ENT Differential lists Flashcards
LARYNGOTRACHEAL STENOSIS x
Congenital
Acquired
- Traumatic
- Internal- intubation (90% of paed stenosis)
- External- penetrating, blunt
- Iatrogenic
- Tracheostomy, glottic web, supraglottic collapse
- Infection
- Tb, syphilis
- Inflammatory
- Wegener’s, sarcoidosis, SLE, pemphigus
- Neoplastic
Pathogenesis of post-intubation stenosis: ETT —> pressure necrosis and mucociliary stasis —> mucosal oedema and ulceration —> exposed cartilage —> infection/perichondritis —> cartilage necrosis —> granulation tissue —>- fibrous tissue deposition
Management:
- Medical- PPI, antibiotics, steroids
- Surgical
- Endoscopic - cold steel, KTP laser, balloon dilatation
PAROTID LUMP x
Neoplastic:
- Benign
- Monomorphic- Warthin’s, basal cell adenoma, oncocytoma
- Pleomorphic- Pleo
- Malignant
- Primary- MEC, Acinic, ACC, AdenoCa, carcinoma ex-pleo
- Secondary- metastatic SCC (MC parotid malignancy in Australia)
Non-neoplastic:
- Sjogren’s
- Sarcoid
- HIV
- Lymhpadenopathy
BILATERAL PAROTID SWELLING x
-
Sialadenosis nutritional/hormonal disturbances
- Enlarged acini + glandular hypertrophy
- Malnutrition
- Obesity
- DM
- Alcoholism
- Liver disease
- Eating disorders
- Recurrent Parotitis of Childhood -
Infective
- Viral- Mumps, HIV assoc lymphoepithelial cysts - Mumps vaccine has only moderate efficacy, thus can still get it after vaccination
- HIV may be- hyperplastic lymphadenopathy, benign lymphoepithelial cysts, diffuse infiltrative lymphocytosis syndrome
- Bacterial- acute suppurative parotitis, bilateral parotid abscesses
- Mycobacterial- TB -
Autoimmune/Granulomatous
- Sjogren’s — primary vs secondary
- Sarcoidosis
- Wegener’s- may be an early presentation of limited disease -
Neoplastic
- Warthin’s tumour
- Lymphoma- associated with Sjogren’s, HIV, chronic sialadenitis -
Iatrogenic
- Anaesthesia mumps
- Iodide mumps- following radiologic investigations
- Hypersensitivity vs toxic accumulation
- Radiation sialadenitis - RAI, EBRT
PARAPHARYNGEAL SPACE LESION x
-
Primary PPS lesion
- Salivary gland 50%
- Prestyloid (ICA posteriorly displaced), parotid > minor glands, benign = pleomorphic, malignant = MEC - Fat plane between mass and parotid differentiates minor salivary gland origin
- Neurogenic 20%
- Schwannoma - MC, X then SNS, IX, XI, XII. Cartoid anteriorly displaced
- Paraganglioma - vagale, carotid body, inferior extension of jugulare
- Neurofibroma - Multiple lesions suggests NF-1 (15% malignancy in NF-1, rare if sporadic)
- Miscellaneous 30% (LNs 50%, other 50%)
- Lipoma, rhabdomyosarcoma, haemangioma, haemangiopericytoma, lymphoma, teratoma, dermoid etc -
Metastatic disease
- H&N sites - Maxillary, Thyroid- papillary, medullary, NPC
- Distant sites - Breast, osteogenic sarcoma -
Direct extension at least as common as primary PPS lesion
- Mandible, maxilla, nasopharynx, neck, oral cavity, oropharynx, temporal bone
HYPERCALCAEMIA x
-
PTH-mediated
a. Primary- elevated PTH and Ca 1:1,000
b. Secondary - CRF —> chronic stim of PT glands due to subtle ionized hypocalcaemia for many years
c. Tertiary - Long-standing CRF —> PT glands autonomous
—> Ca low, PTH elevated
-
non-PTH-mediated
a. Malignancy-
- PTHrP secretion (lung, oesoph, H&N, kidney, ovary, bladder, breast)
- Ectopic PTH secretion (SCLC, Lung SCC, ovary, thymoma, PTC, HCC)
- Ectopic 1,25-dihydroxycholecalciferol
- Bone lytic lesions (multiple myeloma, lymphoma, breast, sarcoma)
b. Non-malignant- benign tumours, granulomatous, meds (thiazides, lithium)
DENTAL LESION x
Cysts
- radicular (periapical) cyst
- dentigerous cyst
- odontogenic keratocyst
Neoplasms
- Odontoma
- Ameloblastoma
- Odontogenic Myxoma
EPIPHORA
-
Excessive tear production
a. Primary
b. Secondary- FB, trichiasis, entropion/ectropion, conjunctivitis, dry eye syndrome, blepharitis, Crocodile tears syndrome - Lacrimal pump failure
-
Poor drainage through lacrimal system
a. Upper system obstruction- puncal/canalicular stenosis
b. Obstruction within lacrimal sac- tumours/dacryoliths/dacrocystitis/mucocele/pyocele
c. Lower system obstruction- NLD stenosis/obstruction
NASOLACRIMAL DUCT OBSTRUCTION
-
Congenital
a. Dacryostenosis
b. Absence of valves
c. Sac anomalies
d. Anomalies of the puncta
e. Anomalies of the canaliculi -
Acquired
a. Primary
b. Secondary
- Infections- bacterial, viral, fungal, parasitic
- Inflammatory- Wegener’s, Sarcoidosis, Histiocytosis, Kawasaki, Scleroderma
- Traumatic- iatrogenic, non-iatrogenic
- Mechanical- FB, external compression/occlusion - Toxic- eye drops, radiation, chemo, bone marrow transplantation
NASAL POLYP
Intracranial:
- Meningocele
- Encephalocele
- Glioma
Nasal/sinuses:
- Congenital
- Thornwaldt’s cyst
- Dermoid
- Infectious
- Adenoiditis
- Bacterial incl atypical
- Inflammatory
- Granulomatous
- Specific - Tb, Syphilis, Lyme
- Non-specific- Sarcoidosis, Wegener’s, Churg-Straus - Non-granulomatous - Neoplastic - Benign
- Malignant- Primary vs Secondary
EPISTAXIS
LOCAL: Idiopathic Traumatic- nose picking, foreign body, nasal fracture Iatrogenic- post-operative Inflammatory/Infectious- ARS/CRS, granulomatous disease, environmental irritants Neoplastic- haemangioma, haemangiopericytoma, JNA, pyogenic granuloma, sinonasal malignancy Structural- septal deformity, septal perforation Drugs- INCS, cocaine
GENERAL: Hypertension Atherosclerosis Coagulopathy- platelet dysfunction/deficiency, Warfarin, liver disease Leukaemia, von Willebrand’s disease HHT Medications- NSAIDs, Aspirin, Clopidogrel, Warfarin, Heparin/Clexane Alcohol- assoc with alcohol intake within last 24 hours
RHINITIS
Allergic: 50% of rhinitis
- Seasonal
- Perennial
- Occupational
Non-allergic: 50% of rhinitis. I/M rhinorrea, NAO, congestion unrelated to allergy
Atrophic replacement of ciliated columnar epi with stratified squamous
- Primary- e.g. aging, hereditary, nutrition, infectious - Secondary- surgery, cocaine, radiation, infectious (syphilis, rhinoscleroma)
Induced
- Exercise
- Gustatory- profuse watery rhinorrhea, esp spicy foods
- Hormone- e.g. pregnancy, hypothyroidism, acromegaly
- Pregnancy: Lasts > 6 weeks, no other cause - Worse in 2nd trimester (highest oestrogen), resolves after delivery
- Medication- Anti-HT, antipsychotics, antidepressants, NSAID
- Rhinitis medicamentosa- a-adrenergic agonists (e.g. oxymetazoline) .
- Rebound congestion with characteristic nasal mucosa, prone to bleeding
- Irritant- Cocaine, perfumes
- Occupational- IgE and non-IgE dependent mechanisms. Freq assoc with occupational asthma - Can be either a new rhinitis at work or an exacerbation of existing rhinitis
- Medicolegal implications
Systemic disorder
- Granulomatous- Wegener’s, Sarcoid, Churg-Strauss, Tb
- Autoimmune- SLE, Sjogren’s, Pemphigoid
- Ciliary- CF, PCD
Idiopathic = vasomotor rhinitis
NARES- non-allergic rhinitis with eosinophilia syndrome
- Symptoms similar to AR. Allergy tests -ve. Prominent eosinophils
SYSTEMIC DISEASE AFFECTING NOSE
Neoplastic
- Benign
- Malignant
- Epithelial- SCC, Adenocarcinoma, SNUC
- Non-epithelial- chondrosarcoma, rhabdomyosarcoma, lymphoma (incl NK-T cell), melanoma, neuroendocrine (Esthesio), vascular
Non-neoplastic
- Granulomatous disease- WG, CSS, Sarcoidosis have a predilection for the nose
- Specific (Tb, foreign body) vs non-specific (WG, Sarcoid) - Infectious- viral, bacterial (typical e.g. T.pallidum, K. rhinoscleromata or atypical e.g. Tb), fungal (immune competent vs compromised)
- Autoimmune - pemphigus, pemphigoid, Behcet’s
- Mucociliary - CF, PCD
SEPTAL PERFORATION
Traumatic:
- Iatrogenic
- Septoplasty, cautery, nasal packing
- Radiation
- Non-iatrogenic
- Haematoma/abscess
- Foreign body
- Gunshot/stab
Non-Traumatic:
- Irritant
- Cocaine, Decongestants, Arsenic, Fumes
- Infective
- Tb, syphilis, leprosy, rhinoscleroma, diptheria
- Fungal- incl Mucor
- Inflammatory
- Sarcoid, WG, RPC, SLE, RA, Crohns
- Neoplastic
- Epithelial- SCC, Adenocarcinoma
- Non-epithelial- Lymphoma (NK-T cell), Melanoma, Metastasis
FIBRO-OSSEOUS LESIONS
3 recognised benign fibro-osseous diseases
- Fibrous dysplasia
- Mono, poly, MAS - Ossifying fibroma
- A benign neoplastic disease - Osseous dysplasia (periapical, focal, florid)
- Close association with tooth roots
Other diseases that may be included in DDx: - Paget’s disease - Osteoid osteoma - Aneurysmal bone cyst - Cherubism - Brown tumour - Renal osteodystrophy - Low grade osteosarcoma
ANOSMIA
-
Conductive
- Tumour
- CRSwNP
- Allergic Rhinitis
- Nasal packing
- Anatomical deformities -
Sensory-Neural
- URTI
- CRSwNP
- Neurodegenerative disorder
- Traumatic Head Injury
- Toxins
- Congenital disorders (Kallman’s)
- Iatrogenic
- Miscellaneous
UNILATERAL MAXILLARY SINUS OPACIFICATION F MEN: Fungal Mucocele Encephalocele Neoplasia
-
Neoplastic
- Benign
- Papilloma- IP
- Fibro-osseous lesion- osteoma, FD, ossifying fibroma
- Salivary gland tumour- pleomorphic adenoma, oncocytoma
- Mesenchymal- fibroma, lipoma, myxoma
- Vascular- haemangiopericytoma, JNA, pyogenic granuloma
- Malignant
- Epithelial- SCC, adenocarcinoma, adenoid cystic carcinoma
- Non-epithelial- lymphoma, melanoma, sarcoma -
Non-neoplastic - Infective- Bacterial (ARS), fungal - Silent sinus syndrome
- Mucosal cyst
- Antrochoanal polyp
- Cholesterol granuloma
- Mucocele
UNILATERAL SPHENOID SINUS OPACIFICATION x
-
Within the sinus
- Sinusitis- bacterial, fungal
- Mucocele
- Fibrous dysplasia
- Neoplasm
- Benign (IP is rare)
- Malignant (SCC, adenocarcinoma) -
Outside of sinus
- Pituitary (adenoma, meningioma)
- Clivus (chordoma, craniopharyngioma)
- Meningoencephalocele
- ICA aneurysm
- Nasopharyngeal mass (NPC, JNA etc)
BENIGN SINONASAL TUMOURS
- Epithelial - Papilloma - Schneiderian papilloma (inverting, cylindrical, fungiform)
- Mesenchymal - Osteoma - Chondroma - Fibroma - JNA
- Neural - Schwannoma - Neurofibroma - Meningioma
- Fibro-osseous - Fibrous dysplasia - Ossifying fibroma - Aneurysmal bone cyst - Giant cell tumour/giant cell granuloma
- Vascular - Haemangioma - Haemangiopericytoma - Pyogenic granuloma
TELANGIECTASIA
- Congenital - HHT - Sturge-Weber syndrome - Ataxia-telangiectasia
- Acquired - Acne roasacea - Sun/cold exposure - Radiotherapy/chemotherapy - Carcinoid syndrome - Chronic steroids Rx
CONGENITAL VII PALSY
-
Developmental:
- Mobius syndrome (see Syndromes cards)
- Goldenhar
- Congenital unilateral lower lip paralysis
- Dystrophia myotonica
- CHARGE
- Alberg-Shoenberg disease (osteopetrosis)
- Melkersson-Rosenthal
- Relapsing peripheral VII palsy
- Chronic orofacial swelling
- Furrowed tongue dorsum (lingua plicata) -
Traumatic: Most common
- Risks: prolonged labour, forceps delivery
- Compression of VII s it exits SM foramen
- Soft TB, superficial location at SMF in neonate
- 90% spontaneous recovery rate
VOICE DISORDERS IN CHILDREN
-
Organic
- Voice quality disorders
- VC paralysis (see separate DDx card)
- Vocal fold pathology
- Granuloma
- Nodules, cysts, sulcus, polyp
- Web, stenosis, papilloma, malignant tumour
- Resonance disorders
- Hypernasality- esp VPI
- Hyponasality
- Choanal atresia
- Adenoid hypertrophy
- DNS/IT hypertrophy/nasal polyps - Functional
This algorithm can guide treatment
- Web/stenosis/papilloma/malignancy- surgery then voice therapy
- Nodules, cysts, sulcus, polyp- voice therapy +/- surgery if not improving
- Granuloma- medical Rx +/- surgery
- Resonance disorders- treatment specific for underlying pathology
- Functional- psych evaluation
Key differences in paediatric voice disorders:
- Inability to cooperate
- Lack of awareness of the problem
- Lack of motivation for change
- Surgery undertaken cautiously - larynx not mature and surgery more difficult
- Voice therapy is the mainstay
VOCAL CORD PARALYSIS IN CHILDREN
2nd most common cause of congenital stridor
- 10% of congenital anomalies of the larynx
Idiopathic 30%
- Onset birth- 8 weeks. U/L > B/L
- Recovery in 20%. May take years
Neurologic 50%
- 50% of cases
- Arnold-Chiari malformation MC
- Small posterior fossa causes cerebellar herniation and kinking of medulla
- 1/3 present with U/L VC palsy
- B/L VC palsy: intubation/trache. Decompression. If in 24 hrs, VC fxn returns in 2/52
Birth trauma 15%
- Complicated delivery requiring LSCS/forceps. U/L or B/L
Surgical trauma rare
- TOF repair or congenital heart disease repair (incl PDA)
Infectious rare
- Syphilis
Congenital - Scant reports with variable postulated inheritance patterns
50% are bilateral Overall 50% will recovery
- Secure airway while minimising detriment to vocal function
CONGENITAL NASAL DISORDERS
-
Anterior Neuropore
- Meningocele/encephalocele
- Faulty closure of foramen caecum — persistent CSF connection
- Glioma
- Premature closure of foramen caecum
- Nasal dermoid
- Irrevocably attached ectoderm pulled towards foramen caecum -
Central midface
- Cleft palate/lip
- Arhinia, polyrhinia
- Congenital pyriform aperture stenosis
- Nasolacrimal duct cysts (dacrocystoceles) -
Nasobuccal membrane
- Choanal atresia
AIRWAY OBSTRUCTION
Considered in terms of the level of obstruction:
-
Nasal
- Congenital pyriform aperture stenosis
- Choanal atresia -
Oropharyngeal
- Macroglossia/glossoptosis -
Supraglottis
- Laryngomalacia -
Glottis
- Vocal cord palsy
- Glottic web
- RRP -
Subglottis
- SG stenosis
- SG haemangioma -
Trachea
- Tracheomalacia
- Vascular compression
- Complete tracheal rings
PAEDIATRIC NECK MASS Central
-
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
PAEDIATRIC NECK MASS Lateral
-
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
VASCULAR ANOMALIES Muliken and Glowacki
-
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 -
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
Pediatric stridor
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
CONDUCTIVE HEARING LOSS
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
WHITE MIDDLE EAR MASS
Cholesteatoma
Tympanosclerosis
Endostosis
Graft/prosthesis
Tumour
BLUE/RED MIDDLE EAR MASS
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
PINNA INFLAMMATION
Infective
Bacterial
Viral- HZV
Inflammatory Allergy (hearing aid/topical med)
Relapsing polychondritis
SLE
Dermatologic disorders
EAC ULCER or BONY EROSION x
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
MIDDLE EAR EFFUSION
Infective- bacterial vs viral
Traumatic- barotrauma
Inflammatory- Wegener’s, Sarcoid
Neoplasia
CPA MASS - location-based
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
CPA MASS - Complete list - mnemonic for most common
- Schwannoma
- Fusiform, intracanalicular, acute angle at porous - 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 - Arachnoid cyst/aneurysm
- Epidermoid cyst/ependymoma
- Facial neuroma
- Petrous apex cholesteatoma
- Metastatic disease
- Haemangiopericytoma
Pnemonic for the common lesions is AMEN
A: acoustic schwannoma (~80%)
M: meningioma (~10%)
E: ependymoma (~5%)
N: neuroepithelial cyst (arachnoid/epidermoid) (~5%)
PETROUS APEX LESION
-
Inflammatory PA effusion>PACG>PA cholesteatoma
- Cholesterol granuloma MC primary lesion of PA - Petrous apex effusion
- Cholesteatoma- congenital vs acquired
- Mucocele -
Infectious
- Petrous apiciits
- Skull base osteomyelitis -
Neoplastic
- Benign- Schwannoma, Meningioma, Glomus
- Malignant- Primary vs Secondary (breast, lung, kidney, prostate)
- Epithelial- chordoma, NPC
- Non-epithelial- chondrosarcoma, rhabdomyosarcoma -
Other
- Asymmetrical pneumatisation
- Giant air cell
- ICA aneurysm- congenital weakness vs trauma vs infectious
AURAL POLYP
Divide it anatomically:
- External ear
- TM
- Middle ear
- 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
SUBJECTIVE TINNITUS
- Otologic- noise, NIHL, SNHL, Otosclerosis, Meniere’s
- Tinnitus may be related to hearing loss at the same frequency - Neurologic- VS, MS, head injury
- Infectious- OM, meningitis, syphilis
- Iatrogenic- surgery, medications- Aspirin, NSAID, aminoglycoside, quinine
- Metabolic- B12 deficiency, Zinc deficiency, Hypo/hyperthyroid, anaemia
- Psychogenic- Depression, Anxiety
- 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
PULSATILE TINNITUS Clinical exam and management
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
PULSATILE TINNITUS causes
- 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
- Myogenic - twitching or clicking sounds - Palate, stapedius, tensor tympani
- Patulous ET - To and fro movt of TM (synchronous with nasal respiration)
- TMJ dysfunction - Audible vibratory sound arising from jaw clenching
- Spontaneous OAEs - Extremely rare
VII PALSY Exam investigation Theories synkinesis
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
VII PALSY differential
Congenital - See separate card
Acquired
- 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 -
Iatrogenic
- Surgery, Anaesthesia
- Surgical complication or planned (e.g. facial rerouting -
Neoplastic
- Benign - schwannoma, meningioma, neuroma, haemangioma
- Malignant - SCC, adenoid cystic ca -
Trauma
- TB trauma, extracranial lacerations -
Toxic
- Thalidomide, Lead -
Inflammatory
- Sarcoidosis - MC otologic manifestation
- In isolation or aprt of uveoparotid fever (Heerfordt’s disease)
- WG - middle ear involvement with dehiscent Fallopian Canal
VERTIGO
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
CSF OTORRHEA
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
COMPLICATIONS OF AOM Contributing factors
Factors contributing to a rise in complications:
- Changing antibiotic resistance patterns
- S. pneumo now 50-60% - 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) - Changing antibiotic prescribing practices for AOM - Guidelines to hold antibiotics for AOM initially (? compliance with this though)
COMPLICATIONS OF AOM Complications diferrential
-
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) -
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
SYSTEMIC DISORDERS OF THE TEMPORAL BONE
1. Granulomatous/Infectious - Langerhan’s Cell Histiocytosis - Tuberculosis - Wegener’s granulomatosis - Sarcoidosis - Syphilis - Lyme disease - Mycotic disease
- Neoplastic - Multiple myeloma - Leukaemia - Metastasis
- Bone diseases - Paget’s disease - Fibrous dysplasia - Osteogenesis imperfecta
- Storage/Metabolic - Mucopolysaccharidoses - Gout
- Collagen vascular/autoimmune
- Immunodeficiency - Congenital - Acquired
BILATERAL SSNHL
- Infectious - HZV, HIV - Lyme, Syphilis - Meningitis
- Autoimmune/granulomatous - AIED - Sarcoidosis - Cogans
- Other - Trauma - Ototoxicity - NF-2 - Genetic (e.g. MELAS, other mitochondrial disorders
- Hyperviscosity
UNILATERAL SSNHL
- Idiopathic- 90% of all SSNHL
- Neoplastic- benign (VS, meningioma) vs malignant
- Traumatic
- Iatrogenic
- Infectious- Syphilis, HIV, HZV, HSV, mumps, rubella
- Inflammatory- WG, SLE, Sarcoid,
PARAGANGLIOMA 1. Vernet syndrome 2. Villaret syndrome 3. Brown’s sign 4. Aquino sign
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
OSSICULAR FIXATION
Congenital - congenital ossicular fixation
Acquired - Tympanosclerosis - Bony fixation - Infectious - cholesteatoma / CSOM - Surgical trauma - Temporal bone # - Bony lesions (Paget’s)
PROGRESSIVE SNHL CHILDHOOD
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
BLEEDING DISORDER
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
VOICE DISORDERS DDx
-
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
VOICE DISORDERS Janet Baker, 2002 Diagnostic Classification System for Voice Disorders (DCSVD)
Organic vs Functional (muscle tension vs psychogenic)
Organic disorders
- Mass lesions or changes
- Laryngeal trauma
- Neurologic- LMN: VC paralysis
- Neurologic- adductor/abductor spasmodic dysphonia
- 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
- Aphonia
- Dysphonia
- Psychogenic spasmodic dysphonia
- 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
RLN PALSY IN ADULTS 1/3 tumour 1/3 trauma 1/3 idiopathic
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
BILATERAL VOCAL CORD PALSY
- Traumatic - Surgical - Non-surgical
- Non-laryngeal malignancy
- Neurologic
- Intubation
- Idiopathic
- RA/CT disorder
Vocal fold immobility may be: \
- Paralysis
- Synkinesis
- CAJ fixation (trauma, arthritis, tumours)
- Interarytenoid scar
HALITOSIS
-
Local 90%
- Oral- gingivitis, periodontitis, tongue coating (bacterial, fungal), ulceration, malignancy - Pharyngeal- chronic tonsillitis, tonsoliths, deep neck space infection (retropharyngeal, peritonsillar) -
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
ORAL ULCER
-
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 -
Malignant
- Primary
- Epithelial
- Non-epithelial
- Secondary
SYSTEMIC EOSINOPHILIA
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
TONGUE LESION x
Ulcerative
Benign
- Erosive OLP
- Median rhomboid glossitis
- Amyloidosis
Malignant
- SCC
- Minor salivary gland tumour
Non-Ulcerative
