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ENT Flashcards

1
Q

What are the two types of hearing loss

A

Conductive

Sensorineural

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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
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3
Q

Describe the presentation of hearing loss

A

Gradual and insidious
Sudden <72hrs

May be associated symptoms

  • Tinnitus
  • Vertigo
  • Pain
  • Discharge
  • Neurological symptoms
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4
Q

What are people with hearing loss more likely to develop

A

Dementia

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5
Q

Where is the tuning fork placed in Weber’s test

A

Forehead

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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

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7
Q

Where is the tuning fork placed in Rinne’s test?

A

On the mastoid process and then in front of the ear

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8
Q

Describe Rinne’s positive

A

Air conduction is better than bone conduction - normal or sensorineural hearing loss

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9
Q

Describe Rinne’s negative

A

When bone conduction is better than air conduction - conductive hearing loss

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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)
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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
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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

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13
Q

What dB is normal hearing

A

0-20dB

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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

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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

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16
Q

Describe the audiometry result for sensorineural hearing loss

A

Both air and bone conduction will be more than 20dB

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17
Q

Describe the audiometry result for conductive hearing loss

A

Bone conduction will be normal

Air conduction will be greater than 20dB

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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

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19
Q

List the risk factors for presbycusis

A 
Age
Male gender
FH
Loud noise exposure
DM
HTN
Ototoxic medications
Smoking
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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

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21
Q

How is presbycusis diagnosed

A

Audiometry - sensorineural pattern - near normal hearing for lower frequencies

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22
Q

Describe the management of presbycusis

A

Optimise the environment
Hearing aids
Cochlear implants if hearing aids are not sufficient

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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

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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
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25
Q

How is sudden sensorineural hearing loss investigated

A

Audiometry - loss of 30 dB in 3 consecutive frequencies

CT/MRI - stroke and acoustic neuroma

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26
Q

How is sudden sensorineural hearing loss managed

A

Same day referral to ENT for assessment <24hrs

Steroids - Oral or intratympanic

May be permanent or may resolve over couple days-weeks

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27
Q

What is the eustachian tube

A

Tube from the middle ear to the throat - equalise the air pressure in the middle ear and drain fluid from the middle ear

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28
Q

Describe eustachian tube dysfunction

A

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

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29
Q

What may cause eustachian tube dysfunction

A

Recent viral upper respiratory tract infection

Smoking

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30
Q

How does eustachian tube dysfunction present

A 
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

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31
Q

What investigations can you do for eustachian tube dysfunction

A

Otoscopy - middle ear infection

Tympanometry - reduced admittance in dysfunction as lower middle ear pressure

Audiometry
Nasopharyngoscopy
CT scan

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32
Q

Describe the management of eustachian tube dysfunction

A

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)

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33
Q

Describe otosclerosis

A

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

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34
Q

Describe how otosclerosis presents

A

Unilateral or bilateral

Hearing loss - lower pitched sounds
Tinnitus

Perception that their voice is louder so they may talk quietly

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35
Q

Describe the examination findings in otoscelrosis

A

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

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36
Q

List some investigations for otosclerosis

A

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

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37
Q

How is otosclerosis managed

A

Hearing aids

Surgery can be curative - stapedectomy or stapedotomy - replace stapes with prosthesis

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38
Q

Describe otitis media

A

Infection of the middle ear

Bacteria enter from back of throat via eustachian tube. Viral infection often precedes bacterial infection

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39
Q

What is the most common bacterial cause of otitis media and some other less common bacterial causes

A

Most common - Streptococcus pneumoniae

Moraxella catarrhalis
Haemophilus influenzae
Staphylococcus aureus

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40
Q

Describe the presentation of otitis media

A 
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
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41
Q

Describe what is seen on examination in otitis media

A

Otoscopy - Red, bulging, inflamed tympanic membrane. May have a hole and discharge in the external auditory canal if it has perforated

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42
Q

Describe the management of otitis media

A

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

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43
Q

List some complications of otitis media

A 
Effusion
Hearing loss
Perforated TM 
Labyrinthitis 
Mastoiditis
Abscess
Facial nerve palsy 
Meningitis
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44
Q

What is otitis externa

A

Inflammation of the skin in the external auditory canal
Localised/diffuse
Acute <3weeks or chronic >3weeks

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45
Q

What causes otitis externa

A 
Swimming
Trauma - ear buds
Bacterial infection
Fungal infection - aspergillus and candida 
Eczema
Seborrheic dermatitis 
Contact dermatitis
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46
Q

What are the two most common bacterial causes of otitis externa

A

Pseudomonas aeruginosa

Staphylococcus aureus

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47
Q

What type of bacteria is pseudomonas aeruginosa

A

Gram negative aerobic Rod

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48
Q

How does otitis externa present

A

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

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49
Q

How is otitis externa diagnosed

A

Otoscopy

Ear swab - identify the organism but not usually required

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50
Q

Describe the management of otitis externa

A

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

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51
Q

What must you check for before prescribing aminoglycoside antibiotics such as topical gentamicin or neomycin

A

Perforated TM - lead to ototoxicity

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52
Q

Which antibiotics are typically used to treat pseudomonas

A

Aminoglycosides - gentamicin or neomycin

Quinolones - ciprofloxacin

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53
Q

Describe malignant otitis externa

A

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

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54
Q

List some risk factors for otitis externa

A

Diabetes
HIV
Immunosuppression

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55
Q

Describe the treatment of malignant otitis externa

A

Admission to hospital
IV antibiotics
Imaging - CT/MRI - extent of infection

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56
Q

List the complications of malignant otitis externa

A 
Facial nerve damage and palsy 
Other cranial nerve involvement 
Meningitis 
Intracranial thrombosis
Death
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57
Q

Describe the symptoms of impacted ear wax

A 
Conductive hearing loss
Discomfort in the ear 
A feeling of fullness
Pain 
Tinnitus 
Can be seen with an otoscope
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58
Q

How is impacted ear wax treated

A

Mild - olive oil or sodium bicarbonate 5% drops
Ear irrigation
Microscution if infection or perforated TM so irrigation is CI

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59
Q

Describe tinnitus

A

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

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60
Q

List the causes of tinnitus

A

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

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61
Q

What is objective tinnitus and what causes it

A

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

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62
Q

Describe the assessment in tinnitus

A

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
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63
Q

List some investigations you can do for tinnitus

A 
FBC - anaemia
Glucose - DM
TSH - thyroid disease
Lipids - hyperlipidaemia 
Audiology 
Imaging - CT/MRI - AV malformation or acoustic neuroma
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64
Q

List some tinnitus red flags which require specialist assessment

A 
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
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65
Q

How is tinnitus managed

A

Most improve/resolve over time with no interventions
Underlying cause treated
Several measures to help improve symptoms
- Hearing aid
- Sound therapy
- CBT

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66
Q

Describe vertigo

A

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

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67
Q

Describe the vestibular system

A

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

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68
Q

What are the two groups the causes of vertigo

A

Peripheral problem - vestibular system

Central problem - brainstem and cerebellum

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69
Q

List the causes of peripheral vertigo

A 
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
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70
Q

Describe what causes benign paroxysmal positional vertigo

A

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.

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71
Q

Describe the presentation of BPPV

A

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

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72
Q

How is BPPV diagnosed

A

Dix-Hallpike manoeuvre

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73
Q

Describe Menieres disease

A

Excessive build up of endolymph in the semicircular canals causing a higher than normal pressure and disrupting the sensory signals.

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74
Q

Describe the presentation of Meniere’s disease

A 
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
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75
Q

Describe the presentation of vestibular neuronitis and its usual cause

A

Acute vertigo that improves within a few weeks

Due to Inflammation of the vestibular nerve
Usually due to viral infection

76
Q

Describe the presentation of labyrinthitis and its usual cause

A

Acute onset vertigo that improves within a few weeks, usually causes hearing loss

Due to viral infection

77
Q

List some central problems causing vertigo

A

Posterior circulation infarct
Tumour
MS
Vestibular migraine

78
Q

Describe the head impulse (hints test)

A

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
Q

What type of vertigo is a horizontal or unilateral nysatgmus likely to indicate

A

Peripheral

80
Q

What is a bilateral or vertical nystagmus likely to indicate

81
Q

Describe the test of skew

A

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
Q

Describe the management of vertigo

A

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
Q

What is a positive finding in the dix-Hallpike manoeuvre for BPPV

A

Rotatory nystagmus - beats towards the affected ear

Onset of vertigo

84
Q

How is the Dix Hallpike manoeuvre performed

A

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
Q

What exercises can be done by the patient at home to help improve BPPV

A

Brandt-daroff exercises

86
Q

Describe how the Epley manoeuvre is performed

A

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
Q

If vestibular neuronitis symptoms do not improve after 1-6weeks what may the patient require

A

Further investigation or vestibular rehabilitation therapy

88
Q

Describe the prognosis for vestibular neuronitis

A

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
Q

What is a complication of bacterial labyrinthitis

A

Meningitis

90
Q

List the symptoms of Meniere’s disease

A 
Unilateral 
Hearing loss
Tinnitus - usually occurs before vertigo before becoming more permanent 
Vertigo
Feeling of fullness 
Imbalance 
Unexplained falls
91
Q

Describe the prophylactic drug used in Meniere’s

A

Betahistine

92
Q

What is an acoustic neuroma

A

Benign tumour of Schwann cells surrounding the auditory nerve - vestibular schwannomas - originate from Schwann cells found in the peripheral nervous system

93
Q

Where do the acoustic neuromas occur

A

Cerebellopontine angle

94
Q

What is an association with bilateral acoustic neuromas

A

Neurofibromatosis type 2

95
Q

Describe the presentation of acoustic neuromas

A 
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
Q

How is acoustic neuroma diagnosed

A

Audiometry - sensorineural pattern of hearing loss

Brain MRI/CT

97
Q

Describe the management of acoustic neuroma

A

Conservative management - monitor if no symptoms or treatment
Surgery - remove the tumour
Radiotherapy - reduce the growth

98
Q

What are the risks of surgical removal of an acoustic neuroma

A

Vestibulocochlear nerve injury - permanent hearing loss and dizziness
Facial nerve injury

99
Q

What is glue ear

A

Recurrent otitis media with effusion

100
Q

Describe cholesteatoma

A

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
Q

Describe the presentation of cholesteatoma

A 
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
Q

Describe the management of cholesteatoma

A

CT head

Surgery

103
Q

Describe the journey of the facial nerve

A

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
Q

What is the function of the facial nerve

A

Motor - muscles of fascial expression, stapedius in inner ear and muscles of neck
Sensory - anterior 2/3 tongue
Parasympathetic -salivary glands and lacrimation

105
Q

How do you distinguish between an UMN and LMN cause of 7th nerve palsy

A

UMN - forehead sparing
LMN - forehead is not spared

Ask the patient to raise their eyebrows

106
Q

List some UMN causes of a facial nerve palsy

A

Stroke
Tumour
If bilateral - pseudobulbar palsy and MND

107
Q

Describe the treatment of Bells palsy

A

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
Q

Describe Ramsay Hunt syndrome

A

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
Q

Describe the treatment of Ramsay-Hunt syndrome

A

Prednisolone
Aciclovir
Lubricating eye drops

110
Q

List the causes of LMN facial nerve palsy

A

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
Q

Where is the most common area for nosebleeds

A

Kiesselbachs plexus in Little’s area

112
Q

What may trigger epistaxis

A 
Nose picking
Trauma
Cold weather
Aggressive nose blowing 
Coagulation disorder 
Anticoagulant medication
Tumours 
Sinusitis
113
Q

Where is bilateral nose bleeding likely to originate

A

Posterior nose - sphenopalatine artery

114
Q

Describe what a patient should do when having a mild nosebleed

A

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
Q

Describe the management of a severe nosebleed

A

Nasal packing - nasal tampons or inflatable packs

Nasal cautery - silver nitrate sticks

116
Q

What is a severe nosebleed

A

Bleeding >15mins
Bilateral bleeding
Haemodynamically unstable

117
Q

What should be prescribed following an acute nosebleed

A

Naseptin - chlorhexidine and neomycin - qds for 10 days - reduce crusting, inflammation and infection

118
Q

When is naseptin CI

A

Peanut or soya allergy

119
Q

Describe sinusitis

A

Inflammation of the paranasal sinuses
May be accompanied by nasal cavity inflammation - rhinosinusitis
Acute <12weeks
Chronic >12weeks

120
Q

Describe the paranasal sinuses

A

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
Q

List some causes of sinusitis

A

Infection - URTI
Allergies and asthmatics
Obstruction - foreign body or polyp
Smoking

122
Q

List the symptoms of acute sinusitis

A 
Recent viral URTI 
Nasal congestion
Nasal discharge
Facial pain or hewadache
Facial pressure
Facial swelling 
Loss of smell
123
Q

What may be found on examination in acute sinusitis

A

Tenderness to palpation over affected areas
Inflammation and oedema of nasal mucosa
Discharge
Fever
Other signs of systemic infection - tachycardia

124
Q

Describe chronic sinusitis

A

> 12 weeks

Associated with nasal polyps - growths of nasal mucosa

125
Q

What are the investigations for persistent sinusitis

A

Nasal endoscopy

CT scan

126
Q

Describe the management of sinusitis

A

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
Q

Describe good nasal spray technique

A

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
Q

What is a question to ask to see if someone has good nasal spray technique

A

Do you taste it in your throat after using it - if yes then it has gone past nasal mucosa and not effective

129
Q

What are nasal polyps

A

Growths of nasal mucosa in the nasal cavity or sinuses
Often grow slowly and may gradually obstruct the nasal passage
Usually bilateral

130
Q

What is a red flag in terms of nasal polyps

A

Unilateral - raise suspicion of tumour

131
Q

Which conditions are polyps associated with?

A

Chronic rhinitus or sinusitis
Asthma
Samter’s triad - nasal polyps, asthma and aspirin intolerance/allergy
CF
Eosinophillic granulomatosis with polyangitis

132
Q

Describe the presentation of nasal polyps

A 
Chronic rhinosinusitis 
Difficulty breathing through the nose
Snoring 
Nasal discharge
Loss of smell (anosmia)
133
Q

How could you examine for nasal polps

A

Nasal speculum
Otoscope with large speculum attached
Nasal endoscopy

134
Q

How do nasal polyps appear

A

Round grey/yellow growths on the mucosal wall

135
Q

How are nasal polyps managed

A

Unilateral - specialist assessment to exclude malignancy
Medical management - intranasal topical steroid drops or spray
Surgical removal - intranasal polypectomy and endoscopic nasal polypectomy

136
Q

Describe obstructive sleep apnoea

A

Pharyngeal airway collapse

137
Q

List some risk factors for obstructive sleep apnoea

A 
Middle age
Male
Obesity
Alcohol
Smoking
138
Q

Describe some features of obstructive sleep apnoea

A 
Episodes of apnoea during sleep 
Snoring
Morning headache
Waking feeling unrefreshed from sleep 
Daytime sleepiness
Concentration problems 
Reduced O2 sat during sleep
139
Q

What can severe obstructive sleep apnoea cause

A

HTN
HF
MI
stroke

140
Q

What scale can be used to assess symptoms of sleepiness associated with obstructive sleep apnoea

A

Epworth sleepiness scale

141
Q

Describe the management of obstructive sleep apnoea

A

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
Q

What are the causes of tonsillitis

A

Bacteria - Group A streptococcus (Streptococcus pyogenes), streptococcus pneumoniae, haemophilus influenza, Moraxella catarrhalis and staphylococcus aureus
Virus

143
Q

Describe the presentation of someone with tonsillitis

A

Sore throat
Fever
Pain on swallowing

Examination - red, inflamed, enlarged tonsils, may have exudates (white patches of pus), may have anterior cervical lymphadenopathy

144
Q

Describe the centor score

A

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
Q

Describe the feverPAIN score

A 
Fever in past 24hrs
Purulence on tonsils
Attended within 3 days
Inflamed tonsils
No cough or coryza
146
Q

Describe the management of tonsilitis

A

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
Q

List some tonsillitis complications

A 
Peritonsillar abscess 
Otitis media
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis
Post-streptococcal reactive arthritis
148
Q

Describe a quinsy

A

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
Q

Describe the presentation of quinsy

A 
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
Q

Which bacteria are commonly involved in quinsy

A

Streptococcus pyogenes (Group A strep)
Staphylococcus aureus
Haemophilus influenza

151
Q

How should quinsy be managed

A

Incision and drainage under GA
Antibiotics - co-amoxiclav (broad spectrum)
Some give dexamethasone to settle inflammation

152
Q

What are the indications for tonsillectomy

A 
>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
Q

How long since tonsillectomy can a post-tonsillectomy bleed occur

154
Q

Describe the management of post-tonsillectomy bleeding

A

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
Q

Describe the anatomy of the neck

A

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
Q

What features do you look for on examination of a neck lump

A 
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
Q

When do you refer a neck lump?

A

Unexplained neck lump in someone >45yo
Persistent unexplained neck lump at any age

2ww referral or urgent direct access investigations - ultrasound

158
Q

What blood tests may be helpful in someone with a neck lump

A

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
Q

What are the 4 causes of lymphadenopathy

A

Reactive - dental infection, tonsillitis or URTI
Infected - TB, HIV, EBV
Inflammatory - sarcoidosis or SLE
Malignancy - lymphoma, leukaemia or mets

160
Q

List some lymph node features which suggest malignancy

A 
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
Q

Describe infectious mononucleosis, its presentation, investigations and treatment

A

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
Q

What happens when you give amoxicillin or cephalosporins to patients with EBV

A

Itchy maculopapular rash

163
Q

What is a goitre

A

Generalised swelling of the thyroid gland

164
Q

What causes a goitre

A 
Graves disease
Toxic multinodular goitre
Hashimotos disease
Iodine deficiency
Lithium
165
Q

What causes individual thyroid lumps

A 
Benign hyperplastic nodules
Thyroid cysts
Thyroid adenoma 
Thyroid cancer - follicular or papillary
Parathyroid tumour
166
Q

Name the 3 types of salivary glands

A

Parotid glands
Submandibular glands
Sublingual glands

167
Q

Why might the salivary glands enlarge

A

Stones
Infection
Tumours

168
Q

Describe carotid body tumour

A

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
Q

What is a sign of a carotid body tumour on USS

A

Splaying of the internal and external carotid arteries - lyre sign

170
Q

How are carotid body tumours treated

171
Q

Give the examination findings of a lipoma

A

Soft
Painless
Mobile
Does not cause skin change

172
Q

Describe a thyroglossal cyst

A

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
Q

Describe branchial cyst

A

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
Q

What type of cancer are head and neck cancers

A

Squamous cell carcinomas of the squamous cells of the mucosa

175
Q

List some risk factors for head and neck cancer

A 
Smoking
Chewing tobacco 
Chewing betel quid (south east asia)
Alcohol 
HPV 16 
EBV
176
Q

Which HPV strains does the HPV vaccine protect against

A

6,11,16,18

177
Q

What are some red flags of head and neck cancers

A 
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
Q

Describe the management of head and neck cancer

A 
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
Q

What is glossitis and what causes it

A

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
Q

Describe angioedema and list its causes

A

Swelling in the tissues due to fluid accumulation

Allergic reactions
ACEi
C1 esterase inhibitor deficiency

181
Q

Describe oral candidiasis and list its causes and management

A

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
Q

Describe geographic tongue and list its associations and management

A

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
Q

What is leukoplakia and its management

A

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
Q

Describe erythroplakia

A

Red lesions - mixture of red and white

High risk of SCC -refer urgently

185
Q

Describe lichen planus and its management

A

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
Q

What causes gingival hyperplasia

A 
Gingivitis
Pregnancy
Vitamin C deficiency 
AML
Medication - CCB, phenytoin and ciclosporin
187
Q

Give some causes of aphthous ulcers

A 
IBD
Coeliac disease
Bechet disease
Vitamin deficiency - iron, B12, folate, vit D 
HIV

Finals (18 decks)

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