TO DO ENT Flashcards
ACOUSTIC NEUROMA
what are the risk factors?
neurofibromatosis type 2 - typically bilateral + earlier onset
ACOUSTIC NEUROMA
what are the symptoms?
- unilateral sensorineural hearing loss
- tinnitus
- unsteadiness
- facial numbness
- facial weakness
- dry eyes/mouth
- dysarthria/dysphagia
ACOUSTIC NEUROMA
what are the clinical signs?
- cerebellar signs - nystagmus, ataxia
- papilloedema
ACOUSTIC NEUROMA
what are the investigations?
- audiological testing (unilateral sensorineural hearing loss)
- Gadolinium-enhanced MRI
ACOUSTIC NEUROMA
what is the management?
- watch and wait (monitored annually with MRIs)
- stereotactic radiosurgery/therapy
- surgical removal
ACOUSTIC NEUROMA
what are the complications?
mass effect
- trigeminal + facial neuropathies
- brainstem compression
- hydrocephalus
following surgery
- hearing loss
- facial weakness
- CSF leak
BPPV
what are the risk factors?
- increasing age
- female
- head trauma
- inflammation (labyrinthitis + vestibular neuritis)
- migraines
BPPV
what are the symptoms?
VERTIGO
- spinning
- episodic
- sudden, severe and <30 seconds
- occurs on head movement
NAUSEA + VOMITING
BPPV
what are the clinical signs?
- positive Dix-Hallpike manoeuvre
- positive supine lateral head turn
- normal neuro exam
BPPV
what is the diagnostic criteria?
ONE of the following:
- positive Dix-Hallpike manoeuvre
- positive supine lateral head turn
BPPV
what is the management?
1st line
- conservative management
- Epley manoeuvre (contraindicated in neck injury + carotid stenosis)
2nd line
- vestibular suppressant medications (prochlorperazine/betahistine)
- vestibular rehab
refer to ENT
surgery
EPISTAXIS
where does the majority of bleeds originate?
95% originate from the Kiesselbach plexus in Littles area
EPISTAXIS
how can you distinguish whether the nose-bleed is anterior or posterior?
ANTERIOR
- visible source of bleed
- minor bleed
- initially unilateral bleed
- history of picking
- first aid controls bleed
POSTERIOR
- no visible source
- bleeding down back of mouth + throat
- bleeding initially bilateral
- visible blood in posterior pharynx
EPISTAXIS
what is the management of anterior epistaxis?
1st line = first aid measures
2nd line = nasal cautery
3rd line = anterior nasal packing for 24-48 hours + admit
EPISTAXIS
what is the management of posterior epistaxis?
1st line = first aid measures
2nd line = posterior nasal packing by ENT specialist
3rd line = surgery
EPISTAXIS
what is the discharge advice?
- do not lie flat for 24 hrs
- avoid nose blowing for 1 week
- avoid alcohol, spicy food + hot drinks for 2 days
- avoid strenuous exercise + straining for 1 week
- avoid dislodging scabs
OTITIS EXTERNA
what microorganisms most commonly cause it?
pseudomonas aeruginosa
s.aureus
OTITIS EXTERNA
what are the risk factors?
- swimming
- humid air
- young age
- diabetes
- trauma
- narrow external auditory meatus
- obstructed external auditory meatus
- eczema, psoriasis
- radiotherapy
OTITIS EXTERNA
which dermatological conditions can cause it?
seborrhoeic dermatitis
contact dermatitis
OTITIS EXTERNA
what is the management?
- analgesia (paracetamol, ibuprofen)
- topical therapy (acetic acid or ciprofloxacin with dexamethasone)
- ENT referral
- micro suction
OTITIS EXTERNA
what are the complications?
- pinna cellulitis
- chronic otitis externa
- myringitis
- necrotising otitis externa
OTITIS MEDIA
what are the most common causative pathogens?
BACTERIA
- s.pneumoniae
- H.influenzae
VIRUSES
- RSV
- rhinovirus
- adenovirus
OTITIS MEDIA
when should you consider antibiotics?
absolute indications
- systemically unwell
- signs and symptoms of more serious illness
- high risk of complications
- otorrhoea in child/young person
- age <2 with bilateral AOM
OTITIS MEDIA
which antibiotics may be prescribed?
5-7 day course
1st line = amoxicillin
2nd line = co-amoxiclav
penicillin allergy = clarithromycin/erythromycin
OTITIS MEDIA
what are the complications?
- glue ear
- tympanic membrane perforation
- mastoiditis
- meningitis
- facial nerve palsy
- chronic or recurrent infection
- hearing loss
TONSILLITIS
what are the causes?
- viral - rhinovirus
- bacterial - strep pyogenes
- recurrent - s.aureus
- non-infectious - GORD, smoking, hayfever
TONSILLITIS
what is the CENTOR criteria?
- presence of tonsillar exudate
- tender anterior cervical lymph nodes
- history of fever
- absence of cough
1 point each
TONSILLITIS
what does the CENTOR score mean?
0-2 = 3-17% strep infection
3-4 = 32-56%
TONSILLITIS
what is the feverPAIN criteria?
- fever (during last 24 hrs)
- pus on tonsils
- attend rapidly (within 3 days of symptom onset)
- inflamed tonsils (severe)
- no cough or coryza
1 point each
TONSILLITIS
what do the scores for feverPAIN criteria mean?
likelihood of strep infection
0-1 = 13-18%
2-3 = 34-40%
4-5 = 62-65%
TONSILLITIS
what is the management?
ALL PATIENTS
- paracetamol + ibuprofen
- fluid intake
low feverPAIN (0-1) or centor (0-2) = no antibiotics
high feverPAIN (4-5) or centor (3-4) = antibiotics
- phenoxymethylpenicillin for 5-10 days
- clarithromycin for 5 days if penicillin allergic
QUINSY
what is it?
peritonsillar abscess, is a collection of pus in the peritonsillar space
QUINSY
what is the clinical presentation?
- sore throat
- fever
- trismus
- dysphagia
- altered voice
- peritonsillar swelling
- exudate
- drooling
displacement of uvula
MENIERES DISEASE
what is the pathophysiology?
it is characterised by endolymphatic hydrops - distention + distortion of membranous endolymph system due to abnormal fluctuations in endolymph
MENIERES DISEASE
what are the risk factors?
- caucasian
- family history
- migraines
- autoimmune diseases e.g. SLE, rheumatoid arthritis
- head trauma
- viral infection
MENIERES DISEASE
what are the clinical features?
- vertigo (spinning/rocking)
- tinnitus
- fluctuating hearing loss
- aural fullness
- unsteadiness on feet
- nystagmus (unidirectional, horizontal-torsional)
- positive rombergs sign
MENIERES DISEASE
what are the investigations?
clinical diagnosis - must be made by ENT specialist
must have:
- >2 episodes of vertigo lasting >20 mins
- hearing loss confirmed by audiometry on >1 occasion
- no better alternative diagnosis
other investigations
- bloods - FBC, U&Es, TFTs, lipid profile, syphilis screen
- audiometry
- MRI
ACUTE RHINOSINUSITIS
what features support a bacterial diagnosis?
- persistent clinical features with no improvement >10 days
- double worsening
- persistent severe symptoms for 3-4 consecutive days
ACUTE RHINOSINUSITIS
what is the management?
SUPPORTIVE
- paracetamol (anti-pyretic + analgesic)
- saline irrigation
- steam inhalation
ANTIBIOTICS
- 1st line = phenoxymethylpenicillin
- co-amoxiclav if systemically unwell
- doxycycline/clarithromycin if penicillin allergic
OTHERS
- intranasal glucocorticoids (mometasone)
- oral decongestants (phenylephrine)
- nasal decongestants (oxymetazoline)
- antihistamines
SINUSITIS
what are the risk factors?
Allergies
Smoking
Asthma
Nasal polyps
Immunodeficiency
SINUSITIS
what is the management?
1st line
- analgesia (paracetamol/ibuprofen)
- nasal decongestants (pseudoephedrine/phenylephrine)
- intranasal corticosteroids (mometasone/fluticasone)
- saline nasal irrigation
2nd line
- antibiotics if symptoms persist for >10 days (amoxicillin/doxycycline)
LABYRINTHITIS
what are the clinical features?
- vertigo
- N+V
- hearing loss
- tinnitus
- imbalance
- nystagmus
- positive rombergs sign
LABYRINTHITIS
what are the investigations?
clinical diagnosis
other investigations to consider
- audiometry
- MRI brain
LABYRINTHITIS
what is the management?
- prochloperazine
- rest and rehydration
- antibiotics if bacterial
- corticosteroids if vasculitis-induced
VESTIBULAR NEURITIS
what are the causes?
viral infection
VESTIBULAR NEURITIS
what are the clinical features?
- vertigo
- N+V
- imbalance
- nystagmus
- unsteady gait
- positive rombergs sign
- normal otoscopic exam
VESTIBULAR NEURITIS
what is the management?
- vestibular rehabilitation therapy (VRT)
- prochlorperazine
GLANDULAR FEVER (INFECTIOUS MONONUCLEOSIS)
what are the clinical features?
SYMPTOMS
- sore throat
- abdominal tenderness
- prodromal features (malaise, fever, fatigue, myalgia, anorexia, retro-orbital headache)
- widespread non-blanching maculopapular rash (if amoxicillin or ampicillin is administered)
SIGNS
- tonsillar enlargement (may have white exudate + palatal petechiae)
- bilateral posterior lymphadenopathy
- splenomegaly and hepatomegaly
GLANDULAR FEVER (INFECTIOUS MONONUCLEOSIS)
what are the investigations?
- FBC = lymphocytosis
- monospot test (in 2nd week) = confirm dx
to consider
- EBV serology (if monospot is negative or rapid diagnosis required)
- LFTs = often abnormal
- CMV/toxoplasmosis (if pt is pregnant or immunocompromised)
- HIV status
GLANDULAR FEVER (INFECTIOUS MONONUCLEOSIS)
what are the complications?
- splenic rupture
- glomerulonephritis
- haemolytic anaemia
- thrombocytopaenia
- chronic fatigue
- Burkitt’s lymphoma
OBSTRUCTIVE SLEEP APNOEA
what are the risk factors?
- increasing age
- male
- obesity
- family history of OSA
- nasopharyngeal obstruction
- craniofacial abnormalities
- macroglossia
- neuromuscular disorders
- smoking
OBSTRUCTIVE SLEEP APNOEA
what are the clinical signs?
- jaw abnormalities
- mouth breathing or nasal speech
- raised BMI + large neck circumference
- HTN
OBSTRUCTIVE SLEEP APNOEA
what are the complications?
- MI
- stroke
- HTN
VERTIGO
what are the causes of peripheral vertgio?
- BPPV
- menieres disease
- vestibular neuritis
- labyrinthitis
VERTIGO
what are the causes of central vertigo?
- posterior circulation infarction (stroke)
- tumour
- MS
- vestibular migraine
VERTIGO
what is the difference in presentation of peripheral vs central vertigo?
PERIPHERAL
- sudden onset
- short (seconds/minutes)
- hearing loss/tinnitus present
- coordination intact
more severe nausea
CENTRAL
- gradual onset (except stroke)
- persistent
- no hearing loss/tinnitus
- coordination impaired
- only mild nausea
VERTIGO
what are the investigations?
- ear examination (look for infection/other pathology)
- neurological exam
- cardiovascular exam
- cerebellar exam
Special tests
- Rombergs test (screen for proprioception issues)
- Dix-Hallpike manoeuvre
VERTIGO
what investigations can be done to distinguish between peripheral and central vertigo?
HINTS examinations
- HI = Head Impulse test (helps to diagnose peripheral vertigo, will be normal if central)
- N = nystagmus (unilateral horizontal = peripheral, bilateral/vertical = central)
- T = test of skew (indicates central cause)
VERTIGO
what is the management?
CENTRAL
- referral for further investigation (CT or MRI head)
PERIPHERAL
- prochlorperazine
- antihistamines (cyclizine, cinnarizine and promethazine)
- if menieres disease = betahistine
if BPPV = epley manoeuvre
- vestibular migraine = triptans for acute, propranolol, topiramate or amitriptyline for prevention
PRESBYCUSIS
what is it?
type of sensorineural hearing loss that affects elderly
typically effects high frequency hearing bilaterally
PRESBYCUSIS
what are the risk factors?
- arteriosclerosis
- diabetes
- accumulated exposure to noise
- drug exposure (salicylates, chemotherapy)
- stress
- genetics
PRESBYCUSIS
what is the clinical presentation?
- speech becoming difficult to understand
- need for increased volume on the TV
- difficulty using telephone
- loss of directionality of sound
- worsening symptoms in noisy environments
- hyperacusis (heightened sensitivity to certain sound frequencies)
SIGNS
- possible Weber’s test bone conduction to one side if not completely bilateral
PRESBYCUSIS
what are the investigations?
- otoscopy = normal
- tympanometry = normal middle ear function with hearing loss
- audiometry = bilateral sensorineural hearing loss
- blood tests = normal
OTOSCLEROSIS
what is it?
replacement of normal bone by vascular spongy bone.
causes progressive conductive deafness due to fixation of the stapes at the oval window
OTOSCLEROSIS
what is the cause?
autosomal dominant inherited condition
OTOSCLEROSIS
what is the epidemiology?
- onset usually at 20-40 years old
- positive family history
OTOSCLEROSIS
what is the pathophysiology?
normal bone is replaced with spongy vascular bone
causes progressive conductive deafness due to fixation of the stapes at the oval window
OTOSCLEROSIS
what is the inheritance pattern?
autosomal dominant
OTOSCLEROSIS
what type of hearing loss does it cause?
progressive conductive deafness
OTOSCLEROSIS
what is the clinical presentation?
- conductive deafness
- tinnitus
- normal tympanic membrane (10% have flamingo tinge)
- positive family history
OTOSCLEROSIS
what is the management?
- hearing aid
- stapedectomy
