ENT Flashcards
Two areas of the tympanic membrane
Pars Flaccida:
- Non conducting
- 2 layers
- Where infections are most likely to occur
Pars Tensa
- Conducting portion
- 3 layers
What is the tonotopic nature of the cochlear referring to?
Means the cochlear will resonate at different areas depending on the frequency of sound received.
What is the Rinne test? What tuning fork?
512Hz
Put fork on mastoid then when the pt can’t hear anymore put by ear.
If they can hear the sound by the ear, this is a normal POSITIVE result.
In practice as long as the sound by the ear is louder then this is a positive test.
What is the weber test, what is this for?
It is to differentiate between conductive and sensorineural hearing loss.
Tuning fork on forehead.
In unilateral conductive hearing loss heard on affected side
In unilateral sensorineural hearing loss then heard on unaffected side.
What is mastoiditis?
Bacterial infection of the mastoid bone behind the ear (normally acute) . Inferior extension of the petrous temporal bone. Can be chronic and if it is it is normally presents as an association with cholesteatoma.
Contains air cells that develop from a central main cavity. There is communication from the tympanic space to this central cavity
Mastoiditis occurs when suppurative infection extends from a middle ear affected by otitis media to the mastoid air cells.
The infective process causes inflammation of the mastoid and surrounding tissues, with accompanying suppuration, and bone necrosis.
May result in Extradural & intracerebral abscesses. Damage to surrounding areas such as the facial nerve. (abducens)
Thyroglossal cyst moves upwards when swallowing or on protrusion of the tongue?
On protrusion.
What type of lump moves on swallowing?
Thyroid swelling.
What is Vestibular neuronitis
Vestibular neuronitis is a cause of vertigo that often develops following a viral infection.
No hearing loss/tinnitus, some vertigo
Nerve supply of nasal cavity?
Sensory - Trigeminal nerve (maxillary)
Secretomotor - Vidian nerve
Vascular supply:
Constriction - sympathetic
Dilatation - Parasympathetic
Smell
Olfactory nerve
4 paranasal air sinuses?
Frontal
Ethmoid
Maxillary sinus
Sphenoid sinus
Allergy testing types?
Skin-prick testing
RAST test
Lymph nodes of the neck?
Superficial cervical Deep cervical Parotid Retroauricular Buccal Submandibular occipital
Difference in the left & right recurrent laryngeal nerves?
Both branch from vagus
Right passes under subclavian and comes back up to thyroid cartilage
Left passes under subclavian + aorta then back up.
Phases of swallowing?
Oral
Pharyngeal (autonomic)
- Larynx rises and constrictors contract towards cricopharyngeus.
What is the The dehiscence of Killian?
The weakness at the back above
cricopharyngeus (oesophageal sphincter)
How is aspiration prevented?
Aspiration is prevented by good sensation
allowing the epiglottis to tilt, the larynx to
rise, and the false cords and cords to close.
H&N cancer presentation?
History of hoarse voice, sore mouth or
tongue, difficulty or pain on swallowing,
neck mass.
What is Odynophagia?
Pain when swallowing.
Treatment for early and late tumours?
Early:
- Surgery or Radiotherapy
- Good outcomes, Low Morbidity
Late:
- Surgery and Radiotherapy
- Chemoradiotherapy
- Poor outcomes, High Morbidity
Ladder of reconstruction in Head and neck cancer patients?
- Secondary healing Direct closure Skin Graft Obturation and implants Local Flaps Pedicled Flaps Free Flaps
Rhinitis history?
Previous Surgery or Trauma Family History Medical History Asthma, Hayfever or Eczema Aspirin sensitivity
Intrinsic rhinitis treatment?
- Steroids
Inhaled Antihistamine (Rhinolast)
Rhinorrhoea (Rinatec)
What is intrinsic rhinitis?
Non-allergic
Middle-aged Males>Females
Post-Nasal Drip predominates
Reactive nasal symptoms
Fumes, Smoke, Temperature, Alcohol
Treatment for allergic rhinitis?
- Topical Corticosteroids Systemic Corticosteroids Sodium cromoglycate Antihistamines Decongestants Ipatropium Bromide Leukotriene Receptor Antagonists
Worries in unilateral nasal polyps?
?Cancer
Treatment for nasal polyps?
Medical
Steroids, Steroids and Steroids
Leukotriene Receptor Antagonists
Surgical
Simple Nasal Polypectomy
FESS (functional endoscopic sinus surgery)
What is rhinosinusitis?
Rhinosinusitis (with or without nasal polyps) is defined as: inflammation of the nose and the paranasal sinuses characterised by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip)
± facial pain/pressure,
± reduction or loss of smell;
and either:
1. Endoscopic signs of polyps and/or;
- mucopurulent discharge primarily from middle meatus and/or;
- oedema/mucosal obstruction primarily in middle meatus,
and/or:
CT changes - mucosal changes within the ostiomeatal complex and/or sinuses.
Rhinosinusitis Management?
Identify predisposing factors RAST & IgE SPT Medical Therapy Oral / Topical nasal steroids Antibiotics: oral, iv, nebulised, topical (high doses) Douches: alkaline, saline Concept of ‘maximal medical therapy’ Endoscopic Sinus Surgery
What is sjorens syndrome?
Autoimmune condition causing dry eye and dry mouth
Give three pre-disposing factors for the development of perichondritis of the pinna? What bacterium is often associated?
Trauma, inflammatory condition, ear piercing. Caused by Pseudomonas.
Management of initial otitis externa presentation?
Topical ear drops. Swab, Pain relief, Examination, Steroids if inflamed
What type of ear loss is caused by chronic wax buildup?
Conductive
Role of earwax?
Cleaning, lubrication, some help against microbial invasion.
What is the percentage of pre-school children who suffer from OME?
8 out of ten children by the age of 10
Three ways OME may present?
Hearing loss,
Pain
Behaviour and development.
What type of hearing loss does OME cause and what level of hearing loss would you expect in terms of decibels?
Mild hearing loss <20db, Conductive
Why do we often wait for three months (watchful waiting) once the diagnosis of OME has been made?
May resolve spontaneously
Give the three treatment options of OME.
Grommets, balloon, hearing aid.
What do you understand by the term Cholesteatoma?
Abnormal collection of cells originating in the pars flacida, can migrate and damage surrounding structures.
Name three ways by which patients with early cholesteatoma may commonly present. What type of hearing loss do they suffer?
Discharge, characteristic smell, painful
What operation is commonly performed for cholesteatoma?
Combined approach tympanoplasty
Give four severe complications of untreated longstanding cholesteatoma.
Meningitis, hearing loss (damage to ossicles), damage to facial nerve, intracerebral abscess
Three causes of a perforated tympanic membrane
Trauma, infection, barotrauma
Hearing loss associated with perforation of tympanic membrane?
Conductive
What operation is commonly performed for a perforated tympanic membrane?
Tympanoplasty
Would you prescribe ear drops to a patient with a perforated ear drum?
No
Vertigo description?
Sensation that you or the environment around you is moving
Acoustic neuroma presentation?
unilateral or asymmetrical hearing loss
impaired facial sensation
balance issues
Meniere’s disease triad?
vertigo, tinnitus, fluctuating hearing loss
What does a patient with BPPV classically complain of?
Attacks of vertigo starting when moving and lasting 20-30 seconds
Between what frequencies is a pure tone audiogram commonly measured?
250 hertz - 8000 hertz
What do circles on an audiogram represent?
Right ear (Red)
What do crosses on an audiogram represent?
Left ear (blue)
Changes to the audiogram in sensorineural, conductive and mixed hearing loss?
In sensorineural hearing loss both air and bone conduction are impaired
In conductive hearing loss only air conduction is impaired
In mixed hearing loss both air and bone conduction are impaired, with air conduction often being ‘worse’ than bone
What is the major cause of hearing loss in adults and what type of loss is this?
Presbyacusis
- Age-related damage to the cochlea
Sensorineural
Name the five categories of hearing ability, and their ranges in decibels.
0-20 is normal
20-40 is normal
40-70 is moderate
70-90 is severe
90-120 is profound
Name the three main types of tympanogram and what they show.
A, B and C
A is normal peak at around 0
B is flat line, may be glue ear or perforation (middle ear pathology)
C is teepee shifted to the left this indicates negative pressure in the middle ear space, often consistent with sinus or allergy congestion, or the end-stages of a cold or ear infection.
Name three styles of hearing aid.
In the canal
In the ear
Behind the ear
Three causes of tinnitus?
Otological: noise-induced and other forms of hearing loss, presbyacusis, otosclerosis, impacted cerumen, ear infection, Ménière’s disease.
Neurological: head injury, multiple sclerosis, acoustic neuroma and other similar tumours.
Infectious: meningitis, syphilis.
Drug-related: salicylates, non-steroidal anti-inflammatory drugs (NSAIDs), aminoglycosides, loop diuretics, cytotoxicity.
What are the three ENG tests?
The standard ENG test battery consists of three parts:
oculomotor evaluation
positioning and positional testing
caloric stimulation of the vestibular system
When might you perform ENG?
To record nystagmus, and determine its cause
Two newborn hearing tests?
Automated otoacoustic emissions (AOAE) test
Automated auditory brainstem response (AABR) test
What are the different ways you can assess hearing from newborns to 3 years
Newborn:
- Automated otoacoustic emissions (AOAE) test
- Automated auditory brainstem response (AABR) test
6-8 months
- Distraction test
18 months to 2.5 years
- Recognition of familiar objects
- 5 years
- Speech discrimination
- Similar sounding objects
> 3
- Pure tone audiometry
Mucosa of the paranasal air sinuses?
Pseudostratified ciliated columnar epithelium
Management of epistaxis?
ABCDE, lean forward and hold lower nasal area
Nasal cautery
- silver nitrate
- electrocautery
Packing
Which major blood vessel supplies the posterior of the nose? Off what vessel is it a branch?
Posterior
- Sphenopalatine artery
- off of maxillary
Anterior
- anterior and posterior ethmoidal arteries
Causes of anosmia?
Congenital anosmia
- rare
Nasal polyps
Infection
What is the significance of a unilateral nasal discharge in a child?
Choanal atresia
What is the significance of a unilateral nasal discharge in an adult?
Rhinitis and Nasal Obstruction
Allergens associated with allergic rhinitis?
Tree pollen - early to late spring
Grass pollen - early summer
House dust mite - worse on waking, all year round
Allergic rhinitis management?
Oral and topical anthistamines
Intranasal topical steroids
Surgical reduction of the inferior turbinates or correction of a deviated nasal septum or nose
Polypectomy
What is an SMR, when would you perform this?
Submucous resection
Deviated nasal septum, chronic sinus infections
What is an SMD, what may it do?
Submucous diathermy, may help to relieve nasal blockage
Unilateral polyp suspicions in children and in adults?
In adults suspect a tumour, as nasal polyps are usually bilateral
In children:
- encephalocele (neural tube defect affecting the brain)
Polys associated with allergic rhinitis or non-allergic?
Non-allergic, often associated with rhinosinusitis (inc. sinuses)
What is the most common cause of obstructive sleep apnoea syndrome (OSAS) in children, and adults? Treatment?
Enlargement of tonsils and adenoids in children - removal
T2DM in adults - CPAP
Gold standard Sleep apnoea investigation?
Polysomnography
Treatment of epiglottitis?
Abx, intubation if airway collapse
Croup treatment?
Steroids, adrenaline if worse.
Acute tonsilittis causative organism?
Group A strep
What is quinsy?
Peritonsillar abscess - normally need to drain it (and Abx)
Glandular fever advice on what not to do?
Contact sports - risk of splenic rupture
Avoid alcohol
What is stridor and stertor?
Stridor
- upper airway sound may be inspiratory or expiratory, or biphasic.
Stertor
- like a snoring inspiratory sound
Otitis externa treatment?
Topical antibiotic drops, normally neomycin, can be combined with topical steroids such as betamethasone
If spreading or particularly bad could use oral Abx
Otitis externa?
Ear canal with erythema, oedema and exudate.
Mobile tympanic membrane.
Pain with movement of the tragus or auricle.
Pre-auricular lymphadenopathy.
What is cerumen impaction? Presentation? Treatment?
Cerumen is a mixture of secretions and sloughed epithelial cells. A cerumen impaction is an accumulation of cerumen that causes symptoms, such as hearing loss, fullness, otorrhoea, tinnitus, dizziness, or other symptoms
Treat with irrigation, manual removal, or topical preparations.
Treatment for perforated eardrum?
Usually nothing, Abx if infected, tympanoplasty if not healing.
Acute mastoiditis presentation?
History of acute or recurrent episodes of otitis media.
Intense otalgia and pain behind the ear.
Fever.
Infants may present with irritability, intractable crying and feeding problems.
Swelling, redness or a boggy, tender mass behind the ear.
The external ear may protrude forwards
Ear discharge
Acute mastoiditis management
Broad spectrum Abx, surgical intervention if there is cholesteatoma, if it is spreading intracranially
What is serous otitis media?
Middle ear effusion, without perforation, persisting for more than 1-3 months.
What is Chronic Suppurative Otitis Media?
Chronic middle ear infection, cycle of inflammation.
Acute infection of the middle ear causes irritation and inflammation of the mucosa of the middle ear with oedema. Inflammation produces mucosal ulceration and breakdown of the epithelial lining
Safe is without cholesteatoma, unsafe is with
Presentation and treatment of acute otitis media in adults?
Hearing loss, otalgia and fever. In children may have feeding difficulty and may pull at ear.
Usually do not treat with Abx, unless signs of spreading or at risk, may consider if symptoms do not resolve within 4 days. Treat with paracetamol and ibuprofen. Similar in children.
What is TMJ dysfunction? Presentation and management?
Temporomandibular joint dysfunction
May affect up to 25% of population
Commonly:
- Intra-articular disc derangement (various types).
- Osteoarthritis.
- Rheumatoid arthritis.
Facial pain, restricted jaw function and joint noise
Most improve with conservative management
Could otherwise inject with steroid, surgery.
Types of Tracheostomy tubes?
Plastic or silver
Cuffed or uncuffed
Fenestrated or unfenestrated
Double or single cannula
Indications for tracheostomy?
Obstruction of the upper airway - eg, foreign body, trauma, infection, laryngeal tumour, facial fractures.
Impaired respiratory function - eg, head trauma leading to unconsciousness, bulbar poliomyelitis.
Nerves associated with submandibular gland?
Maxillary and hypoglossal
Centor criteria for diagnosis of tonsillitis?
- Temperature >38ºC
- Tender anterior cervical lymphadenopathy
- Absence of a cough
- Exudate present on tonsils
What is the treatment given in the acute and chronic phase for sinusitis?
Acute
- Intranasal decongestants
- Analgesia
Chronic
- Intranasal corticosteroids
Treatment for vestibular neuronitis?
Acutely
- Prochlorperazine, stop after a few days
Chronic
- Can do vestibular rehab exercises
What is rhinitis medicamentosa, how do you manage?
Rebound rhinitis after using nasal decongestants for too long, need to stop decongestants cold turkey.
What is tachyphylaxis?
Needing more and more nasal decongestants to do the same job
What are the nice criteria for a tonsillectomy now?
- Sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
- The person has five or more episodes of sore throat per year
- Symptoms have been occurring for at least a year
- The episodes of sore throat are disabling and prevent normal functioning
What is otosclerosis?
Autosomal dominant, replacement of normal bone by vascular spongy bone. Onset is usually at 20-40 years, features include:
- conductive deafness
- tinnitus
- tympanic membrane - 10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
- positive family history
What is malignant otitis externa?
Otitis externa found in immunocompromised individuals, infection with pseudomonas
- Diabetes
- Immunosuppression
In sensorineural hearing loss what conduction is better air or bone?
Air is better (the same as in normal hearing I guess?)
In presbycusis what type of hearing loss do you get?
High frequency bilateral sensorineural hearing loss
What antibiotics do you use in tonsillitis?
Phenoxymethylpenicillin
If allergic to penicillin then use erythromycin
