ENT Flashcards
1
Q
what is atypical facial pain
A
- Diagnosis of exclusion
- UL Burning, aching, cramping sensation
- often in region of CNV
- can extend further to neck, back of scalp
- often linked with mood disorders
- may be worse w fatigue/stress
2
Q
What conditions may cause or predispose to atypical facial pain?
A
- Trigeminal neuralgia
- ***- Temporomandibular joint problems and tendonitis
- Migraines, cluster headaches
- teeth/sinus infections
- neuralgia eg cavitational oseteonecrosis
- ***- C-spine issues
3
Q
ix for ?atypical facial pain
A
exclude other causes: - XR of skull MRI/CT detaile dental and otolaryngologic evaluation - neuro exmination
4
Q
tx for atypical facial pain
A
1st line- TCA (amytriptyline, fluoxetine, venlafaxine)
- gabapentin, pregablin
- capsaicin- topical
- acupuncture
- CBT
- peripheral subcute field stimulation
5
Q
How do you read an audiogram?
A
- one symbol is air, another symbol is bone
X axis is frequency (pitch), Y axis is volume (db) - anything lower than (ie higher on the graph) 20db is normal!
6
Q
Describe how different ear pathologies would appear on an audiogram
A
Conductive hearing loss
- bone-air gap (with bone performing better)
Sensorineural hearing loss
- bone and air are equal but under 20bd on the graph
Meniere’s
- UL sensorineural hearing loss involving **low frequencies only
Cholesteatoma
- UL **mixed hearing loss
- ***- bone and air under 20bd on the graph AND bone air gap
Acoustic neuroma/vestibular schwannomas
- UL sensorineural hearing loss at ***higher frequencies
Presbycusis
- BL sensorineural hearing loss at higher frequencies
7
Q
what is a cholesteatoma
A
collection/sac of keratinizing sq epithelium in the middle ear, behind the eardrum
8
Q
causes of cholesteatoma
A
congenital
repeated middle ear infections
9
Q
Why can a cholesteatoma cause damage?
A
- local expansion causes erosion
- it releases cytokines which upregulate osteoclasts– bone resorption
10
Q
What are the red flags in ear hx
A
- CN VII palsy/bell’s
- UL sensorineural hearing loss
- tinnitus UL
- sudden deafness with no wax/SN
- conductive hearing loss of unknown cause
11
Q
sx of cholesteatoma
A
- repeated UL infections
- very offensive discharge
- conductive hearing loss
- tinnitus/vertigo (if facial nerve is involved- late stage)
- SensoriN hearing loss if large
12
Q
signs of cholesteatoma
A
- otorrhoea (offensive)
- UL mixed hearing loss (hearing under 20bd on graph and a bone air gap)
- may be able to see keratin (white material) on otoscope at attic of the TM, may be a TM perf
13
Q
ix for ?cholesteatoma
A
otoscope
audiometry
CT of temporal bone to determine involvement
14
Q
tx of cholesteatoma
A
dry, safe ear
repair of perf
remove cholsteatoma, mastoidectomy
15
Q
What sx are there in CN VIII palsy
A
- hearing loss
- vertigo, motion sickness
- loss of equilibrium in dark places
- *- nystagmus
- *- gaze-evoked tinnitus
16
Q
what are two Examination tests for hearing using a tuning fork
A
Rinne’s- air/mastoid
Weber’s- tuning fork on forehead (fork makes W shape with person’s ears lol)
17
Q
what size tuning fork do you use for rinne’s/webers
A
512 hz
18
Q
causes of congenital deafness
A
- genetic
- intrauterine infection (rubella)
- drugs in regnancy (streptomycin- abx)
- meningitis
- neonatal jaundice
19
Q
causes of childhood onset deafness
A
no earache:
- BL glue ear
- impacted ear wax
- hereditary
- following meningitis, head injury or birth complications
Earache:
- acute otitis media
20
Q
what are some Qs to ask during hearing loss hx
A
- do people seem like they’e mumbling, saying pardon alot, conversations hard to follow, missed phone calls or someone ringing the doorbell
- high or low sounds
- tinnitus, vertigo
- *- headaches, visual changes
- pain- ear, facial
- weakness
- nasal congestion
- dysphagia
- changes in voice
- infection- fever, ottorhoea
- wt loss, fatigue, appetite, night sweats
- occupation, noise exposure
21
Q
What does a positive rinne test mean
A
the fork in the air sounds louder than on bone
this means normal or sensorineural hearing loss
22
Q
what does a negativee rinne’s test mean
A
fork is louder when on the bone
conductive hearing loss
23
Q
What may it mean when the tuning fork is hear louder in the L ear compared to the R on Weber’s testing
A
Conductive hearing loss in L ear
or R sensorineural hearing loss
24
Q
Causes of conductive hearing loss
A
- impacted ear wax
- debri/foreign body
- eardrum perforation
- middle ear effusion.glue ear
- otosclerosis
- cholesteatoma
25
Causes of senorineural hearing loss
- presbycusis
- infection
- meniere's disease
- drugs
- acoustic neuroma
- noise induced
26
How do you tx impacted ear waxx
olive oil drops for ~2w
| wash out/suction
27
What would be present with eardrum perforation
purulent discharge
28
Describe pattern of hearing loss in presbycusis
- gradual onset
- high frequencies more severely affected
- examination normal as both ears normally affected to same degree
- audiometry- SN (bone and air), BL usually
29
ix for ?presbycusis
audiology
30
tx presbycusis
hearing aids
31
sx of acoustic neuroma, what is it
neurofibroma from acoustic nerve
UL sensorineural hearing loss
tinnitus
facial/bell's palsy
32
pathophysiology of meniere's
- idiopathic dilatation of endolymphatic spaces
| - poor fluid drainage of endolymph
33
sx of meniere's
attacks of:
- vertigo
- tinnitus
* ***- feeling of pressure deep inside the ear
- N+V
- sudden drop in hearing- sensorineural
- cumulative sensorineural hearing loss after repeated attacks
- each attack lasts mins to hours
34
management of meniere's attack
refer to ENT
acute attack- labyrinthine sedatives:
- Prochloperazine (1st gen antipsychotic)
- antihistammines- cyclizine, promethazine
- Ecourage mobilisaiotn after
- try to ID and avoid trigger
35
LT management of meniere's (ie not of acute attack)
LT tx
- hearing aids
- tinnitus markers
- surgery to control vertigo
- thiazide like diuretics (hydrochlorothiazide)/betahistine to reduce freq
- avoid alcohol, caffeine, smoking, salt
must inform DVLA
36
RF for meniere's
- allergies
- immune disorder
- viral infections eg meningitis
- head injury
- migraines
- fam hx
37
What is otosclerosis, sx
- BL Conductive hearing loss
- positive family history of early onset deafness
- young (<40s)
- tinnitus/vertigo sometimes
- focus/foci of spongy bone affecting ossicles
- adheres od stapes footplate to bone
38
tx of otosclerosis
surgery
39
What is glue ear, who is it common in
middle ear effusion
non infective fluid causing
- eustachian tube dysfunction
- most common cause of hearing loss in children- can have grommets inserted
- rarer in adults, may follow a URTI but self-resolves
40
A 32 year old has had a middle ear effusion for 2 months, which has not resolved depsite your previous advice to watch and wait- what could this be?
posterior nasal space tumour- refer to ENT as needs excluding
41
When are cochlear implants used
- profound, BL sensorineural hearing loss
42
What are some causes of vertigo
Central
- MS
- Posterior Stroke
* **- Head Trauma/concussion
* **- Migraine
- Space occupying lesion
Otological
- Benign positional paroxysmal vertigo
- Meniere's Disease
- Vestibular Neuronitis/labrynthitis
- Persistent postural perceptual dizziness- sudden unsteadiness/vertigo
- Acoustic Neuroma
* **- Ramsay Hunt Syndrome- Herpes Zoster Oticus
- Motion Sickness
43
Causes of fainteness/lightheadedness
- haemodynamic orthostatic hypotension (postural hypotension)
- Cardiovascular disease- arrhythmias, narrowed/blocked blood vessel, hypertrophic cardiomyopathy, decrease in blood volume
- hypoglycaemia
- vasovagal- emotional triggers, prolonged standing
44
Name some causes of loss of balance
- nerve damage (peripheral neuropathy
- joint issues
- Muscle issues- weakness
- Vision issues
- Medications
- Parkinson's
- psychiatric disorders- depression, anxiety
- hyperventilation
- vertigo
45
What is benign paroxysmal positional vertigo
- presence of canaliths in the semicircular canals instead of in the utricle
- these crystals cause abnormal movement of the endolymph when the pts head is moved
46
RF for benign paroxysmal positional vertigo
trauma- head injury or whiplash
Vestibular neuronitis
Meniere's
elderly
often idiopathic though
47
what are the symptoms of an episode of benign paroxysmal positional vertigo
```
very sudden onset vertigo
settles after a few seconds
starts when pt looks up.sideways/when turning in bed
N+V
pt feels normal between attacks
```
48
How do you diagnose benign paroxysmal positional vertigo?
Hx
Dix-Hallpike Manoeuvre/supine lateral head turn
- positive if nystagmus and vertigo are evoked
- pt sat up, then lie pt down with head hanging of end of bed, whilst turning their head to the side
- repeat maneouvre twice, turning head on side each time
- posterior canal- rotatory nystagmus on diagnostic procedure
Lateral canal- horizontal nystagmus on diagnostic procedure
49
Management of benign paroxysmal positional vertigo
meds- none
Epley's manoeuvre/particle repositioning manoeuvre
- removes crystals from the canal and resolves
- pts advised not to drive and to keep/sleep upright/not to bend over in 48hours
- Brandt-Doroff exercises given to pts to do at home to reduce intensity of sx
50
What are the theories on the pathophysiology of Meniere's
- endolymphatic pressure, caused by dysfunctioning Na channels
- osmotic gradient created which draws fluid into endolymph
51
sx of Meniere's
- attacks of tinnitus (UL), vertigo, SN hearing loss
- feeling of pressure deep inside the ear (UL)
N+V
hearing recovers after the attacked but cumulative attacks cause progressive SN hearing loss
lasts 2-3 hours, usually resolves fully within 24hours
52
age range of Meniere's
20-40
53
ix for Meniere's
- audiometry (UL SN hearing loss in lower frequencies)
- tympanometry
- otoscopy- normal looking eardrum
54
Management of Meniere's
Refer to ENT
acute attack tx:
- cyclizine/prochloperazine (vestibular sedatives)- N+V and vertigo
- Antihistamines- promethazine- helps with N+V and vertigo
- encourge to mobilize after
- try to ID trigger
LT tx and prophylaxis
- betahistine reduced attack frequency , or thizide like diuretics
- avoid alcohol, caffeine, smoking , slat
- hearing aids, tinnitus markers
- surgery to control vertigo
- must inform DVLA!!
55
RFs/causes of meniere's
- immune disorder
* *- allergies
- viral infection eg meningitis
- fam hx
- head injury
- migraines
56
What is labrynthitis/vestibular neuritis
inflammation of the vestibular never (and cochlear if labrynthitis)
57
causes of labrynthitis/vestibular neuritis
- viral mostly
- can be bacterial
preceded by URTI in about 50% of cases
58
sx of labrythnitis/vestibular neuritis
- vertigo lasts for days or up to 3w
- sudden onset
- severely incapacitating
- N+V
- hearing drop (SN) and tinnitus if labrynthitis
- imbalance
59
ix for ?labrynthitis
- otoscopy- eardrum normal
- horizontal nystagmus
- Neuro exmaination- normal
- hearing normal or reuced
60
complication of labrynthitis/vestibular neuritis
- lasting unsteadiness
61
tx of labrynthitis/vestibular neuritis
vestibular sedative
- prochlorperzine/cyclizine
- promethazine
should be stopped after worst of acute episode as brain needs to get used to new unsteadiness
- consider IV fluids if pt is dehydrated from N+V
- LT vestibular rehab if vestibular hypofucntion persists- Cawthorne-Cooksey exercises
62
What cell type represents most head/neck cancers
sq cell carcinoma
63
Where are most head and neck cancers
oral cavity- buccal mucosa, retromolar triangle, alveolus, anterior 2/3 of tongue, hard palate, floor of mouth, mucosal surface of the lip
Pharynx
Oropharynx- base of tongue, tonsil, soft palate
Hypopahrynx- postcricoid surface, posterior pharyngeal wall
Nasopharynx- behind the nose
Larynx
64
Presentation of tongue cancer
usually dont present util large (>2cm)
speech difficult
sqallowing difficulty
***pain when tumour involved nerve- referred to ear
65
Presentation of tonsillar cancers
- trismus (lockjaw)
* *- neck mass
- foreign body/mass sensation
* *- ear pain
* *- bleeding
- sore throat
O/e- may be under the surface, so may only see a slight increase in size and firmness in the area
66
presentation of buccal mucosa cancer
- warty/ulcerative invasive lesion
- painless in early stages
- bleeding
- difficulty chewing
- leukoplakia, eryhtroplakia
67
When to refer ?oral cavity malignancy on 2ww
- unexplained ulceration in oral cavity lasting >3w
- persistent and unexplained lump in the neck
- lump on the lip or in the oral cavity
- red or red/white patch in the oral cavity (leukoplakia- white, doesn't come off when scraped;, erythroplakia- red, bleeds easily when scraped)
68
Management of oral cavity malignancy
RT
CT
Surgical resection with reconstruction
69
Sx or oropharyngeal malignancy
- persistent sore throat
- lump in mouth.throat
- pain in the ear
- dysphagia
70
sx of hypopharynx cancer
- dysphagia
- ear pain
- hoarseness
71
sx of nasopharynx cancer
```
lump in neck
nasal obstruction
***deafness
recurrent ear effusions- posterior nasal space tumour
postnasal discharge
```
72
what virus are pharyngeal cancers associated with
HPV
73
O/E what may you see in pharyngeal cancers
unexplained red/white pacthed (erythroplakia, leucoplakia), which are painful and bleed easily
mass
nodes (BL mets are common)
74
Ix for ?pharyngeal cancer
biopsy
CT and MRI
CXR and LFTs for mets
75
criteria for 2ww for ?pharyngeal cancer
- neck mass whihc is persistent and unexplained
| - unepxlained ulceration in oral cavity/back of throat >3w
76
Management of pharyngeal cancer
Surgery
RT
CT
mixture of above
77
sx of laryngeal cancer
- chronic hoarseness
- pain- throat, ear
- dysphagia, aspiration
- lump in neck
- haemoptysis, persistent cough , SOB
- Fatigues, weakness, wt loss
78
Referral for ?laryngeal cancer
- Hoarseness >3w
| - unexplained lump in the neck
79
Ix for ?laryngeal cancer
- Laryngoscopy with biopsy - under GA
- fine needle aspiration of a neck mass
- CT/ MRI
- CXR if hoarseness >3w
80
Management of Laryngeal cancer
surgery
CT
RT
81
What cell type are ear malignancies
Sq cell
basal cell
melanoma
82
Sx of ear malignancies
Ear canal:
- Pain
- Otorrhoea
- Loss of hearing
- Lump in ear canal
- Weakness of the face
Middle Ear
- hearing loss
- Earache
- Cannot move face on ipsilateral side
Inner ear
- pain, headache
- hearing loss
- tinnitus
- vertigo
83
Ix of ?ear malignancy
Biopsy
MRI
CT
84
tx of ear malignancy
surgery
RT
CT
85
Name the salivary glands and where they are
sublingual gland (under tongue)
Submadibular- deep to sublingual gland, connected with sublingual
Parotid- slightly inferior and anterior to the ear
Many minor salivary glands widely distributed throughout oral mucosa, palate, uvula, floor of mouth, post tongue, retromolar and peritonsillar regions, pharynx, larynx and paranasal sinuses
86
Where to most of the salivary gland cancers arise from
Parotid gland
87
What cell type are salivary gland tumours
Adenoid cystic carcinomas are most common
Can also be mucoepidermoid, acinic
88
Presentation of salivary gland cancers
- facial nerve weakness/palsy
- Paraesthesia and anaesthesia of neighbouring sensory nerves
- salivary gland mass
- usually painless,or with increasing painfulness, which becomes relentless
- ulceration or induration (or both) of the mucosa or skin overlying
89
RF for salivary gland malignancy
- hx of previous skin ca
- Sjogrens
- previous radiation to head/neck
90
clincial features of salivary gland malignancies
- hardness on palpation of parotid/submandibular/sublingual regions
- fixed lump
- tenderness
- infiltration of surrounding structures- Facial nerve palsy, local lymph node enlargement
- overlying skin ulceration
91
When to refer for ?salivary gland malignancy
- any unexplained neck lump in >45y/o
| - peristent and unexplained neck lump in any pt
92
ix for salivary gland malignancy
- USS- if superficial
- USS guided fine needle aspiration
- MRI/CT
- all tumour in lublinguinal gland should be imaged with MRI as the risk of malignancy is high
93
management of salivary gland malignancy
- ablation
- radiotherapy
- chemotherapy
- removal of the affected gland
94
Eye and optic nerve tumour- presentation
Generally, in over 50s
- pupil distortion
- cataract
- visual decline/disturbances
- pain due to elevated intraocular pressure
95
Management of eye/optic nerve tumours
observe
surgery
radiotherapy
removal of the eyeball
96
Sx /signsof reintoblastoma
sx
- pain
- Apparent change in the colour of the iris
- inflammation, redness or increased pressure in/around the eye without infection
- detioration of vision in one or both eyes
- buphthalmos (enlarged eye)
- leukocoria- after flash is taken (white pupillar reflex)
Signs
- Strabismus
- glaucoma
- nystagmus
- parental hx
97
Ix of ?retinoblastoma
- Examination under anaesthesia with maximally dilated pupil
| - MRI
98
tx of retinoblastoma
radiation
chemo
surgery
99
Where do nosebleeds bleed from most commonly
Little's area/kiesselbach's plexus- most accessible part of the nose anteriorly and very well vascularised
100
Where do posterior epistaxis arise from?
- Sphenopalatine artery
101
causes of epistaxis
- nose picking
- inflammation (URTI, sinusitis)
- foreign body
- trauma- blowing nose with force, insertion of object, injury to nose/face
- bleeding disorder/anticoag/antiplatelets
- HTN
- Dry air
-
102
management of epistaxis
- ABCDE- vast majority are self-limiting
- group and save
IV access
- 15min pressure leanign forward
- silver nitrate cautery if you can see offending BV
- pack the nose
- Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre
- if recurrent- topical naseptin for 10d then consider cautery
surgical
-electrocautery
103
A 14 year old boy presents with his 5th nosebleed in 3 months
He feels he cant breath through his nose anymore
what should you suspect- Ix, and tx
- Juvenile nasopahryngeal angiofibroma
MRI head
Tx- resect
104
What is mononucleosis caused by ?
Epstein Barr Virus
sometimes caused by toxoplasmosis, human herpes virus 6, cytomegalovirus, HIV, adenovirus
105
presentation of mononucleosis
- low grade fever
- fatigue, malaise-- may persist for several months after acute infection
- sore throat, tonsillar enlargement- classically exudative
- petechiae on oropharynx
- uvular oedema, palatal oedema
- fine macular non-pruritic rash- disappears fast
- lymphadenopathy, especial cervical
- nausea, anorexia
- arthralgia, myalgia
- cough
- chest pain
- photophobia
- transient upper eyelid oedema
Later signs
- mild hepatomegaly
- splenomegaly with abdo pain
- may be jaundice
106
ix for ?mononucleosis
- if <12 or immunosupressed-- check EBC serology after person has been ill for at least 7d
- if >12 and immunocompetent- FBC, WCC, monospot test in the 2nd week of illness
- FBC- >20% atypical or reactive lymphcytes
LFTs
- ESR
Abdo USS for splenomegaly assessment in those who do contact sports
- if monospot is negative- repeat in 5-7 days
- If monospot is negative but you have hgih clinical suspicion- can order EBV serology,
- CMV/toxoplasmosis, esp. if pregnant or immunocomprimised
- HIV testing in at risk people
107
Advice and management of mononucleosis
- avoid contacr sports for ~3w (risk of splenic rupture due to splenomegaly)- duraiton should be guided by USS
- avoid alcohol
- advise paracetemol
- no evidence for antivirals or steroids
108
A 19 year old female comes to you complaining of itchy skin. You saw her 1 week ago for a sore throat, which you gave her amoxicillin for. O/E- she has a maculopapular rash. what is the reason for this?
She has mononucleosis
ampicillin and amoxicillin will cause and itchy maculopapular rash during infectious mononucleosis
109
casues of head/neck lumps
- infective- reactiev lymphandenopathy
Neoplastic
- lymphoma
- head/neck cancer
- salivary gland tumour
- mets
- lipoma
Vascular
- carotid body tumour
Inflammatory
- sarcoidosis
- thyroid cyst
Congential
- cystic hygroma
- thyroglossal cyst
- dermoid cyst
110
ddx of neck lumps
Midline:
- lymph node
- lipoma
- thyroglossal cyst
Anterior triangle
- lymph node
- lipoma
- carotid body aneurysm/tumour
Posterior Triangle
- Lymph node
- Lipoma
- subclavian artery aneurysm
111
ddx of head lumps
- Lymph nodes (inflammatory, mets, viral, bacteria)
- Cystic- dermoid , epidermoid, sebaceous, lipoma
- encephalocele- a sac-like protrusion or projection of the brain and the membranes that cover it through an opening in the skull
- tumour secondaries
- SCC, lymphoma
- bone diseases- Paget's, cherubism, malignant, benign (ossifying fibroma)
- salivary glands- stones, cancer, infections
- trauma
112
red flags of neck/head lump
- inflamed >2/52
- enlarging rapdily
- hard, fixed
- assoc with ***otalgia, dysphagia, stridor, hoarse voice
- epistaxis, UL nasal congestion
- unexplained wt loss, night sweats, fever, rigors
- CN palsies
children:
* ***- supraclavicular mass
- >2cm
113
reassuring signs of a neck lump
- <2cm
- small
- persistent
114
ix of head/neck lump
1st line if sus- USS with or without fine needle aspiration
- if suspicious USS- FNA needs to be done
- if ?lymphoma- core excision biopsy should be done instead
- further CTs and MRIs
115
what is a cystic hygroma/lymphangioma
- benign fluid filled sac caused by malformation of lymphatic system
- most commonly noticed in <2 year olds
- can grow large enough to obstruct airways or cause dysphagia
- not all require tx
Ix- USS
tx- surgery, lymphatic sclerotherapy
116
where is a thyroglassal cyst found
midline neck
117
features of thyroglossal cyst
- painless if nto infected
- increase in size
- moves up with protrusion of tongue
- get infected
- sometimes discharge
118
what is a thyroglossal cyst
- embryological part of thyroid gland which descends from base of tongue past hyoid and cricoid cartilage
- thyroglossal cyst is when this persists and remains patent somehwere along the dscent pathway
- they cause a collection of fluid, are prone to infection, and occassionally discharge
119
tx of thyroglossal cyst
surgery and removal of part of hyoid bone to avoid recurrence
120
What is a branchial fistula
branchial arch remnants that have persisted
- if fistula- connect back of mouth into pharynx towards the skins
- they discharge
- they may just become cysts that become inflammed and dont discharge
Appearance
- small lump (red dot)
- may discharge (white)
121
tx of branchial fistula
- surgical resection
122
what is a carotid body tumour
- benign neuroendocrine tumour that arises from paraganglion cells of the carotid body
```
appearance:
- pulsatile , painless neck lump
- bruit
in anterior triangle of neck
slow growing
-
```
123
what is a branchial cyst , ix tx
congential mass arising from lateral aspect of neck
- if large will cause dysphagia, dysphonia, difficulty breathing
ix- USS FNA
tx- surgery, sclerotherapy
124
what is an external angular dermoid cyst , tx
swelling that are superior and lateral to the eyebrow
- embryological remnant
- pocket of skin with epithelium trapped inside- skin cell secrete sebum and proliferate- cyst expands
- risk of infection
tx- removal at 1y of age
125
Ddx of lymphadenopathy
MIAMI
Malignancy, infection, autoimmune, misc/unusual, Iatrogenic (meds)
126
What common medications can cause lymphaneopathy
```
Allopurinol
Atenolol
Carbamazepine
Hydralazine
Penicillins
Phenytoin
Quinidine
Trimethoprim
```
127
What questions do you want to ask in a hx for lymphadenopathy
assoc sx
- fever, SOB, cough, sore throat, painful testicles/discharge (infection)
- malaise, fatigue , abdo pain (mononucleosis)
- wt loss (malignancy)
- night sweats, fever, wt loss >10%- Lymphomas
* ***- arthrlagia, muscle weakness, unusual rash (autoimmune)
- Pain at lymph nodes after alcohol- Hodgkin's
- breast sx
- skin changes
- characteristics of lump- fixed, irregular, hard
Exposure
- infectious contacts
- insect/animal bites or scratches
- hx of recurrent infections
- tobacco
- alcohol
- UV radiation
- Occupational exposure
- Sexual hx- HIV
- travel hx
* ***- immunisation hx
PMHX
```
Medications
Allopurinol
***Atenolol
Carbamazepine, phenytoin
Penicillins, trimethoprim
```
fam hx
- carcinomas of breast, melanoma
128
What must you also palpate in an exmaination of lymph nodes
- the spleen for lymphoma, mononucleosis, lymphocytic leukaemia, sarcoidosis
129
ix for lymphadenopathy
biopsy
blood test for infective causes/leukaemia
USS of the node if ?salivary gland
130
What would make you suspect a malignancy with a pt with lymphadenopathy
- older age
- firm, fixed, nodal
- UL
- painless!
- duration >2w
- supraclavicular location- always investigate these!!!!
-
131
How would a lymph node feel o/e if caused by infection
BL
Mobile
Nontender
132
Causes of superior vena cava obstruction
- SCC and non-small cell lung cancer
- Non-hodgkins lymphoma
- mediastinal lymph node mets
- scarring eg TB
- Aortic anuerysm
- Blood clots
- Constrictive pericarditis
- Goitre
133
sx of SVCO
* **- supraclavicular mass (hard, painless, immobile- lymph node)
- facial oedema
* **- engorged conjunctiva
- anorexia
- Distended veins in upper L chest/trunk
* *- Dyspnoea
- Headache
- Severe- cerebral oedema, laryngeal oedema, airway compromise
134
ix for ?SVCO
```
CXR
CT
MRI
Doppler
Contrast venography
```
135
tx for SVCO
- endovascular stenting, bypass, resection with reconstruction
- Radiotherpay with chemo if cancer
- Corticosteroids if laryngeal oedema present, diuretics
* **- Anticoagulation or thrombolysis if thrombosis related
136
What age is mastoiditis seen in
6-13m
rare in adults as their cortical bone is much thicker
137
What is mastoiditis, how does it occur
Abscess behind the year
- middle ear infections make its way through middle ear and through antrum (mastoid cells and middle ear connection)- will push through the ting cortical tmep bone in temporal bone.
138
What are some examples of autoimmune causes of lymphadenopathy
RA, SLE, dermomyositis
139
what are some misc/unusual causes of lymphadenopathy?
- Sarcoidosis
- Silicosis
- Hyperthyroidism
- Histiocytosis
- Kawasaki
- SVC obstruction
140
tx of mastoiditis
IV abx eg ceftriaxone, vancomycin
| Myringotomy/mastoidectomy if severe
141
sx of nasal polyps
rhinorrhea
BL obstruction, pressure sensation
paroxysmal nocturnal dyspnoea
assoc with chronic rhinosinusitis (facial pain/fullness, mucopurulent discharge, change in sense of smell for >12w)
142
UL nasal polyps- what should you investigate for?
malignancy
143
difference between turbinates and nasal polyps on anterior rhinoscopy with nasal endoscopy
- turbinates- pink, arise laterally, VERY sensitive
| - Polyps- white/pearlish, arise medially, insensate
144
Ix for ?nasal polyps
- anterior rhinoscopy with nasal endoscopy
- CT if considering surgery
- MRI if concerned about malignancy
145
tx for nasal polyps
benign- need ENT referrl for full ENT examination
UL- red flag sx- urgent referral
causing breathing issues- refer
- Topical steroid (memetasone)
- intranasal douche
- If no improvement- polypectomy
146
RF for otitis externa
- swimming
* *- cotton bud use
- hot/humid climates
* *- Narrow ear canals (down's)
- older age
- derm issues (eczema, Seborrhoeic dermatitis)
* *- Prev ear surgery
- Immunosupression
- hx of otitis media/externa
- prev. RT to head/neck
147
causative organisms of otitis externa
```
Psuedomons aeruginosa (esp if diabetic)
Staph aureus
```
- viral
- aspergillus
- candida (otomycosis)
148
sx of otitis externa
- rapid onset
- otlagia
- otorrhoea
* **- itch
* **- tragal tenderness
149
signs O/E of otitis externa
erythematous and oedematous ear canal
150
tx otitis externa
- topical dexamethasone with abx (CIPRO)
- clean ear canal if blocked
- keep ear dry (put insert in when swimming if necessary)
- analgesia
- if no response- refer to ENT !!!! as you should be thinking nec otitis externa
- if ear canal is swollen shut- refer to oncall ENT as will need microsuction and insertion of a pope wick
151
What is malignant/necrotising otits externa
- invasion to the tympanic bone and beyond
| - can affect CN
152
What is a major RF for malignant/necrotising otits externa
Diabetes (90%), immunosupression
153
causative agent of nec otitis externa
Pseudomonas aeruginosa
154
sx of nec otitis externa
- severe otalgia disproportionate to clinical findings
- aural fullness (sensation of blockage or fullness of the ear)
- discharge
155
what would you see on otoscopy for nec otitis externa
- granulation of ear canal
156
ix for ?nec otitis externa
- CT temporal bone
| - MRI internal auditory cana and brain
157
tx nec otitis externa
oral and topical abx (cipro)
| debridement
158
what is the middle ear made up of
behind tympanic membrane
| contains Malleus, Incus, Stapes
159
what is the outer ear made up of
pinna, ear canal, tympanic membrance
160
what is the outer ear made up of
pinna, ear canal, tympanic membrane
161
causative organisms of acute otitis media
Strep pneumoniae, H. influenzae
viral
- respiratory syntactical virus
- rhinovirus
162
causative organisms of acute otitis media
Often precedes or is concurrent with URTI
Strep pneumoniae, H. influenzae
viral
- respiratory syntactical virus
- rhinovirus
163
What may occur in acute otitis media infections
eardrum perf (5%)
164
what are the RFs for recurrent otitis media infections
- early 1st episode
- GORD
- dummy use
- winter season
- supine feeding
165
sx of acute otitis media
- pain- younger children will pull at ear
- reduced hearing
nice n vague infective paeds sx-- malaise, irritable, fever, vomiting, poor feeding
- coryza/rhinorrhea - usually accompanied with URTI
166
signs of acute otitis media O/E
```
febrile
Otoscope
- red/yellow/cloudy TM
- bulging TM
- loss of light reflex
- air-fluid level behind TM
- discharge in canal secondary to perf
- erythema of pinna
```
167
sx of eardrum perf following an acute otitis media infection
- rapid resolution of acute otitis media sx
| - then ear discharges pus
168
management of acute otitis media
- majority will resolve spotaneously- sx should improve within 24 hours and resolve in 3d in 80% of children
- fever- NSAIDs, paracetemol
- advise come back if sx no better in 4 or any worsening (could do delayed px)- offer review of sx in 4d from onset
- abx
1st line- amoxicillin 5d course/erythromycin or clarithro if allergy
2nd line coamox
- give abx straight away if <2yo
- give abx if perforated (discharge) which occur following an episode of acute otitis media, then myringoplasty may be performed if the tympanic membrane does not heal by itself (6w)
169
who do you give immediate abx to for acute otitis media
- children who are systemically very unwell/serious illness
- eardrum has perfed (purulent discharge)
- higher risk of complications eg heart/lung/kidney/liver/neruomusc disease, immunocomp)
- those inwhich sx have lased >4d
170
when to admit a child with acute otitis media
- signs of systemic infection
- acute complication incl. mastoiditis, meningitis, intracranial abscess, sinus thrombosis, CN VII paralysis
- <3m old
_ children 3-6months with temp of 39
171
when should you seek specialist advise for acute otitis media
- 2 courses of abx not worked
- ?perf
- >3 episodes in 6m/>4 in 1 year
- impaired hearign after infection
172
what is glue ear
otitis media with effusion
| - collection of fluid within the middle ear without signs of acute infection
173
sx and signs of glue ear
developmental delay
| conductive hearing loss
174
ix for ?glue ear
- otoscopy
exclude acute otitis media, foreign body, impacted ear wax, imbalance disorder
- tympanometry
- audiometry/audiogram
175
Management of glue ear
1. observe
- consider developmental effects
- resolution occurs commonly in 6-12w
2. eustachian tube autoinflation with otovent tube
- not very effective
- blowing up balloon via the nostril 2-3 times a day
- stop if causes pain
- consider doing in observation phase
- in older children can do valsalva manouvre ie without the balloon- pinch nose and forcibly exhale
3. ventilation tubes- myringotomy and grommet insertion
- can be done with or wihtout adenoidectomy if frequent UTRI sx
4. hearing aids for BL otitis media and surgery not wanted/accepted
176
what is chronic suppurative otitis media , tx
- persistent purulent discharge with hearing loss
- usually due to otitis media or blockage of a eustachian tube
tx- microsuction and topical eardrops
177
sx and signs of pharyngitis
```
sore throat, esp when swallowing
hoarseness
mild cough
fever
headache
nausea
tiredness
```
swollen lymph nodes
may be pus on tonsils
178
when does pharyngitis usually subside by?
a week
179
tx of pharyngitis
fluids
NSAIDS, paracetemol, lozenges
most are caused by viruses so dont use abx routinely- use feverPAIN score (and then use phenoxymethylpenicillin - erythro/clarithro if allergic)
180
causative organsims of laryngitis
viral
- rhino
- adeno
- influenza
bacterial
- H.influenzae B
- Strep pneumoniae
- staph areus
181
other causes (not infective) of laryngitis
- voice misuse
| screaming, yelling, loud singing, coughing, habitual throat clearing
182
causes of chronic laryngitis
- GORD
- Smoking
- Trauma
- Autimmune disease
- Sarcoidosis
- allergies
- meds
183
sx of laryngitis
```
hoarseness
pain/discomfort in the neck
URTI- cough, rhinitis
dysphagia
lump in throat feeling
continual throat clearing
mayalgia, fever, malaise
```
184
qs to ask if laryngitis lasts >3w
```
other conditions:
sx of lung cancer
sx of thyroid disease
**hx of asthma, allergies (pets, mould)
sx of GORD- heartburn, chest pain, wheezing
**hx of intubation/neck trauma
**ingestion of caustic substance
travel hx
voice abuse
immunocoprimise (candida)
```
```
meds
**fam hx- autoimmune diseases, cancer, contagious diseases eg TB
social hx- smoking, rec drug, alcohol
sexual hx- syphillis
diet (GORD)
```
185
what medications may cause laryngitis
GORD inducers- bisphos, NSAIDs, abx, iron, quinidine, K
- immunosupressants
- ACEI, CCBs, nitrates, BB
- inhaled steroids
antihistammines, anticholinergic, diuretics- drying of mucosa
- danazol and testosterone, progesterone
186
redflags for hoarseness of voice ?laryngitis
- assess airway
- recent surgery to neck (consider recurrent laryngeal nerve injury)
- recent RT to neck
- recent endotracheal intubation
- hx of smoking, wt loss, mass in neck
- professional voice use
- otalgia, dysphagia, pain when swallowing (odynophagia)
- signs of serious systemic illness
187
tx of laryngtitis
should be mild and self limiting
vocal hygiene:
- rest voice
- avoid smoking and alcohol
- humidification
- hydration
- reduce caffeine
abx have limited effect
if chronic
- above plus
- voice therapy
tx underlying coniditon eg GORD
188
what is quinsy
peritonsillar abscess
| most commonly follows bacterial tonsillitis , can also be a complicaton of mononucleosis
189
causative agents of quinsy
strep pyogenes
staph areus
h. influenze
anaerobes
190
sx of quinsy
- severe UL sore throat
- dysphagia
- drooling of saliva
- trismus (difficulty opening mouth)
- hot potato voice- due to pharyngeal oedema and trsmus
- neck stiffness/pain
headache/malaise
191
signs of quinsy
* **- difficult to open mouth (trismus)
* **- +- torticollis severe neck muscle spasms- head fixed in place
- breath is fetid
- drooling/salivation
- UL bulging, usually above or lateral to the tnosil
- uvulae displacement
- Medial/anterior shift of tonsil
- erythema, enlarged
- exudate
- lymphadenopathy
192
ix for quinsy
- none- clinical diagnosis
193
Management of quinsy
- urgent ENT referral
- analgesia
- inscision, drainage
- IV abx
-- phenoxymethylpenicillin for 5-10 days
clarithro or erythro if allergic-- 5d
-- 2nd line- cephalosporins, coamox, clindamycin all ok
- consider tonsillectomy at 6w
- IV fluids
- IV immunoglobulins if atypical (eg S.pyogens)
- some studies show steroids IV with abx can help recovery
194
what advise would you give to someone recovering from quinsy
- keep fluid intake up
- avoid hot drinks- can make pain worse
- children may return to school or daycare after fever has resolved and no longer feeling unwell- and after abx for at least 24hours
195
primary causes of otalgia
otitis externa and otitis media
196
secondary causes of otlagia
-- otalgia accompanied with normal ear exam
- temporomandibular joint syndrome
- pharyngitis
- dental disease
- c spine arthritis
- tonsillar /tongue/pharygeal/laryngeal/ear cancer
197
sx of tonsillar ca
nekc mass
sore throat
bleeding
lockjaw
198
sx of tongue cancer
speech changed
| dysphagia
199
sx of pharyngeal ca
dysphagia
lump in throat
hoarseness
sore throat
200
sx of laryngeal ca
```
hoarseness
sore throat
dysphagia
cough, SOB
lump in throat
```
201
sx of ear malignancy
otorrhoea
| loss of hearing
202
what are the four types of hypersensitvity reactions
I- IgE mast cell
- immediate allergy
- eg anaphylaxis , asthma
II- cytotoxic IgG, IgM
- bind to antigen on target cell leading to cellular destruction -- transfusion reactions, autoimmunity
- testing- direct and indirect coombs
III- immune complexes-
- IgG binds to soluble antigen.
- Deposited in and damage tissues eg vessel walls of joint, kidneys
- autoimmunity eg RA, SLE
IV- delayed -
- memory t-cell respond to antigen and activate macrophages
- eg contact dermatitis
```
V
- autoimmune
igM or igG
- used as a dstinction from type 2
- Graves, MG
```
203
sx of allegric rhinitis
- itch
- puffy eyes
- nasal obstruction, rhinorrhoea
- sneezing
pmhx- eczema, asthma
204
ix for allegric rhinitis
clinical dx
| if poor repsonse to tx- skin prick test and RAST
205
tx of allergic rhinitis
mild/intermittent moderate
- intranasal antihistamine- azelastine, cetrizine
mod/severe/no reposnse to above
- intranasal corticosteroid
206
what type of hypersensitivity is allergic rhintiis
type I- IgE/mast cell mediated
207
sx of acute rhinosinusitis
- usually follows URTI
- obstruction
- loss of smell
- rhinorrhoea
- facial pain/pressure- worse when beindign over
- headache, toothache
- viral : <10d- peak then improves, clear discharge
- bacterial- >10d- improvement followed by further worsening of sx, purulent dishcarge
208
tx of rhinosinusitis
- supportive
adjuncts:
**- intranasal steroid
**decongestant- nasal ipratropium, steam
bacterial
- watch and wait for 10d or
- oral amoxicillin
- if immunocomp- just start abx
209
chronic sinusitis- what does this suggest
nasal polyps
| atopy
210
sx of chronic rhinosinusitis
sx of acute rhinosinusitis for >12w:
- change in smell
- obstruction
- mucopurulent discharge
- fail pain/fullness
- post nasal drip leading to (chronic) cough
211
ix for chronic rhinosinusitis
- anterior rhinoscopy with nasal endoscopy- to see if nasal polyps present
- CT is diagnostic and indictaed if medical tx has failed
212
tx of chronic rhinosinusitis
- saline irrigation
- corticosteroids- esp if polyps present
- abx
213
ddx for salivary gland swelling, managament for all in primary care
infection
- viral- mumps, coxsackie, parainfluenza A, parvovirus, herpes
- bacterial- staph aureus
- HIV related lymphcytic infiltration
```
inflammation
obstruction
- stone
- sjorgrens
- sarcoidosis
- granulomatosis with polyangitis
```
tumours
- benign
- malignant
All need urgent referral
214
sx of salivary galnd swelling and their meaning (ie ddx)
- loclised lump- tumour
- generalised swelling- inflammation, obstruction
- weakness in facial nerve- malignancy
- pressure on gland with mouth open can expel pus/stone from duct opening
- swelling on the floor of the mouth (sublinguinal gland)
- dry eyes- Sjogrens
- tooth enamel wasting- bulimia
- pain/swelling gets worse on eating- stone obstruction
215
how do you know if swelling is from salivary gland or lymph node
lymph node- possible to feel infront
| impossible t get infront of the parotid
216
ix for salivary gland swelling
```
FBC, CRP, UE, Blood culture, viral serology, HIV test
pus swab for MCS if present
sialography
USS
CT/MRI to exclude neoplasms
FNA or incisional biopsy
```
217
Management of salivary gland swelling
mumps- notifiable, self limiting
bacterial- abx with incisions for drainage if abscess
warm compress, sialogoes (lemon drops, gum, vit C lozenge), hydration, slaovary gland massage, oral hygeine
remove stones
218
what is a complication of nasal trauma?
septal haematoma
219
what is a risk/complication of septal haematoma
necrosis
220
sx of septal haematoma
obstructed nasal canal- difficulty breathing through nose, often following trauma
221
signs of septal haematoma
- boggy septum on palpation
| BL septal swelling
222
tx of septal haematoma
drainage
| abx if not caught early and has become infected
223
Causes of temporomandibular joint dysfunction
Muscle issues
- tension (clenching)
- overuse- gum chewing, biting nails
- movement disorders- orofacial dystonias
- increased sensitivity to pain
Joint issues
- OA
- RA
- Gout
- injury/trauma to TMJ
224
sx of temporomandibular joint dysfunction
- pain infront of the ear, may spread to the cheek, the ear and the temple
- reduced movement of the jaw- tightness, locking
- clicking/grating o fthe jaw
- ear sx
- noise in the ear
- sensitivity to sounds
- dizziness/vertigo
225
ix of temporomandibular joint dysfunction
- clinical dx
if sx dont settle
- bloods- inflam/gout
- XR- teeth for #, dislocations, severe OA
- MRI/CT
- arthroscopy
226
tx of temporomandibular joint dysfunction
- massage the muscles, hot compress
- improving posture can help
- splints, bite guards
- rest the joint
- physio
- tx underlying condition
- NSAIDs, paracetemol, codeine, TCA (small dose)
- muscle relaxants
- steroid injections
- surgery
- acupuncture
227
what advice can you give to someone with temporomadibular joint dysfunction concerign resting their TMJ
stop chewing gum/biting nails
try and keep teeth slightly apart with tongue resting in the bottom of your mouth
eat soft food
avoiding opening too widely- yawn smaller!
228
what physio exercise can be done for someone with TMJ dysfunction
- put finger on chin
- try to move jaw forward against resistance
- hold this for 12s
- repeat 3x
- do same laterally
- do several times a day
229
sx of tonsilltitis
obstructive sleep apnoea
- snoring with shirt pauses
- often restless, kick quilt off and end up on other side of bed
- behaviour goes off at about 2pm due to fatigue
- stridor- noisy breathing
- restless
- sweaty
- poor eater- drink milk copiously
- FFT
- behaviourla issues- hyperactivtiy, stress
230
O/E appearance of child with tonsillitis
- mouth breather
- adenoid faces- bags under eyes, mouth open, tnogue out a little bit
- large tnosils, may be exudative
- pes excavatum
231
tx of tonsillitis
Abx if indicated (feverpain)
- phenoxymethylpenicillin (penicillin V) for 5-10d
- clarithro or erythro if pregnant of allergic for 5d
- fluid intake
- avoid hot drinks- exacerbates pain
- return to school when fever has gone and no longer feeling unwell and wehn abx have started at leats for 24hours
adenotonsillectomy- GUIDELINES:
- 7 episodes in 1 year
- 5 episodes in 2 years
- 3 episodes in 3 years
- remember- 3 for 3 then two more for each preceding year
monitor O2 sats overnight post op
232
describe the scoring used to decide whether someone with sore throat/tonsillitits should be given abx
feverPAIN
- fever in past 24 hours (1)
- purulent tonsils (1)
- attend rapidly <3d (1)
***- inflammation of the tonsils (1)
- no cough or coryza (1)
calculates chance of strep being isolated
1- no abx
2-3- consider delayed script
4-5- consider abx
233
What is an acoustic neuroma/vestibular schwannoma
tumour of schwann cells of the myelin sheath in the vestibulocochler nerves
234
sx of acoustic neuroma
```
UL SN hearing loss
vertigo
tinnitus
facial numbness
facial N palsy
```
235
ix for ?acoustic neuroma
- audiometry- UL SN hearing loss, worsening in higher frequencies
- MRI gold standard
236
tx of acoustic neuroma
- refer to ENT
- conservative
- RT
- surgery
237
red flag sign concerning nasal polyps
UL
238
tx of perforated tympanic membrane that does not heal spotaneously within 6-8w /keeps getting infected/discharging
myringoplasty
239
what op can improve conductive hearing loss
stapedectomy
240
sx of Ramsay Hunt Syndrome
Herpes Zoster Oticus
- auricular pain
- CN VII palsy
- vesicular rash around the ear
- vertigo and tinnitus
241
tx Ramsay Hunt
PO acyclovir and pred
242
tx CMV
Ganciclovir
243
tx of sudden onset UL Sensorineural hearing loss
high-dose oral corticosteroids
| urgent referral to ENT
244
sx and tx of pharyngeal pouch
dysphagia
halitosis (bad breath)
regurgitation of undigested food
tx- surgical correction - diverticulectomy.
245
sx and signs of oesophageal candida
difficulty swallowing
history of steroid use
white plaques seen in the pharynx
246
what is Globus hystericus
sensation of lump in throat but no physical findings found on laryngoscopy
247
what are the sx of viral parotitis, incl complications
most commonly caused by mumps (orthorubulavirus)
- young adult
- parotid swelling
- pancreatitis
- orchitis
- reduced hearing
- meningoencephalitis
248
sx occurring in face with sarcoidosis
- bilateral (in most cases) parotid gland swelling
- dry mouth
- facial nerve palsies
- improves with steroids
249
Associations with nasal polyps
```
asthma (particularly late-onset asthma)
aspirin sensitivity
infective sinusitis
cystic fibrosis
Kartagener's syndrome
Churg-Strauss syndrome
```
250
side effect of LT use of nasal decongestants
tachyphylaxis (becoming tolerant/need more for same effect)
| rebound nasal congestion
251
management of traumatic haematoma of the ear cartilage
Untreated they can lead to a classic ‘cauliflower ear’ deformity.
- early incision and drainage (not needle aspiration) so same day ENT referral is needed.
252
what antiemetics do you use when
- Ondansetron from your Oncologist- CT induced nausea (5ht3)
- Haloperidol for causes in your Head (intracranial issues)
- Prochlorperazine for when you feel Peculiar (i.e. vestibular vertigo)
- Metoclopramide for things attached to the Mesentry- GI issues
253
complciations of sinusitis
- cerebral abscess (UL weakness, seizure)
| - cavernous sinus thrombosis- UL facial oedema, photophobia, proptosis, III, IV, VI palsies, V1 and V2 sensory palsies
