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
What is inside the vestibular apparatus?
semicircular canals
the semicircular canals that are filled with
a fluid called endolymph
. These semicircular canals are oriented in different directions to detect various movements of the head. As the head turns, the fluid shifts inside the canals. This fluid shift is detected by tiny hairs called ________ found in a section of the canal called the ampulla.
. These semicircular canals are oriented in different directions to detect various movements of the head. As the head turns, the fluid shifts inside the canals. This fluid shift is detected by tiny hairs called stereocilia found in a section of the canal called the ampulla.
The vestibular nerve carries signals from the vestibular ________ to the vestibular ________ in the ________ and the _________
The vestibular nerve carries signals from the vestibular apparatus to the vestibular nucleus in the brainstem and the cerebellum
The vestibular nucleus then sends signals to the ____________, ____________ and ____________ nuclei that control eye movements and the thalamus, spinal cord and cerebellum
The vestibular nucleus then sends signals to the oculomotor, trochlear and abducens nuclei that control eye movements and the thalamus, spinal cord and cerebellum
Vertigo can be caused by either a:
- Peripheral problem, usually affecting the vestibular system
- Central problem, usually involving the brainstem or the cerebellum
There are several peripheral (vestibular) causes of vertigo. The four most common causes to be familiar with are:
- Benign paroxysmal positional vertigo
- Ménière’s disease
- Vestibular neuronitis
- Labyrinthitis
There are several other peripheral causes of vertigo. These are:
- Trauma to the vestibular nerve
- Vestibular nerve tumours (acoustic neuromas)
- Otosclerosis
- Hyperviscosity syndromes
- Varicella zoster infection (often with facial nerve weakness and vesicles around the ear – Ramsay Hunt syndrome)
Trauma to the vestibular nerve
Vestibular nerve tumours (acoustic neuromas)
Otosclerosis
Hyperviscosity syndromes
Varicella zoster infection (often with facial nerve weakness and vesicles around the ear – Ramsay Hunt syndrome)
Posterior circulation infarction (stroke)
Tumour
Multiple sclerosis
Vestibular migraine
Explain how vertigo is presented in Posterior circulation infarction
Posterior circulation infarction will have a sudden onset and may be associated with other symptoms, such as ataxia, diplopia, cranial nerve defects or limb symptoms.
Explain how vertigo is presented in Tumours
Tumours in the cerebellum or brainstem will have a gradual onset with associated symptoms of cerebellar or brainstem dysfunction
Explain how vertigo is presented in Multiple sclerosis
Multiple sclerosis may cause relapsing and remitting symptoms, with other associated features of multiple sclerosis, such as optic neuritis or transverse myelitis
Explain how vertigo is presented in Vestibular migraine
Vestibular migraine will cause symptoms lasting minutes to hours, often associated with visual aura and headache. Attacks may be triggered by:
- Stress
- Bright lights
- Strong smells
- Certain foods (e.g. chocolate, cheese and caffeine)
- Dehydration
- Menstruation
- Abnormal sleep patterns
How do you distinguish between vertigo and lightheadedness
When a patient presents with “dizziness’, it is important to first distinguish between vertigo and lightheadedness. Ask whether the “room is moving” (vertigo) or whether they feel more of a lightheadedness.
how do you differentiate between peripheral and central vertigo
Vertigo
Key features that may point to a specific cause are:
Recent viral illness ()
Headache ()
Typical triggers ()
Ear symptoms, such as pain or discharge ()
Acute onset neurological symptoms ()
Recent viral illness (labyrinthitis or vestibular neuronitis)
Headache (vestibular migraine, cerebrovascular accident or brain tumour)
Typical triggers (vestibular migraine)
Ear symptoms, such as pain or discharge (infection)
Acute onset neurological symptoms (stroke)
There are four things to examine when assessing a patient presenting with vertigo
- Ear examination to look for signs of infection or other pathology
- Neurological examination to assess for central causes of vertigo (e.g., stroke or multiple sclerosis)
- Cardiovascular examination to assess for cardiovascular causes of dizziness (e.g., arrhythmias or valve disease)
- Special tests
How do you remember cerebellar examination
Cerebellar examination is an important part of a full neurological examination in patients with vertigo. The components can be remembered with the DANISH mnemonic:
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
Special tests that may be helpful in patients with dizziness or vertigo include:
- Romberg’s test (screens for problems with proprioception or vestibular function)
- Dix-Hallpike manoeuvre (to diagnose BPPV)
- HINTS examination (to distinguish between central and peripheral vertigo)
The HINTS examination can be used to distinguish between central and peripheral vertigo. It stands for:
HI – Head Impulse
N – Nystagmus
TS – Test of Skew
What is seen on examination for Nystagmus
Nystagmus can be demonstrated by having the patient look left and right. The eyes rapidly saccade or oscillate, meaning they shake side to side as they try to settle into place. A few beats can be normal. Unilateral horizontal nystagmus is more likely to be a peripheral cause. Bilateral or vertical nystagmus suggests a central cause.
What is Test of Skew
The test of skew (also called the alternate cover test) involves the patient sitting upright and fixing their gaze on the examiner’s nose. The examiner covers one eye at a time, alternating between covering either eye. The eyes should remain fixed on the examiner’s nose with no deviation. If there is a vertical correction when an eye is uncovered (the eye has drifted up or down and needs to move vertically to fix on the nose when uncovered), this indicates a central cause of vertigo.
Patients with suspected central vertigo need referral for further investigation (e.g., CT or MRI head) to establish the cause.
For peripheral vertigo, short-term options for managing symptoms include:
Prochlorperazine
Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
________ may be used to help reduce the attacks in patients diagnosed with Ménière’s disease
Betahistine may be used to help reduce the attacks in patients diagnosed with Ménière’s disease
_______ ___________ can be effective in treating BPPV.
Epley manoeuvre can be effective in treating BPPV.
How can Vestibular migraine be managed
Vestibular migraine is usually managed by avoiding triggers and lifestyle changes (e.g., getting enough sleep and staying hydrated). Medical management is similar to migraines, with triptans for the acute symptoms and propranolol, topiramate or amitriptyline to prevent attacks.
What does DVLA say about vertigo
The DVLA guide for medical professionals (updated March 2021) states that patients must not drive and must inform the DVLA if they are liable to “sudden and unprovoked or unprecipitated episodes of disabling dizziness”.
Ear wax is also called
cerumen
how is ear wax produced?
It is normally produced in small amounts in the external ear canal. It is created from a combination of secretions, dead skin cells and any substances that enter the ear. Ear wax has a protective effect, helping to prevent infection in the ear canal. In most people, ear wax does not cause any problems.
Ear wax can build up and become impacted and stuck to the tympanic membrane. This can result in:
Conductive hearing loss
Discomfort in the ear
A feeling of fullness
Pain
Tinnitus
There are three main methods for removing ear wax:
- Ear drops – usually olive oil or sodium bicarbonate 5%
- Ear irrigation – squirting water in the ears to clean away the wax
- Microsuction – using a tiny suction device to suck out the wax
What is sinusitis
Sinusitis refers to inflammation of the paranasal sinuses in the face. This is usually accompanied by inflammation of the nasal cavity and can be referred to as rhinosinusitis. It is very common.
What is paranasal sinuses
The paranasal sinuses are hollow spaces within the bones of the face, arranged symmetrically around the nasal cavity. They produce mucous and drain into the nasal cavities via holes called ostia. Blockage of the ostia prevents drainage of the sinuses, resulting in sinusitis.
What are the four sets of paranasal sinuses
- Frontal sinuses (above the eyebrows)
- Maxillary sinuses (either side of the nose below the eyes)
- Ethmoid sinuses (in the ethmoid bone in the middle of the nasal cavity)
- Sphenoid sinuses (in the sphenoid bone at the back of the nasal cavity)
Inflammation of the sinuses can be caused by:
Infection, particularly following viral upper respiratory tract infections
Allergies, such as hayfever (with allergic rhinitis)
Obstruction of drainage, for example, due to a foreign body, trauma or polyps
Smoking
Patients with asthma are more likely to suffer from sinusitis.
The typical presentation of acute sinusitis is someone with a recent viral upper respiratory tract infection presenting with:
Nasal congestion
Nasal discharge
Facial pain or headache
Facial pressure
Facial swelling over the affected areas
Loss of smell
Sinusitis examination may reveal:
Tenderness to palpation of the affected areas
Inflammation and oedema of the nasal mucosa
Discharge
Fever
Other signs of systemic infection (e.g., tachycardia)
Chronic sinusitis involves a similar presentation but with a duration of more than ____ weeks. Chronic sinusitis may be associated with nasal polyps, which are growths of the nasal mucosa.
Chronic sinusitis involves a similar presentation but with a duration of more than 12 weeks. Chronic sinusitis may be associated with nasal polyps, which are growths of the nasal mucosa.
Sinusitis In most cases, investigations are not necessary. In patients with persistent symptoms despite treatment, investigations include:
Nasal endoscopy
CT scan
Sinusitis
NICE recommend for patients with symptoms that are not improving after 10 days, the options of:
- 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)
Management
Options for chronic sinusitis are:
Saline nasal irrigation
Steroid nasal sprays or drops (e.g., mometasone or fluticasone)
Functional endoscopic sinus surgery (FESS)
What is Nasal Spray Technique
Steroid nasal sprays are often misused, which means they will not be as effective. 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.
The technique involves:
- 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
TOM TIP: It is worth learning and practising how to explain the use of a steroid nasal spray. You may be asked to explain how to use a steroid nasal spray in your OSCEs. I probably explain the technique several times a month in general practice.
There are three descriptions to note the location of a neck lump:
- Anterior triangle
- Posterior triangle
- Midline (vertically along the centre of the neck)
These two triangles are on either side of the ________________ muscle.
These two triangles are on either side of the sternocleidomastoid muscle.
The borders of the anterior triangle are:
- Mandible forms the superior border
- Midline of the neck forms the medial border
- Sternocleidomastoid forms the lateral border
The borders of the posterior triangle are:
- Clavicle forms the inferior border
- Trapezius forms the posterior border
- Sternocleidomastoid forms the lateral border
Differential Diagnosis for Neck Lumps
- Normal structures (e.g., bony prominence)
- Skin abscess
- Lymphadenopathy (enlarged lymph nodes)
- Tumour (e.g., squamous cell carcinoma or sarcoma)
- Lipoma
- Goitre (swollen thyroid gland) or thyroid nodules
- Salivary gland stones or infection
- Carotid body tumour
- Haematoma (a collection of blood after trauma)
- Thyroglossal cysts
- Branchial cysts
Neck lumps in young children may also be caused by:
- Cystic hygromas
- Dermoid cysts
- Haemangiomas
- Venous malformation
It is not uncommon for patients to present worried about a normal bony prominence in the neck. Common areas of concern are the :
hyoid bone, mastoid process and transverse processes of C1.
When examining a neck lump, the things to establish are:
- Location (anterior triangle, posterior triangle or midline)
- Size
- Shape (oval, round or irregular)
- Consistency (hard, soft or rubbery)
- Mobile or tethered to the skin or underlying tissues
- Skin changes (erythema, tethering or ulceration)
- Warmth (e.g., infection)
- Tenderness (e.g., infection)
- Pulsatile (e.g., carotid body tumours)
- Movement with swallowing (e.g., thyroid lumps) or sticking their tongue out (e.g., thyroglossal cysts)
- Transilluminates with light (e.g., cystic hygroma – usually in young children)
Neck lumps with these associated presentations can indicate what?
Ear, nose and throat infections (e.g., ____________)
Weight loss (e.g., ________________)
Skin pallor and bruising (e.g., ________)
Focal chest sounds (e.g., _____ _____)
Clubbing (e.g., ________)
Hepatosplenomegaly (e.g., ________)
Ear, nose and throat infections (e.g., reactive lymph nodes)
Weight loss (e.g., malignancy or hyperthyroidism)
Skin pallor and bruising (e.g., leukaemia)
Focal chest sounds (e.g., lung cancer)
Clubbing (e.g., lung cancer)
Hepatosplenomegaly (e.g., leukaemia)
What is the Neck Lump Red-Flag Referral Criteria
The NICE guidelines on suspected cancer (updated January 2021) suggest a referral for two week wait referral for:
- An unexplained neck lump in someone aged 45 or above
- A persistent unexplained neck lump at any age
They recommend considering an urgent __________ ______in patients with a lump that is growing in size. This should be within 2 weeks in patients 25 and older and within 48 hours in patients under 25. They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma.
They recommend considering an urgent ultrasound scan in patients with a lump that is growing in size. This should be within 2 weeks in patients 25 and older and within 48 hours in patients under 25. They require a two week wait referral if the ultrasound is suggestive of soft tissue sarcoma.
What blood tests would be helpful for a neck lump
- FBC and blood film for leukaemia and infection
- HIV test
- Monospot test or EBV antibodies for infectious mononucleosis
- Thyroid function tests for goitre or thyroid nodules
- Antinuclear antibodies for systemic lupus erythematosus
- Lactate dehydrogenase (LDH) is a very non-specific tumour marker for Hodgkin’s lymphoma
What imaging can you use for neck lumps
Imaging may involve:
- Ultrasound is often the first-line investigation for neck lumps
- CT or MRI scans
- Nuclear medicine scan (e.g., for toxic thyroid nodules or PET scans for metastatic cancer)
What types of biopises can be used for neck lumps
- Fine needle aspiration cytology – aspirating cells from the lump using a needle
- Core biopsy – taking a sample of tissue with a thicker needle
- Incision biopsy – cutting out a tissue sample with a scalpel
- Removal of the lump – the entire lump can be removed and examined
What are the different types of Lymphadenopathy
- Reactive lymph nodes (e.g., swelling caused by viral upper respiratory tract infections, dental infection or tonsillitis)
- Infected lymph nodes (e.g., tuberculosis, HIV or infectious mononucleosis)
- Inflammatory conditions (e.g., systemic lupus erythematosus or sarcoidosis)
- Malignancy (e.g., lymphoma, leukaemia or metastasis)
What characteristics of a neck lump suggests malignancy?
- Unexplained (e.g., not associated with an infection)
- Persistently enlarged (particularly over 3cm in diameter)
- Abnormal shape (normally oval shaped where the length is more than double the width)
- Hard or “rubbery”
- Non-tender
- Tethered or fixed to the skin or underlying tissues
- Associated symptoms, such as night sweats, weight loss, fatigue or fevers
Infectious Mononucleosis
What is it caused by?
What does it cause?
Epstein Barr virus (EBV)
Lymphadenopathy
Infect is transitted through?ious Mononucleosis is transmitted through?
saliva
Mononucleosis can present with an intensely itchy ________ rash in response to ________ or ____________.
Mononucleosis can present with an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins.
What is the first line test for Infectious Mononucleosis
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.
What is the management for infectious Mononucleosis
Management is supportive. Patients should avoid alcohol (risk of liver impairment) and contact sports (risk of splenic rupture).
There are two categories of lymphoma:
What is the difference?
Hodgkin’s lymphoma and non-Hodgkin’s lymphoma.
Hodgkin’s lymphoma is a specific disease and non-Hodgkins lymphoma encompasses all the other lymphomas. Hodgkin’s lymphoma is the most likely specific type of lymphoma to appear in your exams.
The _____________ _____ is the key finding from lymph node biopsy in patients with Hodgkin’s lymphoma.
The Reed-Sternberg cell is the key finding from lymph node biopsy in patients with Hodgkin’s lymphoma.
The _____ _____ staging system is used for both Hodgkins and non-Hodgkins lymphoma.
The Ann Arbor staging system is used for both Hodgkins and non-Hodgkins lymphoma.
What are the four main types of leukaemia?
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
The presentation of leukaemia is quite non-specific. If leukaemia appears on your list of differentials then get an urgent full blood count. Some typical features are:
Fatigue
Fever
Pallor due to anaemia
Petechiae and abnormal bruising due to thrombocytopenia
Abnormal bleeding
Lymphadenopathy
Hepatosplenomegaly
A goitre refers to generalised swelling of the thyroid gland. A goitre can be caused by:
- Graves disease (hyperthyroidism)
- Toxic multinodular goitre (hyperthyroidism)
- Hashimoto’s thyroiditis (hypothyroidism)
- Iodine deficiency
- Lithium
Individual lumps can occur in the thyroid due to:
Benign hyperplastic nodules
Thyroid cysts
Thyroid adenomas (benign tumours the can release excessive thyroid hormone)
Thyroid cancer (papillary or follicular)
Parathyroid tumour
The three salivary gland locations are the:
Parotid glands
Submandibular glands
Sublingual glands
What are the main reasons for enlarged salivary glands
- Stones blocking the drainage of the glands through the ducts (sialolithiasis)
- Infection
- Tumours (benign or malignant)
What are carotid body tumours
The carotid body is a structure located just above the carotid bifurcation (where the common carotid splits into the internal and external carotids). It contains glomus cells, which are chemoreceptors that detect the blood’s oxygen, carbon dioxide, and pH. Groups of these glomus cells are called paraganglia.
Carotid body tumours are formed by excessive growth of the glomus cells. They are also called paraganglioma
How is carotid body tumour presented
Most are benign. They present with a slow-growing lump that is:
- In the upper anterior triangle of the neck (near the angle of the mandible)
- Painless
- Pulsatile
- Associated with a bruit on auscultation
- Mobile side-to-side but not up and down
Carotid body tumours may compress the glossopharyngeal (IX), vagus (X), accessory (XI) or hypoglossal (XII) nerves. Pressure on the sympathetic nerves may result in
Horner syndrome
On examination, lipomas are typically:
Soft
Painless
Mobile
Do not cause skin changes
Thyroglossal cysts occur in the midline of the neck. They are:
Mobile
Non-tender
Soft
Fluctuant
What is the differential for thyroglossal cysts
Ectopic thyroid tissue
Management of a branchial cyst is either:
- Conservative, without any active intervention, where it is not causing problems
- Surgical excision where recurrent infections are occurring, there is diagnostic doubt, or it is causing other problems
How do you differentiate Branchial cysts in exam questions
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. They might ask you where it was most likely to originate, and the answer would be the second branchial cleft.
Causes of Glossitis?
Iron deficiency anaemia
B12 deficiency
Folate deficiency
Coeliac disease
Injury or irritant exposure
What is management for glossitis?
Management involves correcting the underlying cause.
What is angioedema?
Angioedema refers to fluid accumulating in the tissues, resulting in swelling. It can affect a number of areas, such as the limbs, face and lips. It can affect the tongue, causing the tongue to swell.
The three top causes of angioedema to remember for exams are:
- Allergic reactions
- ACE inhibitors
- C1 esterase inhibitor deficiency (hereditary angioedema)
Several common factors can predispose someone to develop oral candidiasis:
- Inhaled corticosteroids (particularly with poor technique, not using a spacer and not rinsing with water afterwards)
- Antibiotics (disrupt the normal bacterial flora giving candida a chance to thrive)
- Diabetes
- Immunodeficiency (consider HIV)
- Smoking
What are the treatmnet options ofr oral candidiasis
- Miconazole gel
- Nystatin suspension
- Fluconazole tablets (in severe or recurrent cases)
What is Geographic Tongue
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.
What is the two key causes of a strawberry tongue to remember are:
Scarlet fever
Kawasaki disease
What is Black Hairy Tongue
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.
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.
What is leukoplakia?
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.
Characterisitics of leukoplakia
The patches are asymptomatic, irregular and slightly raised. They are fixed in place, meaning they cannot be scraped off.
Management for leukoplakia?
Management involves stopping smoking, reducing alcohol intake, close monitoring and potentially laser removal or surgical excision.
What is erythroplakia?
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.
What is Lichen Planus
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.
Lichen planus can also affect the mucosal membranes, including the mouth. Often it only affects the mouth.
In the mouth, it can take three patterns:
Reticular
Erosive
Plaque
What does Reticular, Erosive, Plaque patterns in the mouth suggest?
A reticular pattern involves a net-like web of white lines called Wickham’s striae.
Erosive lesions are where the surface layer of the mucosa is eroded, leaving bright red and sore areas of mucosa.
Plaques are larger continuous areas of white mucosa.
Management for lichen planus?
Management involves good oral hygiene, stopping smoking and topical steroids.
What is Gingivitis?
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.
What does Periodontitis refer to?
refers to severe and chronic inflammation of the gums and the tissues that support the teeth. This often leads to loss of teeth
What is Acute necrotising ulcerative gingivitis
is a rapid onset of more severe inflammation in the gums. It presents similarly to gingivitis, however, it is painful. Anaerobic bacteria usually cause this.
The risk factors for gingivitis are:
- Plaque build-up on the teeth (inadequate brushing)
- Smoking
- Diabetes
- Malnutrition
- Stress
Patients with gingivitis will be managed by a dentist. Treatment involves:
- Good oral hygiene
- Stopping smoking
- Dental hygienist treatment to remove plaque and tartar
- Chlorhexidine mouth wash
- Antibiotics for acute necrotising ulcerative gingivitis (e.g., metronidazole)
- Dental surgery if required
What is Gingival Hyperplasia
Gingival hyperplasia refers to abnormal growth of the gums. The gums are notably enlarged around the teeth
Possible causes of gingival hyperplasia include:
Gingivitis
Pregnancy
Vitamin C deficiency (scurvy)
Acute myeloid leukaemia
Medications, particularly calcium channel blockers, phenytoin and ciclosporin
What are Aphthous Ulcers
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. They may also be an indication of underlying conditions, notably
- Inflammatory bowel disease (Crohn’s disease and ulcerative colitis)
- Coeliac disease
- Behçet disease
- Vitamin deficiency (e.g., iron, B12, folate and vitamin D)
- HIV
Aphthous ulcers usually heal within 2 weeks. Manageable ulcers do not require any intervention.
Topical treatments can be used to treat symptoms, including:
- Choline salicylate (e.g., Bonjela)
- Benzydamine (e.g., Difflam spray)
- Lidocaine
Aphthous ulcers
Topical corticosteroids can be used in more severe ulcers. These may reduce the duration and severity of symptoms. Options include:
- Hydrocortisone buccal tablets applied to the lesion
- Betamethasone soluble tablets applied to the lesion
- Beclomethasone inhaler sprayed directly onto the lesion
Are nasal polyps unilateral or bilateral
Polyps are usually bilateral. Unilateral nasal polyps are a red flag and should raise suspicions of tumours.
TOM TIP: If you remember one thing about nasal polyps, remember that unilateral polyps are concerning for malignancy and require a specialist referral for assessment
Nasal polyps are associated with several conditions:
- Chronic rhinitis or sinusitis
- Asthma
- Samter’s triad (nasal polyps, asthma and aspirin intolerance/allergy)
- Cystic fibrosis
- Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
Nasal polyps may be found on examination in patients presenting with:
- Chronic rhinosinusitis
- Difficulty breathing through the nose
- Snoring
- Nasal discharge
- Loss of sense of smell (anosmia)
What is medical management for nasal polyps?
Medical management involves intranasal topical steroid drops or spray.
What is surgical management of nasal polyps?
Surgical management is used where medical treatment fails. This involves removing the polyps:
- Intranasal polypectomy is used where the polyps are visible close to the nostrils
- Endoscopic nasal polypectomy is used where the polyps are further in the nose or the sinuses
