ENT Flashcards
Weber’s test
- 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
Rinne’s test
- 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
Audiometry interpretation
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
Vertigo
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
Vertigo causes
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
Benign paroxysmal positional vertigo (BPPV)
recurrent episodes of vertigo, triggered by head movt
BPPV Patho
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
BPPV Px
- 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
BPPV Dx
Dix-Hallpike manoeuvre
BPPV Mx
Epley manoeuvre
Brandt-Daroff exercises
Betahistine
Vestibular neuronitis
inflammation of vestibular nerve - usually viral
Vestibular neuronitis Px
- 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
Vestibular neuronitis Dx
Head impulse test
Vestibular neuronitis Mx
Buccal / IM prochlorperazine
Cyclizine, cinnarizine, promethazine
Maybe vestibular rehab therapy
Labyrinthitis
Inflammation of semicircular canals, vestibule, cochlear
Usually after URTI / bacterial infection (eg meningitis, OM)
Labyrinthitis Px
- acute onset vertigo, exacerbated by movt
- hearing loss - sensorineural
- tinnitus
- N+V
- viral sx
- gait - may fall to affected side
- nystagmus
Labyrinthitis Dx
H/E
Head impulse test - abnormal
Labyrinthitis Mx
- prochlorperazine
- cyclizine, cinnarizine, promethazine
- abx for bacterial cause
Meniere’s disease
Long term inner ear disorder
excessive endolymph in labyrinth - disrupt sensory signals
Meniere’s disease Px
- unilateral, maybe bilateral after years
- vertigo, 20mins-hrs episodes, in clusters
- hearing loss - sensorineural
- tinnitus
- fullness in ear
- drop attacks
- imbalance
- nystagmus in attack
Meniere’s disease Dx
clinical dx - by ENT
Audiology
Meniere’s disease Mx
Acute attacks
- prochlorperazine
- cyclizine, cinnarizine, promethazine
Prophylaxis
- betahistine
- vestibular rehab exercises
Inform DVLA - don’t drive until sx controlled
Otitis externa (OE)
inflammation of external ear canal
bacterial, fungal, eczema, contact dermatitis, trauma, swimming….
OE Px
- ear pain, itch, discharge
- red, swollen ear canal
- lymphadenopathy
OE Ix
Can do swab
OE Mx
- OTC acetic acid
- 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
Malignant OE
- 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
Otitis media (OM)
infection of middle ear
often after viral URTI
also bacterial - strep pneumoniae….
OM Px
- ear pain
- reduced hearing
- URTI sx
- balance issues, vertigo
- discharge - if tympanic membrane perf
- young pts - fever, vomiting, irritable, lethargy, poor feeding…
OM Ix
Otoscopy - bulging tympanic membrane (effusion), red, inflamed, discharge
OM Mx
- paeds - admit if high fever…
- analgesia
- amoxicillin 5d / erythromycin / clarithromycin
- abx if sx not improving >4d, perf, co-morbidities….
- consider delayed prescription - eg after 3d if sx worsen
Mastoiditis
- 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
Presbycusis
- 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
Otosclerosis
- 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
Eustachian tube dysfunction
- 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
Glue ear
- 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
Sudden sensorineural hearing loss (SSNHL)
- unexplained hearing loss <72hrs - ENT emergency
Ix
- audiometry
- MRI / CT head
Mx
- ENT referral
- tx cause
- idiopathic - steroids - oral / intra-tympanic
Conductive causes of acute hearing loss
- ear wax
- infection - OM / OE
- middle ear effusion
- eustachian tube dysfunction
- perforated tympanic membrane
Causes of SSNHL
- 90% idiopathic
- infection - meningitis, HIV, mumps
- Meniere’s
- ototoxic meds
- MS
- migraine
- stroke
- acoustic neuroma
Tinnitus
persistent ringing in ears
Tinnitus causes
- 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
Tinnitus Ix
- otoscopy
- Rinne, Weber
- Bloods - FBC, glucose, TSH, lipids
- audiology
- CT / MRI if needed
Tinnitus red flags
- unilateral
- pulsatile
- hyperacusis - hypersensitive to sounds
- sudden hearing loss
- vertigo / dizziness
- visual / neuro sx
- suicidal ideation from tinnitus
Tinnitus mx
- tx cause
- hearing aids
- sound therapy
- CBT
- tinnitus support groups
Ear wax
Px
- conductive hearing loss
- ear discomfort, feels full, pain
- tinnitus
Ix
- otoscopy
Mx
- ear drops - olive oil / sodium bicarb
- ear irrigation
- microsuction - by ENT
Acoustic neuroma
- vestibular schwannoma
- benign tumour of Schwann cells around vestibulocochlear nerve
- 5% intracranial, 90% cerebellopontine angle tumours
- Bilateral - NF2
Acoustic neuroma Px
- 40-60yo
- CN8 - vertigo, unilateral sensorineural hearing loss, tinnitus
- CN5 - absent corneal reflex
- CN7 - facial palsy, forehead not spared
Acoustic neuroma Ix
- urgent ENT referral
- audiometry
- CT / MRI
Acoustic neuroma Mx
- surgery
- radiotherapy
- W+W
Cholesteatoma
- 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
Auricular haematoma
- blood in auricle after trauma
- ENT assessment - incision + drainage - prevent cauliflower ear
Perforated tympanic membrane
- 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
Epistaxis
- nosebleed
- anterior - Kiesselbach’s plexus, in Little’s area
- posterior - deeper - risk of aspiration / airway compromise
Epistaxis causes
Local
- nose picking, trauma
- FB
- colds, sinusitis
- cocaine
- topical drugs - steroids
- vascular, tumours
General
- coag disorders, blood thinners
- HTN, atherosclerosis
- weather changes
- excessive alcohol
Epistaxis Px
- unilateral
- if bilateral - may indicate posterior
- vomiting blood - if swallowed
Epistaxis Ix
FBC, coag, G+S
Epistaxis Mx
- 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
After
- naseptin cream - chlorhexidine + neomycin - 10d QDS
Admission
- if uncontrolled / posterior - ?balloon catheter
- if unstable
- ?splenopalatine artery ligation in theatre (for posterior)
Sinusitis
- inflammation of mucous membranes in paranasal sinuses
- eg strep pneumoniae, H influenzae, rhinoviruses
- RFs - nasal obstruction, recent local infection, swimming, diving, smoking
Sinusitis Px
- 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
Sinusitis Ix
- in chronic (>12wks) - nasal endoscopy, CT
Sinusitis Mx
- analgesia
- intranasal decongestants
- intranasal corticosteroids
- oral abx - if severe - phenoxymethylpenicillin, co-amox (if systemically unwell)
Allergic rhinitis
- 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
Nasal polyps
- growth of nasal mucosa
- usually bilateral - unilateral = ?tumour
associated with
- chronic rhinitis, sinusitis
- asthma
- Samter’s triad
- CF
- granulomatosis with polyangiitis
- Kartagener’s syndrome
Nasal polyps px
- ?chronic rhinosinusitis
- difficulty breathing through nose
- snoring
- nasal discharge
- anosmia
Nasal polyps Ix
- examine with nasal speculum
- nasal endoscopy
Nasal polyps Mx
- intranasal steroid drops / spray
- surgery - intranasal polypectomy / endoscopic if further back
Nasal septal haematoma
- 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
Tonsillitis
Inflammation in tonsils
Causes
- viral - most common
- Group A strep - strep pyogenes
- strep pneumonia…
Tonsillitis Px
- fever
- sore throat
- painful swallowing
- lymphadenopathy
- younger children - fever, poor oral intake, headache, vomiting, abdo pain
Tonsillitis Ix
- examine - red, inflamed, enlarged +/- exudates
- examine ears
- palpate for lymphadenopathy
- rapid antigen for group A strep - if immunocompromised, old/young, severe sx
- throat culture if antigen test negative
Centor criteria
Probability of bacterial infection
> 3 of the following - indicates abx
- fever >38
- tonsillar exudates
- absence of cough
- tender anterior cervical lymph nodes
FeverPAIN score
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
Tonsillitis Mx
- paracetamol, ibuprofen, Difflam
- abx - penicillin V / clarithromycin
- consider delayed prescription
- admit if needed - eg unwell…
Quinsy
- peritonsillar abscess
- bacterial infection with trapped pus
- most commonly strep pyogenes (GAS), also S aureus, H influenzae
Quinsy Px
- sore throat
- painful swallowing
- fever, neck pain, referred ear pain
- swollen lymph nodes
- trismus
- hot potato voice
- swelling / erythema beside tonsils
Quinsy Mx
- ENT admission - incision / drainage
- Co-amoxiclav
- ?dex for inflammation
Tonsillectomy indications
- 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
Tonsillectomy Cx
- pain, sore throat
- damage to teeth
- infection
- risks of GA
- post-tonsillectomy
Post-tonsillectomy bleeding Mx
- 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
Thyroid surgery cx
- recurrent laryngeal nerve damage
- bleeding
- parathyroid gland damage -> hypocalcaemia
Laryngopharyngeal reflux
- 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
Ludwig’s angina
- progressive cellulitis which invades floor of mouth, soft tissues of neck
- from dental infections
Px
- neck swelling
- dysphagia
- fever
Mx
- mx airway
- IV abx
Salivary gland tumours
80% parotid, 80% of these - pleomorphic adenomas, 80% superficial lobe
Pleomorphic adenoma
- benign mixed parotid tumour
Px
- slow growing painless lump, moveable
- middle aged
Mx
- superficial parotidectomy
Warthin’s tumour
- benign, adenolymphoma, 10%
- males, middle aged
- softer, more mobile, fluctuant
Salivary gland stones
- 80% submandibular
Px
- recurrent unilateral pain / swelling on eating
Ix
- XR
- sialography - XR + contrast
Mx
- surgical removal
Neck lumps DDx
- 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
Neck lump H/E
Hx
- SOCRATES
- fever, wt loss, night sweats
- FHx, smoking
Exam
- lump exam
- lymph nodes
- skin changes
- focal chest sounds - cancer
- clubbing
- HSM
Neck lump 2ww referral criteria
- unexplained neck lump >45yo
- persistent unexplained neck lump any age
USS with growing lump:
- <2wks if >25yo, <48hrs if <25yo
Neck lump Ix
- bloods - eg FBC, blood film, HIV, EBV ABs, TFTs, ANA, LDH (Hodgkin’s)
- USS, CT/MRI, nuclear medicine scan
- Biopsy - fine needle / core, incision
Lymphadenopathy causes
Reactive - URTIs, dental infections, tonsillitis
Infective - TB, HIV, IM
Inflammatory - SLE, sarcoidosis
Malignancy - lymphoma, leukaemia, mets, chest/abdo (supraclavicular)
Lymphadenopathy sx suggesting malignancy
unexplained
persistently >3xm
abnormal shape - oval
hard / rubbery
non-tender
tethered / fixed to skin / underlying tissues
night sweats, wt loss, fatigue, fever
Carotid body tumour
- 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
Pharyngeal pouch
- older men
- posteromedial herniation between thyropharyngeus + cricopharyngeus muscles
- Px - dysphagia, regurg, aspiration, cough
Head/neck cancer
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
Head/neck cancer Px
- 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
Head/neck cancer referral criteria
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
Head/neck cancer Ix
- Scans, biopsy
- TNM staging
Head/neck cancer Mx
- chemo / radio
- surgery
- MAbs
Glossitis
- inflammation of tongue
- red, sore, swollen
- papillae atrophy - smooth tongue
Causes
- iron deficiency
- B12 anaemia
- folate anaemia
- coeliac
- injury / irritants
Angioedema
fluid build up in tissues
Causes
- allergic reactions
- ACEi
- hereditary angioedema
Oral candidiasis
- oral thrush - white spots / patches on tongue / palate
RFs
- ICS
- abx
- DM, HIV, smoking
Mx
- miconazole gel
- nystatin suspension
- fluconazole tablets
Geographic tongue
- inflammatory - patches of tongue lose epithelium + papillae - irregular shapes
- related to - stress, mental illness, psoriasis, atopy, diabetes
- benign
- topical steroids / antihistamines for sx control
Strawberry tongue
tongue swollen, red
papillae enlarged + white
Scarlet fever / Kawasaki’s
Black hairy tongue
- 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
Leukoplakia
- white patches on tongue, inside of cheeks - precancerous to SCC
Px
- asym, irregular, slightly raised
Ix
- biopsy
Mx
- stop smoking, alcohol
- potential surgical excision
Erythroplakia
Red patches in mouth, like leukoplakia
Lichen planus
- 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
Gingivitis
- 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
Gingival hyperplasia
abnormal growth of gums
Causes
- gingivitis
- pregnancy
- vit deficiency - scurvy
- AML
- meds - CCBs, phenytoin, ciclosporin
Aphthous ulcers
- small, painful ulcers of mucosa in mouth
Causes
- stress, trauma, foods
- IBD, coeliac, Behcet, vit deficiency, HIV
Mx
- if unexplained >3wks, refer for 2ww
- bonjela
- difflam spray
- lidocaine
- more severe - hydrocortisone buccal tablets, betamethasone, beclometasone
