ENT Flashcards
Describe Epistaxis, the types, causes and management
The Chief ENT emergency, respect all nosebleeds, as they can be fatal. Usually split into anterior or posterior.
Anterior bleeds can be easily seen with rhinoscopy and are simple to treat and usually less severe. Anterior epistaxis is almost invariably septal, usually in little’s area (Kiesslbach’s plexus), is used to describe the area where anterior ethmoidal, sphenopalatine, and facial arteries anastomose to form an anterior anastomotic arcade.
Posterior epistaxis tend to be more severe, and more invasive procedures may be needed. examination under anaesthesia is first, and if a discrete bleeding point is found it can be treated directly e.g. diathermy. Ligation is becoming the gold standard with endoscopic ligation of the maxillary/sphenopalatine artery around the sphenopalatine foramen.
Causes:
- trauma
- dyscrasia/haemophilia
- increased alcohol intake
- septal perforation
- neoplasm
Management:
- Resuscitate as needed DR ABCDE
- apply pressure to lower soft part of nose for 15 minutes while mouth-breathing and sitting forward.
- decongest (e.g. with ephedrine 0.5% drops)
- ice on dorsum of nose
- prepare silver nitrate cautery
- look, locate, suction and spray on lidocaine and phenylephrine wait a few minutes
- find bleeding points and cauterise from outside in, call ENT if unable to find
- If bleeding continues try anterior nasal pack and failing that a posterior nasal pack.
Describe Acute Otitis Media, its presentation, and management
Common condition entailing middle ear inflammation. Usually due to Pneumococcus, haemophilus, streps and staphs.
Presentation: Rapid onset of pain, fever (40C in children) +/- irritability, anorexia, vomiting ofter after a URTI. Drum bulging cause pain, then purulent discharge if it perforates (which often settles in 48h).
Management:
- Give analgesia and amoxicillin for up to 7 days unless patient appears well and follow-up is simple.
- Continuing discharge may indicate complications such as mastoiditis, petrositis, labyrinthitis, meningitis.
- Treat with IV antibiotics and get help if continuing discharge, consider drainage.
Describe Mastoiditis, its risk factors, signs and management
An ENT emergency, middle ear inflammation leads to destruction of air cells in the mastoid bone +/- abscess formation. Beware intracranial extension. Patient who were delayed antibiotics for otitis media are at increased risk.
Signs: Fever, tender boggy mastoid, protruding auricle, erythematous, swollen mastoid.
Management:
- Imaging with CT, to determine extend of disease.
- Requires hospitalisation, IV antibiotics, myringotomy,+/- definitive mastoidectomy
Describe Glue Ear, its signs, tests, and management.
Very common, middle ear condition typically affecting infants and children. The fundamental problem lies with dysfunction of the Eustachian tube though exact cause is unclear. Associated with oversized adenoids and URTIs, and is also more common in boys, downs syndrome, winter season, atopy, children of smokers, and Primary Ciliary dyskinesia. It is the chief cause of hearing loss in young children and can lead to learning problems.
Signs: Hearing impairment noticed by parents is the mode of presentation in 80%, look for delay in communication e.g. poor listening, poor speech, language delay, inattention, poor behaviour. Tympanic membrane may be retracted and look grey, dull or yellow, there may be bubbles or an obvious fluid level.
Tests: Audiograms to look for conductive defects, Impedance audiometry looking for a flat tympanogram which helps distinguish glue ear from eustachian malfunction and otoslcerosis.
Management:
- Usually resolves over time.
- Explantation/reassurance and 3 monthly review may be enough.
- If persistent bilateral OME + hearing level in better ear of less than 25-30 Decibel hearing loss confirmed over 3 months then myringotomy + suction of fluid, insertion of Grommets +/- adenoidectomy (if hearing loss).
- Main complications of grommets are infection and tympanosclerosis.
Describe Tonsillitis, it management, and complications
Sore throat +/- lymphadenopathy often caused by viruses, group A streps, haemophilus
Management:
- Paracetamol +/- Difflam gargle if severe
- antibiotics if suspect bacterial cause, use centor criteria: history of fever, tonisllar exudates, tender anterior cervical adenopathy, absence of cough. 0-2 no abx, 2-4 treat with abx.
- Surgical, Do not do tonsillectomy unless you are sure that sore throats are in fact due to tonsillitis, 7 or more episodes of sore throat occur in a year, 5 or more for 2 years or 3 or more for 3 years.
Complications:
- Retropharyngeal abscess
- Peritonsillar abscess
- Parapharyngeal and hypopharyngeal abscess
- lemierre’s syndrome = pharyngotonsillitis internal jugular vein thrombophlebitis +/- septic emboli. caused by fusobacterium necrophorum. treat with high dose benzylpenicillin, clindamycin and metronidazole.
Describe Stridor and some of its causes.
Stridor is a musical noise heard in inspiration from partial obstruction at the larynx or large airway. Children’s airways are narrower and more readily deformed than adult airways so obstruction happens faster and more dramatically. Look for other signs e.g. swallowing difficulty/drooling, pale/cyanosed, use of accessory muscles of respiration, downward plunging of the trachea with respiration (tracheal tug).
Causes:
- Congenital e.g. laryngomalacia, web/stenosis, vascular rings
- Inflammatory e.g. laryngitis, epiglottitis, laryngotracheobronchitis, anaphylaxis
- Neoplastic e.g. haemangiomas, papillomas
- Trauma - thermal/chemical or from intubation
- Miscellaneous e.g. decreased consciousness, airway or oesophageal foreign body, vocal cord paralysis.
Describe laryngomalacia and its management
Most common cause of congenital stridor (60%), appearing within hours of birth (or up to a few months). It is a noisy inspiratory stridor and increased noise with crying, excitement or activity. usually no cyanosis or distress.
It is due to immature and floppy aryepilgotic folds and glottis which increase laryngeal collapse in inspiration.
Management:
- Usually no management needed and symptoms improve by 2yrs old. Problems may occur with infections or with feeding.
- Try surgery if severe, can also develop in association with GORD
Describe Acute epiglottitis, its signs, an management
An ENT emergency as respiratory arrest can occur, it is rarer than croup but mortality is high. Typically caused by haemophilus or strep pyogenes
Signs: often history is short, septicaemia is rapid and cough is absent, sore throat (100%), fever (88%), dyspnoea (78%), voice change (75%), dysphagia (76%)
Management:
- Take to ITU, dont examine throat
- O2 by mask until anaesthetist and ENT arrive
- give nebulised adrenaline, IV dexamethasone
- Visual diagnosis at nasopharyngeal intubation
- blood/epiglottic culture
- find cricothyrotomy kit
- IVI + pencllin G and ceftriaxone
- anti-pyretic e.g ibuprofen
Describe Croup, its severity grading, and management.
Also known as laryngotracheobronchitis it is the leading cause of stridor with barking cough, 95% due to viral causes e.g. parainfluenza. If there is cough and no drooling, most likely croup.
Severity Grading: 1 = inspiratory stridor +/- barking cough 2 = 1 + expiratory stridor 3 = 2 + pulsus paradoxus 4 = 3 + cyanosis or decreased cognition
Management:
- usually self-limiting, treat at home
- single dose of oral dexamethasone
- admit if severe,
What is Unterberger’s test?
Test of vestibular function. Patient is asked to march up and down on the spot with arms stretched out and eyes closed. +ve if more than 45degree turn in less than 50 steps.
What is the Hallpike test?
Used to diagnose benign positional vertigo, The Hallpike manoeuvre rotates the posterior semicircular canal in the plane of gravity.
‘keep your eyes open and look straight ahead’. While supine the head is held between the examiners hands, turned rapidly 30-40degrees to one side and then rapidly lowered 30 degrees below the couch’s level. Ask the patient if they feel dizzy and look for nystagmus. To be positive there must be a latency period of 5-10seconds before symptoms and there must be symptoms and also it should only last 1min.
Describe Benign Positional Vertigo, its causes, diagnosis, and treatment
Attacks of sudden rotational vertigo lasting more than 30 seconds are provoked by head-turning. It is common after head injury. Thought to be due to displacement of otoconia (calcium carbonate particles displaced from cells within the endolymph) in the semicircular canals
Causes: Idiopathic, middle-ear disease, head injury, otosclerosis, spontaneous labyrinthine degeneration, postviral illness, stapes surgery.
Diagnosis:
- establish important negatives
- no persistent vertigo
- no speech, visual, motor or sensory problems
- no tinnitus, headache, ataxia, facial numbness, or dysphagia
- no vertical nystagmus
- Then perform hallpikes test
Treatment:
- Usually self-limiting in months
- Conservative: Decreased alcohol intake may help, Epley manoeuvres
- Pharmacological: histamine analogues (betahistine), vestibular sedatives (prochlorperazine), antidepressants.
- Surgical: last resort, posterior semicircular canal denervation or obliteration (deafness may follow)
What are some causes of vertigo?
Peripheral causes:
- Meniere’s disease
- benign positional vertigo
- vestibular failure
- labyrinthitis
- cholesteatoma
Central causes:
- Acoustic neuroma
- MS
- Head injury
- Inner ear syphillis
- vertebrobasilar insufficiency
Drugs (cental/ototoxic):
- gentamicin/aminoglycosides (neuronitis)
- diuretics
- co-trimoxazole
- metronidazole
Describe Otitis Externa, its symptoms, and management
Acute inflammation of the skin of the meatus. Pseudomonas is the chief organism involved although staph aureus is another common offender. May also be fungal.
Symptoms: Minimal discharge, usually white cotton consistency, itch, pain, and tragal tenderness.
Management:
- Aural toilet is key to treatment.
- Topical antibiotics/antifungals
- Beware of persistent unilateral otitis externa in diabetics/immunosuppressed/elderly as at risk of malignant otitis externa which is life threatening condition that can lead to temporal bone destruction and base of skull osteomyelitis. (Urgent CT, Requires surgical debridement, systemic antibiotics, and admission.)
Describe Pinna Haematoma and it management
Blunt trauma may cause bleeding in the subperichondrial plane elevating the perichondrium to form a haematoma.
Management:
-Arrange prompt drainage/evacuation. Poor treatment leads to ischaemic necrosis of cartilage, then fibrosis (a cauliflower ear). Secondary infection may cause major loss of cartilage.
How should one deal with foreign bodies in the ear.
Common in children under 5yrs or adults with learning difficulties. Live FBs should be drowned in oil first e.g. insects. Syringing my be succesful with small objects, also able to use jobson-horne probe with small loop to remove FBs or blunt hook.
Describe otosclerosis, is symptoms, and treatment.
Autosomal Dominant disease with incomplete penetrance. 50% have a family history, 85% are bilateral, twice as common in women. Vascular spongy bone replaces normal lamellar bone of otic capsule origin particularly around oval window which fixes the stapes footplate.
Symptoms: usually appear in early adult life and are made worse by pregnancy, menstruation, and menopause. Progressive conductive hearing loss, (hearing is often better with background noise), 75% have tinnitus, mild transient vertigo is common to. 10% have schwartz sign which is a pink tinge to the drum. Audiometry with masked bone conduction shows a dip at 2kHz (Caharts notch)
Treatment: Hearing aid or surgery to replace the stapes
Describe Bell’s Palsy and its treatment.
Inflammatory oedema from entrapment of VII in the narrow bony facial canal, e,g, as part of a viral polyneuropathy +/- demyelination. Onset is abrupt, the mouth sags, dribbling may occur, watering of eye may occur (then drying of eyes) impaired brow wrinkling, whistling, lid closure, cheek-pouting, taste and speech.
May be graded using house-brachman score main point is between 3 and 4 there is incomplete lid closure which requires efficient eye care to avoid damage.
Treatment: Protect the eye with glasses and tape closure during sleep. If recovery is expected to take months consider lateral tarsorrhaphy. Instil artificial tears. If less than 6 days of onset consider prednisoolone 20mg/8h for 5 days. Recovery may be spontaneous and can take up to 6 months may not completely recover.
Describe Sensorineural deafness and some causes
Results from defects central to the oval window in the cochlea (sensory), cochlear nerve (neural), or rarely, more central pathways e.g. medial geniculate/temporal lobe.
Causes:
- Ototoxic drugs (streptomycin, vancomycin, gentamicin, chloroquine, hydroxychloroquine, vinca alkaloids)
- Post-infective (meningitis, measles, mumps, flu, herpes, syphilis)
- Cochlear vascular disease
- Menieres
- Trauma e.g. basal skull fracture
- Presbyacusis
Rarer causes:
- Acoustic neuroma
- B12 deficiency
- MS
- secondary carcinoma of the brain
Describe cholesteatoma, its symptoms, and management
A destructive and expanding growth consisting of keratinising squamous epithelium in the middle ear.
Symptoms: Foul-smelling discharge +/- deafness, tinnitus. Headache, pain, facial paralysis, and vertigo indicate impending CNS complications
Management: Mastoid surgery is needed to make a safe dry ear by removing the disease.
Describe a Peritonsillar abscess (quinsy), its presentation, and management
Presentation: Complication of tonsillitis, presents with sore throat, dysphagia, peritonsillar bulge, uvular deviation, muffled voice (hot potato voice)
Management: Antibiotics and aspiration are needed. Steroids reduce morbidity.
Describe Glandular Fever (Infective Mononucleosis), its symptoms, investigations, and complications.
Epstein-Barr virus infection spread by saliva or droplets. Commonly effects young adults and teenagers.
Symptoms: Sore throat, fever, anorexia, malaise, lymphadenopathy (especially posterior triangle of neck), palatal petechia, splenomegaly.
Investigations: Blood film shows lymphocytosis, heterophil antibody test (Monospot) +ve in 90% by 3 weeks. False +ve monospot causes include hepatitis, rubella, parvovirus, lymphoma, leukaemia, malaria, pancreatic cancer, SLE. PCR if unsure
Management: Usually self-limiting, so fluids and rest. Never give ampicillin or amoxicillin for sore throats as they often cause a severe rash in those with acute EBV infection.
Complications: Thrombocytopaenia, Guillian-Barre syndrome, meningitis, encephalitis, facial nerve palsy. Splenic rupture (Avoid contact sports for 8 weeks)
What is an adenoid and what is adenoidectomy?
A mass of lymphatic tissue situated posterior to the nasal cavity at the roof of the nasopharynx. They enlarge until age 5-7, may even be symptomatic at 18-24months due to rate of growth but as child grows these symptoms decline. They shrink after 7 by adulthood they have disappeared completely.
It may be necessary to remove the adenoids if they become swollen or enlarged due to infection (adenoiditis) or in severe allergies, also may be removed during surgical treatment of glue ear.
Describe the findings in webers and rinnes test and the difference in bone and air conduction.
Rinne test compares perception of sound transmitted by air conduction to those by bone conduction through the mastoid. It allows screening for presence of conductive hearing loss. It is assessed using a low fequency 512hz by ear then on mastoid asking which is louder. Rinne negative is where BC is greater than AC this occurs in conductive hearing loss, but occasionally severe sensorineural hearing loss. Rinne +ve is where AC is greater than BC and this is normal or may be due to sensorineural hearing loss.
In order to intepret the above test one must perform webers test in order to assess for sensorineural deafness. Webers involves using the same tuning fork on the forhead and ask the patient where the sound is localised one ear or both. In conductive hearing loss sound is localised to the affected ear whereas in sensorineural hearing loss it is localised to the contralateral ear, and the midline if bilateral or normal
Describe tinnitus and some causes
Tinnitus is a sensation of non-verbal sound not due to external stimuli.
Causes:
- Ringing, hissing, or buzzing suggests an inner ear or central cause.
- Popping or clicking, suggests problems in the external or middle ear of the palate.
- Pulsatile sounds may reflect anxiety, benign intracranial hypertension, glomus tumours, carotid body tumours, carotid stenosis, AV malformatons, aneurysms, high-output cardiac states.
Two important questions are if the tinnitus is unilateral or pulsatile, both require investigation, unilateral tinnitus is characterstic of acoustic neuroma and requires MRI to exclude and pulsatile tinnitus may be indicative of serious pathology e.g. cardiac
Describe Rhinosinusitis, its symptoms and management
Defined as inflammation in the nose and paranasal sinuses with more than 2 symptoms, one of which must be nasal congestion or nasal discharge
Other symptoms: facial pain or pressure, decreased olfaction, endoscopic signs of nasal polyps or mucus.
Management:
-Topical steroids and oral antiobiotics are first line for adults with acute rhinosinusitis, for adults with chronic rhinosinusitis (more than 12 wks), topical steroids and nasal douching is first line
Describe Ramsay-Hunt syndrome, its symptoms, and management
Also known as herpes zoster oticus. Severe otalgia, often in the elderly, precedes VII and other cranial nerve palsies.
Symptoms: Severe Otalgia, Zoster vesicles appear around the ear, in the deep meatus there may be vertigo +/- sensorineural deafness.
Mangement: Valaciclovir 1g/8h PO + Prednisolone 20mg/8h PO for 5 days reducing gradually over additional 5 days
Describe a branchial cyst
Emerge under the anterior border of the sternocleidomastoid where the upper 1/3 meets the middle 1/3 typically in people under 20. lined by squamous epithelium their fluid contains cholesterol crystals treat by excision.
Describe a thyroglossal cyst.
A midline lump usually in patients under 20 that moves on protruding the tongue and swallowing.
Describe Head+Neck squamous cell carcinomas, the types, and main symptoms.
Types:
- Nasopharyngeal cancer: 25% of all cancers in china vs 1% in UK. Associated with HPV and woodwork
- Oropharyngeal carcinoma: often advanced at presentation.
- Hypopharyngeal tumours: rare, usually disease of elderly
- Squamous cell laryngeal cancer: associated with HPV, typically older patient smoker.
- sinus squamous cell cancer: suspect when chronic sinusitis presents for first time in later life.
Symptoms:
- Neck pain/lump
- Hoarse voice more than 6wks
- Sore throat more than 6wks
- Mouth bleeding
- Mouth numbness
- sinus congestion
- sore tongue
- painless ulcers
- patches in mouth
- earache/effusion
- lumps in lip mouth of gum
- speech change
- dysphagia
- epistaxis.
Have low threshold for referral whenever symptoms above occur especially in smokers.
Describe Meniere’s disease, its symptoms, and management.
Disease of unknown cause that leads to dilatation of the endolymphatic spaces of the membranous labyrinth.
Symptoms: vertigo for around 12h with prostration, nausea/vomiting, aural fullness/pressure, uni or bilateral tinnitus, and progressive sensorineural hearing loss.
Management:
- Life styles measures such as low-salt diet, avoiding caffeine, alcohol and tobacco are often advised.
- vertigo + nausea can be alleviated by prochlorperazine.
- Betahistine 16mg PO TDS may have a role in preventing attacks
Describe hoarseness and its causes
Difficulty in producing sound with change in voice pitch or quality. Investigate hoarseness especially in smokers lasting more than 3wks as it is chief presentation of laryngeal carcinoma. Ask about GORD, dysphagia, smoking, stress, singing.
Causes: laryngitis, sarcoidosis, TB, goitre, carotid body tumour, neoplasia e.g. Pancoasts syndrome, lymphoma, larynx of thymus cancer, epiglottis, aortic dissection, anaphylaxis, acromegaly, addisons.
Describe Scarlet Fever, its symptoms, and management
If a rash develops on the chest, axillae, or behind the ears, which is accentuated in skin folds, 12-48h post sore throat +/- strawberry tongue consider scarlet fever.
Management:
-start penicillin as treatment, if after a week the child presents with odd movements, dizziness, walking difficulty or altered consciousness, you may be able to diagnosis a post eiinfections demyelinating disorder such as ADEM.
Describe Labyrinthitis, its symptoms, and management
A cause of vertigo, due to inflammation of the membranous labyrinth of the inner ear. Usually viral in origin preceded by URTI. If there is no hearing loss consider Vestibular neuritis. Usually occurs in adults 30-60yrs.
Symptoms: sudden severe vertigo, sudden unilateral hearing loss, tinnitus, otorrhoea, N+V, fever, facial weakness, URTI, visual changes. No aural fullness like meneire’s.
Management:
- Sudden unilateral hearing deafness requires urgent assessment by ENT as it may be acute ischaemia.
- Usually self-limiting (up to 3wks) patient can be managed at home advised to lie still with eyes closed.
- Prochlorperazine may help with vertigo and N+V.
- Short course of Prednisolone may be helpful
- advices not to drive or operate machinery until symptoms subside.
What are some contraindications to ear syringing (irrigation)?
- Perforation past or present of ear drum
- ear infection
- presence of grommet
- history of ear surgery
- uncooperative young children
Describe Oral Mucocele, it’s symptoms and management,
Symptoms: Small polyps of the mucosal lining of the mouth, also known as ranula when on the floor of the mouth. May have a bluish tinge and vary from 1mm 2-3cm. May appear Fluctuant but can also be firm, typically last from days to years and may have recurrent swelling with occasional rupturing of contents.
Management:
-not usually a problem unless in the way of chewing or causing distress which may require surgical removal or marsupialisation.
What is Lemierre’s Syndrome?
Septic Thromboplebitis of the internal jugular vein that leads to septic usually pulmonary embolism associated with ENT infection usually fever neck pain and tonsillopharyngitis. It is mainly due to Fusobacterium Necrophorum
