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Year 6 - Surgery > Firms: ENT > Flashcards

Firms: ENT Flashcards

1
Q

What bones can you see during otoscopy?

A

The handle of the malleus and the long process of the incus

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2
Q

What forms the majority and minority of the ear drum?

A

Majority - pars tensa

Minority - pars flaccida

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3
Q

How many layers make up the pars tensa?

A

Three - outer keratinising squamous, middle vascularised fibrous connective tissue, inner nonkeratinising squamous

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4
Q

If you’re ever struggling to see what’s going on where should you pay close attention to?

A

The pars flaccida ie the attic

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5
Q

What is the centre point of the tympanic membrane?

A

Umbo which is where any growth begins

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6
Q

What joint pokes into the ear canal and forms the anterior recess?

A

TMJ

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7
Q

Which nerve runs over the top of the stapes?

A

Facial

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8
Q

How does otitis externa present?

A

Discharge +/- pain and may get closing of the EAC w swelling

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9
Q

Which individual should you beware of w otitis externa and why?

A

The elderly diabetic as it may lead to skull base osteomyelitis

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10
Q

What bacteria are responsible for otitis externa?

A

Staph or Strep -> klebsiella, e coli, pseudomonas

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11
Q

Which group of abx are ototoxic?

A

Aminoglycosides

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12
Q

What can otitis externa as the result of strep become? And tx?

A

Spreading cellulitis of the face which requires admission and IV abx

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13
Q

How does acute otitis media present?

A

Pain -> Discharge

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14
Q

Which individual should you beware of w acute otitis media and why?

A

The immunocompromised diabetic male teenager w a headache as they’re more at risk of intracranial comps

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15
Q

What are the features of the ear drum that is affected w acute otitis media?

A

It bulges out towards you esp the pars flaccida + the tympanic membrane is erythematous and injected w dilated blood vessels

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16
Q

What can acute otitis media progress to?

A

Mastoiditis

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17
Q

What are worrying signs in a child w mastoiditis?

A

Look: a clear defined swelling, displacement of the pinna, loss of post auricular creases

Feel: boggy + fluctuant

Move: take the pt to theatre for abscess drainage

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18
Q

What happens if you don’t do anything for a mastoiditis?

A

It can progress to form a posterior mastoid fistula, track down a muscle and become a neck abscess, track back and become a brain abscess

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19
Q

By what route does the pus get from the mastoid into the brain?

A

Through or alongside the veins

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20
Q

What do veins in the head and neck lack?

A

Valves

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21
Q

What is glue ear?

A

Otitis media w effusion

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22
Q

Which individual should you beware of w OME and why?

A

Unilateral glue ear in an adult may indicate nasopharyngeal cancer

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23
Q

What does OME look like down the otoscope?

A

The tympanic membrane looks stretched around the malleus handle and sucked inwards

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24
Q

Tx of OME

A

Arrange a hearing test, watch and wait for 12wks as 90% get better by themselves, otherwise surgical insertion of a grommet

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25
Q

Acute Perf

A

Due to trauma (head injury, barotrauma, cotton buds) + acute otitis media

Often spontaneous recovery which heals from bleeding edges inwards

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26
Q

Chronic Perf

A

If the edge rolls over it will not heal and become chronic

It can be dry/wet if it is wo/w exudate which inc risk of infection

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27
Q

What should you beware of w trauma to the ear?

A

Injured ossicles and inner ear resulting in hearing loss up to 60dB

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28
Q

Tx of TM perf

A

Keep the ear clean and dry, leave alone for 12wks, if persistent surgical mx

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29
Q

Are pts w TM perf allowed to fly?

A

Yes

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30
Q

What is a cholesteatoma?

A

Destructive cyst of middle ear made of keratinised squamous epithelium

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31
Q

What does a cholesteatoma look like on otoscopy?

A

Wax high up in the ear w white shiny appearance

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32
Q

Comps of Cholesteatoma

A

If it grows into the mastoid it will erode local structures - ossciles, facial nerve, chorda tympani, lateral semicircular canal, middle cranial fossa

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33
Q

What would you worry about if a pt w recurrent unilateral ear infections presents w loss of taste?

A

A cholesteatoma that has erroded the chorda tympani

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34
Q

What surgical approach would you take to tx a cholesteatoma?

A

From behind the ear through the mastoid

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35
Q

Which structures should you beware of when approaching from behind the ear? (2)

A

Sigmoid sinus + dura on posterior cranial fossa

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36
Q

Why is unilateral sensorineural hearing loss a red flag?

A

Vestibular Schwannoma

‘If they need the volume high don’t forget the MRI’

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37
Q

Rhinitis v Rhinosinusitis v Acute Sinusitis

A

Rhinitis - inflam of mucosa inside nose, allergic or non-allergic, asthma of the nose

Rhinosinusitis - above + paranasal sinuses usually chronic +/- polyposis

Acute Sinusitis - painful bacterial infection

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38
Q

Rhinitis: Allergic vs Non-Allergic

A

Allergic: seasonal, sx of irritation, mucosa swollen pale bluish

Non-Allergic: year round, block and thick mucus, mucosa swollen speckled pink

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39
Q

What is the instrument used to open the nostril to examine the nose?

A

Thudichum Nasal Speculum

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40
Q

What structures are viewed when looking in a nostril?

A

Septum, inferior turbinate, nasal vestibule

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41
Q

What do children w allergic rhinitis do to

relieve the itch and running watery mucus?

A

The Allergic Salute

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42
Q

What can the allergic salute lead to?

A

The Allergic Crease

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43
Q

How do you dx allergic rhinitis?

A

Clinical Examination + Allergy Testing

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44
Q

How do you classify allergic rhinitis?

A

Mild: normal sleep + no impairment of daily activities

Mod-Sev: abnormal sleep + impairment of daily activities

Intermittent: <4d/wk + <4wks

Persistent: >=4d/wk + >=4wks

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45
Q

Tx of allergic rhinitis

A

Mild Intermittent: avoid allergen, saline nasal douche, non-sedating antihistamine

Mod-Sev Intermittent: add intranasal steroid spray +/- leukotriene receptor antagonist

Mild Persistent: add topical cromone to potentiate the steroid or add an antihistamine

Mod-Sev Persistent: immunotherapy

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46
Q

How do you dx rhinosinusitis?

A

Nasal block + facial pressure, hyposmia, examination findings w nasal endoscope

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47
Q

When does rhinosinusitis become chronic?

A

> 12wks

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48
Q

Where do nasal polyps tend to arise from?

A

The middle turbinate

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49
Q

You find pale fleshy blobs on speculum: swollen turbinate vs polyps

A

Upon prodding it turbinates are highly sensitive + CT scan

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50
Q

Samter’s Triad

A

Asthma
Nasal Polyps
Aspirin Sensitivity

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51
Q

Which pts should you beware of w chronic rhinosinusitis?

A

If sx are unilateral may indicate tumour which the CT scan should pick up

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52
Q

Tx of chronic rhinosinusitis

A

Long term topical steroids to prevent recurring polyps +/- surgery

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53
Q

How does acute sinusitis px?

A

Bilateral facial pain w purulent discharge following a viral URTI

‘Double Sickening’

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54
Q

Which pts should you beware of w acute sinusitis?

A

The immunocompromised diabetic male teenager, may have spread into cranial cavity, scan if px w headache

55
Q

Tx of acute sinusitis

A

Analgesia, abx, one off nasal decongestant

56
Q

What is the problem w prolonged use of nasal decongestants?

A

Rhinitis Medicamentosa + Tachyphylaxis

They work by reducing blood supply to the nose, when it wears off rebound inc of blood flow and congestion, therefore when you have to use more to get the same desired affect

It’s a slow recovery ~12wks whilst the nose unblocks

57
Q

What is the spectrum of sleep-disordered breathing?

A

Simple snoring

Upper airway resistance syndrome

Obstructive sleep apnoea mild-mod-sev

Alveolar hypoventilation syndrome

58
Q

What is the pathophysiology of SDB?

A

Extreme neg intrathoracic pressure, central venous pooling, raised CVP+ICP, increased right+left heart pressure, pulm HTN+cor pulmonale

59
Q

How would you mx SDB?

A

Hx: ask intimate partner + Epworth scale

O/e: check for airway collapse + lymphoid hypertrophy

Ix: flexible endoscopic exam +/- sedation

Tx: wt loss, red alcohol, legal+safety, mandibular advancement device, CPAP available following sleep study, cause dependent surg

60
Q

Which questionnaire measures risk of daytime somnolence?

A

Epworth Scale

61
Q

What is the legal and safety aspect surrounding SBD?

A

Driving or working w heavy machinery

62
Q

Ddx of enlarged neck LNs (5)

A 
Reactive
Metastatic
Lymphoma
Sarcoid
TB
63
Q

What is the workup for neck lymphadenopathy?

A

Hx, examine neck/lungs/ENT inc flexi endoscopy, imaging w USS+FNAC, CT for malignancy, CXR for sarcoid

64
Q

Tx for cancer in the neck

A

H+N Cancer MDT

65
Q

Which muscle does the ant tonsil pillar enclose?

A

Palatoglossus

66
Q

Which muscle does the post tonsil pillar enclose?

A

Palatopharyngeus

67
Q

What are the posterior pillars a good landmark for?

A

Tonsils + Airway Difficulty

68
Q

What is the last bit of the mandible before it becomes the ramus?

A

Retromolar Trigone

69
Q

Which is the most common cancer of H+N?

A

Tonsil

70
Q

What is tonsil and oropharynx cancer a/w?

A

Young - HPV

Old - Smoking

71
Q

How does nasopharyngeal cancer typically present?

A

As a neck lump

72
Q

Which oral cancers are a/w chewing tobacco?

A

Gingiva + Palate

73
Q

Where does nasopharyngeal cancer develop?

A

Fossa of Rosenmüller ie the pharyngeal recess

74
Q

Which ethnic group are at inc risk of nasopharyngeal cancer?

A

SE Asia

75
Q

Which virus are nasopharyngeal cancers a/w?

A

EBV

76
Q

How does laryngeal cancer typically present?

A

Hoarseness +/- worsening dysphagia, aspiration, red tongue movement, neck lump, smoker

77
Q

How many weeks of hoarseness requires an urgent ENT referral?

A

6wks -> Endoscopy

78
Q

What happens if early sx of laryngeal cancer isn’t ix?

A

May px as an airway emerg requiring a tracheostomy

79
Q

What should you do if you find leukoplakia?

A

Biopsy to dx how bad the dysplasia is

80
Q

What do oral papillomas look like?

A

They have a ‘bunch of grapes’ or ‘soap-bubble’ appearance

81
Q

Do papillomas have the potential for malignant transformation?

A

Yes

82
Q

What should you always do before removing a thyroglossal cyst?

A

An USS to ensure theres other thyroid tissue

83
Q

Which procedure is used to mx thyroglossal cysts surgically?

A

Sistrunk’s, removal of the whole tract and middle third of hyoid, prevents recurrence

84
Q

What is a branchial cyst?

A

Embryological remnant from the development of the pharyngeal arches: internal surface (endoderm-pouches) + external surface (ectoderm-clefts)

85
Q

What are the pharyngeal pouches formed by the arches?

A

I: eustachian tube + middle ear

II: palatine tonsil

III: inferior parathyroid glands + thymus

IV: superior parathyroid glands, ultimobranchial body (along w 5th), musculature and cartilage (along w 6th)

86
Q

How do branchial cysts px?

A

Young adult with a smooth firm fluctuant swelling classically a third the way down ant border of SCM

87
Q

What would be the ddx for a branchial cyst?

A

Lipoma

88
Q

Cyst vs Lipoma

A

Transilluminate

89
Q

Sinus vs Fistula

A

Further abnormalities in the embryology

Sinus: blind ending epithelial tract to one surface

Fistula: abnormal communication b/w two epithelial surfaces

90
Q

Mx of Branchial Cyst

A

Dx: USS

Tx: complete excision of cyst and any underlying tract

91
Q

Pleomorphic Adenoma vs Warthin’s Tumour

A

Both benign parotid tumours

PA: any age + slow growing

WT: older men, a/w smoking, ~15% bilateral

92
Q

What should you examine following clinical suspicion of a parotid swelling?

A

The facial nerve as malignant tumours may invade resulting in a palsy

93
Q

Ddx of Parotid Swelling

A

Infection: mumps, syphilis, TB

Inflammation: stones + sarcoidosis

Malignancy: benign, malignant, metastatic, lymphoproliferative

94
Q

Mx of Parotid Tumour

A

Dx: USS+FNAC

Tx: watch and wait -> surgery

95
Q

Ddx of Submandibular Swelling

A

Infection, Stone, Pleomorphic Adenoma

96
Q

Mx of Submandibular Swelling

A

Dx: hx, bimanual palpation, USS+FNAC

Tx: stone retrieval or gland excision

97
Q

What is perichondritis?

A

Spreading infection of the pinna classically from an insect bite

98
Q

What can perichondritis lead to if left untreated?

A

Osteomyelitis via spread through the temporal bone

99
Q

Tx of Perichondritis

A

Remove insect remnants/piercings and broad spectrum abx

100
Q

What is a pinaa haematoma?

A

Blood collects in subperichondrial space resulting in cartilage ischaemia

101
Q

What can a pinna haematoma lead to if left untreated?

A

Cauliflower Ear

102
Q

Tx of Pinna Haematoma

A

Tx the head injury, look in the ear for other injury, incise and drain the pinna

103
Q

Why is oil > water used to flush the ear?

A

It won’t be absorbed by the insect

104
Q

What must be ruled out before dx bells palsy? (4)

A

Stroke
Parotid Ca
Cholesteatoma
Ramsay-Hunt Syndrome

105
Q

Tx of Bells Palsy

A

Eye drops and patch alongside steroid tx +/- vaciclovir

106
Q

Epistaxis: Ant vs Post

A

Ant: 90%, young, trauma irritants preg

Post: 10%, elderly, vasculopathy hypertension atherosclerosis

107
Q

What is the name of the anastomosis b/w the ethmoid and sphenopalatine arteries?

A

Ant: Kiesselbach’s plexus ie Little’s area

108
Q

Tx for Ant Epistaxis

A

Squeeze soft part of the nose for ten mins w the head leaning forwards + if recur consider AgNO3 cautery

109
Q

Tx for Post Epistaxis

A

Pack back>up, probable admission, drug hx, check pharynx for clots, bloods inc G+S

110
Q

What are the diff packing options for post epistaxis?

A

Rapid Rhino
Brighton Balloon
BIPP Ribbon

111
Q

What is the most important part of tx for a fractured nose?

A

Timing: move back on day 0 or ~10 ie before/after the swelling

112
Q

Comp of Nose #

A

Septal Haematoma -> Saddle Nose Deformity

113
Q

What should you worry about w a head injury in a child?

A

NAI

114
Q

How can you tell if the uvula if acc deviated?

A

Look at the base not the tip

115
Q

Where should you first attempt quinsy drainage?

A

Where the lines from the side of the tongue and base of the uvula intersect

116
Q

What is the standardised progression of a quinsy?

A

Tonsillitis, peritonsillar cellulitis, quinsy, parapharyngeal abscess, retropharyngeal abscess, mediastinitis

117
Q

What voice are pts w a quinsy typically said to have?

A

‘Hot Potato’

118
Q

What is Ludwig’s angina?

A

A deep expanding infection around the mylohyoid usually following dental infection

119
Q

How does Ludwig’s angina px? (3)

A

Rounded neck swelling, tongue displacement, stridor

120
Q

Tx of Ludwig’s Angina

A

Secure airway, IV fluids and abx, CT scan and ultimately admit for abscess drainage

121
Q

What position are pts w epiglottitis or other lower airway obstrc said to sit in?

A

Tripod position: neck pushed forward, leaning forward, supporting themselves on their knees

122
Q

Why has the incidence of epiglottitis declined?

A

The HiB vaccine

123
Q

What senior help should you get for a pt w epiglottitis? And tx?

A

A+E, ENT, Anaesthetist

Give adrenaline nebs and consider heliox

124
Q

What is heliox? And why is it effective?

A

80% Helium + 20% Oxygen

As helium has a lower density than nitrogen it makes breathing through a smaller space easier due to Pascal’s law

125
Q

Stridor vs Stertor

A

Stridor: insp (supraglottis-glottis), biphasic (subglottis), exp (tracheal-bronchi)

Stertor: snoring

126
Q

Where is the narrowest diameter in the airway?

A

Subglottis

127
Q

What are possible causes of stridor? (4)

A

Infection
Inflammation
Foreign Body
Trauma

128
Q

What is the most important thing to check in a pt w stridor?

A

Sats > Noise: if the pt starts to tire or the sats drop this is when you escalate

129
Q

What is the life saving emerg trachy?

A

Cricothyroidotomy

Skin - Fat - Membrane - Air

130
Q

What are your thoughts if a pt px w otitis externa has a perf TM?

A

Media -> Externa

131
Q

When would you use a pack > cautery for an epistaxis?

A

Profuse bleeding w site difficult to localise

132
Q

What cancers is the EBV involved with?

A

Nasopharyngeal + Hodgkin’s

133
Q

When do you refer for tonsillectomy?

A

Recurrent acute tonsillitis or quinsy, chronic tonsillitis >3m w halitosis, any airway obstrc

Year 6 - Surgery (27 decks)

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