Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Neuro + special senses > ENT > Flashcards

ENT Flashcards

1
Q

What signs do you look for on examination of the ear?

A
  • Pinna symmetry, deformity, scars, active infection
  • Mastoid skin changes, scars
  • Pre-auricular pits, sinuses
  • Ear canal: pull back and up, look for wax swelling erythema, discharge FB bony swellings crust
  • Tympanic membrane: colour (should be pearly grey-translucent), bulging (fluid level in OM), perforation, light reflex (absence/distortion-increase IE pressure), scarring, cholesteatoma in attic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Explain the tuning fork tests

A

512Hz fork

  • Rinne (ME function): hold by ear canal + then mastoid process. AC>BC is normal or SNHL [Rinne +], BC>AC is CHL [Rinne -]
  • Weber (more sensitive): hold in centre of forehead. Normal=central, CHL=heard more in deafer ear, SNHL=heard more in better ear
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

An elderly pt presents with hearing loss, but Webers + Rinnes tests are normal. Why?

A

Presbyacusis is commonest form of HL in old age. This is a symmetrical SNHL, so there is no discrepancy between the ears that can be picked up on these tests (even tho the hearing is reduced)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Explain the pure tone audiometry tests

A

Subjective tests for each ear using headphones (AC) and small vibrating thing on MP (BC) where play signals of increasing frequency

Normal threshold os 0dB, shouldn’t go below 20. 1 line for BC and 1 for AC.

SNHL: AC + BC impaired
CHL: AC impaired
Mixed: both impaired, AC often worse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What test is useful for otitis media with effusion?

A

Impedance audiometry - signal of known intensity fed into EAM, microphone measures reflected sound levels. If fluid in ME the curve is flattened

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How is hearing tested in young children/babies?

A
  • Newborns: otoacoustic emission
  • Evoked response audiometry: doesn’t need cooperation, objective test
  • Distraction test: child will turn to a noise 6m-18m
  • From 2y can do various tests involving cooperation, from 3-4y can do the headphone pure tone audiometry tests
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Describe the sensory supply to the pinna

A

Upper lateral-CN V3 (auriculotemporal n)
Lower lateral + posterior-C3 (greater auricular n)
Supero-medial-C2/3 (lesser occipital n)
EAM-CN X auricular branch

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Describe the anatomy of the external ear up to the tympanic membrane

A
  • Pinna: cartilaginous, plus fatty lobule containing bvs
  • EAM: lateral 1/3 cartilage, medial 2/3 temporal bone
  • Tympanic membrane: skin on external side + mucus membrane internal, shallow cone shape, semi-translucent, moves by air vibrations. Innervated by auriculotemporal n (outer) and CN IX (inner)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Tympanic membrane perforation

A

Direct/indirect trauma or otitis media –> acute pain, CHL (usually not severe), tinnitus, vertigo unusual, may bleed from the ear

Usually heal alone (precautions about water), don’t put anything in the ear, only give Abx if evidence of infection, should heal over 6-8w, if taking >6m may need myringoplasty to repair using graft of temporalis fascia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Haemotympanum

A

Blood in the middle ear, often a/w temporal bone #, may cause CHL. TM dull with bluish tinge. Conservative management, may need drainage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Otitis externa ‘swimmers ear’ cause + features

A

Inflammation of skin of EAM often by skin commensals (Strep, Staph, Pseudomonas or fungi). RF are moist/humid, eczema, cotton bud trauma

CF: painful discharging ear, muffled hearing, itching (CHL), discomfort from pressure on tragus, debris/oedema in canal, regional lymphadenopathy, cellulitis spreading beyond ear, fever (more severe features)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Otitis externa management

A
  • Severe (red oedematous canal, debris, CHL, DC, lymphadenopathy, cellulitis, fever) –> 7d topical Abx +/- topical steroid. If spreading - oral flucloxacillin
  • Mild: pruritus, no deafness/discharge, mild discomfort –> topical acetic acid spray
  • Swab if not responding
  • Adv simple analgesia, avoid getting water in it + analgesia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Chronic otitis externa

A

Usually b/l, painless, relapsing condition with thickened skin easily traumatised

Need to remove debris + keep dry

Abx drops not advised unless acute inflammation as they precipitate allergy and fungal infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Malignant otitis externa

A

Aggressive infection a/w DM and immunocompromise, in the soft tissues of the EAM and eventually cause osteomyelitis of temporal bone - Pseudomonas

Chronic ear DC, deep severe pain, CN palsies esp CN VII, temporal headaches

Do CT + isotope scanning

M: aural toilet, IV Abx (ciprofloxacin covers pseudomonas), may need debridement. There is a 10% mortality!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Furunculosis

A

Hair follicle infection in EAM - severe throbbing pain, pyrexia then rupture of abscess

May need drainage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Perichondritis

A

Cartilage infection from trauma or severe otitis externa

Swollen red pinna, oedema that may spread, pre-auricular LN

M: local astringents e.g. magnesium sulphate + systemic Abx (as cart damage irreversible)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Herpes zoster oticus

A

aka Ramsay Hunt syndrome

Reactivation of VZV in facial nerve geniculate ganglion –> severe pain, vesicles in ear canal + pinna (may also be on anterior 2/3 tongue + soft palate), often facial palsy

Antivirals to prevent permanent CN VII damage + corticosteroids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Exostosis

A

Repeated exposure to cold water + wind –> bony growth in EAM. Benign but causes CHL

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Give some common problems with the auricle

A
  • Congenital deformities
  • ‘Bat ears’ - usually b/l, surgery around age 7
  • Pre-auricular sinus - embryological remnant with a small pit, may get infected and need excision of whole sinus tract
  • Infections - erysipelas (strep infection, serpiginous edge, rapidly spreads), spread of OE
  • Perichondritis - inflammation of perichondrium, diffusely swollen shiny painful ear, need Abx + astringents + analgesia to prevent cartilage necrosis (aka cauliflower ear)
  • Auricular haematoma
  • Skin problems e.g. dermatitis from jewellery/eardrops, eczema/psoriasis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is in ear wax?

A

Sebaceous material + products of ceruminous glands + hair + skin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

How and when should ear wax be removed?

A
  • Ind: meatal occlusion, impaction, irritation, hearing loss, OE, based on clinical inspection
  • Syringing (use water, don’t do if have ruptured TM), microsuction (better, done by ENT). May need to soften before
  • Comps: incomplete removal, trauma to ear canal skin, TM perforation, vertigo
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Describe the anatomy of the middle ear

A

Between the TM + IE

  • Pharyngotympanic (Eustachian tube) - equillibrilates pressure + ventilates + drains, linked to nasopharynx. Opens during swallowing
  • Ossicles: malleus, incus and stapes (this articulates with oval window)
  • Muscles: tensor tympani (reduce amplitude, CN V3), stapedius (pulls stapes to decrease oscillatory range, nerve from CN VII)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Cause and features of acute otitis media

A

Usually resp pathogens as resp pseudo stratified columnar epithelium (e.g. S pneumonia, H influenza, Moraxella) and viruses- usually ET dysfunction

CF: ear pain, young child may pull ear, DC (then TM may rupture with pus into canal and pain settles), fever, bulging TM, tachycardia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Management of acute otitis media

A
  • Conservative with analgesia + nasal decongestants - majority, as most viral in origin
  • Abx indications: sx not improving in 4d, systemically unwell (but not needing admission), immunosuppression, <2y with b/l AOM, TM perforation/discharge in canal
  • Abx would be 5d of amoxicillin (or macrolide if allergy)
  • Recurrent: grommets
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What are the types of chronic otitis media?

A
  • Actively discharging or inactive
  • Mucosal - TM rupture doesn’t heal after AOM. Active if perforation still discharging
  • Squamous - keratinised squamous cells introduced into ME from retraction pocket/perforation. Active squamous disease is cholesteatoma, inactive squamous may develop into cholesteatoma in future
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

How is chronic otitis media managed?

A
  • Cholesteatoma-surgical management +/- mastoidectomy

* Mucosal disease-topical Abx + aural toilet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Extracranial complications of middle ear infections

A
  • Mastoiditis: inflammation, severe pain, erythema, sagging of posterior ear canal, oedema, oedema pushed down + out (subperiosteal abscess), drum bulges/discharges, systemically unwell. M: IV Abx prolonged, if abscess mastoidectomy
  • Facial paralysis from acute inflammation
  • Labyrinthitis: dizziness, loss of balance, N+V, SNHL. High dose Abx to prevent Abx
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Intracranial complications of middle ear infections

A
  • Meningitis-often pneumococcal. Infection of IE, lateral sinus or direct extension
  • Abscess-extradural, subdural, temporal lobe (HL, otorrhoea, signs of RICP or seizure), cerebellar (nystagmus, past pointing, ataxia, headache)
  • Lateral sinus thrombosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is glue ear?

A

Otitis media with effusion. TM intact but fluid is in the ME, a/w ET dysfunction (abnormal ventilation-often an URTI). Peak 2-6y; if in adults check post-nasal space for tumours. RF are T21 + cleft palate.

CF: CHL (may present as speech delay, school issues, behavioural/balance problems), flat trace on tympanometry (immobile drum), effusion retracted eardrum + slightly yellow, not painful but can get infected causing AOM/recurrent otalgia

M: most settle in 3m, may need grommets for ventilation (tympanoplasty tubes, stay in place for up to 12m), +/- adenoidectomy and myringotomy to aspirate the fluid

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Otosclerosis

A

Genetic + environmental factors, majority b/l, mature bone replaced by woven bone –> stapes becomes fixed to oval window –> can’t move properly –> CHL. F>M, early adults usually, worse in pregnancy, often a FH (autosomal dominant)

CF: progressive CHL, tinnitus, initially hearing improves in noisy environments. May have pink hue to TM (Schwartze’s sign/Flamingo tinge cos hyperaemia) but otherwise normal
-may also get tinnitus/vertigo but less common

M: hearing aid, stapedectomy (put in prosthesis, but risk complete HL from surgery)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Describe the anatomy of the inner ear

A

In the petrous part of the temporal bone

  • Membranous labyrinth filled with endolymph, suspended in perilymph, contained within bony labyrinth
  • Cochlea: shell shaped, hearing perception
  • Vestibular system: 3 semi-circular canals which detect movement, utricle (hair cells point up to detect horizontal movement), saccule (hair cells point to side to detect vertical movement)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Outline sound perception

A

Vibrating TM –> ossicular chain –> oval window –> cochlear –> organ of Corti hair cells transform into electrical impulses –> depolarises fibres in CN VIII cochlear nerve –> transmitted to brain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Define vertigo

A

Hallucination of movement a/w a problem in the vestibular system

may have nystagmus as brainstem impulses to ocular muscles attempt to correct balance

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What causes vertigo?

A
  • central: stroke, migraine, neoplasia, demyelination, drugs

* peripheral: BPPV, meniere’s, vestibular neuronitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

How does vertigo present by pathology?

A
  • Episodic + ear sx: migraine, Meniere’s disease
  • Episodic, no ear sx: migraine, BPPV, TIA, epilepsy, arrhythmia, postural hypotension, cervical spondylosis
  • Constant + ear sx: chronic otitis media with labyrinthine fistula, ototoxicity, acoustic neuroma
  • Constant, no ear sx: MS, intracranial tumour, CV disease, degenerative disorder of vestibular labyrinth, hyperventilation, alcoholism
  • Solitary acute attack + ear sx: viral infection (e.g. mumps, HZV), vascular occlusion, labyrinthine fistula, rond-window membrane rupture/head injury
  • Solitary acute attack, no ear sx: acute labyrinthitis, vasovagal faint, vestibular neuronitis, trauma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What is BPPV?

A

Benign paroxysmal position vertigo - episodic vertigo that occurs with head movements esp when in bed, lasts a short time, can be v distressing

otoliths in the SCCs cause abnormal stimulation of hair cells giving hallucination of movement

usually spontaneous but may follow URTI/head injury/chronic otitis media

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

How do you diagnose and treat BPPV?

A
  • Diagnosis: Dix-Hallpike test. Turn head to affected side and gently lower head below rest of body, see nystagmus but repeated testing abolishes the vertigo
  • Epley manoeuvre: to ‘reposition particles’, series of controlled movements of head aiming to dislodge otoliths
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What is Meniere’s disease?

A

A rare problem with increased endolymph, occurs in clusters typically in 40-60yos

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

How does Meniere’s disease present?

A
  • Triad of vertigo (episodic, a/w N+V), deafness (SNHL, fluctuating then permanent), tinnitus
  • Aural fullness sensation
  • Nystagmus, positive Romberg test
  • Attacks from a few hours to several days, common to vomit, usually u/l initially but may become b/l (if other ear is fine usually compensate)
  • Over time dont get acute vertigo but may be generally unbalanced
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

How is Meniere’s disease managed?

A
  • Needs ENT to confirm diagnosis
  • Explanation, most resolve in 5-10y but most left with some HL
  • Diet: reduce salt, chocolate, alcohol, caffeine, Chinese food. do not smoke
  • Medical: low dose thiazide diuretics (aim to reduce endolymph pressure), vestibular sedatives (e.g. prochlorperazine, cinnarizine) + anti-emetics for acute attacks; betahistine + vestibular rehab for acute attacks
  • Surgical: grommets, dexamethasone ME injection, endolymphatic sac decompression, vestibular destruction (ME injection of gentamicin)
  • Inform DVLA, stop driving until control satisfactory
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

What is myringitis bullosa?

A

Localised otitis externa on TM - blisters on TM/deep in the EAM - excruciating pain

Presumed to be viral

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Cholesteatoma

A

Epithelium trapped in skull base causing local destruction

most common 10-20y, RF is cleft palate

p/w foul smelling discharge, hearing loss, invasion sx like vertigo/facial n palsy/cerebellopointine angle syndrome, attic crust in upper part of eardrum

may invade labyrinth causing a fistula connecting ME+IE–>balance disorders

also can cause HL, invasion of nerves

m-refer to ENT for removal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What may indicate previous grommet insertion?

A

Tympanosclerosis - white patches in TM
Doesn’t impair healing

Chronic effusion + thinning of TM - retraction pocket -if ET chronically fails to function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

Vestibular neuronitis

A

Inflammation in the inner ear causing severe incapacitating vertigo + N+V for several days, may have horizontal nystagmus. Otherwise no other sx

M: vestibular sedatives e.g. prochlorperazine (dont take after attack as delay recovery), IV fluids. Afterwards may have generalised unsteadiness for a few weeks, vestibular rehabilitation may help

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

Labyrinthitis

A

Infection in the vestibular labyrinth –> sudden onset vertigo, horizontal nystagmus, HL if cochlear involved, N+V

Improves after 24h as central compensation occurs

If b/l produces a bobbing oscillopsia (lose normal eye control)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

How may you test the vestibular system?

A
  • Test balance asking to walk like tightrope, heel toe, march on spot with eyes closed (turn towards side with issue as reduced proprioception)
  • Positional test-sit up on couch then lie flat with head to one side + below horizontal, note vertigo + nystagmus. Implies peripheral cause
  • Fistula test: compress tragus, causes feeling of imbalance
  • Caloric test: nystagmus when irrigate ear canal with water
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Tinnitus

A

Real/imagined noise in the ear, RF-long term high intensity noise exposure

  • Subjective: presbyacusis, noise-induced, ototoxic drugs, Meniere’s, wax, otosclerosis, ME effusion, head injury, labyrinthitis, vestibular schwannoma. Most common is a rushing/hissing/buzzing noise a/w SNHL
  • Objective: maggots, TMJ/ET sounds, AV malformations (pulsatile sound), normal pulsatile noise of ICA (mostly heard at night)

M: reassure not serious, correct hearing deficit with hearing aid/surgery, tinnitus masking devices to mask white noise, may need psychotherapy if stress worsens it

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Causes of otalgia

A
  • Ear causes: otitis externa, furunculosis, malignant otitis externa, myringitis bullosa, perichondritis, AOM, acute otitic barotrauma, Ramsay Hunt syndrome, neoplasia
  • Non-otological: referred pain. E.g. tonsillitis (CN IX), dental disease [impacted molars, malocclusion] or sinusitis (CN V), TMJ dysfunction (CN V), oesophageal (CN X), cervical spondylosis in elderly (CN2+3), referred from nasopharyngeal carcinoma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Causes of otorrhoea

A
  • Watery: skin conditions of EAM, fungal growth, CSF leak from temporal # (rare)
  • Purulent: acute otitis externa, furunculosis
  • Mucoid: ME pathology. E.g. chronic suppurative otitis media with perforation [tubo-tympanic] (M aural toilet, topical steroid drops to dry the ears, sometimes use eye drops with ofloxacin/ciprofloxacin)
  • Mucopurulent/bloody: trauma, AOM, ear carcinoma (rare)
  • Foul smelling: chronic suppurative otitis media (atticoantral disease), a/w cholesteatoma
  • Iatrogenic from surgically-created mastoid cavities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

What are the functions of the facial nerve?

A
  • Greater petrosal nerve - e.g. lacrimation
  • Chorda tympani - taste anterior 2/3 tongue + sublingual + submandibular glands
  • Stapedius nerve
  • Then stylomastoid foramen, then branches to parotid gland and muscles of facial expression (To Zanzibar By MotorCar)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

What may cause facial palsy?

A
  • Intracranial: vestibular schwannoma, stroke, brainstem tumour
  • Intratemporal: Bell’s palsy, Ramsay Hunt syndrome, middle ear infection, trauma
  • Extratemporal: parotid tumours
  • Misc: sarcoidosis, polyneuritis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Bell’s palsy

A

Idiopathic facial paralysis. Diagnosis of exclusion but commonest cause

CN VII palsy, pain around mastoid, HL, taste loss, hyperacusis

Start to recover in 3w, antivirals + steroids often given but evidence lacking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Causes of balance disorders

Can be from inputs ears/eyes/proprioception, cerebellum fine movement, cortex space position), labyrinths + central connections

A
  • Ear causes: ME disease (OME, AOM, cholesteatoma), trauma (post-surgery or temporal #), BPPV, Meniere’s disease, labyrinthitis, otosclerosis, ototoxic drugs, vestibular schwannomas
  • Non-ear: NOT VERTIGO, lightheaded/dizziness. E.g. cervical spondylosis, ageing, migraine, TIAs, head injury, epilepsy, hyperventilation/anxiety (a/w tinnitus + tingling in hands + feet)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Pinna injuries

A
  • Auricular haematoma: blunt trauma/shearing force - bleeding beneath perichondrium - stripped from cartilage - necrosis + scar formation - cauliflower ear. Need to aspirate haematoma + firm pressure dressing + Abx to prevent
  • Lacerations: suture as good blood supply, trim exposed cartilage
  • Keloid scars
  • EAM injuries like from cleaning wax
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Middle and inner ear injuries

A
  • Perforated TM
  • Blast injuries-explosion or ear slap, usually rupture TM, may damage cochlea causing SNHL+tinnitus, may be permanent
  • Otitic barotrauma: esp when pressure rising e.g. descent in flight/Scuba. Otalgia, extravasation of blood into ME, haemotympanum
  • Head injuries - temporal # can damage cochlea or labyrinth
  • Surgical trauma
  • Haemotympanum
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Ear foreign bodies

A

May cause otalgia/otorrhoea

Removal: specialist, usually suction or syringing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

What causes conductive hearing loss?

A
  • Common: wax, AOM, OME, otosclerosis, perforated TM, otitis externa, foreign body
  • Less common: ME trauma, congenital pathology like ossicle abnormalities, tumours
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

What causes sensorineural hearing loss?

A
  • Common: presbyacusis, noise-induced, congenital (genetic, TORCH infection), neonatal jaundice/hypoxia/prematurity, childhood infections (measles, mumps, meningitis), drugs (quinine, aminoglycosides, aspirin)
  • Less common: vestibular schwannoma, CNS disease like MS, hypothyroidism, Meniere’s disease, perilymph fistula
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

What causes childhood deafness?

A
  • OME (CHL, temporary)
  • SNHL rare but usually permanent - 1/2 hereditary, others acquired in utero/early childhood e.g. meningitis or TORCH infections

RF: prematurity, low bw, perinatal hypoxia, chromosomal abnormalities, severe jaundice, FH of hereditary deafness, TORCH infections

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

How do hearing aids work?

A

Amplify sound from small microphone and fed into ear canal

  • In cochlear SNHL they are intolerant to noise over a certain level so amplification is difficult
  • Can have bone-anchored type e.g. due to shape of ear canal with titanium screw into temporal bone so sound transmitted directly by BC to the cochlea
  • COchlear implantS: electrodes in cochlea stimulate auditory nerve, done for profound b/l deafness
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

What are the common ear drops we need to know about?

A
  • Ceruminolytics: soften wax e.g. olive oil, sodium bicarbonate, glycerine. Many irritant so use for short periods
  • Astringents: anti-inflammatory e.g. betamethasone, glycerine. When oedematous canal so reduce swelling so that Abx can work
  • Antibacterial: usually aminoglycosides + anti-inflammatory. If ear drum is perforated use ciprofloxacin instead
  • Anti-fungal e.g. clotrimazole, nystatin.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

What drugs can cause tinnitus?

A

aspirin, alcohol, quinine, ototoxic combinations like aminoglycosdie + loop diuretic, some cytotoxics

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Why can ageing cause balance disorders?

A

Multifactorial:

  • Poor proprioception as reduced vision + hearing
  • Cervical spondylosis
  • Hypotension or arrhythmias
  • Medication

Best to avoid vestibular sedatives as they suppress what’s left of normal function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Why can cervical spondylosis cause balance disorders?

A

Arthritic - osteophytes - vertebrobasilar insufficiency, esp when hyperextend neck - transient cerebral ischaemia

M: neck physio, NSAIDs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Presbyacusis

A

Common cause of SNHL - progressive loss of sensitivity of cochlear hair cells, usually B/L, high frequency, difficulty following conversations. 2 hearing aids used

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Sudden SNHL

A

Rare, thought to be viral/vascular (idiopathic)

Emergency: give steroids, refer to ENT asap, can try intra-tympanic steroids, pure tone audiometry, MRI head to rule out VS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Noise exposure

A

Common, from sudden or prolonged exposure - wooly hearing, tinnitus, SNHL worst in range 3000-6000Hz

Prevention- avoidance, ear defenders

M-hearing age

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Perilymph fistula

A

Rare cause of SNHL due to a rupture of the round/oval window –> perilymph leakage –> SNHL

Usually a trigger like RICP e.g lifting something

69
Q

Vestibular schwannoma

A

A tumour on the vestibular n (used to be called acoustic neuroma), located in the internal auditory meatus or cerebello-pontine angle. Usually u/l but in NF2 may be b/l

CF: progressive SNHL, imbalance, tinnitus, CN V encroachment (CP angle – absent corneal reflex), if advanced can cause RICP/brainstem displacement , CN VII encroachment (facial palsy)

70
Q

Outline the nasal anatomy

A
  • External nose mostly cartilage, septal cartilage biggest, mucosal inside is ciliated columnar + olfactory, bony swellings are the turbinates (x3)
  • Nasal cavity goes from nostrils to posterior nasal aperture (choana) which opens into nasopharynx. Related to anterior cranial fossa @ cribriform plate of ethmoid bone, sinuses, NP, ET, lacrimal apparatus + conjunctiva
  • Conchae/turbinate: covered in MM, longest is inferior
  • Meatuses: superior + inferior
  • Innervation by CN V + CN I
71
Q

Outline the para-nasal sinus anatomy

A

Air-filled extensions of the respiratory part of the nasal cavity lined with ciliated pseudo stratified columnar ep + goblet cells

  • Frontal: drains into middle meatus, roof is floor of anterior cranial fossa + floor is roof of orbit
  • Ethmoidal: into ethmoid bone, medial wall of orbit
  • Sphenoidal: behind nose, close to CN II + ICA + pituitary gland + cavernous sinus
  • Maxillary: bodies of maxilla, roots of upper teeth project into them so tooth infections can spread
72
Q

How would you examine the nose?

A

Inspection external then internal with auriscope with large speculum, assess nasal airway, interior quite horizontal, look back not up, can see anterior septum + inferior turbinates (may look like a polyp, but turbinates v sensitive but polyps aren’t [and are grey-translucent])

73
Q

What may cause epistaxis?

A
  • Local: idiopathic, traumatic, iatrogenic, FB, rhinitis, polyps, neoplastic (e.g. juvenile angiofibroma, pyogenic granuloma), cocaine (vasoconstrictor so repeat use causes obliteration of septum)
  • Systemic: HTN, coagulopathies, HHT (esp elderly), anticoagulants, thrombocytopenia (eg ITP, leukaemia, Waldenstrom’s macroglobulinaemia)
74
Q

How do you manage epistaxis?

A
  • ABCDE
  • First aid: pinch soft part of nose, head forward, tell to spit out blood, lean forward, breathe through mouth
  • Examine for source of bleed
  • Gently remove clots + dried blood w suction
  • Cautery with silver nitrate/bipolar diathermy, can use topical adrenaline before to vasoconstrict, topical anaesthetic
  • Nasal packing if cautery fails or can’t see source, anterior and if continuous posterior (may need GA, causes airway obstruction). Pack with ribbon gauze, nasal tampons or balloon
  • Surgical ligation or radiological embolisation of the sphenopalatine a, or of the ECA as a last resort
75
Q

Nasal foreign body

A

Usually in children, adults may have a rhinolith

  • CF: u/l, v bad smell DC, may be blood-stained, excoriation around nostril
  • Need to remove as may spread to sinus/meninges, inhale, septal perforation, button batteries may burn skin
  • M: if v cooperative + can see may be able to use forceps otherwise GA
76
Q

Nasal trauma

A
  • Septal haematoma: sensation of obstruction most common sx, pain + rhinorrhoea, b/l red swelling arising from septum, boggy (whereas the septum is firm). Comp-irreversible necrosis due to pressure ischaemia causing sale nose deformity. M-surgical drainage, IV Abx
  • CSF leak with base of skull # (rare)
77
Q

Septal deviation

A
  • Usually from trauma, may become more prominent in children who grow, or due to nasal surgery
  • If marked can cause nasal obstruction, recurrent sinusitis from impaired ventilation, facial pain, psychological sx, otitis media as reduced equalisation of middle ear
  • M: treat rhinitis, may opt to correct it as a septoplasty
78
Q

Septal perforation

A
  • Causes: surgery, trauma e.g. repeated picking, inhalation of fumes, cocaine, carinoma
  • V hard to repair, nasal douching to reduce crusting, antiseptic cream
79
Q

Saddle nose deformity

A

Cartilaginous septum necrosis due to trauma/untreated septal haematoma/chronic inflammation

Aesthetic deformity + nasal obstruction

M: difficult, extensive surgery

80
Q

What infections may affect the nose?

A
  • Acute coryza - discourage >5d of nasal decongestants
  • Nasal vestibulitis - sore, fissure, crust. M-topical Abx/antiseptic ointment, look for foreign body
  • Furunculosis: abscess in nasal hair follicle, rare but can lead to CST/meningitis. Tip of nose red + painful. Systemic abx +/- drainage
81
Q

What are the complications of sinus surgery?

A
  • Damage to orbit

* Damage to anterior skull base

82
Q

What is rhinosinusitis?

A

Inflammation of the nose + paranasal sinuses, characterised by 2 or more out of: nasal blockage, nasal discharge, facial pain/pressure, reduction in smell

Usually >1 sinus affected. May have endoscopic signs like polyps/mucopurulent DC/oedema or CT changes like mucosal changes

83
Q

Acute rhinosinusitis

A

Lasts <12w and sx completely resolve

  • Causes: viral (usually rhinovirus/influenza + resolves in 5d, due to oedema which reduces ventilation), or non-viral (>5d, usually a bacteria also invades like S pneumonia/Haemophilus or Moraxella or anaerobes)
  • Predisposing factors: nasal obstruction like polyps, recent local infection, swimming/diving, smoking
  • CF: obstruction, rhinorrhoea (thick purulent DC), congestion in nose/face, facial pain (maxillary-cheeks, ehtmoid/periorbital headahce/periorbital, sphenoid-deep headache), frontal pressure pain on bending forward, pyrexia, pus in nose, tender sinuses, tooth pain
  • OTC management: analgesia, nasal decongesting vasoconstrictors (sparingly, not for >5d)
  • NICE management: analgesia, intra-nasal steroids if sx >10d/severe; Abx if systemically unwell or co-morbidities (phenoxymethylpenicillin, or co-amoxiclav if v unwell); do NOT offer oral steroids/steam/antihistamines (unless also allergy)/mucolytics
  • May need surgical drainage of an empyema
84
Q

Chronic rhinosinusitis

A

12w without complete resolution of sx, +/- polyps

  • Prediposed by allergy, infections, ciliary impairment e.g. CF, anatomical e.g. septal deviation, immunocompromised, irritants like smoking or dust, hormones like in pregnancy, trauma, FB presence, swimming
  • M: usually no cure. Avoid allergens, nasal douching, antihistamines/topical nasal steroids/oral steroids if severe/oral Abx, surgical like nasal polypectomy, functional endoscopic sinus surgery
85
Q

What are the complications of acute rhinosinusitis?

A
  • Orbital cellulitis or abscess
  • Meningitis, extradural or subdural abscess
  • Cerebral abscess of frontal lobe - frontal sinus infection a/w headache + abnormal behaviour
  • Osteomyelitis of the frontal bone - need intensive Abx + debridement
  • Cavernous sinus thrombosis - rare, a/w proptosis, chemosis + ophthalmoplegia, facial oedema, photophobia, u/l CN palsies of III/IV/V/VI
  • Mucocele - bony swelling as secretions accumulate
86
Q

Nasal polyps

A

Close a/w CRS, polypoid swelling of nasal lining

  • A/w late onset asthma, aspirin sensitivity, infective sinusitis, cystic fibrosis, Kartagener’s syndrome, Churg-Strauss syndrome
  • CF: nasal obstruction, rhinorrhoea, poor sense of taste + smell
  • Seen as swollen oedematous nasal mucosa, obstructing nose, yellow-grey, smooth + moist, may be pedunculate, move on probing, insensitive (unlike the turbinates)
  • Usually B/L - if U/L possibly neoplastic
  • In chidden - need to rule out cystic fibrosis
  • M: allergen avoidance, systemic/topical antihistamines, topical steroids, Abx if infected. If large may need polypectomy/functional endoscopic sinus surgery

If GP suspects polyps should refer to ENT

87
Q

Allergic rhinitis

A

IgE-mediated type I hypersensitivity in mucus membranes, strong a/w asthma. Seasonal hay fever or perennial

Allergic rhinitis according to impact on asthma is used to classify, based on severity + duration of sx

CF: nasal congestion, airflow obstruction, rhinorrhoea, sneezing, reduced smell, allergic crease from rubbing, red mucosa, mucoid DC.

May look into allergies but usually no ix needed

M: conservative, antihistmaines/topical steroid, immunotherapy

88
Q

What are the causes of chronic rhinosinusitis?

A
  • Allergic rhinitis
  • Infectious rhinitis like hormonal, drug-induced like beta blockers
  • Occupational from fumes
  • Vasomotor
  • Rhinitis medicaments - excessive decongestant use causes rebound congestion
  • Atrophic - after surgery/radiotherapy, or Sjogren’s syndrome
  • Senile - ipratropium bromide spray often helps
89
Q

Differentials for chronic rhinosinusitis and nasal polyps

A
  • Adenoid hypertrophy
  • Septal deviation
  • Foreign body (esp in child with u/l CRS +dc)
  • CF
  • Primary ciliary dyskinesia
  • Tumours
  • CSF rhinorrhoea
90
Q

What tumours may affect the nose/sinus areas?

A

Most are SCC

RF are tobacco, male, alcohol, exposure to hardwood resins (adenocarcinoma), southern China (nasopharyngeal carcinoma), EBV (nasopharyngeal carcinoma)

  • Maxillary + ethmoid sinus carcinomas - bloody DC, u/l obstruction, facial swelling, epiphora, proptosis, diplopia, pain
  • Osteatoma-benign bony tumours
91
Q

What is the vascular supply to the nose?

A
  • A+P ethmoidal a( from ophthalmic a), sphenopalatine + greater palatine a (from maxillary a), septal branch of superior labial a (from facial a)
  • Little’s area/Kiesselbach’s plexus: v vascular bit on anterior septum, branches from ECA+ICA, anastomosis of the above 5 arteries
92
Q

What are the layers of the neck?

A
  • Superficial cervical fascia
  • Deep cervical fascia - investing layer around whole neck, pre-tracheal layer (anterior only), pre-vertebral layer (laterally becomes axillary sheath)
  • Retropharyngeal space: between pre-vertebral layer + fascia of pharynx, allows pharynx expansion when swallow, has LN in children so can get an infection that may spread to posterior mediastinum
93
Q

Muscles of the H+N

A
  • Neck: trapezius + SCM CN XI, platysma CN VII, infrahyoid + suprahyoid muscles
  • Facial expression: CN VII, LPS CN III
  • Mastication: CN V. Pterygoids, masseter, temporalis
94
Q

Blood supply to the H+N

A
  • ECA: facial, angular, nasal, maxillary, labial branches
  • ICA: ophthalmic –> supraorbital + supratrochlear

Drained into facial vein - IJV - EJV - pterygoid venous plexus - cavernous sinus

95
Q

What is in the anterior cervical triangle?

A

Things between head and thorax - hyoid muscles, CCA bifurcation, IJV, CN VII, IX, X, XI, XII

96
Q

What is in the posterior cervical triangle?

A

Things that go between thorax and upper limb: omohyoid + scalene muscles, EJV, subclavian vein, CN XI, cervical plexus (inc phrenic nerve), trunks of the brachial plexus

97
Q

What are the boundaries of the anterior + posterior cervical triangles?

A
  • Anterior: medial=midline of neck, lateral=anterior border SCM, superior=lower mandible
  • Posterior: anterior=posterior SCM, posterior=anterior trapezius, base=middle 1/3 of clavicle
98
Q

Outline the lymphatics of the H+N

A
  • Right side down to diaphragm drains to right lymphatic duct which goes into right subclavian vein
  • Left side + right side below diaphragm drain to thoracic duct which goes into left subclavian vein
  • Superficial LN: submandibular, submittal, pre-auricular, post-auricular, occipital, superficial anterior + posterior cervical chains
  • Deep LN: drain the superficial LN. Jugulodiagstric (raised on tonsillitis), jugulo-omohyoid, supraclavicular (right mid-chest/oesophagus/lungs, left abdo + thorax [Virchow’s node])
99
Q

What is Waldeyer’s ring?

A

Lymph tissue surrounding pharynx -lingual tonsil (posterior tongue base), palatine tonsils, tubal tonsils (where ETs open into nasopharynx), pharyngeal tonsil (adenoid, behind uvula)

100
Q

Retropharyngeal abscess

A

Abscess in the retropharyngeal space - can spread to the mediastinum. Most common in young children post-URTI

CF: rigid neck, reluctance to move, systemically unwell, airway compromise, dysphagia/odynophagia, mediastinitis

Do CT neck

M: secure airway, IV Abx, incision + drainage

101
Q

Ludwig’s angina

A

Cellulitis of the space between the floor of the mouth + mylohyoid. A/w dental infection or immunocompromise. Spreads in fascial spaces

CF: swelling floor of mouth, painful, protruding tongue, airway compromise, drooling

CT neck

M: secure airway, IV abx, drain collections

102
Q

Parapharyngeal abscess

A

Potential space between oropharynx + nasopharynx

CF: febrile illness, trismus, odynophagia, reduced neck movement, swelling in neck

Contains carotid sheath so risk comps

M: airway, IV Abx, surgical drainage

103
Q

Epiglottitis

A

Emergency, H influenza main cause, 2-6y commonest group (rare now cos of Hib vaccine)

Infection - epiglottitis - obstructs laryngeal inlet

CF: rapidly progressive stridor, drooling, pyrexia, pain, ‘quack like’ cough, child sits up + leans forward to ease airway

M: airway (do not examine-spasm), calm, theatre GA for intubation, IV Abx (amoxicillin)

104
Q

How would you differentiate the causes of a neck lump based on its location?

A
  • Anterior to ear-parotid
  • Angle of mandible-jugulodigastric node (pharynx, tonsils etc)
  • Inferior mandible-submandibular gland
  • Bifurcation of CCA-carotid body tumour or aneurysm
  • Midline between hyoid bone + thyroid gland - thyroglossal cyst
  • Anterior border of SCM - branchial cyst
  • Thyroid - thyroid nodule
  • Supraclavicular fossa - Virchow’s node
105
Q

How do you investigate neck lumps?

A

US-guided FNA

unless pulsatile!

106
Q

Outline the causes of neck lumps

A
  • normal neck structures pt identifies e.g. C1 vertebra transverse process, hyoid bone, cricoid cartilage
  • skin infections
  • lymphadenopathy: inflammatory, post-inflammatory, malignant
  • benign tumours like lipoma, fibroma. poorly defined asymptomatic soft masses deep to skin
  • malignant primary tumours e.g. salivary gland
  • lymphoma: rubbery, painless, rare phenomenon of pain on drinking alcohol
  • thyroid lumps: nodule/diffuse, move upwards on swallowing, often nodules/cysts/follicular adenoma but may be cancer; may by hypo, hyper or euthyroid
  • salivary gland lumps e.g. pleomorphic adenoma of parotid (benign), malignancy (e.g. pain, paraesthesia, facial palsy), calculi (causing swelling + tenderness esp on eating, may be infected), SG infection with mumps or S aureus, chronic inflammation e.g. Sjögrens syndrome
  • congenital + developmental
  • carotid body tumour or aneurysm-painless, slow-growing, pulsatile over carotid bifurcation, can move sideways but not vertically (don’t move on swallowing)
  • trauma: haematoma, surgical emphysema
  • congenital + developmental tumours
  • pharyngeal pouch: in older men, posteromedial herniation, usually not seen but if big lump that gurgles on palpation, dysphagia, regurgitation, aspiration, chronic cough
  • cervical rib - F>M, 10% develop thoracic outlet syndrome. fibrous brand branches towards sternum, often b/l, excised if NV compromise
  • epidermoid cyst: common due to proliferation of endometrial cells, usually asymptomatic, typically firm round nodules with a central puncture
107
Q

What are the causes of airway obstruction?

A

Any obstruction between the nose/oral cavity to the alveoli, partial more common + causes stridor, or complete (may be silent, rapidly fatal)

Causes: trauma, bleeding, pharyngeal infections (epiglottis, croup, diphtheria, Ludwig’s angina), angioedema, laryngitis, epiglottis, intraluminal oedema e.g. croup, inhaled FB, b/l vocal cord paralysis

108
Q

Paediatric causes of airway obstruction

A
  • Supralaryngeal: choanal atresia (severe neonatal airway obstruction, relived on crying, surgery so can feed), micrognathia (e.g. Pierre Robin sequence or Treacher Collins syndrome, needs NP/oral airway), adenotonsillar hypertrophy (may cause OSA)
  • Laryngo-tracheal causes: congenital like laryngomalacia/congenital subglottic stenosis/laryngeal wests, acquired like foreign body (obstructs mostly in expiration), croup/epiglottitis, subglottic stenosis, recurrent respiratory papillomatosis (from HPV 6/11 through birth canal, progressive hoarseness/aphonia)
109
Q

How may airway obstruction present and how do you manage it?

A

CF: stridor, stertor (like snoring sound), confusion, high HR+RR, reducing GCS, IC+SC recession (esp babies as soft bones), accessory muscle use, tracheal tug (trachea moves down in neck during inspiration), cyanosis, exhaustion

M:

  • clear airway
  • inflate lungs
  • alternative airway if needed: guedal (oral to keep tongue base forward in unconscious), endotracheal intubation, laryngeal mask airway (rests on laryngeal inlet to permit ventilation)
  • supportive: O2, nebuliser adrenaline to open small airways, steroids to reduce oedema
110
Q

Neck trauma

A
  • penetrating - can damage N/V/viscuses
  • blunt from RTA, spots, strangulaion
  • iatrogenic from long term ETT causing ischaemia/scarring, laryngeal stenosis
  • inhaled fumes, corrosives
111
Q

What is the cavernous sinus?

A

A plexus of thin walled veins on the upper surface of sphenoid. Contains OTOM CAT:

  • Lat wall S to I: Oculomotor n, Trochlear n, Ophthalmic n, Maxillary m
  • Traversing: ICA, Abducens n
112
Q

What is the cavernous sinus?

A

A plexus of thin walled veins on the upper surface of sphenoid. Contains OTOM CAT:

  • Lat wall S to I: Oculomotor n, Trochlear n, Ophthalmic n, Maxillary m
  • Traversing: ICA, Abducens n
113
Q

Reactive lymphadenopathy

A

Usually acute + painful

  • Pharyngitis/tonsilitis with strep, s aureus, TB, EBV, HIV, parasitic, fungal
  • connective tissue disease
  • URTI, ear infection, headline, dental abscess, cat scratch disease
114
Q

Why may LN be persistently enlarged?

A

Often persist after URTI up to months, firm mobile non-tender and remain same size they are prob fine

  • Refer if solitary, or sudden increase in size or parenteral anxiety
  • In adults refer if remain enlarged after 2w unless clear h/o an infection
115
Q

Malignant lymphadenopathy

A
  • LN mets: u/l progressive swelling of single/multiple nodes. Rubbery
  • Leukaemia - generalised lymphadenopathy
  • Lymphoma - painless rubbery lymphadenopathy often in posterior triangle
116
Q

Congenital + developmental neck lumps

A
  • Thyroglossal cyst: usually child, midline cystic lump nr hyoid bone, moves up when swallow/protrude tongue, may get infected
  • Branchial cyst: usually late childhood/early adult, u/l painless slow-growing smooth fluctuant swellings, lateral neck, anterior triangle, superficial to SCM along line of deep cervical LN, contains cholesterol crystals, may get infected, no transillumination, no movement on swallowing, may have a fistula. May be excised or not
  • Laryngocele: intermittent neck swelling, palpable on Valsalva manouevre
  • Dermoid cyst: along lines of fusion e.g. under tongue
  • Cystic hygroma/lymphangioma: soft fluctuant mass in posterior triangle or axilla, transilluminates, presents in infancy, contains lymph
  • Haemangioma: compressible, appears bluish on overlying skin
  • Lipoma: soft mobile lump in dermal layer
117
Q

What are the congenital causes of airway obstruction?

A
  • Choanal atresia: failure of posterior canalisation so severe obstruction relieved on crying
  • Jaw underdevelopment in syndromes meaning tongue displaced posteriorly e.g. Pierre-Robin (a/w cleft palate)
  • Laryngomalacia-stridor starts soon after birth as collapse of soft laryngeal tissues on inspiration, resolves by 2y or may need excision of aryepiglottic folds
  • Congenital subglottic stenosis @ level of cricoid cartilage (can also get this acquired from ETT ventilation)
  • Laryngeal webs/cysts: webs usually anterior, cysts can be congenital/from ETT
  • Tracheal compression from a vascular ring
  • Tracheomalacia - soft tracheal cartilage, a/w prematurity
118
Q

Anatomy of the throat

A
  • Oral cavity
  • Pharynx: nasopharynx inc adenoids + ET opening, oropharynx up to superior epiglottis
  • Larynx: protects trachea + bronchi, and produces voice. Multiple cartilages, main is thyroid cartilage (Adam’s apple) which is inferiorly linked to the cricoid cartilage. Divided into supra glottis, glottis and sub glottis. True+false cords prevent food entering + also larynx elements when swallow to stop food going in. Cords produce phonatory sound, teeth tongue + lips make speech. Recurrent laryngeal nerves supplies the muscles except cricothyroid (superior laryngeal n)
119
Q

Lesions in the oral cavity causes

A
  • Masses - tongue usually neoplastic, cystic lesion in SG
  • Ulceration: malignant until proven otherwise, may be aphthous e.g. a/w Crohn’s
  • Haemorrhage: gum disease, malignancy, bleeding disorder
  • Discolouration: potential for malignant transformation. white (leukoplakia) and red (erythroplakia) patches

Refer under 2ww. RF for cancer are age, smoker, heavy drinker, chew tobacco/betel nut

120
Q

What causes gingival hyperplasia?

A
  • AML

* Drugs: phenytoin, ciclosporin, calcium channel blockers esp nifedipine

121
Q

Obstructive sleep apnoea

A

Complete obstruction of airway so pt wakes up to alter position, may be prolonged and cause hypoxaemia, repeated-poor sleep + strain on CV system (HTN, stroke, HF, pulmonary HTN).

Children main cause adenotonsillar hypertrophy, adult main cause obesity, worse with alcohol + smoking

Comps: poor work/school performance, relationship problems, daytime sleepiness, increased risk of RTAs, CV comps

Ix: BMI, TFT (hypothyroidism), CXR (obstruction), ECG (RV failure), sleep study

M:

  • Adult: lifestyle, treat rhinitis, improve nasal calibre, CPAP via face mask/nasal prongs
  • Children: treat rhinitis, refer to ENT may do adenotonsillectomy
122
Q

Snoring

A

Partial upper airway obstruction from anywhere between nose to larynx - occurs in sleep as pharyngeal muscles relax

123
Q

What are adenoids and why are they removed?

A

Lymphoid tissue in nasopharynx, regress between 7y-adolescence

  • Repeated URTI - pathological hypertrophy + bacterial develop biofilm so hard to overcome
  • CF: nasal obstruction, pharyngitis from mouth breathing, OSA, rhinosunsitis, recurrent URTIs, otitis media, hypo nasal quality to speech
  • Consider adenoidectomy.
124
Q

Pharyngitis

A

Common usually due to virus and a/w ARS, causes dysphagia, malaise, hyperaemic mucosa, swelling + tender LN. May be chronic esp in smokers, mouth breathing, periodontal disease

M: analgesia, plenty of fluids, Abx if pus/severe pain on swallowing/prolonged unresponsive

125
Q

Tonsillitis

A
  • Cause: typically virus (rhinovirus, adenovirus etc) then bacteria supervene (beta haemolytic strep, staph, strep pneumonia, h influenza)
  • Rarer forms include infectious mononucleosis (EBV, severe membranous tonsillitis, marked nodal enlargement, lymphocytosis, a/w splenomegaly), diphtheria( v rare, grey tonsil membrane, pyrexia usually low), agranulocytosis (ulceration on tonsils + oral mucosa), HIV (pharyngitis + infective tonsillitis with opportunistic organisms like fungi)
  • CF: pyrexia, dysphagia, tender cervical lymphadenopathy, odynophagia, trismus, foetor, otalgia, red swollen tonsils+/- exudate, headache, malaise
  • M: depends on Fever-PAIN score, if Abx use phenoxymethylpenicillin for 10d/cefalor. Avoid amoxicillin/ampicilin as it its actually mono can cause a maculopapular rash
126
Q

Fever-PAIN score for tonsillitis

A 
Give Abx if score is 4-5
Fever during previous 24h
Purulence on tonsils
Attend rapidly within 3d onset
Inflamed (severely inflamed tonsils)
No cough coryza (indicates less likely viral URTI)
127
Q

Possible complications of tonsillitis

A
  • AOM
  • Peritonsillar abscess-pus within peri-tonsillar tissue but outside tonsil capsule. Pt systemically unwell, severe pain + otalgia, buccal mucosa often furred, reduced neck mobility, pain localises to one side, tonsil pushed down + medially, deviation of uvula. M: IV ABx + drainage, consider tonsillectomy when recovered
  • Retropharyngeal abscess
  • Parapharyngeal abscess
  • Pneumonia
  • Glomerulonephritis + rheumatic fever from strep tonsillitis - uncommon now
  • Scarlet fever: streptococcal tonsillitis + punctate erythematous rash + strawberry tongue
128
Q

Tonsillectomy

A

SIGN guidance: 7+ well documented adequately treated sore throats in preceding year/5 or more each year for 2y/3 or more each year for 3y; recurrent febrile convulsions due to tonsillitis; OSA/dysphagia from enlarged tonsils/peritonsillar abscess if other therapy not working

Post-op: adv normal eating to encourage sloughing, adequate analgesia + hydration, warn about norm appearance up to 2w, v v painful esp first 10d (increases in first 6d)

Comp: primary bleeding in first 24h needs return to theatre, or secondary usually due to infection which improves w IV ABx

129
Q

Pharyngeal cancers

A
  • Carcinoma: painful ulceration + induration of pharynx/tonsil, often earache/slight bleed
  • Lymphoma: painless enlargement of affected tonsil
130
Q

Pharyngeal pouch - hypopharyngeal diverticulum

A

Area without muscle between inferior constrictor + cricopharynxgeus - herniation can occur (Killian’s dehiscence) - pouch.

Mostly affects older people

CF: discomfort, dysphagia, delayed regurgitation of food, aspiration pneumonia, gurgling noises on swallowing, halitosis. Almost never causes a neck lump!!

Ix: barium swallow

M: surgery if symptomatic to divide the wall + staple the edges

131
Q

Globus pharyngeus

A

Sensation of lump in throat, often overcome by eating. Often have GORD, may worry about cancer which then aggravates it
M: ENT for reassurance, GORD antacids/PPI if features

132
Q

What are the indications for tracheostomy?

A
  • Relieve upper airway obstruction
  • Protect the tracheobronchial tree e.g. in Guillain-Barre syndrome or a brainstem stroke
  • Artificial ventilation - for long period, more comfortable than an ETT
133
Q

What are the potential complications of tracheostomy?

A

Bleeding, pneumothorax, mediastinal emphysema, obstruction by secretion crusts, dislodgement of tube, surgical emphysema from positive pressure ventilation, perichondritis, sub glottic stenosis

134
Q

Foreign bodies in the throat

A

May impact in pharynx, oesophagus, stomach. May lead to perforation, mediastinitis

CF: feeling of sharp scratch when swallow, odynophagia, dysphagia, may cause airway obstruction if bolus pressing on trachea

135
Q

How may laryngeal lesions present?

A
  • Hoarseness - nr vocal cord
  • Aspiration - failure of laryngeal inlet to close on swallowing
  • Stridor or tachypnoea from turbulent flow
136
Q

Acute laryngitis

A

Affects adults, usually caused by an URTI virus and RF include overuse of voice/smoking/alcohol

CF: aphonia (whisper/lost voice), dysphonia (hoarse), cough, pain, stridor (rare)

137
Q

Supraglottitis

A

Adult epiglottitis - seven pain, slower to develop than epiglottitis + resp obstruction less likely

138
Q

Chronic laryngitis

A

RF: smoking, alcohol, habitual shouting, professional voice users

Chronic inflammation in laryngeal mucosa/muscle imbalance

CF: dysphonia, voice fatigues easily, discomfort, tendency to clear throat

M: voice rest, treat any infection, steam inhalation, stop smoking, voice therapy

139
Q

Muscle tension dysphonia

A

This is when there is abnormal coordination of the intrinsic laryngeal muscles

  • Spasmodic
  • Functional: no apparent structural issue but abnormal voice
  • Functional aphonia ‘mutism’ - may be psychological

Strain to produce good voice, tires easily

RF: URIT, GORD, excessive use, stressful life events

140
Q

Vocal cord nodules

A

Singers/screamers nodules - from excessive use. Made of fibrous tissue, usually respond to rest +/- SALT

141
Q

Inflammatory lesions in the larynx

A

Reinke’s oedema, polyps, cysts, granulation tissue –> interfere with normal cord apposition so get hoarseness

142
Q

Vocal cord paralysis

A

Usually U/L and p/w hoarse breathy voice as the cords cannot appose, if severe may get aspiration

Usually the result of left RLN palsy (as it has the longer course + goes around the aortic arch) - e.g. chest pathology like malignant mediastinal nodes, oesophageal or bronchial carcinoma, aortic aneurysm, chest/neck surgery

Either RLN can be damaged by thyroid surgery or H+N cancers

143
Q

Recurrent laryngeal nerve palsy

A

Can be due to surgery or cancer of the thyroid, or a brainstem pathology

144
Q

Sialdenitis

A

Usually acute inflammation of salivary gland

  • RF: SG stones, reduced flow (dehydration, post-op, drugs), poor oral hygiene, exacerbation of chronic inflammation
  • Mumps: usually parotid glands. Swollen + painful, low grade fever, malaise. Self limiting, can cause deafness/orchitis/encephalitis
  • Acute suppurative parotitis: in immunocompromised, uncommon, Abx/drainage
  • Acute sialadenitis: usually SM gland, infection from oral cavity tracts back/stone in duct. Five, painful swollen gland worse on eating. M: analgesia, fluids, may need Abx/drainage, remove stone after infection
145
Q

Sialolithiasis

A

Stones in salivary duct cause pain + swelling - worse during meals

Mostly affect SM gland (e.g. stone in Wharton’s duct which drains it) as this is where thickest mucus made, can get in parotid (e.g. Stenson’s duct), v rare in SL

Ix: US or sialogram

M: small ones analgesia+hydration, otherwise may need radiological or surgical removal of the stones/gland

Comps: sialadenitis, abscess

146
Q

Sjogren’s syndrome

A

Autoimmune lymphocytic infiltrate into ductal tissue of secretory glands – dry eyes, dry mouth, enlarged SG, higher risk lymphoma, keratoconjunctivitis sicca

Causes b/l, painless enlargmenet of the gland. Lymphocytic infiltrate. Supportive treatment

Primary or a/w CT disease like RA, 90% female

147
Q

Salivary retention cysts

A

Mostly in floor of mouth, surgically removed

148
Q

What is a permanent enlargement of a salivary gland?

A

cancer until proven otherwise

149
Q

What might cause salivary gland hypertrophy that isn’t cancer?

A

endocrine e.g. myxoedema

drugs e.g. oral hypoglycaemics

150
Q

Salivary gland tumours

A
  • Benign: pleomorphic adenoma most common + usually parotid (slow growing, smooth, mobile), can become malignant but slow growth; also Warthin’s tumour (multiple cysts + solid lymphoid tissue, typically elderly male)), haemangioma
  • Malignant: adenoid cystic carcinoma (early perineural invasion), also other types
151
Q

Sialorrhoea

A

Salivary overflow when can’t control SM/SL glands - can cause eczema + soil clothes - hyoscine patches help reduce flow, sometimes botox

152
Q

Effect of HIV on the parotid gland

A

Lymphoepithelial cysts - b/l, multi cystic, symmetrical parotid swelling. Low risk of malignant transformation so usually conservative

153
Q

Sarcoidosis in the salivary glands

A

May affect parotid glands (b/l) with non-tender swelling, xerostomia

154
Q

Epidemiology of H+N cancers

A

M:F 2:1, usually SCC, high mortality + debilitating treatments.
RF: alcohol, tobacco, betel nut chewing (oral cancer), Chinese ethnicity (NP carcinoma), oropharyngeal HPV, male, older, low SES

155
Q

CF of H+N cancers

A 
Dysphonia, dyspnoea- esp laryngeal
Dysphasia/odynophagia
Neck mass
Pain from site or referred otalgia
Bleeding fro nose/moiuth
Nasal blockage
Non-healing ulcer in mouth or tongue
156
Q

Where do H+N cancers arise?

A
  • Larynx: commonest site for SCC, commonest is glottic @ VC. Often need a total laryngectomy so then breathe through a laryngeal stoma + speak through valve
  • Pharynx + oral cavity: less common + worse prognosis, nasopharyngeal mostly chinese men, oropharyngeal in tonsis, ‘hypopharynx’ esp poor prognosis. cf are dysphagia, hoarseness, non-healing ulcers, u/l nasal polyps
157
Q

How to investigate thyroid nodules

A

FNA
Hemithyroidectomy if suspect follicular disease as DNA doesn’t pick up

Lumpectomies don’t give adequate margins

158
Q

Non-neoplastic thyroid nodules

A
  • Single nodules: colloid, cystic

* Multinodular goitre: common, if typical appearance on US don’t need FNA

159
Q

Thyroid neoplasms

A
  • Benign: follicular adenoma
  • Malignant: papillary adenocarcinoma (70%, a/w younger pt or neck irradiation), follicular carcinoma (20%, mets to bones + lungs), medullary carcinoma (5%, of calcitonin secreting C-cells, typical in MEN so screen other organs), anaplastic carcinoma (5%, typically older pt, poor prognosis)
160
Q

How are thyroid nodules managed?

A
  • Non-neoplastic: conservative, unless causing sx or diagnostic uncertainty in which cause aim for hemithyroidectomy to reduce endocrine comps
  • Neoplastic: adenoma hemi-thyroidectomy to confirm, for carcinoma total thyroidectomy +/-adjuvant radio-iodine therapy (for papillary + follicular carcinoma)
161
Q

What are the complications of thyroid surgery?

A
  • Haematomas: confined space so resp compromise can arise - need to immediately remove sutures
  • Airway obstruction due to haemorrhage or RLN palsy
  • VC palsy
  • Hypocalcaemia from parathyroid gland damage/removal, can cause QTc prolongation
162
Q

Differentials for facial pain

A
  • Sinusitis: facial fullness + swelling, nasal discharge, pyrexia, cough from post-nasal drip
  • Trigeminal neuralgia: u/l facial pain, brief electric shock-like pains that have abrupt onset + termination, may have triggers like emotion or light touch
  • Cluster headache: pain 1/2 per day for between 15m-2h, clusters of 4-12w, intense pain around one eye a/w redness, lacrimation, lid swelling, nasal stuffiness
  • Temporal arteritis
163
Q

Black hairy tongue

A

May be brown, green, pink or black

  • RF: poor oral hygiene, Abx, H+N radiation, HIV, IVDU
  • Swab tongue to exclude candida - give topical antifungals
  • M: tongue scraping
164
Q

How do the vocal cords appear in respiration + phonation, in normal + paralytic states?

A
  • Normal: open in resp, fully closed in phonation
  • U/l paralysis, open in resp but not fully on one side, not fully closed on one side in speech
  • B/L paralysis remain slightly open in respiration, fully closed in phonation
165
Q

Scarlet fever

A

Reaction to toxins produced by group A beta haemolytic strep, most commonly 2-6y

  • Typically high fever, malaise, headache, N+V, sore throat, strawberry tongue, fine punctate erythema on torso initially + flexors ‘sandpaper’ texture, children often flushed appearance with circumoral pallor, later get desquamation esp fingers/toes
  • Take throat swab but start Abx empirically
  • Pen V for 10d or azithromycin
  • Notifiable disease
  • May get comps - otitis media after 20d is most common, also acute glomerulonephritis, bacteraemia, nec fasc
166
Q

What is a goitre?

A

Enlarged thyroid gland

If big can compress airway + cause dysphagia

167
Q

What is a thyroid nodule?

A

An abnormal mass in the thyroid, majority aren’t true neoplasms but need to check fro neoplasia + functional nodules causing hyperthyroidism

168
Q

Anterior vs posterior epistaxis

A

Anterior - visible source of bleeding, usually an insult to Kiesselbach’s plexus

Posterior - more profuse, originate from deeper structures, more in elderly pt, higher risk of aspiration + airway comrpmosie

169
Q

Naspharyngeal carcinoma

A

SCC of nasopharynx, rare except in people from Southern China, a/w EBV infection

CF: cervical lymphadenopathy, otalgia, u/l serous otitis media, nasal obstruction/discharge/epistaxis, CN palsies

Combined CT + MRI to image, radiotherapy 1st line treatment

Neuro + special senses (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions