ENT

Question 1

Spot diagnosis:
Recent viral infection e.g URTI
Sudden onset
Vertigo
Nausea and vomiting
Hearing may be affected

Answer 1

Viral labyrinthitis

Question 2

Spot diagnosis:
Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss or tinnitus

Answer 2

Vestibular neuronitis

Question 3

Spot diagnosis:
Vertigo
Gradual onset
Triggered by change in head position
Each episode lasts 10-20 seconds

Answer 3

Benign paroxysmal positional vertigo
BPPV

Question 4

spot diagnosis:
vertigo associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears

Answer 4

Meniere’s disease

Question 5

Spot diagnosis:
Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2

Answer 5

Acoustic neuroma

Question 6

give 4 less common causes of vertigo

Answer 6

posterior circulation stroke
trauma
multiple sclerosis
ototoxicity e.g. gentamicin

Question 7

The most common causes of hearing loss are ear wax, otitis media and otitis externa.
Give 6 other causes

Answer 7

Presbycusis
Noise damage
Otosclerosis
Otitis media with effusion (glue ear)
Meniere’s disease
Drug ototoxicity

Question 8

How does presbycusis present?

Answer 8

age-related sensorineural hearing loss

patients may describe difficulty following conversations

Audiometry shows bilateral high-frequency hearing loss

Question 9

How does otosclerosis present?

Answer 9

Autosomal dominant replacement of normal bone by vascular spongy bone

onset at 20-40 years

conductive deafness
tinnitus
tympanic membrane - 10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
positive family history

Question 10

how does glue ear present?

Answer 10

peaks at 2 years of age
hearing loss (commonest cause of conductive hearing loss childhood)
secondary problems such as speech and language delay, behavioural or balance problems may also be seen

Question 11

how does Meniere’s disease present?

Answer 11

Multiple episodes last Minutes to hours

recurrent episodes of vertigo, tinnitus and sensorineural hearing loss

sensation of aural fullness or pressure

other features include nystagmus and a positive Romberg test

Question 12

causes of drug induced ototoxicity?

Answer 12

aminoglycosides (e.g. Gentamicin), furosemide, aspirin and a number of cytotoxic agents

Question 13

how do acoustic neuromas present?

Answer 13

cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy

Question 14

Complications of thyroid surgery?

Answer 14

recurrent laryngeal nerve damage.

bleeding - haematomas may rapidly lead to respiratory compromise (laryngeal oedema)

damage to the parathyroid glands = hypocalcaemia

Question 15

3 of the following should be present to warrant abx for suspected tonsilitis:

(Centor criteria)

Answer 15

C – Cough absent
E – Exudate
N – Nodes
T – temperature (fever)

(OR – young OR old modifier)

Question 16

Causes of otitis externa?

Answer 16

infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
seborrhoeic dermatitis
contact dermatitis (allergic and irritant)

recent swimming is a common trigger of otitis externa

Question 17

Presentation of otitis externa? Mx?

Answer 17

ear pain, itch, discharge
otoscopy: red, swollen, or eczematous canal

Mx:
topical antibiotic / combined topical antibiotic with a steroid
if the canal is extensively swollen then an ear wick is sometimes inserted

Second-line:
oral antibiotics (flucloxacillin) if the infection is spreading
swab inside the ear canal

Question 18

Give 4 causes of facial pain and outline how they present

Answer 18

Sinusitis:
Facial ‘fullness’ and tenderness
Nasal discharge, pyrexia or post-nasal drip leading to cough

Trigeminal neuralgia:
Unilateral facial pain, brief electric shock-like pains, abrupt in onset and termination
May be triggered by light touch, emotion

Cluster headache:
Pain occurs once or twice a day, each episode lasting 15 mins - 2 hours
Clusters typically last 4-12 weeks
Intense pain around one eye
Accompanied by redness, lacrimation, lid swelling, nasal stuffiness

Temporal arteritis:
Tender around temples
Raised ESR

Question 19

Features of peritonsillar abscess (Quinsy)?
Mx?

Answer 19

severe throat pain, which lateralises to one side
deviation of the uvula to the unaffected side
trismus (difficulty opening the mouth)
reduced neck mobility

Mx: urgent ENT review
incision & drainage + intravenous antibiotics

Question 20

How should post-tonsillectomy haemorrhage be managed?

Answer 20

All should be reviewed by ENT

Primary:
6-8 hours following surgery
immediate return to theatre

Secondary:
5 - 10 days after surgery
often associated with a wound infection
admission and antibiotics

Question 21

Methods to achieve symptomatic relief in BPPV?

Answer 21

Epley manoeuvre

teaching the patient exercises they can do themselves at home - vestibular rehabilitation e.g. Brandt-Daroff exercises

Question 22

Acute otitis media is extremely common in young children, with around half of children having three or more episodes by the age of 3 years.

What commonly causes it?

Answer 22

preceding URTI

Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis

Question 23

Presentation of otitis media?

Answer 23

otalgia (children may tug or rub their ear)
fever
hearing loss
recent viral URTI symptoms are common (e.g. coryza)
ear discharge may occur if the tympanic membrane perforates

Question 24

Findings on otoscopy for otitis media?

Answer 24

bulging tympanic membrane → loss of light reflex
opacification or erythema of the tympanic membrane
perforation with purulent otorrhoea
decreased mobility if using a pneumatic otoscope

Question 25

Mx of acute otitis media?

Answer 25

generally a self-limiting condition that does not require an antibiotic prescription
analgesia for otalgia

Abx if:
Symptoms lasting >4 days
Systemically unwell
Immunocompromise / high risk of complications
< 2 years with bilateral otitis media
perforation and/or discharge in the canal

5-7 day course of amoxicillin is first-line

Question 26

Complications of otitis media?

Answer 26

mastoiditis
meningitis
brain abscess
facial nerve paralysis

Question 27

Causes of acute sinusitis?

Mx?

Answer 27

Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses

Predisposing factors include:
nasal obstruction e.g. septal deviation or nasal polyps
recent local infection e.g. rhinitis or dental extraction
swimming/diving
smoking

Mx:
analgesia
intranasal decongestants or nasal saline
intranasal corticosteroids if the symptoms have been present for > 10 days
oral antibiotics for severe presentations - phenoxymethylpenicillin first-line

Question 28

What is the ‘double-sickening’?

Answer 28

sometimes seen in acute sinusitis where an initial viral sinusitis worsens due to secondary bacterial infection

Question 29

Mx of sudden onset unilateral sensorineural hearing loss?

Answer 29

Refer urgently to ENT and start high dose oral steroids

usually idiopathic

Question 30

Vestibular neuronitis is a cause of vertigo that often develops following a viral infection.

How can it be treated medically?

Answer 30

a short oral course of prochlorperazine

Question 31

Non-resolving otitis externa with worsening pain despite strong analgesia =

Answer 31

urgent ENT referral

suggestive of malignant (necrotising) otitis externa

Question 32

Malignant otitis externa is a type of otitis externa that is found in immunocompromised individuals, most commonly caused by Pseudomonas aeruginosa. It can progress into temporal bone osteomyelitis.

What key features would you expect in the hx?
How do you diagnose?

Answer 32

Diabetes or immunosuppression
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea

Dx is with CT head

Question 33

Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.

How does it present? Tx?

Answer 33

auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus

Tx: oral aciclovir and corticosteroids

Question 34

What drugs can cause tinnitus?

Answer 34

Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine

Question 35

Mastoiditis typically develops when an infection spreads from the middle to the mastoid air spaces of the temporal bone.

How does it present?
Ix? Mx?

Answer 35

otalgia: severe, classically behind the ear
swelling, erythema and tenderness over the mastoid process
the external ear may protrude forwards (proptosis)
ear discharge may be present if eardrum has perforated

CT head and IV abx

Question 36

tx for otitis externa in diabetics?

Answer 36

ciprofloxacin for pseudomonas cover

Question 37

how can Meniere’s disease be managed?

Answer 37

ENT assessment required to confirm dx
patients should inform the DVLA and cease driving until satisfactory control of symptoms is achieved

acute attacks: prochlorperazine
prevention: betahistine and vestibular rehabilitation exercises