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
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
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
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
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
6
Q
Benign paroxysmal positional vertigo (BPPV)
A
recurrent episodes of vertigo, triggered by head movt
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
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
9
Q
BPPV Dx
A
Dix-Hallpike manoeuvre
10
Q
BPPV Mx
A
Epley manoeuvre
Brandt-Daroff exercises
Betahistine
11
Q
Vestibular neuronitis
A
inflammation of vestibular nerve - usually viral
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
13
Q
Vestibular neuronitis Dx
A
Head impulse test
14
Q
Vestibular neuronitis Mx
A
Buccal / IM prochlorperazine
Cyclizine, cinnarizine, promethazine
Maybe vestibular rehab therapy
15
Q
Labyrinthitis
A
Inflammation of semicircular canals, vestibule, cochlear
Usually after URTI / bacterial infection (eg meningitis, OM)
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
17
Q
Labyrinthitis Dx
A
H/E
Head impulse test - abnormal
18
Q
Labyrinthitis Mx
A
- prochlorperazine
- cyclizine, cinnarizine, promethazine
- abx for bacterial cause
19
Q
Meniere’s disease
A
Long term inner ear disorder
excessive endolymph in labyrinth - disrupt sensory signals
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
21
Q
Meniere’s disease Dx
A
clinical dx - by ENT
Audiology
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
23
Q
Otitis externa (OE)
A
inflammation of external ear canal
bacterial, fungal, eczema, contact dermatitis, trauma, swimming….
24
Q
OE Px
A
- ear pain, itch, discharge
- red, swollen ear canal
- lymphadenopathy
25
OE Ix
Can do swab
26
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
27
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
28
Otitis media (OM)
infection of middle ear
often after viral URTI
also bacterial - strep pneumoniae....
29
OM Px
- ear pain
- reduced hearing
- URTI sx
- balance issues, vertigo
- discharge - if tympanic membrane perf
- young pts - fever, vomiting, irritable, lethargy, poor feeding...
30
OM Ix
Otoscopy - bulging tympanic membrane (effusion), red, inflamed, discharge
31
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
32
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
33
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
34
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
35
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
36
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
37
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
38
Conductive causes of acute hearing loss
- ear wax
- infection - OM / OE
- middle ear effusion
- eustachian tube dysfunction
- perforated tympanic membrane
39
Causes of SSNHL
- 90% idiopathic
- infection - meningitis, HIV, mumps
- Meniere's
- ototoxic meds
- MS
- migraine
- stroke
- acoustic neuroma
40
Tinnitus
persistent ringing in ears
41
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
42
Tinnitus Ix
- otoscopy
- Rinne, Weber
- Bloods - FBC, glucose, TSH, lipids
- audiology
- CT / MRI if needed
43
Tinnitus red flags
- unilateral
- pulsatile
- hyperacusis - hypersensitive to sounds
- sudden hearing loss
- vertigo / dizziness
- visual / neuro sx
- suicidal ideation from tinnitus
44
Tinnitus mx
- tx cause
- hearing aids
- sound therapy
- CBT
- tinnitus support groups
45
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
46
Acoustic neuroma
- vestibular schwannoma
- benign tumour of Schwann cells around vestibulocochlear nerve
- 5% intracranial, 90% cerebellopontine angle tumours
- Bilateral - NF2
47
Acoustic neuroma Px
- 40-60yo
- CN8 - vertigo, unilateral sensorineural hearing loss, tinnitus
- CN5 - absent corneal reflex
- CN7 - facial palsy, forehead not spared
48
Acoustic neuroma Ix
- urgent ENT referral
- audiometry
- CT / MRI
49
Acoustic neuroma Mx
- surgery
- radiotherapy
- W+W
50
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
51
Auricular haematoma
- blood in auricle after trauma
- ENT assessment - incision + drainage - prevent cauliflower ear
52
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
53
Epistaxis
- nosebleed
- anterior - Kiesselbach's plexus, in Little's area
- posterior - deeper - risk of aspiration / airway compromise
54
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
55
Epistaxis Px
- unilateral
- if bilateral - may indicate posterior
- vomiting blood - if swallowed
56
Epistaxis Ix
FBC, coag, G+S
57
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)
58
Sinusitis
- inflammation of mucous membranes in paranasal sinuses
- eg strep pneumoniae, H influenzae, rhinoviruses
- RFs - nasal obstruction, recent local infection, swimming, diving, smoking
59
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
60
Sinusitis Ix
- in chronic (>12wks) - nasal endoscopy, CT
61
Sinusitis Mx
- analgesia
- intranasal decongestants
- intranasal corticosteroids
- oral abx - if severe - phenoxymethylpenicillin, co-amox (if systemically unwell)
62
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
63
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
64
Nasal polyps px
- ?chronic rhinosinusitis
- difficulty breathing through nose
- snoring
- nasal discharge
- anosmia
65
Nasal polyps Ix
- examine with nasal speculum
- nasal endoscopy
66
Nasal polyps Mx
- intranasal steroid drops / spray
- surgery - intranasal polypectomy / endoscopic if further back
67
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
68
Tonsillitis
Inflammation in tonsils
Causes
- viral - most common
- Group A strep - strep pyogenes
- strep pneumonia...
69
Tonsillitis Px
- fever
- sore throat
- painful swallowing
- lymphadenopathy
- younger children - fever, poor oral intake, headache, vomiting, abdo pain
70
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
71
Centor criteria
Probability of bacterial infection
>3 of the following - indicates abx
- fever >38
- tonsillar exudates
- absence of cough
- tender anterior cervical lymph nodes
72
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
73
Tonsillitis Mx
- paracetamol, ibuprofen, Difflam
- abx - penicillin V / clarithromycin
- consider delayed prescription
- admit if needed - eg unwell...
74
Quinsy
- peritonsillar abscess
- bacterial infection with trapped pus
- most commonly strep pyogenes (GAS), also S aureus, H influenzae
75
Quinsy Px
- sore throat
- painful swallowing
- fever, neck pain, referred ear pain
- swollen lymph nodes
- trismus
- hot potato voice
- swelling / erythema beside tonsils
76
Quinsy Mx
- ENT admission - incision / drainage
- Co-amoxiclav
- ?dex for inflammation
77
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
78
Tonsillectomy Cx
- pain, sore throat
- damage to teeth
- infection
- risks of GA
- post-tonsillectomy
79
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
80
Thyroid surgery cx
- recurrent laryngeal nerve damage
- bleeding
- parathyroid gland damage -> hypocalcaemia
81
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
82
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
83
Salivary gland tumours
80% parotid, 80% of these - pleomorphic adenomas, 80% superficial lobe
84
Pleomorphic adenoma
- benign mixed parotid tumour
Px
- slow growing painless lump, moveable
- middle aged
Mx
- superficial parotidectomy
85
Warthin's tumour
- benign, adenolymphoma, 10%
- males, middle aged
- softer, more mobile, fluctuant
86
Salivary gland stones
- 80% submandibular
Px
- recurrent unilateral pain / swelling on eating
Ix
- XR
- sialography - XR + contrast
Mx
- surgical removal
87
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
88
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
89
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
90
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
91
Lymphadenopathy causes
Reactive - URTIs, dental infections, tonsillitis
Infective - TB, HIV, IM
Inflammatory - SLE, sarcoidosis
Malignancy - lymphoma, leukaemia, mets, chest/abdo (supraclavicular)
92
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
93
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
94
Pharyngeal pouch
- older men
- posteromedial herniation between thyropharyngeus + cricopharyngeus muscles
- Px - dysphagia, regurg, aspiration, cough
95
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
96
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
97
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
98
Head/neck cancer Ix
- Scans, biopsy
- TNM staging
99
Head/neck cancer Mx
- chemo / radio
- surgery
- MAbs
100
Glossitis
- inflammation of tongue
- red, sore, swollen
- papillae atrophy - smooth tongue
Causes
- iron deficiency
- B12 anaemia
- folate anaemia
- coeliac
- injury / irritants
101
Angioedema
fluid build up in tissues
Causes
- allergic reactions
- ACEi
- hereditary angioedema
102
Oral candidiasis
- oral thrush - white spots / patches on tongue / palate
RFs
- ICS
- abx
- DM, HIV, smoking
Mx
- miconazole gel
- nystatin suspension
- fluconazole tablets
103
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
104
Strawberry tongue
tongue swollen, red
papillae enlarged + white
Scarlet fever / Kawasaki's
105
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
106
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
107
Erythroplakia
Red patches in mouth, like leukoplakia
108
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
109
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
110
Gingival hyperplasia
abnormal growth of gums
Causes
- gingivitis
- pregnancy
- vit deficiency - scurvy
- AML
- meds - CCBs, phenytoin, ciclosporin
111
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
