ENT Flashcards
History of smoking and a cough - where might the cancer originate?
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)
What is troisier’s sign?
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.
What do you think if a neck lump elevates with tongue protrusion?
Thyroglossal duct cyst
What investigations to perform for a neck lump?
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
DDX neck mass
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
what is leukoplakia?
Causes?
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.
What does persistent mouth ulceration indicate?
Suspicion of malignancy especially if co-existing with other risk factors (smoking, sun exposure, presence of neck lump)
What is quinsy?
Signs?
What are potential complications?
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)
Complications of quinsy
Aspiration pneumonia secondary to rupture
Airway obstruction
Dissection into other fascial spaces
Bacteraemia
Clinical features of bacterial tonsillitis
Sore throat +/- dysphagia, odonophagia, fever, malaise, trisumus
Swollen uvula
Tonsils enlarged and inflamed +/- exudates/Follicular ‘ strawberries and cream’ appearance
tender cervical lymphadenopathy
Complications and treatment of bacterial tonsillitis
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
what is trisumus?
motor disturbance of trigeminal nerve leading to spasm of muscles of mastication with lockjaw
when would you suspect EBV as cause for tonsillitis?
More diffuse coating on tonsils, palatal petechiae
+/- hepatosplenomegaly, diffuse lymphadenopathy and impaired LFTs
Why are you concerned with tongue base and floor of mouth swelling? what measure do you take?
Passible fatal airway obstruction
consider nasoipharyngeal airway or tracheostomy
Otalgia
- ear pain. what sources?
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
potential causes of hoarse voice
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)
What can you use to secure an airway?
Guedel airway
Nasopharyngeal tube
Crico-thyroid puncture w 2 19 gauge needles (C-T membrane is relatively bloodless)
Tracheostomy (below 2nd tracheal ring)
what is a thyroglossal duct cyst and how might it present?
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)
How does the nose warm and humidify air?
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
What are the sinuses and where do they drain?
Maxillary, frontal and anterior ethmoids drain into medial meatus
Sphenoid and posterior ethmoid drain into superior meatus
what opening drains into the inferior meatus?
Nasolacrimal duct
Nasal symptoms to ask about
Nasal blockage Nasal congestion Rhinorrhoea (CSF) Sneezing Nasal irritation Post nasal drip Olfaction Epistaxis Facial pressure/pain
Where does the eustachian tube open from/into.
What purpose does it serve and how is this relevant clinically?
= 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.
What nerves lie posterolateral to the sphenoid?
CN 2,3,4,6
V2 (maxillary branch)
sympathetic plexus assoc w ICA
SX
- visual loss/disturbance/diplopia
- horner’s
- retro-orbital pain
What is Samter’s triad?
Aspirin intolerance
Asthma
Nasal polyps
What are polyps in children associated with?
Cystic fibrosis
What is rhinitis and what are causative groups?
inflammation of the nasal mucosa
Groups:
- Allergic (IgE)
- infectious
- occupational
- drugs
- hormonal
- irritants, food
SX of allergic rhinitis
Treatment
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
SX of allergic rhinitis
Ix and Treatment
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
SX of rhinosinovitis
Rhinorhoea (clear or purulent), blockage, itch, sneeze, nasal irritation, epiphora
Mostly caused by rhinovirus
only 0.5-2% bacterial
SX of rhinosinovitis
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)
where is the most common site of bleeding in epistaxis? TX?
Little’s area/Kiesselback (anterior septum) - confluence of multiple vessels. controlled by direct pressure
With posterior epistaxis, where is the common site of bleed and what treatment will likely be needed?
Sphenopalatine artery -> felt as dripping back of nose
May need nasal packing
If you suspect a nasal fracture, do you need to image it?
Not unless you suspect other facial fractures, skull base fracture or there is a drop in GCS
Presentation of a septal haematoma . what are potential complications?
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
Nasal polyp vs enlarged turbinate - appearance
Polyps are more translucent and non-tender
Nasal polyp vs enlarged turbinate - appearance
Polyps are more translucent and non-tender
Treatment of rhinorinovitis
Oral antibiotics if likely bacterial cause
Nasal decongestants (pseudoephridrine) - help to ventilate sinuses and reduce mucosal edema
Saline nasal douche
What is the most likely source for orbital infections?
What SX?
Complications?
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
Treatment for chronic rhinosinovitis (chronic is >=3 month duration of SX)
What if is non-responsive to primary care management?
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
Basic pathway to cortex from sound waves starting with outer ear.
Outer ear -> middle ear -> cochlea -> brainstem nuclei (CN8 in pons) -> temporal lobe of cerebral cortex
Hearing thresholds and impacts on children:
- normal
- mild impairment
- moderate impairment
- severe impairment
- 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
what is the hearing threshold for air vs bone conduction in conductive hearing loss?
Bone: >20db
Air: <20db (air should be better than bone, but not in this case)
what is the hearing threshold for air vs bone conduction in sensorineural hearing loss?
air and bone conduction are similar but there is a negative trend - as frequency (hz) increases, hearing level (dB) decreases
DX and MX: painful blocked left ear w itchy R ear - swims in river every day after school
DX: Otitis externe probably due to local infection from river organism
MX: analgesia, ear cleaning (suction or mopping), topical antibiotics (antifungals)
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
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)
what is ‘glue ear’?
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)
What children should have middle ear ventilation tubes?
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
What to do if grommet is blocked by dried ear secretions or infected granuloma ?
Topical Abx drops (cprofloxacin), NOT oral .
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
Chronic suppurative otitis media with cholesteatoma
MX: examine ENT + tuning fork examination + audiogram + CT scan
What is a cholesteatoma ? potential complications?
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
Weber’s Test - conductive vs sensorineural hearing loss test resutls
Normal: sound heard centrally
Conductive: sound heard in the poor hear
Sensorineural: sound hear in better ear
Causes of otorrheoa (ear discharge)
Wax Otitis externa Acute Otitis media with perforation Chronic suppurative otitis media +/- cholesteatoma Foreign body in ear canal
what nerve runs through the middle ear?
what is the clinical significance?
CN 5 (facial)
Acute otitis media and increased pressure within middle ear can cause compression of CNV -> LMN facial nerve palsy
What is Ramsay Hunt syndrome? what causes it and what are the clinical signs/SX?
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
DX, IX and MX:
Vertigo when rolling over in bed onto R side, passing within a minute
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
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 ?
DDX:
Vestibular neuritis
Vestibular migraine
Brainstem tumour or stroke
MS
MRI to exclude last 2
What is vestibular neuritis?
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.
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
DX: Meniere’s disease
Features of Meniere’s disease
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
MX of Meziere’s disease
Acute episodes:
- Prochlorperazine (DAantag) or diazepam (vestibular suppressants)
Maintenance therapy
- life-style (minimise stresses)
- diet: Low salt diet
- Medications: thiazide diuretic, beta histidine
DDX Vertigo and relative time frames
- BPPV: <1min duration
- Meniere’s disease: 30min-1 day duration
- Vestibular neuritis: days-weeks
- Acoustic neuroma (elderly patients, tinnitis more common presentation than vertigo)
DDX dizziness (light-headedness)
Medical
- Haem: anaemia
- Heart: dysrhythmia
- Endocrine: hypoglycaemia
- Drugs: antihypertensives
Neurological:
- MS
- Migraine
DX and MX of sudden sensorineural hearing loss of at least 30db in at least 3 frequencies
Idiopathic SSNHL.
High dose oral prednisolone for 5 days then tapering, may improve hearing outcome - start early!!
MX of children born with hearing loss?
Referral for a hearing aid to be established by 6 months.
RF for candiasis infection
HIV/AIDS Mononucleosis (EBV) Cancer treatments Steroids Stress Antibiotic usage Diabetes Nutrient deficiency
Pathophyhs of mononucleosis?
MX?
initially infects epithelial cells of pharynx, then moves to infect primarily B cells!
MX: paracetamol and NSAIDs
