ENT 1 Flashcards
What is vertigo?
The false sensation that the body or environment is moving.
What's the diagnosis? Vertigo Recent viral infection Sudden onset Nausea and vomiting Hearing may be affected
Viral labyrinthitis
What's the diagnosis? Vertigo Recent viral infection Recurrent vertigo attacks lasting hours or days No hearing loss
Vestibular neuronitis
What's the diagnosis? Vertigo Gradual onset Triggered by change in head position Each episode lasts 10-20 seconds
Benign paroxysmal positional vertigo
What’s the diagnosis?
Vertigo associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears
Meniere’s disease
What’s the diagnosis?
Vertigo
Elderly patient
Dizziness on extension of neck
Vertebrobasilar ischaemia
What's the diagnosis? Vertigo Hearing loss, vertigo, tinnitus Absent corneal reflex is important sign Associated with neurofibromatosis type 2
Acoustic neuroma
What’s the diagnosis?
By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness
Reactive lymphadenopathy
What’s the diagnosis?
Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly
Lymphoma
What’s the diagnosis?
May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
Thyroid swelling
What’s the diagnosis?
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
What’s the diagnosis?
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
What’s the diagnosis?
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
Cystic hygroma
What’s the diagnosis?
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
Branchial cyst
What’s the diagnosis?
More common in adult females
Around 10% develop thoracic outlet syndrome
Cervical rib
What’s the diagnosis?
Pulsatile lateral neck mass which doesn’t move on swallowing
Carotid aneurysm
When can intranasal corticosteriods be used for sinusitis?
If symptoms persist beyond 10 days
When can antibiotics be used to treat sinusitis?
If there are systemic symptoms or comorbid conditions such as COPD.
What is sinusitis?
Inflammation of the mucous membranes of the paranasal sinuses.
What are the most common causative agents of acute sinusitis?
- Streptococcus pneumoniae
- Haemophilus influenzae
- rhinoviruses
What factors predispose people to getting sinusitis?
- nasal obstruction e.g. Septal deviation or nasal polyps
- recent local infection e.g. Rhinitis or dental extraction
- swimming/diving
- smoking
What are the features of sinusitis?
- facial pain: typically frontal pressure pain which is worse on bending forward
- nasal discharge: usually thick and purulent
- nasal obstruction: e.g. ‘mouth breathing’
- post-nasal drip: may produce chronic cough
How do you manage 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 more than 10 days
- oral antibiotics are not normally required but may be given for severe presentations. The 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’
What are the features of vestibular neuronitis?
- recurrent vertigo attacks lasting hours or days
- nausea and vomiting may be present
- horizontal nystagmus is usually present
- no hearing loss or tinnitus
- often associated with viral illness
How do you manage patients with vestibular neuronitis?
- vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms
- betahistine is often used although the evidence base suggests it is less effective than vestibular rehabilitation
What causes gingival hyperplasia?
- phenytoin
- ciclosporin
- calcium channel blockers (especially nifedipine)
- AML
What’s the diagnosis?
A 19-year-old man has had a sore throat for the past 5 days. Over the past 24 hours he has notices increasing and severe throbbing pain in the region of his right tonsil. He is pyrexial and on examination he is noted to have a swelling of this area.
Quincy. Treat by surgical drainage.
What’s the diagnosis?
A 10-year-old child presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice peticheal haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly.
Infectious mononucleosis
A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics containing penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy.
What’s the diagnosis?
An 8-year-old child presents with enlarged tonsils that meet in the midline and are covered with a white film that bleeds when you attempt to remove it. He is pyrexial but otherwise well.
Acute bacterial tonsillitis
What’s the most common cause of acute tonsillitis?
Strep pyogenes
Where is nasopharyngeal cancer more common?
Southern China
What’s the cell of origin of nasopharyngeal cancer?
Squamous cell in the nasopharynx
What is nasopharyngeal cancer associated with?
EBV
What are the presenting features of nasopharyngeal tumours?
Systemic
- Cervical lymphadenopathy
Local
- Otalgia
- Unilateral serous otitis media
- Nasal obstruction, discharge and/ or epistaxis
- Cranial nerve palsies e.g. III-VI
What imaging and treatment would you use for nasopharyngeal tumours?
Imaging
Combined CT and MRI.
Treatment
Radiotherapy is first line therapy.
What is a cholesteatoma?
A cholesteatoma consists of squamous epithelium that is ‘trapped’ within the skull base causing local destruction.
What’s the typical age of a person with cholesteatoma?
10-20 years
What increases the risk of cholesteatoma by 100 fold?
Being born with a cleft palate
What are the features of a cholesteatoma?
Main features
- foul-smelling discharge
- hearing loss
Other features are determined by local invasion:
- vertigo
- facial nerve palsy
- cerebellopontine angle syndrome
Otoscopy
- ‘attic crust’ - seen in the uppermost part of the ear drum
How do you manage patients with cholesteatomas?
Patients are referred to ENT for consideration of surgical removal.
What’s the most common tumour of the parotid gland?
Pleomorphic adenoma
Which tumours are typically found in elderly males and are composed of multiple cysts and solid components consisting of lymphoid tissue?
Warthins tumour
What’s the most common site for a salivary gland tumour? Are they usually benign or malignant?
80% in parotid gland
80% benign
What are the risk factors for parotid tumours?
- female (apart from Warthins)
- 5th decade of life
What are the types of benign parotid gland tumours?
- Benign pleomorphic adenoma or benign mixed tumor 80%
- Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma) 5%
- Monomorphic adenoma <5%
- Haemangioma 90% of child (<1 year) parotid tumours
What are the types of malignant salivary gland tumours?
- Mucoepidermoid carcinoma 30%
- Adenoid cystic carcinoma
- Mixed tumours
- Acinic cell carcinoma
- Adenocarcinoma
- Lymphoma
What are the features of benign pleomorphic adenoma?
- Most common parotid neoplasm (80%)
- Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
- Slow growing, lobular, and not well encapsulated
- Recurrence rate of 1-5% with appropriate excision (parotidectomy)
- Recurrence possibly secondary to capsular disruption during surgery
- Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma
What are the features of warthin tumours?
- Second most common benign parotid tumor (5%)
- Most common bilateral benign neoplasm of the parotid
- Marked male as compared to female predominance
- Occurs later in life (sixth and seventh decades)
- Presents as a lymphocytic infiltrate and cystic epithelial proliferation
- May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes
- Incidence of bilaterality and multicentricity of 10%
- Malignant transformation rare (almost unheard of)
What are the features of monomorphic adenoma?
- Account for less than 5% of tumours
- Slow growing
- Consist of only one morphological cell type (hence term mono)
- Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas
What are the features of haemangioma?
- Should be considered in the differential of a parotid mass in a child
- Accounts for 90% of parotid tumours in children less than 1 year of age
- Hypervascular on imaging
- Spontaneous regression may occur and malignant transformation is almost unheard of
What are the features of mucoepidermoid carcinoma?
- 30% of all parotid malignancies
- Usually low potential for local invasiveness and metastasis (depends mainly on grade)
What are the features of adenoid cystic carcinoma?
- Unpredictable growth pattern
- Tendency for perineural spread
- Nerve growth may display skip lesions resulting in incomplete excision
- Distant metastasis more common (visceral rather than nodal spread)
- 5 year survival 35%
What are the features of mixed tumours?
Often a malignancy occurring in a previously benign parotid lesion
What are the features of acinic cell carcinoma?
- Intermediate grade malignancy
- May show perineural invasion
- Low potential for distant metastasis
- 5 year survival 80%
What are the features of adenocarcinoma?
- Develops from secretory portion of gland
- Risk of regional nodal and distant metastasis
- 5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement
What are the features of Lymphoma of the parotid?
- Large rubbery lesion, may occur in association with Warthins tumours
- Diagnosis should be based on regional nodal biopsy rather than parotid resection
- Treatment is with chemotherapy (and radiotherapy)
What investigations are considered for a parotid lump?
- Plain x-rays may be used to exclude calculi
- Sialography may be used to delineate ductal anatomy
- FNAC (fine needle aspiration cytology) is used in most cases
- Superficial parotidectomy may be either diagnostic of therapeutic depending upon the nature of the lesion
- 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
Treatment for parotid gland tumours?
For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement.
What are the features of HIV in parotid glands?
- Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid
- Typically presents as bilateral, multicystic, symmetrical swelling
- Risk of malignant transformation is low and management usually conservative
What are the features of sjogren syndrome?
- Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca
- 90% of cases occur in females
- Second most common connective tissue disorder
- Bilateral, non tender enlargement of the gland is usual
- Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma
- Treatment is supportive
- There is an increased risk of subsequent lymphoma
What are the features of sarcoid in the parotid gland?
- Parotid involvement occurs in 6% of patients with sarcoid
- Bilateral in most cases
- Gland is not tender
- Xerostomia may occur
- Management of isolated parotid disease is usually conservative
What is xerostomia?
dry mouth resulting from reduced or absent saliva flow
What’s the term for age related hearing loss and which frequencies are hard to hear?
Presbycusis
High frequencies
What causes presbycusis?
- Sensory hair cells and neurons in the cochlea atrophy over time.
- The precise cause is unknown however is likely multifactorial
- Arteriosclerosis: May cause diminished perfusion and oxygenation of the cochlea, resulting in damage to inner ear structures
- Diabetes: Acceleration of arteriosclerosis
- Accumulated exposure to noise
- Drug exposure (Salicylates, chemotherapy agents etc.)
- Stress
- Genetic: Certain individuals may be programmed for the early ageing of the auditory system
Which sex is more likely to develop presbycusis?
Males
How do patients with presbycusis typically present?
- Speech becoming difficult to understand
- Need for increased volume on the television or radio
- Difficulty using the telephone
- Loss of directionality of sound
- Worsening of symptoms in noisy environments
- Hyperacusis: Heightened sensitivity to certain frequencies of sound (Less common)
- Tinnitus (Uncommon)
Investigations for presbycusis
Signs:
Possible Weber’s test bone conduction localisation to one side if sensorineural hearing loss not completely bilateral
Investigations:
- Otoscopy: Normal, to rule out otosclerosis, cholesteatoma and conductive hearing loss (Foreign body, impacted wax etc.)
- Tympanometry: Normal middle ear function with hearing loss (Type A)
- Audiometry: Bilateral sensorineural pattern hearing loss
- Blood tests including inflammatory markers and specific antibodies: Normal
A 35-year-old woman presents to her GP with hearing loss which has slowly progressed over the last year. She also reports tinnitus that has worsened over the same time period. She is otherwise well and has no significant medical history. Her father also suffered from hearing loss at a young age.
Her neurological examination reveals mild bilateral conductive hearing loss but is otherwise normal. On inspection, the tympanic membrane appears normal.
What is the likely cause of this patient’s symptoms?
Otosclerosis
Otosclerosis is an autosomal dominant cause of deafness affecting young adults This presentation (slowly progressive bilateral conductive hearing loss in a young patient with a positive family history) is most consistent with otosclerosis.
What is otosclerosis?
Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults
What’s the typical age of onset of otosclerosis and what are possible presenting features?
- 20-40 years
Features include:
- conductive deafness
- tinnitus
- normal tympanic membrane*
- positive family history
*10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
What’s the management for otosclerosis?
- hearing aid
- stapedectomy
What are the complications of tonsilitis?
- otitis media
- quinsy - peritonsillar abscess
- rheumatic fever and glomerulonephritis very rarely
What are the indications for a tonsilectomy?
NICE recommend that surgery should be considered only if the person meets all of the following criteria
- sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
- the person has five or more episodes of sore throat per year
- symptoms have been occurring for at least a year
- the episodes of sore throat are disabling and prevent normal functioning
Other established indications for a tonsillectomy include:
- recurrent febrile convulsions secondary to episodes of tonsillitis
- obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
- peritonsillar abscess (quinsy) if unresponsive to standard treatment
What are the complications of a tonsilectomy?
- primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
- secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain
Give examples of ototoxic drugs
- quinine
- furosemide
- aspirin
- gentamicin
- some chemotherapy agents
When is quinine used?
- nocturnal leg cramps
- antimalarial
What’s the other name for glue ear?
otitis media with effusion
What’s the peak age of onset of otitis media?
2 years old
What are the features of glue ear?
- hearing loss is usually the presenting feature
- secondary problems such as speech and language delay, behavioural or balance problems may also be seen
What is the commonest cause of conductive hearing loss and elective surgery in childhood?
Glue ear
What are the features of meniere’s disease?
- More common in middle-aged adults
- recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
- a sensation of aural fullness or pressure is now recognised as being common
- other features include nystagmus and a positive Romberg test
- episodes last minutes to hours
- typically symptoms are unilateral but bilateral symptoms may develop after a number of years
What frequency is typically lost in noise damage?
3000-6000 Hz
Which cranial nerves are typically affected by acoustic neuromas?
- cranial nerve VIII: hearing loss, vertigo, tinnitus
- cranial nerve V: absent corneal reflex
- cranial nerve VII: facial palsy
Bilateral acoustic neuromas are seen in what condition?
neurofibromatosis type 2
What are the causes of a hoarse voice?
- voice overuse
- smoking
- viral illness
- hypothyroidism
- gastro-oesophageal reflux
- laryngeal cancer
- lung cancer
When would you refer someone to ENT for suspected laryngeal cancer?
Aged 45 and over with:
- persistent unexplained hoarseness or
- an unexplained lump in the neck.
What’s the natural history of menieres disease?
- symptoms resolve in the majority of patients after 5-10 years
- the majority of patients will be left with a degree of hearing loss
- psychological distress is common
How do you manage meniere’s disease?
- ENT assessment is required to confirm the diagnosis
- patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
- acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required
- prevention: betahistine and vestibular rehabilitation exercises may be of benefit
Where would a cystic hygroma typically present?
posterior triangle
How do you manage a perforated tympanic membrane?
- no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to 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 the tympanic membrane does not heal by itself
What is Sialadenitis?
Infection of the salivary gland
What is Ramsey Hunt syndrome?
A condition where reactivation of pre-existing Varicella Zoster virus occurs in the geniculate ganglion of the facial nerve.
Characterised by:
- vesicles on the tympanic membrane
- pain in the ear
- facial paralysis
- taste loss
- dry eyes
- tinnitus
- vertigo
- hearing loss
How do you manage Ramsey Hunt syndrome?
oral aciclovir and corticosteroids are usually given
What are the features of mastoiditis?
- otalgia: severe, classically behind the ear
there may be a history of recurrent otitis media - fever
- the patient is typically very unwell
swelling - erythema and tenderness over the mastoid process
- the external ear may protrude forwards
- ear discharge may be present if the eardrum has perforated
What is a centor score?
The Centor criteria are a set of criteria which may be used to identify the likelihood of a bacterial infection in adult patients complaining of a sore throat (pharyngitis, tonsillitis, laryngitis). They were developed as a method to quickly diagnose the presence of Group A streptococcal infection or diagnosis of streptococcal pharyngitis in “adult patients who presented to an urban emergency room complaining of a sore throat.”
A centor score of 3 or more means antibiotics can be used.
How do you calculate the centor score?
C – Cough absent, or the incorrect but memorable "Can't Cough" E – Exudate N – Nodes T – temperature (fever) OR – young OR old modifier
Age under 15 add 1 point
Age over 44 subtract 1 point
When are antibiotics indicated for a sore throat?
- features of marked systemic upset secondary to the acute sore throat
- unilateral peritonsillitis
- a history of rheumatic fever
- an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
- patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
Which antibiotics are used for laryngitis, pharyngitis or tonsilitis? How long must they be given for?
phenoxymethylpenicillin or erythromycin (if the patient is penicillin allergic)
Either a 7 or 10 day course should be given
What’s the classical pathological finding in a branchial cyst?
An acellular fluid with cholesterol crystals encapsulated by stratified squamous epithelium.
Where are branchial cysts usually located?
In the anterior triangle
What are the features of a branchial cyst?
- unilateral, typically on the left side lateral, anterior to the sternocleidomastoid muscle - slowly enlarging - smooth, soft, fluctuant - non-tender - a fistula may be seen - no movement on swallowing - no transillumination
How would you investigate a branchial cyst?
- consider and exclude other malignancy
- ultrasound
- referral to ENT
- fine-needle aspiration
