ENT Flashcards
Tuning Fork Tests + Audiograms + Tympanograms
- Describe results for conductive + sensorineural hearing loss in Rinne’s, Weber’s and on audiogram
- Tympanograms - describe type A, B + C traces
Rinne’s
Positive test: AC > BC (normal)
Condutive loss: BC > AC in affected ear
Sensorineural: AC>BC in affected ear
Weber’s
Conductive loss: localises to affected ear
Sensorineural: localises to normal ear
(if bilateral loss may not localise)
Audiogram
- Above 20dB = normal. Below = hearing loss.
- Conductive loss: air conduction only reduced
- Sensorineural: air + bone reduced
- Mixed: both reduced but air is worse
Tympanogram - measures compliance of TM
- X-axis - pressure (DaPascals)
- Y-axis - compliance (peak when pressure in canal = pressure in middle ear)
- Type A trace = normal (peak 0daPa)
- Type B - flat - can be: middle ear effusion (normal ear canal vol), perforation (larger ear canal vol)
- Type C - Eustachian Tube Dysfunction (peak has -ve pressure)
Give Differentials for Otalgia
Infection
- Otitis externa
- Malignant Otitis Externa
- Acute Otitis media
- Ramsay Hunt Syndrome (herpes zoster oticus)
- Furunculosis (infection of hair follicle in outer ear -> severe pain +/- abscess/rupture)
- Myringitis bullosa (localised otitis externa w/ bullae on drum - viral - supportive Tx)
- Perichondritis (can follow OE or trauma)
Non-Infectious
- Acute otitic barotrauma (can -> rupture of TM)
- Neoplasia of ear (if perichondrium/nerve involvement)
Non-otological
- Many CNs supply ear so chance for referred pain (esp in children) e.g. tonsilitis, dental disease, URTI, TMJ dysfunction, cervical spondylosis
- Neoplasm - if persistent otalgia + normal exam –> refer 2ww
Acute Otitis Media
- Pathophysiology
- Presentation
- Management
- Complications
Pathophysiology
- often preceded by viral URTI (disrupts microbiome) but actual infection bacterial (S pneumoniae, H influenzae, Moraxella)
Presentation
- Otalgia, hearing loss, fever
- Ear discharge (if TM perforation)
- Examination: bulging TM (loss of light reflex), erythema of TM, decreased mobility on pneumatic otoscope
Management
- Generally self-limiting: analgesia + seek advice if worsening/no improvement in 3/7
- BUT give abx (5-7days amoxicillin (or erythromycin/clarithromycin in allergy)) if:
- Symptoms >4/7 + not improving
- Systemically unwell but not needing admission
- Immunocompromise/high risk
- <2yo w/ bilateral OM
- OM w/ perforation and/or discharge in canal
Complications
- TM perforation - can occur due to infection (give 1/52 abx) or trauma (no abx needed if dry/uncomplicated/no evidence infection) - refer ENT if not healed by 6/52
- Chronic otitis media
- Otitis media w/ effusion (glue ear/serous OM) - glue ear is NOT an infective process in itself but can occur following acute infection or if eustachian tube is blocked+ main feature = hearing loss -
- Hearing loss (normally temporary + conductive)
- Labyrinthitis
- Rare: mastoiditis, meningitis, intracranial abscess, sinus thrombosis, facial nerve paralysis
Glue Ear/Otitis media w/ effusion
Pathophysiology
Presentation
Management
Complications
Pathophysiology
- Otitis media w/ effusion w/ intact TM
- Peak age 2-6.
- Causes: ET dysfunction (more common w. cleft palate) - in adults need to look in post-nasal space for tumour
- Risk factors: male, siblings w/glue ear, bottle feeding, day care attendance, parental smoking, seen more in winter/spring
Presentation
- hearing loss, recurrent otalgia (often if concurrent infection)
- If chronic –> TM can thin and collapse onto ossicles -> retraction pocket -> cholesteatoma
- Otoscopy: middle ear effusion
Management
- Conservative - most resolve in 12/52 - if not refer ENT - ? myringotomy + grommet insertion +/- adenoidectomy
- Grommets can -> tympanic sclerosis, replace after 10-12/12, if discharge suggests infection
Chronic Otitis Media
- Classification/Pathophysiology
- Presentation
- Management
Classification
- Mucosal: from episode of acute OM w/ failure of ruptured membrane to heal. Can be Active (discharging), Inactive (no discharge)
- Squamous: active discharging = cholesteatoma. Inactive = no discharge, can be retraction pocket (can later -> cholesteatoma)
Management
- Cholesteatoma - ENT referral for possible surgical removal
- If no cholesteatoma (mucosal) - topical abx + aural toilet
- If unsure whether cholesteatoma - refer
Cholesteatoma
- Pathophysiology
- Presentation
- Investigation
- Management
- Complications
Pathophysiology
- Non-cancerous growth of squamous epithelium ‘trapped’ in skull -> local destruction
- Can occur in chronic otitis media or following any ear surgery (due to damage to TM)
Presentation
- foul-smelling non-resolving discharge
- Hearing loss
- Local invasion –> vertigo, facial nerve palsy, cerbellopontine angle syndrome
- Examination: ‘attic crust’ on otoscopy, retraction pocket, possible TM perf.
- (congenital cholesteatoma (rare) can be white mass behind intact TM
Management
- Refer to ENT for consideration of surgical removal (semi-urgent ref)
- Emergency admission if: facial nerve palsy, veritgo or other neurological sx (including pain) that could be associated w/ devleopment of intracranial abscess/meningitis
Complications
- sensorineural hearing loss, vertigo, facial nerve palsy, meningitis, intracranial abscess
Acute Otitis Externa
- Pathophysiology
- Presentation
- Management
- Complications
Pathophysiology
- Bacterial (staph aureus, pseudomonas), Fungal (candida - white strands; aspergillus (black or white balls)
- Seborrhoeic dermatitis
- contact dermatitis (allergic/irritant)
- Recent swimming
- (fungal infection/dermatitis can also -> chronic OE)
Presentation
- Ear pain (tragus and/or pinna), itch, discharge, hearing loss due to canal occlusion (less common)
- Examination:
- Otoscopy: red, swollen, or eczematous canal +/- TM eryethema (may be difficult to see if canal narrowed)
- possible: cellulitis of pinna/adjacent skin, conductive hearing loss, tender regional lymphadenitis
Investigation
- Ear swab for bacterial/fungal microscopy + culture if: Tx failure, severe/recurrent/chronic OE, suspected spread beyond ear canal
Management
Acute Otitis Externa:
- Keep ear dry + avoid allergens
- Topical abx or combined abx/steroid for 7-14d (+/- aural toilet) (avoid aminoglycosides if TM perforation - risk of ototoxicity)
- PO abx if immunocompromised, severe infection or cellulitis/spread beyond canal (staph - fluclox. Pseudomoas - ciprofloxacin (DM or immunocompromised))
Chronic Otitis Externa:
- Swab
- Dry ear, manage risk factors, analgesia
- If signs of fungal Infec: topical antifungal (eg. clotrimazole for at least 14 days after sx resolve)
- Bacterial: treat as acute
- If no evidence bacterial or fungal: topical steroid (if no effect then trial antifungal)
Complications
- Malignant Otitis Externa - infection into soft tissue of ear canal -> bony ear canal -> temporal bone OM
pseudomonas pyocyaneus. In immunocompromised/DM
Presentation: severe, unrelenting, deep seated otalgia. Temporal headache, Purulent otorrhoea. Possibly dysphagia. Hoarseness and/or facial nerve palsy.
CT to diagnose
Urgen ENT ref for IV + topical Abx +/- surgery
Give possible causes of sensorineural and conductive hearing loss + their key features.
Conductive
- Congenital e.g. atresia of canal or ossicle abnormality
-Ext ear: wax impaction, exostoses, otitis externa, foreign body
Mid ear: otitis media w/ effusion, perf TM, cholesteatoma, otosclerosis
**Sensorineural **
- Congenital - genetic, rubella
- Trauma: noise, head injury, surgery
- Inflammatory: chronic otitis media, meningitis, mumps, syphylis
- Degenerative: presbyacusis
- Ototoxicity: aminoglycosides, cytotoxics
- Neoplastic: acoustic neuroma
- Medieres
- Sudden onset sensorineural hearing loss- urgent ENT referral. Most is idiopathic but need to rule out vestibular schawnoma. ENT management all cases of SSNHL w/ high dose steroids
Describe features of the following causes of hearing loss
- Exostoses
- Presbycusis
- Otosclerosis
- Drug otoxicity
- Noise damage
- Ear Wax
- Acoustic neuroma (vestibular schwannoma)
Exostoses - conductive
- bony growths in canal - predispose to keratin accumulation
- Often in swimmers
- No Tx unless hearing loss of otitis externa
Presbycusis - sensorineural
- high-frequency sensorineural hearing loss. Age-related. Bilateral.
- slow progression - difficulty understanding speech, increased vol needed on tv, loss of directionality of sound, worse sx in noisy environments
- Ix: otoscopy normal. Type A tympanogram. B/L SN loss on audiometry.
- Management: hearing aid
Otosclerosis - conductive
- Replacement of normal bone w/ vascular spongy bone -> conductive loss due to fixation of stapes at oval window
- Autosomal dominant. young adults. Can be tinnitus.
- 10% have flamingo tinge of TM (hyperaemia)
- Management: hearing aid, stapdectomy
Drug Ototoxicity - sensorineural
- Aminoglycosides (gentamicin), furosemide, aspirin + cytotoxic drugs
Noise Damage - sensorineural
- B/L loss. Typically worse at 3000-6000 Hz
Ear Wax
- remove if: symptomatic, TM obscured + needs to be viewed, causing problems w/ hearing aid
- Management: ear drops for 3-5 days to soften wax (unless u suspect perf TM)
- 2nd line: irrigation
Acoustic Neuroma/Vesitbular Schwannoma
- make up 90% of cerebellopontine angle tumours. B/L tumours seen in neurofibromatosis type 2.
- History depends on affected CN:
- - VIII: vertigo, unilateral SN hearing loss, unilateral tinnitus
- -V: absent corneal reflex
- - VII: facial palsy
- Management: urgent referral to ENT. MRI of cerebellopontine angle + audiogram. Management w/ surgery, RT or observation
Benign Paroxysmal Positional Vertigo
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- due to stones in vestibular apparatus
**Presentation **
- Sudden onset vertigo. Triggered by change in head position. Lasts 10-20s. Can -> nausea.
Investigation
- Dix-Hallpike +ve
Management
- Epley maneuvre
- Brandt-Daroff exercises
- Betahistine
Menieres Disease
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology
- Disorder of inner ear (unknown cause) -> excessive pressure + dilation of endolymphatic system
Presentation
- Episodes of: vertigo, tinnitus, hearing loss, aural fullness
- Lasts mins-hours
- Often begins unilateral but can progress to bilateral
- Typically resolves after 5-10yr but often left w/ degree of hearing loss
Management
- ENT to confirm diagnosis
- Inform DVLA (stop driving till symptom control)
- Acute attack: prochlorperazine
- PreventioN; Betahistine + vestibular rehab
Describe the two following causes of veritgo:
- Vestibular neuronitis
- Labyrinthitis
- Posterior Circulation Stroke
Vestibular neuronitis
Presentation
- often follows viral infection
- recurrent vertigo attacks lasting hours - days +/- nausea + vomiting
- NO hearing loss/tinnitus
Management
- Buccal or IM prochlorperazine acutely if severe
- otherwhise short course PO prochlorperazine
- if chronic: vestibular rehab
Labyrinthitis
Presentation
- Vertigo, n+v, hearing loss, tinnitus
- preceding or concurrent URTI
- Signs: sensorineural hearing loss, undirectional horizontal nystagmus to unaffected side, gait disturbance
Management
- Normally self-limiting
- can give prochlorperazine
Posterior Circulation Stroke
- Verterbrobasiclar arteries, 1 of following;
- 1. Cerebellar or brainstem syndromes
- 2. Loss of consciousness
- 3. isolated homonymous hemianopia
- Can differentiate from labyrinthitis using HiNTs exam
Describe features of the following
- Perichondritis
- Pinna Cellulitis
- Keratosis obturans
- Mastoiditis
- Bullous Myringitis
Perichronditis
- Causes: ear piercing. Normally pseudomonas (or staph aureus).
- Presentation –> erythema, pain, if subperiosteal abscess can -> cauliflower ear
- Treat: PO ciprofloxacin + observe closely (if abcess -> ENT for drainage + IV abx)
Pinna cellulitis
- Can be differentiated from perichronditis as perichondritis does NOT involve the earlobe
Keratosis obturans
- Build up of keratin in earcanal –> severe ear pain, conductive hearing loss, rarely ottrhoea
- Treat cause: wax syringing, treat any infection, remove any foreign body
- Can use keratolytic agents eg. salicylic acid, may need surgical removal (sent for histology to rule out malignancy)
Mastoiditis
- Otitis media spreads to mastoid air spaces
- -> otalgia, fever, systemically unwell, swelling, erythema, tenderness of mastoid process, ear may protrude +/- discharge if TM perf
- Clinical diagnosis BUT CT if complications (facial nerve palsy, hearing loss, meningitis) suspected
- IV abx
Bullous myringitis
- Inflammation of TM w/ painful vesicles. Can be caused by: mycoplasma or viral
- (can appear similarly in Ramsay Hunt w/ eardrum involvement)
- Treat cause
Nasal Polyps
- Presentation
- Investigation
- Management
Nasopharyngeal carcinomma
- Pathophysiology
- Presentation
- Investigation
- Management
Nasal Polyps
Presentation
- Nasal obstruction, rhinorrhoea, sneezing, poor sense of taste/small
Associatations
- Asthma, aspirin sensitivity, infective sinusitis, CF, Kartagener’s syndrome, Churg-Strauss syndrome
Investigation
- If red flag: UNILATERAl or BLEEDING –> 2ww ?Ca
Management
- ENT ref for full examination
- Topical steroids helpful in 80%
Nasopharyngeal carcinoma
Pathophysiology
- RFs: Chinese ethnicity, EBV
Presentation (tends to present late)
- Cervical lymphadenopathy, nasal voice, epistaxis, nasal obstuction, conductive hearing loss (eustachian tube involvement), CN involvement if extension into skull base
Investigations: MRI to diagnosis
Management: external irradiation
Facial/Head Trauma.
Give features of the following
- Nasal Injury
- Basal Skull Fracture
Basal Skull Fracture
- Hx of significant head injury
- CSF rhinorrhoea, periorbital ecchymosis, battle sign (mastoid bruising), CSF otorrhoea, otorrhagia (bleeding from ear)
- Ix - CT (look also for underlying haemorrhage)
Nasal Injury
- Nasal Fracture - often due to lateral blow
- Treatment is delayed by 1/52 to allow swelling to subside so can assess for deformity
- Septal haematoma- can form even w/ relatively minor trauma
- -> sensation of nasal obstruction, pain, rhinorrhoea
- –> often b/l, boggy red swelling arising from septum
- Tx: surgical drainage + IV abx
- If untreated -> irreversible septal necrosis within 3-4d + saddle nose deformity
Nasal Foreign Bodies
- Presentation
- Management
Presentation
- Often children –> unilateral foul smelling discharge
- Can be long time after initial insertion, esp w/ inorganic objects
- In adults can present as rhinolith –> nasal obstruction, foul smelling/blood stained discharge often years after insertion
Management
Children
- check both nostrils + ears
- If child cooperative- remove w/ forceps - if difficult or uncooperative refer for GA (risk of inhalation or traumatic haemorrhage)
Epistaxis
Pathophysiology
Presentation
Investigation
Management
Pathophysiology
- Most common site - little’s area (anterior)
- Posterior –> more profuse
- Causes: nose picking, nose blowing, trauma, FB, bleeding disorders, juvenile angiofibroma (benign tumour), cocaine use, hereditary haemorrhagic telangiectasia
Management
- Pinch cartilagenous bit of nose for 20 mins
- If successful consider:
-Topical antiseptic (naseptin - avoid in peanut, soy or neomycin allergy)
-Admission if: cormorbidity, underlying cause suspected, age <2 (higher chance of haemophilia/leukaemia)
If unsuccessful:
- Cautery w/ silver nitrite (if bleeding point well visualised)
- Packing e.g. rapid rhino (if not well visualised) - if packing done then must admit to ENT for observation
- If nil working may need sphenopalatine ligation in theatre
(anyone w/ bleed from unknown or posterior source needs admitting
Allergic Rhinitis
Pathophysiology
Presentation
Management
Pathophysiology
- Seasonal (hay fever)
- Perrenial (throughout the year)
- Occupational
- Causes: dust mites, grass, tree pollen
Presentation
- Sneezing, b/l nasal obstruction, clear discharge, post-nasal drip (can -> bad breath + chronic cough), nasal pruritis
Management
- Mild-moderate: PO or intranasal antihistamines
- Moderate-severe: intranasal steroids
(avoid long courses of nasal decongestants as –> increasing dose requirement, rebound hypertrophy of nasal mucosa (rhinitis medicamentosa) on withdrawal
Sinusitis
Pathophysiology
Presentation
Management
Pathophysiology
- Inflammation of mucous membrane of sinuses. Can be infective (strep pneumoniae, h influenzae, rhinovirus)
- RFs: nasal obs (septal dev or polyps), recent local infection (rhinitis or dental extraction), swimming/diving, smoking, atopy
Acute - <12w
Chronic >12w
Presentation
- Facial pain (frontal, worse on bending)
- Discharge: thick + purulent (in acute/infection), clear in chronic
- Nasal obstruction (-> mouth breathing)
- Post-nasal drip (esp in chronic)
Complications: meningitis
Management
Acute
- <10days (supportive - analgesia, ?intranasal decongestants)
- >10days - intranasal steroids
- PO abx if systemically unwell, signs of more serious illness or high risk for complications - phenoxymethylpenicillin or co–amox
Chronic
- Avoid allergen, intranasal steroids, nasal irrigation w. saline
- RED FLAGs: epistaxis, unilateral, persistent despite 3/12 treatment
- consider referal if recurrent otitis media or pneumonia in children, unuusal opportunistic infection, symptoms significantly affecting QoL or polyps complicating treatment
Ramsay Hunt Syndrome
- Pathophysiology
- Presentation
- Management
Pathophysiology
- Ramsay Hunt = Herpes Zoster Oticus
- Reactivation of VZV in 7th CN (facial nerve)
Presentation
- Auricular pain often first
- Facial nerve palsy
- Vesicular rash around ear
- +/- vertigo + tinnitus
Management
PO aciclovir AND steroids (different to herpes zoster ophthalmicus which is just PO aciclovir)
Describe the location/features/management of the following neck lumps
- Reactive lymphadenopathy
- Lymphoma
- Thyroid swelling
- Thyroglossal Cyst
- Pharyngeal pouch
- Cystic hygroma
- Branchial cyst
- Cervical rib
- Carotid aneurysm
Reactive Lymphadenopathy
- most common. Often w/ hx of local infection/generalised viral illness
Lymphoma
- Rubbery, painless lymphadenopathy
- Pain when drinking alcohol (rare sign)
- B symptoms: fever, nightsweats, weight loss
Thyroid Swelling
- Can be symptomatically hypo, eu or hyperthyroid
- Moves up on swallowing
Thyroglossal cyst
- More common <20yo. Midline, between thyroid + hyoid. Moves up w/ tongue protrusion.
- Can be painful if infected
Pharyngeal pouch
- More in older men. Not normally visible unless large - posterior midline. Gurgles on palpation.
- –> dysphagia, regurgitation, aspiration, chronic cough
Cystic hygroma
- Congenital lymphatic lesion, mostly on left side
- Most seen at birth and 90% before age 2
Branchial Cyst
- oval, mobile, cystic mass between sternocleidomastoid muscle + pharynx
- Usually in early adulthood
- Can be swollen/tender w/ URTI
Cervical Rib
- More in females. 10% –> thoracic outlet syndrome
Carotid aneurysm
- Pulsatile neck mass. Doesn’t move on swallowing
Describe the following mouth conditions
- Leucoplakia and Erythroplakia
- Black Hairy Tongue
- Geographic Tongue
- Gingivial Hyperplasia
Leucoplakia and Erythroplakia
- Pre-malignant conditions (can –> oral cancer) - refer
- N.B. oral hairy leukoplakia is an EBV induced lesion that occurs almost entirely in HIV patients and is NOT premalignant
Black Hairy Tongue
- Defective desquamation of papillae (can be brown, green, pink, black or other colours)
- RFs: poor oral hygeine, Abx, H+N radiation, HIV, IVDU
- Swab to exclude candidia
- Manage: tongue scraping +/- topical antifungals
Geographic Tongue
- Benign. More in females.
- Erythematous areas w/ white-grey border +/- burning after eating certain foods
- Maage w/ reassurance
Gingivial Hyperplasia
- Drugs: phenytoin, ciclosporin, CCB (esp nifedipine)
- Acute myeloid leukaemia
Tonsilitis
Presentation
Complications
Management
When is tonsilectomy considered and what are possible complications?
Presentation
- Most = group A strep or viral
- Sore throat
- Fever, reduced PO intake, cervical lymphadenopathy
Complications
- Otitis media
- Quinsy (peritonsilar abcess. Features: trismus, hot potato voice, difficulty swallowing, deviated uvula)
- Rheumatic fever
Rare inflammatory post-strep disorder. Occurs 2-4/52 post-infection.
Acute = short lived -> fever, malaise, endo/peri/myocarditis, migratory arthritis, erythema marginatum
Managed w/ bed rest, aspirin +/- steroids + then prevent recurrent w/ monthly benpen injections (for 10years or till age 21)
80% develop chronic rheumatic fever -> mitral stenosis (may need surgical repair)
- Glomerulonephritis (rare - 2-3/52 post-infec) (nephritic)
Management
- Supportive in most
- 7-10 days benzylpenicillin (or clarithromycin) if:
- Quinsy/peritonsilar abscess (+ refer ENT for drainage + steroids)
- Systemic upset
- Previous hx of rheumatic fever
- High risk (eg. child w/ immumosupression or DM)
- Centor of 3 or more: exudative tonsils, cervical lymphadenopathy, fever, absence of cough
Tonsilectomy
Consider if:
- 5+ episodes each year AND sx for at least 1 year AND episodes are disabling/prevent normal function
- Recurrent febrile convulsions due to tonsilitis
- Obstructive sleep apnoea, stridor or dysphagia due to large tonsils
- Quinsy if unresponsive to standard tx
Complications of tonsilectomy:
- Pain can increase for up to 6 days (normal)
- Haemorrhage (ALL should be assessed by ENT)
- - Primary/reactionary in first 6-8 hours = immediate return to theatre
- Secondary (5-10days) - often due to wound infection - admit + Abx (if severe -> surgery)
What are the 3 pairs of salivary glands?
Describe the pathology that can occur in salivary glands
3 pairs of salivary glands
- Parotid (serous) = most tumours (80%)
- Submandibular (mixed) = most stones
- Sublingual (mucous)
Tumours
- Pleomorphic adenomas (80% of parotid tumours) - benign, slow growing, painless lump. remove w/ superficial paratoidectomy (risk of facial nerve damage)
- Warthin’s Tumour (10% of tumours) - *benign, more in males, softer, more mobile + fluctuant *
- Malignant tumours (rare) - short hx, painful, hot skin, hard, fixation, CN VII involvement
Stones = sialolithiasis (80% = submandibular)
- recurrent, unilateral pain + swelling on eating. Can become infected -> ludwig’s angina
- View on X-ray (sialography) + remove surgically
Siladenitis (inflammation/swelling)
- Acute viral infection e.g. mumps
- Acute bacterial infection e.g. due to dehydration, DM or stone obstruction
- Autoimmune - Sjogren’s
- Other: sarcoidosis, lymphoma, alcoholic liver disease, tumour
- (unilateral more likley to be tumour, stone or bacterial infection)
