ENT Flashcards
Three complications of thyroid surgery
1- recurrent laryngeal nerve injury
2- haematoma
3- hypocalcaemia ( irritability, seizures, spasms and paresthesia periorally)
most common infective causes of otitis externa [3]
- pseudomonas
- staph aureus
- fungi
how is a visualised nose bleed treated
cautery
how is a nose bleed that can’t be visualised treated?
anterior packing
benign tumours of the parotid gland
pleomorphic adenoma (most common)
Warthin’s tumour
malignant tumours of the parotid gland
mucoepidermoid carcinoma
adenoid cystic carcinoma (these are invasive and cause palsies)
how should unilateral nasal polyps be investigated?
urgent referral to ENT for suspected cancer
inheritance of hereditary haemorrhagic telangectasia
Autosomal dominant
definitive management of otosclerosis
stapedectomy
hearing aids is the other one
mode of inheritance of otosclerosis
autosomal dominant
what can exacerbate otosclerosis
pregnancy
what are children with Down syndrome at risk of with their ears
OME and therefore conductive hearing loss
Definition of OME/glue ear
presence of middle ear fluid without acute signs of bacterial infection or illness.
expect to find visible fluid behind an intact tympanic membrane. Viscous bubbles may also be seen behind the tympanic membrane.
How is OME in adults investigated
Unilateral glue ear in an adult needs evaluation for a posterior nasal space tumour therefore a two week wait referral needed
features of vestibular neuronitis [4]
- horizontal nystagmus
- vertigo and dizziness
- nausea and vomiting
- no hearing loss
features of acute labrinythitis [5]
- horizontal nystagmus
- vertigo and dizziness (exacerbated by movement)
- nausea and vomiting
- tinnitus
- HEARING LOSS (uni- or bilateral)
features of Menieres disease [4]
recurrent attacks of vertigo
symptoms of hearing loss
tinnitus
nystagmus and postive Romberg
a feeling of fullness in the ear
management of vestibular neuronitis [3]
- buccal or intramuscular prochlorperazine (rapid relief for severe cases)
- a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine)
- vestibular rehabilitation exercises (chronic symptoms)
what is the purpose of the HiNTS exam
distinguish between a peripheral and central vestibular cause of vertigo e.g. neuronitis vs posterior circulation infarct
how long would voice hoarseness be present in suspicious cases? what age group
3 weeks or longer in those over 45
signs of OME in a child [3]
retracted ear drum
absent of light reflex
no discharge
which children with OME need immediate referral to ENT [2]
Down’s and cleft palate
Children with persisting significant hearing loss on two separate occasions (usually 6-12 weeks apart) need referral to ENT for further management
management of OME in children
active observation for 3 months from initial presentation then grommet
management of labrinythitis
usually self limiting
prochlorperazine or antihistamines may help reduce the sensation of dizziness
what does an abnormal head impulse show
impaired vestibulo-ocular reflex
how does OME present in childhood
peaks at 2 years of age
hearing loss is usually the presenting feature
secondary problems such as speech and language delay, behavioural or balance problems may also be see
Main complications post tonsillectomy
pain and haemorrhage
when does primary haemorrhage post tonsillectomy occur and how is it managed
bleeding 6-8 hours after
immediate return to theatres
when does secondary haemorrhage post tonsillectomy occur and how is it managed
between 5 and 10 days after surgery, associated with a wound infection.
admission and antibiotics.
Severe bleeding may require surgery.
what is malignant otitis externa
chronic Pseudomonas aeruginosa infection which becomes invasive and erodes the temporal bone eventually leading to osteomyelitis
key differentiating factors between otitis externa and otitis media [3]
OM affects the tympanic membrane while OE doesnt
OM has discharge followed by perforation that receives pain
OE has pain and discharge that co-exist
Children with otitis media often tug or rub their ears, whereas, in otitis externa, this is likely to exacerbate pain.
who are most commonly affected by malignant otitis externa
diabetics and the immunosuppressed
how is malignant otitis externa treated
ciprofloxacin
how is Otitis externa treated
topical flucloxacillin +/- steroid
not used if perforated
which Abx is used to treated otitis media
amoxicillin
5-7 days
macrolides if allergic
features of malignant otitis externa
- purulent discharge
- deep seated, severe otalgia
- temporal headaches
- possibly dysphagia, hoarseness, and/or facial nerve dysfunction
what is the sign that an acute otitis media ear has perforated
bloody discharge followed by resolving of ear pain
when should Abx be given immediately for acute otitis media [5]
- Symptoms lasting more than 4 days or not improving
- Systemically unwell but not requiring admission
- Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
- Younger than 2 years with bilateral otitis media
- Otitis media with perforation and/or discharge in the canal
What is the initial management of otitis media
Observe for 3 days for any worsening, delayed ABx
complication of otitis media [4]
- mastoiditis
- meningitis
- brain abscess
- facial nerve paralysis
3 common sequelae of acute otitis media
1) chronic suppurative otitis media (CSOM) defined as perforation of the tympanic membrane with otorrhoea for > 6 weeks
2) hearing loss
3) labyrinthitis
drugs that can cause tinnitus [4]
- Aspirin/NSAIDs
- Aminoglycosides
- Loop diuretics
- Quinine
management of auricular haematomas [2]
need same-day assessment by ENT
incision and drainage has been shown to be superior to needle aspiration
features of otosclerosis [4]
- conductive deafness
- tinnitus
- normal tympanic membrane
10% of patients may have a ‘flamingo tinge’, caused by hyperaemia - positive family history
which ENT structure drains into the posterior triangle lymphatics
nasopharynx
which ENT structure drains into the anterior triangle lymphatics [3]
larynx, buccal mucosa, and tonsillar fossa
which demographic are nasopharyngeal carcinomas most common in
Asian
how do nasopharyngeal carcinomas present [4]
- epistaxis
- headaches
- lymph node metastasis
- unilateral hearing loss
what is elicits in a positive Dix Hallpike manoever
rotational nystagmus
what drains the submandibular gland
Whartons duct
what drains the parotid gland
Stensens duct
where does sialolithiasis commonly occur
what are the stones made of
submandibular gland
calcium phosphate or calcium carbonate
two symptoms of sialolithiasis
colicky pain and post prandial swelling of the gland
investigation for sialolithiasis
sialography to demonstrate the site of obstruction and associated other stones
Sialadenitis: causative agent
staph aureus
diagnosis of submandibular tumours
FNA
CT and MRI
In a young adult with parotid swelling and pancreatitis/orchitis/reduced hearing/meningoencephalitis suspect…
mumps
treatment of Ramsey Hunt syndrome
oral aciclovir and steroids
how is otitis externa treated in diabetics
ciprofloxacin
otosclerosis: conductive or sensorineural hearing loss
conductive
In Weber’s test if there is a sensorineural problem the sound is localised to the
unaffected side
When performing the Weber test, the patient should localise the sound to the side of a _________ hearing loss, as bone conduction is increased. The sound will localise away from a __________ hearing loss.
When performing the Weber test, the patient should localise the sound to the side of a conductive hearing loss, as bone conduction is increased. The sound will localise away from a sensorineural hearing loss.
presbycusis: conductive or sensorineural hearing loss
bilateral sensorineural
shows deafness to high frequency
Menieres disease: conductive or sensorineural hearing loss
sensorineural
ototoxic drugs [4]
aminoglycosides (e.g. Gentamicin)
furosemide
aspirin
number of cytotoxic agents
management of bilateral nasal polyps
routine referral to ENT and intranasal steroids
Samter’s triad
asthma
aspirin sensitivity
nasal polyposis
what is gingivitis
secondary to poor dental hygiene. Clinical presentation may range from simple gingivitis (painless, red swelling of the gum margin which bleeds on contact) to acute necrotizing ulcerative gingivitis (painful bleeding gums with halitosis and punched-out ulcers on the gums).
management of simple gingivitis
seek dentist
no Abx
management of acute necrotising ulcerative gingivitis
refer the patient to a dentist, meanwhile the following is recommended:
oral metronidazole* for 3 days
chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash
simple analgesia
i.e. paracetomol + metronidazole + chlorhexidine mouthwash
what is tympanosclerosis and what does it suggest
Characterised by a chalky, white plaque on the tympanic membrane, suggestive of a previous middle ear infection or trauma.
a sign of unilateral glue ear in an adult
effusion
what is Ludwig’s angina
progressive cellulitis that invades the floor of the mouth and soft tissues of the neck. Most cases result from odontogenic infections which spread into the submandibular space.
presentation of Ludwig’s angina
fever
dysphagia
neck swelling
management of Ludwig’s angina
It is a life-threatening emergency as airway obstruction can occur rapidly as a result:
urgent hospitalisation
airway management
intravenous antibiotics
Thyroglossal cyst:
More common in patients < __________
Usually _________, between the isthmus of the thyroid and the hyoid bone, linked to the__________
Moves ________ with protrusion of the tongue
May be painful if infected
More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone, linked to the foramen caecum
Moves upwards with protrusion of the tongue
May be painful if infected
Pharyngeal pouch:
More common in older _______
Represents a __________ herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a ______ lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration, halitosis and chronic cough
More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration, halitosis and chronic cough
Cystic hygroma:
A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the _____side
Most are evident at birth, around 90% present before __ years of age
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
Branchial cyst:
An oval, mobile cystic mass that develops between the _____________ and the _________
Develop due to failure of obliteration of the _________ branchial cleft in embryonic development
Usually present in early adulthood
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
Cervical rib:
More common in adult _________
Around 10% develop ____________________
More common in adult females
Around 10% develop thoracic outlet syndrome
Carotid aneurysm:
Pulsatile lateral neck mass which _______ ________on swallowing
Pulsatile lateral neck mass which doesn’t move on swallowing
treatment of chronic rhino sinusitis [3]
avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution
features of chronic rhino sinusitis [4]
facial pain: typically frontal pressure pain which is worse on bending forward
nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection
nasal obstruction: e.g. ‘mouth breathing’
post-nasal drip: may produce chronic cough
features of Ramsay Hunt Syndrome [4]
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear (may also be seen on the tongue)
other features include vertigo and tinnitus
treatment of Ramsay Hunt syndrome [2]
oral aciclovir and corticosteroids are usually given
treatment of strep throat
phenoxymethylpenicillin or clarithromycin
features of benign pleomorphic adenoma [2] and its management
Clinical features
gradual onset, painless unilateral swelling of the parotid gland
typically movable on examination rather than fixed
Management
surgical excision (risk of transformation)
features of the Centor score [4]
presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever (not necessarily at appointment)
absence of cough
3/4 –> give ABx
what is black hairy tongue swabbed for
management?
candida
management: tongue scraper and antifungals if candida positive
complications of tonsillitis
otitis media
quinsy - peritonsillar abscess
rheumatic fever and glomerulonephritis very rarel
how many episodes of tonsillitis in a year warrant a tonsillectomy
the person has five or more episodes of sore throat per year
management of glue ear [3]
active observation: the management for a child with a first presentation of otitis media with effusion is active observation for 3 months - no intervention is required
grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months
adenoidectomy
in Ramsey Hunt syndrome, where does VZV reactivate
geniculate ganglion of the seventh cranial nerve
what is exostosis of the ear
Exostosis is where bone grows abnormally in the ear due to repeated exposure to cold water. It affects people who swim or surf a lot in cold water – that’s why it’s sometimes called surfer’s ear.
which part of the nose is epistaxis most likely to come from?
Little’s area in the anterior nasal septum is the site of Kiesselbach’s plexus, supplied by 4 arteries
which infection is tonsils SCC associated with
HPV-16
why should ntranasal decongestants (e.g. oxymetazoline) not be used for prolonged periods
increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal
observation period in otitis media vs otitis media with effusion
OM is just 3/4 days
OME is 3 months
when does OME need urgent referral
in an adult, especially if unilateral
if bilateral OME as first time presentation , 3 month observation
how does a quinsy present
presents with severe sore throat that can cause difficulty in opening mouth (trismus), drooling, foul-smelling breath and deviation of uvula towards unaffected side due to swelling on one side of the throat.
causative agents of acute otitis media
whilst viral upper respiratory tract infections (URTIs) typically precede otitis media, most infections are secondary to bacteria, particularly
Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
normal threshold on audiogram
20db
in sensorineural hearing loss both air and bone conduction are impaired
in conductive hearing loss only air conduction is impaired
in mixed hearing loss both air and bone conduction are impaired, with air conduction often being ‘worse’ than bone
what should be done if otitis externa does not respond to topical abx
refer to ENT
recent swimming is a risk factor for
otitis externa
features of Otitis externa
ear pain, itch, discharge
otoscopy: red, swollen, or eczematous canal
treatment of quinsy
need urgent review by an ENT specialist.
needle aspiration or incision & drainage + intravenous antibiotics
tonsillectomy should be considered to prevent recurrence in 6 weeks
management of acute sinusitis
analgesia
intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited
NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days
oral antibiotics are not normally required but may be given for severe presentations.
The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’
‘double-sickening’ may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection
If a perforated tympanic membrane does not heal by itself a _________ may be performed
If a perforated tympanic membrane does not heal by itself a myringoplasty may be performed
sudden onset sensorineural hearing loss
urgent referral to ENT.
High-dose oral corticosteroids
Nasal septal haematoma: treatment
surgical drainage
intravenous antibiotics
