ENT Flashcards
Give 4 complications of tonsillitis?
Complications of tonsillitis include:
otitis media
quinsy - peritonsillar abscess
rheumatic fever and glomerulonephritis very rarely
Give 4 main indications for tonsillectomy? Give 3 alternate indications
The indications for tonsillectomy are controversial. NICE recommend that surgery should be considered only if the person meets all of the following criteria
-sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
-the person has five or more episodes of sore throat per year
-symptoms have been occurring for at least a year
-the episodes of sore throat are disabling and prevent normal functioning
Other established indications for a tonsillectomy include
-recurrent febrile convulsions secondary to episodes of tonsillitis
-obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
-peritonsillar abscess (quinsy) if unresponsive to standard treatment
Give the primary and secondary complications of tonsillectomy
Complications of tonsillectomy
-primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
-secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain
What does sore throat encompass? Describe the management
Sore throat encompasses pharyngitis, tonsillitis, and laryngitis.
Clinical Knowledge Summaries recommend:
throat swabs and rapid antigen tests should not be carried out routinely in patients with a sore throat
Management
paracetamol or ibuprofen for pain relief antibiotics are not routinely indicated there is some evidence that a single dose of oral corticosteroid may reduce the severity and duration of pain, although this has not yet been incorporated into UK guidelines
Give 5 indications for antibiotics in sore throat
NICE indications for antibiotics
-features of marked systemic upset secondary to the acute sore throat
-unilateral peritonsillitis
-a history of rheumatic fever
-an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
-patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
What is in the centor criteria? give the likelihood of isolating strep according to the centor score
The Centor criteria are: score 1 point for each (maximum score of 4)
-presence of tonsillar exudate
-tender anterior cervical lymphadenopathy or lymphadenitis
-history of fever
-absence of cough
Centor score Likelihood of isolating Streptococci
0 or 1 or 2 3 to 17%
3 or 4 32 to 56%
What is the FeverPAIN criteria? give the likelihood of isolating strep according to the fever pain score.
The FeverPAIN criteria are: score 1 point for each (maximum score of 5)
-Fever over 38°C.
-Purulence (pharyngeal/tonsillar exudate).
-Attend rapidly (3 days or less)
-Severely Inflamed tonsils
-No cough or coryza
FeverPAIN score Likelihood of isolating Streptococci
0 or 1 13 to 18%
2 or 3 34% to 40%
4 or 5 62% to 65%
What is acute sinusitis? What are the most common infectious agents seen? give 4 predisposing factors
Sinusitis describes an inflammation of the mucous membranes of the paranasal sinuses. The sinuses are usually sterile - the most common infectious agents seen in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses.
Predisposing factors include:
-nasal obstruction e.g. septal deviation or nasal polyps
-recent local infection e.g. rhinitis or dental extraction
-swimming/diving
-smoking
Give 3 features of sinusitis
Features
-facial pain
typically frontal pressure pain which is worse on bending forward
-nasal discharge: usually thick and purulent
-nasal obstruction
Give 5 management points on acute sinusitis? what may occur in sinusitis?
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
What is chronic rhinosinusitis? Give 5 predisposing factors
Chronic rhinosinusitis affects up to 1 in 10 people. It is generally defined as an inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer.
Predisposing factors include:
-atopy: hay fever, asthma
-nasal obstruction e.g. Septal deviation or nasal polyps
-recent local infection e.g. Rhinitis or dental extraction
-swimming/diving
-smoking
Give 4 features of chronic rhinosinusitis
Features
-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
Give 3 management options for chronic rhinosinusitis? Give 3 red flag symptoms
Management of recurrent or chronic sinusitis
avoid allergen intranasal corticosteroids nasal irrigation with saline solution
Red flags symptoms
-unilateral symptoms
-persistent symptoms despite compliance with 3 months of treatment
-epistaxis
What is allergic rhinitis? What are 3 classifications
Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens. It may be classified as follows, although the clinical usefulness of such classifications remains doubtful:
-seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever
-perennial: symptoms occur throughout the year
-occupational: symptoms follow exposure to particular allergens within the work place
Give 5 features of allergic rhinitis?
Features
-sneezing
-bilateral nasal obstruction
-clear nasal discharge
-post-nasal drip
-nasal pruritus
Give 4 management points of allergic rhinitis?
Management of allergic rhinitis
-allergen avoidance
-if the person has mild-to-moderate intermittent, or mild persistent symptoms: oral or intranasal antihistamines
-if the person has moderate-to-severe persistent symptoms, or initial drug treatment is ineffective: intranasal corticosteroids
-a short course of oral corticosteroids are occasionally needed to cover important life events
-there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline). They should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal
How common are nasal polyps? Give 6 associations
Around in 1% of adults in the UK have nasal polyps. They are around 2-4 times more common in men and are not commonly seen in children or the elderly.
Associations
-asthma (particularly late-onset asthma)
-aspirin sensitivity
-infective sinusitis
-cystic fibrosis
-Kartagener’s syndrome
-Churg-Strauss syndrome
What is samters triad? Give 3 features of nasal polyps
The association of asthma, aspirin sensitivity and nasal polyposis is known as Samter’s triad.
Features
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
What symptoms of nasal polyps require further investigations? What is the management of nasal polyp?
Unusual features which always require further investigation include unilateral symptoms or bleeding.
Management
all patients with suspected nasal polyps should be referred to ENT for a full examination topical corticosteroids shrink polyp size in around 80% of patients
Nasopharyngeal carcinoma:
-What type of cancer is this?
-Where is this most commonly seen?
-What is this assoc. with?
Basics
Squamous cell carcinoma of the nasopharynx Rare in most parts of the world, apart from individuals from Southern China Associated with Epstein Barr virus infection
Give 5 ways nasopharyngeal carcinoma can present?
-Cervical lymphadenopathy -Otalgia
-Unilateral serous otitis media
-Nasal obstruction, discharge and/ or epistaxis
-Cranial nerve palsies e.g. III-VI
What imaging and treatment is indicated for nasopharyngeal carcinoma
Imaging
Combined CT and MRI.
Treatment
Radiotherapy is first line therapy.
What is nasal septal haematoma? Give 5 features of nasal septal haematoma?
How may this be differentiated for a deviated septum?
Nasal septal haematoma is an important complication of nasal trauma that should always be looked for. It describes the development of a haematoma between the septal cartilage and the overlying perichondrium.
Features
-may be precipitated by relatively minor trauma
-the sensation of nasal obstruction is the most common symptom
-pain and rhinorrhoea are also seen
-on examination, classically a -bilateral, red swelling arising from the nasal septum
-this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm
What is the management of nasal septal haematoma? What can happen if this is untreated?
Management
-surgical drainage
-intravenous antibiotics
If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis. This may result in a ‘saddle-nose’ deformity
How is epistaxis classified?
Epistaxis (nose bleeds) is split into anterior and posterior bleeds, whereby the former often has a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s plexus.
Posterior haemorrhages, on the other hand, tend to be more profuse and originate from deeper structures. They occur more frequently in older patients and confer a higher risk of aspiration and airway compromise.
Give some causes of epistaxis 8
Causes
-most cases of epistaxis tend to be benign and self-limiting. Exacerbation factors include:
nose picking
nose blowing
-trauma to the nose
-insertion of foreign bodies
-bleeding disorders
immune thrombocytopenia
Waldenstrom’s macroglobulinaemia
-juvenile angiofibroma
benign tumour that is highly vascularised
seen in adolescent males
-cocaine use
-the nasal septum may look abraded or atrophied, inquire about drug use. This is because inhaled cocaine
-cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.
-hereditary haemorrhagic telangiectasia
-granulomatosis with polyangiitis
Describe the first aid measures for epistaxis?
If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves:
-Asking the patient to sit with their torso forward and their mouth open
-avoid lying down unless they feel faint
-his decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth
-it also reduces the risk of aspirating blood
Pinch the cartilaginous (soft) area of the nose firmly
this should be done for at least 20 minutes
also ask the patient to breathe through their mouth.
Describe the management of epistaxis if first aid measures are successful
If first aid measures are successful
-consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis
cautions to this include patients that have peanut, soy or neomycin allergies
Mupirocin is a viable alternative
admission and follow up care may be considered in patients under if
a comorbidity (e.g. coronary artery disease, or severe hypertension) is present, an underlying cause is suspected
they are aged under 2 years (as underlying causes such as haemophilia or leukaemia are more likely in this age group)
self-care advice involves reducing the risk of re-bleeding
patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks should be avoided
Describe the management of epistaxis if bleeding does not stop after 10-15mins of first aid
If bleeding does not stop after 10-15 minutes of continuous pressure on the nose consider cautery or packing
-cautery should be used initially if the source of the bleed is visible and cautery is tolerated
-it is not so well-tolerated in younger children!
-ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume.
-use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
-identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.
-dab the area clean with a cotton bud and apply Naseptin or Muciprocin
packing may be used if cautery is not viable or the bleeding point cannot be visualised
-anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes
-pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions
-pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack.
-examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel.
-patients should be admitted to hospital for observation and review, and to ENT if available
Who requires admission for epistaxis?
Patients that are haemodynamically unstable or compromised should be admitted to the emergency department
control bleeding with first aid measures in the interim patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.
Epistaxis that has failed all emergency management
may require sphenopalatine ligation in theatre
IS acute otitis media common? What pathogens commonly cause this?
Acute otitis media is extremely common in young children, with around half of children having three or more episodes by the age of 3 years.
Pathophysiology
-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
-viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the middle ear via the Eustachian tube
What are 4 features of otitis media
Features
-otalgia
some children may tug or rub their ear
-fever occurs in around 50% of cases
-hearing loss
-recent viral URTI symptoms are -ear discharge may occur if the tympanic membrane perforates
What are 4 findings on otoscopy in acute otitis media?
Possible otoscopy findings:
-bulging tympanic membrane → loss of light reflex
-opacification or erythema of the tympanic membrane
-perforation with purulent otorrhoea
-decreased mobility if using a pneumatic otoscope
Give 3 criteria that are used to diagnose otitis media
Whilst guidelines vary, the majority use the following criteria to diagnose otitis media:
-acute onset of symptoms
otalgia or ear tugging
-presence of a middle ear effusion
bulging of the tympanic membrane, or
otorrhoea
decreased mobility on pneumatic otoscopy
-inflammation of the tympanic membrane
i.e. erythema
Describe the management of acute otitis media
Acute otitis media is generally a self-limiting condition that does not require an antibiotic prescription. There are however some exceptions listed below. Analgesia should be given to relieve otalgia. Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days.
Antibiotics should be prescribed immediately if:
-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
If an antibiotic is given, a 5-7 day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.
What are 3 common sequelae of acute otitis media
Common sequelae include:
-perforation of the tympanic membrane → otorrhoea
-unresolved with acute otitis media with perforation may develop into chronic suppurative otitis media (CSOM)
-CSOM is defined as perforation of the tympanic membrane with otorrhoea for > 6 weeks
hearing loss
labyrinthitis
Give complications of acute otitis media
Complications:
mastoiditis meningitis brain abscess facial nerve paralysis
What is glue ear? Give 6 risk factors
Glue ear describes otitis media with an effusion (other terms include serous otitis media). It is common with the majority of children having at least one episode during childhood
Risk factors
-male sex
-siblings with glue ear
-higher incidence in Winter and Spring
-bottle feeding
-day care attendance
-parental smoking
Give 3 clinical features of glue ear
Features
-peaks at 2 years of age
-hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood)
-secondary problems such as speech and language delay, behavioural or balance problems may also be seen
Give 3 treatment options for glue ear?
Treatment options include:
-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
What is ear wax? Give 3 treatment options
Ear wax is a normal physiological substance which helps protect the ear canal. Impacted ear wax is extremely common and may cause a variety of symptoms including:
pain conductive hearing loss tinnitus vertigo
The main treatment options in primary care are ear drops or irrigation (‘ear syringing’). Treatment should not be given if a perforation is suspected or the patient has grommets. The following drops may be used:
olive oil sodium bicarbonate 5% almond oil
Give 4 causes of otitis externa?
Otitis externa is a common reason for primary care attendance in the UK.
Causes of otitis externa include:
-infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
-seborrhoeic dermatitis
-contact dermatitis (allergic and irritant)
-recent swimming is a common trigger of otitis externa
give the features of otitis externa? what is seen on otoscopy?
Features
-ear pain, itch, discharge
-otoscopy: red, swollen, or eczematous canal
Describe the initial management of otitis externa? 4
The recommended initial management of otitis externa is:
-topical antibiotic or a combined topical antibiotic with a steroid
-if the tympanic membrane is perforated aminoglycosides are traditionally not used*
-if there is canal debris then consider removal
-if the canal is extensively swollen then an ear wick is sometimes inserted
Give 4 second line options for otitis externa management?
Second-line options include
consider contact dermatitis secondary to neomycin oral antibiotics (flucloxacillin) if the infection is spreading taking a swab inside the ear canal empirical use of an antifungal agent
What is indicated if a patient with otitis externa fails to respond to topical treatment? what can occur with untreated otitis externa?
If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.
Malignant otitis externa is more common in elderly diabetics. In this condition, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. Intravenous antibiotics may be required.
Perforated TM
-what is the most common cause?
-what may this lead to?
-What is the management?
The most common cause of a perforated tympanic membrane is infection. Other causes include barotrauma or direct trauma.
A perforated tympanic membrane may lead to hearing loss depending on the size and also increase the risk of otitis media.
Management
no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. NICE support this approach in the 2008 Respiratory tract infection guidelines myringoplasty may be performed if the tympanic membrane does not heal by itself
What is malignant otitis externa? What is this most commonly caused by? What can this progress to?
Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics)
most commonly caused by Pseudomonas aeruginosa
Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal
Progresses to temporal bone osteomyelitis
Give 5 clinical features of malignant otitis externa?
Key features in history
Diabetes (90%) or immunosuppression (illness or treatment-related) Severe, unrelenting, deep-seated otalgia Temporal headaches Purulent otorrhea Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
What is the diagnosis and treatement of malignant otitis externa?
Diagnosis
A CT scan is typically done
Treatment
non-resolving otitis externa with worsening pain should be referred urgently to ENT
Intravenous antibiotics that cover pseudomonal infections
What is an auricular haematoma? what is the management?
Auricular haematomas are common in rugby players and wrestlers. Prompt treatment is important to avoid the formation of ‘cauliflower ear’.
Management
auricular haematomas need same-day assessment by ENT
incision and drainage has been shown to be superior to needle aspiration
Audiiograms:
-What is normal?
-what do you see in sensorineural hearing loss?
-What do you see in conductive hearing loss?
Audiograms are usually the first-line investigation that is performed when a patient complains of hearing difficulties. They are relatively easy to interpret as long as some simple rules are followed:
anything above the 20dB line is essentially normal (marked in green on the audiogram below)
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 is otosclerosis? When does this normally present? what are 4 clinical features?
Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults
Onset is usually at 20-40 years - features include:
-conductive deafness
-tinnitus
-tympanic membrane
the majority of patients will have a normal tympanic membrane
10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
-positive family history
What is the management of otosclerosis
Management
hearing aid
stapedectomy
What is presbycusis ? Who does this affect?
Presbycusis is a type of sensorineural hearing loss that affects elderly individuals. Typically, high-frequency hearing is affected bilaterally, which can lead to conversational difficulties, particularly in noisy environments. Presbycusis progresses slowly, as sensory hair cells and neurons in the cochlea atrophy over time. Although certain factors are associated with presbycusis, it is distinct from noise-related hearing loss.
Epidemiology
In the USA, it is estimated that 25-30% of 65-74 year-olds have impaired hearing. For those over 75 years, the incidence is 40-50%
The age of presentation varies, however, prevalence increases with age
Males are at slightly higher risk of developing presbycusis compared to females (55%:45%)
Give 7 causes for presbycusis?
Causes
-The precise cause is unknown however is likely multifactorial
-Arteriosclerosis: May cause diminished perfusion and oxygenation of the cochlea, resulting in damage to inner ear structures
-Diabetes: Acceleration of arteriosclerosis
-Accumulated exposure to noise
-Drug exposure (Salicylates, chemotherapy agents etc.)
-Stress
-Genetic: Certain individuals may be programmed for the early ageing of the auditory system
Give 7 clinical features of presbycusis
Patients typically present with a chronic, slowly progressing history of:
-Speech becoming difficult to understand
-Need for increased volume on the television or radio
-Difficulty using the telephone
-Loss of directionality of sound
-Worsening of symptoms in noisy environments
-Hyperacusis: Heightened sensitivity to certain frequencies of sound (Less common)
-Tinnitus (Uncommon)
What are the signs and four investigations for presbycusis
Signs:
Possible Weber’s test bone conduction localisation to one side if sensorineural hearing loss not completely bilateral
Investigations:
-Otoscopy: Normal, to rule out otosclerosis, cholesteatoma and conductive hearing loss (Foreign body, impacted wax etc.)
-Tympanometry: Normal middle ear function with hearing loss (Type A)
-Audiometry: Bilateral sensorineural pattern hearing loss
-Blood tests including inflammatory markers and specific antibodies: Normal
What is cholesteatoma? what are 2 main features?
Cholesteatoma is a non-cancerous growth of squamous epithelium that is ‘trapped’ within the skull base causing local destruction. It is most common in patients aged 10-20 years. Being born with a cleft palate increases the risk of cholesteatoma around 100 fold.
Main features
-foul-smelling, non-resolving discharge
-hearing loss
Give 3 features of cholesteatoma that are determined by local invasion?
Other features are determined by local invasion:
-vertigo
-facial nerve palsy
-cerebellopontine angle syndrome
What is the investigation and management for cholesteatoma?
Otoscopy
‘attic crust’ - seen in the uppermost part of the ear drum
Management
patients are referred to ENT for consideration of surgical removal
Sudden-onset sensorineural hearing loss
-What must be done on examination?
-What is the most common cause?
-What is the investigation?
-What is the treatmnet?
When a patient presents with sudden onset hearing loss it is important to examine them carefully to differentiate between conductive and sensorineural hearing loss → sudden-onset sensorineural hearing loss (SSNHL) requires urgent referral to ENT.
The majority of SSNHL cases are idiopathic.
An MRI scan is usually performed to exclude a vestibular schwannoma.
High-dose oral corticosteroids are used by ENT for all cases of SSNHL.
Describe rinnes test?
Rinne’s test
tuning fork is placed over the mastoid process until the sound is no longer heard, followed by repositioning just over external acoustic meatus
‘positive test’: air conduction (AC) is normally better than bone conduction (BC)
‘negative test’: if BC > AC then conductive deafness
Describe webers tests
Weber’s test
-tuning fork is placed in the middle of the forehead equidistant from the patient’s ears
-the patient is then asked which side is loudest
-in unilateral sensorineural deafness, sound is localised to the unaffected side
-in unilateral conductive deafness, sound is localised to the affected side
What is surfers ear? exostosis
Surfer’s ear is a condition seen secondary to repeated exposure to cold water- often seen in surfers, divers, and kayakers. It is more common in New Zealand and the USA. Some areas of the United Kingdom such as Cornwall may see cases. Patients with this condition may suffer from repeated ear infections, decreased hearing and water plugging. It is a progressive condition and preventative measures ought to be taken to prevent repeated exposure - hoods, ear plugs or swim caps can be used. Surgery may be undertaken.
What is a cochlear implant? how is suitability determined?
A cochlear implant is an electronic device that may be offered to patients with severe-to-profound hearing loss.
Suitability for a cochlear implant is determined by:
In children, audiological assessment and/or difficulty developing basic auditory skills.
In adults, patients should have completed a trial of appropriate hearing aids for at least 3 months which they have been objectively demonstrated to receive limited or no benefit from.
Give 4 causes of severe-to-profound hearing loss in children?
Causes of severe-to-profound hearing loss:
In children
Genetic (accounts for up to 50% of cases).
Congenital e.g. following maternal cytomegalovirus, rubella or varicella infection.
idiopathic (accounts for up to 30% of childhood deafness).
Infectious e.g. post meningitis.
Give 5 causes of severe-to-profound hearing loss in adults?
In adults
Viral-induced sudden hearing loss.
Ototoxicity e.g. following administration of aminoglycoside antibiotics or loop diuretics.
Otosclerosis
Ménière disease
Trauma
What is needed before doing a cochlear implant? what is the follow up?
Surgical implantation may be complicated by infection, facial paralysis due to nerve injury intra-operatively, cerebrospinal fluid (CSF) leakage, and meningitis. To reduce the risk of meningitis as far as possible, it is recommended that all patients should have up-to-date vaccinations against Streptococcus and Haemophilus.
Patients are discharged for the post-operative physical recovery of the implantation site and generally return to outpatient clinic 3-5 weeks post-op for device stimulation.
Give 3 contraindications for consideration of cochlear implant? Give 4 relative contraindications
Contraindications to consideration for cochlear implant:
-Lesions of cranial nerve VIII or in the brain stem causing deafness
-Chronic infective otitis media, mastoid cavity or tympanic membrane perforation
-Cochlear aplasia
Relative contraindications:
-Chronic infective otitis media or mastoid cavity infections
-Tympanic membrane perforation
-Patients that may be seen to demonstrate a lack of interest in using the implant to develop enhanced oral communication skills.
Describe the hearing loss found in noise damage?
Workers in heavy industry are particularly at risk
Hearing loss is bilateral and typically is worse at frequencies of 3000-6000 Hz
Acoustic neuroma (vestibular schwannoma) - what are the features?
Features can be predicted by the affected cranial nerves
cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
Bilateral acoustic neuromas are seen in neurofibromatosis type 2
What is BPPV and what are the 4 features?
Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients.
Features
vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
may be associated with nausea
each episode typically lasts 10-20 seconds
positive Dix-Hallpike manoeuvre
rapidly lower the patient to the supine position with an extended neck
a positive test recreates the symptoms of benign paroxysmal positional vertigo
rotatory nystagmus
What is the management of BPPV? what is the relapse rate?
BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by:
Epley manoeuvre (successful in around 80% of cases)
teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises
Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.
Around half of people with BPPV will have a recurrence of symptoms 3–5 years after their diagnosis
What is menieres disease?
-Give 5 features?
Meniere’s disease is a disorder of the inner ear of unknown cause. It is characterised by excessive pressure and progressive dilation of the endolymphatic system. It is more common in middle-aged adults but may be seen at any age. Meniere’s disease has a similar prevalence in both men and women.
Features
-recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
-a sensation of aural fullness or pressure is now recognised as being common
-other features include nystagmus and a positive Romberg test
-episodes last minutes to hours
-typically symptoms are unilateral but bilateral symptoms may develop after a number of years
What is the natural history of menieres disease?
Natural history
-symptoms resolve in the majority of patients after 5-10 years
-the majority of patients will be left with a degree of hearing loss
-psychological distress is common
Describe the management of menieres disease?
Management
-ENT assessment is required to confirm the diagnosis
-patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
-acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required
-prevention: betahistine and vestibular rehabilitation exercises may be of benefit
What is vestibular neuronitis? give 4 clinical features
Vestibular neuronitis is a cause of vertigo that often develops following a viral infection.
Features
-recurrent vertigo attacks lasting hours or days
-nausea and vomiting may be present
-horizontal nystagmus is usually present
-no hearing loss or tinnitus
What is the differential diagnosis for vestibular neuronitis? what is the management
Differential diagnosis
-viral labyrinthitis
-posterior circulation stroke: the HiNTs exam can be used to distinguish vestibular neuronitis from posterior circulation stroke
Management
-buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases
-a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases
-vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms
Give 4 features of viral labrinthitis
Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected
Give 2 clinical features of vertebrobasilar ischaemia
Elderly patient
Dizziness on extension of neck
Give 5 precipitating factors for aphthous mouth ulcers?
People with recurrent ulcers may have a genetic predisposition. Precipitating factors include:
-Oral trauma (for example excessive tooth brushing).
-Anxiety or stress.
-Certain foods (typically chocolate, coffee, peanuts, almonds, strawberries, cheese, tomatoes, and wheat flour).
-Stopping smoking.
-Hormonal changes related to the menstrual cycle.
What is the investigation and management of aphthous mouth ulcers
Investigations are generally unnecessary. Investigations should be considered (for example full blood count, erythrocyte sedimentation rate, ferritin, folate and vitamin B12) if an underlying systemic disease is suspected based on history and examination findings.
Most aphthous ulcers heal within 10-14 days without scarring.
Management of aphthous ulcers includes:
Avoidance of precipitating factors, and
Symptomatic treatment for pain, discomfort, and swelling e.g. a short course of a low potency topical corticosteroid (hydrocortisone lozenges), an antimicrobial mouthwash, or a topical analgesic.
People with a mouth ulcer that persists for more than 3 weeks should be referred urgently to a specialist
What is black hairy tongue? give 5 predisposing factors? What is the investigation and managment
Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour.
Predisposing factors
poor oral hygiene
antibiotics
head and neck radiation
HIV
intravenous drug use
The tongue should be swabbed to exclude Candida
Management
tongue scraping
topical antifungals if Candida
What is a geographic tongue? what are the features and management?
Geographic tongue is a benign, chronic condition of unknown cause. It is present in around 1-3% of the population and is more common in females.
Features
erythematous areas with a white-grey border (the irregular, smooth red areas are said to look like the outline of a map)
some patients report burning after eating certain food
Management
reassurance about benign nature
Give 4 causes of gingival hyperplasia
Drug causes of gingival hyperplasia
phenytoin
ciclosporin
calcium channel blockers (especially nifedipine)
Other causes of gingival hyperplasia include
acute myeloid leukaemia (myelomonocytic and monocytic types)
What is gingivitis? what is the management of simple gingivitis?
Gingivitis is usually 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).
If the patient has simple gingivitis
should be advised to seek routine regular review by a dentist. Antibiotics are not usually necessary
What is the management of acute nectrotising ulcerative gingivitis
If a patient presents with acute necrotizing ulcerative gingivitis CKS recommend the following management:
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
Give six situations in which a two-week wait referral should be made to oral surgery
2 week wait referrals to oral surgery should be done in all of the following cases:
-Unexplained oral ulceration or mass persisting for greater than 3 weeks
-Unexplained red, or red and white patches that are painful, swollen or bleeding
-Unexplained one-sided pain in the head and neck area for greater than 4 weeks, which is associated with ear ache, but does not result in any abnormal findings on otoscopy
-Unexplained recent neck lump, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
-Unexplained persistent sore or painful throat
-Signs and symptoms in the oral cavity persisting for more than 6 weeks, that cannot be definitively diagnosed as a benign lesion
The level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers and those who chew tobacco or betel nut (areca nut).
What are complications of dental abscess? Who is this most commonly seen in?
Complications include loss of the infected tooth, the formation of a fistula or sinus tract, or spread of infection. The spread of infection can include local structures eg maxillary sinus, osteomyelitis, cellulitis, brain abscess or generalised sepsis.
Epidemiology
-The lifetime prevalence has been reported as 5–46% 1 (there is limited data).
-The vast majority of healthy patients have localised infections which can be managed in the community.
-Dental abscesses are rare in infants because they do not form until teeth erupt.
-In children, periapical abscesses are more common, due to the combination of thinner enamel, increased blood supply and poor hygiene.
-In adults, periodontal abscesses are more common than periapical.
What are the symptoms and signs of dental abscess?
Patients typically present with a subacute onset of:
Pain: typically the pain is intense and throbbing and starts suddenly and gets worse over hours to days. The pain may wake the patient from sleep and the tooth may be tender and cause pain when eating.
Temperature sensitivity (e.g. to hot or cold drinks).
Foul taste.
Fever.
General malaise.
Trismus (inability to open the mouth).
Dysphagia (in severe cases).
Signs:
Facial swelling
Gum swelling
Altered tooth appearance (the affected tooth have signs of decay, be elevated or broken).
Local lymphadenopathy.
Gum swelling.
Pus may be visible (it can be intra or extra-oral).
If you palpate the tooth it might wobble and may well be tender.
The gum may also be tender or warm to palpate.
Signs of severe infection include signs of cardio-respiratory compromise or airway obstruction.
What is the investigations and management for a dental abscess?
Investigations:
If a patient presents to their doctor with a tooth abscess a diagnosis is made on the clinical history and examination findings.
Patients should be encouraged to attend their dentist for definitive diagnosis and treatment unless they require emergency admission to a hospital due to severe complications or sepsis.
Treatment:
Definitive treatment can only be given by a dentist and antibiotics will not eliminate the source of infection.
Serious complications can occur if a patient is not treated by a dentist.
Antibiotics are generally not indicated in an otherwise healthy individual unless they are systemically unwell or have signs of severe infection.
If antibiotics are indicated or a patient is unable to attend a dentist amoxicillin or phenoxymethylpenicillin are first line (clarithromycin if there is a history of true penicillin allergy).
If the infection is severe or spreading, or the patient has systemic signs of infection metronidazole should also be prescribed.
Analgesia may be necessary: ibuprofen and paracetamol are first-line (if not contraindicated).
What is the neck lump:
By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness
Reactive lymphadenopathy
What is the neck lump:
Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly
lymphoma
What is the neck lump:
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
thyroglossal cyst
What is a thyroglossal cyst?
The thyroid develops from the floor of the pharynx and descends into the neck during its development. It is connected to the tongue by the thyroglossal duct. The foramen cecum is the point of attachment of the thyroglossal duct to the tongue. The thyroglossal duct normally atrophies but in some people may persist and give rise to a thyroglossal duct cyst.
What is the neck lump?
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 and chronic cough
Pharyngeal pouch
What is the neck lump:
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
Cystic hygroma
What is the neck lump:
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
Branchial cyst
What is a branchial cyst?
A branchial cyst is a benign, developmental defect of the branchial arches. The cyst is filled with acellular fluid with cholesterol crystals and encapsulated by stratified squamous epithelium. Branchial cysts may have a fistula and are therefore prone to infection. They may enlarge following a respiratory tract infection.
They typically present in late childhood or early adulthood and present as asymptomatic neck lateral neck lumps and are usually located anterior to the sternocleidomastoid muscle. There is a slight male predisposition and account for around 20% of paediatric neck masses.
Give 8 typical examination features of a branchial cyst
Typical examination features:
-unilateral, typically on the left side
-lateral, anterior to the sternocleidomastoid muscle
-slowly enlarging
-smooth, soft, fluctuant
-non-tender
-a fistula may be seen
-no movement on swallowing
-no transillumination
What is the management of branchial cyst?
Diagnosis and investigations:
consider and exclude other malignancy
ultrasound
referral to ENT
fine-needle aspiration
Branchial cysts are treated by Ear Nose and Throat (ENT) surgeons and can be treated conservatively or surgically excised. Antibiotics are required for acute infections.
What is the neck lump:
More common in adult females
Around 10% develop thoracic outlet syndrome
Cerivical rib
What is the neck lump:
Pulsatile lateral neck mass which doesn’t move on swallowing
carotid aneurysm
What does head and neck cancer encompass?
Head and neck cancer is an umbrella term. It typically includes:
-Oral cavity cancers
-Cancers of the pharynx (including the oropharynx, hypopharynx and nasopharynx)
-Cancers of the larynx
Features
-neck lump
-hoarseness
-persistent sore throat
persistent mouth ulcer
What are the symptoms to look out for in laryngeal cancer?
Laryngeal cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:
persistent unexplained hoarseness or
an unexplained lump in the neck
What are the symptoms to look out for in oral cancer?
Oral cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
a lump on the lip or in the oral cavity or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
What are the symptoms to look out for in thyroid cancer?
Thyroid cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump.
Give 7 causes of hoarseness? what should be done when investigating hoarseness?
Causes of hoarseness include:
voice overuse
smoking
viral illness
hypothyroidism
gastro-oesophageal reflux
laryngeal cancer
lung cancer
When investigating patients with hoarseness a chest x-ray should be considered to exclude apical lung lesions.
What is laryngopharangeal reflux? give 3 features? what is found on examination?
Laryngopharyngeal reflux (LPR) is a condition caused by gastro-oesophageal reflux resulting in inflammatory changes to the larynx/hypopharynx mucosa. It is a common diagnosis and thought to account for around 10% of ear, nose and throat referrals.
Features
-around 70% of patients have the sensation of a lump in the throat - ‘globus’
-typically felt in the midline
-typically worse when swallowing saliva rather than eating or drinking
other features
-hoarseness (70%)
-chronic cough (50%)
-dysphagia (35%)
-heartburn (30%)
-sore throat
examination findings
-the external examination of the neck should be normal, with no masses
the posterior pharynx may appear erythematous
What is the diagnosis and management of laryngopharangeal reflux?
Diagnosis
-in the absence of red flags a clinical diagnosis of LPR can be made without further investigations
-the NICE cancer referral guidelines should be reviewed for red flags, examples of which include:
persistent, unilateral throat discomfort
dysphagia, odynophagia (i.e. with food rather than just saliva)
persistent hoarseness
Management
-lifestyle measures
-possible triggers include fatty foods, caffeine, chocolate and alcohol
proton pump inhibitor
-sodium alginate liquids (e.g. Gaviscon)
What is ramsay hunt syndrome?
Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
Features
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus
Management
oral aciclovir and corticosteroids are usually given
Give 3 features of TMJ dysfunction? give 4 management options
Features
pain: at the TMJ or may radiate to the head, neck or ear
restricted jaw motion: chewing may cause pain
the patient may notice clicks and other noises whilst moving the jaw
Management options include:
recommending soft foods
simple analgesia including paracetamol and NSAIDs
short-courses of benzodiazepines may be helpful
review by a dentist
Give 6 causes of facial pain?
- Trigeminal Neuralgia: Characterised by severe lancinating facial pain along one or more branches of the trigeminal nerve.
- Sinusitis: Facial pain accompanied by symptoms such as nasal discharge or congestion suggests sinusitis.
- Dental Problems: Dental caries or abscesses can cause localised facial pain.
- Tension-Type Headache: This may present with a band-like pressure around the forehead that can extend into facial regions.
- Migraine: Migraine headaches often involve unilateral throbbing head and face pain associated with nausea, vomiting or photophobia.
- Giant Cell Arteritis: In older patients, new onset facial pain may be a sign of this condition, which can threaten vision.
