ENT Flashcards
1
Q
What is vertigo?
A
Hallucination of movement (caused by problem with vestibular system)
2
Q
What are some central causes of vertigo?
A
Stroke
Migraine
Neoplasms
Demylination e.g. MS
Drugs
3
Q
What are some peripheral causes of vertigo?
A
BPPV
Menieres disease
Vestibular Neuronitis
4
Q
How does benign paroxysmal positional vertigo present?
What causes it?
A
Vertigo associated with head movements lasts seconds
Caused by otoliths (crystals) in the semicircular canals (most commonly posterior) causing abnormal stigmatise of the hair cells
5
Q
How is BPPV diagnosed and how is it treated?
A
Diagnosis = Dix-Hallpike
Treatment = Epley manoeuvre
6
Q
What are the clinical features of Ménière’s disease?
What is the pathophysiology?
A
Tinnitus in affected ear
Episodic vertigo lasting minutes to hours associated with N&V
Fluctuating hearing loss
Aural fullness
(over time the disease burns out with no more vertigo but some reduced hearing - due to increased pressure and dilatation of endolymphatic system)
Caused by increased fluid in the endolymphatic compartment (endolymphatic hydrops)
7
Q
What is the management of Ménière’s disease?
A
Dietary - reduce salt, chocolate, caffeine and Chinese food
Medical - thiazide diuretics, prochlorperazine for acute attacks (vestibular sedatives)
Surgical - grommet insertion
PREVENTION = betahistine and vestibular rehab exercises
8
Q
How does vestibular neuronitis present?
A
Incapacitating vertigo lasting several days associated with N&V (after recent viral infection)
No hearing loss
Horizontal nystagmus
(Think in young fit patient)
9
Q
How is vestibular neuronitis managed?
A
Vestibular sedatives during acute attacks (may still have long term vertibular deficits but don’t take vestibular suppressants as it delays recovery)
Resolves eventually - vestibular rehab exercises if chronic
10
Q
How does viral labyrinthitis present?
A
Recent viral infection
N&V
Hearing loss (unlike vestibular neuronitis - hearing is in tact)
Sudden onset
11
Q
How does vertibrobasilar ischaemia present?
A
Elderly
Dizziness on extension of neck
12
Q
How does acoustic neuroma present?
A
Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2
13
Q
What can happen to the external ear?
How is it treated?
A
Lacerations = primary closure with exposed cartilage covered with skin
Haematoma (blood in between cartilage and perichondrium) = drainage and pressure dressing
Tympanic membrane perforation (causes pain and conductive hearing loss) = usually heals by itself (if not my 6 months then myringoplasty)
Haemotympanum (blood in middle ear - can be associated with temporal bone fracture) = treated conservatively
14
Q
How does otitis externa present?
What organisms can cause it?
A
Painful discharging ear (inflamed ear canal)
Muffled hearing due to discharge
Pseudomonas aeruginosa/ staph aureas
15
Q
What is malignant otitis externa?
A
Seen in diabetics / immunecompromised
Infection spreads from soft tissue into bone
Presentation = chronic ear discharge despite treatment, deep seated severe ear pain and cranial nerve palsies
16
Q
what is the management of otitis externa?
What are the risk factors?
A
Topical eardrops
Swab discharge in resistant cases
Microsuction of pus allowing drops to get to infection
If severe then wick can hold canal open
Malignant otitis externa = IV abx and topical treatment
Risk factors = cotton buds, swimming, humidity, immunocompromised
17
Q
What is the epithelium lining the middle ear?
A
Respiratory epithelium (pseudostratified columnar)
18
Q
What are the features of otitis media?
A
Ear pain (caused by increased pressure in tympanic cavity)
Discharge (pain may settle as tympanic membrane ruptures)
Fever
19
Q
What is the management of otitis media?
What are the complications of AOM?
A
Conservative with analgesia
Medical if severe / persistent
Surgery - if recurrent may benefit from grommet
Complications = meningitis, intracranial abscess, sigmoid sinus thrombosis, bacterial labyrinthitis, facial paralysis
20
Q
What are the two types of chronic otitis media?
A
Active / inactive (if discharging)
Then subdivided into mucosal or squamous disease
21
Q
What is active squamous chronic otitis media also known as?
A
Cholesteatoma
22
Q
How does inactive squamous COM act?
A
Retraction pocket which may develop in to active disease (cholesteatoma)
23
Q
What is active mucosal COM?
What is inactive mucosal COM?
A
Active = chronic discharge from middle ear through tympanic membrane perforation
Inactive = tympanic membrane perforation but no active infection / discharge
24
Q
How does mucosal COM develop?
A
Acute episode of AOM - after rupturing of tympanic membrane there is failure to heal
25
How is squamous COM thought to develop?
When **keratinised squamous cells** are introduced to middle ear from perforation
26
How does **active COM** present?
**Chronic ear discharge** and often **conductive hearing loss**
27
What is the **management** of **COM**?
**Cholesteatoma** = surgery
If no cholesteatoma = topical antibiotic drops and aural toilet
28
What is the **risk** with **mastoid surgery**?
Facial nerve palsy
Alteral taste (damage to chorda tympani)
Tinnitus
Vertigo
Complete loss of hearing
29
What is **otitis media with effusion** (glue ear)?
Fluid in middle ear associated with **eustacian tube dysfunction** (post nasal tumours can also cause glue ear)
**OME** is not painful but can become infected and become **AOM**
30
What are the **clinical features** of **glue ear**?
**Middle ear effusion** on **otoscopy**
**Conductive hearing loss** (associated with speech delay)
31
What are the **investigations** for **glue ear**?
**Typanogram** (flat type B tracing with normal canal volumn)
**Pure tone audiogram** (showing conductive hearing loss)
32
What is the **management** of **glue ear**?
Conservative (usually settles in 3 months)
**Heading aid**
**Surgery** - for prolonged hearing loss causing significant problems with Grommets (ventilation tubes) +/- adenoidectomy
33
34
What are the **examination findings** of **otosclerosis**?
Typically normal
Rarely **pink hue** to the tympanic membrane - **Schwartze's sign**
35
What are the **investigations** for **otosclerosis**?
**Typanogram** (normal type A trace)
**Pure tone audiogram** (conductive hearing loss, carhart notch at 2kHz)
36
What is the management of **otosclerosis**?
**Conservative** - hearing loss
**Surgery** - stapedectomy
37
Where is the **inner ear** found?
**Petrous** part of temporal bone
38
What are the **investigations** for **sudden onset sensorineural hearing loss**?
Confirm sensorineural with tuning forks
**Pure tone audiogram**
**MRI scan** (for lesions along central auditory pathway e.g. acoustic neuroma)
39
What is the **management** for **sudden onset sensorineural hearing loss**?
**Steroids** (normall oral but can be injected into middle ear)
**Anti-virals**
**Other treatments** e.g. **hyperbaric oxygen**, carbogen
40
How to perform **tuning fork test**?
With a **256 or 512 Hz tuning fork**
**Weber** = placed on forehead, louder on right / left
Sensorineural = louder on opposite side
Conductive = louder on same side as hearing loss (conductive hearing loss with block out background noise)
**Rinne** = placed on mastoid (conducted to cochlear via temporal bone) then lateral ear
Sensorineural if air conduction is louder (normal)
Conductive if bone conduction is louder
41
How is a **pure tone audiogram** performed?
Hearing threshold assessed at various frequencies
**Air conduction** assessed with headphones
**Bone conduction** is assessed by playing tone through bone conductor over mastoid bone
42
what are the **three possible results from a tympanogram**?
**Tympanogram** = inserting a probe into external ear canal
**Type A** = peak centered on 0 daPa on x axis (normal)
**Type B** = flat tracing (middle ear effusion / perforation)
**Type C** = peak has negative pressure (eustacian tube dysfunction)
43
Label the following:
44
Label the following:
45
What are some **local** and **idiopathic** causes of **nosebleeds?**
**Local** = idiopathic (85%), traumatic, foreign body, inflammatory e.g. rhinitis, neoplastic
**Systemic** = HTN, coagulopathies, vasculopathies
46
What is the **management** of **epistaxis**?
**ABC** (assess for shock )
**First aid** (pinch soft part of nose, head forward, spit out don't swallow)
**Examination** (anterior / posterior bleed)?
**Conservative management** = cautery (silver nitrate / bipolar diathermy), topical adrenaline may help control bleeding before, nasal packing if cautery fails (anterior +/ posterior)
**Surgical management** = under **GA** ligate / embolise the following vessels (sphenopalatine, anterior ethmoid, external carotid (last resort)
47
What is a complication of **epistaxis**?
How can it be prevented?
Septal haematoma later causing **erosion** of **septal cartilage** and **saddle nose deformity**
Prevented = anterior rhinoscopy and palpation of bulging septum
48
When can **nasal trauma occur**?
Assault
Sports
RTA
49
What are some **complications** of nasal bone fractures?
**Septal haematoma**
**CSF leak** with associated skull base fracture (rare)
50
What is the **management** of **nasal trauma**?
**ABC** (epstaxis is normally self limiting)
Examine for **septal haematoma**
No X-ray required
If deviated then consider **manipulation under anaesthetic** within 2 weeks
51
Label the following:
52
Label the following:
53
Label the following:
54
What is **rhinosinusitis**?
**Inflammation** of the **nose** and **paranasal sinuses** characterised by some of:
* **Nasal blockage** / obstruction / congestion
* **Anterior** or **posterior nasal drip**
* Facial pressure
* Reduction or loss of smell
AND
**Endoscopic signs of** polyps, micropurulent discharge, oedema in middle meatus OR **CT changes** e.g. mucosal changes within osteomeatal complex
55
What is the **difference** between **acute** and **chronic rhinosinusitis**?
**Acute** = \<12 weeks, complete resolution of symptoms (viral / non viral)
**Chronic** = \> 12 weeks (divided as **with nasal polyps** or without)
56
What **causes viral ARS** (common cold)?
**Rhinovirus**
**Influenza virus** with resolution of symptoms within 5 days
\> 5 days = bacterial (strep pneumoniae, haemophilus influenzae, moraxella catarrhalis)
57
What is the **management** of **acute rhinosinusitis**?
**Analgesia** if required
**Nasal decongestants**
If longer then 5 days = topical nasal steroids and oral abx
58
Which factors **predispose** to **chronic rhinosinusitis**?
**Allergy**
**Infections** (e.g. with staph aureus and strep pneumonia)
**Ciliary impairment** e.g. in **cystic fibrosis** (nasal polyps present in 40% of patient with CF)
**Anatomical abnormalities** e.g. septal deviation and abnormal uncinate process
**Immunocompromised**
**Aspirin hypersensitivity**
**Atmospheric irritants** e.g. smoking, dust, fumes
**Swimming / diving**
59
What are the **investigations** for **rhinosinusitis**?
**Skin prick testing** if **allergy suspected**
**CT sinuses** (if surgery planned / atypical features in hx and exam / not got at diagnosis as large number of asymptomatic patients have changes in the sinuses on CT scanning)
60
What is the **management** of **chronic rhinosinusitis**?
**Conservative** = avoidance of allergens, nasal douching
**Medical** = antihistamines, topical nasal steroids, oral steroids (1 week) in severe cases, oral abx
**Surgical** = nasal polypectomy, functional endoscopic sinus surgery to improve ventilation, septoplasty
Generally **no cure** and treatment aims are symptom improvement
61
What type of **hypersensitivity reaction** is **allergic rhinitis**?
Which **allergens** are associated?
IgE mediated type 1 (strongly associated with asthma)
Seasonal = hayfever
Perennial
**Allergens** = pollens, moulds, house dust mites and animal epithelia
62
What are the **investigations** for **allergic rhinitis**?
**Skin prick tests** for **specific allergens**
**RAST** blood test (if SPT not possible)
63
What is the **treatment** of **allergic rhinitis**?
**Conservative** = allergen avoidance, nasal douching
**Medical** = antihistamines, topical nasal steroids
**Immunotherapy**
64
How does **orbital abscess** develop?
How does it present?
What is the treatment?
Direct **spread of pus** from the **ethmoid sinus** / thrombophlebitis of mucosal vessels
**Presentation** = pain, oedema of eyelids, proposed eye and reduced eye movements (risk of **blindness**)
**Treatment** = diagnosis with CT, IV abx, nasal decongestants, urgent surgical drainage of abscess
65
What are the **borders** of the **anterior** and **posterior** triangles of the neck?
**Anterior** = midline of neck, anterior border of SCM, lower border of mandible
**Posterior** = posterior border of SCM, anterior edge of trapezius, middle third of clavicle
66
Where does a **retropharyngeal abscess** occur?
**Anterior** to the **prevertebral fascia** and **behind** the pharynx (retropharyngeal space - extends to mediastinum)
67
What are the **features** of **retropharyngeal abscess**?
Common in **young children** (after a URTI)
Ridgid neck - reluctance to move
Systemically **unwell**
**Airway compromise**
**Dysphagia / odynophagia**
Widening of retropharyngeal space on **lateral X-ray**
68
What are the **investigations** for a **retropharyngeal abscess**?
CT neck
69
What is the **management** of a **retropharyngeal abscess**?
**Secure airway if concerned**
**IV abx**
**Surgery** (incision and drainage)
70
What is **Ludwig's Angina**?
Infection of **space between floor of mouth** and **mylohyoid** (associated with dental infections)
71
What are the **features** of **Ludwig's Angina**?
**Swelling** of floor of mouth
## Footnote
**Painful mouth**
**Protruding tongue**
**Airway compromise**
**Drooling**
72
What are the **investigations for Ludwig's Angina**?
CT neck
OPG
73
What is the **management** of **Ludwig's angina**?
Secure airway if concerns
**IV abx**
**Surgery** to drain any collection
74
Where do **parapharyngeal absecesses** occur?
What does this space contain?
How does it present?
**Posterior-lateral** to oropharynx and nasopharynx (divided by styloid process)
Contains **carotid sheath**
Presents as **quinsy =** febrile illness, odynophagia, trismus, reduced neck movement, swelling of neck around upper part of SCM
75
What is the cause of **epiglottitis**?
**Haemophilus influenzae** (incidence had reduced with vaccine)
Seen in 2-6 year olds
76
How does **epiglottis** present?
**Stridor**
**Drooling**
**Pyrexia**
77
What is the **management** of **epiglottitis**?
**Secure airway** (do not examine as this can precipitate obstruction)
**IV abx** (after a couple of days extubate)
78
What are the **four areas** of the **pharynx** and **oral cavity**?
**Oral cavity** = from lips to posterior soft palate
**Nasopharynx** = from base of skull down to soft palate (contains adenoids and eustacian tube opening)
**Oropharynx** = from soft palate down to superior border of epiglottitis (contains palatine tonsils, anterior and posterior tonsillar pillars)
**Hypopharynx** = from superior border of epiglottitis down to inferior border of cricoid cartilage
79
What are the muscles of the pharynx?
**4 circular muscles** (no longitudinal, unlike rest of GI tract)
Superior, middle and inferior constrictors and cricopharyngeus
80
Where do **pharyngeal pouches form**?
How do they present?
**Killian's dehiscence** (between inferior constrictors and cricopharyngeus)
**Presentation** = dysphagia, delayed regurgitation of food, recurrent chest infections from aspirated food
81
Which muscles cause elevation and depression of pharynx?
Stylopharyngeus
Salpingopharyngeus
Palatopharyngeus
82
What is **obstructive sleep apnoea**? What are the common causes?
**Complete obstruction** of airway which requires patient to wake at night to alter position to open airway
**Children** = adenotonsillar hypertrophy
**Adults** = obesity
83
What are the **investigations** for **obstructive sleep apnoea**?
**BMI**
**TFTs** (hypothyroidism)
**CXR** (obstructive lung disease)?
**ECG** (right ventricular failure)?
**Sleep study**
84
What is the **treatment** of **OSA**?
Weight loss
**CPAP** (mainstay of treatment)
Mandibular positioning devices
Surgery (adenotonsillectomy in children)
85
Which organisms can cause **tonsillitis**?
**Bacterial** = beta-haemoloytic strep, staphylococci, strep. pneumoniae
**Viral** = rhinovirus, adenovirus, Enterovirus
86
What are the **clinical features** of **tonsillitis**?
**Pyrexia**
**Dysphagia**
**Lymphadenopathy**
**Odynophagia**
Trismus
Swollen tonsils (with/without exudates)
Otalgia (referred pain)
87
What is the **management** of **tonsillitis**?
**Analgesia**
**Antibiotics**
Drainage of **peritonsillar abscess**
**Tonsillectomy** for recurrent
88
What treatment should be avoided in **tonsillitis**?
What is the advice for patients with **EBV**?
Avoid **amoxicillin** as causes **maculopapular rash** in presence of **EBV**
EBV = avoid contact sports due to hepatosplenomegaly
89
How do **head and neck cancers present** (excluding thyroid and salivary gland)?
**Dysphonia** (especially laryngeal = hoarseness)
Dysphagia
Dyspnoea - stridor from narrowing of airway
Neck mass
Pain from site of pathology
**Nasal blockage** / unilateral middle ear effusion = nasopharyngeal pathology
90
What type of cancer is HNC?
**Squamous cell carcinoma**
91
Who is typically affected by HNC?
Men (twice as likely)
92
What are the risks factors for HNC?
Alcohol
Tobacco
Beetle nut chewing (oral cavity malignancy)
Chinese ethnic origin for nasopharyngeal malignancy
93
How to investigate primary tumour site in H&N cancers?
Examine under anaesthetic: panendoscopy - for **biopsy** (histological diagnosis, tumour size and second primary)
## Footnote
**CT neck**
94
How to **investigate neck metastasis** in **H&N cancers**?
**US guided FNA** (open biopsy can cause seeding of tumour - more useful for TB and lymphoma)
95
How to look for distant mets in H&N cancers?
CT chest
96
What are the **management options** for H&N cancers?
**Palliation** = reduce suffering / prolong life
**Curative** = RT / surgery (e.g. laryngectomy / neck dissection)
97
Why do enlarged thyroid glands need investigating?
**Hyperthyroidism** (hyper functioning)
## Footnote
**Neoplasm**
**Compression of airway**
98
What is the arterial supply to the thyroid?
**Superior** and **inferior thyroid arteries**
99
What nerve is at risk during thyroid surgery?
**Recurrent laryngeal nerves** (supply muscles of larynx apart from cricothyroid and sensation below vocal cords)
Damage = hoarseness
100
What are the **investigations** for an **enlarged thyroid**?
**TFT**s
**US guided FNA** (if diagnostic doubt then hemithyroidectomy)
101
What are the **possible histopathologies** for **enlarged thyroid**?
**Non-neoplastic** = single nodule (colloid / cystic) or multinodular
**Neoplasm** = adenoma (benign), malignant (papillary adenoma / follicular carcinoma / etc.)
102
What are the **treatment options** for enlarged thyroid glands?
**Non-neoplastic** = conservative, surgery (hemithyroidectomy to prevent need for thyroxine)
**Neoplastic** = adenomas (no treatment after diagnostic hemithyroidectomy) or surgery
103
What are some **complications** for **thyroid surgery**?
Post op **haemorrhage**
**Airway obstruction** (due to haemorrhage / bilateral vocal cord palsy)
**Vocal cord palsy**
**Hypocalcaemia**
104
Name the salivary glands?
**Parotid**
**Submandibular**
**Sublingual**
105
What is a risk of **parotid gland** surgery?
Facial nerve palsy
106
In which **salivary glands** are **infection** more common?
**Submandibular** gland
107
Which **infections** can cause **sialadenitis** (infection of salivary gland)?
How does it present?
**Viral** = mumps, coxsackievirus, HIV
**Bacterial** = staphylococcal
Seen in dehydrated / immunocompromised
**Present** = foul taste and signs of infection
108
What are **investigations** for **sialolithiasis**?
Ultrasound / sialogram (causes pain which is worse during meals)
109
What is the **management** of **sialolithiasis**?
Conservative (most settle, analgesia, hydration)
Radiological removal
Surgery = removal of stones / salivary gland
110
What are the **complications** of **sialolithiasis**?
Sialadenitis
Abscess formation
111
How do differentiate thyroglossal cyst / goitre?
**Cyst** = moves up on tongue protrusion
**Nodule** = up on swallowing
112
What is the course of the recurrent laryngeal nerve on the left and right?
**Left** = loops under aortic arch
**Right** = under right subclavian artery
113
What would suggest low calcium?
Tingling around mouth and fingertips
If severe = muscle spasms
114
What are the features of nasal polyps?
Nasal obstruction
Rhinorrhoea
Poor taste
115
What are some associations of nasal polyps?
Asthma
Aspirin sensitivity
Infective sinusitis
CF
116
What is the management of nasal polyps?
Topical steroids
117
What is **Ramsay Hunt syndrome**?
**Herpes Zoster oticus** - reactivation of varicella zoster virus in geniculate ganglion of 7th CN
118
What are the **features** of **Ramsay Hunt syndrome**?
Auricular pain
Facial nerve palsy
Vesicular rash around ear
Vertigo and tinnitus
119
What is the **management** of **Ramsay-Hunt syndrome**?
Oral aciclovir and corticosteroids
120
How does a **branchial cyst** present?
Mobile and cystic near SCM and pharynx (presents in **early adulthood**)
121
When is a **myringoplasty** performed?
To **repair a perforated tympanic membrane** if it **hasn't repaired after 6-8 weeks**
122
What is **chronic rhinosinusitis?**
Inflammation of paranasal sinuses lasting 12 weeks or longer
123
Which factors **predispose** to **chronic rhinosinusitis**?
Atopy
Septal deviation
Swimming
Smoking
124
What are the **features** of **chronic rhinosinusitis?**
**Facial pain** - worse on bending forward
nasal **discharge**
nasal **blocking** - mouth breathing
post nasal **drip** - chronic cough
125
What is the **management** of **chronic rhinosinusitis**?
Avoid allergen
Intranasal corticosteroids
Nasal irrigation with **saline solution**
126
Which **drugs** can cause **gingival hyperplasia**?
Phenytoin
Cyclosporin
CCB (nifedipine)
127
What are the causes of **facial pain** and **how do they present**?
**Sinusitis** = facial fullness, nasal discharge, pyrexia, post-nasal drip and cough
**Trigeminal neuralgia** = unilateral, shooting facial pain, triggered by light touch
**Cluster headache** = pain twice a day up to 2 hrs, up to 12 weeks, worse in one eye
**Temporal arteritis** = tender around temples, raised ESR
128
What are some causes of **tinnitus**?
**Ménière's disease** = hearing loss, vertigo, fullness
**Otosclerosis** = 20-40 years
**Sudden onset sensorineural** = (normally acoustic neuroma - hearing loss, vertigo, tinnitus, associated with neurofibromatosis)
**Drugs** = quinine, aspirin/NSAIDs, loop diuretics
129
What is the treatment for sudden SN hearing loss?
Oral prednisolone 7 days
130
When to suspect **mumps**?
Bilateral painful **parotid enlargement**
Orchitis
Pancreatitis
Reduced hearing
Meningoencephalitis
131
