ENT Flashcards

Question 1

Q

What is found in the anterior triange of the neck?

Answer

A

Larynx
Hypopharynx
Carotid sheath
Thyroid gland
Deep cervical lymph nodes

Question 2

Q

What is found in the Posterior triangle of the neck?

Answer

A

Lymph nodes
Accessory nerve
Subclavian artery

Question 3

Q

What are the lymph node levels of the neck, what is found in each level?

Level 1

Level 2

Level 3

Level 4

Level 5

Level 6

Level 7

Answer

A

Level 1 – Submental & Submandibular lymph nodes
Level 2 – Upper deep cervical
Level 3 – Mid deep cervical
Level 4 – Lower deep cervical
Level 5 – Posterior triangle
Level 6 – Paratracheal
Level 7 – Upper mediastinal

Question 4

Q

What are the subdivisions of the anterior triangle?

Answer

A

Carotid triangle
Submental triangle
Digastric triangle

Question 5

Q

When taking a Hx concerning a patient with problems with their nose, what are the key questions to ask?

Answer

A

Nasal obstruction
Runny nose (Also called anterior rhinorrhoea)
Loss of sense of smell (Also called hyposmia)
Nose bleeds (Also called epistaxis)
Facial pain

Other symptoms include:

Post nasal drip
Nasal itch
Sneezing
Ocular itching

Question 6

Q

When taking a Hx concerning a patient with problems with their ear, what are the key questions to ask?

Answer

A

Earache (Also called otalgia)
Ear discharge (Also called otorrhoea) – Colour/Smell/Consistency
Hearing loss – How does it affect you?
Tinnitus (the sensation of sound without any external stimulus)
Dizziness
Any problems with balance?

Other symptoms can occur and include:

Aural blockage
Itching

Question 7

Q

When taking a Hx concerning a patient with problems with their throat, what are the key questions to ask?

Answer

A

Sore throat
Difficulty swallowing (Also called dysphagia)
Pain on swallowing (Also called odynophagia)
Hoarse voice (Also called dysphonia)
Regurgitation

Other symptoms include:

A feeling of a lump in the throat
Burning in the throat
Weight loss

Question 8

Q

You are asked to perform an ear examination, what does this involve?

Answer

A

[Introduction]

Wash hands & Introduce self
Ask Patient name & DOB & Age
Today I am going to be doing an examination of your ear, having a look at it from the outside, then using a scope to look inside the ear, this will involve me getting close to your ears
- Does that sound ok?
- Do you have any pain at the moment?
- Would you like some painkillers?
For the examination I will need to have access to both your ears, so can you please tie your hair back, and remove any piercings that might obstruct your ears/canal?
I’ll need you sitting comfortably on a chair please

[General Inspection]

Where exactly is the pain?
Is it in a specific area/generalised?
Look at the patient sat in the chair, assess for:
- Signs of pain
- Discomfort
- Look in ear
- Any hearing aid/cotton wool needs to be removed for the examination

[Inspection]

Assess R & L ear:
- Size & shape of the Pinna
- Extra cartilage tags
- Pre-auricular sinuses or pits
- Signs of trauma
- Perichondral haematoma
- Lesions, Massess
- Condition of the skin
- Inflammation around the ear
- Eryspelas
- Mastoiditis
- Discharge
- Scars of previous surgery
Assess other ear

[Palpation]

Gently palpate, for tenderness:
- Tragus
- Around the mastoid
- Gentle tug on pinna
- Assess lymph nodes
- Pre-auricular
- Post auricular

[Otoscope]

Prepare: Attach the speculum (New speculum for each patient)
- Correct size for patients ear canal
- Ensure it is attached firmly
Put otoscope on
- Check light is working correctly
Insert otoscope into the test ear Hold near head of otoscope like holding a pen
- Left ear - Left hand with handle facing left
- Right ear - Right hand with handle facing right
Gently pull up and back on pinna – To straighten the external auditory meatus
Stabilise otoscope by using little finger to rest on patients temple
Gradually insert speculum into the external auditory meatus
- Look in ear canal:
  - Skin changes
- Foreign body
- Wax (Normal)
- Discharge
- Assess the tympanic membrane
  - Handle
  - Lateral process of the malleus
  - Light reflex/Cone of light
  - Pars tensa
  - Pars flaccida
Comment on any abnormalities
- Otitis externa (Acute/chronic/fungal)
- Otitis Media
- Cholesteatoma
- Perforation
- Tympanosclerosis

[Conductive & Sensorineural hearing loss]

Basic hearing test
Ask patient to put finger in one of their ears
- Whisper letters/numbers into patients other ear
Can you repeat what I just said?
- Repeat in other ear
- Use different letters/numbers
Note:
- If there is a hearing impairment it is a conductive problem/sensorineural
- Conductive -> Outer ear/TM/Middle ear
- Sensorineural -> Inner ear or CN 8

Rinne’s

Rinne’s test Place vibrating 512Hz tuning fork firmly on patients mastoid process of test ear
Can you hear the tuning fork?
Transfer to in front of the ear canal
Which is louder
Note:
- Normal -> In front of the ear should be louder than the mastoid process
  - Air conduction is > Bone conduction
- Rinnes test POSITIVE:Normal + Hearing impairment
  - Sensorineural hearing loss
- Rinnes test NEGATIVE:Abnormal + Hearing impairment
  - Conductive hearing loss
It is possible to have a Rinnes negative result - but have sensorineural deafness
- Because if the sensorineural deafness is complete then the vibration from the test ear -> transfers to the non-test ear via the bone
- That’s why you use Webers test to confirm this, as the sound should lateralise to the non-test ear

Weber’s test

Place the vibrating 512Hz tuning fork centrally and firmly on patients forehead
Ask patient - where can you hear the sound?
- Centrally
- Left
- Right
If the patient has Conductive hearing loss
- Localises TOWARDS the Abnormal ear
Sensorineural hearing loss
- Localises AWAY from affected ear

[Complete exam]

Thank patient & Wash hands
“This is patient x who is a x year old Male/Female with the following findings”
I would take a full Hx + examine any other systems – Nose/Throat
I would consider the differentials
I would order relevant investigations
- Observations
- Bloods
- Imaging
I would initiate management of the most likely differential

Question 9

Q

You are asked to perform a nasal examination, what does this involve?

Answer

A

[Introduction]

Wash hands & Introduce self
Ask Patient name & DOB & Age
Today I am going to be doing an examination of your ear, having a look at it from the outside, then using a scope to look inside the nose
- Does that sound ok?
- Do you have any pain at the moment?
- Would you like some painkillers?
For the examination I will need to have access to your nose so can you please remove your glasses for me?
I’ll need you sitting comfortably on a chair please

[General Inspection]

Where exactly is the pain?
Is it in a specific area/generalised?
Look at the patient sat in the chair, assess for:
- Signs of pain
- Discomfort
- Runny nose
Do they look systemically well?

[Inspection]

Examine the external nose:
- Size and shape
- Obvious bend or deformity
- Swelling
- Bruising
- Scars
- Abnormal creases
- Redness
- Skin changes
- Discharge/crusting
- Offensive smell
Examine the nose internally
- Can you please lift the tip of your nose with your thumb?
- Use pen torch to look, note:
  - Abnormalities
  - Septal deviation

[Palpation]

Gently palpate the nasal bone & cartilage, assess for:
- Tenderness
Alignment
- If signs of trauma then palpate the:
  - Nasal process
  - Facial surface
  - Frontal process of maxilla
  - Infra-orbital ridges
What im going to do next is just to block one of your nostrils and can you just breathe through the other one
- Assess difference in airflow
Block other nostril

[Otoscope]

Attach new speculum to otoscope
- Examine R nostril
- Hold R nostril otoscope in L hand
Examine L nostril
- Hold L nostril with otoscope in R hand
Insert speculum gently into nostril & open up nasal cavity
- Examine nasal cavity
- Septum
- Turbines (Inferior turbine should be visible)
Signs of inflammation
Any polyps or foreign body

[Complete exam]

Thank patient & Wash hands
“This is patient x who is a x year old Male/Female with the following findings”
I would take a full Hx + examine any other systems
I would consider the differentials
I would order relevant investigations
- Observations
- Bloods
- Imaging
I would initiate management of the most likely differential

Question 10

Q

You are asked to perform a neck/throat examination, what does this involve?

Answer

A

[Introduction]

Wash hands & Introduce self
Ask Patient name & DOB & Age
Today I am going to be doing an examination of your throat, having a look at it from the outside, then using a scope to look inside your throat
- Does that sound ok?
- Do you have any pain at the moment?
- Would you like some painkillers?
For the examination I will need you to be able to see your neck, so please take off your scar or top if blocking neck
I’ll need you sitting comfortably on a chair please

[General Inspection]

Where exactly is the pain?
- Is it in a specific area/generalised?
Look at the patient sat in the chair, assess for:
- Signs of pain
- Discomfort
- Systemically well at rest?
- Cachexia
- Hoarse voice

[Inspection]

Look externally
- Scars
- Visible lymph nodes
- Massess on neck If midline - Can you swallow some water for me?
  - Thyroglossal cyst & thyroid mass -> Move up
- Can you please stick your tongue out for me
  - Thyroglossal cyst -> Moves UP, Thyroid mass will NOT
Look internally
- Can you please remove any dentures if you have any?
- Put gloves on and get pen torch & tongue depressors
Im going to just ask you to open your mouth, so that I can have a look at your throat. I’m going to be using these wooden spatula to push your tongue down
- Asses - Mouth
  - Mucosa of the cheeks
  - Condition of tongue
  - Ask them to move tongue out
  - Move tongue to the R & L to check the sides
- Back of tongue and tonsils - with tongue depressor
  - Exudate
  - Quinsy
  - Uvula
  - Soft palate
- Ask patient to tip head back -> Insepct the hard palate
- Buccal area
- Gingivolabial sulcus (Space b/w cheek and gums)
Can you stick your tongue up for me
- Examine floor of mouth

[Palpation]

I’m just going to have a feel of your tongue now
Palpate base of tongue for
- Tumours
Remove gloves, and stand behind patient - Palpate lymph nodes:
- Submental - Submandibular - Preauricular - Postauricular - Anterior cervical - Posterior cervical
- Palpate structures in neck
- Parotids - Tail of parotid (Anterior and inferior to mastoid process)
- Submandibular glands (Singular swelling)
Palpate neck -Tip of chin - submandibular - submental - mastoid process - anterior SCM - Thyroid gland - Larynx - Posteiror triangle - Supraclavicular fossae
- Massess
- Tenderness

[Complete exam]

Thank patient & Wash hands
“This is patient x who is a x year old Male/Female with the following findings”
I would take a full Hx + examine any other relevant systems
I would consider the differentials
I would order relevant investigations
- Observations
- Bloods
- Imaging
I would initiate management of the most likely differential

Question 11

Q

How do you differentiate between a thyroglossal v thyroid cyst?

Answer

A

Massess on neck If midline - Can you swallow some water for me?
- Thyroglossal cyst & thyroid mass -> Move up
Can you please stick your tongue out for me
- Thyroglossal cyst -> Moves UP
- Thyroid mass will NOT

Question 12

Q

You are asked to take a throat swab from a patient, how do you go about this procedure?

Answer

A

[Introduction]

Wash hands & Introduce self
Ask Patient name & DOB & Age
Today I am going to be doing a swab of your throat is that what you were expecting?

[Prepare equipment]

Wash hands
Put on apron
Open procedure pack on to clean surface
Partially open swab packaging
Wear gloves

[Position patient]

Use good light source
I will need you to be seated with your head back and mouth wide open
Stick your tongue out and say ahhh

[Take swab]

Use tongue depressor to flatten tongue
Roll swab over suspect area
Remove swab -> Place in medium
Remove gloves
Wash hands

[Complete]

Thank patient
Explain when they will receive results
Label sample
Place in hazards bag - fill out paper work
Send to microbiology

Question 13

Q

What is the following showing? What are the items labelled?

Answer

A

Normal throat O/E, from top to bottom

Hard palate
Soft palate
Uvula
Palatine Tonsils
Tongue

Question 14

Q

What is the following showing? What do the arrows point to?

Answer

A

Normal ear O/E

Top left – Pars flaccida
Top right – Lateral process of malleus
Bottom Left – Pars tensa
Bottom right – Cone of light

Question 15

Q

Label the following diagram of the ear

Answer

A

1. Tympanic membrane
1. Pinna
1. Helix
1. Outer ear/External acoustic meatus
1. Cartilage
1. Earlobe
1. Malleus - Incus - Stapes (Lateral to medial)
1. Semicircular canals
1. Cochlea
10 + 11. Vestibulococclear nerve
12 + 13. Eustachian tube
1. Bone

Question 16

Q

How are sound waves conducted from outside into the ear?

Answer

A

Sound waves – external auditory canal
Hit the Typmanic membrane
Transfer to ossicles (Malleus + Incus + Stapes) to the inner ear
Hit the Oval window
Tranfer to the cochlea

Question 17

Q

What is the cochlea?

How is it divided?

Answer

A

Spiral shaped cannal within the temporal bone

3 membranous compartments filled with Perilymph:

Scala tympani
Scala media – Filled with Endolymph
- Basilar membrane
- Organ of corti
Scala Vestibuli

Question 18

Q

What is the function of the organ of corti?

Answer

A

Organ of corti = Detects sound waves – converts it into electrical signal for brain via CN8

Question 19

Q

Where is sound transmitted to in the central nervous system?

Answer

A

Cochlear nerve – Cochlear nucleus in brainstem
Decussation to contralateral side
Up brainstem via Superior Olivary nucleus
Through lateral leminiscus (Midbrain) – Inferior Colliculus
Medial geniculate body
Auditory cortex (Superior Temporal gyrus of temporal lobe)

Question 20

Q

What are the 2 types of hearing loss?

Answer

A

Conductive – Problem with transmission of sound waves from external ear – middle ear
Sensorineural – Problem with the cochlear - Cochlear nerve - Brainstem leading to abnormal/absent neurosensory impulses
- Most common in adults

Question 21

Q

Who typically gets deafness/hearing loss in adults?

Answer

A

People >50yrs (Due to age related damage)
Men
Those exposed to excessive noise

Question 22

Q

What can cause conductive hearing loss in adults?

Answer

A

Occlusion – Cerumen/Foreign body/Oedema
Infection – Otitis externa/Otitis media/Sinusitis
Tympanic membrane perforation
Growths – Benign cysts/Benign or Malignant tumours
Cholesteatoma
Adenoids blocking the eustachian tube

Question 23

Q

What can cause sensorineural hearing loss in adults?

Answer

A

Presbyacusis (Age related hearing loss)
Noise induced hearing loss
Ototoxic hearing loss
Acoustic neuroma
Menieres disease

Question 24

Q

What are the risk factors for hearing loss in children?

Answer

A

FHx of deafness
Infection – Congenital/MMR/Meningitis
Ototoxic medications
Low birth weight/prematurity
Head injury

Question 25

Q

What are the common causes of hearing loss in children?

Answer

A

Congenital
Otitis Media with effusion

Question 26

Q

What is Tympanosclerosis?

Answer

A

Calcification of the tissue in the tympanic membrane + middle ear

Classified as:

Myringosclerosis – Only tympanic membrane is involved
Intratympanic tympanosclerosis – Involving ossicles/mastoid cavity

Question 27

Q

Why does tympanosclerosis develop?

Answer

A

May be due to an abnormal healing response
Most commonly develops secondary to acute & chronic otitis media
Increased risk in children with grommet insertion for OM

Question 28

Q

How does Tympanosclerosis typically develop?

Answer

A

Asymptomatic
O/E: Chalky white patches on inspection
May have conductive hearing loss

Question 29

Q

What does the following otoscope exam show?

Answer

A

Tympanosclerosis

Question 30

Q

If you suspect a person has tympanosclerosis, how should this be investigaited?

Answer

A

Not usually required if visualised O/E
Audiometry - if hearing loss

Question 31

Q

How is Tympanosclerosis managed?

Answer

A

Only if there is hearing loss
Hearing aids
Surgery – Excision of sclerotic areas + reconstruction of ossicles

Question 32

Q

What are the differential diagnoses for otalgia (Ear pain)?

Answer

A

External ear

Otitis externa
Foreign body – Object/Impacted cerumen
Trauma

Middle ear

Otitis media
Mastoiditis
Trauma
Obstruction of eustachian tube

Referred pain

Adenoidectomy/Infection
CN referred pain
TMJ

Question 33

Q

What is acute otitis media?

Answer

A

Middle ear infection
Common in children
Commonly caused by H.Influenzae + Streptococcus pneumoniae (Bacteria)
- Rhinovirus + RSV (Viruses)

Question 34

Q

How do patients develop acute OM?

Answer

A

Upper respiratory viruses infect the nasal passages/eustachian tube/middle ear
Impairs mucocilliary clearance of eustachian tube to clear the middle ear

Question 35

Q

What are Chronic OM and Recurrent OM?

Answer

A

Chronic OM:

Inflammation of the middle ear for >3months

Recurrent OM:

>4 episodes of OM in 6 months

Question 36

Q

Who typically gets Acute OM?

Answer

A

Children
Smoking - Passive or Active
During the winter months

Patients with:

Eustachian tube dysfunction
URTI
Sinusitis
Craniofacial abnormalities

Question 37

Q

What is the classic Hx of Acute OM?

Answer

A

Hearing loss
Otalgia
Fever
Preceeding URTI e.g. Flu/Sinusitis/Pneumonia/Tonsilitis
In children:
- Irritability/Crying/Poor feeding
Coryza/Rhinorrhea
Vomiting

Signs:

Fever
Red/Yellow/Cloudy tympanic membrane
Bulging of TM
May have discharge in auditory canal secondary to perforation of TM

Question 38

Q

Why is Acute OM in adults a red flag?

Answer

A

Because it signifies esutachian tube dysfunction which could be caused by malignancy
Especially if unilateral

Question 39

Q

A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?

An 18-month-old toddler presents with 1 week of rhinorrhoea, cough, and congestion. Her parents report she is irritable, sleeping restlessly, and not eating well. Overnight she developed a fever. She attends day care and both parents smoke. On examination signs are found consistent with a viral respiratory infection including rhinorrhoea and congestion. The toddler appears irritable and apprehensive and has a fever. Otoscopy reveals a bulging, erythematous tympanic membrane and absent landmarks.

Answer

A

Acute otitis media
Mastoiditis
Migraine
Herpes Zoster
Trauma
Foreign body in ear

Question 40

Q

What does the following otoscope image demonstrate?

Answer

A

Acute otitis media

Erythema
Bulging membrane

Question 41

Q

A patient presents with the following Hx suggestive of AOM, what investigations should be done?

An 18-month-old toddler presents with 1 week of rhinorrhoea, cough, and congestion. Her parents report she is irritable, sleeping restlessly, and not eating well. Overnight she developed a fever. She attends day care and both parents smoke. On examination signs are found consistent with a viral respiratory infection including rhinorrhoea and congestion. The toddler appears irritable and apprehensive and has a fever. Otoscopy reveals a bulging, erythematous tympanic membrane and absent landmarks.

Answer

A

Examination of ear w/otoscope
- Clinical diagnosis based on findings
Culture of discharge if any
Audiometry - if chronic hearing loss suspected (Not during acute infection)
CT/MRI - in adults to exclude complications

Question 42

Q

How do you manage a patient with confirmed AOM?

Answer

A

Analgesics – Paracetamol ± NSAIDs (Ibuprofen)
If bacterial – Avoid prescribing ABx, unless systemically unwell or symptoms not improving within 4 days
- Amoxicillin for 5 days, If allergic - Erythromycin/Clarithromycin
Immediate ABx if - systemically unwell/risk of complications

Consider admission:

Admission for immediate assesment – If complications of AOM, e.g. Meningitis/mastoiditis/facial nerve paralysis
- If <3 months with Fever
Consider admission – If systemically unwell
- <3 months, or 3-6months with Fever

Question 43

Q

What are the red flags in a patient presenting with symptoms of AOM?

Answer

A

Urgent referral to ENT, due to suspecting nasopharyngeal cancer

Persistent symptoms not responsive to treatment
Persistent cervical lymphadenopathy
Unilateral epistaxis

Question 44

Q

What is Otitis Media with effusion?

Answer

A

AKA - Glue ear
Collection of fluid in the middle ear
Chronic inflammation, usually follows AOM in children
Can cause hearing impairment
Uncommon in adults - Usually due to eustachian tube dysfunction or suspicious cause e.g. tumours

Can be caused by:

Eustachian tube dysfunction
Chronic colonisation of the adenoids/hypertrophy

Question 45

Q

Who classically gets OME?

What are the symptoms/Signs?

Answer

A

Most common cause of aquired hearing loss in childhood
Common in ages 1-6yrs
Less common in adulthood
Male > Females
Contact with people with infections/Smokers

Symptoms/Signs:

Hearing loss
Otalgia, may have fullness ± popping
Hx of recurrent ear infection/URTI/Nasal obstruction
May have balance problems

Otoscope:

Opacification of the tympanic membrane
No inflammation/Discharge
Loss of light reflex
Fullness/bulging of the typmanic membrane
Crackling/popping tinnitus

Question 46

Q

How is a patient with OME investigated & Managed?

Answer

A

Investigations:

Refer for hearing test/ENT
May have mild conductive hearing loss
May have spontenous resolution so active observation for 3 months

Adults:

If unilateral - suspicious finding, MRI to rule out tumour
Full evaluation

Management:

Patient education – Self limiting illness
Smoking cessation
Assist with hearing loss
Hearing aids if required

Surgery:

Only if bilateral present for >3 months
Insertion of Grommets (Ventillation tubes)
Adenoidectomy - if recurrent URTI
Usually resolution in 6-10 wks

Question 47

Q

Why are children particularly vulnerable to AOM?

Answer

A

Vulnerable to the transer of organisms from the nasopharynx to the ear
Angle b/w eustachian tube + wall of pharynx is wide so doesnt close shut with coughing or sneezing – avenue for transfer of pathogens

Usually caused by:

Preceeding URTI – Haemophilus Influenzae/Strep Pneumoniae
Viral – RSV/Rhinovirus

Question 48

Q

What is Chronic Suppurative Otitis Media?

Answer

A

Chronic inflammation in the middle ear + mastoid cavity
TM is perforated

Safe – Tubotympanic perforation (Centre of TM)

Unsafe – Atticoantral perforation (Top of TM) + Cholesteatoma

Question 49

Q

Who classically gets CSOM?

What are the symptoms/Signs?

Answer

A

Uncommon in both children & adults
Male = Females
Patients with multiple episodes of AOM
Children attending daycare/with craniofacial abnormalities

Symptoms/Signs:

Chronically draining ear >2wks
Hx of recurrent AOM
Traumatic perforation/Insertion of grommets
Otorrhoea without Otalgia + fever
Hearing loss – Conductive
Mixed hearing loss – Extensive disease
External auditory canal - oedematous ± tender
Discharge from the ear
Middle ear mucosa visible on examination

Question 50

Q

In a patient with CSOM, what investigations should be ordered?

How should they be managed?

Answer

A

Investigations:

NO EAR SWAB
Audiogram – Conductive hearing loss
MRI – if intratemporal/intracranial complications suspected

Management:

Urgent assessment/admission to ENT – If Mastoiditis (Postauricular tenderness/swelling) or facial paralysis or vertigo or evidence of intracranial infection
If not urgent - routine referral to ENT
Microsuction exudate from ear canal
Keep ear dry, avoid swimming
Aural toilet + ABx (Topical):
Antibiotic + Steroid combination for 3-4wks until otorrhea resolves

Question 51

Q

What is Otitis Externa?

Answer

A

Inflammation of the outer ear (Auricle + External auditory canal + Outer TM)
Can be localised or diffuse
AKA Swimmers ear
Due to disturbance of lipid/acid balance of the ear canal

Usually caused by:

Infection - Most common
Allergies/Irritants/Inflammatory conditions

Question 52

Q

How does the ear canal clean itself normally?

Answer

A

Self cleaning via epithelial migration
Skin surface moves laterally from the TM towards the ear canal opening
Ear wax (Cerumen) - assists with cleaning & lubrication and protection from bacteria/dust/insects

Question 53

Q

What are the causes of Otitis Externa?

Answer

A

Infection:

90% Bacterial – Staph Aureus ± Pseudomonas Aureginosa
Fungal – Aspergillus/Candida, usually following prolonged ABx/steroids
May also be caused by Herpes Zoster – Ramsey Hunt syndrome

Skin inflammation:

Sebhorrheic dermatitis/Psoriasis
Acne
Atopic eczema
SLE

Irritants:

Topical medications/Hearing aids/Ear plugs
Ear trauma – Foreign bodies/Cotton buds
Swimming

Question 54

Q

Who classically gets Otitis Externa?

What are the symptoms/signs?

Answer

A

Common condition
People who swim/immunocompromised
Trauma to ear canal
Foreign body/Wax build-up

Symptoms/Signs:

Otalgia
Itching
Ear canal with erythema
May have exudate/oedema
May have discharge - can become bloody
Mobile TM
Pain with movement of tragus/auricle
Pre-auricular lymphadenopathy
Fever

Question 55

Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 35-year-old man presents with a 2-day history of rapid-onset severe ear pain and fullness. The patient complains of otorrhoea and mild decreased hearing. He reports that his symptoms started after swimming. No fever is reported. On physical examination the external ear canal is diffusely swollen and erythematous. He has tenderness of the tragus and pain with movement of the auricle. The tympanic membrane was partially visualised due to the swelling. The concha and the pinna look normal. Neck examination fails to reveal any lymphadenopathy.

Answer

A

Otitis externa
Foreign bodies
Impacted wax
CSOM
OM
Malignancy

Question 56

Q

A patient presents with the following Hx, suggestive of otitis externa. How would you investigate? And manage the patient?

A 35-year-old man presents with a 2-day history of rapid-onset severe ear pain and fullness. The patient complains of otorrhoea and mild decreased hearing. He reports that his symptoms started after swimming. No fever is reported. On physical examination the external ear canal is diffusely swollen and erythematous. He has tenderness of the tragus and pain with movement of the auricle. The tympanic membrane was partially visualised due to the swelling. The concha and the pinna look normal. Neck examination fails to reveal any lymphadenopathy.

Answer

A

Investigations:

Swabs of ear canal – Microscopy + Culture
Examination of ear + CN + Neck for cervical lymphadenopathy

Management:

Urgent Referral if malignant otitis media suspected
Referral to ENT if – Cellulitis/Extreme pain/Considerable discharge/Systemic symptoms
Manage with topical ear drops
Ear Wicking (Coated in ABx + Steroid) ± removal of debris
Keep ear dry
If there is Cellulitis/cervical lymphadenopathy – Oral ABx
Flucloxacillin/Erythromycin (If allergy)

Question 57

Q

What is Malignant Otitis Externa?

Answer

A

Life threatening extension of Otitis externa into the mastoid & temporal bones
Due to Pseudomonas A. or Staph A
Affects elderly pts, those with DM/immunocompromised

Symptoms/Signs:

Pain + Headache (Severe)
Facial nerve palsy
Oedema/Exudate

Investigations:

CT to determine extent of involvement

Management:

Urgent referral to ENT
Oral + Topical treatment with quinolones for 6-8 weeks

Question 58

Q

What is a Cholesteatoma?

Answer

A

Collection of epidermal + connective tissues in the middle ear
Grows independently - Locally invasive + destructive

Can be:

Congenital – When squamous epithelium is trapped within the temporal bone during embryo development, expansion causes local damage
Primary acquired – Eustachian tube dysfunction causes TM to be sucked back and retracted leads to erosion of the TM epithelium and creates a pocket which can continue to erode
Secondary acquired – Due to perforation/trauma on the TM, squamous epithelium implanted and triggers growth + expansion

Question 59

Q

What are the symptoms/Signs of cholesteatoma?

Answer

A

Depend on the size of the growth
Small lesion – Progressive conducting hearing loss
Erosion – Vertigo/Headache/Facial nerve palsy
Otorrhoea + Hearing impairment
Total deafness + Impaired facial movement
Frequent unremitting painless otorrhoea - may be foul smelling
Recurrent otitis - unresponsive to ABx

Question 60

Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 37-year-old man presents with hearing loss and a painful intermittent purulent discharge from his right ear. He also reports intermittent dizziness, and tinnitus in the right ear. On otoscopy, he has an attic crust on his right tympanic membrane. Examination with an otomicroscope and micro-suctioning reveals keratin in an attic retraction pocket. An audiogram demonstrates a conductive hearing loss on the right side.

Answer

A

Cholesteatoma
Myringosclerosis – Thickening + calcification of TM secondary to inflammation
CSOM
Otitis externa
Benign Necrotising Otitis externa

Question 61

Q

A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?

A 12-year-old girl presents with a history of a recurrently discharging left ear for several months. She complains of an offensive discharge and hearing loss. She reports a previous history of grommet insertion. Otoscopy reveals a posterosuperior perforation of the tympanic membrane with a white keratin-like discharge. She has a conductive hearing loss on audiometry.

Answer

A

Cholesteatoma
Myringosclerosis – Thickening + calcification of TM secondary to inflammation
CSOM
Otitis externa
Benign Necrotising Otitis externa

Question 62

Q

A patient presents with the following Hx, suggestive of cholesteatoma. How would you investigate? How would you manage it?

A 12-year-old girl presents with a history of a recurrently discharging left ear for several months. She complains of an offensive discharge and hearing loss. She reports a previous history of grommet insertion. Otoscopy reveals a posterosuperior perforation of the tympanic membrane with a white keratin-like discharge. She has a conductive hearing loss on audiometry.

Answer

A

Investigations:

Ear examination
Hearing tests - Audiometry
CT imaging – Extent of lesion + bony defects
If soft tissue involvement possible – MRI

Management:

If surgery not possible:

Regular ear cleaning with treatment of infections

Surgery:

Remove the cholesteatoma – Tympanomastoidectomy/Tympanoplasty

Question 63

Q

What is Mastoiditis?

Answer

A

When supparative infection from the middle ear (OM) spread to the mastoid air cells
Causing inflammation of the mastoid & may lead to bony destruction
Rare complication of AOM
Can spread to cause meningitis/cerebral abscess
Typically caused by Strep Pneumoniae/Strep Pyogenes/Pseudomonas A

Question 64

Q

Who classically gets mastoiditis?

What are the symptoms/Signs?

Answer

A

More common in you children
Patients with immunocompromise or Cholesteatoma

Symptoms/Signs:

Hx of acute/recurrent AOM
Intense otalgia + pain behind the ear
Fever
Children – irritability/crying/feeding problems
Swelling redness/bogygy tender mass behind the ear
External ear may protrude forwards
May have ear discharge + Perforated eardrum
TM membrane bulges + erythematous
Patient is systemically well
Local neurological involvement – CN 5 or 7 plsy
May have conductive deafness

Answer 65

A

Investigations:

FBC – Increased WCC
ESR – Elevated
Blood cultures
Ear swabs if no perforation – Culture + Microscopy
CT ± MRI – to look for Intracranial spread
If intracranial spread suspected – LP

Management:

Referral to ENT in hospital
High dose IV ABx for at least 1-2 days
Oral ABx after this
Paracetamol ± Ibuprofen
Myringotomy ± Tympanostomy tube – if required
Mastoidectomy Immediately – if subperiosteal abscess formation/Intracranial extension/Cholesteatoma

Answer 66

A

Conductive/Sensorineural hearing loss
Labrynthitis
Osteomyelitis/bone erosion
Extension to local bone
Subperiosteal abscess – Abscess b/w periosteum and mastoid (Protruding ear)
CN palsy
Cerebral abscess/Meningitis/Subdural Empyema

Answer 67

A

Infection of the connective tissue of the ear (Auricle ± Pinna)
Requires immediate treatment as it can worsen into liquefying chondritis – disfigurement ± Loss of external ear

Causes:

Minor trauma/Burns/Ear piercing causing infection
Pseudomonas A/E.coli/Staph A are all common organisms that cause Perichondritis

Answer 68

A

Clinical diagnosis via:

Physical exam

Patient has:

Dull pain - gradually developing to severe otalgia
Purulent discharge
Erythema/Swelling
Tenderness of auricle
Lobule is unaffected (Otitis externa if affected)

Management:

ABx with anti-pseudomonal activity
Incission + drainage by ENT if necrotic cartilage
Oral therapy with Ciprofloxacin

Answer 69

A

Traumatic collection of blood b/w the cartilage + Perichondrum (Source of blood supply)
Requires prompt treatment to prevent permanent deformity (Cauliflower ear)

Symptoms:

Otalgia
Swollen ear
Fluctuant collection

Management:

Asceptiv evaluation of haematoma + Compression (Prevent re-collection)

Answer 70

A

Most common congenital abnormality of the neck
Arise from persistent thyroglossal duct (Formed from descent of thyroid from foramen cecum to front of neck)
Can lead to sinuses/fistula/cysts
Most common cysts are Infrahyoid + Suprahyoid

Answer 71

A

Commonly <10yrs old but also seen in adults

Symptoms/Signs:

Fluctuant swelling in midline of neck
Moves up when tongue is protruded (Attached to the larynx)
Non-tender + Mobile
If infected may be tender

Associated with:

Dysphagia/Dysphonia
Fever/Increasing neck mass

Answer 72

A

Investigations:

Hx taking
Neck and lymph node examination
Thyroid examination - to distinguish if thyroid or thyroglossal
USS
CT Scan
TFTs – Normal

Management:

Surgical removal of the cyst

Answer 73

A

Contains dermal structures
Found in midline

Diagnosis + treatment:

Excision biopsy

Answer 74

A

Most commonly caused by inflammatory lymph nodes (Reactive

[History]

How long has the lump been present?
Is it painful?
Has it changed? If so, over what time frame?
Are there symptoms of recent infection of nearby structures (cough, cold, sore throat, earache, toothache, skin problems, head lice, bites)?
Has there been a fever?
Does eating affect the lump?
Is there pain on swallowing?
Is there any effect on voice?
Does the person smoke?
Is there a history of travel?
Is there a past history of cancer?

Are there red flag symptoms of systemic illness such as:

Night sweats.
Weight loss.
Unexplained bruising or bleeding.
Persistent fatigue.
Breathlessness

Examination

Examine the:

Anterior triangle (bordered by the midline, the body of the mandible and the anterior border of sternocleidomastoid).
Posterior triangle (bordered by the posterior border of sternocleidomastoid, the clavicle and the trapezius).
Midline.

Whether it is:

tender, hot, red, inflamed.
Consistency.
Size.
Mobility.
How deep the lump is: whether it is intradermal (suggesting sebaceous cyst with a central punctum, or a lipoma), subcutaneous or within deeper tissue.
Whether it is pulsatile.
Whether it is a solitary lump or if there is more than one.
Whether it moves on swallowing (thyroid, thyroglossal cysts).
Whether it moves when the person sticks out their tongue (thyroglossal cysts)

Examination of the skin of the head and neck for rashes, lesions or infection.

Examination of the ears, nose and throat.

Examination of the mouth - for malignancy, dental issues. If parotid disease is suspected, identify the orifice of parotid duct and palpate with the patient’s head tilted backwards.

Examination of the chest.

Examination for lymphadenopathy or organomegaly elsewhere.

Checking for compression of the airway or vasculature.

Taking note of general clues of systemic illness, such as jaundice, pallor, petechiae, bruising, excoriation

Answer 75

A

most common cause is reactive lymph nodes:
- Bacterial causes, such as beta haemolytic streptococci, staphylococcus aureus, tuberculosis and secondary syphilis.
- Viral causes, such as common viruses causing upper respiratory tract infections, Epstein-Barr virus (EBV), cytomegalovirus, HIV, herpes simplex virus
Non-infective causes, such as sarcoidosis and connective tissue disease
Malignant lymph nodes: leukaemia, lymphoma, metastases.
Infections of the skin: abscess, infected sebaceous cyst.
Lipomas and other benign tumours
Thyroid swelling

Answer 76

A

FBC and ESR (within 48 hours if generalised lymphadenopathy to exclude leukaemia).
TFTs.
Viral serology - eg, EBV, cytomegalovirus, toxoplasmosis.
Throat swab.
CXR (within two weeks for supraclavicular lymph node swelling or persistent cervical node in a person over 40 years old)
Endoscopy
Ultrasound scan - for thyroid swellings and as a first-line imaging option where diagnosis is unclear, with or without a view to ultrasound-guided fine-needle aspiration biopsy.
Radionucleotide scanning (if masses of parathyroid or thyroid glands).
CT or MRI scan.
Any new neck mass persisting beyond six weeks should be referred

Answer 77

A

The person has lost weight.
There is associated hoarseness, difficulty swallowing (dysphagia), or dyspnoea for three weeks or more.
There has been haemoptysis.
There are associated symptoms suggestive of lymphoma (weight loss, night sweats, fever, breathlessness, pruritus or bleeding)
An unexplained enlarged lymph node is persistent.

Answer 78

A

Squamous cell carcinoma

Such as:

Oral cavity cancer
Cancers of the pharynx
Larynx
Salivary gland

Answer 79

A

Smoking
Alcohol
Poor diet
HPV 16 – Oral/Pharyngeal/Laryngeal cancer

Answer 80

A

Inflammation of the palatine tonsils due to infection

Typically caused by:

Rhinovrisu/Coronavirus/Adenovirus (Most common)
EBV – Infectious Mononucleosis
Beta haemolytic streotococci/Grou A strep

Answer 81

A

Common condition in children + young adults
Pts with immunodeficiency
FHx of tonsillitis/atopy

Symptoms/Signs:

Pain in throat
Pain on swallowing
May have referred otalgia
Headache
Loss of voice or voice change
Erythema at back of throat
Swollen - may be coated with pus (White/Yellow)
Fever
Cervical lymphadenopathy

Answer 82

A

Tonsillitis
Coryza
Infectious Mononucleosis
Epiglottitis – Emergency
If unilateral enlargement – Malignancy

Answer 83

A

Hepatosplenomegaly
Sexual activity/Kissing/Contact with infected person
Cervical/generalised lymphadenopathy
Fever
Pharyngitis

Answer 84

A

Infectious mononucleosis
Tonsillitis
Coryza
Epiglottitis
Malignancy

Answer 85

A

Investigations:

CENTOR Criteria to determine if viral or bacterial:
- No cough
- Tender Cervical lymphadenopathy
- Fever
- Exudate O/E

Management:

Urgent referral to A&E if:

Breathing difficulty/Dehydration/Peritonsillar abscess

If >3 CENTOR criteria:

Avoid social contact due to risk of spread
Self limiting condition
Paracetamol ± Ibuprofen
ABx – Phenoxymethylpenicillin 5-10 days
- If allergy – Clarithromycin/Erythromycin 10 days

If <3 criteria:

Avoid social contact due to risk of spread
Self limiting condition
Paracetamol ± Ibuprofen
Watchful wait for 3-5 days for resolution or symptom change:
If no resolution then ABx

May require - Tonsillectomy if recurrent

Answer 86

A

Investigations:

Abdominal exam – Hepatosplenomegaly
FBC – Increased WCC
EBV specific antibodies – Positive
PCR – Positive

Management:

Paracetamol ± Ibuprofen
Refrain from physical activity and contact sports for 8 weeks after (Risk of splenic rupture)
Prednisolone if breathing diffiulty due to obstruction

Answer 87

A

Complication of acute tonsillitis or Infectious mononucleosis
Pus becomes trapped between the tonsillar capsule + lateral pharyngeal wall
Can arise w/o prior tonsillitis

Answer 88

A

Severe throat pain which may become unilateral.
Fever.
Drooling of saliva.
Foul-smelling breath.
Swallowing may be painful.
Trismus (difficulty opening the mouth).
Altered voice quality (‘hot potato voice’) due to pharyngeal oedema and trismus.
Earache on the affected side.
Neck stiffness symptoms.
Headache and general malaise

O/E:

Breath is fetid.
There may be drooling and salivation
Tender, enlarged ipsilateral cervical lymph nodes
unilateral bulging, usually above and lateral to one of the tonsils; occasionally the bulging is inferiorly.
There is medial or anterior shift of the affected tonsil and the tonsil may be erythematous, enlarged and covered in exudate
Displaced uvula

Answer 89

A

Investigations:

Throat examination
Clinical diagnosis

Management:

Urgent referral to ENT
IV fluids - correct dehydration
Paracetamol ± Ibuprofen
IV ABx:
- Benzylpenicillin + Metronidazole
Needle aspiration + Incision + drainage

Answer 90

A

Chromosomal abnormalities
Diseases related to prenatal infection
Maternal drug use
Environmental factors
Iatrogenic causes

Answer 91

A

Absence of external nose + Nasal cavity + Olfactory system
- v. rare
Evident at birth
Associated with Trisomy 9
Requires surgical repair

Answer 92

A

Prescence of bony septum b/w nose - pharynx
Most common nasal congenital abnormality
Females > Males
Can be lethal if bilateral
Confirm diagnosis via CT Scan
Treated with surgery

Answer 93

A

Investigation:

Examination of the nose:
- If Rhinorrhoea with CSF leakage or epistaxis
- Septal deviation/malposition
- Any facial # or injury
- Opthalmoplegia

Management:

Refer to ENT if:
- Marked deviation in septum
- Epistaxis that doesnt settle
- CSF leakage - via cribiform plate
CT scan + Referral to neurosurgery
Facial anaesthesia – Immediate referral to maxfax
ICE + Paracetamol + Ibuprofen
Review in 5 days

Answer 94

A

Investigation:

Refer to ENT if:

Hx of prolonged unilateral nasal discharge
Foreign body is in posterior position
Patient is uncooperative/agitated

Management:

Topical anaesthetic + vasocontrictor spray in affected nostril
Blow positive pressure - Patient closing off opposite nostril and you blow sharply into childs mouth
Use nasal speculum + hook or thin forceps to remove object
Balloon catheter past FB, inflate and remove catheter to bring FB with it

Answer 95

A

Defect through any portion of the cartilaginous or bony septum

Causes:

Traumatic/Nose picking
Septal surgery/inflammation
Infection
Cocaine sniffing

Symptoms/Signs:

Nasal whistling sound
Discharge from nose
Nasal congestion
Infection – Cellulitis/fever/discharge
Epistaxis

Management:

Endoscope to visualise the perforation
Nasal douching + saline – Keep mucosa moist
Nasal emollients to inside of nose before bedtime
Surgical closure only if severe QoL impact

Answer 96

A

profuse chronic watery rhinorrhoea which is not allergic

encompassing a number of conditions:
- Vasomotor rhinitis.
- Occupational rhinitis.
- Hormonal rhinitis.
- Drug-induced rhinitis.
- Non-allergic rhinitis with eosinophilia syndrome (NARES)

Answer 97

A

very common condition in adults
Associated with – Asthma/Nasal polyps/Otitis media/Sinusitis

Symptoms/Signs:

rhinorrhoea
sneezing
itchy nose
nasal congestion
acute rhinosinusitis by causing blockage of intranasal passages

Answer 98

A

excessive vascular engorgement of the nasal mucosa and profuse, watery rhinorrhoea
triggered by chemical irritants, changes in weather, excess humidity or a very dry atmosphere, and stress
nasal mucosa can vary in colour from bright red to purple. Symptoms are usually intermittent

Management:

Topical antihistamines are the usual first-line medical treatment

Answer 99

A

Symptoms occur only in the workplace
Common inhaled irritants which trigger the condition include metal salts, animal dander, latex, wood dust and chemicals

Management:

Avoidance of the trigger irritant is the ideal treatment but cannot always be achieved in reality.
Nasal corticosteroids and second-generation antihistamines

Answer 100

A

Rhinorrhoea and nasal congestion are the principal symptoms
linked to increases in oestrogen levels
pregnancy, menstruation and puberty

Management:

Pregnant patients may present with vasomotor rhinitis and may benefit from nasal saline solution, exercise and topical pseudoephedrine.
Hormonal contraceptives might protect young women from allergies including rhinitis

Answer 101

A

eosinophilic inflammation of the nasal mucosa, without evidence of an allergy or other nasal pathologies
symptoms are rhinorrhoea, sneezing, nasal pruritus and hyposmia

Management:

Steroid nasal sprays are useful, as they appear to have a direct action on eosinophils, preventing the activation of the allergic cascade which leads to inflammation

Answer 102

A

Seasonal allergic rhinitis/hay fever: this occurs at certain times of the year. When due to tree pollen or grass it is known as hay fever. Other allergens include mould spores and weeds.
Perennial rhinitis (persistent): this occurs throughout the year. Allergens commonly include house dust mites and domestic pets.
Occupational rhinitis: symptoms occur due to exposure to allergens at work (eg, flour, wood dust, latex gloves)

Pathology:

immunoglobulin E (IgE)-mediated inflammation of the nasal mucosa following exposure to allergens.
This gives rise to a release of preformed mediators (of which histamine appears to be the most important) and chemotactic factors from the mast cells in the nasal mucosa

Answer 103

A

common problem
School-aged children and adolescents are more likely to have seasonal allergic rhinitis, whereas adults tend to have persistent allergic rhinitis
FHx of atopy or rhinitis

Symptoms/Signs:

Seasonal rhinitis tends to occur in the spring or summer
occupational symptoms will be worse at work, improving on days off or during holidays
Sneezing.
Rhinorrhoea and nasal congestion
anterior or posterior, leading to postnasal drip.
Clear - infection unlikely
Itchy nose and/or palate.
Symptoms tend to be bilateral, and worse on waking.
Usually associated symptoms in the eyes, with watering, itching, redness or swelling
nasal mucosa looks swollen and greyish
eyes for signs of conjunctivitis

Answer 104

A

Non-allergic rhinitis
Allergic rhinitis
Nasal polyposis
Deviated septum
Foreign body

Answer 105

A

Allergic rhinitis
Non-allergic rhinitis.
Infective rhinitis.
Nasal polyps.
Sinusitis.
Adenoidal hypertrophy.
Cystic fibrosis

Answer 106

A

Investigations

History and examination should be sufficient to make the diagnosis
allergy testing may be helpful

Management

education, allergy avoidance, antihistamines and topical steroids
Topical nasal antihistamines
Oral antihistamines – Once-daily, non-sedating antihistamines such as cetirizine, loratadine or fexofenadine are recommended
Topical intranasal steroids

Answer 107

A

lesions arising from the nasal mucosa
part of the spectrum of chronic rhinosinusitis
If they occur in children, cystic fibrosis testing is merited
Associated with: Asthma/Aspirin sensitivity/Cystic fibrosis/Churg Strauss

Answer 108

A

Male > Females

Symptoms/Signs:

history of recurring acute or chronic sinusitis
Symptoms depend on the size of the polyp (small polyps may be asymptomatic)
Nasal airway obstruction.
Nasal discharge:
- Watery anterior rhinorrhoea, sneezing, postnasal drainage.
- Green secretions suggest infection due to a polyp blocking the sinus ostia
- Unilateral, blood-tinged secretion suggests a tumour
Dull headaches.
Snoring and obstructive sleep symptoms.
Hyposmia or anosmia (decreased smell) and reduced taste

Answer 109

A

Nasal polyps
Foreign body - particularly if there is unilateral, blood-tinged discharge in young children.
Chronic rhinosinusitis without polyps.
Sinusitis.
Allergic fungal rhinosinusitis.
Tumours, benign and malignant – if unilateral

Answer 110

A

Investigations

Rigid or flexible endoscopy (rhinoscopy) carried out by specialists - this allows localisation and determination of the extent of the polyps

Management:

Unilateral polyps may be a sign of malignancy and should always be referred to ENT
Medical management is first-line, unless the nature of the polyp is uncertain
Topical corticosteroids – Fluticasone, mometasone and budesonide
Surgery if refractory to treatment

Answer 111

A

inflammation of the membranous lining of one or more of the sinuses
Viral disease is said to last less than 10 days, whereas worsening symptoms after 5 days or symptoms extending beyond 10 days suggest bacterial infection

Acute: an infection lasting 7-30 days

Chronic: symptoms persist for >90 days (these may be caused by irreversible changes in the mucosal lining of the sinuses), with or without acute exacerbations

Answer 112

A

Palpation for tenderness
Percussion for dullness
Transillumination

Answer 113

A

tends to arise as a result of a viral infection and a diagnosis of acute sinusitis is made if there is sinus drainage obstruction and subsequent secondary bacterial infection
most commonly caused by Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis
*

Answer 114

A

Symptoms/signs:

non-resolving cold (>1 week or worsening symptoms over 4-5 days)
Facial discomfort (eg, a feeling of congestion or fullness, often unilateral and worse when bending forwards) or pain
Nasal obstruction or (purulent) nasal discharge or postnasal drip
pyrexia, purulent nasal discharge ± decreased or absent smell
pain on palpation of the sinuses.
Erythema and oedema of the nasal mucosa may also be found
Headache.
Halitosis.
Fatigue.
Dental pain.
Cough.
A feeling of pressure or fullness in the ears.

Investigations:

Clinical diagnosis

Management:

Most patients can be reassured that this is generally a viral infection similar to a cold but which takes a little longer to resolve (about 2.5 weeks)
Paracetamol/ibuprofen for pain/fever.
Intranasal decongestant
Adequate fluids and rest
Antibiotics are reserved for severe or prolonged infections (>5 days) – amoxicillin/doxycycline/clarithromycin
If chronic sinusitis – Beclometasone 50 micrograms nasal spray (two sprays per nostril twice a day)

Answer 115

A

Nose bleeding usually when nasal mucosa is eroded and vessels are exposed and break
Due to trauma or Malignancy/Tumour

Can either be Anterior/Posterior

Anterior haemorrhage:

Source of bleeding visible
From nasal septum (Kiesselbachs plexus)

Posterior haemorrhage:

More common in older people
More profuse + Increased risk of airway compromise

Answer 116

A

Internal Carotid artery + External Carotid artery

Internal:

Anterior ethmoid artery
Posterior ethmoid artery

External:

Sphenopalatine artery
Branch of internal maxillary artery

Answer 117

A

Trauma to the nose - most common e.g. nose picking/insertion of foreign body/Excess nose blowing
Disorders of platelet function – Thrombocytopenia/Splenomegaly/ITP
Drugs – Aspirin/Anticoagulants
Hereditary haemorrhagic telangectasia
Malignancy of the nose
Cocaine abuse
Wegeners granulomatosis

Answer 118

A

Blood running out of nose + one nostril – Anterior
Blood running into the throat from both nostrils – Posterior
Hx of trauma to the nose/Malignancy
FHx of clotting disorders/HTN
DHx of warfarin/Aspirin/Clopidogrel use
Rule out nasopharyngeal tumour – Facial pain + Otalgia + Young male pt
Juvenile nasopharyngeal angiofibroma – Nasal obstruction + headache + rhinorrhea + anosmia

Answer 119

A

Epistaxis
Haemoptysis
Haematemesis

Answer 120

A

Epistaxis - Posterior
Haemoptysis
Haematemesis

Answer 121

A

Investigations:

If mild:

None required

If recurrent/Severe:

Referral to ENT
FBC
Coagulation studies
Blood type

If suspected malignancy:

Referral to ENT
CT scan

Management:

ABCDE assesment
Monitor BP + Pulse
If bleeding stopped – Inspect with nasal speculum
Ice pack + pressure on bridge of nose for 20mins – Sit upright + lean slightly forward + breathe through mouth
Nose packing
Silver nitrate cautery/Electrocautery after bleeding has stopped
Nasopharyngoscopy