ENT Flashcards
What are the 3 names of the ossicles?
Malleus
Incus
Stapes
Over what time frame can hearing loss be defined as sudden?
Over less than 72 hours
What is the result of webbers test in sensioneural hearing loss?
Louder in normal ear, quieter in the affected ear
What is the result of webbers test in conductive hearing loss?
Louder in the affected ear
What is the result of Rinne’s test in conductive hearing loss?
Is louder on the mastoid process than by the ear on the affected side.
Which drugs can cause sensioneural hearing loss?
Loop diruretics (furosemide) Gentamicin Chemotherapy drugs (cisplatin)
Which pitch of sounds does presbycusis affect?
High pitched sounds
What is the diagnostic criteria for sudden sensorineural hearing loss?
loss of at least 30 decibels in 3 consecutive frequencies
How can idiopathic SSNHL be managed?
Steroids
How may eustachian tube dysfunction present?
Reduced or altered hearing
Popping noises or sensations in the ear
Pain or discomfort
Tinnitus
What are the investigations for Eustachian tube dysfunction?
Tympanometry
Audiometry
nasopharyngoscopy
CT scan
Which procedure can be done to widen the eustachian tube?
Balloon dilatation eustachian tuboplasty
What is the inheritance pattern of otosclerosis?
Autosomal dominant
What is the typical presentation of otosclerosis?
Conductive hearing loss
Tinnitus
Woman in her 40s
Hearing loss is generally of lower-pitched sounds
Which investigations should be done for otosclerosis?
Audiometry
Typanometry
High resolution CT
What are the management options for otosclerosis?
Stapedotomy
Hearing aids
Which bacteria most commonly causes otitis media?
Streptococcus pneumoniae
what are the symptoms of otitis media?
ear pain
Reduced hearing
Fever
Cough, coryza and sore throat
What can be seen on otoscopy in otitis media?
Red, inflamed looking membrane
What is the first line antibiotic for otitis media and for how long?
Amoxicillin for 5-7 days
What are the 2 most common bacterial causes of otitis externa?
Pseudomonas aeruginosa
Staphylococcus aureus
What are the 2 conditions which psuedomonas aeruginosa can cause?
Otitis externa and can colonise the lungs in patients with cystic fibrosis
What can pseudomonas aeruginosa be treated with?
Gentamycin and ciprofloxacin
What is the management of otitis externa?
Mild= acetic acid 2% Moderate= topical antibiotics and steriod (eg neomycin and dexamethosone) aka otomize ear spray
What is the potentially life threatening complication of otitis externa and which populations does it occur in?
malinant otitis externa (osteomyelitis of the temporal bone)
Occurs in people with diabetes, people who are immunosuppressed or have HIV
What is objective tinnitus? How can you assess this?
The patient can objectively hear an extra sound within their head.
The sound can also be observable on examination by auscultating with a stethoscope around the ear
What does pulsatile tinnitus suggest?
May indicate a cardiovascular cause such as carotid artery stenosis
What are the suggested investigations for tinnitus?
Bloods to assess for underlying causes:
FBC (anaemia), glucose (diabetes), TSH (thyroid), lipids (hyperlipidaemia)
Audiology
Imaging (CT/MRI)
What is the fluid which fills the semicircular canals called?
Endolymph
What are the 4 most common causes of vertigo?
BPPV
Menieres disease
Vestibular neuronitis
Labrynthitis
What causes BPPV?
Crystals of calcium carbonate called otoconia becoming displaced in the semicircular canals
What manoeuvre can be used to diagnose BPPV?
Dix-hallpike
What are the symptoms pf menieres disease?
Unilateral hearing loss, tinnitus, vertigo and a sense of fullness in the ear
What causes acute vestibular neuronitis?
inflammation of the vestibular nerve, usually secondary to a viral infection
What causes labrynthitis?
Inflammation of the inner ear. Usually due to viral infection
Name 4 central causes of vertigo
Posterior circulation infarction
Tumour
MS
Vestibular migraine
Which test can be used to diagnose a peripheral cause of vertigo?
Head impulse test
Which test can be used to diagnose a central cause of vertigo?
Test of skew
Which medications can be used to manage symptoms of peripheral vertigo?
Prochlorperazine
Antihistamines
Which medication can be used to reduce attacks in menieres disease?
Betahistine
Which manoeuvre can treat BPPV?
Epley manoeuvre
Where do otoconia most often occur?
Posterior semi circular canal
What are the symptoms of vestibular neuritis?
Constant vertigo, nausea and vomiting and balance problems
Which symptoms differentiate neuronitis and labrynthitis?
Labrynthitis- loss of hearing and tinnitus
neuronitis- no loss of hearing or tinnitus
Which 2 conditions is labyrinthitis usually secondary to?
Otitis media or meningitis
Which disease are patients always offered an audiology assessment after recovering from?
Meningitis
What is the triad of symptoms in menieres disease?
Hearing loss
vertigo
tinnitus
What is the increased pressure in the inner ear called in menieres disease?
Endolymphatic hydrops
What is the pattern of vertigo in menieres disease?
20 minute episodes
What is the management for acute attacks of menieres?
Prochlorperazine
Antihistamines
What is the prophylaxis for menieres?
Betahistine
Which cells are acoustic neuromas a tumour of?
Schwann cells
Where do acoustic neuromas occur?
Cerebellopontine angle
Which disease are acoustic neuromas associated with?
Neurofibromatosis type II
May be bilateral in this case
What is the presentation of an acoustic neuroma?
Unilateral sensorineural hearing loss
Unilateral tinnitus
Dizziness or imbalance
Sensation of fullness in the ear
What are the investigations for ?acoustic neuroma?
Audiometry Brain injury (CT or MRI)
What is the management of acoustic neuroma?
Conservative
Surgery
Radiotherapy (+/- surgery)
What is a cholesteatoma made up of?
Squamous epithelial cells
What is the presentation of cholesteoma?
Foul discharge from the ear
Unilateral conductive hearing loss
What is the management of cholesteatoma?
CT head to assess the severity
Surgical removal
What is the pathway of the facial nerve?
exists the brainstem at the cerebellopontine angle
Passes through the temporal bone and the parotid gland
What are the 5 branches of the facial nerve?
Temporal Zygomatic Buccal Marginal mandibular Cervical
what are the motor functions of the facial nerve?
Supplies the muscles of facial expression, the stapedius, posterior digastric, stylohyoid platysma muscles of the neck
What are the sensory functions of the facial nerve?
Carries taste from the anterior 2/3 of the tongue
What are the parasympathetic functions of the facial nerve?
Submandibular and sublingual salivary glands
lacrimal gland
In which type of motor neurone lesion is the forehead spared? Why is this and what is the differential?
Upper motor neurone lesion
Each side of the forehead has upper motor neurone innervation by both sides of the brain. However, each side of the forehead only has lower motor neurone innervation from one side of the brain.
Suspect stroke (yikes!)
What is bells palsy?
Unilateral lower motor neurone facial nerve palsy
What is the management of bell’s palsy?
Prednisolone if presented within 72 hours of symptom onset
Lubricating eye drops to protect against exposure keratopathy
which virus causes Ramsay-Hunt syndrome?
Herpes zoster
What is the presentation of ramsay-hunt syndrome?
Unilateral motor neurone facial nerve palsy, tender and painful vesicular rash in the ear canal, pinna and around the ear
What is the management of ramsay hunt?
Prednisolone
Aciclovir
Where does the bleeding in epistaxis usually originate?
Kiesselbach’s plexus in little’s area
If nose bleeding in bilateral, where is the likely location of bleeding?
Posterior in the nose
What is the management of acute epistaxis?
Sit up and tilt head forwards. Squeeze the soft part of the nostrils together for 10-15 mins
If this doesn’t stop, nasal packing or nasal cautery using silver nitrate sticks
What can be prescribed after an acute nosebleed is resolved and why?
Naseptin (chlorhexidine and neomycin) QDS to reduce crusting, inflammation and infection
When is naseptin contraindicated?
Peanut or soya allergy
What are the time periods which define acute and chronic sinusitis?
Acute= <12 weeks Chronic= >12 weeks
What are the holes called in the sinuses which allow the mucous to drain?
Ostia
Name the 4 sets of paranasal sinuses
Frontal
Maxillary
Ethmoid
Sphenoid
Name 4 possible causes for inflammation of the sinuses
Infection
Allergies
Obstruction (foreign bodies, polyps, trauma)
Smoking
How does sinusitis present?
Nasal congestion Nasal discharge Facial pain or headache Facial pressure Facial swelling Loss of smell Fever
What are the investigations which can be done for sinusitis?
Nasal endoscopy
CT scan
What is the management of acute sinusitis?
Do not offer antibiotics for the first 10 days, most causes are viral
High dose steroid spray for 14 days (mometasone)
Delayed abx prescription if not improved after 7 days (phenoxymethylpenicillin)
What are the options for managing chronic sinusitis?
Saline nasal irrigation
Steroid nasal sprays or drops
Functional endoscopic sinus surgery
What is the proper technique for using steroid nasal sprays?
Ask, “do you taste the spray at the back of your throat after using it?” Tasting the spray means it has gone past the nasal mucosa= not be as effective.
- Tilt head forward
- Left hand to spray into right and vice versa (away from septum)
- Don’t sniff hard during the spray
- Very gently inhale through the nose after the spray
Which is a red flag- unilateral or bilateral nasal polyps?
Unilateral - think tumour
Which conditions are nasal polyps associated with?
Chronic rhinitis or sinusitis
Asthma
Samter’s triad (nasal polyps, asthma and aspirin intolerance)
Cystic fibrosis
Eosinophilic granulomatosis with polyangiitis
What is the presentation of nasal polyps?
Chronic rhinosinusitis Difficultly breathing through the nose Snoring Nasal discharge Anosmia
How can nasal polyps be assessed?
Nasal speculum
Otoscope with big attachment
Nasal endoscopy
What is the management of nasal polyps?
Intranasal topical steroid drops or spray
Surgery- intranasal/ endoscopic nasal polypectomy
What are the risk factors for OSA?
Middle age Male Obesity Alcohol Smoking
What are some features of OSA?
Episodes of apnoea during sleep (often reported by partner) Snoring Morning headache Waking up unrefreshed from sleep Daytime sleepiness Concentration problems Reduced oxygen sats during sleep
Which tool is used to assess symptoms of sleepiness associated with sleep apnoea?
The epworth sleepiness scale
What is the management of OSA?
- Correct reversible risk factors
- CPAP
- Surgery- uvulopalatopharyngoplasty
What is the most common bacterial cause of tonsilitis?
Group A strep (Strep pyogenes)
What is the ring of lymphoid tissue in the pharynx (which contains the adenoids, tubal tonsils, palatine tonsils and lingual tonsil) called?
Waldeyer’s tonsillar ring
What is the typical presentation of tonsilitis?
Sore throat
Fever (above 38)
Pain on swallowing
Enlarged tonsils with or without exudate
What are the criteria of the FeverPAIN score?
Fever in 24 hours P- purulence A- attended within 3 days of onset I- inflammed tonsils N- no cough or coryza
What score is needed in FeverPAIN for a antibiotic prescription?
> /= 4
Which abx should be prescribed in tonsilitis? (and if pen allergic)
Penicillin V (phenoxymethylpenicillin)
Clarithromycin if allergic (loser)
Name some complications of tonsilitis
Peritonsillar abscess Otitis media Scarlet fever Rheumatic fever Post-streptococcal glomerulonephritis Post-streptococcal reactive arthritis
What are the borders of the anterior triangle?
Mandible (superior)
Midline of the neck (medial)
Sternocleidomastoid (lateral)
What are the borders of the posterior triangle?
Clavicle (inferior)
Trapezius (posterior)
Sternocleidomastoid (medial)
What are the 2 week wait criteria for neck lumps?
- unexplained neck lump in someone >45 years old
2. Persistent neck lump at any age
Which blood tests should be done for neck lumps?
FBC and blood film HIV test Monospot test or EBV antibodies TFT ANA LDH (tumour marker for hodgkins)
Which investigations should be done for a neck lump?
- Bloods
- Imaging (ultrasound, CT/MRI and nuclear medicine scan)
- Biopsy
What are the 4 groups of lymphadenopathy?
- reactive
- infected
- inflammatory
- malignancy
what is the presentation of infectious mononucleosis?
Fever
Sore throat
Fatigue
Lymphadenopathy
What can occur if you give someone with mononucleosis amoxicillin?
They can develop an intensely itchy maculopapular rash
What is the first line investigation for mononucleosis?
The mono-spot test
What advise should be given to people with mononucleosis?
Avoid alcohol (increased risk of liver impairment) Avoid contact sport (increased risk of splenic rupture)
What are the three reasons for salivary glands to enlarge?
Stones blocking drainage (sialolithiasis)
Infection
Tumours
Where is the carotid body located?
Just above the carotid bifurcation
What are the chemoreceptors in the carotid body called? What is a group of these cells called?
Glomus cells
Paraganglia
What is the other name for a carotid body tumour?
Paragangliomas
Which nerves can carotid body tumours press on?
Glossopharyngeal (IX)
Accessory (XI)
Hypoglossal (XII)
Vagus (X)
What can be caused by a carotid body tumour pressing on the vagus nerve?
Horner’s syndrome:
Ptosis
Anhydrosis
Miosis
What is the characteristic finding on imaging for carotid body tumour?
Splaying of the internal and external carotid arteries (lyre sign)
What is a key differential when considering a thyroglossal cysts?
Ectopic thyroid tissue
What are the red flags for head and neck cancer?
Lump in mouth or on lip Unexplained mouth ulceration which lasts more than 3 weeks Erythoplakia or erythroleucoplakia Persistent neck lump Unexplained horseness of voice Unexplained thyroid lump
Which monoclonal antibody is commonly used to target squamous cell carcinomas of the head and neck?
Cetuximab
What are some causes of glossitis?
Iron deficiency anaemia B12 deficiency Folate deficiency Coeliac disease Injury or irritant exposure
What are the 3 top causes of angioedema (which can lead to tongue swelling)?
Allergic reactions
ACE-i
C1 esterase inhibitor deficiency (hereditary angioedema)
Which factors can cause oral candidiasis?
Inhaled corticosteroids Antibiotics Diabetes Immunodeficiency (HIV) Smoking
What are the treatment options for oral candidiasis?
Miconazole gel
Nystatin suspension
Fluconazole tablets
What are the 2 key causes of strawberry tongue?
Scarlet fever
Kawasaki disease
What is leukoplakia?
white patches in the mouth (tongue and inside of cheeks). It is a precancerous condition and increases the risk of squamous cell carcinoma of the mouth
What are the 3 patterns that lichen planus can form in the mouth?
reticular
Erosive
Plaque
What is wickham’s striae?
A reticular pattern of lichen planus in the mouth. It involves a net-like web of white lines