ENT + MaxFax Flashcards
Red flags for rhinorrhoea
USC:
Unilateral nasal obstruction, bloody discharge, or mass- sinonasal malignancy
Abnormal facial sensation, visual disturbance
Admit:
CSF rhinorrhoea if recent head injury
Foreign body in children (unilateral foul discharge)
Allergic rhinitis treatment
Loratadine 10 mg OD/cetirizine 10 mg OD
Fexofenadine 120 to 180 mg OD
Mometasone 50mcg 2 sprays each nostril OD. 1 spray each nostril once a day when controlled
Avamys 2nd line, dymista 3rd line
Saline irrigation
Decongestants 3-5 days
Nasal antihistamine azelastine 1 spray BD
Montelukast if also asthmatic
Red flags anosmia
USC if anosmia >6 weeks associated with:
-any neurological symptoms
-unilateral nasal bleeding
-a neck lump >3 weeks
Anosmia associated with a recent head or neck injury (admit)
Dangers of anosmia – the smell of smoke, natural gas, and rotting food cannot be detected
Red flags dysphagia
Unable to swallow saliva due to food bolus obstruction or foreign body (admit)
USC if progressive dysphagia or weight loss
ENT oropharyngeal, direct gastroscopy of oesophageal
Causes odynophagia
Pain on swallowing
Infections -candida, HSV, CMV.
Chemical -drugs, radiation,
Crohn’s disease, severe reflux.
Xerostomia (dry mouth) – drugs, Sjogren’s syndrome.
Oesophageal malignancy.
Symptoms and causes of pharyngeal vs oesophageal dysphagia
Pharyngeal:
Delayed or difficulty initiating swallowing and may be associated with coughing, choking or nasal regurgitation
Chest infections
Feels food gets stuck at throat level
Wet/gurgling voice
If hoarseness, dysphonia, nasal speech and dysphagia, consider muscular dystrophies
Parkinson disease, MS, stroke, MND, pharynx tumour.
Oesophageal:
Few seconds after swallowing
Motility disorders, e.g. achalasia, scleroderma (intermittent symptoms)
Oesophageal cancer if weight loss, smoking, alcohol, Barrett’s oesophagus or rapidly progressive dysphagia
Reflux if slower onset
Eosinophilic oesophagitis if associated with atopy, or asthma
Examination for dysphagia
Watch dry swallow then with water
Check cranial nerves, look for muscle weakness, spasticity, tongue atrophy, facial asymmetry, sensory changes.
Looks for tremor/rigidity (PD)
Red flags for ear discharge
Sepsis
Mastoiditis (pinna pushed forward and fever> 38ºC)
Signs of intracranial infection (fever and headache
Facial palsy
Recent head injury with CSF leak
Chronic suppurative otitis media or cholesteatoma or grommet
Persistent, offensive ear discharge, lasting longer than 6 weeks, which is usually painless.
Otomize, review fortnightly until discharge resolved, then again in 4 weeks. If no improvement at 2 weeks, swab and ENT advice
Red flags facial pain
Suspected intracranial malignancy, e.g. severe constant headache that is worse in the mornings and associated with nausea or focal neurology
Suspected meningitis
Differentials for jaw pain
TMJ dysfunction
Temporal arteritis
Migraine
Trigeminal neuralgia
Dental problems
Shingles
Other ENT disorders, e.g. head and neck cancers, salivary gland disorders
When do you refer to maxfax for TMJD?
Same day if open lock
Urgent referral if closed lock
Routine ref:
-Pain or reduced function with known inflammatory or degenerative joint disease.
-Recurrent joint dislocation
-Congenital or development deformities of the face and jaw.
-No resolution within 3 months
Trigeminal neuralgia symptoms and treatment
Unilateral, episodic, lancinating “electric shock like” pains
Minimal triggers, e.g. the cold, wind, eating, brushing teeth, applying make up, shaving
Trial carbamazepine after checking LFTs + rpt 6 weekly until stable dose
Assess response after 2-3 weeks:
Good response-routine neurosurgery ref + MRI trigeminal nerve
No response, wean off carbamazepine + routine maxfax ref (unlikely TGN)
Severe, malnutrition: urgent neurosurg ref
Red flags hearing loss
Acute ENT assessment in children if:
Sudden onset of hearing loss that is not associated with URTI
Offensive discharge associated with hearing loss
Arrange emergency assessment if sudden onset hearing loss:
associated with neurological symptoms, e.g. dizziness, cerebellar signs or symptoms.
with significant head injury.
For unexplained sudden onset of hearing loss, seek ENT advice about emergency assessment.
Routine ENT ref if:
asymmetric sensorineural hearing loss.
perforation persists for 6 weeks or longer.
If chronic hearing loss ref audiology
If chronic conductive hearing loss and:
polyp with offensive discharge (suspected cholesteatoma)-ENT advice.
benign bony growth-routine ENT ref
Childhood hearing loss history
Delay in speech or language development
Frequently bored, fidgety, or uncooperative
Mispronouncing words
Recent infection or trauma
Routine child audiology referral criteria
Concerns about hearing loss.
Concerns about their hearing or glue ear but no other ENT symptoms.
Otitis media> 3 months
Speech, language, or developmental delays.
Previous/current hearing aid user +new concerns.
Unilateral or bilateral sensorineural hearing loss or congenital hearing loss.
Suspected retraction of TM or cholesteatoma
Risk factors hearing loss
Noise exposure in job/hobbies
Water exposure
Head injury
Diabetes, HTN, autoimmune disease, vascular disease, neurofibromatosis type 2, sarcoidosis
Previous otological surgery
FHx of hearing loss or otosclerosis
Sudden onset sensorineural hearing loss management
If otoscopy normal and RInne/Weber suggest sensorineural, ENT advice re urgent audiology and PO prednisolone 1 mg/kg to a maximum of 60 mg once a day for 7 days then wean
Mouth ulcer underlying conditions
Food allergy, e.g. chocolate, cinnamon, benzoate
Nutritional deficiencies, B12, iron, folic acid, B vitamins
Coeliac disease
IBD
Behçet’s disease
Immunodeficiencies, HIV and cyclic neutropenia
Nicorandil, methotrexate
Cancer
FBC, B12, folate, ferritin, anti‑tTG
Red flags oral lesions
Suspicious oral and oropharyngeal (tongue, hard or soft palate, uvula, floor of mouth) lesion or mass with:
Erythroplakia and erythroleukoplakia or non‑healing ulceration more than 3 weeks
Underlying causes of hoarse voice
Asthma and inhaled medications
GORD
MND
Thyroid disease
Post stroke
Parkinson’s disease
Chronic rhinosinusitis
Voice misuse
Red flags voice hoarseness
USC ENT if:
Hoarseness> 4 weeks, especially in smokers
with suspicion of malignancy, e.g. haemoptysis, throat pain, dysphagia, neck mass, mass or tumour on chest X‑ray, or weight loss.
Do CXR with all smokers with hoarse voice
Nasal injury referral criteria
ED if:
Compound (open) fracture.
Other facial fractures – maxilla, zygomatic arch.
Septal haematoma.
Clear watery fluid running from nose following trauma.
Epistaxis that fails to settle.
ENT Hot clinic if:
External nasal deformity within 7 days of the injury for manipulation
Red flags in neck lumps adults
USC ENT if:
Associated upper aerodigestive tract symptoms and any red flags, odynophagia, or weight loss.
Red flags:
Hoarseness
Dysphagia
Nasal obstruction or bleeding
Oral ulceration
Local pain or referred otalgia
Criteria for high suspicion of neck or salivary cancer:
Unexplained neck or salivary mass and:
>1 cm > 3 weeks
Increasing in size
Previous head and neck cancer including skin cancer
Facial palsy
Any new unexplained upper respiratory tract symptoms, e.g. hoarseness, dysphagia, throat or ear pain, blocked nose or ear
Any suspicious neck lumps
USC USS + biopsy criteria for neck lump
Neck lump 3-4 weeks duration
No associated upper aerodigestive tract symptoms
No red flags, odynophagia, or weight loss
No systemic cause
Adult neck lump management
Examine neck, axillae, groin, mouth
If ?systemic cause then bloods, CXR and review in 2 weeks. Consider HIV/TB testing
Child neck lump assessment
Unexplained fevers, fatigue, night sweats, pruritis, bone pain, bruising, pallor, weight loss.
Intercurrent illnesses – URTI/LRTI, mouth ulcers, skin infections.
Family or travel contact with TB.
Check for pallor, bruising, petechiae, hepatosplenomegaly
Temperature, height, and weight loss
Consider lymphoma if progressive,
> 2 cm, rapidly growing, often rubbery or matted, non-tender cervical lymph nodes.
If reducing size<2 cm in 2 weeks no further input required
Red flags neck lumps children
Admit if:
-neonatal vascular mass.
-suspected lymphoma or other malignancy.
-suspected atypical mycobacterial lymphadenitis (non‑tuberculous).
-infected thyroglossal cyst (mid‑line lump).
-suspected abscess.
Referral criteria children with neck lumps
If suspected bacterial lymphadenitis age> 2 years, treat with abx for 1 week. Review after 48 hours. If no improvement, admit for IV abx
If midline lump with no red flags, USS + urgent paeds referral
Features of malignant otitis externa
Otalgia out of proportion to clinical findings
Otorrhoea
Severe canal oedema or signs with open canal and a small granulation of the floor
Involvement of cranial nerves (VII to XII)
Referral criteria otitis externa
Acute ENT assessment if:
any features of malignant otitis externa.
the patient is febrile or systemically unwell.
severe cellulitis (perichondritis or facial cellulitis).
Hot clinic if:
Ear is full of debris.
No improvement after using ear drops.
Recurrent otitis externa causing significant morbidity.
Otitis externa not responding to recommended treatment.
When do you treat acute otitis media with antibiotics?
Aged<= 2 years with bilateral acute otitis media.
Otorrhoea.
Systemically unwell or high risk of complications.
Several presentations during the same illness.
Recurrent AOM – 3 episodes of AOM within 6 months.
Consider delayed script if symptoms not improving within 3 days or worsen rapidly or significantly at any time.
Referral criteria otitis media
Acute ENT:
suspected mastoiditis.
facial nerve palsy.
bacterial labyrinthitis.
Routine paed ENT if:
>6 episode within 12 months.
persisting otitis media with effusion (OME):
more than 3 months if bilateral.
more than 6 months if unilateral.
Seek ENT advice if:
Fails to respond to abx
TM still perforated and discharging at 2 weeks.
What is otitis media with effusion?
Presence of fluid in the middle ear without evidence of acute inflammation.
Absence of pain, fever minimal inflammatory changes of TM.
Peak incidence aged 5 years.
Very common
Spontaneous resolution is common 6-10 weeks
Down’s syndrome incr risk, risk hearing +language impairment
Reduce recovery time with Otovent nasal ventilation balloon if age>3
Referral criteria for otitis media with effusion
Urgent paediatric ENT:
-confirmed or suspected structural damage to the tympanic membrane.
-negative impacts on speech or education
-young patient with physical, structural, or medical comorbidities, or disability precluding audiology.
If hearing is normal but there are concerns about speech and language development, consider requesting routine community paediatric assessment.
If CSOM and a discharging ear that is not responding to 2 weeks treatment, seek ENT advice.
If OME persists and there is high suspicion of significant conductive hearing loss, request paediatric audiology.
Red flags recurrent epistaxis + underlying diagnosis
Angiofibroma (rare benign nasal tumour, usually in males aged 12–20 years of age) — suggested by nasal obstruction and severe epistaxis.
Cancer -nasal obstruction, facial pain, hearing loss, eye symptoms (proptosis or double vision), persistent lymphadenopathy. Incr risk age>50 with occupational exposure to wood dust or chemicals, and South Chinese or North African.
Telangiectasia — Red or purple spots on the fingertip pads, lips, lining of the nose, and occasionally the ears and face. FHx hereditary haemorrhagic telangiectasia.
Age <2 years is uncommon- inflicted or unintentional injury, bleeding disorder, abuse, or neglect.
If abnormal bruising or ecchymosis, weight loss, or pallor, consider bleeding or haematological disorder or malignancy, e.g. leukaemia
If recurrent and severe ?FHx ?vonWillebrand ?clotting disorder
Signs of bacterial sinusitis
Discoloured or purulent secretion in the nose – predominately unilateral.
T> 38°C.
Moderate to severe facial pain – predominantly unilateral.
Deterioration after early improvement of initial milder illness.
>10 days
Referral criteria epistaxis in a child
If bleeding is severe or persistent- ED
If suspected child neglect or abuse- child safeguarding assessment.
If suspected foreign body- acute ENT.
If suspected tumour, angiofibroma, or polyp, request urgent paediatric ENT
If suspected or confirmed bleeding disorder, seek immediate paediatric medicine advice
If suspected malignancy, seek immediate paediatric medicine advice.
Management sinusitis
<5 days: decongestants, saline irrigation
>10 days: mometasone steroid spray
Abx (amoxicillin)
Causes bilateral parotid swelling
Mumps
Sjögren syndrome (ANA + RF)
diabetes
alcohol dependency.
Red flags partoid swelling
Unilateral firm swelling affecting just part of the parotid gland
Facial nerve dysfunction
Treatment sialadenitis
Usually a bacterial infection – fluclox
Regular massage, forwards from the ear to the corner of the mouth.
Encourage the patient to keep well-hydrated, take pain relief, and rest.
If a stone (sialolithiasis) is suspected, sucking a lemon wedge or sour lolly throughout the day can aid in expulsion of a stone.
If it fails to resolve within 7 to 10 days, request acute ENT assessment.
Referrals for parotid swelling
If suspected tumour, USC ENT.
If acute sialadenitis +systematically unwell, or abscess, seek ENT advice ?admit for IV abx.
If inflammation fails to resolve within 7 -10 days, acute ENT assessment.
If chronic or recurrent episodes of infection, consider routine ENT ? surgery.
If Sjögren syndrome, routine rheumatology.
If suspected mumps, notify Public Health Wales who will organise appropriate testing.
Causes tinnitus
Constant:
Recent trauma- loud noise, head injury, barotrauma- should resolve over hours.
Ototoxic medications include:
Gentamicin, SSRIs, Vancomycin
Loop diuretics, NSAIDs
Quinine
Intermittent:
Menieres- Episodic 1-24 hrs vertigo, tinnitus, and sensorineural hearing loss, ear fullness
Pulsatile:
Atherosclerosis,
AV malformations
Vascular tumours
Benign intracranial hypertension
Referral criteria tinnitus
If tinnitus associated with significant neurological symptoms or signs, e.g. facial weakness- urgent ENT
If unilateral tinnitus associated with any neuro symptoms -urgent audiology
Routine audiology if:
unilateral tinnitus (pulsatile or non-pulsatile).
bilateral tinnitus.
tinnitus causing distress despite primary care management.
Acute sore throat in immunosuppressed patients?
DMARD or carbimazole- withhold drug, urgent FBC
HIV, leukaemia, asplenia, post transplant urgent FBC
Referral criteria tonsillitis
Acute ENT if quinsy, dehydrated/unable to swallow
Tonsillectomy if: The episodes of sore throat are disabling and prevent normal functioning.
There is no other explanation for the recurrent symptoms.
Number of episodes of well‑documented, clinically significant, and adequately-treated episodes of sore throat:
7 or more per year for 1 year.
5 or more per year for 2 years.
3 or more per year for 3 years
Signs of quinsy
Unilateral tonsillar displacement
Trismus
Drooling of saliva and severe unilateral ear and neck pain
Peritonsillar cellulitis and/or abscess
FeverPain Scoring
Fever
Purulence
Attend rapidly – within 3 days or less of onset of symptoms
Severely inflamed tonsils
No cough or coryza
Manage according to score:
4 to 5 (likelihood of GAS 65%) – pen v 5 days unless immunocompromised/recurrence then 10 days or 5 days clarithromycin, exclude school 24hrs after abx started
2 to 3 – consider no antibiotics or a delayed prescription
Vertigo associated symptoms and causes
Fever, hearing loss, nausea, and vomiting with or without otorrhoea suggest acute bacterial labyrinthitis.
Unilateral muscle weakness, sensory loss, or ataxia may suggest stroke
Concomitant headache and history of migraine suggest vestibular migraine.
Shortness of breath, palpitations, and chest pain suggest arrhythmias, orthostatic hypotension, coronary artery disease
Unilateral hearing loss and vertigo are more likely suggestive of labyrinthitis, sudden sensorineural hearing loss or vestibular migraine, but can be due to the relatively uncommon Ménière’s disease
Signs and symptoms suspicious of a central cause of vertigo
The patient is unable to stand up or walk even with open eyes.
Hearing loss or tinnitus are usually absent.
Changing nystagmus on lateral gaze.
Other neurological symptoms – cranial nerve dysfunction, visual disturbance, speech defects, dysarthria, weakness, sensory changes, memory loss, and gait ataxia.
Common causes of vertigo and features
Vestibular Neuronitis- Vertigo on head movement associated with unilateral hearing loss, Lasts days to 1 week, no tinnitus
BPPV-Occurs with head turning or head movements, e.g. tipping the head forward or back. Also turning over in bed.Nausea and vomiting
May be history of head injury, Attack < 1 minute and settles if head is kept still. Days-Years. Hearing normal.
Ménière’s disease- Triad of episodic vertigo, tinnitus, and hearing loss. Persistent disequilibrium. “Pressure sensation” in the affected ear.
Lasts 1 to 24 hours. Tinitus worsens with time. Hearing Loss intermittent then permanent loss.
Vestibular neuronitis/labyrinthitis teatment
Prochlorperazine, 5 mg 3 times a day for no longer than 1 week.
Bppv treatment
Epley, brandt daroff
Menieres treatment
avoiding potential triggers such as high salt diet, caffeine, and alcohol.
Ref for hearing aids, steroid injection through TM
What is Ramsay Hunt syndrome?
Herpes zoster oticus- virus infects facial nerve (CN VII). Lesions in the ear, facial paralysis, and associated hearing and vestibular symptoms
Herpes zoster ophthalmicus
When the virus infects the ophthalmic division of the trigeminal nerve. Complications include keratitis, corneal ulceration, conjunctivitis, optic neuritis, retinitis, glaucoma, and blindness if untreated. Hutchinson’s sign (a rash on the tip, side, or root of the nose) indicates nasociliary branch involvement and an increased likelihood of eye inflammation and permanent corneal denervation
