ENT Flashcards
1
Q
Describe the sensory innervation to the pinna?
A
- Upper lateral surface – CN V3 – Auriculotemporal nerve.
- Lower lateral surface and medial surface – C3 – Greater auricular nerve.
- Superior medial surface – C2/C3 – Lesser occipital nerve.
- Auricular branch of vagus – External Auditory Meatus
2
Q
How are lacerations managed?
A
- Mx: Simple primary closure of the skin with sutures after adequate cleaning
- Ensure that any exposed cartilage is covered with skin: if there is significant skin loss where primary closure will not be possible an opinion from a plastic reconstructive surgeon may be required.
3
Q
How are bites mx;d?
A
- Significant risk of infection from skin commensals, or oral commensals from the offending creature/person.
- Take an appropriate history to ascertain likely organisms involved in potential infection, and the wound must be left open.
- Mx: Wound irrigation and antibiotics.
4
Q
How are pinna haematomas mx’d
A
- Mx: Urgent drainage and pressure dressing application to prevent re-accumulation.
5
Q
What are tympanic membrane perforations and how are they mxd?
A
- Can be perforated by direct or indirect trauma, otitis media.
- SX: PAIN, conductive deafness
- Mx: Most perforations will heal by themselves - “watch and wait,” approach with the patients following water precautions
- If perforation does not heal > 6months – consider surgery:
- Myringoplasty: to repair the tympanic membrane if the perforation is causing problems.
6
Q
Describe haemotympanum trauma + its mx’d
A
- Ax: temporal bone fracture
- Examination: Can be seen through the tympanic membrane and is associated with a conductive hearing loss
- Mx: Conservative: it will settle with time.
- Pt should be followed up to ensure that there is no residual hearing loss from damage to the ossicles.
7
Q
How is ear wax mxd
A
- Sx: pain, conductive hearing loss, tinnitus, vertigo
- Mx: olive oil, sodium bicarbonate 5%. almond oil
- Treatment should not be given if a perforation is suspected or the patient has grommets.
- Primary care: syringing/ irrigation
8
Q
How does Otitis Externa present?
A
-
Presentation: painful discharging ear, itchiness, hearing muffled from the discharge present in the ear canal.
- Otoscopy: red, swollen, or eczematous canal
9
Q
What is malignant OE?
A
- Aggressive infection mainly seen in diabetics or immunocompromised patients
- Infection spreads from soft tissue of the ear canal into the bone (osteomyelitis)
- Significant mortality rate
- Sx:
- Chronic ear discharge
- Severe ear pain
- Cranial nerve palsies (most commonly CNVII).
10
Q
How is otitis externa mxd?
A
-
Topical abx (ciprofloxacin) +/- topical steroid
- Severe: PO flucloxacillin
- Ix: swabs
- Other:
- Microsuction of pus/debris
- Wick with aluminium acetate: help hold the canal open for topical treatment
- Mild: topical hydrocortisone + ear calm spray
11
Q
What is necrotizing OE?
A
- Aggresive + life threatening -> temporal bone destruction -> base of skull osteomyelitis
- Pt: otorrhea, severe otalgia, granulations in the floor of the EAC
- ? CN6+7 palsies as disease progresses
12
Q
How is OE mxd?
A
- Ix: swabs, MCS, biopsy of EAC to exclude SCC, CT scan
- Mx: topical abx (ciprofloxacin) +/- topical steroid
13
Q
What is acute otitis media?
A
- Acute otitis media (AOM) is an infection of the middle ear.
- Epithelium lining the middle ear is respiratory epithelium: pseudostratified columnar epithelium – is regarded as a continuation of the upper respiratory tract, and is therefore susceptible to a similar variety of pathogens.
- Common in childhood and is related to eustachian tube dysfunction.
- Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella species.
14
Q
How does acute otitis media present?
A
- Ear pain - in young children this may be evident by ear pulling.
- Discharge: tympanic membrane may rupture with the pus from the middle ear discharging into the ear canal.
- Fever
15
Q
How is acute OM mxd?
A
- Conservative: 24-48h settles on its own. Watch and wait
- Immediate abx prescription: PO amoxicillin 2nd: erythromycin. Give if:
- Immunocompromised
- Bilateral AOM <2 yo
- Perforation
- Systemically unwell
- Surgery: grommet insertion
16
Q
What is the diagnostic criteria of AOM?
A
- Acute sx onset: otalgia/ ear tugging
- Middle ear effusion
- Inflammation of the tympanic membrane
17
Q
How does a cholesteotoma arise? What are its complications?
A
- Pathophysiology: acquired – chronic –ve middle ear pressure, from Eustachian tube dysfunction -> retraction pocket
-
Complications: destruction of ossicles, semicircular canals (vertigo) and cochlea (sensorineural hearing loss)
- Facial nerve palsies
- Erosion into intracranial cavity: meningitis, intracranial abscesses and sinus thrombosis
- RFs: acute OM, Eustachian tube dysfunction, and prior otological surgery
18
Q
How does cholesteotoma appear on otoscopy?
A
- Pearly, keratinized, or waxy mass in the attic region is seen on otoscopy
- Atic crust
19
Q
What are the ix’s and mx for cholesteotoma?
A
- Ix: otoscopy, PTA, CT scan of petrous part of temporal bone
- Mx:
- Surgery: mastoidectomy – cholesteotoma removed and mastoid cleaned out
- Ossicles reconstruction depending on the extent of damage
20
Q
What is otitis media with effusion?
A
- Fluid is present in the middle ear with an intact tympanic membrane
- Related to eustachian tube dysfunction.
- Children
- Adults: (especially unilateral) : v important to look at the post nasal space as tumours in this area can cause eustachian tube dysfunction -> OME
- Not painful but the middle ear may become infected which will lead to an acute otitis media which is painful.
21
Q
What are some the RFs for glue ear?
A
- Bottle fed, Paternal smoking
- Atopy (e.g eczema, asthma
- Genetic disorders/ Mucociliary disorders, CF, PCD
- Craniofacial disorders e.g. DS
22
Q
What are some of the clinical fx of otitis media with effusion (glue ear)?
A
- On otoscopy: Bulging retracted tympanic membrane which can appear dull, grey or yellow
- Loss of light reflex ? bubble
- CHL-> can cause speech/ developmental delay
- Pressure in ear
- Sometimes: disequilibrium + vertigo
23
Q
How is otitis media with effusion ixd and mxd?
A
Ix
- Tympanogram: Flat (Type B) Tracing with normal canal volume
- Pure tone audiogram: CHL
- Sometimes FNE
Mx
- Conservative – most cases settle within 3 months - Hearing aid
-
Surgery - for prolonged hearing loss causing significant problems
- Myringotomy +/- Grommets (ventilation tubes) +/- Adenoidectomy
24
Q
What is otosclerosis?
A
- Cause: genetic and environmental
- Genetic: In families - autosomal dominant transmission.
- Mature bone is gradually replaced with woven bone
- Sx develop as the stapes footplate becomes fixed to the oval window.
- Causes bilateral hearing loss
25
Q
Describe the presentation of otosclerosis?
A
- 2x F>M
- Progressive hearing loss (bilateral), tinnitus, improved hearing in noisy surroundings during early stages of disease
- Family History
26
Q
What examination and ixs are used for otosclerosis?
A
Examination: Most commonly normal
- Rarely pink hue to the tympanic membrane – Schwartze’s sign
Investigations
- Tympanogram - Normal type A trace
- PTA - Conductive hearing loss: characteristic “Carhart notch” at 2kHz
27
Q
What are the central and peripheral causes of vertigo?
A
- Central causes: Stroke,Migraine, Neoplasms, Demyelination eg. MS, Drugs
- Peripheral causes: BPPV, Ménière’s disease, Vestibular Neuronitis
28
Q
What is BPPV + its pathophysiology?
A
- Vertigo occurring with particular head movements, which is benign in nature, and lasts a short amount of time, typically seconds
- Pathophysiology: otoliths (crystals) in the semicircular canals (most commonly posterior) causing abnormal stimulation of the hair cells giving a hallucination of movement i.e. vertigo
29
Q
How is BPPV dx and mxd?
A
- Diagnosis: Dix-Hallpike test - latency rotary nystagmus which is fatigueable with a latency of onset of 5 to 10 seconds
- Mx: Epley manoeuvre – move pt head into 4 sequential positions resting for 30 seconds betweeb movements. Aim to reposition the ocotonia away from posterior canals
30
Q
What are the fx of menieres?
A
- Tinnitus in affected ear
- Episodic vertigo: minutes to hours. N+V
- SNHL
- Aural fullness
- Nystagmus, +ve Romberg test
- Episodes last minutes to hours
- Sx unilateral -> bilateral sx
31
Q
How is Menieres disease mxd
A
- Mx: ENT referral, inform DVLA
- Medical
- Acute attacks: procloperazine
- Prophylactic: betahistine and vestibular relaxation exercises
- Medical
32
Q
What is vestibular labrynthitis?
A
- Inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs.
- Can be viral, bacterial or associated with systemic diseases. Viral labyrinthitis is the most common form of labyrinthitis.
33
Q
What are the key differences between vestibular neuritis + labrynthitis?
A
- Vestibular neuritis: defines cases in which only the vestibular nerve is involved, hence there is no hearing impairment
- Labyrinthitis: when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment
34
Q
How does Labyrinthitis present?
A
- Vertigo: not triggered by movement but exacerbated by movement
- N+V
- Hearing loss: may be unilateral or bilateral, with varying severity
- Tinnitus
- Preceding or concurrent symptoms of URTI
35
Q
What are the signs of labrynthitis?
A
- Spontaneous unidirectional horizontal nystagmus towards the unaffected side
- SNHL: shown by Rinne’s test and Weber test
- Abnormal head impulse test: signifies an impaired vestibulo-ocular reflex
- Gait disturbance: the patient may fall towards the affected side
36
Q
How is viral labrynthitis mxd
A
- Episodes are usually self-limiting
- Prochlorperazine or antihistamines may help reduce the sensation of dizziness
37
Q
What are some the features of vestibular neuronitis?
A
- Recurrent vertigo attacks lasting hours or days
- N+V may be present
- Horizontal nystagmus is usually present
- Ho hearing loss or tinnitus
38
Q
How is vestibular neuronitis mxd?
A
- 1st: Vestibular rehabilitation exercises (chronic sx)
- Acute: Buccal or IM prochlorperazine
- Short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases
39
Q
How is sudden onset SNHL ixd + mxd?
A
- Ix: tuning fork tests + PTA – to work out if conductive or sensorineural
- MRI scan - to exclude lesion along central auditory pathway. e.g. acoustic neuroma
Mx
- High dose steroids – normally orally but can be injected into middle ear
- Anti-virals
- Other treatments are used e.g. hyperbaric oxygen, carbogen but are not widely practiced
- Nose
40
Q
What are the fx of ramsay hunt?
How is it mxd?
A
- 1st: auricular pain
- Facial nerve palsy
- Vesicular rash around the ear
- Other features: vertigo + tinnitus
- Mx: oral aciclovir + corticosteroids
41
Q
What are the causes of epistaxis?
A
- Local
- Idiopathic – 85%
- Traumatic
- Iatrogenic
- Foreign Body
- Inflammatory – Rhinitis, Polyps
- Neoplastic
42
Q
How is epistaxis mxd?
A
Management
- ABC
- Pinch soft part of nose for up to 10 minutes x 2
- Ask patient to breath through mouth and sit with head forward
- Spit out (not swallow) any blood in mouth
- Put ice pack on the dorsum of the nose
- Examination: locate the source of the bleeding (A/p?)
Conservative
- Adrenaline soaked gauze
-
(+/- Topical adrenaline) Cautery – silver nitrate / bipolar diathermy
- Risks: perforation so avoid cauterising large areas on both sides f the sepstum. Refer to ENT if you cant see the vleeding point. Avoid if there is active bleeding
- Anterior bleed – with anterior rhinoscopy – easier to treat
- Posterior bleed – with rigid endoscope
-
2nd line: Nasal packing if cautery fails to control bleeding
- 1st: anterior pack- 10cm long
- 2nd: If continues bleeding into oropharynx anterior & posterior pack
- Consider post natal pack
Surgical/Radiological
- Surgical artery ligation:
- Sphenopalatine
- External carotid (last resort)
- Risks: stroke – if there is communication between the ICA and ECA
43
Q
How is a nasal septum haematoma mxd?
A
- ABC – epistaxis normally-self limiting
- Examine for septal haematoma
- No XR required
- If deviated nose consider Manipulation under anaesthetic (LA/GA) within 2 weeks of injury
- IVAbx
44
Q
What are the fx of nasal septum haematomas?
A
- Hx: minor trauma
- Sensation of nasal obstruction is the most common symptom
- Pain and rhinorrhoea are also seen
- Examination: bilateral, red swelling arising from the nasal septum. Boggy .
45
Q
What are the different sites of draining for paranasal sinuses?
A
46
Q
How does rhinosinusitis present?
A
- Nasal blockage/obstruction/congestion/
- Nasal discharge
- Post nasal-drip (can produce a chronic cough)
- +/- facial pain/pressure
- +/- reduction or loss of smell
47
Q
How can rhinosinusitis be ixd?
A
- FNE - Polyps, mucopurulent discharge, or oedema in middle meatus
- CT scan - Mucosal changes within the osteomeatal complex, or sinuses
48
Q
How is chronic vs acute rhinosinusitis described?
A
- Acute: < 12 weeks, complete resolution of symptoms.
- Viral (common cold): Causes: Rhinovirus, and Influenza virus
- Usually resolution of symptoms within 5 days.
- Non viral ARS: persistence of SX symptoms >5 days
- Causes: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
- Allergy and ciliary impairment can predispose to ARS
- Viral (common cold): Causes: Rhinovirus, and Influenza virus
49
Q
How is ACUTE rhinosinusitis mxd?
A
- analgesia, nasal saline irrigation, nasal decongestant (rebound hypertrophy if overused)
2. Symptoms > 10 days: intranasal corticosteroids (mometasone)
- If severe: oral abx broad spectrum
50
Q
What are the sx of allergic rhinitis?
A
- sneezing
- bilateral nasal obstruction
- clear nasal discharge
- post-nasal drip
- nasal pruritus
51
Q
How is CHRONIC RHINOSINUSITIS MXD?
A
Mx:
- Avoid triggers, stop smoking, practice good dental hygiene
- Nasal irrigation with saline
- Intranasal corticosteroids for max 3 months
- Refer to ENT
52
Q
What are the different types of allergic rhinitis?
A
- seasonal: symptoms occur around the same time every year.
- perennial: symptoms occur throughout the year
- occupational: symptoms follow exposure to particular allergens within the work place
53
Q
How is allergic rhinitis mxd?
A
- Allergen avoidance
- Mild: 1st: oral or intranasal antihistamines
- Moderate: intranasal corticosteroids (beclometosone)
- Consider: topical nasal decongestants (e.g. oxymetazoline). Do not use for prolonged periods. SE: tachyphylaxis: increasing doses are required to achieve the same effect; rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) can occur upon withdrawal
54
Q
What are the sx of nasal polyps?
A
- nasal obstruction
- rhinorrhoea, sneezing
- poor sense of taste and smell
55
Q
How are nasal polyps ixd?
A
- Skin prick tests if allergy suspected
- CT Sinuses: Needed if surgery planned
- Biopsy + histology: Unilateral polyps
56
Q
How are nasal polyps mxd?
A
1. oral prednisolone – 5 days
2. Intranasal steroid drops 4 weeks
3. Intranasal steroid spray until further review
4. Surgery – FESS (polypectomy) improve ventilation/drainage of sinuses
Further surgery:
- Nasal polypectomy – high rate of recurrence
- Septoplasty: to improve nasal airways and reduction of inferior turbinates may be considered.
57
Q
How is pre orbital cellulitis different from orbital cellulitis?
A
- Presentation
- Redness and swelling around the eye
- Severe ocular pain
- Visual disturbance
- Proptosis
- Ophthalmoplegia/pain with eye movements
- Eyelid oedema and ptosis
- Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)
Differentiating orbital from preseptal cellulitis
- Reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis
58
Q
How is orbital cellulitis mxd?
A
- Mx: IV abx (ceftriaxone and metronidazole) nasal decongestants
- Surgery: surgical drainage of any abscess
59
Q
What are the red flag sx of deep neck space infections?
A
- Sore throat in the absence of normal oropharyngeal examination
- Severe neck pain and stiffness
- Signs of airway compromise: stridor, dyspnoea, drooling or dysphonia
60
Q
What are the clinical fx of a retropharyngeal abscess:
A
- Young children after URTI
- Neck help in a rigid ad upright position with a reluctance to move
- Systemically unwell
- Airway compromise
- Dysphagia and odynophagia
- Widening of the retropharyngeal space on lateral X ray
61
Q
How are retropharyngeal abscesses Ixd + mxd
A
Ix: Gold standard: CT Neck with IV contrast
- Plain film lateral view neck radiographs can show widening of retropharyngeal tissue
- Bloods: CRP and cultures
Mx: secure airway, broIV abx
Surgery – incision and drainage - can be done through mouth or neck with drains left In
62
Q
What is Ludwigs Angina? How does it present?
A
Infection of the space between the floor of the mouth and mylohyoid – most commonly associated with dental infection
Clinical fx:
- Swelling of the floor of the mouth
- Painful mouth
- Protruding tongue
- Airway compromise
- Drooling
63
Q
What is the hx + presentation of someone with Parapharyngeal Abscesses?
A
- Parapharyngeal space is a potential space postero lateral to the oropharynx and nasopharynx divided by the styloid process
- Present similar to peritonsillar abscess oe quinsy
- Hx: febrile illness, odonyphagia, trismus, reduced neck movement
- Swelling around the upper part of the SCM
64
Q
How are pharyngeal abscesses ixd + mxd?
A
- Ix: CT neck with IV contrast – urgent
- Plain film lateral view neck radiographs
- Mx
- Secure airway
- IV abx: broad spectrum abx
- Surgical drainage
65
Q
What muscles form the pharynx?
A
- Circular layer: formed in principle by muscles: Superior, middle, and inferior constrictors (vagus nerve), and cricopharyngeus
- Longitudinal muscles: Three pairs of muscles cause elevation and depression of the pharynx – stylopharyngeus (vagus), salpingopharyngeus (from glossopharyngeal), and palatopharyngeus (vagus)
66
Q
What is Killians dehiscence?
A
- Killian’s dehiscence: exists between inferior constrictor and cricopharyngeus; a deficient of muscle at which herniation may occur.
- Site of pharyngeal pouch formation.
67
Q
What are some of the sx of OSA + pre disposing factors?
A
- daytime somnolence
- compensated respiratory acidosis
- hypertension
- obesity
- macroglossia: acromegaly, hypothyroidism, amyloidosis
- large tonsils
- Marfan’s syndrome
68
Q
What ix are used for OSA?
A
- Epsworth sleeping scale (>9)
- BMI: TFT – ?Hypothyroidism; CXR – ?Signs of obstructive lung disease; ECG – ?Signs of right ventricular failure
-
Sleep study.
- Types:
- Overnight oximetry alone
- Limited sleep study – oximetry, snoring, body movement, heart rate, oronasal flow, chest/abdominal movements, leg movements – usual study of choice
- Full polysomnography – limited study plus EEG, EMG
- Types:
69
Q
How is OSA mxd
A
- Conservative: lifestyle changes and weight loss, reduce evening alcohol intake, sleep decubitus
- Driving: do NOT drive while sleepy; stop and have a nap. Notify DVLA on diagnosis and doctor can advise drivers to stop altogether (e.g. HGV drivers)
- Medical: CPAP, Mandibular positioning devices
- Surgical:
- Children – adenoidectomy (rarely an option in adult)
- Adults (if significant OSA): consider gastroplasty/bypass, and rarely tracheostomy
70
Q
How is Bell’s Palsy mxd?
A
- Oral prednisolone within 72 hours of onset of Bell’s pals
- UpToDate recommends the addition of antivirals for severe facial palsy
- Eye care - artificial tears and eye lubricants
- Follow-up - refer to ENT if no sign of improvement after 3 weeks, refer urgently to ENT
- Referral to plastic surgery may be appropriate for patients with more long-standing weakness e.g. several months
71
Q
How is a fractures nose mxd?
A
Ix: cartilaginous injury will not show and radiographs do not alter Mx
Mx:
- Reduction under GA with post op splinting
- Exclude septal haematoma
- Re-examine after 1 week
72
Q
What are septal haematomas and how are they mxd?
A
Septal necrosis, haematoma between septal cartilage + overlying perichondrium
Bilateral swelling from nasal septum
If untreated – ‘saddle nose’ deformity
Mx: surgical drainage + IV abx
