ENT Flashcards
What is the centor criteria?
Predicts risk of infection with Group A beta-haemolytic streptococci
- Absence of cough
- Exudate
- Fever > 38
- Anterior cervical lymphadenopathy
How are sore throats managed?
- Analgesia
- Anti-pyretics (paracetemol/ibuprofen)
- Increase fluid intake
- Salt water gargles
- Antibiotics (penicillin or erythromycin) if:
- >/=3 on centor criteria
- Systemically unwell
- Signs of serious complication
- Risk of complication due to co-morbidity
Name some complications of a sore throat
- Quinsy (peritonsillar abscess) = unilateral peritonsillar swelling
- Difficulty swallowing and opening jaw
- Retropharyngeal abscess (children)
- Inability to swallow and fever
- Rheumatic fever
- Glomerulonephritis
- Lemierre’s syndrome = pharyngotonsilitis, internal jugular vein thrombophlebitis + septic emboli
- Fusobacterium necrophorum
Name the indications for a tonsillectomy
- Recurrent acute tonsilitis
- >7/year, >5/year for 2 years, >3/year for 3 years
- Airway obstruction (sleep apnoea)
- Chronic tonsiltis > 3 months + halitosis
- Recurrent quinsy
- Unilateral tonsillar enlargement
- Risk of malignancy
Describe glandular fever, including symptoms, cause and diagnosis
Infectious mononucleosis
- Symptoms = sore throat > 1 week, malaise, fatigue, lymphadenopathy, enlarged spleen, palatal petachiae
- Caused by Epstein-Barr virus and spread by droplet infection/direct contact
- Diagnosed with FBC (lymphocytes) and glandular fever antibodies (Monospot/Paul Bunnell)
How is glandular fever managed?
- Rest
- Fluids
- Regular paracetemol
- Avoid alcohol
- Salt water/aspirin gargles
- Consider short course of prednisolone if severe
- Antibiotics if secondary infection
What is stridor? Name some causes
Noise created on inspiration due narrowing of the larynx or trachea
- Epiglottitis
- Croup (laryngotracheobronchitis)
- Inhaled foreign body
- Trauma
- Laryngeal paralysis
- Congenital abnormalities
What is croup? What are the clinical signs?
Viral infection of the larynx/trachea, commonly seen in young children
- Fever
- Runny nose
- Barking cough
- Worse at night
- Exacerbated by crying
- Inspiratory stridor
How is croup managed?
- Steam
- Steroids - oral dexamethasone or prednisolone
- Admit as paediatric emergency if:
- Intercostal recession
- Cyanosis
- Carers unable to cope
What is CSF rhinorrhoea? What is it an indication of?
Clear fluid dripping from the nose after trauma can indicated a fracture of the roof of the ethmoid labyrinth/cribriform plate which disrupts dura and arachnoid mater causing consequent CSF leak
- CSF contains ß2 (tau) transferrin on immunoelectrophoresis
- Differentiate from nasal discharge as +ve for glucose
Name some causes of earache
- Local
- Otitis externa/media
- Impacted wax
- Malignancy
- Barotrauma
- Mastoiditis
- Referred
- Trigeminal nerve (dental abscess/TMJ)
- Facial nerve
- Vagus nerve (larynx)
- Glossopharyngeal nerve (tonsilitis/quinsy)
Name some risk factors for developing otitis externa
- Swimming
- Narrow ear canal
- Hearing aid use
- Mechanical trauma
- Cotton buds
- Syringing
- Itching
How is otitis externa managed?
- Analgesia (paracetemol +/- ibuprofen)
- Aural toilets
- Ear drops (if no perforation)
- Antibiotics (gentamicin)
- Steroid (betamethasone)
- Aluminium acetate
- Refer to ENT if no response - microsuction
How does acute otitis media present?
Often after a viral URTI
- Unilateral ear pain
- Fever
- Ear purulent discharge (drum perforation)
- Associated with pain relief
- Red, bulging ear drum
- If perforated - external canal filled with pus
How is acute otitis media managed?
- Fluids
- Paracetemol/ibuprofen
- Delayed prescription of antibiotics (after 4 days)
- Amoxicillin immediately if child with bilateral or otorrhoea
- Immediately if systemically unwell or at high risk of complications
What are the different types of hearing loss?
- Conductive = blockage of outer/middle ear interferes with sound transmission to inner ear
- Wax
- Infection (glue ear)
- Perforated ear drum
- Otosclerosis
- Sensorineural = damage to cochlea and/or auditory nerve
- Noise-induced
- Infection (measles, meningitis)
- Aging (presbyacusis)
- Acoustic neuroma
- Ototoxic drugs (streptomycin, quinines)
What is glue ear?
Accumulation of non-infected fluid in the middle ear due to dysfunction/obstruction of the Eustachian tube
- Secondary to throat or ear infection
- Presents with deafness, ear pain, difficulties with speech, behavioural problems
- Usually resolves <3 months
- Treated with grommets
What is mastoiditis?
Infection from otitis media spreads to the mastoid bone
- Presents with presistent, throbbing earache with creamy, profuse discharge, conductive deafness
- Swelling over mastoid causes ear to stick out
- Drum is red, bulging or perforated
- Refer to ENT as emergency - need mastoidectomy
What is cholesteatoma?
Skin or stratified squamous epithelium growing in the middle ear, thought to result from formation of a retraction pocket in the pars flaccida of the eardrum
- Local expansion damages adjacent strutures
- Facial nerve
- Semicircular canals (vertigo)
- Refer to ENT - microsuction/antiobiotic drops/mastoid surgery
Name some causes of congential deafness
- Genetic
- Birth asphyxia
- Intrauterne infection (rubella)
- Meningitis
- Drugs during pregnancy - streptomycin
Describe hearing tests
- Simple (whispering etc)
- Rinne’s = base of vibrating tuning fork (512) on mastoid process then near external acoustic meatus
- If air conduction > bone conduction = positve, normal
- If BC > AC = negative, conductive deafness
- Weber’s = vibrating tuning fork on forehead
- If normal = not louder on either side
- If on the right
- right conductive
- left sensorineural
- Audiometry - quantifies loss and determines nature (subjective)
- Acoustic impedence audiometry (objective)
Label this ear drum
RIGHT (cone of light towards feet)
Describe anatomy of ear
- External ear = pinna/auricle + external auditory canal
- Middle ear
- Ossicles = malleus, incus, stapes
- Eustachian tube (middle ear to back of nose)
- Inner ear
- Cochlea (hearing) - bony
- Organ of Corti (hair cells)
- Vestibule (balance) / labyrinth
- Semicircular canals 3 (balance) - saccule + utricle
- Cochlea (hearing) - bony
How is sudden sensorineural deafness managed?
- ENT help
- Investigate cause - WR, ANA, INR, TSH, gluc, chol, ESR, FBC, LFT, viral
- Audiology + evoked response audiometry
- Imaging - gondolium MRI, CT
- Prednisolone 80mg/24 hours PO for 4 days
How is sudden sensorineural deafness defined?
Loss of >/= 30 DB in 3 contiguous pure tone frequencies over = 72 hours
What is otosclerosis? Name some symptoms
Vascular spongy bone replaces normal lamellar bone around the oval window - fixes stapes footaplate
- Conductive deafness (better with background noise)
- Tinnitus
- Mild, transient vertigo
- Pink tinge to drum
Symptoms worse with pregnancy, menstruation and menopause
How is otosclerosis managed?
- Fluoride
- Hearing aid
- Cochlear implant
- Surgery
What is presbyacusis?
Age-related hearing loss from accumulated environmental noise toxicity, starting with high frequency sounds
- Most affected with background noise
- Treat with hearing aids
What is tinnitus? Name some causes
Sensation of non-verbal sound not due to stimuli outside the body
- Inner ear/central = ringing/hissing/buzzing
- External/middle ear = popping/clicking
- Drugs - aminoglycosides, aspirin, loop diuretics
- Psychological (anxiety)
- Benign intracranial hypertension
How is tinnitus managed?
- Treat the treatable
- Hearing aid if loss > 35 dB
- Psychological support - tinnitus retraining therapy/cognitive therapy
- Music, massage
- Drugs
- melatonin
- Betahistine (menieres)
- Baclofen
- Intratympanic dexamethasone?
What is an acoustic neuroma?
Indolent subarachnoid tumours of the superior vestibular nerve
- Progressive ipsilateral tinnitus +/- sensorineural deafness
- +/- ipsilateral cerebellar signs
- RICP
- Numb face
Investigate with MRI
Organisms in otitis externa
- Pseudomonas
- Staph aureus
- Fungal
Risk factors for chronic otitis media
- URTI
- Oversized adenoids
- Bottle-feeding
- Asthma
- Passive smoking
- Malformations
- Dummy
History in glue ear
- Poor listening/sppech/behaviour
- Language delay
- Inattention
- Balance
- School work
- URTI
Signs of glue ear
- Retracted bulging ear drum - dull/grey/yellow
- Decreased drum mobility
- Bubbles of fluid level
- Superficial vessels
- Impedence audiometry - flat tympanogram (type B)
- Audiograms= conductive defect
What is vertigo?
Sensation of environment/person moving or spinning
- World seem to spin? Which way? - vertigo
- If not - vascular, ocular, MSK, metabolic, claustrophobic
- Duration of vertigo
- Seconds to minutes - BPPV
- 30 mins to 30 hours - Menier’s or migraine
- 30 hours to 1 week = acute vestibular failure
Name some causes of vertigo
- Peripheral
- Menieres
- Benign paroxysmal positional vertigo
- Vestibular failure
- Labyrinthitis
- Cholesteatoma
- Central
- Acoustic neuroma
- MS
- Head injury
- Drugs (gentamicin, diuretics, co-trimaxazole, metronidazole)
What is menieres disease?
Dilatation of the endolymphatic spaces of membranous labyrinth causes vertigo for around 12 hours
- Extreme weakness
- Nausea/vomiting
- Feeling of full ears
- Unilateral tinnitus
- +/- fluctuating sensorineural deafness
- Attacks in clusters
How is menieres managed?
- Investigate - endolymphatic space MRI, electrocochleography
- Prochlorperazine if vomiting
- Betahistine
- Thiazides
- Surgical (vestibular neurectomy)
- Psychological
- Advice - lie down, close eyes, don’t turn head quickly
What is acute vestibular failure?
Vestibular neuronitis
- Follows febrile illness in adults (HSV)
- Sudden vertigo
- Vomiting
- Prostration (severe weakness) exacerbated by head movements
Managed with cyclizine, methylprednisolone
What is benign paroxysmal positional vertigo?
Attacks of sudden rotational vertigo lasting > 30 seconds provoked by head turning
- Displacement of otoconia in semicircular canals
- Other otological symptoms rare
- Diagnosis with Hallpike test
How is BPPV managed?
- Vestibular habituation exercises
- Drugs
- Betahistine
- Prochlorperazine
- Antidepressants
- Epley manoevres
- Posterior semicircular canal denervation (risk of deafness)
What is rhinosinusitis? How is it managed?
Inflammation in the nose and paranasal sinuses with more than 2 symptoms (1 must be nasal congestion or discharge) including facial pain/pressure, decreased olfaction and nasal polyps
- Acute management - topical corticosteroids and oral antibiotics
- Chronic management - topical corticosteroids and nasal douching
What is allerigc rhinosinusitis? How is it managed?
IgE-mediated inflammation from allergen exposure to nasal mucosa causing histamine release from mast cells
- Antihistamine (loratadine)
- Systemic decongestants (pseudoephedrine)
- Nasal sprays/nasal steroids (beclometasone < 1 month)
- Oral steroids
- Immunotherapy
What are nasal polyps? Name some associations
Ciliated columnar epithelium with thickened basement membrane and avascular oedematous stroma (90% eosinophilic)
- Rhinitis
- Chronic ethmoid sinusitis
- Cystic fibrosis
- Aspirin sensitivity
- Asthma
Symptoms and signs of nasal polyps
- Watery anterior rhinorrhoea
- Purulent postnatal drip
- Nasal obstruction
- Change of voice
- Taste disturbance
- Mouth-breathing
- Snoring
- Signs = pale, mobile, insensitive to gentle palpation
Management of nasal polyps
- 1% betamesthasone drops
- Beclometasone spray (maintenance)
- Oral prednisolone 1-2 weeks
- Anti-leukotrienes and low dose clarithromycin 2 weeks
- Endoscopic polypectomy
If single unilateral polyp +/- epistaxis = prompt CT and histology
Causes of epistaxis
Anterior septum (Little’s area) or posterior
- Trauma
- Infection
- Hypertension
- Haemophilia
- High alcohol
- Septal perforation
- Neoplasm
How is epistaxis managed?
- Resuscitate if needed (hypotension/dizzy) + ABCDE
- Patient pitch lower part of nose for 15 mins sitting forward
- Fully decongest (ephedrine 0.5% drops)
- Ice pack on dorsum of nose
- Silver nitrate cautery (after lidocaine and phenylephrine)
- Anterior nasal pack (paraffin gauze) 24 hours
- Posterior nasal pack (foley catheter)
- Diathermy
- Arterial ligation (sphenopalatine/maxillary)
Symptoms of sinusitis
- Pain - maxillary (teeth/cheek) or ethmoid (between eyes)
- Worse on bending
- Discharge from nose
- Nasal congestion
- Ansomia
- Fever
Causes of bacterial sinusitis
- Direct spread (dental root, swimming)
- Odd anatomy (septal deviation, polyps, large ethmoidal bulla)
- ITU - mechanical ventilation, NG tubes
- Biofilms
Organisms = strep pneumonia, haemophilus influenza, moraxella catarrhalis
Management of sinusitis
- Acute (if after 5 days not resolved):
- Nasal douching
- Topical steroids/decongestants
- +/- amoxicillin
- Chronic (> 12 weeks)
- Functional Endoscopic Sinus Surgery (FESS)
- Suction cleaning 1 weel post-op
- Fluticasone spray 6 weeks post-op
- Smoking cessation
- Functional Endoscopic Sinus Surgery (FESS)
Complications of sinusitis
- Mucocoeles (cysts) - infected pyocoeles
- Orbital cellulitis/abscess
- Osteomyelitis
- Intracranial infection - meningitis, encephalitis, abscess
Name sinuses and drainage
Emergency management of acute airway obstruction
- O2 or heliox
- Nebulised racemic adrenaline
- Dexamethasone/hydrocortisone IV
- ENT+anaesthetics help
- Tracheostomy kit ready
- ABG
- Flexible nasendoscopy (ENT)
- AP + lateral x-rays of neck and chest
Name some causes of dysphonia (hoarseness)
- Laryngitis (viral)
- Reinke’s oedema (vocal cord oedema)
- Functional disroders (aphonia)
- Intrinsic - decreased lubrication (Sjogrens, granulomas)
- Extrinsic - goitre, carotid body tumour, neoplasia
- Bacteria - epiglottitis, aortitis, abscess
- CNS - vagus lesion, myasthenia gravis, laryngeal nerve palsy
Symptoms of laryngeal nerve palsy
- Hoarseness
- Breathy voice
- Weak cough
- Repeated cough/aspiration
- Exertional dyspnoea (glottis too narrow)
Causes of laryngeal nerve palsy
- Cancer (larynx, thyroid, oesophagus, bronchus)
- Iatrogenic (parathyroidectomy)
- TB
- Aoritc aneurysm
- Idiopathic
Causes of dysphagia
- Malignant - oesophageal, pharyngeal, gastric, lung
- Neuro - bulbar palsy, myasthenia gravis
- Benign strictures
- Pharyngeal pouch
- Achalasia
Dysphagia history
- Dyspepsia
- Weight loss
- Lumps
- Fluid be drunk as fast as usual? Yes = stricture. No = motility disorders
- Difficulty making swallowing movement? Yes = bulbar palsy
- Dysphagia constant and painful? Yes = malignant stricture
- Neck bulge or gargle on drinking? Yes = pharyngeal pouch (+ choking, chronic cough, regurgitation, halitosis)
Investigations for dysphagia?
- FBC, ESR
- Barium swallow
- Endoscopy with biopsy
- Oesophageal motility studies
- CXR
Causes of facial nerve palsy
- Intracranial = brainstem tumours, stroke, MS, meningitis
- Intratemporal = otitis media, shingles, cholesteatoma
- Infratemporal = parotid tumours, trauma
- Herpes
- Diabetes
- Bell’s palsy
How to examine facial nerve?
- Inspect at rest - forehead wrinkles, nasolabial folds
- Movements
- Raise eyebrows
- Close eyes
- Blow out cheeks
- Smile
- Pursed lips (whistle)
- Inspect external acoustic meatus - shingles (Ramsay-Hunt)
- Hearing or taste changes?
Contents of anterior and posterior neck triangles
Anterior:
- Supra/infrahyoid muscles
- Common carotid bifurcation
- Internal jugular
- CN VII, IX, X, XI, XII
Posterior:
- Omohyoid
- External jugular + subclavian vein
- CN XI
- Phrenic nerve
Causes of neck lumps
- Midline
- If < 20 = dermoid cyst
- If > 20 = thyroid mass
- Moves on protruding tongue? Thyroglossal cyst
- Submandibular triangle
- If < 20 = self-limiting lymphadenopathy
- If > 20 = malignant?
- Salivary stone
- Sialadenitis (salivary gland infection)
- Anterior triangle
- Nodes
- Branchial cyst (<20)
- Parotid tumour
- Carotid body paraganglioma (pulsatile)
- Posterior triangle
- Nodes
- Lymphoma/mets
How are neck lumps investigated?
- US - lump consistency
- CT - anatomical position
- Nasendoscopy
- Virology + Mantoux test
- CXR - malignancy or hilar lymphadenopathy
- Fine needle aspiration
Name the salivary glands
Name some causes of salivary gland lumps based on acute/chronic/uni/bilateral
- Acute unilateral = mumps, acute parotitis (post-op) abscess
- Acute bilateral = mumps, staph, TB, HIV, ALL
- Recurrent unilateral = stones
- Pain/swelling worse with eating
- Sialography x-ray
- Chronic bilateral = Sjogrens
- Fixed swelling = malignant, idiopathic, sarcoidosis
What is xerostomia? How is it managed?
Dry, atrophic, fissured oral mucosa causing discomfort when eating and speaking
- Increase oral fluids
- No acidic foods/drinks
- Chewing gum (sugar free)
- Saliva substitute
