ENT B presentations Flashcards
BPPV presentation
- Variety of head movements trigger vertigo
- Typical trigger is turning over in bed
- Settle after 20-60s
- Episodes occur overal several weeks then resolve but can reoccur
- NO hearing loss or tinnitus
Diagnosis and management of BPPV
- Diagnose with Dix Hallpike maneuvre
- Treat with Epley
Cause of allergic rhinitis
- Inflammatory condition of nasal mucosa
- Caused by IgE mediated response to allergens within environment eg pollen/dust mites
- Can show seasonal variation
Signs and symptoms of allergic rhinitis
- Nasal pruritis
- Sneezing
- Rhinorrhoea
- Nasal congestion
- May be associated with allergic conjuctivitis = eye redness, puffiness and watery dishcarge
Diagnosis for allergic rhinitis
- Clinical and pt history based
- If needed can refer for skin prick test or blood tests for specific IgE antibodies to identify allergen
Investigations if diagnosis doubt or failure to respond to treatment in allergic rhinitis
- Nasal endoscopy
- Nasal allergy challenge
- Evaluation of nasal nitric oxide and ciliary beat frequency
- Analysis of nasal fluid
- CT scan
What are nasal polyps?
- Growths of nasal mucosa that occur in nasal cavity/sinuses
- Often associated with inflammation, eg chronic rhinitis
- Grow slowly and gradually obstruct passage
- More common in men esp those 40+
Polyps patten
- Bilateral usually
- Unilateral is red flag - tumour?
Presentation of nasal polyps
- Chronic rhinosinusitis
- Difficulty breathing through nose
- Snoring
- Nasal discharge
- Hypo or anosmia
- Post nasal drip = cough
Investigations for nasal polyps
- Examine with nasal speculum to hold nostrils open
- Otoscope + large speculum attached
- Specialist can do nasal endoscopy
- Appear as round, pale/grey/yellow growrht on mucosal wall
When to refer polyps?
Unilateral - 2WW
Management polyps
- Intranasal steroid drops or sprays
- Surgery - intranasal polypectomy (when polyps are visibilt OR
- Endoscopic nasal polypectomy (polyps are further in nose or in sinuses)
Infective cervical lymphadenopathy characteristics
- Tender
- Mobile
- Associated fever, cough, sore throat
Maligmant cervical lymphadenopathy characteristics
- Irregular
- Hard
- Tethered to surrounding tissues
- Painless
- Larger than 2cm
- Associated systemic symptoms - weight loss, night sweats, fatigue
- Other symptoms - change in voice, dysphagia, haemoptysis, rapidly growing
Investigations for cervical lynphadenopathy
- Depends
- May just resolve if viral
- Can do EBV, cyomegalovirus and HIV serology
- Urgent CXR if suspect TB or lung cancer (within 2 weeks)
- If suspect leukaemia need FBC
Management cervical lymphadenopathy
- Viral - self limiting
- Bacterial - assess need for abx,
- If unresolved after 2-4 weeks consider urgent ENT referral
- If suspect cancer 2WW pathway for cancer
Acute sinusitis presentation
- Lasting less than 4 weeks
- Facial pain
- Anosmia
- Purulent discharge
Investigations for chronic sinusitis
- Nasal endoscopy
- Nasal and sinus cultures
- CT if indicated - complications and extent of disease
- Skin prick testing
Management acute sinusitis
- Analgesia
- Intranasal decongestants or nasal saline
- Intranasal corticosteroids if symptoms present for more than 10 days
- Oral abx if severe presentation and suspect bacterial - phenoxymethylpenicillin, co-amoxiclav is systemically very unwell
What is double sickening?
- Viral sinusitis worsens due to secondary bacterial infection - get better and then worse
When to refer to ENT acute sinusitis?
- No improvement after 7-14 days or red flag
Red flag for sinusitis
- Eye signs - periorbital swelling or erythema, displaced globe, visual changes, opthalmoplegia
- Severe unilateral headache
- Bilateral frontal headache
- Frontal swelling
- Neurological signs or reduced conc level
Chronic sinusitis - what is it?
- Inflammation of the paranasal sinuses in the face for more than 12 weeks
- Rhinosinusitis if nasal cavity is also inflamed
- Can last several months
Underlying cause chronic sinusitis
More likely to be inflammatory rather than infection (acute more likely to be infection)
RF for chronic sinusitis
- Allergic rhinitis
- Asthma
- Cystic fibrosis
- Immunocompromised
- Smoking
- Previous sinus surgery
- Nasal polyps - blocks drainage
Signs and symptoms chronic sinusitis
- Nasal blockage
- Nasal discharge with facial pain/pressure or headache
- +/- reduced sense of smell
- Cough
Management chronic sinusitis
- Good control of asthma or any allergic rhinitis
- Avoid triggers
- Smoking cessation
- Nasal irrigation with saline solution
- Consider course intranasal corticosteroids for up to 3 months (esp if allergic cause) - reduces swelling
When to refer chronic sinusitis?
- Persistent symptoms past 3 months
- Unilateral symptoms (cancer?)
- Interefering with QOL
- Allergic/immunologic factors that need investigating
Thyroid nodules - presentation
- Identified on routine examination/incidentally on imaging
- If large can be palpable
- Move upwards on swallowing
- Can present with hyper or hypothyroidism or compressive symptoms
Compressive symptoms of thyroid nodules
On oesophagus or trachea:
* Dysphagua
* Stridor
* Voice changes (hoarseness)
* SVCO - face/neck swelling, distended neck veins and dyspnoea
Causes of thyroid nodules
- Most benign - adenoma, multinodular goitre, hashimotos thyroiditis or cysts (colloid, simple, haemorrhagic)
- Malignancy - PFAM, lymphoma
- Mets - breast, kidney, prostate
Invetsigations for thyroid nodules
- TFTs
- Thyroid USS - solid, irregular, hyperechoic, >1cm, rapid growth and central vascularity suggests cancer
- Thyroid scintigraphy (radioisotope scanning)
- Fine needle aspiration and histological diagnosis
Thyroid scintigraphy findings and meanings
- Non-functioning cold nodule, no uptake of iodine - malignant
- Autonomous hot nodule, increased uptake - unlikely malignancy eg adenoma
- Hot and cold areas, patchy uptake - toxic multinodular goitre
What is thyroid scintigraphy?
Radioactive labelled iodine is given to pt
Measure thyroid uptake using nuclear scan
Management thyroid nodules options
- Emergency hospital admission if signs of obstruction
- Urgent referral to endocrinology (2weeks)
- Serum TFTs
- Routine endo referral
- Monitor
When to urgent refer thyroid nodules to endo?
- Unexplained thyroid lump
- Unexplained hoarseness/voice change
- Cervical lymphadenopathy or supraclavicular
- Sudden onset and rapidly expanding painless thyroid mass - increased in size over days/weeks
- Compressive symptoms
When to routine endo referral thyroid nodule?
- Non-suspicious nodule with abnormal TFTs and normal TFTs
- Sudden onset, painful expansion in pre-existing lump - haemorrhage into benign cyst?
- Non suspcious incidental finding on imaging more than 1cm
When to just monitor thyroid lump in primary care?
- Long standing unchanging over several years
- Non-palpable, asymptomatic incidental finding on imaging less than 1cm
- Non palpable cervical lymphadenopathy and no red flags for malignancy
Acute labyrinthitis vs vestibular neuronitis
- Labyrinthitis = vestibule, semicircular canals and cochlea inflamed
- VN - vestibular portion of CN8th inflamed so no hearing loss/tinnitus present
Cause of AL and VN
- Viral URTI is usually cause (can be otitis media or meningitis too)
Presentaiton of AL and VN
- Acute onset of vertigo, nausea and vomitting
- Can have symptoms of URTI - cough, sore throat, blocked nose etc
- AL can have tinnitus and hearing loss also
Diagnosing AL and VN
- Clinical
- Can do head impulse test to distinguish between peripheral and central causes of vertigo
Management acute labyrinthitis/VN
- Supportive - settles over several weeks
- Advise not to drive if very dizzy
- Short term (up to 3 days) of prochlorperazine or antihistamines (cyclizine, cinnarizine and promethazine) to relieve symptoms
- Abx used if suspect bacterial cause (more likely in otitis media or meningitis)
Hearing loss after acute labyrinthitis
- Rarely have permanent hearing loss
- More common following bacterial infection esp from meningitis
- All patients after meningitis recovery should have audiology assessment
