ENT Flashcards
What is the criteria used as a clinical scoring tool that is used to decide whether antibiotics are warranted to treat a possible streptococcal tonsillitis
Centor criteria
What are the components of the Centor criteria
Tonsillar exudate
Tender anterior cervical lymphadenopathy
Temperature >38
Absence of cough
Centor criteria is a clinical scoring tool that can be used to decide whether antibiotics are warranted to treat a possible streptococcal tonsillitis.
Name a rare but serious complications of strep throat
Scarlet fever
Name 3 common complications of acute tonsillitis
1) Recurrent tonsillitis (most common)
2) Retropharyngeal Abscess
3) Peritonsillar Abscess (Quinsy)
Likely Dx
Sore throat, dysphagia, peritonsillar bulge, uvular deviation, trismus and muffled voice
Peritonsillar Abscess (Quinsy)
Management of peritonsillar abscess (quinsy)
Antibiotics and aspiration
Likely Dx:
Elderly patient
Gradual symmetrical bilateral hearing loss which is most noticeable at higher frequencies
Presbycusis
Due to natural ageing of the auditory system: cochlear hair cells and auditory nerve fibres damaged symmetrically over time
What is the most appropriate management for proliferative diabetic retinopathy
Urgent laser photocoagulation (within 72h to prevent further neovascularisation)
You sacrifice the peripheral retina to reduce the production of vascular endothelial growth factor produced by this ischaemic retina and thus prevent neovascularisation
What do you prevent from happening by urgently doing laser photocoagulation for proliferative diabetic retinopathy
Blindness
Recurrent otitis media is a key characteristic of which inherit condition?
Turner’s Syndrome
What is the first line antibiotic used in the treatment of bacterial tonsillitis
Phenoxymethylpenicillin
What is the first line antibiotic used in the treatment of bacterial tonsillitis with a penicillin allergy
Clarithromycin or Erythromycin for 5 days
Name an extra-cranial complication of otitis media
1) Facial nerve palsy (CN VII)
2) Mastoiditis (infection spread to cause abscess formation in the mastoid air spaces of the temporal bone)
3) Petrositis
4) Labrynthtitis
Name an intra-cranial complication of otitis media
1) Meningitis
2) Sigmoid sinus thrombosis
3) Brain abscess
Hoarseness is a red flag for which kind of head and neck cancer?
Laryngeal cancer
Name a cause of hoarseness
1) Laryngeal cancer
2) Chronic Laryngitis (most commonly hoarseness in the morning)
3) Laryngitis (inflammation of the larynx i.e. voice box)
4) Reinke’s Oedema (caused by enlargement of the vocal cords and is associated with hypothyroidism it leads to prolonged and persistent hoarseness)
Tonsillectomy is considered if a patient suffers more than how many episodes of tonsillitis per year for 2 years and if the episodes interfere with daily life
5 episodes of tonsillitis per year for 2 years
What is the inheritance pattern of Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Syndrome)
Autosomal dominant
This condition should be suspected in a patient with recurrent epistaxis, telangiectasia, and arteriovenous (AV) malformations.
What medication should be started immediately if novel sensorineural hearing loss
ENT emergency
High dose steroids as are highly effective if started early
Immediate referral to ENT for assessment within 24 hours
Likely Dx:
Sudden, unpredictable attacks of vertigo lasting between 20 minutes and 12 hours
Associated sensorineural hearing loss and tinnitus
Ménière’s disease
What medication is used prophylactic to reduce the frequency of attacks of vertigo in Ménière’s disease
Betahistine
What medication is used acutely when a patient experiences an attack of vertigo in Ménière’s disease
Prochlorperazine
A single nasal polyp unilaterally should be investigated with an urgent ENT referral as it suspicious for what kind of cancer?
Nasopharyngeal cancer
HINTS examination is used to determine if the vertigo is peripheral or central in origin.
What does HINTS stand for?
Head Impulse
Nystagmus
Test of Skew
HINTS examination: negative head impulse, bidirectional/vertical nystagmus and abnormal test of skew
Is the vertigo central or peripheral in origin?
The vertigo is central in origin e.g. posterior circulation strokes.
The nystagmus would be bidirectional or vertical
HINTS examination: positive head impulse, no or unidirectional nystagmus and normal test of skew
Is the vertigo central or peripheral in origin?
The vertigo is peripheral in origin
They may have nystagmus but it would be unidirectional rather than bidirectional or vertical which is the case for central origin vertigo
Name 3 common causes of peripheral vertigo
1) Benign paroxysmal positional vertigo (BPPV)
2) Vestibular neuronitis (or labyrinthitis)
3) Ménière’s disease
What is the diagnostic test for Benign positional paroxysmal vertigo (BPPV)
Dix-Hallpike manoeuvre is diagnostic, where certain movements of the head causes fatiguable nystagmus.
What is the treatment manoeuvres for Benign positional paroxysmal vertigo (BPPV)
Epley manoeuvres
Peripheral vertigo after a recent viral illness is a pathognomonic presentation of what condition
Vestibular neuronitis
Characterised by inflammation of the vestibular nerve, often after a viral infection
What is the first line symptomatic treatment of Vestibular neuronitis
Prochlorperazine (anti-sickness medication)
Recurrent episodes of vertigo, sensorineural hearing loss, tinnitus are cardinal features of what condition?
Ménière’s disease
Patients may also experience a feeling of aural fullness however it is not a cardinal feature of MD
Presence of Reed-Sternberg cells on biopsy is a pathognomonic finding of what type of lymphoma
Hodgkin’s lymphoma
Likely Dx:
20 year or 70 year old
Non-tender and “rubbery” lymph nodes
Presence of B symptoms (fever, night sweats and weight loss)
Hodgkin’s lymphoma
Midline neck lump, ascends on swallowing but not on protrusion of the tongue is what:
A) Thyroid lump
B) Thyroglossal lump
A) Thyroid lump
Voice hoarseness due to hypothyroidism is secondary to laryngeal oedema, which varies in intensity over time; therefore this type of hoarseness is intermittent. In contrast, permanent hoarseness in the setting of a thyroid lump is likely due to malignant infiltration of the recurrent laryngeal nerve. Additional features of thyroid malignancy include those of local mass effect (difficulty swallowing i.e. dysphagia, painful swallow i.e. odynophagia, airway compromise or stridor), constitutional (unexplained significant weight loss, low-grade fever), or metastasis (enlarged rubbery painless cervical lymphadenopathy, and rarely bone or lung metastasis)
Midline neck lump, ascends both on swallowing and tongue protrusion is what:
A) Thyroid lump
B) Thyroglossal lump
B) Thyroglossal lump
How can you differentiate between voice hoarseness secondary to hypothyroidism and malignant infiltration of the recurrent laryngeal nerve
(the patient also has a thyroid lump (a feature of both conditions))
In hypothyroidism - it is due to laryngeal oedema and hence the hoarseness is intermittent
In malignant infiltration of the recurrent laryngeal nerve the hoarseness is permanent
Name some of the features of thyroid malignancy
Thyroid lump
Permanent voice hoarseness
Difficulty swallowing i.e. dysphagia
Painful swallow i.e. odynophagia
Stridor
Constitutional symptoms (unexplained significant weight loss, low-grade fever)
What type of imaging is required to determine the type of stroke
Non-contrast CT head
What is the thrombolysis interval for a stroke?
4.5 hours
What are the three classic signs of Horner’s syndrome
Miosis (constricted pupil)
Ptosis (weak droopy eyelid)
Anhydrosis (reduced sweating)
Cholesteatoma is a serious and rare complication of what condition
Chronic otitis media
Likely Dx:
Persistent foul smelling discharge
Conductive hearing loss
Cholesteatoma
Non-cancerous growth of squamous epithelium that is ‘trapped’ within the skull base causing local destruction
How is Cholesteatoma managed
Referred to ENT for consideration of surgical removal
Likely Dx:
Midline neck lump
Moves on tongue protrusion and swallowing
Thyroglossal cyst
How are thyroglossal cyst managed?
Reassurance
Can be surgically removed for cosmetic reasons
What is the first line treatment for mild symptoms of allergic rhinitis
Oral antihistamine
What is the first line treatment for moderate or severe symptoms of allergic rhinitis
Intranasal corticosteroids (most effective class of medication)
Likely Dx:
Early adult patient
Conductive hearing loss which is characteristically better when there is background noise
Patients speaking quietly as their voice sounds louder in their head
Otosclerosis caused by the thickening of the trabecular part of the bone. This causes hearing loss as the stapes bone (which transmits sound through the oval window) becomes fused with the surrounding bone removing its ability to move
How is otosclerosis managed
Treated with hearing aids or surgery to replace the stapes bone with a metal version
Acoustic neuromas are benign tumours that grow on what cranial nerves?
Vestibular or cochlear nerves
Likely Dx:
Sudden onset severe vertigo
Vomiting
Nystagmus
Recent Hx of viral infection
Vestibular neuritis
NOTE: No hearing loss in vestibular neuritis
What are the two most common causes of episodic vertigo and vomiting
Meniere’s disease
Benign Paroxysmal Positional Vertigo (BPPV)
What severity is this description of otitis externa:
Complete occlusion of the external auditory meatus and inability to view the tympanic membrane
Severe otitis externa
What severity is this description of otitis externa:
Ear pain and discharge and partially occludes the external auditory meatus
Moderate otitis externa
What severity is this description of otitis externa:
Itch with scanty discharge. There is no pain and no occlusion of the external auditory meatus
Mild otitis externa
What is the most common cause of hearing impairment post head injury
Perforated tympanic membrane
Weber’s test lateralises to the which side of a sensorineural hearing loss
Contralateral side i.e. if Weber’s test lateralises to the left the sensorineural hearing loss is in the right
How is acute otitis media managed in those with no acute complications or systemic illness
Symptomatic relief such as regular analgesia
Conductive hearing loss and otoscope shows chalky white patches on the tympanic membrane is pathognomonic of what condition
Tympanosclerosis
Characterised by chronic inflammation and scarring of the tympanic membrane leading to subsequent calcification of the tympanic membrane and associated structures
Often patients have a background childhood history of recurrent otitis media and grommet insertion is
How is septal haematoma managed?
Immediate referral to ENT for emergency incision and drainage as if left untreated there can be damage to the septal cartilage leading to irreversible septal perforation and necrosis
Bilateral cherry-red swelling arising from the nasal septum after a nasal injury is pathognomonic of what condition
Septal Haematoma
What is the most common tumour of the parotid gland?
Pleomorphic adenoma
Likely Dx:
Sudden onset unilateral constant vertigo
Tinnitus
Recent viral infection
Acute (viral) labrynthitis
Child with tender mass over the mastoid process with ear pain (or tugging at their ear) is pathognomonic of what condition?
Acute mastoiditis
What is the first-line management for epistaxis
Direct compression of the nasal alae (cartilaginous part) for at least 10-15 minutes
This is because most anterior bleeds resolve after 10-15 minutes of compression without interruption
If direct compression of the nasal alae for 10-15 minutes does not resolve epistaxis, what is the next most appropriate management step if the bleeding site is visible
Nasal cautery
If direct compression of the nasal alae for 10-15 minutes does not resolve epistaxis, what is the next most appropriate management step if the bleeding site is not visible
Nasal Packing
What age group would you consider amoxicillin immediately as the most appropriate management for otitis media
< 2 years old
Ten day course of amoxicillin
In an older child it could be acceptable to hold off antibiotics for 48 hours to see if symptoms improve spontaneously
Likely Dx
- Child
- Slow growing painless neck lump in the anterior triangle of the neck
- Does not move on tongue protrusion or on swallowing
Branchial cyst
Formed due to the failure of obliteration of the second, third, and fourth branchial cleft.
Typically undetectable until the cyst swells in size, commonly due to infection
Likely Dx
Watery nasal discharge worsen on bending forwards
Recent Hx of nasal trauma
CSF rhinorrhoea
Gold standard investigation for anterior skull base fracture
CT Head
What time after gentamicin dose should a patient have a gentamicin level taken at?
6 -12 hours
A Centor criteria score of what warrants antibiotics for acute tonsillitis
3 out of 4
What is the first line antibiotics used in the treatment of acute tonsillitis
Penicillin V 500mg PO QDS for 5-10 days
What is the first line antibiotics used in the treatment of acute tonsillitis if patient has a penicillin allergy
Clarithromycin/Erythromycin 250-500mg PO BD for 5 days
Patients with a penicillin allergy cannot have penicillin based antibiotics as well as what other kind of antibiotics
Cephalosporins because of cross-reactivity
In patients with chronic or recurrent ear discharge what part of the tympanic membrane to important visualise?
The attic is visualised to exclude cholesteatoma
What is the treatment of Ramsay Hunt syndrome
Oral aciclovir and corticosteroids
Following referral to ENT, patients with sudden-onset sensorineural hearing loss are treated with what?
High-dose oral corticosteroids
What feature is used to distinguish between vestibular neuronitis from labyrinthitis
In vestibular neuronitis the hearing is unaffected
Remember:
Neuronitis = No hearing loss
Labyrinthitis = Loss of hearing
Likely Dx:
- Recently developed an upper respiratory tract infection
- Sudden onset of symptoms
- Vertigo and associated vomiting
- Sensorineural hearing loss
Viral labyrinthitis
In benign paroxysmal positional vertigo, if patient declines the Epley manoeuvre, what is the next best management option?
Brandt-Daroff exercises
What is the 1st line treatment for uncomplicated acute otitis externa
Topical antibiotics +/- topical steroid
What type of nystagmus is indicative of a positive Dix-Hallpike manoeuvre
Rotatory nystagmus
What type of stroke presents with vertigo, nystagmus, ipsilateral facial pain, and contralateral loss in temperature sensation
Posterior circulation stroke
What is the first line management option for patients with acute otitis media with a perforated tympanic membrane
A 5-7 day course of oral amoxicillin
What is the most common causative organisms for bacterial otitis media
Haemophilus influenzae
How is peritonsillar abscess (quinsy) managed
IV antibiotics and surgical drainage and a tonsillectomy should be considered in 6 weeks.
NICE recommends that unexplained and persistent (>3 weeks) oral ulcers warrant what kind of referral
Urgent referral to secondary care due to the likelihood of malignancy.
Elderly patient dizzy on extending neck is pathognomonic of what condition
Vertebrobasilar ischaemia
BPPV does causes vertigo upon head movement but the characteristic production of symptoms on neck extension makes this a less likely diagnosis than vertebrobasilar ischaemia
What is the Samters triad
- Nasal polyp/s
- Asthma
- Aspirin hypersensitivity
What is the most appropriate next step in managing a perforated tympanic membrane does not heal by itself
Myringoplasty
Likely Dx:
Swollen salvia gland, which is often most painful when eating or thinking about food
Parotid sialolithiasis
Presence of calculus (stone) within the parotid gland obstructing the flow of salvia through the gland
