ENT Flashcards
What is allergic rhinitis?
Inflammatory condition of the nasal mucosa
Characterised by nasal pruritus, sneezing, rhinorrhoea, nasal congestion
It is associated w/ allergic conjunctivitis with eye redness, puffiness and watery discharge
It is IgE MEDIATED RESPONSE TO ALLERGENS WITHIN THE ENVIRONMENT AND may demonstrate a seasonal variation
What are the causes of sensironeural hearing loss?
Presbycusis Noise induced hearing loss congenital infections- rubella, CMV Neonatal complications drug induced deafness (aminoglycosides- gentamicin/neomycin) 7 Vascular pathology- stroke, TIA,
What are the risk factors for H+N neoplasia?
Smoking
Alcohol misuse
Viral infections- HPV (TYPE 16) and EBV
Radiation exposure
Immunosuppresion (Organ transplantation)
Occupational exposure (acid mists, asbestos, wood dust)
FHx
What do H+ N cancers present with?
Hoarseness, throat pain, tongue ulcers or a painless neck lump and symptoms for longer than 3 weeks duration should prompt utgent referral
they may present with weight loss and lymphadenopathy
What are the features of acute otitis media?
Deep seated pain, impaired hearing with systemic illness and fever
The onset is usually rapid with a feeling of aural fullness, followed by discharge when the tympanic membrane perforates with relief of pain
Tympanic membrane shows injection of blood vessels and then diffuse erythema
Bacterial infection is common particularly in young children
What are the complications of otitis media?
Extra cranial complications’ facial nerve palsy, mastoiditis, petrositis, labyrinthitis
Intra cranial- Meningitis, sigmoid sinus thrombosis (sepsis, swinging pyrexia, meningitis), brain abscess
What is the treatment of AOM?
most the time don’t need to treat but can give Amoxicillin for 5-7 days if systemically unwell, bilateral otitis media and under 2, >4days etc…
What is a cholesteatoma and what does it present like?
Overgrowth of stratified squamous epithelium in the middle ear
persistent foul smelling discharge, headache, otalgia
On examination there will be an area of white in the attic behind the tympanic membrane
What is a vestibular schwannoma, what are the clinical features, Ix, Management?
Benign subarachnoid tumour that causes local pressure effects on the VIII cranial nerve
clinical features- asymmetric or unilateral hearing loss and progressive ipsilateral tinnitus
MRI should always be performed in a pt with unilateral tinnitus and sensorineural deafness
Management is with surgery
What are the causes of conductive hearing loss?
Wax impaction Otitis media w/ effusion Eustachian tube dysfunction Ear infections Perforations of the tympanic membrane Chronic suppurative otitis media
What are the clinical features of Menieres?
typically affects one ear, in 30 to 60 year old
Characterised by sudden paroxysmal vertigo (lasting 12-24 hours)
associated with deafness and tinnitus
attacks normally occur in clusters with periods of remission
nausea and vomiting, bed bound, fluctuating hearing
How do you manage menieres?
Betahistine
Prochlorperazine for acute attack
epistaxis
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What are the risk factors for head and neck cancers?
Leukoplakia (1/3 become cancerous) Erytroplakia (1/2 become cancerous) Tobacco/alcohol HPV 16 and 18 Occupation- woodwork, textiles, nickel
What are the symptoms of head and neck cancer?
Odynophagia/dysphagia >3 weeks Hoarseness >3 weeks Trismus- oropharyngeal malignancy Referred otalgia Dyspnoea/stridor
If they have had odynophagia/dysphagia/hoarseness for >3 weeks then they need a 2ww referral
What are the signs of H and N cancer?
Erythroplakia Leukoplakia Bleeding in mouth/throat or haemoptysis Persistent mouth ulceration (>3 weeks) Persistent unexplained neck lump (>3 weeks) Weight loss, night sweats, fever
How do you diagnose H and N cancer?
History and H and N exam Flexible nasal endoscopy Fine needle aspiration cytology CT/MRI of neck CXR/CT chest Bloods- FBC, UEs, LFT, TFT, glucose, albumin
Biopsy is diagnostic however avoid because it needs GA
In terms of H and N, what symptoms/signs would warrant 2ww referral?
Odynophagia/dysphagia >3 weeks Hoarseness >3 weeks Persistent unexplained neck lump >3 weeks Persistent mouth ulceration>3 weeks Leukoplakia Erytroplakia
What are the causes of dysphagia?
Structural changes- post op/radiotherapy
Obstructive- malignancy, pharyngeal oouch
Neurological- CVA/stroke
Muscular- age related weakness, cerebral palsy
Resp- COPD
Gastro oesophageal- LP reflux/GORD
What are the causes of neck lumps?
Infection
Neoplasm (lymphoma)
Thyroid- cyst, neoplasm, multinodular goitre
Thyroglossal cyst, cystic hygroma, branchial cyst
Salivary gland- neoplasm, infection, syone
Carotid aneurysm
Sebaceous cyst, lipoma
What are the 3 types of salivary glands?
Parotid
Submandibular
Sublingual
What are the causes of dry mouth?
Depression/anxiety
Drugs- antimuscarinics
Radiotherapy to head/neck
Sjorgens syndrome
What is scialadenitis?
Inflammation of gland
Caused by infection, stones, malignancy
Symptoms= swollen, tender gland
+/- Pus, +- fever and systemic symptoms
Treat w/ analgesia and abx
What is scialothiasis?
Calculi in glands
After eating swelling and pain
What is tonsilitis? What does it present with What scoring system is used for tonsilitis? Management? Complications?
Acute bacterial infection (strep pyogenes, staph, m. Catarrhalis)
Symptoms= sore throat and odynophagia, pyrexia, malaise, lymphadenopathy +/- Pus on tonsils
Centor score= absence of cough, fever >38, tender cervical nodes, tonsillar exudates
Management
Analgesia, fluids, soft food, PO penicillin V if increased chance of being bacterial
Tonsillectomy if recurrent/complications
Complications= peritonsillar abscess (quincy), deep neck space infection
What is peritonsillar abscess?
What are the symptoms?
Pus between tonsil capsule and lateral pharyngeal wall (strep pyogenes)
Sore throat, odynophagia, dysphagia, TRISMUS (restriction of the range of motion of the jaws), hot potato voice, referred otalgia
What are the signs of peritonsillar abscess?
Unilateral swelling lateral to tonsil
Deviated tonsil and uvula to the opposite side
What is the management of tonsilitis?
ENT referral
Needle aspiration/incision and drainage
IV ABX +/- steroids for swelling
Analgesia, fluids, soft food
What are the symptoms, investigations and management of glandular fever (infectious mononucleosis)?
Symptoms= prodromal illness= fever/malaise Sore throat/dysphagia Cervical lymphadenopathy Abdo pain Hepatosplenomegaly
Investigations: FBC, LFTS, blood film, monospot test
Management: supportive (analgesia, fluids), monitor LFTS, advice - avoid intimate contact, no contact sport as it can cause splenic rupture, no alcohol because this can lead to liver damage
What are the symptoms of pharyngitis ?
What are the causes?
What advice would you give?
Acute= sudden onset sore throat
Causes are usually viral- rhinovirus, influenza, coronavirus, HSV, VZV
May be bacterial= group A strep
What is epiglottitis caused by?
What are the symptoms of epiglottitis
What is the management
Haemophilus influenza B
Symptoms= very dore throat and high fever, dysphagia, drooling, stridor
Management= immediate admission, airway protection (intubation/tracheostomy), IV abx and steroids
What is the safety netting for tonsilitis?
Seek urgent medical help if develop abdo pain (splenic rupture in EBV) , reduced urine output, breathing problems
Come back if abx dont work
What should you ask about in a patient who has came in with epistaxis?
Whether its bleedings from one side or both sides
One side= more likely to be anterior bleed
Both side= more likely to be posterior
How long
Any SOB, lethargy?
Previous episodes/surgery/trauma
Blood thinning medication
What is the stepwise management of epistaxis?
Silver nitrate cauterisation
Nasal packing
Surgical intervention- ligation of the sphenopalantine artery
What do foreign bodies in kids present like?
Offensive grey discharge from one nostril
What are the clinical features of otitis externa?
Otalgia
Deafness
Discharge
What pathogens cause otitis externa?
Pseudomonas auerignosa
Staph aureus
Candida
Aspergillus
What is the managemeng of otitis externa?
Aural toilet (hoover out debris)
Antibiotics and steroid drops
Keep ear dry
If this doesnt work then referral to ENT for microsuction
What do you need to think about in patients with otitis externa who have diabetes?
Necrotizing otitis externa
What is necrotizing otitis externa?
Skull based osteomyelitis
Potentially fatal
What are the suspicious features of necrotising otitis externa and what are the complications?
Suspicious features- night pain, granulations in ear canal, non resolving otitis externa
Complications- sinus thrombosis, cerebral abscess, meningitis, aspiration due to palsies
What is the management of necrotising otitis externa?
Admit
Get a CT
Mdt management
IV abx until resolution of pain and inflammatory markers
When should you give abx in acute otitis media?
Under 2 years old Bilateral Symptoms of local complications- facial weakness, diziness, visual change, neck swelling Severe or recurrent If no resolution after 3 days
What should you do if pt has mastoiditis?
Admit
IV abx
+/- CT scan and surgery
How do you read a audiogram
If there is a gap between the two lines= conductive hearing loss
If both low= sensironeural hearing loss
X= left
When is hearing los an emergency?
If sensorineural treat as an emergency
Give high dose prednisolone for 1 week
They should have an audiogram the next working day
What would be the rinnes and webers test show in conductive hearing loss?
Bone > air
Webers localises to affected ear
What would the rinnes and webers show in sensironeueal hearing loss?
Air > bone in Rinnes
Normal ear localisation in Webers
When would you admit someone with tonsilitis?
If they are unable to eat and drink
What should your immediate management for quinsy be?
Aspiration
Admit IV Abx- benpen and metronidazole
Dexamethasone
Why is stridor more common in children?
Small diameter of the airways
What are the causes of stridor in children?
Croup Acute epiglottitis Foreign body Laryngeal papilloma Congenital abnormalities Laryngomalacia
What are the causes of stridor in Adults?
Laryngeal neoplasms Bilateral vocal cord palsy Croup Epiglottitis Trauma FB Stenosis
Why would you do a tracheostomy?
Real upper airway obstruction- supraglottic, glottic, subglottic
Impending upper airway obstruction
If they are in ITU for a long period of time
What are the causes of otitis externa?
Can be bacterial or fungal
Bacterial= staph aureus or pseudomonas
Fungi- candida, aspergillus
What advice should you give someone with otitis externa?
Dont go swimming
Dont use ear buds
Professional removal of ear wax
What are the causes of middle ear infections?
Influenza, H influenza, staph pneumonia
What are the symptoms of otitis media?
Otalgia Fever Conductive hearing loss Bulging tympanic membrane May have tympanic membrane perforation and pus/blood
What is the treatment of acute otitis media?
Most cases resolve within 24 hours
May give topical abx/steroids
Oral amoxicillin in some cases
What is chronic suppurative otitis media?
What are the symptoms?
What is the management?
This is repeated ASOM (for more than 6 weeks)
Non healing TM perforation
Symptoms= repeated ottorhoea, conductive hearing loss
Regular aural toilet, ENT referral, abx and steroid drops
What are the symptoms of mastoiditis?
Otalgia Hearing loss Malaise Pyrexia Pinna down and forwards Post auricular swelling
What is acute otitis media w/ effusion?
What are the symptoms?
What are the causes?
What is the management?
Fluid in the middle ear
Glue ear
Symptoms
- middle ear fluid with no signs of infection (it is painless)
- conductive hearing loss 20-30
- speech delay and school problems
Causes eustachian tube dysfunction Nasal/ sinus infeftion Allergic response Ciliary dysfuncton
Management
Most resolve by themselves
If more than 3 months without resolution then give grommets and hearing aids
What is cholesteatoma?
Accumulation of keratinising squamous epithelium in the middle ear
Caused by pseudomonas aeurignosa
What is the presentation of cholesteatoma?
Conductive hearing loss
Foul smelling otorrhoea
Attic retractuin and squamous debris
What do you get with tympanic membrane perforation?
Conductive HL
+/- pain, tinnitus, vertigo
What are the causes of sensironeural hearing loss?
Anything that affects the inner ear Menieres Viral infection Ototoxic drugs Temporal bone fracture Tumour (exclude acoustic neuroma with an MRI or CT)
What is an acoustic neuroma?
A vestibular schwannoma which compresses the craniak nerve 8
What are the symptoms of acoustic neuroma?
Unilateral SNHL, tinnitus, vertigo +/- neuro symptoms
How do you investigate acoustuc neuroma?
How do you manage?
Pure tone audiometry
CT/MRI
Management is with surgical excision (there is a risk to the facial nerve), highly focused radiotherapy
What is presbyacusis?
What symptoms do you get?
A cause of sensironeural hearing loss, it is due to aging and loss of outer hair cells of cochlea
You get bilateral SNHL +/- tinnitus which is worse with background noise
Pure tone audiometry and otoscopy can be used to disgnose
What are some causes of ototoxicity?
Diuretics
Aminoglycosides (gentamicin)
Salicylates
Chemo agents
What are the causes of vertigo?
Menieres Acoustic neuroma Ramsay hunt Otoxicity BPPV Acute labyrinthitis
What is BPPV
What is the diagnostic Ix
What is the treatment
The presence of debris in the semicircular canals of the ears causing vertigo upon head movement
The hallpike manouevre is diagnostic, where certain movements of the head causes fatiguable nystagmus
Epley manoueveres and vestibular sedatives (prochlorperazine)
What is the management of labyrinthitis and vestibular neuronitis?
Vestibular sedatives (prochlorperazine)
Bed rest
Antiemetics
What are the features of menieres disease and how do you treat?
Vertigo
Sensironeural hearing loss
Tinnitus
Aural fullness
Treatment involves antihistamines and bed rest
Give some causes of facial palsy..,
Bells palsy
Ramsay hunt
Stroke
What should you do Ix wise for facial palsy?
Hx Ent exam Neuro exam PTA Electroneurogeaphy MRI/CT
What is bells palsy?
What is the management?
Viral infection of facial nerve (increased risk in diabetes and pregnancy)
Ipsilateral facial palsy +/- pain
Management= high dose PO steroids, eye care and analgesia
What is ramsay hunt syndrome?
What are the symptoms
What is the management
Herpes zoster virus infection of the facial nerve
Symptoms= ipsilateral facial palsy, ear pain/vesicles, vesicular rash +/- SNHL, vertigo, tinnitus
Management= acyclovir +/- steroids
Eye care and analgesia
What are the red flags for FNP?
Neuro symptoms- CVA
Progressive palsy/ parotid mass- neoplasm
Associated ear infection/ foul otorrhoea- cholesteatoma
