ENT Flashcards
Acute rhinosinusitis: symptomatic management (5)
Regular oral analgesia
Saline nasal preparations (drops, rinses, sprays)
Intranasal corticosteroids (e.g Nasonex/mometasone 100mcg = 2 sprays daily for 4/52)
Intranasal decongestants (use up to max 3 days –> rhinitis medicamentosa)
Intranasal ipratropium (for rhinorrhoea)
Acute bacterial rhinosinusitis criteria (5)
and Management (1)
if penicillin allergic (2)
If not improving after 5 days (1)
Criteria:
1) Discoloured, purulent discharge
2) Fever >38.0
3) Severe unilateral/localised pain
4) Elevated CRP/ESR
5) Double sickening
Rx
-Amoxicillin 500mg TDS 5/7, or 1g BD 5/7
Pen allergic
-Cefuroxime 500mg BD 5/7
Severe allergy - Doxycycline 100mg BD 5/7
Not improving
-Augmentin DF BD 5/7
Otitis externa pharmacological management - if fungal not and if fungal suspected
Dexamethasone/Framycetin/Gramicidin ear drops 3 drops TDS for 7/7 - fungal infection NOT suspected, OR if GROMMET or PERF in situ
If fungal - flumethasone/clioquinol drops 3 drops BD for 7/7
Otitis externa non pharm management (4)
Keep ear dry
Aural toilet w/ tissue spears 6 hourly
Avoid syringing w/ water
Keep dry 2 weeks after treatment (ear plugs, shoewr cap when bathing/swimming)
Bell’s Palsy treatment (1), if Ramsay Hunt present (1)
high dose prednisolone 1mg/kg (up to 75mg) daily for 5 days
+ antiviral if Ramsay Hunt (Valaciclocvir 500mg TDS for 5/7)
Acute Rheumatic Fever - ?what is it
?High risk groups
Abnormal immune response to Strep A infection (of throat/skin)
high risk:
- ATSI rural/remote area
- ATSI/Maori/Pacific Islander in overcrowded/low SES place
- PHx of ARF or rheumatic heart disease, or recent FHx
- Living in ARF endemic setting
Conductive hearing loss DDx (7)
-Otitis media
-Ear wax impaction
-Otitis externa
-Cholesteatoma
-Otosclerosis
-Foreign object
-TM perforation
Sensorineural hearing loss DDx (7)
-SSNHL
-Presbyacusis (bilat)
-Meniere’s Disease
-Acoustic neuroma (can be bilat)
-Labyrinthitis
-Noise damage/ototoxicity (bilat)
-Head trauma
Sensorineural hearing loss DDx (7)
-SSNHL
-Presbyacusis (bilat)
-Meniere’s Disease
-Acoustic neuroma (can be bilat)
-Labyrinthitis
-Noise damage/ototoxicity (bilat)
-Head trauma
Tinnitus Ix (2)
Pure tone audiometry (FOR ALL PTS)
CT if ?unilateral ?pulsatile (CT Angio or temporal bone)
Otosclerosis = progressive hearing loss + tinnitus
Tinnitus Mx options (4)
○ Reassurance
○ Hearing aids (if SNHL is bothersome)
○ Sound therapy (reduce perception of tinnitus)
- CBT
Vertigo general Mx measures (4)
BPPV Rx (3)
General measures
○ Anti-emetics e.g betahistine
○ Salt restriction
○ Avoid eTOH and coffee
○ Vestibular physio
BPPV
-Epley manoeuvre/Semont manoeuvre/Brandt-Daroff exercises
-Drugs (only use for 48hrs max)
–Prochlorperazine (stemetil) 5-10mg QID PRN
–Promethazine (phenergan) 25-50mg TDS PRN
Diagnosis?
Vertigo + hearing loss + tinnitus
Preceding URTI
Vertigo lasts seconds - minutes
Symptoms present days - weeks
Acute labyrinthitis
Diagnosis?
Preceding viral infection
Acute onset vertigo
NO hearing loss
Horizontal/torsional nystagmus
Severe symptoms, 2-3 days
Can use high dose pred to treat (1mg/kg up to 75mg)
Vestibular neuritis
Vertigo lasting >20 mins, hours
Tinnitus + hearing loss
+Rombergs, Fukuda stepping test, impaired heel-toe walking
Investigate for SNHL - audiometry
Rx - hydrochlorothiazide 25mg daily - reduce endolymphatic pressure with lowered salt/water content?
Meniere’s disease
no cure - progressive hearing loss expected. other Rx options - hearing aids, reduce salt <2g/day, intratympanic injections, positive pressure therapy, surgery
Facial pain DDx (8)
Migraine
Trigeminal neuralgia
Cluster/tension headache
TMJ Dysfunction
Sinus disease
Paroxysmal hemicrania
Dental source/infection
Salivary gland lesions
trigeminal autonomic cephalgias = unilateral, side-locked, a/w autonomic features (ptosis, tearing, rhinorrhoea, aural fullness, tinnitus, photophobia)
-Rx w/ indometacin
-DIFFERENT from trigeminal neuralgia - no autonomic features
Chronic rhinosinusitis Rx
Oral/intranasal antihistamine
+intranasal steroid BD
for 8 weeks
Short course steroids 25mg daily 5-10 days or tapering longer dose if polyps
Refer ENT if 6-8 week trial fails
Nasal polyps in kids = ?CF
- Contraindications to ear syringing (4)
○ Otitis externa/media (current)
○ Tympanic membrane perforation (–> Rx w/ ciprofloxacin topical drops)
○ History of ear surgery
○ Unilateral deafness/only good ear
Trigeminal Neuralgia management, 1st/2nd/3rd line options
Ix to consider? (1)
§ eTG says - 1st line - carbamazepine MR 100mg BD, assess response after 7/7
§ 2nd line - oxcarbazepine 300mg BD, assess post-7/7
§ 3rd line - baclofen 5mg DD/gabapentin 300mg nocte/pregab 75mg nocte/phenytoin 300mg daily/lamotrigine 25mg alternate daily
MRI (?brain ?trigeminal nerve) - exclude secondary causes such as MS or tumour
TMJ Dysfunction Clin features (5)
Diagnosis?
○ Mandibular pain, radiating to scalp or neck
○ Aggravated by chewing, yawning, long talking
○ Difficulty mouth opening, clicking/crepitus
○ Tension-like headache
○ Otalgia (+ tinnitus, aural fullness, vertigo)
usually clinical, MRI actually gold standard
TMJ Dysfunction Management (6)
○ Patient education/reassurance
- Jaw rest/soft diet
- Warm compress/massage
- Jaw muscle stretching/massage w/ physio
- Intraoral occlusal splint overnight (?mouthgard)
○ CBT, sleep hygiene
○ NSAIDs 1st-line/Benzos for masticatory muscle spasm
Undisplaced vs. displaced nasal fracture management
- Undisplaced nasal fractures w/o functional symptoms - conservative Rx
- Displaced fractures - refer ENT for reduction within two weeks (2 week window before displaced nasal bones begin uniting)
Epistaxis management (3)
-Pressure to hold nose closed w/ thumb and forefinger (10-20 mins)
-Lean forwards
-Nasal packing (e.g RapidRhino) - leave in for 3-5 days
?No Abx prophylaxis
Septal haematoma/abscess clin. features
-management
Bilateral septal swelling, boggy to palpate
Urgent referral to ED, drainage, IV Abx
Facial fracture examination features (5)
-Palpate over mandible/zygoma/maxilla
-Assess mouth occlusion
-Intra-oral & nasal examination
-Visual acuity, range of eye movements
-Mid-face/forehead sensation
Neck mass red flags (5)
Neck mass Ix (2)
○ Mass present >2 weeks
○ Recent voice change
○ Dysphagia/odynophagia
○ Ipsilateral otalgia/nasal obstruction/epistaxis
- Unexplained LOW/LOA
CT of neck w/ contrast + FNA
Oral SCC clin. features
- Non-healing ulcer
-indurated/firm
-irregular margins
-raised, rolled edges
-May not be painful
Oral candidiasis risk factors (8)
-Poor hygiene/dry mouth (xerostomia)
-Dentures
-Immunodeficiency
-Diabetes
-Abx use
-Steroids (inhaled)
-Chemo/RadioTx
-Smoking
?Diagnosis
Interlacing white lines (Wickham striae) on oral buccal mucosa
Can be asymptomatic or ulcerate
Most don’t need Rx, or topical steroids/retinoids/oral hygiene
Oral lichen planus
Leukoplakia vs. Erythroplakia - definitions & management
Leukoplakia = “white plaques of questionable risk”
-NEEDS BIOPSY
Erythroplakia = ‘red’ discolouration, 90% rate of SCC/high-grade dysplasia –> URGENT REFER FOR BIOPSY
Submucosal/jaw swelling DDx (7)
1st line Ix?
Mucocele
Fibroepithelial polyp
Pyogenic granuloma - raised, red, bleeds easily
Palatal abscess/cyst
Salivary gland tumours
Exsostes/tori (hard bony swellings)
Jaw cyst - periapical cysts most common
OPG to Ix
Central cause vertigo DDx (4)
Cerebellar infarction/haemorrhage
Vertebrobasilra insufficiency
Vestibular migraine
Multiple sclerosis
Ix of choice for r/o acoustic neuroma or demyelinating disease
Gadolinium-enhanced MRI Brain
Allergic rhinitis - testing options
Management features (3)
-?For persistent nasal obstruction
-?For marked rhinorrhoea
-?For coexisting asthma
Total/specific IgE
§ Total = screening test
§ RAST = allergen-specific - directly measures quantity of specific IgE to particular antigen
§ MBS only 4 tests at once - so e.g dust mite mix, Alternaria mould, grass pollen mix, animal dander mix (pts can continue antihistamines prior to these tests)
○ Skin testing against specific antigen
Minimise exposure to allergen
-Oral/intranasal antihistamine
-+intranasal steroid
-Persistent nasal obstruction - intranasal antihist/steroid combo
-Rhinorrhoea - intranasal ipratropium
-Asthma - montelukast
Diagnosis?
Gentle pressure of tragus - induces vertigo/nystagmus
Perilymphatic fistula
Rare cause of vertigo. Abnormal connection between inner and middle ear, from head or barotrauma
Otitis media - high risk episode (2)
<2 years old + bilateral Acute Otitis Media
<2 years old + fever >38.5
Otitis Media ATSI children guidelines - high risk factors (8)
-Living in remote community
-<2 y.o
-1st episode OM <6 months of age
-Persistent OME/current bilateral AOMwoP, recurrent AOMwoP, current AOMwiP/recurrent, current CSOM, Phx or FHx of CSOM
-Craniofacial abnormalities/cleft palate
-Down syndrome/developmental delay
-Immunodeficiency
-Hearing loss/visual impairment
Acute Otitis Media dx criteria
-Treatment
Fluid behind TM + at least one of
-Bulging TM
-Injected TM
-Fever
-Recent purulent discharge
-Ear pain
-Irritability
If not high risk episode - monitor - review 4-7 days
If high risk - amoxicillin 50mg/kg daily in divided doses for 7 days
-If no improvement - increase dose to 90mg/kg
-If no improvement + penicillin resistant region - change to Aug DF
-If adherence poor/no fridge - stat dose azithro 30mg/kg + repeat dose 1/52 after
Recurrent Acute Otitis Media - is prophylaxis recommended?
Routine prophylaxis NOT recommended
Recurrent = >3 eps in 6/12, >4 in last 12/12
If so - amoxi 50mg/kg daily for 3-6 months
Acute Otitis Media w/ Perforation Rx
Amoxicillin 50-90mg/kg daily for 14 days or stat dose azithro 30mg/kg
If no improvement - max dose amoxi or 2nd dose azithro
Oral burning/Burning Mouth Syndrome DDx (8)
?Rx
-Medication related (ACEi, Abx)
-Trauma (physical/chemical/thermal/RTx)
-Autoimmune - Sjogrens, oral lichen planus
-Cancer
-Idiopathic
-Infective e.g candidiasis
-Nutritional deficiency
-Diabetes
Rx - topical clonazepam, B12/zinc supp.
Salivary gland swelling DDx (7 broad categories)
Neoplastic - lymphoma, adenocarcinoma etc.
Infection - viral (mumps, EBV), staph parotitis
Metabolic - Alcoholic liver disease, malnutrition/bulimia, obesity
Endocrine - Diabetes, hypothyroidism, Cushing’s
Meds - Anticholinergics, antipsychotics
Obstructive - stones, ranula
Autoimmune - Sjogrens
Salivary gland swelling Ix (2)
Suspected inflammatory process –> USS
Suspected solid mass or neoplasm –> MRI/CT
Oral Manifestations of Crohn’s disease (7)
-Lip swelling
-Deep linear ulcerations/apthous ulcers
-Cobblestoning of mucosa
-Mucosal tags
-Mucogingivitis
-Angular chelitis
-Pyostomatitis (oral pustules)
