be controlled with first aid measures. This involves:
Asking the patient to sit with their torso forward and their mouth open - decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth - reduces the risk of aspirating blood Pinch the cartilaginous (soft) area of the nose firmly for at least 20 minutes
60
How should you manage epistaxis that does not resolve after 10-15 minutes of constant pressure?
bleeding point visualised = silver nitrate cautery bleeding point not able to be visualised = packing Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre
61
Give 6 differentials for facial pain
Trigeminal Neuralgia Sinusitis Giant Cell Arteritis Dental Problems Tension-Type Headache Migraine
62
What may cause gingival hyperplasia?
Drugs: phenytoin ciclosporin CCBs (especially nifedipine) Other causes: AML
63
Gingivitis (inflammation of the gums) is usually secondary to poor dental hygiene. How does it present?
simple gingivitis: painless, red swelling of the gum margin which bleeds on contact acute necrotizing ulcerative gingivitis: painful bleeding gums with halitosis and punched-out ulcers on the gums
64
If a patient has simple gingivitis they should be advised to seek routine regular review by a dentist. If they present with ulcerative gingivitis, how should they be managed?
refer the patient to a dentist, meanwhile the following is recommended: oral metronidazole for 3 days chlorhexidine or hydrogen peroxide mouth wash simple analgesia
65
What are the risk factors for otitis media with effusion (glue ear)?
male sex siblings with glue ear bottle feeding day care attendance parental smoking higher incidence in Winter and Spring
66
How does otitis media with effusion present?
peaks at 2 years of age hearing loss (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood) secondary problems such as speech and language delay, behavioural or balance problems
67
How can otitis media with effusion be managed?
first presentation of otitis media with effusion is active observation for 3 months - no intervention is required grommet insertion adenoidectomy
68
Give some ddx for a patient presenting with new hoarseness of their voice
voice overuse smoking viral illness hypothyroidism gastro-oesophageal reflux laryngeal cancer lung cancer
69
Laryngopharyngeal reflux (LPR) is a condition caused by GORD resulting in inflammatory changes to the larynx/hypopharynx mucosa. How does it present?
Globus sensation (in the midline, worst when swallowing saliva) dysphagia hoarseness chronic cough
70
How can laryngopharyngeal reflux be managed?
lifestyle measures: avoid fatty foods, caffeine, chocolate and alcohol PPI sodium alginate liquids (e.g. Gaviscon)
71
What is Ludwig's angina?
progressive cellulitis that invades the floor of the mouth and soft tissues of the neck Features: neck swelling dysphagia fever can cause airway obstruction
72
How can Ludwig's angina be managed?
airway management intravenous antibiotics
73
Mastoiditis typically develops when an infection spreads from the middle to the mastoid air spaces of the temporal bone. How does it present?
otalgia: severe, classically behind the ear fever may be a history of recurrent otitis media the patient is typically very unwell
74
Examination findings for mastoiditis?
swelling, erythema and tenderness over the mastoid process the external ear may protrude forwards ear discharge may be present if the eardrum has perforated
75
How can mastoiditis be investigated and managed? Complications?
Clinical dx / CT if complications suspected Mx: IV antibiotics Complications: facial nerve palsy hearing loss meningitis
76
Meniere's disease is a disorder of the inner ear characterised by excessive pressure and progressive dilation of the endolymphatic system. How does it present?
Meniere's in Middle Age episodes last Minutes to hours typically unilateral recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural) a sensation of aural fullness nystagmus and a positive Romberg test
77
How can Meniere's disease be managed?
ENT assessment patients should inform the DVLA cease driving until satisfactory control of symptoms is achieved acute attacks: buccal or IM prochlorperazine prevention: betahistine and vestibular rehabilitation exercises may be of benefit
78
What are the associations of nasal polyps?
asthma (particularly late-onset asthma) aspirin sensitivity infective sinusitis cystic fibrosis Kartagener's syndrome Churg-Strauss syndrome
79
What is Samter's triad?
The association of asthma, aspirin sensitivity and nasal polyposis
80
How may nasal polyps present?
nasal obstruction rhinorrhoea, sneezing poor sense of taste and smell
81
What are the red flags for nasal polyps?
unilateral symptoms or bleeding
81
What is a nasal haematoma?
collection of blood between the septal cartilage and the overlying perichondrium looks like a bilateral, red swelling arising from the nasal septum sensation of nasal obstruction is the most common symptom pain and rhinorrhoea are also seen
81
How should nasal polyps be managed?
all patients with suspected nasal polyps should be referred to ENT for a full examination topical corticosteroids shrink polyp size in around 80% of patients
82
How should nasal haematomas be managed?
differentiated from a deviated septum by gently probing the swelling - nasal septal haematomas are typically boggy whereas septums will be firm Mx: surgical drainage and IV antibiotics
83
Why is it important to treat nasal haematomas promptly?
If untreated irreversible septal necrosis may develop within 3-4 days due to pressure-related ischaemia of the cartilage resulting in necrosis may result in a 'saddle-nose' deformity
84
In which country are squamous cell carcinomas of the nasopharynx more common?
Southern China the other key association is with EBV
85
How does SCC of the nasopharynx present?
Otalgia Unilateral serous otitis media Nasal obstruction, discharge and/ or epistaxis Cranial nerve palsies e.g. III-VI
86
How can SCC of the nasopharynx be investigated and managed?
Ix: Combined CT and MRI. Mx: Radiotherapy is first line
87
Give some causes of neck lumps
Reactive lymphadenopathy Lymphoma Thyroid swelling Thyroglossal cyst Branchial cyst Pharyngeal pouch Cystic hygroma Cervical rib Carotid aneurysm
88
How does a thyroglossal cyst present?
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
89
How does a pharyngeal pouch present?
More common in older men 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

Y4 Neuro and Special Senses (21 decks)

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