ENT Flashcards
Four main features of vestibular neuronitis
- Vertigo
- Nausea + vomiting
- Horizontal nystagmus
- NO hearing loss or tinnitus
What examination can be used to distinguish vestibular neuronitis from posterior circulation stroke
HiNTs exam
Management of vestibular neuronitis (vertigo, N+V, nystagmus, NO hearing loss or tinnitus)
- Buccal or IM prochlorperazine
- Oral prochlorperazine or antihistamine for less severe cases for 1 week only then review
- Chronic symptoms for 6 weeks or more - vestibular rehabilitation exercises
Criteria for cochlear implant
- Children - issues developing basic auditory skills
- Adults - trialled hearing aids for at least 3 months with no improvement
Differences between allergic rhinitis:
(a) seasonal
(b) perennial
(c) occupational
(a) seasonal - same time each year
(b) perennial - throughout the year
(c) occupational - work place allergens
Management of allergic rhinitis
- Oral or intranasal anti-histamines if mild to moderate symptoms
- Intranasal corticosteroids if moderate to severe symptoms
- Short course of corticosteroids to cover important life events
Note short courses of topical nasal decongestants can lead to rebound symptoms if used for long time
3 red flags for sinusitis
- unilateral symptoms
- persistent symptoms despite compliance with 3 months of treatment
- epistaxis
More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
what neck lump is this
thyroglossal cyst
A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age
what neck lump is this
cystic hygroma
An oval, mobile cystic mass that develops between SCM muscle and pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
Can present after URTI
what neck lump is this
brachial cyst
Patients with this neck lump - 10% of them develop thoracic outlet syndrome. What is the lump/mass?
Cervical rib
Management of otitis externa
- Topical antibiotic or combined with steroid
- If tympanic membrane is perforated then avoid aminoglycoside
- If canal is swollen then ear wick is sometimes inserted
- If infection spreading then use oral flucloxacillin +/- antifungal
If a patient fails to respond to topical antibiotics in otitis externa what is the management
Oral antibiotics (flucloxacillin)
Refer to ENT
What are recommended as indications for consideration of adenotonsillectomy
- Sore throats due to tonsillitis
- episodes are disabling and prevent normal functioning
- 7 or more sore throats in last year; or
- 5 or more in each of last two years; or
- 3 or more in each of last three years
3 complications of tonsillitis
- otitis media
- quinsy - abscess
- rheumatic fever + glomerulonephritis
complications of tonsillectomy:
(a) primary <24 hours
(b) secondary >24 hours to 10 days
haemorrhage and pain for both
Diagnostic manoeuvre for BPPV
Dix-Hallpike manoeuvre
BPPV management
- Epley manoeuvre (80% success)
- Vestibular rehabilitation i.e. Brandt-Daroff exercises at home
Glue ear describes what
Otitis media with effusion
Glue ear - otitis media with effusion can lead to hearing loss. What is the treatment
- Monitor for 6-12 weeks as spontaneous resolution is common
- If hearing loss persists on 2 separate occasions (e.g. 1 week + 12 weeks) then refer to ENT for hearing tests
- Grommet insertion
- Adenoidectomy
What type of cancer is nasopharyngeal cancer
Squamous cell carcinoma
What virus is nasopharyngeal carcinoma associated with
EBV
Meinere’s disease features
Vertigo
Tinnitus
Hearing loss
Sensation of aural fullness
Treatment for Meniere’s disease
ACUTE ATTACKS
buccal or IM prochlorperazine
(prevention = betahistine + vestibular rehab exercises)
Prophylaxis treatment of Meniere’s disease
Betahistine
Vestibular rehab exercises
Acute Rx = buccal or IM propchlorperazine
All post-tonsillectomy haemorrhages should be managed through…
immediate ENT referral
Nasal septal haematoma shows bilateral red swelling from nasal septum. These feel boggy
What treatment is needed?
Surgical drainage
IV antibiotics
If left untreated, septal necrosis may develop
Recurrent epistaxis without red flags can be treated with
Naseptin cream
Silver nitrate cautery can be attempted in primary care for nosebleeds if what is identified
A clear bleeding point!
Naseptin nosebleed cream is contraindicated in what 3 allergies
peanut
soy
neomycin
Mupirocin is an alternative
If bleeding in nosebleed does not stop after 10-15 minutes of continuous pressure on the nose consider what 2 options
- cautery - if the source of bleeding is visible
- packing - admit to hospital with ENT review
Globus (sensation of lump in throat), hoarseness and no red flags
What is the diagnosis
laryngopharyngeal reflux
Management of laryngopharyngeal reflux
Lifestyle measures - triggers include fatty foods, caffeine, chocolate and alcohol
PPIs
Sodium alginate liquids (e.g. Gaviscon)
What is the cause for the majority of sudden-onset sensorineural hearing loss?
Idiopathic
Sudden onset unilateral sensorineural hearing loss - management
urgent referral to ENT
Sudden onset unilateral sensorineural hearing loss treatment
High dose corticosteroidsM
Why do MRIs tend to be done for patients with sudden onset unilateral sensorineural hearing loss?
To rule out vestibular schwanonoma
Management of otitis media
Antibiotics are given if:
- symptoms >4 days
- systemically unwell
- immunocompromised
- younger than 2 years with bilateral otitis media
- otitis media with perforation and/or discharge in canal
what is the antibiotic of choice for otitis media
amoxicillin 5-7 day course
complications of otitis media
- perforation of tympanic membrane with otorrhoea
- chronic suppurative otitis media
- hearing loss
- labyrinthitis
- mastoiditis
(brain abscess, meningitis, paralysis)
what is the definition of chronic suppurative otitis media
otitis media with perforation of tympanic membrane with otorrhoea for >2-6 weeks
Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected
what is the diagnosis
viral labyrinthitis
Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss
what is the diagnosis
vestibular neuronitis
Associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears
what is the diagnosis
Meniere’s disease
Elderly patient
Dizziness on extension of neck
what is the diagnosis
vertebrobasilar ischaemia
Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2
what is the diagnosis
acoustic neuroma
How to confirm diagnosis of Meniere’s diseas
ENT assessment
Do patients need to inform DVLA for Meniere’s disease
YES
Stop driving until satisfactory control of symptoms
Management of mouth ulcers
- avoid triggers
- symptomatic treatment for pain and swelling e.g. hydrocortisone steroid lozenges (topical), antimicrobial mouthwash or topical analgesia
- mouth ulcer for >3 weeks - refer to ENT
What are red flags for mouth apthous ulcers
- Persisting >3 weeks
- Unexplained red and white patches that are painful, swollen or bleeding
- Lesion for more than 6 weeks with no other diagnosis
which neck lump typically contains cholesterol crystals
branchial cyst
unilateral, usually on left
lateral, anterior to SCM muscle
smooth, non-tender
Ramsay Hunt syndrome is caused by the reactivation of what virus and where
VZV virus in geniculate ganglion of 7th cranial nerve
Features of Ramsay Hunt Syndrome (reactivation of VZV in CN7)
- auricular pain
- facial nerve palsy
- vesicular rash around ear
- vertigo + tinnitus
Where are vesicular rash lesions seen in Ramsay Hunt syndrome (VZV reactivation of CN7)
Around ear
Anterior 2/3rds of tongue
Management of ramsay hunt syndrome (reactivation of VZV in CN7)
Oral acyclovir
Corticosteroids
What 5 drugs can cause tinnitus
- Aspirin
- NSAIDs
- Aminoglycosides
- Loop diuretics
- Quinine
Otosclerosis causes progressive conductive deafness. what inheritance mode is it?
autosomal dominant
Otosclerosis leads to progressive deafness + it is autosomal dominant. It causes normal bone to be replaced by vascular spongy bone.
What type of deafness does it cause
conductive
Conductive deafness
Tinnitus
Tympanic membrane - flamingo tinge
Positive family history
What is the diagnosis
Otosclerosis
What disease shows flamingo tinge of tympanic membrane
Otosclerosis
Management of otosclerosis
Hearing aid
Stapedectomy
Positive dix-hallpike manoeuvre shows what kind of nystagmus
rotatory
what type of hearing loss do you get with Menieres disease
sensorineural
what is the most common cause of vertigo
BPPV
management of simple gingivitis
advise routine review by dentist
no need for Abx
management of acute necrotising ulcerative gingivitis
refer to dentist
while give oral metronidazole for 3 days
chlorhexidine or hydrogen peroxide mouthwash
simple analgesia
Presbycusis describes…
age-related sensorineural hearing loss
patients find it hard to follow conversations
what does audiometry show for presbycusis (age-related sensorineural hearing loss)
bilateral high-frequency hearing loss
Glue ear can lead to what in children
speech and language delay
Acoustic neuromas can lead to what effects in cranial nerves
CN8 - hearing loss, vertigo, tinnitus
CN10 - absent corneal reflex
CN12 - facial palsy
NICE indications for antibiotics with sore throat
- systemic upset
- unilateral peritonsillitis
- history of rheumatic fever
- risk of acute infection e.g. immunodeficiency
- 3 or more Centor criteria
what are 4 centor criteria
- no cough
- presence of tonsillar exudate
- tender anterior cervical lymphadenopathy
- history of fever
feverpain criteria
fever >38
purulent/exudate
attends within 3days or less
severely inflamed tonsils
no cough/coryza
main treatment options for ear wax
irrigation - microsuction
eardrops - olive oil, sodium bicarb or almond oil
MANUAL SYRINGING IS NO LONGER RECOMMENDED BY NICE
what contraindications are there for ear syringing /irrigation for ear wax
grommet in situ
or perforation
nasal polyps are associated with which conditions
asthma
aspirin sensitivity
sinusitis
cystic fibrosis
Kartagener’s syndrome
Churg-Strauss (EGPA)
Samter’s triad is made up of
asthma
aspirin sensitivity
nasal polyps
nasal polyps management
referral to ENT
topical corticosteroids
most common pathogen causing malignant otitis externa
pseudomonas
malignant otitis externa can progress into…
temporal bone osteomyelitis
treatment of malignant otitis externa
- non-resolving otitis externa with worsening pain should be referred urgently to ENT
- IV antibiotics to cover pseudomonas
Otoscopy shows attic crust - in the uppermost part of ear drum
what is the diagnosis
cholesteatoma
Being born with which neurological defect increases the risk of cholesteatoma by x10
Cleft palate
Foul-smelling, non-resolving discharge
Hearing loss
Attic crust on otoscopy
What is the diagnosis
Cholesteatoma
refer to ENT for surgical removal
Hoarseness - when should these be referred to ENT
Age 45 and over with persistent unexplained hoarseness
auricular haematomas management
same-day assessment by ENT
incision + draining > needle aspiration
treatment of acute sinusitis
- analgesia
- intranasal corticosteroids if symptoms longer than 10 days
- antibiotics (phenoxymethylpenicillin or co-amoxiclav) if severe presentations
sudafed (psuedoephedrine) is contraindicated with what type of medications
monoamine oxidase inhibitors
can cause hypertensive crisis
perforated tympanic membrane management
- usually self-resolves within 6-8 weeks. avoid water in this time. monitor and review then
- antibiotics are given if perforation is after acute otitis media
- myringoplasty if it does not heal itself
4 causes of Gingival hyperplasia
- phenytoin
- ciclosporin
- CCBs especially nifedipine
- AML
Unilateral serous middle otitis media that is not improving, management?
Urgent 2ww ENT referral
this is a red flag for nasopharyngeal carcinoma
Children presenting with glue ear with a background of what 2 conditions should be referred to ENT
Down’s syndrome
Cleft palate
Ludwig’s angina is a type of …
progressive cellulitis of mouth and soft tissues of neck
Ludwig’s angina is a life threatening emergency because..
airway obstruction can occur
Rx - refer to A&E for airway management and IV Abx
