ENT Flashcards
Cervical lymphadenopathy Causes + Complication
EBV (fever, pharyngitis, lymphadenopathy) HIV (Cervical, axillary, occipital) Adenovirus Strep pharyngitis (Pyogenes) Malig: NHL, HL, CLL
SVC obstruction
When to refer Cervical lymphadenopathy
Not resolving with ABx at 2 weeks,
Unexplained Cervical lymphadenopathy
48 hour urgent blood count for leukaemia if under 25
Salivary gland swellings
- Causes
- Glands
Infection
Inflammation
Obstruction
Tumour
Parotid, Submandibular, sublingual
Parotid swelling:
- Causes
- When to worry
Viral parotitis (Mumps)
Stone in duct, benign/malig tumours
Sjogren’s
Sarcoidosis
Assoc withFacial nerve palsy - suggests malignant infiltration
Parotitis - Causes - Mumps pres - Ix Tx
Viral (mumps), Bacterial (s.aureus from oral cavity)
Bilateral swelling, pyrexia, orchitis
Viral serology, antibody testing (Mumps IgM)
Sialography for blockage
CT/MRI exclude malignancy
Mumps self limiting (supportive analgesia)
Salivary gland obstruction
- Main gland
- Pres
- Ix
- Tx
Submandibular
Pain and swelling at meal time (when they prod most)
USS and contrast sialogaphy
Many pass spontaneously (warm compress, gland massage. oral hygiene)
Surgical removal
Sialadenosis
- What is it
- Assoc with what
Generalised Parotid gland swelling
Sjogren’s & Sarcoid
Salivary gland tumours
- Benign v Malig and E.G of each
- Red flags
70% benign
Benign: Pleomorphic adenoma (Parotid)
Malignant: Mucoepithelioid carcinoma (Parotid)
Nerve parenthesis (CN VII palsy = malignant), Hx skin cancer, rapid growth
Salivary gland tumour
- Ix
- Tx
USS 1st line
Fine needle aspiration (cytology). Core needle biopsy for histology if FNA +ve
MRI - staging, CT - mets
Surgery - superficial parotidectomy + facial nerve
Radiotherapy
Benign paroxysmal positional vertigo
- Epi
- Pathophys
- Cause
- Attack character
Commonest cause of vertigo
Caused by otolith (crystal) detachment. Sensation of ongoing movement
Idiopathic (60%)
Head injury, labyrinth degeneration
Vertigo provoked by head movement. Attacks 20-30 seconds
No hearing loss/tinnitus/pain (red flags)
May cause nausea
BPPV examination + management
Otoscopy, CN exam, Dix-Hallpike (+ve = rotary nystagmus. usually unilateral. Bilateral = central cause)
Reduce head movement,
Epleys manoeuvre (reposition otoliths in utricles)
Contact DVLA - don’t drive when dizzy
Recurrence common
Menieres
- Def/pathophys
- Pres
- Cause
Overproduction/impaired absorption of endolymph
Auditory and vestibular disease (vertigo - mins/hours assoc N&V, hearing loss - unilateral, sensorineural, tinnitus, fullness in ear)
Genetic, Trauma (acoustic/physical), recent virus
Menieres
- Ix
- ddx
- Tx
- Complications
Positive Rombergs (standing with arms out)
Sensorineural hearing loss
MRI normal, TFT normal, lyme disease serology normal
- rule out acoustic neuroma, viral labyrinthitis/neuritis
Low salt and diuretics
(Acetazolamide - Carbonic anhydrase inhibitor … also used in glaucoma)
Falls, Progressive hearing loss
Vesitbular neuritis and labyrinthitis
- Pres
- Cause
- Nystagmus
VN - vertigo only (only vestibular nerve)
L - Vertigo and hearing loss
VN - HSV reactivation
L - Post viral URTI, aminoglycosides also cause (assoc with sensorineural hearing loss e.g. Gent)
Nystagmus usually unidirectional (bidirectional seen in stroke)
Vestibular neuritis and labyrinthitis Tx
Vertigo: Prochlorperazien
Encourage to be active ASAP
Surgery considered in Labyrinthitis
Acoustic neuroma
- Def
- Pres
- Assoc gene
Tumour of CN8 (vestibulocochlear) arising from schwann cells
Unilateral hearing loss/tinnitus (AN until proven otherwise)
Impaired facial sensation (Trigeminal involvement)
Balance problems
Ataxia - cerebellar compression
NF-t2 (Bilateral AN)§
AN Tx
Microsurgery
Conservative if small tumours with preserved sharing
Tinnitus
- Types
- Causes
- General management
Objectivists (actual noise in head), subjective (inorganic)
Pulsatile: carotid stenosis, valvular heart disease
TMJ dysfunction
Merniers, infection, MS, Acoustic neuroma, Head injury, acoustic trauma, stress (strong assoc(
After through Head, neck, ear and jaw exam most can be reassured
Sinuses:
- names
- sinusitis def
- Referred pain
- Viral Vs bacterial
Frontal, Ethmoid, Sphenoid, Maxillary
Inflam of mucous membrane slinging sinuses
Toothache, upper jaw, skin
Viral lasts less than ten days. Purulent discharge& worse after 5 days = bacterial
Sinusitis:
- Pres
- Predisposing factors
- Assessment
- Organisms
Rhinitis/nasal purulence, sinus pain, loss of smell
URTI, allergy, asthma, smoking, DM, swimming,
Palpation - tenderness
Strep pneumoniae, H.influenza
Sinusitis:
- management add referral
Reassure 2.5 wk recovery Paracetamol/Ibuprofen Nasal decongestant (7d max) Nasal douching Chronic - Topical nasal steroids (Beclomethasone)
Severe: 1st line amoxicillin, 2nd line coamoxiclav
Refer if recurrent, Or complication (orbital cellulitis, meningitis osteomyelitis)
Trigeminal neuralgia
- Def
- Tx
Sharp pain in distribution of trigeminal nerve
TCA - amitryptaline ± CBT
TMJ dysfunction
- Pres triad
- Cause
- Tx
Pain, limited mouth opening, joint noises
OA, RA, Ank spond, Grinding teeth (muscle affected)
Reassurance (self limiting)
Drugs: NSAIDs, muscle relaxants
Causes of congenital hearing loss
Rubella and CMV
Causes of post-natal hearing loss
Mumps and measles
Rinnes
- Hz
- Conductive loss
- SN loss
512Hz
Louder at mastoid
Both air and mastoid lost
Webers
- Hz
- conductive
- SN
512Hz
Louder in affected ear
Quieter in affected ear
Causes of conductive loss
Occlusion (foreign body, bony growth - Otosclerosis = bone deposition at stapes)
Infection (otitis externa - S.aureus, media - effusion)
Perforation (chronic otitis, trauma, surgery)
Growths (cysts, tumours (sarcoma, melanoma, carcinoma)
Sensorineural deafness causes
Acoustic neuroma
Mernier’s
Paget’s disease of bone (auditory canal stenosis)
Occupational (auditory trauma - refer for legal)
Ototoxics (ahminoglycosides, Cis-platinum)
MS
Other: age related (Presbycusis), trauma, infection (meningitis)
Management of Deafness
Urgent ENT referral
Ossicles
Type of joint, what can affect
Malleus–>Incus–>Stapes–>Oval window
Synovial joint. Can be affected by RA
What nerve runs through middle ear?
Chorda tympani
Branch of CNVII (facial)
Carries taste to anterior two thirds of the tongue
Otosclerosis:
- Genes
- Def
- Pres
Autosomal dominant
Normal bone replaced by spongy bone
Conductive deafness, Flamingo tinge of Tympanic membrane (inc vascularity)
Causes of Otorrhoea(discharge)
- If with pain
- If there was pain but now not
- If with hearing loss
Otitis externa
Acute otitis media
Cholesteatoma (keratinisation in the middle ear)
Otitis externa:
- def and cause
- pres
- complication
Painful discharging ear. Normally infection (can also be inflammatory, allergic)
Erythematous ear, discharge, pain on moving trigs, pre-auricular lymphadenopathy, May have cellulitis
Facial nerve palsy
Otitis externa pathogen
Bact: S.aureus
Fungus (aspergillus)
Viral otitis externa
Ramsay hunt syndrome (Bell’s palsy, Rash behind ear)
Otitis externa Tx
Topical neomycin (also covers fungal)
ENT review
Flucloxacillin (erythromycin if allergic)
Olive oil for waxy build up
Otitis media
- What is it & types
- Who gets
- Causes (Bact + Viral)
Acute otitis media- inflammation of middle ear. may have pus = risk perforation
Otitis media with effusion - acute inflammation with effusion behind TM (glue ear)
Children
B: S.pneumoniae, H.influenza
V: Rhinovirus, RSV
Otiti media
- RF
- Pres
- Ix
- Tx
Smoking, winter, URTI, DM, immunosuppression
Hearing loss, otalgia, pyorrhoea, fever.
Culture of discharge, CT/MRI (exclude complications)
Analgesics (Para, NSIADs)
Abx: amoxicillin (only if symptom over 5 days)
Otitis media complications
Perforation, Glue ear
Meningitis, mastoiditis/osteomyelitis (air cell infect), Facial nerve palsy, brain abscess
Glue ear
- Complications
- management
Conducive hearing loss (may fall behind in school)
Grommets if persistent over 3m
Chronic supportive otitis media:
- What is it
- Pres
- Ix
- Tx
chronic inflammation of middle ear (often with perforation)
Ottorhoea, conductive hearing loss, red flags (fever, vertigo, otalgia)
CT/MRI to rule out intracranial complications
Topical Abx (Fluclox) Surgical repair eardrum
Mastoiditis
- What bone
- What is the concern
- Organism
- Ix
- Tx
Petrous temporal bone
Air cells in close relation to cranial fossa Infection with boney destruction can cause meningitis, cerebral abscess, facial nerve damage
S.pneumonia/pyogenes
Blood cultures
CT/MRI
LP if intracranial spread suspected
Tympanocentesis (G stain and culture)
3rd Gen cephalosporin
Para + Ibuprofen
Surgery (mastoidectomy) if osteomyelitis
Blood in middle ear. Cause? What nerve?
Worry about head trauma
Abducens runs over temporal bone
Staging head and neck cancer
1 = early disease 2 = locally advanced 3 = LN spread 4 = distant mets
Head and neck cancer Tx
Surgery or radiotherapy for early disease
Later stage - surgery and chemoradiotherapy ± reconstruction
Oral cancer
- Cell type
- RF
- Appearance
- Pres
Squamous cell carcinomas
Smoking, Alcohol, Chewing tobacco, low fruit
Leukoplakia, mass, speech/swllow difficulty, bleeding/ulcerating
What to refer for suspected oral cancer
Unexplained ulceration for over 2 weeks
Lump in oral cavity over 2 weeks
Red or white patch (erythro/leukoplakia)
Oral cancer diagnosis
Fine needle aspiration/biopsy
CT/MRI for staging
CT thorax all H&N Ca
surgical resection ±reconstruct
External beam radiotherapy ± Cisplatin
Pharyngeal cancer
- Tx
Surgery ± neck dissection (LN removal)
Radiochemoherapy (cisplatin, External bam radio)
Laryngeal cancer
- Cell type
- Where
- RF
- Pres
SCC
Most commonly at Glottis
Smoking, Alc, HPV16, asbestos/nickel
Chronic hoarseness, pain, dysphagia, lump in neck, weightless, sore throat, stridor
Laryngeal cancer
- Ix
- Tx
Palpate for Los CXR to see if hoarseness lung or ENT Laryngoscopy FNA neck mass CT/MRI staging
Transoral microsurgery/Partial/Total laryngectomy depending on stage
Postop chemoradio
Cause of tonsilitis
Bacterial: strep pyogenes
Viral: Coxsakie, EBV/IM in teens (splenomegaly), Herpes simplex (Adolescents)
Centor criteria and Tx
1) Fever > 38
2) Tender anterior cervical lymphadenopathy
3) No cough
4) Tonsillar exudate
3/4 = 40-60% chance bacterial Give phenoxymethypenicillin (Clarithromycin if allergic)
Signs of strep throat
Red, swollen, Exudate, LNs, Temperature
Tx tonsilitis
Reassure self limiting, Ibuprofen/Paracetamol
ABx if 3+ on Centor (10d phenoxymethypenicillin)
When tosillitis get surgery
7 well documented episodes in last 12m
Tonsils obstructing airway
Tonsilitis compliations
Peritonsillar abscess, acute otitis media
Group A strep throat (pyogenes) complication
Rheumatic fever
Glomerulonephritis
Scarlet fever (red skin eruption, flushed face, strawberry tongue)
Causes of pharyngitis (Pharyngeal inflam)
Viral: rhinovirus, coronavirus, influenza, parainfluenza, adenovirus
Bact: Group A strep
When not to examine sore throat?
- Sympt
- What is it and what organis?
Drooling, stridor
Epiglottitis
H.influenza type b
Tx for normal pharyngitis
- normal
- Abx?
- When refer
Reassure
Para, Ibuprofen, oral fluids
If doesn’t settle in 1 week or if cantor 3/4 then Abx
Urgent referral:
- resp diffuculty,
- stridor,
- suspected kawasaki’s (sore throat, palm/sole peeling - risk Coronary aneurysm)
Complications of pharyngitis:
- Suppurative
- Non-suppurative
Otits media, Sinusitis, Quinsy, Mastoiditis, Scarlet fever
Rheumatic fever (Pyogenes), Glomerulonephritis
Causes of Laryngitis
Infection: viral (corona, adeno, HSV), bacterial (H.influenza b, S.pneum)
Reflux
Allergy
AI disease (SLE, RA, Amyloid)
Smoking
Tx according to cause e.g. GORD -> PPI
Epiglotitis:
- Cause
- Age
- Pres
- DONT …
- Ix
- Tx
Haemophilus Influenzae b
2-5 or adults 40-50
Sore throat, unable to swallow (drooling), Muffled voice, Fever/hihg temp, tripod sign (leaning forward)
Stridor + resp distress
Examine airway with tongue depressor - precipitates laryngeal oedema
Same day urgent laryngoscopy IN THEATRE
IV abs ± intubation/Tracheostomy
Peritosilar abscess (Quinsy)
- Assoc with..
- Organism
- RF
- Pres
- Diagnosis
- Tx
Complication of acute tonsillitis
Strep pyogenes, Staph aureus, H.influenzae
Smoking
Severe pain, fever, drooling, foul breath, reduced jaw mobility (Trismus)
Ipsilateral LN
Unilateral bulge with uvula displacement
Clinical Dx, may need CT
IV fluids, IV ABx (Penicillin, co-amoxiclav, cephalosporin)
Needle aspiration and drainage
Quinsy complications
Abscess Spread
Haemorrhage
Stridor (loud inspiratory sound)
- Causes in child
- Causes in adult
Croup, inhaled foreign body, epiglottis
Airway trauma, anaphylaxis, acute laryngitis
Chronic: Laryngeal ca, Mediastinal tumour,
Where do foreign bodies lodge
Right lung
Right main bronchus is more vertical than left
Worrying presentation following nasal injury
CSF rhinorrhoea
Septal haematoma
Septal deviation
Facila anaesthesia (loss of feeling)
Commonest cause Rhinorrhoea
Coryza (cold)
Hay fever
Nasal polyps (due to chronic allergy or inflammation)
Nasal polyps
- Causes
- Tx
Chronic inflammation, asthma, CF, Churg-Strauss, aspirin sensitivity
1st line: Topical corticosteroid (fluticasone)
Gold standar = surgery (endoscopic sinus surgery)
Lump in neck Ddx:
1- Rubbery painless lymphadenopathy
2- Hx of local infection
3- Palpitations, thin hair
4- Midline lump which moves up when stick out tongue
5- Older man with a midline lump that gurgles on palpation
6- Left sided lump on child under 2
7- Young adult with oval, mobile cystic mass between sternocleidomastoid and pharynx
8- Adult female with thoracic outlet syndrome
9- Pulsatile lateral neck mass which doesn’t move on swallowing
1) Lymphoma
2) Reactive lymphadenopathy
3) Thyroid swelling
4) Thyroglossal cyst
5) Pharyngeal pouch
6) Cystic hygroma
7) Branchial cyst
8) Cervical rib
9) Carotid aneurysm
Neurological causes of dysphagia
CVA, achalasia, oesophageal spasm, MND, MS, Parkinson’s
Obstructive causes of dysphagia
GORD, oesophagitis, oesophageal/gastric cancer, pharyngeal cancer, oesophageal stricture
CREST dysphagia pathophys
Thickening of oesophageal wall due to fibrosis = reduced motility
Dysphagia red flags
Weight loss
Pain
Hoarseness
Regurgitation
Obstructive sleep apnoea
- Def
- Assess
- Assoc
- Tx
Repeated Upper airway collapse during sleep going excessive waking and daytime sleepiness. Due to relaxation of neck soft tissue = obstruction
Epworth sleepiness scale, Polysomnography
HTN, Obesity, asthma, Big neck circumference
Stop smoking, weight loss
CPAP = gold standard
Bell’s palsy
- Def
- Type of palsy
- Assoc features
- Tx
Acute, idiopathic facial nerve paralysis
LMN lesion (forehead affected)
Hyperacusis (hearing - CNVII innervation of stapedius muscle) Altered taste (lingual nerve)
Prednisolone +artificial tears
Ddx Bells palsy
Ramsay-Hunt syndrome
Due to Herpes Zoster
Rash behind ear with symptoms of Bell’s
