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ENT Flashcards

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1
Q

Progressive unilateral sensorineural hearing loss, associated vertigo. Diagnosis?

A

Acoustic neuroma (vestibular schwannoma)

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2
Q

Cranial nerves affected by acoustic neuroma

A

VIII: hearing loss, vertigo, tinnitus
V: absent corneal reflex
VII: facial nerve palsy

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3
Q

Investigation for suspected acoustic neuroma

A

MRI of cerebellopontine angle

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4
Q

Describe the features of vestibular neuronitis

A

Often develops following a viral infection

  • recurrent vertigo attacks lasting hrs or days
  • N+V may be present
  • horizontal nystagmus
  • NO hearing loss or tinnitus
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5
Q

Management of vestibular neuronitis

A

Vestibular rehab exercises if chronic symptoms

Betahistine is often used although the evidence base suggests it’s less effective than rehab

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6
Q

When would you prescribe ABx in otitis media?

A
  • symptoms >4d or not improving
  • systemically unwell but not requiring admission
  • immunocompromise or high risk complications 2’ to heart, lung, kidney, liver or NM disease
  • <2yo with bilateral otitis media
  • with perforation and/or discharge in the ear
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7
Q

Describe the vertigo seen in Meniere’s disease, and compare to BPPV

A

Meniere’s - vertigo is spontaneous + last mins to hrs with accompanied unilateral hearing loss + tinnitus
BPPV - vertigo is provoked by a change in position + lasts for seconds (no hearing change)

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8
Q

Management of Ménière’s disease

A

ENT assessment to confirm diagnosis
Patients should inform the DVLA - cease driving until satisfactory control of symptoms
Acute attacks - buccal/IM prochlorperazine
Prevention - betahistine and vestibular rehab

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9
Q

Features of cholesteatoma

A

Foul-smelling discharge
Hearing loss
May also have features of local invasion - vertigo, facial n palsy, cerebellopontine angle syndrome

On otoscopy, an ‘attic crust’ may be seen in the uppermost part of the ear drum

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10
Q

Audiogram findings in sensorineural hearing loss

A

Both air and bone conduction is impaired

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11
Q

Audiogram findings in conductive hearing loss

A

Only air conduction is impaired

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12
Q

Audiogram findings in mixed hearing loss

A

Both air and bone conduction are impaired, with air conduction worse than bone

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13
Q

What is Ramsay Hunt syndrome? Outline the features and management

A

Herpes zoster oticus - caused by the reactivation of the varicella zoster virus in the geniculate ganglion of CN VII

Features - auricular pain, facial n palsy, vesicular rash around the ear, vertigo, tinnitus

Management - oral aciclovir and corticosteroids

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14
Q

Differential diagnoses for vertigo

A

Viral labyrinthitis - recurrent viral infection, sudden, N+V, hearing may be affected
Vestibular neuronitis - recurrent viral infection, recurrent vertigo (h-d), no hearing loss
BPPV - gradual, triggered by change in head position (10-20s)
Meniere’s - hearing loss, tinnitus, feeling of pressure in ear(s)
Vertebrobasilar ischaemia - elderly pt, dizziness on ext of neck
Acoustic neuroma - hearing loss, vertigo, tinnitus, absent corneal reflex

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15
Q

Common causative organism of otitis media

A

H. influenzae

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16
Q

Features and management of Quinsy

A

Quinsy is the development of a local abscess after bacterial tonsillitis
Features - unilateral tonsillar swelling, fever, severe pain, uvula deviated to unaffected side, dec neck mobility
IV ABx and surgical drainage usually resolves symptoms

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17
Q

Outline Rinne’s test and what the results mean

A

Tuning fork placed on mastoid process until sound no longer heard, followed by repositioning just over external acoustic meatus
AC usually better than BC
If BC > AC then conductive deafnes

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18
Q

Outline Weber’s test and what the results mean

A

Tuning fork is placed in middle of forehead, pt is asked which side is loudest
In unilateral sensorineural deafness, sound localises to unaffected side
In unilateral conductive deafness, sound localises to affected side

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19
Q

Describe the anatomy of the tympanic membrane

A

Central umbo with manubrium of malleus pointing towards pt’s face (R hand side in R ear, L hand side in L ear)
Cone of light is seen at 5 o’clock in R ear, 7 o’clock in L
Pars tensa below umbo
Pars flaccida above manubrium of malleus

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20
Q

What are you looking at in otoscopy

A

Identify the pars tensa, pars flaccida, handle of malleus, and cone of light (points to toes)
Note colour, translucency, any bulging or retraction, and perforations

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21
Q

Common causes of otitis externa

A

Pseudomonas

Staph aureus

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22
Q

Differential diagnosis for otitis externa

A

Contact eczema

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23
Q

Presentation, investigations and management of temporomanibular joint dysfunction

A

Symptoms - earache, facial pain, joint clicking/popping, teeth grinding, stress
Signs - joint tenderness exacerbated by lateral movement of the open jaw, or trigger points in pterygoids

Imaging - MRI
Rx - NSAIDs, CBT, physio, surgery

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24
Q

Causes of discharge from the ear

A

Otitis externa/media
Cholesteatoma
CSF otorrhoea

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25
Describe the symptoms and causes of acute otitis media and give the treatment
Middle ear infection - presents with rapid onset pain, fever, irritability, anorexia, vomiting Common organisms - pneumococcus, haemophilus, moraxella, streps and staphs Treat with analgesia +/- co-amoxiclav (only if unwell!)
26
Complications of acute otitis media
``` Mastoiditis Petrositis Labyrinthitis Facial n palsy Meningitis IC abscesses ```
27
Management of chronic otitis media
``` Topical/systemic ABx Aural cleaning Water precautions FU Surgery may be required ```
28
Complications of cholesteatoma
Rare, but serious - meningitis, cerebral abscess, hearing loss, mastoiditis, facial n dysfunction
29
Presentation and management of cholesteatoma
Foul discharge +/- deafness, headache, pain, facial paralysis, vertigo Rx - mastoid surgery
30
Causes, presentation, investigations and treatment of mastoiditis
Middle ear inflammation leads to destruction of air cells in mastoid bone +/- abscess formation. Presentation - fever, tenderness, swelling + redness behind pinna Imaging - CT Rx - admit for IV ABx, myringotomy +/- mastoidectomy
31
Risk factors for otitis media
``` URTI Bottle-feeding Passive smoking Dummy Presence of adenoids Asthma Malformations GOR/inc BMI in adults ```
32
Outline a typical history and exam in a child with glue ear
Hx - poor listening and speech, language delay, inattention, poor behaviour, hearing fluctuation, ear infections, URTIs, balance problems O/E - may be retracted or bulging, can look dull, grey or yellow. May be bubbles or a clear fluid level
33
Management of glue ear
Active observation for 3m | Surgery if persistent OME -> grommets
34
Define conductive hearing loss. Give some causes
Impaired sound transmission via the external canal and middle ear ossicles to the foot of the stapes Causes - external canal obstruction, drum perforation, problems with ossicular chain, inadequate Eustachian tube ventilation of middle ear
35
Define sensorineural hearing loss. Give some causes
Results from defects central to the oval window in the cochlea, cochlear nerve, or more central pathways. Causes - ototoxic drugs (vanc, gent), postinfective (meningitis, MM), cochlear vascular disease, Meniere’s, trauma
36
Causes of tinnitus
Disorders causing SNHL - noise-induced HL, Meniere’s Ototoxic drugs - cisplatin, aminoglycosides OME Hyper/hypothyroidism, DM and MS Acoustic neuroma Trauma to head or neck
37
Management of tinnitus
Treat underlying cause. If none found: - hearing aids (if hearing loss >35dB) - psychological support - CBT
38
Define acoustic neuroma. How do they typically present?
Aka vestibular schwannomas | Benign subarachnoid tumours that cause problems by local pressure, and behave as SOL
39
Presentation and management of acoustic neuromas
Progressive ipsilateral tinnitus +/- SNHL Large tumours may give ipsilateral cerebellar or rICP signs Giddiness is common, vertigo rare Management - surgery (but difficult and often not needed)
40
Describe noise-induced HL
May be one-time exposure to an intense sound or continuous exposure to loud sounds. Rupture of the drum and ossicular fracture may occur. Usually bilateral SNHL +/- tinnitus
41
Define vertigo. What is vestibular vertigo?
Sensation that you, or the world around you, is moving or spinning Vestibular vertigo is often severe, there may be loss of balance, N+V, HL, tinnitus, nystagmus, diaphoresis
42
Peripheral and central causes of vertigo
Peripheral - Meniere’s, BPPV, vestibular failure, labyrinthitis Central - acoustic neuroma, MS, head injury, migraine associated dizziness
43
Describe benign paroxysmal positional vertigo. Give causes and management
Commonest cause of peripheral vertigo Attacks of sudden rotational vertigo lasting >30s are provoked by head turning Causes - idiopathic or head injury Treat - usually self-limiting, can try Epley manoeuvre
44
Describe Meniere’s disease. Give investigations and management
Sudden attacks of vertigo lasting 2-4h. Nystagmus is always present Inc fullness in ear +/- tinnitus followed by vertigo Unknown cause Investigation - electrocochleograpy, post fossa MRI Treat - acute = procloperazine, prophylaxis = betahistine
45
Describe acute vestibular failure. Give presentation and management
Aka vestibular neuronitis/labyrinthitis Sudden attacks of unilateral vertigo and vomiting in a prev well person Signs - nystagmus away from affected side Treat - vestibular suppressants (cyclizine)
46
Define rhinosinusitis
Inflammation in nose and paranasal sinuses with >2 symptoms: - nasal congestion - nasal discharge - facial pain/pressure - dec sense of smell - endoscopic or CT signs
47
Non-infective/allergic causes of nasal congestion
Children - large adenoids, postnasal space tumour, foreign body Adult - deviated nasal septum, granuloma
48
Presentation of chronic rhinosinusitis with polyps. Give investigations and management
Watery ant rhinorrhoea, sneezing, purulent post-nasal drip, nasal obstruction, sinusitis, mouth-breathing, snoring, headaches Investigations - rhinoscopy or endoscopy Treat: - medical -> betamethasone spray - surgical -> endoscopic sinus surgery
49
Define acute bacterial rhinosinusitis
Presence of at least 3 symptoms/signs: - discoloured discharge and purulent secretion in nasal cavity - severe local pain - fever - elevated ESR/CRP
50
Differentials for sinusitis
``` Migraine TMJ dysfunction Dental pain Neuropathic pain Temporal arteritis Herpes zoster ```
51
Causes of bacterial sinusitis. Which organisms?
Most follow viral infection. Others: - direct spread - odd anatomy (septal deviation, polyps) - ITU causes (venilation, NG tubes) - systemic cause (Kartagener’s) - biofilms Strep pneumoniae, H influenzae, S aureus
52
Management of bacterial sinusitis
Acute/single episode - simple analgesia, amoxicillin or doxy | Recurrent - as above, plus imaging/surgery
53
Causes and management of CSF rhinorrhoea
Ethmoid fractures that disrupt the dura and arachnoid. | Manage conservatively
54
Management of septal perforation
Saline nasa irrigation Vaseline Surgical closure may be needed
55
Management of epistaxis
Resus as needed Apply pressure by squeezing lower part of nose for 20min Ice pack on dorsum of nose Apply cotton ball soaked in 1:200,000 adrenaline for 2m Cauterise with silver nitrate Anterior nasal pack Postnasal pack
56
Causes of epistaxis
``` Local trauma (nose picking) Facial trauma Dry/cold weather Haemophilia Septal perforation ```
57
Which arteries are involved in anterior epistaxis?
Kiesselbach’s plexus - ant ethmoidal, sphenopalatine, facial arteries, sup labial
58
Causes of a sore throat
Viral - rhinovirus, parainfluenza virus Bacterial - GABHS Rarer - HIB
59
Complications of tonsillitis
``` Otitis media Sinusitis Peritonsillar abscess (quinsy) Parapharyngeal abscess Lemierre syndrome ```
60
Cause, presentation, and management of scarlet fever
Caused by exotoxins released from Strep pyrogenes (a GABHS) Rash often develops on chest, axillary, or behind ears Facial flushing with circumoral pallor Strawberry tongue Treat - penicillin V
61
Define stridor
High-pitched noise heard in inspiration from partial obstruction at larynx or large airways
62
Define stertor
Inspiratory snoring noise, coming from obstruction of the pharynx
63
Causes of stridor
Congenital - laryngomalacia, stenosis Inflammation - laryngitis, epiglottitis, croup, anaphylaxis Tumours - haemangiomas or papillomas Trauma - thermal/chemical
64
Describe croup. Give the management
Leading cause of stridor with a barking cough Treat - single dose of dexamethasone Admit if severe, or moderate that isn’t settling
65
Describe laryngomalacia
Main congenital anomaly of the airway Often noticed within hrs of birth Excessive collapse and indrawing of supraglottic airways during inspiration, leading to stridor
66
Define dysphonia. Give some causes. When would you investigate?
Difficulty producing sound, with a change in voice pitch or quality Majority are due to viral URTI Investigate if lasting >3wk (esp in smokers)
67
Differential diagnoses of dysphonia
Laryngeal cancer - progressive and persistent gruff voice Vocal cord palsy - often due to cancer Laryngitis - often viral and self-limiting Reflux laryngitis
68
Causes of dysphagia
Stricture (benign or malignant) - esp if solids worse than fluid Motility disorders (achalasia) - if solids = fluids Bulbar palsy - if difficult to initiate swallowing Pharyngeal pouch - if neck bulges on drinking
69
Define globes pharyngeus
Sensation of a lump in the throat that’s most noticed when swallowing saliva May complain of mucous in the throat which they’re unable to clear Cause is unclear - possibly due to muscle tension in pharynx or inc acid exposure
70
What’s the most common type of cancer in the head and neck?
90% Squamous cell carcinoma (HNSCC)
71
Causes/associations of HNSCC
``` Cigarette smoking Inc alcohol consumption Vit A+C deficiency HPV GORD ```
72
Signs and symptoms of oral cavity SCC
``` Persistent, painful ulcers White or red patches on the tongue, gums or mucosa Otalgia Odonophagia Lymphadenopathy ```
73
General symptoms of HNSCC
``` Neck pain/lump Hoarse voice >6wks Sore throat >6wks Mouth bleeding Mouth numbness Sore tongue Painless ulcers Patches in mouth Earache/effusion Lumps Speech change Dysphagia ```
74
Causes of facial nerve palsy
Intracranial - brainstem tumours, strokes, polio, MS Intratemporal - otitis media, cholesteatoma Infratemporal - parotid tumours, trauma Others - Lyme disease
75
Signs of a facial nerve palsy
LMN lesions - paralyse all of one side of face | UMN lesions - forehead muscle and closing of the eyes may be intact
76
Signs, complications, and management of xerostomia
Dry, atrophic, fissured oral mucosa Discomfort, difficulty eating and speaking ``` Complications = dental caries, candida infection Treat = inc oral fluids, good dental hygiene, saliva substitutes ```
77
Causes of xerostomia
``` Hypnotics + tricyclics Antipsychotics B-blockers, diuretics Mouth breathing Dehydration ENT radio Sjogren’s SLE and scleroderma Sarcoidosis ```
78
Management of nasal polyps
All pts should be referred to ENT for full examination -> urgently if unilateral (red flag for NP cancer) Topical steroids shrink 80% of polyps
79
What is presbycusis? What’s the underlying pathology?
SNHL affecting elderly individuals High-freq hearing is affected bilaterally Progresss slowly as sensory hair cells and cochlea neurons atrophy
80
Signs and audiometry results in presbycusis
Weber’s may lateralise if SNHL is not completely bilateral. Audiometry shows bilateral high-frequency SNHL pattern
81
First-line ABx for otitis media
Amoxicillin | Co-amoxicillin is 2nd
82
Neck lump in anterior triangle. Doesn’t transluminate, but is mobile and has cholesterol crystals in fluid
Branchial cyst
83
Causes of gingival hyperplasia
Phenytoin Ciclosporin CCB AML
84
Vertigo + hearing loss + absent corneal reflex?
Acoustic neuroma
85
Pathophysiology of otosclerosis
Replacement of normal bone by vascular spongy bone Causes progressive CHL due to fixation of stapes at oval window. AD and tends to affect young adults
86
Features and management of otosclerosis
``` Onset 20-40yr CHL Tinnitus Normal tympanic membrane +ve FHx ``` Treat = hearing air, stapedectomy
87
Describe the neck lump seen in lymphoma
Rubbery, painless lymphadenopathy | Associated night sweats and spleen omega
88
Differentials for a neck lump that moves upwards on swallowing
Thyroid swelling
89
Differentials for a neck lump that moves upwards with tongue protrusion
Thyroglossal cyst
90
Differentials for a neck lump that is fluctuant but doesn’t transilluminate or move during swallwing
Branchial cyst

Finals (25 decks)

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