ENT Flashcards
(72 cards)
1
Q
Describe the sensory innervation to the pinna?
A
- Upper lateral surface – CN V3 – Auriculotemporal nerve.
- Lower lateral surface and medial surface – C3 – Greater auricular nerve.
- Superior medial surface – C2/C3 – Lesser occipital nerve.
- Auricular branch of vagus – External Auditory Meatus
2
Q
How are lacerations managed?
A
- Mx: Simple primary closure of the skin with sutures after adequate cleaning
- Ensure that any exposed cartilage is covered with skin: if there is significant skin loss where primary closure will not be possible an opinion from a plastic reconstructive surgeon may be required.
3
Q
How are bites mx;d?
A
- Significant risk of infection from skin commensals, or oral commensals from the offending creature/person.
- Take an appropriate history to ascertain likely organisms involved in potential infection, and the wound must be left open.
- Mx: Wound irrigation and antibiotics.
4
Q
How are pinna haematomas mx’d
A
- Mx: Urgent drainage and pressure dressing application to prevent re-accumulation.
5
Q
What are tympanic membrane perforations and how are they mxd?
A
- Can be perforated by direct or indirect trauma, otitis media.
- SX: PAIN, conductive deafness
- Mx: Most perforations will heal by themselves - “watch and wait,” approach with the patients following water precautions
- If perforation does not heal > 6months – consider surgery:
- Myringoplasty: to repair the tympanic membrane if the perforation is causing problems.
6
Q
Describe haemotympanum trauma + its mx’d
A
- Ax: temporal bone fracture
- Examination: Can be seen through the tympanic membrane and is associated with a conductive hearing loss
- Mx: Conservative: it will settle with time.
- Pt should be followed up to ensure that there is no residual hearing loss from damage to the ossicles.
7
Q
How is ear wax mxd
A
- Sx: pain, conductive hearing loss, tinnitus, vertigo
- Mx: olive oil, sodium bicarbonate 5%. almond oil
- Treatment should not be given if a perforation is suspected or the patient has grommets.
- Primary care: syringing/ irrigation
8
Q
How does Otitis Externa present?
A
-
Presentation: painful discharging ear, itchiness, hearing muffled from the discharge present in the ear canal.
- Otoscopy: red, swollen, or eczematous canal
9
Q
What is malignant OE?
A
- Aggressive infection mainly seen in diabetics or immunocompromised patients
- Infection spreads from soft tissue of the ear canal into the bone (osteomyelitis)
- Significant mortality rate
- Sx:
- Chronic ear discharge
- Severe ear pain
- Cranial nerve palsies (most commonly CNVII).
10
Q
How is otitis externa mxd?
A
-
Topical abx (ciprofloxacin) +/- topical steroid
- Severe: PO flucloxacillin
- Ix: swabs
- Other:
- Microsuction of pus/debris
- Wick with aluminium acetate: help hold the canal open for topical treatment
- Mild: topical hydrocortisone + ear calm spray
11
Q
What is necrotizing OE?
A
- Aggresive + life threatening -> temporal bone destruction -> base of skull osteomyelitis
- Pt: otorrhea, severe otalgia, granulations in the floor of the EAC
- ? CN6+7 palsies as disease progresses
12
Q
How is OE mxd?
A
- Ix: swabs, MCS, biopsy of EAC to exclude SCC, CT scan
- Mx: topical abx (ciprofloxacin) +/- topical steroid
13
Q
What is acute otitis media?
A
- Acute otitis media (AOM) is an infection of the middle ear.
- Epithelium lining the middle ear is respiratory epithelium: pseudostratified columnar epithelium – is regarded as a continuation of the upper respiratory tract, and is therefore susceptible to a similar variety of pathogens.
- Common in childhood and is related to eustachian tube dysfunction.
- Common pathogens: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella species.
14
Q
How does acute otitis media present?
A
- Ear pain - in young children this may be evident by ear pulling.
- Discharge: tympanic membrane may rupture with the pus from the middle ear discharging into the ear canal.
- Fever
15
Q
How is acute OM mxd?
A
- Conservative: 24-48h settles on its own. Watch and wait
- Immediate abx prescription: PO amoxicillin 2nd: erythromycin. Give if:
- Immunocompromised
- Bilateral AOM <2 yo
- Perforation
- Systemically unwell
- Surgery: grommet insertion
16
Q
What is the diagnostic criteria of AOM?
A
- Acute sx onset: otalgia/ ear tugging
- Middle ear effusion
- Inflammation of the tympanic membrane
17
Q
How does a cholesteotoma arise? What are its complications?
A
- Pathophysiology: acquired – chronic –ve middle ear pressure, from Eustachian tube dysfunction -> retraction pocket
-
Complications: destruction of ossicles, semicircular canals (vertigo) and cochlea (sensorineural hearing loss)
- Facial nerve palsies
- Erosion into intracranial cavity: meningitis, intracranial abscesses and sinus thrombosis
- RFs: acute OM, Eustachian tube dysfunction, and prior otological surgery
18
Q
How does cholesteotoma appear on otoscopy?
A
- Pearly, keratinized, or waxy mass in the attic region is seen on otoscopy
- Atic crust
19
Q
What are the ix’s and mx for cholesteotoma?
A
- Ix: otoscopy, PTA, CT scan of petrous part of temporal bone
- Mx:
- Surgery: mastoidectomy – cholesteotoma removed and mastoid cleaned out
- Ossicles reconstruction depending on the extent of damage
20
Q
What is otitis media with effusion?
A
- Fluid is present in the middle ear with an intact tympanic membrane
- Related to eustachian tube dysfunction.
- Children
- Adults: (especially unilateral) : v important to look at the post nasal space as tumours in this area can cause eustachian tube dysfunction -> OME
- Not painful but the middle ear may become infected which will lead to an acute otitis media which is painful.
21
Q
What are some the RFs for glue ear?
A
- Bottle fed, Paternal smoking
- Atopy (e.g eczema, asthma
- Genetic disorders/ Mucociliary disorders, CF, PCD
- Craniofacial disorders e.g. DS
22
Q
What are some of the clinical fx of otitis media with effusion (glue ear)?
A
- On otoscopy: Bulging retracted tympanic membrane which can appear dull, grey or yellow
- Loss of light reflex ? bubble
- CHL-> can cause speech/ developmental delay
- Pressure in ear
- Sometimes: disequilibrium + vertigo
23
Q
How is otitis media with effusion ixd and mxd?
A
Ix
- Tympanogram: Flat (Type B) Tracing with normal canal volume
- Pure tone audiogram: CHL
- Sometimes FNE
Mx
- Conservative – most cases settle within 3 months - Hearing aid
-
Surgery - for prolonged hearing loss causing significant problems
- Myringotomy +/- Grommets (ventilation tubes) +/- Adenoidectomy
24
Q
What is otosclerosis?
A
- Cause: genetic and environmental
- Genetic: In families - autosomal dominant transmission.
- Mature bone is gradually replaced with woven bone
- Sx develop as the stapes footplate becomes fixed to the oval window.
- Causes bilateral hearing loss
25
Describe the presentation of otosclerosis?
* 2x F\>M
* Progressive hearing loss (bilateral), tinnitus, improved hearing in noisy surroundings during early stages of disease
* Family History
26
What examination and ixs are used for otosclerosis?
Examination: Most commonly normal
* Rarely **pink hue** to the tympanic membrane – **Schwartze’s sign**
Investigations
* **Tympanogram** - Normal **type A** trace
* **PTA** - Conductive hearing loss: characteristic **“Carhart notch”** at **2kHz**
27
What are the central and peripheral causes of vertigo?
* Central causes: Stroke,Migraine, Neoplasms, Demyelination eg. MS, Drugs
* Peripheral causes: BPPV, Ménière’s disease, Vestibular Neuronitis
28
What is BPPV + its pathophysiology?
* Vertigo occurring with particular head movements, which is benign in nature, and lasts a short amount of time, typically seconds
* **Pathophysiology:** otoliths (crystals) in the semicircular canals (most commonly posterior) causing abnormal stimulation of the hair cells giving a hallucination of movement i.e. vertigo
29
How is BPPV dx and mxd?
* **Diagnosis:** Dix-Hallpike test - latency rotary nystagmus which is fatigueable with a latency of onset of 5 to 10 seconds
* **Mx: Epley manoeuvre** – move pt head into 4 sequential positions resting for 30 seconds betweeb movements. Aim to reposition the ocotonia away from posterior canals
30
What are the fx of menieres?
* **Tinnitus** in affected ear
* Episodic **vertigo**: minutes to hours. N+V
* **SNHL**
* **Aural fullness**
* **Nystagmus**, +ve **Romberg** test
* Episodes last minutes to hours
* Sx **unilateral** -\> bilateral sx
31
How is Menieres disease mxd
* Mx: ENT referral, inform DVLA
* Medical
* Acute attacks: **procloperazine**
* Prophylactic: **betahistine** and **vestibular relaxation exercises**
32
What is vestibular labrynthitis?
* Inflammatory disorder of the membranous labyrinth, affecting both the vestibular and cochlear end organs.
* Can be viral, bacterial or associated with systemic diseases. Viral labyrinthitis is the most common form of labyrinthitis.
33
What are the key differences between vestibular neuritis + labrynthitis?
* Vestibular neuritis: defines cases in which only the vestibular nerve is involved, hence there is no hearing impairment
* Labyrinthitis: when both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment
34
How does Labyrinthitis present?
* **Vertigo**: not triggered by movement but exacerbated by movement
* **N+V**
* **Hearing loss:** may be unilateral or bilateral, with varying severity
* **Tinnitus**
* Preceding or concurrent symptoms of **URTI**
35
What are the signs of labrynthitis?
* Spontaneous **unidirectional horizontal nystagmus** towards the unaffected side
* **SNHL**: shown by Rinne's test and Weber test
* **Abnormal head impulse test:** signifies an impaired vestibulo-ocular reflex
* **Gait disturbance:** the patient may fall towards the affected side
36
How is viral labrynthitis mxd
* Episodes are usually **self-limiting**
* **Prochlorperazine** or antihistamines may help reduce the sensation of dizziness
37
What are some the features of vestibular neuronitis?
* Recurrent **vertigo** attacks lasting **hours or days**
* **N+V** may be present
* **Horizontal nystagmus** is usually present
* **Ho hearing loss or tinnitus**
38
How is vestibular neuronitis mxd?
* 1st: **Vestibular rehabilitation exercises** (chronic sx)
* Acute: Buccal or IM **prochlorperazine**
* Short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases
39
How is sudden onset SNHL ixd + mxd?
* Ix: **tuning fork tests** + **PTA** – to work out if conductive or sensorineural
* **MRI scan** - to exclude lesion along central auditory pathway. e.g. **acoustic neuroma**
**Mx**
* **High dose steroids** – normally orally but can be injected into middle ear
* Anti-virals
* Other treatments are used e.g. hyperbaric oxygen, carbogen but are not widely practiced
* Nose
40
What are the fx of ramsay hunt?
How is it mxd?
* 1st: **auricular pain**
* Facial nerve palsy
* **Vesicular rash** around the ear
* Other features: **vertigo + tinnitus**
* **Mx:** oral **aciclovir** + corticosteroids
41
What are the causes of **epistaxis**?
* Local
* Idiopathic – 85%
* Traumatic
* Iatrogenic
* Foreign Body
* Inflammatory – Rhinitis, Polyps
* Neoplastic
42
How is epistaxis mxd?
**Management**
* ABC
* Pinch soft part of nose for up to 10 minutes x 2
* Ask patient to breath through mouth and sit with head forward
* Spit out (not swallow) any blood in mouth
* Put **ice pack** on the dorsum of the nose
* Examination: locate the source of the bleeding (A/p?)
**Conservative**
* **Adrenaline soaked gauze**
* **(+/- Topical adrenaline) Cautery** – silver nitrate / bipolar diathermy
* Risks: perforation so avoid cauterising large areas on both sides f the sepstum. Refer to ENT if you cant see the vleeding point. Avoid if there is active bleeding
* **Anterior bleed** – with **anterior rhinoscopy** – easier to treat
* **Posterior bleed** – with **rigid endoscope**
* **2nd line:** **Nasal packing** if cautery fails to control bleeding
* 1st: anterior pack- 10cm long
* 2nd: If continues bleeding into oropharynx anterior & posterior pack
* Consider post natal pack
**Surgical/Radiological**
* Surgical artery ligation:
* **Sphenopalatine**
* **External carotid** (last resort)
* **Risks:** stroke – if there is communication between the ICA and ECA
43
How is a **nasal septum haematoma** mxd?
* ABC – epistaxis normally-self limiting
* Examine for septal haematoma
* No XR required
* If deviated nose consider Manipulation under anaesthetic (LA/GA) within 2 weeks of injury
* + IVAbx
44
What are the fx of nasal septum haematomas?
* Hx: minor trauma
* Sensation of nasal obstruction is the most common symptom
* Pain and rhinorrhoea are also seen
* Examination: bilateral, red swelling arising from the nasal septum. Boggy .
45
What are the different sites of draining for paranasal sinuses?
46
How does **rhinosinusitis** present?
* **Nasal blockage/obstruction/congestion/**
* **Nasal discharge**
* **Post nasal-drip (**can produce a chronic cough)
* +/- **facial pain/pressure**
* +/- **reduction or loss of smell**
47
How can rhinosinusitis be ixd?
* **FNE** - Polyps, mucopurulent discharge, or oedema in middle meatus
* **CT scan** - Mucosal changes within the osteomeatal complex, or sinuses
48
How is chronic vs acute rhinosinusitis described?
* Acute: \< 12 weeks, complete resolution of symptoms.
* Viral (common cold): Causes: Rhinovirus, and Influenza virus
* Usually resolution of symptoms within 5 days.
* Non viral ARS: persistence of SX symptoms \>5 days
* Causes: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
* Allergy and ciliary impairment can predispose to ARS
49
How is ACUTE rhinosinusitis mxd?
1. analgesia, nasal saline irrigation, nasal decongestant (rebound hypertrophy if overused)
**2**. Symptoms \> 10 days: intranasal corticosteroids (**mometasone**)
3. If severe: oral abx broad spectrum
50
What are the sx of **allergic rhinitis**?
* sneezing
* bilateral nasal obstruction
* clear nasal discharge
* post-nasal drip
* nasal pruritus
51
How is CHRONIC RHINOSINUSITIS MXD?
Mx:
1. Avoid triggers, stop smoking, practice good dental hygiene
2. Nasal irrigation with saline
3. Intranasal corticosteroids for max 3 months
4. Refer to ENT
52
What are the different types of allergic rhinitis?
* **seasonal:** symptoms occur around the same time every year.
* **perennial:** symptoms occur throughout the year
* **occupational:** symptoms follow exposure to particular allergens within the work place
53
How is allergic rhinitis mxd?
* Allergen avoidance
* Mild: 1st: oral or **intranasal antihistamines**
* Moderate: **intranasal corticosteroids (beclometosone)**
* Consider: **topical** **nasal decongestants (e.g. oxymetazoline***). Do not use for prolonged periods. SE: tachyphylaxis: increasing doses are required to achieve the same effect; rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) can occur upon withdrawal*
54
What are the sx of nasal polyps?
* nasal obstruction
* rhinorrhoea, sneezing
* poor sense of taste and smell
55
How are nasal polyps ixd?
* **Skin prick tests** if **allergy** suspected
* **CT Sinuses:** Needed if surgery planned
* **Biopsy + histology:** Unilateral polyps
56
How are nasal polyps mxd?
**1. oral prednisolone – 5 days**
**2. Intranasal steroid drops 4 weeks**
**3. Intranasal steroid spray until further review**
**4. Surgery – FESS (polypectomy)** improve ventilation/drainage of sinuses
**Further surgery:**
* **Nasal polypectomy –** high rate of recurrence
* **Septoplasty**: to improve nasal airways and reduction of inferior turbinates may be considered.
57
How is pre orbital cellulitis different from orbital cellulitis?
* Presentation
* Redness and swelling around the eye
* Severe ocular pain
* Visual disturbance
* Proptosis
* Ophthalmoplegia/pain with eye movements
* Eyelid oedema and ptosis
* Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)
Differentiating orbital from preseptal cellulitis
* Reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis
58
How is orbital cellulitis mxd?
* Mx: IV abx **(ceftriaxone and metronidazole)** nasal decongestants
* Surgery: surgical drainage of any abscess
59
What are the red flag sx of deep neck space infections?
* **Sore throa**t in the absence of normal oropharyngeal examination
* Severe **neck pain** and **stiffness**
* **Signs of airway compromise:** stridor, dyspnoea, drooling or dysphonia
60
What are the clinical fx of a retropharyngeal abscess:
* Young children after URTI
* Neck help in a rigid ad upright position with a reluctance to move
* Systemically unwell
* Airway compromise
* Dysphagia and odynophagia
* Widening of the retropharyngeal space on lateral X ray
61
How are retropharyngeal abscesses Ixd + mxd
Ix: Gold standard: **CT Neck with IV contrast**
* **Plain film lateral view neck radiographs** can show widening of retropharyngeal tissue
* Bloods: CRP and cultures
Mx: secure airway, broIV abx
Surgery – incision and drainage - can be done through mouth or neck with drains left In
62
What is Ludwigs Angina? How does it present?
Infection of the space between the floor of the mouth and mylohyoid – most commonly associated with dental infection
Clinical fx:
* Swelling of the floor of the mouth
* Painful mouth
* Protruding tongue
* Airway compromise
* Drooling
63
What is the hx + presentation of someone with Parapharyngeal Abscesses?
* Parapharyngeal space is a potential space postero lateral to the oropharynx and nasopharynx divided by the styloid process
* Present similar to peritonsillar abscess oe quinsy
* Hx: febrile illness, odonyphagia, trismus, reduced neck movement
* Swelling around the upper part of the SCM
64
How are pharyngeal abscesses ixd + mxd?
* Ix: **CT neck with IV contrast** – urgent
* Plain film lateral view neck radiographs
* Mx
* Secure airway
* IV abx: broad spectrum abx
* Surgical drainage
65
What muscles form the pharynx?
* **Circular layer:** formed in principle by muscles: Superior, middle, and inferior constrictors (vagus nerve), and cricopharyngeus
* **Longitudinal muscles:** Three pairs of muscles cause elevation and depression of the pharynx – stylopharyngeus (vagus), salpingopharyngeus (from glossopharyngeal), and palatopharyngeus (vagus)
66
What is Killians dehiscence?
* **Killian’s dehiscence:** exists between inferior constrictor and cricopharyngeus; a deficient of muscle at which herniation may occur.
* Site of **pharyngeal pouch** formation.
67
What are some of the sx of OSA + pre disposing factors?
* daytime somnolence
* compensated respiratory acidosis
* hypertension
* obesity
* macroglossia: acromegaly, hypothyroidism, amyloidosis
* large tonsils
* Marfan's syndrome
68
What ix are used for OSA?
* **Epsworth sleeping scale (\>9)**
* BMI: **TFT** – ?Hypothyroidism; **CXR** – ?Signs of obstructive lung disease; **ECG** – ?Signs of right ventricular failure
* **Sleep study.**
* Types:
* **Overnight oximetry alon**e
* **Limited sleep study** – oximetry, snoring, body movement, heart rate, oronasal flow, chest/abdominal movements, leg movements – usual study of choice
* **Full polysomnography** – limited study plus **EEG, EMG**
69
How is OSA mxd
* **Conservative:** lifestyle changes and weight loss, reduce evening alcohol intake, sleep decubitus
* **Driving**: do NOT drive while sleepy; stop and have a nap. Notify DVLA on diagnosis and doctor can advise drivers to stop altogether (e.g. HGV drivers)
* Medical: **CPAP, Mandibular positioning devices**
* Surgical:
* Children – **adenoidectomy** (rarely an option in adult)
* **Adults** (if significant OSA): consider gastroplasty/bypass, and rarely tracheostomy
70
How is Bell's Palsy mxd?
* **Oral prednisolone** within 72 hours of onset of Bell's pals
* UpToDate recommends the addition of **antivirals** for severe facial palsy
* Eye care - **artificial tears** and eye lubricants
* Follow-up - refer to ENT if no sign of improvement after 3 weeks, refer urgently to ENT
* Referral to plastic surgery may be appropriate for patients with more long-standing weakness e.g. several months
71
How is a fractures nose mxd?
Ix: cartilaginous injury will not show and radiographs do not alter Mx
Mx:
* Reduction under GA with post op splinting
* Exclude septal haematoma
* Re-examine after 1 week
72
What are septal haematomas and how are they mxd?
Septal necrosis, haematoma between septal cartilage + overlying perichondrium
Bilateral swelling from nasal septum
If untreated – ‘saddle nose’ deformity
Mx: surgical drainage + IV abx
