ENT Brief Flashcards
which part of the ear is responsible for converting sound vibration into a nervous signal?
the cochlea
which nerve transmits signals from the chochlea and the semicircular canals to the brain
vestibulocochlear nerve
which part of the ear is responsible for sensing head movement?
semicircular canals
describe weber’s test and possible results
- make fork vibrate and place it on their forehead
- ask which ear it’s loudest in or if it’s the same in both
- normal result
- same in both
- sensorineural hearing loss
- louder in the unaffected ear
- conductive hearing loss
- louder in the affected ear
- affected ear adapts to become more sensitive so when sound transmitted directly to the cochlea through vibration they should hear it louder in the affected ear
describe rinne’s test and possible results
- put vibrating tuning fork on patient’s mastoid process until they can’t hear it anymore
- then move it 1cm away from same ear
- normal result:
- they can hear it again since air conduction should be better than bone conduction
- abnormal result (AKA rinne’s negative):
- bone conduction is better than air conduction and suggests a conductive cause of hearing loss
causes of adult onset sensorineural hearing loss
- sudden sensorineural hearing loss (over less than 72hrs)
- presbycusis (age related)
- noise exposure
- meniere’s disease
- labrynthitis
- acoustic neuroma
- neurological conditions (stroke, MS, brain tumour)
- infections
- medications
name three drug classes and an example of each that can cause hearing loss
- loop diuretics
- e.g. furosemide
- aminoglycoside antibiotics
- e.g. gentamicin
- chemotherapy drugs
- e.g. cisplatin
causes of conductive hearing loss in adults
- something blocking the canal such as ear wax
- infection
- fluid in the middle ear
- eustachian tube dysfunction
- perforated tympanic membrane
- otosclerosis
- cholesteatoma
- exostoses
- tumours
in an audiogram what symbol is used for left sided air conduction
X
in an audiogram what symbol is used for left sided bone conduction
]
in an audiogram what symbol is used for right sided air conduction
O
in an audiogram what symbol is used for right sided bone conduction
[
what will the audiogram reading be in sensorineural hearing loss
both air and bone conduction readings will be more than 20 dB, plotted below the 20 dB line on the chart.
This may affect only one side, one side more than the other or both sides equally.
what will conductive hearing loss appear like on the audiogram
bone conduction readings will be normal (between 0 and 20 dB).
air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart
what will the audiogram look like in mixed hearing loss
Both air and bone conduction readings will be more than 20 dB in patients with mixed hearing loss
However, there will be a difference of more than 15 dB between the two with bone conduction being more sensitive and therefore plotted higher
what is presbycusis
age related hearing loss
how does presbycusis present
as people get older
sensorineural
affects high pitched sounds first
gradual
symmetrical
risk factors for presbycusis
- Age
- Male gender
- Family history
- Loud noise exposure
- Diabetes
- Hypertension
- Ototoxic medications
- Smoking
what will audiometry show in presbycusis
sensorineural hearing loss pattern, with normal or near-normal hearing at lower frequencies and worsening hearing loss at higher frequencies.
what is the definition of sudden sensorineural hearing loss
hearing loss over less than 72 hours, unexplained by other causes
a loss of at least 30 decibels in three consecutive frequency on an audiogram
what should you do if a patient presents with sudden sensorineural hearing loss
otological emergency
immediate referral to the on call ENT team for assessment within 24hrs
what are the causes of sudden sensorineural hearing loss
- most cases (90%) are idiopathic
- other causes
- infection such as meningitis or mumps
- meniere’s disease
- ototoxic medication
- MS
- migraine
- stroke
- acoustic neuroma
management of idiopathic sudden sensorineural hearing loss
- steroids under the guidance of the ENT team
- these can be
- oral
- intra-tympanic (via injection)
what is eustachian tube dysfunction normally caused by
urti
hayfever
smoking
investigations for eustachian tube dysfunction
- often investigation is not required and it will resolve on its own
- if chronic
- tympanometry
- audiometry
- nasopharyngoscopy
- CT scan
what is tympanometry and what does it show in health and in eustachian tube dysfunction
- checks the pressure in the middle ear
- in healthy ears the ambient pressure matches the pressure in the middle ear
- in ETD the middle ear pressure may be lower than ambient
management of eustachian tube dysfunction
- no treatment (probably will resolve on its own)
- valsalva
- decongestant nasal sprays
- antihistamines (if caused by allergies/hayfever)
- surgery if severe and persistent
surgical options for eustachian tube dysfunction
treating other causative pathology e.g. adenoidectomy
grommets
balloon dilation eustachian tuboplasty
what are grommets
tiny tubes inserted into the tympanic membrane allowing pressure to equalise
they normally fall out within 18 months
what is balloon dilation eustachian tuboplasty
inserting a deflated balloon into the eustachian tube, inflating the balloon for a short period (e.g. 2 mins) to stretch the tube then deflating and removing it
what happens in otosclerosis
there is remodelling of the malleus, incus and stapes which leads to stiffening and fixaton
it causes conductive hearing loss
what is the presentation of otosclerosis
- typically presents before the age of 40
- can be inherited autosomal dominant (no gene identified)
- hearing loss
- tinnitus
- affects lower pitched sounds more
- conductive hearing loss is fine so they may experience their voice as loud and therefore speak quietly
what will webers test be in otosclerosis
normal if bilateral
if unilateral then louder in affected ear
management of otosclerosis
- conservative with the use of hearing aids
- surgical with stapedectomy or stapedotomy
- usually successful and can restore hearing to normal
what happens in stapedectomy
stapes bone is removed and replsced with a prosthesis
what happens in stapedotomy
part of stapes is removed but base is left
a prosthesis is inserted
what are the most common bacterial causes of otitis media
- streptococcus pneumoniae (most common)
- haemophilus influenzae
- moraxell catarrhlis
- staphylococcus aureus
how will otitis media look through an otoscope
bulging, red and inflamed looking typmanic membrane
if perforation you may see discharge in the ear canal and a hole in the tympanic membrane
when should you consider immediate antibiotics in otitis media
significant comorbidities
if they’re systemically unwell
if immunocompromised
when should you consider a delayed presentation in otitis media
if they’re pressing for abx
if you suspect symptoms may worsen
it’s for collection after 3 days
which antibiotics would you prescribe for otitis media
amoxicillin 5-7 days
clarithromycin in penicillin allergy
erythromycin in pregnant women allergic to penicillin
what is otitis externa?
inflammation of the skin of the external ear canal
what are the two most common causes of bacterial otitis externa
pseudomonas aeruginosa
staphylococcus aureus
describe the microscopic appearance of pseudomonas aeruginosa
gram-negative aerobic rod shaped bacteria
what antibiotics work agains psudomonas aeruginosa
aminoglycosides (e.g., gentamicin) or quinolones (e.g., ciprofloxacin).
management of mild otitis externa
acetic acid 2% (available over the counter as earcalm)
can also be used prophylactically before and after swimming in patients that are prone to otitis externa
management of moderate otitis externa
bacterial: neomycin and dexamethasone and acetic acid spray (otomize)
fungal: clotrimazole ear drops
what is malignant otitis externa
- infection spreads to bone around ear and causes osteomyelitis of temporal bone
- usually related to poor immunity
- Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along) is a key finding that indicates malignant otitis externa.
- can cause death
- management:
- admission
- IV abx
- imaging: CT or MRI head
causes of tinnitus
- primary tinnitus
- idiopathic - related to sensorineural hearing loss
- seconday tinnitus
- ear infection
- meniere’s
- noise exposure
- medication
- loop diuretics
- gentamicin
- chemo
- acoustic neuroma
- MS
- systemic conditions
- anaemia
- diabetes
- hyperlipidaemia
- hypo/hyperthyroidism
- objective tinnitus
- carotid artery stenosis
- aortic stenosis
- AV malformations
- eustachian tube dysfunction
blood tests for tinnitus
- FBC (anaemia)
- Glucose (diabetes)
- TSH (thyroid disorder)
- Lipids (hyperlipidaemia)
red flags in tinnitus
- unilateral
- pulsatile
- associated unilateral hearing loss
- associated sudden onset hearing loss
- associated vertigo or dizziness
- headaches or visual symptoms
- associated neurological symptoms
what are the two broad categories of problems that can cause vertigo
- a peripheal problem - affecting the vestibular system
- a central problem - involving the brainstem or the cerebellum
4 causes of peripheral vertigo
benign paroxysmal positional vertigo
meniere’s disease
vestibular neuronitis
labrynthitis
what causes benign paroxysmal positional vertigo
- crystals of calcium carbonate become dysplaced in the semicircular canals
- disrupt normal flow
- movement is required to disrupt the system sso it’s positional
- dix hallpike maneuver to diagnose
- rotate head 45 degees towards you
- lay back quickly and smoothly and flex neck to 20 degrees
- nystagmus if BPPV
- need to watch for a minute
what is acute vestibular neuonitis
inflammation of the vestibular nerve
usually attributed to viral infection
typical history is acute onset vertigo that impoves within a few weeks
what is labrynthitis
inflammation of the structures of the inner ear
usually attributed to a viral infection
typical history is of acute onset vertigo that improves within a few weeks
how do you distinguish labrynthitis from vestibular neuronitis
labrynthitis can cause hearing loss and vestibular neuronitis cannot
name causes of central vertigo
- pathologies that affect the cerebellum or the brainstem will disrupt the signals from the vestibular system and cause vertigo
- posterior circulation infarction
- tumour
- MS
- vestibular migraine
dizziness history important points
- distinguish between vertigo and lightheadedness
- “is the room moving or do you feel more lightheded”
- then differentiate between central and peripheral vertigo as per table
- key features that could point to a cause:
- Recent viral illness (labyrinthitis or vestibular neuronitis
- Headache (vestibular migraine, cerebrovascular accident or brain tumour)
- Typical triggers (vestibular migraine)
- Ear symptoms, such as pain or discharge (infection)
- Acute onset neurological symptoms (stroke)
treatment options for peripheral vertigo
prochlorperazine
antihistmines (cyclizine, cinnarizine, promethazine)
BPPV: epley manouvre
if someone has vertigo how do you differentiate between vestibular neuronitis and labrynthitis and menieres
- tinnitus and loss of hearing are NOT features of vestibular neuronitis as the cochlear and cochlear nerve are not affected
- if there is loss of hearing or tinnitus then suspect menieres or labrynthitis
- you can remember this with:
- Labyrinthitis – Loss of hearing
- Neuronitis – No loss of hearing
presentation of vestibular neuronitis
- acute onset vertigo
- maybe history of viral urti
- balance problems
- nausea and vomiting that may be severe
prognosis in vestibular neuronitis
symptoms most severe for the first few days after which they usually resolve over the following 2-6 weeks
what is meniere’s disease
Ménière’s disease is a long-term inner ear disorder that causes recurrent attacks of vertigo, and symptoms of hearing loss, tinnitus and a feeling of fullness in the ear.
what is the triad of symptoms in meniere’s
Hearing loss
Vertigo
Tinnitus
what causes meniere’s disease
excessive buildup of endolymph in the labrynth of the inner ear - this is called endolymph hydrops
this causes higher pressure than normal and disrupts sensory signals
typical presentation of meniere’s disease
- pt is 40-50yrs old
- unilateral episodes of vertigo, hearing loss and tinnitus
- the vertigo
- lasts for 20 minutes to a few hours
- episodes cluster over several weeks with months in between
- vertigo is not triggered by movement
- hearing loss
- fluctuates at first before becoming more permanent
- is sensorineural
- unilateral
- affects low frequency first
- tinnitus
- initially occurs with the vertigo before becoming more permanent
- other symptoms
- unexplained falls
- feeling of fullness
- imbalance
management of meniere’s
- for acute attacks
- prochlorperazine
- antihistamines (e.g. cyclizine, cinnarizine and promethazine)
- prophylaxis
- betahistine
what is an acoustic neuroma
Acoustic neuromas are benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear.
They are also called vestibular schwannomas, as they originate from the Schwann cells. Schwann cells are found in the peripheral nervous system and provide the myelin sheath around neurones.
They occur at the cerebellopontine angle and are sometimes referred to as cerebellopontine angle tumours.
presentation of acoustic neuroma
- The typical patient is aged 40-60 years presenting with a gradual onset of:
- Unilateral sensorineural hearing loss (often the first symptom)
- Unilateral tinnitus
- Dizziness or imbalance
- A sensation of fullness in the ear
- may also be associated with facial nerve palsy if the tumour grows big enough
NB if bilateral acoustic neuromas it’s NF2
managmenet of acoustic neuroma
- Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate
- Surgery to remove the tumour (partial or total removal)
- Radiotherapy to reduce the growth
what is cholesteatoma
abnormal collection of squamous epithelial cells in the middle ear
non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear
can predispose to significant infections
what are the symptoms of cholesteatoma
- foul discharge
- unilateral conductive hearing loss
- if it continues to expand
- infection
- pain
- vertigo
- facial nerve palsy
what is penicillin V aka
phenoxymethylpenicillin
what is the most likely location of bleeding in epistaxis
usually originates from Kiesselbach’s plexus which is located in Little’s area
this is an are of nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels
how to advise patients on how to manage nosebleeds
- sit up and tilt head forwards
- squeeze the soft part of the nostrils together for 10-15 minutes
- spit out blood in the mouth rather than swallowing
managment of severe nosebleeds
nasal packing using nasal tampons or inflatable packs
nasal cautery with silver nitrate
after treating consider giving naseptin nasal cream four times daily for 10 days to reduce crusting, inflammation and infection
difference between acute and chronic sinusitis
Acute (less than 12 weeks)
Chronic (more than 12 weeks)
name these sinuses
management for acute sinusitis
- no abx for symptoms up to 10 days - most will resolve within 3 weeks
- if not improving after 10 days
- high dose steroid nasal spray for 14 days
- mometasone
- delayed abx for if not improving within 7 days
- phenoxylmethylpenicillin
- high dose steroid nasal spray for 14 days
management of chronic sinusitis
Saline nasal irrigation
Steroid nasal sprays or drops (e.g., mometasone or fluticasone)
Functional endoscopic sinus surgery (FESS)
are nasal polyps usually bilateral or unilateral
usually bilateral
unilateral polyps are a RED FLAG and should raise suspicion of tumours
unilateral polyps need specialist referral
how do you investigate for nasal polyps
with a nasal speculum
alternatively use an otoscope with large speculum attached
they appear as round pale grey/yellow growths on the mucosal wall
management of nasal polyps
- unilateral polyps need to be referred for specialist treatment to exclude malignancy
- medical management of bilateral polyps
- intranasal topical steroid drops or spray
- surgical management for where medical management fails
- intranasal polypectomy if they’re close to nostrils
- endoscopic nasal polypectomy if further up
severe sleep apnoea can cause
hypertension
heart failure
myocardial infarction
stroke
how do you assess for OSA
epworth sleepiness scale
what is the most common and second most common cause of bacterial tonsillitis
most common: group A streptococcus (streptococcus pyogenes)
second most common: streptococcus pneumoniae
how do you decide whether to give abx for tonsilitis
- centor criteria
- a point for each of the following
- fever over 38
- tonsillar exudates
- absence of cough
- tender anterior cervical lymph nodes
- a score of 3 or more and give abx
- a point for each of the following
choice of abx for tonsillitis
Penicillin V (AKA phenoxymethylpenicillin) for a 10 day course is first line
if penicillin allergic then clarithromycin
relative incidence of quinsy and tonsillitis in children and adults
quinsy can occur just as frequently in teenagers and adults as it can in children
tonsillitis occurs much more commonly in children
what is the most common organism to cause quinsy
streptococcus pyogenes (group A strep)
staph aureus and haemophilus influenzae can also cause it
management of quinsy
referral to ENT for incision and drainage
abx before and after surgery (broad spec such as co-amoxiclav)
indications for tonsillectomy
- number of episodes of acute sore throat
- 7 or more in 1 year
- 5 per year for 2 years
- 3 per year for 3 years
- other indications
- 2 episodes of tonsillar abscesses
- enlarged tonsils that cause snoring or difficulty swallowing
most important complication of tonsillectomy
post-tonsillectomy bleeding
management of post-tonillectomy bleeding
- can be severe and life threatening due to aspiration of blood
- get ENT reg involved early
- IV access and send bloods
- fbc
- clotting
- group and save
- cross match
- sit up and encourage to spit out blood rather than swallow
- nil by mouth in case anaesthetic needed
- IV fluids for maintenance and resus if required
- to stop bleeding
- hydrogen peroxide gargle
- adrenalin soaked swab topically
- back to theatre
neck lump red flag referral criteria
- two week wait for:
- unexplained neck lump in someone aged 45 or above
- a persistent unexplained neck lump at any age
- urgent ultrasound for:
- a lump growing in size
- within 2 weeks in pts over 25
- within 48hrs if under 25
- then if US is suggestive of soft tissue sarcoma they need a 2 week wait
- a lump growing in size
what is often the first line investigation for neck lumps?
ultrasound
what are the broad causes of lymphadenopathy
- reactive
- e.g. URTI
- infected
- e.g. TB, infectious mononucleosis
- inflammatory
- e.g. SLE or sarcoid
- malignancy
- lymphoma, leukaemia, metastasis
features about lymph nodes that would suggest malignancy
- unexplained
- persistently enlarged
- over 3cm in diameter
- abnormal shape (normally length double width)
- hard or rubbery
- non-tender
- tethered or fixed to skin and underlying tissues
- associated symptoms
- night sweats
- weight-loss
- fatigue
- fevers
what is the presentation of infectious mononucleosis
- fever
- sore throat
- fatigue
- lymphadenopathy
- in response to amoxicillin or cefalosporins
- intensely itchy maculopapular rash
investigation of infectious mononucleosis
monospot test is first line
how many lymphomas are hodgkin’s lymphoma
1/5
what is the key finding on lymph node biopsy that would tell you it’s hodgkin’s lymphoma?
reed-sternberg cells
what is the staging system for lymphoma
ann-arbor
describe the ann arbor staging system
stage I: involvement of a single lymph node region or of a single extralymphatic organ or site
stage II: involvement of two or more lymph node regions on the same side of the diaphragm or localised involvement of an extralymphatic organ or site
stage III: involvement of lymph node regions or structures on both sides of the diaphragm
stage IV: diffuse or disseminated involvement of one or more extralymphatic organs
additionally A or B depending on presence or absence of B symptoms
what cells can grow carotid body tumours
glomus cells
these are the ones that contain the chemoreceptors to detect blood’s oxygen, carbon dioxide and pH
groups of glomus cells are called paraganglia
so carotid body tumours can sometimes be called paragangliomas
how would a carotid body tumour look
- in the upper anterior triangle of the neck
- near the angle of the mandible
- painless
- pulsatile
- associated with bruit on auscultation
- mobile side to side but not up and down
- can compress
- glossopharyngeal (IX)
- accessory (X)
- hypoglossal (XI)
- vagus (XII)
- horners
- ptosis
- miosis
- anhidrosis
- horners
characteristic finding on imaging investigations of carotid body tumour
splaying of internal and external carotid arteries
aka lyre sign
what is a thyroglossal cyst
During fetal development, the thyroid gland starts at the base of the tongue. From here, it travels down the neck to the final position in front of the trachea, beneath the larynx. It leaves a track behind called the thyroglossal duct, which then disappears.
When part of the thyroglossal duct persists, it can give rise to a fluid-filled cyst. This is called a thyroglossal cyst.
how do thyroglossal cysts look
- Thyroglossal cysts occur in the midline of the neck. They are:
- Mobile
- Non-tender
- Soft
- Move up and down with the movement of the tongue
management of thyroglossal cyst
surgical removal and histology
provides confirmation of diagnosis and prevents infetions
name 4 causes of glossitis
iron deficiency anaemia
folate deficiency
b12 deficiency
coeliac
treatment for oral candidiasis
miconazole gel
nystatin suspension
fluconazole tablets
name two causes of strawberry tongue
scarlet fever
kawasaki disease
what is leukoplakia
pre-cancerous condition
white patches on the tongue or buccal mucosa
increased risk of squamous cell carcinoma
patches are asymptomatic, irregular and slightly raised
may require biopsy to exclude abnormal cells
causes of apthous ulcers
- no cause - they can occur in healthy people
- coeliac
- IBD
- behcet disease
- vitamin deficiency
- iron
- b12
- folate
- vitamin D
- HIV
abx for throat infections
Phenoxymethylpenicillin (erythromycin alone if penicillin-allergic)
abx for sinusitis
Phenoxymethylpenicillin
abx for otitis media
Amoxicillin (erythromycin if penicillin-allergic)
abx for otitis externa
Flucloxacillin (erythromycin if penicillin-allergic)
abx for periodontal abscess
amoxicillin
