ENT Flashcards
Allergic rhinitis Mx (4)
- Nasal irrigation with saline + advice
Mild-moderate
2. Intranasal antihistamines e.g azelastine hydrochloride PRN/ oral e.g loratadine/ ceterizine
Moderate- severe
3. Intranasal steroids e.g mometasone furoate, fluticasone furoate, or fluticasone propionate
Severe, uncontrolled
4. Consider short course of pred for 5-10 days
What is the first-line investigation for hearing difficulties? What is normal?
Audiograms
>20
Audiogram findings
Sensorineural hearing loss
Air and bone conduction are both impaired
Audiogram findings
Conductive hearing loss
Only air conduction is lost
Audiogram findings
Mixed hearing loss
Both are lost, but air conduction is worse than bone conduction
What is BPPV? Caused by Duration of symptoms Age Dx Mx (3)
Sudden onset of dizziness and vertigo triggered by changes in head position, usually lasts 10-20 seconds Caused by crystals of calcium carbonate (otoconia) get displaced. >55yo Dx Dix-Hallpike Mx 1. Epley manouvre 2. Betahistine 3. Vestibular rehabilitation
Black hairy tongue
What is it?
Defective desquamation (peeling) of the filiform papillae
(build-up of dead skin cells on tongue)
Colour can be brown/ green/ pink/ any colour
Black hairy tongue Predisposing factors (5)
- Poor oral hygiene
- HIV
- Abx use
- Head and neck radiation
- IVDU
Black hairy tongue
Mx (2)
- Swab to rule out candida and topical antifungals if +ve
2. Tongue scraping
Choleasteatoma
What is it?
Age
Non cancerous growth of squamous epithelium usually in the middle part of ear
Age 10-20yo
Choleasteatoma
Features (5)
Mx
- Hearing loss
- Foul smelling non resolving discharge
If local invasion: - Vertigo
- Facial paralysis
- Cerebellopontine angle syndrome/ unilateral hearing loss
Mx surgery - refer to ENT
What is cerebellopontine angle syndrome?
Unilateral hearing loss (85%), speech impediments, disequilibrium, tremors
Choleasteatoma
Dx - what do you see?
Otoscopy - attic crust seen in upper most part of eardrum
Chronic rhinosinusitis - symptoms for how many weeks? Predisposing factors (5)
> 12 weeks
- Swimming
- Smoking
- Recent infection
- Septal deviation/ polyps
- Atopy
Chronic rhinosinusitis
Features (5)
- Frontal pressure pain worse on bending forward
- Nasal discharge - clear, if thick and purulent then likely infection
- Post nasal drip - can lead to cough
- Nasal obstruction - mouth breathing
Chronic rhinosinusitis
Mx
- Avoid allergen
- Intranasal corticosteroids
- Nasal irrigation with saline
Red flags in chronic rhinosinusitis
- Unilateral symptoms
- Epistaxis
- Persistent symptoms after 3 months
Otitis externa
Causes
- Infection e.g Staphylococcus aureus/ Pseudomonas aeruginos/ fungal
- Seborrhoeic dermatitis
- Contact dermatitis
Otitis externa Rx (4)
- Topical abx - fluclox
- +/- topic steroid
- PO abx if severe
If fails to respond to topical rx then for ENT referral
What is malignant otitis externa and which group of patients is it most common in? Mx
Elderly diabetics
Infection spreads to bony ear canal and the soft tissues deep to the bony canal –> IV abx
Otitis media
When to prescribe abx? (5)
Mx
- Symptoms >4days
- Systemically unwell, but not requiring admission
- Immunocompromised
- <2yo with bilateral otitis media
- Perforation or discharge in ear
Abx amoxi - 5/7
Otitis media
Tympanic membrane signs:
Distinctly red, yellow, or cloudy and may be bulging.
Explain Rine’s + Weber’s
512Hz tuning fork
Rine’s air conduction (AC) should be better than bone conduction (BC) = positive test
If BC louder than AC = negative test and conductive hearing loss
Weber’s
Place on forehead
If louder on right side, could have right sided conductive hearing loss or left sided sensorineural hearing loss
What is Ramsay Hunt syndrome
Caused by?
Features (6)
Herpes Zoster 1. Paralysis of facial nerve 2. Rash around ear 3. Blisters can form in ear canal 4. Tinnitus + vertigo 5. Hearing loss 6. Auricular pain Rx oral aciclovir + steroids
Vertigo ddx (4)
- BPPV
- Meniere’s
- Vestibular neuronitis
- Viral labyrinthitis
Vertigo caused by excess build up of endolymph
Lasts minutes to hours
Caused by excess build up of endolymph
1. Hearing loss, increased hearing loss between attacks
2. Tinnitus
3. Aural fullness/ pressure (usually unilateral)
4. Not positional
5. Spontaneous nystagmus
6. Positive Romberg’s test
Meniere’s disease
Vertigo Recent viral infection Sudden onset Nausea and vomiting Hearing may be affected
Viral labyrinthitis
Vertigo Gradual onset Triggered by change in head position Each episode lasts 10-20 seconds No hearing loss
BPPV
Vertigo Recent viral infection Recurrent vertigo attacks lasting hours or days No hearing loss Horizontal nystagmus
Vestibular neuronitis
Vertigo
Elderly patient
Dizziness on extension of neck
Vertebrobasilar ischaemia
Vertigo
Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2
Acoustic neuroma/ vestibular schwannomas
Mx Meniere’s (2)
Driving
Acute 1. Buccal/ IM prochlorperazine Prevention 2. Betahistine Cease driving until satisfactory control of symptoms is achieved
Duration of symptoms
BPPV
Meniere’s
Vestibular neuronitis
BPPS 10-20seconds
Meniere’s minutes to hours
Vestibular neuronitis hours to days
What is the HINTS exam used for?
What two conditions does it differentiate between?
Patient with hours to days of vertigo and spontaneous nystagmus
To help differentiate between vestibular neuronitis and a stroke/ brain issue
What is the HINTS exam and how is it interpreted?
Made up of three tests
- Nystagmus
- Vertical skew
- Head impulse test
- Has to be unidirectional
- Nil vertical skew
- Positive head impulse test
All three above findings = neuronitis
Vestibular neuronitis
Mx
Acute
1. Buccal/ IM prochlorperazine
Prevention
1. PO prochlorperazine or PO antihistamine e.g cinnarazine, cyclizine, promethazine
Viral labyrinthitis Signs (Hint: uni or birectional nystagmus?) (hearing loss or no hearing loss) (head impulse test normal or abnormal) (gait) (skew test normal or abnormal)
- spontaneous unidirectional horizontal nystagmus towards the unaffected side
- sensorineural hearing loss
- abnormal head impulse test: signifies an impaired vestibulo-ocular reflex
- gait disturbance: the patient may fall towards the affected side
- normal skew test
Tonsillitis complications (4)
- Otitis media
- Quincy - peritonsillar abscess
- RhF
- Glomerulonephritis
Tonsillitis
When would you refer a patient to ENT for consideration of tonsillectomy? (3)
- Recurrent tonsillitis
- 7 episodes / year for 1 year
- 5 episodes / year for 2 years
- 3 episodes / year for 3 years - Obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
- Recurrent febrile convulsions secondary to tonsillitis
When would you prescribe abx for tonsillitis?
Which abx in normal pt, in pregnant/ pen allergic pt, length of time?
Group A Strep (GAS) has been confirmed on rapid antigen testing OR Fever PAIN score >=4 OR CENTOR score >=3
Phenoxymethylpenicillin or erythro if pregnant or pen allergic 7-10 days
What is the most common bacterium causing tonsillitis?
Group A Strep
Strep pyogenes
What is the CENTOR score used for?
What is the score?
To assess likelihood of GAS causing pharyngitis/ assess likelihood of tonsillitis caused by GAS
Can't cough (+1) Exudate/ swelling (+1) Nodes - tender/ swollen ant cervical lymph nodes (+1) Temp >38 (+1) OR Age 3-14 (+1) OR >= 45yo (-1)
Indications for abx for a sore throat
- Significant systemic upset
- Unilateral peritonsitis
- Hx of rheumatic fever
- Increased risk from acute infection e.g T1DM or immunodeficient
- CENTOR score >=3
FeverPain criteria
PACTS
Purulence/ exudate Acute onset within 3 days Cannot cough Temperate >38 in last 24 hours Severely inflamed tonsils
Moves upwards with protrusion of the tongue
Thyroglossal cyst
Sudden-onset sensorineural hearing loss
What do you do next?
What investigation is needed to rule out which likely condition?
Mx
Refer to ENT
MRI internal auditory meatuses (IAM) to rule out acoustic neuroma aka vestibular schwannoma
High dose oral steroids
Onset is usually at 20-40 years Conductive deafness Tinnitus Normal tympanic membrane although 10% of patients may have a 'flamingo tinge', caused by hyperaemia Positive family history
AD/AR
Mx (2)
Otosclerosis
Replacement of normal bone by vascular spongy bone
AD
FH
- Hearing aid
- Stapedectomy
Age-related sensorineural hearing loss.
Pts may describe difficulty following conversations
Audiometry shows bilateral high-frequency hearing loss
= which condition?
Presbycusis
Workers in heavy industry are particularly at risk
Hearing loss is bilateral and typically is worse at frequencies of 3000-6000 Hz =
Noise damage
Acoutstic neuromas affect which three CNs?
Which condition are bilateral acoustic neuromas seen in?
CN VIII: hearing loss, vertigo, tinnitus
CN V: absent corneal reflex
CN VII: facial palsy
Neurofibromatosis type 2
Non pulsatile tinnitus versus pulsatile tinnitus
What is the difference in investigation required
Pulsatile requires magnetic resonance angiography (MRA) as likely vascular cause
Non pulsatile does not require imaging unless it is unilateral or there are other neurological or ontological signs
What is glue ear also known as? Age peak Presenting feature Conductive/ sensorineural Other features (3)
Also known as otitis media with effusion 2yo Conductive hearing loss Other features 1. Speech and language delay 2. Behavioural 3. Balance problems
Glue Ear Mx
- Grommet insertion
2. Adenoidectomy
What is geographic tongue?
M/F more common?
Features (2)
Benign condition
More common in females
Erythematous areas with a white-grey border (looks like outline of a map)
Burning after eating food
Facial ‘fullness’ and tenderness
Nasal discharge, pyrexia or post-nasal drip leading to cough = which condition?
Sinusitis
Four causes of gingival hyperplasia (three are drugs)
- AML
- Phenytoin
- Ciclosporin
- CCB especially nifedipine
Hoarseness
Causes (7)
Ix to consider and why
- voice overuse
- smoking
- viral illness
- hypothyroidism
- gastro-oesophageal reflux
- laryngeal cancer
- lung cancer
CXR to rule out any apical lung pathology
Epistaxis
Acute management if haemodynamically stable (2)
What can be given and why after successful termination of epistaxis (1)
- Sit torso forward, mouth open
- Pinch soft part of nose for 20 minutes, mouth breathing
If successful - Topical antiseptic such as naseptin/ mupirocin (to reduce crusting/ vestibulitis)
Epistaxis
When would admission/ follow up be needed?
If has any comorbidities e.g
- HTN
- CAD
- <2yo as could have bleeding disorder
Epistaxis
Acute management if initial management if unsuccessful and ongoing bleeding after 10-15 minutes
- Cautery - if source of bleed can be seen
OR - Packing - if done in GP, send to hospital for review
Factors that increase risk of re-bleed - epistaxis (5)
- Blowing or picking the nose
- Heavy lifting
- Exercise
- Lying flat
- Drinking alcohol or hot drinks
2ww to ENT for suspected laryngeal cancer criteria
> =45yo
- Persistent unexplained hoarseness
- Unexplained lump in the neck
2WW to oral surgery criteria (6)
- Unexplained oral ulceration/ mass persisting >3 weeks
- Unexplained painful/ swollen/ bleeding red/white patches
- Unexplained one-sided pain in head/ neck >4 weeks, associated with ear ache and normal otoscopy
- Unexplained recent neck lump, or prev undiagnosed lump that has changed over 3-6 weeks
- Unexplained persistent sore or painful throat
- Signs in the mouth >6 weeks that are not benign
2WW for oral cancer review by a dentist
- a lump on the lip or in the oral cavity
2. a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
What is hairy leukoplakia?
Common in which patient group?
Caused by?
White patch on side of tongue with hairy appearance
Common in immunocompromised
Caused by EBV
Nasal polyps
M/F
Associated conditions (6)
2-4 times more common in men
Not commonly seen in children or elderly
Associations
- Asthma (particularly late-onset asthma)
- Aspirin sensitivity
- Infective sinusitis
- CF
- Kartagener’s syndrome
- Churg-Strauss syndrome
What is Samter’s triad?
Association of asthma, aspirin sensitivity and nasal polyposis
Nasal polyps
Features (4)
Mx (2)
Nasal obstruction
Rhinorrhoea
Sneezing
Poor sense of taste and smell
Mx
- ENT referral
- Topical corticosteroids (shrink polyp size)
Nasal septal haematoma Caused by? Features (3) O/E: How can you differentiate between a nasal haematoma versus deviated septum?
- Relatively minor trauma
Features
- Sensation of nasal obstruction
- Pain
- Rhinorrhoea
O/E: bilateral, red swelling arising from nasal septum
Nasal haematoma = boggy
Deviated septums = firm
Nasal septal haematoma
Mx (2)
What can happen if left untreated?
Management
- surgical drainage
- intravenous antibiotics
Irreversible septal necrosis may develop within 3-4 days Can result in a ‘saddle-nose’ deformity
Name the condition
Rubbery, painless lymphadenopathy
Pain whilst drinking alcohol (rare)
Night sweats and splenomegaly
Lymphoma
Name the condition
More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
Thyroglossal cyst
Name the condition
More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough
Pharyngeal pouch
Pulsatile lateral neck mass which doesn’t move on swallowing
Carotid aneurysm
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
Branchial cyst
A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age
Transilluminable
Cystic hygroma
Parotid gland causes
Bilateral (5)
Unilateral (3)
Bilateral causes
- viruses: mumps
- sarcoidosis
- Sjogren’s syndrome
- lymphoma
- alcoholic liver disease
Unilateral causes
- tumour: pleomorphic adenomas
- stones
- infection
Features parotid gland swelling (2)
- Swelling and pain worse on eating or talking
2. May be associated fever and a foul taste
Name three salivary glands
Which is most common for a tumour?
Which is most common for stones?
Parotid (tumour - most adenomas, malignant is rare)
Submandibular (stones)
Sublingual
Parotid tumours Most common type Age Features (1) Mx (1) Risk
Pleomorphic adenomas
Middle aged
Feature
1. slow growing, painless lump
Mx
1. Superficial parotidectomy
Risk = CN VII damage
Stones Most common in which gland? Features (1) Ix (2) Name of condition if it becomes infected?
Submandibular (80%)
Features
1. Recurrent unilateral pain & swelling on eating
Infected → Ludwig’s angina
Ix
- Xray
- Sialography
Rx
Surgical removal
What is Ludwig’s angina?
Rare bacterial skin infection that occurs on the floor of the mouth, underneath tongue.
Often occurs after a tooth abscess
What is sicca syndrome also known as?
Sicca syndrome AKA Sjogren’s
Retracted ear drum =
Glue ear
