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MRCS - ENT Nov > MRCS ENT > Flashcards

MRCS ENT Flashcards

1
Q

Criteria for treatment of glue ear?

A

Hearing level in better ear of 25db-30db or worse averaged at 500, 1000, 2000 and 4000 Hz for more than 3 months

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2
Q

Management options for glue ear? (3)

A

Watchful waiting 3-6 months
Hearing aid
Grommet +/- adenoidectomy

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3
Q

Which muscle opens the eustachian tube when swallowing?

A

Tensor veli palatini

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4
Q

What is Trotter’s triad?

A

Decreased mobility of ipsilateral palate due to direct infiltration, glue ear due to involvement of eustachian tube, pain in trigeminal area due to trigeminal nerve irritation

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5
Q

Presentation of NPC?

A

Trotters triad, neck nodes

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6
Q

Which structure is thought to rupture in meniere’s disease?

A

Reissner’s membrane (vestibular membrane)

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7
Q

List 4 symptoms of a vestibular schwannoma?

A

Unilateral hearing loss, unilateral tinnitus, vertigo, facial pain due to trigeminal nerve involvement

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8
Q

Management of vestibular schwannoma?

A

Watchful waiting with serial MRI scans
Stereotactic surgery (gamma knife)
Surgery

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9
Q

What are the 3 surgical approaches to vestibular schwannoma?

A

Middle cranial fossa
Translabyrinthine/transmastoid
Retrosigmoid/suboccipital

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10
Q

Which investigation to rule out glandular fever?

A

Paul-Bunnell or Monospot test

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11
Q

Which antibiotic to avoid in EBV and why?

A

Amoxicillin - type IV hypersensitivity reaction rash

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12
Q

SIGN guidelines for tonsillectomy due to recurrent tonsillitis?

A

7 episodes/1 year
5 episodes/2 consecutive years
3 episodes/3 consecutive years

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13
Q

List three ways in which a tonsillectomy can be performed?

A

Cold steel dissection
Bipolar diathermy
Coblation
Laser

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14
Q

List 4 instruments used in a tonsillectomy

A

Boyle-Davis mouth gag with Doughty split tongue blade
Draffin rods
Dennis-Browne tonsil holding forceps
Mollison pillar retractor

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15
Q

Management of subperiosteal abscess? (Orbital cellulitis)

A

IV antibiotics as per hospital’s antimicrobial policy
Nasal decongestants and steroid drops
Urgent ophthalmology review and regular eye observations
Surgery - open ethmoidectomy via modified Lynch Howarth incision
If any maxillary sinus disease to perform endoscopic maxillary antrostomy at the same time
Take pus swabs for cultures

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16
Q

List at least 2 intracranial complications of orbital abscess?

A

Epidural empyema
Subdural empyema
Cerebral abscess
Venous thrombosis
Osteomyelitis

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17
Q

Where is Killian’s dehiscence?

A

Between thyropharyngeus and cricopharyngeus

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18
Q

Name 5 presenting symptoms of Zenker’s diverticulum?

A

Dysphagia
Halitosis
Regurgitation of undigested food
Weight loss
Cough
Recurrent chest infection due to aspiration
Neck lump

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19
Q

Management of pharyngeal pouch?

A

Conservative
Open surgery
Endoscopic stapling

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20
Q

Define stridor

A

Noise from disrupted airflow due to partial obstruction of the respiratory tract at or below the larynx

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21
Q

List 5 causes of stridor

A

Laryngomalacia, laryngeal web, laryngeal cyst
Vocal cord paralysis
Subglottic stenosis
Epiglottitis
Foreign body
Allergy
Neoplasia (benign or malignant)

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22
Q

Describe the initial management of stridor

A

Humidified O2
Nebulised adrenaline (1ml 1:1000 in 2ml NACL)
Heliox (21%oxygen and 79% helium - generates less airway resistance than air so reduced work of breathing)
Dexamethasone

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23
Q

Describe the landmarks for an elective tracheostomy

A

Horizontal incision made halfway between cricoid cartilage and suprasternal notch, lateral borders of incision are marked by medial borders of SCM

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24
Q

Tests you can perform on fluid to check for CSF?

A

Glucose
Beta-2 transferrin
Beta-trace protein

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25
Q

Otoscopy findings in temporal bone fractures? 3

A

Haemotympanum
Stepping of EAC
Traumatic TM perforation

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26
Q

5 symptoms of a cholesteatoma?

A

Recurrent foul smelling otorrhoea
Hearing loss
Tinnitus
Vertigo/dysequilibrium
Pain
Facial nerve weakness

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27
Q

5 complications of chloesteatoma if left untreated?

A

Hearing loss (conductive/SN/mixed)
Facial nerve palsy
Vertigo
Cerebral abscess
Meningitis

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28
Q

Management of cholesteatoma?

A

Get a baseline PTA
Get a CT temporal bones - optional
Conservative - regular aural toiler, topical ear drops +/- steroids
Surgery - atticotomy, combined approach tympanoplasty, modified radical mastoidectomy

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29
Q

List 4 complications of parotidectomy

A

Frey’s syndrome (gustatory sweating)
Numbness to lower half of pinna due to division of great auricular nerve
Salivary fistula
Facial weakness
Bleeding
Haematoma
Infection
Scar

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30
Q

Explain the pathophysiology of Frey’s syndrome

A

Neo-innervation of parasympathetic secretomotor nerves distributed via auriculotemporal nerve into sympathetic fibres supplying facial sweat glands

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31
Q

List 5 conditions which may cause parotid enlargement

A

Viral parotitis - mumps, HIV related lymphocytic infiltration, parainfluenza, parovirus B19
Acute and chronic bacterial parotitis (usually staph aureus)
Stone in salivary duct
Neoplasia (benign or malignant)
Autoimmune - Sjogrens syndrome
Sarcoidosis

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32
Q

Where do you find the parotid duct opening?

A

Buccal mucosa, opposite 2nd upper molar tooth

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33
Q

List two differential diagnosis of a thyroglossal duct cyst

A

Dermoid cyst
Thyroid goitre

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34
Q

Which investigations can you perform for a thyroglossal duct cyst?

A

TFTs
US neck
MRI/CT neck
Radioactive iodine scan

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35
Q

How to treat a thyroglossal duct cyst?

A

Treat any acute infections with aspiration and antibiotics
Formal excision with Sistrunk’s procedure

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36
Q

What is this structure and label the diagram

A

This is a membranous labyrinth
a saccule
b utricle
c cochlear duct
d endolymphatic duct
e lateral scc
f posterior scc
g superior scc

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37
Q

Which structures of the inner ear detect linear acceleration?

A

vertical - macula of saccule
horizontal - macula of utricle

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38
Q

which structures of inner ear detect angular acceleration?

A

Lateral, posterior and superior semicircular canals

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39
Q

which structures are tested in the caloric test?

A

lateral semicircular canal

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40
Q

which structures play a role in pathophysiology of BPPV

A

Utricle and posterior scc

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41
Q

What is the temperature of water in caloric testing?

A

cold - 30 degrees C
warm - 44 degrees C
ice - 10 degrees C

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42
Q

What does BPPV stand for

A

benign paroxysmal positional vertigo

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43
Q

Describe the pathophysiology of BPPV

A

stimulation of posterior scc by otoconia dislodged from the macula in the utricle

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44
Q

History of vertigo in BPPV?

A

Lasts seconds
Brought on by sudden head movements

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45
Q

List 3 features of the nystagmus provoked by dix hallpike in BPPV

A

if left ear - anticlockwise, if right ear - clockwise
Torsional
Latency period
Fatigable
Lasting 20-40 seconds

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46
Q

What can you recommend as home treatment for BPPV

A

Brandt-Daroff exercises

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47
Q

Complications following nasal polypectomy/FESS

A

Orbital - loss of vision, double vision, orbital haematoma
CSF leak, meningitis, frontal lobe abscess
Epistaxis, infection, adhesions

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48
Q

Diagnostic criteria for CRS

A

2 or more of:
- nasal congestion/blockage/nasal discharge anterior/posterior (must be present)
- facial pain/pressure
- Anosmia/hyposmia

> 12 weeks

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49
Q

What is aspirin exacerbated respiratory disease

A

also known as samter’s triad
asthma
aspirin sensitivity
nasal polyps

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50
Q

What are three structures preserved in a modified radical neck dissection

A

spinal accessory nerve
SCM
internal jugular vein

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51
Q

What are the anatomical boundaries for level V neck dissection?

A

Boundaries of the posterior triangle!
posterior border SCM, anterior border trapezius, superior border clavicle

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52
Q

What structures can be damaged in level V neck dissection?

A

Spinal accessory nerve

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53
Q

What nerves can be damaged in level 3 neck dissection?

A

greater auricular nerve
vagus nerve
hypoglossal nerve

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54
Q

Label this

A

a septal cartilage
b maxilla
c palatine bone
d vomer
e perpendicular plate of ethmoid

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55
Q

How may a patient with an anterior septal perforation present?

A

bleeding
crusting
whistling
asymptomatic

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56
Q

list 5 causes of septal perforation

A

trauma - nose picking, nasal inhalers, following septal haematoma/abscess
Iatrogenic - post septoplasty, excessive cautery
Drugs - intranasal cocaine
Systemic disease - GPA, sarcoidosis, SLE, syphilis (usually posterior perforation), TB
Neoplasm - SCC, BCC, T-cell lymphoma

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57
Q

List some investigations for a septal perforation

A

FBC, U&E, ESR
ANCA
ACE
VDRL for syphilis (veneral disease research laboratory)
CXR
urine dip
?biopsy if malignancy suspected

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58
Q

Which age group presents with laryngomalacia?

A

neonates - symptoms usually start at 2 weeks to resolve by 2 years

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59
Q

How will a child with laryngomalacia present

A

inspiratory stridor
Worse on exertion (e.g. feeding)
normal cry when supine

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60
Q

Muscle and nerve supply for abduction of VCs?

A

posterior cricoarytenoid. RLN

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61
Q

Muscle and nerve supply for adduction of VCs?

A

lateral cricoarytenoid muscle mostly, RLN

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62
Q

Muscle and nerve supply for tensing of VCs?

A

cricothyroid muscle, external branch of superior laryngeal nerve

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63
Q

Which bones form the lateral nasal wall?

A

maxilla
perpendicular plate of palatine bone
medial pterygoid plate
ethmoid labyrinth
inferior concha

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64
Q

Where does the frontal sinus open into?

A

middle meatus

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65
Q

Where does the anterior ethmoidal sinus open into?

A

middle meatus

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66
Q

Where does the posterior ethmoidal sinus open into?

A

superior meatus

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67
Q

Where does the maxillary sinus open into?

A

middle meatus

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68
Q

where does the sphenoid sinus open into?

A

sphenoethmoidal recess

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69
Q

How may a quinsy present?

A

odonyphagia
halitosis
trismus
fever
referred otalgia
hot potato voice
drooling of saliva

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70
Q

Initial management of a quinsy

A

resuscitation and pain control
abscess drainage
IV antibiotics and steroids
antiseptic mouthwash

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71
Q

list two differentials of acute mastoiditis

A

infected post auricular lymph node
infected epidermoid cyst

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72
Q

how to manage acute mastoiditis?

A

resuscitatoin
assess for neurological signs
start IV antibiotics as per hospital antimicrobial policy
CT with contrast of temporal bone with brain windows
surgery - cortical mastoidectomy +/- ventilation tube

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73
Q

list 5 complications of acute mastoiditis

A

intracranial abscess
venous sinus thrombosis (lateral sinus thrombosis)
meningitis
Bezolds abscess
citellis abscess
facial nerve palsy

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74
Q

What is a Bezold’s abscess?

A

abscess within sheath of SCM forming a fluctuant mass along anterior border

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75
Q

What is a Citelli’s abscess

A

Abscess in the digastric fossa

76
Q

list 5 causes of a facial nerve palsy

A

trauma - temporal bone fracture, facial wounds
iatrogenic - parotid or ear surgery
infection - AOM, NOE, lyme disease (borreliosis), cholesteatoma
Viral - herpes zoster oticus, HIV
Neoplasia - skull base, parotid
Idiopathic - bell’s palsy

77
Q

Describe the grading system for facial nerve palsies?

A

House Brackmann scale
1 - normal function
2 - slight weakness on close inspection but complete eye closure
3 - obvious weakness, still has complete eye closure. Strong but asymmetrical mouth. Can move with maximal effort.
4 - inability to lift brow/close eye/asymmetry of mouth
5 - motion barely perceptible, slight movement of corner of mouth
6 - no movement

78
Q

Management of an idiopathic facial nerve palsy?

A

explanation and reassurance
eye care - artificial tears, eye taping, ophthalmology review
steroids - pred 1mg/kg for 7-10 days and then wean down
follow up in clinic

79
Q

what are the 5 branches of the facial nerve?

A

temporal, zygomatic, buccal, marginal mandibular, cervical

80
Q

which muscle does the temporal branch of the facial nerve supply and how do you test?

A

frontalis (frontal belly of occipitofrontalis muscle) + corrugator supercilii, raise eyebrows/frown

81
Q

which muscle does the zygomatic branch of the facial nerve supply and how do you test?

A

orbicularis oculi, close eyes tightly

82
Q

which muscle does the buccal branch of the facial nerve supply and how do you test?

A

buccinator, puff cheeks out

83
Q

which muscle does the marginal mandibular branch of the facial nerve supply and how do you test?

A

depressor labii inferioris, depressor anguli oris - show me bottom teeth

84
Q

which muscle does the cervical branch of the facial nerve supply and how do you test?

A

platysma - tense your neck

85
Q

Other than the muscles of facial expression, which other muscles does the facial nerve supply?

A

posterior belly of digastric
stylohyoid
stapedius

86
Q

Mechanism of orbital haematoma after FESS?

A

breach of lamina paprycea during surgery, injury to orbital veins if slow symptoms, injury to anterior and posterior ethmoidal arteries if rapid symptoms

87
Q

How may an orbital haematoma present?

A

proptosis
reduced visual acuity
increasing swelling of eye

88
Q

How to manage an orbital haematoma

A

remove any nasal packs
consider IV mannitol and steroids
urgent ophthalmology review
senior help
lateral canthotomy and inferior cantholysis under LA
If eye remains proptosed, needs superior canthotomy and medial orbital decompression/ligation of any bleeding vessels under GA

89
Q

label

A

a - superior crus of lateral canthal tendon
b - lateral canthal tendon
c - inferior crus of lateral canthal tendon

90
Q

List complications of FESS

A

Orbital harmorrhage
Diplopia due to injury to medial rectus and superior oblique muscles
Epiphora due to nasolacrimal duct injury
Optic nerve injury and blindness due to haematoma
CSF leak
meningitis
Adhesions
Epistaxis
Infection
recurrence

91
Q

How may bony exostoses of the ear present?

A

wax impaction
otitis externa
Hearing loss
asymptomatic

92
Q

Management of exostosis?

A

conservative - treat infections and wax impaction
surgical - canaloplasty

93
Q

Which tuning fork to use for Rinne and Weber’s test

A

512 Hz

94
Q

What does masking mean?

A

presenting a constant noise to the non test ear to prevent the non test ear from detecting sound presented by the test ear by crossover

95
Q

what are the following symbols in PTAs?
o
X
^ (triangle)
[
]

A

o - right air conduction threshold
X - left air conduction threshold
^ - unmasked bone conduction
[ - right bone conduction threshold
] - left ear bone conduction threshold

96
Q

Describe mild, moderate, severe, profound hearing loss thresholds

A

mild - 20-40
moderate - 41-70
severe - 71-95
profound - >95dB

97
Q

What are risks of nasal cautery

A

burn to upper lip
septal perforation

98
Q

what does BIPP stand for

A

bismuth iodoform paraffin paste

99
Q

what do you need to check before giving naseptin nasal cream?

A

allergy to peanuts/neomycin/chlorhexadine

100
Q

what is the blood supply to the nasal septum?

A

ICA: anterior and posterior ethmoidal ateries from the ophthalmic artery
ECA: sphenopalatine artery (terminal branch of maxillary), greater palatine artery (from descending palatine artery from maxillary artery), superior labial artery (from facial artery)

101
Q

Which vessels contribute to the anastomosis in Little’s area?

A

SPA
greater palatine
superior labial
anterior ethmoidal

102
Q

list 5 causes of epistaxis

A

trauma (nose picking, facial injuries, foreign body)
inflammatory (sinusitis, rhinitis)
drugs (aspirin, clopi, warfarin, cocaine)
neoplasm (SCC, juvenile angiofibroma)
GPA
HHT
vWD

103
Q

Two pathogens in OE?

A

pseudomonas aeruginosa
staphylococcus aureus

104
Q

Presentation of OE

A

tragal tenderness
otorrhoea
hearing loss
erythema and oedema of EAC
aurual fullness
cellulitis spreading to surrounding skin

105
Q

List 3 risk factors for OE

A

swimming
skin conditions (eczema, psoriasis, atopic dermatitis)
trauma (cotton buds)
Diabetes
medications e.g. steroids

106
Q

List two species causing otomycosis

A

aspergillus niger/flavus/fumigatus
candida albicans

107
Q

How to treat otomycosis?

A

regular aural toilet
antifungal ear drops (1% clotrimazole)
keep ear dry
ear swab

108
Q

What are the advantages of cuffed tracheostomy tubes?

A

inflated cuff descreases risk of aspirate into lungs
inflated cuff enables positive pressure ventilation

109
Q

what are the disadvantages of cuffed tracheostomy tubes?

A

pressure trauma
if cuff inflated and tracheostomy lumen is occluded, no airflow
swallowing can be impaired due to pressure against oesophagus

110
Q

list 3 indications for tracheostomy

A

facilitate weaning from positive pressure ventilation (reduced dead space)
minimise risk of aspiration in absence of laryngeal reflexes
obtain/secure airway in patients with upper airway obstruction

111
Q

What layers does surgeon go through in a tracheostomy

A

skin
subcutaneous tissue
platysma
investing layer of deep cervical fascia
strap muscles (usually pulled aside)
pretracheal fascia
thyroid isthmus (usually ligated and then divided)
trachea (window usually placed between 2nd and 4th ring)

112
Q

list 5 complications of tracheostomy

A

bleeding
airway obstruction
misplacement
pneumothorax
damage to oeseophagus
damage to recurrent laryngeal nerve
tracheoesophageal/trachea cutaneous/ tracheo innominate artery fistula

113
Q

Advantages of uncuffed trachey ?

A

patients can breathe around trache tube if it gets blocked
suitable for long term use because decreased risk of pressure trauma
can speak with an uncuffed tube

114
Q

what is the advantage of an inner cannula

A

facilitates cleaning of crusted secretions whilst outer tube maintains the airway but it does reduce the diameter of inner lumen therefore increasing the work of breathing

115
Q

what is tympanometry?

A

measurement of acoustic compliance of eardrum as a function of change in pressure in ear canal

116
Q

what information can you obtain from tympanogram? 3

A

volume of ear canal
middle ear pressure
compliance of eardrum

117
Q

3 causes of a type B tympanogram

A

glue ear
perforation/patent grommet is ear canal volume above normal limits
inaccurate reading if ear canal volume below normal limits

118
Q

list two causes of an As tympanogram

A

shallow peak i.e. decreased compliance and normal middle ear pressure
suggests a normal middle ear fucntion or a stiff middle ear system from ossicular fixation or tympanosclerosis

119
Q

list two causes of an Ad tympanogram

A

high peak i.e. increased compliance and normal middle ear pressure, indicating a hyper mobile/flaccid middle ear system
Suggests ossicular discontinuity, flaccid tympanic membrane e.g. healed tympanic membrane perforation

120
Q

which three nerves can be injured during submandibular gland excision

A

lingual nerve
hypoglossal nerve
marginal mandibular branch of facial nerve

121
Q

list the structures lying within the substance of the parotid gland from superficial to deep

A

facial nerve
retromandibilar vein (maxillary vein +superficial temporal vein)
carotid artery giving off terminal branches (maxillary artery and superficial artery)
lymph nodes

122
Q

what causes laryngeal papillomatosis

A

HPV 6 and 11

123
Q

list 5 symptoms of supraglottic cancer

A

dysphagia
odonophagia
referred otalgia
hoarseness
neck lump

124
Q

risk factors for supraglottic cancer

A

smoking
alcohol
HPV 16 and 18

125
Q

label this

A

a - epiglottis
b - aryepiglottic fold
c - anterior commisure
d - true vocal vord
e - false vocal cord
f - arytenoid cartilage
g - piriform fossa
h - rima glottis

126
Q

Type of laser for HHT treatment

A

NdYAG, KTP532 or argon laser

127
Q

Unit of x axis on tympanogram

A

daPa

128
Q

Unit of y axis on typamnogram

A

ml

129
Q

what is a normal middle ear pressure in adults

A

-50 to 50 daPa in adults
150 daPa in children

130
Q

why can a cholesteatoma cause both CH and mixed HL?

A

conductive - erosion of ossicular chain
mixed - erosion into labyrinth/inner ear

131
Q

dizziness with cholesteatoma is suggestive of?

A

labyrinthine fistula of lateral SCC

132
Q

Causes for a CT temporal bone for a cholesteatoma?

A

plan approach
check for anatomical abnormalities - especially if syndromic
check if facial nerve is dehiscent
check for bony destruction or fistula
revision cases

133
Q

two muscles which attach to mastoid process

A

SCM
posterior belly of digastric muscle

134
Q

what are branchial cysts

A

cysts which contain lymphoid tissue and are lined by squamous epithelial tissue

135
Q

name the intrinsic laryngeal muscles

A

cricothyroid
thyroarytenoid (vocalis) - paired
lateral cricoarytenoid -paired
posterior cricoarytenoid - paired
transverse arytenoid - unpaired

136
Q

coughing during microsuction - which nerve

A

arnolds nerve

137
Q

describe hearing loss seen in menieres

A

fluctuating SNHL, initially seen in the lower frequencies

138
Q

2 surgical options for menieres

A

myringotomy tube insertion
endolymphatic sac surgery

139
Q

management of menieres

A

dietary - limit salt and caffeine, eat at regular intervals
lifestyle - stop smoking, reduce stress
medical - stemetil during acute attacks, vestibular rehabilitation, hearing aids
surgical - grommets, steroid inection, IT gent, endolymphatic sac surgery, vestibular nerve section

140
Q

side effects of moffetts solution

A

tachycardia
arryhthmias
HTN
hyperthermia
sweating
anxiety

141
Q

which theory are the rules of masking based on

A

theory on interaural attenuation

142
Q

Q-5 : Describe the first rule of masking.

A

Air conduction audiometry: masking is needed at any frequency where the difference between the left and right not-masked air conduction thresholds is 40 dB or more (55dB if using insert earphones).

143
Q

what is the second rule of masking

A

Bone conduction audiometry: masking is needed at any frequency where the non-masked bone conduction threshold is more acute than the air conduction threshold (on either side) by 10dB or more.

144
Q

how does dabigatran work

A

direct inhibitor of free thrombin, fibrin bound thrombin and thrombin induced platelet aggregation

145
Q

how does rivaroxaban work

A

inhibitor of activated factor Xa

146
Q

what does gentisone HC contain

A

gentamicin
hydrocortisone

147
Q

what should a patient be warned of prior to undergoing tracheostomy insertion

A

initial inability to talk after surgery
need for humidification
possibility of going home with trache after appropriate training

148
Q

what is the function of a heat moisture exchanger

A

It provides humidification of the airway and is used when no extra oxygen is needed. It is very useful when patient is out of bed and mobilising.

149
Q

3 causes of type B tympanogram - consider the ear canal volumes

A

If the earcanal volume is within the normal limits, type B tympanogram indicates the presence of fluid behind the eardrum, usually due to otitis media with effusion (OME) - ‘glue ear’.
If the ear canal volume is above the normal limits, type B tympanogram indicates presence of perforation / patent grommet.
If the ear canal volume is below the normal limits, type B tympanogram suggessts an innacurate reading due to a misplacement of the tympanometer probe tip (pushed against the canal wall).

150
Q

Describe briefly what tympanogram ‘As’ and list two possible causes of this type of tympanogram.

A

Type ‘As’ tympanogram is characterised by a shallow peak (decreased compliance) and normal middle ear pressure.
It can represent normal middle ear function or a ‘stiff’ middle ear system with normal Eustachian tube function, resulting from:

Ossicular fixation (e.g., in otosclerosis).
Tympanosclerosis (restricted movements of the tympanic membrane).

151
Q

Describe briefly what tympanogram ‘Ad’ is and list two possible causes of this type of tympanogram.

A

Type ‘Ad’ tympanogram is characterised by a high peak (increased compliance) and normal middle ear pressure. It indicates flaccid or hyper-mobile middle ear system.
Ossicular discontinuity (partial or full).
Flaccid tympanic membrance (e.g., healed tympanic membrane perforation).

152
Q

where on the VC are singers nodules usually found

A

Pale lesions at the junction of anterior one third and posterior two thirds of the true vocal cords

153
Q
A

a Ear mould
b Connecting tube
c Battery
d Volume control
e On / Off button

154
Q

explain cleft lip

A

It involves the lip, alveolus and hard palate anterior to the incisive foramen (premaxilla). There is a failure of fusion between medial nasal, maxillary and lateral nasal prominences. If extending posterior to the incisive foramen, it is called cleft lip and palate (impaired palatal shelf fusion).

155
Q

Q-3. What are the challenges in patients with cleft lip/palate? List three.

A

a. Difficulty feeding.

b. Ear infections and hearing loss (cleft lip and palate)

c. Dental problems

d. Speech difficulties

e. Challenges of coping with a medical condition

156
Q

surgical management of cleft palate

A

repair of soft palate at 6 months, hard palate at 9 months, further palatal surgery depending on treatment needs, alveolar bone grafts from 7 years

157
Q

label

A

a. tectorial membrane
b. outer hair cells
c. inner hair cells

d. basilar membrane

e. VIII th nerve fibres f. stereocilia

158
Q

Sound transmitted via the oval window creates a wave in the …………………………. Movement of the ……………..causes shearing forces between the ………………….and the ____________, causing the movement of the hair cells’ ____________. The ____________ depolarize, releasing neurotransmitters at their bases, which generates action potential in the ______________.

A

Sound transmitted via the oval window creates a wave in the basilar membrane (d). Movement of the basilar membrane (d) causes shearing forces between the basilar membrane (d) and the tectorial membrane (a), causing the movement of the hair cells’ stereocilia (f). The inner hair cells (c) depolarize releasing neurotransmitters at their bases, which generates action potential in the VIII th nerve fibres (e).

159
Q

3 characteristic features of downs syndrome

A

small nose, flat nasal bridge
upslating palpebral fissures
epicanthal fold
macroglossia
low set, small pinna

160
Q

issues with grommet insertion in children with downs syndrome

A

narrower eustachian tubes
defects in tensor palatini muscles so insertion of grommets is more challenging and child may require multiple sets of grommets

161
Q

3 factors which contribute to increased severity of OSA in downs syndrome children

A

midfacial and mandibular hypoplasia
macroglossia
narrowing of oropharynx/nasopharynx
generalised hypotonia
increased secretions

162
Q

what to consider before adenotonsillectomy in downs syndrome children

A

a. atlantoaxial joint instability- careful and limited neck extension , cautious use of the monopolar suction diathermy (see also question 3d, station 7); if suspicion- consider pre operative neck x-ray /MRI, neurologic examination.

b. Reported increased incidence of velopharyngeal dysfunction and hypernasal speech.

163
Q

signs of food bolus on lateral soft tissue neck XR

A

preservation of the cervical lordosis (loss of the cervical lordosis may be due to pain or inflammation of the preverterbal muscles secondary to impacted foreign body/abscess)

b. swelling of the prevertebral tissues*

c. presence of any radioopaque objects

d. presence of high oesophageal bubble/air/fluid level (suggestive of food bolus obstruction)

e. presence of free air (secondary to perforation)

164
Q

which levels of assess width of prevertebral space

A

C3 < than 1/3 AP width of C3 vertebral body
C6 < than the AP width of C6 vertebral body

165
Q

how to get FB at level of cricopharyngeus

A

rigid oesophagoscopy
could try flexible gastroscopy but harder for high fbs

166
Q

Management of soft FBs

A

IV buscopan
rectal diazepam
fizzy drinks

167
Q

initial management of oesophageal perforation

A

NBM
NG insertion
IV fluid and antibiotics
gastrograffin swallow study

168
Q

symptoms of oesophageal perforation

A

a. tachycardia

b. tachypnoe

c. spiking temperatures

d. pain between scapulae

e. surgical emphysema

169
Q

what distance from incisors to cricopharyngeus, aortic arch, left bronchus and gastric inlet

A

15 cm to the cricopharyngeus

22 cm to the aortic arch

27.5 cm to the left bronchus

40 cm to the gastric inlet

170
Q

pit in anterior neck (along anterior border SCM) with recurrent mucinous discharge?

A

second branchial cleft sinus/fistula

171
Q

4 nerves that need to be infiltrated for anaesthesia of the external node

A

external nasal nerve - over nasal dorsum
nasopalatine nerve - at base of columella and nasal top
infraorbital nerve
infratrochlear nerve - near medial canthus area

172
Q
A

walsham forceps

173
Q
A

a. Jobson Horne probe

b. Wax hook

c. Myringotome/myringotomy knife

d. Crocodile forceps (Cawthorne/Hartman silver)

e. Cawthorne needle f. Shah grommet

174
Q

is the eustachian tube usually open or closed?

A

closed - swallowing or yawning opens to ET

175
Q

list the 4 muscles of the eustachian tube

A

levator veli palatini
salpingopharyngeus
tensor tympani
tensor veli palatini

176
Q

childs eustachian tube compared to adults?

A

shorter straighter course in children

177
Q

function of hypoglossal nerve

A

motor supply to all intrinsic and extrinsic muscles of tongue except palatoglossus

178
Q

grading system for subglottic stenosis

A

Cotton myer classification
Grade 1: 0-50% obstruction

Grade 2: 51-70% obstruction

Grade 3: 71- 99% obstruction

Grade 4 : No detectable lumen

179
Q

how to grade subglottic stenosis practically

A

endoscopically - use a uncuffed ETT and compare the size with expected size of ETT of healthy child of same age

180
Q

treatment of subglottic stenosis?

A

mild - endoscopic balloon dilation, excision with cold steellaser
severe - laryngotracheal reconstruction +/- surgcial trache

181
Q

what is the narrowest part of the paediatric airway

A

cricoid

182
Q

what is the narrowest part of the adult airway

A

glottis

183
Q

Q-6 : How would you calculate the internal diameter of an age appropriate uncuffed paediatric tube for children 1-10 years of age?

A

Uncuffed endotracheal tube size (mm ID) =(age in years/4) + 4

184
Q

post grommet insertion instructions

A

water precautions for 2 weeks
follow up with audiogram in 1 year

185
Q

complications of grommets

A

otorrhoea
infection
tympanosclerosis
perforation persists
cholesteatoma
bleeding

MRCS - ENT Nov (7 decks)

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