ENT Flashcards
which 5 medications can cause ototoxicity? (hearing and/or balance can be affected)
quinine gentamicin furosemide aspirin some chemotherapy
what is presbycusis?
examinations + investigations?
age-related sensorineural hearing loss, usually of high-frequency sound
r+ w - weber’s (bone conduction) may lateralise to one side if sensorineural loss isn’t bilateral
otoscopy - rule out otosclerosis, cholesteatoma + conductive hearing loss
tympanometry - normal middle ear function with hearing loss (type A)
audiometry - bilateral sensorineural loss
bloods incl inflam markers + antibodies - normal
otosclerosis - what is it + who does it affect?
autosomal dominant (+ve FH)
replacement of normal bone by vascular spongy bone
2° to fixation of stapes in oval window
onset at 20-40 years
otosclerosis - features? management?
tinnitus
progressive conductive deafness
flamingo tinge to tympanic membrane in 10% - hyperaemia
hearing aid
stapedectomy + insertion of prosthesis
otitis media with effusion (glue ear) - what age does it affect + what problems can result? management?
peaks age 2
conductive hearing loss
balance problems
behavioural problems
SAL delay
TM dull + injected
no retraction/infection/perf
none if not problematic
problematic - grommets (temp hearing aids)
meniere’s - what is it? who does it affect? prognosis?
inner ear disorder of unknown cause, characterised by excess pressure + progressive dilatation of endolymphatic (fluid) system
middle-aged adults mainly but can be any age
resolves after 5-10 years but may leave hearing loss
what is an acoustic neuroma (vestibular schwannoma)? association?
benign tumour on trigeminal / facial / vestibulocochlear nerve
neurofibromatosis II
meniere’s - presentation? exam findings?
every few days, for mins-hours, pt will have vertigo, tinnitus + sensorineural hearing loss
aural fullness / roaring sound, nausea
usually unilateral
nystagmus
romberg’s sign
sensorineural loss
menieres - management (general + acute)
ENT assessment
inform DVLA - stop driving until symptoms controlled
prophylaxis: betahistine + vestibular rehab
acute: prochlorperazine (buccal / IM) ± admission
quinsy - management
bleep ENT reg on call analgesia IV abx needle aspiration or incision + drainage difflam rinse
enlarged tonsils that meet in the midline, white film over them - what is it?
acute bacterial tonsillitis
main organism that causes acute tonsillitis?
streptococcus pyogenes (group A strep)
management of tonsillitis
analgesia
7-10d phenoxymethylpenicillin (erythro if allergic)
admit if can’t eat drink
screen infectious mononucleosis (mimics)
what pathogen is infectious mononucleosis caused by?
EBV
splenomegaly, pyrexia and throat symptoms - what is it?
infectious mononucleosis
what does monospot test for?
infectious mononucleosis
recurrent unilateral pain + swelling on eating - what is it? investigation + management?
salivary gland stone - usually submandibular
xray + sialography → surgical removal
sore throat - investigations?
CENTOR (3 of Cough absent, Exudate, Nodes, Temp)
rubbery, painless lymphadenopathy - what is it?
lymphoma
neck lump that moves up on swallowing
thyroid swelling
neck lump that moves up on tongue protrusion - what is it? what about if it hurts?
thyroglossal cyst
may hurt if infected
RHS - features
ear pain vertigo, tinnitus, deafness vesicular rash around ear facial nerve palsy taste loss in anterior ⅔
RHS - management
oral acliclovir + high dose corticosteroids
otitis media - mgmt
if necessary, amoxicillin 5 days (macrolide if allergic)
eg systemically unwell, comorbidities, immunocompromise, perforation or discharge in canal
nasal polyp - presentation
nasal obstruction
sneezing + rhinorrhoea
poor taste + smell
postnasal drip - presentation
excess mucus from nasal mucosa accumulates → chronic cough + bad breath
sensorineural loss on audiogram
air + bone impaired
conductive loss on audiogram
air impaired only
mixed hearing loss on audiogram
air + bone impaired but air oft worse than bone
acoustic neuroma - symptoms? investigation?
CN 8 - hearing loss, vertigo, tinnitus
CN 5 - absent corneal reflex
CN 7 - facial palsy
MRI cerebellopontine angle
quinsy - what is it? features?
peritonsillar abscess - complication of tonsillitis
unilateral tonsil swelling + pain, uvula deviated away
trismus (diff opening mouth)
reduced neck mobility
fever
what is RHS?
reactivation of the varicella zoster virus in the geniculate ganglion of the facial nerve. LMN palsy.
BPPV - presentation? diagnosis + management? outlook?
sudden onset dizziness, vertigo ± nausea on moving head/eyes, lasts 10-20s
dix-hallpike (head bent back 30° off bed → symptoms + nystagmus)
usually resolves spontaneously in weeks-months
epley helps 80%
teach vestibular rehab exercises (eg brandt-daroff)
betahistine is prescribed but little effect
cholesteatoma - what is it? RFs?
growth of squamous epithelium behind the TM. trapped within skull base + causes local destruction. may be congenital but usually caused by repeated middle ear infections. most common age 10-20. cleft palate = 100x RF
cholesteatoma - features? management?
intermittent, foul-smelling discharge
not usually painful
hearing ± balance loss, vertigo, FN palsy, CPA angle syndrome (depending on local invasion)
otoscopy - ‘attic crust’ in uppermost part of TM
perforated pars flaccida
microsuction then inspection
audiometry
ENT referral - ?surgical removal eg mastoidectomy
infected - topical abx + steroids
acute otitis externa - what is it? features?
inflammation of ear canal - boil causing:
pain on moving pinna
± conductive deafness
if ruptures - pus from ear
otoscope - swollen, tender canal with debris
acute otitis externa - management
keep dry
analgesia
topical abx + steroid
chronic otitis externa - what is it? features?
chronic combined infection in external auditory meatus - usually staph + fungal
chronic discharge
chronic otitis externa - management
cleansing of external ear
antifungal + antibacterial ear drops
acute suppurative otitis media - what is it? features?
viral middle ear effusions 2° to eustachian tube dysfunction
usually in kids (rare in adults)
may present as symptoms elsewhere eg vomiting
severe pain ± fever
± discharge if TM rupture
ear canal not inflamed
acute suppurative otitis media - management
not always needed
5d amoxicillin
chronic suppurative otitis media - types?
with vs without cholestetoma, active vs inactive
without:
active mucosal
perforation of pars tensa (below handle of malleus) allows infection to develop in ear
with:
active squamous
results from cholesteatoma formation
± perforation of pars flaccida (above handle)??
inactive mucosal - dry perf of PT, no inflam
inactive squamous - shallow self-cleansing, retracted TM
chronic suppurative otitis media without cholesteatoma - features?
infection comes and goes
intermittent, non-offensive discharge
perforated pars tensa
white plaque in anterior TM
chronic suppurative otitis media without cholesteatoma - management?
microsuction then inspection
infected - abx + steroid drops 7-10d
keep dry
myringoplasty (TM repair if) troublesome
acute otitis externa - complications
perichondritis (spread to cartilage)
cellulitis (spread to skin)
malignant otitis externa
perichondritis - what is it? management?
inflamed cartilage eg pinna (but not lobe)
systemic illness
external canal swollen
painful
IV abx
microsuction ear
topical abx + steroid drops via aural wick
malignant otitis externa - what is it? RFs?
pseudomonas
infection progresses to bony ear canal + temporal bone osteomyelitis
RF - immunocompromise / DM
cellulitis or perichondritis?
cellulitis - inflamed pinna + lobe
perichondritis - inflamed pinna only
acute otitis media - complications
mastoiditis
anterior epistaxis - what is it?
visible bleeding source
insult to capillary network that form Kiesselbach’s Plexus
posterior epistaxis - what is it?
more profuse
originate from deeper structures
more common in older pts
risk aspiration + airway compromise
epistaxis - management if pt is haem stable
avoid lying down unless faint
sit forward + mouth open - decreases blood flow to nasopharynx, allows pt to spit any blood in mouth + reduces aspiration risk
pinch soft area of nose for 15m+ + breathe through mouth
± naseptin (topical chlorhexidine + neomycin - antiseptic) - reduce crusting + vestibulitis risk - ask allergies
?admission if comorbidities, ?pathology or <2y (?leukaemia / haemophilia)
epistaxis - still bleeding after 15 min of pressure
cautery - if source visible + it’s tolerated (not great in young kids)
packing - if not
admit + refer ENT
when should epistaxis be admitted?
post cautery/packing
haem unstable
unknown or posterior source
epistaxis - discharge counselling - what should pt avoid?
blowing + picking
heavy lifting + exercise
lying flat
alcohol + hot drinks
sinusitis - presentation
facial fullness + tenderness
nasal discharge, pyrexia or post-nasal drip → cough
malignant otitis externa - features
reduced hearing ear canal full of debris + TM not visible severe pain temporal headaches purulent otorrhoea ± dysphagia, hoarseness, FN dysfunction
malignant otitis externa - investigations + management
swab + topical abx
6wk IV abx
monitor CRP
CT or MR skull base
mastoiditis - features
fever + unwell severe otalgia, oft behind ear hx recurrent otitis media mastoid tenderness + inflammation forward protrusion of external ear discharge if perf
nasal polyps - RFs
asthma
CF
churg-strauss (eGPA)
nasal polyps - red flags
unilateral symptoms
bleeding
nasal polyps - management
ENT assessment
topical corticosteroids - shrink 80%
bleeding post-tonsillectomy - management
primary - <24h:
immediate return to theatre
secondary haemorrhage - >24h:
likely due to infection
admit + abx
sinusitis - RFs
nasal obstruction - septal deviation, polyps
recent local infection
swimming
smoking
sinusitis - features
facial pain/pressure - oft worse bending forward
nasal discharge - thick + purulent
nasal obstruction
post-nasal drip > cough
acute sinusitis - management
analgesia
intranasal decongestants or nasal saline - but evidence poor
>10d - intranasal steroids
severe - abx eg phenoxy
chronic sinusitis - management
treat acute elements
intranasal corticosteroids
± refer ENT
thyroid surgery - complications
anatomical eg recurrent laryngeal damage
bleeding ± resp compromise
damage to PT glands > hypocalcaemia
2 physical causes of tinnitus (other than the main conditions)
impacted ear wax
chronic suppurative otitis media
3 causes of vertigo other than the main conditions
trauma
MS
ototoxicity
vestibular neuronitis - what is it?
vertigo following viral infection
vestibular neuronitis - features
NO hearing loss/tinnitus
recurrent vertigo attacks lasting hours or days
horizontal nystagmus
± N+V
vestibular neuronitis - management
vestibular rehab if chronic
betahistine - but poor evidence
prochlorperazine for acute phase only
