ENT Flashcards
Vertigo differentials and investigations
BPPV Meniere's Vestibular neuronitis Labyrinthitis Acoustic neuroma Stroke - PICA - Lateral medullary syndrome
Investigations
- Audiometry
- CN exam
- CT/MRI
- HiNTS exam
HiNTS exam
Patients presenting with…
- Persistent vertigo over hours/days
- Nystagmus
- Normal neuro exam
Head impulse test - Ipsilateral vestibulocochlear nerve pathology
- Positive - Eyes move with head before returning to point of fixation
- Must be performed when patient symptomatic
Nystagmus
- Unidirectional - Peripheral
- Bidirectional or vertical - Central - E.g. stroke
Test of skew
- Cover the patients eye
- Quickly swap to cover the other eye
- Positive - Abnormal movement or diplopia - Suggests central cause
BPPV aetiology / presentation / red flags
Loose otoliths
Post-infection or head trauma
More common in older women
Presentation
- Vertigo - 10-20 seconds, occurs with head movement
- No hearing loss
- N/V
Red flags
- Headache
- Pain
- Deafness
- Tinnitus
BPPV investigations and management
Investigations - Dix-Hallpike manoeuvre
- Turn head 45 degrees then lay down
- Positive = Dizziness / Nystagmus
Otoscopy - Infection?
CN exam
Management - Epley’s manoeuvre
- Betahistine
- Advised not to drive
Meniere’s aetiology and presentation
Increased pressure and dilatation of endolymphatic system
- Idiopathic
- Trauma
- Infection
Presentation
- Vertigo
- “Fullness” in the ear
- Tinnitus
- SN deafness - Low frequency sounds
Meniere’s investigations and management
Romberg’s +ve - Unable to maintain balance with eyes closed
CN exam - SN deafness
Audiometry - Loss of low frequency sounds
CT - SOL?
Management
- Acute - IM Prochlorperazine / Admision
- Low salt diet
- Diuretics - Hydrochlorothiazide
- Antihistamine - Betahistine
- Meniett device
- Advised not to drive
- Surgery - Drain endolymph sac
Vestibular neuronitis
Post-infection - HSV
Vertigo - Non-positional - Hours-days
No hearing loss
Horizontal nystagmus
N/V
Investigations
- HiNTS
- Gait - Fall to side of lesion
Management
- Vestibular rehabilitation exercises
- Acute - IM Prochlorperazine
- PO Prochlorperazine / Cyclizine
Labyrinthitis
Inflammation of membranous labyrinth
Vestibular and cochlear organs affected
Usually viral - Post-infectious - URTI
Clinical features
- Vertigo - Not triggered by movement
- SN deafness
- Nystagmus- Unidirectional
- Tinnitus
- N/V
Investigations
- HiNTS
- Gait - Falls to side of lesion
Management
- Prochlorperazine
- Prednisolone
Vestibular neuronitis vs Labyrinthitis
VN only affects vestibular nerve - Vertigo WITHOUT hearing loss
Labyrinthitis affects vestibular nerve and labyrinth - Vertigo WITH hearing loss
Acoustic neuroma
Associated with NF2 - Bilateral
CN5 - Absent corneal reflex
CN7 - Facial palsy
CN8 - Vertigo, SN deafness, tinnitus
Nystagmus - Bidirectional
Investigations
- HiNTS
- MRI cerebellopontine angle - 2ww referral
Management - Surgery + Chemo/Radio
Conductive deafness aetiology
Occlusive - Wax / Foreign body Infection - OM / Sinusitis Perforation - Trauma / Surgery Cholesteatoma Otosclerosis Growth - Fibroma
SN deafness aetiology
Noise
Trauma
MS
Meningitis
Mumps
VZV - Ramsay Hunt syndrome - CN7/8
HIV
Labyrinthitis
Meniere’s
Acoustic neuroma
Animoglycosides - Gent
Thiazides
Quinines
Rinne’s and Weber’s
Rinne’s
- Place tuning fork at external ear canal
- Then place on mastoid process
- Conductive hearing loss is louder by bone
- Positive = Normal = Louder in air
Weber’s
- Place tuning fork in middle of forehead
- SN deafness - Sound localised to unaffected side
- Conductive deafness - Sound localised to affected side
Facial pain differentials
GCA
Trigeminal neuralgia
Cluster headache
Cellulitis
Shingles
Mastoiditis
Sinusitis
OE/OM
Mumps
Dental abscess
Parotid swelling differentials
Parotid cancer - Pleomorphic adenoma - Warthrin tumour
Frey’s syndrome post-surgery
- Sweating
- Erythema - Post-prandial
Stones
- Colicky pain - Post-prandial
- Investigation - Sialography
Sarcoidosis
Sjogren’s
Mumps
HIV
Submandibular swelling differentials
Stones
Cancer
Cervical lymphadenopathy - Including EBV
Nasal blood supply
Anterior and posterior ethmoidal - Branch of internal carotid
Sphenoidal artery - Branch of maxillary - From internal carotid
Keisselbach’s plexus / Little’s area - Most common area for epistaxis
Epistaxis
Usually Keisselbach’s plexus
Aetiology - Trauma and nose picking
- Blood disorders
- Anticoagulants
- Hereditary telangiectasia
- Wegener’s
- Malignancy
- Cocaine
Management - ABCDE
- Holding - Pinch anterior nose and lean forwards - Sit upright
- Topical antiseptic - Naseptin
- Packing
- If still bleeding after 15 minutes
- Silver nitrate
- Electrocautery
- Treat cause
Nasal polyps
Lesions from the mucosa - Middle meatus
Aetiology - AACCCChu - That’s a sneeze
- Asthma
- Aspirin
- CF
- Churg Strauss
- Cancer
- Chronic sinusitis
Samter’s triad
- Asthma
- Aspirin sensitivity
- Nasal polyposis
Presentation
- Bilateral
- Obstruction / Apnoea
- Hyposmia
- Rhinorrhoea
- Unilateral - Suggests malignancy - 2ww referral
Investigations - 2ww referral - Rhinoscopy
Management - Topical steroids
Nasal trauma
Red flags - BOPSS on the nose
- Basal skull fracture - CSF rhinorrhoea, Battle’s sign, raccoon eyes
- Signs of facial fracture
- Prolonged / profuse epistaxis
- Septal haematoma - Boggy on probing
- Ophthalmoplegia - Orbital blow out fracture
Investigations - Imaging - XR/CT
Management - Re-alignment surgery
Complications
- Septal haematoma
- Needs surgical drain and abx
- Risk of AVN / abscess formation
OSA aetiology and clinical features
Intermittent and transient upper airway collapse
Aetiology
- Family history
- Obesity
- Smoking / alcohol
- Macroglossia - Acromegaly, hypothyroid, amyloidosis
- Large tonsils
- Sedatives
Clinical features
- Daytime sleepiness
- Collateral history - Snoring and periods of apnoea
OSA investigations and management
Polysomnography - Sleep studies
Epworth sleepiness score
FBC - Secondary polycythaemia
Management
- Lose weight
- CPAP
- Intra-oral device
- Tonsillectomy if large tonsils
- Inform DVLA
Otitis externa aetiology and clinical features
Increased risk with DM
Seborrhoeic dermatitis
Contact dermatitis
Infection
- Staph A
- Pseudomonas - diabetics
- Fungal - Aspergillus
Clinical features
- Ear pain - Pain on moving the tragus
- Discharge
- Pre-auricular lymphadenopathy
Otitis externa investigations / management / complications
Investigations - Otoscopy
- Red
- Oedematous
- Pre-auricular lymphadenopathy
Management
- Abx/steroid drops - Cipro / Dex
- Oral abx - Cipro
- ENT referral if not responding
Complications - Malignant necrotising OE
- Presents with deterioration / Not responding to abx
- Urgent ENT referral + IV abx
- Can cause CN7/8 palsy + Osteomyelitis
OM aetiology
May be preceded by viral URTI - Rhinovirus / RSV
Nasopharyngeal microbiome is disturbed
Bacteria infect middle ear via eustachian tube
- Strep P
- H. Influenzae
- Moraxella Catarhalis
Risk factors
- Winter
- Immunocompromise
- Sinusitis
- 6-12 months - ET shorter and more horizontal
OM clinical features and investigations
Pain - Children may pull at ear
Conductive hearing loss
Fever
Discharge - Perforated TM
Investigations - Otoscopy - Bulging TM - Loss of light reflex - TM opacification and erythema - Possible TM perforation - Purulent discharge \+ Swab for MC&S \+ CT - Exclude mastoiditis
OM criteria / management
- Acute onset of symptoms
- Presence of middle ear infection
- Inflammation of tympanic membrane - Erythema
Management - Amoxicillin - Criteria…
- Symptoms > 4 days
- Age < 2 + Bilateral
- Perforation / Discharge
OM complications
Chronic suppurative OM
- Chronic infection + Inflammation + Ruptured TM + Cholesteatoma
= Perforation + Conductive deafness
OME - Glue ear
- Fluid in middle ear
- Conductive deafness
- Management - Supportive + Grommets
CN7 palsy
Perforation
Local spread - Mastoiditis / Meningitis
Cholesteatoma
Non-cancerous growth of squamous epithelium
Causes local destruction
Aetiology - Chronic ear infections
- Risk x 100 with cleft palate
Clinical features
- Foul smelling discharge - Non-resolving
- Conductive hearing loss
- Vertigo
- Facial nerve palsy
- Cerebellopontine angle syndrome
Investigations - Otoscopy
- Attic crust
- Perforation of pars flaccida
Management - Surgical removal
Tonsillitis
Bacterial - Strep
Viral - Rhinovirus
Diagnosis - FeverPAIN score
- Fever
- Pus on tonsils
- Attend rapidly < 3 days from onset of symptoms
- Inflamed tonsils
- No cough
1 - No abx
2-3 - Consider back-up abx prescription
4-5 - Prescribe abx
Management
- Penicillin V - CI if suspected EBV
- Gargle saltwater
- Increase fluid intake
Tonsillectomy referral criteria
Tonsillitis complications
> 5 episodes in 1 year
Recurrent febrile convulsions
Obstruction - OSA, stridor, dysphagia, etc.
Peritonsillar abscess
Complications
- OM
- Quinsy - Peritonsillar abscess
- Rheumatic fever / Glomerulonephritis
Quinsy
Jugulodigastric lymph node
Severe throat pain "Hot potato" voice Drooling Dysphagia Uvula deviation Trismus - Difficulty opening mouth Reduced neck mobility
Management - Urgent ENT referral
- Needle aspiration / I&D
- IV abx
- Consider tonsillectomy
Pharyngitis aetiology / clinical features / DDx
Bacterial - Strep
Viral - CRAPI
- Coronavirus
- Rhinovirus
- Adenovirus
- Parainfluenza
- Influenza
Clinical features
- Sore throat
- Fever
- URTI symptoms
DDx
- Epiglottitis - Tripod sign, muffled voice, drooling
- Scarlet fever - Strawberry tongue, rash
Pharyngitis investigations / management / complications
If prolonged…
- Throat swab MC&S
- ASO titre
- Monospot for EBV
Management - Penicillin V
Complications
- Bacterial - Strep
- Rheumatic fever
- PSGN
- Scarlet fever - Local sprea
- Mastoiditis
- Sinusitis
- OM
Mastoiditis aetiology and clinical features
Local spread from OM
Strep pneumonia
Strep pyogenes
Clinical features
- Ear protrudes anteriorly
- Boggy mastoid process
- Facial pain - Behind the ear
- Fever
- CN palsy - 6/7/8
Mastoiditis investigations / management / complications
CT
Blood cultures
Tympanoscentesis
Management
- IV Cef
- Analgesia
- Mastoidectomy
Complications
- Meningitis
- Osteomyelitis
- CN palsy
Sinusitis aetiology
Inflammation of mucosal lining of sinuses
- Frontal
- Maxillary
- Ethmoidal
- Sphenoid
Strep pneumonia
H. Influenza
Rhinovirus
Nasal obstruction - Septal deviation / polyps
Recent local infection - Rhinitis / dental extraction
Swimming / Diving
Smoking
Sinusitis clinical features / investigations / management / complications
Facial pain - Worse bending forward Nasal discharge - Thick and purulent Nasal obstruction Headache Fever
Investigations
- Nasal swab MC&S
- CT if severe
Management
- Analgesia
- Intranasal decongestants / Saline
- Intranasal CS - If symptoms > 10 days - Mometasone
- Oral abx - Penicillin V
Complications
- OM
- Meningitis
- Osteomyelitis
Laryngitis aetiology
Acute - Infection
Bacterial - Strep + HiB
Viral - CRAPI
- Coronavirus
- Rhinovirus
- Adenovirus
- Parainfluenza
- Influenza
Chronic
- Asthma / allergies
- Trauma
- Reflux
- SLE / RA
Laryngitis clinical features / investigations / management
Hoarse voice
Dysphagia / Globus
Pain - Anterior neck
Investigations - Laryngoscopy if chronic
Management
- Humidification - Steam inhalation
- Stop smoking
- Voice rest
Neck lump differentials
Thyroid - Goiter
Thyroglossal cyst - Midline, moves with tongue
Pharyngeal pouch - Dysphagia, regurg, halitosis
Cancer - Pharyngeal
Lymphoma - Rubbery, painless
Abscess -
Lipoma - Smooth, mobile, painless
Cervical lymphadenopathy
- EBV
- Infection - Tonsillitis
- HIV
Weird and wonderful…
- Cyst hygroma - LEFT, congenital
- Branchial cyst - Oval, SCM to pharynx
- Cervical rib - Adult females
Oropharyngeal cancer aetiology and clinical features
Alcohol
HPV
Smoking
Hot drinks
Clinical features
- Neck lump
- Hoarseness
- Persistent sore throat
- Persistent mouth ulcer
Oropharyngeal cancer investigations
2ww referral criteria…
Laryngeal cancer - Aged > 45
+ Persistent unexplained hoarseness
+ Unexplained neck lump
Oral cancer
- Unexplained ulceration > 3 weeks
- Persistent unexplained neck lump
- Lip or oral lump
- Red/white patch in oral cavity
Thyroid cancer - Unexplained thyroid lump
Investigations
- Examination under anaesthetic
- Biopsy + HPV testing
- CT/MRI
Management - Surgery + Chemo/Radio
