ENT Flashcards
26-M urgent appointment in your duty clinic. 2/52 left sided facial pain and malaise. Symptoms initially were improving after 7/7 however they then worsened again and he is now feeling worse than he did initially. He is normally fit and well.
Low grade pyrexia of 37.9 degrees but other obs N. Anterior rhinoscopy shows a purulent discharge coming from the left middle meatus. dx?
bacterial sinositis
‘double sickness’ - secondary bacterial infection
unilateral swelling of one of the salivary glands =
sialadenitis
common bacterial causes sinositis adults?
Streptococcus pneumoniae, Haemophilus influenzae
facial pain - worse on bending forwards?
sinusitis (acute)
mx sinusitis?
analgesia
IN corticosteroids if sx> 10 days
PO abx if severe presentation (Pen V)
44M. perforated left eardrum. mx?
watch and wait
ENT referral if not healed after 6/52
BPPV ix, mx?
Dix-Hallpike manoeuvre is diagnostic
Epley manoeuvre is for treatment
sudden onset of dizziness and vertigo triggered by changes in head position. dx?
bppv
sudden-onset sensorineural hearing loss causes?
idiopathic commonest 85%
acoustic neuroma or other brain mass
trauma, blasts and loud noise, barotrauma, meningitis, herpes zoster, syphilis, immunological disease, AIDS, MS, Meniere’s disease, Lyme disease and stroke.
which ix would exclude a vestibular schwannoma.?
MRI
mx suden onset sensorineural hearing loss?
urgent ENT referral
corticosteroids PO high doses
what in high doses can cause tinnitus?
nsaids or aspirin
also loop diuretics and aminoglycosides.
Associated with hearing loss, vertigo, tinnitus and sensation of fullness or pressure in one or both ears
dx?
meniere’s disease
also have nystagmus sometimes
audiogram rules:
> 20 = normal
in sensorineural hearing loss both air and bone conduction are impaired
in conductive hearing loss only air conduction is impaired
mixed - both but air worse than bone
what symptom distinguishes vestibular neuronitis from labyrinthitis?
normal hearing in vestibular neuronitis
Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2
dx?
acoustic neuroma
unilateral sensorineural hearing loss
3-M. 2/52 left-sided otalgia associated with a purulent discharge. You prescribed amoxicillin and arranged to see him today. Much better and says she has managed to keep the ear dry. Left side a perforation of the tympanic membrane is noted. What is the most appropriate action?
keep ear dry
review again in 4/52
-no indication to continue abx if ear dry
what may be used to decide whether to give antibiotics in the context of sore throat ?
centor or feverpain
centor criteria and what score indicates abx?
Tonsillar exudate Tender anterior lymphadenopathy or lymphadenitis History of fever Absence of cough 3+ = pen V
non-ent related causes of vertigo?
posterior circulation stroke
trauma
multiple sclerosis
ototoxicity e.g. gentamicin, quinine
sudden onset horizontal nystagmus, hearing disturbances, nausea, vomiting and vertigo
acute viral labyrinthitis
42M 2 week history of a worsening sore throat, is complaining of painful swallowing. On examination you notice that he has difficulty opening his jaw, purulent tonsils and his uvula is deviated to the right. Given the likely diagnosis, how should this condition be managed?
quinsy (peritonsilar abscess)
iv abx and surgical drainage
consider tonsillectomy in 6/52
Rinne’s test negative means?
bone conduction > air conduction and thus there is a conductive hearing loss in that ear ABNORMAL finding (even tho says negative)
Weber’s test can lateralise to the right….?
right ear has a conductive hearing loss, or the left ear has a sensorineural hearing loss
17-F One week previously she had an elective tonsillectomy for recurrent tonsillitis. She initially made a good recovery however last night had a sudden bleed from her left tonsillectomy site. Spontaneously resolved after five minutes. Well, normal obs. She has normal post-operative appearances of her oropharynx with a small blood clot visible adhered to her left tonsillar bed. mx?
same day ENT assessment
all post-tonsillectomy haemorrhages need referral
62-M 2 days after receiving a punch to his head on the right side. Since the injury, hearing muffled on the right side. No bruising. Both his ears are obscured by a thin translucent layer of wax. On the right, Rinne’s test demonstrates the tuning fork is easier to hear when pressed on the mastoid bone. On Weber’s test the sound is heard best on the right hand side.dx?
perforated eardrum
leading to sensorineural hearing loss on right
37-M otalgia. Seen in ED 2/7 previously but was discharged with advice only. He has now had otalgia for 5 days. Temp 38.5ºC, and red bulging ear drum on the right. How should you manage this gentleman?
otitis media amoxicillin treatment after a delay of 2-3 days if there is no improvement in symptoms. erythro if pen allergic coamox 2nd line
acute otitis media commonly viral (50%), which bacteria can cause?
Streptococcus pneumonaie, Haemophilus influenzae and Moraxella catarrhalis
33-M-> GP 4/12 hx persistent nasal discharge on his left hand side and facial pressure which is worse on bending forward. He often finds he has to breath through his mouth due to his nose being blocked. PMH asthma and is a smoker with a 5 pack-year history.
What is the most appropriate management?
ent referral
unilateral chronic sinusitis is a red flag
(along with persistence >3/12 and epistaxis)
An unexplained persistent sore throat with hoarseness. mx?
2ww referral for oral ca
laryngeal nerve - either laryngeal ca or lung ca
56-M reduced hearing and mild discomfort in his left ear for two weeks which he attributes to an ear infection, and he is asking for antibiotics. hearing a bit muffled, and he hears clicking and popping at times, especially when swallowing. He says he hasn’t had a cold recently. He is a current smoker. Right tympanic membrane appears normal, left tympanic membrane looks dull and retracted. The oral cavity looks normal and there are no enlarged cervical lymph nodes. mx:
2ww ent for ca
unilateral middle ear effusion could be nasopharngeal cancer
5-m -> GP 5/7 hx right-sided otalgia and reduced hearing. temp 38.5ºC hr 120 bpm. There is swelling around his right ear and the ear appears to be displaced anteriorly. The canal appears normal however the tympanic membrane is red and bulging. mx?
referral to ENT - sx of mastoiditis
25F slowly enlarging mass on the side of the face. Clinical examination demonstrates that the mass is located in the tail of the parotid gland. There is no evidence of facial nerve involvement. What is the most likely cause?
pleomorphic adenoma
benign
typically found in elderly males and are composed of multiple cysts and solid components consisting of lymphoid tissue. ???
warthins tumours
- most often found in the tail of the parotid gland
If a perforated tympanic membrane does not heal by itself after 6/12 - mx?
myringoplasty
42M->GP 6/52 after developing a cold. Whilst all of his other symptoms have now resolved, the patient is experiencing persistent blockage of his left nostril associated with rhinorrhoea and sneezing. Large polyp is seen in the left nostril. Examination of the right nostril is unremarkable. Next step in management?
urgent ENT referral -
unilateral polyp is red flag sx
bilateral polyp mx?
routine ENT referral
topical corticosteroids
asthma, aspirin sensitivity and nasal polyps triad =
samter’s triad
2M parents are concerned after he develops a lump in his neck. On examination there is a swelling in the subcutaneous tissue of the posterior triangle which transilluminates. dx?
cystic hygroma
congenital lymphatic lesion
40F presents with a painless neck lump. There is a mass noted beneath the sternocleidomastoid muscle. There is a long history and somewhat unkindly her husband remarked on her rather noticeable halitosis. dx?
pharyngeal pouch
32F referred to the clinic with recurrent infections and abscesses in the neck. Midline defect with an overlying scab, which moves upwards on tongue protrusion. dx?
thyroglossal cyst
Tonsilar SCC is associated with >
HPV 16
oral sex
25-M->ED: injury in a rugby game, went to ground, another player’s boot impacted his left ear. No LOC and only had some ear pain immediately after. In the ensuing minutes the pain worsened and he noticed a persistent ringing. When he felt his ear it was tender and swollen, with other players telling him it looked very red and puffy. No neurological deficit or pain other than in his left ear. The ear is ecchymotic and swollen with loss of normal anatomy to the anterosuperior pinna. Next step?
urgent ENT referral
same day assessment needed with auricular haematoma
A 42-year-old man with a 3 month history of chronic cough presents with a persistent headache dx?
sinusitis
- chronic - cough 2nd to post nasal drip
64F 7/7 hx pain above and lateral to her left eye. Tender over that area. dx?
temporal arteritis
62F 2/52 hx shooting pains across her left cheek. The pain is sometimes triggered by touching her face. She has no past medical history note. dx?
trigeminal neuralgia
presbycusis =
age related hearing loss (sensorineural at higher frequencies)
bilateral high-frequency hearing loss. AC>BC?
presbycusis
19M swelling on the left side of his neck. Smooth swelling in between the sternocleidomastoid muscle and the pharynx. It is fluctuant but doesn’t transilluminate or move during swallowing. dx?
branchial cyst
usually present during urti
(congen)
28F Bangladeshi woman presents with a three day history of sweats, headache, lethargy and muscle aches. On examination she has bilateral tender swellings in the submandibular region. dx?
reactive lymph nodes
67M->GP ‘dizziness’. PMH: HTN, cholesterolaemia and hayfever. 40 pack-year history. Sudden onset of a sensation at 9am this morning - ‘like the room is spinning’ - accompanied by nausea but no vomiting. The dizziness has persisted and is constant. He looks well, blood pressure 170/120 mmHg, with other obs nad. Normal power, tone, sensation and reflexes throughout both upper and lower limbs bilaterally. There is notable nystagmus on cranial nerve testing. There is also mild past pointing and dysdiadochokinesis. What is the most appropriate action?
urgent hospital referral
possible posterior stroke
vascular history
tragus tender in?
otitis externa
tx topical abx (cipro/gent) and steroid
pseudomonas
staph aureus
cause which ear condition?
otitis externa (pseudomona particular problem in T2DM)
tx otitis media?
regular analgesia
OM + pinna displaced forward and down - tx?
IV abx - mastoiditis
what will dix-hallpike manouvre show in BPPV?
rotary nystagmus
why don’t give amoxicillin in EBV -> tonsilitis?
causes maculopapular rash
malignant otitis externa cx?
Osteomyelitis of temporal / mandibular bone
risk for malignant OE ?
T2DM
immunocompromised
meniere’s mx:
acute: prochlorperazine
prevent: Betahistines
43F total thyroidectomy for multinodular goitre. You are called to see her because of respiratory distress. On examination she has a marked stridor, her wound seems healthy but there is a swelling within the operative site. Explanation for this problem? mx?
contained haematoma
removal of sutures and call snr help
which under 2s get abx for OM?
bilateral
child 5 - OM - what constitutes giving abx?
purulent discharge indicating perforation
sx for over 4 days
review in 2 weeks
people with sensitivity to which drug can get nasal polyps?
aspirin
Haemorrhage 5-10 days after tonsillectomy is commonly associated with ?
wound infection - admit for IV abx
Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following tonsillectomy. It is managed by?
immediate return to theatre
how long duration of mouth ulcer before 2ww referral to oral surgery?
3 weeks
21M halitosis and mouth pain. Examination reveals very poor dental hygiene with bleeding gums and widespread gingival ulceration. He has a temperature of 38.0ºC. You advise him to see a dentist. What other treatment options should be offered?
paracetamol+oral metronidazole+chlorhexadine mouthwash
acute necrotizing ulcerative gingivitis
26F IVDU 2/7 hx dysphagia. General malaise and fatigue 2 days prior. Pyrexial with extensive swelling of her submental and submandibular lymph nodes. There is pharyngeal oedema and extensive erythema on the floor of her mouth, however, no exudation can be seen on the tonsils and there are no abscesses near the tonsils . Poor dentition. No splenomegaly. Admitted. Develops stridor and difficulty breathing. Monospot test negative bloods: neutrophilia. Dx?
ludwig’s angina
cellulitis of floor of mouth
->ENT emergency
23F 1/52 after being prescribed a combined antibiotic and steroid spray for otitis externa. No improvement in her symptoms and the erythema seems to have extended to the ear itself. appropriate treatment?
oral fluclox
if haven’t responded to topical abx refer to ent
contraindication to receiving a cochlear implant?
chronic infective OM - risk TM rupture, meningitis
cochlear aplasia
Lesions of cranial nerve VIII or in the brain stem causing deafness
most suitable management option for epistaxis where the bleed site is difficult to localise?
anterior packing
23F three week history of bilateral nasal obstruction, cough at night and a clear nasal discharge. She had similar symptoms around this time last year. PMH: asthma. Dx?
allergic rhinitis
34M GP complaining of nasal congestion, a post-nasal drip and sneezing. He has been using nasal decongestants for 1 month, and after initially improving noted his symptoms returned.
advice?
stop nasal decongestants - Rhinitis medicamentosa is a condition of rebound
also can lead to tachyphylaxis - increasing doses -> same effect
Branchial cysts characteristically contain?
cholesterol crystals
59M severe pain deep within his right ear. He feels dizzy and reports that the room ‘is spinning’. Partial facial nerve palsy on the right side and vesicular lesions on the anterior two-thirds of his tongue. Dx?
ramsay hunt syndrome
also vesicular rash on otoscopy
27M GP with intense left-sided ear pain which he has had for 24 hours. Left ear is protruding forward, with a tender, boggy mass behind the ear. The tympanic membrane is bulging and erythematous. He is tachycardic and his temperature is 37.9 ºC.
dx and key cx?
mastoiditis
meningitis
15M recurrent discharge from his right ear. Hearing is worse on that side. PMH: glue ear treated with grommets but his symptoms settled by the age of 6 years, thinks the grommets fell out by themselves. dx?
cholesteatoma
what is an autosomal dominant cause of deafness affecting young adults?
otosclerosis
slowly progressive bilateral conductive hearing loss in a young patient with a positive family history??
otosclerosis
replacement of normal bone by vascular spongy bone
8M enlarged tonsils that meet in the midline and are covered with a white film that bleeds when you attempt to remove it. He is pyrexial but otherwise well. dx?
acute bacterial tonsilitis
10M enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice peticheal haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly. dx?
infectious mononucleosis
19M sore throat for the past 5 days. Over the past 24 hours he has noticed increasing and severe throbbing pain in the region of his right tonsil. He is pyrexial and on examination is noted to have a swelling around the right tonsillar region. dx?
quinsy
62-F 4/12 hx painless, malodorous discharge from the left ear. 1/12 previously prescribed gentamicin/hydrocortisone drops, did not improve her symptoms. Wax in the attic of the left ear. dx, tx?
cholesteatoma likely
refer to ENT o/p
55M from Hong Kong left sided otalgia and recurrent episodes of epistaxis. His pharynx appears normal. Left sided cervical lymphadenopathy. What is the most likely underlying diagnosis?
nasopharyngeal carcinoma
which med has sfx of tinitus?
quinine
loop diuretics
aspirin/nsaids
aminoglycosides
vestibular neuronitis mx?
short oral course prochlorperazine acute
chronic - vestibular rehabilitation exercises
chronic rhinosinusitis - mx?
IN Corticosteroids but only up to 3/12
Nasal irrigation with saline solution
if unilateral -> urgent ENT referral
Treatment of Ramsay Hunt syndrome consists of ?
oral aciclovir and corticosteroids
A 49-year-old Caucasian male presents with a 12 week history of pus-like discharge from his ear. You decide to perform otoscopy. What is the most important part of the tympanic membrane to visualise?
attick - suspected cholesteatoma
56M episodic facial pain and discomfort whilst eating. He has suffered from halitosis recently and he frequently complains of a dry mouth. He has a smooth swelling underneath his right mandible. Dx?
stone impacted in wharton’s duct
sialolithiasis
50F dry mouth that has been present for the past few months. She also has a sensation of grittiness in her eyes. Diffuse swelling of her parotid gland. There is no evidence of facial nerve palsy. dx?
sjogren’s
50F bilateral parotid gland swelling and symptoms of a dry mouth. Bilateral facial nerve palsies. This improved following steroid treatment. dx?
sarcoidosis
An 18-year-old boy presents with pancreatitis. He has bilateral painful parotid enlargement. dx?
viral parotitis (mumps)
Complications of thyroid surgery - damage to parathyroid glands leading to ecg changes??
prolonged QT interval
54F neck swelling. She is systemically well apart from some recent weight loss. On examination she is noted to have a midline, non-tender neck swelling which moves upwards when she swallows. dx?
goitre
Globus, hoarseness and no red flags →
laryngopharyngeal reflux
erythema on endoscopy
Elderly patient dizzy on extending neck -??
vertebrobasilar ischaemia
4yoF 2/7 hx right ear pain. She is systemically well with no fevers and a normal fluid intake. Her mum has been using paracetamol when needed for pain relief. Left TM normal but her right tympanic membrane is erythematous, inflamed and bulging. t 36.5ºC. she is allergic to penicillin. mx?
supportive mx with ibuprofen and paracetamol
effusion needed for dx of OM
Persistent unexplained hoarseness in a patient aged >45 years old??
ENT urgent referral + CXR!!
9M falling off his skateboard two hours ago. Fell forward, breaking his fall with his right arm. His nose is erythematous with some abrasions. Nostrils: bilateral red swelling arising from the midline, which is slightly boggy. No other signs of a head injury are seen. mx?
ent referral urgent
nasal septal haematoma -> necrosis if untreated - saddle nose
A 61-year-old woman with a history of cardiac problems develops hearing loss after a prolonged admission in hospital. Drug toxicity is suspected. cause?
furosemide
Gingival hyperplasia: ddx:
phenytoin, ciclosporin, calcium channel blockers and AML
A perforated tympanic membrane caused by barotrauma - mx?
self-limiting - reassure
A 74-year-old man presents with an 8-week history of right sided otalgia. This is associated with a sore throat and odynophagia. He smokes 20 cigarettes every day and is known to be a heavy drinker. On examination of the ear, there are no abnormalities noted. ear pain why??
referred pain form nasopharyngeal ca
A 80-year-old lady presents with a 5 day history painful left sided neck swelling below the angle of the jaw. She also complains of a foul taste in her mouth. On examination, she has a temperature of 37.8ºC and a 4x5cm submandibular mass which is tender to palpation. There is associated tender lymphadenopathy. dx?
sialadenitis
2M concerns about his hearing and delayed speech past three months. You can see from the notes that he has had frequent courses of amoxicillin for otitis media in the past. There is no evidence of excessive ear wax.
dx?
glue ear
70-M geriatrics ward who is on warfarin complains of a nosebleed. He is not known to have any nasal pathology or coryzal symptoms.
What is the most likely anatomical origin of the epistaxis?
little’s area anterior nasal septum
confluence of 4 arteries
A 4-year-old is brought to the general practitioner by her mother. She has been distressed with ear pain for the past 14 hours. She is constantly touching and pulling at her ear. Whilst she is sat in the waiting room her mother notices a discharge of foul smelling fluid from the ear, following which the pain resolves. dx?
acute supporative OM
pain goes cos TM ruptures
A 4-year-old child is brought to the clinic by his father. They are concerned because the child has been noted to have a small epithelial defect anterior to the left ear and is has been noted to discharge foul smelling material for the past 2 days. dx?
preauricular sinus
accumulate secretions and produce foul smelling discharge.
first-line treatment for impacted ear wax?
olive oil drops
then ear syringing
31M ongoing hearing loss, otalgia and tinnitus bilaterally. Wax in the canals and normal tympanic membranes. Weber’s test demonstrates no lateralisation and Rinne’s test is positive bilaterally, yet a coarse hearing test shows hypoacusis bilaterally. PMH: testicular seminoma now in remission, treated with orchidectomy and cisplatin-based chemotherapy. next management step?
ent referral for acoustic hearing aids
if this fails then cochlear implants but need to fail with hearing aids first
due to cisplatin chemo the ototoxicity
A 25-year-old cat lover presents with symptoms of abdominal pain, lethargy and sweats. These have been present for the past two weeks. On examination she has lymphadenopathy in the posterior triangle. dx?
bartonella infection
