ENT Flashcards by Kate Lambert

Head + neck masses in adults - red flags hx (5)

present for >2/52
recent voice change
dysphagia/odynophagia
ipsilateral otalgia/epistaxis/nasal obstruction
constitutional Sx - unexplained WL, reduced appetite

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Head + neck masses in adults - risk factors for malignancy (6)

smoker
ETOH ++
age>40
PMHx malignancy
PMhx cutaneous head + neck cancers/lesions
HPV

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Head + neck masses in adults ddx (8)

Infection:
strept throat
lymphadenitis
abscess
Neoplastic :
Head + neck cancer - most common cause = SCC
Lymphoma
Endocrine:
Goitre
Parathyroid mass

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Head + neck masses in adults examination

assess location of the neck mass - LN region, thyroid?
characteristics of the neck mass:
mobility vs fixed
size (>1.5cm)
firmness
overlying skin ulceration
Full head + neck exam:
cutaneous lesions
otoscopy - unilateral effusion
anterior rhinoscopy
inspection of oral cavity and pharynx - masses, ulceration, tonsil enlarged/symmetry

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Head + neck masses in adults -

single most important Ix

CT neck with contrast and FNA biopsy

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Head + neck masses in adults Ix

FBC
ESR
TSH
PTH
Thyroid ultrasound
CT chest with contrast - Lung cancer, TB, sarcoidosis
EBV/HIV/CMV serology

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Head + neck masses in adults Mx

Refer to ENT early
Mx other causes - infection POABX
viral - supportive
Thyroid

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Acute rhinosinusitis causes -

bacterial
viral
post viral syndrome

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Acute diffuse otitis externa - key features presentation (4)

otalgia/pruritis
reduced hearing
d/c from ear
hx water exposure (recent, chronic or recurrent)

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Acute diffuse otitis externa - key features examination (4)

inflamed canal - erythema +/or oedema
external auditory meatus tenderness - from manipulation of tragus or auricle
+/- discharge
severe cases - regional lymphadenitis, cellulitis of pinna or surrounding skin

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Acute diffuse otitis externa - key features immediate mx (5)

analgesia - panandol nurofen
dry aural toilets - tissue spears
topical rx : otodex or kenacomb otic 3 drops tds for 7 days
keep ear dry for 2/52 after tx 
\+/- ear wick if canal very oedematous

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Acute diffuse otitis externa - key features long term mx (4)

dry ear -precautions
dry ears after swimming
wear occlusive ear buds
avoid putting fb in ear (fingers, cotton buds)
avoid swimming in dirty water
acetic acid plus isopropyl alcohol ear drops following exposure to water to prevent recurrence

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Mx of acute localised otitis externa and/or severe acute diffuse otitis externa (2)

1. flucloxacillin 500mg qid for 7 days
OR
clindamycin 450mg tds for 7 days  
PLUS
2. ciprofloxacin 750 mg (child: 20 mg/kg up to 750 mg) orally bd for 7 days

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Meniere’s disease - key features presentation

non positional vertigo
SN hearing loss
tinnitus
aural fullness

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Rinne test - what does it detect? what is normal?

what is a negative test finding indicate?

detects conductive hearing loss
positive test = Air conduction > bone conduction = normal hearing
negative test = BC > AC = CHL

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Weber test - what does it detect?
what is normal finding?
what does contralateral finding mean?
what does ipsilateral finding mean?

detects if the unilateral hearing loss is conductive or sensorineural
normal - sound heard equally on both sides
sound lateralises to opposite, unaffected hearing side = SNHL
sound lateralises to ipsilateral, affected hearing side + CHL

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Sudden onset hearing loss - red flags (3)

concurrent head trauma
unilateral middle ear effusion
neurological SOS

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Nasal obstruction +/or discharge - red flags for serious pathology (8)

unilateral blockage/d/c
bloody rhinorrhoea/epistaxis
ipsilateral head or neck lumps
frontal swelling of medial canthus/ethmoid sinus
unilateral facial pain/headache
visual disturbance - diplopia, proptosis, eye pain, opthalmoplegia, periorbital swelling/cellulitis
Hx woodworker/formaldehyde exposure
persistent d/c or blockage despite 4/52 of medical management

Persistent nasal obstruction +/or discharge Ix

Ct face/sinuses

Refer for urgent endoscopy upper resp tract

Nasal obstruction (subjective insufficient airflow through nasal cavity) causes

VITAMIN CDEF
Vascular - TG autonomic cephalalgia/cluster headache
Infection/inflammatory - Rhinitis - allergic, non allergic
chronic rhinosinusitis with/out polyps
adenoid hypertrophy, inferior turbinate hypertrophy
traumatic - septal deviation
idiopathic - dry mucosal membranes
iatrogenic - empty nose syndrome from previous excessive surgery
neoplastic - benign polyp, SCC, sinonasal adenocarcinoma
congentinal - choanal atresia
drugs - antithyroid rx - carbimazole, propylthiouracil, C-OCP + oestrogens, NSAIDS, b-blocker, CCB, ACEI, ARB
cocaine - septal perforation
Functional - pregnancy

Nasal obstruction key examinations

oropharyngeal exam - lesions, lumps, polyps
head and neck exam for cutaneous lesions, masses/lumps and LN
nose exam - external nose and cartilage
pig nose manoeuvre - direct inspection of anterior nasal passages
ear exam - otoscopy effusion/AOM

vestibular neuronitis - Mx (4)

prednisolone 1 mg/kg (up to 75 mg) PO, mane for 5 days, then taper dose over 15 days and stop.
stemetil 5-10mg tds prn for 2 days
bedrest for 2-3/7
diazepam 5mg tds for 2 days

Excessive ear wax/wax impaction - hx (5)

reduced hearing (CHL)
otalgia
itching or aural fullness
dizziness
tinnitus

Excessive ear wax/wax impaction - Mx (3)

1/3 will resolve in 5/7 without tx
cerumenolytic agents - waxsol drops
ear syringing/microsuction

Contraindications for ear syringing (3)

hearing impaired Infection - AOE/AOM PMHx TM perforation

Acute pharyngitis/tonsillitis - when to give POABx

Scarlett fever Existing RHD Suspected strept throat in high risk populations (ATSI, refugees, PMHX - ARF, GN, RHD)

Suspected strept throat - Ix and timing (3)

Throat swab MCS for strept throat - active/acute infection Bloods - ASOT, AntidnaseB - sos suggesting ARF or GN and recent sore throat, takes 1/52 post infection to have detectable titres

Scarlet fever - clinical features (4)

sudden high fever >38.5 distinctive rash (red initially, becoming dry and rough with a sandpaper feel) facial flushing with circumferential pallor tongue discolouration (white initially, then strawberry tongue)

Acute strept throat - clinical features (4)

fever >38 tender cervical lymphadenopathy tonsillar exudate absence of viral symptoms - rhinorrhoea, cough or nasal congestion

Acute strept throat - Tx (3)

``` phenoxymethyl penicillin 15mg/kg <500mg po bd for 10 days OR cefalexin 25mg/kg <1g, bd for 10 days OR azithromycin 12mg/kg <500mg od for 5days ```

Acute otitis media - clinical features (3)

Acute onset of: fever >38 middle ear effusion - bulging TM +/- air fluid level +/- TM perf with otorrhoea AND middle ear inflammation - redness of the TM

non suppurative acute otitis media - mx (7)

advise in absence of systemic symptoms, routine POABx not helpful at reducing duration or severity of pain or illness watchful waiting and delayed script for POABx if failed to improve in 2-3days review in 48hrs regular paracetamol regular ibuprofen

non suppurative Acute otitis media - indications for POABx (8)

``` Not improved at 48hrs AOM with systemic features - lethargy, high fever, vomiting ATSI, refugee, hearing impaired Age <6/12 Bilat AOM in <2yr olds AOM with TM perf + otorrhoea ```

non suppurative acute otitis media POABx, drug, dose, duration (3)

``` amoxicillin 15mg/kg PO TDS for 5/7 OR cefuroxime 15mg/kg BD for 5/7 OR Bactrim DS 4/20mg/kg BD for 5/7 ```

recurrent bacterial otitis media risk factors (6)

``` exposure to environmental smoke (cigarette, wood fires) group childcare (daycare) allergic rhinitis adenoid disease cleft palate downs syndrome ```

Persistent otitis media with effusion - definition

persistent middle ear effusion for ≥3/12

Persistent otitis media with effusion - key features hx (4)

``` ***difficult to dx usually present with behavioural problems secondary to hearing loss rarely: hearing loss imbalance dull aching otalgia ```

Persistent otitis media with effusion (OME)- key features otoscopy (3)

visible loss of lucency of TM visible grey-white or blue tinged effusion fluid behind TM No signs acute inflammation of TM

Persistent otitis media with effusion - management (4)

Audiometry Manage hearing loss secondary to OME - optimise learning conditions, child at front of class, hearing aids, optimise/tx modifiable risk factors Referral to ENT for myringotomy + grommet insertion OME + high risk for recurrent AOM or chronic suppurative OM = 3/12 course of PO amoxicillin

Otitis media with effusion - indication for ENT referral (4)

Persistent OME ≥3/12 OME plus b/l hearing loss on audiometry OME plus speech delay or educational handicap or developmental delay OME plus structural damage to TM (retraction, cholesteatoma)

Chronic suppurative otitis media - dx

middle ear infection with TM perf and discharge for ≥ 6/52

Chronic suppurative otitis media - Mx for d/c ≥ 6/52 for d/c < 6/52

for d/c ≥ 6/52: - dry aural toilet tissue spears QID until dry - then instillation of ear drops: ciprofloxacin 0.3% 5 drops BD until ear free of d/c for 3 days for d/c < 6/52: - as above PLUS - POABx as per AOM with otorrhoea

Thyroid examination

``` Inspection of the swelling Palpation: Site Size consistency tenderness Movement on swallowing (upwards) Auscultation of swelling for bruits (graves) palpation of LN of neck examination of thyroid signs: pulse tremor eyes - proptosis/exopthalmus warmth of peripheries reflexes (hypo/hyper/clonus) general skin changes ```