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