ENT Flashcards
Nmae 3 common DDx of cervical lymphadenopathy
EBV: fever, pharyngitis, lymphadenopathy: posterior cervical
HIV: flu-like etc. cervical, axillary and occipital
Adenovirus: cold or flu/RTI axillary, cervical, occipital
CMV: immunocompromised, nt sweats, pneumonia
HZV: shingles - axillary, cervical, occipital
Streptococcal pharyngitis (pyogenes): cervical lymphadenopathy, enlarged tonsils
NHL, HL, CLL - generalised etc
What travels through parotid
facial nerve (if this is affected = malignant)
Name 3 causes of parotid swelling
viral parotitis (mumps), stone, sarcoidosis, tumours, HIV, wegners
Pt comes in with Bilateral swelling of parotids lasting one week, associated by low grade pyrexia… What Ix ? name 3
FBC, ESR/CRP, UE, blood culture, viral serology,
salivary antibody testing (*salivary mumps IgM)
Pus swab culture and sensitivities
USS
Sialography for blockage (contrast into gland + X-ray)
CT/MRI scan to exclude neoplasm
Which salivary gland do you normally get obstruction?
submandibular (parotid wider / more water)
Parotid Pain + swelling at meal times, colicky, relapse and remit…What is it likely? Ix?
obstruction
USS + contrast sialography
Mx of obstruction
Many pass spontaneously: good hydration, warm compress, gland massage, oral hygiene
Surgical removal
Most tumours of salivary glands are benign (75%) but name 3 red flags that might indicate malignancy
Rapid increase in size, ulceration, fixation, paresthesia of associated nerves, past Hx skin cancer, Sjogren’s, *facial nerve weakness,
Specific Ix of salivary gland tumour
USS if first line
+ Fine needle aspiration - cytology
+ Core biopsy if tumour is seen
MRI for tumour staging or margins (*sublingual = high malignancy risk)
CT for metastatic spread
Post surgical removal of a salivary tumour what is the main complications
Damage to facial nerve
recurrence
Freys syndrome (redness or swelling on cheek when eating/salivating from autonomic nerves)
Most common cause of vertigo?
Benign paroxysmal positional vertigo
Who gets BPPV
50 year old women with anxiety + Menieres
BPPV what type of vertigo? how long does it last”?
Vertigo provoked by head movement, worse when head tilted one way
Sudden onset attacks: 20-30 seconds
Assoc nausea
Name any Sx you might think were red flags in BPPV
hearing loss, tinnitus, pain or headache
What test confirms BPPV?
2 other examinations?
Dix-Hallpike test
(turn head to one side and quickly lay them down
-> vertigo and rotary nystagmus)
Otoscopy: for exclude cholesteatoma and vesicles (VZV)
Cranial nerve exam: palsies/hearing loss
In BPPV the dix hallpike test is only positive on 1 side - what might it suggest if its bilateral?
vestibular neuritis, central cause
Name 3 DDx of BPPV
Acute vestibular labyrinthitis, MS, Menieres, acoustic neuroma, Ramsay Hunt syndrome (varicella zoster oticus - pain within ear radiates to pinna, vertigo, tinnitus, facial weakness, rash)
Mx of BPPV ? ADVICE?
Get out of bed slowly, reduce head movements
Epley’s manoeuvre
Advise not to drive when dizzy
High risk of recurrence
What is this and cause?…Episodic auditory and vestibular disease characterised by sudden onset vertigo, hearing loss, tinnitus (*low frequency roaring) and fullness in ear - *unilatera
menieres
overproduction / lack of absorption of endolymph
Meniers presentation
Recurrent vertigo - 30 mins
Unilateral hearing loss: fluctuating and worsening around vertigo *sensorineural
Tinnitus: unilateral and roaring
Aural fullness
Drop attacks
Positive Romberg’s
Hearing loss: pure tone air and bone conduction (low frequency loss early in disease), otoacoustic emissions absent in low frequency
The Ix in menieres is mostly about exclusion - name2
MRI normal,
TFT normal,
lyme disease/syphillis serology - normal
Acoustic neuroma and menieres present quite similarly - what is an easy difference?
Hearling loss - menieres is low frequency (in early disease )
Neuroma - high frequency
Mx of menieres
Low salt diet and diuretics
Symptomatic vertigo:
Meniett device: delivers pressure pulses to ear canalmeclozine (vestibular suppressant) ± intratympanic corticosteroids,
Hearing aids
What if mx of menieres fails?
endolymphatic sac surgery
How to tell the difference between Vestibular neuritis and labyrinthitis
Presentation - Acute vertigo (AN/L) + hearing loss (L only)
This is because vestibular neuritis only affects the vestibular nerve whereas labyrinthitis is a disorder affecting the inner ear as a whole or CN 8 as a whole.
Cause of vestibular neuritis?
Most causes are a viral infeciton e.g. measles, flu, rubella.
reactivation of HSV in vestibular ganglion
What usually precedes labarynthitis
post viral URTI (50%) - bronchitis
Presentation of VN / L
VERTIGO
Sudden, severe incapacitating vertigo (illusion of moving)
assoc N+V
Not triggered by mvmt, but may be exacerbated (dizzy at rest) - *No Dix-Hallpike!!!!!
Hearing loss = labyrinthitis (unilateral/bilateral) ± tinnitus
URTI symptoms
Name 3 things you would do OE of VN/L ?
External ear and TM : herpes zoster oticus, cholesteatoma
Herpes zoster IS VZV.
CN exam - to look for hearing loss
Mastoid tenderness, nuchal rigidity, high fever
Assess gait - fall towards affected side
Hearing test: 256 Hz Weber’s - nerve = quieter in affected, conductive = louder in affected
How to differentiate VN/L from stroke
HINTS test: Head impulse, nystagmus type, skew
What result of HINTS test would indicate VN/L? stroke?
- VN or LN
unidirectional nystagmus, no vertical skew (cover/uncover)
Stroke
bidirectional nystagmus, vertical skew - sensitive for ischaemic stroke esp PICA - posterior inferior cerebellar artery syndrome
specific Ix for VN/L
Culture and sensitivity of middle ear perfusions
CT scan for mastoiditis
Pure tone audiometry in hearing loss
Vestibular function testing
Mx of vertigo in VN/L
prochlorperazine
What is an acoustic neuroma
CN8 tumour of Schwann cells at cerebellopontine angle
What presentation is always an acoustic neuroma until proven otherwise
Unilateral hearing loss
Pres of acoustic neuroma
Unilateral or asymmetrical hearing loss or tinnitus - progressive
Impaired facial sensation (involvement of trigeminal nerve loss of corneal reflex)
Balance problems
Bilateral acoustic neuroma seen when?
Neurofibromatosis T2
2 key Ix in acoustic neuroma
audiology
MRI
Mx acoustic neuorma
treatment of choice is microsurgery
Conservative: if small tumour with good preserved hearing
What nerve innervates the maxiliary sinus ? what does this mean?
infraorbital - can get referred pain to upper jaw pain, toothache, pain in skin
Basic exam of sinus ?
palpate
simple assessment of nose
Name 2 bugs that usually are the cause of sinusitis
strep pneumoniae, h. Influenza, moraxella catarrhalis (children)
Mx of sinusitis
Paracetamol/ibuprofen - pain/fever
Intranasal decongestant (max 7 days)
Nasal douching
Warm face packs
Abx if bacterial - amox
Complications of sinusitis
Orbital cellulitis, meningitis, osteomyelitis
Chronic sinusitis Mx
topical nasal steroids: beclomethasone
Good dental hygiene, stop smoking
If a pt has facial pain associated with getting Worse with fatigue or stress, often linked with depression or mood disturbance…..
Mx/
TCA - amitryptiline ± CBT
triad in TMJ dysfunction
pain, limited mouth opening, joint noises
What is the pain in TMJd
typically in front of tragus (lil ting on inner side of external ear) radiating to ear, temple, cheek, mandible
Mx of TMJ dysfuction
Explanation and reassurance (mainly benign and self-limiting)
Rest, education: limit chewing, massage, relaxation
Manage pain psychologically
Drugs: NSAIDs, muscle relaxants, TCA (2-4 weeks)
2 causes of congenital hearing loss ? Post natal?
rubella
CMV
malformation
Mumps
measles
What are rinnes and webers
Weber’s:
in conductive = louder in affected ear
in sensorineural = quieter in affected ear
Rinne’s: start at mastoid then to ear
+ve both retained
-ve air lost = conductive
Both lost = sensorineural - also +ve
What to examine in deafness
Inspection of external ear andexamination of tympanic membrane
Rinne’s and Weber’s
Deafness Ix
Audiometry
Tympanometry
otoacoustic emission testing
Sudden hearing loss - whatcha do?
urgent referral to ENT
Qs to differentiate otitis externa and acute otitis media with pt presenting with otorrhoea
Is there pain?
Y = otitis externa
There was pain but it is now settled = acute otitis media
Well + unilateral - otitis externa
Pain then discharge late - AOM
[Basically - Media has pain and then discharge later]
Pres of otitis externa
Erythematous ear canal with oedema and exudate
Mobile tympanic membrane
Pain on move tragus
Pre-auricular lymphadenopathy
What are the 3 main types of otitis externa and usual cause
acute diffuse otitis externa (Swimmer’s ear)
-bacterial
chronic otitis externa
-fungal
necrotising otits externa
p.aeruginosa (gets to mastoid / temporal bones)
Mx of necrotising otitis externa
Use oral and topical quinolones (6-8 weeks)
eg ciprofloxacin
Mx of otitis externa
Pain management
Cure infection
Prevent complications
Mx of acute Otitis externa? When oral Abx?
Topical drops - *neomycin (also covers fungal)
Oral ABX if cellulitis or cervical lymphadenopathy
Mx if you suspect fungal cause of otitis externa
clotrimazole
Mx of chronic otits externa with no apparent cause
acetic acid and corticosteroid ear drops (hydrocortisone)
Advice to prevent recurrence of otitis externa. Name 3
Keep ear dry
Use ear plugs when swimming
Do not use cotton swabs for wax
Olive oil to prevent waxy build up
Presentation of acute otitis media
Hearing loss (not in OE), otalgia, otorrhoea, fever
ix in otitis media? if worried about comps?
Culture of discharge if chronic / perforation
CT or MRI to exclude complications
Mx of otitis mediA
Analgesics
nasal steroids - if allergy based
abx if sx >5 days
What is otitis media with effusion called?
glue ear
how does glue ear present/
conductive hearing loss
Feeling of aural fullness
Cracking tinnitus
What is being described?
Which nerves can be involved?
: Intense pain behind ear, fever, boggy mass behind ear, external ear protrudes forwards
mastoiditis
VI (petroud apex) or VII CN palsy
ix in mastoiditis
FBC (WCC), blood cultures,
CT/MRI for Dx and comp
LP if suspect IC spread
fluid extraction - tympanocentesis for gram stain and culture
mx of mastoiditis
High dose broad spec IV ABX: 3rd generation cephalosporin (2 days)
Then oral ABX for 2 weeks
What to do if cranial extension of mastoiditis ?
Mastoidectomy + tympanoplasty
What is a cholesteatoma?
Keratinising squamous epithelium within the middle ear cleft
Whats the issue with cholesteatoma?
may be locally invasive affecting bones of middle ear.
Erodes bones with *osteolytic enzymes
how does Cholesteatoma present?
progressive conductive hearing loss
Features of erosion - vertigo, headache, CN7 palsy, meningitis
Frequent otorrhoea (foul smelling) + progressive unilateral hearing loss + tympanic membrane perforation or TM retraction
Ix for Cholesteatoma
CT
MRI
mX Cholesteatoma
surgical removal
what nerve runs over temporal bone
abducens
Where can refer pain to ear?
Cervical spine (C2, C3) - worse at night
Laryngo-pharynx (CN10) - in carcinoma of pyriform fossa
Upper molars/TMJ/parotid gland (CN5 mandibular)
Oropharynx (CN9) (tonsillitis or carcinoma of posterior ⅓ tongue)
Dx and staging of oral Ca
fibre optic endoscopy, fine needle aspiration/biopsy (neck masses)
CT/MRI for spread and nodal metastasis
CT thorax for all with head and neck cancers
Mx of early oral Ca
Surgical resection or brachytherapy
If no neck disease - prophylactic radiotherapy
Postoperative radiotherapy ± CISPLATIN
Rfs oral / pharyngeal Ca
Tobacco, HPV, alcohol, too hot drinks
Big Rf for nasopharyngeal Ca? common issue?
EBV
(smoking too obvs)
50% have cervical mets at presentation
Pres of layngeal Ca?
Chronic hoarseness* +
PERSISTENT COUGH, pain, dysphagia, lump in neck, sore throat, earache, breathlessness, aspiration, weight loss, *stridor
What Ix in chronic hoarseness
urgent CXR to decide if lung or ENT
When would you Ix sore throat
Only if prolonged, FBC and glandular fever screen, ASO (antistreptolysin O titres)
What things would you advise about for saftey net of sore throat
stridor, drooling, muffled voice, severe pain
Cause of epiglottitis and presentation?
HIB
Sore throat, unable to swallow (drooling), muffled voice (hot potato voice), fever, ear pain, high temp, tachycardia, *tripod sign - patient leaning forward
*Stridor and respiratory distress
Seen on lateral Xray of epiglotitis?
thumbprint sign
Mx of epliglotitis
IV or oral abx ± intubation/tracheostomy
Usual cause of quinsy?
s pyogenes
Mx of quinsy?
IV fluids, analgesia, IV abx (penicillin/cephalosporin/co-amoxiclav)
Needle aspiration, incision and drainage
Ix in reccurent epistaxis ?
FBC, coagulation studies
If ?malignancy - to ENT ± CT ± nasopharyngoscopy
Mx reccurent / severe epistaxis?
Nasal cautery with caustic agent e.g. silver nitrate or electrocautery
What features would cause you to refer a nasal injury immediately
Marked deviation, prolonged epistaxis, septal haematoma (requires incision and drainage) CSF rhinorrhoea - breach of cribiform plate -> for CT and neurosurgery
Ix of nasal polyps
Rigid or flexible rhinoscopy by ENT -
Mx of nasal polyps
topical corticosteroids (beclomethasone may affect growth) \+ saline douche
2nd - functional endoscopic sinus surgery
What is congenital lymphatic lesion, lymphangioma, classically found on left side
90% are evident at birth
Cystic hygroma
what is oval, mobile mass between sternocleidomastoid and pharynx
Develop due to failure of obliteration of second branchial cleft
Usually present in adulthood
brancial cyst
What is? Dysphagia, regurgitation, aspiration, chronic cough, weight loss. Gurgling lump on palpation, halitosis from decaying food
key Ix?
pharyngeal pouch
barium swallow
DDx of swallowing difficulties…name 3
Obstructive
GORD, oesophagitis, oesophageal/gastric cancer, pharyngeal cancer, oesophageal stricture
Neuro
CVA, achalasia, oesophageal spasm, MND, MS, Parkinson’s
Other
Pharyngeal pouch, globus hystericus, external compression (mediastinal tumour), inflammation (tonsillitis, laryngitis), CREST syndrome
Rfs of obstructive sleep apnea
Obesity, male, middle age, smoking, sedatives, alcohol, family history
Pres of obstructive sleep apnea
Hx of snoring and witnessed apnoeas + excessive daytime sleepiness + macroglossia, apnoea
how to assess sleepiness?
epworth sleeiness score
mx obstructive sleep apnea
Behavioural: smoking, wt loss, alcohol
CPAP (gold standard)
?modafinil for daytime sleepiness
Surgical for tonsils etc….
What is bells palsy? features?
Acute, unilateral, idiopathic facial nerve paralysis
20-40yrs
LMN palsy - forehead affected
Hyperacusis (hearing), altered taste
Mx bells palsy
Prednisolone 1mg/kg for 10 days within 72 hours
+ artificial tears (for eyecare)
What should normal ear look like down an otoscope?
“pearly-grey“, translucent and slightly shiny
should be able to visualise the malleolus through the membrane and a “cone of light” in reflection to the otoscope light.
33y complains of poor hearing in the left ear, which has become worse in the past year. She has a family history of uncle and father going deaf in their 40’s
Examination reveals normal ear drums and tuning-fork testing shows Weber test localising to the right and a negative Rinne test on that side.
Diagnosis?
mx?
Otosclerosis
ADominant
Observation – if mild
Hearing Aid – if symptomatic
Stapedectomy – if large conductive loss
stapes replaced with a prosthetic Teflon piston
Comp of stapedectomy in otosclerosis?
5% may become completely deaf if surgery fails
61 year old female presents with left sided hearing loss over the past 48h. No PMHx
Otoscopy NAD
Dx?
Mx?
Acoustic neuroma
Observation if small and slow-growing
Surgical excision
3 year old presented with fever, irritability, ear tugging, not responding when called by mum
OE: bulging, erythematous TM with a absence of light reflex
Dx?
Key comp?
Acute Otitis Media
Mastoiditis
Matsoiditis /AOM can
lead to intracranial infection
and death
A 24-year old has had problems with his ears for most of his life. He has had three sets of grommets for glue ear and numerous ear infections. However, he now has a constant discharge from his right ear for 3 months, which is foul-smelling.
Examination shows the ear canal to be full of debris and mucus. Once this had been removed, a polyp was seen to be filling most of the ear canal, obscuring the tympanic membrane.
Dx?
Mx?
3 comps?
Cholesteatoma
Surgical removal
Atticotomy – if small and limited to the attic
Radical Mastoidectomy – if more advanced and extends into mastoid
Complications can arise if the sac erodes into:
Ossicles – causing conductive deafness
Facial Nerve – causing facial palsy
Labyrinth – causing vertigo
Tegmen (roof of middle ear) – causing intracranial sepsis
Cochlea – causing sensorineural deafness
Sigmoid Sinus – causing it to thrombosis
discharging ear and VII nerve palsy
cholesteatoma until proven otherwise
3 Dx for CNVII palsy
Trauma:
Fractured temporal bone
Vascular:
CVA (Rapid onset, forehead unaffected)
Infection:
Ramsay Hunt Syndrome (Rapid onset, vesicles in ear)
Cholesteatoma (Ear discharge + CHL)
Otitis Media
Neurological:
MS
Neoplasm: Parotid Carcinoma (Gradual onset, facial pain)
Intracranial
Idiopathic
Bells Palsy
Bells palsy vs ramsay hunt
Cause?
Sx Different?
Mx?
Bells - Idiopathic
RH - Reactivation of varacella zoster virus in geniculate ganglion
RH Sx
More pain
Hearing loss
Vesicles
Mx
BP - eye care / corticosteroid
RH - Eye care / Acyclovir
