ENT Flashcards
What is chronic rhinosinusitis
Inflammation of the paranasal sinuses lasting over 12 weeks
Presentation of chronic rhinosinusitis
Facial pain worse on bending forward
Nasal discharge
Mouthy breathing
Post nasal drip causing chronic cough
Management options of chronic rhinosinusitis
First line
- Intranasal corticosteroids
- Nasal irrigiation with saline solution
If severe and persistent
- Functional endoscopic sinus surgery
Red flag symptoms requiring ENT referral for chronic rhinosinusitis
Unilateral symptoms
Persistent symptoms despite 3 months of treatment
Epistaxis
If any of these then 2 week referral
Presentation of vestibular neuronitis
Vertigo and nausea following a viral infection
Horizontal nystagmus
NO hearing loss or tinnitus
Management of chronic vestibular neuronitis
Vestibular rehabilitation exercises- brandt daroff exercises
Avoid medications
Management of vestibular neuronitis
If mild= oral antihistamine like prochlorperazine or cylizine
If more severe then buccal or intramuscular prochlorperazine
NICE advise that symptomatic treatment can be used for up to 3 days. More extended use may slow down the recovery.
if the symptoms not improved after 1 week or resolved after 6 weeks, refer to ENT for further investigation or vestibular rehabilitation therapy (VRT)
Mastoiditis presentation
otalgia
fever
typically very unwell
swelling, erythema and tenderness over the mastoid process
the external ear may protrude forwards
ear discharge may be present if the eardrum has perforated
Management of mastoiditis
IV abx- ceftriaxone
May require myringotomy with grommet or mastoidectomy
What is ramsay hunt syndrome
Reactivation of VZV in the facial nerve
Presentation of ramsay hunt syndrome
Facial droop
Rash in the ear- can get over anterior 2/3 tongue
Ear pain
Can get vertigo and tinnitus
Management of ramsay hunt
Oral aciclovir and corticosteroids
Lubricating eye drops
Management of perforated tympanic membrane
Watch and wait to see if persists post 6 weeks
If does then ENT referral
Management if watch and wait did not work for perforated tympanic membrane
Myringoplasty- surgically repairing it
What abx give for AOM
Amoxicillin
Second line- clari
What is chronic supporative otitis media
Post AOM get tympanic membrane perforation with otorrhoea for over 6 weeks
Complications of AOM
mastoiditis
meningitis
brain abscess
facial nerve paralysis
Chronic supporative otitis media
Presentation of benign paroxysmal positional vertigo
Older than 55:
- vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
- may be associated with nausea
- each episode typically lasts 10-20 seconds
What is seen on positive dix hallpike
Patient gets vertigo alongside a rotary nystagmus
What is investigation for BPPV
dix hallpike
Management of BPPV
Epley manoeuver
Teaching patient exercises they can do at home- brandt daroff exercises
What are associations of nasal polyps
Asthma
Chronic rhinosinusitis
CF
Kartageners
Churg strauss
Aspirin sensitivity
What is aspirin sensitivity
When people take aspirin or other NSAIDs like ibuprofen they may get a reaction
- itchy rash
- nasal congestion
- watery eyes
What is in samters syndrome
Nasal polyps
Aspirin sensitivity
Asthma
How can nasal polyps present
Snoring
Difficulty breathing through nose
Rhinorrhoea
Loss of smell
Which nasal polyps need urgent referral ENT
Unilateral as should normally develop bilaterally
Bleeding
These signs may suggest nasopharyngeal cancer
Management of nasal polyps
If unilateral or bleeding then urgent ENT referral
If bilateral
- routine ENT referral for topical corticosteroids
- can consider polypectomy if medical tx fails
How distinguish labyrinthitis from vestibular neuronitis
Hearing loss or tinnitus can be present in labyrinthitis but NEVER in vestibular neuronitis
What is pathophysiology of otosclerosis
Genetic condition where get replacement of normal bone in ear by vascular spongy bone
Inheritance of otosclerosis
AD
Presentation of otosclerosis
Family history of hearing loss
Conductive hearing loss
Tinnitus
What do if someone diagnosed with sudden onset sensorineural hearing loss
Refer urgently to ENT to be seen within 24 hours
What will ENT do for sudden onset sensorineural hearing loss
MRI to exclude vestibular schwannoma
Audiology assessment
High dose oral corticosteroids
What is most common cause of sudden onset sensorineural hearing loss
Idiopathic
What is most likely salivary gland to become blocked with stones
Submandibular
What is sialadenitis
Inflammation of the salivary glands
Presentation of sialadenitis
Pain and swelling in mouth
Skin can become red above it
Poor taste in mouth
What are nasopharyngeal carcinomas
Squamous cell carcinomas which occur in the nasopharynx typically caused by EBV
What is main risk factor for nasopharyngeal carcinoma
Being from south china
EBV
Presentation of nasopharyngeal carcinoma
Lymphadenopathy
Otalgia
Unilateral otitis media
Nasal discharge
Epistaxis
Get cranial nerve palsies too if invades cavernous sinus
What is gingivitis and how does it present
Inflammation of the gums typically caused by poor dental hygiene
Simple gingivitis presents with bleeding and painless swelling of the gums
What can simple gingivitis progress to
Acute necrotising ulcerative gingivitis where get infection of anaerobic bacteria
What is presentation of Acute necrotising ulcerative gingivitis
Painful bleeding gums
Punched out ulcers in the gums
Halitosis
Management of simple gingivitis
Routine appointment with dentist
- mouthwash
- encourage good brushing
Management of acute necrotizing ulcerative gingivitis
Metronidazole
Urgent dental referral
Analgesia
Chlorhexidine mouth wash
What is pathophysiology of menieres disease
Build up of endolymph fluid in the ear
Presentation of menieres disease
Random attacks of vertigo
Associated with sensorineural hearing loss
Tinnitus
Get feeling of fullness in ear
Most likely cause of bacterial otitis media
Strep pneumonia
Other causes include HIB or moraxella
What neck lumps move upwards on swallowing
Thyroglossal cyst
Goitre
What is presentation of nasal septal haematoma
Post even slight trauma
Nasal obstruction sensation
Pain and rhinorrhoea
Nasal septal haematoma on examination
Bilateral red swelling arising from septum
Feels boggy
Management of nasal septal haematoma
Urgent ENT referral for surgical drainage
Labyrinthitis presentation
vertigo: not triggered by movement but exacerbated by movement
nausea and vomiting
hearing loss: may be unilateral or bilateral, with varying severity
tinnitus
preceding or concurrent symptoms of upper respiratory tract infection
Management of labyrinthitis
Usually self limiting but can give prochlorperazine to help with vertigo
Presentation of presbycusis
Difficulty following conversations
Bilateral high frequency hearing loss
Which drugs are ototoxic
Aminoglycosides
Aspirin
Furosemide
Cytotoxic drugs
Quinines
What is an acoustic neuroma
Vestibular schwannoma aka
Benign tumour of the schwann cells which surround the vestibulocochlear nerve
How can acoustic neuromas present
Unilateral hearing loss
Unilateral tinnitus
Dizziness
Can get other facial nerve palsies if grows large enough
- CN5 get absent corneal reflex
- CN7 get facial nerve palsy
What is hypo vs hyperacusis
Hypo= poor hearing acuity
Hyper= extreme sensitivity to sounds
What is done if someone has hypoacusis
Referral to ENT for audiometric assessment. Will trial hearing aids then if not a cochlear implant will be trialled
Treatment options for sensorineural hearing loss
Hearing aids
Cochlear implant
What must a patient do prior to having a cochlear implant inserted
Trial hearing aids for 3 months
Complications of cochlear implant insertion
Meningitis
CSF leak
Infection
Facial nerve paralysis
Contraindications for cochlear implant
Lesions on CN 8 or brainstem
Chronic otitis media
Antibiotic for tonsillitis
Phenoxymethicillin V for 7 or 10 days
Clarithomycin in contraindicated
What is in centor criteria
No cough
Tonsillar exudate
Fever
Anterior cervical lymphadenopathy
What are indications for abx in tonsillitis
Systemic upset
Unilateral peritonsillitis
Rheumatic fever history
Increased risk from acute infection (e.g. immunodeficient child)
Centor 3 or above
Initial management of nose bleed
A-E to determine if haemodynamically stable
If stable then pinch soft part of the nose and lean forward for 20 minutes
What do if first aid successful in managing epistaxis
Use topical antiseptic- naseptin (chlorhexidine and neomycin) to reduce crusting
Consider admission if coagulopathy or severe comorbidity like HF
What do if in epistaxis first aid is unsuccessful
Look for site of bleed
- if can be visualised then cautery
- if cant be visualised then anterior packing
What need to use before cautery or anterior packing
Lidocaine anaesthetic spray
What is cause of ludwigs angina most commonly
Infection proceeding odontogenic procedure
Management of ludwigs angina
Immediate transfer to hospital
IV abx
Airway management
Presentation of ludwigs angina
Neck swelling
Dysphagia
Fever
Severe pain
What is urgent referral guideline for suspected laryngeal cancer
Unexplained persistent hoarseness if over 45
Unexplained neck lump
What is first investigation do to if unexplained hoarseness
CXR to rule out apical lung tumour
Causes of hoarseness
voice overuse
smoking
viral illness
hypothyroidism
gastro-oesophageal reflux
laryngeal cancer
lung cancer
Which drugs can cause tinnitus
Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine
What is sialolithiasis
Salivary stones
Where do most salivary stones occur
Submandibular glands blocking whartons duct
What are salivary stones most often made from
Calcium phosphate
Presentation of sialolithiasis
Colicky pain
Post prandial swelling of the gland
Dry mouth
Halitosis
What are causes of gingival hypertrophy
CCB
Ciclosporin
Phenytoin
AML
What is management for all post tonsillectomy bleeds
Immediate ENT referral
What is management of primary tonsillectomy bleed
Immediate return to theatre
What most often causes secondary tonsillectomy bleeds
Infection of the wound
What is management of secondary tonsillectomy bleeds
Admission and abx
If very severe return to theatre
What do if epistaxis has failed to respond to cautery or packing
Sphenopalatine artery ligation in theatre
What is most common symptom of laryngopharyngeal reflux
Lump in throat felt in the midline that is felt worse on swallowing saliva not food or drink
Presentation of laryngopharyngeal reflux
Lump in throat felt in the midline that is felt worse on swallowing saliva not food or drink
hoarseness (70%)
chronic cough (50%)
dysphagia (35%)
heartburn (30%)
sore throat
What may be seen on examination of laryngopharyngeal reflux
Posterior pharynx may be red
How diagnose laryngopharyngeal reflux
Clinical diagnosis provided no red flag symptoms
- persistent hoarseness
- unilateral discomfort
- malaena
- weight loss
- dysphagia
- odonyphagia to food
Management of laryngopharyngeal reflux
Trial lifestyle first- typical GORD measures
The consider PPI or gavison
What prompts urgent referral for head and neck cancer
Ulcer lasting over 3 weeks
Persitent lump in neck
Lump on lip or in oral cavity
Erythro or erythroleukoplakia
What does the HINTS test do
Differentiate between central and peripheral causes of vertigo
Central causes of vertigo
MS
Stroke
Tumour
Trauma
Peripheral causes of vertigo
Anything related to the vestibulocochlear nerve
How can head and neck cancer present
Oral cancer
- ulcer
- unexplained lump
- unexplained red or white patch
Pharynx or larynx
- persistent sore throat
- hoarseness
- neck lump
How can nasopharyngeal cancer present with ear pain
A lot of pain in the head and neck can be referred to the ear
What is linked to oropharyngeal squamous cell carcinoma
HPV
Where do SCC occur in the oropharynx most commonly
The tonsil
What is pathogen most likely to cause malignant otitis externa
Pseudomonas
What is main risk factor for malignant otitis externa
Diabetic
How does malignant otitis externa present
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
How manage otitis externa in diabetic
Ciprofloxacin drops to prevent progression to malignant otitis externa
How manage malignant otitis externa
Do a CT scan
Start IV antibiotics which cover pseudomonas
What do if have otitis externa that is non resolving and getting worse
Urgently refer to ENT to rule out or manage malignant otitis externa
How are auricular haematomas managed
Same day assessment by ENT for incision and drainage to prevent cauliflower ear
What is cause of stridor in a post neck operation patient
Haematoma
What do in case of stridor in a post neck operation patient
There is haematoma obstructing trachea so need to cut sutures to release blood
Call for senior help too
Which salivary gland is a tumour most liekly to be in
Parotid gland
What is most likely tumour of parotid gland
Pleomorphic adenoma
Tumours in the parotid are 80% benign and pleomorphic adenoma most likely
What is most common cause of bilateral parotid tumours
Warthins tumour
How evaluate a parotid tumour
X-ray to exclude calculi
Saliography to delineate anatomy
USS guided fine needle aspiration most diagnostic
Management of parotid tumours
Benign- superficial parotidectomy
Malignant- radical parotidectomy
What can HIV patients present with in their parotids
Cysts in their parotids
Bilateral multicystic swellings of the paroid
What is sarcoid parotid presentation
Xerostomia
Parotid gland swelling
Facial palsies
Occurs in about 5% of sarcoid patients
How can impacted ear wax present
Not just with conductive hearing loss
Patients can also present with pain, tinnitus and vertigo
Management of ear wax
Either drops or ear syringing
- olive oil
- sodium bicarbonate
- almond oil
What may be seen on examination of the mouth in IDA
Glossitis
What causes tongue to appear black, brown or green
Black hairy tongue
What are causes of black hairy tongue
poor oral hygiene
antibiotics
head and neck radiation
HIV
intravenous drug use
Management of black hairy tongue
Tongue swab to exclude candida
Tongue scrapings
Management of menieres
ENT referral
Inform DVLA
In acute attacks- IM or buccal prochlorperazine
Prevention- betahistine and vestibular rehab
How manage acute attacks of menieres
Buccal or intramuscular prochlorperazine
Admission is sometimes required
How prevent attacks of menieres
Betahistine- histamine analogue
Vestibular rehabilitation exercises
What is double sickening in sinusitis
If bacteria are responsible then can get an improvement in sx followed by a deterioration
How can thyroglossal cyst present
Recurrent infections and abscesses
Presentation of of pharyngeal pouch
Halitosis
Recurrent throat infections
Neck lump around the sternocleidomastoid muscle
What do if erythema in otitis externa extends to the ear
Add oral flucloxacillin
How does cholesteatoma present
Recurrent purulent discharge
Conductive hearing loss
If local invasion then
- vertigo
- facial nerve palsy
What presents with dizziness on extension of the neck
Vertebrobasilar ischaemia
What is rhinitis medicamentosa
Where after prolonged use of nasal decongestants there is hypertrophy of the nasal mucosa
What presents with a white film over tonsils that bleeds on contact
Bacterial tonsillitis
Differentials for facial pain
Trigeminal neuralgia
GCA
Sinusitis
Cluster headache
Management of pleomorphic adenoma
Routine surgical resection
What is rinnes test
Tuning fork placed over mastoid and then once it is no longer audible, it is placed over the ear to see if is audible
What is webers test
Tuning fork placed on forehead and it is seen if louder in one ear or is heard the same in both
What is a positive rinnes test
Air conduction>bone conduction meaning when can no longer hear by mastoid you can hear in ear
What is a negative rinnes test
Bone conduction> air conduction
How would conductive hearing loss present in webers and rinnes
Lateralisation in weber to affected side
On affected side would be negative rinnes- bone conduction>air conduction
How would sensorineural hearing loss present in webers and rinnes
Lateralisation to good side
On both sides air conduction > bone conduction
What is normal on an audiogram
Anything above 20dB
What suggests sensorineural hearing loss on an audiogram
Both air and bone conduction hearing loss are low
What suggests conductive hearing loss on an audiogram
Only air conduction is abnormal (above 20dB)
Bone conduction is normal
What suggests mixed hearing loss on an audiogram
Both air and bone conduction are poor with air worse than bone- creating an air bone gap
What is exostosis
Cold water and wind exposure leads to bony growths in the ear
How manage unilateral glue ear in adult
Referral under 2 WW
Differentiating menieres from chronic vestinular neuronitis
Menieres can present with tinnitus and hearing loss
Presbycusis on audiogram
High pitched hearing affected
What are cholesteatomas
Squamous cell granulomas
Management of cholesteatoma
ENT referral for surgery
Most common infectious causes of vestibular neuronitis
HSV
VZV
What is important thing to bear in mind when prescribing prochlorperazine
Do not give for too long as can interfere with brains signals
Bones in ear
Remembering tool= MIS- in order from tympanic membrane to cochlear
Malleus
Incus
Stapes
Otitis externa management
Depends on severity
- if mild can give acetic acid
- if moderate give neomycin with corticosteroid
If diabetic cipro drops
What do if otitis externa so severe is conductive hearing loss
Add in ear wick
What do if treatment refractory otitis externa
Re-examine
Ear swab
Important side effect to consider when using neomycin for otitis externa
Ototoxic
Management of presbycusis
Hearing aids/cochlear implants etc
Acute sinusitis management
Less than 10 days= supportive
Over 10 days consider intransal mometasone or back-up phenoxymethicillin if more severe
If systemically unwell then co-amox
Causes of sinusitis
Infection- strep pneumoniae, haemophilus, rhinoviruses
Smoking
Allergies
What do if medical treatment for polyps fails
Polypectomy done either intransally or endoscopically depending on how far into nose they are
Where are most nosebleeds from
Littles area
What do if blood in mouth from nose bleed
Spit out
Infective causes of facial nerve palsy
Ramsay hunt
Lyme disease
HIV
Invasive ear infections
Non infectious causes of facial nerve palsy
Systemic diseases
- sarcoid
- DM
- MS
- leukaemia
Tumours
- cholesteatoma
- parotid tumours
- acoustic neuroma
What are the 3 salivary glands
Parotid (in cheeks)
Submandibular (more posteriorly under tongue)
Sublingual (more anteriorly under tongue)
Causes of sialedinitis
Stones
Malignancy
Sarcoid
Viral- mumps
Bacterial- only if immunocompromised
Sjogrens
Which medications increase risk of salivary stones
Diuretics
Anti-cholinergics
Management of salivary stones
Refer to ENT
- stay hydrated
- NSAIDs for pain
- stop any precipitating meds
Gold standard investigation for parotid tumours
USS guided FNA
Causes of gingivitis
Poor brushing
Smoking
How manage patient with leukoplakia
Stop smoking and reduce alcohol
Biopsy if persistent
What is erythoplakia vs erythroleukoplakia
Erythroplakia is red raised lesions in mouth (red leukoplakia)
Erythroleukoplakia where mixture of red and white
Management of erythroplakia and erythroleukoplakia
Refer under 2WW as highly premaligant
Causes of gingival hyperplasia
Gingivitis
Scurvy
AML
Drugs- CCB, phenytoin, ciclosporin
Management of oral lichen planus
Good hygiene- stop smoking
Topical steroids
Oral lichen planus presentation
Wickhams striae- shiny purple raised patches with white lines across
Causes of apthous ulcers
Crohns
Behcets
Vitamin deficiencies- iron, B12
HIV
Management of apthous ulcers
Can be managed without intervention
If moderate pain- bonjela (choline salicylate) or lidocaine
If severe discomfort- buccal steroids applied to ulcer
3 causes of tongue angioedema to remember
Allergy
ACE inhibitor
C1 esterase deficiency
Management of oral candidiasis
Nystatin suspension or miconazole gel
Management of quinsy
Co amoxiclav
Incision and drainage or aspiration
How does otitis media with effusion present
Muffled hearing
What is fluid behind the tympanic membrane with bubbles
Otitis media with effusion
What is main thing horiztonal nystagmus is seen in
Vestibular neuronitis
Labyrinthitis
