ENT Flashcards

Question

What is the most common type of larngeal tumour?

Answer 1

The forgiven body Surgical emphysema (air seen in soft tissue)

Answer 2

Prevertabral space increased in size

Answer 3

ABC Secure airway first Rapid history and careful examination Give O2/Heliox Pharmacological management: adrenaline steroid antihistamine abx Nasopharyngeal/orophrangeal airway Intubation Cricothyroidotomy (needle/surgical) Surgical tracheostomy

Answer 4

Helium and oxygen mixture Helium decreases viscosity of oxygen so it can get to the lungs easier

Answer 5

Oxygen or heliox Adrenaline Steroids Antihistamines Antibiotic is

Answer 6

Space between crycoid cartilage and thyroid cartilage incised or needle inserted during airway emergency

Answer 7

Airway obstruction To protect tracheobronchial tree (e.g. patients who can’t protect their own airway following a stroke) Ventilatory insufficiency (e.g. advanced lung disease) Airway risk during oropharyngeal and laryngeal surgery

Answer 8

Thyroid gland anterior to trachea Thyroid cartilage superior to the cricoid cartilage

Answer 9

Window created between the 2nd and 4th tracheal rings, which is where the tracheostomy is inserted

Answer 10

Larynx moves up Epiglottis comes down and closes off airway Vocal cords close to protect the airway

Answer 11

Epiglottis to the cricoid cartilage

Answer 12

Vagus nerve Recurrent, internal and external laryngeal nerves RLN: Motor with exception of the cricothyroid muscle ILN: Sensory ELN: Motor to cricothyroid muscle

Answer 13

Acute otitis media: Bacterial infection of the MIDDLE EAR Glue ear is otitis media with effusion - not infective but can become infected leading to acute otitis media - commmon cause of childhood deafness

Answer 14

Acute otitis media

Answer 15

preceding URTI, unwell Fever Otalgia (or signs of - tugging at ear) Hearing loss Later otorrhoea (if TM ruptures) - pain will settled once this happens due to resolution of increased pressure in the tympanic cavity

Answer 16

Increased pressure in the tympanic cavity Accumulation of pus within the middle ear cavity (cleft) but eardrum remains intact (pain improves if perforated)

Answer 17

Erythamatous and buldging tympanic membrane If the fluid pressure has perforated the TM a small tear with purulent discharge in the auditory canal may be visible

Answer 18

Conductive

Answer 19

Acute mastoiditis (osteomyelitis) Intracranial infections: cerebellar abcess, extradural abcess, meningitis, temporal lobe abcess Thrombosis of the sigmoid sinuses (vein travels in close proximity to the mastoid air cells) Bacterial Labyrinthitis Facial nerve palsy - facial paralysis Petroys apicitis Gradanigo's sybdrome Citelli abscess Temp. hearing loss OME

Answer 20

Children present unwell Protrusion of the pinna Loss of posterior sulcus Mastoiditis may cause posturicular swelling (abcess formation) Surgical management and IV abx

Answer 21

Paracetomol to control fever - this is the only treatment required usually Sometimes abx required to prevent complications or if complications have occured - (Amoxicillin for 5-7 days first-line, Clarithromycin (in pencillin allergy), Erythromycin (in pregnant women allergic to penicillin)) In severe or recurrent cases myringotomy to insert grommet to release pus

Answer 22

EXAMINE BOTH SIDES Use auriscope

Answer 23

Peanuts, peanut oil invokes inflammation

Answer 24

Right main bronchus Wider and has more direct extension of trachea

Answer 25

Septal haematoma Haematoma becoming in an abcess is not drained/vascular necrosis of cartilage to leading to saddle nose deformity/ infection pain and fever

Answer 26

Surgical drainage +/- abx

Answer 27

URTI leads to infection from anterior ethmoidal space, spreading into the orbit. Lateral deviation of medial recuts Can cause proptosis, loss of colour vision

Answer 28

Just cellulitis then IV abx sufficient Involve ophthalmology, assess colour vision (pressure on optic nerve), if compromised incision and drainage in theatre

Answer 29

Sore throat Pyrexia Neck lymphadenopathy

Answer 30

Glandular fever - hepato/splenomegaly, no contact sports for six weeks, and do not give amampacillin can cause rash

Answer 31

Quinsy - peritonsillar abcess: Buldging of the soft pallette Uvula deviation

Answer 32

Drainage under local anaesthetic

Answer 33

Keep child calm as the airway may close if they cry (laryngospasam) Give wafting oxygen Intubation in theatre to protect airway Emergency tracheotomy in rare cases IVabx broad spectrum

Answer 34

Typically follows URTI, Cervical lymphadenitis Usually bacterial - painful, spinning temp, neutrophils raised Atypical mycobacteria - purple discolouration - painless, bloods may be normal or lymphocytic picture Rarely, TB is cause

Answer 35

Incision and drainage Pus to microbiology

Answer 36

Ring enhancement

Answer 37

Paraphyrangeal abscess Retropharyngeal abscess

Answer 38

Abscess: Retropharyngeal, parapharyngeal Cystic hygroma (lymphangioma) problems Cervical teratoma

Answer 39

Also known as lymphangioma Benign congenital neck swelling Respiratory and feeding problems Soft, compressible Managed by excision once airway secured

Answer 40

Benign congenital neck swelling Firm consistency Extreme cases require tracheostomy

Answer 41

Branches of the internal carotid artery : Anterior and posterior ethmoidal arteries (branches of the opthalmic artery Branches of the external carotid artery: Sphenopalatine Descending palatine Greater and lesser palatine

Answer 42

Branches of the internal carotid artery: Anterior and posterior ethmoidal Branches of the external carotid artery: Septal branches of Sphenopalatine artery Septal branch of the superior labial artery Branch of greater palatine

Answer 43

Little’s area / Kiesselbach’s plexus - in the septum Area of nasal mucosa at the front of nasal cavity This is where all the branches of ICA and ECA supplying the septum meet When mucosa is disrupted and blood vessels are exposed they become prone to bleeding

Answer 44

Idiopathic Traumatic (fracture foreign body picking) Inflammatory (rhinitis) Neoplastic Environmental Iatrogenic (surgery, steroid nasal spray)

Answer 45

Anticoagulants Coagulapathies Hereditary haemorrhaged telangiectasia (abnormality of the blood vessel wall) HTN

Answer 46

Pinch cartilaginous part of nose (soft lower portion) Topical adrenaline +/- cautery with silver nitrate sticks Anterior nasal lacking (merocel tampon, BIPP) Posterior nasal pack (Foley catheter, Brighton balloon) Surgical intervention

Answer 47

Merocel tampon BIPP

Answer 48

Brighton balloon

Answer 49

Anterior bleed visualised with a thudiculum speculum Visualise bleeding point Local anaesthetic spray Control with adrenaline And or Cauterise bleeding point and 5mm radius circle around the bleed

Answer 50

Horizontally, along floor of nose, to avoid damage to skull base

Answer 51

Rigid nasendoscope with electrocautery Sphenopalatine artery ligation Anterior ethmoid artery ligation External carotid artery ligation Embolization of vessels under radiographic control

Answer 52

The Eustation tube (connecting the middle ear to the back of the throat) becomes blocked and causes middle ear secretions to build up in the middle ear space. .Build up of fluid causes loss of hearing in that ear May result in infection (acute otitis media) Otitis media with effusion (glue ear): ET tube dysfunction leading to presence of fluid in the middle ear with intact TM - non infective but can lead to infection Unlike the external ear the epithelium lining the middle ear is respiratory epithelium or pseudostratified collumnar epithelium - regarded as a continutation of the upper respiratory tract and hence susceptible to similar pathogens - streptococcus pneumoniae, haemophillus influenzae, moraxella species (AOM)

Answer 53

Referral to audiometry to establish extent of the hearing loss - pure tone audiogram, tympanogram Conservative management unless persists past 3 months or child has comorbidities (Down's syndrome, clef palate) Surgical: Grommet insertion (ventillation tubes) +/- adenoidectomy Hearing aids

Answer 54

Device inserted by ENT surgeon. This allows fluid from the middle ear to drain through the tympanic membrane to the ear canal. Usually grommets are inserted under general anaesthetic as a day case procedure.

Answer 55

Grommets usually fall out within a year, and only 1 in 3 patients require further grommets to be inserted for persistent glue ear.

Answer 56

On examination, the tympanic membrane will appear dull (Fig. 2) and the light reflex will be lost, indicating fluid in the middle ear. Air fluid level There may also be a bubble seen behind the TM. The external ear will be normal.

Answer 57

Hearing loss - conductive May be sensation of pressure in the ear accompanied by popping or cracking noises Disequilibrium and vertigo (rare)

Answer 58

of chronic inflammatory changes and Eustachian tube dysfunction. The anatomy of the Eustachian tube in younger children is immature, typically short, straight, and wide (only becoming more oblique as the child develops), therefore infection is more likely.

Answer 59

Adults should have mature anatomy of the ET tube The condition is less common in adults, however will occur if there is any blockage of the Eustachian tube, either from infective causes or from occlusive masses

Answer 60

Bottle fed Paternal smoking Atopy (e.g eczema, asthma) Genetic disorders Mucociliary disorders, such as Cystic Fibrosis or Primary Ciliary Dyskinesia Craniofacial disorders, such as Downs Syndrome

Answer 61

In young children this may be noticed as difficulty with attention at school or poor speech and language development

Answer 62

Clinical diagnosis Both pure tone audiometry and tympanometry are nearly always performed in such cases, which will reveal a conductive hearing loss and reduced membrane compliance (a type B tracing) respectively. In adults, a full ENT examination should be performed, including flexible nasoendoscopy (to exclude a post-nasal space mass).

Answer 63

> 3 months of bilateral OME and hearing level in better ear < 25-30dBHL

Answer 64

Potential adenoidectomy

Answer 65

Bacterial infection of the middle ear results from nasopharyngeal organisms migrating via the eustachian tube. The anatomy of the eustachian tube in younger children is immature, typically being short, straight, wide (only becoming more oblique as the child grows), meaning infection is more likely. Common causative bacteria include S. pneumoniae (most common), H. influenza, M. catarrhalis, and S. pyogenes, all common upper respiratory tract microbiota. Common viral pathogens are respiratory syncytial virus (RSV) and rhinovirus.

Answer 66

Children with cleft palate, or with genetic conditions such as Down's syndrome, may be more likely to get glue ear as they often have smaller eustachian tubes that don’t function well.

Answer 67

Risk factors for AOM include age (peak age 6-15 months), gender (more common in boys), passive (parenteral) smoking, bottle feeding, and craniofacial abnormalities

Answer 68

Recurrent AOM is seen more commonly with the use of pacifiers, who are typically fed supine, or their first episode of AOM occurred <6months. AOM is most common in the winter season.

Answer 69

It is important to test and document the function of the facial nerve (due to its anatomical course through the middle ear). Examination should also include checking for any intracranial complications, cervical lymphadenopathy, and signs of infection in the throat and oral cavity.

Answer 70

1. Systemically unwell children not requiring admission 2. Known risk factors for complications, such as congenital heart disease or immunosuppression 3. Unwell for 4 days or more without improvement, with clinical features consistent with acute otitis media 4. Discharge from the ear (ensure swabs are taken prior to commencing antibiotic therapy) 5. Children younger than 2 years with bilateral infections 6. Systemically unwell adult, provided not septic and with no signs of complications

Answer 71

All children under 3 months with a temperature >38c, or aged 3-6 months with a temperature >39c, for further assessment. Also, consider admission for those with evidence of an AOM complication or the systemically unwell child. Patients with a cochlear implant will need to be seen by a specialist and may require inpatient treatment.

Answer 72

The middle ear and mastoid are one cavity, and as such, there will nearly always be a degree of mastoiditis with AOM. However, if the inflammation within the air cells progresses to necrosis and subperiosteal abscess, this is of significant concern.

Answer 73

It presents clinically as a boggy, erythematous swelling behind the ear, which if left untreated progressing to pushing the pinna forward

Answer 74

Any suspected cases should be admitted for IV antibiotics and investigated further via CT head if no improvement is seen after 24 hours of IV antibiotics. There is a higher risk of intracranial spread and meningitis, hence cases are often considered for mastoidectomy as definitive management if there is no improvement with IV antibiotics

Answer 75

The middle ear is the space that sits between the tympanic membrane (eardrum) and the inner ear.

Answer 76

Amoxicillin for 5-7 days first-line Clarithromycin (in pencillin allergy) Erythromycin (in pregnant women allergic to penicillin

Answer 77

Conductive hearing loss relates to a problem with sound travelling from the ENVIRONMENT TO INNER EAR. The sensory system may be working correctly, but the sound is not reaching it. Putting earplugs in your ears causes conductive hearing loss.

Answer 78

Problem with the sensory system or vestibulocochlear nerve in the inner ear

Answer 79

Pinna External auditiory canal Tympanic membrane ET Malleus, incus and stapes (small bones in the middle ear that connect the tympanic membrane) Semicircular canals (responsible for sensing head movement (vestibular system) Cochlea (converting vibration into nervous signal) Vestibulocochlear nerve (transmits nerve signals from the semicircular canals and chochlea to the brain)

Answer 80

Tinnitus (ringing in the ears) Vertigo (the sensation that the room is spinning) Pain (may indicate infection) Discharge (may indicate an outer or middle ear infection) Neurological symptoms Sudden onset (less than 72hrs) requires a thorough assessment to establish the cause

Answer 81

Reduces risk of dementia (hearing loss increases) Improved speech and language development in children

Answer 82

Information about the position of the head is used to coordinate balance and the vestibulo-ocular reflex. The vestibulo-ocular reflex (also called the oculocephalic reflex) allows images on the retina to be stabilised when the head is turning by moving the eyes in the opposite direction. It can be demonstrated by holding one finger still at a comfortable distance in front of you and twisting your head from side to side whilst staying focused on the finger. Simple three neuron system: vestibular nerve to vestibular nuclei to ocular muscle nuceli to eye muscles The ability to remain focused upon and object as the head is turned rapidly from or towards the object and maintain balance Lateral semicircular canals engaged when head moved sideways (horizontal acceleration) action potentials increase in nerve on side the head turns, decreased input on the contra lateral side Eyes move to contra lateral side Gain: ratio of the lapse between one command in another The gain in this reflex is nearly 1

Answer 83

Postural hypotension - drop of more than 20mm in systolic BP, loss of blood pressure control with age and polypharmacy OA

Answer 84

In the opposite direction to the defect Eyes move wrong way as no input from the vestibular nerve when head is turned in direction of defect (loss is vestibulocular reflex)

Answer 85

Coronal Axial Saggital

Answer 86

Soft tissue windows - expansion of the greys pertaining soft tissue Bone windows - detail of the bone including density

Answer 87

Trauma - same size inferior terminal on both sides of CT Developmental - hypoplastic terminal and enlarged terminal on CT

Answer 88

Loss of cartilage (secondary to repeated trauma for example) Repaired with costal cartilage

Answer 89

Above the larynx e.g. large adenoids and tonsils, oropharngeal mass, etc Snoring - obstruction is above the larynx e.g. nose, tongue, younger base, back of nose

Answer 90

Obstruction is at level of the vocal cords or below Subglottic stenosis

Answer 91

Inflammation of the nose and paranasal sinuses characterised by two or more symptoms, one of which should be nasal blockage/discharge/congestion or nasal discharge - anterior or posterior +/-Facial pain or pressure +/-reduction/loss of smell

Answer 92

Acute: resolution within 12 weeks VS chronic with and without nasal polyposis Allergic vs non allergic

Answer 93

Nasal blockage/congestion and discharge Loss/reduction of smell Itchy runny eyes Permenant/intermittent Time of day Jobs/hobbies Pets- Cats - wash them with grooming glove and damp water!

Answer 94

Type 1 hypersensitivity reaction to allergens Increased permeability of capillaries Mucosal infiltration of oesinophils and oedema

Answer 95

Conservative - allergy avoidance Medical - nasal sprays, long course of macrolides (calithromycin, up to 12 weeks) Surgical management of sinus: septoplasty, turbinate surgery (SMD reduction of inferior turbinates) Nasal polypectomy Functional endoscopic sinus surgery (FESS)

Answer 96

Use local anesthetic lignocaine with adrenaline on cotton wool Don’t simply spray Don’t allow silver nitrate to drop out the nose Don’t use silver nitrate for more than 20 seconds each side

Answer 97

Hearing loss (sensioneural) Vertigo Tinnitus

Answer 98

Pain Discharge - scant serous Late hearing loss (conductive hearing loss)

Answer 99

Wash hands, intro Tenderness Which ear is better Inspect pinna, mastoid area, Otoscopy: external auditory canal, tympanic membrane Hearing test Cranial nerve VII, co-ordination and Romberg

Answer 100

Pure tone audiogram Tympanogram CT MRI

Answer 101

Air conduction should be better than bone conduction and persiist) - POSITIVE TEST Begin by striking a 512 Hz tuning fork against your knee or elbow. Place the base against the patient’s mastoid process (for those who like to watch it on a video, check one out here) Allow it to stay there for 2-3 seconds to allow them to appreciate the intensity of the sound then promptly raise the fork off the mastoid process and place the vibrating tips about 1cm from their external auditory meatus Leave it there for a few seconds before taking the tuning fork away from their ear Ask the child whether the sound was louder at the beginning (when it was held against their mastoid) or whether it became louder (when it was held in front of their ear). If bone conduction is better than air conduction (negative test) indicates conductive hearing loss

Answer 102

Should not localise Localises to affected ear in conductive hearing loss Localises to the unaffected ear in sensioneural hearing loss As in Rinne’s test, begin by striking the 512 Hz tuning fork against your knee or elbow Then, place the base of the fork in the midline, high on the patient’s forehead Ask whether they hear the sound in the midline or if the sound lateralises to either the affected or good ear.

Answer 103

Collection of blood between skin and cartillage, can lead to avascular necrosis and change in shape of the ear (cauliflour ear) Aspirate x2 in sterile conditions and apply compression bandage (review in 24 hours)

Answer 104

Otitis externa is inflammation of the skin in the external ear canal, also known as swimmers ear.

Answer 105

Water exposure (swimming) Removal of earwax (as it is protective) Ear canal trauma (ear plugs, cotton buds) Immunosupression

Answer 106

Bacterial infection Fungal infection (e.g., aspergillus or candida) Eczema Seborrhoeic dermatitis Contact dermatitis

Answer 107

Pseudomonas aeruginosa (gram-negative aerobic rod-shaped bacteria. It likes to grow in moist, oxygenated environments, also causes resp problems in CF pts) Staphylococcus aureus

Answer 108

Ear pain (severe due to stretching of nerve fibres with inflammation) Discharge (serous) Itchiness Conductive hearing loss (if the ear becomes blocked) *Tympanic membrane is intact - if not points to OM

Answer 109

Erythema and swelling in the ear canal Tenderness of the ear canal Pus or discharge in the ear canal Narrowing or ear canal TM may be red but often obstructed by debris (earwax, discharge) Lymphadenopathy (swollen lymph nodes) in the neck or around the ear

Answer 110

The tympanic membrane may be obstructed by wax or discharge It may be red if the otitis externa extends to the tympanic membrane. If it is ruptured, the discharge in the ear canal might be from otitis media rather than otitis externa.

Answer 111

Otomize spray (Neomycin/Dexamethasone/Acetic Acid)

Answer 112

Mild otitis externa may be treated with acetic acid 2% (available over the counter as EarCalm). Acetic acid has an antifungal and antibacterial effect. This can also be used prophylactically before and after swimming in patients that are prone to otitis externa. Topical toilet

Answer 113

Forehead sparing - upper motor neuron

Answer 114

Moderate otitis externa is usually treated with a topical antibiotic and steroid, for example: Neomycin, dexamethasone and acetic acid (e.g., Otomize spray) Neomycin and betamethasone Gentamicin and hydrocortisone Ciprofloxacin and dexamethasone

Answer 115

Typmanic membrane perforation or when it cannot be visualised Aminoglycosides (e.g., gentamicin and neomycin) are potentially ototoxic, rarely causing hearing loss if they get past the tympanic membrane. Therefore, it is essential to exclude a perforated tympanic membrane before using topical aminoglycosides in the ear. (This can be difficult if the patient has discharge, swelling or wax blocking the ear canal. Patients with a blocked ear canal may need to be seen by ENT to microsuction the debris from the canal and visualise the tympanic membrane. They will also require a referral if the canal is so blocked or swollen that topical treatments cannot reach the site of infection.)

Answer 116

Patients with severe or systemic symptoms may need oral antibiotics (e.g., flucloxacillin or clarithromycin) or discussion with ENT for admission and IV antibiotics.

Answer 117

Children have narrow airways and respond poorly to small changes in radius

Answer 118

Children have narrow airways and respond poorly to small changes in radius Obligate nasal breaters Larger toungues Laryncy is more cranial and anterior Subglottiss (cricoid) is the narrowest part of the airway (as opposed to the vocal cords in adults)

Answer 119

clotrimazole ear drops

Answer 120

Diabetes Immunosuppressant medications (e.g., chemotherapy) HIV

Answer 121

Malignant otitis externa is a severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull. Malignant otitis externa is usually related to underlying risk factors for severe infection

Answer 122

persistent headache, severe pain and fever History of chronic ear discharge despite topical treatment Deep seated ear pain Sometimes cranial nerve palsies (CNVII) - facial nerve

Answer 123

Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along) is a key finding that indicates malignant otitis externa.

Answer 124

Admission to hospital under the ENT team IV antibiotics Imaging (e.g., CT or MRI head) to assess the extent of the infection

Answer 125

Facial nerve damage and palsy Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves) Meningitis Intracranial thrombosis Death

Answer 126

Adenotonsillectomy Sleep study

Answer 127

recurrent attacks of vertigo, hearing loss, tinnitus, and the sensation of aural fullness.

Answer 128

Topical toilet and steroids Eczema

Answer 129

Cold water swimmers

Answer 130

Benign neoplasia of the bone, may be visable on otoscopy of external ear if involved

Answer 131

Cholesteatoma Although often no treatment required

Answer 132

Dry: may need no treatment Recurrent infection: can be repaired

Answer 133

Onset Duration Exaccerbating/relieving factors Fever H/O coughing/choking (FB) Change in voice Swallowing/feeding Weight gain/loss History of prolonged intubation

Answer 134

Humidified O2 Nebulised adrenaline Systemic steroids Theatres to secure airway - intubation/tracheostomy if not responding

Answer 135

Recurrent respiratory papillomatosis (RRP) is a disease in which benign (noncancerous) tumors called papillomas grow in the air passages leading from the nose and mouth into the lungs (respiratory tract). Tracheal tug, inspiratory stridor and subcostal recession may be present. Microlaryngobronchoscopy, surgical debridement

Answer 136

A hallucination of movement of oneself or one's surroundings. The movement is often rotatory (e.g. pt may feel floor is tilting)

Answer 137

On held tilt: Benign positional paroxysmal vertigo (BPPV) Hearing loss and tinnitus: Acute labyrinthitis No hearing loss nor tinnitus: Vestibular neuritis Unilateral hearing loss progressing to involve CN 5,6,9,10 and the ipsilateral cerebellum: Acoustic neuroma Sensioneural hearing loss, tinnitus, feeling of aural fullness: Meniere's disease Facial nerve palsy (+/- tinnitus, hearing loss): Ramsay Hunt syndrome Ototoxicity features: aminoglycoside abx, loop diuretics

Answer 138

Heriditary haemorrhagic telangiectasia (Osler Weber Rendu disease - telangiectasia on skin and mucous membranes, malformations within the nasal mucosa prone to bleeding)

Answer 139

After 5 days

Answer 140

An ear wick may be used if the canal is very swollen, and treatment with ear drops or sprays will be difficult. An ear wick is made of sponge or gauze. They contain topical treatment for otitis externa (e.g., antibiotics and steroids). Wicks are inserted into the ear canal and left there for a period of time (e.g., 48 hours). As the swelling and inflammation settle, the ear wick can be removed, and treatment can continue with drops or sprays.

Answer 141

Otitis externa - 'swimmers ear'

Answer 142

Possible trauma/perforation of TM Likely to further impact earwax Risk of ear canal trauma - OE

Answer 143

Watch + wait Perform otoscopy and audiogram Water precautions, keep dry, no more cleaning, avoid FB in ear Review pt after 4 weeks If no resolution after 6 months consider surgical intervention - myringoplasty

Answer 144

Myringoplasty

Answer 145

TM perforation

Answer 146

Topical eardrops empirically (e.g. Gentamycin) Swab any discharge in resistant cases Microsuction of pus/debris - allows eardrops to reach source of infection Wick (severe) Topical antifungals if fungal MOE- aggressive IVAbx therapy

Answer 147

Upper lateral surface - CNV3 - auriculotemporal nerve Lower lateral surface - C3 - greater auricular nerve Superior medial surface - C/2 C3 - less occiputal nerve Auricular branch of vagus - external auditory meatus

Answer 148

Laceration: simple primary closure of the skin with sututres after adequete cleaning is all that is required usually, it is important to ensure that any exposed cartillage is covered with skin - otherwise seek plastics Bites: significant risk of infection from skin commensals or oral commensals - require hx to ascertain likely organisms involved in potential infection - MUST LEAVE WOUND OPEN - treatment includes wound irrigation and topical abx Hematoma: Pinna haeamtoma causes disruption in blood supply to the cartillage which would normally obtain nutrients via diffusion from vessels in the overlying perichondrium (hence disruption can lead to avasucluar necrosis - risk of cauliflower ear) REQUIRES URGENT DRAINAGE AND DRESING TO PREVENT RE-ACCUMULATION Perforation of Tympanic membrane - direct or indirect trauma or otitis media - pain, possible conductive deafness Haemotympanum (blood in middle ear): May be associated with temporal bone fracture. Can be seen through tympanic membrane and is associated with conductive hearing loss. Conservative treament with follow up to ensure no residual hearing loss from damage to ossicles

Answer 149

Tympanic membrane perforation and haemotypanum (blood in middle ear) - conductive hearing loss

Answer 150

Haemotympanum

Answer 151

Chronic: squamous (inactive/active) or mucosal Acute

Answer 152

Amoxicillin for 5-7 days first-line Clarithromycin (in pencillin allergy) Erythromycin (in pregnant women allergic to penicillin)

Answer 153

Squamous: Cholesteatoma Mucosal: Chronic discharge from the middle ear through a TM prtforation Associated with chronic ear discharge and often a conductive hearing loss , can also be associated with complications associated with spread of the disease within the temporal bone and intracranially?

Answer 154

Squamous: Retraction pocket which may develop into cholesteatoma Mucosal: TM perforation without active infection or discharge

Answer 155

Active: Cholesteatoma Inactive: Retraction pocket which may develop into active disease (cholesteatoma) Active develops when keratinized squamous cells are introduced to the middle ear from a retraction pocket or perforation

Answer 156

Active: Perforated TM with discharge Inactive: Perforated TM without discharge or infection Thought to develop from an episode of AOM where after TM rupture there is failure to heal

Answer 157

Depends on type - active squamous disease (cholesteatoma) requires surgery to clear No cholesteatoma (often not known if this is the case when there is active ear discharge, initially assume there is not and opt for medical treatment and then surgicl if fails ) medical treatment: topical abx drops and an aural toilet

Answer 158

When there is known cholesteatoma or ?cholesteatoma (chronically discharging ear that is not responding to medical therapy): COMPLPETE clearence of cholesteatoma Often requires surgery to the mastoid bone (mastoidectomy) as the cholesteatoma will often grow from the middle ear into the mastoid bone. If no cholesteatoma is found during surgery (mucosal COM) repair of perforation and ensure good ventillation of the middle ear and mastoid bone (no need to remove every last trace of disease as in cholesteatoma)

Answer 159

Facial nerve palsy Altered taste from damage to chorda typani CSF leak Tinnitus Vertigo Compete loss of hearing in the operated ear

Answer 160

Accidental damage to the chorda typani

Answer 161

Acute otitis medial - buldging red tympanic membrane

Answer 162

A cholesteatoma (an abnormal collection of skin cells in the middle ear) They're rare but, if left untreated, they can damage the delicate structures inside the ear ear that are essential for hearing and balance.

Answer 163

“Pearly-grey”, translucent and slightly shiny. Can visualise the pars tensa, pars flacida, cone of light and lateral process of maleoulus

Answer 164

Cone of light/light reflex Pars flacida Pars tensa Lateral process of malleolus

Answer 165

Normal TM Pearly grey, translucent, slightly shiny Not budlging Light reflex present Able visualise the malleus through the membrane

Answer 166

Squamous epithelial cells originate from the outer surface of the tympanic membrane Negative pressure in the middle ear, caused by Eustachian tube dysfunction, causes a pocket of the tympanic membrane to retract into the middle ear. Essentially, a small area of the tympanic membrane gets sucked inwards. The squamous epithelial cells of this pocket continue to proliferate and grow into the surrounding space, bones and tissues. It can damage the ossicles (the tiny bones of the middle ear involved in hearing), resulting in permanent hearing loss.

Answer 167

Permenant conductive hearing loss secondary to damage of the ossicles Infection Pain Vertigo Facial nerve palsy Tinnitus

Answer 168

A CT head can be used to confirm the diagnosis and plan for surgery. MRI may help assess invasion and damage to local soft tissues.

Answer 169

No but may lead to acute otitis media which is (up until TM perforates)

Answer 170

Otoscopy: Tympanic membrane is retracted and usually has a yellowish hue. There may also be air bubbles or increased opacity of TM Posterior rhinoscopy (to visualize the post nasal space) - tumours in this area can cause ET dysfunction leading to OME - especially important in adults with unilateral OME Tympanogram: Flat (Type B) Tracing Pure tone audiogram: conductive hearing loss Rinne's: abnormal in affected ear Weber's: localizes to effected ear (if unilateral)

Answer 171

Associated speech delay Reports of problems at school

Answer 172

Otitis media with effusion (GLUE EAR) Tympanic membrane is retracted and usually has a yellowish hue. Air bubbles Increased opacity of the tympanic membrane.

Answer 173

In adults, especially when otitis media with effusion is unilateral - tumours in the postnasal space, as unilateral adult serous effusion is considered a nasopharyngeal tumour until proven otherwise Posterior rhinoscopy

Answer 174

OME is caused by the build-up of a viscous inflammatory fluid within the middle ear, resulting in a conductive hearing impairment.

Answer 175

Foul discharge from the ear Unilateral conductive hearing loss

Answer 176

Meaning abnormal test - bone conduction is better than air conduction (normal hearing should mean that air conduction is best) Suggests conductive hearing loss If the patient has negative or abnormal Rinne negative, air vibrations are not being transmitted across the external auditory canal, the tympanic membrane, the ossicular chain, or the oval window.

Answer 177

Breach of the otic capsule bone causing dizziness on pressure change transmitted from the middle ear to the vestibular system

Answer 178

Conductive Debris or erosion by cholestotoma of the ossicles

Answer 179

BPPV - benign paroxysmal positional vertigo

Answer 180

Dix Hallpike maneuver

Answer 181

When affected ear is undermost, the following will be observed: Latency Torsional geotropic nystagmus Fatigue Habituation on repeating the test

Answer 182

Epley manouvere

Answer 183

When performing the Dix-Hallpike test, make sure to warn the patient in advance of each step, so that they know what to expect: 1. Ask the patient to sit upright on the examination couch. 2. Adjust the patient’s position so that when supine, their head will hang over the edge of the bed, allowing for head extension below the horizontal plane. 3. Position yourself standing behind the patient. 4. Turn the patient’s head 45º to one side. 5. Whilst supporting the neck, move the patient from their sitting position to a supine position in one brisk smooth motion, ensuring their head hangs over the bed 30º below the horizontal plane. Ask the patient to keep their eyes open throughout this process. 6. Inspect the patient’s eyes carefully for evidence of nystagmus for at least 30 seconds. 7. If no nystagmus is observed, the test is then complete for that side and you should carefully help the patient sit back up. 8. After a short break, the test should be repeated on the other side, turning the patient’s head in the opposite direction during step 4.

Answer 184

1. The Epley manoeuvre typically follows on from a positive Dix-Hallpike test, so we will assume the patient is still positioned lying flat, with the head hanging over the end of the bed, turned 45º away from the midline. 2. Turn the patient’s head 90º to the contralateral side, approximately 45º past the midline, still maintaining neck extension over the bed. Keep the patient in this position for 30 seconds. 3. Whilst maintaining the position of the patient’s head, ask the patient to roll onto their shoulder (on the side their head is currently turned towards). 4. Once the patient is on their side, rotate the patient’s head so that they are looking directly towards the floor. Maintain this position for 30 seconds to a minute. 5. Sit the patient up sideways, whilst maintaining head rotation. 6. Once the patient is sitting upright, the head can be re-aligned to the midline and the neck can be flexed so that the patient is facing downwards (chin to chest). Maintain this position for 30 seconds. The entire procedure can be repeated 2-3 times if needed, however, this will depend on whether the patient is able to tolerate further manoeuvres (as they often precipitate vertigo).

Answer 185

Is the room spinning around the patient? When did it start? Eposodic? How long does it last How often does it happen Positional? - lying down, head turning Other specific triggers Associated hearing loss Associated tinnitus Loss of conciousness with episodes If it has happened before - resolution: spontaneous? treatment?

Answer 186

The Dix-Hallpike manoeuvre is indicated for patients with paroxysmal vertigo in whom BPPV is considered in the differential diagnosis. These patients experience vertigo in brief episodes lasting less than one minute with changes of head position and return to normal between episodes. Light-headedness or a sensation of nausea might last longer than one minute, however, if the sensation of movement persists for more than one-minute alternative diagnoses should be considered. ¹

Answer 187

Fractured odontoid peg Recent cervical spine fracture Atlanto-axial subluxation Cervical disc prolapse Vertebrobasilar insufficiency Recent neck trauma

Answer 188

Carotid sinus syncope Severe neck or back pain Recent stroke Cardiac bypass surgery within the last 3 months Rheumatoid arthritis affecting the neck Recent neck surgery Cervical myelopathy Severe orthopnea

Answer 189

Disease affecting the ossicles in the middle ear with both genetic and environmental components. Remoddling of small bones in ear Mature bone is gradually replaced with woven bone and symptoms begin as the stapes footplate becomes fixed to the oval window. Most patients develop bilateral disease and most are female (2:1)

Answer 190

Autosomal dominant tranmission

Answer 191

Before 40 years

Answer 192

The auditory ossicles are the tiny bones in the middle ear that transmit sound vibrations from the tympanic membrane to the cochlea. They are the malleus, incus and stapes. The stapes is connected to the oval window (fenestra ovalis) of the cochlea, where it transmits vibrations into the cochlea, which converts them into sensory signals. In patients with otosclerosis, these tiny bones in the middle are affected by abnormal bone remodelling and formation. Mature bone is gradually replaced with woven bone. This mainly affects the base of the stapes, where it attaches to the oval window, causing stiffening and fixation and preventing it from transmitting sound effectively. It causes conductive hearing loss and symptoms begin as the stapes footplate becomes fixed to the oval window.

Answer 193

Progressive hearing loss (more so with lower pitched sounds - women are easier to hear, conductive type hearing loss) Tinnitus Patient may speak quietly (bone conduction of their voice makes the patient think they are speaking loudly) Patients in early disease may report improved hearing in noisy surroundings Family history of hearing loss Pts presenting before age of 40

Answer 194

Worse with lower pitch/frequency (male voices harder to hear) Better in noise enviornments (early disease) Conductive hearing loss with intact sensory hearing so patient experiences their voice being loud compared to the environment (due to bone conduction of their voice) - patients will talk quietly

Answer 195

Otoscopy: normal usually, ocassionally Schwatze's sign (pink hue to tympanic membrane) Tympanogram: Normal type A trace - reduced admittance of sound as TM is stiff and non compliant and doesn't absorb sound, reflecting most of it back Pure tone audiogram: conductive hearing loss, characteristic ''Carhart notch'' at 2kHz Weber's: Localises to worst affected ear but may be normal if even bilateral disease Rinne's: Negative - conductive hearing loss - sound easily heard when fork applied to mastoid process (bone conduction > air conduction) High resolution CT: Can detect bondy changes associated with otosclerosis although not always required

Answer 196

Rare sign in otosclerosis - pink hue to tympanic membrane

Answer 197

Conservative - hearing aids Surgical (stapedectomy or stapedotomy) generally scuessful with potential to restore hearing to normal - involves lifting the tympanic membrane and some of the surrounding skin out of the way to access the middle ear through the canal

Answer 198

STAPEDECTOMY - removal of the entire stapes bone, replacing it with a prosthesis which attacthed to the oval window and hooks around the incus (transmitting sound from incus to choclea the same way the stapes normally would) STAPEDOTOMY - removal of part of stapes bone and leaving the base (footplate) attatched to the oval window. A small hole is made in the base of the stapes for the prosthesis to enter, which is added to transmit sound from the incus to cochlea

Answer 199

Petrous part of the temporal bone

Answer 200

1. The vestibule and semicircular canals. 2. The cochlea

Answer 201

Filled with endolymph Surrounded by bony labyrinth Suspended in perilymph Contained within the bony labyrinth

Answer 202

The perilymphatic system communicates with the subarachnoid space and CSF via the cochlear aqueduct Perilymph fluid resembles CSF, and endolymph fluid resembles intracellular fluid

Answer 203

INtracellular fluid

Answer 204

Responsible for perception of hearing - Articulated with oval window causing movement of perilymph and pressure change compensated by the round window - Vibrations are transmitted through the tectorial membrane -Low frequency sounds detected at apex (of the cochlea) - High frequency sounds detected at base (of the cochlea) -Movement of the tectorial membrane causes movement of the hair cells and subsequent depolarization of neuronal fibers - allowing for perception of sound - Transmission of information occurs via the cochlear nerve - Has 2.5 turns around a bony core- the modiolus

Answer 205

Semicircular canals (x3 at 90 degrees to eachother, detect movement in a rotational fashion) Utricle (detects linear/horizontal movement) Saccule (detects vertical movement) (Utricle – Hair cells point Up – Detect linear/horizontal movement Saccule – Hair cells stick out to the Side – Detect vertical movement)

Answer 206

Stroke Migraine Neoplasms Demyelination e.g. MS Drugs

Answer 207

BPPV Menieres disease Vestibular neuronitis

Answer 208

Crystals of calcium carbonate (otoconia) become displaced into the semicircular canals (most often posterior semicircular canal) due to a viral infection, head trauma, ageing or without clear cause Otoliths (crystals) disrupt the normal flow of endolymph through the canals, causing abnormal stimulation of hair cells giving the hallucination of movement - ie. triggering episodes of vertigo

Answer 209

Attacks of vertigo that settle after around 20-60 seconds Often episodes occur over several weeks and then resolve but can reoccur weeks or months later Triggers: lying down, turning head

Answer 210

BRANDT-DAROFF EXERCISES Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.

Answer 211

An acoustic neuroma, also known as a vestibular schwannoma, is a tumour of the vestibulocochlear nerve (cranial nerve VIII). They are classically benign tumours that are slow-growing but may become symptomatic through local mass effect, and in some cases may be life-threatening if they extend into the cerebellopontine angle, where they behave as a space-occupying lesion and can lead to hydrocephalus. The most common presentation is unilateral sensorineural hearing loss, with other symptoms including tinnitus, dizziness and balance problems. With enlarging tumours, compression of local structures may lead to facial paraesthesia/sensory loss, ear pain, ataxia, and in severe cases there may be evidence of raised intracranial pressure (e.g. headache).

Answer 212

NIHL usually develops after long periods of noise exposure and is usually bilateral in nature. NIHL typically causes sensorineural hearing loss in both ears. The ability to perceive higher sound frequencies is lost first, later followed by impairment of lower frequency perception.

Answer 213

Weber’s test does not lateralise if the level of sensorineural loss is equal bilaterally Rinnes test will confirm that air conduction is greater than bone conduction in both ears (in the absence of conductive hearing loss). Pure tone audiometry will highlight a bilateral sensorineural hearing loss (i.e. bone and air conduction thresholds in both ears will be above 25dB and within 10 dB of one another).

Answer 214

Normal hearing can be defined as the ability to detect noises between 0-25dB.

Answer 215

Antibiotics are generally recommended in patients with AOM If they are: <6 months of age 6 months to 2 years with bilateral AOM >2 years or older who appear toxic have persistent otalgia for > 48 hours have temperature > 39 C in the past 48 hours have bilateral AOM

Answer 216

Ofloxacin otic drops are used first-line in both bacterial cases of otitis externa when the tympanic membrane is intact

Answer 217

Hearing loss (initally fluctuates, associated with vertigo attacks, gradually becomes oermenant, sensorineural, unilateral, low frequencies affected first) Vertigo Tinnitus (unilateral) Aural fullness Drop attacks (unexplained falls without LOC) Imbalance which can persist after episodesnresolve

Answer 218

Long term inner ear disorder that causes recurrent attacks of vertigo, tinnitus hearing loss and aural fullness. Excessive build up of ENDOLYMPH in the LABYRINTH of the INNER EAR, causing a higher pressure than normal and disrupting the sensory signal. This increased pressure of the endolymph is called endolymphatic hydrops.

Answer 219

Initially patients are well between attacks As disease progresses patients may start to develop reduced vestibular function on the side of the disease and a progressive sensioneural hearing loss. Episodes tend tom come in clusters over several weeks followed by prolonged periods (months) without symtpoms. Over time the disease often burns itself out so that the patient doesn’t suffer from acute vertigo but will have reduced hearing and maybe generally unbalanced. If the vestibular system of the other ear is working well this can compensate for the bad ear to improve the overall balance but this can take time especially in the elderly.

Answer 220

20 minutes to several hours

Answer 221

BPPV: hearing unaffected, vertigo lasts seconds, no associated symptoms except nausea, triggered by movement Ménèires: hearing loss and tinnitus, lasts up to several hours and no less than 20 mins, aural fullness, drop attacks and persistent imbalance, spontaneous nystagmus NO MOVEMENT OR POSTURAL TRIGGER

Answer 222

Hearing Initially fluctuates Hearing loss and tinnitus Associated with vertigo attacks Hearing loss and tinnitus gradually become permenant Sensioneural hearing loss Unilateral Affecting low frequencies first (male voices worse)

Answer 223

Spontaneous nystagmus (unidirectional)

Answer 224

Clinical diagnosis made by ENT specialist Audiology assessment required Rinnes positive (as sensioneural) Webers lateralises to unaffected ear Pure tone audiometry: sensioneural Electronystagmogram (ENG) to help guide cause of vertigo MRI/CT head can rule out other causes of vertigo - will not show changes in Ménière’s

Answer 225

Acute attacks (no more than 3 days use): Prochlorperazine Antihistamines (cyclizine,cinnarizine and Promethazine) Prophylaxis of attacks: Betahistine Thiazide diuretics e.g. bendrofluazide Dietary – reduce salt, chocolate, alcohol, caffeine, chinese food Surgical o Grommet insertion o Dexamethasone middle ear injection o Endolymphatic sac decompression o Vestibular destruction using middle ear injection of gentamicin o Surgical labyrinthectomy – very rarely required

Answer 226

Stages 1, 2, 3 and 4 1 and 2 are considered early reversible disease susceptible to remission 3 and 4 are considered fixed or not reversible

Answer 227

40-50 years old

Answer 228

The typical patient is aged 40-60 years presenting with a gradual onset of: Unilateral sensorineural hearing loss (often the first symptom) Unilateral tinnitus Dizziness or imbalance A sensation of fullness in the ear If tumour grows large enough may be a facial nerve palsy

Answer 229

Bilateral acoustic neuromas almost certainly indicate neurofibromatosis type II.

Answer 230

Acoustic neuromas (vestibular schwannomas) are benign tumours of the Schwann cells (PNS cells providing myelin sheath around neurones) surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear. They occur at the cerebellopontine angle and are sometimes referred to as cerebellopontine angle tumours.

Answer 231

Audiometry: sensioneural pattern of hearing loss Brain imagaing (MRI or CT): establish dgx and features of the tumour

Answer 232

ENT specialist management options include: Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate Surgery to remove the tumour (partial or total removal) Radiotherapy to reduce the growth

Answer 233

Vestibulocochlear nerve injury, with permanent hearing loss or dizziness Facial nerve injury, with facial weakness

Answer 234

Vestibular neuronitis describes inflammation of the vestibular nerve. This is usually attributed to a viral infection.

Answer 235

In this condition inflammation in the inner ear causes severe incapacitating vertigo lasting several days associated with nausea and vomiting. During an attack patients will have horizontal nystagmus but an otherwise normal neurological examination.

Answer 236

Posterior circulation infarction (neurological signs present) Labrinythitis (hearing loss present) In VN no neurological signs (other than horizontal nystagmus) and no hearing loss

Answer 237

IV fluids (Patients may need admission if they are becoming dehydrated due to severe nausea and vomiting For peripheral vertigo, short-term options for managing symptoms include: Prochlorperazine Antihistamines (e.g., cyclizine, cinnarizine and promethazine) (NICE advise that symptomatic treatment can be used for up to 3 days. More extended use may slow down the recovery) NICE also recommend referral if the symptoms do not improve after 1 week or resolve after 6 weeks, as they may require further investigation or vestibular rehabilitation therapy (VRT) - (Cawthorne-Cooksey exercises)

Answer 238

Symptoms are most severe for the first few days, after which they gradually resolve over the following 2-6 weeks. (There is often an associated long term vestibular deficit after the acute episode which can lead to a generalized unsteadiness after the acute episode for a number of weeks while the brain compensates for this) Benign paroxysmal positional vertigo (BPPV) may develop after vestibular neuronitis.

Answer 239

Vestibular neuronitis refers to inflammation of the vestibular nerve. A viral infection may trigger this inflammation. It distorts the signals travelling from the vestibular system to the brain, confusing the signal required to sense movements of the head. This results in episodes of vertigo, where the brain thinks the head is moving when it is not. Cochlea nerve is not affected and hence there is no hearing loss

Answer 240

Rotation of the head

Answer 241

Gravity and acceletation

Answer 242

Head impulse test

Answer 243

The head impulse test involves the patient sitting upright and fixing their gaze on the examiner’s nose. The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose. The head is slowly moved back to the centre before repeating in the opposite direction. Ensure they have no neck pain or pathology before performing the test.

Answer 244

Normal: eyes remain fixed on examiners nose - no problem with vestibular system - either no vertigo or central cause Abnormal: Eyes will saccade (rapidly move back and forth) and will eventually fix back on examiner - abnormally functioning vestibular system - ie. vestibular neuronititis, labrythitis

Answer 245

Labyrinthitis refers to inflammation of the bony labyrinth of the inner ear, including the semicircular canals, vestibule (middle section) and cochlea. The inflammation is usually attributed to a viral upper respiratory tract infection. Rarely labyrinthitis can be caused by a bacterial infection. This may be an inflammatory response to a nearby infection or the result of bacteria or bacterial toxins entering the labyrinth. It is usually secondary to otitis media or meningitis.

Answer 246

(Vestibular neuronititis+hearing loss and tinnitus) Hearing loss Tinnitus Acute onset vertigo Possible nystagmus Patients may have symptoms associated with the causative virus, such as a cough, sore throat and blocked nose. May arise as a compliaction of AOM

Answer 247

A clinical diagnosis is based on history and examination findings. It is important to exclude a central cause of the vertigo. The head impulse test can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g., vestibular neuronitis or labyrinthitis).

Answer 248

Management is the same as with vestibular neuronitis, with supportive care and short-term use (up to 3 days) of medication to suppress the symptoms. Options for managing symptoms are: Prochlorperazine Antihistamines (e.g., cyclizine, cinnarizine and promethazine) Antibiotics are used to treat bacterial labyrinthitis. The underlying infection (e.g., otitis media or meningitis) needs appropriate treatment.

Answer 249

Patients rarely have lasting symptoms, including permanent hearing impairment. This is more common after bacterial labyrinthitis, particularly associated with meningitis (All patients with meningitis are offered audiology assessment as soon as they are recovered to assess for hearing impairment. )

Answer 250

Sudden sensorineural hearing loss (SSNHL) is defined as hearing loss over less than 72 hours, unexplained by other causes. This is considered an otological emergency and requires an immediate referral to the on-call ENT team. The diagnosis is made when someone rapidly loses their hearing, and no conductive cause can be found. With SSNHL, hearing loss is most often unilateral. It may be permanent or resolve over days to weeks.

Answer 251

Conductive causes of rapid-onset hearing loss (not classed as SSNHL) include: 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

Answer 252

Most cases (90%) of SSNHL are idiopathic, meaning no specific cause is found. Other causes of SSNHL include: Infection (e.g., meningitis, HIV and mumps) Ménière’s disease Ototoxic medications Multiple sclerosis Migraine Stroke Acoustic neuroma Cogan’s syndrome (a rare autoimmune condition causing inflammation of the eyes and inner ear)

Answer 253

Audiometry is required to establish the diagnosis. A diagnosis of SSNHL requires a loss of at least 30 decibels in three consecutive frequencies on an audiogram. MRI or CT head may be used if a stroke or acoustic neuroma are being considered.

Answer 254

Sensorineural hearing loss over less than 72 hours at least 30 decibels in three consecutive frequeencies on audiogram

Answer 255

The NICE clinical knowledge summaries (updated September 2019) recommend an immediate referral to ENT for assessment within 24 hours for patients presenting with sudden sensorineural hearing loss presenting within 30 days of onset. Where an underlying cause is found (e.g., infection), treatment can be directed at this (e.g. antivirals, antibiotics) Idiopathic SSNHL may be treated with steroids under the guidance of the ENT team. Steroids may be: Oral Intra-tympanic (via an injection of steroids through the tympanic membrane) Other treatments are used e.g. hyperbaric oxygen, carbogen but are not widely practice

Answer 256

1/3 recover to normal 1/3 some recovery 1/3 no recovery

Answer 257

Age related hearing loss. Loss of hair cells in the cochlea, Loss of neurones in the cochlea Atrophy of the stria vascularis Endolymphatic potential

Answer 258

Sensorineural Symmetrical High pitched sounds lost first (female voices harder to head) Gradual and insidious Worse in noisey environments

Answer 259

Sensorineural symmetrical hearing loss, gradual and insidious, loss of high pitched sounds first, harder to hear in noisy environments. History of ‘not paying attention’ or missing parts of conversations - may be concerns of dementia when the actual issue is hearing loss May be associated tinnitus

Answer 260

Age Male gender Family history Loud noise exposure Diabetes Hypertensive Loud noise exposure HTN Ototoxic medications Smoking

Answer 261

Sensorineural hearing loss pattern Normal or near normal hearing at lower frequencies Worsening hearing loss at higher frequencies

Answer 262

Audiometry

Answer 263

The effects of presbycusis cannot be reversed. Management involves supporting the person to maintain normal functioning: Optimising the environment, for example, reducing the ambient noise during conversations Hearing aids Cochlear implants (in patients where hearing aids are not sufficient)

Answer 264

Ear wax is also called cerumen. It is normally produced in small amounts in the external ear canal. It is created from a combination of secretions, dead skin cells and any substances that enter the ear. Ear wax has a protective effect, helping to prevent infection in the ear canal. In most people, ear wax does not cause any problems.

Answer 265

Ear wax can build up and become impacted and stuck to the tympanic membrane. This can result in: Conductive hearing loss Discomfort in the ear A feeling of fullness Pain Tinnitus

Answer 266

Impacted ear wax (cerumen)

Answer 267

In most cases, ear wax does not require any interventions. The ears should naturally regulate the amount of wax in the ear canal without any issues. Inserting cotton buds into the ear should be avoided, as this can press the wax in further and cause impaction. There are three main methods for removing ear wax: Ear drops – usually olive oil or sodium bicarbonate 5% Ear irrigation – squirting water in the ears to clean away the wax Microsuction – using a tiny suction device to suck out the wax Ear drops may be enough to clear the ears. If not, ear irrigation can often be performed in primary care. Where there are contraindications to ear irrigation (e.g., perforated tympanic membrane or infection), microsuction can be performed by specialist ear, nose and throat services.

Answer 268

The pinna is the external portion of the ear The external auditory canal is the tube into the ear The tympanic membrane is the eardrum The Eustachian tube connects the middle ear with the throat to equalise pressure The malleus, incus and stapes are the small bones in the middle ear that connect the tympanic membrane to the structures of the inner ear The semicircular canals are responsible for sensing head movement (the vestibular system) The cochlea is responsible for converting the sound vibration into a nervous signal The vestibulocochlear nerve transmits nerve signals from the semicircular canals and cochlea to the brain

Answer 269

Causes Of Sensorineural Hearing Loss The causes of adult-onset sensorineural hearing loss are: 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

Answer 270

Loop diuretics (e.g., furosemide) Aminoglycoside antibiotics (e.g., gentamicin) Chemotherapy drugs (e.g., cisplatin)

Answer 271

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

Answer 272

Tinnitus refers to a persistent addition sound that is heard but is not present in the surrounding environment. It may be described as a “ringing in the ears”, but it can also be a buzzing, hissing or humming noise. The additional noise experienced with tinnitus is thought to be the result of a background sensory signal produced by the cochlea that is not effectively filtered out by the central auditory system. In a quiet enough environment, almost everyone will experience some background noise (tinnitus). This becomes more prominent the more attention it is given.

Answer 273

Primary tinnitus has no identifiable cause and often occurs with sensorineural hearing loss. Secondary tinnitus refers to tinnitus with an identifiable cause. Causes include: Impacted ear wax Ear infection Ménière’s disease Noise exposure Medications (e.g., loop diuretics, gentamicin and chemotherapy drugs such as cisplatin) Acoustic neuroma Multiple sclerosis Trauma Depression Tinnitus may also be associated with systemic conditions: Anaemia Diabetes Hypothyroidism or hyperthyroidism Hyperlipidaemia Objective tinnitus refers to when the patient can objectively hear an extra sound within their head. This sound can also be observable on examination by auscultating with a stethoscope around the ear. Actual additional sounds may be caused by: Carotid artery stenosis (pulsatile carotid bruit) Aortic stenosis (radiating pulsatile murmur sounds) Arteriovenous malformations (pulsatile) Eustachian tube dysfunction (popping or clicking noises)

Answer 274

Ask about the pattern of symptoms: Unilateral or bilateral Frequency and duration Severity Pulsatile or non-pulsatile (pulsatile may indicate a cardiovascular cause, such as carotid artery stenosis with a bruit) A focused history and examination can be used to identify any underlying causes, including: Contributing factors, such as hearing loss or noise exposure Associated symptoms (e.g., hearing loss, vertigo, pain or discharge) Stress and anxiety Otoscopy to look for causes such as ear wax or infection Weber’s and Rinne’s tests for hearing loss

Answer 275

The NICE clinical knowledge summaries (updated March 2020) suggest considering blood tests for possible underlying causes: Full blood count (anaemia) Glucose (diabetes) TSH (thyroid disorders) Lipids (hyperlipidaemia) Audiology can be used to assess the hearing in detail and help establish the underlying cause. Imaging (e.g., CT or MRI) may be rarely required to investigate for underlying causes such as vascular malformations or acoustic neuromas.

Answer 276

Unilateral tinnitus Pulsatile tinnitus Hyperacusis (hypersensitivity, pain or distress with environmental sounds) Associated unilateral hearing loss Associated sudden onset hearing loss Associated vertigo or dizziness Headaches or visual symptoms Associated neurological symptoms or signs (e.g., facial nerve palsy or signs of stroke) Suicidal ideation related to the tinnitus

Answer 277

Tinnitus tends to improve or resolve over time without any interventions. Underlying causes of tinnitus can be treated, such as impacted ear wax or infection. Several measures can be used to help improve and manage symptoms: Hearing aids Sound therapy (adding background noise to mask the tinnitus) Cognitive behavioural therapy

Answer 278

BPPV Meniere's disease Labyrinthitis Acute vestibular neuronitis Trauma to the vestibular nerve Vestibular nerve tumours (acoustic neuromas) Otosclerosis Hyperviscosity syndromes Varicella zoster infection (often with facial nerve weakness and vesicles around the ear – Ramsay Hunt syndrome)

Answer 279

Posterior circulation infarction (stroke) Tumour Multiple sclerosis Vestibular migraine

Answer 280

All the central causes of vertigo will cause sustained, non-positional vertigo. Posterior circulation infarction will have a sudden onset and may be associated with other symptoms, such as ataxia, diplopia, cranial nerve defects or limb symptoms. Tumours in the cerebellum or brainstem will have a gradual onset with associated symptoms of cerebellar or brainstem dysfunction. Multiple sclerosis may cause relapsing and remitting symptoms, with other associated features of multiple sclerosis, such as optic neuritis or transverse myelitis. Vestibular migraine will cause symptoms lasting minutes to hours, often associated with visual aura and headache. Attacks may be triggered

Answer 281

Vestibular migraine will cause symptoms lasting minutes to hours, often associated with visual aura and headache. Attacks may be triggered by: Stress Bright lights Strong smells Certain foods (e.g. chocolate, cheese and caffeine) Dehydration Menstruation Abnormal sleep patterns

Answer 282

Peripheral: Sudden onset Central: Gradual onset (except stroke)

Answer 283

Peripheral: Short (seconds or minutes) Central: Persistent

Answer 284

Peripheral: often present Central: Usually not

Answer 285

Peripheral: intact Central: lost

Answer 286

Peripheral: severe Central: mild

Answer 287

Ear examination to look for signs of infection or other pathology Neurological examination to assess for central causes of vertigo (e.g., stroke or multiple sclerosis) Cerebellar examination Cardiovascular examination to assess for cardiovascular causes of dizziness (e.g., arrhythmias or valve disease) Special tests: Romberg’s test (screens for problems with proprioception or vestibular function) Dix-Hallpike manoeuvre (to diagnose BPPV) HINTS examination (to distinguish between central and peripheral vertigo)

Answer 288

The HINTS examination can be used to distinguish between central and peripheral vertigo. It stands for: HI – Head Impulse N – Nystagmus TS – Test of Skew

Answer 289

Unilateral horizontal nystagmus is more likely to be a peripheral cause. Bilateral or vertical nystagmus suggests a central cause.

Answer 290

Eustachian tube dysfunction is when the tube between the middle ear and throat is not functioning properly. The Eustachian tube is present mainly to equalise the air pressure in the middle ear and drain fluid from the middle ear. When the Eustachian tube is not functioning correctly or becomes blocked, the air pressure cannot equalise properly and fluid cannot drain freely from the middle ear. The air pressure between the middle ear and the environment can become unequal. The middle ear can fill with fluid. Eustachian tube dysfunction may be related to a viral upper respiratory tract infection (URTI), allergies (e.g., hayfever) or smoking.

Answer 291

Reduced or altered hearing Popping noises/sensation within the ear A fullness sensation within the ear Pain or discomfort Exacerbation of symptoms when the external air pressure changes and the middle ear pressure cannot equalize to the outside pressure - for example when scuba diving, flying in an earoplane

Answer 292

Often Eustachian tube dysfunction gives a typical set of symptoms and is associated with a clear cause, for example, a recent viral upper respiratory tract infection or hayfever. In this situation, investigations are not required as the symptoms will resolve with time or simple treatments.

Answer 293

Tympanometry Audiometry Nasopharyngoscopy (inspect the ET tube openings) CT scan (asses for structural pathology)

Answer 294

Measurement of compliance of TM, can be done at any age as minimal complience required from patient (small probe in ear only) A device is inserted into the external auditory canal, creating different ear pressures within the canal Sound is sent in the direction of the tympanic membrane The amount of sound reflected back off the tympanic membrane is measured A tympanogram of the sound absorbed (admittance) is plotted at different air pressures

Answer 295

The amount of sound absorbed by the TM and middle ear (measured at various ear pressures)

Answer 296

Normally, sound is absorbed best when the air pressure in the ear canal matches the ambient air pressure. The ambient air pressure is equal to the middle ear pressure in healthy ears.

Answer 297

Peak admittance at negative ear canal pressures This is because the air pressure is lower in the middle ear than the ambient air pressure (new air cannot get through TM to equalise the pressures)

Answer 298

None - wait for it to resolve spontaneously - e.g. recovering from URTI Valsalva maneuverer (holding nose and blowing into it to inflate the ET tube). Decongestant nasal sprays (short term only) Antihistamines and a steroid nasal spray (short term only) Antihistamines - steroid nasal spray for allergies or rhinitis Sugery may be required in severe or persistent cases Otovent - OTC device where the patient blows into a balloon which can help inflate the ET tube, clear blockages and equalize pressure

Answer 299

Treatment of other pathology that might cause symptoms, for example, adenoidectomy Grommets (tubes inserted into TM by ENT surgeon allowing air or fluid to drain through the ear canal, fall out typically within about 18 months) Under local Balloon dilation ET tuboplasty involves insetring a deflated balloon into the ET tube for a short period of time (a2 mins) to stretch the ET tube, then deflating and removing it, Under GA

Answer 300

Recurrence Chronic otitis media, a middle ear infection Otitis media with effusion, or “glue ear,” a fluid buildup in the middle ear that can last for weeks and could damage hearing Eardrum retraction, when the eardrum is seemingly sucked farther into the ear canal

Answer 301

Cleft pallette Nasal polyps Smoking (damage to cilia) Obesity (fatty deposits can form around the Eustachian tubes, leading to dysfunction) Allergies (frequent episodes of mucus production and congestion) Down syndrome Young children - 1 - 6 years (narrower ET tube)

Answer 302

Testing a patients hearing by playing a variety of tones and volumes using headphones (air conduction) and an oscillator (conduction device) . Audiometry results are recorded on an audiogram. Audiograms can help identify and differentiate conductive and sensorineural hearing loss.

Answer 303

Chart documenting the volume at which patients can hear differnt tones x axis: frequency/Hz y axis: volume/decebils (quitest volume that can be heard at given frequency) (gets lower going upwards)

Answer 304

X - left sided air conduction ] - left sided bone conduction O - right sided air conduction [ - right sided bone conduction

Answer 305

In patients with sensorineural hearing loss, both air and bone conduction readings will be more than 20 dB, plotted below the 20 dB line on the chart. This may affect only one side, one side more than the other or both sides equally.

Answer 306

In patients with conductive hearing loss, bone conduction readings will be normal (between 0 and 20 dB). However, air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart. In conductive hearing loss, sound can travel through bone but is not conducted through air due to pathology along the route into the ear.

Answer 307

When a patient has normal hearing, all readings will be between 0 and 20 dB, at the top of the chart.

Answer 308

Normal audiogram

Answer 309

Conductive hearin loss

Answer 310

Sensorineural hearing loss

Answer 311

Both air and bone conduction readings will be more than 20 dB in patients with mixed hearing loss. However, there will be a difference of more than 15 dB between the two (bone conduction > air conduction).

Answer 312

Both air and bone conduction readings will be more than 20 dB in patients with mixed hearing loss. However, there will be a difference of more than 15 dB between the two (bone conduction > air conduction).

Answer 313

Maternal rubella or cytomegalovirus infection during pregnancy Genetic deafness can be autosomal recessive or autosomal dominant Associated syndromes, for example Down’s syndrome

Answer 314

Prematurity Hypoxia during or after birth

Answer 315

Jaundice Meningitis and encephalitis Otitis media or glue ear Chemotherapy

Answer 316

The UK newborn hearing screening programme (NHSP) tests hearing in all neonates. This involves special equipment that delivers sound to each eardrum individually and checks for a response. This can identify congenital hearing problems early.

Answer 317

Children with hearing difficulties may present with parental concerns about hearing or with behavioural changes associated with not being able to hear: Ignoring calls or sounds Frustration or bad behaviour Poor speech and language development Poor school performance

Answer 318

NHSP - neonates - special equiptment that delivers sound to each eardrum and checks for a response Looking for basic turning towards a sound - children under 3 Audiometry - headphones at specific tones and volumes

Answer 319

Establishing the diagnosis is the first step. After the diagnosis is established, input from the multidisciplinary team is required for support with hearing, speech, language and learning: Speech and language therapy Educational psychology ENT specialist Hearing aids for children who retain some hearing Sign language

Answer 320

The point at which pressure in the canal equals that of the middle ear

Answer 321

Normal result Peak centred on 0 daPa on x axis

Answer 322

Type A Tympanogram (normal, peak centred at 0daPa on x axis)

Answer 323

Flat tracing Suggests middle ear effusion or perforation

Answer 324

Both type b (flat line) Effusion: normal canal volume (around 1cm3 in adults) Perforation: Larger volume measure as both middle and external ear volume

Answer 325

Type B tympanogram

Answer 326

Suggests ET tube dysfunction The peak of the tracing has negative pressure

Answer 327

Nosebleeds are common in young children and older adults. They can be triggered by: Nose picking Colds Sinusitis Vigorous nose-blowing Trauma Changes in the weather Coagulation disorders (e.g., thrombocytopenia or Von Willebrand disease) Anticoagulant medication (e.g., aspirin, DOACs or warfarin) Snorting cocaine Tumours (e.g., squamous cell carcinoma) When a patient swallows blood during a nosebleed, they may present with vomiting blood. Bleeding is usually unilateral. Bleeding from both nostrils may indicate bleeding posteriorly in the nose. Posterior bleeding presents a higher risk of aspiration of blood.

Answer 328

Sit up and tilt the head forwards (tilting the head backwards is not advised as blood will flow towards the airway) Squeeze the soft part of the nostrils together for 10 – 15 minutes Spit out any blood in the mouth, rather than swallowing

Answer 329

Nasal packing using nasal tampons or inflatable packs Nasal cautery using silver nitrate sticks After treating an acute nosebleed, consider prescribing Naseptin nasal cream (chlorhexidine and neomycin) four times daily for 10 days to reduce any crusting, inflammation and infection. This is contraindicated in peanut or soya allergy.

Answer 330

Recurrent and significant nosebleeds might require further investigation to look for an underlying cause, such as thrombocytopenia or clotting disorders.

Answer 331

Sinusitis refers to inflammation of the paranasal sinuses in the face. This is usually accompanied by inflammation of the nasal cavity and can be referred to as rhinosinusitis. It is very common. Sinusitis can be: Acute (less than 12 weeks) Chronic (more than 12 weeks)

Answer 332

Frontal sinuses (above the eyebrows) Maxillary sinuses (either side of the nose below the eyes) Ethmoid sinuses (in the ethmoid bone in the middle of the nasal cavity) Sphenoid sinuses (in the sphenoid bone at the back of the nasal cavity)

Answer 333

The paranasal sinuses are hollow spaces within the bones of the face Arranged symmetrically around the nasal cavity Produce mucous and drain into the nasal cavities via ostia (holes) Blockage of the ostia prevents drainage of the sinuses, resulting in sinusitis

Answer 334

Inflammation of the sinuses can be caused by: Infection, particularly following viral upper respiratory tract infections Allergies, such as hayfever (with allergic rhinitis) Obstruction of drainage, for example, due to a foreign body, trauma or polyps Smoking Patients with asthma are more likely to suffer from sinusitis.

Answer 335

The typical presentation of acute sinusitis is someone with a recent viral upper respiratory tract infection presenting with: Nasal congestion Nasal discharge Facial pain or headache Facial pressure Facial swelling over the affected areas Loss of smell

Answer 336

Nasal polyps

Answer 337

Tenderness to palpation of the affected areas Inflammation and oedema of the nasal mucosa Discharge Fever Other signs of systemic infection (e.g., tachycardia)

Answer 338

Nasal endoscopy CT scan

Answer 339

High dose steroid nasal spray for 14 days (e.g., mometasone 200 mcg twice daily) A delayed antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin first-line)

Answer 340

Options for chronic sinusitis are: Saline nasal irrigation Steroid nasal sprays or drops (e.g., mometasone or fluticasone) Functional endoscopic sinus surgery (FESS)

Answer 341

Tilting the head slightly forward Using the left hand to spray into the right nostril, and vice versa (this directs the spray slightly away from the septum) NOT sniffing hard during the spray Very gently inhaling through the nose after the spray

Answer 342

Spray has gone past the nasal mucosa It will be ineffective

Answer 343

Functional endoscopic sinus surgery (FESS) involves using a small endoscope inserted through the nostrils and sinuses. Instruments are used to remove or correct any obstructions to the sinues. Obstruction may be cause by swollen mucosa, bone, polyps or a deviated septum. Balloons may be inflated to dilate the opening of the sinuses. Patients need a CT scan before the procedure to confirm the diagnosis and assess the structures?

Answer 344

Septoplasty

Answer 345

Nasal polyps are growth of the nasal mucosa that can occur in the nasal cavity or sinuses. They are often associated with inflammation (chronic rhinitis) They grow slowly and gradually obstruct the nasal passage Polyps are usually bilateral

Answer 346

unilateral polyps are concerning for malignancy and require a specialist referral for assessment

Answer 347

Chronic rhinitis or sinusitis Asthma Samter's triad (nasal polyps, asthma and aspirin intolerance/allergy) Cystic fibrosis Eosinophillic granulomatosis with polyangitis (Chrug-Strauss syndrome)

Answer 348

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

Answer 349

Nasal speculum - hold the nostrils open Otoscope with large speculum Nasal endoscopy to visualize the cavity in detail to assess any polyps

Answer 350

Nasal polyps appear as round pale grey/yellow growths on the mucosal wall.

Answer 351

Nasal polyp

Answer 352

Unilateral polyps should be referred for specialist assessment to exclude malignancy. Medical management involves intranasal topical steroid drops or spray. Surgical management is used where medical treatment fails. This involves removing the polyps: Intranasal polypectomy is used where the polyps are visible close to the nostrils Endoscopic nasal polypectomy is used where the polyps are further in the nose or the sinuses

Answer 353

Obstructive sleep apnoea is caused by collapse of the pharyngeal airway. It is characterised by episodes of apnoea during sleep, where the person stops breathing periodically for up to a few minutes. The partner usually reports this happening, and the patient is unaware of the episodes.

Answer 354

Middle age Male Obesity Alcohol Smoking

Answer 355

Episodes of apnoea during sleep (reported by their partner) Snoring Morning headache Waking up unrefreshed from sleep Daytime sleepiness Concentration problems Reduced oxygen saturation during sleep Severe cases can cause hypertension, heart failure and can increase the risk of myocardial infarction and stroke.

Answer 356

Epworth sleepiness scale

Answer 357

Sleep studies under sleep clinic (measuring sats, HR, respiratory rate and breathing to establish any episodes of apnoea and the extent of pts snoring) Address risk patients (drinking alcohol, stop smoking and lose weight) CPAP to maintain patency of the airway using continous pressure Surgery - uvulopalatopharyngoplasty (UPPP) to reconstruct the soft palate and jaw, children –adenotonsillectomy Mandibular positioning devices in selected cases

Answer 358

Quadrangular cartillage Ethmoid Vomer Anterior ethmoidal, posterior ethmoidal, septal branches of the spheno-palatine, branch of greater palatine, Little's area , septal branch of superior labial

Answer 359

Local  Idiopathic – 85%  Traumatic  Iatrogenic  Foreign Body  Inflammatory – Rhinitis, Polyps  Neoplastic

Answer 360

 Hypertension  Coagulopathies  Vasculopathies  Hereditary Haemorrhagic Telangiectasia/Osler-Weber-Rendu disease

Answer 361

Cautery, then anterior packing, then posterior packing (if continues to bleed into the oropharynx

Answer 362

Anterior bleed: anterior rhinoscopy Posterior bleed - rigid endoscope (Topical adrenaline may also help to control the bleed)

Answer 363

Septal hematoma CSF leak associated with skull base fracture (rare)

Answer 364

 ABC – epistaxis normally self-limiting  Examine for septal haematoma  No XR required  If deviated nose consider Manipulation under anaesthetic (LA/GA) within 2 weeks of injury

Answer 365

Structures of importance: lamina papracea forming the medial wall of the orbit, anterior cranial fossa, internal catorid artery

Answer 366

Sphenoid sinus: spheno-ethmoidal recess Posterior ethmoid cells: superior meatus Frontal, maxillary and anterior ethmoid cells: Middle meatus Nasolacrimal duct: inferior meatus

Answer 367

Surgery Damage to orbit (orbit lies lateral to the ethmoid sinus and superior to the maxillary sinus and its contents are at risk during sinus surgery and in severe cases can cause loss of sight. Anterior skull base - lies just above the sphenoid and ethmoid sinuses and can be breached during surgery which can cause as CSF leak and even brain damage Rhinosinusitis: Orbit - infective rhinosinusitis can spread to the orbit and cause periobrital sinusitis (can be sight threatneing) Intracranial infection - infective rhinosisitus particularly of the frontal sinuse can spread intracranially to cause menigitis and intracranial abcsess formation

Answer 368

Inflammation of the nose and the paranasal sinuses characterised by TWO or more symptoms, one of which should be: - Nasal blockage/obstruction/congestion or discharge - Anterior/posterior nasal drip - Facial pain/pressure - Reduction or loss of smell And either of: - Endoscopic signs of: polyps, mucopurulent discharge or oedema in the middle meatus - CT changes - mucosal changes within the osteomeatal complex or sinuses

Answer 369

Allergy: atopy can predispose and associated Infections: Bacterial such as Staph aureus and streptococcus pneumonia and fungal infections Cillary impairment such as CF due to inability of cilia to clear mucus. Nasal polyps are present in about 40% of patients with cystic fibrosis. An anatomical abnormality such as spetal deviation and abnormal uncinate process leads to narrow infundibulum and occlusion of osteomeatal complex Immunocompromised host Aspirin hypersentivity Atmostpheric irritants: smoking, dusts, fumes Hormonal: pregnancy and hypothroidism, nasal congestion is high due to oestrogen and progesterone effect on nasal mucosal vascularity Trauma: surgical (oroantral fistula), nasal sinus fracture Swimming and diving

Answer 370

Skin prick test Radiology o CT Sinuses If surgery planned / Atypical features to history or examination ( Not good for diagnosis as large numbers of asymptomatic patients have changes in the sinuses on CT scanning )

Answer 371

Allergic rhinosinusitis impact on asthma (classification of allergic rhinosinusitis) Duration: intermittent (less than 4 days a week less than 4 weeks), persistent (more than 4 days a week for more than 4 weeks) Severity Mild: normal daily activities, and sleep. No troublesome symptoms Moderate to severe: Impairment of daily activities and sleep. Troublesomesymptoms.

Answer 372

Skin prick tests (SPT) for specific allergens RAST blood tests if SPT not possible

Answer 373

Type 1 hypersensitivity reaction Allergic reaction leads to synthesis and release of arachidonic acid metabolites (prostaglandin D& leukotrienes) and mast cell degranulation to release histamine. The effect is to increase capillary permeability which leads to congestion, oedema, rhinorrhoea, sneezing and irritation

Answer 374

Conservative o Allergen avoidance o Nasal douching Medical o Antihistamines o Topical nasal steroids Immunotherapy

Answer 375

This is a site-threatening emergency which is more common in children and often results from direct spread of pus from the ethmoid sinus, or from thrombophlebitis of mucosal vessels in any of the sinuses. Patients develop pain followed by oedema of the eyelids and with orbital collection, the eye will become proptosed and eye movements will be reduced. There is a risk of blindness as a result of tension and septic necrosis of the optic nerve. Colour blindness is an early sign. A CT scan will confirm the collection and extent of the disease. Treatment with intravenous antibiotics, nasal decongestants, and urgent surgical drainage of any abscess is indicate

Answer 376

Post traumatic Palpable buldging septum Can detect on anterior rhinoscopy

Answer 377

Nasal septal haematoma left untreated leading to erosion of the septal cartillage

Answer 378

Cocaine Disruption of blood supply to the cartillage

Answer 379

Use tounge depressor and torch to visualise the oropharynx wall, if fresh blood is running down it remove anterior pack and post nasal pack or inflate nasopharangeal balloon followed by further anterior nasal packign

Answer 380

GA to cauterise bleeding point/pack more effectively/ ligate sphenopalaetine and possibly anterior ethmoidal artery

Answer 381

Trachea Eosophagous Carotid sheath Spine

Answer 382

Lateral - Anterior boarder of the SCM (sternocleidomastoid) Medial - midline of neck Superior - Lower border of the mandible

Answer 383

Medial: posterior boarder of sternocleidomastoid Inferior: middle third of clavicle Lateral: anterior edge of the trapezius

Answer 384

Submental Supraclavicular Occipital Carotid Supramandibular (digastric) Omotracheal (muscular)

Answer 385

Airway problems Mediastinitis

Answer 386

Potential space behind the pharynx and anterior to the prevertable fascia extending from the base of the skull to the mediastinum.

Answer 387

Retropharyngeal abscess

Answer 388

Infection of the space between the FLOOR OF THE MOUTH and MYLOHYOID - associated with dental infection

Answer 389

Swelling of the floor of the mouth Painful mouth Protuding tongue Airway compromise Drooling

Answer 390

CT neck OPG

Answer 391

Secure airway IV abx Surgical drainage of any collections

Answer 392

Potential space postero-lateral to the oropharynx and nasopharynx which is divided by the styloid process. Contains carotid sheath

Answer 393

Abcess in parapharyngeal space (potential space postero-lateral to the oropharynx and nasopharynx which is divided by the styloid process) Presents ins a similar manner to quinsy (peritonsillar abscess)

Answer 394

Hx febrile illness Odynophagia Tismus Reduced neck movement Swelling in the neck around the upper part of the SCM

Answer 395

Secure airway if any concerns IV abx Surgical drainage

Answer 396

Do not examine patient as this may precipitate airway obstruction and keep them in a calm environment with their parents to avoid undue distress (ditto) If possible, child taken to theatre to be intubated by a pediatric anesthetist with an ENT surgeon on standby to do a surgical airway if intubation not possible, if transfer unsafe intubation in A&E IV abx, pts usually respond well and can be intubated after a couple of days

Answer 397

Ultrasound guided fine needle aspiration (except for pulsitile masses)

Answer 398

Parotid neoplasam - anterior to ear Jugulodiagastric - angle of mandible Submandibular gland - inferior border of madnible Carotid body tumor or aneurysm - at bifurcation of common carotid artery (usually C3-C5 level) Thryoglossal cysts - in midline between hyoid bone and thyroid gland Brachial cyst - anterior border of sternocleidomastoid Thyroid nodule - level of thryoid Virchow's node - supravicular fossa node (may represent mets)

Answer 399

Oral cavity – Extends from the lips to the posterior soft palate. Nasopharynx – Superiorly bound by the base of the skull, and inferiorly by an imaginary line at the level of the soft palate o Contents include the adenoids and eustachian tube opening Oropharynx – Extends from the level of the soft palate to the superior border of the epiglottis o Contents include the palatine tonsils, anterior and posterior tonsillar pillars Hypopharynx – Extends down from the superior border of the epiglottis to the inferior border of the cricoid cartilage. It is posterior to the larynx.

Answer 400

Unlike the rest of the GI tract where the muscular layers are arranged in circular and longitudinal layers, the pharynx has only a circular layer which is formed in principle by four muscles; Superior, middle, and inferior constrictors, and cricopharyngeus

Answer 401

Pharyngeal weak point formed between the horizontal fibers of the cricopharyngeus (CP) muscle and the oblique fibers of the inferior pharyngeal constrictors (IPCs) This is the site of pharyngeal pouch formation

Answer 402

Pharyngeal pouches typically present with dysphagia, delayed regurgitation of food and sometimes recurrent chest infections from aspirated food.

Answer 403

Killian's triangle (pharyngeal weak point formed between the horizontal fibers of the cricopharyngeus (CP) muscle and the oblique fibers of the inferior pharyngeal constrictors (IPCs)) - also known as Killian's dehiscence.

Answer 404

stylopharyngeus, salpingopharyngeus, and palatopharyngeus.

Answer 405

Barium swallow Pharangeal pouch

Answer 406

adenotonsillar hypertrophy

Answer 407

TFTs - ?hypothyroidism

Answer 408

 CXR – ?Signs of obstructive lung disease  ECG – ?Signs of right ventricular failure

Answer 409

 Beta-haemolytic Streptococci  Staphylococci  Streptococcus pneumoniae  Haemophilus influenza  Escherischia coli

Answer 410

 Rhinovirus  Adenovirus  Enterovirus  Epstein-Barr virus (EBV)

Answer 411

group A streptococcus (Streptococcus pyogenes).

Answer 412

 Pyrexia > 38  Dysphagia  Lymphadenopathy (anterior cervical lymphadenopathy)  Odynophagia  Trismus  Swollen tonsils with or without exudate  Otalgia (Referred pain)

Answer 413

There may be anterior cervical lymphadenopathy, which refers to swollen, tender lymph nodes in the anterior triangle of the neck (anterior to the sternocleidomastoid muscle and below the mandible). The tonsillar lymph nodes are just behind the angle of the mandible (jawbone).

Answer 414

Treatment with amoxicillin should be avoided as this will cause a maculopapular rash in the presence of EBV (glandular fever). Furthermore, patients with EBV should be advised to avoid contact sports for 2-3 months as the virus commonly causes hepatosplenomegaly.

Answer 415

In the pharynx, at the back of the throat, there is a ring of lymphoid tissue. There are six areas of lymphoid tissue in Waldeyer’s ring, comprising of the adenoids, tubal tonsils, palatine tonsils and the lingual tonsil. The palatine tonsils are the ones typically infected and enlarged in tonsillitis. These are the tonsils on either side at the back of the throat.

Answer 416

The Centor criteria can be used to estimate the probability that tonsillitis is due to bacterial infection and will benefit from antibiotics. A score of 3 or more gives a 40 – 60 % probability of bacterial tonsillitis, and it is appropriate to offer antibiotics. A point is given if each of the following features are present: Fever over 38ºC Tonsillar exudates Absence of cough Tender anterior cervical lymph nodes (lymphadenopathy)

Answer 417

The FeverPAIN score is an alternative to the Centor criteria. A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis: Fever during previous 24 hours P – Purulence (pus on tonsils) A – Attended within 3 days of the onset of symptoms I – Inflamed tonsils (severely inflamed) N – No cough or coryza

Answer 418

Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis. When tonsillitis is the most likely diagnosis, calculate the Centor criteria or FeverPAIN score. Educate patients with likely viral tonsillitis and give safety net advice about when to seek medical advice. Advise simple analgesia with paracetamol and ibuprofen to control pain and fever. NICE clinical knowledge summaries suggest advising patients to return if the pain has not settled after 3 days or the fever rises above 38.3ºC. Starting antibiotics or an alternative diagnosis should be considered. Consider prescribing antibiotics if the Centor score is ≥ 3, or the FeverPAIN score is ≥ 4. Also, consider antibiotics if they are at risk of more severe infections, such as young infants, immunocompromised patients or those with significant co-morbidity, or a history of rheumatic fever. Delayed prescriptions can be considered. This involves educating patients or parents about the likely viral nature of the sore throat and providing a prescription to be collected only if the symptoms worsen or do not improve in the next 2 – 3 days. Draining of peritonsilar abcsess

Answer 419

Penicillin V (also called phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes. Clarithromycin is the usual first-line choice in true penicillin allergy.

Answer 420

Peritonsillar abscess, also known as quinsy Otitis media, if the infection spreads to the inner ear Scarlet fever Rheumatic fever Post-streptococcal glomerulonephritis Post-streptococcal reactive arthritis

Answer 421

Quinsy (peritonsilar abscess)

Answer 422

Peritonsilar abscess These normally present with a sore throat that is lateralised to one side and a “hot potato” voice. They may be amenable to drainage under local anaesthetic Peritonsillar abscess arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils. Peritonsillar abscess is a complication of untreated or partially treated tonsillitis, although it can arise without tonsillitis. Quinsy can occur just as frequently in teenagers and adults as it does in children, unlike tonsillitis which is much more common in children.

Answer 423

Patients present with similar symptoms to tonsillitis: Sore throat Painful swallowing Fever Neck pain Referred ear pain Swollen tender lymph nodes Additional symptoms that can indicate a peritonsillar abscess include: Trismus, which refers to when the patient is unable to open their mouth Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice” Swelling and erythema in the area beside the tonsils

Answer 424

Quinsy is usually due to a bacterial infection. The most common organism is streptococcus pyogenes (group A strep), but it is also commonly caused by staphylococcus aureus and haemophilus influenzae.

Answer 425

Patients should be referred to the hospital under the ENT team’s care for needle aspiration or surgical incision and drainage to remove the pus from the abscess. Quinsy typically has an underlying bacterial cause. Therefore, antibiotics are appropriate before and after surgery. A broad-spectrum antibiotic such as co-amoxiclav would be an appropriate choice to cover the common causes, but local guidelines will guide antibiotic selection according to local bacterial resistance. Some ENT surgeons give steroids (i.e. dexamethasone) to settle inflammation and help recovery, although this is not universal.

Answer 426

The SIGN guidelines (2010) give the indications for tonsillectomy. The number of episodes of acute sore throat they specify for a tonsillectomy are: 7 or more in 1 year 5 per year for 2 years 3 per year for 3 years Other indications are: Recurrent tonsillar abscesses (2 episodes) Enlarged tonsils causing difficulty breathing, swallowing or snoring

Answer 427

Sore throat where the tonsillar tissue has been removed (this can last 2 weeks) Damage to teeth Infection Post-tonsillectomy bleeding (can be significant and an emegrency, can occur as late as 2 weeks after tonsilectomy) Risks associated with a general anaesthetic

Answer 428

Call the ENT registrar and get them involved early Get IV access and send bloods including an FBC, clotting screen, group and save and crossmatch Keep the patient calm and give adequate analgesia Sit them up and encourage them to spit out the blood rather than swallowing Make the patient nil by mouth in case an anaesthetic and operation is required IV fluids for maintenance and resuscitation, if required If there is severe bleeding or airway compromise, call an anaesthetist. Intubation may be required. Before going back to theatre there are two options for stopping less severe bleeds: Hydrogen peroxide gargle Adrenalin soaked swab applied topically

Answer 429

Dysphonia (esp laryngeal malignancy which may cause hoarseness) Dysphagia/odynaphagia Dyspnoea –stridor from narrowing of airway, especially laryngeal tumours Neck Mass Pain from site of pathology or referred e.g. to ear Bleeding from nose or mouth depending on site of primary(rare presentation) Nasal blockage –normally unilateral progressive for nasal/nasopharyngeal pathology

Answer 430

The majority (90%) are squamous cell carcinomas.

Answer 431

T= Tumour size, 1 (small) – 4 (big) N= Nodal Metastasis, 0 (no nodes) - N3 (big/multiple nodes) M= Distant metastasis 0 (none) – 1 (present)

Answer 432

Alcohol Chewing tobacco Beetle nut chewing for oral cavity malignancies Chinese ethnic origin for nasopharyngeal malignancy HPV strain 16 EBV infection Smoking

Answer 433

Oral cavity mallignancies

Answer 434

Examination under anaesthetic o Also called Panendoscopy or laryngopharyngo-oesophagoscopy in H&N o Purpose – Biopsy for histological diagnosis, assess size of tumour, look for second primary  CT Neck o Purpose – assess size of tumour and neck node metastasis

Answer 435

If a patient has a biopsy proven primary squamous cell carcinoma in the head and neck it can be assumed that any palpable cervical lymphadenopathy is secondary to this primary and the CT scan of the neck to assess the primary will give all the information required for staging. If this is not the case any palpable neck masses should be investigated with an ultrasound guided fine needle aspiration (FNA). While blind (i.e. no US) FNA can be done the ultrasound will increase the accuracy of the specimen taken and will give extra information on the mass being sampled.

Answer 436

These should be diagnosed with a FNA of the neck mass

Answer 437

Biopsy can lead to seeding and poor prognosis, however FNA is not so good for other causes of cervical lymphadenopathy other than SCC, such as tuberculosis and lymphoma which often require an open biopsy so in these cases an FNA should be carried out to exclude SCC before an open biopsy is done

Answer 438

CT chest are routinely done to check for metastasis in the chest, the commonest site of distant metastasis. Other investigations are not routinely done unless there is suspicion of other distant metastesis

Answer 439

Treatment needs to be aimed at the primary site and also any neck metastases. In some head and neck cancers there is a high rate of metastasis to the neck so even if no neck metastasis are detected treatment will still be given to the neck (if curative aim) Radiotherapy – to the primary site +/- to the neck, +/- chemotherapy - curative or palliative Endoscopic surgery - e.g. laser resection Open surgery  To primary site – e.g. laryngectomy  To neck – i.e. neck dissection

Answer 440

Anterior triangle Posterior triangle Midline (vertically along the centre of the neck)

Answer 441

Normal anatomy - ie bony prominence Skin abcess Lymphadenopathy Tumour (SCC, sarcoma) Lipoma Goitre Salivary gland stone or infection Carotid body tumour/anyerysm Haematoma Thyroglossal cyst Brachial cyst

Answer 442

Cystic hygromas Dermoid cyst Haemangioma Venous malformation

Answer 443

Location (anterior/posterior triangle or midline) Size Shape (oval, round, irregular) Consistency (hard, soft, rubbery) Mobile or tethered to underlying tissue or skin Warmth Tenderness (?infection) Pulsatile (think carotid body anyeurysm) Movement with swallowing (thyroid) or tounge protusion (thyroglossal cyst) Transillunination with light (cystic hygroma)

Answer 444

Weight loss (malignancy, hyperthyroid) ENT infection Skin pallor and bruising - leukaemia Focal chest sounds (lung ca) Clubbing (lung cancer) Hepatosplenomegaly (leukaemia)

Answer 445

Unexplained neck lump in over 45s A persistent neck lump at any age

Answer 446

Within 2 weeks if under 25 Within 48hrs if 25+ If suggestive of soft tissue sarcoma requires a 2WW

Answer 447

Dependent on the suspected cause FBC and blood film for leukaemia and infection HIV test Monospot test or EBV antibodies for infectious mononucleosis Thyroid function tests for goitre or thyroid nodules Antinuclear antibodies for systemic lupus erythematosus Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma

Answer 448

Bloods (FBC, blood film, TFTs, HIV, monospot/EBV ab, ANA, LDH) Imaging (USS first line, CT or MRI, nuclear medicine scan - toxic thyroid nodules, PET scan for metastatic cancer) Biopsy (FNA, core, incision, removal of lump)

Answer 449

REACTIVE: URTI, dental infection, tonsillitis INFECTED: HIV, TB, EBV INFLAMMATORY CONDITIONS: SLE, sarcoidosis MALIGNANCY: lymphoma, leukaemia, metastasis

Answer 450

Supraclavicular lymph nodes (malignancy of chest of abdomen)

Answer 451

Unexplained - not associated with infection Persistently enlarged > 3cm diameter Abnormally shaped (ie oval with length more than double width) Hard or rubbery Thethered or fixed to skin or underlying tissues Associated constitutional symptoms

Answer 452

Infectious mononucleosis is a cause of lymphadenopathy. It is caused by infection with the Epstein Barr virus (EBV) and most often affects teenagers and young adults. It is found in the saliva of infected individuals and may be spread by kissing or sharing cups, toothbrushes and other equipment that transmits saliva. It presents with Fever Sore throat Fatigue Lymphadenopathy Mononucleosis can present with an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins. The first-line investigation is the Monospot test. It is also possible to test for IgM (acute infection) and IgG (immunity) to the Epstein Barr virus. Management is supportive. Patients should avoid alcohol (risk of liver impairment) and contact sports (risk of splenic rupture).

Answer 453

Reed Sternberg cells

Answer 454

Systemic symptoms, including: Fever Weight loss Night sweats

Answer 455

Lymphomas are a group of cancers that affect the lymphocytes inside the lymphatic system. These cancerous cells proliferate within the lymph nodes and cause the lymph nodes to become abnormally large (lymphadenopathy). There are two categories of lymphoma: Hodgkin’s lymphoma and non-Hodgkin’s lymphoma. Hodgkin’s lymphoma is a specific disease and non-Hodgkins lymphoma encompasses all the other lymphomas.

Answer 456

Lymphocytes

Answer 457

Binomial age distribution Peak around 20 and 75 years

Answer 458

Lymphadenopathy is the key presenting symptom. The enlarged lymph node or nodes might be in the neck, axilla (armpit) or inguinal (groin) region. They are characteristically non-tender and feel “rubbery”. Some patients will experience pain in the lymph nodes when they drink alcohol.

Answer 459

Ann Arbor staging system

Answer 460

Leukaemia is the name for cancer of a particular line of the stem cells in the bone marrow. This causes the unregulated production of certain types of blood cells. They can be classified depending on how rapidly they progress (chronic is slow and acute is fast) and the cell line that is affected (myeloid or lymphoid) to make four main types: Acute myeloid leukaemia Acute lymphoblastic leukaemia Chronic myeloid leukaemia Chronic lymphocytic leukaemia The presentation of leukaemia is quite non-specific. If leukaemia appears on your list of differentials then get an urgent full blood count. Some typical features are: Fatigue Fever Pallor due to anaemia Petechiae and abnormal bruising due to thrombocytopenia Abnormal bleeding Lymphadenopathy Hepatosplenomegaly

Answer 461

Generalised swelling of the thyroid gland

Answer 462

Graves disease (hyperhtyroidism) Toxic multinodular goitre (hyperthyroidsm) Hashimoto's thyroiditis (hypothyroidism) Iodine deficiency Lithium

Answer 463

Parotid glands Submandibular glands Sublingal glands

Answer 464

Benign hyperplastic nodules Thyroid cysts Thyroid adenomas (benign tumours that can release excessive thyroid hormone) Thyroid cancer (papillary or follicular) Parathyroid tumour

Answer 465

Sialolithasis - stones blocking the drainage of the glands Infection Tumours (benign or mallignant)

Answer 466

Glomus cells - chemoreceptors that detect the bloods oxygen, CO2 and pH. Paraganglia - group of glomus cells

Answer 467

Tumour of the glomus cells of the carotid body. Usually benign and slow growing. Painless, pulsatile lump which is mobile laterally (not vertically) with associated bruit found in the anterior triangle of the neck (near the angle of the mandible)

Answer 468

Compression of the glospharygeal (IX) nerve, vagus nerve (X), acessory nerve (XI) or hypoglosssal (XII) nerve

Answer 469

Horners syndrome: Ptosis, miosis, anhidrosis

Answer 470

Vagus nerve

Answer 471

Ptosis Miosis Anhidrosis

Answer 472

A characteristic finding on imaging investigations is splaying (separating) of the internal and external carotid arteries (lyre sign).

Answer 473

Surgical removal

Answer 474

Benign tumours of adipose tissue Soft Painless Mobile Absence of skin changes They are typically treated conservatively with reassurance (after excluding other pathology). Alternatively, they can be surgically removed.

Answer 475

Midline of neck Mobile Non tender Soft Fluctuant Move up and down with movement of the tongue (due to connection between thyroglossal duct and tounge) Can use USS or CT to confirm diagnosis

Answer 476

Surgical removal: To confirm diagnosis on histology To prevent infection of the cyst (causing a hot, tender and painful lump) May recurr after surgical removal

Answer 477

Thyroglossal cyst

Answer 478

Ectopic thyroid tissue

Answer 479

Thyroid gland starts developing in the fetus at the base of the toungue It graduall travels down the neck to final position in front the the trachea and beaneath the larynx It leaves a track behind called the thyroglossal duct which usually regresses but can persist and give rise to a fluid-filled cyst

Answer 480

Congenital abnormality Failure of complete second brachial cleft formation This leaves space surrounded by epitherial tissue in the LATERAL aspect of the neck which can fill with fluid

Answer 481

Soft Round Cystic swelling Between angle of the jaw and sternocleidomastoid muscle in the anterior triangle of the neck Usually after 10 years of age once the cyst becomes noticible or infected

Answer 482

Soft Round Cystic swelling Between angle of the jaw and sternocleidomastoid muscle in the anterior triangle of the neck Usually after 10 years of age once the cyst becomes noticible or infected

Answer 483

Conservative, without any active intervention, where it is not causing problems Surgical excision where recurrent infections are occurring, there is diagnostic doubt, or it is causing other problems

Answer 484

Likely brachial cyst (most commonly originating from the second brachial cleft)

Answer 485

Nasal cavity Paranasal sinuses Mouth Salivary gland Pharynx (throat) Larynx (epiglottis, supraglottic, vocal cords, glottis and sub glottis)

Answer 486

Management will be guided by the multidisciplinary team (MDT). It will be dependent on the location, stage and individual patient factors. Staging usually involves the TNM staging system, grading the tumour, node involvement and metastases. Treatment may involve any combination of: Chemotherapy Radiotherapy Surgery Targeted cancer drugs (i.e., monoclonal antibodies) Palliative care Cetuximab is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck. It may also be used to treat bowel cancer. It targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.

Answer 487

Cetuximab is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck. It may also be used to treat bowel cancer. It targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.

Answer 488

Glossitis refers to an inflamed tongue. The tongue becomes red, sore and swollen. The papillae of the tongue atrophy (shrink), giving the tongue a smooth appearance. It is sometimes described as “beefy”.

Answer 489

Iron deficiency anaemia B12 deficiency Folate deficiency Coeliac disease Injury or irritant exposure

Answer 490

Angioedema refers to fluid accumulating in the tissues, resulting in swelling. It can affect a number of areas, such as the limbs, face and lips. It can affect the tongue, causing the tongue to swell. The three top causes of angioedema to remember for exams are: Allergic reactions ACE inhibitors C1 esterase inhibitor deficiency (hereditary angioedema)

Answer 491

Angioodema

Answer 492

Oral candidiasis is also called oral thrush. It refers to an overgrowth of candida albicans, a type of fungus, in the mouth. This results in white spots or patches that coat the surface of the tongue and palate.

Answer 493

Inhaled corticosteroids (particularly with poor technique, not using a spacer and not rinsing with water afterwards) Antibiotics (disrupt the normal bacterial flora giving candida a chance to thrive) Diabetes Immunodeficiency (consider HIV) Smoking

Answer 494

Miconazole gel Nystatin suspension Fluconazole tablets (in severe or recurrent cases)

Answer 495

Inflammatory condition where patches of epithelium and papillae of the tongue are lost. Patches are irregular shaped (resembelling a map) The condition tends to relapse and remit, with episodes of the abnormal tongue appearance that can last days to weeks before resolving or changing. The cause of these changes is not known. Geographic tongue is a benign condition and does not cause any harmful effects. It does not usually require any treatment. Symptoms such as discomfort or burning are sometimes treated with topical steroids or antihistamines.

Answer 496

Geographic tongue

Answer 497

Geographic tongue often occurs without any associations. However, it can be related to: Stress and mental illness Psoriasis Atopy (asthma, hayfever and eczema) Diabetes

Answer 498

Geographic tongue often occurs without any associations. However, it can be related to: Stress and mental illness Psoriasis Atopy (asthma, hayfever and eczema) Diabetes

Answer 499

A strawberry tongue appearance occurs when the tongue becomes swollen and red, and the papillae become enlarged, white and prominent. The two key causes of a strawberry tongue to remember are: Scarlet fever Kawasaki disease

Answer 500

Strawberry tongue

Answer 501

Black hairy tongue results from decreased shedding (exfoliation) of keratin from the tongue’s surface. The papillae elongate and take on the appearance of hairs. Bacteria and food cause the dark pigmentation. This gives the appearance of black hair on the tongue. Patients may also report sticky saliva and a metallic taste. Black hairy tongue may be due to dehydration, a dry mouth, poor oral hygiene and smoking. Management involves ensuring adequate hydration, gentle brushing of the tongue and stopping smoking.

Answer 502

Black hairy tongue results from decreased shedding (exfoliation) of keratin from the tongue’s surface. The papillae elongate and take on the appearance of hairs. Bacteria and food cause the dark pigmentation. This gives the appearance of black hair on the tongue. Patients may also report sticky saliva and a metallic taste.

Answer 503

White patches on mouth (tongue/buccal mucosa)

Answer 504

It is a precancerous condition, meaning it increases the risk of squamous cell carcinoma of the mouth. They may require a biopsy to exclude abnormal cells (dysplasia) or cancer.

Answer 505

Management involves stopping smoking, reducing alcohol intake, close monitoring and potentially laser removal or surgical excision.

Answer 506

Leukoplakia

Answer 507

Erythroplakia is similar to leukoplakia (white patches on tongue/bucal mucosa), except the lesions are red. Erythroleukoplakia refers to lesions that are a mixture of red and white. Both erythroplakia and erythroleukoplakia are associated with a high risk of squamous cell carcinoma and should be referred urgently to exclude cancer.

Answer 508

Erythroplakia/erythroplasia

Answer 509

Lichen planus is an autoimmune condition that causes localised chronic inflammation of the skin. The skin has shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae. It usually occurs in patients over 45 and is more common in women. Lichen planus can also affect the mucosal membranes, including the mouth. Often it only affects the mouth. In the mouth, it can take three patterns: Reticular Erosive Plaque

Answer 510

Lichen planus

Answer 511

A reticular pattern involves a net-like web of white lines called Wickham’s striae.

Answer 512

Lichen plannus reticular pattern (Wickham's striae)

Answer 513

Erosive lesions are where the surface layer of the mucosa is eroded, leaving bright red and sore areas of mucosa.

Answer 514

Erosive lichen planus

Answer 515

Plaques are larger continuous areas of white mucosa.

Answer 516

Oral lichen planus plaque pattern

Answer 517

Smoking cessation Good oral hygiene Topical steroids

Answer 518

Gum inflammation Swollen gums Bleeding after burshing Halitosis (bad breath)

Answer 519

Periodontitis refers to severe and chronic inflammation of the gums and the tissues that support the teeth. This often leads to loss of teeth. Acute necrotising ulcerative gingivitis is a rapid onset of more severe inflammation in the gums. It presents similarly to gingivitis, however, it is painful. Anaerobic bacteria usually cause this.

Answer 520

Palque build up - inadequete brushing Smoking Diabetes Malnutrition Stress

Answer 521

Bacteria live in plaque, damaging the teeth and gums. Hardened plaque is called tartar.

Answer 522

Good oral hygiene Stopping smoking Dental hygienist treatment to remove plaque and tartar Chlorhexidine mouth wash Antibiotics for acute necrotising ulcerative gingivitis (e.g., metronidazole) Dental surgery if required

Answer 523

Gingival hyperplasia refers to abnormal growth of the gums. The gums are notably enlarged around the teeth. Possible causes of gingival hyperplasia include: Gingivitis Pregnancy Vitamin C deficiency (scurvy) Acute myeloid leukaemia Medications, particularly calcium channel blockers, phenytoin and ciclosporin

Answer 524

Two parts, superficial and deep to the posterior boarder of the mylohiod in a U shaped pattern. Superficial part: in the digastric triangle, partially deep to the maindible, covered superficially by the plasmyta and the skin Deep part: between myohyoid and the hypoglossus Duct runs from deep part and is crossed by the lingual nerve Hypoglossal nerve runs deep to the gland Cervical branch of the facial nerve runs superfically to the gland

Answer 525

Submandibular (cervical branch runs superfically to gland)

Answer 526

Lingual Hypoglossal Cervical branch of CN7

Answer 527

Inferior belly of omohyoid muscle crosses SCM to anterior triangle A number of vertebral muscles (covered by prevertebral fascia) form the floor of the posterior triangle: Splenius capitis Levator scapulae Anterior, middle and posterior scalenes

Answer 528

External jugular vein (superficially) after crossing SCM Within the posterior triangle, the external jugular vein pierces the investing layer of fascia and empties into the subclavian vein.

Answer 529

The external jugular vein has a relatively superficial course down the neck, leaving it vulnerable to damage. If it is severed, in an injury such as a knife slash, its lumen is held open – this is due to the thick layer of investing fascia Air will be drawn into the vein, producing cyanosis, and can stop blood flow through the right atrium. This is a medical emergency, managed by the application of pressure to the wound – stopping the bleeding, and the entry of air. The transverse cervical and suprascapular veins also lie in the posterior triangle The subclavian, transverse cervical and suprascapular veins are accompanied by their respective arteries in the posterior triangle.

Answer 530

Accessory nerve (XI) crosses the posterior triangle in an oblique, inferoposterior direction, within the investing layer of fascia. It lies relatively superficial in the posterior triangle, leaving it vulnerable to injury. The cervical plexus forms within the muscles of the floor of the posterior triangle. A major branch of this plexus is the phrenic nerve, which arises from the anterior divisions of spinal nerves C3-C5. It descends down the neck, within the prevertebral fascia, to innervate the diaphragm. Other branches of the cervical plexus innervate the vertebral muscles, and provide cutaneous innervation to parts of the neck and scalp. The trunks of the brachial plexus also cross the floor of the posterior triangle.

Answer 531

For anaesthesia of the neck area, a cervical plexus block can be used. Local anaesthetic is injected along the posterior border of sternocleidomastoid at the junction of its superior and middle thirds. This junction is where the cutaneous branches of the cervical plexus emerge, known as the nerve point of the neck.

Answer 532

The omohyoid muscle splits the posterior triangle of the neck into two: The larger, superior part is termed the occipital triangle. The inferior triangle is known as the subclavian triangle and contains the distal portion of the subclavian artery. It is also known as the omoclavicular or supraclavicular triangle.

Answer 533

Neck mass anterior to the ear

Answer 534

Lump anterior to ear Palpable lymph nodes in neck Facial nerve palsy (drooling, face droop, etc)

Answer 535

Shoulder drop

Answer 536

Freys syndrome is a rare neurological disorder resulting from damage to or near the parotid glands responsible for making saliva, and from damage to the auriculotemporal nerve often from surgery.

Answer 537

High risk of bleeding Thyrotoxic storm

Answer 538

Hypothyroidism Damage to parathyroid glands - hypoparathyroidism and hypocalcemia RLN damage Bleeding infection

Answer 539

The nerves branch off the vagus nerves in the neck Left side loops under the aortic arch The right loops under the right subclavian artery Both then pass upawrds to supply the larygeal muscles passing deep to the cricothyroid joint

Answer 540

Aphthous ulcers are very common, small, painful ulcers of the mucosa in the mouth. They have a well-circumscribed, punched-out, white appearance.

Answer 541

Apthous ulcers

Answer 542

Aphthous ulcers commonly occur in otherwise healthy people, with no underlying cause. They may be triggered by emotional or physical stress, trauma to the mucosa or particular foods. They may also be an indication of underlying conditions, notably: Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) Coeliac disease Behçet disease Vitamin deficiency (e.g., iron, B12, folate and vitamin D) HIV

Answer 543

Aphthous ulcers usually heal within 2 weeks. Manageable ulcers do not require any intervention. Topical treatments can be used to treat symptoms, including: Choline salicylate (e.g., Bonjela) Benzydamine (e.g., Difflam spray) Lidocaine Topical corticosteroids can be used in more severe ulcers. These may reduce the duration and severity of symptoms. Options include: Hydrocortisone buccal tablets applied to the lesion Betamethasone soluble tablets applied to the lesion Beclomethasone inhaler sprayed directly onto the lesion The NICE guidelines on suspected cancer (updated January 2021) recommend a two week wait referral in patients with “unexplained ulceration” lasting over 3 weeks.

Answer 544

The facial nerve exits the brainstem at the cerebellopontine angle. On its journey to the face, it passes through the temporal bone and parotid gland. It then divides into five branches that supply different areas of the face: Temporal Zygomatic Buccal Marginal mandibular Cervical

Answer 545

Muscles of facial expression Stapedius Posterior digastric, stylohyoid and platysma muscles in the neck

Answer 546

Anterior 2/3 of the tongue

Answer 547

Submandibular and salivary glands Lacrimal glands

Answer 548

It is essential to make this distinction because, in a patient with a new-onset upper motor neurone facial nerve palsy, you should be referring immediately with a suspected stroke. In contrast, patients with a lower motor neurone facial nerve palsy can be managed with less urgency.

Answer 549

Each side of the forehead has upper motor neurone innervation by both sides of the brain. However, each side of the forehead only has lower motor neurone innervation from one side of the brain. In an upper motor neurone lesion, the forehead will be spared, and the patient can move their forehead on the affected side. In a lower motor neurone lesion, the forehead will NOT be spared, and the patient cannot move their forehead on the affected side. You can differentiate between an upper and lower motor neurone lesion by asking the patient to raise their eyebrows. If they can raise both eyebrows and wrinkle both sides of the forehead, the patient has an upper motor neurone lesion. If the eyebrow on the affected side cannot be raised and the forehead remains smooth, the patient has a lower motor neurone lesion.

Answer 550

Unilateral upper motor neurone lesions occur in: Cerebrovascular accidents (strokes) Tumours Bilateral upper motor neurone lesions are rare. They may occur in: Pseudobulbar palsies Motor neurone disease

Answer 551

Bells plasy Ramsy hunt syndrome Infection Trauma Tumour Systemic disease

Answer 552

Bell’s palsy is a relatively common condition. It is idiopathic, meaning there is no apparent cause. It presents as a unilateral lower motor neurone facial nerve palsy. The majority of patients fully recover over several weeks, but recovery may take up to 12 months. A third are left with some residual weakness. If patients present within 72 hours of developing symptoms, NICE clinical knowledge summaries (updated 2019) recommend considering prednisolone as treatment, either: 50mg for 10 days 60mg for 5 days followed by a 5-day reducing regime of 10mg a day Patients also require lubricating eye drops to prevent the eye on the affected side from drying out and being damaged. If they develop pain in the eye, they need an ophthalmology review for exposure keratopathy. The eye can be taped closed at night.

Answer 553

Ramsay-Hunt syndrome is caused by the varicella zoster virus (VZV). It presents as a unilateral lower motor neurone facial nerve palsy. Patients stereotypically have a painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side. This rash can extend to the anterior two-thirds of the tongue and hard palate. Treatment should ideally be initiated within 72 hours. Treatment is with: Prednisolone Aciclovir Patients also require lubricating eye drops.

Answer 554

Diabetes Sarcoidosis Leukaemia MS Gulliane Barre syndrome

Answer 555

Otitis media Mallignant otits externa HIV Lyme disease VZV

Answer 556

Acoustic neuroma Parotid tumour Cholesteoma

Answer 557

Direct trauma Damage during surgery Base of skull fracture

Answer 558

The thyroid gland is located at the base of the neck. It is a highly vascular structure responsible for controlling the basal metabolic rate of the body through the production of thyroxine and triiodothyronine hormones.

Answer 559

The arterial supply to the thyroid is from the superior and inferior thyroid arteries. Venous drainage of the thyroid is via the superior, middle, and inferior thyroid veins

Answer 560

The recurrent laryngeal nerves are intimately associated with the thyroid gland running in the tracheo-oesophageal groove and are at risk during surgery. They supply the muscles of the larynx (except cricothyroid) and sensation below the vocal cords. Injury causes vocal cord palsy with associated hoarseness and can also give problems with airway obstruction if the nerves on both sides are injured.

Answer 561

The parathyroid glands are also closely related to the thyroid gland. They are involved in calcium haemostasis and can be accidentally removed or damaged during surgery leading to hypocalcaemia. This is normally only a problem when both sides of the thyroid have been operated on. i.e. total or completion thyroidectomy

Answer 562

TFTs FNA If there is any diagnostic doubt a hemithyroidectomy should be carried out to give definitive histology. Lumpectomies are not done on the thyroid because if it is a malignant nodule this will not give adequate margins on the mass and it would also make further surgery very difficult due to scarring and put the recurrent laryngeal nerve at an unacceptably high risk

Answer 563

Both managed with total hemithyroidectomy as CANNOT differentiate between the two on FNA, sent for definitive histology

Answer 564

Single nodule – colloid, cystic Multinodular goitre These are common and if they show typical features on ultrasound do not necessary require fine needle aspiration. Any dominant nodule should have an FNA.

Answer 565

Adenoma - mainly follicular

Answer 566

o Papillary adenocarcinoma – 70% - Often seen in younger patients, or where there is a history of irradiation of the neck. o Follicular carcinoma – 20% - It has a preponderance to metastasis to the bones and lungs. o Medullary carcinoma – 5% - This is a neoplasm of the calcitonin regulating C-cells. It is typically seen in multiple endocrine neoplasia, and therefore screening of other organs involved in MEN syndromes is required. There is a genetic component. o Anaplastic carcinoma - ~5% - Typically seen in older patients. This has a poor prognosis and by the time of diagnosis the prognosis if often a matter of weeks to months.

Answer 567

Conservative –these can be managed conservatively unless there is diagnostic uncertainty Surgery o For compressive symptoms, cosmesis or patient preference. o Should aim to restrict surgery to hemithyroidectomy due to the increased morbidity from a total thyroidectomy and the need for lifelong thyroxine replacement.

Answer 568

Adenomas – require no further treatment after diagnostic hemithyroidectomy Carcinoma o Surgery Total Thyroidectomy for papillary, follicular and medullary carcinoma Anaplastic disease is normally too far advanced for curative surgery o Radio-iodine therapy For papillary and follicular carcinoma after surgery

Answer 569

Post-operative haemorrhage Airway obstruction o Secondary to haemorrhage o Secondary to bilateral vocal cord palsy Vocal cord palsy Hypocalcaemia

Answer 570

The parotid gland is a serious salivary gland located anterior to the pinna and lateral to the ramus of the mandible. The gland is split into deep and superficial lobes by the facial nerve which passes through the gland. The majority of the gland lies superficial to the facial nerve. Facial palsy is one of the most serious risks from parotid surgery and can also be caused by a parotid malignancy

Answer 571

 80% of salivary gland neoplasms occur in the parotid gland.  80% of parotid neoplasms are benign in nature.  80% of benign parotid neoplasms are pleomorphic adenomas.

Answer 572

Parotid gland

Answer 573

Submandibular gland

Answer 574

The submandibular gland is located inferior to the body of the mandible and superior to the digastric muscle. It’s duct opens into the mouth close to the frenulum of the tongue. The hypoglossal and lingual nerves run medial to the gland and are at risk during submandibular gland surgery. Unlike the parotid gland, the submandibular gland has mixed mucous and serous secretions.

Answer 575

In the floor of the mouth

Answer 576

50% of neoplasms occurring in the submandibular gland are malignant

Answer 577

Submandibular abscesses may develop following sialolithiasis or sialadenitis

Answer 578

Sublingual (80%)

Answer 579

Acute sialadenitis may be viral or bacterial. Bacterial disease is typically due to staphylococcal infection and is typically seen in dehydrated or immunocompromised individuals. Viral disease is caused by a range of viruses including: 1. Paramyxovirus – Mumps 2. Coxsackievirus 3. Echovirus 4. HIV Chronic sialadenitis is rare, and sometimes seen in TB, sarcoidosis, HIV, and syphilis.

Answer 580

Sialadenitis is the inflammation and enlargement of one or several major salivary glands.

Answer 581

Submandibular

Answer 582

 Ultrasound  or sialogram

Answer 583

During meals

Answer 584

Conservative o most will settle conservatively o analgesia o hydration o sialogogues Endoscopy Radiological removal Surgery o Intraoral removal of palpable stones o Removal of salivary gland

Answer 585

 Sialadenitis  Abscess formation

Answer 586

This is an autoimmune disease causing lymphocytic infiltration into the ductal tissue of secretary glands. It classically presents with dry eyes and dry mouth and patients may have enlarged salivary glands. Patients are at increased risk of developing lymphoma. The disease may be primary: Xerostomia and xerophthalmia without connective tissue abnormality. Or secondary: As primary disease, with connective tissue disease, most commonly rheumatoid arthritis. Diagnosis is made from the history, examination, some specific autoantibodies and a biopsy of minor salivary glands on the inner lip

Answer 587

Cervical lymphadenopathy slow-onset and persistent pain, voice changes, family history, or rapidly enlarging masses.

Answer 588

Causes of bilateral sensorineural hearing loss include genetic diseases such as Charcot-Marie-Tooth disease, congenital rubella syndrome, presbycusis and ototoxicity at varying frequency range

Answer 589

Patients with a positive Schwartze sign may be more likely to have sensorineural (cochlear) otosclerosis. [5] [6] The finding of a reddish discoloration in a patient with hearing loss may suggest otosclerosis, especially of the sensorineural (cochlear) area

Answer 590

Movement of the facial muscles Otoscopy Palpation of the parotid gland and neck detailed examination of the external auditory canal and tympanic membrane

Answer 591

The facial nerve demarcates superficial and deep lobes

Answer 592

The facial nerve arises from the skull base via the stylomastoid foramen.

Answer 593

Xerostomia (dry mouth) represents a common sequelae following radiotherapy for parotid, oral cavity and oropharyngeal cancers. It is also a recognised side effect from medications including, but not limited to, diuretics, beta blockers, tricyclic antidepressants, antihistamines, anticonvulsants and antipsychotics.

Answer 594

External carotid artery Retromandibular vein Facial nerve

Answer 595

The apnoea hypopnoea index (AHI) is the number of apnoeas (stopping breathing) or hypopnoeas (reduced airflow during breathing) recorded during the sleep study per hour of sleep. It is generally expressed as the number of events per hour. Based on the AHI, the severity of OSA is classified as follows: None/Minimal: AHI < 5 per hour Mild: AHI ≥ 5, but < 15 per hour Moderate: AHI ≥ 15, but < 30 per hour Severe: AHI ≥ 30 per hour

Answer 596

Hypertension Depression Ischaemic heart disease Accidents Diabetes

Answer 597

Book the patient for an ENT clinic appointment within 7-10 days

Answer 598

Apply high flow oxygen via face-mask and remove surgical clips/sutures

Answer 599

Glottic tumours have the best prognosis

Answer 600

Thyroid surgery Aortic aneurysm repair Carcinoma of the oesophagus Carcinoma of the bronchus Polio

Answer 601

Ludwig’s angina is a form of severe, diffuse cellulitis with bilateral involvement of the submandibular space. Signs may include diffuse, bilateral submandibular and sublingual swelling. Oropharyngeal examination typically reveals elevation of the floor of mouth and posterior displacement of the tongue, creating the potential for a airway compromise. Ludwig’s angina therefore, represents a medical emergency. Temporising measures may include a nasopharyngeal airway. Oropharyngeal intubation is often extremely challenging due to retrograde tongue displacement. In extremis and in the presence of imminent, life-threatening airway obstruction, an emergency tracheostomy is indicated.

Answer 602

Marginal mandibular nerve- a branch of the facial nerve

Answer 603

Tonsilar SCC is associated with HPV infection

Answer 604

In patients with chronic or recurrent ear discharge, ensure the attic is visualised to exclude cholesteatoma

Answer 605

Rotatory nystagmus is indicative of a positive Dix-Hallpike manoeuvre

Answer 606

Unaffected hearing distinguishes vestibular neuronitis from labyrinthitis

Answer 607

A biopsy is performed and reveals cholesterol crystals in the fluid extracted.

Answer 608

After using topical decongestants for prolonged periods increasing doses are needed to provide the same effect, a phenomenon known as tachyphylaxis.

Answer 609

Cranial nerves V, VII and VIII are affected in vestibular schwannomas

Answer 610

Pure tone audiogram shows that bone and air conduction in both ears are poor at lower volumes (below 25dB) and within 10 dB of one another

Answer 611

Prochlorperazine may be useful in the acute phase of vestibular neuronitis, but should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms