ENT Flashcards
Vestibular Schwannoma (aka Acoustic neuroma)
Classic history?
Features by affected cranial nerve?
When do you see bilateral schwannomas?
Ix + Mx?
account for approximately 5% of intracranial tumours and 90% of cerebellopontine angle tumours!
The classical history = a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex.
Features can be predicted by the affected cranial nerves:
CN VIII = vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
CN V = absent corneal reflex
CN VII = facial palsy
Bilateral schwannomas = neurofibromatosis type 2
Ix = Refer urgently to ENT + MRI (cerebellopontine angle) + Audiometry
Mx = surgery, radiotherapy or observation
It should be noted though that the tumours are often slow growing, benign and often observed initially.
Audiometry is also important as only 5% of patients will have a normal audiogram.
Benign paroxysmal positional vertigo
Trigger?
Age of onset?
Features?
Ix + Mx?
Rate of reoccurance?
One of the most common causes of vertigo
It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position.
The average age of onset is 55 years and it is less common in younger patients.
Features
- vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
- nausea
- each episode typically lasts 10-20 seconds
Ix = Dix-Hallpike* + History
Mx = Epley
BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months.
Symptomatic relief may be gained by:
Epley manoeuvre (successful in around 80% of cases)
teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises
Around half of people with BPPV will have a recurrence of symptoms 3–5 years after their diagnosis
*pt feels vertigo + rotary nystagmus
Cholesteatoma
What is it and who gets it?
Features?
Ix + Mx ?
Cholesteatoma is a non-cancerous growth of squamous epithelium that is ‘trapped’ within the skull base causing local destruction.
Who gets it? - pts aged 10-20yo + Being born with a cleft palate increases the risk of cholesteatoma around 100 fold.
Main features;
foul-smelling,
non-resolving discharge
hearing loss
Other features are determined by local invasion:
vertigo
facial nerve palsy
cerebellopontine angle syndrome
Ix = Otoscopy
‘attic crust’ - seen in the uppermost part of the ear drum
Mx = Referred to ENT for surgical removal
Epiglottitis
Cause?
Features?
Ix + Mx?
Caused by Haemophilus influenzae type B
Features
- rapid onset
- high temperature, generally unwell
stridor
- drooling of saliva
- ‘tripod’ position
Ix: 1st = Senior inspection, 2nd = Lateral view X-Ray (thumb sign)
Mx: Seniors + intubate + ab’s +
if suspected do NOT examine the throat due to the risk of acute airway
obstruction
X-rays may be done, particularly if there is concern about a foreign body:
a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
in contrast, a posterior-anterior view in croup will show subglottic narrowing, commonly called the ‘steeple sign’
Hearing aidsProcedure
Myringotomy Procedure. What is it?
A myringotomy is a procedure to create a hole in the ear drum to allow fluid that is trapped in the middle ear to drain out. The fluid may be blood, pus and/or water. In many cases, a small tube is inserted into the hole in the ear drum to help maintain drainage.
Nasal trauma (septal haematoma)
Features?
How to differentiate from a deviated septum?
Ix + Mx?
Nasal septal haematoma = a haematoma between the septal cartilage and the overlying perichondrium.
Features:
- may be precipitated by relatively minor trauma
- the sensation of nasal obstruction is the most common symptom
- pain and rhinorrhoea are also seen
on examination, 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 deviated septums will be firm
Mx = surgical drainage + IV ab’s
If untreated irreversible septal necrosis may develop within 3-4 days!!
This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis. This may result in a ‘saddle-nose’ deformity
Otitis externa
Causes?
Features?
Ix + Mx?
What is malignant otitis, epi, + mx?
Causes:
- infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
- seborrhoeic dermatitis
- contact dermatitis (allergic and irritant)
- recent swimming is a common trigger of otitis externa
Features
ear pain, itch, discharge
Ix = otoscopy: red, swollen, or eczematous canal
Mx:
Topical Ab’s or Ab’s + steroid
If pt fails to respond to topical ab’s then refer to ENT
canal debris = remove
Swollen canal = ear wick
Spreading infection = oral ab’s (fluclox)
Elderly diabetics get Malignant otitis. In this condition, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal.
Intravenous antibiotics may be required
Otitis media
pathophys?
Features?
Findings on otoscopy?
Criteria to diagnose otitis media?
Mx?
when to give ab’s?
Half of children having 3+ episodes by the age of 3 years.
Pathophysiology
Viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the Eustachian tube
Particularly: Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
Clinical features and diagnosis
- otalgia
- some children may tug or rub their ear
- fever occurs in around 50% of cases
- hearing loss
- recent viral URTI symptoms are common (e.g. coryza)
- ear discharge may occur if the tympanic membrane perforates
Possible otoscopy findings:
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
Criteria to diagnose otitis media:
acute onset of symptoms
otalgia or ear tugging
presence of a middle ear effusion
bulging of the tympanic membrane, or
otorrhoea
decreased mobility on pneumatic otoscopy
inflammation of the tympanic membrane
i.e. erythema
Mx = self-limiting condition that does not require an antibiotic prescription
Analgesia should be given to relieve otalgia.
Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days.
Antibiotics should be prescribed immediately if:
Sx for 4+days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
<2yo with bilateral otitis media
Perforation and/or discharge in the canal
Ab 1st line = 5-7 day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.
Sequelae and complications
Common sequelae include:
perforation of the tympanic membrane → otorrhoea
unresolved with acute otitis media with perforation may develop into chronic suppurative otitis media (CSOM)
CSOM = perforation for > 6 weeks + hearing loss + labyrinthitis
Complications:
mastoiditis
meningitis
brain abscess
facial nerve paralysis
Rhinosinusitis (acute and chronic)
predisposing factors and features?
Mx?
1 in 10 people have Chronic rhinosinusitis
inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer.
Predisposing factors include:
- atopy: hay fever, asthma
- nasal obstruction e.g. Septal deviation or nasal polyps
- recent local infection e.g. Rhinitis or - - - dental extraction
- swimming/diving
- smoking
Features
- facial pain: typically frontal pressure pain which is worse on bending forward
- nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection
nasal obstruction: e.g. ‘mouth breathing’
- post-nasal drip: may produce chronic cough
Management of recurrent or chronic sinusitis:
- avoid allergen
- intranasal corticosteroids
- nasal irrigation with saline solution
Red flags symptoms;
- unilateral symptoms
- persistent symptoms despite compliance with 3 months of treatment
- epistaxis
Thyroglossal cysts (presentation and features?)
thyro (thyroid) and glossal (tongue)
The thyroid develops from the floor of the pharynx and descends into the neck during its development. It is connected to the tongue by the thyroglossal duct. The foramen cecum is the point of attachment of the thyroglossal duct to the tongue. The thyroglossal duct normally atrophies but in some people may persist and give rise to a thyroglossal duct cyst.
Presentation:
pt < 20yo
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
Tonsillitis and Tonsillectomy
Complications of tonsilitis?
4 Criteria for tonsilectomy
Complications of tonsilectomy?
Complications of tonsillitis include:
otitis media
quinsy - peritonsillar abscess
rheumatic fever and glomerulonephritis very rarely
The indications for tonsillectomy are when the pt meets ALL of the following criteria:
- sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
- 5+ episodes of sore throat per year
- Sx for >1year
- The episodes of sore throat are disabling and prevent normal functioning
Other established indications for a tonsillectomy include
- 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
Complications of tonsillectomy
primary (< 24 hours) = haemorrhage in 2-3% (due to inadequate haemostasis) + pain
secondary (24 hours to 10 days) = haemorrhage (due to infection) + pain
Tracheostomy Procedure - what is it?
Reduces the work of breathing (and dead space)
May be useful in slow weaning
Percutaneous tracheostomy widely used in ITU
Dries secretions, humidified air usually required
Vestibular neuritis and Labyrinthitis
What is Labyrinthitis?
Most common cause?
Difference between vestibular neuritis and labyrinthitis?
Presentation?
Signs on examination?
Labyrinthitis is an inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs. Labyrinthitis can be viral, bacterial or associated with systemic diseases.
Most common form = viral
Vestibular neuritis = vertigo with NO HEARING LOSS (only the vestibular nerve is affected)
Laryrinthitis = BOTH vertigo and hearing impairment. (as both the vestibular nerve and labyrinth are involved)
Patients typically present with an acute onset of:
- 40-70yo
- vertigo: not triggered by movement but exacerbated by movement
- nausea and vomiting
- hearing loss: may be unilateral or bilateral, with varying severity
tinnitus
- preceding URTI!
Signs of labyrinthitis:
Abnormal head impulse test: signifies an impaired vestibulo-ocular reflex
gait disturbance: the patient may fall towards the affected side
Ix = History and examination.
Mx = self-limiting!
prochlorperazine or antihistamines may help reduce the sensation of dizziness
