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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

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2
Q

Hearing Loss

what is Sensorineural hearing loss

A

a problem with the sensory system or vestibulocochlear nerve in the inner ear.

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3
Q

Hearing Loss

what is classed as sudden onset hearing loss

A

over less than 72h

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4
Q

Hearing Loss

pts with hearing loss are more likely to develop what?

A

dementia

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5
Q

Hearing Loss

what is Weber and Rinne’s test used for

A

to differentiate between sensorineural and conductive hearing loss

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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
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7
Q

Hearing Loss

what is normal result for the Weber’s test

A

patient hears the sound equally in both ears

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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

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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

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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.

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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
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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

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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

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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

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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.

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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
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17
Q

Hearing Loss

common medications that cause sensorineural hearing loss

A
  • Loop diuretics (furosemide)
  • Aminoglycoside antibiotics (gentamicin)
  • Chemotherapy drugs ( cisplatin)
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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
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19
Q

Neck Lumps

what are the 3 descriptions to note the location of a neck lump

A
  • anterior triangle
  • posterior triangle
  • midline
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20
Q

Neck Lumps

what are the borders of the anterior triangle

A

mandible
midline
sternocleidomastoid

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21
Q

Neck Lumps

what are the borders of the posterior triangle

A

clavicle
trapezius
sternocleidomastoid

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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
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23
Q

Neck Lumps

Ddx in young children

A
  • Cystic hygromas
  • Dermoid cysts
  • Haemangiomas
  • Venous malformation
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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

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25
Q

Neck Lumps

pt with lump that is growing in size mnx

A

urgent USS

  • within 2w in pts ≥25
  • within 48h in pts <25
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26
Q

Neck Lumps

if USS is suggestive of soft tissue sarcoma, then what?

A

2 week wait referral

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27
Q

Neck Lumps

imaging

A

1st line: US

CT or MRI scans

Nuclear medicine scans e.g. for toxic thyroid nodules or PET scans for metastatic cancer

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28
Q

Neck Lumps

how to establish exact cause

A

biopsy may be required for histology

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29
Q

Neck Lumps

causes of enlarged lymph nodes

A
  • reactive (e.g. URTI)
  • infected (TB, HIV, mono)
  • inflammatory conditions (SLE, sarcoidosis)
  • malignancy
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30
Q

Neck Lumps

which enlarged cervical lymph nodes are most concerning for malignancy

A

supraclavicular nodes

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31
Q

Neck Lumps

features of malignant lymphadenopathy

A
  • 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
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32
Q

Neck Lumps

what can a goitre be caused by

A
  • Graves disease (hyperthyroidism)
  • Toxic multinodular goitre (hyperthyroidism)
  • Hashimoto’s thyroiditis (hypothyroidism)
  • Iodine deficiency
  • Lithium
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33
Q

Neck Lumps

individual lumps can occur in the thyroid due to?

A
  • Benign hyperplastic nodules
  • Thyroid cysts
  • Thyroid adenomas (benign tumours the can release excessive thyroid hormone)
  • Thyroid cancer (papillary or follicular)
  • Parathyroid tumour
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34
Q

Neck Lumps

what are the 3 salivary glands

A
  • parotid
  • submandibular
  • sublingual
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35
Q

Neck Lumps

reasons for salivary gland enlargement

A
  • stones (block drainage)
  • infection
  • tumours
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36
Q

Neck Lumps

what is the carotid body

A

a structure located just above the carotid bifurcation (where the common carotid splits into the internal and external carotids).

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37
Q

Neck Lumps

what cells do the carotid body contain

A

glomus cells: chemoreceptors that detect the blood’s O2, CO2 and pH

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38
Q

Neck Lumps

what are groups of glomus cells called

A

paraganglia

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39
Q

Neck Lumps

what are carotid body tumours

A

excessive growth of the glomus cells

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40
Q

Neck Lumps

presentation of carotid body tumours

A
  • slow growing lump
  • Painless
  • Pulsatile
  • bruit on auscultation
  • Mobile side-to-side but not up and down
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41
Q

Neck Lumps

location of carotid body tumour

A

upper anterior triangle of the neck (near the angle of the mandible)

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42
Q

Neck Lumps

how may a carotid body tumour result in Horner syndrome (ptosis, miosis, anhidrosis)

A

pressure on the vagus nerve

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43
Q

Neck Lumps

what nerves may a carotid body tumour compress

A

glossopharyngeal (IX)
vagus (X)
accessory (XI)
hypoglossal (XII)

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44
Q

Neck Lumps

characteristic finding on imaging of a carotid body tumour

A

splaying (separating) of the internal and external carotid arteries (lyre sign).

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45
Q

Neck Lumps

mnx of carotid body tumour

A

surgical removal

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46
Q

Neck Lumps

examination of lipomas

A

Soft
Painless
Mobile
Do not cause skin changes

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47
Q

Neck Lumps

where do thyroglossal cysts occur

A

midline of neck

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48
Q

Neck Lumps

what is a thyroglossal cysts

A

the thyroglossal duct normally atrophies but may persist in some ppl.

fills with mucus

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49
Q

Neck Lumps

thyroglossal cyst key feature

A

move up and down with movement of the tongue.

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50
Q

Neck Lumps

what age group are thyroglossal cysts most common in

A

<20y

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51
Q

Neck Lumps

dx of thyroglossal cysts

A

US or CT

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52
Q

Neck Lumps

why are thyroglossal cysts surgically removed

A

to provide confirmation of the dx on histology and prevent infections

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53
Q

Neck Lumps

what is the main complication of a thyroglossal cyst

A

infection, causing a hot, tender and painful lump

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54
Q

Neck Lumps

what is a branchial cyst

A

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

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55
Q

Neck Lumps

where do branchial cysts occur

A

between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck.

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56
Q

Neck Lumps

features of a branchial cysts

A

round, soft, cystic swelling

transilluminates

> 10y

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57
Q

Neck Lumps

mnx of branchial cysts

A
  • conservative

- surgically excised

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58
Q

Tonsillitis

what is the most common cause

A

viral infections

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59
Q

Tonsillitis

what is the most common bacterial cause

A
  1. strep pyogenes (group A)
    then
  2. Strep pneumoniae
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60
Q

Tonsillitis

what are the 6 areas of lymphoid tissue in Waldeyer’s Tonsillar Ring

A

adenoids, tubal tonsils, palatine tonsils and the lingual tonsil.

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61
Q

Tonsillitis

which part of Waldeyer’s Tonsillar Ring is typically affected

A

palatine tonsils: the tonsils on either side at the back of the throat

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62
Q

Tonsillitis

typical presentation

A
  • sore throat
  • fever above 38
  • pain on swallowing
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63
Q

Tonsillitis

examination findings

A
  • red, inflamed and enlarged tonsils
  • with or without exudates (small white patches of pus)
  • anterior cervical lymphadenopathy
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64
Q

Tonsillitis

what score on the centor criteria means you should offer abx

A

3 or more

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65
Q

Tonsillitis

what is the centor criteria

A
  • fever over 38
  • tonsillar exudates
  • absence of cough
  • tender anterior cervical lymph nodes
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66
Q

Tonsillitis

what is the FeverPAIN score

A

Fever during previous 24h

Purulence

Attended within 3d of onset

Inflamed tonsils (severe)

No cough or coryza

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67
Q

Tonsillitis

what FeverPAIN score should indicate you to offer abx

A

≥ 4

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68
Q

Tonsillitis

when should you consider admission

A
  • immunocompromised
  • systemically unwell
  • dehydrated
  • has stridor
  • respiratory distress
  • evidence of a peritonsillar abscess
  • cellulitis.
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69
Q

Tonsillitis

when should you advise pts to return

A

if the pain has not settled after 3 days or the fever rises above 38.3ºC

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70
Q

Tonsillitis

what is a delayed prescription

A

providing a prescription to be collected only if the symptoms worsen or do not improve in the next 2 – 3 days.

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71
Q

Tonsillitis

if bacterial what is the 1st line abx

A

Penicillin V aka phenoxymethylpenicillin

for 10d (effective against Strep pyogenes)

allergic? then clarithromycin

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72
Q

Tonsillitis

complications

A
  • 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
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73
Q

Quinsy

aka

A

peritonsillar abscess

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74
Q

Quinsy

pathophysiology

A
  • bacterial infection w/ trapped pus
  • forms abscess in region of tonsils
  • usually a complication of untreated or partially treated tonsillitis
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75
Q

Quinsy

additional symptoms that can indicate peritonsillar abscess

A
  • trismus
  • hot potato voice
  • swelling + erythema in the area beside tonsils
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76
Q

Quinsy

what is trismus

A

unable to open mouth

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77
Q

Quinsy

most common cause

A

streptococcus pyogenes (group A strep),

also staphylococcus aureus and haemophilus influenzae.

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78
Q

Quinsy

mnx

A

incision + drainage of the abscess under GA

usually co-amoxiclav

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79
Q

Cholesteatoma

what is it

A

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

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80
Q

Cholesteatoma

pathophysiology

A

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

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81
Q

Cholesteatoma

presenting sx

A
  • Foul discharge from the ear

- Unilateral conductive hearing loss

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82
Q

Cholesteatoma

what further sx may develop as the cholesteatoma continues to expand into the surrounding spaces and tissues

A

Infection
Pain
Vertigo
Facial nerve palsy

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83
Q

Cholesteatoma

what will it show on otoscopy

A

an abnormal build-up of whitish debris or crust in the upper tympanic membrane

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84
Q

Cholesteatoma

diagnostic inx

A

CT head

but MRI may help assess invasion and damage to local soft tissues.

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85
Q

Cholesteatoma

trx

A

surgical removal of the cholesteatoma.

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86
Q

Acoustic Neuroma

what are they

A

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

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87
Q

Acoustic Neuroma

aka

A

vestibular schwannomas as they originate from the Schwann cells

cerebellopontine angle tumours: because they occur at the cerebellopontine angle

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88
Q

Acoustic Neuroma

where are schwann cells found

A

the peripheral nervous system and provide the myelin sheath around neurones.

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89
Q

Acoustic Neuroma

bilateral or unilateral

A

usually unilateral

Bilateral acoustic neuromas are associated with neurofibromatosis type II.

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90
Q

Acoustic Neuroma

presentation

A

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
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91
Q

Acoustic Neuroma

if the tumour grows large enough what can it cause

A

facial nerve palsy as it compresses the facial nerve

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92
Q

Acoustic Neuroma

what is the pattern of hearing loss

A

sensorineural pattern

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93
Q

Acoustic Neuroma

diagnostic inx

A

MRI or CT

MRI is more detailed

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94
Q

Acoustic Neuroma

Mnx

A
  • Conservative
  • surgery
  • radiotherapy
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95
Q

Acoustic Neuroma

notable risks associated with trx

A

Vestibulocochlear nerve injury, with permanent hearing loss or dizziness

Facial nerve injury, with facial weakness

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96
Q

Ménière’s Disease

typical triad of sx

A
  • hearing loss
  • vertigo
  • tinnitus
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97
Q

Ménière’s Disease

pathophysiology

A
  • excessive buildup of endolymph in the labyrinth of the inner ear
  • causing a higher pressure than normal and disrupting the sensory signals
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98
Q

Ménière’s Disease

what is the name for increased pressure of endolymph

A

endolymphatic hydrops

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99
Q

40-50 years old, presenting with unilateral episodes of vertigo, hearing loss, and tinnitus. What is it

A

Ménière’s Disease

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100
Q

Ménière’s Disease

describe the vertigo

A
  • episodes lasting 20 min - several hours
  • clusters over several weeks. followed without vertigo for months
  • not triggered by movement or posture
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101
Q

Ménière’s Disease

describe the hearing loss

A
  • fluctuates at first
  • then gradually more permanent
  • sensorineural hearing loss
  • generally unilateral
  • affects low frequencies first
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102
Q

Ménière’s Disease

other symptoms apart from the vertigo, hearing loss, tinnitus

A
  • sensation of fullness in the ear
  • Unexplained falls (“drop attacks”) without loss of consciousness
  • Imbalance, which can persist after episodes of vertigo resolve
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103
Q

Ménière’s Disease

what may be seen in an acute attack

A

Spontaneous nystagmus

usually in one direction (unidirectional).

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104
Q

Ménière’s Disease

dx

A
  • clinical
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105
Q

Ménière’s Disease

inx

A

audiology assessment to evaluate hearing loss.

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106
Q

Ménière’s Disease

mnx for acute attacks

A
  • Prochlorperazine

- Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

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107
Q

Ménière’s Disease

prophylactic medication to reduce frequency of attacks

A

Betahistine

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108
Q

Labyrinthitis

pathophysiology

A
  • 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
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109
Q

Labyrinthitis

presentation

A
  • viral URTI
  • acute onset vertigo
    can be associated with
  • hearing loss
  • tinnitus
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110
Q

Labyrinthitis

similarity to vestibular neuronitis

A

acute onset vertigo

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111
Q

Labyrinthitis

difference to vestibular neuronitis

A
  • hearing loss

- tinnitus

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112
Q

Labyrinthitis

dx

A

clinical

important to exclude central cause of vertigo

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113
Q

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).

A

head impulse test

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114
Q

Labyrinthitis

mnx

A
  • supportive

up to 3 days of medication to suppress sx:

  • Prochlorperazine
  • Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
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115
Q

key complication of meningitis

A

bacterial labyrinthitis

All patients with meningitis are offered audiology assessment as soon as they are recovered to assess for hearing impairment

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116
Q

Vertigo

what is vertigo

A

a sensation that there is movement between the patient and their environment

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117
Q

Vertigo

what are the sensory inputs that are responsible for maintaining balance and posture

A
  • vision
  • proprioception
  • signals from the vestibular system
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118
Q

Vertigo

what are the semicircular canals filled with

A

endolymph

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119
Q

Vertigo

As the head turns, the fluid shifts inside the canals. What detects the fluid shift

A

tiny hairs called stereocilia

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120
Q

Vertigo

where is the stereocilia found

A

in a section of the canal called the ampulla

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121
Q

Vertigo

what lets the brain know that the head is moving in a particular direction

A
  • sensory input of shifting fluid detected by the stereocilia
  • transmitted to the brain by the vestibular nerve
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122
Q

Vertigo

where does the vestibular nerve carry signals from and to

A

from the vestibular apparatus

to the vestibular nucleus in the brainstem and the cerebellum

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123
Q

Vertigo

where does the vestibular nucleus send signals to

A

the oculomotor, trochlear and abducens nuclei that control eye movements

and the thalamus, spinal cord and cerebellum.

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124
Q

Vertigo

what can the causes of vertigo be split up into

A
  • peripheral: affecting the vestibular system

- central: involving the brainstem or the cerebellum

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125
Q

Vertigo

what are the 4 most common causes of peripheral vertigo

A
  • labyrinthitis
  • vestibular neuronitis
  • Benign paroxysmal positional vertigo
  • Ménière’s disease
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126
Q

Vertigo

less common causes of peripheral vertigo

A
  • 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)
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127
Q

Vertigo

how does a central problem cause vertigo

A

Pathology that affects the cerebellum or the brainstem disrupt the signals from the vestibular system

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128
Q

Vertigo

4 common causes of central vertigo

A
  • Posterior circulation infarction (stroke)
  • Tumour
  • Multiple sclerosis
  • Vestibular migraine
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129
Q

Vertigo

what kind of vertigo will all central causes present as

A

sustained, non-positional vertigo

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130
Q

Vertigo

difference between peripheral and central vertigo

  • onset
  • duration
  • hearing loss or tinnitus
  • coordiantion
  • nausea
A

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
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131
Q

Vertigo

what may a recent viral illness point to

A

labyrinthitis or vestibular neuronitis

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132
Q

Vertigo

what may a headache point to

A

Vertigo

vestibular migraine, cerebrovascular accident or brain tumour

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133
Q

Vertigo

what may Ear symptoms, such as pain or discharge point to

A

infection

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134
Q

Vertigo

what may an acute onset of neurological symptoms point to

A

stroke

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135
Q

Vertigo

four things to examine when assessing a patient presenting with vertigo:

A
  • ear
  • neuro
  • cardio (CVD causes of dizziness - arrythmias, valve disease)
  • special tests: Romberg, Dix-Hallpike manoeuvre, HINTS)
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136
Q

Vertigo

components of a cerebellar examination

A

DANISH

Dysdiadochokinesia

Ataxic gait ( walk heel-to-toe)

Nystagmus

Intention tremor

Speech (slurred)

Heel-shin test

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137
Q

Vertigo

what does the Romberg’s test do

A

screens for problems with proprioception or vestibular function

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138
Q

Vertigo

what does the HINTS exam for

A

to distinguish between central and peripheral vertigo

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139
Q

Vertigo

what does HINTS stand for

A

HI – Head Impulse
N – Nystagmus
TS – Test of Skew

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140
Q

Vertigo

describe the head impulse test

A
  • 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
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141
Q

Vertigo

normal head impulse test

A

pt will keep their eyes fixed on the examiner’s nose

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142
Q

Vertigo

head impulse test result with a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis),

A

eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner.

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143
Q

Vertigo

head impulse test result with a patient with a central cause of vertigo

A

normal

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144
Q

Vertigo

what does Unilateral horizontal nystagmus demonstrate

A

more likely to be a peripheral cause

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145
Q

Vertigo

what does Bilateral or vertical nystagmus suggest

A

a central cause

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146
Q

Vertigo

what is test of skew (aka alternate cover test)

A
  • 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
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147
Q

Vertigo

what indicates a central cause in the test of skew

A

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)

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148
Q

Vestibular Neuronitis

what is it

A

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

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149
Q

Vestibular Neuronitis

What does the inner ear comprise of

A
  • Semicircular canals
  • Vestibule (middle section)
  • Cochlea
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150
Q

Vestibular Neuronitis

which part of the ear is responsible for detecting movement of the head

A

semicircular canals

and otolith organs within the vestibule (the utricle and saccule)

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151
Q

Vestibular Neuronitis

which structure detects rotation of the head

A

the semi-circular canals

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152
Q

Vestibular Neuronitis

which structure detects gravity and linear acceleration

A

the otolith organs within the vestibule (the utricle and saccule)

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153
Q

Vestibular Neuronitis

which structure is responsible for hearing

A

cochlea

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154
Q

Vestibular Neuronitis

which nerve transmits signals from the vestibular system (the semicircular canals and vestibule) to the brain to help with balance

A

vestibular nerve

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155
Q

Vestibular Neuronitis

which nerve transmits signals from the cochlea to provide hearing.

A

The cochlear nerve

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156
Q

Vestibular Neuronitis

presentation

A
  • acute onset of vertigo
  • recent viral URTI
  • vertigo constant then worsened by head movement
  • N+V
  • balance problems
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157
Q

Vestibular Neuronitis

why is tinnitus and hearing loss not a feature

A

the cochlea and cochlear nerve are not affected

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158
Q

Vestibular Neuronitis

different between labyrinthitis and neuronitis

A

Labyrinthitis – Loss of hearing

Neuronitis – No loss of hearing

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159
Q

Vestibular Neuronitis

which test can diagnose peripheral cause of vertigo (Vestibular neuronitis or labyrinthitis)

A

head impulse test (peripheral cause if their eyes saccade)

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160
Q

Vestibular Neuronitis

mnx

A
  • Prochlorperazine
  • Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

for up to 3 days

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161
Q

Vestibular Neuronitis

when do NICE recommend referral

A

if sx do not improve after 1w or resolve after 6w

as they may require further invx or vestibular rehabilitation therapy (VRT).

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162
Q

Vestibular Neuronitis

prognosis

A

Sx most severe for the first few days

after which they gradually resolve over the following 2-6 weeks.

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163
Q

Vestibular Neuronitis

what may develop after

A

BPPV

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164
Q

Benign Paroxysmal Positional Vertigo

presentation

A
  • 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
Q

Benign Paroxysmal Positional Vertigo

does BPPV cause hearing loss or tinnitus

166
Q

Benign Paroxysmal Positional Vertigo

pathophysiology

A

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
Q

Benign Paroxysmal Positional Vertigo

which part of the semi-circular canal is where the otoconia is displaced

A

the posterior semicircular canal

168
Q

Benign Paroxysmal Positional Vertigo

why may the otoconia be displaced

A
  • viral infection
  • head trauma
  • ageing
  • idiopathic
169
Q

Benign Paroxysmal Positional Vertigo

dx

A

Dix-Hallpike Manoeuvre

170
Q

Benign Paroxysmal Positional Vertigo

how does the Dix-Hallpike work

A

moves endolymph through the semicircular canals and triggers vertigo in pts with BPPV

171
Q

Benign Paroxysmal Positional Vertigo

In patients with BPPV, the Dix-Hallpike manoeuvre will trigger?

A

rotational nystagmus and symptoms of vertigo

eye will have rotational beats of nystagmus towards the affected ear

172
Q

Benign Paroxysmal Positional Vertigo

mnx

A

Epley manoeuvre

Brandt-Daroff exercises

173
Q

Tinnitus

definition

A

a persistent addition sound that is heard but is not present in the surrounding environment

174
Q

Tinnitus

pathophysiology

A

a background sensory signal produced by the cochlea that is not effectively filtered out by the central auditory system

175
Q

Tinnitus

what are the types

A

primary - unknown cause

secondary - cause known

176
Q

Tinnitus

causes

A
  • 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
Q

Tinnitus

what systemic conditions may it also be associated with

A
  • Anaemia
  • Diabetes
  • Hypothyroidism or hyperthyroidism
  • Hyperlipidaemia
178
Q

Tinnitus

what is objective tinnitus

A

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
Q

Tinnitus

what may actual additional sounds (objective tinnitus) be caused by

A
  • Carotid artery stenosis (pulsatile carotid bruit)
  • Aortic stenosis (radiating pulsatile murmur sounds)
  • Arteriovenous malformations (pulsatile)
  • Eustachian tube dysfunction (popping or clicking noises)
180
Q

Tinnitus

what may pulsatile indicate

A

a cardiovascular cause, such as carotid artery stenosis with a bruit)

181
Q

Tinnitus

inx

A
  • FBC, glucose, TSH, lipids
  • audiology
  • rarely CT, MRI: vascular malformations or acoustic neuromas
182
Q

Tinnitus

red flags

A
  • 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
Q

Tinnitus

mnx

A
  • tends to resolve
  • treat underlying cause (ear wax, infection)
  • hearing aids
  • sound therapy (adding background noise to mask tinnitus)
  • CBT
184
Q

Ear Wax

aka

185
Q

Ear Wax

impacted ear wax presentation

A
  • Conductive hearing loss
  • Discomfort in the ear
  • A feeling of fullness
  • Pain
  • Tinnitus
186
Q

Ear Wax

what are the 3 main methods of removing ear wax

A
  • ear drops: olive oil or sodium bicarbonate 5%
  • ear irrigation: squirting water in ears to clean away wax
  • microsuction
187
Q

Nosebleeds

aka

188
Q

Nosebleeds

where does bleeding usually originate

A

Kiesselbach’s plexus, which is located in Little’s area

189
Q

Nosebleeds

how may patients present as if they swallow blood during a nosebleed

A

vomiting blood

190
Q

Nosebleeds

what may bleeding from both nostrils indicate

A

posterior bleed (higher risk of aspiration of blood)

191
Q

Nosebleeds

advise pt on how to manage a nosebleed

A
  • 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
Q

Nosebleeds

when may pts require hospital admission

A
  • bleeding doesn’t stop after 10-15 min
  • severe
  • bleeding from both nostils
  • haemodynamically unstable
193
Q

Nosebleeds

treatment options in hospital

A
  • nasal packing: nasal tampons or inflatable packs

- nasal cautery using silver nitrate sticks

194
Q

Nosebleeds

what to prescribe after an acute nosebleed and why

A

Naseptin nasal cream (chlorhexidine and neomycin) QDS for 10d

to reduce crusting, inflammation + infection

195
Q

Nosebleeds

who is Naseptin CI’s in

A

people with a peanut or soya allergy

196
Q

Nasal polyps

what are they

A

growths of the nasal mucosa that can occur in the nasal cavity or sinuses.

197
Q

Nasal polyps

what are they often associated with

A

chronic rhinitis

198
Q

Nasal polyps

red flag presentation

A

unilateral polyps are concerning for malignancy

199
Q

Nasal polyps

which conditions is it associated with

A
  • 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
Q

Nasal polyps

presentation

A
  • chronic rhinosinusitis
  • difficulty breathing through the nose
  • snoring
  • nasal discharge
  • anosmia
201
Q

Nasal polyps

what to use to examine

A
  • nasal speculum
    or a otoscope with a large otoscope attached
  • nasal endoscopy to visualsie the basal cavity in detail
202
Q

Nasal polyps

how do nasal polyps present on the mucosal wall

A

round pale grey/yellow growths on the mucosal wall

203
Q

Nasal polyps

medical mnx

A

intranasal topical steroid drops or spray.

204
Q

Nasal polyps

surgical mnx for where the polyps are visibly close to the nostrils

A

Intranasal polypectomy

205
Q

Nasal polyps

surgical mnx for where the polyps are further in the nose or the sinuses

A

Endoscopic nasal polypectomy

206
Q

Obstructive Sleep Apnoea

what is it caused by

A

collapse of the pharyngeal airway

207
Q

Obstructive Sleep Apnoea

RFs

A
  • middle age
  • male
  • obese
  • alcohol
  • smoking
208
Q

Obstructive Sleep Apnoea

presentation

A
  • 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
Q

Obstructive Sleep Apnoea

what can severe cases cause

A

hypertension, heart failure and can increase the risk of myocardial infarction and stroke.

210
Q

Obstructive Sleep Apnoea

what is used to assess sx of sleepiness associated with OSA

A

Epworth Sleepiness Scale

211
Q

daytime sleepiness and is a heavy vehicle operator. Mnx?

A

suspected OSA

urgent referral to ENT

212
Q

Obstructive Sleep Apnoea

inx

A

sleep studies

213
Q

Obstructive Sleep Apnoea

1st step in mnx

A

correct reversible RFs:

  • stop drinking alcohol
  • stop smoking
  • lose weight
214
Q

Obstructive Sleep Apnoea

2nd step in mnx

A

CPAP machine to maintain patency of airway

215
Q

Obstructive Sleep Apnoea

surgical mnx

A

uvulopalatopharyngoplasty (UPPP)

216
Q

Tonsillectomy

indications

A

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
Q

Tonsillectomy

complications

A
  • sore throat
  • post-tonsillectomy bleeding
  • damage to teeth
  • infection
  • risks associated with GA
218
Q

Tonsillectomy

what is the main significant complication

A

post tonsillectomy bleeding

219
Q

Tonsillectomy

how can post tonsillectomy bleeding be life threatening

A

due to the aspiration of blood

220
Q

Tonsillectomy

mnx of post-tonsillectomy bleeding

A
  • 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
Q

Tonsillectomy

mnx if there is severe post-tonsileltomy bleeding or airway cmopromise

A

call anaesthetist, intubation may be required

222
Q

Tonsillectomy

2 options for stopping less severe post-tonsillectomy bleeds

A

hydrogen peroxide gargle

adrenaline soaked swab applied topically

223
Q

Sinusitis

what is it

A

inflammation of the paranasal sinuses in the face

usually accompanies by inflammation of the nasal cavity (rhinosinusitis)

224
Q

Sinusitis

types

A

acute (<12w)

chronic (>12w)

225
Q

Sinusitis

pathophysiology

A

blockage of the ostia (hole that drains mucous) in the paranasal sinuses

226
Q

Sinusitis

what are the 4 sets of paranasal sinuses

A
  • 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
Q

Sinusitis

causes

A
  • infection (viral URTI)
  • allergies (hayfever)
  • obstruction of drainage (foreign body, trauma, polyps)
  • smoking
  • asthmatics more likely to suffer from it
228
Q

Sinusitis

presentation of acute sinusitis

A

recent viral URTI:

  • nasal congestion
  • nasal discharge
  • facial pain or headache
  • facial pressure
  • facial swelling over the affected area
  • loss of smell
229
Q

Sinusitis

what will examination reveal

A
  • 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
Q

Sinusitis

what may chronic sinusitis be associated with

A

nasal polyps

231
Q

Sinusitis

inx in patients with persistent symptoms despite treatment

A
  • nasal endoscopy

- CT scan

232
Q

Sinusitis

mnx in pts with systemic infection or sepsis

A

require admission to hospital for emergency management

233
Q

Sinusitis

mnx for pts up to 10d

A

NICE: do not offer abx as most are viral and resolve within 2-3w

234
Q

Sinusitis

mnx for pts with sx after 10d

A
  • 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
Q

Sinusitis

mnx options for chronic sinusitis

A
  • Saline nasal irrigation
  • Steroid nasal sprays or drops (e.g. mometasone or fluticasone)
  • Functional endoscopic sinus surgery (FESS)
236
Q

Sinusitis

explain the nasal spray technique

A
  • 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
Q

Sinusitis

what does functional endoscopic sinus surgery involve

A
  • endoscope inserted through nostrils and sinuses
  • remove or correct obstructions
  • balloons may be inflated to dilate the opening of the sinuses
238
Q

Sinusitis

what do pts need before a functional endoscopic sinus surgery

A

CT scan to confirm dx and assess the structures

239
Q

Otitis Media

what is it

A

infection in the middle ear (contains the malleus, incus and stapes)

240
Q

Otitis Media

what is the most common bacterial cause

A

streptococcus pneumoniae

then
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus

241
Q

Otitis Media

what is the primary presenting feature

242
Q

Otitis Media

presentation

A
  • ear pain
  • reduced hearing in the affected ear
  • generally unwell: fever
  • upper airway infection: cough, coryzal sx, sore throat
243
Q

Otitis Media

sx when infection affects the vestibular system

A

balance issues and vertigo

244
Q

Otitis Media

sx when the tympanic membrane has perforated

A

discharge from ear

245
Q

Otitis Media

what will a normal tympanic membrane show on otoscopy

A

“pearly-grey”, translucent and slightly shiny

malleus through the membrane

cone of light reflecting the light of the otoscope

246
Q

Otitis Media

otoscope findings

A

bulging, red, inflamed looking membrane

247
Q

Otitis Media

otoscope findings when there is perforation

A

discharge in the ear canal and a hole in the tympanic membrane.

248
Q

Otitis Media

when to consider immediate abx

A

patients who have significant co-morbidities, are systemically unwell or are immunocompromised.

249
Q

Otitis Media

when to consider a delayed prescription

A

collected and used after 3 days if symptoms have not improved or have worsened at any time.

250
Q

Otitis Media

1st line abx

A

amoxicillin for 5-7d

clarithromycin in penicillin allergy

erythromycin in pregnant women allergic to penicillin

251
Q

Otitis Media

complications

A
  • 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
Q

Otitis Externa

what is it

A

inflammation of the skin in the external ear canal

253
Q

Otitis Externa

what are the types

A

acute <3w

chronic >3w

254
Q

Otitis Externa

why is it called swimmers ear

A

exposure to water whilst swimming can lead to inflammation in the ear canal

255
Q

Otitis Externa

causes

A
  • Bacterial infection
  • Fungal infection (e.g., aspergillus or candida)
  • Eczema
  • Seborrhoeic dermatitis
  • Contact dermatitis
256
Q

Otitis Externa

pt has had multiple courses of topical abx, what should you now think about

A

fungal infection

257
Q

Otitis Externa

what are the 2 most common bacterial causes of otitis externa

A
  • Pseudomonas aeruginosa

- Staphylococcus aureus

258
Q

Otitis Externa

what kind of bacteria is Pseudomonas aeruginosa

A

gram-negative aerobic rod-shaped bacteria

259
Q

Otitis Externa

what abx are used against Pseudomonas aeruginosa

A

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

260
Q

Otitis Externa

typical presentation

A
  • Ear pain
  • Discharge
  • Itchiness
  • Conductive hearing loss (if the ear becomes blocked)
261
Q

Otitis Externa

what will examination show

A
  • 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
Q

Otitis Externa

mnx of mild otitis externa

A

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

can also be used prophylactically before and after swimming

263
Q

Otitis Externa

mnx of moderate otitis externa

A

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
Q

Otitis Externa

what do you need to exclude before prescribing aminoglycosides in the ear (gentamicin + neomycin)

A

a perforated tympanic membrane

because they’re ototoxic

265
Q

Otitis Externa

when may pts need oral abx (e.g., flucloxacillin or clarithromycin)

A

Patients with severe or systemic symptoms

266
Q

Otitis Externa

what may be used if the canal is very swollen, and treatment with ear drops or sprays will be difficult.

A

an ear wick

267
Q

Otitis Externa

mnx for fungal infections

A

clotrimazole ear drops

268
Q

Otitis Externa

what is malignant otitis externa

A

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
Q

Otitis Externa

RFs for malignant otitis externa

A
  • Diabetes
  • Immunosuppressant medications (e.g., chemotherapy)
  • HIV
270
Q

Otitis Externa

sx of malignant otitis externa

A

more severe

  • persistent headaches
  • severe pain
  • fever
271
Q

Otitis Externa

key finding on examination for malignant otitis externa

A

Granulation tissue

at the junction between the bone and cartilage in the ear canal

272
Q

Otitis Externa

mnx of malignant otitis externa

A
  • admission
  • IV abx
  • CT/MRI to assess extent of infection
273
Q

Otitis Externa

complications of malignant otitis externa

A
  • Facial nerve damage and palsy
  • Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves)
  • Meningitis
  • Intracranial thrombosis
  • Death
274
Q

Head and Neck Cancer

what type are they usually

A

squamous cell carcinomas arising from the squamous cells of the mucosa.

275
Q

Head and Neck Cancer

where are the potential areas of head and neck cancers

A
  • Nasal cavity
  • Paranasal sinuses
  • Mouth
  • Salivary glands
  • Pharynx (throat)
  • Larynx (epiglottis, supraglottis, vocal cords, glottis and subglottis)
276
Q

Head and Neck Cancer

what is cancer of unknown primary

A

Squamous cell carcinoma cells may be found in an enlarged, abnormal lymph node (lymphadenopathy), and the original tumour cannot be found

277
Q

Head and Neck Cancer

where do they spread to first

A

lymph nodes

278
Q

Head and Neck Cancer

RFs

A
  • Smoking
  • Chewing tobacco
  • Chewing betel quid (a habit in south-east Asia)
  • Alcohol
  • HPV, particularly strain 16
  • EBV
279
Q

Head and Neck Cancer

red flags

A
  • 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
Q

Head and Neck Cancer

trx

A

any combination of:

  • chemo
  • radio
  • surgery
  • targeted cancer drugs e.g. monoclonal antibodies
  • palliative care
281
Q

Head and Neck Cancer

example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck

A

Cetuximab

targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.

282
Q

Glossitis

presentation

A
  • red, sore swollen tongue
  • smooth tongue: papillae of the tongue atrophy
  • ‘beefy’
283
Q

Glossitis

causes

A
  • Iron deficiency anaemia
  • B12 deficiency
  • Folate deficiency
  • Coeliac disease
  • Injury or irritant exposure
284
Q

Glossitis

mnx

A

correct underlying cause

285
Q

Angioedema

what is it

A

fluid accumulating in the tissues, resulting in swelling

286
Q

Angioedema

3 top causes

A
  1. allergic reactions
  2. ACEi
  3. C1 esterase inhibitor deficiency (hereditary angioedema)
287
Q

Oral Candidiasis

presentation

A

white spots or patches that coat the surface of the tongue and palate.

288
Q

Oral Candidiasis

RFs

A
  • ICS: not rinsing mouth after
  • abx
  • diabetes
  • immunodeficiency
  • smoking
289
Q

Oral Candidiasis

trx options

A
  • Miconazole gel
  • Nystatin suspension
  • Fluconazole tablets (in severe or recurrent cases)
290
Q

Geographic Tongue

what is it

A

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
Q

Geographic Tongue

progression

A

relapse and remit, with episodes of the abnormal tongue appearance that can last days to weeks before resolving or changing

292
Q

Geographic Tongue

which factors can it be related to

A
  • Stress and mental illness
  • Psoriasis
  • Atopy (asthma, hayfever and eczema)
  • Diabetes
293
Q

Geographic Tongue

trx

A

none but discomfort or burning are sometimes treated with topical steroids or antihistamines

294
Q

Strawberry Tongue

describe it

A

tongue becomes swollen and red

papillae become enlarged, white and prominent.

295
Q

Strawberry Tongue

2 key causes

A

Kawasaki disease

Scarlet Fever

296
Q

Black Hairy Tongue

pathophysiology

A

decreased shedding (exfoliation) of keratin from the tongue’s surface

The papillae elongate and take on the appearance of hairs

297
Q

Black Hairy Tongue

what can cause the dark pigmentation

A

bacteria and food

298
Q

Black Hairy Tongue

sx

A
  • black hairy tongue
  • sticky saliva
  • metallic taste
299
Q

Black Hairy Tongue

cause

A
  • dehydration, dry mouth
  • poor oral hygiene
  • smoking
300
Q

Black Hairy Tongue

mnx

A
  • adequate hydration
  • gentle brushing of tongue
  • stop smoking
301
Q

Leukoplakia

characteristics

A

white patches
- often on the tongue or buccal mucosa

  • asymptomatic, irregular and slightly raised
  • fixed in place, meaning they cannot be scraped off.
302
Q

Leukoplakia

is it cancerous

A

no but precancerous

it increases the risk of squamous cell carcinoma of the mouth

303
Q

Leukoplakia

inx

A

may require biopsy to exclude abnormal cells (dysplasia) or cancer

304
Q

Leukoplakia

mnx

A
  • stop smoking
  • reduce alcohol intake
  • close monitoring
  • potentially laser removal or surgical excision
305
Q

Erythroplakia

what is it

A
  • similar to leukoplakia, except the lesions are red.

- lesions that are a mixture of red and white.

306
Q

Erythroplakia

why should pts be urgently referred

A

associated with a high risk of squamous cell carcinoma

307
Q

Lichen Planus

what is it

A

an autoimmune condition that causes localised chronic inflammation of the skin

308
Q

Lichen Planus

how does it present on the skin

A

Wickham’s striae

  • shiny, purplish, flat-topped raised areas
  • with white lines across the surface
309
Q

Lichen Planus

who is it more common in

A

> 45

women

310
Q

Lichen Planus

what 3 patterns can it take in the mouth

A
  • reticular
  • erosive
  • plaque
311
Q

Lichen Planus

what does a reticular pattern involve

A

net-like web of white lines called Wickham’s striae.

312
Q

Lichen Planus

how does the erosive lesions pattern present

A

urface layer of the mucosa is eroded, leaving bright red and sore areas of mucosa

313
Q

Lichen Planus

how does the plaque pattern present

A

larger continuous areas of white mucosa

314
Q

Lichen Planus

mnx

A
  • good oral hygiene
  • stop smoking
  • topical steroids
315
Q

Gingivitis

what is it

A

inflammation of the gums

316
Q

Gingivitis

presentation

A
  • swollen gums
  • bleeding after brushing
  • painful gums
  • bad breath (halitosis)
317
Q

Gingivitis

what can it lead to if not adequately managed

A

Periodontitis

318
Q

Gingivitis

what is Periodontitis

A

severe and chronic inflammation of the gums and the tissues that support the teeth. This often leads to loss of teeth.

319
Q

Gingivitis

what is acute necrotising ulcerative gingivitis

A

rapid onset of more severe inflammation in the gums

painful

320
Q

what causes

acute necrotising ulcerative gingivitis

A

Anaerobic bacteria usually cause this

321
Q

Gingivitis

RFs

A
  • plaque build up (inadequate brushing)
  • smoking
  • diabetes
  • malnutrition
  • stress
322
Q

Gingivitis

what is a hardened plaque called

323
Q

Gingivitis

trx

A
  • good oral hygiene
  • stop smoking
  • dental hygienist to remove plaque + tartar
  • chlorhexidine mouth wash
  • dental surgery if required
324
Q

Gingivitis

trx for acute necrotising ulcerative gingivitis

A

metronidazole

325
Q

Gingival Hyperplasia

what is it

A

abnormal growth of the gums

326
Q

Gingival Hyperplasia

causes

A
  • gingivitis
  • pregnancy
  • Vit C deficiency
  • Acute myeloid leukaemia
  • CCB, phenytoin, ciclosporin
327
Q

Aphthous Ulcers

what are they

A

very common, small, painful ulcers of the mucosa in the mouth

328
Q

Aphthous Ulcers

appearance

A

well-circumscribed, punched-out, white appearance

329
Q

Aphthous Ulcers

triggers

A
  • emotional or physical stress
  • trauma to the mucosa
  • particular foods
330
Q

Aphthous Ulcers

indications for which underlying conditions

A
  • IBD
  • coeliac
  • Behcet disease
  • vit deficiency
  • HIV
331
Q

Aphthous Ulcers

which topical trx can be used to treat symptoms

A
  • Choline salicylate (e.g., Bonjela)
  • Benzydamine (e.g., Difflam spray)
  • Lidocaine
332
Q

Aphthous Ulcers

what can be used if more severe

A
  • Hydrocortisone buccal tablets applied to the lesion
  • Betamethasone soluble tablets applied to the lesion
  • Beclomethasone inhaler sprayed directly onto the lesion
333
Q

Aphthous Ulcers

when do NICE recommend a 2 week wait referral

A

“unexplained ulceration” lasting over 3 weeks.

334
Q

Audiometry

what is plotted on the x axis on an audiogram

A

frequency in hertz (Hz)

from low to high pitched

335
Q

Audiometry

what is plotted on the y axis on an audiogram

A

volume in decibels (dB)

from loud at bottom to quiet at top

336
Q

Audiometry

what symbol is used to mark left sided air conduction

337
Q

Audiometry

what symbol is used to mark right sided air conduction

338
Q

Audiometry

what symbol is used to mark left sided bone conduction

339
Q

Audiometry

what symbol is used to mark right sided bone conduction

340
Q

Audiometry

what is a normal hearing dB level

A

0 -20 (at the top of the chart)

341
Q

Audiometry

what will a pt with sensorineural hearing loss show on an audiogram

A

both air + bone conduction readings will be >20dB (plotted below the 20dB line)

342
Q

Audiometry

what will a pt with conductive hearing loss show on an audiogram

A

bone conduction readings will be normal (0-20 dB)

air conduction readings will be >20dB, below the 20dB line on the chart

343
Q

Audiometry

what will a pt with mixed hearing loss show on an audiogram

A

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
Q

Presbycusis

what is it

A

sensorineural hearing loss that occurs as people get older

345
Q

Presbycusis

which sounds are affected first

A

high-pitched sounds first and more notably than lower-pitched sounds.

346
Q

Presbycusis

why does it happen

A
  • loss of hair cells in the cochlea
  • loss of neurones in the cochlea
  • atrophy of the stria vascularis
  • reduced endolymphatic potential
347
Q

Presbycusis

RFs

A
  • age
  • male
  • FH
  • loud noise exposure
  • diabetes
  • HTN
  • ototoxic medications
  • smoking
348
Q

Presbycusis

presentation

A
  • gradual and insidious hearing loss
  • speech difficult to hear + understand . Males easier to hear
  • tinnitus
  • may be worried of dementia
349
Q

Presbycusis

diagnostic inx

A

audiometry

350
Q

Presbycusis

what will audiometry show

A
  • sensorineural hearing loss

- worsening hearing loss at higher frequencies

351
Q

Presbycusis

mnx

A
  • optimise environment e.g. reduce ambient noise during convo
  • hearing aids
352
Q

Presbycusis

what can be used in pts when hearing aids are not sufficient

A

cochlear implants

353
Q

Sudden Sensorineural Hearing Loss

definition

A

hearing loss over <72 h

unexplained by other causes

354
Q

Conductive causes of rapid-onset hearing loss (not classed as SSNHL)

A
  • ear wax/ foreign body
  • infection
  • fluid in middle ear
  • Eustachian tube dysfunction
  • Perforated tympanic membrane
355
Q

Sudden Sensorineural Hearing Loss

cause

A
  • idiopathic (90%)
  • infection (meningitis, HIV, mumps)
  • oxotoxic meds
  • MS
  • Migraine
  • Stroke
  • Acoustic neuroma
  • Cogan’s syndrome
356
Q

Sudden Sensorineural Hearing Loss

what is Cogan’s syndrome

A

a rare autoimmune condition causing inflammation of the eyes and inner ear

357
Q

Sudden Sensorineural Hearing Loss

diagnostic inx

A

audiometry:
- loss of at least 30dB
- in 3 consecutive frequencies

358
Q

Sudden Sensorineural Hearing Loss

mnx

A
  • immediate referral to ENT
  • assessment within 24h if presented within 30d of onset
  • treat underlying cause
359
Q

Sudden Sensorineural Hearing Loss

inx if stroke or acoustic neuroma considered

A
  • MRI or CT head
360
Q

Sudden Sensorineural Hearing Loss

trx if idiopathic SSNHL

A
  • PO steroids
    or
  • intra-tympanic (via an injection of steroids through the tympanic membrane)
361
Q

Eustachian Tube Dysfunction

what is it

A

when the tube between the middle ear and throat is not functioning properly.

362
Q

Eustachian Tube Dysfunction

what is the eustachian tube for

A

to equalise the air pressure in the middle ear

and drain fluid from the middle ear.

363
Q

Eustachian Tube Dysfunction

what may it be related to

A
  • viral URTI
  • allergies (hayfever)
  • smoking
364
Q

Eustachian Tube Dysfunction

presentation

A
  • altered hearing
  • popping noises or sensations in the ear
  • fullness sensation in ear
  • pain or discomfort
  • tinnitus
365
Q

Eustachian Tube Dysfunction

when do sx tend to get worse and why

A

flying, climbing a mountain or scuba diving

external air pressure changes and the middle ear pressure cannot equalise to the outside pressure

366
Q

Eustachian Tube Dysfunction

what will otoscopy show

A

normal but important to rule out other causes e.g. otitis media

367
Q

Eustachian Tube Dysfunction

when are inx not required

A

clear cause: recent viral URTI, hayfever etc

sx will resolve with time or simple trx

368
Q

Eustachian Tube Dysfunction

inx for persistent, problematic or severe sx

A
  • Tympanometry
  • Audiometry
  • Nasopharyngoscopy
  • CT
369
Q

Eustachian Tube Dysfunction

what does Tympanometry involve

A
  • 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
Q

Eustachian Tube Dysfunction

what is admittance

A

The amount of sound absorbed by the tympanic membrane and middle ear (not reflected back to the device)

371
Q

Eustachian Tube Dysfunction

what will a normal ear show on tympanometry

A

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
Q

Eustachian Tube Dysfunction

what will tympanometry show

A

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
Q

Eustachian Tube Dysfunction

mnx

A
  • none, wait
  • valsalva manoeuvre
  • Decongestant nasal sprays (short term only)
  • Antihistamines and a steroid nasal spray for allergies or rhinitis
374
Q

Eustachian Tube Dysfunction

what may be required in severe persistent cases

A

surgery:

  • grommets
  • Balloon dilatation Eustachian tuboplasty
  • Treating any other pathology that might be causing symptoms, for example, adenoidectomy
375
Q

Eustachian Tube Dysfunction

what is otovent

A

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
Q

Eustachian Tube Dysfunction

how do grommets work

A
  • tube inserted into tympanic membrane

- allows air or fluid from the middle ear to drain through the tympanic membrane into the ear canal

377
Q

Otosclerosis

what is it

A

remodelling of the small bones in the middle ear, leading to conductive hearing loss.

378
Q

Otosclerosis

who is it more common in

379
Q

Otosclerosis

cause

A
  • can be autosomal dominantly inherited

- combination of environmental and genetic factors

380
Q

Otosclerosis

pathophysiology

A
  • 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
Q

Otosclerosis

what kind of hearing loss is it

A

conductive

382
Q

Otosclerosis

presentation

A

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
Q

Otosclerosis

which pitched sound does it tend to affect

A

lower-pitched sounds

female speech may be easier to hear than male

384
Q

Otosclerosis

otoscopy findings

385
Q

Otosclerosis

Weber’s test finding

A

normal if otosclerosis is bilateral

if unilateral, the sound will be louder in the more affected ear.

386
Q

Otosclerosis

Rinne’s test

A

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
Q

Otosclerosis

initial inx

A

audiometry: conductive hearing loss

388
Q

Otosclerosis

what will tympanometry show and why

A

reduced admittance (absorption) of sound.

The tympanic membrane is stiff and non-compliant and does not absorb sound, reflecting most of it back

389
Q

Otosclerosis

what can detect boney changes associated with otosclerosis

A

high resolution CT scan

390
Q

Otosclerosis

mnx

A
  • Conservative: hearing aids

- Surgical (stapedectomy or stapedotomy)

391
Q

what does a positive Schwartze’s sign indicate

A

Otosclerosis

392
Q

what is the definitive test for a pharyngeal pouch

A

barium swallow, which usually reveals the diverticulum

393
Q

some key points of follicular thyroid cancer

A
  • 2nd most common
  • more common in women
  • presents later in life than papillary thyroid cancer
  • metastasises late but more often via haematogenous spread
394
Q

some key points of papillary thyroid cancer

A
  • most common
  • more common in women
  • presents in the 3rd or 4th decade of life
  • solitary nodule
  • metastases locally early in the disease.
395
Q

what is a pharyngeal pouch aka

A

Zenker’s diverticulum

396
Q

what is chronic analchasia a RF for

A

Oesophageal squamous cell carcinoma

397
Q

definitive treatment for achalasia

A

Heller’s cardiomyotomy: surgical procedure where the muscle fibers of the lower oesophagus are divided

398
Q

what is achalasia

A

failure of the lower oesophageal sphincter to relax due to degeneration of the myenteric plexus

399
Q

what medical trx can be given for achalasia

A
  • Botulinum toxin injections (botox)

- CCB/ nitrites in patients who fail botox therapy or are not suitable surgical candidates

400
Q

what is the gold standard inx for achalasia

401
Q

what would manometry show if pt has achalasia

A
  1. high resting pressure in the lower oesophageal sphincter
  2. incomplete relaxation of the lower oesophageal sphincter upon swallowing
  3. absence of peristalsis
402
Q

85y female with an irregular midline hard neck lump. Pain on swallowing, intermittent stridor, weight loss

What is it

A

anaplastic carcinoma

403
Q

which histological sign is pathognomonic of papillary thyroid cancers

A

Orphan Annie Cells

404
Q

medications that can relax the oesophagus

A
  • IV Hyoscine butyl-bromide

- CCB e.g. nifedipine

405
Q

techniques which may assist in removing food lodged in oesophagus

A
  • drink carbonated drink

- eat wet bread

406
Q

Ddx for dysphagia

A
  • oesophageal cancer
  • Oesophagitis
  • achalasia
  • pharyngeal pouch
  • systemic sclerosis
  • Myasthenia gravis
  • Globus hystericus
407
Q

what causes trismus

A

inflammation of the pterygoid muscles

408
Q

what is the name of the lymph node affected by quinsy

A

Jugulodigastric lymph nodes

Finals (47 decks)

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