ENT Flashcards
What anatomical landmark is the boundary between the external and middle ear?
Tympanic membrane
Which nerve runs through the middle ear?
Facial nerve
What is the anterior and posterior blood supply to the nose?
Anterior = Little’s area/Kiesselbach’s plexus (most common site for nose bleeds)
Posterior = Woodruff’s plexus
Which muscle separates the anterior and posterior triangles of the neck?
Sternocleidomastoid
What are the common neck lumps found in the anterior triangle?
Branchial cysts
What are the common neck lumps found in the posterior triangle?
Cystic hygromas
Which salivary gland is the most common site for tumours?
Parotid gland
What is the definition of conductive hearing loss?
Problem with sound travelling from environment to inner ear, the sensory system may be working but sound is not reaching it
What is the definition of sensorineural hearing loss?
Caused by a problem with the sensory system or vestibulocochlear nerve in the inner ear
How to you interpret the results of Weber’s?
Equal volume in each ear = normal
In sensorineural hearing loss = will be louder in the normal ear and quieter in bad ear
In conductive hearing loss = sound will be louder in the affected ear
How do you interpret the results of Rinne’s?
Normal = air conduction is better than bone conduction so can still hear it after it has been moved (positive)
Abnormal = bone conduction is better than air conduction, suggests conductive cause for hearing loss (negative)
What are the causes of conductive hearing loss?
Ear wax, infection, effusion, eustachian tube dysfunction, perforated tympanic membrane, otosclerosis, cholesteatoma, tumours
What are the causes of sensorineural hearing loss?
Presbycusis, noise exposure, Meniere’s disease, labyrinthitis, acoustic neuroma, ototoxic medications
What is the pattern of hearing loss in presbycusis?
Tends to affect high pitched sound first before lower pitched sounds, hearing loss occurs gradually and symmetrically
What are the risk factors for presbycusis?
Age, male, family history, loud noise exposure, diabetes, hypertension, ototoxic medications, smoking
What is the management of presbycusis?
Audiometry to diagnose, hearing aids, cochlear implants
What type of hearing loss requires urgent ENT referral?
Sudden onset (over <72 hours) sensorineural hearing loss (no conductive cause can be found)
What are the causes of sudden onset sensorineural hearing loss?
Idiopathic = most common
Infection, Meniere’s disease, ototoxic medications, migraine, stroke, acoustic neuroma, Cogan’s syndrome
What investigations may be done in someone with sudden onset sensorioneural hearing loss?
Audiometry
MRI/CT head
What is the function of the eustachian tube?
Equalise the air pressure in the middle ear and drain fluid from the middle ear
What are the causes of eustachian tube dysfunction?
Viral URTI, allergies, smoking
What is the presentation of eustachian tube dysfunction?
Reduced or altered hearing, popping noises in the ear, feeling of fullness, pain or discomfort, tinnitus, otoscopy will be normal
What investigations are done if eustachian tube dysfunction is persistent or severe?
Tympanometry, audiometry, nasopharyngoscopy, CT to assess for structural pathology
What is the management of eustachian tube dysfunction?
No treatment, valsalva manoeuvre, decongestant nasal sprays, antihistamines and steroid nasal spray if related to allergies, surgery if severe or persistent
What is otosclerosis?
Condition where there is remodelling of the small bones in the middle ear leading to conductive hearing loss
What is the presentation of otosclerosis?
Patient under 40 presenting with unilateral/bilateral hearing loss and tinnitus, tends to affect lower pitched sounds more than higher pitched sounds
What investigations are done in otosclerosis?
Audiometry, tympanometry, high resolution CT scan
What is the management of otosclerosis?
Hearing aids, surgical procedures (stapedectomy)
Why are ear infections more common in children?
Their eustachian tubes are shorter and wider and allow easier transmission of bacteria from the throat to the ear
What is the most common cause of otitis media?
Strep pneumoniae
What is the presentation of otitis media?
Ear pain, reduced hearing in affected ear, generally unwell, may have had preceding URTI
What is found on otoscopy in someone with otitis media?
Bulging red inflamed tympanic membrane, may be perforation in which case there will be discharge in ear canal
What is the management of otitis media?
Most resolve spontaneously, simple analgesia but need to safety net
Give abx if systemically unwell, immunocompromised
Consider delayed prescription if symptoms have not improved or have worsened
1st line = amoxicillin for 5-7 days
What is mastoiditis?
A complication of otitis media
Will have painful mastoid process, tired and appear meningitic, bulge/abscess behind ear
Refer to ENT and treat like sepsis, abx = ceftriaxone
What is otitis media with effusion (glue ear)?
A collection of non-infective fluid in the middle ear, seen only in children
What is the otoscopy of someone with glue ear?
Viscous bubbles behind tympanic membrane, dull tympanic membrane, absent light reflex
How is glue ear managed?
Regular follow up as most will resolve in 3 months, if persistent hearing aids/grommets
What are the causes of perforated ear drum?
Recurrent otitis media infections, trauma, grommet insertion
What is the management of a perforated ear drum?
Washing out ear canal, topical antibiotics/steroids, allow perforation to heal
What are the risk factors for otitis externa?
Swimming, trauma to the ear, excessive use of cotton buds, immunocompromised
What are the causes of inflammation in the otitis externa?
Bacterial infection, fungal infection, eczema, seborrhoeic dermatitis, contact dermatitis
What is the most common bacterial cause of otitis externa?
Pseudomonas aeruginosa (gram negative rod)
What is the presentation of otitis externa?
Ear pain, discharge, itchiness, conductive hearing loss, erythema and swelling/tenderness in ear canal, lymphadenopathy
What is the management of otitis externa?
Mild = topical acetic acid 2%
Moderate = topical antibiotic and steroid e.g. neomycin/dexamethasone/acetic acid (need to exclude perforation before giving this
What is the management if the otitis externa has spread to the pinna (i.e. chondritis)?
IV antibioitics
What is malignant/necrotising otitis externa?
Severe and potentially life-threatening form of otitis externa where the infection has spread to the bones surrounding the ear canal and skull
What are the symptoms of malignant otitis externa?
Persistent headache, severe pain and fever
What is the management of malignant otitis externa?
Admission under ENT, IV abx, imaging to assess extent of infection
What should you do when an adult presents with unilateral glue ear?
Urgent referral to ENT for assessment to rule out posterior nasal space tumour
What are the symptoms of impacted ear wax?
Conductive hearing loss, discomfort in ear, pain, tinnitus, feeling of fullness
What are the red flags for tinnitus?
Unilateral, pulsatile, associated with any neurological deficits
What are the causes of tinnitus?
Impacted ear wax, ear infection, menieres disease, ototoxic medications, acoustic neuroma, MS, trauma, depression, anaemia, diabetes, thyroid disorders
What is associated with unilateral tinnitus?
Acoustic neuromas
What is associated with pulsatile tinnitus?
Glomus tumour
What is vertigo?
Sensation that either you are moving or that the room is moving - often a horizontal spinning sensation
Acute onset of vertigo is … until proven otherwise
Posterior circulation stroke (unless they have known meniere’s disease)
What are the causes of peripheral vertigo?
BPPV, meniere’s disease, vestibular neuronitis, labyrinthitis (more often sudden onset)
What are the central causes of vertigo?
Posterior circulation stroke (sudden) , tumours, MS, vestibular migraine (rest are gradual onset)
What would be the results of the HINTS exam in someone with a peripheral cause of vertigo?
Unidirectional nystagmus, no vertical skew, abnormal head impulse test
What would be the results of the HINTS exam in someone with a central cause of vertigo?
Bidirectional nystagmus, vertical skew, normal head impulse test
Once central causes have been ruled out how is vertigo managed?
Prochlorperazine is 1st line antiemetic for vertigo
What is the presentation of BPPV?
Recurrent episodes of vertigo triggered by head movements, symptoms settle after 20-60 seconds and patients are asymptomatic between attacks, NO hearing loss/tinnitus
What is done to diagnose BPPV?
Dix-Hallpike manoeuvre
How is BPPV managed?
Epley manoeuvre or Brandt-Daroff exercises done at home
What is the difference between vestibular neuronitis and labyrinthitis?
Vestibular neuronitis does not cause hearing problems or tinnitus whereas laryrinthitis does
What is the presentation of vestibular neuronitis?
Acute onset vertigo, may have preceding viral URTI (can be spontaneous), N+V, balance problems
What is the management for vestibular neuronitis?
Ensure not central cause of vertigo, prochlorperazine and antihistamine antiemetics, if do not improve after 1 week or resolve after 6 weeks refer to ENT
What is the presentation of labyrinthitis?
Acute onset vertigo, hearing loss, tinnitus, preceding URTI
What is the management of labyrinthitis?
Prochlorperazine and antihistamines, antibiotics are sued to treat bacterial cause, if hearing loss has not resolved after few weeks refer to ENT
What are the symptoms of meniere’s disease?
40-50 years old with unilateral episodes of vertigo, hearing loss and tinnitus, can last 20mins-2 hours before settling, patient feels unwell between episodes, tinnitus can become permanent, may have feeling of fullness in air or struggle with balance
How is meniere’s disease managed?
Clinical diagnosis by ENT, usually self resolves, use prochlorperazine during acute attacks, betahistine (can only be used short term)
Where do acoustic neruomas occur?
At the cerebellopontine angle
What is the presentation of acoustic neuromas?
40-60 years
Gradual onset and unilateral symptoms
Sensorineural hearing loss, tinnitus, dizziness, imbalance, fullness in ear, facial nerve palsy
What is the management of acoustic neuroma?
Audiometry, MRI/CT used to diagnose
Surgery to remove tumour or radiotherapy to shrink it, can leave it alone if not causing any symptoms
What is a cholesteatoma?
Abnormal collection of squamous epithelial cells in middle ear, not cancerous but can invade local tissues and erode bone etc.
What is the presentation of cholesteatoma?
Persistent foul-smelling brown discharge from ear, unilateral conductive hearing loss
On otoscopy = pearly white/grey appearance and brown discharge in ear canal
What is the management of cholesteatoma?
CT head/temporal bone = confirm diagnosis
Surgical removal of cholesteatoma (all of it must be removed or it will recur)
What foreign bodies require emergency care if suspected in the ear?
Live insects or button batteries
What is the presentation of Ramsay-Hunt syndrome?
Unilateral LMN facial nerve palsy, painful, tender vesicular rash in ear canal - due to VZV
What is the management of Ramsay-Hunt syndrome?
Prednisolone and aciclovir
What are the causes of epistaxis?
Nose picking, colds, sinusitis, vigorous nose blowing, trauma, coagulation disorder/anticoagulants, recreational drug use, tumours
What is the step wise approach for managing epistaxis?
- Sit up and tilt head forwards, squeeze nostrils together for 15-20 minutes
- Nasal cautery using silver nitrate sticks
- Nasal packing using nasal tampons
- Surgical ligation of the arteries
What are the causes of sinusitis?
Infection particularly viral URTI, allergies, obstruction in nasal passage, smoking, asthma
What is the presentation of sinusitis?
Nasal congestion, facial pain or headache, facial pressure/swelling, loss of smell, tenderness on palpation, fever
What is chronic sinusitis and what is the most common cause?
Chronic sinusitis involves symptoms for >12 weeks and is associated with nasal polyps
What is the management of sinusitis?
Reassurance unless not resolving after 10 days in which case high dose steroid nasal spray (mometasone) and a delayed abx prescription (phenoxymethylpenicillin)
What is a nasal polyp?
Growth of the nasal mucosa that can occur in the nasal cavity or sinuses
Is bilateral and unilateral nasal polyps a red flag and what is it a red flag for?
Red flag = unilateral as it raises suspicions of nasopharyngeal tumours
What are the symptoms of nasal polyps?
Chronic rhinosinusitis, difficulty breathing through nose, snoring, nasal discharge, loss of sense of smell
What is the management of nasal polpys?
Intranasal topical steroid drops/spray
Surgery is used when medical treatment fails
When assessing a nasal fracture what should you look for?
Nose deformity and septal haematoma (collection of blood within the septum which cuts off the blood supply to the cartilage and leads to saddle nose deformity
What are the most common causes of viral and bacterial tonsilitis?
Viral - adenovirus, influenza, rhinovirus
Bacterial - Group A strep
What do you score points for on the Centor/FeverPain scores?
Fever, exudative tonsils, absence of cough, tender lymph nodes, severely inflamed tonsils
When should you give antibiotics to a patient with tonsilitis?
Centor score >3 or FeverPAIN >4, immunocompromised, young infants or history of rheumatic fever
What is the 1st line antibiotic for tonsilitis?
Penicillin V for 10 day course (clarithromycin if penicillin allergy)
What are the complications of tonsilitis?
Peritonsillar abscess (quinsy), otitis media, scarlet fever, rheumatic fever, post-strep glomerulonephritis
What is the presentation of Quinsy?
Sore throat, painful swallowing, fever, neck/ear pain, swollen lymph nodes, unable to open mouth, change in voice, unilateral tonsil swelling with uvula deviating away from swelling
How is quinsy managed?
Needle aspiration or surgical incision and drainage
Abx before and after surgery e.g. IV co-amoxiclav
What are the indications for tonsillectomy surgery?
7 or more episodes of acute sore throat in a year
5 per year for 2 years
3 per year for 3 years
Recurrent tonsillar abscess
How is post-tonsillectomy bleeding managed?
Call ENT, gain IV access, analgesia, nil by mouth, IV fluids and encourage them to spit out rather than swallow
Hydrogen peroxide gargle and adrenalin-soaked swab can be applied topically if initial measures are unsuccessful
What is obstructive sleep apnoea?
Collapse of the pharyngeal airway which causes episodes of apnoea during sleep
What are the risk factors for OSA?
Middle age, male, obesity, alcohol, smoking
What is the presentation of OSA?
Episodes of apnoea during sleep, snoring, morning headache, waking up unrefreshed from sleep, daytime sleepiness
What scoring system is used to assess for OSA in primary care?
Epworth sleepiness scale
What is the management of OSA?
Sleep studies to diagnose
1st step = correct any reversible risk factors
CPAP
Surgery
What is the 2ww referral criteria for neck lumps?
Unexplained neck lump in someone aged 45 or above
A persistent unexplained neck lump at any age
USS neck is investigation
What are the causes of lymphadenopathy?
URTI, HIV, EBV, SLE, sarcoidosis, malignancy
What test is done to confirm EBV infection?
Monospot test
What should patients avoid following EBV infection?
Alcohol and contact sports due to risk of liver impairment and splenic rupture
What is the presentation of thyroglossal cyst?
Mobile, non-tender, midline neck lump which moves up and down with movement of tongue
What is a branchial cyst?
Round, soft, cystic swelling in anterior triangle of neck which usually presents after age of 10
What is a cystic hygroma?
Congenital lesion in posterior triangle of neck found in young children
What are the risk factors for head and neck cancer?
Smoking, chewing tobacco, alcohol, HPV strain 16, EBV infection
What are the red flags for head and neck cancer?
Lump in mouth or on the lip, unexplained ulceration in the mouth lasting more than 3 weeks, erythroplakia, unexplained hoarseness of voice, unexplained thyroid lump
What investigation is done to diagnose head and neck cancer?
Fine needle aspiration
What is the management of oral candidiasis?
Miconazole gel, nystatin suspension, fluconazole tablets
