ENT Differential lists Flashcards

Question

PAEDIATRIC NECK MASS   Central

Answer 1

1. **Central** - TGDC - Dermoid - Teratoma (need to excise as will enlarge - Arise from pluripotent cells, tissues foreign to the site from which they arise - Carinomatous or sarcomatous change occurs in 10-35% - Plunging ranula

Answer 2

2. **Lateral** - Branchial cleft cyst - Pseudotumour of infancy- not present at birth. Onset 1-8 weeks - Fibrous tissue, aetiology unknown ? birth trauma - Mid-portion of SCM, fusiform swelling - U/S for Dx, physio. Increase 2-3/12 then regress over 4-8/12 (disappear in 80%) - Lymphadenopathy - Viral- adenovirus, rhinovirus, enterovirus, EBV, CMV, HIV - Suppurative- S. aureus, Group A B-streptococci - Cat scratch- Bartonella henselae. Cervical adenopathy in \>90% - Most patients have a Hx of cat exposure (90%) and cat scratch (50%) - Malaise, fever, aches, anorexia - Dx = serology, Rx = Azithromycin/Ciprofloxacin - Toxoplasmosis- Toxoplasma gondii. Adenitis in 90% - Serology is Dx, Sulfonamide is Rx. Oocytes excreted in cat faeces - Dx = serology, Rx = Sulfonamide - Mycobacterium- 80% tuberculous, 20% NTM (MAC, kansaii, scrofulaceum) - Ant/sup neck, overlying skin discolouration, 50% fluctuant, 10% fistula - Dx = Mantoux (strong = tub, weak = non-tub). Rx: tub= 2 drug, non-tub=excision - Kawasaki's- Fever / Erythema lips - oral / Rash / Red hands / feet / Coronary Aneurysms - Vascular malformation- Lymphoma, RMS - Neoplastic- Lymphoma, RMS

Answer 3

1. **Vascular Tumours** endothelial cell hyperplasia - Haemangioma of Infancy - MC tumour of infancy (10% of infants, 60% in H&N) - Localised (75%) vs Segmental (25%) - Congenital haemangioma- RICH vs NICH - Kaposiform Haemangioepithelioma - Tufted angioma - Pyogenic granuloma 2. **Vascular Malformations** error of vasculogenesis - High flow - AVM (intracranial:extracranial = 20:1) - Arterial - Low flow - Capillary - Venous- soft compressible, increase size with straining and IJV compression - Rx with PDL laser - Lymphatic- macrocystic (\>2cm3) vs microcystic (\<2cm3) vs mixed

Answer 4

**Differential by anatomical subsite:** **Pharynx/hypopharynx** Glossoptosis Laryngopharyngeal reflux Vascular malformation Vallecular cyst **Supraglottis** Laryngomalacia Laryngocele Stenosis Vascular malformation Neck mass **Glottis** Vocal cord paralysis (bilateral\>unilateral) Intubation injury Laryngeal cleft Glottic web Stenosis Laryngeal trauma/fracture **Subglottis** Croup Intubation granulation/edema Acquired stenosis Hemangioma Cysts Congenital cricoid malformation Foreign body **Tracheobronchus** Tracheobronchomalacia Foreign body Complete tracheal rings Vascular compression Stenosis Bacterial tracheitis Neck/chest mass

Answer 5

**Congenital** Anotia/microtia, EAC atresia Syndromes- Treacher-Collins, PRS, Crouzon's/Apert's, Goldenhar's Otosclerosis, Paget's, Osteogenesis imperfecta **Acquired** Inflammatory/Infectious OE, AOM, OME, Cholesteatoma, Tympanosclerosis, Myringitis, Syphilis **Iatrogenic** Surgical complication/failure, traumatic ear cleaning, trauma, burns, FB, Barotrauma, TB fracture, Penetrating injury **Neoplasia** SCC, BCC, Melanoma, Pleomorphic adenoma **Metabolic/Systemic** Cerumen, Wegener's, Relpasing Polychondritis, Fibrous dysplasia, Polyarteritis nodosa, Sarcoidosis, Keratosis obturans **Other** Canal osteoma, canal exostosis, haemotympanum

Answer 6

Cholesteatoma Tympanosclerosis Endostosis Graft/prosthesis Tumour

Answer 7

**Normal variant-** high jugular bulb, dehiscent ICA, persistent Stapedial artery **Tumour**- glomus, minor salivary gland, schwannoma, Histiocytosis X, carcinoid **Inflammation**- cholesterol granuloma, Schwartze's sign **Trauma**- haemotympanum

Answer 8

Infective Bacterial Viral- HZV Inflammatory Allergy (hearing aid/topical med) Relapsing polychondritis SLE Dermatologic disorders

Answer 9

**Neoplasia** SCC Adenoid cystic BCC MSG Lymphoma Choelsteatoma/KO **Malignant** OE **Irradiation**- ORN **Others** 1st arch anomaly dermatologic disorders Trauma- burns, chemical Viral. fungal inflam

Answer 10

**Infective**- bacterial vs viral **Traumatic**- barotrauma **Inflammatory**- Wegener's, Sarcoid Neoplasia

Answer 11

**Extra-axial** - Vestibular schwannoma - Meningioma - Epidermoid (or other cysts- arachnoid, dermoid) - Non-acoustic neuromas (V, VII, IX, X, XI, XII) - Vascular lesions (loops, aneurysms, malformations) **Extradural** - Paraganglioma - Bone lesions (benign vs malignant, primary vs secondary) **Intra-axial** - Astrocytoma, Ependymoma, Papilloma, Haemangioblastoma

Answer 12

1. Schwannoma - Fusiform, intracanalicular, acute angle at porous 2. Meningioma - dural tail, obtuse angle with porous - Arise from arachnoid villi (present at porous) - More likely to be incompletely excised but better chance of hearing preservation 3. Arachnoid cyst/aneurysm 4. Epidermoid cyst/ependymoma 5. Facial neuroma 6. Petrous apex cholesteatoma 7. Metastatic disease 8. Haemangiopericytoma Pnemonic for the common lesions is **AMEN** A: acoustic schwannoma (~80%) M: meningioma (~10%) E: ependymoma (~5%) N: neuroepithelial cyst (arachnoid/epidermoid) (~5%)

Answer 13

1. **Inflammatory** PA effusion\>PACG\>PA cholesteatoma - Cholesterol granuloma MC primary lesion of PA - Petrous apex effusion - Cholesteatoma- congenital vs acquired - Mucocele 2. **Infectious** - Petrous apiciits - Skull base osteomyelitis 3. **Neoplastic** - Benign- Schwannoma, Meningioma, Glomus - Malignant- Primary vs Secondary (breast, lung, kidney, prostate) - Epithelial- chordoma, NPC - Non-epithelial- chondrosarcoma, rhabdomyosarcoma 4. **Other** - Asymmetrical pneumatisation - Giant air cell - ICA aneurysm- congenital weakness vs trauma vs infectious

Answer 14

Divide it anatomically: 1. External ear 2. TM 3. Middle ear 4. From outside (e.g. meningoencephalocele, parotid tumour e.g. SCC, TMJ fistula) Also then use surgical seive for each location: **Infective**- viral, bacterial, fungal, parasitic **Inflammatory**: - Chronic granulomatosis - Specific- Tb, Fungal, Syphilis, Leprosy - Non-specific- WG, PAN, SLE, Sarcoidosis **Neoplastic** - Benign- incl Histiocytosis - Malignant - Epithelial (SCC, adenoCa) - Non-epithelial (incl Lymphoma) **Traumatic**

Answer 15

1. Otologic- noise, NIHL, SNHL, Otosclerosis, Meniere’s - Tinnitus may be related to hearing loss at the same frequency 2. Neurologic- VS, MS, head injury 3. Infectious- OM, meningitis, syphilis 4. Iatrogenic- surgery, medications- Aspirin, NSAID, aminoglycoside, quinine 5. Metabolic- B12 deficiency, Zinc deficiency, Hypo/hyperthyroid, anaemia 6. Psychogenic- Depression, Anxiety 7. Other- TMJ / somatic Neurophysiologic model of tinnitus (Jastreboff): - Auditory perception due to aberrant spontaneous neural activity (altered state of excitation/inhibition within auditory system) - Limbic system responsible for development of tinnitus annoyance

Answer 16

**History**: - Vascular risk factors: HT, Hyperchol, smoking, DM, FHx - BIH risk factors: obese, female, steroid use. H/A, visual change, aural fullness, dizziness **Examination**: - Compression of IJV (reduce venous tinnitus) - Auscultation of neck/cranium (carotid bruit/AVM). Dural AVF --- retroauricular bruit - Otoscopy- glomus, high riding jugular bulb - Oropharyngeal exam- palatal myoclonus - Increase HR (e.g. run up stairs) to differentiate myoclonus from vascular cause **Investigation**: - Tympanometry- patulous ET = fluctuating trace - PTA- CHL (ME mass) - Bloods- hyperdynamic state- FBE, TFTs, BSL - Rarely required - Imaging - Suspicion of atherosclerosis Ultrasound (carotids, Echo) - Venous tinnitus- MRI/MRV - BHI: empty sella, small ventricles, flattening of posterior globes - Arterial tinnitus- CTA - Abnormal otoscopy- CTA - Cerebral angiography- if strong suspicion of AVM/AVF **Management**: Treat underlying cause BIH- weight loss, ? Acetazolamide Surgery- based on cause

Answer 17

1. **Vascular Arterial vs Venous Arterial -** Atherosclerotic disease (ICA) - Vascular tumours (glomus, haemangioma) - Vascular malformations (AVM, aneurysm- AICA, ICA, vertebral, fistulae e.g. dural AVM/AV fistula) - Dural AVF accounts for 15% of intracranial AVMs. Retroauricular bruits - Pulsatile tinnitus is MC manifestation of AVMs and dural AVFs - Dural AVFs --- risk of haemorrhage or ischaemic stroke (10%/year) --- mortality 20% - Management with transvenous + transarterial coiling - Transmitted cardiac murmurs - Hyperdynamic states - Superior canal dehiscence - Otosclerosis Venous - Increased ICP (venous hum)- MC cause of venous pulsatile tinnitus - Jugular bulb abnormalities   2. **Myogenic** - twitching or clicking sounds - Palate, stapedius, tensor tympani 3. **Patulous ET** - To and fro movt of TM (synchronous with nasal respiration) 4. **TMJ dysfunction** - Audible vibratory sound arising from jaw clenching 5. **Spontaneous OAEs** - Extremely rare

Answer 18

**Examination**: - Tone - Voluntary movement - Synkinesis (aberrant regeneration) **Investigation**: - Audio - Topodiagnostic testing (historical) - Electrophysiologic testing - NET, MST, ENoG, EMG **Synkinesis Theories:** - Cross re-innervation - Focal demyelination —\> lateral transmission btwn adj nerve fibres allowing depolarisation of adjacent nerve fibres - Facial nucleus hyperactivity secondary to continuous irritation

Answer 19

**Congenital** - See separate card **Acquired** 1. Infectious - Bell's (50%) - Pain around ear in 2/3, dysguesia, change in facial sensation - Normal audio (if abnormal, have to think of another diagnosis) - Complete recovery 85%, partial recovery 95% - Recovery: 60% by 3 months, 90% by 6 months - Viral - e.g. HZV, Gullian-Barre, EBV, HIV - Ramsey-Hunt (10%) order of Sx: severe pain, complete VII palsy, vesicles - May also have cochleovestibular disturbance - Bacterial- incl AOM, CSOM/cholesteatoma, MOE - Atypical- Tb, Lyme (can be B/L), Syphilis 2. **Iatrogenic** - Surgery, Anaesthesia - Surgical complication or planned (e.g. facial rerouting   3. **Neoplastic** - Benign - schwannoma, meningioma, neuroma, haemangioma - Malignant - SCC, adenoid cystic ca 4. **Trauma** - TB trauma, extracranial lacerations 5. **Toxic** - Thalidomide, Lead 6. **Inflammatory** - Sarcoidosis - MC otologic manifestation - In isolation or aprt of uveoparotid fever (Heerfordt's disease) - WG - middle ear involvement with dehiscent Fallopian Canal

Answer 20

**Can differentiate by sieve or by timing of Sx** **VERTIGO** acronym: **Vascular** - CNS causes - VBI, CVA **Epilepsy** **Rx** - Ototoxic drugs- Aminoglycosides, Cisplatin, Quinine, Salicylates (Aspirin), Diuretics (Frusemide) **Trauma** - TB #, PLF, Acoustic trauma **Infection** - TORCHS - Vestibular neuronitis **General med** - Hypo/hypertension - Hyper/hypoglycaemia - Cardiac- incl WPW **Otologic** (COMA) - Cholesteatoma - Otosclerosis - Meniere's - Acoustic Neuroma & Other - SSCC dehiscence

Answer 21

**Congenital** - Meningoencephalocele - Perilymph fistula **Acquired** - Traumatic - Iatrogenic- e.g. cholesteatoma surgery - Non-iatrogenic- TB #, PLF - Non-traumatic - Idiopathic- see Pathogenesis - Infectious- e.g. CSOM/cholesteatom - Neoplastic

Answer 22

**Factors contributing to a rise in complications:** 1. Changing antibiotic resistance patterns - S. pneumo now 50-60% 2. S. pneumo and H. flu vaccinations - Reduction in vaccine serotype infections (esp 19F) - Increase in non-serotype infections (now 19A most common, rare prior to vaccine) 3. Changing antibiotic prescribing practices for AOM - Guidelines to hold antibiotics for AOM initially (? compliance with this though)

Answer 23

1. **Intracranial** - Sigmoid sinus thrombosis - 5-15% of advanced mastoiditis cases. MC intracranial complication - Neuro signs (H/A, nuchal rigidity, photophobia, papilloedema, VI palsy) may predominate over otologic signs if ABx prescribed - Mastoidectomy + VT insertion. Opening sinus controversial. - No clear role for anti-coagulants. Only if extended (IJV/CST) - Brain abscess and subdural/extradural empyema - Combined ENT/Neurosurgical intervention - Otitic hydrocephalus\*\* - Meningitis \*\*Inc CSF pressure (nausea, vomiting, optic nerve head swelling)   2. **Extracranial** a. **Intratemporal** - VII Palsy - SNHL/CHL - Dizziness/Tinnitus - Petrous apicitis b. **Extratemporal** - Subperiosteal abscess - Bezold's abscess = deep to SCM - Citelli's abscess = PBD - Luc's abscess = zygomatic root **Griesinger's sign:** erythema/oedema over mastoid process due to septic thrombosis of mastoid emissary vein and thrombophlebitis of the sigmoid sinus

Answer 24

**1. Granulomatous/Infectious** - Langerhan's Cell Histiocytosis - Tuberculosis - Wegener's granulomatosis - Sarcoidosis - Syphilis - Lyme disease - Mycotic disease 2. **Neoplastic** - Multiple myeloma - Leukaemia - Metastasis   3. **Bone diseases** - Paget's disease - Fibrous dysplasia - Osteogenesis imperfecta 4. **Storage/Metabolic** - Mucopolysaccharidoses - Gout 5. **Collagen vascular/autoimmune** 6. **Immunodeficiency** - Congenital - Acquired

Answer 25

1. **Infectious** - HZV, HIV - Lyme, Syphilis - Meningitis 2. **Autoimmune/granulomatous** - AIED - Sarcoidosis - Cogans 3. **Other** - Trauma - Ototoxicity - NF-2 - Genetic (e.g. MELAS, other mitochondrial disorders 4. **Hyperviscosity**

Answer 26

1. Idiopathic- 90% of all SSNHL 2. Neoplastic- benign (VS, meningioma) vs malignant 3. Traumatic 4. Iatrogenic 5. Infectious- Syphilis, HIV, HZV, HSV, mumps, rubella 6. Inflammatory- WG, SLE, Sarcoid,

Answer 27

**VERNET SYNDROME** AKA Jugular foramen syndrome CN IX, X, XI palsy 50% have PCF disease (if CN XII included too, 75%) **VILLARET SYNDROME** Vernet + Horner's syndrome 50% have MCF involvement (via the ICA) Collet-Sicard IX - XII palsy **BROWN'S SIGN** Blanching of the middle ear mass on pneumatic otoscopy AQUINO SIGN Ipsilateral carotid compression leads to reduced pulsatile tinnitus

Answer 28

**Congenital** - congenital ossicular fixation **Acquired** - Tympanosclerosis - Bony fixation - Infectious - cholesteatoma / CSOM - Surgical trauma - Temporal bone # - Bony lesions (Paget's)

Answer 29

Tends to be bilateral, asymmetric, often fluctuating Hereditary cause most common    Hereditary - Syndromic - Alport's / Pendred - Non syndromic (MCC PSNHL) - tend to be AD - Present 1st / 2nd decade (AR tend to be prelingual hearing loss) Developmental - Mondini / EVAS / ECA Infectious - Congenital - CMV, Rubella, Syphilis, Toxoplasmosis - Acquired - Meningitis / Other viruses - HIV / HSV Metabolic - Hyperlipidaemia / hypothyroidism / Alport's Toxic - Ototoxic eg aminoglycosides esp if A1555G Autoimmune - Kawasaki / Cogan's Traumatic - PLF (congenital or acquired), CHI Vascular

Answer 30

**INCREASED VESSEL FRAGILITY** Infections (e.g. meningococcal) Drug reactions Scurvy, Ehlers-Danlos syndrome Henoch-Schonlein purpura HHT Perivascular amyloidosis **PLATELET DEFICIENCY/DYSFUNCTION** Reduced production- aplastic anaemia, leukaemia, chemo, NSAIDs, CRF Decreased survival- ITP, TTP, connective tissue disorders Sequesteration- Spleen normally sequesters 30%, splenomegaly = 80-90% **DERANGEMENT OF COAGULATION** Congenital typically a single factor - Haemophilia A and B- VIII and IX respectively - Von Willebrand's Disease- platelet function defects and VIII deficiency Acquired rarely affects a single factor - Vit K deficiency- inadequate stores, malabsorption, oral anticoagulants - Liver failure- Vit K deficiency, reduced synthesis, thrombocytopenia, functional abnormalities, DIC - DIC- consumption coagulopathy - Massive transfusion

Answer 31

1. **Organic** a) Anatomical - Epithelium - Leukoplakia - Hyperkeratosis - CIS/Carcinoma - Lamina propria - Diffuse = Reinke's - Focal = nodules, polyp, scar, cyst, sulcus, vascular, reactive - Arytenoid - Vocal fold granuloma - Infection - Other - Laryngeal web - Stenosis b) Movement disorder - Vocal cord paralysis/paresis - Paradoxical vocal fold motion - Muscle tension - Spasmodic dysphonia (adductor, abductor, mixed) - Essential tremor of the larynx 2. **Non-organic** - Psychogenic - Conversion

Answer 32

**Organic vs Functional (muscle tension vs psychogenic)** **Organic disorders** 1. Mass lesions or changes 2. Laryngeal trauma 3. Neurologic- LMN: VC paralysis 4. Neurologic- adductor/abductor spasmodic dysphonia 5. Neurologic UMN and assoc dysarthrophonia (wekaness/incoord of muscles of articulation/respiration/resonation/phonation) **Muscle tension disorders** Type 1: no secondary pathology Type 2: secondary pathology - 2a- mod hoarseness. Abuse inciduced inflam, oedema, nodule, ulcer - 2b- Severe hoarseness. Diffuse erythema and chronic laryngitis - 2c- Severe hoarseness. Reinke's oedema **Psychogenic disorders** 1. Aphonia 2. Dysphonia 3. Psychogenic spasmodic dysphonia 4. Puberphonia/mutational falsetto Functional Voice Disorders: aphonia/dysphonia with no organic pathology or, if there is, it is insufficient to account for nature/severity or is secondary to the functional problem Functional Voice Disorders consist of 2 main areas: - Muscle tension: disrupted vocal behaviours lead to poor vocal habits and susbsequent development of organic changes to the vocal folds - Psychogenic: disturbed psychological processes leading to loss of volitional control over voice

Answer 33

**Neoplastic** 25% - Bronchogenic Ca (50%) - Thyroid Ca - Upper oesophageal Ca - Laryngeal Ca **Surgical trauma** 20% - Thyroid (MC), carotid endarterectomy, ant approaches to cervical spine, skull base surgery, lung, heart, oesophagus, mediastinum **Idiopathic** 13% - Dx of exclusion. ? viral aetiology **Inflammatory** 13% - Tb **Traumatic** 11% - Enlargement of left atrium - Aortic aneurysm - Neck trauma **Neurologic** 7% - CHI, CVA, MS, Parkinsons, encephalitis, Bulbar palsy, Wallenber syndrome (PICA occlusion) **Miscellaneous** 11% - RA, haemolytic anaemia, Syphilis, Collagen diseases L = 75%, R = 25% (longer course of left RLN) - 10% bilateral

Answer 34

1. **Traumatic** - Surgical - Non-surgical 2. **Non-laryngeal malignancy** 3. **Neurologic** 4. **Intubation** 5. **Idiopathic** 6. **RA/CT disorder** Vocal fold immobility may be: \ 1. Paralysis 2. Synkinesis 3. CAJ fixation (trauma, arthritis, tumours) 4. Interarytenoid scar

Answer 35

1. **Local 90%** - Oral- gingivitis, periodontitis, tongue coating (bacterial, fungal), ulceration, malignancy - Pharyngeal- chronic tonsillitis, tonsoliths, deep neck space infection (retropharyngeal, peritonsillar) 2. **Systemic 10%** - Sinonasal disease- sinusitis, foreign body, PND - Gastrointestinal- pharyngeal pouch, reflux oesophagitis, hiatus hernia, achalasia - Hepatic- liver cirrhosis, cholecystitis - Respiratory- chronic bronchitis, bronchial carcinoma, bronchiectasis - Other- renal impairment, DKA - Psychogenic

Answer 36

1. **Benign** - Drugs - Stevens-Johnson Syndrome - Traumatic - Infectious - Bacterial - Staph / Strep / TB / Diptheria / Gonorrhoea - Viral (HSV, VZV, HHV, EBV, CMV, HIV, Coxsackie, Adenovirus) - Fungal - Candidiasis / Actinomyces - Parasitic/Spirochete - Syphilis - Inflammatory . - Sarcoidosis, Wegener's Granulomatosis, SLE, Crohn's - OLP, PV, MMP, Crohn's, Erythema Multiforme, Behcet's - Melkersson- Rosenthal = lip swelling / fissured tongue / VII palsy - Dental / periodontal - Necrotizing sialometaplasia - Recurrent Aphthous Stomatitis - Systemic disease - Nutritional - Immunosuppression- Leukaemia, HIV, Chemotherapy, Radiotherapy 2. **Malignant** - Primary - Epithelial - Non-epithelial - Secondary

Answer 37

1**. Allergic disorders** - Asthma - Hay fever - Drug allergies - Allergic skin disease (pemphigus, dermatitis herpetiform) 2. **Parasitic infection** 3. **Malignancy** - Hodgkin's +/- NHL 4. **Systemic autoimmune disease (SLE)** 5. **Vasculitis** - Churg-Strauss 6. **Cholesterol embolus (transient)** 7. **Hyperimmunoglobulin E syndrome**

Answer 38

**Ulcerative** **Benign** 1. Erosive OLP 2. Median rhomboid glossitis 3. Amyloidosis **Malignant** 1. SCC 2. Minor salivary gland tumour **Non-Ulcerative**