ENT Flashcards
Describe the external auditory canal:
About 2.5cm
Outer 1/3rd is cartilage with hairs and ceruminous (wax)
glands
Inner 2/3rd is bony and lined with sensitive skin
What is chondrodermatitis nodularis helicis?
Tender cartilaginous inflammed nodule on helix due to pressure
What is pinna haematoma?
Blunt trauma can cause bleeding in the subperichondrial plane elevating perichondrium to form a haematoma
How should pinna haematoma be treated?
Incision of haematoma and primary closure
What is the consequence of poor treatment of pinna haematoma?
Ischemic necrosis then fibrosis (cauliflower ear)
What are auditory exostoses?
Smooth, multiple, bilateral swelling of bony canals that represent local bone hypertrophy from cold exposure
What are the management options for excess ear wax?
Olive oil drops
Suction under direct vision using microscope
Syringing after softening with olive oil
Describe the main features seen when examining the tympanic membrane:
Cone of light pointing to side of ear being examined Malleus and incus often seen Pars tensa (inferior drum) and pars flaccida (superior drum)
What are some presenting features of otitis externa?
Discharge, itch, pain and tragal tenderness
What are the main causative organisms of otitis externa?
Pseudomonas or S. aureus
What are some predisposing factors to otitis externa?
Excess canal moisture, trauma, high humidity, absence of wax, narrow ear canal, hearing aids
What is the treatment for mild-moderate otitis externa?
Clean EAC, topical Abx ± steroid drops
Keep ears water free
What is the treatment for severe otitis externa?
Thin ear wick can be inserted with aluminium acetate
Once meatus opens up - microsuction or careful
cleansing
How can the external auditory canal be cleaned?
Gentle syringing to remove debris, dry mopping with cotton wool under direct vision, microsuction
What is furunculosis and what condition is it associated with?
Painful staph abscess arising in hair follicle within canal
Associated with diabetes
How can malignant/necrotising otitis externa present?
Chronic ear discharge, deep severe otalgia, temporal headaches and sometimes CN palsies
What are the consequences of malignant/necrotising otitis externa?
Temporal bone destruction and base of skull osteomyelitis
What is the main causative organism of malignant/necrotising otitis externa and what condition is this disease associated with?
Pseudomonas
Diabetes
What is the treatment for malignant/necrotising otitis externa?
Surgical debridement, systemic Abx, specific Ig
What conditions can cause referred otalgia?
TMJ dysfunction
Ramsay-Hunt syndrome
Cervical spondylosis
Tonsillitis, quinsy
What are the presenting features of acute otitis media?
Rapid onset of pain, fever, anorexia, vomiting
Bulging of TM causes pain and eases if drum perforates ± discharge
What are some common organisms causing otitis media?
Pneumococcus, haemophilus, moraxella, streps + staph
What is the management for otitis media, when would you give Abx?
Analgesia
Amoxicillin if: systemically unwell, immunocompromised, symptoms >4d, <3m, perforation
What is chronic otitis media and what are some symptoms?
TM perforation in setting of recurrent or chronic infections
Hearing loss, otorrhoea, fullness, otalgia
What is the management for chronic otitis media?
Topical/systemic Abx, aural cleaning, water precautions
May need myringoplasty/mastoidectomy
What is a complication of chronic otitis media?
Prolonged low middle ear pressure allows for retraction pocket of pars tensa/flaccida which can enlarge resulting in cholesteatoma
What is cholesteatoma and what are some symptoms?
Growth of squamous epithelium
Foul discharge, hearing loss, headache, pain
What can be the complications of cholesteatoma?
Meningitis, cerebral abscess, hearing loss, mastoiditis
What is the treatment for cholesteatoma?
Mastoid surgery
What is mastoiditis?
Middle ear inflamm leads to destruction of air cells in mastoid bone ± abscess formation, can spread intracranially
What are some symptoms of mastoiditis?
Fever, tenderness, mastoid swelling and redness, protruding auricle
What is the management for mastoiditis?
CT imaging and admit for IV Abx, myringotomy ± mastoidectomy
What is myringoplasty?
Perforation in TM is patched using a graft (perichondrium/fascia) and applied underneath TM
Acts as scaffold for TM to grow across
What is mastoidectomy?
Mastoid surgery and tympanoplasty used to eradicate source of chronic infection/excise cholesteatoma
Removal of mastoid air cells
What are some presenting features of glue ear?
Poor speech, language delay, balance problems, poor progress at school
What are the management options for glue ear?
Actively observe for 3m
Autoinflation of Eustachian tube
Insertion of grommets
What does pure tone audiometry aim to measure?
Quantifies hearing loss and determines its nature
What does tympanometry aim to measure?
Measuring pressure in middle ear and establishing cause of conductive deafness
What hearing tests may be used in newborns?
Otoacoustic emissions
Audiological brainstem responses
Describe the tympanogram seen if there is disruption of ossicles or if part of drum is flaccid:
Large peak (high compliance) when canal pressure = middle ear pressure
Describe the tympanogram if there is fluid in the middle ear:
Low flat result (low compliance) due to stiff ear drum
Describe the tympanogram seen in developing or resolving OM:
Shift in peak of curve to left found in negative middle ear pressure
How would you perform a Rinne’s test?
Vibrating fork on mastoid to test BC
When sound is no longer audible move in front of ear to test AC
What are the positive and negative results of Rinne’s test?
Rinne’s +ve if AC > BC (normal or SNHL)
Rinne’s -ve if BC > AC (CHL)
What are the possible results of Weber’s test?
Equal = normal
Localised to side of HL if CHL
Localised away from side of HL if SNHL.
Define normal hearing, mild, moderate and severe hearing loss based on dBHL:
Normal hearing = -10-25dBHL with 0 as average
Mild HL = 26-40dBHL
Moderate = 41-70dBHL
Severe = 71-90dBHL
Describe the audiogram in presbycusis:
Bilateral, symmetrical, high freq SNHL
Describe the audiogram in noise-induced hearing loss:
Cahart’s notch at 4kHz with recovery at 8kHz
Describe the audiogram in conductive hearing loss:
Air-bone gap
Describe the audiogram in Meniere’s disease:
Poor hearing a low frequencies in one ear, recovering at higher frequencies
What are some genetic causes of childhood deafness?
Congenital anomalies of pinna, EAC, drum or
ossicle
Treacher-Collins, Pierre-Robin
Alport’s, Turner’s
What are some non-genetic causes of childhood deafness?
Intrauterine TORCH infection (CMV, rubella, toxo, HSV, syphilis)
Prematurity, IVH, hypoxia
Meningitis, measles, mumps
What are the management options for childhood deafness?
Support + advice advice
Hearing aids or cochlear implants
Provide support to develop spoken or signed communication
Who are cochlear implants for?
Children and adults with profound SNHL who do not
benefit from a conventional hearing aid
How do cochlear implants work?
Multichannel electrode inserted surgically into cochlea that directly stimulates the auditory nerve when electrical signals are applied
When are bone-anchored hearing aids used?
Intolerance to conventional hearing aid, congenital malformations, single sided deafness
How do bone-anchored hearing aids work?
Sound is transmitted to cochlea via bone conduction,
titanium screw implanted into bone and attached to hearing aid
What are some causes of conductive hearing loss in adults?
External canal obstruction: wax, pus, debris, FB
Drum perforation: trauma, barotrauma, infection
Otosclerosis
What are some causes of sensorineural hearing loss in adults?
Acoustic neuroma, cholesteatoma
Ototoxic drugs
Post-infective: meningitis, measles, herpes, syphilis
Meniere’s, trauma, presbycusis
What are some drugs that can cause of sensorineural hearing loss?
Vancomycin, gentamicin, chloroquine, vinca alkaloids
What are some causes of sudden hearing loss?
Conductive infection, occlusion, trauma, fracture
If SN: noise exposure, gent toxicity, acoustic neuroma, MS
How should sudden hearing loss be investigated?
EAC and TM examination, tuning forks
FBC, CRP, U+E, LFT, TSH, clotting, glucose
Audiometry, MRI
What is otosclerosis?
New bone is formed around stapes footplate, leads to fixation and CHL
What is the inheritance pattern of otosclerosis?
Autosomal dominant
What are the features of otosclerosis?
Early adult life, accelerated by pregnancy, conductive deafness, tinnitus, transient vertigo, pink tinge to drum (Schwartze’s)
What is the treatment for otosclerosis?
Hearing aid, surgery (stapedectomy/stapedotomy)
What is presbycusis?
Age-related, bilateral, high freq SNHL
Deafness (loss of hair cells) is gradual
Describe how the cochlea is involved in the perception of sound:
Stapes articulates with oval window causing movement of perilymph and pressure change
Vibrations transmitted through endolymph to tectorial membrane and movement of this causes movement of hair cells resulting in depolarisation and perception of sound
What is tinnitus?
Perception of sound, typically in absence of auditory stimulation
What can cause objective tinnitus?
AV malformations, Paget’s, hyperthyroidism, anaemia
What can cause subjective tinnitus?
Presbycusis, noise induced HL, Meniere’s, wax, ototoxic drugs, OM, AN, trauma, mental health issues
What drugs can cause tinnitus?
Cisplatin + aminoglycosides
Aspirin, NSAIDs, quinine, macrolides, loop diuretics
How should tinnitus be investigated?
Audiometry, tympanogram, unilateral may need MRI to exclude AN
What are some management options for tinnitus?
Treat cause
Explain tinnitus often improves with time
Hearing aids, sound therapy, CBT, pt support groups, hypnotics
What is an acoustic neuroma?
Vestibular schwannomas, usually arising on superior vestibular nerve Schwann cell layer
What are some presenting features of acoustic neuroma?
Progressive ipsilateral tinnitus ± SNHL
If large, ipsilateral cerebellar signs, RICP, numb face
How might acoustic neuroma be investigated and managed?
MRI
Watch and wait, surgery, radiosurgery
What are some symptoms of noise induced hearing loss?
Bilateral symmetrical SNHL, tinnitus, hearing improves away from source of exposure
What is the management for noise induced hearing loss?
Reduce risk of occupational exposure – ear defenders, screening of at risk
Hearing aids
What is vertigo?
Sensation that you, or the world around you, is moving or spinning
What are some causes of peripheral vertigo?
Meniere’s, BPPV, vestibular failure, labyrinthitis
How should vertigo be investigated?
CNs and ear examination, cerebellar function, reflexes,
Romberg’s, head thrust test, Hallpike test
What are some causes of central vertigo?
AN, MS, head injury, migraine associated dizziness, vertebrobasilar insufficiency, stroke
Describe benign paroxysmal positional vertigo:
Attacks of sudden rotational vertigo lasting >30sec, provoked by head-turning
What is the cause of benign paroxysmal positional vertigo?
Displacement of otoconia stimulating semi-circular canals
How is BPPV diagnosed?
Dix-Hallpike +ve
No persistent vertigo; no tinnitus, headache, ataxia,
How is BPPV treated?
Often self-limiting
If persistent: Epley manoeuvre, home repositioning manoeuvres
Describe the Dix-Hallpike test:
Ask pt to keep eyes open and look straight ahead
With pt sitting on coach, turn head 45° towards test ear Continue to hold head between hands and ask them to lie backwards then quickly lower head 30° below level of couch
Ask if they feel dizzy and look for nystagmus
If +ve, there is vertigo and rotary nystagmus towards undermost ear, lasting 30sec
Describe the Epley manoeuvre:
Move pt head through 4 sequential positions, resting for 30sec between movements
Aim is to reposition otoconia away from sensitive posterior canals
Describe the features of Meniere’s disease:
Sudden attacks of vertigo lasting 2-4h with nystagmus May be increasing fullness in ears ± tinnitus followed by vertigo
Symptoms often become bilateral and fluctuating SNHL common
What is the management for Meniere’s? (include acute, prophylactic + persistent)
Low-salt diet
Acute: prochlorperazine
Prophylaxis: betahistine, thiazides.
If persistent, instillation of gentamicin via grommets, labyrinthectomy, vestibular neurectomy, vestibular destruction with gent injection
What are the features of vestibular neuronitis/labyrinthitis?
Sudden attacks of unilateral vertigo and vomiting in previously well person, often following recent URTI
Lasts 1-2d
Hearing loss in labyrinthitis
What is the treatment for vestibular neuronitis/labyrinthitis?
Vestibular suppressants - prochlorperazine, cyclizine
What is vestibular migraine?
Migraine variant, characterised by a combination of vertigo, dizziness, or balance disturbance with migrainous features
What is acute rhinosinusitis and how is it managed?
Common cold and most episodes are self-limiting
If symptoms persist >5d, consider intranasal corticosteroids
What is chronic rhinosinusitis and how is it managed?
> 12w
Intranasal corticosteroids and nasal saline irrigation
If a single unilateral nasal polyp is found, what investigation should be carried out?
Biopsy
What conditions are nasal polyps associated with?
Allergic + non-allergic rhinitis, CF, asthma,
septal deviation, immunosuppression, aspirin hypersensitivity, pregnancy
What are some symptoms of nasal polyps?
Watery anterior rhinorrhoea, sneezing, purulent postnasal drip, nasal obstruction, sinusitis, mouth-breathing, snoring, headaches
How can nasal polyps be investigated?
Anterior rhinoscopy or nasal endoscopy, CT
How can nasal polyps be differentiated from turbinates?
Polyps pale, mobile and insensitive to gentle palpation
Turbinates pink, mobile and sensate
What are the management options for nasal polyps?
Topical steroid drops shrink polyps
Long term Abx (doxycycline)
Endoscopic sinus surgery, polypectomy
How should allergic rhinosinusitis be investigated?
Skin prick testing/RAST
What are some symptoms of allergic rhinosinusitis?
Sneezing, pruritus, nasal discharge, bilateral itchy red eyes, swollen turbinates, pale mucosa, may be nasal polyps
How can allergic rhinosinusitis be managed?
Allergen avoidance, nasal saline irrigation, antihistamines, intranasal corticosteroids sprays
What are some features associated with acute bacterial sinusitis?
Discoloured discharge, purulent secretions,
severe local pain (unilateral), fever, elevated CRP
What are some common causative organisms of acute bacterial sinusitis?
S. pneumoniae, H. influenzae, S. aureus, Moraxella, fungi
How should acute bacterial sinusitis be managed?
Amoxicillin
Analgesia, nasal saline irrigation, intranasal decongestants
How should recurrent sinusitis be investigated?
CT paranasal sinuses and nasal endoscopy
Which sinuses drain into the middle meatus?
Maxillary
Anterior + middle ethmoidal
Frontal
Which sinus drains into superior meatus?
Posterior ethmoidal
Where does the sphenoid sinus drain into?
Spheno-ethmoidal recess
Where does the naso-lacrimal duct drain into?
Inferior meatus
What are some complications of sinusitis?
Orbital cellulitis/abscess, meningitis, encephalitis, cerebral abscess, cavernous sinus thrombosis
How can nasal fractures present?
New nasal deformity, facial swelling, black eyes, may have septal haematoma
How should nasal fractures be managed?
Treat epistaxis, analgesia, ice, close injuries
Reassess 5-7d after and MUA can be performed 10-14d after
What can cause septal perforation?
Septal surgery, trauma, inhalants (sprays, cocaine), TB, SCC
How should septal perforation be managed?
Saline nasal irrigation, petroleum jelly, surgical repair
How can nasopharyngeal cancer present?
Cervical lymphadenopathy, unilateral hearing loss, nasal bleeding/obstruction/discharge, CN palsies
What is a septoplasty?
Corrects deviated nasal septum
What is a septorhinoplasty?
Aims to straighten and/or refashion shape of nose
What is nasal saline irrigation?
Pts sniff saline solution into nostril, removes debris and prevents crusts from forming after surgery or epistaxis, clears irritant allergens
What are some causes of epistaxis?
Idiopathic, local trauma (nose picking), facial trauma, dry/cold weather, haemophilia, vasculopathies, septal perforation
Describe the management steps for epistaxis:
Pinch lower part of nose for 20min, sit forward
Silver nitrate cautery of bleeding points
If bleeding continues: anterior nasal pack
If still bleeding, postnasal pack – Foley catheter to occlude posterior choana
Arterial ligation/embolisation
What is Little’s area (Kiesselbach’s plexus)?
Where anterior ethmoidal, sphenopalatine and facial arteries anastomose
What is the name of the site where pharyngeal pouches can form?
Killian’s dehiscence
Between inferior constrictor and cricopharyngeus is area deficient of muscle
What are the common organisms that cause tonsillitis? (virus + bacteria)
Rhinovirus, parainfluenza virus, influenza, adenovirus, EBV
Group A beta-haemolytic strep (S. pyogenes), staph, S. pneumoniae
How should tonsillitis be managed?
Reassurance, regular ibuprofen ± paracetamol
If Centor criteria 3 or 4, consider pen V for 10d
Describe the Centor criteria:
Presence of tonsillar exudate, presence of tender anterior cervical lymphadenopathy, fever, absence of cough
Presence of 3/4 suggest Strep infection
What are some complications of tonsillits?
Otitis media, sinusitis
Peritonsillar abscess (quinsy)
Parapharyngeal abscess
Lemierre syndrome
What are some symptoms of quinsy?
Sore throat, dysphagia, peritonsillar bulge, uvular deviation, trismus, muffled voice
How should quinsy be managed?
IV Abx and aspiration needed
What is Lemierre syndrome?
Acute sepsis and jugular vein thrombosis secondary to infection with Fusobacterium + septic emboli
What are the indications for tonsillectomy?
Recurrent tonsillitis where episodes of sore throat are disabling
≥7 sore throats in preceding year, ≥5 in each of last 2y, ≥3 in each of last 3y
What are the complications of tonsillectomy?
Primary haemorrhage (<24h) – return to theatre Secondary haemorrhage (typically after 5-10d) due to infection of tonsillar fossae
What is the cause of scarlet fever?
Exotoxins released by S. pyogenes
What are some symptoms of scarlet fever?
Red ‘pin-prick’ blanching rash develops on chest, axilla and behind ears after initial sore throat + fever
Strawberry tongue and facial flushing
What is the treatment for scarlet fever?
Pen V for 10d
What is stridor?
High-pitched noise heard in inspiration from partial obstruction at larynx or large airways
What are some causes of stridor?
Laryngomalacia, laryngitis, epiglottitis, croup, anaphylaxis
What can cause dysphonia?
Laryngeal cancer
Vocal cord palsy and nodules
Laryngitis + reflux laryngitis
Reinke’s oedema
What are the features of recurrent laryngeal nerve palsy?
Weak, breathy voice, weak cough, repeated coughing, aspiration, exertional dyspnoea
What are the causes of recurrent laryngeal nerve palsy?
Cancer, iatrogenic (parathyroidectomy, oesophageal/pharyngeal pouch surgery), syringomyelia, TB, aortic aneurysm, idiopathic
What investigations should be performed if recurrent laryngeal nerve palsy is suspected?
CXR, CT, US thyroid, laryngoscopy
What are some malignant causes of dysphagia?
Oesophageal, pharyngeal, gastric, extrinsic pressure e.g. lung Ca, node enlargement
What are some neurological causes of dysphagia?
Bulbar palsy, lateral medullary syndrome, MG, syringomyelia
What are some other causes of dysphagia (not malignant/neuro)?
Benign strictures, pharyngeal pouch, achalasia, oesophagitis
How should dysphagia be investigated?
FBC, CRP, CXR, barium swallow, endoscopy + biopsy
What are some features of pharyngeal pouch?
Dysphagia with gurgling, regurgitation of undigested food, halitosis, lump in neck, aspiration
How should pharyngeal pouch be treated?
Endoscopic sampling of wall that divides pouch from oesophagus
What is globus pharyngeus/hystericus?
Sensation of lump in throat most noticed when
swallowing saliva, can be due to stress/anxiety
What are some symptoms associated with H+N SCC?
Neck pain, lump, hoarse voice (>6w), sore throat (>6w), painless ulcers
How should H+N SCC be investigated?
Panendoscopy, FNA/biopsy of masses, CT/MRI
neck
Describe the course of the facial nerve?
Arises in medulla and emerges between pons and medulla, travels through posterior fossa and runs through middle ear before emerging from
stylomastoid foramen to pass into parotid
What are some intracranial causes of facial nerve palsy?
Brainstem tumour, stroke, MS, acoustic neuroma, meningitis
What are some intratemporal causes of facial nerve palsy?
OM, RH syndrome, cholesteatoma
What are some infratemporal causes of facial nerve palsy?
Parotid tumour, trauma
How should neck lumps be investigated?
Neck examination, endoscopy, US, FNA cytology, biopsy, CT, virology
What can be the cause of midline neck lumps?
Dermoid cysts, thyroglossal cysts, thyroid mass (goitre)
What are the borders of the submandibular triangle?
Bordered above by mandible and below by digastric
What can be the cause of lumps within the submandibular triangle?
Reactive or malignant lymphadenopathy, salivary stone
What are the borders of the anterior triangle?
Between midline, anterior border of SCM and mandible
What can be the cause of lumps within the anterior triangle?
Lymphadenopathy, branchial cysts, parotid tumour, laryngoceles, carotid artery aneurysm
What are the borders of the posterior triangle?
Posterior border of SCM, anterior edge of trapezius, clavicle
What can be the cause of lumps within the posterior triangle?
Cervical ribs, pharyngeal pouches, cystic hygromas,
lymphadenopathy
Where do retropharyngeal abscesses form?
Anterior to prevertebral fascia and behind pharynx
Extends from base of skull to mediastinum
What are some symptoms of retropharyngeal abscesses?
Rigid neck, reluctance to move, systemically unwell, dysphagia, odynophagia
How should retropharyngeal abcesses be managed?
Secure airway, IV Abx, incision and drainage
What is Ludwig’s angina?
Infection of space between floor of mouth and mylohyoid
What are some symptoms of Ludwig’s angina?
Swelling of floor of mouth, painful mouth, protruding tongue, airway compromise, drooling
How should Ludwig’s angina be managed?
Secure airway, IV Abx, surgery to drain collection
What are the commonest causes of obstructive sleep apnoea in adults and children?
In children, adenotonsillar hypertrophy
In adults, obesity
How should obstructive sleep apnoea be investigated?
BMI, TFT, CXR, ECG, sleep study, Epworth score
What is the management for obstructive sleep apnoea?
Weight loss, CPAP, surgery in children (adenotonsillectomy)
What are the main types of thyroid neoplasms?
Benign adenoma – mainly follicular Papillary adenocarcinoma – 70% Follicular adenocarcinoma – 20% Medullary carcinoma – 5% Anaplastic carcinoma – 5%
How should thyroid neoplasms be managed?
Adenomas require no further treatment after diagnostic hemithyroidectomy
Carcinoma: total thyroidectomy + adjuvant radio-iodine if papillary and follicular
What are the complications of thyroidectomy?
Post-op haemorrhage
Airway obstruction
Vocal cord palsy
Hypocalcemia
What is sialadenitis?
Acute infection of submandibular or parotid glands
How should sialadenitis be managed?
Abx, good oral hygiene, sialogogues, may need surgical drainage
How can sialolithiasis present and which gland is usually affected?
Pain and tense swelling of gland during/after meals
Submandibular gland
What is Sjogren’s syndrome?
Autoimmune, lymphocytic infiltration into ductal tissue of secretory glands
How can Sjogren’s present?
Dry eyes, dry mouth, enlarged salivary glands
What can cause xerostomia?
Hypnotics, tricyclics, antipsychotics, beta blockers, diuretics
Dehydration, ENT RT, Sjogren’s, SLE, sarcoid, HIV, parotid stones
How should xerostomia be managed?
Increase oral fluids, good dental hygiene, saliva substitutes
In which gland are the majority of salivary gland tumours found?
80% in parotid
What are some symptoms of salivary gland tumours?
Hard fixed mass, pain, overlying skin ulceration, lymphadenopathy
What investigations can be performed if suspected salivary gland tumour?
US, MRI, FNA cytology/CT guided biopsy, X-ray, sialography
How should salivary gland tumours be managed?
Surgery, RT
