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Eye ENT Patho > ENT > Flashcards

ENT Flashcards

1
Q

Blood supply to the nasal cavity (what makes up Little’s area)

A

Main: sphenopalatine artery (from carotid)
Others: superior labial, anterior ethmoid

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2
Q

Local causes of epistaxis

A

Trauma - Little’s area, base of skull #

Vascular nipple - mucosal arteriovenous malformation

Neoplasm - NPC, SCC, JNA

Carotid blowout - NPC post RT

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3
Q

Systemic causes of epistaxis

A

coagulopathies

hereditary haemorrhagic telangiectasia

idiopathic thrombocytopenic purpura

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4
Q

Characteristic of bleeding in NPC

A

Usually blood stained oral secretions

Blood form tumour gravitate towards pharynx -> appear in saliva

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5
Q

What is carotid blowout

A

NPC treated with radiotherapy - erosion of protective bone around carotids

Dry air from nasal cavity weakens carotid artery wall -> massive haemorrhage

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6
Q

Adolescent male, epistaxis, persistent blocked nose. Diagnosis?

A

Juvenile nasopharyngeal angiofibroma

  • very vascular and invasive tumour, does not metastasise
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7
Q

Epistaxis tx (1st, 2nd, 3rd line)

A

1st:
- epistaxis first aid, silver nitrate cautery (at GP)

2nd line (ENT)
- electrocautery
- anterior packing (merocel, bismuth iodine paraffin paste)
- posterior packing

3rd line (ENT):
- ligation of ethmoidal arteries if ICA bleed
- embolisation if ECA bleed

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8
Q

Complication of silver nitrate cautery

A

Lack of judicious cautery -> devascularise nasal septal cartilage -> avascular necrosis -> saddle nose deformity

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9
Q

Complications of nasal trauma

A
  • Septal haematoma
  • CSF rhinorrhea
  • Nasal obstruction
  • cosmetic deformities
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10
Q

What is septal haematoma

A

Blood collects under nasal septum due to rupture of capillaries in nasal septum -> separation of perichondrium from cartilaginous portion

  • cx: infection (abscess), devascularisation of cartilage (saddle nose deformity)

EMERGENCY that requires I&D

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11
Q

CSF rhinorrhea caused by ____. ___ sign seen in CSF rhinorrhea. describe the sign.

A

base of skull #

halo sign

clear fluid outer ring (CSF) and red inner ring (blood)

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12
Q

How to manage nasal # acutely

A

Ix:
- nasal endoscopy
- CT TRO BOF #
- nasal XR for medicolegal

Reassess in 3-5 days after swelling goes down

M&R within 14 days under GA

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13
Q

Residual deformity after nasal fracture M&R. Management?

A

Septorhinoplasty (nose job)
Done 6-9 months after injury

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14
Q

Bones involved in tripod fracture

A

zygomaticomaxillary complex fracture

  • zygomatic arch
  • zygomaticofrontal suture
  • inferior orbital rim
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15
Q

Features of anterior BOS #

A
  • racoon eyes (haematoma around eyes)
  • CSF rhinorrhea
  • CN: I, V, VI, VII, VIII
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16
Q

Features of posterior BOS #

A
  • battle sign (haematoma behind ear)
  • haemotympanum
  • CSF otorrhea
  • CN: VI, VIII, VIII
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17
Q

What structures make up internal nasal valve

A
  • nasal septum
  • inferior turbinate
  • junction between lower and upper lateral cartilage

area of largest resistance to nasal air flow, if narrowed, can cause perception of nasal obstruction

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18
Q

Anatomic causes of nasal obstruction

A
  • deviated nasal septum
  • adenoid hypertrophy
  • inferior turbinate hypertrophy
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19
Q

Inflammatory causes of nasal obstruction

A

a) Acute rhinosinusitis
- infection
- AR
- rhinitis medicamentosa

b) chronic rhinosinusitis
- chronic RNS with/without polyp
- systemic: Wegener’s granulomatosis (blood vessel inflammation)

c) others
- foreign body
- tumours

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20
Q

What is rhinitis medicamentosa

A

overuse of topical decongestants causing rebound nasal congestion (vasodilation) once stopped

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21
Q

Allergic rhinitis is a ___ mediated inflammation (Type __ hypersensitivity)

A

IgE, type I

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22
Q

Definitive diagnosis of AR

A

1) Skin prick
- allergens pricked into skin, check for wheal >= 3mm

2) serum specific IgE ab

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23
Q

management of AR

A

1) allergen avoidance - wash linens in hot water 60deg to kill HDM
- anti dustmite pillow cases

2) Pharmacotherapy
- oral antihistamine, intranasal steroids
- combined topical nasal antihistamine-steroids

3) immunotherapy
- increase exposure of allergens in pt until sx relieved
- only tx that arrests allergic march
- 3-5 years of subcutaneous/sublingual tx

4) surgical
- radiofrequency ablation of inferior turbinates
- inferior turbinate reduction

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24
Q

Disease progression in atopic march

A

eczema -> food allergy -> allergic rhinitis -> asthma

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25
Q

Features of AR

A

rhinorrhea, nasal obstruction, sneezing, itchy eye/nose

  • allergic shiners
  • allergic salute
  • Dennie’s lines: wrinkles along lower eyelids
  • pale and oedematous nasal mucosa, inferior turbinates
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26
Q

Cx of perichondritis

A

Subperichondrial abscess -> devascularise cartilage -> avascular necrosis -> cauliflower ear, cosmetic deformity

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27
Q

Organisms that cause otitis externa

A

Bacterial: P.aeruginosa, S.aureus

Fungal: candida (white), aspergillus (black)

Viral: ramsay-hunt (VZV)

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28
Q

What causes necrotising otitis externa? Symptoms?

A

rapid spread of infection by p.aeruginosa, causes osteomyelitis of bony external ear -> skull base

presents with excessive otalgia out of proportion, interferes with sleep and function

can affect cranial nerves as it spreads along skull base

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29
Q

Common organisms in acute otitis media

A

H.influenzae
Strep pneumoniae
Moraxella catarrhalis
Anaerobes (mouth organisms)

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30
Q

___ is usually not perforated in acute OM. Once perforated, becomes ___.

A

Tympanic membrane

Chronic OM

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31
Q

What is chronic suppurative otitis media

A

repeated bouts of AOM -> non-healing perforation

dry CSOM: perforated but not infected, no purulent discharge

wet CSOM: perforation with infection by organisms from external ear (p.aeruginosa, s.aureus), recurrent ear discharge

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32
Q

What is otitis media with effusion?

What does unilateral OME in adults indicate?

A

presence of fluid in middle ear without sx of infection

Unilateral OME in adults = NPC UNTIL PROVEN OTHERWISE

occurs in children following acute OM

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33
Q

What is treatment for persistent OM

A

myringotomy and tympanostomy tube insertion

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34
Q

Pathophysiology of cholesteatoma

A

Eustachian tube dysfunction -> Inward retraction of pars flaccida -> retraction pocket behind TM

Traps epithelium, debris, cerumen

Infection -> erosion and destruction of surrounding bony structures

Conductive hearing loss

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35
Q

Mastoiditis presentation

A

fever, otorrhea

Tenderness over mastoid

Retroauricular swelling (obliteration of post-auricular sulcus)

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36
Q

What is otosclerosis?

Feature of otosclerosis on audiogram

A

New bone formation causing fusion of stapes footplate to oval window

Carhart’s notch (dip in bone conduction at 2000Hz

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37
Q

NPC highest incidence in ___. Risk factors?

A

Southern chinese ethnic group (males)

EBV infection
nitrosamines in salt-preserved food
Fam hx in 1st deg relative

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38
Q

NPC usually diagnosed at stage ___

A

Stage III/IV

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39
Q

How does NPC cause OME

A

obstruction of eustachian tube -> effusion in eustachian tube -> impeded sound movement -> deafness/sensation of ear fullness

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40
Q

most common sites of mets for NPC

A

bone > lung > liver

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41
Q

Investigations for NPC

A

Nasoendoscopy + biopsy for histo confirmation

Staging: MRI, PET-CT

Bloods:
- EBV DNA (for surveillance)

Audiogram
- for baseline, radiation/chemo can cause sensorineural hearing loss

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42
Q

Treatment of NPC

A

Firstline: radiation +/- chemo

Recurrence
- surgery (nasopharyngectomy)

  • repeat radiation (avoid unless not amenable to surgery)
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43
Q

Cx of NPC treatment

A

radiotherapy/chemo
- mucositis
- xerostomia (dry mouth)
- sensorineural hearing loss

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44
Q

Borders of triangles of neck

A

Anterior: midline, lower border of mandible, anterior border of SCM

Posterior: posterior border of SCM, clavicle, anterior border of trapezius

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45
Q

Most common midline neck masses

A

Lymph nodes
thyroid nodule
thyroglossal cyst
plunging ranula

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46
Q

Most common anterior triangle neck masses

A

lymph nodes
thyroid nodule
branchial cyst
carotid body tumour
pharyngeal pouch
submandibular mass

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47
Q

Most common posterior neck masses

A

Lymph nodes
cystic hygroma
cervical rib
neural masses (neuroma/schwanomma)

48
Q

Causes of cervical lymphadenopathy

A

1) Infectious
- viral, bacterial, parasite

2) Inflammatory
- SLE
- Kikuchi’s lymphadenitis
- Kimura

3) Neoplastic
- lymphoma
-mets

49
Q

Cervical LNs divided into __ levels

A

7

  • I: submental, submandibular
    • Ia and Ib divided by digastric muscle
  • II: upper jugular
    • IIa and IIb divided by accessory nerve
  • III: mid jugular
  • IV: lower jugular
  • V: posterior triangle
  • VI: pretracheal
  • Supraclavicular (lowest nodes in level IV and V)
    • Left supraclavicular node: Virchow’s node
50
Q

Ultrasound features of metastatic LNs

A

1) size
2) shape
- oval: benign
- roundish, hilum destroyed: malignant

3) echogenecity
- malignant: hypoechoic, microcalcifications

4) vascularity
- malignant: peripheral vascularity
- benign: central vascularity

51
Q

Investigations for cervical lymphadenopathy

A

1) Fine needle aspiration biopsy (ultrasound-guided)
- less risk of tumour seeding

2) core biopsy

3) open biopsy
- high risk of cancer seeding

52
Q

Features of thyroglossal cyst

A

midline neck mass, moves with swallowing and tongue protrusion

cystic expansion of remnant thyroglossal duct that failed to obliterate after embryonic descent of thyroid from foramen cecum

mx: sistrunk procedure

53
Q

features of plunging ranula

A

midline neck mass

pseudocyst/mucocele a/w sublingual and submandibular cysts

mx: complete resection with sublingual gland

54
Q

5 branches of facial nerve after passing through parotid gland

A

temporal
zygomatic
buccal
marginal mandibular
cervical

55
Q

Causes of facial nerve palsy

A

1) Idiopathic (bell’s palsy)

2) trauma
- temporal bone fracture
- facial trauma

3) infectious
- ramsay hunt (VZV)
- otitis media
- malignant otitis externa
- mumps, syphilis, HIV

4) neoplastic

56
Q

How to differentiate UMN vs LMN facial palsy?

A

UMN: able to close eyes, wrinkle forehead (contralateral nerve supply)

LMN: loss of nasolabial fold, no wrinkling of forehead, increased scleral show

57
Q

Complications of facial nerve palsy

A

Drooling, problems eating

Inability to close eyes - dry eyes, tearing, exposure keratopathy

Problems with speech

58
Q

How to grade degree of facial nerve palsy

A

House-Brackmann grading

Grade 4 = disfiguring at rest, cannot close eyes

59
Q

How to manage facial nerve palsy

A

1) eye protection
- eye drops
- tape eyes at night

2) Facial nerve rehabilitation
- flaccid paralysis: face massage, stretching, assistive movement, avoid overactivity of normal side

  • active movement without synkinesis: train fine control of muscles
  • active movement with synkinesis: teach brain how to control synkinesis
60
Q

What is synkinesis

A

Abnormal movement of the facial muscle due to aberrant nerve regeneration after palsy

eg. closing eyes when chewing

61
Q

tx of Bell’s palsy

A
  • oral steroid for better recovery of complete motor function
  • no ix for one time, recurrent need TRO tumour
62
Q

Time course of bell’s palsy

A

Appears over 48-72hrs, tends to recover fully over weeks. some have residual muscle weakness

63
Q

dBs heard for each degree of hearing loss

normal:
mild loss:
moderate:
moderate-severe:
severe
profound

A

0-25dB

26-40dB

41-55dB

56-70dB

71-90dB

> 90dB

64
Q

describe mild hearing loss

A

trouble with soft sounds when there is background noise, requires increased listening effort

65
Q

describe moderate hearing loss

A

trouble with conversational speech especially when other sounds are present

66
Q

Types of hearing loss and how they present on audiogram

A

1) Conductive hearing loss
- air conduction diminished, bone conduction normal (air-bone gap)

2) Sensorineural hearing loss
- air conduction and bone conduction both diminished

3) mixed
- air and bone both diminished + air bone gap

67
Q

Causes of conductive hearing loss

A
  • obstruction in ear canal: ear wax, foreign body, cholesteatoma
  • middle ear: ossicle issues (malformation, dislocation, fixation), effusion, masses
68
Q

Causes of sensorineural hearing loss

A

1) Cochlear hearing loss
- congenital, presbycusis, noise-induced, iatrogenic, Meniere’s disease

2) Auditory nerve
- auditory neuropathy, tumours, nerve atresia

3) Cortical
- central auditory processing disorder
- cortical deafness

69
Q

Rinne’s test. How is it performed, results and interpretation

A

Tuning fork strike, put beside ear or on mastoid process

air > bone (normal/sensorineural)
bone > air (conductive)

70
Q

Weber’s test. How is it performed, results and interpretation

A

Tuning fork strike, place in middle of forehead

normal = heard in both ears
localises in good ear = sensorineural
localises in bad ear = conductive

71
Q

Normal hearing can hear ___ dB

A

-10 to 25 dB

72
Q

Audiogram of noise-induced hearing loss

A

Bilateral sensorineural hearing loss

Both air and bone conduction diminished

Dipper shape on audiogram - dip at 4000hz and recover at 6000Hz

73
Q

Audiogram of presbycusis

A

Both air and bone conduction diminished

Gradual downward sloping pattern with increasing frequency

74
Q

Tympanogram types and what it means

A

type A: normal
type B: reduced TM mobility
C: negative pressure in middle ear, retracted TM (suggests eustachian tube dysfunction)

75
Q

Difference between infant and adult larynx

A

Infant: short aryepiglottic fold, omega shaped epiglottis

Adult: long AE fold, epiglottis unfolded

76
Q

What causes laryngomalacia

A

Short A/E folds, redundant arytenoid tissue, omega epiglottis

Arytenoid tissue and epiglottis prolapses into airway with inspiration

77
Q

Clinical course of laryngomalacia

A

Most common cause of stridor in children

Appears in the first 2 weeks of life, worsens by 6 months

Improves by 18-24 months

78
Q

features of laryngomalacia

A

intermittent, low pitched stridor

exacerbated by exertion, crying, agitation, feeding, supine position

severe obstruction -> substernal retractions, pectus excavatum

79
Q

complications of laryngomalacia

A

feeding issues -> failure to thrive

respiratory distress -> apnea, cyanosis

cardiac failure

80
Q

management of laryngomalacia

A

reassure parents about self-resolving time course

if complications -> supraglottoplasty surgery

81
Q

Epiglottitis commonly caused by ___. __ sign seen on XR in epiglottitis.

A

haemophilus influenzae B

thumb sign

82
Q

most common cause of congenital stridor in newborns is due to ___

A

bilateral vocal cord palsy

83
Q

Infection by __ causes croup. Most significant symptoms are ___, ___, ___

A

parainfluenza

large barking cough, stridor (inspiratory/biphasic), fever

84
Q

Trauma in intubation can lead to ___

A

subglottic stenosis

pressure from ETT -> mucosal ischemia, oedema, erosion -> aberrant wound healing and scar formation -> stenosis

subglottis most susceptible due to circumferential cricoid ring

85
Q

Thyroid nodule investigations

A

thyroid function test

ultrasound

CT - if suspecting nodal extension

Thyroid scintigraphy

FNAC

86
Q

Suspicious ultrasound thyroid features

A

microcalcifications
hypoechoic
irregular margins
taller than wide
lymph node involvement

87
Q

Management of thyroid lumps

A

Classify into Bethesda I-VI from FNAC results

Surgery
- thyroidectomy

Radiation
- radioactive iodine (Iodine131)

88
Q

Post thyroidectomy complications

A

1) vocal cord palsy - damaged to RLN

2) hypocalcaemia - damage to parathyroid

3) haematoma - airway distress

89
Q

Post-op management for thyroid cancer

A

1) give thyroxine to suppress TSH - prevent recurrence

2) use thyroglobulin (PTC/FTC), calcitonin (medullary) as recurrence marker

90
Q

Tonsillitis can be caused by

A

bacterial: group A beta haemolytic strep

Viral: infectious mononucleosis (EBV)

91
Q

Indication for tonsillectomy

A

Paradise criteria for recurrent tonsillitis

> 7x/year, >5x/year for 2 years, >3x/year for 3 years

92
Q

Cx of tonsillitis

A

quinsy (peritonsillar abscess)

acute rheumatic fever

glomerulonephritis

93
Q

EBV vs GAS tonsillitis

A

EBV has CONFLUENT tonsillar exudates

MULTIPLE enlarged tender cervical LN

longer sore throat than tonsillitis

94
Q

treatment of EBV vs GAS tonsillitis

A

GAS: penicillin, augmentin if recurrent

EBV: AVOID amoxicillin -> can cause scarring rash. supportive tx and steroids to relieve inflammation

95
Q

features of quinsy

A

unilateral sore throat, not better despite abx

trismus - lockjaw from spasm of pterygoid muscles

hot potato voice - muffled from oropharynx obstruction

96
Q

how to check for retropharyngeal abscess

A

lateral neck xray

normal for adults (rmb 6226):
- 6mm from C2
- 2cm from C6

97
Q

Most common sites for swallowed foreign body to lodge

A

vallecula
tonsils
tongue base
pyriform sinus
upper esophageal sphincter

98
Q

What is laryngopharyngeal reflux

A

laryngeal manifestation of GERD

sticky phlegm, globus sensation, sore throat, chronic cough

99
Q

What is Ludwig’s angina

A

Deep neck space infection - cellulitis of submental, sublingual and submandibular spaces

Usually secondary to dental infection

100
Q

Clinical features of Ludwig’s angina

What investigation

A

Submental pain and swelling, lower toothache, dyspnea, dysarthria, dysphagia, fever

Can progress to airway obstruction and death - emergency!!

CT neck will show abscess (ring-enhancing lesion)

101
Q

What is Lemierre’s syndrome

A

infection of deep neck space spreading into IJV, causing IJV thrombophlebitis

102
Q

What is sialadenitis

Swelling in ____ due to ___, caused by ___
Triggered by ___

A

Painful swelling in submandibular triangle due to stasis of salivary flow, caused by blocked ducts (stones, strictures, bacterial, viral)

Pain is triggered by meals

103
Q

Pain central hard mass in the neck is ___ until proven otherwise

A

anaplastic thyroid CA

  • rapidly enlarging thyroid swelling
  • dypnea, dysphagia, haemoptysis
104
Q

Classification for causes of OSA

A

Anatomic: small mandible + large tongue, enlarged adenoids/tonsils, obesity, increased tissue laxity

Arousal threshold low: slight collapse in epiglottis -> pt wakes up

Loop gain

Muscle responsiveness

105
Q

What is STOP-BANG score for? What are the components

A

For risk stratification of OSA

S - snoring
T - tiredness (daytime)
O - observed apnoea
P - high BP
B - BMI >35
A - age >50
N - neck circumference >40
G - gender (male)

106
Q

Symptoms of OSA

A

1) nighttime
- snoring
- waking up choking
- witnessed apnea
- nocturia

2) daytime
- sleepiness
- irritability
- poor concentration, memory
- morning headaches (hypoxia)

3) children
- hyperactivity to compensate
- mouth breathing
- awkward sleep positions
- poor school performance

107
Q

Diseases associated with OSA

A

metabolic syndrome
hypertension
heart disease, AMI, stroke, AF

108
Q

What do you look out for in polysomnography in OSA?

A

Apnoea-hypopnoea index (AHI)

Adults: AHI > 5 abnormal (no symptoms then >15)

Children: AHI >1 abnormal

109
Q

Management of OSA

A

1st line:
- continuous positive airway pressure machine
- lifestyle measures - weight loss, quit smoking, avoid alcohol
- optimise nasal breathing - allergy control, chin strap for habitual mouth breathers

2nd line:
- hypoglossal nerve stimulation, causes tongue protrusion on inspiration to prevent obstruction

  • positional therapy
  • oral appliances - mandibular advancement device, tongue retaining device
  • surgery to correct anatomical abnormalities
110
Q

Indications for tracheostomy

A

1) Airway obstruction

2) Prolonged ventilation requirements - COPD, neurological/neuromuscular disease

3) Tracheobronchial toilet - pt cannot handle secretions, need regular suction

111
Q

How often need to change tracheostomy tube

A

Single lumen: every 1-2 weeks
double lumen: every 1-3 months

112
Q

Innervation of laryngeal muscles

(what nerve, what muscles, what function)

A

recurrent laryngeal nerve - innervates all intrinsic muscles EXCEPT cricothyroid (for talking)

superior laryngeal nerve - innervates sensory supraglottis, motor cricothyroid (for screaming)

113
Q

Vocal cord papillomas are associated with HPV __ and ___

A

6 and 11

114
Q

laryngeal CA is most commonly ___ (histology)

A

squamous cell carcinoma

115
Q
A

Eye ENT Patho (2 decks)

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