ENT workbook

Question 1

What assessments/management should be done when a patient presents with a perforated eardrum?

Answer 1

Otoscopy
Pure tone audiogram (to asses degree and type of hearing loss)
Keep the ear dry
No more cleaning with cotton ear buds
No eardrops
Review in 4 weeks

Question 2

What complication are you worried about with chronic otitis media with effusion?

Answer 2

Acute mastoiditis

Question 3

What organisms are commonly involved with chronic otitis media with effusion?

Answer 3

• Staphylococcus aureus
• Streptococcus pneumoniae
• Haemophilus influenzae

Question 4

What important relations of the middle ear/mastoid are at risk during a mastoidectomy?

Answer 4

Facial nerve palsy
Sigmoid sinus- bleeding, air embolism
Dura mater- CSF leak or meningitis

Question 5

What intracranial complications are associated with otitis media?

Answer 5

• Meningitis
• Intracranial abscess
• Sigmoid sinus thrombosis

Question 6

What intra temporal bone complications are associated with otitis media?

Answer 6

• Bacterial labyrinthitis
• Facial paralysis
• Petrous apicitis (inflammation of the petrous apex of the temporal bone)
• Gradenigo syndrome (otorrhoea, retro-orbital pain, lateral rectus palsy)
• Citelli abscess (abscess in the posterior part of the petrous apex)

Question 7

Why do you get hearing loss with a cholesteatoma

Answer 7

• Ossicular chain erosion
• tympanic membrane damage
• Involvement of the labryinth

Question 8

What would new onset vertigo after a cholesteatoma surgery indicate?

Answer 8

• Otic capsule erosion- fistula forms between the middle ear and the vestibular system.
• Abnormal stimulation leads to vertigo and dizziness
• Pressure changes in the middle ear

Question 9

Questions to ask in a history of BPPV

Answer 9

How long has he had it

How often are episodes

How long do the episodes last

What are the specific triggers

Has he had it before and if so did it resolve spontaneously or require treatment

Any hearing loss or tinnitus associated

Any loss of consciousness with episodes

Question 10

What recreational drug is commonly implicated in nasal septal defects, and what is its method of damage?

Answer 10

Cocaine.
It causes loss of blood supply to the cartilage of the septum

Question 11

What is the most common type of nystagmus seen in BPPV?

Answer 11

Geotropic nystagmus which involves the posterior circular canal
The nystagmus is torsional and upbeating, with the fast phase rotating toward the lowermost ear.

Question 12

What is functional endoscopic sinus surgery?

Answer 12

Uses an endoscope to remove obstructions like polyps, mucosal swellings or infected tissue.

Question 13

What are the potential complications of sinus surgery?

Answer 13

Bleeding, infection, CSF leak, visual loss or disturbance.

Question 14

What are the steps to control a posterior epistaxis?

Answer 14

Look at the posterior wall of the oropharynx by shining a light in the mouth and using a tongue depressor.

If there is fresh blood running down the wall he will require removal of the anterior packing and either a post nasal pack or a nasopharyngeal balloon followed by further anterior nasal packing

Question 15

Where does posterior epistaxis arise from?

Answer 15

Branches of the sphenopalatine artery
This supplies the posterior nasal cavity
The bleeding may involve the posterior ethmoidal artery

Question 16

How is posterior packing inserted?

Answer 16

• Using local or general anaesthetic
• The balloon catheter is inserted and gently advanced until it reaches the choanae (the opening between the nasal cavity and the nasopharynx)
• The pack is inflated to apply pressure

Question 17

How would you manage a patient with posterior epistaxis if packing and cautery of the bleeding vessels were to fail?

Answer 17

He would require a general anaesthetic either to pack more effectively or to cauterise the bleeding point or ligation of the sphenopalatine artery and possibly the anterior ethmoidal artery.

Question 18

What are the complications of submandibular surgery?

Answer 18

Bleeding infection, damage to the lingual or hypoglossal nerves or cervical branch of the facial nerve.

Question 19

Anatomically where is the hypoglossal nerve in relation to the submandibular gland?

Answer 19

Lies deep

Question 20

Anatomically where is the facial nerve in relation to the submandibular gland?

Answer 20

The cervical branch of the facial nerve runs superficial to the gland and can be damaged in a high skin/platysma incision.

Question 21

An 80-year old man is referred with a left sided mass anterior to the ear. He complains of drooling, and his face is drooping on the left. He has several hard lymph nodes in his neck on examination.

What salivary gland is likely to be affected?

Answer 21

Parotid

The parotid gland is located anterior to the ear and extends to the area over the mandible

The facial nerve passes through the parotid (facial drooping)

Hard lymph nodes indicate a malignancy

Question 22

What is Frey’s syndrome?

Question 23

Why is facial nerve involvement indicative of parotid gland malignancy?

Answer 23

Malignant tumors (mucoepidermoid, adenoid cystic carcinoma and acinic cell carcinoma) grow infiltratively

Tumours that grow rapidly or involve the deep lobe of the parotid gland are more likely to involve the facial nerve

Question 24

When performing a neck dissection, what important structure in the posterior triangle is at risk of damage? If damaged, how might this affect the patient?

Answer 24

Accessory nerve
Shoulder drop

Question 25

What is Frey’s syndrome?

Answer 25

Damage to the auricolutemporal nerve (innervates the parotid gland to produce saliva)

Undergoes aberrant nerve regeneration

Innervates the sweat glands of the skin instead

You get sweating and flushing of the skin

Question 26

Difference in the risks between doing thyroid surgery on a patient who is hyperthyroid vs euthyroid.

Answer 26

Hyperthyroid= Thyrotoxic storm and a higher risk of bleeding.

Euthyroid= Bleeding, infection, injury to the recurrent laryngeal nerves, hypothyroidism, hypoparathyroidism

Question 27

Describe the course of the recurrent laryngeal nerve on the left and the right

Answer 27

Both the left and right recurrent laryngeal nerves branch off of the vagus nerve

Left
- Loops underneath the aortic arch
- Then travels upwards to the larynx

Right
- Loops underneath the right subclavian artery
- Travels upwards to the larynx, simliar to the left but the right is shorter

Question 28

What is the most important blood test to check after a routine total thyroidectomy and what symptoms would suggest that this blood test was going to be low?

Answer 28

Calcium.
Tingling around mouth and fingertips. If severely decreased muscle spasm occurs.