ENT Flashcards
What are acoustic neuromas?
Benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear
Vestibular schwannoma
Where do acoustic neuromas occur in the brain?
Cerebellopontine angle
What do bilateral acoustic neuromas indicate?
Neurofibromatosis type II
Acoustic neuromas are usually unilateral
What are the features of acoustic neuromas?
cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
sense of fullness in the ear
What are the investigations for acoustic neuromas?
Audiometry: Sensorineural pattern of hearing loss
MRI or CT for tumour
MRI is the investigation of choice
What is the management of acoustic neuromas?
Urgent ENT referral
Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate
Surgery to remove the tumour (partial or total removal)
Radiotherapy to reduce the growth
What are the features of Benign Paroxysmal Positional Vertigo?
vertigo triggered by a change in head position (e.g. rolling over in bed or gazing upwards)
can be associated with nausea
each episode typically lasts 10-20 seconds
Positive Dix-Hallpike manoeuvre (rotary nystagmus)
What manoeuvre is used to diagnose BPPV? What manoeuvre is used to treat BPPV?
Diagnosis: Dix-Hallpike manoeuvre (elicits rotary nystagmus)
Treat: Epley Manoeuvre
Patient home manouveres: Brandt-Daroff Exercises
What are the features of Menieres disease?
Recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural)
Vertigo is usually the prominent symptom
full ear
Nystagmus and a positive Romberg test
typically symptoms are unilateral but bilateral symptoms may develop after several years
What is the management of Menieres disease?
ENT assessment
Inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
Acute attacks: buccal or intramuscular prochlorperazine.
Prevention: betahistine and vestibular rehabilitation exercises may be of benefit
What are the features of epiglottitis?
Rapid onset
High temperature, generally unwell
Stridor
Drooling of saliva
‘tripod’ position: the patient finds it easier to breathe if they are leaning forward and extending their neck in a seated position
What causes acute epiglottitis?
Haemophilus influenzae type B
What is the investigation for acute epiglottitis?
Diagnosis is made by direct visualisation (ENT specialist)
- lateral view in the acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
- posterior-anterior view in croup will show subglottic narrowing, commonly called the ‘steeple sign’
What is the management for acute epiglottitis?
immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
endotracheal intubation may be necessary to protect the airway
DO NOT examine the throat due to the risk of acute airway obstruction
oxygen
intravenous antibiotics
What are some causes of epistaxis?
- nose picking, nose blowing
- trauma to the nose
- insertion of foreign bodies
- bleeding disorders
- immune thrombocytopenia
- Waldenstrom’s macroglobulinaemia
- juvenile angiofibroma
- benign tumour (highly vascularised)
- cocaine use
- hereditary haemorrhagic telangiectasia
- granulomatosis with polyangiitis
What is the management for epistaxis?
First-aid measures:
- Sit with torso forward and their mouth open
- Pinch the cartilaginous (soft) area of the nose firmly
- At least 20 minutes
If first aid measures are successful:
- Topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis
-Mupirocin is a viable alternative
If bleeding does not stop after 10-15 minutes:
- consider cautery or packing
Patients who are haemodynamically unstable or compromised:
- admit to A&E
- Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre
What are the features of Infectious Mononucleosis?
The classic triad of sore throat, pyrexia and lymphadenopathy is seen in around 98% of patients:
Other features include:
malaise, anorexia, headache
palatal petechiae
splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture
hepatitis, transient rise in ALT
lymphocytosis: the presence of 50% lymphocytes with at least 10% atypical lymphocytes
haemolytic anaemia secondary to cold agglutins (IgM)
a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis
What is the diagnosis of Infectious Mononucleosis?
Heterophil antibody test (Monospot test)
NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.
What is the management of Infectious Mononucleosis?
Supportive:
Rest during the early stages, drink plenty of fluid, avoid alcohol
simple analgesia for any aches or pains
Avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture
What are the features of otitis media?
otalgia
some children may tug or rub their ear
fever occurs in around 50% of cases
hearing loss
recent viral URTI symptoms are common (e.g. coryza)
ear discharge may occur if the tympanic membrane perforates
What findings are on otoscopy for otitis media?
Possible otoscopy findings:
bulging tympanic membrane → loss of light reflex
opacification or erythema of the tympanic membrane
perforation with purulent otorrhoea
decreased mobility if using a pneumatic otoscope
What are the diagnosis criteria for otitis media?
Acute onset of symptoms
- otalgia or ear tugging
Presence of a middle ear effusion
- bulging of the tympanic membrane, or
otorrhoea
- decreased mobility on pneumatic
- otoscopy
Inflammation of the tympanic membrane
i.e. erythema
What is the management for otitis media?
Acute otitis media is generally a self-limiting condition that does not require an antibiotic prescription.
Analgesia should be given to relieve otalgia. Parents should be advised to seek medical help if the symptoms worsen or do not improve after 3 days.
Antibiotics should be prescribed immediately if:
Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
Otitis media with perforation and/or discharge in the canal
If an antibiotic is given, a 5-7 day course of amoxicillin is the first line. In patients with penicillin allergy, erythromycin or clarithromycin should be provided.
What are some complications of otitis media?
mastoiditis
meningitis
brain abscess
facial nerve paralysis
