Renal, Vasc surg, Breast surg, ENT Flashcards

Question

What is acute tubular necrosis?

Answer 1

Acute tubular necrosis is damage and death (necrosis) of the epithelial cells of the renal tubules. It is the most common cause of acute kidney injury. Damage to the kidney cells occurs due to ischaemia or toxins. The epithelial cells have the ability to regenerate making acute tubular necrosis reversible.

Answer 2

It usually takes 7-21 days to recover.

Answer 3

“Muddy brown casts” found on urinalysis is a pathognomonic finding specific to acute tubular necrosis. There can also be renal tubular epithelial cells in the urine.

Answer 4

Treatment is the same as with other causes of an acute kidney injury: Supportive management IV fluids Stop nephrotoxic medications Treat complications

Answer 5

Renal tubular acidosis is where there is a metabolic acidosis due to pathology in the tubules of the kidney.

Answer 6

The tubules are responsible for balancing the hydrogen and bicarbonate ions between the blood and urine and maintaining a normal pH.

Answer 7

Type 1 renal tubular acidosis is due to pathology in the distal tubule. The distal tubule is unable to excrete hydrogen ions.

Answer 8

FTT in children CKD Bone disease Hypokalaemia

Answer 9

Oral bicarbonate

Answer 10

Caused by reduced aldosterone. This can be due to adrenal insufficiency, medications such as ACE inhibitors and spironolactone or systemic conditions that affect the kidneys such as systemic lupus erythematosus, diabetes or HIV.

Answer 11

Management is with fludrocortisone. Sodium bicarbonate and treatment of the hyperkalaemia may also be required.

Answer 12

Haemolytic uraemic syndrome (HUS) occurs when there is thrombosis in small blood vessels throughout the body.

Answer 13

Haemolytic anaemia Acute kidney injury Low platelet count (thrombocytopenia)

Answer 14

The most common cause is a toxin produced by the bacteria e. coli 0157 called the shiga toxin.

Answer 15

E. coli 0157 causes a brief gastroenteritis often with bloody diarrhoea. Around 5 days after the diarrhoea the person will start displaying symptoms of HUS:

Answer 16

HUS is a medical emergency and has up to 10% mortality. The condition is self limiting and supportive management is the mainstay of treatment: Antihypertensives Blood transfusions Dialysis 70-80% of patients make a full recovery.

Answer 17

Rhabdomyolysis is a condition where skeletal muscle tissue breaks down and releases breakdown products into the blood. This is usually triggered by an event that causes the muscle to break down, such as extreme underuse or overuse or a traumatic injury.

Answer 18

Myoglobin (causing myoglobinurea) Potassium Phosphate Creatine kinase

Answer 19

Myoglobin in particular is toxic to the kidney in high concentrations. This results in acute kidney injury. The acute kidney injury causes the breakdown products to further accumulate in the blood.

Answer 20

Muscle aches and pain Oedema Fatigue Confusion (particularly in elderly frail patients) Red-brown urine

Answer 21

Suspect rhabdomyolysis in patients with trauma, crush injury, prolonged immobilisation or excessive exercise. IV fluids are the mainstay of treatment. The aim is to rehydrate the patient and encourage filtration of the breakdown products.

Answer 22

Consider IV sodium bicarbonate. This aims to make the urine more alkaline (pH ≥ 6.5), reducing the toxicity of the myoglobin on the kidneys. The evidence on this is not clear and there is some debate about whether to use it.

Answer 23

This aims to increase the glomerular filtration rate to help flush the breakdown products and to reduce oedema surrounding muscles and nerves. Hypovolaemia should be corrected before giving mannitol. The evidence on this is not clear and there is some debate about whether to use it.

Answer 24

Ventricular fibrillation

Answer 25

Tall peaked T waves Flattening or absence of P waves Broad QRS complexes

Answer 26

Patients with a potassium ≤ 6 mmol/L with otherwise stable renal function don’t need urgent treatment and may just require a change in diet and medications (i.e. stopping their spironolactone or ACE inhibitor). Patients with a potassium ≥ 6 mmol/L and ECG changes need urgent treatment. Patients with a potassium ≥ 6.5 mmol/L regardless of the ECG need urgent treatment. The mainstay of treatment is with an insulin and dextrose infusion and IV calcium gluconate: Insulin (e.g. actrapid 10 units) and dextrose (e.g. 50mls of 50%) drives carbohydrates into cells and takes potassium with it, reducing the blood potassium. Calcium gluconate stabilises the cardiac muscle cells and reduces the risk of arrhythmias.

Answer 27

Mostly supportive Tolvaptan (a vasopressin receptor antagonist) can slow the development of cysts and the progression of renal failure in autosomal dominant polycystic kidney disease. It is recommended by NICE in certain situations although it should be initiated and monitored by a specialist.

Answer 28

The features are pain at rest, non-healing ulcers and gangrene.

Answer 29

Gangrene refers to the death of the tissue, specifically due to an inadequate blood supply.

Answer 30

(burning) Pain (worse at night) Pallor Pulseless Paralysis Paraesthesia (abnormal sensation or “pins and needles”) Perishing cold

Answer 31

Thigh/buttock claudication Absent femoral pulses Male impotence

Answer 32

Leriche syndrome occurs with occlusion in the distal aorta or proximal common iliac artery.

Answer 33

Using a hand-held Doppler

Answer 34

Skin pallor Cyanosis Dependent rubor (a deep red colour when the limb is lower than the rest of the body) Muscle wasting Hair loss Ulcers Poor wound healing Gangrene (breakdown of skin and a dark red/black change in colouration)

Answer 35

Buerger’s test is used to assess for peripheral arterial disease in the leg. There are two parts to the test. The first part involves the patient lying on their back (supine). Lift the patient’s legs to an angle of 45 degrees at the hip. Hold them there for 1-2 minutes, looking for pallor. Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease. Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply. For example, a Buerger’s angle of 30 degrees means that the legs go pale when lifted to 30 degrees.

Answer 36

The second part involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour. In a patient with peripheral arterial disease, they will go: Blue initially, as the ischaemic tissue deoxygenates the blood Dark red after a short time, due to vasodilation in response to the waste products of anaerobic respiration

Answer 37

Are smaller than venous ulcers Are deeper than venous ulcers Have well defined borders Have a “punched-out” appearance Occur peripherally (e.g., on the toes) Have reduced bleeding Are painful

Answer 38

Occur after a minor injury to the leg Are larger than arterial ulcers Are more superficial than arterial ulcers Have irregular, gently sloping borders Affect the gaiter area of the leg (from the mid-calf down to the ankle) Are less painful than arterial ulcers Occur with other signs of chronic venous insufficiency (e.g., haemosiderin staining and venous eczema)

Answer 39

0.9 – 1.3 is normal 0.6 – 0.9 indicates mild peripheral arterial disease 0.3 – 0.6 indicates moderate to severe peripheral arterial disease Less than 0.3 indicates severe disease to critical ischaemic

Answer 40

Atorvastatin 80mg Clopidogrel 75mg once daily (aspirin if clopidogrel is unsuitable) Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator)

Answer 41

Endovascular angioplasty and stenting Endarterectomy – cutting the vessel open and removing the atheromatous plaque Bypass surgery – using a graft to bypass the blockage

Answer 42

Peripheral arterial disease

Answer 43

If the patient has significant kidney impairment or a contrast allergy.

Answer 44

In most patients, NICE (2020) recommend treatment dose apixaban or rivaroxaban. It should be started immediately in patients where DVT or PE is suspected, and there is a delay in getting the scan.

Answer 45

Low molecular weight heparin (LMWH)

Answer 46

Varicose veins are distended superficial veins measuring more than 3mm in diameter, usually affecting the legs.

Answer 47

Reticular veins are dilated blood vessels in the skin measuring less than 1-3mm in diameter.

Answer 48

Telangiectasia refers to dilated blood vessels in the skin measuring less than 1mm in diameter. They are also known as spider veins or thread veins.

Answer 49

The deep and superficial veins are connected by vessels called the perforating veins (or perforators), which allow blood to flow from the superficial veins to the deep veins. When the valves are incompetent in these perforators, blood flows from the deep veins back into the superficial veins and overloads them. This leads to dilatation and engorgement of the superficial veins, forming varicose veins.

Answer 50

When blood pools in the distal veins, the pressure causes the veins to leak small amounts of blood into the nearby tissues. The haemoglobin in this leaked blood breaks down to haemosiderin, which is deposited around the shins in the legs. This gives a brown discolouration to the lower legs.

Answer 51

Pooling of blood in the distal tissues results in inflammation. The skin becomes dry and inflamed, referred to as venous eczema.

Answer 52

Tap test – apply pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein, feeling for a thrill at the SFJ. A thrill suggests incompetent valves between the varicose vein and the SFJ.

Answer 53

Cough test – apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ. A thrill suggests a dilated vein at the SFJ (called saphenous varix).

Answer 54

With the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve. If the varicose veins appear, the incompetent valve is below the level of the tourniquet. Repeat the test with the tourniquet at different levels to assess the location of the incompetent valves.

Answer 55

Perthes test – apply a tourniquet to the thigh and ask the patient to pump their calf muscles by performing heel raises whilst standing. If the superficial veins disappear, the deep veins are functioning. Increased dilation of the superficial veins indicates a problem in the deep veins, such as deep vein thrombosis.

Answer 56

Varicose veins in pregnancy often improve after delivery. Simple treatment measures include: Weight loss if appropriate Staying physically active Keeping the leg elevated when possible to help drainage Compression stockings (exclude arterial disease first with an ankle-brachial pressure index) Surgical options: Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein Stripping – the veins are ligated and pulled out of the leg

Answer 57

Management involves: Keeping the skin healthy Improving venous drainage to the legs Managing complications The skin is kept healthy by: Monitoring skin health and avoiding skin damage Regular use of emollients (e.g., diprobase, oilatum, cetraben and doublebase) Topical steroids to treat flares of venous eczema Very potent topical steroids to treat flares of lipodermatosclerosis

Answer 58

The management of arterial ulcers is the same as peripheral arterial disease, with an urgent referral to vascular to consider surgical revascularisation. If the underlying arterial disease is effectively treated, the ulcer should heal rapidly. Debridement and compression are not used in arterial ulcers.

Answer 59

Good wound care

Answer 60

Primary lymphoedema is a rare, genetic condition, which usually presents before aged 30. It is a result of faulty development of the lymphatic system. Secondary lymphoedema is due to a separate condition that affects the lymphatic system. The most common example is when patients develop lymphoedema after breast cancer surgery, due to the removal of axillary lymph nodes in the armpit.

Answer 61

Lipoedema is an important differential diagnosis, where there is an abnormal build-up of fat tissue in the limbs, often the legs. The feet are spared in lipoedema, unlike lymphoedema. This affects women more often than men.

Answer 62

Stemmer’s sign can be used to assess for lymphoedema. The skin at the bottom of the second toe or middle finger is gently pinched together using two fingers. If it is possible to lift and “tent” the skin, Stemmer’s sign is negative. If it is not possible to pinch the skin together, lift and “tent” it, Stemmer’s sign is positive, suggesting lymphoedema.

Answer 63

A specialist lymphoedema service manages patients with lymphoedema. Non-surgical treatment options include: Massage techniques to manually drain the lymphatic system (manual lymphatic drainage) Compression bandages Specific lymphoedema exercises to improve lymph drainage Weight loss if overweight Good skin care

Answer 64

All men in England are offered a screening ultrasound scan at age 65 to detect asymptomatic AAA. Early detection of an AAA means preventative measures can stop it from expanding further or rupturing.

Answer 65

Abdominal aortic aneurysm (AAA) refers to dilation of the abdominal aorta, with a diameter of more than 3cm.

Answer 66

The Public Health England (updated 2017) screening and surveillance programme recommends follow up scans: Yearly for patients with aneurysms 3-4.4cm 3 monthly for patients with aneurysms 4.5-5.4cm The NICE guidelines (2020) recommend elective repair for patients with any of: Symptomatic aneurysm Diameter growing more than 1cm per year Diameter above 5.5cm

Answer 67

CT angiogram can be used to diagnose or exclude ruptured AAA in haemodynamically stable patients.

Answer 68

Ehlers-Danlos Syndrome Marfan’s Syndrome

Answer 69

Aortic dissection refers to when a break or tear forms in the inner layer of the aorta, allowing blood to flow between the layers of the wall of the aorta. There are three layers to the aorta, the intima, media and adventitia. With aortic dissection, blood enters between the intima and media layers of the aorta. A false lumen full of blood is formed within the wall of the aorta.

Answer 70

The typical presentation is a sudden onset, severe, “ripping” or “tearing” chest pain. The pain may be in the anterior chest when the ascending aorta is affected, or the back if the descending aorta is affected. The pain may change location (migrate) over time. Some patients with aortic dissection do not have chest pain. Other features that may suggest aortic dissection are: Hypertension Differences in blood pressure between the arms (more than a 20mmHg difference is significant) Radial pulse deficit (the radial pulse in one arm is decreased or absent and does not match the apex beat) Diastolic murmur Focal neurological deficit (e.g., limb weakness or paraesthesia) Chest and abdominal pain Collapse (syncope) Hypotension as the dissection progresses

Answer 71

CT angiogram is usually the initial investigation to confirm the diagnosis and can generally be performed very quickly.

Answer 72

Endarterectomy involves an incision in the neck, opening the carotid artery and scraping out the plaque. This is the first-line treatment for most patients requiring surgical intervention. A key complication of the procedure is stroke (around 2%).

Answer 73

Hoarse voice

Answer 74

Facial nerve injury causes facial weakness (often the marginal mandibular branch causing drooping of the lower lip)

Answer 75

Glossopharyngeal nerve injury causes swallowing difficulties

Answer 76

Unilateral tongue paralysis

Answer 77

Also known as thromboangiitis obliterans, it is an inflammatory condition that causes thrombus formation in the small and medium-sized blood vessels in the distal arterial system (affecting the hands and feet).

Answer 78

The typical presenting feature is painful, blue discolouration to the fingertips or tips of the toes. The pain is often worse at night. This may progress to ulcers, gangrene and amputation.

Answer 79

Found on angiogram in Buerger disease, they are new collateral vessels that form to bypass the affected arteries.

Answer 80

Completely stopping smoking is the main component of treatment. This usually results in a significant improvement. Cutting down or using nicotine replacement products does not seem to be adequate to improve the condition.

Answer 81

Clinical assessment (history and examination) Imaging (ultrasound or mammography) Histology (fine needle aspiration or core biopsy)

Answer 82

Lumps that are hard, irregular, painless or fixed in place Lumps may be tethered to the skin or the chest wall Nipple retraction Skin dimpling or oedema (peau d’orange)

Answer 83

Fibroadenoma Fibrocystic breast changes Breast cyst Fat necrosis

Answer 84

Low mood, bloating, fatigue or headaches Cyclical breast pain (Bilateral and generalised, heaviness, aching)

Answer 85

Medications (e.g., hormonal contraceptive medications) Infection (e.g., mastitis) Pregnancy

Answer 86

Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen) Testicular cancer (oestrogen secretion from a Leydig cell tumour) Liver cirrhosis and liver failure Hyperthyroidism Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer

Answer 87

(reduce testosterone) Testosterone deficiency in older age Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours, radiotherapy or surgery) Klinefelter syndrome (XXY sex chromosomes) Orchitis (inflammation of the testicles, e.g., infection with mumps) Testicular damage (e.g., secondary to trauma or torsion)

Answer 88

Gynaecomastia

Answer 89

Tamoxifen (a selective oestrogen receptor modulator that reduces the effect of oestrogen on the breast tissue)

Answer 90

Galactorrhoea refers to breast milk production not associated with pregnancy or breastfeeding. Breast milk is produced in response to the hormone prolactin.

Answer 91

Idiopathic (no cause can be found) Prolactinomas (hormone-secreting pituitary tumours) Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome Medications, particularly dopamine antagonists (i.e., antipsychotic medications)

Answer 92

Galactorrhoea Menstrual irregularities, particularly amenorrhoea (absent periods) Reduced libido (low sex drive) Erectile dysfunction (in men) Gynaecomastia (in men)

Answer 93

Dopamine agonists (e.g., bromocriptine or cabergoline) can be used to treat the symptoms of hyperprolactinaemia. They block prolactin secretion and improve symptoms. Trans-sphenoidal surgical removal of the pituitary tumour is the definitive treatment of hyperprolactinaemia secondary to a prolactinoma. The pituitary gland and tumour are accessed and removed through the nose and sphenoid bone.

Answer 94

Mammary duct ectasia is a benign condition where there is dilation of the large ducts in the breasts. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green. Mammary duct ectasia occurs most frequently in perimenopausal women. Smoking is a significant risk factor.

Answer 95

Nipple discharge Tenderness or pain Nipple retraction or inversion A breast lump (pressure on the lump may produce nipple discharge)

Answer 96

Triple assessment

Answer 97

Reassurance after excluding cancer may be all that is required Symptomatic management of mastalgia (supportive bra and warm compresses) Antibiotics if infection is suspected or present Surgical excision of the affected duct (microdochectomy) may be required in problematic cases

Answer 98

An intraductal papilloma is a warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells. The typical presentation is with clear or blood-stained nipple discharge. Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

Answer 99

Triple assessment for diagnosis Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.

Answer 100

The most common bacterial cause is Staphylococcus aureus.

Answer 101

Mastitis can be caused by an obstruction in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent this from occurring.

Answer 102

When conservative management is not effective, or infection is suspected (e.g., they have a fever), antibiotics should be started. Flucloxacillin is the first line, or erythromycin when allergic to penicillin. A sample of milk can be sent to the lab for culture and sensitivities. Fluconazole may be used for suspected candidal infections.

Answer 103

Both the mother and baby need treatment, or it will reoccur. Treatment is with: Topical miconazole 2% to the nipple, after each breastfeed Treatment for the baby (e.g., oral miconazole gel or nystatin)

Answer 104

It can lead to recurrent mastitis

Answer 105

Co-amoxiclav (amoxicillin plus clavulanic acid) covers anaerobes

Answer 106

Metronidazole gives excellent anaerobic cover

Answer 107

Fluctuance refers to being able to move fluid around within the lump using pressure during palpation.

Answer 108

Women who are breastfeeding are advised to continue breastfeeding when they have mastitis or breast abscesses. They should regularly express breast milk if feeding is too painful, then resume feeding when possible. This is not harmful to the baby and is important in helping resolve the mastitis or abscess.

Answer 109

BRCA1 and BRCA 2 genes

Answer 110

The NHS breast cancer screening program offers a mammogram every 3 years to women aged 50 – 70 years.

Answer 111

Breast and melanoma

Answer 112

This is because there is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.

Answer 113

The vestibulocochlear nerve transmits nerve signals from the semicircular canals and cochlea to the brain

Answer 114

The semicircular canals are responsible for sensing head movement (the vestibular system)

Answer 115

The cochlea is responsible for converting the sound vibration into a nervous signal

Answer 116

A normal result is when the patient can hear the sound again when bone conduction ceases and the tuning fork is moved next to the ear rather than on the mastoid process. It is normal for air conduction to be better (more sensitive) than bone conduction. This is referred to as “Rinne’s positive”.

Answer 117

Tinnitus (ringing in the ears) Vertigo (the sensation that the room is spinning) Pain (may indicate infection) Discharge (may indicate an outer or middle ear infection) Neurological symptoms

Answer 118

Sudden sensorineural hearing loss (over less than 72 hours) Presbycusis (age-related) Noise exposure Ménière’s disease Labyrinthitis Acoustic neuroma Neurological conditions (e.g., stroke, multiple sclerosis or brain tumours) Infections (e.g., meningitis) Medications

Answer 119

Loop diuretics (e.g., furosemide) Aminoglycoside antibiotics (e.g., gentamicin) Chemotherapy drugs (e.g., cisplatin)

Answer 120

Ear wax (or something else blocking the canal) Infection (e.g., otitis media or otitis externa) Fluid in the middle ear (effusion) Eustachian tube dysfunction Perforated tympanic membrane Otosclerosis Cholesteatoma Exostoses Tumours

Answer 121

Presbycusis is described as age-related hearing loss. It is a type of sensorineural hearing loss that occurs as people get older. It tends to affect high-pitched sounds first and more notably than lower-pitched sounds. The hearing loss occurs gradually and symmetrically.

Answer 122

Audiometry is the investigation of choice for establishing the diagnosis and extent of hearing loss. Presbycusis will give a sensorineural hearing loss pattern, with normal or near-normal hearing at lower frequencies and worsening hearing loss at higher frequencies.

Answer 123

Sudden sensorineural hearing loss (SSNHL) is defined as hearing loss over less than 72 hours, unexplained by other causes. This is considered an otological emergency and requires an immediate referral to the on-call ENT team. The diagnosis is made when someone rapidly loses their hearing, and no conductive cause can be found.

Answer 124

Idiopathic SSNHL may be treated with steroids under the guidance of the ENT team. Steroids may be: Oral Intra-tympanic (via an injection of steroids through the tympanic membrane)

Answer 125

Eustachian tube dysfunction is when the tube between the middle ear and throat is not functioning properly. The Eustachian tube is present mainly to equalise the air pressure in the middle ear and drain fluid from the middle ear. When the Eustachian tube is not functioning correctly or becomes blocked, the air pressure cannot equalise properly and fluid cannot drain freely from the middle ear. The air pressure between the middle ear and the environment can become unequal. The middle ear can fill with fluid.

Answer 126

Reduced or altered hearing Popping noises or sensations in the ear A fullness sensation in the ear Pain or discomfort Tinnitus Symptoms tend to get worse when the external air pressure changes and the middle ear pressure cannot equalise to the outside pressure, for example, flying, climbing a mountain or scuba diving.

Answer 127

Tympanometry involves: Inserting a device into the external auditory canal (ear canal) Creating different air pressures in the canal Sending a sound in the direction of the tympanic membrane Measuring the amount of sound reflected back off the tympanic membrane Plotting a tympanogram (graph) of the sound absorbed (admittance) at different air pressures

Answer 128

Normally, sound is absorbed best when the air pressure in the ear canal matches the ambient air pressure. The ambient air pressure is equal to the middle ear pressure in healthy ears. When there is Eustachian tube dysfunction, the air pressure in the middle ear may be lower than the ambient air pressure because new air cannot get in through the tympanic membrane to equalise the pressures. As a result, the tympanogram will show a peak admittance (most sound absorbed) with negative ear canal pressures.

Answer 129

Treatment options for Eustachian tube dysfunction include: No treatment, waiting for it to resolve spontaneously (e.g., recovering from the viral URTI) Valsalva manoeuvre (holding the nose and blowing into it to inflate the Eustachian tube) Decongestant nasal sprays (short term only) Antihistamines and a steroid nasal spray for allergies or rhinitis Surgery may be required in severe or persistent cases

Answer 130

Otosclerosis is a condition where there is remodelling of the small bones in the middle ear, leading to conductive hearing loss. Oto- refers to the ears, and -sclerosis means hardening. It usually presents before the age of 40 years.

Answer 131

The typical presentation is a patient under 40 years presenting with unilateral or bilateral: Hearing loss Tinnitus It tends to affect the hearing of lower-pitched sounds more than higher-pitched sounds. Female speech may be easier to hear than male speech (due to the generally higher pitch). This is the reverse of the pattern seen in presbycusis. Due to conductive hearing loss with intact sensory hearing, the patient can experience their voice as being loud compared to the environment (due to bone conduction of their voice). This can lead to them talking quietly.

Answer 132

Surgical management is generally successful and can potentially restore hearing to normal. It involves lifting the tympanic membrane and some of the surrounding skin out of the way to access the middle ear through the ear canal. Stapedectomy involves removing the entire stapes bone and replacing it with a prosthesis. The prosthesis attaches to the oval window and hooks around the incus, transmitting the sound from the incus to the cochlea in the same way the stapes normally would. Stapedotomy involves removing part of the stapes bone and leaving the base of the stapes (the footplate) attached to the oval window. A small hole is made in the base of the stapes for the prosthesis to enter. A prosthesis is added to transmit sound from the incus to the cochlea.

Answer 133

A normal tympanic membrane is “pearly-grey”, translucent and slightly shiny.

Answer 134

Other than causing otitis externa, an important exam-related point to remember is that it can colonise the lungs in patients with cystic fibrosis, significantly increasing their morbidity and mortality. It is naturally resistant to many antibiotics, making it very difficult to treat in children with cystic fibrosis. It can be treated with aminoglycosides (e.g., gentamicin) or quinolones (e.g., ciprofloxacin).

Answer 135

Mild otitis externa may be treated with acetic acid 2% (available over the counter as EarCalm). Acetic acid has an antifungal and antibacterial effect. This can also be used prophylactically before and after swimming in patients that are prone to otitis externa.

Answer 136

Moderate otitis externa is usually treated with a topical antibiotic and steroid

Answer 137

Aminoglycosides (e.g., gentamicin and neomycin) are potentially ototoxic, rarely causing hearing loss if they get past the tympanic membrane. Therefore, it is essential to exclude a perforated tympanic membrane before using topical aminoglycosides in the ear. This can be difficult if the patient has discharge, swelling or wax blocking the ear canal. Patients with a blocked ear canal may need to be seen by ENT to microsuction the debris from the canal and visualise the tympanic membrane. They will also require a referral if the canal is so blocked or swollen that topical treatments cannot reach the site of infection.

Answer 138

Malignant otitis externa is a severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull.

Answer 139

Admission to hospital under the ENT team IV antibiotics Imaging (e.g., CT or MRI head) to assess the extent of the infection

Answer 140

Facial nerve damage and palsy Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves) Meningitis Intracranial thrombosis Death

Answer 141

Primary tinnitus has no identifiable cause and often occurs with sensorineural hearing loss.

Answer 142

D – Dysdiadochokinesia A – Ataxic gait (ask the patient to walk heel-to-toe) N – Nystagmus (see below for more detail) I – Intention tremor S – Speech (slurred) H – Heel-shin test

Answer 143

Benign paroxysmal positional vertigo Ménière’s disease Vestibular neuronitis Labyrinthitis

Answer 144

Benign paroxysmal positional vertigo (BPPV) is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. They may be displaced by a viral infection, head trauma, ageing or without a clear cause. The crystals disrupt the normal flow through the canals and therefore disrupt the function of the system.

Answer 145

The symptoms are usually positional, because movement is required to confuse the system. Therefore, attacks of vertigo are triggered by movement and can last around a minute before the symptoms settle. Often symptoms occur over several weeks and then resolve, then can reoccur weeks or months later.

Answer 146

A special test called the Dix-Hallpike manoeuvre can be used to diagnose BPPV.

Answer 147

Ménière’s disease is caused by an excessive buildup of endolymph in the semicircular canals, causing a higher pressure than normal, disrupting the sensory signals.

Answer 148

It causes attacks of hearing loss, tinnitus, vertigo and a sensation of fullness in the ear. These attacks typically last several hours before settling. It most often occurs in middle-aged adults and is not associated with movement. The symptoms are not positional. Patients will have spontaneous nystagmus during attacks (nystagmus is discussed in more detail later). Over time, the patient’s hearing will gradually deteriorate.

Answer 149

Acute vestibular neuronitis describes inflammation of the vestibular nerve. This is usually attributed to a viral infection. Typically, the history is of acute onset of vertigo that improves within a few weeks.

Answer 150

Labyrinthitis describes inflammation of the structures of the inner ear. This is usually attributed to a viral infection. Usually the history is of acute onset of vertigo that improves within a few weeks. Labyrinthitis can cause hearing loss, which distinguishes it from vestibular neuronitis.

Answer 151

Posterior circulation infarction (stroke) Tumour Multiple sclerosis Vestibular migraine

Answer 152

For peripheral vertigo, short-term options for managing symptoms include: Prochlorperazine Antihistamines (e.g., cyclizine, cinnarizine and promethazine)

Answer 153

Betahistine may be used prophylactically to help reduce the attacks in patients diagnosed with Ménière’s disease.

Answer 154

Tinnitus and hearing loss are not features of vestibular neuronitis, as the cochlea and cochlear nerve are not affected.

Answer 155

The head impulse test can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g., vestibular neuronitis or labyrinthitis).

Answer 156

Hearing loss Vertigo Tinnitus

Answer 157

Acoustic neuromas are benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear.

Answer 158

Acoustic neuromas are usually unilateral. Bilateral acoustic neuromas are associated with neurofibromatosis type II.

Answer 159

Unilateral sensorineural hearing loss (often the first symptom) Unilateral tinnitus Dizziness or imbalance A sensation of fullness in the ear They can also be associated with a facial nerve palsy if the tumour grows large enough to compress the facial nerve.

Answer 160

Cholesteatoma is an abnormal collection of squamous epithelial cells in the middle ear. It is non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear. It can predispose to significant infections. Nothing to do with cholesterol or a tumour

Answer 161

The typical presenting symptoms are: Foul discharge from the ear Unilateral conductive hearing loss As the cholesteatoma continues to expand into the surrounding spaces and tissues, further symptoms may develop, including: Infection Pain Vertigo Facial nerve palsy

Answer 162

A CT head can be used to confirm the diagnosis and plan for surgery. MRI may help assess invasion and damage to local soft tissues. Treatment involves surgical removal of the cholesteatoma.

Answer 163

Ramsay-Hunt syndrome is caused by the varicella zoster virus (VZV).

Answer 164

Treatment should ideally be initiated within 72 hours. Treatment is with: Prednisolone Aciclovir Patients also require lubricating eye drops.

Answer 165

Patients stereotypically have a painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side.

Answer 166

Little’s area (the area most affected by Little fingers picking noses) is a popular topic in exams. Remember the name of this area as examiners like to ask, “what is the most likely location of the bleeding?”

Answer 167

High dose steroid nasal spray for 14 days (e.g., mometasone 200 mcg twice daily) A delayed antibiotic prescription, used if worsening or not improving within 7 days (phenoxymethylpenicillin first-line)

Answer 168

Saline nasal irrigation Steroid nasal sprays or drops (e.g., mometasone or fluticasone) Functional endoscopic sinus surgery (FESS)

Answer 169

Tilting the head slightly forward Using the left hand to spray into the right nostril, and vice versa (this directs the spray slightly away from the septum) NOT sniffing hard during the spray Very gently inhaling through the nose after the spray A good question to ask is, “do you taste the spray at the back of your throat after using it?” Tasting the spray means it has gone past the nasal mucosa and will not be as effective.

Answer 170

If you remember one thing about nasal polyps, remember that unilateral polyps are concerning for malignancy and require a specialist referral for assessment.

Answer 171

Obstructive sleep apnoea is caused by collapse of the pharyngeal airway. It is characterised by episodes of apnoea during sleep, where the person stops breathing periodically for up to a few minutes.

Answer 172

Epworth sleepiness scale

Answer 173

The FeverPAIN score is an alternative to the Centor criteria. A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis: Fever during previous 24 hours P – Purulence (pus on tonsils) A – Attended within 3 days of the onset of symptoms I – Inflamed tonsils (severely inflamed) N – No cough or coryza

Answer 174

Penicillin V (also called phenoxymethylpenicillin) for a 10-day course is typically first-line. It has a relatively narrow spectrum of activity and is effective against Streptococcus pyogenes.

Answer 175

Quinsy is the common name for a peritonsillar abscess. Peritonsillar abscess arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils.

Answer 176

Patients should be referred to the hospital under the ENT team’s care for needle aspiration or surgical incision and drainage to remove the pus from the abscess. Abx before and after surgery

Answer 177

The SIGN guidelines (2010) give the indications for tonsillectomy. The number of episodes of acute sore throat they specify for a tonsillectomy are: 7 or more in 1 year 5 per year for 2 years 3 per year for 3 years Other indications are: Recurrent tonsillar abscesses (2 episodes) Enlarged tonsils causing difficulty breathing, swallowing or snoring

Answer 178

Post tonsillectomy bleeding is the main significant complication after a tonsillectomy. Significant bleeding can occur in up to 5% of patients who have had a tonsillectomy requiring urgent management. This can happen up to 2 weeks after the operation. Bleeding can be severe and, in rare cases, life-threatening due to aspiration of blood.

Answer 179

Infectious mononucleosis is a cause of lymphadenopathy. It is caused by infection with the Epstein Barr virus (EBV) and most often affects teenagers and young adults. It is found in the saliva of infected individuals and may be spread by kissing or sharing cups, toothbrushes and other equipment that transmits saliva. It presents with Fever Sore throat Fatigue Lymphadenopathy Mononucleosis can present with an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins.

Answer 180

The first-line investigation is the Monospot test. It is also possible to test for IgM (acute infection) and IgG (immunity) to the Epstein Barr virus.

Answer 181

Management is supportive. Patients should avoid alcohol (risk of liver impairment) and contact sports (risk of splenic rupture).

Answer 182

The Ann Arbor staging system is used for both Hodgkins and non-Hodgkins lymphoma.

Answer 183

The Reed-Sternberg cell is the key finding from lymph node biopsy in patients with Hodgkin’s lymphoma.

Answer 184

Lump in the mouth or on the lip Unexplained ulceration in the mouth lasting more than 3 weeks Erythroplakia or erythroleukoplakia Persistent neck lump Unexplained hoarseness of voice Unexplained thyroid lump

Answer 185

Iron deficiency anaemia B12 deficiency Folate deficiency Coeliac disease Injury or irritant exposure

Answer 186

Allergic reactions ACE inhibitors C1 esterase inhibitor deficiency (hereditary angioedema)

Answer 187

Miconazole gel Nystatin suspension Fluconazole tablets (in severe or recurrent cases)

Answer 188

Geographic tongue is an inflammatory condition where patches of the tongue’s surface lose the epithelium and papillae. The patches form irregular shapes on the tongue, resembling a map, with countries and oceans bordering each other.

Answer 189

Scarlet fever Kawasaki disease

Answer 190

Black hairy tongue results from decreased shedding (exfoliation) of keratin from the tongue’s surface. The papillae elongate and take on the appearance of hairs. Bacteria and food cause the dark pigmentation. This gives the appearance of black hair on the tongue. Patients may also report sticky saliva and a metallic taste.

Answer 191

Black hairy tongue may be due to dehydration, a dry mouth, poor oral hygiene and smoking. Management involves ensuring adequate hydration, gentle brushing of the tongue and stopping smoking.

Answer 192

Leukoplakia is characterised by white patches in the mouth, often on the tongue or insides of the cheeks (buccal mucosa). It is a precancerous condition, meaning it increases the risk of squamous cell carcinoma of the mouth.

Answer 193

Erythroplakia is similar to leukoplakia, except the lesions are red. Erythroleukoplakia refers to lesions that are a mixture of red and white. Both erythroplakia and erythroleukoplakia are associated with a high risk of squamous cell carcinoma and should be referred urgently to exclude cancer.

Answer 194

Lichen planus is an autoimmune condition that causes localised chronic inflammation of the skin. The skin has shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae. It usually occurs in patients over 45 and is more common in women.

Answer 195

Management involves good oral hygiene, stopping smoking and topical steroids.

Answer 196

Gingivitis refers to inflammation of the gums. This can present with swollen gums, bleeding after brushing, painful gums and bad breath (halitosis). Gingivitis can lead to periodontitis if not adequately managed.

Answer 197

Periodontitis refers to severe and chronic inflammation of the gums and the tissues that support the teeth. This often leads to loss of teeth.

Answer 198

Aphthous ulcers are very common, small, painful ulcers of the mucosa in the mouth. They have a well-circumscribed, punched-out, white appearance. Aphthous ulcers commonly occur in otherwise healthy people, with no underlying cause. They may be triggered by emotional or physical stress, trauma to the mucosa or particular foods.

Answer 199

Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) Coeliac disease Behçet disease Vitamin deficiency (e.g., iron, B12, folate and vitamin D) HIV

Answer 200

Topical treatments can be used to treat symptoms, including: Choline salicylate (e.g., Bonjela) Benzydamine (e.g., Difflam spray) Lidocaine Maybe steroids in severe cases

Answer 201

The NICE guidelines on suspected cancer (updated January 2021) recommend a two week wait referral in patients with “unexplained ulceration” lasting over 3 weeks.

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