ENT Flashcards
The presence of an indurated ulcer involving the lateral tongue in a patient with a long-term smoking history should be considered what (until proven otherwise)?
Squamous cell carcinoma
If there is a suspected oral cavity malignancy, what examination is essential?
Cervical lymph node examination
What would your examination of a patient with a hemifacial paresis comprise of? Choose the 3 most appropriate options. Fundoscopy Otoscopy Palpation of the parotid gland and neck Palpation of the floor of mouth Movement of the facial muscles Assess facial sensation Palpation of the abdomen
Otoscopy, palpation fo parotid gland and neck, movement of the facial muscles.
Course of the facial nerve= from the skull base, within the middle ear cavity and temporal bone, to emerge via the stylomastoid foramen and then within the substance of the parotid gland
‘80% of parotid tumours are (benign/malignant), and 80% of these are ________’
Complete the sentence
Benign
Pleomorphic adenomas
Which 3 of the following statements about the facial nerve are true:
It provides special secretory innervation to the lacrimal glands
It provides motor innervation to the stapedius muscle
It provides motor innervation to the tensor tympani muscle
It supplies motor innervation to the intrinsic muscles of the tongue
The nerve exits the skull base via the foramen lacerum.
The nerve exits the skull base via the stylomastoid foramen
- It provides special secretory innervation to the lacrimal glands
- It provides motor innervation to the stapedius muscle
- The nerve exits the skull base via the stylomastoid foramen
Give 2 risk factors of Bell’s palsy?
Diabetes
Recent upper respiratory tract infection
Pregnancy
True/false: pleomorphic adenomas can be managed conservatively in the majority of patients?
False, they have the potential for malignant transformation, so may need excision.
Which 3 structures pass through the parenchyma of the parotid? External carotid artery Internal jugular vein Retromandibular vein Facial nerve Internal carotid artery Vagus nerve
External carotid artery
Retromandibular vein
Facial nerve
Match up thyroid nodule, thyroglossal duct cyst and dermoid cyst to each of the following.
1) Moves on BOTH swallowing AND tongue protrusion
2) Moves on swallow, does NOT move on tongue protrusion
3) Does NOT move on EITHER swallowing or tongue protrusion
1) Thyroglossal duct cyst
2) Thyroid nodule
3) Dermoid cyst
What is the most common type of thyroid malignancy: Follicular carcinoma Lymphoma Medullary carcinoma Papillary carcinoma Anaplastic carcinoma
Papillary carcinoma (75-80%)
Then follicular carcinoma (15-20%)
Hoarseness exceeding three weeks requires urgent investigation to exclude ?
Laryngeal malignancy
What is the single best investigation to rule out laryngeal malignancy?
Flexible naso-laryngoscopy
What 2 investigations are required for staging of laryngeal malignancy?
CT thorax and MRI neck
What is the most common histological subtype of laryngeal cancer?
Squamous cell carcinoma
T/F: carcinomas of the larynx most typically occur in the subglottis region?
F- 5% arise from subglottis, majority are in the glottis
Recurrent laryngeal nerve palsy is a cause of vocal cord paresis and resultant hoarseness. Which of the following is NOT commonly associated with recurrent laryngeal nerve palsy? Thyroid surgery Thyrotoxicosis Aortic aneurysm repair Carcinoma of the oesophagus Carcinoma of the bronchus Polio
Thyrotoxicosis
Single most effective analgesia for dental pain?
NSAID based analgesic
What imaging should be used to demonstrate a dental abscess?
Orthopantomogram radiograph
In a peritonsillar abscess (quinsy), the uvula is deviated toward/away from the site of infection?
Away
What is the most common causative organism of peritonsillar abscess?
Second?
Group A strep
Haem influenzae
What Abx is the treatment of choice for peritonsillar abscess?
What are 2 management options?
IV benzylpencillin (oral doesn’t penetrate the abscess)
Intra-oral incision and drainage or needle aspiration of peritonsillar space
What antibiotic should be avoided in infectious mononucleosis and why?
Amoxicillin (+co-amox)
Skin reaction- generalised maculopapular rash
What is the first line Abx for acute suppurative otitis media?
Amoxicillin
What are the two common causative organisms of otitis externa?
What is the first line treatment?
Pseudomonas aeruginosa, staph aureus
Ciprofloxacin/gentamicin ear drops (+steroid if really inflamed/severe)
Initial management for newly diagnosed glue ear in children?
Active surveillance- 70% resolve spontaneously after 3 months.
If glue ear hasn’t resolved spontaneously after 3 months, what is the management?
Grommet insertion under general anaesthesia
A 7 year old presents following an ear infection, with a painful mastoid and their ear on the left appears pushed forward and down. What complication is this likely to be?
Outline the management.
Acute mastoiditis.
Management= refer to ENT. Will need CT to look for abscess. Also blood cultures, bloods, culture any discharge.
Broad spectrum IV Abx (e.g. cefotaxime) +/- surgical drainage. Paracetamol/NSAID
Give 5 causes of conducive hearing loss.
- Otitis media with effusion
- Otosclerosis
- Tympanic membrane perforation
- External canal obstruction e.g. wax/foreign body
- Acute mastoiditis
- Cholesteatoma
What is the inheritance pattern of otosclerosis?
More common in F or M?
How does it present?
AD (so likely to have FH).
F>M. Onset 15-35yrs.
Slowly progressive bilateral hearing loss.
Do the symptoms of otosclerosis get better or worse in pregnancy and menstruation?
Worsen.
Due to increased oestrogen levels.
What is the investigation for otosclerosis?
Audiometry
Give 2 management options for otosclerosis?
Bilateral hearing aids
Surgical- stapedectomy or stapedotomy.
What is a cholesteatoma?
Destructive and expanding keratinised squamous cell debris which collects on ear drum and keeps growing
Where does a cholestatoma extend into?
Commonly into attic of ear , slowing destroying the middle ear and eroding bone.
Give 3 features of presentation of cholesteatoma?
Unilateral, watery smelly discharge from ear Gradual conductive hearing loss Unilateral ear discomfort Vertigo May get facial nerve palsy from invasion
What Ix for cholesteatoma?
Otoscopy –> attic crust
What is the management of cholesteatoma?
Seen by ENT. Aural toilet and surgical removal.
Which type of hearing loss would show air conduction worse than bone conduction on an audiogram?
Conductive hearing loss
Give 4 causes of sensorineural hearing loss.
- Noise induced
- Acoustic neuroma
- Infections e.g. encephalitis, meningitis, labrynthitis, MUMPS
- Meniere’s disease
- Ototoxicity e.g. gent, quinine, salicylates
Is an air-bone gap seen on audiogram of sensorineural hearing loss?
No, no significant air-bone gap.
What is a major risk factor for cholesteatoma?
Cleft palate- increases risk 100 fold!
A 76 year old man presents to the GP complaining of finding it increasingly difficult to hear is noisy environments and finding it hard to understand speech. Otoscopy is normal, and audiometry shows loss of hearing sounds at higher frequency.
What is the most likely diagnosis?
What is the pathogenesis?
Presbyacusis.
Gradual loss of outer hair cells in the cochlea causes insidious onset progressive bilateral hearing loss (high frequencies lost first)
What is the management of presbyacusis?
Hearing aids
Possibly cochlear implant.
A patient presents with gradual bilateral hearing loss and tinnitus. The audiogram reveals a trough at 4kHz. What is the likely diagnosis and pathogenesis?
Noise induced hearing loss.
Exposure to excessive sounds e.g. fireworks, bombs, loud music –> permanent increased stimuli threshold for outer hair cells in cochlea
What is the treatment fr noice induced hearing loss?
Hearing aids.
Moderate exposure may have recovery, but severe/prolonged exposure causes permanent damage.
Unilateral hearing loss = ? until proven otherwise?
Acoustic neuroma (vestibular schwannoma)
What is an acoustic neuroma?
Benign, slow-growing tumour of CN VIII, arising from schwann cells
What are the 4 features in a classical presentation of acoustic neuroma?
- unilateral progressive hearing loss
- tinnitus
- vertigo
- absent corneal reflex
Also may get facial pain, weakness, ataxia
Which cranial nerve must be affect by an acoustic neuroma to cause absent corneal reflex?
Cranial nerve 5
Bilateral acoustic neuromas are seen in = ?
Neurofibromatosis type 2
Give the 2 important investigations for acoustic neuroma?
- MRI cerebellopontine angle
- audiometry
Give the 3 management options of acoustic neuroma?
1) watchful waiting if small
2) radiotherapy may shrink
3) large tumours resected by microsurgery
Give 3 peripheral and 3 central causes of vertigo.
3 drug causes?
Periph = BPPV, meniere's, labrynthitis, vestibular neuritis Central = Acoustic neuroma, head injury, MS Drug= gent, diuretics, metronidazole
What is vertigo?
The illusion of movement causes dizziness
What is the pathogenesis of BPPV?
Otoliths detach into semicircular canals, continue to move when head has stopped moving –> dizziness/vertigo
What are otoliths made of?
Calcium carbonate
4 features of BPPV vertigo?
- Sudden onset
- Worse in morning
- Lasts 20-30s
- Rapid resolution
- Provoked by head movements
Do you get hearing loss or tinnitus with BPPV?
No
What examination is used to diagnose BPPV and what is a positive result.
Dix Hallpike manouevre : rapidly move pt from sitting to supine wth head tilted 45 degree to R (then repeated on the L)
Positive= vertigo and rotatory nystagmus
What is the management of BPPV?
- Advise pt to reduce alcohol, slowly get out of bed, not to drive
- Epley’s manouevre
- Prochlorperazine
A patient presents to their GP complaining of vertigo that comes in bouts several times a year with resolution between. They also have tinnitus, and some hearing loss.
What is the likely diagnosis?
What is the pathogenesis?
What is another feature seen in this condition?
Meniere’s disease.
Endolymphatic hydrops = increase in fluid volume (endolymph) in the membranous labyrinth–> progressive distension.
Sensation of aural pressure
How do you manage an acute attack of Meniere’s?
Bed rest, reassurance, antihistamine (e.g. cinnarizine), prochlorperazine buccal/IV
What drug is used for prophylaxis of Meniere’s, to reduce frequency and severity?
Betahistine
T/F: A patient must inform the DVLA if they have Meniere’s disease?
True
What two structures are inflamed in labyrinthitis?
Membranous labyrinth and vestibular nerve
Labrythitis and vestibular neuritis usually follow what?
URTI
Describe the vertigo experienced with labyrinthitis and vestibular neuritis?
Sudden onset, severe, incapacitating rotational vertigo, not triggered by movement
What is the differentiating feature in presentation between labrynthitis and vestibular neuritis?
Vestibular neuritis doesn’t have hearing loss as it’s just the inflammation of the vestibular nerve whereas labrynthitis does cause hearing loss
Examination to diagnoses labrynthitis/vest neuritis?
Head impulse test
What is the management of labrynthitis/vestibular neuritis?
What must you tell the patient not to do?
Self limiting 1-3 weeks
Bed rest and oral fluids, antihistamine, prochlorperazine, prednisolone
Pt must not drive!
What do you give if otitis externa is spreading and topical treatment hasn’t worked?
Oral antibiotics
A 50 year old man attends his GP complaining of severe, deep-seated otalgia which is not helped by painkillers. He has a headache and a fever, and described some pus coming out of the right ear. He was recently treated for an ear infection, but this never settled. His PMH is HTN and diabetes.
What is the likely diagnosis?
Necrotising otitis externa
90% cases of necrotising otitis externa is found in …?
Diabetics
Causitive organism of nec otitis externa?
What does the infection eventually progress to?
Pseudomonas aeruginosa
Progresses to temporal osteomyelitis
What Ix is done in suspected nec otitis externa?
What treatment?
CT
IV gent or ciproflox
A 5 year old comes to the GP with her mother, with right ear pain, fever and coryzal symptoms. She recently had a chest infection. O/E the right pinna is red and the TM is red and bulging. What is the most likely diagnosis?
Give 3 possible complications.
Acute otitis media
Treated with PO amox
Comps = OME, TM perforation, infratemporal infection e.g. labrynthitis, mastoiditis, facial nerve palsy, intracranial infection e.g. encephalitis, meningitis
Give 3 presenting features of otitis media with effusion.
Conductive hearing loss
Intermittent mild otalgia
History of recurrent URTI/AOM
Aural fullness sensation +/- cracking/popping
What is seen on otoscopy in OME?
- No features of inflammation/infection
- Opaque intact TM
- Loss of light reflex
Give 3 causative organisms of acute mastoiditis?
Strep pneumonia, Strep pyogenes, Haem influenzae, staph aureus, Pseudomonas.
3 comps of acute mastoiditis?
Hearing loss, osteomyelitis, subperiosteal abscess , CN palsies (V, VI, VII), intracranial spread
A patient presents to their GP with a blocked nose, a headache, and a feeling of frontal pressure which gets worse on bending forwards.
Likely diagnosis?
Common cause?
Management?
Acute sinusitis
Viral
Paracetamol, intranasal decongestants (for <7 days, evidence limited)
What management is indicated for acute sinusitis if symptoms have been longer than 10 days?
Intranasal corticosteroid (beclomethasone)
When are Abx indicated in acute sinusitis?
Which Abx?
If very severe infection or at high risk of comps.
BNF recommends phenoxymethylpenicillin first line
Chronic sinusitis is inflammation of paranasal sinuses and lining of nasal passages for > ? weeks?
12 weeks
Give 3 predisposing factors for chronic sinusitis?
Asthma Hayfever Nasal polyps Swimming Smoking Rhinitis
Outline the management of chronic sinusitis
Avoid allergen
Intranasal corticosteroids
Saline irrigation
Acute unilateral idiopathic facial nerve paralysis = ?
Bell’s palsy
Do you get forehead sparing in Bell’s palsy and why/whynot?
No, the forehead is affected because it’s a LMN palsy
What is the Mx of Bell’s palsy?
- PO prednisolone for 10 days (within 72 hours onset)
- Artificial tears
Will commonly spontaneously resolve
A patient presents with hemiparesis of the right facial muscles, with eyelid drooping, loss of nasolabial fold. They have painful erythematous vesicles on the right ear and hearing loss. The pain is severe.
What is the likely diagnosis?
What’s the pathogenesis?
What’s the treatment?
Ramsey Hunt syndrome
Varicella Zoster LMN Facial palsy
Acyclovir within 72 hours
What criteria are used to decide Abx treatment in tonsillitis?
Describe each criteria.
Modified centor criteria, each score 1 Age 3-14 Exudate or swelling on tonsils Tender/swollen anterior cervical LNs Temp >38 Absence of cough
What is management for centor criteria 3?
And 4?
3 –> consider rapid strep antigen testing/cultures
4–> Abx (PO phenoxymethylpenicillin 10 days)
What is the classic triad of glandular fever?
Give 3 other features
Pyrexia, lymphadenopathy and sore throat
Splenomegaly, hepatitis, lymphocytosis, malaise, haemolytic anaemia
How and when is glandular fever diagnosed?
NICE suggests heterophil antibody test (Monospot test) and FBC in 2nd week of illness
Management of glandular fever?
What advice is given regarding cautions to take following illness?
- bed rest, analgesia, fluids
- avoid contact sports for 8 weeks to avoid splenic rupture
What are 2 EBV specific antigen?
Viral capsid antigens
EBV nuclear antigen
Why do you get trismus qith quinsy?
Pterygoid muscle spasm
A patient complains of swelling and pain in his glands when he eats. Which salivary gland is most affected by stones?
What Ix would you do?
What is the Mx of stones?
- Submandibular
- USS, sialography (contrast + Xray)
- May pass spontaneously (warm compress, hydration, gland massage) or need surgical removal
Which area of the nose is common to bleed and why?
Little’s area in the anterior septum, as it’s the confluence of 4 arteries
Double-sickening, where a patient’s initial sinusitis symptoms improve, but then worsen again is associated with what?
Bacterial sinusitis
NSAIDs in large doses have been found to cause …?
Tinnitus
What are the 3 red flag symptoms for chronic rhinosinusitis?
Unilateral symptoms
Persistent symptoms despite 3 months compliant with treatment
Epistaxis
What is the step by step management of epistaxis if first aid measures (digital pressure, sucking ice) have failed?
1- cauterisation with silver nitrate (then alginate dressing)
2- Insert nasal pack (ant/post) + analgesia!
3- surgical management
What is the surgical management of
a) standard epistaxis
b) traumatic epistaxis?
a) endoscopic sphenopalatine artery ligation under GA
b) ligation of anterior ethmoidal ligation
