ENT Flashcards
How should a pinna haematoma be managed?
Urgent drainage <24 hrs : aspiration or incision
Secure a dental roll in place + tight headband to prevent re-accumulation
PO Abx if infected
ENT clinic followup to ensure no deformity
What is the difference between pinna perichondritis and pinna cellulitis?
Perichondritis spares the earlobe, cellulitis affects whole ear
Perichondritis most commonly pseudomonas
Cellulitis most commonly staph aureus
What are the risk factors for otitis externa?
Swimming Cotton bud use Canal obstruction Humidity Allergy and skin disease Immunocompromise Prolonged topical antibiotics
What are the key bacteria involved in otitis external?
Staph aureus and pseudomonas
What are the symptoms of otitis external?
Ear pain (pulling in children) Tragal tenderness Erythema and swelling Otorrhoea Sensation of fullness Itching Reduced hearing
What are differentials for otitis externa?
Foreign body Cellulitis Otitis media Dermatitis Mastoiditis
How is otitis external managed?
KEEP EAR DRY
Mild cases may be treated with acetic acid 2%
7-10 days topical antibiotics with steroids e.g. sofradex
Oral abx if resistant
Analgesia
Microsuction
What are symptoms of malignant otitis externa?
Severe deep otalgia Foul smelling discharge Headache Vertigo Hearing loss Not responding to topical antibiotics
May have granulation tissue / exposed bone in the ear canal
Facial nerve palsy
How is malignant otitis externa managed?
High resolution CT of temporal bones
6 weeks IV and topical abx
May need surgical management of collections and abscesses
What are symptoms of mastoiditis?
Usually present days-weeks after otitis media
Fever, persistent throbbing otalgia
Redness
Swelling
Tenderness
Fluctuance and swelling of mastoid process
Lateral and inferior displacement of the pinna
How is mastoiditis managed?
IV ceftriaxone and steroids
May need surgical mastoidectomy to manage abscesses
What are the common causative organisms in otitis media?
Strep pneumoniae, Haemoglobin influenzae
RSV, rhinovirus
What are the symptoms of otitis media?
Often preceding URTI
Otalgia = primary presenting feature in adults
Fever
Spontaneous perforation of tympanic membrane
Purulent Otorrhoea
Ear pulling and poor feeding in small children
Bulging tympanic membrane
May have a fluid membrane
What is the management for otitis media?
Oral analgesia
Viral infections are self-limiting usually within 3 days
5-7d oral amoxicillin first line in suspicion of bacterial infection
Clarithromycin if penicillin allergic
What are the two types of chronic otitis media?
Mucosal- perforation of the tympanic membrane, chronic middle ear infection
Squamous- tympanic membrane retraction, accumulation of keratin, cholesteatoma
Characterised by ear discharge >2w without pain, fever or tinnitus
What are the symptoms of cholesteatoma?
Conductive hearing loss Ear discharge resistant to antibiotics Crusting of retraction pocket Tinnitus Otalgia
With progression: vertigo, sensorineural hearing loss, facial nerve palsy, meningitis, abscess
How would you manage cholesteatoma?
Canal wall-up mastoidectomy
What are the causes of sudden sensorineural deafness?
90% idiopathic Meningitis/mumps/HIV Extreme noise Barotrauma Acoustic neuroma Ototoxic medication Stroke/vasculitis Labyrinthitis
What are the causes of chronic sensorineural deafness?
Presbyacusis
Environmental noise toxicity
Inherited disorders
Diabetic neuropathy
What are the causes of conductive deafness?
Obstruction: foreign body, earwax Cholesteatoma Otosclerosis Otitis media/glue ear Otitis externa Trauma- ossicle fracture Facial nerve palsy (stapedius paralysis)
What is the most common cause of rhinosinusitis?
Viral URTI
What are the symptoms of rhinosinusitis?
Nasal congestion
Facial pain- worse on leaning forward
Sensation of fullness
Decreased sense of smell
How is rhinosinusitis managed?
Saline irrigation
Antihistamines + trigger avoidance in allergic causes
Topical nasal steroids
Only abx if symptoms suggestive of bacterial sinusitis complication/ symptoms >14 days
Which is a red flag: unilateral or bilateral nasal obstruction?
Unilateral
How are nasal polyps managed?
Oral prednisolone
Topical steroid e.g. fluticasone, beclometasone
Nasal saline irrigation
Surgical removal if refractory and bothersome
What is the recommended management algorithm for epistaxis?
Compression 10-15 min, lean forward \+ ice to try vasoconstrict If source visible: silver nitrate cautery (topical lidocaine first) If not: try anterior packing If no help: posterior pack Sphenopalatine artery ligation
Naseptin antiseptic ointment 1-2w to prevent crusting and keep clean
Prevent blowing nose, hot showers + baths, exercise, spicy food
What are important investigations in epistaxis?
FBC + Clotting
BP
Rule out bleeding disorders
Examination incl. rhinoscopy
What is the most common bacterium causing quinsy?
Streptococcus pyogenes
How does quinsy commonly present?
Following recent episode of bacterial tonsilitis
Unilateral peritonsillar swelling, displacement of the uvula
Sore throat, Fever, Malaise
Muffled voice, dysphagia, drooling, difficulty breathing
Trismus
Neck swelling
How is quinsy managed?
Incision and drainage IV antibiotics- clindamycin IV steroids- dex IV fluids Analgesia
What is the management of epiglottitis?
Airway management + A-E IV cephalosporin antibiotics IV dexamethasone IV fluids Humidified oxygen
What is the most common type of thyroid cancer?
Papillary carcinoma
Which thyroid cancer is part of MEN-2?
Medullary carcinomas
How are papillary and follicular thyroid cancers managed?
total thyroidectomy
followed by radioiodine (I-131) to kill residual cells
yearly thyroglobulin levels to detect early recurrent disease
What are the differential causes of hoarse voice?
Laryngitis Pancoast tumours Largyngeal fold carcinoma Vocal cord palsy Vocal fold polyps
How does presbyacusis present?
Gradual and insidious hearing loss
Loss of high frequency sounds first
May have associated tinnitus
Diagnosed by audiometry
What is the inheritance pattern of otosclerosis?
Autosomal dominant
What type of hearing loss occurs in otosclerosis?
Conductive
Which frequencies are most affected by otosclerosis?
Lower pitched sounds
What are treatment options for otosclerosis?
Conservative with use of hearing aids
Stapedectomy
What are the peripheral causes of vertigo?
BPPV Meniere's disease Vestibular neuronitis Labyrinthitis Acoustic neuroma HZV infection
What are the central causes of vertigo?
Posterior circulation stroke
Tumour
MS
Vestibular migraine
How would you investigate vertigo?
Ear examination Neurological examination CV examination Cerebellar examination Romberg's/Dix-Hallpike/HINTS
What are the components of cerebellar examination?
DANISH
Dysdiadochokinesia Ataxic gait Nystagmus Intention tremor Speech Heel-shin test
What makes up a HINTS exam?
Exam to differentiate between central and peripheral causes of vertigo.
Head Impulse
Nystagmus
Test of Skew
What symptomatic treatments can be given in vertigo?
Prochlorperazine
Antihistamines
What are the symptoms of BPPV?
Triggered by head movement
20-60second episodes of vertigo and asymptomatic in between
How is BPPV diagnosed and managed?
Diagnosed using Dix Hallpike manoeuvre
Managed using Epley manoeuvre
What are the symptoms of vestibular neuronitis?
Usually a recent viral URTI
Vertigo
Nausea and vomiting
Balance problems
NO LOSS OF HEARING
How is vestibular neuronitis managed?
Symptomatic treatment < 3 days- any longer may slow down recovery
Symptoms should resolve on their own- intense for a few days then gradually improve over following weeks
What are the features of labyrinthitis?
Recent viral URTI Acute onset vertigo Hearing loss Tinnitus Nausea, vomiting Balance problems
What are the features of meniere’s disease?
Usually presents between ages of 40 and 50
Unilateral symptoms
Episodes of vertigo, hearing loss and tinnitus
Vertigo lasting 20m-few hours not triggered by movement/posture
Fluctuating episodes of unilateral SN hearing loss, gradually becomes more permanent, affects low frequencies first
May have sensations of fullness in the ear, unexplained falls without LOC and imbalance
Spontaneous unilateral nystagmus
What can be used for prophylaxis of meniere’s disease attacks?
Betahistine
How do acoustic neuromas usually present?
Unilateral sensorineural hearing loss Unilateral tinnitus Dizziness or imbalance A sensation of fullness in the ear May have associated facial nerve palsy (LMN, forehead not spared)
In bacterial sinusitis, what is the first line antibiotic?
Phenoxymethylpenicillin
What is the most common cause of bacterial tonsillitis?
Group A strep (strep pyogenes)
Strep pneumoniae second
Which antibiotic is indicated for bacterial tonsilitis?
Phenoxymethylpenicillin (penicillin V)
Clarithromycin in pen allergy
What is the Centor criteria?
Fever >38 degrees
Tonsillar exudate
Absence of cough
Tender lymphadenopathy
3+ increases likely of bacterial and appropriate to give abx.
What is an alternative to the centor criteria?
Fever PAIN Fever Purulence Attended within 3 days of symptoms Inflamed tonsils No cough or coryza
Score 4+ likely bacterial
What are potential complications of tonsilitis?
Peritonsillar abscess Otitis media Scarlet fever Rheumatic fever Post-strep GN Post-strep reactive arthritis
What are the indications for tonsillectomy?
Episodes of tonsillitis:
7 or more in 1 year
5 per year for 2 years
3 per year for 3 years
Recurrent quinsy (2 episodes) Enlarged tonsils causing difficulty breathing, swallowing or snoring
How is post-tonsillectomy bleeding managed?
LIFE THREATENING due to aspiration of blood.
Call the ENT registrar
Get IV access
Bloods including FBC, clotting screen, group & save, crossmatch
Keep the patient calm and give adequate analgesia
Sit them up and encourage them to spit out the blood
Make NBM in case an anaesthetic and operation is required
IV fluids for maintenance and resuscitation, if required
In less severe: Hydrogen peroxide gargle or adrenalin soaked swab can be tried before returning to surgery
What are the borders of the anterior triangle?
Mandible forms the superior border
Midline of the neck forms the medial border
Sternocleidomastoid forms the lateral border
What are the borders of the posterior triangle of the neck?
Clavicle forms the inferior border
Trapezius forms the posterior border
Sternocleidomastoid forms the lateral border
What are the features of carotid body tumours?
Slow-growing lump: in anterior triangle, painless, pulsatile, bruit, mobile horizontally
May cause Horner’s syndrome
Splaying of int and ext carotid arteries
What is a branchial cyst?
Congenital abnormality
Soft, cystic swelling between angle of jaw and SCM in anterior triangle
Will transilluminate
Usually present after age of 10
Conservative or surgical management
What are red flags for head and neck cancers?
Lump in the mouth or on the lip Unexplained ulceration in the mouth lasting more than 3 weeks Erythroplakia or erythroleukoplakia Persistent neck lump Unexplained hoarseness of voice Unexplained thyroid lump
What is leukoplakia of the mouth?
Precancerous condition- SCC
White patches - usually on side of tongue or cheeks
Asymptomatic, irregular and raised patches which can’t be scraped off
What is Erythroplakia of the mouth?
Similar to leukoplakia but red
Also pre-cancerous
What is lichen Planus?
autoimmune condition that causes localised chronic inflammation of the skin
shiny, purplish, flat-topped raised areas with white lines across the surface
