ENT Flashcards
Otalgia in the absence of any ear signs is ______
a red flag for head and neck malignancy
Unexplained persistent sore throat?
urgent referral to ENT ?laryngeal cancer
Is primary haemorrhage after tonsillectomy serious?
yes need urgent return to theatre
can lose a lot of blood as supply is from external carotid artery so potential to lose a lot of blood
also potential for airway obstruction
Otalgia, fever, protruding ear and post-auricular tenderness?
→ ?mastoiditis - same day admission to hospital Mastoiditis can lead to meningitis, facial nerve palsies, and hearing loss and requires immediate medical treatment with broad-spectrum IV antibiotics.
Boggy swelling in midline of nose?
nasal septal haematoma > urgent ENT involvement > risk of septal necrosis
Unilateral sinusitis symptoms?
refer to ENT - suspect cancer
Haemorrhage 5-10 days after tonsillectomy?
associated with wound infection
admit for IV antibiotics
Acute sensorineural hearing loss?
emergency - urgent referral to ENT for audiology assessment and brain MRI
What is head impulse test?
differentiates between central and vestibular causes of vertigo
positive test means vestibular cause
The clinician briskly rotates the patient’s head to detect “overt” catch-up saccades after head rotation as a sign of semicircular canal paresis
means your vestibular ocular reflex is abnormal i.e. a peripheral problem (which is reassuring!)
What is the most common cause of neck swellings?
reactive lymphadenopathy
Describe how a neck swelling that is a thyroglossal cyst would present?
more common in patients < 20 yo, usually midline between isthmus of thyroid bone and hyoid bone, moves upwards with protrusion of the tongue, may be painful if infected
Describe how a neck swelling that is a pharyngeal pouch would present?
more common in older men, represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles, usually not seen but if large a midline on the neck that gurgles with palpation, symptoms = dysphagia, regurgitation, aspiration and a chronic cough
Describe how a neck swelling that is a cystic hyrgoma would present?
a congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side, most are present at birth, around 90% before 2 years of age
Describe how a neck swelling that is a branchial cyst would present?
an oval mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx, develop due to failure of obliteration of the second branchial cleft in embryonic development, usually present in early adulthood
Describe how a neck swelling that is a cervical rib would present?
more common in adult females, around 10% develop thoracic outlet syndrome, extra rib that forms above first rib present from birth, will be a firm swelling, won’t be symptomatic unless thoracic outlet syndrome, different sizes etc.
Describe how a neck swelling that is a carotid aneurysm would present?
pulsatile lateral neck mass that doesn’t move on swallowing
What is Ramsay Hunt Syndrome? Presentation?
reactivation of varicella zoster in the geniculate ganglion of the seventh cranial nerve
auricular pain, facial nerve palsy, vesicular rash around the ear, can get vertigo and tinnitus and hearing loss
Management of Ramsay Hunt Syndrome?
oral acyclovir and corticosteroids
What is a vestibular schwannoma?
- Tumour derived from schwann cells (glial cells that make the myelin sheath for nerves in PNS)
- Can get other types of schwannoma, but vestibular schwannomas are most common
Vestibular schwannoma arises from ______
from CNVIII in the cerebellopontine angle
Although vestibular schwannomas are benign ______
it tends to grow around adjacent structures and have an irregular surface so it can be difficult to remove
Presentation of vestibular schwannoma?
- Unilateral sensorineural hearing loss, tinnitus and vertigo
- If it invades the facial nerve can sometimes get facial nerve palsies
Bilateral vestibular schwannoma?
occurs in neurofibromatosis type 2
Management of vestibular schwannoma?
- Treatment depends on size, growth rate and location
- Those who have no symptoms may just be monitored
- Tumour can be removed through surgery however it does risk hearing loss and facial nerve palsy
- Can also do radiation therapy to shrink the tumour
Common benign head and neck tumour?
papillomas which can be single or multiple caused by HPV 11 and 16 virus
What is the predominant type of head and neck cancer?
squamous cell carcinoma
Risk factors for squamous cell carcinoma of the head and neck?
smoking and alcohol, hardwood dusts and the betel nut (nut from tropical pacific and asia that is now classed as a carcinogen)
There is an increasing trend in development of oropharyngeal tumours in a younger cohort which is thought to be related to ___________
HPV infection
What type of infection is implicated in nasopharyngeal SCC?
EBV infection
Where are the most common sites for SCC of head and neck?
oral cavity most common then larynx
Cancers of the mouth tend to be found ______
on the lateral part of the tongue
Larynx tumours can be found ________ this determines _________
- Larynx tumours can be at the glottis, supraglottis or subglottis and location can determine growth and spread rates
- Glottic tumours tend to stay on the chords with minimal lymphatic change
- Supraglottic tumours drain to superior deep cervical nodes
- Subglottic tumours drain to paratracheal nodes
- Only glottic and subglottic tumours cause vocal changes
9 red flags for head and neck cancer?
- Lump in the neck particularly if enlarging and painless
- Hoarseness persisting for more than 3 weeks
- Dysphagia
- Odynophagia
- Unexplained otalgia
- Non healing ulcers of the oral cavity or oropharynx for more than 3 weeks
- Leukoplakia and erythoplakia (white and red lesions that cannot be scraped off in the mouth) – these are generally premalignant lesions
- Stridor
- Facial or cheek swelling
Investigations for head and neck cancer?
- Nasoendoscopy or laryngoscopy to view the larynx
- Biopsy – either done on endoscopy or if lump in neck may do FNA
- May then do imaging – CT scan, MRI, PET or US of neck nodes
Define sensorineural hearing loss? Rinne and weber test?
- Definition: hearing loss caused by damage to inner ear or auditory nerve
- Weber test: in unilateral sensorineural hearing loss, sound lateralises to the normal or better side
- Rinne test: will be normal with AC > BC
List some causes of sensorineural hearing loss?
- Presbycusis: old age hearing loss, higher frequencies affected most (easier to hear male voices), treated with a high frequency specific hearing aid
- Noise trauma: causes loss at 4kHz
- Vestibular Schwannoma
- Menieres disease: specifically, a low frequency sensorineural hearing loss
- Labyrinthitis
Noise trauma specifically causes sensorineural hearing loss at _____
4khz
Presbycusis causes a __________ sensorineural hearing loss
higher frequencies - easier to hear male voices than female
Menieres disease causes specifically a __________ sensorineural hearing loss
low frequency
Define conductive hearing loss? Rinne and weber test?
- Definition: natural movement of sound through the external or middle ear is blocked (the actual inner ear and nerve is fine)
- Weber test: lateralises to the affected ear
- Rinne test: BC > AC in the affected ear
List some causes of conductive hearing loss?
- Otitis media with effusion
- Perforated tympanic membrane
- Cholesteatoma
- Otosclerosis: hereditary disorder where you get bony deposits in stapes footplate causing gradual conductive hearing loss, can be treated with stapedectomy where stapes is removed)
- Otitis externa
Explain what otosclerosis is and how it is treated?
- Otosclerosis: hereditary disorder where you get bony deposits in stapes footplate causing gradual conductive hearing loss, can be treated with stapedectomy where stapes is removed)
What is a cholesteatoma?
- Abnormal mass of keratinising squamous epithelium growing in the middle ear of mastoid process (usually the epithelium growing in the middle ear is non-keratinised seems to be debate over the shape of it though)
- Cause is uncertain – can be congenital or acquired, repeated ear infections (metaplastic change) or trauma (perforated ear drum means epithelium deposited in wrong place)
Presentation of cholesteatoma?
- May present with hearing loss, aching pain, vertigo or ottorhoea
- Can also present with complications such as erosion or ossicles or facial nerve palsy
- Can also get a perforated ear drum or retracted ear drum that is stuck to middle ear structures
Management of cholesteatoma?
- Almost always need removed surgically and reconstruction done
What is epiglottitis?
- The epiglottis is a flap of elastic cartilage that sits at the entrance of the larynx that prevents food from entering the larynx and trachea when swallowing
- Epiglottitis is inflammation of the epiglottis usually caused by Haemophilus Influenzae
- Occurs in children – life threatening infection as can cause stridor
Presentation of epiglottitis?
- Hot, feverish, drooling child
- Thumb print sign on XR
Management of epiglottitis?
- Medical emergency must get ENT and anaesthetist involved
- Incidence is generally decreasing as we are vaccinating children against haemophilus influenzae
The nose gains a blood supply from a number of vessels originating from both ________
internal and external carotid arteries
One of the most common sites of bleeding in the nose is ______________
Little’s area (Keisselbach’s plexus), this is where a number of vessels anastamose on the anterior septum
What vessels make up Littles area/ Keisselbachs plexus?
anterior ethmoidal artery, posterior ethmoidal artery, sphenopalatine, greater palatine and lateral nasal artery
List some causes of epistaxis?
Causes
* Idiopathic
* Iatrogenic e.g. post operative, secondary to intranasal steroids and nasal O2 prongs
* Trauma e.g. fractures, picking nose, foreign bodies
* Inflammation
* Tumours
* Cold air
* Medications e.g. anticoagulants and antiplatelets
* Haematological conditions e.g. haemophilia, thrombocytopenia, leukaemia
* GPA
Explain anterior vs posterior epistaxis?
- Anterior bleeds are more common and usually from littles area, coming out one nostril anteriorly and then blood swallowed after first aid applied
- Posterior presents with heavy bleeding from both nostrils with blood being swallowed from onset
Overview of management of epistaxis?
immediate trotters/ hippocratic method
cautery if bleeding still not stopped
nasal packing if still not stopped
operative if still not stopped
Trotters/ hippocratic management of nosebleed?
- Pinch soft part of nose and don’t let go for 20 minutes
- Lean forward with head over a bowl
- Ice on the back of the neck and on forehead and given patient ice to suck (causes vasoconstriction)
- Advise patient to spit out blood as swallowing can cause nausea
Explain what obstructive sleep apnoea is?
- Apnoea refers to a period where you stop breathing temporarily
- Obstructive sleep apnoea occurs due to intermittent upper airways collapse in the sleep
- The patient becomes hypoxic and the effort to overcome the obstruction wakes them briefly
- They usually don’t notice being woken but ultimately being woken briefly so many times results in sleep deprivation
- (Note that you can also get central sleep apnoea which is actually due to a problem in the CNS not an obstruction)
Risk factors for obstructive sleep apnoea?
The most common cause is obesity
Other risk factors include:
* Enlarged adenoid tonsils
* Retrognathia (far back maxilla or mandible)
* Acromegaly (cause you will get growth of soft tissues but not bones due to excess GH)
* Hypothyroidism
* Oropharyngeal deformities
* Drugs and alcohol
* Stroke
* Myotonic dystrophy
* After anaesthesia
Signs and symptoms of obstructive sleep apnoea?
- Typically, patient complains of poor and unrefreshing sleep and daytime tiredness
- May have been told they snore very loudly
Diagnosis of obstructive sleep apnoea?
- Patient completes an Epworth sleepiness score firstly
- If think sleep apnoea is likely it is diagnosed by an overnight sleep study
- Diagnosis is confirmed if > 10-15 apnoeas/ hypoapnoeas in any 1hr of sleep
Management of obstructive sleep apnoea?
- Remove underlying cause if possible e.g. tonsillectomy, treat acromegaly, lose weight if obese
- cPAP (continuous positive airways pressure) is the most effective treatment and involves the patient wearing a mask at night where air pressure stops collapse of the airways preventing apnoeas
Otoscope technique?
pull pinna upwards and backwards, handle is going forward, right hand for right ear, left hand for left ear
What exam is used to differentiate between peripheral and central causes of vertigo?
hints
Management of vestibular neuronitis?
prochlorperazine in acute phase
stop after few days as slows recovery
Double sickening suggests
bacterial sinusitis
If downs syndrome or cleft palate and glue ear
refer to ent
Danger with nasal decongestants?
rhinitis medicamentosa - rebound nasal decongestion from extended use of topical decongestants - treatment is essentially stop the decongestants completely and should get better
Horizontal vs vertical nystagmus?
horizontal nystagmus is more commonly associated with inner ear problems and vertical with central problems (eyes point in direction of problem ie brain or ears!)
Most commonly involved sinuses in sinusitis?
maxillary and anterior ethmoid air cells
