ENT 1 Flashcards
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?
(URTIs) typically precede otitis media as they disrupt the nasal microbiome
most infections are bacterial: Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
How does otitis media present?
recent viral URTI
fever
otalgia (children may tug their ear)
hearing loss
ear discharge may occur if the tympanic membrane perforates
What may you find on otoscopy of acute otitis media?
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
What clinical criteria is commonly used for dx of otitis media?
acute onset of symptoms (otalgia or ear tugging)
presence of a middle ear effusion
inflammation of the tympanic membrane (erythema)
How can acute otitis media be managed?
generally a self-limiting condition that does not require antibiotics
good analgesia
advise to return if worse / not improved after 2 days
When should patients with otitis media receive abx?
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
What abx can be given for prolonged / complicated otitis media?
5-7 day course of amoxicillin is first-line
erythromycin or clarithromycin if pencillin allergic
What are the potential complications of acute otitis media?
mastoiditis
meningitis
brain abscess
facial nerve paralysis
Sinusitis describes an inflammation of the mucous membranes of the paranasal sinuses.
What are the most common causative agents?
Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses
What factors predispose to developing acute sinusitis?
nasal obstruction e.g. septal deviation or nasal polyps
recent local infection e.g. rhinitis or dental extraction
swimming/diving
smoking
What features may acute sinusitis present with?
facial pain: frontal pressure pain which is worse on bending forward
nasal discharge: usually thick and purulent
nasal obstruction
How can acute sinusitis be managed?
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
What is the ‘double sickening’?
when an initial viral sinusitis worsens due to secondary bacterial infection
Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens.
How may it be classified?
seasonal
perennial
occupational
How may allergic rhinitis present?
sneezing
nasal pruritus
bilateral nasal obstruction
clear nasal discharge
post-nasal drip
How can allergic rhinitis be managed?
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
Short courses of topical nasal decongestants (e.g. oxymetazoline) can be used to control allergic rhinitis.
Why can longer courses not be prescribed?
increasing doses are required to achieve the same effect (tachyphylaxis)
rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal
Audiograms are usually the first-line investigation that is performed when a patient complains of hearing difficulties.
What are the rules for audiogram interpretation?
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
Auricular haematomas are common in rugby players and wrestlers. How should these be managed?
prompt tx to avoid cauliflower ear
same-day assessment by ENT
incision and drainage has been shown to be superior to needle aspiration
Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo.
What is the usual patient group?
average age of onset is 55 years and it is less common in younger patients
How does BPPV present?
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
What is the clinical test for BPPV?
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
BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months.
Symptomatic relief may be gained by:
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
What does the Epley manoeuvre involve?
involves patient turning their head in a series of movements
specifically designed to use gravity to dislodge the crystals from the semi-circular canals
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
How should black hairy tongue be managed?
tongue should be swabbed to exclude Candida, if +ve then use topical antifungals
tongue scraping
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
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
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
How can you investigate a branchial cyst?
consider and exclude malignancy
ultrasound
referral to ENT for fine-needle aspiration
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
What is the biggest risk factor for developing a cholesteatoma?
cleft palate (increases risk by 100 fold)
How do cholesteatomas present?
foul-smelling, non-resolving otorrhea
hearing loss
local invasion:
vertigo
facial nerve palsy
cerebellopontine angle syndrome
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
What is chronic rhinosinusitis?
an inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer
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
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
How can chronic rhinosinusitis be managed?
avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution
What are the red flags for recurrent rhinosinusitis?
unilateral symptoms
persistent symptoms despite compliance with 3 months of treatment
epistaxis
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
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
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
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
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
What are the 3 most common causes of hearing loss?
ear wax, otitis media and otitis externa
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
How does presbycusis present?
age-related sensorineural hearing loss
patients may describe difficulty following conversations
Audiometry shows bilateral high-frequency hearing loss
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
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
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
Causes of drug induced ototoxicity?
Ototoxicity is my FAV Q&A
Furosemide
Aminoglycoside (e.g. gentamicin)
Vancomycin
Quinine
Aspirin
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
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
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
Impacted ear wax is extremely common and may cause a variety of symptoms including:
pain
conductive hearing loss
tinnitus
vertigo
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
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
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
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
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
Give 6 differentials for facial pain
Trigeminal Neuralgia
Sinusitis
Giant Cell Arteritis
Dental Problems
Tension-Type Headache
Migraine
What may cause gingival hyperplasia?
Drugs:
phenytoin
ciclosporin
CCBs (especially nifedipine)
Other causes:
AML
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
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
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
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
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
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
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
How can laryngopharyngeal reflux be managed?
lifestyle measures: avoid fatty foods, caffeine, chocolate and alcohol
PPI
sodium alginate liquids (e.g. Gaviscon)
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
How can Ludwig’s angina be managed?
airway management
intravenous antibiotics
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
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
How can mastoiditis be investigated and managed? Complications?
Clinical dx / CT if complications suspected
Mx: IV antibiotics
Complications:
facial nerve palsy
hearing loss
meningitis
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
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
What are the associations of nasal polyps?
asthma (particularly late-onset asthma)
aspirin sensitivity
infective sinusitis
cystic fibrosis
Kartagener’s syndrome
Churg-Strauss syndrome
What is Samter’s triad?
The association of asthma, aspirin sensitivity and nasal polyposis
How may nasal polyps present?
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
What are the red flags for nasal polyps?
unilateral symptoms or bleeding
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
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
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
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
In which country are squamous cell carcinomas of the nasopharynx more common?
Southern China
the other key association is with EBV
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
How can SCC of the nasopharynx be investigated and managed?
Ix: Combined CT and MRI.
Mx: Radiotherapy is first line
Give some causes of neck lumps
Reactive lymphadenopathy
Lymphoma
Thyroid swelling
Thyroglossal cyst
Branchial cyst
Pharyngeal pouch
Cystic hygroma
Cervical rib
Carotid aneurysm
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
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
