ENT Flashcards
1
Q
Hearing Loss
what is conductive hearing loss
A
a problem with sound travelling from the environment to the inner ear.
The sensory system may be working correctly, but the sound is not reaching it
Putting earplugs in your ears causes conductive hearing loss
2
Q
Hearing Loss
what is Sensorineural hearing loss
A
a problem with the sensory system or vestibulocochlear nerve in the inner ear.
3
Q
Hearing Loss
what is classed as sudden onset hearing loss
A
over less than 72h
4
Q
Hearing Loss
pts with hearing loss are more likely to develop what?
A
dementia
5
Q
Hearing Loss
what is Weber and Rinne’s test used for
A
to differentiate between sensorineural and conductive hearing loss
6
Q
Hearing Loss
how to perform Weber’s test
A
- Place stricken tuning fork it in the centre of the pt’s forehead
- Ask if they can hear and which ear it is loudest in
7
Q
Hearing Loss
what is normal result for the Weber’s test
A
patient hears the sound equally in both ears
8
Q
Hearing Loss
Weber’s test: what type of hearing loss is it if the sound is louder in the normal ear
A
sensorineural hearing loss
9
Q
Hearing Loss
Weber’s test: what type of hearing loss is it if the sound is louder in the affected ear
A
conductive hearing loss
10
Q
Hearing Loss
Weber’s test: why is the sound louder in the affected ear in conductive hearing loss
A
the affected ear “turns up the volume” and becomes more sensitive, as sound has not been reaching that side as well due to the conduction problem
When the tuning fork’s vibration is transmitted directly to the cochlea, rather than having to be conducted, the increased sensitivity makes it sound louder in the affected ear.
11
Q
Hearing Loss
how to perform Rinne’s test
A
- place stricken tuning fork on mastoid process : bone conduction
- tell me when you can no longer hear the hum
- ‘now’: hover tuning fork 1cm from same ear : air conduction
- can you hear sound now
12
Q
Hearing Loss
what is a normal Rinne’s test result
A
when the patient can hear the sound again when bone conduction ceases and the tuning fork is moved next to the ear rather than on the mastoid process
13
Q
Hearing Loss
what is a Rinne’s positive
A
normal! when the patient can hear the sound again when bone conduction ceases and the tuning fork is moved next to the ear rather than on the mastoid process
It is normal for air conduction to be better (more sensitive) than bone conduction
14
Q
Hearing Loss
what is an abnormal Rinne’s test result (Rinne’s negative)
A
when bone conduction is better than air conduction.
the sound is not heard after removing the tuning fork from the mastoid process and holding it near the ear canal
15
Q
Hearing Loss
what does a negative Rinne’s test indicate
A
conductive hearing loss
Sound is transmitted through the bones of the skull directly to the cochlea, meaning bone conduction is intact. However, the sound is less able to travel through the air, ear canal, tympanic membrane and middle ear to the cochlea due to a conductive problem.
16
Q
Hearing Loss
causes of sensorineural hearing loss
A
- Sudden sensorineural hearing loss
- Presbycusis (age-related)
- Noise exposure
- Ménière’s disease
- Labyrinthitis
- Acoustic neuroma
- Neuro conditions (stroke, MS or brain tumours)
- Infections (meningitis)
- Medications
17
Q
Hearing Loss
common medications that cause sensorineural hearing loss
A
- Loop diuretics (furosemide)
- Aminoglycoside antibiotics (gentamicin)
- Chemotherapy drugs ( cisplatin)
18
Q
Hearing Loss
causes of conductive hearing loss
A
- Ear wax (or something else blocking the canal)
- Infection (otitis media or otitis externa)
- Fluid in the middle ear (effusion)
- Eustachian tube dysfunction
- Perforated tympanic membrane
- Otosclerosis
- Cholesteatoma
- Exostoses
- Tumours
19
Q
Neck Lumps
what are the 3 descriptions to note the location of a neck lump
A
- anterior triangle
- posterior triangle
- midline
20
Q
Neck Lumps
what are the borders of the anterior triangle
A
mandible
midline
sternocleidomastoid
21
Q
Neck Lumps
what are the borders of the posterior triangle
A
clavicle
trapezius
sternocleidomastoid
22
Q
Neck Lumps
Ddx in adults
A
- Normal structures (e.g., bony prominence)
- Skin abscess
- Lymphadenopathy
- Tumour (e.g SCC or sarcoma)
- Lipoma
- Goitre or thyroid nodules
- Salivary gland stones or infection
- Carotid body tumour
- Haematoma
- Thyroglossal cysts
- Branchial cysts
23
Q
Neck Lumps
Ddx in young children
A
- Cystic hygromas
- Dermoid cysts
- Haemangiomas
- Venous malformation
24
Q
Neck Lumps
whom needs a 2 week wait referral
A
- unexplained neck lump in someone aged 45 or above
- a persistent unexplained neck lump at any age
25
Neck Lumps
pt with lump that is growing in size mnx
urgent USS
- within 2w in pts ≥25
- within 48h in pts <25
26
Neck Lumps
if USS is suggestive of soft tissue sarcoma, then what?
2 week wait referral
27
Neck Lumps
imaging
1st line: US
CT or MRI scans
Nuclear medicine scans e.g. for toxic thyroid nodules or PET scans for metastatic cancer
28
Neck Lumps
how to establish exact cause
biopsy may be required for histology
29
Neck Lumps
causes of enlarged lymph nodes
- reactive (e.g. URTI)
- infected (TB, HIV, mono)
- inflammatory conditions (SLE, sarcoidosis)
- malignancy
30
Neck Lumps
which enlarged cervical lymph nodes are most concerning for malignancy
supraclavicular nodes
31
Neck Lumps
features of malignant lymphadenopathy
- Unexplained (e.g not associated with an infection)
- Persistently enlarged (particularly over 3cm in diameter)
- Abnormal shape (normally oval shaped where the length is more than double the width)
- Hard or “rubbery”
- Non-tender
- Tethered or fixed to the skin or underlying tissues
- Associated symptoms, such as night sweats, weight loss, fatigue or fevers
32
Neck Lumps
what can a goitre be caused by
- Graves disease (hyperthyroidism)
- Toxic multinodular goitre (hyperthyroidism)
- Hashimoto’s thyroiditis (hypothyroidism)
- Iodine deficiency
- Lithium
33
Neck Lumps
individual lumps can occur in the thyroid due to?
- Benign hyperplastic nodules
- Thyroid cysts
- Thyroid adenomas (benign tumours the can release excessive thyroid hormone)
- Thyroid cancer (papillary or follicular)
- Parathyroid tumour
34
Neck Lumps
what are the 3 salivary glands
- parotid
- submandibular
- sublingual
35
Neck Lumps
reasons for salivary gland enlargement
- stones (block drainage)
- infection
- tumours
36
Neck Lumps
what is the carotid body
a structure located just above the carotid bifurcation (where the common carotid splits into the internal and external carotids).
37
Neck Lumps
what cells do the carotid body contain
glomus cells: chemoreceptors that detect the blood's O2, CO2 and pH
38
Neck Lumps
what are groups of glomus cells called
paraganglia
39
Neck Lumps
what are carotid body tumours
excessive growth of the glomus cells
40
Neck Lumps
presentation of carotid body tumours
- slow growing lump
- Painless
- Pulsatile
- bruit on auscultation
- Mobile side-to-side but not up and down
41
Neck Lumps
location of carotid body tumour
upper anterior triangle of the neck (near the angle of the mandible)
42
Neck Lumps
how may a carotid body tumour result in Horner syndrome (ptosis, miosis, anhidrosis)
pressure on the vagus nerve
43
Neck Lumps
what nerves may a carotid body tumour compress
glossopharyngeal (IX)
vagus (X)
accessory (XI)
hypoglossal (XII)
44
Neck Lumps
characteristic finding on imaging of a carotid body tumour
splaying (separating) of the internal and external carotid arteries (lyre sign).
45
Neck Lumps
mnx of carotid body tumour
surgical removal
46
Neck Lumps
examination of lipomas
Soft
Painless
Mobile
Do not cause skin changes
47
Neck Lumps
where do thyroglossal cysts occur
midline of neck
48
Neck Lumps
what is a thyroglossal cysts
the thyroglossal duct normally atrophies but may persist in some ppl.
fills with mucus
49
Neck Lumps
thyroglossal cyst key feature
move up and down with movement of the tongue.
50
Neck Lumps
what age group are thyroglossal cysts most common in
<20y
51
Neck Lumps
dx of thyroglossal cysts
US or CT
52
Neck Lumps
why are thyroglossal cysts surgically removed
to provide confirmation of the dx on histology and prevent infections
53
Neck Lumps
what is the main complication of a thyroglossal cyst
infection, causing a hot, tender and painful lump
54
Neck Lumps
what is a branchial cyst
a congenital abnormality that arises when the second branchial cleft fails to form properly during fetal development.
This leaves a space surrounded by epithelial tissue in the lateral aspect of the neck.
This space can fill with fluid. This fluid-filled lump is called a branchial cyst
55
Neck Lumps
where do branchial cysts occur
between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck.
56
Neck Lumps
features of a branchial cysts
round, soft, cystic swelling
transilluminates
>10y
57
Neck Lumps
mnx of branchial cysts
- conservative
| - surgically excised
58
Tonsillitis
what is the most common cause
viral infections
59
Tonsillitis
what is the most common bacterial cause
1. strep pyogenes (group A)
then
2. Strep pneumoniae
60
Tonsillitis
what are the 6 areas of lymphoid tissue in Waldeyer’s Tonsillar Ring
adenoids, tubal tonsils, palatine tonsils and the lingual tonsil.
61
Tonsillitis
which part of Waldeyer’s Tonsillar Ring is typically affected
palatine tonsils: the tonsils on either side at the back of the throat
62
Tonsillitis
typical presentation
- sore throat
- fever above 38
- pain on swallowing
63
Tonsillitis
examination findings
- red, inflamed and enlarged tonsils
- with or without exudates (small white patches of pus)
- anterior cervical lymphadenopathy
64
Tonsillitis
what score on the centor criteria means you should offer abx
3 or more
65
Tonsillitis
what is the centor criteria
- fever over 38
- tonsillar exudates
- absence of cough
- tender anterior cervical lymph nodes
66
Tonsillitis
what is the FeverPAIN score
Fever during previous 24h
Purulence
Attended within 3d of onset
Inflamed tonsils (severe)
No cough or coryza
67
Tonsillitis
what FeverPAIN score should indicate you to offer abx
≥ 4
68
Tonsillitis
when should you consider admission
- immunocompromised
- systemically unwell
- dehydrated
- has stridor
- respiratory distress
- evidence of a peritonsillar abscess
- cellulitis.
69
Tonsillitis
when should you advise pts to return
if the pain has not settled after 3 days or the fever rises above 38.3ºC
70
Tonsillitis
what is a delayed prescription
providing a prescription to be collected only if the symptoms worsen or do not improve in the next 2 – 3 days.
71
Tonsillitis
if bacterial what is the 1st line abx
Penicillin V aka phenoxymethylpenicillin
for 10d (effective against Strep pyogenes)
allergic? then clarithromycin
72
Tonsillitis
complications
- Peritonsillar abscess, aka quinsy
- Otitis media, if the infection spreads to the inner ear
- Scarlet fever
- Rheumatic fever
- Post-streptococcal glomerulonephritis
- Post-streptococcal reactive arthritis
73
Quinsy
aka
peritonsillar abscess
74
Quinsy
pathophysiology
- bacterial infection w/ trapped pus
- forms abscess in region of tonsils
- usually a complication of untreated or partially treated tonsillitis
75
Quinsy
additional symptoms that can indicate peritonsillar abscess
- trismus
- hot potato voice
- swelling + erythema in the area beside tonsils
76
Quinsy
what is trismus
unable to open mouth
77
Quinsy
most common cause
streptococcus pyogenes (group A strep),
also staphylococcus aureus and haemophilus influenzae.
78
Quinsy
mnx
incision + drainage of the abscess under GA
usually co-amoxiclav
79
Cholesteatoma
what is it
an 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
80
Cholesteatoma
pathophysiology
Eustachian tube dysfunction --> negative pressure in middle ear --> small area of tympanic membrane gets sucked inwards
squamous epithelial cells originate from the outer surface of the tympanic membrane.
The squamous epithelial cells of this pocket continue to proliferate and grow into the surrounding space, bones and tissues
It can damage the ossicles
81
Cholesteatoma
presenting sx
- Foul discharge from the ear
| - Unilateral conductive hearing loss
82
Cholesteatoma
what further sx may develop as the cholesteatoma continues to expand into the surrounding spaces and tissues
Infection
Pain
Vertigo
Facial nerve palsy
83
Cholesteatoma
what will it show on otoscopy
an abnormal build-up of whitish debris or crust in the upper tympanic membrane
84
Cholesteatoma
diagnostic inx
CT head
but MRI may help assess invasion and damage to local soft tissues.
85
Cholesteatoma
trx
surgical removal of the cholesteatoma.
86
Acoustic Neuroma
what are they
benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear.
87
Acoustic Neuroma
aka
vestibular schwannomas as they originate from the Schwann cells
cerebellopontine angle tumours: because they occur at the cerebellopontine angle
88
Acoustic Neuroma
where are schwann cells found
the peripheral nervous system and provide the myelin sheath around neurones.
89
Acoustic Neuroma
bilateral or unilateral
usually unilateral
Bilateral acoustic neuromas are associated with neurofibromatosis type II.
90
Acoustic Neuroma
presentation
aged 40-60 years presenting with a gradual onset of:
- Unilateral sensorineural hearing loss (often the first symptom)
- Unilateral tinnitus
- dizziness or imbalance
- sensation of fullness in the ear
91
Acoustic Neuroma
if the tumour grows large enough what can it cause
facial nerve palsy as it compresses the facial nerve
92
Acoustic Neuroma
what is the pattern of hearing loss
sensorineural pattern
93
Acoustic Neuroma
diagnostic inx
MRI or CT
| MRI is more detailed
94
Acoustic Neuroma
Mnx
- Conservative
- surgery
- radiotherapy
95
Acoustic Neuroma
notable risks associated with trx
Vestibulocochlear nerve injury, with permanent hearing loss or dizziness
Facial nerve injury, with facial weakness
96
Ménière’s Disease
typical triad of sx
- hearing loss
- vertigo
- tinnitus
97
Ménière’s Disease
pathophysiology
- excessive buildup of endolymph in the labyrinth of the inner ear
- causing a higher pressure than normal and disrupting the sensory signals
98
Ménière’s Disease
what is the name for increased pressure of endolymph
endolymphatic hydrops
99
40-50 years old, presenting with unilateral episodes of vertigo, hearing loss, and tinnitus. What is it
Ménière’s Disease
100
Ménière’s Disease
describe the vertigo
- episodes lasting 20 min - several hours
- clusters over several weeks. followed without vertigo for months
- not triggered by movement or posture
101
Ménière’s Disease
describe the hearing loss
- fluctuates at first
- then gradually more permanent
- sensorineural hearing loss
- generally unilateral
- affects low frequencies first
102
Ménière’s Disease
other symptoms apart from the vertigo, hearing loss, tinnitus
- sensation of fullness in the ear
- Unexplained falls (“drop attacks”) without loss of consciousness
- Imbalance, which can persist after episodes of vertigo resolve
103
Ménière’s Disease
what may be seen in an acute attack
Spontaneous nystagmus
usually in one direction (unidirectional).
104
Ménière’s Disease
dx
- clinical
105
Ménière’s Disease
inx
audiology assessment to evaluate hearing loss.
106
Ménière’s Disease
mnx for acute attacks
- Prochlorperazine
| - Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
107
Ménière’s Disease
prophylactic medication to reduce frequency of attacks
Betahistine
108
Labyrinthitis
pathophysiology
- viral URTI (rarely could be bacterial like otitis media or menigitis)
- inflammation of the bony labyrinth of the inner ear, inc the semicircular canals, vestibule (middle section) and cochlea
109
Labyrinthitis
presentation
- viral URTI
- acute onset vertigo
can be associated with
- hearing loss
- tinnitus
110
Labyrinthitis
similarity to vestibular neuronitis
acute onset vertigo
111
Labyrinthitis
difference to vestibular neuronitis
- hearing loss
| - tinnitus
112
Labyrinthitis
dx
clinical
important to exclude central cause of vertigo
113
Labyrinthitis
what test can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g. vestibular neuronitis or labyrinthitis).
head impulse test
114
Labyrinthitis
mnx
- supportive
up to 3 days of medication to suppress sx:
- Prochlorperazine
- Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
115
key complication of meningitis
bacterial labyrinthitis
All patients with meningitis are offered audiology assessment as soon as they are recovered to assess for hearing impairment
116
Vertigo
what is vertigo
a sensation that there is movement between the patient and their environment
117
Vertigo
what are the sensory inputs that are responsible for maintaining balance and posture
- vision
- proprioception
- signals from the vestibular system
118
Vertigo
what are the semicircular canals filled with
endolymph
119
Vertigo
As the head turns, the fluid shifts inside the canals. What detects the fluid shift
tiny hairs called stereocilia
120
Vertigo
where is the stereocilia found
in a section of the canal called the ampulla
121
Vertigo
what lets the brain know that the head is moving in a particular direction
- sensory input of shifting fluid detected by the stereocilia
- transmitted to the brain by the vestibular nerve
122
Vertigo
where does the vestibular nerve carry signals from and to
from the vestibular apparatus
to the vestibular nucleus in the brainstem and the cerebellum
123
Vertigo
where does the vestibular nucleus send signals to
the oculomotor, trochlear and abducens nuclei that control eye movements
and the thalamus, spinal cord and cerebellum.
124
Vertigo
what can the causes of vertigo be split up into
- peripheral: affecting the vestibular system
| - central: involving the brainstem or the cerebellum
125
Vertigo
what are the 4 most common causes of peripheral vertigo
- labyrinthitis
- vestibular neuronitis
- Benign paroxysmal positional vertigo
- Ménière’s disease
126
Vertigo
less common causes of peripheral vertigo
- Trauma to the vestibular nerve
- Vestibular nerve tumours (acoustic neuromas)
- Otosclerosis
- Hyperviscosity syndromes
- Herpes zoster infection (often with facial nerve weakness and vesicles around the ear – Ramsay Hunt syndrome)
127
Vertigo
how does a central problem cause vertigo
Pathology that affects the cerebellum or the brainstem disrupt the signals from the vestibular system
128
Vertigo
4 common causes of central vertigo
- Posterior circulation infarction (stroke)
- Tumour
- Multiple sclerosis
- Vestibular migraine
129
Vertigo
what kind of vertigo will all central causes present as
sustained, non-positional vertigo
130
Vertigo
difference between peripheral and central vertigo
- onset
- duration
- hearing loss or tinnitus
- coordiantion
- nausea
peripheral:
- sudden onset
- sec - mins
- hearing loss or tinnitus (except BPPV)
- intact coordination
- more severe nausea
central:
- gradual onset (except stroke)
- persistent duration
- usually no hearing loss or tinnitus
- impaired coordination
- mild nausea
131
Vertigo
what may a recent viral illness point to
labyrinthitis or vestibular neuronitis
132
Vertigo
what may a headache point to
Vertigo
vestibular migraine, cerebrovascular accident or brain tumour
133
Vertigo
what may Ear symptoms, such as pain or discharge point to
infection
134
Vertigo
what may an acute onset of neurological symptoms point to
stroke
135
Vertigo
four things to examine when assessing a patient presenting with vertigo:
- ear
- neuro
- cardio (CVD causes of dizziness - arrythmias, valve disease)
- special tests: Romberg, Dix-Hallpike manoeuvre, HINTS)
136
Vertigo
components of a cerebellar examination
DANISH
Dysdiadochokinesia
Ataxic gait ( walk heel-to-toe)
Nystagmus
Intention tremor
Speech (slurred)
Heel-shin test
137
Vertigo
what does the Romberg's test do
screens for problems with proprioception or vestibular function
138
Vertigo
what does the HINTS exam for
to distinguish between central and peripheral vertigo
139
Vertigo
what does HINTS stand for
HI – Head Impulse
N – Nystagmus
TS – Test of Skew
140
Vertigo
describe the head impulse test
- sit upright
- fix gaze on examiner's nose
- examiner rapidly jerks pt's head 20 degrees while pt still looks at nose
- repeat in opposite direction
141
Vertigo
normal head impulse test
pt will keep their eyes fixed on the examiner’s nose
142
Vertigo
head impulse test result with a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis),
eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner.
143
Vertigo
head impulse test result with a patient with a central cause of vertigo
normal
144
Vertigo
what does Unilateral horizontal nystagmus demonstrate
more likely to be a peripheral cause
145
Vertigo
what does Bilateral or vertical nystagmus suggest
a central cause
146
Vertigo
what is test of skew (aka alternate cover test)
- pt sits upright
- fix gaze on examiner's nose
- examiner covers one eye at a time
- eyes should remain fixed on the examiner’s nose with no deviation
147
Vertigo
what indicates a central cause in the test of skew
if there is a vertical correction when an eye is uncovered (the eye has drifted up or down and needs to move vertically to fix on the nose when uncovered)
148
Vestibular Neuronitis
what is it
inflammation of the vestibular nerve.
This is usually attributed to a viral infection.
it distorts the signals travelling from the vestibular system to the brain, confusing the signal required to sense movements of the head
149
Vestibular Neuronitis
What does the inner ear comprise of
- Semicircular canals
- Vestibule (middle section)
- Cochlea
150
Vestibular Neuronitis
which part of the ear is responsible for detecting movement of the head
semicircular canals
and otolith organs within the vestibule (the utricle and saccule)
151
Vestibular Neuronitis
which structure detects rotation of the head
the semi-circular canals
152
Vestibular Neuronitis
which structure detects gravity and linear acceleration
the otolith organs within the vestibule (the utricle and saccule)
153
Vestibular Neuronitis
which structure is responsible for hearing
cochlea
154
Vestibular Neuronitis
which nerve transmits signals from the vestibular system (the semicircular canals and vestibule) to the brain to help with balance
vestibular nerve
155
Vestibular Neuronitis
which nerve transmits signals from the cochlea to provide hearing.
The cochlear nerve
156
Vestibular Neuronitis
presentation
- acute onset of vertigo
- recent viral URTI
- vertigo constant then worsened by head movement
- N+V
- balance problems
157
Vestibular Neuronitis
why is tinnitus and hearing loss not a feature
the cochlea and cochlear nerve are not affected
158
Vestibular Neuronitis
different between labyrinthitis and neuronitis
Labyrinthitis – Loss of hearing
Neuronitis – No loss of hearing
159
Vestibular Neuronitis
which test can diagnose peripheral cause of vertigo (Vestibular neuronitis or labyrinthitis)
head impulse test (peripheral cause if their eyes saccade)
160
Vestibular Neuronitis
mnx
- Prochlorperazine
- Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
for up to 3 days
161
Vestibular Neuronitis
when do NICE recommend referral
if sx do not improve after 1w or resolve after 6w
as they may require further invx or vestibular rehabilitation therapy (VRT).
162
Vestibular Neuronitis
prognosis
Sx most severe for the first few days
after which they gradually resolve over the following 2-6 weeks.
163
Vestibular Neuronitis
what may develop after
BPPV
164
Benign Paroxysmal Positional Vertigo
presentation
- head movement triggers vertigo e.g. turning over in bed
- settles around 20-60s after
- asymptomatic between attacks
- often episodes occur over several weeks. then resolve
- but can reoccur weeks or months later
165
Benign Paroxysmal Positional Vertigo
does BPPV cause hearing loss or tinnitus
no
166
Benign Paroxysmal Positional Vertigo
pathophysiology
otoconia (crystals of calcium carbonate) become displaced into the semicircular canals
- which disrupt normal flow of endolymph through the canals, confusing the vestibular system
- Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.
167
Benign Paroxysmal Positional Vertigo
which part of the semi-circular canal is where the otoconia is displaced
the posterior semicircular canal
168
Benign Paroxysmal Positional Vertigo
why may the otoconia be displaced
- viral infection
- head trauma
- ageing
- idiopathic
169
Benign Paroxysmal Positional Vertigo
dx
Dix-Hallpike Manoeuvre
170
Benign Paroxysmal Positional Vertigo
how does the Dix-Hallpike work
moves endolymph through the semicircular canals and triggers vertigo in pts with BPPV
171
Benign Paroxysmal Positional Vertigo
In patients with BPPV, the Dix-Hallpike manoeuvre will trigger?
rotational nystagmus and symptoms of vertigo
eye will have rotational beats of nystagmus towards the affected ear
172
Benign Paroxysmal Positional Vertigo
mnx
Epley manoeuvre
Brandt-Daroff exercises
173
Tinnitus
definition
a persistent addition sound that is heard but is not present in the surrounding environment
174
Tinnitus
pathophysiology
a background sensory signal produced by the cochlea that is not effectively filtered out by the central auditory system
175
Tinnitus
what are the types
primary - unknown cause
secondary - cause known
176
Tinnitus
causes
- Impacted ear wax
- Ear infection
- Ménière’s disease
- Noise exposure
- Medications (e.g., loop diuretics, gentamicin and chemotherapy drugs such as cisplatin)
- Acoustic neuroma
- Multiple sclerosis
- Trauma
- Depression
177
Tinnitus
what systemic conditions may it also be associated with
- Anaemia
- Diabetes
- Hypothyroidism or hyperthyroidism
- Hyperlipidaemia
178
Tinnitus
what is objective tinnitus
when the patient can objectively hear an extra sound within their head
can hear sound on exam by auscultating with a stethoscope around the ear
179
Tinnitus
what may actual additional sounds (objective tinnitus) be caused by
- Carotid artery stenosis (pulsatile carotid bruit)
- Aortic stenosis (radiating pulsatile murmur sounds)
- Arteriovenous malformations (pulsatile)
- Eustachian tube dysfunction (popping or clicking noises)
180
Tinnitus
what may pulsatile indicate
a cardiovascular cause, such as carotid artery stenosis with a bruit)
181
Tinnitus
inx
- FBC, glucose, TSH, lipids
- audiology
- rarely CT, MRI: vascular malformations or acoustic neuromas
182
Tinnitus
red flags
- Unilateral
- Pulsatile
- Hyperacusis (hypersensitivity, pain or distress with environmental sounds)
- unilateral hearing loss
- sudden onset hearing loss
- vertigo or dizziness
- Headaches or visual symptoms
- Associated neuro sx or signs (e.g. facial nerve palsy or signs of stroke)
- Suicidal ideation
183
Tinnitus
mnx
- tends to resolve
- treat underlying cause (ear wax, infection)
- hearing aids
- sound therapy (adding background noise to mask tinnitus)
- CBT
184
Ear Wax
aka
cerumen
185
Ear Wax
impacted ear wax presentation
- Conductive hearing loss
- Discomfort in the ear
- A feeling of fullness
- Pain
- Tinnitus
186
Ear Wax
what are the 3 main methods of removing ear wax
- ear drops: olive oil or sodium bicarbonate 5%
- ear irrigation: squirting water in ears to clean away wax
- microsuction
187
Nosebleeds
aka
epistaxis
188
Nosebleeds
where does bleeding usually originate
Kiesselbach's plexus, which is located in Little's area
189
Nosebleeds
how may patients present as if they swallow blood during a nosebleed
vomiting blood
190
Nosebleeds
what may bleeding from both nostrils indicate
posterior bleed (higher risk of aspiration of blood)
191
Nosebleeds
advise pt on how to manage a nosebleed
- sit up + tilt the head forward
- squeeze the soft part of the nostrils together for 10-15 min
- spit out blood rather than swallowing
192
Nosebleeds
when may pts require hospital admission
- bleeding doesn't stop after 10-15 min
- severe
- bleeding from both nostils
- haemodynamically unstable
193
Nosebleeds
treatment options in hospital
- nasal packing: nasal tampons or inflatable packs
| - nasal cautery using silver nitrate sticks
194
Nosebleeds
what to prescribe after an acute nosebleed and why
Naseptin nasal cream (chlorhexidine and neomycin) QDS for 10d
to reduce crusting, inflammation + infection
195
Nosebleeds
who is Naseptin CI's in
people with a peanut or soya allergy
196
Nasal polyps
what are they
growths of the nasal mucosa that can occur in the nasal cavity or sinuses.
197
Nasal polyps
what are they often associated with
chronic rhinitis
198
Nasal polyps
red flag presentation
unilateral polyps are concerning for malignancy
199
Nasal polyps
which conditions is it associated with
- Chronic rhinitis or sinusitis
- Asthma
- Samter’s triad (nasal polyps, asthma and aspirin intolerance/allergy)
- Cystic fibrosis
- Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
200
Nasal polyps
presentation
- chronic rhinosinusitis
- difficulty breathing through the nose
- snoring
- nasal discharge
- anosmia
201
Nasal polyps
what to use to examine
- nasal speculum
or a otoscope with a large otoscope attached
- nasal endoscopy to visualsie the basal cavity in detail
202
Nasal polyps
how do nasal polyps present on the mucosal wall
round pale grey/yellow growths on the mucosal wall
203
Nasal polyps
medical mnx
intranasal topical steroid drops or spray.
204
Nasal polyps
surgical mnx for where the polyps are visibly close to the nostrils
Intranasal polypectomy
205
Nasal polyps
surgical mnx for where the polyps are further in the nose or the sinuses
Endoscopic nasal polypectomy
206
Obstructive Sleep Apnoea
what is it caused by
collapse of the pharyngeal airway
207
Obstructive Sleep Apnoea
RFs
- middle age
- male
- obese
- alcohol
- smoking
208
Obstructive Sleep Apnoea
presentation
- Episodes of apnoea during sleep (reported by their partner)
- Snoring
- Morning headache
- Waking up unrefreshed from sleep
- Daytime sleepiness
- Concentration problems
- Reduced oxygen saturation during sleep
209
Obstructive Sleep Apnoea
what can severe cases cause
hypertension, heart failure and can increase the risk of myocardial infarction and stroke.
210
Obstructive Sleep Apnoea
what is used to assess sx of sleepiness associated with OSA
Epworth Sleepiness Scale
211
daytime sleepiness and is a heavy vehicle operator. Mnx?
suspected OSA
urgent referral to ENT
212
Obstructive Sleep Apnoea
inx
sleep studies
213
Obstructive Sleep Apnoea
1st step in mnx
correct reversible RFs:
- stop drinking alcohol
- stop smoking
- lose weight
214
Obstructive Sleep Apnoea
2nd step in mnx
CPAP machine to maintain patency of airway
215
Obstructive Sleep Apnoea
surgical mnx
uvulopalatopharyngoplasty (UPPP)
216
Tonsillectomy
indications
number of episodes of acute sore throat:
≥7 in 1 year
5/yr for 2 years
3/yr for 3 years
- 2 episodes of tonsillar abscesses
- enlarged tonsils causing difficulty breathing, swallowing or snoring
217
Tonsillectomy
complications
- sore throat
- post-tonsillectomy bleeding
- damage to teeth
- infection
- risks associated with GA
218
Tonsillectomy
what is the main significant complication
post tonsillectomy bleeding
219
Tonsillectomy
how can post tonsillectomy bleeding be life threatening
due to the aspiration of blood
220
Tonsillectomy
mnx of post-tonsillectomy bleeding
- call ENT reg
- IV access, bloods: FBC, clotting, G+S, crossmatch
- analgesia
- spit out blood
- nil by mouth (in case op required)
- IV fluids if required
221
Tonsillectomy
mnx if there is severe post-tonsileltomy bleeding or airway cmopromise
call anaesthetist, intubation may be required
222
Tonsillectomy
2 options for stopping less severe post-tonsillectomy bleeds
hydrogen peroxide gargle
adrenaline soaked swab applied topically
223
Sinusitis
what is it
inflammation of the paranasal sinuses in the face
usually accompanies by inflammation of the nasal cavity (rhinosinusitis)
224
Sinusitis
types
acute (<12w)
chronic (>12w)
225
Sinusitis
pathophysiology
blockage of the ostia (hole that drains mucous) in the paranasal sinuses
226
Sinusitis
what are the 4 sets of paranasal sinuses
- frontal: above eyebrow
- maxillary: either side of the nose below the eyes
- ethmoid: in the ethmoid bone in the middle of the nasal cavity
- sphenoid: in the sphenoid bone at the back of the nasal cavity
227
Sinusitis
causes
- infection (viral URTI)
- allergies (hayfever)
- obstruction of drainage (foreign body, trauma, polyps)
- smoking
- asthmatics more likely to suffer from it
228
Sinusitis
presentation of acute sinusitis
recent viral URTI:
- nasal congestion
- nasal discharge
- facial pain or headache
- facial pressure
- facial swelling over the affected area
- loss of smell
229
Sinusitis
what will examination reveal
- tenderness to palpation of the affected areas
- inflammation and oedema of the nasal mucosa
- discharge
- fever
- other signs of systemic infection (e.g. tachycardia)
230
Sinusitis
what may chronic sinusitis be associated with
nasal polyps
231
Sinusitis
inx in patients with persistent symptoms despite treatment
- nasal endoscopy
| - CT scan
232
Sinusitis
mnx in pts with systemic infection or sepsis
require admission to hospital for emergency management
233
Sinusitis
mnx for pts up to 10d
NICE: do not offer abx as most are viral and resolve within 2-3w
234
Sinusitis
mnx for pts with sx after 10d
- High dose steroid nasal spray for 14d (e.g. mometasone 200 mcg BD)
- Delayed abx prescription, used if worsening or not improving within 7d (1st line: phenoxymethylpenicillin)
235
Sinusitis
mnx options for chronic sinusitis
- Saline nasal irrigation
- Steroid nasal sprays or drops (e.g. mometasone or fluticasone)
- Functional endoscopic sinus surgery (FESS)
236
Sinusitis
explain the nasal spray technique
- tilt head slightly forward
- use left hand to spray into right nostril and vice versa (to direct away from septum)
- do not sniff hard during the spray
- very gently inhale through the nose after the spray
- tasting the spray means it has gone past the nasal mucosa and will not be as effective
237
Sinusitis
what does functional endoscopic sinus surgery involve
- endoscope inserted through nostrils and sinuses
- remove or correct obstructions
- balloons may be inflated to dilate the opening of the sinuses
238
Sinusitis
what do pts need before a functional endoscopic sinus surgery
CT scan to confirm dx and assess the structures
239
Otitis Media
what is it
infection in the middle ear (contains the malleus, incus and stapes)
240
Otitis Media
what is the most common bacterial cause
streptococcus pneumoniae
then
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
241
Otitis Media
what is the primary presenting feature
ear pain
242
Otitis Media
presentation
- ear pain
- reduced hearing in the affected ear
- generally unwell: fever
- upper airway infection: cough, coryzal sx, sore throat
243
Otitis Media
sx when infection affects the vestibular system
balance issues and vertigo
244
Otitis Media
sx when the tympanic membrane has perforated
discharge from ear
245
Otitis Media
what will a normal tympanic membrane show on otoscopy
“pearly-grey”, translucent and slightly shiny
malleus through the membrane
cone of light reflecting the light of the otoscope
246
Otitis Media
otoscope findings
bulging, red, inflamed looking membrane
247
Otitis Media
otoscope findings when there is perforation
discharge in the ear canal and a hole in the tympanic membrane.
248
Otitis Media
when to consider immediate abx
patients who have significant co-morbidities, are systemically unwell or are immunocompromised.
249
Otitis Media
when to consider a delayed prescription
collected and used after 3 days if symptoms have not improved or have worsened at any time.
250
Otitis Media
1st line abx
amoxicillin for 5-7d
clarithromycin in penicillin allergy
erythromycin in pregnant women allergic to penicillin
251
Otitis Media
complications
- Otitis media with effusion
- Hearing loss (usually temporary)
- Perforated tympanic membrane (with pain, reduced hearing and discharge)
- Labyrinthitis (causing dizziness or vertigo)
- Mastoiditis (rare)
- Abscess (rare)
- Facial nerve palsy (rare)
- Meningitis (rare)
252
Otitis Externa
what is it
inflammation of the skin in the external ear canal
253
Otitis Externa
what are the types
acute <3w
chronic >3w
254
Otitis Externa
why is it called swimmers ear
exposure to water whilst swimming can lead to inflammation in the ear canal
255
Otitis Externa
causes
- Bacterial infection
- Fungal infection (e.g., aspergillus or candida)
- Eczema
- Seborrhoeic dermatitis
- Contact dermatitis
256
Otitis Externa
pt has had multiple courses of topical abx, what should you now think about
fungal infection
257
Otitis Externa
what are the 2 most common bacterial causes of otitis externa
- Pseudomonas aeruginosa
| - Staphylococcus aureus
258
Otitis Externa
what kind of bacteria is Pseudomonas aeruginosa
gram-negative aerobic rod-shaped bacteria
259
Otitis Externa
what abx are used against Pseudomonas aeruginosa
aminoglycosides (e.g., gentamicin) or quinolones (e.g., ciprofloxacin)
260
Otitis Externa
typical presentation
- Ear pain
- Discharge
- Itchiness
- Conductive hearing loss (if the ear becomes blocked)
261
Otitis Externa
what will examination show
- Erythema and swelling in the ear canal
- Tenderness of the ear canal
- Pus or discharge in the ear canal
- Lymphadenopathy (swollen lymph nodes) in the neck or around the ear
262
Otitis Externa
mnx of mild otitis externa
acetic acid 2% (available over the counter as EarCalm)
| can also be used prophylactically before and after swimming
263
Otitis Externa
mnx of moderate otitis externa
a topical abx + steroid e.g:
- Neomycin, dexamethasone and acetic acid (e.g., Otomize spray)
- Neomycin and betamethasone
- Gentamicin and hydrocortisone
- Ciprofloxacin and dexamethasone
264
Otitis Externa
what do you need to exclude before prescribing aminoglycosides in the ear (gentamicin + neomycin)
a perforated tympanic membrane
because they're ototoxic
265
Otitis Externa
when may pts need oral abx (e.g., flucloxacillin or clarithromycin)
Patients with severe or systemic symptoms
266
Otitis Externa
what may be used if the canal is very swollen, and treatment with ear drops or sprays will be difficult.
an ear wick
267
Otitis Externa
mnx for fungal infections
clotrimazole ear drops
268
Otitis Externa
what is malignant otitis externa
a severe and potentially life-threatening form of otitis externa
the infection spreads to the bones surrounding the ear canal and skull
it progresses to osteomyelitis of the temporal bone of the skull
269
Otitis Externa
RFs for malignant otitis externa
- Diabetes
- Immunosuppressant medications (e.g., chemotherapy)
- HIV
270
Otitis Externa
sx of malignant otitis externa
more severe
- persistent headaches
- severe pain
- fever
271
Otitis Externa
key finding on examination for malignant otitis externa
Granulation tissue
at the junction between the bone and cartilage in the ear canal
272
Otitis Externa
mnx of malignant otitis externa
- admission
- IV abx
- CT/MRI to assess extent of infection
273
Otitis Externa
complications of malignant otitis externa
- Facial nerve damage and palsy
- Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves)
- Meningitis
- Intracranial thrombosis
- Death
274
Head and Neck Cancer
what type are they usually
squamous cell carcinomas arising from the squamous cells of the mucosa.
275
Head and Neck Cancer
where are the potential areas of head and neck cancers
- Nasal cavity
- Paranasal sinuses
- Mouth
- Salivary glands
- Pharynx (throat)
- Larynx (epiglottis, supraglottis, vocal cords, glottis and subglottis)
276
Head and Neck Cancer
what is cancer of unknown primary
Squamous cell carcinoma cells may be found in an enlarged, abnormal lymph node (lymphadenopathy), and the original tumour cannot be found
277
Head and Neck Cancer
where do they spread to first
lymph nodes
278
Head and Neck Cancer
RFs
- Smoking
- Chewing tobacco
- Chewing betel quid (a habit in south-east Asia)
- Alcohol
- HPV, particularly strain 16
- EBV
279
Head and Neck Cancer
red flags
- Lump in the mouth or on the lip
- Unexplained ulceration in the mouth lasting >3w
- Erythroplakia or erythroleukoplakia
- Persistent neck lump
- Unexplained hoarseness of voice
- Unexplained thyroid lump
280
Head and Neck Cancer
trx
any combination of:
- chemo
- radio
- surgery
- targeted cancer drugs e.g. monoclonal antibodies
- palliative care
281
Head and Neck Cancer
example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck
Cetuximab
targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.
282
Glossitis
presentation
- red, sore swollen tongue
- smooth tongue: papillae of the tongue atrophy
- 'beefy'
283
Glossitis
causes
- Iron deficiency anaemia
- B12 deficiency
- Folate deficiency
- Coeliac disease
- Injury or irritant exposure
284
Glossitis
mnx
correct underlying cause
285
Angioedema
what is it
fluid accumulating in the tissues, resulting in swelling
286
Angioedema
3 top causes
1. allergic reactions
2. ACEi
3. C1 esterase inhibitor deficiency (hereditary angioedema)
287
Oral Candidiasis
presentation
white spots or patches that coat the surface of the tongue and palate.
288
Oral Candidiasis
RFs
- ICS: not rinsing mouth after
- abx
- diabetes
- immunodeficiency
- smoking
289
Oral Candidiasis
trx options
- Miconazole gel
- Nystatin suspension
- Fluconazole tablets (in severe or recurrent cases)
290
Geographic Tongue
what is it
inflammatory condition
patches of the tongue’s surface lose the epithelium and papillae.
The patches form irregular shapes on the tongue, resembling a map, with countries and oceans bordering each other.
291
Geographic Tongue
progression
relapse and remit, with episodes of the abnormal tongue appearance that can last days to weeks before resolving or changing
292
Geographic Tongue
which factors can it be related to
- Stress and mental illness
- Psoriasis
- Atopy (asthma, hayfever and eczema)
- Diabetes
293
Geographic Tongue
trx
none but discomfort or burning are sometimes treated with topical steroids or antihistamines
294
Strawberry Tongue
describe it
tongue becomes swollen and red
papillae become enlarged, white and prominent.
295
Strawberry Tongue
2 key causes
Kawasaki disease
Scarlet Fever
296
Black Hairy Tongue
pathophysiology
decreased shedding (exfoliation) of keratin from the tongue’s surface
The papillae elongate and take on the appearance of hairs
297
Black Hairy Tongue
what can cause the dark pigmentation
bacteria and food
298
Black Hairy Tongue
sx
- black hairy tongue
- sticky saliva
- metallic taste
299
Black Hairy Tongue
cause
- dehydration, dry mouth
- poor oral hygiene
- smoking
300
Black Hairy Tongue
mnx
- adequate hydration
- gentle brushing of tongue
- stop smoking
301
Leukoplakia
characteristics
white patches
- often on the tongue or buccal mucosa
- asymptomatic, irregular and slightly raised
- fixed in place, meaning they cannot be scraped off.
302
Leukoplakia
is it cancerous
no but precancerous
it increases the risk of squamous cell carcinoma of the mouth
303
Leukoplakia
inx
may require biopsy to exclude abnormal cells (dysplasia) or cancer
304
Leukoplakia
mnx
- stop smoking
- reduce alcohol intake
- close monitoring
- potentially laser removal or surgical excision
305
Erythroplakia
what is it
- similar to leukoplakia, except the lesions are red.
| - lesions that are a mixture of red and white.
306
Erythroplakia
why should pts be urgently referred
associated with a high risk of squamous cell carcinoma
307
Lichen Planus
what is it
an autoimmune condition that causes localised chronic inflammation of the skin
308
Lichen Planus
how does it present on the skin
Wickham’s striae
- shiny, purplish, flat-topped raised areas
- with white lines across the surface
309
Lichen Planus
who is it more common in
>45
women
310
Lichen Planus
what 3 patterns can it take in the mouth
- reticular
- erosive
- plaque
311
Lichen Planus
what does a reticular pattern involve
net-like web of white lines called Wickham’s striae.
312
Lichen Planus
how does the erosive lesions pattern present
urface layer of the mucosa is eroded, leaving bright red and sore areas of mucosa
313
Lichen Planus
how does the plaque pattern present
larger continuous areas of white mucosa
314
Lichen Planus
mnx
- good oral hygiene
- stop smoking
- topical steroids
315
Gingivitis
what is it
inflammation of the gums
316
Gingivitis
presentation
- swollen gums
- bleeding after brushing
- painful gums
- bad breath (halitosis)
317
Gingivitis
what can it lead to if not adequately managed
Periodontitis
318
Gingivitis
what is Periodontitis
severe and chronic inflammation of the gums and the tissues that support the teeth. This often leads to loss of teeth.
319
Gingivitis
what is acute necrotising ulcerative gingivitis
rapid onset of more severe inflammation in the gums
painful
320
what causes
| acute necrotising ulcerative gingivitis
Anaerobic bacteria usually cause this
321
Gingivitis
RFs
- plaque build up (inadequate brushing)
- smoking
- diabetes
- malnutrition
- stress
322
Gingivitis
what is a hardened plaque called
tartar
323
Gingivitis
trx
- good oral hygiene
- stop smoking
- dental hygienist to remove plaque + tartar
- chlorhexidine mouth wash
- dental surgery if required
324
Gingivitis
trx for acute necrotising ulcerative gingivitis
metronidazole
325
Gingival Hyperplasia
what is it
abnormal growth of the gums
326
Gingival Hyperplasia
causes
- gingivitis
- pregnancy
- Vit C deficiency
- Acute myeloid leukaemia
- CCB, phenytoin, ciclosporin
327
Aphthous Ulcers
what are they
very common, small, painful ulcers of the mucosa in the mouth
328
Aphthous Ulcers
appearance
well-circumscribed, punched-out, white appearance
329
Aphthous Ulcers
triggers
- emotional or physical stress
- trauma to the mucosa
- particular foods
330
Aphthous Ulcers
indications for which underlying conditions
- IBD
- coeliac
- Behcet disease
- vit deficiency
- HIV
331
Aphthous Ulcers
which topical trx can be used to treat symptoms
- Choline salicylate (e.g., Bonjela)
- Benzydamine (e.g., Difflam spray)
- Lidocaine
332
Aphthous Ulcers
what can be used if more severe
- Hydrocortisone buccal tablets applied to the lesion
- Betamethasone soluble tablets applied to the lesion
- Beclomethasone inhaler sprayed directly onto the lesion
333
Aphthous Ulcers
when do NICE recommend a 2 week wait referral
“unexplained ulceration” lasting over 3 weeks.
334
Audiometry
what is plotted on the x axis on an audiogram
frequency in hertz (Hz)
from low to high pitched
335
Audiometry
what is plotted on the y axis on an audiogram
volume in decibels (dB)
from loud at bottom to quiet at top
336
Audiometry
what symbol is used to mark left sided air conduction
X
337
Audiometry
what symbol is used to mark right sided air conduction
O
338
Audiometry
what symbol is used to mark left sided bone conduction
]
339
Audiometry
what symbol is used to mark right sided bone conduction
[
340
Audiometry
what is a normal hearing dB level
0 -20 (at the top of the chart)
341
Audiometry
what will a pt with sensorineural hearing loss show on an audiogram
both air + bone conduction readings will be >20dB (plotted below the 20dB line)
342
Audiometry
what will a pt with conductive hearing loss show on an audiogram
bone conduction readings will be normal (0-20 dB)
air conduction readings will be >20dB, below the 20dB line on the chart
343
Audiometry
what will a pt with mixed hearing loss show on an audiogram
Both air and bone conduction readings will be > 20 dB
however, there will be a difference of >15dB (bone conduction better than air conduction)
344
Presbycusis
what is it
sensorineural hearing loss that occurs as people get older
345
Presbycusis
which sounds are affected first
high-pitched sounds first and more notably than lower-pitched sounds.
346
Presbycusis
why does it happen
- loss of hair cells in the cochlea
- loss of neurones in the cochlea
- atrophy of the stria vascularis
- reduced endolymphatic potential
347
Presbycusis
RFs
- age
- male
- FH
- loud noise exposure
- diabetes
- HTN
- ototoxic medications
- smoking
348
Presbycusis
presentation
- gradual and insidious hearing loss
- speech difficult to hear + understand . Males easier to hear
- tinnitus
- may be worried of dementia
349
Presbycusis
diagnostic inx
audiometry
350
Presbycusis
what will audiometry show
- sensorineural hearing loss
| - worsening hearing loss at higher frequencies
351
Presbycusis
mnx
- optimise environment e.g. reduce ambient noise during convo
- hearing aids
352
Presbycusis
what can be used in pts when hearing aids are not sufficient
cochlear implants
353
Sudden Sensorineural Hearing Loss
definition
hearing loss over <72 h
unexplained by other causes
354
Conductive causes of rapid-onset hearing loss (not classed as SSNHL)
- ear wax/ foreign body
- infection
- fluid in middle ear
- Eustachian tube dysfunction
- Perforated tympanic membrane
355
Sudden Sensorineural Hearing Loss
cause
- idiopathic (90%)
- infection (meningitis, HIV, mumps)
- oxotoxic meds
- MS
- Migraine
- Stroke
- Acoustic neuroma
- Cogan's syndrome
356
Sudden Sensorineural Hearing Loss
what is Cogan's syndrome
a rare autoimmune condition causing inflammation of the eyes and inner ear
357
Sudden Sensorineural Hearing Loss
diagnostic inx
audiometry:
- loss of at least 30dB
- in 3 consecutive frequencies
358
Sudden Sensorineural Hearing Loss
mnx
- immediate referral to ENT
- assessment within 24h if presented within 30d of onset
- treat underlying cause
359
Sudden Sensorineural Hearing Loss
inx if stroke or acoustic neuroma considered
- MRI or CT head
360
Sudden Sensorineural Hearing Loss
trx if idiopathic SSNHL
- PO steroids
or
- intra-tympanic (via an injection of steroids through the tympanic membrane)
361
Eustachian Tube Dysfunction
what is it
when the tube between the middle ear and throat is not functioning properly.
362
Eustachian Tube Dysfunction
what is the eustachian tube for
to equalise the air pressure in the middle ear
and drain fluid from the middle ear.
363
Eustachian Tube Dysfunction
what may it be related to
- viral URTI
- allergies (hayfever)
- smoking
364
Eustachian Tube Dysfunction
presentation
- altered hearing
- popping noises or sensations in the ear
- fullness sensation in ear
- pain or discomfort
- tinnitus
365
Eustachian Tube Dysfunction
when do sx tend to get worse and why
flying, climbing a mountain or scuba diving
external air pressure changes and the middle ear pressure cannot equalise to the outside pressure
366
Eustachian Tube Dysfunction
what will otoscopy show
normal but important to rule out other causes e.g. otitis media
367
Eustachian Tube Dysfunction
when are inx not required
clear cause: recent viral URTI, hayfever etc
sx will resolve with time or simple trx
368
Eustachian Tube Dysfunction
inx for persistent, problematic or severe sx
- Tympanometry
- Audiometry
- Nasopharyngoscopy
- CT
369
Eustachian Tube Dysfunction
what does Tympanometry involve
- insert device into external auditory canal
- creates different air pressures in canal
- send sound in direction of tympanic membrane
- measure amount of sound reflected back off the tympanic membrane
- plot tympanogram (graph) of the sound absorbed (admittance) at different air pressures
370
Eustachian Tube Dysfunction
what is admittance
The amount of sound absorbed by the tympanic membrane and middle ear (not reflected back to the device)
371
Eustachian Tube Dysfunction
what will a normal ear show on tympanometry
he ambient air pressure is equal to the middle ear pressure in healthy ears
because sound is absorbed best when the air pressure in the ear canal matches the ambient air pressure
372
Eustachian Tube Dysfunction
what will tympanometry show
air pressure in the middle ear may be lower than the ambient air pressure
because new air cannot get in through the tympanic membrane to equalise the pressures.
tympanogram will show a peak admittance (most sound absorbed) with negative ear canal pressures.
373
Eustachian Tube Dysfunction
mnx
- none, wait
- valsalva manoeuvre
- Decongestant nasal sprays (short term only)
- Antihistamines and a steroid nasal spray for allergies or rhinitis
374
Eustachian Tube Dysfunction
what may be required in severe persistent cases
surgery:
- grommets
- Balloon dilatation Eustachian tuboplasty
- Treating any other pathology that might be causing symptoms, for example, adenoidectomy
375
Eustachian Tube Dysfunction
what is otovent
over the counter device
pt blows into a balloon using a single nostril, which can help inflate the Eustachian tube,
clear blockages and equalise pressure.
376
Eustachian Tube Dysfunction
how do grommets work
- tube inserted into tympanic membrane
| - allows air or fluid from the middle ear to drain through the tympanic membrane into the ear canal
377
Otosclerosis
what is it
remodelling of the small bones in the middle ear, leading to conductive hearing loss.
378
Otosclerosis
who is it more common in
<40
women
379
Otosclerosis
cause
- can be autosomal dominantly inherited
| - combination of environmental and genetic factors
380
Otosclerosis
pathophysiology
- abnormal bone remodelling and formation of the base of the stapes
- where it attaches to the oval window
- causing stiffening and fixation and preventing it from transmitting sound effectively
381
Otosclerosis
what kind of hearing loss is it
conductive
382
Otosclerosis
presentation
unilateral or bilateral
- hearing loss
- tinnitus
- talks quietly because conductive hearing loss with intact sensory hearing. Pt experiences their voice as being loud compared to the environment (due to bone conduction of their voice).
383
Otosclerosis
which pitched sound does it tend to affect
lower-pitched sounds
female speech may be easier to hear than male
384
Otosclerosis
otoscopy findings
normal
385
Otosclerosis
Weber's test finding
normal if otosclerosis is bilateral
if unilateral, the sound will be louder in the more affected ear.
386
Otosclerosis
Rinne's test
conductive hearing loss
sound will be easily heard when fork applied to mastoid process
will not hear sound when held close to ear canal
387
Otosclerosis
initial inx
audiometry: conductive hearing loss
388
Otosclerosis
what will tympanometry show and why
reduced admittance (absorption) of sound.
The tympanic membrane is stiff and non-compliant and does not absorb sound, reflecting most of it back
389
Otosclerosis
what can detect boney changes associated with otosclerosis
high resolution CT scan
390
Otosclerosis
mnx
- Conservative: hearing aids
| - Surgical (stapedectomy or stapedotomy)
391
what does a positive Schwartze’s sign indicate
Otosclerosis
392
what is the definitive test for a pharyngeal pouch
barium swallow, which usually reveals the diverticulum
393
some key points of follicular thyroid cancer
- 2nd most common
- more common in women
- presents later in life than papillary thyroid cancer
- metastasises late but more often via haematogenous spread
394
some key points of papillary thyroid cancer
- most common
- more common in women
- presents in the 3rd or 4th decade of life
- solitary nodule
- metastases locally early in the disease.
395
what is a pharyngeal pouch aka
Zenker's diverticulum
396
what is chronic analchasia a RF for
Oesophageal squamous cell carcinoma
397
definitive treatment for achalasia
Heller's cardiomyotomy: surgical procedure where the muscle fibers of the lower oesophagus are divided
398
what is achalasia
failure of the lower oesophageal sphincter to relax due to degeneration of the myenteric plexus
399
what medical trx can be given for achalasia
- Botulinum toxin injections (botox)
| - CCB/ nitrites in patients who fail botox therapy or are not suitable surgical candidates
400
what is the gold standard inx for achalasia
manometry
401
what would manometry show if pt has achalasia
1. high resting pressure in the lower oesophageal sphincter
2. incomplete relaxation of the lower oesophageal sphincter upon swallowing
3. absence of peristalsis
402
85y female with an irregular midline hard neck lump. Pain on swallowing, intermittent stridor, weight loss
What is it
anaplastic carcinoma
403
which histological sign is pathognomonic of papillary thyroid cancers
Orphan Annie Cells
404
medications that can relax the oesophagus
- IV Hyoscine butyl-bromide
| - CCB e.g. nifedipine
405
techniques which may assist in removing food lodged in oesophagus
- drink carbonated drink
| - eat wet bread
406
Ddx for dysphagia
- oesophageal cancer
- Oesophagitis
- achalasia
- pharyngeal pouch
- systemic sclerosis
- Myasthenia gravis
- Globus hystericus
407
what causes trismus
inflammation of the pterygoid muscles
408
what is the name of the lymph node affected by quinsy
Jugulodigastric lymph nodes
