ENT Investigations and Management Flashcards
Tonsillitis investigations
None (throat swab not recommended)
Bacterial tonsillitis criteria
Centor
Fever PAIN
Bacterial tonsillitis management
Penicillin (clarithromycin if allergic)
If severe: IV fluids, IV antibiotics, steroids
Only need admission if can’t eat or drink
Tonsillectomy criteria
- Sore throats are due to tonsillitis
- Episodes of sore throat are disabling and prevent normal functioning
- 7 or more in past year OR
- 5 or more each of the past 2 years OR
- 3 or more each of the past 3 years
Peritonsillar abscess management
Aspiration and antibiotics
Infectious mononucleosis investigations
Atypical lymphocytes in peripheral blood
+ve monospot/Paul-bunnel test (heterophile antibody tests)
Low CRP
EBV IgM
Infectious mononucleosis management
Supportive management
Antibiotics in secondary bacterial infection
Maybe steroids if severe
Glue ear investigations
“age appropriate hearing assessment”
Audiometry
Tympanometry
Glue ear management
Review at 3 months with otoscopy, audiometry and tympanometry
May try autoinflation If persistent for >3/12 with symptoms: <3 years - grommets >3 years, first intervention - grommets >3 years, second intervention - grommets and adenoidectomy
If nasal syptoms, adenoidectomy may be considered earlier
Referral criteria for OME
Bilateral OME for 3 months CHL>25dB Speech/language problems Developmental behavioural problems Basically if symptoms persist
Management of airway obstruction
ABCDE Oxygen/heliox Steroid Nebulised adrenaline Flexible fibre-optic endoscopy ET tube (first line) Emerency needle cricothyroidotomy (temporary measure pending tracheostomy, only works for 30-45 mins as CO2 builds up) Tracheostomy
Treat underlying pathology
What may you need to give before airway endoscopy?
General anaesthesis (gas - sevoflurane. IV - propofol, remifentanyl)
Otitis externa management
Mild - acetic acid spray (Ear Calm) continuing 2 days after resolution
Moderate - sofradex or otomise (antibiotic and steroid) spray
Don’t swab
Severe - oral or IV antibiotics
Otitis media management
Most will resolve without antibiotics
Consider if otorrhoea
1st line amoxicillin
2nd line clarithromycin
Tympanic membrane perforation management
Nothing, usually heals spontaneously
Requires surgery if doesn’t heal (myringoplasty)
Management of cholesteatoma
Mastoid surgery (mastoidectomy)
Mastoiditis management
IV antbiotics
Middle ear drainage (myringotomy)
Mastoidectomy
Otosclerosis investigation
Audiometry with masked bone conduction shows a dip at 2kHz (Cahart’s notch)
Otosclerosis management
Stapedectomy
Or hearing aid
Vestibular schwannoma investigation
MRI scan
Septal haematoma management
Incision, drainage and packing
Nasal fracture investigations
None - clinical diagnosis
Nasal fracture management
Treat any symptoms
Reasses 5-7 days post-injury
Consider digital manipulation under anaesthetic within 3 weeks (10-14 days in handbook)
Epistaxis first aid management
Local treatment External pressure to nose Ice Cautery Nasal packing
Epistaxis specialist management
Resus on arrival if necessary
Pressure, ice, topical vasoconstrictor with maybe local anaesthetic
Remove clot (suction/nose blowing)
Anterior rhinoscopy
Cauterise vessel: silver nitrate/diathermy
Use rapid rhino pack if bleeding continues
Management of epistaxis controlled with initial specialist management
Arrange admission if packed/poor social circumstances
FBC, G&S (group and save)
NO SEDATION
Management of epistaxis not controlled with initial specialist management
Arterial ligation Maybe embolisation (can cause stroke)
Management of CSF leak
Often settle spontaneously
Need repair if lasting for 10 days
Management of pinna haematoma
Aspiration OR
Incision and drainage OR
Pressure dressing
No good evidence which technique is best
Management of pinna lacerations
Debridement
Close (primary or reconstruction)
Local anaesthetic
Antibiotics if exposed cartilage
Temporal bone fracture investigation
Axial CT
Temporal bone fracture management
Often delayed as polytrauma
Facial nerve decompression if no recovery and EMG studies
CSF leak, most settle but need repair
May need hearing restoration (hearing aid or ossiculoplasty)
Difference between immediate and delayed facial paralysis in temporal bone fracture
Immediate - disruption to facial nerve by fracture that can be treated.
Delayed - likely swelling causing it which will improve with time
Management of sudden sensorineural hearing loss
Steroid
Urgent referral to ENT
If no improvement then intra-tympanic steroids
Foreign body in ear management
Can wait till urgent clinic
Remove watch batteries immediately
Drown live animals with oil which can be removed the next day
Management of neck injury that has not gone through the platysma
Just stitch it up
Neck trauma investigations
FBC, G&S/cross matching AP/lateral neck x-ray (foreign body?) CXR (haemopneumothorax, emphysema) CT angiogram (vascular, pseudoaneurysm, laryngeal, aerodigestive tract) MR angiogram
Neck trauma management
Urgent exploration - expanding haematoma, hypovolaemic shock, airway obstruction, blood in aerodigestive tract
Laryngoscopy, bronchoscopy, pharyngoscopy and oesophagoscopy
Angiography - embolise
Deep space neck infection investigation
CT
Deep space neck infection management
Fluid resus
IV antibiotics
Incision and drainage of neck space
Orbital blowout fracture investigation
CT sinuses (tear drop sign)
Orbital blowout fracture management
Conservative
Surgical repair of bony walls if: entrapment, large defect, significant enophthalmos
Le fort fracture investigation
CT
Le fort fracture management
Surgery
Ageing cosmetic treatment ladder
Botulinum toxin Fillers Blepharoplasty Skin rejuvenation Face lift
Skin and soft tissue reconstruction options
Primary closure
Healing by secondary intention
Skin grafts
Skin flaps
What is used to harvest skin in skin grafts?
Dermatome
Investigation for laryngeal cancer
Ultrasound and FNA
Laryngoscopy and biopsy
HPV status
CT/MRI for staging
Investigation for salivary gland tumour
US FNA CT (staging) MRI (deep lobe) PET (metastatic nodes)
Minimally invasive technique for parotidectomy
Facelift approach
Indications of transoral robotic surgery
Tonsil cancer
Laryngeal cancer
Pharyngeal cancer
Tongue cancer
Laryngeal cancer management
Radical radiotherapy for small tumours
Larger tumours treated with laryngectomy and block dissection of neck glands
Oropharyngeal cancer investigations
Forceps biopsy of lesion
CT/PET CT of neck
Orophayngeal cancer management
Surgery and radiotherapy (either first line in early cancer)
General management of salivary gland tumours
Surgery
Radiotherapy
Management of pleomorphic adenoma
Surgical removal
Management of warthins tumour
Partial parotidectomy
Management of mucoepidermoid carcinoma
Low grade - excision
High grade - excision and radiotherapy
Management of adenoid cystic carcinoma
Surgical excision and post-operative radiotherapy
Pain management where oral route no-longer an option
Syringe driver
Transdermal patch
Palliative management of stridor
Active sedation
Palliative management of major haemorrhage
Large doses of midazolam IM or IV
Don’t leave patient alone
Rhinitis examination
Airway patency
External nose
Rhinoscopy
Allergic rhinitis management
Allergen avoidance
Nasal irrigation
1. Intranasal antihistamine/oral antihistamine
2. Intranasal steroid
Nasal polyps management (commoner in non-allergic asthma)
Steroid drops for 6 weeks then long term nasal spray
If no better then endoscopic sinus surgery
Acute infective rhinosinusitis management
Analgesics and decongestants (98% are viral)
If persisting/worsening add antibiotic
Potential allergy testing
Skin prick tests
RAST (IgE levels)
(I don’t think you do these unless clinical suspicion)
Vasomotor rhinitis management
Topical anticholinergic
Management of unilateral nasal discharge
Refer urgently
In a young child it might be foreign body
In adult it might be nasal or paranasal tumour
BPPV investigation
Dix-hallpike test
BPPV management
Epley manoeuvre
Semont manoeuvre
Brandt-Daroff exercises
Vestibular neuronitis/labyrinthitis management
Supportive management with vestibular sedatives
Prolonged or atypical then may require further investigation
Rehab exercises if prolonged
Menieres disease investigation
Audiometry
Menieres disease management
Supportive during episodes Tinnitus therapy Hearing aids Grommet insertion (meniette) Intratympanic steroid/gentamicin Surgery e.g. labyrinthectomy/vestibular nerve section
Diphtheria management
Antitoxin and supportive
Penicillin/erythromycin
Candida throat infection management
Nystatin or fluconazole
Malignant otitis (basically osteomyelitis) investigations
PV/CRP
radiological imaging
Biopsy and culture
Malignant otitis management
Ciprofloxacin PO or piperacillin/tazobactam IV
Fungal otitis externa management
Topical clotrimazole
Acute sinusitis management
1st line - phenoxymethypenicillin
2nd line - doxycycline (not in children)
