ENT Essentials Flashcards
when do adenoids usually regress by
aged 13
causes of hypertrophy of adenoids
acute infection
allergy
inflammatory conditions
symptoms of enlarged adenoids
nasal obstruction - mouth breathing, snoring, hyponasal speech
Nasal discharge
OSA
otalgia from eustachian tube obstruction
deafness from AOM and otitis media with effusion
Diagnosing adenoid enlargement
clinically
FNE
Indications for adenoidectomy
nasal obstruction
Glue ear
recurrent AOM
OSA
Methods for performing adenoidectomy
curettage
suction diathermy
coblation
contraindications to adenoidectomy
URTI recently
uncontrolled bleeding disorders
Cleft palate - either overt or submucosal
why is cleft palate a contraindication to adenoidectomy?
adenoids assist in closure of nasopharynx from oropharynx - velopharyngeal insufficiency can result
Complications of adenoidectomy
soft palate damage
haemorrhage
subluxation of atlanto-axial joint
eustachian tube stenosis
hypernasal speech - treat with speech therapy and give it time, otherwise pharyngoplasty
treatment of post adenoidectomy bleed
return to theatre
post nasal pack
what % of blood volume can children lose before increase in SVR and HR
30%
define age associated hearing loss
prev. known as presbyacusis
progressive bilateral SNHL where other causes have been excluded
describe the pathophysiology of age associated hearing loss
reduction in number of inner and outer hair cells, particularly at basal end of cochlea
indications for an MRI if SNHL?
asymmetry on PTA of 15dB or more at any 2 adjacent test frequencies
commonest pattern on PTA of age associated hearing loss
sloping, high frequency SNHL
Aim of treatment of age associated hearing loss
assess degree of disability
provide hearing aid
rehabilitate patient
rehabilitation available for age associated hearing loss?
lip reading classes
auditory training
Define barotrauma
damage to body structures due to changes in atmospheric pressure
Causes of barotrauma (3)
flying
diving
hyperbaric oxygen therapy
Describe boyles law
as ambient pressure increases, volume of a gas decreases
advice to prevent barotrauma
dont sleep during aircraft descent
encourage eating and drinking i.e. ET opening
topical decongestants or oral decongestants if needed
Control any co-existant rhinitis prior to flying
why are divers advised not to dive if have an URTI
ETD - if unable to equalise pressures may get a perforation - cold water caloric - resulting acute vertigo and vomiting can be fatal in a diving situation
Causes of cervical lymphadenopathy
infection - URTI, dental, EBV, Kawasaki
inflammatory - SLE, sarcoidosis
Neoplastic - lymphoma, mets from H&N primary, mets from skin cancer or distant sites
Investigations for cervical lymphadenopathy
FNA
US
CT/MRI
Bloods
Sulphur granules on FNA cytology?
actinomycosis
what is heerfordt’s syndrome
bilateral parotid swelling, anterior uveitis, facial palsy and fever –> sarcoidosis
diagnosis of sarcoidosis
CXR
ACE
serum calcium (elevated)
caseating granuloma on biopsy
negative tuberculin test
treatment of sarcoidosis
steroids
ENT presentation of SLE
cervical lymphadenopathy
recurrent mouth ulcers
motility disorders of oesophagus
diagnosis of SLE
ANA on serology
treatment of SLE
NSAIDs
Steroids
immunosuppresants
hydroxychloroquine
methotrexate
diagnosis of lymphoma
Can be suspected from FNA but needs formal biopsy
level 2 nodes are
upper jugular nodes
level 3 nodes are
mid jugular nodes
level 4 nodes are
lower jugular
level 5 nodes are
posterior triangle
level 6 nodes are
anterior compartment group
level 7 nodes are
superior mediastinal group
first echelon draining lymph nodes for primaries are
define cholesteatoma
collection of migrating keratinising squamous epithelium trapped within the middle ear or mastoid
describe pathophysiology of congenital cholesteatoma
arises from epithelial cell rests in forming middle ear which would usually have disappeared at 17 weeks gestation, usually present as a pearly white mass behind an intact TM
describe how a cholesteatoma causes its complications
proteolytic enzymes released by outermost layer of cholesteatoma erode adjacent bone, ossicles, exposing inner ear, facial nerve, meninges of brain
deafness due to damage of bones in middle ear but also erosion of labyrinth (would be associated with dizziness due to damage to vestibular apparatus) - usually damages lateral SCC causing positive fistula sign
invasion of facial nerve directly
brain abscess, meningitis, venous thrombosis from direct spread of cholesteatoma to brain
why is cholesteatoma easily infected
contents of cholesteatoma have no blood supply so easily infected by any bacteria
presentation of cholesteatoma
hearing loss
foul smelling otorrhoea
may have otalgia
investigations for cholesteatoma
PTA
CT temporal bones
MRI for recurrence monitoring
Biopsy only needed if suspect malignancy
how to perform masking
tragal rub - occlusion of auditory canal by putting pressure on tragus with rubbing motion
Barany box
what is bings test
similar to rinne’s test - tuning fork strunk and placed on mastoid then ipsilateral meatus occluded by examiners finger and subject asked if noise is quieter or louder
external parts of a cochlear implant
microphone
speech processor
transmitter coil
differential diagnosis of cough
laryngopharyngeal reflux
post nasal drip
CRS
laryngeal hypersensitivity
laryngeal dysfunction
allergic response
airway stenosis
Management of laryngopharyngeal reflux
lifestyle changes - avoiding certain food and drink, food diary, avoiding large meals at bedtime, avoiding caffeine at bedtime because relaxes lower oesophageal sphincter
medication - PPI, antacids
investigate for causes such as hiatus hernia and refer to appropriate team
management of drooling
watchful waiting
anticholinergic agents to dry secretions such as hyoscine patches, oral glycopyrrolate
SLT physical therapies
Botox into salivary glands occasionally
surgery - rare but removal of glands for example or adenotonsillectomy
organisms responsible for epiglottitis
haemophilus influenza type B
streptococcus pyogenes
streptococcus pneumoniaw
staphylococcus aureus
Which vessel usually responsible for traumatic epistaxis and why
nasal trauma often involves the vomer and superior part of nasal septum which is supplied by a branch of anterior ethmoidal artery - therefore ligation of SPA and anterior ethmoidal may be required in traumatic epistaxis
causes of epistaxis
iatrogenic (nasal surgery, intranasal steroids)
trauma (fractures, foreign body, nose picking)
inflammatory (rhinitis, sinusitis)
neoplastic (pyogenic granuloma, juvenile angiofibroma, SCC)
idiopathic
anticoagulants
bleeding disorders
HHT
HTN
inheritance of HHT
AD
treatment of HHT epistaxis
KTP laser
septodermoplasty
Young’s procedure
tamoxifen
bevacizumab (inhibits vascular endothelial growth factor)
commonest abnormalities which cause a prominent ear
poorly developed antihelical fold
overly developed prominent deep conchal bowl
treatment of bat ears
small babies with modest deformity - ‘ear buddies’ - splints which enourage pinna to adopt appropriate shape
earfold nitinol implants
pinnaplasty
risk factors for perichondritis
local trauma (burns/bites/piercings)
OE
commonest organism responsible for perichondritis
pseudomonas aeruginosa
staph aureus
what is chondrodermatitis nodularis helicis and treatment
tender red nodule on ear
usually due to area of localised damage to cartilage skeleton from trauma or inflammatory reaction to cold temperatures
keep ear warm, excision biopsy
name of syringe used for ear syringing
higgison syringe
exostoses vs osteoma
osteoma - benign tumour of bone arising from tympanosquamous or tympanomastoid suture line
exostoses - more common, hyperostoses of tympanic bone of external canal
define fistula
communication between 2 epithelial lined surfaces
define sinus
epithelial lined blind ending tract
when does the branchial apparatus appear
4th week of foetal development
consequence of persistance of a branchial cleft or pouch
simple sinus opening externally or internally respectively
consequence of persistence of both a cleft or a pouch
development of a fistula with internal and external openings, joined by a fistula tract
what is the first branchial arch responsible for forming
malleus, incus, mandible, maxilla
what is formed from first arch pouch
eustachian tube
middle ear
what is formed from first arch cleft
external auditory meatus
how do first branchial arch fistulas present
very uncommon
but usually large with superior opening in external auditory canal and inferior opening in neck between tragus and hyoid bone
what does the second branchial arch form
stapes, stylohyoid ligament, posterior portion of hyoid bone
what does the second arch pouch form
bed of tonsillar fossa
how does a second branchial arch fistula form
skin opening in neck at anterior border of SCM and internal opening in tonsillar fossa
investigation of second branchial arch fistula
fistulogram
CT with contrast
MRI
how would 3rd and 4th branchial arch fistula present
uncommon
skin opening in neck, internal opening in pyriform fossa or pharynx
what is an oroantral fistula
communication between oral cavity and maxillary sinus - caused by infection, cancer, developmental clefts, cocaine abuse, tooth extraction (most commonly)
management of oroantral fistula
small - conservative management or simple primary closure
larger - buccal or palatal mucoperiosteal flap
what suggests a FB in pharynx
increasing odonophagia
pain on gentle side to side manipulation of larynx
history
how does button battery cause trauma
button battery in contact with tissue on both sides of battery creates an electric current between the terminals, causes sodium hydroxide to build up in tissues, causes caustic burn
complications of button battery
nose - septal perforation
ear - external ear canal skin destruction, TM destruction
phayrngeal perforation
oesophageal perforation
what to do after FB removal from nasal cavity
reexamine afterwards to ensure no second FB more posteriorly
how to determine if there is an oesophageal perforation post FB
gastrografin swallow or omnipaque 500 swallow
soft food bolus in oesophagus management
admit
IV buscopan
diazepam
fizzy drink
barium swallow to look for cause of obstruction
management of sharp FB in oesophagus
rigid oesophagoscopy
if a mucosal tear, keep in hospital post procedure, IV abx, 4 hours NBM post procedure
CXR findings of FB in trachea/bronchi
show the FB if radoiopaque
consolidation/collapse/hyperinflation/mediastinal shift
management of fb in bronchi
bronchoscopy
how to remove fb in bronchi of young children
ventilating hopkins rod bronchoscopes
t1 vs t2 mri images
t1 - csf/globe fluid signal dark, fat white
t2 - fluid white, fat also white
contrast agent used in mri
gadolinium
imaging choice for cholesteatoma
hrct temporal bones - shows well defined mass in middle ear cleft with or without ossicular erosion
what is an ager nasi cell
pneumatisation of agger mound which can extend into frontal recess and cause mechanical obstruction
pneumatised middle turbinate, when enlarged can narrow middle meatus and osteomeatal complex, resulting in obstruction. inflammation and fluid opacification can also occur in concha bullosa resulting in bullitis
haller cell
ethmoid air cells which have projected inferiorly along the medial aspect of the orbital floor and obstruct the maxillary ostium if enlarged
exercises used in acute labyrinthitis and when to start them
cooksey cawthorne exercises but only commence once initial phase of symptoms have settled. Can accelerate recovery and central compensation.
what is a labyrinthine fistula
bony erosion of labyrinthine capsule to expose/rupture endosteum of labyrinth - endosteum is a thin layer of periosteum separating membranous labyrinth from dense cortical bone covering SCCs, breach results in perilymph fistula and may cause vertigo and a dead ear
what is tullio phenomenon
vertigo in presence of loud sounds - associated with semicircular canal dehisence
speech options for laryngectomy patients
oesophageal voice
prosthetic speech valve
electrolarynx
laser stands for
light
amplification by the
stimulated
emission of
radiation
safety precautions laser
designated laser environment with appropriate sinage (signs on all theatre access doors when laser in use, with theatre doors locked/signs saying dont enter)
laser safety officer and supervisor appointed and trained appropriately
all laser users should attend regular update courses
anaesthetic consideration - non inflammable anaesthetic agent, ensure ET cuff inflated with saline not air
patient - saline soaked drapes on face and taped eyes/safety goggles
all theatre personnel to wear safety goggles
regular maintenance and checking of aiming beam and laser output
non refelctie scopes
adequate suction availability
complications of mastoid surgery
facial nerve injury
hearing loss
tinnitus
vertigo
change in taste
dural injury
vascular injury - sigmoid sinus, petrous carotid artery
complications and management of complications of temporal bone fractures
facial palsy - steroids, monitor, surgical decompression
CSF otorrhoea/rhinorrhoea - bed rest, head elevation, stool softeners, LD if not settling, if persists more than 10 days surgical exploration
perilymph fistula - surgical exploration
TM perforation - conservatively with water precautions, if not healed after 6-8 weeks tympanoplasty
EAC fracture - conservative, but may result in canal stenosis and cholesteatoma
ossicular damage - monitor for some time then tympanotomy
