ENT AS Flashcards
What types of audiometry are there?
Pure tone audiometry (PTA)
Tympanometry
Evoked response audiometry
What is pure tone audiometry?
Headphones deliver tones at different frequencies and strengths in a sound-proofed room.
Patient indicates when sound appears and disappears.
What is tympanometry?
Measures stiffness of ear drum
- Evaluates middle ear function
Flat tympanogram: mid ear fluid or perforation
Shifted tympanogram: +/- mid ear pressure
What is an evoked response audiometry?
- Auditory stimulus with measurements of elicited brain response by surface electrodes
- Used for neonatal screening (if otoacoustic emission testing negative).
What is otitis externa presentation?
Watery discharge
Itch
Pain and tragal tenderness - acute main on moving the pinna.
Conductive hearing loss if lesion is large.
Inflammation is more likely to be severe if there is:
- a red, oedematous ear canal which is narrowed and obscured by debris
- conductive hearing loss
- Discharge
- Regional lymphadenopathy
- Cellulits
- Fever
Chronic otitis externa
- Chronic discharge from affected ear, hearing loss, and severe pain.
What are the risk factors of otitis externa ?
Moisture: e.g swimming
Trauma: e.g fingernails
Absence of wax
Hearing aid
What are the most common organisms for otitis externa?
Mainly pseudomonas
Staph Aureus
Management of otitis externa?
Mild cases (no deafness no discharg) topical acetic acid.
Aural toilet with drops
- Betamethasone for non-infected eczematous OE
- Betamethasone with neomycin
- Hydrocortisone with gentamicin
- Acidifying drops
Use flucloxacillin for uncomplicated otitis externa if systemic therapy was warranted.
If not responsive do a swab.
If they fail to respond refer to ENT urgently. This is despite strong analgesia therefore suggests malignant otitis externa
Poor response to topical antibiotics should be referred to ENT. This is for microsuction and insertion of a pope wick.
What is malignant otitis externa?
- Life-threatening infection which can –> skull osteomyelitis
- 90% of pts are diabetic (or other immune compromise)
Common in diabetics with pseudomonas infection.
Therefore need ciprofloxacin.
Presentation
- Severe otalgia which is worse @ night
- Copious otorrhoea
- Granulation tissue in the canal
Management
- Surgical debridement
- Systemic antibiotics
What is bullous myringitis ?
- Painful haemorrhagic blisters on deep meatal skin and TM
- Associated with influenza infection
What are the symptoms of TMJ dysfunction?
temporomandibular joint
- Earache (referred pain from auriculotemporal N)
- Facial pain
- Joint clicking/popping
- Teeth grinding (bruxism)
Signs
- Joint tenderness exacerbated by lateral movements of an open jaw
Investigations of TMJ dysfunction?
MRI
Management of TMJ dysfunction?
NSAIDS
Stabilising orthodontic occlusal prostheses.
What is the classification of otitis media?
Acute: Acute phase
Glue ear/OME: effusion after symptom regression
Chronic: effusion >3 months if bilateral or >6 months if unilateral
Chronic suppurative OM: Ear discharge with hearing loss and evidence of central drum perforation
What are the organisms for otitis media?
Viral
Strep Pneumococcus
Haemophilus influenza
Moraxella catarrhalis
Acute OM presentation?
Usually children post viral URTI
Secondary to eustacian tube dysfunction.
Rapid onset ear pain, tugging @ ear
Irritability, anorexia, vomiting
Purulent discharge if drum perforates. Green discharge more likely to be mucinous and OE.
O/E
- Bulging, red TM
- Fever
Management of Acute OM?
Paracetamol: 15mg/kg
Give antibiotics if:
- Symptoms lasting more than 4 days or not improving
- Immunocompromised
- Younger than 2 with bilateral otitis media
- Otitis media with perforation.
Amoxicillin: may use delayed prescription
What are the complications of otitis media?
Complications - Intratemporal OME Perforation of TM Mastoiditis Facial nerve palsy
- Intracranial
Meningitis/encephalitis
Brain abscess
Sub/epidural abscess
Systemic
- Bacteraemia
- Septic Arthritis
- IE
OME presentation?
Inattention at school
Poor speech development
Hearing impaired
o/e
- retracted dull TM
- Fluid level
Investigations for OME?
Audiometry: flat tympanogram
Management of OME?
Usually resolves spontaneously
- Consider grommets if persistent hearing loss
SE: infections and tympanosclerosis
Chronic suppurative OM?
Presents with painless discharge and hearing loss
o/e - TM perforation
Management
- Aural toilet
- Abx/Steroid ear drops
Complications
- Cholesteatoma. Those with cholesteatoma have a perforation of the pars tensa. Complain of intermittent discharge. IMpaired hearing and foul smelling discharge.
Mastoiditis presentation and management?
Middle-ear inflammation –> destruction of mastoid air cells and abscess formation.
Presents with
- Fever
- Mastoid tenderness
- Protruding auricle
- Bogguness of the space behind ear.
Imaging
- CT
Management
- IV abx
- Myringotomy ± mastoidectomy
What is a cholesteatoma?
Locally destructive expansion of stratified squamous epithelium within the middle ear.
Form in early childhood - repeated ear infection weakening the ear drum leading to it collapsing inwards. Developing into a cyst.
Classification
- Congenital
- Acquired: 2ndry to attic perforation in chronic suppurative OM.
Presentation of cholesteatoma?
**Foul smelling white discharge** Headache, pain CN involvement - Vertigo - Deafness - Facial paralysis
o/e of cholesteatoma?
Appears pearly white with surrounding inflammation.
Any crusting or ear wax obscuring the attic is a cholesteatoma until proven otherwise.
The attic is extremely important to visualise to see attic crust.
Never trust an attic crust.
Complications of cholesteatoma?
Deafness –> ossicle destruction
Meningitis
Cerebral abscess
Management of cholesteatoma?
Surgery
What is tinnitus?
Sensation of sound without external sound stimulation
Causes of tinnitus?
Specific
- Meniere’s
- Acoustic neuroma (hearing loss, vertigo, tinnutis, Absent corneal reflex). NF2.
- Otosclerosis (20-40yrs, conductive deafness, tinnitus, normal tympanic membrane)
- Noise-induced - typically high range (3,000-6,000)
- head injury
- Hearing loss - presbyacusis
General
- Increased BP
- decreased Hb
Ototoxicity is my FAV.Q&A Furosemide Aminoglycoside (gentamicin, neomycin) Vancomycin Quinine Aspirin
History of tinnitus?
Character: constant, pulsatile
Unilateral: acoustic neuroma
FH: otosclerosis
Alleviating/exacerbating factors: worse @ night
Associations
- Vertigo: Meniere’s, acoustic neuroma
- Deafness: Meniere’s, acoustic neuroma
Cause: head injury, noise, drugs, FH
Examination of tinnitus?
Otoscope
Tuning fork tests
Pulse and BP
Investigation of tinnitus?
Audiometry and tympanogram
MRI if unilateral to exclude acoustic neuroma
Management of tinnitus?
Treat any underlying causes
Psych support: tinnitus retraining therapy
Hypnotics @ night may help.
What is vertigo?
The illusion of movement
Causes of peripheral/vestibular vertigo?
Peripheral/Vestibular?
Meniere’s = Hearing loss, tinnitus, sensation of fullness or pressure in one or both ears. >30 mins but lasts few hours.
BPPV = Gradual onset, triggers by change in head position. Each episodes lasts 10-20 s.
Viral Labyrinthitis = Recent viral infection. Sudden onset, N+V. Hearing may be affected. = Days.
Vestibular neuronitis (No Hearing loss) = Recent viral infection, recurrent vertigo attacks lasting hours or days. No hearing loss.
Central causes of vertigo?
- Acoustic neuroma
- MS
- Vertebrobasilar insufficiency/stroke
- Inner ear syphilis
Drugs
- Gentamicin
- Loop diuretics
- Metronidazole
- Co-trimoxazole
History of vertigo?
Is it true vertigo or just light-headedness - Which way are things moving
Timespan
Associated symptoms: n/v, hearing loss, tinnitus, nystagmus
Examination of vertigo and tests?
- Hearing
- Cranial nerves
- Cerebellum and gait
- Rombergs +ve = vestibular or proprioception
- Hallpike manoeuvre
- Audiometry, calorimetry, LP, MRI.
Meniere’s Disease?
Dilatation of endolymph space of membranous labyrinth (endolymphatic oedema)
Presents with
- Attacks occur in clusters up to 12hrs
- Progressive SNHL (sensorineural hearing loss)
- vertigo and n/v
- Tinnitus
- Aural fullness
- Romberg’s test +ve.
- Lasts minutes to hours
Ix
- Audiometry shows low-freq SNHL which fluctuates
Management
- Medical = Vertigo: Cyclizine, betahistine
acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required
prevention: betahistine and vestibular rehabilitation exercises may be of benefit
- Surgical = Gentamicin instillation via grommets, saccus decompression.
What is vestibular neuronitis
/viral labyrinthis?
Vestibular neuritis = only vestibular nerve so no hearing impairment
Labyrinthitis = vestibular nerve and labyrinth are involved.
Both
- Follows febrile illness
- Sudden vomiting
- Horizontal nystagmus
- No hearing loss of tinnitus
- Severe vertigo exacerbated by head movement
DDx
- Viral labyrinthitis (includes hearing loss)
/posterior circulation stroke (HiNTs exam helps to tell apart)
Management
- Vestibular rehabilitation exercises are preferred treatment for patients who experience chronic symptoms
- A short oral course of prochlorperazine or an antihistamine (cinnarize, cyclizine, promethazine) may be used to alleviate less severe cases.
- Buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases. FOR THE ACUTE PHASE. Delays recovery.
What is BPPV?
Displacement of otoliths in semicircular canals
Common after head injury
Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients.
Features
- vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
may be associated with nausea
- each episode typically lasts 10-20 seconds
- positive Dix-Hallpike manoeuvre
Management
- Epley manoeuvre
- Teaching patient exercises they can do themselves.
Presentation of BPPV
Sudden rotational vertigo for <30s
- Provoked by head turning
Nystagmus
Causes by: idiopathic, head injury, otosclerosis, post-viral
Diagnosis
- Hallpike manoeuvre –> Upbeat-torsional nystagmus
Management
- Self-limiting
- Epley manoeuvre
- Betahistine: histamine analogue
What is conductive hearing loss?
Impaired conduction anywhere between auricle and round window
What is conductive hearing loss caused by?
External canal obstruction
- Wax, pus, foreign body
TM perforation
- trauma, infection
Ossicle defects
- Otosclerosis
- Infection
- Trauma
Sensorineural adult hearing loss?
Defects in the cochlea, cohlear nerve or brain.
Drugs
- Aminoglycosides
- Vancomycin
Post-infective
- Meningitis
- Measles
- Mumps
- Herpes
Misc
- Meniere’s
- Trauma
- MS
- CPA lesion (acoustic neuroma)
- Decreased B12
What is an acoustic neuroma?
Benign, slow-growing tumour of superior vestibular nerve
Acts as SOL –> CPA
- Associated with NF2
What is the presentation of acoustic neuroma?
Should also be considered in patients with unilateral sensorineural deafness or tinnitus.
- Slow onset, unilateral SNHL, tinnitus ± vertigo. Absent corneal reflex.
- Headache (Increased ICP)
- CN palsies:
5, = Absent corneal reflex
7, = Facial palsy
8. = vertigo, unilateral sensorineural hearing loss, unilateral tinnitius. - Cerebellar signs
Investigations
- MRI of cerebellopontine angles (Gadolinium-enhanced)
- MRI all patients with unilateral tinnitus/deafness
PTA (pure tone audiometry)
Differential
- Meningioma
- Cerebellar astrocytoma
- Mets
Management
Refer urgently to ENT.
- Gamma knife
- Surgery (risk of hearing loss)
Otosclerosis?
AD condition characterised by fixation of stapes at the oval window
F>M = 2:1
Presentation of otosclerosis?
Begins in early adult life
Bilateral conductive deafness + tinnitus. Key is bilateral.
HL improved in noisy places: Willis’ paracousis
Worsened by pregnancy/menstruation/menopause
Investigations of otosclerosis?
PTA shows dip (Caharts notch) @ 2kHz
Management of otosclerosis?
Hearing aids or stapes implant
What is presbycusis?
Age-related hearing loss - SNHL
Presentation
- > 65 yrs old
- Bilateral
- Slow onset
- ± tinnitus
High freqeuncy hearing loss.
Ix: PTA
Management: hearing aid
Conductive hearing loss in children?
Anomalies in pinna, external auditory canal, ossicles
Pierre-Robin syndrom
SNHL In children?
AD: Waardenburgs
AR: Alports or Jewell-Lange-Nielson
X-linked: alports
Infections: CMV, Rubella, HSV
Ototoxic drugs
May be perinatal - anorxia, cerebral palsy, kernicterus, infection
Miscellaneous ear conditions?
Congenital anomalies
- 1st and 2nd branchial arches form auricle while 1st brachial groove forms external auditory canal.
- Malfusion –> accessory tags auricles and preauricular pits, fistulae, sinuses.
- Sinuses may get infected, mimicking a sebaceous cyst
What is a pinna haematoma?
BLunt trauma –> Subperichondrial haematoma
Can –> Ischaemic necrosis of cartilage and subsequent fibrosis to cauliflower ears.
Management: aspiration + firm packing to auricle contour.
Exostosis?
Smooth symmetrical bony narrowing of external canals.
path - Bony hypertrophy due to cold exposure. Eg. from swimming/surfing.
Symptoms
- Asymptomatic unless narrowing occludes –> conductive deafness
Management: conservative or surgical widening.
Cerumen Auris?
Secreted in outer 3rd of canal to prevent maceration
Wax accumulation can –> conductive deafness
Management
- Suction under direct vision with microscope
- Syringing after 1 week softening with olive oil.
TM perforation?
Causes - OM - Foreign body - Barotrauma Trauma
No treatment needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. Advisable to avoid getting water in the ear during this time,
Common practise is to prescribe antibiotics to perforations which occur following an episode of acute otitis media.
Myringoplasty may be performed if the tympanic membrane does not heal by itself.
Myringoplasty is the closure of the perforation of pars tensa of the tympanic membrane. When myringoplasty is combined with ossicular reconstruction, it is called tympanoplasty.
What is allergic rhinosinusitis?
Classification
- Seasonal: hay-fver
- Perennial
Pathology
- T1HS IgE mediated inflammatory from allergen exposure –> Mediator release from mast cells
Allergens: pollen, house dust mites
Symptoms
- Sneezing
- Pruritis
- Rhinorrhoea
- Post nasal drip
Signs
- Swollen, pale, boggy tubinates
- Nasal polyps
Ix - Skin prick test to find allergens
- RAST test
Management of allergic rhinosinusitis?
Washing bedding on high
Avoid going outside when pollen count is high
1st line - Cetirazine, desloratidine
- beclometasone nasal spray
2nd lin: intranasal steroids
3rd line : Zarfirlukast
Topical nasal decongestant = oxymetazoline. Prolonged periods not used as increasing doses required to achieve same effect.
4th line: immunotherapy
- Aim to induce densensitiation to allergen
- OD SL grass-pollen tablets
Sinusitis - pathophysiology?
Virusus –> mucosal oedema and decreased mucosal ciliary actions –> Mucus retention ± 2ndry bacterial infection
Acute: Pneumococcus, Haemophilus, Moraxella
Chronic: s.aureus, anaerobes
Cause of sinusitis?
Bacterial infection secondary to viral
5% secondary to dental root infection
Diving/swimming in infected water
Smoking
Anatomical susceptibility: deviated septum, polyps
Systemic disease
- PCD/Kartagener’s
- Immunodeficiency
Symptoms of sinusitis?
Pain
- Maxillary (cheek/teeth)
- Ethmoidal (between eyes)
increased on bending/straining
Discharge: from nose –> post-nasal drip with foul taste
Nasal obstruction/congestion
Anosmia.
Imaging
- Nasendoscopy + CT
Management of Sinusitis?
Acute/Single Episode
- Bed-rest, decongestants, analgesia
- Nasal douching and topical steroids. Treat with intra-nasal corticosteroids if symptoms of sinusitis are severe or have lasted for period of 10 days or more.
Antibiotics NOT recommended (can sometimes give if symptoms present more than 10 days)
Chronic/recurrent
- Usually a structural or drainage problem
- Stop smoking + fluticasone nasal spray
- Functional endoscopic sinus surgery
Complications of sinusitis?
Mucoceles --> pyoceles Orbital cellulitis/abscess Osteomyelitis - Staph in frontal bone Intracranial infection - Meningitis - ABscess - Cavernous sinus thrombosis
Nasal polpys?
Patient male, >40yrs
Sites
- Middle turbinates
- Middle meatus
- Ethmoids
Symptoms
- Watery, anterior rhinorrhoea
- Purulent post-nasal drip
- Nasal obstruction
- Sinusitis
- Headache
- Snoring
Signs
- Mobile, pale, insensitive
Associations of Nasal polyps?
Allergic/non-allergic rhinitis
CF
Aspirin hypersensitivity
Asthma
Single unilateral polyp in nose?
May be sign of rare or sinister pathology
- Nasopharyngeal Ca
- Glioma
- Lymphoma
- Neuroblastoma
- Sarcoma
Do CT and get histology
Nasal polyp in children
- Must consider neoplasm and CF
Must do urgent ENT referral for examination.
Management of nasal polyp?
Betamethasone drops for 2/7
Short course of oral steroids
Endoscopic polypectomy
Fractured nose?
Anatomy
- Upper 3rd of nose has bony support
- Lower 2/3 and septum are cartilaginous
History - Time of injury - Loss of Consciousness - CSF rhinorrhoea - Epistaxis - Previous nose injury - Obstruction - Consider facial £ check for Teeth malocclusion Piplopia (orbital floor)
Investigations for fractured nose?
Radiographs dont change management
Management of fractured nose?
Exclude septal haematoma
Re-examine after 1wk (reduced swelling)
Reduction under GA with post-op splinting best within 2 weeks
What is a septal haematoma
Septal necrosis + nasal collapse if untreated
- Cartilage blood supply come from mucosa
Boggy swelling and nasal obstruction
Needs evacuation under GA with packing + suturing.
What are the causes of epistaxis?
80% Unknown Trauma: nose-picking Local infection: URTI Pyogenic granuloma - Overgrowth of tissue on Little's area due to irritation or hormonal factors. This is in the anterior of the nasal septum in the site of Kiesselbach's plexus.
Osler-Weber-Rendu/HHT
Coagulopathy: warfarin, NSAIDs, haemophilia, decreased platelets, vWD, increased alcohol
Neoplasms
Classification of epistaxis?
Anterior
Posterior - more serious and originate from deeper structures, more common in older patients.
Initial management of epistaxis?
Wear PPE
Assess for shock and manage accordingly
IF not shocked
- Sit up, head tilted down
- Compress nasal cartilage for 15 mins
If bleeding not controlled remove clots with suction or by blowing and try to visualise bleed by rhinoscopy
Anterior epistaxis?
Usually septal haemorrhage: Little’s area/Kisselbach’s plexus.
- Anterior Ethmoidal A
- Sphenopalatine A
- Facial A
- Sit forward - open mouth. Pinch cartilaginous area of nose for 15 mins -> if successful, consider topical antiseptic.
Insert gauze soaked in vasoconstriction + LA.
Xylometazoline + 2% lignocaine
- 5mins
Bleeds can be cauterised with silver nitrate sticks. If there is no visible bleeding side. Ask patient to blow nose. Use local anaesthetic spray and wait 3-4 mins.
Persistent bleeds should be packed with mericel pack
- Refer to ENT if this fails or if you can’t visualise the bleeding point
They may insert a posterior pack or take patient to theatre for endoscopic control.
Posterior/Major Epistaxis?
Postior packing + anterior packing
Pass 18/18G foley catherer through nose into nasopharynx, inflate with 10ml water and pull forward until it lodges.
- Admit patient and leave pack for 48hrs.
Gold standard is endoscopic visualisation and direct control: e.g by cautery or ligation.
After the bleed?
Don't pick nose Sit upright out of the sun Avoid bending, lifting or straining eense through mouth No hot food or drink Avoid ETOH and tobacco
Can use intranasal epinephrine to prevent re-bleeding once the initial bleeding has stopped.
Osler-Weber-Rendu/HHT?
Telangiectasias in mucosa
- Recurrent spontaneous epistaxis
- GI Bleed
INternal telangioectasis and AVMs
- Lungs
- Liver
- Brain
Rarely
- Pulmonary HTN
- Colon polyps: may –> CRC
What are the symptoms and signs of tonsillitis?
- Sore throat
Fever, malaise - Lymphadenopathy, esp jugulodigastric node
- Inflamed tonsils and oropharynx
- Exudates
What are the organisms of tonsillitis?
Viruses are most common (consider EBV)
GAS: Pyogenes
Staphs
Moraxella
Management of tonsillitis?
Swabbing superficial bacteria overdiagnosis therefore not routine.
Analgesia: Ibuprofen/paracetamol + Difflam gargles
Consider Abx only if ill: use Centor Criteria
- Pen V 250mg PO QDS or erythromycin
- Phenoxymethylpenicillin or erythromycin. 7 or 10 day course.
- If allergic give erythromycin 250mg QDS for 7 days.
NOT AMOXICILLIN –> MACPAP rash in EBV
Centor criteria for tonsillitis?
Guideliens for admin of Abx is acute sore throat/ tonsillitis/pharyngitis
1 point for each of
- hx of fever
- Tonsillar exudate
- Tender anterior cervical adenopathy
- No cough
Management of tonsillitis?
0-1: no abx (risk of strep infection <10%)
- 2: consider rapid Ag test + Rx if +ve
- > 3: abx
Tonsillectomy indications?
Recurrent tonsillitis if all the below criteria are met
- Caused by tonsillitis
- 5+ episodes a year
- Symptoms for >1yrs
- Episodes are disabling and prevent normal functioning
Airway obstruction: e.g OSA in children
Quinsy
Suspicious of Ca: unilateral enlargement or ulceration
Method of tonsillectomy?
Cold steel
Cautery
Complications of tonsillitis?
- Reactive haemorrhage: Haemorrhage 5-10 days after tonsillectomy is commonly associated with wound infection and should therefore be treated with antibiotics.
Primary haemorrhage within hours after tonsillectomy requires immediate return to theatre.
- Tonsillar gag may damage teeth, TMJ or posterior pharygeal wall.
Strep throat complications?
Peritonsillar abscess (quinsy) - Typically occurs in aduls SYmptoms - Trismus (lockjaw) - Odonophagia: unable to swallow saliva - Halitosis
Signs
- Tonsillitis
- Unilateral tonsillar enlargement
- Trismus (difficulty opening mouth)
- Uvula deviated to unaffected side.
- Cervical lymphadenopathy
Management
- Admit
- IV abx
- I+D under LA or tonsillectomy under GA.
retropharyngeal abscess?
Rare
Presents with unwell child with stiff, extended neck who refused to eat or drink.
Fails to improve with IV Abx
Unilateral swelling of tonsil and neck
Ix: Lateral neck x-ray show soft tissue swelling. CT from skull-base to diaphragm
Management
- IV Abx
- ID
Lemierre’s syndrome?
IJV thrombophlebitis with septic embolisation - caused by fusobacterium necrophorum
Management - IV abx: pen G, clinda, metro.
Scarlet fever
Sandpaper like rash on chest, axillae or behind ears 12-48hrs after pharyngotonsillitis.
Circumoral pallor
Strawberry tongue
Management
- Start Pen V/G and notify HPA.
Rheumatic fever?
Arthritis Carditis - Subcut Nodules Erythema marginatum Sydenham's chorea
What is the function of the larynx?
Phonation
Positive thoracic pressure
Respiration
Prevention of aspiration
Laryngitis?
Usually viral and self-limiting
2ndry bacterial infection may develop
- Symptoms: pain hoarseness and fever
- o/e: redness and swellign of vocal cords
- Management: supportive, Pen V if necessary
What is a laryngeal papiloma?
Pedunculated vocal cord swellign caused by HPV.
Presents with hoarseness
Usually occur in children
Manage: laser removal
Recurrent laryngeal N palsy?
Supplies all intrinsic muscle of the larynx except for cricothyroideus.
Responsible for ab + aduction of vocal folds.
Symptoms of RLNP?
Hoarseness
Breathy voice with bovine cough
Repeated coughing from aspiration (decreased supraglottic sensation)
Exertional dyspnoea (narrow glottis)
Causes of RLNP?
cancer - larynx, thyroid, oesophagus, hypopharynx, bronchus
25% iatrogenic: parathyroidectomy, carotid endartectomy
Othe: aortic aneurysm, bulbar/pseudobulbar palsy.
Laryngeal SCC
Incidence: 2000/ yr.
Associated with smoking, ETOH.
Presentation of Laryngeal SCC?
Male smoker
Age over 45
Progressive hoarseness –> Stridor. If unexplained needs 2WW.
Dys/odonophagia
Weight loss
Investigation for laryngeal SCC?
Do a chest x-ray to exclude an apical lung lesion. A normal chest x-ray does not rule out the diagnosis of a lung malignancy.
Laryngoscopy + biopsy (in nodes)
MRI staging
Management of laryngeal SCC?
Based on stage
Radiotherapy
Laryngectomy
After total laryngectomy
- Pts have permanent tracheostomy
- Speech valve
- Electrolarynx
- Oesophageal speech (swallowed air)
Regular f/up
Samter’s triad
Asthma
Aspirin Sensitivity
Nasal polyposis
Avoid aspirin.
Nasal polyps
Asthma Aspirin Sensitivity Infective sinusitis Cystic fibrosis Kartagener's Churg-Strauss
Management
- All patients should be referred to ENT for full examination
- Topical corticosteroids shrink size in 80% of patients.
Black hairy tongue
Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour.
Predisposing factors poor oral hygiene antibiotics (penicillin, erythromycin, tetracycline ) head and neck radiation HIV intravenous drug use
The tongue should be swabbed to exclude Candida
Management
tongue scraping
topical antifungals if Candida
Post-operative stridor in patients undergoing neck surgery
ABCDE
Patient has a compromised airway and breathing.
Each patient is returned to the ward with a suture blade. In the event of post-operative bleed, the pressure behind the suture line increases and the trachea becomes compressed resulting in stridor
Sensorineural hearing loss?
Air conduction is superior to bone conduction.
This is because they are both affected equally, but AC is better.
Conductive hearing loss?
Bone conduction is superior to air conduction.
Ramsay Hunt
Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
Features
auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus
Management
oral aciclovir and corticosteroids are usually given
Weber’s test
Centre.
if sound is louest in one ear, there is either conductive hearing loss of the left ear or SNHL of the right ear.
Rinne’s
Fork is struck causing it to vibrate.
Conductive hearing loss is if bone is louder than air.
Sudden unilateral sensorineural hearing loss?
Some evidence that high dose steroids for seven daus improves prognosis.
ENT checks for pure tone audiometry testing to arrange an MRI to exclude acoustic neuroma.
Gingival hyperplasia?
Phenytoin
Cyclosporin
CCB - Nifidepine
AML
CIA - CCB (nifedipine), immunosuppressants (ciclosporin), anticonvulsants - phenytoin.
Nasopharyngeal carcinoma?
SCC of the nasopharynx
Rare in most parts of the world.
Associated with EPV.
Presenting features
- Systemically = Cervical Lymphadenopathy
- Local = Otalgia, unilateral serous otitis media, nasal obstruciton, discharge and epistaxis, cranial nerve palsies III-VI. Referred pain through V-X
Image = CT and MRi
Radiotherapy = First line
Presents with a painless lymphadenopathy with a tendency to spread early.
Remember the nasopharynx drains to the posterior triangle
Larynx, buccal mucosa and tonsillar fossa drains to anterior triangle.
Oral cancer referral?
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
a lump on the lip or in the oral cavity or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.
Vertebrobasilar ischaemia?
Vertigo upon neck extension = characteristic for this condition and results in falls in elderly patients.
RF: atherosclerosis etc.
Sialadenitis
Inflammation of the salivary gland likely secondary to obstruction by a stone impacted in the duct.
Usually due to Staph A.
Duct from the submandibular gland drain into the floor of the mouth. Purulent discharge causes a foul taste in mouth.
3 main salivary glands
- Parotid glands, submandibular glands, sublingual glands.
Disorders of glands occur due to infection, inflammation , obstruction or malignancy.
ENT Surgery post op
Haematoma is a complication of surgery that is typically resolved by placement of a drain.
Emergency management is to remove the surgical clips
Ludwig’s angina?
Cellulitis which occurs on the floor of the mouth of a patient.
Deadly, as it spreads into the fascial spaces of the head and neck.
Swelling ensues from the inflammation begins to push the floor of the mouth upwards and blocks air entry.
Patient has compromised immune system (IVDU puts risk for HIV and AIDS) and poor dentition.
Thyroid surgery?
Complications following surgery:
- Anatomical such as recurrent laryngeal nerve damage
- Bleeding. Confined space haematoma’s may rapidly lead to respiratory compromised owing to laryngeal oedema.
- Damage to the parathyroid glands resulting in hypocalcaemia.
Diphtheria
White film covering tonsils = Diphtheria however patients are NOT systemically well.
Gingivitis?
Secondary to poor dental hygiene.
Ranges from simple gingivitis (Painless red swelling of gum margin which bleeds on contact) to necrotizing ulcerative gingivitis (painful bleeding gums with halitosis and punched out ulcers on gums).
Simples = Review by dentist.
Patient presents with acute necrotising ulcerative gingivitis
- Refer patient to dentist
- Oral metronidazole 3 days.
- Chlorhexidine or hydogen peroxide
- Simple analgesia
Unilateral middle ear effusion in an adult
Can be presenting symptoms of nasopharyngeal cancer.
Unilateral middle ear effusion in an adult can be a presenting symptom of nasopharyngeal cancer, especially in smokers and people of Chinese or South-East Asian origin. A tumour may cause obstruction of the eustachian tube.
NICE advises you should consider a two week wait referral for patients of Chinese or South-East Asian origin with unilateral ear effusion, if not associated with an upper respiratory tract infection.
Tonsillar SCC?
Tonsils are most common site for SCC in the oropharynx. Presents at an advanced stage.
RF = Smoking, high levels of alcohol intake and poor oral hygiene.
HPV (HPV-16) linked to development of tonsillar SCC.
EBV is associated with nasopharyngeal in origin of lymphoma.
Rhinitis medicamentosa?
Rebound nasal congestion brought on by extended use of topical decongestants.
Withdrawal of offending nasal spray (cold turkey).
