ENT Flashcards
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
Head + neck masses in adults - risk factors for malignancy (6)
smoker ETOH ++ age>40 PMHx malignancy PMhx cutaneous head + neck cancers/lesions HPV
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
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
Head + neck masses in adults -
single most important Ix
CT neck with contrast and FNA biopsy
Head + neck masses in adults Ix
FBC ESR TSH PTH Thyroid ultrasound CT chest with contrast - Lung cancer, TB, sarcoidosis EBV/HIV/CMV serology
Head + neck masses in adults Mx
Refer to ENT early
Mx other causes - infection POABX
viral - supportive
Thyroid
Acute rhinosinusitis causes -
bacterial
viral
post viral syndrome
Acute diffuse otitis externa - key features presentation (4)
otalgia/pruritis
reduced hearing
d/c from ear
hx water exposure (recent, chronic or recurrent)
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
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
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
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
Meniere’s disease - key features presentation
non positional vertigo
SN hearing loss
tinnitus
aural fullness
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
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
Sudden onset hearing loss - red flags (3)
concurrent head trauma
unilateral middle ear effusion
neurological SOS
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
