ENT Flashcards
1
Q
What are vestibular schwannomas?
A
(Acoustic neuromas)
Benign slow-growing tumour
Account for 5% of intracranial tumours and 90% of cerebellopontine angle tumours
2
Q
What is the aetiology of Vestibular schwannomas?
A
A benign cerebellopontine angle tumour that grows from the superior vestibular component of the vestibulocochlear nerve
Hence why PC is unilateral sensorineural hearing loss
3
Q
What are the features of vestibular schwannomas?
A
Most common symptom: unilateral sensorineural hearing loss
Followed by intermittent dizziness and facial numbness
Larger tumours may cause headaches, coordination difficulties (vertigo), tinnitus, absent corneal reflex
Can also lead to obstructive hydrocephalus → may be life threatening
4
Q
How can the features of vestibular schwannomas be predicted by the affected cranial nerves?
A
CN VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
CN V: absent corneal reflex
CN VII: facial palsy
5
Q
What disease are bilateral vestibular schwannomas seen in?
A
Neurofibromatosis type 2
6
Q
What are the appropriate investigations for vestibular schwannomas?
A
Patients with a suspected vestibular schwannoma should be referred urgently to ENT
MRI of the cerebellopontine angle is the investigation of choice Audiometry is also important as only 5% of patients will have a normal audiogram
7
Q
What is the management of vestibular schwannomas?
A
Tumours are often slow growing, benign and often observed initially
Management includes observation, focused radiation, or surgery
8
Q
What is Bell’s palsy?
A
An acute, unilateral, idiopathic, facial nerve paralysis
Evolves over 72 hours affecting all facial zones equally
9
Q
What is the aetiology of Bell’s palsy?
A
Unknown although the role of the herpes simplex virus has been investigated previously
10
Q
What is the epidemiology of Bell’s palsy?
A
The peak incidence is 20-40 years and the condition is more common in pregnant women
11
Q
What are the risk factors for Bell’s palsy?
A
Pregnancy (x3)
Diabetes (x5)
12
Q
What are the features of Bell’s palsy?
A
Lower motor neuron facial nerve palsy - forehead affected:
- Complete unilateral facial weakness
- Unilateral sagging of the mouth
- Drooling of saliva
- Food trapped between gum and cheek
- Speech difficulty
- Failure of eye closure may cause a watery or dry eye
Patients may also notice post-auricular pain -lymph nodes in front of ear (may precede paralysis), altered taste, dry eyes, hyperacusis (everyday sounds are louder than usual)
13
Q
Why is Bell’s palsy a lower motor neurone facial nerve palsy?
A
Involvement of the forehead
Upper motor neuron lesion ‘spares’ the upper face e.g. stroke
14
Q
How is Bell’s palsy diagnosed?
A
Diagnosis of exclusion
Acute unilateral peripheral facial nerve palsy in patients for whom physical examination and history are otherwise unremarkable
15
Q
What is the management of Bell’s palsy?
A
All patients should receive oral prednisolone within 72 hours of onset
Antiviral medications = NICE CKS state: ‘Antiviral treatments alone are not recommended. Antiviral treatment in combination with a corticosteroid may be of small benefit, but seek specialist advice if this is being considered.’
Eye care is important to prevent exposure keratopathy: prescription of artificial tears and eye lubricants should be considered
If they are unable to close the eye at bedtime, they should tape it closed using microporous tape
16
Q
What is the follow up care for Bell’s palsy?
A
If the paralysis shows no sign of improvement after 3 weeks, refer urgently to ENT
A referral to plastic surgery may be appropriate for patients with more long-standing weakness e.g. several months
Failure to demonstrate any return of hemi-facial tone or movement within 4 to 6 months suggests an alternative diagnosis
17
Q
What is the prognosis for Bell’s palsy?
A
Most people with Bell’s palsy make a full recovery within 3-4 months (70%)
Permanently impaired facial function occurrs to a minor degree in 13% and to a major degree in 16% of case
If untreated around 15% of patients have permanent moderate to severe weakness
18
Q
What differentiates Lyme disease, Guillain–Barré, sarcoid, and trauma from Bell’s palsy?
A
They all often present with bilateral weakness
19
Q
What are some of the complications of Bell’s palsy?
A
Keratoconjunctivitis sicca: dry eye
Ectropion: sagging eyelid
Synkinesis: e.g. eye blinking causes synchronous upturning of the mouth
Gustatory hyperlacrimation: (crocodile tears) misconnection of parasympathetic fibres can produce crocodile tears (gusto–lacrimal reflex) when eating → stimulates unilateral lacrimation, not salivation
20
Q
What is benign paroxysmal positional vertigo (BPPV)?
A
One of the most common causes of vertigo encountered
It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position
21
Q
What is the aetiology of BPPV?
A
50% to 70% = without a known cause and is referred to as primary (or idiopathic) BPPV
Secondary BPPV = associated with a range of underlying conditions (migraines, head trauma, labyrinthitis, Ménière’s disease)
22
Q
What is the epidemiology of BPPV?
A
Average age of onset is 55 years and it is less common in younger patients
23
Q
What are the features of BPPV?
A
Vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
May be associated with nausea
Each episode typically lasts 10-20 seconds
Positive Dix-Hallpike manoeuvre, indicated by: patient experiences vertigo and rotatory nystagmus
24
Q
How is the diagnosis of BPPV made?
A
Based on a suggestive history and physical examination with a positive Dix-Hallpike manoeuvre (vertigo and rotatory nystagmus) or a positive supine lateral head turn
25
What is the management of BPPV?
Symptomatic relief may be gained by:
Epley manoeuvre (successful in around 80% of cases)
Teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises
Medication is often prescribed (e.g. Betahistine) but is of limited value
Surgery is highly effective but is reserved for intractable and severe cases
26
What is the prognosis of BPPV?
Often self-limiting, but can become chronic and relapsing with considerable effects on a patient's quality of life
Around half of people with BPPV will have a recurrence of symptoms 3–5 years after their diagnosis
27
What is a Cholesteatoma?
A non-cancerous growth of squamous epithelium that is 'trapped' within the skull base causing local destruction
28
Where do cholesteatomas form?
The accumulation of squamous epithelium and keratin debris usually involves the middle ear and mastoid
29
What is the epidemiology of cholesteatomas?
It is most common in patients aged 10-20 years
Being born with a cleft palate increases the risk of cholesteatoma around 100 fold
30
What are the main features of cholesteatomas?
Malodorous/ foul-smelling, non-resolving discharge
Hearing loss
Other features are determined by local invasion:
- vertigo
- facial nerve palsy
- cerebellopontine angle syndrome
31
How is the diagnosis of cholesteatomas made?
Clinical based on history and otoscopic findings = 'attic crust' - seen in the uppermost part of the ear drum
CT scan of the temporal bone, provides lesion definition and extent
32
What is the management of cholesteatomas?
Patients are referred to ENT for consideration of surgical removal
Adjunctive topical antimicrobial treatment may help reduce acute symptoms preoperatively
33
What are the complications of cholesteatomas?
Hearing loss, recurrence, meningitis, facial palsy, and a labyrinthine fistula
34
What is epiglottis?
Rare but serious infection caused by Haemophilus influenzae type B
Prompt recognition is needed due to progression of airway obstruction
Also known as cellulitis of the supraglottis that may cause airway compromise
35
What is the main organism that causes epiglottis?
Haemophilus influenzae type B (HIb)
36
What is the epidemiology of epiglottitis?
Was generally considered a disease of childhood but in the UK it is now more common in adults due to the immunisation programme
The incidence of epiglottitis has decreased since the introduction of the Hib vaccine
37
What are the main features of epiglottitis?
Rapid onset
High temperature, generally unwell
Stridor
Drooling of saliva
'tripod' position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
38
What are the signs of acute epiglottitis?
Rapid onset of high fever
Sore throat
Inability to control secretions
Classic tripod positioning
Difficulty breathing
Irritability
Adults may have a more indolent presentation and may not require airway intervention (only about 11% of adults require intubation whereas most children do)
39
What are the appropriate investigations for epiglottitis?
No action should be taken that could stimulate a child/adult with suspected epiglottitis, including examination of the oral cavity (plus starting IV lines, taking blood, or even separation from a parent)
Diagnosis is made on clinical grounds (only a senior/airway trained staff can made it on direct visualisation), and laboratory or other interventions should not preclude or delay timely control of the airway if epiglottitis is suspected
40
What is the role of x-rays in epiglottitis?
X-rays may be done, particularly if there is concern about a foreign body
Lateral view = show swelling of the epiglottis - the 'thumb sign'
41
What is the sign on lateral x-ray in epiglottitis and how is this different to croup?
Thumb sign = swelling of the epiglottis in lateral view
*Different to posterior-anterior view in croup* = will show subglottic narrowing, commonly called the 'steeple sign'
42
What is the management of epiglottitis?
1. Immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
2. Endotracheal intubation may be necessary to protect the airway (if suspected do NOT examine the throat due to the risk of acute airway obstruction)
3. The diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary
4. Oxygen and IV antibiotics (after senior involvement)
43
What is the prognosis of epiglottitis?
Once the airway has been secured and antibiotics have been initiated, the condition usually resolves rapidly
Vaccination does not preclude the possibility of epiglottitis (just makes it less likely)
44
What is head and neck cancer?
An umbrella term, includes:
Oral cavity cancers
Cancers of the pharynx (including the oropharynx, hypopharynx and nasopharynx)
Cancers of the larynx
45
What are the features of head and neck cancer?
Neck lump
Hoarseness (voice change)
Persistent sore throat
Persistent mouth ulcer
46
What is laryngeal cancer?
Form of cancer that is frequently associated with smoking and alcohol use
47
What are the features of laryngeal cancer?
Hoarseness
Dysphonia
Sore throat
Difficulty swallowing
Referred otalgia
48
What is the NICE (2WW) referral pathway criteria for laryngeal cancer?
In people aged 45 and over with:
Persistent unexplained hoarseness or
An unexplained lump in the neck
49
What is the management for laryngeal cancer?
Dictated by TNM stage
Modalities include surgical resection, radiotherapy, chemotherapy, or any combination of these
Goals of therapy are eradication of cancer with organ preservation
Speech therapy is appropriate after treatment
50
What is the prognosis of laryngeal cancer?
Overall mortality has not changed in nearly 30 years, but the rate of organ preservation has significantly improved
51
What is oropharyngeal cancer (carcinoma)?
Cancer of the oropharynx strongly associated with tobacco and alcohol use
Also strongly implicated with human papilloma virus (HPV) infection in people not exposed to smoking and alcohol use
(Betel nut chewing in developing countries)
52
What are the features of oropharyngeal cancer?
Sore throat
Referred oral pain
Dysphagia
Trismus (muscle spasms in jaw = tightness)
Weight loss and neck mass can be the first signs of otherwise asymptomatic oropharyngeal cancer
53
What is the NICE referral pathway (2ww) for suspected oral cancer?
Consider a 2ww referral in people with either:
1. Unexplained ulceration in the oral cavity lasting for more than 3 weeks or
2. Persistent and unexplained lump in the neck.
Consider an urgent 2ww referral for assessment by a dentist in people who have either:
1. A lump on the lip or in the oral cavity or
2. A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
54
What is the management of oropharyngeal cancer?
Dictated through staging (via CT or MRI with contrast and ultrasound-guided fine needle aspiration cytology, followed by triple endoscopy (nasolaryngopharyngoscopy, oesophagoscopy, and bronchoscopy), positron emission tomography (PET), or CT-PET.
Treatment involves surgery, chemotherapy, radiotherapy, and monoclonal antibodies (in combination with radiotherapy)
Patients should be managed by an MDT in specialised head and neck centres to optimise outcome
55
What is the NICE referral criteria (2ww) for suspected thyroid cancer?
People with an unexplained thyroid lump
56
What is infectious mononucleosis?
A clinical syndrome most commonly caused by Epstein Barr virus (EBV) infection, also known as glandular fever
57
What is the aetiology of infectious mononucleosis?
Caused by Epstein-Barr virus (EBV, also known as human herpesvirus 4, HHV-4) in 90% of cases
Less frequent causes include cytomegalovirus and HHV-6
58
What is the epidemiology of infectious mononucleosis?
It is most common in adolescents and young adults
Risk factors include close contact e.g. kissing, sharing eating utensils, sexual behaviour
59
What is the classic triad seen in infectious mononucleosis?
Seen in around 98% of patients:
1. Sore throat
2. Lymphadenopathy: may be present in the anterior and posterior triangles of the neck, in contrast to tonsillitis which typically only results in the upper anterior cervical chain being enlarged
3. Pyrexia
60
What are some of the other features seen in infectious mononucleosis?
Incubation period: 4–8 weeks
Malaise, anorexia, headache
Palatal petechiae
Splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture
Hepatitis, transient rise in ALT
Lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes
Haemolytic anaemia secondary to cold agglutins (IgM)
61
What happens to patients with infectious mononucleosis if they take ampicillin/amoxicillin?
A maculopapular, pruritic rash
62
How is the diagnosis of infectious mononucleosis made?
Heterophil antibody test (Monospot test)
NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever
63
What is the management of infectious mononucleosis?
Self-limiting infection therefore supportive, includes:
Rest during the early stages, drink plenty of fluid, avoid alcohol
Simple analgesia for any aches or pains
Consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture
64
What are some of the complications of infectious mononucleosis?
Rare but potentially life-threatening complications include:
Severe upper airway obstruction
Splenic rupture
Fulminant hepatitis
Encephalitis
Severe thrombocytopaenia
Haemolytic anaemia
65
What is Ménière's disease?
A disorder of the inner ear
Episodic auditory and vestibular disease characterised by sudden onset of vertigo, hearing loss, tinnitus, and sensation of fullness in the affected ear
66
What is Ménière's disease characterised by?
Excessive pressure and progressive dilation of the endolymphatic system
67
What is the epidemiology of Ménière's disease?
More common in middle-aged adults but may be seen at any age
Meniere's disease has a similar prevalence in both men and women
68
What are the three main symptoms of Ménière's disease?
Recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural)
Vertigo is usually the prominent symptom
69
What are some of the other symptoms of Ménière's disease?
Main = vertigo, tinnitus and sensorineural hearing loss
Sensation of aural fullness or pressure
Other features include nystagmus and a positive Romberg test
episodes last minutes to hours
Typically symptoms are unilateral but bilateral symptoms may develop after a number of years
70
How long do episodes last for in Ménière's disease?
Minutes to hours of vertigo, tinnitus, sensorineural hearing loss and feeling of fullness (unilateral)
71
What is the natural history of Ménière's disease?
Symptoms resolve in the majority of patients after 5-10 years
The majority of patients will be left with a degree of hearing loss
Psychological distress is common
72
What sign can be seen of Ménière's disease on physical examination?
Positive Romberg's test: Swaying or falling when asked to stand with feet together and eyes closed
Also Fukuda's stepping test: Turning towards the affected side when asked to march in place with eyes closed
73
How is the diagnosis of Ménière's disease made?
ENT assessment is required to confirm the diagnosis
Made on clinical history and detailed audiological tests (pure-tone audiometry and bone conduction: unilateral sensorineural hearing loss)
Other investigations may be required to exclude other causes
74
What is the management for Ménière's disease?
Dietary changes and diuretics may control symptoms in early stages of the disease
Acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required
Prevention: betahistine and vestibular rehabilitation exercises may be of benefit
75
What is the guidance regarding driving in Ménière's disease?
Patients should inform the DVLA
The current advice is to cease driving until satisfactory control of symptoms is achieved
76
What are the goals of treatment for Ménière's disease?
Vertigo control
Prevention of further deterioration in hearing whenever possible
Amelioration (improvement) of tinnitus
Balance control
77
What are the complications of Ménière's disease?
Falls
Profound hearing loss
78
What is the prognosis for patients with Ménière's disease?
Symptoms tend to get worse over time regardless of medical intervention
If symptoms persist despite maximal medical therapy, several surgical interventions are available
Goes into periods of remission that are variable in duration and frequency
The progression of hearing loss over time is unpredictable for the individual patient
79
What is a nasal septal haematoma?
An important complication of nasal trauma that should always be looked for
It describes the development of a haematoma between the septal cartilage and the overlying perichondrium
80
What are the features of a nasal septal haematoma?
May be precipitated by relatively minor trauma
Sensation of nasal obstruction = most common symptom
Pain and rhinorrhoea
81
What signs will be seen on physical examination of a nasal septal haematoma?
Classically a bilateral, red swelling arising from the nasal septum
Can be differentiated from a deviated septum by gently probing the swelling = Nasal septal haematomas are typically boggy whereas septums will be firm
82
What is the management of nasal septal haematomas?
Surgical drainage and IV antibiotics
83
What are the complications of not treating nasal septal haematomas?
Septal necrosis may develop within 3-4 days
This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis
May result in a 'saddle-nose' deformity
84
What is otitis externa?
Infection of the outer ear
85
What are the causes of otitis externa?
1. Infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
2. Seborrhoeic dermatitis
3. Contact dermatitis (allergic and irritant)
86
What is a common trigger for otitis externa?
Recent swimming
87
What are the features of otitis externa?
1. Ear pain
2. Itch
3. Discharge
88
What are the examination findings of otitis externa?
On otoscopy: red, swollen, or eczematous canal
89
What is the recommended initial management of otitis externa?
1. Topical antibiotic or a combined topical antibiotic with a steroid
2. If the tympanic membrane is perforated aminoglycosides are traditionally not used*
3. If there is canal debris then consider removal
4. If the canal is extensively swollen then an ear wick is sometimes inserted
90
What are the second line options for otitis externa following topical antibiotic ± steroid?
1. Consider contact dermatitis secondary to neomycin
2. Oral antibiotics (flucloxacillin) if the infection is spreading
3. Taking a swab inside the ear canal
4. Empirical use of an antifungal agent
91
What happens next if a patient fails to respond to TOPICAL antibiotic treatment for otitis externa?
If a patient fails to respond to topical antibiotics then the patient should be referred to ENT
92
What is malignant otitis externa?
1. More common in elderly diabetics
2. There is extension of infection into the bony ear canal and the soft tissues deep to the bony canal
3. Intravenous antibiotics may be required
93
What is otitis media?
Extremely common middle ear infection in young children
94
What is the epidemiology of otitis media?
Extremely common in young children, with around half of children having three or more episodes by the age of 3 years
95
What is the pathophysiology of otitis media?
1. Viral upper respiratory tract infections (URTIs) typically precede otitis media
2. Most of these viral infections are secondary to bacteria, particularly Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
3. Viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the Eustachian tube
96
What are the features of otitis media?
1. Otalgia: some children may tug or rub their ear
2. Fever occurs in around 50% of cases
3. Hearing loss
4. Recent viral URTI symptoms are common (e.g. coryza)
5. Ear discharge may occur if the tympanic membrane perforates
97
What are the findings of otitis media on examination?
Otoscopy findings:
1. Bulging tympanic membrane → loss of light reflex
2. Opacification or erythema of the tympanic membrane
3. Perforation with purulent otorrhoea
4. Decreased mobility if using a pneumatic otoscope
98
What is the diagnostic criteria for otitis media?
1. Acute onset of symptoms:
a. otalgia or ear tugging
2. Presence of a middle ear effusion:
a. bulging of the tympanic membrane, or
b. otorrhoea
c. decreased mobility on pneumatic otoscopy
3. Inflammation of the tympanic membrane i.e. erythema
99
What is the management of otitis media?
1. Generally a self-limiting condition that does not require an antibiotic prescription
2. There are some exceptions e.g. systemically unwell, symptoms > 4 days
3. Analgesia should be given to relieve otalgia
4. Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days
100
When should otitis media be treated with antibiotics?
1. Symptoms lasting more than 4 days or not improving
2. Systemically unwell but not requiring admission
3. Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
4. Younger than 2 years with bilateral otitis media
5. Otitis media with perforation and/or discharge in the canal
101
What antibiotics should be given to certain cases of otitis media?
1. First line: a 5-7 day course of amoxicillin
2. In patients with penicillin allergy: erythromycin or clarithromycin should be given
102
What are the common sequelae of otitis media?
1. Perforation of the tympanic membrane → otorrhoea
2. Unresolved with acute otitis media with perforation may develop into chronic suppurative otitis media (CSOM): defined as perforation of the tympanic membrane with otorrhoea for > 6 weeks
3. Hearing loss
4. Labyrinthitis
103
What are the complications of otitis media?
1. Mastoiditis
2. Meningitis
3. Brain abscess
4. Facial nerve paralysis
104
What is acute sinusitis?
Inflammation of the mucous membranes of the paranasal sinuses
105
What is the aetiology of acute sinusitis?
1. The sinuses are usually sterile
2. Most common infectious agents seen in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses
106
What are the predisposing factors for acute sinusitis?
1. Nasal obstruction e.g. septal deviation or nasal polyps
2. Recent local infection e.g. rhinitis or dental extraction
3. Swimming/diving
4. Smoking
107
What are the features of acute sinusitis?
1. Facial pain: typically frontal pressure pain which is worse on bending forward
2. Nasal discharge: usually thick and purulent
3. Nasal obstruction
108
What is the management of acute sinusitis?
1. Analgesia
2. Intranasal decongestants or nasal saline may be considered (but evidence supporting these is limited)
3. NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days
4. Oral antibiotics only in severe cases
109
What is the antibiotic management of acute sinusitis?
1. Oral antibiotics are not normally required but may be given for severe presentations
2. Phenoxymethylpenicillin first-line
3. Co-amoxiclav if 'systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications'
4. 'double-sickening' may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection
110
What is chronic rhinosinusitis?
An inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer
111
What is the aetiology of chronic rhinosinusitis?
Affects up to 1 in 10 people
112
What are the predisposing factors for chronic rhinosinusitis?
1. Atopy: hay fever, asthma
2. Nasal obstruction e.g. Septal deviation or nasal polyps
3. Recent local infection e.g. Rhinitis or dental extraction
4. Swimming/diving
5. Smoking
113
What are the features of chronic rhinosinusitis?
1. Facial pain: typically frontal pressure pain which is worse on bending forward
2. Nasal discharge: usually clear if allergic or vasomotor. 3. Thicker, purulent discharge suggests secondary infection
4. Nasal obstruction: e.g. 'mouth breathing'
5. Post-nasal drip: may produce chronic cough
114
What are some of the red flag features of chronic rhinosinusitis that warrant further investigation?
1. Unilateral symptoms
2. Persistent symptoms despite compliance with 3 months of treatment
3. Epistaxis
115
What is the management of chronic rhinosinusitis?
1. Avoid allergen
2. Intranasal corticosteroids
3. Nasal irrigation with saline solution
116
What are thyroglossal cysts?
Fluid-filled sac which can be a remnant of the development of the thyroid gland
117
What is the aetiology of thyroglossal cysts?
The thyroid is connected to the tongue by the thyroglossal duct which normally atrophies but in some people may persist and give rise to a thyroglossal duct cyst
118
What is the epidemiology of thyroglossal cysts?
More common in patients < 20 years old
119
What are the features of thyroglossal cysts?
1. Usually midline, between the isthmus of the thyroid and the hyoid bone
2. Moves upwards with protrusion of the tongue
3. May be painful if infected
120
What are the signs of thyroglossal cysts on physical examination?
1. On examination of the neck: soft, round lump in the front centre of the neck
2. They will typically move when the person swallows or sticks their tongue out
121
What are the investigations for a thyroglossal cyst?
1. Bloods: infection markers (WCC), TFTs
2. Ultrasound examination:
a. Thin walled and anechoic on USS
b. Echogenicity suggests infection of cyst
3. Fine needle aspiration
122
What is the management for thyroglossal cysts?
1. Surgery is a standard treatment option (for the comfort of the patient): low risk of recurrence
2. Antibiotics if the cyst is infected
123
What is an important sign to elicit to diagnose thyroglossal cyst?
It will move upwards on tongue protrusion
124
What are the indications for a total thyroidectomy?
Mainly papillary and follicular thyroid cancer
125
What must be done following thyroidectomy?
1. Radioiodine (I-131) to kill residual malignant cells
2. Then early thyroglobulin levels to detect early recurrent disease
126
What can a thyroidectomy lead to?
Hypothyroidism: requires lifelong levothryoxine replacement therapy
127
What is tonsillitis?
An acute infection of the parenchyma of the palatine tonsils
128
What is the aetiology of tonsillitis?
Over half of all cases are bacterial with Streptococcus pyogenes the most common organism
129
What is the epidemiology of tonsillitis?
1. Acute tonsillitis is more common in children between the ages of 5-15 years
2. More common in winter and early spring although can occur at any time of the year
130
What is tonsillitis characterised by?
Pharyngitis, fever, malaise and lymphadenopathy
131
What are the presenting symptoms of tonsillitis?
1. Sudden onset of sore throat
2. Headache
3. Fever
4. Pain on swallowing
5. Presence of cough or runny nose
6. Tonsillar enlargement
7. Associated nausea and vomiting
132
What are the signs of tonsillitis on physical examination?
1. Tonsillar exudate (purulent “discharge/pus milky looking”)
a. particularly when caused by Group A beta-haemolytic streptococci
2. Tonsillar erythema
3. Tonsillar enlargement
4. Enlarged anterior cervical lymph nodes
133
What other condition may mimic tonsillitis?
Infectious mononucleosis
134
What are the scoring systems for a sore throat?
1. Centor criteria
2. FeverPAIN criteria
135
What is the purpose of the scoring systems for a sore throat?
To determine the likelihood of tonsillitis compared to laryngitis or pharyngitis and thus the use of antibiotics
136
What is the Centor criteria for tonsiliitis?
1. Presence of tonsillar exudate
2. Tender anterior cervical lymphadenopathy or lymphadenitis
3. History of fever
4. Absence of cough
(looking for scores >2 which make the likelihood of tonsillitis likely)
137
What is the FeverPAIN criteria for tonsillitis?
1. Fever over 38°C
2. Purulence (pharyngeal/tonsillar exudate)
3. Attend rapidly (3 days or less)
4. Severely Inflamed tonsils
5. No cough or coryza
(scores >1 increase likelihood)
138
When should antibiotics be given in regards to the Centor score for tonsillitis?
Patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
139
What is the guidance regarding investigations for sore throat?
Throat swabs and rapid antigen tests should not be carried out routinely in patients with a sore throat
140
What is the management for tonsillitis?
1. Analgesia
2. Antibiotics:
a. If 3 or more points on Centor criteria
b. Phenoxymethylpenicillin is first choice
3. Corticosteroids (dexamethasone)
4. Tonsillectomy may be considered for patients who have recurrent symptoms of tonsillitis and no other explanation for recurrent symptoms
141
What antibiotics are indicated for the management of tonsillitis?
1. phenoxymethylpenicillin is first line
2. Clarithromycin (if the patient is penicillin-allergic) 3. Either a 7 or 10 day course should be given
142
What are the indications for a tonsillectomy?
Only if the person meets all of the following criteria:
1. Sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
2. The person has five or more episodes of sore throat per year
3. Symptoms have been occurring for at least a year
4. The episodes of sore throat are disabling and prevent normal functioning
143
What are the other indications for a tonsillectomy aside from recurrent tonsillitis?
1. Recurrent febrile convulsions secondary to episodes of tonsillitis
2. Obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
3. Peritonsillar abscess (quinsy) if unresponsive to standard treatment
144
What are the complications of a tonsillectomy?
1. Primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
2. Secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain
145
What are the complications of tonsillitis?
1. Otitis media
2. Quinsy: peritonsillar abscess
3. Rheumatic fever and glomerulonephritis very rarely
146
What is a quinsy?
A peritonsillar abscess typically develops as a complication of bacterial tonsillitis
147
What are the features of a quinsy?
1. Severe throat pain, which lateralises to one side
2. Deviation of the uvula to the unaffected side
3. Trismus (difficulty opening the mouth)
4. Reduced neck mobility
148
What is the next step if a quinsy is suspected?
Urgent review by an ENT specialist
149
What is the management of a quinsy?
1. Needle aspiration or incision & drainage + IV antibiotics
2. Tonsillectomy should be considered to prevent recurrence
150
What is vestibular neuronitis?
A cause of vertigo that often develops following a viral infection
151
What are the differential diagnoses of vestibular neuronitis?
1. Viral labyrinthitis
2. Posterior circulation stroke: the HiNTs exam can be used to distinguish vestibular neuronitis from posterior circulation stroke
152
What are the features of vestibular neuronitis?
1. Recurrent vertigo attacks lasting hours or days
2. Nausea and vomiting may be present
3. Horizontal nystagmus is usually present
4. No hearing loss or tinnitus
153
What is the management of vestibular neuronitis?
1. Buccal or IM prochlorperazine: often used to provide rapid relief for severe cases
2. A short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine): used to alleviate less severe cases
3. Vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms
154
What is Labyrinthitis?
An inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs
155
What is the aetiology of Labyrinthitis?
1. Can be viral, bacterial or associated with systemic diseases
2. Viral labyrinthitis is the most common form
156
What is the main difference between vestibular neuritis and Labyrinthitis?
1. Vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment
2. Labyrinthitis is used when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment
157
What is the epidemiology of Labyrinthitis?
The average age of presentation is 40-70 years
158
What are the features of Labyrinthitis?
Acute onset of:
1. Vertigo: not triggered by movement but exacerbated by movement
2. Nausea and vomiting
3. *Hearing loss: may be unilateral or bilateral, with varying severity
4. Tinnitus
5. Preceding or concurrent symptoms of URTI
159
What are the signs of Labyrinthitis on examination?
1. Spontaneous unidirectional horizontal nystagmus towards the unaffected side
2. Sensorineural hearing loss: shown by Rinne's test and Weber test
3. Abnormal head impulse test: signifies an impaired vestibulo-ocular reflex
4. Gait disturbance: the patient may fall towards the affected side
160
How is Labyrinthitis diagnosed?
Largely on history and examination
161
What is the management of Labyrinthitis?
1. Episodes are usually self-limiting
2. Prochlorperazine or antihistamines may help reduce the sensation of dizziness
162
What is a myringotomy?
A procedure to create a hole in the ear drum to allow fluid that is trapped in the middle ear to drain out
163
What is the common indication of a myringotomy?
Middle ear infection that has led to a glue ear: persistent fluid trapped in the middle ear
164
When is a grommet needed in a myringotomy?
1. A small tube (grommet) may be inserted into the eardrum during the myringotomy in order to keep the incision open for a longer period
2. This is typically between 2 and 12 months, to allow air to ventilate the middle ear and settle down
3. Grommets tend to block naturally and are then pushed out of the ear drum, which almost always heals up during this extrusion process
165
What are cochlear implants?
An electronic device that may be offered to patients with severe-to-profound hearing loss
166
What are the causes of severe to profound hearing loss in children?
1. Genetic (accounts for up to 50% of cases)
2. Congenital e.g. following maternal cytomegalovirus, rubella or varicella infection.
3. Idiopathic (accounts for up to 30% of childhood deafness)
4. Infectious e.g. post meningitis
167
What is the suitability criteria for a cochlear implant in children?
Audiological assessment and/or difficulty developing basic auditory skills
168
What are the causes of severe to profound hearing loss in adults?
1. Viral-induced sudden hearing loss
2. Ototoxicity e.g. following administration of aminoglycoside antibiotics or loop diuretics
3. Otosclerosis
4. Ménière disease
5. Trauma
169
What is the suitability criteria for a cochlear implant in adults?
Patients should have completed a trial of appropriate hearing aids for at least 3 months which they have been objectively demonstrated to receive limited or no benefit from
170
What are the contraindications to consideration for cochlear implant?
1. Lesions of cranial nerve VIII or in the brain stem causing deafness
2. Chronic infective otitis media, mastoid cavity or tympanic membrane perforation
3. Cochlear aplasia
