ENT Flashcards
which arteries supply the nose and sinuses
ICA - ethmoid branch
ECA - facial + internal maxillary branches
where does bleeding usually arise in epistaxis?
little’s area [vessel anastamosis] in the nasal septum
give 5 risk factors for epistaxis
- anticoagulants, steroid sprays
- bleeding disorder/ thrombocytopenia
- deviated nasal septum
- irritants e.g. smoking
- allergies/inflamm
- infection
- trauma
- HTN
- neoplasia/polyp
- atherosclerosis
in an epistaxis patient, a FH of bleeding might suggest what disease
Hereditary hemorrhagic telangiectasia
[or hereditary bleeding disorder]
give 4 causes of facial pain
teeth sinusitis temporomandibular joint dysfunction salivary gland migraine trigem neur trauma atypical/idiopathic cluster headache angina frontal bone osteomyelitis ENT tumours
give 4 typical causes of gradual vision loss
macular degeneration glaucoma cataract diabetic retinopathy HTN optic atrophy slow retinal detachment
presentation of age related macular degeneration
elderly
deteriorating central vision
difficulty making out images, faces. Reading, night vision.
fluctuation
pathogenesis of age related macular degeneration
drusen, new vessel proliferation [wet]
> retinal atrophy
> central retinal degeneration
risk factors for age related macular degeneration
age smoking CV disease FH cataract surgery
difference in prognosis for wet and dry age-related macular degen
dry much slower progression.
causes of optic atrophy [pale disc]
glaucoma retinal artery occlusion retinitis pigmentosa MS etc.
Mx of macular degen
dry - no Tx
wet - Anti-VEGF injections, Photodynamic therapy/laser
causes of dry eyes
reduced secretion from lacrimal gland [age] sjogren's mumps sarcoid amyloidosis lymphoma leukaemia haemochromatosis
hordeolum externum/ stye. Pathology + Tx
lash follicle infection/ abscess.
warm compress several times a day.
give 4 causes of ptosis
Horner's syndrome 3rd nerve palsy congenital muscular dystrophy myasthenia [oedema, xanthelasma, tumour]
define xanthelasma
lipid deposition seen in hyperlipidaemia
what is blepharospasm
involuntary contraction of orbicularis oculi, often in response to pain
Mx of blepharospasm
botox
give 3 causes of vestibular [peripheral] vertigo and 3 causes of central vertigo
peripheral: BPPV, meniere’s, labyrinthitis, vestibular failure
central: acoustic neuroma, MS, head injury, migraine, vertebrobasilar insufficiency
other Sx of vestibular vertigo
loss of balance, N+V, hearing loss, tinnitus, nystagmus, sweating
distinguish BPPV, meniere’s, migraine, vestibular failure in terms of duration of vertigo
BPPV: seconds-minutes
menieres/migraine: 30 mins to 30 hrs
vestibular failure: 30 hours to 1 week
examinations that are useful in vertigo
neuro: cerebellar, reflexes, nystagmus, gait, Romberg’s
ears
hallpike, head thrust
what brings on BPPV sx
head turning
what is the pahtology behind BPPV
displaced otoconia stimulating the semi-circular canals
mX of BPPV
self -limiting
epley manoeuvres
features of meniere’s disease
sudden vertigo 2-4hrs nystagmus fullness in ears tinnitus SN hearing loss
Ix in meniere’s
Electrocochleography
MRI posterior fossa
Mx in meniere’s
Prochlorperazine betahistine prophylaxis surgery gent through gromet labyrinthectomy vestibular neurectomy
sudden attack of unilateral vertigo, vomiting, following URTI. lasting 1-2 days. nystagmus away from affected side. Diagnosis?
labyrinthitis [=acute vestibular failure/ vestibular neuritis]
Mx of labyrinthitis
reassure self limiting
prochlorperazine [vestibular suppressant]
cyclizine
Sx / features of temporomandibular joint dysfunction
earache
facial pain
joint clicking/popping related to teeth grinding
stress
Mx of temporomandibular joint dysfunction
reassurance, analgesia dental physio CBT [surgery rare]
Ix in head and neck SC carcinoma
endoscopy
needle aspiration + biopsy
CT/MRI
risk factors for head and neck squamous cell carcinoma
smoking alcohol HPV GORD deprivation
Sx suspicious for head and neck squamous cell carcinoma
neck pain/ lump hoarse voice >6/52 sore throat >6/52 mouth bleeding mouth numbness sore tongue painless ulcers patches in the mouth earache/ effusion lumps [lip, mouth, gum] speech change dysphagia
give 5 causes of stridor
anaphylaxis croup laryngitis epiglottitis larygomalacia web/stenosis intubation thermal /chemical trauma hemangioma, papilloma
Mx of laryngotracheobronchitis [croup]
dex
Mx points for epiglottitis
keep Pt upright dont examine throat get anaesthetist + ENT surgeon intubate/surgical airway dex abx
excessive collapse and indrawing of supraglottic airwaysduring inspiration leading to stridor, breathing + feeding difficulties. Diagnosis?
larygomalacia
oropharyngeal carcinoma risk factors
male
age
smoking
HPV
typical presentation of oropharyngeal carcinoma
smoker with a sore throat, sensation of lump, otalgia
imaging for oropharyngeal carcinoma
MRI
Mx for oropharyngeal carcinoma
surgery + radio
laryngeal cancer typical presentation
older male smoker progressive hoarseness stridor dysphagia Odynophagia haemoptysis otlagia
or young HPV
Ix.s in laryngeal cancer
laryngoscopy
biopsy
HPV status
MRI staging
Mx of laryngeal cancer
radio
laryngectomy
gland dissection
tests for lump in the neck
US fine needle aspiration cytology CT mantoux virology [HIV/Hep/EBV] CXR [malignancy/hilar nodes] biopsy
what problems might cervical ribs [enlarged costal elements of C7] cause?
neuro Sx from pressure on brachial plexus
Raynauds - compressing subclavian artery
what are the 3 main pairs of salivary glands and where are they?
parotid - side of face in front of ear
submandibular - below jaw in angle of mandible
sublingual - in the floor of the mouth
which cranial nerve would you assess when examining the salivary glands
facial
causes of swelling of the parotid gland
sjogrens syndrome
mumps, HIV
sarcoid
malignancy
risk factors for salivary gland malignancy
smoking
neck radiation
symptoms suggestive of salivary gland malignancy
hard fixed mass \+/- pain oveerlying skin ulceration local lymphadenopathy no variation on eating [seen in inflammation/stone] facial nerve palsy
Mx salivary gland malignancy
surgery, radio
give 4 causes of dry mouth [xerostomia]
hypnotics, tricyclics antipsychotics BB diuretics mouth breathing dehydration ENT radiotherapy sjogrens SLE, scleroderma sarcoidosis HIV/AIDS parotid stones
causes of pre-lingual deafness other than genetic
intrauterine torch infection prem hypoxia kernicterus meningitis, enceph intraventricular hemorrhage measles, mumps ototoxic drugs e.g.NSAIDs trauma
indication for cochlear implant
children + adults
profound S-N deafness
dont benefit form conventional hearing aid
give 4 causes of conductive hearing loss
wax/pus/debris/foreign body
developmental abnormalities
drum perf [trauma/ infection]
ossicular chain: Otosclerosis/infection/trauma
inadequate Eustachian tube ventilation [effusion/CA]
give 4 causes of sensorineural hearing loss
ototoxic drugs e.g. gent infection [meningitis] cochlear vascular disease meniere's trauma presbyacusis
give 3 examples of ototoxic drugs
gent, vancomycin, streptomycin
chloroquine, hydroxychloroquine
vincristine
cisplatin
infections that can lead to sensorineural hearing loss
meningitis mumps measles flu herpes syphilis
if unilateral sensorineural hearing loss, exclude…
acoustic neuroma
cholesteatoma
effusion from CA
30 year old pregnant woman presents with bilateral conductive hearing loss, worsening during pregnancy. She has a FH of same problem. She also describes tinnitus and says she sometimes feels the room is spinning. On examination, the drum is tinged pink. What is the diagnosis and how would you manage?
otosclerosis
hearing aid or surgery or cochlear implant
what is presbyacusis? and what is the Mx?
age related
bilateral
high frequency SN hearing loss
hearing aid
Ix in sudden sensori neural hearing loss
FBC, ESR/CRP, U+E, LFT, TSH autoimmune profile clotting fasting glucose cholesterol audiology
causes of subjective tinnitus
presbyacusis noise induced menieres less commonly wax/otosclerosis ototoxic drugs` otitis media ^/hypothyroid DM MS acoustic neuroma trauma anxiety/depression
investigations in tinnitus
audiometry
tympanogram
MRI [acoustic neuroma]
Mx of tinnitus
hearing aid if hearing loss too - mask tinnitus
councelling
sound therapy [fan or music to mask]
CBT
give 5 causes of otalgia
otitis externa
furunculosis
mailgnant otitis externa
barotrauma
TMJ dysfn. dental geniculate herpes primary glossopharyngeal neuralgia laryngeal CA tonsilitis/quinsy post-tonsillectomy soft tissue injury to neck cervical spondy/arth
Sx of otitis externa
discharge
itch
otalgia
tragal tenderness
causes of otitis externa
excess canal moisture eczema > itching hearing aids self-removal of wax humidity narrow ear canal
chief organism in otitis externa
pseudomonas
also, staph A
Mx of otitis externa
clean ext. auditary meatus
keep ear dry
mild - hydrocort cream to pinna
earcalm spray [antifungal/bact]
moderate - swab, ABx/steroid drops
severe - aluminium acetate wick
what is the risk of persistent unilateral otitis externa in elderly/DM/imm.supp.
malignant otitis externa
describe furunculosis
very painful staph abscess arising in a hair follicle within auditory canal
Mx of pinna cellulitis
oral abx
describe malignant otitis externa + usual organism
agressive life-threatening infection of the external ear that can lead to temporal bone destruction, osteomyelitis
pseudomonas
Mx malignant otitis externa
surgical debridement
systemic Abx
Ig
give 4 causes of damage to the 8th cranial nerve
brainstem CVA noise damage pagets disease menieres herpes acoustic neuroma drugs [gent]
differnetials for a sore thrtoat
tonsilitis or pharyngitis:
viral - common cold [rhino/coronovirus], flu, adenovirus, herpes simplex, EBV
bacterial -group A strep, Hib [epiglott]
Mx of sore throat
PCM/ibuporofen, reassurance
difflam
centor 3+ = pen V
give 3 complications of tonsilities
sinusitis otitis media peritonsilar abscess [quinsy] parapharyngeal abscess lemierre syndrome
how does quinsy present and what is the Mx
sore throat, dysphagia, peritonsillar bulge, uvular deviation, trismus, muffled voice
Abx, aspiration
differentials for unilateral tonsilar enlargement
peritonsillar/ parapharyngeal absess > shift
malignancy
what causes scarlet fever
exotoxins produced released from strep pyogenes [groupA beta haem strep]
typical presentation of scarlet fever
red pin prick blanching rash on chest, axillae, behind ears
facial flushing, circumoral pallor, strawberry tongue
12-48 h after sore throat + fever
Mx of scarlet fever
pen V
indication for tonsillectomy
7 documented disabling episodes in last yr, or 5/yr for 2 yrs, or 3/yr for 3yrs
malignancy or child w/ Obstructive sleep apnoea
complications of tonsilectomy
prim haemorrhage secondary haem (>24hrs) due to infection
sX of chronic rhinosinusitis with nasal polyps
watery anterior rhinnorhoea sneezing purulent postnasal drip nasal obstruction sinusitis moutoh breeathing snoring headache
mx of chronic rhinosinusitis with nasal polyps
topical betamethasone
?longterm doxy
surgery
Mx of chronic rhinosinusitis without nasal polyps
intranasal steroid
nasal saline irrigation
[abx if not imprving]
CT > suregry
mx of allergic rhinosinusitis
allergen avoidance nasal saline irrigation antihist if persistent, intranasal steroid spray short course pred
causes of ear discharge
otitis externa/media
cholesteatoma
CSF leak following trauma
presentation of otitis media
rapid onset pain [bulging of tymp.mem] fever irritability anorexia vomioting often post-urti purulent discharge
Mx of otitis media
analgesia
amoxi if systemically unwell/ imm.comp./ >4days
complications of otitis media
glue ear chronic otitis media [perf, recurrent infections] mastoiditis petrositis labyrinthitis facial palsy meningitis intracranial abscess
what is otitis media with effusion/ glue ear?
effusion present after regression of Sx of otitis media
sx of chronic otitis media
hearing loss
ottorhoea
fullness
otalgia
Mx of chronic otitis media
What is a complicaiton of chronic otitis media?
topical/ systemic Abx
cleaning
keep dry
surgery - myringoplasty [repair drum]
cholesteatoma
complications of cholesteatoma
meningitis cerebral abscess hearing loss mastoiditis facial nerve dysfn.
mx of cholesteatoma
mastoid surgery
define mastoiditis
destruction of air cells +/- abscess formation following middle ear inflamm
signs of mastoiditis
tenderness, swelling and redness behind the pinna
fever
protruding auricle
whta imaging and what Mx for mastoiditis
CT
IV ABx, surgery
risk factors for otitis media
URTI bottle feeding passive smoking adenoids asthma malformations e.g. cleftpalate GORD ^BMI in adults
why investigate hoarseness of >3 months?
because it is the chief [and often only] symptom of layngeal carcinoma
[especially in smokers!]
differentials for hoarseness give 4
viral URTI laryngeal carcinoma GORD vocal cord palsy laryngitis reinke's odema vocal cord nodules stress singing/shouting/overuse
causes of layrngitis
viral
bacterial
secondary to gORd
secondary to RA
hypothyroid elderly female smoker complains of deep gruff voice, says she sounds like a man. Diagnosis?
Reinke’s oedema [chronic cord irritation -> enlargement]
causes of laryngeal nerve palsy
CA - larynx, thyroid, oesoph, hypopharynx, bronchus
iatrogenic - parathyroidectomy, oesophageal/pharyngeal pouch surgery
TB
aortic aneurysm
Ix in laryngeal nerve palsy
CXR
CT
+/- US thyroid
+/- OGD
risk factors for glue ear
parental smoking male downs, cleft palate winter atopy primary ciliary dyskinesia
presentation of otitis media with effusion in children
hearing loss noticed by parents poor speech, language delay ear infections, URTIs poor behavior balance problems school problems
what might you see on otoscopy in glue ear
[variable] retracted or bulging drum dull, grey, yellow bubbles/fluid level superficial radial vessels reduced mobility with pneumatic attachment
otitis media w/ effusion Mx
autoinflation of eustacian tube
grommets
main complications of gromets
infection
tympanosclerosis
mx of gromet infection
aural cleaning
topical Abx/steroid ear drops
gromet removal may be needed
post op Mx of gromet/ advice
ok to swim but avoid diving + ear plug
gromet will extrude after 3 to 6 months, then recheck hearing
a quarter need re-insertion
where do acoustic neuromas arise from
superior vestibular nerve schwann cell layer
sx of acoustic neuroma
progressive ipsilateral tinnitus sensorineural deafness cerebellar signs + ^ICP signs if large giddy [vertigo rare] numb face [trigeminal] CN V/VI/VII may be affected
why sensorineural hearing loss in acoustic neuroma
cochlear nerve compression
differential for acoustic neuroma
meningioma
Mx of acoustic neuroma
surgery
Mx of epistaxis
ABCDE
Pt pinch soft part of nose + sit forward
ice pack on bridge
silver nitrate cautery [1st - cotton ball soaked in adrenaline 2 mins / lidocaine spray]
nasal pack - anterior then postnasal
serious posterior epistaxis Mx
anaesthesia diathermy pack arterial ligation embolisation [stroke risk]
advice to Pt after nosebleed
dont pick dont blow direct sneeze through open mouth avoid bending, lifting, straining no hot food/drink
if restarts - pinch soft bit + ice to bridge
Mx of septal haematoma in nasal injury
incision and drainage
casues of facial palsy, give 4
brainstem tumour stroke MS acoustic neuroma meningitis
otitis media
ramsay hunt syndrome
cholesteatoma
parotid tumour
trauma
lyme disease
sarcoid
DM
bells palsy
facial palsy, iX
ESR glucose lyme disease serology examine parotid for lumps examine ears for cholesteatoma/ramsay hunt MRI
give 2 things that ^risk of bells palsy [idiopathic facial palsy]
pregnancy
DM
Tx of bells palsy
pred
lubricate eye with drops
common causes of bilateral facial palsy
lyme disease GBS leukaemia sarcoidosis EBV trauma myasthenia gravis
how do you differentiate facial palsy of stroke and bells
stroke is forehead sparing