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Phase 4 > ENT > Flashcards

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
- ear pain, secretory otitis media, hearing loss
- cranial nerve palsy
- epistaxis / discharge
- nasal obstruction

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 signs and symptoms of otitis externa

A

inflammatory or infective process affecting the skin of the external auditory canal

pathogens: pseudomonas aeruginosa, staph aureus

features
- pruritus
- otalgia
- otorrhoea
- aural fullness
- hearing not affected unless substantial swelling of ear canal

signs
- pain on distraction of pinna
- 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:
> strep 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 sublingual or submandibular space

often secondary to dental infection

airway may be compromised, may require tracheostomy

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22
Q

list causes of sore throat

A
  • glandular fever
  • tonsillitis
  • quinsy
  • epiglottitis/supraglottitis
  • deep neck space infection
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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
Q

describe quinsy

A

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

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26
Q

describe indications for tonsillectomy and management of post-tonsillectomy bleeds

A

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

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27
Q

describe deep neck abscesses

A

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
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28
Q

describe mastoiditis

A

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

management
- 24h IV antibiotics if well
- CT head / temporal bones and drainage if unwell
- surgical intervention: tympanocentesis, myringotomy, cortical mastoidectomy

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29
Q

describe an intracerebral abscess

A

imaging: CT brain with contrast

presents as ring-enhancing lesion

requires neurosurgical referral

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30
Q

describe Pott’s puffy tumour

A

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

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31
Q

describe the treatment of epistaxis

A

bleeding most likely to originate from Kiesselbach’s plexus, located in Little’s area

first aid
- head forward over bowl/sink
- pinch soft part of nose
- ice over bridge/back of neck/in mouth
- naseptin (unless peanut/soy allergy, in which case bactroban)

secondary care intervention
- headlight and thudichum’s nasal speculum
- suction clot
- spray local anaesthetic
- identify bleeding points
- cauterise with silver nitrate
- pledget +/- adrenaline if persistent ooze

if unable
- nasal packing
- BIPP
- Foley catheter + BIPP

surgery in traumatic epistaxis
- endoscopic sphenopalatine artery ligation and anterior ethmoid ligation

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32
Q

list causes of epistaxis

A
  • trauma
  • nasal septum deviation / spur / perforation
  • iatrogenic
  • inflammation
  • foreign body
  • environmental
  • malignancy
  • systemic disorders: Hereditary Haemorrhagic Telangiectasia (HHT)
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33
Q

describe a septal haematoma

A

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

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34
Q

state the presentation and treatment of a nasal fracture

A

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

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35
Q

describe facial nerve palsy

A

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

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36
Q

describe Ramsay Hunt syndrome

A

caused by herpes zoster virus

features
- CN VII palsy
- vesicles: ear, hard palate, tongue
- hearing loss
- vertigo
- pain

management
- analgesia
- steroids
- aciclovir

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37
Q

describe an auricular haematoma

A

usually due to trauma

cartilage loses blood supply, leads to necrosis and infection

cauliflower ear deformity

management
- urgent drainage

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38
Q

describe tympanic membrane perforation

A

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

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39
Q

describe acoustic neuroma

A

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: audiometry, CT/MRI

management
- conservative: monitoring
- surgery
- radiotherapy to reduce growth

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40
Q

describe a cholesteatoma

A

aka active squamous otitis media

squamous epithelium in middle ear or mastoid

features
- unilateral conductive hearing loss
- foul discharge
- discharging ear that does not resolve with antibiotic treatment
- frequent infections
- pain
- vertigo
- facial nerve palsy

management - surgical removal
- mastoidectomy
- atticotomy
- atticoantrostomy

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41
Q

describe active mucosal chronic otitis media (COM)

A

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
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42
Q

list causes of otorrhoea

A
  • otitis externa
  • acute otitis media with perforation
  • active chronic otitis media
    > mucosal
    > squamous
  • trauma: CSF / blood
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43
Q

list causes of otalgia

A
  • otitis externa
  • necrotising otitis externa
  • acute otitis media
  • furuncle in ear canal
  • otitis media with effusion (OME)
  • temporomandibular joint (TMJ)
  • referred pain
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44
Q

describe otitis media with effusion (OME)

A

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

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45
Q

describe allergic rhinitis

A

features
- nasal congestion
- runny nose
- itchy nose
- sneezing
- +/- red/watery eyes

intranasal signs
- pale, oedematous and enlarged turbinates
- nasal congestion
- clear discharge

common allergens (RAS or skin prick testing)
- house dust mite
- cats / dogs
- grass / trees

management
- oral antihistamines
- inhaled corticosteroids
- severe: systemic corticosteroids

46
Q

describe non-allergic rhinitis

A

causes
- air pollutants
- smoke
- alcohol
- weather changes
- hormonal changes

treatment
- saline douching / spray
- trigger avoidance / reduction
- +/- nasal steroid

47
Q

describe rhinitis medicamentosa

A

rebound nasal congestion and rhinorrhoea due to decongestant nasal sprays

e.g. xylometazoline HCl, phenylephrine

can occur after 7 days

treatment - stop use

48
Q

what is the test for a CSF leak?

A

beta transferrin

49
Q

describe nasal polyps

A

growths of nasal mucosa that can occur in nasal cavity or sinuses

features
- round pale grey/yellow growths
- insensate

symptoms
- rhinorrhoea
- blockage
- smell disturbance
- subset of chronic rhinosinusitis

unilateral - concerning for malignancy and requires referral

associations
- chronic rhinitis or sinusitis
- asthma
- eosinophilic granulomatosis with polyangiitis
- cystic fibrosis

management
- intranasal topical steroid drops/spray
- surgery: intranasal polypectomy or endoscopic nasal polypectomy

50
Q

describe sinusitis

A

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)
51
Q

describe acute bacterial rhinosinusitis

A

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

52
Q

describe septal deviation

A

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

53
Q

list red flags for sinonasal malignancy

A
  • unilateral symptoms
  • blood-stained discharge
  • dental/orbital signs
    > loose teeth
    > proptosed eye
    > unilateral decreased eye movements
54
Q

describe septal perforation

A

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

55
Q

describe differentials for facial pain referred as sinusitis

A

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

56
Q

list causes of reduced sense of smell (hyposmia)

A

anatomical obstruction
- polyps
- rhinosinusitis
- tumour - olfactory neuroblastoma
- turbinate oedema

sensorineural
- post-viral / URTI
- congenital - Kallman syndrome
- idiopathic

57
Q

describe globus sensation

A

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

58
Q

list red flags for head and neck cancer

A

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

59
Q

list causes of hoarse voice

A
  • laryngeal cancer
  • laryngitis
  • vocal cord palsy (lung primary)
  • vocal cord polyp
  • vocal cord granuloma
  • respiratory papillomatosis
  • reinke’s oedema
  • vocal nodules
  • muscle tension dysphonia
60
Q

list differential diagnoses for neck masses in adults

A

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
61
Q

list causes of a parotid lump

A

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

62
Q

describe vestibular neuronitis

A

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

> chronic: vestibular rehabilitation exercises (>1 week)

63
Q

describe acute labyrinthitis

A

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

64
Q

describe Meniere’s disease

A

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

65
Q

describe vestibular migraine

A

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

66
Q

describe pharyngeal pouch

A

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

67
Q

list silent reflux symptoms

A
  • 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)
68
Q

describe signs of laryngopharyngeal reflux disease (LPR) and its treatment

A

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

68
Q

list complications of GORD

A
  • oesophagitis including erosions and ulcers
  • Barrett’s oesophagus
  • carcinoma of oesophagus
  • laryngeal granulomas
  • laryngospasm
  • stenosis
  • laryngeal carcinoma
68
Q

describe sialolithiasis

A

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
69
Q

describe sialadenitis

A

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

70
Q

describe the Centor criteria and the FeverPAIN score

A

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

71
Q

describe universal hearing screening programme (UNHS)

A

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

72
Q

describe otitis media with effusion (OME)

A

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)

73
Q

describe hearing tests in children

A

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

74
Q

management of hearing loss in children

A

dependent on type of hearing loss

conservative
> conductive: bone-conducting bands
> sensorineural: hearing aids

surgery
> conductive: bone-conducting hearing aids
> sensorineural: cochlear implant

75
Q

describe recurrent acute otitis media and its management

A

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

76
Q

describe the management of otitis externa

A

ear care - keep dry, avoid shampoo contamination

ear bacteriological swab only if recurrent

may be fungal: black spores (aspergillus) / cotton wool wisps (give topical antifungals e.g. clotrimazole)

treatment: antibiotic/steroid drops for one week
- gentamicin + hydrocortisone
- ciprofloxacin + dexamethasone
- otomize (neomycin/dexamethasone/acetic acid)

77
Q

describe the management and complications associated with acute otitis media

A

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 amoxicillin/co-amoxiclav 2nd line)

> > consider topical antibiotics (ciprofloxacin) if prolonged otorrhoea

complications
- intracranial abscess
- facial nerve palsy
- mastoiditis
- meningitis

78
Q

describe the following tongue conditions
- glossitis
- oral candidiasis

A
  • 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)

79
Q

describe the following tongue conditions
- geographical tongue
- strawberry tongue
- black hairy tongue

A
  • 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
80
Q

describe gingivitis

A

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: metronidazole

81
Q

describe aphthous ulcers

A

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

82
Q

describe a cystic hygroma

A

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

83
Q

list causes of hearing loss in children

A

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

84
Q

describe obstructive sleep apnoea (OSA)

A

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)

85
Q

list causes of rapid onset conductive hearing loss

A
  • ear wax
  • infection e.g. otitis media/otitis externa
  • fluid in the middle ear (effusion)
  • Eustachian tube dysfunction
  • perforated tympanic membrane
86
Q

describe sudden sensorineural hearing loss (SSHL)

A

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 (oral or intra-tympanic)

87
Q

describe age-related voice change (presbyphonia)

A

common cause of hoarse voice

bowing of vocal cords due to atrophy

leads to incomplete glottic closure

88
Q

describe presbycusis

A

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

89
Q

describe laryngitis

A

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

90
Q

describe vocal cord palsy

A

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)

91
Q

describe the following
- vocal cord polyp
- vocal cord granuloma

A

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

92
Q

describe recurrent respiratory papillomatosis (RRP)

A

affects children and adults
> HPV types 6 & 11

treatment
- endoscopic removal with microdebrider
- laser
- mitomycin / interferon
- HPV vaccination

93
Q

describe Reinke’s oedema

A

inflammatory oedema, often bilateral

causes
- smoking
- severe laryngeal reflux

results in deepening of voice

management
- lateral cordotomy (remove fluid) if required
- smoking cessation

94
Q

describe vocal cord nodules

A

due to voice misuse - singers, sports coaches, children

treatment: speech and language therapy

95
Q

describe TMJ dysfunction

A

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

96
Q

describe glomus tumours

A

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

97
Q

explain the interpretation of Rinne’s test

A

+ve test: air conduction louder than bone conduction
> normal hearing
> sensorineural hearing loss

-ve test: bone conduction louder than air conduction
> conductive hearing loss

98
Q

explain the interpretation of Weber’s test

A

normal: sounds the same in both ears

sensorineural hearing loss: heard louder in healthy ear

conductive hearing loss: heard louder in affected ear

99
Q

describe a tracheostomy

A

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

100
Q

describe a laryngectomy

A

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

101
Q

differentiate between pinna perichondritis and cellulitis

A

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

102
Q

describe indications for urgent referral for head and neck cancer

A
  • 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).
103
Q

describe otosclerosis

A

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

104
Q

describe a pleomorphic adenoma of the parotid gland

A

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

105
Q

list causes of tinnitus

A
  • 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

106
Q

briefly describe the following causes of hearing loss

  • presbycusis
  • otosclerosis
  • glue ear
  • meniere’s disease
  • drug ototoxicity
  • noise damage
  • acoustic neuroma (Vestibular schwannoma)
A

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

107
Q

describe sialolithiasis

A

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

108
Q
A
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Phase 4 (14 decks)

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