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
Glue ear - key features
Also known as otitis media with effusion
- peaks at 2 years of age
- HEARING LOSS is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood)
- secondary problems such as SPEECH AND LANGUAGE DELAY, behavioural or balance problems may also be seen
Otosclerosis - key features
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
What is haemorrhage 5-10 days after tonsillectomy commonly associated with?
- Wound infection and therefore should be treated with ANTIBIOTICS - which will reduce the bleeding
Post -operative complications of tonsillectomy
PAIN - The pain may increase for up to 6 days following a tonsillectomy.
HAEMORRHAGE - Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection.
Why could otitis externa prevent topical treatment with antibiotic drops?
As otitis externa can cause significant
canal oedema
canal stenosis
Causes of otitis externa
- infection: bacterial (Staphylococcus aureus,
- Pseudomonas aeruginosa) or fungal
- seborrhoeic dermatitis
- contact dermatitis (allergic and irritant)
Features of otitis externa
- ear pain, itch, discharge
- otoscopy: red, swollen, or eczematous canal
What is the recommended initial treatment of otitis externa?
- topical antibiotic or a combined topical antibiotic with a steroid
if the tympanic membrane is perforated aminoglycosides are traditionally not used - if there is canal debris then consider removal
- if the canal is extensively swollen then an ear wick is sometimes inserted
What are the second line options to treat otitis externa?
- 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
Name causes of tinnitus
- Meniere’s
- otosclerosis
- acoustic neuroma
- hearing loss
- drugs: aspirin, aminoglycosides, loop diuretics, quinine
- impacted ear wax
- chronic suppurative otitis media
Nasopharyngeal carcinoma - information, presenting features - both systemic and local, imagining and treatment?
- SQUAMOUS cell carcinoma of the nasopharynx
Rare in most parts of the world, apart from individuals from Southern China
Associated with Epstein Barr virus infection
Presenting features:
- SYSTEMIC : cervical lymphadenopathy
- LOCAL: otalgia, UNILATERAL serous otitis media, nasal obstruction , discharged /or epistaxis , cranial nerve palsies e.g. III-VI
Imaging : combined CT and MRI
Treatment : RADIOTHERAPY is first line therapy
Vestibular neuronitis - features
- RECURRENT vertigo attacks lasting hours or days
- nausea and vomiting may be present
- horizontal nystagmus is usually present
- no hearing loss or tinnitus
Vestibular neuronitis - management
- vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms
- buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases
- a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases
What is given in the acute phase of vestibular neuronitis? Why?
Prochlorperazine useful in acute phase. Should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms
What is the difference between vestibular neuronitis and labyrinthitis?
Labyrinthitis would also include hearing loss
Bulging tympanic membrane is suggestive of…
Otitis media
it would also be red
Otitis media - when should antibiotics be prescribed immediately? And what abx would you prescribe?
- Symptoms lasting more than 4 days or not improving
- Systemically unwell but not requiring admission
- Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
- Younger than 2 years with bilateral otitis media
- Otitis media with perforation and/or discharge in the canal
If an antibiotic is given, a 5-day course of AMOXICILLIN is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given.
What is the most suitable management option for epitaxis where the bleed site is difficult to localise?
Anterior packing
Anterior packs are lengths of absorbent material that are inserted into the nose and expand to fill the nasal canal, absorbing blood and compressing the walls of the airway. Some versions contain a small balloon which can be inflated to increase the tamponade effect.
(Cryotherapy or cautery with silver nitrate requires the bleeding vessel to be visible, which is not the case in this situation.)
Epistaxis - management
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.
If bleeding does not stop after 10-15 minutes of continuous pressure on the nose, consider cautery or packing. Cautery should be used if the source of the bleed is visible and cautery is tolerated- it is not so well tolerated in younger children! Packing may be used if cautery is not viable or the bleeding point cannot be visualised. If the nose is packed in primary care, the patient should be admitted to hospital for review.
Cautery:
Ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume.
Use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
Identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation.
Dab the area clean with a cotton bud and apply Naseptin or Muciprocin
Packing:
Anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes
Pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions
Pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack.
Examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel.
Patients should be admitted to hospital for observation and review, and to ENT if available
Patients that are haemodynamically unstable or compromised should be admitted to the emergency department- control bleeding with first aid measures in the interim. Patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.
Self-care advice involves reducing the risk of re-bleeding. Patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks should be avoided. The same applies for patients who have just been cauterised, as any strain on the nostril may induce a re-bleed.
A patient has a fever, cough and sore throat. What are you thinking?
Absence of cough makes you think tonsillitis. Also no exudate - therefore not thinking tonsillitis - thinking sore throat
What medication can be used in BPPV?
betahistine - but it tends to be of limited value
Tonsillectomy - when it is considered?
Surgery should only be considered if the person meets ALL of the following criteria:
- sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
- the person has FIVE or more episodes of sore throat per year
- symptoms have been occurring for at least a year
- the episodes of sore throat are disabling and prevent normal functioning
Other established indications for a tonsillectomy include:
- recurrent febrile convulsions secondary to episodes of tonsillitis
- obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
- peritonsillar abscess (quinsy) if unresponsive to standard treatment
What are the complications of a tonsillectomy ?
- primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
- secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain
What can otosclerosis be precipitated by?
By pregnancy in those who are genetically predisposed
otosclerosis would not be seen on otoscopy
What are the features of mastoiditis?
- otalgia - severe, classically behind the ear
- May be a history of recurrent otitis media
- Fever, patient 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
Benign tumours - parotid gland disease - general info
Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve. With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the 5th decade of life.
Benign pleomorphic adenoma or benign mixed tumour - features?
BENIGN PARTOID TUMOUR
- Most common parotid neoplasm (80%)
- Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
- Slow growing, lobular, and not well encapsulated
- Recurrence rate of 1-5% with appropriate excision (parotidectomy)
- Recurrence possibly secondary to capsular disruption during surgery
- Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma
Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma) - features?
BENIGN PARTOID TUMOUR
- Second most common benign parotid tumor (5%)
- Most common bilateral benign neoplasm of the parotid
- Marked male as compared to female predominance
- Occurs later in life (sixth and seventh decades)
- Presents as a lymphocytic infiltrate and cystic epithelial proliferation
- May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes
- Incidence of bilaterality and multicentricity of 10%
- Malignant transformation rare (almost unheard of)
Monomorphic adenoma- features ?
BENIGN PARTOID TUMOUR
- Account for less than 5% of tumours
- Slow growing
- Consist of only one morphological cell type (hence term mono)
- Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas
Haemangioma - features?
BENIGN PARTOID TUMOUR
- Should be considered in the differential of a parotid mass in a child
- Accounts for 90% of parotid tumours in children less than 1 year of age
- Hypervascular on imaging
- Spontaneous regression may occur and malignant transformation is almost unheard of
Mucoepidermoid carcinoma- fetaures?
MALIGNANT PAROTID TUMOUR
- 30% of all parotid malignancies
- Usually low potential for local invasiveness and metastasis (depends mainly on grade)
Adenoid cystic carcinoma
- features?
MALIGNANT PAROTID TUMOUR
- Unpredictable growth pattern
- Tendency for perineural spread
- Nerve growth may display skip lesions resulting in incomplete excision
- Distant metastasis more common (visceral rather than nodal spread)
- 5 year survival 35%
Diagnostic evaluation - of parotid tumours?
- Plain x-rays may be used to exclude calculi
- Sialography may be used to delineate ductal anatomy
- FNAC is used in most cases
- Superficial parotidectomy may be either diagnostic of therapeutic depending upon the nature of the lesion
- Where malignancy is suspected the primary approach should be definitive resection rather than excisional biopsy
- CT/ MRI may be used in cases of malignancy for staging primary disease
Treatment of parotid tumours?
For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement.
Sjogren’s syndrome - (parotids)?
- Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca
- 90% of cases occur in females
- Second most common connective tissue disorder
- Bilateral, non tender enlargement of the gland is usual
- Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma
- Treatment is supportive
- There is an increased risk of subsequent lymphoma
Sarcoidosis - parotid?
- Parotid involvement occurs in 6% of patients with sarcoid
- Bilateral in most cases
- Gland is not tender
- Xerostomia may occur
- Management of isolated parotid disease is usually conservative
Complications following thyroid surgery?
- Anatomical such as recurrent laryngeal nerve damage.
- Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
- Damage to the parathyroid glands resulting in HYPOCALCAEMIA.
What is the most likely anatomical origin of the epistaxis?
Anterior nasal septum
-Little’s area (site of Kiesselbach’s plexus) in the nasal septum is a common site for epistaxis to originate because it is the confluence of 4 arteries
Unilateral middle ear effusion in an adult - serious or no? How you manage?
- Unilateral middle ear effusion in an adult can be a presenting symptoms of NASOPHARYNGEAL cancer
- -especially in smokers and people of Chinese or South-East Asian origin
- Two week wait referral to ENTif not associated with an upper respiratory tract (routine referral appropriate if a unilateral effusion which is non-resolving following having a cold (most should self-resolve within six weeks )
A tumour may cause obstruction of the eustachian tube.
What differentiates viral labyrinthitis from vestibular neuronitis?
Unaffected hearing distinguishes vestibular neuronitis from labyrinthitis
The lack of damage to hearing - = vestibular neuronitis
Non-resolving unilateral discharge suggests …
cholesteatoma
NICE recommend that cholesteatoma should be suspected in any patient with unexplained unilateral ear discharge that is not responsive to antibiotics.
Appears to be a small amount of bleeding from the wound 4 hours after a tonsillectomy. What is the next management step?
Arrange immediate return to theatre
Primary (reactive) haemorrhage occurs within 24 hours after tonsillectomy, and requires immediate return to theatre due to the risk of further, more extensive bleeding which may need surgical intervention.
What is the main side-effect of using topical decongestants for prolonged periods?
Tachyphylaxis
Intranasal decongestants (e.g. oxymetazoline) should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis).
sialadenitis
Inflammation of the salivary gland likely secondary to obstruction by a stone impacted in the duct. The duct from the submandibular gland drain into the floor of the mouth and purulent discharge from this duct causes a foul taste in the mouth.
Management for sudden sensorineural hearing loss?
High dose steroids
There is some evidence that high dose steroids (60mg/day) for seven days improves prognosis, so all patients should start treatment as soon as possible. ENT assessment should be arranged as soon as possible to allow pure tone audiometry testing and to arrange an MRI to exclude an acoustic neuroma. Intra-tympanic steroids can also be given if there is no response to oral steroids.
Stensens duct drains …
the parotid gland
Samter’s triad ?
asthma + aspirin sensitivity + nasal polyposis
In patients with asthma , what medication should be avoided?
aspirin and other NSAIDs
Viral labyrinthitis - epidemiology, present, signs , Ix, Ix if unsure of diagnosis
Labyrinthitis is an inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs. Labyrinthitis can be viral, bacterial or associated with systemic diseases. Viral labyrinthitis is the most common form of labyrinthitis.
Labyrinthitis should be distinguished from vestibular neuritis as there are important differences: vestibular neuritis is used to define cases in which only the vestibular nerve is involved, hence there is no hearing impairment; Labyrinthitis is used when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment.
Epidemiology
The average age of presentation is 40-70 years2
The reported one-year prevalence of all conditions causing vestibular dysfunctions varies between 3.1% and 35.4%3. There is a lack of definitive epidemiological data on the incidence and prevalence of labyrinthitis, but viral labyrinthitis is the most common form of labyrinthitis observed in clinical practice. One study reported that 37 of 240 patients presenting with positional vertigo had viral labyrinthitis4.
Patients typically present with an acute onset of:
- vertigo: not triggered by movement but exacerbated by movement
- nausea and vomiting
- hearing loss: may be unilateral or bilateral, with varying severity
- tinnitus
- preceding or concurrent symptoms of upper respiratory tract infection
Signs of labyrinthitis:
- spontaneous unidirectional horizontal nystagmus towards the unaffected side
- sensorineural hearing loss: shown by Rinne’s test and Weber test
- abnormal head impulse test: signifies an impaired vestibulo-ocular reflex
- gait disturbance: the patient may fall towards the affected side
- normal skew test
- abnormality on inspection of the external ear canal and the tympanic membrane e.g. vesicles in herpes simplex infection
Investigations
- diagnosis is largely based on history and examination
- glucose is helpful in excluding hypoglycaemia.
- in most patients with suspected viral labyrinthitis, no other investigation is necessary
Investigations to consider if the diagnosis is uncertain or suspecting the more sinister causes
- pure tone audiometry can be done to assess hearing loss
- full blood count and blood culture: if systemic infection suspected
- culture and sensitivity testing if any middle ear effusion
- temporal bone CT scan: indicated if suspecting mastoiditis or cholesteatoma
- MRI scan: helpful to rule out causes such as suppurative labyrinthitis or central causes of vertigo
- vestibular function testing: may be helpful in difficult cases and/or determining prognosis
Elderly patient dizzy on extending neck…
vertebrobasilar ischaemia
A large cholesteatoma can result in …
A large cholesteatoma can invade the inner ear resulting in sensorineural hearing loss and vertigo
Thyroid surgery: complications following surgery
Complications following surgery
Anatomical such as recurrent laryngeal nerve damage.
Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
Damage to the parathyroid glands resulting in hypocalcaemia.
Oral phenoxymethylpenicillin is the antibiotic of choice for a…
acute sinusitis
Ludwig’s angina
Ludwig’s angina is a type of progressive cellulitis that invades the floor of the mouth and soft tissues of the neck. Most cases result from odontogenic infections which spread into the submandibular space.
Features
- neck swelling
- dysphagia
- fever
It is a life-threatening emergency as airway obstruction can occur rapidly as a result.
Management
- airway management
- intravenous antibiotics
Any suspicion of Ludwig’s Angina must prompt an urgent transfer to the emergency department.It can cause rapid deterioration with airway compromise within minutes and requires urgent airway management and aggressive surgical treatment.
In tonsillitis, uvular deviation may indicate…
may indicate development of a peritonsillar abscess (quinsy)
What surgery can you become hypocalcaemic afteR?
thyroid surgery
- damage to parathyroid glands can result in hypocalcaemia- (a due to direct damage of the parathyroid glands which results in hypoparathyroidism. )
can be suggested by the presence of muscle cramps and perioral paraesthesia following thyroid surgery.
The ECG findings most often seen in hypocalcemia is a prolonged QT interval
A mass likely to contain acellular fluid with cholesterol crystals
A branchial cyst
Auricular haematomas - including mx
Auricular haematomas are common in rugby players and wrestlers. Prompt treatment is important to avoid the formation of ‘cauliflower ear’.
Management
- auricular haematomas need same-day assessment by ENT
- incision and drainage has been shown to be superior to needle aspiration
Tonsillitis and tonsillectomy 0 complications of tonsillitis , indications for tonsillectomy, complications of tonsillectomy
Complications of tonsillitis include:
- otitis media
- quinsy - peritonsillar abscess
- rheumatic fever and glomerulonephritis very rarely
The indications for tonsillectomy are controversial. NICE recommend that surgery should be considered only if the person meets all of the following criteria
- sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
- the person has five or more episodes of sore throat per year
- symptoms have been occurring for at least a year
- the episodes of sore throat are disabling and prevent normal functioning
Other established indications for a tonsillectomy include
- recurrent febrile convulsions secondary to episodes of tonsillitis
- obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
- peritonsillar abscess (quinsy) if unresponsive to standard treatment
Complications of tonsillectomy
- primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
- secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain
Ear wax
Ear wax is a normal physiological substance which helps protect the ear canal. Impacted ear wax is extremely common and may cause a variety of symptoms including:
- pain
- conductive hearing loss
- tinnitus
- vertigo
The main treatment options in primary care are ear drops or irrigation (‘ear syringing’). Treatment should not be given if a perforation is suspected or the patient has grommets. The following drops may be used:
- olive oil
- sodium bicarbonate 5%
- almond oil
Acute tonsillitis - characteristics
Characterised by pharyngitis, fever, malaise and lymphadenopathy.
- Over half of all cases are bacterial with Streptococcus pyogenes the most common organism
- The tonsils are typically oedematous and yellow or white pustules may be present
- Infectious mononucleosis may mimic the condition.
- Treatment with penicillin type antibiotics is indicated for bacterial tonsillitis.
- Bacterial tonsillitis may result in local abscess formation (quinsy)
Unilateral swelling and fever - in patients presenting with pharyngitis. diagnosis ?
Quinsy
A combination of pharyngitis and tonsillitis is often seen in …
glandular fever
aka Infectious mononucleosis
What is common causes of bacterial otitis media?
Haemophilus influenzae, Streptococcus pneumoniae Moraxella catarrhalis
In patients with chronic or recurrent ear discharge, exclude…
cholesteatoma
Otitis externa with worsening unrelenting pain despite strong analgesia is suggestive of …
malignant (necrotising) otitis externa
Presbycusis presents with what type of frequency hearing loss?
bilateral high-frequency hearing loss
sensorineural deafness
Presbycusis- causes, signs, Ix
Causes
- The precise cause is unknown however is likely multifactorial
- Arteriosclerosis: May cause diminished perfusion and oxygenation of the cochlea, resulting in damage to inner ear structures
- Diabetes: Acceleration of arteriosclerosis
- Accumulated exposure to noise
- Drug exposure (Salicylates, chemotherapy agents etc.)
- Stress
- Genetic: Certain individuals may be programmed for the early ageing of the auditory system
Patients typically present with a chronic, slowly progressing history of:
- Speech becoming difficult to understand
- Need for increased volume on the television or radio
- Difficulty using the telephone
- Loss of directionality of sound
- Worsening of symptoms in noisy environments
- Hyperacusis: Heightened sensitivity to certain frequencies of sound (Less common)
- Tinnitus (Uncommon)
Signs:
- Possible Weber’s test bone conduction localisation to one side if sensorineural hearing loss not completely bilateral
Investigations:
- Otoscopy: Normal, to rule out otosclerosis, cholesteatoma and conductive hearing loss (Foreign body, impacted wax etc.)
- Tympanometry: Normal middle ear function with hearing loss (Type A)
- Audiometry: Bilateral sensorineural pattern hearing loss
- Blood tests including inflammatory markers and specific antibodies: Normal
Nasal septal haematoma- features, management
Nasal septal haematoma is an important complication of nasal trauma which should always be looked for. It describes the development of a haematoma between the septal cartilage and the overlying perichondrium.
Features
- may be precipitated by relatively minor trauma
- the sensation of nasal obstruction is the most common symptom
- pain and rhinorrhoea are also seen
- on examination, classically a bilateral, red swelling arising from the nasal septum
- this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm
Management
- surgical drainage
- intravenous antibiotics
If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis. This may result in a ‘saddle-nose’ deformity
Pharyngeal pouch - features
neck lump
- More common in older men
- Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
- Usually not seen but if large then a midline lump in the neck that GURGLES on palpation
- Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough
Goitre - features
neck lump
May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
Does a goitre move on swallowing?
Moves upwards on swallowing
Thyroglossal cyst- when does it tend to present?
More common in patients < 20 years old
Cystic hygroma
neck lump
- A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
- Most are evident at birth, around 90% present before 2 years of age
