ENT - Other Flashcards
What is the likely location of bleeding in epistaxis?
Little’s area - Kiesselbach’s plexus.
Triggers of epistaxis.
- nose picking
- colds
- sinusitis
- trauma
- changes in weather
- snorting cocaine
- tumours
Why may a patient with epistaxis have haematemesis?
Patient swallows blood during nosebleed.
What is the cause of bilateral bleeding (from both nostrils)?
Indicates bleeding posteriorly in the nose - presents as a higher risk of aspiration.
Initial management of nosebleeds.
- Sit up and tilt the head forwards
- Squeeze the soft part of the nostrils together for 10-15 minutes
- Spit any blood out, rather than swallowing
Escalating management of nosebleeds.
When bleeding does not stop after 15 minutes, treatment options are:
1. Nasal cautery
2. Nasal packing
After treating a nosebleed, what can be prescribed to reduce inflammation and infection?
What are the contraindications?
Naseptin nasal cream
Contraindicated in peanut or soya allergy.
Define sinusitis.
a) acute
b) chronic
Inflammation of the paranasal air sinuses in the face.
a) <12 weeks
b) >12 weeks
What is the function of paranasal air sinuses?
Produce mucous and drain into the nasal cavity.
Causes of sinusitis.
- infection (URTI)
- allergies (e.g hayfever)
- obstruction of drainage (foreign body, trauma, polyps)
- smoking
Symptoms of acute sinusitis.
Recent viral URTI:
- nasal congestion
- nasal discharge
- facial pain / headache
- facial pressure
- facial swelling
- loss of smell
Signs of acute sinusitis.
- tenderness to palpation of face
- inflammation / oedema of nasal mucosa
- nasal discharge
- fever
Associations of chronic sinusitis.
Associated with nasal polyps.
Investigations of acute sinusitis.
Clinical diagnosis - investigations not necessary.
Investigations of chronic sinusitis.
- nasal endoscopy
- CT scan
Management of acute sinusitis.
Conservative management - warm compresses to the face, inhaling steam, paracetamol and ibuprofen.
When are antibiotics prescribed for acute sinusitis?
If symptoms are not improving after 10 days, options are:
- high dose steroid nasal spray
- delayed antibiotic prescription
Management of chronic sinusitis.
- saline nasal irrigation
- steroid nasal sprays
- functional endoscopic sinus surgery
Question to ask to check nasal spray technique.
Do you taste the spray at the back of your throat after using it?
This suggests it has gone past the nasal mucosa and will not be as effective.
Nasal spray technique.
- Tilt the head forwards
- Use the left hand to spray into the right nostril, and vice versa (spray away from the septum)
- Gently inhale through the nose after the spray.
NB: Do NOT sniff hard during the spray.
What is functional endoscopic sinus surgery?
A small endoscope inserted to remove or correct any obstructions to the sinuses.
Obstruction may be caused by:
- swollen mucosa
- bone
- polyps
- deviated nasal septum
What are nasal polyps?
Growths of nasal mucosa that occur in the nasal cavity or sinuses, associated with inflammation.
They grow slowly and gradually obstruct the nasal passage.
Associations of nasal polyps.
- chronic sinusitis
- asthma
- Samter’s triad
- cystic fibrosis
What is Samter’s triad?
- Nasal polyps
- Asthma
- Aspirin allergy
Symptoms of nasal polyps.
- chronic sinusitis
- difficulty breathing through the nose
- snoring
- nasal discharge
- anosmia
Investigating nasal polyps.
- nasal speculum
- otoscope with large speculum
- nasal endoscopy
Management of bilateral nasal polyps.
Medical management - intranasal steroid drops / spray.
Surgical management:
- intranasal polypectomy
- endoscopic nasal polypectomy
What is obstructive sleep apnoea?
Collapse of the pharyngeal airway results in episodes of apnoea during sleep.
The partner usually reports this happening, and the patient is unaware.
Risk factors for obstructive sleep apnoea.
- middle age
- male
- obesity
- alcohol
- smoking
Symptoms of obstructive sleep apnoea.
- episodes of apnoea during sleep (reported by their partner)
- snoring
- morning headache
- daytime sleepiness
- concentration problems
Complications of obstructive sleep apnoea.
- hypertension
- heart failure
- myocardial infarction
- stroke
What scale can be used to assess symptoms of sleepiness associated with obstructive sleep apnoea?
Epworth sleepiness scale.
Safety questions in obstructive sleep apnoea.
Ask about daytime sleepiness and occupation.
Patients that need to be fully alert for work, for example, heavy goods vehicle operators, require an urgent referral and may need amended work duties whilst awaiting assessment and treatment.
Investigating obstructive sleep apnoea.
Sleep clinic - monitoring of:
- oxygen saturation
- heart rate
- respiratory rate
Managing obstructive sleep apnoea.
- Correct any reversible risk factors (e.g. smoking cessation, weight loss, no alcohol).
- CPAP
- Surgery
What is the most common cause of tonsillitis?
Viral infection - do not require or respond to antibiotics.
What are the common causes of bacterial tonsillitis?
- Streptococcus pyogenes
- Streptococcus pneumoniae
Symptoms of tonsillitis.
- sore throat
- fever
- pain on swallowing
Signs of tonsillitis.
- inflamed tonsills +/- exudates
- anterior cervical lymphadenopathy
- tonsillar lymphadenopathy
Centor criteria.
Used to estimate the probability that tonsillitis is due to bacterial infection.
C - Cough absence
E - Exudates
N - Nodes
T - Temperature
A score of ≥3 suggests a bacterial cause, and it is appropriate to offer antibiotics.
Management of viral tonsillitis.
Simple analgesia with paracetamol and ibuprofen to control pain and fever.
Can consider a delayed prescription.
Safety netting - return if pain has not settled within 3 days or gets worse.
Management of bacterial tonsillitis.
Centor ≥3
Phenoxymethylpenicillin prescription.
Complications of tonsillitis.
- peritonsillar abscess
- otitis media
- Scarlet fever
- Rheumatic fever
- post-streptococcus glomerulonephritis
- post-streptococcal reactive arthritis
What is a peritonsillar abscess?
AKA quinsy.
When there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils.
Symptoms of peritonsillar abscess.
Symptoms of tonsillitis plus:
- trismus
- change in voice
- swelling and erythema of the tonsils
Most common cause of quinsy.
Streptococcus pyogenes.
Management of quinsy.
Urgent referral to ENT team:
- needle aspiration
- surgical incision and drainage
Antibiotics are appropriate before and after surgery (e.g. co-amoxiclav).
What are the indications of tonsillectomy?
- recurrent tonsillitis (several episodes in one year)
- recurrent quinsy
- enlarged tonsils causing difficulty breathing, swallowing or snoring
Complications of tonsillectomy.
Post-tonsillectomy bleeding most significant risk factor - can be life-threatening due to aspiration of blood.
Other complications are:
- sore throat
- damage to teeth
- infection
- risks associated with general anaesthetic
Borders of the anterior triangle of the neck.
Borders of the posterior triangle of the neck.
What are the red-flag referral criteria for a neck lump?
- Unexplained neck lump aged >45 years
- Persistent unexplained neck lump at any age
Causes of neck lumps.
- normal bony anatomy
- lymphadenopathy
- glandular fever
- lymphoma
- leukaemia
- goitre
- salivary gland pathology
- carotid body tumours
- lipoma
- thyroglossal cyst
- ## branchial cyst
What are the causes of lymphadenopathy?
- reactive lymph nodes (URTI, tonsillitis)
- infective lymph nodes (TB, HIV, EBV)
- inflammatory conditions (e.g. SLE, sarcoidosis)
- malignancy (e.g. lymphoma, leukaemia, metastasis)
Features of lymph nodes that indicate malignancy.
- unexplained
- abnormal shape
- hard or rubbery
- non-tender
- fixed to underlying tissue
What is the cause of glandular fever?
EBV - found in the saliva of infected individuals.
Symptoms of glandular fever.
- fever
- sore throat
- fatigue
- lymphadenopathy
- splenomegaly
Investigating glandular fever.
- Monospot test
- IgM and IgG to EBV
Management of glandular fever.
Management is supportive.
Patients should avoid alcohol (risk of liver impairment) and contact sports (risk of splenic rupture).
Causes of goitre.
- Grave’s disease
- toxic multinodular goitre
- Hashimoto’s thyroiditis
- iodine deficiency
- lithium
Individual lumps can occur in the thyroid due to:
- benign hyperplastic nodules
- thyroid cysts
- thyroid adenomas
- thyroid cancer
- parathyroid tumour
Anatomy of the salivary glands.
Causes of salivary gland pathology.
- stones blocking the drainage of the glands
- infection
- tumours
Features of a carotid body tumour.
Slow growing lump in the upper anterior triangle of the neck:
- painless
- pulsatile
- bruit on auscultation
- mobile side-to-side
Nerve palsies associated with carotid body tumours.
- CN IX
- CN X
- CN XI
- CN XII
- sympathetic nerves (Horner’s syndrome)
Management of carotid body tumour.
Surgical removal.
What is a lipoma?
A benign tumour of adipose tissue.
Features of lipomas on examination.
- soft
- painless
- mobile
- do not cause skin changes
Management of lipomas.
Conservative treatment with reassurance.
They can be surgically removed.
What is a thyroglossal cyst?
Persistence of the thyroglossal duct gives rise to a fluid-filled cyst in the midline of the neck.
Features of a thyroglossal cyst.
Lump in the midline of the neck:
- mobile
- non-tender
- fluctuant
- soft
- moves with tongue
Why do thyroglossal cysts move up and down with movement of the tongue?
During fetal development, the thyroid gland starts at the base of the tongue.
This is results in a connection between the thyroglossal duct and the base of the tongue.
Investigations of thyroglossal cyst.
Ultrasound or CT to confirm the diagnosis.
Management of thyroglossal cysts.
Surgical excision with biopsy to confirm the diagnosis.
Complication of thyroglossal cysts.
Infection of the cyst:
- hot
- tender
- painful
Pathophysiology of a branchial cyst?
A congenital abnormality arising due to malformation of the second branchial cleft.
This leaves a space of epithelial tissue that can fill with fluid in the lateral aspect of the neck.
Presentation of a branchial cyst.
Lump in the lateral neck, just anterior to the SCM:
- soft
- round
- non-tender
Mostly present after the age of 10, when it becomes noticeable or infected.
Where are branchial cysts most likely to originate?
Second branchial cleft
Management of branchial cysts.
Conservative - no active intervention if not causing problems.
Surgical excision - recurrent infections, diagnostic doubt.
What is the most common type of head and neck cancer?
Squamous cell carcinoma
Risk factors for head and neck cancer.
- smoking
- chewing tobacco
- chewing betel liquid
- alcohol
- HPV 16
- EBV
Red flags of head and neck cancer.
- lump in mouth or lip
- ulcer in mouth >3 weeks
- erythroplakia / leukoplakia
- persistant neck lump
- unexplained hoarseness of voice
- unexplained thyroid lump
Management of head and neck cancer.
Management guided by an MDT - dependent on location, stage and patient factors.
Treatment may involve a combination of:
- chemotherapy
- radiotherapy
- surgery
- targeted cancer drugs
- palliative care
What is glossitis?
Inflammation of the tongue, causing it to become red, sore and swollen.
Causes of glossitis.
- iron deficiency anaemia
- B12 deficiency
- folate deficiency
- coeliac disease
- injury
- irritant exposure
Management is to correct the underlying cause.
What is oral candidiasis?
Overgrowth of candida in the mouth, resulting in white spots or patches that coat the surface of the tongue and palate.
Risk factors for oral candidiasis.
- inhaled corticosteroids
- antibiotics
- diabetes
- immunodeficiency
- smoking
Treatment options of oral candidiasis.
First line: miconazole gel
Fluconazole tablets can be used in severe or recurrent cases.
What is geographic tongue?
Inflammatory condition causing patches of the tongue’s surface to lose epithelium and papillae.
Associations of geographic tongue.
- idiopathic
- stress / mental illness
- psoriasis
- atopy
- diabetes
Causes of strawberry tongue.
- Scarlet fever
- Kawasaki disease
What is black hairy tongue?
Decreased shedding of keratin from the tongue’s surface causes papillae to elongate and take on the appearance of hairs.
Patients may report sticky saliva or a metallic taste.
Causes of black hairy tongue.
- dehydration
- dry mouth
- poor dental hygiene
- smoking
Management involves adequate hydration, gentle brushing of the tongue and smoking cessation.
What is leukoplakia?
White patches in the mouth.
Precancerous condition, increasing risk of squamous cell carcinoma of the mouth.
NB: Urgent cancer pathway referral warranted.
What is erythroplakia?
Red patches in the mouth.
Precancerous condition, increasing risk of squamous cell carcinoma of the mouth.
NB: Urgent cancer pathway referral warranted.
What is lichen planus?
An autoimmune condition causing chronic inflammation of the skin.
It can affect the mucosal membranes, including the mouth.
Patterns of lichen planus in the mouth.
Reticular - net-like web of white lines.
Erosive - surface layer is eroded.
Plaques - large continuous areas of white mucosa.
Management of lichen planus.
- good oral hygiene
- smoking cessation
- topical steroids
What is gingivitis?
Inflammation of the gums, leading to peridontitis if not managed adequately.
Presentation of gingivitis.
- swollen gums
- bleeding after brushing
- painful gums
- halitosis
What is peridontitis?
Severe and chronic inflammation of the gyms and the tissues that support the teeth.
Often leads to loss of teeth.
What is acute necrotising ulcerative gingivitis?
Rapid onset of severe inflammation of the gums, causing a painful gingivitis.
Anaerobic bacteria usually cause this.
Risk factors for gingivitis.
- plaque build-up
- smoking
- diabetes
- malnutrition
- stress
NB: bacteria live in plaque, damaging the teeth and gums.
Treatment of gingivitis.
- good oral hygiene
- smoking cessation
- dental hygienest treatment
- chlorhexidine mouth wash
- dental surgery
What is gingival hyperplasia?
Abnormal growth of the gums.
Causes of gingival hyerplasia.
- gingivitis
- pregnancy
- scurvy
- acute myeloid leukaemia
- medications
Which medications can cause gingival hyperplasia?
- CCBs
- phenytoin
- ciclosporin
