ENT Flashcards
what is the comments cause of mouth cancer?
What is a RF?
squamous cell carcinoma (90%)
-> MSM is a RF because there is a higher incidence of HPV
-> smoking
-> viral infections (HPV-16, EBV0
-> exposure to radiation
-> occupational history (asbestos, acid mists, wood dust)
-> FH of head and neck cancers
What is battle sign?
bruising around the mastoid process
indicates petrous temporal bone #
what is the halo sign on testing in ear discharge?
indicates that there is a CSF leak
the halo sign is seen when dropping the fluid onto filter paper
What type of hearing loss does Ménière’s disease cause?
sensorineural (not conductive)
-> fluctuating, low to mid-frequency SNHL
What is the commonest cause of progressive deafness in young adults?
otosclerosis
What is Ménière’s disease?
caused by impaired endolymph resorption that results in endolymph hydrops (accumulation of fluid in the endolymph sac)
peak incidence age of meniere’s disease
40-50
is Meniere’s more common in men or women?
women
how long do attacks in Meniere’s disease last?
20 minutes to 12h
Sx of Ménière’s disease incl. triad
Meniere’s triad:
- peripheral vertigo
- tinnitus
- asymmetric fluctuating SNHL
may also have:
- spontaneous horizontal or horizontal rotary nystagmus (direction of nystagmus is variable and can change)
- N&V
- ear fullness
get recurrent episodes of acute, unilateral sx lasting minutes to hours
investigation findings in Meniere’s disease
Weber lateralises to healthy ear
Rinne is positive bilaterally
low- to mid frequency SNHL in the affected ear on audiometry
Treatment of Ménière’s disease
- refer to ENT
Conservative:
- low sodium diet
- identification and avoidance of environmental and dietary triggers (e.g. caffeine, alcohol, nicotine, stress)
Medical:
- short term symptomatic therapy with vestibular suppressants (e.g. first gen antihistamines, benzodiazepines, antiemetics)
- diuretics (thiazides)
- betahistine
Interventional therapy
- chemical ablation wit intratympanic gentamicin (reduces attacks and improves vertigo sx)
NICE criteria for definite and probable dx of Ménière’s disease
A definite diagnosis requires all of the following criteria:
- Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours.
- Audiometrically documented low-to-medium frequency sensorineural hearing loss in one ear, defining and locating to the affected ear on at least one occasion before, during, or after an episode of vertigo.
- Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear.
- Not better accounted for by an alternative vestibular diagnosis.
A probable diagnosis requires all of the following criteria:
- Two or more episodes of vertigo or dizziness, each lasting 20 minutes to 24 hours.
- Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear.
- Not better accounted for by an alternative vestibular diagnosis.
what causes Ménière’s disease?
exactly aetiology of endolymph malabsorption is unknown but viral infections, autoimmunity and allergies are thought to play a role
what is the beta 2 transferrin test used for?
to diagnose CSF leakage
What is Cahart’s notch?
a fip at 2kHz on audiometry
typical for otosclerosis
What is the first-line management of otosclerosis?
hearing aid
What is the commonest microbe causing otitis externa?
Pseudomonas aeruginosa (gram - ve rod)
followed by staph aureus
also fungal
Pseudomonas aeruginosa - what type of bacteria is it?
gram -ve rod
What is the imaging modality of choice in a neck lump? why?
USS -> allows for US guided biopsy
What is Reinke’s oedema? What is the main cause? What condition can it be linked to?
vocal cord oedema
it is a progressive problem caused by thickening of the vocal cords
main cause is chromic inflammation and irritation from smoking
commonly liked with hypothyroidism
what are the symptoms of vestibular schwannoma?
unilateral SNHL
tinnitus
balance problems
what is hereditary haemorrhagic telangiectasia and what ENT presentation does it predispose to?
it is an AD disorder characterised by telangiectasua on the skin and mucous membranes
–> these malformations can occur within the nasal mucosa and are prone to bleeding (epistaxis)
Management of a pinna haematoma
incision with primary closure (decompress the haematoma within 24h of injury to avoid complications such as avascular necrosis)
What are the indications for an ENT referral within 24h
- sudden onset (over 3d or less) unilateral or bilateral hearing loss which occurred within the past 30d and cannot be explained by external or middle ear causes
- unilateral hearing loss associated with focal neurology (such as altered sensation or facial droop)
- hearing loss associated with head or neck injury
- hearing loss associated with severe infection such as necrotizing otitis externa or Ramsay Hunt syndrome
What are red flags in nasal polyps?
unilateral
bleeding
black hairy tongue
- benign condition characterized by elongation and discoloration of the filiform papillae on the dorsal surface of the tongue
- it can cause discomfort and tickling sensation
- generally asymptomatic and can be managed by good oral hygiene practices
RF for otitis externa
trauma
cotton buds
swimming
Immunosuppression
T2DM
mx of otitis externa
ear swab, abx/steriod ear drops, microsuction and pope wick, water precautions (don’t use oral abx because they don’t penetrate)
what are red flags in otitis externa and what condition do they indicate?
pain out of proportion, cranial nerve palsy, worsening despite treatment
-> malignant OE / necrotising OE -> osteomyelitis of adjacent bones (temporal bone, skull base) -> need 6/52 of IV abx, commoner in elderly/T2DM
What is cholesteatoma?
Accumulation of benign keratinizing Squamous cells involving the middle ear -> skin in the wrong place
Sx of cholesteatoma
unilateral recurrent/ persistent ear discharge (painless otorrhoea)
unilateral conductive hearing loss
what can you see on otoscopy in otitis media?
Bulging, red, inflamed on otoscopy; exudate may be seen.
commonest causes of otitis media
70% viral
30% bacterial
management of otitis media
supportive management
if no improvement abx (elf, 5d course of amoxicillin)
if the pt gets mastoiditis as a complication, they will require admission
at what age is ‘glue ear’ / acute OM with effusion most common?
bimodal distribution
peaks at 2yo and 5yo
what can ‘glue ear’ / acute OM with effusion in adults indicate?
nasopharyngeal tumour
‘glue ear’ / acute OM with effusion on otoscopy
looks bubbly
management of ‘glue ear’ / acute OM with effusion
50% resolves spontaneously in 3monthss
In children you would use hearing aids and if not enough -> grommet
(in children you don’t want to wait it out because it will delay their speech development)
what are the risks associated with grommet insertion?
tympanosclerosis, TM perf, recurrence
what are the indications for grommet insertion?
inserted into the TM of children with glue ear / acute OM with effusion
Causes of TM perf
trauma (e.g. ear buds), otitis media with effusion, grommet insertion
Management of TM perforation
- water precautions
- Usually heal on their own in 2 months
- if not resolved may need myringoplasty
Causes of facial nerve palsy
trauma, infection (OM, Ramsay-Hunt), Stroke (forehead sparing),neoplastic (e.g. protid tumour) Bells palsy (idiopathic)
What scale is used for facial nerve palsy?
House Brackman scale
management of Ramsay Hunt syndrome
steroids
plus antivirals to cover for varicella zoster
also refer to ophthal for eye drops and advice on how to keep eye closed at night.
management of facial nerve palsy
Address underlying cause
Eye care (-> refer to ophthal re drops and close eye at night)
Bells -> steroids
RH -> steroids plus antivirals for varicella zoster
Causes of conductive hearing loss
Ear canal: FB, OE, ear wax
TM: perf, tympanosclerosis
Middle ear: otosclerosis, effusion, otitis media, otitis media with effusion (glue ear), cholesteatoma
Causes of SNHL
- acoustic neuroma/vestibular schwannoma (rare), more gradual onset -> get MRI
- sudden sensorineural hearing loss (needs urgent treatment with high dose steroids - the earlier the treatment, the better)
- Presbyacusis (Bilateral sensorineural hearing loss (high pitch goes first)
- noise induced
- ototoxic meds (e.g, gentamicin)
- meniere’s disease
- Congenital
Steps of otoscopy and ear examination
- Inspection
- Palpate mastoid process
- Otoscopy
a. Pull pinna, put finger on the tragus
b. Otoscope handle should align with patient glasses (Point forwards)
c. Look down and more forward to see the light reflex - Crude hearing test
- Rinne (512Hz)
- Weber (512Hz)
Which test do you do first Weber or Rinne?
Rinne (R/L) first, then Weber (middle/forehead)
What are the 2 types of otalgia?
-> primary or secondary?
If no other sx, think of secondary causes, might not be an ear problem but referred pain
Do you need a scan in nasal fractures ?
no
usually you don’t because it won’t change your management
(unless you think there might be other bones broken or they meet the NICE criteria for CT head)
What in a nasal bone # would require immediate treatment?
Nasal septal heamatoma
Must deal with it right away (drain) -> there is a risk of septal ischaemia
management of nasal fractures
- Is there a new change in shape of the noes or a new obstruction
If yes, consider manipulation under anaesthetic, must be within 2 weeks (so before the bones start fusing) but not within the first week because of the swelling and difficulty visualising)?
usually no need for scan unless there is a separate indication e.g. head injury warranting CT under NICE guidelines or ?other broken bones
Septoplasty and septorhinoplasty indication
(if post injury, when would you do it?)
septal deviation / bony vault deviation
- Minimum 6-12 months post nasal injury (if not done within the first 2 w)
- Not urgent surgery
Septoplasty and septorhinoplasty types
External or endonasal approach
What is rhinitis and what are the sx?
- Nasal mucosa inflammation
Sx: nasal congestion, rhinorrhoea, sneezing, post nasal drip
Aetiology of rhinitis
allergic and non-allergic (pollution, tobacco, infection, vasculitis)
Ix in rhinitis
skin prick
Mx of rhinitis
nasal douching + xylometazoline (5 days only!!) + intranasal steroids + intranasal antihistamine spry
The steroids are low dose so no SE, but must take them for months, might only see results later
What is rhinosinusitis? + sx and aetiology?
- Nasal mucosa and paranasal sinus inflammation
- Sx: rhinitis, nasal obstruction, facial headache, reduced sense of smell, more than 12 w
- Allergic vs non allergic
Ix in rhinosinusitis
CT sinuses
Mx of rhinosinusitis
- nasal douching
- nose spray (e.g. 5days xylometazoline, steroids, antihistamines)
- abx
- FESS (surgical) -> functional endoscopic sinus surgery
Indication: chronic rhinosinusitis
To remove diseased tissue incl. polyps
what is FESS and what are the indications?
functional endoscopic sinus surgery
Indication: chronic rhinosinusitis
To remove diseased tissue incl. polyps
what are possible complications of rhinosinusitis?
- Cavernous sinus thrombosis
- Pre-septal cellulitis / orbital cellulitis (emergency because can easily compress the optic nerve)
What are the symptoms of cavernous sinus thrombosis?
Headache
Signs associated with intracranial hypertension
Bilateral papilledema
Vision impairment (diplopia, vision loss)
N&V
Seizures (focal or generalized)
Signs of cranial nerve dysfunction, including: Cavernous sinus syndrome
Steps of nose examination
- Inspection
- Feel over sinuses
- Non dominant hand for holding the instrument to open the nose
- Look at septum
- Look back at the nose to see if you can see the inferior turbinate and if there are any issues there
Sometimes flexible nasendoscopy is used
examples of midline neck lumps
- Goitre / thyroid pathology
- Thyroglossal cyst
- Dermoid cyst
examples of anterior triangle neck lumps
- Lymphadenopathy
- Sebaceous cyst
- Aneurysms
- Carotid body tumour / carotid pathology
- Submandibular glands
- Lipoma
examples of posterior triangle neck lumps
- Cystic hygroma
- Sebaceous cyst
- Lymphadenopathy
- Cervical rib
What are brachial cysts?
Congenital anomalies arising from 1st to 4th pharyngeal pouches
what structures make up the anterior and posterior triangles of the neck?
anterior: midline of neck, mandible, anterior border of sternocleidomastoid
posterior: posterior border of sternocleidomastoid muscle (anteriorly), anterior border of the trapezius muscle (posteriorly) , middle 1/3 of the clavicle (inferiorly)
what is a cystic hygroma?
- Rare
- Presents in children in the posterior triangle
- Transilluminates
May obstruct the airway so has to be operated on
name congenital neck lumps
thyroglossal cyst
brachial cleft cyst
cystic hygroma
https://next.amboss.com/us/article/aP0QWT?q=cystic%20hygroma#GlcByc0
What is Zenker’s diverticulum? Who dies it affect and what symptoms does it cause and what ix?
pharyngeal pouch
- Commoner in older men
- Halitosis, food regurgitation, dysphagia
- Ix: barium swallow
What is quinsy and how do you manage it?
- Peritonsillar abscess
- Between the tonsil and the pharyngeal wall
- Mx: hot potato voice
- Unilateral pain (this condition is unilateral)
- Trismus (all muscles in the area clench up and they cannot open their mouth)
Mx: IV BenPen & metronidazole, IVF, steroids, analgesia; requires aspiration or incision & drainage
indications and risks of tonsillectomy
- Indications: recurrent tonsillitis, malignancy, obstructive sleep apnoea in children
- (7+ in 1yr, 5+ for 2y, 3+ every year for 3 y)
Risks: bleeding, pain (particularly after 5d), infection, dental/lip/jaw injury
- (7+ in 1yr, 5+ for 2y, 3+ every year for 3 y)
what is Sialadenitis and what causes it?
- Inflammation of the salivary glands
RF: poor dental hygiene, dehydration○ Viral (mumps, coxsackie, parainfluenza) ○ Stones ○ Bacterial ○ Chronic scarring ○ Benign/malignant tumours ○ Granulomatous conditions
Ix in sialadenitis?
USS ?abscess or recurrent presentation
mx of sialadenitis
oral abx, sialgogues (citrus), analgesia
Rf for head and neck cancers
- Smoking
- Alcohol
- Betel nut
- Chronic dental infection
- Immunosuppression
- Sun exposure (lips)
- HPV - oropharyngeal
- EBV - nasopharyngeal
reasons for tracheostomy
ITU
Gradual Weaning on ITU
Long term: brain injury, trauma
Airway obstruction or when one is anticipated
reasons for laryngectomy
Advanced laryngeal malignancy
Post-traumatic laryngeal stenosis
what are the main differences between tracheostomy and laryngectomy
Laryngectomy: mainly because of laryngeal cancer -> new anatomy made. There is a separate tube to the oesophagus and the lung; this patient can never be intubated vi the mouth or receive oxygen via the mouth.
Difference can be seen because hole in laryngectomy is bigger; angle is different. Tubes are different;
In emergencies, you would give air over mouth and tube in laryngectomy
What medicolegal things do you have to tell patients with anosmia?
they need to have a working gas and smoke detector
they might not be able to smell a gas leak or smoke
Duration of vestibular neuritis
acute phase of vertigo usually lasts a few days and sx typically resolve in 2-3 weeks with treatment
What is the management of vestibular neuritis
- treat sx (e.g. antiemetics, vestibular suppressants
- reassure that sx should improve in weeks
- do not drive with vertigo
- if they cannot keep any food down, refer to hospital
What is the key difference in presentation of labyrinthitis and vestibular neuritis?
Unlike the differential diagnosis of labyrinthitis, vestibular neuronitis is not associated with hearing loss or tinnitus.
both can follow a viral infection (URTI mainly)
Mx of labyrinthitis
usually self-limiting
can give antihistamine or prochlorperazine for sx relief (dizziness)
