ENT Flashcards
Centor criteria for Group A Strep tonsilitis
1 Point for:
- Hx of fever
- White exudates on tonsils
- Abscence of cough
- Tender cervical lymphadenopathy
Pts w/ 3-4 points should be concidered for abx therapy
Bacterial tonsilitis management
Phenoxymethylpenicillin - clari/erythromycin if pen allergic
Tonsilitis complications
- Recurrent tonsilitis
- Retropharyngeal abcess
- Quincy
- Lemierre’s syndrome = inflammation leads to pharygeotonsilitis, inflammation w/in the internal jugular vein and septic emboli - treated w/ high dose benzylpencillin and debridement
Paediatric otitis media management
- Admit if < 3 months old or worried about severe complications
- Offer a delayed abx perscription to be taken if symptoms arnt improving after 4 days (can offer immediate perscirption if pt is systemically unwell)
Otitis media complications
Extra-cranial:
- Facial nerve palsy
- Mastoiditis
- Petrositis
- Labrynthitis
Intra-cranial:
- Meningitis
- Sigmoid sinus thrombosis
- Brain abscess
Indications for adenoidectomy
- Recurrent or persistent otitis media (due to obstruction of the eustachian tubes by enlarged adenoids)
- Adenoid hypertrophy leading to upper airway obstrucion (snorking, OSA)
- In association w/ tonsilectomy for recurrent tonsilitis
- Recurrent sinusitis or adenoiditis
- Dysphagia w/ failure to thrive
- Speech impendements
Allergic rhinitis management
- Avoid triggers
- Nasal irrigation w/ saline
- Oral/intra-nasal antihistamines
- Regular intra-nasal steroids
- Oral steroids if QOL severely affected
- Referal to ENT (red flags, refractory, for allergen testing)
Define Basal skull fractures
Fracturing of one or more of the bones at the base of the skull
Anterior cranial fossa = superior sphenoid and ethmoid bones
Posterior cranial fossa = occipital, temporal and part of the spehnoid bone
Basal skull fractures features
- Hx of head trauma
- Reduced consciousness
- Rhinorrhoea (CSF leakage from nose)
- Otorrhoea (CSF leakge from ears)
- Cranial nerve palsy
- Epistaxis or ottorhagia (bleeding from ears)
- Haemotympanum (blood visible behind the tympanic membrane)
- Battle sign = bruising of the mastoid process
- Racoon eyes = periorbital bruising
Define Benign paroxysmal positional vertigo
A condition caused by detachment of otoliths in the inner ear during head movements, resulting in hair cell stimulation and vertigo
Benign paroxysmal positional vertigo features
- Vertigo attacks triggered by head movements
- Episodes of rotational vertigo lasting 30 secs - 1 min
- Absence of audiotory symptoms
- Reccurent episodes, often resolving naturally over weeks to months
Benign paroxysmal positional vertigo investigations
Dix-Hallpike manoeuvre - causes vertigo and nystagmus if +ve for BPPV
Benign paroxysmal positional vertigo management
Epley manoeuvre - aims to move the detached otholiths out of the semicircular canal and back into the urticle where they belong
Define Branchial cyst
A congenital malformation formed from the incomplete obliteration of the branchial arches (an integral part in devloping the structure of the head and neck)
Branchial cyst features
A painless, cystic mass located anterior to the sternocleidomastoid just below the ear - it may increase in size during URTI
Branchial cyst investigations
- US
- CT/MRI
- Fine-needle aspiration to rule out malignancy
Define Cholesteatoma
An abnormal accumulation of skin and squamous cells w/in the middle ear clerft and mastoid air cells - often caused by recurrent otitis media
Cholesteatoma features
- Persisten foul-smelling discharge
- Headache
- Otalgia
- White area in attic behind the tympanic membrane
Sinusitis features
Acute:
- Bilateral intense pain
- Fever
- Pain worse on sitting forwards
- Purulent discharge
Chronic:
- Bilateral pain
- Purulent discharge
- Nasal obstruction due to muscosal hypertrophy
Sinusitis investigations
- Hx and examination
- Imaging
- Nasal endoscopy
- Microbiology
Sinusitis management
- Analgesia
- Nasal sprays to reduce inflammation
- Abx if bacterial
- Surgery for severe or recurent cases (to remove polyps that may have formed)
Conductive hearing loss causes
- Wax impaction
- Glue ear
- Eustachian tube dysfunction
- Ear infections
- Perforated tympanic membrane
- Chronic suppurative otitis media
- Otosclerosis
Conductive hearing loss investigations
Audiometry shows bone conduction greater than air conduction
Which vessels are involved in anterior epistaxis?
Kiesselbach’s plexus, a vascular network located on the anterior part of the nasal septum
Which vessels are involved in posterior epistaxis?
Branches of the sphenopalatine artery
Epistaxis management
Stepwise approach:
1) Direct compression = pinch nose and lean fowards (to avoid aspirating) - mostly resolves w/in 10-15 min
2) Cautery w/ silver nitrate or electricity - must have a visible bleeding point
3) Nasal packing to tamponade the bleeding
4) Aggressive therapies = reserved to posterior bleeds and uncontrolled severe bleeds that dont resolve w/ nasal packing - includes nasal balloon catheters, transnasal endoscopy w/ cautery/ligation, embolisation, oral/IV transexamic acid
Posterior bleed signs = profuse bleeding, both nostrils involved, unidentifiable bleeding site
Nasal foreign body features
- Organic objects = local inflammation, secondary infections and sinusitis
- Inorganic objects = asymptomatic unless big enough to cause nasal obstruction
- Button batteries = tissue necrosis though electrolysis at the negative pole, leading to septal perforation (epistaxis, purulent/black discharge, facial swelling, pain and fever)
Head and neck cancer features
- Hoarsness
- Throat pain
- Tonhue ulcers
- Painless neck lump
- WL, fevers, NS
- Lymphadenopathy
- Sympoms persisiting longer than 3 wks
Laryngeal papillomatosis management
Surgery to remove the papillomas +/- cidofovir
Define Laryngeal papillomatosis
A rare disease caused by HPV which results in the growth of papillomas inside thew voice box, vocal cords, or anywhere in the air passages from the nose to the lungs
Laryngeal papillomatosis features
- Dysphagia
- SOB
- Hoarsness
- Feeling something stuck in the throat
- Choking
- Coughing
- Recurrent pnuemonia
- Snoring
Define Hereditary haemorrhagic telangiectasia
A rare genetic condition characterised in the abnormal formation of blood vessles - results in telangiectasia and AV malformations
Hereditary haemorrhagic telangiectasia features
- Episatxis
- Anaemia
- GI blood loss
- Emobolic manifestations
Hereditary haemorrhagic telangiectasia investigations
- Nasoendoscopy - may show telangectasia in the nose
- CT/MRI to find AV malfomrations
- FHx
Hereditary haemorrhagic telangiectasia management
- Iron replacement
- Blood transfusion
- Emobolisation of AV malformations w/in organs
Primary causes of hoarsness
- Laryngeal cancer = hoarsness >3 wks, sig smoking history
- Chronic laryngitis = associated w/ GORD, worse in the mornings
- Acute laryngitis = usually viral and self-limiting
- Reinke’s oedema = enlargement of the vocal cords associated w/ hypothyroidism
Define Meniere’s disease
An inner ear disorder caused by dilation and subsequent increased fluid pressure in the endolymphatic spaces of the membranous labyrinth
Meniere’s disease features
- Sudden attacks of vertigo - often in clusters
- Associated deafness
- Tinnitus
- N&V
Meniere’s disease management
- Betahistine (anti-vertigo medication) for prophylaxis
- Prochlorperazine to reduce N&V during attacks
- Duiretics to reduce endolymphatic volume (only done by ENT)
- Low salt diet to reduce endolymphatic volume
Acute VS chronic nasal obstruction
Acute lasts < 12 wks, chronic lasts >12 wks
Define Septal haematoma
The accumulation of blood in the septal space due to bleeding under the perichondrium lining the septal cartilage - often due to nasal trauma and can lead to a disruption in blood supply to the septum, resulting in septal perforation and necrosis w/in 24hrs and a saddle-nose deformity
Septal haematoma features
Bilateral cherry-red swelling visible on the nasal septum (from inside the nose)
Should be suspected w/ any nasal trauma
Septal haematoma management
ENT referal for immediate incision and drainage
Most common caustive agents of Otitis externa
Staph aureus and Pseudomonas species
Otitis externa features
- Otalgia
- Minimal discharge
- Itchiness
- Impaired hearing if the meatus becomes blocked due to inflammation
Otitis externa management
Mild - moderate:
- Combined steroid/abx drops (e.g. Gentamix)
- Acetic acid drops
- Advice to keep ear dry for 7-10 days
Severe:
- Pope wicks (strips of ribbon gauze) to enable deeper penetration of abx (usually gentamicin)
- Oral abx if cellulitis beyond the ear canal, or canal so swollen that wicks cannot enter
Otits media features
Acute:
- Rapid-onset of deep-seated ear pain
- Systemically unwell
- Impaired hearing
- Aural fullness followed by discharge when the typanic membrane perforates, leading to relief of pain
- Injection of blood vessels and diffuse erythema of the typnaic membrane
Benign chronic - dry tympanic membrane perforation w/out infection
Chronic secretory (glue ear) = persitent pain lasting wks after the initial episode w/ an abnormal looking drum and reduced membrane mobility
Chronic suppurative = persistent purulent discharge through the perforated tympanic membrane
Define Otosclerosis
An autosomal dominant condition where abnormal bone growth occurs around the stapes bone in the middle ear, impeding its function as a piston onto the cochlea - results in progressive conductive hearing loss
Otosclerosis features
- Progressive hearing loss, starting unilaterally and then becoming bilateral
- Tinnitus
Otosclerosis investigations
Adiometry shows conductive hearing loss and may present w/ Carhart’s notch (an apparent loss of bone conduction at 2000 Hz)
Otosclerosis management
- Hearing aids
- Stapedecetomy (removal and replacement of the stapes) which can restore hearing in many cases
Define Pinna haematoma
The formation of a blood clot between the cartilage of the pinna and the overlying perichondrium - occurs due to shearing injuries to the ear (e.g. in rugby)
Pinna haematoma features
Pain, swelling of the ear - may become discoloured due to the accumulation of blood
Pinna haematoma management
Decompress the haematoma w/in 24 hrs to avoid complications such as avascular necrosis
Define Quinsy
A complication of tonsilitis where an abscess forms around the tonsil (peritonsilar abscess)
Quinsy features
- Sore throat
- Dysphagia
- Bulge behind 1 tonsil
- Uvula devation (due to the abscess pushing it away)
Quinsy management
- Broad spectrum abx
- Aspiration w/ a needle to remove the abscess
Nasopharangeal carcinoma features
- Symptoms of eustachians tube blockage (hearling loss, tinnitus, otalgia, feeling of aural fullness)
- Nasal obstruction
- Blood-stained nasal discharge
- Persisten epistaxis
- Development of glue ear
Nasopharangeal carcinoma investigations
- Full ENT exam including inspecting the post-nasal space with a flexible nasoendoscopy
- Biopsy of any massess seen
- Imaging and histology
Define Rhinosinusitis
Inflammation of the nose and paranasal sinuses - caused by viral, bacterial or fungal infections, allergies, AI or deviations/obstructions of the septum
Rhinosinusitis features
Need to have 2 symptoms of which 1 must be:
- Nasal blockage
- Nasal obstruction
- Nasal congestion
- Nasal discharge
Other possible symptoms:
- Facial pain or heaviness
- Reduced olfaction
- Headache
- Ear pain
- Sore throat
- Cough
Rhinosinusitis investigations
- Nasal endoscopy
- CT = to look for sinus inflammation
- Cultures
Rhinosinusitis management
- Nasal saline irrigation
- Analgesia
- Intranasal steroids
- Oral high dose corticosteroids if symptoms persisitng for >10 days
- Abx if severe
Salivary gland tumours features
- Swelling in the associated gland (parotid, submanibular or sublingual)
- Invasion of surrounding structures if malignant leading to facial nerve palsy
Salivary gland tumours management
Removal of glands which have been swollen for 1 month or longer w/ no clear underlying cause
Causes of Sensorineural hearing loss
- Presbycusis (most common)
- Noise-induced hearing loss
- Congenital infections (CMV, rubella)
- Neonatal complications = kernictus or menigitis
- Drug-induced (esp aminoglycosides)
- Stroke/TIA
Sensorineural hearing loss investigations
Audiogram - shows hearing loss at higher frequencies
Define Turbinectomy
Surgical removal of all or some of the tissue or bone from the turbinate’s in the nasal passage - used to fix snoring/nasal obstruction due to enlarged turbinates
Define Septoplasty
A surgical procedure that straightens a deviates septum
Define Empty nose syndrome
A rare complication of nasal surgery due to unknown aetiology
Empty nose syndrome features
- SOB
- Nasal obstruction or dryness
- Paradoxical nasal obstruction = pt feels obstructed despite being unobstructed on nasal examination
Empty nose syndrome management
- Nasal irrigation = to moisturise the nasal cavity
- Topical therapies = nasal saline and oil-based emollients
- Psychological support
- Reconstructive surgery in severe cases
Define Sialadenitis
Inflammation of the salivary glands, commonly due to viral/bacterial infections
Sialadenitis features
Pain, tenderness, redness and localised swelling of the affected area
Sialadenitis investigations
- Examination
- USS or CT
- Saliva culture
Sialadenitis management
- Abx
- Oral hygiene advice
- Ensuring good hydration/use of saliva stimulants to encourage good saliva flow
- Incision and drainage of any abscess’ formed
Define Stridor
High-pitched, musical noise heard during inspiration hat results for a partial obstruction of the larynx or large airways
Major causes of Sialadenitis
- Croup
- Epiglottitis
- Bacterial tracheitis = bacterial infection of the trachea
- Foreign body inhalation
Define Temporo-mandibular joint dysfunction
A collection of clinical problems involving the masticatory musculature, the tempomandibular joint and associated structures
Temporo-mandibular joint dysfunction causes
- Jaw trauma
- Stress which leads to clenching or grinding of teeth
- Arthritis of the TMJ
- Abnormal jaw/tooth alignment
Temporo-mandibular joint dysfunction features
- Pain in the jaw, face and ear
- Difficulty opening/closing the mouth
- Clicking, popping or grating sounds in the jaw when opening/closing - A sense of the jaw being stuck or locked
Temporo-mandibular joint dysfunction management
Conservative:
- Resting the jaw
- Adhering to a soft diet
- Avoid opening the jaw wide
- Physio
- Heat/cold packs
Medical:
- Analgesia
- Muscle relaxants
- NSAIDs
Dental:
- Oral splints
- Mouth guards
- Correct misaligned teeth
Define Thyroglossal cyst
A benign neck mass that raised from the remnants of the thyroglossal duct - forms a cyst
Thyroglossal cyst features
- Painless midline neck mass
- Fluctuant swelling
- Moves upwards on tongue protrusion and swallowing
- Can become infected
Thyroglossal cyst investigations
- Examination
- USS
- Fine-needle aspiration
Thyroglossal cyst management
Surgical excision via Sistrunk procedure = removal of the cyst + the middle part of the hyoid bone and core of the tongue base (to prevent reoccurrence)
Define Tinnitus
A condition characterised by the perception of non-verbal sounds in the absence of external stimuli, often described as a hissing, ringing, clicking or buzzing - it may be constant or intermittent
Tinnitus causes
- Chronic noise exposure
- Presbycusis
- Acute acoustic trauma
- Perforation of the tympanic membrane
- Otitis media
- Meniere’s disease
- Vestibular schwannoma
- Ototoxic drugs (quinine, aminoglycosides, loop diuretics)
- Trauma
Tinnitus management
- Treat underlying cause
- CBT
- Sound therapy = background noise to mask the tinnitus
- Hearing aids
Define Tympanosclerosis
A chronic disease which involves inflammation, fibrosis and calcification of the tympanic membrane - associated w/ chronic otitis media and the insertion of gromets
Tympanosclerosis features
- Significant hearing loss
- Chalky white patches on tympanic membrane
Tympanosclerosis management
- Hearing aids
- Surgical excision of the sclerotic areas and repair of the ossicular chain
Vestibular neuritis causes
Viral infections
Vestibular neuritis features
Have an acute phase (~1 week) and then a chronic phase (weeks to months)
Acute:
- Sudden, severe, prolonged vertigo/dizziness
- Severe balance issues
- N&V
- Nystagmus (non-fatiguing)
Chronic:
- Light-headedness
- Mild dizziness w/ head and body movements
- Mild nausea
- Feeling of aural fullness
- Anxiety
Vestibular neuritis management
- Antivirals
- Anti-sickness medication
- Corticosteroids
- Vestibular rehabilitation therapy
Define Vestibular migraine
A neurological condition that is the 2nd most common cause of vertigo - may or may not be associated with a headache
Vestibular migraine features
- Vertigo lasting minutes-days
- N&V
- Photo/phonophobia
- Headache
Vestibular migraine management
Prophylactic:
- TCA’s
- CCBs
- Antiepileptics
- Beta-blockers
Acute:
- NSAIDs
- Motion-sickness mediation
- Antipsychotics
Lifestyle changes + vestibular rehabilitation therapy
Define Vestibular schwannoma
A benign subarachnoid tumour originating from the Schwan cells of the vestibulocochlear nerve - can rarely be associated with Neurofibromatosis type 2
Vestibular schwannoma features
- Asymmetrical/unilateral sensorineural hearing loss and progressive ipsilateral tinnitus
- Large tumours may become SOL
- Dizziness
- Headache
- Disequilibrium
Vestibular schwannoma investigations
All pts w/ unilateral tinnitus and sensorineural deafness should have an MRI to exclude malignancy
Vestibular schwannoma management
Definitive management is surgery - but only for tumours >40mm in size
For smaller tumours - 6 monthly MRIs for surveillance + symptomatic relief
