ENT Flashcards
On examination of the external auditory canal, you find if the canal appears defective when you look posteriorly. Why?
If you look posteriorly and the posterior canal appears defective - mastoid operation. Likely some years ago, still in clinic for irrigation of accumulated wax.
Mastoid cavity, reason for this is either chronic infection of cholesteatoma (benign slow growing epithelial tumour causing progressive destruction of ossicles, labyrinth, facial nerve, hearing.
Complications of brain abscess, meningitis, sigmoid sinus thrombosis.
Cholesteatoma
Benign slow growing epithelial tumour causing progressive destruction of ossicles, labyrinth, facial nerve, hearing.
Complications of brain abscess, meningitis, sigmoid sinus thrombosis.
Tuning fork tests - which frequency?
512 Hz
Rinne’s Test - what is a positive test? What is a negative test? What is it mean?
Normally air conduction > bone conduction = Rinne’s positive
Conductive loss if bone conduction > air conduction = Rinne’s negative
Weber’s Test
Place tuning fork on forehead. Should be heard equally.
Pure conductive loss - will be heard better in bad ear
Pure sensorineural loss - will be heard better in good ear
Pure tone audiometry
Produces pure tones and carried out in soundproofed room. Pt wears headphones and listens as sound appears and when it disappears.
Threshold of hearing at different frequencies is plotted and this is audiogram
Evoked Response Audiometry
Auditory stimulus (click or tone transmitted via headphones) with measurements of elicited brain waveform response by surface electrodes. Can detect acoustic neuromas or determine hearing threshold in children.
Tinnitus
Auditory sensation of noise without external sound stimulation. Very common. Associated with age and noise induced hearing loss.
Unilateral - ENT assessment as can herald acoustic neuroma.
Treatment - positive reassurance, use of background noise such as TV, radio or tinnitus masker (white noise machine)
Vertigo - definition
Illusion of movement experienced, often with a rotational component (dizziness). Should be distinguished from light-headedness.
BPPV
Trauma + positional vertigo + nystagmus + short duration + fatiguability
Degenerative condition of utricular neuroepithelium, may occur spontaneously or following head injury
Labyrynthitis
URTI + severe vertigo + vomiting + last few days
Anti emetic - e.g. prochlorperazine (buccal, IM, suppository), cyclizine
Vestibular sedative - e.g. Ca channel antagonist cinnarizine, H2 analogue betahistamine
What is responsible for balance?
Visual feedback - 70%
Proprioception - 15%
Vestibular system - 15%
Congenital causes of deafness
Hereditary
Intrauterine insult - CMV, rubella, hypoxia
DDx hearing loss
Congenital Presbyacussis (deafness of old age) Noise induced hearing loss Otosclerosis Meniere's disease Acoustic neuroma
Deafness of old age
Presbyacussis. Common >65 with B/L slow onset hearing loss ±tinnitus. Progressive symmetrical slope on audiometry.
If >40db loss at 2kHz hearing aid may help
Otosclerosis
AD with variable penetration. F>M, presents with conductive hearing loss in adulthood. Due to fixation of stapes at oval window.
Carharts notch - classic dip at 2 kHz on audiometry.
Treatment: hearing aid or stapedotomy
Meniere’s disease
Fluctuating hearing loss + vertigo lasting days + tinnitus + aural fullness (a sensation of pressure within middle ear as in descending aeroplane). Cause thought to be related to excessive endolymphatic fluid. During acute episodes pt feels very unwell with N&V. Chronic history which burns over time.
DVT - deafness, vertigo, tinnitus
MRI - to rule out acoustic neuroma.
Audiometry - fluctuating low frequency sensorineural loss
Treatment 1* conservative (no caffeine, salt, other triggers); 2* surgical with grommet, saccus decompression, cortical mastoid. Vestibular nerve resection in extreme cases
What is a grommet? Where and why is it placed?
Tympanostomy tube. Small tube placed into eardrum to keep middle ear aerated for prolonged periods of time and prevent accumulation of fluid. Operation involves a myringiotomy (perforation of eardrum). A “T” shaped tube can sometimes be used if need to be in place 2-4 years.
Acoustic neuroma
Slow onset of unilateral hearing loss and tinnitus ± vertigo.
As it enlarges will feature headaches, VI - VIII palsies and IC hypertension.
Rare - if presents B/L think MENII
MRI to confirm and monitor annually for growth
Treatment - Rx with gamma knife or translabyrynthine/middle fossa approach.
Acute otitis media
Febrile child with URTI, rubbing ears, in pain. Tympanic membrane red and inflamed, bulging or retracted.
Paracetamol ± Amoxicillin.
Complications of glue ear, perforation (heal spontaneously after 6/52), mastoiditis (ostitis of temporal bone ± abscess formation)
Glue ear
Otitis media with effusion (OME). Common complication of acute otitis media. Prevalence highest age 2. Inattention at school, poor speech development, abnormal milestones.
Resolves spontaneously / with conservative treatment of Otovent nasal balloons (child blows up balloon through nose - opening up Eustachian tube, making it easier to drain)
If persistent >30db B/L hearing loss >3/12 grommet may be considered.
Microtia
Congenital underdevelopment of the pinna. Can be caused by Accutane use in pregnancy
SCC of the pinna
Treatment involves wedge resection of 1* lesion and neck dissection if regional spread to deep cervical chain.
Chronic otitis externa
Most common condition affecting external auditory canal. Treated with manual cleansing (aural toilet), swab for cultures and sensitivity and topical Abs in form of ear drops.
Bony exostosis of external auditory canal
Smooth symmetrical narrowing of external auditory canal in people who do a lot of swimming. Unknown cause. Treatment conservative. If significantly problematic, drilling of bony exostosis can be done.
Anatomy of the facial nerve
Originates in cerebro-pontine angle. Travels into internal auditory canal and traderses length of temporal bone. Gives rise to 3 branches:
Greater superficial petrosal
Nerve to stapedius
Chorda tympani
Exits temporal bone through stylomastoid foramen. Runs forward in to substance of parotid gland.
Note: UMN = sparing of forehead due to suprapontine crossover.
Note: Facial trauma and parotid lumps may cause facial paralysis
Note: In 5% cases VII exposed as passes through middle ear and acute otitis media putting pressure on unprotected nerve can lead to LMN palsy.
Bell’s Palsy
LMN VII palsy of unknown (but suspected viral) origin. Diagnosis of exclusion, full clinical examination + audiometry to make sure VII not compromised within temporal bone due to cholesteatomas or other cause.
85% full recovery
High dose steroids within 24h of onset.
Vestibular Schwannoma
Acoustic neuroma. Benign lesion of superior vestibular nerve. Slow growing, presents with unilateral tinnitus, vertigo, sensorineural hearing loss.
MRI of cerebro-pontine angle with gadolinium contrast
Hereditary Haemorrhagic Telangectasia in ENT
AD, several genes implicated, all part of TGFB pathway, resulting in abnormal angiogenesis. Most common symptom is frequent sometimes torrential epistaxis. Look for facial telangectasia on/in lips and nose. Bleeding from nose but also in GIT, and AV malformations common in lungs (50%), liver (30-70%) and brain (10%)
Managing torrential/persistant epistaxis in A&E
Acute bleeding - manage as for shock
Appropriate shielding apparatus for own face.
Check medication and stop all anticoagulants
Mericel Pack - white tampon for nose inserted after LA (lignocaine 2%) and KY jelly. Insert straight back parallel to hard palate (not up)
If fails to stop bleeding, ENT emergency, as they may need to insert posterior pack using Foley catheter balloon. If this fails, theatre for endoscopic control of bleeding, including ligation of sphenopalatine artery
Allergic Rhinitis
Type 1 hypersensitivity reaction. Itching, sneezing, rhinorrhoea and nasal blockage. 60-70% of pts with asthma
Hx - try and elicit trigger factors
Examine for polyps, skin prick or RAST for various antigens.
Allergy avoidance + long term anti H ± intranasal steroids.
Glandular fever
EBV causing tonsillitis, associated with contact. Marked cervical lymphadenopathy. Possible SM, advise not contact sports 6/12. Incidence of splenic rupture most likely in 2-3 week of illness.
WCC + mono spot test (detecting heterophil Ab) + LFTs. Abx especially ampicillin should be avoided as can cause rash.
Up to 10% develop chronic fatigue after.
What are the complications of tonsillitis? When would you suspect and how might you manage?
Peritonsillar Abscess - Quinsy’s. Marked truisms (difficulty in opening/closing mouth), intense sore throat, dysphagia in context of febrile patient. O/E unilateral tonsilar enlargement with B/L tonsilitis and cervical lymphadenopathy. Admission, aspiration/incision and drainage, analgesia, IV Abx and fluids. If not improved, suspect:
Parapharyngeal abscess - suspect if pt unduly unwell, no improvement after 24-36h IV Abx and unilateral swelling of tonsil and neck. Urgent CT from skull base to diaphragm. Abscess drained through the neck.
Cancer of tonsils/adenoids
SCC and lymphomas. FNA of neck nodes and staging with CT or MRI. Presentation varies, can include U/L tonsil enlargement/ulceration ± cervical lymphadenopathy, U/L glue ear, dysphagia.
OSA/Snoring in ENT
Snoring, nocturnal waking, daytime somnolence, high BMI with large neck ± long dependent uvula. Diagnosed by sleep study (polysomnography) showing >30 episodes of cessation of breathing >10s over 7h or apnoea index >5
Treatment - weight loss, no %% or sedatives at night, dental positioning devices and CPAP.
Functions of the larynx
Phonation - left recurrent laryngeal nerve runs into chest, loops around arch of aorta and ligamentum arteriosum before running up to larynx deep to the thyroid. Right RLN loops around SC artery.
Respiration - during swallowing epiglottis flips backwards and cords abducted to prevent aspiration
Laryngeal Cancer: Risk factors. What is the stereotypical patient like?
Smoking
Alcohol
Social deprivation
Long term smoker over 40 with persistent lump, hoarse voice, dysphagia or other ENT pain >2 weeks.
Laryngeal Cancer: Investigation and management, prognosis
Investigated with flexible nasendoscopy; FNA of any neck nodes, panendoscopy and biopsy + CT skull base to diaphragm to stage or rule out occult tumours.
Treatment based on histological type, TNM staging, comorbidity, preference.
T1-T2 = surgery or Rx alone; 5yr survival 80-90% T3-T4 = usually both; 5yr survival 10-15%
Surgery: endoscopic resection. Open laryngectomy ± neck LN dissection + Rx for 6/52 post op usual regimen for advanced disease.
Laryngomalacia
Commonest Ddx of stridor in children. Presents 1-2/52 of life. Esp bad when feeding, lying on back. If severe failure to thrive. ENT referral must have. Flexible nasendoscopy and bronchoscopy (MBL) to confirm. Treatment usually conservative, but in severe cases laser epiglottoplasty highly effective.
Epiglottitis
Drooling, acutely unwell febrile child. H. Influenza B (HiB). ENT + anaesthetic, no examination. Emergency intubation followed by swabs and IV Abx (3rd gen ceph)
Foreign body in kids
Sudden onset stridor in kids
Examination + CXR + bronchoscopy
Laryngeal Papillomatosis
Child with progressive hoarseness or aphonia and airway obstruction. Caused by HPV 6 and 11 (warts) and presents <5 with hoarse voice ± stridor. Direct laryngoscopy + treatment with laser resection
Subglottic Stenosis
Caused by congenital abnormalities and prolonged intubation.
Stridor and failure to thrive.
Treatment ranges from conservative observation to tracheostomy and partial cricotracheal resection
Examination of ear
WIPE and Examine better ear first
Inspect Pinna - Congenital abnormalities such as pre auricular sinuses. Use light from auroscope to look for and aural and post auricular incisions:
Endaural incision - surgical scar running from superior to inferior just above tragus (cartilage just in from of external auditory meatus)
Postauricular incision - runs in hidden grove between back of pinna and skull
External auditory canal
Signs of infection or Mastoid operation?
Tympanic membrane - is it perforated?
Light reflex - light bouncing off angled tympanic membrane antero inferiorly
Clockwise towards top and look at pars flaccid - bit at top of tympanic membrane above maleus. Retracted or debris? - cholesteatoma.
Opposite ear
Hearing tests - Weber’s and Rinne’s
Examination of nose
WIPE
Inspect - front, side and top
Palpate - which part is bony and which cartilage. Obvious deviations?
Ask to breath in hard, is there obvious alar collapse?
Do a pig nose - symmetrical?
Auroscope - look at septum for perforation or recent points of bleeding. Compare gaps between septum and lateral wall for septal deviation.
Lateral wall - should be healthy pink, boggy looking in allergic rhinitis. Any polypoidal lesions?
Check sensation around V2 (maxillary)
