ENT Flashcards
Persistent sore throat in a patient with smoking history
2ww ENT if >4weeks
mouth ulcer >3 weeks
2ww
conductive hearing loss, tinnitus and positive family history
otosclerosis
macupapular rash starting on trunk post antibiotics
amoxicillin
Gingival hyperplasia
phenytoin, ciclosporin, calcium channel blockers and AML
Examination of the nostrils reveals a bilateral red swelling arising from the midline, which is slightly boggy.
urgent ENT review for ?nasal septal haematoma
If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis. This may result in a ‘saddle-nose’ deformity
management septal haematoma
surgical drainage
IV Abx
bilateral acoustic neuroma/ vestibular schwannoma -associated with
Neurofibormatosis type 2
bilateral acoustic neuroma cranial nerve impact
cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
when to refer for tonsillectomy
7 episodes per year for one year, 5 per year for 2 years, or 3 per year for 3 years, and for whom there is no other explanation for the recurrent symptoms
Sore throat FeverPAIN
Fever over 38°C.
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (3 days or less)
Severely Inflamed tonsils
No cough or coryza
5-10 day course of antibiotics is appropriate to ensure eradication of possible Streptococcus infection. Phenoxymethylpenicillin is the first-line antibiotic choice in the BNF
complications of tonsillectomy
primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain
sudden sensorineural hearing loss, idiopathic
steroids and refer ENT urgent
Treatment of Ramsay Hunt syndrome
acyclovir and prednisolone
Parathyroid surgery -> damage to parathyroid = which electrolyte abnormality?
Hypocalcaemia
isolated QT elongation
thyroid surgery complications
recurrent laryngeal nerve damage
bleeding
damage to parathyroid glands (hypocalacemia)
juvenile angiofibroma
benign tumour that is highly vascularised
seen in adolescent males
how to stop nose bleeding if holding nose has failed
1- Cautery OR packing
Cautery= if bleeding point visible
ask pt to blow nose
use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.
packing = If can’t visualise
v bad nosebleed that has failed all other management (cautery/packing)
may require sphenopalatine ligation in theatre
when to admit those with nose bleed
if haemodynamically unstable or from unknown/posterior source (i.e. bleeding from both nostrils)
acute onset vertigo following a viral illness NO auditory Sx
vestibular neuronitis
Neck lumps:
local infection or generalised viral illness
reactive lymphadenopathy
Neck lumps:
rubbery, painless lymphadenopathy
night sweats and splenomegaly
thyroid swelling
Neck lumps:
<20 years old
midline
between isthmus of thyroid and hyoid bone
moves upwards with tongue
may be painful if infected
throglossal cyst
Neck lumps:
older man
gurgles on palpation
dysphagia, regurigitaiton, aspiration, chronic cough
pharyngeal pouch
Neck lump>
congenital lymphatic lesion
L side neck
evident at birth
cystic hygroma
neck lump:
oval mobile cystic mass
between sternocleidomastoid muscle and pharynx
develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
can present during intercurrent URTI
branchial cyst
neck lump: Pulsatile lateral neck mass which doesn’t move on swallowing
carried aneurysm
neck lump: midline non tender swelling that moves upwards when swallows
goitre
A newborn baby is noted to have a large swelling on the left-side of the neck. On examination a soft, fluctuant and highly transilluminable lump is noted just beneath the skin.
cystic hygroma
what is postnasal drip
excess mucus by nasal mucosa
–> chronic cough + bad breath
Ramsay Hunt: which cranial nerve?
CN 7 (facial)
Ramsay Hunt:
features?
auricular pain
facial nerve palsy
vesicular rash
vertigo/ tinnitus
Oral aciclovir + corticosteroids
Mastoiditis: 1st line management?
IV Abx (then CT head)
Mastoiditis: complications
facial nerve palsy
hearing loss
meningitis
T wave inversion, QTc prolongation and visible U waves
hypokalaemia
tall, peaked T waves, QTc shortening and ST-segment depression
hyperkaemia
Recurrent otitis externa following numerous antibiotic treatment and curd-like discharge
Candida (fungal)
Unexplained, unilateral ear ache for more than 4 weeks with unremarkable otoscopy
how to manage?
2WW
when to give in sinusitis?
- intranasal steroids
- Abx?
- when >10 days (give steroids for 14 days
- Abx (phenoxymethylpenicillin) if systematically unwell or Sx of serious complications OR “double sickening” (getting worse later due to bacterial infection)
Haemorrhage 5-10 days after tonsillectomy
wound infection –> ABX
Ménière’s disease PREVENTION
Betahistine AND vestibular rehabilitation
when can you drive with Meniers disease?
need to inform DVLA and shouldn’t drive until symptoms under control
acute attacks meniers
prochlorperazine
(used short term as delays recovery by interfering with central compensatory mechanisms)
ototoxic drugs (4)
gentamicin, quinine, furosemide, aspirin and some chemotherapy agents.
Otitis externa management
TOPICAL aminoglycaside (if bacterial) +/- corticosteroid
if don’t respond to topical –> REFER TO ENT
second line:
- consider contact dermatitis secondary to neomycin
- oral antibiotics (flucloxacillin) if the infection is spreading
- taking a swab inside the ear canal
- empirical use of an antifungal agent
diabetic + otitis externa?
Malignant otitis externa is more common in elderly diabetics. In this condition, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. Intravenous antibiotics may be required.
vertigo, tinnitus (often described as a ‘roaring’ sensation), and sensorineural hearing loss.
Menieres
(lasts 20mins-hours)
Samters 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.
nasal polyps
asthma (particularly late-onset asthma)
aspirin sensitivity
infective sinusitis
cystic fibrosis
Kartagener’s syndrome
Churg-Strauss syndrome
Glue ear RF
male sex
siblings with glue ear
higher incidence in Winter and Spring
bottle feeding
day care attendance
parental smoking
glue ear treatment
active observation: the management for a child with a first presentation of otitis media with effusion is active observation for 3 months - no intervention is required
grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months
adenoidectomy
children should be observed for 6-12 weeks as symptoms are normally self-limiting and referral should be reserved if symptoms persist beyond this period.
but refer earlier if: Sx affecting hearing/ development/ education
immediate referral for otitis media with effusion if:
Downs syndrome/ cleft palate
Otitis externa in diabetics:
what are you concerned about? (1)
investigations? (1)
treatment (1)
malignant otitis externa (necrotising otitis externa)
CT scan
Pseudomonas - CIPROFLOXACN
A newborn baby is noted to have a large swelling on the left-side of the neck. On examination a soft, fluctuant and highly transilluminable lump is noted just beneath the skin.
cystic hygroma
Neck lump:
difference between thyroglossal cyst and thyroid swelling? (movement) (2)
Thyroglossal cyst –> between isthmus of the thread and hyoid bone. moves upwards with protrusion of TONGUE
Thyroid swelling –> moves upwards on swallowing.
when to refer sinusitis to ENT
Unilateral symptoms (consider urgent referral as this increases suspicion of neoplasia).
Persistent symptoms despite compliance with 3 months of treatment.
Nasal polyps complicating assessment or treatment, particularly if present in children.
Recurrent episodes of otitis media and pneumonia in a child.
Unusual opportunistic infections.
Symptoms that significantly interfere with functioning and quality of life.
Allergic or immunologic risk factors that need investigating.
RED FLAGS:
unilateral symptoms
persistent symptoms despite compliance with 3 months of treatment
epistaxis
sinusitis management
avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution
haloperidol vs risperidone
HALI = 1st gen (TYPICAL)
Risperidone = 2nd gen (ATYPICAL)
parotid tumor - most common
pleomorphic= most common
middle age
slow growing, painless lump
superficial parotidectomy; risk = CN VII damage
warthins vs pleomorphic tumor
warthins softer, more mobile and fluctuant (although difficult to differentiate)
sailvrAY GLAND stones - which gland is most common
recurrent unilateral pain & swelling on eating
may become infected → Ludwig’s angina
80% are submandibular
plain x-rays; sialography
surgical removal
causes of salivary gland enlargement
cancer
stones
acute viral infection e.g. mumps
acute bacterial infection e.g. 2nd to dehydration diabetes
sicca syndrome and Sjogren’s (e.g. RA)
refer to 2nday Care for otitis media
meningitis, mastoiditis, or facial nerve paralysis
when to give Abx for otitis media
> 4 days
unwell
immunocompromised / high risk e.g. heart/lung disease
<2 years old with bilateral otitis media
perforted and/or discharge
—> 5-7 day course
NICE indications for antibiotics sore throat
features of marked systemic upset secondary to the acute sore throat
unilateral peritonsillitis
a history of rheumatic fever
an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
centor
presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever
absence of cough
(feverPAIN :
Fever over 38°C.
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (3 days or less)
Severely Inflamed tonsils
No cough or coryza)
Unexplained, unilateral ear ache for more than 4 weeks with unremarkable otoscopy
2WW ENT
oral cancer 2ww
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
a lump on the lip or in the oral cavity or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
glue ear management
–> hearing test
This child has otitis media with effusion (glue ear). Following the revised NICE guidelines in 2011, children should be observed for 6-12 weeks as symptoms are normally self-limiting and referral should be reserved if symptoms persist beyond this period.
However, referral should be earlier if:
Symptoms are significantly affecting hearing, development or education
Immediate referral in children with Downs syndrome or cleft palate
presbycusis: Patients typically present with a chronic, slowly progressing history of:
Speech becoming difficult to understand
Need for increased volume on the television or radio
Difficulty using the telephone
Loss of directionality of sound
Worsening of symptoms in noisy environments
Hyperacusis: Heightened sensitivity to certain frequencies of sound (Less common)
Tinnitus (Uncommon)
irregularly shaped red, smooth and sometimes slightly raised patches on the tongue surface. The lesions often have a white or light-coloured border..
erythematous areas with a white-grey border (the irregular, smooth red areas are said to look like the outline of a map)
some patients report burning after eating certain food
Geographic tongue. This condition, also known as benign migratory glossitis,
This chronic inflammatory condition affects the mucous membranes inside your mouth. May appear as white, lacy patches; red, swollen tissues; or open sores. These lesions may cause burning, pain or other discomfort.
oral lichen planus
thickened white patches that form on the gums, inside of the cheeks and/or under the tongue. These patches cannot be scraped off easily and this condition does not match with our patient’s presentation either.
oral leukoplakia
acute sinusitis= when to give steroids
if >10 days
