ENT Flashcards
I’ve been told I was going deaf…
It was very difficult to hear
Ok I’ll stop…
These jokes are too ear-itating
Back to the flash cards…
Ear we go!
What symptoms are related to the nose?
Obstruction Rhinorrhoea Hyposmia Epistaxis Facial pain
-also sneeze, post nasal drip
What symptom are related to the ear?
Earache Ear discharge Hearing loss Tinnitus Dizziness
What symptoms are related to the throat?
Dysphagia Odynophasia Hoarseness Sore throat Regurgitation
What can cause otalgia not in the ear?
Pharynx
Dental infections
TMJ
What differential are there for otorrhoea?
Acute otitis externa
Cholestoma
Impacted wax
Acute otitis media -rarer
RF for otitis externa?
Skin conditions
instrument insertion or water into canal
Wha tis first line for otitis externa?
Oral analgesia
keep ear dry
swab ear
Topical abs + steroid
What complications are there of otitis externa
Osteomyelitis
Canal stenosis
Ear drum perforation management.
Conservative - 6w wait until referral to ENT
Medical - Topical Abx if infection
Surgical - myringoplasty
What are the symptoms of a cholesteoma?
Discharge
Otalgia
Conductive hearing loss
Off balance
What is glomus jugular?
A paragangioma - a benign growing tumour
How should a cholestoma be investigated?
Microscopy
Treat infection
Pure tone audiogram
What imaging is used for planning ENT surgery?
Usually CT over MRI
What surgical treatment is there for cholestoma?
Mastoidectomy
Red flag symptoms for H&N cancers?
6w hx of hoarsenes
3w hx of swelling, dysphagia, nasal obstruction, neck mass
What to ask with a dysphonia?
Smoking
Alchohol
Infection - EBV, HPV
GORD
What features of a thyroid lump would suggest a malignancy?
Child
Red flags - hoarseness, stridor
Rapidly enlarging mass and cervicle lymph nodes
What happens to TFT with a thyroid malignancy?
TFTs are usually normal
What is the most common type of thyroid cancer?
Papillary carcinoma
What must be explained in order for a patient to give consent to a procedure?
Explanation of procedure
Intended benefits
Risks
Alternative treatment
What can cause enlarged turbinates with inflammation on nasal examination?
GPA
Chronic rhinosinusitis without polyps
Sarcoidosis
What investigations should be done for Chronic rhinosinusitis?
RAST testing for allergies
How is rhinosinusitis treated
Topical nasal steroid + saline nasal irrigation.
Antihistamine with allergy
How are nasal polyps treated?
Medical - Topical and oral steroids
Surgical - if recurrent
Questions about neck lumps
DurationChange in sizeAssociated features- pain, redness, dischargeLumps elsewhere Preceding symptoms Recent travel esp TBoccupation Cat scratch Radiation exposure Red flags- persistent sore throat, hoarseness, dysphagia, odynophagia, Weight Loss, fevers, night sweatsSmoking Alcohol consumption HIV status Dental problems
Investigations of a neck lump
USS with fine needle aspiration CT can be useful
Red flags in neck lump
persistent sore throat, hoarseness, dysphagia, odynophagia, Weight Loss, fevers, night sweats
Elderly maleNeck lump for three months Increasing in sizePersistent sore throatChange in voice Heavy smoker Heavy drinker Next steps Diagnosis?
Do full exam Flexible nasopharynolaryngoscopy If lump going do USS and FNACDiscuss at MDTNeck cancer eg SCC mets
Risk factors for SCC if head and neck
Betel nut chewing Smoking HPVEBVAlcohol
Elderly man Hoarse voice
Head and neck cancerSpreading to larynx
Other questions to ask when hoarseness present
DysphagiaOdynophagiaWeight lossHeart burn or indigestion Post nasal drip Systemic upset
Urgent referral needed for throat when
Hoarseness for more than six weeksOral swellings for more than six weeks Dysphagia got more than three weeksUnresolving neck masses for more than three weeks Cranial neuropathiesOrbital masses
Causes of hoarseness
Overuse of larynx Acute laryngitisChronic laryngitis secondary to reflux Use of asthma inhalerSmokingSCC of larynx Vocal cord Palsy
Treat for SCC mets
Radiotherapy- multiple small doses, can be curative or palliativeSurgical resectionChemo- not curative but can be used to shrinkThen if unsuccessful look at palliative
Middle aged female. Non smoker. Neck lump. Differentials
Thyroid lump (follicular adenoma, hyperplastic nodules, thyroid cysts, malignancy- papillary carcinoma, follicular carcinoma, etc)GoitreThyroglossal cystCervical lymphadenopathy Dermoid cyst
Signs that thyroid lump seem more likely
Enlarged cervical lymph nodesUnexplained hoarsenessStridor- indicates narrowing of airwayRapidly enlarging painless massThyroid nodule in child
Key investigations for neck lumps
Ultrasound and FNACIf can we then need staging scans
Three broad categories for nasal Blockage
StructuralInflammatoryInfective
Nasal blockage questions
Both sides or just one How long has it felt blockedIntermittent or constantIs it ever clearAny trauma to nose recently or in pastPrevious nasal surgeryOther nasal symptoms- sneezing, rhinorrhoea, facial pain, post nasal drip, epistaxisWhat meds does pt take
If nasal blockage and history of trauma- what is wrong and next step?
Probably a deviated septum but still good to rule out the other causes as blockage may be mulitfactorial. If deviated septum that is symptomatic - septoplasty
Risks of septoplasty
The need for future surgeriesFailure to improve symptomsAltered appearanceSeptal perforationNumbness of upper teethAnosmia or hyposmia- rare and often transient Numbness of the noseBleeding and infection
Middle aged woman. Nasal obstruction. 15 year history of symptoms. Worse in past four months. Associated with sneezing and rhinorrhea. Asthma and eczema in HxFurther questions, further investigations and likely diagnosis
Worse at any time of yearSense of smellTried any medsAllergies?Examine the nose.Probably a chronic rhinosinusitis. With or without polyps as would need to scope to visualise
Further testing after a chronic rhinosinusitis diagnosis
Scope to look for polypsRAST testing to identify allergies and antigens through blood
Management of chronic rhinosinusitis
Saline nasal irrigation, antihistamines (only when clear evidence of allergies), advise to avoid allergens, topical nasal steroids
Lumps and bumps in the nose
PolypsSeptal haematoma Nasaopharyngeal carcinoma - typical unilateral symptoms Inferior turbinates
If suspecting polyps what is the next step
CT scan of sinuses if surgery required and need to see extent of diseaseShort course pred to shrink polyps and provide some relief of symptomsTopical nasal steroids
Purulant nasal discharge Nasal obstruction Facial pain and fullnessUp to four weeks of symptoms
Acute rhinosinusitis
Clear nasal discharge- what could it be
Viral rhinosinusitis secretions Allergic rhinosinusitis Could be CSF! Check for glucose. If glucose present then is CSF
Purulent discharge with other signs of rhinosinusitis- differential and treatment
Bacterial rhinosinusitis Treat with clarithromycin
Epistaxis - Questions to ask in history
Frequency DurationWhich side of noseIs blood dripping out or down throatHistory of previous bleeds including easy bruising Previous treatmentPMH- GPA, bleeding disorders, rhinitisDrug history- clopidogrel, warfarin, aspirinTrauma including digital trauma
Examination of nose in epistaxis
External nose for signs of trauma, surgery or deformities eg saddle nose deformitiesAnterior rhinoscopyPosterior rhinoscopy Use a Thuddicum’s speculum or an otoscope
Most likely source of epistaxis
Little’s area - highly vascular and quite exposed Kiesselbach’s plexus lies within little’s area
Treatment and advice for epistaxis
- Advise do not blow nose for a week, do not clean the nose, avoid hot baths, do not drink hot tea or coffee for 72 hours, no strenuous exercise for a week2. Naseptin ointment - reduces crusting in nose (contains peanuts so check allergies)3. Silver nitrate cautery 4. If epistaxis recurs then apply firm pressure for 15 minutes . If this fails go to A&E
Young male. Punched in face yesterday, initially stopped bleeding but started again. Prolonged episode and big clots evident. No meds. What do you do?
ABCDE!!!Get IV access for cannulationExamine the nose and get adequate protection as blood may spray. Suction may be used to visualise the area. If origin found then cauterise. If not then need to move on to nasal packing and admit to ENT and get help. Test- FBC, Coag profile, group and save
Factors that could cause epistaxis in adults
Trauma including digital traumaHTNCoagulopathiesMeds eg aspirin, warfarin, clopidogrelInflammation Rare- malignancy eg SCC.
Epistaxis in child- usual cause and next steps
Usually from Little’s area from digital trauma. Treat Using naseptin (check allergies) or bactroben. These have antibacterial properties Discourage digital trauma
