ENT Flashcards
What are the main differentials for vertigo?
- benign paroxysmal positional vertigo
- menieres disease
- vestibular neuronitis /labrynthitis
- iron deficiency anaemia
describe the features of BPPV?
episodic vertigo - lasts for seconds
occurs when turn head e.g. in bed
relapsing remitting
What is BPPV precipitated by?
upper resp viral infection
head injury
inner ear pathology e.g. vestibular neuronitis
ear surgery
How is BPPV diagnosed?
dix hallpike manoeuvres - nystagmus if +ve
How is BPPV managed?
Epley Manoevres - by specialist
or Brandt Daroff exercises at home
Describe the features of menieres disease?
- episodic vertigo - lasts for 20 mins - 12 hours
- tinnitus - precedes the attack
- aural fullness “pressure, warm feeling in ear”
- hearing loss
-> leads to chronic unsteadiness and hearing loss
How can menieres disease be managed through lifestyle?
salt restriction
stop smoking
caffeine restriction
consider risks before driving, swimming, diving or operating machinery
How can menieres disease be managed with medication?
- anti emetic and anti histamine (e.g. cyclizine) for nausea
- betahistine for reducing endolymphatic fluid imbalance in inner ear
- IV labarynthe sedatives and fluids
Define vestibular neuronoitis?
inflammation of the vestibular nerve, usually by viral infection
Define labarythitis?
inflammation of the labarinth
how does vestibular neuronitis present?
sudden onset debilitating vertigo for 2-3 days + gradual recovery over few weeks
nausea and vomiting
unsteadiness
unwell for first few days
What sign can you see on examination of vestibular neuronitis?
Head Impulse Nystagmus Type Skew deviation test
How is vestibular neuronitis managed?
- supportive care - for nausea and vomiting can give oral /IM cyclizine or prochlorperazine but delays recovery time as interferes with cerebral compensatory mechanisms
- if persist for >6 weeks, consider referral
List the differentials for a sore throat?
tonsilitis pharyngitis glandular fever quinsy laryngitis epiglottitis diphtheria
What are the causes of tonsilitis?
- VIRAL (80%) - epstein barr virus **, herpes simplex, adenovirus
- BACTERIAL (20%) - streptococcus pyogenes** , strep pneumonia, staph aureus
What are the common features of tonsilitis?
- sore throat
- fever
- malaise
- cervical upper anterior lymphadenopathy
+ anorexia, dysphagia, halitosis
bacterial infection is a MORE SEVERE ILLNESS
Which criteria is used to assess the likelihood that the tonsilitis is a bacterial infection?
CENTOR CRITERIA
- fever
- tonsillar exudate
- tender anterior cervical adenopathy
- no cough
How is the centor criteria calculated and what does each score mean?
1 pt for each criteria + 1pt for age <15 y/o (subtract 1pt if > 44y/o)
0-1 pt = no antibiotics needed
2-3 pts = throat culture + antibiotic if culture +ve
4-5 pts = treat with antibiotic
Describe the appearance of tonsilitis on examination?
oedematous + yellow +/- white pustules
How is a bacterial tonsilitis treated?
phenoxymethylpenicillin (or erythromycin) for 7-10 days
supportive care - bed rest, hydration, analgesia
What are the complications of tonsilitis?
peritonsillar abscess (quinsy) otitis media rheumatic fever scarlet fever glomerulonephritis
What are the indications for a tonsillectomy?
> 7 bacterial infections in 12 months
1 quinsy
suspected malignancy
sleep disordered breathing e.g. sleep apnoea
What are the complications of tonsillectomy?
haemorrhage, pain
What is the most common cause of chronic sore throat?
pharyngitis- caused by adenovirus, enterovirus, rhinovirus
How is pharyngitis treated?
paracetemol or ibuprofen
bed rest
plenty of fluids
What is the cause of glandular fever?
Epstein Barr virus (HHV4)
How does glandular fever present?
FOR 2-4 WEEKS:
- sore throat
- fever
- cervical lymphadenopathy - anterior and posterior triangles
+ anorexia, tiredness, headache, hepatosplenomegaly
How is glandular fever investigated and diagnosed?
- MONOSPOT *test - confirms in week 2
- FBC *
+ UandE , LFTS (causes hepatitis)
what would you find on examination of someone with glandular fever?
tonsils greatly enlarged and covered by membranous exudate
+ petechial haemorrhages + hepatosplenomegaly
How is glandular fever managed and what advice should be given?
- supportive care - bed rest, analgesia, fluids
- avoid alcohol
- avoid contact sports for 8 weeks (at risk of splenic rupture)
What happens if you take amoxicillin whilst having glandular fever?
maculopapular pruritic rash
What is quinsy?
= peritonsillar abscess
abscess/ pus forms between the tonsil capsule and superior constrictor muscle from a bacterial tonsillitis
How does a peritonsillar abscess typically present?
usually after bacterial tonsilitis
severe unilateral sore throat "hot potato" voice dysphagia -> can result in dribbling trismus = difficulty opening mouth cervical adenopathy reduced neck mobility
Explain the findings on examination of quinsy?
uvula deviation
unilateral tonsillar inflammation
cervical adenopathy
reduced neck mobility
How is quinsy managed?
- refer to hospital
- IV penicillin
- surgical aspiration under local anaesthetic
- tonsillectomy
List the differentials for facial pain?
- atypical facial pain
history of depression, vague history, unresponsive to medications - trigeminal neuralgia
sharp pain in maxillary and mandibular regions,
Rx: carbamazepine - giant cell arteritis
+ jaw claudication, scalp tenderness, fever, amaurosis fugax, polymyalgia rheumatica
Rx: high dose pred - sinusitis
- dental causes
e. g. abscess - migraine
+ severe unilateral pulsating throbbing pain, nausea
Rx: NSAIDS, triptans - ENT malignancy e.g. malignant pleomorphic adenoma
Define sinusitis?
inflammation of the mucous membranes of paranasal sinuses
List the 4 paranasal sinuses
- frontal sinus
- ethmoidal sinus
- sphenoidal sinus
- maxillary sinus
What is the common cause of sinusitis?
viral / bacterial infection - strep pneumonia **, h. influenza*, rhinovirus
What are the risk factors for sinusitis?
recent local infection smoking swimming / diving nasal polyposis deflected nasal septum or turbinate hypertrophy
List the features of acute sinusitis?
diffuse throbbing headache and facial pain - pressure in the forehead, between eyes and occipital ***
pain worse on bending forward
post coryzal nasal congestion and discharge
recurrent
halitosis
How is sinusitis treated?
- analgesia e.g. paracetemol, codeine
- intranasal decongestant or nasal drops e.g. oxymetazoline
- saline irrigation
- steam or menthol inhalations
if severe and suspect bacterial cause, give phenoxymethylpenicillin
What is a possible complication of sinusitis?
periorbital cellulitis, brain abscess, meningitis
When would a pt with sinusitis be referred to surgery?
refer if >3 antibiotics needed throughout the year, if suspected intracranial/ orbital involvement , refer for CT
- intranasal polypectomy
- septal correction
List the LOCAL causes of epistaxis?
idiopathic ** trauma e.g. injury, nose picking, surgery foreign body infection neoplasia
List the GENERAL causes of epistaxis?
coagulation disorders e.g. thrombocytopenia, ITP, splenomegaly
drugs e.g. aspirin, warfarin, cocaine use
malignancy e.g. leukaemia
Hypertension
hereditary haemorrhagic telangiectasia
What are two areas that can bleed in epistaxis?
ANTERIOR (90%) - epistaxis occurs in Kiesselbachs plexus (littles area)
POSTERIOR - more profuse bleeding and from deeper structures (higher risk of aspiration and airway compromise)
How are nose bleeds initially managed?
ABC + Trotters method = nostrils pinched together, patient leans forward, mouth open
+ topical anti septic (Naseptin) - to reduce crusting and vestibular risk
If epistaxis continues after initial first aid measures, what should you do?
- assess blood loss - BP, pulse, signs of shock, FBC, clotting screen and cross matched
- cauterize with local anaesthetic spray and silver nitrate
- if continue to bleed, use anterior nasal pack -> POSTNASAL PACK
- if continues need to examine under anaesthetic with arterial ligation
after epistaxis, what lifestyle advice is given?
avoid picking nose
avoid hot drinks, alcohol
avoid heavy lifting or exercise
avoid lying flat
List the differentials for cervical lymphadenopathy / lump in neck?
MALIGNANCY - lymphoma (single neck lump), metastaic spread of cancer, primary cancer (thyroid carcinoma)
INFECTION - TB, glandular fever, mumps, hIV
AUTOIMMUNE - Sjogrens, SLE, scleroderma, RA
OTHER - sarcoidosis, branchial arch cyst , thyroglossal cyst
How should a thyroid swelling be assessed?
- examination - differentiate between goitre or a nodular single mass, determine size, associated symptoms
- TSH *
- thyroid ultrasound scan * - determine if cystic or solid
How should a thyroid swelling be treated?
thyroidectomy or thyroid lobectomy
List the main risk factors for head and neck cancers?
smoking **
alcohol **
viruses - HPV 16, Epstein Barr virus **
What is the main type of head and neck cancers?
- squamous cell carcinoma *
How are head and neck cancers investigated?
- examination - palpate lymph nodes, use flexible fibroptic endoscopy
- CT scan
- PET scan
- biopsy
What are general features of head and neck cancers?
- neck lump
- persistent sore throat
- hoarseness
- persistent mouth ulcers
How are head and neck cancers managed?
- surgery - quick local clearance of disease
- radiotherapy - can be option on its own
+ establish nutritional status, refer for dental assessment, correct anaemia, encourage smoking cessation, refer to SALT
What are the main features of laryngeal cancer?
2nd most common head and neck cancer
hoarse voice, persistent irritating cough, dysphagia, dyspnoea
What are the main features of cancer of the oral cavity?
high incidence world wide
persistent mouth ulcers, dental problems, dysphagia, numbness, referred ear pain
What are the main features of cancer of the pharynx?
nasopharyngeal - cervical lymphadenopathy, nasal symptoms, unilateral hearing loss
oropharyngeal - sore throat, lump in throat
hypopharyngeal - dysphagia, odynophagia, hoarse voice
What are the features of tumours of salivary gland?
painless lump in neck - difficult to distinguish between benign and malignant
facial pain, facial nerve palsy, infiltration of surroundings
What are the different types of thyroid cancers?
- papillary * - good prognosis
- follicular * - good prognosis
- medullary
- anaplastic - poor prognosis
Describe the presentation of papillary or follicular thyroid cancer?
painless neck lump **
younger females
10% have spread to lymph nodes
Describe the features of anaplastic thyroid cancer?
elderly females rapidly enlarging painful neck lump bilateral lymphadenopathy 90% have distant/ regional spread at diagnosis aggressive
Describe who is more likely to get medullary thyroid cancer and how are they present?
MEN !! - familial
painless unilateral neck lump
cervical lymphadenopathy
Describe the pathology of medullary thyroid cancers?
neuroendocrine tumour arising from the parafollicular C cells -> secrete calcitonin !!!
How is a neck lump that is suspected to be thyroid cancer investigated?
- thyroid ultrasound * and fine needle aspiration
- calcitonin - high in medullary cancers, used to monitor disease
- TFT, FBC, LFTS, U&Es
- CT and PET scan
How is papillary and follicular cancer managed?
total thyroidectomy + radioiodine (I-131) + yearly thyroglobulin levels to detect recurrence
What are the risks with a thyroidectomy?
hypoparathyroidism
recurrent laryngeal nerve injury - hoarse voice, bovine cough
bleeding
How is anaplastic thyroid cancer managed?
palliation with radiotherapy, resection if possible
What are the different types of salivary gland neoplasia?
BENIGN
benign pleomorphic adenoma - painless lump
Warthins tumour - usually in parotid, mobile mass
VARIABLE
mucoepidermoid tumour - in paroid gland
acinic cell tumour
MALIGNANT
malignant pleomorphic adenoma - panful lump with facial pain
adenoid cystic carcinoma - swelling and facial pain
squamous cell carcinoma
List the differentials for stridor?
croup acute epiglottitis foreign body inhalation laryngomalacia congenital tumours e.g. supraglottis haemangioma anaphylaxis subglottis stenosis acute laryngitis laryngeal carcinoma
What are the main features of croup?
cause: parainfluenza
s+s : fever, stridor, painful barking cough
who: 6 months - 3 years old
How is croup treated?
high flow oxygen + nebulised dexamethasone +/- nebulised adrenaline
How does acute epiglottitis present?
cause: group B haemophilus influenza
s+s: stridor, fever, severe sore throat, dribbling, breathing with open mouth
How is acute epiglottitis managed?
- emergency - do not examine throat
- IV cefuroxime
- nebulised adrenaline
- extubate - call anaesthetist
How does inhalation of foreign body present?
acute sudden onset coughing/ wheezing/ stridor
well in themselves
How is anaphylaxis managed?
- high flow oxygen
- adrenaline 1:1000 0.5ml IM
- fluid bolus 500ml 0.9% saline
- stop causative drug
- IV chlorphenamine 10mg
- 200mg IV hydrocortisone
List the differentials for otalgia (ear pain)
EAR RELALTED CAUSES otitis media otitis externia malignant otitis externa mastoiditis ramsay hunt syndrome neoplasia perichronditis otosclerosis acute otitis barotrauma
NON EAR RELATED CAUSES tonsilitis TMJ disorders neoplasmas of oropharyngeal dental problems foreign body
Define otitis externa
inflammation of the external ear canal (between the outer ear and ear drum)
What are the risk factors for otitis externa?
swimming "swimmers ear" eczema in the ear canal contact dermatitis seborrhoeic dermatitis trauma with cotton wool buds
What are the common infective agents of otitis externa?
staphylococcus aureus
pseudomonas aeruginosa
fungi
How does otitis externa present?
painful discharging ear **
itching and irritation of ear
How does ear look on examination in otitis externa?
red, swollen, tender ear
pain when pressing tragus or moving the pinna
discharge visible
How is otitis externa treated?
- topical antibiotics
- removal of any canal debris +/- otowick if ear v swollen
- precautions: avoid swimming, keep ears dry, don’t touch
Define otitis media
inflammation of the middle ear
How is otitis media caused?
- VIRUS- RSV**, rhinovirus
2. BACTERIA - streptococcus pneumonia, h. influenzae
How does otitis media present?
rapid onset of painful ear
rubbing/ tugging of ear
+ fever, systemic upset, irritable
often after a resp tract infection
How is viral otitis media managed?
paracetemol and ibuprofen + nasal decongestants
When should children with otitis media be prescribed antibiotics?
- <6 months old
- < 2y/o with bilateral OM
- immunocompromised
- increasingly unwell, decreased oral intake
- no improvement after 4 days
What does the ear look like o/e in otitis media
tympanic membrane is red, yellow or cloudy and can be bulging
What should be given if suspect bacterial otitis media?
5 days of amoxicillin (erythyromycin if allergic)
What are the possible complications of otitis media?
mastoiditis hearing loss recurrence of infection perforation of tympanic membrane intracranial complications: meningitis, extradual abscess
Define otitis media with effusion and what can it cause?
glue ear= collection of fluid within the middle ear space with no signs of inflammation
most common cause of hearing loss in children
What are the risk factors for otitis media with effusion?
cleft lip, downs syndrome, CF, recurrent otitis media, allergic rhinitis
When is mastoiditis common and what is it?
inflammation of the mastoid lining
common after otitis media infection and in young children
How does mastoiditis present?
painful ear
fever
systemically unwell
What signs on examination points towards a diagnosis of mastoiditis?
sagging ear canal wall
swelling, tenderness, redness over the mastoid and zygomatic
pinna pushed down
drum head bulges / discharging pus
How is mastoiditis treated?
IV antibiotics prolonged
who does malignant otitis externa affect?
elderly diabetics ***
immuncompromised
What is malignant otitis externa?
infection of the external ear canal that spreads into the temporal and mastoid bone - dangerous
which organism causes malignant otitis externa?
pseudomonas aeruginosa **
How does malignant otitis externa present?
severe unremitting ear pain
temporal headaches
purulent discharge
What are the complications of malignant otitis externa?
meningitis
cerebral abscess
dural sinus thrombosis
How is malignant otitis media diagnosed and treated?
- CT scan *
- oral/ IV flucloxacillin
- surgical debridement?
what is ramsay hunt syndrome?
facial nerve infection by varicella zoster (shingles)
How does ramsay hunt syndrome present?
unilateral severe facial pain
vesicles on tM/ pinna
facial palsy
+ vertigo, deafness
How is ramsay hunt syndrome managed?
- oral acyclovir and corticosteroids
2. analgesia
What is conductive deafness?
when there is impediment / obstruction to the passage of sound waves between the external ear and footplate of the stapes
-> so there is decreased transmission of sound to the cochlea via air conduction
What are the possible causes of conductive deafness?
- obstruction of the ear canal e.g. wax, oedema, foreign body
- perforation of the tympanic membrane
- otosclerosis
- infection
- trauma
What is sensorineural deafness?
when there is fault in the cochlea or the cochlear nerve but sound transmitted normally to inner ear
What are the causes of sensorineural deafness?
- drug ototoxicity e.g. gentamicin, chemotherapy, aspirin, furosemide
- noise damage
- menieres disease
- acoustic neuroma
- viral infections e.g. mumps
How is acute deafness investigated?
- examination - ear, cranial nerves and neuro exam
- pure tone audiogram
- MRI
Describe the webers test
put tuning fork in middle of head and asked which side is loudest
unilateral sensorineural deafness = sound localised to unaffected ear
unilateral conductive deafness = sound localised to affected ear
Describe the Rinnes test
put tuning fork on mastoid process and when no longer heard, then reposition to over external acoustic meatus
normal = air conduction > bone conduction
conductive deafness= bone conduction > air conduction
what are the signs of acoustic neuroma?
associated with type 2 neurofibromatosis
cancer of the vestibulocochlear nerve (CN 8) so causes:
- hearing loss
- tinnitus
- vertigo
if causes cancer of CN7 then facial paralysis or CN5 absent corneal reflex
What is otosclerosis?
autosominal dominant condition where normal bone replaced with spongy bone
What are the features of otosclerosis and how is it managed?
conductive hearing loss, tinnitus, “flamingo tinge” to tympanic membrane
Rx: stapedectomy
What is presbycusis?
age related sensorineural hearing loss causing difficulty to follow conversations
what are the complications of quinsy?
airway obstruction
necrotising fasciitis
mediastinitis
what is a branchial cyst?
most common midline cyst in children
asymptomatic, moves on tongue protrusion
located below hyoid bone
what is a branchial arch cyst?
lateral cysts and located in the anterior triangle in front of sternomastoid
non tender lump, does NOT MOVE on tongue protrusion
aspirate and surgical excise
What is a cholesteoma?
Cholesteatoma is a non-cancerous growth of squamous epithelium that is ‘trapped’ within the skull base causing local destruction. It is most common in patients aged 10-20 years
causes hearing loss and discharge
