ENT Flashcards
interpreting audiograms
X = left ear
O = right ear
] = left ear bone conduction
[ = right ear bone conduction
1st test normal conduction, if reduced test bone conduction (sensorineural)
further down the graph = deafer you are
0-20dB normal
what does the audiogram show
left ear conductive hearing loss
- decreased air conduction
- normal bone conduction
- therefore air not getting through inner eat - obstruction
e. g. glue ear (otitis media)
what does the audiogram show
sensorineural hearing loss
all the ] on all the X’s declining = sensorineural hearing loss
common in old people - lose high freq first = presbycusis
congenital and acquired causes of sensorineural hearing loss
congenital: born deaf
- genetic
- disease exposure as a foetus - CMV (cytomegalovirus), rubella
- congenital absence of CN/cochlear
generally flat on audigram
- cookie bite hearing loss - in congenital hearing loss -loss of mid range freq sounds e.g. conversation
acquired:
- presbycusis (old age)
- noise induced
- drugs - IV gentamycin/ chemo
- trauma - loud sounds, fractured skull base
old people + noise induced - lose higher frequencies first
causs of conductive hearing loss
obstruction to inner ear
- ear wax
- otitis externa - inflamed outer ear passage
- otitis media (glue ear)
- sclerotic TM
- perforated eardrum
- otosclerosis - ossicle joint calcification –> decreased movement –> decr sound transmission
- cholesteatoma - low middle ear pressure
how do you treat otosclerosis
operate to cure - stapedectomy (remove stapes, replace with prosthetic one)
foul smelling green discharge
headache
pain in ear
vertigo, deafness, facial palsy
diagnosis + management
cholesteatoma
management: surgery
may only see small hole in TM, behind skin sebris and pus can collect - damage ossicles - hearing loss, vertigo, tinnitus
can erode to brain (meningitis, temporal nerve abscess, pus against facial nerve - facial palsy)
what can cause a sclerotic tympanic membrane
can be 2ndry to:
chronic OM
grommets (used to treat OM - tube through TM)
only notice if decreased hearing
causes ossification of edge of footplate of stapes which stops it moving
child
deep ear pain (child may pull on ear)
mucuous from ear
hearing loss, poor speech development if chronic
TM red, bulging, may perforate.
fever if acute
diagnosis and management
otitis media
management:
OME (otitis media with effusion) - usually resolves after 3 months
conservative management - watch and wait
acute otitis media:
majority self limiting
if not settling - oral abx & ear drops
risk factors and causes of otitis media
risk factors:
- passive smoking
- downs
- cleft lip/palate
causes:
- acute: viral URTI (pneumococcus, h. influenza, viral)
- eustation tube dysfunction
adult
superficial ear pain - itchy, tragal tenderness
watery discharge
erythema of external auditory meatus
regularly swims
diagnosis and management
otitis externa
management:
- aural toilet - clean the external auditory meatus of wax, discharge, debris
- topical abx & steroid (7 days gentamicin + hydrocortisone)
causes and risk factors of otitis externa
risk factors:
- swimming
- cotton buds
- eczema
causes:
- moisture (swimming)
- trauma (finger nails)
- wax absence
- hearing aid
organisms:
staph aureus
pseudomonas
what is tinnitus + causes
sensation of sound without external sound stimulation (e.g. ringing in ears)
causes:
- meniere’s - with vertigo/ deafness
acoustic neuroma - unilateral, with vertigo/ deafness
otosclerosis - family hx
noise-induced, head injury, presbyacusis
- decreased Hb, increased BP
- drugs: aspirin, loop diuretics, ETOH, aminoglycosides (gentamicin)
investigations and management of tinnitus
investigations:
- otoscopy
- tympanogram - tests middle ear and TM function using different air pressures in ear canal
- audiometry
- if pulsatile/unilateral - MRI to excluse intracranial abnormality (arterio-venus abnormalities or neuroma)
pulsatile - listen in neck - can be transmitted from carotic artery stenosis bruit
management:
- treat cause
- counselling support:
- hearing aids
- CBT - prevent it becoming all consuming
- use of masking devices
when is disequilibrium seen in people
vague feeling of imbalance
seen in diabetic people with peripheral neuropathy - loss of proprioception and complain of disequilibrium
what is Brandt Daroff exercise
for BPPV
fling yourself from side to side on bed x15
will flood nerve with so much movement it can cause desensitisation
must do it for weeks to keep desensitisation
turned over in bed
sudden vertigo for <30s
nausea + vomiting
audiometry normal
diagnosis and managment
BPPV
displaced Ca crystals in semicircular canals –> false movement
- sudden rotational vertigo <30s provoked by head turning, nystagum
diagnostic test: Dix-Hallpike (sitting -> lying, head off bed. turn face to side- illicit vertigo (can see nystagmus)) (do on both sides of head)
treatment: Epley manouver (park loose crystals where it wont cause issues)
causes of BPPV
recent URTI
recent head injury - dislodge of crystals
central causes of vertigo
acoustic neuroma
MS
head injury
inner ear syphilis
drugs: gentamicin, loop diuretics, metronidazole, co-trimoxazole
tinnitus
vertigo - unprovoked, recurrent, disabling (+- nause, vomiting)- lasts for hrs
fluctuating hearing loss (lower frequencies) (full sensation in ear)
audiometry fluctuant
diagnosis + management
Meniere’s diease
triad of: tinnitus, vertigo (lasts hrs), hearing loss
audiometry (PTA) fluctuant
fullness sensation in ear
two or more episodes
management:
- beta-hystine to sedate labrynith
following febrile illness
vertigo lasting for days/weeks
PTA normal
diagnosis and management
Labyrinthitis (vestibular neuritis)
- inner ear inflammation
causes:
- febrile illness
- head injury
- stress
- allergies or reaction
management:
- symptomatic relief (nausea, vomiting)
if persists - physio for vestibular rehab exercises
management for auricular haematomas
same day ENT assessment (prevent formation of cauliflower ear)
- incision and drainage
cough, tooth pain, purulent nasal discharge 2 wks
pressure in head increased
facial pain worse on bending forward
diagnosis + management
uncomplicated acute sinusitis
intranasal corticosteroids and discharge if symptoms >10 days
what is complicated sinusitis + treatment
complications:
- intraorbital involvement (eye pain, eye cellulitis, vision changes)
- intracranial (headaches, cranial nerve palsies)
- systemic infection
Mx: abx (phenoxymethypenicillin) (or co-amoxiclav if very unwell)
sudden acute hearing loss/ muffling
pain/ aching ear
tinnitus
diagnosis
perforated tympanic membrane
gradual reduction in hearing
tinnitus
box of cotton buds each week
no pain or discharge
rinnes -ve on left
+ve on right
weber: lateralises to left ear
diagnosis?
management?
conductive hearing loss: ear wax impaction
non painful, use of cotton buds
rinnes +ve: normal (air conduction louder)
rinnes -ve: sound heard louder from mastoid - conductive hearing loss
webers: lateralises (sounds louder) in side of defective ear
management:
- ear drops: olive oil, sodium bicarb 5%, almond oil
- irrigation (ear syringing)
- not if perforation of TM or grommets
therefore conductive hearing loss in left ear
what do rinne and weber results mean
conductive hearing loss:
rinnes +ve: normal (air conduction louder)
rinnes -ve: sound heard louder from mastoid - conductive hearing loss
webers: lateralises (sounds louder) in side of defective ear in conductive hearing loss
sensorineural hearing loss:
- rinnes +ve on affected ear - normal
- webers louder in normal ear
watery anterior rhinorrhoea
purulent post-nasal drip - from nose to pharynx
nasal obstruction
sinusitis
headaches
snoring
diagnosis
management
simple nasal polyp
- mobile, pale, insensitive
management:
drugs:
- nasal steroid drops (ongoing tx)
- short course of oral steroids (1 wk)
endoscopic polypectomy
what are nasal polyps associated with
allergic/ non-allergic rhinitis
CF
aspirin hypersensitivity
asthma
what to do if you have a single unilateral polyp
CT + histology
may be a sign of sinister pathology:
- nasopharyngeal ca
glioma
lymphoma
neuroblastoma
sarcoma
are polyps in children common?
rare <10yrs
must consider neoplasma and CF
inspiratory stridor - cause?
laryngeal obstruction
stridor is ENT emergency until proven otherwise
cause of expiratory stridor (wheeze)
tracheobronchial obstruction
cause of biphasic stridor
subglottic/glottis anomaly (under vocal cords)
common in croup - narrowing of subglottic airways
acute stidor
6m-2yrs
low fever
felt unwell before (coryza symptoms)
barking cough
worse at night
diagnosis?
managment?
croup/ laryngotracheobronchitis
Tx: self limiting (symptomatic relief)
acute biphasic stridor
hx cough/choking before resp symptoms
diagnosis?
inhaled foreign body
acute stridor
uncommon
<3yrs
bacterial infection following viral infection
diagnosis
tracheitis
chronic stridor
neonates/early infancy
difficulty breathing
poor weight gain
diagnosis
laryngomalacia
- floppy larynx
biphasic chronic stridor
associated with weak cry
vocal cord paralysis
- unlateral vocal cord palsy - most common - can be 2ndry to birth trauma or intrathoracic surgery
usually resolves in 2yrs of life
what vaccine is used which helps against epiglottitis
hameophillis influenza type B (HIB) vaccine
common cause of epiglottitis
rapid onset stridor
felt well before
difficulty swallowing, drooling
voice changes - muffled/ hot potato
dramatic swelling of supraglottal region
pools of saliva around larynx on fine nasal endoscopy
diagnosis and management
epiglottitis
most common cause - H. influenza type B (HIB)
EMERGENCY: can cause total airway obstruction
Mx: admit, keep upright
STRAIGHT TO THEATRE –> INTUBATE –> tx with steroids & abx
causes of stridor in adults
traumatic: RTA (renal tubular acidosis), foreign body
inflammatory: acute epiglottitis, supraglottitis, croup
neoplastic: carcinoma of larynx/thyroid (late sign + dysphagia, dysphonia, enlarged cervical lymph nodes)
pathological: bilateral vocal cord paralysis (rare) - post surgery, tumour
investigations and management for stridor
Ix:
- O2 sats
- ABG
- larygoscopy and bronchoscopy - when O2 sats stable and epiglottitis excluded
- CT if suspected cancer
Tx:
- assess - speaking? using accessory muscles? can wait for help or act now?
acute distress - nasal flaring, tachypnea, cyanotic, tripod position, drooling
DOHA
D- Dexamethasone IV
O- O2 high flow
H- Heliox (He 79%, O2 21%)
A- Abx broad spec
- Adrenaline nebs
what is the management for stridor if medical management fails
- intubation, ventilation, ICU
- emergency cricothyroidotomy (if cant intubate) - temporary, small diameter
- tracheostomy
- larygectomy - done in H&N cancer - planned definitive airway
what to look for when examining neck lumps
SHE CUTS THE FISH PERFECTLY
S- site, size, shape
C- colour, consistency, contour
T- temp, tender, transillumination (fluid?)
F- fixed, fluctuant (fluid), fields (anything around it)
P- pulsatile
E- expansile
R- reducible
differentials for neck lump
tumour (benign/malignant) - primary/secondary
lymph nodes
cysts
abscesses
infection
congenital
vascular/ haemorrhagic
painless swelling in neck
swallowing difficulty - dysphagia
voice change - dysphonia
ear ache
weight loss
smoker
diagnosis
investigations
H&N cancer
Ix:
- fine needle aspiration biopsy
- USS
- CT, MRI
operative Ix: panendoscopy and biopsy
lump in picture
moves on swallowing and when sticking out tongue
midline
tender, red, swollen
no systemic symptoms
diagnosis and management
thyroglossal cyst
move upward on swallowing and when sticking out tongue
midline
may contain thyroid tissue
may become infected or develop a fistula
Ix: USS + TFTs
Tx: removed - Sistrunk’s procedure - remove median third of hyoid bone
image attached
swelling on neck
moves on swallowing
prefer hot/cold, lost/gained weight, diarrhoea/constipation, palpitations, anxiety/depression
diagnosis?
Investigations?
management?
thyroid swelling - goitre - moves on swallowing
solitary nodule: multinodular goitre, adenoma, carcinoma, haemorrhagic cysts
diffuse swelling: multinodular goitre, hashimoto’s thyroiditis, graves disease, carcinoma
Ix:
TFTs
Fine needle aspiration
USS
Tx: treat underlying cause:
hypothyroidism: levothyroxine
hyperthyroidism: radioiodine therapy, surgery
hashimoto’s thyroiditis - (autoimmune –> hypothyroidism symptoms) - Tx with levothyroxine
De Quervain’s thyroiditis - (after viral infection (mumps/ flu)) - hyperthyroidism then hypothyroidism. Tx pain relief, may need levothyroxine
thyroid cancer: surgical removal, radioiodine therapy, radiotherapy
most common type of thyroid cancer
papillary - 70% (young)
follicular - 20%
anaplastic <5% (older)
medullary - 5%
parotid swelling causes
infective
autoimmune (sjogren’s syndrome)
salivary stones
tumour: 80s rule
- 80% of salivary tumours are in parotid gland
- 80% of parotid tumours are benign
- 80% of the benign tumours in the parotid gland are pleomorphic adenomas
investigations for parotid gland swelling
USS
sialogram - dye into gland duct, see if narrowing/stone, examine by x-ray
CT +- fine needle aspiration
most common cause of lump seen
investigation?
submandibular gland swelling
usually due to stone in duct
Ix: USS
presents in 30s
unilateral
tender
fluctuant but does not transilluminate
does not move on swallowing
no other enlarged lymph nodes
may have fistula to skin
diagnosis
Ix
management
branchial cyst
there from birth - can enlarge after URTI
presents in 30s
- if outside normal age range consider secondary lymphadenopathy to primary tumour elsewhere (FNA to exclude)
on anterior border of sternocleidomastoid upper and middle thirds
Ix: USS + fine needle aspiration
Tx: excision (may need delaying if acutely swollen)
sore throat
lump (in image)
diagnosis
tonsillar lymph node swelling
tonsilitis/ glandular fever
but consider malignany
erythema
swelling
tender
fluctuant
warm
diagnosis
Ix
management
abscess
Ix: bloods, CT, fine needle aspiration
Tx: drain
horse voice
neck lump
pain (referred to ear)
breathing/swallowing issues
stridor
lymph node enlargement
weight loss
smoker
most common H&N cancer
diagnosis?
risk factors?
Ix?
laryngeal cancer - most common H&N cancer- majority squamous cell cancers
RFs: smoking, ETOH, HPV
Ix:
- biopsy
- CXR
- panendoscopy
- CT/ MRI - staging
what is more common - anterior nasal bleed or posterior nasal bleed
anterior nasal bleed most common
- usually from Little’s Area (Kiesselbach’s Plexus) on anterior-inferior septum
posterior bleed - often from Woodruff’s plexus
unilateral bleeding,
progressive hoarseness,
dysphagia,
hearing loss,
significant smoking history,
Southeast Asian descent
diagnosis?
nasopharyngeal carcinoma
younger male patients with unilateral epistaxis
diagnosis
Juvenile nasal angiofibroma
most common benign tumour of nasopharynx
most common in male teens and young adults - androgens can increase growth
young age,
recurrent nose bleeds
family history of HHT,
partially blanching cutaneous lesions.
Hereditary haemorrhagic telangiectasia (HHT)
blood vessel disorder - genetic
recurrent nosebleeds
nosebleeds usually first sign
causes of local nose bleeds in adults
trauma
anatomical differences (septal deviation)
neoplasm (most common squamous cell carcinoma, adenoid cystic carcinoma, melanoma, and inverted papilloma)
bacterial sinusitis
topical or illicit medications
causes of local nose bleeds in children
trauma (nose picking)
inflammatory conditions (rhinitis - allergic and non-allergic, frequent use of intranasal steroids and decongestants)
juvenile nasopharyngeal angiofibroma
systemic causes of nose bleeds in adults
anticoagulant medications
alcohol
von willebrand disease
granulomatosis with polyangiitis
chemotherapeutic drugs
systemic causes of nose bleeds in children
hereditary haemorrhagic telangiectasia (HHT)
von willebrand disease
unilateral hearing loss with vertigo occuring later
headache
diagnosis
acoustic neuroma
noncancerous growth presses on vestibulocochlear nerve - sound and balance
late signs indicating large tumour - increased ICP signs
painful external ear rash
facial palsy
+/- deafness, tinnitus, vertigo
diagnosis
Ramsay Hunt syndrome (herpes zoster oticus)
- shingles outbreak affects facial nerve near one of your ears
- painful rash in ear, facial paralysis & hearing loss in affected ear
nose bleed running out front of nose
type of nose bleed
investigations
management
anterior nose bleed
Ix:
FBC
clotting
group and save
anterior rhisocopy/ endoscopy to visualise bleeding
Mx:
- ABCDE for profuse bleeding - insertion of two wide-bore cannula + fluid resus
patient lean forward and pinch nose 10mins
- first line treatment for anterior bleed: chemical or electrical cautery + local anaesthetic + topical vasoconstrictors
bait and switch approach: alternating btwn local anaesthetic and cautery with silver nitrate
second line: anterior nasal packing if does not stop bleeding with cautery - nasal tampons, rapid, rhino balloon catheter
review in 24-48hrs after pack inserted
blood from nose dripping down throat
persistent bleeding despite bilateral anterior packing
diagnosis
management
posterior nose bleed
- blood from nose dripping down throat
- persistent bleeding despite bilateral anterior packing
Mx:
first line: packing - foley catheter (through nasal cavity - balloon) + anterior gauze pack
admitted to hospital whilst packing in place - increased risk of MI, stroke, hypoxic episode
when is surgical management of a nose bleed needed?
ligation of sphenopalatine, internal maxillary or anterior ethmoid arteries
indications:
- life threatening bleeding (emergency surgery)
- patients bleeding has resolved but high risk of re-bleeding
- follow-up surgery for suspected malignancy
causes of dysphonia
hoarse voice
- due to laryngitis - inflammation of larynx (vocal)
organic (physiological change):
- structural (physical)
- neurogenic (CNS, PNS)
examples:
- laryngitis (acute: viral, bacterial), (chronic: smoking)
- neoplasm: (premalignant: dysplasia) (malignant: squamous cell carcinoma)
- trauma: e.g. intubation
- endocrine: hypothyroidism, hypogonadism
- haematological: amyloidosis
iatrogenic: inhaled corticosteroids
functional (result of vocal use): vocal misuse
- psychogenic (personality/psychological)
investigation for dysphonia
flexible nasal endoscopy (FNE).
FNE allows visualisation of the larynx and the vocal cords
vocal cord nodules management
speech and language therapy
if severe- surgical
hoarse voice worsening towards the end of the day or following prolonged use
diagnosis
management
muscle tension dysphonia
- confirmed via stroboscopy
Mx: speech and language therapy
laryngitis Ix & Mx
laryngitis
Ix: flexible nasal endoscopy
conservative management
pulsatile neck lump
differentials
Ix
management
carotid artery aneurysm
tortous carotid artery (twists and turns in artery)
carotid body tumours (chemodectoma)
Ix: duplex USS or digital computer angiography
Mx: extirpation (removal)
bulge in neck
usually lies to left side
can protude into posterior triangle on swallowing
dysphagia
gurgle on drinking
reflux
diagnosis?
pharyngeal pouch
pocket that forms in upper part of oesophagus - food collects in pouch instead of going down oesophagus
–> dysphagia + weight loss
multiloculated
classically found in left posterior triangle of neck and armpits
in infants
transilluminate
diagnosis + management
cystic hygroma
congenital multiloculated lymphatic lesion
transilluminate
Mx: surgery or hypertonic saline sclerosant injection (sclerotherapy)
which two lumps will be pulsatile in the posterior triangle of the neck
pancoast’s tumour - base of neck (lung cancer of the apex)
subclavian artery
acute swelling of salivary glands
differentials
mumps
HIV
recurrent unilateral pain and swelling of a salivary gland (parotid, submanibular, sublingual)
pain and swelling on eating
red tender swollen but uninfected gland
may have dry mouth, dry eyes
most likely diagnosis
Ix
Mx
stones
Ix: x-ray or sialography (contrast injected into salivary duct, then xray)
Mx:
distal stones removed via mouth
deeper stones may need excision of gland
deflection of ear outwards
classical sign of what tumour
salivary gland tumour in parotid
dysphagia for fluids and solids
regurgitation
diagnosis?
management?
Achalasia - lower oesophageal stricture
bird beak sign on barium swallow
LOS fails to relax
management:
- endoscopic balloon dilation
- PPI - omeprazole
- calcium channel blockers and nitrates to relax sphincter
surgical procedure to treat GORD
nissen fundoplication
intermittent dysphagia
regurg
sudden severe chest pain - few mins to hrs
diagnosis
Ix
oesophageal spasms
2 types:
- diffuse oesophageal spasm - uncoordinated oesophageal contractions - several sections contract at once
- nutcracker oesophagus - hypertensive peristalsis - coordinated but excesive amplitude
as a result of GORD or achalasia
Ix: barium swallow: corkscrew/ ribbon oesophagus
causes of nasal congestion
due to nasal lining becoming swollen
causes:
allergies - hay fever
common cold or influenza
deviated septum
sinusitis
rhinitis medicamentosa - caused by extended use of topical decongestants
treatment for nasal congestion
first line: alpha adrenergic agonists: oxymetazoline and phenylephrine
analgensia
antihistamines and decongestants: naphazoline (privine), oxymetazoline, phenylephrine
(topical decongestants max 3 days in a row - can form rhinitis medicamentosa)
two most common causes of mouth ulcers
+ other causes
- local trauma (e.g. rubbing from sharp edge on broken filling, braces)
- aphthous stomatitis (‘canker sores’) - common - repeated formation of benign, non-contagious mouth ulcers in otherwise healthy individual
other causes:
- infections: herpes simplex, varicella zoster, coxsackie A virus
most common type of oral cancer
squamous cell carcinoma
usually a non-healing mouth ulcer
treatment for minor and major mouth ulcers
minor ulcer:
- tetracycline or antimicrobial mouth wash (chlorhexidine)
severe:
- systemic corticosteroids (e.g. oral pred) or thalidomide (contraindicated in pregnancy)
dysphagia
high temp
tonsils erythematous and swollen
purulent exudate
anterior cervical lymphadenopathy
diagnosis
criteria for treatment
tonsilitis
centor criteria: to assess likelyhood of bacterial infection in tonsilitis
- fever
- tonsillar exudate
- no cough
- tender anterior cervical lymphadenopathy
management for tonsilitis
clinical diagnosis + throat swab to look for bacteria
Mx:
- analgesia
- hydration
- bacterial: abx (penicillin/ amox - 10 days) (most common bacteria group A strep)
tonsillectomy
indications for tonsillectomy
>= 7 episodes in one year,
or >= 5 episodes in each of 2 yrs
or 3 episodes in each of 3 yrs
suspected malignancy
sleep apnoea
two previous peritonsillar abscesses
main complication of tonsillectomy is secondary bleeding
severe sore throat
severe difficulty swallowing
hot potato speech
soft palate swelling
deviated uvula
diagnosis + management
peritonsillar abscess (quinsy)
Mx:
- IV abx
- analgesia
- needle aspiration or incision and drainage
most common facial fracture
nasal fracture - nose bleeds, bruising
sudden hearing loss
earache/ pain in ear
itching in ear
fluid leaking from ear
high temp
tinnitus
diagnosis + management
perforated tympanic membrane
Mx:
some heel on their own
Abx
if does not heal in a few weeks - surgery
causes of perforated tympanic membrane
ear infection
injury
changes in pressure - flying, scuba diving
sudden loud noise - explosion
