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ENT Flashcards

1
Q

Otitis externa presentation

A

Watery discharge
Itch
Pain and tragal tenderness
otoscopy: red, swollen or eczematous canal

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2
Q

Causes of otitis externa

A

Moisture, eg swimming
Trauma, eg fingernails
absence of wax
hearing aid
organisms: mostly pseudomonas, or some staph aureus

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3
Q

Mx otitis externa

A

Clean external auditory canal
Drops: topical antibiotic or combined topical antibiotic with steroid
If tympanic membrane is perforated then traditionally don’t use aminoglycosides
2nd line options: oral fluclox if infection spreading, swab ear canal, empirical antifungal
fail to respond to topical? refer to ENT

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4
Q

Malignant otitis externa

A

extension of infection into bony ear canal and soft tissues deepp to bony canal. May require IV abx.
90% of pts are diabetic
copious otorrhoea and granulation tissue in the canal

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5
Q

Organisms causing otitis media

A

Viral
Pneumococcus
Haemophilus
Moraxella

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6
Q

Presentation acute otitis media

A

Usually children post viral URTI
Rapid onset ear pain, tugging at ear
Irritability, anorexia, vomiting
Purulent discharge (otorrhoea) if drum perforates
O/E bulging red tympanic membrane, fever

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7
Q

Mx acute otitis media

A

Generally self limiting and doesn’t require abx. analgesia to relieve otalgia. Parents seek help if worsened or not improved after 3 days
abx immediately if:
symp >4 days
Systemically unwell (buut not needing admission)
Immunocompromise or high risk of complications as other disease
Under 2 years and bilateral OM
OM with perforation and/or discharge in canal
Antibiotic choice: 5-7d amoxicillin 1st line. if allergic, erythromycin or clarithro

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8
Q

Complications of acute OM

A

Mastoiditis
Meningitis
Brain abscess
Facial nerve paralysis

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9
Q

Glue ear (Otitis media with effusion) risk factors

A

male sex
siblings with glue ear
higher incidence winter and spring
bottle feeding
day care attendance
parental smoking

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10
Q

Features of glue ear

A

Peak at 2 yrs
Hearing loss usually presenting feature
-> inattention at school, poor speech development
O/E: retracted dull TM, poss fluid level
audiometry: flat tympanogramM

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11
Q

Mx glue ear

A

Usually resolves spontaneously
Consider grommets if persistent hearing loss (they normally work for approx 10 months and then fall out)
Adenoidectomy

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12
Q

Chronic suppurative OM

A

Painless discharge and hearing loss after TM perforates
Need aural cleansing
Antibiotics + steroid ear drops
Complic: cholesteatoma

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13
Q

Cholesteatoma what is

A

Locally destructive expansion of stratified squamous epithelium within the middle ear
Either congenital, 2ndary to attic perforaiton in chronic suppurative otitis media

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14
Q

Presentation of cholesteatoma

A

Foul smelling, white discharge
Headache, pain
CN involvement -» vertigo, deafness, facial paralysis
O/E: pearly white w surroundign inflammation

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15
Q

Complications of cholesteatoma

A

Deafness (ossicle destruction)
meningitis
cerebral abscess

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16
Q

Management of cholesteatoma

A

Surgery

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17
Q

History and examination w tinnitus

A

Character: cosntant, pulsatile
Unilateral: acoustic neuromal
FH: otosclerosis
Allerviating/exac ffactors
Associations:
- vertigo and deafness –> Meniere’s, acoustic neuroma
cause: head injury, noise, drugs, FH
Otoscopy
Weber and Rinne’s
Pulse and BP
Audiometry and tympanogram

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18
Q

Ototoxic drugs

A

Gentamicin
Loop diuretics
Metronidazole
Cotrimoxazole

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19
Q

Peripheral/vestibular causes of vertigo

A

Meniere’s
BPPV
Labyrinthitis

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20
Q

Central causes of vertigo

A

Acoustic neuroma
MS
Vertebrobasilar insufficiency/stroke
Head injury
Inner ear syphilis

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21
Q

Meniere’s disease what is

A

Dilation of endolymph spaces of membranous labyrinth
Unknown cause

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22
Q

Featuers of Meniere;s disease

A

Attacks occur in clusters and last up to 12h
Progressive sensori-neural hearing loss
Vertigo and N&V
tinnitus
Nystagmus and positive Romberg test
Aural fullness
Middle aged adults, M=F
Audiometry: fluctuating low freq SNHL

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23
Q

Management of Meniere’s disease

A

Conserve: symptoms resolve in majority after 5-10 yrs, but leaving degree of hearing loss, psych distress
Inform DVLA and no driving until symptom control
Acute attacks: buccal or IM procholrperazine
prevent: betahistine and vestibular rehab exercises
Surg: gentamicin instillation via grommets, saccus decompression?

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24
Q

Vestibular neuronitis/viral labyrinthitis presentation

A

Following febrile illness eg URTI
Severe vertigo exacerbated by head movement
Sudden vomiting
Attacks last hours to days
No hearing loss or tinnkitus if neuronitus but YES if labyrinthitis

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25
Mx vestibular neuronitis/viral labyrinthitis
Cyclizine Improves in days
26
BPPV cause and path
Displacement of otoliths in semicircular canals, common after head injury Or idiopathic Otosclerosis Post-viral
27
presentation BPPV
Sudden rotational vetigo for <30 seconds provoked by head turning (eg rolling over in bed) Nystagmus
28
management BPPV
Dix-hallpike manouevre -> upbeat torsional nystagmus is diagnostic Epley manoeuvre and teach to self-Epley Betahistine but tends to be of limited value Spontaneously resolvse after a few weeks-months But 50% recur 3-5 years later
29
Differentials for conductive hearing loss
External canal obstruction: wax, pus, foreign body TM perforation: trauma, infection Ossicle defects: otosclerosis, infection, trauma
30
Differentials for sensorineural hearing loss
Drugs: aminoglycosides, vancomycin Post-infective: meningitis, measles, mumps, herpes Misc; Meniere's, trauma. MS, cerebellopontine angle lesion (eg acoustic neuroma), reduced B12
31
Acoustic neuroma
Path: benign slow growing tumour of superior vestibular nerve, acts as space occupting lesion. Associated with neurofibromatosis 2 Present; slow onset, unilateral sensorineural hearing loss, tinnitus +/- vertigo Headache (incr ICP) CN palsies: 5,7,8 Cerebellar signs IX: MRI cerebellopontine angle Differential: meningioma, cerebellar astrocytoma, mets Mx: gamma knife, surgery
32
Otosclerosis
Autosomal dominant condition, fixation of stapes at oval window, F>M, 2:1 begins early adult life, bilatereal conductive deafness and tinnitus Hearing loss IMPROVED in noisy places Worsened by pregnancy, menstruation, menopaus PTA shows dip at 2kHz Mx: hearing aid/stapes implant
33
Presbyacusis
Age related hearing loss >65s, bilateral, slow onset +/- tinnitus PTA Mx: hearing aid
34
Nasal polyps who where what
Male >40yrs, middle turbinates, middle meatus, ethmoid Sympt watery, anterior rhinorrhoea purulent post-nasa drip Nasal obstruction sinusitis headaches Snoring SIgns: mobile pale, insensitive
35
single unilateral nasal polyp
Is a sinister sign eg of Nasopharyngeal cancer Glioma Lymphoma Neuroblastoma Sarcoma -> do CT and get histology
36
Management nasal polyps
Betamethasone drops for 2 days, short coue oral steroids Endoscopic polypectomy, but apparently limited use
37
Fractured nose where ad history
Upper 3rd of nose = bony support, lower 2/3 and septum are cartilaginous Find out - time of injury - LOC - CSF rhinorrhoea - epistaxis - prev nose injury - obstruction - consider facial fracture
38
Management fractured nose
Very little use doing radiographs as cartilaginous injury won't show, and won;t change Mx Exclude septal haematoma Re-examine after 1 week check swelling reducing Reduction under GA with post op splinting best within 2 weeks
39
Septal haematoma
Septal necrosis + nasal collapse if untreated - as cartilage blood supply comes from mucosa Boggy swelling and nasal obstruction Needs evacuation under GA w packing +/- suturing
40
Causes of epistaxis
80% unknown Trauma eg nose picking, fractures Local infection Pyogenic granulosa (overgrowth of tissue Little's area due to irritation or hormonal factors Coagulopathy: warfarin, NSAIDs, haemophilia, reduced platelets, vWD, incr alcohol Neoplasm
41
Initial management epistaxis
Wear PPE Assess for shock and manage accordingly If not shocked, sit up, head tilt down, compress nasal cartliage for 15 mins If bleeding not controlled, remove clots by suction/blowing and try to visualise bleed w rhinoscopy
42
Anterior epistaxis
Usually septal haemorrhage: Little's area = anterior ethmoidal artery, sphenopalatine A, facial A 1. insert gauze soaked in vasoconstrictor and local anaesthetic (xylometazoline +2% lidocaine) for 5 mins 2. cauterise w silver nitrate sticks 3. pack with Mericel pack Refer to ENT if this fails or you can't visualise bleeding point, they may insert posterior pack or take to theatre
43
44
Posterior/major epistaxis management
Posterior pack (+anterior pack) -> pass 18/18G Foley atheter through nose into nasopharynx, inflate w 10ml water and pull forward until it lodges -> admit patient and leave pack for ~48h GOld standard: endoscopic visualisation and direct control, eg by cautery or ligation
45
Management post-epistaxis
Don't pick nose sit upright, out of the sun Avid bending, lifting or straining Sneeze through mouth No hot food or drink Avoid alcohol and tobacco`
46
Causes of tonsillitis
Viruses are most common (consider EBV) Group A strep (pyogenes) Staphs Moraxella
47
Centor criteria
1 point for each of: history of fever tonsillar exudates tender anterior cervical lymphadenopathy no cough 0-1: no abx 2: consider rapid Ag test and mx if +ve 3+: abx (pen V 250mg PO QDS for 5-7days, or erythyromyvin if pen allergic)
48
Tonsillectomy indications
7 episodes in one year 5+ episoder per 2 year episodes are disabling and prevent normal functioning also if recent febrile convulsions secondary to episodes of tonsillitis OSA, stridor or dysphagia 2ndary to enlarged tonsils Quinsy if unresponsive to standard treatment
49
Complications of tonsillectomy
primary: haemorrhage in 2-3% (RETURN TO THEATRE), pain Secondary: harmorrhage (commonly due to infection), pain Tonsillar gag may damage teeth, TMJ or posterior pharyngeal wall
50
Quinsy (peritonsillar abscess)
complication of bacterial tonsilitis Severe throat pain, lateralising to one side deviation of uvula to the UNAFFECTED side trismus (difficulty opening the mouth) reduced neck mobilitiy -> urgent ENT review Mx: needle aspiration or incision+ drainage, + IV abx tonsillectomy consideration to prevent recurrence
51
Retropharyngeal abscess
Rare complication of tonsillitis Unwell child w stiff, extended neck who refuses to eat/drink, fails to improve w IV abx unilateral swelling of tonsil and neck Lat neck XR show soft tissue swelling CT from skull base to diaphtagm Need IV abx and I&D
52
Scarlet fever
strep throat complication Sandpaper like rash on chest, axillae or behind ears 12-48h after pharyngotonsillitis circumoral pallor strawberry tongue start Pen V/G and notify HPA
53
Rheumatic fever
Strep throat complication Carditis Arthritis subcutaneous nodules Erythema marginatum Sydenham's chorea
54
Post-streptococcal glomerulonephritis
Malaise and smoky urine 1-2 weeks after a pharyngitis
55
Functions of the larynx
Phonation Positive thoracic pressure, incl auto PEEP Respiration Prevention of aspiration
56
Recurrent laryngeal nerve palsy sympt
Supplies all intrinsic laryngeal muscles except for cricothyroideus = responsible for ab and adduction of the vocal folds Sympt: hoarseness "breathy" voice w bovine cough repeated coughing from aspiration exertional dyspnoea (narrow glottis)
57
Causes of recurrent laryngeal nerve palsy
30% are cancers: larynx, thyroid, oesophagus, hypopharynx, bronchus 25% are iatrogenic: para/thyroidectomy, carotid endarterectomy Other: aortic aneurysm, bulbar/pseudobulbar palsy
58
Laryngomalacia
Immature and floppy aryepiglottic fikds and glottis -> laryngeal collapse on inspiration Present: stridor (most common cause in first weeks of life) Partic noticeable when lying on back, feeding, excited/upset Problems can occu w concurrent laryngeal infections or w feeding Usually no manamgent required, but severe cases may need surgery
59
Bell's palsy cause
Inflammatory oedema from entrapment of CN7 in narrow facial canal Probably of viral origin (HSV1) 75% of facial palsy
60
Features of bell's palsy
Sudden onset, eg overnight Complete, unilateral facial weakness in 24-72h -> failure of eye closure -> dryness and conjunctivitis -> drooling, speech difficulty Numbness or pain around ear Reduced taste Hyperacusis (stapedius palsy)
61
Ix for Bell's Palsy
Serology: Borrelia or VZV abs MRI: SOL, stroke or MS LP
62
Mx Bell's palsy
Protect eye: dark glasses, artificial tears, tape closed at night Give pred within 72h, 60mg PO for 5 days then taper Valaciclovir if zoster suspected Plastics if no recovery Incomplete paralysis normally recovvers within weeks If complete, 80% have full recovery, but remainder delayed or permanent abnormalities
63
Ramsay Hunt syndrome
Reactivation of VZV in geniculate ganglion of CN7 Preceding ear pain/stiff neck -> vesicular rash in auditory canal +/- tympanic membrane, pinna, tongue, hard palate Ipsilateral facial weakness, ageusia, hyperacusis. May have CN8 involvement -> vertigo, tinnitus, deafness Give valaciclovir and pred within 72h -> 75% recovery
64
Allergic rhinosinusitis pathol
Seasonal hayfever = 2% prevalence, or perennial T1 cells IGE mediated inflammation from allergen exposure. Allergens: pollen, house dust mites (perennial)
65
Sympt and sngs of allergic rhinosinusitis
Sneezing, pruritus, rhinorrhoea Swollen, pale and boggy turbinates Nasal polyps
66
Ix for allergic rhinosinusitis
Skin prick testing to find allergens (but don't if prone to eczema) RAST tests
67
Manaement of allergic rhinosinusitis
Allergen avoidance. Regular washing on high heat, stay indoors when pollen count high 1st: anti histamines, or beclometasone nasal spray 2nd: inrtanasal steroids + antihistamines 3rd: zafirlukast 4th: immunotherapy aim to induce desensitisation to allergen
68
Sinusitis pathol and caus
Viruses -> muvosal oedema and reduce ciliary actions -> mucus retention and 2ndary bacterial infection Acute: pneumococcus, haemophilus, moraxella Chronic: staph, anaerobes 5% are 2ndary to dental root infections Diving/swimming in infected water Anatomical susceptibility, PCD and immunodefic incr risk
69
Symptoms of sinusitis
Pain: maxillary (cheek/teeth) or ethmoidal (between eyes), incr on bending/straining discharge: from nose -> post nasal drip w foul taste Nasal obstruction/congestion Anosmia or cacosmia (bad smell) Fever
70
Mx sinusitis
Acute/single episode - bed rest, decongestants, analgesia - nasal douching and topical steroids - abx eg clarithro uncertain benefit Chronic/recurrent - usually structural/drainage problem - stop smoking +fluticasone nasal spray - if failed medical therapy= functional endoscopic sinus surgery

Year 6 (9 decks)

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