ENT

Question 1

On examination of the external auditory canal, you find if the canal appears defective when you look posteriorly. Why?

Answer 1

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.

Question 2

Cholesteatoma

Answer 2

Benign slow growing epithelial tumour causing progressive destruction of ossicles, labyrinth, facial nerve, hearing.
Complications of brain abscess, meningitis, sigmoid sinus thrombosis.

Question 3

Tuning fork tests - which frequency?

Answer 3

512 Hz

Question 4

Rinne’s Test - what is a positive test? What is a negative test? What is it mean?

Answer 4

Normally air conduction > bone conduction = Rinne’s positive

Conductive loss if bone conduction > air conduction = Rinne’s negative

Question 5

Weber’s Test

Answer 5

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

Question 6

Pure tone audiometry

Answer 6

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

Question 7

Evoked Response Audiometry

Answer 7

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.

Question 8

Tinnitus

Answer 8

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)

Question 9

Vertigo - definition

Answer 9

Illusion of movement experienced, often with a rotational component (dizziness). Should be distinguished from light-headedness.

Question 10

BPPV

Answer 10

Trauma + positional vertigo + nystagmus + short duration + fatiguability

Degenerative condition of utricular neuroepithelium, may occur spontaneously or following head injury

Question 11

Labyrynthitis

Answer 11

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

Question 12

What is responsible for balance?

Answer 12

Visual feedback - 70%
Proprioception - 15%
Vestibular system - 15%

Question 13

Congenital causes of deafness

Answer 13

Hereditary

Intrauterine insult - CMV, rubella, hypoxia

Question 14

DDx hearing loss

Answer 14

Congenital
Presbyacussis (deafness of old age)
Noise induced hearing loss
Otosclerosis
Meniere's disease
Acoustic neuroma

Question 15

Deafness of old age

Answer 15

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

Question 16

Otosclerosis

Answer 16

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

Question 17

Meniere’s disease

Answer 17

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

Question 18

What is a grommet? Where and why is it placed?

Answer 18

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.

Question 19

Acoustic neuroma

Answer 19

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.

Question 20

Acute otitis media

Answer 20

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)

Question 21

Glue ear

Answer 21

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.

Question 22

Microtia

Answer 22

Congenital underdevelopment of the pinna. Can be caused by Accutane use in pregnancy

Question 23

SCC of the pinna

Answer 23

Treatment involves wedge resection of 1* lesion and neck dissection if regional spread to deep cervical chain.

Question 24

Chronic otitis externa

Answer 24

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.

Question 25

Bony exostosis of external auditory canal

Answer 25

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.

Question 26

Anatomy of the facial nerve

Answer 26

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.

Question 27

Bell’s Palsy

Answer 27

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.

Question 28

Vestibular Schwannoma

Answer 28

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

Question 29

Hereditary Haemorrhagic Telangectasia in ENT

Answer 29

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%)

Question 30

Managing torrential/persistant epistaxis in A&E

Answer 30

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

Question 31

Allergic Rhinitis

Answer 31

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.

Question 32

Glandular fever

Answer 32

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.

Question 33

What are the complications of tonsillitis? When would you suspect and how might you manage?

Answer 33

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.

Question 34

Cancer of tonsils/adenoids

Answer 34

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.

Question 35

OSA/Snoring in ENT

Answer 35

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.

Question 36

Functions of the larynx

Answer 36

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

Question 37

Laryngeal Cancer: Risk factors. What is the stereotypical patient like?

Answer 37

Smoking
Alcohol
Social deprivation

Long term smoker over 40 with persistent lump, hoarse voice, dysphagia or other ENT pain >2 weeks.

Question 38

Laryngeal Cancer: Investigation and management, prognosis

Answer 38

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.

Question 39

Laryngomalacia

Answer 39

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.

Question 40

Epiglottitis

Answer 40

Drooling, acutely unwell febrile child. H. Influenza B (HiB). ENT + anaesthetic, no examination. Emergency intubation followed by swabs and IV Abx (3rd gen ceph)

Question 41

Foreign body in kids

Answer 41

Sudden onset stridor in kids

Examination + CXR + bronchoscopy

Question 42

Laryngeal Papillomatosis

Answer 42

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

Question 43

Subglottic Stenosis

Answer 43

Caused by congenital abnormalities and prolonged intubation.
Stridor and failure to thrive.
Treatment ranges from conservative observation to tracheostomy and partial cricotracheal resection

Question 44

Examination of ear

Answer 44

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

Question 45

Examination of nose

Answer 45

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)