ENT Flashcards
Name the three ossicles.
Malleus
Incus
Stapes
What is conductive hearing loss?
Problem transferring sound waves to the ear canal/middle ear
Name three causes of conductive hearing loss.
Cerumen Ruptured eardrum Otosclerosis Glue ear Middle ear effusion
What is otosclerosis?
Increased bone turnover –> sclerosis –> ankylosis of stapes footplate in oval window of cochlea
May be precipitated by pregnancy if genetically predisposed (incomplete penetrance so may skip generations)
Causes fixation of the stapes bone
How does conductive hearing loss present?
All sounds are faint and muffled
Worse in lower frequencies
What tests are used to diagnose deafness?
Otoscopy
Rinne/Weber test
Tympanometry
Pure tone audiometry
What conductive hearing loss causes are treated with surgery?
Middle ear effusion
Ototsclerosis
Cholesteatoma
What is presbyacusis?
Hearing loss of older people
Loss of outer hair cells in cochlea
What is sensorineural hearing loss?
Deafness due to a problem with the cochlea or vestibulocochlear nerve.
What are the causes of sensorineural hearing loss?
Presbyacusis
Noise induced hearing loss (permanent increased stimuli threshold for outer hair cells in cochlea)
Head injury/acoustic neuroma/Meniere’s/viral infection
What is a treatment of sensorineural hearing loss?
Cochlear implants
Hearing aids
Name three causes of childhood conductive hearing loss.
Treacher Collins syndrome
Pierre Robin syndrome
Congenital cholesteatoma
Nam three causes of childhood sensorineural hearing loss.
Idiopathic
Alport/Turner syndrome
Ototoxic drugs
Infection with CMV, HSV, syphilis, rubella, toxoplasmosis, group B strep sepsis
What are some peri/postnatal causes of childhood deafness?
Cerebral palsy
Meningitis
Birth trauma
The perception of sound in the ears or head where no external source of the sound exists is called what?
Tinnitus
In examination of a patient with tinnitus, what is important to check for?
Impacted cerumen and otitis media
Carotid bruit
CN defects
Masses or glands in neck
What is the treatment of tinnitus?
Relaxation techniques, tinnitus retraining therapy, and masking devices.
Give five subjective causes of tinnitus.
Meniere's disease Deafness - all types Acoustic neuroma MS Head injury Ear infection Drugs: aminoglycosides, quinine, aspirin, loop diuretics
What is mastoiditis?
Rare complication of acute otitis media
Acute inflammation of the mastoid with colliquation of the air filled mastoidal bone
Where is the mastoid process?
An inferior extension of the petrous temporal bone
How does mastoiditis occur?
A suppurative infection extends from the middle ear to the mastoid air cells, leading to inflammation and bony destruction.
What organisms are implicated in mastoiditis?
Strep pneumoniae
Strep pyogenes
Staph
Pseudomonas aeruginosa
What are the risk factors for development of mastoiditis?
Pre-existing cholesteatoma
Young children
Immune deficiency
Intellectual impairments
How does acute mastoiditis differ from chronic mastoiditis?
Patients will have intense otalgia and fever at present, rather than recurrent bouts with an insidious onset.
What is seen when examining an inflamed mastoid process?
Swelling and redness
Boggy tender mass behind ear
External ear may protrude forwards
Ear discharge and erythematous tympanic membrane
How is mastoiditis diagnosed?
Leukocytosis and increased ESR
Blood cultures
Tympanocentesis for staining and culture
Skull XR - clouding of mastoid air cells
How is mastoiditis managed?
Admit to hospital
Broad spectrum IV abx with third gen cephalosporin
What are three complications of mastoiditis?
Hearing loss
Osteomyelitis
Labyrinthitis
What are the symptoms of TMJ disorders?
TMJ pain that may be referred to head, neck, and ear
Restricted jaw motion
Joint noise
Locking episodes
What are some TMJ disorders?
TMJ hypermobility TMJ osteoarthritis Chronic pain syndrome Orofacial dystonias Dental malocclusion
How are TMJ disorders managed?
TMJ rest
Bite guards
Physio
Analgesics/anti-depressants
Defined the following:
1) Sialadenitis
2) Sialectasis
3) Sialolithiasis
1) inflammation of a salivary gland
2) Dilation of salivary duct
3) Stone related disease within salivary gland ducts
What are five causes of parotid swelling?
Viral parotitis - mumps Sjogrens syndrome Benign and malignant tumours Sarcoidosis (with facial nerve palsy) Acute and chronic bacterial parotitis Salivary stones
What are salivary gland stones composed of and which gland do they usually affect?
Submandibular
Mucus, cellular debris, calcium, magnesium phosphates
How does sialolithiasis present?
Colicky post prandial swelling of the gland
USS - hyperechoic lines
How is obstruction salivary gland disease managed?
Many stones pass spontaneously
Otherwise dilation and incision
What are some general symptoms of salivary gland swelling?
Painful, tender swelling Dry mouth Abnormal tastes Facial pain Decreased mouth opening Fever
What blood tests are important in a patient presenting with salivary gland swelling?
FBC, CRP/ESR, UEs, Cultures, Viral serology/salivary antibody testing
What investigations are important in a patient presenting with salivary gland swelling?
Pus swab for culture and sensitivity
Sialography
Later - US, fine needle aspirate
Name two benign tumours of the salivary gland.
Pleomorphic adenoma
Warthin’s tumour
What percentage of salivary gland tumours are malignant?
20%
What is the most common cause of vertigo?
Benign paroxysmal positional vertigo
What is the cause of BPPV?
Otoliths become detached from the macula into the semi-circular canals
Hair cells embedded in the otoliths are stimulated as they are pushed by endolymph through the canals during head movement.
Detached otoliths may continue to move after the head has stopped moving - vertigo results from conflicting sensation of ongoing movement.
Apart from idiopathic (60%), what are the other causes of BPPV?
Head injury
Post viral illness (viral neuronitis)
Chronic middle ear disease
What are the symptoms of BPPV?
Episodes of vertigo provoked by head movement
Symptoms worse when head is tilted.
Nausea not vomiting
Worse in the mornings
How is BPPV assessed?
Dix-Hallpike test - reproduces symptoms/nystagmus
How is BPPV managed?
Self limiting
Epley’s manoeuvre
How does Epley’s manoeuvre treat BPPV?
Repositions otoliths back into utricles from posterior semi-circular canals
What is Meniere’s disease?
Disorder of the inner ear caused by increased fluid volume of the labyrinth, injuring the vestibular system or cochlea.
What are three risk factors of Meniere’s disease?
Allergy
Migraine
Genetic susceptibility
Viral illness
What are the core symptoms of Meniere’s disease?
Vertigo
Tinnitus
Fluctuating hearing loss with a sensation of aural pressure
How are the attacks of Meniere’s disease distributed?
Occur in clusters
6-11 per year
Last a few hours
What tests are used in the diagnosis of Meniere’s disease?
Weber/Rinne’s test
Dix-Hallpike test
Bloods
Audiometry
What is the treatment of an acute attack of Meniere’s disease?
Prochlorperazine or cyclizine
What is the prophylactic treatment of choice for Meniere’s disease?
Betahistine TD
What is vestibular neuronitis?
A vestibular neuropathy caused by a viral infection (hx of recent viral URTI)
How does labyrinthitis differ from vestibular neuronitis?
Labyrinthitis - both vestibular nerve and labyrinth are involved.
L - hearing loss
VN - no hearing loss
Both self limiting, do not drive
What triggers vestibular neuronitis?
Prior URTI
How does vestibular neuronitis/labyrinthitis present?
Sudden severe constant vertigo
Not triggered by movement but may be exacerbated by movement.
Nausea and vomiting
Hearing loss/tinnitus in labyrinthitis
What may be seen in the external ear in vestibular neuronitis?
Cholesteatoma
Vesicles suggestive of herpes zoster oticus
What must be ruled out during examination of a patient with vertigo?
Mastoid tenderness
High fever
Nuchal rigidity
Basically, mastoiditis or meningitis
Describe the gait of a person with vestibular neuronitis.
Patients fall towards the affected side.
What is the management of vestibular neuronitis/labyrinthitis?
Prochlorperazine in the acute phase (if continued for duration of the illness it interferes with central rehabilitation processes)
Mobilisation and 2x daily vestibular rehabilitation exercises
Myringotomy and evacuation of effusion
What is oral cancer a potential malignancy of?
Buccal mucosa Alveolus Hard palate Tongue Tonsils Lip Mouth floor
What is the name of a tumour of the vestibulocochlear nerve?
Acoustic neuroma
What is the main risk factor for acoustic neuromas?
Neurofibromatosis type 2
What are the symptoms of acoustic neuroma?
Asymmetrical hearing loss or tinnitus
Vestibular dysfunction - balance problems, ear ache
Smoking is a risk factor for which ENT malignancies?
Oral
Laryngeal
Pharyngeal
What type of cancer are oral, laryngeal, and pharyngeal cancers?
Squamous cell carcinomas
can have oral mucosal melanomas
What are the classifications of salivary gland cancers?
Mucoepidermoid
Acinic cell
Adenoid cystic carcinomas
Chronic hoarseness suggests which ENT malignancy?
Laryngeal
What are the other symptoms of laryngeal cancer?
Dysphagia/sore throat
Lump in neck
Persistent cough
How is laryngeal cancer diagnosed?
Urgent CXR
Flexible laryngoscopy
Fine needle aspiration of any neck masses
What is the treatment of laryngeal cancer?
Total and partial laryngectomy
Transoral laser microsurgery
What is the gold standard of diagnosis for salivary gland cancers?
Ultrasound
What are the symptoms of salivary gland cancers?
Most slowly enlarging painless mass
Intermittent pain
Facial nerve palsy/paraesthesiae
Name three pre-cancerous lesions of the oropharynx and oral cavity.
Leukoplakia
Erythroplakia
Mixed erythroleukoplakia
Give some symptoms of naso-pharyngeal cancer.
Nasal obstruction
Deafness
Post nasal discharge
What is otitis externa?
Inflammation of the outer ear
“Swimmers’ ear”
What does the outer ear consist of?
Auricle, external auditory canal, eardrum
What are the symptoms of otitis externa?
Otalgia and pain moving ear/jaw
Discharge
Itching
Deafness
What is seen on examination in otitis externa?
Pre-auricular lymphadenopathy
Erythematous canal, oedema and exudate
Fever (<38)
How is otitis externa managed, first line and second line?
Keep the ear dry
Topical drops. Mild - acetic acid. Severe - topical antibiotic with or without topical steroid
Severe = discharge, debris, deafness
Second line: PO flucloxacillin (ciprofloxacin for diabetics to cover pseudomonas)
What are some risk factors for otitis externa?
Swimming
Diabetes
Low or high amounts of cerumen
Dermatitis
What are some red flags that suggest a serious or other cause of trigeminal neuralgia?
Sensory changes Deafness Poor response to carbamazepine Onset under 40 Optic neuritis/FH of MS
What is a surgical alternative to nerve decompression in trigeminal neuralgia?
Rhizotomy
A dull, yellowing, retracted ear drum suggests what condition?
Recurrent otitis media with effusion (glue ear)
What are the usual causative organisms of acute otitis media?
RSV
Rhinovirus
Hib
Strep pneumoniae
Moraxella catarrhalis
What is a cholesteatoma
A destructive and expanding growth consisting of keratinizing squamous epithelium
Where is a cholesteatoma found?
Middle ear or mastoid process - check attic
What is the result of the cholesteatoma?
Destruction of the bones of the middle ear/growth through the base of the skull into the brain
What is the name of the conditions where there is painful bleeding gums with halitosis and punched out ulcers?
Necrotizing ulcerative gingivitis
What is the treatment of NUG?
Refer patient to a dentist
PO metronidazole 3d
Chlorhexidine mouthwash
Analgesia
In left sided sensorineural deafness, what does Weber’s test show
Sound is localised to the right unaffected side
Name an ototoxic drug.
Gentamycin Quinine Aspirin Furosemide Chemotherapy
What is a thyroglossal cyst?
Midline neck lump which moves upwards with protrusion of the tongue
What is a cystic hygroma?
Congenital lymphangioma found on the left side of the neck. Fluctuates and transilluminates.
What is a branchial cyst?
A cystic mass that develops between the sternocleidomastoid muscle and the pharynx.
Contains cholesterol crystals
Which test forms part of the Newborn Hearing Screening Programme?
Otoacoustic emission test
If the otoacoustic emission test is abnormal in a newborn, what is the next step?
Auditory brainstem response test
What is the treatment of sinusitis?
Antipyretic, nasal saline/decongestants
Symptoms present for more than 10 days - antibiotics
Name a red flag nasal symptom that warrants urgent referral to ENT.
Unilateral nasal polyp
What is the initial treatment of epistaxis?
Sit leaning forwards with mouth open
Pinch the cartilaginous part of nose
If successful, use topical antiseptic such as Naseptin
What is the treatment of continuing epistaxis?
Can’t see site of bleeding: anterior packing
Can see site of bleeding: cautery with silver nitrate
What score is used to assess severity of tonsillitis and what is the threshold?
Centor/FEVERpain score >3
What is the treatment of tonsillitis?
Centor score <3: regular analgesia
Centor score >3: phenoxymethylpenicillin 7 to 10d
What are four associations of nasal polyps?
Asthma
Cystic fibrosis
Aspirin sensitivity
Infective sinusitis
What is the treatment of otosclerosis?
Sodium fluoride
Stapedectomy
What is the treatment of acoustic neuroma?
Watch and wait
Stereotactic radiosurgery
Microsurgery
What is the treatment of chronic sinusitis?
Nasal corticosteroids
Give three risk factors for sinusitis.
URTI Allergic rhinitis GPA/Churg-Strauss Asthma Immunocompromised
