ENT Flashcards
define tonsilitis
inflammation of the palantine tonsils, suaully bilateral and can be viral or bacterial
bacterial causes of tonsilitis
group A beta haemoltic strep
staphylococci
H. influenzae
pneumococci
presentation of tonsilitis
few days of sore throat
referred otalgia, fever, generally unwell and dehydrated
may have difficutly eating and drinking
enlarged tonsils, muffled voice
when to refer tonsuilitis to ENT
unable to eat and drink
difficulty swalllowing salviva
signs of resp distress or airway compromise
glandular fever AKA
infectious mononucleosis
cause of glandular fever
epstein barr virus (EBV) and some CMV
complications of galndular fever
bacterial tonsilitis
hepatitis and splenic rupture
testing of glandular fever
infectious mononucleosis screen acutely
EBV serology or IgG testing
presentation of glandular fever
tonsilitis
already treated with course of antibiotics with minimal effect
amox + EBV = widespread rash (not allergic)
advise for those with glandular fever
avoid contact sports, alcohol and attend A+E if sudden onset abdo pain - hepatitis and splenic rupture
avoid kissing and sharing cutlery/gasses
when to refer glandular fever to ENT
- Unable to eat and drink
- Difficulty swallowing saliva
- Signs of respiratory distress or airway compromise (very rare!)
Quinsy AKA
peritonsillar abscess
what is qunisy
pus collects between tonsillar caosule and superior constrictor muscle as a complication of tonsilitis, usually unilateral
presentation of quinsy
few day history of bilateral sore throat which has significantly worsened unilaterally
severe odynophagia, fever, unwell, dehydrated, trismus, hot potato voice, spitting oiut saliva
when to refer quinsy to ENT
all suspected should be referred for needle aspiration or incision and drainage of pus
most drained and patient goes home same day with oral antibiotics
red flags of acute throat infections
severe sore throat:
- without evidence of tonsilitis/pharyngitis
- with hoarse/croaky voice, dysphagia and fever
- with neck swelling or neck stiffness (reduced range of movement)
severe trismus
stridor
what is supraglottisis and epiglottis
inflammation of the supraglottis and/or epiglottis
cause of supraglottis and epiglottisis
Haemophilus influenza type B
but reduced due to vaccinations
presentation of supra/epiglotttis
worsening sore throat
uanble to eat and drink often drooling saliva
hoarse or croaky and possibly stridor
children = tripod for airflow
treatment of supra/epiglottisis
adrenaline nebulisers
IV steroids
broad spec antibiotics (IV ceftriaxone)
what are deep neck space infections
collection of pus within potential spaces of the neck formed by investing layer of cervical fascia
cause of deep neck space infectioms
mostly dental origin
can progress from tonsils/quinsies or infected epidermoid, branchial or thyroglossal cysts
presentation of deep neck space infections
toothache, sore throat or prev neck swelling (cyst) now progressed to neck pain
redyuced neck movements, localised or widespread nbeck swelling (fluctuant or firm) possibly with overlying cellulitis
management of deep neck space infecdtionns
FNE and liekly CT of the neck, broad spectrum antibiotics and possbily surgical drainage and debridement
who gets epistaxis
<10 yo
45-65 yo
why male predomination of epistaxis in < 49 yo
protective effect of oestrogen
seasonal factors affecting epsitaxis?
incidence of upper respiratory infections
allergic rhinitis
mucosal changes associated with fluctuations in temp and humidity
types of epistaxis
anterior = from kiesselbatches plexus or littles area –> slef limited, most common, managed in primary setting, mucosal truama or irritation
posterior - postlateral bracnhes of sphenpalantine artery but also arise from branches of the carotid, significant haemorrhage
risk factors of epistaxis
trauma inflammatory - sinusitis or rhinitis drugs - apsirin, clopidogrel, anticoagulant and cocaine neoplasm systemic disease- granulomatosis with polyangitis, CPA, sarcoidosis hereditary bleeding disorder low moisture contnet of air intranasal drug use hypertension
management of epsitaxis
ABCDE approach
local compression for 20min and ice packs
examine nose - rule out septal haematoma and reduce nasal fracture
nasal cautery
nasal pakcing
surgical option s- intervential radiologist angiogrpahic embolization
house-brackmann clasification
facial nerve weakness classficiation of facial nerve palsy
I for normal, VI for no movement
House-Brackmann Grading System I
normal facial function
House-Brackmann Grading System II
- Slight weakness, normal symmetry and tone
- Complete eye closure and forehead movement with effort
- Mouth slightly weak
House-Brackmann Grading System III
- Small difference between 2 sides at rest
- Complete eye closure with effort, slight to moderate forehead movement
- Mouth slightly weak
House-Brackmann Grading System IV
- Obvious weakness and disfiguring asymmetry
- No forehead movement
- Incomplete eye closure
- Mouth asymmetrical
House-Brackmann Grading System V
- Only barely perceptible motion, asymmetrical at rest
- No forehead movement
- Incomplete eye closure
- Mouth asymmetrical
House-Brackmann Grading System VI
• No movement / Total paralysis
forehead involved
forehead sparred (contralateral supply)
LMN lesions
UMN lesions
idiopathic - bells palsy (most)
trauma - temporal bone or facial wound
infection - ear infections, lymes disease, viral infection
tumour - parotid malignanc iatrogenic - parotid or ear surgery autoimmune - sarcoidosis neurological conditions congenital - CHARGE, mobius syndrome, melkersson-rosenthal syndrome, birth trauma/forceps
causes of FN palsy
neurological conditions causing FN palsy
MS
CVA (stroke)
Myasthenia gravis
Guillain Barre
investigations for FN palsy
full facial nerve examination and grade weakness
classify into UMN and LMN
assess hearing of ipsilateral ear and mastoid + tuning fork
cranial nerve examination
examination of neck and parotid to exclude parotid tumour
examination of oral cavity to assess palatal weakness etc
schrimers test for lacrimation - what does it suggest in FN lesion?
abnormal lesion suggests lesion affecting the geniculate ganglion
stapedial reflex - what does it suggest in FN lesion?
abnormal suggests lesion proximal nerve to stapedius
taste testing - what does it suggest in FN lesion?
clinically or electrogustometry and salivary flow testing
- if abnoramla suggests lesion proximal to the root of chorda tympani
treatment of FN palsy
- education
- blood tests
- bells palsy
- ramsay hunt syndrome
education - eye protection since corneal drying can lead to ulceration and then blindness
manage obvious cause
blood tests - lymes disease if indicated in history
if bells palsy - 7-10day reducing dose of corticosteroids
ramsay hunt syndrome (VZV) - course of aciclovir and reducing corticosteroids
follow up in 3-4 weeks - lakc of recover, investigate for neoplasia via MRI
prognosis of bells palsy
full recovery in 3-4 months
advise for bells pasly
keep affected eye lubricated
tape eye closed at bedtime if needed
wear sunglasses outdoors to protect eye
swimming and dusty environments should be avoided
surgery for protection - tarsorraphy +/- gold weight implant to aid eyelid closure
eye irritation pain or vsion changes - seek immediate medical advice
if facial weakness or paralysis affects eating
suggest using straw for liquids and advice soft foods
exercise to rehab facial muscles
things to do in first 6 weeks of bells palsy
massage face with strokes towards ear
facial exercises to achieve symmetrical movements in front of mirror and use fingers to assist
perform slowly and gently
conductive deafness
failure of the conversion of sound waves into movements by the ear drum and ossicles of the middle ear
sensorineural deafness - congenital or acquired
problem of the inner ear or of the nerve that carries the signal from the inner ear to the hearing centres of the brain
weber test results
forehead
unilateral conudctive loss = lateralisation to the affected side
unilateral sensorineural loss = lateralisation to normal or better hearing side
rinnes test results
air conduction and bone conduction
normal = AC >BC - (pt can hear fork at ear)
conductive loss = BC>AC (pt will not hear fork at ear)
conductive hearing loss causes
wax/foreign body/polyps
otitis externa
otitis media
perforation
sensorineural hearing loss causes
age related/trauma
ototoxic drugs
infections of labyrinth
acoustic neuroma
congenital hearing loss causes
TORCH infections in pregnancy
low birth weight
asphyxia
red flag for ENT
sudden sensorineural hearing loss
infections causing sudden sensorineural hearing loss
mumps herpes zoster syphilis meningitis encephalitis
vascular causing sudden sensorineural hearing loss
haemorrhage thrombosis leukaemia vasospasm diabetes HTN sickle cell
trauma causing sudden sensorineural hearing loss
head injury
noise trauma
surgery
toxic causing sudden sensorineural hearing loss
ototoxic insecticides
ear causes of sudden sensorinueral hearing loss
meniere
large aqueduct
neoplastic causing sudden sensorineural hearing loss
acoustic neuroma
CP tumors
vertigo
hallucination of rotatory movement
light headedness
Non-specific term: temporary reduction of cerebral blood flow
dizziness
Non-specific term: disorientation
Unsteadiness
Indicates gait issue/central causes: cerebellum/MSK
central causes of vertigo and dizziness
stroke/TIA postural hypotension cervical spondylosis/age-related disequilibrium migraine MS tumour medication related hypoglycaemia sleep deprivation
peripheral causes of vertigo and dizziness
labyrinthitis
BPPV
mineres disease
vestibular schwannomma
vestibular neuronitis
reactivation of latent type 1 HSV in vestibular ganglion
presentation of vestibula r neuronitis
prior URTI
sudden, spontaneous, severe vertigo which is constant and ongoing
common cause of vertigo often used interchangeably with labyrinthitis =WRONG
affects adults 4-50 y ears
labyrinthitis
viral origin, URTI precedes the onset of symptoms
bacterial also possible
presentation of labyrinthitis
affects adults in 30-60 yo, rarely in children F>M
vertigo associated with hearing loss +/- tinnitus
menieres disease
change in fluid volume in the labyrinth
progressive distension of the membranous labyrinth
allergy, metabolic disturbance, vascular factors, viral infections
presentation of menieres disease`
40-60 yo
attacks lasting minutes/hours
fluctuating and episodic patterns, tinnitus, hearing loss, aural fullness
nystagmus
side, fast component, vertical, horizontal, rotatory
rombergs posititve
suggestive of proprioception or vestibular function
unterbergs test
labyrinth function, assessing whether rotation is induced when marching on the spot eyes closed
tinnitus
perception of sounds in the ear/head with no external source
- ringing/buzzing/hissing/whistling/humming
unilateral or bilateral
subjective tinnitus
common
noise-induced
impacted wax, infection (ear infection, meningitis, syphilis), drugs related, jaw disorders, no cause found
drugs related to subjective tinnitus
NSAIDs, aminoglycosides, loop diuretics
common and important neck lumps
malignancy salivary glands sebaceous cysts lymph nodes thyroglossal cysts thyroid goitre
intradermal
non-tender
well circumscribed fluctuant lumps
relatively fixed and do not have overlying skin changes
central punctum blocks outflow of sebum which can lead to infection and abscesses
sebaceous cysts
fluid filled sac occuring due to incomplete closure of the thyroglossal duct during embryological development
normally presents in children or young adults as a painlss midline fluctuant lump - mostly in hyoid bone
USS investigation and then surgical excision + antibiotics if acutely inflamed
thyroglossal cyst
non tender lumps/swelling which are fixed
moves upwards with swallowing as the isthmus is attached to the trachea
investigate for thyroid function tests and antibodies, USS and referral to head and neck/endocrine surgeons
thyroid goitre
diffuse thyroid goitre causes
may be phsyiologcal
graves disease
hashimotos thyroiditis
subacute thyroiditis
nodular thyroid goitre causes
multinodular goitre
adenoma
carcinoma
- sepsis with post-auricular swelling
- cranial nerve palsy
- symptoms of meningism
- altered conscious state
acute otitis media - RED FLAGS
risk of progression to extra and intracranial complications
who gets acute otitis media?
usually children under 7 yo
adults sometimes - more likely primary acute otitis externa
presentation of AOM
gradually increasing otalgia with no discharge
red bulging ear drum on otoscopy
common pathogens causing AOM
influenza virus
haemophilus
streptococcus pneumoniae
otoscopy findings of AOM
opaque and protruding ear drum with erythema and prominent blood vessels
history of acute suppurative otitis media (ASOM)
history of gradually increasing otalgia followed by appearance of discharge with some reduction of otalgia
hear/feel a pop just before this appears
may also get hearing loss, tinnitus, and fever
small children= unwell, crying and be pulling the affected ear
otoscopy of ASOM
mucopurulent watery discharge in the ear canal and perforation of the tympanic membrane
discharge and associated ear canal swelling may make the tympanic membrane no visible
with AOM what examinations are needed?
facial nerve, neurological status and ear examination inc mastoid area
treatment of ASOM
antibiotic and steroid combination drops/sprays - sofradex, otomise
when to admit AOM
any sign of mastoiditis, petrositis or intracranial complications
extracranial complications of AOM
facial palsy - AOM and faical palsy without sparing of frontalis - when infection spreads to nerve
mastoiditis - when ifection spreads to mastoid air spaces of temporal bone
petrositis - infection spread to apex of petrous temporal bone
gradenigos syndrome
in petrositis
triad: pururlent ottorhoea, pain deep inside ear (V1) and ipsilateral lateral rectus palsy (VI)
intracranial complications of AOM
meningitis
sigmoid sinus thrombosis
brain abscess
investigations for complicated AOM
microbiological swabs and blood cultures
FBC, U+Es, CRP, G+S
CT head
LP if signs of meningitis
management of facial palsy in AOM
myringotomoy +/- grommet insertion
management of mastoiditis
cortical mastoidectomy, possible incision and drainage of spreading abscess
bacterial labyrinthitis treatment
observe carefully for mastoiditis
otitis media with effusion
glue ear, middel ear effusion, secretory otitis media
types of otitis media
acute otitis media
acute suppurative otitis media
otitis media with effusion
red fkags of otitis media with effusion
unilateral - urgent outpatient appointment is appropriate
presentation of OME
sensation of pressure inside ear (sometimes painful) noises inside ear (popping) conductive hearing loss poor speech development dysequilibrium
pinna and ear canal normal
tympanic membrane dull or opque
fluid level or bubbles behind it
examination of OME
risk factors for OME in children
young male multiple runny noses/URTI bottle fed daycare parents smoke cranial facial abnormalities mucociliary abnormalities - CF
red flags of acute otitis externa
complete acute stenosis of the ear canal - sepculum cannot insert
cellulitis of the pinna or peri-auricular area
ipsilateral cranial nerve palsy
ipsilateral severe deep otalgia (causing insomnia)
swimmers ear
primary bacterial AOE
- occurs after a change in environment of the ear canal (increased humidity, pH change due to impacted wax etc)
pseudomonas spp
staphylococcus spp
history of AOE
short history of increasing otalgia
with custard like ear discharge
hearing loss and tinnitus sometimes
NOE
necrotising otitis externa
infection spreads through soft tissue resulting in osteomyelitis of the tmeporal bone and skull base
who is at risk of NOE
DM
>65
recurrent AOE
chem/radio therpay or immune compromise
secondary AOE cause
occurs in the presence of ASOM or foreign body
fungal acute otitis externa - presentation and cuase
all hallmarks of bacterial AOE except discharge looks like white blobs of rice pudding (candida albicans) with or without black spots
cause = prolonged use of antibiotic drops
what is furunculosis
infection of the hair follicle in the canal
what is Ramasay hunt syndrome
zoster of the VII nerve causing palsy and vesicles in the canal
treatment of otitis externa
topical drops - antibitoic and steroid, canesten in fungal AOE
microsuction of the ear - removal of exudates and debris
insertion of popewick in stenosed/oedematous canals
analgesia
avoid water near ears
NOE presentation
non resolving AOE despite treatment,
severe pain - insomnia
purulent ottorhoea
granulation and necrotic tissue with ear canal
hearing loss and lower crnaila nerve neuropathies in severe
pinna perichondritis or cellulitis red flags
pinna abscess or necrosis
any ear infection with central neurological signs such as low GCS
what causes pinna cellulitis
complication of acute otitis externa, eczema, psoriasis or insect bite
cause of pinna peichondritis
penetrating truama - inc ear peircing - can form abscess resulting innecrosis and cauliflower deformity
DM increases risk
what can pinna perichondritis lead to?
systemic infection or serious soft tissue infection inc necrotising fasicitis
presentation of pinna perichondritis
infection of cartilaginous pinna and sparing of the lobule (ear lobe) whereas cellulitis does not spare the lobule
look for:
- painful erythema or loss of contour sof pinna
- localised abscess frmation
- necrosis of soft tissue
- primary otitis externa (ototscopy)
- clinical hearing deficit
- spreading of cellulitis to face or scalp
- trauma or wounds
treatment of pinna perichondritis
swabs of pinna, any otitis externa and MRSA status
trial with systemic and topical antibiotics
good analgesia
control blood sugars
blood cultures if septic
rhinosinusitis definition
inflammation of the nose and the paranasal sinuses characterised by 2 or more symptoms:
- rhinorrhoea (nasal discharge), postenasal drip, nasal blockage or obstruction
- w/wo facial pain/pressure
- w/wo reduction (hyposmia) or loss of smell (anosmia) +/- cough
endoscopic signs of rhinosinusistis
nasal polyps
mucopurulent dishcarge from middle meatus
oedema/mucosal obstruction in middle meatus
CT signs of rhinosinusitis
mucosal changes within the ostemeatal unit and/or sinuses
cause of rhinosinusitis
usually due to URTI followed by bacterial infection, dental sepsis
broad classification of rhinosinusitits
acute (ARS) <4 weeks with complete resolution of symptoms
chronic (CRS) >12 weeks without complete resolution of symptoms. with or without polyp
define these types of ARS:
- common cold/acute viral rhinosinusitis
- acute post viral rhinosinusitis
coryzal symptoms + duration <10 days
increase in symptoms after 5 days or persistent symptoms after 10 days
suggested by presenc eof least 3 symptoms - discoloured discharge and purulent secretion in nasal cavity, severe local pain (unilat. predom), fever, elevated ESR/CRP, double sickening (deterioration)
investigations for rhinosinusitis
nasal swab for pus nasoendoscopy dental examination skin prick test or RAST to exclude an allergic element after 6-12 weeks CT scan
treatment of rhinosinusitis
analgesia steroids nasal drops or systemic oral steroids (for facial pain) nasal decongestants nasal irrigation with saline antihistamine antibiotics if bacterial steam inhalation
functional endoscopic sinus surgery
alarm symptoms of the eye, extension and malignancy in rhinosinusitits
Eyes:
1) Periorbital Oedema/Erythema
2) Reduced Visual Acuity
3) Ophthalmoplegia
4) Double Vision
5) Displaced Globe
Extension:
1) Frontal Swelling
2) Signs Of Sepsis
3) Signs Of Meningitis
4) Neurological Signs
Malignancy:
1) Unilateral Symptoms
2) Bleeding Crusting
3) Cacosmia
3 major pairs of salivary glands
parotid
submandibular
sublingual
viral parotitis causes
mumps (paramyxovirus)
HIV
why mumps is a notifiable disease
risk of orchitis and therefore subsequent infertility in males
females may experience generalised abdo pain
causes of bacterial parotitis/submandibular gland infection
most commonly due to obstruction from salivary stone
presentation of bacterial parotitis/submandibular infection
intermittent swelling of gland followed by acute pain and swelling which is tender to palpation
overlying cellulitis/erythema
septic with fever and raised WCC
who gets bacterial parotitis/submandibular infection
elderly
dehydrated
poor oral hygiene
sjogrens
treatment of bacterial parotitis/submandibular infection
rehydration
antibiotics (IV if required)
oral hygiene advice
investigations for bacterial parotitis/submandibular infection
bloods - sepsis etc
stensens duct in oral cavity for pus
whartons duct if submandibular gland inflammation
assess facial nerve
CT or USS if any suspician of abscess formation
presentation of salivary stones
cuase intermittent unilateral swelling which is markedly worse on eating
gland is red and tender with swelling but not appear infected
stones seen on xrat, sialogram or USS can be removed via duct if sited distally
viral parotitis
bacterial parotitis/submandibular infection
salivary gland stones
acute swelling of salivary glands
tumours
- pleomorphic adenomas - parotid
- warthins tumour - parotid
- carcinomas
chronic swelling of slivary glands
presentation of salivary tumours
slow growing lumps in the gland, pain and/or nerve infiltration indicates malignancy
pleomorhpic adenomas
most common salivary tumour
warthins tumour
benign slow growing swelling in parotid
middle aged men
carcinomas of salivary gland
fast growing, hard and fixed
may be painful or have nerve involvement
which salivary tumour:
- facial nerve palsy
- lingual nerve parasthesia
- parotid tumour
2. submandibular gland tumour
investigations of salivary tumours
MRI
FNE
treatment of salivary tumours
mostly surgical - superifical parotidectomy for benign tumours and radical for malignant +/- neck dissection
complications of salivary tumour radical ressection?
facial nerve damage and freys syndrome (facial flushing and sweating when patient salivates)
risk factors for head and neck cancer
carcingens - smoking, alcohol, sun exposure, occupation exposure
infection - HPV16, hyerplastic candidiasis
immunodeficiency or immunosuppression
most common head and neck cancer
squamous cell carcinomas
what are head and neck cancers?
any cancer of the upper aerodigestive tract
pesentation of head and neck cancer
present to GP, dentist or A+E then reffered to a 2 week ait
may have seen them many times with unsuccessful treatment
neck lump/swelling
red flags for head and necl lumps
Persistent oral ulcers, often painful and bleed
o Oral swelling – be suspicious of unexplained loose teeth or an asymmetrically
enlarged tonsil
o Persistent sore throat (not responsive to antibiotics or nystatin)
o Dysphagia
o Unilateral otalgia in the absence of other otological symptoms
§ Unilateral recurrent otitis media or new glue ear
o Hoarse voice lasting >3 weeks (chest malignancy should be excluded)
o Persistent and unilateral epistaxis or serosanguinous nasal discharge
