ENT Flashcards
Which bone directly contacts the Tympanic Membrane?
Malleus
During examination, how may you test hearing?
Gross hearing
Weber’s Test (512Hz): central forehead
Rinner’s Test (512Hz): mastoid process until stopped, then 1cm from external auditory canal
Give 5 differentials for Sensorineural Hearing Loss.
Presbyacusis Noise exposure Meniere's Disease Labyrinthitis Acoustic neuroma Neurological conditions Infections (e.g. meningitis) Medications (loop diuretics; Aminoglycoside antibiotics; Chemotherapy drugs)
Which drugs may cause sensorineural hearing loss?
Loop diuretics
Aminoglycosides
Chemotherapy drugs
Give 5 differentials of conductive hearing loss.
Ear wax Infection (AOM; OE) Effusion Eustachian tube dysfunction Perforated TM Otosclerosis Cholesteatoma Exostoses Tumours
what investigation may be used to examine a patient’s hearing?
Audiometry
How does Audiometry work?
Variety of tones and volumes played via air conduction (headphones) and bone conduction (oscillator).
Recorded on an audiogram which helps differentiate conductive and sensorineural hearing loss
Audiogram charts the volume at which a patient can hear different tones.
Frequency (Hz) on X-axis and Volume (dB) on y-axis
Hearing is tested to find quietest volume patient can hear each frequency.
Note: Best hearing (lowest dB) will be highest on a chart. It is a test of hearing, so dB is placed inversely on the graph.
X = LS air conduction
O = RS air conduction
[ = R sided bone conduction
] = L sided bone conduction
What is the healthy range of hearing shown on an audiogram?
0-20dB
In sensorineural hearing loss, what will an audiogram show?
Both air and bone conduction is greater than 20dB
In conductive hearing loss, what will an audiogram show?
Air conduction readings >20dB thus below normal range line and lower on audiogram
In mixed hearing loss, what will an audiogram show?
Both air conduction and bone conduction will be >20dB however there will be a >15dB difference between the two values
What are the clinical features of Presbyacusis?
Hearing loss: Gradual, Higher pitch sounds lost first; symmetrical
May be associated tinnitus
How is Presbycusis treated?
Supportive: Optimising environment; Hearing aids
or
Surgery: Cochlear implant surgery
What would Audiometry show in Presbycusis?
Age-related hearing loss is a sensorineural hearing loss.
Both air and bone conduction will be reduced thus >20dB and move inferiorly
Will be symmetrical, affecting both ears
What is the definition of Sudden Sensorineural hearing loss?
Hearing loss that is sensorineural <72 hours which is unexplained by other causes
What is the most common cause of Sudden Sensorineural Hearing Loss?
A. Acoustic neuroma
B. Cogan’s syndrome
C. Migraine
D. Idiopathic
D - 90%
What is the audiometry criteria required to establish a diagnosis of sudden sensorineural hearing loss?
> 30dB loss at 3 consecutive frequencies
How is Sudden Sensorineural Hearing Loss managed?
Referral to ENT (24 hours)
+
Steroids: Intra-tympanic or PO
A patient presents with a reduced hearing in their L ear over the past 2 months; there is a feeling of fullness in the ear with some discomfort. They are hearing some popping noises in the ear. Symptoms get worse when walking up hills of flying.
Otoscopy shows nothing abnormal.
What investigations may you wish to undertake?
Tympanometry
Audiometry
Nasopharyngoscopy
CT scan
A patient presents with a reduced hearing in their L ear over the past 2 months; there is a feeling of fullness in the ear with some discomfort. They are hearing some popping noises in the ear. Symptoms get worse when walking up hills of flying.
Otoscopy shows nothing abnormal.
Tympanometry shows a peak admittance with negative ear canal pressures.
What is your diagnosis?
Eustachian Tube Dysfunction
A patient presents with a reduced hearing in their L ear over the past 2 months; there is a feeling of fullness in the ear with some discomfort. They are hearing some popping noises in the ear. Symptoms get worse when walking up hills of flying.
Otoscopy shows nothing abnormal.
Tympanometry shows a peak admittance with negative ear canal pressures.
What is your management?
Supportive: Watch and wait; Valsalva manoeuvre; Decongestant nasal sprays; Otovent
±
Surgery: Tx cause; Grommets (tiny tubes into TM); Balloon dilation Eustachian tuboplasty
How is otosclerosis inherited?
Autosomal dominant
What is the pathophysiology involved in otosclerosis?
Middle ear bones undergo sclerosis e.g. stapes which attaches to oval window (fenestra ovalis) of cochlea thus reduced sound transmission
This is a form of conductive hearing loss
What is the epidemiology of Otosclerosis?
Female
<40
What would the Rinne’s and Weber’s test show in a patient with R ear Otosclerosis?
Rinne’s negative in affected ear as conductive, thus hear bone better
Sound heard better in the R ear (affected ear)
Which investigations may you conduct in a patient with suspected Otosclerosis?
Audiometry - conductive hearing loss thus will show a pattern of air conduction being worse than bone conduction.
Tympanometry - reduced admittance, less is absorbed, more is reflected back
High-resolution CT: Bony changes associated with otosclerosis
What is the management for Otosclerosis?
Conservative: Hearing aids
±
Surgical: Stepedectomy; Stepedotomy
What is the most common cause of AOM?
S pneumoniae
What are the common causes of AOM?
S pneumoniae
H influenzae
M catarrhalis
S aureus
A 17 year old patient presents with reduced hearing in their R ear. The ear feels full, like a pressure is present. There is no discharge. They have been feeling generally under the weather with a fever and cough in the last few days.
On otoscope, there is a bulging TM that is red and non-reflecting.
What is your DDx?
AOM
A 17 year old patient presents with reduced hearing in their R ear. The ear feels full, like a pressure is present. There is no discharge. They have been feeling generally under the weather with a fever and cough in the last few days.
On otoscope, there is a bulging TM that is red and non-reflecting.
What is your management?
Supportive: Analgesia; Rest
Often resolves within 3 days
OR >4 days; Severely unwell; significant comorbidities; systemically unwell
Medical: ABX - Amoxicillin 5-7 days
What are the potential complications of AOM?
TM Perforation
Chronic suppurative otitis media
Hearing loss
Labyrinthitis
Mastoiditis
Meningitis
Brain abscess
Facial nerve palsy
What is glue ear?
Otitis media with an effusion (Serous otitis media)
What is the management for a perforated tympanic membrane?
Supportive: Avoid water in ear; analgesia; avoid pressure changes
± No healing in 6-8 weeks
Surgery: Myringoplasty
What is the most common cause of Otitis externa?
P aeurgionsa
S aureus
How is Otitis Externa managed?
Medical:
Topical ABX (or via ear wick)
+
Topical steroid
E.g. Otomize ear spray (Neomycin + Dexamethasone + Acetic acid)
If TM ruptured, do not use aminoglycosides
In what patient group is Malignant Otitis Externa more common?
Elderly diabetics
What is malignant otitis externa?
infection spreads into bony ear canal and soft tissues deep to bony canal - osteomyelitis of temporal bone
IV ABX required and imaging
What are the common causes of otitis externa?
Infection Eczema Seborrheic dermatitis Contact dermatitis Recent swimming
what is the management of Cerumen impaction?
Supportive: Ear drops (sodium bicarbonate 5%); ear irrigation; micro-suction
What are the causes of Tinnitus?
Primary Tinnitus
Meniere's Disease Otosclerosis SSNHL Presbycusis Drugs (NSAIDs; Loop diuretics; Quinine; Aminoglycosides) Impacted ear wax Acoustic neuroma Multiple sclerosis Noise exposure Systemic conditions: Anaemia; Diabetes; Thyroid disease; Dyslipidaemia
What is objective tinnitus?
Give 3 causes
Hearing an extra sound within their head which can be confirmed when auscultating the stethoscope around the ear.
Eustachian tube dysfunction Carotid artery stenosis Carotid Cavernous Fistula Aortic stenosis AV malformations
What are the red flags of tinnitus to ask?
Unilateral Hyperacusis Unilateral hearing loss Vertigo Visual changes Neurological signs Suicidal ideation (related to tinnitus)
Outline how balance is determined in the vestibulocochlear system.
The semicircular canals of the ear are filled with endolymph which shifts within the canals when the head is moved. The endolymph fluid shift is detected by stereocilia in the ampulla of the canal. This is transmitted by the vestibular nerve (CN VIII) to the vestibular nucleus in the brainstem and cerebellum.
This nucleus then sends signals to CN III, CN IV and CN 6 nuclei which control eye movements, thalamus, spinal cord and cerebellum
How can vertigo be classified?
Peripheral vs Central
A patient presents with a vertigo triggered by changing head position. They feel nauseous. Each episode lasts for 10-20 seconds.
There is a positive Dix-Hallpike manoeuvre showing rotatory nystagmus.
What is the management?
Supportive: Vestibular rehab; Epley manoeuvre
What is the cause of BPPV?
Otoconia become displaced in the semicircular canals which disrupt endolymph flow and cause aberrant stimulation of vestibular system
What are the clinical features of Meniere’s disease?
Tinnitus + Hearing loss + Vertigo
How do you differentiate between Peripheral vertigo and Central vertigo?
1) History
Peripheral:
- Sudden
- Short duration
- Hearing loss
- Coordination
- Nausea
Central:
- Gradual
- Persistent
- No hearing loss
- Impaired coordination
- Mild nausea
2) Clinically - Mnemonic: HINTS
Head Impulse: upright and gaze at examiner nose; rapidly jerk head 10-20 degrees in one direction - check to see if saccade (peripheral if positive)
Nystagmus - horizontal (peripheral) vs vertical (central)
Test of Skew: cover eye and see if vertical correction (central cause)
How do you conduct a cerebellar exam?
D – Dysdiadochokinesia
A – Ataxic gait (ask the patient to walk heel-to-toe)
N – Nystagmus (see below for more detail)
I – Intention tremor
S – Speech (slurred)
H – Hypotonia
How do you manage vertigo?
Tx cause
+
Inform DVLA - if liable to sudden, unprovoked or unprecipitated episodes of disabling dizziness
How do you conduct a Brandt-Daroff exercise?
These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.
A 34 year old female presents due to recurrent vertigo attacks. The attacks last for several hours or days. During them she has nausea and vomiting.
There is no hearing loss. There is no tinnitus.
She is generally well other than a URTI she had for 4/7 about a week ago.
What is your diagnosis?
Vestibular neuronitis
A 34 year old female presents due to recurrent vertigo attacks. The attacks last for several hours or days. During them she has nausea and vomiting.
There is no hearing loss. There is no tinnitus.
She is generally well other than a URTI she had for 4/7 about a week ago.
What is your management?
Prochlorperazine
What condition may develop following vestibular neuronitis?
A. Otosclerosis
B. Labyrinthitis
C. BPPV
D. Meniere’s disease
C
What is the key difference between Labyrinthitis and Vestibular neuronitis?
No hearing loss in VN vs Hearing loss in Labyrinthitis
A 50 year old male presents with vertigo which began suddenly. The vertigo episodes last several hours and occur again and again. They report having to turn the TV up louder than usual.
They are generally well other than a recent URTI 4/7 and their glycaemic control has been off.
Otoscopy shows nothing. Weber’s test shows soudn louder in the ear with fine hearing. Rinne’s negative in the L ear. Head impulse test shows impaired vestibule-ocular reflex in L eye.
What is your diagnosis?
Labyrinthitis
A 50 year old male presents with vertigo which began suddenly. The vertigo episodes last several hours and occur again and again. They report having to turn the TV up louder than usual.
They are generally well other than a recent URTI 4/7 and their glycaemic control has been off.
Otoscopy shows nothing. Weber’s test shows soudn louder in the ear with fine hearing. Rinne’s negative in the L ear. Head impulse test shows impaired vestibule-ocular reflex in L eye.
What is your management?
Self-limiting
Prochlorperazine can reduce sensation of dizziness
How long does it take for Meniere’s Disease to resolve?
5-10 years
What is the driving advice given to a patient with Meniere’s disease?
Cease driving until symptoms are controlled
What is the age of onset for Meniere’s disease?
40-50 years
What is the management for Meniere’s disease?
Acute attacks:
- Prochlorperazine
Prophylaxis:
- Betahistine
In which condition are bilateral vestibular schwannomas seen in?
NF 2
Where do Vestibular Schwannomas tend to occur?
Cerebellopontine angle
A 50 year old male presents with hearing loss in his L ear. The ear is ringing constantly. Additionally, he feels a fullness in his ear. This has began several months ago and worsened with time.
O/E you elucidate it likely a sensorineural hearing loss. You see a facial nerve palsy on the LHS. Furthermore, there is an absent corneal reflex.
Audiometry shows both air and bone conduction reduced by more than 20dB.
What is your DDx?
Acoustic neuroma
A cholesteatoma is an accumulation of which type of cells?
Squamous epithelial cells
A 15 year old patient presents with foul-smelling, non-resolving discharge from the R ear. The R ear has also experienced some hearing loss.
Otoscopy shows attic crust in the upper part of the eardrum.
What is your DDx?
Cholesteatoma
Which condition increases your risk of developing a Cholesteatoma?
Eustachian tube dysfunction
What does the facial nerve supply?
Mnemonic: Face, ear, taste, tear
face: muscles of facial expression
ear: nerve to stapedius
taste: supplies anterior two-thirds of tongue
tear: parasympathetic fibres to lacrimal glands, also salivary glands
Give 3 causes of lower motor neurone facial nerve palsy.
Bell’s Palsy
Acoustic Neuroma
Parotid tumour
Cholesteatoma
Ramsay-Hunt Syndrome Otitis media Malignant otitis externa HIV Lymes disease
MS Diabetes Mellitus Guillain-Barre Syndrome Leukaemia Sarcoidosis
Direct trauma
Iatrogenic
Base of skull fractures
What are the 3 branches of the facial nerve?
- greater petrosal nerve
- nerve to stapedius
- chorda tympani
Mnemonic: GCS
Give 5 causes of Epistaxis.
Trauma Colds Nose picking Sinusitis Changes in weather Snorting cocaine Coagulopathies Tumours Anticoagulation
Which type of nosebleed holds a higher chance of aspiration?
Posterior epistaxis
How do you manage a nosebleed?
Haemodynamically stable
Supportive: Lean forward with mouth open; pinch nose firmly for 20 minutes
± Does not stop
Supportive: Cautery (if visible) + Naseptin + Silver nitrate; Packing
± Failed all emergency management
Surgery: Sphenopalatine ligation
Which allergy means Naseptin is contraindicated?
Peanut/Soya allergy
Outline the different paranasal sinuses present in the head.
Frontal
Ethmoid
Sphenoid
Maxillary
What pathogen is the commonest cause of sinusitis?
S pneumoniae
H influenzae
Rhinoviruses
How is acute sinusitis managed?
Supportive: Analgesia; Intranasal decongestants
Should resolve within 2-3 weeks
± Symptoms more than 10 days
Intranasal corticosteroids for 14 days
± Systemically unwell
Medical: Co-amoxiclav
What is the definition of chronic sinusitis?
> 3 months of sinusitis
Explain to a patient how to take a nasal spray.
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
What surgical procedure may be used in recurrent sinusitis due to anatomical variations resulting in obstruction?
Functional endoscopic sinus surgery (FESS)
In which population group are nasal polyps more common?
Males
Which conditions are nasal polyps associated with?
Asthma Aspirin sensitivity Sinusitis Cystic fibrosis Kartagener's Syndrome Churg-Strauss Syndrome
The association of asthma, aspirin sensitivity and nasal polyps is known as?
Samter’s triad
What is the management for Nasal polyps?
Conservative: ENT referral; Topical corticosteroids
±
Surgery: Endoscopic nasal polypectomy
Give 3 RFs for OSA.
Middle age Male Obesity Alcohol Smoking
What screening scale is used to assess symptoms of OSA?
Epworth Sleepiness Scale
What is the management for OSA?
Conservative: ENT referral; CPAP; RF modification
+
Surgery: Uvulopalatopharyngoplasty (UPPP)
What is the most common cause of tonsillitis?
Viral causes - adenovirus; rhinovirus; CMV; Covid
What is the most common cause of bacterial tonsillitis?
GAS
Which groups make up Waldeyer’s ring?
Starting at 12 o’clock:
Adenoid -> Tubal -> Palatine -> Lingual
Which scoring criteria can be used to assess the risk of bacterial tonsillitis?
CENTOR Score
Cough (absence) Exudate Nodes Temperature Age category
How do you manage tonsillitis?
Calculate Centor score
Conservative: Patient education; safety net (<3 days and temperature below 38.3C); analgesia
+
Medical: Penicillin-V 10 days
What are the complications of Tonsillitis?
Peritonsillar abscess Otitis media Scarlet fever Rheumatic fever Post-streptococcal glomerulonephritis Post-streptococcal reactive arthritis
How do you manage a quinsy?
Medical: Co-amoxiclav
+
Surgery: Incision and drainage
What are the indications for a tonsillectomy?
Rule of 7…
7 in 1 year
5 per year for 2 years
3 per year for 3 years
Recurrent tonsillar abscesses (2 episodes)
Obstructive tonsills
What proportion of tonsillectomy patients may experience a significant bleed?
5%
You identify a neck lump, how can you describe it?
Distribution/Location Size Colour Associated change Morphology
Location: Anterior triangle/Posterior triangle/Midline
What are the borders of the anterior triangle?
Mandible
Midline
SCM
What are the borders of the posterior triangle?
Clavicle
Trapezius
SCM
When examining a patient with a neck lump, what are you checking for?
Distribution/Location Size Colour Associated changes Morphology Movement
Warmth
Tenderness
Pulsatile
Movement with swallowing
Transilluminates with light
General examination
When should you refer for a neck lump?
Unexplained lump in someone >45 years
Persistent unexplained neck lump
What investigations may you conduct in someone presenting with a neck lump?
FBC U+Es LFTs TFTs Abs EBV/Monospot test HIV test LDH
US-Neck
CT/MRI-Neck
PET
Fine needle aspiration
Core biopsy
Incision biopsy
Removal of the lump
What are the general causes of lymphadenopathy?
Infective
Reactive
Inflammatory
Malignancy
Which pathogen causes Infectious Mononucleosis?
EBV
What is the first line test for Infectious Mononucleosis?
Monospot test
What advice is given to a patient with Infectious Mononucleosis?
Supportive: Rest; Avoid alcohol; Avoid contact sports
What ages do Hodgkin’s lymphoma tend to present?
Bimodal age distribution; 20 and 75
What are the clinical features of Hodgkin’s Lymphoma?
Fever Weight loss Night sweats Itch Lymphadenopathy: hard, fixed, rubbery
Reed-Sternberg cells
The presence of Reed-Sternberg cells are suggestive of what condition?
Hodgkin’s Lymphoma
What are the clinical features of a leukaemia?
Fatigue Fever Pallor (secondary to anaemia) Bruising Abnormal bleeding Lymphadenopathy Hepatosplenomegaly
What is the term for an enlarged Thyroid gland?
Goitre
What are the 3 salivary glands?
Parotid
Submandibular
Sublingual
What cells are contained in the carotid body?
Chemoreceptors (Glomus cells) - forming paraganglia
What are the clinical features of a Paraganglioma?
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
What CT/MRI-Neck sign is shown in a Paraganglioma?
Lyre Sign (splaying of internal and external carotid arteries)
What are the clinical features of a lipoma?
Soft (not fluid-filled)
Painless
Mobile
Do not cause skin changes
How is a thyroglossal cyst formed?
During embryological development, the thyroid migrates from the base of the tongue to become anterior of the trachea.
The migration leaves a track called the thyroglossal duct - which can become filled with a cyst called a thyroglossal cyst.
What are the clinical features of a thyroglossal cyst?
Found in the midline Mobile: Move up and down with tongue movement due to connection of thyroglossal duct and tongue base Non-tender Soft Fluctuant
What is the management of a thyroglossal cyst?
Surgical removal - may cause infection if left
How is a Branchial cyst formed?
Failure of second branchial cleft to form leaving space surrounded by epithelial tissue in lateral aspect of neck which a cyst may form.
What are the clinical features of a branchial cyst?
Round
Soft
Cystic swelling
Located between angle of jaw and SC in anterior triangle
Present at 10 years old and young childhood
How is a branchial cyst managed?
Conservative: Watch and wait
or
Surgery: Surgical excision
What is the most common type of cancer occurring on the head or neck?
Squamous cell carcinomas
Give 5 RFs for head and neck cancers.
Smoking UV Chewing betel quid Alcohol EBV HPV Genetic
What is the MOA of Cetuximab?
Anti-EGFR mAb
Give 3 causes of glossitis.
Folate deficiency B12 deficiency Iron deficiency anaemia Coeliac diease Injury or irritant exposure
What may cause angiooedema?
Allergic reactions
ACEi
Hereditary angiooedema (C1 esterase deficiency)
NSAIDs
Describe Geographic Tongue.
What conditions is it associated with?
Inflammatory condition whereby tongue loses epithelium and papillae with irregular patches forming resembling a map
Idiopathic Stress/mental illness Psoriasis Atopy Diabetes
What are the two common causes of strawberry tongue?
Scarlet Fever
Kawasaki disease
How is Black Hairy Tongue caused?
Reduced shedding of keratin from tongue’s surface thus papillae elongate - resembling hairs. Bacteria and food cause dark pigmentation.
White patches, that are fixed in the buccal mucosa is termed what?
What condition is it associated with?
Leukoplakia
Pre-cancerous to SCC
Red fixed lesions in the oral mucosa are termed?
Erythroplakia
Purple, polygonal, pruritic, planar plaques with white lines across in the oral mucosa are termed?
What is the name of the white lines?
Lichen Planus
Wickham’s Striae
How is Gingivitis managed?
Supportive: Good oral hygiene; stop smoking; dental treatment; chlorhexidine mouthwash
±
Surgery: Dental surgery
How does an aphthous ulcer appear in the mouth?
Well-circumscribed, discrete, punched-out white appearance
What are some causes of aphthous ulcers?
Idiopathic CD UC Coeliac disease Behcet's Disease B12 deficiency Folate deficiency Iron deficiency HIV
How may aphthous ulcers be managed?
Medical: Choline salicylate (Bonjela); Hydrocortisone buccal tablets; Betamethasone soluble tablet
Which pathogens may cause sinusitis?
S pneumoniae
H influenzae
Rhinovirus
Give 5 associations of nasal polyps.
Asthma Aspirin sensitivity Sinusitis Kartagener's Syndrome Churg-Strauss Syndrome
What is the management of a nasal septum haematoma?
Surgical drainage
What is the main risk factor for a nasal septal haematoma?
Trauma
What allergy should you check before prescribing Naseptin (chlorhexidine and neomycin) cream?
Peanut, soy or neomycin allergy.
Give 3 potential complications of tonsillitis.
Quinsy
AOM
RF
GN
What is the diagnostic test for OSA?
Polysomnography
What is the sensory innervation of the facial nerve (CN 7)?
Anterior 2/3 of the tongue
What is the parasympathetic function of the facial nerve (CN 7)?
Submandibular, sublingual glands
Lacrimal glands
What are the branches of the facial nerve (CN 7)?
Mnemonic: Tall Zulus Bear Many Children
Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical
What does C1 esterase deficiency result in?
Hereditary angiooedema
Which medications may cause gingival hyperplasia?
Ciclosporin
Phenytoin
CCBs
What are the clinical features of Sialolithiasis?
Colicky pain in the submandibular gland
Swelling
Worse after meals
What are the clinical features of Sialadenitis?
Erythema
Pus (or abscess) - may cause deep neck infection
What are the clinical features of a pleiomorphic adenoma?
Features epithelial and myoepithelial ductal component proliferation
Parotid mass
Most common parotid neoplasm
What are the clinical features of a Haemangioma?
Children
Hypervascular
Supportive management
What are the clinical features of a Warthin (adenolymphoma) tumour?
bilateral parotid swelling
M > F
Presents later in life
What is the most common salivary gland tumour?
A. Warthin’s
B. Mucoepidermoid carcinoma
C. Adenoid cystic carcinoma
D. Adenocarcinoma
B - 30%
Slow growing
Which parotid tumour features perineural spread?
A. Warthin’s
B. Mucoepidermoid carcinoma
C. Adenoid cystic carcinoma
D. Adenocarcinoma
