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ENT Flashcards

1
Q

What is the centor criteria?

A

Predicts risk of infection with Group A beta-haemolytic streptococci

  • Absence of cough
  • Exudate
  • Fever > 38
  • Anterior cervical lymphadenopathy
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2
Q

How are sore throats managed?

A
  • 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
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3
Q

Name some complications of a sore throat

A
  • 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
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4
Q

Name the indications for a tonsillectomy

A
  • 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
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5
Q

Describe glandular fever, including symptoms, cause and diagnosis

A

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)
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6
Q

How is glandular fever managed?

A
  • Rest
  • Fluids
  • Regular paracetemol
  • Avoid alcohol
  • Salt water/aspirin gargles
  • Consider short course of prednisolone if severe
  • Antibiotics if secondary infection
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7
Q

What is stridor? Name some causes

A

Noise created on inspiration due narrowing of the larynx or trachea

  • Epiglottitis
  • Croup (laryngotracheobronchitis)
  • Inhaled foreign body
  • Trauma
  • Laryngeal paralysis
  • Congenital abnormalities
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8
Q

What is croup? What are the clinical signs?

A

Viral infection of the larynx/trachea, commonly seen in young children

  • Fever
  • Runny nose
  • Barking cough
    • Worse at night
    • Exacerbated by crying
  • Inspiratory stridor
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9
Q

How is croup managed?

A
  • Steam
  • Steroids - oral dexamethasone or prednisolone
  • Admit as paediatric emergency if:
    • Intercostal recession
    • Cyanosis
    • Carers unable to cope
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10
Q

What is CSF rhinorrhoea? What is it an indication of?

A

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
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11
Q

Name some causes of earache

A
  • Local
    • Otitis externa/media
    • Impacted wax
    • Malignancy
    • Barotrauma
    • Mastoiditis
  • Referred
    • Trigeminal nerve (dental abscess/TMJ)
    • Facial nerve
    • Vagus nerve (larynx)
    • Glossopharyngeal nerve (tonsilitis/quinsy)
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12
Q

Name some risk factors for developing otitis externa

A
  • Swimming
  • Narrow ear canal
  • Hearing aid use
  • Mechanical trauma
    • Cotton buds
    • Syringing
  • Itching
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13
Q

How is otitis externa managed?

A
  • Analgesia (paracetemol +/- ibuprofen)
  • Aural toilets
  • Ear drops (if no perforation)
    • Antibiotics (gentamicin)
    • Steroid (betamethasone)
    • Aluminium acetate
  • Refer to ENT if no response - microsuction
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14
Q

How does acute otitis media present?

A

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
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15
Q

How is acute otitis media managed?

A
  • 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
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16
Q

What are the different types of hearing loss?

A
  • 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)
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17
Q

What is glue ear?

A

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
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18
Q

What is mastoiditis?

A

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
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19
Q

What is cholesteatoma?

A

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
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20
Q

Name some causes of congential deafness

A
  • Genetic
  • Birth asphyxia
  • Intrauterne infection (rubella)
  • Meningitis
  • Drugs during pregnancy - streptomycin
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21
Q

Describe hearing tests

A
  • 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)
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22
Q

Label this ear drum

A

RIGHT (cone of light towards feet)

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23
Q

Describe anatomy of ear

A
  • 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
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24
Q

How is sudden sensorineural deafness managed?

A
  • 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
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25
Q

How is sudden sensorineural deafness defined?

A

Loss of >/= 30 DB in 3 contiguous pure tone frequencies over = 72 hours

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26
Q

What is otosclerosis? Name some symptoms

A

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

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27
Q

How is otosclerosis managed?

A
  • Fluoride
  • Hearing aid
  • Cochlear implant
  • Surgery
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28
Q

What is presbyacusis?

A

Age-related hearing loss from accumulated environmental noise toxicity, starting with high frequency sounds

  • Most affected with background noise
  • Treat with hearing aids
29
Q

What is tinnitus? Name some causes

A

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
30
Q

How is tinnitus managed?

A
  • 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?
31
Q

What is an acoustic neuroma?

A

Indolent subarachnoid tumours of the superior vestibular nerve

  • Progressive ipsilateral tinnitus +/- sensorineural deafness
  • +/- ipsilateral cerebellar signs
  • RICP
  • Numb face

Investigate with MRI

32
Q

Organisms in otitis externa

A
  • Pseudomonas
  • Staph aureus
  • Fungal
33
Q

Risk factors for chronic otitis media

A
  • URTI
  • Oversized adenoids
  • Bottle-feeding
  • Asthma
  • Passive smoking
  • Malformations
  • Dummy
34
Q

History in glue ear

A
  • Poor listening/sppech/behaviour
  • Language delay
  • Inattention
  • Balance
  • School work
  • URTI
35
Q

Signs of glue ear

A
  • 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
36
Q

What is vertigo?

A

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
37
Q

Name some causes of vertigo

A
  • Peripheral
    • Menieres
    • Benign paroxysmal positional vertigo
    • Vestibular failure
    • Labyrinthitis
    • Cholesteatoma
  • Central
    • Acoustic neuroma
    • MS
    • Head injury
    • Drugs (gentamicin, diuretics, co-trimaxazole, metronidazole)
38
Q

What is menieres disease?

A

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
39
Q

How is menieres managed?

A
  • Investigate - endolymphatic space MRI, electrocochleography
  • Prochlorperazine if vomiting
  • Betahistine
  • Thiazides
  • Surgical (vestibular neurectomy)
  • Psychological
  • Advice - lie down, close eyes, don’t turn head quickly
40
Q

What is acute vestibular failure?

A

Vestibular neuronitis

  • Follows febrile illness in adults (HSV)
  • Sudden vertigo
  • Vomiting
  • Prostration (severe weakness) exacerbated by head movements

Managed with cyclizine, methylprednisolone

41
Q

What is benign paroxysmal positional vertigo?

A

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
42
Q

How is BPPV managed?

A
  • Vestibular habituation exercises
  • Drugs
    • Betahistine
    • Prochlorperazine
    • Antidepressants
  • Epley manoevres
  • Posterior semicircular canal denervation (risk of deafness)
43
Q

What is rhinosinusitis? How is it managed?

A

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
44
Q

What is allerigc rhinosinusitis? How is it managed?

A

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
45
Q

What are nasal polyps? Name some associations

A

Ciliated columnar epithelium with thickened basement membrane and avascular oedematous stroma (90% eosinophilic)

  • Rhinitis
  • Chronic ethmoid sinusitis
  • Cystic fibrosis
  • Aspirin sensitivity
  • Asthma
46
Q

Symptoms and signs of nasal polyps

A
  • Watery anterior rhinorrhoea
  • Purulent postnatal drip
  • Nasal obstruction
  • Change of voice
  • Taste disturbance
  • Mouth-breathing
  • Snoring
  • Signs = pale, mobile, insensitive to gentle palpation
47
Q

Management of nasal polyps

A
  • 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

48
Q

Causes of epistaxis

A

Anterior septum (Little’s area) or posterior

  • Trauma
  • Infection
  • Hypertension
  • Haemophilia
  • High alcohol
  • Septal perforation
  • Neoplasm
49
Q

How is epistaxis managed?

A
  • 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)
50
Q

Symptoms of sinusitis

A
  • Pain - maxillary (teeth/cheek) or ethmoid (between eyes)
    • Worse on bending
  • Discharge from nose
  • Nasal congestion
  • Ansomia
  • Fever
51
Q

Causes of bacterial sinusitis

A
  • 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

52
Q

Management of sinusitis

A
  • 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
53
Q

Complications of sinusitis

A
  • Mucocoeles (cysts) - infected pyocoeles
  • Orbital cellulitis/abscess
  • Osteomyelitis
  • Intracranial infection - meningitis, encephalitis, abscess
54
Q

Name sinuses and drainage

A
55
Q

Emergency management of acute airway obstruction

A
  • 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
56
Q

Name some causes of dysphonia (hoarseness)

A
  • 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
57
Q

Symptoms of laryngeal nerve palsy

A
  • Hoarseness
  • Breathy voice
  • Weak cough
  • Repeated cough/aspiration
  • Exertional dyspnoea (glottis too narrow)
58
Q

Causes of laryngeal nerve palsy

A
  • Cancer (larynx, thyroid, oesophagus, bronchus)
  • Iatrogenic (parathyroidectomy)
  • TB
  • Aoritc aneurysm
  • Idiopathic
59
Q

Causes of dysphagia

A
  • Malignant - oesophageal, pharyngeal, gastric, lung
  • Neuro - bulbar palsy, myasthenia gravis
  • Benign strictures
  • Pharyngeal pouch
  • Achalasia
60
Q

Dysphagia history

A
  • 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)
61
Q

Investigations for dysphagia?

A
  • FBC, ESR
  • Barium swallow
  • Endoscopy with biopsy
  • Oesophageal motility studies
  • CXR
62
Q

Causes of facial nerve palsy

A
  • Intracranial = brainstem tumours, stroke, MS, meningitis
  • Intratemporal = otitis media, shingles, cholesteatoma
  • Infratemporal = parotid tumours, trauma
  • Herpes
  • Diabetes
  • Bell’s palsy
63
Q

How to examine facial nerve?

A
  • 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?
64
Q

Contents of anterior and posterior neck triangles

A

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
65
Q

Causes of neck lumps

A
  • 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
66
Q

How are neck lumps investigated?

A
  • US - lump consistency
  • CT - anatomical position
  • Nasendoscopy
  • Virology + Mantoux test
  • CXR - malignancy or hilar lymphadenopathy
  • Fine needle aspiration
67
Q

Name the salivary glands

A
68
Q

Name some causes of salivary gland lumps based on acute/chronic/uni/bilateral

A
  • 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
69
Q

What is xerostomia? How is it managed?

A

Dry, atrophic, fissured oral mucosa causing discomfort when eating and speaking

  • Increase oral fluids
  • No acidic foods/drinks
  • Chewing gum (sugar free)
  • Saliva substitute

IPE (13 decks)

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