ENT surgery Flashcards
Audiometry
- Used to differentiate between conductive and sensorineural hearing loss
Sensorineural - both air and bone conduction will be more than 20db (can be only one or both sides)
Conductive - bone conduction readings will be normal but air conduction will be greater than 20db
Mixed - both air and bone conduction will be greater than 20db but there will be a difference of more than 15db between the two (bone more than air)
Presbycusis
*Age related hearing loss - a type of sensorineural hearing loss
* Affects higher pitched sounds
*Occurs gradually and symmetrically
Sx - male voices can be easier to hear, not paying attention or missing conversations, concerns about dementia, tinnitus,
Ix - audiometry - sensorineural (both reduced)
Mx - Hearing aids
Sudden sensorial hearing loss
- Hearing loss over less than 72 hrs, unexplained by other causes
- ENT emergency
Cx - MS, infection, Menieres, medications, migraines, acoustic neuroma, stroke
Sx - often unilateral
Ix - Tuning fork, audiometry (reduction by 30db in 3 consecutive frequencies)
- CT head
Mx - steroids asap
Eustachian tube dysfunction
- When the tube that drains the inner ear to the throat and equalises pressure becomes blocked
Sx - reduced or altered hearing, popping noises, a fullness sensation in the ear, pain or discomfort, tinnitus
* Worsened when external ear pressure changes and inner ear cannot adjust
Ix - typanometry (CHANGING PRESSURE), audiometry, nasopharyngoscopy, CT head
Mx - nasal sprays, valsalva manoeuvre, anti histamines
- Surgery if persistent
Otosclerosis
- Remodelling of small ear bones (mostly base of stapes), causing stiffening, preventing sound being transmitted
**Conductive hearing loss
**Autosomal dominant
Sx - patient under 40 - tinnitus, hearing loss - unilateral hearing loss, lower frequency sounds affected,
Ix - audiometry, tymapometry, CT head
Mx - hearing aids, surgical stapedectomy with replacement
**Surgery generally curative
otitis media
*infection in the middle ear (space between tympanic membrane and inner ear) where vestibular apparatus and nerves are found
*Effusion present means glue ear (common in kids)
Cx - Bacteria entering via eustachain tube via back of the throat from upper resp tract infection
**Strep pneumonia most common
- haemophilous influenza
Px - ear pain, reduced hearing, fever, upper resp infection
- vertigo and discharge possible (perforation)
Ix - otoscope - bulging red, tympanic membrane, discharge if perforation
- decreased mobility of membrane indicates effusion
Mx - Amoxicillin
- allergy give clarithromycin
Otitis externa
- Inflammation of the skin in the external ear canal
Cx - swimmers ear, trauma, removal of ear wax, eczema, fungal infections (lots of antibiotics)
* Staph aureus and pseudomonas aeruginosa
^later can colonise the lung in cystic fibrosis patients - resistant to many antibiotics (mx with gentamicin)
Sx - ear pain, itchiness, discharge, conductive hearing loss
Ix - otoscopy and ear swab
Mx - acetic acid (mild)
- topical antibiotic (neomycin) and topical steroid spray (moderate)
- oral antibiotic (severe)
**Ciprophloxacin for diabetics to cover pseudomonas
Tinnitus
- Ears trying to turn up the volume when they cant hear sound
Primary - associated with sensorial hearing loss
Secondary - tinnitus with an identifiable cause (gentamicin and loop diuretics***)
Systemic conditions Axs - anaemia, diabetes, thyroid issues, hyperlipademia
Objective tinnitus - where the patient can hear an extra sound, that can be heard on auscultation with a stethoscope - carotid bruit, aortic murmur, AVM, Eustachian tube dysfunction
Ix - underlying conditions - anaemia, glucose, thyroid, lipids, audiology,
Mx - x
Vertigo
- Imbalance between sensory inputs and the environment of a person
Cx - Proprioception, vision, signals from vestibular system (fluid shifting detection problems in the inner ear)
BPPV
Cx - calcium carbonate crystals building up in the inner ear, disrupting flow of endolymph in (posterior) semi circular canals
Px - head movement triggers attacks that last up to a minute
- no hearing loss or tinnitus
Ix - Dix hall pike - triggering rotational nystagmus and vertigo
Mx - eply manœuvre
Vestibular neuronitis
- Inflammation of vestibular nerve - usually due to a viral infection
Sx - acute onset vertigo - initially constant then triggered by head movement, nausea and vomiting, balance problems
*No hearing loss or tinnitus
* History of upper resp viral infections
Ix - Head impulse test - diagnosis for peripheral vertigo (problem with nerve)
Mx - Prochlorperazine (in acute phase only) and antihistamines
- If chronic - vestibular rehab exercises
HiNTS exam - distinguishes between posterior circulation stroke
Labyrinthitis
- Inflammation of the bony labyrinth in the inner ear (cochlea affected)
**Often post upper viral resp infection - Can be bacterial via otitis media or meningitis
Px - acute onset vertigo, can have associated tinnitus and hearing loss, horizontal nystagmus
Ix - head impulse test - to detected movement problems
Mx - prochlorperazine and antihistamines
- antibiotics
Menieres disease
- Long term inner ear disorder that causes recurrent attacks of vertigo, hearing loss and tinnitus
- Full feeling in ear
Cx - excessive build up of endolymph in the labyrinth, increasing pressure
Px - 40-50 yo with unilateral vertigo, tinnitus and hearing loss, episodic lasting for 20mins to hours (can be clustered over weeks and months)
- unexplained drop attacks
- spontaneous nystagmus during attacks (horizontal)
Ix - clinical diagnosis
Mx - conservative
- acute attacks - prochlorperazine and anti histamines
*Beta histine to prevent attacks
Vestibular schwannomas
- Benign tumours of Schwann cells surrounding the auditory/vestibular nerve
- Occur at cerebellopontine angle
- Unilateral but if bilateral - neurofibromatosis II
Sx - Unilateral sensory hearing loss, unilateral tinnitus, dizziness, fullness in the ear
*Patient typically 40-60
Ix - Audiometry - sensorineural hearing loss
- CT or MRI to detect presence
Mx - Surgery to remove (scar behind ear)
- radiotherapy to shrink
- Associated with facial nerve palsy
Cholesteatoma
- Abnormal collection of squamous epithelial cells in the middle ear - non cancerous
- can erode middle ear boned and invade tissues
Px - foul discharge, unilateral conductive hearing loss
- infection, pain, vertigo, facial nerve palsy (if expanding)
Ix - otoscopy - build up of white debris or crust in upper tympanic membrane - locate the attic to exclude cholesteatoma
- CT head for surgery
Mx - surgical removal
Nosebleeds
*epistaxis
**Bleeding from Kiesselbach’s plexus in little’s area - nasal mucosa at the front of nasal cavity that is very vascular
Mx - Anterior nasal packing - where bleeding site hard to locate
- nasal cautery (silver nitrate)
Sinusitis
*Inflammation of paranasal sinuses - produce mucus and drain into nasal cavities via Ostia holes - blockage leads to sinusitis
- usually accompanied by inflammation of the nasal cavity - rhino sinusitis
Cx - Infection, allergies, obstruction (polyps), smoking
Px - facial pain, congestion, discharge, loss of smell..
Ix - nasal endoscopy
- CT head
Mx - high dose steroid spray if severe or last longer than 10 days
- irrigation if chronic rhino sinusitis
- Functional endoscopic sinus surgery - obstructions
Nasal polyps
- Growth of the nasal mucosa that occur in the nasal cavity or sinuses
- Usually bilateral - unilateral raise suspicions of a tumour
Px - chronic rhinosinusitis
- Difficulty breathing through the nose, snoring, nasal discharge, loss of sense of smell
Ix - nasal endoscopy, otoscopy
- polyps appear round pale grey/yellow
Mx - steroid spray
- intra cranial or endoscopic polypectomy - if they are close to the nostrils or further in respectively
Obstructive sleep apnoea
- Collapse of the pharyngeal airway causing episodes of apnoea - patient unaware
Px - episodes of apnoea, snoring, morning headache, poor sleep, concentration problems, daytime sleepiness
Ix - sleep studies by specialist
Mx - correct reversible risk factors - smoking, obesity…
- CPAP to maintain open airway
- surgical (UPPP)
Tonsillitis
- Most commonly viral but can be viral:
strep pyogenes most common (group A)
Px - sore throat, fever, pain on swallowing
Criteria for bacterial: fever, tonsillar pus, absence of cough, tender c lymph
Ix - red, inflamed, enlarged tonsils with or without exudates
- cervical lymphadenopathy (only anterior)
Mx - Penicillin 5
- clarithromycin in allergy
Quinsy
- Peritonsilar abscess
- complication of tonsillitis
Cx - group A strep (pyogenes)
- staph aureus and haem influenza
Px - tonsillitis sx
plus - trismus, change in voice, swelling and redness
- uvula deviated to opposite side
Mx - Fine needle aspiration or surgical drainage
Tonsillectomy
- Preventing recurrent tonsillitis
*7 or more in 1 year, 5 per year for 2 years, 3 per year for 3 years
`*Any bleeding within 24hrs straight back to surgery
* Bleeding 5-10 days post op - infection - refer to ENT and give co-amoxiclav
Neck lumps
- Arises in anterior and posterior triangle plus midline of neck
Carotid body tumours - at bifurcation, slow growing in ant triangle, pulsatile, painless, side to side but not up and down - associated nerve palsy
Cystic hygroma - form in post triangle and are soft
Branchial cysts - Congenital - 2nd branchial cleft fails to form space with epithelial tissue in lateral aspect of the neck
Px - soft, round, swelling between jaw angle and sternocleidomastoid in ant triangle
Throglossal cysts
- During fetal developement, thyroid begins at base of tongue and moves to front of trachea leaving a tract (thyroglossal duct) which should disappear
- if left it can give rise to a fluid filled cyst
Px - midline, mobile, non tender, soft, moves with tongue
Mx - conservative
- surgical excision
Head and neck cancer
*Usually SCC
locations - nasal cavity, paranasal sinuses, mouth, salivary glands, pharynx, larynx
** Spread to lymph nodes first
Red flags - mouth or lip lumps, unexplained ulceration, persistent neck lump, unexplained hoarseness, thyroid lump
Mx - radio, chemo, surgery
*Cetuximab - targets epidermal growth factor, blocking growth and mets (for head and neck)
Tongue conditions
Glossitis - smooth, red, swollen tongue
cx - anaemia
Angioedema - fluid accumulating - swollen tongue Cx - allergies, ACE inhibitors, hereditary
Oral candidiasis (thrush) - white spots and patches Cx - ICS, antibiotics, HIV…
Mx - miconazole (anti fungal), nystatin (antibiotic)
Geographic tongue - patches that lose epithelial surface
Strawberry tongue - swollen, red and papillae (tb) become enlarged and white
**Scarlet fever and Kawasaki disease
Black hairy tongue - decreased shedding of keratin, papillae elongate and take on appearance of hairs - bacteria and food cause dark pigmentation *metalic taste
Mouth and gum conditions
Leukoplakia - white patches in mouth - precancerous SCC (cant be scraped off)
Erythroplakia - similar^ but lesions are red and white - pre cancerous SCC
Lichen planus - auto immune chronic inflammation of skin - skin shiny, purple, with white lines (web)
Apthous ulcer - small painful ulcers in mucosa, punched out appearance
Axs - IBD, coeliac, HIV and vit deficiency
- Givingial hyperplasia - drugs - phenytoin, CCBs, cyclosporin
Glue ear
*Otitis media with an effusion
* Peaks at 2 years old
*If adults, need to rule put posterior nasal space tumour - 2 week ENT referral
Sx - conductive hearing loss, speech and language delay, behavioural and balance problems
Mx - Active observation 3 months
- grommet insertion
- adenoidectomy
* If perf noted, keep dry and see in 4 weeks
- If adult - 2 week referral to ENT
- If acute give amoxicillin for 2 weeks
- If downs syndrome - refers to ENT
- Can cause mastoiditis - displaced external ear, tender mastoid bone, septic picture
- just give IV antibiotics
Branchial cyst
Px - painless swelling, lateral aspect, smooth, fluctuant
Thyroglossal cyst
Px - midline neck lump, cystic, painless, upwards on protrusion of the tongue
Auricular haematomas
- Trauma to ear
Mx - same day ENT referral for incision and drainage
- if left untreated can cause cauliflower ear
Nasal septal haematomas
Cx - trauma
Sx - bilateral nasap swelling
Mx - urgently referred to ENT for drainage
*If left untreated can cause saddle shaped deformity via septic necrosis where blood supply os cut off
Sore throat criteria
CENTOR CRITERIA
- Tonsillar exudate
- Tender anterior lymphadenopathy or lymphadenitis
- History of fever
- Absence of cough
- 3-4 of these present - 60% chance of strep infection
Mx - Penicillin 5 - 1-2 of these present - 80% chance viral
Mx - pain relief
Infectious mononucleosis
Cx - EBV virus
Sx - combination of pharingitis and tonsillitis
- Tonsils can meet in the midline, evidence of mild bleeding (oropharynx), splenomegaly,
**Triad of - sore throat, pyrexia, and lymphadenopathy (ant and post neck)
Ix - heterophil antibody test (monospot test)
* 99% of patients that take amoxicillin when they have mono will have a rash
Mx - Rest and pain relief
Givingial hyperplasia
Cx drugs - phenytoin, CCBs, cyclosporin
Cx - acute myeloid leukaemia
Mastoiditis
- Complication of otitis media
Sx - ear displayed anteriorly, swelling, erythema, ear discharge
Mx - admit for IV antibiotics
Verterbrobasilar ischaemia
- Elderly patient with dizziness on neck extension
Globus pharyngitis
Px - thumb in throat, sometimes diffucltty swallowing water and food, swallowing salvia easier
