ENT Flashcards
What feverPAIN score would normally indicate immediate abx prescription? What is the first line choice of abx?
- 4/5
- Phenoxymethylpenicillin
Give 2 complications of otitis media
- Acute mastoiditis
- Intracranial abscess
- Otitis media with effusion
- Perforated ear drum
What is classed as the middle ear?
Space between the tympanic membrane and inner ear
What is located in the inner ear?
Cochlea, vestibular apparatus and nerves
What is a bacterial infection of the middle ear usually preceded by?
VIRAL upper respiratory tract infection
What’s the most common cause of otitis media?
Strep pneumoniae
How should the tympanic membrane normally look? How does it look in otitis media?
- ‘Pearly-grey’, translucent, slightly shiny
- Bulging, red, inflamed
When should you consider immediate antibiotic prescription for otitis media?
- Significant co-morbidities
- Systemically unwell
- Immunocompromised
What is the antibiotic of choice in otitis media?
Amoxicillin for 5 days
What is another name for tongue tie?
Ankyloglossia
What is the reason for tongue tie? What is the management?
- A short and tight lingual frenulum
- Frenotomy
What is glue ear also known as?
Otitis media with effusion
What does otoscope normally show in glue ear?
A dull tympanic membrane with air bubbles or a visible fluid level
When does glue ear normally resolve without treatment?
Within 3 months
What feature would be present in acute suppurative otitis media?
Mucopurulent discharge
When would you refer a child with otitis media to ENT?
If >6 episodes in 12 months/persistent otitis media with effusion for >3 months bilaterally or >6 months unilaterally
What is the treatment of BPPV?
Epley maneuver
What is the diagnostic test for BPPV?
Dix-Hallpike test
Do you get hearing loss and tinnitus in BPPV?
No!
What is BPPV?
- Benign paroxysmal positional vertigo
- Vertigo triggered by head movement
How long does it take for vertigo to settle in BPPV?
20-60 seconds
What causes BPPV? What are possible triggers of the condition?
- Displacement of crystals in the semicircular canals. This disrupts the normal flow of endolymph through the canals
- Viral infection, head trauma, ageing, unknown trigger
What traid is typical of Ménière’s disease?
- Hearing loss
- Tinnitus
- Vertigo
What is Ménière’s disease?
A long-term inner ear disorder that causes recurrent attacks of vertigo
What is the typical age of presentation in Ménière’s disease?
40-50 years
What is the pathophysiology of Ménière’s disease?
Buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals
How long does vertigo last in Ménière’s disease?
> 20 mins
What is the medical management of Ménière’s disease attacks?
- Prochlorperazine
- Antihistamines (cyclizine)
What medication is used for prophylaxis of Ménière’s disease attacks?
Betahistine
What are acoustic neuromas?
Benign tumours of the Schwann cells surrounding the vestibulocochlear nerve
What are bilateral acoustic neuromas associated with?
Neurofibromatosis II
How can acoustic neuroma present?
- Unilateral sensorineural hearing loss
- Unilateral tinnitus
- Dizziness or imbalance
- A sensation of fullness in the ear
Facial nerve palsy if it grows large enough to compress the facial nerve
What’s the name for age related hearing loss?
Presbycusis
What is the investigation of choice for hearing loss? What pattern of hearing loss does presbycusis give?
- Audiometry
- Sensorineural hearing loss
- Worse hearing at higher frequencies
What are the 3 options for prescribing antibiotics for otitis media?
- Immediate prescription
- Delayed prescription
- No antibiotics
Explain delayed prescribing for otitis media
Prescription that can be collected and used after three days if symptoms have not improved or have worsened at any time
What are the two most common causes of bacterial otitis external?
- Pseudomonas aeruginosa
- Staphylococcus aureus
What is the management of mild otitis externa?
Acetic acid 2% (available over the counter as EarCalm)
What is the management of moderate otitis externa?
Neomycin, dexamethasone and acetic acid (Otomize spray)
What is the management of severe otitis externa?
Oral antibiotics (flucloxacillin or clarithromycin)
What do you need to exclude before prescribing topical aminoglycosides for otitis external? Why?
- Perforated tympanic membrane
- Gentamicin and neomycin are potentially ototoxic if they get behind the ear drum
What is malignant otitis externa?
- A severe and potentially life-threatening form of otitis externa
- The infection spreads to the bones surrounding the ear canal and skull
- It progresses to osteomyelitis of the temporal bone of the skull
What is primary tinnitus? How can you explain it to patients?
- Has no identifiable cause, is often associated with sensorineural hearing loss
- It’s the ears ‘turning the volume uo’ when they can’t hear surrounding sounds as well
What is secondary tinnitus? What medications are a cause?
- Tinnitus with an identifiable cause
- Loop diuretics, gentamicin and chemotherapy drugs such as cisplatin
What is objective tinnitus? Give 4 causes
- When the patient can objectively hear an extra sound within their head. This sound can also be observable on examination by auscultating around the ear
- Carotid artery stenosis (pulsatile carotid bruit)
- Aortic stenosis (radiating pulsatile murmur sounds)
- Arteriovenous malformations (pulsatile)
- Eustachian tube dysfunction (popping or clicking noises)
What measures are used to help improve the symptoms of tinnitus?
- Hearing aids
- Sound therapy (adding background noise to mask the tinnitus)
- CBT
What happens in eustachian tube dysfunction?
- The eustachian doesn’t function properly or become blocked
- The air pressure between the middle ear and the environment becomes unequal
- The middle ear fills with fluid
What are risk factors for eustachian tube dysfunction?
- Recent viral upper respiratory tract infection
- Allergies (hayfever)
- Smoking
How does Eustachian tube dysfunction present?
- Reduced/altered hearing
- Popping noises or sensations in the ear
- A fullness sensation in the ear
- Pain or discomfort
- Tinnitus
Give 3 simple management options and 2 surgical options for Eustachian tube dysfunction?
- No treatment
- Valsalva manoeuvre
- Decongestant spray
- Grommets (allow fluid to drain out middle ear)
- Balloon dilatation Eustachian tuboplasty (surgically inserting and inflating ballon in Eustachian tube to open the eustachian tube)
Give a surgical sieve for neck lumps
VITAMIN C
- Vascular - carotid body tumour
- Infective/inflammatory - skin abscess, salivary gland stones/infection, reactive/infective/inflammatory lymphadenopathy
- Trauma - haematoma after trauma
- Autoimmune - goitre, thyroid nodules
- Metabolic
- Iatrogenic
- Neoplastic - tumour, lipoma, malignant lymphadenopathy
- Congenital - thyroglossal cyst, branchial cyst
When do neck lumps warrant 2ww referral?
- Unexplained neck lump in someone <45 yrs
- Persistent unexplained neck lump at any age
When should you organise an urgent USS of a neck lump within 48 hours?
- Patient under 25
- Neck lump that is growing in size
What is the first line investigation for neck lumps?
USS
How can the causes of lymphadenopathy by grouped? Give examples
- Reactive - swelling caused by URTI, tonsilitis
- Infected - TB, HIV, infectious mononucleosis
- Inflammatory - SLE, sarcoidosis
- Malignancy - lymphoma, leukaemia, mets
Infectious mononucleosis:
1. Cause?
2. Presentation?
3. First line Ix?
4. Management?
5. Pt advice?
- EBV
- Sore throat, lymphadenopathy, fever, fatigue
- Monospot test
- Supportive
- No contact sports (splenic rupture) or alcohol (liver impairment) for 6-8 weeks
What can cause salivary gland enlargement?
- Stones
- Infection
- Tumours
Carotid body tumours:
1. What is the carotid body?
2. What does it contain?
3. What is a carotid body tumour?
4. Benign/malignant?
5. How do they present?
6. Characteristic finding on imaging?
7. Management?
- Structure located above the carotid bifurcation
- Glomus cells which are chemoreceptors (detect bloods O2, CO2, pH)
- Tumour formed by excessive growth of glomus cells
- Most are benign
- Slow growing lump in upper anterior triangle, painless, pulsatile, bruit on auscultation
- Splaying of internal and external carotid arteries (Lyre sign)
- Surgical removal
What are lipomas?
Benign tumours of adipose (fat) tissue
A patient presents with a midline lump. It is mobile, non-tender and moves upwards when they stick they tongue out. What is this? What does it result from?
Thyroglossal cyst
- During fetal development the thyroid develops at the back of the tongue
- This move down the neck to position infant of the trachea and beneath the larynx
- It leaves a track called the thyroglossal duct which disappears
- When part of the thyroglossal duct persist a fluid filled cyst can arise
What is a complication of thyroglossal cyst? How would this present?
- Infection of the cyst
- Hot, tender lump
What is a branchial cyst? When do they present? Where are they located?
- Congenital abnormality that occurs when the second brachial cleft fails to form properly
- Present after the age of 10
- Just anterior to the sternocleidomastoid muscle in the anterior triangle of the neck
What is the most common malignancy of the head and neck?
Squamous cell carcinomas
Risk factors for head and neck cancer?
- Smoking
- Chewing tobacco
- Alcohol
- HPV (particularly strain 16)
- EBV infection
What are red flags for head and neck cancer?
- Lump in the mouth
- Lump on the lip
- Persistent neck lump
- Erythroplakia or erythroleukoplakia
- Unexplained hoarseness of voice
What are potential locations for head and neck cancer?
- Nasal cavity
- Paranasal sinuses
- Mouth
- Salivary glands
- Pharynx
- Larynx
Are nasal polyps normally unilateral or bilateral?
Bilateral
- Unilateral polyps are a red flag for tumours
How can nasal polyps present?
- Snoring
- Anosmia
- Chronic rhinitis or sinusitis
- Difficultly breathing through the nose
What is the management of nasal polyps?
- Medical - intranasal steroid drops
- Surgery - Intranasal polypectomy or endoscopic polypectomy
What are the 4 sets of paranasal sinuses?
- Frontal
- Ethmoidal
- Maxillary
- Sphenoid
What is rhinosinusitis?
Inflammation of the nasal cavity
What can cause sinusitis?
- Infection - viral URTI
- Allergies - hay fever
- Obstruction of drainage - due to a foreign body, trauma or polyps
- Smoking
What is the management of acute sinusitis?
- Supportive if <10 days
- > 10 days:
1. Steroid nasal spray for 2 weeks
2. Delayed abx prescription if not improving in 7 days (Pen V)
What is the management of chronic sinusitis?
- Saline nasal irrigation
- Steroid nasal sprays or drops
- Functional endoscopic sinus surgery (FESS)
What is obstructive sleep apnoea?
Collapse of the pharyngeal airway causing episodes of apnea during sleep
How may a patient with obstructive sleep apnea present?
- Complain of snoring
- Morning headache
- Waking unrefreshed
- Daytime sleeping
- Poor concentration
What is a serious complication of sleep apnea?
HTN -> MI/stroke
What is the management of obstructive sleep apnea?
- Refer to ENT
- Lifestyle changes - decrease wt, stop smoking, reduce alcohol
- CPAP
- Surgery for severe cases - involves significant surgical reconstruction of the soft palate and jaw
What’s the most common location of bleeding in nosebleed?
Little’s area
When may patients with nosebleed require hospital admission?
- Bleeding for over 10/15 mins
- Bleeding from both nostrils
- Haemodynamically unstable
- Severe bleeding
What are treatment options for severe nosebleed?
- Nasal packing with nasal tampons/inflatable packs
- Nasal cautery with silver nitrate
What can be prescribed following a significant nosebleed?
Naseptin cream four times daily for 10 days to reduce any crusting, inflammation and infection
What can be prescribed following a significant nosebleed?
Naseptin cream four times daily for 10 days to reduce any crusting, inflammation and infection
