ENT Flashcards
What is the role of the semicircular canals
Sensing head movement - the vestibular system
What is the function of the cochlea
Converting the sound vibration into a nervous signal
Management of sudden onset hearing loss Occurring within 72 hours
Urgent need refer to ENT
How is sudden onset sensory neural hearing loss treated
high dose cortical steroids
Weber’s test results in sensorineural hearing loss
Sound will be Louder in the normal ear as a normal ear it’s better sensing the sound
The Web is test results in conductive hearing loss
The sound is louder in the affected ear because the affected ear becomes more sensitive
rinne positive
Air conduction is better than born conduction which is normal
When bone conduction is better than air conduction this suggests
A conductive cause for the hearing loss
What are the causes of sensory neural hearing loss
Sudden sensorineural hearing loss (over less than 72 hours)
Presbycusis (age-related)
Noise exposure
Ménière’s disease
acoustic neuroma
Which three common medications can cause sensorineural hearing loss
Loop diuretics (e.g., furosemide)
Aminoglycoside antibiotics (e.g., gentamicin)
Chemotherapy drugs (e.g., cisplatin)
What are the causes of conductive hearing loss
Ear wax (or something else blocking the canal)
Infection (e.g., otitis media or otitis externa)
Fluid in the middle ear (effusion)
Eustachian tube dysfunction
Perforated tympanic membrane
Otosclerosis
Cholesteatoma
Exostoses
Tumours
rinne and weber results table
image
audiogram interpretation
Anything below 20dB is abnormal (i.e. bad)
A significant difference between AC and BC is >10dB (this is what was taught at our med school)
- Sensorineural = both AC and BC bad with no significant difference between them
- Conductive = AC bad, BC normal, significant difference between
- Mixed = AC bad, BC bad, significant difference between
Presbycusis =
Age-related sensor renewal hearing loss. Affects high pitch sounds first
key rf for presbycusis
Exposure to loud noise over time
Pres of presbycuis
> 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)
diagnosing presbycusis
> audiometry - worse hearing at higher freq, SN pattern
Audiometry: Bilateral sensorineural pattern hearing loss
management of presbycuis
> Hearing aids -> Cochlear implants if not sufficient
causes of SSHL
> 90% are idiopathic
Acoustic neuroma, Ménière’s disease, MS, migraine
Investigations for SSHL
> Audiometry - A diagnosis of SSNHL requires a loss of at least 30 decibels in three consecutive frequencies on an audiogram.
MRI or CT head to exclude a stroke or acoustic neuroma
Presentation of Eustation tube dysfunction
> Reduced hearing
‘popping noises
Fullness sensation in the ear
Symptoms tend to get worse when the external air pressure changes in the middle ear cannot equalize for example flying climbing scuba diving
Most cases of et dysfunction resolve rapidly but in the case of persistent symptoms investigations can be done such as
Tympanometry - measuring air pressure differences
Audiometry
Nasopharyngoscopy
Treatment of ET dysfunction
> no Mx
Valsaba maneuver Deep congestion nasal sprays short term only
Surgery for severe cases
Inheritance of otosclerosis
auto dominant
What is Otosclerosis
Remodeling of the small bones in the middle ear leading to conductive hearing loss. Many affects the base of the Stapes
features of otosclerosis
> Onset usually at 20 to 40 years
Conductive hearing loss, tinnitus, positive family history
mx of OS
hearing aid
stapedectomy
Which frequency sounds are most affected in os
Effects the hearing of lower pitch sounds more than higher pitch sounds - reverse of the presbycusis
Examination findings in OS
> Webbers is normal if the auto sclerosis is bilateral or is louder in the more affected ear
Renee’s will show conductive hearing loss
Which pathogens typically cause ortitis media
Streptococcus pneumonaie,Haemophilus influenzaeandMoraxella catarrhalis
Features of otitis Media
> otalgia, hearing loss
fever
recent viral URTI
Ear discharge if the temp panic membrane perforates
Otoscopy findings in otitis Media
> Bulging tympanic membrane -> loss of light reflex
opacification of membrane
perforation
What are the criteria used to diagnose otitis media
> Acute onset of symptoms - otalgia or ear tugging
Presence of a middle ear effusion - bulging, ottorhoea, decreased mobility on otoscopy
Inflammation of tympanic membrane
what is the most common cause of otitis media
Streptococcus
Management of acute or otitis media
> It’s generally self limiting doesn’t that does not require an antibiotic prescription
Analgesia for pain relief
Advised to seek medical help if symptoms worse than or do not improve after three DAYS
what necessitates an immediate antibiotic prescription in acute otitis media
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
First line antibiotic in Ottitis Media
a 5-7 day course ofamoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.
Comps of OM
mastoiditis
meningitis
brain abscess
facial nerve paralysis
Causes of OE
> infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
seborrhoeic dermatitis
contact dermatitis (allergic and irritant)
What is a common trigger for OTITIS external
Recent swimming
features of OE
ear pain, itch, discharge
otoscopy: red, swollen, or eczematous canal
MX OF OE
topical antibiotic or a combined topical antibiotic with a steroid
if the tympanic membrane is perforated aminoglycosides are traditionally not used - ototoxocity risk
recurrent otitis external following the use of multiple courses of antibiotics should raise suspicion of
Fungal otitis externa - use CLOMITRAZOLE ear drops
When is a referral to ENT required for otitis externa
Failure to respond to topical antibiotics
ear wicks for OE
Maybe used if the canal is very swollen it is a sponge that contains topical treatment
what is malignant ortitis externa
Life threatening form of otitis external where the infection spreads to the bone - Leads to osteomyelitis of the temporal born of the skull
What are the key risk factors for malignant OE
Diabetes, IS, HIV
Most common cause of malignant OE
Pseudomonas aeruginosa
Features of MOE
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
Tx of Malignant OE
non-resolving otitis externa with worsening pain should be referred urgently to ENT
Intravenous antibiotics that cover pseudomonal infections
Key finding that indicates malignant OE
Granulation tissueat the junction between the bone and cartilage in the ear canal
Mx of MOE
Admission to hospital under the ENT team
IV antibiotics
Imaging (e.g., CT or MRI head) to assess the extent of the infection
3 Methods of removing ear wax
Ear drops – usually olive oil or sodium bicarbonate 5%
Ear irrigation – squirting water in the ears to clean away the wax
Microsuction – using a tiny suction device to suck out the wax
Causes of secondary tinnitus
> ear wax
MN
meds
acoustic neuroma
primary tinnitus
no identifiable cause and often occurs with sensori neural hearing loss
MN sx
Associated with hearing loss, vertigo, tinnitus and sensation of fullness or pressure in one or both ears
acoustic neuroma sx
Hearing loss, vertigo, tinnitus
Absent corneal reflex is an important sign
Associated with neurofibromatosis type 2
drugs -> tinnitus
Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine
pulsatile tinnitus
pulsatile tinnitus generally requires imaging as there may be an underlying vascular cause. Magnetic resonance angiography (MRA) is often used to investigate pulsatile tinnitus
ix for tinnitus
> test for under;ying causes: Anemia,diabetes, thyroid disorders, lipids for hyperelliptemia
red flags for tinnitus
Unilateral tinnitus
Pulsatile tinnitus
Hyperacusis (hypersensitivity, pain or distress with environmental sounds)
Associated unilateral hearing loss
Associated sudden onset hearing loss
Associated vertigo or dizziness
Headaches or visual symptoms
Associated neurological symptoms or signs (e.g., facial nerve palsy or signs of stroke)
Suicidal ideation related to the tinnitus
causes of vertigo
> BPPV
viral labyrinithitis
vestibular neuronitis
MN
Vertiobrobasilar ischaemia
AN
Features of viral labyrinithis
> Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected
vestibular neuronitis
Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss
BPPV
Gradual onset, peripheral cause of vertigo
Triggered by change in head position
Each episode lasts 10-20 seconds
Vertebrobasilar ischaemia
Elderly patient
Dizziness on extension of neck
test for BPPV
positive dix-hallpike manouvre - rotatory nystagmus
tx of BPPV
> Epley manouvre
brandt-daroff exercises
Betahistine
cause of BPPV
calcium carbonate crystals - otoconia become displaced in SCC which disrupts flow of endolymph
what is vestibular neuronitis
inflammation of vestibular nerve - usually following viral infection
labyrinithis vs neuronitis
Labyrinthitis – Loss of hearing
Neuronitis – No loss of hearing
features of vest neuronitis
recurrent vertigo attacks lasting hours or days
nausea and vomiting may be present
horizontal nystagmus is usually present
no hearing loss or tinnitus
How can we distinguish vestibular neuronitis from posterior circulation stroke
theHead impulse tests exam can be used to distinguish vestibular neuronitis from posterior circulation stroke
VN - For peripheral vertigo, short-term options for managing symptoms include:
Prochlorperazine
Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
Tx for chronic VN
vestibular rehabilitation exercises are the preferred treatmentfor patients who experience chronic symptoms
What can be used to provide rapid relief for severe cases of VN
buccal or intramuscularprochlorperazineis often used to provide rapid relief for severe cases
labyrinithis =
Inflammation of the Bonilla of the inner ear including the semicircular canals vistabule and cochlear usually following a viral upper respiratory tract infection
symptoms of labyrinithis
> Acute onset vertical following viral infection
hearing loss, tinitus
signs of labyrinithis
spontaneous unidirectional horizontal nystagmus towards the unaffected side
sensorineural hearing loss: shown by Rinne’s test and Weber test
abnormal head impulse test: signifies an impaired vestibulo-ocular reflex
gait disturbance: the patient may fall towards the affected side
mx of labyrinithis
episodes are usually self-limiting
prochlorperazine or antihistamines may help reduce the sensation of dizziness - up to 3 day course
key comp of meningitis
Hearing loss - All meningitis patients are offered ideology assessment as soon as they have recovered to assess for hearing impairment
Which type of labrinitis causes more hearing impairment
Bacterial particularly associated with meningitis
triad of menieres
Hearing loss - and feeling of fullness in ear
recurrent Vertigo
Tinnitus
pathophys of menieres
build of endolymph in the labyrinth -> increased pressure -> endolymphatics hydrops
spont nystagmus may be seen following an attack of
MN - one directional spont nystagmus
MN and driving
patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
managing acute attacks of MN
Prochlorperazine
Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
MN prophylaxis
betahistine
what is an acoustic neuroma
benign tumors of the Schwan cells surrounding the vestibular cochlear nerve
Bilateral acoustic neuromus indicate
neurofibromatosis type II.
symptoms of vestibular schwannoma/ AN
vertigo, hearing loss, tinnitus and an absent corneal reflex.
The symptoms of a acoustic neuroma will depend on which cranial nerves are affected
cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
AN Ix
> urgent ENT ref
MRI of the cerebellopontine angle is the investigation of choice
audiometry
cholesteatoma
Collection of squamous epithelium cells in the middle ear which is noncancerous but can invade local tissues. Significantly associated with being born with a cleft lip
features of cholesteatoma
foul-smelling, non-resolving discharge
hearing loss - unilateral conductive
features of cholesteatoma that come with local invasion
vertigo, facial nerve palsy
attic crust finding in
cholesteatoma
mx of cholesteatoma
> refer for ENT for surgical removal
causes of sinusitis
Infection, particularly following viral upper respiratory tract infections
Allergies, such as hayfever (with allergic rhinitis)
Obstruction of drainage, for example, due to a foreign body, trauma or polyps
Smoking
features of sinusitis
facial pain
typically frontal pressure pain which is worse on bending forward
nasal discharge: usually thick and purulent
nasal obstruction
mx of sinusitis
analgesia
intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited
intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days
severe sinusitus Mx
> Oral antibiotics- phenoxymethyl penicillin is first line
Double sickening suggests a? cause of sinusitis
bacterial cause - initial viral sinusitis worsens due to secondary bacterial infection
what is chronic rhinocinositis
Sinusitis that lasts longer than 12 weeks
Management of recurrent or chronic sinusitis
avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution
red flags of chronic sinusiis
unilateral symptoms
persistent symptoms despite compliance with 3 months of treatment
epistaxis
nasal polyps are associated with
Chronic rhiinitis
What feature of polyps would be concerning for malignancy and would require a two week wait referral
unilateral polyps or bleeding
samters triad =
asthma + aspirin sensitivity + nasal polyposis
features of nasal polyps
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
difficulty breathing thru nose
mx of nasal polyps
> All patients with nasal polyps should be referred to ent for a full examination
topical steroids shrink polyps
if medical mx fails -> surgery
predisposing factors for OSA
> Obesity
macroglossia: acromegaly, hypothyroid, amyloid
large tonsils
features of OSA
> Episodes of apnoea during sleep (reported by their partner)
daytime sleepiness
morning headache
scoring system for OSA
Epworth sleepiness scale
diagnostic test for OSA
sleep studies (polysomnography)
Mx of OSA
> weight loss
CPAP
intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated
when should DVLA be informed of OSA
theDVLA should be informedif OSAHS is causing excessive daytime sleepiness
tonsillitis is usuall caused by
viral infection
most common cause of bacterial tonsillitis
group A streptococcus(Streptococcus pyogenes - treated w phenoxymethylprnicillin
TP of tonsillitis
Sore throat
Fever (above 38°C)
Pain on swallowing
examination findings in tonsillitis
Write informed and enlarged tonsils with or without exudates. Anterior cervical lymphadenopathy can occur
when should ab be given for tonsillitis
> Centor score > 3 = bacterial tonsillitis
scored on:Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
feverPAIN scoring for tonsillitis
Fever over 38°C.
Purulence (pharyngeal/tonsillar exudate).
Attend rapidly (3 days or less)
Severely Inflamed tonsils
No cough or coryza
When should antibiotics be given for tonsillitis
antibioticsif theCentor scoreis≥ 3, or theFeverPAINscore is≥ 4.
Which antibiotics should be prescribed for tonsillitis
phenoxymethylpenicillinorclarithromycin(if the patient is penicillin-allergic) should be given.
indications for ab - nice
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
mx of viral tonsillitis
paracetamol or ibuprofen for pain relief
antibiotics are not routinely indicated
what is quinsy
peritonsillar abscess - comp of tonsillitis
symptoms of quinsy
severe throat pain, which lateralises to one side
deviation of the uvula to the unaffected side
trismus (difficulty opening the mouth)
reduced neck mobility
mx of quinsy
> urgent ENT review
needle aspiration or incision & drainage + intravenous antibiotics
hot potato voice =
Change invoice scene in Quinsy from pharyngeal swelling
most common cause of quinsy
strep pyogenes
number of tonsillitis episodes needing tonsilectomy
7 or more in 1 year
5 per year for 2 years
3 per year for 3 years
other indications for tonsillectomy
Recurrent tonsillar abscesses (2 episodes)
Enlarged tonsils causing difficulty breathing, swallowing or snoring
comps of tonsillitis
> sore throat
post tonsillectomy bleeding - can be life threatening from blood aspiration
mx of post tonsillectomy haemorrhages
All post-tonsillectomy haemorrhages should be assessed by ENT.
Management of primary post tonsillectomy hemorrhage
Occurs within six to eight hours following surgery is managed by immediate return to theater
Management of secondary post tonsillectomy hemorrhage
occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics.
pulsatile neck lumps
Carotid body tumors
which neck lump moves w swallowing
thyroid lumps
which neck lump moves w sticking tongue out
thyroglossal cysts)
which neck lump transilluminates with light
(e.g., cystic hygroma – usually in young children)
neck lump red referral criteria
An unexplained neck lump in someone aged 45 or above
A persistent unexplained neck lump at any age
tests for a neck lump
> FBC & blood film
HIV
thyroid function test
ANA- SLE
Imaging for neck lumps
US first line, CT/MRI next, fine needle aspiration, biopsy
4 causes of lymphadenopathy
> reactive LN - after viral URT infection
infected LN
Inflammatory conditions - lupus
malignancy
Which lymph nodes are most concerning for malignancy
enlarged supraclavicular
features of LN -> malignancy
Unexplained (e.g., not associated with an infection)
Persistently enlarged (particularly over 3cm in diameter)
Abnormal shape (normally oval shaped where the length is more than double the width)
Hard or “rubbery”
Non-tender
Tethered or fixed to the skin or underlying tissues
Associated symptoms, such as night sweats, weight loss, fatigue or fevers
infective mono
> Causes lymphadenopathy
infection w EBV
spread by saliva
triad of mono
sore throat
lymphadenopathy: may be present in the anterior and posterior triangles of the neck,
pyrexia
other features seen in mono
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:
Which type of hemolitic anemia is seen in mono
cold agglutins (IgM)
How is mono diagnosed
heterophil antibody test (Monospot test
A maculopapular rash following amoxicillin indicates
a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis
How is mono managed
> Supportive management, simple analgesia
What should patients with mono avoid for 4 weeks
avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture
Lymphedema seen in lymphoma
lymphadenopathy in neck, axilla (armpit) or inguinal (groin) region - non tender and rubbery
Key finding in a lymph node biopsy in patients with Hodgkin’s lymphoma
reid Steinberg cell
Features of a carotid body tumor
> most benign
In the upper anterior triangle of the neck (near the angle of the mandible)
Painless
Pulsatile
Associated with a bruit on auscultation
Mobile side-to-side but not up and down
How else can a carotid body tumor present
> Compression of cranial nerves
Horners syndrome
Finding on imaging in carotid body tumor
splaying(separating) of theinternalandexternal carotidarteries (lyre sign).
lipomas
> benign tumors of adequate tissue
Typically soft painless mobile and do not cause skin changes
Features suggestive of sarcomatous change - liposaecoma
Size >5cm
Increasing size
Pain
Deep anatomical location
The features of a thyroglossal cyst
Soft nontender mobile cyst in the midline of the neck . Move up and down with movement of the tongue
Management of thyroglossal cyst
Most are surgically removed to prevent infections
Neck mass that moves up and down with tongue movement indicates
Thyroglossal cyst
Where do brachial cysts originate from
Second brachial cleft
Management options for brachial cyst
Conservative or surgical excision where there are recurrent infection or if it is causing other problems
lymphatix malformations
Usually located posterior to the sternocleidomastoid
The painless, fluid filled, lesions usually present prior to the age of 2#
They are typically hypoechoic on USS
infantile hemangioma
May present in either triangle of the neck
Grow rapidly initially and then will often spontaneously regress
Plain x-rays will show a mass lesion, usually containing calcified phleboliths
Reactive lymphedemopathy occurs a following
This is the most common cause of neck swelling. History of local infection or generalized viral illness
Presentation of a lymphoma
> rubbery, painless lymphadenopathy
Pain when drinking alcohol
may be associated night sweats and splenomegaly
A thyroid swelling moves on
Moves upwards on swallowing
phaeyngeal pouch
> More common in older men
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough, hallitosis
Cystic hygroma Is typically found in
Children under two years of age typically found on the left side
When do brachial cysts tend to present
Usually early adulthood
features of head and neck cancer
neck lump
hoarseness
persistent sore throat
persistent mouth ulcer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:
persistent unexplained hoarseness or
an unexplained lump in the neck
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.
ref criteria thyroid cancer
Unexplained thyroid lump
Risk factors for head and neck cancer
Smoking
Chewing tobacco
alcohol
HPV - 16 #
EBV
Red flags for head and neck cancer
Lump in the mouth or on the lip
Unexplained ulceration in the mouth lasting more than 3 weeks
Erythroplakia or erythroleukoplakia
Persistent neck lump
Unexplained hoarseness of voice
Unexplained thyroid lump
Glossitis
Inflamed tongue that looks smooth
What are the causes of glossitis
Iron, B12, folate deficiency, coeliac
What are the top three causes of angiodema
Allergic reactions
ACE inhibitors
C1 esterase inhibitor deficiency (hereditary angioedema)
What increases risk of oral thrush
Diabetes, inhaled cortical steroids, antibiotics, smoking
Two key causes of strawberry tongue
Scarlet fever
Kawasaki disease
leukplakia =
premalignant condition which presents as white, hard spots on the mucous membranes of the mouth. It is more common in smokers
mx of leukoplakia
biopsy and reg follow up to exclude transformation to sq cell carcinoma
Erythroplakia & erythroleukoplakia
red lesions, high risk of SCC -> urgent 2WWW
Wickams striae are seen in
lichen planua
gingivitis =
swollen gums, bleeding after brushing, painful gums and bad breath (halitosis).
What can untreated gingivitis lead to
periodontitis
RF for gingivitis
plaque, smoking, malnutrition
What is glue ear
Ottitis media W effusion
Risk factors for Glue ear
male sex, bottle feeding, ;arental smoking
features of glue ear
> Hearing loss is the presenting feature
secondary problems such as speech and language delay, behavioural or balance problems may also be seen
tx of glue ear
> active observation for 3 months
grommet insertion
adenoidectomy
glue ear in adults - suspect
nasopharyngeal carcinoma espec if unilateral
NP carcinoma is
sq cell carcinoma, assoc w EBV
Features of NP carcinoma
> otalgia
Unilateral serous otitis media
Nasal obstruction, discharge and/ or epistaxis
CN palsies
cervical lymphadenopathy
imaging for NP carcinoma
Combined CT and MRI.
First line treatment for NP carcinoma
radiotherapy
Cholesterol crystals are found in
brachial cysts
brachial cyst vs cystic hyoma
brACHial cysts
A = anterior triangle
CH = cholesterol crystals
Cystic hyGLOWma = transilluminates
What indicates mastoditis rather than acute otitis media
post-auricular swelling. - Mastoiditis is a medical emergency due to the potential risk of meningitis
What is not consistent with the diagnosis of otosclerosis
Onset after the age of 50
how long can prochlorperazine be used for vestibular neuronitis
few days max
ludwigs angina
> Type of cellulitis that invades the floor of the mouth and the soft tissues of the neck
Mostly from dental infections
neck swelling, dysphagia, fever
Management of Ludwig’s angina
Immediately transferred to hospital as airway management is crucial
CENTOUR mneumonic
C- Cervical lymphadenopathy/ lympahdenitis
E- exudate of tonsils
N- no cough
T- temperature
children w glue ear w ? -> ENT ref
Children presenting with glue ear with a background of Down’s syndrome or cleft palate should be referred to ENT
elderly patient dizzy on extending neck ->
verterbrobasilar ischaemia
mx of tympanic membrane perforation
watch n wait 6 weeks
sign of glue ear
viscousbubblesbehind thetympanicmembrane.
which drugs cause a gingival hyperplasia
Gingival hyperplasia: phenytoin, ciclosporin, calcium channel blockers and AML
watch is the most common cause of sudden onset sensory neural hearing loss
The majority of sudden-onset sensorineural hearing loss is idiopathic in nature
brachial cyst vs cystic hyoma
Anterior location contains cholesterol crystals
unilateral glue ear/ middle ear effusion ->
Urgent referral to ENT
What would point to MN over labyrinithis or neuronitis
If it is episodic it is MN
RHS
> Herpes zosta reactivation in the facial nerve
sx of RHS
> auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus
Mx of RHS
oral aciclovir and corticosteroidsare usually given
When should a perf be reassessed
4 weeks
first line in post tonsillectomy hemorrhage
Refers right to ENT they can prescribe antibiotics
What is an auricular hematoma
Common in rugby players and wrestlers, Direct trauma which leads to a build of her blood
mx of auricular haematoma
Same day assessment by Ent
Use of procloperazine in vestibular neuronitis
Should be used in the acute phase only as it delays recovery by interfering with central compensatory mechanisms
What is the main side-effect of using topical decongestants for prolonged periods?
Intranasal decongestants (e.g. oxymetazoline) should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis)
mx of septal haematomas
urgent ENT ref
And Tosca be finding of glue ear
OME is characterised by a retracted tympanic membrane (as opposed to the bulging membrane seen in acute otitis media) with visible fluid build-up behind it. T
what is the management of a child with a first presentation of a Titus media with effusion
active observation for 3 months - no intervention is required
What infection can occur following cat scratch
Bartonella
What can precipitate Otto’s sclerosis
Pregnancy
what is the most important part of the tympanic membrane to visualize
In patients with chronic or recurrent ear discharge, ensure the attic is visualised to exclude cholesteatoma
Most common area of epistaxis
Little’s area- Anterior nasal septum
rhinitis medicamentosa
Rhinitis medicamentosa is a condition of rebound nasal congestion brought on by extended use of topical decongestants - cease use
Double sickening suggests
bac sinusitis
How should otitis external and diabetics be treated
Otitis externa in diabetics: treat with ciprofloxacin to coverPseudomonas
first line in OE
antibiotic and steroid EG neomyosin and dexamethasone ear spray
Mneumonic for hearing loss
> SU - SN localizes to the unaffected side
CA - conductive -> affected size
definitive tx for acute angle closure glaucoma
Laser peripheral iridotomy is the definitive treatment for acute angle-closure glaucoma
Consider ? if a patient with rheumatoid arthritis presents with a painful red eye
Consider scleritis if a patient with rheumatoid arthritis presents with a painful red eye
new onset dysphagia ->
red flag symptomthat requires urgent endoscopy, regardless of age or other symptoms.
Mx of SN hearing loss
> hearing aids/ ADL - mild to moderate
cochlear implant - severe to profound not benefitting from hearing aids
indications for cochlear implant
In children, audiological assessment and/or difficulty developing basic auditory skills.
In adults, patients should have completed a trial of appropriate hearing aids for at least 3 months
risks of cochlear implant
nfection, facial paralysis due to nerve injury intra-operatively, cerebrospinal fluid (CSF) leakage, and meningitis - should have up to date injections to strep and haemophilis
CI to the cochlear implant
Lesions of cranial nerve VIII or in the brain stem causing deafness
Chronic infective otitis media, mastoid cavity or tympanic membrane perforation
Cochlear aplasia
Mx of tinnitus
> investigate underlying cause
amplication device - if hearing loss
psych therapy & tinnitus support
Anterior versus posterior nosebleeds
> anterior: Visible source of bleeding usually occurs due to an insult to the capillaries
posterior: More profuse and originate from deeper structures
Pause of nosebleeds seen in Adolescent males
juvenile angiofibroma
benign tumour that is highly vascularised
seen in adolescent males
cocaine use -> nose bleeds
Nasal septum may look abraded or atrophied
mx of epistaxis - haemodynamically stable
> first aid - Sitting torso also forward with the mouth open or pinching the soft area of the nose of 20 minutes
If a first aid is successful then use topical antiseptic like Niceptin to reduce crusting and risk of vestibuliitis
naseptin safety info
When should admission be considered in the context of Nosebleed
> comorb - like severe HTN, CAD
Child under two
If bleeding does not stop after 10-15 minutes of continuous pressure on the nose consider
> Cautery - Should be used as the initial measure if the source of bleeding is visible and caught tree is tolerated (involves silver N)
Packing may be used if Cautrey is not tolerated or bleeding point cannot be visualized
Nosebleeds and hemodynamically unstable patients
control bleeding with first aid measures in the interim
patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.
Epistaxis that has failed all emergency management
sphenopalatine ligationin theatre
anterior packing used when
eyes saccading on HINTS ->
Indicates an abnormally functioning vestibular system eg vestibular labyrinthis or vestibular neurinitis
keeping eyes fixed on HINTS ->
this is normal and means that the patient either has no current symptoms or a central cause is causing the symp
Peripheral versus central vertigo
Peripheral problem, usually affecting the vestibular system
Central problem, usually involving the brainstem or the cerebellum -> sustained non positional vertigo
causes of central vertigo
> posterior circulation infarction
tumour
MS
vestibular migraine
post circ stroke
sudden onset and may be associated with other symptoms, such as ataxia, diplopia, cranial nerve defects or limb symptoms
vertigo & driving
patients must not drive and must inform the DVLA if they are liable to “sudden and unprovoked or unprecipitated episodes of disabling dizziness”.
symptoms of nasal septum haematoma
may be precipitated by relatively minor trauma
the sensation of nasal obstruction is the most common symptom
pain and rhinorrhoea are also seen
on examination, classically a bilateral, red swelling arising from the nasal septum
nasal septal haematoma vs deviated nasal septum
Nasal septal haematomas are typically boggy whereas septums will be firm
mx of nasal septal haematoma
surgical drainage
intravenous antibiotics
Who gets auricular hematomas
Rugby players and wrestlers
mx of auricular hematomas
auricular haematomas need same-day assessment by ENT - prevent development of cauliflower ear
types of allergic rhinitis
seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever
perennial: symptoms occur throughout the year
occupational: symptoms follow exposure to particular allergens within the work place
features of allergic rhinitis
> sneezing
bilateral nasal obstruction
clear nasal discharge
post-nasal drip
nasal pruritus
mx of Mild to moderate allergic rhinitis
avoid Allergen and oral or intranasal antihistamines
Management of moderate to severe allergic rhinitis or if initial drug treatment is ineffective
Intranasal steroids
Summary of management of allergic rhinitis
> Intranetal antihistamines
If this doesn’t work intranasal steroids
oral Steroids can be used temporarily
Allergic rhinitis - why can topical nasal congestions not be used for prolonged periods-
e.g. oxymetazoline). Tachyphylaxis & rebound hypertrophy of nasal mucosa
tachyplaxis =
Increased doses are needed to achieve the same effect
rhinitis medicamentosa
Complication of using nasal decongestants which involves rebound hypertrophy of the nasal mucosa
2 www criteria
> unresolved neck lumps > 3 weeks
hoarseness > 6 weeks
dysphagia > 3 weeks
ulcer > 3 weeks
unilateral nasal obstruction
tongue protrusion vs swallowing
> tongue protrusion: thyroglossal cyst
swallowing: thyroid goitre
