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ENT Flashcards

1
Q

Weber’s test?

A

512Hz tuning fork placed in middle of forehead, ask which ear is loudest

Normal
- both equal

Sensorineural
- sound louder in normal ear

Conductive
- sound louder in affected ear

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2
Q

Rinne’s test

A
  • flat end of tuning fork on mastoid, when pt can no longer hear, move to 1cm away from ear, wait until not heard again

Normal
- pt can hear sound in air - AC>BC - Rinne’s positive

Abnormal
- Can’t hear sound in air - BC>AC - Rinne’s negative - conductive hearing loss

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3
Q

Audiometry interpretation

A

Normal - anything above 20db line

Sensorineural - both air and bone conduction reduced

Conductive - bone normal, air reduced

Mixed - both air and bone reduced, >15db difference between - air often worse than bone

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4
Q

Vertigo

A

sensation of movt between pt + environment - feel like they are spinning / room is spinning

mismatch of sensory inputs for balance / posture - vision / proprioception / vestibular issues

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5
Q

Vertigo causes

A

Peripheral - vestibular
- BPPV
- Meniere’s
- vestibular neuronitis
- labyrinthitis
- Ramsay-Hunt, trauma to vestibular nerve, acoustic neuroma, otosclerosis

Central - brainstem / cerebellum
- posterior circulation infarct
- tumour
- MS
- vestibular migraine

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6
Q

Benign paroxysmal positional vertigo (BPPV)

A

recurrent episodes of vertigo, triggered by head movt

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7
Q

BPPV Patho

A

Calcium carbonate crystals displaced into semicircular canals

disrupt endolymph flow, confusing vestibular system

head movt creates flow of endolymph - triggers vertigo

Causes - viral infection, head trauma, aging, no cause

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8
Q

BPPV Px

A

vertigo triggered by head movt
- 10-20s episode
- nausea
- asym between attacks
- episodes occur over several weeks, resolve, can recur later
- no hearing loss / tinnitus

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9
Q

BPPV Dx

A

Dix-Hallpike manoeuvre

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10
Q

BPPV Mx

A

Epley manoeuvre

Brandt-Daroff exercises

Betahistine

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11
Q

Vestibular neuronitis

A

inflammation of vestibular nerve - usually viral

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12
Q

Vestibular neuronitis Px

A

acute onset vertigo
- URTI hx
- most severe at start (constant), then triggered by head movt
- N+V
- balance issues
- horizontal nystagmus
- no neuro sx
- no tinnitus / hearing loss

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13
Q

Vestibular neuronitis Dx

A

Head impulse test

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14
Q

Vestibular neuronitis Mx

A

Buccal / IM prochlorperazine

Cyclizine, cinnarizine, promethazine

Maybe vestibular rehab therapy

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15
Q

Labyrinthitis

A

Inflammation of semicircular canals, vestibule, cochlear

Usually after URTI / bacterial infection (eg meningitis, OM)

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16
Q

Labyrinthitis Px

A
  • acute onset vertigo, exacerbated by movt
  • hearing loss - sensorineural
  • tinnitus
  • N+V
  • viral sx
  • gait - may fall to affected side
  • nystagmus
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17
Q

Labyrinthitis Dx

A

H/E
Head impulse test - abnormal

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18
Q

Labyrinthitis Mx

A
  • prochlorperazine
  • cyclizine, cinnarizine, promethazine
  • abx for bacterial cause
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19
Q

Meniere’s disease

A

Long term inner ear disorder

excessive endolymph in labyrinth - disrupt sensory signals

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20
Q

Meniere’s disease Px

A
  • unilateral, maybe bilateral after years
  • vertigo, 20mins-hrs episodes, in clusters
  • hearing loss - sensorineural
  • tinnitus
  • fullness in ear
  • drop attacks
  • imbalance
  • nystagmus in attack
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21
Q

Meniere’s disease Dx

A

clinical dx - by ENT

Audiology

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22
Q

Meniere’s disease Mx

A

Acute attacks
- prochlorperazine
- cyclizine, cinnarizine, promethazine

Prophylaxis
- betahistine
- vestibular rehab exercises

Inform DVLA - don’t drive until sx controlled

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23
Q

Otitis externa (OE)

A

inflammation of external ear canal

bacterial, fungal, eczema, contact dermatitis, trauma, swimming….

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24
Q

OE Px

A
  • ear pain, itch, discharge
  • red, swollen ear canal
  • lymphadenopathy
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25
Q

oe Ix

A

Can do swab

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26
Q

OE Mx

A

Mild;
- OTC acetic acid
Moderate:
- otomize spray - neomycin + dex + acetic acid

  • oral abx (cipro / fluclox) - if immunocompromised, severe infection, spread beyond canal
  • ear wick - sponge/gauze with topical tx
  • fungal - clotrimazole
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27
Q

malignant OE?

A
  • severe life-threatening form of OE
  • commonly pseudomonas
  • spreads to bones - osteomyelitis of temporal bone

Px
- OE and more severe
- headache, pain, fever
- purulent ear discharge
- granulation tissue in ear canal
- facial nerve palsy, hoarse voice, dysphagia

Mx
- admit under ENT
- IV abx
- CT / MRI head

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28
Q

Otitis media (OM)

A

infection of middle ear

often after viral URTI

also bacterial - strep pneumoniae….

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29
Q

OM Px

A
  • ear pain
  • reduced hearing
  • URTI sx
  • balance issues, vertigo
  • discharge - if tympanic membrane perf
  • young pts - fever, vomiting, irritable, lethargy, poor feeding…
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30
Q

OM Ix

A

Otoscopy - bulging tympanic membrane (effusion), red, inflamed, discharge

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31
Q

OM Mx

A
  • paeds - admit if high fever…
  • analgesia
  • most self resolve

Immediate Abx if: systemically unwell, immunocompromised or significant comorbidities

Offer delayed prescription to pick up after 3 days if symptoms unresolved

  • amoxicillin 5d
  • erythromycin - if pregnant + pen allergy
  • clarithromycin - if pen allergy
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32
Q

Mastoiditis?

A
  • infection in mastoid air spaces of temporal bone (spread from middle ear)

Px
- otalgia - behind ear
- hx of OM
- fever, unwell
- swelling, red, tender over mastoid process

Ix
- CT

Mx
- IV abx

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33
Q

Presbycusis - Px, Ix and Mx

A
  • age-related sensorineural hearing loss - high pitches first

Px
- gradual, insidious hearing loss
- speech difficult to hear
- tinnitus

Ix
- audiometry
- otoscopy - r/o ddx
- tympanometry
- bloods

Mx
- hearing aids
- cochlear implants

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34
Q

Otosclerosis

A
  • remodelling of base of stapes - becomes stiff - conductive hearing loss
  • <40yo

Px
- uni/bilateral
- hearing loss - lower pitches affected more
- tinnitus

Ix
- otoscopy - normal
- Weber’s / Rinne’s
- audiometry
- tympanometry
- ?CT

Mx
- hearing aids
- surgical - stapedectomy / stapedotomy - replace whole / part of stapes with prosthesis

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35
Q

Eustachian tube dysfunction?

A
  • tube not working properly / blocked - eg URTI, allergies, smoking

Px
- reduced hearing
- popping in ear
- fullness
- pain, tinnitus

Ix
- otoscopy - r/o OM

Mx
- Valsalva
- decongestant nasal sprays
- antihistamines, steroid nasal spray
- Otovent - OTC
- surgery if severe

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36
Q

Glue ear? Px, Ix and Mx

A

OM + effusion -> loss of hearing
- eustachian tube blocked

Px
- reduction of hearing
- peak 2yo

Ix
- otoscopy - dull tympanic membrane, air bubbles / fluid level
- audiometry

Mx
- resolves alone <3mo
- hearing aids
- grommets
- ?adenoidectomy

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37
Q

Sudden sensorineural hearing loss (SSNHL): definition, Ix and Mx

A
  • unexplained hearing loss <72hrs - ENT emergency

Ix
- audiometry
- MRI / CT head

Mx
- ENT referral
- tx cause
- idiopathic - steroids - oral / intra-tympani

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38
Q

Conductive causes of acute hearing loss

A
  • ear wax
  • infection - OM / OE
  • middle ear effusion
  • eustachian tube dysfunction
  • perforated tympanic membrane
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39
Q

Causes of SSNHL

A
  • 90% idiopathic
  • infection - meningitis, HIV, mumps
  • Meniere’s
  • ototoxic meds
  • MS
  • migraine
  • stroke
  • acoustic neuroma
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40
Q

Tinnitus

A

persistent ringing in ears

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41
Q

Tinnitus causes

A
  • idiopathic
  • meniere’s
  • otosclerosis
  • SSNHL
  • acoustic neuroma
  • hearing loss
  • drugs
  • ear wax
  • anaemia, DM, hypo/hyperthyroid, hyperlipidaemia
  • objective tinnitus - carotid artery stenosis, AS, AV malformation
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42
Q

Tinnitus Ix

A
  • otoscopy
  • Rinne, Weber
  • Bloods - FBC, glucose, TSH, lipids
  • audiology
  • CT / MRI if needed
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43
Q

Tinnitus red flags

A
  • unilateral
  • pulsatile
  • hyperacusis - hypersensitive to sounds
  • sudden hearing loss
  • vertigo / dizziness
  • visual / neuro sx
  • suicidal ideation from tinnitus
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44
Q

tinnitus mx

A

treat underlying cause

symptom managment:
- hearing aids
- sound therapy (background noise to mask tinnitus)
- CBT

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45
Q

ear wax?

A

Px
- conductive hearing loss
- ear discomfort, feels full, pain
- tinnitus

Ix
- otoscopy

Mx
- ear drops - olive oil / sodium bicarb
- ear irrigation
- microsuction - by ENT

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46
Q

acoustic neuroma?

A
  • vestibular schwannoma
  • benign tumour of Schwann cells around vestibulocochlear nerve
  • 5% intracranial, 90% cerebellopontine angle tumours
  • Bilateral - NF2
47
Q

acoustic neuroma Px

A

-typical patient is aged 40-60 years presenting with a gradual onset of:

Unilateral sensorineural hearing loss (often the first symptom)
Unilateral tinnitus
Dizziness or imbalance
A sensation of fullness in the ear

NB can be associated with facial nerve palsy

48
Q

acoustic neuroma Ix

A
  • urgent ENT referral
  • audiometry
  • CT / MRI
49
Q

acoustic neurone mx

A
  • Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate
  • Surgery to remove the tumour (partial or total removal)
  • Radiotherapy to reduce the growth
50
Q

Cholesteatoma

A
  • non-cancerous growth of squamous epithelium in skull base -> local destruction, infections

Px
- foul-smelling discharge
- hearing loss
- local invasion -> vertigo, facial nerve palsy, pain….

Ix
- otoscopy - attic crust
- CT / MRI

Mx
- ENT - surgery

51
Q

auricular haematoma

A
  • blood in auricle after trauma
  • ENT assessment - incision + drainage - prevent cauliflower ear
52
Q

perforated tympanic membrane

A
  • eg from infection, barotrauma, direct trauma
  • may have hearing loss

Mx
- 6-8wks to heal alone - avoid water
- abx for perf after acute OM
- myringoplasty - surgery to close perforation

53
Q

Epistaxis: what is it and most common area affected?

A

nosebleeds

usually originates from Kiesselbach’s plexus, which is located in Little’s area

54
Q

epistaxis causes

A

Local
- nose picking, trauma
- FB
- colds, sinusitis
- cocaine
- topical drugs - steroids
- vascular, tumours

General
- coag disorders, blood thinners
- HTN, atherosclerosis
- weather changes
- excessive alcohol

55
Q

epistaxis px

A
  • unilateral
  • if bilateral - may indicate posterior
  • vomiting blood - if swallowed
56
Q

epistaxis Ix

A

FBC, coag, G+S

57
Q

epistaxis mx

A
  • A-E, cannulate if needed

First aid
- sit up, tilt head forwards
- squeeze soft part of nostrils 10-15mins
- spit out blood, don’t swallow

Next
- nasal packing - nasal tampons / inflatable packs
- cautery - silver nitrate sticks - only one side of septum

Admission
- if uncontrolled / posterior - ?balloon catheter
- if unstable
- ?splenopalatine artery ligation in theatre (for posterior)

58
Q

sinusitis?

A
  • inflammation of mucous membranes in paranasal sinuses
  • eg strep pneumoniae, H influenzae, rhinoviruses
  • RFs - nasal obstruction, recent local infection, swimming, diving, smoking
59
Q

sinusitis Px?

A
  • recent URTI
  • facial pain, frontal, worse bending forward
  • nasal discharge, nasal obstruction
  • loss of smell
  • fever

Red flags
- unilateral
- persistent despite tx for 3mo
- epistaxis

60
Q

sinusitis Ix

A
  • in chronic (>12wks) - nasal endoscopy, CT
61
Q

sinusitis mx

A
  • analgesia
  • intranasal decongestants
  • intranasal corticosteroids
  • oral abx - if severe - phenoxymethylpenicillin, co-amox (if systemically unwell)
62
Q

allergic rhinitis

A
  • inflammatory disorder of nose - to allergens
  • seasonal / perennial / occupational

Px
- sneezing, blocked nose, itchy
- clear discharge, also at back of throat

Mx
- avoid allergen
- antihistamines - oral / intranasal
- intranasal corticosteroids
- topical nasal decongestants

63
Q

nasal polyps?

A
  • growth of nasal mucosa
  • usually bilateral - unilateral = ?tumour

associated with
- chronic rhinitis, sinusitis
- asthma
- Samter’s triad
- CF
- granulomatosis with polyangiitis
- Kartagener’s syndrome

64
Q

nasal polyps Px

A
  • ?chronic rhinosinusitis
  • difficulty breathing through nose
  • snoring
  • nasal discharge
  • anosmia
65
Q

nasal polyps Ix

A

examine with nasal speculum
- nasal endoscopy

66
Q

nasal polyps Mx

A
  • intranasal steroid drops / spray
  • surgery - intranasal polypectomy / endoscopic if further back
67
Q

nasal septal haematoma? Px, Mx and key complication?

A
  • haematoma between septal cartilage and overlying perichondrium - cx of nasal trauma

Px
- nose blocked, pain, rhinorrhoea
- bilateral, red swelling arising from nasal septum - boggy

Mx
- surgical drainage
- IV abx

Cx
- septal necrosis -> saddle nose deformity

68
Q

tonsillitis

A

Inflammation in tonsils

Causes
- viral - most common
- Group A strep - strep pyogenes
- strep pneumonia…

69
Q

tonsillitis px

A
  • fever
  • sore throat
  • painful swallowing
  • lymphadenopathy
  • younger children - fever, poor oral intake, headache, vomiting, abdo pain
70
Q

CENTOR criteria

A

Probability of bacterial infection

> 3 of the following - indicates abx

  • fever >38
  • tonsillar exudates
  • absence of cough
  • tender anterior cervical lymph nodes
71
Q

FeverPAIN score

A

score /5, gives % chance of strep infection

2-3 is 34-40%, 4-5 is 62-65%

  • fever in past 24hrs
  • pus
  • attend <3d of sx onset
  • inflamed tonsils
  • no cough / coryza
72
Q

tonsillitis Mx

A
  • paracetamol, ibuprofen, Difflam
  • abx - penicillin V / clarithromycin
  • consider delayed prescription
  • admit if needed - eg unwell…
73
Q

Quinsy

A
  • peritonsillar abscess
  • bacterial infection with trapped pus
  • most commonly strep pyogenes (GAS), also S aureus, H influenzae
74
Q

Qunisy Px

A
  • sore throat
  • painful swallowing
  • fever, neck pain, referred ear pain
  • swollen lymph nodes
  • trismus
  • hot potato voice
  • swelling / erythema beside tonsils
75
Q

Quinsy Mx

A
  • ENT admission - incision / drainage
  • Co-amoxiclav
  • ?dex for inflammation
76
Q

Indication for tonsillectomy?

A
  • 7+ cases in 1yr
  • 5/yr for 2yrs
  • 3/yr for 3yrs
  • Recurrent tonsillar abscesses (2 episodes)
  • Enlarged tonsils causing - difficulty breathing, swallowing, snoring
  • Recurrent febrile convulsions secondary to tonsillitis
77
Q

complications of tonsillectomy

A
  • pain, sore throat
  • damage to teeth
  • infection
  • risks of GA
  • post-tonsillectomy
78
Q

Post-tonsillectomy bleeding Mx

A
  • ENT registrar
  • IV access, send FBC, coag, G+S/C
  • keep child calm, analgesia
  • spit blood out
  • NBM for GA
  • IV fluids / bloods
  • hydrogen peroxide gargle
  • adrenaline soaked gauze
79
Q

thyroid surgery complications

A
  • recurrent laryngeal nerve damage
  • bleeding
  • parathyroid gland damage -> hypocalcaemia
80
Q

Laryngopharyngeal reflux

A
  • inflammatory changes in larynx / hypopharynx due to GORD

Px
- sensation of lump in throat - midline, worse swallowing saliva (rather than food/drink)
- hoarse voice, chronic cough, dysphagia, heartburn, sore throat

Ix
- clinical dx
- if red flags, 2ww referral - persistent unilateral discomfort, dysphagia, odynophagia, persistent hoarseness

Mx
- diet chages
- PPI, gaviscon

81
Q

ludwig’s angina?

A
  • progressive cellulitis which invades floor of mouth, soft tissues of neck
  • from dental infections

Px
- neck swelling
- dysphagia
- fever

Mx
- mx airway
- IV abx

82
Q

salivary gland tumours?

A

80% parotid, 80% of these - pleomorphic adenomas, 80% superficial lobe

83
Q

pleomorphic adenoma

A
  • benign mixed parotid tumour

Px
- slow growing painless lump, moveable
- middle aged

Mx
- superficial parotidectomy

84
Q

warthin’s tumour

A
  • benign, adenolymphoma, 10%
  • males, middle aged
  • softer, more mobile, fluctuant
85
Q

salivary gland stones?

A
  • 80% submandibular

Px
- recurrent unilateral pain / swelling on eating

Ix
- XR
- sialography - XR + contrast

Mx
- surgical removal

86
Q

neck lumps DDx

A
  • Bony prominence - hyoid bone, cervical rib
  • lymphadenopathy
  • tumour
  • lipoma
  • goitre, thyroid nodules
  • salivary gland stones / infection
  • carotid body tumour
  • haematoma
  • thyroglossal cyst
  • branchial cyst
  • cystic hygroma
  • dermoid cyst
  • haemangioma
  • venous malformation
87
Q

Neck lump Hx and Ex

A

Hx
- SOCRATES
- fever, wt loss, night sweats
- FHx, smoking

Exam
- lump exam
- lymph nodes
- skin changes
- focal chest sounds - cancer
- clubbing
- HSM

88
Q

Neck lump 2ww referral criteria

A
  • unexplained neck lump >45yo
  • persistent unexplained neck lump any age

USS with growing lump:
- <2wks if >25yo, <48hrs if <25yo

89
Q

neck lump ix

A

bloods - eg FBC, blood film, HIV, EBV ABs, TFTs, ANA, LDH (Hodgkin’s)

  • USS, CT/MRI, nuclear medicine scan
  • Biopsy - fine needle / core, incision
90
Q

Lymphadenopathy causes

A

Reactive - URTIs, dental infections, tonsillitis

Infective - TB, HIV, IM

Inflammatory - SLE, sarcoidosis

Malignancy - lymphoma, leukaemia, mets, chest/abdo (supraclavicular)

91
Q

Lymphadenopathy sx suggesting malignancy

A

unexplained
persistently >3xm
abnormal shape - oval
hard / rubbery
non-tender
tethered / fixed to skin / underlying tissues
night sweats, wt loss, fatigue, fever

92
Q

carotid body tumour

A
  • glomus cells (grouped into paraganglia) just above carotid bifurcation - benign tumour of this

Px
- slow growing lump, near angle of mandible
- painless, pulsatile
- bruit
- mobile side-to-side, not up/down
- may compress nerves - eg Horner’s

Ix
- imaging - splaying of internal / external carotids - lyre sign

Mx
- surgical removal

93
Q

pharyngeal pouch

A
  • older men
  • posteromedial herniation between thyropharyngeus + cricopharyngeus muscles
  • Px - dysphagia, regurg, aspiration, cough
94
Q

head/neck cancer

A

usually SCC

Locations
- nasal cavity, paranasal sinuses, mouth, salivary glands, pharynx, larynx

usually spread to lymph nodes first

RFs
- smoking, chewing tobacco, alcohol, HPV 16, EBV

95
Q

head/neck cancer Px

A
  • lump in mouth / lip
  • unexplained mouth ulcer >3wks
  • erythroplakia, erythroleukoplakia
  • persistent neck lump
  • unexplained hoarse voice
  • unexplained thyroid lump
  • CN palsies, nasal obstruction, epistaxis, otalgia
96
Q

head/neck cancer referral criteria

A

Laryngeal
- >45yo with persistent unexplained hoarseness / lump in neck

Oral
- unexplained mouth ulcer >3wks / lump in neck
- lump on lip / oral cavity / red or red/white patch - dentist to see

Thyroid
- unexplained thyroid lump

97
Q

head/neck cancer Ix

A
  • Scans, biopsy
  • TNM staging
98
Q

Head/neck cancer Mx

A
  • chemo / radio
  • surgery
  • MAbs
99
Q

glossitis

A
  • inflammation of tongue
  • red, sore, swollen
  • papillae atrophy - smooth tongue

Causes
- iron deficiency
- B12 anaemia
- folate anaemia
- coeliac
- injury / irritants

100
Q

angioedema

A

fluid build up in tissues

Causes
- allergic reactions
- ACEi
- hereditary angioedema

101
Q

Oral candidiasis

A
  • oral thrush - white spots / patches on tongue / palate

RFs
- ICS
- abx
- DM, HIV, smoking

Mx
- miconazole gel
- nystatin suspension
- fluconazole tablets

102
Q

Geographic tongue

A
  • inflammatory - patches of tongue lose epithelium + papillae - irregular shapes
  • related to - stress, mental illness, psoriasis, atopy, diabetes
  • benign
  • topical steroids / antihistamines for sx control
103
Q

strawberry tongue?

A

tongue swollen, red
papillae enlarged + white

Scarlet fever / Kawasaki’s

104
Q

black hairy tongue

A
  • defective exfoliation of keratin from tongue’s surface, papillae elongate + look like hairs

Causes
- dehydration, poor oral hygiene, smoking, abx, HIV, IVDU, radiation

Ix
- swab to r/o candida

Mx
- hydrate
- gently brush tongue
- stop smoking

105
Q

leukoplakia

A
  • white patches on tongue, inside of cheeks - precancerous to SCC

Px
- asym, irregular, slightly raised

Ix
- biopsy

Mx
- stop smoking, alcohol
- potential surgical excision

106
Q

erythroplakia

A

Red patches in mouth, like leukoplakia

107
Q

lichen planus

A
  • autoimmune - local chronic inflammation of skin

Px
- shiny, purplish, raised areas with white lines
- bright red, sore
- plaques
- often only mouth, but can affect all mucosal membranes

Mx
- oral hygiene, stop smoking
- topical steroids

108
Q

gingivitis

A
  • inflammation of gums
  • acute necrotising ulcerative version - rapid onset

RFs
- plaque, smoking, diabetes, malnutrition, stress

Px
- swollen gums, bleeding, painful, bad breath

Mx
- hygiene, stop smoking, dental hygienist clean
- chlorhexidine mouth wash
- abx for acute necrotising ulcerative - metronidazole, amoxicillin

109
Q

gingival hyperplasia

A

abnormal growth of gums

Causes
- gingivitis
- pregnancy
- vit deficiency - scurvy
- AML
- meds - CCBs, phenytoin, ciclosporin

110
Q

aphthous ulcers

A

abnormal growth of gums

Causes
- gingivitis
- pregnancy
- vit deficiency - scurvy
- AML
- meds - CCBs, phenytoin, ciclosporin

111
Q

Common bacterial causes of OE?

A

Pseudomonas aeruginosa
Staphylococcus aureus

112
Q

which infection is commonly known as swimmers ear?

A

OE

113
Q

what can you consider prescribing after an acute nosebleed? who is this contraindicated in?

A

Naseptin nasal cream (chlorhexidine and neomycin) QDS for 10 days

C/I in peanut or soya allergy

finals (21 decks)

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