MRCS ENT Flashcards
Define nystagmus
involuntary
rhythmic
oscillation
of the eyes
Describe what a true vestibular nystagmus will look like
slow movement of eyes in one direction with quick corrective movement in the opposite direction
Describe how caloric tests work
water at temps of 30 and 44 degrees (or air) - generates convection currents in the endolymph on that side, so will elicit a vestibular response in the form of nystagmus if the vestibule is functioning correctly.
Cold water leads to nystagmus with fast phase towards opposite side
Cold - opposite, warm - same COWS - the expected response to the rest. Lack of response may indicate a peripheral vestibular failure on one side
what is rombergs test
patient stands still with arms by side and eyes closed, if there is an uncompensated vestibular lesion on one side, the patient will show tendency to fall on that side
what is unterbergers test
patient marches on the spot with arms outstretched and eyes closed for 30 seconds. Abnormal response is rotation of at least 30 degrees or a forwards or backwards movement of at least 1m. Rotation will be towards the side of the lesion.
risks of thyroid surgery?
pain
bleeding including haematoma
infection
seroma
scar
hoarseness
airway compromise
hypocalcaemia
long term thyroid replacement
name and describe the innervations of the branches of the superior laryngeal nerve
external branch - supplies cricothyroid
internal branch - sensory to laryngeal mucosa above VCs
what is the sensory innervation of the mucosa of larynx below VCs
recurrent laryngeal
blood supply to parathyroid glands?
inferior thyroid artery
how to investigate parathyroid enlargement?
serum ca and PTH
US neck
MIBI scan
name the tensors of the VCs and what the effect of tensing the vocal cords is
cricothyroid
raises pitch of voice
name the relaxors of the VCs
thyroarytenoid
vocalis
3 causes of VC palsy
malignancy (bronchus, oesophagus, thyroid, nasopharynx)
iatrogenic from thyroid/parathyroid/oesophageal/pharyngeal pouch/left lung surgery
stab wound/external trauma
idiopathic
neurological disorders
how may a unilateral VC palsy present
hoarseness
choking
coughing on food
recurrent chest infections
inability to raise voice
what is the effect of a superior laryngeal nerve palsy?
will change pitch of patients voice but if the recurrent laryngeal is intact, VC abduction and adduction remains unchanged
risks of parotid surgery?
pain
bleeding
infection
scar
facial nerve weakness
freys syndrome
recurrence of disease
most common type of parotid tumour
pleomorphic adenoma in 80%
what is freys syndrome
gustatory sweating in distribution of auriculotemporal nerve on eating/thinking/talking about food
where does the submandibular duct open?
lateral to lingual frenulum
name 3 nerves related to the submandibular gland
marginal mandibular
lingual
hypoglossal
where are the sublingual glands found
deep in floor of mouth between mandible and genioglossus muscle
describe the sublingual duct
numerous small sublingual ducts open into FOM along sublingual folds
Risk factors for SCC tonsil
smoking
alcohol
HPV
betel nut chewing
Investigations for SCC tonsil
FNAC neck nodes
MRI neck
CT thorax
panendoscopy and biopsy
HPV testing of biopsy specimen
TNM staging for tonsillar ca
T0 - no cancer
T1 - tumour <2cm in greatest dimension
T2 - tumour 2-4cm
T3 - >4cm
T4a invasion of larynx, tongue muscles, medial pterygoid, hard palate, mandible
T4b - lateral pterygoid, pterygoid plates, lateral nasopharynx, skull base, encases carotid artery
risks and benefits of fenestrated trache tubes
benefits - allow speaking by allowing airflow to pass superiorly through fenestrations and through VCs
risks - of aspiration
risks and benefits of cuffed tracheostomy tubes
benefits - prevent leaking of secretions around tubes into lungs, provide airtight seal to enable positive pressure ventilation
risks - prolonged use of a cuff can lead to trauma to tracheal wall, tracheal stenosis and tracheo-oesophageal fistula
when to use adjustable flange trache tube?
deep neck patients
Advantages of trache compared to ET intubation?
reduces risk of tracheal trauma/stenosis
reduces amount of dead space in respiratory system and effort of breathing - easier weaning
reduces need for sedation and permits speech and oral feeding when patient awake
Complications of tracheostomy?
infection
tracheal necrosis
tracheoarterial fistula
TOF
dysphagia
tracheal stenosis
tracheocutaneous fistula
dislodgement
describe the mechanism of freys syndrome
abberrant innervation of cutaneous sweat glands overlying the parotid gland by post ganglionic parasympathetic salivary nerves causing localised sweating during eating or salivation
diagnosis of freys syndrome?
clinical diagnosis mostly
can use minor iodine starch test
treatment options for freys syndrome
conservative
topical anticholinergics/antihydrotics
Botulinum A toxin
Surgical - excision of affected areas but limited success and put facial nerve at risk
signs of smoke inhalation injury
facial burns
blistering/oedema of oropharynx
hoarse voice
carbonaceous sputum
stridor
cough
wheeze
irritability
headaches
lethargy
management of suspected smoke inhalation injury
ABC
bronchodilators
low risk - monitor, discharge after 8-12 hours
what % of blood loss results in hypotension in a child
20-25%
how to estimate a childs blood volume?
80ml/kg
how to arrest post tonsillectomy bleed surgically
electrocautery of a specific bleeding point
tying off a specific bleeding point
suture tonsillar pillars together
pass NG tube at the end of procedure to aspirate any swallowed blood
Rarely - ligate ECA
paediatric fluid resuscitation?
20ml/kg as boluses
risk factors for apthous ulcers
haematinic deficiency
trauma
drug reactions (e.g. NSAIDS)
hiv
Neutropenia
IBD - crohns
Treatment of apthous ulcers?
supportive
treat any predisposing factors
what is ludwigs angina
rapidly progressive cellulitis of soft tissues of neck and FOM
why is ludwigs angina dangerous
progressive swelling of soft tissues and posterior displacement of tongue can lead to airway obstruction
which symptoms to ask about in a patient presenting with a thyroid swelling?
pain
dysphagia
voice change
aspiration
breathing difficulties
any FH of thyroid ca
history of radiation exposure
symptoms of hyper/hypo thyroidism
Cytological grading for thyroid lesions?
Thy1 - non diagnostic
Thy2 - non neoplastic
thy3- follicular lesion/suspected follicular neoplasm
thy4 - suspicious of malignancy (papillary, medullary, anaplastic, lymphoma)
thy 5- diagnostic of malignancy
in which thyroid cancers is it important to reduce TSH levels most and why
papillary and follicular, important to reduce TSH levels to <0.1mU/L as in medullary ca, the C cells are not thyroxine sensitive
main chemotherapy agents in thyroid cancer?
tyrosine kinase inhibitors
management of anaplastic thyroid ca
surgery if very small
otherwise chemoradiotherapy
what type of tumour is a warthins tumour
adenolymphoma
differential diagnosis of parotid lumps
pleomorphic adenoma
warthins tumour
intra/extra parotid lymph node
malignancy
mets
haemangioma
red flag features of a parotid lump
recent increase in size
skin involvement
fixed hard mass
facial nerve involvement
Which surgery for a pleomorphic adenoma?
superficial parotidectomy usually
what is the risk of malignant transformation of a pleomorphic adenoma?
2-10%
most common site of SCC larynx?
glottis 50%
supraglottis 40%
subglottis 10%
what is the name of the classification system used to divide the neck into zones
roon and christensens classification
describe the anatomical pathway of the nasolacrimal duct and clinical sinificance
drains tears from the lacrimal sac into inferior meatus of the nasal cavity
blockage can result in dacryocystitis or chronic tearing
label
management of saddle deformity of nose
nasal douching
nasal steroids
septoplasty
causes of saddle nasal deformity
GPA
relapsing polychondritis
iatrogenic (septoplasty)
trauma
intranasal cocaine use
bloods for saddle deformity
FBC
ESR
U&E
ACE
cANCA
pANCA
two causes of pansinusitis in a child
CF
Kartageners syndrome
unilateral nasal polyp in an elderly patient - concerns re?
malignancy?
meningioencephalocele
3 risks of button battery in nose
aspiration
tissue necrosis
septal perforation
2 risks of button battery in ear
ear canal stenosis
tissue necrosis
what is this and why does it matter
infraorbital ethmoidal air cell/Haller cell
if very large can narrow ostiomeatal complex
may get infected with extension into orbit
may not be expected in surgery and lead to inadvertent entry into orbit in endoscopic surgery
5 differentials of a solid nasal mass lesion
benign nasal polyp
inverted papilloma
antrochoanal polyp
glioma
SCC
meningocele
histological type of NPC?
SCC
Preferred imaging for NPC?
MRI
What are the components of Moffet’s solution
sodium bicarbonate
cocaine
adrenaline
safe dose of lidocaine with and without adrenaline
3mg/kg without
7mg/kg with
2 bacteria and 2 fungi responsible for otitis externa
staph aureus, pseudomonas aeruginosa
aspergillus niger
candida albicans
Bilateral acoustic neuromas are suggestive of?
Neurofibromatosis type 2
4 presenting complaints of cholesteatoma
hearing loss
otorrhoea
vertigo
tinnitus
facial nerve palsy
4 presenting complaints of acoustic neuroma
hearing loss
vertigo
tinnitus
where do cholesteatomas tend to originate from
attic - prussacks space/epitympanic space
symptoms of herpes zoster oticus
hearing loss
taste disturbance
otalgia
vertigo
tinnitus
where does the virus lay dormant in herpes zoster oticus
geniculate ganglion of facial nerve
2 types of graft for myringoplasty
tragal cartilage
temporalis fascia
Why does a thyroglossal cyst move with tongue protrusion?
attached to tongue via the embryological tract
why is doing imaging for a thyroglossal cyst helpful?
to see if any normal thyroid tissue is also present (otherwise removal will result in hypothyroidism)
3 presenting symptoms of mastoiditis
pyrexia
otalgia
otorrhoea
2 management options for mastoiditis
IV antibiotics
cortical mastoidectomy
most common organism implicated in mastoiditis
Strep pneumoniae, haemphilus influenza
then moraxella catarrhalis, strep pyogenes, staph aureus
bug which can cause postauricular lymphadenopathy in children?
rubella
what is Gradenigo’s syndrome?
complication of AOM due to spread to petrous apex of temporal bone - otorrhoea, trigeminal nerve pain and diplopia due to abducens nerve palsy
What is Luc’s abscess?
Complication of AOM - abscess under temporal muscle
What is Holman Miller sign
anterior bowing of posterior wall of maxillary antrum due to juvenile angiofibroma
where does a juvenile angiofibroma usually arise?
lateral wall of nasal cavity close to superior border of sphenopalatine foramen
name a staging system for juvenile angiofibroma
radkowski
andrews-fisch
sessions
Which investigations to request for a juvenile angiofibroma?
CT
MRI
Angiography
treatment of juvenile angiofibroma?
surgical resection with pre-op embolisation
omega shaped epiglottis is indicative of?
laryngomalacia
how may laryngomalacia present
mild tachypnoea
stridor on feeding
investigations for laryngomalacia? (2)
laryngotracheobronchoscopy
sleep study/overnight pulse oximetry
Treatment options for laryngomalacia
conservative
surgical - aryepiglottoplasty, rarely tracheostomy
how may subglottic haemangioma’s present?
stridor
cough
SOB
how are subglottic haemangiomas diagnosed?
microlaryngoscopy
management of subglottic haemangioma?
propranolol
steroids
small - laser
larger - surgical removal
why can children get laryngeal papillomatosis?
immature immune system
which viruses cause laryngeal papillomatosis
HPV 6 and 11
how does laryngeal papillomatosis present
hoarseness, stridor, SOB, weak cry, chronic cough
Rx laryngeal papillomatosis?
debridement
adjuvent cidofovir
why avoid tracheostomy in laryngeal papillomatosis
risk of seeding around trache site and into lungs
pathophysiology of choanal atresia
failure of breakdown of bucconasal membrane in utero
button battery in oesophagus management
immediate removal
follow up swallow imaging to review for complications
2 anatomical causes of ‘bat’/protroding ears
deep conchal bowl
absence of antihelical fold
management options for bat ear
conservative
ear spint in neonates
surgical - pinnaplasty via scoring technique (scoring a new fold anteriorly after exposure of posterior cartilage) or mustarde suturing method
complications of pinnaplasty
bleeding
infection
scar
pinna haematoma
cartilage necrosis
patient dissatisfaction
what condition is a bifid uvula associated with
submucous cleft
why is an adenoidectomy contraindicated in a submucous cleft?
may result in velopharyngeal insufficiency, causing speech problems
complications of adenoidectomy
bleeding, ascending pharyngeal/SPA bleed, hyponasal speech, nasal regurgitation, regrowth, damage to soft palate/teeth
What is Grisel’s syndrome
atlantoaxial joint subluxation following suction diathermy (infection)
surgical options for choanal atresia
transnasal puncture and stenting
endoscopic resection of posterior nasal septum
why does a preauricular sinus occur?
incomplete fusion of hillocks of his
2 techniques to ensure the whole tract intraoperatively (pre auricular sinus)
use of methylene blue to stain tract
use of lacrimal probe
Pendred’s syndrome - type of hearing loss, genetics, association
Treacher Collins syndrome - type of hearing loss, genetics, association
Pierre Robin syndrome - type of hearing loss, genetics, association
Crouzons disease - type of hearing loss, genetics, association
Alperts syndrome - type of hearing loss, genetics, association
CHARGE syndrome components
Branchio-oto-renal syndrome genetics and components
Treatment of microtia and anotia
bone conduction hearing aids (first soft band then BAHA)
cosmesis - prosthesis if neonate (will correct), reconstruction with rib cartilage 6-8 years
bilateral SNHL and goitre suggests
pendred syndrome AR inheritance
management of pendred syndrome
thyroxine, cochlear implants, MDT
What is Waardenburg syndrome
congenital progressive hearing loss (70% unilateral) and heterochromia irides (different iris colours0, white forelock, skin pigmentation changes. AD inheritance
label
which semicircular canal is most commonly affected in BPPV
posterior semicircular canal
characteristics of nystagmus in BPPV
torsional
geotropic
latency
fatiguable
lasts 20-60 seconds
Manouevers for BPPV
label
a - mould
b - connection tube
c - battery
d - on off switch
e - pull cord
2 complications of behind ear hearing aid
wax build up
otitis externa
skin irritation
2 causes of whistling when wearing a behind ear hearing aid
wax build up
loose fitting
2 indications for BAHA
profound unilateral SNHL
2 complications of BAHA
abutment site problems (loosening)
skin infection
skin overgrowth
discomfort/pain
failure to osseointegrate
what are the 4 components of all hearing aids
microphone
amplifier
sounds transmitter
power source
types of hearing aid
what does Rinne’s positive mean
NORMAL
PTA symbols
X
O
[
]
3 rules of masking
What is the stapedial reflex
contraction of stapedius and tensor tympani in response to noise >85dB
what is stengers test
type of hearing loss in meniere’s disease
low frequency SNHL - can be high in acute attacks
pathophysiology of menieres disease
expansion of endolymphatic fluid volume, pressure of basilar membrane, rupture of reisners membrane
tests for menieres
electrocochleography, caloric testing
type of hearing loss in presbyacusis
high frequency SNHL
type of hearing loss in noise induced hearing loss
SNHL at 4000Hz
components of NF2
label
main ion in perilymph
sodium
how many turns are there in a normal cochlear
2.5
which part of the cochlear is thought to expand resulting in rupture of the membranous labyrinth in menieres disease
scala media
label
origin of malleus/incus/stapedius
1st pharyngeal arch
origin of stapes/tensor tympani
2nd pharyngeal arch
origin of middle ear
1st pharyngeal pouch
muscle attachment ro pharyngeal tubercle
superior pharyngeal constrictor
muscle attachments to mastoid
SCM
posterior digastric
splenius capitus
lonissimus capitis
attachments to styloid process
stylomandibular ligament
stylohyoid ligament
stylohyoid muscle
stylopharyngeus
styloglossus
how does superior orbital fissure syndrome present
double vision, ptosis due to 3rd nerve function, numbness to upper eyelid due to superior orbital nerve dysfunction
causes of superior orbital fissure syndrome
trauma (blow out fracture), cancer, infection, inflammatory
what is orbital apex syndrome
same as superior orbital fissure syndrome but with blindness due to dysfunction of orbital apex
ECA branches and what they supply
label
label
label
label
vocal cord layers (superficial to deep)
VC abduction?
posterior cricoarytenoid
VC adduction
lateral cricoarytenoid
transverse arytenoid
oblique arytenoid
vocal cord tension
cricothyroid
thyroarytenoid
what type of cartilage is thyroid/cricoid/arytenoid/corniculate/cuneiform
hyaline
what type of cartilage is epiglottis
fibrocartilage
2 tests used in national newborn hearing programme?
automated otoacoustic emission
automated auditory brainstem response
what happens if hearing issue detected in newborn hearing programme tests?
referred for further investigations including diagnostic OAE, diagnostric ABR, tympanometry
investigations to confirm hashimotos?
ESR
Anti thyroglobulin antibodies
TSH receptor antibodies to rule out graves
TPO antibodies
when does a behind ear hearing aid whistle?
microphone too close to speaker
ear canal is impacted with wax
aetiology of laryngeal papillomatosis
hpv 6 and 11
how to treat laryngeal papillomatosis
microdebrider surgical debridement - laser will cause airway fire
+ alpha interferon + antivirals like intralesional cidofivir
how to reduce risk of laryngeal papillomatosis
HPV vaccination using gardasil
4 causes of enlarged inferior tubrbinate
infection
neoplasia
congenital
rhinitis medicamentosa
allergic rhinitis
3 medications to treat enlarged inferior turbinate
steroids
antihistamines
leukotriene antagonists
3 surgical techniques to treat enlarged inferior turbinate
outfracture of turbinates
submucous diathermy
turbinate trimming
CNS lesions associated with NF2
vestibular schwannoma
ependymomas
meningiomas
what is a pathonomonic sign of inheritance of NF2
juvenile subscapular cataract
why are paediatric tracheostomy tubes uncuffed
reduce risk of subglottic stenosis
complication of bilateral radical neck dissection
increased intracranial pressure due to removal of both internal jugular veins
describe the neck trauma zones
1 - clavicle to cricoid
2 - cricoid to angle of mandible
3 - angle of mandible to skull base
what sound level is required to elicit stapedial reflexes
85dB
why do a US and radioiodine uptake scan for a thyroglossal duct cyst prior to excision?
may be active thyroid tissue in the cyst
2 syndromes associated with anotia/microtia
goldenhar syndrome
treacher collins
pierre robin
CHARGE
what is schwartz’s sign and what is it indicative of
pink tinge on cochlear promontry
indicative of otosclerosis
embryological origin of pre auricular sinus
incomplete fusion of hillock of his
which syndrome are pre auricular sinuses associated with
brachio-oto-renal syndrome
management of submandibualr gland stones
lithotripsy
therapeutic sialendoscopy
excision of stone
excision of gland
2 uses for BIPP
nasal packing
following ear surgery
5 causes for a goitre
graves disease
infective thyroiditis
sarcoidosis
iodine deficiency
thyroid cancer
hashimotos
sarcoidosis
which nerve is found in beahrs triangle
recurrent laryngeal nerve
which nerve is found in Joll’s triangle
superior laryngeal nerve
borders of jolls triangle
midline
superior thyroid
strap muscle
borders of beahrs triangle
common carotid artery
trachea
inferior thyroid artery
WHO classification of NPC?
keratinising SCC
non keratinising SCC
undifferentiated SCC
5 drugs which can result in parotid enlargement
T - thiouracil
O - oral contraceptive pill
P - phenulbutazone
I - isoprenaline
C - CO proxamol
where does retropharyngeal space extend to compared to parapharyngeal space
retropharyngeal - skull base to lower border of pharynx
parapharyngeal - skull base to hyoid
normal thickness of prevertebral soft tissue between C2-4
7mm
normal thickness of soft tissue between C4-T1
17mm
2 syndromes associated with drooling
cerebral palsy
downs syndrome
2 medical and 2 surgical treatments for drooling
medical - anticholinergic agents, botox
surgical - submandibular duct transposition, adenotonsilectomy, submandibular gland excision
at what age is drooling considered a problem
aged 5
factors other than developmental delay which may contribute to drooling
poor neck control
posture
nasal blockage
dental factors
anti epileptic agents
initial management of drooling
oromotor exercises
improving posture
SLT
why antibiotic to treat acute mastoiditis and why
co -amox because haemophilus influenza is a common bacteria for this condition and it is resistant to amoxicillin
what to do for a child with mastoiditis who isn’t getting better with IV antibiotics?
request urgent CT with contrast to look for intracranial complications and subperisoteal abscess. may need cortical mastoidectomy and grommet
causative organisms for mastoiditis
steptoccous pneumoniae
haemophilus influenzae
moraxella catarrhalis
which structures are usually damaged in a transverse temporal bone fracture
cochlear and vestibular structures
label letters
what is superior orbital fissure syndrome
ptosis due to 3rd nerve involvement
diplopia due to dysfunctional eye movement
numbness above upper eyelid due to superior orbital nerve dysfunction
what is heterochromia irides and what does it suggest
different coloured eyes and waardenburg syndrome
list 4 features of waardenberg syndrome and its inheritance pattern
heterochromia irides
hearing loss
white forelock
skin pigmentory changes
AD
3 types of malignant melanoma
superficial spreading
acral lentiginous
lentigo maligna
histological staging systems for melanoma
clark
breslow
3 ways to identify facial nerve during parotid surgery
tympanomastoid suture
posterior belly of digastrics
tragal pointer
4 cancer of parotid gland
adenoid cystic carcinoma
mucoepidermoid
accinic
metastatic lesion
lymphoma
which artery which exits with facial nerve at stylomastoid foramen should you be aware of in parotid surgery
stylomastoid artery
4 instructions for patient post epley manouver
avoid driving
avoid lying flat for 48h
avoid bending forwards
avoid lying on affected side
5 differentials of a solid nasal lesion
inverted papilloma
antrochoanal polyp
nasal polyp
glioma
pyogenic granuloma
adenocarcinoma
SCC
what does a RAST stand for
radioallergosorbent test
syndrome associated with enlarged vestibular aqueduct
pendred syndrome
what is pendred syndrome caused by
mutation in pendrin genes - codes for iodine/chloride transporter protein chromosome 7
what is a cystic hygroma
low flow vascular malformation
what to include in an op note
name of operation
hospital
date
time
patient name/DOB/hospital/theatre
surgeon
assistant
anaesthetist
scrub nurse
indication
antibiotics
anaesthesia
standard drape
findings
procedure
post op instructions
signature
print name
GMC number
contact number
Noise induced hearing loss
symmetrical hearing loss
asymmetrical hearing loss
Menieres disease - low frequency SNHL
Concern with bilateral condylar process fractures
airway compromise
commonest cause of congenital tracheal stenosis
complete congenital rings
What is Cahart’s notch
reduction of air bone gap at 2000Hz, characteristic in otoscleorosis
what type of tympanogram is typically seen in otosclerosis
As curve
4 treatment options for otoscleorosis
conservative
conventional hearing aid
stapes surgery
bone conduction device/implant
contraindication/relative contraindications to stapedectomy/stapedotomy
infection
only hearing ear (surgery has 1% risk of profound SNHL)
Describe Sistrunk’s procedure
Excision of thyroglossal cyst, central portion of hyoid bone, extending dissection to base of tongue (foramen caecum) and excising a 1cm core of geniohyoid and genioglossus to ensure no tract left behind
which structures detect angular acceleration
lateral, posterior and superior SCCs
pathophysiology of BPPV
stimulation of posterior SCC by otoconia dislodged from macula of the utricle
nerves which can be damaged in level V neck dissection
spinal accessory nerve
brachial plexus (roots and trunks)
phrenic nerve
which nerves are damaged in level 3 neck dissection
greater auricular nerve
cagus nerve
hypoglossal nerve
