ENT Flashcards
1
Q
what medications may be prescribed in BPPV
A
prochlorperazine
Betahistines
2
Q
what is labrynthitis
A
inflammatory disorder of the membranous labyrinth affecting both vestibular and cochlear end organs
3
Q
what is the most common form of labrynthitis
A
viral
4
Q
what are the key differences between labyrinthitis and vestibular neuritis
A
- vestibular neuritis only involves the vestibular nerve so there is no hearing impairment
- labrynthitis involved both vestibular nerve and labyrinth
5
Q
what is the average age of presentation of labyrinthitis
A
40-70
6
Q
how does labyrinthitis typically present
A
Acute onset of:
- vertigo
N&V
- hearing loss
- tinnitus
7
Q
What are signs of labyrinthitis (4)
A
- Spontaneous unidirectional horizontal nystagmus towards unaffected side
- Sensorineural hearing loss
- Abnormal head impulse test: impaired vestibule-ocular reflex
- Gait disturbance: pt may fall towards affected side
8
Q
how might labyrinthitis be managed
A
- usually self limiting episodes
- prochlorperazine or antihistamines to reduce sensation of dizziness
9
Q
how does vestibular neuritis usually arise
A
following viral infection
10
Q
what are the features of vestibular neuritis
A
- recurrent vertigo attacks lasting hours or days
- nausea and vomiting may be present
- horizontal nystagmus is usually present
- no hearing loss or tinnitus
11
Q
Give 2 ddx of vestibular neuritis
A
- Viral labyrinthitis
- Posterior circulation stroke
12
Q
how is vestibular neuritis managed
A
- Severe: buccal or IM prochlorperazine
- Less severe: short oral course or prochlorperazine or antihistamines
13
Q
What is the preferred treatment for patients experiencing chronic symptoms of vestibular neuritis
A
Vestibular rehabilitation exercises
14
Q
what are indications for tonsillectomy
A
- sore throats are due to tonsillitis
- person has 7 episodes/year for 1 yr, 5 per year for 2 yrs or 3 per year for 3 years and for whom there is no other explanation for recurrent symptoms
- episodes of sore throat are disabling and prevent normal functioning
15
Q
what are the main complications of tonsillectomy
A
- primary <24hrs: haemorrhage (mostly due to inadequate haemostasis), pain
- secondary 24hrs - 10 days: haemorrhage (due to infection), pain
16
Q
what is Ménière’s disease
A
long term inner ear disorder causing recurrent attacks of vertigo, hearing loss and tinnitus
17
Q
what is the typical triad of symptoms of Ménière’s disease
A
hearing loss
Vertigo
Tinnitus
18
Q
what is the pathophysiology of Ménière’s disease
A
excessive buildup of endolymph in the labyrinth of the inner ear
- this causes a higher pressure than normal and disrupts sensory signals
19
Q
what is the increased pressure of the endolymph called
A
endolymphatic hydrops
20
Q
describe the features of vertigo in Ménière’s disease
A
- episodic
- last for 20 mins before settling
- can come in clusters over several weeks followed by prolonged periods without any symptoms
- not triggered by movement or posture
21
Q
what are features of hearing loss in Ménière’s disease
A
- typically fluctuates at first associated with vertigo attacks and then gradually becomes more permanent
- sensorineural
- generally unilateral and affects low frequencies first
22
Q
what is the management of Ménière’s disease
A
- acute, short term attacks: prochlorperazine and antihistamines
- prophylaxis: betahistines
23
Q
what is the pathophysiology of acute otitis media
A
middle ear infection caused by bacteria entering via the eustachian tube
24
Q
what often precedes otitis media
A
viral URTI
25
what is the most common bacterial cause of otitis media
S.pneumoniae
## Footnote
also commonly causes other ENT infections e.g. rhino-sinusitis/tonsilitis
26
what are other causative organisms of otitis media
* Haemophilus influenzae
* Moraxella catarrhalis
* Staphylococcus aureus
26
what are the clinical features of AOM
- otalgia (children may tug or rub ear)
- fever in 50%
- hearing loss
- recent viral URTI symptoms e.g. coryza
- ear discahrge if tympanic membrane perforation
27
what are possible otoscopic findings of AOM
* **bulging tympanic membrane → loss of light reflex**
* **opacification** or **erythema** of the tympanic membrane
* perforation with purulent otorrhoea
* decreased mobility if using a pneumatic otoscope
28
what advice should be given to patients about management of AOM
- generally **self-limiting** and does not require abx
- **analgesia** to relieve otalgia
- seek medical helps if symptoms worsen or do not improve after 3 days
29
what are indications for abx in AOM
* 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 year**s with **bilateral** otitis media
* Otitis media with **perforation** and/or **discharge** in the canal
30
what is the 1st line choice of abx for AOM
**5-7 day course of amoxicillin**
- erythromycin/clarithromycin if penicillin allergy
31
what are common sequelae of AOM
- tympanic membrane perforation --> otorrhoea
- may develop into chronic suppurative otitis media (CSOM)
- hearing loss
- labyrinthitis
32
what are complications of AOM
* mastoiditis
* meningitis
* brain abscess
* facial nerve paralysis
33
describe the otoscopic appearance of a normal tympanic membrane
pearly-grey
translucent
slightly shint
look for cone of light
34
what is otitis externa
inflammation of skin in the **external ear canal**
- can be diffuse or localised
- can **spread to pinna**
- can be acute < 3 weeks or chronic > 3 weeks
35
what is otitis externa also known as
swimmers ear
- exposure to water leads to inflammation in ear canal
36
what has a protective effect against otitis externa
earwax - thus removal can inc chances of infection
37
give 4 common causes of otitis externa
* infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
* seborrhoeic dermatitis
* contact dermatitis (allergic and irritant)
* recent swimming is a common trigger of otitis externa
38
what are the 2 most common bacterial causes of otitis externa
* Pseudomonas aeruginosa
* Staphylococcus aureus
39
what is the typical presentation of otitis externa
* Ear pain
* Discharge
* Itchiness
* Conductive hearing loss
40
what might examination of otitis externa show
* Erythema and swelling in the ear canal
* Tenderness of the ear canal
* Pus or discharge in the ear canal
* Lymphadenopathy in the neck or around the ear
41
what might otoscopy of otitis externa show
red, swollen, or eczematous canal
42
how is mild otitis externa treated
**acetic acid 2%** (EarCalm OTC)
- antibacterial and antifungal effect
- can also be used prophylactically before and after swimming pt who are prone to this infection
43
how is moderate otitis externa treated
**topical abx + steroid**
* Neomycin, dexamethasone and acetic acid (e.g., **Otomize spray**)
* Neomycin and betamethasone
* Gentamicin and hydrocortisone
* Ciprofloxacin and dexamethasone
44
what must be excluded before commencing aminoglycosides for otitis externa
**perforated tympanic membrane**
- ototoxic and can rarely causing hearing loss
- if ear canal is blocked by discharge, swelling or wax, may need referral to ENT to microsuction debris
45
if there is not response to topical abx for otitis externa, what is the next step
ENT referral
46
how can otitis externa be treated if the ear canal is very swollen and treatment with ear drops or sprays seems difficult
**ear wick**
- contain topical treatment
- inserted into the ear canal and left there for a period of time (e.g., 48 hours)
- As the swelling and inflammation settle, the ear wick can be removed, and treatment can continue with drops or sprays
47
how can fungal ear infections be treated
**clotrimazole** ear drops
48
what is malignant otitis externa
severe and potentially life-threatening form of otitis externa where infection spreads to the bones surrounding the ear canal and skull
49
what does malignant otitis externa progress to
**osteomyelitis** of the temporal bone
50
what are risk factors for malignant otitis externa
* Diabetes
* Immunosuppressant medications (e.g., chemotherapy)
* HIV
51
what is a key finding that indicates malignant otitis externa
**granulation tissue** at the junction between bone and cartilage in the ear canal
52
what is the emergency management of malignant otitis externa
* **Admission** to hospital under the ENT team
* **IV antibiotics**
* **Imaging** (e.g., CT or MRI head) to assess the extent of the infection
53
what are potential complications of malignant otitis externa
* **Facial nerve damage** and palsy
* Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves)
* **Meningitis**
* **Intracranial thrombosis**
* Death
54
what is cerumen
ear wax
## Footnote
combination of secretions, dead skin cells and any substances that enter the ear
55
what are the symptoms of impacted ear wax
* pain
* conductive hearing loss
* tinnitus
* vertigo
* feeling of fullness
56
what are the 3 main options for 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
57
what are contraindications to ear irrigation
* perforated tympanic membrane
* infection
58
what are the 2 main types of hearing loss and give a brief description
- **conductive**: problem with external ear i.e. sound travelling from the environment to the inner ear
- **sensorineural**: sensory system or vestibulocochlear nerve in inner ear
59
what are patients with hearing loss more likely to develop
dementia
60
how is weber's test performed
- strike tuning fork and place on the centre of pt forehead
- ask pt if they can hear sound and which ear it is loudest in
61
describe how weber's test can be interpreted
- **normal**: sounds same in both ears
- **conductive**: sound louder in affected ear as it 'turns up volume' and becomes more sensitive
- **sensorineural**: sound louder in normal ear as it is better at sensing sound
62
how is rinne's test conducted
- strike tuning fork
- place flat end on mastoid process to test bone conduction
- ask pt when they can no longer hear the humming noise
- then remove the tuning fork and hover it 1cm from same ear
- ask the pt if they can hear the sound now to test air conduction
- repeat process on the other side
63
how is rinne's test interpreted
- **normal**: pt can hear the sound again when bone conduction ceases (air conduction > bone conduction) = rinne's positive
- **abnormal**: bone conduction > air conduction which suggests **conductive** cause of hearing loss
64
what are causes of sensorineural hearing loss
- SSHL
- presbycusis
- noise exposure
- meniere's disease
- labyrinthitis
- acoustic neuroma
- neuro e.g. stroke, MS
- infection e.g. meningitis
- meds
65
what are examples of medications that can cause sensorineural hearing loss
* Loop diuretics (e.g., furosemide)
* Aminoglycoside antibiotics (e.g., gentamicin)
* Chemotherapy drugs (e.g., cisplatin)
66
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
67
what is SSNHL
sudden sensorineural hearing loss over <72 hours unexplained by other causes
- otological emergency and requires immediate referral to ENT team
- mostly unilateral
- may be permanent or resolve over days to weeks
68
what can cause SSNHL
most are idiopathic ~ 90%
- infection
- meniere's disease
- ototoxic meds
- MS
69
what is cogan's syndrome
rare autoimmune condition causing inflammation of the eyes and inner ear
70
what investigation are required to establish diagnosis of SSNHL
- **audiometry**: loss of at least 30 decibels in 3 consecutive frequencies on an audiogram
- **MRI/CT head** if stroke or acoustic neuroma are being considered
71
what is the referral criteria for SSNHL
immediate referral to ENT for assessment **within 24 hours** for patients presenting with sudden sensorineural hearing loss presenting **within 30 days of onset**
72
how might idiopathic SSNHL be managed
steroids
- oral
- intra-tympanic
73
what is bell's palsy
acute, unilateral, idiopathic, facial nerve paralysis
- ?involvement of HSV
- peak incidence 20-40 and more common in pregnant women
74
what are the features of bell's palsy
- **lower motor neuron facial nerve palsy** → forehead affected
- in contrast, an upper motor neuron lesion 'spares' the upper face
- patients may also notice: post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis
75
what should all patients receive within 72hours of onset of bell's palsy
- oral prednisolone: 50mg for 10 days
76
why is eye care important in bell's palsy
to prevent exposure keratopathy
## Footnote
lubricating eye drops or tape closed at night
77
what is the follow-up management of bell's palsy
- if paralysis shows no signs of improvement after 3 weeks, refer urgently to ENT
- referral to plastics for those with long-standing weakness
78
what is ramsay-hunt sydrome caused by and how does it present
**VZV**
- **unilateral** LMN facial nerve palsy
- **painful and tender vesicular rash** in ear canal, pinna and around ear on affected side
- rash can extend to **anterior 2/3 of tongue and hard palate**
79
what is the treatment of ramsay-hunt syndrome
within 72 hours:
- prednisolone
- aciclovir
## Footnote
+ lubricating eye drops
80
what is sinusitis
inflammation of the mucous membranes of the **paranasal sinuses (usually sterile)**
- acute: <12 weeks
- chronic: >12 weeks
81
what are the most common infectious agents see in acute sinusitis
- s.pnuemoniae
- h.influenzae
- rhinoviruses
82
what are predisposing factors to sinusitis
- nasal obstruction e.g. septal deviation or nasal polyps
- recent local infection e.g. rhinitis or dental extraction
- swimming
- smoking
83
what are features of acute sinusitis
- facial pain typically frontal pressure which is worse on bending forwards
- nasal discharge: thick and purulent
- nasal obstruction
- loss of smell
84
what are the paransal sinuses
- hollow spaces within the bones of the face which produce mucous
- drain into nasal cavities via holes called ostia
- when ostia become blocked, drainage of sinuses is prevented = sinusitis
85
patients with what condition are more likely to suffer from sinusitis
asthma
86
what are examination findings of acute sinusitis
- tenderness to palpation
- inflammation and oedema of nasal mucosa
- discharge
- fever
87
what finding is chronic sinusitis associated with
nasal polyps
88
what are suitable investigations for patients with persistent sinusitis symptoms depsite treatment
- nasal endoscopy
- CT scan
89
what are the abx guidelines for acute sinusitis
NICE recommends no abx for patients with symptoms up to 10 days
- most cases are viral so self-limiting within 2-3 weeks
90
what are the abx guidelines for acute sinusitis that has not improved after 10 days
- **high dose steroid nasal spray** for 14 days e.g. mometasone 200mcg BD
- delayed abx prescription used if worsening or not improving within 7 days
- **phenoxymethylpenicillin** 1st line
91
what are treatment options for chronic sinusitis
- saline nasal irrigation
- steroid nasal sprays
- functional endoscopic sinus surgery (FESS)
92
explain how to use a steroid nasal spray
- tilt head slightly forward
- using left hand to spray into right nostril which directs the spray away from septum
- not sniffing hard during spray
- gently inhaling through nose after spray
- ask pt: do you taste the spray at the back of your throat after you spray? - if yes, means has gone past nasal mucosa and will not be as effective
93
what is presbycusis
type of sensorineural hearing loss that affects elderly individuals
94
what is the pattern of hearing loss in presbycusis
tends to affect high pitched sounds first > lower-pitched sounds
- occurs gradually and symmetrically
95
what are possible causes of presbycusis
- arteriosclerosis: may diminish perfusion/oxygenation of cochlea = damage to inner ear structures
- diabetes
- accumulated exposure to noise
- drug exposure e.g. salicylates
- stress
96
what are risk factors for presbycusis
- age
- male
- FHx
- HTN
- smoking
97
what is the investigation of choice for presbycusis
audiometry
98
what are other relevant investigations in presbycusis
- otoscopy: rule out otosclerosis, choleasteatoma, conductive hearing loss
- tympanometry
- blood tests
99
what does audiometry of presbycusis show
bilateral sensorineural pattern hearing loss
100
what is the typical presentation of presbycusis
- speech difficult to understand
- increased volume on radio/tv
- difficulty using telephone
- hyperacusis
- tinnitus
101
label the outer, middle and inner ear on the diagram
102
label tympanic membrane
103
what is a pure tone threshold
measures an individual's hearing sensitivity to calibrated pure tones to determine the softest sound they can hear at least 50% of the time at various frequencies
- results then potted on an audiogram
104
what is masking
presenting noise to the non-test ear during a hearing test to prevent the sound from interfering with the test ear's response
105
what is mastoiditis
typically develops when infection spread from middle ear to the mastoid air cells in the petrous part of the temporal bone
- commonly after AOM
106
what is the most common bacterial cause of mastoiditis
S. pneumoniae
107
what are the clinical features of mastoiditis
- otalgia behind the ear
- hx of recurrent otitis media
- fever
- swelling, erythema and tenderness over mastoid process
- external ear may protrude forwards
108
what scan may be ordered in mastoiditis to monitor complications
CT temporal bone
109
what is the management of mastoiditis
broad spec IV abx e.g. tazocin
110
what are possible complications of mastoiditis
- meningitis
- facial nerve palsy
- hearing loss
- abscess formation
111
what is cholesteatoma
abnormal collection of squamous epithelial cells in the middle ear
- non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear
112
what is the typical presentation of cholesteatoma
- foul discharge from the ear
- unilateral conductive hearing loss
113
what does otoscopy of cholesteatoma show
- abnormal build up of whitish debris or crust in upper tympanic membrane
- sometimes not possible to visualise eardrum if discharge or wax blocking canal
## Footnote
'attic crust'
114
what scan can be used to confirm diagnosis of cholesteatoma
CT head
- MRI to assess invasion and damage to local soft tissues
115
what is the management of cholesteatoma
referral to ENT for surgical removal
116
label the paranasal sinuses
117
label the adenoid, tonsil, uvula, tongue
118
label little's area
119
label the conchae and meati
120
label the anatomy of the nose & mouth
121
what are the main physiological functions of the mouth & throat (5)
1. **digestion**
2. **respiration**: air passage to lungs, filtering and humidification, epiglottis protects food/liquid entering trachea
3. **communication**: speech production, resonance
4. **immune**: tonsils/adenoids have lymphoid tissue that traps pathogens, saliva has antimicrobial properties
5. **sensory**: taste, touch & temperature
122
what are the 3 sensory inputs of the balance system
- vestibular
- visual
- somatosensory
123
describe how the balance system works
- sensory inputs are **processed by the brain** (brainstem, cerebellum and cerebrum)
- **efferent pathways** act on the **extra-ocular muscles** to adjust eye position and limb/trunk muscles to maintain body position
124
define syncope and pre-syncope
transient loss of consciousness due to global cerebral hypoperfusion with rapid onset, short duration and spontaneous complete recovery
- pre-syncope: no LOC
125
define vertigo
false sensation that the body or environment is moving
126
define nystagmus
rapid, uncontrollable eye movements in one or both eyes
- can be congenital or acquired
127
describe the 2 phases of jerk nystagmus
1. **slow phase**: inital phase where eyes slowly drift from the intended gaze or fixation point
2. **fast phase**: corrective phase where the eyes rapidly move back towards the intended gaze or fixation point
## Footnote
direction of jerk nystagmus is typically defined by the direction of the fast phase.
128
what are 3 causes of cervical lymphadenopathy
- infections e.g. common cold, TB, abscess, cellulitis
- inflamm/autoimmune: RA, SLE
- cancer: lymphoma, leukemia, mets
129
what are red flag signs of cervical lymphadenopathy
- large >2cm or rapidly growing
- hard, fixed, painless
- >4 weeks without improvement
- other: weight loss, night sweats, fever
130
what are symptoms of a deviated septum
- nasal obstruction
- breathing difficulty
- snoring/sleep
- frequent sinus infections
- nosebleeds
- postnasal drip & headaches
130
what are causes of a deviated septum
- congenital
- injury or trauma
- aging
131
what are treatment options for deviated septum
- **non surgical**: steroid sprays, saline nasal rinse, mudifiers
- **surgical**: septoplasty outpt, swelling and congestion will improve within weeks
132
what are indications for septoplasty
- chronic nasal congestion
- frequent sinus infection
- severe sleep apnoea
- affecting QOL
133
what is appropriate imaging for a nasal fracture
- no role for plain radiographs in clinical diagnosis or management of isolated nasal injury
- CT where co-existing fractures suspected
134
what needs to be ruled out in a suspected nasal fracture
septal haematoma
135
what is the follow up for nasal fracture
once septal haematoma has been ruled out by the initial assessment, patients with suspected nasal fractures can be seen semi-electively (usually within 7-10 days post-injury) in the ENT clinic to assess for:
- **Nasal deformity**– objective assessment for any bony or septal deviation including nasal step deformity, as well as the patient’s perception of the appearance of their nose
- **Nasal obstruction** – ask how the patient is symptomatically; air flow can be assessed by holding a metal tongue depressor below the nose and observing misting during nasal breathing
138
central vs peripheral vertigo
HINTS exam
- **HIT**: positive HIT in peripheral vertigo with corrective saccade, normal in central
- **Nystagmus**: unidirectional/horizontal in peripheral vertigo, vertical/rotary/direction changing in central
- **Test of skew**: negative in peripheral
139
Vestibular migraine
140
Vestibulopathy
141
what is the appropriate management of unilateral glue ear in an adult
2WW referral to ENT to rule out posterior nasal space tumour
