ENT Flashcards
Tonsillitis definition
Inflammation of pharyngeal tonsils, usually extending to lingual tonsils and adenoids
Causes of tonsillitis
Mostly viral: Adenovirus, rhinovirus, RSV, EBV
Also bacterial: Group A strep (beta haemolytic)
Symptoms of tonsillitis
Fever Sore throat Halitosis Dysphagia Odynophagia Mild airway obstruction
Signs of tonsillitis
Respiratory distress
Tonsillar changes: Erythema, oedema, +/- exudate
Tender cervical lymphadenopathy
Requires flexible nasoendoscopy if severe or presence of respiratory distress
Management of tonsillitis
ABCs with resus and airway care of necessary
If bacterial- ABX- GAS- IV penicillin 2mu Q6h for acute inpatients, 10/7 oral for outpatients
Steroids for inpatients- dexamethasone stat or ads
Supportive therapy: Antiemetics, analgesia, antipyretics
Complications of GAS tonsillitis
Suppurative: Peritonsillar abscess, deep neck space infections, cervical lymphadenitis
Non-suppurative: Scarlet fever, rheumatic fever, post-streptococcal glomerulonephritis
Describe EBV tonsillitis and the management of this condition
EBV is also called mononucleosis
Consider it with tonsillitis + tender lymphadenopathy, splenomegaly, severe lethargy, and a white/grey membrane over tonsils
Confirmed via blood test
Takes longer to resolve, avoid contact sport due to risk of splenic rupture
Define peritonsillar abscess (quinsy)
Abscess formation between the tonsil and its capsule
Causes of peritonsillary abscess
Secondary to tonsillitis (progresses to cellulitis, then necrosis, then pus formation)
Infection of a minor salivary gland
Often polymicrobial, anaerobic growth. Aerobes likely to be strep, Aureus and H influenzae
Symptoms of peritonsillar abscess
Neck pain
Throat pain, worse one side +/- unilateral ear pain
Trismus (lockjaw)
Voice change to hot potato voice- sounds as if a mouthful of hot food
Signs of peritonsillar abscess
Resp distress
Tonsillar changes- erythema, uvula deviation to contralateral side, inferior-medial tonsillar displacement, supratonsillar fold/soft palate swelling
Drooling
Trismus
Dehydration
Tender cervical lymphadenopathy
Flexi-nasoendoscopy needed if respiratory distress or to rule out epiglottitis
How do diagnose peritonsillar abscess
FBC and U and Es
Monospot to rule out EBV
If deep neck infection suspected, lateral neck X-ray/CT
Management of peritonsillar abscess
ABCs
Incision and drainage- mainstay
Supportive therapy- fluids, ABX as for tonsillitis, antipyretics, analgesia
Complications of peritonsillar abscess
Deep neck space infection as peritonsillar space is contiguous with parapharyngeal and retropharyngeal spaces
Definition of supraglottitis/epiglottitis
Inflammation of structures above the insertion of the glottis in the oropharynx, eg. epiglottis, vallecula, arytenoids and aryepiglottic folds
Causes of supraglottitis/epiglottitis
Predominantly strep, staph and gram negatives
H Influenzae used to be the most common cause so ask about vaccination status!
Symptoms of supraglottitis/epiglottitis
Sore throat Odynophagia/dysphagia Muffled/hot potato voice Preceding RTI Fever Cough
Signs of supraglottitis/epiglottitis
Tripodding Toxic appearance of patient Drooling Irritability Stridor (late sign indiciating airway obstruction Cervical lymphadenopathy
How to diagnose supraglottitis/epiglottitis
Clinical
Lateral neck Xray shows epiglottitis thumb sign where epiglottis becomes swollen and pointed
Flexible nasoendoscopy if tolerated
Blood cultures
Management of supraglottitis/epiglottitis
ABCs and early ENT review- key is managing airway
ABX- ceftriaxone is firstline
Supportive measures- analgesics, antiemetics, IV fluids
Definition of deep neck space infections
Infection within a neck space created by planes
Most worrying is involvement of the space anterior to the prevertebral fascia- the danger space
Causes of DNSI
Inadequately treated pharyngitis, dental abscess or tonsillitis
Sialadenitis (salivary gland inflammation)
IVDU
Malignancy
Symptoms of DNSI
Sore throat Dysphagia Odynophagia Trismus Neck and neck movement pain \+/- painful neck mass
Signs of DNSI
Retropharyngeal abscess: posterior pharynx erythema and swelling
Parapharyngeal abscess: Medial displacement of tonsil and lateral pharyngeal wall
General
Torticollis: Holding neck in twisted position
Tender lymphadenopathy
Danger signs
Neurological deficit eg. hoarse voice due to vocal paralysis (carotid sheath and vagal/recurrent laryngeal nerve pressure)
Horner’s syndrome
Diagnosis of DNSI
CT neck
FBC, U and Es
Blood cultures
Management of DNSI
ABCs and IV fluids
ABX
I and D
Complications of DNSI
Internal jugular thrombophlebitis (Lemiere syndrome)- septic emboli and sepsis
Mediastinitis- Chest pain, widened mediastinum on CXR
Rare: Carotid rupture. meningitis, cavernous sinus thrombosis
Surgical sieve causes of neck lumps
VITAMIN CD
V: Vascular (AVM, aneurysm)
I: Inflammatory (Submandibular sialadenitis
T: Traumatic (Haematoma, ranula- spit cyst following damaged salivary gland
A: Autoimmune/allergic (thyroiditis)
M: Metabolic (goitre)
I: Infective (lymphadenitis, reactive lymphadenopathy, TB)
N: Neoplastic (carotid body tumour, chemodectoma, thyroid, lymphoma, SCC)
C: Congentita; (Branchial cyst, thyroglossal cyst, dermoid cyst)
Degenerative
History things to know of neck lumps
Pain: Chronic oral suggests malignancy, unilateral otalgia can be referred and is assoc with tumours at the tongue base, larynx and oropharynx
Dysphagia: Tumours are gradual, nasal regurg/aspiration suggests neurological
Stridor: Inspiratory sounds caused by blockage at or above vocal cords
Hoarseness: suggests laryngeal disease and requires ENT referral
Constitutional symptoms suggest malignancy
Social factors- smoking and alcohol assoc with cancer, HPV
Exam for neck lumps
Neck lump size, position, contour, texture, mobility and tenderness Ears Rhinoscopy Oral cavity Cranial nerves Nasoendoscopy Head and neck skin (ca) Thyroid signs
Ix for neck lumps
Imaging- USS, CT, MRI
Cytology/histology- FNA/biopsy
Blood tests: FBC, TFTs
ENT referral if necessary
Define Sinusitis
Inflammation of the sinuses, always accompanies by inflammation of the nasal cavity
Define acute sinusitis
Up to 4/52 of sx
Causes of acute sinusitis
Viral- symptoms for <10/7 and do not worsen
Bacterial- sx for 10/7 beyond URTI, worsen after initial improvement (caused by strep. pneumonia, h influence, mortadella)
- Both usually preceded by URTY
Sx of acute sinusitis
Purulent nasal discharge
Nasal obstruction
Facial pain/pressure/fullness
This all suggests bacterial more than viral
Management of acute sinusitis
1/52 co-amoxiclav
Sinus rinse or surgery may also be indicated
Definition of chronic sinusitis
12+ weeks of symptoms post URTI, with 2 or more additional symptoms
Causes of chronic sinusitis
Multifactorial
- Immune mediated (B and T cells)
- Microbial (Aureus)
- Anatomical- sinus ostia obstruction
Symptoms of chronic sinusitis
Mucopurulent discharge Inflammation- mucus, polyps, imaging Congestion Facial pain, pressure, fullness Reduced smell
Management of chronic sinusitis
ABX- culture directed, 3-4/52
Anti-inflammatories- intra-nasal, oral and any allergy management
Saline irrigation
Surgery if symptoms are still present following 4-6 weeks of maximal therapy (surgery is called FESS for functional endoscopic sinus surgery)
Sinusitis exam
- Anterior rhinos copy with headlight and thudicum speculum
- Flexible nasendoscopy
Complications of sinusitis (orbital infection)
Periorbital oedema Orbital celllulitis Subperiosteal abscess Orbital abscess Cavernous sinus thrombosis
Intracranial complications of sinusitis
Meningitis
Epidural abscess
Pott’s puffy tumour (osteomyelitis of the frontal bone with subperiosteal abscess)
Definition of allergic rhinitis
Inflammation of the nasal mucous membranes caused by IgE reaction to one or more allergens
Symptoms of allergic rhinitis
Clear, watery nasal discharge
Itching nose, eyes and throat
Nasal congestion
May be seasonal or trigger based such as pollen or cats
Management of allergic rhinitis
Antihistamines
Intranasal corticosteroids
Other options include systemic steroids if consistently failing above or decongestants (but these have rebound effects)
Definition of epistaxis
Bleeding from the nose due to mucosal erosion and exposure of underlying vessels
Causes of epistaxis
Infection- cold/flu
Trauma- nose picking, foreign body, dry air inhalation
Medications- anticoagulants, topical therapy, drugs
Rare: systemic such as coagulopathy, sarcoidosis, wegeners granulomatosis
Tumour
More than 95% of bleeding comes from Kiesselbach’s plexus (little’s area)
History points to know about epistaxis
Unilateral or bilateral start? (ant bleeds are uni, post bi)
General med hx for systemic conditions, anticoagulants and smoking
Bruising/bleeding/nosebleed hx
FHx bleeding disorders
Foreign body insertion
Exam for epistaxis
Local anaesthetic required! (may stop the bleed)
Headlight, speculum and suction- identify source
Ix for epistaxis
FBC- haemorrhage severity
Coag screen esp if warfarin
BP- this can contribute to bleeds
Management of anterior epistaxis
- Pinch nose for 10 mins with or without ice sucking
- Cotton bowls soaked in lidocaine and adrenaline- multiple times
- Cautery with silver nitrate sticks- only when sourced and stopped
- Rapid rhino/merocal for 24h
- Bilat rapid rhinos
- Arterial ligation and embolisation
Management of posterior epistaxis
- Uni/bilateral rapid rhinos
2. Endoscopic sphenopalatine ligation for persistent bleeds
What is the danger of batteries and the nose?
Batteries causes alkali burns and tissue necrosis
Define stridor
A mainly inspiratory noise indicating a partial upper airway obstruction
A MEDICAL EMERGENCY in children
Causes of stridor in children
Traumatic: Foreign body
Autoimmune/allergic: Anaphylaxis
Infective: Croup, tracheitis, supra/epiglottitis, DSNI
Neoplastic: Respiratory papillomatosis, vocal cord papilloma, cysts, nodules
Congenital: Laryngomalacia, laryngeal web, vocal cord paralysis, subglottic stenosis
Pathogenesis of laryngomalacia
Stridor develops due to the prolapse of supraglottic structures into the laryngeal inlet during inspiration
Most common cause of infantile stridor and most common laryngeal anomaly
Management of laryngomalacia
Conservative- 10% need surgery
Often resolves by 18-20 months of age
Pathogenesis of laryngeal web
Congenital condition presenting with abnormal cry and stridor
Due to embryonic failure of laryngeal recanalisation
Management of laryngeal web
Thin webs- incision
Thick webs - stenting
Definition and causes of subglottic stenosis
Partial or complete subglottic narrowing
May be congenital or acquired
Congenital- birth stridor (intermittent if mild)
Acquired- secondary to previous ET intubation
Management of subglottic stenosis
Varies based on age, grade and type of stenosis
Anything from observation if mild to reconstruction if severe
Definition of dysphonia (hoarseness)
Change in voice
Causes of dysphonia
Trauma: Voice abuse and misuse leading to inflammation, nodules and polyps
Neoplasm: Benign- nodule, polyp, papilloma, cyst. Malignant- laryngeal SCC
Other: Vocal cord paralysis, recurrent laryngeal nerve paralysis
Symptoms of dysphonia to ask about
Onset, duration and progression
Preceding URTI, trauma, ET intubation
Smoking and alcohol use
Employment- professional voice users have increased trauma rates
Thyroid and reflux history
Age- assoc. with increased malignancy, whereas children likely have benign nodules or papillomatosis
Assoc symptoms such as dysphagia/odynophagia
Dysphonia exam components
Head and neck exam
Flexible nasoendoscopy
Video stroboscopy- slow motion recording of vocal cords
Management of dysphonia
Malignancy- depends on histology, grade and stage
Multidisciplinary. Surgery may require partial or total laryngectomy +/- flap reconstruction, radiotherapy may be primary or adjuvant. Chemotherapy is rarely used
Vocal fold papilloma- requires collation (surgery)
Chronic cough definition
Cough lasting >8 weeks
Causes of chronic cough
Post-nasal drip as secretions increase cough
Asthma
GORD either through acid exposure or micro aspiration if no heartburn sx
These 3 make up 95% of causes!
Others include ACE inhibitors, smoking, CHF etc
How to differentiate between causes of chronic cough
Post-nasal drip is diagnosed often due to long term response to chronic rhino sinusitis treatments. Underlying allergies should also be managed
Non-asthmatic eosinophilic bronchitis Is diagnosed on sputum showing eosinophilia (very good response to corticosteroids)
GORD is based on PPI treatment
Stepwise management of chronic cough
- Smoking cessation and other factors (eg allergies) for 1 month
- CXR to rule out pulmonary lesions
- Trial PPI
- CT sinuese
- Induced sputum
- TB culture sputum, high res CT, bronchoscopy
Globus definition
Persistent or intermittent painless sensation of a lump or foreign body in the throat
Causes of globus
GORD accounts for up to 50% Nonspecific oesophageal motility disorder Malignancy Psychosomatic or stress dincued Retroverted epiglottis Thyroid disease TMJ dysfunction
Investigations and management for globus
Evaluate for reflux, malignancy and psych factors
3 month PPI trial
ENT exam to exclude sinister causes
If PPI not helping, 24h monitoring of gastric pH, as well as endoscopy and barium swallow
If no cause or response found- psych input
Define Zenker diverticulum
Herniation of the posterior pharyngeal/oesophageal mucosa and submucosa secondary to increased intraluminal pressure
Causes of zenker
Lack of muscle coordination
Hypertensive upper oesophagus
Symptoms of Zenker diverticulum
Dysphagia
Regurgitation (+/- aspiration) of undigested food
Halitosis
Zenker diverticulum investigations
Barium swallow
Fiberoptic endoscopic swallow evaluation +/- GORD pH evaluation
Management of zenker diverticulum
Endoscopic CO2 laser/electrocautery
Open repair
Definition of otitis externa
An inflammatory and infectious process of the external auditory canal +/- auricle
Causes of otitis externa
Bacterial- pseudomonas, S aureus, S epidermidis, proteus, E coli, diphteroids
Risk factors for otitis externa
Heat
Humidity
Trauma
Water exposure- results in cerumin removal from EAC- swimmers especially prone
Symptoms of otitis externa
ear pain Ear discharge Aural fullness Pruritis Tenderness Hearing loss IF ADVANCED Oedema Erythema of auricle/pinna
Signs of otitis externa
EAC oedema, erythema and otorrhea
Pain on distraction of the pinna
Periauricular/cervical lymphadenopathy
Management of otitis externa
- ABX- sofradex firstling, cipro and steroid for pseudomonas or second line
- Earwick for 48h to stent EAC if occluded- allows ABX to reach infection site
- Suction and microscope guidance if experienced
- Analgesia
- If exostoses present- surgical management to prevent recurrence
Steroids help reduce ear canal swelling
Complications of otitis externa
Malignant otitis externa- skullbase osteomyelitis
EAC -> temporal bone –> beyond, especially in elderly diabetics
Define acute otitis media
Inflammation and infection of the middl ear
Causes of acute otitis media
Pathogenesis is Eustachian tube dysfunction leading to pathogens from the nasopharynx moving to the middle ear
Usually preceded by a viral URTY, causing tube inflammation and dysfunction
Common agents include S pneumonia, H influenza and moraxella
Symptoms of otitis media
Otalgia Fever Hearing loss Otorrhea if perforated drum reduced appetite Concurrent URTI Children- fussiness and irritability
Signs of otitis media
Bulging erythematous tympanic membrane
Management of acute otitis media
Analgesia and watchful waiting for low risk children
ABX in severe illness, those less than 6mo old and those not improving within 48h
Amox is first line and erythromycin/cotrimoxazole are second line
In paeds always give max dose for weight range
Analgesia- paracetamol firstline, ibuprofen if not contraindicated
List the complications of acute otitis media
TM perforation Mastoiditis Facial nerve paresis in children Labyrinthitis Intracranial complications
Describe TM perforation as complication of AOM
Most heal in 3 weeks, if not within 3 months then ORL referral
Can cause long term hearing loss and choleastoma
Describe mastoiditis as complication of AOM
Fevers, post-auricular erythema, tenderness, ear proptosis and other AOM findings- emergency due to infection spread
Facial nerve paresis as complication of AOM
Children secondary to bacterial toxins or cytokines on CNVII in the mastoid cavity
NB other causes can be herpes zoster oticus (Ramsay Hunt Syndrome), skull base fracture, parotid tmoursm cholesteatoma and meningioma
Describe labyrinthitis as complication of AOM
Sudden sensorineural hearing loss, vertigo and nystagmus with nausea and vomiting
In AOM this is secondary to bacteria invading the round window and can cause meningitis
What intracranial complications can occur as complication of AOM
Meningitis
Abscess- epi/subdural, cerebral
Sigmoid sinus thrombophlebitis
Define AOM plus effusion (glue ear)
Inflammation of the middle ear with presence of effusion
Causes of glue ear
Eustachian tube dysfunction either secondary to pressure dysfunction (causing ‘ve pressure in the middle ear, transudative secretion and chronic inflammation) OR AOM reflux induced mucin transudate
Dysfunction is worsened by parental smoking, lack of breast feeding, adenoid hypertrophy and daycare attendance
Symptoms of glue ear
Often asymptomatic
Hearing loss
Trouble sleeping secondary to pressure
Signs of glue ear
Dull grey/yellow immobile TM on otoscopy Abnormal tympanometry (TM motility test) Conductive hearing loss on audiometry NB flexible nasoendoscopy should be performed in adults to rule out nasopharyngeal tumour
Management of glue ear
Varies depending on pt risk
High risk of speech language or learning deficiency in children- ENT referral, ?grommets or adenoidectomy
Low risk- watchful waiting
Complications of glue ear
Conductive hearing loss and developmental impact
Speech delay
Atelectasis/retractive TM secondary to negative pressure in middle ear, potentially leading to ossicular erosion, hearing loss and cholesteatoma
Cholesteatoma- retracted tympanic membrane leading to disruption of squamous epithelial movement
Cholesteatoma definition
Destructive lesion of the skull base and middle ear formed by trapped squamous epithelium
Causes of cholesteatoma
Secondary to TM retraction
Squamous epithelium migration during surgery such as grommets
Congenital
Pathogenesis of cholesteatoma
Trapped epithelium forms a sac with keratin debris, which grows and migrates
This causes osteoclast activation, eustachian tube dysfunction and oedema, leading to a bacterial medium
Symptoms of cholesteatoma
Persistent/recurrent purulent discharge Painless discharge is the hallmark Hearing loss tinitus Vertigo Ataxia Facial nerve paresis
Signs of cholesteatoma + ix
No response to otitis externa treatment
Retraction on otoscopy
Copious discharge on otoscopy
Investigate with audiometry, CT and MRI if other structures involved such as factial nerve, cranium, labyrinth
Management of cholesteatoma
Mastoidectomy, extent depending on location
Microscopic debris removal from external canal
Keep ears dry
Topical ABX
Complications of cholesteatoma
Bone and ossicular chain erosion
Sensorineural hearing loss and dizziness
Facial nerve injury
Infection- mastoiditis, meningitis, intracranial abscess, sigmoid sinus thrombosis
Conductive causes of hearing loss
Cerumen impaction Middle ear effusion and glue ear TM perforation Chronic suppurative otitis media Cholesteatoma Otosclerosis
Sensorineural causes of hearing loss
Syndromic or non syndromic conditions LBW/sepsis Infections pre or post natal Trauma Ototoxic drugs like aminoglycosides Presbycusis/age related Neoplasms- accoustic neuroma/cerebellopontine angle tumours
History to know about hearing loss
Duration, nature, progression and side(s) of hearing loss
Presence or absence of tinnitus, vertigo, imbalance, otorrhea, headache, facial nerve dysfunction
Previous head trauma, ototoxic drugs, noise exposure and family history
Exam for hearing loss
Otoscopy
Nose, nasopharynx and oral exam with nasoendoscopy if needed
CN exam- V, VII and VIII plus weber and rinne tests
Ix for hearing loss
Audiometry
Imaging- CT if cholesteatoma, MRI if asymmetric SNHL
Management of hearing loss
Environmental: Reduce background noise and ensure good lighting on speakers face
Amplification- hearing aids, bone anchored hearing aids
Cochlear implant
Define presbycusis
Otherwise unexplained SNHL in the elderly
Causes of presbycusis
Multifactorial
- Genetic
- Noise trauma
- Diet and ototoxic drugs
- Age related changes- decreased auditory cells, increased processing time, reduced hair/supporting cells, CNVIII fibre loss
Sx of presbycusis
Progressive hearing loss Worse with ambient noise Often high noise jobs or FHx involved Exam to exclude other DDx Audiometry is diagnostic but consider other tests if unsure
Management of presbycusis
Hearing aids
Assisting devices- amplifiers, TV headsets
Cochlear implants only for profound loss
Definition of vertigo
Perception of movement in the absence of movement
Overall cause of vertigo
Asymmetry in baseline vestibular centre input, causing vertigo, nystagmus and vomiting
Central causes of vertigo
Ischaemic- TIA, stroke, vertebrobasilar insufficiency, migraine
Neoplastic- accoustic neuroma assoc with unilateral progressive hearing loss
MS
Peripheral causes of vertigo
BPPV Meniere disease Vestibular neuronitis Labyrinthitis Others including otitis media and sinusitis
History things to know for vertigo
How long episodes last
Sudden or gradual onset
Assoc with movements or postures
Tinnitus, hearing loss, otalgia, aural fullness, otorrhea
Preceding URTI
Smoking, medication, herbal remidies
Systems review for gait, head trauma, pmhx and other ENT issues
Exam for vertigo
Vital signs- lying standing BP
full ENT exam- esp for infection and hearing loss
Dix hallpike manoeuvre, romberg’s head thrust and caloric testic
Ix for vertigo
MRI with asymmetric hearing loss (suspect accoustic neuroma)
Baseline bloods- FBC, u and es, glucose
Definition of BPPV
Vertigo elicited by certain head positions, which trigger nystagmus
Causes of BPPV
Canalithiasis- otoliths become detached from saccule/utricle and float freely, exerting force on the cupula mechanism (think pebbles in a tyre)
Cupulolithiasis- otolith deposits on the cupulae themselves, causing them to be more sensitive to gravity in certain positions (think top heavy pole hard to hold straight)
Sx of BPPV
sudden, severe 30s vertigo
Assoc with head movement and position changes
Assoc with nausea and vomiting
Exam for BPPV
Dix hallpike is diagnosis- shows nystagmus
Otherwise normal exam
Management of BPPV
Canalith repositioning with modified epley manoeuver
Vestibulosuppressants if symptomatic relief needed- promethazine, benzos, scopolamine
Surgery if intractable
Definition of meniere disease
An inner ear disorder causing syndromic features including vertigo
Causes of meniere disease- overall unknown, but thought to be due to infections/immune responses/allergies
Sx of meniere disease
Occurs as attacks lasting hours Unilateral fluctuating SNHL Vertigo for minutes to hours Constant or intermittent tinnitus Aural fullness Assoc with nausea and vomiting Lethargy a few days post
Ix for meniere disease
Clinical diagnosis
Audiometry confirms SNH
Rule out syphilis and do MRI for neoplasm
Management of meniere disease- acute
Vestibular suppressants- promethazine, benzos, scopolamine
Betahistine
Management of meniere disease- long term
Salt restriction Thiazide diuretic Betahistine Aminoglycoside injection to middle ear Surgery if severe and intractable
Definition of vestibular neuronitis
A sustained, acute dysfunction of the peripheral vestibular system
Causes of vestibular neuronitis
Reactivation of HSV in vestibular ganglion/nerve (most likely)
Other viruses
Sx of vestibular neuronitis
Vertigo, N and V
No hearing loss
Lasts days and is debilitating
- If SNHL is present, suggests labyrinthitis- ABX and admit
Signs of vestibular neuronitis
Normal hearing and neuro exam
Nystagmus with slow phase towards affected ear
Management of vestibular neuronitis
Vestibular suppressants- promethazinem benzos and scopolamine
3 weeks of corticosteroids (reduces risk of long term vestibular functional loss)
