ENT Flashcards
Herpes Simplex Virus types
1 (oral lesions) and 2 (gential)
Herpes Simplex Virus signs/symptoms
vesicles 1-2 mm and ulcers on lips, buccal mucosa and hard palate
Herpes simplex virus Mx
Aciclovir
Herpangina
enterovirus via faecal oral route - coxsackie virus
- vesicles/ulcers on soft palate
Hand, foot and mouth
coxsackie
Apthous ulcers
Recurring painful ulcers of the mouth that are round or ovoid and have inflammatory halo.
Confined to mouth, absence of systemic disease
sore throat and lethargy persist into the second week, especially if the person is 15-25 years of age ….
EBV
Throat: signs for admission or referral?
Throat cancer is suspected (persistent sore throat, especially if there is a neck mass)
Sore or painful throat lasts for 3 to 4 weeks. There is pain on swallowing or dysphagia for more than 3 weeks
Red, or red and white patches, or ulceration or swelling of the oral/pharyngeal mucosa persists for more than 3 weeks
Stridor/respiratory difficulty is an emergency
Acute Otitis Media
inflammation of middle ear accompanied by the symptoms and signs of acute inflammation with / without an accumulation of fluid
AOM bacteria causes
Streptococcus pneumoniae, Haemophilus influenzae, Streptococcus pyogenes, Moraxella catarrhalis and Staphylococcus aureus
AOM signs/symptoms
Ear pain, reduced hearing (conductive) in affected ear
Ear drum red and inflamed.
Drum is bulging towards you due to pus and pressure on other side
general symptoms of upper airway infection such as fever, cough, coryzal symptoms, sore throat and feeling generally unwell.
AOM Mx
80% resolve in 4 days without antibiotics.
Simple analgesia for pain and fever
First line – amoxicillin
Second line – erythromycin
Otitis externa
Inflammation of the outer ear canal
Almost always infective
Common causes include water, cotton buds, skin conditions
Otitis externa signs/symptoms
Redness and swelling of the skin of the ear canal
It may be itchy
Can become sore and painful. There may be a discharge, or increased amounts of ear wax
If the canal becomes blocked by swelling or secretions, hearing can be affected
OE bacterial causes
Staph aureus
Proteus spp
Pseudomonas aeruginosa
OE Mx
Topical aural toilet (clean the EAM)
Swab to microbiology and prescription of antimicrobial reserved for unresponsive or severe cases
Treat depending on culture results
Topical clotrimazole (trade name canesten) for Aspergillus niger,
Gentamicin 0.3% drops
Malignant otitis externa
extension of otitis externa into the bone surrounding the ear canal (i.e. the mastoid and temporal bones).
Malignant otitis signs/symptoms
pain and headache, more severe than clinical signs
Granulation tissue at bone-cartilage junction of ear canal
- exposed bone
- facial nerve palsy
Otitis Media with Effusion
Inflammation of the middle ear accompanied by accumulation of fluid without the symptoms and signs of acute inflammation
associated with Eustachian tube dysfunction or obstruction (e.g. enlarged adenoids)
otitis media with effusion signs/symptoms
deafness poor school behaviour behavioural problems speech delay no ear pain (otalgia)
TM retraction, reduced TM mobility and altered TM colour
Visible ME fluid/bubbles
otitis media with effusion diagnosis
Otoscopy
tunning fork
audiometry
tympanometry
otitis media with effusion Mx
watchful waiting (3 months) - otoscopy, PTA and tympanomtery
Referral
- Persistent (> 3/12), bilateral OME
- CHL >25dB
< 3: grommets
> 3: grommets
> 3 (2nd intervention): grommets and adenoidectomy
Cholesteatoma
Presence of keratin within middle ear (Keratinizing squamous epithelium within the middle ear cleft)
Retraction pocket – squamous epithelium builds up on it
Erodes surrounding bone
Cholesteatoma signs/symptoms
- Causes hearing loss, discharge, complications
- Chronic, smelly aural discharge
- Facial nerve paralysis
- tympanic membrane full of white, cheesy material
- retracted ear drum?
Otosclerosis
Gradual onset conductive hearing loss
Stapes footplate becomes fixed in oval window due to abnormal bone formation
Otosclerosis Mx
Hearing aid
Correction by stapedectomy – remove the stapes and prothesis
Usually patients have no history at all of problems with ears.
Presbycusis
progressive, sensorineural hearing loss that occurs with age.
It results from a gradual loss of cochlea hair cells and degeneration in the cochlea nerve.
- Loss of outer hair cells (sensory)
- Loss of ganglion cells (neural)
Presbycusis low or high frequency
high
Noised induced hearing loss occurs at what level?
4000Hz
Drug-Induced Hearing Loss
- Gentamicin and other aminoglycosides
- Chemotherapeutic drugs - Cisplatin, Vincristine
- Aspirin and NSAIDs (in overdose)
Vestibular schwannoma (acoustic neuroma)
- Slow-growing benign schwannoma of the vestibular nerve (subarachnoid tumours)
- Benign tumour arising in Internal Auditory Meatus
Vestibular schwannoma (acoustic neuroma) signs/symptoms
• Progressive sensorineural hearing loss, tinnitus and imbalance
• Asymmetric
Loss of corneal reflex
• Nearby Cranial nerves V, VI, VII at risk
Acoustic neuroma Mx
o Serial observation: periodic neuro exam, hearing aid and periodic MRI.
o Stereotactic radiosurgery: involves image-guided accurate delivery of radiation to small volumes of brain, to reduce area subjected to radiation.
o Microsurgical excision: surgery is performed via a retrosigmoid approach in the prone position.
Benign Positional Paroxysmal Vertigo
Causes: Head trauma, ear surgery, idiopathic
Pathophysiology: Otoconia (crystals – break off) from utricle (horizontal) and are displaced into semi-circular canals.
Most commonly into posterior SCC.
BPPV signs/symptoms
Lasts seconds to a few minutes e.g. looking up and turning in bed - often worse to one side
- Repeated, brief periods of vertigo with movement, that is, of a spinning sensation upon changes in the position of the head.
VERTEBROBASILAR INSUFFICIENCY
Visual disturbance, weakness and numbness (impaired circulation to the posterior brain associated with the vertigo)
BPPV diagnosis
Dix Hallpike test (observe for rotational nystagmus)
BPPV management
- Epley Maoeuvre
- Semont Manouvre
- Brandt-Daroff exercises
Vestibular Neuronitis/Labyrinthitis
infection of the vestibular nerve in the inner ear. It causes the vestibular nerve to become inflamed, disrupting your sense of balance.
Probable viral aetiology
Vestibular Neuronitis/Labyrinthitis signs/symptoms
- Prolonged vertigo
- Associated tinnitus or hearing loss in labyrinthitis – not in vestibular neuritis
- Maybe viral prodromal symptoms
- Was your first attack severe, lasting hours with nausea and vomiting?
- Nystagmus away from the affected side
VN/L Mx
Supportive management with vestibular sedatives e.g.
- rapidly relieve severe N&V: buccal prochlorperazine, or an intramuscular injection of prochlorperazine or cyclizine.
- To alleviate less severe N&V and vertigo, consider prescribing a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine teoclate).
Meniere’s disease
idiopathic endolymphatic hydrops, is one of the most common causes of dizziness originating in the inner ear.
Meniere’s disease signs/symptoms
recurrent, spontaneous, rotational vertigo with at least two episodes >20mins (often lasting hours)
- New tinnitus (or worsening) on the affected side
- Aural fullness on the affected side
- Does one ear feel full or do you notice a change to your hearing (or tinnitus) around the time of the dizzy spell
- Documented SNHL on at least one occasion (low frequency SN loss)
Meniere’s Mx
IV labyrinthine sedatives and fluids
- rapidly relieve severe N&V: buccal prochlorperazine, or an intramuscular injection of prochlorperazine or cyclizine.
- To alleviate less severe N&V and vertigo, consider prescribing a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine teoclate).
- betahistine
refractory
- Intratympanic gentamicin via grommets
- Vestibular nerve resection last resort
Acute tonsillitis causes (bacterial and viral)
- EBV, rhino, adeno, entero, influenza and parainfluenza (undertake normal activity)
- step pyogenes, H. influenza. s.aureus, strep pneuomonia (systemic upset and fever: unable to work)
Centor criteria
1) History of fever
2) Tonsillar exudates (small white patches)
3) Tender anterior cervical adenopathy
4) Absence of cough
2/3 points: antibiotics if it progresses
4/5 - treat empirically
FeverPAIN
Fever Pus on tonsils Attend rapidly (3 or less days) Inflammed tonsils No cough
Tonsillitis Mx
supportive (if antibiotics)
- 10 days of phenoxymethylpenicillin
- clarithromycin if pen allergic
- erythromycin for pregnant woman with pen allergy
if admitted (IV fluids, antibiotics and steriods)
Tonsillectomy rules
a frequency of more than 7 episodes per year for one year, 5 per year for 2 years, or 3 per year for 3 years, and for whom there is no other explanation for the recurrent symptoms)
Peritonsilar abscess (Quincy)
Complication of Acute tonsillitis
Bacteria between muscle and tonsil produce pus (in the egg and the egg cup)
3-7 days of preceding acute tonsillitis
Quincy signs/symptoms
Unilateral throat pain and odynophagia
trismus
medial displacement of tonsil and uvula
Quincy Mx
aspiration and antibiotics
Glandular fever signs/symptoms
- Gross tonsillar enlargement with membranous exudate
- Marked cervical lymphadenopathy
- Palatal petechial haemorrhages
- Generalised lymphadenopathy
- Hepatosplenomegaly due to being systemic
- Linked to chronic fatigue syndrome
- Jaundice and rash
Glandular fever diagnosis
- Blood count and film: Atypical lymphocytes in peripheral blood
- +ve Monospot or Paul-Bunnell test
- Low CRP (<100)
- Epstein-Barr virus IgM
- Heterophile antibody
- Liver function tests
Glandular fever Mx
- Bed rest – paracetamol
- Avoid sport
- Symptomatic treatment
- Do NOT prescribe ampicillin: diagnostic generalised macular rash will result!
- Antibiotics – stop secondary bacterial infection
- Steroids – reduce inflammatory
- DO NOT GIVE AMOXICILLIN TO TONSILITIS
Candida Albicans causes
Cause: endogenous (post antibiotics, immunosuppressed, smokers, inhaled steroids
Candida Albicans Mx
Miconazole 1st line
Nystatin suspension 2nd line
oral fluconazole 50mg if extensive
Diphtheria
Corynebacterium diphtheriae
Severe sore throat with a grey white membrane across the pharynx.
The organism produces a potent exotoxin which is cardiotoxic and neurotoxic
Rhinitis
Infective: Viral upper respiratory tract infection
Non-infective: Allergic and non-allergic
Allergic rhinitis classification
Intermittent (symptoms <4 days per week or symptoms for <4 weeks) e.g. hayfever
- normal sleep, no impairment of daily activities, sport, leisure & normal work and school, no troublesome symptoms
Persistent (symptoms >4 days per week or symptoms for >4 weeks)
- one or more items: abnormal sleep, impairment of daily activities, sport, leisure, missing work or school, troublesome symptoms
Allergic rhinitis Mx
1) allergen avoidance
Mild-moderate:
- anti-histamine: cetirizine
- intranasal chromone: sodium cromoglicate if anti-histamine contra
Moderate-severe - persistent
- Topical nasal steroids: fluticasone furoate, or fluticasone propionate.
- topical steroids and anti-histamine
- topical anti-cholinergic: ipratropium bromide
surgery
severe
- For adults — prednisolone 0.5 mg/kg in the morning for 5–10 days.
- For children — prednisolone 10–15 mg in the morning for 3–7 day
Immunotherapy
Vasomotor rhinitis
blood vessels inside your nose dilate, or expand.
• Dilation of the vessels in the nose produces swelling and can cause congestion.
Nasal polyps
inflammation and oedema of the sinus nasal mucosa
Tends to occur in the middle meatus
Often associated with non-allergic asthma and aspirin tolerance
Nasal Polyps Mx
topical steroids and then oral steroids
Surgery
Nasal Fracture
clincial diagnosis - dont need to x ray
review in 5-7 days and consider digital manipulation/rhinoplasty
Septal Haematoma
septal hematoma is a collection of blood in the septum, or space between the two nostrils. If under perichondrium it prevents blood flow and death to cartilage
Nasal epistaxis Mx
First aid:
- upper body tilted forward and mouth open
- pinch soft part of nose
- ice
Bleeding does not stop after 10-15 mins of nasal pressure
- nasal cautery (silver nitrate)
- nasal packing
Bleeding controlled?
- FBC, G&S
- do not consider sedation if naso pack
Bleeding not controlled
- admit, FBC, G&S
- arterial ligation
systemic treatment
- reverse anti-coags
- correct clotting abs
- platelt transfusion
- reduce hypertension
CSF leak
site of fracture at cribriform plate
Acute sinusitis Mx
- Av. length illness 2.5 weeks.
- Nasal decongestants (Oxymetazoline or Pseudo-ephedrine)
- Topical corticosteroid (fluticasone propionate nasal spray)
Antibiotics (>10 days duration)
- 1st line: phenoxymethylpenicillin 500mg 4 times per day for 5 days
- 2nd line: intolerant or allergic to pen: doxycycline (not under 12)
- preganant - erythromycin
Pinna haematoma + Mx
sub perichondral - if left will die
Aspirate
Incise and drain
pressure dressing
Lacerations
Debridement – cut out dead or bad stuff Closure o Primary o Reconstruction Usually Local anaesthetic Antibiotics – cartilage
Temporal bone fracture history (important)
- Injury mechanism
- Hearing loss and vertigo
- Facial palsy
- CSF leak
- Associated injuries
Temporal bone fracture exam
- Bruising – Battle sign
- Condition of TM and ear canal
- CN VII
- Hearing test – not able to come to a clinic to do a test though. Most HDU
Temporal bone classification fracture
Longitudinal vs transverse
Sudden Sensorineural hearing loss Mx
Treat as emergency
Weber test – tuning fork on forehead. Sound away from affected ear
• Steroids 1mg/kg and consider intratympanic treatment
• Then refer up and possibly steroids into the ear
Foreign bodies Mx
Batteries - immediately
Live animals – drown with oil can be removed next day
If swallowed – must be removed – require GA
Deep Neck Space Infection
Extension of infection from tonsil or oropharynx into deeper tissues
History: sore throat, unwell, limited neck movement
Examination: Febrile, trismus, red / tender neck
Deep Neck Space Infection Mx
- Admit
- Iv access, bloods,
- Fluid rehydration
- Intravenous antibiotics, such as co-amoxiclav or clindamycin (if allergic to penicillin)
- May need theatre for incision & drainage unless abscess is small and improves with cons treatment.
- Airway compromise may be imminent so need to drain infection
Facial (maxillary) trauma signs/symptoms
Pain Decreased visual acuity and diplopia Hypoaesthesia in infraorbital region Periorbital ecchymosis (racoon eyes) Oedema Enopthalmos Restriction of ocular movement Bony step of orbital rim
Airway obstruction - infective or foreign bodies Mx
- A,B,C: Resuscitation
- Oxygen high flow
- Heliox (79% Helium+ 21% Oxygen – easier to breathe due to the helium)
- Steroid: Nebulised Budesonide 2mg and Dexamethasone 0.15-0.6 mg/kg
- Adrenaline: Nebulised Adrenaline 1:10000 (5ml)
- Flexible fibre-optic endoscopy – what is going on? But do not aggravate a precarious airway
- Secure airway with ET Tube/Tracheostomy
- Treat underlying pathology
Head and Neck Cancers types
- Squamous cell carcinoma by far the commonest type of cancer but there are regional variations
- Nasopharyngeal carcinoma – South China , related to EBV
- Laryngeal carcinoma – typically cigarettes & alcohol aetiology
- Oropharyngeal carcinoma – in ‘West’ commonly associated with HPV (produces proteins E6 and E7 which disrupts p53 and RB pathways)
- Oral Cavity carcinoma – Southern Asia , chewing tobacco
Head/neck cancers - signs/symptoms
- Dysphonia – >3 weeks warrants urgent referral for laryngoscopy
- Dysphagia – particularly if progressive
- Odynophagia – pain on swallowing
- (Unilateral) otalgia – if no other cause (remember referred pain)
- Neck lump
- Can present with airway obstruction - Stridor
Head/Neck Cancers Ix
USS: lymph nodes FNA CT: neck and chest MRI: deep lobe of partoid and nasopharynx PET: mets
Laryngeal cancer Mx
1) Early (T1 & T2) >90% 5 year survival
- Transoral laser surgery
- Radiotherapy
2) Advanced (T3 and T4)
- Partial or Total laryngectomy (curative but high morbidity)
- Chemo & Radiotherapy
- Neck nodes will need treatment, either chemo-radiotherapy or surgery to remove
Oropharyngeal cancer management depends on TNM classification & HPV status
1) Early (T1 & T2): >90% 5 year survival
- Chemo-radiotherapy
- Transoral surgery
2) Advanced (T3 and T4)
- Chemo-radiotherapy
- Neck nodes will need treatment, either chemo-radiotherapy or surgery to remove
Nasopharyngeal Cancer (EBV)
30-40% have unilateral ear symptoms
Up to 50% have nasal symptoms
• Up to 70% have palpable neck lymphadenopathy
• CN III, IV, V2, V3, VI involvement
• Presents with a lump in the neck (painless, posterior triangle
• Hearing deficit (because the cancer has blocked the Eustachian tube) leading to glue ear
• Is monitored by measurement of EBV antibodies
Chemo/radiotherpay
Schneiderian papilloma
Benign Tumour
- Inverted and oncocytic on lateral walls and paranasal sinuses, exophytic on nasal septum
Laryngeal Polyps
Reactive change in laryngeal mucosa secondary to vocal abuse (singers), infection and smoking. Occ. in hypothyroidism.
Nodules are usually seen in young women and are bilateral on middle 1/3 to posterior 1/3 on vocal cord.
Polyps are unilateral and pedunculated.
Contact Ulcer
Benign response to injury
Posterior vocal cord
Chronic throat clearing, voice abuse, gastrooesophageal reflux (GORD), intubation
Squamous Papilloma
Two peaks of incidence - <5years and between 20-40 years
Related to HPV exposure – types 6 and 11
Children – aggressive disease
Adults – often solitary and possibly not related to HPV 6 & 11.
Salivary gland mass Ix
USS + FNC: Lymph node, thyroid
CT: Local relations
MRI: deep lobe of parotid and VII
Mass in parotid
likely to be benign: pleomorphic adenoma
Submandibular and sublingual glands malignancy and types of tumour
Malignant more likely
1) Mucoepidermoid carcinoma (worldwide)
2) Adenoid cystic carcinoma (UK)
Mass in salivary glands Mx
Superficial or total parotidectomy
Warthin’s Tumour
- Second most common benign tumour
- Usually males over 50.
- Rare outwith the parotid. Strong association with smoking. Often bilateral and multicentric.
