ENT

Question 1

Symptoms of ear disorders

Answer 1

Otalgia
Otorrhoea
Dizziness
Hearing loss
Tinnitus
Injury to the ear
Deformity of the ear

Question 2

Symptoms of ear disorders: otalgia

Answer 2

SOCRATES.
Ask about discharge, hearing loss, previous ear operations, or ear syringing, use of cotton buds, trauma, swimming, and air travel.
Pain may be referred from several other areas- the ear has a sensory supply from cranial nerves V, IX, X, and the 2nd and 3rd cervical nerves.

Question 3

Symptoms of ear disorders: otalgia, otological causes

Answer 3

Acute otitis externa
Acute otitis media
Perichondritis
Furunculosis
Trauma
Neoplasm
Herpes zoster (Ramsey Hunt syndrome)

Question 4

Symptoms of ear disorders: otalgia, non-otological causes

Answer 4

Cervical spine disease
Tonsillitis
Dental disease
Temporo-mandibular joint disease
Neoplasms of the pharynx or larynx

Question 5

Symptoms of ear disorders: otorrhoea

Answer 5

This is discharge from the external auditory meatus.
Ask about other ear symptoms, when the discharge began, and any precipitating or exacerbating factors.
Ask especially about the nature of the discharge.
Watery: eczema, CSF.
Purulent: acute otitis externa.
Mucoid: chronic suppurative otitis media with perforation.
Mucopurulent/blood-stained: trauma, acute otitis media, cancer.
Foul-smelling: chronic suppurative otitis media ± cholesteatoma.

Question 6

Symptoms of ear disorders: dizziness

Answer 6

The term ‘dizziness’ can mean different things to different people and must be distinguished from light-headedness, pre-syncope, and pure unsteadiness.
2 features of dizziness suggest that it arises from the vestibular system: vertigo (hallucination of movement, most commonly rotational) and dizziness related to movement or position change.
Both these symptoms can occur together, separately in time, or alone in different people.
Disequilibrium (unsteadiness or veering) may accompany vestibular dizziness.
Nature and severity of dizziness?
Is it persistent or intermittent ‘attacks’?
Duration of attacks- seconds, hours, days?
Pattern of events since onset?
Relation to movement or position? especially lying down.
Associated symptoms? e.g. nausea, vomiting, hearing change, tinnitus, headaches.
DHx including alcohol.
Other ear problems or previous ear surgery?

Question 7

Symptoms of ear disorders: dizziness, peripheral vestibular lesions

Answer 7

Vertigo caused by vestibular problems is most commonly rotational, but may be swaying or tilting.
Whether it is movement of the person or surroundings is irrelevant.
Any rapid head movement may provoke the dizziness, but dizziness provoked by lying down, rolling over, or sitting up is specific to benign paroxysmal positional vertigo.

Question 8

Symptoms of ear disorders: dizziness, central vestibular disorders

Answer 8

These are not always easy to distinguish on the history but vertigo is not so marked and gait disturbance and other neurological symptoms and signs would suggest this.

Question 9

Symptoms of ear disorders: dizziness, otological causes

Answer 9

Benign paroxysmal positional vertigo.
Méniere's disease.
Vestibular neuronitis.
Trauma (surgery or temporal bone fracture).
Perilymph fistula.
Middle ear infection.
Otosclerosis.
Syphilis.
Ototoxic drugs.
Acoustic neuromas.

Question 10

Symptoms of ear disorders: dizziness, non-otological causes

Answer 10

These are often more disequilibrium than dizziness.
Ageing (poor eyesight and proprioception).
Cerebrovascular disease.
Parkinson’s disease.
Migraine.
Epilepsy.
Demyelinating disorders.
Hyperventilation.
Drugs, e.g. cardiovascular, neuroleptic drugs, and alcohol).

Question 11

Symptoms of ear disorders: hearing loss

Answer 11

Deafness or total hearing loss is unusual.
Hearing loss is usually described as being mild, moderate, or profound.
Hearing loss may be conductive, sensorineural, mixed, or non-organic.
Conductive hearing loss may be due to pathology of the ear canal, eardrum, or middle ear.
Sensorineural hearing loss is caused by disease in the cochlea or the neural pathway to the brain.
Time and speed of onset?
Is it partial or complete?
Are bot ears affected or just one?
Is there associated pain, discharge, or vertigo?
PMH: especially TB and septicaemia.
FHx: hearing loss may be inherited, e.g. otosclerosis.
DHx: certain drugs, particularly those which are toxic to the renal system, affect the ear (e.g. aminoglycosides, some diuretics, cytotoxic agents), salicylates are and quinine show reversible toxicity.
SHx: occupation and leisure activities should not be overlooked- prolonged exposure to loud nose, e.g. heavy industrial machinery, can lead to sensorineural hearing loss.

Question 12

Symptoms of ear disorders: hearing loss, conductive causes

Answer 12

Wax.
Otitis externa, if ear is full of debris.
Middle ear effusion.
Trauma to ossicles.
Otosclerosis.
Chronic middle ear infection (current or previous).
Tumours of the middle ear.

Question 13

Symptoms of ear disorders: hearing loss, sensorineural causes

Answer 13

Presbyacusis.
Vascular ischaemia.
Noise exposure.
Inflammatory/infectious diseases, e.g. measles, mumps, meningitis, syphilis.
Ototoxicity.
Acoustic tumours (progressive unilateral hearing loss, but may be bilateral).

Question 14

Symptoms of ear disorders: tinnitus

Answer 14

Character of tinnitus?
Associated hearing loss?
How the tinnitus bothers them, i.e. is sleep or daily living affected?
Previous history of ear disease?
Rushing, hissing, or buzzing: commonest tinnitus, usually associated with hearing loss, caused by pathology in the inner ear, brainstem, or auditory cortex.
Pulsatile tinnitus: caused by noise transmitted from blood vessels close to the ear, including internal carotid artery and internal jugular vein.
Cracking and popping: dysfunction of Eustachian tube or rhythmic myoclonus of the muscles in the middle ear or attached to Eustachian tube.

Question 15

Symptoms of ear disorders: tinnitus, causes

Answer 15

Presbyacusis.
Noise-induced hearing loss.
Méniere's disease.
Ototoxic drugs, trauma.
Any cause of conductive hearing loss.
Acoustic neuromas.

Question 16

Symptoms of ear disorders: pulsatile tinnitus, causes

Answer 16

Arterial aneurysms.

Arteriovenous malformations.

Question 17

Symptoms of ear disorders: injury to the ear

Answer 17

Trauma may be self-inflicted, especially in children, when foreign bodies inserted in the ear can damage the meatal skin or the eardrum.
Head injuries can cause temporal bone fractures, with bleeding from the ear and may be associated with dislocation of the ossicles, or may involve the labyrinth causing severe vertigo and complete deafness.
Temporary or permanent facial nerve palsy may also occur.

Question 18

Symptoms of ear disorders: deformity of the ear

Answer 18

This may be either congenital or acquired (usually traumatic).
Complete or partial absence of the pinna (anorexia or microtia), accessory auricles (anterior to the tragus), or a pre-auricular sinus.
Protruding ears may cause social embarrassment and can be surgically corrected.
Small auricles are seen in Down’s syndrome- often with a rudimentary or absent lobule.

Question 19

Symptoms of nasal disorders

Answer 19

Nasal obstruction
Nasal discharge
Epistaxis
Sneezing
Disorders of smell
Nasal deformity
Nasal and facial pain

Question 20

Symptoms of nasal disorders: nasal obstruction

Answer 20

Is the nose blocked constantly or intermittently?- constant = long-standing structural deformity such as deviated septum, nasal polyps, or enlarge turbinates; intermittent = allergic rhinitis or common cold.
Unilateral or bilateral obstruction?
Associated nasal discharge?
Relieving or exacerbating factors?
Use of nose drops or any other per-nasal substance, e.g. glue-sniffing or drug-snorting?
Previous nasal surgery?

Question 21

Symptoms of nasal disorders: epistaxis

Answer 21

This is a nasal haemorrhage or ‘nose bleed’.
The anterior septum, ‘Little’s area’, is the point of convergence of the anterior ethmoidal artery, the septal branches of the sphenopalatine and superior labial arteries, and greater palatine artery. A common site of bleeding.
Epistaxis is most commonly due to spontaneous rupture of blood vessel in the nasal mucous membrane.
Explore possible causes.
Distinguish between anterior bleed (blood running out of the nose, usually one nostril) and posterior bleed (blood running in the throat or from both nostrils).

Question 22

Symptoms of nasal disorders: sneezing

Answer 22

Sneezing is a very frequent accompaniment to viral upper respiratory tract infection and allergic rhinitis.
Commonly associated with rhinorrhoea and itching of the nose and eyes.
Ask about exacerbating factors and explore the timeline carefully, looking for precipitants.

Question 23

Symptoms of nasal disorders: disorders of smell

Answer 23

Patients may complain of reduced sense of smell (hyposmia) or, more rarely, a total loss of smell (anosmia).
Ask about the exact timing of the hyposmia and any other associated nasal symptoms,
Anosmia: most commonly caused by nasal polyps but may be caused by ear injury disrupting the olfactory fibres emerging through the cribriform plate; may also complicate a viral upper respiratory tract infection (viral neuropathy).
Cacosmia: the hallucination of an unpleasant smell and may be caused by infection interfering with the olfactory structures.

Question 24

Symptoms of nasal disorders: nasal deformity

Answer 24

May occur as a result of trauma causing pain ± swelling ± epistaxis ± displacement of nasal bones and septum.
Disruption of the bones and nasal septum may produce a ‘saddle’ deformity.
Wegener’s granulomatosis, congenital syphilis, and long term cocaine snorting also cause saddle deformity.
Acne rosacea can cause an enlarge, red, and bulbous rhinophyma.
Widening of the nose is an early feature of acromegaly.

Question 25

Symptoms of nasal disorders: nasal and facial pain

Answer 25

Facial pain is not normally due to local nasal causes.
More frequently it is related to infection within the sinuses, trigeminal neuralgia, dental sepsis, migraine, or mid-facial tension pain.

Question 26

Causes of watery/mucosal nasal discharge

Answer 26

Allergic rhinitis
Infective (viral) rhinitis
Vasomotor rhinitis
A unilateral copious eatery discharge may be due to CSF rhinorrhoea.

Question 27

Causes of purulent nasal discharge

Answer 27

Infective rhinosinusitis
Foreign body (esp. unilateral)

Question 28

Causes of blood stained nasal discharge

Answer 28

Tumours (with unilateral symptoms)
Bleeding diathesis
Trauma

Question 29

Causes of epistaxis

Answer 29

Trauma from nose picking, nasal surgery, cocaine use, or infection.
Prolonged bleeding may be caused by hypertension, alcohol, anticoagulants, coagulation defects, Waldenström’s macroglobulinaemia, Wegener’s granulomatosis, and hereditary telangiectasia.
Neoplasia and angiomas of the postnasal space and nose may present with epistaxis.

Question 30

Symptoms of throat disorders

Answer 30

Oral pain
Throat pain
Lumps in the mouth
Globus pharyngeus
Lumps in the neck
Dysphonia
Halitosis
Stridor

Question 31

Symptoms of throat disorders: oral pain

Answer 31

The commonest cause of pain in the oral cavity is dental caries and periodontal infection.
Periodontal disease can cause pain on tooth-brushing and is associated with halitosis.
Gum disease is a common cause of oral pain.
In elderly patients, dentures may cause pain if improperly sized or if they produce an abnormal bite.
SOCRATES and other mouth/throat symptoms?

Question 32

Symptoms of throat disorders: throat pain

Answer 32

A sore throat is an extremely common symptom.
SOCRATES.
Throat pain often radiates to the ear because the pharynx and external auditory meatus are innervated by the vagus nerve CNX.
Most acute sore throats are viral in origin and are associated with rhinorrhoea and a productive cough- consider infectious mononucleosis in teenagers.
Acute tonsillitis is associated with systemic symptoms such as malaise, fever, and anorexia.
Consider malignancy in all chronically sore throats in adults- also ask about dysphagia, dysphonia, weight loss, smoking history or excessive alcohol.

Question 33

Symptoms of throat disorders: lumps in the mouth

Answer 33

Lips: localised malignancy e.g. BCC, SCC.
Tongue: nearly always neoplastic.
Oral cavity: ranula (cystic lesion on floor of mouth caused by blocked salivary gland); malignancy presents late on floor of mouth or buccal lining.

Question 34

Symptoms of throat disorders: globus pharyngeus

Answer 34

Sensation of a lump in the throat.
Symptoms of GORD or postnasal drip?
Malignancy- dysphagia, odynophagia, hoarseness, weight loss?

Question 35

Symptoms of throat disorders: lumps in the neck

Answer 35

Neck lumps are usually secondary to infection but a minority are due to malignant disease.
The most common cause of neck swelling is lymph node enlargement.
Metastatic neck disease may represent spread from structures below the clavicle including lung, breast, stomach, pancreas, kidney, prostate and uterus.
Duration of swelling?
Progression in size?
Associated pain or other symptoms in upper aerodigestive tract- odynophagia, dysphagia, dysphonia?
Systemic symptoms- weight loss, night sweats, malaise?
Smoking and alcohol habits?

Question 36

Symptoms of throat disorders: dysphonia

Answer 36

Alteration in quality of voice.
Inflammatory: acute laryngitis, chronic laryngitis (chronic vocal abuse, alcohol, smoke inhalation).
Neurological, central: pseudobulbar palsy, cerebral palsy, multiple sclerosis, stroke, Guillain-Barré syndrome, head injury.
Neurological, peripheral: lesions affecting X and recurrent laryngeal nerves (e.g. lung cancer, post-thyroidectomy, cardiothoracic and oesophageal surgery), myasthenia gravis, motor neuron disease.
Neoplastic: e.g. laryngeal cancer.
Systemic: rheumatoid arthritis, angiogenic oedema, hypothyroidism.
Psychogenic: underlying anxiety or depression.

Question 37

Symptoms of throat disorders: halitosis

Answer 37

This is offensive-smelling breath.
Commonly caused by poor dental hygiene or diet.
Tonsillar infection, gingivitis, pharyngeal pouch, and chronic sinusitis with purulent postnasal drip can also cause bad breath.

Question 38

Symptoms of throat disorders: stridor

Answer 38

Noise from the upper airway, caused by narrowing of the trachea or larynx.
Main causes are laryngeal cancer, laryngeal trauma, epiglottitis, and cancer of the trachea or main bronchus.

Question 39

Examining the ear: inspection and palpation

Answer 39

Briefly inspect the external structures of the ear, paying particular attention to the pinna, noting its shape, size, and any deformity.
Carefully inspect for any skin changes suggestive of cancer.
Don’t forget to look behind the ears for any scars or a hearing aid.
Pull on the pinna and ask the patient if it is painful- infection of the auditory meatus.
Palpate the area in front of the tragus and ask if there is any pain- temporomandibular joint disease.
Look for any discharge.

Question 40

Examining the ear: otoscope, technique

Answer 40

Introduce yourself and clean your hands.
Explain the procedure to the patient and obtain verbal consent.
Turn the light source on.
Place a clean speculum on the end of the scope.
Gently pull the pinna upwards and backwards with your left hand to straighten out the cartilaginous part of the canal, allowing easier passage of the scope.
Holding the otoscope in your right hand, place the tip of the speculum in the opening of the external canal, under direct vision before looking through the viewing window.
Slowly advance the otoscope whilst looking through it, stabilise by putting your little finger on the patient’s head.
Inspect the skin of the auditory canal for signs of infection, wax, and foreign bodies.
Examine the tympanic membrane. A healthy eardrum should appear greyish and translucent. Look for light reflex- the reflection off the surface of the drum visible just below the malleus. Notice any white patches (tympanosclerosis) or perforation. A reddened, bulging drum is a sign of acute otitis media. A dull grey, yellow drum may indicate middle ear fluid.