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Phase 4 - Katherine > ENT > Flashcards

ENT Flashcards

1
Q

Nmae 3 common DDx of cervical lymphadenopathy

A

EBV: fever, pharyngitis, lymphadenopathy: posterior cervical
HIV: flu-like etc. cervical, axillary and occipital
Adenovirus: cold or flu/RTI axillary, cervical, occipital
CMV: immunocompromised, nt sweats, pneumonia
HZV: shingles - axillary, cervical, occipital
Streptococcal pharyngitis (pyogenes): cervical lymphadenopathy, enlarged tonsils
NHL, HL, CLL - generalised etc

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2
Q

What travels through parotid

A

facial nerve (if this is affected = malignant)

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3
Q

Name 3 causes of parotid swelling

A

viral parotitis (mumps), stone, sarcoidosis, tumours, HIV, wegners

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4
Q

Pt comes in with Bilateral swelling of parotids lasting one week, associated by low grade pyrexia… What Ix ? name 3

A

FBC, ESR/CRP, UE, blood culture, viral serology,
salivary antibody testing (*salivary mumps IgM)

Pus swab culture and sensitivities

USS

Sialography for blockage (contrast into gland + X-ray)

CT/MRI scan to exclude neoplasm

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5
Q

Which salivary gland do you normally get obstruction?

A

submandibular (parotid wider / more water)

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6
Q

Parotid Pain + swelling at meal times, colicky, relapse and remit…What is it likely? Ix?

A

obstruction

USS + contrast sialography

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7
Q

Mx of obstruction

A

Many pass spontaneously: good hydration, warm compress, gland massage, oral hygiene

Surgical removal

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8
Q

Most tumours of salivary glands are benign (75%) but name 3 red flags that might indicate malignancy

A

Rapid increase in size, ulceration, fixation, paresthesia of associated nerves, past Hx skin cancer, Sjogren’s, *facial nerve weakness,

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9
Q

Specific Ix of salivary gland tumour

A

USS if first line
+ Fine needle aspiration - cytology
+ Core biopsy if tumour is seen

MRI for tumour staging or margins (*sublingual = high malignancy risk)

CT for metastatic spread

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10
Q

Post surgical removal of a salivary tumour what is the main complications

A

Damage to facial nerve

recurrence

Freys syndrome
(redness or swelling on cheek when eating/salivating from autonomic nerves)

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11
Q

Most common cause of vertigo?

A

Benign paroxysmal positional vertigo

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12
Q

Who gets BPPV

A

50 year old women with anxiety + Menieres

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13
Q

BPPV what type of vertigo? how long does it last”?

A

Vertigo provoked by head movement, worse when head tilted one way

Sudden onset attacks: 20-30 seconds

Assoc nausea

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14
Q

Name any Sx you might think were red flags in BPPV

A

hearing loss, tinnitus, pain or headache

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15
Q

What test confirms BPPV?
2 other examinations?

A

Dix-Hallpike test
(turn head to one side and quickly lay them down
-> vertigo and rotary nystagmus)

Otoscopy: for exclude cholesteatoma and vesicles (VZV)

Cranial nerve exam: palsies/hearing loss

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16
Q

In BPPV the dix hallpike test is only positive on 1 side - what might it suggest if its bilateral?

A

vestibular neuritis, central cause

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17
Q

Name 3 DDx of BPPV

A

Acute vestibular labyrinthitis, MS, Menieres, acoustic neuroma, Ramsay Hunt syndrome (varicella zoster oticus - pain within ear radiates to pinna, vertigo, tinnitus, facial weakness, rash)

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18
Q

Mx of BPPV ? ADVICE?

A

Get out of bed slowly, reduce head movements

Epley’s manoeuvre

Advise not to drive when dizzy

High risk of recurrence

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19
Q

What is this and cause?…Episodic auditory and vestibular disease characterised by sudden onset vertigo, hearing loss, tinnitus (*low frequency roaring) and fullness in ear - *unilatera

A

menieres
overproduction / lack of absorption of endolymph

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20
Q

Meniers presentation

A

Recurrent vertigo - 30 mins
Unilateral hearing loss: fluctuating and worsening around vertigo *sensorineural
Tinnitus: unilateral and roaring
Aural fullness
Drop attacks
Positive Romberg’s
Hearing loss: pure tone air and bone conduction (low frequency loss early in disease), otoacoustic emissions absent in low frequency

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21
Q

The Ix in menieres is mostly about exclusion - name2

A

MRI normal,
TFT normal,
lyme disease/syphillis serology - normal

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22
Q

Acoustic neuroma and menieres present quite similarly - what is an easy difference?

A

Hearling loss - menieres is low frequency (in early disease )

Neuroma - high frequency

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23
Q

Mx of menieres

A

Low salt diet and diuretics

Symptomatic vertigo:
Meniett device: delivers pressure pulses to ear canalmeclozine (vestibular suppressant) ± intratympanic corticosteroids,

Hearing aids

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24
Q

What if mx of menieres fails?

A

endolymphatic sac surgery

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25
How to tell the difference between Vestibular neuritis and labyrinthitis
Presentation - Acute vertigo (AN/L) + hearing loss (L only) This is because vestibular neuritis only affects the vestibular nerve whereas labyrinthitis is a disorder affecting the inner ear as a whole or CN 8 as a whole.
26
Cause of vestibular neuritis?
Most causes are a viral infeciton e.g. measles, flu, rubella. reactivation of HSV in vestibular ganglion
27
What usually precedes labarynthitis
post viral URTI (50%) - bronchitis
28
Presentation of VN / L
VERTIGO Sudden, severe incapacitating vertigo (illusion of moving) assoc N+V Not triggered by mvmt, but may be exacerbated (dizzy at rest) - *No Dix-Hallpike!!!!! Hearing loss = labyrinthitis (unilateral/bilateral) ± tinnitus URTI symptoms
29
Name 3 things you would do OE of VN/L ?
External ear and TM : herpes zoster oticus, cholesteatoma Herpes zoster IS VZV. CN exam - to look for hearing loss Mastoid tenderness, nuchal rigidity, high fever Assess gait - fall towards affected side Hearing test: 256 Hz Weber’s - nerve = quieter in affected, conductive = louder in affected
30
How to differentiate VN/L from stroke
HINTS test: Head impulse, nystagmus type, skew
31
What result of HINTS test would indicate VN/L? stroke?
- VN or LN unidirectional nystagmus, no vertical skew (cover/uncover) Stroke bidirectional nystagmus, vertical skew - sensitive for ischaemic stroke esp PICA - posterior inferior cerebellar artery syndrome
32
specific Ix for VN/L
Culture and sensitivity of middle ear perfusions CT scan for mastoiditis Pure tone audiometry in hearing loss Vestibular function testing
33
Mx of vertigo in VN/L
prochlorperazine
34
What is an acoustic neuroma
CN8 tumour of Schwann cells at cerebellopontine angle
35
What presentation is always an acoustic neuroma until proven otherwise
Unilateral hearing loss
36
Pres of acoustic neuroma
Unilateral or asymmetrical hearing loss or tinnitus - progressive Impaired facial sensation (involvement of trigeminal nerve loss of corneal reflex) Balance problems
37
Bilateral acoustic neuroma seen when?
Neurofibromatosis T2
38
2 key Ix in acoustic neuroma
audiology MRI
39
Mx acoustic neuorma
treatment of choice is microsurgery Conservative: if small tumour with good preserved hearing
40
What nerve innervates the maxiliary sinus ? what does this mean?
infraorbital - can get referred pain to upper jaw pain, toothache, pain in skin
41
Basic exam of sinus ?
palpate simple assessment of nose
42
Name 2 bugs that usually are the cause of sinusitis
strep pneumoniae, h. Influenza, moraxella catarrhalis (children)
43
Mx of sinusitis
Paracetamol/ibuprofen - pain/fever Intranasal decongestant (max 7 days) Nasal douching Warm face packs Abx if bacterial - amox
44
Complications of sinusitis
Orbital cellulitis, meningitis, osteomyelitis
45
Chronic sinusitis Mx
topical nasal steroids: beclomethasone Good dental hygiene, stop smoking
46
If a pt has facial pain associated with getting Worse with fatigue or stress, often linked with depression or mood disturbance..... Mx/
TCA - amitryptiline ± CBT
47
triad in TMJ dysfunction
pain, limited mouth opening, joint noises
48
What is the pain in TMJd
typically in front of tragus (lil ting on inner side of external ear) radiating to ear, temple, cheek, mandible
49
Mx of TMJ dysfuction
Explanation and reassurance (mainly benign and self-limiting) Rest, education: limit chewing, massage, relaxation Manage pain psychologically Drugs: NSAIDs, muscle relaxants, TCA (2-4 weeks)
50
2 causes of congenital hearing loss ? Post natal?
rubella CMV malformation Mumps measles
51
What are rinnes and webers
Weber’s: in conductive = louder in affected ear in sensorineural = quieter in affected ear Rinne’s: start at mastoid then to ear +ve both retained -ve air lost = conductive Both lost = sensorineural - also +ve
52
What to examine in deafness
Inspection of external ear andexamination of tympanic membrane Rinne’s and Weber’s
53
Deafness Ix
Audiometry Tympanometry otoacoustic emission testing
54
Sudden hearing loss - whatcha do?
urgent referral to ENT
55
Qs to differentiate otitis externa and acute otitis media with pt presenting with otorrhoea
Is there pain? Y = otitis externa There was pain but it is now settled = acute otitis media Well + unilateral - otitis externa Pain then discharge late - AOM [Basically - Media has pain and then discharge later]
56
Pres of otitis externa
Erythematous ear canal with oedema and exudate Mobile tympanic membrane Pain on move tragus Pre-auricular lymphadenopathy
57
What are the 3 main types of otitis externa and usual cause
acute diffuse otitis externa (Swimmer’s ear) -bacterial chronic otitis externa -fungal necrotising otits externa p.aeruginosa (gets to mastoid / temporal bones)
58
Mx of necrotising otitis externa
Use oral and topical quinolones (6-8 weeks) eg ciprofloxacin
59
Mx of otitis externa
Pain management Cure infection Prevent complications
60
Mx of acute Otitis externa? When oral Abx?
Topical drops - *neomycin (also covers fungal) Oral ABX if cellulitis or cervical lymphadenopathy
61
Mx if you suspect fungal cause of otitis externa
clotrimazole
62
Mx of chronic otits externa with no apparent cause
acetic acid and corticosteroid ear drops (hydrocortisone)
63
Advice to prevent recurrence of otitis externa. Name 3
Keep ear dry Use ear plugs when swimming Do not use cotton swabs for wax Olive oil to prevent waxy build up
64
Presentation of acute otitis media
Hearing loss (not in OE), otalgia, otorrhoea, fever
65
ix in otitis media? if worried about comps?
Culture of discharge if chronic / perforation CT or MRI to exclude complications
66
Mx of otitis mediA
Analgesics nasal steroids - if allergy based abx if sx >5 days
67
What is otitis media with effusion called?
glue ear
68
how does glue ear present/
conductive hearing loss Feeling of aural fullness Cracking tinnitus
69
What is being described? Which nerves can be involved? : Intense pain behind ear, fever, boggy mass behind ear, external ear protrudes forwards
mastoiditis VI (petroud apex) or VII CN palsy
70
ix in mastoiditis
FBC (WCC), blood cultures, CT/MRI for Dx and comp LP if suspect IC spread fluid extraction - tympanocentesis for gram stain and culture
71
mx of mastoiditis
High dose broad spec IV ABX: 3rd generation cephalosporin (2 days) Then oral ABX for 2 weeks
72
What to do if cranial extension of mastoiditis ?
Mastoidectomy + tympanoplasty
73
What is a cholesteatoma?
Keratinising squamous epithelium within the middle ear cleft
74
Whats the issue with cholesteatoma?
may be locally invasive affecting bones of middle ear. Erodes bones with *osteolytic enzymes
75
how does Cholesteatoma present?
progressive conductive hearing loss Features of erosion - vertigo, headache, CN7 palsy, meningitis Frequent otorrhoea (foul smelling) + progressive unilateral hearing loss + tympanic membrane perforation or TM retraction
76
Ix for Cholesteatoma
CT MRI
77
mX Cholesteatoma
surgical removal
78
what nerve runs over temporal bone
abducens
79
Where can refer pain to ear?
Cervical spine (C2, C3) - worse at night Laryngo-pharynx (CN10) - in carcinoma of pyriform fossa Upper molars/TMJ/parotid gland (CN5 mandibular) Oropharynx (CN9) (tonsillitis or carcinoma of posterior ⅓ tongue)
80
Dx and staging of oral Ca
fibre optic endoscopy, fine needle aspiration/biopsy (neck masses) CT/MRI for spread and nodal metastasis CT thorax for all with head and neck cancers
81
Mx of early oral Ca
Surgical resection or brachytherapy If no neck disease - prophylactic radiotherapy Postoperative radiotherapy ± CISPLATIN
82
Rfs oral / pharyngeal Ca
Tobacco, HPV, alcohol, too hot drinks
83
Big Rf for nasopharyngeal Ca? common issue?
EBV (smoking too obvs) 50% have cervical mets at presentation
84
Pres of layngeal Ca?
Chronic hoarseness* + PERSISTENT COUGH, pain, dysphagia, lump in neck, sore throat, earache, breathlessness, aspiration, weight loss, *stridor
85
What Ix in chronic hoarseness
urgent CXR to decide if lung or ENT
86
When would you Ix sore throat
Only if prolonged, FBC and glandular fever screen, ASO (antistreptolysin O titres)
87
What things would you advise about for saftey net of sore throat
stridor, drooling, muffled voice, severe pain
88
Cause of epiglottitis and presentation?
HIB Sore throat, unable to swallow (drooling), muffled voice (hot potato voice), fever, ear pain, high temp, tachycardia, *tripod sign - patient leaning forward *Stridor and respiratory distress
89
Seen on lateral Xray of epiglotitis?
thumbprint sign
90
Mx of epliglotitis
IV or oral abx ± intubation/tracheostomy
91
Usual cause of quinsy?
s pyogenes
92
Mx of quinsy?
IV fluids, analgesia, IV abx (penicillin/cephalosporin/co-amoxiclav) Needle aspiration, incision and drainage
93
Ix in reccurent epistaxis ?
FBC, coagulation studies If ?malignancy - to ENT ± CT ± nasopharyngoscopy
94
Mx reccurent / severe epistaxis?
Nasal cautery with caustic agent e.g. silver nitrate or electrocautery
95
What features would cause you to refer a nasal injury immediately
Marked deviation, prolonged epistaxis, septal haematoma (requires incision and drainage) CSF rhinorrhoea - breach of cribiform plate -> for CT and neurosurgery
96
Ix of nasal polyps
Rigid or flexible rhinoscopy by ENT -
97
Mx of nasal polyps
topical corticosteroids (beclomethasone may affect growth) + saline douche 2nd - functional endoscopic sinus surgery
98
What is congenital lymphatic lesion, lymphangioma, classically found on left side 90% are evident at birth
Cystic hygroma
99
what is oval, mobile mass between sternocleidomastoid and pharynx Develop due to failure of obliteration of second branchial cleft Usually present in adulthood
brancial cyst
100
What is? Dysphagia, regurgitation, aspiration, chronic cough, weight loss. Gurgling lump on palpation, halitosis from decaying food key Ix?
pharyngeal pouch barium swallow
101
DDx of swallowing difficulties...name 3
Obstructive GORD, oesophagitis, oesophageal/gastric cancer, pharyngeal cancer, oesophageal stricture Neuro CVA, achalasia, oesophageal spasm, MND, MS, Parkinson’s Other Pharyngeal pouch, globus hystericus, external compression (mediastinal tumour), inflammation (tonsillitis, laryngitis), CREST syndrome
102
Rfs of obstructive sleep apnea
Obesity, male, middle age, smoking, sedatives, alcohol, family history
103
Pres of obstructive sleep apnea
Hx of snoring and witnessed apnoeas + excessive daytime sleepiness + macroglossia, apnoea
104
how to assess sleepiness?
epworth sleeiness score
105
mx obstructive sleep apnea
Behavioural: smoking, wt loss, alcohol CPAP (gold standard) ?modafinil for daytime sleepiness Surgical for tonsils etc....
106
What is bells palsy? features?
Acute, unilateral, idiopathic facial nerve paralysis 20-40yrs LMN palsy - forehead affected Hyperacusis (hearing), altered taste
107
Mx bells palsy
Prednisolone 1mg/kg for 10 days within 72 hours + artificial tears (for eyecare)
108
What should normal ear look like down an otoscope?
“pearly-grey“, translucent and slightly shiny should be able to visualise the malleolus through the membrane and a “cone of light” in reflection to the otoscope light.
109
33y complains of poor hearing in the left ear, which has become worse in the past year. She has a family history of uncle and father going deaf in their 40’s Examination reveals normal ear drums and tuning-fork testing shows Weber test localising to the right and a negative Rinne test on that side. Diagnosis? mx?
Otosclerosis ADominant Observation – if mild Hearing Aid – if symptomatic Stapedectomy – if large conductive loss stapes replaced with a prosthetic Teflon piston
110
Comp of stapedectomy in otosclerosis?
5% may become completely deaf if surgery fails
111
61 year old female presents with left sided hearing loss over the past 48h. No PMHx Otoscopy NAD Dx? Mx?
Acoustic neuroma Observation if small and slow-growing Surgical excision
112
3 year old presented with fever, irritability, ear tugging, not responding when called by mum OE: bulging, erythematous TM with a absence of light reflex Dx? Key comp?
Acute Otitis Media Mastoiditis Matsoiditis /AOM can lead to intracranial infection and death
113
A 24-year old has had problems with his ears for most of his life. He has had three sets of grommets for glue ear and numerous ear infections. However, he now has a constant discharge from his right ear for 3 months, which is foul-smelling. Examination shows the ear canal to be full of debris and mucus. Once this had been removed, a polyp was seen to be filling most of the ear canal, obscuring the tympanic membrane. Dx? Mx? 3 comps?
Cholesteatoma Surgical removal Atticotomy – if small and limited to the attic Radical Mastoidectomy – if more advanced and extends into mastoid Complications can arise if the sac erodes into: Ossicles – causing conductive deafness Facial Nerve – causing facial palsy Labyrinth – causing vertigo Tegmen (roof of middle ear) – causing intracranial sepsis Cochlea – causing sensorineural deafness Sigmoid Sinus – causing it to thrombosis
114
discharging ear and VII nerve palsy
cholesteatoma until proven otherwise
115
3 Dx for CNVII palsy
Trauma: Fractured temporal bone Vascular: CVA (Rapid onset, forehead unaffected) Infection: Ramsay Hunt Syndrome (Rapid onset, vesicles in ear) Cholesteatoma (Ear discharge + CHL) Otitis Media Neurological: MS Neoplasm: Parotid Carcinoma (Gradual onset, facial pain) Intracranial Idiopathic Bells Palsy
116
Bells palsy vs ramsay hunt Cause? Sx Different? Mx?
Bells - Idiopathic RH - Reactivation of varacella zoster virus in geniculate ganglion RH Sx More pain Hearing loss Vesicles Mx BP - eye care / corticosteroid RH - Eye care / Acyclovir

Phase 4 - Katherine (26 decks)

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