ENT Flashcards
whats conductive hearing loss and casues
where sound cant get to the sensory system -> probelm with sound travelling from outer enviroment to the inner ear
ear wax
foreign body
ottitis externa / interna
fluid in middle ear- effusion
eustachian tube dysfunction
perforated tympanic membrane
osteosclerosis
cholesteoma
exostoses
tumours
whats sensironeural hearing loss and casues
problem with the snesory system/vestibular nerve
stroke
brain tumour
sudden sensironeural hearing loss
prebsycusis- age related
noise exposure
menieres disease
labrynthitis
acoustic neuroma
neure- stroke, MS , brain tumpour
infecitons- meningitits
meds: loop diuretics, aminoglycosdies (gentamycin) , chemo- cisplatin
drugs that can casue sensironeural hearing loss
loop diuretics- furosemide
aminoglycoside abx- gentamicin
chemo- cisplatin
otitis externa
inflammation of external ear cancal
infection can be diffuse/ localsied
acute- less 3 weeks
chronic - mpore 3 weeks
risk factors ottits externa
swimming
trauma- ear plugs, cotton buds
removal ear wax
lots of course of abx- can casue fungal infection- candia / aspergillus
casues of ottis externa
bacterial infection
fungal infection- candida/ aspergillus
eczema
seborrheic dermatitis
cxontact dermatitis
casues of bacterial inection of otitis externa
pseudomonas aeuringosa
staphylcoccus aureus
treat psuedomonas aeuginosa infection ottitis externa
aminoglcoside-gentamyic/ quinolones- ciprfloxacin
presentation otitis externa
pain
discarge
itchy
conducive hearing lsos if blcoked
eyrhtmea
tender
swelling in cancal
pus/discharge in ear canal
typanic memebrane may be obstructed by wax/discharge - if perfroated then discharge may ne from ottis media not externa
investigations otits externa
otoscop- clinical
ear swap- not really needed often
managemnt of mild otits externa
acetic acid 2% - antifungal and antibacterial
can use for prophylaxiss before and after swimming
managemnt of moderate otitis externa
topical abx and steroids
otomize spray- neomycin, dexamethoasone, acetic acid
neomycin and betamethoason
gentamycin and hydrocortisone
ciprofloxacin and dexamethoasone
when giving aminoglycosides to otitis externa what need do
check not got perforateed tympanic membrane as aminoglycosed can be ottoixic- gentamyicn and neomycin
severe/ suystemic symtpoms otitis externa
oral abx- flucloxacillin/clarithromycin
ent to discuss iv
treat fingal otitis externa
clotrimazole ear drops
if ear canal swollen / discharge cant get dropsspray in how treat
ear wick - opens it up once swelling gone down can put drops in
whats malignat otits externa
severe potentilally lifethreatinging form otitis externa
infection spread to bones surroudning ear canal and skull
progresses to osteomyeltitis of temporal bone
rf for malinangt otitis externa
rf for severe infection
diabetes
hiv
immunsupress drugs
s and s malingant otitis externa
severe pain
more severe otitis externa
peristatn headache
fever
grnaluation tissue at junction between bone and cartilage of ear canal- bout half way along
granulation tissue at junction of bone and cartilage in ear canal
malingant otitis externa
treat malgiant otitis externa
hosp
iv abx
ct/mri head
complications malignant otitis externa
death
facial nerve dmaange and palsy
other cn damage
menigngitis
intracranial thrombosis
fucntion ear wax
cerumen
pritective fucntion againtst infection
made of secretions from xternal ear, dead skin cells and anything entering ear
s and s impacted ear wax
build up and stuck in ear
pain
tinnitus
discomfort
feeling fullness in ear
conductive hearing loss
investigations ear waxq
ototscope- may not see tympanic membrane if ear wx
managment eat wax
non
ear drops- oliver oil/ sodium bicarbonate 5% = frist
ear irrigation- 2nd
contraindications irrigation: infection, perforated tympanic memnrare
if irrigation ci then microscution
tinitus
presitant addition sound thats not present in surrounding enviroment
ringing
cxan be buzzing, humming, hissing
background sensory signal produced by cohclea thats not effectively filtered out but the central auditory syste,
casues tinnitus
primary= no found cause
often occurs iwth sensironeural hearing loss
secondary- odentifiable causes:
impacted ear wax
infection
meneiers
noise exposure
MS
truama
depression
meds:
loop diuretcis, gentamycin, chemo- cisplatin
acoustic neuroma
can be associatefd with system conditions:
diabtetes
hyperlipidameia
hypo/hyperthryoidism
anemia
objective tinnitus:
an acutalcause can hear if asucultate aorund ear:
carotid artery stensois- pulsatile carotid bruit
aortic stneosis- pulsatile raadiating murmur sound
arterivenous malformation- pulsatile
eustachian tube dysfucntion- popping and clicking
systemi conditions assocaited with tinnitus
diabetes
anemia
hyperlipidameia
hypo/hyper thyroidsim
investigations for tinnitus
fbc- anemia
tsh=thyroid issues
glucose-diabetes
lipids- hyperlipdamiea
audiology
rarely ct/ mri head for vcascualr malformations/ acoustic neuorm
assesment of hx for tinnitus
stress axneirty
pattern: unilaterla/bilateral
hearingloss?
frequency/uration
severity
pulsatile
noise exposure
vertigo, pain, discharge
ototscope
webers and rinnes test to asses hearing loss
red flags for tinnitus
pulsatile
unilateral
assicated with unilateral hearing loss
assocaited with sudden onset hearing loss
assocaited with vertigo/dizzy
assoaited with headache/vision symtpoms
assocaited with neuro- stroke signs, facial n pasly
sucicadal ideation
hyperacinus- hypersenstitivty, pain, discomfort to enviromental sounds
management tinnitus
ususally resovles by self
underyling cause treat
hearing aids
cbt
sound therpay- add noise to backgrund to masl it
vertigo
feel room moving/ they are moving
associated symtpoms vertigo
nasuea
vomiting
feeling unwell
sweating
maintaing balacne and posture comes form
mantiantng balance and posture of are vision, signals from vestibular system and proprioception
causes peripheral - veestibalr of vertigo
menieres disease
labrynthitis
bppv
vestibular neuritis
herpes zoster ewith facial n palsy and vesciles round eae- ramsay hunt
casues of vertigo thats central casues- cerrebelum / brainstem
tumour
vestibular migraine
posterior circulation infarction- stroke
ms
= all sustaine dna dnon posittional vertigo
if recent illness and vertigo
prob labyrhthintits/ vestibular neuritits
headache with vertigo
vestibular migraine, tumour
cerebrovascualr accident
typical triggers and vertigo
vestibular migraine
ear symptoms vertigo
infection
acute onset neuo symtposm and vertigo
stroke
examination of person vertigo
ear examination
neuro exam
cv exam- arrythmia, heart valve
danish - cerebellum examn
rombergs test
dix hallpike manouvere- dx BPPV
hints exam = head impulse- nomral then currently no symptoms or central - abnormal then peripheral casue
nyastgmus- unilateral and horizontal- peropherla
bilateral and vertical- central
test of skew
managment f central vertigo
ct/mri head
managemnt peripheral vertigo
antihistmaines
prochlorperazine
managment menieres disease
betahistine- dec number attacks
treat BPPV
epley manouvere
treat vestibular migraines
avoid triggers
same mifraine
acute- triptans
prophylaxis- propanolol, amitrypitaline, topiramate
vertigo and dvla
cant drive and inform dvla if have sudden unprovocked attacks of vertigo
orignation of nosebleeds
littles area- where kiesselbacks plexus is locatied
triggers of nosebleed
weather changes
trauma
nose picking
blowing nose vigourosuly
colds
sinusitits
coagulation disorders- thromocytopenia, von willebrands disease
anti coag meds
snorting coacain
tumours
can swallow blood- look likevomit blood if vomit
nose bleed bilateral
more likely from posterio and increase risk aspirate
mnangment nose bleeds
normally resov
lean head forward and sit up
oinch soft nose 10-15 mins
not resovled after this time, sevre, haemodynamically unstable, both nostril:
hosp
nasalpacking with nasal tampons/ inflatable packs
nasal cautery with silver nitrate sticks
after rx consider prescribing naseptin nasal cream- chlorhexadine and neomycin- 4 a day for 10 days- reduces crusting, inflam and infection
ci= peanut or soya allergy
ci fro naseptin nasal cream
peanut soya allergy
sinusitits
inflammation of paranasal sonuses
usally accompanied by inflamation of nasal cavity=> rhinosinusitits
acute sinusisits and chronic duration
acute- less 12 weeks
chronic - more 12 weeks
sinsues function
produce mucous and drain into nasal cavities via holes- ostia
blockage of these holes prevents drainage and so get sinusiits
casues of sinusitis
infection- esp get after a VIRAL upper resp tract infection
allergies with alergic rhinitits (hayfever)
obstrucition of drainage- foregin body, trauma, nasal polyp
smoking
risk factor for sinusutits
asthma
presentation sinusitis
often after viral upper resp tract infection
facial swelling over affected area
facial pressure
facial pain / headache
nasal congestion
nasal discharge
loss of smell
tenderness on palpation of affected area
inflam and oedema of nasal mucosa
dishcarge
fever
sighns of systemic illness- tachycardia
chronic similar
chronic sinutisist associated with what
nasal polyps
investigfations sinusitis
nthing
if persitant despite rx:
nasal endoscopy
ct scan
management of acute sinusits
nothigng - usally resocles 2-3 weeks and due to viral so not keen for abx
if not improved after 10 days of symtoms then:
high dose nasal steroid spray for 14 days = mometasone 200mcg BD
or
delayed abx prescition- if worsening or not improving whtin 7 days abx= phenoxymethylpenicillin
managemnt chronic sinusitis
steroid nasal spray/ drops= mometasone/ fluticasone
saline nasal irrigation
functional endocopic sinus surgfery
technique of nasal spray
tilt head foreward slighlty
left hand for r nostril - not directly to septum
not sniff during spray
inhale gently through nose after spray
ask do you taste it in back of mouth after it - shouldnt as means not in nose
tonsilits- which tonstils
inflammation of tonsils
palatine tonsils in waldeyers ring
cause of tonstitlits
most common cause is viral!
bacterial- most common is streptococcus pyogenes
second most common is streptococcus pneumoniae
other bacterial:
moraxella catarrhalis
haemophilus influenzae
staphylcoccus aureus
presentationtonsitltis
fever- over 38
sore throat
pain on swallowing
inflammed, red, enlarged tonsils
can have exudate
may have anterior cervical lymphadenopathy
how to know if bacterail tonsitlits
feverPAIN score- 4 or more likely bacteria
Centor criteria - 3 or more liekly bacterial
feverPAIN score criteria
fever- during previous 24hrs
purulence- pus
attended within 3 days of onset
inflammed
no cough.coryza
if 4 or more then tonsiltits bacterial likely = abx
centor score
fever
tonsilar exudates
no cough
lymphadenopathy - tender anterior cervical lymph nodes
3 or more ikly bacterial tonsiltis
managemnt of tonisittlis- viral and bacterial and what abx givr
consider admit if:
immunocompromised
dehydrated
strifor
resp disease
cellulitis
peritonsilar abscess
systemically unwell
viral:
resolve by self- use soimple analgesia for pain and fever - paracetamol and nsaids
if not settled with 3 days/ fever over 38.3 then return and consider abx
score centor 3 or more, painFEVER 4 or more consider abx or if at risk of severe infection - young infant, sign co morbities, hx of rheumatic fever, immunocompromised
consider delayed prescirbtio if not imrpvoe / worse 2-3 days
abx= penicillin v (phenoxymethylpenicillin)- narrow good agasint streptococcus pyogenes
if pen allergy- clarightromycin
complciations tonisiltis
quinsy
otits media
scarlet fever
rheumatic fever
post streptococccal glomerulonephritis
post streptococcal reactive arthritits
whats post streptococcal reactive arthirits
usally within 10 days after strep infection
joint pain and swelling- localised
sore throat
fever
no cough
neck pain
refered ear pain
swollen and tender lymoh nodes neck
differentials- qu to differentiate
tonsiiltis
quinsy- able to open mouth? , change voice?, swellijng and red beside tonsils?
sore throat
fever
pain on swallowing
rfered ear pain
voice sounds diff
dx
quinsy
whats quinsy
peritonsilar abscess
bacterial infection with trapped pus foprming an abscess in region of tonsils
casues of peritonsilar abscess/ quinsy
bacterial infection
untreated/ partially treated tonsiltits
can arise without tonsiltis
streptococcus pyogenes- most common
streptococcus aureus
haemophilus influenzae
presentation quinsy/peritonsillar abscess
like tonsilits
fever
pain swallowing
sore throat
pain radiate to ear
tender cervical anterior lymoh nodes
neck pain
indicate abscess and not tonsiltis:
change in voice- pharangeal swelling
trismus = cant open mouth
erythma and swelling beside the tonsils too
mangment peritonisllar abscess/ quinsy
hos- incision and drainage under GA
abx before and after surgey as usually bacterial casue
co - amoxiclav- want broad specturm
some surgeons give steorids- dexamethoason- to reduce inflam and help recovery
tonsillectomy procedure
GA
day case
can still get sore throat other casues- pharyngitits
to prevent further tonsilitis
indications for tonsilectomy
number of episodes of acute sore throat:
7 in 1 yr
5 per yr for 2yrs
3 per year for 3 years
recurrent episodes tonsillar abscess- 2
enlarged tonsils casuing diff breathing, swallowing, snoring
complications tonsilectomy
infection
GA risks
post tonsillectomy bleeding!!
sore throat- can last 2 weeks after op
damage to teeth
treatment for post tonsillectomy bleeding
severe- can be lifethreatenigng esp if aspiration of blood
5% occur
can occur up to 2 weeks afger op
ent reg
iv acess- bloods= fbc, clotting screen, group and save and crossmatch
keep pt calm and appropriate analgesia
sit pt up and encouage spit out blood and not swallow it
nbm
iv fluids - maintence and resus if needed
if severe bleedig or airway compromised may need anaethesitits for intubatio n
stop the bleeding:
hydrogen peroxide gargle
adrenalin soaked swab topically
if not work theatre
differentials for neck lumps
normal strucutres
skin abscess
lymphadenopathy
thyroid nodules/ goitre
lipoma
branchial cyst
carotid body tumour
thryoglossal cysts
haematoma
salivary gland stones/ infection
tumour- squamous cell carcinoma/sarcoma
childnre also:
cystic hygromas
dermoid cysts
haemangiomas
venous malformations
redflas when to refer 2ww neck lumpps
45 and over if unexpalined neck lumo- eg. no infection
persitant neck lump any age
us pt if lump growong in size
witin 2 weeks if 25 and over
within 48hrs if under 25
investigations may consider for neck lums
bloods- fbc, and blood film if leukaemia / infection
hiv test
monospot test/ EBV antiboides
ANA- SLE
thhyroid levels
LDH- non specific marker for non-hodgkins lymphoma
us- first line often
MRI/CT
nuclear medicine scan - thryoid toxic nodules
pet sscan- mets
biopsy
causes of lymphadenopathy in neck
reactive lymph nodes- swelling, viral upper resp infection, dental infection, tosiltis
infected lymoh nodes- TB,HIV,EBV
inflammaation- SLE, sarcoidosis
malignacyc- lymphoma, leukaemia, mets
lump in neck thats maligant on examination
non tender
hard/rubbery
unexpalined
enalrge always
abnomral shape
tehtered
weight lsos
fatigue
night swats
fecers
s and s infectios mononucleosis
and rx and investigation frst line
casued by EBV
trnamissionvia saliva
fever
lymphadenopathy
sore thorat
fatigue
itchy maculopapular rash rxn to amoxicllin/ceflosporins
investigations: monospot test
IgM= actue
IgG= immunity
rx= support
no contact sport as risk splenic rupture
no alcohol as liver
s and s lymphoma
lymphodenopathy- inguinal, cervical, axialla
fever
weight loss
fatigue
night sweats
finding on biopsy for lymphona
ree-sternberg cell on biopsy
leaukaemia investiation and s and s
fever
night sweats
weight loss
lymphadenopahty
pallor-anaemia
petechiaa and abnormal brusing- thrombocytopenia
abnormal bleeding
hepatosplenomegaly
casues of thryoid neck lumos
goitre:
graves - hyper
toxic multinodular goitre- hyper
hashimotis thryoididits- hypo
idoine def
lithium
individual lumps:
benign hyperplastic nodules
thryoid cysts
thryoid adenomas- bengin increase in thryoid hormone
thryoid cancer
parathrypid tumours
casues of salovary gland casuing neck lumo
glands:
parotid
submandibular
sublingual
casues:
stone blocking drainage
infection
tumours
carotid body tumours what are they and s and s
carotid body made of glomus cells that are cehmo receptors- co2, ph
excesivve growth of glomus cells
most are benign
= paragliomas
s and s
slow growing lump
upper anteiro triganle
painless
pulsitile
bruit on auscultation
mobile side to side bu not up and down
can compress cn 9,12,11,12
compress 10= horners syndrome - triad of miosis, ptosis, anhydrosis
imaging shows splaying of internal and external carotid arties
casues this and what name of this sign
splaying of internal and external carotid a = lyre sign
due to carotid body tumour
lipoma s and s
bengin fat lumo- anywhere adipose tissue
soft
painess
mobile
no skin changes
can leaveor can remove
branchial cyst
s and s
congenital
normally second branchial cleft
anteior to sternocleidomastoid muscle and under jaw angle
round soft
transillumiate
treat- conservative or can remove if recurrent infection
lump on midline that moves when stick tongue out/ swallow
thyroglossal cysts
thyroglossal cyst
and s and s
embryo thryoid gland moves down from base of tongue and leaves a thryoglossal duct which then closes
sometimes this persitis and fluid cyst can occur
midline in neck
mobile
soft
non tender
fluctuant
move with tongue up and down wehn stick tongue out and move when swallow- upawards
investigations and treamnt and compliation thryoglossal cyst
us/ct
remove
infection complication
differential for midline lump on neck
thryoglossal cysts
ectopic thyroid tissue
drugs can casue goitre
lithium
amiodarone
goitre will they move on tongue protrustion?
swallowing?
no
thryoglossal cysts will move on tongue protursion as connected to base of tongue
Thyroid gland masses (e.g. a goitre) and thyroglossal cysts typically move upwards with swallowing.
Lymph nodes will typically move very little with swallowing.
An invasive thyroid malignancy may not move with swallowing if tethered to surrounding tissue
nasal polyps
growths of nasal mucosa that can occur in nasal cavity/ sinuses
important thing to remebr about nasal polyps
unilateral consider malignancy and refer to specilaist
assocaitions with nasal polyps
inflammation- chronic sunisitits/rhinitits (something there grwoing and obstructing so going to get inflammation which can then cause sinusuits/rhinitis depndisng locations)
asthma
samters triad- asthma, nasal polyps, aspiring intolerenace/allergy
cystic fibrosis
eosinophilic granulomatosis with polyangitits= chrug strauss syndrome
what presentations may you see nasal polyps
may be found in patients presenting with:
chronic rhinosinusitis
diff breathing through nose
snoring
nasal discharge
loss of sense of smell
how to view nasal polyps and what look like
nasal speculum/otoscope with large speculum
nasal endocsopy
round pale yellow/grey growths on the mucosal wall
managment nasal polyps
unilateral - refer to specialst to exclude malignancy
intranasal topical steroid spray/drops
if doenst work:
surgical removal:
intranasal polypectomy- if close to nostrils and visisble
endoscopic nasal polypectomy- polyps further insdie the nose/sinuses
obstructive sleep apnoea
episides of apnoea during sleep
stops breathing periodically for up to a few mins
casue of obstructive sleep apnoea
collaspe of pharyngeal airway
risk factors obstructive sleep apnoea
male
middle age
obesity
alcohol
smoking
features of obstricitve sleep apnoea
episodes of apnoea at noght- wkaing at night - usually reported by partner
daytime sleepiness- ask re job may need amened duties
waking feeling unrefreshed
morning headache
snoring
reduced o2 sats at night
concentration problems
important questions to ask in pt with obstrucitve sleep apnoea
whats their occupation and if they have day time sleepiness - if so may need amend work dutites
severe obstructive sleep apnoea can cause
hypertension
heart failure
increase risk for stroke and mi
management obstrucitve sleep apnoea
refer to ent specialst/ specialsit sleep clinic-> sleep studies
1-correct revrisble risk factors- loose weight, stop drinking, stop smoking
2- cpap at night
3- surgry- uvulopalatopharyngeoplasty= UPPP
