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Special senses > ENT > Flashcards

ENT Flashcards

1
Q

What is vertigo?

A

Hallucination of movement (caused by problem with vestibular system)

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2
Q

What are some central causes of vertigo?

A

Stroke

Migraine

Neoplasms

Demylination e.g. MS

Drugs

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3
Q

What are some peripheral causes of vertigo?

A

BPPV

Menieres disease

Vestibular Neuronitis

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4
Q

How does benign paroxysmal positional vertigo present?

What causes it?

A

Vertigo associated with head movements lasts seconds

Caused by otoliths (crystals) in the semicircular canals (most commonly posterior) causing abnormal stigmatise of the hair cells

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5
Q

How is BPPV diagnosed and how is it treated?

A

Diagnosis = Dix-Hallpike

Treatment = Epley manoeuvre

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6
Q

What are the clinical features of Ménière’s disease?

What is the pathophysiology?

A

Tinnitus in affected ear

Episodic vertigo lasting minutes to hours associated with N&V

Fluctuating hearing loss

Aural fullness

(over time the disease burns out with no more vertigo but some reduced hearing - due to increased pressure and dilatation of endolymphatic system)

Caused by increased fluid in the endolymphatic compartment (endolymphatic hydrops)

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7
Q

What is the management of Ménière’s disease?

A

Dietary - reduce salt, chocolate, caffeine and Chinese food

Medical - thiazide diuretics, prochlorperazine for acute attacks (vestibular sedatives)

Surgical - grommet insertion

PREVENTION = betahistine and vestibular rehab exercises

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8
Q

How does vestibular neuronitis present?

A

Incapacitating vertigo lasting several days associated with N&V (after recent viral infection)

No hearing loss

Horizontal nystagmus

(Think in young fit patient)

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9
Q

How is vestibular neuronitis managed?

A

Vestibular sedatives during acute attacks (may still have long term vertibular deficits but don’t take vestibular suppressants as it delays recovery)

Resolves eventually - vestibular rehab exercises if chronic

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10
Q

How does viral labyrinthitis present?

A

Recent viral infection

N&V

Hearing loss (unlike vestibular neuronitis - hearing is in tact)

Sudden onset

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11
Q

How does vertibrobasilar ischaemia present?

A

Elderly

Dizziness on extension of neck

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12
Q

How does acoustic neuroma present?

A

Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2

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13
Q

What can happen to the external ear?

How is it treated?

A

Lacerations = primary closure with exposed cartilage covered with skin

Haematoma (blood in between cartilage and perichondrium) = drainage and pressure dressing

Tympanic membrane perforation (causes pain and conductive hearing loss) = usually heals by itself (if not my 6 months then myringoplasty)

Haemotympanum (blood in middle ear - can be associated with temporal bone fracture) = treated conservatively

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14
Q

How does otitis externa present?

What organisms can cause it?

A

Painful discharging ear (inflamed ear canal)

Muffled hearing due to discharge

Pseudomonas aeruginosa/ staph aureas

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15
Q

What is malignant otitis externa?

A

Seen in diabetics / immunecompromised

Infection spreads from soft tissue into bone

Presentation = chronic ear discharge despite treatment, deep seated severe ear pain and cranial nerve palsies

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16
Q

what is the management of otitis externa?

What are the risk factors?

A

Topical eardrops

Swab discharge in resistant cases

Microsuction of pus allowing drops to get to infection

If severe then wick can hold canal open

Malignant otitis externa = IV abx and topical treatment

Risk factors = cotton buds, swimming, humidity, immunocompromised

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17
Q

What is the epithelium lining the middle ear?

A

Respiratory epithelium (pseudostratified columnar)

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18
Q

What are the features of otitis media?

A

Ear pain (caused by increased pressure in tympanic cavity)

Discharge (pain may settle as tympanic membrane ruptures)

Fever

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19
Q

What is the management of otitis media?

What are the complications of AOM?

A

Conservative with analgesia

Medical if severe / persistent

Surgery - if recurrent may benefit from grommet

Complications = meningitis, intracranial abscess, sigmoid sinus thrombosis, bacterial labyrinthitis, facial paralysis

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20
Q

What are the two types of chronic otitis media?

A

Active / inactive (if discharging)

Then subdivided into mucosal or squamous disease

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21
Q

What is active squamous chronic otitis media also known as?

A

Cholesteatoma

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22
Q

How does inactive squamous COM act?

A

Retraction pocket which may develop in to active disease (cholesteatoma)

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23
Q

What is active mucosal COM?

What is inactive mucosal COM?

A

Active = chronic discharge from middle ear through tympanic membrane perforation

Inactive = tympanic membrane perforation but no active infection / discharge

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24
Q

How does mucosal COM develop?

A

Acute episode of AOM - after rupturing of tympanic membrane there is failure to heal

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25
Q

How is squamous COM thought to develop?

A

When keratinised squamous cells are introduced to middle ear from perforation

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26
Q

How does active COM present?

A

Chronic ear discharge and often conductive hearing loss

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27
Q

What is the management of COM?

A

Cholesteatoma = surgery

If no cholesteatoma = topical antibiotic drops and aural toilet

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28
Q

What is the risk with mastoid surgery?

A

Facial nerve palsy

Alteral taste (damage to chorda tympani)

Tinnitus

Vertigo

Complete loss of hearing

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29
Q

What is otitis media with effusion (glue ear)?

A

Fluid in middle ear associated with eustacian tube dysfunction (post nasal tumours can also cause glue ear)

OME is not painful but can become infected and become AOM

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30
Q

What are the clinical features of glue ear?

A

Middle ear effusion on otoscopy

Conductive hearing loss (associated with speech delay)

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31
Q

What are the investigations for glue ear?

A

Typanogram (flat type B tracing with normal canal volumn)

Pure tone audiogram (showing conductive hearing loss)

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32
Q

What is the management of glue ear?

A

Conservative (usually settles in 3 months)

Heading aid

Surgery - for prolonged hearing loss causing significant problems with Grommets (ventilation tubes) +/- adenoidectomy

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33
Q

What are the examination findings of otosclerosis?

A

Typically normal

Rarely pink hue to the tympanic membrane - Schwartze’s sign

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34
Q

What are the investigations for otosclerosis?

A

Typanogram (normal type A trace)

Pure tone audiogram (conductive hearing loss, carhart notch at 2kHz)

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35
Q

What is the management of otosclerosis?

A

Conservative - hearing loss

Surgery - stapedectomy

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36
Q

Where is the inner ear found?

A

Petrous part of temporal bone

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37
Q

What are the investigations for sudden onset sensorineural hearing loss?

A

Confirm sensorineural with tuning forks

Pure tone audiogram

MRI scan (for lesions along central auditory pathway e.g. acoustic neuroma)

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38
Q

What is the management for sudden onset sensorineural hearing loss?

A

Steroids (normall oral but can be injected into middle ear)

Anti-virals

Other treatments e.g. hyperbaric oxygen, carbogen

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39
Q

How to perform tuning fork test?

A

With a 256 or 512 Hz tuning fork

Weber = placed on forehead, louder on right / left

Sensorineural = louder on opposite side

Conductive = louder on same side as hearing loss (conductive hearing loss with block out background noise)

Rinne = placed on mastoid (conducted to cochlear via temporal bone) then lateral ear

Sensorineural if air conduction is louder (normal)

Conductive if bone conduction is louder

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40
Q

How is a pure tone audiogram performed?

A

Hearing threshold assessed at various frequencies

Air conduction assessed with headphones

Bone conduction is assessed by playing tone through bone conductor over mastoid bone

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41
Q

what are the three possible results from a tympanogram?

A

Tympanogram = inserting a probe into external ear canal

Type A = peak centered on 0 daPa on x axis (normal)

Type B = flat tracing (middle ear effusion / perforation)

Type C = peak has negative pressure (eustacian tube dysfunction)

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42
Q

Label the following:

A
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43
Q

Label the following:

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44
Q

What are some local and idiopathic causes of nosebleeds?

A

Local = idiopathic (85%), traumatic, foreign body, inflammatory e.g. rhinitis, neoplastic

Systemic = HTN, coagulopathies, vasculopathies

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45
Q

What is the management of epistaxis?

A

ABC (assess for shock )

First aid (pinch soft part of nose, head forward, spit out don’t swallow)

Examination (anterior / posterior bleed)?

Conservative management = cautery (silver nitrate / bipolar diathermy), topical adrenaline may help control bleeding before, nasal packing if cautery fails (anterior +/ posterior)

Surgical management = under GA ligate / embolise the following vessels (sphenopalatine, anterior ethmoid, external carotid (last resort)

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46
Q

What is a complication of epistaxis?

How can it be prevented?

A

Septal haematoma later causing erosion of septal cartilage and saddle nose deformity

Prevented = anterior rhinoscopy and palpation of bulging septum

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47
Q

When can nasal trauma occur?

A

Assault

Sports

RTA

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48
Q

What are some complications of nasal bone fractures?

A

Septal haematoma

CSF leak with associated skull base fracture (rare)

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49
Q

What is the management of nasal trauma?

A

ABC (epstaxis is normally self limiting)

Examine for septal haematoma

No X-ray required

If deviated then consider manipulation under anaesthetic within 2 weeks

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50
Q

Label the following:

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51
Q

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52
Q

Label the following:

A
53
Q

What is rhinosinusitis?

A

Inflammation of the nose and paranasal sinuses characterised by some of:

  • Nasal blockage / obstruction / congestion
  • Anterior or posterior nasal drip
  • Facial pressure
  • Reduction or loss of smell

AND

Endoscopic signs of polyps, micropurulent discharge, oedema in middle meatus OR CT changes e.g. mucosal changes within osteomeatal complex

54
Q

What is the difference between acute and chronic rhinosinusitis?

A

Acute = <12 weeks, complete resolution of symptoms (viral / non viral)

Chronic = > 12 weeks (divided as with nasal polyps or without)

55
Q

What causes viral ARS (common cold)?

A

Rhinovirus

Influenza virus with resolution of symptoms within 5 days

> 5 days = bacterial (strep pneumoniae, haemophilus influenzae, moraxella catarrhalis)

56
Q

What is the management of acute rhinosinusitis?

A

Analgesia if required

Nasal decongestants

If longer then 5 days = topical nasal steroids and oral abx

57
Q

Which factors predispose to chronic rhinosinusitis?

A

Allergy

Infections (e.g. with staph aureus and strep pneumonia)

Ciliary impairment e.g. in cystic fibrosis (nasal polyps present in 40% of patient with CF)

Anatomical abnormalities e.g. septal deviation and abnormal uncinate process

Immunocompromised

Aspirin hypersensitivity

Atmospheric irritants e.g. smoking, dust, fumes

Swimming / diving

58
Q

What are the investigations for rhinosinusitis?

A

Skin prick testing if allergy suspected

CT sinuses (if surgery planned / atypical features in hx and exam / not got at diagnosis as large number of asymptomatic patients have changes in the sinuses on CT scanning)

59
Q

What is the management of chronic rhinosinusitis?

A

Conservative = avoidance of allergens, nasal douching

Medical = antihistamines, topical nasal steroids, oral steroids (1 week) in severe cases, oral abx

Surgical = nasal polypectomy, functional endoscopic sinus surgery to improve ventilation, septoplasty

Generally no cure and treatment aims are symptom improvement

60
Q

What type of hypersensitivity reaction is allergic rhinitis?

Which allergens are associated?

A

IgE mediated type 1 (strongly associated with asthma)

Seasonal = hayfever

Perennial

Allergens = pollens, moulds, house dust mites and animal epithelia

61
Q

What are the investigations for allergic rhinitis?

A

Skin prick tests for specific allergens

RAST blood test (if SPT not possible)

62
Q

What is the treatment of allergic rhinitis?

A

Conservative = allergen avoidance, nasal douching

Medical = antihistamines, topical nasal steroids

Immunotherapy

63
Q

How does orbital abscess develop?

How does it present?

What is the treatment?

A

Direct spread of pus from the ethmoid sinus / thrombophlebitis of mucosal vessels

Presentation = pain, oedema of eyelids, proposed eye and reduced eye movements (risk of blindness)

Treatment = diagnosis with CT, IV abx, nasal decongestants, urgent surgical drainage of abscess

64
Q

What are the borders of the anterior and posterior triangles of the neck?

A

Anterior = midline of neck, anterior border of SCM, lower border of mandible

Posterior = posterior border of SCM, anterior edge of trapezius, middle third of clavicle

65
Q

Where does a retropharyngeal abscess occur?

A

Anterior to the prevertebral fascia and behind the pharynx (retropharyngeal space - extends to mediastinum)

66
Q

What are the features of retropharyngeal abscess?

A

Common in young children (after a URTI)

Ridgid neck - reluctance to move

Systemically unwell

Airway compromise

Dysphagia / odynophagia

Widening of retropharyngeal space on lateral X-ray

67
Q

What are the investigations for a retropharyngeal abscess?

A

CT neck

68
Q

What is the management of a retropharyngeal abscess?

A

Secure airway if concerned

IV abx

Surgery (incision and drainage)

69
Q

What is Ludwig’s Angina?

A

Infection of space between floor of mouth and mylohyoid (associated with dental infections)

70
Q

What are the features of Ludwig’s Angina?

A

Swelling of floor of mouth

Painful mouth

Protruding tongue

Airway compromise

Drooling

71
Q

What are the investigations for Ludwig’s Angina?

A

CT neck

OPG

72
Q

What is the management of Ludwig’s angina?

A

Secure airway if concerns

IV abx

Surgery to drain any collection

73
Q

Where do parapharyngeal absecesses occur?

What does this space contain?

How does it present?

A

Posterior-lateral to oropharynx and nasopharynx (divided by styloid process)

Contains carotid sheath

Presents as quinsy = febrile illness, odynophagia, trismus, reduced neck movement, swelling of neck around upper part of SCM

74
Q

What is the cause of epiglottitis?

A

Haemophilus influenzae (incidence had reduced with vaccine)

Seen in 2-6 year olds

75
Q

How does epiglottis present?

A

Stridor

Drooling

Pyrexia

76
Q

What is the management of epiglottitis?

A

Secure airway (do not examine as this can precipitate obstruction)

IV abx (after a couple of days extubate)

77
Q

What are the four areas of the pharynx and oral cavity?

A

Oral cavity = from lips to posterior soft palate

Nasopharynx = from base of skull down to soft palate (contains adenoids and eustacian tube opening)

Oropharynx = from soft palate down to superior border of epiglottitis (contains palatine tonsils, anterior and posterior tonsillar pillars)

Hypopharynx = from superior border of epiglottitis down to inferior border of cricoid cartilage

78
Q

What are the muscles of the pharynx?

A

4 circular muscles (no longitudinal, unlike rest of GI tract)

Superior, middle and inferior constrictors and cricopharyngeus

79
Q

Where do pharyngeal pouches form?

How do they present?

A

Killian’s dehiscence (between inferior constrictors and cricopharyngeus)

Presentation = dysphagia, delayed regurgitation of food, recurrent chest infections from aspirated food

80
Q

Which muscles cause elevation and depression of pharynx?

A

Stylopharyngeus

Salpingopharyngeus

Palatopharyngeus

81
Q

What is obstructive sleep apnoea? What are the common causes?

A

Complete obstruction of airway which requires patient to wake at night to alter position to open airway

Children = adenotonsillar hypertrophy

Adults = obesity

82
Q

What are the investigations for obstructive sleep apnoea?

A

BMI

TFTs (hypothyroidism)

CXR (obstructive lung disease)?

ECG (right ventricular failure)?

Sleep study

83
Q

What is the treatment of OSA?

A

Weight loss

CPAP (mainstay of treatment)

Mandibular positioning devices

Surgery (adenotonsillectomy in children)

84
Q

Which organisms can cause tonsillitis?

A

Bacterial = beta-haemoloytic strep, staphylococci, strep. pneumoniae

Viral = rhinovirus, adenovirus, Enterovirus

85
Q

What are the clinical features of tonsillitis?

A

Pyrexia

Dysphagia

Lymphadenopathy

Odynophagia

Trismus

Swollen tonsils (with/without exudates)

Otalgia (referred pain)

86
Q

What is the management of tonsillitis?

A

Analgesia

Antibiotics

Drainage of peritonsillar abscess

Tonsillectomy for recurrent

87
Q

What treatment should be avoided in tonsillitis?

What is the advice for patients with EBV?

A

Avoid amoxicillin as causes maculopapular rash in presence of EBV

EBV = avoid contact sports due to hepatosplenomegaly

88
Q

How do head and neck cancers present (excluding thyroid and salivary gland)?

A

Dysphonia (especially laryngeal = hoarseness)

Dysphagia

Dyspnoea - stridor from narrowing of airway

Neck mass

Pain from site of pathology

Nasal blockage / unilateral middle ear effusion = nasopharyngeal pathology

89
Q

What type of cancer is HNC?

A

Squamous cell carcinoma

90
Q

Who is typically affected by HNC?

A

Men (twice as likely)

91
Q

What are the risks factors for HNC?

A

Alcohol

Tobacco

Beetle nut chewing (oral cavity malignancy)

Chinese ethnic origin for nasopharyngeal malignancy

92
Q

How to investigate primary tumour site in H&N cancers?

A

Examine under anaesthetic: panendoscopy - for biopsy (histological diagnosis, tumour size and second primary)

CT neck

93
Q

How to investigate neck metastasis in H&N cancers?

A

US guided FNA (open biopsy can cause seeding of tumour - more useful for TB and lymphoma)

94
Q

How to look for distant mets in H&N cancers?

A

CT chest

95
Q

What are the management options for H&N cancers?

A

Palliation = reduce suffering / prolong life

Curative = RT / surgery (e.g. laryngectomy / neck dissection)

96
Q

Why do enlarged thyroid glands need investigating?

A

Hyperthyroidism (hyper functioning)

Neoplasm

Compression of airway

97
Q

What is the arterial supply to the thyroid?

A

Superior and inferior thyroid arteries

98
Q

What nerve is at risk during thyroid surgery?

A

Recurrent laryngeal nerves (supply muscles of larynx apart from cricothyroid and sensation below vocal cords)

Damage = hoarseness

99
Q

What are the investigations for an enlarged thyroid?

A

TFTs

US guided FNA (if diagnostic doubt then hemithyroidectomy)

100
Q

What are the possible histopathologies for enlarged thyroid?

A

Non-neoplastic = single nodule (colloid / cystic) or multinodular

Neoplasm = adenoma (benign), malignant (papillary adenoma / follicular carcinoma / etc.)

101
Q

What are the treatment options for enlarged thyroid glands?

A

Non-neoplastic = conservative, surgery (hemithyroidectomy to prevent need for thyroxine)

Neoplastic = adenomas (no treatment after diagnostic hemithyroidectomy) or surgery

102
Q

What are some complications for thyroid surgery?

A

Post op haemorrhage

Airway obstruction (due to haemorrhage / bilateral vocal cord palsy)

Vocal cord palsy

Hypocalcaemia

103
Q

Name the salivary glands?

A

Parotid

Submandibular

Sublingual

104
Q

What is a risk of parotid gland surgery?

A

Facial nerve palsy

105
Q

In which salivary glands are infection more common?

A

Submandibular gland

106
Q

Which infections can cause sialadenitis (infection of salivary gland)?

How does it present?

A

Viral = mumps, coxsackievirus, HIV

Bacterial = staphylococcal

Seen in dehydrated / immunocompromised

Present = foul taste and signs of infection

107
Q

What are investigations for sialolithiasis?

A

Ultrasound / sialogram (causes pain which is worse during meals)

108
Q

What is the management of sialolithiasis?

A

Conservative (most settle, analgesia, hydration)

Radiological removal

Surgery = removal of stones / salivary gland

109
Q

What are the complications of sialolithiasis?

A

Sialadenitis

Abscess formation

110
Q

How do differentiate thyroglossal cyst / goitre?

A

Cyst = moves up on tongue protrusion

Nodule = up on swallowing

111
Q

What is the course of the recurrent laryngeal nerve on the left and right?

A

Left = loops under aortic arch

Right = under right subclavian artery

112
Q

What would suggest low calcium?

A

Tingling around mouth and fingertips

If severe = muscle spasms

113
Q

What are the features of nasal polyps?

A

Nasal obstruction

Rhinorrhoea

Poor taste

114
Q

What are some associations of nasal polyps?

A

Asthma

Aspirin sensitivity

Infective sinusitis

CF

115
Q

What is the management of nasal polyps?

A

Topical steroids

116
Q

What is Ramsay Hunt syndrome?

A

Herpes Zoster oticus - reactivation of varicella zoster virus in geniculate ganglion of 7th CN

117
Q

What are the features of Ramsay Hunt syndrome?

A

Auricular pain

Facial nerve palsy

Vesicular rash around ear

Vertigo and tinnitus

118
Q

What is the management of Ramsay-Hunt syndrome?

A

Oral aciclovir and corticosteroids

119
Q

How does a branchial cyst present?

A

Mobile and cystic near SCM and pharynx (presents in early adulthood)

120
Q

When is a myringoplasty performed?

A

To repair a perforated tympanic membrane if it hasn’t repaired after 6-8 weeks

121
Q

What is chronic rhinosinusitis?

A

Inflammation of paranasal sinuses lasting 12 weeks or longer

122
Q

Which factors predispose to chronic rhinosinusitis?

A

Atopy

Septal deviation

Swimming

Smoking

123
Q

What are the features of chronic rhinosinusitis?

A

Facial pain - worse on bending forward

nasal discharge

nasal blocking - mouth breathing

post nasal drip - chronic cough

124
Q

What is the management of chronic rhinosinusitis?

A

Avoid allergen

Intranasal corticosteroids

Nasal irrigation with saline solution

125
Q

Which drugs can cause gingival hyperplasia?

A

Phenytoin

Cyclosporin

CCB (nifedipine)

126
Q

What are the causes of facial pain and how do they present?

A

Sinusitis = facial fullness, nasal discharge, pyrexia, post-nasal drip and cough

Trigeminal neuralgia = unilateral, shooting facial pain, triggered by light touch

Cluster headache = pain twice a day up to 2 hrs, up to 12 weeks, worse in one eye

Temporal arteritis = tender around temples, raised ESR

127
Q

What are some causes of tinnitus?

A

Ménière’s disease = hearing loss, vertigo, fullness

Otosclerosis = 20-40 years

Sudden onset sensorineural = (normally acoustic neuroma - hearing loss, vertigo, tinnitus, associated with neurofibromatosis)

Drugs = quinine, aspirin/NSAIDs, loop diuretics

128
Q

What is the treatment for sudden SN hearing loss?

A

Oral prednisolone 7 days

129
Q

When to suspect mumps?

A

Bilateral painful parotid enlargement

Orchitis

Pancreatitis

Reduced hearing

Meningoencephalitis

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