ENT Flashcards

1
Q

interpreting audiograms

A

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

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2
Q

what does the audiogram show

A

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)
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3
Q

what does the audiogram show

A

sensorineural hearing loss

all the ] on all the X’s declining = sensorineural hearing loss

common in old people - lose high freq first = presbycusis

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4
Q
A
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5
Q

congenital and acquired causes of sensorineural hearing loss

A

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

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6
Q

causs of conductive hearing loss

A

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
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7
Q

how do you treat otosclerosis

A

operate to cure - stapedectomy (remove stapes, replace with prosthetic one)

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8
Q

foul smelling green discharge

headache

pain in ear

vertigo, deafness, facial palsy

diagnosis + management

A

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)

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9
Q

what can cause a sclerotic tympanic membrane

A

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

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10
Q

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

A

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

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11
Q

risk factors and causes of otitis media

A

risk factors:

  • passive smoking
  • downs
  • cleft lip/palate

causes:

  • acute: viral URTI (pneumococcus, h. influenza, viral)
  • eustation tube dysfunction
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12
Q

adult

superficial ear pain - itchy, tragal tenderness

watery discharge

erythema of external auditory meatus

regularly swims

diagnosis and management

A

otitis externa

management:

  • aural toilet - clean the external auditory meatus of wax, discharge, debris
  • topical abx & steroid (7 days gentamicin + hydrocortisone)
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13
Q

causes and risk factors of otitis externa

A

risk factors:

  • swimming
  • cotton buds
  • eczema

causes:

  • moisture (swimming)
  • trauma (finger nails)
  • wax absence
  • hearing aid

organisms:

staph aureus

pseudomonas

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14
Q

what is tinnitus + causes

A

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)
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15
Q

investigations and management of tinnitus

A

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
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16
Q

when is disequilibrium seen in people

A

vague feeling of imbalance

seen in diabetic people with peripheral neuropathy - loss of proprioception and complain of disequilibrium

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17
Q

what is Brandt Daroff exercise

A

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

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18
Q

turned over in bed

sudden vertigo for <30s

nausea + vomiting

audiometry normal

diagnosis and managment

A

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)

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19
Q

causes of BPPV

A

recent URTI

recent head injury - dislodge of crystals

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20
Q

central causes of vertigo

A

acoustic neuroma

MS

head injury

inner ear syphilis

drugs: gentamicin, loop diuretics, metronidazole, co-trimoxazole

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21
Q

tinnitus

vertigo - unprovoked, recurrent, disabling (+- nause, vomiting)- lasts for hrs

fluctuating hearing loss (lower frequencies) (full sensation in ear)

audiometry fluctuant

diagnosis + management

A

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
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22
Q

following febrile illness

vertigo lasting for days/weeks

PTA normal

diagnosis and management

A

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

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23
Q

management for auricular haematomas

A

same day ENT assessment (prevent formation of cauliflower ear)

  • incision and drainage
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24
Q

cough, tooth pain, purulent nasal discharge 2 wks

pressure in head increased

facial pain worse on bending forward

diagnosis + management

A

uncomplicated acute sinusitis

intranasal corticosteroids and discharge if symptoms >10 days

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25
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)
26
sudden acute hearing loss/ muffling pain/ aching ear tinnitus diagnosis
perforated tympanic membrane
27
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
28
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
29
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
30
what are nasal polyps associated with
allergic/ non-allergic rhinitis CF aspirin hypersensitivity asthma
31
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
32
are polyps in children common?
rare \<10yrs must consider neoplasma and CF
33
inspiratory stridor - cause?
laryngeal obstruction stridor is ENT emergency until proven otherwise
34
cause of expiratory stridor (wheeze)
tracheobronchial obstruction
35
cause of biphasic stridor
subglottic/glottis anomaly (under vocal cords) common in croup - narrowing of subglottic airways
36
37
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)
38
acute biphasic stridor hx cough/choking before resp symptoms diagnosis?
inhaled foreign body
39
acute stridor uncommon \<3yrs bacterial infection following viral infection diagnosis
tracheitis
40
chronic stridor neonates/early infancy difficulty breathing poor weight gain diagnosis
laryngomalacia - floppy larynx
41
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
42
what vaccine is used which helps against epiglottitis
hameophillis influenza type B (HIB) vaccine common cause of epiglottitis
43
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**
44
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
45
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**
46
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
47
48
what to look for when examining neck lumps
**S**HE **C**UTS **T**HE **F**ISH **PER**FECTLY 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
49
differentials for neck lump
tumour (benign/malignant) - primary/secondary lymph nodes cysts abscesses infection congenital vascular/ haemorrhagic
50
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
51
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
52
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
53
most common type of thyroid cancer
**papillary - 70% (young)** follicular - 20% anaplastic \<5% (older) medullary - 5%
54
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**
55
investigations for parotid gland swelling
USS sialogram - dye into gland duct, see if narrowing/stone, examine by x-ray CT +- fine needle aspiration
56
most common cause of lump seen investigation?
**submandibular gland** swelling usually due to **stone in duct** Ix: **USS**
57
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)
58
sore throat lump (in image) diagnosis
**tonsillar lymph node** swelling **tonsilitis/ glandular fever** but consider malignany
59
erythema swelling tender fluctuant warm diagnosis Ix management
abscess Ix: bloods, CT, fine needle aspiration Tx: **drain**
60
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
61
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
62
unilateral bleeding, progressive hoarseness, dysphagia, hearing loss, significant smoking history, Southeast Asian descent diagnosis?
nasopharyngeal carcinoma
63
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
64
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
65
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
66
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
67
systemic causes of nose bleeds in adults
anticoagulant medications alcohol von willebrand disease granulomatosis with polyangiitis chemotherapeutic drugs
68
systemic causes of nose bleeds in children
hereditary haemorrhagic telangiectasia (HHT) von willebrand disease
69
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
70
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
71
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
72
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
73
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
74
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)
75
investigation for dysphonia
**flexible nasal endoscopy** (FNE). FNE allows visualisation of the larynx and the vocal cords
76
vocal cord nodules management
speech and language therapy if severe- surgical
77
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
78
laryngitis Ix & Mx
laryngitis Ix: flexible nasal endoscopy conservative management
79
pulsatile neck lump differentials Ix management
**carotid artery aneurysm** **tortous carotid arter**y (**twists** and turns in artery) **carotid body tumours** (chemodectoma) Ix: **duplex USS** or digital computer **angiography** Mx: extirpation (**removal**)
80
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
81
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**)
82
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
83
acute swelling of salivary glands differentials
mumps HIV
84
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
85
deflection of ear outwards classical sign of what tumour
salivary gland tumour in parotid
86
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
87
surgical procedure to treat GORD
nissen fundoplication
88
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
89
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
90
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)
91
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
92
most common type of oral cancer
squamous cell carcinoma usually a non-healing mouth ulcer
93
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)
94
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**
95
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
96
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
97
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**
98
most common facial fracture
nasal fracture - nose bleeds, bruising
99
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
100
causes of perforated tympanic membrane
ear infection injury changes in pressure - flying, scuba diving sudden loud noise - explosion