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MD2 > ENT > Flashcards

ENT Flashcards

1
Q

History of smoking and a cough - where might the cancer originate?

A

External - skin of head and neck (SCC or melanoma)

Internal - upper air/digestive tract

  • oral cavity + tonsils + larynx + pharynx
  • Nasopharynx (esp in asians)
  • lungs

Other

  • salivary glands
  • thyroid
  • lymphoma
  • supraclavicular lymph node (virchow’s node assoc w visceral malignancy)
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2
Q

What is troisier’s sign?

A

hard, enlarged virchow’s node (lymph node in the left supraclavicular fossa (the area above the left clavicle). It takes its supply from lymph vessels in the abdominal cavity)

strongly indicative of the presence of cancer in the abdomen, specifically gastric cancer, that has spread through the lymph vessels.

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3
Q

What do you think if a neck lump elevates with tongue protrusion?

A

Thyroglossal duct cyst

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4
Q

What investigations to perform for a neck lump?

A

Fine needle aspiration cytology (for SCC, melanoma, papillary thyroid carcinoma, nasopharyngeal carcinoma) - usually don’t need to take a biopsy.

Neck U/S
CT scan neck, oral cavity, nasopharynx
CXR

Thyroid function tests, Mantoux Tb text, FBC

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5
Q

DDX neck mass

A

Congenital (most common <20)

  • lateral: brachial cleft cyst
  • midline: thyroglossal duct cyst

Infectious/inflammatory (most common 20-40yo)

  • reactive lymphadenopathy (to tonsillitis or pharyngitis)
  • mono (glandular fever/EBV)
  • Kawasaki vasculitis
  • HIV
  • thyroiditis

Granulomatous

  • Tb
  • sarcoid

Neoplastic (most common >40)

  • lymphoma
  • thyroid tumour
  • salivary gland tumour
  • mets
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6
Q

what is leukoplakia?

Causes?

A

Areas of keratosis appear as firmly attached white patches on the mucous membranes of the oral cavity

Pre-malignant lesion, chance of formation to SCC is around 3%

Causes include smoking and alcohol and UV radiation.

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7
Q

What does persistent mouth ulceration indicate?

A

Suspicion of malignancy especially if co-existing with other risk factors (smoking, sun exposure, presence of neck lump)

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8
Q

What is quinsy?
Signs?
What are potential complications?

A

Peri-tonsillar abscess, can develop from acute tonsillitis

Displaced uvula and unilateral swelling + dysphonia (‘hot potato voice’)

Treatment

  • secure airway
  • surgical drainage with C&S
  • IV penicillin (GAS) or IV metronidazole (bactericides)
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9
Q

Complications of quinsy

A

Aspiration pneumonia secondary to rupture
Airway obstruction
Dissection into other fascial spaces
Bacteraemia

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10
Q

Clinical features of bacterial tonsillitis

A

Sore throat +/- dysphagia, odonophagia, fever, malaise, trisumus

Swollen uvula
Tonsils enlarged and inflamed +/- exudates/Follicular ‘ strawberries and cream’ appearance
tender cervical lymphadenopathy

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11
Q

Complications and treatment of bacterial tonsillitis

A

Fluids and salt water gargle
Antibiotics with swab and MCS - penicillin or amoxyxillin is 1st line (GAS)

Tonsillectomy if >6 episodes in one year or OSA, especially in children

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12
Q

what is trisumus?

A

motor disturbance of trigeminal nerve leading to spasm of muscles of mastication with lockjaw

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13
Q

when would you suspect EBV as cause for tonsillitis?

A

More diffuse coating on tonsils, palatal petechiae

+/- hepatosplenomegaly, diffuse lymphadenopathy and impaired LFTs

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14
Q

Why are you concerned with tongue base and floor of mouth swelling? what measure do you take?

A

Passible fatal airway obstruction

consider nasoipharyngeal airway or tracheostomy

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15
Q

Otalgia

- ear pain. what sources?

A

Otitis externa
Otitis media

Referred pain:

  • Temporo-mandibular joint (anxiety, teeth clenching, poor molar support)
  • Teeth (Impacted molar teeth)
  • Neck (C2, C3)
  • Sinus
  • carcinoma of tongue base
  • pyriform fossa
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16
Q

potential causes of hoarse voice

A

Vocal cord nodules

  • benign polyps
  • callus with long term voice strain (singers, teachers, bartenders, kids) or alcohol/tobacco/freq URTI
  • HPV papilloma

Reflux (GORD)

SCC of larynx

Paralysed vocal cord (impingement by enlarged neck mass or damage from neck surgery or laryngitis)

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17
Q

What can you use to secure an airway?

A

Guedel airway

Nasopharyngeal tube

Crico-thyroid puncture w 2 19 gauge needles (C-T membrane is relatively bloodless)

Tracheostomy (below 2nd tracheal ring)

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18
Q

what is a thyroglossal duct cyst and how might it present?

A

vestigial remnant of migration of thyroid to the inferior aspect of neck

presents in childhood or 20-40yo as a midline cyst that enlarged w URTI and elevates w swallowing and tongue protrusion

TX: complete excision w pre-op antibiotics (due to small potential for neoplastic transformation)

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19
Q

How does the nose warm and humidify air?

A

Turbinates (superior, middle, inferior) direct airflow - turbulent and laminar

Pseudo stratified ciliated columnar epithelium w goblet cells - cilia beat to funnel to post nasal space

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20
Q

What are the sinuses and where do they drain?

A

Maxillary, frontal and anterior ethmoids drain into medial meatus

Sphenoid and posterior ethmoid drain into superior meatus

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21
Q

what opening drains into the inferior meatus?

A

Nasolacrimal duct

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22
Q

Nasal symptoms to ask about

A 
Nasal blockage
Nasal congestion
Rhinorrhoea (CSF)
Sneezing
Nasal irritation
Post nasal drip
Olfaction
Epistaxis
Facial pressure/pain
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23
Q

Where does the eustachian tube open from/into.

What purpose does it serve and how is this relevant clinically?

A

= Pharyngotympanic tube.

Is a tube that links the nasopharynx to the middle ear

Normally, the Eustachian tube is collapsed, but it gapes open both with swallowing and with positive pressure. allowing equalising pressure between the middle ear and outside atmospheric pressure. Also drains fluid from middle ear.

Upper respiratory tract infections or allergies can cause the Eustachian tube, or the membranes surrounding its opening to become swollen, trapping fluid, which serves as a growth medium for bacteria, causing ear infections.

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24
Q

What nerves lie posterolateral to the sphenoid?

A

CN 2,3,4,6

V2 (maxillary branch)

sympathetic plexus assoc w ICA

SX

  • visual loss/disturbance/diplopia
  • horner’s
  • retro-orbital pain
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25
Q

What is Samter’s triad?

A

Aspirin intolerance
Asthma
Nasal polyps

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26
Q

What are polyps in children associated with?

A

Cystic fibrosis

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27
Q

What is rhinitis and what are causative groups?

A

inflammation of the nasal mucosa

Groups:

  • Allergic (IgE)
  • infectious
  • occupational
  • drugs
  • hormonal
  • irritants, food
28
Q

SX of allergic rhinitis

Treatment

A

Clear rhinorhoea
Nasal blockage +/- nose itch often alternating between nares
Sneeze

TX: oral or local non-sedative H1 blocker +/- decongestant
Intranasal steroid if mod-severe
Irritant/allergen avoidance
Immunotherapy for severe

29
Q

SX of allergic rhinitis

Ix and Treatment

A

Clear rhinorhoea
Nasal blockage +/- nose itch often alternating between nares
Sneeze

Inv: skin prick test
TX: oral or local non-sedative H1 blocker +/- decongestant
Intranasal steroid if mod-severe
Irritant/allergen avoidance
Immunotherapy for severe
30
Q

SX of rhinosinovitis

A

Rhinorhoea (clear or purulent), blockage, itch, sneeze, nasal irritation, epiphora

Mostly caused by rhinovirus
only 0.5-2% bacterial

31
Q

SX of rhinosinovitis

A

Rhinorhoea (clear or purulent), blockage, itch, sneeze, nasal irritation, epiphora

Mostly caused by rhinovirus
only 0.5-2% bacterial (strep pneumonia, H. infl, M. catarrhalis)

32
Q

where is the most common site of bleeding in epistaxis? TX?

A

Little’s area/Kiesselback (anterior septum) - confluence of multiple vessels. controlled by direct pressure

33
Q

With posterior epistaxis, where is the common site of bleed and what treatment will likely be needed?

A

Sphenopalatine artery -> felt as dripping back of nose

May need nasal packing

34
Q

If you suspect a nasal fracture, do you need to image it?

A

Not unless you suspect other facial fractures, skull base fracture or there is a drop in GCS

35
Q

Presentation of a septal haematoma . what are potential complications?

A

Bilaterally enlarged, red inferior nares blocking nasal passage

Needs immediate ENT referral and drainage!

Complications:
- progression to a septal abscess -> cartilage destruction -> saddle nose deformity

36
Q

Nasal polyp vs enlarged turbinate - appearance

A

Polyps are more translucent and non-tender

37
Q

Nasal polyp vs enlarged turbinate - appearance

A

Polyps are more translucent and non-tender

38
Q

Treatment of rhinorinovitis

A

Oral antibiotics if likely bacterial cause

Nasal decongestants (pseudoephridrine) - help to ventilate sinuses and reduce mucosal edema

Saline nasal douche

39
Q

What is the most likely source for orbital infections?

What SX?

Complications?

A

Sinusitis

SX: eye pain and swelling (unilateral), double vision, ophthalmoplegia, Red/green colourblind (BAD!)
Following sinus infection

Complication is increased IOP leading to optic nerve compression and vision compromise

40
Q

Treatment for chronic rhinosinovitis (chronic is >=3 month duration of SX)

What if is non-responsive to primary care management?

A

Nasal steroid spray is the mainstay of therapy

Saline nasal douche

Antibiotics if purulent rhinorrhea

ENT review only if non-resolving after primary care management -> endoscopy and CT -> functional endoscopic sinus surgery if non-responsive to maximal medical therapy

41
Q

Basic pathway to cortex from sound waves starting with outer ear.

A

Outer ear -> middle ear -> cochlea -> brainstem nuclei (CN8 in pons) -> temporal lobe of cerebral cortex

42
Q

Hearing thresholds and impacts on children:

  • normal
  • mild impairment
  • moderate impairment
  • severe impairment
A
  • normal: >20db
  • mild: 20-40db (can manage in quiet situations w clear voices)
  • moderate: 40-60 (miss most of the conversation thus pronunciation is not clear and limited vocab)
  • severe: 60-90 (will not hear most of conversational speech so speech and language do not develop spontaneously and very limited vocab - will need a hearing aid and visual cues)
  • profound >90 (hears no speech sounds - cochlear implant or sign language) - reading will plateau at grade 4 level
43
Q

what is the hearing threshold for air vs bone conduction in conductive hearing loss?

A

Bone: >20db

Air: <20db (air should be better than bone, but not in this case)

44
Q

what is the hearing threshold for air vs bone conduction in sensorineural hearing loss?

A

air and bone conduction are similar but there is a negative trend - as frequency (hz) increases, hearing level (dB) decreases

45
Q

DX and MX: painful blocked left ear w itchy R ear - swims in river every day after school

A

DX: Otitis externe probably due to local infection from river organism

MX: analgesia, ear cleaning (suction or mopping), topical antibiotics (antifungals)

46
Q

DX and MX: 18yo baby with a cold woke up and cried several times during the night. in the morning there is a thick purulent discharge on his pillow and matted in his hair. he is happy but rubs at his ear. on otoscopic examination there is a hole in his tympanic membrane

A

DX: acute otitis media with perforation, probably caused by Strep pneumonia/h. influenzae/moraxella catarrhalis

MX: analgesia, ear cleaning, Ab w 2-3month follow up (oral amoxycillin of cefuroxime PLUS topical abX if there is TM perforation)

47
Q

what is ‘glue ear’?

A

Chronic otitis media with effusion. Fluid instead of air in middle ear.

This fluid dampens the vibrations made by sound waves as they travel through the eardrum and ossicles. The cochlea in turn receives dampened vibrations, and so the ‘volume’ of hearing is essentially ‘turned down’.

Presents as hearing loss/language development delay

MX: audiogram +/- insertion of middle ear ventilation tube (grommet)

48
Q

What children should have middle ear ventilation tubes?

A

Otitis media with effusion for at least 4 months with hearing loss or other SX or in an ‘at risk’ child (cleft palate, visualy impaired/developmental delay, autism spectrum)

OME and structural damage to TM

49
Q

What to do if grommet is blocked by dried ear secretions or infected granuloma ?

A

Topical Abx drops (cprofloxacin), NOT oral .

50
Q

DX and MX

63 year old man with intermittent discharge from L ear with offensive smell + decreased hearing from L ear, off-balance when he sneezes

A

Chronic suppurative otitis media with cholesteatoma

MX: examine ENT + tuning fork examination + audiogram + CT scan

51
Q

What is a cholesteatoma ? potential complications?

A

Destructive and expanding growth consisting of keratinizing squamous epithelium in the middle ear.

Over time, the cholesteatoma can increase in size and destroy the:

  • Tympanic membrane
  • The ossicles of the middle ear leading to CONDUCTIVE hearing loss.
  • May erode into labrynth causing sensorineural hearing loss and imbalnace/vertigo.
  • facial paralysis
  • intracranial penetration
52
Q

Weber’s Test - conductive vs sensorineural hearing loss test resutls

A

Normal: sound heard centrally

Conductive: sound heard in the poor hear

Sensorineural: sound hear in better ear

53
Q

Causes of otorrheoa (ear discharge)

A 
Wax
Otitis externa
Acute Otitis media with perforation
Chronic suppurative otitis media +/- cholesteatoma
Foreign body in ear canal
54
Q

what nerve runs through the middle ear?

what is the clinical significance?

A

CN 5 (facial)

Acute otitis media and increased pressure within middle ear can cause compression of CNV -> LMN facial nerve palsy

55
Q

What is Ramsay Hunt syndrome? what causes it and what are the clinical signs/SX?

A

Herpes Zoster Oticus -> reactivation of HZV in geniculate/facial ganglion

SX:
LMN facial nerve palsy 
**Vesicular rash on external ear**
Loss taste on anterior 2/3 tongue 
\+/- vertigo/imbalance if CN8 involved

TX: oral steroids, acyclovir

56
Q

DX, IX and MX:

Vertigo when rolling over in bed onto R side, passing within a minute

A

DX: BPPV (otoliths from utricle become loose and lodge in posterior SC canal)

IX: Dix-Hallpike manoeuvre -> head turned towards right, after a minute he has vertigo AND rotational nystagmus

MX: Epley manoeuvre

57
Q

DDX: 29yo male became acutely ill on honeymoon with severe rotational vertigo, with vomiting every time he rolled over.
No tinnitus. Recovered after a week but still feels off-balance when walking in the dark.

ENT exam unremarkable w no nystagmus; falls to r with romberg test; no hearing loss

What investigation ?

A

DDX:

Vestibular neuritis
Vestibular migraine
Brainstem tumour or stroke
MS

MRI to exclude last 2

58
Q

What is vestibular neuritis?

A

Abrupt onset of vertigo with no hearing loss or tinnitus , improvement in balance over next few weeks.
Lasts DAYS-WEEKS

Possibly due to viral inflammation of vestibular ganglion.

59
Q

DX:
26 yo female w 3 episodes of severe vertigo lasting several hours each, over 6 month period . L ear feels blocked for days after attack, like she can’t hear properly.
Associated nausea and vomiting
+ Tinnitus (roaring sound)

Normal audiogram and MRI

A

DX: Meniere’s disease

60
Q

Features of Meniere’s disease

A

3 of the following features:

  • vertigo (lasting between 30min-24 hours)
  • fullness in ear
  • roaring tinnitis
  • initially low-freq hearing loss that fluctuates and eventually becomes worse and permanent
61
Q

MX of Meziere’s disease

A

Acute episodes:
- Prochlorperazine (DAantag) or diazepam (vestibular suppressants)

Maintenance therapy

  • life-style (minimise stresses)
  • diet: Low salt diet
  • Medications: thiazide diuretic, beta histidine
62
Q

DDX Vertigo and relative time frames

A
  1. BPPV: <1min duration
  2. Meniere’s disease: 30min-1 day duration
  3. Vestibular neuritis: days-weeks
  4. Acoustic neuroma (elderly patients, tinnitis more common presentation than vertigo)
63
Q

DDX dizziness (light-headedness)

A

Medical

  • Haem: anaemia
  • Heart: dysrhythmia
  • Endocrine: hypoglycaemia
  • Drugs: antihypertensives

Neurological:

  • MS
  • Migraine
64
Q

DX and MX of sudden sensorineural hearing loss of at least 30db in at least 3 frequencies

A

Idiopathic SSNHL.

High dose oral prednisolone for 5 days then tapering, may improve hearing outcome - start early!!

65
Q

MX of children born with hearing loss?

A

Referral for a hearing aid to be established by 6 months.

66
Q

RF for candiasis infection

A 
HIV/AIDS
Mononucleosis (EBV)
Cancer treatments
Steroids
Stress
Antibiotic usage
Diabetes
Nutrient deficiency
67
Q

Pathophyhs of mononucleosis?

MX?

A

initially infects epithelial cells of pharynx, then moves to infect primarily B cells!

MX: paracetamol and NSAIDs

MD2 (16 decks)

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