ENT Flashcards
When should prochlorperazine be used in vestibular neuronitis?
In the acute phases only as it can delay recovery if used long term
What can be used to distinguish vestibular neuronitis from a posterior circulation stroke?
HiNTs exam - head impulse test, test of skew and assessing nystagmus
What are the red flags of chronic rhinosinusitis?
unilateral symptoms
persistent symptoms despite compliance with 3 months of treatment
epistaxis
Chronic rhinosinusitis features? Predisposing factors?
Frontal pressure facial pain worse bending forward; nasal discharge/obstruction. Atopy; nasal obstruction (nasal polyps); recent infection (rhinitis); swimming; smoking
Chronic rhinosinusitis Mx
Avoid allergen, intranasal corticosteroids, nasal irrigation with saline solution.
Vestibular neuronitis vs acute labyrinthitis?
Hearing will not be affected in VN
Ear swelling/rash behind the ear in someone with ?otitis media
Same day referral to Paeds ?Mastoiditis
Horizontal nystagmus is a sign of what?
Vestibular neuronitis
How should a perforated ear drum be managed?
Refer to ENT if persists beyond 6 weeks
What is a C/I to prescribing naseptin cream?
peanut, soy or neomycin allergies
conductive hearing loss, tinnitus and positive family history
Otosclerosis
bilateral high-frequency hearing loss suggests what?
Prebycusis
What are the 2 common post op complications of tonsillectomy?
- Pain
- Haemorrhage
How does haemorrhage present following tonsillectomy?
Primary: Within 6-8 hours following surgery -> needs immediate return to theatre
Secondary: 5-10 days after surgery usually associated with wound infection -> treated with admission/abx
When should intranasal steroids be considered for sinusitis?
If symptoms have been present for 10 days or more
What is the management of acute sensorineural hearing loss?
Urgent referral to ENT for audiology and brain MRI
What is Ludwigs angina?
A progressive cellulitis which invades floor of the mouth and soft tissues of the neck usually following dental infection
How does Ludwigs angina present?
- Neck swelling
- Dysphagia
- Fever
- Needs immediate referral to hospital for airway management and IV Abx
Management of post op stridor for thyroidectomy?
Urgent removal of sutures and call for senior help
What does post thyroidectomy stridor suggest?
Post op bleed which build pressure behind suture line and compresses trachea causing stridor
What are the NICE indications for tonsillectomy?
- Sore throats due to tonsillitis
- 5 or more episodes per year
- Symptoms occurring for atleast 1 year
- Episodes of sore throat are preventing normal function
What is the most common cause of bacterial otitis media?
H influenzae
What does pain on palpation of the tragus, itching, discharge and hearing loss suggest?
Otitis externa
What is the management of a patient with persistent hoarse voice?
Refer to ENT
What causes gingival hyperplasia?
phenytoin, ciclosporin, calcium channel blockers and AML
When should Abx be given for acute otitis media?
- Symptoms lasting more than 4 days or not improving
- Systemically unwell but not requiring admission
- Immunocompromise or high risk of complications
- Younger than 2 years with bilateral otitis media
- Otitis media with perforation and/or discharge in the canal
If give Abx then 5-7d amoxicillin or clarithromycin
CP of acute otitis media?
Very common
Otalgia; fever (50%); hearing loss; recent URTI symptoms; ear discharge if tympanic membrane perforates.
Possible otoscopy findings in acute otitis media?
- bulging tympanic membrane → loss of light reflex
- opacification or erythema of the tympanic membrane
- perforation with purulent otorrhoea
- decreased mobility if using a pneumatic otoscope
Sequelae and Cx of acute otitis media?
- Otorrhoea if perforation of tympanic mem; CSOM (perforation with otorrhoea >6w)
- Cx: mastoiditis, meningitis, brain abscess, facial nerve paralysis
Which drugs cause tinnitus?
- Aspirin/NSAIDs
- Aminoglycosides e.g gentamicin
- Loop diuretics
- Quinine
What is the most important part of the tympanic membrane to visualise in patients with chronic discharge?
Attic - rule of cholesteatoma
After referral to ENT, patients with sudden onset sensorineural loss should be given what?
high-dose oral corticosteroids
What is an indication of positive Dix-Hallpike?
Rotatory nystagmus
What can be used to shrink nasal polyps?
Intranasal steroid spray/drops
What is the biggest risk factor for malignant otitis externa?
Diabetes Mellitus
What is malignant otitis externa?
Uncommon, most in diabetics; caused by pseudomonas aeruginosa. Starts in soft tissues of external auditory meastus then progresses to temporal bone osteomyelitis.
Key features in history for malignant otitis externa?
- diabetes or immunosupression
- severe unreleting deep-seated otalgia
- temoral headaches
- purulent otorrhea
- possible dysphagia, hoarseness and/or facial nerve dysfunction
Maligant otitis externa Mx?
Typically CT.
Non-resolving otitis externa worsening pain refer urgent ENT.
IV Abx that cover pseudomonal infections.
What is the most common cause of sudden onset sensorineural hearing loss?
Idiopathic
What is a complication of nasal trauma?
Nasal septal haematoma
What is a nasal septal haematoma?
- Bilateral red swelling arising from the nasal septum
- Needs ENT referral for surgical drainage and IV Abx
Otitis externa CP
Ear pain, itch, discharge. Otoscopy: red, swollen or exzematous canal.
What are signs of more severe otitis externa?
- a red, oedematous ear canal which is narrowed and obscured by debris
- conductive hearing loss
- discharge
- regional lymphadenopathy
- cellulitis spreading beyond the ear
- fever
How should otitis externa be managed?
Over the counter acetic acid ear drops or spray. Consider topical Abx or Abx + Steroids.
How to interpret audiograms?
- is there anything below 20dB
yes = move to step 2
no = normal hearing - is there a gap? (b/w air and bone conduction)
yes = conductive or mixed hearing loss
no = sensorineural hearing loss - is one below or both below the 20dB line
one = conductive
both = mixed
What would be the results of audiometric testing for presbycusis?
Bilateral high-frequency hearing loss with air conduction better than bone
Patient with black/brown/green tongue?
- Think black hairy tongue
- More common in those with poor hygiene/IV drug users/HIV
- Treated with tongue scraping/antifungals if candida
What can occur after trauma to the ear?
Auricular haemtoma - needs same day assessment by ENT for drainage
What is the first line oral abx for otitis externa?
Oral Flucloxacillin
What is the management of otitis externa in diabetics?
Ciprofloxacin ear drops to cover for Pseudomonas
Elderly patient dizzy on extending neck/moving head up?
Vertebrobasilar ischaemia
Managament of Children presenting with glue ear with a background of Down’s syndrome or cleft palate
Refer to ENT
Epistaxsis management?
- Direct compression
- Nasal cautery
- Nasal packing
- Aggressive therapies such as balloon catheter
Why do FBC when someone has epistaxis?
- Assess HB
- Assess platelet count
What is the term for pain upon swallowing?
Odynophagia
What is the name of the lymph node commonly enlarged in tonsillitis?
Jugulodigastric lymph node
What does difficulty swallowing solids suggests vs solids and liquids?
Solids - stricture issue (benign or malignant)
Both - motility issue
Management of oesophageal carcinoma
- Surgery
- Chemoradiotherapy
Recurrent otitis externa despite antibiotic treatment?
Candida
Unilateral symptoms in someone with chronic rhinosinusitis?
Urgent referral to ENT
BPPV Mx
Usually resolves spontaneously after w-mths. Symptomatic relief: epley manoeuvre, home exercies (Brandt-Daroff exercies); Betahistine prescribed. May reoccur 3-5yrs later.
dysphagia, regurgitation, halitosis, and a bulging neck on swallowing
Pharyngeal pouch
Branches of the facial nerve
Two Zebras Bite My Cake
Temporal
Zygomatic
Buccal
Mandibular
Cervical
What are long term impacts of Bells?
- Damage to eye
- Inability to close eye
- Altered taste
- Psychological impacts
What is vertigo?
The illusion of movement
Pathophysiology of BPPV
Debris in the semi circular canals which are disrupt movement of endolymph
BPPV CP
sudden onset dizziness and vertigo triggered by changes in head position. Typically 10-20secs, may be associated with nausea and +ve Dix-Hallpike manoeuvre.
How do childrens and adult eustachian tubes differ?
Childrens is shorter, narrower and more horizontal
What are the 4 paranasal sinuses?
Ethmoid, Frontal, Maxillary, Sphenoid
What are risk factors for head and neck cancers?
- Smoking
- HPV 16
- EBV
- Immunosuppression
- FH
Loss of corneal reflex
Acoustic neuroma
Unilateral glue ear in an adult
Refer to ENT to rule out posterior nasal space tumour
Prophylaxis of sinusitis?
Intranasal corticosteroids
What does ulnar deviation in someone with tonsillitis suggest?
Peritonsilar abscess- Quinsy
Atypical lymphocytes on blood film are suggestive of what?
Infective mono
palatal petechiae + cervical lymphadenopathy are suggestive of what?
Glandular fever
What can deranged LFTs with sore throat be indicative of>
Infective mononucleosis
What anaemia can infective mono cause?
Cold Haemolytic anaemia - IgM
C
Infectious mononucleosis (glandular fever) caused by what maining?
EBV. Spread by contact with saliva eg. kissing, sharing food or drink; sexual contact (blood/semen), blood transmission.
Infective mono triad?
sore throat, pyrexia and lymphadenopathy (anterior and posterior triangles of neck). Also: malaise, palatal petechiae, splenomegaly, hepatitis, lmphocytosis.
When do symptoms resolve in patients with infective mono? Incubation period?
After 2-4w, sometimes longer. Incubation period 4-7w. May be contagious for up to 18m after. EBV is lifelong latentent carrier state so may reactivate but doesn’t always cause symptoms.
Infective mono diagnosis?
Monospot test (heterophil antibody test) and FBC in 2nd week of illness to confirm.
Infective mono Mx?
Supportive, rest, fluids, simple analgesia. AVOID SPORTS FOR 4 weeks AFTER having glandular fever to reduce risk of splenic rupture.
What happens to patients who take ampicillin/amoxicillin whilst they have infective mono?
Maculopapular pruritic rash.
Cx of infective mono
upper airway obstruction, splenic rupture, neutropenia, fatigue. if immunocompromised can lead to hodgkins or nasopharyngeal carcinoma.
OSA can cause what?
HTN
What are risk factors for OSA?
- Obesity
- Macroglossia (acromegaly, hypothyroidism)
- Large tonsils
- Marfans
What acid base problem can OSA cause?
Compensated respiratory acidosis
Epistaxis which fails all management may require ligation of what?
Sphenopalatine ligation
Types of epistaxis?
Anterior (visible source of bleeding, usually due to insult of network of capillaries forming Kiesselbach’s plexus) and Posterior (profuse, deeper structures)
Epistaxis Mx
First aid measures (sit forward with mouth open and pinch carilaginous area of nose for >20min). If doesn’t stop then cautery or packing.
What are signs of quinsy?
- Deviation of uvula to unaffected side
- Trismus
- Reduced neck mobility
- Bulging of the soft palate
Which organism cause quinsy?
Strep pyogenes
Management options for nasal fractures?
- See in clinic in a week to allow swelling to subside
- Manipulate under anaesthetic
Discharge from nose which tests positive for beta-2 transferrin?
CSF
Why should haematomas be aspirated as soon as possible?
Risk of avascular necrosis
What is a cholesteatoma?
Overgrowth of keratinised squamous epithelium in the middle ear
What can suggest cholesteatoma on otoscopy?
- Discharge
- Attic crust
- Retracted/Perforated tympanic membrane
What are complications of cholesteatoma?
- Facial nerve palsy
- Meningitis
- Abscess
- Deafness
- Recurence
What are signs of thyroglossal cyst?
- Moves up when protruding tongue
- Mobile
- Non tender
What causes trismus in quinsy?
Pus causes the pterygoid muscles to go into spasm which prevents a patient from opening their mouth
Post tonsillectomy haemorrhage?
Refer for same day ENT assessment even if bleeding has resolved
Hearing impairment post head trauma?
Perforated tympanic membrane
What is the name for a malignant tumour of the parotid gland?
Adenoid cystic carcinoma
Most common bacteria which cause otitis externa?
- Staph aureus
- Pseudomonas
What can be exacerbated in pregnancy?
Otosclerosis
Pink tinge to tympanic membrane?
Schwarze sign -> otosclerosis
What can be a S/E of removal of mastoid abscess?
Unilateral facial weakness -> facial nerve runs close to the mastoid
Which sinus is most commonly involved in chronic sinusitis when mucus drains out upon leaning forward?
Maxillary
Which virus is associated with squamous cell carcinoma of the oropharynx?
HPV
What is the pathophysiology of Menieres?
Excessive build up of endolymph in inner ear which increases pressure and disrupts sensory signals -> sensorineural hearing loss
What are symptoms of Ramsay-Hunt?
- Vesicular rash
- Facial weakness
- Vertigo
- Headaches
- Fever
- Tinnitus
What is a complication of untreated tonsillitis?
- Parapharyngeal abscess
- Lemeirre’s syndrome: infective thrombophlebitis
What is the most common tumour of parotid gland?
Pleomorphic adenoma -> benign
Bilateral conductive hearing loss and tinnitus in young person?
Think otosclerosis
Snoring in someone with chronic sinusitis?
Nasal polyps have formed -> nasal steroid drops needed
Glue ear
Otitis media with an effusion, most children will have at least one episode. Peaks at 2yrs; hearing loss (conductive); secondary problems eg. speech delay, balance problems.
Glue ear Mx
Observe 3m if 1st presentation. Grommet insertion (does job normally done by eustachian tube allowing air to pass through middle ear, lasts 10m). Adenoidectomy.
Management of otosclerosis?
- Hearing aids
- Stapedectomy is gold standard
Unilateral glue ear?
Red flag -> nasopharyngeal carcinoma
Chinese person with history of EBV infection and one sided hearing loss?
Nasopharyngeal tumour
p16 is a marker for what?
HPV -> squamous cell carcinoma of oropharynx
What is temporo-mandibular joint dysfunction?
Pain in jaw with difficulty moving it as well as clicking/popping in the jaw when opening mouth
What can trigger temporomandibular dysfunction?
Trauma to the jaw
Stress
Management of TMD?
Resting, address triggers and ENT referral if severe
Anaphylaxis acute Mx
IM adrenaline 1:1000 in anterolateral aspect of middle third of thigh/arm. Repeat in 5mins if no response. If no response keep giving every 5mins. Remove trigger; Oxygen; inhaled salbutamol or ipratropium if wheezy/asthmatic.
Anaphylaxis Mx if presence of hypotension or shock, or poor response to adrenaline
IV fluid bolus (Hartmann’s or saline), 500-100ml for adult or 10ml/kgfor child.
Adrenaline dose in anaphylaxis?
1mg/mL (1:1000) conc.
>12yrs= 500 micrograms (0.5ml 1:1000 solution)
6-12: 300
6m-6yrs: 150
<6m: 100-150
Anaphylaxis Mx following stabilisation
- oral antihistamines eg. chlorphenamine
- serum tryptase levels (elevated for 12hrs following acute episode)
- refer to specialist allergy service
- prescribe 2 adrenaline auto-injectors
- biphasic reaction can occur in up to 20% patients
Anaphylaxis discharge?
- Fast track (2hrs after symptom resolution): complete resolution and good response to single dose
- 6hrs after: 2 does of adrenaline or previous biphasic reaction
- 12hrs: >2 doses, severe asthma, ongoing reaction (eg. slow release meds), late at night.
Acute epiglottitis caused by?
H.influenzae type B
Acute epiglottitis features?
rapid onset, stridor, tripod position, drooling, high temp, generally unwell
Acute epiglottitis diagnosis?
If suspected DO NOT examine throat. Direct visualisation by senior staff. X-ray: lateral view will show swelling of epiglottis- thumb sign.
Acute epiglottitis Mx?
Immediate senior invol. (endotracheal intubation). Oxygen, IV antibiotics.
Croup cause and aage most common?
Parainfluenzae. 6m-3yrs.
Croup CP
Barking seal-like cough worse at night; stridor (due to laryngeal oedema and secretions); fever; retraction-increase work of breathing; coryzal
Croup sign on xray (posterior anterior view)
Steep sign due to subglottic narrowing
Croup Mx
Single dose dexamethasone (0.15mg/kg).
Emergency: high flow O2 and nebulised adrenaline
Vestibular schwannoma (acoustic neuroma) CP
Vertigo, hearing loss, tinnitus and absent corneal reflex. Seen in neurofibromatosis type 2.
Features can be precipitated by the affected CNs:
- cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
- cranial nerve V: absent corneal reflex
- cranial nerve VII: facial palsy
Acoustic neuroma Ix
Urgent ENT referral. MRI of cerebellopontine angle and audiometry.
Acoustic neuroma Mx
Surgery, radiotherapy or observe. Often benign tumour, slow growing and often observed initially.
Acoustic neuroma?
account for approximately 5% of intracranial tumours and 90% of cerebellopontine angle tumours
Achalasia?
Failure of oesophageal peristalsis & relaxation of lower oesophageal sphincter due to degenerative loss of ganglia from Auerbach’s plexus. LOS contracted, oesophagus above dilated.
Achalasia CP
Commonly middle aged. Dysphagia of BOTH liquids and solids, heartburn, regurgitation, malignant change in small no. patients.
Achalasia Ix
Oesophageal manometry: XS LOS tone which doesn’t relax on swallowing. Barium swallow- bird’s beak.
Achalasia Mx
Pneumatic (balloon) dilation. Surgical intervention with Heller cardiomyotomy if recurrent.
Causes of dysphagia
Oesophaeal cancer; oesophagitis; oesophageal candidiasis; achalasia; pharyngeal pouch; systemic sclerosis; MG; globus hystericus.
New onset dysphagia
Urgent endoscopy
Samter’s triad
Association of asthma, aspirin sensitivity and nasal polyposis
What shrinks nasal polyps in 80% pts?
topical corticosteroids
Bell’s palsy?
Acute unilateral, idiopathic facial nerve paralysis. ?HSV. More common in pregnant.
Bell’s CP
LMN facial nerve palsy = forehead AFFECTED. Post-auricular pain, altered taste, dry eyes, hyperacusis.
Bell’s Mx
Oral pred within 72hrs onset. Eyecare to prevent exposure keratopathy (artifical tears and eye lubricants, tape eye at night). If no improvement after 3w urgent ENT referral. Most fully recover in 3-4m.
Meniere’s disease?
Disorder of inner ear of unknown cause. Excessive pressure and progressive dilation of endolymphatic system.
Meniere CP
Recurrent episodes of VERTIGO (20mins to 24hrs), tinnitus, hearing loss (sensorineural). Sensation of aural fullness or pressure; nystagmus; +ve Rombergs. Episodes mins to hrs. Usually unilateral.
Meniere Mx
ENT assessment to confirm. Inform DVLA- stop until control of symptoms. Acute attacks= buccal or IM prochlorperazine. Severe= admit for IV labyrinthine sedatives and fluids. Prevention= betahistine and vestibular rehab.
Face innervation
Trigeminal nerve (V) which has 3 branches: opthalmic (V1), maxillary (V2), mandibular (V3)
Facial pain differential diagnosis
Trigeminal neuralgia, sinusitis, dental problems, tension headache, migraine, giant cell arteritis.
Trigeminal neuralgia CP
Severe unilateral pain- brief electic shock like pains limited to 1+ divisions of trigeminal nerve. Evoked by light touch eg. shaving. Most idiopathic but sometimes by compression of nerve roots by tumour or vasular problems
Trigeminal neuralgia red flags
Sensory changes; deafness; pain only in opthalmic division (eye, forehead and nose); optic neuritis; Fx of MS; <40yrs; history of skin or oral lesions that could spread perineurally
Trigeminal neuralgia Mx
Carbamazepine 200mg 3/4times per day. Refer neurology if failure to respond.
Rinne’s test
- Normal= air conduction>bone condition bilaterally
- Conductive hearing loss= BC>AC in affected ear
- Sensorineual hearing loss= AC>BC bilaterally
Weber test
- Normal= midline
- Conductive hearing loss= lateralises to affected ear
- Sensorineural hearing loss= lateralises to unaffected ear
Sensorineual hearing loss vs conductive hearing loss
Sensorineural hearing loss stems from damage in the inner ear, whereas conductive hearing loss is caused by a breakdown or blockage in the outer and/or middle ear.
Causes of hoarseness?
Voice overuse, smoking, viral illness, hypothyroidism, GORD, laryngeal cancer, lung cancer.
CXR should be considered to exclude apical lung lesions.
Suspected laryngeal cancer- ENT referral for people 45yrs+ with what?
Peristent unexplained hoarseness of unexplained lump in neck.
What does the term head and neck cancer include?
- oral cavity cancers
- cancers of pharynx (incl oropharynx, hypopharynx & nasopharynx)
- cancers of larynx
Features of head and neck cancers
neck lump, hoarseness, persistent sore throat, persistent mouth ulcer
When to consider 2ww cancer referral for oral cancer?
- unexplained ulceration in oral cavity >3w or
- persistent and unexplained lump in neck or
- (dentist) lump on lip/in oral cavity or red/red&white patch in oral cavity consistent with erythroplakia or erythroleukoplakia
2 ww cancer referral for thryoid cancer?
Unexplained thyroid lump
Causes of neck lumps
Reactive lymphadenopathy, lymphoma, thyroid swelling, thyroglossal cyst, pharyngeal pouch, cystic hygroma, branchial cyst, cervical rib, carotid aneurysm
Obstructive sleep apnoea/hypopnoea syndrome CP?
Snoring, daytime somnolence, compensated respiratory acidosis, HTN
Obstructive sleep apnoea/hypopnoea syndrome Ix?
Assess sleepiness: Epworth Sleepiness Scale, Multiple Sleep Latency Test.
Diagnostic= polysomnography.
Obstructive sleep apnoea/hypopnoea syndrome Mx
Weight loss; CPAP if moderate/severe; inform DVLA.
Polysomnography includes what?
EEG, respiratory airflow, thoraco-abdo movement, snoring and pulse oximetry.
Antiviral drug for influenza
Oral oseltamivir. Only if serious risk of developing serious complications or in an at risk group eg. pregnant
Sore throat includes what?
Pharyngitis, tonsilitis, larygngitis
Indications for Abx if sore throat?
Systemic very unwell;; 3 or more centor criteria present/ FeverPAIN score of 4 or 5; group A strep confirmed by rapid antigen testing, history RF, increased risk from acute infection eg. child with DM or immunodef.
Scoring systems that indicate need to ABx?
Centor cirteria and FeverPAIN (Fever over 38, Purulence- tonsillar exudate, Attend rapidly-3 days or less, severely Inflamed tonsils, No cough or coryza). Assesses likelihood of isolating strep and guide decision making re Abx.
Abx if indicated for sore throat
Phenoxymethylpenicillin or clarithromycin if allergy. Back-up prescription if don’t improve within 3-5days or worsen rapidly. Abx only shorten symptoms by 16 hours and most people feel better within 1w regardless.
Main causes of viral URTIs?
Rhinoviruses most.
Cause of whooping cough?
Gram -ve Bordeteela pertussis. Vaccination doesn’t have lifelong protection so adolescents and adults may still develop.
Features of whooping cough
- Catarrhal phase (1-2w)= similar to viral URTI
- Paroxysmal phase (2-8w)
- Convalescent phase= cough subsides over weeks to months
Paroxysmal phase of whooping cough
Cough increases in severity; worse at night and after eating; can cause vomiting and central cyanosis; inspiratory whoop (not always); infants- apnoea spells; subconjunctival haemorrhages or anoxia (causing syncope and seizures).
Diagnostic criteria for whooping cough?
Acute cough 14d or more without apparent cause + 1 or more of:
- paroxysmal cough
- inspiratory ‘whoop’
- post-tussive vomiting
- undiagnosed apnoeic attacks in young infants
Diagnosis of whooping cough?
Nasal swab culture for Bordetella pertussis/PCR if cough <21d. Serology if cough >14d
Whooping cough Mx
- NOTIFIABLE DISEASE
- <6m admit to hospital
- if cough <21days then oral macrolide eg. clarithromycin
- school exclusion= 48hrs after starting Abx or 21 days from onset of symptoms.
- Close contacts (at risk or household)= clarithromycin
Whooping cough- pregnant?
- Erythromycin
- Vaccinate women between 16-32w
Cx of whooping cough
Subconjunctival haemorrhage, pneumonia, bronchiectasis, seizures.
Causes of tinnitus?
Idiopathic; meniere’s; otosclerosis; SSNHL; acoustic neuroma; hearing loss; drugs (aspirin, NSAIDs, loop diuretics, aminoglycosides, quinnine); impacted ear wax
Assessment and Mx of tinnitus
- Audiological assessment. Sometimes MRI of internal auditory meatuses. If pulsatile then magnetic resonance angiography as may be vascular cause.
- Mx= TUC, amplification devices if associated hearing loss; support groups
What is vertigo?
False sensation that body or environment is moving
Causes of vertigo?
Viral labyrinthitis; vestibular neuronitis; BPPV; meniere’s; vertebrobasilar ischaemia; acoustic neuroma; posterior circulation stroke; trauma; MS; Ototoxicity eg. gentamicin.
Vestibular neuronitis?
Cause of vertigo often develops following viral infection
Vestibular neuronitis CP?
Recurrent vertigo attacks lasting hrs or days; nausea & vomiting; horizontal nystagmus; no hearing loss or tinnitus
Vestibular neuronitis differentials?
Viral labryinthitis; posterior circulation stroke (the HiNTs exam can distinguish)
Vestibular neuronitis Mx
Buccal or IM prochlorperazine for rapid relief for severe. Less severe: oral prochlorperazine or antihistamine eg. cyclizine. Vestibular rehab exercises preferred.
What is peritonsillar abscess (qunisy)?
Peritonsillar abscess develops as a Cx of bacterial tonsillitis
CP of quinsy?
Severe throat pain lateralises to one side; deviation of uvula to unaffected side; trismus (diff opening mouth); reduced neck mobility
Qunisy Mx
Urgent ENT review. Needle aspiration or inscision & drainage + IV Abx. Tonsillectomy considered to prevent recuurence.
Post op Cx of tonsillectomy?
Pain (increase for up to 6days after). Haemorrhage- all should be assessed by ENT.
Primary or reactionary haemorrhage following tonsillectomy?
First 6-8hrs after surgery; immediate return to theatre
Secondary haemorrhage after tonsillectomy?
> 24hrs-10d after surgery, often associated with wound infection. Admission and Abx, severe may need surgery.
Cx of tonsillitis?
Otitis media; quinsy; RF and glomerulorephritis very rare
Indications for tonsillectomy?
- Sore throats are due to tonsillitis (eg. not URTR)
- 7 episodes for 1 year; 5 per year for 2 years or 3 per year for 3 years and no other explanation for recurrent symptoms
- episodes are disabling and prevent normal functioning
Rare indications for tonsillectomy?
Recurrent febrile convulsions secondary to tonsillitis; obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils; quinsy if unresp to standard Mx
What is Ramsay hunt syndrome (herpes zoster oticus) caused by?
Reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
Ramsay hunt syndrome (herpes zoster oticus) Mx?
Oral aciclovir and corticosteroids
3 pairs of salivary glands?
parotid (serous) - most tumours
submandibular (mixed) - most stones
sublingual (mucous)
Branchial cysts characteristically contain what?
Cholesterol crystals
Immunocompromised patients with poor dentition can develop airway compromise from cellulitis at the floor of the mouth known as?
Ludwig’s angina
Loop diuretics can be a cause of…
Tinnitus
Elderly patient dizzy on extending neck
Vertebrobasilar ischaemia
Otosclerosis may be precipiated by
pregnancy in those who are genetically predisposed
What does spontaneous rotatory nystagmus and positive head impulse test suggest?
Signs of a peripheral cause of vertigo (not central).
Peripheral causes of vertigo?
BPPV, middle ear infections, menieres, vestibular neuritis ect.
Central causes of vertigo?
Stroke, tumours
Most common bacterial cause of ottitis media?
H.influenzae
Rhinitis medicamentosa?
Rebound nasal congestion brought on by extended use of topical decongestants
Mastoiditis Mx?
IV antibiotics
Complications of thyroid surgery
Damage to parathyroid glands can result in hypocalcaemia
If a perforated tympanic membrane does not heal by itself what may be performed?
myringoplasty
In patients with chronic or recurrent ear discharge, ensure the attic is visualised to exclude…
cholesteatoma
Consider 2ww appointment for laryngeal cancer in people >45yrs and over with…
persistent unexplained hoarseness or unexplained lump in neck
Consider 2ww appointment for oral cancer in people with….
unexplained ulceration in oral cavity lasting >3w or persistent and unexplained lump in neck
Consider urgent 2ww referral for oral cancer by dentist in people with…
lump on lip or in oral cavity or a red/red and white patch in oral cavity consistent with erythroplakia or erythroleukoplakia
Consider 2ww for thyroid cancer in people with…
Unexplained thyroid lump
Reactive lymphadenopathy
By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness
Lymphoma
Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly
Thyroid swelling
May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
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
Pharyngeal pouch
More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough, halitosis.
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
Brachial cyst
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
Cervical rib
More common in adult females
Around 10% develop thoracic outlet syndrome
Carotid aneurysm
Pulsatile lateral neck mass which doesn’t move on swallowing
Thyroid nodules may be found by…
pt, during exam or imaging
Primary aim of investigating thyroid nodules?
exclude thyroid ca, accounts for 5% of all nodules
Benign causes of thyroid nodules?
Multinodular goitre
Thyroid adenoma
Hashimoto’s thyroiditis
Cysts (colloid, simple, or hemorrhagic)
Malignant causes of thyroid nodules?
Papillary carcinoma (most common malignant cause)
Follicular carcinoma
Medullary carcinoma
Anaplastic carcinoma
Lymphoma
Ix for thyroid nodules?
TFTs
USS
