ENT Flashcards
What is an Acoustic neuroma ?
A benign tumour of the Schwann cells surrounding the vestibulocohlear nerve that innervates the inner ear
What is Benign paroxysmal positional vertigo ?
One of the MCC of vertigo
Caused by calcium carbonate crystals (otoconia) being displaced into the semicircular canals (MCC in the posterior semicircular canal) confusing the normal flow of endolymph though the canals confusing the vestibular system.
What is Epiglottitis ?
A rare and potentially life-threatening infection caused by Haemophilus influenzae type B
What is Epistaxis ?
- Nose bleeds that can be anterior or posterior
- Anterior (MCC) usually due to insult to the Kiesselbach’s plexus
- Posterior bleeds tend to be more profuse and originate from deeper structures and are more common in older patients (with high risk of aspiration and airway compromise)
What is Infectious mononucleosis (Glandular Fever) ?
Infection caused by Epstein Barr Virus commonly transmitted by saliva
What is Meunière’s disease ?
- A long term condition associated with excessive build up of endolymph in the labyrinth of the inner ear, causing higher pressure
- Causes recurrent attacks of vertigo and hearing loss, tinnitus and a feeling of fullness in the ear.
What is Obstructive sleep apnoea ?
Apnoea = during sleep the pt will stop breathing periodically for up to a few minutes
Caused by collapse of the pharyngeal airway
What is Otitis externa ?
- Inflammation of the skin in the external ear canal
- Sometimes referred to as swimmer’s ear
What is Otitis media ?
- Infection of the middle ear MMC by streptococcus pneumoniae
- Bacteria enters through the throat or Eustachian tube
- Typically preceded by viral URT infection
What is Rhinosinusitis ?
An inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer
What is Tonsillitis ?
Inflammation of the tonsils
Cause and management is determined by a fever pain score
What are the components of a Fever Pain Score
Fever in the last 24 hours
Absence of cough or coryza
Symptom onset less than 3 days
Purulent tonsils
Severe tonsil inflammation
Potential causes of vertigo
- Viral labyrinthitis
- Vestibular neuronitis
- Benign paroxysmal positional vertigo
- Meniere’s disease
- Vertebrobasilar ischaemia
- Acoustic neuroma
What is the typical presentation of Acoustic neuroma/ vestibular schwannoma ?
Vertigo, hearing loss, tinnitus and absent corneal reflex
What is another name for an acoustic neuroma ?
Vestibular schwannoma
Determining which CNs have been impacted by an acoustic neuroma ?
CN5 - trigeminal - absent corneal reflex
CN7 -facial - facial palsy
CN8 - vestibulocochlear - vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
What type of hearing loss occurs with an acoustic neuroma ?
Sensorineural
What is the typical presentation of Benign paroxysmal positional vertigo ?
Vertigo and nausea triggered by changes in head position
Each episode typically lasts 10–20 seconds
What is the typical presentation of Epiglottitis
Fever
General malaise
Stridor
Muffled voice
Scared and quite child
Drooling and quite child
Tripod positions
What is the typical presentation of Epistaxis ?
Nose bleeds
Infectious mononucleosis (Glandular Fever) Classic Triad
Sore throat, pyrexia and lymphadenopathy
What is the typical presentation of Glandular Fever - other features
- Malaise anorexia, headache
- Palatal petechiae
- Splenomegaly - confers risk of splenic rupture
- Hepatitis - transient rise in ALT
- Lymphocytosis
- Haemolytic anaemia secondary to cold agglutins (IgM)
- Macullopapular pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin while infected
What is the typical presentation of Meunière’s disease classic triad
Hearing loss
Vertigo
Tinnitus
Meunière’s disease episodic nature
- Episodes typically last 20 minutes to several hours before settling
- These episodes can come in clusters over several weeks followed by prolonged periods (often months) without symptoms
- No clear triggers
Meunière’s disease tinitic features
Occurs with episodes of vertigo before eventually becoming more permanent
Usually unilateral
Meunière’s disease other features
Sensation of fullness in the ear
Unexplained falls (drop attacks) without LOC
Imbalance which can persist after episodes of vertigo resolve
Meunière’s disease Vertigo features
Episodes typically last for 20 minutes to several hours before settling
Come in clusters over several weeks followed by prolonged periods without episodes
Not triggered by movement or posture
Meunière’s disease hearing loss features
Typically fluctuates at first associated with vertigo attacks then gradually becomes more permanent
Sensorineural hearing loss, generally unilateral and affects low frequencies first
What is the typical presentation of Obstructive sleep apnoea
Excessive snoring and apnoea leading to daytime somnolence, compensated respiratory acidosis and HTN
May be morning headache and sleepiness
What is the typical presentation of Otitis externa
Ear pain, discharge, itchiness and conductive hearing loss
Erythema and swelling in the ear canal
Tenderness of the ear canal
Pus or discharge in the ear canal
Lymphadenopathy
Otitis externa on ear examination
May be obstructed by wax or discharge
May be red if the otitis externa extends to the tympanic membrane
If it is ruptured the discharge in the ear canal might be from otitis media rather than otitis externa
What is the typical presentation of Otitis externa on ear examination ?
- May be obstructed by wax or discharge
- May be red if the otitis externa extends to the tympanic membrane
- If it is ruptured the discharge in the ear canal might be from otitis media rather than otitis externa
What is the typical presentation of Otitis media ?
Ear pain
Reduced hearing, general malaise
Symptoms of upper airway infection such as cough, coryzal symptoms and sore throat
Balance issues and discharge if perforation and/or severe
Otitis media on otoscope
Bulging red and inflamed looking membrane
Discharge may be seen in ear canal and a hole in the tympanic membrane
What is the typical presentation of Rhinosinusitis
Facial pain - typically frontal pressure pain which is worse on bending forward
Nasal discharge
Nasal obstruction
Post-nasal drip
What is the typical presentation of Tonsillitis
Sore throat
Fever (>38)
Pain on swallowing
What is the typical presentation of Tonsillitis - signs
Red, inflamed and enlarged tonsils with or without exudates
May be anterior cervical lymphadenopathy
Fever PAIN score
Fever during previous 24 hours
Purulence (pus on tonsils)
Attended within 3 days of onset of symptoms
Inflamed tonsils
No cough
Score of 4-5 gives a 62-65% chance of bacterial infection
What is the typical presentation of Peripheral Vertigo
Sudden onset
Short duration (seconds to minutes)
Tends to occur with hearing loss or tinnitus (except BPPV)
Co-ordination intact
More severe nausea
What is the typical presentation of Central Vertigo
Gradual onset (except stroke)
Persistent duration
Usually not associated with hearing loss or tinnitus
Co-ordination is impaired
Mild nausea
Cerebellar Exam
DANISH
Dysdiadochokinesia
Ataxic gait
Nystagmus
Intention tremor
Speech
Heel Shin test
What is the treatment of Acoustic neuroma
Refer to ENT
Surgery to remove tumour
Radiotherapy to reduce growth
Conservative if no symptoms or treatment inappropriate
What is the treatment of Benign paroxysmal positional vertigo
Good prognosis and usually spontaneously resolves after a few weeks to months
Epley manoeuvre is successful in 80% to relieve symptoms
Brandt-Daroff exercise can also be effective
Epley Manoeuvre
Follow steps of Dix-Hallpike manoeuvre
Then rotate the head 90 degrees past the central position
Have the patient roll onto their side so their head rotates a further 90 degrees in the same directions
Have the patient sit up sideways with the legs off the side of the couch
Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle
What is the treatment of Epiglottitis
Immediate senior involvement including those able to provide emergency airway support e.g. anaesthetics, ENT
Do not examine the throat due to risk of acute airway obstruction
Oxygen
IV Ceftriaxone or Cefotaxime
Steroids e.g. dexamethasone
What is the treatment of Epistaxis
If haemodynamically stable then first aid measures - sit forward with open mouth and pinch cartilaginous area of nose firmly
In severe cases hospital admission may be required then consider nasal packing using nasal tampons or inflatable packs or using sliver nitrate to cauterise
Naseptin (chlorhexidine and neomycin) QDS for 10 days to reduce crusting, inflammation and infection
What is the treatment of Infectious mononucleosis (Glandular Fever)
Supportive
Rest, fluids and avoid alcohol
Simple analgesia or aches and pains
Avoid contact sports
What is the treatment of Meunière’s disease
Managing symptoms - buccal or IM prochlorperazine - antihistamines e.g. cyclizine
Prophylactic medications e.g. Betahistine
What is the treatment of Obstructive sleep apnoea
Weight loss, stop alcohol/smoko
CPAP is 1st line for moderate - severe
Intra-oral devices e.g. mandibular advancement if CPAP not tolerated
DVLA should be informed
Surgery uvulopalatopharyngoplasty
What is the treatment of Otitis externa
Mild - acetic acid 2%
Moderate - neomycin, dexamethasone and acetic aid
Severe - flucloxacillin or clarithromycin, consider ENT admission for IV abxs
Ear wick - may be used if canal very swollen
What is the treatment of Otitis media
Usually resolves without ABxs within 3 days - simple analgesia
ABxs immediate if systemic illness, co-morbid or immunocomp
Delayed can be given - if so then amoxicillin for 5-7 days and clarithromycin if not
What is the treatment of Rhinosinusiti
ABxs are not recommended for symptoms up to 10 days.
If not improving after 10 days
High dose steroid nasal spray for 14 days - 200 mcg BDD
Delayed ABx prescription - phenoxymethylpenicillin 1st line
What is the treatment of Tonsillitis
Calculate Centor Criteria or FeverPain score
ABxs if CS > 3 or FPS >4
Educate and give safely net about when to seek medical advice
Simple analgesia to control pain and fever
Return if
Pain has not settled after 3 days or if fever rises above 38.3
If ABxs then Pen V for 10 days or Clarithromycin if allergy
