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ENT Flashcards

1
Q

which part of the ear is responsible for converting sound vibration into a nervous signal?

A

the cochlea

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2
Q

which nerve transmits signals from the chochlea and the semicircular canals to the brain

A

vestibulocochlear nerve

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3
Q

which part of the ear is responsible for sensing head movement?

A

semicircular canals

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4
Q

describe weber’s test and possible results

A
  • make fork vibrate and place it on their forehead
  • ask which ear it’s loudest in or if it’s the same in both
  • normal result
    • same in both
  • sensorineural hearing loss
    • louder in the unaffected ear
  • conductive hearing loss
    • louder in the affected ear
    • affected ear adapts to become more sensitive so when sound transmitted directly to the cochlea through vibration they should hear it louder in the affected ear
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5
Q

describe rinne’s test and possible results

A
  • put vibrating tuning fork on patient’s mastoid process until they can’t hear it anymore
  • then move it 1cm away from same ear
  • normal result:
    • they can hear it again since air conduction should be better than bone conduction
  • abnormal result (AKA rinne’s negative):
    • bone conduction is better than air conduction and suggests a conductive cause of hearing loss
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6
Q

causes of adult onset sensorineural hearing loss

A
  • sudden sensorineural hearing loss (over less than 72hrs)
  • presbycusis (age related)
  • noise exposure
  • meniere’s disease
  • labrynthitis
  • acoustic neuroma
  • neurological conditions (stroke, MS, brain tumour)
  • infections
  • medications
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7
Q

name three drug classes and an example of each that can cause hearing loss

A
  • loop diuretics
    • e.g. furosemide
  • aminoglycoside antibiotics
    • e.g. gentamicin
  • chemotherapy drugs
    • e.g. cisplatin
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8
Q

causes of conductive hearing loss in adults

A
  • something blocking the canal such as ear wax
  • infection
  • fluid in the middle ear
  • eustachian tube dysfunction
  • perforated tympanic membrane
  • otosclerosis
  • cholesteatoma
  • exostoses
  • tumours
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9
Q

in an audiogram what symbol is used for left sided air conduction

A

X

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10
Q

in an audiogram what symbol is used for left sided bone conduction

A

]

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11
Q

in an audiogram what symbol is used for right sided air conduction

A

O

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12
Q

in an audiogram what symbol is used for right sided bone conduction

A

[

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13
Q

what will the audiogram reading be in sensorineural hearing loss

A

both air and bone conduction readings will be more than 20 dB, plotted below the 20 dB line on the chart.

This may affect only one side, one side more than the other or both sides equally.

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14
Q

what will conductive hearing loss appear like on the audiogram

A

bone conduction readings will be normal (between 0 and 20 dB).

air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart

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15
Q

what will the audiogram look like in mixed hearing loss

A

Both air and bone conduction readings will be more than 20 dB in patients with mixed hearing loss

However, there will be a difference of more than 15 dB between the two with bone conduction being more sensitive and therefore plotted higher

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16
Q

what is presbycusis

A

age related hearing loss

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17
Q

how does presbycusis present

A

as people get older

sensorineural

affects high pitched sounds first

gradual

symmetrical

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18
Q

risk factors for presbycusis

A
  • Age
  • Male gender
  • Family history
  • Loud noise exposure
  • Diabetes
  • Hypertension
  • Ototoxic medications
  • Smoking
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19
Q

what will audiometry show in presbycusis

A

sensorineural hearing loss pattern, with normal or near-normal hearing at lower frequencies and worsening hearing loss at higher frequencies.

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20
Q

what is the definition of sudden sensorineural hearing loss

A

hearing loss over less than 72 hours, unexplained by other causes

a loss of at least 30 decibels in three consecutive frequency on an audiogram

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21
Q

what should you do if a patient presents with sudden sensorineural hearing loss

A

otological emergency

immediate referral to the on call ENT team for assessment within 24hrs

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22
Q

what are the causes of sudden sensorineural hearing loss

A
  • most cases (90%) are idiopathic
  • other causes
    • infection such as meningitis or mumps
    • meniere’s disease
    • ototoxic medication
    • MS
    • migraine
    • stroke
    • acoustic neuroma
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23
Q

management of idiopathic sudden sensorineural hearing loss

A
  • steroids under the guidance of the ENT team
  • these can be
    • oral
    • intra-tympanic (via injection)
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24
Q

what is eustachian tube dysfunction normally caused by

A

urti

hayfever

smoking

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25
Q

investigations for eustachian tube dysfunction

A
  • often investigation is not required and it will resolve on its own
  • if chronic
    • tympanometry
    • audiometry
    • nasopharyngoscopy
    • CT scan
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26
Q

what is tympanometry and what does it show in health and in eustachian tube dysfunction

A
  • checks the pressure in the middle ear
  • in healthy ears the ambient pressure matches the pressure in the middle ear
  • in ETD the middle ear pressure may be lower than ambient
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27
Q

management of eustachian tube dysfunction

A
  • no treatment (probably will resolve on its own)
  • valsalva
  • decongestant nasal sprays
  • antihistamines (if caused by allergies/hayfever)
  • surgery if severe and persistent
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28
Q

surgical options for eustachian tube dysfunction

A

treating other causative pathology e.g. adenoidectomy

grommets

balloon dilation eustachian tuboplasty

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29
Q

what are grommets

A

tiny tubes inserted into the tympanic membrane allowing pressure to equalise

they normally fall out within 18 months

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30
Q

what is balloon dilation eustachian tuboplasty

A

inserting a deflated balloon into the eustachian tube, inflating the balloon for a short period (e.g. 2 mins) to stretch the tube then deflating and removing it

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31
Q

what happens in otosclerosis

A

there is remodelling of the malleus, incus and stapes which leads to stiffening and fixaton

it causes conductive hearing loss

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32
Q

what is the presentation of otosclerosis

A
  • typically presents before the age of 40
  • can be inherited autosomal dominant (no gene identified)
  • hearing loss
  • tinnitus
  • affects lower pitched sounds more
  • conductive hearing loss is fine so they may experience their voice as loud and therefore speak quietly
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33
Q

what will webers test be in otosclerosis

A

normal if bilateral

if unilateral then louder in affected ear

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34
Q

management of otosclerosis

A
  • conservative with the use of hearing aids
  • surgical with stapedectomy or stapedotomy
    • usually successful and can restore hearing to normal
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35
Q

what happens in stapedectomy

A

stapes bone is removed and replsced with a prosthesis

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36
Q

what happens in stapedotomy

A

part of stapes is removed but base is left

a prosthesis is inserted

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37
Q

what are the most common bacterial causes of otitis media

A
  • streptococcus pneumoniae (most common)
  • haemophilus influenzae
  • moraxell catarrhlis
  • staphylococcus aureus
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38
Q

how will otitis media look through an otoscope

A

bulging, red and inflamed looking typmanic membrane

if perforation you may see discharge in the ear canal and a hole in the tympanic membrane

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39
Q

when should you consider immediate antibiotics in otitis media

A

significant comorbidities

if they’re systemically unwell

if immunocompromised

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40
Q

when should you consider a delayed presentation in otitis media

A

if they’re pressing for abx

if you suspect symptoms may worsen

it’s for collection after 3 days

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41
Q

which antibiotics would you prescribe for otitis media

A

amoxicillin 5-7 days

clarithromycin in penicillin allergy

erythromycin in pregnant women allergic to penicillin

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42
Q

what is otitis externa?

A

inflammation of the skin of the external ear canal

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43
Q

what are the two most common causes of bacterial otitis externa

A

pseudomonas aeruginosa

staphylococcus aureus

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44
Q

describe the microscopic appearance of pseudomonas aeruginosa

A

gram-negative aerobic rod shaped bacteria

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45
Q

what antibiotics work agains psudomonas aeruginosa

A

aminoglycosides (e.g., gentamicin) or quinolones (e.g., ciprofloxacin).

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46
Q

management of mild otitis externa

A

acetic acid 2% (available over the counter as earcalm)

can also be used prophylactically before and after swimming in patients that are prone to otitis externa

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47
Q

management of moderate otitis externa

A

bacterial: neomycin and dexamethasone and acetic acid spray (otomize)
fungal: clotrimazole ear drops

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48
Q

what is malignant otitis externa

A
  • infection spreads to bone around ear and causes osteomyelitis of temporal bone
  • usually related to poor immunity
  • Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along) is a key finding that indicates malignant otitis externa.
  • can cause death
  • management:
    • admission
    • IV abx
    • imaging: CT or MRI head
49
Q

causes of tinnitus

A
  • primary tinnitus
    • idiopathic - related to sensorineural hearing loss
  • seconday tinnitus
    • ear infection
    • meniere’s
    • noise exposure
    • medication
      • loop diuretics
      • gentamicin
      • chemo
    • acoustic neuroma
    • MS
    • systemic conditions
      • anaemia
      • diabetes
      • hyperlipidaemia
      • hypo/hyperthyroidism
  • objective tinnitus
    • carotid artery stenosis
    • aortic stenosis
    • AV malformations
    • eustachian tube dysfunction
50
Q

blood tests for tinnitus

A
  • FBC (anaemia)
  • Glucose (diabetes)
  • TSH (thyroid disorder)
  • Lipids (hyperlipidaemia)
51
Q

red flags in tinnitus

A
  • unilateral
  • pulsatile
  • associated unilateral hearing loss
  • associated sudden onset hearing loss
  • associated vertigo or dizziness
  • headaches or visual symptoms
  • associated neurological symptoms
52
Q

what are the two broad categories of problems that can cause vertigo

A
  • a peripheal problem - affecting the vestibular system
  • a central problem - involving the brainstem or the cerebellum
53
Q

4 causes of peripheral vertigo

A

benign paroxysmal positional vertigo

meniere’s disease

vestibular neuronitis

labrynthitis

54
Q

what causes benign paroxysmal positional vertigo

A
  • crystals of calcium carbonate become dysplaced in the semicircular canals
  • disrupt normal flow
  • movement is required to disrupt the system sso it’s positional
  • dix hallpike maneuver to diagnose
    • rotate head 45 degees towards you
    • lay back quickly and smoothly and flex neck to 20 degrees
    • nystagmus if BPPV
    • need to watch for a minute
55
Q

what is acute vestibular neuonitis

A

inflammation of the vestibular nerve

usually attributed to viral infection

typical history is acute onset vertigo that impoves within a few weeks

56
Q

what is labrynthitis

A

inflammation of the structures of the inner ear

usually attributed to a viral infection

typical history is of acute onset vertigo that improves within a few weeks

57
Q

how do you distinguish labrynthitis from vestibular neuronitis

A

labrynthitis can cause hearing loss and vestibular neuronitis cannot

58
Q

name causes of central vertigo

A
  • pathologies that affect the cerebellum or the brainstem will disrupt the signals from the vestibular system and cause vertigo
    • posterior circulation infarction
    • tumour
    • MS
    • vestibular migraine
59
Q

dizziness history important points

A
  • distinguish between vertigo and lightheadedness
    • “is the room moving or do you feel more lightheded”
  • then differentiate between central and peripheral vertigo as per table
  • key features that could point to a cause:
    • Recent viral illness (labyrinthitis or vestibular neuronitis
    • Headache (vestibular migraine, cerebrovascular accident or brain tumour)
    • Typical triggers (vestibular migraine)
    • Ear symptoms, such as pain or discharge (infection)
    • Acute onset neurological symptoms (stroke)
60
Q

treatment options for peripheral vertigo

A

prochlorperazine

antihistmines (cyclizine, cinnarizine, promethazine)

BPPV: epley manouvre

61
Q

if someone has vertigo how do you differentiate between vestibular neuronitis and labrynthitis and menieres

A
  • tinnitus and loss of hearing are NOT features of vestibular neuronitis as the cochlear and cochlear nerve are not affected
  • if there is loss of hearing or tinnitus then suspect menieres or labrynthitis
  • you can remember this with:
    • Labyrinthitis – Loss of hearing
    • Neuronitis – No loss of hearing
62
Q

presentation of vestibular neuronitis

A
  • acute onset vertigo
  • maybe history of viral urti
  • balance problems
  • nausea and vomiting that may be severe
63
Q

prognosis in vestibular neuronitis

A

symptoms most severe for the first few days after which they usually resolve over the following 2-6 weeks

64
Q

what is meniere’s disease

A

Ménière’s disease is a long-term inner ear disorder that causes recurrent attacks of vertigo, and symptoms of hearing loss, tinnitus and a feeling of fullness in the ear.

65
Q

what is the triad of symptoms in meniere’s

A

Hearing loss

Vertigo

Tinnitus

66
Q

what causes meniere’s disease

A

excessive buildup of endolymph in the labrynth of the inner ear - this is called endolymph hydrops

this causes higher pressure than normal and disrupts sensory signals

67
Q

typical presentation of meniere’s disease

A
  • pt is 40-50yrs old
  • unilateral episodes of vertigo, hearing loss and tinnitus
  • the vertigo
    • lasts for 20 minutes to a few hours
    • episodes cluster over several weeks with months in between
    • vertigo is not triggered by movement
  • hearing loss
    • fluctuates at first before becoming more permanent
    • is sensorineural
    • unilateral
    • affects low frequency first
  • tinnitus
    • initially occurs with the vertigo before becoming more permanent
  • other symptoms
    • unexplained falls
    • feeling of fullness
    • imbalance
68
Q

management of meniere’s

A
  • for acute attacks
    • prochlorperazine
    • antihistamines (e.g. cyclizine, cinnarizine and promethazine)
  • prophylaxis
    • betahistine
69
Q

what is an acoustic neuroma

A

Acoustic neuromas are benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear.

They are also called vestibular schwannomas, as they originate from the Schwann cells. Schwann cells are found in the peripheral nervous system and provide the myelin sheath around neurones.

They occur at the cerebellopontine angle and are sometimes referred to as cerebellopontine angle tumours.

70
Q

presentation of acoustic neuroma

A
  • The typical patient is aged 40-60 years presenting with a gradual onset of:
    • Unilateral sensorineural hearing loss (often the first symptom)
    • Unilateral tinnitus
    • Dizziness or imbalance
    • A sensation of fullness in the ear
  • may also be associated with facial nerve palsy if the tumour grows big enough

NB if bilateral acoustic neuromas it’s NF2

71
Q

managmenet of acoustic neuroma

A
  • Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate
  • Surgery to remove the tumour (partial or total removal)
  • Radiotherapy to reduce the growth
72
Q

what is cholesteatoma

A

abnormal collection of squamous epithelial cells in the middle ear

non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear

can predispose to significant infections

73
Q

what are the symptoms of cholesteatoma

A
  • foul discharge
  • unilateral conductive hearing loss
  • if it continues to expand
    • infection
    • pain
    • vertigo
    • facial nerve palsy
74
Q

what is penicillin V aka

A

phenoxymethylpenicillin

75
Q

what is the most likely location of bleeding in epistaxis

A

usually originates from Kiesselbach’s plexus which is located in Little’s area

this is an are of nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels

76
Q

how to advise patients on how to manage nosebleeds

A
  • sit up and tilt head forwards
  • squeeze the soft part of the nostrils together for 10-15 minutes
  • spit out blood in the mouth rather than swallowing
77
Q

managment of severe nosebleeds

A

nasal packing using nasal tampons or inflatable packs

nasal cautery with silver nitrate

after treating consider giving naseptin nasal cream four times daily for 10 days to reduce crusting, inflammation and infection

78
Q

difference between acute and chronic sinusitis

A

Acute (less than 12 weeks)

Chronic (more than 12 weeks)

79
Q

name these sinuses

A
80
Q

management for acute sinusitis

A
  • no abx for symptoms up to 10 days - most will resolve within 3 weeks
  • if not improving after 10 days
    • high dose steroid nasal spray for 14 days
      • mometasone
    • delayed abx for if not improving within 7 days
      • phenoxylmethylpenicillin
81
Q
A
82
Q

management of chronic sinusitis

A

Saline nasal irrigation

Steroid nasal sprays or drops (e.g., mometasone or fluticasone)

Functional endoscopic sinus surgery (FESS)

83
Q

are nasal polyps usually bilateral or unilateral

A

usually bilateral

unilateral polyps are a RED FLAG and should raise suspicion of tumours

unilateral polyps need specialist referral

84
Q

how do you investigate for nasal polyps

A

with a nasal speculum

alternatively use an otoscope with large speculum attached

they appear as round pale grey/yellow growths on the mucosal wall

85
Q

management of nasal polyps

A
  • unilateral polyps need to be referred for specialist treatment to exclude malignancy
  • medical management of bilateral polyps
    • intranasal topical steroid drops or spray
  • surgical management for where medical management fails
    • intranasal polypectomy if they’re close to nostrils
    • endoscopic nasal polypectomy if further up
86
Q

severe sleep apnoea can cause

A

hypertension

heart failure

myocardial infarction

stroke

87
Q

how do you assess for OSA

A

epworth sleepiness scale

88
Q

what is the most common and second most common cause of bacterial tonsillitis

A

most common: group A streptococcus (streptococcus pyogenes)

second most common: streptococcus pneumoniae

89
Q

how do you decide whether to give abx for tonsilitis

A
  • centor criteria
    • a point for each of the following
      • fever over 38
      • tonsillar exudates
      • absence of cough
      • tender anterior cervical lymph nodes
    • a score of 3 or more and give abx
90
Q

choice of abx for tonsillitis

A

Penicillin V (AKA phenoxymethylpenicillin) for a 10 day course is first line

if penicillin allergic then clarithromycin

91
Q

relative incidence of quinsy and tonsillitis in children and adults

A

quinsy can occur just as frequently in teenagers and adults as it can in children

tonsillitis occurs much more commonly in children

92
Q

what is the most common organism to cause quinsy

A

streptococcus pyogenes (group A strep)

staph aureus and haemophilus influenzae can also cause it

93
Q

management of quinsy

A

referral to ENT for incision and drainage

abx before and after surgery (broad spec such as co-amoxiclav)

94
Q

indications for tonsillectomy

A
  • number of episodes of acute sore throat
    • 7 or more in 1 year
    • 5 per year for 2 years
    • 3 per year for 3 years
  • other indications
    • 2 episodes of tonsillar abscesses
    • enlarged tonsils that cause snoring or difficulty swallowing
95
Q

most important complication of tonsillectomy

A

post-tonsillectomy bleeding

96
Q

management of post-tonillectomy bleeding

A
  • can be severe and life threatening due to aspiration of blood
  • get ENT reg involved early
  • IV access and send bloods
    • fbc
    • clotting
    • group and save
    • cross match
  • sit up and encourage to spit out blood rather than swallow
  • nil by mouth in case anaesthetic needed
  • IV fluids for maintenance and resus if required
  • to stop bleeding
    • hydrogen peroxide gargle
    • adrenalin soaked swab topically
    • back to theatre
97
Q

neck lump red flag referral criteria

A
  • two week wait for:
    • unexplained neck lump in someone aged 45 or above
    • a persistent unexplained neck lump at any age
  • urgent ultrasound for:
    • a lump growing in size
      • within 2 weeks in pts over 25
      • within 48hrs if under 25
    • then if US is suggestive of soft tissue sarcoma they need a 2 week wait
98
Q

what is often the first line investigation for neck lumps?

A

ultrasound

99
Q

what are the broad causes of lymphadenopathy

A
  • reactive
    • e.g. URTI
  • infected
    • e.g. TB, infectious mononucleosis
  • inflammatory
    • e.g. SLE or sarcoid
  • malignancy
    • lymphoma, leukaemia, metastasis
100
Q

features about lymph nodes that would suggest malignancy

A
  • unexplained
  • persistently enlarged
  • over 3cm in diameter
  • abnormal shape (normally length double width)
  • hard or rubbery
  • non-tender
  • tethered or fixed to skin and underlying tissues
  • associated symptoms
    • night sweats
    • weight-loss
    • fatigue
    • fevers
101
Q

what is the presentation of infectious mononucleosis

A
  • fever
  • sore throat
  • fatigue
  • lymphadenopathy
  • in response to amoxicillin or cefalosporins
    • intensely itchy maculopapular rash
102
Q

investigation of infectious mononucleosis

A

monospot test is first line

103
Q

how many lymphomas are hodgkin’s lymphoma

A

1/5

104
Q

what is the key finding on lymph node biopsy that would tell you it’s hodgkin’s lymphoma?

A

reed-sternberg cells

105
Q

what is the staging system for lymphoma

A

ann-arbor

106
Q

describe the ann arbor staging system

A

stage I: involvement of a single lymph node region or of a single extralymphatic organ or site

stage II: involvement of two or more lymph node regions on the same side of the diaphragm or localised involvement of an extralymphatic organ or site

stage III: involvement of lymph node regions or structures on both sides of the diaphragm

stage IV: diffuse or disseminated involvement of one or more extralymphatic organs

additionally A or B depending on presence or absence of B symptoms

107
Q

what cells can grow carotid body tumours

A

glomus cells

these are the ones that contain the chemoreceptors to detect blood’s oxygen, carbon dioxide and pH

groups of glomus cells are called paraganglia

so carotid body tumours can sometimes be called paragangliomas

108
Q

how would a carotid body tumour look

A
  • in the upper anterior triangle of the neck
    • near the angle of the mandible
  • painless
  • pulsatile
  • associated with bruit on auscultation
  • mobile side to side but not up and down
  • can compress
    • glossopharyngeal (IX)
    • accessory (X)
    • hypoglossal (XI)
    • vagus (XII)
      • horners
        • ptosis
        • miosis
        • anhidrosis
109
Q

characteristic finding on imaging investigations of carotid body tumour

A

splaying of internal and external carotid arteries

aka lyre sign

110
Q

what is a thyroglossal cyst

A

During fetal development, the thyroid gland starts at the base of the tongue. From here, it travels down the neck to the final position in front of the trachea, beneath the larynx. It leaves a track behind called the thyroglossal duct, which then disappears.

When part of the thyroglossal duct persists, it can give rise to a fluid-filled cyst. This is called a thyroglossal cyst.

111
Q

how do thyroglossal cysts look

A
  • Thyroglossal cysts occur in the midline of the neck. They are:
    • Mobile
    • Non-tender
    • Soft
    • Move up and down with the movement of the tongue
112
Q

management of thyroglossal cyst

A

surgical removal and histology

provides confirmation of diagnosis and prevents infetions

113
Q

name 4 causes of glossitis

A

iron deficiency anaemia

folate deficiency

b12 deficiency

coeliac

114
Q

treatment for oral candidiasis

A

miconazole gel

nystatin suspension

fluconazole tablets

115
Q

name two causes of strawberry tongue

A

scarlet fever

kawasaki disease

116
Q

what is leukoplakia

A

pre-cancerous condition

white patches on the tongue or buccal mucosa

increased risk of squamous cell carcinoma

patches are asymptomatic, irregular and slightly raised

may require biopsy to exclude abnormal cells

117
Q

causes of apthous ulcers

A
  • no cause - they can occur in healthy people
  • coeliac
  • IBD
  • behcet disease
  • vitamin deficiency
    • iron
    • b12
    • folate
    • vitamin D
  • HIV
118
Q
A

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