ENT

Question 1

Describe Weber’s, Rinne’s, audiometry

Answer 1

Weber’s: tuning fork on middle of forehead, ask which ear is loudest; sensorineural affected ear will be quieter, conductive affected will be louder (more sensitive to compensate, skips the conductive issue)
Weber’s = spiderman web to forehead

Rinne’s: tuning fork on mastoid process (bone conduction) until they can’t hear it, hover 1cm away from same ear; normal / positive result is air conduction to be better, negative = conductive hearing loss

Audiometry: variety of tones + volumes using headphones + oscillator (bone conductor) recorded on audiogram; audiogram plots Hz on a and volume dB on y; X left air conduction, ] L bone, O R air, [ R bone
Normal all readings between 0 and 20 dB; sensorineural readings for bone and air >20; conductive just bone >20; mixed both >20 but bone >15 more than air

Question 2

Presbycusis pathogenesis and RF

Answer 2

Age related sensorineural that affects high pitched first, gradual and symmetrical onset; several different mechanisms - loss of hair cells, loss of neurones in cochlea, atrophy of stria vascularis, reduced endolymphatic potential

Age, male, FHx, loud noise exposure, diabetes, hypertension, ototoxic meds, smoking

Question 3

Describe sudden sensorineural hearing loss

Answer 3

<72h unexplained by other causes, otological emergency, 90% idiopathic but also more serious like stroke, MS etc

May present uni / bilateral, with tinnitus and vertigo

Ix: audiometry: loss of at least 30dB in 3 consecutive frequencies, MRI / CT head if stroke etc considered, serology for vasculitis / infection, otoscope to rule out

Idiopathic treated with oral / intratympanic steroids

Question 4

Otosclerosis patho, Px, Ix, Mx

Answer 4

Remodelling of small bones in middle ear with spongy bone leading to conductive hearing loss, base of stapes most affected - becomes fixed / immobilised; combination of environmental and genetic, can be autosomal dominant
30-40, women, pregnancy, Fhx

Px: progressive, bilateral, conductive hearing loss (affecting lower pitched more); tinnitus, vertigo, Schwartz’s sign - purple hue behind tympanic membrane
Normal otoscopy, RInne’s shows conductive

Ix: audiometry FL, tympanometry will show reduced admittance, high resolution CT can detect bone changes

Mx: conservative - hearing aids, surgery to remove part of stapes or replace all with prosthesis

Question 5

Otitis media Px, Mx

Answer 5

Px: pain, reduced hearing, fever, URTI sx (cough, coryza, sore throat)
Vestibular system - balance and vertigo. Can cause perforation and discharge
Otoscopy: bulging, red / opacity, inflamed looking membrane, potential perforation

Mx: paracetamol, majority will resolve without abx, prescribe amoxicillin 5d but say only to take if not improving after 3d, if still worsening give co-amoxiclav. Avoid smoking and supine feeding
Abx straight away: <2 with bilateral, <3m and T >38, ear discharge, systemically unwell, high risk of complication

Question 6

Describe otitis media complications and glue ear

Answer 6

Complications: chronic, tympanic membrane perforation, hearing loss, tinnitus. Mastoiditis uncommon but serious requiring IV ceftriaxone, grommets and sometimes mastoidectomy. Other uncommon: bacterial meningitis, extradural / subdural abscess, labyrithnitis, facial nerve paralysis

Mastoiditis Px: recent otitis media, deep otalgia, progressive hearing loss, systemically unwell, signs of intracranial infection. Fever, bulging tympanic membrane, erythema + swelling over mastoid process, mastoid tenderness

With effusion (glue ear): pure tone audiometry, observation for 6-12w. Referral: concern over development, hearing loss persists after symptoms resolve, severe hearing loss, Down’s / cleft palate
Secondary care: hearing aids, eustachian tube autoinflation, myringotomy + grommet

Question 7

Otitis externa Px, Ix, Mx

Answer 7

Px: pain + tenderness, itch, discharge, conductive hearing loss. Otoscopy: erythema + swelling, discharge, eczematous, debris

Ix: otoscopy and swab

Mx: mild - acetic acid (antibacterial + antifungal, OTC - earcalm); moderate - topical abx +/- steroid, otomize (neomycin, dexamethasone, acetic acid); severe / systemic - oral flucloxacillin; ENT referral for microsuction if debris or too swollen to visualise tympanic membrane
Aminoglycosides avoided in perforated eardrums due to ototoxicity
Acetic acid also used prophylactically around swimming in those with recurrent
Clotrimazole ear drops for more severe fungal

Question 8

Describe malignant otitis externa and Mx

Answer 8

Malignant otitis externa: severe + potentially life threatening, immunocompromised (90% diabetic), spreads to bony ear canal and temporal bone osteomyelitis, p aeruginosa
Complications: facial nerve palsy (or other cranial nerves), meningitis, intracranial thrombosis

Mx: admission to hospital, IV ciprofloxacin (fluclox does not cover pseudomonas), CT / MRI head

Question 9

What are the red flags and investigations for tinnitus

Answer 9

Red flags: unilateral, pulsatile, hyperacusis, unilateral hearing loss, sudden onset hearing loss, vertigo / dizziness, neuro symptoms
Ix: FBC (anaemia), glucose, TSH, lipids; audiology, CT if required

Question 10

How do you determine central vs peripheral vertigo and what are the causes of each

Answer 10

Peripheral: nystagmus horizontal / unidirectional / improves with fixation, usually positional, hearing loss
Central: nystagmus vertical / bidirectional / does not improve with fixation, less positional, neurological signs
HINTS exam: head impulse, nystagmus, test of skew; head impulse - looking forward, jerk head 10-20d whilst they are still fixated, move slowly back and repeat opposite direction (peripheral will cause nystagmus)
Test of skew - vision fixated forwards, cover one eye at time (central will deviate up or down)

Peripheral vertigo: benign paroxysmal positional vertigo, meniere’s, vestibular neuronitis, labyrinthitis; also: trauma, vestibular nerve tumours, otosclerosis, hyperviscosity syndromes, varicella zoster
Central vertigo: posterior circulation infarction, tumour, MS, vestibular migraine

Question 11

BPPV patho, Px, manoeuvres for diagnosis and management

Answer 11

Crystals of calcium carbonate (otoconia) displaced into the semicircular canal (posterior most common) disrupting the flow of endolymph, displaced by: infection, head trauma, ageing, no reason

Recurrent sudden onset vertigo and dizziness, triggered by head movement (i.e. rolling in bed), settling after 20-60s, asymptomatic between attacks, episodes occur over several weeks and resolve

Dix-Hallpike manoeuvre to diagnose: sits upright with head 45d to one side, support patients head and rapidly lower backwards to 25d off the couch, look for rotational nystagmus and repeat on other side

Epley manoeuvre to treat: dix-hallpike manoeuvre then turn head 90 degrees to the other side, roll onto side so head rotates a further 90d, sit up sideways and flex neck 45d so chin towards neck. Waiting 30s at each stage waiting for nystagmus to stop
Brandt-Daroff to do at home: sitting up, lie sideways with head facing up, sit back up and repeat

Question 12

Vestibular neuronitis patho, Px, Ix, Mx

Answer 12

Px: acute onset vertigo, usually following URTI, worsened by head movement, nystagmus, nausea + vomiting, balance problems

Does not affect cochlear nerve so should be no hearing loss of tinnitus
Do head impulse test to determine peripheral vs central (rapidly jerking head to side whilst they look forwards, abnormal vestibular system will saccade before settling)

Mx: buccal / IM prochlorperazine or antihistamine (cyclizine, promethazine), vestibular rehabilitation exercises

Question 13

Labyrinthitis Px, Mx

Answer 13

Px: acute onset vertigo (n+v, balance), sensorineural hearing loss, tinnitus, following URTI. Spontaneous unidirectional horizontal nystagmus towards unaffected side, abnormal head impulse test, gati disturbance
Mx: conservative - usually self limiting, prochlorperazine or cyclizine

Question 14

Meniere’s Px, Mx

Answer 14

Long term inner ear disorder with unknown cause, excessive pressure / endolymph and progressive dilation of endolymphatic system, disrupting sensory signals

Classic triad, episodes of unilateral: vertigo (most prominent), sensorineural hearing loss, tinnitus. Also: aural fullness, nystagmus, imbalance, unexplained falls without LOC, positive romberg’s
Sx usually resolve in 5-10y but may have long term hearing loss

Mx: ENT referral, buccal / IM prochlorperazine or cyclizine. Prevention: betahistine and vestibular rehabilitation exercises. Inform DVLA, shouldn’t drive with symptoms

Question 15

Vestibular schwannoma / acoustic neuroma Px, Ix, Mx

Answer 15

Benign tumours of schwann cells surrounding the vestibulocochlear nerve (CN VIII), but predominantly the vestibular portion. Mass effect of tumour can lead to severe complications (CN palsies)
Nearly always unilateral, if bilateral = neurofibromatosis II

Px: sensorineural hearing loss, tinnitus, vertigo + balance. Facial nerve weakness / numbness, headache + nausea + vomiting (raised ICP)

Ix: audiometry, MRI

Mx: referral to ENT, observation for small, surgery, stereotactic radiosurgery

Question 16

Causes of facial nerve palsies, UMN vs LMN

Answer 16

Forehead has UMN innervation from both sides but LMN from one, UMN lesion forehead will be spared - immediate referral for stroke (also tumours, bilateral = MND)

Causes of facial nerve palsy: Bell’s palsy, Ramsay-Hunt, otitis media, malignant otitis externa, HIV, lyme’s; diabetes, sarcoidosis, leukaemia, MS, guillain-barre; acoustic neuromas, parotid tumours, cholesteatomas; trauma

Question 17

Cholesteatoma Px, Ix, Mx

Answer 17

Non cancerous growth of squamous epithelial cells in the middle ear behind the eardrum, believed to be due to poor eustachian tube function, negative pressure causing tympanic membrane retraction, growth of skin / cystic structure in (filled with keratin debris) in pocket, can cause erosion of ossicles leading to permanent hearing loss or growth into mastoid / intracranial compartment

Px: foul smelling + non resolving discharge, unilateral conductive hearing loss. Also infection, pain, vertigo, facial nerve palsy

Otoscopy: ‘attic crust’ (upper eardrum), retraction, perforation, white debris. Audiometry, CT / MRI

Mx: surgery - canal wall up / down mastoidectomy; audiological rehab and patient education

Question 18

Describe Bell’s and Ramsay-Hunt Px, Mx

Answer 18

Bell’s palsy acute unilateral facial paralysis, idiopathic, linked to HSV, majority resolve after weeks but can take 1y and have residual weakness
If present within 72h pred 50mg for 10d +/- aciclovir. Lubricating eye drops

Ramsay-Hunt syndrome: varicella zoster, reactivation within geniculate ganglion (age, stress, immunosuppression). Characteristic vesicular painful rash in ear, LMN facial nerve palsy, loss of anterior taste. Prednisolone + aciclovir, lubricating eye drops

Question 19

Mx of epistaxis

Answer 19

Mx: sit up, tilt head forwards, squeeze under bone, spit out any blood. If does not stop after 10m / haemodynamically unstable - hospital admission, nasal packing (nasal tampons), nasal cautery with silver nitrate

After consider naseptin cream (chlorhexidine + neomycin) QDS for 10d, reduce inflammation + infection. Contraindicated in peanut or soya allergy

Question 20

Sleep apnoea Px, Ix, Mx

Answer 20

Px: snoring, episodes of apnoea in sleep (reported by partner), morning headache, daytime sleepiness, concentration issues. Low sats during sleep, compensated respiratory acidosis, hypertension

Epworth sleepiness scale, sleep studies (polysomnography)

Mx: ENT / sleep specialist referral, weight loss + smoking cessation, CPAP - not tolerated intra oral devices (mandibular advancement), inform DVLA and occupational assessment. Surgery in severe

Question 21

Tonsilitis viral vs bacterial, Px, Ix, Mx

Answer 21

Px: sore throat, fever, dysphagia; viral: nasal congestion, headache, earache, cough. Severely inflamed tonsils, painful enlarged anterior cervical lymph nodes, purulent tonsils (bacterial)

Ix: clinical diagnosis, FeverPAIN score / centor, rapid antigen test for GAS if immunosuppressed / severe
FeverPAIN: fever, purulence, attended within 3d, inflamed tonsils, no cough / coryza. For bacterial, 2-3 35%, 4-5 65%
Centor criteria: fever (38), tonsillar exudates, absence of cough, tender anterior cervical lymph nodes

Mx, viral: reassurance, paracetamol, good fluid intake; bacterial: phenoxymethylpenicillin (erythromycin)
Surgery indicated: 7+ in 1y, 5+ 2 consecutive years, 3+ in 3 consecutive; does not respond to long term abx, peritonsillar abscess

Question 22

Quinsy abscess Px, Ix, Mx

Answer 22

Peritonsillar / quinsy abscess: severe complication, trismus (inability to open jaw), deviation of uvula, fluctuant mass, reduced neck mobility, systemic symptoms

Diagnosis confirmed with needle aspiration / imaging

Mx: ibuprofen + paracetamol, co-amoxiclav, incision + drainage, tonsillectomy if others fail

Question 23

Glossitis Px, causes + Mx

Answer 23

Glossitis: red, sore, swollen, papillae atrophy (smooth); causes: iron / B12 / folate deficiency, coeliac disease, injury / irritant exposure. Mx is just treating cause

Question 24

Angioedema Px, causes

Answer 24

Angioedema: fluid accumulation in limbs, face, lips, tongue. Causes: allergic reactions, ACE, hereditary (C1 esterase inhibitor deficiency)

Question 25

Oral candidiasis Px, Mx

Answer 25

Oral candidiasis: white spots on tongue and palate; RF: inhaled steroids (particularly poor technique), diabetes, immunodeficiency, smoking. Mx: miconazole gel, nystatin suspension, fluconazole in severe / recurrent

Question 26

Geographic tongue Px, Mx

Answer 26

Geographic tongue: patches with lost epithelium and papillae, irregular shapes, relapsing and remitting. Unknown cause, can be associated with stress, psoriasis, atopy, diabetes. Benign condition that does not require treatment unless pain - topical steroids or antihistamines

Question 27

Leukoplakia + Erythroplakia Px and Mx

Answer 27

Leukoplakia: asymptomatic, irregular, slightly raised white patches on tongue / inside cheek, fixed (can’t scrape off). Precancerous squamous cell carcinoma - biopsy to exclude dysplasia or cancer. Mx: stopping smoking, reducing alcohol, close monitoring, laser / surgical removal
Erythroplakia: same as leukoplakia but are red / red + white

Question 28

Lichen planus Px, Mx

Answer 28

Lichen planus: autoimmune chronic inflammation, shiny / purple / flat topped raised, white lines across surface (wickham’s striae). Usually women over 45. Can affect mucosal membranes, most commonly in the mouth (reticular, erosive, plaque)

Mx: good oral hygiene, stopping smoking, topical mometasone

Question 29

Gingivitis Px, RF, Mx. Periodontitis

Answer 29

Gingivitis: inflammation of gums, swelling, bleeding after brushing, painful, bad breath, can lead to periodontitis if not adequately managed. RF: plaque build up, smoking, diabetes, malnutrition, stress. Managed by dentist, good hygiene, stopping smoking, chlorhexidine mouth wash, abx / surgery if required
Periodontitis: severe + chronic inflammation of gums and tissues supporting the teeth, often leads to loss of teeth

Question 30

Gingival hyperplasia causes

Answer 30

gingivitis, pregnancy, vit C deficiency, acute myeloid leukaemia, meds (CCB, phenytoin, ciclosporin)

Question 31

Aphthous ulcers Px, Mx, causes

Answer 31

Aphthous ulcers: common in healthy with no underlying cause, small + painful ulcers, usually heal within 2w without intervention. Symptomatic treatment: choline salicylate (bonjela), benzydamine (difflam spray), lidocaine; in severe: hydrocortisone buccal tablets, beclomethasone inhaler onto lesion. Unexplained over 3w - 2w referral. Could be signs of: IBD, coeliac, behcet, iron / B12 / folate / vit D deficiency, HIV

Question 32

Laryngomalacia patho, Px, Ix, Mx

Answer 32

Most common congenital abnormality of larynx, inward collapse of supraglottic structures during inspiration due to immature arytenoid cartilage + surrounding tissues, usually resolves by 18-24m as laryngeal cartilage matures

Px: inspiratory stridor, increase in severity in first 8m; rare: respiratory distress, failure to thrive, cyanosis

Ix: sats, laryngoscopy in severe

Mx: conservative, hyperextending neck during stridor, surgical intervention in severe respiratory distress

Question 33

Salivary gland stones (sialolithiasis), most common, Px, Ix, Mx

Answer 33

Submandibular most common, mostly calcium phosphate

Px: pain and swelling, triggered by eating / chewing; can present with hard lump, fever + systemic upset

Clinical diagnosis, sometimes stone seen in opening, CT / US highly sensitive but usually not required

Mx: conservative + NSAID, recurrent / infected ENT referral. Good hydration, stop meds causing dry mouth (TCA), suck on citrus / sweets