ENT Flashcards
What are some causes of conductive hearing loss?
Pinna - atresia
External auditory canal - wax, FB, otitis externa, osteoma
Tympanic membrane - large perforation, tympanosclerotic plaque
Middle ear - OME, haemotympanum, cholesteatoma, otosclerosis
What tests can you perform in hearing loss?
Pure tone audiogram (subjective) and tympanogram (objective)
Free field hearing test
What are some causes of sensorineural hearing loss?
Inner ear - meningitis, cochlear aplasia, ototoxic medication, menieres, cochlear otosclerosis, noise induced hearing loss, presbycusis
Retrocochlear - cochlear nerve damage, IC lesions, IAM lesions
What is the commonest cause of sensorineural HL?
Age related HL - Presbycusis
Progressive bilateral degeneration due to loss of inner and outer hair cells.
Hearing impaired in background noise, may be described and sound is loud but not clear
What is characteristic of otosclerosis on an audiogram?
Carhart’s notch (dip in bone conduction)
Otosclerosis - abnormal bone growth at stapes so it may become fixed
What does conductive HL look like on a pure tone audiogram?
Air - bone gap
Reduction in air conduction compared to bone conduction
What does sensorineural HL look like on a pure tone audiogram?
Both are low
Most common cause - Presbycusis
What results can you get in a typanogram? (A, B, C)
Type A - normal middle ear
Type B - high volume - perforation, Low volume - middle ear effusion
Type C - Eustachian tube dysfunction
What decibels indicate normal hearing?
From - 10 to 20dB
What dB classifies mild - profound HL?
Mild = 20-40dB Moderate = 40-70dB Severe = 70-90dB Profound = 90-120dB
What might you present with in acute otitis media?
Rapid onset Otalgia, pyrexia
If perforates the pain eases and there is discharge
What commonly causes otitis media with effusion?
> 50% occur after AOM infection
Hearing loss, otalgia, ear fullness
common between 6 months and 4 years
Social problems - poor behaviour and listening, delay in speech and language, inattention
What is otitis externa?
Infection of the outer external auditory canal
Otalgia, discharge, ITCH
Commonly due to pseudomonas or candida
What is necrotising OE?
Aggressive and life threatening
Usually due to psuedomonas
Severe otalgia, keeps them awake at night, otorrhoea, ±facial/abducens palsy
Destruction of temporal bone and base of skull osteomyelitis
What is a cholesteatoma?
Build up or keratin debris in the middle ear
Dizziness, conductive hearing loss, ear pain and numbness, facial muscle weakness
Can lead to an infection - discharge
What is tinnitus?
A sound perceived for more than 5 minutes at a time, in the absence of any external acoustical or electrical stimulation of the ear and not occurring after loud sound exposure
Objective or Subjective
Intrusiveness depends on psychological state of pt
What is objective tinnitus?
Tinnitus audible to both the patient and examiner - somatosounds (AVM, glomus tumour, tympanic myoclonus)
What is Subjective tinnitus?
Tinnitus audible to only the patient - SNHL, Hyper-dynamic states (hyperthyroidism, pregnancy)
What symptoms must you have to diagnose Sinusitis in a patient presenting with facial pain?
Nasal blockage ± discharge
What are the red flags for sinonasal malignancy?
Unilateral symptoms, blood stained discharge, nasal obstruction, dental/orbital signs
Where do most nose bleeds originate?
Little’s area in the anterior septum - Kiesselbach’s plexus
What arteries make up Kiesselbach’s plexus?
Anterior ethmoidal (from internal carotid), Greater palatine, sphenopalatine* (from maxillary from external carotid) and Superior labial (from facial artery from the EC)
Why is it important to look for a septal haematoma (boggy cherry red swelling) after a nasal fracture?
Septal haematomas deprive the cartilage of its blood supply and can lead to ischaemic necrosis of the cartilage, perforation and then saddle nose deformity or can lead to a septal abscess
What is the difference between a tracheostomy and a laryngectomy?
Tracheostomy - Upper airway still patent
Laryngectomy - Larynx has been removed. Trachea is plugged into the front of the neck - no air from nose or mouth can reach the trachea
What are some indications for a tracheostomy?
Mechanical obstruction, respiratory failure, retention of bronchial secretions, protection of the tracheobronchial tree, elective surgery
What position are tracheostomys in?
Between tracheal ring 3 and 4
Where do you insert a needle in an emergency where the airway is obstructed? e.g., in angioedema, FB, massive facial trauma.
Cricothyroid ligament
What are the phases of nystagmus?
Slow phase - pathological drift
Fast phase - correcting the position
What is vertigo?
The sensation of movement between the patient and their environment. Due to a mismatch in the sensory inputs = visual, proprioception and vestibular function
What are the different types of vertigo?
Peripheral - BPPV, ototoxic medication, meniere’s disease
Central - CVA, MS, migraine, posterior circulation stroke, SoL
How might someone with benign parsoxymal positional vertigo present?
Sudden attacks of rotational vertigo
Related to head position
sec-min ± nausea
60-70y females
What prophylaxis can be given in Menirere’s disease?
Betahistine
What triad of symptoms may a patient with Ménière’s disease have?
Hearing loss
Tinnitus
Vertigo
Due to an excessive build up in pressure in the semicircular canals
(spontaneous nystagmus)
Patient presents with sudden onset vertigo. They have an URTI (viral infection) last week.
Establish if they have had any hearing loss -
Yes - Acute labyrinthitis
No - Vestibular neuronitis
What is Bell’s palsy?
An idiopathic unilateral LMN facial nerve palsy
Diagnosis of exclusion
How might Ramsay Hunt syndrome present?
Unilateral LMN facial nerve palsy WITH a painful, tender vesicular rash around the ear canal, pinna and around the ear
(can also be in ant 2/3 of mouth)
What are some causes of LMN Facial nerve palsy?
Infections - Otitis media, malignant OE, HIV, lymes
Systemic - Diabetes, sarcoidosis, MS, GB, Leukaemia
Tumours
Trauma
What can you use to grade facial nerve function?
House Brackmann Grading: I - VI
Where is the nasopharynx and what does it contain?
From base of skull to soft palate
Contains adenoids and Eustachian tube
Where is the oropharynx and what does it contain?
Lies behind oral cavity, from soft palate to hyoid bone
Contains lingual surface of epiglottis and tonsils
Where is the Laryngopharynx and what does it contain?
From hyoid bone to epiglottis, then where it divides (into larynx and oesophagua), down to the cricoid cartilage Contains: Pyriform fossa, post-cricoid region
What is the Centor criteria?
Used to determine whether tonsilitis is likely due to a bacterial cause and so give abx
- Fever > 38
- Tonsillar excudate
- Absence of cough
- Tender anterior cervical LN
What drug should you NOT give in glandular fever?
Amoxicillin / ampicillin - Can cause a non-allergic rash that takes ~6 months to recover
What is the most common type of head and neck cancer?
Squamous cell carinoma
Patient complains of an itchy ear, what is it likely to be?
Otitis externa
What are some causes of vertigo?
Peripheral:
BPPV, meniere’s disease, vestibular neuronitis, alcohol, vestibulotoxicity
Central
Migraine, stroke/TIA, head trauma, MS, SoL
What is BPPV?
Rotational vertigo seconds - min Related to head movement - commonly turning in bed, looking up Causes: idiopathic, head injury Hallpike test usually positive
Otolith dislodgment in the posterior semicircular canal, causing capula irritation - like a snow globe
What are some management options for meniere’s disease?
Lifestyle (low salt, reduce caffeine), education (have to let DVLA know)
Medical - prevention - betahistine, symptomatic - buccal prochlorperazine
Surgical - intratympanic steroid injection, intratympanic gentamicin
How does Meniere’s present?
Cardinal prodrome of hearing loss, tinnitus and aural fullness then vertigo
How does vestibular neuronitis present?
Acute vertigo and vomiting
No hearing loss
(hearing loss =acute labyrinthitis)
Typical 3 days bedriffen, then 3-6wks recurrent episodes, 3 months - intemittent vertigo, gradually lessening
tx - proclorperazine
What are some red flags in an oropharyngeal presentation such as tonsillitis?
Stridor, hoarse voice, hot–potato voice, trismus, sepsis, absolute dysphagia
What are some signs of a peri-tonsillar abscess (quinsy)?
Deviation of tonsil and uvula towards midline (away from quinsy), trismus, hot-potato voice, painful sore throat, drooling of saliva, dysphagia, ipsilateral otalgia, lymphadenopathy
What is stridor?
Harsh sound created. by upper tracheal and laryngeal obstruction. can be inspiratory, biphasic or expiratory
What are some causes of stridor?
Extra luminal - tumour, abscess, haematoma in the neck
Intramural - tumour of the larynx, paralysis of the vocal cords, epiglottitis, subglottic stenosis
Intraluminal - FB, blood, secretions inside the airway
How might Sialolithasis present?
Salivary gland stones-
Intermittent pain and swelling associated with meals ± palpable hard lump in the duct
Most commonly in submandibular
How might you manage sialolithasis?
Hydration, sialogogues, analgesia ± antibiotics
Sialendoscopy
Surgery to remove stones ± gland
What is sialadentitis?
Infection or inflammation of the salivary gland
Swelling of gland ± pain ± systemic upset
Supportive tx
How would you manage achalasia?
- CCB or nitrates
2. POEM (per pral endoscopic myotomy) or endoscopic balloon dilation
What would you suspect in a child with a protruding ear, with redness, tenderness and swelling behind the ear?
Mastoiditis - infection of the air cells in the mastoid bone ± abscess
- Neuro observations - checking for IC abscess
- well - 24h IV abx, unwell - CT head
What does a intracerebral abscess look like on a CT with contrast?
Ring enhancing lesion
A glomus tumour can cause objective tinnitus, what is it?
A paraganglioma that can occur in the middle ear.
A persistent, pulsatile tinnitus
Can secrete catecholamines - HTN
?Red pulsatile mass on the tympanic membrane
How might a patient with allergic rhinitis present?
Hx of atopy?
Nasal congestion, rhinorrhoea, nasal puritis, conjunctivitis? sneezing
How might you manage allergic rhinitis?
Nasal irrigation or saline rinses
PO/ intranasal antihistamines or intranasal steroids
What is non-allergic rhinitis?
Inflammation of the nasal mucosa not caused by an allergen
Similar Sx to allergic rhinitis but a negative allergy test. May be a crust, foul smell and bleeding
Rebound nasal congestion and rhinorrhoea to rhinitis nasal sprays
What happens in Non-allergic rhinitis if you give nasal sprays?
May have rebound nasal congestion and rhinorrhoea
What criteria do you need to meet for a diagnosis of rhinosinusitis?
At least 1 of:
Nasal obstruction or discharge (mucopurulent) with facial pain or pressure ± hyosmia or anosmia
Acute < 12 with complete resolution of sx
Chronic > 12 weeks without resolution of sx
In a nasal fracture, what immediate complications do you need to assess for?
Epistaxis
**Septal haematoma - you must document that you have looked for one
What can anterior rhinoscopy be used for?
Epistaxis, septal haematoma, septal devaition
In a nasal fracture, when will the nasal fracture clinic see you?
5-7 days after once the swelling has settled and allows for a better examination
If conservative management is inappropriate for a nasal fracture e.g. due to major deformity, what procedure can be performed?
Septorhinoplasty
Usually done >6mon after injury
What is a septal haematoma?
Injury to the blood vessels of the muchoperichondrium overlying the cartilaginous septum
Why do you need to refer a septal haematoma urgently and ensure you always look for one?
They can deprive the cartilage of its blood supply and cause ischemic necrosis, septal perforation and result in a saddle nose deformity
Delayed complication- abscess - IC abscess, meningitis, cavernosus sinus thrombosis
What would you see on inspection of a nose with a septal haematoma?
Boggy cherry red swelling
?unilateral or bilateral (?nasal obstruction)
Needs seen URGENTLY by ENT
How do you manage a septal haematoma?
Incision and drainage
Antibiotics
What can a septal abscess present with?
Its a delayed complication
Headache, malaise, increasing pain, worsening nasal obstruction, fever
Examine CN *
I&D, IV abx
What factors are important in balance and can be disrupted in vertigo?
Sensory input (vestibulo-ocular reflex) Vestibular function Proprioception
What is nystagmus?
A rhythmic, biphasic, oscillatory movement of the eyes
phase 1 - slow drift (pathological)
phase 2 - fast correction of the drift
Defined by the direction of the fast phase
Explain the pathophysiology of BPPV **
Normally when the head turns, endolymph moves, semicircular canal receptors fire to say the head is moving. When the head stops moving the endolymph stops and the receptors stop firing.
In BPPV
The head stops turning, but due to the otoliths being dislodged, it drags the endolymph and so the receptors in the semicircular canals keep firing.
Vestibular system =’head is still moving’
Visual = Head is not moving
Brain = room must be spinning
Explain the positive results from a dix-hallpike test.
Upbeating torsional nystagmus - Posterior canal BPPV
Downbeating torsional nystagmus - Anterior canal BPPV
How can you manage ménière’s disease?
Lifestyle - Low salt and caffeine intake
Supportive - hearing aid, counselling, vestibular rehabilitation
Medical - Acute attack - Prochlorperazine (anti-histamine)
Preventative - beta histine (histamine analogue)
Surgery - grommet insertion? Intratympanic Gentamicin
How might you manage a patient with Bell’s palsy?
Prednisolone within 72h onset of sx 7-10d
Usually takes several weeks to recover but can take 12m and some are left with some weakness
- Lubricating eye drops (if eye pain- exposure keratopathy - refer)
- Tape to close eye at night
What is Ramsay Hunt syndrome?
Painful vesicular rash around the ear (EAC, pinna and around ear), with unilateral LMN facial nerve palsy
Varicella zoster virus
rash can extend to ant 2/3 tongue and hard palate
? hearing loss + vertigo
How would you manage Ramsay Hunt syndrome?
Prednisolone and acyclovir within 72h
Lubricating eye drops
Analgesia
What is tonsillitis and what commonly causes bacterial tonsillitis?
Infection of the palatine tonsils
Group A step such as strep pyogens
The centor criteria is used to assess if the tonsillitis is bacterial (group a step), what does it consist of?
Fever >38
Absence of a cough
Tonsillar exudate
Tender anterior cervical lymphadenopathy
> = 3 - offer abx
Penicillin V + analgesia 10d
What drug should you avoid in glandular fever?
Amoxicillin, ampicillin
Can cause a non-allgeric rash that cab last 6months
What are some complications of tonsillitis?
Quinsy (peritonsillar abscess)
Retropharyngeal abscess (Dec neck ROM, well child, swinging pyrexia, ?airway compromise)
Deep neck abscess/ parapharyngeal abscess (Dec neck ROM, unwell, febrile child, neck mass, ?airway compromise)
Epiglottitis (cherry red swelling) or supraglottitis
Potts puffy tumour
Periorbital cellulitis
Laryngeal cancer is a cause of hoarse voice, why does this occur and what is the most common laryngeal cancer?
Malignant changes in the larynx prevents normal movement of the vocal cords
Squamous cell carcinoma
Vocal cord paralysis can cause a hoarse or breathy voice, what can occur if the vocal cords are paralysed and adducted?
Potential for airway compromise
Abducted causes breathy voice but no airway compromise
Chocking and coughing after swallowing
HPV can cause a hoarse voice, what is this called and what strains are involved?
Recurrent respiratory papillomatosis
HPV 6, 11
Warty looking
What are some causes of hoarse voice?
Laryngeal cancer (squamous cell)
Lung primary (Pancoast, presses on RLN)
Pesbyphonia (age related, bowing of cords)
Laryngitis
Vocal cord polyp (voice abuse, chronic cough, smoking, alcohol)
Vocal cord granuloma (repeated damage and healing)
Vocal cord nodule (voice misuse)
Rinkes oedema (inflammatory, lateral cordotomy to drain. Deepening of voice - smokers*)
Muscle tension dysphoria (functional disorder)
Vocal cord paralysis (breathy voice, if Abducted ?airway compromise)
Recurrent respiratory papillomatosis (HPV 6, 11, warty looking)
What is Samter’s triad?
Aspirin sensitivity + asthma + nasal polyposis
When should an auricular haematoma be seen by ENT?
Same day referral - can cause necrosis of the cartilage
What should you do if a patient post-tonsillectomy has a small amount of bleeding?
Send to ENT for assessment - all bleeding in a post-tonsillectomy pt
What is a branchial cyst and what may tell you it is this?
A benign developmental defect of the branchial arches. usually a lump in the anterior triangle just in front of the SCM
Cholesterol crystals **
When you should refer a sudden SNHL?
Always refer a sudden onset SNHL urgently
What is a pleomorphic adenoma?
(also known as a benign mixed tumour) is a benign tumour of the parotid gland. There is potential for malignant transformation so should be removed routinely
What is double sickening and what does it indicate has happened in a pt with facial pain and purulent discharge?
‘Double sickening’ associated with bacterial sinusitis – an initial period of recovery followed by a sudden worsening of symptoms. It is thought to be caused by a secondary bacterial infection following a viral rhinosinusitis.
What is the Moa of promethazine (in vertigo)?
Prevent histamine from binding and stimulating the cells. Promethazine also blocks the action of acetylcholine (anticholinergic effect), and this may explain its benefit in reducing the nausea of motion sickness. It is used as a sedative because it causes drowsiness as a side effect.
