ENT 2 Flashcards
What are the causes of otitis externa?
- infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
- seborrhoeic dermatitis
- contact dermatitis (allergic and irritant)
What are the features of otitis externa?
- ear pain
- itch
- discharge
otoscopy:
- red
- swollen
- eczematous canal
How do you manage otitis externa?
The recommend initial management of otitis externa is:
- topical antibiotic or a combined topical antibiotic with steroid
- if the tympanic membrane is perforated aminoglycosides are traditionally not used*
- if there is canal debris then consider removal
- if the canal is extensively swollen then an ear wick is sometimes inserted
Second line options include
- consider contact dermatitis secondary to neomycin
- oral antibiotics (flucloxacillin) if the infection is spreading
- taking a swab inside the ear canal
- empirical use of an antifungal agent
What is a common cause of bacterial otitis media?
Haemophilus influenza
What are the most common bacterial causes of otitis media?
- Haemophilus influenzae
- Streptococcus pneumoniae
- Moraxella catarrhalis
When should antibiotics be prescribed for otitis media?
- 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 years with bilateral otitis media
- Otitis media with perforation and/or discharge in the canal
If indicated, which antibiotics are used for otitis media?
A 5-day course of amoxicillin is first-line.
In patients with penicillin allergy, erythromycin or clarithromycin should be given.
How do you treat inflammation of the ear canal?
For mild cases (mild discomfort and/or pruritus; no deafness or discharge), consider prescribing topical acetic acid 2% spray.
When features of more severe inflammation are present, such as in this case, they advise 7 days of a topical antibiotic with or without a topical steroid.
What are epidermoid cysts?
- common cutaneous cysts that result from the proliferation of epidermal cells within a circumscribed space of the dermis
- occur at any age
- typically asymptomatic
- typically firm, round nodules of various sizes
- a central punctum may be present
What does tachyphylaxis mean?
rapidly diminishing response to successive doses of a drug, rendering it less effective
What are the classification of allergic rhinitis?
- seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever
- perennial: symptoms occur throughout the year
- occupational: symptoms follow exposure to particular allergens within the work place
What are the features of allergic rhinitis?
- sneezing
- bilateral nasal obstruction
- clear nasal discharge
- post-nasal drip
- nasal pruritus
How do you manage allergic rhinitis?
- allergen avoidance
- oral or intranasal antihistamines are first line
- intranasal corticosteroids
- course of oral corticosteroids are occasionally needed
- there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline). They should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa may occur upon withdrawal
What are the features of a peritonsillar abcess (quincy)?
- severe throat pain, which lateralises to one side
- deviation of the uvula to the unaffected side
- trismus (difficulty opening the mouth)
- reduced neck mobility
Which infection is tonsilar SCC is associated?
HPV (particularly 16)
What is malignant otitis externa?
- An uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics)
- Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal
- Progresses to temporal bone osteomyelitis
What’s the underlying condition of a patient with malignant otitis externa?
Diabetes 90%
What’s the most common causative agent of malignant otitis externa
Pseudomonas aeruginosa
What can malignant otitis externa progress to?
temporal bone osteomyelitis
What’s the typical history of someone with malignant otitis externa?
- Diabetes (90%) or immunosuppression (illness or treatment related)
- Severe, unrelenting, deep-seated otalgia
- Temporal headaches
- Purulent otorrhea
- Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
How would you diagnose and treat malignant otitis externa?
Diagnosis
- A CT scan is typically done
Treatment
- Intravenous antibiotics that cover pseudomonal infections
- Hyperbaric oxygen is sometimes used in refractory cases
What is the most likely anatomical origin of the epistaxis?
Anterior nasal septum
Little’s area in the anterior nasal septum is the site of Kiesselbach’s plexus, supplied by 4 arteries. Epistaxis therefore most commonly originates from the anterior of the nose.
What causes septum obliteration during cocaine use?
Inhaled cocaine is a powerful vasoconstrictor.
How do you manage a patient with nose bleeds?
Initially:
- Asking the patient to sit with their torso forward and their mouth open- avoid lying down unless they feel faint. This decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth. It also reduces the risk of aspirating blood.
- Pinch the cartilaginous (soft) area of the nose firmly and consistently for at least 15 minutes and ask the patient to breathe through their mouth.
If bleeding does not stop after 10-15 minutes of continuous pressure on the nose, consider cautery or packing. Cautery should be used if the source of the bleed is visible and cautery is tolerated- it is not so well tolerated in younger children! Packing may be used if cautery is not viable or the bleeding point cannot be visualised. If the nose is packed in primary care, the patient should be admitted to hospital for review.
How do you cauterise a nosebleed?
- Ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume.
- Use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
- Identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.
- Dab the area clean with a cotton bud and apply Naseptin or Muciprocin
Are nasal polyps more common in men or women?
2-4 x more common in men
What are nasal polyps associated with?
- asthma* (particularly late-onset asthma)
- aspirin sensitivity*
- infective sinusitis
- cystic fibrosis
- Kartagener’s syndrome
- Churg-Strauss syndrome
How do you manage nasal polyps?
- all patients with suspected nasal polyps should be referred to ENT for a full examination
- topical corticosteroids shrink polyp size in around 80% of patients
What is Samter’s triad?
asthma, aspirin sensitivity and nasal polyposis
When would you refer someone to ENT with a nasal polyp?
unilateral symptoms or bleeding
How does the centor criteria relate to the chance of a streptococcal throat infection?
The presence of 3 or 4 of these gives a 40-60% chance of the patient having a streptococcal throat infection, and therefore antibiotics should be prescribed. If two or fewer are present, there is an 80% chance of there not being a bacterial throat infection.
Where does a nasal septal haematoma occur?
Between the septal cartilage and the overlying perichondrium.
What are the features of nasal septal haematoma?
- may be precipitated by relatively minor trauma
- the sensation of nasal obstruction is the most common symptom
- pain and rhinorrhoea are also seen
- on examination, classically a bilateral, red swelling arising from the nasal septum
this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm
How do you treat a nasal septal haematoma?
- surgical drainage
- intravenous antibiotics
What happens if a nasal septal haematoma is left?
If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis. This may result in a ‘saddle-nose’ deformity
What causes black hairy tongue?
Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae
What colour can a black hairy tongue be?
black brown green pink another colour
What are predisposing factors for black hairy tongue?
- poor oral hygiene
- antibiotics
- head and neck radiation
- HIV
- intravenous drug use
How do you manage black hairy tongue?
The tongue should be swabbed to exclude Candida
Management
- tongue scraping
- topical antifungals if Candida
A 78-year-old male is recovering on the ward following a partial thyroidectomy to remove a thyroid nodule 48 hours previously.
He complains of muscle cramps and a ‘tingling sensation’ around his mouth. An ECG is performed on the ward.
Given the likely cause of his symptoms, which of the following abnormalities may be observed on his ECG?
Prolonged QT interval
Complications of thyroid surgery - damage to parathyroid glands can result in hypocalcaemia
What are the complications of thyroid surgery?
- Anatomical such as recurrent laryngeal nerve damage.
- Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
- Damage to the parathyroid glands resulting in hypocalcaemia.
What causes tinnitus?
- Meniere’s disease
- Otosclerosis
- Acoustic neuroma
- Hearing loss
- Drugs
- Impacted ear wax
- Chronic suppurative otitis media
Which drugs can cause tinnitus?
- Aspirin
- Aminoglycosides
- Loop diuretics
- Quinine
What is a primary bleed following a tonsillectomy and how do you treat it?
Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.
What is a secondary bleed following a tonsillectomy and how do you treat it?
Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in around 1-2% of all tonsillectomies.
What’s the condition?
Facial ‘fullness’ and tenderness
Nasal discharge, pyrexia or post-nasal drip leading to cough
Sinusitis
What’s the condition?
Unilateral facial pain characterised by brief electric shock-like pains, abrupt in onset and termination
May be triggered by light touch, emotion
Trigeminal neuralgia
What’s the condition?
Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
Clusters typically last 4-12 weeks
Intense pain around one eye
Accompanied by redness, lacrimation, lid swelling, nasal stuffiness
Cluster headache
What’s the condition?
Tender around temples
Raised ESR
Temporal arteritis
How do you treat otitis externa in diabetics?
Treat with ciprofloxacin to cover Pseudomonas
What does a negative Rhinne test mean?
There is a conductive hearing loss. Bone conduction is better than air conduction.
Who would you refer for an urgent appointment to ENT for suspected laryngeal cancer?
- people aged 45 and over with:
- persistent unexplained hoarseness
- or an unexplained lump in the neck
A 19-year-old woman is on the Specialist Surgical Ward recovering from a tonsillectomy. She returned from theatre 4 hours ago. Nurses report that there appears to be a small amount of bleeding from the wound.
After your initial assessment, what is your next management step?
Primary haemorrhage within hours after tonsillectomy requires immediate return to theatre
Which duct drains the parotid gland?
Stensens duct
Which duct drains the submandibular gland?
Whartons duct
What’s the most common place to get a salivary gland calculi?
Submandibular gland
What is sialadenitis?
- infection of the salivary glands
- Usually occurs as a result of Staphylococcus aureus infection
- Pus may be seen leaking from the duct, erythema may also be noted
- Development of a sub mandibular abscess is a serious complication as it may spread through the other deep fascial spaces and occlude the airway
What’s the condition?
painful bleeding gums with halitosis and punched-out ulcers on the gums
Acute necrotizing ulcerative gingivitis
How do you manage a patient with acute necrotizing ulcerative gingivitis?
Refer the patient to a dentist, meanwhile the following is recommended:
- oral metronidazole* for 3 days
- chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash
- simple analgesia
*the BNF also suggest that amoxicillin may be used
You are called to do a house visit for a 30-year-old woman who is unable to get to your surgery. She was previously fit and well, apart from having ‘a bit if a cold’, but this morning she woke up feeling very dizzy with the sensation that the room is spinning, and feels too ill to leave the house. She has vomited twice this morning.
Given the likely diagnosis, how should you manage this patient?
Prochlorperazine may be useful in the acute phase of vestibular neuronitis, but should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms.
After the acute phase, mobilisation should be encouraged as well as twice daily vestibular rehabilitation exercises.
A 21-year-old woman presents to the emergency department with a 3-hour history of continued epistaxis. She was training with her university rugby team when she collided with another player.
X-ray imaging has confirmed she has not broken her nose, however, there is still profuse bleeding in spite of compression. You are unable to identify the bleeding site.
Which of the following is the most appropriate initial management option?
Anterior packing is the most suitable management option for epistaxis where the bleed site is difficult to localise
When is intranasal adrenaline used?
To prevent re-bleeding once the initial bleeding has been stopped as this will cause blood vessels in the nasal cavity to constrict.
A 1-year-old boy is brought to the GP as his mother has noticed an unusual lump on his neck. She is not sure how long it has been there for. It is located in the anterior triangle just in front of the sternocleidomastoid muscle and is soft in texture. The lump does not transilluminate but is mobile. A biopsy is performed and reveals cholesterol crystals in the fluid extracted.
What is the most likely underlying diagnosis?
Branchial cyst Cystic hygroma Lipoma Thyroglossal cyst Thyroid mass
Branchial cysts characteristically contain cholesterol crystals
What are the differentials for a neck lump in a child?
- congenital: branchial cyst, thyroglossal cyst, dermoid cyst, vascular malformation
- inflammatory: reactive lymphadenopathy, lymphadenitis,
- neoplastic: lymphoma, thyroid tumour, salivary gland tumour
A mother brings in her three-year-old daughter, because she has noticed a discharge from her right ear. She states that over the last few days her daughter has been more irritable, has been tugging at her ear and has felt a bit feverish. Since the discharge started, she states her daughter seems more comfortable and does not appear to be in pain. On examination, you visualise a perforated tympanic membrane.
How should you manage this condition?
Oral antibiotics should be given in acute otitis media with perforation
Who should be sent to oral surgery as 2 week wait referrals?
- Unexplained oral ulceration or mass persisting for greater than 3 weeks
- Unexplained red, or red and white patches that are painful, swollen or bleeding
- Unexplained one-sided pain in the head and neck area for greater than 4 weeks, which is associated with ear ache, but does not result in any abnormal findings on otoscopy
- Unexplained recent neck lump, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
- Unexplained persistent sore or painful throat
Signs and symptoms in the oral cavity persisting for more than 6 weeks, that cannot be definitively diagnosed as a benign lesion
The level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers and those who chew tobacco or betel nut (areca nut).
A 34-year-old man presents to his GP complaining of nasal congestion, a post-nasal drip and sneezing. He has been using nasal decongestants for 1 month, and after initially improving noted his symptoms returned.
What should you recommend?
Cease nasal decongestants
Rhinitis medicamentosa is a condition of rebound nasal congestion brought on by extended use of topical decongestants. Treatment of rhinitis medicamentosa involves withdrawal of the offending nasal spray (cold turkey).
