ENT II Flashcards
Presentation of BPPV
A variety of head movements can trigger attacks of vertigo.
A common trigger is turning over in bed.
Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks
BPPV does not cause hearing loss or tinnitus
Treatment for BPPV
Epley manoeuvre
Exercises to help improve BPPV symptoms at home
Brandt-daroff exercises
Neck lump red-flag referral criteria
An unexplained neck lump in someone aged 45 or above
A persistent unexplained neck lump at any age
Ultrasound scan referral criteria for neck lumps
Patients with a lump that is growing in size.
This should be within 2 weeks in patients 25 and older and within 48 hours in patients under 25.
They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma.
Causes of lymphadenopathy in the neck
Reactive lymph nodes (swelling caused by URTI, dental infection or tonsillitis)
Infected lymph nodes(TB, HIV or infectious mononucleosis)
Inflammatory conditions (e.g., systemic lupus erythematosus or sarcoidosis)
Malignancy (e.g., lymphoma, leukaemia or metastasis)
Which type of lymphadenopathy is most concerning in the neck
Enlarged supraclavicular nodes are the most concerning for malignancy of the cervical lymph nodes. They may be caused by malignancy in the chest or abdomen and require further investigation.
Features of malignant lymphadenopathy
Unexplained
Persistently enlarged (particularly over 3cm in diameter)
Abnormal shape (normally oval shaped)
Hard or “rubbery”
Non-tender
Tethered or fixed to the skin or underlying tissues
Features of lymphadenopathy in lymphomas
Characteristically non-tender and feel “rubbery”. Some patients will experience pain in the lymph nodes when they drink alcohol.
Causes of a goitre
Graves disease (hyperthyroidism) Toxic multinodular goitre (hyperthyroidism) Hashimoto’s thyroiditis (hypothyroidism) Iodine deficiency Lithium
Causes of salivary gland pathology
Stones blocking the drainage of the glands through the ducts (sialolithiasis)
Infection
Tumours (benign or malignant)
How do carotid body tumours present
They present with a slow-growing lump that is:
In the upper anterior triangle of the neck (near the angle of the mandible) Painless Pulsatile Associated with a bruit on auscultation Mobile side-to-side but not up and down
Neurological effects of carotid body tumours
May compress the glossopharyngeal (IX), vagus (X), accessory (XI) or hypoglossal (XII) nerves.
Pressure on the vagus nerve may result in Horner syndrome
Characteristic sign of carotid body tumours on imaging
splaying (separating) of the internal and external carotid arteries (lyre sign)
Features of lipomas
Soft
Painless
Mobile
Do not cause skin changes
Features of thyroglossal cysts
Mobile
Non-tender
Soft
Fluctuant
Move up and down with movement of tongue
Diagnosis of thyroglossal cysts
Ultrasound/CT
Mx of thyroglossal cysts
Thyroglossal cysts are usually surgically removed to provide confirmation of the diagnosis on histology and prevent infections.
The cyst can reoccur after surgery unless the entire thyroglossal duct is removed.
Main complication of thyroglossal cysts
Infection of the cyst, causing a hot, tender and painful lump.
What is a branchial cyst
A branchial cyst is a congenital abnormality that arises when the second branchial cleft fails to form properly - fluid filled lump is called a branchial cyst
Features of branchial cyst
Branchial cysts present as a round, soft, cystic swelling between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck.
Mx of branchial cysts
Conservative, without any active intervention, where it is not causing problems
Surgical excision where recurrent infections are occurring, there is diagnostic doubt, or it is causing other problems
What is vestibular neuronitis and what is it usually associated with
Inflammation of vestibular nerve attributed to a viral infection
What do semicircular canals detect
Rotation of head
What do otolith organs detect(utricle and saccule)
gravity and linear acceleration
Purpose of vestibular nerve
transmits signals from the vestibular system (the semicircular canals and vestibule) to the brain to help with balance
Presentation of vestibular neuronitis
History of URTI
Nausea and vomiting
Balance problems
Neuronitis vs labyrinthitis
Labyrinthitis – Loss of hearing
Neuronitis – No loss of hearing
Test to diagnose peripheral causes of vertigo
Head impulse test
Mx of peripheral vertigo such as neuronitis
Prochlorperazine
Antihistamines
(can be used up to 3 days)
Referral if symptoms do not improve after 1 week or resolve after 6 weeks –> may need vestibular rehabilitation therapy
Complication of neuronitis
BPPV
What is labyrinthitis
Inflammation of the bony labyrinth of the inner ear, including the semicircular canals, vestibule (middle section) and cochlea.
The inflammation is usually attributed to a viral upper respiratory tract infection
What can labyrinthitis be secondary to
Otitis media or meningitis
Presentation of labyrinthitis
Acute onset vertigo
Hearing loss
Tinnitus
What are acoustic neuromas
benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear
Where do acoustic neuromas tend to occur
cerebellopontine angle and are sometimes referred to as cerebellopontine angle tumours
Presentation of acoustic neuromas
Unilateral sensorineural hearing loss (often the first symptom)
Unilateral tinnitus
Dizziness or imbalance
A sensation of fullness in the ear
What can acoustic neuromas sometimes be associated with
Facial nerve palsy if tumour grows large enough
Diagnosis of acoustic neuromas
Audiometry(sensorineural hearing loss)
Brain imaging(MRI or CT)
Mx of acoustic neuromas
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
Risks of surgery for acoustic neuroma removal
Vestibulocochlear nerve injury, with permanent hearing loss or dizziness
Facial nerve injury, with facial weakness
Pathophys of meniere’s disease
Ménière’s disease is associated with the excessive buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals.
This increased pressure of the endolymph is called endolymphatic hydrops.
Presentation of meniere’s disease
Hearing loss(sensorineural)
Vertigo
Tinnitus
(unilateral)
What can sometimes be seen during an acute attack of meniere’s disease
Spontaneous nystagmus may be seen during an acute attack. This is usually in one direction (unidirectional).
Mx of acute attacks of meniere’s disease
Prochlorperazine
Antihistamines
Prophylaxis in meniere’s disease
Betahistine
What is a cholesteatoma
Abnormal collection of squamous epithelial cells in the middle ear.
It is non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear. It can predispose to significant infections.
Presentation of cholesteatoma
Foul discharge from the ear Unilateral conductive hearing loss Infection Pain Vertigo Facial nerve palsy
What can be seen on otoscope in cholesteatomas
build-up of whitish debris or crust in the upper tympanic membrane
Mx of cholesteatoma
CT head - diagnosis and plan for surgery
MRI may help assess invasion
Surgical removal
Where do nosebleeds usually originate from
Kiesselbach’s plexus, which is located in Little’s area. This is an area of the nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels.
What might bleeding from both nostrils indicate
Bleeding posteriorly in the nose –> higher risk of aspiration of blood
How should patients manage a nosebleed
Sit up and tilt the head forwards
Squeeze the soft part of the nostrils together for 10 – 15 minutes
Spit out any blood in the mouth, rather than swallowing
Treatment options for epistaxis
Nasal packing using nasal tampons or inflatable packs
Nasal cautery using silver nitrate sticks
what can be considered after an acute nosebleed
Naseptin nasal cream (chlorhexidine and neomycin) four times daily for 10 days to reduce any crusting, inflammation and infection. This is contraindicated in peanut or soya allergy.
What are nasal polyps associated with
Chronic rhinitis or sinusitis Asthma Samter’s triad Cystic fibrosis Eosinophilic granulomatosis with polyangiitis
Presentation of nasal polyps
Chronic rhinosinusitis Difficulty breathing through the nose Snoring Nasal discharge Loss of sense of smell (anosmia)
When should nasal polyps be referred
Unilateral polyps should be referred for specialist assessment to exclude malignancy.
Medical mx of nasal polyps
intranasal topical steroid drops or spray
Surgical mx of nasal polyps
Intranasal polypectomy
Endoscopic nasal polypectomy
What type of cancers are head and neck tumours usually
SCC
Risk factors for head and neck tumours
Smoking Chewing tobacco Chewing betel quid Alcohol HPV(strain 16) EBV
Red flags - head and neck tumours
Lump in the mouth or on the lip Unexplained ulceration in the mouth lasting more than 3 weeks Erythroplakia or erythroleukoplakia Persistent neck lump Unexplained hoarseness of voice Unexplained thyroid lump
Mx of head and neck tumours
MDT
Staging - TNM
Chemo/radiotherapy
Surgery
Indications for tonsillectomy
Acute sore throat(7 or more in 1 year)
Recurrent tonsillar abscess(2)
Enlarged tonsils causing difficulty breathing, swallowing or snoring
Complications of tonsillectomy
Sore throat where the tonsillar tissue has been removed (this can last 2 weeks)
Damage to teeth
Infection
Post-tonsillectomy bleeding
Risks associated with a general anaesthetic
Mx of post-tonsillectomy bleeding
Senior referral
IV access + bloods + group and save/crossmatch
Analgesia
Sit them up and encourage to spit blood rather than swallow
NBM
IV fluids
Options for stopping bleeding post-tonsillectomy
Hydrogen peroxide gargle
Adrenalin soaked swab applied topically
Intubation may be Druid
Causes of glossitis
Iron deficiency anaemia B12 deficiency Folate deficiency Coeliac disease Injury or irritant exposure
Causes of angioedema
Allergic reactions
ACE inhibitors
C1 esterase inhibitor deficiency (hereditary angioedema)
Risk factors for oral candidiasis
ICS Abx Diabetes Immunodeficiency Smoking
Treatment options for oral candidiasis
Miconazole gel
Nystatin suspension
Fluconazole tablets
What is leukoplakia and what is it associated with
White patches in the mouth, often on the tongue or insides of the cheeks (buccal mucosa). It is a precancerous condition, meaning it increases the risk of squamous cell carcinoma of the mouth.
Mx of leukoplakia
biopsy to exclude abnormal cells (dysplasia) or cancer. Management involves stopping smoking, reducing alcohol intake, close monitoring and potentially laser removal or surgical excision.
What is lichen planus
autoimmune condition that causes localised chronic inflammation of the skin. The skin has shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.
Mx of lichen planus
good oral hygiene, stopping smoking and topical steroids
Risk factors for gingivitis
Plaque build-up on the teeth (inadequate brushing) Smoking Diabetes Malnutrition Stress
Mx of gingivitis
Good oral hygiene
Stopping smoking
Dental hygienist treatment to remove plaque and tartar
Chlorhexidine mouth wash
Antibiotics for acute necrotising ulcerative gingivitis (e.g., metronidazole)
Dental surgery if required
Causes of gingival hyperplasia
Gingivitis Pregnancy Vitamin C deficiency (scurvy) Acute myeloid leukaemia Medications, particularly calcium channel blockers, phenytoin and ciclosporin
What are apthous ulcers
small, painful ulcers of the mucosa in the mouth. They have a well-circumscribed, punched-out, white appearance.
Causes of apthous ulcers
Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)
Coeliac disease
Behçet disease
Vitamin deficiency (e.g., iron, B12, folate and vitamin D)
HIV
Mx of apthous ulcers
Usually no intervention required
Choline salicylate (e.g., Bonjela) Benzydamine (e.g., Difflam spray) Lidocaine
topical corticosteroids in more severe ulcers
When should patients be referred for mouth ulcers
“unexplained ulceration” lasting over 3 weeks.
