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YR6 Rotations > Surgery - Ear, nose and throat > Flashcards

Surgery - Ear, nose and throat Flashcards

1
Q

What is a normal result in pure tone audiometry?

A

All results above 20dB line

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2
Q

What is Rinne’s test? Describe the results

A

tuning fork placed over mastoid process until sound no longer heard, followed by repositioning just over external acoustic meatus
+ve: AC > BC bilaterally = normal or SNHL
-ve: BC > AC = conductive deafness

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3
Q

What is Weber’s test? Describe the results

A

Tuning form placed in middle of forehead, equidistant from ears
patient asked which side is loudest

Normal: equal

Unilateral SNHL: localises to unaffected ear

Unilateral conductive HL: sound localises to affected ear

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4
Q

What is the difference between SNHL, conductive HL and mixed HL?

A

SNHL = both air + bone conduction are impaired (AC better than BC)

Conductive: only air conduction impaired

Mixed: air + bone conduction both impaired, but BC better than AC

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5
Q

How can middle ear function be evaluated?

A

Tympanometry - measures stiffness of ear drum

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6
Q

What is automated auditory brainstem response audiometry?

A

Auditory stimulus with measurement of elicited brain response by surface electrode

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7
Q

What are the components of the child hearing exams?

A

All babies get evoked otoacoustic emission testing
If not normal –>
Automated auditory brainstem response audiometry

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8
Q

What are the signs and symptoms of TMJ dysfunction?

A 
Otalgia (referred pain from auriculotemporal nerve) 
Facial pain 
TMJ joint clicking/popping 
Bruxism (teeth grinding) 
Stress
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9
Q

What condition does ‘swimmer’s ear’ refer to?

A

Acute diffuse otitits externa

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10
Q

How should necrotising otitis externa be managed?

A

Urgent ENT referral
CT head
IV ciprofloxacin

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11
Q

What is acute otitis media?

A

Inflammation in the middle ear a/w effusion accompanied by rapid onset S/S of ear infection

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12
Q

What is the most common pathogen implicated in acute otitis media? Name 2 others

A

S. pneumoniae (as secondary to URTI)

Haemophilus influenzae
Moraxella catarrhalis

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13
Q

List 3 viral causes of acute otitis media

A

Respiratory syncytial virus (RSV)
Rhinovirus
Adenovirus

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14
Q

Give 4 risk factors specific to infants for acute otitis media

A

Nursery
Formula feeding
Use of a dummy
Bottle feeding supine

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15
Q

List 3 general risk factors for acute otitis media

A

Smoking/ passive smoking
FH
Craniofacial abnormalities e.g. cleft palate

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16
Q

Give 5 signs/ symptoms of acute otitis media

A

Otalgia +/- tugging/ rubbing
Fever
Conductive HL
Recent viral URTI Sx
Discharge if TM perforates

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17
Q

List 4 features found on otoscopy in acute otitis media

A

Bulging TM: loss of light reflex
Air-fluid level behind TM indicates effusion
Opacification/ erythema of TM
Perforation with purulent otorrhoea

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18
Q

How should acute otitis media without perforation be managed?

A

Analgesia

Delayed/ no script Abx unless:

  • Sx >4 days + not improving
  • systemically unwell but not requiring admission
  • Immunocompromised
  • <2y with BL OM
  • Perforation / discharge in canal
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19
Q

If antibiotics are indicated in acute otitis media, what is firstline?

A

Amoxicillin
If Pen allergy: erythromycin or clarithromycin

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20
Q

Describe 3 common sequalae to acute otitis media

A

TM perforation + otorrhoea
Hearing loss
Labyrinthitis

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21
Q

What may unresolved acute otitis media with perforation progress to?

A

Chronic suppurative otitis media: perforation of TM with otorrhoea for >6w

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22
Q

List 4 complications of acute otitis media

A

Mastoiditis
Meningitis
Brain abscess
Facial nerve paralysis

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23
Q

How should acute otitis media with perforation be managed?

A

Oral amoxicillin 5 days

Review in 6w

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24
Q

What condition is known as ‘glue ear’?

A

Otitis media with effusion

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25
Q

List 6 risk factors for glue ear

A

Male
Siblings with glue ear
Winter/ Spring
Bottle feeding
Day care attendance
Parental smoking

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26
Q

What is the peak age of glue ear?

A

2y
Most common cause of CHL + elective surgery in childhood

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27
Q

How does glue ear usually present? What secondary problems may also be seen?

A

Hearing loss

Speech + language delay
Behavioural problems
Balance problems

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28
Q

How should glue ear be managed?

A

If no comorbidities: active observation for 6-12w, If no improvement: ENT referral
If co-existent cleft palate/ Down’s: ENT referral

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29
Q

What surgical options are available for glue ear?

A

Grommet insertion: allows air to pass into middle ear + do job normally done by Eustachian tube
Adenoidectomy

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30
Q

How long do grommets last?

A

10-12 months

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31
Q

What are the signs and symptoms of cholesteatoma?

A

Foul smelling, non-resolving discharge from ear
Hearing loss
Vertigo
Facial nerve palsy
Cerebellopontine angle syndrome

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32
Q

What is cholesteatoma?

A

Non-cancerous growth of squamous epithelium trapped in skull base causing local destruction
Most common in 10-20y
RF: Cleft palate

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33
Q

What do cholesteatomas often result from?

A

Chronic ear infections
Eustachian tube dysfunction

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34
Q

What is seen on otoscopy in cholesteatoma?

A

‘Attic crust’ seen in uppermost part of ear drum

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35
Q

How should cholesteatoma be managed?

A

Refer for surgery

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36
Q

Recall 4 drugs that can cause tinnitus

A

Aspirin
Aminoglycosides
Loop diuretics
Ethanol

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37
Q

What is the most concerning cause of unilateral tinnitus?

A

Acoustic neuroma

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38
Q

Recall 3 vestibular causes of vertigo

A

Meniere’s
BPPV
Labyrinthitis

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39
Q

Recall 5 central causes of vertigo

A 
Vestibular schwannoma
MS
Stroke
Head injury 
Inner ear syphillis
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40
Q

What is Meniere’s?

A

Dilatation of endolymph spaces of membranous labyrinth

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41
Q

What are the symptoms of Meniere’s?

A

Clustered attacks lasting mins-hours
Recurrent episodes of vertigo, tinnitus + SNHL
Aural fullness/ pressure
N+V
Nystagmus + positive Romberg test

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42
Q

How is Meniere’s managed?

A

ENT assessment to confirm Dx
Patients should inform DVLA + stop driving until satisfactory control of Sx

Acute: Buccal/ IM Prochlorperazine

Prevention: Betahistine + vestibular rehabilitation

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43
Q

What are the symptoms of viral labyrinthitis/ vestibular neuronitis?

A

Severe vertigo, nystagmus + vomiting following an URTI

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44
Q

How can you differentiate between vestibular neuronitis and viral labyrinthitis clinically?

A

Hearing may be affected in viral labyrinthitis but isn’t in vestibular neuronitis

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45
Q

How can vestibular neuronitis be differentiated from posterior circulation stroke?

A

HiNTS exam
(Head impulse, Nystagmus and Test of Skew)
Peripheral vertigo: abnormal Hi, no/ unidirectional N + no vertical skew
Central vertigo: normal Hi, vertical/ saccadic N, vertical skew

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46
Q

How should viral labyrinthitis/ vestibular neuronitis be managed?

A

If severe: IV prochlorperazine

If less severe: PO cyclizine and prochlorperazine

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47
Q

Give 4 signs and symptoms of vestibular neuronitis

A

Recurrent vertigo attacks: hours-days
N+V
Horizontal nystagmus
NO hearing loss or tinnitus

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48
Q

Describe management of vestibular neuronitis

A

Mild: Short course PO Prochlorperazine/ antihistamine e.g. cyclizine, promethazine

Severe: Buccal/ IM Prochlorperazine (rapid relief)

Chronic Sx: vestibular rehabilitation exercises

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49
Q

What is BPPV? What is the pathophysiology?

A

disorder of inner ear characterised by repeated episodes of positional vertigo
Otoconia (crystals) dislodge + migrate into semi-circular canals, disrupting endolymph dynamics, causing motion of fluid, inducing vertigo
Posterior semi-circular canal affected in 85-95%

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50
Q

List 3 precipitants to BPPV

A

Head injury
Ear surgery
Post-inner ear pathology e.g. Meniere’s, labrynthitis, vestibular neuronitis

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51
Q

Describe the vertigo in BPPV

A

Sx brought on by specific movements/ positions of head
Transient; <60s
N+V may occur
Lightheadedness/ imbalance persist

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52
Q

Name 2 symptoms that do NOT occur in BPPV

A

Hearing loss
Tinnitus

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53
Q

How can BPPV be diagnosed?

A

Dix-Hallpike manoevre:
Rapidly lower patient to supine position with extended neck
Provokes vertigo + torsional (rotatory) upbeating nystagmus

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54
Q

How can BPPV be managed?

A

Resolves in weeks-months
Symptomatic relief with:
* Epley manoevre
* Vestibular rehabilitation (patient exercises e.g. Brandt-Daroff)

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55
Q

What medication is often prescribed in BPPV, but is of limited value?

A

Betahistine
Vasodilates + improves blood flow to inner ear

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56
Q

Prognosis in BPPV

A

Often relapsing-remitting
~50% have recurrence 3-5y after dx

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57
Q

What is acoustic neuroma also known as?

A

Vestibular schwannoma

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58
Q

What are acoustic neuromas?

A

Benign tumours arising from Schwann cells
Primarily originate within vestibular portion of CN VIII
Form in internal acoustic canal with variable extension into cerebellopontine angle

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59
Q

What are the symptoms of acoustic neuroma?

A

Slow-onset, unilateral SNHL
Tinnitus
Vertigo
Absent corneal reflex

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60
Q

How can clinical features of acoustic neuroma be predicted by cranial nerve involvement?

A

CN V: absent corneal reflex
CN VII: Facial palsy
CN VIII: Vertigo, unilateral SNHL, unilateral tinnitus

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61
Q

In which condition are bilateral acoustic neuromas seen in?

A

Neurofibromatosis type 2

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62
Q

How should possible acoustic neuroma be investigated?

A

Contrast MRI of cerebellopontine angle
Pure tone audiometry: >90% have some type of HL

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63
Q

Describe management of acoustic neuromas

A

Observation (MRI every 6-12m): small tumours/ minimal HL
Surgery/ Radiotherapy: large tumours/ significant hearing los

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64
Q

Give 4 signs and symptoms of impacted earwax

A

Pain
Conductive HL
Tinnitus
Vertigo

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65
Q

Describe management of impacted ear wax

A

Olive oil drops
(or sodium bicarbonate 5% or almond oil)
Irrigation (ear syringing)

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66
Q

What is otosclerosis?

A

Replacement of normal bone by vascular spongy bone
Causes progressive conductive HL due to fixation of the stapes at the oval window
Autosomal dominant
Onset 20-40y

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67
Q

What are the symptoms of otosclerosis?

A

BL conductive HL
Tinnitus
Hearing loss improves with noise but worsens with pregnancy, menstruation, menopause

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68
Q
A
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69
Q

Describe the appearance of the tympanic membrane in otosclerosis

A

Majority normal
10% have ‘flamingo tinge’ caused by hyperaemia

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70
Q

How should otosclerosis be managed?

A

Hearing aid, stapes implant

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71
Q

What is Presbycusis?

A

Age related sensorineural hearing loss

High freq. hearing affected bilaterally- difficulty in conversation in noisy environments

Progresses slowly- atrophy of sensory hair cells + neurones in cochlea over time

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72
Q

List 6 contributory factors to Presbycusis

A

Arteriosclerosis: diminished perfusion + oxygenation of cochlea

Diabetes: acceleration of arteriosclerosis

Accumulated exposure to noice

Drugs: salicylates, chemo

Stress

Genetics: predisposed to early ageing of auditory system

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73
Q

Give 5 features of presentation of presbycusis

A

Speech difficult to understand
Need for increased vol on TV/ radio
Difficulty using phone
Loss of directionality of sound
Worsening of Sx in noisy environments

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74
Q

What are 2 less common symptoms of presbycusis?

A

Hyperacusis: heightened sensitivity to certain freq of sound
Tinnitus

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75
Q

What sign may be found in presbycusis?

A

Possible Weber’s test BC localisation to 1 side if SNHL not completely bilateral

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76
Q

What 4 investigations should be performed in presbycusis?

A

Otoscopy: Normal, to r/o otosclerosis, cholesteatoma + conductive HL (FB, impacted wax etc.)

Tympanometry: Normal middle ear function with hearing loss (Type A)

Audiometry: Bilateral SNHL pattern

Blood tests inc. inflammatory markers + specific antibodies: Normal

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77
Q

Give 3 features of audiogram in presbycusis

A

Bilateral impairment
High frequency hearing loss
Downward-sloping pure tone thresholds

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78
Q

How should sudden SNHL be managed?

A

Refer to ENT in <24h
High dose PO prednisolone
MRI to r/o vestibular schwannoma

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79
Q

Give 5 causes of sudden onset sensorineural hearing loss

A

Idiopathic (most common)
AI: Behcets, SLE
Infection: bacterial meningitis, mumps, Lyme
Metabolic: diabetes, hypothyroidism
Neoplasm

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80
Q

In which patients are auricular haematomas most common? Why is prompt treatment needed? What does this involve?

A

Rugby players + wrestlers

To avoid formation of Cauliflower ear

Mx: same day ENT assessment + incision + drainage

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81
Q

What is chronic rhinosinusitis?

A

Inflammatory disorder of paranasal sinuses + linings of nasal passages >,12w

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82
Q

Give 5 pre-disposing factors for chronic rhinosinusitis

A

Atopy: hay fever, asthma
Nasal obstruction e.g. septal deviation, polyps
Recent local infection e.g. Rhinitis, dental extraction
Swimming/ diving
Smoking

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83
Q

Give 4 signs and symptoms of chronic rhinosinusitis

A

Facial pain: frontal pressure pain, worse on bending forward
Nasal discharge: clear if allergic/ vasomotor. thicker, purulent if secondary infection
Nasal obstruction: “mouth breathing”
Post-nasal drip: may produce chronic cough

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84
Q

How should recurrent/ chronic rhinosinusitis be managed?

A

Avoid causative allergen
Nasal irrigation with saline

Mild Sx: PRN oral antihistamine (eg cetirizine) + PRN intranasal antihistamine (eg azelastine)

Severe Sx:
Intranasal CS (eg beclomethasone)

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85
Q

What is acute sinusitis?

A

Inflammation of mucous membranes of paranasal sinuses
Most common organisms: Streptococcus pneumoniae, Haemophilus influenzae + rhinoviruses

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86
Q

List 4 predisposing factors to acute sinusitis

A

Nasal obstruction e.g. septal deviation/ polyps
Recent local infection e.g. rhinitis/ dental extraction
Swimming/ diving
Smoking

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87
Q

Give 3 signs and symptoms of acute sinusitis

A

Facial pain: frontal pressure pain, worse on bending forward
Nasal discharge: usually thick + purulent
Nasal obstruction

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88
Q

What are the red flags in sinusitis that would prompt an urgent ENT referral?

A

Unilateral Sx
Persistent Sx >3m despite Tx
Epistaxis

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89
Q

What are the indications for admission to hospital with sinusitis?

A 
Severe systemic infection 
Signs of dangerous complications of sinusitis eg: 
Periorbital/orbital cellulitis 
Meningitis 
Brain abscess
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90
Q

How should acute sinusitis be managed?

A

If Sx <10d: analgesia, advice + safety-netting
If Sx >10d: 14 day course of high-dose nasal corticosteroid
Abx PO for severe cases: phenoxymethylpenicillin

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91
Q

What is a ‘double-sickening’?

A

Initial period of recovery from viral sinusitis followed by worsening of Sx due to secondary bacterial sinusitis

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92
Q

What are nasal polyps?

A

benign lesions of nasal mucosa or paranasal sinuses due to chronic mucosal inflammation

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93
Q

Epidemiology of nasal polyps

A

1% adults
M > F
Not common in kids/ elderly

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94
Q

List 6 conditions associated with nasal polyps

A

Asthma (esp. late onset)
Aspirin sensitivity
Infective sinusitis
Cystic fibrosis
Kartagener’s syndrome
Churg-Strauss syndrome

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95
Q

What are 4 symptoms of nasal polyps?

A

Nasal obstruction
Watery anterior rhinorrhoea +/- post nasal drip
Sneezing
Poor sense of taste + smell

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96
Q

Describe management of nasal polyps

A

Refer all to ENT for assessment
Topical CS shrink polyps in 80%

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97
Q

What is Samter’s triad?

A

Triad of nasal polyps, asthma + aspirin hypersensitivity

If person has nasal polyps + asthma, advise to avoid NSAIDs + aspirin as could cause a life-threatening reaction

98
Q

What would make nasal polyps seem concerning?

A

If single + unilateral
Assumed neoplastic until proven otherwise

99
Q

How should nasal polyps be managed?

A
  • Routine referral to ENT for exam
  • Medical: 4-6w course of topical steroids
  • Surgically: can be removed endoscopically
100
Q

What is a septal haematoma?

A

Complication of nasal trauma

Untreated nasal fracture –> septal necrosis + nasal collapse as cartillage blood supply comes from the mucosa

Haematoma between septal cartilage + overlying perichondrium.

101
Q

Give 3 signs and symptoms of nasal septal haematoma

A

Sensation of nasal obstruction (most common Sx)
Pain + rhinorrhoea
Classically a bilateral, red swelling arising from the nasal septum

102
Q

How is a nasal septal haematoma differentiated from a deviated septum?

A

Gently probing the swelling.
Nasal septal haematomas = boggy
Septums = firm

103
Q

What is the management for nasal septal haematoma?

A

Surgical drainage
IV Abx

104
Q

What results if nasal septal haematoma goes untreated?

A

Irreversible septal necrosis develops within 3-4 days
Due to pressure-related ischaemia of cartilage resulting in necrosis
May result in a ‘saddle-nose’ deformity

105
Q

How should all nosebleeds be initially managed?

A

Sit up
Lean forwards
Mouth open
Compress nasal cartilage for 15 mins

106
Q

Describe the aetiology of tonsillitis

A

Viral 50-80%
Bacterial 15-30%

107
Q

What are the 2 most common causes of tonsilitis?

A

Viral: EBV
Bacterial: GAS

GAS: Streptococcus pyogenes

108
Q

List 4 s/s of bacterial tonsillitis

A

Sudden onset fever, sore throat, dysphagia
Inflamed pharynx: erythema, oedema, exudates
Cervical lymphadenitis
Absence of cough

109
Q

Give 5 s/s of viral tonsillitis

A

Coryza: cough, runny nose
Absence of fever
Conjunctivitis
Diarrhoea
Oral ulcers, anterior stomatitis

110
Q

When can the Centor criteria be used?

A

Only with recent onset (,<3 days) acute pharyngitis

111
Q

Describe the Centor criteria

A

Cough absent
Exudate/ swelling on Tonsils
Node enlargement (Tender/ swollen anterior cervical LNs)
Temperature >38
OR young (3-14y= +1) or old (>44y = -1)

M-CENTOR
M= Must be older than 3y + have presented in ,<3 days

112
Q

What does each score in the Centor criteria indicate?

A

0-2: 3-17% likelihood. No Abx.
3-4: 32-56% likelihood. Rapid strep test + Abx

113
Q

Describe the components of the FeverPAIN score

A

FEVER: during previous 24h
PURULENCE: pharyngeal/ tonsilar exudate
ATTEND rapidly: within 3 days
INFLAMED: severely inflamed tonsils
NO Cough or coryza (inflammation of mucous membranes in nose)

114
Q

What does each score in FeverPain indicate?

A

0-1: 13-18% likelihood. No Abx
2-3: 34-40% likelihood. Delayed Abx
4-5: 62-65% likelihood. Immediate Abx

Likelihood of isolating streptococci

115
Q

What investigations may be used in suspected bacterial tonsillitis?

A

Rapid strep test if >3y + Centor >2
Throat culture in kids to r/o GAS

Throat culture deferred in adults w/o RFs for GAS infection since their risk of subsequent acute rheumatic fever is low.

116
Q

What is the most common cause of infectious mononucleosis?

A

Epstein-Barr virus

117
Q

What is the classic triad of signs/ symptoms seen in infectious mononucleosis?

A

Sore throat
Pyrexia
Lymphadenopathy: anterior + posterior triangles of neck

118
Q

In addition to the classic triad, what are 5 other symptoms/ signs of infectious mononucleosis?

A

Malaise
Anorexia
Headache
Petechiae on soft palate
Splenomegaly

119
Q

What investigations are used for infectious mononucleosis?

A

Heterophil antibody test (Monospot test)
FBC

NICE suggest FBC + monospot in 2nd week of illness

120
Q

Give 3 abnormalities/ features of bloods in infectious mononucleosis

A

Hepatitis: transient rise in ALT
Lymphocytosis with at least 10% atypical lymphocytes
Haemolytic anaemia secondary to cold agglutins (IgM)

121
Q

Describe management of infectious mononucleosis

A

Supportive
Rest, fluids
Simple analgesia
Avoid alcohol
Avoid contact sports for 4w to reduce risk of splenic rupture

122
Q

What reaction occurs to patients given a certain antibiotic whilst they have infectious mononucleosis? What is the antibiotic?

A

Maculopapular, pruritic rash

Ampicillin/ Amoxicillin

123
Q

What antibiotic is used in bacterial tonsilitis? What is given to penicillin-allergic individuals?

A

Phenoxymethylpenicillin
Clarithromycin if pen allergic
7-10 days

124
Q

How does diptheria classically appear?

A

Pseudomembranous ‘web’ at back of throat

125
Q

When would you admit for tonsilitis?

A
  • Difficulty breathing
  • Clinical dehydration
  • Peri-tonsillar abscess (quinsy) or cellulitis
  • Marked systemic illness or sepsis
  • Suspected rare cause (e.g. Kawasaki disease, diphtheria)
126
Q

Name 3 complications of tonsilitis

A

Peritonsillar abscess (Quinsy)
Otitis media
Rheumatic fever + glomerulonephritis (very rarely)

127
Q

Give 4 signs and symptoms of quinsy

A

Severe throat pain which lateralises to 1 side
Deviation of uvula to unaffected side
Trismus (difficulty opening mouth)
Reduced neck mobility

128
Q

What is the management for quinsy?

A

Urgent ENT review
Needle aspiration or I+D
IV Abx
Tonsillectomy considered to prevent recurrence

129
Q

How frequent does tonsilitis have to be to indicate tonsillectomy?

A

7 bouts in 1y
5 bouts/ year for 2y
3 bouts/year for 3y

130
Q

Other than number of episodes of tonsillitis, give 3 indications for tonsillectomy

A

Recurrent febrile convulsions secondary to tonsillitis
OSA, stridor or dysphagia secondary to large tonsils
Quinsy unresponsive to standard Tx

131
Q

What are the complications of tonsillectomy?

A

Primary (<24h): haemorrhage (mostly due to inadequate haemostasis), pain
Secondary (>24h-10d): haemorrhage (mostly due to infection), pain

132
Q

How should post-tonsillectomy haemorrhage be managed?

A

All assessed by ENT
Primary (<24h, mostly 6-8h): Immediate return to theatre

Secondary (>24h, mostly 5-10d): often a/w wound infection. Admission + co-amoxiclav. May require surgery

133
Q

What are the signs that GAS infection has progressed to scarlet fever?

A

Rash (‘sandpaper’)

Strawberry tongue

134
Q

What is the risk of scarlet fever?

A

May progress to rheumatic fever with a week latency period

135
Q

How should scarlet fever be managed?

A

Notify PHE

Phenoxymethylpenicillin

136
Q

What is the main RF for tonsilar SCC?

A

HPV infection

137
Q

What are the symptoms of Bell’s palsy?

A

UL facial weakness
Otalgia
Ageusia (loss of taste)
Hyperacusis (due to stapedius palsy)

138
Q

What is Bell’s sign?

A

Failure of eye closure –> dryness and conjunctivitis

Seen in Bell’s palsy

139
Q

How should Bell’s palsy be investigated?

A

Serology, possible LP

140
Q

How should Bell’s palsy be managed?

A

Eye care

Prednisolone (50mg PO OD for 10 days)

141
Q

What is the aetiology of RamsayHunt syndrome?

A

Reactivation of the varicella zoster virus in the genticulate ganglion of CNVII

142
Q

What are the symptoms of Ramsay Hunt syndrome?

A

Otalgia
Facial nerve palsy
Vesicular rash around ear
Vertigo + tinnitus

143
Q

Where a re vesicular lesions seen in Ramsay hunt syndrome?

A

External auditory canal + pinna (classically)

Anterior 2/3 of tongue + soft palate (less common)

144
Q

How should Ramsay Hunt syndrome be managed?

A

Aciclovir/ Valaciclovir PO
Steroids PO
If treated within 72h, 75% recover, otherwise only 1/3 fully recover

145
Q

If a small parotid lump enlargens very quickly, what is the likely cause?

A

Stone that has blocked parotid duct

146
Q

Give 3 causes of a perforated tympanic membrane

A

Infection (most common)
Barotrauma
Direcr trauma

147
Q

How long after a TM perforation should a referral to ENT be made if it hasn’t healed? What may be performed in this case?

A

6-8w (avoid getting water in ear)

Myringoplasty (closes hole)

148
Q

Recall some differentials for the cause of salivary gland swelling

A 
Infective (TB/mumps) 
Neoplastic 
Calculi blockage 
Autoimmune (Sjogren's/IgG4) 
Sarcoidosis
149
Q

How is a pharyngeal pouch managed?

A

Surgical repair with minimally-invasive stapling (Dohlman’s procedure)

150
Q

What are the symptoms of pharyngeal pouch?

A

Hallitosis

Food getting stuck

151
Q

What are the FeverPAIN criteria?

A

Fever (during previous 24h)

Purulence (pus on tonsils)

Attend rapidly (within 3 days after onset of Sx)

severely Inflamed tonsils

No cough or coryza

152
Q

Recall the 2 most common pathogens in otitis externa

A

Staph aureus
Pseudomonas aeruginosa

153
Q

Give 4 symptoms of otitis externa

A

Itch of ear canal
Ear pain
Discharge
Conductive HL (less common)

154
Q

Give 4 signs of otitis externa

A

Tenderness of tragus +/- pinna
Red, oedematous, eczematous canal
TM erythema
Cellulitis of pinna + adjacent skin

155
Q

Describe initial management of otitis externa

A

TOP Abx or combined TOP Abx + steroid 7-14d

If TM perforated, dont use aminoglycoside

Consider removal of canal debris

Insert ear wick if canal v swollen

156
Q

Describe second line management of otitis externa

A

Refer to ENT
Consider contact dermatitis secondary to neomycin
Flucloxacillin PO if infection spreading
Swab inside canal
Antifungal empirically

157
Q

How should necrotising otitis externa be managed?

A

Admit
Tazocin

158
Q

Name 3 complications of otitis media

A

Facial nerve palsy
Chronic perforation
Mastoiditis

159
Q

When does mastoiditis typically develop? What is the most common causative organism?

A

When an infection spreads from the middle ear to mastoid air spaces
Strep pneumoniae

160
Q

Give 6 signs and symptoms of mastoiditis

A

Otalgia: severe, classically behind ear
Fever, v unwell
Post-auricular inflammation + erythema
Ear proptosis
Discharge if eardrum perforated
+/- Hx of recurrent otitis media

161
Q

How is mastoiditis diagnosed? Describe management

A

Clinical dx
+/- CT if complications suspected

Emergency Tx with IV Abx

162
Q

List 3 complications of mastoiditis

A

Facial nerve palsy
Hearing loss
Meningitis

163
Q

What is Ludwig’s angina?

A

Rapidly spreading infection of submandibular space
Classically “woody” to touch
Causes neck pain and drooling

164
Q

6 predisposing factors to otitis externa

A

Swimming

Skin conditions Seborrhoeic dermatitis, eczema, psoriasis

Contact dermatitis (allergic + irritant): neomycin, shampoos, ear buds

Diabetes

FB, hearing aids, ear plugs

Trauma inc. cotton buds

165
Q

What type of mouth ulcer is typically described as centralised white ulcer and erythematous “halo”?

A

Apthous ulcers

166
Q

What is this a typical history for?

“an indurated ulcer involving the lateral tongue in a patient with a long-term smoking history”

A

Squamous cell carcinoma

167
Q

What is Heerfordt’s syndrome?

A

Rare manifestation of sarcoidosis characterized by the presence of facial nerve palsy, parotid gland enlargement, anterior uveitis, + low grade fever

Source: Capsule case 145

168
Q

What is the most common type of parotid malignancy in adults?

A

Mucoepidermoid tumours

169
Q

What is Warthin’s tumour?

A

Benign parotid tumour that typically appears in older male smokers

170
Q

What is a pleomorphic adenoma?

A

benign tumour of parotid gland.
most common tumour of parotid
Typically in 40-60y.
aka: benign mixed tumour

171
Q

Describe the pathophysiology of pleomorphic adenoma

A

Proliferation of epithelial + myoepithelial cells of the ducts + an increase in stromal components

Slow-growing, lobular, + not well encapsulated

172
Q

Give 2 features of pleomorphic adenoma

A

Gradual onset, painless unilateral swelling of parotid gland
Mobile OE (rather than fixed)

173
Q

Describe management and prognosis of pleomorphic adenoma

A

Mx: surgical excision
Prognosis:
Recurrence rate 1-5% with parotidectomy
Malignant transformation if not removed in 2-10%

174
Q

Describe anterior bleed epistaxis

A

Visible source; usually due to insult to network of capillaries that form Kiesselbach’s plexus

175
Q

Give 4 features of posterior bleed epistaxis

A

More profuse
Originate from deeper structures
More common in elderly
Higher risk of aspiration + airway compromise

176
Q

Describe the first aid measures used for epistaxis in a haemodynamically stable patient

A

Sit with torso forward + mouth open- decreases blood flow to nasopharynx, allows patient to spit blood + reduces risk of aspiration
Pinch soft area of nose firmly for 20 mins
Breathe through mouth

177
Q

What topical antiseptic may be used alongside first aid measures for epistaxis? Why? What are contraindications to this?

A

Naseptin (Chlorhexidine + Neomycin)
Reduces crusting + risk of vestiubulitis
CI: peanut, soy or neomycin allergy
Alternative: Mupirocin

178
Q

In which patients with controlled epistaxis should admission be considered?

A

If comorbidity present (e.g. coronary artery disease, severe HTN)
If <2y as more likely due to haemophilia or leukaemia

179
Q

What self-care advice should be given to reduce risk of re-bleeding after epistaxis?

A

Avoid:
- blowing/ picking nose
- heavy lifting
- exercise
- lying flat
- alcohol + hot drinks

180
Q

When is cautery indicated for epistaxis?

A

If continuous bleeding after 10-15 mins pressure + if source is visible

181
Q

Describe cautery for epistaxis

A

Ask to blow their nose to remove any clots (bleeding may resume)
Use LA spray (e.g. Co-phenylcaine) and wait 3-4 mins for it to take effect
Identify bleeding point + apply silver nitrate stick for 3-10s until it becomes grey-white.
Avoid touching areas which do not require Tx
Only cauterise 1 side of septum (risk of perforation)
Dab area clean with a cotton bud + apply Naseptin or Muciprocin

182
Q

Describe packing for epistaxis

A

Anaesthetise with LA spray (e.g. Co-phenylcaine) + wait for 3-4 mins
Pack nose while they sit with their head forward, following manufacturer’s instructions
Pressure on cartilage around nostril can cause cosmetic changes + should be reviewed after inserting the pack.
Examine mouth + throat for any continuing bleeding, + consider packing other nostril as this increases pressure on the septum + offending vessel.
Admit for observation + review, + to ENT if pos

183
Q

What surgical management can be used for epistaxis that has failed all emergency management?

A

Sphenopalatine ligation

184
Q

List 3 products that can be used for nasal packing

A

Nasal tampon
Inflatable pack e.g. Rapid-Rhino
Ribbon gauze impregnated with vaseline

185
Q

What is binocular vision post-facial trauma indicative of?

A

Depressed fracture of zygoma

186
Q

What intranasal treatments are used for the treatment vs prophylaxis of sinusitis?

A

Tx: intranasal decongestant
Prophylaxis: intranasal corticosteroid

187
Q

4 features of Thyroglossal cyst

A

Midline
Non-tender (can be tender if infected)
Mobile
Moves up with protrusion of tongue

188
Q

What are exostoses?

A

Benign bony growths in external auditory canal
Due to repeated exposure to cold water + wind
Causes conductive hearing loss

189
Q

List 3 potential complications following thyroid surgery

A

Anatomical: recurrent laryngeal nerve damage

Bleeding: owing to confined space, haematomas may lead to rapid respiratory compromise due to laryngeal oedema

Damage to parathyroid glands resulting in hypocalcaemia

190
Q

List 6 indications to refer make 2ww referral to oral surgery

A

ue oral ulceration/ mass persisting >3w
ue red/ red+ white patches that are painful, swollen or bleeding
ue 1 sided pain in H+N area >4w a/w earache but no abnormal findings on otoscopy
ue recent neck lump/ previously undiagnosed lump that has changed over 3-6w
ue persitent sore/ painful throat
S/S in oral cavity persisting >6w that can’t be definitively diagnosed as a benign lesion

UE = unexplained

191
Q

What abnormality in ECG timing may be caused by hypocalcaemia?

A

Prolonged QT interval

192
Q

Give 2 indications to refer under 2ww for potential laryngeal cancer

A

Persistent unexplained HOARSENESS
Unexplained LUMP in the neck

193
Q

Give 2 indications to refer under 2ww for potential oral cancer

A

Unexplained ULCERATION in oral cavity lasting >3w
Persistent + unexplained LUMP in neck

194
Q

Give 2 indications to refer to a DENTIST under 2ww for potential oral cancer

A

LUMP on lip or in oral cavity

Red or Red + white patch in oral cavity consistent with erythroplakia or erythroleukoplakia

195
Q

Give 1 indications to refer under 2ww for potential thyroid cancer

A

Unexplained thyroid lump

196
Q

Give 1 indication to refer under 2ww for potential nasopharyngeal cancer

A

Hearing loss + unilateral middle ear effusion not related to URTI in a Chinese or SE Asian patient

197
Q

What is malignant otitis externa?

A

Uncommon type of otitis externa
Infection commences in soft tissues of external auditory meatus, progresses to temporal bone osteomyelitis

198
Q

What is the most common cause of malignant otitis externa?

A

Pseudomonas aeruginosa

199
Q

Give 2 risk factors for malignant otitis externa

A

Diabetes (90% cases)
Immunosuppression

200
Q

Give 8 signs and symptoms of malignant otitis externa

A

Severe, unrelenting, deep-seated otalgia
Purulent otorrhea
Profound conductive HL
Vertigo
Ipsilateral facial nerve palsy
Temporal headaches
Systemically unwell, fever
+/- Dysphagia + Hoarseness

201
Q

What investigation is used for malignant otitis externa?

A

CT

202
Q

Describe management of malignant otitis externa

A

Urgent referral to ENT
IV Abx that cover pseudomonal infections

203
Q

4 causes of epiglottitis

A

Haemophilus influenzae B (traditionally)
Streptococcus pyogenes
Streptococcus pneumoniae
Staphylococcus aureus

204
Q

Give 8 signs and symptoms of epiglottitis

A

Rapid onset sore throat
Fever
Inspiratory stridor
Drooling of saliva
Dysphagia
‘Tripod’ position
Toxic appearance
“Hot potato” voice

205
Q

What investigations are performed in epiglottitis?

A

Clinical dx
Do NOT examine throat
If X-ray is performed, lateral view: swelling of epiglottis = ‘thumb sign’

206
Q

Describe management of epiglottitis

A

Immediate senior involvement: anaesthetists, ENT
+/- endotracheal intubation

IV Abx: Cefotaxime, Ceftriaxone

O2

207
Q

Describe the epidemiology of epiglottitis

A

Adults > Children (since HiB vaccine)
Peak in kids 6-12y
Peak in adults 40-50y

208
Q

What is a Branchial cyst?

A

Benign developmental defect in branchial arches
Filled with acellular fluid with cholesterol crystals
Encapsulated by stratified squamous epithelium

209
Q

When do branchial cysts usually present?

A

Late childhood-early adulthood

210
Q

Give 6 features of branchial cysts

A

Unilateral (typically LHS)
Lateral, anterior to sternocleidomastoid
Slowly enlarge
Smooth, soft, fluctuant
Non tender
Fistula may be seen (RF for infection)

211
Q

Give 2 features on examination of a branchial cyst

A

No movement on swallowing
No transillumination

212
Q

Describe investigations and management for branchial cysts

A

Consider + r/o malignancy
USS
ENT referral
FNA

Mx: conservative/ surgical excision
Abx for infections

213
Q

What is the most common cause of neck swellings?

A

Reactive lymphadenopathy
Hx local infection or generalised viral illness

214
Q

Give 3 features of lymphoma neck lumps

A

Rubbery, painless
Pain on drinking alcohol is RARE
+/- night sweats + splenomegaly

215
Q

Give 2 features of thyroid swellings

A

Hypo-, Eu- or Hyper-thyroid
Moves UP on swallowing

216
Q

Give 4 features of thyroglossal cyst neck lumps

A

More common in <20s
Usually midline, between isthmus of thyroid + hyoid bone
Moves up with protrusion of tongue
+/- pain if infected

217
Q

In which group is pharyngeal pouch more common?

A

Older men

218
Q

What does a pharyngeal pouch represent?

A

Posteromedial herniation between thyropharyngeus + cricopharyngeus muscles

219
Q

Describe the appearance of pharyngeal pouches

A

Usually not seen
If large: midline lump that gurgles on palpation

220
Q

Give 4 signs/ symptoms experienced with a pharyngeal pouch

A

Dysphagia
Regurgitation
Aspiration
Chronic cough

221
Q

What is a cystic hygroma?

A

Congenital lymphatic lesion (Lymphangioma) typically in neck on LHS
Most evident at birth: 90% present before 2y

222
Q

If a cystic hygroma was aspirated, what would be found?

A

Lymph

223
Q

Give 2 features of cervical ribs

A

More common in adult females
~10% develop thoracic outlet syndrome

224
Q

Describe the appearance of a carotid aneurysm

A

Pulsative lateral neck mass
Doesn’t move on swallowing

225
Q

What type of hearing loss is seen in:
* tympanic membrane perforation
* base of skull fracture

(after trauma to the head)

A

TM perforation: CHL
Base of skull #: SNHL

226
Q

What is Wallenberg syndrom? How does it present?

A

Posterior inferioer cerebellar artery stroke
Vertigo
Nystagmus
Ipsilateral facial pain
Contralateral loss of temperature sensation

227
Q

Describe obstructive sleep apnoea

A

recurrent episodes of complete or partial obstruction of upper airway during sleep, causing apnoea (complete airflow obstruction with temporary absence or cessation of breathing) or hypopnoea (decreased airflow)

228
Q

How does obstructive sleep apnoea differ from obstructive sleep apnoea syndrome?

A

OSA: irregular breathing at night, no Sx
OSAS: irregular breathing at night + excessive daytime sleepiness

229
Q

Give 6 predisposing factors for obstructive sleep apnoea

A

Male
Obesity
FH
Macroglossia: acromegaly, hypothyroidism, amyloidosis
Adenotonsillar hypertrophy
Craniofacial abnormalities

230
Q

List 3 lifestyle factors that may contribute to obstructive sleep apnoea

A

Smoking
Alcohol
Sleeping supine

231
Q

List 3 consequences of obstructive sleep apnoea

A

Daytime somnolence
Compensated respiratory acidosis
HTN

232
Q

How can sleepiness be assessed in suspected obstructive sleep apnoea?

A

Epworth Sleepiness scale: questionnaire
STOP-Band questionnaire
Multiple Sleep Latency Test: measures time to fall asleep in dark room

233
Q

What investigations are used in obstructive sleep apnoea?

A

Refer to sleep clinic
Sleep studies (polysomnography)

234
Q

List 3 specialist treatments for obstructive sleep apnoea in adults

A

CPAP (mod-sev)
Mandibular advancement device (mild)
Upper airway surgery (if nasopharyngeal obstruction causing Sx)

235
Q

Name 2 specialist treatments for obstructive sleep apnoea in children

A

Adenotonsillectomy: if hypertrophy- usually curative
CPAP

236
Q

List 4 conservative measures for obstructive sleep apnoea

A

Weight loss
Smoking cessation
Reducing alcohol intake
Avoid sleeping on back (use pillows to prop on side)

237
Q

What is allergic rhinitis?

A

Inflammatory disorder of nose where nose becomes sensitised to allergens e.g. house dust mites + grass, tree + wood pollens

238
Q

How can allergic rhinitis be classified?

A

Seasonal: Sx occur around same time each year
Perennial: Sx throughout year
Occupational: Sx following exposure to allergens in workplace

239
Q

Give 5 s/s of allergic rhinitis

A

Sneezing
Bilateral nasal obstruction
Clear nasal discharge
Post-nasal drip
Nasal pruritis

240
Q

Describe management of allergic rhinitis

A

Allergen avoidance
Mild-mod: Antihistamines PO/ intranasal
Mod-sev: CS intranasal
Important life events: short course CS PO

YR6 Rotations (22 decks)

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