ENT Flashcards
ACUTE otitis media = is preceeded by what?
Viral URTI
most common bacterial cause of otitis media
- strep pneumonia
when do you admit a child for otitis media
- <3 months old with 38 degrees + temp
- 3-6monthhs with 39 degrees
rx otitis media
- no abx as most resolve in 3 days
most common complication of otitis media
mastoiditis
who should you give abx to for otitis media
- no improve after 4/7
- immunocompromised
- systemic unwell
- severe co morbidities
- <2yrs with bilateral
- those with discharge
what abx would you give if you had to for otitis media
- amoxicillin 5/7
- erythromycin/ clairthro if pen allergy
protective factors for otitis media
- pneumococcal and influenzae vaccine
- breastfeeding for 6/12
- avoidign smoke
risk factors or otitis media
- first epidose in 6/12, male. day care, smoking exposure, winter, sibling with recurrent AOM, Craniofacial abnormalities, pacifiers use, not breastfed, bilateral disease
what is rx for recurrent AOM
- Grommets
glue ear rx
- wait and watch
3/12 - autoinfalte eustachian tube by otovent
- grommet if persists or recurs
complications of grommet insertion
- tympanosclerosis
- infection
grommet insertion criteria
- > 4 AOM /year
- >3 AOM in 6/12
what happens to grommets once inserted
- natuurally falls out after 6-12/12
what pars perforates in chronic supparative otitis media without choleostatoma
- pars tensa
what pars perforates in chronic supparative otitis media with choleostatoma
- pars flaccida
rc chronic supparative otis media
- pars tensa - conservative or myringoplaty if severe
- pars flaccida; mastoidectomy
what is pericondirits
- inflammation of the pinna - inflammed cartilage layer
what causes pericondirits
- piercing
- otitis externa
- haematoma
periconditis infective organism
- pseudomonas
- sometimes staph aureus
rx pericondirits
- IV abx - ciprofloxacin/tazocin
- IV steroids
- I and D if need be
name abx used for otitis externa
- sofradex
rx refractory otitis externa
think fungal
- swab
- canestan and prolonged for 3/52
- if still suspect bacterial; high dose steroid/antifungal/abx = all 3 = triadcortyl
acute labrynthitis triad
- vertigo
- n and v
- tinnitus/ hearing involved
note - recent viral infection usual
- sudden onset sx
what is gradenigo syndrome/ apical petrositis
- trigeminal pain distribution
- acute otitis media
- abducens palsy
rx for apical petrositis
- IV abx
subjective vs objective tinnitus
- subjective - not a an actual sound but a defect in auditroy pathway
- objective - sound made in inner ear.
most common causes of objective tinnitus
- Vascular; AV malformations, eustachian abnormalities, myoclonus of osccicualr msucles, high output CCF
causes of subjective tinnitus
- Presbyacusis
- NIHL
- menieres
- otoxicity
which drugs cause reversible tinnitus
- macrolides and loops
Acoustic neuromas are associated with which type of neurofibromatosis
- NF2
what happens to corneal reflex in acoustic neuromas
- absent
triad of acoustic neuroma
- hearing loss, vertigo, tinntitus
vestibular neuronitis sx
- no hearing loss
- recurrent vertigo attacks lasting hrs to days
what does and elderly patient with dizziness on extension of th neck have
- vertbrobasilar ischaemia
in acute vestibular failure (neuronitis/labrynthitis) where does nystagmus go
- away from affected side
which 6 nerves give rise to referred pain in the ear
- auriculotemporal branch of trigeminal
- aurivular branch of vagus
- greater auiicular nerve
- lesser occipital - facial
- glossopharyngeal
auriculotemporal nerve arises from which CN and gives pain from what issues
- V
- TMJ dysfunction and dental disease
which nerve causes pain in ramsey hunt syndrome
- CN VII
what cause ear pain via glossopharyngeal nerve
- primary glossopharyngwal neuralgia induced by talking ro swallowing
what conditions cause ear pain due to tympanic breach of glossopharyngeal nerve and auricular branch of vagus
- refer pain from cancer of posterior 1/3 of tongue, pyriform fossa, or larynx
- quinsy
- post tensillectomy
what conditions do you get ear pain due to the great auricular nerve at c2 and c3
- soft tissue injury in cervival spondylosis/arthritis
what drug is used to prevent barotraum
xylometazoline
what drug users have a obliterated septum
cocaine
rx epistaxis
- lean forward mouth open, spit out blood
- naseptin to reduce crusting and risk of vestibulitis
who should you not give naseptin to
those with peanut allergy or soy or neomycin allergy
what should you give those with a nosebleed that cannot have naseptin
- mupirocin
who with epistaxis, do you admit
- comorbidity such as HTN thats severe or coronary artery disease
- aged under 2 - as more likely underlying cause
what do you do if a nosebleed does not stop with initial measures and lasts more than 15mins
- packing. and cautery if visible source
- packing if cautery not viable or no visual of bleeding point
- go to hospital if packed
why should you never cauterise both sides of a septum
risks perforation
what if bleeding does nto stop after 24hrs of packing
- foley catheter
what does serious posterior epistaxis need
- EUA, Endoscopic arterial ligation or embolisation
if after nasal facture, Examinationn under anaesthesia is required when shoudl you do this
- not till 10-14 days after injury before nasal bones set
diagnostic criteria for rhinosinusitis
- inflammation of nose and paranasal sinuses with at least 2 sx:
- must have; nasal blockage/obstruction/congestion or discharge
- facial pain/pressure
- reduced/loss of smell
- endoscopic or CT imaging changes
how many weeks is chronic rhinosinusitis diagnosis
> 12
rx chronic rhinosinusitis
- intranasal steroids and saline irrigation
- if no improved after 4/52 = mod/severe endoscopic findings - culture and prophylactoc abx if ige normal
if nasal polyps are identified in a person <10yrs , what are the ddx
- tumours
- CF
- Meningeocoele
- Encephalocoele
ix for single unilateral polyp
- biopsy for NPC or lymphoma
ix for polyps
rhinoscopy
rx for polyps
- steroids ; topical.
- endoscopic sinus surgery
rhinitis urgent referral criteria
- numbness
- tooth loss
- bleeding - -unilateral
acute bacterial rhinosinusitis diagnostic criteria
- 3 of:
- discoloured discharge with unilateral prominence and purulent secretion
- severe local pain; unilateral
- fever > 38
- inflam markers
- deteriorates after mild illness
acute bacterial rhinosinusitis rx
- simple analgesia
- nasal saline irrigation, intranasal decongenstants
- stop smoking
define acute post viral sinusitis
- worsening in sx 5/7 after or perisstent sx >10/7
rx acute sinusitis
<10/7 = support 10+ = high dose IN corticosteroids
what type of ca are head and neck ca in genral
- SCC
RF laryngeal ca
- age, male. hc RDT, Hx Family, smoking, alcohol
at how many weeks of hoarse voice do you refer to ENT and what ix do you do
- 3 weeks
- CXR
Types of laryngeal ca
supraglottis
glottis
subglottis
which organ does laryngeal ca spread to commonly
lungs
rx laryngeal ca
- total laryngectomy if sybglottis with perm trache and valve for speaking
- RDT +/- chemo
- partial laryngectomy
- palliative
sx of tonsillar ca
- otalgia
- asymettrical tonsil = tonsillectomy
do pharyngeal ca present late or early
late
Nasopharyngeal ca sx
- middle ear effusion
nasopharyngeal ca is most common in which ethnicity
southern china
how do maxillary antral tumours present
- epiphora (tears spill on face), loose teeth, glue ear, face swelling, nasal obstruction
if there is a neck lump in <20yrs old in midline - what is likely dx
- thyroglossal cyst
- dermoid cyst
neck lump in >20yrs in midleine?
- thyroid mass
- chondroma
submandibular neck mass <20
- self limiting LNA
Submandibular lump >20yrs dx
- salivary stone/tumour
- ca
anterior triangle tumours
- LN
- Branchial cyst; at junction of upper and middle 1/3rd
- cystic hygroma; transilluminates
- carotid bdy paragangliomas - move laterally and firm
- parotid tumours
wegeners granulomatosis sx
- epistaxis, ulcers, obstruction nasal
- haemoptysis, pleuritis
- glomerulonephritis, proteinuria, haematuria
- purpura, neuropathy, arthritis, uveitis
wegeners granulomatosis ix
- cANCA
- urinalysis
- CXR and CT lung
wegeners granulomatosis rx
induce remission
- corticosteroids
- cyclophosphamide
maintain
- azothioprine
- methotrexate
prophylaxis for infection
- pneumocystis jirovecii
laryngitis rx
- supportive
- if severe = phenoxymethylpen 1/52
what is reinkes oedema
- fusiform gelatinous enlarged cords due to chronic cord irritation
reinkes oedema occurs in which patients
- female smokers
- hypoTH
- Elderly
- chronic voice use
sx reinkes oedema
- deep gruff voice
rx reinkes oedema
- support if early
- laser if late
vocal cord nodules symptoms
- husky voice + laryngitis sx
cause of vocal cord nodules
- chronic voice abuse
rx vocal cord nodules
- speech therapy/surgical excision
laryngitis causes
- viral
- bacterial
- reflux- fungal
- chemicals
-foreign body
-
what are the common bacterial and viruses that cause laryngitis and what are the prognosis
- viral; rhino in spring and autumn, influenza in winter. are self limiting
- bacterial most common HIb = life threatening
predisposing factors to laryngitis
- pollution
- croup
- epiglottitis
- smoking
- mouth breathing
- climate
- immunodeficient
- DM
- HypoTH
- IDA
- Voice use
diptheria laryngitis rx
- abx and antitoxin
- only negative after 3 clear swabs and a culture
define acute laryngitis
<7/7
define chronic laryngitis
> 3/52
epiglottitis definition
- cellulitis of supraglottis
epiglottitis neck XR findings and rx
- thumb sign; enlarged epiglottitis
- ceftriaxone = empirical
what is the most worrying cause of pharyngitis
- GAS
What is the centor criteria
- whether or not to give abx for tonsillitis
score 1 for each of the following:
- exudate
- fever
- cervical LNA
- absence of cough
3/4 = pen v 10 days or erythro
complications of tonsillitis
- acute otitis media
- sinusitis
- quinsy; abx nd aspirate
- parapharyngeal abscess - I and D
- lemierres disease; acute septicaemia and jugular vein thrombosis secondary to fusobacterium + septic emboli
scarlet fever organism
- GABHS
- Strep pyogenes
where does rash spread to in scarlet fever and how quickly
- chest
- axillae
- behind ears
12-28hrs after rash
+ facial flush and strawberry tongue
rx scarlet fever
- pen v 10/7
complications scarlet fever
- sydenhams choreo
- demyleiantign disorders
tonsillectomy criteria
> 7 /12, >4 in 2 years, >3 in 3 years
tonsillectomy complications
- primary = in 24hrs - back to theatre
- secondary; after 24hrs but typical 5-10 days = major haemorrhaoge protocol
if bleedign stops - hydrogen peroxide gargles and IV ABX
what type of cancers are most head and neck cancers
- SCC
RF for head and neck cancers
- smoking
- alcohol
- Vit A and C deficiency
- HPV 16
- Nitrosamines
- GORD
sx for head and neck cancer
- neck pain/lump/ hoarse or soar throat >6/52
- mouth bleeding and numbness
- sore tongue
- painless ulcers
- oral patches
- toaglia effusion
- speech change and effusion
which head and neck cancers is HPV linked to
- lingual, tonsillar and pharyngeal and laryngeal
anterior triangle lump ddx
- lymphoma
- branchial cyst ( squamous lined cholesterol)
- parotid ca esp if >40yrs
posterior triangle lump ddx
- pharyngeal pouch
- cystic hygroma (transilluminates)
- cervical rib
- EBV LNA
- lymphoma
options for voice restoration after laryngectomy
- artificial larynx
- trans-oesophageal puncture
what does a radical neck dissection involve
- all neck LN + spinal accessory nerve and internal jugular vein and SCM
where do head and neck cancers spread to
- cervical LN first
- lungs after
suspected head and neck cancer ix
- flexible nasolaryngoscopy
- CT neck and chest
- FNA LN +/- USS - core/excision biopsy
- primary tumour = GA; BIOPSY through panendoscopy
dx criteria for OSA
- Epworth scale.. 17/21 = narcolepsy
- overnight pulse oxiemtry = cyclical desaturation with sawtooth appearance
- if nto diagnosed by above then inpatient sleep study
- dx if 10-15 hypoapneas or apnoea in 1hr of sleep
rx OSA
- CPAP
- CNS stimulant = modafinil
what does the recurrent laryngeal nerve supply
- most of the isntrinsic muscles of the larynx except cricothyroid
what are the only muscles to open vocal fold
- posterior cricoarytenoid
sx vocal cord paralysis
- hoarsness = breathy
- SOBOE
- Repeat coughing and aspiration
- weak cough
causes of vocal cord paralysis
- tumours
- iatrogenic
- CNS
- TB
- Iatrogenic
ix vocal cord paralysis
- MRI, Endoscopy, CXR, Barium swallow
rx vocal cord paralysis
- medialisation - medialisation thyroplasty
- treat tumour
what metabolic abnormalities cause bilateral vocal cord paralysis
- hypokalaemia and hypocalcaemia
- DM
what is the one cause that causes bilateral not unilateral palsy
- neurological disease
the parotid gland is innervated by which cranial nerve
- CN XI - accessory nerve
parotid gland produces what
- serous saliva
submandibular gland produces what
mucous and serous saliva
submandibular gland is innervated by what
- CNVII
unilateral salivary gland enlargement causes
- tumour
- bacterial infection
- stone
bilateral hypofunctioning salivary gland enlargement causes
- infections often viral, HIV or mumps
- autoimmune - sjogrens
- granulomatous disease; sarcoid, TB
bilateral asymptomatic Salivary gland enlargement causes
- eating disorder - anorexia, BN
- Cirrhosis
- chronic pancreatitis
- endocrine - acromegaly/DM
pain and sweling when eating indicates what
= duct
what does a dry mouth indicate about salivary issues
they are diffuse
ix for salivary stones
- plain XR
- if not seen = sialogram or USS
what is heerfordts syndrome
- sarcoidosis with bilateral parotid enlargmeent, fever, anterior uveitis and facial nerve palsy
parotid duct pathway
- crosses the masseter and opens via small papilla on the buccal membrane opposite the crown of second upper molar
- facial nerve passes through it
parotid enlargement with facial nerve palsy = ?
- malignancy
benign tumour s of parotid
- benign pleomoprhic adenoma; slow growth - remove with parotidectomy
- adneolymphoma - soft, old men
- haemangioma
- lympangioma = kids
intermediate ca parotid tumours
- mucoepidermoid
- acinic cell cancer
- oncocytoma
malignant parotid tumours
- adenoid cystic ca - slow growing, distant mets, exocrine mucous glands
- adenocarcinoma; rapid growth, hard mass, pain and 7th CN palsy
- SCC
when should you not do a sialogram in patients with parotid tumours-
iodine/ contrast allergy
- acute infections
- CT instead
complications of parotid surgery and RDT
- facial palsy
- salivary fistula
- freys syndrome; auriculotemporal branch of trigeminal resprouts to swiitch symp fibres to parotid and paraymp to facial sweat glands = gustatory sweating
