ENT Flashcards
Which antibiotic when given for pharyngitis of an EBV origin causes a pathogonomic rash?
Amoxicillin
Centor criteria:
The presence of 3+/4 suggests infection with
- tonsillar exudate
- tender ant. cervical lymphadenopathy
- history of fever
- absence of cough
Streptococcus
What is Lemierre syndrome?
Acute septicaemia and jugular vein thrombosis secondary to infection with
Fusobacterium species + septic emboli (to lungs, bone, muscle, kidney, liver)
Don’t do tonsillectomy unless your sure:
Give 3 points
- recurrent sore throat is due to tonsillitis
- the episodes are disabling and prevent normal functioning
- > 7 clinically signif adequately treated sore throats in last year
- > 5 in each of last 2 years or
- > 3 in each of last 3 years
- OBSTRUCTIVE SLEEP APNEA
What is laryngomalacia (common cause of chronic stridor in children)?
When arytenoids/epiglottis are soft and floppy so as baby breathes they fall in and block the airway
What type of tumour can cause stridor? Related to which virus?
Laryngeal papillomata HPV related
What condition is the most common cause of stridor and what is the most common cause?
Croup aka laryngotracheobronchitis
Parainflueza virus
What is the treatment for mod/severe laryngotracheobronchitis/croup?
single dose dexamethasone 0.15mg/kg (or presnis 1-2mg/kg)
Admit if severe
What is the treatment for mild laryngotracheobronchitis/croup?
reassure
usually self-limiting ~48hrs
In an anti-vax adult presenting with a severe sore throat and painful swallowing what emergency must you consider?
Acute epiglottitis (Haemophilus Influenzae
85% cases of laryngomalacia resolve by 2yrs, what signs warrent further investigation?
- failure to thrive
- cyanotic episodes
Which surgery is done in severe cases of laryngomalacia?
Aryepiglottoplasty
How should you initially manage acute epiglottitis?
- keep pt upright
- don’t examine throat
- don’t distress pt
- summon anesthetist and ENT surgeon
How do you diagnose suspected acute epiglottitis? What should be open and ready in case needed?
- laryngoscopy with pt intubated
- have tracheostomy set and tube prepared
How is acute epiglottitis treated? Give 2
- dexamethasone
- antibiotics
Laryngeal paralysis can be congenital and may affect one or both sides. Signs include:
- hoarse, breathy cry
- feeding difficulties + aspiration
Bilateral Laryngeal paralysis in a baby that is agitated can lead to ___ requiring treatment by___
- respiratory distress
- urgent airway intervention
- +/- tracheotomy, surgery
Acute airway obstruction in adults 3 key initial management aspects?
-give 02/heliox -reduces work of breathing
-nebulised adrenaline 1ml of 1:1000 with 1ml saline
-monitor obs closely
call on call ENT reg and anaesthetist
-take collateral hx
Acute airway obstruction in adults, 3 options for treatment, in order of escalation?
- Endotracheal intubation
- Emergency needle cricothyroidotomy
- Surgical Cricothroidotomy
What does an Emergency needle cricothyroidotomy do?
- works as a temporary measure until tracheostomy can be done
- it oxygenates but doesn’t ventilate so CO2 builds up
- lasts only up to 45mins
After how long should you investigate a hoarse voice? What red flag can it be a presentation of? Especially in__?
- 6weeks
- laryngeal carcinoma
- smokers
With a hoarse voice, what screening questions should you ask?
- GORD
- dysphagia
- smoking
- stress
- singing and shouting
What investigations can be done to assess larynx in pt presenting with hoarse voice?
- laryngoscopy (assess cord mobility and mucosa)
- video flex or rigid endoscopy with stroboscopy
5 ddx of hoarse voice
- Laryngeal cancer
- vocal cord palsy
- laryngitis
- reflux laryngitis
- Reinke’s oedema
- vocal cord nodules
Laryngitis is often self-limiting and viral but what can it be secondary to?
- staph/strep bacterial infection
- GORD
- autoimmune e.g. RA disease
What are the symptoms of laryngitis?
- hypopharngeal pain
- dysphagia
- pain on phonation
- hoarseness
- fever
Reflux laryngitis is chronic laryngeal symptoms associated w GORD, suggest 3 treatments:
- PPI
- diet/lifestyle change/ weight loss
- elevate head of bed
- surgical fundoplication
What is Reinke’s oedema? In whom is it commonly seen?
- chronic cord inflamm. from smoking/voice abuse -> gelatinous fusiform enlargement of cords
- hypothyroid, elderly female smokers
The deep gruff voice from Reinke’s oedema can be treated by…
- quitting smoking
- SALT
- laser therapy ()
Where do vocal cord nodules occur (often due to voice abuse –> husky voice)?
- junction of anterior 1/3rd and posterior 2/3rds of cord
- this is the middle of the membranous cords (posterior is cartilage)
Vocal cord nodule treatments:
- speech therapy (early)
- surgical excision
Name some Vocal cord nodule causes ddx..
- hyperkeratosis 2* to alcohol, smoking, pollution)
- leukoplakia
- granulomata
- papillomata (from HPV)
- polyps, cysts
- high dose ICS inhalers
RLN supplies the ___ muscles of the larynx except ____ which is supplied by the ___
- intrinsic
- cricothryoid
- external branch of superior laryngeal nerve
RLN is responsible for _ and _ of the vocal cords.
It arises from the __ nerve.
abduction and adduction
vagus
Signs of laryngeal nerve palsy:
- weak “breathy” voice + weak cough
- repeated coughing/aspiration
- exertional dyspnoea
Explain why you can get exertional dyspnoea with a laryngeal nerve palsy:
- at rest contralat. cord can compensate by increased abduction
- on exertion narrow glottis reduces air flow
State the stepwise investigations into a laryngeal nerve palsy:
- CXR (if no recent surgery history)
- if normal do CT
- +/- US thyroid
- +/- OGD
For non-malignant laryngeal nerve palsies, treatments include:
- injections/throplasty to support compensating cord
- reinnervation e.g. ansa-cervicallis to RLN
Name 3 speech articulation disorders that can result in a hoarse voice?
- spasmodic dysphonia
- muscle tension dysphonia
- functional speech disorders in children
What is spasmodic dysphonia?
A focal laryngeal dystonia of unknown cause, involuntary spasms of larynx cause strained strangled breaks in connected speech
How can spasmodic dysphonia treated?
Botox injections
Muscle tension dysphonia is a functional disorder, what do patients complain of?
Husky, hoarse voice that tires easily
Globus symptoms
Frequent clearing of throat
What is Muscle tension dysphonia associated with?
- voice missuse
- psychological stress
What are the 2 most common causes of a RLN palsy? other causes ?
- cancer (30%)
- iatrogenic (surgery-25%)
- CNS: polio, syringomyleia
- TB
- aortic aneurysm
What are the 4 stages in the natural history of acute otitis media?
- pre-suppuration
- suppuration
- tubal occlusion
- resolution
What is the treatment for AOM? Generally what would warrant abx? Which abx?
- analgesia and anti-pyretics
- if persists >4days
- Amoxicillin/Clarithromycin
In what groups/presentations of AOM should Abx always be given?
<2yrss old
bilateral
Perforated
If mastoiditis arises as a complication of AOM, what should you do? (3)
- urgent ENT review, admit
- IV Abx
- Myringotomy +/-grommets
What is the commonest cause of acquired hearing loss in children?
-glue ear: chronic middle ear inflammation with accumulation of fluid but no sign of infection
How does the ear look on exam in a child with glue ear?
- dull and retracted tympanic membrane
- loss of light cone
- air bubbles/fluid level behind TM
Glue ear that is unilateral in adults should be investigated for what? with? esp in whom?
- nasopharyngeal cancer
- nasoendoscopy
- chinese and >40yrs
What is suppurative otitis media? how does it present? for how long? What kind of hearing loss?
- chronic inflamm of middle ear and mastoid cavity
- painless otorrhoea >2weeks and conductive hearing loss
What is the treatment for suppurative otitis media?
ENT referral
Aural toilet
Topical abx
+/-myringoplasty/tympanoplasty
What is a cholesteatoma? What type of epithelium? Where most common?
-expanding destructive growth of keratinised squamous epithelium in middle ear especially the “attic”
How does cholesteatoma erode bone?
- local expansion
- releasing enzymes e.g. alkaline phosphatase
Symptoms of cholesteatoma:
ottorhoea, conductive hearing loss, ostitis
If cholesteatoma is untreated, what complications can arise?
- facial nerve palsy
- labyrinthitis
- meningitis
- extra/sub-dural abscess
Management of cholesteatoma?
-always surgery:: mastoidectomy
Name3+ RFs for otitis externa:
- cotton bud use
- swimming
- hot climate
- immunocompromised
- diabetes
- eczema
How may otitis externa present?
severe otalgia
discharge, aural fullness
decreased hearing
What is the management for otitis externa? Which abx?
- swab for MC&C
- microsuction
- pope wick insertion
- steroid drops
- abx drops: ciprofloxacin/ofloxacin
Name 2 complications of untreated otitis externa:
- perichrondritis
- pinna cellulitis
What is Necrotising Otitis Externa?
-OE with bone involved (osteomyelitis of ear canal and temporal bone)
How may Necrotising Otitis Externa present?
-severe otalgia +/- CN palsies
What is the most common organism causing Necrotising Otitis Externa?
Pseudomonas
Management for Necrotising Otitis Externa? Which abx? Dose is 500mg BD
-admit for IV abx
-Piperacillin/Tazebactam for 2 weeks
-or Ciprofloxacin for 6 weeks
then do microsuction
Name 5 causes of conductive hearing loss:
- wax
- infection
- trauma -> e.g. stenosis, ext damage
- foreign body
- absence of ossicles (congenital)
- ossisclerosis (fixation)
Name 3 causes of sensioneural hearing loss?
- age related presbycusis
- tumour of CNVII, VIII
- tumour at CPA e.g. acoustic neuroma
- ototoxic drugs
- cochlear pathology
Name 3 ototoxic drug:
Vancomycin, loop diuretics-ferosemide, quinine, cisplatin,
What is the definition of SSNHL: sudden sensorineural hearing loss? dB loss? How many frequencies? Time frame of loss?
- 30dB+ sensorineural loss over at least 3+ contiguous audiometric frequencies
- occurring in less than 3 days
SSNHL management? Note only 60% recover.
- high dose steroids (60mg prednisolone/day for a week) or dexameth injections intra-tympanically
- do a scan to rule out causes
98% of acute sinusitis is of viral cause post-URTI, how should it be treated? When should abx be considered, which ones?
- analgesia, nasal douches and decongestant
- if symptoms >1week give amoxicillin/doxycycline oral
What is a possible cause of recurrent acute sinusitis that can be ruled out via a referral to ENT with imaging? If present what is mainstay of treatment?
A polyp in the middle meatus
Intranasal or oral steroids
you get referred pain to the ear with tonsillitis because the tonsillar fossa is supplied by the ___, and pain is referred along the __ branch of this nerve
Glossopharyngeal nerve (CN IX) Tympanic branch of CN IX
Name 3 viral causes of tonsillitis and 3 bacterial:
Viral: rhinovirus, parainfluenza, adenovirus, EBV
Bacterial: strep pneumo, strep pyogenes, staph aureus, haemophilus influenza
What group of organisms does streptococcus pyogenes belong to?
Group A B-haemolytid Streptococcus (GABHS)
Name 2 of the criteria for admission in tonsillitis?
- unable to eat/drink
- peritonsillar abscess
If 3+ centor criteria present what Abx should be administered (2)
- benzylpenicillin
- metronidazole
Alcohol and contact sports advice following EBV infection?
-avoid alcohol for 2 months and contact sports for 6 weeks
Quinsy is a collection of pus between the __
tonsillar capsule and the pharyngeal constrictor
What is trismus?
Jaw muscle spasm so the mouth is tightly closed
What is the management of Quinsy (3)
- LA incision and drainage/aspiration of puss
- IV dexamethasone (8mg)
- IV benzylpenicillin + metronidazole
Management of post-tonsillectomy bleed:
- ABCDE, admit and monitor
- crossmatch 2 units
- transexamic acid
- H202 mouthwash
- adrenaline soaked guaze
OSA is diagnosed when there are more than __ episodes/hour, when the ___ muscles relax during sleep causing upper airway __
- 5
- pharyngeal
- obstruction
name 2 causes of paediatric OSA and its treatment
- adenotonsillar hypertrophy
- craniofacial or neuromuscular abnormalities
- adenotonsillectomy
Gold standard rx for adult OSA is __ but not well tolerated, next best is.. :)
- CPAP
- lifestyle change (weight, alcohol, stop sedative meds.)
What ear trauma can cause a cauliflower ear? How is it prevented?
- pinna haematoma
- not drained cartilage necrosis -> deformity
- must be drained so fluid doesn’t build up
In Bell’s Palsy what motor neurone is affected and forehead condition? What must be protected? to avoid?
- lower MN
- forehead droops too
- protect eye w drops and bandage
- to avoid exposure keratitis
What is Ramsey Hunt S?
-Bell’s palsy with vesicles in Pinna from shingles
What 5 vessels make up the Little’s area of Epistaxis
- ant. ethmoidal
- post. ethmoidal
- SPHENOPALANTINE
- greater palatine
- superior labial
From where does the sphenopalatine artery of epistaxis originate from?
-maxillary branch of the external carotid artery
Epistaxis management: in escalation -what should be examined, for what -cauterise w ? -Which abx prophylaxis Last step?
ABC, apply pressure head down
- ice to neck
- examine oropharynx & suction visible clots
- wide bore cannulae, fluid resus to maintain BP#
- packing or cauterise w silver nitrate
- coamoxiclav
- ligate artery
Why is septal haematoma an emergency? What is the risk?
Saddle deformity from collapse without I&D because septum gets supply from mucopericardium only -> necrosis
Why is removal of a nasal foreign body urgent?
Risk of aspiration
Thumb sign on a lateral x-ray in a child with stridor and odynophagia is suggestive of?
Acute epiglottitis
Name 3+ non-malignant, non-neurological causes of dysphasia
- benign structures
- pharyngeal pouch
- achalasia
- systemic sclerosis
- oesophagitis
- IDA
Name 3 neurological causes of dysphagia
- bulbar palsy
- lateral medullary syndrome
- myasthenia gravis
- syringomyelia
If pt with dysphagia finds it difficult to make the swallowing movement and has cough on swallowing what dx do you suspect?
Bulbar palsy
If pts neck bulges and gurgles on drinking, with regurgitated food what is the likely dx?
Pharyngeal pouch
Name 4 associations of HNSSC (head and neck SCC)
- alcohol
- HPV (oropharyngeal)
- smoking
- vitamin A & C defiiciency
- GORD
How is suspected H&N SCC investigated (3)
- fibreoptic endoscopy
- FNA/biopsy of masses
- CT or MRI to stage neck nodes
A smoker with painful persistent ulcers, white patched on mucosa and otalgia is concerning for…
Oral cavity/tongue cancer
What is the most common cause of oropharyngeal cancer?
HPV especially type 16
What are the 3 forms of voice restoration available post-laryngectomy?
- oseophageal speech
- trans-oesophageal puncture
- artificial larynx (servox)
The facial nerve arises from the __ exiting the brianstem at the ___,it passess through the ____ before emerging from the __ foramen to pass into the ___.
- pons
- pontomedullary junction
- middle ear
- stylomastoid foramen
- parotid gland
Name the 3 intracranial branches of the facial nerve and their functions. Clue: tears, ears and tongue
- greater superficial petrosal nerve (lacrimation)
- branch to stapedius
- chorda tympani (ant 2/3rd tongue taste)
Name as many extracranial facial nerve branches as poss: (3 + 5 in parotid)
posterior auricular nerve
nerve to digastric post belly
nerve to stylohyoid
in parotid: Temporal, zygomatic, buccal, marginal mandibular, cervical
Facial palsy causes:
give e,g, of intracranial, intra-temporal, infratemporal
intracranial: tumour, stroke, polio, MS, CPA lesions
intratemp.:otitis media, Ramsey hunt s, cholesteatoma
Infratemp: parotid tumours, trauma to nerve canal
A facial nerve palsy is a __ motor neurone lesion therefore (unlike a stroke) the forehead muscles and closing the eyes ___
- lower MN
- forehead will be paralysed fully
Which disease can cause a facial nerve palsy?
Therefore what investigations are useful if suspected?
-Lyme’s disease
-Diabetes
do ESR, glucose and Lyme disease serology
Name some common causes of bilateral facial nerve palsy:
lyme disease Guillan-Barre leukaemia sarcoidosis EBV Myasthenia gravis Trauma
Why do you get hyperaccusis with bells palsy? And what medication has been shown to improve rate of recovery if given within 72hr symptom onset?
- due to stapedius palsy
- prednisolone
What is the likely diagnosis of a midline neck lump in an adolescent?
Dermoid cyst
Cystic hygromas are macrocytic ____ malformations that ____ brightly. Treat by surgery or ___ sclerosant
Lymphatic malformations
Transilluminate
Hypertonic saline sclerosant
What is sialadenitis? Who does it commonly affect?
Acute infection of submandibular/parotid glands.
Elderly/debilitated pts w poor oral hygiene
Name something that can cause chronic inflamm ir recurrent attacks of sialadentitis
- strictures from previous infection
- salivary gland stones
Sialolithiasis are ____. These usually affect the ____ where secretions are ___ and richer in ___
Salivary stones
Submandibular gland
Thicker
Calcium
Complete the stats on salivary gland tumours 80% Are.. 80% Are.. 80% Are.. 50% of submandibular Are..
80% -occur in parotid -benign pleomorphic adenomas -in the superficial lobe 50% of submandibular = malignant
Warthin’s tumour (adenolymphoma) usually occur in __ most commonly in the ___ gland. Treatment is __
Elderly men
Parotid gland
Partial parotidectomy
What is the mode of spread of adenoid cystic tumours, these are painful and slow growing
Peri neural infiltration (along nerves)
-surgical excision and radiotherapy
Vincent’s angina (necrotising ulcerative gingivitis) is associated with ___ and caused by anaerobes e.g. __ +/- spirochetes e.g.___ treat with __ and ___ and dental referral
Smoking or HIV
Fusobacteria
Borellia vincentii
Amoxicillin and metronidazole
What should you investigate with MRI to rule out in a pt with unilateral tinnitus?
Acoustic neuroma
Acoustic neuroma arises from Schwann cells of the __ nerve. It is a __ tumour but can grow indolently and put __ on cranial nerves _ &_ and can continue to grow into the CPA acting as a ___
Superior vestibular nerve
Benign
Pressure CN VII & VIII
Space occupying lesion
95% acoustic neuromas are sporadic the other 5% are related to___
Neurofibromatosis type 2
What type of tinnitus can occur with acoustic neuromas?
Unilateral non-pulsatile
Slow growing acoustic neuromas can be watched and waited w MRI, what surgical approaches can treat large/fast growing?
- translabyrinthine, middle fossa, retrosigmoid approaches
- stereotactic radiosurgery
What conditions match the following durations of vertigo:
- Seconds-minutes
- 30min-30hr
- 30hr-1week
- BPPV
- Meniere’s, migraines
- acute vestibular failure
Benign paroxysmal positional vertigo are attacks lasting >__ provoked by —
30seconds
Head turning/turning over in bed
What is the pathophys of BPPV? Displacement of…
Displacement of otoconia stimulates the semicircular canals
BPPV is usually self limiting, if it persists what can you do that is often effective?
Epley manoeuvre (head moved in 4 sequential positions, 30s rest between each to move to otoconia away from sensitive posterior canals)
Vestibular migraines cause vertigo attacks what can you treat with/consider?
- vestibular suppressants
- trip tans for prolonged symptoms
- consider migraine prophylaxis
Ménière’s disease is 2 or more episodes of vertigo lasting 20min-12hr. The cause is an abnormality of ___ production leading to __
Endolymph production leading to endolymphatic hydrops in inner ear
What is the acute medication of choice for Ménière’s disease? And the prophylactic medication?
Acute: Prochlorperazine 3mg/8hr buccal
Prophx: Betahistine 16mh/8hr oral
What is acute vestibular failure/labyrinthitis? Often following what? Can last? But full recovery?
Sudden attacks of unilateral vertigo and vomiting
Often post-URTI
Lasts 1-2 days but full recovery months
Suggest medications for acute symptom control of acute vestibular failure/labyrinthitis
- vestibular suppressants
- cyclizine
- prochlorperazine
Mild sinusitis that persists >10days can be treated with:
intranasal corticosteroids e.g. mometasone
Management/investigating acute sinusitis may include:
- nasal endoscopy
- culture
- imaging
- admit for IV abx if severe/surgery
Name 4 complications of sinusitis
- orbital cellulitis/abscess (!)
- intracranial e.g. meningitis, encephalitis, cerebral abscess, cavernous sinus thrombosis
- mucoceles that can become pyoceles
- osteomyelitis
Pott’s puffy tumour is a complication of sinusitis in which a ___ abscess arises from __
- subperiosteal
- frontal osteomyelitis
What is choanal atresia (a cause of nasal congestion in infants)
-congenital blockage of one or both nasal passages by bone or tissue
Allergic rhinitis can be relieved by:
- avoidance of trigger
- nasal saline irrigation
- antihistamine e.g. loratadine
- intranasal corticosteroid spray e.g. mometasone
When is FESS (Functional Endoscopic Sinus Surgery) done?
-max. medical rx failed/to treat complications of rhinosinusitis
What is/can de done in FESS (Functional Endoscopic Sinus Surgery) ?
- max, ethmoid, frontal and sphenoid sinuses can be opened
- septoplasty and reduction of inf. turbinates
What orbital complications may arise in FESS (Functional Endoscopic Sinus Surgery)?
- breach of medial orbital wall ->periorbital bruising or haematoma (!)
- damage to medial rectus muscle
- optic nerve bruised or transected (!)
What does this make you suspect.. -blood stained nasal discharge, nasal obstruction, cheek swelling ..
-cancer of the paranasal sinuses
MRI/CT and endoscopy w biopsy can help diagnose a paranasal sinus cancer, what is the most common form? Any others. NB: Rx with radiotherapy and surgery
- Squamous cell (50%)
- lymphoma
- adenocarcinoma
- olfactory neuroblastoma…
