ENT 👂🏽👃🏽👅 Flashcards
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1
Q
What is BPPV?
A
Benign paroxysmal positional vertigo - sudden onset of vertigo following head movements
2
Q
How does BPPV present?
A
Sudden onset vertigo after head movements
Vertigo lasts 20-60 seconds
Patients are asymptomatic between attacks
3
Q
How is BPPV differentiated from labyrnithitis?
A
BPPV does not cause hearing loss
4
Q
What is the cause of BPPV?
A
Calcium carbonate crystals called octonia become lodged in the semi circular canals. The normal flow of endolymph through the canals is distrupted.
5
Q
What causes the crystals to become displaced?
A
Viral infection
Head trauma
Aging
Idiopathic
6
Q
Where are the crystals most commonly displaced?
A
Posterior semicircular canal
7
Q
How is BPPV diagnosed?
A
Dix-hallpike manoeuvre
8
Q
How is the dix-hallpike manoeuvre performed?
A
Start with the patient sitting upright on a couch
Turn the patient’s head to 45 degrees
Quickly lower the patient backwards, with their head hanging off the back of the bed
Look for nystagmus
Repeat on the other side
9
Q
What is the first line management of BPPV?
A
Epley manoeuvre
10
Q
What else can be done to improve BPPV?
A
Brandt-Daroff exercises
11
Q
What is involved in Brandt-Daroff exercises?
A
Involves sitting on the edge of a bed and lying sideways, from one side to the other
12
Q
What is meniere’s disease?
A
Meniere’s disease is a condition of the inner ear
- It is characterised by vertigo, unilateral fluctuating hearing loss, tinnitus, and fullness of the ear
13
Q
What are the risk factors for meniere’s disease?
A
Middle aged
Family history
Migraines
Autoimmune disease
Head trauma
Viral infection
14
Q
What are the clinical features of meniere’s disease?
A
Vertigo
Tinnitus (unilateral)
Fluctuating hearing loss (unilateral)
Aural fullness
Nystagmus
Positive romberg’s test
Unsteadiness
Unexplained falls without loss of consciousness
15
Q
What are the differentials of meniere’s disease?
A
Acoustic neuroma
Migraine with brainstem aura
BPPV
16
Q
What is the criteria for diagnosis of meniere’s disease?
A
Vertigo - at least two spontaneous episodes lasting between 20 minutes and 12 hours
Fluctuating - fluctuating hearing, tinnitus, and/or perception of aural fullness
Hearing loss - confirmed by audiometry to be sensorineural, low-to-mid frequency, and in the affected ear
17
Q
What investigations may be useful in suspected meniere’s disease?
A
Otoscopy
Pure-tone audiometry
MRI head - exclude acoustic neuroma
Lyme disease serology
Syphilis serology
18
Q
What is the acute management of meniere’s disease?
A
Severe attacks - prochlorperazine
Non-severe attacks - short course (7 days) of prochlorperazine or antihistamine (cyclizine or promethazine)
19
Q
What is the prophylactic treatment of meniere’s disease?
A
Betahistine
20
Q
What is vestibular neuronitis?
A
Inflammation of the vestibular nerve, usually due to a viral infection
21
Q
What is the inner ear comprised of?
A
Semi-circular canals
Vestibule
Cochlea
22
Q
What is the action of the semicircular canals?
A
The semicircular canals detect rotation of the head
23
Q
What is the vestibular system made up of?
A
Semicircular canals
Otolith organs
24
Q
What is the action of the otolith organs?
A
They detect gravity and linear acceleration
25
What is the function of the vestibular nerve?
The vestibular nerve transmits signals from the vestibular system to the brain to help with balance
26
What is the presentation of vestibular neuronitis?
Vertigo
Nausea and vomiting
Balance problems
Unsteady gait
Nystagmus
Positive Romberg's sign
27
What investigations may be useful in the diagnosis of vestibular neuronitis?
Audiometry - to differentiate from causes of vertigo that are associated with hearing loss
28
What is the head impulse test?
The patient sits upright and fixes their gaze on the examiners nose
- The patients head is jerked 10-20 degrees while they continue to look at the examiner's nose
- The head is slowly moved back to the centre before repeating in the opposite direction
29
What is a positive head impulse test result?
In a patient with vestibular neuronitis, their eyes will saccade as they fix back on the examiner
30
What is the management of vestibular neuronitis?
Prochlorperazine
Antihistamines (cyclizine, cinnarizine, promethazine)
- Symptomatic treatment can be used for up to 3 days
31
What is the treatment of chronic vestibular neuronitis?
Vestibular rehabilitation therapy
32
What is the difference between vestibular neuronitis and viral labyrinthitis?
Both cause sudden onset of vertigo after a recent viral infection, however there is no hearing loss in vestibular neuronitis
33
What is tonsillitis?
Inflammation of the tonsils
34
What is the most common cause of tonsillitis?
Viral infection
35
What is the most common causative pathogen of tonsillitis?
Rhinovirus
36
What are the other causative organsims of tonsillitis?
Viruses:
- Coronavirus
- Adenovirus
Bacteria:
- Group A Streptococcus (strep pyogenes) - most common bacterial cause
- Streptococcus pneumoniae
- Stapylococcus aureus
37
What are the symptoms of acute tonsillitis?
Sore throat
Pain on swallowing
Fever
38
What are the clinical signs of tonsillitis?
Pyrexia > 38
Tonsillar exudate
Enlargement and erythema of the tonsils
Anterior cervical lymphadenopathy
39
What makes up the Centor criteria?
Fever > 38 degrees
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes
A score of 3 or more warrants antibiotics
40
What makes up the feverPAIN score?
Fever in past 24 hours
Purulent tonsils
Attended within 3 days of onset of symptoms
Inflamed tonsils
No cough or coryza
A score of 4 or more warrants antibiotics
41
What is the first line management of suspected bacterial tonsillitis?
Phenoxymethylpenicillin for 5-10 days
Clarithromycin or erythromycin for 5 days if penicillin allergic
42
What are the complications of tonsillitis?
Acute otitis media
Peri-tonsilar abscess
Parapharyngeal abscess
Acute rheumatic fever
Post-streptococcal glomerulonephritis
43
What is otitis media?
An infection of the middle ear
44
What is the most common causative organism of otitis media?
Streptococcus pneumoniae
45
What are the other common causes of otitis media?
Haemophilus influenzae
Moraxella catarrhalis
Staphylococcus aureus
46
What is the presentation of otitis media?
Ear pain
Reducing hearing in the affected ear
Fever
Symptoms of URTI
- Cough
- Coryzal symptoms
- Sore throat
47
When should patients with otitis media be given an immediate prescription?
Systemically unwell
Immunocompromised patients
Significant co-morbidities
48
What is the first line antibiotic in otitis media?
Amoxicillin - 5-7 days
49
What is the second line antibiotic in otitis media?
Co-amoxiclav (if no improvement with amoxicillin)
Use a macrolide in pencillin allergic patients
50
What are the complications of otitis media?
Glue ear
Tympanic membrane perforation
Mastoiditis
Meningitis
Facial nerve palsy
Chronic or reccurent infection
Hearing loss
51
What is the management options for otitis media?
Immediate antibiotics
Delayed prescription
No antibiotics
52
What is otitis externa?
An infection of the external auditory canal
53
What are the two most common causes of otitis externa?
Pseudomonas aeruginosa
Staphylococcus aureus
54
What are the symptoms of otitis externa?
Ear pain
Discharge
Itchiness
Conductive hearing loss
55
What are the signs of otitis externa on examination?
Erythema and swelling of the ear canal
Tenderness of the ear canal
Pus/discharge in the ear canal
Lymphadenopathy
Fever
56
What are the risk factors for otitis externa?
Diabetes
Deramtitis
Trauma
Moisture - swimming, humid environment
57
What investigations are used in the diagnosis of otitis externa?
Swab - for microbiological analysis
Otoscopy
Blood glucose - poor blood glucose control in a diabetic can exacerbate infection
58
What is the management of mild otitis externa?
Topical 2% acetic acid
59
What is the management of moderate otitis externa?
Topical antibiotic and steroid
- Neomicin, dexamethasone and acetic acid
- Ciprofloxacin 3% with dexamethasone
- Clotrimazole 1% if fungal infection suspected
60
What is malignant otitis externa?
Infection spread to the bones surrounding the ear canal and skull
- Progresses to osteomyelitis of the temporal bone
61
What is the management of malignant otitis externa?
Admission under ENT team
IV antibiotics
CT or MRI head to assess extent of infection
62
When should otitis externa be referred urgently to ENT?
Non-resolving otitis externa with worsening pain
63
What are the types of nosebleeds and where do they come from?
Anterior nosebleed
- Bleeding occurs from Kisselbach's plexus (an anastomosis of five arteries)
Posterior nosebleed
- Comes from sphenopalatine artery
64
What are the risk factors for epistaxis?
Digital or other trauma
Infection
Tumours
Septal deviation
Hypertension
Anticoagulants
NSAIDs
Bleeding disorders
Illicit drug use
65
What is the presentation of epistaxis?
Bleeding from the nares
Feeling of blood in the throat
Pain
Blood visible in the oropharynx
Pseudohaematemesis
Severe:
- Dizziness and pre-syncope
- Shock
- Tachycardia
66
What makes an anterior bleed more likely?
Visible source of bleeding
Minor bleeding
Unilateral bleeding
History of digital trauma
First-aid measures successfully control bleeding
67
What makes a posterior bleed more likely?
No visible source of bleeding
Bleeding in the back of the mouth and throat
Bleeding initially bilateral
Visible blood in the posterior pharynx
Pseudohaematemesis
Anterior nasal packing fails to control bleed
68
What is the initial management of epistaxis?
Advise patients on how to manage nosebleed
- Sit up and tilt head forwards
- Squeeze the soft part of the nostrils together for 10-15 minutes
- Spit out any blood rather than swallowing it
69
What is the further management of epistaxis?
Nasal packing using nasal tampons or inflatable packs
Nasal cautery using silver nitrate sticks
70
What is the longer term management of epistaxis?
Naseptin nasal cream to be used QDS for 10 days
- Contraindicated in peanut or soya allergy
71
What is the management of a posterior nosebleed?
Posterior nasal packing - undertaken by ENT specialist
72
What advice should be given to patients on discharge?
Do not lie flat for 24 hours
Avoid nose-blowing for one week
Avoid alcohol, hot drinks and spicy food for 2 days
Avoid strenuous exercise for 1 week
Avoid dislodging scabs and nose-picking
73
What is OSA?
Collapse of the pharyngeal airway that causes episodes of apnoea during sleep
74
What are the risk factors for OSA?
Increasing age
Male sex
Obesity
Family history of OSA
Nasopharyngeal obstruction
Craniofacial abnormalities
Macroglossia
Neuromuscular disorders
Alcohol and smoking
75
What are the features of OSA?
Episodes of apnoea during sleep
Snoring
Morning headache
Waking up unrefreshed from sleep
Daytime sleepiness
Concentration problems
Reduced oxygen saturation during sleep
76
What are the primary investigations for OSA?
Screening questionnaire
- Epworth sleepiness scale
- OSA-50 score
Sleep studies
- Gold standard for diagnosis of OSA
77
What is the management of OSA?
First line - CPAP (for moderate to severe OSA)
Lifestyle changes
- Weight loss
- Smoking cessation
- Reducing alcohol intake
- Avoid sleeping on back
78
What is rhinosinusitis?
Inflammation of the nose and paranasal sinuses
79
What are the causes of rhinosinusitis?
Viral
Bacterial
Fungal
Allergies
Autoimmune reactions
Deviations or obstructions of the nasal septum
80
What is the clinical presentation of rhinosinusitis?
Nasal congestion/blockage
Nasal discharge
Facial pain or heaviness
Reduced olfaction
Headache
Ear pain
Sore throat
81
What are the differentials of rhinosinusitis?
Common cold
Allergic rhinitis
Nasal polyps
82
What investigations are used to diagnose rhinosinusitis?
Nasal endoscopy
CT
Cultures - if bacterial sinusitis suspected
83
What is the management of rhinosinusitis?
Nasal saline irrigation
Analgesia
Intranasal corticosteroids
84
What is the second line management of rhinosinusitis?
High dose-nasal corticosteroids - 14 day course
Antibiotics reserved for persistent cases
85
How is Rinne's test performed?
A tuning fork is held on the mastoid process
Once the patient can no longer hear the tuning fork, it is moved to the front of the external auditory meatus
86
How is Weber's test performed?
A tuning fork is placed in the middle of the forehead
87
What is a positive Rinne's test?
The patient can hear the tuning fork in front of the external auditory meatus, after they can no longer hear it on the mastoid process
88
What does a positive Rinne's test mean?
Normal air conduction (air conduction should be better than bone conduction)
89
What Rinne's result is seen in conductive hearing loss?
The patient can hear the tuning fork more when held over the mastoid process, than the auditory meatus
90
What is a normal Weber's test?
The sound is heard equally in both ears
91
What Rinne's result is seen in conductive hearing loss?
The sound is heard louder in the affected ear
92
What Rinne's result is seen in sensorineural hearing loss?
The sound is heard louder in the unaffected ear
93
What is conductive hearing loss?
External or middle ear pathology affects the conduction of sound into the ear
94
What is sensorineural hearing loss?
Inner ear, cochlear or auditory nerve pathology leads to impaired neuronal transmission of sound to the brain
95
What is a cholesteatoma?
A non-cancerous growth of squamous epithelium in the middle ear cleft
96
What are the features of a cholesteatoma?
Persistent foul smelling discharge
Headaches
Otalgia
97
What are the differentials of cholesteatoma?
Chronic otitis media
Otosclerosis
Squamous cell carcinoma
98
What is the main investigation in diagnosis of cholesteatoma?
CT head
99
What is the management of cholesteatoma?
Surgical removal of cholesteatoma
100
What are nasal polyps?
Growths of the nasal mucosa that can occur in the nasal cavity or sinuses
101
Are nasal polyps typically unilateral or bilateral?
Typically bilateral - unilateral nasal polyps is a red flag
102
What conditions are nasal polyps associated with?
Chronic rhinitis
Chronic sinusitis
Samter's triad
Cystic fibrosis
Asthma
103
What is Samter's triad?
Nasal polyps
Asthma
Aspirin intolerance/allergy
104
What is the presentation of nasal polyps?
Chronic rhinosinusitis
Difficulty breathing through the nose
Snoring
Nasal discharge
Anosmia
105
What examinations are used in the diagnosis of nasal polyps?
Examination with a nasal speculum
Nasal endoscopy
106
What is the management of nasal polyps?
Intranasal steroids
Intranasal polypectomy
Endoscopic nasal polypectomy
107
What is otosclerosis?
A condition where there is remodelling of the small bones in the middle ear
108
What type of hearing loss does otosclerosis lead to?
Conductive hearing loss
109
What is the pathophysiology of otosclerosis?
The remodelling of the bones in the middle ear primarily affects the base of the stapes, where it attaches to the oval window
This causes stiffening, and fixation - preventing it from transmitting sound
110
What is the typical presentation of otosclerosis?
Hearing loss
Tinnitus
Patient under 40
111
What type of sounds does otosclerosis tend to affect?
Lower-pitched sounds
112
What is seen on audiometry in otosclerosis?
Bone conduction readings normal
Air conduction readings greater than 20 dB
113
What is the management of otosclerosis?
Hearing aids
Stapedectomy or stapedotomy
114
How does Meniere's disease differ from acute labyrinthitis?
Symptoms are similar, but Meniere's disease is recurrent whereas acute labyrinthitis occurs as one episode
115
What medication can be used for prophylaxis of menieres disease?
Betahistine
116
What medication an be used to treat acute attacks of menieres's disease?
Prochlorperazine
Antihistamines
117
What is the progression of hearing loss in meniere's disease?
Fluctuated at first, with hearing loss associated with attacks of vertigo
- Then becomes a more progressive and permenant sensorineural hearing loss
118
What is the pathophysiology of Meniere's disease?
It is associated with excessive build up of endolymph in the labyrintyh of the inner ear, which increases pressure in the inner ear and disrupts signalling
119
What is Meniere's disease?
Recurrent episodes of vertigo, nausea, hearing loss, tinnitus and aural fullness
120
What is quinsy?
A peritonsillar abscess - a bacterial infection with trapped pus forms an abscess in the region of the tonsils
121
What is the presentation of quinsy?
Sore throat
Painful swallowing
Fever
Neck pain
Swollen lymph nodes
Trismus
Change in voice
122
What is trismus?
Where the patient is unable to open their mouth
123
Why does trismus occur in quinsy?
Pus causes the pterygoid muscles to go into spasm, preventing the patient from opening their mouth
124
What organism most commonly causes quinsy?
Streptococcus pyogenes - group A strep
125
What other organisms can cause quinsy?
Staphylococcus aureus
Haemophilus influenzae
126
What is the management of quinsy?
Needle aspiration or surgical incision and drainage
Antibiotics - co-amoxiclav
IV fluids
127
What lymph nodes are most commonly enlarged in quinsy?
Jugulodigastric lymph nodes
