ENT Flashcards
Anatomy and function of
- Outer ear
- Middle ear
- Inner ear
- Pinna, auditory canal, tympanic membrane. Collect sound.
- Ossicles bones = malleus, incus + stapes, opening of Eustachian tube. Convert sound from sound energy to mechanical energy, amplifies and relays it.
- Labyrinth = semicircular canals, vestibule, cochlea, CN8.
What turns the mechanical energy of sound into electrical energy to process
Organ of Corti.
Types of hearing loss
Conductive - sound energy does not reach cochlear. Problem in outer or middle ear. Normal bone conduction. Rinne’s negative.
Sensorineural - cochlea or auditory nerve defect. Problem in inner ear. Rinne’s test positive.
Mixed
Testing hearing loss
512Hz tuning fork 🍴
Rinne’s test = tuning fork on mastoid then in air by ear.
- Air conduction usually better than bone so hear vibrations better when by ear than placed on mastoid or with sensorineural hearing loss.
- If heard louder on mastoid = conductive hearing loss
Weber’s test = tuning fork on forehead
- Normal = equal on both sides.
If sound louder on one side, this suggests:
- Conductive hearing deficit on this side (bone conduction)
OR
- Sensorineural hearing loss on the other side (no air conduction).
Audiogram!!
Audiogram
y axis = hearing level in dB.
x axis = frequency in Hz.
Normal is 0-20dB.
Causes of conductive hearing loss
External canal obstruction = wax, foreign body, oedema from otitis media, otitis externa.
Tympanic membrane perforation
Eustachian tube problems = otitis media with effusion.
Acute mastoiditis
Otosclerosis
Chostesteatoma
Causes of sensorineural hearing loss
Ototoxicity = Gentamicin. Meniere's disease Infections = Mumps, encephalitis, meningitis. Presbycusis Noise induced Acoustic neuroma
Tympanic membrane perforation
Sudden onset, painful hearing loss.
O/E can see perforation.
Rx:
If small heal spontaneously +/- topical Abx.
If larger may need ear drum replacement surgery - Myringoplasty.
Inheritance and pathology of otosclerosis
Autosomal dominant.
More common in women.
Hardening and stiffening of the stapes footplate in oval window of cochlea.
Presentation, Ix and Rx for otosclerosis
Slowly progressive bilateral conductive hearing loss.
Worsen in pregnancy and menses.
May also suffer form tinnitus and transient vertigo.
Ix with audiogram.
Rx = hearing aids, surgical management with stapedotomy (hole to help movement) or replace stapes.
Cholesteatoma pathology and causes
Persistent discharge though a damaged tympanic membrane. Pressure difference causes tympanic membrane retraction. Creates retraction pocket in tympanic membrane which are lined by squamous epithelium (normally resp epithelium) and initiate inflammation.
Can be due to recurrent middle ear infections, perforated tympanic membrane, congenital.
Presentation, Ix and Rx for cholesteatoma
Conductive deafness in affected ear (unilateral)
Discharge (smelly) but not painful (∆ for otitis media).
Local invasion can cause facial paralysis, erosion to brain cavity.
O/E = tympanic membrane retraction.
Ix = CT! if worried about bone erosion. Rx = surgical removal of cholesteatoma via open mastoid cavity technique.
Audiogram in
- Sensorineural loss
- Conductive
- Mixed
- Both air and bone lines are at lower dB
- Only the air conduction line is lower.
- Both lines are low but to different extents.
Main pathogens in acute otitis media
Viral
H.influenza
Streptococcus pneumoniae
Presentation of acute otitis media
Severe acute ear pain (otalgia)
Discharge (discharge release can ease pain).
Kids pull ears, crying, pyrexial.
Conductive hearing loss.
O/E = bulging red tympanic membrane.
Why is otitis media more common in kids
More acute angle of Eustachian tube so harder to clear mucus in area.
Ix and Mx for acute otitis media
Ix = Visualise tympanic membrane with otoscope.
Rx =
- Analgesia (pcm), steam inhalations.
- Can give ABx e.g. amoxicillin if remains symptomatic for over 3 days in kids. Most adults will need ABx as it is unusual for them to get disease.
Complications of acute otitis media
Intracranial = meningitis, encphalitis, brain abscess. Infratemporal = mastoiditis, CN7 palsy, labrynthitis
What is otitis media with effusion and who gets it?
Collection of fluid in middle ear, >3months. Usually following acute otitis media.
- Kids with Eustachian tube acute angle
- Adults with nasopharyngeal carcinoma.
Presentation, Ix and Mx for otitis media with effusion
Painless but feeling of fullness in ear.
Conductive hearing loss - speak quietly.
Tinnitus, cracking/popping.
Hx of AOM.
O/E = opaque, intact tympanic membrane, loss of light reflex.
Ix = Audiogram, tympanogram (flat). If adult must exclude tumour!!!
Mx = Most self limiting in kids within 1yrs sports may not need Rx.
Grommets to act as ventilation tubes and release mucus.
Hearing aids.
Dr tries to treat AOM but it won’t go away.
Cholesteatoma. (‘unsafe chronic otitis media’)
Chronic otitis media
- Chronic inflammation of the middle ear and mastoid cavity. >2weeks.
- CFX = Mild ear pain but lots of mucoid discharge. No systemic illness. Kids may speak quietly and have behavioural problems from poor hearing.
- O/E = granulation tissue in canal, perforation.
- Ix = CT to rule our cholesteatoma bone erosion or abscess.
- Rx = ENT referral to use off licence ABx, ear hygiene (keep dry), maybe steroids too 💊
Mastoiditis
- Causes = cholesteatoma, acute otitis media.
- CFx = swelling and pain in mastoid area. Anterior-inferior displacement of pinna.
- Ix = complete cranial nerve exam, blood cultures, ear discharge mc+s, audiogram, skull XR, LP, CT scan (opacity in mastoid air cells).
- Rx = high dose IV ABx (ceftriaxone) and surgical drainage.
Presentation of otitis externa
Itching.
Ear pain, tenderness at tragus.
Feeling of fullness in ear.
Poor hearing (conductive).
O/E
Furuncles (painful swelling on external ear) if infected hair follicle.
Canal is erythematous, shiny and can be oedematous if severe.
Pathology of otitis externa
RFx = swimming, narrow canal, less wax.
Viral = Ramsey-Hunt V.zoster or Herpes simplex. Bacterial = S.aureus, Pseudomonas aeruginosa. Fungal = Candida albicans, Aspergillus niger.
Name 3 ototoxic drugs
gentamicin
loop diuretics - furosemide
platinim chemo - cisplatin.
Mx of otitis externa
Hygiene = avoid swimming, keep ear dry, can use olive oil to help move wax. Viral = aural toilet, topical antivirals or corticosteroids. Bacterial = aural toilet anf ABx e.g. Ciprofloxacin. Fungal = Clotrimazole.
Complication of otitis externa and who is more likely to get it
Necrotising Otitis Externa 🦻.
More common in immunocompromised and diabetes.
Necrotising otitis externa
- Granulation formation, erosion of bone (temporal bone) and cartilage in ear. Can go on to disrupt CN7, 9, 11, 12.
- More common on P.aeruginosa.
- CFx = severe pain, blood-stained discharge, headache, CN palsy.
- O/E = granulations.
- Rx = IV gentamicin or ciprofloxacin
3 peripheral and 3 central causes of vertigo
Peripheral = Meniere's disease Benign positional vertigo Labyrinthitis Cholesteatoma
Central =
Acoustic neuroma
MS
Head trauma
Episodic tinitus, vertigo and can’t hear low frequency things
Meniere’s disease
Pathology of meniere’s disease
Not completely known.
Endolymphatic hydrops
Probs over-production or impaired absorption of endolymph in inner ear.
Presentation of Meniere’s disease
Episodic sudden onset. Usually episodes last longer than BPPV.
Vertigo
Low frequency, unilateral hearing loss - Sensorineural
Roaring tinnitus
Sense of fullness in ear
‘Drop attacks’ - sudden loss of balance but no LOC.
Ix and Rx for meniere’s disease
Ix = audiogram, normal tympanogram. Exclude other causes with CT, syphilis serology.
Rx = low salt diet. Drugs such as betahistine, trimetazidine (benzo). TELL DVLA 🚘
Age related sensorineural hearing loss
- Presbycusis, loss of outer hair cells in cochlear.
- Struggles to hear in noisy environment.
- Usually loose high frequency hearing first.
- Rx with hearing aid, cochlear implant.
- Cx = loneliness and psych, worsen dementia.
Noise induced hearing loss
Trough on audiogram at 4000Hx/ ‘reversed tick’ sign on audiogram.
Bilateral sensironeural hearing loss.
Tinnitus.
NOT progressive.
Unilateral hearing loss
Tinnitus
Poor facial sensation
Balance problems
Acoustic neuroma
What is an acoustic neuroma
A benign and slow growing tumour arising from the Schwann cells of the vestibularchochlear nerve (CN8) at the cerebellopontine angle.
Presentation of an acoustic neuroma
UNILATERAL HEARING LOSS IS A ACOUSTIC NEUROMA UNTIL PROVEN OTHERWISE.
Unilateral or asymmetrical hearing loss.
Tinnitus
Impaired facial sensation and loss of corneal reflex - involves trigeminal nerve.
Balance problems and ataxia.
Ear ache
If super big = raised ICP.
Ix and Rx for acoustic neuroma
Ix = audiogram (sensorineural loss), MRI.
Rx = Surgical excision, stereotactic radiosurgery
What is the most common cause of vertigo
Benign paroxysmal positional vertigo 🧚♀️🧚🧚♂️
Pathology of benign paroxysmal positional vertigo
Otolith (small calcium carbonate crystals) detach and are free in semicircular canals. When head stops moving they carry on, putting pressure on cilia hair cells causing causing signal of movement to brain.
Presentation of BPPV
Episodic vertigo. Usually comes on when turning over in bed, sitting up, leaning forward.
Short episodes with sudden onset (last 30seconds).
No hearing loss
No tinnitus
Ix and Rx for BPPV
∆ with Dix Hallpike test, get nystagmus. (+ve if BPPV)
Treat with Epley’s manoeuvre which puts otoliths back in urticles..
Presentation of labyrinthitis
Vertigo even at rest but worsens on head movements.
Hearing loss - sensorineural.
Tinnitus
Balance problems.
N+V
Hx of otitis media, mumps, measles or influenza-type illness.
O/E:
- Head Impulse test, Nystagmus Type and Skew: impaired vestibule-ocular reflex (saccades), unidirectional nystagmus, no vertical skew.
3 subtypes of labyrinthitis
Circumscribed = erosion of bony capsule in labyrinth by a cholesteatoma. Serous = non-purulent inflammation of labyrinth. Suppurative = infiltration of inflammatory cells and pus cells. Usually bacterial. Can lead to total, permanent hearing loss.
Mx of labyrinthitis
Depends on type.
Circumscribed = remove cholesteatoma.
Serous = bed rest, labyrinth sedatives (prochlorperazine).
Suppurative = bed rest, prochlorperazine, ABx.
Advise against driving 🚙
Difference between labyrinthitis and vestibular neuritis
VN has no hearing loss, affects vestibular nerve ONLY.
Vestibular neuritis
- Inflammation of vestibular nerve.
- Preceding URT infection. Can be reactivation of H.simplex.
- CFx = NO HEARING LOSS. Sudden vertigo even at rest, worsened on movement, gait instability, N+V.
- O/E = Head Impulse test, Nystagmus Type and Skew: impaired vestibule-ocular reflex (saccades), unidirectional nystagmus, no vertical skew.
- Rx = self-limiting. Prochlorperazine, bed rest, fluids and no driving please 🚙
HINTS
Head Impulse test, Nystagmus Type and Skew
Differentiate labyrinthitis + vestibular neuritis from a stroke.
Labyrthinitis + VN = abnormal head impulse (saccades), unidirectional nystagmus, no vertical skew.Stroke esp PICA = abnormal head impulse, bidirectional nystagmus, vertical skew.
2 types of tinnitus and examples
Objective - noise in head and can be heard by observer. Carotid stenosis, valvular heart disease, tympanic muscle spasm.
Subjective - more common. no noise audible to observer. otosclerosis, Menieres’ disease, MS, acoustic neuroma, syphilis.
Non pharmacological measures to help hearing impaired patients
Electronic hearing aids Environmental aids e.g. flashing light with door bell and telephone calls. Sign language Organisation support e.g. RNID Cochlear implants
Ramsay-Hunt syndrome
- Herpes zoster Oticus.
- Reactivation of Varicella zoster from geniculate ganglia of cranial nerve 7.
- Different from shingles as motor component, Shingles is sensory disease.
- CFx = otalgia, tinnitus, vertigo, vesicles on skin of ear canal, hearing loss.
- Rx = acyclovir if caught in early stage + prednisolone.
Definition of vertigo
Illusion of movement.
Functions of the nose
Olfaction
Airway/ventilation, warms and humidifies air.
Mucus secretion - filtration and infection prevention.
Name the paranasal sinuses
Frontal
Maxillary
Ethmoid
Sphenoid
Brief anatomy of the nose 👃
Lateral walls have conchae = 3 turbinates. Increase surface area of nose.
Below each turbinate is a meatus draining the sinuses.
Nasal trauma Mx
Rule out red flags of serious injury 🚩: CSF rhinorrhoea, septal haematoma, respiratory obstruction, haemorrhage.
Wait for soft tissue swelling to subside and reduce within 10days (otherwise may become fixed).
If there is haematoma need to intervene ASAP and drain the haematoma. If no immediate intervention can get necrosis of cartilage and collapse of nose.
Epitaxis
Anterior (most common) - from Keisselbach’s plexus in Little’s area.
Posterior - more severe blood flow. From branches of the sphenopalatine arteries.
Mx =
- pressure on NOSTRILS, lean forward, ice on neck and forehead.
- Silver nitrate cautery.
- Packing
- Artery ligation.
Allergic rhinitis presentation, Ix and Rx
- CFx = nasal obstruction (vasodilation and oedema), rhinorrhoea, sneezing, itchiness, sense of congestion/fullness in sinuses. Hx of atopy e.g. asthma.
- O/E = oedematous mucosa, watery secretions.
- Ix = may have a skin prick test.
- Rx = avoid allergen. Inhaled corticosteroids e.g. beclomethasone. Antihistamine (fexofendaine). If severe can have surgical resection of turbinates.
Common allergens for allergic rhinitis and difference between seasonal allergic rhinitis and perennial allergic rhinitis.
Seasonal = hayfever. Allergens include pollen, grass. Seasonal variation in symptoms. Perennial = house dust mites, pet fur. No seasonal variation.
Definition of acute and chronic sinusitis
Common pathogens
Acute = < 4 weeks of paranasal sinus inflammation. Chronic = >12 weeks of paranasal sinus inflammation.
Mostly viral. If bacterial commonly S.pneumoniae, H.influenza (therefore usually have Hx of preceding URTI).
Presentation of acute sinusitis
Nasal congestion/obstruction Nasal discharge Facial tenderness, esp on tapping affected sinus. Headache Dental pain Loss of sense of smell.
Bacterial = symptoms longer than 5 days. Fever, purulent discharge, severe pain, raised ESR, deterioration after URTI.
Pathogen if isolated maxillary sinusitis
Streptococcus viridians from dental.
Ix and Rx for acute sinusitis
Clinical ∆ Rx = - supportive e.g. pcm, nasal douching. - vasoconstricting nose drops e.g. ephidrine. - decongestant nose drops e.g. Sudafed. - ABx not routinely given.
Complications of acute sinusitis
Chronic sinusitis.
Emergencies =
Cerebral abscess
Orbital cellulitis
Cavernous sinus thrombosis
RFx for sinusitis
Smoking
Asthma
Allergic rhinitis.
Mx for chronic sinusitis
Intranasal corticosteroids - beclometasone.
2 diseases which have increased incidence of nasal polyps
Cystic fibrosis
Asthma
What is a nasal polyp 🕵️
Benign swellings of the mucosal lining of the paranasal sinuses (most commonly ethmoidal cells).
Can prolapse into the nose via meatus.
Almost always bilateral - unilateral rule out neoplasms!!
2 types of chronic sinusitis
With nasal polyps
Without nasal polyps.
Presentation, Ix and Rx for nasal polyps
Progressive nasal obstruction Recurrent sinusitis Rhinorrhea A posterior nasal drip O/E with rhinoscopy = semi-translucent, grey bags of tissue.
Ix = need to visualise with rhinoscopy.
Rx =
- Topical corticosteroids.
- Endoscopic ethmoidectomy.
Presentation of a neoplastic nasal polyp
Unilateral
Nasal obstruction
Foul smelling discharge
Epistaxis
O/E = bleed, fleshy.
Histology of malignant nose cancer and risk factors
Squamous cell carcinoma - exposure to nickel, welding fumes and arsenic.
Adenocarcinomas - wood dust, leather dust.
Schneiderian papillomas can go on to become SCC.
Nasal SSC
- RFx = men, occupation in wood, leather or chemical substances. Non-keratinising = HPV. Keratinising = EBV and smoking.
- CFx = nasal obstruction, facial pain, rhinorrhea, epistaxis. CN palsy. Enlarged cervical lymph nodes.
- Ix =- biopsy to distinguish keratinising or nonkeratinsising SCC. MRI.
- Rx = Surgical resection + post-op radiotherapy.
Differentials for nasal obstruction
Acute = allergic rhinitis, acute sinusitis, foreign body, haematoma from trauma. Chronic = nasal SCC, chronic sinusitis, nasal polyps, syphilis, adenoid hypertrophy.
Acute tonsillitis
- Infection and inflammation of palatine tonsils.
- Most commonly viral or group A beta-haemolytic Streptococcus pyogenes.
- CFx = sore throat, dysphagia, cachexia, headache, nausea, smelly breathe (halitosis), pyrexia, tonsillar exudate (pus), tonsil enlargement, tonsillar erythema, cervical lymphadenopathy (more suggestive in EBV).
- Ix = swabs not helpful. Rule out EBV with Monospot test.
- Rx = paracetamol, fluids, CENTOR for ABx use (penicillin).
NB size of tonsils does not correlate to disease severity, unless airway obstruction then that is bad 👎.
CENTOR CRITERIA
Tonsillar exudate
Tender cervical lymphadenopathy
History of fever
No cough
ABx if >3.
Another name for glandular fever
Infectious mononucleosis
Epstein-Barr virus
Presentation of infectious mononucleosis
- Adolescent and young adults.
- Tonsils are grossly enlarged, coated in membranous exudate film.
- Malaise, low grade fever, myalgia, sore throat.
- Cervical lymphadenopathy.
- Hepatosplenomegaly.
- Fatigue, can last 6 months.
Ix and Rx for Infectious mononucleosis
Ix:
- PRIMARY CARE FBC - high WCC, lymphocytosis.
- Monospot test = serology for heterophiles antibodies for ABV. Can be negative in initial infection (false negative).
- USS of abdo (splenomegaly).
Rx:
- Analgesia, fluids.
- Avoid contact sports for 8 weeks as risk of splenic rupture.
- No ABx, can get itchy, maculopapular skin rash with EBV + penicillins.
- May need steroids.
Indications for tonsillectomy
Complications of tonsillectomy.
Indications:
- Chronic tonsillitis (>1yr).
- 4 or more episodes of tonsillitis in a year.
- OSA due to tonsillar hypertrophy.
- Quinsy.
- Asymmetrical/unilateral tonsillar enlargement.
Complications:
- Post-op bleeding.
- PONV
- Delay in oral intake.
3 conditions linked with EBV
Glandular fever
Multiple sclerosis
Burkitt’s lymphoma
Peritonsillar abscess
Quinsy
Hot potato voice 🥔 pathogen
Quinsy - beta-haemolytic streptococcus.
Complication fo tonsillitis
Causes of chronic pharyngitis
Smoking GORD Posterior nasal drip from chronic sinusitis Chronic tonsillitis Chronic, non-infectious laryngitis
Quinsy presentation
- Unilateral.
- Severe pain.
- Dysphagia and DRIBBLING
- ‘Hot potato voice’
- Fluctuating pyrexia
- Can’t open mouth = trismus, ear pain.
- Hx of tonsillitis.
O/E:
- Unilateral tonsillar inflammation and uvula deviation AWAY from abscess
- Erythema of soft palate
- Lymphadenopathy.
Pathology of quinsy
Peritonsillar abscess
Pus in-between tonsil capsule and superior constrictor muscle.
Rx of quincy
IV fluids
IV ABx (benxylpenicillin).
Drainage
Laryngitis causes, CFx, Ix and Rx
- Most commonly self-limiting viral infection (Rhinovirus, RSV, adenovirus) , bacterial laryngitis (H.influenza, S.pneumoniae) can be life-threatening.
- CFx = sore throat, hoarse voice, ear pain, dysphagia, globes (lump in throat), malaise, fever.
- Mostly clinical ∆.
- Rx = rest voice, stop smoking, good hydration, steam inhalation.
Laryngitis but have Hx of DM and poorly controlled COPD
Think fungal (steroid inhaler)- Candidiasis.
More severe laryngitis CFx, Ix and possible causes
- Difficulty breathing/airway obstruction.
- Stridor.
- Hoarse voice >3 weeks (?cancer).
- Diphtheria - membranous pharyngitis, lymphadenopathy, ‘bull neck’.
- Ix: sputum mc+s, laryngeal swabs, laryngoscopy.
Causative organisms for pharyngitis
Viral = Adenovirus, parainfluenza, rhinovirus, influenza, coronavirus. Bacterial = groupa A beta-haemolytic Streptococcus pyogenes.
Presentation, Ix and Rx for pharyngitis
- Painful swallowing (odynophagia), fever, headache, malaise, rhinitis, cough, hoarse voice.
- Ix not routine. If prolonged or severe = ASO titre for scarlet fever/rheumatic fever, Monospot test.
- Rx: paracetamol, good fluid intake, throat lozenges, safety net advice (stridor, drooling, rash, muffled voice). Use CENTOR criteria for ABx use.
Epiglottitis
- H.influenza.
- Inflammation of the supraglottis.
- CFx = stridor, tripod position of patient, high fever, sore throat, drooling, difficulty breathing, irritability.
- Ix = laryngoscopy.
- Rx = NO EXAMINATION! Nothing to stimulate child! Secure airway and supplemental oxygen, ABx (ceftriaxone), dexamethasone.
Differentials for stridor
- Croup (barking cough, biphasic)
- Inhaled foreign body
- Anaphylaxis (urticaria)
- Epiglottitis (get anaesthetist!)
- Laryngeal carcinoma
Name for lymphatic tissue in superior pharynx
Waldeyer’s ring
Causes of parotitis
Bacterial (S.aureus)
Viral = Mumps.
Can also swell in Sjorgren’s (bilateral, no pain) and sarcoidosis (+uveitis).
Presentation, Ix and Rx for parotitis
- Painful, tender swelling. Difficulty opening mouth. Dry mouth, fever.
- Usually unilateral, Mumps = bilateral, low grade fever.
- Ix = Sialography, FBC, blood cultures, viral serology, USS.
- Rx = good hydration. ABx if bacterial.
Mumps
- RNA paramyxovirus, respiratory droplet spread.
- CFx = Bilateral parotitis, Low grade fever, pain on jaw opening, tender to touch.
- Ix = Salivary IgM antibody testing. Serum amylase for pancreatic involvement.
- Mx = supportive, analgesia, good hydration.
Get vaccine!!! - Complications = meningitis, encephalitis, orchitis.
Pharyngeal pouch
- Hernia of pharyngeal mucosa though weakness (Killian’s dehiscence).
- CFx = regurgitation, enlargement as food collects there, smelly breathe, gurgles on palpation, chronic cough, aspiration (pneumonia), compress oesophagus = dysphagia.
- Ix = barium swallow.
- Rx = surgical excision.
Middle aged woman with ‘lump in throat’
Globus pharyngeus.
Increase in anxiety periods.
When is stridor heard and why?
Inspiration = upper larynx and upper trachea narrowing.
Expiration = carina and bronchi narrowing
Can also be biphasic.
Ix for foreign body?
Bronchoscopy.
Orbital cellulitis
- Complication of bacterial acute sinusitis.
- Shiny, swollen, purple-red eyelid, eye is forwardly displaced, pain, blurred vision, general malaise, fever.
- CT scan
- IV fluids, ABx (cefuroxime + metronidazole), drain any abscess.
Down’s syndrome ENT aspects
- Narrow Eustachian tube = increased risk of otitis media with effusion or chronic otitis media.
- Ear canal stenosis = conductive hearing loss.
- Adenotonsillar hypertrophy = increased risk of OSA.
RFx for head and neck cancers
- SMOKING, chewing tabacco.
- Alcohol
- HPV16
- EBV
- FHx, more common in males.
- Occupational exposure = hard wood dust, heavy metals (nickel).
Premalignant state of oral cavity cancer
Leukoplakia
Erythroplasia
Lichen planus
Differentials for persistent ulcers in oral cavity
Squamous cell carcinoma
Syphilus
TB
Cancer of oropharynx
- Squamous cell carcinoma, most commonly on tonsil/faucial pillars.
- RFx = smoking, alcohol, HPV16, Betel nut chewing (India)
- CFx = ulcer lesion in oral cavity, dysphagia, ear pain, globus (‘lump in throat’), pain on swallowing, trismus, lymphadenopathy!!
- Ix = CT of head and neck, fine needle aspiration for biopsy histology.
- Rx = surgical excision, chemotherapy, radiotherapy
Differentiating between thyroid cancer, oral cancer and laryngeal cancer
Laryngeal = hoarse voice! ∆ with laryngoscopy and biopsy. Oral = persistent ulceration, bleeding. Thyroid = nodule/diffuse thyroid swelling.
Laryngeal carcinoma
- Vocal cords, epiglottis, subglottis.
- RFx = male, smoking, alcohol.
- Chronic hoarse voice, dysphagia, ear pain, sore throat, lymphadenopathy.
- Ix = good examination and palpation, CXR (lung mets), laryngoscopy + biopsy (TMN staging).
- Rx = radiotherapy, laryngectomy, SALT!!.
2WW if >3 weeks hoarse voice!
Nasopharyngeal cancer cause
EBV
Nasopharyngeal tumour types
Squamous cell carcinomas of nose
Non-hodgkin’s lymphoma
Chordoma
Difference between child and adult neck lumps
Adults 80% are malignant, paediatric neck lumps 80% are benign.
Symptoms in a neck lymph Hx pointing to neoplasia
Referred ear pain
Weight loss
Malignant and non-malignant lymphadenopathy
Malignant = Virchow's node for upper GI met (left supraclavicular fossa), leaukaemia, rubbery = lymphoma. Non-malignant = tonsillitis, pharyngitis, infectious mononucleosis, Kawasaki's, connective tissue disease (Sjorgren's).
Differentials for neck lumps
- Thyroid origin = nodular or diffuse (goitre) thyroid lump. Move UPWARDS on swallowing.
- Salivary gland origin = tumour of salivary gland, Mumps, parotitis.
- Congenital = thyroglossal cyst, brachial cyst, laryngocele.
- Lymphadenopathy = metastasis, lymphoma, local infection.
- Pharyngeal pouch.
- Carotid aneurysm = pulsatile, no movement on swallowing.
Thyroid masses
- Causes = thyroiditis, toxic multinodular goire, follicular adenoma, thyroid carcinoma.
- CFx of hypo or hyper thyroidism. Lump moves upwards on swallowing.
- Ix = thorough examination and palpation. TFT, serology for autoimmune thyroid antibodies, USS, Fine Needle Aspiration Cytology (FNAC), CT.
- Rx = control thyroid status with carbimazole/levothyroxine. Thyroid lobectomy or thyroidectomy surgery.
Site of potential airway obstruction leading to OSA
Nasopharynx = nasal polyps, Adenoid hypertrophy, nasal squamous cell carcinoma.
Oropharynx = macroglossia.
Laryngotrachea = laryngeal carcinoma
Down’s syndrome, Prader-Willi syndrome.
RFx for OSA
Male Obese Large neck circumference (>43cm) FHx Smoking Alcohol intake before bed Acromegaly.
Complications of OSA
Pulmonary HTN Cor pulmonale Lethargy, poor concentration and memory Cot death in kids. Polycythaemia
CFx of OSA in adults and kids
Excessive daytime sleepiness and poor concentration.
Witness patterns of snoring, apnoea and then waking to catch breathe/gasp (at least 5 per hour in night).
Feeling of not refreshed on waking
Low libido.
Kids = similar pattern of snoring and sudden arousal to catch breath.
Irritable in daytime, poor school performance, failure to thrive.
Ix and Rx for OSA
- Examine for tonsil enlargement nasal obstruction, small jaw.
- Check BP, BMI, neck circumference.
- Epworth sleepiness scale.
- Polysomnography.
- Referral to ENT
- ?FBC for polycythaemia
Rx = continuous positive airway pressure at night, itoa-oral devices e.g. mandible advancement device.
Bell’s palsy
- Acute, unilateral facial nerve palsy. Unknown aetiology. Diagnosis of exclusion.
- Abrupt onset facial paralysis, dry eyes, sagging mouth, dribbling, impaired taste. FOREHEAD SPARING AS LMN DISEASE!!
- Rx = oral steroids, most make full recovery.
Complications of cholesteatoma
Intratemporal: facial nerve paralysis, Labyrinthine fistula, mastoiditis.
Intracranial: meningitis, inter cranial abscess, lateral sinus thrombus.
Why is a drug history important in a patient presenting with bilateral nasal obstruction, lessening smell, rhinorrhoea.
They sound like they have nasal polyps.
Do they have SAMTER’S TRIAD of nasal polyps, asthma and aspirin sensitivity?!
O/E of nasal polyps
Soft, non-tender, mobile masses. Pale and bilateral.
CFx of glandular fever and causative organism
Epstein-Barr virus // infectious mononucleosis.
Symptoms = Malaise, fever, headache, sore throat/pharyngitis.
Signs = Fever, tender cervical adenopathy, splenomegaly, hepatomegaly, palatal petechiae.
Complications of EBV
Guillian Barre syndrome
Splenic rupture
Malignancy - EBV is associated with naso carcinomas and lymphomas.
O/E of otitis media with effusion
Fluid level behind TM
RFx for acoustic neuroma
Neurofibromatosis 2
Causes of CSF rhinorrhoea
Post-surgical (trans-sphenoidal)
Fracture to ethmoidal bone
Fracture to fronto-basal skull
ABx for tonsillitis and what to avoid
If CENTOR criteria >3, give Penicillin V
NOT amoxicillin as if due to EBV can cause maculopapular rash
RFx for Bells Palsy
Pregnancy
Diabetes mellitus
Differentials for neck lumps in midline
Goitre/thyroid mass
Thyroglossal cyst
Dermoid cyst
Differentials for submandibular triangle neck lumps
Lymphadenopathy - reactive to infection or malignancy
TB
Differentials for anterior triangle neck lump
Lymphadenopathy
Brachial cyst
Parotid tumour
Carotid artery aneurysm
Differentials for posterior triangle neck lump
Pharyngeal pouch
Cervical rib
Lymphadenopathy.
