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Phase 4 > ENT > Flashcards

ENT Flashcards

1
Q

What is the pathophysiology of benign paroxysmal positional vertigo?

A

calcium carbonate crystals called otoconia become displaced in the semicircular canals which disrupt the usual flow of endolymph triggering vertigo

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2
Q

what are the 4 possible causes of BPPV?

A

viral infection
trauma
aging
idiopathic

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3
Q

what are 3 features of BPPV?

A

20-60 second duration
triggered by movement
no hearing loss or tinnitus

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4
Q

what does the Dix-Hallpike manouver test for?

A

Benign paroxysmal positional vertigo

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5
Q

what is a positive Dix-Hallpike?

A

nystagmus is observed - beating is towards affected ear

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6
Q

what manoeuvre is used to treat BPPV?

A

epley manoeuvre

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7
Q

what manoeuvre is used to test for BPPV?

A

Dix-Hallpike manoeuvre

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8
Q

what exercises can be done by patients to improve BPPV?

A

Bradt-daroff exercises

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9
Q

what are the 4 most common causes of peripheral (vestibular) vertigo?

A

Benign paroxysmal positional vertigo
Menieres disease
vestibular neuritis
labrinthitis

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10
Q

what kind of nystagmus is seen in BPPV?

A

rotational nystagmus

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11
Q

How do you perform the dix-hallpike manouver?

A

Patients sat on flat exam couch with head turned 45 degrees to side of ear being tested
Rapidly lower patient backwards until head hanging off couch while holding head at 45 degrees
Hold head still 20-30 degrees below couch and at 45 degrees
Watch eyes for 30-60s for nystagmus

repeat on other side

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12
Q

How do you perform the epley manouver?

A

Patient sat on couch with head at 45 degrees towards affected side
Lie patient with head of the bed
Rotate their head 90 degrees past central point with head off couch
Have patient roll onto side with head still in position
Have patient sit up with legs off side of couch
position head centrally with neck flexed and chin to chest

at each stage support patients head in place for 30s and wait for nystagmus/dizziness to pass

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13
Q

when should patients with BPPV be referred to ENT?

A

Repeat symptoms despite repositioning procedures
Not resolved in 4 weeks
atypical symptoms or signs
3+ periods of vertigo

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14
Q

What is Meniere’s disease?

A

excessive build up of endolymph in membranous labyrinth which causes high pressure and sensory signals

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15
Q

what is the classic triad of Meniere’s disease?

A

Hearing loss
Vertigo
Tinnitus

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16
Q

what are 8 features of menieres disease?

A

hearing loss
tinnitus
vertigo
sensation of fullness in ear
Nystagmus during attack

last several hours
not associated with movement
unilateral hearing loss
drop attacks

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17
Q

what are vertigo attacks like in Meniere’s disease?

A

Episodes lasting 20 mins to hours that can come in clusters with long periods of remssion

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18
Q

what is the hearing loss like in Meniere’s disease?

A

fluctuant at first associated with vertigo attacks then becoming permanent

unilateral sensorineural hearing loss starting with low frequencies

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19
Q

what is the acute management of meniere’s disease?

A

Prochlorperazine - 5mg TDS

antihistamines

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20
Q

what is the prophylaxis for Meniere’s disease?

A

Betahistine - 16mg TDS taken with food

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21
Q

what are 4 risk factors for Meniere’s disease?

A

FHx
Caucasian
Migraines
Autoimmune diseases

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22
Q

what is acute vestibular neuritis?

A

inflammation of the vestibular nerve usually due to viral infection. Typically presents as acute onset vertigo which improves within a few weeks. NO HEARING LOSS OR TINNITUS

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23
Q

what kind of nystagmus is usually seen in vestibular neuritis?

A

Horizontal

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24
Q

what is labrynthitis?

A

inner ear inflammation usually due to viral infection which causes acute onset vertigo which improves within a few weeks and CAN CAUSE HEARING LOSS and nausea

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25
Q

what is the management of labyrinthitis AND vestibular neuritis ?

A

3 days of

Prochlorperazine - 5mg TDS (max 30mg)

Antihistamine - Cyclizine - 50mg TDS
Promethazine - 20-25mg
Cinnazine

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26
Q

what is the HINTS examination?

A

Head Impulse test
Nystagmus
Test of Skew

to determine peripheral or central cause of vertigo

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27
Q

How can prochlorperazine be administered to provide rapid relief to labyrinthine disorders?

A

Buccal or IM

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28
Q

what are the 4 most common central causes of vertigo?

A

posterior circulation stroke
tumour
MS
vestibular migraine

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29
Q

what kind of vertigo do you get with central casues?

A

non-positional
doesn’t affect hearing
no tinnitus

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30
Q

what is a test that can be used to determine a peripheral cause of vertigo?

A

the head impulse test - +ve in peripheral

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31
Q

what is the head impulse test?

A

for peripheral causes of vertigo

ask patient to fix eyes on nose, move head rapidly 10-20 degrees to one side then slowly back to middle then to other side

Positive if eyes saccade (rapidly move back and forth) before fixing back on nose

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32
Q

what is the test of skew?

A

tests for central cause of vertigo

ask patient to look at nose, cover one of their eyes then the other alternating, if eye has to refix on nose after being uncovered - may indicate central vertigo

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33
Q

what test can be used to determine a central cause of vertigo?

A

the test of skew

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34
Q

what medications can be used to manage peripheral vertigo acutely?

A

prochlorperazine 5-30mg TDS
antihistamines

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35
Q

what medication can be used prophylactically for Menieres disease?

A

Betahistine

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36
Q

what is the classical triad of menieres disease?

A

hearing loss
vertigo
tinnitus

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37
Q

where does anterior epistaxis usually occur from?

A

kiesselbach’s plexus located in little’s area

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38
Q

what is are 10 risk factors for epistaxis?

A

nose picking
colds
sinusitis
vigorous nose blowing
trauma
changes in weather
Coagulation disorders
anticoagulant meds
snorting cocaine
tumours

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39
Q

what do posterior nose bleeds increase risk of?

A

aspiration of blood

may bleed from both nostrils

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40
Q

what is a benign tumour that can cause epistaxis?

A

juvenile angiofibroma - benign tumour that is highly vascularised - seen an adolescent males

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41
Q

How is epistaxis managed in first aid?

A

Sit leant forwards with mouth open and pinch soft area of nose firmly

at least 20 mins!

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42
Q

what can be given if first aid management of epistaxis IS successful after bleeding has stopped?

A

Naseptin (chlorhexidine and neomycin) - topical aseptic QDS for 10 days - reduces crusting, inflammation and infection

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43
Q

Who should not be given naseptin?

A

Peanut, soy or neomycin allergy

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44
Q

what should be done I epistaxis does not stop after 10-15 mins of first aid?

A

1 - Cautery using silver nitrate sticks if source of bleeding visible

2 - Packing - if bleeding point not visualised - ent review

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45
Q

what surgery can be used for failed initial management of epistaxis?

A

sphenopalatine ligation

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46
Q

what anaesthetic can be used for cautery in epistaxis?

A

co-phenylcaine

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47
Q

what is hereditary haemorrhage telangiectasia?

A

autosomal dominant condition causing telangiectasis (dilated blood vessels), epistaxis, GI haemorrhage and anaemia

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48
Q

what can be used for nasal packing in epistaxis?

A

Morocel nasal tampons
Rapid Rhinos
ribbon gauze impregnated with bismuth iodoform paraffin paste (BIPP)

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49
Q

what are 4 contraindications to nasal packing?

A

basal skull fracture
facial or nasal fracture
airway emergency/haemodynamic instability

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50
Q

Where do posterior nosebleed occur from usually?

A

sphenopalatine artery or terminall branches of maxillary artery

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51
Q

what is the second line measure for post epistaxis care?

A

Mupirocin nasal ointment

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52
Q

what are 4 complications of nasal packing?

A

bacterial sinusitis
staphylococcal toxic shock syndrome - with prolonged use
asphyxiation
necrosis of nasal septum

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53
Q

what are 5 bits of advice for patients post epistaxis?

A

Avoid:
Blowing or picking the nose
Heavy lifting
Strenuous exercise.
Lying flat
Drinking alcohol or hot drinks

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54
Q

what is the middle ear?

A

between tympanic membrane and inner ear (cochlea, vestibular apparatus and nerves)

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55
Q

what are 6 risk factors for otitis media?

A

Eistachian tube dysfunction
Age - children
Immunodeficiency
Allergies
Smoking
CF

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56
Q

what is the most common causative organism for otitis media?

A

strep pneumoniae

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57
Q

what are 3 other common causative organisms for otitis media?

A

H. Influenzae
Moraxella catarrhalis
Staph aureus

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58
Q

why are children predisposed to otitis media?

A

Narrower Eustachian tube
more horizontal eustachian tube
Less developed immune system

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59
Q

what are 5 presenting features of otitis media?

A

ear pain
reduced hearing
feeling generally unwell - fever
URTI symptoms
balance issues, vertigo

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60
Q

what might be seen O/E in otitis media?

A

Bulging, red, inflamed tympanic membrane

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61
Q

what are 8 complications of otitis media?

A

hearing loss
perforated tympanic membrane
labrynthitis
mastoiditis
abcess
fascial nerve palsy
meningitis

62
Q

how long do most otitis media infections last?

A

5 days

63
Q

what classes as recurrent acute otitis media?

A

3+ separate episodes of otitis media in past 6 months or 4 in 1 year

64
Q

what is the first line treatment for otitis media?

A

1 - consider no Abx

amoxicillin 5-7 days PO
- 1-11 months - 125mg TDS
- 1-4 years - 250mg TDS
- 5-17 years - 500mg TDS
- Adults - 500mg TDS

clarithromycin - in penicillin allergy
- Adults - 250mg BD

erythromycin - pregnancy
- 250-500mg QDS

65
Q

what is the management of otitis media in pregnant women allergic to penicillins?

A

erythromycin

66
Q

when should you consider immediate abx prescription in otitis media?

A

Symptoms >4 days and not improving
Systemically unwell
Immunocompromised or high risk comorbidities
<2 years with b/l
Perforation and/or discharge in canal

67
Q

what is chronic suppurative otitis media?

A

chronic inflammation >2 weeks of the middle ear and mastoid cavity that presents with recurrent ear discharges through a tympanic membrane perforation

usually hearing loss in affected ear with a Hx of otitis media

68
Q

what are the two most common causes of otitis externa?

A

Pseudomonas aeruginosa

Staph aureus

69
Q

what kind of bacteria is pseudomonas aeruginosa?

A

gram neg aerobic bacilli

naturally resistant to many antibiotics - tx with aminoglycosides (gent) or quinolones (ciproflox)

70
Q

what are 5 conditions that can cause inflammation in the external auditory cannal?

A

bacterial infection
fungal infection
eczema
seborrhoeic dermatitis
Contact dermatitis

71
Q

what are 4 typical symptoms in otitis externa?

A

ear pain
discharge
itchiness
conductive hearing loss - if ear blocked

72
Q

what 4 things can be seen o/e in otitis externa?

A

Erythema and swelling of ear canal
Tender tragus/pinna
Debris in ear canal
Cellulitis on pinna
Lymphadenopathy

73
Q

what are 4 things that can be seen o/e in chronic otitis externa?

A

lack of earwax in canal
dry scaly skin in ear canal
canal stenosis
fluffy cotton like black debris in canal - fungal infection
Conductive hearing loss

74
Q

what is the treatment for mild otitis externa?

A

acetic acid 2% (earcalm)

can also be used prophylactically

75
Q

what is advice for otitis externa?

A

do not use cotton buds to clean ear canal
keep ears clean and dry
use cotton wool in vaseline for bathing and ear plugs for swimming

76
Q

what is the management of moderate otitis externa?

A

topical Abx + steroid

neomycin + dexamethasone and acetic acid (OTOMISE)

Gentamicin and hydrocortisone
ciproflaxacin and dexamethasone

77
Q

what is a contraindication to using gentamicin/neomycin in otitis externa?

A

perforated tympanic membrane - they are ototoxic

78
Q

what is the management of sever/systemic otitis externa?

A

oral Abx - fluclox/clarithromycin

79
Q

what is the treatment for fungal otitis externa?

A

clotrimazole ear drops

80
Q

what is the management of otitis externa if tympanic membrane cannot be visualised?

A

ENT referral for microsuction or wick insertion

81
Q

what is the management of necrotising otitis externa?

A

Admission under ENT
IV ceftazidime for 6 weeks

82
Q

what are 3 complications of otitis externa?

A

Regional spread - cellulitis, perichondritis, parotitis
Fibrosis and stenosis of ear canal
Malignant otitis externa

83
Q

what is malignant otitis externa?

A

severe otitis externa where infection spreads to temporal bone. Causes severe persistent headache, fever, vertigo

granulation tissue is found at junction between bone and cartilage in ear canal

84
Q

what increases the risk of malignant otitis externa?

A

Diabetes
Immunocompromise
Older age
radiotherapy to head, neck, ear
Previous ear surgery/irrigation

85
Q

what is the most common causative organism of bacterial tonsilitis?

A

Group A strep - strep pyogenes

86
Q

What is the treatment for bacterial tonsilitis?

A

1st - penicillin V (phenoxymethylpenicillin) 10 days
<11mon - 62.5mg QDS
1-5 years - 125mg QDS
6-11years - 250mg QDS
12+ - 500mg QDS

PENICILLIN ALLERGY- Clarithromycin
12+ - 250-500mg BD

PREGNANCY + PEN ALLERGY
Erythromycin
250-500mg QDS

87
Q

what are 2 groups who need an FBC when presenting with tonsilitis?

A

On DMARDs - also hold DMARD till results

On carbimazole - due to risk of idiosyncratic neutropenia - also hold drug

88
Q

what is the most common viral cause of tonsillitis?

A

Adenovirus

89
Q

what is the second most common bacterial cause of tonsilitis?

A

strep pneumnoniae

90
Q

what 2 criteria can be used to determine the probability that tonsilitis is bacterial?

A

Centor criteria
FeverPAIN score

91
Q

what is the centor criteria?

A

for bacterial tonsilitis

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

SCORE >3 => offer Abx

92
Q

what is the feverPAIN score

A

for bacterial tonsilitis

Fever in last 24 hours
Purulence
Attended in 3 days of onset
Inflamed tonsils
No cough or coryza

SCORE >4 - consider Abx

93
Q

what are 2 investigations that can be used for tonsillitis?

A

Throat culture - gold
Rapid group A streptococcal antigen test

94
Q

what are 6 complications of bacterial tonsilits?

A

Peritonsillar abcess (quinsey)
Otitis media
Scarlet fever
Rheumatic fever
Post-streptococcal glomerulonephritis
Post-streptococcal reactive arthritis

95
Q

what are the criteria for tonsillectomy?

A

7 episodes in 1 year
OR
5 episodes in 2 years
OR
3 episodes in 3 years

episodes must disabling and prevent normal functioning

Recurrent febrile convulsions secondary to tonsillitis

OSA, stridor or dysphagia due to enlarged tonsils

Unresponsive peritonsillar abscess

96
Q

what are 2 primary (<24h) complications of tonsillectomy?

A

Haemorrhage - due to inadequate haemostasis

Pain

97
Q

what are 2 secondary (>24h) complications of tonsillectomy?

A

Haemorrhage - usually due to infection
Infection
Pain

98
Q

what is the most common bacterial cause of peritonsillar abscess?

A

strep pyogenes

99
Q

what is the most common age range for peritonsillar abscess?

A

20-30 years

100
Q

what are 6 features of peritonsillar abscess?

A

Severe sore throat pain lateralising to one side
difficulty swallowing and talking (hot potato voice
Deviation of uvula to unaffected side
Trismus
Reduced neck motility
Systematic features - fever, chills, malaise

101
Q

what is the management of peritonsillar abscess?

A

Abx - a penicillin + beta lactamase
Analgesia
Steroids

Needle aspiration
Intraoral incision and drainage
Quinsy tonsillectomy

102
Q

what is acute sinusitis?

A

<12 weeks

103
Q

what is chronic sinusitis?

A

> 12 weeks

104
Q

what are the 4 pairs of paranasal sinuses?

A

frontal - above eyebrows
maxillary - either side of nose
ethmoid - in middle of nasal cavity
sphenoid - in back of nasal cavity

105
Q

what are 4 causes of sinusitis?

A

infection
allergies
obstruction of drainage - foreign body, polyps
smoking

106
Q

what is the typical presentation of acute sinusitis? 5

A

nasal congestion and discharge
facial pain/headache
facial pressure
facial swelling
loss of smell

107
Q

what 5 things may be seen o/e of sinusitis?

A

tenderness to palpation
inflammation and oedema of nasal mucosa
discharge
fever
signs of systemic infection

108
Q

how long should you wait to give abx for sinusitis?

A

10 days

109
Q

what is the management of sinusitis?

A

After 10 days conservative management

high dose steroid nasal spray for 14 days - 200mcg Mometasone BD

Delayed till day 17 phenoxymethylpenicillin

110
Q

what is the most common cause of acute sinusitis?

A

viral URTI

111
Q

what are 4 risk factors for sinusitis ?

A

Nasal obstruction - septal deviation/polyps
Recent local infection - dental, rhinitis
Swimming/diving
Smoking

112
Q

what are 2 investigations for chronic sinusitis?

A

Nasal endoscopy
Imaging - CT paranasal sinuses

113
Q

what is the management of chronic sinusitis?

A

Nasal saline irrigation, topical corticosteroids, Abx if indicated

Surgery - functional endoscopic sinus surgery, balloon sinuplasy

114
Q

what can be used as a nasal decongestant in sinusisitis?

A

Pseudoephedrine - 60mgQDS

Phenylephrine

115
Q

what is the other name for an acoustic neuroma?

A

Vestibular schwannoma

116
Q

what is an acoustic neuroma?

A

a benign tumour of the of the schwann cells surrounding the vestibulocochlear nerve

117
Q

what are bilateral acoustic neuromas associated with?

A

neurofibromatosis type II

118
Q

what are 6 presentations of acoustic neuroma?

A

gradual onset of:

Unilateral sensorineural hearing loss
Unilateral tinnitus
Dizziness or imbalance/vertigo
Sensation of fullness in ear
Facial nerve palsy - forehead not spared in LMN
Headache, nausea, vomiting

119
Q

what are 2 investigations for acoustic neuroma?

A

Audiometry
Gadolinium enhanced MRI head

120
Q

what are 3 complications of acoustic neuroma management?

A

Vestibulocochlear nerve injury - permanent hearing loss and dizziness
Facial nerve injury
CSF leak

121
Q

where are acoustic neuromas most commonly found?

A

cerebellopontine angle

122
Q

what is the management of acoustic neuroma?

A

Watch and wait - MRI annually for first 5 years
Stereotatic radiosurgery/radiotherapy
Surgical removal

123
Q

what virus is infectious mononucleosis caused by?

A

epstein-barr virus (EBV)

124
Q

what is the classical triad of infectious mononucleosis?

A

Sore throat
lymphadenopathy - anterior or posterior triangles of neck
pyrexia

125
Q

what are 10 features of infectious mononucleosis?

A

Malaise, fatigue, headache
Fever
Sore throat
Lymphadenopathy
Palatal petechiae
Splenomegaly
Hepatitis - transient ALT rise
Lymphocytosis
Haemolytic anaemia
maculopapular rash with ampicillin/amox ise

126
Q

what can be seen on FBC in infectious mononucleosis?

A

lymphocytosis

127
Q

what does NICE suggest for confirmation of infectious mononucleosis?

A

FBC + Monospot in second week of illness to confirm diagnosis

128
Q

what is the management of infectious mononucleosis?

A

Analgesia
+ Hydration

129
Q

what advice needs to be given to those with infectious mononucleosis?

A

Avoid contact sport for 1 month due to risk of spleen rupture

May have post viral fatigue for several weeks to months

130
Q

what are 5 complications of infectious mononucleosis?

A

Haemolytic anaemia
Splenic rupture
Hepatitis
GBS
Secondary bacterial infection

131
Q

what is tested for in the monospot test?

A

Heterophile antibodies for EBV

132
Q

What cancer is EBV associated with?

A

Burkitt’s lymphoma

133
Q

what is the cause of haemolytic anaemia in infectious mononucleosis?

A

secondary to cold agglutins (IgM)

134
Q

what are 6 risk factors for OSA?

A

Obesity
Age + post menopause
Male
FHx
Smoking
Medical conditions - hypothyroid, aromegaly, PCOS

135
Q

what are 7 features of OSA?

A

episodes of apnoea during sleep
snoring
morning headache
waking up unrefreshed
daytime sleepiness
concentration problems
reduced O2 sats during sleep

136
Q

what are 4 complications of OSA?

A

HTN
Heart failure
MI
Stroke

137
Q

What 2 scoring systems can be used to assess for OSA?

A

Epworth sleepiness scale
STOP BANG

138
Q

what is the management of OSA?

A

Weight loss + lifestyle management

CPAP
Inform DVLA - must not drive if have excessive daytime sleepiness

139
Q

what are 2 investigations of OSA?

A

screening questionnaires
Sleep studies

140
Q

what antibiotic causes ototoxicity?

A

Aminoglycosides - gentamicin, neomycin

141
Q

what is a cholesteatoma?

A

A non-cancerous abnormal collection of squamous epithelial cells in the middle ear

142
Q

what is the pathophysiology of cholesteatoma?

A

theory

there is negative pressure in the middle ear due to eustachian tube dysfunction which causes a pocket of the tympanic membrane to retract into the middle ear forming a pocket where squamous epithelial cells continue to proliferate and grow into the surrounding spaces

143
Q

what are 2 presentations of cholesteatoma?

A

Foul ear discharge
unilateral conductive hearing loss

Also vertigo, facial nerve palsy

144
Q

what is used to confirm diagnosis of cholesteatoma?

A

CT/MRI head

145
Q

what can be seen on otoscopy in cholesteatoma?

A

Abnormal build up of whitish debris or crust under tympanic membrane

146
Q

what are 4 complications of cholesteatoma?

A

Ossicular chain erosion - leading to conductive hearing loss
Labyrinthine fistula
Intracranial extension - meningitis, brain abscess, lateral sinus thrombosis
Mastoiditis

147
Q

what is the management of cholesteatoma?

A

Canal wall up mastoidectomy

Canal wall down mastoidectomy

148
Q

what is the presentation of oral candidiasis?

A

Curd-like white or yellowish plaques in mouth on cheeks, gums, palate, tongue

149
Q

what are 5 risk factors for oral candida?

A

Inhaled Corticosteroids
ABx
Diabetes
Immunodeficiency -HIV
Smoking

150
Q

what is the management of oral candidiasis?

A

1 - Miconazole oral gel 7 days

2 - Nystatin suspension
OR
Oral Fluconazole 50mg OD 7 days

151
Q

what is the management of oesophageal candidiasis?

A

Oral fluconazole 100mg 7 days

Phase 4 (22 decks)

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