ENT Flashcards
Blood supply to the nasal cavity (what makes up Little’s area)
Main: sphenopalatine artery (from carotid)
Others: superior labial, anterior ethmoid
Local causes of epistaxis
Trauma - Little’s area, base of skull #
Vascular nipple - mucosal arteriovenous malformation
Neoplasm - NPC, SCC, JNA
Carotid blowout - NPC post RT
Systemic causes of epistaxis
coagulopathies
hereditary haemorrhagic telangiectasia
idiopathic thrombocytopenic purpura
Characteristic of bleeding in NPC
Usually blood stained oral secretions
Blood form tumour gravitate towards pharynx -> appear in saliva
What is carotid blowout
NPC treated with radiotherapy - erosion of protective bone around carotids
Dry air from nasal cavity weakens carotid artery wall -> massive haemorrhage
Adolescent male, epistaxis, persistent blocked nose. Diagnosis?
Juvenile nasopharyngeal angiofibroma
- very vascular and invasive tumour, does not metastasise
Epistaxis tx (1st, 2nd, 3rd line)
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
Complication of silver nitrate cautery
Lack of judicious cautery -> devascularise nasal septal cartilage -> avascular necrosis -> saddle nose deformity
Complications of nasal trauma
- Septal haematoma
- CSF rhinorrhea
- Nasal obstruction
- cosmetic deformities
What is septal haematoma
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
CSF rhinorrhea caused by ____. ___ sign seen in CSF rhinorrhea. describe the sign.
base of skull #
halo sign
clear fluid outer ring (CSF) and red inner ring (blood)
How to manage nasal # acutely
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
Residual deformity after nasal fracture M&R. Management?
Septorhinoplasty (nose job)
Done 6-9 months after injury
Bones involved in tripod fracture
zygomaticomaxillary complex fracture
- zygomatic arch
- zygomaticofrontal suture
- inferior orbital rim
Features of anterior BOS #
- racoon eyes (haematoma around eyes)
- CSF rhinorrhea
- CN: I, V, VI, VII, VIII
Features of posterior BOS #
- battle sign (haematoma behind ear)
- haemotympanum
- CSF otorrhea
- CN: VI, VIII, VIII
What structures make up internal nasal valve
- 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
Anatomic causes of nasal obstruction
- deviated nasal septum
- adenoid hypertrophy
- inferior turbinate hypertrophy
Inflammatory causes of nasal obstruction
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
What is rhinitis medicamentosa
overuse of topical decongestants causing rebound nasal congestion (vasodilation) once stopped
Allergic rhinitis is a ___ mediated inflammation (Type __ hypersensitivity)
IgE, type I
Definitive diagnosis of AR
1) Skin prick
- allergens pricked into skin, check for wheal >= 3mm
2) serum specific IgE ab
management of AR
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
Disease progression in atopic march
eczema -> food allergy -> allergic rhinitis -> asthma
Features of AR
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
Cx of perichondritis
Subperichondrial abscess -> devascularise cartilage -> avascular necrosis -> cauliflower ear, cosmetic deformity
Organisms that cause otitis externa
Bacterial: P.aeruginosa, S.aureus
Fungal: candida (white), aspergillus (black)
Viral: ramsay-hunt (VZV)
What causes necrotising otitis externa? Symptoms?
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
Common organisms in acute otitis media
H.influenzae
Strep pneumoniae
Moraxella catarrhalis
Anaerobes (mouth organisms)
___ is usually not perforated in acute OM. Once perforated, becomes ___.
Tympanic membrane
Chronic OM
What is chronic suppurative otitis media
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
What is otitis media with effusion?
What does unilateral OME in adults indicate?
presence of fluid in middle ear without sx of infection
Unilateral OME in adults = NPC UNTIL PROVEN OTHERWISE
occurs in children following acute OM
What is treatment for persistent OM
myringotomy and tympanostomy tube insertion
Pathophysiology of cholesteatoma
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
Mastoiditis presentation
fever, otorrhea
Tenderness over mastoid
Retroauricular swelling (obliteration of post-auricular sulcus)
What is otosclerosis?
Feature of otosclerosis on audiogram
New bone formation causing fusion of stapes footplate to oval window
Carhart’s notch (dip in bone conduction at 2000Hz
NPC highest incidence in ___. Risk factors?
Southern chinese ethnic group (males)
EBV infection
nitrosamines in salt-preserved food
Fam hx in 1st deg relative
NPC usually diagnosed at stage ___
Stage III/IV
How does NPC cause OME
obstruction of eustachian tube -> effusion in eustachian tube -> impeded sound movement -> deafness/sensation of ear fullness
most common sites of mets for NPC
bone > lung > liver
Investigations for NPC
Nasoendoscopy + biopsy for histo confirmation
Staging: MRI, PET-CT
Bloods:
- EBV DNA (for surveillance)
Audiogram
- for baseline, radiation/chemo can cause sensorineural hearing loss
Treatment of NPC
Firstline: radiation +/- chemo
Recurrence
- surgery (nasopharyngectomy)
- repeat radiation (avoid unless not amenable to surgery)
Cx of NPC treatment
radiotherapy/chemo
- mucositis
- xerostomia (dry mouth)
- sensorineural hearing loss
Borders of triangles of neck
Anterior: midline, lower border of mandible, anterior border of SCM
Posterior: posterior border of SCM, clavicle, anterior border of trapezius
Most common midline neck masses
Lymph nodes
thyroid nodule
thyroglossal cyst
plunging ranula
Most common anterior triangle neck masses
lymph nodes
thyroid nodule
branchial cyst
carotid body tumour
pharyngeal pouch
submandibular mass
Most common posterior neck masses
Lymph nodes
cystic hygroma
cervical rib
neural masses (neuroma/schwanomma)
Causes of cervical lymphadenopathy
1) Infectious
- viral, bacterial, parasite
2) Inflammatory
- SLE
- Kikuchi’s lymphadenitis
- Kimura
3) Neoplastic
- lymphoma
-mets
Cervical LNs divided into __ levels
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
Ultrasound features of metastatic LNs
1) size
2) shape
- oval: benign
- roundish, hilum destroyed: malignant
3) echogenecity
- malignant: hypoechoic, microcalcifications
4) vascularity
- malignant: peripheral vascularity
- benign: central vascularity
Investigations for cervical lymphadenopathy
1) Fine needle aspiration biopsy (ultrasound-guided)
- less risk of tumour seeding
2) core biopsy
3) open biopsy
- high risk of cancer seeding
Features of thyroglossal cyst
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
features of plunging ranula
midline neck mass
pseudocyst/mucocele a/w sublingual and submandibular cysts
mx: complete resection with sublingual gland
5 branches of facial nerve after passing through parotid gland
temporal
zygomatic
buccal
marginal mandibular
cervical
Causes of facial nerve palsy
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
How to differentiate UMN vs LMN facial palsy?
UMN: able to close eyes, wrinkle forehead (contralateral nerve supply)
LMN: loss of nasolabial fold, no wrinkling of forehead, increased scleral show
Complications of facial nerve palsy
Drooling, problems eating
Inability to close eyes - dry eyes, tearing, exposure keratopathy
Problems with speech
How to grade degree of facial nerve palsy
House-Brackmann grading
Grade 4 = disfiguring at rest, cannot close eyes
How to manage facial nerve palsy
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
What is synkinesis
Abnormal movement of the facial muscle due to aberrant nerve regeneration after palsy
eg. closing eyes when chewing
tx of Bell’s palsy
- oral steroid for better recovery of complete motor function
- no ix for one time, recurrent need TRO tumour
Time course of bell’s palsy
Appears over 48-72hrs, tends to recover fully over weeks. some have residual muscle weakness
dBs heard for each degree of hearing loss
normal:
mild loss:
moderate:
moderate-severe:
severe
profound
0-25dB
26-40dB
41-55dB
56-70dB
71-90dB
> 90dB
describe mild hearing loss
trouble with soft sounds when there is background noise, requires increased listening effort
describe moderate hearing loss
trouble with conversational speech especially when other sounds are present
Types of hearing loss and how they present on audiogram
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
Causes of conductive hearing loss
- obstruction in ear canal: ear wax, foreign body, cholesteatoma
- middle ear: ossicle issues (malformation, dislocation, fixation), effusion, masses
Causes of sensorineural hearing loss
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
Rinne’s test. How is it performed, results and interpretation
Tuning fork strike, put beside ear or on mastoid process
air > bone (normal/sensorineural)
bone > air (conductive)
Weber’s test. How is it performed, results and interpretation
Tuning fork strike, place in middle of forehead
normal = heard in both ears
localises in good ear = sensorineural
localises in bad ear = conductive
Normal hearing can hear ___ dB
-10 to 25 dB
Audiogram of noise-induced hearing loss
Bilateral sensorineural hearing loss
Both air and bone conduction diminished
Dipper shape on audiogram - dip at 4000hz and recover at 6000Hz
Audiogram of presbycusis
Both air and bone conduction diminished
Gradual downward sloping pattern with increasing frequency
Tympanogram types and what it means
type A: normal
type B: reduced TM mobility
C: negative pressure in middle ear, retracted TM (suggests eustachian tube dysfunction)
Difference between infant and adult larynx
Infant: short aryepiglottic fold, omega shaped epiglottis
Adult: long AE fold, epiglottis unfolded
What causes laryngomalacia
Short A/E folds, redundant arytenoid tissue, omega epiglottis
Arytenoid tissue and epiglottis prolapses into airway with inspiration
Clinical course of laryngomalacia
Most common cause of stridor in children
Appears in the first 2 weeks of life, worsens by 6 months
Improves by 18-24 months
features of laryngomalacia
intermittent, low pitched stridor
exacerbated by exertion, crying, agitation, feeding, supine position
severe obstruction -> substernal retractions, pectus excavatum
complications of laryngomalacia
feeding issues -> failure to thrive
respiratory distress -> apnea, cyanosis
cardiac failure
management of laryngomalacia
reassure parents about self-resolving time course
if complications -> supraglottoplasty surgery
Epiglottitis commonly caused by ___. __ sign seen on XR in epiglottitis.
haemophilus influenzae B
thumb sign
most common cause of congenital stridor in newborns is due to ___
bilateral vocal cord palsy
Infection by __ causes croup. Most significant symptoms are ___, ___, ___
parainfluenza
large barking cough, stridor (inspiratory/biphasic), fever
Trauma in intubation can lead to ___
subglottic stenosis
pressure from ETT -> mucosal ischemia, oedema, erosion -> aberrant wound healing and scar formation -> stenosis
subglottis most susceptible due to circumferential cricoid ring
Thyroid nodule investigations
thyroid function test
ultrasound
CT - if suspecting nodal extension
Thyroid scintigraphy
FNAC
Suspicious ultrasound thyroid features
microcalcifications
hypoechoic
irregular margins
taller than wide
lymph node involvement
Management of thyroid lumps
Classify into Bethesda I-VI from FNAC results
Surgery
- thyroidectomy
Radiation
- radioactive iodine (Iodine131)
Post thyroidectomy complications
1) vocal cord palsy - damaged to RLN
2) hypocalcaemia - damage to parathyroid
3) haematoma - airway distress
Post-op management for thyroid cancer
1) give thyroxine to suppress TSH - prevent recurrence
2) use thyroglobulin (PTC/FTC), calcitonin (medullary) as recurrence marker
Tonsillitis can be caused by
bacterial: group A beta haemolytic strep
Viral: infectious mononucleosis (EBV)
Indication for tonsillectomy
Paradise criteria for recurrent tonsillitis
> 7x/year, >5x/year for 2 years, >3x/year for 3 years
Cx of tonsillitis
quinsy (peritonsillar abscess)
acute rheumatic fever
glomerulonephritis
EBV vs GAS tonsillitis
EBV has CONFLUENT tonsillar exudates
MULTIPLE enlarged tender cervical LN
longer sore throat than tonsillitis
treatment of EBV vs GAS tonsillitis
GAS: penicillin, augmentin if recurrent
EBV: AVOID amoxicillin -> can cause scarring rash. supportive tx and steroids to relieve inflammation
features of quinsy
unilateral sore throat, not better despite abx
trismus - lockjaw from spasm of pterygoid muscles
hot potato voice - muffled from oropharynx obstruction
how to check for retropharyngeal abscess
lateral neck xray
normal for adults (rmb 6226):
- 6mm from C2
- 2cm from C6
Most common sites for swallowed foreign body to lodge
vallecula
tonsils
tongue base
pyriform sinus
upper esophageal sphincter
What is laryngopharyngeal reflux
laryngeal manifestation of GERD
sticky phlegm, globus sensation, sore throat, chronic cough
What is Ludwig’s angina
Deep neck space infection - cellulitis of submental, sublingual and submandibular spaces
Usually secondary to dental infection
Clinical features of Ludwig’s angina
What investigation
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)
What is Lemierre’s syndrome
infection of deep neck space spreading into IJV, causing IJV thrombophlebitis
What is sialadenitis
Swelling in ____ due to ___, caused by ___
Triggered by ___
Painful swelling in submandibular triangle due to stasis of salivary flow, caused by blocked ducts (stones, strictures, bacterial, viral)
Pain is triggered by meals
Pain central hard mass in the neck is ___ until proven otherwise
anaplastic thyroid CA
- rapidly enlarging thyroid swelling
- dypnea, dysphagia, haemoptysis
Classification for causes of OSA
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
What is STOP-BANG score for? What are the components
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)
Symptoms of OSA
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
Diseases associated with OSA
metabolic syndrome
hypertension
heart disease, AMI, stroke, AF
What do you look out for in polysomnography in OSA?
Apnoea-hypopnoea index (AHI)
Adults: AHI > 5 abnormal (no symptoms then >15)
Children: AHI >1 abnormal
Management of OSA
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
Indications for tracheostomy
1) Airway obstruction
2) Prolonged ventilation requirements - COPD, neurological/neuromuscular disease
3) Tracheobronchial toilet - pt cannot handle secretions, need regular suction
How often need to change tracheostomy tube
Single lumen: every 1-2 weeks
double lumen: every 1-3 months
Innervation of laryngeal muscles
(what nerve, what muscles, what function)
recurrent laryngeal nerve - innervates all intrinsic muscles EXCEPT cricothyroid (for talking)
superior laryngeal nerve - innervates sensory supraglottis, motor cricothyroid (for screaming)
Vocal cord papillomas are associated with HPV __ and ___
6 and 11
laryngeal CA is most commonly ___ (histology)
squamous cell carcinoma
