Ear, Nose + Throat Flashcards

Question

categorise sensineural causes of adult hearing loss

Answer 1

``` Sensorineural • Defects of cochlea, cohlear N. or brain. Drugs • Aminoglycosides • Vancomycin Post-infective • Meningitis • Measles • Mumps • Herpes Misc. • Meniere’s • Trauma • MS • CPA lesion (e.g. acoustic neuroma) • ↓B12 ```

Answer 2

Acoustic Neuroma / Vestibular Schwannoma Pathology • Benign, slow-growing tumour of superior vestibular N. • Acts as SOL → Cerebellopontine angle syndrome § 80% of CPA tumours • Assoc. ¯c NF2 Presentation • Slow onset, unilat SNHL, tinnitus ± vertigo • Headache (↑ICP) • CN palsies: 5,7 and 8 • Cerebellar signs

Answer 3

``` Ix • MRI of cerebellopontine angle § MRI all pts. ¯c unilateral tinnitus / deafness • PTA Differential • Meningioma • Cerebellar astrocytoma • Mets Rx • Gamma knife (RadioT) • Surgery (risk of hearing loss) ```

Answer 4

Otosclerosis • AD condition characterised by fixation of stapes at the oval window. • F>M=2:1 Presentation • Begins in early adult life • Bilateral conductive deafness + tinnitus • HL improved in noisy places: Willis’ paracousis • Worsened by pregnancy/ menstruation/ menopause Ix • PTA shows dip (Caharts notch) @ 2kHz Rx • Hearing aid or stapes impla

Answer 5

``` Presbyacussis • Age-related hearing loss Presentation • >65yrs • Bilateral • Slow onset • ± tinnitus Ix: PTA Rx: hearing aid ```

Answer 6

``` Hearing Loss in Children Congenital Causes Conductive • Anomalies of pinna, external auditory canal, TM or ossicles. • Congenital cholesteatoma • Pierre-Robin SNHL • Autosomal Dominant § Waardenburgs: SNHL, heterochromia + telecanthus • Autosomal recessive § Alport’s: SNHL + haematuria § Jewell-Lange-Nielson: SNHL + long QT • X-linked § Alport’s • Infections: CMV, rubella, HSV, toxo, GBS • Ototoxic drugs Perinatal • Anoxia • Cerebral palsy • Kernicterus • Infection: meningitis Acquired Causes • OM/OME • Infection: meningitis, measles • Head injury ```

Answer 7

``` Universal Neonatal Hearing Tests • Detection and Mx of hearing loss before 6mo improves language. • Tests § Otoacoustic emissions § Audiological brainstem responses. ```

Answer 8

``` TM Perforation Causes • OM • Foreign body • Barotrauma • Trauma ```

Answer 9

``` Allergic Rhinosinusitis Classification • Seasonal: hay-fever (prev = 2%) • Perennial Pathology • T1HS IgE-mediated inflam from allergen exposure → mediator release from mast cells. • Allergens: pollen, house dust mites (perennial) Symptoms • Sneezing • Pruritus • Rhinorrhoea Signs • Swollen, pale and boggy turbinates • Nasal polyps ```

Answer 10

Ix • Skin-prick testing to find allergens - Don’t perform if prone to eczema • RAST tests Mx Allergen Avoidance • Regularly washing bedding (inc. toys) on high heat or use acaricides. • Avoid going outside when pollen count high. 1st Line • Anti-histamines: cetirazine, desloratidine • Or, beclometasone nasal spray • Or, chromoglycate nasal spray (children) 2nd Line: intranasal steroids + anti-histamines 3rd Line: Zafirlukast 4rd Line: Immunotherapy • Aim to induce desensitisation to allergen • OD SL grass-pollen tablets → ↑ QOL in hay-fever • Injection immunotherapy Adjuvants • Nasal decongestants: Pseudoephedrine, Otrivine

Answer 11

Sinusitis Pathophysiology • Viruses → mucosal oedema and ↓ mucosal ciliary actions → mucus retention ± 2O bacterial infection • Acute: Pneumococcus, Haemophilus, Moraxella • Chronic: S. aureus, anaerobes Causes • Majority are bacterial infection 2O to viral • 5% 2O to dental root infections • Diving / swimming in infected water • Anatomical susceptibility: deviated septum, polyps • Systemic Disease § PCD / Kartagener’s § Immunodeficiency

Answer 12

``` Symptoms • Pain § Maxillary (cheek/teeth) § Ethmoidal (between eyes) § ↑ on bending / straining • Discharge: from nose → post-nasal drip ¯c foul taste • Nasal obstruction / congestion • Anosmia or cacosmia (bad smell w/o external source) • Systemic symptoms: e.g. fever Imaging • Nasendoscopy ± CT ```

Answer 13

``` Mx Acute / Single Episode • Bed-rest, decongestants, analgesia • Nasal douching and topical steroids • Abx (e.g. clarithro) of uncertain benefit Chronic / recurrent • Usually a structural or drainage problem. • Stop smoking + fluticasone nasal spray • Functional Endoscopic Sinus Surgery - If failed medical therapy Complications (rare) • Mucoceles → pyoceles • Orbital cellulits / abscess • Osteomyelits – e.g. Staph in frontal bone • Intracranial infection § Meningitis, encephalitis § Abscess § Cavernous sinus thrombosi ```

Answer 14

``` The Patient • Male, > 40yrs Sites • Middle turbinates • Middle meatus • Ethmoids Symptoms • Watery, anterior rhinorrhoea • Purulent post-nasal drip • Nasal obstruction • Sinusitis • Headaches • Snoring Signs • Mobile, pale, insensitive Associations • Allergic / non-allergic rhinitis • CF • Aspirin hypersensitivity • Asthma ```

Answer 15

``` Single Unilateral Polyp • May be sign of rare but sinister pathology § Nasopharyngeal Ca § Glioma § Lymphoma § Neuroblastoma § Sarcoma • Do CT and get histology Nasal Polyps in Children • Rare <10yrs old • Must consider neoplasms and CF Mx • Drugs § Betamethasone drops for 2/7 § Short course of oral steroids • Endoscopic polypectomy ```

Answer 16

``` Anatomy • Upper 3rd of nose has bony support • Lower 2/3 and septum are cartilaginous. Hx • Time of injury • LOC • CSF rhinorrhoea • Epistaxis • Previous nose injury • Obstruction • Consider facial #, check for § Teeth malocclusion § Diplopia (orbital floor #) Ix • Cartilaginous injury won’t show and radiographs don’t alter Mx. ```

Answer 17

Mx • Exclude septal haematoma • Re-examine after 1wk (↓ swelling) • Reduction under GA ¯c post-op splinting best w/i 2wks Septal haematoma • Septal necrosis + nasal collapse if untreated § Cartilage blood supply comes from mucosa • Boggy swelling and nasal obstruction • Needs evacuation under GA ¯c packing ± suturing.

Answer 18

``` Causes • 80% unknown • Trauma: nose-picking / #s • Local infection: URTI • Pyogenic granuloma § Overgrowth of tissue on Little’s area due to irritation or hormonal factors. • Osler-Weber-Rendu / HHT • Coagulopathy: Warfarin, NSAIDs, haemophilia, ↓plats, vWD, ↑EtOH • Neoplasm Classification • Anterior • Posterior ```

Answer 19

Initial Mx • Wear PPE • Assess for shock and manage accordingly • If not shocked § Sit up, head tilted down § Compress nasal cartilage for 15min. • If bleeding not controlled remove clots ¯c suction or by blowing and try to visualise bleed by rhinoscopy

Answer 20

Anterior Epistaxis • Usually septal haemorrhage: Little’s area / Kisselbach’s plexus § Ant. Ethmoidal A. § Sphenopalatine A. § Facial A. • Insert gauze soaked in vasoconstrictor + LA § Xylometazoline + 2% lignocaine § 5min • Bleeds can be cauterised ¯c silver nitrate sticks • Persistent bleeds should be packed with Mericel pack § Refer to ENT if this fails or if you can’t visualise the bleeding point. § They may insert a posterior pack or take pt. to theatre for endoscopic control.

Answer 21

Posterior / Major Epistaxis • Posterior packing (+ anterior pack) § Pass 18/18G Foley catheter through the nose into nasopharynx, inflate ¯c 10ml water and pull forward until it lodges. § Admit pt. and leave pack for ~48hrs. • Gold standard is endoscopic visualisation and direct control: e.g. by cautery or ligation.

Answer 22

``` After the Bleed • Don’t pick nose • Sit upright, out of the sun • Avoid bending, lifting or straining • Sneeze through mouth • No hot food or drink • Avoid EtOH and tobacco ```

Answer 23

``` Osler-Weber-Rendu / HHT • Autosomal dominant • 5 genetic subtypes Features • Telangiectasias in mucosae § Recurrent spontaneous epistaxis § GI bleed (usually painless) • Internal telangiectasias and AVMs § Lungs § Liver § Brain • Rarely § Pulmonary HTN § Colon polyps: may → CRC ```

Answer 24

``` Symptoms • Sore throat • Fever, malaise Signs • Lymphadenopathy: esp. jugulodigastric node • Inflamed tonsils and oropharynx • Exudates Organisms • Viruses are most common (consider EBV) • Group A Strep: pyogenes • Staphs • Moraxella ```

Answer 25

Mx • Swabbing superficial bacteria is irrelevant and can → overdiagnosis. • Analgesia: Ibuprofen / Paracetamol ± Difflam gargle • Consider Abx only if ill: use Centor Criteria § Pen V 250mg PO QDS (125mg TDS in children) or erythromycin for 5/7 • NOT AMOXICILLIN → MACPAP RASH IN EBV

Answer 26

``` Centor Criteria • Guideline for admin of Abx in acute sore throat / tonsillitis / pharyngitis 1 Point for each of • Hx of fever • Tonsillar exudates • Tender anterior cervical adenopathy • No cough Mx • 0-1: no Abx (risk of strep infection <10%) • 2: consider rapid Ag test + Rx if +ve • ≥3: Abx ```

Answer 27

``` Tonsillectomy Indications • Recurrent tonsillitis if all the below criteria are met § Caused by tonsillitis § 5+ episodes/yr § Symptoms for >1yr § Episodes are disabling and prevent normal functioning • Airway obstruction: e.g. OSA in children • Quinsy • Suspicion of Ca: unilateral enlargement or ulceration Methods • Cold steel • Cautery Complications • Reactive haemorrhage • Tonsillar gag may damage teeth, TMJ or posterior pharyngeal wall. • Mortality is 1/30,000 ```

Answer 28

``` quinsy - peritonsillar abscess Retropharyngeal Abscess Lemierre’s Syndrome Scarlet Fever Rheumatic Fever post strep GN ```

Answer 29

``` Peritonsillar Abscess (Quinsy) • Typically occurs in adults • Symptoms § Trismus § Odonophagia: unable to swallow saliva § Halitosis • Signs § Tonsillitis § Unilateral tonsillar enlargement § Contralateral uvula displacement § Cervical lymphadenopathy • Rx § Admit § IV Abx § I&D under LA or tonsillectomy under GA ```

Answer 30

``` Retropharyngeal Abscess • Rare • Presentation § Unwell child ¯c stiff, extended neck who refuses to eat or drink § Fails to improve ¯c IV Abx § Unilateral swelling of tonsil and neck • Ix § Lat. neck x-rays show soft tissue swelling § CT from skull-base to diaphragm. • Rx § IV Abx § I&D ```

Answer 31

``` Lemierre’s Syndrome • IJV thrombophlebitis ¯c septic embolization most commonly affecting the lungs. • Organism: Fusobacterium necrophorum • Rx § IV Abx: pen G, clinda, metro ```

Answer 32

``` Scarlet Fever • “Sandpaper”-like rash on chest, axillae or behind ears 12-48h after pharyngotonsillitis. • Circumoral pallor • Strawberry tongue • Rx § Start Pen V/G and notify HPA. ```

Answer 33

``` Rheumatic Fever • Carditis • Arthritis • Subcutaneous nodules • Erythema marginatum • Sydenham’s chorea ```

Answer 34

Post-streptococcal Glomerulonephritis | • Malaise and smoky urine 1-2wks after a pharyngitis

Answer 35

``` Laryngitis • Usually viral and self-limiting • 2O bacterial infection may develop • Symptoms: pain, hoarseness and fever • o/e: redness and swelling of the vocal cords • Rx: Supportive, Pen V if necessary ```

Answer 36

``` Laryngeal Papilloma • Pedunculated vocal cord swellings 2O to HPV • Present ¯c hoarseness • Usually occur in children • Rx: laser removal ```

Answer 37

Recurrent Laryngeal N. Palsy • Supplies all intrinsic laryngeal muscles except for cricothyroideus. § Ext. branch of sup laryngeal N. • Responsible for ab- and ad-uction of vocal folds Symptoms • Hoarseness • “Breathy” voice ¯c bovine cough • Repeated coughing from aspiration (↓ supraglottic sensation) • Exertional dyspnoea (narrow glottis) Causes • 30% are cancers: larynx, thyroid, oesophagus, hypopharynx, bronchus • 25% iatrogenic: para- / thyroidectomy, carotid endarterectomy • Other: aortic aneurysm, bulbar / pseudobulbar palsy

Answer 38

``` Laryngeal SCC • Incidence: 2000/yr in uk • Associations: smoking, EtOH Presentation • Male smoker • Progressive hoarseness → stridor • Dys-/odono-phagia • Wt. loss Ix • Laryngoscopy + biopsy (inc. nodes) • MRI staging Mx • Based on stage • Radiotherapy • Laryngectomy After total laryngectomy • Pts have permanent tracheostomy § Speech valve § Electrolarynx § Oesophageal speech (swallowed air) • Regular f/up for recurrence ```

Answer 39

Laryngomalacia • Immature and floppy aryepiglottic folds and glottis → laryngeal collapse on inspiration ``` Presentation • Stridor: commonest cause in children § Presents w/i first wks of life. • Noticeable @ certain times § Lying on back, § Feeding § Excited/upset • Problems can occur ¯c concurrent laryngeal infections or ¯c feeding. Mx • Usually no Rx required but severe cases may warrant surger ```

Answer 40

``` Epiglottitis Symptoms • Sudden onset • Continuous stridor • Drooling • Toxic Pathogens: haemophilus, Group A Strep Rx • Don’t examine throat • Consult ¯c anaesthetists and ENT surgeons • O2 + nebulised adrenaline • IV dexamethasone • Cefotaxime • Take to theatre to secure airway by intubation ```

Answer 41

Foreign Body • Sudden onset stridor in a previously normal child. • Back slaps and abdominal thrusts. • Needle cricothyrotomy in children • Can only exclude foreign body in bronchus by bronchoscopy

Answer 42

``` Subglottic Stenosis • Subglottis is narrowest part of respiratory tract in children. • Symptoms: stridor, FTT • Causes § Prolonged intubation § Congenital abnormalities • Rx § Mild: conservative § Severe: Tracheostomy or partial tracheal resectio ```

Answer 43

``` Bell’s Palsy • Inflammatory oedema from entrapment of CNVII in narrow facial canal • Probably of viral origin (HSV1). • 75% of facial palsy Features • Sudden onset: e.g. overnight • Complete, unilateral facial weakness in 24-72h § Failure of eye closure (Bell’s Sign) → dryness and conjunctivitis § Drooling, speech difficulty • Numbness or pain around ear • ↓ taste (ageusia) • Hyperacusis: stapedius palsy ```

Answer 44

``` Ix • Serology: Borrelia or VZV Abs • MRI: SOL, stroke, MS • LP Mx • Protect eye § Dark glasses § Artificial tears § Tape closed @ night • Give prednisolone w/i 72hrs § 60mg/d PO for 5/7 followed by tapering • Valaciclovir if zoster suspected (otherwise antivirals don’t help). • Plastic surgery may help if no recovery ```

Answer 45

Prognosis • Incomplete paralysis usually recovers completely w/i wks. • With complete lesions, 80% get full recovery but the remainder have delayed recovery or permanent neurological / cosmetic abnormalities. Complications: Aberrant Neural Connections • Synkinesis: e.g. blinking causes up-turning of mouth • Crocodile tears: eating stimulates unilateral lacrimation, not salivation

Answer 46

• Reactivation of VZV in geniculate ganglion of CNVII Features • Preceding ear pain or stiff neck • Vesicular rash in auditory canal ± TM, pinna, tongue, hard palate (no rash = zoster sine herpete) • Ipsilateral facial weakness, ageusia, hyperacusis, • May affect CN7 → vertigo, tinnitus, deafness Mx • If Dx suspected give valaciclovir and prednisolone w/i first 72h Prognosis • Rxed w/i 72h: 75% recovery • Otherwise: 1/3 full recovery, 1/3 partial, 1/3 poor

Answer 47

``` May be suggested by • Bilateral symptoms (Lyme, GBS, leukaemia, sarcoid) • UMN signs: sparing of frontalis and orbicularis oculi • Other CN palsies (but seen in 8% of Bell’s) • Limb weakness • Rashes Intracranial Lesions • Vascular, MS, SOL § Motor cortex → UMN signs § Brainstem nuclei → LMN signs • Cerebellopontine angle lesion § May be accompanied by 5th, 6th, and 8th CN palsies Intratemporal Lesions • Otitis media • Cholesteatoma • Ramsay Hunt Syndrome Infratemporal • Parotid tumours • Trauma Systemic • Peripheral neuropathy § Demyelinating: GBS § Axonal: DM, Lyme, HIV, Sarcoid • Pseudopalsy: MG, botulism ```

Ear, Nose + Throat Flashcards

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