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MSRA Content > ENT - Level 3 > Flashcards

ENT - Level 3 Flashcards

1
Q

Definition of cholesteatoma?

A
  • Abnormal accumulation of squamous epithelium and keratinocytes within middle ear
  • Active squamous chronic otitis media
  • Keratinising squamous epithelia (of the skin) within middle ear with foul-smelling otorrhoea
  • Can be locally invasive
  • Bone erosion occurs mainly by pressure and release of osteolytic enzymes
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2
Q

Epidemiology of cholesteatoma?

A
  • Young children
  • 1 in 10000
  • Peak Age: 5-15 years
  • Males
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3
Q

Risk factors of cholesteatoma?

A

o Ear trauma
o Insertion of Grommets
o Otitis media

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4
Q

Classifications of cholesteatoma - congenital?

A

 Squamous epithelium becomes trapped within temporal bone during embryogenesis
 It expands, resulting in conducting hearing loss

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5
Q

Classifications of cholesteatoma - primary acquired?

A

 Most common type
 Chronic negative middle ear pressure
 Dysfunctional Eustachian tube causes erosion of tympanic membrane and defect

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6
Q

Classifications of cholesteatoma - secondary acquired?

A

 Insult to tympanic membrane (perforation or trauma)

 Squamous epithelium implanted by insult

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7
Q

Symptoms of cholesteatoma?

A 
o	Foul-smelling otorrhoea
o	Deafness
o	Headache
o	Ear pain
o	Facial paralysis
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8
Q

Signs of cholesteatoma?

A

o Ear discharge
o Deep retraction pocket in tympanic membrane, with or without granulation tissue
o Crust or keratin in upper tympanic membrane

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9
Q

Assessment of cholesteatoma?

A
  • If ear drum cannot be seen:
    o Treat infection if present
    o Refer to ENT
  • CT imaging
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10
Q

Management of cholesteatoma - all people?

A

arrange semi-urgent referral to ENT specialist

o For audiology and CT scan

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11
Q

Management of cholesteatoma - emergency referral?

A

o Facial paralysis, pain, signs of meningitis

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12
Q

Management of cholesteatoma - medical therapy?

A
  • Medical therapy (only if unfit/refuse for surgery/prior to surgery)
    o Regular ear cleaning with topical antibiotics
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13
Q

Management of cholesteatoma - surgical therapy?

A
  • Mastoid surgery to remove disease
    o Mastoidectomy and tympanoplasty
     Second procedure after 9-12 months
    o Myringoplasty – repair of tympanic membrane
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14
Q

Complications of cholesteatoma?

A 
o	Meningitis
o	Cerebral Abscess
o	Conductive Hearing Loss
o	Mastoiditis
o	Facial Nerve Dysfunction
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15
Q

Definition of acoustic neuroma?

A
  • Indolent, histologically benign slow-growing subarachnoid tumours
  • Causes problems by local pressure and behave as space-occupying lesions
  • Tumour of vestibulocochlear nerve - arise from superior vestibular nerve Schwann cell layer
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16
Q

Location of acoustic neuroma?

A

o Internal auditory canal or cerebellopontine angle

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17
Q

Causes of acoustic neuroma?

A

o 40% a defect in long arm of chromosome 22
o Neurofibromatosis Type-2 – particularly bilateral
o High-dose ionising radiation

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18
Q

Symptoms and signs of acoustic neuroma?

A

Progressive ipsilateral tinnitus +/- sensorineural deafness (cochlear nerve compression)
o Any unilateral sensorineural hearing loss suspicious

Impaired facial sensation

Balance problems

Large tumours – ipsilateral cerebellar or raised ICP symptoms

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19
Q

Management of acoustic neuroma - referral?

A
  • Refer urgently ENT for:
    o Audiological assessment
    o MRI for all those with unilateral tinnitus/deafness
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20
Q

Management of acoustic neuroma - conservative?

A

o Small neuromas and good hearing

o Watch and wait – annual scans to monitor growth

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21
Q

Management of acoustic neuroma - surgical?

A

o Microsurgery

 Risks include – death, CSF leak, meningitis, cerebellar injury, stroke

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22
Q

Management of acoustic neuroma - radiotherapy?

A
  • Stereotactic Radiosurgery

o Single large dose of radiation to control growth of tumour

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23
Q

Definition of nasal polyps?

A
  • Lesions arising from nasal mucosa, occurring at any site in nasal cavity or paranasal sinuses
  • Most commonly in clefts of middle meatus
24
Q

Pathology of nasal polyps?

A

o Sac-like entities with eosinophil rich oedematous wall

o Poor blood supply

25
Q

Epidemiology of nasal polyps?

A
  • Males more than females
26
Q

Causes of nasal polyps?

A
  • Linked with chronic inflammation – chronic rhinosinusitis and vasculitis
27
Q

Symptoms and signs of nasal polyps?

A
  • Recurring acute or chronic sinusitis
  • Symptoms
    o Nasal airway obstruction
    o Nasal discharge – watery, sneezing, postnasal drainage
    o Dull headaches
    o Snoring
    o Decreased smell/taste
  • Examination with nasal speculum
    o Visualise polyp – often bilateral
28
Q

Investigations of nasal polyps?

A

o Rigid or flexible endoscopy (rhinoscopy)

29
Q

Management of nasal polyps - referral to ENT?

A

o Unilateral polyp

o Children – risk of cystic fibrosis

30
Q

Management of nasal polyps - medical management (1st line)?

A 
o	Topical corticosteroids – nasal sprays
	Betnesol spray
o	Nasal douche – saline 
o	Antihistamines (if allergic rhinitis present)
	Beconase spray
31
Q

Management of nasal polyps - surgical management?

A

Functional endoscopic sinus surgery (FESS)

 Used when medical management fails

32
Q

Complications of nasal polyps?

A

o Acute bacterial sinusitis
o Sleep disruption
o Structural abnormalities

33
Q

Prognosis of nasal polyps?

A

o Recurrence is common

34
Q

Most common form of H&N cancer?

A
  • SCC represent >90% of H&NC

- 6th most common cancer

35
Q

Risk factors for H&N cancer?

A 
o	Smoking
o	Alcohol
o	Poor dentition
o	Poor diet
o	GORD
o	HPV Type 16 (oropharyngeal)
36
Q

Types of H&N cancer?

A

o Oral cavity cancers (buccal mucosa, alveolus, hard palate, anterior 2/3rd of tongue, floor of mouth, lip)
o Cancer of pharynx
o Cancer of larynx
o Salivary gland, nose, sinus, middle ear

37
Q

Symptoms of oral cavity H&N cancer?

A

o Mass, painless and felt on inner lip/tongue/floor of mouth/hard palate
o Bleeding
- Erythroleukoplakia

38
Q

Symptoms of pharyngeal H&N cancer?

A

o Odynophagia, dysphagia, otalgia

39
Q

Symptoms of laryngeal H&N cancer?

A

o Horse voice, stridor, dysphagia, persistent cough, referred otalgia

40
Q

Referral H&N cancers - laryngeal cancer?

A

 Aged 45 and over with:
• Persistent unexplained hoarseness or
• Unexplained lump in the neck

41
Q

Referral H&N cancers - laryngeal cancer?

A

 Unexplained ulceration in oral cavity for >3 weeks or
 Persistent and unexplained lump in neck
 Consider to dentist if lump on lip, red/white patch consistent with erythroplakia, erythroleukoplakia

42
Q

Investigations in H&N cancers?

A

o Clinical examination
o Endoscopy
o Fine-needle aspiration
o CT/MRI for staging

43
Q

Management of H&N cancers - early stage?

A

o Surgery
o Radiotherapy
o Neoadjuvant chemotherapy

44
Q

Management of H&N cancers - advanced stage?

A

o Radiotherapy + Surgery

45
Q

Definition of trigeminal neuralgia?

A
  • Severe, episodic facial pain in distribution of 1 or more branches of 5th cranial nerve
  • Typically, maxillary or mandibular branches
  • Frequency from a couple of times a year – hundred of times a day
46
Q

How common is trigeminal neuralgia?

A
  • Rare

- 3% cases bilateral

47
Q

Causes of trigeminal neuralgia?

A

o 95% caused by vascular compression of trigeminal nerve, leading to demyelination of nerve root entry zone
o Other causes – MS, tumours, skull base abnormalities

48
Q

Risk factors of trigeminal neuralgia?

A 
o	MS
o	Advancing age
o	Females
o	FHx
o	Hypertension and stroke
49
Q

Triggers of trigeminal neuralgia?

A 
o	Touching face
o	Talking
o	Cold wind
o	Vibration
o	Cleaning teeth
o	Shaving
50
Q

Symptoms of trigeminal neuralgia?

A

o Pain in distribution of trigeminal nerve that is:
 Severe, unilateral, short-lived, recurrent, episodic
 Often described like sharp ‘electric shocks’
 Provoked by factors like light touch, eating, talking or exposure to cold air
o Preceding symptoms – tingling/numbness

51
Q

Red flag symptoms of trigeminal neuralgia?

A 
o	Sensory changes
o	Deafness
o	Pain in eye socket
o	Optic neuritis
o	FHx of MS
o	Age <40
52
Q

Diagnosis of trigeminal neuralgia?

A
  • Clinical diagnosis
  • Rule out dental causes of pain
  • Specialist tests:
    o MRI to exclude causes
53
Q

Management of trigeminal neuralgia - if red flag symptoms?

A
  • Refer urgently for specialist assessment if red flag symptoms
54
Q

Management of trigeminal neuralgia - if severe pain?

A
  • Refer to neurologist or specialist pain service
55
Q

Management of trigeminal neuralgia - if no red flag symptoms?

A

o Carbamazepine 100mg BDS and titrate up every 2 weeks in 100-200mg until pain relieved
o If contraindicated/ineffective then refer to specialist
o Early follow-up to assess progress

56
Q

Management of trigeminal neuralgia - specialist treatments?

A

o Lamotrigine, phenytoin or gabapentin
o Microvascular decompression surgery
o Stereotactic radiosurgery (gamma knife)

57
Q

Prognosis of trigeminal neuralgia?

A
  • Attacks can occur daily for time or can be remission
    o 50% experience remissions of >6 months
  • 10% will not respond to neuropathic pain drug therapy

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