ENT Flashcards
what is BPPV?
vertigo triggered by change in head position e.g. rolling over in bed or gazing upwards
diagnosis of BPPV?
Dix hallpike manoeuvre
mx of BPPV?
Epley manoeuvre- moves debris out of semi-circular canals and back into utricle
causes of vertigo?
BPPV
Meniere’s disease
vetibular neuronitis
acoustic neuroma
What is Meniere’s disease
excess fluid in the inner ear
features of Meniere’s disease?
recurrent episodes of tinnitus and hearing loss sensation of aural fullness nystagmus positive Romberg's test episodes last minutes to hours
mx of Meniere’s disease?
inform DVLA
acute attacks -> buccal or IM prochlorazone
prevention-> betahistine and vestibular rehab exercises
what is vestibular neuronitis?
infection of vestibular nerve- may follow URTI
Features of VN?
recurrent vertigo attacks lasting hours or days
N&V
horizontal nystagmus away from the affected side
no hearing loss or tinnitus
mx of VN?
- vestibular rehab exercises
- buccal or IM 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 vestibular schwannoma?
benign tumour of the schwann cells of the vestibulocochlear nerve
also known as acoustic neuroma
features of vestibular schwannoma?
cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
what is bilateral vestibular schwannomas associated with?
neurofibromatosis type 2
Ix of vestibular schwannoma?
MRI of the cerebellopontine angle
mx of vestibular schwannoma?
surgery, radiotherapy or observation
other causes of vertigo?
viral labyrinthitis posterior circulation stroke ototoxicity e.g. MS MS trauma
differentials of facial pain?
bell's palsy sinusitis trigeminal neuralgia atypical facial pain ramsey hunt syndrome rhinosinusitis TMJ syndrome nasal injury
what is bell’s palsy?
LMN facial nerve palsy (forehead affected)
acute, unilateral and idiopathic
RFs for bells palsy?
pregnant women
20-40 years
features of bell’s palsy?
LMN facial palsy- drooping face symptoms
post-auricular pain, altered taste, dry eyes, hyperacusis
mx of bell’s palsy?
prednisolone 1mg/kg for 10 days within 72 hours on onset
eye care- artificial tears and eye lubricants
refer if suspicious
what is sinusitis?
inflammation of the mucous membranes of the paranasal sinuses
common infectious agents of sinusitis?
strep pneumoniae
h. influenzae
rhinovirus
features of sinusitis?
- facial pain- typically frontal pressure pain which is worse on bending forward
- nasal discharge: usually thick and purulent
- nasal obstruction
mx of acute sinusitis?
analgesia
intranasal decongestants
oral Abx for severe presentations- phenoxymethylpenicillin or co-amoxiclav
what is trigeminal neuralgia?
a pain syndrome characterised by severe unilateral pain
causes of trigeminal neuralgia?
majority are idiopathic but compression of trigeminal roots by tumours or vascular problems may occur
features of trigeminal neuralgia?
electric shock-like pains brought on by light touch, washing, shaving etc
mx of trigeminal neuralgia?
1st line- carbamazepine
failure to respond to treatment or atypical features e.g. <50 years old should prompt referral to neurology
what is atypical facial pain?
diagnosis of elimination, functional cause
iunilateral pain, poorly localised, continuous
what is ramsay hunt syndrome?
herpes zoster oticus
caused by reactivation of the varicella zoster virus in the geniculate ganglion of the 7th cranial nerve
features of ramsay hunt syndrome?
auricular pain is often first feature
facial nerve palsy
vesicular rash around ear
other features include vertigo and tinnitus
mx of ramsay hunt syndrome?
oral acyclovir and corticosteroids
RFs for ramsay hunt syndrome?
elderly, immunocompromised
what is rhinosinusitis?
inflammation in the nose and paranasal sinuses with >2 of :
- nasal blockage
- facial pressure
- loss of smell
- endoscopic or CT changes
also runny nose, sneezing, headaches
when to refer for biopsy in rhinosinusitis?
a single unilaterl polyp
mx of rhinosinusitis?
with polyps- beclomethasone, fluticasone, long term Abx, endoscopic sinus surgery
w/o polyps- intranasal corticosteroids, nasal saline irrigation
what is allergic rhinosinusitis?
caused by IgE mediated inflammation, can have nasal polyps and swollen turbinates
tx= loratadine, saline irrigation, intranasal corticosteroids (mometasone)
what is TMJ syndrome?
biopsychosocial disorder
earache, facial pain and joint clicking
tx of TMJ syndrome?
simple analgesia
PT
CBT
oral splinting
what is Samter’s triad?
association of asthma, aspirin sensitivity and nasal polyps
what is nasal septal haematoma?
an important complication of nasal trauma that should be looked for
describes the development of a haematoma between the septal cartilage and overlying perichondrium
features of nasal septal haematoma?
nasal obstruction
pain and rhinorrhoea
bilateral red swelling from nasal septum
mx of septal haematoma?
surgical drainage
IV antibiotics
if suspect CSF rhinorrhoea- test for glucose in fluid
complications of septal haematoma?
irreversible septal necrosis -> saddle-nose deformity
differentials for deafness
ear wax otitis media (+ glue ear) otitis externa presbycusis otosclerosis Meniere's disease drug ototoxicity noise damage acoustic neuroma
what is conductive deafness?
pathology in outer or middle ear e.g. glue ear, otosclerosis
bone conduction> air conduction on Rinnes
sound is localised to the affected side on webers
what is sersorineural deafness?
Sensorineural hearing loss occurs due to abnormalities in the cochlea, auditory nerve or other structures in the neural pathway leading from the inner ear to the auditory cortex.
ac>bc
Sound is localised to the unaffected side if unilateral sensorineural deafness
unilateral causes of sersorineural deafness?
Meniere’s disease
acoustic neuroma
bilateral causes of sersorineural deafness?
ototoxic antibiotics chemo measles mumps meningitis noise exposure trauma
what is otosclerosis?
AD
replacement of normal bone by vascular spongy bone
causes conductive deafness and tinnitus
name some ototoxic drugs?
aminoglycosides (e.g. Gentamicin), furosemide, aspirin and a number of cytotoxic agents e.g. cisplastin
what is presbycusis?
age-related sensorineural hearing loss
audiometry shows bilateral high-frequency hearing loss
what is acute otitis externa?
infection of the outer ear canal
known as SWIMMERS ear
causes of otitis externa?
- infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
- seborrhoeic dermatitis
- contact dermatitis (allergic and irritant)
features of otitis externa?
discharge, itch, pain, tragal tenderness
Ix for otitis externa?
otoscopy
swab for microscopy
tx 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
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
causes of chronic otitis externa?
combined staphylococcal and fungal infection
tx of otosclerosis?
stapedectomy and insertion of prosthesis
what is malignant otitis externa?
life-threatening
can progress to temporal bone osteomyelitis
needs CT, IV Abx and surgical debridement
RFs for malignant otitis externa?
diabetes, elderly, immunosuppression
causes of acute otitis media?
pneumococcus
H.influenzae
Moraxella catarrhalis
RFs for acute otitis media?
URTI Bottle feeding passive smoking GORD raised BMI
symptoms of acute otitis media?
otalgia, fever, irritability, anorexia, vomiting, discharge
Ix of acute otitis media?
otoscope- bulging tympanic membrane
tx of acute otitis media?
analgesia, decongestants
amoxicillin if symptoms lasting more than 4 days or not improving, systemically unwell or immunocompromised
what is glue ear?
otitis media with effusion
causes of glue ear?
URTI, oversized adenoids, post-nasal space, tumour
Ix of glue ear?
otoscopy- fluid levels behind the ear drum, bulging drum or retracted
tx of glue ear?
usually mild and resolves spontaneously
popping ears
hearing aids
grommets or tympanostomy tube
what is a complication of chronic otitis media?
cholesteatoma
what is mastoiditis?
infection of the mastoid bone that often follows an ear infection
features of mascoiditis?
otalgia: severe, classically behind the ear
fever
unwell
swelling, erythema and tenderness over the mastoid process
the external ear may protrude forwards
ear discharge if the ear has perforated
Ix of mastoiditis?
increased ESR, FBC, blood cultures
tympanocentesis- sample of fluid
tx of mastoiditis?
IV Abx for 1-2 days then oral Abx
ENT referral- surgical drainage
mastoidectomy
what is cholesteatoma?
an abnormal skin growth that develops in the middle ear behind the ear drum
build up of squamous epithelium
features of cholesteatoma?
foul discharge +/- deafness, headache, pain, facial paralysis, vertigo
tx of cholesteatoma?
surgery
what is furunculosis?
a very painful abscess arising from a hair follicle within the ear canal
caused by staphylococcus
tx= lancing (cut open)
mx of cellulitis of pinna
flucloxacillin
differentials of tinnitus?
otosclerosis
acoustic neuroma
hearing loss
drugs- aspirin, aminoglycosides, loop diuretics, quinine
red flag of tinnitus?
unilateral tinnitus= acoustic neuroma
tx of tinnitus
treat underlying cause
red flag for oral cancer
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
RFs for oral cancer?
smoking, alcohol
features of oral cancer?
non-healing ulcer, red/white plaques inside the mouth, painful lump, bleeding, numbness
ix of oral cancer?
biopsy
CT/MRI
Tx of oral cancer?
surgery-excision
photodynamic therapy
causes of epistaxis?
trauma platelet disorders- thrombocytopenia, splenomegaly, leukaemia, ITP Juvenile angiofibroma- benign tumour Drug use HHT Granulomatosis with polyangiitis
origin of epistaxis?
anterior nasal septum (little’s area) as it the confluence of 4 arteries
tx of epistaxis?
pinch lower nose
nasal packing
cauterise with silver nitrate
if setpal haematoma -> drain in theatre
name some viral causes of tonsillitis?
rhinovirus coronavirus parainfluenza adenovirus HSV EBV
bacterial causes of tonsillitis
group A beta-haemolytic strep
what is the centor criteria?
guidance for Abx prescribing fever absence of cough tonsillar exudate cervical lymphadenopathy
tx of tonsillitis?
phenoxymethylpenicillin clarithromycin if allergic
tonsillectomy
what is quinsy?
peritonsillar abscess
features of quinsy?
deviated uvula
purulent tonsils
difficulty opening jaw
painful swallowing
tx of quinsy?
Abx and aspiration
tonsillectomy considered in 6 weeks
what is the most common type of oropharyngeal neoplasm?
> 90% are SCC
Occur anywhere from the oral cavity to the trachea
RFs for oropharyngeal neoplasm?
smoking, alcohol, vitamin A and C deficiency, HPV 16 and 18, GORD
Features of oropharyngeal neoplasm?
neck lump
hoarseness
persistent sore throat
persistent mouth ulcer
2 week wait for laryngeal cancer for ENT referral?
In people aged 45 and over with:
persistent unexplained hoarseness or
an unexplained lump in the neck
causes of stridor?
- Congenital- laryngomalacia
- Inflammatory/infective- laryngitis, croup, acute epiglottitis, anaphylaxis
- Tumours- haemangionas, papillomas, oesophageal cancer
- Trauma- intubation, burns
what is laryngomalacia?
cartilage of the upper larynx collapses inwards during inhalation, causing airway obstruction
what is laryngeal nerve palsy?
paralysis/impingement of the recurrent laryngeal nerve- responsible for movement of vocal cords
30% due to cancer 25% iatrogenic 15% idiopathic CNS disease TB
differentials of neck lumps in children?
congenital- brachial cyst, thyroglossal cyst, dermoid cyst
inflammatory- reactive lymphadenopathy, lymphadenitis
neoplastic- lymphoma, thyroid tumour, salivary gland tumour
what is the most common cause of neck lump?
archive lymphadenopathy
what is a red flag for 2 week referral for suspected thyroid cancer?
unexplained thyroid lump
what are the features of lymphoma?
rubbery, painless lymphadenopathy
- can get pain while drinking alcohol
- associated B symptoms
what happens to a thyroid swelling on swallowing?
moves upwards
features of a thyroglossal cyst?
most 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
what is a pharyngeal pouch?
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
what is a cystic hygroma?
a congenital lymphatic lesion typically found in the neck, classically on the left side
90% present before the age of 2
what is a brachial 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
what is a carotid aneurysm?
a pulsatile lateral neck mass which doesn’t move on swallowing
what are the borders of the anterior triangle in the neck?
clavicle
sternocleidomastoid
mandible
what are the borders of the posterior triangle in the neck?
skull base
trapezius
sternocleidomastoid
what is a sialadenitis?
infection of the submandibular or parotid glands
usually in the elderly
tx- abx
what is sialolithiasis?
salivary gland stones
pain after eating in the submandibular glands
