ENT Flashcards
clinical features of acute tonsillitis
pharyngitis
fever
malaise
lymphadenopathy
organism tonsillitis
strep pyogenes - over 1/2 bacterial
tx tonsillitis
penicillin type abx for bacterial
ddx of tonsillitis
infectious mononucelosis
complication tonsillitis
local abscess formation - quinsy
otitis media
rheumatic fever and glomerulonephritis rarely
auricular haematomas tx
same day assessment by ENT
incision and drainage
define brachial cyst
branchial cyst is a benign, developmental defect of the branchial arches. The cyst is filled with acellular fluid with cholesterol crystals and encapsulated by stratified squamous epithelium. Branchial cysts may have a fistula and are therefore prone to infection. They may enlarge following a respiratory tract infection.
clinical fx of brachial cyst
late childhood/early adulthood
asx lateral neck lump anterior to SCM
male risk fx
examination fx of brachial cyst
unilateral, typically on the left side
lateral, anterior to the sternocleidomastoid muscle
slowly enlarging
smooth, soft, fluctuant
non-tender
a fistula may be seen
no movement on swallowing
no transillumination
ddx of neck lump in children
congenital: branchial cyst, thyroglossal cyst, dermoid cyst, vascular malformation
inflammatory: reactive lymphadenopathy, lymphadenitis,
neoplastic: lymphoma, thyroid tumour, salivary gland tumour
diagnosis of neck lump
consider and exclude other malignancy
ultrasound
referral to ENT
fine-needle aspiration
branchial cyst tx
ENT surgeons
concervatively or surgically excised
abx if infective
what are the main features of cholesteatoma?
foul smelling non resolving discharge
hearing loss
if local invasion - vertigo, facial nerve palsy, cerebellopontine angle syndrome
otoscopy cholesteatoma
attic crust - in uppermost part of ear drum
cholesteatoma management
referred to ENT for consideration of surgical removal
causes of severe to profound hearing loss for a cochlear implant
In children
Genetic (accounts for up to 50% of cases).
Congenital e.g. following maternal cytomegalovirus, rubella or varicella infection.
idiopathic (accounts for up to 30% of childhood deafness).
Infectious e.g. post meningitis.
In adults
Viral-induced sudden hearing loss.
Ototoxicity e.g. following administration of aminoglycoside antibiotics or loop diuretics.
Otosclerosis
Ménière disease
Trauma
contraindications to cochlear implant
Contraindications to consideration for cochlear implant:
Lesions of cranial nerve VIII or in the brain stem causing deafness
Chronic infective otitis media, mastoid cavity or tympanic membrane perforation
Cochlear aplasia
Relative contraindications:
Chronic infective otitis media or mastoid cavity infections
Tympanic membrane perforation
Patients that may be seen to demonstrate a lack of interest in using the implant to develop enhanced oral communication skills.
most common causes of deafness
presbycusis - age relating sensorineural hearing loss
otosclerosis - aut dom, replacement of normal bone by vascular spongy bone, conductive
glue ear
meniere’s
drug otoxicity
noise damage
acoustic neuroma
tx of ear wax
ear syringing - except if perforation or pt has grommets
olive oil
causes of epistaxis
trauma
insertion of foreign bdoies
bleeding disorders
juvenile angiofibroma
cocaine use
hereditary haemorrhagic telangiectasia
granulomatosis with polyangititis
causes of facial pain
sinusitis
trigeminal neuralgia
cluster headache
temporal arteritis
what are the drug causes of gingival hyperplasia?
phenytoin
ciclosporin
calcium channel blocker
gingivitis
secondary to poor dental hygiene. Clinical presentation may range from simple gingivitis (painless, red swelling of the gum margin which bleeds on contact) to acute necrotizing ulcerative gingivitis (painful bleeding gums with halitosis and punched-out ulcers on the gums).
tx gingivitis
dentist
abx not usually necessary
tx acute necrotizing ulcerative gingivitis
refer the patient to a dentist, meanwhile the following is recommended:
oral metronidazole* for 3 days
chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash
simple analgesia
*the BNF also suggest that amoxicillin may be used
laryngeal cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:
persistent unexplained hoarseness or
an unexplained lump in the neck
oral cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
a lump on the lip or in the oral cavity or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
thyroid cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump.
causes of hoarseness
voice overuse
smoking
viral illness
hypothyroidism
gastro-oesophageal reflux
laryngeal cancer
lung cancer
ludwig’s angina
a type of progressive cellulitis that invades the floor of the mouth and soft tissues of the neck. Most cases result from odontogenic infections which spread into the submandibular space.
Features
neck swelling
dysphagia
fever
It is a life-threatening emergency as airway obstruction can occur rapidly as a result.
Management
airway management
intravenous antibiotics
define mastoidits
when an infection spreads from the middle to the mastoid air spaces of the temporal bone.
fx of mastoiditis
otalgia: severe, classically behind the ear
there may be a history of recurrent otitis media
fever
the patient is typically very unwell
swelling, erythema and tenderness over the mastoid process
the external ear may protrude forwards
ear discharge may be present if the eardrum has perforated
diagnosis mastoidits
diagnosis clinical
Ct if complications suspected
mastoiditis management
iV ABX
mastoiditis complication
facial nerve palsy
hearing loss
meningitis
common nasal polyps
1% in adults in UK
2-4x more common in men and not in children or elderly
nasal polyps assoications
asthma (particularly late-onset asthma)
aspirin sensitivity
infective sinusitis
cystic fibrosis
Kartagener’s syndrome
Churg-Strauss syndrome
fx of nasal polyps
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
management of nasal polyps
referred to ENT for full examination
topical corticosteroid to shrink
nasal septal haematoma
classically a bilateral, red swelling arising from the nasal septum
this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm
nasal septal haematoma tx
surgical drainage
IV abx
nasopharyngeal carcinoma type
squamous cell
associated with EBV
nasopharyngeal presenting features
cervical lymphadenopathy
Otalgia
Unilateral serous otitis media
Nasal obstruction, discharge and/ or epistaxis
Cranial nerve palsies e.g. III-VI
nasopharyngeal carcinoma tx
radiotherapy
causes of neck lump
reactive lymphadenopathy
lymphoma
thyroid swelling
thyroglossal cyst
pharyngeal pouch
cystic hygroma
branchial cyst
cervical rib
carotid aneurysm
parotid gland tumours
Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve. With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the 5th decade of life.
imaging for parotid gland tumours
Plain x-rays may be used to exclude calculi
Sialography may be used to delineate ductal anatomy
FNAC is used in most cases
Superficial parotidectomy may be either diagnostic of therapeutic depending upon the nature of the lesion
Where malignancy is suspected the primary approach should be definitive resection rather than excisional biopsy
CT/ MRI may be used in cases of malignancy for staging primary disease
parotid gland tumours tx
For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement.
other conditions affecting parotid gland
HIV infection
sjogren’s
sarcoidosis
perforated tympanic membrane tx
no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time
abx if following AOM
clinical fx of quinsy
severe throat pain, which lateralises to one side
deviation of the uvula to the unaffected side
trismus (difficulty opening the mouth)
reduced neck mobility
how is quinsy managed?
urgent referral by ENT
needle aspiration or incision & drainage + intravenous antibiotics
tonsillectomy should be considered to prevent recurrence
define pleomorphic adenoma
Pleomorphic adenoma (also known as a benign mixed tumour) is a benign tumour of the parotid gland. It is the most common tumour of the parotid gland and typically appears at the age of 40-60 years.
what are the post op complications of tonsillectomy?
Pain
The pain may increase for up to 6 days following a tonsillectomy.
Haemorrhage
Haemorrhage is a feared complication following tonsillectomy. All post-tonsillectomy haemorrhages should be assessed by ENT.
Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.
Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in around 1-2% of all tonsillectomies.
which frequency affected prescbycusis
high frequency
causes of presbycusis
The precise cause is unknown however is likely multifactorial
Arteriosclerosis: May cause diminished perfusion and oxygenation of the cochlea, resulting in damage to inner ear structures
Diabetes: Acceleration of arteriosclerosis
Accumulated exposure to noise
Drug exposure (Salicylates, chemotherapy agents etc.)
Stress
Genetic: Certain individuals may be programmed for the early ageing of the auditory system
clinical fx of presbycusis
chronic, slowly progressing history of:
Speech becoming difficult to understand
Need for increased volume on the television or radio
Difficulty using the telephone
Loss of directionality of sound
Worsening of symptoms in noisy environments
Hyperacusis: Heightened sensitivity to certain frequencies of sound (Less common)
Tinnitus (Uncommon)
clinical signs of presbycusis
Possible Weber’s test bone conduction localisation to one side if sensorineural hearing loss not completely bilateral
investigations presbycusis
Otoscopy: Normal, to rule out otosclerosis, cholesteatoma and conductive hearing loss (Foreign body, impacted wax etc.)
Tympanometry: Normal middle ear function with hearing loss (Type A)
Audiometry: Bilateral sensorineural pattern hearing loss
Blood tests including inflammatory markers and specific antibodies: Normal
define ramsay hunt syndrome
caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
fx ramsay hunt syndrome
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus
ramsay hunt syndrome management
oral aciclovir and corticosteroids
criteria for bacterial cause of sore throat/tonsillitis
centor score - presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever
absence of cough
if 3 or 4 - 32-56% chance its bacterial
FeverPAIN score - Fever over 38°C.
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (3 days or less)
Severely Inflamed tonsils
No cough or coryza
4 or 5 - 62%-65
…..phenoxymethylpenicillin or clarithromycin for 10 days
sialolithiasis
80% of all salivary gland calculi occur in the submandibular gland
70% of these calculi are radio-opaque
Stones are usually composed of calcium phosphate or calcium carbonate
Patients typically develop colicky pain and post prandial swelling of the gland
Investigation involves sialography to demonstrate the site of obstruction and associated other stones
Stones impacted in the distal aspect of Wharton’s duct may be removed orally, other stones and chronic inflammation will usually require gland excision
sudden onset senorineural hearing loss
urgent referral ENT
majority are iditopathic
MRI - vestibular schwannoma
high dose oral corticosteroids
clinical fx of thyroglossal cysts
More common in patients < 20 years old.
Features
usually midline, between the isthmus of the thyroid and the hyoid bone
moves upwards with protrusion of the tongue
may be painful if infected
thryoid surgery complications
Anatomical such as recurrent laryngeal nerve damage.
Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.
causes of tinnitus
meniere’s disease
otosclerosis
sudden onset sensorineural hearing loss - acoustic neuroma
hearing loss
drugs
impacted ear wax
tinnitus investigated
audiological assessment for hearing loss
enerally, non-pulsatile tinnitus does not require imaging unless it is unilateral or there are other neurological or ontological signs. MRI of the internal auditory meatuses (IAM) is first-line
pulsatile tinnitus generally requires imaging as there may be an underlying vascular cause. Magnetic resonance angiography (MRA) is often used to investigate pulsatile tinnitus
tinnintus management
investigate and treat any underlying cause
amplification devices
more beneficial if associated hearing loss
psychological therapy may help a limited group of patients
examples include cognitive behavioural therapy
tinnitus support groups
indications for tonsillectomy
meets all criteria:
sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
the person has five or more episodes of sore throat per year
symptoms have been occurring for at least a year
the episodes of sore throat are disabling and prevent normal functioning
less common indications for tonsillectomy
recurrent febrile convulsions secondary to episodes of tonsillitis
obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
peritonsillar abscess (quinsy) if unresponsive to standard treatment
causes of vertigo
viral labyrinthitis
vestibular neuronitis
BPPV
meniere’s disease
vertebrobasilar ischaemia
acoustic neuroma
other - posterior circulation stroke, trauma, MS, ototoxicity
clinical fx of vestibular neuronitis
recurrent vertigo attacks lasting hours or days
nausea and vomiting may be present
horizontal nystagmus is usually present
no hearing loss or tinnitus
ddx for vestibular neuronitis
viral labyrinthitis
posterior circulation stroke: the HiNTs exam can be used to distinguish vestibular neuronitis from posterior circulation stroke
vestibular neuronitis management
buccal or IM prochlorperazine
short course of oral proclorperazine or antihistamine
vestibular rehab exercises
define labyrinthitis
nflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs. Labyrinthitis can be viral, bacterial or associated with systemic diseases. Viral labyrinthitis is the most common form of labyrinthitis.
vestibular neuritis v labyrinthitis
vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment; Labyrinthitis is used when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment.
age labyrinthitis
40-70 yrs
clinical fx of labyrinthitis
acute
vertigo: not triggered by movement but exacerbated by movement
nausea and vomiting
hearing loss: may be unilateral or bilateral, with varying severity
tinnitus
preceding or concurrent symptoms of upper respiratory tract infection
signs labyrinthtisi
spontaneous unidirectional horizontal nystagmus towards the unaffected side
sensorineural hearing loss: shown by Rinne’s test and Weber test
abnormal head impulse test: signifies an impaired vestibulo-ocular reflex
gait disturbance: the patient may fall towards the affected side
management labyrinthitis
episodes are usually self-limiting
prochlorperazine or antihistamines may help reduce the sensation of dizziness
