ENT passmed

Question 1

what abx in malignant OE

Answer 1

Otitis externa in diabetics: treat with ciprofloxacin to cover Pseudomonas (IV) (commonly pseudonomas aeruginosa..)

Question 2

who gets malignant oe?

Answer 2

diabetics 90% or immunosuppresion..

Question 3

how does malignant OE present?

Answer 3

Diabetes (90%) or immunosuppression (illness or treatment-related)
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Possibly dysphagia, hoarseness, and/or facial nerve dysfunction

Question 4

what can malignant OE progress to?

Answer 4

temporal bone osteomyelitis

Question 5

treatment of malignant OE?

Answer 5

Treatment
non-resolving otitis externa with worsening pain should be referred urgently to ENT
Intravenous antibiotics that cover pseudomonal infections

Question 6

what is useful in the acute phase of vestibular neuronitis

why do you need to stop it after

Answer 6

Prochlorperazine may be useful in the acute phase of vestibular neuronitis, but should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms

Question 7

common causes of BACTERIAL OM?

Answer 7

The most common bacterial causes of otitis media are Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis.

Question 8

primary and secondary haemorrhage post tonsillectomy

what are the cutoffs

what are the causes of each….

Answer 8

Primary (reactive) haemorrhage occurs within 24 hours after tonsillectomy (tends to be 6-8hrs..), and requires immediate return to theatre due to the risk of further, more extensive bleeding which may need surgical intervention.

Secondary haemorrhage >24 hours after tonsillectomy is more likely to be due to infection. (usually 5-10 days post surgery) As this is a primary haemorrhage, antibiotics are not yet an appropriate management plan.

Question 9

management of a perforated eardrum?

Answer 9

A perforated eardrum will usually heal by itself within 6-8 weeks. Patients with a perforation should be advised that the eardrum is a skin-like structure and therefore it heals in the same way as a cut on the skin. They should avoid getting water into the ear as this can impair healing and increase the chance of infection.

It would be inappropriate to refer to ENT either urgently or routinely before 6 weeks as this would be an inappropriate use of NHS resources. Leaving it beyond 12 months to refer would also be inappropriate as it could cause long-term complications.

NB - prescribe ABx if the perforation occured foloowing an episode of AOM

Question 10

rinnes and webers test?

Answer 10

Webers - which - can differentiate between conductive and sensorineural
localises to the affected side if conductive, and the unaffected if sensorineural

WEBERS ONLY REALLY GOOD FOR UNILATERAL DEFECTS..

Rinnes - shows whether air conduction is better than bone on each ear (it should be) - if bone is better than air - then CONDUCTIVE DEAFNESS
negative = all fine :)

Question 11

when to prescribe antibiotics in AOM - and which antibioitc is first line…

Answer 11

Antibiotics should be prescribed immediately if:
Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
Otitis media with perforation and/or discharge in the canal

amoxicillin

Question 12

bacterial sore throat - which antibiotics…

Answer 12

If antibiotics are indicated then either phenoxymethylpenicillin or erythromycin (if the patient is penicillin allergic) should be given. Either a 7 or 10 day course should be given

Question 13

when shoudl you refer nasal polyps to ent?

Answer 13

unilateral

bleeding

Question 14

what is samter’s triad?

Answer 14

asthma, aspirin sensitivity and nasal polyposis

Question 15

when to consider a 2ww referral for laryngeal cancer?

Answer 15

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:
persistent unexplained hoarseness or
an unexplained lump in the neck

Question 16

when to consider a 2ww referral for oral cancer?

Answer 16

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:

unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
a lump on the lip or in the oral cavity or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Question 17

when to consider a 2ww referal for suspected thyroid Ca?

Answer 17

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump.

Question 18

managing acute sinusitis

standard
when to give steroids
when to give abx?>

Answer 18

Management of acute sinusitis
analgesia
intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited
NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days
oral antibiotics are not normally required but may be given for severe presentations. The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’

Question 19

causes of swollen painful gums (gingival hyperplasia)

Answer 19

Gingival hyperplasia

Drug causes of gingival hyperplasia
phenytoin
ciclosporin
calcium channel blockers (especially nifedipine)

Other causes of gingival hyperplasia include
acute myeloid leukaemia

Question 20

general features of a head and neck cancer

Answer 20

neck lump
hoarseness
persistent sore throat
persistent mouth ulcer

Question 21

epistaxis:

two anatomical types - explain them.

Management of mild

Management of severe

Answer 21

anterior - often has a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s Plexus.

posterior - tend to be more profuse and originate from deeper structures. They occur more frequently in older patients and confer a higher risk of aspiration and airway compromise.

1. mild
   sit with their torso forward and their mouth open- avoid lying down unless they feel faint. This decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth. It also reduces the risk of aspirating blood.
   Pinch the cartilaginous (soft) area of the nose firmly and consistently for at least 15 minutes and ask the patient to breathe through their mouth.

If first aid measures are successful, consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of vestibulitis

if the bleeding doesn’t stop after 15 mins of constant pressure on the nose - ?cautery if can visualise the source of the bleed or ?packing.

2. severe
   pack / cauterise as approipriate
   Patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.
   intranasal epinephrine may be of benefit post..