ENT Flashcards
(208 cards)
1
Q
Where are the inputs for balance from?
A
Visual- eyes
Vestibular
Proprioception
Also; auditory, cerebral/cerebellar
2
Q
What is the role of the vestibular system?
A
Detects motion, head position and spatial orientation
3
Q
What is the composition of the CNVIII?
A
Vestibular nerve- both superior and inferior.
Cochlear nerve
4
Q
Where does the balance proportion occur?
A
Semilunar canals which are filled with endolymph that move around with movement:
-Anterior, posterior and horizontal. The horizontal pairs with the horizontal on the other side i.e. L with R. Anterior of L will pair with posterior of R and vice versa.
Otolith organs:
Utricle- Flat plane where hair sits, detecting movement in the horizontal plane. (Hair points up)
Saccule- Detecting movement in the vertical plane, anti-gravity. (Hair points to the side)
The collected information is then transmitted to the central portion via the CNVIII.
5
Q
How does the vestibular system work?
A
Head movement moves the endolymph in SCC.
Fluid shift is detected by the stereocilia in the ampulla.
Input is transmitted to the vestibular nerve.
CNVIII carries the info to the vestibular nuclei in the brainstem and cerebellum.
Vestibular nuclei then sends info to the nuclei of CNIII, CNIV, CNVI and cerebellum, SC and thalamus which helps co ordinate movement.
6
Q
What is the importance of visual input in balance?
A
-Vision is important for depth perception.
Some people begin to have visual preference- where they rely heavily on their visual system to determine their balance- disregarding their vestibular system.
This is usually a big problem in supermarkets, crowds f people, in the dark/eyes closed. Px will feel symptoms of disorientation, symptoms of panic, and severe discomfort, since they can’t determine a focus point to help them balance.
7
Q
What is the importance of proprioception in balance?
A
Receive input from pressure receptors, i.e. in the feet, ankles, knees and hip.
Interfered with by joint replacement or peripheral neuropathy i.e. in diabetes.
8
Q
What is the importance of sensory input in balance?
A
-Sensation (where cerebellum uses this and links to the surroundings)
9
Q
What is the pathophysiology of visual preference?
A
Usually a unilateral vestibular insult- viral, toxic, BPPV.
Px is given medication to suppress the irritability, half Px will recover being asymptomatic, other half will have the brain compensate using the visual system. The brain will not return back to normal compensation and so the Px will become heavily reliable on the visual system.
10
Q
What is the importance of postural hypotension in balance?
A
Px will take a pause when standing up.
Diagnose with supine and erect BP- drop by 20mmHg.
Ask about medications (anti-hypertensives), getting out of a bed or out of the chair in the morning.
Encourage cycling in the bed before standing, placing legs out and plantar and dorsiflexing in the chair before standing.
Dizziness due to pooling of blood at the legs.
11
Q
What is the vestibular ocular reflex (VOR)?
A
Stabilises gaze during head movement, allowing the preservation of visual acuity during this movement.
12
Q
What happens when the VOR stops working?
A
If the VOR stops working on one side, the body thinks the head has moved to the working side (since increased innervation on that side compared to the non-working side). I.e. if the right side is not working, since there is more stimulation of the left, it is believed the head is moving to the left. The eyes then move to the right as part of the VOR.
The visual cortex quickly recognises this is incorrect, now the eyes move back- causes nystagmus.
To compensate for this Px keep their head still whilst moving.
13
Q
How do you test for VOR impairment?
A
Ask the Px to turn their head to one side then quickly move it back into the centre, looking for nystagmus.
14
Q
How are vestibular disorders classified?
A
Affecting the central vestibular system:
- Cerebrovascular disease
- Cerebellum tumours
- MS
- Migraine
Affecting the peripheral vestibular system:
- Otoxicity
- BPPV
- Meniere’s
- Vestibular neuronitis.
15
Q
Which drugs can affect the vestibular system?
A
Gentamicin
Loop diuretics
Metronidazole
Co-trimoxazole
16
Q
What is dizziness?
A
Generic term used to describe; Light headedness Faint Giddy Imbalance Mental confusion
Can sometimes describe true giddiness.
17
Q
What are some common causes of dizziness in the elderly?
A
Polypharmacy
Multifactorial disequilibrium of age (There is no apparent cause for the dizziness, just many factors along with the natural aging process).
Cerebral/cerebellar degeneration (causes can include cerebral vascular disease, stroke, hereditary etc).
18
Q
What is vertigo?
A
Sensation between the Px and their environment.
May feel they are moving or the room is.
Often a horizontal spinning sensation.
Often associated with N+V, sweating and feeling generally unwell.
Can have either a peripheral or central cause.
19
Q
What is BPPV?
A
Disorder of inner ear
Most common cause of vertigo
Gradual onset
Average age >55
Underlying pathophysiology is due to otoliths (crystals) in the semicircular canals (most commonly
posterior) causing abnormal stimulation of the hair cells giving a hallucination of movement.
20
Q
What are some signs/symptoms of BPPV?
A
Vertigo triggered by change in head position
Associated nausea
Repeated episodes lasting 10-20 seconds
21
Q
What are some investigations of BPPV?
A
Dix-Hallpike manoeuvre
- The patient is seated and positioned on an examination table such that the patient’s shoulders will come to rest on the top edge of the table when supine, with the head and neck extending over the edge
- The patient’s head is turned 45° towards the ear being tested
- The head is supported, and then the patient is quickly lowered into the supine position with the head extending about 30° below the horizontal while remaining turned 45° towards the ear being tested
- The head is held in this position and the physician checks for nystagmus (rotatory)
- To complete the manoeuvre, the patient is returned to a seated position and the eyes are again observed for reversal nystagmus
Consider audiogram in patients with hearing loss
Brain MRI to exclude CNS conditions eg multiple sclerosis.
22
Q
How would you manage BPPV?
A
Wait for symptoms to settle
Patient education and reassurance
Epley manoeuvre
Ask patient to come back if not resolved in 4 weeks
Medication often prescribed (betahistine) but tends to be of limited value.
23
Q
What are the central and peripheral causes of vertigo?
A
Central: o Stroke o Migraine o Neoplasms o Demyelination eg. MS o Drugs
Peripheral:
o BPPV
o Ménière’s disease
o Vestibular Neuronitis
24
Q
What is a vestibular migraine?
A
Sudden or gradual onset
- Headache
- Vertigo
- Visual disturbances, photophobia
- Phonophobia
- Hearing loss (can overlap with Menieres)
25
How would you manage a vestibular migraine?
- Avoid triggers- such as dehydration, foods (chocolate, cheese), anxiety, poor sleep
- Keep symptom diary
26
What is Ménière’s Disease?
Disorder of inner ear, can affect balance and hearing
Unknown aetiology but may be associated with endolymphatic hydrops (raised endolymph pressure in the membranous labyrinth of the inner ear)
Suggested risk factors: autoimmunity, genetics, metabolic disturbances involving levels of Na + K in inner ear, vascular factors, viral infection, head trauma
- Natural history
-Symptoms resolve in the majority of patients after 5-
10 years
- The majority of patients will be left with a degree of
hearing loss
- Psychological distress is common
27
What are some signs/symptoms of Ménière’s Disease?
Tinnitus in affected ear
Episodic vertigo lasting minutes to hours with associated N+V
Fluctuating sensorineural hearing loss, which gradual becomes permanent
Aural fullness
Initially between attacks, Px will not experience any symptoms. With disease progression Px is more unsteady, with reduced vestibular function on affected side and progressive SNHL. Eventually disease burns out, so no more acute vertigo, but SNHL persists. Other ear can compensate for the vestibular system of affected ear but this takes longer in older people.
28
What investigations would you conduct in Ménière’s Disease?
Pure tone audiometry:
- Air and bone conduction are equal, indicating that the underlying pathology is in the cochlea or auditory nerve, not the outer and the middle ear
- Unilateral sensorineural hearing loss
- Usually low-frequency hearing loss is present in early stages of MD
- As disease progresses, middle and high frequencies are affected
29
How would you manage Ménière’s Disease medically?
- ENT referral to confirm diagnosis
- Self-care
- Reassure it is a LTC but vertigo usually significantly improves with treatment
- Advise that an acute attack of vertigo will normally settle within 24 hours in most people
- Reduce salt, chocolate, alcohol.
Medical:
- Acute attacks: **oral or IM prochlorperazine** (to help alleviate N&V, vertigo)- short course 1-2 weeks
- Reducing severity and frequency of attacks: **betahistine** and vestibular rehabilitation exercises
- If betahistine doesn't provide clinical benefit; refer to ENT
- **Patients should inform the DVLA**. The current advice is to cease driving until satisfactory control of symptoms is achieved
30
How would you manage Ménière’s Disease surgically?
Grommet insertion
- Dexamethasone middle ear injection
- Endolymphatic sac decompression
- Vestibular destruction using middle ear injection of gentamicin
- Surgical labyrinthectomy – very rarely required
31
What is vestibular neuronitis?
Inflammation of the inner ear causing severe vertigo lasting several days with associated nausea and vomiting. During the attack Px will have horizontal nystagmus.
32
How would you manage vestibular neuronitis?
```
Vestibular sedatives (i.e. prochlorperazine) during the acute attack, and IV fluids if needed.
Often post attack Px may still experience long term vestibular deficit- unsteadiness lasting a number of weeks whilst the brain tries to compensate. Px should engage in rehabilitation exercises e.g. Cawthorne-Cooksey exercises.
Do not take vestibular sedatives after the attack as this can delay recovery.
```
33
What is labyrinthitis?
Labyrinthitis is inflammation of the labyrinth in the vestibular system of inner ear
Acute onset
Often preceded by viral URTI
Features- acute onset vertigo, exacerbated by movement, N&V, sensorineural hearing loss, disequilibrium tinnitus, preceding URTI symptoms
34
How is labyrinthitis investigated and managed?
Investigated with the head impulse test.
| Managed with vestibular suppressant/anti-emetic- promethazine, cyclizine
35
What is the head impulse test?
Diagnose peripheral vertigo.
Pt sits upright and focuses on examiner’s nose, hold patients head and rapidly jerk it 10-20 degrees in one direction whilst pt continues to focus on your nose, head is slowly moved back to centre before repeating in opposite direction
Ask about neck pain beforehand
Observe for eyes rapidly moving back and forth
36
What is Unteberger's test?
Identifying peripheral causes of vertigo
Ask pt to remain stationary and step for 60 seconds with eyes closed and arms outwards
Positive test- rotational movement of pt toward side of lesion
37
What is the difference between the length of vertigo experienced in BPPV, Meniere's and vestibular neuronitis?
BPPV- Seconds
Meniere's- Minutes
Vestibular neuronitis- Days
38
What is tinnitus?
Persistent sound which is not present in the environment.
Ringing in ears, buzzing, hissing or humming
39
What are some causes of tinitus?
Primary- often occurs w/ sensorineural hearing loss, no identifiable cause
```
Secondary-
Impacted ear wax
Ear infection
Meniere’s
Noise exposure
Medications eg loop diuretics, gentamicin, chemotherapy- cisplatin
Acoustic neuroma
MS
Trauma
Depression
```
```
Systemic conditions may be associated w/ tinnitus-
Anaemia
Diabetes
Hypo/ hyperthyroidism
Hyperlipidaemia
```
40
What is otitis externa?
What are the different types?
What are the causes of otitis externa?
Inflammation of the external ear canal.
Acute <3 weeks
Chronic >3 months
Diffuse- through the entire external ear canal.
Localised- to one hair follicle.
Malignant- Spread to the temporal and mastoid bone; needs urgent treatment. This is common in diabetics, immunocompromised. Presents with chronic discharge, ear pain and may have some CN palsies.
41
What are the causes of otitis externa?
Infection (bacterial- staph aureus or fungal; bacterial more common)
Non infectious dermatological causes (seborrhoeic dermatitis or allergic dermatitis).
N.B Always consider OME as a cause, where otitis externa is secondary to otorrhea.
42
What are the RF for developing OE?
```
Frequent water contact i.e. swimmers
Local trauma i.e. ear buds
Ear eczema/psoriasis
Diabetic/Immunocompromised
Humid environment
Ear polyps
```
43
What are the signs and symptoms of otitis externa?
Ottorhoea
Otalgia
Ear discomfort- Ranging from pruritis to severe pain worsened by motion of ear eg chewing
Feeling of fullness in ear + loss of hearing
Px may have tender ear canal, can become swollen and closed, have pus/discharge. Px may have some lymphadenopathy.
44
How is otitis externa investigated?
Hx is usually enough for a diagnosis.
| Can take a swab if persistent for MSC.
45
How is otitis externa managed?
Protect canal from water entry.
Topical Abx first line eg ciprofloxacin, gentamicin drops- TDS, for 7-14days
Topical acetic acid 2% spray for mild cases
Failure to improve with a
Abx may suggest fungal cause- topical fungal treatment eg clotrimazole drops.
May require swelling to reduce swelling and allow better penetration of the Abx.
Analgesia
If affecting a single hair follicle or cellulitis then requires oral Abx; flucloxacillin or clarithromycin if penicillin allergy.
Diabetes- the likely organism is pseudomonas therefore use ciprofloxacin.
If non resolving then urgent ENT referral for malignant otitis externa.
Malignant OE- Aggressive IV Abx and topical ear drops to eradicate infection.
46
What are the complications of otitis externa?
| What are the associated RF?
```
Significant risk factors:
Diabetes mellitus
Age > 65
Recurrent AOE
Chemo or radiotherapy or immunocompromised in another way
```
Complications:
=>Malignant otitis externa)- infection spreads from external auditory canal to skull base. Classic example is elderly diabetic man with severely painful chronically discharging ear.
Deep seated severe ear pain
Cranial nerve palsy- commonly CN VII
=>Localised abscess formation
Cause: staph aureus
Localised fluctuant swelling which may form in or around affected ear
Rupture- purulent discharge
=>Peri-auricular or pinna cellulitis
Pain, erythema, swelling and warmth of pinna or around ear
Systemic symptoms- fever, generalised illness, regional lymphadenopathy
=>Chronic stenosis of ear canal
Due to fibrosis within ear canal
Formation of a false fundus covering the TM
Distinct from irreversible acute stenosis (which is due to inflammation).
47
What is the most likely causative agent of Malignant otitis externa?
How would you act to manage it?
Pseudomonas aeruginosa
Ix- microbiology/ swabs of discharge, IV access, FBC, U&Es, serum glucose, CRP, ESR
Blood cultures if pyrexial
Sepsis 6
CT scan: thickening & enhancement of soft tissue, opacification of mastoid air cells & abscess formation.
Mx- Aggressive IV Abx as well as topical treatment required to eradicate infection
6wks
48
What is acute otitis media?
| What are the causes of acute otitis media?
Common acute onset inflammation of the middle ear with effusion.
Commonly caused by a preceding viral URTI but can have bacterial causes; strep or H.influenza.
Increased risk in young males, +ve FHx, previoius viral URTI.
49
What are the signs and symptoms of acute otitis media?
| What are the complications?
Otalgia
Discharge- TM rupture- pus from middle ear- pain stops at this point
Reduced hearing in affected ear
Symptoms of URTI- cough, coryzal symptoms, sore throat
Fever, feeling generally unwell
Complications include:
Recurrence of infection
Hearing loss
Tympanic membrane perforation
Rarely; mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis
50
How is acute otitis media investigated?
Use an otoscope-
- TM is distinctly red, yellow, or cloudy and may be bulging
- Perforation with purulent otorrhoea
- Looks like a donut- evidence of positive pressure
- Otoscopy appearance of a bulging, erythematous tympanic membrane and absent landmarks
51
How is acute otitis media managed?
- Self-limiting- Pain & fever- paracetamol, ibuprofen. Advise the normal course is 3-7 days.
- Admit child under 6 months
- If need Abx: 5-7 days amoxicillin is first-line (For penicillin allergy- clarithromycin or erythromycin {in pregnant})
Abx needed if;
- **Symptoms not improving within 4 days**
- **Have otorrhoea - perforation**
- **Bilateral otitis media in child <2 years of age**
- People who are systemically very unwell
- People who have symptoms and signs of a more serious illness or condition
- People who have a high risk of complications
- If unresponsive to Abx or severe pain: tympanocentesis
- Relieves pressure in the middle ear space and provide relief of otalgia
- Risks of trauma to the TM and middle ear structures and risk of anaesthesia.
- Preventing recurrent infection
- In children — avoiding exposure to passive smoking, use of dummies, and flat, supine feeding; and ensuring that children have had a complete course of pneumococcal vaccinations as part of the routine childhood immunization schedule
- In adults — avoiding smoking and/or passive smoking.
52
What is otitis media with effusion?
| What are the causes?
This is a non infectious cause of glue ear, i.e. effusion of the ear.
The exact cause is unknown but may be due to a impaired eustachian tube i.e. impaired pressure balance in the ear.
More likely if the Px has Downs syndrome, cleft palate etc.
53
What are the signs and symptoms of otitis media with effusion?
Commonly present with hearing loss
Ottorhoea- where if persistent/foul smelling need urgent referral
Recurrent URTI or ear infections
54
How is otitis media with effusion investigated?
Tympanometry: assesses ability of eardrum to react to sound, may be used to improve accuracy of OME diagnosis
Audiometry to determine level of hearing loss
Otoscopy- retracted TM, abnormal colour/opacification of TM, signs of inflammation are not seen.
55
How is otitis media with effusion managed?
Common to have spontaneous resolution- active observation for 12 weeks.
Abx, antihistamines, mucolytic, decongestants, corticosteroids are all NOT recommended
- Hearing aids
- Auto-inflation
- Surgery: myringotomy and insertion of grommets (ventilation tubes)
56
What are the complications of otitis media with effusion?
Chronic TM damage
Problems with speech and language development
Conductive hearing loss
57
What is otosclerosis?
How is it investigated?
How is it managed?
```
Remodelling of small bones in the ear- to spongy bones.
The stapes fixes onto the oval window.
Get progressive conductive hearing loss.
May also get tinnitus.
Autosomal dominant inheritance.
Affecting 20-40yrs old.
```
High resolution CT is used to identify changes.
Manage conservatively with hearing aids.
or
Surgically with:
Stapedectomy- Remove stapes and replace with prosthesis.
Stapedotomy- Remove part of stapes, allowing some attached to the OW. A prosthesis is inserted then through a hole in the stapes.
58
What is cholesteatoma?
- Abnormal sac of keratinising squamous epithelium + accumulation of keratin within middle ear/ mastoid air cell spaces
- Benign but can become infected or erode nearby structures, nerves and middle ear cavity; predisposes to severe infections.
- Common age 10-20
Although aetiology is unknown, suspected dysfunctional ET creates a -ve pressure, retracting the TM and creating a pocket for keratin to accumulate.
59
What are the signs and symptoms of cholesteatoma?
- Foul-smelling, non-resolving discharge
- Hearing loss
- Local invasion: vertigo, facial nerve palsy, altered taste, cerebellopontine angle syndrome.
60
How would you investigate a cholesteatoma?
- Otoscopy: attic crust seen in upper part of ear drum; retraction pocket in attic
- If infected- signs of otitis externa (redness, swelling, narrow ear canal, debris + discharge)- this has to be treated before diagnosis as ear drum becomes hard to see.
61
How is a cholesteatoma managed?
- Semi-urgent ENT referral
- They will investigate further including CT scan to assess local invasion.
- Definitive treatment: surgical removal
- Commonly canal wall up mastoidectomy, allowing removal of cholesteatoma and canal wall left intact.
Need a second-look procedure 9-12 months later to ensure no residue.
62
What are the different types of hearing loss?
Conductive- Pathology of the external and middle ear.
Sensorineural- Pathology of the inner ear or the CNVIII.
Mixed- Conductive and sensorineural.
63
How is mastoiditis diagnosed?
Septic- pyrexia, anorexia, lethargy, irritable child, not feeding
Features of ear infection- red bulging TM, purulent ear discharge
The sharp angle between the ear and the mastoid is lost (the auriculomastoid sulcus)- compare to normal ear
The pinna is classically pushed downwards and forwards w/ boggy oedema of the mastoid
64
What are the causes of sensorineural hearing loss?
```
Presbycusis- Most common cause
Noise exposure (also a common cause)
Labyrinthitis
Trauma to head/ear
Malignancy i.e. nasopharyngeal tumour
Vestibular Schwannoma
Ototoxic drugs
Meniere's
Neurological i.e. MS, stroke
Sudden SNHL
```
65
What are the causes of conductive hearing loss?
```
Impacted ear wax
Foreign body i.e cotton bud
SCC of the external canal
Cholesteatoma
Ear infection
Otosclerosis
Middle ear effusion
TM perforation
```
66
What is presbycusis?
Age related sensorineural hearing loss.
- Slow, gradual hearing loss, usually bilateral
- Speech becoming difficult to understand
- Need for increased volume on the television or radio
- Difficulty using the telephone
- Loss of directionality of sound
- Worsening of symptoms in noisy environments
- Hyperacusis: Heightened sensitivity to certain frequencies of sound (Less common)
- Tinnitus (Uncommon)
67
Why does presbycusis occur?
Loss of hair cells in cochlea
Loss of neurones in cochlea
Atrophy of stria vascularis
Reduced endolymphatic potential
68
What are the RF for presbycusis?
```
Age
Male
FHx
Loud noise exposure
Diabetes
HTN
Ototoxic medications
Smoking
```
69
How is presbycusis investigated?
Rule out otosclerosis, cholesteatoma or conductive hearing loss (due to foreign body/impacted wax) with otoscopy.
Weber's test lateralises to least affected side.
Audiometry- bilateral hearing loss of high frequency.
70
How is presbycusis managed?
Reassure that this is normal for their age
Assisted hearing devices
Hearing aids
If hearing aids ineffective then may consider cochlear implants
71
What is sudden SNHL?
Sudden hearing loss
Almost always unilateral
Many go to bed fine and awaken with deafness
May be associated tinnitus or vertigo
No significant otalgia, discharge, or other neuro signs eg nystagmus
72
What are the causes of sudden SNHL?
```
90% of cases are idiopathic
Infection eg meningitis, HIV, mumps
Meniere’s
Ototoxic medications
MS
Migraine
Stroke (ix- MRI)
Acoustic neuroma (ix- MRI)
Cogan’s syndrome (a rare autoimmune condition causing inflammation of the eyes and inner ear)
```
73
What are the diagnostic criteria for sudden SNHL?
Rule of 3:
Sensorineural loss worse than 30dB
In 3 consecutive frequencies
Within 3 days (72hrs)
74
How is sudden SNHL managed?
Oral steroid eg 60mg prednisolone reducing over 10 days
Gastric protection
MRI IAM (internal auditory meati) as a routine outpatient
Assess in next ENT clinic with Audiology support
Hearing recovers spontaneously 66% of the time
Presence of vertigo = poor prognostic sign
Intra-tympanic steroid injections if no hearing improvement within 1-3 weeks
Persistent hearing loss- consider hearing aids
75
What are the consequences of impacted ear wax?
```
Conductive hearing loss
Discomfort in ear
Feeling of fullness
Pain
Tinnitus
```
76
How is a build up of earwax managed?
Ear drops- olive oil or sodium bicarbonate 5%
Ear irrigation- squirting water in ears to clean away wax- performed by GP, contraindications: perforated TM, infection
Microsuction- to suck out the wax, performed by ENT specialist
77
What are the 4 levels of hearing loss?
The thresholds are based on the quietest sound that can be heard in decibels on pure tone audiometry
Mild (25-39dB)
Moderate (40-69dB)
Severe (70-94dB)
Profound (>95 dB)
78
What are types of hearing aids are available?
1) Behind the ear hearing aids- most common type
2) In the ear hearing aids
3) Completely in canal
79
What are the types of hearing implants?
1) Bone conduction hearing aids
Conductive hearing loss
Mixed hearing loss
Bone conduction > 65
2) Middle ear implant
3) Cochlear implants
4) Auditory brainstem implant
Bilateral acoustic neuroma (neurofibromatosis II)
80
What are the indications for a cochlear implant?
According to NICE:
Unilateral cochlea implant for severe to profound deafness in adults who do not benefit from hearing aids, after a 3 month trial with the aids
Simultaneous bilateral cochlear implant for:
Children
Adults who are blind or who have other disabilities that increase their reliance on auditory stimuli as a primary sensory mechanism for spatial awareness
81
What are the contraindications for a cochlear implant?
Lesions of cranial nerve VIII or the brainstem causing deafness
Chronic infective otitis media, mastoid cavity or tympanic membrane perforation
Cochlear aplasia
82
What is the difference between a cochlear implant and bone anchored hearing aid (BAHA)?
Cochlear implant: implanted surgically with electrodes so directly stimulates the auditory nerve with electrodes
BAHA: sound is transmitted to the cochlear via bone conduction
83
Which medications cause SNHL?
Loop diuretics eg furosemide
Aminoglycoside abx eg gentamicin
Chemotherapy drugs eg cisplatin
84
What are the causes of severe/profound HL?
```
Children
Genetic- 50% cases
Congenital- maternal CMV, rubella or varicella infection
Idiopathic- 30% childhood deafness
Infectious- eg post meningitis
```
```
Adult
Viral-induced sudden hearing loss
Ototoxicity eg aminoglycoside abx or loop diuretics
Otosclerosis
Meniere’s disease
Trauma
```
85
What are the signs/symptoms of congenital deafness?
Poor speech development
Difficulty following verbal directions
Difficulty with oral expression
Poor response to auditory cues
86
How is deafness recognised in a child?
Newborn hearing screening
If babies fail, they repeat the test
If they fail again they’re referred to ENT
Audiometry to determine range of hearing
It is important to recognise deafness within 12 months of life.
87
What is the importance of an audiogram?
X-axis: frequency in Hz (different tones)
Y-axis: volume in dB (loud at bottom, quiet at the top- the higher up the y axis the more sensitive a pt’s hearing is)
Differentiates between CHL and SNHL.
Normal hearing: all readings between 0 and 20 dB
Sensorineural hearing loss: air and bone conduction are >20dB
Conductive hearing loss: BC normal, but air >20dB
Mixed hearing loss: both air and bone conduction >20dB but there is a difference of >15dB between the two.
88
What is an acoustic neuroma?
Vestibular Schwannoma
Usually unilateral
Tumour of the Schwann cells of CNVIII
89
What should be suspected with a bilateral acoustic neuroma?
Neurofibromatosis type II
Autosomal dominant
Chromosome 22
Also causes multiple intracranial schwannomas, meningiomas and ependymomas
90
How does an acoustic neuroma present?
Unilateral sensorineural hearing loss- this is often the initial symptom
Unilateral tinnitus
Dizziness or imbalance
Sensation of fullness in ear
91
How is an acoustic neuroma investigated?
| How is an acoustic neuroma managed?
Ix- MRI of cerebellopontine angle, audiometry as only 5% pts will have a normal audiogram
Conservative- monitor if no symptoms or if it is inappropriate to treat
Surgery- partial or total removal of tumour
Radiotherapy- reduce the growth of the tumour
Risks- vestibulocochlear nerve injury leading to permanent hearing loss, facial nerve injury, facial weakness
92
Describe the course of CNVII
Arises at the lower pons as a large motor and small sensory root.
Travels to the petrous part of the temporal bone via the internal acoustic meatus.
Then enter the facial canal (still in temporal bone)
The 2 roots fuse forming the facial nerve.
The nerve forms the geniculate ganglion
The nerve gives rise to the following-
Greater petrosal nerve
Nerve to stapedius
Chorda tympani
Then the CNVII exits the facial canal (and cranium) via stylomastoid foramen
First extracranial branch is posterior auricular nerve
Immediately distal to this, motor branches to posterior belly of digastric and stylohyoid muscles
```
The motor root continues anteriorly & inferiorly into the parotid gland- 5 branches
Temporal branch
Zygomatic branch
Buccal branch
Marginal mandibular branch
Cervical branch
```
93
What are the functions of CNVII?
MOTOR FUNCTIONS
Muscles of facial expression
Stapedius in inner ear
Posterior digastric, stylohyoid, platysma in neck
SENSORY FUNCTIONS
Taste from anterior 2/3 of tongue
PARASYMPATHETIC FUNCTIONS
Greater petrosal nerve- lacrimal gland, mucous glands of oral cavity, nose + pharynx
Chorda tympani- submandibular + sublingual salivary glands
94
How would you distinguish between an UMN and LMN facial nerve palsy?
In new onset UMN suspect stroke.
LMN is less urgent.
Each side of the forehead has UMN innervation from both sides of the brain, but a LMN innervation from only one side.
So UMN will have forehead sparing whilst LMN will not- will be unable to raise eyebrows on the affected side.
95
What are the causes of UMN facial nerve palsy?
Unilateral:
Stroke
Tumour
Bilateral: rare
Pseudobulbar palsies
Motor neurone disease
96
What are the red flags of a facial nerve palsy?
Facial nerve palsy associated w/ severe otalgia- ?mastoiditis, necrotising otitis externa
Facial nerve palsy w/ parotid swelling in elderly pt- ?parotid malignancy
Facial nerve palsy w/ trauma- urgent decompression may be required
Other associated neuro symptoms- ?stroke
97
What is a Bells palsy?
How does it present?
How is it managed?
Often idiopathic
Unilateral LMN facial nerve palsy
Most pts recover over several weeks up to 1 year
1/3 left with residual weakness
If they present within 72 hours of developing symptoms- treat w/ prednisolone:
50mg for 10 days
60mg for 5 days followed by 5 day reducing regime of 10mg a day
Lubricating eye drops to prevent eye on affected side drying out/ damaged
98
How does a CNVII present?
Facial weakness or droop
Weakness can cause asymmetry at rest or only on movement of the face
Hyperacusis (nerve to stapedius)
Loss of taste sensation in anterior 2/3 of tongue (chorda tympani)
99
What are the causes of a CNVII palsy?
Idiopathic:
Bell’s palsy is the most common cause; diagnosis of exclusion
```
Infection:
AOM +/- mastoiditis
NOE
Lyme disease
Ramsey-Hunt syndrome (Herpes zoster)
```
Trauma:
Temporal bone #
Damage during surgery to middle ear or parotid
Neoplastic:
Parotid carcinoma
Acoustic neuroma
Cholesteatoma (benign)
```
Neurological:
Stroke
GB syndrome
Sarcoidosis
MS
```
100
What is the cause of Ramsey-Hunt Syndrome?
| How is it managed?
Caused by Herpes zoster virus
Presents as unilateral LMN facial nerve palsy
Painful and tender vesicular rash in ear canal, pinna and around the ear on the affected side
The rash can extend to the anterior 2/3 of the tongue and hard palate
Mx- within 72 hrs initiate prednisolone & acyclovir
Lubricating eye drops
PPI cover- gastroprotection
(RH syndrome is a common MCQ)
101
What is the skeletal structure of the nose?
Bony component- superiorly, contributions from nasal bones, maxillae and frontal bone
Cartilaginous component- inferiorly
102
What are the causes of saddle nose deformity?
Granulomatosis with polyangiitis (Wegener’s granulomatosis)
Direct trauma to septal bone or cartilage
Untreated nasal septal haematoma- leads to avascular necrosis of cartilaginous septum
103
What is the innervation to the nasal cavity?
Sensory- trigeminal nerve
| Motor- facial nerve
104
Describe the blood supply to the nasal mucosa
Anterior and posterior ethmoidal branches from ophthalmic artery (from internal carotid)
Sphenopalatine branch of maxillary artery (from external carotid)
Arterial anastomoses in anterior septum- Kisselbach’s plexus/ Little’s area
Venous drainage from nasal cavity into pterygoid venous plexus, cavernous sinus, and facial vein. This is known as the danger triangle of the face.
Infection from the nasal area can spread to the brain because the cavernous sinus is in the brain, where retrograde spread of infection can cause cavernous sinus thrombosis, meningitis, brain abscess.
105
Where does bleeding usually occur in the nasal mucosa?
Majority is anterior
Little’s area on the anterior septum
Posterior- small minority
106
How should a Px be advised in managing a nosebleed?
Sit up & tilt head forwards
Squeeze the soft part of the nostrils together for 10-15 mins
Spit out any blood in the mouth (don’t swallow)
107
How is a nosebleed managed?
Conservative measures for 15 mins- squeeze soft parts of nostrils together
- Nasal cautery using silver nitrate sticks- first line
- Nasal packing using nasal tampons or inflatable packs- try the above before nasal packing- drawbacks of packing:
=>Mucosal trauma
=>Pain and discomfort for pt
=>Obstruction of nasal airway in COPD etc may need to sleep semi-upright or require supplementary O2
=>Need for admission/ increased length of stay. Tend to stay in for 24-48hrs max. prolonged packing -> Abx
After bleed- Naseptin nasal cream (chlorhexidine and neomycin) QDS for 10 days can reduce crusting, inflammation, infection. Contraindicated in peanut/ soya allergy
108
What advice should be given to Px post nosebleed?
Don’t blow or pick nose
Avoid piping hot food and drink for a day
Avoid strenuous activity/ exercise for a couple of days
Apply antiseptic cream twice a day for 2 weeks
First-aid measures in case of re-bleed
Attend A&E If nosebleed >20mins
109
What are the complications of a nasal fracture?
- Septal haematoma; Need to be wary of this as can cause an abscess and ascending cavernous sinus infection, necrosis of septal cartilage, saddle deformity, septal perforation.
- CSF leak
- Anosmia
- Septal deviation leading to nasal obstruction
110
How is a nasal fracture managed?
Isolated nasal injuries can be managed as outpatient as the nose is too swollen immediately after trauma
Discharge from A&E and book into emergency ENT clinic 7-10 days later for manipulation under anaesthesia
111
What is a septal haematoma?
Blood collects under the nasal cartilage and perichondrium.
Red-purple fluctuant swelling on both sides of the nasal septum
Early diagnosis and treatment is important to prevent abscess formation, septal perforation, saddle nose deformity
Most common symptoms in children- nasal obstruction, pain, rhinorrhoea, fever
Mx- urgent surgical drainage to reduce risk of cartilage necrosis
112
How would you determine a Px has CSF rhinorrhoea?
Send a sample of nasal discharge looking for β-2-transferrrin/ tau protein to determine if it is CSF or not.
Give Px sterile container to catch discharge in.
113
What are the types of rhinitis?
What are the causes?
How are they managed?
Acute or chronic
Allergic or non-allergic
Allergic: IgE mediated inflammatory disorder where the nasal mucosa is exposed + sensitised to allergens, to produce typical symptoms of sneezing, nasal itching, discharge (rhinorrhoea), and congestion
Mx- nasal irrigation w/ saline, avoid allergens, intranasal corticosteroid during periods of allergen exposure, add-on treatments include intranasal decongestant, intranasal anticholinergic
Non-allergic can be caused by a cold or the flu, spicy foods
114
What is acute rhinosinusitis?
Acute inflammatory condition following a viral URTI
Increase in symptoms following initial viral illness- double sickening
115
How does a Px with acute rhinosinusitis present?
- Nasal blockage
- Rhinorrhoea (nasal discharge)
- Hyposmia (reduced smell)
-Facial or dental pressure/ pain
Tenderness over the sinuses
Usually no swelling- any swellings below zygoma (cheek or jaw) consider dental abscess or salivary gland infection
The above 4 are the most predictive symptoms; not all 4 have to be present
Also may have systemic malaise, fever, cough, sore throat.
116
How is acute rhinosinusitis managed?
Symptomatic care- simple analgesia (paracetamol, ibuprofen), 5 day course nasal decongestant
NO Abx unless persistent infective symptoms >10 days or suspecting sepsis, or immunosuppressed
-Penicillin V 500mg QDS for 5 days
Px who are systemically unwell/ more serious illness/ high risk of complications/ not responding after 2-3 days- co-amoxiclav 500/125 TDS 5 days
117
What is sinusitis?
Inflammation of the paranasal sinuses in the face
This can be accompanied by inflammation of the nasal cavity – rhinosinusitis
118
What are the paranasal sinuses?
| What is their function?
```
Frontal sinuses (2, above eyebrows)
Maxillary sinuses (either side of nose below the eyes)
Ethmoid sinuses (in ethmoid bone in middle of nasal cavity)
Sphenoid sinuses (in sphenoid bone at back of nasal cavity)
```
```
Function- various roles are suggested
Lightening the weight of the head
Supporting immune defence of nasal cavity
Humidifying inspired air
Increasing resonance of voice
```
119
Why might sinusitis present with a toothache?
Maxillary nerve supplies both the maxillary sinus and maxillary teeth so inflammation of the maxillary sinus can present with toothache
120
What are the causes of sinusitis?
Infection- viral URTI
Allergies- hayfever
Obstruction of draining eg foreign body, trauma, polyp
Smoking
Asthma is associated with higher incidence of sinusitis
121
How does a Px with sinusitis present?
```
Nasal congestion
Facial pain or headache
Nasal discharge
Facial pressure
Facial swelling
Loss of smell
Tenderness to palpation over affected areas
Fever
Chronic sinusitis= >12wks
```
122
How are acute and chronic sinusitis managed?
Acute-
Analgesia for pain/ fever
Abx? – if worsening or not improving within a week
High dose intranasal corticosteroids in adults with severe or prolonged symptoms
```
Chronic-
Manage any associated disorder eg allergic rhinitis, asthma
Avoid triggers
Nasal irrigation with saline solution
Intranasal corticosteroids
Long term abx? Consult specialist
```
Surgery-
- Functional endoscopic sinus surgery- inserting small endoscope through nostrils and sinuses to remove any obstructions to the sinuses – eg swollen mucosa, bone, polyps, deviated septum (septoplasty)
- CT required beforehand to confirm diagnosis
123
How is a nasal steroid spray used?
Tilt head slightly forward
Use the left hand to spray into the right nostril and vice versa
NOT sniffing hard during the spray
Very gently inhaling through the nose after the spray
124
What are nasal polyps?
Growths of nasal mucosa that occur in the nasal cavity or sinuses
Often associated with inflammation – chronic rhinitis
Grow slowly & obstruct nasal passage gradually
Usually bilateral
*Unilateral = red flag for tumour
125
Which conditions can nasal polyps give rise to?
| What are some symptoms of nasal polyps?
Chronic rhinitis/ sinusitis
Asthma
Samter’s triad- nasal polyps, asthma, aspirin sensitivity
Cystic fibrosis
Eosinophilic granulomatosis with polyangiitis (Churg Strauss syndrome)
Symptoms- difficulty breathing, snoring, nasal discharge, anosmia
126
How are nasal polyps managed?
Unilateral- urgent 2WW referral, suspect malignancy
Medical- intranasal topical steroid drops or spray
Surgery- if medical mx fails- intranasal polypectomy (for more visible polyps) or endoscopic nasal polypectomy (where they’re deeper inside)
127
What is the sensory supply to the tongue?
Anterior 2/3
Sensation- trigeminal- lingual branch of V3 (mandibular)
Taste- facial- chorda tympani branch
Posterior 1/3
Sensation & taste- glossopharyngeal (IX)
128
How do salivary stones present?
| How are they managed?
Sialolithiasis
Formation of calculi (sialoliths) inside the ducts or parenchyma of salivary glands
Most common in submandibular gland
Symptoms- stimulated by eating (since salivate more)- pain in gland, swelling, infection
Diagnosis- X-ray, sialogram
Mx- conservative, hydrate, moist head, NSAIDs, sucking something sour to increase saliva production
129
How does tonsillitis present?
```
Sore throat
Fever
Pain on swallowing (however if they can still swallow good amount of fluid, they don’t need to be admitted)
Cervical lymph nodes
Bad breath
```
O/E- red, inflamed, enlarged tonsils, +/- exudates (small white patches of pus on tonsils), anterior cervical lymphadenopathy
130
What are the causes of tonsillitis?
```
Most common- viral infection
Bacteria- commonest is group A strep (strep pyogenes)
Strep pneumoniae
Haemophilius influenzae
Moraxella catarrhalis
```
131
What are the red flags associated with tonsillitis?
Severe sore throat, hoarse croaky voice, dysphagia and fever – epiglottitis until proven otherwise
Px may develop stridor as late sign and can decompensate very quickly
Severe sore throat where you cant see evidence of tonsillitis- epiglottitis until proven otherwise
Hot potato voice, stertor, trismus (reduced mouth opening)- peritonsillar abscess or quinsy
132
What is the Centor criteria?
| What is the importance of the criteria?
Used to estimate the probability that tonsillitis is due to a bacterial infection and will benefit from Abx
A score of 3 or more gives 40-60% chance of bacterial so will offer Abx
```
A point for each of the following:
-Fever >38
-Tonsillar exudates
-Absence of cough
-Tender anterior cervical lymph nodes
(CENT: cant cough, exudate, nodes, temperature)
```
133
What is the FeverPAIN score?
Used as an alternative to the Centor criteria
A score of 2-3 gives a 34-40% chance, and 4-5 gives 62-65% chance of bacterial cause of tonsillitis (strep pyogenes)
A point for each of the following:
- Fever during previous 24 hrs
- Pus on tonsils
- Attended within 3 days of onset of symptoms
- Inflamed tonsils
- No cough or coryza
134
How is tonsillitis managed?
Calculate Centor criteria or FeverPAIN score
Safety net
Simple analgesia for pain and fever
Advise pts to return if pain hasn’t settled within 3 days or fever > 38.3
```
Antibiotics if:
Centor >3
FeverPAIN >4
Young infants
Immunocompromised
Co-morbidities
Rheumatic fever hx
```
Consider a delayed prescription, where you advise the pts or parents about the likely viral nature of sore throat & if symptoms worsen within 3 days to collect the abx prescription
Which abx?
Penicillin V 10-day course
Clarithromycin if penicillin allergy
135
Who is admitted to hospital with tonsillitis?
| How are they managed?
```
Admit if-
Immunocompromised
Systemically unwell
Dehydrated
Stridor/ stertor
Respiratory distress
Peritonsillar abscess or cellulitis
```
Mx-
IV access
FBC, U&Es, LFTs, glandular fever screen
Regular basic IV/ PO analgesia- paracetamol + ibuprofen, stronger PRNs
Topical analgesic spray eg benzydamine spray
Fluids- 1 L normal saline over 1-2 hrs often needed as majority pts are often young and dehydrated
Single stat dose steroid eg 6.6mg dexamethasone sodium phosphate IV, or 40mg prednisolone PO, esp. for those with stertor
Abscesses may need aspiration
136
What are the complications of tonsillitis?
```
Quinsy (Peri-tonsillar abscess)
Post-strep GN
Post strep reactive arthritis
Scarlet fever
Otitis media
Rheumatic fever
```
137
What is a quinsy?
Collection of pus collecting in the peritonsillar space as a post tonsillitis complication.
This pushes the tonsils infero-medially.
138
How does a quinsy present?
```
Similar symptoms as tonsillitis-
Sore throat
Painful swallowing
Fever
Neck pain
Referred ear pain
Swollen tender lymph nodes
```
Additional symptoms that can indicate peritonsillar abscess-
Trismus- unable to open mouth
Change in voice- due to pharyngeal swelling = hot potato voice
Swelling and erythema in the area behind the tonsils
139
What are the causes of quinsy?
Usually bacterial infection.
| Strep pyogenes commonly, but also Staph.aureus and H.influenza.
140
How is quinsy managed?
ENT hospital admission- esp for Px who can't swallow fluids- dehydration.
Abscess incision and drainage under GA.
Give Abx before and after surgery. Broad spectrum co-amoxiclav.
Some ENT surgeons may give dexamethasone to reduce swelling.
141
How is a quinsy different from tonsillitis?
- Trismus
- On the affected side, the anterior arch is pushed medially
- On the affected side, the palate will bulge toward you, ie the normally concave palate becomes convex
- The uvula may be pushed away from affected side
- On the affected side, the mucosa of the arch and palate look angrily erythematous
142
What is a tonsillectomy?
| What are the indications?
Surgical removal of tonsils
Prevents further episodes of tonsillitis
Patients can still get a sore throat from other causes such as pharyngitis
Generally a day case procedure under GA
Indications-
7+ episodes of acute sore throat in 1 year
5 per year for 2 years
3 per year for 3 years
Recurrent tonsillar abscess (2 episodes)
Enlarged tonsils causing difficulty breathing, swallowing or snoring
143
What are the complications of tonsillectomy?
```
Infection
Damage to teeth
Post tonsillectomy bleeding
Complications of GA
Sore throat at the site of tonsillar tissue (upto 2wks)
```
144
How is post-tonsillectomy bleeding managed?
This is the main significant complication after a tonsillectomy
Occurs in ~5% pts who have had a tonsillectomy
Happens up to 2 wks after
Get IV access, send bloods- FBC, clotting screen, G&S, cross match
Call ENT reg
Keep pts calm and give adequate analgesia
Sit pts up and advise to spit out blood rather than swallowing
Suction should be available if needed
Make pts NBM in case of surgery
IV fluids for maintenance & resuscitation as required
Ice pack on back of neck
IV tranexamic acid
If very severe bleeding, compromise to airway- call anaesthetist- may intubate
For less severe bleeds
Hydrogen peroxide gargle
Adrenaline soaked swab applied topically
145
What are the borders of the anterior triangle?
Medial- Midline of neck
Lateral- SCM
Superior- Mandible
146
What are the borders of the posterior triangle?
Lateral- SCM
Posterior- Trapezius
Inferior- Clavicle
147
What are the differentials of neck lumps in adults?
```
Normal structures i.e. bones
Skin abscess
Goitre/thyroid nodules
Dermoid cyst
Branchial cyst
Lymphadenopathy
Lymphoma
Lipoma
Tumour
Thyroglossal duct cyst
Salivary gland stones
Carotid body tumour
Haematoma
```
148
What are the differentials of neck lumps in children?
Cystic hygromas
Dermoid cysts
Hemangiomas
Venous malformation
149
When is a Px referred via 2WW for a H+N lump?
If >45yrs with unexplained neck lump.
Or persistent unexplained neck lump of any age.
If growing lump refer for an urgent USS;
-Within 2wks if >25yrs
-Within 48hrs if <25yrs
If USS suggestive of soft tissue sarcoma then refer via 2WW.
150
How is a neck lump investigated?
```
Bloods:
FBC and blood film for leukaemia and infection
HIV test
IM test- EMV antibodies
TFTs- goitre, thyroid nodules
ANA- SLE
LDH- Hodgkin lymphoma
```
Imaging
USS often first line
CT or MRI
Nuclear medicine scan- for toxic thyroid nodules or PET scans for metastatic cancer
```
Biopsy:
FNA cytology
Core biopsy
Incision biopsy
Removal of lump
```
151
What are the causes of lymphadenopathy?
Reactive- viral URIT, dental infection, tonsillitis
Infected- TB, HIV, IM
Inflammatory- SLE, sarcoidosis
Malignancy- lymphoma, leukaemia, metastasis
152
What is infectious mononucleosis (glandular fever)?
Caused by EBV
Spread via saliva
Presentation- classic triad of sore throat, pyrexia, lymphadenopathy
Fatigue
Very itchy maculopapular rash in response to amoxicillin or cephalosporins
Splenomegaly ~50% pts
Hepatitis, transient rise in ALT
153
How is infectious mononucleosis (glandular fever) investigated?
First-line- Monospot test = heterophil antibody test
NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever
IgM (acute infection)
IgG (immunity)
154
How is infectious mononucleosis (glandular fever) managed?
Supportive- rest, drink plenty fluids, simple analgesia for aches or pains
Avoid alcohol- risk of alcohol impairment
Avoid sports for at least 8 weeks after having glandular fever- splenic rupture
155
Where is the thyroid located?
| What is its function?
```
Anterior to trachea
Inferior to larynx
Midline of neck
C5-T1
Two lobes joined by isthmus
Surrounded by fibrous capsule
```
When stimulated by TSH, it produces T3/T4
156
What is the blood supply to the thyroid?
Superior thyroid artery from the external carotid.
| Inferior thyroid artery from the thyrocervical trunk (from subclavian artery)
157
What is the recurrent laryngeal nerve?
Branch of vagus nerve
The right side branches at level of subclavian artery.
The left side branches at the level of the arch of aorta.
158
What are the functions of the recurrent laryngeal nerve?
Motor:
Intrinsic muscles of larynx (except cricothyroid muscle)
Sensory:
Glottis
Subglottis
Trachea
159
What are the names of the salivary glands?
Parotid
Submandibular
Sublingual
160
What are the causes of enlarged salivary glands?
Stones- blocking the drainage- sialolithesis
Infection
Tumours
161
How would a carotid body tumour present?
Slow growing lump in upper anterior triangle of the neck
Painless
Pulsatile
Associated with a bruit on auscultation
Mobile side-to-side but not up & down
May compress glossopharyngeal, vagus, accessory, hypoglossal nerves
Pressure on vagus nerve- Horner syndrome
Ptosis
Miosis
Anhidrosis
Imaging- splaying of internal & external carotid arteries- Lyre sign
162
What is a lipoma?
Benign growth of adipose cells.
| Soft, painless, mobile, no skin changes.
163
What are the features of a thyroglossal duct cyst?
How is it investigated?
How is it managed?
Patent thyroglossal duct causing a fluid filled cyst
Midline of neck
Mobile, non-tender, soft, fluctuant
Move up & down w/ tongue movements
Due to the connection between the thyroglossal duct and the base of tongue
US or CT scan to confirm diagnosis
Mx- surgical removal & histology
Main complication- infection of cyst
164
What is a branchial cyst?
Congenital abnormality
Second branchial cleft fails to form properly during foetal development
Round, soft, cystic swelling between the angle of the jaw and the SCM in the anterior triangle of the neck
Transilluminates w/ light
165
What are the common locations for H+N cancers?
```
Nasal cavity
Paranasal sinuses
Mouth
Salivary glands
Pharynx (throat)
Larynx (epiglottis, supraglottis, vocal cords, glottis, subglottis)
```
166
What are the RF for developing H+N cancers?
```
Smoking
Chewing tobacco
Chewing betel quid
Alcohol
HPV (16)
EBV
```
167
What are the red flags for H+N cancers?
```
Lump in mouth/lip
Persistent mouth ulceration >3wks
Unexplained erythroplakia or erythroleukoplakia
Persistent neck lump
Unexplained thyroid lump
Unexplained voice hoarseness
```
168
What is cetuximab?
Monoclonal antibody
Used in treating SCC’s of H&N, bowel cancer
Targets epidermal growth factor receptor, blocking activation of this receptor and inhibiting growth and metastasis of the tumour
169
What are the types of thyroid cancer?
Thyroid follicular epithelial derived cancer:
- Papillary (70%)
- Follicular (20%)
- Anaplastic (1%)
Medullary thyroid cancer
Primary thyroid lymphoma
170
How is papillary and follicular thyroid cancer managed?
Remove entire thyroid gland- Total thyroidectomy.
Followed by radioiodine to kill remaining cells.
Need to measure thyroglobulin levels yearly to identify early recurrent disease.
171
What are the RF for developing papillary and follicular thyroid cancer?
```
Radiation exposure- especially as a child
Fx
Female
Obesity
Cowden's syndrome
FAP
```
172
What are the features of thyroid cancer?
Thyroid nodule/ mass
Hoarseness/ change in voice
Cervical lymphadenopathy
Stridor
173
What are the causes of glossitis?
Iron/B12/Folate deficiency
Coeliac disease
Injury/irritant exposure
174
What are the causes of angioedema?
Allergic reaction
ACEi
C1 esterase inhibitor deficiency (hereditary angioedema)
175
What are the causes of oral candidiasis?
```
Abx
Diabetes
Immunocompromised i.e. HIV
Inhaled corticosteroids
Smoking
```
176
How is oral candidiasis managed?
Oral antifungals-
Miconazole gel
Nystatin suspension
Fluconazole tablets
177
What is a strawberry tongue?
| What are the causes?
Red, inflamed, angry tongue.
White, enlarged, prominent papillae.
Caused commonly by Kawasaki disease or Scarlet Fever.
178
What is leucoplakia?
| How is it managed?
White patches in mouth, often tongue or insides of cheeks (buccal mucosa)
Pre-cancerous condition- increases risk of SCC of mouth
Asymptomatic, irregular, slightly raised patches
Fixed in place- can’t be scraped off
Mx- stop smoking, reducing alcohol, close monitoring, potentially laser removal or surgical excision
179
What is gingivitis?
Inflammation of gums --> swollen gums, bleeding after brushing, painful gums, halitosis
Can lead to periodontitis if not adequately managed
```
Risk factors-
Plaque build up on teeth
Smoking
Diabetes
Malnutrition
Stress
```
180
What is the treatment of gingivitis?
Good oral hygiene
Stop smoking
Dental hygienist to remove plaque and tartar
Chlorhexidine mouth wash
Abx for acute necrotising ulcerative gingivitis eg metronidazole
Dental surgery may be required
181
What are the causes of gingival hyperplasia?
```
Gingivitis
Pregnancy
Vit C deficiency- scurvy
Acute myeloid leukaemia
Medications- CCBs, phenytoin, ciclosporin
```
182
What are the causes of aphthous ulcers?
```
IBD
Coeliac
Behcet disease
HIV
Vitamin deficiency- B12, Folate, Iron, Vit D
```
183
How are aphthous ulcers treated?
Topical treatments
Choline salicylate
Benzydamine
Lidocaine
Topical corticosteroids
Hydrocortisone buccal tablets applied to lesion
2WW referral- unexplained ulceration lasting >3 wks
184
What are the borders of the nasopharynx?
Superior- Skull base
Anterior- Nasal cavity
Posterior- Posterior pharyngeal wall
Inferior- Soft palate
185
What is the clinical significance of the fossa of rosemuller (posterolateral pharyngeal abscess)?
The common origin place of nasopharyngeal cancer.
186
What are the borders of the oropharynx?
Superiorly- Soft palate free border
Inferiorly- Hyoid bone
Anterior- Base of tongue
Posterior- Posterior pharyngeal wall.
187
How would you manage a swelling in the sub mandible area, in clinical practice?
Take Hx
How long?
USS
Syelogram- look for radio opaque calculi in the parotid ducts
May need interventional radiology to remove duct stones
May need excison of ducts
188
What is a pharyngeal cancer?
Cancer of the:
Oropharynx- Including tumours at the base of the tongue, tonsils and under surface of soft palate. (Likely SCC)
Hypopharynx (Likely SCC)
Nasopharynx
189
What is the epidemiology of pharyngeal cancers?
More common in South Asian population
40-70yrs old
HPV
EBV
190
How does a pharyngeal cancer present?
Oropharynx: Persistent sore throat, a lump in the mouth or throat, pain in the ear.
Hypopharynx: Dysphagia, ear pain and hoarseness.
Nasopharynx: Lump in the neck, nasal obstruction, deafness and postnasal discharge.
Can also get haemoptysis, halitosis, trismus and weight loss.
191
How is a pharyngeal cancer investigated?
| How is it managed?
LFTs- Ab mets
CXR- Lung mets
CT/MRI
Biopsy- FNA
Mx-
Surgical resection of tumour and involved LN
Chemotherapy (Palliative if unresectable)
Radiotherapy
192
What are nasopharyngeal cancers?
Strongly associated with EBV.
Very rarely can get sinonasal tumours.
Peak age group 30-40yrs and 50-60yrs
RF:
Chinese (or Asian) ancestry.
EBV exposure.
Heavy alcohol intake.
193
How does a Px with nasopharyngeal cancer present?
```
Can present with blocked nse
Blocked ear
Epistasis
Weight loss
Local pressure
Distal metastasis
```
194
How is a nasopharyngeal cancer investigated?
| How is it managed?
Examination
Skull XR
CT/MRI
These would then warrant a FNA biopsy.
Mx-
If previously untreated then external beam radiation.
Chemotherapy as an adjuvant radiotherapy.
If persistent then nasopharyngectomy.
195
How would you manage a Sinonasal cancer?
Endoscopic sinus surgery
| Use navigation
196
What are cancers of the oral cavity?
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Mainly SCC which can appear on the;
Buccal mucosa
Alveolar (gum)
Lips (inc melanoma with sun exposure)
Ant 2/3 tongue
Hard palate
Floor of oral cavity
Retromolar traingle
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197
What are the RF for developing oral cavity cancer?
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Smoking
Tobacco chewing
Alcohol consumption
Poo dentition
Betal quid
Radiation exposure
HPV (oral sex)
Plummer-Vinson syndrome
XS sunglight- Melanoma at the lips
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198
How do cancers of the tongue present?
Tumours can grow quite large before causing symptoms.
Lesions commonly at the lateral tongue.
Greyish-reddish rough, shaggy, papillomatous surface/plaque.
Raised, may not be painful- unless nerves involved i.e. lingual nerve can give painful tongue.
Speech and swallowing difficulties.
199
How does a cancer of the buccal mucosa present?
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Starts off as a painless lesion.
Becomes painful when;
-Ulcerates and is infected secondarily
-Invades a local nerve
At this stage it is easily treatable with a good prognosis, as it is unlikely to have metastasised.
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If the lesion does not become painful, then it is noticed later and so has a poorer prognosis, as it may have already metastasised.
200
How are oropharyngeal cancers managed?
Altered fractionation radiotherapy
Can also undergo chemotherapy + radiotherapy + surgery.
In early OC cancer consider surgical resection or brachytherapy. If Px +ve for nodes then consider radiotherapy following the surgery.
In late OC cancer consider radical surgery if surgically accessible and Px is fit. If nodes +ve then radical neck dissection otherwise.
If surgery contraindicated then consider radical external beam radiotherapy.
201
What is laryngeal cancer?
| What are the RF?
SCC of the larynx, including the supraglottis, glottis and infraglottis.
2nd most common H+N cancer.
```
M:F= 4:1
Smoking
Occupational exposure i.e. asbestos, formaldehyde etc.
HPV
Tobacco smoke
Diet rich in fruit and veg is protective
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202
How does laryngeal cancer present?
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Chronic hoarseness
Pain
Dysphagia
Lump in the neck
Sore throat
Earache
Persistent cough
Breathlessness
Aspiration
Haemoptysis
Fatigue
Weakness
Weight loss
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203
How is a laryngeal cancer investigated?
Urgent CXR referral for hoarse voice >3wks. Especially if Px is smoker, alcoholic or >50yrs.
If CXR abnormal refer to lung cancer specialists. If CXR normal refer to H+N cancer specialists.
Flexible laryngoscopy
CT/MRI for staging
204
How is a laryngeal cancer managed?
Main management is through total/partial laryngectomy.
| Can also do chemoradiation in the way of organ preservation.
205
What are tumours of the brain?
VERY RARE.
Not referred to as benign or malignany, since even growth of benign tumours will lead to mortality through increased ICP and compression. Refer to as high grade (fast growing, aggressive) and low grade (slow growing)
Commonly gliomas (HG) and meningiomas (LG).
206
How does a brain cancer present?
Headache- typically worse in the mornings.
Nausea and vomiting.
Seizures.
Progressive focal neurological deficits - eg, diplopia associated with a cranial nerve defect, visual field defect, neurological deficits affecting the upper and/or lower limb.
Cognitive or behavioural symptoms.
Symptoms relating to location of mass - eg, frontal lobe lesions associated with personality changes, disinhibition and parietal lobe lesions might be associated with dysarthria.
Papilloedema (absence of papilloedema does not exclude a brain tumour).
Focal/generalised seizures are common with meningiomas.
207
How is a brain cancer investigated?
Urgent MRI (or CT if contraindicated) for Px presenting with progressive, subacute loss of central neurological function.
Early MRI/CT is useful
Can take biopsy
208
How is brain cancer managed?
Reduce ICP
Surgery is the first line option
If surgery contraindicated then radiotherapy.
Chemotherapy can be used alongside surgery/radiotherapy.
