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Y4 NSS > ENT > Flashcards

ENT Flashcards

1
Q

What are the two main types of hearing loss?

A
  • conductive - problem with sound travelling from environment to the inner ear, sensory working fine but sound not reaching eg: ear plugs
  • sensorineural - problem with sensory system or vestibulocochlear nerve in inner ear
    • ie defects to oval window in cochlea (sensory), cochlear nerve (neural), rarely more central pathways
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1
Q

What is the physiology of hearing?

A
  • outer ear directs and funnels sound towards the TM, pinna and external acoustic canal amplify sound along the way until it reaches TM which vibrates as a result
  • vibration of the of TM spreads through the ossicles (malleus, incus and stapes) and is sent to the oval window setting up vibrations and movement in cochlear fluid of inner ear
  • this is sensed by stereocilia in cochlear duct (part called spiral organ of corti)
  • movement of stereocilia in organ of corti triggers action potentials in cochlear part of CN 8
  • semicircular canals to primary auditory context makes sense of this input as sound
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2
Q

How might hearing loss present?

A

may be gradual and insidious
- associated sx
- tinnitus
- vertigo
- pain - infection
- discharge - ear infection
- neuro symptoms

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3
Q

What are some common causes of conductive hearing loss?

A

external canal obstruction
TM perforation
osteosclerosis
infection
trauma
otitis media with effusion
glue ear
cholesteotoma

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4
Q

What are some common causes of sensorineural hearing loss?

A

ototoxic drugs
post infective
cochlear vascular disease
meniere’s
noise damage
presbycusis
labyrinthitis
acoustic neuroma
neuro causes

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5
Q

How might you assess hearing loss?

A

rinne’s and weber’s
pure tone audiometry
tympanometry
other methods of hearing tests

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6
Q

What are some common causes of sudden hearing loss?

A

conductive - ear wax, foreign body, infection, effusion, Eustachian tube dysfunction, perforated TM *cause found commonly

sensorineural - most often unilateral, idiopathic, infection, meniere’s, medication, MS, stroke etc

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7
Q

How might you investigate sudden hearing loss?

A
  • Audiometry to establish diagnosis - loss of at least 30 decibels in 3 consecutive frequencies on audiogram
  • MRI or CT head if acoustic neuroma or stroke
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8
Q

How might you manage sudden hearing loss?

A
  • immediate ENT referral for assessment within 24h of patient presenting and within 30 days on onset
  • when underlying cause found, treatment as required
  • idiopathic SSNHL with steroids under ENT guidance
    • oral or intra-tympanic (via injection of steroids through TM)
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9
Q

What causes deafness in childhood?

A

conductive - genetic abnormalities in canal
sensorineural - autosomal dominant like in alports
non genetic - intrauterine infections, perinatal causes

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10
Q

what intrauterine infections and perinatal causes may lead to deafness in childhood?

A
  • intrauterine infection eg: CMV, rubella, HSV
  • perinatal causes eg: prematurity, hypoxia, kernicterus, iVH
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11
Q

What is the universal newborn hearing screening?

A
  • otoacoustic emissions - microphone in external meatus to detect tiny cochlear sounds by outer hair cell movement which occurs in response to sound
  • auditory brainstem response - ears covered with earphones that emit series of soft clicks and electrodes on infants forehead and neck to measure brain wave activity in response
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12
Q

How do you test hearing in older children?

A

distraction testing - 6 to 18m
visual reinforced audiometry - 6m to 2.5y
speech discrimination - 2y to 5y

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13
Q

How is deafness in childhood managed?

A

cochlear implants
hearing aids
MDT care

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14
Q

What is the pathophysiology of otalgia?

A

inside the ear, pain fibres in nerve endings are stimulated by distension of skin due to swelling or compression against bony or cartilaginous structures

cervical nerves, trigeminal, glossopharyngeal and vagal nerves involved in referred pain to the ear

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15
Q

What are some differentials for otalgia?

A

otitis externa
necrotising otitis externa
otitis media
furunculosis
barotrauma
TMJ dysfunction
Ramsay hunt
neoplasia

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16
Q

What is the nerve supply to the ear?

A

great auricular + auriculotemporal branch of trigem - pinna
facial nerve - lateral ear drum
glossopharyngeal - TM medial
vagus

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17
Q

What are some red flag sx for otalgia?

A
  • oropharyngeal symptoms may suggest a head and neck cancer
  • Progressive or sudden onset hearing loss
  • Eye symptoms (loss of vision, black spots)
  • Immunosuppressed or diabetes mellitus which may allow an infection to rapidly progress
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18
Q

How might you investigate otalgia?

A

otoscopy + mastoid
TMJ examine
nerve function
neck examination
flexible nasal endoscopy
ear swabs and culture
radiology for MRI

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19
Q

What are the 3 components of the physiology of balance?

A
  • vision
  • proprioception - muscles and joints
  • inner ear vestibular system
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20
Q

What is vertigo?

A

a sensation of movement when stationary - unsteady or spinning rotation, “being on a boat” or “fairground ride”

N+V, falling over or bumping into things, holding on when walking

*no consciousness loss

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21
Q

What is the vestibular ocular reflex?

A
  • when gaze forwards, both Vestibular systems send equal strength signals
  • when head turned right with gaze still forwards the right VS sends stronger signal than left this makes eye turn towards weaker signal and maintain same direction of gaze vice versa *almost pushes eye away
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22
Q

What are some differentials for loss of balance?

A

BPPV
vestibular neuronitis
meniere’s
vestibule migraine
acoustic neuroma
Ramsay hunt syndrome
cerebellar lesions

r/o cardiac

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23
Q

What is nystagmus?

A

abnormal involuntary eye movements that can be caused by problems in the vestibular system or in the cerebellum and brain stem

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24
Q

How might you investigate balance?

A

*balance clinic
ENT exam - vestibular ocular reflex, dix-hallpike
neuro - gait, eyes, Romberg, cerebellar, joint position
CVS exam

specific - posturography, videonystagmography, calorie testing, VHIT

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25
Q

what leads to nasal congestion?

A

inflammation - histamine which manifests as venous engorgement, increased nasal secretions, and tissue swelling/ oedema ultimately impairing airflow and sensory afferents

*The nose is lined by a thin mucous membrane which can swell to cause blockage. Folds of the mucous membrane called turbinates are particularly prone to swelling

26
Q

what could cause nasal congestion?

A
  • allergies like hay fever
  • common cold, influenza or COVID
  • rebound nasal congestion due to extended use of topical decongestants
  • sinusitis
  • narrow or collapsing nasal valve
  • pregnancy - increased blood flow
  • nasal polyps
27
Q

how would you assess a patient complaining of nasal congestion?

A
  • allergy assessment - skin prick
  • nasal speculum examination
  • flexible nasal endoscope examination
  • MRI or CT
28
Q

what are some red flags when considering nasal congestion?

A

new onset or rapidly progressive:

  • Unilateral facial pain / swelling
  • Persistent bleeding/crusting with unilateral nasal obstruction
  • Persistent clear watery discharge (CSF leak - presents like a dripping tap from tip of nose)
  • Persistent bulging eye associated with partial or total loss of vision, painful eye movements or double vision
  • New onset rapid dental changes e.g. loosening of upper teeth
29
Q

what is the aetiology of rhinitis?

A
  • seasonal
  • perennial with dust mites or pets
  • sensitivity to substances like smoke
  • vasomotor rhinitis
  • coexisting with other conditions like asthma
30
Q

how would you classify rhinitis?

A
  • mild - normal sleep, activities, work and school
  • moderate to severe - all affected
  • intermittent - <4 days a week and <4w a year
  • persistent >4 days a week and >4w a year
31
Q

how would you manage rhinitis?

A

*severity dependant
- allergen avoidance
- oral antihistamines or spray
- nasal steroid spray or drops
- short course of oral steroids
- referral to ENT

32
Q

what is the origin of epistaxis?

A

anterior bleeds: ruptures vessels in little’s area, highly vascularised area of 5 artery anastomosis (90% cases)

posterior bleeds: posterior nasal cavity from branches of sphenopalatine arteries of nose, 10% and common in older patients

33
Q

what 5 arteries make up the littles area?

A

sphenopalatine
anterior and posterior ethmoidal
superior labial
greater palatine

34
Q

what can trigger epistaxis?

A
  • trauma
  • infection
  • coagulation disorders
  • medication
  • drug abuse
  • tumours
35
Q

what does a bilateral bleed suggest as apposed to a unilateral bleed?

A

usually u/L, when b/L may indicate bleeding posteriorly in nose! higher risk of aspiration of blood!!

*when patient swallows blood may vomit it too

36
Q

how would you assess a patient with epistaxis?

A
  • history, other sx like infections etc
  • recent trauma
  • FBC, clotting
  • G&S and cross match
37
Q

how would you manage epistaxis?

A
  • keep patient sat forward to ensure no aspiration
  • compression to soft lower cartilage for 10-15 mins
  • inspect septum and cauterise with silver nitrate if visible
  • pack bleeder
  • if packing failed ligate surgically or embolism radiologically
38
Q

what would you consider after treating acute bleed?

A

consider prescribingNaseptinnasal cream (chlorhexidineandneomycin) four times daily for 10 days to reduce any crusting, inflammation and infection

*contraindicated in peanut or soya allergy

39
Q

what is a complication of nasal trauma to be aware of?

A

*nasal septal haematoma between septal cartilage and the overlying perichondrium

o/e: b/L red swelling from nasal septum

mx: surgical drainage, IV abx

40
Q

what would happen if nasal septal haematoma not managed?

A

untreated irreversible septal necrosis develop within 3-4 days due to pressure related ischaemia of cartilage → saddle nose deformity

41
Q

what is odynophagia?

A

Pain with swallow + NO sensation of food boluses being stuck!

*associated with dysphagia

42
Q

how might odynopagia present?

A
  • dull, burning pain, or sharp, stabbing pain in mouth, throat or oesophagus when swallowing
  • worse with dry foods, some liquids too
  • weight loss from reduced food intake
  • dehydration if fluids affected
43
Q

what are some causes of odynophagia to consider?

A

oesophagitis
deep neck infections
ulcers
malignancy
trauma

44
Q

what causes a sore throat?

A

pharyngitis, tonsillitis, and laryngitis

45
Q

how is a sore throat managed?

A

paracetamol or ibuprofen for pain relief
antibiotics are not routinely indicated
there is some evidence that a single dose of oral corticosteroid may reduce the severity and duration of pain

46
Q

when might you consider antibiotics in a sore throat?

A

features of marked systemic upset secondary to the acute sore throat
unilateral peritonsillitis
a history of rheumatic fever
an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present

  • phenoxymethylpenicillin or clarithromycin
47
Q

what scoring systems are used when assessing a sore throat?

A

CENTOR
FeverPAIN

48
Q

what could cause a difficulty in swallowing?

A
  • malignancy
  • foreign body
  • candidiasis
  • achalasia
  • stroke
  • pharyngeal pouch
  • MG
  • muscular dystrophy
49
Q

what other sx could be associated with dysphagia?

A

chest pain
odynophagia
reflux
coughing
palate incompetence
weight loss
hoarse voice

50
Q

how would you assess dysphagia?

A

history
examination - motor dysfunction, resting tremor, dysarthria, massess
bloods: FBC, LFT, TFT, U&E
upper GI endoscopy
swallowing studies
manometry

51
Q

what specific features in dysphagia help you tailor your diagnosis?

A
  • Progressively worse dysphagia –suggestsmalignancy
  • Difficulty swallowing solids but not liquids –suggests muscular incoordination
  • Dysphagia with retrosternal pain and regurgitation –suggests stricture orcarcinoma
  • Dysphagia with weight loss –suggestsmalignancy
52
Q

how would you manage dysphagia?

A
  • nutritional assessment - malnourished and WL
  • involve dietician
  • SALT for those post stroke
  • MDT
  • neurology for MG etc
53
Q

what conditions could cause s neck swelling?

A

reactive lymphadenopathy
lymphoma
thyroid swelling
pharyngeal pouch
thryoglossal cyst
dermoid cyst
brachial cyst
cervical rib
carotid aneurysm
malignancy
sarcoidosis

54
Q

differentiate between thyroglossal, dermoid and branchial cyst?

A
  • thyroglossal: moves up when tongue protrudes, centre
  • dermoid: swelling and tenderness increases when eating
  • branchial: anterior triangle, mobile, between SCM and pharynx
55
Q

how would you assess a neck lump?

A

history
risk factors
examination
USS +/- fine needle aspiration
core needle biopsy
CT, MRI

56
Q

what are some red flag signs associated with a neck lump?

A
  • dysphagia, odynophagia, persistent cough, sore throat, hoarseness, haemoptysis
    • hard, painful, fixed lump
    • unilateral nasal symptoms like epistaxis, discharge, congestion
    • unexplained weight loss, night sweat, fever, rigors
    • cranial nerve palsies
    • children - supraclavicular mass, lumps larger than 2cm, and a previous history of malignancy
57
Q

how do you manage neck lumps?

A
  • treat infection or abscess
  • urgent referral for red flags - HNC, haem
  • FBC and bloods
  • arrange routine or urgent referrals for suspected thyroid pathology, congenital lump
  • neck USS if increasing in size
58
Q

what do you understand by the term hoarse voice?

A

hoarse voice refers to a weak or altered voice

  • “husky, strained or breathy”
  • changes in pitch
  • even Aphonia - complete loss of voice, whisper
59
Q

what is the physiology of voice?

A
  • true vocal cords are responsible for producing voice by being able to abduct and adduct
    • through innervation from the recurrent laryngeal nerve and external branch of superior laryngeal nerve
    • recurrent laryngeal nerve - intrinsic muscles of the larynx, except cricothyroid muscle (external laryngeal nerve) which increases pitch of our voice through causing tension on the VC
60
Q

what are some causes of hoarse voices?

A
  • overuse
  • smoking
  • vocal cord nodules
  • cysts
  • viral illness
  • reflux
  • papilloma
  • vocal cord paralysis
  • malignancy
61
Q

what could cause vocal cord paralysis?

A
  • nerve lesions eg: RLN (vagus+glossopharyngeal)
  • thyroid cancer, lung cancer, thoracic aortic aneurysm, MS, stroke
62
Q

how would you investigate a hoarse voice?

A

CXR
FNE
microlaryngobronchoscopy
CT neck and chest
video-stroboscopy
swallowing assessments

63
Q

when would you refer someone on a 2ww for hoarse voice?

A

A suspected cancer pathway referral to an ENT specialist should be considered for people aged 45 and over with:

  • persistent unexplained hoarsenessor
  • An unexplained lump in the neck

Y4 NSS (11 decks)

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