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ENT Flashcards

1
Q

Name of of the triangles in the neck and important structures within

A

Submental: Bilateral anterior digastrics and hyoid bone
- submental lymph nodes
- myohyoid muscle
Submandibular: anterior and posterior digastric and mandible
- submandibular gland
- facial artery and vein
- mandibular branch of facial nerve
- hypoglossal nerve
Muscular: Median line, omohyoid, sternocleidomastoid
- thyroid gland
- larynx
- strap muscles
Carotid: omohyoid, sternocleidomastoid, posterior digastric
- Carotid artery and its division into the internal and external carotid
- internal jugular vein
- Vagus nerve
- Ansa cervicalis
Posterior cervical: sternocleidomastoid, trapezius, clavicle
- External jugular vein
- Phrenic nerve
- Accessory nerve
- Roots of brachial plexus
- ansa cervicalis

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2
Q

Name the divisions of the External Carotid Artery

A 
Some Anatomists Like Freaking Out Poor Medical Students
Superior thyroid
Ascending pharyngeal
Lingual
Facial
Occipital
Posterior auricular 
Maxillary
Superficial temporal
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3
Q

Name the Levels of the neck

A 
Submental - I (Ia and Ib)
Submandibular - II (IIa and IIb)
Middle sternocleidomastoid - III
Inferior sternocleidomastoid - IV
Posterior cervical - V
Muscular - VI
Supraclavicular
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4
Q

List the differential for a midline neck mass

A 
Congenital:
- Thyroglossal duct cyst
- Dermoid 
- Teratoma
- Thymic cyst
- Vascular tumours and malformations
Inflammatory/Infectious:
- lymphadenitis
- thyroiditis
Neoplastic
- thyroid
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5
Q

List the differential for a lateral neck mass

A 
Congenital:
- Brachial cleft cyst
- pre-auricular pit/sinus/cyst
- vascular malformation
- pseudotumour of infancy
- thymic cyst
Infectious:
- lymphadenitis: viral, bacterial, infectious mononucleosis, atypical mycobacterium, cat-scratch disease
- infection of congenital mass
- deep neck space infection
- parotitis
Inflammatory:
- Kawasaki
- Sarcoidosis
Neoplastic:
Benign: vascular tumour, teratoma, dermoid, lipoma, nerve tumour
Malignant: lymphoma, rhabdomyosarcoma, thyroid
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6
Q

List the most common brachial cleft cyst?

A

Second brachial cleft

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7
Q

Discuss the presentation and treatment of a first brachial cleft cyst

A

Presentation:
- Cyst or draining sinus that is anterior to the ear
- can extend over parotid or angle of mandible
- tract can extend into external auditory canal
Treatment:
- surgical excision with careful dissection of facial nerve

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8
Q

Discuss the presentation and management of a second brachial cleft cyst

A 
Location: 
- Cyst located along anterior border of middle to lower third of SCM
- tract extends along carotid sheath -> between divisions of carotid -> terminating in tonsillar fossa
Presentation: 
- cyst with clear or mucoid drainage
Investigations: 
- ultrasound and then CT
Treatment: 
- surgical excision
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9
Q

Discuss the presentation and management of pseudotumour of infancy

A 
- Intra-uterine trauma to the neck resulting in hematoma and subsequent fibrosis
Presentation: 
- firm, round mass along SCM that presents in 2-3 weeks of life
- possible torticollis
Investigations:
- ultrasound
- FNA
Treatment:
- physiotherapy
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10
Q

Discuss the presentation and management of a lymphatic malformation of the neck

A

Presentation: soft, mobile, painless, cystic mass in posterior triangle. Grow with infant growth
Investigations: MRI
Treatment: bleomycin

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11
Q

Discuss the presentation and management of infantile hemangioma

A

Presentation: soft, mobile, bluish/red masses. Must discuss risk of airway hemangioma. Most improve within 5-7 years
Treatment: Propanolol

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12
Q

What are the risks of propanolol therapy for infantile hemangioma?

A

Cardiac: hypotension, arrhythmia, bradycardia
Hypoglycaemia
Respiratory: worsening of asthma, bronchospasm

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13
Q

What are the most likely organisms for acute suppurative lymphadenitis?

A

Staph aureus

Group A beta-hemolytic strep

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14
Q

What inflammatory neck lesion presents in an asymptomatic child in the submandibular region of the neck?

A

Atypical mycobacterium

Concern with surgery is mandibular branch of facial nerve

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15
Q

Discuss the presentation and management of a thyroglossal duct cyst

A

Demographics:
- Children 2-10 years old
Presentation:
- soft, smooth, painless cyst at the level of the hyoid
- Elevates with swallowing
Investigations:
- ultrasound (must ensure normal thyroid is present)
Treatment:
- Sistrunk procedure (remove cyst and hyoid bone)

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16
Q

What are the most common neck masses by age group?

A 
0-15:
Infectious
Congenital
Malignant
Benign
16-40
Infectious
Congenital
Benign
Malignant
>40:
Malignant/Benign mass (SCC common)
Infectious
Congenital
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17
Q

What are the red flags for a child presenting with stridor?

A 
Hypoxemia
Tachypnea
Tripod positioning 
Respiratory distress
Decreased level of consciousness
Drooling
Agitation
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18
Q

List the clinical findings and possible cause of a child with stridor?

A

Inspiratory stridor and snoring:
- Nasal problems (polyps, choanal atresia)
- foreign body
- neoplasm
Gurgling with muffled voice -> pharyngeal problem:
- afebrile: macroglossia, neoplasm, adenotonsillar hypertrophy
- febrile: epiglotittis, acute tonsillitis, infectious mononucleosis, abscess
High pitched inspiratory stridor with voice change and hoarseness -> laryngeal problem:
- afebrile: laryngeal mass, subglottic stenosis, vocal cord paralysis
- febrile: epiglotittis, croup
Inspiratory and expiratory wheezes -> tracheal problem:
- acute: foreign body
- chronic: tracheal mass
Expiratory wheeze -> bronchial pathology
- symmetric breath sounds: asthma, foreign body
- asymmetric breath sounds: foreign body, asthma

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19
Q

Discuss the presentation and management of laryngeomalacia

A

Pathophysiology:
- collapse of tissue above airway from short aryepiglotic folds
- arternoid prolapse
- omega-shaped epiglottis
Symptoms:
- Presents 2 weeks after birth
- inspiratory stridor that is intermittent and increases with feeding, normal cry, noisy sleep
Treatment:
- surveillance
- surgical if apnea, failure to thrive, difficulty feeding

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20
Q

Discuss the presentation and management of unilateral and bilateral vocal cord paralysis

A

Unilateral:
- no stridor and able to maintain airway, voice changes
Bilateral:
- significant inspiratory stridor and respiratory distress resulting in tracheostomy

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21
Q

Discuss the presentation and treatment of tracheomalacia

A 
Presentation: 
- expiratory wheeze
- apnea
- feeding difficulties and failure to thrive
Investigations: 
- bronchoscopy showing vascular rings
22
Q

Discuss the presentation and management of retropharyngeal abscess

A 
Demographics:
- children <2 with antecedent URTI
Symptoms: 
- stridor
- muffled voice
- gurgling
- odynophagia
- fever
Signs: 
- mass in lateral neck
- painful hyper extension
Investigation: 
- x-ray showing enlarged retropharyngeal space
Treatment: 
- Group A beta-hemolytic strep so receive penicillin following I/D
23
Q

Discuss the presentation and treatment of epiglotittis

A 
Demographics: 
- 2-12 year olds
- haemophilus influenza type B
Symptoms: 
- stridor
- muffled voice
- hoarseness
- odynophagia leading to drooling
- leaning forward
- fever
Investigations: 
- x-ray showing thumb sign of epiglotis
Treatment: 
- Maintain airway and cefuroxime
24
Q

Discuss the presentation and management of croup (laryngeotracheobronchitis)

A 
Demographics: 
- 3 months to 5 years, 
- Spring and Fall
Organism: 
- para-influenza 1&3, 
- influenze A&B,
- RSV
Symptoms: 
- stridor
- hoarseness
- barky cough
- rhinitis
- worse at night
Investigation: 
- x-ray show steeple sign
Treatment: 
- oxygen
- dexamethasone PO 0.6mg/kg, 
- nebulized epinephrine
25
Discuss the presentation and management of malignant otitis externa
Develops from otitis externa where pseudomonas extends through haversion canals into the skull causing osteomyelitis Presentation: - otitis externa with granulation tissue - CNVII palsy Treatment: - topical ciprodex - long term IV 3rd generation cephalosporin
26
List the indications for tympanostomy tubes with acute otitis media
Recurrent (>=4 in 6 months or >=6 in 12 months) Language delay Febrile seizures
27
List some of the complications of acute otitis media
``` Intra-temporal: - tympanic membrane perforation - mastoiditis - cholesteatoma Intracranial: - meningitis - subdural abscess - extradural abscess - cavernous sinus thrombosis Extracranial: - retropharyngeal abscess - parapharyngeal abscess - lymphadenitis ```
28
What is the mechanism of a cholesteatoma?
Perforated tympanic membrane -> squamous epithelium invaginate and shed kerratin -> form epithelial cyst cholesteatoma -> activates osteoclasts -> erodes ossicles and nerves
29
List the indications for tympanostomy tubes for chronic otitis media with effusion (>3 months)
Bilateral COME with hearing loss >30dB for >3 months Any language or speech delay Unilateral COME with hearing loss >30dB for >6 months
30
What are the different forms of hearing loss and how are they detected?
Conductive hearing loss: air-bone gap where bone is better than air Sensorineural hearing loss: decrease in both air and bone conduction, especially in higher frequencies Mixed: both
31
List the differential and pertinent signs for sensorineural hearing loss
Presbycusis: bilateral high frequency hearing loss, age-related Noise-related: bilateral, acute with temporal shift, chronic have 4kHz decrease in hearing Meniere’s disease: unilateral low frequency hearing loss, tinnitus, episodic vertigo, sensation of fullness Vestibular Schwannoma: unilateral hearing loss, tinnitus, vertigo Ototoxicity: Aminoglycosides, Erythromycin, Furosemide, Cisplatin, Quinone Sudden Sensorineural Hearing Loss: Occur over 3 days, >30dB loss in 3 consecutive frequencies
32
List the common typanometry findings
Type A: Normal Type Ad: flaccid tympanic membrane (dislocation of ossicle) - increased Type As: stiff tympanic membrane or ossicle - decreased Type B: fluid or mass in middle ear - flat with no peak Type C: Eustachian tube dysfunction - negative peak pressure
33
List the differential for conductive hearing loss
``` Intact tympanic membrane: - Otosclerosis - Ossicular dysfunction - Trauma - acute otitis media - Middle ear effusion Perforated tympanic membrane: - trauma ```
34
Discuss the approach to dizziness
Vertigo: sensation of spinning when none exists: - migraine - hearing loss: -> episodic vertigo: Menieres -> nonepisodic vertigo: Labyrinthitis - non hearing loss: -> episodic vertigo: benign positional paraoxysmal vertigo -> nonepisodic vertigo: vestibular neuritis Disequilibrium: off-balance when standing or walking - multiple underlying conditions: peripheral neuropathy, medications, muscle weakness, decreased vision Presyncope: feeling off going to pass out - orthostatic hypotension - cardiac: arrhythmia, myocardial infarction, arterial stenosis Lightheadedness: disconnect to environment - psychological: anxiety, depression - medications: alpha blockers, anti-hypertensives, nitrates, antipsychotics, TCA, opioids, Parkinson’s drugs, muscle relaxants, urological drugs
35
Discuss the presentation and management of BPPV
Symptoms: - episodic vertigo lasting seconds to minutes - aggravated with head motion Signs: - positive Dix-Hallpike - rotatory nystagmus with reversibility and latency Treatment: - Epley maneuver to remove cupololithiasis from posterior semicircular canal
36
Discuss the presentation and management of Meniere’s disease
``` Symptoms: - severe episodic vertigo lasting hours to days - sensation of fullness - tinnitus - ataxia - nystagmus Signs: - unilateral low frequency hearing loss - decreased vestibular activity Treatment: - lifestyle: smoking cessation, decreased salt intake - Medications: hydrochlorothiazide, antihistamine - Surgery ```
37
Discuss the presentation and management of vestibular neuritis
``` Symptoms: - antecedent URTI - vertigo lasting days to weeks - nausea/vomiting Signs: - ataxia - nystagmus - decreased vestibular activity Treatment: - self-limiting in 3-6 weeks - methylprednisone 100mg PO daily tapered to 10mg PO daily over 3 weeks - gravol, ondansetron ```
38
List the two main arteries and their divisions within the nose
``` Internal carotid: - anterior ethmoidal - posterior ethmoidal External carotid - sphenopalantine - greater palantine - superior labial ```
39
What is the most common location of epistaxis
Kiesselbech’s plexus
40
List the differential for causes of epistaxis
``` Local: - trauma - inflammatory: allergy, infection - neoplasm - foreign body - medication: steroid, cocaine - idiopathic Systemic - medication: anticoagulant - vascular: congenital - cardiovascular: hypertension ```
41
Discuss the presentation and management of anterior epistaxis
``` Pathophysiology: bleeding from Kiesselbech’s plexus Presentation: blood out of nose first then oropharynx, can visualize bleeding with anterior rhinoscopy Treatment: - Trotter method - silver nitrate coagulation - Surgicel - Anterior nasal packing - Surgery ```
42
Discuss the presentation and management of posterior epistaxis
Location: sphenopalantine artery Presentation: bleeding into the oropharynx and then anterior nose, not visualized on anterior rhinoscopy Treatment: posterior nasal pack, embolization, surgery
43
List the investigations for epistaxis
ABC’s CBC, INR, pTT, type and screen Cardiac monitoring and fluid resuscitation Blow out clots Soak cotton ball in vasoconstrictor (cocaine, Otrixin) and anaesthetic (lidocaine) to examine
44
Differentiate between anterior nasal packing and posterior nasal packing
Anterior: - apply nasal tampon with Otrixin in nose horizontal to palate OR - use Vaseline gauze inserting from inferior to superior compressing down after each pass - tape string on outside cheek to avoid aspiration - Packing remains for 2-3 days as outpatient and have MD remove - post-removal use nasal saline spray (hydrasense) and vaseline q12h for 2 weeks Posterior: - insert Foley into nostril and inflate balloon in oropharynx and pull back - proceed with nasal packing technique - treat as inpatient with continuous cardiac monitoring
45
List some complications of anterior and posterior packing for epistaxis
- Toxic shock syndrome (prevented with Amoxicillin or Cephalexin) - sinusitis (prevented with Amoxicillin or Cephalexin) - nasal trauma or synechiae - alar necrosis - aspiration of packing material
46
What is Samter’s Triad?
Asthma Nasal polyps Sensitivity to NSAIDs
47
What are some of the complications of acute sinusitis?
``` Eye: - pre-septal cellulitis - orbital cellulitis - sub-periosteum abscess - orbital abscess Skull - Pott’s puffy tumour (frontal bone abscess) - vascular necrosis of frontal bone - osteomyelitis Intracranial - cavernous sinus thrombosis - meningitis - epidural, subdural abscess ```
48
List some indications to refer to ENT for sinusitis
Failure of 2nd line antibiotics Chronic or recurrent sinusitis immune compromised Allergic rhinitis
49
What are the most common pathogens for chronic sinusitis?
Staph aureus Anaerobes Strep pneumonia Haemophilus influenza
50
Discuss the presentation and management of chronic sinusitis
Definition: chronic sinusitis with or without nasal polyp Symptoms: - CPODS (C for congestion) Treatment: - With nasal polyp: topical intransal corticosteroid and antibiotic, surgery - Without nasal polyp: topical intranasal corticosteroid spray with irrigation, 2nd-line long term antibiotics (clarithromycin)
51
Discuss the treatment of a tympanic membrane perforation
Most will heal spontaneously Must avoid ototoxic antibiotic ear drops and water in ear antibiotics only if signs of infection (otalgia, otorrhea) - amoxicillin, Septra Surgery if persists >2 months or have conductive hearing loss
52
What are some of the reversible risk factors for COME?
``` Sleeping with a bottle Smoking or wood burning stove in household Cat Daycare with >=6 kids Pacifier ```

Mandatory Selectives (9 decks)

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