ENT Flashcards
How common are acoustic neuromas?
5% of intracranial tumours
90% of cerebellar pontine angle tumours
Where are acoustic neuromas found?
Cerebellar pontine angle
Name 4 masses that can be found at the cerebellar pontine angle.
S - schwannoma
A - aneurysm, arachnoid cyst
M - meningioma
E - ependymoma
What causes a bilateral acoustic neuroma?
Neurofibromatosis type II
What is the classic history of acoustic neuroma?
Vertigo
Hearing loss
Tinnitus
Absent corneal reflex
Which cranial nerves are affected by an acoustic neuroma?
5, 7 and 8
V - trigeminal (absent corneal reflex)
VII - facial (absent corneal reflex)
VIII - vestibulocochlear (vertigo, tinnitus, hearing loss)
What is the gold standard investigation for an acoustic neuroma?
MRI of CPA
How should an acoustic neuroma be managed?
Referral to ENT –> surgery, radiotherapy, observation
What is a cholesteatoma?
A destructive, hyperproliferating growth of keratinizing squamous epithelial cells of the middle ear.
What are the risk factors for developing a cholesteatoma?
Recurrent acute otitis media
Eustachian tube dysfunction
Previous ear surgery
How do cholesteatoma’s commonly present?
Otorrhoea, often brown (most common)
Conductive hearing loss - damage to the ossicles
Sensorineural hearing loss - invasion of the cochlea
Dizziness - invasion of the semi-circular canals
Facial nerve palsy - invasion of cranial nerve II (runs through the middle ear)
Which investigation is needed to confirm the diagnosis of cholesteatoma?
CT temporal bone (also needed for pre-operative planning).
What might be seen on otoscopy in cholesteatoma?
Pearly white/grey appearance
Brown discharge
What is the management of cholesteatomas?
Complete surgical removal.
Name two complications of cholesteatomas.
Intracranial invasion
Infection
Name two causes of true ear pain.
Otitis media
Otitis externa
Name 4 causes of referred ear pain.
CN V - trigeminal nerve (disease of the teeth)
CN VII - facial nerve (herpes zoster infection, Bell’s palsy)
CN IX - glossopharyngeal (tonsillitis, pharyngitis)
Cervical spinal nerves (cervical arthritis)
What is conductive hearing loss?
Sound is not conducted at the ear canal to the inner ear
It is a problem of the external or middle ear
Think about what it sounds like when you have ear plugs or headphones in - this mimics the symptoms of conductive hearing loss
What is sensory hearing loss?
Sound is received at the inner ear but issue at the sensory organ (Cochlear) or the vestibulocochlear nerve
It is a problem of the inner ear or cranial nerve VIII
Most commonly caused by age-related changes- think of elderly family and friends who you always have to speak loudly to
What are the different causes of sensorineural hearing loss?
• Sudden sensorineural hearing loss (over less than 72 hours) • Presbycusis (age-related) • Noise exposure • Ménière’s disease • Labyrinthitis • Acoustic neuroma • Neurological conditions (e.g., stroke, multiple sclerosis or brain tumours) • Infections (e.g., meningitis) Medications
Which drugs cause sensorineural hearing loss? Name three.
• Loop diuretics (e.g., furosemide)
• Aminoglycoside antibiotics (e.g., gentamicin)
Chemotherapy drugs (e.g., cisplatin)
What are the different causes of conductive hearing loss?
• Ear wax (or something else blocking the canal) • Infection (e.g., otitis media or otitis externa) • Fluid in the middle ear (effusion) • Eustachian tube dysfunction • Perforated tympanic membrane • Otosclerosis • Cholesteatoma • Exostoses Tumours
What are the risk factors associated with presbycusis?
Age
Exposure to loud noise
Smoking
Male
What is the typical presentation of presbycusis?
Gradual Symmetrical High-pitched sound lost first Concerns about dementia Tinnitus
What is the management of presbycusis?
Supportive
Hearing aid
What are the causes of sudden sensorineural hearing loss?
Idiopathic (80%) Infection Ototoxic medications MS Migraine Stroke Acoustic neuroma
How does sudden sensorineural hearing loss present?
<72 hours
Unilateral
What is seen on audiometry in sudden sensorineural hearing loss?
loss of 30 decibels in 3 consecutive frequencies
What is the management of sudden sensorineural hearing loss?
• Emergency - immediate referral to ENT (within 24 hours)
• Treat underlying cause
High-dose PO prednisolone
What are the risk factors for otosclerosis?
Women
Autosomal dominant
How does otosclerosis present?
<40 years
Tinnitus
Talk quieter
What is seen on audiometry in otosclerosis?
Low-pitched sound loss
What is the management of otosclerosis?
Supportive
Surgery: stapedectomy
What are the risk factors for Eustachian tube dysfunction?
Upper RTI
Smoking
Allergy
How does Eustachian tube dysfunction usually present?
Popping sensation Fullness Pain Tinnitus (symptoms worse when air pressure changes)
What is the management of Eustachian tube dysfunction?
• Conservative. • Valsalva manoeuvre • Decongestant nasal spray • Antihistamines/steroids Surgery (adenoidectomy, grommets, balloon dilation Eustachian tuboplasty)
What is true vertigo?
Sensation that the room is spinning.
What are the three most common causes of vertigo?
- BPPV
- Meniere’s disease
- Vestibular neuronitis
Name three central causes of vertigo.
- Stroke
- MS
- Migraine
How can the causes of vertigo be classified?
Otological
Central
What is the gold standard test to confirm BPPV?
Dix-Hallpike Manoeuvre
Who is at risk of developing necrotising otitis externa?
Diabetes
When should you use intranasal steroids in acute sinusitis?
symptoms >10 days
When should you use antibiotics in acute sinusitis? What is first-line?
Severe/systemically unwell
Phenoxymethylpenicillin
What is included under the umbrella term ‘Head and neck cancer’?
oral cavity cancers
cancers of the pharynx
cancers of the larynx
Name some features of head and neck cancer
neck lump
hoarseness
persistent sore throat
persistent mouth ulcer
When should you refer for 2WW in suspected laryngeal cancer?
> 45 and:
- persistent unexplained hoarseness
- an unexplained lump in the neck
When should you refer for 2WW in suspected oral cancer?
unexplained ulceration in the oral cavity lasting for more than 3 weeks
a persistent and unexplained lump in the neck.
When should your refer to a dentist in suspected oral cancer?
a lump on the lip or in the oral cavity
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
When should you refer to 2WW in suspected thyroid cancer?
unexplained thyroid lump
What is double-sickening?
an initial period of recovery followed by a sudden worsening of symptoms - associated with bacterial sinusitis
What is tonsilitis?
Infection of the palatine tonsils caused by viral or bacterial infection
What causes tonsilitis?
70% of infections are viral, the rest bacterial
Which virus’ most commonly cause tonsilitis?
Adenovirus, influenza, rhinovirus and parainfluenza are the common viruses involved
Which bacteria most commonly cause tonsilitis?
Group A beta-haemolytic streptococci
What are the symptoms of tonsilitis?
Sore thorat
Odynophagia
Earache
What is the management of tonsilitis?
Self-resolving in 5-7 days (viral)
Paracetamol
Which criteria are used to indicate antibiotic use in tonsilitis?
Centor criteria
1-2 unlikely to benefit from abx
3-4 = penicillin V (10 days)
What four features make up the Centor criteria?
• History of pyrexia
• Exudates on tonsil
• Absence of cough
- Tender cervical lymphadenopathy
What is the management of severe tonsilitis?
Admit: • IV fluids • IV analgesia • IV abx • IV dexamethasone • Throat swab Send home when can eat/drink normally
Name two complications of tonsilitis.
Quinsy (peritonsillar abscess)
Parapharyngeal and retropharyngeal abscess
What is the treatment of peritonsillar abscess (Quinsy)?
Incision & drainage
Send pus for MC&S
What is the tonsillectomy criteria?
• 7 episodes in the last year OR
• 5 episodes in each of the last two years OR
• 3 episodes in each of the last three years
- Swelling from tonsillitis affecting normal function
Which nerves provide sensory innervation to the ear?
CN V - trigeminal nerve (disease of the teeth)
CN VII - facial nerve (herpes zoster infection, Bell’s palsy)
CN IX - glossopharyngeal (tonsillitis, pharyngitis)
Cervical spinal nerves (cervical arthritis)
What is otitis externa?
Infection of the external ear - can cause canal oedema
What are the risk factors for otitis externa?
Increased water contact Humid conditions Excessive use of cotton buds Presence of hearing aids Immunocompromised patients
What is the most common bacterial cause of otitis externa?
Pseudomonas aeruginosa
What is the first-line management of otitis externa?
Topical abx and steroids (may need to be inserted by a Pope Wick)
Amoxicillin PO if systemically unwell
When should you refer to ENT in otitis media?
Poor response to topical abx
What is malignant otitis externa?
Uncommon type of otitis externa found in immunocompromised individuals - diabetes.
How is malignant otitis externa diagnosed?
CT
How is malignant otitis externa treated?
IV ciprofloxacin
What causes AOM?
Upper respiratory tract infections: viral OR bacterial
Viral: RSV, rhinovirus, enterovirus
Bacterial: s.pneumoniae
Who is most likely to be affected by AOM?
Children (shorter eustachian tube)
What is first-line management of AOM?
Supportive, analgesia
What is management for severe AOM?
Abx: amoxicillin
How can you treat recurrent AOM?
Gromets
Name three complications of AOM.
- Tympanic membrane rupture
- Hearing loss (recurrent infections)
- Mastoiditis
- Facial nerve palsy
- Intracranial infection
What are the symptoms of a perforated tympanic membrane?
Otorrhoea (discharge from the ear)
Sudden relief of pain
What causes chronic OM?
Recurrent otitis media infections leading to a perforated tympanic membrane
Trauma
Iatrogenic (gromet insertion)
What might be seen on otoscopy in chronic otitis media?
Perforated tympanic membrane
What is first-line management of chronic OM?
- Aural toilet - washing out the ear canal
2. Topical abx and steriods
What causes OM with effusion?
NON-INFECTIVE fluid in the middle ear
Most common cause us eustachian tube dysfunction
Other: cleft plate, allergies are risk factors
What might be seen on otoscopy in OM with effusion?
Dull tympanic membrane
Light reflex reflected upwards
Absent light reflex
What is management of OM with effusion?
50% resolve within 3 months
If more than 3 months: hearing aids or gromets
What are the complications of OM with effusion in children?
Delayed speech development
What are the features of quinsy?
severe throat pain, which lateralises to one side
deviation of the uvula to the unaffected side
trismus (difficulty opening the mouth)
reduced neck mobility
What is the treatment of post-tonsillectomy haemorrhage?
Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.
Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in around 1-2% of all tonsillectomies.
How long does it take for a perforated ear drum to heal?
6-8 weeks
When should packing be used before cautery in the management of epistaxis?
When the bleed is not visible
What is the most common type of parotid tumour?
Pleomorphic tumour
Which virus is associated with tonsillar SCC?
HPV
What is Ludwig’s angina?
Cellulitis that occurs on the floor of the mouth
Common in immunocomprised patients
can cause airway obstruction
Describe the arterial supply to the nose.
- There are two clinically important plexuses to be aware of; anterior and posterior
- Anterior is known as Little’s area or Kiesselbach’s plexus and has a rich blood supply that is the frequent source of epistaxis (nose bleeds)
- Posterior is Woodruff’s plexus and is the site of posterior nose bleeds
Which type of nosebleed is most common?
Anterior 90%
Which factors might predispose nose bleeds?
Mucosal dryness
Children/elderly
Hypertension/atherosclerotic disease
How should epistaxis be managed?
Step-wise approach, if the bleeding has not stopped, move on to the next step:
- A–>E assessment
- Pinch cartilage, sit forward - 20 minutes
- Cauterise with silver nitrate
- Pack
- Surgical ligation
How is the nose packed?
Pack the nose, anterior or posterior depending on where you suspect the bleed is. This is essentially a tampon that absorbs and tamponades any bleeding. Posterior packing requires a catheter - the same as is used for urinary catheters.
What are the key symptoms on epiglottis?
3 D’s are the key symptoms:
Drooling
Distressed
Dysphagia
What is seen on a lateral C-spine in epiglottis?
Thumb-print sign
What causes epiglottis?
Haemophilus Influenza type B
What is the management of acute epiglottis?
Intubation
IV antibiotics
