ENT Flashcards
Questions about neck lumps
Duration Change in size Associated features- pain, redness, discharge Lumps elsewhere Preceding symptoms Recent travel esp TB occupation Cat scratch Radiation exposure Red flags- persistent sore throat, hoarseness, dysphagia, odynophagia, Weight Loss, fevers, night sweats Smoking Alcohol consumption HIV status Dental problems
Investigations of a neck lump
USS with fine needle aspiration
CT can be useful
Red flags in neck lump
persistent sore throat, hoarseness, dysphagia, odynophagia, Weight Loss, fevers, night sweats
Elderly male Neck lump for three months Increasing in size Persistent sore throat Change in voice Heavy smoker Heavy drinker
Next steps
Diagnosis?
Do full exam
Flexible nasopharynolaryngoscopy
If lump going do USS and FNAC
Discuss at MDT
Neck cancer eg SCC mets
Risk factors for SCC if head and neck
Betel nut chewing Smoking HPV EBV Alcohol
Elderly man
Hoarse voice
Head and neck cancer
Spreading to larynx
Other questions to ask when hoarseness present
Dysphagia Odynophagia Weight loss Heart burn or indigestion Post nasal drip Systemic upset
Urgent referral needed for throat when
Hoarseness for more than six weeks Oral swellings for more than six weeks Dysphagia got more than three weeks Unresolving neck masses for more than three weeks Cranial neuropathies Orbital masses
Causes of hoarseness
Overuse of larynx Acute laryngitis Chronic laryngitis secondary to reflux Use of asthma inhaler Smoking SCC of larynx Vocal cord Palsy
Treat for SCC mets
Radiotherapy- multiple small doses, can be curative or palliative
Surgical resection
Chemo- not curative but can be used to shrink
Then if unsuccessful look at palliative
Middle aged female. Non smoker. Neck lump. Differentials
Thyroid lump (follicular adenoma, hyperplastic nodules, thyroid cysts, malignancy- papillary carcinoma, follicular carcinoma, etc) Goitre Thyroglossal cyst Cervical lymphadenopathy Dermoid cyst
Signs that thyroid lump seem more likely
Enlarged cervical lymph nodes Unexplained hoarseness Stridor- indicates narrowing of airway Rapidly enlarging painless mass Thyroid nodule in child
Key investigations for neck lumps
Ultrasound and FNAC
If can we then need staging scans
Three broad categories for nasal Blockage
Structural
Inflammatory
Infective
Nasal blockage questions
Both sides or just one How long has it felt blocked Intermittent or constant Is it ever clear Any trauma to nose recently or in past Previous nasal surgery Other nasal symptoms- sneezing, rhinorrhoea, facial pain, post nasal drip, epistaxis What meds does pt take
If nasal blockage and history of trauma- what is wrong and next step?
Probably a deviated septum but still good to rule out the other causes as blockage may be mulitfactorial.
If deviated septum that is symptomatic - septoplasty
Risks of septoplasty
The need for future surgeries Failure to improve symptoms Altered appearance Septal perforation Numbness of upper teeth Anosmia or hyposmia- rare and often transient Numbness of the nose Bleeding and infection
Middle aged woman. Nasal obstruction. 15 year history of symptoms. Worse in past four months. Associated with sneezing and rhinorrhea. Asthma and eczema in Hx
Further questions, further investigations and likely diagnosis
Worse at any time of year
Sense of smell
Tried any meds
Allergies?
Examine the nose.
Probably a chronic rhinosinusitis. With or without polyps as would need to scope to visualise
Further testing after a chronic rhinosinusitis diagnosis
Scope to look for polyps
RAST testing to identify allergies and antigens through blood
Management of chronic rhinosinusitis
Saline nasal irrigation, antihistamines (only when clear evidence of allergies), advise to avoid allergens, topical nasal steroids
Lumps and bumps in the nose
Polyps
Septal haematoma
Nasaopharyngeal carcinoma - typical unilateral symptoms
Inferior turbinates
If suspecting polyps what is the next step
CT scan of sinuses if surgery required and need to see extent of disease
Short course pred to shrink polyps and provide some relief of symptoms
Topical nasal steroids
Purulant nasal discharge
Nasal obstruction
Facial pain and fullness
Up to four weeks of symptoms
Acute rhinosinusitis
Clear nasal discharge- what could it be
Viral rhinosinusitis secretions
Allergic rhinosinusitis
Could be CSF! Check for glucose. If glucose present then is CSF
Purulent discharge with other signs of rhinosinusitis- differential and treatment
Bacterial rhinosinusitis
Treat with clarithromycin
Epistaxis - Questions to ask in history
Frequency Duration Which side of nose Is blood dripping out or down throat History of previous bleeds including easy bruising Previous treatment PMH- GPA, bleeding disorders, rhinitis Drug history- clopidogrel, warfarin, aspirin Trauma including digital trauma
Examination of nose in epistaxis
External nose for signs of trauma, surgery or deformities eg saddle nose deformities
Anterior rhinoscopy
Posterior rhinoscopy
Use a Thuddicum’s speculum or an otoscope
Most likely source of epistaxis
Little’s area - highly vascular and quite exposed
Kiesselbach’s plexus lies within little’s area
Treatment and advice for epistaxis
- Advise do not blow nose for a week, do not clean the nose, avoid hot baths, do not drink hot tea or coffee for 72 hours, no strenuous exercise for a week
- Naseptin ointment - reduces crusting in nose (contains peanuts so check allergies)
- Silver nitrate cautery
- If epistaxis recurs then apply firm pressure for 15 minutes . If this fails go to A&E
Young male. Punched in face yesterday, initially stopped bleeding but started again. Prolonged episode and big clots evident. No meds. What do you do?
ABCDE!!!
Get IV access for cannulation
Examine the nose and get adequate protection as blood may spray. Suction may be used to visualise the area.
If origin found then cauterise. If not then need to move on to nasal packing and admit to ENT and get help.
Test- FBC, Coag profile, group and save
Factors that could cause epistaxis in adults
Trauma including digital trauma HTN Coagulopathies Meds eg aspirin, warfarin, clopidogrel Inflammation Rare- malignancy eg SCC.
Epistaxis in child- usual cause and next steps
Usually from Little’s area from digital trauma.
Treat Using naseptin (check allergies) or bactroben. These have antibacterial properties
Discourage digital trauma
