ENT + opthalmology Flashcards
what other symptoms to ask about in hearing loss
tinnitus
pain
discharge
vertigo
neurological symptoms
describe webers test and the results
- vibrate tuning fork
- put it on middle of forehead
sensorineural hearing loss = louder in NORMAL ear
conductive hearing loss = louder in DEAF ear (vibration directly to cochlear)
describe rinne’s test
- vibrate tuning fork
- place flat end on mastoid process (tests bone conduction)
- ask pt when they can no longer hear humming noise
- move it to outside ear (still vibrating) = air conduction
- repeat on other side
describe the results of rinne’s test
normal = pt can hear fork through air - air conduction is better = rinne’s POSITIVE
abnormal = pt cannot hear fork after removing from bone = rinne’s NEGATIVE = suggests CONDUCTIVE loss
name some causes of sensorineural hearing loss
sudden onset
presbycusis (age related)
noise exposure
menieres
labrynthitis
acoustic neuroma
neuro conditions
infections
medications (furosemide/gentamicin/cisplatin)
name some causes of conductive hearing loss
ear wax
fluid
infection
Eustachian tube dysfunction
perforated tympanic membrane
tumours
what is a cholesteatoma
abnormal collection of squamous epithelial cells in middle ear
non cancerous but can invade local tissue and erode bones of middle ear
can cause bad ear infections with FOUL discharge
what is the presentation and management of cholesteatoma
foul discharge from the ear
unilateral conductive hearing loss
?infection
?pain
?vertigo
CT head to confirm + surgical removal
what are the 4 sets of paranasal sinuses
frontal sinuses
maxillary sinuses
ethmoid sinuses
sphenoid sinuses
how to treat sinusitis if symptoms not improved after 10 days
high dose steroid nasal spray 14 days
OR
delayed phenoxymethylpenicillin prescription for if not improved after 7 further days
how to correctly use a nasal spray
head tilt slightly forward
opposite hand to nostril
DONT sniff hard during spray
gently inhale through the nose after the spray
name some causes of TMJD
stress/low mood
teeth grinding
chronic pain
trauma to teeth/face causing abnormal bite
what are the symptoms and signs of TMJD
symptoms:
pain in pre-auricular area radiate to jaw
crepitus of joint
locking of joint
difficulty fully opening the mouth
signs:
tenderness on palp of joint
crepitus on movement
locking of jaw
how is TMJD managed
conservatively - painkillers and jaw exercises
mouth guard for grinding
rare but can have surgery/botox injections?
what investigations should be done for tinnitus
bloods:
FBC
glucose (diabetes)
TSH
lipids
audiology
CT/MRI if vascular/neuro cause considered
what are some red flags with tinnitus
unilateral
pulsatile
pain with noise
unilateral hearing loss
vertigo/dizziness/headaches/visual sympts
suicidal ideation related to tinnitus
what is malignant otitis externa
severe/life threatening
infection spreads to bone –> osteomyelitis of temporal bone
usually occurs in immune suppressed
symptoms more severe
requires emergency admission and treatment with IV abx
what are the additional symptoms of a quinsy
trismus = cant open mouth
change in voice due to swelling (hot potato)
swelling and erythema
what is the management of a quinsy
needle aspiration
surgical incision and drainage
broad spectrum Abx
?dexamethasone
what is the main complication of a tonsillectomy
bleeding!!
up to 2 weeks after
risk of aspiration of blood
what type of cancers are head and neck cancers
squamous cell carcinoma
what are the risk factors for head and neck cancers
smoking
chewing tobacco or betel quid (paan)
alcohol
EBV
HPV 16
what are some red flags for head and neck cancer
unexplained lump or ulceration >3 weeks
erythoplakia (ulcer bleeds when scraped)
persistent neck lump/thyroid lump
unexplained hoarseness of voice
name the monoclonal antibody used in treating head and neck cancer
cetuximab
what is the most likely location of epistaxis
little’s area
keisselbach’s plexus
how should nosebleeds be managed
sit up and tilt head forwards
squeeze soft part of nostrils together 10-15 mins
spit out blood
severe:
nasal packing
nasal cautery
what is leukoplakia
white patches on buccal mucosa
precancerous = increase risk of squamous cell carcinoma
what is erythroplakia
red lesion on buccal mucosa
higher risk of squamous cell carcinoma
bleed easily when scraped
what is lichen planus
autoimmune condition = chronic inflammation of skin
purple raised areas with white lines (wickham’s striae)
good oral hygeine + no smoking + topical steroids
vertigo
20-30 second spells
?viral infection
no hearing loss
no tinnitus
BPPV
Hallpike to Dx
Epleys to Tx
betahistine limited benefit
calcium carbonate crystals in semicircular canals
vertigo - hours to days
N+V
struggling to balance
no tinnitus
no hearing loss
recent viral illness
vestibular neuronitis
only vestibular nerve affected
do HINTs to Dx
prochlorperazine + antihistamine
vestibular rehab for chronic
important to differential for vestibular neuronitis and how to distinguish
posterior circulation stroke
do head impulse nystagmus test (HiNTs)
eye saccade = +ve for VN
40-50 years old
vertigo - episodic clusters
hearing loss - fluctuates with vertigo
tinnitus
aural fullness
menieres disease
see ENT
audiology = sensorineural loss
acute attacks = prochlorperazine + antihistamines
prophylaxis = beta histine
sudden onset
vertigo - not triggered by movement but exacerbated by it
N+V
hearing loss - uni or bi
tinnitus
recent URTI
viral labyrinthitis
vestibular nerve + labyrinth involved
sensorineural hearing loss
spontaneous nystagmus towards affected side
self-limiting
?prochlorperazine / antihistamine to reduce vertigo
elderly patient
dizzy on extension of neck
vertebrobasilar ischaemia
40-60 years old
gradual onset
hearing loss
tinnitus
vertigo
absent corneal reflex
acoustic neuroma/vestibular schwannoma
urgent ENT referral
MRI to Dx
Tx = conservative or surgery
importand ddx = meningioma
hearing loss
aural fullness
popping sensation
pain/tinnitus
eustacian tube dysfunction
clinical Dx or can do audiometry/tympanometry
no Mx
?vasalva
?decongestants
?grommets
what can cause otitis media
s.pneumoniae
h.influenzae
m.catarrhalis
s.aureush
how does otitis media present
kids
pain
hearing loss
unwell
URTI
+/- vertigo
+/- discharge
how does otitis media with effusion present
= glue ear!
most common in children <2
hearing loss/delay in speech
otoscopy = dull, loss of light reflex
how is otitis media managed
3 days - 1 week resolve by self
Abx make no difference
simple analgesia
?delayed Abx = amoxicillin 5-7 days
how is glue ear managed
in child first presentation = nothing
multiple in child = grommet or adenoidectomy
ear pain
discharge
itchy
hearing loss
red/swollen inner ear
otitis externa
swimmers ear
otoscopy + ear swab
mild = acetic acid (antibac/antifungal)
moderate = otomize (neomycin, dexa, acetic acid)
define acute and chronic otitis externa
acute = <3 weeks
chronic = >3 weeks
what can cause otitis externa
p.aeruginosa (CF)
s.aureus
what is it important to do before prescribing topical antibiotics for the ear
exclude tympanic membrane perforation
because gentamicin cause hearing loss
describe the feverpain score
fever in past 24 hrs
purulence
attend w/n 3 days
inflamed tonisls
no cough/coryza
2-3 consider delayed Abx
4+ = give abx
= phenoxymethylpenicillin 10 days
describe the CENTOR criteria
fever >38
tonsillar exudate
no cough
tender lymphadenopathy
1 point for each
3+ = 40-60% bacterial = ABx
what is a serious complication of otitis media and who is more likely to get it
mastoiditis !!
s.pneumoniae/h.influenzae
children
LD/autism
immunocomp
oh no! a 4 year old autistic child presents unwell, tugging at his right ear
on inspection there is a red swelling behind the ear and the ear appears more prominent than the left
on otoscopy the tympanic membrane appears bulging
what do you do now?
immediate urgent to ENT
ABCDE
Sepsis 6
HELP!
CT head to show ? progression to temporal bone
21 year old student present generally unwell, with swollen cervical lymph nodes
what investigations do you want to do?
what management would you give?
monospot test = heterophile Antibodies
paul bunnel test
self limiting but give advice:
avoid alcohol
avoid contact sports
what are the complications of EBV
burkitts lymphoma
splenic rupture
chronic fatigue
glomerularnephritis
haemolytic anaemia
18 year old with a neck lump
mobile
non-tender
soft
moves with movement of tongue
thyroglossal cyst
can be sublingual!
18 year old with a neck lump
midline
mobile
non-tender
soft
moves with movement of tongue
lump has turned hard and is emitting discharge!
infected thyroglossal cyst
Tx = antibiotics + surgical
teenager with a neck lump
soft, round
no movement with tongue
doesnt transilluminate
branchial cyst
arise from second branchial cleft
Mx = conservative or surgery
60 year old man
choking on food
regurgitating food
chronic cough
halitosis
feels a lump in the neck
pharyngeal pouch
do a barium swallow + fluroscopy
management is surgery
4 month old
large neck lump
on LEFT side
fluctuant
cystic hygroma = lymphagioma
surgical excision
68 year old
complaining because left eye drooping
ptosis + miosis
has a pulsatile lump in side of neck
carotid body tumour
surgical treatment
causes of hornerys syndrome if anhidrosis in:
1. head /arm/trunk
2. just face
3. no anhidrosis
- stroke
- pancoast tumour / cervical rib
- absent = carotid artery tumour/pressure
what eye complication following renal transplant
CMV retinitis
cotton wool spots
infiltrates
haemorrhages
what are the branches of the facial nerve and how can you remember them
To Zanzibar By Motor Car
temporal
zygomatic
buccal
marginal mandibular
cervical
