ENT Flashcards
A 23-year-old woman presents one week after being prescribed a combined antibiotic and steroid spray for otitis externa. There has been no improvement in her symptoms and the erythema seems to have extended to the ear itself. What is the most appropriate treatment?
Oral flucloxacillin
The spreading erythema is an indication for oral antibiotics
What duration of antibiotics is given for tonsilitis with marked systemic upset?
Phenoxymethlpeniillin for 10 days
What is the most common cause of bacterial otitis media?
Haemophilus influenzae
What is the first line management of mastoiditis?
Mastoiditis is typically diagnosed clinically and requires IV antibiotics
List the CENTOR criteria
- Tonsillar exudate
- Tender anterior lymphadenopathy or lymphadenitis
- History of fever
- Absence of cough
Recurrent otitis externa following numerous antibiotic treatment should raise suspicion of what infectious organism?
Candida albicans
What are the clinical features of a thyroglossal cyst?
- More common in patients < 20 years old
- Usually midline, between the isthmus of the thyroid and the hyoid bone
- Moves upwards with protrusion of the tongue
- May be painful if infected
What are the clinical features of a pharyngeal pouch?
- More common in older men
- Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough
- Associated with halitosis or throat infections
What are the clinical features of a cystic hygroma?
- A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
- Most are evident at birth, around 90% present before 2 years of age
- Swelling will transluminate
What are the clinical features of a branchial cyst?
- Usually presents in early adulthood
- An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx (anterior triangle)
- Lump won’t transluminate
What are the clinical features of a cervical rib?
- More common in adult females
- Around 10% develop thoracic outlet syndrome
What are the clinical features of a carotid aneurym?
Pulsatile lateral neck mass which doesn’t move on swallowing
What symptom distinguishes vestibular neuronitis from labyrinthitis?
Hearing will be unaffected in vestibular neuronitis
When do guidelines suggest oral antibiotics in otitis media?
- Symptoms lasting more than 4 days or not improving
- Systemically unwell but not requiring admission
- Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
- Younger than 2 years with bilateral otitis media
- Otitis media with perforation and/or discharge in the canal
What findings on Rinne’s and Weber’s tests indicate normal hearing?
- Rinne result: air conduction > bone conduction bilaterally
- Weber result: same in both ears
What is the normal first line management for sinusitis?
- Analgesia
- Intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited
When should intranasal steroids be considered for sinusitis?
If symptoms have persisted for 10 days or more
When would antibiotics be indicated in sinusitis?
- The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’
- ‘Double-sickening’ may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection
You review a 23-year-old woman who presents with a three week history of bilateral nasal obstruction, cough at night and a clear nasal discharge. She had similar symptoms around this time last year and the only history of note is asthma. What is the most likely diagnosis?
Allergic rhinitis
What findings on Rinne’s and Weber’s tests indicate conductive hearing loss?
- Rinne result: bone conduction > air conduction in affected ear, Air conduction > bone conduction in unaffected ear
- Weber result: lateralises to affected ear
What diagnosis should you consider in a patient with globus, hoarseness and no red flags?
Laryngopharyngeal reflux
What is the management of Ramsay Hunt syndrome?
Oral aciclovir and corticosteroids
List 3 drugs associated with gingival hyperplasia
- Phenytoin
- Ciclosporin
- Calcium channel blockers
What findings on audiogram would indicate presbycusis?
Bilateral high-frequency hearing loss
Describe the management of a perforated tympanic membrane caused by barotrauma
Self limiting so reassurance and followup
A 25-year-old woman presents with a slowly enlarging mass on the side of the face. Clinical examination demonstrates that the mass is located in the tail of the parotid gland. There is no evidence of facial nerve involvement. What is the most likely cause?
Pleomorphic adenoma
What clinical features would suggest a Warthin tumour?
- Most common bilateral benign neoplasm of the parotid
- Marked male as compared to female predominance
- Occurs later in life (sixth and seventh decades)
List 3 potential complications of thyroid surgery
- Damage to recurrent laryngeal nerve
- Bleeding which can lead to respiratory compromise
- Damage to the parathyroid glands resulting in hypocalcaemia
What ECG change is associated wth hypocalcaemia?
Isolated QTc elongation
What is the most appropriate course of action for a patient with non-resolving unilateral ear discharge?
Suspect cholesteatoma - refer to ENT outpatient clinic
A 56-year-old man presents with episodic facial pain and discomfort whilst eating. He has suffered from halitosis recently and he frequently complains of a dry mouth. He has a smooth swelling underneath his right mandible. What is the most likely underlying diagnosis?
Stone impacted in Wharthons duct
Symptoms are typical for sialolithiasis
A 3-year-old boy is brought to surgery. His mum reports that he has been complaining of a sore left ear for the past 2-3 weeks. This morning she noticed some ‘green gunge’ on his pillow. On examination his temperature is 37.8ºC. Otoscopy of the right ear is normal. On the left side the tympanic membrane cannot be visualised as the ear canal is full with a yellow-green discharge. What is the most appropriate action?
Amoxicillin + review in 2 weeks
Presentation consistent with OME; presence of dischage suggests membrane may have perforated and so antibiotics are indicated
A 42-year-old man presents to his general practitioner 6 weeks after developing a cold. Whilst all of his other symptoms have now resolved, the patient is experiencing persistent blockage of his left nostril associated with rhinorrhoea and sneezing. He is otherwise well.
On examination, a large polyp is seen in the left nostril. Examination of the right nostril is unremarkable.
What is the most appropriate next step in management?
Urgent referral to ENT
Unilateral polyps are a red flag symptom
What antibiotic is indicated in diabetis with otitis externa?
Ciprofloxacin to cover Pseudomonas
What is the most common cause of sudden-onset sensorineural hearing loss?
Idiopathic
A 43-year-woman had a tonsillectomy one week ago. She presents to her GP one week later because she has noticed a small amount of blood pooling in her mouth from this morning. She believes that the blood is coming from the wound site.
The GP examines her mouth and throat and sees no other obvious source of the bleeding. A set of basic observations are all normal.
What is the most appropriate next step for the GP to take?
Admit to hospital for ENT review and antibiotic therapy
Haemorrhage 5-10 days after tonsillectomy is commonly associated with a wound infection and should therefore be treated with antibiotics
What kind of crystals do branchial cysts characteristically contain?
Cholesterol
Describe the features and management of mild acute otitis externa
- Mild discomfort and/or pruritus; no deafness or discharge
- Consider prescribing topical acetic acid 2% spray
What clinical features of acute otitis externa would make you consider a topical antibiotic +/- topical steroid?
- A red, oedematous ear canal which is narrowed and obscured by debris
- Conductive hearing loss
- Discharge
- Regional lymphadenopathy
- Cellulitis spreading beyond the ear
- Fever
What is the most appropriate management for sudden-onset sensorineural hearing loss?
- Urgent referral to ENT for audiology assessment and brain MRI
- Drug treatment for idiopathic SSNHL involves high-dose oral corticosteroids (oral prednisolone 1mg/kg/day (maximum 60mg/day) for 7 days and then tapered over the next week)
What findings on Rinne’s and Weber’s tests indicate left sensorineural deafness?
- Rinne’s test: air conduction > bone conduction in both ears
- Weber’s test: localises to the right side
Describe the management of a haemorrhage within hours of tonsillectomy
- Immediate return to theatre - primary haemorrhage
- Ensure the airway remains patent in the meantime
- ENT and anaesthetics should be called immediately
What is ‘black hairy tongue’?
- Black hairy tongue is a benign condition characterized by the elongation and discolouration of the filiform papillae on the dorsal surface of the tongue
- The brown or black coating seen in this case is due to the accumulation of keratin and dead cells, as well as staining from food, drinks, or tobacco products
- Although it may cause some discomfort or tickling sensation, it is generally asymptomatic and can be managed with good oral hygiene practices
What is the most appropriate management for an unexplained persistent sore throat?
2-week wait referral to oral surgery
What type of hearing loss is associated with otosclerosis?
Bilateral, conductive pattern hearing loss, sometimes with associated tinnitus
Describe the management of nasal polyps
- Intranasal corticosteroid spray or drops can be used to shrink nasal polyps
- If topical steroids do not work oral steroids may be considered whilst awaiting ENT review
Describe the clinical features of a goitre
- Midline, non-tender neck swelling which moves upwards on swallowing
- Patients with a goitre are often euthyroid or have minor symptoms
Describe the management of persistent unexplained hoarseness in a patient aged >45 years old
Request a CXR and refer urgently to ENT
Any patient presenting with hoarseness who are being referred down the suspected cancer pathway should have a chest x-ray to exclude an apical lung lesion
List 4 potential causes of drug ototoxicity
Aminoglycosides (e.g. Gentamicin), furosemide, aspirin and a number of cytotoxic agents
How would you differentiate between Meniere’s disease and a vestibular schwannoma?
Will be symptom free episodes between ‘attacks’ in Meniere’s disease
What is the most likely diagnosis for this finding on otoscopy?
Cholesteatoma
Describe the findings on audiogram associated with sensorineural hearing loss
- In patients with sensorineural hearing loss, both air and bone conduction readings will be more than 20 dB, plotted below the 20 dB line on the chart
- This may affect only one side, one side more than the other or both sides equally
Describe the findings on audiogram associated with conductive hearing loss
- In patients with conductive hearing loss, bone conduction readings will be normal (between 0 and 20 dB)
- However, air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart
- In conductive hearing loss, sound can travel through bone but is not conducted through air due to pathology along the route into the ear
Describe the findings on audiogram associated with mixed hearing loss
- Both air and bone conduction readings will be more than 20 dB in patients with mixed hearing loss
- However, there will be a difference of more than 15 dB between the two (bone conduction > air conduction)
What signs are used to represent air conduction on audiogram?
- O = right ear unmasked
- △ = right ear masked
- X = left ear unmasked
- ▢ = left ear masked
What signs are used to represent bone conduction on audiogram?
- < = right ear unmasked
- [ = right ear masked
- > = left ear unmasked
- ] = left ear masked
