ENT (B) Flashcards
1
Q
Main physiological functions of nose?
A
- Humidify and warm air
- Special sense smell
- Hairs trap foreign material
- Speech - resonating chamber
2
Q
Main functions of throat and mouth?
A
- Nutrition - saliva lubricates, amylase production starts digestion, muscles mastication
- Airway - entry into lungs, epiglottis closes airway off when swallowing
- Immune - mucosal membranes are barriers, saliva contains immunoglobulins
- Special sense taste
- Speech articulation
3
Q
Symptoms you’d get from disease of the nose
A
- Visible deformity - eg saddle, deviated septum or swelling
- Epistaxis - unilateral is red flag
- Facial pressure/pain - sinusitis
- Anosmia
- CSF leak
- Rhinorrhoea
- Blocked nose
- Snoring
- Post nasal drip
4
Q
Symptoms you’d get from disease of throat and neck
A
- Hoarse voice/change in voice
- Odonophagia
- Dysphagia
- Halitosis
- Sore throat
- Bad taste in mouth
- Cough
- Palpable mass/swelling
- Enlarged lymph nodes
- Weight loss
- Referred pain to ear/jaw
- Fever
- SOB
5
Q
How to examine the nose
A
- Inspect - from front, side and below. Split nose into 1/3rds when describing Shape, deviation, symmetry, scars, skin changes, sunken
- Palpate - assess tip recoil and thickness of nasal skin
- Anterior rhinoscopy - Thudichum’s speculum and
headlight - look for septal deviation, inflammation, swelling, polyps, prominent blood vessels - Can do nasal misting to assess humidifcation of each nostil on Lacks cold metal depressor
- Examine oropharynx
- Can then do special tests eg flexible nasal endoscopy
6
Q
Examination of throat and neck
A
- Inspect - masses, scars
- Palpate - thyroid from behind, use fingertips, get patient to swallow water and stick out tongue. Assess if tender, temp difference, any nodules/masses
- Examine LN - anterior and posterior triangle, then begin with submental and work backwards. Don’t forget supraclavicular
- Auscultate for bruit for hyperthyroidism
- Percuss superior sternum - stoney dullness associated with retrosternal enlarge goitre
7
Q
Thyroid status exam
A
- General - appropriate dress, sweaty?
- Hands - nails for thyroid acropachy, tremor, palmar erythema, feel temp
- Radial pulse
- Face - peaches and cream for hypothyroidism, loss outer 1/3rd eyebrow?,
- Examine eye movements and check for lid lag
- Legs - pretibial myxoedema? ankle reflexes
- Pembertons test - raise arms above head, check for head and neck venous congestion and hoarse voice - shows retrosternal goitre
8
Q
Three sensory inputs of the balance system
A
- Vestibular
- Visual
- Somatosensory
9
Q
What happens once these inputs are processesd by the brain?
A
- They are processed - involves brainstem, cerebellum and cerebrum
- Efferent pathways then act on extraocular muscles to adjust eye position
- Also act on limb and trunk muscles to maintain body position
10
Q
Define vertigo
A
- A sensation that you or the environment around you is moving or spinning
- It is often described as dizziness
11
Q
How does vertigo differ from other dizziness?
A
- Vertigo is a rotational sensation
- Feels like the room is spinning
- Other dizziness descriptions may be from lightheadedness, instability, presyncope
12
Q
How to ask a patient if they have vertigo?
A
- Do you ever have the sensation that the room is spinning around you?
13
Q
Define syncope and presyncope
A
- Syncope - temporary loss of consciousness and posture usually due to decreased blood flow to the brain
- Presyncope - the feeling that one is about to faint or lose consciousness. May feel lightheaded, dizzy or nauseaous and can get tunnel vision
- Usually associated with decreased blood flow to the brain but not enough to cause syncope
14
Q
Define nystagmus
A
- Rhythmic, involuntary oscillation or movement of the eyes
- May involve horizontal, vertical or rotational movements
15
Q
What is the slow and fast phase of jerk nystagmus?
A
- Slow phase - slow and smooth movement/ drift of the eyes away from their primary position (straight ahead gaze). Considered normal/phsyiological and usually tries to reset the eyes back to primary position
- Fast phase - quick fast movement of eyes in the opposite direction. Abnormal and pathological component
- These two together create a back and forwards jerking motions
16
Q
Multifactorial causes for balance problems in older people
A
- Sensory neuropathy
- OA hips and knees
- Parkinsons
- OAB
- Stroke - altered motor function
- AF - syncope
- Postural hypotension
- Z drugs - drowsiness
- Glicazides/diabetes- hypoglycaemia
- Alcohol
- Worsening eyesight
- Anxiety
- Gout - on thiazides?
- Strong pain relief - drowsy
- Waking up at night
17
Q
Red flags for nose throat and neck symptoms
A
- Persistent hoarseness - 2WW
- Unexplained neck mass
- Dysphagia - persistent and progressive, worsening +/- weight loss
- Persistent sore throat
- Chronic nasal obstruction - esp if unilateral and associated with epistaxis
- Recurrent epistaxis
- Unexplained weight loss
- Persistent headache/facial pain
- Change in voice - persists
- Dyspnoea
- Stridor
Either referral to ENT or gastro if needed
18
Q
S
Management otitis externa
A
- Keep ears dry
- Avoid swimming and water sports for 7-10 days
- When swimming wear ear plugs and tight fitting hat
- Keep shampoo and water out of ears when showering where possible - cotton wool balls?
- Hair dryer to dry ears after shower
- Consider OTC acetic acid 2% ear drops
- Paracetamol and ibuprofen for symptom relief
- Can do ear irrigation if lots of debris
- Consider antibiotic ear drops without steroid or with steroid if lots of inflammation
19
Q
Management meniere’s disease
A
- Acute attacks - prochlorperazine (buccal or IM) or antihistamines to reduce symptoms
- Preventative - Betahistine and vestibular rehabilitation exercises
- If need hopsital admission - IV labyrinth sedatives, fluids
20
Q
Triad for Meniere’s
A
- Vertigo
- Tinnitus
- Hearing loss
21
Q
Typical presentation Meniere’s
A
- 40-50yr old
- Vertigo that lasts 20mins-few hours
- Cluster of episodes
- Hearing loss and tinnitus then start to occur even when vertigo episodes are not occuring
22
Q
Approach to assess hearing loss
A
- Unilateral vs bilateral?
- Onset - gradual or sudden
Sudden is red flag could be cancer/stroke, need high dose steroids to try and save hearing - admit that day
23
Q
Age related hearing loss and noise related hearing loss management
A
- Hearing aids
- Loop systems to aid the hearing aids - can tune into TV or have associated flashing lights/vibrations
- Cochlear implant - last resort if hearing aid not helping
24
Q
Management of perforated tympanic membrane
A
- Visualise - confirm diagnosis
- Will self resolve in 2 months usually
- Keep it dry
- Use analgesia and warm compress
- Don’t blow nose too hard
- Can fly
- If not resolving in 6-8 weeks - refer, may need myringoplasty surgery to repair
25
Child/vulnerable adult with ruptured tympanic membrane
* Think carefully about abuse as cause
* Severe trauma to side of head can cause rupture
26
Management + what is supparative chronic otitis media with ruptured tympanic membrane
* Causes otorrhoea for more than 2 weeks
* Oedematous EAM/cholesteatoma can occur alongside
* Conductive hearing loss
* Keep ear dry
* Cotton wool mopping
* Refer to ENT - DO NOT swab or initiate treatment (will often involve abx, cleaning and steroids)
27
Mastoiditis
* Complication of recent AOM
* Proptosed auricle, post auricular swelling, erythema or tenderness
* Children do ear pulling
* Can have associated fever, headache, otorrhoea
* Bulging TM
* And sagging of superior wall of EAM
* A&E
28
AOM management
* Usually goes away within 3-5 days without use of abx - analgesia and conservative
* Consider prescribing in children under 2, or if bilateral AOM, or if systemically unwell
* Amoxicillin is 1st line, Erythromycin/Clarithromycin if allergic
* Grommets if reoccur
* Review in 7 days if no improve or at any time if symptoms worsen
29
Cholesteatoma management
* Semi-urgent referral to ENT
* Surgical removal may be needed
30
Causes of referred pain to ear
* Temporomandibular joint - CN Vc (trigemincal mandibular portion)
* Diseases of oropharynx - CN IX (glossopharyngeal)
* Diseases of larynx and pharynx eg cancers - CN IX and X (glossopharyngeal and vagus)
Consider this if normal ear exam
31
Otitis media with effusion management
* No hearing loss - reassure should resolve
* Some hearing loss suspected - refer for tympanometry and hearing tests
* ENT referral for either: watch and wait, hearing aids, myringotomy and insertion of grommets
32
What happens after grommets are inserted?
* Falls out several months later
* Allows ventilation between middle ear with eustachian tube and external environment
33
Congenital deafness causes
* CMV or Rubella as a baby
* Faulty ion channels - pH of endolymph affected
* Syndrome related - down syndrome
* Baby's have newborn hearing tests which detects
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