ENT Flashcards
Pathophysiology of acute otitis media
Viral- following a viral URTI
Bacterial- streptococcus pneumoniae, haemophilus influenzae, moraxella
Features of acute otitis media
Otalgia
Ear tugging/ anorexia/ irritability in children
Fever
Conductive hearing loss
Recent viral URTI (Coryzal symptoms)
Ear discharge if tympanic membrane bursts ie. One morning there is discharge on the pillow (perforation)
Otoscopy findings for acute otitis media
Bulging tympanic membrane if effusion present (loss of light reflex)
Opacification or erythema of TM
Perforation with purulent otorrhea
Decreased mobility if using a pneumatic otoscope
Management of acute otitis media
Generally self limiting and doesn’t require ABX
Seek medical advice if symptoms worsen or don’t improve after 3 days
Immediate ORAL ABX (not topical unless TM ruptured) if;
Symptoms last longer than 4 days or not improving
Systemically unwell but doesn’t need admission
Immunosuppression
Younger than 2 with bilateral otitis media
Otitis media with perforation and or discharge in the canal (including suppurative otitis media)
NB- ABX of choice is amoxicillin fir 5-7 days (erythromycin if allergy)
Sequelae of acute otitis media
Perforation- otorrhoea. Unresolved may develop into chronic suppurative otitis media (6 weeks)- need ABX
Glue ear (if an effusion develops and persists)
Hearing loss
Labyrinthitis
Mastoiditis
Meningitis
Brain abscess
Facial nerve paralysis
Infective agents in acute sinusitis
Streptococcus Pneumoniae
Haemophilus influenzae
Rhinoviruses
Features of sinusitis
Facial pain- frontal pressure worse when bending forward
Nasal discharge- thick and purulent
Nasal obstruction
Coryza- cough, sore throat
Management of acute sinusitis
Analgesia
Intranasal decongestants
Intransal corticosteroids if symptoms longer than 10 days
Oral ABX not normally required, unless severe presentation (Pen V)
NB- double sickening, where a viral sinusitis becomes a secondary bacterial infection
Features of allergic rhinitis
Sneezing
Bilateral nasal obstruction
Clear nasal discharge
Post nasal drip
Nasal pruritus
Management of allergic rhinitis
Allergen avoidance
Oral or intranasal antihistamines (CHLORPHENAMINE MALEATE)
Persistent- intranasal corticosteroids
NB- can use nasal decongestants (oxymetazoline), but don’t used for long as tachyphylaxis (becomes less effective) can be seen, and rebound hypertrophy of nasal mucosa may occur upon withdrawal (symptoms go then come back)
Auricular haematoma
Same day assessment by ENT
Incision and drainage
Features of BPPV
Vertigo triggered by change in head position- rolling over in bed, gazing upwards
Associated with nausea
10-20 seconds per episode
Positive Dix hallpike manoeuvre- patient experiences vertigo and rotator nystagmus
Management of BPPV
Good prognosis and usually resolves by itself
Epley manoeuvre (89% successful)
Vestibular rehabilitation- exercises the patient can do at home (Brandt-Daroff Exercises)
Betahistine is if limited value
Black hairy tongue
Defective desquamation of the piliform papillae (can be several colours)
Risks- poor oral hygiene, ABX, head and neck irradiation, HIV, IVDU
Swab tongue to exclude Candida
Management- tongue scraping, topical anti fungals if Candida
Branchial cyst features
Typically present in late childhood or early adulthood, usually anterior to the SCM
Unilateral
Slowly enlarging
Smooth, soft, fluctuate
Non tender
Fistula may be seen
No movement on swallowing
No trans illumination
Cholesterol crystals (even in young people)
Management of a branchial cyst
Consider/exclude (with tests) a malignancy
Refer to ENT
USS with FNA
Can be treated conservatively or surgically excised
ABX if they become infected
Cholesteatoma
Foul smelling, non resolving discharge
Hearing loss
If local invasion- vertigo, facial nerve palsy, cerebellopontine angle syndrome
Attic crust seen on Otoscopy
Refer to ENT for surgical removal
Common in patients 10-20 years old
What is Chronic rhinosinusitis
Lasts 12 weeks or longer
Predisposing factors- atopy (hay fever, eczema), nasal obstruction (polyps), recent local infection, swimming, smoking
Features of rhinosinusitis
Facial pain (bending forward)
Nasal discharge- clear if allergic or vasomtor, thick and purulent if secondary infection
Nasal obstruction (mouth breathing)
Post nasal drip (chronic cough)
Management of chronic sinusitis
Conservative- Avoid allergen, Nasal irrigation with saline solution
Medical- Intranasal corticosteroids (polyps)
Surgery- Functional endoscopic sinus surgery (FESS) if persistent
Red flag sinusitis symptoms
Unilateral (one side/nasal cavity affected)
Persistence despite compliance with 3 months of treatment
Epistaxis alongside
Requirements for cochlear implants in adults
Completed a trial of appropriate hearing aids for at least 3 months Which they have received limited or no benefit from
Contraindications for a cochlear implant
Lesions of cranial nerve VIII or in brain stem causing deafness
Chronic infective otitis media, mastoid cavity, or tympanic membrane perforation
Cochlear aplasia
Features of IMPACTED ear wax
Pain
Conductive hearing loss
Tinnitus
Vertigo
Management of impacted wax
Ear drops (olive oil, sodium bicarbonate) for 1 week
Irrigation (ear syringing)
NB- don’t treat if perforation suspected or the patient has grommets
Gingival hyperplasia
Phenytoin
Calcium channel blockers
AML
Simple GINGIVITIS
Painless red swelling of the gum margin which bleeds on contact
Secondary to poor dental hygiene
Seek routine regular review by dentist, ABX not necessary
Acute necrotising ulcerative gingivitis
Similar to gingivitis, but very painful
Refer to dentist
Oral hygiene and stop smoking
Oral ABX eg. metronidazole for 3 days (can also use amoxicillin)
Chlorhexidine or hydrogen peroxide mouth wash
Simple analgesia
Management of epistaxis
If haemodynamically stable;
Sit forward and pinch cartilaginous area of nose firmly for 20 minutes (can use naseptin (chlorhexidine and neomycin) to reduce crusting- careful in peanut allergy)
If continues after 20 minutes;
Refer to hospital/ENT
Silver nitrate cautery if bleeding point visualised (one side of septum)
Packing if bleeding point cannot be identified
Haemodynamically unstable;
Admit to hospital
May need sphenopalatine ligation in theatre
NB- patient advice, don’t pick nose, heavy lifting, vigorous exercise, drinking alcohol or hot drinks as they may introduce a re-bleed
Causes of hoarseness
Voice overuse
Smoking
Reflux laryngitis/GORD
Laryngeal cancer
Lung cancer
Viral illness
Hypothyroidism
Reinkes oedema
Spasmodic dysphonia
Suspected laryngeal cancer
2 week wait referral for anyone with persistent or unexplained hoarseness (or a lump in the neck)
Nasal endoscopy to visualise vocal cords
CXR (exclude apical tumour)
What is laryngopharyngeal reflux (reflux laryngitis)
GORD causing inflammatory changes to the larynx
Common
Features of laryngopharyngeal reflux
70% have a sensation of lump in the throat (globus)- worse swallowing saliva than eating or drinking, felt in midline
Hoarseness
Chronic cough
Heartburn
Sore throat
External examination of neck normal
Posterior pharynx- erythematous
Investigations
Bedside examination of neck and throat
Observations
Bloods
Refer to ENT
Nasal endoscopy to visualise vocal cords
NB- if other red flags present/doesn’t resolve, may need to put on 2 week wait pathway
Management of laryngopharyngeal reflux
Lifestyle measures- avoid triggers such as fatty foods, caffeine, chocolate, alcohol
PPI
Sodium alginate liquids (Gaviscon)
Ludwig’s angina
Progressive cellulitis that invades the Flor of the mouth and soft tissues of the neck
Mainly from Odontogenic infections that spread into submandibular space
Neck swelling
Dysphagia
Fever
Airway management, IV antibiotics
What is malignant osteomyelitis
Uncommon form of otitis externa found in immunosuppressed individuals (90% diabetics)
Pseudomonas
Temporal bone osteomyelitides
Features of malignant osteomyelitis
Diabetes or immunosuppression
Severe unrelenting deep seated otalgia
Temporal headaches
Purulent otorrhoea
May have dysphagia, hoarseness, and or facial nerve dysfunction
Investigations for malignant otitis externa
Full ENT exam, observations, ear swab, diabetic screen
Otoscopy
Bloods- systemic dysfunction (ABG, FBC etc.)
CT Head (looking at bone)
Treatment of malignant Otis externa
Refer urgently to ENT (won’t know it’s malignant in primary care, but any one with non resolving OE with worsening pain should be referred)
IV ABX that cover pseudomonas (ciprofloxacin)
Surgical debridement if required
NB- you’ll know its otitis externa if it is in a T2DM patient and it has a very prolonged course
Mastoiditis
Complication of otitis media
Otalgia (behind the ear)
History of recurrent otitis media
Fever
Typically unwell patients
Swelling, erythema, tenderness over the mastoid process
External ear may protrude forward
Ear discharge may be present if eardrum has perforated
Features of Ménière’s disease
Recurrent episodes of vertigo, tinnitus, hearing loss (sensorineural)- vertigo usually prominent
Sensation of aural fullness or pressure
Nystagmus and positive Rhombergs test
Episodes last minutes to hours
Typically unilateral but symptoms can become bilateral
Drop attacks
Natural history of Ménière’s disease
Usually resolve after 5-10 years
Majority left with a degree of hearing loss
Psychological distress common
Investigations for Ménière’s disease
Observations, full ENT examination
Otoscopy
PTA
CT head (structural cause)
Management of Ménière’s disease
Inform DVLA (can’t drive until satisfactory control of Sx)
Acute attacks- buccal prochloperazine (may require admission)
Prevention- betahistine and vestibular rehabilitation exercises
Nasal polyps associations
Asthma
Aspirin sensitivity
Inective sinusitis
Cystic fibrosis
Kartageners syndrome
Churg Strauss syndrome
Asthma, aspirin sensitivity, nasal polyps triad- Samters triad
Management
Refer to ENT
Nasal corticosteroids will shrink them in 80% patients
Nasal septal haematoma features
Precipitated by trauma (even if minor)
Sensation of nasal obstruction
On examination- a bilateral, red swelling from the septum
Boggy on palpation (deviated septum’s will be firm)
Management of septal haematoma
Surgical drainage
IV ABX
NB- if not treated in 3-4 days, may get saddle nose deformity
Features of nasopharyngeal carcinoma
Otalgia
Unilateral serous otitis media (in an adult)
Nasal obstruction, discharge, and or epistaxis
Cranial nerve palsies III-VIb
Cervical lymphadenopathy
Causes of otitis externa
Infection- staph aureus, pseudomonas
Seborrhoeic dermatitis
Contact dermatitis
Recent swimming
Features of otitis externa
Ear pain, itch, discharge, tender Tragus
Otoscopy- red, swollen, eczematous canal, furuncle
Management of otitis externa
Don’t wet ear
Remove canal debris
Topical antibiotic (combined with steroid). Don’t use aminoglycoside (gentamicin,neomycin,streptomycin) if TM perforated
Ear wick if canal swollen
Failure to respond- refer to ENT
NB- oral ABX and swab if infection spreading or immunosuppression
Otosclerosis
Autosomal dominant cause of conductive deafness
20-40 years, in women seen during times of hormonal change eg. Pregnancy
Conductive deafness
Tinnitus
Normal TM (10% have flamingo tinge- hyperaemia)
Positive FH
Investigations for otosclerosis
Full ENT exam and observations
Otoscopy
PTA
Tympanometry- stiff TM/ reduced admittance
Management of otosclerosis
Conservative- Hearing aid
Surgical- Stapedectomy
Investigations for parotid disease
Full ENT examination (neck lump), Observations
Nasal endoscopy (make sure nothing else is causing the swelling)
XRay to exclude calculus
USS guided FNA
MRI head and neck staging
Management of a ruptured TM
No treatment, usually heal in 6-8 weeks
Don’t get wet, go scuba diving, get on plane
If following episode of OM- antibiotics, if barotrauma- conservative management
Myringoplasty performed if TM doesn’t heal itself
Most common parotid neoplasm
Benign pleomorphic adenoma
Malignant transformation in 2-10%
Post operative complications of tonsillectomy
Haemorrhage- need to be assessed by ENT. Immediate return to theatre (usually 6-8 hours after surgery). Get IV access and send bloods including an FBC, clotting screen, group and save and crossmatch. Fluids if necessary and keep NBM
Secondary haemorrhage occurs between 5-10 days after surgery and is associated with infection (may have fever, give ABX)
NB- Hydrogen peroxide gargle and Adrenalin soaked swab applied topically can be used to manage less severe bleeds
Features of presbyacusis
Slow progressing history
Speech difficult to understand
Difficulty using telephone
Loss of directionality of sound
Worse symptoms in noisy environments
Investigations for older age hearing loss
Otoscopy- normal
Tympanometry- normal middle ear function with hearing loss
Audiometry- bilateral sensorineural hearing loss
Blood tests including inflammatory markers
Ramsay hunt syndrome features
Herpes zoster oticus- reactivation of varicella zoster virus in genticulate ganglion of 7th cranial nerve
Auricular pain
Facial nerve palsy
Vesicular rash around ear
Vertigo and tinnitus
Management of Ramsay hunt syndrome
Oral aciclovir and corticosteroids
Sore throat indication for ABX
Features of marked systemic upset
Unilateral peritonsilitis
History of rheumatic fever
Increased risk of infection eg. Immunosuppression (DM)
When 3 or more centor criteria/4 or more feverPAIN criteria are present
Centor criteria
Presence of tonsillar exudate
Tender anterior cervical lymphadenopathy
Fever
Absent cough
FeverPAIN Criteria
Fever (38+)
Purulence (exudate)
Attend rapidly (3 days or less)
Severe,y inflamed tonsils
No cough or Coryza
Antibiotics for sore throat
Pen V or clarithromycin (penicillin allergic)
7-10 day course
NB- can they take tablets if they have a sore throat?
Sudden onset sensorineural hearing loss
The diagnosis is made when someone rapidly loses their hearing, and no conductive cause can be found.
Urgent referral to ENT
The majority are idiopathic
MRI- exclude vestibular schwannomas
High dose oral corticosteroids can be used by ENT
Complications of thyroid surgery
Recurrent laryngeal nerve damage
Bleeding- laryngeal oedema
Hypocalcaemia
Investigations for tinnitus
Full ENT exam
Observations
Otoscopy
PTA
Unilateral (asymmetrical) or bilateral and neuro Sx- MRI head
pulsating tinnitus- MR angiography
Management of tinnitus
Investigate and treat underlying cause
Amplification devices- helpful if hearing loss (hearing aid) or adding background sounds to cancel it out
Psychological therapy and support groups
Features if vestibular neuronitis
A cause of vertigo that develops following a viral infection
Recurrent vertigo attacks lasting hours or days
Nausea and vomiting
Horizontal nystagmus
No hearing loss or tinnitus
Differentials for vestibular neuronitis
Viral labyrinthitis
Posterior circulation stroke- HiNTS exam can distinguish the 2
Management of vestibular neuronitis
Short course of prochloperazine or an antihistamine (promethazine)
Vestibular rehabilitation exercises (chronic symptoms)- urgent referral to specialist if prochloperazine doesn’t work
Features of labarynthtis
Vertigo- not triggered by movement, but made worse by it
Nausea and vomiting
Hearing loss (unilateral or bilateral)
Tinnitus
May have preceding or concurrent URTI
Horizontal nystagmus
Gait disturbance (towards affected side)
Management of labyrinthitis
Usually self limiting
Prochloperazine or antihistamine (cyclizine) can help reduce dizzy sensations.
Glue ear
Otitis media with effusion
Serous effusion in middle ear in absence of infection lasting longer than 3 months
Features of glue ear
Painless sensation of pressure in affected ear
Conductive hearing loss
Speech and language impairment
Otoscopy findings of glue ear
Air fluid level
Intact TM
Management of glue ear
Pain relief, no speech impediment- monitor for 3 months
Surgical- grommets
Unrelenting ear pain and diabetes
THINK MALIGNANT OTITIS EXTERNA
Investigations for mastoiditis
Full ENT exam, ENT referral, admit to hospital, Otoscopy
Bloods- FBC UE LFT clotting ABG
Imaging- CT scan temporal bone
Management of mastoiditis
Refer to ENT, analgesia
Empirical IV ABX
SUrgical- grommet insertion to facilitate drainage or in severe cases- mastoidectomy
Oropharyngeal and laryngopharyngeal cancer
Local lymph node metastases causing enlarged cervical lymph nodes
Severe ear pain
Foreign body sensation, dysphagia, sore throat (persistent)
Dysphonia (muffled voice)
Investigations for a neck lump
Observations, head and neck exam eg. Examine nasopharynx, oropharynx, oral cavity, refer to ENT
Bloods- FBC UE LFT CRP coagulation profile calcium ANA (SLE can cause lymphadenopathy)
Imaging- pan endoscopy and biopsy, USS with FNA
Features of oral cavity cancer
Halitosis
Pain (earache)
Dysphagia
Non healing ulcer
Unusual bleeding in mouth
Facial swelling
Paralysis of part of face
Lymphadenopathy
Question to ask in hoarseness history
GORD- reflux symptoms
Features of nasal polyps
Post nasal drip
Bilateral nasal obstruction
Impaired olfactory functions
NB- refer if alarming features, then intranasal steroids, then surgery if that fails
Causes of epistaxis
Nose picking
Foreign body
Intranasal drug use (corticosteroids, cocaine)
Nasal blunt force trauma
HHT
Anticoagulants
Allergic rhinitis
Nasopharyngeal carcinoma
Bleeding disorder- haemophilia, VWD
HTN
Vasculitis (Wegners)
Causes of tonsillitis
Viral
Bacterial- group A strep, strep pneumoniae, haemophilus, staph aureus
Features of tonsillitis
Sore throat
Fever
Pain on swallowing
Erythematous, large tonsils
Tonsillar exudate
Anterior cervical lymphadenopathy
Complications of tonsillitis
Quinsy
Otitis media
Post strep glomerulonephritis
Post strep reactive arthritis
Management of tonsillitis
Supportive- analgesia, fluids, safety net (pain not settled after 3 days, fever rises above 38.3)
Medical- if centor is 3+ or feverPAIN is 4+- ABX (pen V for 10 days, clarithromycin if penicillin allergy)
Surgery- tonsillectomy if 5 times a year for 3 years or 7 times a year for 2 years
Quinsy (peritonsilar abscess) Features
Same Sx as tonsillitis
May also get;
Trismus
Change in voice (hot potato voice)
Deviation of uvula away from affected side
Swelling around the tonsils
Management of quinsy
Supportive- refer to ENT, analgesia, fluids
Medical- ABX (co amoxiclav)
Surgical- incision and drainage
Features of glandular fever
Fever
Sore throat
Fatigue
Lymphadenopathy
Tonsillar lymph nodes
Splenomegaly
Palatial petechiae
Hepatitis (transient rise in ALT)
NB- itchy rash after taking amoxicillin or cephalosporin
Investigations for glandular fever
Bedside- observations, full ENT exam
Bloods- FBC, UE, LFT CRP monospot test in 2nd week illness
Imaging- may need USS with FNA if concerned about malignancy
Management of glandular fever
Supportive- analgesia, rest, avoid alcohol, increase fluids, avoid contact sports for 8 weeks
Causes of epistaxis
HTN
Coagulopathy eg. Drug induced, VWD, haemophilia
Nasopharyng carcinoma
Trauma eg. Nose picking
Sensorineural causes of hearing loss
Genetic
Presbyacusis
Vestibular schwannoma
Gentamicin, frusemide, aspirin, chemotherapy, quinine
Trauma
Noise-induced/excessive noise
Conductive causes of hearing loss
Earwax
Foreign body
OE
OM
Otosclerosis
Cholesteatoma
Perforated TM
Exotosis (benign bony growth)
Investigations for epistaxis
Bedside- full head and neck exam, nasal speculum, flexible nasoendoscopy
Bloods- FBC and clotting
Imaging- CT if worried about underlying pathology
Investigations if suspecting impacted ear wax (or a conductive pathology)
Otoscopy, PTA, tympanometry
Investigations for vertigo
Bedside- Otoscopy, neuro exam, cardiac exam (rule out cardiogenic syncope), Dix hallpike manoeuvre, PTA (cochlear disturbance), HINTS exam, Romberg’s
Imaging- MRI if want to rule out a central cause
Mumps
Young adult
Parotid swelling and pancreatitis, orchiditis, reduced hearing, meningoencephalitis
Vertebrobasilar ischaemia
Elderly patient dizzy on extending neck
Vascular risk factors/ history
Causes of tinnitus
Idiopathic
Meniere’s disease
Labyrinthitis
Otosclerosis
Sudden onset sensorineural hearing loss
Presbycusis
Impacted ear wax
Drugs- Aspirin/NSAIDs, Aminoglycosides, Loop diuretics, Quinine
Otitis media
Noise exposure
MS
Trauma
Acoustic neuroma
NB- carotid bruit due to carotid artery stenosis or IIH can cause pulsatile tinnitus
Conductive causes of rapid onset hearing loss (not associated with sudden sensorineural hearing loss (SSNHL))
Conductive causes of rapid-onset hearing loss (not classed as SSNHL) include:
Ear wax (or something else blocking the canal)
Infection (e.g., otitis media or otitis externa)
Fluid in the middle ear (effusion)
Eustachian tube dysfunction
Perforated tympanic membrane
Causes of SSNHL
Most cases (90%) of SSNHL are idiopathic, meaning no specific cause is found.
Other causes of SSNHL include:
Infection (e.g., meningitis, HIV and mumps)
Ménière’s disease
Ototoxic medications
Multiple sclerosis
Migraine
Stroke
Acoustic neuroma/ vestibular schwannoma
Cogan’s syndrome (a rare autoimmune condition causing inflammation of the eyes and inner ear)
NB- Audiometry is required to establish the diagnosis. A diagnosis of SSNHL requires a loss of at least 30 decibels in three consecutive frequencies on an audiogram.
MRI or CT head may be used if a stroke or acoustic neuroma are being considered.
Management of SSNHL
Urgent referral to ENT
Steroids
Treat underlying cause if applicable
Eustachian tube dysfunction
When the tube between the middle ear and throat is not functioning properly. The Eustachian tube is present mainly to equalise the air pressure in the middle ear and drain fluid from the middle ear.
Features;
Reduced or altered hearing
Popping noises or sensations in the ear
A fullness sensation in the ear
Pain or discomfort
Tinnitus
Investigations for eustachian tube dysfunction
Usually investigations aren’t necessary as a simple underlying cause can be identified. However further tests may be necessary;
Tympanometry (pressure in middle ear/ TM stiffness)
Audiometry
Nasopharyngoscopy (an endoscopic camera through the nose to the throat to inspect the Eustachian tube openings)
CT scan to assess for structural pathology
Management of eustachian tube dysfunction
No treatment, waiting for it to resolve spontaneously (e.g., recovering from the viral URTI)
Valsalva manoeuvre (holding the nose and blowing into it to inflate the Eustachian tube)
Decongestant nasal sprays (short term only)
Antihistamines and a steroid nasal spray for allergies or rhinitis
Surgery (if persistent)- grommets or Balloon dilatation Eustachian tuboplasty
HINTS exam
Normal HINTS (ie. negative), central cause of vertigo (so positive HINTS is reassuring)
NB- negative/normal HINTS is worrying
Nystagmus- central cause if vertical/bidirectional nystagmus
Vertical test if skew- central
Nasal spray technique
Steroid nasal sprays are often misused, which means they will not be as effective. A good question to ask is, “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 and will not be as effective.
The technique involves:
Tilting the head slightly forward
Using the left hand to spray into the right nostril, and vice versa (this directs the spray slightly away from the septum)
NOT sniffing hard during the spray
Very gently inhaling through the nose after the spray
Causes of lymphadenopathy
Reactive lymph nodes (e.g., swelling caused by viral upper respiratory tract infections, dental infection or tonsillitis)
Infected lymph nodes (e.g., tuberculosis, HIV or infectious mononucleosis)
Inflammatory conditions (e.g., systemic lupus erythematosus or sarcoidosis)
Malignancy (e.g., lymphoma, leukaemia or metastasis)
Carotid body tumours
Slow growing lump
In the upper anterior triangle of the neck (near the angle of the mandible)
Painless
Pulsatile
Associated with a bruit on auscultation
Mobile side-to-side but not up and down
If it presses on vagus nerve- Horners syndrome
What medication can be used to treat some head and neck cancers
Cetuximab is an example of a monoclonal antibody. It may also be used to treat bowel cancer. It targets epidermal growth factor receptor
Glossitis
Iron deficiency anaemia
B12 deficiency
Folate deficiency
Coeliac disease
Injury or irritant exposure
NB- can be atrophic/desquamative/folded etc.
Angioedema (tongue)
Allergic reactions
ACE inhibitors
C1 esterase inhibitor deficiency (hereditary angioedema)
Oral candidiasis
Inhaled corticosteroids (particularly with poor technique, not using a spacer and not rinsing with water afterwards)
Antibiotics (disrupt the normal bacterial flora giving candida a chance to thrive)
Diabetes
Immunodeficiency (consider HIV)
Smoking
Management;
Miconazole gel
Nystatin suspension
Fluconazole tablets (in severe or recurrent cases)
Strawberry tongue
A strawberry tongue appearance occurs when the tongue becomes swollen and red, and the papillae become enlarged, white and prominent.
Scarlet fever
Kawasaki disease
Leukoplakia
Leukoplakia is characterised by white patches in the mouth, often on the tongue or insides of the cheeks (buccal mucosa). It is a precancerous condition, meaning it increases the risk of squamous cell carcinoma of the mouth.
The patches are asymptomatic, irregular and slightly raised. They are fixed in place, meaning they cannot be scraped off.
They may require a biopsy to exclude abnormal cells (dysplasia) or cancer. Management involves stopping smoking, reducing alcohol intake, close monitoring and potentially laser removal or surgical excision.
Erythroplakia
Erythroplakia is similar to leukoplakia, except the lesions are red. Erythroleukoplakia refers to lesions that are a mixture of red and white. Both erythroplakia and erythroleukoplakia are associated with a high risk of squamous cell carcinoma and should be referred urgently to exclude cancer.
Lichen planus
An autoimmune condition that causes localised chronic inflammation of the skin. The skin has shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.
Often affects the mucosal membranes, including the mouth. Often it only affects the mouth.
NB- oral hygiene, stopping smoking and topical steroids.
Aphthous ulcer
Idiopathic
Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)
Coeliac disease
Behçet disease
Vitamin deficiency (e.g., iron, B12, folate and vitamin D)
HIV
Usually heal within 2 weeks- longer than 3+ 2 week wait pathway
Management- either Topical bonjela, lidocaine, or steroids
Unilateral middle ear effusion
Urgent referral to ENT in adults (could be nasopharyngeal carcinoma)
Investigations for suspected acoustic neuroma
Bedside- full ENT assessment, PTA
Bloods
Imaging- gadolinium-enhanced MRI head scan
Motion sickness
Management
the BNF recommends hyoscine (e.g. transdermal patch) as being the most effective treatment. Use is limited due to side-effects
non-sedating antihistamines such as cyclizine or cinnarizine are recommended in preference to sedating preparation such as promethazine
Patient snoring/making airway noises/unconscious
Head tilt chin lift jaw thrust
Then insert oropharyngeal airway (nasopharyngeal is contraindicated in basal skull fracture)
Glue ear and Down’s syndrome/cleft palate
Refer to ENT
