ENT Flashcards
You are the ED intern on duty. You are asked to see and treat a 20 year-old man who has broken his nose playing football three hours previously. It has not stopped bleeding. You can ignore all other issues other than those related directly or indirectly to do with his nose. How will you proceed to assess and treat his nosebleed?
- Primary survey to determine breathing difficulty and haemodynamic stability
- Apply pressure to the anterior nose and lean forward to prevent aspiration. Obtain history to determine anticoagulation/past history
- If bleeding persists, use rhinoscope to identify source of the bleed and use cautery, nasal packing
- if persists, add posterior packing using a foley catheter
- If persists, refer to ENT for endoscopic ligation
- Once haemostasis is achieved, look for fracture
A -> anterior and posterior ethmoid arteries
S -> superior labial artery
S -> sphenopalatine arteries
You are a GP. You are consulted by a 55 year-old man who has a hoarse voice. What features of his history must you establish before deciding on your next steps?
History features should include: duration, progression, initiating incident, consistency, dysphagia, weight loss, lethargy/tiredness, smoking status, PMH, otalgia, cough/dyspnoea, occupation For hoarse voice referral -> SCALD S -> smoker or stridor C -> constant haemoptysis A -> acute onset (<3 weeks) L -> loss of weight D -> dysphagia/dyspnoea
You are the ED intern on duty. Your patient is a 30 year-old man who has had a sore throat for three days, which is getting worse. He has difficulty opening his mouth, ear pain on the right and cannot swallow his saliva. On examination he has a temperature of 39°C, pulse 115 bpm.
Oral examination reveals a unilateral, left sided tonsillar swelling with a diffuse, oedematous bulge superior and lateral to the tonsil. The uvula is deviated to the right.
What is the diagnosis?
What is the cause of the problem?
The diagnosis is a peri-tonsillar abscess
Cause of the problem is poorly treated tonsillitis, sometimes due to perforation of tonsil infiltration surrounding tissue. It can occur without prior infection due to obstruction of Weber glands.
Triad of Quinsy is trismus, uvular deviation and dysphonia (hot potato voice).
Uvula deviation on contralateral side due to CNX palsy. Trismus due to involvement of motor branch of CN V.
Peritonsillar abscesses are commonly multi-microbial. Microbes include:
The most common pathogen is streptococcus. Other organisms may be seen on culture
Referred ear pain can be due to involvement of the glossopharyngeal nerve
You are the ED intern on duty. Your patient is a 30 year-old man who has had a sore throat for three days, which is getting worse. He has difficulty opening his mouth, ear pain on the right and cannot swallow his saliva. On examination he has a temperature of 39°C, pulse 115 bpm.
Oral examination reveals a unilateral, left sided tonsillar swelling with a diffuse, oedematous bulge superior and lateral to the tonsil. The uvula is deviated to the right.
What is the diagnosis?
What is the management?
The diagnosis is a peri-tonsillar abscess
Management includes initial primary survey. Requires surgical incision and drainage by ENT. Corticosteroids may be given to reduce swelling . IV fluids and analgesia
Penicillin and metronidazole cover aerobic and anaerobic.
You are on duty in A & E. Your next patient is a 3 year-old child with rapidly progressive airway obstruction, looking toxic, drooling, tachycardic and tachypnoeic, sitting up leaning forward looking worried. The child is not immunised.
What is the most important differential diagnosis?
What will you do?
The most important differential diagnosis is acute epiglottitis.
Uncommon due to Hib being the most likely pathogen and the availability of its vaccine. Organisms now include strep or staph.
requires urgent referral to paediatrics, ENT, ICU
airway management by qualified staff -> ABCDE
Abx empirical -> ceftriaxone
corticosteroids
IV fluid
Heather is a 4 year-old girl who had a tonsillectomy seven days ago. She presents to the ED with bleeding per orally. She has bled around two cupfuls of fresh blood in 30 minutes. You are one of the Emergency Department doctors. Heather is in the waiting room.
What is the diagnosis?
What is your management plan?
Diagnosis is a post-tonsillectomy haemorrhage
These occur in 2-5% of patients and occur 5-10 days post-operatively. Caused by separation of the eschar, may be due to SSI.
Management is ABCDE. Ensure appropriate fluid replacement. Stop source of bleeding by applying adrenaline soaked gauze and pressure/adrenaline injection/cautery
Discuss with ENT about need for Abx and admittance
A 45 year-old male comes to your GP practice with a two month history of hoarse voice. He has recently developed a swelling on the left side of his neck. He is a heavy smoker and consumes substantial alcohol daily. You are the doctor examining him.
What is the most likely diagnosis and examination findings?
What are relevant investigations/referrals for him?
Most likely diagnosis is a laryngeal squamous cell carcinoma (LSCC) with cervical lymph node involvement.
Glottic (rather than supra or sub) is most common
Examination findings include hoarse voice, lymph node involvement, weight loss, dysphagia/dyspnoea, parotid or thyroid masses
investigations include a FBC, CT head/neck, USS of mass, FNA of mass
Referral to ENT
A 45 year-old female comes to your GP practice with a one year history of a midline neck swelling. She also gets tremors and says that her heart races at times and has lost some weight that she is pleased about.
What are the relevant investigations that are related to this case?
Concerned about hyperthyroidism.
Investigations include FBC, UEC, TSH, T3, T4, anti-TPO, anti-TSH, ECG, neck USS, radioisotope thyroid scanning
Liam was involved in a fight yesterday at the local pub and was slapped in the face. He had a sharp shooting ear pain following the slap and says that he cannot hear too well since then. He also says that he cannot pop his ear drums since that incident. He comes to your practice.
What is the most likely diagnosis and what will you expect from the examination point of view? What will be your advice?
Most likely diagnosis is a perforated tympanic membrane.
Examination:
Weber’s test will show poorer air than bone conduction in affected ear. Rhines test will be negative
Examination will show perforated membrane, with potential for blood/serous exudate
Advice is that it will heal spontaneously. Do not get wet. Come back if still painful or infected for Abx. Avoid similar injuries in the future.
Be wary of balance issues due to inner ear damage
You are working in emergency and you see a 4 year-old boy with fever, left otalgia and acute left facial nerve palsy. What is the likely diagnosis and what would you do from here?
Diagnosis is AOM
Refer to ENT due to involvement of facial nerve
provide analgesia (ibuprofen). For children >2, pain <48h, fever <39, no treatment.
otherwise consider amoxycillin 5-7 days
You are working in emergency and you see a 4 year-old boy with fever, left otalgia and acute left facial nerve palsy.
What is the most likely diagnosis?
What condition could this develop into that causes swelling behind the ear and the ear to stick out/forwards?
The most likely diagnosis is AOM.
The condition is mastoiditis. This infection spreads from the middle ear posteriorly into the mastoid air cells. Cause inflammation and swelling causing pressure on ear.
other features of mastoiditis include: persistent/recurrent fever/otalgia, profuse ear discharge, swollen and erythematous mastoid
You are working in emergency and you see a 4 year-old old boy with fever, left otalgia and acute left facial nerve palsy. What is the most likely diagnosis?
How would you manage this boy?
AOM
Manage with referral to ENT. Requires fluid and analgesics. Discuss need for Abx. Potential for CT.
You are working in emergency and you see a 4 year-old boy with fever, left otalgia and acute left facial nerve palsy. What is the most likely diagnosis?
What dangerous complications can result from this condition?
AOM
Intracranial: abscess, vestibulitis, labyrinthitis, , meningitis, encephalitis,
Extracranial: cholesteatoma, mastoiditis, tympanic membrane perforation, balance and motor problems, facial nerve compression/palsy
A 65 year-old lady has presented with a lump in her right cheek, centred near the angle of the mandible. What is the differential diagnosis?
80:20 rule -> most likely to be cancer.
Sebaceous cyst, lipoma, abscess, lymphadenopathy, mumps, HIV, salivary duct stones/stenosis.
Parotid tumour -> pleomorphic adenoma, Warthin’s tumour, primary carcinoma, secondary from SCC
osteoma, dental abscess
How do you go about assessing a 40 year-old woman who presents with a lump in her lateral neck?
80:20 rule -> think malignant until proven otherwise.
History -> duration, pain, inciting incident, fever, dysphagia, smoking, haemoptysis
Examination -> location, feel, warmth, tugging, mobile, location in anterior/posterior triangle.
Investigation -> FNA, biopsy, USS, TSH, T3/T4, anti-TPO
