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DPD 2020 > ENT surgery > Flashcards

ENT surgery Flashcards

Nose, Otology, Vestibular system and Paediatric A and E [tonsils, adenoids],

1
Q

Chronic Rhinosinusitis

What is it- definition?

Associated symptoms

Treatment

A

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
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2
Q

How do you investigate nasal polyp?

A

Naso endoscopy

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3
Q

What are the complications of nasal polpectomy?

A

Debriding eye

  • extra ocular fact
  • medial rectus
  • orbital bone

Injury to brain

V low risk- one in a thousand

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4
Q

What is the first/ most important step when assessing nasal trauma/suspected broken nose?

Why?

A

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

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5
Q

Is a broken nose an ENT emergency?

A

No

Unless complicated

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6
Q

How do you treat a broken nose?

A

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

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7
Q

How common is rhinitis?

A

V common

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8
Q

How do you diagnose allergic rhinitis?

A

Positive allergy test- blood, skin prick tests

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9
Q

Symptoms of allergic rhinitis

A 
Watery eyes
Itchy sore throat
Runny nose- rhinorrhoea
Nasal congestion
Sneezing

No loss of smell, facial pain

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10
Q

How do you treat allergic rhinitis?

A

Antihistamines- intranasal

Intranasal corticosteroids

If still bad- oral antihistamine

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11
Q

What is a contraindication to intranasal corticosteroids?

A

Glaucoma

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12
Q

Why do a rhinoplasty?

A

Broken nose can cause deviated septum- blocking breathing

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13
Q

Nature of complications of rhinoplasty?

A

Long lasting

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14
Q

Purpose of eustachian tube

A

Brings fresh air into middle ear and equalises air pressure

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15
Q

What is otitis externa?

Aetiology/Causative organism

Risk factors/Precipitating factor

A

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
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16
Q

Otitis media- what is it?

Symptoms

Complication

A

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

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17
Q

Causes of tympanic membrane perforation

A
  • Otitis media
  • Trauma- eg. blow to head
  • Barotrauma- sudden pressure changes
  • Cotton wool bud/foreign objects
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18
Q

Perforation prognosis

A
  • 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
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19
Q

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?

A

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

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20
Q

What can unilateral glue ear be a sign of?

A

Cancers

Usually precipitated by a cold

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21
Q

What is the problem with hearing aids?

A

Mechanically inefficient

Using lots of battery to transfer vibration

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22
Q

What is a BAHA?

A

Bone anchored hearing aid
Used when no middle ear bones [ossicular chain]
Causes vibration of bones in skull near cochlea- transmits to cochlea

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23
Q

What is an auditory brainstem implant?

A

Electrodes directly to brainstem
Experimental
Used if eighth nerve not working

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24
Q

What causes dizziness in ENT?

A

Vestibular system

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25
Q

Bony labyrinth- what are the five parts?

A

Semicircular canals:
Anterior
Posterior
Lateral

Utricle
Saccule
- Gravity and linear acceleration

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26
Q

How do semi circular canals work?

A

Endolymph moves over hair cells when head moves

Opens ion channels- depolarises nerves

27
Q

How do the utricle and saccule work?

A

Hair cells stimulated by gel containing otoliths

Otoliths constantly activate hair cells- tell you if standing or lying down even when not moving

28
Q

What is the vestibulospinal reflex?

A

Keeps head still while moving around

Allows to keep balance

29
Q

What types of dizziness are there?

A

Vertigo- abnormal sensation of motion

Light headedness- presyncope

Spaced out- dissociation

Unsteadiness/off balance- dysequilibrium

30
Q

What are associated symptoms/signs of vertigo?

A

Nausea + Vomiting

Nystagmus

31
Q

BPPV

Cause

Symptoms/signs

Diagnosis

Treatment

A

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

32
Q

Meniere’s

Symptoms

A

Meniere’s

Symptoms

33
Q

Peripheral causes of vertigo

A

BPPV
Meniere
vestibular neuronitis/labrynthitis

34
Q

Meniere’s

Symptoms

Treatment

A

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
35
Q

Time course of vertigo due to vestibular neuronitis/labyrinthitis

A

Resolves after infection is gone usually

36
Q

What is the difference between vestibular neuronitis and labyrinthitis?

A

Vestibular neuronitis= affects nerve

Labyrinthis- affects utricle and saccule, SCC

37
Q

Central causes of vertigo

What indicates a central cause?

A

Vestibular migraine
Brainstem, cerebellar, thalamic, cortical pathology

Non- horizontal nystagmus

38
Q

What are the types of tonsil disease?

A
  • Acute tonsilitis
  • Recurrent tonsilitis
  • Malignancy- rare in children
  • Obstructive hyperplasia
39
Q

What are the symptoms of tonsillitis?

A 
> Prodrome- fever, malaise
> Cervical lymphadenopathy- more than two cm/tender lymph nodes
> Off school/work
> Sore throat, odynophagia, dysphagia
> Otalgia- ear pain
40
Q

What are the causes of tonsillitis?

A 
Viral- most common- adenovirus, enterovirus, EBV, RSV, CMV
Bacterial:
Strep pyogenes
Strep pneumoniae
[Haemophilus influenza]
[Staph aureus]
41
Q

Do you do throat swabs for tonsillitis?

A

Not really

If abscess, take pus

42
Q

Can you clinically differentiate between viral and bacterial anitibiotics?

A

No

43
Q

What is the treatment for tonsillitis?

A

Analgesia
Penicillin- delayed prescription- give and let to take in seventy two hours if symptoms have not resolved
Erythromycin

44
Q

What are the differentials for tonsillitis?

A 
Infectious mononucleosis
Malignancy
- Lymphoma, leukaemia carcinoma
Diphtheria- almost wiped out
Scarlet fever
Agranulocytosis
45
Q

What is obstructive hyperplasia?

A

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
46
Q

What are the symptoms of obstructive hyperplasia?

What are the investigations?

A

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

47
Q

What other conditions can compound obstructive hyperplasia in children and increase likelihood of sleep apnea?

A

Down’s syndrome

Cranio facial problems [reduced oral airway, set back jaw]- Pierre Robin, Treacher Collins

Neuromuscular disorders

48
Q

What are the complications of severe obstructive sleep apnoea?

A 
Cardio and resp complications:
Pulmonary hypertension
Cor pulmonale
Dysrhythmia
Heart failure

Intracranial hypertension

49
Q

What does unilateral tonsil enlargement suggest?

A

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

50
Q

What are non neoplastic causes of unilateral tonsillar enlargement?

A

Hypertrophy
Acute infection
Chronic infection- TB, actinomycosis, congenital syphilis
Congenital- teratoma, haemangioma, lymphangioma, cystic hygroma

51
Q

What are neoplastic causes of unilateral tonsillar enlargement?

A

Benign papillomas
Lymphomas
Squamous cell carcinoma

52
Q

What are the types of adenoid disease?

A

Acute adenoiditis
Recurrent adenoiditis
Obstructive hyperplasia
Malignancy [adults]

53
Q

What is adenoid facies?

A

Overbite
Long face
Crowded incisors

Associated with increased risk of adenoid disease

54
Q

What are the symptoms of adenoid disease?

A

Obstruction related:

  • Snoring
  • Mouth breathing
  • Hyponasality

Discharge related:

  • Rhinorrhoea
  • Post nasal drip
  • Nocturnal cough
55
Q

What investigations do you do for adenoid disease?

A

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’

56
Q

What are the indications for tonsillectomy?

A

> 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
57
Q

What are the indications for adenoidectomy?

A

Obstruction

  • chronic nasal obstruction/mouth breathing
  • Obstructive sleep apnea/sleep disordered breathing
  • Speech problems

Infection

  • Recurrent/chronic adenoiditis
  • Recurrent/chronic glue ear
58
Q

What do you consider about palate before doing an adenoidectomy?

A 
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
59
Q

Techniques for tonsillectomy?

A 
Guillotine
Cold steel
Electrodissection- diathermy
Laser dissection
Microdebridement
Coblation

ALL EQUALLY EFFECTIVE

60
Q

Techniques for adenoidectomy?

A

Curretage
Suction diathermy
Laser ablation
Microdebridement

ALL EQUALLY EFFECTIVE

61
Q

What are the contraindications for adenoidectomy?

A

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

62
Q

What is an active middle ear implant?

A

Directly stimulates stapes

63
Q

What is an acoustic neuroma/vestibular schwannoma?

A

Benign tumour of CNVIII

DPD 2020 (48 decks)

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