Otorhinolaryngology (ENT) Flashcards
Ear: - Sensorineural & Conductive hearing loss - Tumours of ear Nose: -Rhinitis
NasoOropharyngeal squamous cell carcinomas (OPSCC)
- In the head and neck, OPSCC are associated with HPV
-Ebstein Barr virus (suspect 2nd) - Arise in the soft palate, tonsils, base of
tongue, pharyngeal wall, and vallecula, the fold located between the base of tongue
and the epiglottis. Often present with neck masses - Classic symptoms of odynophagia and otalgia (usually no other clinical complaints)
Squamous cell carcinomas risk factors
- smoking & drinking (strongest)
Oropharyngeal squamous cell carcinomas (OPSCC) differentials
- Branchial cleft cyst carcinomas (exceptionally rare and its diagnosis should be one of exclusion rather than presumption)
Oropharyngeal squamous cell carcinomas (OPSCC) diagnosis
-Test for HPV
- CT head & neck (assessing the degree of local infiltration, involvement of regional
lymph nodes, and presence of distant metastases or second primary tumours)
1st line treatment for moderate to severe rhinitis?
Intranasal corticosteroid glucocorticoid (fluticasone)
-include antihistamines, leukotriene-receptor blockers, and topical glucocorticoids
Types of Rhinitis
- Allergic
- vasomotor (perennial and
is not associated with itching) - infectious (nasal turbinates red and inflamed)
Allergic rhinitis
- Caused by allergens that trigger a local hypersensitivity reaction (Specific IgE antibodies attach to circulating mast cells or basophils)
- Rhinorrhoea and pruritus
- nasal turbinates appear pale and
boggy
If all conservative approaches to rhinitis have been unsuccessful, what the next step?
Immunotherapy:
- requires identification of specific antigen by dermal or serum testing
- 3-to-5-year course (treatment duration of less than a year is ineffective)
Pleomorphic adenoma diagnosis
- CT to assess for deep lo be involvement
Pleomorphic adenoma management
- If there’s no deep lobe involvement: superficial parotidectomy (treatment of choice for most cases)
- If there’s deep lobe involvement: Total parotidectomy
clinical features of otitis media
- one-week history of unwellness with URTI
- unilateral earache
- tympanic membrane red and bulging
Acute Otitis media risk factors
- Age (6-18 months)
- Lack of breastfeeding
- Day care attendance
- Smoke exposure
Pathogens that give arise to acute otitis media
- Streptococcus pneumoniae
- Nontypeable (?) Haemophilus influenzae
- Moraxella catarrhali
Chronic Suppurative Otitis Media treatment
Ear toileting + ciprofloxacin ear drops
Complications of Otitis media
Acute mastoiditis
Acute mastoiditis initial treatment
sample from the ear discharge should be taken for culture DONE BY ENT
flucloxacillin + a third-generation cephalosporin
Acute otitis media treatment
- Amoxicillin 1st choice (used for 1 week)
- 2nd line: amoxicillin-clavulanate
Acute otitis media px that’s allergic to penicillin
- clindamycin
- azithromycin
Aboriginal px with otitis media management
Antibiotics straight away
Chronic suppurative otitis media treatment
Assess if tympanic membrane intact or perforated:
If intact: ciprofloxacin ear drops to treat on going infection
If perforated: initial treatment ear toilet with povidone-iodine solution, followed by
dry mopping with rolled toilet papers2 to 3 times a day using 20ml syringe with plastic tubing. In addition, ciprofloxacin ear drops
Untreated a tympanic membrane perforation secondary to chronic otitis media
- Marginal perforation with discharge
- Perforation that is surrounded by granulation tissue
- Continuously discharging central perforation
- Perforation associated with a cholesteatoma
Benign growth of the squamous epithelium squamous epithelium and
accumulation of keratin debris within the middle ear
Cholesteatoma
Cholesteatoma risk factors
- history of recurrent acute otitis media
- chronic middle ear effusion
- tympanostomy tube placement
- history of cleft palate
Cholesteatoma features
- pearly white mass in the anterosuperior quadrant of the TM
- chronic otorrhea (runny ear)
- conductive hearing loss
Cholesteatoma treatment
surgical excision
Chronic sinusitis
- Symptoms that persist beyond 3 months (symptoms that improve with therapy
then reoccur)
Chronic sinusitis treatment
- 2-3 weeks amoxicillin/clavulanate or fluoroquinolones
- if above are unsuccessful, high-dose
amoxicillin or a cephalosporin for 14 to 21 days
Chronic sialadenitis features
- recurrent jaw pain
- swelling of the affected salivary gland
- minimal saliva expression
Salivary duct calculi are composed predominantly of
calcium salts
Chronic sialadenitis investigation
-
Intraoral plain X-ray (80% stones are
radio-opaque) - CT
- US (best used for parotid glands)
Parotid gland tumour features
- painless firm and mobile mass (same side)
- facial nerve dysfunction (same side)
Parotid gland tumour investigation
CT head & neck
Midline neck swelling which moves with tongue protrusion
Thyroglossal cyst
Painless neck lumps in adults
- Malignant unless proven otherwise
- FNAC and CT investigations of choice first
-Excisional biopsy after CT
Lateral neck swelling which doesn’t move with tongue protrusion
Branchial cysts
Sleep apnoea features
– Excessive daytime sleepiness.
– Fatigue.
– Snoring at night.
– Choking or gasping while asleep.
– Morning headaches.
– Moodiness, irritability or depression
- Impaired vigilance
- Depression
- Narcolepsy
Difference between obstructive sleep apnoea and central sleep apnoea
- sleep maintenance insomnia (experiencing a lot of prolonged
awakenings during the night or one long wakeful period associated with daytime tiredness)
Sleep apnoea treatment
Continuous positive airway pressure (CPAP)
- sleep studies & respiratory specialist referral for diagnosis confirmation of the
Sleep apnoea most important risk factor
Congestive cardiac failure (most important)
- obesity (50%)
- myotonic dystrophy
- Ehlers-Danlos syndrome
- smoking
Sleep apnoea stroke mechanisms
- Large swings in blood pressure
- Increased coagulopathy
- Development of atrial fibrillation
- Local vibrational damage to the carotid artery bifurcation
- Paradoxical emboli through the asymptomatic patent foramen ovale opening during transient sleep-related hypoxia with pulmonary hypertension.
Anterior triangle of the neck mass
BCC
- Branchial cyst
- Carotid body tumour
- Carotid aneurysm
Branchial Cyst
- 20 – 40 y/o
- Location: inferior to the EAM and
anterior to the sternomastoid muscle - diagnosis: Mainly clinical
- management: Excision
Carotid body tumour
- 40 – 60 y/o
- Location: opposite thyroid cartilage
- Pulsatile mass that moves laterally
- Management: referral for excision
Posterior triangle of the neck mass
CPP
- Cystic hygroma
- Cervical rib
- Pancoast tumour
- (Naso/oropharyngeal squamous cell carcinomas)
Cystic hygroma
Paediatric condition (developmental
remnant)
* Transluminal mass
Treatment:
* refer Surgery
* Sclerosis
Pancoast tumour
-Tumour of lung APEX
- non-small cell cancer.
- Unilateral or bilateral
Pancoast tumour Complications
Mainly compression of:
- Subclavian artery: subclavian syndrome
- Brachial plexus: painful paraesthesia
- Sympathetic ganglion: Horner’s syndrome
- brachiocephalic vein compression
- phrenic nerve: cough
- recurrent laryngeal nerve: hoarseness
Pancoast tumour treatment
- Surgery
- Radiotherapy if life-threatening (subclavian syndrome)
- Chemotherapy if surgery too difficult
Horner’s Syndrome
- Anhidrosis
– pseudo enophthalmos - Ptosis
- Miosis
Midline of the neck mass
**TTD **
- Thyroid nodule
- Thyroglossal cyst
- Dermoid cyst
Thyroglossal cyst
Paeds remnant
- most common cause of midline
neck masses
- will move upwards with protrusion of the tongue
Dermoid cyst
-
teratoma that contains an array of
developmentally mature, solid tissues - Management: imaging (CT) and
surgical resection
Epistaxis management
- Sitting forward to prevent blood dripping down the throat.
- Compress the cartilaginous portion of nose for 5 -10 minutes
without interruption
Most common cause of epistaxis
Local incidental trauma
Recurrent epistaxis in a sleep apnoeic patient
CPAP use
- recommend warming & humidification of CPAP
- nasal saline irrigation
Painless swelling in front of the ear and slight drooping of mouth
Parotid gland carcinoma Parotid gland carcinoma
Ramsay Hunt syndrome
- Also termed herpes zoster oticus (reactivation of varicella-zoster virus)
- acute peripheral facial neuropathy
Triad of symptoms:
1. ipsilateral facial paralysis (lower motor neuron cranial nerve 7)
palsy
2. ear pain
3. erythematous vesicular rash of the skin of the ear canal, auricle, and mucous membrane of the oropharynx. - may be a loss of taste at anterior two-thirds of the tongue and hyperacusis
Ramsay Hunt syndrome treatment
- antiviral therapy and corticosteroid
within 72 hours of presentation (rash onset). - Oral Acyclovir (800 mg five times per day), valaciclovir (1 g three times per day for 7–10 days) and famciclovir (250 mg three times per day)
- valaciclovir and famciclovir have replaced acyclovir as drug of choice
- oral corticosteroids combined with antivirals (eg, 40 mg prednisolone daily for 7 days, tapering to 5 mg daily over the next 2 weeks – total of 14 days)
Cancer of the oral cavity
- > 50 years
- Heavy smoker
-Heavy drinker
If no ulcerations or lesions present, follow up in 12 months
Rinne test
Weber test
Diseases of the middle ear
Otitis media
Otosclerosis
Types of sensorineural hearing loss
- Meniere’s
- Labyrinthitis
- Vestibular neuritis
Sensorineural deafness diseases are all found in
inner ear
Types of conductive hearing loss
- Otitis media
- Otosclerosis
- Cholesteatoma
- TM perforation
- Head trauma
Under normal circumstances, bone conduction is ________ than air conduction
worse
Under the Weber test, sensorineural loss localises to
the good ear, therefore the bad ear won’t be able to hear it as well
Ménière’s syndrome diagnosis
vertigo + vomiting + tinnitus + aural fullness + sensorineural deafness
Abrupt onset. Attacks
last 30 minutes to
several hours.
Ménière’s syndrome. Acute severe attack TREATMENT
Diazepam ±
Prochlorperazine, or if
episodic, a thiazide
diuretic
IF Anticipation of
attack (Aural fullness,
tinnitus) : Prochlorperazine
Ménière’s syndrome: Prophylaxis
Hydrochlorothiazide or
Triamterene
+
amiloride (K+ sparing
diuretic) combination
Labyrinthitis diagnosis
acute onset vertigo provoked with changes in head position + tinnitus + hearing loss + URTI
URTI + vertigo + loss of balance + nystagmus + change in head position + reduced caloric test
Vestibular neuritis
Vestibular neuritis cause
Herpes Zoster URTI
Investigation of choice in a patient suspected with hearing loss + tinnitus + vertigo
Pure tone audiometry (audiogram)
BPPV investigation
Hallpike manoeuvre
BPPV treatment
Epley manoeuvre
Red flags for
dizziness/vertigo
– Neurological signs
– Ataxia out of proportion to vertigo
– Nystagmus out of proportion to vertigo
– Central nystagmus
– Central eye movement abnormalities
Vestibular Neuronitis
VS
Labyrinthitis
Vestibular Neuronitis:
Acute vertigo
Nausea
Vomiting
Labyrinthitis: PLUS
Hearing loss ± Tinnitus
Vestibular Neuronitis and Labyrinthitis MANAGEMENT
Bed rest
Prochlorperazine
or
Ondansetron
or
Promethazine
or
Diazepam
for the first 2 days
