Surgery ENT 2 Flashcards
Quinsy is the common name for a
peritonsillar abscess
When can peritonsillar abscess arise?
Peritonsillar abscess arises when there is a bacterial infection with trapped pus, forming an abscess in the region of the tonsils.
What are peritonsillar abscess usually a complication of ?
Peritonsillar abscesses are usually a complication of untreated or partially treated tonsillitis, although it can arise without tonsillitis.
Presentation of Quinsy
Patients present with similar symptoms to tonsillitis:
- Sore throat
- Painful swallowing
- Fever
- Neck pain
- Referred ear pain
- Swollen tender lymph nodes
Additional symptoms that can indicate a peritonsillar abscess include:
- Trismus, which refers to when the patient is unable to open their mouth
- Change in voice due to the pharyngeal swelling, described in textbooks as a “hot potato voice”
- Swelling and erythema in the area beside the tonsils on examination
Quinsy is usually due to a bacterial infection. The most common organism is ______________ __________, but it is also commonly caused by ________________ ________ and _____________ ________.
Quinsy is usually due to a bacterial infection. The most common organism is streptococcus pyogenes (group A strep), but it is also commonly caused by staphylococcus aureus and haemophilus influenzae.
Management for Quinsy?
Patients should be referred into hospital under the care of the ENT team for incision and drainage of the abscess under general anaesthetic.
Quinsy typically has an underlying bacterial cause, therefore antibiotics are appropriate before and after surgery. A broad spectrum antibiotic such as co-amoxiclav would be an appropriate choice to cover the common causes, but local guidelines will guide antibiotic choice according to local bacterial resistance.
Some ENT surgeons give steroids (i.e. dexamethasone) to settle inflammation and help recovery, although this is not universal.
What should you always do if you have an infant younger than 3 months with a temp above 38ºC or 3 – 6 months with a temperature higher than 39ºC.
Always refer for specialist assessment and to consider admission
What is Glue Ear also known as?
otitis media with effusion
What is GLue ear
The middle ear becomes full of fluid, causing a loss of hearing in that ea
Cause of Glue Ear
The Eustachian tube connects the middle ear to the back of the throat. It helps drain secretions from the middle ear. When it becomes blocked, this causes middle ear secretions (fluid) to build up in the middle ear space
What is the main symptom of Glue Ear?
The main symptom of glue ear is a reduction in hearing in that ear.
What is the main complication of Glue Ear?
The main complication of glue ear is infection (otitis media).
What will show on Otoscopy with Glue Ear?
dull tympanic membrane with air bubbles or a visible fluid level, although it can look normal.
Management for Glue Ear
Referral for audiometry to help establish the diagnosis and extent of hearing loss. Glue ear is usually treated conservatively, and resolves without treatment within 3 months. Children with co-morbidities affecting the structure of the ear, such as Down’s syndrome or cleft palate may require hearing aids or grommets.
What are grommets?
Grommets are tiny tubes inserted into the tympanic membrane by an ENT surgeon. This allows fluid from the middle ear to drain through the tympanic membrane to the ear canal.
Usually grommets are inserted under general anaesthetic as a day case procedure. The procedure is relatively safe with few complications. Grommets usually fall out within a year, and only 1 in 3 patients require further grommets to be inserted for persistent glue ear.
common congenital causes of hearing loss in children
- Maternal rubella or cytomegalovirus infection during pregnancy
- Genetic deafness can be autosomal recessive or autosomal dominant
- Associated syndromes, for example Down’s syndrome
common perinatal causes of hearing loss in children
- Prematurity
- Hypoxia during or after birth
common after birth causes of hearing loss in children
- Jaundice
- Meningitis and encephalitis
- Otitis media or glue ear
- Chemotherapy
What is NHSP
**newborn hearing screening programme (NHSP) **
tests hearing in all neonates. This involves special equipment that delivers sound to each eardrum individually and checks for a response. This can identify congenital hearing problems early.
Presentation of hearing loss in children?
Children with hearing difficulties may present with parental concerns about hearing or with behavioural changes associated with not being able to hear:
- Ignoring calls or sounds
- Frustration or bad behaviour
- Poor speech and language development
- Poor school performance
What is used to differentiate conductive and sensorineural hearing loss.
Audiometry
What is a Audiogram?
Audiograms are charts that document the volume at which patients can hear different tones. The frequency in hertz (Hz) is plotted on the x-axis, from low to high pitched. The volume in decibels (dB) is plotted on the y-axis, from loud at the bottom to quiet at the top. It is worth noting that the lower down the chart, the higher the decibels and the louder the volume.
Explain the results of Audiogram
Hearing is tested to establish the minimum volume required for the patient to hear each frequency, and this level is plotted on the chart. The louder the sound required for the patient to hear, the worse their hearing is and the lower on the chart they will plot. For example, a 1000 Hz sound will be played at various volumes until the patient can just about hear the sound. If this sound is heard at 15 dB, a mark is made on the chart where 1000 Hz meets 15 dB. If this sound can only be heard at 80 dB, a mark is made where 1000 Hz meets 80 dB.
Hearing is tested in both ears separately. Both air and bone conduction are tested separately. The following symbols are used to mark each of these separate measurements:
X – Left sided air conduction
] – Left sided bone conduction
O – Right sided air conduction
[ – Right sided bone conduction
When a patient has normal hearing, all readings will be between
0 and 20 dB, at the top of the chart.
What will the audiogram show for sensorineural hearing loss,
In patients with sensorineural hearing loss, both air and bone conduction readings will be more than 20 dB, plotted below the 20 dB line on the chart. This may affect only one side, one side more than the other or both sides equally.
What will the audiogram show for conductive hearing loss,
In patients with conductive hearing loss, bone conduction readings will be normal (between 0 and 20 dB), however air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart. In conductive hearing loss, sound can travel through bones but is not conducted through air due to pathology along the route into the ear.
What will the audiogram show for mixed hearing loss
In patients with mixed hearing loss, both air and bone conduction readings will be more than 20 dB, however there will be a difference of more than 15 dB between the two (bone conduction > air conduction).
Management for hearing loss in children?
Establishing the diagnosis is the first step. After the diagnosis is established, input from the multidisciplinary team is required for support with hearing, speech, language and learning:
- Speech and language therapy
- Educational psychology
- ENT specialist
- Hearing aids for children who retain some hearing
- Sign language
What is the little’s area?
Kiesselbach’s plexus
Causes of Epitaxis?
They can be triggered by nose picking, colds, vigorous nose blowing, trauma and changes in the weather.
Why might children present with vomitting blood after a nosebleed?
They might have swalloed the blood during nosebleed
Are nosebleeds usally bilateral or unilateral?
Unilateral
What would bleeding from both nostrils suggest?
Bleeding is usually unilateral. Bleeding from both nostrils may indicated bleeding posteriorly in the nose.
Nosebleeds will usually resolve without needing any medical assistance. Recurrent and significant nosebleeds might require investigations to look for an underlying cause, such as
thrombocytopenia or clotting disorders
You may have to advise patients and parents on how to manage a nosebleed:
- Sit up and tilt the head forwards. Tilting the head backwards is not advised as blood will flow towards the airway.
- Squeeze the soft part of the nostrils together for 10 – 15 minutes
- Spit any blood in the mouth out rather than swallowing
What is classed as a severe nosebleed?
When bleeding does not stop after 10 – 15 minutes, the nosebleed is severe, from both nostrils or they are unstable, patients may require admission to hospital
What are the treatment options for severe nosebleed?
- Nasal packing using nasal tampons or inflatable packs
- Nasal cautery using a silver nitrate stick
What should you consider after treating severe nosebleed
After treating a nosebleed consider prescribing naseptin (chlorhexidine and neomycin) four times daily for 10 days to reduce any crusting, inflammation and infection. This is contraindicated in peanut or soya allergy.
What is a cleft lip?
Cleft lip is a congenital condition where there is a split or open section of the upper lip. This opening can occur at any point along the top lip, and can extend as high as the nose
What is cleft palate?
Cleft palate is where a defect exists in the hard or soft palate at the roof of the mouth. This leaves an opening between the mouth and the nasal cavity. Cleft lip and cleft palate can occur together or on their own.
Causes of cleft lip/palate?
Most cases of cleft lip and cleft palate occur randomly. Having a relative with cleft lip or palate makes it slightly more likely, however it does not follow a traditional inheritance pattern like conditions such as cystic fibrosis. 3 in 10 cases of cleft lip or palate are associated with another underlying syndrome.
Cleft lip or cleft palate complications?
Complications
Cleft lip or cleft palate is not life threatening, although it can lead to significant problems with feeding, swallowing and speech. It can also have significant psycho-social implications, including affecting bonding between mother and child. Surgery generally resolves these problems. Children with cleft palates can be more prone to hearing problems, ear infections and glue ear.
Management for cleft lip/palate?
- Patients should be referred to the local cleft lip services.
- The first priority is to ensure the baby can eat and drink. This may involve specially shaped bottles and teats. The specialist nurse will follow the child up through surgery and beyond to ensure good development.
- The definitive treatment is to surgically correct the cleft lip or palate. This leaves a subtle scar, but is generally very successful, giving full functionality to the child. Cleft lip surgery is usually performed at 3 months, whilst cleft palate surgery done at 6 – 12 months.
Who is involved in the cleft lip services?
- Specialist nurses to support and coordinate care
- Plastic, maxillofacial and ENT surgeons
- Dentists
- Speech and language therapists
- Psychologists
- General practitioners
Tongue Tie can also be known as?
ankyloglossia
What is ankyloglossia?
his is when a baby is born with a short and tight lingual frenulum, the attachment of the tongue to the floor of the mouth. This prevents them properly extending their tongue out of the mouth and makes it difficult for them to latch onto the breast. It usually presents as poor feeding or when noticed by the mother, midwife or doctor on newborn checks.
Management of ankyloglossia
Mild tongue tie can be monitored and would not be expected to cause any issues.
When it affect feeding they may benefit from treatment. Tongue tie can be cured with a frenotomy. This involves a trained person cutting the tongue tie. This can usually be done on the ward or in the clinic without any anaesthetic. Complications are very rare, and include excessive bleeding, scar formation and infection.
What is a Cystic Hygroma
A cystic hygroma is a malformation of the lymphatic system that results in a cyst filled with lymphatic fluid. It is most commonly a congenital abnormality and is typically located in the posterior triangle of the neck on the left side.
How do you diagnose Cystic Hygroma
It may be seen on antenatal scans, picked up on routine baby checks or discovered later when noticed incidentally.
Key Features of
Cystic hygromas
Cystic hygromas most commonly present in the neck or armpit. They:
- Can be very large
- Are soft
- Are non-tender
- Transilluminate
To transilluminate the cystic hygroma, hold a pen torch flat against the skin and watch as the whole thing lights up like a bulb.
Complications of Cystic Hygroma?
Depending on the location and size, cystic hygromas can interfere with feeding, swallowing or breathing. It can become infected, in which case it will turn red, hot and tender. There can be haemorrhage into the cyst.
Management of Cystic Hygroma?
Treatment varies based on the size, location and complications. Watching and waiting can be appropriate as it is a benign condition. They do not resolve spontaneously, but can show some regression.
Aspiration (giving temporary improvement), surgical removal and sclerotherapy are treatment options.
What is thyroglossal cyst.
During fetal development, the thyroid gland starts at the base of the tongue. From here it gradually travels down the neck to its final position in front of the trachea, beneath the larynx. It leaves a track behind called the thyroglossal duct, which then disappears. When part of the thyroglossal duct persists it can give rise to a fluid filled cyst. This is called a thyroglossal cyst.
What is a key differential for thyroglossal cyst
Ectopic thyroid tissue is a key differential diagnosis, as this commonly occurs at a similar location.
What is the main complication for Thyroglossal Cysts
The main complication is infection of the cyst, causing a hot, tender and painful lump.
Thyroglossal cysts Features?
Thyroglossal cysts usually occur in the midline of the neck. They are:
- Mobile
- Non-tender
- Soft
- Fluctuant
Thyroglossal cysts move up and down with movement of the tongue. This is a key feature that demonstrates a midline neck lump is a thyroglossal cyst. This occurs due to the connection between the thyroglossal duct and the base of the tongue.
TOM TIP: Remember the key feature of thyroglossal cysts moving with movement of the tongue. This is a unique fact examiners like to use to test your knowledge. Look out for a thyroglossal cyst as a differential of a neck lump in your MCQ exam. If you come across a midline neck lump in a young child in your OSCEs, ask them to stick their tongue out and look for the lump moving upwards.
Thyroglossal cysts Management
Thyroglossal cysts are usually **surgically removed **to provide confirmation of the diagnosis on histology and prevent infections. The cyst can reoccur after surgery unless the full thyroglossal duct is removed.
Thyroglossal cysts Diagnosis
Ultrasound or CT scan can confirm the diagnosis.
What is Branchial Cysts?
A branchial cyst is a congenital abnormality arising when the second branchial cleft fails to properly form during fetal development. This leaves a space surrounded by epithelial tissue in the lateral aspect of the neck. This space can fill with fluid. This fluid filled lump is called a branchial cyst. Branchial cysts arising from the first, third and fourth branchial clefts are possible, although they are much more rare.
Branchial cysts presentation?
Branchial cysts present as a round, soft, cystic swelling between the angle of the jaw and the sternocleidomastoid muscle in the anterior triangle of the neck.
Branchial cysts tend to present after the age of 10 years, most commonly in young adulthood when the cyst becomes noticeable or infected
How do you differentiate between Branchial cysts and Cystic Hygroma?
Branchial cysts may appear in exams as a differential of neck lumps in teenagers or as part of a neck examination in an OSCE. Remembering the key features will help you differentiate them in your exams. They are just anterior to the sternocleidomastoid muscle, round, soft and non-tender. If the lump transilluminates, it is more likely to be a cystic hygroma. They might ask you where it was most likely to originate, and the answer would be the second branchial cleft.
What is branchial cleft sinus
A branchial cleft sinus describes when the branchial cyst is connected via a tract to the outer skin surface. There will be a small hole visible in the skin beside the cyst. There may be a noticeable discharge from the sinus.
What is branchial pouch sinus
A branchial pouch sinus describes when the branchial cyst is connected via a tract to the oropharynx.
What is branchial fistula
A branchial fistula describes when there is a tract connecting the oropharynx to the outer skin surface via the branchial cyst.
Definition of a Fistula?
A fistula is an abnormal connection between two epithelial surfaces.
Management for Branchial Cyst?
Where the branchial cleft is not causing any functional or cosmetic issues, conservative management may be appropriate.
Where recurrent infections are occurring, there is diagnostic doubt about the cause of the neck lump or it is causing other functional or cosmetic issues, surgical excision may be appropriate
What is Sudden Sensorineural Hearing Loss
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
Conductive causes of rapid-onset hearing loss (not classed as SSNHL) include:
- 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
Can Sudden sensorineural hearing loss be permanent
With SSNHL, hearing loss is most often unilateral. It may be permanent or resolve over days to weeks.
Causes of Sudden Sensorineural Hearing Loss
Most cases (90%) of SSNHL are idiopathic, meaning no specific cause is found.
Other causes of SSNHL include:
- Infection (e.g., meningitis, HIV and mumps)
- Ménière’s disease
- Ototoxic medications
- Multiple sclerosis
- Migraine
- Stroke
- Acoustic neuroma
- Cogan’s syndrome (a rare autoimmune condition causing inflammation of the eyes and inner ear)
Investigations of Sudden Sensorineural Hearing Loss
Audiometry is required to establish the diagnosis. A diagnosis of SSNHL requires a loss of at least 30 decibels in three consecutive frequencies on an audiogram.
**MRI or CT head **may be used if a stroke or acoustic neuroma are being considered.
Management of Sudden Sensorineural Hearing Loss
The NICE clinical knowledge summaries (updated September 2019) recommend an immediate referral to ENT for assessment within 24 hours for patients presenting with sudden sensorineural hearing loss presenting within 30 days of onset.
Where an underlying cause is found (e.g., infection), treatment can be directed at this.
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)
What is vertigo
Vertigo is a descriptive term for a sensation that there is movement between the patient and their environment. They may feel they are moving or that the room is moving. Often this is a horizontal spinning sensation, similar to how you feel after turning in circles then stopping abruptly.
Vertigo is often associated with
nausea, vomiting, sweating and feeling generally unwell.
The sensory inputs that are responsible for maintaining balance and posture are:
Vision
Proprioception
Signals from the vestibular system
Vertigo is caused by a mismatch between these sensory inputs
how do you differentiate between peripheral and central vertigo
