ENT Flashcards
Epistaxis management
recurrent + visible blood vessels on nasal septum bilaterally + NO active bleeding
1- nasal cautery @ 1 side or topical naseptin (chlorhexidine & neomycin)
Can’t do cautery on both sides at same time
Avoid cautery with silver nitrate when there is active bleeding
Epistaxis management
recurrent + visible blood vessels on nasal septum bilaterally + ACTIVE bleeding
anterior nasal packing bilaterally
- left for 24-48 hrs
Encourage mouth breathing
Oral lichen planus
Treatment
Lace like appearance
Topical steroids - benzydamine mouthwash/spray recommended
If extensive - oral steroids
Ear Foreign body removal
- insect
1- kill with 2% lidocaine/ olive oil/mineral oil or alcohol drops
Syringe out water irrigation or olive oil
Ear FB removal
- seed
Rapid access - not urgent referral to ENT
Removal by suction with catheter or by hook
Do not irrigate - can cause it to swell
Ear FB removal
-super glues
Remove manually in 1-2 days - after desquamation
Refer to ENT if eardrum involved
Ear was build up
Olive oil to soften hard wax
Batteries in ear
Refer ent , should be taken without 24 hrs
Any spherical object in the ear should be removed by. -
Hook
RFs for nasopharyngeal carcinoma
EBV
Smoking
Alcohol
Features of nasopharyngeal ca
Swollen cerviacal LNs - painless
Eustachian tube obstruction
CHL , tinnitus
Tonsil ca spreads to
Mandible
- pain in the throat + trismus - spasm of jaw muscles
Quinsy / peritonsillar abscess
Features
Usually after hx of tonsillitis Severe trismus Drooling saliva Otalgia Uvular deviation Hot potato voice
Quinsy treatment
Admit for IV antibiotics - benzylpenicillin
I&D
Majority of sinusitis caused by
Viral infection
Treatment sinusitis
Mostly self limiting
Symptomatic relief
- nasal decongestant containing ephedrine
Paracetamol/ ibuprofen
Nasal steroids if sx >10 days w/o improvement
Plummer Vinson syndrome
Features (3)
It is a RF for -
Common in -
AKA Paterson Kelly / sideropenic dysphagia
IDA + gloss it is + dysphagia (due to post-cricoid oesophageal web )
Koilonychia
RF for oropharyngeal ca
Common in postmenopausal women
Treatment of Plummer Vinson
Balloon dilation
Paranasal sinus tumour
Features
Pressure/pain/tenderness/swelling - cheek upper teeth Blood in nasal discharge Nasal obstruction Hx of chronic sinusitis If orbit involved - epiphora , diploia
Treatment otitis media
Viral - analgesics, supportive
Bacterial - oral amoxicillin
Otitis external
Features
Treatment
Itching - pain
Travel tenderness
T-
1- acetic acid 2%, 1 spray TID 7 days
2- topical gentamicin
3- aminoglycoside + topical corticosteroid 3 drops TID 7-14 days
Aminogly - gentamicin
= avoid if TM rupture - ototoxic ; use cipro instead
Fist investigation in ear trauma
Otoscopy
Investigation for mandibular lump / salivary gland mass
US FNAC
Chronic sialadenitis
Submandibular swelling - more painful and prominent on chewing
Usually 2ry to sialolithiasis
Sour taste in my mouth , dry mouth
Decreased jaw mobility
Mikulicz syndrome
Triad of
Symmetrical enlargement of all salivary glands
Lacrimal gland enlargement - narrowing of palpebral fissures
Dryness of mouth - parchment like
2ry to sarcoidosis , TB or lymphoma
Rinne test vs Weber test
Both use 512 hz Normal AC > BC twice as long Rinne: CHL - BC> AC SNHL - AC > BC - not twice as long
Weber :
CHL - sound heard best in abnormal ear
SNHL - hear best in normal ear
Ménière’s disease
Features
DVT + fullness Deafness - usually unilateral SNHL vertigo Tinnitus Fullness/ pressure in ear \+/- nausea and vomiting Lasts mins to hrs
Treatment of Ménière’s
Prochlorperazine - buccal or IM
Or
Promethazine , cyclizine, cinnarizine
SNHL means
Investigations
Defect in cochlea - hair cells in inner ear , cochlear nerve or brain stem
MRI
Vestibular neuritis
Features
Treatment
VN - vestibular nerves inflammation , vestibular neuropathy
3 Vs - vertigo, vomiting , viral URTI
No hearing loss!
Treatment - prochlorperazine
Labyrinthitis
Features
Treatment
Inflammation of vestibular nerve AND labyrinth
Attacks of vertigo nausea and vomiting aggravated by moving head
Preceded by URTI
SNHL +- tinnitus
Vestibular neuritis vs BPPV
VN - hours - day s
BPPV - minutes
Otitis media with effusion / glue ear
Commonest cause of CHL in children
TM - retracted (more common) or bulging
- bluish gre , dull to yellow +- an air fluid level
CHL
Treatment of OME
1st visit / recent dx
- reassure and review in 3 months
> 3 months & bilateral
- grommets insertion
- if CI - ear aids
Advise parents to stop smoking
Commonest cause of progressive CHL in young adults (15-45 yrs old)
Otosclerosis
Bluish grey or yellow TM with air fluid level
OME
Flamingo pink blush TM (Schwartz sign)
Otosclerosis
Inflamed TM cartwheel appearance of vessels
Acute suppurative OM
Otosclerosis -cause - genetics -uni/bilateral - male:female -hearing loss Accelerated by
Increased stapes bony growth (turnover) 50% genetic 80% bilateral F>M 2:1 CHL Accelerated by - pregnancy
Otosclerosis treatment
No cure
Stapedectomy or stapedotomy with prosthesis insertion
Not fit for surger - bilateral hearing aids
Chalky white patches over eardrum
CHL
Acquired cholesteatoma
Features
Complications
Collection of keratinising squamous epithelium in middle ear
Expands and can erode adj structures - TM perforation and ossicle damage
Pearly white mass behind TM
Chronic foul discharge.
Hx recurrent otitis media
CHL
Congenital vs acquired cholesteatoma
Congenital - child 6mo to 5 years
Usually no recurrent hx of OM or TM perforation
Management of cholesteatoma
Referral ENT for surgical removal
Acoustic neuroma / vestibular Schwannoma
Pressure effect on CN 8th - DVT deafness, vertigo, tinnitus 7- facial palsy/drooping 6- diplopia same side 5- loss of corneal reflex \+- ICP sx
Imaging for Acoustic neuroma / vestibular Schwannoma
MRI cerebellopontine angle / MRI internal auditory meats
MRI brain
MRI in Ménière’s disease
Normal
Malignant otitis externa
Usually caused by -
Features-
Aggressive infection - NOT cancer Pseudomonas infection of auditory canal - gangrene & necrosis Necrosis can extend deep - facial n palsy 50% Severe pain , foul discharge, CHL
Malignant otitis externa
Imaging
Management
CT scan
Urgent referral to ENT - it can be fatal
50% death if untreated
IV antibiotics - cipro
Malignant otitis externa - important RF
Immunocompromised
Commonest organism in OM
RSV , rhinovirus
H influenza
S.pneumoniae
S.pyogenes
Dx of BPPV
Hallpike’s manoeuvre
Epley’s manoeuvre
Treatment of BPPV
BPPV mostly resolves spontaneously
BPPV involves what part of the ear
Posterior Semi circular canal - usually but not exclusively
BC >AC - bilateral;
Weber not lateralised
In a child , can’t hear teacher well in class
Think of ___
OME
Hearing test in children
< 6 months
Otoacoustic emission
Audiological brainstem response
Hearing test
6-18 mo
Distraction testing
2- 4 years
Hearing test
Speech discrimination or
Conditioned response audiometry
> 5 - hearing test used
Pure tone audiogram
Ear furuncle
- common organism
-RFs
Treatment
S. Aureus
DM , immunocompromised
Mostly resolves spontaneously
Or give flucloxacillin
If large - I & D
Furuncle vs carbuncle
Furuncle - infection of hair follicle
Carbuncle - group of hair follicles next
Arrange or refer for hearing assessment in following conditions
(6)
Any parental concern about hearing loss at any time - despite normal tests before !
Professional doctor’s concern
Temporal bone fracture
Bacterial meningitis
Severe unconjugated indirect hyperbilirubinemia
Delayed speech and language milestones
Itching in ear followed by ear pain and serum discharge
Otitis externa
Nasal trauma
Later develops nasal pain tenderness general malaise and fever
Dx?
Nasal septal abscess
- possible infected nasal hematoma
Functional dysphonia
Voic disturbance in absence of any structural abnormality of larynx and vocal cords
Presbycusis
Features
Can’t hear high frequency sounds Affects elderly Bilateral SNHL Difficulty understanding speech and follow convo Poor hearing esp in noisy environment
Presbycusis treatment
Bilateral digital hearing aids that increase high frequency sound
Otosclerosis vs presbycusis
Otosclerosis - CHL, can’t hear LOW freq sounds
Presbycusis - SNHL , can’t hear HIGH frequency sounds
Oto - young 15-45 yrs , can hear better in noisy environments
First aid measure - epistaxis
Pinch nose - cartilaginous soft tissue , open mouth
Hold 10-15 mins
If hemodynamically unstable - send to a&e
Acute tonsillitis
Viral vs bacterial - centor criteria
Centor criteria 1- Fever >38 2- tender and enlarged anterior cervical LNs 3- tonsillar exudates/pus 4- no associated cough
1st line bacterial otitis media
Amoxicillin
1st line bacterial tonsillitis
Phenoxymethylpenicllin - penicillin V
1st line in bacterial sinusitis
Phenoxymethylpenicillin - penicillin V
Asthmatic patient on long term oral steroid
+ hoarseness of voice
Think of laryngeal candidiasis 2ry to prolonged steroid intake.
Most common type of parotid tumour
Benign pleomorphic adenoma
= benign mixed tumour
Features of benign pleomorphic adenoma
Painless Firm Mobile Grows slowly Solitary Asymptomatic
Treatment benign pleomorphic adenoma
Superficial parotidectomy or enucleation
Risk of malignant transformation of benign pleomorphic adenoma
2-10% risk
Parotid enlargement
DDX
Sjögren’s syndrome
Mumps
Mumps is infective during what period
How long is the IP
7 days before and 9 days after parotid swelling starts
14-21 days
Mumps complications
Orchitis
Meningoencephalitis
Pancreatitis
Hearing loss - usually unilateral transient HL
Temporomandibular mandibular joint
Features
Pain in ear cheek mandible
Increases on chewing + bruxism
Noise induced hearing loss
2nd most common form of SNHL (1-presbycusis)
Cause - exposure to loud sounds
Form of occupational hearing loss - bilateral SNHL
Mixed hearing loss seen in
Paget’s disease
Osteogenesis imperfecta
Insect removal from ear
Initial step
Next step
Initial - kill with lidocaine or alcohol
Next - Instill mineral or olive oil
Indication for tonsillectomy
> 7 episodes tonsillitis / year
5/yr for 2 years
3/year for 3 years
How do you know the TM is bulging?
Absent light reflex
RF for laryngeal ca
Smoking
Asbestos, formaldehyde
Poor fruit and veggie diet
HPV16 - oral pharyngeal and laryngeal ca
Samter’s triad
Asthma + aspirin sensitivity + nasal polyps
Initial & gold standard diagnosis fro obstructive sleep apnoea
Initial - pulse oximetry, overnight breathing study pattern
Gold standard - polysomnography
Treatment OSA
Conservative - wt loss, reduce alcohol intake
Mod/sever - CPAP = 1st line
Rarely surgery to alleviate pharyngeal obstruction
DVLA should be informed if its causing excessive daytime sleepiness
Complications of tonsillectomy
1ry bleeding - first 24 hrs = return to theatre
2ry /reactive bleeding - >24 hrs post op (1-10 days)
- infection - admit for IV antibiotics
Antiseptic mouth washes also indicated
Large hematoma of the ear pinna treatment
I&D
+ co amoxiclav 1 week - prophylaxis
Buccal ulcer with palpable cervical LNs
Dx?
Think SCC
CHL seen in
Otosclerosis Tympanosclerosis OME “glue ear” Malignant otitis extrerna Cholesteatoma
SBHL seen in
Presbycusis
Ménière’s disease
Acoustic neuroma
Noise induced hearing loss
Suspected ca pathway referral (appt within 2 weeks ) to ENT specialist considered for:
Aged 45 + older with “
Persistent unexplained hoarseness of voice >3 weeks
Unexplained lump in neck
Perichondritis
- organism
- causes
Pseudomonas
Infection if hematoma, complication of severe otitis externa, laceration, mastoid surgery, high ear piercing
Perichondritis treatment
Oral ABx - fluoroquinolone +- aminoglycoside & semisynthetic penicillin
Fluoroquinolones:
Cipro
Ofloxacin
Levofloxacin
When should DVLA be informed in OSA
Already diagnosed mod-sever OSAor
Mild OSA diagnosed + excessive daytime sleepiness not controlled for >3 months
Nasal fracture dx
Imaging unreliable
It’s a clinical diagnosis
Speculum exam done
Treatment allergic rhinitis
Xylometazoline - intranasal
- should not be used > 7 days - can cause rebound nasal congestion
Advise pt to stop and medicine free interval
Antibiotic indicated in sinusitis
Phenoxymethylpenicillin
If very unwell - co amoxiclav
If allergic - doxy or clarithromycin
