ENT Flashcards
Menieres anti emetic
prochlorperazine
What is the most common cause of hearing impairment post head injury
Perforated tympanic membrane
cervical lymphadenopathy suspicious of malignancy Ix
FNAC
Tympanometry showing a type B (flat) curve with normal canal volume has a very high positive predictive value for
otitis media with effusion (OME)
when to give delayed prescription for ear infection
1-2 days = delayed
adult-onset asthma, symptoms of nasal obstruction and bilateral nasal polyps classical features of
Eosinophilic granulomatosis with polyangitis
A 50-year-old woman presents to her GP with a painless swelling in her right parotid gland area for the past six months. She also reports experiencing dry mouth and eyes over the same period. She is afebrile, and denies any weight loss over this period. Schirmer’s test is abnormal.
Which of the following is the most likely diagnosis?
The patient’s presentation of painless parotid gland swelling along with symptoms of xerostomia (dry mouth), keratoconjunctivitis sicca (dry eyes) and decreased tear production is highly suggestive of Sjögren’s syndrome. Sjögren’s syndrome is associated with an increased risk of developing lymphoma, particularly mucosa-associated lymphoid tissue (MALT) lymphoma, also known as marginal cell lymphoma, in the salivary glands. The presence of a painless parotid gland swelling raises concern which should be investigated further with imaging studies and possibly biopsy.
The Type C tympanogram in the right ear is indicative of
negative middle ear pressure, which often occurs due to Eustachian tube dysfunction.
Pleomorphic adenomas are the most common tumours within the parotid gland, however rarely
invade the facial nerve and rarely cause facial nerve palsy
Name the malignant tumour of the parotid gland more likely to invade the surrounding structures such as the facial nerve, leading to facial nerve palsy
Adenoid cystic carcinoma
A 55 year old man has voice hoarseness, throat pain and right ear pain that has gradually progressed over one week. He has a 20 pack year smoking history and drinks 30 units of alcohol per week. He has no significant medical history and takes no regular medications. ENT examination is unremarkable.
What is the most likely diagnosis?
laryngeal SSC
A 54 year old woman presents with acute onset right sided vertigo lasting 15 hours. This is associated with dulling of her hearing on the right side. She states that it began suddenly with no obvious trigger while she was sitting on the sofa. She can hear a faint buzzing in her ear and feels nauseous. She states that she had a mild viral illness one week earlier. On examination all cranial nerves are intact. Otoscopy reveals a translucent tympanic membrane with normal ossicles and no effusion.
What is the most likely diagnosis?
acute (viral) labyrinthitis
Biggest head and neck cancer RF
Human papillomavirus type 16 (HPV16) seropositivity is associated with an increased risk of oral, pharyngeal and laryngeal cancer
A 72-year-old man presents to the emergency department with recent onset of sore throat, difficulty swallowing and pain on swallowing. From the bedside, you hear a loud, harsh, high-pitched respiratory sound on inspiration. His respiratory rate is 26 and his oxygen saturation is 95% on air. He is started on high-flow oxygen. His respiratory rate and his oxygen saturation remain unchanged. On brief examination, the oropharynx appears unremarkable. There is anterior neck tenderness, especially over the hyoid bone.
What is the best next step in the management of this patient?
Give nebulised adrenaline and IV dexamethasone
This is the correct answer. The most likely diagnosis is supraglottitis (inflammation of the soft tissues just above the vocal cords). Nebulised adrenaline and IV dexamethasone are effective in reducing mucosal oedema. You should call for senior ENT and anaesthetics input immediately as this is an airway emergency and will require a definitive airway
A 42-year-old man presents to ENT clinic with a neck lump. He is otherwise asymptomatic. He occasionally drinks alcohol and smokes. The lump is located 7 cm below the right ear lobe, just anterior to the anterior border of the sternocleidomastoid muscle. A biopsy is taken. Pathology results indicate squamous cell carcinoma (SCC) that is p16 positive.
What is the most likely primary site?
Oropharynx
This is the correct answer. p16 is a surrogate marker for human papilloma virus (HPV), and oropharyngeal squamous cell carcinoma (SCC) is very commonly driven by HPV. Oropharyngeal cancer commonly present as an isolated neck mass without any symptoms. Tonsils and tongue base are the primary sites most associated with a HPV+ve oropharyngeal SCC. They tend to be seen in younger (40-50s) patients with little smoking and/or drinking history
Not oral cavity as not HPV driven
A 20 year old man presents to his GP complaining of foul smelling discharge from the right ear.
It has been persistent for the past three months and has been getting progressively worse. He is particularly aware of the discharge upon waking, as it covers his pillow. He does not report any pain in his ear, but does report some problems hearing in the right ear.
On examination there are no signs of focal neurology.
What is the definitive management for the most likely diagnosis?
surgical excision for cholesteatoma
A 30 year old woman is on the ward 12 hours post-op after parathyroidectomy to remove a parathyroid adenoma. A drain is in situ from the wound. On the ward she suddenly develops respiratory distress. From the end of the bed, an obvious large neck swelling is apparent overlying the surgical site. There are no obvious abnormalities on inspection inside the mouth.
What is the most appropriate initial management?
remove surgical clips
haematoma mx
incision and primary closure if 7 days old, otherwise just aspirate
A 30 year old woman is involved in a road traffic accident. Primary survey shows no obvious abnormalities and her observations are normal. However, there is blood-stained serous discharge from the right ear. On otoscopy, blood is visualised behind the tympanic membrane. When the discharge is dropped onto filter paper, it demonstrates the “halo sign”.
Which additional finding would be most in keeping with the most likely diagnosis?
Bruising around the mastoid region
This patient has a basal skull fracture, specifically in the middle fossa through the petrous temporal bone. When cerebrospinal fluid leaks through the fracture out of the auditory canal, it can be dropped onto filter paper and a “halo sign” can be seen. Another feature of petrous temporal bone fracture is a collection of blood behind the tympanic membrane. Bruising around the mastoid region is otherwise called “battle sign” and is an additional feature of petrous temporal bone fracture that may take hours to develop
Noise-induced hearing loss, the patient has a strong risk factor (heavy metal band) and has sensorineural deafness and tinnitus worse when trying to fall asleep (i.e. worse when the environment is quiet). Established noise-induced hearing loss should be treated with
hearing aids in the first instance
watery anterior rhinorrhoea, purulent post-nasal drip, snoring, mouth-breathing and headaches. Diagnosis?
The diagnosis is likely nasal polyps as a complication of chronic sinusitis. Nasal polyps are associated with allergic rhinitis (hay fever), aspirin hypersensitivity, non-allergic rhinitis and cystic fibrosis.
Nasal polyps Dx and Mx
Diagnosis is confirmed by anterior rhinoscopy or nasal endoscopy. First-line management comprises topical steroid drops to shrink the polyps. The patient must be counselled to tilt their head upside down when administering the drops, not backwards
sensorineural hearing loss (SSNHL) is an
ENT emergency. Differentiate from tympanic membrane rupture
what is this
Tympanosclerosis- chalky white patches
what is this
cholesteatoma
indications for 2 week wait as suspicious of malignancy in paranasal sinus malignancy
This should be suspected in any adult that presents with chronic (>12 weeks) rhinosinusitis for the first time. Additional alarm symptoms include blood-stained nasal discharge and swelling overlying the sinus.
probably SSC
unilateral nasal obstruction, epistaxis, facial pain, and/or swelling. Persistent bleeding/crusting
red flags for
The most common presenting symptoms of sinonasal carcinoma
An anxious mother has brought her 18 month old son into your practice as he has been crying for the last 2 days with a fever of 38 degrees according to a temperature colour strip she has used at home. He seems playful in clinic but repeatedly tugs at his left ear. On examination with an otoscope you see erythema of the tympanic membrane, which is bulging, and behind it is an effusion.
What is the correct management for this patient?
Analgesia and observe for 48 hours and if symptoms worsen, consider antibiotics
This is the correct option. Antibiotics are only considered for children under two years if they have bilateral otitis media or systemtic infection or symptoms >3 days.
OE in DM treatment
Otitis externa in diabetics: treat with ciprofloxacin to cover Pseudomonas
gentamicin if no DM
Et dys details
symptoms usually go away within a few weeks, need to rest after insertion,
A 34-year-old lady presents with a long standing offensive discharge from the ear and on examination is noted to have a reduction in her hearing of 40 decibels compared to the opposite side.
cholesteatoma
Acute sensorineural hearing loss management
Acute sensorineural hearing loss is an emergency and requires urgent referral to ENT for audiology assessment and brain MRI
idiopathic/acoustic neuroma/may need steroids orally
Weber’s test localises to the left ear, which is typical in
left ear conductive hearing loss, as sound lateralises to the affected ear.
78-year-old male , partial thyroidectomy- muscle cramps and a ‘tingling sensation’ around his mouth. An ECG is performed on the ward.
what will the ECG show
Complications of thyroid surgery - damage to parathyroid glands can result in hypocalcaemia
prolongued QT
OE not responding to abx drops Mx
Otitis externa can cause significant canal oedema and stenosis, preventing topical treatment with antibiotic drops. In these cases microsuction and insertion of a pope wick is needed so referral to on-call ENT is indicated.
facial pain (classically described as frontal pressure pain which is worse on bending forward), nasal discharge (usually thick and purulent) and difficulty breathing
Diagnosis and Mx
analgesia and abundant fluids for uncomplicated acute sinusitis
conductive hearing loss, tinnitus and positive family history
Otosclerosis
The majority of sudden-onset sensorineural hearing loss is
idiopathic in nature
common cause of bacterial otitis media
Haemophilus influenzae is a common cause of bacterial otitis media
dental extraction now worsening pain and fever, trismus, displaced tongue, tender swelling. Diagnosis?
Unilateral glue ear in an adult needs
evaluation for a posterior nasal space tumour
What 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
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
Slow growing, painless, mobile lump in the parotid gland of older female → ?
Slow growing, painless, mobile lump in the parotid gland of older female → ? Pleomorphic adenoma
benign mixed tumour, needs surgery due to malignant transformation
Children presenting with glue ear with a background of Down’s syndrome or cleft palate should be
referred to ENT
Naseptin (chlorhexidine/neomycin) cream contains
peanut oil
cauterise only if
bleeding focus identified. If not then recommend first aid measures
Acute viral labrynthitis cardinal features
sudden onset horizontal nystagmus, hearing disturbances, nausea, vomiting and vertigo
A 3-year-old boy is brought to surgery. His mum reports that he has been complaining of a sore left ear for the past 2-3 weeks. This morning she noticed some ‘green gunge’ on his pillow. On examination his temperature is 37.8ºC. Otoscopy of the right ear is normal. On the left side the tympanic membrane cannot be visualised as the ear canal is full with a yellow-green discharge. What is the most appropriate action?
amoxicillin and review in 2 weeks
OME when to refer onwards
Urgent referral to ENT would generally only be required if there were signs of complications such as facial nerve palsy or intracranial spread of infection, neither of which are suggested by this scenario.
Admit to paediatrics would not be necessary unless the child was systemically unwell or there were complications such as mastoiditis or meningitis.
prebycusis presents with
bilateral high-frequency hearing loss
All post-tonsillectomy haemorrhages should be
assessed by ENT
In tonsillitis, uvular deviation may indicate development of a
peritonsillar abscess (quinsy)
Ramsay hunt management
high dose steroids and acyclovir and eye protection
common causes of vertigo
BPPV, Menieres, MS, gentamicin, acoustic neuroma
A 55-year-old woman with a background of hypertension and type 2 diabetes mellitus presents to the emergency department with recurrent episodes of vertigo exacerbated by moving her head. She describes the episodes as debilitating and that they make it difficult for her to walk. They only last up to 10 seconds before resolving but have been happening increasingly frequently over the last 2 days.
Her neurological examination during the initial assessment is normal.
What is the most appropriate diagnostic test to perform?
BPPV: Dix-Hallpike manoeuvre is diagnostic
A perforated eardrum will usually heal by itself within
A perforated eardrum will usually heal by itself within 6-8 weeks.
4+ centor score
phenoxymethlpenicillin and paracetamol
acute otitis media with perforation
Oral antibiotics should be given in acute otitis media with perforation - amoxicillin first line, erythromycin if pen allergic
acute labyrinthitis vs vestibular neuritis presentation
Vestibular neuronitis presents after a viral infection- vertigo, nausea, vomiting, and horizontal nystagmus. The key differentiating point here is the hearing loss and tinnitus would not be present in vestibular neuronitis as hearing is not affected.
Haemorrhage 5-10 days after tonsillectomy is commonly associated with
Haemorrhage 5-10 days after tonsillectomy is commonly associated with a wound infection and should therefore be treated with antibiotics
A 42-year-old man with a 3 month history of chronic cough presents with a persistent headache
sinusitis - post nasal drip causing cough
A 64-year-old woman with a one week history of pain above and lateral to her left eye. On examination she is tender over that area.
temporal arteritis
Intranasal decongestants (e.g. oxymetazoline) should not be used for prolonged periods as
Intranasal decongestants (e.g. oxymetazoline) should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis0
positive Dix-Hallpike manoeuvre?
Rotatory nystagmus is indicative of a positive Dix-Hallpike manoeuvre. Also onset of vertigo
bilateral parotid gland swelling and dry mouth with facial nerve palsy, improved by steroids
Sarcoid occurs bilaterally in 70% of cases and facial nerve involvement is recognised. Treatment is conservative in most cases although individuals with facial nerve palsy will usually receive steroids with good effect.
n a young adult with parotid swelling and pancreatitis/orchitis/reduced hearing/meningoencephalitis suspect.
mumps
vestibular neuronitis Mx
Prochlorperazine is recommended to alleviate vertigo, nausea and vomiting associated with vestibular neuronitis
Menderes vs acoustic neuroma how to differentiate
Symptoms with an acoustic neuroma tend to be more progressive rather than episodic.
epistaxis initial mx
Initial management for epistaxis is with adequate first aid - pinch the nasal ala (nostrils) firmly and lean forward for 20 minutes
Non-resolving otitis externa with worsening pain should be
Non-resolving otitis externa with worsening pain should be referred urgently to ENT
The HiNTs exam can be used to distinguish
vestibular neuronitis from posterior circulation stroke
Immunocompromised patients with poor dentition can develop
airway compromise from cellulitis at the floor of the mouth known as Ludwig’s angina.
contraindication to having a cochlear implant?
Chronic infective otitis media is a contraindication to having a cochlear implant
what may present as a painless lymphadenopathy because of its tendency for early spread
Nasopharyngeal carcinoma
can you have cochlear implant right away
Adults are generally required to have had a failed trial of acoustic hearing aids before having a cochlear implant
noise damage vs otosclerosis
noise damage causes sensorineural, otosclerosis causes conductive and often has FH and presents in young adults
Ototoxic medicines
Ototoxic medicines include gentamicin, quinine, furosemide, aspirin and some chemotherapy agents.
typical BPPV history
‘Double-sickening’ suggests
bacterial sinusitis
