ENT Flashcards
Describe the difference between a laryngectomy and a tracheostomy
Laryngectomy - surgical removal of larynx and vocal cords, no functional upper airway, trachea separated from oesophagus and brought out opening at front of neck
Tracheostomy - opening in neck made and trachea brought out, voice box in tact, can be permanent/temporary. Tracheostomy tube then placed below level of vocal cords
Describe types of dizziness
Can be
- light headedness
- vertigo (rotational)
- unsteadiness
Describe the types of vertigo
Subjective - patient is stationary and environment rotates
Objective - patient is in motion and environment is stationary
List the differential causes of vertigo
BPPV
Meniere’s disease
Vestibular neuronitis (acute vertigo with no hearing loss)
Labyrinthitis (acute vertigo and hearing loss)
Vestibular migraine
Acoustic neuroma (vestibular schwannoma)
Describe the hallmark features of BPPV:
- comes on with head movements
- symptoms last seconds
- repeated episodes
- no hearing changes
- Dix-Hallpike manouevre is diagnostic
Describe the hallmark features of Meniere’s disease:
- PRODROME of aural fullness, SN hearing loss and tinnitus, THEN vertigo occurs
- episodic lasting days/months
Between episodes of the disease the patient is completely fine
Describe the hallmark features of vestibular neuronitis:
- acute onset vertigo, unwell and bed bound, lasts constantly for weeks before resolving, NO HEARING CHANGES
Describe the hallmark features of acute labyrinthitis:
- acute onset vertigo, unwell and bed bound, lasts constantly for weeks before resolving, WITH HEARING LOSS
What special tests are used to
a) diagnose
b) treat
BPPV
a) Dix-Hallpike to diagnose
b) Epley to treat
Define tinnitus (subjective and objective)
Tinnitus = perception of sound in the absence of acoustic or electrical stimulation of the cochlea lasting >5 minutes
Sub - only heard by the patient, obj - audible to the patient and the examiner
List 7 causes of tinnitus
Idiopathic Ototoxic drugs Hearing loss Meniere's disease Otosclerosis Acoustic neuroma Somatosounds
What are glomus tumours
A type of paraganglioma
Can occur in the middle ear, temporal bone, vagus nerve or carotid body
Present with persistent pulsatile tinnitus
Can also secrete catecholamines and present with hypertension
Often a pulsatile red mass can be seen behind the eardrum
When should tinnitus be investigated?
If it is pulsatile, unilateral or associated with neurological of vestibular (balance) symptoms
What Q’s would you ask in a tinnitus Hx?
constant or intermittent?
Disturbing sleep?
Pulsatile/with heart beat?
Is it in both ears?
How is tinnitus managed
Objective - treat the underlying cause -> surgery
Subjective - reassurance, explanation, hearing aids, white noise, councelling, ?TCA’s
Describe red flag symptoms for head and neck cancers
Hoarseness Weight loss Dysphagia New persistent neck lump Unilateral nasal obstruction Unilateral otalgia with normal examination
Describe a thyroglossal duct cyst
Forms due to failure of the duct to obliterate during embryological development
Midline, firm, trans-illuminatable lump which elevates with tongue protrusion/swallowing
Can malignant transformation later in life
Tx: surgical removal + portion of hyoid bone (sistrunk procedure)
Describe a branchial cyst, its classical presentation and investigation
Usually <30yrs (rare >35 therefore need to exclude a cystic met)
A swelling in the middle 1/3 of SCM in the anterior triangle, a developmental abnormality due to failure of closure of branchial cyst
Investigate with USS and FNA
What 2 H&N malignancies present with hoarseness
Laryngeal cancer Lung cancer (compressing RLN)
What is the most common type of H&N cancer
Squamous cell
Describe the centor clinical prediction score
Used to predict the risk that a patient has bacterial tonsillitis caused by GABHS and assists the decision to prescribe antibiotics
If >3 are present, then 50% chance the sore throat is caused by GABHS
- absent cough
- history of fever
- presence of tonsillar exudate
- tender cervical LN
Describe the emergency management of epiglottitis
1) O2
2) Get senior help - anaesthetist/ENT
3) Secure airway with ET tube
4) Nebulised adrenaline 1:1000 1mg in 5ml normal saline
5) IV dexamethasone 6.6mg
6) IV antibiotics (ceftriaxone) 2g
7) Heliox if available
8) NBM
Describe the cardinal features of otitis externa
ITCH
Discharge and pain which onset at the same time
Sloughy debris seem in the EAM on examination
What is the most common causative bacterial agent of otitis externa?
Pseudomonas aeroguinosa
How is otitis externa treated?
CLEAN - cut nails, no cotton buds
Topical steroids
Topical Abx drop
(May need Pope Wick insertion by ENT in some cases)
Describe necrotising otitis externa
A form of skull base osteomyelitis
Seen in immunocompromised/DM
Caused by pseudomonas
Ear pain which KEEPS AWAKE AT NIGHT and discharge
Granulation tissue seen on examination
Needs Tx with IV Abx with bony penetration for 6/52
Describe otitis media
Infection of middle ear with fluid present
Can be sterile fluid (glue ear) or pussy (acute OM)
Commonly caused by strep pneumoniae
Ear pain, discharge then occurs later if TM perfs
Buldging red TM seen on examination
Tx: paracetamol +/- amoxicillin
Differentiate PTA testing from tympanometry
PTA = pure tone audiogram, this is subjective and needs soundproof conditions
Tympanometry = objective, tests middle ear compliance, more time consuming
List conductive causes of hearing loss
- pinna malformation
- ear wax
- otitis externa
- TM performation
- otitis media
- cholesteatoma
- otosclerosis
Describe a cholesteatoma and how it may present
= active squamous otitis media
- a sac of keratinising squamous epithelium occurs in the middle ear and presents with a DISCHARGING EAR THAT DOES NOT RESPOND TO ABX
What is the most common cause of sensorineural hearing loss?
Presbyacusis (age related SNHL)
List causes of SNHL
Presbyacusis Cochlear nerve damage Menieres disease Labyrinthitis Ototoxic medication Infection e.g. meningitis CPA lesions e.g. acoustic neuroma
Describe otosclerosis
Abnormal bone growth around the stapes leading to stapes fixation
What is the characteristic feature of otosclerosis on PTA
Carhart’s notch
How is otosclerosis treated
Hearing aid
Stapedectomy
When are air conduction and bone conduction hearing aids used?
Air conduction hearing aids -> for CHL
Bone conduction hearing aids -> for CHL when ^ does not work, or for some types of SNHL
Describe the newborn hearing tests which exist
AOAE (automated oto-acoustic emission test): from birth to 3 months, plays noise into ear and looks for rebound response. May need repeated if noisy surroundings or fluid in ear canal
AABR (automated auditory brainstem response): used if failed result from ^, sensors placed on baby’s head and noise played through headphones, looks for brainstem stimulation
Wha are the impacts of hearing loss in childhood?
Slowed development
Poor speech and language
Peer acceptance/social isolation
Access to work/higher education opportunities reduced
Define allergic rhinitis vs non-allergic rhinitis
Allergic rhinitis = inflammation of the nasal mucosa caused by an allergen, and non-allergic rhinitis = inflammation of the nasal mucosa not formed caused an allergen but by an irritant e.g. smoke, air pollution (allergy tests are -ve)
What are the features of allergic rhinitis
nasal congestion, runny nose (discharge), itch, sneezing, red watery eyes, associated with other atopic disease e.g. house dust, pollen
What are the findings on examination of allergic rhinitis
Oedematous, swollen nasal turbinates, nasal congestion and clear discharge
What should you ask in a history for allergic rhinitis?
When did symptoms start?
Do they occur every year or always at the same time?
Do they have pets/feather bedding?
When are their symptoms worst - e.g. when visiting a relative with pets?
What treatments are they on/have tried?
What are the treatments for allergic rhinitis
self care
nasal saline / steroid sprays / antihistamine nasal sprays
barrier creams (vaseline) to catch allergen
Oral antihistamine for seasonal allergic rhinitis only
Is itchiness mainly a feature of allergic or non-allergic rhinitis?
Allergic
Define acute and chronic sinusitis/rhinosinusitis
Sinusitis = inflammation of the paranasal sinuses Rhinosinusitis = inflammation of the paranasal sinuses + nasal mucosa
Acute <12/52, chronic >12/52
Describe the EPOS criteria for diagnosing rhinosinusitis
2+ of the following symptoms:
- nasal obstruction
- nasal blockage
- nasal congestion
- nasal discharge
What investigations may be carried out for sinusitis?
- CT paranasal sinuses
- endoscopy
What complication can arise from nasal fracture which must be ruled out
Septal haematoma -> can lead to ischaemia, necrosis and perforation
List 5 causes of voice hoarseness
Laryngeal cancer (SCC) Functional dysphonia Vocal cord nodules Reinke's oedema (smokers) Presbyphonia
What are the branches of the facial nerve?
temporal zygomatic buccal marginal mandibular cervical
Describe the common parotid tumours
80% benign (pleomorphic adenomas and warthlin’s tumour)
20% malignant (mucoepidermoid carcinomas, adenocarcinomas and squamous cell carcinomas)
parotid tumours make up 80% of all salivary gland tumours
What virus causes ramsay hunt syndrome
HZV (herpes zoster virus)
What are the red flag symptoms that warrant a 2 week urgent referral for suspicion of H&N cancer?
Hoarseness > 6 weeks
Oral mucosa (ulcerations or swellings) > 3 weeks
Red/white patches on oral mucosa
New persistent neck lump >3 weeks
Dysphasia
Persistent unilateral nasal obstruction (esp. accompanied with purulent discharge)
Persistent unilateral otalgia with normal otoscopy
Cranial nerve involvement
List 6 differentials of hoarse voice
Laryngeal cancer Vocal cord palsy (from RLN damage 2o to lung ca) Presbyphonia Laryngitis (from reflux) Reinke's oedema Vocal cord cyst/polyp
What is the most common type of H&N cancer
Squamous cell carcinoma
Contrast the infective agents which cause OM vs OE
OE = pseudomonas aerginosa OM = strep pneumoniae, haem influenza
What is the visible difference between costochondritis and pinna cellulitis
Lobe is spared in costochondritis
What 4 blood vessels converge to form Little’s area in the nose?
GASS
- greater palatine
- anterior ethmoidal
- sphenopalatine
- superior labial
(all branches of the internal and external carotid branches)
