ENT Flashcards
Meniere’s disease
Meniere’s disease is a disorder of the INNER EAR of unknown cause. It is characterised by excessive pressure and progressive dilation of the endolymphatic system. It is more common in middle-aged adults but may be seen at any age. Meniere’s disease has a similar prevalence in both men and women.
Features:
- recurrent episodes of VERTIGO, TINNITUS and HEARING LOSS (sensorineural). Vertigo is usually the prominent symptom
- a sensation of aural fullness or pressure is now recognised as being common
- other features include NYSTAGMUS and a POSITIVE ROMBERG test
- episodes last MINUTES TO HOURS
- typically symptoms are unilateral but bilateral symptoms may develop after a number of years
Natural history:
- symptoms resolve in the majority of patients after 5-10 years
- the majority of patients will be left with a degree of hearing loss
- psychological distress is common
Management:
- ENT assessment is required to confirm the diagnosis
- patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved
- acute attacks: buccal or intramuscular PROCHLORPERAZINE. Admission is sometimes required
- prevention: BETAHISTINE and vestibular rehabilitation exercises may be of benefit
Acute sinusitis -pathophysiology, predisposing , features, mx
Sinusitis describes an inflammation of the mucous membranes of the paranasal sinuses. The sinuses are usually sterile - the most common infectious agents seen in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses.
Predisposing factors include:
- nasal obstruction e.g. Septal deviation or nasal polyps
- recent local infection e.g. Rhinitis or dental extraction
- swimming/diving
- smoking
Features:
- facial pain: typically frontal pressure pain which is worse on bending forward
- nasal discharge: usually thick and purulent
- nasal obstruction
Management of acute sinusitis:
- analgesia
- intra nasal DECONGESTANTS or nasal saline may be considered (symptomatic relief)
- NICE CKS recommend that INTRANASAL CORTICOSTEROIDS may be considered if the symptoms have been present for more than 10 days
- oral antibiotics are not normally required but may be given for severe presentations.
- -The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’
- -‘double-sickening’ may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection
Mastoiditis- features
Features:
- otalgia: severe, classically behind the ear
- there may be a history of recurrent otitis media
- fever
- the patient is typically very unwell
- swelling, erythema and tenderness over the mastoid process
- the external ear may protrude forwards
- ear discharge may be present if the eardrum has perforated
Perforated tympanic membrane - including mx
The most common cause of a perforated tympanic membrane is INFECTION. Other causes include barotrauma or direct trauma.
A perforated tympanic membrane may lead to hearing loss depending on the size and also increase the risk of otitis media.
Management
- no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time- KEEP DRY
- it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. NICE support this approach in the 2008 Respiratory tract infection guidelines
- myringoplasty may be performed if the tympanic membrane does not heal by itself
If there is still a perforation 6 weeks since the perforation occurred then ENT referral should be considered.
Cholesteatoma - features, otoscopy, mx
Cholesteatoma is a non-cancerous GROWTH of squamous epithelium that is ‘trapped’ within the skull base causing local destruction. A cholesteatoma is a benign keratinising squamous epithelium that forms a cyst within the middle ear or mastoid.
It is most common in patients aged 10-20 years. Being born with a cleft palate increases the risk of cholesteatoma around 100 fold.
Main features
One would expect one with a cholesteatoma to have generally insidious and slowly progressive symptoms
- foul-smelling, non-resolving DISCHARGE
- hearing LOSS
Other features are determined by local invasion:
- vertigo
- facial nerve palsy
- cerebellopontine angle syndrome
(persistent otitis media, otalgia, vertigo and facial weakness)
Otoscopy
- ‘attic crust’ - seen in the uppermost part of the ear drum
Management
- patients are referred to ENT for consideration of surgical removal
FeverPAIN criteria
score 1 point for each (maximum score of 5)
- Fever over 38°C.
- Purulence (pharyngeal/tonsillar exudate).
- Attend rapidly (3 days or less)
- Severely Inflamed tonsils
- No cough or coryza
tonsillitis - abx
If antibiotics are indicated then either phenoxymethylpenicillin (PENICILLIN V) or ERYTHROMYCIN (if the patient is penicillin allergic) should be given. Either a 7 or 10 day course should be given
NICE indications for antibiotics - tonsillitis
- features of marked systemic upset secondary to the acute sore throat
- unilateral peritonsillitis
- a history of rheumatic fever
- an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)
- patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present
Sinusitis - features
- Facial ‘fullness’ and tenderness
- Nasal discharge, pyrexia or post-nasal drip leading to cough
Trigeminal neuralgia - features
Unilateral facial pain characterised by brief electric shock-like pains, abrupt in onset and termination
May be triggered by light touch, emotion
Cluster headache- features
Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
Clusters typically last 4-12 weeks
Intense pain around one eye
Accompanied by redness, lacrimation, lid swelling, nasal stuffiness
Treatment for tonsillitis
Phenoxymethylpenicillin for 10 days
Audiograms- rules?
Audiograms are usually the first-line investigation that is performed when a patient complains of hearing difficulties. They are relatively easy to interpret as long as some simple rules are followed:
- anything above the 20dB line is essentially normal (<20)
- in sensorineural hearing loss both air and bone conduction are impaired
in conductive hearing loss only air conduction is impaired
- in mixed hearing loss both air and bone conduction are impaired, with air conduction often being ‘worse’ than bone
Vestibular schwannoma (acoustic neuroma)
The classical history of vestibular schwannoma includes a combination of VERTIGO, hearing LOSS, TINNITUS and an ABSENT CORNEAL REFLEX.
Features can be predicted by the affected cranial nerves:
- cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
- cranial nerve V: absent corneal reflex
- cranial nerve VII: facial palsy
Bilateral vestibular schwannomas are seen in neurofibromatosis type 2.
Patients with a suspected vestibular schwannoma should be referred urgently to ENT. It should be noted though that the tumours are often slow growing, benign and often observed initially.
MRI of the cerebellopontine angle is the investigation of choice. Audiometry is also important as only 5% of patients will have a normal audiogram.
Management is with either surgery, radiotherapy or observation.
Ramsey Hunt syndrome
Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve-SHINGLES AFFECTING THE FACIAL NERVE
Features:
- auricular PAIN is often the first feature
- facial nerve palsy
- vesicular rash around the ear (not always)
- other features include vertigo and tinnitus
Management
- oral aciclovir and corticosteroids are usually given
Acronym - PURPLE RASH (look at desktop pics)
Nasal - associations, features, mx
Associations:
- asthma* (particularly late-onset asthma)
- aspirin sensitivity*
- infective sinusitis
- cystic fibrosis
- Kartagener’s syndrome
- Churg-Strauss syndrome
Features:
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
Unusual features which always require further investigation include UNILATERAL symptoms or bleeding.
Management:
all patients with suspected nasal polyps should be referred to ENT for a full examination
topical corticosteroids shrink polyp size in around 80% of patients
*the association of asthma, aspirin sensitivity and nasal polyposis is known as Samter’s triad
Malignant otitis externa- what is, feature , diagnosis, treatment ?
Uncommon type of otitis externa that is found in IMMUNOCOMPROMISED individuals (90% cases found in diabetics)
- most commonly caused by Pseudomonas aeruginosa
- Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal
- Progresses to temporal bone osteomyelitis
Key features in history:
- DIABETES (90%) or immunosuppression (illness or treatment-related)
- Severe, unrelenting, deep-seated otalgia
- Temporal headaches
- Purulent otorrhea
- Possibly dysphagia, hoarseness, and/or facial nerve dysfunction
Diagnosis
A CT scan is typically done
Treatment
non-resolving otitis externa with worsening pain should be referred urgently to ENT
Intravenous antibiotics that cover pseudomonal infections
Epidermoid cysts
common cutaneous cysts that result from the proliferation of epidermal cells within a circumscribed space of the dermis.
They can occur at any age and are typically asymptomatic.
On physical examination they are typically firm, round nodules of various sizes and a central punctum may be present.
Thyroglossal cyst
More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
Branchial cyst
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
Pre auricular sinus
- Common congenital condition in which an epithelial defect forms around the external ear
- Small sinuses require no treatment
- Deeper sinuses may become blocked and develop episodes of infection, they may be closely related to the facial nerve and are challenging to excise
Management of epistaxis
If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves:
- Asking the patient to sit with their torso forward and their mouth open- avoid lying down unless they feel faint. This decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth. It also reduces the risk of aspirating blood.
- Pinch the cartilaginous (soft) area of the nose firmly and consistently for at least 15 minutes and ask the patient to breathe through their mouth.
Obscure causes of vertigo….
POSTERIOR CIRUALTION stroke
trauma
MS
Ototoxicity e.g. gentamicin
Acute Viral labyrinthitis - features
Recent viral infection Vertigo Sudden onset Nausea and vomiting Hearing may be affected sudden onset horizontal nystagmus
Patients will typically present with symptoms such as a previous ear infection, tinnitus, or previous coryzal symptoms.
Benign paroxysmal positional vertigo- features?
Gradual onset
Triggered by change in head position
Each episode lasts 10-20 seconds
Positive Dox-Hallipike manoeuvre
Vertebrobasilar ischaemia
Elderly patient
Dizziness on extension of neck
If a perforated tympanic membrane does not heal by itself then…
A MYRINGOPLASTY may be performed
Following a perforation healing should occur within 6-8 weeks
Peritonsillar abscess (quinsy)
A peritonsillar abscess typically develops as a complication of bacterial tonsillitis.
Features include:
- severe throat pain, which LATERALISES to one side
- deviation of the uvula to the unaffected side
- trismus (difficulty opening the mouth)
- reduced neck mobility
Patients need urgent review by an ENT specialist. Most patients are treated with needle aspiration under local anaesthesia.
Sudden vertigo and hearing loss secondary to a viral infection…. what is the diagnosis?
Viral labyrinthitis
Acute externa more likely to be severe if:
- a red, oedematous ear canal which is narrowed and obscured by debris
- conductive hearing loss
- discharge
- regional lymphadenopathy
- cellulitis spreading beyond the ear
- fever
Management of otitis externa
Mild cases (mild discomfort and/or pruritus; no deafness or discharge), consider prescribing topical ACETIC ACID 2% spray.
- When features of more severe inflammation are present, such as in this case, they advise 7 days of a TOPICAL ANTIBIOTIC with or without a topical STEROID. e.g. topical ciprofloxacin +dexamethasone ; topical gentamicin + hydrocorticose
Second-line options include
- consider contact dermatitis secondary to neomycin
- oral antibiotics (flucloxacillin) if the infection is spreading
- taking a swab inside the ear canal
- empirical use of an antifungal agent
Gingival hyperplasia - medication that causes it
Drug causes of gingival hyperplasia
- phenytoin
- ciclosporin
- calcium channel blockers (especially nifedipine)
Other causes of gingival hyperplasia include
- acute myeloid leukaemia (myelomonocytic and monocytic types)
Otitis externa in diabetics - treatment?
Ciprofloxacin to cover Psuedomonas
Diabetics are likely to have malignant otitis externa - The cause of malignant otitis externa is a chronic Pseudomonas aeruginosa infection which becomes invasive and erodes the temporal bone.
When to give antibiotics for otitis externa?
And what is the antibiotic given?
- spreading erythema
- no improvement in symptoms with antibiotic and steroid spray
First line is:
Oral flucloxacilin
What is Rhinitis medicamentosa?
A condition of rebound nasal congestion brought on by EXTENDED USE of topical decongestants.
Treatment of rhinitis medicamentosa involves withdrawal of the offending nasal spray (cold turkey). Use of over the counter saline nasal sprays may help open the nose without causing rhinitis medicamentosa if the spray does not contain a decongestant. Antibiotics are not indicated as it is not an infective process. Referral to ENT is not typically indicated.
Allergic rhinitis
Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens. It may be classified as follows, although the clinical usefulness of such classifications remains doubtful:
- seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever
- perennial: symptoms occur throughout the year
- occupational: symptoms follow exposure to particular allergens within the work place
Features:
- sneezing
- bilateral nasal obstruction
- clear nasal discharge
- post-nasal drip
- nasal pruritus
Management of allergic rhinitis:
- allergen avoidance
if the person has mild-to-moderate intermittent, or mild persistent symptoms:
oral or intranasal antihistamines
if the person has moderate-to-severe persistent symptoms, or initial drug treatment is ineffective
intranasal corticosteroids
a short course of oral corticosteroids are occasionally needed to cover important life events
there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline). They should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal
Features of head and neck cancer
neck lump
hoarseness
persistent sore throat
persistent mouth ulcer
Cancer pathway referral critera for laryngeal cancer
people aged 45 and over with:
- persistent unexplained hoarseness or
- an unexplained lump in the neck
Cancer pathway referral criterial for oral cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
- unexplained ulceration in the oral cavity lasting for more than 3 weeks or
- a persistent and unexplained lump in the neck.
Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
- a lump on the lip or in the oral cavity or
- a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
Cancer pathway referral criteria for thyroid cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with:
- an unexplained thyroid lump.
If someone had unexplained hoarseness ages over 45 - consider urgent referral to ENT. What other investigation would you do?
Any patient presenting with hoarseness who are being referred down the suspected cancer pathway should have a CHEST X-RAY to exclude an apical lung lesion.
Causes of hoarseness?
Voice overuse Smoking Viral illness Hypothyroidism Gastro-oesophageal reflux Laryngeal cancer Lung cancer
How to investigate for laryngeal cancer?
An ultrasound is not suitable
Further imagine to exclude after referral to ENT includes a neck and chest CT with contrast, flexible fibre-optic laryngoscopy and fine needle aspiration is there is a neck mass.
What to do for a perforated eardrum?
A perforated eardrum will usually heal by itself within 6-8 weeks
It heals in the same way as a cut on the skin. They should avoid getting water into the ear as this can impair healing and increase the chance of infection.
Other management:
- it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. NICE support this approach in the 2008 Respiratory tract infection guidelines
- myringoplasty may be performed if the tympanic membrane does not heal by itself
Otosclerosis- features and management
Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window.
Autosomal dominant, replacement of normal bone by vascular spongy bone.
Onset is usually at 20-40 years features include:
- conductive deafness
- tinnitus
- tympanic membrane - 10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
- positive family history
Management:
hearing aid
stapedectomy
Mouth lesions - when to do 2 week wait referrals?
2 week wait referrals to oral surgery should be done in all of the following cases:
- Unexplained oral ulceration or mass persisting for greater than 3 weeks
- Unexplained red, or red and white patches that are painful, swollen or bleeding
- Unexplained one-sided pain in the head and neck area for greater than 4 weeks, which is associated with ear ache, but does not result in any abnormal findings on otoscopy
- Unexplained recent neck lump, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
- Unexplained persistent sore or painful throat
- Signs and symptoms in the oral cavity persisting for more than 6 weeks, that cannot be definitively diagnosed as a benign lesion
Conditions that have the feature of vertigo?
Viral labyrinthitis Vestibular neutonitis BPPV Meniere's disease Vertebrobasilar iscahemia Acoustic neuroma Posterior circulation stroke Trauma MS Ototoxicity e.g. gentamicin Ramsey hunt
Deafness can be caused drug ototoxicity - examples of drugs include
Examples include:
- aminoglycosides (e.g. Gentamicin),
- furosemide,
- aspirin
- and a number of cytotoxic agents
