ENT Flashcards
What characteristics of a hoarse voice would be more worrying for cancer?
If it was constantly hoarse rather than being worse in the evening
or if there is a neck lump
What is the best imaging modality for the nature of a neck lump?
What is the best investigation in general?
Ultrasound, as very accessible.
Definitive diagnosis requires fine needle aspiration (best initial investigation)
What type of cancer do head and neck cancers tend to be?
Squamous cell carcinoma
If you want to know tumour grade in head and neck tumour, how should it biopsied?
What should be avoided?
Ultrasound guided fine needle aspiration
NOT excision
risk of seeding cancer or compromising margins and creating scarring
When is a barium swallow useful in head and neck cancers?
If suspecting lower oesophageal tumours as well
Why do vocal nodules form?
In people who use their voice alot and shout, the constant impact of speaking smacks chords together leading to nodules forming
How do you treat vocal nodules?
Vocal therapy (not surgery)
Risk Factors for head and neck cancers
Smoking Alcohol Betel nut chewing (tobacco) Male Publicans- who are exposed to smoke
In TNM staging for head and neck tumours, what characteristics determine the N score?
Nodes- size, unilateral/bilateral, multiple/single
40 year old presents with throat cancer, has never smoke or drunk to excess. What might be the cause? What puts you at risk?
Human papillomavirus 16 +18
Oral sex with multiple partners
A patient with severe tonsillitis can’t swallow, can’t take antibiotics, how to treat?
Admit as they can’t swallow so can give IV antibiotics
plus dexamethosone
Epstein Barr virus = glandular fever
why should you avoid amoxicillin?
Gives an erythematous rash
When should tonsils be removed in children?
In children, if they get tonsillitis
7x year for 1 year
5x year for 2 years
3x year for 3 years
What are the complications of tonsillitis?
Abscesses
Upper airway compromise (very rare)
In sleep studies of obstructive sleep apnoea patients, what variables are measured?
Apnoea = cessation of sleep for 10 seconds
Hypoapnoea = reduction in ventilation by 50% for 10 seconds
Or drop in 02 sats 4% blow baseline
Where are most salivary glands found?
80% in parotid gland
What pathological type of tumour are salivary gland tumours?
80% benign- pleomorphic adenoma
Cheek and earlobe numb unilaterally and a cheek swelling.
Diagnosis?
Salivary gland tumour of parotid
numbness is due to compression of auricular nerve as it passes over parotid
What is Frey’s syndrome?
Auriculotemporal nerve damage causes erythema and sweating in the cutaneous distribution of the auriculotemporal nerve, usually in response to gustatory stimuli.
Which viruses cause tonsillitis?
herpes simplex Epstein- Barr Cytomegalovirus Other herpes Adenovirus Measles
Bacterial causes of tonsillitis
Group A beta haemolytic strep- strep pyogenes
steph pneumoniae
staph aureus
haemophilus influenzae
Unilateral tonsil enlargement + loss of weight
whats the possible cause?
Lymphoma
Types of squint
esotropia = eye turns in, convergent squint
exotropia = eye faces out, divergent squint
accommodative convergent squint- corrects with glasses for near vision
Imaging for foreign body in the orbit?
CT
Which wall of the eye is most commonly fractured?
Referral?
The orbital floor- often with squash balls impact
Refer maxfax + avoid blowing nose
In a ruptured globe what is the treatment in A+E?
eye shield NOT cotton pad
The accessory nerve innervates what?
CNXI- trapezius and sternocleidomastoid
Palsy of CN III causes what abnormal eye movement?
Looking down and out
40 year old man has severe and recurrent nose bleeds, he gets nosebleeds during sleep sometimes, his lips have av malformations visible as red splodges on them. What could a rare cause be? And complication?
Osler-Weber-Randu
Autosomal dominant hereditary haemorrhagic telangiectasia
May become anaemic requiring transfusion
What is the blood supply to the nose broadly?
External carotid a:
Maxillary a (sphenopalatine)
Facial
Internal carotid a:
Ophthalmic a (ethmoid a)
Where do most nosebleeds occur?
What type of haemorrhage do these cause
Kisselbachs plexus (little's area) Where internal carotid and external carotid branches anastamose Anterior haemorrhage
10% sphenopalatine a (from maxillary + eca)
Posterior haemorrhage
How can anterior and posterior haemorrhage in nosebleeds be differentiated?
Anterior hameorrhages have a visible source with rhinoplasty
Person with asthma complains of a chronic cough and constantly blocked nose? Treatment?
Allergic rhinitis + asthma:
nasal steroids + antileukotrine (zafirlukast)
(stops rhinitis triggering asthma)
Rx for allergic rhinitis:
1st line:
- Oral antihistamines
- Oral decongestants
- Nasal antihistamines or steroids (for 1 MONTH at a time MAX)
2nd line:
Oral steroids
How can rhinitis be differentiated from a csf leak?
Nasal dipsticks: csf is +ve for glucose
But not that accurate
Send to lab for better results, csf has b2-transferrin
Gentleman has a blow to the nose, a few days later he has a big red cherry in the middle of his nose where the septum is, what is it? What are the risks of it?
Septal haematoma
Drain in theatre and pack
Risk: septal necrosis, nasal collapse
How soon does a nasal fracture need to be reduced before it sets in place?
Aim to reduce under general anaesthetic before two weeks
Sets by three weeks
What is the management of different types of foreign body put in nostrils or ear holes?
Inorganic- can leave a little while, may not get discharge
Organic- remove quickly (one day or so), purulent discharge
Button batterys- remove immediately, erodes, causes death
How can you differentiate between a nasal polyp and inflamed inferior turbinate if you’re a gp?
Nasal polyps are pale (greyish) and insensitive, mobile
Whereas a swollen inferior turbinate will be sore
Medical Rx for nasal polyps?
Betamethasone sodium phosphate drops (polyps are eosinophilic in 90%) for 2 days
Beclometasone spray
Doctor notices a nasal polyp in his 8 year old patient. Whats most likely diagnosis?
Polyps are rare in the under 10s
Commoner is:
Neoplasms
Meningocele/encephalocele (herniation of cranial contents)
Especially if under 2 + unilateral
Cystic fibrosis
Unilateral nasal polyp in 54 year old patient. Investigations?
As unilateral, could be malignant
CT
Biopsy for histology
Common causes of tonsillitis?
Sore throat
Group A streps- strep pyogenes
Staphs Moraxella catarrhalis Mycoplasma Chlamydia Haemophilius
Differential of tonsillitis (sore throat + lymphadenopathy)
Infectious mononucleosis- Epstein Barr (HHV-4)
doesn’t resolve in one week, systemic symptoms
Agranulocytosis- low WCC
leukaemia
Diptheria- Corynebacteria
grey green membrane over oropharynx
Child has a very sore throat that is not resolving and a small neck lump, what Ix to exclude retropharyngeal abscess?
Lateral xray to look for soft tissue swelling
30 year old had a sore throat for a week and now cannot swallow saliva due to pain, on ehx the uvula is displaced to the left. Diagnosis?
Other typical symptoms?
Peritonsillar abscess (quinsy) Can be a life threatening complication of acute tonsillitis
Odynophagia (pain on swallowing)
Hot potato voice
Trismus (jawlock)
Name that syndrome:
Pharyngotonsillitis
+ internal jugular vein phlebitis
+ septic embolization (often lungs)
And causative pathogen
Lemierres syndrome
Fusobacterium necrophorum
High dose benpen, clindamycin, metronidazole
Difference between scarlet fever and rheumatic fever?
Both caused by group a strep:
Scarlet fever- strep pharyngitis + sandpaper rash
Rheumatic fever- post-infectuous sequelae of strep pharyngitis according to jones criteria
(Jones= carditis, polyarthritis, erythema marginatum, chorea, nodules)
What is the pathophysiology of post-infectious demyelinating disorder or chorea following strep throat?
Demyelinating: antigen mimicry leading to antibodies forming against cns epitopes
(Can occur with mycoplasma, streps + ebv)
Chorea: antibodies against corpus striatum in basal ganglia causing jerky uncoordinated movements
How many episodes of tonsillitis a year warrant a tonsillectomy?
5 or more
Commonest cause of barking cough and stridor in children?
Laryngotracheobronchitis/croup
95% is viral like parainfluenza
Especially if no drooling
Much commoner than epiglossitis- tend to drool
What is the severity grading for croup?
1 = barking cough + inspiratory stridor 2 = 1+ expiratory stridor 3 = 2 + pulsus paradoxus 4 = 3 + cyanosis or decreased consciousness
Child has barking cough and stridor, what xray sign would confirm croup (laryngotracheobronchitis)?
Steeple sign (trachea tapering around the thyroid area)
Rx for severe croup?
Mild croup is self-limiting
Antibiotics
Humidified o2
Adrenaline 5mL 1:1000 neb
Steroid PO or NEB
Someone who doesn’t have the haemophilus vaccine is at risk of…?
Acute epiglottitis
Newborn baby has some stridor, whats the cause and treatment?
laryngomalacia
Immature and floppy aryepiglottic folds leads to larynx collapse on inspiration
Generally self limiting, improves by age 2
How do laryngomalacia and laryngeal paralysis present different in neonates in classical presentations?
Laryngomalacia (floppy larynx) = stridor
Laryngeal paralysis = hoarse breathy cry
If someone has airway obstruction, and you can hear the stridor, once stable what IHx can help identify the cause?
Flexible nasendoscopy
AP + lateral xrays of neck and chest
Causes: inflammation, tumour, trauma, foreign body, vocal cord paralysis
Patient complains of a hoarse voice and pain after eating sometimes, likely cause and rx?
Reflux laryngitis (from gastro-oesophageal reflux disease)
PPI
+/- surgical fundoplication
Reinke’s oedema is…?
And is associated with…?
A gelatinous enlargement of the vocal cords
Associated with smoking and hypothyroidism
How can you distinguish between partial and complete cord paralysis when looking with a scope?
Partial- cords fixed in midline as abductors tend to be damaged more often than adductors so muscles are unopposed
Complete- fixed mid-way (abductors and adductors wiped out)
What risk factors is nasopharyngeal cancer (squamous cell) associated with?
HLA-A2 allele Human papillomavirus virus (oral sex) Epstein barr virus Tobacco, formaldehyde, wood dust exposure Salted fish
What is the mainstay of treatment for nasopharyngeal squamous cancers?
Radiotherapy
+/- chemotherapy or surgery
What is the histology of oropharyngeal cancers?
85% are squamous
Adenocarcinoma of salivary glands
Lymphoma
Melanoma
Patient has increasing hoarseness and smokes, what investigations?
Want to exclude squamous cell laryngeal cancer:
Laryngoscopy + biopsy
Hpv +ve
Mri for staging
Child has barking cough and stridor, what xray sign would confirm croup (laryngotracheobronchitis)?
Steeple sign (trachea tapering around the thyroid area)
Rx for severe croup?
Antibiotics
Humidified o2
Adrenaline 5mL 1:1000 neb
Dexamethosone po / budesonide neb
Someone who doesn’t have the haemophilus vaccine is at risk of…?
Acute epiglottitis
Newborn baby has some stridor, whats the cause and treatment?
Immature and floppy aryepiglottic folds leads to larynx collapse on inspiration
Generally self limiting, improves by age 2
How do laryngomalacia and laryngeal paralysis present different in neonates in classical presentations?
Laryngomalacia (floppy larynx) = stridor
Laryngeal paralysis = hoarse breathy cry
If someone has obstruction, once stable what IHx can help?
Flexible nasendoscopy
AP + lateral xrays of neck and chest
Causes: inflammation, tumour, trauma, foreign body, vocal cord paralysis
Patient complains of a hoarse voice and pain after eating sometimes, likely cause and rx?
Reflux laryngitis (from gastro-oesophageal reflux disease)
PPI
+/- surgical fundoplication
Reinke’s oedema is…?
And is associated with…?
A gelatinous enlargement of the vocal cords
Associated with smoking and hypothyroidism
How can you distinguish between partial and complete cord paralysis when looking with a scope?
Partial- cords fixed in midline as abductors tend to be damaged more often than adductors so muscles are unopposed
Complete- fixed mid-way (abductors and adductors wiped out)
What risk factors is nasopharyngeal cancer (squamous cell) associated with?
HLA-A2 allele Human papillomavirus virus (oral sex) Epstein barr virus Tobacco, formaldehyde, wood dust exposure Salted fish
Patient has increasing hoarseness and smokes, what investigations?
Want to exclude squamous cell laryngeal cancer:
Laryngoscopy + biopsy
Hpv +ve
Mri for staging
Arteries making up the littles area
Legs
Superior Labial
Ethnoidal (anterior and posterior)
Greater palatine
Sphenopalatine
Common causes of otitis externa?
Staph and pseudomonas
Old man has foul smelling discharge coming from his ear and pain, not responding to antibiotics. Diagnosis?
Cholesteatoma
Chronic otitis media would respond to antibiotics
What is the different typical demographic of adenocarcinoma of the maxillary sinus vs nasopharygneal cancer?
Adenocarcinoma- lumberjack, wood particle inhalation
Nasopharyngeal- southern chinese man who eats salted fish
If a child has a thyroglossal cyst what must you do before removing it and why?
Radioactive isotope scan incase the cyst is the only functional thyroid tissue they have
15 year old has a lump around his sternocleidomastoid muscle, he is fit and well. What could be the cause and its derivative
Branchial cyst, occurs when the second branchial cleft doesn’t obliterate
What are the benign tumours of the parotid gland?
Pleomorphic adenoma
Adenolymphoma
How many episodes of apnoea (10 secs no breathing) or hypapnoea (50% decreased ventilation) per hour would define mild, moderate or severe obstructive sleep apnoea in adults?
Mild: 5-15
Moderate: 15-30
Severe: 30+
How do you classify different bleeding after surgery?
Intra-operative
Primary (within 24hours)
Secondary (after 24hours)
For tonsillectomy most bleeding occurs 5 days later
What things in the history suggest neurological vs stricture (benign or malignant) causes of dysphagia- swallowing difficulty?
Fluids can be swallowed still- suggests stricture rather than neuro cause (bulbar palsy/ lat medullary syndrome)
Difficult to do swallowing movement + causes coughing (neuro)
Constant + painful (stricture)
Neck bulge or gurgle on drinking (pharyngeal pouch)
60 year old man has had swallowing difficulty, has a bulge in their neck and can hear gurgling upon swallowing fluid and bad breath. What imaging modality will help plan management?
Rx?
Pharyngeal pouch- barium meal
At increased risk of oesophageal perforation.
Can do endoscopic stapling
Which branch of the facial nerve runs through the middle ear and what structures does it run between?
Chorda tympani (2/3rds taste anterior tongue) Between malleus and incus and tensor tympani muscle
What are the bones of the middle ear and which connect to the tympanic membrane?
Mis
Malleus (connects with tympanic membrane)
Incus and stapes
What tests could you do to determine the level of a facial nerve lesion?
Above geniculate ganglion, loss of lacrimation (parasympathetic, greater petrosal nerve)
Above middle ear, loss of stapedius dampening noise
Loss of taste to ant 2/3rds tongue- electrogustometry
And submandibular salivation (chorda tympani)
Patient has fever, ear pain and has noticed the side of her face is drooping, she can’t raise her eyebrows. No vesicles noted in the ear or surround.
Ehx: tympanic membrane is bulging
Diagnosis and rx?
Otitis media, facial nerve palsy due to compression in middle ear
(Vesicles would suggest herpes zoster/ramsay hunt)
Amoxicillin
If a patient has bells palsy with severe paralysis, what three symptoms would suggest a herpes zoster cause and indicate highdose antivirals like valaciclovir?
Ear pain
Stiff neck
Red auricle
(Also vesicles around ear)
Rx for bells palsy onsetting in last 24 hours?
Prednisolone if in the last 24 hours
Valaciclovir (higher dose if prodrome of virus)
Artificial tears
Likely diagnosis of a midline lump in someone under 20
Dermoid cyst (teratoma) Thyroglossal cyst (fluctuant that moves onto protruding tongue)
What are branchial cysts?
Found at the upper third of sternocleidomastoid
Lined by squamous epithelium
Filled with cholesterol crystals
In under 20s
Describe the course and branches of the facial nerve
- Medulla- internal acoustic meatus- facial canal
- Forms geniculate ganglion, gives off greater petrosal nerve with parasympathetic to lacrimal gland
- Middle ear, gives off nerve to stapedius and chorda tympani
- Stylomastoid foramen
- Nerve to occipitofrontalis
Nerve to post belly of digastric and stylohyoid
Nerves to face (ten zebras broke my car)
Patient has fever, ear pain and has noticed the side of her face is drooping, she can’t raise her eyebrows. No vesicles noted in the ear or surround.
Ehx: tympanic membrane is bulging
Diagnosis and rx?
Otitis media, facial nerve palsy due to compression in middle ear
(Vesicles would suggest herpes zoster/ramsay hunt)
Amoxicillin
Acute bilateral parotid gland swelling with dry mouth. Differential diagnosis?
Mumps
Staph infections
HIV
TB
Acute lymphoblastic leukaemia
Heerfordt’s syndrome- acute sarcoid with fever, uveitis, salivary gland swelling
Patient who has sarcoid develops:
Fever
Uveitis
Salivary gland swelling
Name the syndrome and the mechanism
Heerfordt’s syndrome: uveoparotid fever
Investigations to look at a red, swollen tender lump under the chin. Pain is worse on eating. Keeps happening and resolving.
Salivary gland stones- 80% submandibular
Plain radiograph/sialography
Contrast injected into salivary glands
Rx for chronic infection of the salivary glands?
Prolonged oxyetracycline
Freys syndrome?
Thinking of food or eating food causes a rashy redness and swelling of the cheek.
Due to a mix up between the parasympathetic to parotid salivary glands and synpathetic input to facial sweat glands.
Normally auriculo-temporal nerve of Trigeminal carries parasympathetics to parotid
Patient has tooth pain, what features suggest whether the tooth is alive, dead or with an abscess?
Character:
Intermittent = alive
Constant = dead
Exacerbating:
Worse with sugar, heat or cold = alive
Worse on percussion = dead
Worse on movement with finger or thumb = abscess
Causes of gum swelling (fibrous hyperplasia)
Pen, knife, spoon
Phenytoin, nifedipine, ciclosporin Pregnancy AML- leukaemic infiltrate HIV Scurvy
What kind of analgesia and antibiotics does tooth pain and infection tend to respond to?
Nsaids- not opioids
Penicillin + metronidazole
Gardener has a very tender inflamed nodule on the helix of his ear. Name the condition and treatment?
Chondrodermatitis nodularis helicis
Excise skin and underlying cartilage
Why do people get cauliflower ear, how can it be prevented?
From ischaemic necrosis following a pinna haematoma.
Drain and pack the ear to avoid this
When should syringing of the ear be avoided?
If the eardrum is perforated (keep it dry)
Or grommets
Cleft palate or mastoid surgery
What does tympanometry and audiometry measure?
Typanometry: Middle ear pressure and tympanic membrane compliance
Audiometry: Lowest dBs that can be heard with each ear
What age should children be referred to speech therapy by if they have a stammer or a lisp/difficulty with ‘r’ or ‘th’ sounds?
Stammer- age 4
Lisps etc- age 5
A child has an itchy painful ear and tenderness of the tragus. What is the diagnosis and possible causes?
In an adult, if resistant to rx what should be done?
Otitis externa
Pseudomonas
Staph aureus
Resistant- biopsy incase its malignant
Carbuncles (collection of boils) or furunculosis (infected hair follicle) are caused by…?
Staph aureus
Strep pyogenes typically
A patient has pain of the jaw, she often grinds her teeth and in her pmh she has depression. What may be the cause? And Rx?
Temporomandibular joint dysfunction
Lateral movement of open jaw makes it worse
Rx nsaids, stabilizing orthodontic prostheses, cognitive therapy etc
What nerves refer pain to the pinna of the ear and what areas are the real source of injury?
Upper half pinna- V (auriculotemporal nerve) refers dental or TMJ dysfunction pain
Lower half pinna- C2,3 (auricular nerve) in neck injury and cervical spondylosis
What nerves refer pain to eardrum and what is the real site of injury?
Lateral drum- VII refers in geniculate herpes
Medial drum- IX (tympanic) + X (auricular) refers posterior tongue, larynx, throat in tonsillitis, quinsy
Which patients are most at risk of necrotizing otitis externa?
90% occurs in diabetic patients
=life threatening infection that can destroy temporal bone and base of skull.
Requires surgical debridement, abx, IV Ig
First line Rx of acute otitis media?
Amoxicillin 7days
How does chronic and acute otitis media present differently?
Acute- pain, fever +/- irritability, anorexia, vomiting
Often after viral URTI
Chronic- discharge, reduced hearing, little pain
EHx if discharge can’t drain retraction of pars tensa/flaccida occurs
Foul smelling discharge from the ear with pain suggests…? Rx?
Cholesteatoma- squamous cell overgrowth eroding bone etc
Mastoid surgery to remove the disease
Imaging if suspect mastoiditis?
CT scan
A tympanometry study on an adult found there was middle ear fluid, what needs to be excluded and how?
Postnasal space tumour incase it is blocking the eustacian tube
Use nasendoscopy to visualise
What are the risk factors for glue ear?
Boys, winter
PMH: downs, atopy, primary ciliary dyskinesia
SHx: passive smoking
When would you give surgery for glue ear?
(Chronic serous/secretory otitis media)
What do patients need to know about their grommets?
Persistent bilateral otitis media for 3 months +
With hearing in better ear below 25-30dB
No diving, use cotton wool and vaseline to plug ear when using shampoo
Pierre robin syndrome?
Micrognathia (short chin)
+/- cleft palate, eye abnormality, conductive deafness
Treacher collins syndrome?
Autosomal dominant
Eyes slant down, notch in lower eyelid, underdeveloped facial bones
Associated with deafness
Autosomal dominant causes of sensorineural hearing loss?
WAK
Waardenburg- hearing loss and odd coloured eyes/blue eyes
Alport- kidney disease, hearing loss, misshapen lens in eye or retinal defects
Klippel-Fiel - fused cervical vertebrae so short neck, restricted neck turning,n
Baby has sensorineural hearing loss, which autosomal recessive syndrome would they have if they also had:
A) goitre
B) retinitis pigmentosa (rod degeneration)
C) long qt interval
A) goitre = pendred
B) retinitis pigmentosa = ushers
C) long QT= jervell and lange-nielisen
Which x linked conditions may cause sensorineural hearing loss?
Alports- pyelonephritis, haematuria, renal failure
(Can also be autosomal recessive)
Turners- short stature, webbed neck
What screening tests can you do on a newborn to check for deafness?
Otoacoustic emissions-
Detects the sounds of fluid moving in the basilar membranes in response to auditory stimuli
Audiological brainstem responses-
Measure brain wave activity in response to earphones producing soft clicks
In what types of deafness will cochlear implants not help with?
What can cause this congenitally?
The h’s
Central deafness-
hyperbilirubinaemia
hypoxia
intraventricular haemorrhage
When would you c…c…consider a bone anchored hearing aid?
3 C’s
Can’t use traditional hearing aids:
draining ear
mastoid cavity
topical sensitivity
Congenital malformations:
Microtia (no pinna)
Atresia (no external ear canal)
Can hear on one side (unilateral deafness)
What are the dangerous causes of unilateral deafness that need to be excluded?
Acoustic neuroma
Cholesteatoma
Nasopharyngeal cancer effusion
What is the definition of sudden sensorineural deafness in an adult?
(Rule of 3s)
Loss of more than 30dB
in three neighbouring pure tone frequencies
in 3 days
Gentleman comes in with sudden sensorineural deafness, he mentions he started antibiotics recently, what antibiotic could be the cause?
Gentamycin (ototoxicity)
What audiometry finding suggests otosclerosis?
What is otosclerosis?
Cahart’s notch: a dip dB threshold for bone conduction at 2kHz.
(85% bilateral)
Otosclerosis- replacement of lamellar bone with vascular spongy bone around the stapes footplate fixing it in place
Rx of otosclerosis?
Fluoride may inhibit sclerotic progression
Surgery to replace the adherent stapes with an artificial implant
Hearing aid
What are the ototoxic drugs to look out for on a drug chart?
Will cause difficulties watching VHS of Gangsta’s + Cowboys
Vancomycin
Hydrochloroquine (DMARD)
Streptomycin
Gentamycin
Chloroquine (malaria)
Postinfective causes of sensorineural deafness?
Mmm, her philis flew
Meningitis
Mumps
Measles
Herpes
Syphilis
Flu
How are severe and significant hearing loss defined?
Severe- more than 100-120dB loss
Significant- more than 35dB loss
Causes of pulsating tinnitus sounds in the ear?
Vascular causes: Tumours- glomus or carotid body
Vessel shape- Aneurysm, aortic stenosis, AV malformations
Cardio- hypertension, high output cardiac states (hyperthyroid, Pagets)
Anxiety
Benign intracranial hypertension
How does the type of tinnitus sound help point towards to the site of the problem?
Hissing, buzzing or ringing = inner ear or central
Popping or clicking = middle or external ear
Pulsatile = vascular/anxiety
Drug causes of tinnitus?
Daaa
Loop diuretics
Aspirin
Aminoglycosides
Alcohol excess
Type of tumour in acoustic neuromas?
Origin
Tumour of the schwann cell layer of the superior vestibular nerve (CN VIII)
Which cranial nerves may be affected in acoustic neuromas?
CN V (facial numbness) CN VI (abducting eye) CN VII CN VIII (giddiness, deafness, tinnitus)
What is vibroacoustic disease?
An occupational disease occurring in workers
exposed to large pressure or low frequency noise
leading to abnormal growth of extracellular matrices in blood vessels, thickening pericardium and lung fibrosis etc
How do peripheral causes of vertigo differ in presentation from central causes?
Peripheral- often hearing loss, tinnitus, nausea, vomiting
Central- hearing loss and tinnitus less common, tends to be less severe
Audiometry shows bilateral hearing loss of high frequencies, what is the likely cause in adults?
Presbycusis
From death to hair cells with age
Inheritance pattern of otosclerosis?
Autosomal dominant
What signs may occur in Meniere’s disease?
Nystagmus
Rhomberg’s sign +ve (fall over when closing eyes)
What inherited condition is associated with bilateral acoustic neuromas?
Other symptoms?
Neurofibromatosis type 2
Auto-dominant Early cataracts (juvenile posterior subcapsular lenticular opacity) May get meningiomas also
Signs of neurofibromatosis type 1?
Cafe-au-lait spots Freckling in skin folds- axillae, groin Dermal neurofibromas- skin coloured moles Lisch nodules- brown mounds in iris Short stature
Rx for trigeminal neuralgia?
Carbamazepine (antiepileptic)
Baby has a massive lump on the side of her neck that transilluminates brightly and is soft and fluctuant, likely diagnosis?
Cystic hygroma
Congenital lymphatic lesion
A patient has a red eye, how do glaucoma and uveitis present differently?
Glaucoma- severe pain, halos, semi-dilated pupil, cloudy pupil
Uveitis- small fixed oval pupil, ciliary flush (ring of red spreading out from the cornea)
How does the duration of vertigo help indicate the possible cause?
Seconds to minutes- benign positional vertigo
Up to 30 minutes- Menieres
30 hours to a week- acute vestibular failure (follows febrile illness)
First line Rx for meniere’s disease where the patient is throwing up?
Prochlorperazine (D2 receptor antagonist)
Betahistine may help (H3 histamine antagonist)
What causes benign positional vertigo?
Dislodged calcium carbonate crystals (otoconia) going from being embedded in cells, floating into the semicircular canal fluid
What test differentiates benign positional vertigo and a central cause of vertigo (and how?)
Hallpike manoeuvre:
Rotate the head 45 degrees, lie down suddenly with head extended 20 degrees, wait 45 secs. Look for nystagmus
CNS cause suggested if
If up and down beating nystagmus with no rotational nystagmus
No latency of 15-20 seconds before onset of nystagmus on lying
Nystagmus isn’t fatiguable on repetitions
No dizziness
Electronystagmography
What happens to lines on a amsler grid in macular disease?
Intersecting lines appear wavy and squares distorted
Young guy has unilateral hearing loss, examination of ear is normal, possible diagnosis to exclude?
Acoustic neuroma
Retraction of the ear drum in the ‘attic’ commonly occurs with what?
Cholesteotoma, as the attic is the weakest thinnest part of the tympanic membrane and so more prone to retraction
Common cause of acute otitis media in children?
Viruses
Strep pneumo
Haemophilis
Moraxella catarrhalis
Describe the course and branches of the facial nerve
- Pons- internal acoustic meatus- facial canal
- Forms geniculate ganglion, gives off greater petrosal nerve with parasympathetic to lacrimal gland
- Middle ear, gives off nerve to stapedius and chorda tympani
- Stylomastoid foramen
- Nerve to occipitofrontalis
Nerve to post belly of digastric and stylohyoid
Nerves to face (ten zebras broke my car)
Name for benign outgrowth of cartilage in the ear?
Exostosis
On ear examination what test can identify a patent eustacian tube?
Valsalva manoeuvre- check the ear drum moves
Why do accessory tags or fistulas/sinuses form congenitally in the ear?
Malfusion of the 1st and 2nd branchial arches
White patches on an eardrum are due to?
Tympanpsclerosis- calcium deposits following trauma or infection
Often of no significance unless severe (may cause conductive loss then)
Rx for severe otitis externa?
Meatus may be narrowed, take swab + scoop out wax/debris
Non-infected eczema = steroid drops
Infection = Steroid + antibiotic drops (sofradex)
Resistent pseudomonas = gent + hydrocortisone drops (max 2 weeks)
Patient has been using antibiotic and steroid drops for otitis externa for the last few weeks. What are they at risk of?
Fungal infection- clotrimazole Rx
What is the risk of diabetic or immunocompromised ear infection and Rx?
Necrotizing otitis externa- can lead to temporal bone destruction + osteomyelitis
Rx: surgical debridement, systemic antibiotics, Ig
Name for a very painful haemorrhagic blister deep in the ear canal + likely causative agent?
Bullous myringitis
Influenza
Rx: supportive
Drops that can be added in if wax is a problem in an otitis externa infection?
Sodium bicarbonate 5% drops
1st line investigation for someone with ear pain + redness with fever and a tender mastoid?
Mastoiditis
CT
Rx: IV antibiotics, incision of tympanic membrane (myringotomy)
Risk factors for otitis media?
Bottle feeding, use of a dummy
PC: Adenoids or cleft palate
PMH: URTI or GORD or Asthma
SHx: increased BMI in adults, passive smoking
Risk factors for otitis media with effusion (glue ear)?
Boys, winter season
PMH: atopy, Down’s syndrome, primary ciliary dyskinesia
SHx: parents smoke
(Not infectious)
What are the indications for grommets?
Bilateral persistent hearing loss
Where better ear hears
What do you need to tell parents if their child has grommets about what they can or can’t do?
Swimming yes
Diving no (forces water into middle ear)
Ear plugs when washing hair
Grommets extrude after 3-12 months
What are the syndromes associated with congenital conductive hearing loss.
NB note conductive not sensorineural
Pierre Robin: small jaw, cleft palate
Treacher Collins: small jaw, slanting eyes, malformed/absent ears
Autosomal dominant causes of sensorineural hearing loss?
WAK
Waardenburg: heterochromia, white lock of hair, wide set eyes
Alport: haematuria, cataracts
Klippel-Feil: limited movement of neck, scoliosis, cleft palate, short stature
Autosomal recessive causes of sensorineural hearing loss?
PUJ
Pendred: goitre
Usher’s: retinitis pigmentosa
Jervell + Lange-Nielson: long QT interval
X linked causes of sensorineural hearing loss?
Alport’s- haematuria, cataracts
Turner’s- webbed neck, short stature, XO
What hearing tests does a baby undergo and at what age?
Newborn hearing screening: within hours of birth
(Otoacoustic emissions + brainstem responses)
7 months: distraction testing
2-4 years: speech discrimination, conditioned response audiometry
5 years: pure tone audiogram
What imaging can damage cochlear implants?
MRI
Cause of gradual hearing loss with old age?
Presbycusis: loss of high-frequency sounds as hair cells are destroyed.
Problems encountered when high frequency vibrations of consonants cannot be heard.
What imaging can help to elucidate a cause in adults with hearing loss?
MRI- MS or Schwannoma
CT- cholesteatoma
What is the difference between vestibular neuritis and viral labyrinthitis?
Both tend to be viral, often proceeded by URTI and may have vertigo and vomiting.
Neuritis = nerve inflammation, labyrinthitis = inner ear
Neuritis affects vestibular branch, doesn’t cause hearing loss
Labyrinthitis affects cochlear nerve also so hearing loss
What determines 1st line Rx in Meniere’s disease?
Salt restriction
If vomiting: prochlorperazine (Dr antagonist)
If not: betahistine (histamine analogue)
Red flags that should not be present in a likely benign positional vertigo diagnosis?
- Persistent vertigo
- Speech, visual, motor or sensory problems
- Tinnitus, headache, ataxia, facial numbness, dysphasia
- Vertical nystagmus
What is the Hallpike test and what is it used to diagnose?
Benign positional vertigo
Patient sitting, examiner extends their neck and turns head to one side
Rapidly lower patient so laying flat with head hanging over the edge of the bed
Nystagmus after 5 seconds that lasts for 1 min is +ve
Rx for benign positional vertigo?
Epley manoeuvres:
Rapidly lower patient to supine
Rotate head quickly to the left, wait 30 seconds
Patient rolls onto left side, turn head to face floor
Patient is rapidly repositioned to sitting position
Or drugs (prochlorperazine/betahistine)
Difference between Rx for acute and chronic rhinosinusitis?
NB- not allergic rhinosinusitis
Acute- less than 12 weeks
Topical corticosteroids + oral antibiotics
Chronic- more than 12 weeks
Topical steroids + nasal douching
Difference in presentation between allergic rhinosinusitis and infectious rhinosinusitis
Allergic: sneezing, pruritis, atopy
Infectious: loss of smell, facial pain/pressure
Histology of nasal polyps?
Ciliated columnar epithelium
thickened basement membrane
Rx to get rid of nasal polyps?
Steroid drops
Oral steroids
Antileukotrienes + ciprofloxacin
IHx for a unilateral single polyp?
CT + biopsy
May be malignant
What investigation is used to identify the presence of tau transferrin in clear nasal discharge to determine the presence of a CSF leak?
Immunoelectrophoresis
+ a lab glucose (+ve in CSF)
In managing a nosebleed what protective layers should be worn?
Gloves
Gown
Goggles
Steps of nosebleed management:
- Gloves, gown, goggles
- 15 mins of pinching nose
- 0.5% ephedrine drops + ice on dorsum nose
- Remove clots, spray lidocaine
- Silver nitrate cautery for bleeding points
Nosebleed, silver nitrate hasn’t worked, next steps?
- Pack nose (lubricate pack)- remove after 24 hours
- Postnasal pack (foley catheter, filled with water)
Admit patients with packs.
- Serious posterior bleeds: endoscopic ligation of maxillary or sphenopalatine artery
Child has tonsillitis, you note that they have some skin peeling. What do you need to be thinking of?
Kawasaki- 5 day fever + 4 of: Non-purulent conjunctivitis Lymph nodes Dry lips/strawberry tongue Rash on trunk Joint pain, palmar erythema
Rx for tonsillitis fulfilling the centor criteria?
Penicillin
Allergic: erythromycin
Not amoxicillin
Rx for quinsy (peritonsillar abscess)?
Antibiotics: penicillin + metronidazole
+ Fine needle aspiration
NB preferred to surgical drainage but requires a cooperative child
What is distinctive about Scarlet fever?
Rash on chest, axilla or behind the ears
Accentuated in skin folds
+ strawberry tongue
Which infections can cause acute disseminated encephalopmyelitis because of their antigenic mimicry to CNS epitopes?
Mycoplasma (hence Guillian Barré)
Streps (post-scarlet fever)
EBV
Children under what age can’t have a surgical cricothyrotomy?
Under 12 years
Management of salivary gland swellings?
Remove if present for 1 month +
Or examine with fine needle aspiration, unlike neck lumps less fear of seeding tumour cells
Rx of pleomorphic adenoma?
1st: superficial parotidectomy
2nd: radiotherapy if recurrent or residual disease post-surgery
What symptoms makes a parotid tumour more likely to be malignant than an adenoma?
CN VII palsy
Children under what age can’t have a surgical cricothyrotomy?
Under 12 years
Management of salivary gland swellings?
Remove if present for 1 month +
Or examine with fine needle aspiration, unlike neck lumps less fear of seeding tumour cells
Rx of pleomorphic adenoma?
1st: superficial parotidectomy
2nd: radiotherapy if recurrent or residual disease post-surgery
What symptoms makes a parotid tumour more likely to be malignant than an adenoma?
CN VII palsy
