ENT surgery Flashcards
Nose, Otology, Vestibular system and Paediatric A and E [tonsils, adenoids],
Chronic Rhinosinusitis
What is it- definition?
Associated symptoms
Treatment
Chronic Rhinosinusitis
What is it- definition?: Constellation of symptoms - nasal congestion bilaterally AND rhinorhhoea/post nasal drip AND Loss of smell/ cough [in children] Facial pain For more than 3 months
Associated symptoms:
Nasal oedema/swelling
Nasal polyps
Treatment:
Intranasal steroids- MEDICAL TX IS DEFINITIVE
- Flucticasone proprionate- less systemic
- Betametasone proprionate- 60% systemic
Adjuncts:
- If too many polyps- obstructing path of intra nasal steroids
> Medical polypectomy- oral steroid short chours
> Surgery - remove polyps
then re administer intra nasal steroids
- Sea salt- rinse nose- nasal steroid applies more easily
How do you investigate nasal polyp?
Naso endoscopy
What are the complications of nasal polpectomy?
Debriding eye
- extra ocular fact
- medial rectus
- orbital bone
Injury to brain
V low risk- one in a thousand
What is the first/ most important step when assessing nasal trauma/suspected broken nose?
Why?
Septal haematoma
Cartilage of septum blood flow comes from overlying mucosa
Bilateral septal haematoma- separates cartilage and mucosa- devascularisation of nasal cartilage
If anterior perforation in septum- causes saddle nose
Drain immediately
Is a broken nose an ENT emergency?
No
Unless complicated
How do you treat a broken nose?
Leave- allow swelling to go down
ENT clinic- one week later
If still a problem:
Manipulation - surgery- push back to midline under anaesthesia- after three weeks
If still problem:
Septorhinoplasty- 9-12 months after injury
How common is rhinitis?
V common
How do you diagnose allergic rhinitis?
Positive allergy test- blood, skin prick tests
Symptoms of allergic rhinitis
Watery eyes Itchy sore throat Runny nose- rhinorrhoea Nasal congestion Sneezing
No loss of smell, facial pain
How do you treat allergic rhinitis?
Antihistamines- intranasal
Intranasal corticosteroids
If still bad- oral antihistamine
What is a contraindication to intranasal corticosteroids?
Glaucoma
Why do a rhinoplasty?
Broken nose can cause deviated septum- blocking breathing
Nature of complications of rhinoplasty?
Long lasting
Purpose of eustachian tube
Brings fresh air into middle ear and equalises air pressure
What is otitis externa?
Aetiology/Causative organism
Risk factors/Precipitating factor
What is otitis externa?
Aetiology/Causative organism: Staphyloccous- commensal evolves to: Klebsiella E Coli Pseudomonas- esp bad b/c produces mucopolysaccharide biofilm- traps bacteria under it Need to use vacuum to remove film before treating
Risk factors/Precipitating factor - Water in ear- swimmer's ear Break in skin - Eczema - Psoriasis - Sebhorrhoeic dermatitis - Using cotton bud to clear wax - Contact dermatitis- shampoo, detergent etc
Otitis media- what is it?
Symptoms
Complication
Infection of middle ear- like an abscess behind tympanic membrane
Symptoms
Injected- inflamed blood vessels on ear drum
Pus
V painful- until pus drains
Grows bigger until causes perforated eardrum + discharged pus- relieving pain
Pus can also collect back into mastoid- mastoiditis
Can create a hole in mastoid- can become permanent and cause mastoid fistula
Can spread backwards - causing brain abscess
Causes of tympanic membrane perforation
- Otitis media
- Trauma- eg. blow to head
- Barotrauma- sudden pressure changes
- Cotton wool bud/foreign objects
Perforation prognosis
- May either resolve
- Or become permanent- not problem as long as kept clean and dry
- Higher risk of infection
- Middle ear infection v likely if large perforation + exposed to water
What is glue ear?
How is it treated?
What can precipitate it? How does the precipitating factor change the presentation?
Who is it most common in and why?
Otitis media with effusion
Treatment:
Insertion of grommets- drain effusion and remove low pressure environment that caused effusion
Precipitated by:
Upper respiratory tract system
If due to URTI- usually bilateral
If unilateral- something compressing Eustacian tube- maybe cancer
Most common in children:
Eustacian tube less well developed
What can unilateral glue ear be a sign of?
Cancers
Usually precipitated by a cold
What is the problem with hearing aids?
Mechanically inefficient
Using lots of battery to transfer vibration
What is a BAHA?
Bone anchored hearing aid
Used when no middle ear bones [ossicular chain]
Causes vibration of bones in skull near cochlea- transmits to cochlea
What is an auditory brainstem implant?
Electrodes directly to brainstem
Experimental
Used if eighth nerve not working
What causes dizziness in ENT?
Vestibular system
Bony labyrinth- what are the five parts?
Semicircular canals:
Anterior
Posterior
Lateral
Utricle
Saccule
- Gravity and linear acceleration
How do semi circular canals work?
Endolymph moves over hair cells when head moves
Opens ion channels- depolarises nerves
How do the utricle and saccule work?
Hair cells stimulated by gel containing otoliths
Otoliths constantly activate hair cells- tell you if standing or lying down even when not moving
What is the vestibulospinal reflex?
Keeps head still while moving around
Allows to keep balance
What types of dizziness are there?
Vertigo- abnormal sensation of motion
Light headedness- presyncope
Spaced out- dissociation
Unsteadiness/off balance- dysequilibrium
What are associated symptoms/signs of vertigo?
Nausea + Vomiting
Nystagmus
BPPV
Cause
Symptoms/signs
Diagnosis
Treatment
BPPV
- otoliths get stuck in wrong place
Symptoms/signs Positional: Vertigo N + V Horizontal nystagmus Lasts for a few seconds
Diagnosis
Dix Hallpike
Treatment
Epley maneouvre
Meniere’s
Symptoms
Meniere’s
Symptoms
Peripheral causes of vertigo
BPPV
Meniere
vestibular neuronitis/labrynthitis
Meniere’s
Symptoms
Treatment
Meniere’s
Symptoms Last up to an hour Vertigo Hearing loss- unilateral Tinnitus Ear fullness
Treatment No cure Betahistine Intra tympanic steroid injection Balance therapy + physio Antiemetics
Time course of vertigo due to vestibular neuronitis/labyrinthitis
Resolves after infection is gone usually
What is the difference between vestibular neuronitis and labyrinthitis?
Vestibular neuronitis= affects nerve
Labyrinthis- affects utricle and saccule, SCC
Central causes of vertigo
What indicates a central cause?
Vestibular migraine
Brainstem, cerebellar, thalamic, cortical pathology
Non- horizontal nystagmus
What are the types of tonsil disease?
- Acute tonsilitis
- Recurrent tonsilitis
- Malignancy- rare in children
- Obstructive hyperplasia
What are the symptoms of tonsillitis?
> Prodrome- fever, malaise > Cervical lymphadenopathy- more than two cm/tender lymph nodes > Off school/work > Sore throat, odynophagia, dysphagia > Otalgia- ear pain
What are the causes of tonsillitis?
Viral- most common- adenovirus, enterovirus, EBV, RSV, CMV Bacterial: Strep pyogenes Strep pneumoniae [Haemophilus influenza] [Staph aureus]
Do you do throat swabs for tonsillitis?
Not really
If abscess, take pus
Can you clinically differentiate between viral and bacterial anitibiotics?
No
What is the treatment for tonsillitis?
Analgesia
Penicillin- delayed prescription- give and let to take in seventy two hours if symptoms have not resolved
Erythromycin
What are the differentials for tonsillitis?
Infectious mononucleosis Malignancy - Lymphoma, leukaemia carcinoma Diphtheria- almost wiped out Scarlet fever Agranulocytosis
What is obstructive hyperplasia?
Tonsils are so big that they affect breathing
On a spectrum from: Mouth breathing Snoring Sleep disordered breathing Upper airways resistance syndrome Complete sleep apnea
What are the symptoms of obstructive hyperplasia?
What are the investigations?
Symptoms:
Day time somnolence, decreased attention, school performance
Daytime chronic mouth breathing
Daytime dysphagia and failure to thrive
Snoring
Restless sleep
Investigations:
Sleep study-polysomnography- oxygen and carbon dioxide levels
Sleep video diary over a month
If surgery - check for perioperative issues- post op HDU
What other conditions can compound obstructive hyperplasia in children and increase likelihood of sleep apnea?
Down’s syndrome
Cranio facial problems [reduced oral airway, set back jaw]- Pierre Robin, Treacher Collins
Neuromuscular disorders
What are the complications of severe obstructive sleep apnoea?
Cardio and resp complications: Pulmonary hypertension Cor pulmonale Dysrhythmia Heart failure
Intracranial hypertension
What does unilateral tonsil enlargement suggest?
Can either be true enlargement or apparent enlargement [Tonsil displaced medially by abscess/mass]
Often non neoplastic
Can be neoplastic- unlikely in small children, but investigate in teenagers, and adults
What are non neoplastic causes of unilateral tonsillar enlargement?
Hypertrophy
Acute infection
Chronic infection- TB, actinomycosis, congenital syphilis
Congenital- teratoma, haemangioma, lymphangioma, cystic hygroma
What are neoplastic causes of unilateral tonsillar enlargement?
Benign papillomas
Lymphomas
Squamous cell carcinoma
What are the types of adenoid disease?
Acute adenoiditis
Recurrent adenoiditis
Obstructive hyperplasia
Malignancy [adults]
What is adenoid facies?
Overbite
Long face
Crowded incisors
Associated with increased risk of adenoid disease
What are the symptoms of adenoid disease?
Obstruction related:
- Snoring
- Mouth breathing
- Hyponasality
Discharge related:
- Rhinorrhoea
- Post nasal drip
- Nocturnal cough
What investigations do you do for adenoid disease?
Nasendoscopy [rarely in children]
Posterior rhinoscopy - rarely done
Lateral neck X ray- rarely done- [only useful if history and exam contradictory, and quality often compromised due to poor positioning of child due to poor cooperation’
What are the indications for tonsillectomy?
> Recurrent or chronic tonsillitis
- 7 episodes in 3 year
- 5 in 2 years
- 3 in 3 years
> Obstructive sleep apnea- hypertrophy
> Peritonsilar abscess + tonsillitis
In adults
- Very last resort for tonsiloliths/halitosis
- Unilateral tonsillar enlargement- if malignancy
What are the indications for adenoidectomy?
Obstruction
- chronic nasal obstruction/mouth breathing
- Obstructive sleep apnea/sleep disordered breathing
- Speech problems
Infection
- Recurrent/chronic adenoiditis
- Recurrent/chronic glue ear
What do you consider about palate before doing an adenoidectomy?
Bifid uvula- submucosal cleft palate Cleft palate- if weak palate and take out adenoid- food up nose when swallow Midline muscle diastasis Velopharyngeal insufficiency Neuromuscular disease
Techniques for tonsillectomy?
Guillotine Cold steel Electrodissection- diathermy Laser dissection Microdebridement Coblation
ALL EQUALLY EFFECTIVE
Techniques for adenoidectomy?
Curretage
Suction diathermy
Laser ablation
Microdebridement
ALL EQUALLY EFFECTIVE
What are the contraindications for adenoidectomy?
Overt or submucous cleft palate
Neuromuscular abnormalities- impaired palatal function
[both of these cause food to come out of nose if adenoid removed]
Anaemia/haemostasis disorders
What is an active middle ear implant?
Directly stimulates stapes
What is an acoustic neuroma/vestibular schwannoma?
Benign tumour of CNVIII
