ENT Flashcards

1
Q

describe a thyroglossal duct cyst

A

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

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2
Q

describe a branchial cyst

A

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

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3
Q

describe a dermoid cyst

A

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

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4
Q

describe a ranula

A

cystic swelling of floor of mouth

mucous extravasation from sublingual salivary gland

plunging ranula extends through FOM muscles into neck

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5
Q

describe a carotid body tumour (paragangliomas)

A

pulsatile compressible mass that refills rapidly on release of pressure

located at the adventitia of the common carotid artery bifurcation

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6
Q

list causes of dysphagia

A

oropharyngeal
- neurological
- pharyngeal diverticula
- tumour

oesophageal
- achalasia
- stricture
- oesophageal ring
- tumour

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7
Q

list causes of dysphonia

A
  • 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
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8
Q

list investigations and red flag symptoms in dysphonia

A

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

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9
Q

describe the presenting features of oral cavity cancer

A
  • 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
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10
Q

describe laryngeal cancer and its treatment

A

symptoms
- dysphonia (painless and persistent)
- stridor and haemoptysis
- odynophagia and dysphagia
- neck lump

treatment
- early: radiotherapy or transoral laser surgery
- late: surgery, chemoradiotherapy

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11
Q

describe nasopharyngeal cancer and its treatment

A

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

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12
Q

describe oropharyngeal cancer and its treatment

A

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

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13
Q

describe hypopharyngeal cancer and its treatment

A

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

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14
Q

describe the causes, signs and symptoms of otitis externa

A

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

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15
Q

describe necrotising otitis externa

A

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

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16
Q

describe the signs and symptoms of acute otitis media

A

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

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17
Q

describe benign paroxysmal positional vertigo (BPPV)

A

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

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18
Q

describe the HINTS exam

A

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

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19
Q

describe angioedema and its causes

A

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

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20
Q

compare stridor and stertor

A

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

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21
Q

describe Ludwig’s angina

A

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

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22
Q

describe the causes and management of sore throat

A

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

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23
Q

describe tonsillitis

A

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

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24
Q

describe glandular fever

A

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

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25
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
26
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
27
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
28
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
29
describe an intracerebral abscess
imaging: CT brain with contrast presents as ring-enhancing lesion requires neurosurgical referral
30
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
31
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
32
list causes of epistaxis
- trauma - nasal septum deviation / spur / perforation - iatrogenic - inflammation - foreign body - environmental - malignancy - systemic disorders: Hereditary Haemorrhagic Telangiectasia (HHT)
33
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
34
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
35
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
36
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
37
describe an auricular haematoma
usually due to trauma cartilage loses blood supply, leads to necrosis and infection cauliflower ear deformity management - urgent drainage
38
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
39
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
40
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
41
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
42
list causes of otorrhoea
- otitis externa - acute otitis media with perforation - active chronic otitis media > mucosal > squamous - trauma: CSF / blood
43
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
44
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
45
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
46
describe non-allergic rhinitis
causes - air pollutants - smoke - alcohol - weather changes - hormonal changes treatment - saline douching / spray - trigger avoidance / reduction - +/- nasal steroid
47
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
48
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
49
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)
50
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
51
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
52
list red flags for sinonasal malignancy
- unilateral symptoms - blood-stained discharge - dental/orbital signs > loose teeth > proptosed eye > unilateral decreased eye movements
53
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
54
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
55
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
56
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
57
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
58
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
59
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
60
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
61
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)
62
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
63
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
64
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
65
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
66
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)
67
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
67
list complications of GORD
- oesophagitis including erosions and ulcers - Barrett's oesophagus - carcinoma of oesophagus - laryngeal granulomas - laryngospasm - stenosis - laryngeal carcinoma
67
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
68
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
69
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
70
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
71
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)
72
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
73
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
74
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
75
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
76
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
77
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)
78
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
79
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
80
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
81
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
82
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
83
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)
84
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
85
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
86
describe age-related voice change (presbyphonia)
common cause of hoarse voice bowing of vocal cords due to atrophy leads to incomplete glottic closure
87
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
88
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
89
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)
90
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
91
describe recurrent respiratory papillomatosis (RRP)
affects children and adults > HPV types 6 & 11 treatment - endoscopic removal with microdebrider - laser - mitomycin / interferon - HPV vaccination
92
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
93
describe vocal cord nodules
due to voice misuse - singers, sports coaches, children treatment: speech and language therapy
94
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
95
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
96
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
97
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
98
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
99
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
100
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
101
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).
102
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
103
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
104
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
105
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
106
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
107
describe management of MRSA colonisation in surgical pre-assessment
nasal mupirocin + chlorhexidine for the skin