ENT Flashcards
47 You are the ED intern on duty. You are asked to see and treat a 20 yoa man who has broken his nose playing football 3 hours previously. It has not stopped bleeding. You can ignore all other issues other than those related directly or indirectly to do with his nose. How will you proceed to assess and treat his nosebleed?
Immediate
Fluid resuscitation if the patient is haemodynamically unstable
Keep the patient calm - excitement increases BP
Elevate the upper body and bend the patient’s head forward
Apply cold packs and sustained, direct pressure by pinching the nose at the nostrils for 10-15 minutes
Apply topical vasoconstrictors e.g., oxymetazoline, adrenaline
If epistaxis continues after 10-15 minutes
First line: cauterisation of the bleeding vessel using silver nitrate or electrocautery
Second line: nasal packing using gauze impregnated with paraffin and antibiotics (covering for Staphylococcus aureus)
If epistaxis persists
Arterial embolisation or endoscopic ligation of the bleeding
Anterior ethmoidal artery for anterior epistaxis
Sphenopalatine artery for posterior epistaxis
48 You are a GP. You are consulted by a 55 yoa man who has a hoarse voice. What features of his history must you establish before deciding on your next steps?
The cause of this man’s hoarseness needs to be determined and my next steps would be guided by the history and which aetiologies are most likely.
V - Vascular
I - Infective: laryngitis, epiglottitis, croup
T - Trauma: recent intubation, overuse, GORD, foreign body
A - Autoimmune: goitre
M - Metabolic
I - Iatrogenic: surgical damage to the recurrent laryngeal nerve
N - neoplastic: laryngeal and lung cancer
C - congenital
D - degenerative: myasthenia gravis, motor neurone disease, normal with age
E - Endocrine/environment: smoking, thyroid
F - Functional:
49 You are the ED intern on duty. Your patient is a 30 year old man who has had a sore throat for 3 days, which is getting worse. He has difficulty opening his mouth, ear pain on the right and can’t swallow his saliva. On examination he has a temperature of 39 degrees celcius, pulse 115bpm. Oral examination reveals a unilateral, left sided tonsillar swelling with a diffuse, oedematous bulge superior and lateral to the tonsil. The uvula is deviated to the right. What is the diagnosis? What is the cause of the problem?
Dx: peritonsillar abscess (aka quinsy) - a collection of pus in the peri-tonsillar space, between the capsule of the palatine tonsil and the pharyngeal muscles
Typical presentation:
- severe sore throat (usually unilateral)
- fever
- muffled voice
- drooling
- trismus (reflex spasm of internal pterygoid muscle aka lockjaw)
- ipsilateral ear pain
- swollen fluctuant tonsil
- contralateral uvula deviation
Pathogenesis:
- preceded by tonsillitis or pharyngitis (Group A strep, staph, or MRSA), progresses from cellulitis to phlegmon to abscess
- obstruction of Weber glands (salivary glands in soft palate)
50 You are the ED intern on duty. Your patient is a 30 year old man who has had a sore throat for 3 days, which is getting worse. He has difficulty opening his mouth, ear pain on the right and can’t swallow his saliva. On examination he has a temperature of 39 degrees Celsius, pulse 115bpm. Oral examination reveals a unilateral, left sided tonsillar swelling with a diffuse, oedematous bulge superior and lateral to the tonsil. The uvula is deviated to the right. What is the diagnosis? What is the management?
Diagnosis: peritonsillar abscess
- Airway management
- IV antibiotics - benzylpenicillin (eTG)
- I&D or needle aspiration
- Tonsillectomy (if unresponsive, recurrent or complications occur)
51 You are on-duty in A & E. Your next patient is a 3 year old child with rapidly progressive airway obstruction, looking toxic, drooling, tachycardic and tachypnoeic, sitting up leaning forward looking worried. The child is not immunised. What is the most important differential diagnosis? What will you do?
Most important differential diagnosis = epiglottis
- Lack of immunisation against Haemophilus influenza type B
- Age 1-6 predominantly
- Key symptoms: rapid onset severe sore throat, febrile, unable to speak or swallow, sitting upright with mouth open and drooling
Management:
1) Keep child calm - DO NOT examine throat with spatula, take bloods, or lay child down
2) Airway management
3) Call for paediatric + ENT + anaesthetic consult
4) Start IV antibiotics: ceftriaxone/cefotaxime + vancomycin (anti-staph agent)
52 Lana is a 52 year old female who is day 1 post total thyroidectomy. You are the RMO in-charge of the ward and have been called by the NUM to assess Lana urgently. Lana is having difficulty breathing and her neck looks significantly swollen. What is the most likely diagnosis? What will you do?
Most likely diagnosis = Acute post-op haematoma
- Most frequent cause of airway swelling/obstruction in first 24hrs post-thyroidectomy
- Dyspnoea, stridor, hypoxia, neck swelling/pain
Management:
1) Call on-call ENT for consult, MET call
2) Stabilise airway: keep patient calm, elevate head of bed, high flow O2
3) Evacuate the haematoma (down to and including deep fascial structures)
- Consider doing immediately if patient is cyanosed or unconscious as cardiorespiratory arrest may be imminent and loss of blood from open wound will be trivial in comparison
4) Intubate to secure the airway
5) Return to theatre for definitive treatment: re-exploration + ligation + drain placement
53 Heather is a 4 year old girl who had a tonsillectomy 7 days ago. She presents to the ED with bleeding per orally. She has bled around 2 cupfuls of fresh blood in 30 minutes. You are one of the emergency department doctors. Heather is in waiting room. What is the diagnosis? What is your management plan?
Diagnosis: Secondary/delayed post-op haemorrhage following tonsillectomy
- Usually occurs day 5-10 post-op when fibrin clot sloughs off
- Premature eschar separation precipitated by infection or dehydration
Management:
- Usually stops spontaneously
- May require return to OT for haemorrhage control
1) Get out of waiting room and into a consult bed
2) Primary survey: airway priority (sit up, spit/suction blood), assess haemodynamic stability, IV access, supplemental O2, group and save
3) Call for ENT + paediatric consult
4) Mild bleeding
- Gargle cold water/hydrogen peroxide
- Ice-pack on back of neck
- Pressure on tonsillar fossa with adrenaline-soaked gauze (1:10,000)
- Injection of lignocaine + adrenaline
- Cautery
5) Severe bleeding
- Electrocautery
- Silver nitrate
- Suture ligation
54 45 year old male comes to your GP practice with a 2 month history of hoarse voice. He has recently developed a swelling on the left side of his neck. He is a heavy smoker and consumes substantial alcohol daily. You are the doctor examining him. What is the most likely diagnosis and examination findings and what are relevant investigations/referrals for him?
Most likely diagnosis = laryngeal cancer with lymph node involvement
Examination findings:
- Signs: stridor, lymphadenopathy, cachexia
- Symptoms: hoarsness/change in voice, foreign body sensation, SOB, dysphagia, aspiration
Investigations:
1) Laryngoscopy
2) Contrast CT neck = cervical lymphadenopathy, cartilage invasion
3) Contrast CT chest = lymphadenopathy, metastatic nodules
4) FNA of neck mass
Referral to ENT surgeon for assessment
55 45 year old female comes to your GP practice with a 1 year history of a midline neck swelling. She also gets tremors and says that her heart races at times and has lost some weight that she is pleased about.
A neck mass in an adult >40yo should be considered neoplastic/malignant until proven otherwise
A midline neck lump is more likely to be related to thyroid pathology or malignancy
From the brief history, this would appear to be more indicative of a hyperthyroid condition
Investigations:
1) Bedside
- ECG = evaluate cardiac function (heart palpitations)
2) Bloods
- TSH, FT4, FT3 - assess thyroid function, determine likely source of thyroid dysfunction
- Thyroid antibodies: TSI (Graves disease)
3) Imaging
- USS - detection and characterisation of nodules, assessment of lymph nodes, FNA of nodules
- Radioisotope imaging (Tc99) - assess for foci of hyperfunctional thyroid tissue
56 Liam was involved in a fight yesterday at the local pub and was slapped in the face. He had a sharp shooting ear pain following the slap and says that he cannot hear too well since then. He also says that he cannot pop his ear drums since that incident. He comes to your practice. What is the most likely diagnosis and what will you expect from the examination point of view? What will be your advice?
Traumatic perforation of the tympanic membrane
O/E
- Conductive hearing loss: Webber’s = louder on side of injury, Rinne’s = louder with bone conduction
- **Otorrhoea
- Haemotympanum**
- Tympanic membrane perforation on otoscopy
- Battle sign (retroauricular haematoma)
- Possibly ataxia, nystagmus
Advice:
1) Keep ear dry to prevent middle ear infection
2) Topical antibiotics if contaminated wound or canal occluded with blood
3) Follow-up in 4-6 weeks - most perforations are small enough to heal on their own in that time but will re-evaluate with audiometry
4) Stay out of bar fights in the future
57 You are working as rural relief resident in a remote town GP practice. A 12yo aboriginal boy is brought in by his mum to see you as he is complaining of poor hearing in his right ear that is getting gradually worse. He gives a history of constant offensive discharge from the same ear with frequent infections. You look into his ear and see some dry white crusting wax at the top of his ear drum. What is the likely diagnosis and what would you do from here?
Likely diagnosis = acquired cholesteatoma due to chronic middle ear disease
Predisposing factors: recurrent acute otitis media and/or chronic middle ear effusions; fx, cleft palate, craniofacial abnormalities, Turner or Downs syndrome
Next steps:
1) High resolution CT scan of the petrous temporal bones (if available) - assess for mastoid pathology and complications
2) Pure tone audiogram (if available)
Refer to larger hospital centre for above if not available
3) Urgent ENT referral for: otoscopy, pure-tone audiogram, surgery
- Excision of keratinizing squamous epithelium from temporal bone
- Preservation/restoration of hearing
Complications of cholesteatoma to make mum aware of and advocate need for surgery:
- Continued enlargement → hearing loss (ossicle erosion), CN6/7 palsies, other neuro symptoms (e.g. vertigo)
- Secondary infection → potentially life-threatening (brain abscess, meningitis)
4) On-going post-op follow-up (high recurrence rate, varied depending on age, size, location, erosion, etc.)
58 You are working in emergency and you see a 4yr old boy with fever, left otalgia and acute left facial nerve palsy. What is the most likely diagnosis? What condition could this develop into that causes swelling behind the ear and the ear to stick out/forwards?
Most likely diagnosis = acute otitis media
Signs and symptoms
- Middle ear inflammation: bulging TM, distinct erythema of TM, otalgia, fever
- Middle ear effusion: TM opacity, decreased TM mobility, air-fluid level, otorrhoea
Pathogens:
- Bacterial: s. pneumoniae, h. influenzae, morazella catarrhalis
- Viral: RSV, picornaviruses, coronaviruses, influenza, adenovirus
What this develop into = acute mastoiditis
Characteristics:
- Post-auricular tenderness, erythema, swelling, fluctuance or draining fistula, mass
- Protrusion of auricle
- Non-specific ear pain/irritability in young children
59 You are working in emergency and you see a 4yr old boy with fever, left otalgia and acute left facial nerve palsy. What is the most likely diagnosis? How would you manage this boy?
Most likely diagnosis = acute otitis media
Signs and symptoms
- Middle ear inflammation: bulging TM, distinct erythema of TM, otalgia, fever
- Middle ear effusion: TM opacity, decreased TM mobility, air-fluid level, otorrhoea
Pathogens:
- Bacterial: s. pneumoniae, h. influenzae, morazella catarrhalis
- Viral: RSV, picornaviruses, coronaviruses, influenza, adenovirus
Management:
1) Analgesia: systemic (paracetamol, ibuprofen) or topical (benzocaine if >2yo, procaine, lidocaine)
2) Antimicrobial therapy
- Avoid routine use of Abx for AOM - suppurative complication (e.g. mastoiditis) are now rare in most Australian children, BUT still common and warranted in some groups (e.g. ATSI)
- Limited benefit in non-suppurative
Indications:
- <6mo old
- 6mo-2yrs (suggested)
- >2yrs + toxic/>48hrs otalgia/T >39/bilateral/uncertain access to follow-up
Abx:
a) Amoxycillin (for children with systemic features such as fever, vomiting, lethargy)
b) Amoxycillin + clavulanate (if inadequate response within 48-72hrs)
c) Bactrim (for children >1mo hypersensitive to penicillin)
3) Urgent hospital referral if suppurative complications such as:
- Facial palsy = treatment of underlying disease, ENT/paediatric consult
- Mastoiditis = ENT/neurosurg consult, Abx, drainage
60 You are working in emergency and you see a 4yr old boy with fever, left otalgia and acute left facial nerve palsy. What is the most likely diagnosis? What dangerous complications can result from this condition?
Most likely diagnosis = acute otitis media
Signs and symptoms
- Middle ear inflammation: bulging TM, distinct erythema of TM, otalgia, fever
- Middle ear effusion: TM opacity, decreased TM mobility, air-fluid level, otorrhoea
Pathogens:
- Bacterial: s. pneumoniae, h. influenzae, morazella catarrhalis
- Viral: RSV, picornaviruses, coronaviruses, influenza, adenovirus
Potential complications
- Extra-cranial: hearing loss, balance and motor problems, TM perforation, cholesteatoma
- Suppurative: mastoiditis, petrositis (inflammation of the petrous part of the temporal bone), labrynthitis, facial nerve paralysis
- Intra-cranial (uncommon in developed countries): meningitis, epidural abscess, brain abscess, lateral sinus thrombosis, cavernous sinus thrombosis, subdural empyema, carotid artery thrombosis
61 You are the surgical ward resident. A nurse calls you saying that a patient who had frontal sinus surgery this morning had a fall in the toilet. They have also been bleeding intermittently throughout the day. What will you do?
Concern: hypovolemia 2o haemorrhage
1) ABCDE and treat as required e.g., fluids, packing
2) History of fall - head injury, dizziness, palpitations, dyspnoea, precipitating factor
3) Medications - anticoagulants, anaesthetic agents, regulars e.g., beta blockers
4) Full examination of surgical site and neurological exam
4) Review chart, operative report, perioperative progress notes, adequacy of fluid replacement, medications
5) Investigations - VBG, FBC, UEC, BGL, LFTs, Coags, ECG
6) ENT review
119 What are the main types of thyroid cancer and what is their prognosis?
