ENT

Question 1

CN I: Olfactory nerve

Answer 1

Nerve type: sensory

Function: smell

exits skull via cribriform plate

palsy most commonly due to trauma to lateral/occipital regions, intracranial space occupying lesions

clinical features: anosmia

testing: identifying certain smells e.g. mint

Question 2

CN II: Optic nerve

Answer 2

Nerve type: sensory

Function:
vision & afferent leg of pupillary light reflex

exits skull via optic canal

Causes of palsy: infection, tumours, ischaemic optic neuropathy, inflammation (MS), drugs (e.g. amiodarone, ethambutol)

clinical features:
impaired vision, ipsilateral blindness & absent direct pupillary light reflex

testing: visual fields, visual acuity, fundoscopy

Question 3

CN III: Oculomotor nerve

Answer 3

Nerve type: somatic & parasympathetic motor

Function:

• eye movements (superior rectus (elevation/intorsion/adduction), inferior rectus (depression/extorsion),medial rectus (adduction), inferior oblique (extorsion/elevation/abduction)
• eyelid opening, pupillary constriction (efferent limb of pupillary light reflex), accommodation

exits skull via superior orbital fissure

Causes of palsy: strokes, MS, myasthenia gravis, aneurysms

clinical features:
down & out gaze, ptosis, weak adduction, horizontal diplopia, absent pupillary light reflex (both direct & indirect)

testing: ocular/extraoccular movements, pupillary response

NB parasympathetic fibres are on the outside so compression causes pupillary dilation before motor dysfunction

Question 4

CN IV: Abducens nerve

Answer 4

Nerve type: motor

Function: 
eye movements (superior oblique (intorsion, depression, abduction))

exits skull via SOF

Causes of palsy: cavernous sinus thrombosis, microvascular damage

clinical features:
extortion of eye (inability to depress & adduct simultaneously) & diplopia (exacerbated on downward age e.g. going down stairs, reading)

testing: eye movements

Question 5

CN V: Trigeminal nerve

Answer 5

Nerve type: sensory (V1/V2/V3) & motor (V3)

Function: 
facial sensation (V1 = ophthalmic, V2 = maxillary, V3 = mandibular), afferent limb of corneal reflex & jaw jerk reflex, muscle of mastication (V3)

exits skull via SOF (V1), foramen rotundum (V2), foramen ovale (V3)

Causes of palsy: cavernous sinus thrombosis, vascular compression

clinical features:
V1 = absent corneal reflex, loss of sensation to ipsilateral forehead
V2 = loss of sensation to ipsilateral midface
V3 = anaesthesia of lower 1/3 of face, anterior 2/3 of tongue, paresis of ipsilateral muscles of mastication & diminished jaw jerk reflex

testing: facial sensation, corneal reflex, jaw jerk, muscle of mastication

Question 6

CN VI: Trochlear nerve

Answer 6

Nerve type: motor

Function: 
eye movements (lateral rectus = abduction)

exits skull via SOF

Causes of palsy: cavernous sinus thrombosis, diabetic neuropathy

clinical features:
horizontal diplopia worse when looking at far objects, esotropia (medial deviation of eye on neutral gaze), inability to abduct eye

testing: eye movements

NB most common ocular nerve plays

Question 7

CN VII: Facial nerve

Answer 7

Nerve type: sensory, somatic & parasympathetic motor

Function:
taste (anterior 2/3 of tongue), sensation to tympanic membrane
muscles of facial expression, efferent limb of corneal reflex
salivation & lacrimation (submandibular/sublingual/lacrimal glands)

exits skull via internal acoustic meatus

clinical features:
flaccid paralysis of face, loss of taste, hyperacusis, loss of corneal reflex

testing: facial expression

Question 8

CN VIII: Vestibulocochlear nerve

Answer 8

Nerve type: sensory

Function:
balance & equilibrium (vestibular)
hearing (cochlear)

exits skull via internal acoustic meatus

Causes of palsy:bacterial meningitis, lyme disease, acoustic neuroma, neurofibromatosis 2, basilar skull fracture

clinical features:
sensorineural hearing loss, vertigo, motion sickness, horizontal nystagmus

testing: audiometry (hearing test, Weber’s & Rhinnes)

Question 9

CN IX: Glossopharyngeal nerve

Answer 9

Nerve type: sensory & somatic/parasympathetic motor

Function:
taste (posterior 1/3 of tongue), afferent limb of gag reflex
carotid sinus/body (chemo & baroreceptors)
swallowing, innervates stylopharyngeus
salivation (parotid gland), sensation to posterior 1/3 of tongue/soft palate/upper pharynx

exits skull via jugular foramen

clinical features:
absent gag reflex, loss of carotid sinus reflex, sensory loss of back of mouth & upper throat, mild dysphagia

Question 10

CN X: Vagus nerve

Answer 10

Nerve type: somatic/visceral sensory & somatic/parasympathetic motor

Function:
sensation (supraglottic region, larynx, trachea), couch reflex , efferent limb of gag reflex, swallowing (pharyngeal muscles) speech (laryngeal muscles via recurrent laryngeal nerve), SA & AV node innervation

exits skull via jugular foramen

Causes of palsy: trauma, diabetes inflammation

clinical features:
flaccid paralysis & ipsilateral lowing of soft palate, dysphagia, loss of gaga & cough reflex, uvuala deviation away from lesion, dysphonia (unilateral recurrent laryngeal) or aphonia (bilateral)

Question 11

CN XI: Accessory nerve

Answer 11

Nerve type: motor

Function: head turn via sternocleidomastoid, shoulder elevation via trapezius

exits skull via jugular foramen

clinical features:
paresis, atrophy, asymmetry of sternocleidomastoid & trapezius, ipsilateral shoulder drooping & lateral winging of scapula

Question 12

CN XII: Hypoglossal nerve

Answer 12

Nerve type: motor

Function: tongue protrusion (intrinsic & extrinsic muscled of tongue)

exits skull via hypoglossal canal

clinical features:
fasciculations & atrophy of tongue, tongue deviated towards lesion

Question 13

Tonsillitis

Answer 13

an infection of the parenchyma of the palatine tonsils, frequently occurring i combination with inflammation of the pharynx = tonsilopharyngitis

common in children & young adults

Question 14

Aetiology of tonsillitis

Answer 14

Viral (50-80%)
adenovirus, EBV, CMV,

Bacterial (15-30%)
strep progenes (Group A strep)

NB viral = cough, bacterial = no cough

Question 15

Presentation of tonsillitis

Answer 15

pain in throat/sore throat
dysphagia
fever
lymphadenopathy
headache
tonsillar exudates
tonsillar erythema
tonsillar enlargement

Question 16

Investigations for tonsillitis

Answer 16

throat culture

rapid streptococcal antigen test

Question 17

Management of tonsillitis

Answer 17

Viral:
self limiting, supportive (antipyretics, analgesia)

Bacterial:
if confirmed on swab/antigen test or CENTOR score >3
5-10 day course of phenoxymethylpenicillin (erythromycin/clarithromycin if penicillin allergy)

Surgical:
tonsillectomy, if recurrent (≥5x in previous year) / chronic episodes

Question 18

CENTOR criteria

Answer 18

The Centor criteria are: score 1 point for each

• presence of tonsillar exudate
• tender anterior cervical lymphadenopathy/lymphadenitis
• history of fever
• absence of cough
• age (<15 yrs = +1 point, >44 yrs = -1 point)

Abx indicated if CENTOR score >3

Question 19

Peritonsillar abscess (Quinsy)

Answer 19

ENT emergency

usually in bacterial tonsillitis, seen in young adults & adolescents

presentation includes features of tonsillitis, drooling, severe throat pain, trismus, halitosis, ‘hot potato’ voice, contralateral uvula devotion, ↓ neck mobility

management:
1st line: needle aspiration or incision & drainage + Abx
2nd line: tonsillectomy, considered 6 weeks after

Question 20

Acute otitis media (AOM)

Answer 20

a painful infection of the middle ear, generally secondary to a viral URTI as a bacterial superinfection e.g. due to strep pneumonia/H. influenzae/moraxella catarrhalis

very common in children (~80% experience AOM by age 3)

Question 21

Presentation of Acute otitis media (AOM)

Answer 21

throbbing otalgia/earache
young children may be irritable & repeatedly touching/tugging at ear
hearing loss in affected ear
fever
otrohoea (if tympanic membrane perforated)

preceding URTI (coryza, rhinorrhoae etc)

Question 22

Investigations of Acute otitis media (AOM)

Answer 22

Otoscopy (bulging tympanic membrane, opacification/erythema of tympanic membrane, visible perforation, purulent discharge from ear canal)

Weber’s/Rhinne’s test (conductive hearing loss)

consider culturing discharge

Question 23

Management of Acute otitis media (AOM)

Answer 23

generally self limiting (~80%)
=pain relief & observation

Abx
1st line: amoxicillin (erythromycin if penicillin allergy)

indications for Abx
if >4 days of symptoms/no improvement, systemically unwell, bilateral AOM in <2y/o, perforation/discharge, immunocompromise

Question 24

Indications for giving Abx in Acute otitis media (AOM)

Answer 24

Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
Otitis media with perforation and/or discharge in the canal

Question 25

Otitis media with effusion (OME) or glue ear

Answer 25

chronic mucoid/serous effusion in the tympanic cavity in the absence of infection lasting >3 months, though to be due to eustachian tube dysfunction causing fluid to accumulate most common cause of hearing impairment in childhood, where it usually follow and episode of AOM usually seen age 1-6 yrs

Question 26

Risk factors for Otitis media with effusion (OME)

Answer 26

craniofacial malformations e.g. cleft palate Down's syndrome allergic rhinitis impaired ciliary motility e.g. cystic fibrosis

Question 27

Presentation of Otitis media with effusion (OME)

Answer 27

hearing loss* presents as mishearing, difficulty communicating in a group, needing thing to be repeated, excessively high TV volume painless sensation of pressure school progress may be impaired easily missed in young children

Question 28

Otitis media with effusion (OME) in adults

Answer 28

acute unilateral presentation in adults should trigger thoughts of nasopharyngeal carcinoma

Question 29

Investigating Otitis media with effusion (OME)

Answer 29

hearing test (mild conductive hearing loss i.e. ↓20-40 dB)

Question 30

Otitis media with effusion (OME) management

Answer 30

generally self limiting 1st line: active observation 2nd line surgery e.g. tympanovstomy tubes (grommets) indications for surgery: bilateral OME ≥3 months, hearing loss >30dB, developmental/educational difficulties

Question 31

Chronic suppurative otitis media (CSOM)

Answer 31

chronic inflammation of the middle ear & mastoid cavity with persistent drainage from the middle ear through a perforated tympanic membrane lasting >6-12 weeks generally caused by bacterial infection following perforated tympanic membrane e.g. due to recurrent AOM, trauma, tympanostomy most common seen in those <15 y/o

Question 32

Presentation of Chronic suppurative otitis media (CSOM)

Answer 32

``` painless recurrent otorrhoea conductive hearing loss no pain no fever perforated tympanic membrane on otoscopy ```

Question 33

Complications of Chronic suppurative otitis media (CSOM)

Answer 33

cholesteatoma (keratinising epithelium growing into middle ear) hearing loss may improve but may not fully recover

Question 34

Management of Chronic suppurative otitis media (CSOM)

Answer 34

specialist (ENT) referral topical Abx rinsing/cleaning of ear topical steroids

Question 35

Infective labyrinthitis

Answer 35

inflammation/infection of the inner ear frequently secondary to AOM, where it spreads through the road window presents with severe vertigo, nausea, sensorineural hearing loss, nystagmus towards healthy ear management with IV Abx, tympanostomy, glucocorticoids

Question 36

Otitis externa

Answer 36

acute otitis external (AOE) is a diffuse inflammation of the external ear canal which may involve the pinna or tympanic membrane, also known as swimmers ear

Question 37

Aetiology of otitis externa

Answer 37

most common bacterial infection e.g staph aureus, pseudomonas aeruginosa fungal is less common, but usually aspergillum non infectious e.g. seborrhoeic dermatitis or contact dermatitis

Question 38

Risk factors for otitis externa

Answer 38

``` hot/humid climates swimming local trauma diabetes external auditory canal obstruction ```

Question 39

Presentation of otitis externa

Answer 39

``` intense itching of external ear canal ear pain tender tragus ear canal swelling & erythema otorrhoea aural fullness conductive hearing loss ```

Question 40

Management of otitis externa

Answer 40

1st line: topical Abx e.g. neomycin ± steroids 2nd line: ENT referral + systemic flucloxacillin + swab for culture

Question 41

Perichondritis

Answer 41

infection of the tissue covering the cartilage of the pinna, usually after trauma e.g. piercing

Question 42

Malignant otits externa (necrotising otitis externa)

Answer 42

a necrotising inflammation of the external ear canal, i.e. an infection extending into the bony ear canal & deep soft tissue 95% of cases are due to pseudomonas aeruginosa risk factors include poorly controlled diabetes, immunosuppression, elderly

Question 43

Malignant otits externa (necrotising otitis externa)

Answer 43

a necrotising inflammation of the external ear canal, i.e. an infection extending into the bony ear canal & deep soft tissue 95% of cases are due to pseudomonas aeruginosa risk factors include poorly controlled diabetes, immunosuppression, elderly

Question 44

Malignant otitis externa presentation

Answer 44

typically elderly pt with poorly controlled diabetes severe ear pain, erythematous/swollen periauricular soft tissue, otorrhoea, may have facial nerve palsy

Question 45

Complication of Malignant otitis externa

Answer 45

osteomyelitis of the skull base, which may cause intracranial expansion of the infection

Question 46

Investigations for Malignant otitis externa

Answer 46

CT/MRI (identify bone destruction & intracranial expansion e.g. cranial abscess or venous sinus thrombosis) biopsy (to distinguish from a tumour)

Question 47

Treatment of Malignant otitis externa

Answer 47

IV Abx e.g. ciprofloxacin high mortality even with treatment

Question 48

Epistaxis

Answer 48

Nosebleeds types: Anterior (~90%), bleeding usually from Kiesselbach plexus located on anterioinferioir nasal septum (Little's area) and anastomoses of the anterior ethmoidal/sphenopalatine/greater palatine/superioir labial arteries Posterior (~10%), more dangerous, generally seen in older individuals, ↑ risk of airway compromise & aspiration, usually bleeding from both nostrils & blood running own throat

Question 49

Causes of epistaxis

Answer 49

``` trauma including picking nose vascular malformations nasal septum defect (e.g. deviated septum) tumours bleeding disorders ```

Question 50

Management of epistaxis

Answer 50

1) ABCDE assessment 2) sit upright with torso forward, squeeze cartilaginous part of nose for 20 minutes ``` 3) Cautery with silver nitrate = 1st line if source of bleeding is visible use packing (nasal tampons, rapid rhino) if cautery not tolerated or source of bleeding not visible ``` 4) if persistent epistaxis then artery embolisation/ligation

Question 51

Sinusitis

Answer 51

inflammation of the mucous membranes of the paranasal sinuses, rarely occurring without concurrent inflammation of the nasal mucous (rhinitis) = rhinosinusitis

Question 52

Type of sinusitis

Answer 52

Acute <4 weeks subacute 4-12 weeks chronic > 12 weeks

Question 53

Aetiology of sinusitis

Answer 53

viral: very common e.g. rhinovirus, influenza, parainfluenza, adenovirus bacterial: strep pneumonia, H. Influenzae

Question 54

Risk factors for sinusitis

Answer 54

URTI smoking nasal obstruction e.g. septal deviation or nasal polyps nasal foreign body

Question 55

Presentation of sinusitis

Answer 55

``` facial pain (frontal pressure pain, worse on bending forward) nasal discharge (thick & purulent) nasal obstruction ```

Question 56

Management of sinusitis

Answer 56

intranasal decongestants/nasal saline intranasal corticosteroids (>10 days of symptoms) if severe = oral Abx if chronic consider intranasal saline washout

Question 57

complications of sinusitis

Answer 57

``` preseptal/orbital cellulitis orbital abscess cavernous sinus thrombosis brain abscess subdural abscess (most common) osteomyelitis (especially of frontal bone = Pott's puffy tumour) ```

Question 58

Rhinitis

Answer 58

inflammation & swelling of the nasal mucous membranes can be allergic or non allergic

Question 59

allergic rhinitis

Answer 59

acute/chronic rhinitis due to inhaled allergens causing a type I hypersensitivity reaction (IgE mediated), may be seasonal, occupational or perennial (throughout year) most common form of rhinitis presents with sneezing, bilateral nasal congestion, clear nasal discharge, post nasal drip, nasal pruritis managed with allergen avoidance, oral/intranasal antihistamines, short course of decongestants e.g. oxyetazoline

Question 60

Complications of intranasal decongestant use

Answer 60

prolonged use leads to tolerance meaning ↑ doses are needed to achieve the same affect & may cause rebound hypertrophy of the nasal mucosa when withdrawn

Question 61

types of non allergic rhinitis

Answer 61

rhinitis medicamentosum: rebound nasal congestion when discontinuing nasal decongestant, pts often use ↑dose/frequency to treat leading to vicious cycle atrophic rhinitis: chronic rhinitis associated with atrophy & sclerosis of the nasal mucosa drug induced rhinitis: e.g. snorting cocaine or ketamine

Question 62

Epiglottitis

Answer 62

progressive inflammation of the epiglottis & supra glottis with the potential to cause airway compromise caused by haemophilia infleuzae type B (Hib), has become rare since Hib vaccination usually seen ages 2-5 yrs

Question 63

Presentation of epiglottitis

Answer 63

acute onset high fever, sore throat, dysphagia, odynophagia tripod position, stridor, respiratory distress muffled ('hot potato' voice) drooling

Question 64

Investigating epiglottitis

Answer 64

direct visualisation via laryngoscopy (must be airway trained/senior doctor) lateral neck X-ray (thumb sign)

Question 65

Management of epiglottitis

Answer 65

immediate senior & airway trained personnel involvement DO NOT examine throat (using tongue depressor may cause obstruction) IV/PO Abx supplemental O2 airway management if indicated

Question 66

Nasal polyps

Answer 66

associated with asthma cystic fibrosis, Kartengers affect ~1% of adult population 2-4x more common in men features include nasal obstruction, rhinorrhoea, sneezing, poor sense of taste & smell NB unilateral nasal polyp should raise suspicion of cancer management with ENT referral, topical steroids (↓ polyp size)

Question 67

Nasal septum deviation

Answer 67

most common cause of nasal obstruction, usually due to direct trauma to nose/face or due to Marfan's/Ehler-Danlos syndrome features include recurrent sinusitis, facial pain, mouth breathing, ↓ wens of smell, repetitive sneezing, noisy breathing managed with topical decongestants, steroid, antihistamines & surgery

Question 68

Choanal atresia

Answer 68

congenital bony/membranous obstruction of the posterior nasal passage which can be unilateral/bilateral associated with other abnormalities e.g. CHARGE syndrome features: if bilateral = obligate mouth breathing, cyanosis worse on feeding, noisy breathing, struggling with food intake if unilateral: chronic rhinitis, congestion, rhinorrhoea management surgical perforation (urgently if bilateral, or at 1-2y/o if unilateral)

Question 69

Thyroglossal cyst

Answer 69

a remnant of the thyroglossal duct formed during embryonic development of the thyroid gland & normally regress before birth 2nd most common neck abnormality (~7% of population) Presents as cyst present from birth, painless firm midline neck mass that elevates with swallowing & tongue protrusion USS neck (evaluate cyst & confirm location of thyroid) elctive surgical removal to treat

Question 70

Brachial cyst

Answer 70

remand of the embryological 2nd brachial cleft/cervical sinus which normally regresses after birth ~20% of paediatric neck masses presents as cyst diagnosed in late childhood/adolescence usually when cyst becomes infected, painless firm mass located lateral to midline usually anterior to SCM and does not move on swallowing USS neck & CT/MRI (to plan surgery) managed with surgical excision

Question 71

Head & neck cancers

Answer 71

90% are squamous cell carcinomas

Question 72

Risk factors for head & neck cancer

Answer 72

``` smoking heavy alcohol consumption poor dentition poor diet GORD HPV 16 +ve male gender ```

Question 73

Cancer of the oral cavity

Answer 73

cancers of oral mucosa, tonsils, salivary glands & tongue, usually seen in males aged 55-60 present as dysphagia, non healing ulcers, halitosis, unusual bleeding in mouth, facial swelling, lymphadenopathy biopsy & histopathology, panednoscopy (to assess extent of tumour), CT chest/abdo/pelvis (check for spread) treat with surgical resection if local, or resection +radio/chemotherapy

Question 74

Pharyngeal cancer

Answer 74

cancer of the oro/naso/hypopharynx, less common than other head & neck cancers, generally seen in males aged >50yrs presents as enlarged lymph nodes, severe air pain, dysphagia, sore throat, foreign body sensation, recurrent otitis media & conductive hearing loss, epistaxis investigate with panendoscopy, biopsy, MRI/CT (to check infiltration into surrounding structure) Managed with surgery ± radio/chemo therapy NB nasopharyngeal cancer usually not SCC

Question 75

Laryngeal cancer

Answer 75

cancers of supraglottis, glottis, subglottis, 2nd most common head & neck cancer, usually seen in males age 40-70 presents with hoarseness, change in voice, foreign body sensation, dyspnoea, dysphagia, stridor, aspiration investigate with direct laryngoscopy, CT/MRI or USS neck Management with radiotherapy/transednoscpopic laser resection if early, larynectomy if advanced

Question 76

Reineke's oedema

Answer 76

benign build up of fluid in the lamina propria of the true vocal cords, looks like a sac-like fluid filled vocal cords due to irritation & inflammation secondary to smoking presents with deep/low pitched voice,rough voice, dysphonia, bilaterally swollen vocal cords on laryngoscopy managed with smoking cessation & voice therpay

Question 77

Laryngeal papillomatosis/recurrent respiratory papillomatosis (RRP)

Answer 77

being tumour of the laryngeal epithelium caused by HPV infection (the 6&11) presents as white exophylic cauliflower like lesion located in the larynx/trachea/vocal cords which may cause dysphonia, hoarseness, stridor should be surgical removed but may reoccur

Question 78

Laryngopharyngeal reflux (LPR)

Answer 78

inflammatory changes of the larynx/pharynx secondary to GORD, common presents with globes (felt in midline, worse on swallowing), hoarseness, chronic cough, dysphagia, heart burn managed with lifestyle changes, PPIs or alginates e.g. gaviscon

Question 79

Laryngopharyngeal reflux (LPR)

Answer 79

inflammatory changes of the larynx/pharynx secondary to GORD, common presents with globus (felt in midline, worse on swallowing), hoarseness, chronic cough, dysphagia, heart burn managed with lifestyle changes, PPIs or alginates e.g. gaviscon

Question 80

Laryngitis

Answer 80

inflammation of the larynx acute: <3 wks, usually viral ± bacterial superinfection chronic >3 wks, usually GORD related or smoking related

Question 81

Presentation of laryngitis

Answer 81

hoarseness of voice, dysphonia, dry cough, stridor, fever, dysphagia, lymphadenopathy, globus, sore throat mainly clinical diagnosis, consider laryngoscopy (shows oedema, eryhtma, or cobble stoning (if GORD))

Question 82

Management of laryngitis

Answer 82

``` vocal rest smoking cessation speech therapy humidification Abx for bacterial superinfection ```

Question 83

Foreign nasal body

Answer 83

mostly young children (<2.5yrs) presents as unilateral nasal obstruction, epistaxis or mould smelling purulent rhinorrhoea nasal cavity inspection (otoscope) or flexible fiberoptic endoscopy removal via positive pressure, forceps or endoscopy

Question 84

Foreign bodies in the ear

Answer 84

usually seen in children (older children/adults will know something is i their ear) may present as ear pain, deafness, ↓hearing or discharge visualise on otoscopy remove with forceps (if insect should kill insect first)

Question 85

Swallowed foreign bodies

Answer 85

generally seen in children <5yrs coins = most common object to swallow, items like button batteries are very dangerous presents with vomiting, choking, refusal to eat, blood stained saliva, drooling, wheezing, respiratory distress investigate with plain CXR or endoscopy managed by endoscopic removal or if in stomach waiting for it to pass in stool

Question 86

Obstructive sleep apnoea (OSA)

Answer 86

characterised by episodes of complete/partial upper airway obstruction during sleep most common breathing related sleep disorder, 2x more common in men

Question 87

Risk factors for OSA

Answer 87

``` obesity adenotonsillar hypertrophy (in children) nasal septum deviation nasal polyps macroglossia family history Down's syndrome ```

Question 88

Presentation of OSA

Answer 88

excessive snoring reports of apnoea (from sleep partner/parents) day time somnolence restless sleep frequent waking mouth breathing impaired cognitive function (poor concentration)

Question 89

Investigating OSA

Answer 89

Polysomnography (1st line) | Epworth sleepiness scale

Question 90

Management of OSA

Answer 90

weight loss, sleep hygiene, lateral sleeping position CPAP surgical removal of tonsils/adenoids in children

Question 91

Vertigo

Answer 91

dizziness is a general, non specific term to indicate the sense of disorientation vertigo is a type of dizziness & refers to the false sensation that oneself or the surroundings are moving/spinning due to mismatch of vestibular, visual & somatosensory systems

Question 92

Causes of vertigo

Answer 92

cerebral: CVD, migraine, MS, acoustic neuroma, alcohol intoxication Vestibular: vestibular neuritis, viral labyrinthitis, BPPV, Meniers, motion sickness, ototoxicity (e.g. gentamicin), HZV (ramsay hunt syndrome)

Question 93

Benign paroxysmal positional vertigo (BPPV) presentation

Answer 93

gradual onset, triggers by change in head position, episodes lasts 10-20secs

Question 94

Meniere's disease presentation

Answer 94

hearing loss, tinnitus & sensation of pressure/fullness in one/both ears nystagmus

Question 95

Vertebrobasillar ischaemia

Answer 95

elderly pts, presents with dizziness on extension of neck

Question 96

acoustic neuroma presentation

Answer 96

hearing loss, vertigo, tinnitus ± absent corneal reflex/facial nerve palsy if bilateral then neurofibromatosis 2

Question 97

Investigating vertigo

Answer 97

``` Romberg's test Dix-Hallpike manoeuvre head impulse test CT/MRI audiometry vestibular function ```

Question 98

Laryngeal nerve palsy/vocal cord paralysis

Answer 98

clinical features depend if one or 2 cords are affected & position of chords, due to injury of one/both recurrent laryngeal nerves unilateral: hoarseness bilateral: dysphonia, stridor, snoring, breathing problems treatment: voice therapy, surgery

Question 99

Benign lesions of the vocal cords

Answer 99

present as hoarseness include: vocal cord nodules (bilateral), treated with voice therapy polyps of vocal folds (unilateral), treated with excision to exclude malignancy

Question 100

Voice overuse/misuse

Answer 100

common in professions such as acting/singing/teaching may lead to being lesions such as nodules (singers nodules) or cysts treated with voice therapy or surgery

Question 101

Labyrinthitis

Answer 101

inflammatory disorder of the membranes of the labyrinth affecting both vestibular & cochlear organs, usually preceded by URTI may be viral (most common), bacterial or associated with systemic disease usually seen age 40-70

Question 102

Presentation of labyrinthitis

Answer 102

acute onset vertigo (not triggered by movement but exacerbated by movement) hearing loss* nausea&vomiting, tinnitus spontaneous unidirectional horizontal nystagmus towards unaffected side, sensorineural hearing loss

Question 103

Vestibular neuritis

Answer 103

inflammation of the vestibular nerve, usually follows a viral illness

Question 104

Presentation of vestibular neuritis

Answer 104

recurrent vertigo attacks lasting hours to days, nausea & vomiting, horizontal nystagmus NO hearing loss or tinnitus (unlike labyrinthitits)

Question 105

Management of vestibular neuritis

Answer 105

vestibular rehabilitation exercises

Question 106

Cholesteatoma

Answer 106

presence of keratinising squamous cell epithelium within the middle ear or in other pneumatised areas of the temporal bone, the epithelium exhibits independent growth leading to expansion & reabsorption of underlying bone risk ↑ 100x with cleft palate

Question 107

presentation of cholesteatoma

Answer 107

painless otorhhoea (scant but foul smelling discharge from affected ear) conductive hearing loss (painless) retraction pocket/attic crust seen on otoscopy

Question 108

Pleomorphic adenoma

Answer 108

commonest tumour of parotid glands Slow growing, lobular, and not well encapsulated

Question 109

Normal Webers & Rhinnes test

Answer 109

Rhinnes: Air conduction > bone conduction bilaterally Webers: equal on both sides, no lateralisation, stays in midline

Question 110

Conductive hearing loss Webers & Rhinnes test

Answer 110

Rhinnes: Bone conduction > air conduction in affected ear Air conduction > bone conduction in unaffected ear Webers: Lateralises to affected ear

Question 111

Sensorineural hearing loss Webers & Rhinnes test

Answer 111

Rhinnes: Air conduction > bone conduction bilaterally Webers: Lateralises to unaffected ear