ENT Flashcards
What are the clinical features of otitis media?
- Ear pain
- Discharge
- Fever
How do you manage otitis media?
Conservative - watch and wait, monitor childs development
Medical - abx after 2-3 day delay, amoxicillin first line, erythromycin if allergy
Surgical - grommet insertion to correct Eustachian tube dysfunc
What are the complications of otitis media?
- Chronic otitis media and chronic ear discharge
- Cholesteatoma
- TM peforation
- Conductive hearing loss
- Infection spread intracranially - brain abscess
What is the management of chronic otitis media?
Cholesteatoma - surgery to remove and mastoidectomy
If no cholesteatoma found = repair perforation
What are the causes of pain in the ear?
- Otitis externa
- Otitis media
- Otitis interna
- TM perforation
- Haemotympanum
What is haemotympanum? What are the signs and sx?
Blood in the middle ear, often associated w temporal bone fracture.
Signs - conductive hearing loss, blood seen through TM
What are the risks of mastoid surgery?
- Facial nerve palsy
- Alt taste due to damage of chorda tympani
- CSF leak
- Tinnitus, vertigo and complete hearing loss in operated ear
What are the clinical features of otitis media w effusion?
- Conductive hearing loss
- Ear pain
- Can see effusion and fluid behind tympanic membrane
What are the ix of otitis media w effusion?
- Tympanogram - type B/flat tracing w normal canal vol
- Pure tone audiogram - conductive hearing loss
What is the management of otitis media w effusion?
- Conservative to see if spont resolution
- Grommets
What is a tympanogram?
Measure compliance of the TM in response to pressure changes in the middle ear. Can be performed at all ages.
Type A - normal, peak at 0
Type B - flat
Type C - peak earlier than 0, on the neg side of the chart
What is a pure tone audiogram?
Measures hearing sensitivity. Can be performed 4+.
The higher the line on the graph, the better the hearing.
Conductive - normal bone conduction and reduced air conduction
Sensorineural - reduced bone and air conduction
What are the different types of hearing loss and what are the results of tuning fork tests?
- Conductive, outer or middle ear pathology, bone louder than air and sound louder in bad ear
- Sensorineural, inner ear pathology, air louder than bone and sound loud in good ear
What are the causes of type B and type C tympanograms?
Type B - otitis media w effusion or perforation
Type C - eustachian tube dysfunction
How should sensorineural hearing loss be investigated?
With an MRI scan to exclude lesions along the pathway eg. acoustic neuroma/vestibular schwanoma
What are some causes of childhood hearing loss?
Congenital - infections eg. rubella, drug and alcohol use in pregnancy, genetic causes, preeclampsia, hypoxia at birth
Acquired -meningitis, perforated TM, otitis media, otosclerosis/Menieres disease, noise induced head injury
What is otosclerosis and what are the clinical features?
Autosomal dominant disease causing fusing of the ossicles and progressive hearing loss.
- Hearing loss
- Tinnitus
- Hearing improved in noisy surroundings
- FH
- Carhart’s notch on PTA = loss of bone conduction at 2000Hz
What is Schwartze sign?
Rare but pink hue to TM in otosclerosis
What are the ix into otosclerosis?
- Tympanogram - type A trace
- PTA - conductive hearing loss
What is the management on otosclerosis?
- Hearing aid
- Stapedectomy
What are some non vestibular causes of dizziness?
- Hypoglycaemia
- Postural hypotension/hypotension
- Dehydration
- Incontinence
- Cervical dizziness
- Visual disturbances
- Stress and fatigue
- Neuropathies eg. diabetic foot, less sensation in feet and feel unsteady and dizzy
- Aneurysm
- Arrythmia
- Heart failure and MI
- Medications
What are the vestibular causes of vertigo/dizziness?
Central - stroke, migraine, cancer, demyelination eg. MS, drugs
Peripheral - BPPV, Meniere’s, vestibular neuritis
What are the clinical features of BPPV?
Vertigo w head movements, lasts for a few seconds.
How do you diagnose and treat BPPV?
Diagnose - Dix Hallpike manoeuvre - torsional geotrophic nystagmus, recreates sx
Treat - Epley manoeuvre
What are the clinical features of Meniere’s disease?
- Vertigo
- Nausea and vomiting
- Tinnitus
- Aural fullness
- Sensorineural hearing loss, goes from fluctuating to permanent
What is the management of Meniere’s?
Medical - thiazide diuretics eg. bendrofluazide, betahistine, prochloperazine for acute attacks
Surgery - grommets, dex middle ear injection, vestibular destruction = inject gentamicin in middle ear, labrinthectomy
What are the clinical features of vestibular neuronitis?
- Severe vertigo lasting days
- nausea and vomiting
- General unsteadiness for weeks following the episode
- Horizontal nystagmus - HINTS exam
What is the management of vestibular neuronitis?
Vestibular sedatives during acute attacks and IV fluids if vomiting is severe enough
What is the prognosis of sudden onset sensorineural hearing loss?
Is an otological emergency
1/3 recover completely, 1/3 partially recover, 1/3 no recovery at all
What are the ix into sudden sensorineural hearing loss?
- Pure tone audiogram
- MRI scan to exclude lesion along central auditory pathway eg. acoustic neuroma
What is the management of sudden sensorinural hearing loss?
- Steroids - oral or injected into middle ear
- Anti virals
What is Weber’s test?
Tuning fork placed on patients forehead and pt is asked where they can hear the noise:
- Sensorineural - tone heard in good ear
- Conductive - tone heard in bad ear
What is Rinne test?
Tuning fork is placed on the pt mastoid and then just outside the ear:
+ve Rinnes = tuning fork louder in air, Sensorinueral (or not heard)
-ve Rinnes = tuning fork louder in bone, Conductive
What are the local causes of epitaxis?
- Idiopathic (85%)
- Trauma
- Iatrogenic
- Foreign body
- Inflam - rhinitis, polyps
- Neoplastic
What are the systemic causes of epitaxis?
- HTN
- Coagulopathies
- Vasculopathies
- Hereditary haemorrhagic telangiectasia
How do you initially manage a pt presenting w epitaxis?
- AtoE
- Pinch soft part of nose and lean the head forward
- Spit out any blood in mouth
What is the conservative treatment of epitaxis?
- Try topical adrenaline to help control bleeding
- Cautery, if ant w ant rhinoscopy, topical silver nitrate or bipolar diathermy or it post w rigid endoscope
- Nasal packing if cautery fails - ant pack and if bleeding cont can add post packing
What is the surgical treatment of epitaxis?
Surgical ligation or radiological emobolism of sphenopalatine, ant ethmoid (can’t embolise as comes from int carotid) or ex carotid (last resort)
What are the complications of nasal trauma?
Septal haemotoma - if undetected will lead to saddle nose deformity due to avascular necrosis or CSF leak w basalar skull fracture.
Ix - ant rhinoscopy and palpation, very painful
What is rhinosinusitis?
Inflam or the nose and paranasal sinuses w two or more of the following sx:
- Nasal blockage, obstruction, congestion, discharge
- Nasal drip
+/- facial pain and reduction in smell and..
endoscopic signs of polyps, mucopurulent discharge or oedema in the middle meatus and/or
CT changes.
What is the definition of acute rhinosinusitis? (ARS)
<12 weeks w complete resolution of sx, can be viral or non viral
What is the definition of chronic rhinosinusitis? (CRS)
> 12 weeks w/o complete resolution of sx. Can be
- CRS w nasal polyps
- CRS w/o nasal polyps
What are the causes of ARS?
- Viral = rhinovirus or influenza virus, these sx normally resolve in 5 days
- Non viral, considered if sx >5 days = S.pneumoniae, H.influenzae or M.catarrhalis
How is ARS managed?
- Nasal decongestants
- Analgesia
- Topical nasal steroids and oral abx if >5 days
What are the RF of CRS?
- Atopy and pollutants
- Infections eg. S.aureus or fungal infections
- Ciliary impairment eg. CF
- Anatomical abnormalitiy - septal deviation, abnormal ucinate process
- Immunocompromised
- Aspirin hypertsensitivity
- Pregnancy, nasal congestion high as O+P effect nasal mucosal vascularity
- Foreign body
- Swimming and diving
- Trauma
What are the ix into CRS?
- Skin prick tests if suspect allergy
- CT sinuses only if surgery planned or atypical features on hx/exam
What is the management of CRS?
No cure, just symptomatic:
- Conservative = avoid allergens and nasal doucing
- Medical = antihistamines, topical nasal/oral steroids if severe, oral abx at least 6-8 week course
- Surgery = nasal polypectomy but recurrence, surgery to improve drainage of sinuses = Functional Endoscopic Sinus Surgery
What are the causes of allergic rhinitis and how is it classified?
Caused by IgE mediated type 1 hypersensitivity reaction in mucous membranes of nasal airways.
Intermittent = sx <4 days a week for less than 4 weeks
Persistent = sx >4 days a week, more than 4 weeks
Mild = can cont normal daily activities and sleep
Mod to severe = impairs daily activity and sleep
What is the treatment of allergic rhinitis?
- Avoid allergens
- Nasal douching
- Antihistamines
- Topical nasal steroids
- Immunotherapy
How is a retropharyngeal abscess able to form?
Ant to the prevertebral fascia behind the pharynx is a potential space = retropharyngeal space, a abscess may form here. From base of skull to mediastinum. There is associated mortality due to airway problems and mediastinitis.
What are the clinical features of a retropharyngeal abscess?
- Young child following URTI
- Pt unwilling to move neck, held rigid
- Systemically unwell
- Airway compromise
- Dysphagia/odynophagia
What are the ix and management into retropharyngeal abscesses?
Ix - CT neck
M - secure airway, IV abx, surgery for incision and drainage
What is Ludwig’s angina?
Cellulitis of the soft tissue of the floor of the mouth, commonly associated w dental infection. Is life threatening.
What are the CF of Ludwig’s angina?
- Swelling of the floor of the mouth
- Painful mouth
- Protruding tongue
- Airway compromise
- Drooling
What are the ix into Ludwig’s angina and how is it managed?
Ix - CT neck
M - secure airway, IV abx, surgery to drain collections
What is the presentation of a parapharyngeal abscess?
- Hx of febrile illness
- Odynophagia
- Trismus
- Reduced neck movement
- Swelling in neck around upper part of SCM
Management the same for other ENT abscesses.
What is the cause of epiglottis?
H.influenzae but incidence has reduced w vaccine against it
What is the presentation of epiglottits?
- Stridor
- Drooling
- Pyrexia
- Child aged 2-6
What is the management of epiglottis?
- Secure airway - don’t examine or upset pt, may precipitate obstruction
- Intubate and have ENT surgeon to do surgical airway if not possible
- Iv abx and then extubate
What are some differentials for neck lumps?
Midline - dermoid cyst, thyroglossal duct cyst, thyroid gland pathology
Lateral - submandibular pathology, branchial cyst on SCM, lymph node (inflam/infective/metastatic), vascular
What are the CF of head and neck cancer? What type of cancer are they?
- Dysphonia
- Dysphagia/odynophagia
- Dyspnoea/stridor
- Mass in the neck
- Pain or referred pain
- Bleeding from mouth/nose
- Nasal blockage
Vast majority (90%) SCC
What are the RF of head and neck cancer?
- Alcohol
- Smoking
- Beetle nut chewing for oral cavity cancer
- Chinese ethnic origin for nasopharyngeal malignanyc
What are the ix into head and neck cancer?
- US guided FNA of all neck masses except those that are palpable
- EUA to biopsy, assess size of tumour and assess if others
- CT neck - size of tumour and mets
- CT check to test for mets
What is the management of head and neck cancer?
- Palliation - reduce suffering eg. chemo and RT to reduce size of tumour and reduce sx
- Curative - RT to primary site +/- neck and chemo or surgery eg. laser resection or laryngectomy or neck dissection
What is the most common type of thyroid cancer?
Papillary adenocarcinoma, (70%) seen in young pt or those w ht of radiation to neck.
Follicular carcinoma 20%
What are some non neoplastic nodules of the thyroid and what is the management?
Single nodule = colloid, cystic or multinodular goitre.
M - surgery for compressive sx or cosmesis = hemithyroidectomy. Total thyroidectomy = increased morbidity and lifelong thyroxine replacement needed.
What is the management of neoplastic nodules?
Adenoma - hemithyroidectomy
Carcinoma - total thyroidectomy for most types unless disease too advanced. Radio iodine for papillary and follicular carcinoma after surgery.
What are the complications of thyroid surgery?
- Post op haemorrhage
- Airway obstruction secondary to haemorrhage or bilat vocal cord palsy
- Vocal cord palsy
- Hypocalcaemia
What are the causes of acute and chronic sialadenitis?
Acute - mumps (paramyxovirus), HIV
Chronic - rare but TB, sarcoidosis, syphilis
What are sialothiasis and what are the ix into them?
Stones in the salivary duct - cause obstruction = pain and swelling, worse during meals. Most common in submandibular gland.
Ix - USS, sialogram
What is the management of sialothiasis and what are some complications?
- Conservative - settle on their own mostly w analgesia + hydration
- Endoscopy
- Radiological removal
- Surgical removal of stones or salivary gland
Complications = sialadenitis, abscess formation
What are the causes of nasal blockage?
- Rhinosinusitis (viral, bacterial, allergic)
- Nasal polyps
- Rhinitis
- Adenoiditis and tonsilitis
- Sinonasal tumour
- Turbinate hypertrophy
- Deviated nasal septum
What are some causes of deafness/hearing loss in adults?
- Presbycusis
- Acoustic neuroma
- Cholesteatoma
- Meniere’s disease
- Ototoxic drugs - loop diuretics, quinine, NSAIDs,
- Otosclerosis
- Noise related deafness
What are some differentials for pain in the ear?
- Foreign body
- Otitis media/externa/w effusion
- Wax impaction
- Referred ear pain - TMJ disorder, dental pain, head and neck malignancy (need to exclude red flags when taking otalgia hx), temporal arteritis
- TM perforation
- Chronic suppurative otitis media
- Myringitis
What are some differentials for pain in the throat? (children and adults)
- Tonsilitis/quincy
- Pharyngitis
- Oesophageal cancer
- GORD and oesophagitis
- Foreign body
What are some differentials for dysphagia?
- GORD
- Oesophageal cancer
- Neurological causes eg. MS, Parkinsons
- Oesophageal strictures
- Myasthenia Gravis
- Achalasia
What are some differentials for facial pain?
- Sinusitis
- Migraine
- GCA
- TMJ disorder
- Trigeminal neuralgia
- Dental pain
What are some causes of conductive hearing loss?
- Wax impaction
- Otitis media w effusion
- Eustachian tube dysfunction
- Ear infections
- Perforation of TM
- Chronic supprative otitis media
What are some causes of sensorineural hearing loss?
- Presbycusis
- Noise related hearing loss
- Congenital infections
- Neonatal complications
- Drug induced deafness
- Vascular pathology eg. stroke, TIA
What are some causes of a hoarse voice?
- Laryngeal cancer, >3 weeks = 2WW for ENT, smoke hx
- Chronic laryngitis, associated w GORD, worse in morning
- Laryngitis, viral and self limiting
- Reinke’s oedema, enlargement of vocal cords, associated w hypothyroidism
- RLN palsy, thyroid surgery
What are some of the complications of FESS?
- Bleeding and infection
- CSF leak
- Visual loss/disturbance
Why is Little’s area significant and what vessels make it up?
- Sphenopalantine artery
- Ant and post ethmoidal artery
- Sup labial artery
- Greater palantine artery
Is the area of the nose where most epitaxis originates from. Also called Keisselbach’s plexus
What are some complications of submandibular gland removal?
- Bleeding and infection
- Palsy of hypoglossal nerve, lingual nerve or cervical branch of facial nerve
What structures are within the submandibular triangle?
Borders - mandible and ant and post belly of diagastric muscle
Contents:
- Submandibular gland and lymph nodes
- Hypoglossal nerve
- Cervical brand of facial nerve
- Lingual nerve and artery and vein
- Facial artery and vein
What is the management of perforated TM ?
Review in 6 weeks - should self resolve ~6-8 weeks
