ENT

Question 1

What are the borders of the neck?

Answer 1

Anterior triangle:

• anterior - midline of neck
• posterior - anterior of sternocleidomastoid
• superiorly - inferior border of the mandible Posterior triangle:
  - anterior - posterior border of sternocleidomastoid
• posterior - anterior border of trapezius
• inferiorly - clavicle

Question 2

Lymph nodes in the neck are divided into how many groups? What do these groups drain?

Answer 2

6 groups.
Group 1 submental/submandibular - drain oral cavity and oropharynx
Group 2 upper deep cervical - drain oral cavity and oropharynx
Group 3 mid deep cervical - oral cavity, naso/oropharynx, hypopharynx, larynx.
Group 4 lower deep cervical - hypopharinx, subglottal layrinx, thyroid, oesophagus.
Group 5 posterior triangl, nasopharynx
Group 6 paratrachael - thyroid

Question 3

When considering the age of a patient presenting with a neck lump, what are the most common causes by age?

Answer 3

Paediatric - reactive lymph node, congenital, or neoplasm.
16-40yrs - inflammatory, thyroid malignancy.
40+ - consider a neck lump malignant unit proven otherwise.

Question 4

In terms of time span of a lump, a lump that appears within the last three weeks is likely to be…?

Answer 4

Inflammatory or infective.

Question 5

When examination of neck lump is performed, how should it take place?

Answer 5

With the patient seated and the clinician standing behind the patient, with the neck adequately exposed.

Question 6

What are three neck lumps commonly found in the posterior triangle?

Answer 6

Lymph node.
Lymphoma.
Cystic hygroma.

Question 7

What are three neck lumps commonly found in the midline of the neck?

Answer 7

Dermis cyst.
Thyroglossal cyst.
Thyroid mass.

Question 8

What non-midline masses may frequently be found in the anterior triangle of the neck? (5)

Answer 8

Pharyngeal pouch.
Branchial cyst.
Salivary gland pathology.
Lymph node.
Caroitid body tumour.

Question 9

When assessing a lump, what characteristics should be assessed? (7)

Answer 9

Shape.
Size.
Surface.
Consistency.
Relationship to other anatomical structures.
Mobility (if a lump moves on swallowing it is likely to be fixed to the trachea and thyroid in origin; if a lump moves on protrusion of the tongue it is likely fixed to the hyoid bone, e.g., a thyroglossal cyst).
Tenderness.

Question 10

What would a tender lump suggest?

Answer 10

Usually an infective or inflammatory process.

Question 11

What would a painless head mass represent?

Answer 11

Would raise fears of malignancy.

Question 12

On identifying a parotid mass, what warrants careful observation?

Answer 12

The facial nerve should be thoroughly examined as the facial nerve passes through the parotid glad.

Question 13

A neck lump may prompt a more general examination - for example?

Answer 13

A thyroid lump may prompt a thorough examination for thyroid disease manifest elsewhere in the body.A Virchows node may prompt an examination of the abdomen, e.g., organomegally or other organ masses.

Question 14

Neck lumps can be classified into four group - what are they?

Answer 14

CongenitalInflammatory NeoplasiaMiscellaneous

Question 15

What congenital causes of neck lump might there be?

Answer 15

Thyroglossal cyst

Question 16

What percentage of the population suffers with chronic dizziness?

Answer 16

About 20% - note these patients often present to a new doctor with what sounds like it might be a new episode, but closer questioning reveals a chronic relapsing/remitting condition.

Question 17

What might muddy the waters when talking to a patient complaining of dizziness or vertigo?

Answer 17

Tension and anxiety.

Question 18

A recent primary care study found that giving what improved what after what time in patients with dizziness and vertigo?

Answer 18

Giving a booklet explaining rehab exercises and some CBT techniques.
Symptoms improved at 52 weeks - lower vertigo scores, fewer symptoms related to dizziness, reduced handicaps related to dizziness.

Question 19

Which sex has more sleep apnoea? How much of the population? More common in concert with which condition?

Answer 19

1% of men in UK have sleep apnoea.

More common in those with type 2 diabetes, hypertension, and metabolic syndrome.

Question 20

Why is it important not to miss sleep apnoea? (3)

Answer 20

Undiagnosed individuals have:

1) A 7 x increased risk of having a road traffic accident. 2
2) It is associated with hypertension, type 2 diabetes and metabodic syndrome.
3) Treatment reduces cardiovascular risk.

Question 21

Who should the diagnosis of sleep apnoea be considered in?

Answer 21

Complaining of sleepiness rather than tiredness.

Who are overweight, especially if they have diabetes, hypertension or heart failure.

Question 22

If sleep apnoea is suspected what should be asked? (5)

Answer 22

1) Snoring and nocturnal choking
2) Waking unrefreshed
3) Daytime sleepiness (not tiredness).
Epworth sleepiness scale objectively measures degree of sleepiness, although not the cause (see Appendix). Scores of 9 or more suggest significant daytime sleepiness.
4) Collar size is a good predictor: those with a collar size of >43cm/17 inches who are symptomatic should be referred for sleep studies.
5) Ask partners about sleep apnoea.

Question 23

?How is a diagnosis of sleep apnoea confirmed

Answer 23

Sleep studies

Question 24

What scale is used to assess degree of daytime sleepiness? What do they NOT assess? What is a significant score?

Answer 24

Epworth sleepiness scale objectively measures degree of sleepiness, although not the cause . Scores of 9 or more suggest significant daytime sleepiness.

Question 25

What is the treatment for sleep apnoea? (5)

Answer 25

1) Continuous positive airway pressure (CPAP) is the mainstay of treatment and is approved by NICE (TA139).
2) Lifestyle is also important (weight loss, sleep hygiene). An RCT of 260 obese people with moderate to severe sleep apnoea showed that a 10kg weight loss led to significant improvement in the severity of the sleep apnoea (Arch. Intern. Med. 2009;169:1619–26). Another RCT of 63 men confirmed weight loss reduced sleep apnoea, with those with most severe disease gaining the most (BMJ 2009;339:b4609).
3) Mandibular advancement devices (looks a bit like a gum shield but lifts the bottom jaw forward). Made by some dentists – anecdotal evidence only for their use. The handful of my patients who have them report they are effective and surprisingly well tolerated.
4) Uvulopalatopharyngoplasty lacks an evidence base, and hence is rarely done now.
5) Bariatric surgery to reduce obesity is likely to be beneficial.

Question 26

Is there any relationship between a diagnosis of sleep apnoea and the DVLA?

Answer 26

Once diagnosed, patients must inform the DVLA.

Once effectively treated the DVLA does allow driving, even for those with HGV/PSV licences (subject to annual review).

Question 27

What is glue ear? How common is it? How long does it have to last for to be called glue ear? When is it of clinical significance?

Answer 27

Glue ear is very common in children. Indeed most children, and many adults, may get an effusion in the middle ear with ear infections and URTIs. However, if this persists (6w seems to be the definition used by most) it earns the label otitis media with effusion. However, it is only really of clinical significance when it impairs function, particularly hearing, speech and language development, or behaviour.

Question 28

In a child, if glue ear is suspected, what should be asked about in the history? (7)

Answer 28

1) Poor listening skills
2) Indistinct speech
3) Delayed language development
4) Inattention and behavioural problems
5) Hearing fluctuation
6) Recurrent ear infection or URTIs
7) Balance problems and clumsiness

Question 29

If glue ear is suspected, what should be looked at on examination/Ix?

Answer 29

1) Ears and tympanic membranes
2) General development
3) Age-appropriate hearing tests
4) (Tympanometry - Ix)

Question 30

If otitis media with effusion is confirmed, what do NICE recommend?

Answer 30

NICE recommend observation for 3m. During this time offer educational/behavioural strategies to minimise the impact of any hearing loss. Offer auto-inflation if children are old enough to do this

Question 31

In glue ear, after 3 months of watchful waiting, what would trigger the next course of action, and what is that?

Answer 31

If after 3m of watchful waiting:
1) there is a hearing loss of 25–30dB loss or more

OR
2) if hearing loss is <25dB but with significant impact on development/education:
Consider surgical interventions (ventilation tubes/grommets) OR consider offering hearing aids.

Question 32

There is no role for any of the following in the management of glue ear (10)

Answer 32

1) Antibiotics
2) Adenoidectomy
3) Antihistamines
4) Decongestants
5) Steroids (Steroids did not offer any benefit compared with placebo either in the short or long term after 9m). (BMJ 2010;340:b4984)
6) Acupuncture
7) Dietary modification
8) Homeopathy
9) Massage
10) Cranial osteopathy

Question 33

What are auto-inflation devices and how do they work?

Answer 33

For those of you not familiar with auto-inflation, it involves the child learning to blow up a balloon through their nostril, not their mouth. As you do this you hold open your Eustachian tube, allowing pressure in your middle ear to equalise with atmospheric pressure (in effect you are doing what divers learn to do and what you do when you yawn, but in a more sustained fashion and with immediate feedback to show you are doing it correctly). You can buy special devices (e.g. Otovents, about £7 from pharmacies) that consist of a plastic nozzle and a couple of balloons. Most 6-year-olds seem able to learn with practice. Please note the balloons used are more lax than party balloons which cannot be used!!

Question 34

When a patient presents with oral symptoms, why is it important to ask certain questions that might not seem immediately relevant, and why?

Answer 34

Systemic symptoms may be early indicators of significant or malignant problems in the oral region.
Ask about:
1) If this dentist is regularly seen and whine they were last seen by one.
2) Detailed history of alcohol and tobacco use (important as can be aetiologically related to pre-malignant lesions, oral cancers, and peri-ordontal disease.

Question 35

When examining the oral cavity, what is the overriding principle that should be followed?
Any special equipment required?

Answer 35

Do it systematically, like any other exam!
Document positive and negative findings for each area.
Equipment: good light source (overhead lamp better than pen torch); two wooden tongue depressors OR two dental mirrors).

Question 36

What are the three criteria for diagnosis of acute otitis media?

Answer 36

1) Acute symptoms of infection.
2) Evidence of middle ear inflammation.
3) Presence of middle ear effusion.

BUT…There are no gold standards for any of these and one study comparing an ENT surgeon’s opinion with primary care found 22% of patients diagnosed by their GP with AOM had other diagnoses given by the ENT surgeon including glue ear, viral otitis and a normal tympanic membrane.

Question 37

How is acute otits media treated? What happens if you give antibiotics?

Answer 37

NNT=9 for clinical success rate at day 12.
No evidence that one antibiotic is better than others.
If a deferred antibiotic script is issued they are used in about one-third of cases. Resolution is slightly better in those given immediate antibiotics at 12 days.
NNH= 10 with diarrhoea and rash most common.
So what are we to make of all this? Undoubtedly antibiotics help resolve AOM. 2 recent studies demonstrate the benefit is greatest where we are able to make a clear diagnosis of AOM using a number of clinical parameters. Yet even in the last study half the children in the placebo arm did not have treatment failure and two-thirds did not require rescue treatment.

Question 38

What symptoms would suggest a child has acute otitis media?

Answer 38

1) Middle ear fluid detected by pneumatic otoscopic examination (at least two of the following: bulging position, reduced or absent motility, abnormal colour or opacity, or air-fluid interfaces). (Although in practice, this technique is not really done!)
2) Inflammation
3) Erythema
4) Increased vasculature over TM
5) Bulging, or yellow TM.
6 The child also requires acute symptoms: fever, ear pain, respiratory symptoms.

Question 39

What does The National Prescribing Centre (MeReC) say about prescribing in acute otitis media?

Answer 39

1) Children do receive some benefit from antibiotics, but this benefit is not great when balanced against side-effects of treatment, so antibiotics should not routinely be prescribed to children with AOM.
2) Age alone should not be used to determine who to treat.
3) Those with other markers of illness are likely to benefit most (bilateral AOM in under 2s, those with otorrhoea), BUT these benefits are small and don’t necessarily justify prescribing antibiotics routinely.
4) Those with systemic upset are more likely to benefit than other children, but a delayed script (48 hours) is still appropriate as many will get better in this time.
5) No antibiotics (or delayed scripts) are appropriate for many.

Question 40

If an antibiotic is used in acute otitis media, which one should be used?

Answer 40

A five-day course of amoxicillin should be first line (MeReC 2006;17(3)).
H. influenzae is the cause in 25% of people and erythromycin is not effective against this.
Azithromycin or clarithromycin are effective alternatives.

Question 41

If a young child is treated with antibiotics for otitis media, apart from acute drug reactions, what is a potential pitfall?

Answer 41

A study has shown that children aged 6m–2y with otitis media who are treated with antibiotics are at increased risk of getting further episodes (BMJ 2009;338:b2525).
The study followed children aged 6m–2y who were diagnosed with AOM. They were randomised to receive amoxicillin or placebo and followed up by questionnaire 3.5y later (quite a long delay so potential for recall bias in both directions – over-recalling and forgetting!). It was a small study (240 children) but the findings are interesting.
For every 5 children given antibiotics, one developed AOM in the following year who would not have done so if they had not been given antibiotics!

Question 42

How can otitis media and otitis externs be distinguished?

Answer 42

Otitis media (OM) and otitis externa (OE) are sometimes difficult to distinguish. Pain tends to accompany the discharge with OE but comes before the discharge starts with OM. Also moving the tragus (pulling on the external ear) will tend to be sore in patients with OE.

Question 43

In otitis externa, what other diagnose(s) need to be considered?

Answer 43

Foreign bodies can trigger OE and we need to be wary of cholesteatoma, especially in patients who have recurrent infections. A GP with 2000 patients might expect to see a new case every 5 years. Cholesteatoma tends to affect the upper part of the tympanic membrane and if a good view is not possible at the time call these patients back in 2–4 weeks for a second look when all has settled.

Question 44

Do I need to worry about aminoglycosides causing deafness when using aminoglycosides in otitis externa?

Answer 44

OE is best treated with antibiotic and steroid eardrops and it is suggested that aminoglycoside-based drops be used as Pseudomonas and Staphylococcus make up the majority of infections. Even in patients with perforated ear drums aminoglycoside ear drops will not reach ototoxic levels in short courses of 1–2 weeks, but the drops can remain in the inner ear fluid for up to 6 months so beware using repeat courses.
Consider taking a swab if infection fails to respond.
Only 2% of primary OE is fungal but consider it in patients who have had multiple courses of treatment. Clotrimazole is available as eardrops for these patients.

Question 45

How to prevent otitis externa?

Answer 45

External ear infections are often related to other skin problems the patient might have (psoriasis or eczema, for example), can be self-induced through occupational hazards such as using ear defenders or headphones, or the use of cotton buds or bent paper clips, tooth picks, keys, etc. Water exposure is also a risk and ear infections seem more common in people whose head is wet for long periods. Avoid using a hearing aid in the affected ear until the infection has settled.

Question 46

When examining the mouth, what are the logical steps that should be performed? (7)

Answer 46

1) Examine lips and face for any obvious abnormality.
2) Next the gingivae/gums, using the dental mirror or tongue depressor to “sweep away” lips/tongue for better visualisation. Remember to look at both sides of the gums!
3) Next the buccal mucosa (inside of the cheeks).
4) Then hard and soft palate, tongue (lateral, dorsal, and ventral), and floor of mouth.
5) Dentition. Divide into 4 quadrants, if pain or obvious dental caries, perhaps tap with dental mirror to see if acute infection or tooth mobility.
6) Palpate all groups of lymph nodes in head and neck.
7) Palpation of submandibular and parotid glands.

Question 47

What affects can anaemia have within the oral cavity? (4)

Answer 47

1) Glossitis (inflammation of the tongue).
2) Angular stomatitis.
3) Recurrent oral aphthae or ulceration.
4) Burning sensations or generalised discomfort.

Question 48

What is Glossitis?

Answer 48

Inflammation of the tongue.
Gives a smooth appearance with lack of papillae by atrophy.
Most commonly associated with Fe deficiency anaemia, but is sometimes also seen in B12 and/or frolic acid deficiency (in this case, the tongue displays a classic ‘beefy’ or reddened appearance.

Question 49

What is angular stomatitis? What is it also known as?

Answer 49

AKA cheilitis.
Inflammation and fissuring at the corner of the mouth.
Sometimes seen in Fe deficiency anaemia, but more commonly with both bacterial and fungal infection.
If anaemia excluded, Rx with something to cover both pathogens, e.g., miconazole cream or sodium fusidate ointment).