ENT Flashcards
(39 cards)
Acute epiglossitis
Px
Ix
Mx
Cause: Hib infection
Presentation: Adults (severe sore throat and dysphagia). Children (irritable, fever, leaning forward, drooling, muffled voice/cry, heaving breathing)
Investigation: Clinical diagnosis. Do not do throat exam.
Management: Leaning patient forwards –> Get ENT surgeon and anaesthetist –> Intubation + IV dex and ceftriaxone
Tonsillitis
Infection agent: >50% due to streptococcus pyogeens
Diagnosis: Clinical. No throat swab.
Scoring: Centor criteria (ant lymphadenopathy, no cough, tonsillar exudate, history of fever).
Management:
- 1st line Antibiotics (7-10 days phenoxymethylpenicillin. If pen allergic, give erythromycin). Indications: Centor criteria met OR systemic upset OR immunocompromised OR history of rheumatic fever.
- 2nd line Tonsillectomy. Indications: Recurrent tonsillitis (>7 eps a year), sore throat, symptoms for >1 year. Complications of haemorrhage (Primary due to inadequate haemostasis. Secondary due to infection) and pain
ENT abscesses
Types
Severity
Cx
Px and mx of each
Two type: Peritonsillar abscess and Parapharyngeal abscess
Severity: ENT emergencies!!
Cause: Complications of tonsillitis
Peritonsillar abscess
- Px: Sore throat, uvular deviation, peritonsillar bulge, dysphagia
- Mx: Abx and aspiration
Parapharyngeal abscess
- Px: Diffuse swelling of the neck
- Mx: Us to location and drainage under GA
Laryngitis
Cx Progression Px Ix Mx Ix to admit
Cause: Viral mostly
Can be secondary to bacterial infection (staph or strep) GORD (“reflux laryngitis”)
Autoimmune e.g. RA
Progression: Self-limiting
Presentation:
- Hoarseness
- Fever
- Pain (hypopharyngeal, dysphagia, on phonation)
Ix: No throat swab. Clinical Dx
Management:
1st line- Conservative
2nd line- 1 week of phenoxymethylpenicillin
Indications to admit:
- Stridor
- Breathing difficulties
- Life threatening emergency e.g. epiglossitis, kawasaki
- Clinical dehydration
Acute sinusitis
Cx
Px
Mx
Causes:
- Obstruction e.g. septal deviation, polyps
- Swimming /diving
- Recent local infection
- Smoking
Causative agents
- Bacteria (Hib, strep pneomoniae)
- Viral (rhinoviruses)
Presentation
- Facial pain (frontal, worse on bending forwards)
- Nasal discharge (purulent and thick)
- Nasal obstruction
Management:
1st line: Analgesia. If symptoms >10 days, take inhaled corticosteroids
2nd line: Oral phenoxymethylpenicillin. If severe symptoms, oral co-amoxiclav
Acute rhinosinusitis
What? i.e. Common cold
Presentation: Nasal discharge, nasal obstruction, facial pain/ pressure, reduced smell, endoscopic/CT signs
Duration: <12 weeks
Progression: 80% self-limiting
Management:
1st line: If <5 days, nothing
2nd line: If >5 days, corticosteroids (mometasone or fluticasone)
Chronic rhinosinusitis
What? RS for >12 weeks. Most commonly inflammation at the middle meatus.
Presentation: Water, anterior rhinorrhoea, purulent post-nasal drip, sneezing, snoring, nasal obstruction, mouth breathing, headaches
Investigations: Anterior rhinoscopy or nasal endoscopy. (Polyps = Pale, mobile, insensitive to touch)
Classification? With or without polyps
Management:
WITH POLYPS
1st line- Steroids (Topical beclometasone for 2 weeks then fluticasone nasap spray for 3 months)
2nd line - Add Abx (Doxy long term)
3rd line - Surgery for ESS (endoscopic sinus surgery) Risk of CSF leakage or CN II damage
WITHOUT POLYPS
1st line- Steroids or saline nasal irrigation
2nd line - If no improvement after 4 weeks, culture and start >12 weeks Abx
3rd line- CT scan and consider surgery
Septal perforation
Cause: Septal surgery, infections, drugs, trauma, SCC
Risk: Progressive enlargement
Management:
1st line- Symptomatic treatment (Saline nasal irrigation, petroleum jelly around edges)
2nd line- Septal prosthesis (“button surgery”)
Foreign body in nasal cavity
Presentation: Organic material –> Purulent unilateral dischage. Inorganic material –> Can remain unnoticed for years
Management:
1st line- Blow nose / parental kiss / removal with forceps. Batteries require URGENT removal
2nd line- ENT referral
Nasal fractures
Cause: Trauma **
Presentation: Facial swelling, nasal deformity, epistaxis , black eyes.
Investigation: Nasal examaintion. Exclude head an c-spine injury. X-ray NOT required. Check for nasal haematoma (risk of complete nasal obstruction. Urgent treatment required if present)
Management:
1st line- Treat epistaxis, analgesia, ice –> Reassess in 5 days. If MUA required, perform 10-14 days after injury
2nd line- Urgent drainage and incision
manipulation under anaesthetic
CSF leakage
Cx
Ix
Mx
Cause: Ethmoid bone fractures, neoplasm
Investigation
1st line: Lab testing for nasal CSF (positive for glucose)
Gold standard: Lumbar puncture (contains high B2 tau transferrin)
Management (if traumatic)
1st line- 7-10days bed with head elevation + Avoid sneezing/coughing/blowing nose + Abx + pneumococcal vaccine +/- lumbar drain
Allergic rhinitis
Presentation: Bilateral red itchy eyes, nasal discharge, pruritis, atopy, sneezing
Signs of auroscope: Mucosa pale, turbinates swollen, nasal polyps present
Management: 1st line- Allergen or irritant avoidance. Saline nasal irrigation 2nd line (mild-mod intermittent or mild persistent symptoms)- Loraditine OD 3rd line (mod-severe intermittent or 2nd line ineffective) - intranasal corticosteroids e.g. mometasone, fluticasone 4th line (cover big life events) - 5-10 days course of prednisolone
Prevention: OD SLIT (sublingual immunotherapy) or allergy vaccine Inj
Epistaxis
Cause:
- Direct trauma
- Injury
- Illicit drug use
- Bleeding disorders e.g. (thrombocytopaenia, leukaemia, haemophilia, ITP, splenomegaly)
- Cold and dry weather
Emergency management
- Gown up and ABCDE
- Pinch lower part of nose for 20 mins + lean forwards
- Ice of dorsum of nose
- Patient to blow out clots. or remove clots gently with forceps
- Vasoconstriction using adrenaline soaked cotton wool for 2 mins OR lidocaine
- Silver nitrate cautery (not of actively bleeding areas. If you cannot see bleeding origin, refer)
- Anterior nasal pack
- Postnasal pack
Management of serious posterior bleed
Options:
- EUA: If bleeding source found, the diathermy or repacking
- Arterial ligation via endoscopy e.g. of sphenopalatine artery
- Embolisation of internal maxillary or facial artery (e.g. lifesaving in stroke risk patients)
Periorbital / preseptal cellulitis
Cause: Infection spread from nearby structures (cellulitis, RTI, sinusitis,
Epidemiology: Children >. Winter months >
Pathogen: Staph aureus, streptocci
Presentation: Eye swelling/pain/redness + fever. *Absent orbital signs * (e.g. pain on movement, RAPD, chemosis, restricted movements, visual disturbance)
DDx: Orbital cellulitis, allergic reaction
Investigation: Bloods (raised ESR and CRP). Culture any discharge. If needing to exclude orbital cellulitis, contrast CT head required.
Management: Refer to secondary care for assessment. Microguide abx = 5 days of flucloxacillin (if pen allergic, doxy or clarithromycin)
Risk: Orbital cellulitis
Labyrinthitis
What? Viral infection of the labyrinth (cochlear and vestibular end organs)
Duration: Acute onset for 1-2 days, then improves over week
Who? 40-70y/o
Presentation:
- Vertigo (exacerbated by movement)
- N/V
- Hearing loss (can be bilateral or unilateral)
- Tinnitus
Signs:
- SNHL
- Abnormal head impulse test
- Unidirectional horizontal nystagmus
DDx:
- Hearing loss excludes vestibular neuritis
Investigation: History and exam. Check BM to exclude hypoglycaemia
Management: Vestibular suppressants e.g. Buccastem oral
Pinna Haematoma
What? Bleeding into the sub-perichondrial plane typically due to blunt trauma
Management: Surgery (incision + primary closure with packing ) AND antibiotic cover with ciprofloxacin
Complications:
- Cauliflower ear due to ischaemic necrosis and subsequent fibrosis
- Infection and loss of cartilage
Acute otitis media
What? Inflammation of the middle ear.
Organisms: Most commonly Streptococcus Pneumonia, haemophilis, moraxella
Presentation:
Symptoms: Rapid onset of pain + Fever. +/- anorexia, vomiting and irritability
Progression: Most cases resolve in 24hrs. If there is sudden relief of pain and purulent discharge, think TM perforation
Investigation:
1st line - Otoscopy (TM bulging, erythma, dilatation of the circumferential vessels)
Management:
1st line- Conservative
2nd line- Antiobiotics. Indications: Systemically unwell, immunocompromised, <3 months old, <2 years old with bilateral OM, perforation + discharge, symptoms for 4 days. What? Amoxicillin for 5 days.
Complications:
Present with continuous discharge
1. Perforation and discharge (Mx: Top Abx)
2. Recurrent AOM (Mx: Expectant treatment, long term Abx, grommet)
3. Acute mastoiditis (Mx: Urgent ENT referral for IV Abx and Surgical drainage)
4. Intracranial sepsis or meningitis (Mx: Urgent referral for IV Abx
5. Facial falsy (Mx: Urgent referral for grommet insertion)
Chronic otitis media
What? Perforation of the TM likely due to recurrent or prolonged infections
Presentation: Otalgia, hearing loss, fullness, otorrhoea
Classification
- Squamous or mucosal
- Active or inactive.
Management:
1st line: Abx (systemic or topical), aural cleaning, water precautions
2nd line: Surgery
Complications:
- Cholesteatoma due to retraction of pars flaccida or tensa leading to epithelium build up
Otitis Externa
What? Inflammation to external ear and canal
Cause: Bacterial infection e.g. Pseudomonas aeruginosa, staph aureus
Precipitating factors:
- Excessive moisture
- Trauma
- Dermatitis (contact or seborrheic )
R/F
- DM
- Radiotherapy to head and neck
Classification:
Timing: <3 months is acute, >3 months is chronic
Severity: Diffuse, localised and malignant
Presentation:
- Hearing loss
- ITCH
- Ear pain
- Discharge
Signs: Red, swollen, eczematous ear canal / external ear
Diagnosis: By examination
Management;:
1st line: Risk factor management. Analgesia. Topical ABx
2nd line: Referral to ENT if… excessive cellulitis / extreme pain / excessive swelling / obstruction to topical Abx. URGENT referral for malignant OE as IV abx required.
Complication:
- Abscess
- Malignant OE
- TM inflammation i.e. OM
Vestibular neuronitis
What? Acute, spontaneous, prolonged, isolated vertigo
Cause? Viral infection leads to inflammation of the vestibular nerve
Presentation
Progression: Acute spontaneous onset. Severe Sx for 1-2 days followed by a few weeks of recovery and improvement
Symptoms:
- Vertigo
- N/V
- NO hearing loss
- NO tinnitus
- NO focal neurology
Signs: Fine horizontal nystagmus
DDx:
- Labyrinthitis
- BPPV
- Meniere’s disease
- Central causes: Migraine, stroke, MS, cerebellar tumour
Investigation: Clinical diagnosis (HiNTs tests excludes posterior circulation stroke)
Management:
Hospital admission indications: Cannot tolerate oral intake. No improvement with 1st line medication after 1 week. Focal neurology. 6 weeks of symptoms
Acute- 1st line Symptomatic relief with antiemetics (if N/V is severe then IM or Buccal prochlorperazine or cyclizine. If moderate N/V then oral prochlorperazine, cinnarazine, cyclizine).
Chronic: Vestibular rehab exercises
Meniere’s disease
What? Disease of the inner ear from an unknown case, associated with endolymph hydrops which would increase pressure
Risk factors: Autoimmunity, female gender, FH, metabolic abnormalities, vascular factor
Presentation:
Symptoms- Vertigo, fluctuating hearing loss and tinnitus in episodes lasting minutes-hrs.
Signs- Nystagmus present. Romberg’s positive
Progression: Most symptoms resolve after 5-10 years but patients left with some degree of HL.
Investigation: Clinical examination/history + audiometry to confirm SNHL
Mangement
In primary care: Refer to ENT for formal audiometry assessment
In secondary care: Audiometry assessment. Prescribe medications for acute attack of N/V and vertigo (Prochlorperazine or anti-histamine). Patient to inform DVLA and take care operating machinery
Hospital admission: Required for severe symptoms to give IV labyrinthine sedative + fluids
Prevention: Beta-histamine trial or vestibular rehab exercises
Sensorineural hearing loss define causes px ddx ix mx prognosis
What? Loss of hearing due to the defect in the oval window of the cochlea or the cochlear nerve
Cause:
Vascular (Cochlear vascular disease)
Inf (Meningitis, Meniere’s, measles, mumps, herpes, TB, syphilis)
Trauma
Autoimmune (MS)
Idiopathic (Presbycusis)-
Drugs (ABx e.g. streptomycin, gentamicin, vancomycin. -“Quines”
Presentation: Onset can vary depending on cause. Usually unilateral hearing loss.
DDx: CHL, OME
Investigations:
In primary care: Detailed history, esp drugs. Rinnes shows AC>BC in affected ear. Weber’s is louder in non-affected ear. Exam EAMeatus and do otoscopy
In secondary care: Formal audiology +/- audiological BS response
Management:
1st line: If inflammatory cause then 4 days oral prednisolone and taper for 8 days
2nd line: If inflammatory cause then intratympanic dexamethasone
Prognosis: Good with 30-65% getting complete/partial resolution
Presbycusis is usually a sensorineural hearing disorder. It is most commonly caused by gradual changes in the inner ear. The cumulative effects of repeated exposure to daily traffic sounds or construction work, noisy offices, equip- ment that produces noise, and loud music can cause sensorineural hearing loss
BPPV
What? Benign paroxysmal positional vertigo
Who? Women> in 50-70s
Precipitating factors: Head injury, ear surgery, prolonge recumbent postition, past inner ear pathology (meniere’s, labyrinthitis, vestibular neuronitis)
Presentation: Repeated episodes of vertigo. Likely to recur and have spontaneous resolution
Diagnosis: Positive Dix-Hallpike manoeuvre
Management:
1st line in primary care: Watchful waiting or Epley manoeuvre. Follow-up in 4 weeks
2nd line: Refer balance specialist if persistent symptoms, S/S atypical, 3+ episodes, Epley manoeuvre cannot be performed or was unsuccessful
Admission to hospital: If N/V prevent oral intake.
Acoustic Schwannoma
Aka acoustic neuroma
What? Indolent, benign subarachnoid tumour. Acts are SoL leading to pressure issues. Forms 90% of cerebellopontine tumours
Presentation:
- Ipsilateral > (if bilateral, think neurofibromatosis type 2)
- Symptoms dependent on CN involved (CN V = Absent corneal reflex. CN VII= Facial palsy. CN VIII = Vertigo, SNHL and tinnitus.
Investigation:
1st line: MRI of cerebellopontine angle + Audiometry
Management:
1st line: Urgent ENT referral. Watchful waiting initially to monitor growth.
