ENT Flashcards
colour and shape of right ear on audiometry
red
circles
colour and shape of left ear on audiometry
blue
crosses
bone conduction on audiometry
triangles
conductive hearing loss on audiometry
gap between air & bone conduction
sensorineural hearing loss on audiometry
NO gap between air an bone conduction
noise exposure audiometry
sensorineural hearing loss at high frequency
meniere’s disease audiometry
one sided low frequency sensorineural hearing loss
otosclerosis audiometry
conductive hearing loss with dip at 2KHz
Woman with cold, went on plane, now hearing loss, tympanic membrane intact
barotrauma
surfers ear
exostosis
Female who had permanent complete hearing loss in pregnancy - Dx?
otosclerosis
presentation OME
poor listening poor speech language delay inattention poor school work
signs of OME on otoscopy
variable - retracted or bulging drum
can be dull, grey or yellow in colour
Ix OME
audiometry (conductive deafness)
tympanometry (flat, type B)
Mx OME
- conservative - usually resolves in 3m
2. hearing aids or grommets
causes of conductive deafness
external canal obstruction
ear drum perforation (barotrauma, infection)
ossicular chain problems (otosclerosis, infection)
what is otosclerosis
replacement of bone by vascular spongy bone particularly at oval window
inheritance of otosclerosis
autosomal dominant
presentation otosclerosis
young woman conductive deafness tinnitus normal tympanic membrane \+ve FH
Mx otosclerosis
hearing aid
stapedectomy
causes of sensorineural deafness
otoxic drugs post-infection menieres presbycusis acoustic neuroma B12 deficiency
what is presbycusis
aged related sensorineural hearing loss due to accumulated environmental noise toxicity
presentation presbycusis
difficulty using telephone
difficulty following convo
tympanometry in OME
Flat (type B)
tympanometry in presbycusis
normal middle ear function with hearing loss (Type A)
causes of otitis externa
moisture (swimmers) narrow ear canal trauma absence of ear wax high humidity
organisms causing otitis externa
bacterial:
pseudomonas aeruginosa
staph aureus
fungal:
aspergillus niger
who gets fungal otitis externa
divers
who gets malignant otitis externa (++ aggressive)
diabetics
Mx malignant otitis externa
IV Abx +/- debridement
Mx otitis externa
topical Abx/steroid
- ciprofloxacin/dexamethasone
- if debris: aural toilet
- if severe swelling: insert wick, then Abx
Ix malignant otitis externa
CT
cause of otitis media
complication of resp viruses
- strep pneumoniae
- haemophilus influenze
- moraxella catarrhalis
travels up eustachian tube causing inflammation and effusion. complicated by bacteria
presentation otitis media
\+/- preceding URTI otalgia bulging tympanic membrane fever irritability
Mx otitis media
- analgesia + observe for a few days
2. delayed Abx: amoxicillin 500mg tds for 5d +/- clavulanate
when should abx Tx be given immediately in otitis media
symptoms lasting >4d and not improving systemically unwell immunocompromised <2y with bilateral otitis media perforation and/or discharge
cholesteatoma
presence of keratinising squamous epithelium in the middle ear that is locally destructive
causes of cholesteatoma
retraction of pars flaccida +/- atrophy of pars tensa, which traps epithelium that can then proliferate
migration of squamous epithelium through defect in tympanic membrane
risk factors for cholesteatoma
congenital conditions - cleft palate
prior ear surgery
middle ear disease
eustachian tube dysfunction
presentation cholesteatoma
foul otorrhoea
conductive hearing loss
tinnitus
crust of keratin in upper pocket of middle ear “attic crust”
Mx of cholesteatoma
referral to ENT for MRI and surgery
vestibular schwannoma
benign cerebellopontine angle tumour growing from vestibular schwann cell layer
bilateral vestibular schwannoma - Dx?
NF type 2
presentation vestibular schwannoma
intermittent dizziness
giddiness
facial numbness
unilateral sensorineural HL
Ix vestibular schwannoma
MRI
Mx vestibular schwannoma
any of:
- observation
- focussed radiation
- surgery
BPPV
attacks of vertigo lasts >30 secs that are provoked by head turning
cause of BPPV
displacement of calcium particles in the semicircular canals
presentation BPPV
vertigo lasts a few mins clear positional trigger no ass HL or tinnitus no aural fullness nausea/light-headedness
Ix BPPV
hallpike’s test
Mx BPPV
epley manoeuvre
meniere’s disease
dilation of the endolymphatic spaces of the membranous labyrinth
cause of menieres disease
unknown
presentation of meniere’s disease
vertigo lasting hours unilateral fluctuating sensorineural hearing loss tinnitus (roaring) aural fullness nystagmus
Ix menieres
endocochleography
endolymph MRI
Mx menieres
acute attacks - supportive (anti emetics - prochlorperazine)
if severe - intratympanic gentamicin
prevention - salt restriction, betahistine, vestibular rehab exercises
labyrinthitis
inflammation of the labyrinth in the cochlea and the vestibular system in the inner ear
causes of labyrinthitis
viral - preceding URTI most common
bacterial - complication of otitis media most common
presentation labyrinthitis
vertigo - days hearing loss no aural fullness n+v nystagmus
Ix labyrinthitis
clinical Dx
Mx labyrinthitis
supportive - vestibular suppressants
- diazepam
- lorazepam
- meclizine
vestibular neuronitis
inflammation of the vestibular nerve following viral illness
presentation vestibular neuronitis
vertigo lasting weeks no HL no tinnitus no aural fullness nystagmus
Mx vestibular neuronitis
supportive - vestibular suppressants
- diazepam
- lorazepam
- meclizine
pt who is has sudden onset headache and very dizzy, never had before - Dx?
vestibular migraine
Vertigo and tingling in arms especially on looking up (pinching blood supply at basilar arteries)
vertebrobasilar insufficiency
Sudden onset sensorineural hearing loss - Mx?
urgent referral to ENT and high dose steroids
presentation bells palsy
abrupt onset
dry/watering eyes
no motor movement of CNVII distribution on one half
mouth sagging
Mx bells palsy
prednisolone 1mg/kg for 10d - prescribe within 72h of onset
+ artifical tears
what must pts with bells palsy be advised to do
tape eyes shut at night bcos they cant blink
ramsay hunt syndrome
reactivation ofvaricella zoster in CNVII ganglion
presentation ramsay hunt
auricular pain CNVII palsy vesicular rash around ear vertigo tinnitus
Mx ramsay hunt
oral antivirals
Mx of perforated tympanic membrane that has failed to heal within 6-8w
myringoplasty
pain on eating - who to refer to
dentist
sub-types of allergic rhinitis
seasonal/intermittent i.e. hayfever
- grass, flow, tree pollen
persistent/perennial
- house dust mites, cats, dogs
single crease on nose is a sign of -?
allergy (allergic rhinitis) from constant rubbing nose
Ix allergic rhinitis
IgE skin prick testing
RAST testing
- both will be +ve
Mx allergic rhinitis
- antihistamine
- intranasal corticosteroid
- combo Tx
+ allergen avoidance
cause of non-allergic/vasomotor rhinitis
nasal hypersensitivity - imbalance between sympathetic and parasympathetic supply to nasal mucosa
Ix non-allergic rhinitis
IgE skin prick testing
RAST testing
- both will be -ve
Mx non-allergic rhinitis
- intranasal antihistamine or intranasal corticosteroid
2. combo therapy
if rhinorrhoea is predominant symptom in rhinitis - Tx?
intranasal ipratropium
intranasal corticosteroids
budesonide
beclometasone
anti-histamines
cetirizine
fexofenadine
loratadine
nasal decongestants
oxymetazoline
pseudoephedrine
intranasal anticholinergics
ipratropium
farmer, has a cat and has recurrent rhinitis - Ix?
RAST
samter’s triad
asthma
aspirin sensitivity
nasal polyps
nasal polyps - sensitive or not sensitive to touch?
not sensitive
nasal turbinates - sensitive or not sensitive to touch?
sensitive
nasal polyps - unilateral or bilateral most common
bilateral - unilateral considered neoplastic until proven otherwise.
nasal polyps presentation
nasal obstruction
rhinorrhoea
poor sense of taste and smell
Ix nasal polyps
anterior rhinoscopy or nasal endoscopy
unilateral - CT and biopsy
Mx nasal polyps
moderate - nasal corticosteroids
severe - oral corticosteroid. if not improving - endoscopic polypectomy
acute sinusitis - how long do symptoms need to last for
<4w
chronic sinusitis - how long do symptoms need to last for
> 12 w
presentation sinusitis
facial fullness/tenderness worse on bending forward nasal discharge post-nasal drip nasal congestion fever
Mx sinusitis
- analgesia and decongestant (if <3d)
if persisting/worsening add Abx: amoxillin
Mx chronic sinusitis with nasal drip
CT sinus
and
sinusectomy
anterior or posterior nosebleeds - what is more common
anterior - kisselbachs area
posterior nosebleed
from posterior nasal cavity or nasopharynx
what arteries make up little’s area
posterior ethmoidal anterior ethmoidal sphenopalatine greater palatine superior labial
Mx of nosebleed
if haemodynamically stable - first aid measures
- if this controls bleeding, then use topical antiseptic
- if this doesnt control bleeding:
cautery or packing
(cautery if bleeding area can be visualised, packing if area cant be visualised)
if cautery doesnt work, then do packing
nosebleeds - order of ligation of arteries
- sphenopalatine
- anterior ethmoidal
- external carotid
most common bacterial cause of tonsillitis
group A strep
centor criteria - and how many indicated bacterial infection
no cough fever cervical lymphadenopathy tonsillar exudate 3/4 = bacterial
feverPAIN criteria - and how many indicated bacterial infection
fever Purulent tonsils Attend rapidly (<3d) Inflamed tonsils No cough
Mx bacterial tonsillitis
Phenoxymethylpenicillin + Analgesia
if unable to swallow - admit for IV benzylpenicillin + fluids
complications of tonsillitis
otitis media
quinsy
rheumatic fever
glomerulonephritis
indications for tonsillectomy
sore throats are due to acute tonsillitis
episodes are disabling and prevent normal function
7 eps in last 1 y
5 eps in each of the last 2y
3 eps in each of the last 3y
“7 in 1, 5 in 2, 3 in 3”
presentation quinsy
pain worse 1 side deviation of uvula towards affected side trismus (lock jaw) stertor hot potato voice
Mx quinsy
needle aspiration \+ IV benzylpenicillin \+ IV dexamethasone
What not to give in someone with glandular fever and why
Amoxicillin - will get a rash
why should people with glandular fever avoid contact sport
risk of spleen rupture
pleomorphic adenoma
benign salviary gland tumour
middle age
female
slow growing painless lump
Mx pleomorphic adenoma
superficial parotidectom y
risk in superficial parotidectom y
CN VII damage (runs through parotid gland but doesnt supply it)
warthins tumour
benign salivary gland tumour
middle age
male
softer and more fluctuant than pleomorphic adenoma
most common parotid tumour in children <1y
haemangioma
triple assessment of a neck lump
- history and examination
- imaging: USS, CT, MRI or laryngoscopy
3 biopsy + FNA
associations with nasopharyngeal ca
EBV southern china (salty fish diet) - rare in other parts of world
presentation nasopharyngeal ca
otalgia
cervical lymphadenopathy
recurrent epistaxis
Mx nasopharyngeal ca
radiotherapy
+/- chemo
+/- surgery
presentation oropharyngeal ca
sore throat
sensation of lump
referred otalgia
irritation by hot or cold food
Mx oropharyngeal Ca
radiotherapy
+/- surgeyr
presentation laryngeal ca
progressive hoarseness, then stridor
pain swallowing
+/- haemoptysis
+/- ear pain
cause of younger patient with laryngeal ca
HPV+ve
Ix laryngeal ca
- laryngoscopy + biopsy
- HPV status
- MRI staging
Mx laryngeal ca
radiotherapy + total laryngectomy + tracheostomy
