ENT Flashcards
function of semicircular canals
sense head movements
function cochlear
converts sound vibration -> nervous signal
webers test results
sensorineural loss = louder in normal ear
conductive loss = louder in affected ear
webers test
tuning fork in middle of forehead
rinnes test
air vs bone
rinnes test results
positive=normal=air conduction better
negative=bone conduction better=conductive cause
causes sensorineural hearin gloss
presbyacusis
noise exposure
menieres
labyrinthitis
acoustic neuroma
stroke
MS
tumour
meningiits
meds: loop diuretics, aminoglycoside abx, chemo
causes conductive hearing loss
wax
otitis media/externa
tumours
effusion
perforated tympanic membrane
otosclerosis
cholesteatoma
exostosis
audiometry symbols: X
L sided air conduction
audiometry symbols: O
R sided air conduction
audiometry symbols: ]
L sided bone conduction
audiometry symbols: [
R sided bone conduction
normal audiometry
all readings 0-20dB (top of chart)
sensorineural hearing loss audiometry
readings >20dB
conduction hearin gloss audiometry
air conduction (X, O) >20dB
mixed hearing loss audiometry
all readings >20dB and >15dB difference between bone and air (bone>air)
what is presbycusis
age-related hearin gloss
sensorineural
features presbycusis
gradual
high pitched sounds first
+/- tinnitus
cause presbycusis
due to hair loss cells in chochlear
loss neurons
atrophy stria vascularis
reduced endolymphatic potential
RF presbycusis
age
M
fhx
noise exposure
DM
HTN
smoking
mx presbycusis
hearing aids
causes sudden (<72hr) sensorineural hearin gloss
idiopathic
infection
menieres
meds
MS
migraine
stroke
acoustic neuroma
cogan’s syndrome (AI)
diagnosis sudden sensorineural heaing loss
loss >30dB in 3 consecutive frequencies
mx sensorineural hearing loss
emergency referral
steroids
role of eustachian tube
equalises pressure and drains fluid from middle ear
features eustachian tube dysfunction
reduced hearing
popping
full sensation
pain
tinnitus
ix eustachian tube dysfunction
tympanogram: peak admittance with negative ear canal pressures
mx eustachian tube dysfunction
none
valsalva
decongestants
antihistamines/steroid spray
surgery: grommets, balloon dilatation, eustachian tuboplasty
otosclerosis
remodelling malleus/incus/stapes
more common F <40y
features otosclerosis
conductive hearing loss
lower pitched sounds
tinnitus
mx otosclerosis
hearing aids
surgery: stapedectomy/stapedotomy
what is otitis media
infection middle ear
causes otitis media
strep pneumoniae
h.influenzae
moraxella catarrhalis
s.aureus
features otitis media
pain
reduced hearing
fever
bulging red tympanic membrane
mx otitis media
immediate abx if systemic sx
delayed abx or none if not
5-7d amoxicillin or clarithromycin
complications otitis media
otitis media with effusion
hearing loss
perforated tympanic membrane
labrinthitis
mastoiditis
abscess
facial nerve palsy
meningitis
causes otitis externa
bacterial: pseudomonas aeruginosa, staph aureus
fungal
eczema
features otitis externa
pain
discharge
itching
conductive hearing loss
mx otitis externa
mild=acetic acid
moderate=topical abx and steroid (neomycin, dex, acetic acid)
what abx is ototoxic
aminoglycoside
must exclude perforated tympanic membrane before topical use
malignant otitis externa
spreads to bones
RF malignant otitis externa
DM
immunocompromised
HIV
features malignant otitis externa
severe pain
headache
fever
granulation tissue in ear canal
mx malignant otitis externa
CT/MRI
IV abx
complications malignant otitis externa
facial nerve palsy
meningitis
intracranial thrombosis
features excess ear wax
conductive hearing loss
fullness
tinnitus
mx excess ear wax
drops (olive oil)
irrigation
microsuction
tinnitus
ringing or buzing in ears
cause tinnitus
background sensory signal produced by cochlear
causes tinnitus
primary=none
secondary=wax, infection, menieres, noise, meds, acoustic neuroma, MS, trauma, depression
what conditions is tinnitus associated with
anaemia
DM
thyroid
high lipids
what is objective tinnitus
the sound is caused by carotid artery or aortic stenosis, arteriovenous malformations, eustachian tube dysfunction
ix tinnitus
FBC
glucose
TSH
lipids audiology
tinnitus red flags
unilateral
pulsatile
hyperacusis
unilateral hearing loss
sudden hearing loss
vertigo
headaches
visual changes
neuro sx
suicidal ideation
mx tinnitus
hearing aids
sound therapy CBT
what is vertigo
patient feels like they or the room is moving
peripheral causes vertigo
vestibular system: BPPV, menieres, vestibular neuronitis, labyrinthitis
central causes vertigo
brainstem/cerebellum: posterior circulation infarct, tumour, MS, vestibular migraine
peripheral vs central vertigo
perioheral: sudden onset, short, tinnitus nausea
central: gradual onset, persistant, coordination impaired
O/E in vertigo
HINTS
head impulse (jerk head and eyes soccade) positive in peripheral
nystagmus: positive in central
test of skew (cover eye and verticle correction): positive in central
ix vertigo
if central cause suspected need CT/MRI
mx vertigo
tx cause
short term for peripheral: prochlorperazine, antihistamines
benign paroxysmal positional vertigo cause
displaced otoconia (calcium carbonate) into semicircular canals which disrupts flow endolymphs
features BPPV
vertigo due to head movements
no tinnitus
diagnosis BPPV
dix hallpike manoevre (triggers sx)
mx BPPV
epley manoevre
brandt-daroff exercises
vestibular neuronitis
inflammation vestibular nerve due to viral infection
features vestibular neuronitis
URTI
vertigo
N+V
balance problems
NO HEARING LOSS
mx vestibular neuronitis
prochlorperazine
cyclizine
vestibular rehab
inner ear
bony labyrinth
semicircular canals
vestibule
cochlea
labyrinthitis
inflammation inner ear
cause labyrinthitis
viral URTI
features labyrinthitis
acute onset vertigo
hearing loss
tinnitus
mx labyrinthitis
up to 3d prochlorperazine or cyclizine
abx if bacterial
menieres
build up of endolymph in labyrinth
features menieres
unilateral sensorineural hearing loss
vertigo (in clusters)
tinnitus
drop attacks
imbalance
mx menieres
acute attacks=prochlorperazine, cyclizine
prophylaxis=betahistine
acoustic neuroma
=vestibular schwannoma
benign tumour schwann cells surrounding the auditory nerve
occur at cerebellopontine angle
bilater acoustic neuroma
neurofibromatosis type II
features acoustic neuroma
40-60y
unilateral sensorineural hearing loss and tinnitus
dizziness/imbalance
fulless in ear
+/- facial nerve palsy
mx acoustic neuroma
conservative
surgery
radiotherapy
cholesteatoma
abnormal squamous epithelial cells in middle ear
non cancerous but locally invasive
features cholesteatoma
foul discharge
unilateral conductive hearing loss
infection
pain
vertigo
facial nerve palsy
ix cholesteatoma
otoscopy=white debris/crust in tympanic membrane
CT
mx cholesteatoma
surgery
divisions facial nerve
temporal
zygomatic
buccal
marginal manddibular
cervical
facial nerve function
motor: facial expressio, stapedius, posterior digastric, stylohyoid, platysma
sensory: taste to anterior 2/3 tongue
parasymp: submandibular and sublingual salivary glands, lacrimal gland
features UMN facial nerve lesion
forehead spared
cause UMN facial nerve lesion
stroke
tumour
features LMN facial nerve lesion
forehead not spared
cause LMN facial nerve lesion
bells palsy
ramsay hunt
infection: otitis media, HIV, lyme disease
systemic: DM, sarcoid, leukaemia, MS, guillain barre
tumour: acoustic neuroma, parotid, cholesteatoma
traum
mx bells palsy
pred within 72h
lubricating eye drops
recovery can take 12m, 1/3 have residual weakness
cause ramsay hunt syndrome
VZV
features ramsay hunt syndrome
unilateral LMN VII palsy
vesicualr and painful rash around ear
mx ramsay hunt syndrome
pred/aciclovir
lubricating eye drops
where does epistaxis commonly come from
kiesselbacks plexus in litttles area
mx epistaxis
squeeze nostrils and head forward
not stopped after 15m=nasal tampon or cautery with silver nitrate stick
naseptin (chlorhex and neomycin) for 10d to reduce inflammation and infeection
paranasal sinuses
frontal
maxillary
ethmoid
sphenoid
causes sinusitis
infection: viral URTI
allergy
obstruction
smoking
features sinusitis
nasal congestion and discharge
facial pain/pressure/swelling
headache
mx acute sinusitis
nothing for first 10d, then steroid nasal spray (mometasone) 14d or abx if bacterial (phenoxymethylpenicillin)
mx chronic sinusitis
saline nasal irrigation
steroid nasal spray
functional endoscopic sinus surgery
unilateral nasal polyps
RED FLAG
bilateral nasal polyps associations
chroni rhinitis/sinusiits
asthma
CF
churg strauss
snoring
mx nasal polyps
steroid drops/spray
surgery
samters triad
nasal polyps
asthma
aspirin intolerance/allergy
what happens in obstructive sleep apnoea
collapse pharyngeal airway
RF obstructive sleep apnoea
age
M
obese
alcohol
smoking
features obstrutive sleep apnoea
apnoea
snoring
daytime sleepiness
reduced oxygen sats in sleep
what can obstrutive sleep apnoea lead to
HTN
HF
risk MI, stroke
ix obstructive sleep apnoea
epworth sleepiness scale=daytime sleepines
sleep studies
mx obstrutive sleep apnoea
ENT/sleep clinic
CPAP
uvulopalatopharyngiplasty
causes tonsilitis
group A strep - pyogenes
strep pneumoniae
h.influenzae
morazella catarhallis
staph aureus
waldeyers tonsillar ring
adenoids
tubal tonsils
palatine tonsils
lingual tonsils
what is usually affected in tonsilitis
palatine tonsils
features tonsilitis
sore throat
fever
swallowing pain
anterior cervical lymphadenopathy
centor criteria
likelihood tonsilits is bacterial
fever >/= 38, tonsillar exudates, no cough, anterior lymphadenopathy
interpreting centor criteria
> /= 3 likely bacterial tonsilitis
fever PAIN score
likelihood bacterial
fever within 24h
purulence
attended within 3d sx
inflammed tonsils
no cough or coryza
interpreting fever pain score
likely bacterial if >/= 4
mx tonsilitis
pnehoxymethylpenicillin (or clarithromycin) if centor >/= 3 or fever pain >/= 4
complications tonsilitis
quinsy
otitis media
scarlet fever
rheumatic fever
post strep glomerulonephritis
post strep reactive arthritis
quinsy
peritonsillar abscess
causes quinsy
strep pyogenes
staph aureus
h influenzae
features quinsy
tonsillitis ->
trismus (cant open mouth), hot potato voice, swelling and erythema around tonsils
mx quinsy
ENT refer
needle aspiration +/- dex and abx (co-amox
indications for tonsillectomy
episodes sore throat:
>/= 7 / yr for 1yr
>/= 5 /yr for 2yr
>/= 3 / yr for 3yr
2 tonsillar abscesses
tonsils cause difficulty breathing
complications tonsillectomy
sore throat
damage to teeth
infection
post tonsillectomy bleeding
mx post tonsillectomy bleeding
emergency
IV access
hydrogen peroxide gargle
adrenaline swab
theatre
anterior triangle
mandible=superior
midline neck=medial
sternocleidomastoid=lateral
posterior triangle
clavicle=inferior
trapezius=posteriir
sternocleidomastoid=lateral
neck lump differencital
abscess
lymphadenopathy
tumour
lipoma
goitre
salivary gland stones/infeection
carotid body tumour
haematoma
thyroglossal cyst
branchial cyst
children: cystic hygroma, dermoid cyst, haemangioma, venous malformation
2ww for neck lump
unexplained >45y
persistant lump at any age
for USS
carotid tumour
excessive growth glomus cells above carotid bifurcation
features carotid tumour
painless
pulsatile
bruit
may compress CN IX/X/XI/XII or sympathetic NS ->horners
ix carotid tumour
imaging=splaying-lyre sign
features thyroglossal cyst
move up and down with tongue
midline
mobile soft
branchial cyst formation
from 2nd branchial cleft
features branchial cyst
> 10y
round and soft between angle of jaw and sternocleidomastoif (ant triangle)
mx branchial cyst
none
surgery
head and neck cancer
usually SCC
where does head and neck cancer spread
lymph nodes
RF head and neck cancer
smoking
chewing tobacco/betel quid
alcohol
HPV
EBV
features head and neck cancer
lump
ulcer
hoarse voice
erythoplakia
mx head and neck cancer
surgery
chemo
radio
cetuximab
glositis
inflamed red tongue
causes glositis
iron/B12/folat defiency
coeliac
injury
causes angiodema
allergic rxn
ACE i
hereditary: CI esterase inhibitor deficiency
RF oral candidiasis
inhaled corticosteroids
abx
DM
HIV
smoking
mx oral candidiasis
miconazole gel
nystatin suspension
fluconazole tablet
geographic tongue
patches of epithelium and papillae lost
causes geographic tongue
none
stress
psoriasis
atopy
DM
features strawberry tongue
red
swollen
enlarged white palpillae
causes strawberry tongue
scarlet fever
kawasaki
black hairy tongue
reduced shedding of keratin leading to elongated papillae which bacteria and food cause dark pigmentayion
features black hairy tongue
dark pigmentation
sticky saliva
metallic taste
cause black hairy tongue
dehydration
poor hygiene
smoking
mx black hairy tongue
hydrate
hygiene
leukoplakia
raised white hairy patches in mouth
increased risk SCC
mx leukoplakia
biopsy and excision
erythroplakia
red lesions in mouth
erythroleukoplakia
red and white lesions in mouth
mx erythroplakia and erythroleukplakia
need to exclude SCC - biopsy
cause lichen planus
AI
inflammation
features reticular lichen planus
wickhams striae
erosive
plaques
mx lichen planus
hygiene
topical steroid
gingivitis
gum inflammation
features gingivitis
swelling
bleeding
halitosis
can lead to periodontitis ->teeth loss
RF gingivitis
poor hygiene
smoking
DM
malnutrition
stress
features acute necrotising ulcerative gingivitis
rapid onset
pain
causes acute necrotising ulcerative gingivitis
anaerobic bacteria
gingival hyperplasia
abnormal growth of gums
causes gingival hyperplasia
gingivitis
pregnancy
Vit C deficeincy
AML
meds: CCB, phenytoin, ciclosporin
aphthous ulcers features
small
painful
white
well punched out
cause aphthous ulcers
none
IBD
coeliac
behcets
iron/B12/folate/vit d deficiency
HIV
mx aphthous ulcers
none
topical: bonjela (choline salicylate), lidocaine, steroids
2ww if unexplained and been there for 3w
head and neck red flags
dysphagia, odynophagia, dysphonia, wt loss, spitting blood, unilateral nasal obstruction, neck mass
RF head and neck malignancy
SMOKING
alcohol, beta nut, HPV
when to urgently refer mouth ulcers (red flag0
ulcer present for over 3w
persistent lump on lip
persistent red white lesions consistent with cancer
when to urgently refer for dysphonia
persistent >/= 3w as potential SCC
mx dysphonia
voice rest
steam inhalation
hydration
lifestyle
PPI
unilateral tonsil enlargement
RED FLAG
adult=SCC
children=lymphoma (v rare)
where may unilateral otalgia be referred from?
throat
when to refer sore throat
routine ENT referral if persists for 6w and no improvement/new sx
globus pharyngeus
sensation of lump in throat
most common parotid masses
warthins: M>60y, bilateral, benign
pleomorphic adenoma: F, middle aged, removed as may turn malignant
sialadenitis
infection salivary gland
old, dehydrated
mx: hydrate +/- abx
shape of nodes in lymphoma
round
shape of nodes reactive lymphadenopathy
oval
neck lump clinic
hx
examination
USS
fine needle aspiration
unilateral nasal obstruction
child: foreign body
teenage boy: juvenile angiofibroma (unilateral nosebleed)
adult: sinusoidal malignancy (blood dicharge)
chinese and malaysian q stem stereotype
sinonasal malignancy due to ebv
(higher incidence in chinese)
nasal polyposis
associated with allergic rhinitis
painless, reduced smell and taste
tx with intranasal steroids -> ENT for oral steroids
predisposing factors to otitis externa
water
cotton buds
eczema
fungal otitis externa
usually after systemic abx tx
black hyphae
canestan drops and clean
malignant otitis externa
spread to bone
nerve palsys: VII first
need IV abx
when to refer otitis externa
no response to tx
canal oedematous
needs aural toilet
suspicion invasive OE
subperichondrial haematoma
trauma
needs aspiration or leads to cauliflower ear (fibrosis)
foreign body in ear/nose
only 1 attemt at removal before urgent referral
dont use forceps for round things
can syringle with warm water
nasal # mx
exclude other injuries
analegesia
routine referral (5-7d) if obvious deformity as need time for swelling to decrease, however hard to manipulate after 2-3 w(rhinoplasty needed)
urgernt referral if septal haematoma
acute sinusitis complications
extracranial: orbital celluliits, potts puffy tumour (frontal sinusitis bursts forward)
intracranail: meningitis, brain abscess, cavernous sinus thrombosis
preseptal celluliits progression
->orbital cellulitis->subperiosteal abscess->intraorbital abscess-> cavernous sinus thrombosis
cause parotitis
elderly
paramyxovirus
mx parotitis
metronidazole, fluclox, hydrate, pineapple
deep neck space infection
increasing incidence
mixed organisms
mx deep neck space infection
neck and chest CT
broad spectrum ab
surgical drainage
maintain away
