ENT

Question 1

How would you manage a unilateral polyp?

Answer 1

Urgent ENT referral - red flag symptom

Question 2

A 78-year-old man attends his general practitioner concerned about a small lesion on his inner, lower lip. It has been present for around a month but does not seem to have changed over this time. Management?

Answer 2

A history of more than 3 weeks persistent oral ulceration should be referred to oral surgery under the two week wait

Question 3

What is tympanosclerosis?

Answer 3

Tympanosclerosis is characterised by a chalky, white plaque on the tympanic membrane which is not visualised in this case. This finding is suggestive of a previous middle ear infection or trauma.

Question 4

How do we diagnose and treat BPPV?

Answer 4

Dix to Diagnose, Epley to End

Question 5

How do we treat acute sensorineural hearing loss?

Answer 5

There is some evidence that high dose steroids (60mg/day) for seven days improves prognosis, so all patients should start treatment as soon as possible. ENT assessment should be arranged as soon as possible to allow pure tone audiometry testing and to arrange an MRI to exclude an acoustic neuroma. Intra-tympanic steroids can also be given if there is no response to oral steroids.

Question 6

What is chronic rhinosinusitiss?

Answer 6

Chronic rhinosinusitis affects up to 1 in 10 people. It is generally defined as an inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer.

Question 7

How do we treat chronic rhinosinusitis?

Answer 7

Management of recurrent or chronic sinusitis
avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution

Question 8

What is presbycusis?

Answer 8

Presbycusis (or age-related hearing loss) occurs bilaterally and affects 1 in 3 adults over 65 years. It is a progressive, bilateral sensorineural hearing loss.

Question 9

What is allergic rhinitis?

Answer 9

Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens.

Question 10

How do we treat otitis media?

Answer 10

Amoxicillin (co-amox 2nd line)

Question 11

What is the pathophysiology in Meniere’s disease?

Answer 11

These symptoms result from an accumulation of endolymphatic fluid within the inner ear, leading to increased pressure and subsequent dysfunction of the vestibular and cochlear systems. The exact cause of Meniere’s disease remains unclear, but it is thought to involve a combination of genetic and environmental factors.

Question 12

How does cholesteatoma present?

Answer 12

Cholesteatoma is an epithelial growth behind the tympanic membrane which could cause local invasion leading to cranial nerve abnormalities. This boy has a combination of cranial nerve abnormalities, ear discharge and hearing loss. Otoscopy shows ‘attic crust’. You may see multiple previous ear infections.

Question 13

Which ear does Weber’s test localise to?

Answer 13

Weber localises to affected ear

Weber’s test lateralized to the left, which indicates a conductive hearing loss in the left ear or sensorineural loss in the right ear.

Question 14

How do we manage acute sensorineural hearing loss

Answer 14

Urgent referral to ENT (emergency)

Question 15

A 23-year-old man is diagnosed as having nasal polyps. Sensitivity to which medication is associated with this condition?

Answer 15

Nasal polyps are a common finding in patients with aspirin sensitivity, forming part of the Samter’s triad (aspirin sensitivity, asthma and nasal polyps). Aspirin can exacerbate respiratory symptoms by inhibiting the cyclooxygenase pathway of arachidonic acid metabolism, leading to an overproduction of leukotrienes. This causes bronchoconstriction and inflammation in sensitive individuals.

Question 16

Which ENT SE can quinine cause?

Answer 16

Quinine, an antimalarial drug also used for nocturnal leg cramps, is known to cause tinnitus as a side effect. This ototoxicity is often reversible upon discontinuation of the drug.

Question 17

How does acoustic neuroma present?

Answer 17

Features can be predicted by the affected cranial nerves
cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy

Bilateral acoustic neuromas are seen in neurofibromatosis type 2

Question 18

When do thyroglossal cysts typically present/

Answer 18

<20y.o.

Question 19

What is postnasal drip?

Answer 19

Post-nasal drip (PND) occurs as a result of excessive mucus production by the nasal mucosa. This excess mucus accumulates in the throat or in the back of the nose resulting in a chronic cough and bad breath.

Question 20

How does Meniere’s disease present?

Answer 20

Meniere’s disease, a disorder of the inner ear, commonly results in symptoms such as vertigo, tinnitus, aural fullness and sensorineural hearing loss.

Question 21

When do we refer for an perforated eardrum?

Answer 21

6-8wks

Question 22

What is sialadenitis?

Answer 22

inflammation of the salivary gland likely secondary to obstruction by a stone impacted in the duct. The duct from the submandibular gland drain into the floor of the mouth and purulent discharge from this duct causes a foul taste in the mouth.

Question 23

How do we treat vestibular neuronitis?

Answer 23

Prochlorperazine may be useful in the acute phase of vestibular neuronitis, but should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms

Question 24

What are the most common bacterial causes of otitis media?

Answer 24

The most common bacterial causes of otitis media are Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis.

Question 25

How do we treat Ramsay-Hunt syndrome?

Answer 25

Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids

Question 26

What is the triad in Meniere’s disease?

Answer 26

Unilateral hearing loss
Vertigo
Tinnitus

Question 27

What causes Meniere’s diseasE?

Answer 27

Ménière’s disease is associated with the excessive buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals. This increased pressure of the endolymph is called endolymphatic hydrops.

Question 28

How does Meniere’s disease present?

Answer 28

Unilateral hearing loss, vertigo, tinnitus

A sensation of fullness in the ear
Unexplained falls (“drop attacks”) without loss of consciousness
Imbalance, which can persist after episodes of vertigo resolve

Spontaneous nystagmus may be seen during an acute attack. This is usually in one direction (unidirectional).

Question 29

How do we treat Meniere’s disease?

Answer 29

For acute attacks, short-term options for managing symptoms include:

Prochlorperazine
Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

Prophylaxis is with:

Betahistine

Question 30

What is an acoustic neuroma?

Answer 30

Acoustic neuromas are benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear. Vestibular schwannomas.

Question 31

Are acoustic neuromas usually unilateral or bilateral?

Answer 31

Acoustic neuromas are usually unilateral. Bilateral acoustic neuromas are associated with neurofibromatosis type II.

Question 32

How does acoustic neuroma present?

Answer 32

Unilateral sensorineural hearing loss (often the first symptom)
Unilateral tinnitus
Dizziness or imbalance
A sensation of fullness in the ear

They can also be associated with a facial nerve palsy if the tumour grows large enough to compress the facial nerve.

Question 33

What would vestibulocochlear nerve injury present with?

Answer 33

permanent hearing loss or dizziness

Question 34

What is labyrinthitis?

Answer 34

Labyrinthitis refers to inflammation of the bony labyrinth of the inner ear, including the semicircular canals, vestibule (middle section) and cochlea. The inflammation is usually attributed to a viral upper respiratory tract infection.

Question 35

How does labyrinthitis present?

Answer 35

Labyrinthitis presents with acute onset vertigo, similarly to vestibular neuronitis.

Unlike vestibular neuronitis, labyrinthitis can also be associated with:

Hearing loss
Tinnitus

Question 36

How do we manage labyrinthitis?

Answer 36

Management is the same as with vestibular neuronitis, with supportive care and short-term use (up to 3 days) of medication to suppress the symptoms. Options for managing symptoms are:

Prochlorperazine
Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

Question 37

Why do we offer audiology assessment for every patient who has recovered from meningitis?

Answer 37

Patients rarely have lasting symptoms, including permanent hearing impairment. This is more common after bacterial labyrinthitis, particularly associated with meningitis.

TOM TIP: Remember hearing loss as a key complication of meningitis. All patients with meningitis are offered audiology assessment as soon as they are recovered to assess for hearing impairment. This complication comes up often in exams and is worth remembering.

Question 38

What is vestibular neuronitis?

Answer 38

Vestibular neuronitis describes inflammation of the vestibular nerve. This is usually attributed to a viral infection.

Question 39

How does vestibular neuronitis present?

Answer 39

Typically, the history involves the acute onset of vertigo. In addition, there may be a history of a recent viral upper respiratory tract infection.

Symptoms are most severe for the first few days. Initially, vertigo may be constant, after which it is triggered or worsened by head movement. It is often associated with:

Nausea and vomiting (may be severe)
Balance problems

Question 40

How do we manage acute sinusitis?

Answer 40

analgesia and abundant fluids - normally viral

Question 41

How does acute sinusitis present?

Answer 41

facial pain (classically described as frontal pressure pain which is worse on bending forward), nasal discharge (usually thick and purulent) and difficulty breathing

Question 42

What is black hairy tongue?

Answer 42

Black hairy tongue is a benign condition characterized by the elongation and discolouration of the filiform papillae on the dorsal surface of the tongue. The brown or black coating seen in this case is due to the accumulation of keratin and dead cells, as well as staining from food, drinks, or tobacco products. Although it may cause some discomfort or tickling sensation, it is generally asymptomatic and can be managed with good oral hygiene practices.

Question 43

Which medications can cause gingival hyperplasia?

Answer 43

phenytoin, ciclosporin, calcium channel blockers and AML

Question 44

Who needs abx with otitis media?

Answer 44

More than 4 days of symptoms
Extremely unwell (systemically)
Discharge or perforation
Immunocompromised or significant co-morbidity
Age <2 & bilateral

Media

Question 45

How do we manage haemorrhage 10 days after tonsillectomy?

Answer 45

Haemorrhage 5-10 days after tonsillectomy is commonly associated with a wound infection and should therefore be treated with antibiotics

Question 46

How do branchial cysts present?

Answer 46

Brachial cysts often present during intercurrent upper respiratory tract infection. On examination he has a smooth swelling in between the sternocleidomastoid muscle and the pharynx. It is fluctuant but doesn’t transilluminate or move during swallowing.

Question 47

How does thyroglossal cyst present?

Answer 47

A midline, cystic swelling is noted in the region of the hyoid bone. It moves upwards when she swallows or sticks her tongue out.

Question 48

How does hypocalcaemia present on ECG?

Answer 48

isolated QTc elongation

Question 49

How do we prevent attacks of Menieres disease?

Answer 49

Betahistine

Question 50

How do we manage malignant otitis externa in diabetics?

Answer 50

Otitis externa in diabetics: treat with ciprofloxacin to cover Pseudomonas

NOE = necrotising OE = malignant OE

This is essentially osteomyelitis of the temporal bone. She should be referred to ENT for CT scan of the temporal bones and managed with a prolonged course of IV antibiotics.

Question 51

What is geographic tongue?

Answer 51

This condition, also known as benign migratory glossitis, is characterised by irregularly shaped red, smooth and sometimes slightly raised patches on the tongue surface. The lesions often have a white or light-coloured border. They can change location over time, which is why the condition is called ‘migratory’. It’s typically asymptomatic and the cause remains unknown. No specific treatment is required for geographic tongue.