ENT Flashcards
Describe the pathophysiology of acoustic neuroma
Benign tumour of Schwann cells surrounding the auditory nerve
Usually unilateral
-If bilateral is suggestive of neurofibromatosis type II
Describe the presentation of acoustic neuroma
Unilateral sensorineural hearing loss
Unilateral tinnitus
‘Fullness’ in ear
Facial nerve palsy
Dizziness/imbalance
What does a positive Rinne’s test suggest?
Air and bone conduction reduced equally - test appears normal
Describe the results of Rinne’s and Weber’s testing in acoustic neuroma
Sensorineural hearing loss
Rinne’s positive - air and bone conduction reduced equally
Weber’s - sound louder on unaffected side
Describe the diagnosis of acoustic neuroma
Audiometry - sensorineural hearing loss
MRI/CT brain - shows tumour
Describe the management of acoustic neuroma
Conservative - if surgery inappropriate or no symptoms
Surgery - classic scar behind ear
Radiotherapy
Describe the risks of acoustic neuroma surgery
Permanent hearing loss/dizziness
Facial weakness
Describe the presentation of BPPV
Vertigo on head movement (lasts 20-60 seconds)
Asymptomatic between attacks
Does not cause hearing loss/tinnitus
Usually in older population
Describe the pathophysiology of BPPV
Calcium carbonate crystals - otoconia - become displaced in the semicircular canals
These crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system
Describe the Dix-Hallpike maneouvre
To diagnose BPPV
Rapidly lower patient from seated position with head turned laterally 45 degrees - positive test illicits an attack or nystagmus
Describe the Epley maneouvre
To treat BPPV
Extension of Dix-Hallpike maneouvre which moves crystals to untroublesome area
Describe the pathophysiology of epiglottitis
Inflammation and swelling of the epiglottis typically caused by Haemophilus infleunza infection
May swell and obstruct airway
Describe the epidemiology of epiglottitis
Unvaccinated children!!!
Describe the presentation of epiglottitis
Sore throat
Drooling
Stridor
Tripod position - sat forward with hands on knees
Fever
Difficult or painful swallowing
Describe the diagnosis of epiglottitis
CLINICAL - treat if high suspicion
Lateral neck XR - ‘thumb sign’, exclude foreign body
Describe the management of epiglottitis
IV ceftriaxone + dexamethasone
AIRWAY MANAGEMENT - may require intubation/tracheostomy
DO NOT DISTRESS THE PATIENT - may prompt airway closure
-Do not examine or make them upset
Give a complication of epiglottitis
Epiglottic abscess
Describe the pathophysiology of glandular fever
Infectious mononucleosis
Infection with EBV, commonly spread by sharing saliva
Describe the presentation of glandular fever
Classical: adolescent with sore throat who develops itchy rash after taking amoxicillin
Fever
Sore throat
Fatigue
Lymphadenopathy
Tonsillar enlargement
Splenomegaly - may rupture
Describe the management of glandular fever
Usually self-limiting - lasting 2-3 weeks
Avoid alcohol - EBV interfered with hepatic alcohol metabolism
Avoid contact sports - risk of splenic rupture
Describe the diagnosis of glandular fever
Monospot test/Paul-Bunnell test - almost 100% specific for glandular fever
Describe the pathophysiology of Meniere’s disease
Excessive build-up of endolymph in the labyrinth
Raised pressure results in disrupted sensory signals
Describe the presentation of Meniere’s disease
Hearing loss (sensorineural)
Tinnitus
Vertigo (not triggered by movement - unlike BPPV)
Typically 40-50 years
Unilateral symptoms
Fullness in ear
Imbalance
“Drop attacks” - unexplained falls without LOC
Describe the diagnosis of Meniere’s disease
Clinical - requires ENT referral
Audiology assessment
Describe the management of Meniere’s disease
Acute attacks: prochlorperazine, cyclizine, promethazine
Prophylaxis - betahistine
Describe the pathophysiology of obstructive sleep apnoea
Collapse of the pharyngeal airway during sleep - characterised by periods of not breathing
Describe the risk factors for obstructive sleep apnoea
Middle aged
Male
Obesity
Smoking/alcohol
Describe the presentation of obstructive sleep apnoea
Usually reported by partner - episodes of apnoea in sleep
Snoring
Morning headache
Waking unrefreshed from sleep
Daytime sleepiness
Concentration problems
Describe the management of obstructive sleep apnoea
Epworth sleepiness scale - determine daytime sleepiness and relate to occupation - i.e. those in high risk jobs (incl. HGV driver) should have immediate referral
ENT/Sleep clinic referral
Correct reversible factors - weight, alcohol
CPAP - maintains airway patency
Uvulopalatopharyngoplasty (surgery)
Describe the pathophysiology of otitis externa
Inflammation of the skin of the external auditory canal, which can be localised or diffuse
Acute (<3 weeks) or chronic
Describe the aetiology of otitis externa
Bacteria - pseudomonas aeruginosa, S. aureus
Fungus - aspergillus, candida
Eczema
Seborrhoeic dermatitis
Contact dermatitis
Describe the presentation of otitis externa
Ear pain
Ear discharge
Itchiness
Conductive hearing loss
Describe the diagnosis of otitis externa
Clinical - otoscopy
-If tympanic membrane is perforated, suggests otitis media
Describe the management of otitis externa
Mild: acetic acid
Moderate: topical neomycin + betamethasone OR topical gentamicin + hydrocortisone
Severe: Oral flucloxacillin
Fungus: topical clotrimazole
Describe the risks associated with topical gentamicin in otitis externa
Aminoglycosides are ototoxic, so must ensure tympanic membrane is not perforated before prescribing
Describe the pathophysiology of malignant otitis externa
Infection spreads to bone around ear, causing osteomyelitis of the temporal bone
Describe the aetiology of malignant otitis externa
Diabetes
Immunosuppression (e.g. HIV, chemotherapy)
Describe the presentation of malignant otitis externa
Otitis externa PLUS:
-Headache
-Fevere
-Severe pain
Granulation at junction between bone and cartilage in ear - seen as ring roughly halfway along ear canal
Describe the management of malignant otitis externa
IV antibiotics
CT/MRI to assess spread
Describe the complications of malignant otitis externa
Facial nerve palsy (and other cranial nerve pathologies)
Meningitis
Intracranial thrombosis
Death
Describe the pathophysiology of otitis media
Infection of the middle ear, with bacteria entering via the eustachian tube
Usually preceded by a viral URTI
Describe the aetiology of otitis media
S. pneumoniae - most common
H. influenzae
S. aureus
Describe the presentation of otitis media
Ear pain
Hearing loss
Fever
Cough
Sore throat
Coryzal symptoms
Discharge - if tympanic membrane perforated
Describe the examination findings in otitis media
Bulging, red, inflamed membrane on otoscopy
Describe the management of otitis media
Most resolve spontaneously in 3-7 days
Simple analgesia
Antibiotics:
-Amoxicillin - first line
-Clarithromycin - in penicillin allergy
-Erythromycin - in pregnant women allergic to penicillin
Give the complications of otitis media
Mastoiditis
Otitis media with effusion
Hearing loss
Tympanic membrane rupture
Abscess
Describe the pathophysiology of rhinosinusitis
Inflammation of the paranasal sinuses and nasal cavity.
Blockage of ostia (drainage holes from sinus)
Acute (<12 weeks) or chronic
Describe the aetiology of rhinosinusitis
Infection - esp. following URTI
Allergy - e.g. allergic rhinitis, hayfever
Foreign body
Trauma
Polyps
Describe the presentation of rhinosinusitis
Recent viral URTI
Nasal congestion/discharge
Facial pain/discharge/pressure/swelling
Loss of sense of smell
Describe the diagnosis of rhinosinusitis
Clinical - may use nasal endoscopy
Describe the management of rhinosinusitis
Most resolve in 2-3 weeks without antibiotics
High dose nasal steroid (e.g. mometasone)
Saline nasal irrigation
Functional endoscopic sinus surgery - to remove obstruction
Describe nasal spray technique
Spray using opposite hand (e.g. L hand to R nostril)
Dont inhale too hard (to prevent steroid going to back of nose)
Tilt head forward slightly
Ask patient if they can taste the steroid after using - if so, they are inhaling too hard
Describe the pathophysiology of tonsillitis
Inflammation of the tonsils
Describe the aetiology of tonsillitis
Usually viral
Bacterial:
-Strep. pneumoniae
-H. influenzae
Describe the presentation of tonsillitis
Sore throat
Fever
Pain on swallowing
Red, inflamed tonsils
Exudate - of bacterial
Anterior cervical lymphadenopathy
Describe the Centor criteria
Estimates the likelihood that tonsillitis is bacterial in nature, and as such whether antibiotics are required.
Score >3 implies antibiotic use. 1 point for each of:
-Fever >38
-Tonsillar exudate
-Absence of cough
-Tender anterior cervical lymphadenopathy
Describe the FeverPAIN score
Estimates the likelihood that tonsillitis is due to bacterial infection.
Score 4-5 implies antibiotics are recommended. 1 point for each of:
-Fever
-Purulence
-Attended within 3 days of symptom onset
-Inflamed tonsils
-No cough or coryza
Give the management of tonsillitis
Admission if: immunocompromised, systemically unwell, stridor, resp. distress
No treatment if likely viral - consider delayed abx prescription
Phenoxymethylpenicillin
Clarithromycin (if penicillin allergy)
Give the complications of tonsillitis
Peri-tonsillar abscess (AKA quinsy)
Otitis media
Post-strep glomerulonephritis
Post-strep reactive arthritis
Describe vestibular neuronitis
Vertigo due to inflammation of the vestibular nerve, usually due to a viral infection, improves within a few weeks
Describe labyrinthitis
Inflammation of structures of the inner ear, usually due to viral infection.
Improves within a few weeks
Can cause hearing loss - distinguishes from vestibular neuronitis
Describe the presentation of a posterior circulation stroke
Vertigo
Ataxia
Diplopia
Cranial nerve defects
Sudden onset
Which features of vertigo point to a specific cause
Recent viral illness - labyrinthitis/vestibular neuronitis
Headache - vestibular migraine/CVA/tumour
Describe a cerebellar examination
DANISH
-Dysdiadochokinesia
-Ataxia (gait)
-Nystagmus (eye movements)
-Speech
-Heel-shin test (coordination)
Dix-Hallpike maneouvre
Romberg’s test - arms by side and close eyes
-Swaying when eyes closed only = proprioceptive deficit
-Swaying with eyes open and closed = cerebellar deficit
Describe the management of vertigo
CT/MRI if thought to be central cause
Prochlorperazine
Antihistamine (e.g. cyclizine)
Betahistine - prophylaxis in Meniere’s
Epley maneouvre (BPPV)
