ENT Flashcards
1
Q
What are the two types of hearing loss
A
Conductive
Sensorineural
2
Q
List the basic stuctures of the ear from outside in
A
Outer ear - Pinna - External auditory canal Middle ear - Tympanic membrane - Eustachian tube - Malleous, incus and stapes Inner ear - Semicircular canals - Cochlea - Vestibulocochlear nerve
3
Q
Describe the presentation of hearing loss
A
Gradual and insidious
Sudden <72hrs
May be associated symptoms
- Tinnitus
- Vertigo
- Pain
- Discharge
- Neurological symptoms
4
Q
What are people with hearing loss more likely to develop
A
Dementia
5
Q
Where is the tuning fork placed in Weber’s test
A
Forehead
6
Q
Describe the results of Weber’s test
A
Normal - sound heard equally in both ears
Sensorineural - sound heard louder in the normal ear
Conductive - sound heard louder in affected ear
7
Q
Where is the tuning fork placed in Rinne’s test?
A
On the mastoid process and then in front of the ear
8
Q
Describe Rinne’s positive
A
Air conduction is better than bone conduction - normal or sensorineural hearing loss
9
Q
Describe Rinne’s negative
A
When bone conduction is better than air conduction - conductive hearing loss
10
Q
List some causes of sensorineural hearing loss
A
Sudden sensorineural hearing loss - <72hrs Presbycusis (age related) Noise exposure Meniere's disease Labyrinthitis Acoustic neuroma Neurological conditions Infection Medications - loop diuretics (furosemide), aminoglycoside antibiotics (gentamicin), chemotherapy drugs (cisplatin)
11
Q
List some causes of conductive hearing loss
A
Ear wax Infection Fluid in middle ear - effusion Eustachian tube dysfunction Perforated tympanic membrane Otosclerosis Cholesteatoma Exostoses Tumour
12
Q
Describe the symbols on an audiogram for the different ears and air conduction and bone conduction
A
Bone conduction
[ Right ear
] Left ear
Air conduction
O Right ear
X Left ear
13
Q
What dB is normal hearing
A
0-20dB
14
Q
How is hearing tested in audiometry
A
Bone conduction - ossiclators
Air conduction - headphones
Different tones/frequencies (Hz) played at different volumes (dB) The louder the volume needed to hear a tone, the worse the hearing
15
Q
Describe the audiometry result in mixed conductive and sensorineural hearing loss
A
Bone conduction better than air conduction with more than 15dB difference between the two
Both greater than 20dB
16
Q
Describe the audiometry result for sensorineural hearing loss
A
Both air and bone conduction will be more than 20dB
17
Q
Describe the audiometry result for conductive hearing loss
A
Bone conduction will be normal
Air conduction will be greater than 20dB
18
Q
What is presbycusis
A
Age related hearing loss
Type of sensorineural hearing loss
Affects high pitched sounds first and more notably
Loss of hair cells in cochlea, loss of neurones in cochlea, atrophy of the stria vascularis and reduced endolymphatic potential
19
Q
List the risk factors for presbycusis
A
Age Male gender FH Loud noise exposure DM HTN Ototoxic medications Smoking
20
Q
How do people with presbycusis present?
A
Gradual and insidious hearing loss
May have associated tinnitus
Male voices easier to hear
May struggle to keep up with conversations in loud environments
21
Q
How is presbycusis diagnosed
A
Audiometry - sensorineural pattern - near normal hearing for lower frequencies
22
Q
Describe the management of presbycusis
A
Optimise the environment
Hearing aids
Cochlear implants if hearing aids are not sufficient
23
Q
Define sudden sensorineural hearing loss
A
Hearing loss less than 72hrs unexplained by other causes
Otological emergency and requires immediate referral to the on call ENT team
When conductive hearing loss causes excluded
24
Q
List the causes of sudden sensorineural hearing loss
A
Most are idiopathic >90%
Infection Meniere's disease Ototoxic medications Multiple sclerosis Migraine Stroke Acoustic neuroma Cogan's syndrome
25
How is sudden sensorineural hearing loss investigated
Audiometry - loss of 30 dB in 3 consecutive frequencies
CT/MRI - stroke and acoustic neuroma
26
How is sudden sensorineural hearing loss managed
Same day referral to ENT for assessment <24hrs
Steroids - Oral or intratympanic
May be permanent or may resolve over couple days-weeks
27
What is the eustachian tube
Tube from the middle ear to the throat - equalise the air pressure in the middle ear and drain fluid from the middle ear
28
Describe eustachian tube dysfunction
When the eustachian tube is not functioning correctly or becomes blocled, the air pressure cannot equalise properly and fluid cannot drain freely from the middle ear
The air pressure between middle ear and environment becomes unequal and middle ear can fill with fluid
29
What may cause eustachian tube dysfunction
Recent viral upper respiratory tract infection
Smoking
30
How does eustachian tube dysfunction present
```
Reduced or altered hearing
Popping noises or sensations in the ear
A fullness sensation in the ear
Pain or discomfort
Tinnitus
```
Symptoms get worse when external air pressure changes and the middle ear cannot equalise to the outside pressure
31
What investigations can you do for eustachian tube dysfunction
Otoscopy - middle ear infection
Tympanometry - reduced admittance in dysfunction as lower middle ear pressure
Audiometry
Nasopharyngoscopy
CT scan
32
Describe the management of eustachian tube dysfunction
No treatment -wait for it to resolve on its own
Valsalva manoeuvre - holding nose and blowing into it to inflate eustachian tubes or otovent (balloon you blow into with one nostril bought OTC to inflate Eustachian tubes)
Decongestant nasal sprays
Antihistamines and steroid nasal spray
Surgery - remove adenoids, grommets, balloon dilation eustachian tuboplasty (insert balloon into tube and inflate it for a couple mins before removal)
33
Describe otosclerosis
Remodelling of the small bones in the middle ear - stapes connected to oval window of the cochlea where it transmits vibrations into cochlea and converts them into sensory signals. Stapes becomes stiff and cannot transmit the sound
Occurs <40yo
Combined environment and genetic factors (autosomal dominant)
Conductive hearing loss
Lower frequency sound
34
Describe how otosclerosis presents
Unilateral or bilateral
Hearing loss - lower pitched sounds
Tinnitus
Perception that their voice is louder so they may talk quietly
35
Describe the examination findings in otoscelrosis
Otoscopy is normal
Conductive hearing loss - Weber's is normal if bilateral otosclerosis, otherwise sound heard more in affected ear
Rinnes - bone conduction is greater than air conduction
36
List some investigations for otosclerosis
Audiometry - conductive hearing loss - bone conduction normal however air conduction greater than 20dB at lower frequencies
Tympanometry - reduced admittance (absopriton) - TM stiff and non compliant reflecting most sound back
High resolution CT - bony changes
37
How is otosclerosis managed
Hearing aids
Surgery can be curative - stapedectomy or stapedotomy - replace stapes with prosthesis
38
Describe otitis media
Infection of the middle ear
| Bacteria enter from back of throat via eustachian tube. Viral infection often precedes bacterial infection
39
What is the most common bacterial cause of otitis media and some other less common bacterial causes
Most common - Streptococcus pneumoniae
Moraxella catarrhalis
Haemophilus influenzae
Staphylococcus aureus
40
Describe the presentation of otitis media
```
Ear pain
Reduced hearing in affected ear
Feeling generally unwell - fever
Symptoms of URTI - cough, coryzal, sore throat
Vertigo and balance issues
When TM perforated - pain and discharge
```
41
Describe what is seen on examination in otitis media
Otoscopy - Red, bulging, inflamed tympanic membrane. May have a hole and discharge in the external auditory canal if it has perforated
42
Describe the management of otitis media
Most redsolve without Antibioitics within 3 days to a week
Consider antibiotics if co-morbidity, systemically unwell or immunocompromised. Also consider delayed prescription of antibiotics for patients wanting them
1st line - amoxicillin 5-7days
Clarithromycin in penicillin allergic patients and erythromycin in pregnant penicillin allergic
Safety net the patients
Advise simple analgesia for fever and pain
43
List some complications of otitis media
```
Effusion
Hearing loss
Perforated TM
Labyrinthitis
Mastoiditis
Abscess
Facial nerve palsy
Meningitis
```
44
What is otitis externa
Inflammation of the skin in the external auditory canal
Localised/diffuse
Acute <3weeks or chronic >3weeks
45
What causes otitis externa
```
Swimming
Trauma - ear buds
Bacterial infection
Fungal infection - aspergillus and candida
Eczema
Seborrheic dermatitis
Contact dermatitis
```
46
What are the two most common bacterial causes of otitis externa
Pseudomonas aeruginosa
| Staphylococcus aureus
47
What type of bacteria is pseudomonas aeruginosa
Gram negative aerobic Rod
48
How does otitis externa present
Ear pain
Discharge
Itchiness
Conductive hearing loss
O/E: Erythema and swelling in the ear canal, tenderness, pus or discharge from the ear canal and lymphadenopathy
49
How is otitis externa diagnosed
Otoscopy
Ear swab - identify the organism but not usually required
50
Describe the management of otitis externa
Mild - acetic acid 2% (ear calm) - anti-fungal and antibacterial so can be used prophylactically before and after swimming in those prone
Moderate - topical antibiotic and steroid - otomize spray (neomycin, dexamethasone and acetic Acid)
Patients with severe/systemic symptoms may need oral antibiotics (flucloxacillin or clarithromycin) or discussion with ENT for admission for IV
Ear wick may be used if canal very swollen and treatment with sprays and drops difficult - made of sponge or gauze. Contain topical treatment. Inserted into the ear for 48hrs and left so the swelling settles and treatment can continue with drops or sprays after
51
What must you check for before prescribing aminoglycoside antibiotics such as topical gentamicin or neomycin
Perforated TM - lead to ototoxicity
52
Which antibiotics are typically used to treat pseudomonas
Aminoglycosides - gentamicin or neomycin
Quinolones - ciprofloxacin
53
Describe malignant otitis externa
Severe and life threatening
Infection spreads to bones - osteomyelitis of the temporal bone
Symptoms are more severe than otitis externa with persistent headaches, severe pain and fever
Granulation tissue at the junction between the bone and cartilage in the ear canal
54
List some risk factors for otitis externa
Diabetes
HIV
Immunosuppression
55
Describe the treatment of malignant otitis externa
Admission to hospital
IV antibiotics
Imaging - CT/MRI - extent of infection
56
List the complications of malignant otitis externa
```
Facial nerve damage and palsy
Other cranial nerve involvement
Meningitis
Intracranial thrombosis
Death
```
57
Describe the symptoms of impacted ear wax
```
Conductive hearing loss
Discomfort in the ear
A feeling of fullness
Pain
Tinnitus
Can be seen with an otoscope
```
58
How is impacted ear wax treated
Mild - olive oil or sodium bicarbonate 5% drops
Ear irrigation
Microscution if infection or perforated TM so irrigation is CI
59
Describe tinnitus
Ringing/extra sound heard that is not present in the environment
Additional noise experienced is a result of background sensory signal produced by the cochlea that is not effectively filtered out by the CNS
Becomes more prominent the more attention is given to it
60
List the causes of tinnitus
Primary - idiopathic and likely sensorineural hearing loss too
Secondary - impacted ear wax, ear infection, Meniere's disease, noise exposure, medications (furosemide, gentamicin, quinine, NSAIDs and chemo), acoustic neuroma, MS, trauma and depression
May occur with systemic conditions - anaemia, DM, hypo/hyperthyroidism, hyperlipidaemia
61
What is objective tinnitus and what causes it
The patient can objectively hear an extra sound within their head
Carotid artery stenosis - pulsatile carotid bruit
Aortic stenosis - radiating pulsatile murmur
AV malformation - pulsatile,
Eustachian tube dysfunction - clicking or popping noises
62
Describe the assessment in tinnitus
Hx
- Unilateral or bilateral
- Frequency and duration
- Severity
- Pulsatile or non-pulsatile
- Contributing factor - hearing loss or loud noise
- Associated symptoms - hearing loss, vertigo, pain or discharge
- Stress and anxiety
- Otoscopy
- Weber's and Rinnes test
63
List some investigations you can do for tinnitus
```
FBC - anaemia
Glucose - DM
TSH - thyroid disease
Lipids - hyperlipidaemia
Audiology
Imaging - CT/MRI - AV malformation or acoustic neuroma
```
64
List some tinnitus red flags which require specialist assessment
```
Unilateral
Pulsatile
Hyperacusis - hypersensitivity, pain and distress with environmental sounds
Hearing loss (especially if sudden)
Vertigo/dizziness
Headache/visual symptoms
Neurological symptoms
Suicidal ideation related to tinnitus
```
65
How is tinnitus managed
Most improve/resolve over time with no interventions
Underlying cause treated
Several measures to help improve symptoms
- Hearing aid
- Sound therapy
- CBT
66
Describe vertigo
Sensation that there is movement between the patient and their environment
Associated with nausea, vomiting, sweating and feeling generally unwell
Sensory inputs responsible for maintaining balance and posture are vision, proprioception and signals from the vestibular system. Vertigo is caused by a mismatch between these sensory inputs
67
Describe the vestibular system
Vestibular apparatus is in the inner ear, it consists of three loops called the semi-circular canals that are filled with endolymph. As the head turns, the endolymph moves and the fluid shift is detected by stereocilia in the ampulla. Signal is transmitted to the brain by the vestibular nerve to the vestibular nucleus in brainstem and cerebellum
68
What are the two groups the causes of vertigo
Peripheral problem - vestibular system
| Central problem - brainstem and cerebellum
69
List the causes of peripheral vertigo
```
Benign paroxysmal positional vertigo (BPPV)
Meniere's disease
Vestibular neuronitis
Labyrinthitis
Trauma to the vestibular nerve
Vestibular nerve tumour
Otosclerosis
Hyperviscosity syndrome
Herpes zoster infection - ramsay hunt syndrome - facial weakness and vesicles around the ear
```
70
Describe what causes benign paroxysmal positional vertigo
Crystals of calcium carbonate (otoconia) displaced in the semi-circular canals with viruses, age, trauma or without clear cause. Crystals disrupt the normal flow through the canals and therefore disrupt the function of the system.
71
Describe the presentation of BPPV
Positional attacks - triggered by movement
Last around a minute before symptoms settle
Occur over several weeks and then resolve, then can recur weeks or months later
72
How is BPPV diagnosed
Dix-Hallpike manoeuvre
73
Describe Menieres disease
Excessive build up of endolymph in the semicircular canals causing a higher than normal pressure and disrupting the sensory signals.
74
Describe the presentation of Meniere's disease
```
Hearing loss
Tinnitus
Vertigo
Sensation of fullness in the ear
Attacks last several hours
Mostly occurs in middle aged
Not associated with movement/position
Spontaneous nystagmus during episodes
hearing will gradually deteriorate overtime
```
75
Describe the presentation of vestibular neuronitis and its usual cause
Acute vertigo that improves within a few weeks
Due to Inflammation of the vestibular nerve
Usually due to viral infection
76
Describe the presentation of labyrinthitis and its usual cause
Acute onset vertigo that improves within a few weeks, usually causes hearing loss
Due to viral infection
77
List some central problems causing vertigo
Posterior circulation infarct
Tumour
MS
Vestibular migraine
78
Describe the head impulse (hints test)
To determine if person has a peripheral cause of vertigo but will be normal if patient has no current symptoms or a central cause
Ensure no neck pain/pathology first, patient asked to look at examiners nose while examiner turns their head quickly 20 degrees in one direction and then again in the other. Peripheral vestibular cause if the eyes saccade before focusing back on examiner
79
What type of vertigo is a horizontal or unilateral nysatgmus likely to indicate
Peripheral
80
What is a bilateral or vertical nystagmus likely to indicate
Central
81
Describe the test of skew
Test for central causes of vertigo
Patient focuses on examiners nose
Examiner covers one eye at a time alternating between covering eyes. If there is vertical correction when eye is uncovered (eye has drifted up/down and is moved vertically to dix on nose) then this indicates central cause
82
Describe the management of vertigo
Central causes need referral for CT/MRI
Peripheral - prochlorperazine (antipsychotic) and antihistamines such as Cyclizine, promethazine or cinnarizine to manage symptoms
Betahistine to help reduce attacks in patients with Meniere's disease
```
Epley manoeuvre (stepwise rotation of the head) for BPPV
Vestibular migraines managed by avoiding triggers and lifestyle changes, medical management is with triptans for the acute symptoms and then propranolol, topiramate or amitriptyline for attacks
```
DVLA states patients must not drive and must inform DVLA if susceptible to vertigo attacks
83
What is a positive finding in the dix-Hallpike manoeuvre for BPPV
Rotatory nystagmus - beats towards the affected ear
| Onset of vertigo
84
How is the Dix Hallpike manoeuvre performed
Pt sits upright on couch with head turned to 45 degrees
Support pts head while rapidly lowering them backwards
Hold the patients head still, turned 45degrees to one side and extended
Watch the eyes closely for nystagmus for up to 60 seconds
Repeat with head turned to the other direction
85
What exercises can be done by the patient at home to help improve BPPV
Brandt-daroff exercises
86
Describe how the Epley manoeuvre is performed
Follow the Dix-Hallpike steps and then rotate the pts head 90 degrees past the central position, have them roll onto their side and then get them to sit up and position the head in the central position with neck flexed to 45 degrees - support the head at each stage for 30 seconds
87
If vestibular neuronitis symptoms do not improve after 1-6weeks what may the patient require
Further investigation or vestibular rehabilitation therapy
88
Describe the prognosis for vestibular neuronitis
Symptoms are most severe for the first few days after which they gradually resolve over the following 2-6weeks
Benign paroxysmal positional vertigo may develop after vestibular neuronitis
89
What is a complication of bacterial labyrinthitis
Meningitis
90
List the symptoms of Meniere's disease
```
Unilateral
Hearing loss
Tinnitus - usually occurs before vertigo before becoming more permanent
Vertigo
Feeling of fullness
Imbalance
Unexplained falls
```
91
Describe the prophylactic drug used in Meniere's
Betahistine
92
What is an acoustic neuroma
Benign tumour of Schwann cells surrounding the auditory nerve - vestibular schwannomas - originate from Schwann cells found in the peripheral nervous system
93
Where do the acoustic neuromas occur
Cerebellopontine angle
94
What is an association with bilateral acoustic neuromas
Neurofibromatosis type 2
95
Describe the presentation of acoustic neuromas
```
40-60 yos
Gradual onset
Unilateral sensorineural hearing loss
Unilateral tinnitus
Dizziness and imbalance
Sensation of fullness in the ear
Facial nerve palsy - LMN lesion and forehead is not spared
```
96
How is acoustic neuroma diagnosed
Audiometry - sensorineural pattern of hearing loss
| Brain MRI/CT
97
Describe the management of acoustic neuroma
Conservative management - monitor if no symptoms or treatment
Surgery - remove the tumour
Radiotherapy - reduce the growth
98
What are the risks of surgical removal of an acoustic neuroma
Vestibulocochlear nerve injury - permanent hearing loss and dizziness
Facial nerve injury
99
What is glue ear
Recurrent otitis media with effusion
100
Describe cholesteatoma
Abnormal collection of squamous epithelial cells in the middle ear
Non-cancerous but can invade tissues and nerves and erode the bones in the middle ear
101
Describe the presentation of cholesteatoma
```
Foul discharge from the ear
Unilateral conductive hearing loss
Infection
Pain
Vertigo
Facial nerve palsy
Otoscopy - build up of whitish debris or crust in the upper tympanic membrane - may not be possible to visualise the eardrum if discharge or wax blocking the canal
```
102
Describe the management of cholesteatoma
CT head
| Surgery
103
Describe the journey of the facial nerve
From brainstem at cerebellopontine angle
Passes through the temporal bone and parotid gland
Divides into 5 branches that supply different areas of the face
- Temporal
- Zygomatic
- Buccal
- Marginal mandibular
- Cervical
104
What is the function of the facial nerve
Motor - muscles of fascial expression, stapedius in inner ear and muscles of neck
Sensory - anterior 2/3 tongue
Parasympathetic -salivary glands and lacrimation
105
How do you distinguish between an UMN and LMN cause of 7th nerve palsy
UMN - forehead sparing
LMN - forehead is not spared
Ask the patient to raise their eyebrows
106
List some UMN causes of a facial nerve palsy
Stroke
Tumour
If bilateral - pseudobulbar palsy and MND
107
Describe the treatment of Bells palsy
May take a year to recovery and 1/3 left with permanent damage
50mg prednisolone for 10 days
60mg for 5 days followed by 5 day reducing regime of 10mg a day
Lubricating eye drops and referral to ophthalmology if exposure keratopathy
108
Describe Ramsay Hunt syndrome
Caused by herpes zoster virus
Unilateral LMN facial nerve palsy
Vesicular rash in ear canal, pinna and around ear on affected side, may extend to anterior 2/3 tongue
109
Describe the treatment of Ramsay-Hunt syndrome
Prednisolone
Aciclovir
Lubricating eye drops
110
List the causes of LMN facial nerve palsy
Infection - otitis media, malignant otitis externa, HIV, lyme disease
Systemic disease - DM, sarcoidosis, leukaemia, MS, GB
Tumours - acoustic neuromas, parotid tumours, cholesteatoma
Trauma - direct nerve trauma, damage to the nerve during surgery, base of skull fractures
111
Where is the most common area for nosebleeds
Kiesselbachs plexus in Little's area
112
What may trigger epistaxis
```
Nose picking
Trauma
Cold weather
Aggressive nose blowing
Coagulation disorder
Anticoagulant medication
Tumours
Sinusitis
```
113
Where is bilateral nose bleeding likely to originate
Posterior nose - sphenopalatine artery
114
Describe what a patient should do when having a mild nosebleed
Sit forward and tilt the head forward
Squeeze the soft part of the nostrils together for 10-15mins
Spit out any blood in the mouth rather
than swallowing
If bleeding does not stop within 15mins then attend hospital
115
Describe the management of a severe nosebleed
Nasal packing - nasal tampons or inflatable packs
| Nasal cautery - silver nitrate sticks
116
What is a severe nosebleed
Bleeding >15mins
Bilateral bleeding
Haemodynamically unstable
117
What should be prescribed following an acute nosebleed
Naseptin - chlorhexidine and neomycin - qds for 10 days - reduce crusting, inflammation and infection
118
When is naseptin CI
Peanut or soya allergy
119
Describe sinusitis
Inflammation of the paranasal sinuses
May be accompanied by nasal cavity inflammation - rhinosinusitis
Acute <12weeks
Chronic >12weeks
120
Describe the paranasal sinuses
Hollow spaces within the facial bones which produce mucosa and drain into the nasal cavities through ostia
Frontal - above the eyebrows
Maxillary - either side of nose below the eyes
Ethmoid - in the ethmoid bone in the middle of nasal cavity
Sphenoid sinuses - sphenoid bone at back of the nose
121
List some causes of sinusitis
Infection - URTI
Allergies and asthmatics
Obstruction - foreign body or polyp
Smoking
122
List the symptoms of acute sinusitis
```
Recent viral URTI
Nasal congestion
Nasal discharge
Facial pain or hewadache
Facial pressure
Facial swelling
Loss of smell
```
123
What may be found on examination in acute sinusitis
Tenderness to palpation over affected areas
Inflammation and oedema of nasal mucosa
Discharge
Fever
Other signs of systemic infection - tachycardia
124
Describe chronic sinusitis
>12 weeks
| Associated with nasal polyps - growths of nasal mucosa
125
What are the investigations for persistent sinusitis
Nasal endoscopy
| CT scan
126
Describe the management of sinusitis
Systemic infection/sepsis - hospital
High dose steroid nasal spray (mometasone 200mcg twice daily) for 14 days or A delayed antibiotic prescription used if worsening or not improving within 7 days - phenoxymethylpenicillin
Chronic sinusitis - saline irrigation, steroid nasal sprays or functional endoscopic sinus surgery
127
Describe good nasal spray technique
Tilt head forwards slightly
Use left hand to spray the right nostril and vice versa
Not sniffing hard, just inhale through nose after spray
128
What is a question to ask to see if someone has good nasal spray technique
Do you taste it in your throat after using it - if yes then it has gone past nasal mucosa and not effective
129
What are nasal polyps
Growths of nasal mucosa in the nasal cavity or sinuses
Often grow slowly and may gradually obstruct the nasal passage
Usually bilateral
130
What is a red flag in terms of nasal polyps
Unilateral - raise suspicion of tumour
131
Which conditions are polyps associated with?
Chronic rhinitus or sinusitis
Asthma
Samter's triad - nasal polyps, asthma and aspirin intolerance/allergy
CF
Eosinophillic granulomatosis with polyangitis
132
Describe the presentation of nasal polyps
```
Chronic rhinosinusitis
Difficulty breathing through the nose
Snoring
Nasal discharge
Loss of smell (anosmia)
```
133
How could you examine for nasal polps
Nasal speculum
Otoscope with large speculum attached
Nasal endoscopy
134
How do nasal polyps appear
Round grey/yellow growths on the mucosal wall
135
How are nasal polyps managed
Unilateral - specialist assessment to exclude malignancy
Medical management - intranasal topical steroid drops or spray
Surgical removal - intranasal polypectomy and endoscopic nasal polypectomy
136
Describe obstructive sleep apnoea
Pharyngeal airway collapse
137
List some risk factors for obstructive sleep apnoea
```
Middle age
Male
Obesity
Alcohol
Smoking
```
138
Describe some features of obstructive sleep apnoea
```
Episodes of apnoea during sleep
Snoring
Morning headache
Waking feeling unrefreshed from sleep
Daytime sleepiness
Concentration problems
Reduced O2 sat during sleep
```
139
What can severe obstructive sleep apnoea cause
HTN
HF
MI
stroke
140
What scale can be used to assess symptoms of sleepiness associated with obstructive sleep apnoea
Epworth sleepiness scale
141
Describe the management of obstructive sleep apnoea
Refer to ENT/sleep study clinic to perform sleep studies
Manage reversible factors - lose weight, stop drinking alcohol, stop smoking, lose weight
Inform DVLA - i tiredness may impair driving
CPAP - maintain patency of airway
Surgery - uvulopalatopharyngoplasty
142
What are the causes of tonsillitis
Bacteria - Group A streptococcus (Streptococcus pyogenes), streptococcus pneumoniae, haemophilus influenza, Moraxella catarrhalis and staphylococcus aureus
Virus
143
Describe the presentation of someone with tonsillitis
Sore throat
Fever
Pain on swallowing
Examination - red, inflamed, enlarged tonsils, may have exudates (white patches of pus), may have anterior cervical lymphadenopathy
144
Describe the centor score
Estimates the probability the tonsillitis is due to bacterial infection and will benefit from antibiotics
Fever >38
Tonsillar exudates
Absence of cough
Tender anterior cervical lymphadenopathy
145
Describe the feverPAIN score
```
Fever in past 24hrs
Purulence on tonsils
Attended within 3 days
Inflamed tonsils
No cough or coryza
```
146
Describe the management of tonsilitis
If likely viral, advise fluids and simple analgesia - safetynet - tell them to come back in 3 days if worsening or fever rises above 38.3, consider a delayed prescription and educate patient about likely virus and only to collect prescription if symptoms worsen
If likely bacterial or if co-morbidity, immunocompromised, rheumatic fever history then antibiotics - penicillin V 500mg qds for 10day course is first line (narrow spectrum of activity), clarithromycin if penicillin allergic
Admit if unwell, dehydrated, stridor, respiratory distress or evidence of peritonsillar abscess or cellulitis
147
List some tonsillitis complications
```
Peritonsillar abscess
Otitis media
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis
Post-streptococcal reactive arthritis
```
148
Describe a quinsy
A peritonsillar abscess formed from partially or untreated tonsillitis
Can arise without tonsillitis
Bacterial infection with trapped pus forming an abscess in the tonsils
149
Describe the presentation of quinsy
```
Sore throat
Painful swallowing
Fever
Neck pain
Referred ear pain
Swollen tender lymph nodes
Trismus - unable to open their mouth
Change in voice
Swelling and erythema
```
150
Which bacteria are commonly involved in quinsy
Streptococcus pyogenes (Group A strep)
Staphylococcus aureus
Haemophilus influenza
151
How should quinsy be managed
Incision and drainage under GA
Antibiotics - co-amoxiclav (broad spectrum)
Some give dexamethasone to settle inflammation
152
What are the indications for tonsillectomy
```
>7 episodes in a year
>5 episodes per year in 2 years
>3 episodes per year for 3 years
Recurrent tonsillar abscesses
Enlarged tonsils causing difficulty in breathing, swallowing or snoring
```
153
How long since tonsillectomy can a post-tonsillectomy bleed occur
2 weeks
154
Describe the management of post-tonsillectomy bleeding
Call ENT reg
Get IV access and send bloods - FBC, Clotting screen, group and save and cross match
Keep patient calm, give analgesia, sit them up and encourage them to spit out the blood instead of swallowing
Make the patient NBM
IV fluids - maintenance and resus
If severe bleeding or airway compromise - call anaesthetist as intubation may be required
Hydrogen peroxide gargle or adrenalin soaked swab applied locally may be used to stop bleed and avoid theatre
155
Describe the anatomy of the neck
Midline - vertically along the centre of the neck
Anterior triangle - mandible (superior border), midline of the neck (medial border) and sternocleidomastoid (lateral border)
Posterior triangle - clavicle (inferior border), trapezius (posterior border), sternocleidomastoid (lateral border)
156
What features do you look for on examination of a neck lump
```
Location
Size
Shape
Consistency
Mobile or tethered to the skin or underlying tissues
Skin changes
Warmth
Tenderness
Pulsatile
Movement with swallowing
Transilluminates with light
```
157
When do you refer a neck lump?
Unexplained neck lump in someone >45yo
Persistent unexplained neck lump at any age
2ww referral or urgent direct access investigations - ultrasound
158
What blood tests may be helpful in someone with a neck lump
FBC and blood film - anaemia, leukaemia and infection
HIV test
Monospot test or EBV antibodies - Infectious mononucleosis
TFTs - goitre or thyroid nodules
Antinuclear antibodies - SLE
Lactate dehydrogenase - Hodgkin's lymphoma
Imaging - USS, CT/MRI, Nuclear medicine scans
Biopsy - fine needle aspiration cytology, core biopsy, incision biopsy, removal of the lump
159
What are the 4 causes of lymphadenopathy
Reactive - dental infection, tonsillitis or URTI
Infected - TB, HIV, EBV
Inflammatory - sarcoidosis or SLE
Malignancy - lymphoma, leukaemia or mets
160
List some lymph node features which suggest malignancy
```
Unexplained
Persistently enlarged >3cm in diameter
Abnormal shape
Hard or rubbery
Non-tender
Tethered to skin or underlying tissue
Associated symptoms - night sweats, weight loss, fatigue or fevers
```
161
Describe infectious mononucleosis, its presentation, investigations and treatment
EBV -Found in saliva
Sore throat, fever, fatigue and lymphadenopathy
Monospot test - IgM (acute infection) and IgG (immunity) to EBV
Management - avoid alcohol (risk of liver toxicity) and contact sports (risk of splenic rupture)
162
What happens when you give amoxicillin or cephalosporins to patients with EBV
Itchy maculopapular rash
163
What is a goitre
Generalised swelling of the thyroid gland
164
What causes a goitre
```
Graves disease
Toxic multinodular goitre
Hashimotos disease
Iodine deficiency
Lithium
```
165
What causes individual thyroid lumps
```
Benign hyperplastic nodules
Thyroid cysts
Thyroid adenoma
Thyroid cancer - follicular or papillary
Parathyroid tumour
```
166
Name the 3 types of salivary glands
Parotid glands
Submandibular glands
Sublingual glands
167
Why might the salivary glands enlarge
Stones
Infection
Tumours
168
Describe carotid body tumour
Located just above the carotid bifurcation
Contains glomus cells which are chemoreceptors, lots of them form paraglanglia - when a tumour this is a paraganglioma
Benign - slow growing lump in the upper anterior triangle of the neck, painless, pulsatile, associated with a bruit on auscultation and mobile side to side but not up and down
May compress the glossopharyngeal vagus, accessory or hypoglossal nerves - Horner's syndrome
169
What is a sign of a carotid body tumour on USS
Splaying of the internal and external carotid arteries - lyre sign
170
How are carotid body tumours treated
Surgery
171
Give the examination findings of a lipoma
Soft
Painless
Mobile
Does not cause skin change
172
Describe a thyroglossal cyst
Persistent thyroglossal duct which gives rise to fluid filled cyst
Occurs in the midline of the neck - mobile, non tender, soft, fluctuant
Move up and down with movement of the tongue
US/CT to confirm diagnosis
Surgical removal to provide diagnosis on histology and prevent infection
Main complication is infection - hot, tender and painful lump
173
Describe branchial cyst
Congenital abnormality when the 2nd branchial cleft fails to form during fetal development
Leaves a space surrounded by epithelial tissue which fills with fluid
Soft, round, cystic swelling at the angle of the jaw and sternocleidomastoid in anterior triangle of the neck
Common presentation in young adulthood
Management is conservative or surgical excision if recurrent excision or diagnostic doubt
174
What type of cancer are head and neck cancers
Squamous cell carcinomas of the squamous cells of the mucosa
175
List some risk factors for head and neck cancer
```
Smoking
Chewing tobacco
Chewing betel quid (south east asia)
Alcohol
HPV 16
EBV
```
176
Which HPV strains does the HPV vaccine protect against
6,11,16,18
177
What are some red flags of 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
```
178
Describe the management of head and neck cancer
```
MDT
Chemotherapy
Radiotherapy
Surgery
Targeted drugs - monoclonal antibodies - cetuximab (monoclonal antibody to the epidermal growth factor receptor, blocks the activation of this receptor and inhibits growth and metastasis of the tumour)
Palliative care
```
179
What is glossitis and what causes it
Inflamed, red, sore, swollen tongue
Papillae of the tongue atrophy and give the tongue a smooth appearance - beefy
```
Iron deficiency anaemia
B12 deficiency
Folate deficiency
Coeliac disease
Injury/irritant exposure
```
180
Describe angioedema and list its causes
Swelling in the tissues due to fluid accumulation
Allergic reactions
ACEi
C1 esterase inhibitor deficiency
181
Describe oral candidiasis and list its causes and management
Fungal infection of the mouth - white spots and patches in the tongue and palate
```
Causes:
Inhaled corticosteroids
Antibiotics
DM
HIV/immunodeficiency
Smoking
```
Treatment with
- Miconazole gel
- Nystatin suspension
- Fluconazole tablets
182
Describe geographic tongue and list its associations and management
Inflammatory condition where patches of the tongues surface lose epithelium and papillae
Patches form irregular shapes on the tongue
Relapse and remit
Associated with stress, mental illness, psoriasis, atopy and diabetes
No specific treatment however burning and discomfort treated with topical steroids or antihistamines
183
What is leukoplakia and its management
Precancerous condition - risk of SCC of the mouth
Asymptomatic, irregular and slightly raised white patches in mouth and on tongue or side of cheeks
Management - biopsy to exclude abnormal cells - stop smoking, reducing alcohol intake, close monitoring and potentially laser removal or surgical excision
184
Describe erythroplakia
Red lesions - mixture of red and white
| High risk of SCC -refer urgently
185
Describe lichen planus and its management
Autoimmune condition causing chronic inflammation of the skin
Skin has shiny, purplish, flat topped raised areas with white lines across the surface called Wickham's striae
Occurs in >45 and women
Affects the mucosal membranes in the mouth
- reticular - web of white lines - whickams striae
- erosive - surface is eroded leaving sores
- plaque - larger continuous areas
Management - good oral hygiene, stop smoking and topical steroids
186
What causes gingival hyperplasia
```
Gingivitis
Pregnancy
Vitamin C deficiency
AML
Medication - CCB, phenytoin and ciclosporin
```
187
Give some causes of aphthous ulcers
```
IBD
Coeliac disease
Bechet disease
Vitamin deficiency - iron, B12, folate, vit D
HIV
```
