ENT Flashcards
What is acute otitis media and what are the most common causative organisms?
Acute middle ear infection
Most common cause = strep pneumonia or haemophilus influenzae
How does acute otitis media present?
Ear pain
Reduced hearing
Fever
Cough/coryza/sore throat
If tympanic membrane has ruptured - discharge
What is seen on otoscopy in acute otitis media?
Bulging red tympanic membrane
Dull/absent light reflex (due to middle ear effusion)
What are indications for antibiotics for acute otitis media?
Symptoms lasting more than 4 days
Systemically unwell
Immunocompromised
<2 years + bilateral otitis media
Perforation/discharge
What antibiotic is used for acute otitis media?
Amoxicillin
Clarithromycin if pen allergic
What are complications of acute otitis media?
Perforation of the tympanic membrane
Labyrinthitis
Mastoiditis –> urgent ENT referral needed
What is otitis externa and what are the most common causative organisms?
Inflammation of the outer ear
Organisms = Pseudomonas / staph aureus
How does otitis externa present?
Ear pain
Itching
Discharge
What is seen on otoscopy in otitis externa?
Normal tympanic membrane
However often not able to be visualised
How is otitis externa managed?
Topical Neomycin + Dexamethasone
If tympanic membrane is perforated has to be Clarithromycin + Dexamethasone
If no response -> oral flucloxacillin
What is malignant otitis externa?
Life-threatening form of otitis externa - spreads to the temporal bone and becomes temporal bone osteomyelitis
found in immuno-compromised people esp. diabetics
How does malignant otitis externa present?
Deep-seated severe ear pain
Temporal headaches
Purulent discharge
May be cranial nerve palsies
How is malignant otitis externa managed?
ENT referral for IV Abx/debridement
What is acute sinusitis and how does it present?
Inflammation of the facial sinuses
Facial pressure which is worse on bending forewards
Thick, purulent nasal discharge
Nasal obstruction
Tenderness of the affected areas
How is acute sinusitis managed?
Supportive
If symptoms have not improved after 10 days - intranasal corticosteroids can be tried
What is allergic rhinitis and how does it present?
Inflammatory disorder of the nose (sensitised to dust mites/grass/pollen)
Sneezing
Bilateral nasal obstruction
Clear nasal discharge
Nasal pruritus
How is allergic rhinitis managed?
Anti-histamines e.g. Cetirizine
What is chronic rhinosinusitis? How does it present?
Inflammatory disorder of the paranasal sinuses
Facial pain worse on bending forwards
Nasal obstruction
Symptomsneed to have been present for at least 12 weeks
When do nasal polyps/chronic rhinosinusitis require referral for 2WW?
If unilateral
What is the most common bacterial cause of acute tonsillitis?
Group A strep (Strep pyogenes)
How does acute tonsillitis present?
Red, inflamed, enlarged tonsils
+/- exudae
+/- fever
+/- cough
What is the Centor criteria?
Estimates probability of acute tonsillitis being bacterial
Fever
Exudate
Lymphadenopathy
Absence of cough
If 3 or more = abx indicated
What is the antibiotic of choice for acute tonsillitis?
Penicillin V
If pen allergic = Clarithromycin
What are the indications for tonsillectomy?
7 episodes in a year
5 episodes every year for 2 years
3 episodes every year for 3 years
Enlarged tonsils causing difficulty
Recurrent abscess
When is post-tonsillectomy bleeding a cause for concern?
If bleeding occurs less than 24 hours post surgery -> immediate return to surgery
If occurs more than 24 hours post surgery -> antibiotics
What is Quinsy and how does it present?
Peritonsillar abscess (complication of untreated bacterial tonsillitis)
Symptoms of tonsillitis
Trismus - patient unable to open mouth
UNILATERAL Swelling + erythema
Patient will be extremely unwell - fever, tachycardia
How is Quinsy managed?
Admit for incision and drainage + abx
How should post-tonsillectomy bleeding be managed as an F1?
Call ENT reg
Get IV access - take bloods (FBC, clotting, group and save, cross match)
Nil by mouth in case surgery is needed
If severe bleeding- anaesthetics should be called
What is the causative organism for glandular fever?
Epstein-barr virus
How does glandular fever present?
Triad of sore throat, fever and lymphadenopathy
Malaise
Palatal petechiae
Splenomegaly - at risk of splenic rupture
Deranged LFTs
Lymphocytosis
Haemolytic anaemia
What blood test results may be seen in glandular fever?
Deranged LFTs
Lymphocytosis
Haemolytic anaemia
Which antibiotics should you not give to someone with glandular fever and why?
Ampicillin/Amoxicillin
Causes a maculopapular pruritic rash
How is glandular fever diagnosed? When should the test be conducted?
Monospot test
Conduct in 2nd week of illness
How is glandular fever managed?
Supportive
Advise patients to avoid contact sports for 4 weeks due to risk of splenic rupture
What is otosclerosis and how does it present?
Otosclerosis = remodelling of the bones in the middle ear
Causes conductive hearing loss
Presents as hearing loss and tinnitus (usually mainly difficulty which lower pitched sounds)
Which hearing problem causes issues with lower pitched sounds?
Otosclerosis
What is seen on otoscopy in otosclerosis?
Normal tympanic membrane
May be flamingo pink tinge
How is otosclerosis managed?
Hearing aid/stapedectomy
How does Meniere’s disease present?
Triad - hearing loss, tinnitus and vertigo
Symptoms come on episodes
Most prominent symptom = vertigo
Symptoms are usually unilateral
Feeling of fullness/pressure
What medication is used for acute management of Meniere’s, and what is used as prevention?
Acute attacks = Prochlorperazine
Prophylaxis = Betahistine
What is classed as sudden sensorineural hearing loss? How is investigated? How is it managed?
Hearing loss over less than 72 hours
Referral to ENT for investigation with audiometry
Oral or intra-tympanic high-dose corticosteroids
How does Eustachian tube dysfunction present?
Often a recent URTI
reduced/altered hearing
Popping noises
Sensation of fullness
Pain/discomfort
Tinnitus
What is benign paroxysmal positional vertigo? How is it diagnosed and how is it treated?
Sudden onset of vertigo triggered by movement of head position (e.g. rolling over in bed)
Symptoms settle after 20-60 seconds
Diagnosis = Dix-Hallpike manoeuvre will show rotary nystagmus
Management = Epley manoeuvre
What is vestibular neuronitis?
Inflammation of the vestibular nerve which develops following a viral infection
How does vestibular neuronitis present?
Recurrent vertigo
Nausea/vomiting
Horizontal nystagmus
NO HEARING LOSS OR TINNITUS
How is vestibular neuronitis and labyrinthitis differentiated?
Labyrinthitis = vertigo, hearing loss, tinnitus
Vestibular neuronitis = just vertigo
How is vestibular neuronitis managed?
Short course of Prochlorperazine (up to 3 days)
if no improvement -> vestibular rehabilitation
What is labyrinthitis?
Inflammatory disorder of the labyrinth usually secondary to a viral infection e.g. otitis media/meningitis
How does labyrinthitis present?
Recent URTI
Acute onset vertigo
Sensorineural hearing loss
Tinnitus
Horizontal nystagmus
How is labyrinthitis managed?
Self-limiting
Prochlorperazine can provide symptomatic relief
What is an acoustic neuroma/vestibular schwannoma?
Benign tumour of the Schwann cells of the vestibulocochlear nerve
What condition is associated with bilateral acoustic neuromas?
Neurofibromatosis type II
How does an acoustic neuroma present?
Gradual onset
Unilateral sensorineural hearing gloss
Tinnitus
Dizziness
Imbalance
Sensation of fullness
What is a characteristic finding of acoustic neuroma?
Absent corneal reflex
What is a cholesteatoma?
A benign growth of squamous epithelial cells deep inside ear
How does a cholesteatoma present?
Foul-smelling, non-resolving discharge
Conductive hearing loss
What is seen on otoscopy in cholesteatoma?
Attic crust (brown dried skin in the upper eardrum?
How is a cholesteatoma managed?
Any discharge which does not respond to abx should be referred to ENT
What is Ramsay Hunt syndrome?
Syndrome caused by herpes zoster virus - when a shingles outbreak occurs in the facial nerve distribution
Ear pain
Lower motor neurone facial nerve palsy (forehead not spared)
Vesicular rash around the ear
How is Ramsay Hunt syndrome managed?
Oral aciclovir + oral prednisolone
What is the most common site for a nose bleed to originate from?
Little’s area (in the Kiesselbech’s plexus)
What are common triggers for epistaxis?
Nose picking
Colds
Sinusitis
Trauma
Changes in weather
Coagulation disorders
Cocaine use
How is a nose bleed managed?
Tilt head forwards
Pinch nose for up to 20 mins
If bleeding does not stop…
If source of bleed is visible -> Cautery
If source of bleed is not visible -> packing
What does a bilateral nose bleed suggest?
More likely to be a posterior source of bleeding
What are features of nasal polyps?
Nasal obstruction
Snoring
Anosmia
Usually bilateral - if unilateral it is suggestive of tumours
How are unilateral nasal polyps managed?
Urgent referral to ENT
What conditions are associated with nasal polyps?
Samter’s triad
Asthma
Cystic fibrosis
Eosinophilic GPA
How are nasal polyps managed?
Topical corticosteroids
Polypectomy
What is presbycusis and how does it present?
Sensorineural hearing loss which affects the elderly
Usually affects higher frequency first e.g. female voices
Difficulty using telephone
How can you tell the difference between a thyroid swelling and a thyroglossal cyst?
Thyroid swelling - moves upward on swallowing
Thyroglossal cyst - moves upward on protrusion of tongue
Neck lump: dysphagia, regurgitation, halitosis?
Pharyngeal pouch
Neck lump: evident at birth, soft, transilluminates?
Cystic hygroma
Neck lump: presents in childhood, infront of sternocleidomastoid, does not transilluminate?
Branchial cyst
Neck lump: firm swelling with weakness/numbness?
Cervical rib
Neck lump which moves upwards on swallowing?
Thyroid swelling
Neck lump which moves upwards on protrusion of the tongue?
Thyroglossal cyst
What are risk factors for head + neck cancers?
Smoking
Alcohol
HPV
EBV
What are red flags for head and neck cancers?
Lump in the mouth or on lip
Unexplained mouth ulceration persisting for more than 3 weeks
Erythroplakia or Leukoplakia
Unexplained hoarse voce
Unexplained thyroid lump
What type of cancer are head and neck cancers usually?
Squamous cell carcinoma
What is a normal Rinne’s test result and what does an abnormal test mean?
Normal result = air conduction > bone conduction
Conductive hearing loss = bone conduction > air conduction
How can you interpret Weber’s test?
Sensorineural deafness = louder in non-affected ear
Conductive deafness = louder in affected ear
What is a cervical rib and how can it present?
An extra rib above first rib
Can be felt as a lump in the neck
Can lead to thoracic outlet syndrome
Whens should otitis externa be referred to ENT?
Non-resolving + worsening pain
What is the usual causative organism of malignant otitis externa?
Pseudomonas
Management for otitis externa + perforation?
Topical clarithromycin+dexamethasone
What is sialdenitis? How is it treated?
Inflammation of the salivary glands due to viral/bacterial infection
Treated w/ Abx + oral hygiene advice.
How should noise-induced hearing loss be treated?
Hearing aid
What is the hereditary pattern of otosclerosis?
Autosomal dominant
Which salivary gland swelling can cause facial nerve palsy?
Malignant tumours – e.g. Adenoic cystic carcinoma
What is the most common benign salivary tumour?
Pleomorphic adenoma
What are symptoms of a thyroid lump?
Voice hoarseness Difficulty swallowing – dysphagia, painful swallow Airway compromise Weight loss Low-grade fever May be cervical lymphadenopathy
Which type of head and neck cancer is most associated with HPV?
Oropharyngeal squamous cell carcinoma
What does loss of corneal reflex suggest?
Vestibular schwannoma/acoustic neuroma
When should a hoarse voice be investigated?
If it has lasted more than 3 weeks
What is the most common cause of hearing impairment post head injury?
Perforated tympanic membrane
What can you prescribe for epistaxis to reduce crusting?
Topical antiseptic e.g. Naseptin (chlorhexidine + neomycin)- caution in peanut allergies
What is seen during Dix-Hallpike manoevure in BPPV?
Vertigo + Rotary nystagmus
How is an auricular haematoma managed?
Require same day ENT assessment for incision ad drainage
How can you manage epistaxis which has failed all emergency management?
Ligation of the sphenopalatine artery in theatre
How does a nasal septal haematoma present and how should it be managed?
Head/facial trauma- may be relatively minor
Bilateral red boggy swelling from nasal septum
Surgical drainage + IV Abx
What is Ludwig’s Angina and how is it managed?
Type of progressive cellulitis which affects the floor of the mouth and the soft tissues of the neck- presents with neck swelling, dysphagia and fever
needs emergency airway management = IV Abx
Preauricular sinus
What is glue ear?
Otitis media with effusion
What are risk factors for glue ear?
Male Family history Bottle feeding Parental smoking Eustachian tube dysfunction Down syndrome
How does glue ear present?
Hearing loss
Most common cause of conductive hearing loss in children
May be secondary problems e.g. speech and language delay
How is glue ear treated?
Grommet insertion or Adenoidectomy
Which drugs can cause hearing loss?
Gentamicin/Vancomycin Furosemide Sildenafil Aspirin Quinines
How are acoustic neuromas diagnosed?
MRI of the cerebellopontine angle
What is the 2WW criteria for laryngeal cancer?
> 45 + persistent unexplained hoarse voice
>45 + unexplained lump in neck
