ENT Flashcards
key symptoms regarding the nose (history taking)
key 5 symptoms:
-Nasal obstruction
-Runny nose (anterior rhinorrhoea)
-Loss of sense of smell (hyposmia/anosmia)
-Nose bleeds (epistaxis)
-Facial pain
Other symptoms include:
-Post nasal drip
-Nasal itch
-Sneezing
-Ocular itching
key symptoms regarding the ear (history taking)
key 5 symptoms:
-Earache (otalgia)
-Ear discharge (otorrhoea)
-Hearing loss
-Tinnitus (the sensation of sound without any external stimulus)
-Dizziness
Other symptoms include:
-Aural blockage
-Itching
key symptoms regarding the throat (history taking)
key 5 symptoms:
- sore throat
- difficulty swallowing (dysphagia)
- pain on swallowing (odynophagia)
- hoarse voice (dysphonia)
- regurgitation
Other symptoms include
-A feeling of a lump in the throat
-Burning in the throat
-Weight loss
what systemic conditions may also affect the ears, nose and throat
- Asthma - strong association with allergic chronic rhinosinusitis
- Diabetes mellitus
- Hypertension
- Sarcoidosis
- Tuberculosis
- Granulomatosis with polyangitis (previously Wegener’s granulomatosis)
- Neurofibromatosis type 2
+ more
what are the lymph node levels in the neck
Level 1: Submental and submandibular
Level 2: Upper deep cervical
Level 3: Mid-deep cervical
Level 4: Lower deep cervical
Level 5: Posterior triangle
Level 6: Paratracheal
Level 7: Upper mediastinal
what is a quinsy
how is it managed
also known as a peritonsillar abscess - complication of acute tonsillitis
don’t normally respond to antibiotics alone - need to be drained
done under local anaesthetic either by aspiration of pus or by incision and drainage with a knife
why does earache often occur with a sore throat
glossopharyngeal nerve supplies sensation to the throat but also to the ear
common causes of referred otalgia
dental infection
pharyngeal pathology
temporomandibular joint
where is the auditory cortex located?
superior temporal gyrus of the temporal lobe and extends in to the lateral sulcus and the transverse temporal gyri
how does auditory signal pass from the cochlea to the auditory cortex
The auditory signal passes along the cochlear nerve to the cochlear nucleus in the brainstem
Most then crosses to the contralateral side
The signal then passes up the brainstem through the superior olivary nucleus and then the lateral lemniscus in the midbrain to the inferior colliculus
Then passes through the medial geniculate body to the auditory cortex
what is the order of the ossicle bones from lateral to medial
malleus, incus, stapes
what is the chorda tympani
a branch of the facial nerve that carries taste fibres to the anterior two thirds of the tongue
also carries parasympathetic secretomotor fibres to the submandibular and sublingual glands.
What does otorrhoea as a symptom reflect
pyorrhoea/discharge from ear signifies Infection or inflammation in the middle ear
Acute otitis external presentation
Painful generalised swelling of external ear canal which is often moist and may be purulent discharge present
earache
hearing loss
history of swimming
Risk factors otitis external
Water entering ear
Skin conditions e.g. eczema or psoriasis
Instrumentation of the ear e.g. with cotton buds
What organisms commonly cause otitis externa
Staph aureus
Pseudomonas auriguinosa
Fungal; aspergillosis Niger
Simple otitis externa management
Keep ear dry
Analgesia
Topical antibiotics drop (+/- steroid containing)
- cipro or gent
Perichondritis due to otitis external
Complication of OE where the cartilage of the pinna is inflamed
If unwell with this needs referral to ENT
Management if OE becomes more severe I.e. external canal is swollen closed, pt systemically unwell
Continue topical drops via aural wick
Gentle micro suction of the ear
Admit and Start IV antibiotics
Complications of OE
Early:
Facial cellulitis
Otomycosis
Perichondritis
Late:
Canal stenosis with hearing loss
Osteomyelitis of the temporal bone
Osteomyelitis of the temporal bone
Also called necrotising otitis external - Complication of OE where infection spreads to underlying bone especially in those immunocompromised or with diabetes
Can affect cranial nerves particularly CNVII
If left untreated can cause sensorineural hearing loss and is potentially life threatening
Treatment of Osteomyelitis of the temporal bone
Topical antibiotics continued
+ IV Antibitoics for at least 6 weeks!
Causative organism is usually pseudomonas aeruginosa but liase with micro
Complications of Osteomyelitis of the temporal bone
Abscess of or around bone or cerebral abscess
CN palsy
Meningitis
Seizures
What can cause a hole in the tympanic membrane
Iatrogenic e.g. grommet insertion
Trauma
Recurrent infections
Chronic otitis media organisms
haemophillus influenza
less common:
Pseudomonas aeruginosa
Staph aureus
Streptococcus
Anaerobic bacteria
Treatment of chronic otitis media
Micro suck and inspection of the ear under microscope
Topical antibiotic and steroid drops for 7-10 days if active infection
Strict water precautions
If medical strategies not effective or the ear discharge is particularly affecting pts life then myringoplasty can be performed - surgical repair of the ear drum
Presentation of chronic otitis media
inflammatory condition affecting the middle ear for a period greater than 3 months.
Active or inactive and 2 types, mucosal and squamous epithelial COM.
Active mucosal disease - perforated tympanic membrane allows infection to develop in the middle ear
Active squamous epithelial disease results from cholesteatoma formation
Inactive mucosal disease -dry perforation
Inactive squamous epithelial -shallow self cleaning retracted tympanic membrane.
can present with Recurrent intermittent discharge arising from ear
hearing loss may be present
mucosal usually to do with pars tensa
squamous usually pars flaccida
What is a cholesteatoma
Symptoms
Complications
Deep retraction of the tympanic membrane that has keratin accumulated in it and can develop into a keratin cyst
Usually forms due to chronic Eustachian tube dysfunction
Discharge from the can be offensive
Hearing loss
Doesnt respond to antibiotic drops or oral antibiotics
Imbalance
The keratin cyst can expand and erode the ossicles and eventually damage structures adjacent to the middle ear
What is a glomus jugulare
Vascular tumour that presents as a red mass behind an intact tympanic membrane
Patient may have pulsatile tinnitus
initial management of cholesteatoma
topical abx and steroid drops if infection present
pure tone audiogram to determine degree of hearing loss
close inspection and cleaning of the ear under the microscope
definitive surgical management of cholesteatoma
mastoidectomy - opening the mastoid air cells, removing the cholesteatoma from the middle ear followed by reconstructing of the ossicles and tympanic membrane
CT guided
complications of middle ear surgery (for chronic otitis media or other conditions)
Infection
Bleeding
No improvement in hearing
Complete loss of hearing, called a dead ear (if the inner ear is damaged)
Tinnitus
Vertigo
Facial nerve injury, resulting in facial palsy
Altered taste (chorda tympani nerve damage)
Recurrence of disease needing revision surgery
Otitis media with effusion
inflammatory condition of the middle ear in which there is development of a middle ear effusion.
This causes a conductive hearing loss.
It is not an infection although it may follow an infection.
where in the tympanic membrane do
- retractions tend to occur
- perforations tend to occur
retraction - pars flaccida (attic)
perforations - pars tensa
intratemporal complications of Chronic Otitis Media
Vertigo - inflammation spread to labyrinth
Hearing loss - conductive or SN
Acute otitis externa
Facial weakness - facial nerve involvement
extratemporal complications of chronic otitis media
Meningitis - by eroding through the tegmen
Subdural abscess - spread from infection to extradural then subdural
Temporal lobe abscess
Sigmoid sinus thrombosis
acute otitis media presentation
earache
ear discharge
hearing affected
fever
often young child
often associated URTI
tympanic membrane looks inflamed
what investigations may be used to investigate lymph nodes after examination
Ultrasound Scan
Fine needle aspiration cytology
CT
causes of neck lumps (broadly)
Vascular
Infective/inflammatory
(trauma unlikely)
Autoimmune - thyroid
(metabolic none)
(iatrogenic unlikely)
Neoplastic
Congenital
vascular neck lump causes
Carotid body tumours
Carotid artery aneurysms
infective neck lump causes
- Lymphadenopathy
(Bacterial – suppurative (e.g. Streptococcus, Staphylococcus)
Viral (e.g. Epstein Barr, Cytomegalovirus)
Fungal
TB
Toxoplasmosis) - Neck abscess
- Sialadenitis (salivary gland inflammation)
inflammatory neck lump causes
Sarcoidosis
Kawasaki disease
Sinus histiocytosis
Castleman’s syndrome
thyroid neck lump causes
Nodule
Goitre
May be benign or malignant
Thyroiditis
Neoplastic neck lumps
Benign
- salivary gland tumours
- Lipoma
- Sebaceous cyst
Malignant
- Metastatic squamous cell carcinoma (SCC)
- Lymphoma
- Malignant salivary gland tumour
Congenital neck lumps
Dermoids
Thyroglossal duct cyst
Branchial cysts
Teratomas
Larygocoele
Haemangloma
Plunging ranula (fluid collection under the tongue
risk factors for squamous cell carcinoma (cancer) of the head & neck?
smoking
alcohol
betel nut chewing
Human Papilloma Virus (+EBV in nasopharyngeal)
basic steps of diagnosing a head and neck cancer
- Panendoscopy and biopsy ie. an examination under anaesthetic of the pharynx, laryx & upper oesophagus.
- CT skull base to diaphragm to assess the extent of the primary tumour and to identify any regional or distant metastases
- MDT discussion
NICE guidelines for urgent referral head and neck cancer
- hoarseness > 6 weeks
- oral swelling > 3 weeks
- dysphagia > 3 weeks
- neck mass > 3 weeks
- unilateral nasal obstruction, particularly when associated with purulent discharge
- cranial neuropathies
- orbital massess
what symptoms or usually referred to maxillofacial surgery
- All red or red and white patches of the oral mucosa.
- Ulceration of oral mucosa persisting for more than three weeks.
- Unexplained tooth mobility not associated with periodontal disease.
Common causes of dysphonia
Overuse
Acute laryngitis
Chronic laryngitis secondary to reflux
Use of asthma inhalers
Smoking
Squamous cell carcinoma of the larynx
Vocal cord palsy of which there are many aetiologies inc recurrent laryngeal and vagus nerve palsies
vocal cord polyp
benign inflammatory lesions of the vocal fold and usually result from overuse.
may settle with appropriate speech therapy but can be removed surgically
Reinke’s oedema
oedema of the vocal folds with gelatinous material within
most common in women who are smokers
treatment is cessation of smoking, control of gastroesophageal reflux and, in refractive cases, incision of the vocal fold with evacuation of the gelatinous material.
treatment in head and neck cancers
radiotherapy - curative or palliation
surgery - curative intent
chemotherapy - not usually curative for head and neck
palliative?
need for rehabilitation? swallow, voice
choices for treatment determined by patient factors (age, comorbidity, previous treatment, lifestyle) and tumour factors (site, size, staging, previous treatment)
benign causes of a thyroid nodule
Follicular adenoma
Hyperplastic nodules
Thyroid cysts
malignant causes of a thyroid nodule
Papillary carcinoma
Follicular carcinoma
Medullary carcinoma
Anaplastic carcinoma
common causes of generalised thyroid swelling
Physiological – Pregnancy, puberty
Degenerative – Multinodular goitre
Thyroiditis – Most commonly Hashimoto’s thyroiditis
Grave’s Disease
what symptoms associated with a thyroid lump are suspicious for malignancy
- thyroid lump in a child
- rapidly growing painless lump
- unexplained hoarseness
- stridor
- enlarged cervical lymph nodes
what are the treatment options/roles in thyroid malignancies
Thyroidectomy +/- lymph node resection
External beam radiotherapy or Immunotherapy - inoperable or recurrent disease or distant disease that has failed to respond to previous radioactive iodine therapy
Radioactive iodine therapy - post-operatively for larger tumours or those with unfavourable histological features / distant spread
(chemotherapy not used in thyroid malignancy)
how can the causes of nasal obstruction be divided
structural
inflammatory
infective
causes of nasal obstruction
rhinosinusitis
septal deviation
nasal polyps
foreign body in the nose
Granulomatosis with polyangitis - systemic disorder that can affect the cartilage of the nose
adenoids
typical history of chronic rhinosinusitis?
bilateral nasal obstruction associated with anterior rhinorrhea and sneezing
often atopic history
can be worse in summer
O/E oedema of the nasal mucosa and a watery discharge in the nose.
what test is relevant to chronic rhinosinusitis
RAST testing (Radioallergosorbent) - identifies allergies to specific allergens
treatments in chronic allergic rhinosinusitis
Antihistamines if specific allergies identified + other allergy management techniques such as avoidance
Topical nasal steroid as a spray - mainstay as treatment
when are decongestants used in rhinosinusitis
short term relief in acute rhinosinusitis (maximum 1 week)
is surgery used in chronic rhinosinusitis
only if no response to medical treatment
how is chronic rhinosinusitis with polyps managed
topical nasal steroid + short course of prednisolone
if not effective then Functional endoscopic sinus surgery + carry on topical steroid afterwards
what constitutes acute or chronic rhinosinusitis
Acute rhinosinusitis (ARS) lasts less than 12 weeks with complete resolution of symptoms.
Chronic rhinosinusitis (CRS) lasts more than 12 weeks without complete resolution of symptoms.
key points of nasal examination
external inspection
anterior nose - Thuddicums speculum
posterior nose - flexible nasal endoscope
where is the most common side of epistaxis
Littles area/ Kiesselbach’s plexus - formed by 3 arteries; anterior ethmoid artery, the sphenopalatine artery and the greater palatine artery
silver nitrate cautery
if a prominent vessel identified as the source of epistaxis
can only be done to one side of septum
cauterised holding the silver nitrate stick in each position for 15 seconds. The vessel itself can then be cauterised.
Antiseptic cream, such as Naspetin, should then be applied and given to the patient to apply twice daily for 2 weeks.
advice to patients to reduce occurrence of epistaxis
for a few weeks;
avoid hot drinks
avoid very hot baths/showers
avoid picking the nose
avoid very hot and spicy foods
if recurrence; apply pressure for 15 mins and if this fails attend A&E
management of epistaxis that doesn’t stop with pressure
A-E
check airway and breathing
circulation; IV access, haemodynamically stable? FBC, coag profile, group and save
apply pressure
if identifiable cauterise source of bleeding
continued bleeding? anterior nasal packing
continued bleeding? posterior nasal packing
continued bleeding? ligate artery in surgery
factors that contribute to development of epistaxis in adults
-most common cause is trauma i.e. punching
-pmhx of hypertension, anticoagulant or antiplatelet therapy
- inflammation of the nasal mucosa
- rarely malignancy
what nasal malignancy is most common
squamous cell carcinoma
most commonly occurs in individuals of Chinese origin
most common cause of epistaxis in children
mainly due to bleeding from Little’s area primarily due to trauma
in most cases stops with pressure and can be prevented from bleeding recurring using cream such as naspetin or bactroban
what is tranexamic acid
when is its use contraindicated
used for epistaxis sometimes
anti fibrinolytic agent.
contraindicated
- blood clots, bleeding in the brain, or urine, heart valve problems, visual problems secondary to bleeding, irregular heartbeat, irregular unexplained menstrual bleeds, using birth control medication or devices, taking medication such as clotting factors and medication containing tretinoin
otosclerosis
replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window.
Otosclerosis is autosomal dominant and typically affects young adults
sometimes shows up in pregnancy
Management
hearing aid
stapedectomy
unilateral nasal polyps management
urgent referral to ENT - red flag for nasopharyngeal carcinoma
symptoms and management of nasal polyps
symptoms
- nasal obstruction
- rhinorrhoea, sneezing
- poor sense of taste and sme
Management
-all patients with suspected nasal polyps should be referred to ENT for a full examination
-topical corticosteroids shrink polyp size in around 80% of patients
Ménière’s disease presentation
spontaneous vertigo accompanied by unilateral hearing loss and tinnitus
sudden onset sensorineural hearing loss
high dose corticosteroids and referral to ENT
red flag symptoms chronic rhino sinusitis
unilateral symptoms
persistent symptoms despite 3 months treatment
epistaxis
vestibular neuronitis
typically develops following a viral infection with recurrent vertigo attacks lasting hours or day, usually nystagmus and sometimes associated vomiting
no hearing loss or tinnitus
treated with prochlorperazine or an antihistamine
needs to be distinguished from a posterior circulation stroke - use HINTs test
Ramsay hunt syndrome
Reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
- auricular pain progresses to include a vesicular rash around the ear, tinnitus and vertigo. Facial nerve palsy may also occur.
treatment oral aciclovir 7 days and oral prednisolone 5 days
what kind of hearing loss does presbyacusis cause
sensorineural hearing loss of higher frequencies
what kind of hearing loss does noise damage cause
sensorineural particularly at frequencies 3000-6000Hz
viral labyrinthitis
Recent viral infection
Sudden onset vertigo
Nausea and vomiting
Hearing may be affected
When should antibiotics be prescribed in acute otitis media
- symptoms for >4 days or not improving
- systemically unwell
- immunocompromised or at high risk of secondary infections
- acute otitis media with perforation
5-7 days of amoxicillin is first line
What score on Centor criteria indicate antibiotics should be prescribed
3 or more
Absence of cough
Fever
Anterior cervical lymphadenopathy
Presence of tonsillar exudate
Management chronic symptoms of vestibular neuronitis
Vestibular rehabilitation - make urgent referral
What drugs can cause tinnitus
Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine
acute sinusitis treatment
analgesia
intranasal corticosteroids if symptoms present >10 days
oral Abs not normally required but may be given for severe presentations
positive dix-hallpike test
onset of vertigo and rotatory nystagmus
Samter’s triad
asthma
aspirin sensitivity
nasal polyposis
mastoiditis presentation
management
typically spread from a middle ear infection
pt v unwell with fever, middle ear symptoms + post auricular inflammation and ear proptosis
needs admission and IV Abx
