ENT Passmedicine Flashcards
1
Q
What is otosclerosis?
A
Replacement of normal bone by vascular spongy bone
2
Q
What kind of deafness does otosclerosis cause?
A
Progressive conductive deafness
3
Q
Why do you get deafness in otosclerosis?
A
The stapes becomes fixed at the oval window
4
Q
How is otosclerosis inherited?
A
Autosomal dominantly
5
Q
When is the typical onset of otosclerosis?
A
20-40y
6
Q
What are the clinical features of otosclerosis?
A
Conductive deafness
Tinnitus
Normal tympanic membrane (10% have flamingo tinge caused by hyperaemia)
+ve FH
7
Q
How do you manage otosclerosis?
A
Hearing aid
Stapedectomy
8
Q
What is Meniere’s disease?
A
Disorder of the inner ear of unknown cause
9
Q
What is Meniere’s characterised by?
A
Excessive pressure and progressive dilation of the endolymphatic system
10
Q
In which age group is Meniere’s most common?
A
Middle aged
11
Q
What are the features of Meniere’s?
A
Recurrent episodes of vertigo, tinnitus and sensorineural hearing loss
Sensation of aural fullness/pressure
Nystagmus
Positive Romberg test
12
Q
How long do the symptoms last in episodes of Meniere’s?
A
minutes to hours
13
Q
Are symptoms of Meniere’s typically bilateral or unilateral?
A
Unilateral usually
14
Q
What is the natural history of Meniere’s?
A
Symptoms tend to resolve after 5-10 years
Majority are left with hearing loss
15
Q
What is involved in the management of Meniere’s?
A
ENT assessment req. for diagnosis
Inform DVLA (cease driving until adequate control of sx)
Rx of acute attacks and prevention
16
Q
How do you treat acute attacks in Meniere’s?
A
Buccal/IM prochlorperazine
17
Q
How do you prevent attacks in Meniere’s?
A
Betahistine and vestibular rehabilitation exercises
18
Q
What drugs can cause gingival hyperplasia?
A
Phenytoin
Ciclosporin
CCB, esp nifedipine
19
Q
What conditions can cause gingival hyperplasia?
A
AML
20
Q
What are complications of tonsillitis?
A
Otitis media
Quinsy/peritonsillar abscess
Rheumatic fever + GN very rarely
21
Q
When do NICE recommend tonsillectomy should be considered?
A
If they meet all of the following:
- Sore throats are due to tonsillitis
- Person has 5+ episodes pa
- Symptoms been occurring for at least 1 year
- Episodes of sore throat are disabling + prevent normal functioning
22
Q
What are some established indications for a tonsillectomy?
A
Recurrent febrile convulsions 2ndary to tonsillitis
Obstructive sleep apnoea/stridor/dysphagia due to enlarged tonsils
Quinsy unresponsive to standard Rx
23
Q
What are the primary complications of tonsillectomy?
A
Occur within 24h:
- Haemorrhage
- Pain
24
Q
What are the secondary complications of tonsillitis?
A
Occur after 24h:
- Haemorrhage (mostly due to infection)
- Pain
25
Define vertigo
False sensation that the body/environment is moving
26
List 10 causes of vertigo
```
Meniere's disease
BPPV
Acoustic neuroma
Viral labyrinthitis
Vestibular neuronitis
Vertebrobasilar ischaemia
Posterior circulation stroke
Trauma
Otoxoticity
MS
```
27
What are the things that should stand out in a history that point towards a diagnosis of viral labyrinthitis?
Recent viral infection
Sudden onset
NV
Hearing affected
28
What are the things that should stand out in a history that point towards a diagnosis of vestibular neuronitis?
Recent viral infection
Recurrent vertigo attacks lasting hours/days
No hearing loss
29
What are the things that should stand out in a history that point towards a diagnosis of BPPV?
Gradual onset
Triggered by change in head position
Episodes last 10-20s
30
What are the things that should stand out in a history that point towards a diagnosis of Meniere's?
Hearing loss
Tinnitus
Vertigo
Sensation of fullness/pressure in one/both ears
31
What are the things that should stand out in a history that point towards a diagnosis of vertebrobasilar ischaemia?
Elderly patient
| Dizziness on extension of neck
32
What are the things that should stand out in a history that point towards a diagnosis of acoustic neuroma?
```
Gradual progressive unilateral deafness
Vertigo
Tinnitus
Absent corneal reflex is important sign
Facial nerve palsy
```
33
With which condition is acoustic neuroma associated?
NF2
34
What is Ramsay-Hunt syndrome?
Reactivation of the varicella zoster virus in the geniculate ganglion of the 7th cranial nerve
35
What are the features of Ramsay-Hunt syndrome?
```
Auricular pain
Facial nerve palsy
Vesicular rash around hear
Vertigo
Tinnitus
May also get vesicular lesions on anterior 2/3rd of tongue and soft palate
```
36
How do you manage Ramsay-Hunt syndrome?
Oral acyclovir
| Corticosteroids
37
What infection is tonsillar SCC associated with?
HPV 16
38
What are risk factors for tonsillar SCC?
Smoking
High alcohol intake
Poor oral hygiene
39
Head and neck cancer encompasses what cancers?
Oral cavity cancers
Cancers of the pharynx (oropharynx, nasopharynx, hypopharynx)
Cancers of larynx
40
What are possible features of a head and neck cancer?
Neck lump
Hoarseness
Persistent sore throat
Persistent mouth ulcer
41
How quickly do you get an appointment with the suspected cancer pathway referral?
Within 2 weeks
42
What is the suspected laryngeal cancer pathway referral criteria?
Age 45y+ with:
| Persistent unexplained hoarseness or unexplained lump in neck
43
What is the suspected oral cancer pathway referral criteria?
Unexplained ulceration in the oral cavity >3weeks or persistent or unexplained neck lump
44
When should you consider urgent referral (2w) for assessment of possible oral cancer by a dentist?
Those with either:
Lump on lip/oral cavity
Red/red-white patches in the oral cavity consistent with erythroplakia/erythroleukoplakia
45
What is the suspected thyroid cancer pathway referral criteria?
Unexplained thyroid lump
46
How do you investigate an acoustic neuroma?
MRI
47
What resources can you use to help you decide whether or not to give antibiotics for a sore throat?
FEVERpain
Centor
These predict whether the sore throat is likely to be bacterial and would benefit from antibiotics
48
What are the centor criteria?
Tonsillar exudate
Absence of cough
Hx of fever
Cervical lymphadenopathy/lympadenitis
49
What centor score should you give antibiotics for?
3 or 4
50
What does a centor 3/4 sore equate to % chance of having a strep throat infection?
40-60%
51
What does a centor 0/1/2 sore equate to % chance of having a strep throat infection?
80% chance of not having a bacterial throat infection
52
How should you manage a sore throat?
Paracetamol/ibruprofen
| Antibiotics if indicated
53
When are antibiotics indicated for sore throat?
```
Centor 3/4
Marked systemic upset
Unilateral peritonsillitis
Hx rheumatic fever
Increased risk from acute infection, e.g. someone with DM/immunodef
```
54
What are the FEVERpain criteria?
```
Fever >38
Pharyngeal/tonsillar exudate
Attends rapidly (3 days or less)
Severely inflamed tonsils
No cough/coryza
```
55
What antibiotics should be given for tonsillitis?
Phenoxymethylpenicillin or erythromycin if penicillin allergic for 7-10d
56
What tends to be the first line investigation for those presenting with hearing difficulties?
Audiograms
57
How do you interpret an audiogram?
Anything above 20b is normal
Sensorineural deafness - air + bone conduction impaired
Conductive deafness - only air conduction impaired
Mixed hearing loss - air and bone conduction impaired, air worse than bone
58
What are the causes for otitis externa?
Infection (staph, aureus, pseudomonas, fungi)
Seborrheic dermatitis
Contact dermatitis
59
What are the features of otitis externa?
```
Ear pain
Itch
Discharge
Pain on palpation of tragus
Conductive hearing loss
```
60
What are the otoscopy findings in otitis externa?
Red, swollen, eczematous canal
61
What do you manage otitis externa in the first instance?
Topical antibiotic and steroid ear drop
Consider removal of ear canal debris
If ear canal is swollen consider ear wick insertion
62
What are second line management options for otitis externa?
Flucloxacillin (oral) if infection spreading
Swab ear canal
Empirical use of an antifungal
IF PATIENT FAILS TO RESPOND TO TOPICAL ANTIBIOTICS SHOULD BE REFERRED TO ENT
63
In which groups is malignant otitis externa most common?
Elderly
| DM
64
What happens in malignant otitis externa?
Infection extends into bony ear canal and soft tissues deep to the bony canal
65
When should you prescribe antibiotics for otitis media?
Symptoms >4 days + not improving
Systemically unwell
Immunocomprised/high risk of complications due to significant heart, lung, kidney, liver or neuromuscular disease
Age <2 with bilateral otitis media
Otitis media w. perforation +/or discharge in the canal
66
What antibiotic is given for otitis media?
Amoxicillin 5 days
| Penicillin allergy: erythromycin/clarithromycin
67
What is the commonest cause of bacterial otitis media?
H. influenzae
68
What other organism can cause otitis media?
Strep pneumoniae
| Moraxella catarrhalis
69
What is Ludwig's angina?
Cellulitis on the floor of the mouth
Deadly as it spreads in the fascial spaces of the head and neck
Swelling pushes on floor of mouth upwards and can block airway
70
What are risk factors for Ludwig's angina?
Immunocompromise
Poor denition
Pericoronitis
71
What is pericoronitis?
Inflammation around a partially erupted wisdowm tooth
72
What are the three salivary glands called?
Parotid
Submandibular
Sublingual
73
What kind of secretions come from the parotid glands?
Serous
74
What kind of secretions come from the submandibular glands?
Mixed
75
What kind of secretions come from the sublingual glands?
Mucous
76
In which salivary gland do most tumours arise?
Parotid
77
Which salivary glands are most commonly blocked by stones?
Submandibular
78
What are the most common parotid tumours?
Pleomorphic adenomas
79
What is the typical hx of a pleomorphic adenoma?
Middle aged
| Slow growing, painless lump
80
How do you manage a pleomorphic adenoma?
Superficial parotidectomy
81
What is the major risk of a superficial parotidectomy?
CNVII damage
82
What is the second most common parotid tumour?
Warthin's tumour
83
What is the typical hx of a Warthin's tumour?
Male, middle aged
| Soft, mobile and fluctuant mass
84
What is a typical hx of a stone lodging in the salivary gland ducts?
Recurrent unilateral pain and swelling on eating
If becomes infected may --> Ludwig's angina
85
How do you investigated a suspected stone in the salivary glands ducts?
Plain xray
| Sialography
86
How are blocked salivary ducts managed?
Surgery
87
What things apart from tumours and stones can cause salivary gland enlargement?
Acute viral infections, e.g. mumps
Acute bacterial infection
Sicca syndrome
Sjogrens
88
What are the two types of epistaxis?
Anterior bleed - visible source of bleeding
| Posterior bleed - tends to be more profuse, due to damage of deeper structures
89
Where do anterior bleeds tend to be from?
Kiesselbach's plexus (little's area - where 4 arteries come together)
90
What is the most common cause of epistaxis?
Trauma to nose (insertion of FB, nose picking, nose blowing)
91
What might recurrent epistaxis indicate?
Platelet disorders (e.g. thrombocytopenia, splenomegaly, leukaemia, ITP)
Juvenile angiofibroma (benign highly vascularised tumour)
Granulomatosis with polyangiitis
Pyogenic granuloma
92
In epistaxis, what may an atrophied nasal septum indicate?
Cocaine use - cocaine is a powerful vasoconstrictor and may lead to obliteration of the septum
93
How do you manage epistaxis?
Lean forward, mouth open
Pinch cartilaginous area of nose for 15m and breath through mouth
If this is successful use antiseptic e.g. Naseptin to reduce crusting and risk of vestibulitis
94
If bleeding doesn't stop within 10-15m of continuous pressure on the nose, what management should be considered?
Cautery (source of bleeding isolated)
| Packing and admit to secondary care
95
What is Naseptin a combination of?
Chlorhexidine and neomycin
96
What are CI to naseptin?
Peanut, soy or neomycin allergies
Can cause mupirocin as alternative
97
What patients might you consider follow up care even if bleeding is halted by pressure?
Co-morbidity (e.g. severe HTN, CAD)
Underlying cause suspected
<2y (more at risk of haemophilia, leukaemia)
98
Describe how to carry out cautery
Blow nose to remove clots
Use topical anaesthetic spray + wait 3-4m to take effect
Identify bleeding point + apply silver nitrate stick until it becomes grey-white
ONLY cauterise 1 side of septum due to risk of perforation
Dab area with naseptin/muciprocin
99
Describe the process of packing for epistaxis
Use topical LA + wait 3-4m
Pack nose while patient sits forward
Ex nose/mouth for continued bleeding
Admit to hospital for review by ENT
100
Which patients should be immediately referred into ED with epistaxis?
Haemodynamically unstable or compromised
| Bleeding from unknown posterior source
101
What self-care advice should be given re. the risk of another bleed?
Avoid blowing/picking nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks
102
What sore symptoms do you get in infectious mononucleosis?
Pharyngitis and tonsillitis
103
Why should you not give penicillin in glandular fever?
Will cause a reash
104
What may indicate quinsy in a sore throat?
Unilateral swelling and fever
105
What pathogen causes >50% of sore throats?
Streptococcus pyogenes
106
What is the appearance of the tonsils in bacterial tonsillitis?
Oedematous, yellow or white pustules
107
How can you distinguish vestibular neuronitis from viral labyrinthitis?
Hearing is unaffected in vestibular neuronitis
108
What are complications of thyroid surgery?
Recurrent laryngeal nerve damage
Bleeding - due to confined space haematomas may lead to respiratory compromise
Parathyroid gland damage --> hypocalcaemia
109
What ECG sign do you see with hypocalcaemia?
Prolonged QT interval
110
What otoscopy findings do you get with otitis media?
Bulging tympanic membrane
111
What is the biggest risk factor for malignant otitis externa?
DM
112
What causes most causes of malignant otitis externa?
Pseudomonas aeruginosa
113
What can malignant otitis externa progress to?
Temporal bone osteomyelitis
114
What are the key features of malignant otitis externa in the history?
```
DM/immunosuppression
Severe, unrelenting, deep seated otalgia
Temporal headaches
Purulent otorrhoea
Dysphagia/hoarseness/facial nerve dysfunction
```
115
How do you diagnose malignant otitis externa?
CT
116
How do you manage malignant otitis externa?
NON-RESOLVING OTITIS EXTERNA WITH WORSENING PAIN SHOULD BE REFERRED URGENTLY TO ENT
IV antibiotics usually req.
117
What causes acute otitis externa?
Boil in external auditory meatus
118
What causes chronic otitis externa?
Usually combined staph and fungal infection (req. antibacterial and antifungal ear drops)
119
What is acute suppurative otitis media?
Viral induced middle ear effusion secondary to eustachian tube dysfunction
120
What are the features of acute suppurative otitis media?
Usually in children
Severe pain
Fever
Discharge if tympanic membrane ruptures
121
How do you treat acute suppurative otitis media?
Amoxicillin
122
What causes chronic suppurative otitis media?
Cholesteatoma with perforation of pars flaccida
| No cholesteatoma + perforation of pars tensa
123
What are the symptoms of chronic suppurative otitis media?
Without cholesteatoma - intermittent non-offensive discharge
| With cholesteatoma - impaired hearing, foul discharge
124
How do you manage chronic suppurative otitis media?
Without cholesteatoma - non-operative/myringoplasty
| With cholesteatoma - radical mastoidectomy
125
What are pre-auricular sinuses?
Common congenital condition in which an epithelial defect forms around the external ear
126
How do you treat pre-auricular sinuses?
Small - no Rx
| Deeper - may become blocked and infected so can be difficult to excise
127
What is exostosis?
Benign bony growth in EAC
128
What causes exostosis?
Repeated exposure to cold water and wind
129
What two tests can you use to differentiate between sensorineural and conductive hearing loss?
Rinne's
| Weber's
130
What is Rinne's test?
Tuning fork placed on mastoid process and over acoustic meatus
+ve: AC > BC (normal)
-ve: BC>AC (conductive deafness)
131
What is Weber's test?
Tuning form place on forehead
Asked which sound is loudest
Unilateral sensorineural deafness - localises to unaffected side
Unilateral conductive deafness - localises to affected side
132
What should you do if someone has undergone neck surgery and develops post-operative stridor?
Urgent removal of stiches and call for senior help
| May be due to post-op bleed --> pressure behind suture line compresses trachea
133
What are the most common causes of hearing loss?
Ear wax
Otitis media
Otitis externa
134
What is presbycusis?
Age related sensorineural hearing loss
135
What do you see on the audiogram in presbycusis?
Bilateral high frequency hearing loss
136
What is glue ear?
Otitis media with effusion
137
When is glue ear most common?
Age 2
138
How does glue ear present?
```
Hearing loss (conductive hearing loss)
Secondary problems, e.g. speech and language delay, behavioural or balance problems
```
139
What drugs can cause hearing loss through ototoxicity?
```
Aminoglycosides, e.g. gentamicin
Furosemide
Aspirin
Cytotoxic agents
Quinine
```
140
What kind of hearing loss is seen with noise damage?
Bilateral
| Typically worse at frequencies of 3000-6000Hz
141
If the acoustic neuroma is affecting cranial nerve 8 what signs will you see?
Hearing loss
Vertigo
Tinnitus
142
If the acoustic neuroma is affecting cranial nerve 5 what signs will you see?
Absent corneal reflex
143
If the acoustic neuroma is affecting cranial nerve 7 what signs will you see?
Facial palsy
144
What can cause a perforated tympanic membrane?
Infection (most common)
Barotrauma
Trauma
145
What are the clinical features of a perforated tympanic membrane?
Hearing loss depending on size
| Increased risk of otitis media
146
How do you manage a perforated tympanic membrane?
Should heal spontaneously within 6-8w
Antibiotics for perforations due to acute otitis media
Myringoplasty if failure to spontaneously heal
147
What advise should you give patients with a perforated ear drum?
Keep it dry if possible
148
What % of the population have nasal polyps?
1%
149
What things are associated with nasal polyps?
```
Asthma
Aspirin sensitivity
Infective sinusitis
CF
Kartagener's syndrome
Churg-strauss syndrome
```
150
What are the clinical features of nasal polyps?
Nasal obstruction
Rhinorrhoea, sneezing
Poor sense of taste and smell
151
How do you manage nasal polyps?
Referral to ENT
| Topical corticosteroids shrink polyps
152
What is samter's triad?
Asthma
Aspirin sensitivity
Nasal polyps
153
What would you expect in the hx of a lymphoma?
Rubbery, painless lymphadenopathy
Night sweats
Splenomegaly
154
What would you expect on hx of thyroid swelling?
Moves upwards on swallowing
| May be hypo/hyper/euthyroid
155
What would you expect in the hx of a thyroglossal cyst?
<2oy
Midline, between isthmus of thyroid and hyoid bone
Moves upwards with protrusion of tongue
May be painful if infected
156
What is a typical hx of pharyngeal pouch?
```
Older men most commonly
Midline lump that gargles on palpation
Dysphagia
Regurgitation
Aspiration
Halitosis
Chronic cough
```
157
What is a pharyngeal pouch?
Posteriomedial herniation between thyropharyngeus and cricopharyngeus muscles
158
What is a cystic hygroma?
Congenital lymphatic lesion on neck, classically the left side(transilluminates, and is soft and painless)
159
What is a branchial cyst?
Oval, mobile cystic mass that develops between the SCM and pharynx
160
What causes a branchial cyst?
Failure of obliteration of the second brachial cleft in embryonic development
161
When do branchial cysts tend to present?
Early adulthood
162
Who are cervical ribs most common in?
Adult females
163
What do 10% of those with cervical rib develop?
Thoracic outlet syndrome
164
What is a typical hx of a carotid aneurysm?
Pulsatile lateral neck mass which doesn't move on swallowing
165
What is a cholesteatoma?
Non-cancerous growth of squamous epithelium trapped in the skull base causing local destruction
166
At what age is cholesteatoma most common?
10-20y
167
What condition increases the risk of developing cholesteatoma?
Cleft palate
168
What are the features of cholesteatoma?
Foul smelling, nonresolving discharge
Hearing loss
Symptoms due to local invasion -
Vertigo
Facial nerve palsy
Cerebellopontine angle syndrome
169
What do you see on otoscopy with cholesteatoma?
Attic crust seen in uppermost part of ear drum
170
How do you manage cholesteatoma?
Referral to ENT for surgical removal
171
What is SCC of the nasopharynx associated with?
EBV
172
What are the presenting features of nasopharyngeal carcinoma?
```
Cervical lymphadenopathy
Otalgia
Unilateral serous otitis media
Nasal obstruction, discharge
Epistaxis
Cranial nerve palsies
```
173
What imaging should be done for suspected nasopharyngeal carcinoma?
CT and MRI
174
What is the first line treatment for nasopharyngeal carcinoma?
Radiotherapy
175
Which ethnicity is most affected by SCC of the nasopharynx?
Asian
176
List causes of hoarseness
```
Voice overuse
Smoking
Viral illness
Hypothyroidism
GOR
Laryngeal cancer
Lung cancer
```
177
What investigation should be done when investigating hoarseness?
CXR to exclude apical lung lesions
178
What are features of mastoiditis?
```
Ear displaced anteriorly
Swelling, erythema and tenderness over mastoid process
Systemically unwell
Pain behind ear
Fever
Hx of recurrent otitis media
```
179
What are acute complications of otitis media?
Meningitis
Mastoiditis
Facial nerve paralysis
180
What are the criteria for 2 week wait referrals to oral surgery?
Unexplained oral ulceration/mass >3w
Unexplained red/red/white patches that are painful, swollen or bleeding
Unexplained one sided pain in head/neck region >w associated with ear ache and no abnormal otoscopy findings
Unexplained recent neck lump/prev. undiagnosed lump that has changed over a period of 3-6w
Unexplained persistent sore throat
Sx/sx in oral cavity >6w that cannot be diagnosed as benign
181
In who should we have an increased level of suspicion for oral cancer?
Patients who are >40, smokers, heavy drinkers and chew tobacco/betel nut
182
List 7 causes of tinnitus
```
Impacted ear wax
Chronic suppurative otitis media
Drugs (aspirin, aminoglycosides, loop diuretics, quinine)
Hearing loss
Acoustic neuroma
Otosclerosis
Meniere's
```
183
What % of salivary gland tumours are benign?
80%
184
What is a pleomorphic adenoma a proliferation of?
Epithelial and myoepithelial cells and stromal components
185
What cancer does pleomorphic adenoma most commonly transform into?
Carcinoma ex-pleomorphic adenoma
186
How does Warthin's tumour present?
Lymphocytic infiltrate and cystic epithelial proliferation
187
Is malignant transformation common in Warthin's tumour?
Very rare
188
What kind of cells do monomorphic adenomas consist of?
Just one morphological cell type (e.g. basal cell, canalicular cell..)
189
What is the most common parotid tumour in <1y?
Haemangioma
190
Name the benign parotid tumours
Pleomorphic adenoma
Warthins tumour
Monomorphic adenoma
Haemangioma
191
What are the malignant parotid tumours?
```
Mucoepidermoid carcinoma
Adenoid cystic carcinoma
Mixed tumours
Acinic cell carcinoma
Adenocarcinoma
Lymphoma
```
192
How do you diagnose parotid tumours?
```
Plain x-ray
Sialography
FNAC
Superficial parotidectomy (can be diagnostic or therapeutic)
CT/MRI for staging
```
193
How do you treat parotid tumours?
Surgical resection (if benign superficial parotidectomy, if malignant may need radical parotidectomy and neck dissection if nodal involvement)
194
How might HIV affect the parotids?
Lymphoepithelial cysts may occur in parotid
Typically bilateral, multicystic symmetrical swelling
195
What is Sjogren's syndrome?
Autoimmune condition with parotid enlargement, xerostomia, keratoconjunctivitis sicca
196
How are the parotids affected by Sjogren's?
Bilateral, non-tender enlargement of gland usually
197
How might the parotid glands be affected in sarcoidosis?
Bilateral usually
Non-tender gland
May also get xerostomia
198
What is allergic rhinitis?
Inflammatory disorder of nose where nose becomes sensitised to allergens
199
What are common allergens in allergic rhinitis?
Tree, grass and weed pollens
| House dust mite
200
How can you classify allergic rhinitis?
Seasonal - symptoms at same time every year
Perennial - symptoms throughout the year
Occupational - due to particular allergens in the work place
201
What are the features of allergic rhinitis?
```
Sneezing
Bilateral nasal obstruction
Clear nasal discharge
Post-nasal drip
Nasal pruritus
```
202
What is the management of allergic rhinitis?
Allergen avoidance
Mild-moderate symptoms: oral/intranasal antihistamines
Mod-severe symptoms: intranasal corticosteroids
occasionally may need short courses of oral corticosteroids/topical decongestants
203
Why should intranasal decongestants not be used for long periods?
Increasing doses are req. to give same effect = tachyphylaxis
Rebound hypertrophy of nasal mucous may occur on withdrawal
204
What are the features of vestibular neuronitis?
Recurrent vertigo attacks lasting hrs/days
NV
Horizontal nystagmus
205
How do you manage vestibular neuronitis?
Vestibular rehab exercises
Buccal/IM prochlorperazine for rapid relief
Antihistamine may be used for less severe cases
206
What is sinusitis?
Inflammation of the mucous membranes of the paranasal sinuses
207
What are the most common infective agents seen in sinusitis?
Strep pneumoniae
H. influenzae
Rhinoviruses
208
What factors predispose to sinusitis?
Nasal obstruction, e.g. septal deviation, nasal polyps
Recent local infection, e.g. rhinitis, dental extraction
Swimming/diving
Smoking
209
What are the features of sinusitis?
Facial pain, worse on bending forward
Thick and purulent nasal discharge
Nasal obstruction
210
How do you manage acute sinusitis?
Analgesia
Intranasal decongestants/saline
Intranasal corticosteroids if symptoms present 10+ days
Phenoxymethylpenicillin if severe presentation or co-amoxiclav if systemically unwell/at high risk of complications
211
Should a tonsillectomy be considered for quinsy?
Yes - but 6w after episode
212
What are the features of quinsy?
Severe throat pain, lateralising to one side
Deviation of the ulna to unaffected side
Trismus (difficulty opening mouth)
Reduced neck mobility
213
How do you manage quinsy?
Urgent ENT review
| Needle aspiration or incision and drainage with IV antibiotics
214
What are branchial cysts filled with?
Acellular fluid containing cholesterol crystals, encapsulated by stratified squamous epithelium
215
What are typical Ex features of a branchial cyst?
```
Unilateral, usually on left
Lateral, ant. to SCM
Slowly enlarging
Smooth, soft, fluctuant
Non-tender
Fistula may be present
No movement on swallowing
No transillumination
```
216
How should you investigate a branchial cyst?
US
Referral to ENT
FNAC
217
How are branchial cysts managed?
Conservatively or surgery
218
For very mild otitis externa what is an alternative treatment option?
Topical acetic acid 2% spray
219
List some causes of facial pain
Sinusitis
Trigeminal neuralgia
Cluster headache
Temporal arteritis
220
What are the characteristic features of sinusitis?
Facial fullness and tenderness
| Nasal discharge, pyrexia, post-nasal drip leading to cough
221
What are the characteristic features of trigeminal neuralgia?
Unilateral facial pains that are brief and electric shock-like, abrupt in onset and termination
Triggered by light touch and emotion
222
What are the characteristic features of cluster headache?
Pain 1/2x per day, lasting 15m-2h
Clusters typically last around 4-12w
Intense pain around 1 eye
Accompanied by redness, lacrimation, lid swelling, nasal stuffiness
223
What are the characteristic features of temporal arteritis?
Tender around temples
| Raised ESR
224
What is sialadenitis?
Inflammation of the salivary gland usually due to obstruction by an impacted stone
225
How do you manage primary haemorrhage after a tonsillectomy?
Immediate return to theatre
226
How long may patients experience pain after a tonsillectomy?
Pain may increase for up to 6 days post-op
227
How do you treat a secondary haemorrhage post-tonsillectomy?
Admission and IV antibiotics
228
If you identify sensorineural hearing loss what drug can you give that may potentially be of some benefit?
High dose steroids for 7 days may improve prognosis
Most sensorineural hearing loss is idiopathic
229
What is labyrinthitis?
Inflammatory disorder of membranous labyrinth affecting both the vestibular and cochlear end organs
230
What are the types of labyrinthitis?
Viral, bacterial or associated with systemic disease
231
What is a typical presentation of viral labyrinthitis?
```
Acute onset of -
Vertigo: exacerbated by movement
NV
Hearing loss
Tinnitus
Preceding/concurrent symptoms of a URTI
```
232
What are the signs of viral labyrinthitis?
```
Unidirectional horizontal nystagmus
Sensorineural hearing loss
Abnormal head impulse test
Gait disturbance: patient may fall towards affected side
Normal skew test
```
233
How do you diagnose viral labyrinthitis?
Hx, Ex
| In most pts Ix aren't req.
234
What investigations can you do in viral labyrinthitis if diagnosis is uncertain?
Pure tone audiometry
FBC, BC
Temporal bone CT scan (if suspecting mastoiditis/cholesteatoma)
MRI
Vestibular function testing: helpful in difficult cases or in determining prognosis
235
What is the most commonly used antibiotic/steroid topical preparation used for otitis externa?
Gentamicin and hydrocortisone
236
What kind of nervous activity causes the submandibular glands to produce more serous secretions?
Parasympathetic
237
What is sialothiasis?
Stone formation in the salivary gland ducts
238
What are the stones formed in sialothiasis usually composed of?
Calcium phosphate or calcium carbonate
239
What are the typical symptoms of sialothiasis?
Colicky pain
Prandial swelling of the gland
Halitosis
Dry mouth
240
How do you investigate sialothiasis?
Sialography
241
How do you manage sialothiasis?
If in distal aspect of Whartons duct may be removed orally
| Other stones and chronic inflammation usually req. gland excision
242
What most commonly causes sialadenitis?
Staph aureus
243
What are the signs of sialadenitis?
Pus leaking from duct
| Erythema
244
What is a serious complication of sialadenitis?
Submandibular abscess (may spread through other deep fascial spaces + occlude airway)
245
How do you diagnose submandibular tumours?
FNAC
| Imaging with CT/MRI
246
What are the clinical features of BPPV?
Vertigo triggered by change in head position
Associated nausea
Lasts 10-20s
247
What age of onset of BPPV is most common?
55y
248
What is the prognosis of BPPV?
Good - usually resolves spontaneously after a few weeks/mouths
Recurrence in 50%
249
What are the management options for BPPV?
Epley manoeuvre (successful in 80%)
Vestibular rehabilitation exercises
Betahistine is of limited vlalue
250
How do you diagnose BPPV?
Dix-Hallpike manoeuvre
251
What is gingivitis usually secondary to?
Poor dental hygiene
252
What is the spectrum of presentations of gingivitis?
Simple gingivitis (painless, red, swelling of gum margin which bleeds on contact) to acute necrotizing ulcerative gingivitis (painful bleeding gums with halitosis and punched out ulcers on the gyms)
253
How do you manage simple gingivitis?
Advise to seek regular rv with dentist
254
How do you manage acute necrotizing ulcerative gingivitis?
Refer to dentist, in meanwhile, oral metronidazole for 3 days, chlorhexidine/hydrogen peroxide mouthwash
Simple analgesia
255
What is a nasal septal haematoma?
Development of a haematoma between the septal cartilage and overlying perichondrium
256
What may cause a nasal septal haematoma?
Relatively minor trauma may precipitate it
257
What are the symptoms of a nasal septal haematoma?
Nasal obstruction
Pain
Rhinorrhoea
258
What are the signs of a nasal septal haematoma?
Bilateral, red swelling arising from the nasal
| Gently prod it and it will be boggy if it is a haematoma
259
How do you manage a nasal septal haematoma?
Surgical drainage
| IV antibiotics
260
What can happen if a nasal septal haematoma is left untreated?
Irreversible septal necrosis may develop within 3-4 days
Due to pressure related ischaemia in the cartilage
--> saddle nose deformity
261
What is rhinitis mediacmentosa?
Rebound nasal congestion brought on by extended use of topical decongestants
262
How do you manage rhinitis mediacmentosa?
Remove offending nasal spray
| Saline nasal sprays may help
263
What are risk factors for vertebrobasilar ischaemia?
CV disease
264
What causes vertebrobasilar ischaemia?
Atherosclerosis in the vertebrobasilar distribution exacerbated by changes in head position --> ischaemia and symptoms
265
Why is mastoiditis a medical emergency?
Due to potential risk of meningitis
May also cause cranial nerve palsies, hearing loss, OM, and carotid artery spasm
266
What causes acute mastoiditis?
Acute otitis media spreads out from the middle ear
267
Recurrent unilateral epistaxis is a red flag for what condition?
Nasal cancer
