ENT Flashcards
describe a thyroglossal duct cyst
fibrous cyst that forms from a persistent thyroglossal duct
most common congenital neck mass
features
- midline mass
- elevates with tongue protrusion
- painless (unless infected)
- smooth and cystic
presentation
- dysphagia
- breathing difficulty
treatment
- Sistrunk’s procedure: total resection with central part of hyoid bone to avoid recurrence
describe a branchial cyst
a cystic mass, remnant of embryonic development resulting from failure of obliteration of the second branchial cleft
squamous-lined cyst which develops under skin between SCM and pharynx
presentation
- asymptomatic
- painful if infected
- usually younger adults
investigation - US + FNA
treatment
- conservative
- surgical excision
describe a dermoid cyst
cystic teratoma
> midline mass that does not elevate upon tongue protrusion
contains mature skin, fat, hair
almost always benign
solid or hard in consistency usually limited to the skin
treatment
- complete surgical removal
describe a ranula
cystic swelling of floor of mouth
mucous extravasation from sublingual salivary gland
plunging ranula extends through FOM muscles into neck
describe a carotid body tumour (paragangliomas)
pulsatile compressible mass that refills rapidly on release of pressure
located at the adventitia of the common carotid artery bifurcation
list causes of dysphagia
oropharyngeal
- neurological
- pharyngeal diverticula
- tumour
oesophageal
- achalasia
- stricture
- oesophageal ring
- tumour
list causes of dysphonia
- malignant: squamous cell carcinoma
- benign: vocal cord nodules, papillomas, polyps or cysts
- neuromuscular: vocal cord palsy
- trauma: surgery, intubation, excess use of voice
- endocrine: hypothyroidism
- infective: laryngitis, candida
- functional: muscle tension dysphonia
list investigations and red flag symptoms in dysphonia
investigations
- CXR
- bloods e.g. TFTs
- flexible nasoendoscopic examination of the larynx
red flags
- persistent and worsening
- history of smoking and alcohol use
- accompanying haemoptysis, dysphagia, odynophagia, otalgia, neck mass
- unexplained weight loss
- hoarseness in immunocompromised patient
describe the presenting features of oral cavity cancer
- painless swelling
- non-healing ulcer
- neck swelling, if metastases are present
- red, erythematous, velvety mucous membrane (erythroplakia)
- white (leukoplakia) or mixed red-white lesions (speckled leukoplakia)
- lichen planus
describe laryngeal cancer and its treatment
symptoms
- dysphonia (painless and persistent)
- stridor and haemoptysis
- odynophagia and dysphagia
- neck lump
treatment
- early: radiotherapy or transoral laser surgery
- late: surgery, chemoradiotherapy
describe nasopharyngeal cancer and its treatment
rare tumour of postnasal space
risk factors: South Asian population, EBV
symptoms
- cervical lymphadenopathy
- otalgia
- unilateral secretory otitis media
- hearing loss
- cranial nerve palsy e.g. III-VI
- epistaxis / discharge
- nasal obstruction
imaging - CT/MRI
treatment
- chemotherapy and radiotherapy
- surgery
describe oropharyngeal cancer and its treatment
tongue base, posterior 1/3 of tongue, tonsils, soft palate
risk factors: smoking, alcohol, HPV 16/18
symptoms
- painless unilateral tonsillar swelling
- unilateral throat pain with worsening dysphagia
- otalgia
- neck lump
treatment
- early: radiotherapy or endoscopic surgery / TORS surgery
- late: chemoradiotherapy, surgery
describe hypopharyngeal cancer and its treatment
pyriform fossa, postcricoid or posterior pharyngeal wall tumours
risk factors: smoking, alcohol, Paterson-Brown-Kelly syndrome
symptoms
- dysphagia
- odynophagia
- otalgia
- dysphonia
- neck lump
treatment
- early: surgery, radiotherapy
- late: chemoradiotherapy, surgery
describe the causes, signs and symptoms of otitis externa
inflammatory or infective process affecting the skin of the external auditory canal
causes
- infection: bacterial (Pseudomonas aeruginosa, Staphylococcus aureus) or fungal
> pseudomonas aeruginosa: gram negative rod, non-lactose fermenting, oxidase positive
- Seborrhoeic dermatitis
- contact dermatitis
- recent swimming
features
- pruritus
- otalgia
- aural fullness
- hearing not affected unless substantial swelling of ear canal
- more severe: deafness, otorrhoea
signs
- pain on distraction of pinna
- otoscopy: red, swollen or eczematous canal / erythema and debris
- post-auricular lymphadenopathy
describe necrotising otitis externa
aka skull base osteomyelitis
features
- pain out of proportion with clinical examination
- discharge
risk factors: elderly, diabetes, immunosuppression, granulations/polyps
otoscopy - granulation tissue on floor of ear canal
associated with intracranial complications
> cranial nerve palsies, subdural empyema
investigations: biopsy, CT/MRI temporal bones, CRP
management
- 6-8 weeks IV antibiotics
- analgesia
describe the signs and symptoms of acute otitis media
acute inflammation of the middle ear with or without effusion
> most cases occur following viral URTI
> superimposed bacterial infection:
> streptococcus pneumoniae, haemophilus influenzae, moraxella catarrhalis
features
- otalgia
- otorrhoea follows pain (if drum perforates)
- pyrexia
- hearing loss
- children may tug at ear
otoscopy - thick hyperaemic tympanic membrane, sometimes spontaneous rupture of TM
describe benign paroxysmal positional vertigo (BPPV)
features
- positional vertigo (triggered by head movements)
- asymptomatic in between short-lived attacks (lasting seconds)
- no spontaneous nystagmus, no hearing loss or tinnitus
investigations
- confirm by Dix-Hallpike test
> head turned 45 degrees and neck extended 30 degrees
> nystagmus: latent period, torsional, repeatable, fatiguable
management
- Epley manoeuvre
- Brandt-Daroff exercises
describe the HINTS exam
head impulse test
- vestibular: positive
- brain: negative (usually)
nystagmus
- vestibular:
> unidirectional
> horizontal/torsional
> away from affected ear
> amplified by visual fixation suppression
- brain
> direction changing
> vertical
test of skew (cover test)
- vestibular: no skew deviation
- brain: skew deviation (ocular misalignment)
head shake nystagmus worsens in vestibular pathology not brain pathology
describe angioedema and its causes
causes
- idiopathic
- allergic: ACEi, aspirin, foods, transfusions
- non-allergic: C1 esterase inhibitor deficiency (acquired v hereditary)
pathophysiology
- allergic: type 1 response
- non-allergic: type 3 (autoimmune)
- C1-esterase inhibitor deficiency: unabated C1/C2 kinin mediator for angioedema
management
- oral antihistamines
- sometimes tranexamic acid
compare stridor and stertor
stridor
- high-pitched inspiratory or expiratory respiratory noise due to obstruction at the level of/ below larynx
- inspiratory: larynx
- expiratory noise: tracheobronchial
- biphasic: subglottic/glottic
stertor
- pharyngeal obstruction - snoring
describe Ludwig’s angina
infection spreading to floor of the mouth and soft tissues of neck
often secondary to dental infection
features
- neck swelling
- dysphagia
- fever
airway may be compromised, may require tracheostomy
management
- airway management
- IV antibiotics
describe the causes and management of sore throat
Causes: pharyngitis, tonsillitis, laryngitis
Management
> paracetamol / ibuprofen for pain relief
> antibiotics not routinely indicated
NICE indications for antibiotics
- features of marked systemic upset
- unilateral peritonsillitis
- history of rheumatic fever
- increased risk from acute infection (child with diabetes, immunodeficiency)
- Centor criteria >=3
- FeverPAIN score 4-5
Centor criteria:
- tonsillar exudate
- tender anterior cervical lymphadenopathy
- fever
- absence of cough
FeverPAIN
- Fever >38
- purulence (pharyngeal / tonsillar exudate)
- attend rapidly (3 days or less)
- severely inflamed tonsils
- no cough/coryza
Management: phenoxymethylpenicillin or clarithromycin if penicillin-allergic (7 or 10 day course)
CAUTION: DNSI
describe tonsillitis
symptoms
- odynophagia
- dysphagia
- lethargy
- pyrexia
signs
- red, enlarged, inflamed tosils
- +/- tonsillar exudate
- anterior cervical lymphadenopathy
causes
- viral: most common
- bacterial: group A beta haemolytic strep (Strep pyogenes), strep pneumoniae
management
- penicillin V: phenoxymethylpenicillin
> not amoxicillin as could be glandular fever (rash for up to 6 months)
- analgesia: paracetamol and diclofenac
- does not need admission unless unable to eat/drink
describe glandular fever
aka infectious mononucleosis, caused by EBV infection
spread by saliva: kissing, sharing toothbrushes…
features
- fever, fatigue
- sore throat
- tonsillar exudate
- lymphadenopathy
- hepatosplenomegaly (avoid alcohol, contact sports, sharing saliva)
investigation - monospot test
pruritic maculopapular rash (non-allergic) with amoxicillin in 50% of cases; can last 6 months
describe quinsy
aka peritonsillar abscess
symptoms
- sore throat
- painful swallowing
- fever
- neck pain
- referred ear pain
- swollen tender lymph nodes
- trismus - decreased mouth opening
- deviation of uvula
- change in voice - hot potato voice
causes: group A strep (strep pyogenes), haemophilus influenzae, staph aureus
management
- drain abscess
- IV antibiotics +/- dexamethasone
- consider tonsillectomy if more than one episode
describe indications for tonsillectomy and management of post-tonsillectomy bleeds
indications for tonsillectomy
- 7 or more episodes in 1 years
- 5 per year for 2 years
- 3 per year for 3 years
other indications
- recurrent quinsy (2 episodes)
- enlarged tonsils causing difficulty breathing, swallowing or snoring
management of post-tonsillectomy bleed
- mild bleeds: hydrogen peroxide gargle, adrenalin soaked swab applied topically
- severe bleed: return to theatre
- bleeds within 24h: return to theatre
- secondary bleed (5-10 days): likely infection
> antibiotics + admission unless severe bleed
describe deep neck abscesses
types
- submental (Ludwig’s)
- parapharyngeal
> neck mass, unwell, febrile
> decreased rotational neck movements - retropharyngeal
> swinging pyrexia (picket fence)
> decreased neck movements
> may be relatively well
> may cause airway compromise
> abscess may rupture during intubation - prevertebral
describe mastoiditis
usually in children
symptoms
- ear pulling (children)
- otalgia
- fever
- headache
- otorrhoea
- hearing loss
- vertigo
signs: recent episode of AOM +
- proptosed auricle
- post-auricular swelling
- post-auricular erythema
- post-auricular tenderness
investigations: clinical diagnosis
> - CT head / temporal bones and drainage if unwell
management
- 24h IV antibiotics if well
- surgical intervention if unwell: tympanocentesis, myringotomy, cortical mastoidectomy
describe an intracerebral abscess
imaging: CT brain with contrast
presents as ring-enhancing lesion
requires neurosurgical referral
describe Pott’s puffy tumour
complication of frontal sinusitis
frontal swelling due to frontal bone osteomyelitis with associated subperiosteal abscess
usually preceding URTI
management
- IV antibiotics urgently for 4-6 weeks
- surgery: abscess drainage
describe the treatment of epistaxis
bleeding most likely to originate from Kiesselbach’s plexus, located in Little’s area
haemodynamically stable:
> first aid
- head forward over bowl/sink
- pinch soft part of nose
- ice over bridge/back of neck/in mouth
- topical antiseptic e.g. naseptin (unless peanut/soy allergy, in which case bactroban)
if bleeding does not stop after 10-15 minutes of continuous pressure consider cautery or packing
> silver nitrate cautery if source is visible
> nasal packing if source is not visible
- haemodynamically unstable
> control with first aid measures, if source is not visible admit to hospital
> if fails all emergency management - sphenopalatine artery ligation in theatre
list causes of epistaxis
- trauma
- nasal septum deviation / spur / perforation
- iatrogenic
- inflammation
- foreign body
- environmental
- malignancy
- systemic disorders: Hereditary Haemorrhagic Telangiectasia (HHT)
describe a septal haematoma
causes
- nasal trauma
- post-operative complication
appearance - boggy cherry red swelling outpouching from nasal septum
needs to be seen by ENT same day
management
- incision and drainage
- antibiotics
complications
- septal perforation leading to saddle nose deformity
- septal abscess
- cavernous sinus thrombosis
- meningitis
- cerebral abscess
state the presentation and treatment of a nasal fracture
presentation
- bilateral/unilateral ecchymosis
- swelling over nasal bridge (within 2h)
- visible deformity of nasal bones
- epistaxis
anterior rhinoscopy
- epistaxis
- septal deviation
- septal haematoma
management
- assessment in nasal fracture clinic after 5-7 days when swelling settles
- conservative or manipulation under LA/GA
- septorhinoplasty if manipulation unsuccessful or severe deformity
describe facial nerve palsy
causes
- upper motor neuron
> unilateral: stroke, tumour
> bilateral: pseudobulbar palsy, MND
- lower motor neuron
> Bell’s palsy: idiopathic
» management: prednisolone within first 72h, lubricating eye drops, eye taping
> Ramsay Hunt Syndrome: caused by varicella zoster virus (VZV), accompanied by painful vesicular rash around ear, tongue and hard palate
> management: prednisolone, aciclovir
- other: infection, trauma, malignancy
treatment
- underlying cause
- start steroids if within 72h
- eye protection
- if no improvement after 3 weeks, refer urgently to ENT
describe Ramsay Hunt syndrome
aka herpes zoster oticus caused by reactivation of the varicella zoster virus in the geniculate ganglion of CN VII
features
- auricular pain
- facial nerve palsy
- vesicular rash: ear, hard palate, tongue
- hearing loss
- vertigo, tinnitus
management
- analgesia, eye protection
- oral aciclovir and prednisolone
describe an auricular haematoma
usually due to trauma
cartilage loses blood supply, leads to necrosis and infection
cauliflower ear deformity
management
- urgent drainage
describe tympanic membrane perforation
causes
- trauma (exclude base of skull fracture)
- barotrauma
- acoustic trauma
- infection
features
- hearing loss
- bleeding ear / discharge
management
- uncomplicated perforations usually heal within 6-8 weeks and do not require review
- antibiotics if caused by otitis media
- myringoplasty if TM does not heal by itself
describe acoustic neuroma
aka vestibular schwannoma
bilateral acoustic neuromas are associated with neurofibromatosis type II
presentation (40-60 years of age)
- unilateral sensorineural hearing loss
- unilateral tinnitus
- dizziness or imbalance
- sensation of aural fullness
- facial nerve palsy
investigations: MRI of cerebellopontine angle
management
- conservative: monitoring
- surgery
- radiotherapy to reduce growth
describe a cholesteatoma
aka active squamous otitis media
non-cancerous growth of squamous epithelium in middle ear or mastoid causing local destruction
most common in patients aged 10-20 years
risk factor: cleft palate
features
- unilateral conductive hearing loss
- foul discharge
- discharging ear that does not resolve with antibiotic treatment
- frequent infections
- pain
- vertigo
- facial nerve palsy
otoscopy - attic crust - seen in uppermost part of ear drum
management - ENT referral for surgical removal
- mastoidectomy
- atticotomy
- atticoantrostomy
describe active mucosal chronic otitis media (COM)
perforation with inflammation of middle ear mucosa
symptoms
- pain initially
- discharging ear
- hearing loss
management
- medical
> aural toilet (microsuction)
> antibiotics/steroid drops/sprays
- surgical
> myringoplasty or tympanoplasty
list causes of otorrhoea
- otitis externa
- acute otitis media with perforation
- active chronic otitis media
> mucosal
> squamous - trauma: CSF / blood
list causes of otalgia
- otitis externa
- necrotising otitis externa
- acute otitis media
- furuncle in ear canal
- otitis media with effusion (OME)
- temporomandibular joint (TMJ)
- referred pain
describe otitis media with effusion (OME)
Very common in children
fluid or “glue” in middle ear
features: reduction in hearing in affected ear, otalgia only in early stages
otoscopy: dull tympanic membrane with air bubbles or visible fluid level
associated with air travel + URTI
management
- referral for audiometry
- decongestant nose drops to nasopharynx
- Valsalva manoeuvre / otovent
- ventilation tubes
- hearing aid
describe allergic rhinitis
inflammatory disorder of the nose where it becomes sensitised due to allergens such as house dust mites, grass and tree pollens
classification
- seasonal (hay fever)
- perennial
- occupational
features
- bilateral nasal obstruction
- clear nasal discharge
- nasal pruritus
- post-nasal drip
- sneezing
- +/- red/watery eyes
- pale, oedematous and enlarged turbinates
management
- allergen avoidance
- mild symptoms: oral / intranasal antihistamines
- moderate/severe: intranasal steroids
- topical nasal decongestants e.g. oxymetazoline (short courses)
- severe: systemic corticosteroids
describe non-allergic rhinitis
causes
- air pollutants
- smoke
- alcohol
- weather changes
- hormonal changes
treatment
- saline douching / spray
- trigger avoidance / reduction
- +/- nasal steroid
describe rhinitis medicamentosa
rebound nasal congestion and rhinorrhoea due to decongestant nasal sprays
e.g. xylometazoline HCl, phenylephrine
can occur after 7 days
treatment - stop use
describe nasal polyps
growths of nasal mucosa that can occur in nasal cavity or sinuses
features
- round pale grey/yellow growths
- insensate
symptoms
- rhinorrhoea
- nasal obstruction
- sneezing
- smell disturbance
- poor sense of taste
red flags: unilateral symptoms, bleeding
associations
- chronic rhinitis or sinusitis
- asthma
- eosinophilic granulomatosis with polyangiitis
- cystic fibrosis
- kartagener’s syndrome
- aspirin sensitivity
management
- intranasal topical steroid drops/spray e.g. mometasone furoate 4-6 weeks
- surgery: intranasal polypectomy or endoscopic nasal polypectomy
describe sinusitis
inflammation of the nose and paranasal sinuses leading to:
- two or more symptoms of nasal blockage / obstruction / congestion or nasal discharge
+/- facial pain, +/- hyposmia/anosmia AND endoscopic features
> nasal polyps
> mucopurulent discharge / oedema in middle meatus
OR CT changes of osteomeatal complexes
acute rhinosinusitis: <12 weeks with complete resolution of symptoms
chronic rhinosinusitis: >12 weeks without complete resolution of symptoms
management
- acute
> high dose steroid nasal spray
> delayed antibiotic prescription (phenoxymethylpenicillin)
- chronic:
> saline nasal irrigation
> steroid nasal sprays or drops
> functional endoscopic sinus surgery (FESS)
describe acute bacterial rhinosinusitis
features
- discoloured discharge
- severe, localised facial pain
- pyrexia
- raised CRP/ESR
- deterioration after initial milder symptoms
examination: anterior rhinoscopy
treatment
- nasal irrigation
- consider topical steroids and oral antibiotics
describe septal deviation
normal variant, can be post-traumatic
symptoms
- mostly asymptomatic
- snoring
treatment
- exclude or treat concurrent pathology e.g. allergic rhinitis
- trial of medical therapy
- septoplasty if symptoms match deformity
list red flags for sinonasal malignancy
- unilateral symptoms
- blood-stained discharge
- dental/orbital signs
> loose teeth
> proptosed eye
> unilateral decreased eye movements
describe septal perforation
sensation of nasal obstruction due to altered airflow and crusting
causes
- idiopathic
- rhinotillexomania
- cocaine use
- iatrogenic
- autoimmune
symptomatic treatment
- saline douching
- vaseline
surgery
- septal button
- flaps
describe differentials for facial pain referred as sinusitis
midfacial segment pain
- tension type headache of mid face
- can have blocked nose sensation, symmetrical, hypersensitivity, normal examination
- treatment: amitriptyline
trigeminal autonomic cephalalgias
- cluster headache
- autonomic symptoms including blocked nose, watery eye
- treatment: tryptan / verapamil
chronic paroxysmal hemicrania
- unilateral headache around the eye
- treatment: NSAIDs
list causes of reduced sense of smell (hyposmia)
anatomical obstruction
- polyps
- rhinosinusitis
- tumour - olfactory neuroblastoma
- turbinate oedema
sensorineural
- post-viral / URTI
- congenital - Kallman syndrome
- idiopathic
describe globus sensation
feeling of lump / something stuck in throat / tightness in throat
no sinister pathological findings or red flag symptoms
caused by increased tension in muscles of neck / pharynx
> stress and anxiety
> acid reflux
list red flags for head and neck cancer
hoarseness for >3 weeks
ulceration or swellings of the mucosa >3 weeks
red and white patches in oral mucosa
dysphagia
persistent unilateral nasal obstruction especially if accompanying purulent discharge
neck masses >3 weeks duration
cranial nerve involvement
persistent unilateral otalgia with normal otoscopy
list causes of hoarse voice
- laryngeal cancer
- laryngitis
- vocal cord palsy (lung primary)
- vocal cord polyp
- vocal cord granuloma
- respiratory papillomatosis
- reinke’s oedema
- vocal nodules
- muscle tension dysphonia
list differential diagnoses for neck masses in adults
midline
- non-inflammatory
> thyroid nodules
> thyroglossal duct cyst
> dermoid cyst - inflammatory thyroiditis
lateral
- non-inflammatory
> benign
» branchial cyst
» parotid tumours
» paraganglioma
» lipoma
> malignant
> metastatic SCC
> parotid cancer
> lymphomas
- inflammatory
> lymphadenitis
> parotitis
> submandibular sialadenitis
list causes of a parotid lump
lateral mass
- mostly benign
> pleomorphic adenoma (malignant potential)
> warthin’s tumour (can be bilateral) - malignant
> pain
> facial nerve palsy
> skin changes
> lymphadenopathy
> may have intraoral component
investigations - US + FNA
describe vestibular neuronitis
symptoms
- acute vertigo without hearing loss/tinnitus
- horizontal nystagmus
- usually after URTI
- nausea and vomiting
- balance problems
- vertigo starts out as constant, then may be triggered/exacerbated by head movement
- resolves after weeks
patient may be unwell, bedbound, absent from work
symptomatic management
> mild/moderate: oral cinnarazine, cyclizine, promethazine
> severe: buccal or IM prochlorperazine, acute phase only
> chronic: vestibular rehabilitation exercises (>1 week)
describe acute labyrinthitis
symptoms
- acute vertigo
- hearing loss, tinnitus
- follows URTI, may have coryzal symptoms
lasts weeks, constant then resolves
patient will be unwell, bedbound, absent from work
management
- prochlorperazine (max 3 days)
- antihistamines e.g. cyclizine
describe Meniere’s disease
features
- prodrome of unilateral aural fullness
- unilateral sensorineural hearing loss and tinnitus
> initially accompany vertigo then may become permanent
- vertigo
- unexplained falls, or “drop attacks” without loss of consciousness
- imbalance
- unidirectional nystagmus during acute attack
lasts days to months, episodes of vertigo last from 20 mins to several hours
patient usually 40-50 years old
management
- symptomatic: prochlorperazine, antihistamines
- prophylaxis: betahistine
- vestibular destructive treatment
describe vestibular migraine
presents with vertigo as well as typical features of migraine
> unilateral headache, photophobia, phonophobia
usually diagnosis of exclusion as can mimic central causes of vertigo
associated with history of migraine
management - migraine treatment
describe pharyngeal pouch
aka Zenker’s diverticulum, due to defect in Killian’s dehiscence
features
- dysphagia
- regurgitation of unaltered food
- foul breath
- chronic cough
- recurrent chest infections
- weight loss
usually over 70s
management
- conservative: alter diet, manage risk factors
- medical: reflux control
- surgical: endoscopic division / stapling or open resection
list silent reflux symptoms
- sore throat
- lump in throat sensation
- post-nasal drip sensation
- nocturnal cough
- hoarse voice
- excessive throat clearing
- throat closing over (laryngospasm)
- water brash (liquid appearing in throat)
describe signs of laryngopharyngeal reflux disease (LPR) and its treatment
features
- posterior commissure oedema
- cobblestoning of posterior pharyngeal wall
treatment
- weight loss
- alginate (patients may still have silent reflux on PPI due to reflux of other gastric enzymes into pharynx)
- PPI
- H2 receptor antagonist
list complications of GORD
- oesophagitis including erosions and ulcers
- Barrett’s oesophagus
- carcinoma of oesophagus
- laryngeal granulomas
- laryngospasm
- stenosis
- laryngeal carcinoma
describe sialolithiasis
features
- intermittent pain and swelling associated with meals
> +/- palpable hard lump in duct
may develop infection, associated with erythema and discharging pus
- mostly submandibular gland (longest duct)
treatment
- non-operative:
> hydration, sialogogues, analgesia +/- antibiotics
> sialendoscopy if required - surgery:
> incision over duct to remove stone
> gland removal
describe sialadenitis
infection or inflammation of salivary glands
can be acute or chronic
swelling of gland +/- pain +/- systemic upset
causes
- virus/bacteria e.g. mumps
- autoimmune e.g. Sjogren’s
- parotitis can be associated in elderly or institutionalised adults
management
- supportive: rehydration, sialogogues, antibiotics
describe the Centor criteria and the FeverPAIN score
Centor criteria: >=3 offer antibiotics
- fever over 38
- tonsillar exudates
- absence of cough
- tender anterior cervical lymphadenopathy
FeverPAIN score: >=4 offer antibiotics
- fever during previous 24h
- purulence
- attended within 3 days of onset
- inflamed tonsils
- no cough or coryza
also consider antibiotics if
- young infants or immunocompromised
- significant comorbidity
- history of rheumatic fever
describe universal hearing screening programme (UNHS)
2 types
- otoacoustic emissions test
- automated brainstem responses (if abnormal otoacoustic emissions test)
part of newborn screening
> key part of speech and language development
if hearing is normal consider other causes e.g. developmental delay, autism
describe otitis media with effusion (OME)
aka glue ear
> due to shorter, wider Eustachian tube in children, easily occluded
very common in 3-5 age group
middle ear fluid for at least 3 months in the absence of overt signs of infection
risk factors: parental smoking, nursery attendance, siblings with OME, bottle feeding, low socioeconomic groups, AOM
associated conditions
- cleft palate
- Down’s syndrome
- craniofacial abnormalities
- primary ciliary dyskinesia
management:
> conservative - watch and wait (3 months)
> if unimproved after 3 months
» hearing aid
» grommet insertion (ventilation tube) (+/- adenoidectomy to improve ventilation of nasopharynx)
describe hearing tests in children
dependent on developmental stage of child
subjective:
- distraction testing: 6-9 months
- recognition of familiar objects: 18 months-2.5 years
- performance testing and speech discrimination tests: >24 months
- pure tone audiometry: >3 years (done at school entry)
objective
- tympanometry
- audiogram: air and bone conduction comparisons
> gap in air bone conduction: conductive hearing loss
> both reduced: sensorineural hearing loss
management of hearing loss in children
dependent on type of hearing loss
conservative
> conductive: bone-conducting bands
> sensorineural: hearing aids
surgery
> conductive: bone-conducting hearing aids
> sensorineural: cochlear implant
describe recurrent acute otitis media and its management
recurrent acute otitis media
- 3 or more episodes of AOM in 6 months OR 4 or more in 12 months
- more common <2 years old
- breast milk is protective
management
- prophylactic amoxicillin for 6 weeks
- grommet insertion
describe the management of otitis externa
mild
- topical acetic acid 2%
moderate/severe
- topical antibiotic + steroid for 1-2 weeks
> e.g. gentamicin + hydrocortisone
- ciprofloxacin + dexamethasone
- otomize (neomycin/dexamethasone/acetic acid)
- if canal debris consider removal, if canal is extensively swollen then insert ear wick
second-line
- consider contact dermatitis secondary to neomycin
- oral antibiotics (flucloxacillin) if infection is spreading
- take a swab inside ear canal
- empirical use of topical antifungal e.g. clotrimazole
If the patient fails to respond to topical antibiotics refer to ENT
Malignant otitis externa more common in elderly diabetics - extension of infection into bony ear canal and soft tissues
describe the management and complications associated with acute otitis media
management
> paracetamol and ibuprofen first 48-72h, usually self-limiting
> > antibiotic treatment if failed watch & wait OR less than 2 years old
> > 5 day course of oral amoxicillin/co-amoxiclav 2nd line)
> > consider topical antibiotics (ciprofloxacin) if prolonged otorrhoea
complications
- intracranial abscess
- facial nerve palsy
- mastoiditis
- meningitis
describe the following tongue conditions
- glossitis
- oral candidiasis
- glossitis: smooth, red, sore, swollen tongue
> iron deficiency anaemia
> B12 deficiency
> folate deficiency
> coeliac disease
management - treat underlying cause
- oral candidiasis: white spots/patches on tongue
> inhaled corticosteroids
> antibiotics
> diabetes
> immunodeficiency
> smoking
management - miconazole gel, nystatin suspension, fluconazole tabletes (if severe or recurrent)
describe the following tongue conditions
- geographical tongue
- strawberry tongue
- black hairy tongue
- geographical tongue
> benign inflammatory condition causing patches of tongue with no epithelium / papillae
> related to: mental illness/stress, psoriasis, atopy, diabetes
> management: conservative with antihistamines or topical steroids if burning/discomfort - strawberry tongue
> swollen red tongue with enlarged white papillae
> causes: Kawasaki disease and scarlet fever - black hair tongue
> due to lack of exfoliation of keratin
> also sticky saliva and metallic taste
> causes: dehydration, dry mouth, poor oral hygiene, smoking
> management: adequate hydration, gentle brushing of tongue, smoking cessation
describe gingivitis
symptoms
- swollen gums
- bleeding after brushing
- painful gums
- halitosis
risk factors
- plaque build-up
- smoking, diabetes, malnutrition, stress
management
- good oral hygiene
- smoking cessation
- removal of tartar and plaque by dental hygienist
- chlorhexidine mouth wash
complication: periodontitis
> severe and chronic inflammation of the gums and tissues that support teeth
> can lead to loss of teeth
acute necrotising ulcerative gingivitis
- rapid onset of more severe inflammation in the gums
- painful
- cause: anaerobic bacteria
- management: paracetamol + chlorhexidine moutwash + oral metronidazole
describe aphthous ulcers
very common, small, painful ulcers of mucosa in mouth
well-circumscribed, punched-out, white appearance
causes
- idiopathic
- stress
- trauma
- associated with
> IBD, coeliac disease
> Behcet’s disease
> vitamin deficiency: iron, B12, folate, vit D
> HIV
management
- usually heal within 2 weeks
- topical symptomatic treatment: choline salicylate, benzydamine, lidocaine
- if more severe, topical steroids e.g. hydrocortisone buccal tablets
describe a cystic hygroma
malformation of the lymphatic system that results in a cyst filled with lymphatic fluid
most commonly a congenital abnormality located in posterior triangle of neck on left side
features
- can be very large
- soft
- transilluminates
- non-tender
treatment
- watch and wait
- aspiration (temporary solution)
- surgical removal
- sclerotherapy
list causes of hearing loss in children
congenital
- maternal rubella, cytomegalovirus infection during pregnancy
- genetic deafness
- down’s syndrome
perinatal
- prematurity
- hypoxia during/after birth
after birth
- jaundice
- meningitis and encephalitis
- otitis media or glue ear
- chemotherapy
describe obstructive sleep apnoea (OSA)
risk factors: middle age, obesity, smoker, alcohol, male
features
- episodes of apnoea during sleep reported by partner
- snoring
- morning headache
- waking up unrefreshed from sleep
- daytime sleepiness
- concentration problems
- reduced oxygen saturation during sleep
complications - hypertension, heart failure, MI, stroke
investigations
> Epworth Sleepiness Scale
> polysomnography
management
> Weight loss
> oral appliances: mandibular advancement devices, tongue retaining devices
> CPAP
> surgery: uvulopalatopharyngoplasty (UPPP)
list causes of rapid onset conductive hearing loss
- ear wax
- infection e.g. otitis media/otitis externa
- fluid in the middle ear (effusion)
- Eustachian tube dysfunction
- perforated tympanic membrane
describe sudden sensorineural hearing loss (SSHL)
causes
- 90% are idiopathic
- infection: meningitis, HIV, mumps
- Meniere’s disease
- ototoxic medications e.g. gentamicin
- MS
- migraine
- stroke
- acoustic neuroma
- Cogan’s syndrome
investigations
- audiometry: at least 30dB hearing loss in 3 consecutive frequencies
- MRI/CT head
management
- immediate referral to ENT
- idiopathic SSHL:
> steroids: 7 days oral prednisolone
describe age-related voice change (presbyphonia)
common cause of hoarse voice
bowing of vocal cords due to atrophy
leads to incomplete glottic closure
describe presbycusis
aka age-related sensorineural hearing loss
features
- affects high-pitched sounds more
- gradual and symmetrical hearing loss
- sometimes tinnitus
risk factors: age, male gender, family history, smoking, ototoxic medications
audiometry
> sensorineural hearing loss, almost normal at low pitches worsening with higher pitches
management
- hearing aids
- cochlear implants
describe laryngitis
common, short-lasting acute inflammation affecting laryngeal mucosa
causes
- URTI
- chemical injury
- physical injury
management
- spontaneous recovery: voice rest, hydration, steam
chronic/recurrent laryngitis: laryngeal reflux, smoking, alcohol, snoring
describe vocal cord palsy
features
- breathy voice
- cough/choking after swallowing
causes
- iatrogenic: neck surgery
- malignancy: direct invasion of larynx or recurrent laryngeal nerve
- stroke
- neck or chest injury
- neurological
- viral infections
treatment
- conservative
- speech and language therapy
- cord medialisation procedures
- cordotomy procedures (if airway compromise)
describe the following
- vocal cord polyp
- vocal cord granuloma
vocal cord polyp
- pedunculated or sessile lesions, often unilateral
- associated with inflammatory changes
- causes
> physical: voice abuse, chronic cough
> chemical: LPR, smoking, alcohol
> infection
> allergy
vocal cord granuloma
- caused by continuous damage and subsequent healing process
> intubation trauma, arytenoid granuloma
describe recurrent respiratory papillomatosis (RRP)
affects children and adults
> HPV types 6 & 11
treatment
- endoscopic removal with microdebrider
- laser
- mitomycin / interferon
- HPV vaccination
describe Reinke’s oedema
inflammatory oedema, often bilateral
causes
- smoking
- severe laryngeal reflux
results in deepening of voice
management
- lateral cordotomy (remove fluid) if required
- smoking cessation
describe vocal cord nodules
due to voice misuse - singers, sports coaches, children
treatment: speech and language therapy
describe TMJ dysfunction
features
- women 30-50
- pain in jaw or front of ear
- associated with clicking, grinding or crepitus
- pain can spread around ear, cheek, temple, teeth
- worsened by stress
management
- self-resolving but requires analgesia or jaw muscle exercises
describe glomus tumours
paragangliomas that can occur within
- middle ear (tympanicum)
- temporal bone (jugulare)
- vagus nerve (vagale)
- carotid body (carotid body tumour)
presentation
- persistent pulsatile tinnitus
- hypertension (release of catecholamines)
otoscopy
- pulsating red mass behind eardrum
explain the interpretation of Rinne’s test
+ve test: air conduction louder than bone conduction
> normal hearing
> sensorineural hearing loss
-ve test: bone conduction louder than air conduction
> conductive hearing loss
explain the interpretation of Weber’s test
normal: sounds the same in both ears
sensorineural hearing loss: heard louder in healthy ear
conductive hearing loss: heard louder in affected ear
describe a tracheostomy
tracheostomy
- between 3-4th tracheal rings
- connection remains between nose and mouth to lungs
- can be temporary or permanent
- types
> percutaneous
> Björk flap
> Slit (children)
emergency management (call senior)
- A-E assessment
- oxygen (mouth + stoma)
- emergency airway manouevres (head tilt / chin lift) + airway adjuncts
- suction: remove foreign body
- nebulised adrenaline 1:1000 1mg in 5mls saline
- IV steroids / IV antibiotics
- Heliox
- NBM
describe a laryngectomy
laryngectomy
- removal of larynx
- indications: usually due to cancers
- no connection between nose/mouth and lungs
emergency management
- do not perform airway manouevres
- place O2 mask over neck stoma
differentiate between pinna perichondritis and cellulitis
perichondritis affects cartilage of pinna but NOT lobe
cellulitis affects lobe
most common cause is penetrating ear trauma e.g. piercings
if symptoms involve pinna and nose and are mild, may be relapsing polychondritis, autoimmune condition
features
- erythema
- swelling
- pain
- associated otitis externa
- clinical hearing deficit
- spreading cellulitis to face/scalp
- abscess
- necrosis of soft tissue
common organisms: P. aeruginosa, S. aureus
management: oral fluoroquinolones
describe indications for urgent referral for head and neck cancer
- mouth ulcers persisting > 3 weeks: oral surgery
- unexplained red, or red and white patches that are painful, swollen or bleeding
- unexplained one-sided pain in the head and neck area > 4 weeks, associated with ear ache, but normal 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
- symptoms in oral cavity persisting > 6 weeks, that cannot be definitively diagnosed as a benign lesion
- level of suspicion should be higher in patients who are >40, smokers, heavy drinkers, chewing tobacco or betel nut (areca nut).
describe otosclerosis
replacement of normal bone by vascular spongy bone
causes a progressive conductive deafness due to fixation of the stapes at the oval window.
onset 20-40 years
features
- conductive hearing loss
- tinnitus
- positive family history (AD inheritance)
otoscopy
- normal or “flamingo” tinge due to hyperaemia
management
- hearing aid
- stapedectomy
describe a pleomorphic adenoma of the parotid gland
benign most common tumour of parotid gland
Clinical features
- gradual onset, painless unilateral swelling of the parotid gland
- movable on examination
Management: surgical excision due to risk of malignant transformation
list causes of tinnitus
- idiopathic
- meniere’s
- vestibular neuronitis
- labyrinthitis
- otosclerosis
- sudden onset sensorineural hearing loss
- acoustic neuroma
- drugs
> aspirin / NSAIDs
> aminoglycosides
> loop diuretics
> quinine - impacted ear wax
imaging
- non-pulsatile: MRI of internal auditory meatuses
- pulsatile: magnetic resonance angiography
management
- treat underlying cause
- amplification devices
- support groups, CBT
briefly describe the following causes of hearing loss
- presbycusis
- otosclerosis
- glue ear
- meniere’s disease
- drug ototoxicity
- noise damage
- acoustic neuroma (Vestibular schwannoma)
presbycusis: age-related sensorineural hearing loss.
otosclerosis: genetic disorder causing conductive deafness and tinnitus at 20-40 years of age. Flamingo tinge on tympanic membrane.
glue ear: otitis media with effusion
meniere’s disease: recurrent episodes of spontaneous vertigo, tinnitus and hearing loss (sensorineural). Sensation of aural fullness or pressure. Nystagmus and positive Romberg’s. patients have episodes that remit and recur.
Drug ototoxicity: aminoglycosides e.g. gentamicin; furosemide, aspirin, cytotoxic agents
Noise damage: workers in heavy industry, bilateral hearing loss
acoustic neuroma:
> CN VIII: hearing loss, vertigo, tinnitus
> CN V: absent corneal reflex
> CN VII: facial palsy
> bilateral acoustic neuromas seen in neurofibromatosis type 2
> visualise with MRI of cerebellopontine angle
describe sialolithiasis
stones most commonly form in submandibular gland
can occlude Wharton’s duct
features
- episodic facial pain
- discomfort whilst eating
- halitosis
- dry mouth
- smooth swelling under mandible
Investigation - sialography
Management
- Stones impacted in the distal aspect of Wharton’s duct - removed orally
- other stones and chronic inflammation - gland excision
describe management of MRSA colonisation in surgical pre-assessment
nasal mupirocin + chlorhexidine for the skin
