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Y4 Special senses > ENT > Flashcards

ENT Flashcards

1
Q

Input- balance

A
  • Vestibular
  • Proprioceptive
  • Visual
  • Auditory
  • Cerebellar/cerebral
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2
Q

What senses linear acceleration (going 30 to 70 mph in a car)

A

Anterior and lateral semi-circular canals
Utricle takes in input

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3
Q

What senses angular acceleration

A

Saccule is verticle- anti-gravity sensor
Posterior semi-circular canal

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4
Q

Advantage of binocular vision (two eyes working together)

A

You can assess depth
Input to vestibular system- if there is an imbalance in vestibular, have to rely on eyes to balance (very fatiguing- constantly thinking, visual preference)

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5
Q

Smooth pursuit

A

Central function- using your eyes to follow an object and not using your head
Retinal slip- when you lose focus, objects move too quickly??

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6
Q

Diagnosis for a patient waiting a couple of seconds once stood up- why you should watch patients in the waiting room

A

Postural hypotension
Autonomic system worsens as you age
Vessels are more calcified, rigid, imbalance when they stand up

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7
Q

Most common conditions at the balance clinic

A
  • Parkinsonian gait- slapping gait, trying to get more information from the ground. Peripheral sensory neuropathy (diabetes)
  • Arthritic gait
  • Postural hypotension
  • Patients who are not turning their neck- they feel off balance (vestibular problems)
  • Vestibular migraine (fluorescent strip lighting in the clinic)
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8
Q

Advice for patients with postural hypotension

A

Before they get out of bed- ask them to make cycling movements with their legs- getting the blood back to their brain

Bring toes up, swing legs up and down

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9
Q

Vestibulo ocular reflex

A
  1. Vestibular nerve gives input to the vestibular nuclei at the back of the brain
  2. Vestibular nuclei- gives input to 3,4,5 nuclei to move the eyes
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10
Q

Nystagmus

A

Fast phase- peripheral problems will give you nystagmus
Input not coming from the left side- visual cortex not matching up to vestibular system

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11
Q

Most common condition seen in the balance clinic

A

Multifactorial degeneration- age

  • Cerebellovascular
  • Arthritis
  • Poor eye sight
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12
Q

How to manage vestibular migraines

A
  • Sleep
  • Stress
  • Hormones
  • Diet-
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13
Q

CT bone windows vs soft tissue

A

Bone windows- no detail on the brain for example, more general grey
Soft tissue window- bone appears very bright

Make sure to mention axial, coronal, saggital views when describing scans

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14
Q

What do you use to re-construct the nasal septum

A

Thoracic cartilage ff

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15
Q

Most common cause of stridor in infants

A

Laryngomalacia
Where the vocal cords are soft and floppy and fold in when the baby breathes in.
Uniphasic
Tends to get better

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16
Q

Biphasic

A
  • Stridor breathing in and out
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17
Q

Stertor

A

Above the level of the vocal cords
Large adenoids and tonsils, oropharyngeal mass
Snoring

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18
Q

Symptoms and management of Rhinosinusitis

A
  • Inflammation of the mucous membranes

Nasal blockage
Facial pain or pressure
Reduction and loss of smell

Acute = <12 weeks
Chronic >12 weeks, with

Nasal blockage
Loss reduction in smell
Sneezing and nasal itching
Itchy eyes
Job/hobbies
Pets
Sneezing, nasal itching

Inx
Allergy
- Skin prick test
- RAST test (A radioallergosorbent test (RAST) is a blood test that measures the amount of immunoglobulin E (IgE) antibodies in the blood to determine what a person is allergic)

CT
- before surgery
concerns about malignancy

No XR of the sinuses

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19
Q

Breathing patterns through the nose

A
  • Lying on left side, breathe through right nostril
  • Swap nostril every 4-6 hours of breathing
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20
Q

What does a nasal polyp look like?

A

Peeled grape- no blood vessels

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21
Q

CRS management
Chronic rinusinusitis

A

Without polyps

Topical steroids
Macrolides- clarithromycin
Anti-histamines
Nasal douche

With polpys (treatment needs to be more aggressive because the nasal polyps can obstruct the nasal passages)
- Oral steroids
- Anti-leukotrienes (monteluklast)

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22
Q
A
  • Warm and humidify air
  • Picking through, scabbing
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23
Q

Epistaxis management

A
  • Suck an ice cube- vasoconstrictor the top of the mouth
  • Hold Little’s area for about 3-4 minutes and the bleeding should stop
  • Tilt the head forwards
  • Nasal packs (anterior packing) go straight back, horizontally- floor of the nose

Rigid nasoendoscopy and electro-cautery
Sphenopalatine artery ligation
Anterior ethmoid artery ligation
External carotid artery ligation
Embolisation of vessels under radiographic control

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24
Q

3 pairs of salivary glands

A

Parotid (serous/watery)
Submandibular (serous/mucous)
Sublingual

Many minor glands opening directly- mucosal surfaces of mouth/nose/pharynx

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25
Q

How much saliva do we produce a day

A

1.5L
Parasympathetic reflex response

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26
Q

How does saliva act as immune defence

A

Immunoglobulin A

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27
Q

Where do most salivary calculi occur?

A

Submandibular gland, rarely parotid
Composed of calcium and magnesium phosphate

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28
Q

Where does the submandibular duct empty?

A

Wharton’s- in floor of mouth near midline
May be able to see the stone
When the saliva backs up - submandibular gland swells

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29
Q

When do mucus retention cysts occur?

A

Occur when duct of gland becomes blocked
Can occur in lips/cheek/tonsil/floor of mouth (ranula)
Excise if symptomatic

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30
Q

Most common infection for salivary gland

A

Paramyxovirus- usually unilateral but can be bilateral

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31
Q

Most common salivary gland infection seen in elderly patients

A

Ascending bacterial infection (parotitis)
Associated with dehydration and poor dentition
Seen more in frail, elderly
Encourage fluids, sialogogues (lemon juice), possible antibiotics (Co-Amoxiclav)

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32
Q

Possible causes of parotid gland swelling

A
  • Skin cancer on the scalp- drained by lymph nodes around parotid gland
  • Mumps
  • Salivary gland stones
  • Autoimmune diseases like rheumatoid arthritis and sjogren’s
  • Chronic alcohol use
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33
Q

Most common parotid neoplasm

A

Mixed partodi tumour, rarely become malignant

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34
Q

What are Warthin tumours

A

benign lesions
Cystadenolymphoma- not a lymphoma!
Older individuals
Smoker
May be bilateral

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35
Q

How do adenoid cystic carcinomas spread?

A

Spread along nerves- metastasize to the lungs

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36
Q

Types of parotid neoplasms

A
  • Pleomorphic adenoma
  • Warthin tumours
  • Adenoid cystic carcinomas
  • Mucoepidermoid cancers
  • Mets from skin caners
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37
Q

How common are submandibular and sublingual neoplasms

A

Majority are malignant
But make up a very small proportion of neoplasms in total

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38
Q

Using ultrasound in H&N lesions

A

FNA
Core Bx
Confirm location, characteristics, vascularity
Biopsy to indicate neoplasm type- Milan classification

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39
Q

Mainstay treatment of salivary gland tumours

A

Surgery and radiotherapy
Close margins on tumours- can’t lose facial nerves
If the nerves work before they should work after surgery!
Very little role of chemotherapy in these conditions

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40
Q

Complications of general surgery

A
  • Anaesthesia
  • DVT
  • PE
  • Chest infection
  • UTI
  • Urinary retention
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41
Q

Complications of salivary gland surgery

A
  • Bleeding
  • Wound infection
  • Collections of saliva/leakage of saliva via a wound sinus
  • Nerve injury

Motor
- Parotid (facial nerve)
- Submandibular (hypoglossal- tongue movement)

Sensory
- Parotid- great auricular nerve division (numbness of earlobe and adjacent face)
- Submandibular- lingual nerve (taste, sensory disturbance)

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42
Q

What is Gustatory sweating

A

Frey’s syndrome
Sweating and reddening of periparotid facial skin during meals
Complication of salivary gland surgery
You sweat loads when you think about food

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43
Q

How to separate causes for acquired diseases

A

INVITED MD

Infectious
Neoplastic
Vascular
Inflammatory/autoimmune
Traumatic
Endocrine
Degenerative
Metabolic
Drugs

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44
Q

Cause of acute bilateral parotid gland swelling

A

Mumps

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45
Q

Causes of acute unilateral parotid gland swelling

A

Mumps
Parotitis

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46
Q

Causes of chronic bilateral parotid gland swelling

A
  • Chronic infection
  • Fatty deposition
  • Bilateral cysts HIV
  • Warthin’s tumours
  • Masseteric hypertrophy
  • Sjogren’s, sarcoidosis
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47
Q

Causes of chronic unilateral parotid gland swelling

A

Calculus
Neoplasm (bening/malignant-primary/secondary

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48
Q

Why is there a decreasing incidence in cancers of the hypopharynx/larynx?

A

Smoking reduction

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49
Q
A

Children aged 12-13
Boys have been vaccinated in the last 4 years
Reduces risk of cervical and H&N cancers

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50
Q

Who should have the HPV vaccine?

A

Children aged 12 to 13

Men under 45 who have sex with men

Sex workers
People with HIV

Any transgender people who are felt to have the same risk as men who have sex with men

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51
Q

What are risk factors for H&N cancers?

A
  • Tobacco smoking/chewing South Asian populations, betel nut chewing
  • Alcohol consumption (works synergistically with smoking)
  • Genetics/hereditary
  • Virally mediated- HPV, EBV
  • Sexually transmitted- HPV
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52
Q

Substances that can cause cancers of the nasopharyngeal sinuses?

A
  • Formaldehyde
  • Nickel, Chromium
  • Wood dust
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53
Q

Cancers EBV causes

A
  • Lymphoma
  • Nasopharyngeal
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54
Q

Most common location for nasopharyngeal cancers to arise

A

Fossa of Rossemnuller

55
Q

What blood supply supplies the nasal septum?

A

Kiesselbach’s plexus in Little’s area

56
Q

Where do tears drain?

A

Inferior tubercle

57
Q

Common larynx pathology in smokers

A

Reinke’s oedema
- Hoarsness of voice
- SOB

58
Q

List of laryngeal lesions (benign)

A
  • Reinke’s oedema
  • Granuloma
  • Pachyderma
  • Polyps
  • Nodules (singer’s nodules)
  • Leukoplakia (can be pre-malignant so will need biopsy)
59
Q

T4 laryngeal tumours

A

See if it has invaded the thyroid cartilage

60
Q

Hypopharyngeal and post-cricoid lesions

A
  • Referred otalgia
  • Difficulty swallowing
  • Changes to voice
61
Q

Complications of retropharyngeal abscesses and how they would present

A
  • Compression of the trachea
  • Avoid moving the neck
  • Many present with difficulty swallowing
62
Q

How many lymph nodes are there in the neck?

A

About 800

63
Q

Causes of mid-line swellings in the neck (within the anterior triangle)

A
  • Goitre
  • TDC- congenital. Thyroid starts at the base of the tongue so will move when you swallow. Moves when sticking tongue out
  • Dermoid cyst- won’t move on swallowing or sticking tongue out. More superficial
64
Q

What is the first line investigation of neck lumps

A

Ultrasound

65
Q

Most common causes of left sided neck lumps

A
  • Branchial cleft cyst (remnant of the pharyngeal cleft)
  • Submandibular salivary gland
66
Q

Most common cause of a posterior triangle mass?

A
  • Cystic hygroma (associated with turner and down syndrome)
  • Swollen lymph nodes
67
Q

Causes of upper airway obstruction

A
  • Laryngomalacia
  • Anaphylaxis
  • Epiglottitis
68
Q

What is a bovine cough suggestive of?

A

Recurrent laryngeal nerve palsy
Vocal cords do not come together

69
Q

Most common epithelium to cause a laryngeal/H&N cancer?

A

Squamos cell epithelium

70
Q

Initial management of epistaxis

A
  • Sit the patient upright, slightly lean forward, tilt chin down
  • Direct pressure on little’s area
  • Ice application
71
Q

Medical management of epistaxis

A

Topical treatments
- Topical vasoconstrictors (oxymetazoline)
- Topical nasal decongestants (phenylphrine)

Cauterisation
- Chemical cauterisation with silver nitrate or electrocautery

Nasal packing
- Anterior packing
- Posterior packing

72
Q

What are characteristics of Meniere’s?

A
  • Episodes last for about three hours
  • Sustained vertigo
  • Fluctuating loss of hearing
  • Aural fullness
  • Tinnitus in the affected ear
73
Q

What are features of a vestibular migraine?

A
  • Symptoms may last from 5 mins to 72 hours
  • Current history of migraines (with other features – e.g. headache, photophobia, visual aura etc)
  • Vomiting
  • ## Dizziness
74
Q

How can you tell vestibular migraine apart from menier’s?

A

With Meniere’s you lose low frequency hearing

75
Q

Treatment for vestibular migraines

A
  • Magnesium
  • Vitamin B2
  • Increase dose of Amitryptyline
76
Q

What is a catch up saccade?

A

When your smooth pursuit doesn’t work
Eyes lag behind and then make a catch-up saccade to jump forward
Sign that there is an issue with the vestibular system or the cerebellum

77
Q

What would right side beating nystagmus and a positive left sided head thrust indicate?

A

Left sided vestibular system problem

78
Q

Where do 90% of all orofacial infections come from?

A

The teeth

79
Q

What is a complication of an odontogenic abscess?

A

Ludwig’s angina

Ludwig’s angina is a form of severe, diffuse cellulitis with bilateral involvement of the submandibular space. Signs may include diffuse, bilateral submandibular and sublingual swelling.

80
Q

Can you treat peritonsillar abscesses with antibiotics?

A

Abscesses are characterised by pseudomembranes, which prevent antibiotics from penetrating them effectively. As such, the mainstay of treatment is incision and drainage.

81
Q

What are the five cardinal symptoms of ear disease?

A
  • Hearing loss
  • Otalgia
  • Otorrhoea
  • Facial weakness
  • Vertigo
82
Q

Where is the most common place for a cholesteatoma to form?

A

Cholesteatomas are benign growths of keratinising squamous epithelium.

Most common location is the pars flaccida of the tympanic membrane, located in the attic region of the ear drum. This area is prone to retraction pockets, which can trap squamous epithelium.

83
Q

What are four functions of the nose

A
  • Breathing
  • Immunological (immunoglobulin A, lymphoid tissue, mucociliary clearance)
  • Humidification of air
  • Smell
84
Q

What factors would make you admit a patient with tonsilitis?

A
  • Immunocompromised
  • Diabetic
  • Shortness of breath
  • Signs of severe dehydration or septic shock
85
Q

If you suspect tonsilitis but the patient is either unable to swallow fluids or saliva or the pain is out of control what do you do?

A

Perform flexible laryngoscopy

86
Q

What is the medical management of tonsillitis?

A
  • IV Benzylpenicillin
  • IV Dexamethasone 4mg
  • PRN Diclofenac
87
Q

When are antibiotics given for acute otitis media?

A

If it has been present for 4 days

88
Q

Explain really simply what sinusitis is?

A

The sinuses are hollow spaces in the bones of the face
They produce mucus
There are ostia that drain the mucus into the nasal passage
When the ostia are blocked, the mucus can’t flow and you get sinusitis

89
Q

Draw out what a left sided conductive hearing loss would look like on a pure tone audiogram

A
90
Q

Draw out what a bilateral sensorineural hearing loss would look like on a pure tone audiogram

A
91
Q

Draw out what a left sided mixed hearing loss would like on a pure tone audiogram

A
92
Q

What is the difference between a myringoplasty and a tympanoplasty?

A

Myringoplasty is fixing a perforation in the ear drum
Tympanoplasty is fixing the middle ear structures too

93
Q

What is a tympanogram

A

Myringoplasty
A simpler procedure that’s best for small holes in the eardrum. A small piece of tissue or gel-like material is used to cover the hole, encouraging the body to heal. Recovery time is usually a few days, but may take up to two weeks.

Tympanoplasty
A broader procedure that can also reconstruct the small bones in the middle ear, called the ossicles. A graft of the patient’s own tissue, such as fascia or perichondrium, is used to patch the hole. The surgeon may also remove diseased parts of the ossicles or replace them with artificial implants. Recovery time can take a few days to several weeks, and it may take two months or longer for hearing to improve

94
Q

What is a Tympanogram?

A

An earphone that measures the compliance of the tympanic membrane by exerting a pressure and sound- makes the eardrum move

95
Q

What would a type A tympanogram look like and what does it mean?

A
  • Normal result
  • Peak centre at 0 on x axis
  • Normal triangle
96
Q

What would a type B tympanogram look like and what does it mean?

A
  • Flat tracing
  • Suggests middle ear effusion or perforation
97
Q

How to tell the difference between an ear drum perforation and an effusion on tympanogram?

A

Perforation will have a higher volume as it is measuring the external and middle ear.

98
Q

What would a type C tympanogram suggest?

A
  • Suggests eustachian tube dysfunction
  • The peak has a negative pressure
99
Q

When would admission to hospital be indicated for tonsilitis?

A

An urgent admission to hospital would be indicated if there was stridor, respiratory difficulty, dehydration, severe suppurative complications such as a peritonsillar abscess, suspected epiglottitis or severe systemic illness.

100
Q

What are specific features suggestive of a warthin’s tumour?

A

The patient presents with clinical features consistent with Warthin’s tumour (papillary cystadenoma lymphomatosum) including: older male preponderance, bilateral and smoking history

101
Q

When the discharge is dropped onto filter paper, it demonstrates the “halo sign”.

A

CSF fluid
Sign of a basilar fracture if there is otorrhoea

102
Q

What would a superior laryngeal nerve lesion present with?

A

The superior laryngeal nerve supplies the cricothyroid muscle which would present with an inability to use the voice at higher pitches

103
Q

Removal techniques of foreign bodies for upper and lower airways

A

Upper
- Magill forceps (oropharynx/laryngeal inlet)

Lower
- Rigid bronchoscopy

104
Q

Where does the facial nerve enter the skull?

A

Through the internal acoustic meatus which is located in the petrous part of the temporal bone

105
Q

What branches are given off in the petrous part of the temporal bone?

A

Facial Canal: Within the temporal bone, the facial nerve travels through the facial canal. During this journey, it gives off key branches:

The greater petrosal nerve (parasympathetic to the lacrimal gland and nasal mucosa).
The nerve to stapedius (controls the stapedius muscle in the middle ear).
The chorda tympani (carries taste from the anterior two-thirds of the tongue and parasympathetic fibers to the submandibular and sublingual glands).

106
Q

What would thyroid eye disease look like on CT?

A
  • Have a look at images
  • Enlargement of the muscle belly
  • Extra-ocular muscles
  • Sparing of the tendinous insertions
  • Mainly inferior and medial rectus
107
Q

What condition will cause enlargement of the extra-ocular muscles without sparing of the tendinous insertion

A

Idiopathic orbital inflammation

108
Q

What is tolosa-hunt syndrome?

A

Rare, idiopathic disorder characterised by painful eye movement
Caused by inflammation of the cavernous sinus, superior orbital fissure or orbital apex.

109
Q

What causes a inspiratory stridor?

A

Supraglottic

110
Q

How many episodes of tonsilitis do kids have to have in order to be eligble for tonsillectomy?

A

SIGN guidelines
7 spells a year
5 spells a year for two years in a row

111
Q

What painkillers are used in kids after tonsillectomy?

A

Paracetamol is first line
Ibuprofen
You can alternate them

112
Q

Contra-indicated pain killers in kids

A

Codeine- risk of respiratory distress
Opioids
Aspirin

113
Q

FY1 seeing a patient with fresh bleeding after a tonsillectomy

A

A-E
Sit the kid up
Fluids- 10-20mls/kg
G&S
Coagulation screen, APTT, PT (Vonwillebrand is most common)
FBC, Us&Es- fluid replacement
Back to ENT theatres and urgent senior review
Get consent from the parents
NBM but will have rapid sequence induction- NG tube
Get anaesthetic team on board, book with emergency theatre co-ordinator

114
Q

What clinically would be present and with otoscopy with mastoiditis?

A
  • High temp
  • Tachycardic
  • Dehydrated
  • Bulging TM
  • Tender post auricularly
  • Loss of posterior sulcus
115
Q

Management for mastoiditis

A
  • Admit to hospital and observe
  • Sepsis 6
  • IV co-amoxiclav. Ceftriaxone & metronidazole for intracranial cover
  • Paracetamol/ibuprofen
  • ENT review
  • IV fluids
  • Myringotomy if not improving- drain all the pus and send to microbiology to see if there is a particular bug
116
Q

What would you do if there was an intra-cranial abscess after acute mastoiditis?

A

Neurosurgeon involvement
Decompress the ear- myringotomy
Incision and drainage

117
Q

Complications of acute otitis media

A

Intra-temporal
- Acute mastoiditis
- Facial nerve palsy

Intra-cranial
- Meningitis
- Extradural/subdural
- Lateral sinus thrombosis
- Gradenigo’s syndrome

Extra-temporal (neck abscesses)
- Citelli’s abscess
- Bezold’s abscess
- Luc’s abscess

118
Q

What test should be done after acute otitis media?

A

Audiometry
Persistent- grommet or hearing aid
Recurrent ear infections- have they had all their vaccinations? pneumococcal, haemophilus.

119
Q

If a kid can’t swallow from bacterial tonsillits- what is the management?

A
  • Dose of Dexamethasone
  • IV fluids
  • IV painkillers
  • IV antibiotics
120
Q

Symptoms of deep neck space abscess

A
  • Odynophagia
  • Pyrexia
  • Drooling
  • Torticollis
  • Stridor
121
Q

Management of deep neck space abscess

A
  • Secure the airway and drain the abscess
  • Experienced anaesthetic team
  • Risk of getting a mediastinal abscess too (small risk)
122
Q

CXR result of an inhaled object- foreign body

A

Hyperinflated lung
Mediastinal shift

123
Q

How to manage a foreign body

A

Ventilating bronchoscope

124
Q

Why do you get hyperinflation with foreign body obstructions?

A

During inspiration- negative intrathoracic pressure pulls air past the obstruction into the distal lung.

During expiration- the obstruction partially or completely blocks airflow out of the lung

125
Q

Temporising measures for children with upper airway obstruction

A

Keep the child calm and with mum
Adrenaline nebulisers (ml of 1 in 1000 in 5mls of saline) will wear off in about an hour- have a plan!!
Dexamethasone (200mcg/kg stat IV)
Heliox- helps oxygen delivery
Anaesthetist!!

126
Q

Epiglottitis

A
  • Haemophilus influenzae
  • Life-threatening medical emergency
  • 3-7 years old
  • Thumb sign on cervical X ray (but should never be taken due to emergency)
127
Q

Symptoms and management of epiglottitis

A

Rapid onset
- Drooling
- Dysphagia
- Respiratory distress with inspiratory stridor
- Fever

Do NOT upset the child!!
- Intubate in theatre by paediatric anaesthetist with ENT surgeon on standby

128
Q

Assessing the eye in post-septal orbital cellulitis

A
  • Can you physically open the eye
  • Can the eye open itself
  • Pain on movement? abscess, impingement of muscles
  • Colour vision- in trouble (hour left before you lose vision)
  • Reactive to light
  • White of eye oedematous
129
Q

Eye signs of orbital cellulitis

A
  • Proptosis
  • Ophthalmoplegia
  • Chemosis
  • Eyelid swelling and erythema
  • Decreased visual acuity
  • Pain
  • Diplopia
130
Q

How to get foreign bodies out of nose

A
  • Mother’s kiss
  • Suction
  • Most important one to be aware of is the button battery!!! very dangerous- can cause skin damage. Emergency to get it removed.
131
Q

9 month old boy: MLB performed earlier today. You are called to see him as the nurses are worried about his stridor.

What do you do?

A
  • IV Dex
  • Nebulised adrenaline
  • Keep them with their mum
  • Might need intubating
132
Q

1 year old boy, previous cardiac surgery, long term ventilation. Having difficulty breathing with a tracheostomy. What do you do?

A

Check if it is patent
Suction down the tracheostomy- cameras down the tracheostomy

If airway is clear
- Viral infection? chest infection? pneumothorax?
- CXR

133
Q
A

Y4 Special senses (8 decks)

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