ENT Flashcards
Give 3 differentials for a sore throat.
Tonsillitis - viral and bacterial
Quinsy
Infectious mononucleosis (OM)
What are the common causative organisms of tonsillitis?
Viruses most common
Bacteria - Grp A Strep (GAS), esp strep pyogenes
Strep pneumoniae
How is tonsillitis managed? When would you give antibiotics?
Centor criteria: Fever >38 Tonsillar exudates Absence of cough Lymphadenopathy score 3 or more of these = 40-60% probability of bacterial tonsillitis, can give abx. Penicillin V 10 days first line.
What is quinsy? How does it present?
Peritonsillar abscess - bacterial infection, trapped pus.
Usually a complication of untreated tonsillitis. Usually bacterial (Grp A Strep, staph aureus, H. influenzae)
Presentation: similar to tonsillitis, sore throat, painful swallow, fever, neck pain, referred otalgia, lymphadenopathy.
Trismus
Hot potato voice
How is quinsy managed?
Refer to ENT for incision+drainage (I+D) under GA
Abx appropriate eg co-amoxiclav
Give 3 differentials for otalgia.
Otological: -Middle ear - otitis media. Usually viral -External ear - otitis externa Referred (50% of otalgia): dental TMJ dysfunction, malocclusion C spine osteoarthritis Malignancy Acute pharyngitis
How does otitis media present?
Otalgia, hearing loss in affected ear, generally unwell, upper URTI symptoms (cough, coryza, sore throat), discharge if perforated eardrum, bulging red tympanic membrane (TM).
May get vertigo/balance issues.
How would you manage otitis media? When would you give abx?
Usually resolves within 3-7 days without abx, give pcm/ibuprofen for pain/fever
Abx eg amoxicillin 5-7 days, clarithromycin if penicillin-allergic, erythromycin in pregnant penicillin-allergic.
Admit if systemically unwell <3 months old
Safety net for complications - mastoiditis, meningitis, abscess
How would you manage an adult patient with painful, discharging ear, with debris in the ear on examination?
Bacterial otitis externa (swimmers ear) - Usually pseudomonas. Topical abx may be needed. Use Otomize: neomycin (pseudomonas is resistant to many abx) + dexamethasone + acetic acid. EXCLUDE TM PERFORATION before giving neomycin.
Give 3 differentials for facial pain
Sinus: Sinusitis Neuro: Trigeminal neuralgia, herpes zoster, Temporal arteritis Eye: glaucoma Cluster headaches, migraine, MOH Dental abscess Ear: OM, OE Nose: URTI, nasal injury Functional: Atypical Facial Pain (ATFP) TMJ dysfunction
How does acute sinusitis present?
Dull constant aching pain over maxillary sinus, tenderness, postnasal drip, ethmoid/sphenoid pain (midline root on nose), worse on bending, lasts 1-2 weeks (but can be up to 12 weeks), asso coryza.
[Almost a doctor]
How is sinusitis managed?
Usually self-resolves in 2-3 weeks.
Sx <10 days: no treatment
>10 days: 2 weeks high-dose steroid nasal spray
No improvement: consider abx - Penicillin V 5 day course.
What are the most common causative organisms for sinusitis?
Usually viral. Bacterial causes: Group A Strep Strep Pneumoniae H. influenzae Morazella Catarrhalis Staph aureus
What are the complications of sinusitis and what investigations would you do?
CT if suspecting complications eg spread of infection to orbit/intracranial region. Chandler classification: 1 Preseptal cellulitis 2 Orbital cellulitis 3 Subperiosteal cellulitis 4 Orbital Abscess 5 Cavernous sinus thrombosis
What is chronic sinusitis?
Chronic = >12 weeks, >2 symptoms (nasal blockage, obstruction, congestion, discharge, nasal drip), change in sense of smell.
Give 5 differential diagnoses for a neck lump.
Developmental abnormalities: Thyroglossal cysts, branchial cysts
Cervical lymphadenopathy (most common in GP) eg infective (IMN, CMV), malignant (lymphoma, mets)
Thyroid masses eg goitre, nodule
Salivary gland swellings
Haematoma
Sardoidosis
Cancer eg oropharyngeal - ask about RFs eg tobacco, alcohol, odynophagia, otalgia, dyspnoea, wt loss)
What is the likely cause of a midline neck lump which is smooth, painless, and moves on movements of the tongue?
Thyroglossal duct cysts.= benign cyst that forms in midline of neck, base of tongue to sternal notch, embryological remnant.
How would you investigate a neck lump?
Hx - ca risk factors, odynophagia, otalgia, wt loss, exposure to HIV/travel
Examination: lump size, shape, appearance, relation to other tissues eg does it move with swallowing/ tongue protrusion
Flexible nasopharyngology
What causes a neck lump that moves on swallowing but not tongue protrusion?
A thyroid lump (nodule).
How can you differentiate a malignant neck lump from a benign one?
(Cancer til proven otherwise)
Benign: younger age, mobile, present from birth (congenital)/ 2-6 week hx (inflammatory)
Malignant red flags: older age, gradually increasing in size, hard, non-mobile, changed over 3-6 weeks, hoarse voice >3 weeks, new onset dysphagia, unexplained persistent salivary gland swellings, otalgia >4 weeks with normal otoscopy, sore throat, non-healing ulcers, white/red oral lesion.
If any of these, refer 2 week wait.
Give 5 causes of sensorineural hearing loss.
Congenital Presbycusis (age-related) Noise exposure (occupational) Meniere's disease (unilat) Drug toxicity (bilat - furosemide, gentamicin, cisplatin) Acoustic neuroma (acute) Infections eg Meningitis
How would you investigate hearing loss?
Hx - onset, rate, otalgia, otorrhea, tinnitus (pulsatile?), vertigo, nasal, drug hx (furosemide ototoxic), FHx, exposure to noise
Ex: pinna, mastoid, both ears,
External auditory canal: discharge, bony swellings, wax oedema
TM:
Pars tensa: perforations, retraction pockets, ossicles gromets
Pars flaccida: attic retraction pockets, cholesteatoma
Hearing assessment
CN examination (House-Brackmann scale)
Nasendoscopy
Pure tone audiogram (PTA)
Tympanometry
Describe Rinne’s and Weber’s tests and what they show.
Hearing assessment:
512 Hz tuning fork
Weber’s: Middle of forehead, louder on the opposite side to a SNHL or towards the side of a CHL
Rinne’s: Put tuning fork on mastoid, ask patient to tell you when it stops humming, then hover 1cm over ear and ask when it stops. Positive = normal = patient can still hear it after being taken off, so AC > BC. Negative (abnormal) = They cant hear it after taken off on the side with conductive hearing loss so BC > AC.
What type of hearing loss is indicated by the air and bone conduction lines being far apart on PTA?
Conductive hearing loss.
Describe the House-Brackmann scale.
Classification of facial nerve palsy.
I = normal
II = slight weakness
III = complete eye closure, obvious weakness
IV = incomplete eye closure, weakness, disfiguring asymmetry
V = flicker of motion
VI = no movement
Management of chronic deafness in adults?
OME - examine post-nasal space to exclude neoplasia
Unilat sx asso tinnitus + vertigo –> MRI to exclude acoustic neuroma
If chest infection/sinusitis/kidney problem this may suggest autoimmune/granulomatous disease –> ab screen, refer
Presbyacusis –> hearing aid
Management of acute deafness in adults?
If asso neurology –> CVA/MS - MRI and refer
Review medications - chemo, aspirin, ototoxic abx, loop diuretics
Ask abt recent head/barotrauma
Menieres episode - supportive
5-10% have identifiable cause, 50% have complete spontaneous recovery.
[lecture]
What causes vertigo with sudden onset, N+V, often following a sore throat, and can cause hearing loss?
Viral labyrinthitis. L for Loss of hearing
How does vestibular neuronitis present?
Viral infection, acute onset vertigo, gradually improves over weeks, N for No hearing loss
What is BPPV and what causes it?
Benign Paroxysmal Positional Vertigo. Otoconia (CaCO3 crystals) in the semicircular canals disrupt flow of endolymph. Attacks last minutes and are triggered by movement.
What factors in the history + examination point to a central cause of vertigo?
HINTS:
Head impulse: Jerk patients head laterally, patient should continue to focus on you. Saccades in vestibular dysfunction. Normal in central or no symptoms.
Nystagmus - unilateral/horizontal in peripheral, bilateral/vertical in central.
Test of skew/alternate cover test - cover each eye, should keep fixed on you, vertical drift/correction in central.
Gradual onset (except stroke)
Persistent
No hearing loss
Ataxia and abnormal neurology
No/mild nausea
What causes Ménière’s disease?
How is it treated?
Excessive endolymph in the semicircular canals, causing a higher pressure than normal, disrupting the sensory signals. Relapsing remitting attacks of rotatory vertigo, hearing loss and tinnitus lasting hours, with nystagmus.
Worse with stress. Treat symptomatic with betahistine.
Give 5 causes of conductive hearing loss.
Ear wax Infection eg OM/OE Middle ear effusion Eustachean tube dysfunction Fixation of the ossicular chain (otosclerosis) Perforated TM
What would you see on audiometry in sensorineural hearing loss?
Both air and bone conduction readings more than 20db (need to be louder to hear so line is lower down on graph).
What is presbycusis and how does it present?
Age-related hearing loss, gradual loss of high-pitched sounds, +/- tinnitus. Increased risk of dementia in untreated hearing loss.
