3D ENT Flashcards
(197 cards)
1
Q
What Hz tuning fork is used in Rinne’s and Weber’s test?
A
512Hz
(because it offers a good balance between the duration of the sound and the level of tactile vibration it produces)
2
Q
Rinne’s test is performed by holding the 512Hz tuning fork on the mastoid process & then once pt cannot feel the vibration the tuning fork is moved in front of the ear canal.
- What is meant by a Rinne’s positive result
- What is a Rinne’s negative result
A
- Rinne’s positive (normal): air conduction > bone conduction
- Rinne’s negative (abnormal): bone conduction > air conduction
—> this suggests a conductive HL
3
Q
Weber’s test is performed by placing the 512Hz tuning fork in the centre of the patient’s forehead & asking the patient if they can hear the sound and whether it is equal to both ears or louder in one ear.
- What is a normal result?
- Sensorineural HL (unilateral)
- Conductive HL
A
- Normal result —> pt hears sound equally in both ears
(note: sound is also heard equally in both ears if there is bilateral sensorineural HL) - Sensorineural HL —> sound will be louder in the normal ear (quieter in affected ear)
(ie. the normal ear is better at sensing the sound) - Conductive HL —> sound will be louder in the affected ear
(affected ear has increased sensitivity as sound hasn’t been reaching that side as well)
4
Q
Name some causes of conductive HL.
A
- Ear waxOR foreign object blocking ear canal
- Infection—> otitis media (+/- effusion) or otitis externa
- Otosclerosis
- Perforated tympanic membrane
- others: Eustachian tube dysfunction, Cholesteatoma, Exostoses, Tumours
5
Q
Name some causes of sensorineural HL (not including medications).
A
- Sudden sensorineural hearing loss(SSHL) —> over less than 72 hrs
- Presbycusis(age-related)
- Noise exposure
- Acoustic neuroma
- others: Ménière’s disease, Labyrinthitis, Neurological conditions(e.g., stroke, MS, brain tumours), Infections(e.g., meningitis), Medications
6
Q
What are some medications that cause sensorineural HL?
A
- Loop diuretics(e.g., furosemide, bumetanide) → disrupt the K+ gradient in the cochlea (inner ear)
- Aminoglycosides(e.g., gentamicin) → can accumulate in the inner ear & damage hair cells
- Chemotherapy drugs(e.g., cisplatin) → can cause hair cell damage & apoptosis through reactive oxygen species
- Antimalarials (eg. quinine)
7
Q
What is the normal range (dB) on an audiogram?
A
0-20 dB
8
Q
Audiogram symbols.
- What symbols are used for air conduction (left/right)
- What symbols are used for bone conduction (left/right)
A
- X– Left-sided air conduction
- O– Right-sided air conduction
- ]– Left-sided bone conduction
- [– Right-sided bone conduction
9
Q
On an audiogram 0-20 dB is normal hearing.
Define mild, moderate, severe, and profound hearing loss
A
- Mild: 21–40 dB
- Moderate: 41–70 dB
- Severe: 71–95 dB
- Profound: >95 dB
10
Q
Interpret this audiogram
A
Normal audiogram (below 20dB in all frequencies)
11
Q
What is the air-borne gap on an audiogram & what type of hearing loss is this seen in?
A
- Air-bone gap(ABG) - the difference betweenair-conductionandbone-conductionaudiometric thresholds
(difference of greater than 10dBat a given frequency)
–> seen in conductive HL or mixed HL (outer/middle ear pathology)
12
Q
Interpret this audiogram
A
Conductive hearing loss (right ear): air-bone gap present:
13
Q
Interpret this audiogram
A
Sensorineural hearing loss (right ear): no air-bone gap present:
14
Q
Interpret this audiogram
A
Presbycusis (age-related hearing loss)
- characterised by bilateral hearing loss above 2000Hz (affects high frequencies first)
15
Q
Interpret this audiogram
A
Noise-induced hearing loss
- sensorineural HL with a notch at 4000Hz
16
Q
Interpret this audiogram.
- patient presents with vertigo, tinnitus, and hearing loss
A
Meniere’s disease (right ear)
- characterised bylow-frequency sensorineural HL
17
Q
Interpret this audiogram
A
Otosclerosis (right ear)
- characterised byconductive HLwith loss in bone conduction at2000 Hz(referred to as Carhart’s notch) —> due to stapes fixation
18
Q
Interpret this audiogram
A
Bilateral sensorineural hearing loss
- both air and bone conduction readings will be more than 20 dB, plotted below the 20 dB line on the chart
19
Q
Interpret this audiogram
A
Conductive hearing loss
- bone conductionreadings will be normal (between 0 and 20 dB)
- air conductionreadings will be greater than 20 dB, plotted below the 20 dB line on the chart
20
Q
Interpret this audiogram
A
Mixed hearing loss
- Bothairandboneconduction readings will be more than 20 dB
- However, there will be a difference ofmore than15 dB between the two (bone conduction>air conduction) –> air-borne gap
21
Q
Cochlea implants are needed due to non-functioning organ of Corti (ie. bypasses damaged hair cells), but why does the patient need to have functioning spiral ganglion for cochlear implant success?
A
Because the implant stimulates the spiral ganglion neurons and relies on these neurons to transmit the electrical signals to the auditory nerve
22
Q
Audiometry is used to diagnose presbycusis & the extent of the hearing loss.
What type of hearing loss is seen & is high or low frequencies affected worse?
A
bilateral sensorineural HL + worsening hearing loss at higher frequencies
23
Q
What is the cause of presbycusis & why is hearing loss worse at high frequencies?
A
- A sensorinerual HL that occurs with age, due to gradual atrophy of cochlear hair cells and neurons due to ageing and cumulative damage
- The hair cells that process high-frequency sounds are located at the base of the cochlea and are more vulnerable to damage from noise exposure and the natural aging process
24
Q
What is the management of presbycusis?
A
(the effects of presbycusis cannot be reversed)
- Hearing aids
- Cochlear implants (in patients where hearing aids are not sufficient)
25
Sudden sensorineural HL (SSNHL) is defined as hearing loss over less than 72 hours, unexplained by other causes.
What should you do if a patient presents with SSNHL?
- Urgent referral to ENT (within 24hrs)
1. High-dose oral corticosteroids —> used by ENT for all cases of SSNHL
26
What is the most common cause of SSNHL (sudden sensorineural HL)?
Idiopathic (90%)
27
What are acoustic neuromas (vestibular schwannomas)?
- benign tumours of the Schwann cells surrounding the auditory nerve (vestibulocochlear nerve) that innervates the inner ear
- Schwann cells are found in the peripheral NS and provide the myelin sheath around neurons
28
Where do acoustic neuromas (vestibular schwannomas) occur?
cerebellopontine angle
29
What are the three cranial nerves affected in an acoustic neuroma (vestibular schwannoma) & their associated symptoms?
- CN VIII (vestibulocochlear nerve) —> **unilateral sensorineural HL**, unilateral tinnitus, vertigo
- CN V (trigeminal nerve) —> absent corneal reflex
- CN VII (facial nerve) —> facial palsy (if tumour grows large enough to compress the facial nerve)
30
Acoustic neuromas are usually unilateral, what do bilateral acoustic neuromas indicate?
Neurofibromatosis type 2
31
What is the management of a confirmed acoustic neuroma (vestibular schwannoma)?
1. Urgent referral to ENT
- although slow-growing, they can cause significant hearing loss
- Conservative —> observation/monitoring
- Surgery —> to remove the tumour (partial/total)
- Radiotherapy —> to reduce the growth
32
What is the investigation of choice of a suspected acoustic neuroma (vestibular schwannoma)?
MRI of the cerebellopontine angle
(MRI shows vestibular schwannoma at the right cerebellopontine angle)
33
What are the 4 most common peripheral (vestibular) causes of vertigo?
- BPPV —> displaced crystals of calcium carbonate (otoconia) in the semicircular canals
- Ménière’s disease —> excessive endolymph in the semicircular canals
- Vestibular neuronitis —> inflammation of the vestibular nerve (usually caused by viral infection)
(NO HEARING LOSS)
- Labyrinthitis —> inflammation of the structures of the inner ear (usually caused by viral infection)
(HEARING LOSS)
(Note: vestibular schwannoma is another cause of peripheral vertigo)
34
Central causes of vertigo refers to pathology affecting the cerebellum or brainstem that disrupts the signals from the vestibular system.
What is the most common pathology that results in a central cause of vertigo?
Posterior circulation infarction (stroke)
- sudden-onset + may be associated with other symptoms (eg. ataxia, diplopia, CN defects, or limb symptoms)
(other causes of central vertigo: tumours in brainstem/cerebellum, vetsibular migraine)
—> All the central causes of vertigo will cause sustained, non-positional vertigo
35
The HINTS examination is used to distinguish between central and peripheral causes of vertigo.
In the Head Impulse part of the test, what do the following indicate:
1. Pt keep their eyes fixed on the examiner's nose
2. Pt's eyes saccade (rapidly move back and forth) and eventually fix back on the examiner
1. Pt keep their eyes fixed on the examiner's nose —> Normal functioning vestibular system (will be normal with central vertigo too)
2. Pt's eyes saccade (rapidly move back and forth) and eventually fix back on the examiner —> Abnormally functioning vestibular system (ie. peripheral vertigo)
36
The HINTS examination is used to distinguish between central and peripheral causes of vertigo.
In the nystagmus part of the test, what do the following indicate:
1. Unilateral horizontal nystagmus
2. Bilateral or vertical nystagmus
1. Unilateral horizontal nystagmus —> suggests a peripheral cause
2. Bilateral or vertical nystagmus —> suggests a central cause
37
The HINTS examination is used to distinguish between central and peripheral causes of vertigo.
In the Test of Skew (alternative cover test), the patient's eyes should remain fixed on the examiner's nose with no deviation.
What is indicated if there is a vertical correction when an eye is uncovered (ie. the eye has drifted up or down and needs to move vertically to fix on the nose when covered?
this indicates a central cause of vertigo
38
BPPV is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals.
Which semicricular canal is most commonly affected/
Posterior semicircular canal
- due to its anatomical orientation and the influence of gravity
39
Why does head movements trigger vertigo in BPPV?
Head movement creates the flow of endolymph in the canals
- Otoliths (calcium carbonate crystals) have dislodged from their normal location in the inner ear (otolith organs - utricle & saccule) and end up in the semicircular canals of the inner ear
40
In BPPV, what triggers vertigo & how long do the episodes last?
- Vertigo triggered by change in head position —> e.g. rolling over in bed or gazing upwards
- each episode typically lasts 10-20 seconds (up to 1 min) —> pts are asymptomatic between attacks
41
How is BPPV diagnosed & what is a +ve result?
Dix-Hallpike manoeuvre —> involves moving the pt’s head in a way that moves endolymph through the semicircular canals
- +ve result --> triggers rotational nystagmus and symptoms of vertigo
(rotational beats of nystagmus will be towards the affected ear - ie. clockwise for left ear)
42
BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months.
What are 2 options for symptomatic relief?
- short-term
- longer-term
- **Epley manoeuvre** (successful in around 80% of cases)
- Vestibular rehabilitation —> eg. Brandt-Daroff exercises
43
Meniere's disease is assoicated with the excessive buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals.
What is the typical triad of symptoms in Meniere's disease?
- **Vertigo** —> usually most prominent symptom
(not triggered by movement or posture)
- Hearing loss —> sensorineural HL + affects low frequencies first
- **Tinnitus**
--> note: a sensation of aural fullness/pressure is now recognised as a common symptom
(episodes last minutes to hours)
44
What is the management of Meniere's disease?
- Acute attacks
- Prophylaxis
(Note: Symptoms resolve in the majority of patients after 5-10 years)
- Acute attacks —> buccal or IM prochlorperazine
(antihistamines are also used (eg. cyclizine, cinnarizine and promethazine))
- Prophylaxis —> betahistine + vestibular rehabilitation exercises
45
How does betahistine work as prophylaxis in Meniere's disease?
- increases blood flow to the inner ear and reducing fluid accumulation
- acts on histamine H1 receptors located on blood vessels in the inner ear, leading to vasodilation and increased vascular permeability
46
Vestibular neuronitis is caused by inflammation of the vestibular nerve (often triggrered by a viral infection).
Why is there no hearing loss in vestibular neuronitis?
- Vestibular nerve —> transmits signals from the vestibular system (semicircular canals and vestibule) to the brain to help with balance
- Cochlear nerve —> transmits signals from the cochlea to provide hearing
—> Together they form the vestibulocochlear nerve (CN VIII)
—> in vestiublar neuronitis only the vestiublar nerve is affected, the cochlea nerve is not affected so hearing is intact
47
What type of nystagmus is seen in vestibular neuronitis?
Horizontal nystagmus is usually present
48
What is the management of vestibular neuronitis?
- Acute relief of symptoms
- Chronic symptoms
- Acute relief of symptoms —> buccal or intramuscular prochlorperazine
- Chronic symptoms —> vestibular rehabilitation exercises
(NICE recommend referral if the symptoms do not improve after 1 week or resolve after 6 weeks)
49
Why is acute symptomatic treatment in vestibular neuronitis (ie. prochlorperazine) only given for a maximum of 3 days?
more extended use may slow down the recovery due to interfering with central compensatory mechanisms
50
Symptoms of viral labyrinthitis are similar to vestibular neuronitis, what is the key difference in symptoms between the two conditions?
- Viral labyrinthitis presents with hearing loss and tinnitus --> inflammation affects the semicircular canals, vestibule (middle section) and cochlea
—> vestibular neuronitis does not present with these, as only the vestibular nerve is involved
51
Episodes of viral labyrinthitis are usually self-limiting.
What can be given for acute symptomatic relief?
- prochlorperazine or antihistamines (cyclizine, cinnarizine and promethazine) may help reduce the sensation of dizziness
(note: only use symptomatic treatment for up to 3 days)
52
Name 3 common bacterial causes of otitis media.
- **Streptococcus pneumoniae (most common)**
(also commonly causes other ENT infections —> eg. rhinosinusititis and tonsillitis)
- Haemophilus influenzae
- Moraxella catarrhalis
53
Acute otitis media is generally self-limiting and does not require an antibiotic prescription.
1. What can be given for ear pain (otlagia) and fever?
2. If antibiotics are indicated, what antibiotics should be given?
- if pt is penicillin allergic?
- if pt is pen allergic + pregnant?
1. Simple analgesia —> eg. paracetamol, ibuprofen
2. NICE suggest —> amoxillin 5-7 days (1st-line)
- Clarithromycin (if penicillin allergy)
- Erythromycin (in pregnant women allergic to penicillin)
(note: a delayed antibiotic prescription is often prescribed - ie. can be collected and used after 3 days if symptoms not improved/worsened)
54
Name 3 complications of otitis media.
1. Perforated tympanic membrane —> otorrhoea
- unresolved —> may develop into chronic suppurative otisis media (CSOM)
(CSOM is defined as perforation of the tympanic membrane with otorrhoea for >6 weeks)
2. Hearing loss (usually temporary)
3. Labyrinthitis —> causing dizziness or vertigo
55
Mastoidits is a rare (but serious) complication of otitis media.
What is mastoidits & how is it managed?
- typically develops when an infection spreads from the middle ear to the mastoid air spaces of the temporal bone
- Treatment --> IV antibiotics
56
Chronic suppurative otitis media (CSOM) is another potential complication of otitis media, it presents with chronic otorrhoea and hearing loss.
What can be done if there is active discharge from the ear & what is the management of CSOM?
- If active discharge from ear —> ear swab for culture and sensitivity
(guides antibiotic therapy)
1. Empirical antibiotic therapy —> aminoglycoside eardrop (eg. gentamicin or ciprofloxacin)
(if medical management fails - Surgery —> Tympanoplasty or mastoidectomy)
57
What are the most common organisms involved in chronic suppurative otitis media (CSOM)?
Pseudomonas aeruginosa & Staph. A
58
What is the primary cause of otitis media with effusion?
The Eustachian tube connects the middle ear to the back of the throat (nasopharynx) --> it helps drain secretions from the middle ear
- when it becomes blocked —> causes middle ear secretions (fluid) to build up in the middle ear space
59
What is the management of otitis media with effusion (glue ear)?
1. Active observation for 3 months —> if first presentation of otitis media with effusion
2. Grommet insertion —> to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube
(usually children with Down's syndrome or cleft palate may require hearing aids or grommets)
60
Why should all adult patients exhibiting unilateral symptoms of otitis media with effusion (glue ear) receive an urgent assessment (within two weeks) by an ENT specialist
due to the potential risk that a posterior nasal space tumour could be altering Eustachian tube pressure
61
Name 3 common triggers of otitis externa.
- Recent swimming —> “swimmer’s ear”
- Trauma from ear canal —> eg. cotton buds or earplugs
- Removal of ear wax can increase risk of infection —> ear wax (cerumen) has a protective effect against infection
62
Name 2 bacterial causes of otitis externa/
- Staphylococcus aureus
- Pseudomonas aeruginosa
63
In otitis externa, why should fungal infection (eg. Candida albicans) be suspected in patients that have had multiple courses of topical antibiotics?
Antibiotics kill the “friendly bacteria” that have a protective effect against fungal infections
(this is similar to how oral antibiotics can predispose people to develop oral or vaginal candidiasis (thrush))
64
What is the management of very mild otitis externa that can be purchased over the counter & can also be used prophylactically before and after swimming in patients that are prone to otitis externa?
Acetic acid 2% (available over the counter as EarCalm)
- Acetic acid has an antifungal and antibacterial effect
65
What are the initial management options for treating otitis externa?
1. **Topical antibiotic OR a combined topical antibiotic with a steroid**
- Neomycin, dexamethasone and acetic acid (e.g., Otomize spray)
- Gentamicin and hydrocotisone
.
- If there is canal debris —> consider removal
- If the canal is extensively swollen —> an ear wick (soaked in medication) is sometimes inserted
.
(Note: if a pt fails to respond to topical antibiotics —> the pt should be referred to ENT)
66
What group of people are most likely to develop malignant otitis externa?
Diabetics (particularly elderly diabetics)
67
What is malignant otitis externa & what can it progress to?
the infection spreads to the bones surrounding the ear canal and skull —> it progresses to osteomyelitis of the temporal bone of the skull
.
68
What is the most common causative organism in malignant otitis externa?
Pseudomonas aeruginosa
- gram -ve aerobic rod-shaped bacteria (likes to grow in moist, oxygenated environments)
69
How is malignant otitis externa managed?
It is an emergency —> admission to hospital under the ENT team
1. IV antibiotics —> ciprofloxacin covers Pseudomonas
2. Imaging (e.g., CT or MRI head) —> to assess the extent of the infection
70
The most common cause of a perforated tympanic membrane is infection (other causes include barotrauma or direct trauma).
How is a perforated tympanic membrane managed?
1. Majority of cases are self-limiting (6-8 weeks)
(avoid getting water in the ear during this time)
2. If perforation is following an episode of otitis media --> antibiotics can be prescribed
3. If tympanic membrane does not heal by itself --> myringoplasty may be performed
71
What is Ramsay Hunt syndrome (herpes zoster oticus) caused by?
the reactivation of the varicella zoster virus in the geniculate ganglion of CN VII (facial nerve)
72
Auricular pain + facial nerve palsy + vestibular rash around the ear.
What is your diagnosis & how would you treat it?
Ramsay Hunt syndrome (herpes zoster oticus)
1. Oral aciclovir and corticosteroids are usually given
73
What makes Eustachian tube dysfunction symptoms worse?
flying, climbing a mountain, or scuba diving
- when the external air pressure changes and the middle ear pressure cannot equalise to the outside pressure
74
What are some non-surgical management options for Eustachian tube dysfunction
1. Can just wait for it to resolve spontaneously (e.g., recovering from the viral URTI)
2. Valsalva manoeuvre (holding nose and blowing into it to inflate the Eustachian tube)
- Otovent = over the counter device where pt blows into a balloon using a single nostril (can help inflate the Eustachian tube, clear blockages and equalise pressure)
3. Decongestant nasal sprays (short-term only)
4. Antihistamines and a steroid nasal spray for allergies or rhinitis
75
Surgery may be required for severe or persistent cases of eustachian tube dysfunction.
Other than treating other pathology that might be causing symptoms (eg. adenoidectomy), name 2 surgical options.
1. Grommets —> tiny tubes inserted into the tympanic membrane
- allows air/fluid from the middle ear to drain through the tympanic membrane to the ear canal
- grommets typically fall out within a year
2. Balloon dilatation Eustachian tuboplasty
- involves inserting a deflated balloon into the Eustachian tube, inflating the balloon for a short period (eg. 2 mins) to stretch the Eustachian tube, then deflating and removing it
76
What genetic inheritance pattern is otosclerosis?
Autosomal dominant
- typically affects young adults
77
In otosclerosis, there is abnormal bone remodelling of the malleus, incus, and stapes.
Which part of the small bones in the middle ear is mainly affected in otosclerosis & what type of hearing loss?
base of the stapes, where it attaches to the oval window, causing stiffening and fixation and preventing it from transmitting sound effectively —> it causes conductive hearing loss
78
10% of otosclerosis patients have a 'flamingo tinge' on otoscopy, what is this caused by?
caused by hyperaemia (excess blood vessels) —> due to replacement of normal bone by vascular spongy bone
79
Audiometry is the initial investigation of choice for osteosclerosis & tympanometry can also be done.
what are the findings of each?
1. Aduiometry --> conductive HL pattern
- bone conduction readings will be normal (0-20 dB), whereas air conduction readings will be greater than 20dB
- hearing loss tends to be greater at lower frequencies
2. Tympanometry --> will show generally reduced admittance (absorption) of sound
- the tympanic membrane is stiff and non-compliant and does not absorb sound, reflecting most of it back
80
What are the management options for otosclerosis?
Conservative —> hearing aids
.
Surgical:
- stapedectomy —> involves removing entire stapes bone and replacing it with a prosthesis (prosthesis attaches to oval window and hooks around incus - transmitting sound from the incus to the cochlea in the same way the stapes normally would)
- stapedotomy —> involves removing part of the stapes bone and leaving the base of the stapes (the footplate) attached to the oval window, a small hole is made in the base of the stapes for the prosthesis to enter, and a prosthesis is added to transmit sound from the incus to the cochlea.
81
Cholesteatoma is an abnormal growth of _________ _______ ________ in the middle ear.
Cholesteatoma is an abnormal growth of **keratinised squamous epithelium** in the middle ear.
82
What are the main features of cholesteatoma?
- foul-smelling, non-resolving discharge
- hearing loss —> unilateral conductive HL
83
What is a major risk factor for cholesteatoma?
Being born with a cleft palate increases the risk of cholesteatoma around 100 fold
- it affects Eustachian tube dysfunction --> creates negative pressure whcih causes a retracted tympanic membrane provides an area for keratin (byproduct of skin) to accumulate
84
'attic crust' on otoscopy - what is the diagnosis?
Cholesteatoma
- 'attic crust' --> yellow-white crust/debris
85
What is the management of cholesteatoma?
1. Patients are referred to ENT for consideration of surgical removal
- CT head —> can be used to confirm the diagnosis and plan for surgery
- MRI —> may help assess invasion and damage to local soft tissues
86
What are some management options for impacted/excessive ear wax?
- ear drops —> olive oil OR sodium bicarbonate 5% OR almond oil
- ear irrigation —> squirting water in the ears to clean away the wax
(AVOID inserting cotton buds into the ear —> this can press the wax in further and cause impaction)
87
When should treatment for ear wax (eg. ear drops/ear irrigation) not be given?
(Note: treatment should NOT be given if a tympanic perforation is suspected or if the pt has grommets)
88
1. What type of tinnitis requires imaging as there may be an underlying vascular cause?
2. What is the 1st-line imaging for tinnitus?
1. Pulsatile tinnitus
2. MRI of the internal auditory meatuses (IAM) OR MRA
89
What are some red flags for tinnitus?
- Unilateral tinnitus
- Pulsatile tinnitus
- Hyperacusis (hypersensitivity, pain or distress with environmental sounds)
- Associated unilateral hearing loss
- Associated sudden onset hearing loss
- Associated vertigo or dizziness
- Headaches or visual symptoms
- Associated neurological symptoms or signs (e.g., facial nerve palsy or signs of stroke)
- Suicidal ideation related to the tinnitus
90
Why is prompt traetment of an auricular haematoma needed?
To avoid the formation of 'cauliflower ear'
- a build up of blood between the cartilage and perichondrium can restrict blood supply and lead to necrosis of the connective tissue
91
What is the management of an auricular haematoma?
- **Auricular haematomas need same-day assessment by ENT**
1. **Incision and drainage has been shown to be superior to needle aspiration**
(+/- a drainge wick depending on size)
92
Where does bleeding originate from in an anterior nosebleed?
Kiesselbach’s plexus in Little’s area (an area of the nasal mucosa at the front of the nasal cavity that contains a lot of blood vessels)
93
Where does bleeding originate from in a posterior nosebleed?
branches of the sphenopalatine artery
- more severe, higher risk of aspiration of blood
94
Epistaxis management.
Patient is haemodynamically stable, what are your first aid measures to control the nosebleed?
1. ask the pt to sit down and lean their head forward —> *this decreases blood flow to the nasopharynx*
2. Pinch/squeeze the soft (cartilaginous) area of the nose firmly —> this should be done for 10-15 mins
3. ask pt to breathe through their mouth
(Note: ask pt to spit out any blood rather than swallowing —> reduces risk of aspiration)
95
Epistaxis management.
A patient has presented with a nosebleed, first aid measures have been done, but the bleeding has not stopped and it has been 10-15 minutes of continuous pressure on the nose. What is your management?
If bleeding does not stop after 10-15 mins of continuous pressure on the nose —> it is considered severe
.
1. **Nasal cautery using silver nitrate + Naseptin afterwards** —> *if anterior bleed and can see bleed point*
- not so well-tolerated in younger children
- ask pt to blow their nose in order to remove any clots (bleeding may resume)
- only cauterise one side of septum, as there is risk of perforation
2. **Nasal packing —> *if cautery not viable or bleeding point cannot be visualised***
- If low*-*volume bleeding, but no obvious bleed point —> *nasal packing (tranexamic acid soaked nasopore pack)*
- If high-volume bleeding —> *Rapid Rhino pack*
(note: remove pack after 24hrs and reassess —> *nasal examination +/- cautery)*
96
Surgery for epistaxis should be reserved for when all emergency management has failed. What surgery is done?
sphenopalatine artery ligation
97
Once epistaxis has been managed and the patient is ready to be discharged, what should you discharge the patient with?
Naseptin nasal cream (or vaseline) —> QDS for 10 days to reduce crusting, inflammation (vestibulitis), and infection
98
What group of people should you NOT prescribe Naseptin nasal cream to?
Naseptin is contraindicated in peanut or soya allergy
99
What is Samter's triad?
- nasal polyps + ...?
nasal polyps + asthma + aspirin sensitivity (intolerance)
100
What features of nasal polyps would be a red flag for malignancy?
unilateral symptoms or bleeding
101
All patients with suspected nasal polyps should be refereed to ENT for a full examination.
What medication can be given to shrink polyp size in around 80% of patients?
Topical corticosteroids —> intranasal steroid drops or spray
102
What type of Ig & what type of hypersensitivity reaction is allergic rhinitis?
IgE-mediated type I hypersensitivty reaction
(type I is immediate hypersensitivity mediated by IgE antibodies - eg. hives, asthma, anaphylaxis)
- When IgE binds to a specific allergen, it triggers the release of inflammatory chemicals like histamine
103
How is allergic rhinitis diagnosed & what can be useful in determining the trigger?
Diagnosis based on clinical features:
- sneezing, bilateral nasal obstruction, discharge, itchy/red/swollen eyes etc. + a trigger (eg. tree pollen, dust mites, pets etc.)
.
- Skin prick testing can be useful to determine the trigger
104
What is the initial management of allergic rhinitis?
- conservative + mild-to-moderate symptoms
1. Avoid the triggerl/allergen
2. Mild-to-moderate intermittent, or mild persistent symptoms —> **oral or intranasal antihistamines**
- Non-sedating antihistamines: cetirizine, loratadine, and fexofenadine
- Sedating antihistamines: chlorphenamine (Piriton), promethazine
*(note: intranasal antihistamines are good for rapid onset symptoms in response to a trigger)*
105
How is moderate-to-severe persistent symptoms of allergic rhinitis (or initial drug treatment ineffective) managed?
Intranasal corticosteroids —> eg. fluticasone and mometasone
106
How is a septal haematoma managed?
surgical drainage + IV antibiotics
107
Why is urgent treatment of a septal haematoma needed?
If untreated irreversible septal necrosis may develop within 3-4 days
- this is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis
- this may result in a 'saddle-nose' deformity
108
Label the paranasal sinuses & which sinus is most commonly infected?
- Maxillary sinus --> largest sinus
109
Usually sinusitis is caused by a viral infection (eg. URTI, recent local infection), this can sometimes predispose to bacterial sinusitis (if sinus drainage is blocked and allows bacteria to thrive).
What are the most common infectious agents in acute bacterial sinusitis?
- bacterial (2)
- viruses (1)
- Streptococcus pneumoniae
- Haemophilus influenzae
- Viral infection --> Rhinoviruses
110
Chronic rhinosinusitis involves a similar presentation to acute sinusitis but with a duration of more than 12 weeks.
Name 3 features associated with chronic rhinosinusitis.
Hints:
- a risk factor
- due to nasal obstruction
- may produce a chronic cough
- may be associated with nasal polyps, which are growths of the nasal mucosa
(two types of chronic rhinosinusitis: CRS with nasal polyps, CRS without nasal polyps)
- ‘mouth breathing’ - due to nasal obstruction
- post-nasal drip —> may produce a chronic cough
111
What is 'double sickening' in sinusitis?
where an initial viral sinusitis worsens due to secondary bacterial infection
- due to blocked drainage of sinus creating an environment for bacteria to grow in
112
What investigation for persistent sinusitis symptoms, despite treatment?
- Nasal endoscopy
- CT scan
113
What is the management for acute sinusitis?
1. Analgesia
2. NICE recommend NOT offering antibiotics to patients with symptoms for up to 10 days
**—> most cases are caused by a viral infection and resolve within 2-3 weeks.**
3. 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
- If worsening or not improving within 7 days —> give a delayed antibiotic prescription (eg. phenoxymethylpenicillin first-line)
114
What are red flag symptoms for sinusitis?
- **unilateral symptoms**
- **persistent symptoms despite compliance with 3 months of treatment**
- epistaxis
115
What is the management of recurrent or chronic rhinosinusitis (ie. > 12 week duration of symptoms)?
- Avoid allergen
- Intranasal corticosteroids —> e.g., mometasone or fluticasone
(steroid nasal sprays or drops)
(oral corticosteroids for severe cases)
- Nasal irrigation with saline solution
- Functional endoscopic sinus surgery (FESS)
116
Rhinitis VS Rhinosinusitis - locations affected
- Rhintitis - nasal mucosa
- Rhinosinusitis - nasal mucosa + paranasal sinuses
117
The most common cause of tonsillitis is a viral infection, however bacterial cause is more serious.
What are the most common causative organisms of bacterial tonsillitis?
1. Group A streptococcus (Streptococcus pyogenes)
.
Other causes:
- Haemophilus influenzae
- Morazella catarrhalis
- Staphylococcus aureus
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Waldeyer's tonsillar ring is a ring of lymphoid tissue, primarily tonsils and adenoids, located in the upper part of the throat. This ring serves as a crucial part of the body's immune system, filtering and trapping pathogens entering through the nose and mouth.
Label the 4 key tonsils that make up this ring & which tonsil is most commonly affected in tonsillitis?
- Palatine tonsils - located either side of the throat
- Pahryngeal tonsil (adenoids) - located in the back of the nasopharynx (upper part of throat)
- Lingual tonsils - located at the base of the tongue
- Tubal tonsils - located near the openings of the Eustachian tubes in the nasopharynx
119
What is the Centor criteria used to estimate the probability that tonsillitis is due to a bacterial infection, and will therefore benefit from antibiotics?
A point is given if each of the following features are present:
- Fever over 38ºC
- Tonsillar exudates
- Absence of cough
- Tender anterior cervical lymph nodes (lymphadenopathy)
.
- a score ≥3 gives a 40 – 60 % probability of bacterial tonsillitis —> it is appropriate to offer antibiotics
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The FeverPAIN score is an alternative to the Centor criteria, it is again used to estimate the probability that tonsillitis is due to a bacterial infection, and will therefore benefit from antibiotics?
A point is awarded for each of the following features:
- Fever during previous 24 hours
- P – Purulence (pus on tonsils)
- A – Attended within 3 days of the onset of symptoms (ie. symptoms have come on in the last 3 days)
- I – Inflamed tonsils (severely inflamed)
- N – No cough or coryza
.
- score of 2 – 3 —> gives a 34 – 40% probability of bacterial tonsillitis
- score of 4 – 5 —> gives a 62 – 65% probability of bacterial tonsillitis
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In bacterial tonsillitis, what is the choice of antibiotic used?
1. 10-day course of Penicillin V (aka. phenoxymethylpenicillin) —> 1st-line
- it has a relatively narrow spectrum of activity + is effective against Strep. pyogenes
.
- If penicillin allergy —> Clarithromycin is the first-line choice
122
Name 2 complications of tonsillitis.
- Peritonsillar abscess (quinsy)
- Otitis media —> if the infection spreads to the inner ear
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When should surgery be considered in tonsilitis?
- number of tonsillitis episodes
- peritonsillar abscess criteria
- another reason (hint: pt's partner says they sometimes stop breathing in their sleep + daytime sleepiness)
Tonsillitis episodes:
- - 7 or more episodes in 1 year
- 5 per year for 2 years
- 3 per year for 3 years
.
Peritonsillar abscess (quinsy) if unresponsive to standard treatment OR if recurrent tonsillar abscesses (2 episodes)
.
- obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
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What is the main significant complication after a tonsillectomy?
Post-tonsillectomy bleeding (occurs in up to 5%) —> pt needs to be urgently admitted and bleed needs to be managed + go back into surgery
- high risk of aspiration of blood
125
Name some characteristc features of a periotonsillar abscess (quinsy)
- Severe throat pain, which lateralises to one side
- Deviation of the uvula to the unaffected side
- Trismus (difficulty opening the mouth)
- Reduced neck mobility
- “hot potato voice” —> change in voice due to the pharyngeal swelling
- symptoms/signs of fever
126
What is the management of a peritonsillar abscess (quinsy)?
1. Needle aspiration OR surgical incision & drainage + IV antibiotics
- co-amoxiclav is often used
- Consider tonsillectomy to prevent recurrence
127
How is infectious mononucleosis (EBV) diagnosed?
NICE guidelines suggest FBC and Monospot (heterophile antibody test) in the 2nd week of the illness to confirm a diagnosis of glandular fever
128
Why should contact sports be avoided for 4 weeks in patients with infectious mononucleosis (EBV)?
- 50% of pts have splenomegaly --> predisposes to splenic rupture
129
What test is used to diagnose obstructive sleep apnoea (OSA)?
Sleep studies (polysomnography)
- monitoring of pulse oximetry at night
(OR full polysomnography --> where wide rang eof physiological factors are measured)
130
What is the management of obstructive sleep apnoea (OSA)?
1. Weight loss
2. CPAP (continuous positive airway pressure) —> 1st-line for moderate or severe OSAHS
- provides continuous pressure to maintain the patency of the airway
3. Intra-oral devices (e.g. mandibular advancement) —> may be used if CPAP is not tolerated or for pts with mild OSAHS where there is no daytime sleepiness
(Note: surgery is rarely used)
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What is laryngomalacia?
The most common congenital laryngeal abnormality —> characterised by flaccidity of the supraglottic structures
(accounts for 60-70% of cases of congenital stridor)
- the larynx is soft and floppy as a result and collapses during breathing
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What is the disease course & what is the management of laryngomalacia?
99% of cases resolve spontaneously by 18-24 months —> resolves as the larynx matures, grows, and can better support itself (preventing it from flopping over the airway)
1. Symptomatic relief —> hyperextending the neck during episodes of stridor
2. Surgical intervention —> only required with severe respiratory distress
(eg. tracheostomy)
133
Laryngopharyngeal reflux is a common condition caused by GORD, it is thought to account for around 10% of ENT referrals.
What are some common symptoms that patients will have?
- sensation of a lump in the throat ('globus') --> 70%
- hoarseness (70%)
- chronic cough (50%)
- dysphagia (35%)
- heartburn (30%)
134
Name 3 red flags of laryngopharyngeal reflux.
- persistent, unilateral throat discomfort
- dysphagia, odynophagia (i.e. with food rather than just saliva)
- persistent hoarseness
135
What is the causative organism of epiglottitis & why is epiglottitis rarely seen now in the UK?
Haemophilus influenzae type B
- rare now due to the HiB vaccine
(Note: epiglottitis used to be a disease of childhood, but in the UK it is now more common in adults due to the vaccination programme)
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What is the management of laryngopharyngeal reflux?
1. lifestyle measures --> possible triggers include fatty foods, caffeine, chocolate and alcohol
- proton pump inhibitor (omeprazole, lansoprazole)
- sodium alginate liquids (e.g. Gaviscon)
137
Name some characteristic features of epiglottitis.
- Rapid onset
- High temperature, generally unwell
- Stridor
- Drooling of saliva
- ‘tripod’ position —> the pt finds it easier to breathe if they are leaning forward and extending their neck in a seated position
- sore throat
- dysphagia
- muffled ‘hot potato’ voice
(in exams --> suspect epiglottitis in an unvaccinated child with a high fever, sore throat, dysphagia, and drooling)
138
Diagnosis of epiglottitis is clinical as it is a life-threatening condition.
However, if a lateral x-ray is done (ofetn when a foreign body is suspected), what characteristic sign can be seen in epiglottitis?
‘thumb sign’ (swelling of the epiglottis)
(image shows normal epiglottitis on the left and inflamed one on the right)
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What is the management of epiglottitis?
If suspected do NOT examine the throat due to the risk of acute airway obstruction
1. Get help --> senior paediatrician & anaesthetist
2. Airway support:
- **Endotracheal intubation** may be necessary to protect the airway
- tracheostomy through the neck if the airway closes
3. Oxygen + IV antibiotics (eg. ceftriaxone)
(note: oxygen may be administered by holding the mask close to the child but not putting it on them)
140
What is the most common nerve damage to cause hoarseness and vocal cord palsy?
Recurrent laryngeal nerve
141
What is the 1st-line investigation to visualise vocal cords (eg. in suspected vocal cord palsy or polyps)?
Flexible nasoendoscopy
- a type of laryngoscopy
142
What are the borders of the anterior cervical triangle?
- Superior = inferior border of mandible
- Medial = midline of neck
- Lateral = anterior border of sternocleidomastoid
143
What are the borders of the posterior cervical triangle?
- Anterior = posterior margin of sternocleidomastoid
- Posterior = anterior margin of trapezius
- Inferior = middle 1/3 of clavicle
144
Enlargement of what lymph node/s are concerning and warrant further investigation?
Supraclavicular lymph nodes
- Left sided (Virchow's node) --> associated with abdominal malignancies (esp. gastric cancer)
- Right sided --> can be linked to cancers in the mediastinum (space between the lungs) or thyroid/lung/oesophagus
145
What is the 1st-line investigation for neck lumps?
Ultrasound
146
What are the NICE guidelines for a 2 week wait (2WW) ENT referral for a neck lump?
- An unexplained neck lump in someone aged 45 or above
- A persistent unexplained neck lump at any age
--> they recommend an ultrasound in patients with a lump that is growing in size
147
A differential of a neck lump is a lymphoma, lymphadenopathy is the key presenting symptom, they are characteristically non-tender and "rubbery".
What are B symptoms associated with lymphoma?
- Fever
- Weight loss
- Night sweats
148
What do Reed-Sternberg cells in a lymph node biopsy indicate?
Hodgkin's lymphoma
149
What is the Lugano (used to be Ann Arbor) classification for Hodgkin's and non-Hodgkin's lymphoma
- Stage 1 --> Confined to one node or group of nodes
- Stage 2 --> In more than one group of nodes but on the same side of the diaphragm (either above or below)
- Stage 3 --> Affects lymph nodes both above and below the diaphragm
- Stage 4 --> Widespread involvement, including non-lymphatic organs, such as the lungs or liver
150
Carotid body tumours (also called paragangliomas) are usually benign, slow-growing, painless, pulsatile, and located in the upper anterior triangle of the neck (near the mandible).
What nerves can a carotid body tumour press on?
- CN IX (glossopharyngeal), X (vagus), XI (accessory), XII (hypoglossal) --> may result in a Horner's syndrome
- Ptosis
- Miosis
- Anhidrosis (loss of sweating)
151
Branchial cysts often present during intercurrent URTIs. They tend to present in adolescent years and will present with URTIs.
- Where are branchial cysts located?
- Where are branchial cysts most likely to originate from?
- anterior to the sternocleidomastoid muscle, round, soft and non-tender
- most likely to originate from the second branchial cleft
152
A midline neck lump that moves up with swallowing & on protrusion of the tongue, what is it?
A thyroglossal duct cyst
- This occurs due to the connection between the thyroglossal duct and the base of the tongue
153
What are the majority of head and neck cancers?
Squamous cell carcinoma (SCC) --> 90%
154
What are some red flags for head and neck cancer?
- Lump in the mouth or on the lip
- Unexplained ulceration in the mouth lasting more than 3 weeks
- Erythroplakia or erythroleukoplakia
- Persistent neck lump
- Unexplained hoarseness of voice
- Unexplained thyroid lump
155
Head and neck cancers are managed by an MDT and involve the use of chemotherapy/radiotherapy, surgery, targeted cancer drugs, and palliative care.
What drug is used to treat SCCs of the head/neck?
Cetuximab (monoclonal antibody)
- works by targeting a protein called EGFR (epidermal growth factor receptor) found on the surface of some cancer cells
- cetuximab binds to EGFR and prevents the receptor from being activated by growth factors (ligands)
- this blockade inhibits the signalling pathways that promote cancer cell growth and survival
156
What is gingivitis usually secondary to?
poor dental hygiene
157
How does the presentation of simple gingivitis and acute necrotising gingivitis differ?
- Simple gingivitis —> painless, red swelling of the gum margin which bleeds on contact
- Acute necrotizing ulcerative gingivitis —> painful bleeding gums with halitosis and punched-out ulcers on the gums
(anaerobic bacteria usually cause this)
158
What are some risk factors for gingivitis?
- Plaque build-up on the teeth (inadequate brushing) —> ie. poor dental hygiene
- Smoking
- Diabetes
- Malnutrition
- Stress
159
What is the management of simple gingivitis?
1. advise to seek routine regular review by a dentist
2. stop smoking, good oral hygiene, chlorhexidine mouthwash
(antibiotics are NOT usually necessary)
160
What is the management of acute necrotising ulcerative gingivitis?
1. Refer the patient to a dentist, meanwhile the following is recommended:
- oral metronidazole for 3 days (BNF also suggest that amoxicillin may be used)
- chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash
- simple analgesia
161
What is leukoplakia?
Precancerous condition --> increase risk of SCC of the mouth
- characterised by white patches in the mouth (buccal mucosa)
- patches cannot be scraped off (fixed in place)
162
Leukoplakia - management
1. Biopsy - to exclude SCC
2. Conservative: smoking cessation + reducing alcohol intake
3. Close monitoring +/- laser removal or surgical excision
163
How is erythroplakia different from leukoplakia and how should you manage it?
Erythroplakia is similar to leukoplakia, except the lesions are red
- also associated with a high risk of SCC --> should be urgently referred to exclude cancer (biopsy)
164
Lichen planus is characterised by Wickham striae (a reticular pattern - 'web-like').
How should lichen planus be managed?
- good oral hygiene
- stopping smoking
- topical steroids
165
Aphthous ulcers are very common, they are small painful ulcers of the mucosa of the mouth. They have a well-circumscribed punched-out, white appearance.
Aphthous ulcers usually heal within 2 weeks, what are some topical treatments that can be used to manage symptoms?
- Choline salicylate (e.g., Bonjela)
- Benzydamine (e.g., Difflam spray)
- Lidocaine
(topical corticosteroids can be used in more severe ulcers --> eg. hydrocortisone buccal tablets applied to the lesion)
166
When should a mouth ulcer be referred via a 2-week-wait pathway?
“unexplained ulceration” lasting over 3 weeks
167
Glossitis is caused by inflammation & atrophy of the papillae of the tongue (giving the smooth appearance)
What are some causes of glossitis?
("beefy")
- Iron deficiency anaemia
- B12 deficiency
- Folate deficiency
- Coeliac disease
- Injury or irritant exposure
168
Name the top 3 causes of angioedema.
- Allergic reactions --> histamine release causes blood vessels to leak fluid into the tissues
- ACE inhibitors --> increasing the activity of bradykinin, a peptide that can cause inflammation and fluid leakage
- C1 esterase inhibitor deficiency (hereditary angioedema) --> disrupting the normal regulation of the kinin system, specifically by allowing uncontrolled production of bradykinin
169
What are some common factors that predispose someone to develop oral candidasis?
- 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
170
What are some treatment options for oral candidasis?
- Miconazole gel
- Nystatin suspension
- Fluconazole tablets (in severe or recurrent cases)
171
What are the 2 key causes of strawberry tongue?
- Scarlet fever
- Kawasaki disease
172
Despite the name, black hairy tongue can be brown, green, pink etc.
What is black hairy tongue?
- results from decreased shedding (exfoliation) of keratin from the tongue’s surface (filiform papillae)
(the papillae elongate and take on the appearance of hairs)
173
What are some predisposing factors for black hairy tongue?
- poor oral hygiene/dry mouth/smoking/dehydration
- antibiotics
- head and neck radiation
- HIV
- intravenous drug use
174
What is the management of black hairy tongue?
The tongue should be swabbed to exclude Candida.
- Tongue scraping/gentle brushing
- adequate hydration
- stopping smoking
- Topical antifungals (if Candida)
175
What are the three pairs of major salivary glands, and what type of secretion does each produce?
- Parotid: Serous secretion (watery, enzyme-rich); most common site of salivary gland tumours
- Submandibular: Mixed serous and mucous secretion; most common site of salivary stones (sialolithiasis)
- Sublingual: Primarily mucous secretion
176
What is the most common type of salivary gland tumour?
pleomorphic adenoma --> most commonly in the parotid gland
177
Warthin's tumour is a type of benign parotid tumour, what group of people is it more commonly seen in?
Typically affects middle-aged males + smokers
178
What are the clinical features of salivary gland stones?
Recurrent unilateral pain and swelling during or after meals (saliva stimulation)
179
What rapidly progressive and potentially life-threatening infection of the floor of the mouth can an infected salivary gland stone result in? (relatively rare)
Ludwig’s angina (submandibular space infection) --> can lead to airway obstruction
(treatment involves airway support & antibiotic therapy)
180
Which gland is most commonly affected by salivary stones, and why?
Submandibular gland (80%)
- Due to its longer and upward course of Wharton’s duct, and more mucous secretion which predisposes to stone formation
(Wharton's duct = a thin tube that carries saliva from the submandibular gland to the oral cavity)
181
How are salivary gland stones diagnosed and managed?
- Plain X-rays --> may detect radiopaque stones
- Sialography (contrast imaging of duct) --> can visualise non-opaque stones
Management: surgical removal, hydration, sialogogues (eg. lemon drops)
(sometimes antibiotics if infected)
182
A patient presents with bilateral parotid swelling, fever, and malaise.
What is the likely viral cause & what can prevent this?
- Mumps is the most common viral cause of parotid gland enlargement
(prevention with MMR vaccine)
183
A patient presents with unilateral parotid gland swelling, fever, and purulent discharge from the duct.
What is the most likely cause & how would you treat this?
- Acute bacterial sialadenitis often affects the parotid gland --> Staph. A is most common cause
- Common in elderly, dehydrated, or immunocompromised patients (eg. diabetic pts)
- Treatment: IV antibiotics, rehydration, sialogogues, and drainage if abscess forms
184
What autoimmune condition can cause chronic salivary gland enlargement?
1. Sjögren’s syndrome: chronic autoimmune disease affecting exocrine glands
Presents with:
- Xerostomia (dry mouth)
- Keratoconjunctivitis sicca (dry eyes)
- Bilateral parotid swelling
.
- Sicca syndrome refers to dry eyes and dry mouth without autoimmune features of Sjögren's
.
--> commonly assocaited with rheumatoid arthritis
185
What is the management of a pleomorphic adenoma?
Routine surgical excision —> to avoid the chance of malignant transformation
186
Why can pleomorphic adenomas present with:
- **Xerostomia** (dry mouth)
- **Keratoconjunctivitis sicca** (dry eyes)
- **Bilateral parotid swelling and potential facial nerve palsy**
- The tumours can exert pressure on the salivary and lacrimal glands, leading to reduced saliva and tear production
- If tumours grow, they can cause swelling
(while most pleomorphic adenomas are benign, they can turn malignant which leads to more swelling/compression)
187
What are risk factors for head and neck cancer (SCC)?
- Smoking
- Alcohol
- chewing betel quid (a habit in south-east Asia)
- HPV-16 (strain 16)
- EBV
188
Describe the TNM staging of head and neck cancer
Staging (TNM) or stages 1-4:
- Tumour (size of tumour): 1 = small, 4 = large
- Node involvement (has cancer spread to lymph nodes): 0 = no lymph nodes containing cancer cells, 3 = lots of lymph nodes containing cancer cells
- Metastases (whether cancer has spread to another part of the body): M0 = cancer hasn't spread, M1 = cancer has spread
189
How do laryngeal tumours typically present?
1. Glottic tumours
2. Supraglottic tumours
3. Subglottic tumours
- General symptoms
1. Glottic tumours (most common):
- Hoarseness +/- dysphonia +/- stridor (advanced disease)
2. Supraglottic tumours:
- Dysphagia/Odynophagia +/- referred otalgia (ear pain) +/- neck mass
3. Subglottic tumours:
- Dyspnoea/airway obstruction +/- stridor (advanced disease)
- General symptoms: persistent sore throat, weight loss
190
What are vocal cord polyps & what groups of people are at an increased risk?
- Benign growths on the vocal cords due to chronic voice overuse or irritation
- Vocal strain (e.g., singers).
- Smoking or chronic irritation.
191
What are the features of vocal cord polyps & how are they managed?
Symptoms:
- Hoarseness or rough voice.
- Loss of vocal range.
- No associated pain
.
Management:
- Vocal rest, speech therapy.
- Surgery if persistent or large
192
What is a thyroglossal cyst - pathophysiology
- 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
193
Why does unilateral glue ear in an adult require a referral to ENT under a 2-week wait?
? posterior nasal space tumour
- Tumours in the post-nasal space can obstruct the openings of the Eustachian tubes, leading to persistent middle ear effusion
194
2 year old child with neck lump in posterior triangle which transilluminates
Cystic hygroma
195
What is Hutchingson's sign?
Hutchinson's sign: vesicles extending to the tip of the nose. This is strongly associated with ocular involvement in shingles
196
A patient presents with bleeding in the mouth 7 days after a tonsillectomy, what is your management?
Immediate referral to ENT & prescribe antibiotics
- Haemorrhage 5-10 days after tonsillectomy is commonly associated with a wound infection and should therefore be treated with antibiotics
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