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Clinical Practice > ENT > Flashcards

ENT Flashcards

1
Q

describe the structure and function of the outer ear

A

pinna; elastic cartilage part of the side of the head, some use in localising sounds
ear canal; S shaped tube, protects the eardrum from foreign bodies

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2
Q

describe the eustachian tube

A

travels forwards and downwards towards the back of the nose

keeps atmospheric and middle ear pressure the same

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3
Q

what is the function of the mastoid tube?

A

connects the mastoid air system

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4
Q

what are the contents of the middle ear?

A 
malleus
incus
stapes
two muscles; protect the inner ear from damage from loud sounds
very closely related to the facial nerve
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5
Q

how does the middle ear act as an amplifier?

A

area ratio effect; the tympanic membrane is much bigger than the oval window, so small movements of the tympanic membrane cause 14x movements of the oval window
lever effect; the handle of the malleus is 1.4x bigger than the handle of the stapes

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6
Q

describe the cochlea

A

the basilar and Reissner’s membranes divide it into 3 compartments; including the scala media
contains the outer and inner hair cells which sit below the tectoral membrane

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7
Q

what is the function of the outer hair cells?

A

allow us to discriminate between speech and background noise

by maintaining the vibration of the basilar membrane for longer than if they weren’t there

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8
Q

how is the fluid of the cochlea arranged?

A

the top and bottom fluid compartments share the same fluid

this is different from the scala media

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9
Q

what is the oval window attached to?

A

the stapes

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10
Q

what is the function of the round window?

A

so that the fluid is incompressible

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11
Q

how does the ear produce differences in pitch?

A

one end of the hair cells produce high pitch sounds and the other end of the hair cells produce low pitch sounds

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12
Q

how does the ear produce differences in volume?

A

a difference in the number of hair cells stimulated

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13
Q

what is the function of the nose?

A

airway
warms, moistens and filters the air
sense of smell

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14
Q

what are the contents of the nasal cavity?

A

superior, middle and inferior turbinates

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15
Q

what are the main functions of the larynx?

A

sphincter; to stop food and fluid from getting into the chest
traps air in the chest; allowing fixation of the chest wall
allows the diaphragm to expel intra-abdominal contents
speech

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16
Q

name an example of direct trauma to the ear

A

surgical trauma in a myringotomy

fractured skull

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17
Q

name an example of indirect trauma to the ear

A

bomb explosion
slap on the ear
changes in atmospheric pressure

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18
Q

describe an essential perforation of the eardrum

A

most common perforation
the tympanic membrane is still all the way around the perforation
may be at the front, back or the bottom
less risk of ingrowth of squamous epithelium than the others; resulting in a cholesteatoma

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19
Q

describe a marginal perforation of the eardrum

A

one edge of the perforation is against the edge of the ear canal

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20
Q

describe an attic perforation of the eardrum

A

in the pars flaccida

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21
Q

what are the causes of tympanic membrane perforation?

A

trauma

infection

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22
Q

what are the symptoms and signs of an eardrum perforation?

A

asymptomatic; small
conductive hearing loss
discharge; infection

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23
Q

what can be seen in a healthy tympanic membrane?

A

lateral process of malleus
handle of malleus
light reflex

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24
Q

what can be seen in a tympanic membrane with acute otitis media?

A

lateral process of malleus
handle of malleus; red and inflamed
some redness in the attic area; often the first area to be affected
later; bulging of the tympanic membrane, cannot identify any individual landmarks

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25
Q

what can be seen in a tympanic membrane with glue ear/otitis media with effusion?

A

eardrum sucked inward
handle of the malleus is lying almost horizontally
golden-brown colour; middle bit of the ear is full of a thick, sticky effusion

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26
Q

describe the signs and causes of tympanosclerosis

A

scarring of the eardrum
white chalky patches on the surface of the tympanic membrane
no hearing loss or symptoms when confined to the tympanic membrane

previous infection
surgery; inserting ventilation into the eardrum

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27
Q

what are the signs of a cholesteatoma developing?

A

attic part of the eardrum is sucked inwards

retraction pocket

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28
Q

describe a large tympanic membrane perforation

A

sub-total perforation of the right/left tympanic membrane
cochlea can be seen
no bony junction between the process of the incus and the head of the stapes

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29
Q

describe cholesteatoma

A

untreated retraction pockets
bone in the attic area has been eroded
squamous epithelium and skin growing into the middle ear mastoid

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30
Q

what is the treatment of tympanic membrane perforation?

A

left alone for 6 months; heal spontaneously, encourage to keep it dry
surgery (tympanoplasty); episodes of recurrent infection, significant hearing loss

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31
Q

what are the complications of tympanoplasty?

A

infection
sensorineural hearing loss; if the ossicular chain is manipulated
dizziness

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32
Q

define otitis media

A

acute inflammation of the tympanic cavity (middle ear)

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33
Q

what are the causes of otitis media?

A

infection enters the middle ear via
eustachian tube; in a child with a URTI or head cold
pre-existing perforation
carried via the bloodstream; rare

viral; RSV, parainfluenza, adenovirus
bacterial; strep pneumonia, haemophilus influenza, moraxalla catarrhalis, strep pyogenes

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34
Q

what are the symptoms and signs of otitis media?

A 
fever
pain
agitation/irritability
discharge
deafness
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35
Q

what is the difference between the attic and the pars tensa (the rest of the eardrum)?

A

attic; 2 epithelial layers

pars tensa; little fibrous layer

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36
Q

describe the pathogenesis of acute otitis media

A

infection enters the post-nasal and middle ear space via the eustachian tube
swelling of the mucosa blocks off the Eustachian tube
middle ear starts to fill with pus
attic portion bulges; tension in the eardrum

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37
Q

what are the consequences of acute otitis media?

A

resolution; infection settles, eardrum doesn’t burst, fluid may/may not be reabsorbed
perforation; tension is too great, ear will discharge (bloodstained then becomes mucopurulent), pain is relieved

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38
Q

what are the complications of acute otitis media?

A

rare
mastoiditis
facial palsy
most improve within 10-14 days; occasionally can become persistent AOM
recurrent; check diagnosis, consider myringotomy and ventilator insertion

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39
Q

describe otitis media with effusion (OME)/glue ear in adults

A

a collection of serous fluid behind the ear drum
uncommon in adults
can indicate underlying problems; allergic rhinitis, chronic Eustachian tube dysfunction
can occur after flying
must always refer to an ENT surgeon if it does not occur after flying
unilateral; may be nasopharyngeal carcinoma

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40
Q

what are the risk factors for developing otitis media with effusion?

A

eustachian tube dysfunction; URTIs which cause the mucosa to swell and blocks the tube
allergy
downs syndrome; very thick URT mucosa
cystic fibrosis; problems with RT mucosa
adenoid hypertrophy; mechanical problems
cleft palate; before repair, cannot open the eustachian tube
partly resolved ear infection; infection has settled but the fluid is still trapped in the middle ear

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41
Q

describe the pathogenesis of otitis media with effusion

A

oxygen is absorbed in the middle ear
creating a vacuum
eustachian tube is blocked; air cannot get into it
the eardrum is in-driven
irritation of the mucosal glands in the middle ear; filling up with sticky mucous

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42
Q

what are the symptoms and signs of otitis media with effusion?

A 
may be asymptomatic; picked up by screening
otalgia
deafness
speech disturbance
behavioural disturbance
indriven tympanic membrane
dull/pink/golden colour
fluid level seen
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43
Q

what investigations are required to diagnose otitis media with effusion?

A 
age-appropriate hearing test;
to acoustic emissions
distraction test
visual reinforcement audiometry
brainstem evoked auditory responses
audiogram; from age 4
tympanogram; appears flat
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44
Q

what is the management of otitis media with effusion?

A

leave it for 3 months; 50% resolve on their own
otovent; ear popper
persistent deafness or sore ears; surgery (grommet)
adenoidectomy; reduced the likelihood of grommets being needed to be reinserted

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45
Q

what are the complications of ventilator insertion?

A

infection; best treated with a very short course of antibiotic ear drops (particularly ototoxic)
perforation
scarring; tympanosclerosis

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46
Q

what are the congenital causes of sensorineural deafness?

A

genetic; AD, AR, X-linked, mutation
maternal infections; rubella, cytomegalovirus, toxoplasmosis, syphilis
perinatal; pre-term, low birth weight, hypoxic, toxic substance exposure, rhesus disease, blood incompatibility, jaundice
unknown; genetic mutations, undiagnosed maternal disease

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47
Q

what are the acquired causes of sensorineural deafness?

A

leisure noise
occupational noise
depends on volume, duration, individual susceptibility
trauma; surgery

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48
Q

describe a temporary hearing threshold shift

A

after being out somewhere in the evening which is noisy and then hearing a ringing
caused by the exhaustion of neurotransmitters

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49
Q

describe a permanent hearing threshold shift

A

keep being exposed to noise
permanent hearing loss
hair cells are destroyed; humans cannot regenerate hair cells

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50
Q

describe the hearing loss associated with noise-induced deafness

A

a notch in the higher frequencies

if they keep being exposed to noise; the notch will deepen and widen to affect many more frequencies

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51
Q

describe mumps and sensorineural deafness

A

most common cause of unilateral sensorineural deafness in children

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52
Q

describe herpes zoster oticus/ramsey hunt syndrome

A

reasonably common
vesicles in the concha of the ear; last for a short time
unilateral ear pain
unilateral sensorineural deafness
unilateral facial palsy
dizziness
sometimes the 9th cranial nerve is involved (glossopharyngeal); difficulty swallowing

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53
Q

what is the treatment of herpes zoster oticus/ramsey hunt syndrome?

A

aciclovir

steroids

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54
Q

what are the trauma-related causes of sensorineural deafness?

A 
surgical
bacterial
viral
tumour
drugs; aminoglycoside antibiotics
vascular; thrombus
degeneration; presbyacusis
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55
Q

describe bacterial causes of sensorineural deafness

A

acute otitis media might spread to the inner ear; very rare complication
more likely in chronic otitis media; cholesteatoma

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56
Q

describe tumour causes of sensorineural deafness

A

vestibular schwannoma/acoustic neuroma
presents with unilateral sensorineural deafness in adults
diagnose with MRI; must be excluded in unilateral sensorineural deafness

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57
Q

what is the treatment of vestibular schwannomas?

A

small/asymptomatic; observed
bigger/starting to cause trouble; removal
benign tumours

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58
Q

what is the treatment of vascular deafness?

A

carbogen; a mixture of carbon dioxide and oxygen

very powerful vasodilator

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59
Q

what is the treatment of sensorineural deafness?

A 
prevention
genetic counselling
noise protection
hearing aid
cochlear implant
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60
Q

what are the contents of the facial nerve?

A

motor fibres; muscles of facial expession
parasympathetic fibres; lacrimal and submandibular glands
special sense; taste to the anterior 2/3s of the tongue
ordinary sensation; skin of the external ear

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61
Q

what are the causes of facial nerve palsy?

A

congenital; rare

acquired; trauma, infection, tumour, vascular (brain stem vascular accident), idiopathic

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62
Q

how can trauma cause a facial nerve palsy?

A

temporal bone trauma;
longitudinal fractures; middle ear and mastoid damage, no cochlear damage
transverse fractures; fracture band can run straight through the facial nerve
immediate onset after trauma; direct facial nerve damage, requires surgical exploration repair
gradual onset; due to bleeding, oedema or other form of pressure, no urgent treatment required
facial surgery

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63
Q

describe the infective causes of facial nerve palsy

A

viral;
ramsey hunt; caused by herpes zoster which has involved into the 7th, 8th and sometimes 9th CN
pain, vesicles on the concha, facial palsy, sensorineural deafness, dizziness, often short-lived
treatment; acyclovir and steroid combination

bacterial;
very rare complication of acute otitis media in children
cholesteatoma; a form of chronic suppurative otitis media

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64
Q

how can a tumour cause a facial nerve palsy?

A

vestibular schwannoma; presents with sensorineural deafness and facial palsy
investigations; MRI, requires excision if its causing symptoms
parotid gland tumour; if it presents with facial palsy it is malignant

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65
Q

describe the idiopathic causes of facial nerve palsy

A

Bell’s palsy;
diagnosis of exclusion
accounts for 70-80% of facial palsies
worse prognosis and require treatment if complete palsy present
treatment; acyclovir, steroid (reduce the oedema around the facial nerve and restore function)

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66
Q

describe the input section of the vestibular system

A

eyes
vestibular apparatus; gives you information about movement
proprioceptors; stretch receptors in muscles and joints that detect how you are working
touch and pressure receptors in the skin

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67
Q

describe the output section of the vestibular system

A

cerebral cortex; tells the higher centres what’s going on

muscles; adjust

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68
Q

describe the peripheral vestibular system

A

made up of a central box; utricle and saccule
attached to the semicircular canals
fluid is made in the cochlea and reabsorbed in the CSF through the endolymphatic sac

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69
Q

describe the semicircular canal

A 
ampulla houses the sensory apparatus
made up of hair cells
detects movement
embedded in cupula; jelly like substance
contains otoliths; tiny stones
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70
Q

what is the function of the vestibular system?

A

semicircular canal; detect rotatory or angular acceleration and deceleration
utricle and saccule; detect linear acceleration and deceleration, respond to gravity

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71
Q

describe the examination of a patient with reduced balance

A 
rombergs test
extended rombergs test
unterbergers test
nystagmus
finger-nose test
dysdiadochokinesis
cranial nerve examination
peripheral nerve; sensation, motor, reflexes
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72
Q

what are the causes of dizziness and vertigo?

A 
congenital; uncommon
trauma (fractured skull, surgery)
infection
age degeneration
tumour
aminoglycoside drugs; associated with dizziness and deafness
meniere's disease
73
Q

describe longitudinal fractures

A

account for 80% of fractures
mostly miss the inner ear
usually cause damage to the middle and external ear
often cause bleeding from the ear

74
Q

describe transverse fractures

A

account for 20% of fractures

damage the damage the cochlear and vestibular system directly

75
Q

what is the management of fractures?

A

bed rest
labyrinthine sedation; cinnarizine, prochlorperazine
outcome; usually settles in 10-14 days because of central compensation

76
Q

describe the pathogenesis of vertigo

A

the otoliths get dislodged from the cupula of the saccule
drift downwards in the endolymphatic fluid
become attached to the crista of the posterior semicircular canal
upset its function

77
Q

describe the clinical presentation of vertigo

A 
episodes of very short rotatory vertigo
1/2 minutes
may feel unwell for longer
almost always provoke by movement
normal hearing, no tinnitus
short delay for nystagmus
rotatory nystagmus; eyes looking straight forward and flick in a rotatory fashion
fatiguable response; put the patient back and forth in the provoking posterior several times, the response will fatigue
78
Q

what is the management of vertigo?

A

reassure the patient there is no brain tumour
epley’s manoeuvre; dislodge otoliths towards semicircular canal
no labyrinthine sedations; makes them feel worse

79
Q

describe infection in vertigo

A

vestibular neuronitis; viral infection of vestibular nerves, treated with labyrinthine sedatives
ramsey hunt syndrome/herpes zoster oticus; combination of vertigo, sensorineural deafness, facial palsy
sometimes the 9th CN is involved (swallowing problems)
cholesteatoma; important infection, labyrinth is invaded by infected cholesteatoma, requires surgical treatment

80
Q

describe tumours in vertigo

A

vestibular schwannoma; most associated, commonly presents with unilateral sensorineural deafness in adults, unsteadiness, sometimes facial palsy
tumour proximity to 7th and 8th CN

81
Q

what is the diagnosis pathway and treatment of vestibular schwannoma?

A

confirmation; MRI scan

treatment; surgery (benign, will cause problems if it gets bigger)

82
Q

describe meniere’s disease

A

too much endolymph
combination of fluctuating sensorineural deafness, dizziness, tinnitus
treatment; labyrinthine sedatives
surgery; if dizziness if a major problem

83
Q

describe the defence mechanism of the oropharynx

A

made up of lymphoid tissue
main bits in the tonsils on each side
adenoid pad at the back in the postnasal space
tonsil tissue at the back of the tongue
ring of circular lymph nodes; jugulodigastric is the main draining site for the tonsils in children

84
Q

what problems can be associated with the tonsils?

A 
infection
site of lymphoma
obstruction
tonsil stones
foreign bodies
85
Q

what are the symptoms and complications of tonsillitis?

A

sore throat
unpleasant swallowing

not common;
quinsy; peritonsillar abscess
peripheral obstructive sleep apnoea

86
Q

what is the treatment of tonsillitis?

A

if possible, avoid antibiotics
overuse causes MRSA and c. diff
few days of analgesia before starting antibiotics
if they improve in those few days, leave the antibiotics

87
Q

describe sleep apnoea

A

two types
1; something wrong with the brain stem and the respiratory centre
2; more common, obstructive, due to large tonsils
muscles relax, tonsils will fall back and obstruct the airway

88
Q

what are the indications for tonsillectomy?

A 
recurrent sore throats; depends on age
recurrent tonsillitis causing exacerbations of asthma or guttate psoriasis
two or more episodes of quinsy
suspicion of tumour; lymphoma
obstructive sleep apnoea
adult with unilateral enlarged tonsil
severely symptomatic tonsoliths
89
Q

what are the contraindications for tonsillectomy?

A

infection

bleeding disorder; must be investigated first and dealt with correctly

90
Q

what are the complications of tonsillectomy?

A

secondary haemorrhage; return to emergency threat, blood transfusion
infection of the tonsil bed
earache (otalgia); pain referred from the glossopharyngeal nerve (CN 9)
sore throat afterwards
taste disturbance
voice change; singers

91
Q

describe the classification of post-tonsillectomy bleeding

A

primary haemorrhage; occurs during surgery, caused by cutting of a blood vessels
reactionary haemorrhage; occurs in the first 24hrs, due to a ligature sticking off a blood vessel or a clot
secondary haemorrhage; 5-10 days post-surgery, due to infection

92
Q

what are the signs of haemorrhage?

A 
bleeding
excessive swallowing; swallowing blood
increase in pulse
decrease in pressure
increase in power
93
Q

describe adenoidectomy

A

the adenoid pad is removed at the same time as the tonsils as it is made of the same type of tissue

94
Q

what are the indications for adenoidectomy?

A

a child with recurrent glue ear; less likely to have vents reinserted
significant nasal obstruction; very large adenoid gland

95
Q

what are the contraindications for adenoidectomy?

A

bleeding disorder
infection
cleft palate; before or after repair, find it difficult to eat or drink
bifid uvula; often have a submucosal gland

96
Q

what is the most common cause of a swelling of the back of the neck?

A

nits

97
Q

name the midline neck lumps

A

thyroglossal cyst

dermoid cyst

98
Q

describe the embryology of the thyroid gland and thyroglossal cysts

A

the thyroid gland develops from the foramen caecum of the tongue
descends in the neck to its final position
leaves a tiny bit behind as it descends; eventually becoming a cyst

99
Q

what are the clinical features of a thyroglossal cyst?

A

a midline neck lump
lump moves up when they stick out their tongue
attached to the back of the tongue by a tract

100
Q

what are the complications of a thyroglossal cyst?

A

cosmetically

infection

101
Q

what are the investigations and treatment of a thyroglossal cyst?

A

USS; confirms the cyst
fine need aspiration cytology; colloid material

treatment; excise the duct, follow the tract up to the base of the tongue and ensure none is left behind (it will recur)
sistrunk’s procedure; remove middle 1/3 of hyoid bone and cut off tongue muscle

102
Q

describe dermoid cysts

A

arise along the lines of fusion
bridge of nose and neck lumps
contain all 3 germ cell layers; endoderm, mesoderm, ectoderm

103
Q

what are the complications, investigations and treatment of dermoid cysts?

A

cosmetically
infection

MRI or CT; may have a deeper extension, rule out meningocele and encephalocoele
FNA cytology

treatment; excision of lump
nasal columnar incision
deglove nose

104
Q

describe lateral neck swelling

A

most commonly caused by lymph nodes

causes; infection (most common), tumour

105
Q

describe primary and secondary tumours presenting as lateral neck lumps

A

primary; Hodgkins and non-hodgkins lymphoma

secondary; look for the possible primary before excising the gland
excision may seat the tumour cells into the skin and compromise treatment

106
Q

describe swelling of the submandibular gland

A

most commonly caused by a ductal stone
clinically; painful swelling in the gland area, related to eating

investigations; USS, x-ray will show the stone in the duct

treatment;
stone in duct;
surgical removal via oral cavity
flush out small stones during sialogram
removal radiologically via balloon

stone in gland;
submandibular gland excision

107
Q

what are the causes of parotid gland swelling?

A

most commonly caused by mumps
can be present due to poor dental hygiene and dehydration
tumour; benign pleomorphic adenoma
malignant; mucoepidermoid, adenoid cystic carcinoma, squamous carcinoma, squamous lymphoma

108
Q

describe thyroid swellings

A

either diffuse goitres or nodular goitres
nodular goitres may be malignant

investigations;
USS (confirm if it is multi-nodular/benign, or solitary/malignant)
radioisotope scan (hot/benign, cold/malignant)
FNA cytology
TFTs; usually normal in carcinoma
thyroid autoantibodies; TSI, TPA

109
Q

name the 4 types of thyroid tumours

A

papillary
follicular
anaplastic
medullary/C cell

110
Q

describe branchial cysts

A 
embryological remnants
can occur anywhere in the neck; most commonly at the junction at the upper 1/3 and lower 2/3s of the sternocleidomastoid
can be soft but swells up and get firmer
can cause infection and other problems
investigations; USS, FNA cytology
treatment; excision
111
Q

describe the location of the sinuses

A

maxillary; each side of the nose
ethmoidal; at the top of the nose, between the eyes
frontal; above the eyes
sphenoidal; further back, related to the pituitary gland most drain directly into the middle meatus

112
Q

what is the function of the sinuses?

A

the buttresses and air cells fold up, protect and absorb most of the impact of the blow

113
Q

where does the infection in sinusitis come from?

A

the nose via the ostium; URTI
via a compound fracture
via the bloodstream
dental abscesses

114
Q

what are the symptoms and signs of sinusitis?

A

blocked nose
discharge
pain; in the face, radiation to the vertex and teeth, throbbing, made worse by stooping and cough, worse in the morning
most commonly in the maxillary
can spread to the ethmoidal
may be swelling around the eyes; periorbital cellulitis

115
Q

what investigations are required to diagnose sinusitis?

A

x-ray; shows a fluid level, opaque antrum, unreliable

CT; if the patient is having surgery it shows the anatomy of the nose and sinus

116
Q

what are the complications of sinusitis?

A 
periorbital cellulitis;
big red swollen eye
very dangerous
once colour vagueness starts to disappear, patient will start to lose site in that eye
requires urgently ENT referral

intracranial infections; rare

117
Q

define stridor

A

noisy breathing due to airway obstruction

118
Q

describe the types of stridor

A

inspiratory; most common, airway collapses on inspiration, making it narrower, extra thoracic lesion
expiratory; less common, airway expands slightly on expiration, intrathoracic lesion
mixed

119
Q

describe the pathophysiology of stridor

A

lesion in the lumen or inside the wall

lesion depressing in from outside

120
Q

describe laryngomalacia

A

the child’s laryngeal cartilage is floppy
collapse during inspiration
usually mild and resolves over time
associated with feeding, sleeping and activity
severe; can cause respiratory distress and require surgery
disorders can be mimicked by webs and cysts
investigation; endoscopy
treatment; none required, usually firm up by 2yrs

121
Q

what are the congenital causes of stridor?

A

laryngomalacia
laryngeal webs/cysts
vascular ring compressing trachea

122
Q

what are the acquired causes of stridor?

A 
infection;
laryngotracheobronchitis
acute epiglottitis
adult acute epiglottitis
tumour;
supraglottis
glottis
subglottis
123
Q

describe laryngotracheobronchitis (LTB)

A

caused by a viral infection
relatively slow onset
mild-moderate stridor
treatment; steam, steroids

124
Q

describe acute epiglottitis in children

A

caused by bacteria (haemophilus influenza, part of childhood vaccination programme)
very rapid onset
very severe stridor
often in the tripod position by the time they get to hospital
may be drooling
appear unwell

treatment; place O2 source near child, require immediate airway protection (endotracheal tube insertion), antibiotic and steroids
do not cannulate, x-ray or reposition child
call anaesthetics and ENT

125
Q

describe acute epiglottitis in adults

A

rarely presents with airway obstruction; adult airway is much bigger
painful swallowing
hot potato voice

126
Q

describe supraglottic tumours

A

contains the epiglottis and aryepiglottic folds
very rich vascular and lymphatic supply
50% of tumours in this area present with neck nodes

127
Q

describe glottic tumours

A

comprises the vocal cords
fibrous tissue with poor lymphatic and vascular supply
present early with hoarseness
spread late

128
Q

describe subglottic tumours

A

connects to the trachea

present with stridor

129
Q

describe the thyroid FNA classification

A 
thy1; insufficient
thy2; benign colloid nodule
thy3; atypical
thy4; probable thyroid carcinoma
thy5; definite thyroid carcinoma
130
Q

what are the complications of thyroid surgery

A

recurrent laryngeal nerve injury
hypocalcaemia
bleeding
tracheomalacia

131
Q

what are the investigations and treatment of branchial cysts?

A

FNA
MRI or CT neck and chest
PET/CT; >40yrs, possible cystic metastasis from oropharyngeal cancer

surgical removal
cancer; discuss at MDM

132
Q

what are the risks of submandibular gland excision

A

mandibular branch of facial nerve
hypoglossal neve
lingual nerve

133
Q

what are the causes of salivary gland swellings?

A

bilateral; mumps, diabetes, acromegaly, fatty infiltration
single; sialadenitis, tumour
benign; pleomorphic adenoma, adenolymphoma
malignant; adenocarcinoma, adenoid cystic, mucoepidermoid, lymphomas, metastatic (squamous)

134
Q

what signs of a parotid gland swelling indicate malignancy?

A

unilateral facial nerve weakness
skin tethering
weight loss

135
Q

describe the causes of the different types of facial nerve weakness

A

UMNL; forehead spared, caused by strokes etc.

LMNL; Bell’s palsy, ramsey hunt syndrome, parotitis, middle ear infection, cholesteatoma, surgical, skull fracture, bottle to face trauma, parotid cancers, middle ear/ear canal cancer, skin cancer

136
Q

describe a carotid body tumour

A

a paraganglioma of the carotid sinus
smooth lateral neck swelling over carotid bifurcation
mobile laterally but not vertically

137
Q

what is the function of the tonsils?

A

sample micro-organisms in the upper aerodigestive tract

produce antibodies

138
Q

describe adenoid hypertrophy

A

common idiopathic condition in childhood
snoring
nasal blockage and discharge
may contribute to glue ear
requires further investigation in adults; lymphoma, squamous cell carcinoma, secondary to allergic rhinitis
present with unilateral otitis media with effusion in adults

139
Q

describe palatine tonsil hypertrophy

A

common in childhood
may lead to snoring and obstructive apnoea
may be related to eating difficulties

140
Q

describe tonsillitis associated with systemic upset

A

fever, chills, lethargy, anorexia
treat with antibiotics
can be complicated by septicaemia and streptococcal infections; glomerulonephritis, scarlet fever

141
Q

describe peritonsillar abscesses

A

quinsy
an abscess of webers salivary gland in the soft palate
mostly unilateral
causes swelling of the palate; the tonsil is often hidden behind the swelling
pushes the uvula to the opposite side
can develop into parapharyngeal abscess and septicaemia
treatment; drainage, usually needle aspiration

142
Q

describe glandular fever/infectious mononucleosis

A

a clinical diagnosis
syndrome of pharyngitis, relapsing high temperature, generalised cervical lymphadenopathy
monospot test
risk factors; Hx of drug abuse, sexual history
pregnancy; CMV and rubella are potentially teratogenic

143
Q

what is the treatment of glandular fever?

A

symptomatic
amoxicillin; often produces a rash
steroids; severe cases

144
Q

describe neoplastic change of the tonsils

A

usually lymphoma or squamous cell carcinoma
adenoid affected; nasal blockage, epistaxis, unilaterally otitis media with effusion, neck mass
tonsil affected; pain, dysphagia, trismus, unilateral tonsil swelling, neck mass

145
Q

describe tonsil stones/tonsoliths

A

accumulation of keratin within a tonsil crypt which extrude
occur after a period of inflammation
extrusion; manual pressing on the palatoglossal arch
dimish over time
can be smelly and uncomfortable
fish bones can stick in the tonsils

146
Q

what are the major causes of severe stridor?

A 
viral croup; caused by measles etc
foreign body
retropharyngeal abscess
diptheria
larynx trauma
147
Q

describe subglottic haemangioma

A

blood vessel growth below vocal cords from before birth to 6-18 months
spontaneously regresses
associated with other skin haemangiomas
stridor

treatment; steroids, propanolol, laser, microdebrider, tracheostomy

148
Q

what are the causes of adult stridor?

A 
supraglottitis
laryngeal tumour
vocal cord paralysis (bilateral); surgery, malignancy, viral association (Guillian barre)
foreign body
anaphylaxis
angioedema
149
Q

what is the treatment of adult stridor?

A 
airway emergency; anaesthetics, ENT
oxygen
nebuliser adrenaline
dexamethasone
intubation/tracheostomy if needed
150
Q

what are the risk factors associated with acute otitis media?

A 
young
male
smoking
contact with children
formula feeding
craniofacial abnormalities; cleft palate
dummy use
prolonged bottle feeding in supine position
FHx
lack of pneumococcal vaccination
GORD
prematurity
recurrent URTI
immunodeficiency
151
Q

what is the treatment of otitis media?

A

60% of children improve after 24hrs
most will recover within 3 days
treatment; weight appropriate analgesia
prescription to obtain an antibiotics if symptoms have not improved after 3 days
antihistamines and decongestants; no benefit

152
Q

what are the exceptions to the standard treatment of otitis media?

A

<2yrs with suspected bacterial infection
otorrhoea
systemic symptoms
co-morbidities

amoxicillin or clarithromycin/erythromycin 5-7 days

153
Q

describe AOM with vent in situ

A

no more than mild pain
effusion and mucopurulent material can discharge easily though the vent
ENT; 5 day course of topical aminoglycoside and steroid

154
Q

when should a patient with acute otitis media be admitted to hospital?

A

<6 months with a temperature of >38 degree
<3 months with a temperature of >39 degree
systemically unwell
suspicion for complications

155
Q

describe mastoiditis

A

inflammation of the mastoid cavity
will become inflamed every time there is acute otitis media
mastoid abscess; abscess formation
postauricular tenderness; poor prognostic sign

156
Q

describe the complications of mastoid abscesses

A

bezold’s; extends into sternocleidomastoid muscle
citelli; extends into posterior belly of digastric
meningitis and cerebral abscess; extends superiorly
sigmoid sinus thrombosis, infection, septic emboli to lungs (lemierre’s syndrome); extends posteriorly

157
Q

what are the function of hair cells?

A

inner; detect sound
outer; tension the basilar membrane, can focus sound energy in the basilar membrane onto a narrow group of inner cells
allows hearing against background noise
creates sound; otoacoustic emissions

158
Q

describe hair cell loss

A

inner; difficulty detecting sounds energy, deafness
outer; allows sound energy to spread out over more inner cells, sound becomes less distinct, more inner hair cells are triggered, loud sounds become louder

159
Q

what are the complications of otitis media with effusion?

A

otorrhoea
persistent perforation of ear drum
recurrent glue ear
tympanosclerosis

160
Q

describe chronic otitis media

A

a defect in the tympanic membrane which may discharge
mucosal disease; perforated ear drum
squamous disease; ingrowth of skin from the ear canal

161
Q

what are the symptoms and signs of mucosal disease/CSOM?

A

can be inactive or active
deafness
discharge
otalgia

162
Q

what are the symptoms and signs of squamous disease/CSOM?

A

rotatory vertigo
facial nerve palsy
abscess formation

163
Q

what is the management of mucosal disease/CSOM?

A

inactive mucosa; watch, surgical closure

active mucosa; medical treatment (toilet and drops), surgical closure

164
Q

what is the management of squamous disease/CSOM?

A

mastoidectomy;
posterior canal wall removed
mastoid incorporated into external canal
removal of all cholesteatoma

mastoid cavity care; repeated cleaning with micro suction to remove skin and wax, usually every 6-12 months

165
Q

what are the features of nasal discharge?

A 
quantity and quality
uni/bilateral
clear/mucopurulent
persistent/intermittent
anterior/posterior

unilateral purulent in a child; probable foreign body
unilateral clear with salty taste; possible CSF leak

166
Q

describe postnasal drip

A

can accompany rhinitis/sinusitis, CSF rhinorrhoea
isolated symptom; related to GORD, can be improved by saline nasal rinses and avoiding dairy products
not a cause of chronic cough/throat clearing

167
Q

describe the physiology of epistaxis

A

the nose warms, humidifies and filters air
this cools and dries the mucosa
epistaxis occurs if dry mucosa cracks over a vessel
treatment; emollients, naseptin, nasogel, vaseline

168
Q

describe the nasal cycle

A

to prevent the nasal mucosa from drying out
the inferior turbinates and septal body in each nasal cavity reciprocally congest and decongest over 1/2 hour periods to direct airflow predominantly down one side

169
Q

what is the treatment of major epistaxis?

A 
present to A&E
nasal pressure; ice to back of neck
lidocaine and adrenalin packs
cauterise if possible
balloon packs
admit for arterial ligation

nasal fracture can cause external nasal artery tearing; immediate reduction of the fracture will stop bleeding

170
Q

how does cocaine cause septal perforations?

A

a vasoconstrictor
excessive nasal use can cause avascular necrosis of the nasal septum
can be cut with levamisole; induces vasculitis

171
Q

what is the management of a septal haematoma?

A

requires drainage; aspiration or incision
packs inserted to stop reformation of haematoma
antibiotics given

172
Q

what are the complications of septal haematoma?

A

untreated; loss of septal cartilage, septal perforation, supra tip depression, columellar retraction

173
Q

describe the different types of fungal sinusitis

A

fungal ball (mycetoma) in the sinus; most common, requires surgery
allergic fungal sinusitis; polyps with thick mucin
invasive; necrotic sinuses, potentially lethal, immunocompromised

174
Q

what are the causes of facial pain?

A 
mid segmental facial pain syndrome
sinusitis
tension headache
facial migraine
trigeminal neuralgia
myofacial pain
175
Q

what is the treatment of acute sinusitis (<2 weeks)?

A

decongestants
analgesics
saline nasal rinse
herbal remedies

additional intranasal corticosteroid and antibiotics; if bacterial infection suspected, fever >38 and unilateral severe pain

176
Q

what are the dangerous signs of acute sinusitis?

A 
periorbital oedema/erythema
displaced globe
diplopia
ophthalmoplegia
reduced visual acuity
severe headache
frontal swelling
signs of sepsis
signs of meningitis
neurological signs
177
Q

describe the results of Weber’s test

A

lateralisation to affected side; unilateral conductive loss

lateralised to normal side; unilateral sensorineural loss

178
Q

describe the results of Rinne’s test

A

bone conduction > air conduction; conductive loss

179
Q

what is the management of otitis externa?

A

topical antibiotics and steroids

not resolving; oral

Clinical Practice (14 decks)

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