ENT Flashcards

Question

WHAT IS MALIGNANT OTITIS EXTERNA?

Answer 1

1. Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics) 2. most commonly caused by Pseudomonas aeruginosa 3. Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal 4. Progresses to temporal bone osteomyelitis

Answer 2

1. Diabetes (90%) or immunosuppression (illness or treatment-related) 2. Severe, unrelenting, deep-seated otalgia 3. Temporal headaches 4. Purulent otorrhea 5. Possibly dysphagia, hoarseness, and/or facial nerve dysfunction

Answer 3

A CT scan is typically done

Answer 4

1. non-resolving otitis externa with worsening pain should be referred urgently to ENT 2. Intravenous antibiotics that cover pseudomonal infections

Answer 5

Leucoplakia is a premalignant, white coloured thickening of the oral mucosa that cannot readily be scraped off. In the mouth the cheeks and the tongue are most often affected.

Answer 6

Sore teeth Smoking Spirits Sepsis Syphilis

Answer 7

Candida can be scraped off the tongue

Answer 8

If leucoplakia is severe or extensive then the patient should be referred for dermatological opinion and biopsy. If dysplasia is severe then this may necessitate surgical removal. Grafting may then be required.

Answer 9

This is a congenital lesion comprised of lymph-filled spaces which arise from an embryonic remnant of the jugular lymph sac. It is not a true cyst but rather a lymphatic hamartoma which forms multilocular cyst-like spaces.

Answer 10

Cystic hygromas of the neck in early fetal life are responsible for the webbed neck in Turner's and Noonan's syndromes.

Answer 11

Most occur in the base of the neck Both in the anterior and the posterior triangle, and may extend up to the jaw, over the anterior chest wall, and down into the axilla. Rarely, it occurs alone in the axilla, pelvis, or groin. It presents as a soft, fluctuant and highly transilluminable lump just beneath the skin. It may be lobular and usually is painless. It contains clear fluid and may be of any size.

Answer 12

1. **Surgery** Surgical excision of all affected tissue, but this can be difficult because of infiltration of vital neck structures. 2. **Sclerosing agents** e.g. doxycycline Can be injected directly into the cystic hygroma.

Answer 13

This arises from embryonic remnants of the second branchial cleft in the neck.

Answer 14

The cyst may enlarge during an upper respiratory tract infection and then persist. In the acute stage, it may be tender.

Answer 15

It is most common in young adults where it presents as a smooth swelling in front of the anterior border of the sternomastoid at the junction of its upper and middle thirds. The position is characteristic.

Answer 16

The cyst may enlarge during an upper respiratory tract infection and then persist. In the acute stage, it may be tender. **On examination** 1. It is usually fluctuant but does not transilluminate. 2. It does not move on swallowing. 3. Other enlarged lymph nodes are absent 4. Contains cholesterol

Answer 17

Treatment is by excision. Care must be taken not to damage the carotid vessels and internal jugular vein which usually lie deep to the swelling

Answer 18

The thyroid gland develops from the lower portion of the thyroglossal duct, which begins at the foramen caecum at the base of the tongue. If a portion of this duct remains patent it can form a cyst - a thyroglossal cyst.

Answer 19

The cysts are usually found between the isthmus of the thyroid gland and the hyoid cartilage, or just above the hyoid cartilage. They occur at any age but the majority are seen in patients between 15 and 30 years of age

Answer 20

Presentation is usually, as a painless, smooth, cystic, midline swelling in the region of the hyoid bone. A thyroglossal cyst may become symptomatic if it becomes inflamed; resulting in pain and swelling.

Answer 21

On examination, the cyst rises as the patient swallows or protrudes their tongue because of its attachment to the tongue via the tract of thyroid descent.

Answer 22

Often, it presents with infection requiring drainage prior to excision.

Answer 23

The nasopharynx (behind the nose) The oropharynx, which includes the under surface of the soft palate, the base of the tongue and the tonsils The hypopharynx (bottom part of the throat)

Answer 24

**Nasopharynx** Most likely to cause a lump in the neck, but may also cause nasal obstruction, deafness and post-nasal discharge **Oropharynx** Common symptoms are a persistent sore throat, a lump in the mouth or throat, and otalgia **Hypopharynx** Problems with swallowing and ear pain are common symptoms and hoarseness is not uncommon

Answer 25

The majority of upper airway tract (UAT) cancers are triggered by alcohol and tobacco, which together probably account for three-quarters of cases

Answer 26

1. Ultrasound 2. Fine-needle aspiration cytology or core biopsy for people with a neck lump that is suspected of being cancer of the upper aerodigestive tract

Answer 27

Bleeding from the nose

Answer 28

1. **Anterior bleeding** More common - seen in around 90% of cases Occurs from **Keisselbach’s plexus** in a site known as the **Little’s area** 2. **Posterior bleeding** Present in around 10% of cases **Woodruff plexus -** Behind the posterior part of the middle turbinate The posterior superior roof of the nasal cavity

Answer 29

1. **A hot, dry indoor climate** This causes the delicate nasal skin to crack 2. **Deviated nasal septum** This alters airflow pattern and causes the skin on one side of the nasal septum to become dry 3. **Colds and allergies** Upper respiratory tract infections and allergies increase the risk of bleeding.due to inflammation 4. **Irritant chemical exposure** 5. **Medical causes** Kidney failure, thrombocytopenia,hypertension, hereditary bleeding disorders (e.g.hemophilia) 6. **Anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin and ibuprofen**

Answer 30

1. Chronic sinusitis 2. Irritants (cigarette smoke) 3. Medications (e.g. topical corticosteroids) 4. Rhinitis 5. Trauma 6. Nasal vessel degeneration 7. Septal deviation and perforation 8. Vascular malformation (e.g. telangiectasia 9. Neoplastic

Answer 31

1. **Medication** Warfarin Aspirin and other NSAIDS 2. **Haematological disorders** Hereditary haemorrhagic telangiectasia Bleeding diatheses Leukaemia 3. **Liver disease (cirrhosis)**

Answer 32

**Examination** Nasal passage should be done with a Thudicum nasal speculum under adequate lighting to identify bleeding points **Laboratory studies are indicated in** 1. Patients with severe hemorrhage - full blood count, coagulation studies, blood typing and screening for possible transfusion 2. Patients taking warfarin - full blood count, coagulation studies 3. Patients with systemic conditions - investigations for hepatic or renal dysfunction

Answer 33

1. **First aid measures** 2. **Cautery -using a silver nitrate stick** Used in epistaxis that is refractory to first aid measures and if the bleeding site can be identified 3. **Nasal packing** If bleeding continues despite cautery methods or if the bleeding point cannot be seen If nasal packing fails refer the patient to secondary care for further management

Answer 34

Unilateral epistaxis - nasal cancer

Answer 35

1. Are skin or stratified keratinising squamous epithelium growing in the middle ear 2. They are a greasy-looking mass or accumulation of debris that is seen in a retraction pocket or perforation 3. They often take the form of a cyst or pouch that sheds layers of old skin

Answer 36

**Smelly (faecal) discharge and chronic drainage** Often presents as chronic otorrhea unresponsive to antibiotic therapy **Hearing loss** in 90 percent of patients there is conductive hearing loss caused by ossicular erosion

Answer 37

**Otoscopy** 1. Pearly, white, glistening debris occupying a perforation in the tympanic membrane - usually the pars flaccida 2. Crusting in the uppermost part of the ear drum - the attic - beneath which lies a cholesteatoma **Tuning fork** Conductive hearing loss

Answer 38

Surgical Excision

Answer 39

Meniere's disease is a disorder of the inner ear of unknown cause. It is characterised by excessive pressure and progressive dilation of the endolymphatic system.

Answer 40

1. The exact mechanism of the disease is controversial. 2. Although Ménière's disease is idiopathic, endolymphatic hydrops has been postulated as the cause of the disease 3. The increased pressure causes rupture of the inner ear membranes and mixing of endolymph and perilymph which are biochemically dissimilar, having a high and a low potassium content, respectively. 4. This causes acute vestibulo-cochlear failure, with sudden vertigo and deafness

Answer 41

**Periodic episodes of rotary vertigo or dizziness** Attacks occur intermittently, often in clusters. 1. Fluctuating, progressive, unilateral or bilateral **hearing loss** 2. **Tinnitus** 3. A sensation of **fullness or pressure** in one or both ears 4. **Tumarkin attacks** 5. **Nystagmus** **NOT AFFECTED BY HEAD POSITION**

Answer 42

Meniere's disease is a clinical diagnosis. Patients usually present with episodic dizziness. Acute episodes of vertigo should be differentiated from non-rotatory dizziness * *To exclude systemic conditions.** - Renal function, glucose - metabolic disturbances - FBC, ESR, CRP - infections - TFT - hormonal imbalances **For testing of hearing** Pure tone audiometry **ENG (electronystagmograph) or video nystagmography** May be performed to evaluate balance function

Answer 43

1. **Acute attacks:** * ****Buccal or intramuscular **prochlorperazine**. Admission is sometimes required 2. **Prevention:** * ******Betahistine and vestibular rehabilitation exercises** may be of benefit 3. ENT assessment is required to confirm the diagnosis 4. Patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved

Answer 44

Ménière's disease is an idiopathic condition while Ménière's syndrome results secondary to various processes interfering with normal production or resorption of endolymph

Answer 45

Rhinitis is inflammation of the lining of the nose.

Answer 46

**_Allergic rhinitis_ Seasonal (also called "hay fever")** Caused by grass, tree pollen allergens, symptoms can seen during the same time each year **Perennial** Caused by house dust mites, symptoms occur right throughout the year **Occupational** Caused by allergens at workplace e.g.- flour allergy in a baker **_Non-allergic rhinits_** Streptococcus pneumoniae

Answer 47

Itching, sneezing and watery nasal discharge

Answer 48

**Acute \<12w** 1. If not improving after 10 days prescribe high dose steroid spray (memetasone 200mcg BD 14d) 2. If still not improving consider prescribing penicillin V (adult dose PO 500mg QDS 5d) **Chronic \>12w** 1. Saline nasal irrigation 2. Steroid nasal sprays 3. FESS (functional endoscopic sinus surgery) to remove or correct obstructions.

Answer 49

Acute tonsillitis is acute inflammation of the tonsils

Answer 50

1. Sore throat 2. Otalgia 3. Headache and malaise **On examination:** 1. Patient is pyrexial 2. Tonsils are enlarged and may be exuding pus from the tonsillar crypts - follicular tonsillitis 3. Pharyngeal mucosa is inflamed 4. Fetor - foul smell 5. Cervical lymph nodes are enlarged and tender

Answer 51

**Analgesia** Paracetamol and NSAIDs 90% of cases resolve in 7 days without treatment **Consider antibiotics** If Centor score 3 or 4 OR FeverPAIN score 4 or 5 Phenoxymethylpenicillin If allergic then clarithromycin

Answer 52

Used to predict the likelihood of the patinet having Group A beta-haemolytic streptococcus

Answer 53

Otitis media Quinsy - peritonsillar abscess

Answer 54

1. **Absolute:** * Biopsy in selected malignancy 2. **Relative:** Tonsillectomy is recommended for recurrent severe sore throat in adults * Seven or more well documented, clinically significant, adequately treated sore throats in the preceding year or * Five or more such episodes in each of the preceding two years or * Three or more such episodes in each of the preceding three years

Answer 55

Pleomorphic adenoma (also known as a benign mixed tumour) is a benign tumour of the parotid gland. It is the most common tumour of the parotid gland and typically appears at the age of 40-60 years.

Answer 56

1. gradual onset, painless unilateral swelling of the parotid gland 2. typically movable on examination rather than fixed

Answer 57

1. surgical excision

Answer 58

1. voice overuse 2. smoking 3. viral illness 4. hypothyroidism 5. gastro-oesophageal reflux 6. laryngeal cancer 7. lung cancer

Answer 59

When investigating patients with hoarseness a chest x-ray should be considered to exclude apical lung lesions.

Answer 60

1. A suspected cancer pathway referral to an ENT specialist should be considered for people aged 45 and over with: * persistent unexplained hoarseness or * An unexplained lump in the neck.

Answer 61

Mastoiditis typically develops when an infection spreads from the middle to the mastoid air spaces of the temporal bone.

Answer 62

1. Otalgia: severe, classically behind the ear 2. There may be a history of recurrent otitis media 3. fever 4. the patient is typically very unwell 5. swelling, erythema and tenderness over the mastoid process 6. the external ear may protrude forwards 7. ear discharge may be present if the eardrum has perforated

Answer 63

1. Clinically 2. Can use CT

Answer 64

IV antibiotics

Answer 65

1. facial nerve palsy 2. hearing loss 3. meningitis

Answer 66

Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.

Answer 67

1. auricular pain is often the first feature 2. facial nerve palsy 3. vesicular rash around the ear 4. other features include vertigo and tinnitus

Answer 68

1. Oral aciclovir and corticosteroids are usually given

Answer 69

Sinusitis describes an inflammation of the mucous membranes of the paranasal sinuses. The sinuses are usually sterile - the most common infectious agents seen in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses.

Answer 70

1. Facial pain 2. typically frontal pressure pain which is worse on bending forward 3. nasal discharge: usually thick and purulent 4. nasal obstruction

Answer 71

1. Analgesia 2. Intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited 3. NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days 4. oral antibiotics are not normally required but may be given for severe presentations. 5. The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if 'systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications'

Answer 72

1. 'double-sickening' may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection

Answer 73

A pharyngeal pouch (also known as Zenker's diverticulum) is a posteromedial diverticulum through Killian's dehiscence. Killian's dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles. It is more common in older patients and is 5 times more common in men

Answer 74

1. Dysphagia 2. regurgitation 3. aspiration 4. neck swelling which gurgles on palpation 5. halitosis

Answer 75

barium swallow combined with dynamic video fluoroscopy

Answer 76

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients.

Answer 77

1. Displacement of an otolith with the semicircular cancals 2. Causes abnormal movement with the canals, giving vertigo

Answer 78

1. Vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards) 2. May be associated with nausea 3. Each episode typically lasts 10-20 seconds 4. Positive Dix-Hallpike manoeuvre, indicated by: * Patient experiences vertigo * **Rotatory nystagmus**

Answer 79

1. **Epley manoeuvre** (successful in around 80% of cases) 2. teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises 3. Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.

Answer 80

1. asthma (particularly late-onset asthma) 2. aspirin sensitivity 3. infective sinusitis 4. cystic fibrosis 5. Kartagener's syndrome 6. Churg-Strauss syndrome

Answer 81

Samter's triad

Answer 82

1. All patients with suspected nasal polyps should be referred to ENT for a full examination * Unilateral nasal polyps are a red flag 2. Topical corticosteroids shrink polyp size in around 80% of patients

Answer 83

1. pain 2. conductive hearing loss 3. tinnitus 4. vertigo

Answer 84

1. olive oil 2. sodium bicarbonate 5% 3. almond oil

Answer 85

1. Recent viral infection 2. Recurrent vertigo attacks lasting hours or days 3. **NO HEARING LOSSSSSS**

Answer 86

1. Buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases 2. A short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases 3. **vestibular rehabilitation** exercises are the preferred treatment for patients who experience **chronic symptoms**

Answer 87

1. Recent viral infection 2. Sudden onset 3. Nausea and vomiting 4. Hearing may be affected

Answer 88

1. Squamous cell carcinoma of the nasopharynx 2. Rare in most parts of the world, apart from individuals from Southern China 3. Associated with Epstein Barr virus infection

Answer 89

**Systemic** 1. Cervical lymphadenopathy **Local** 1. Otalgia 2. Unilateral serous otitis media 3. Nasal obstruction, discharge and/ or epistaxis 4. Cranial nerve palsies e.g. III-VI

Answer 90

Combined CT and MRI

Answer 91

Radiotherapy

Answer 92

1. Haemorrhage 2. Pain

Answer 93

1. Haemorrhage is a feared complication following tonsillectomy. All post-tonsillectomy haemorrhages should be assessed by ENT. 2. Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre. 3. Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in around 1-2% of all tonsillectomies.

Answer 94

1. In unilateral **S**ensorineural deafness, sound is localised to the **S**uperior/unaffected side 2. In unilateral **C**onductive deafness, sound is localised to the **C**rap/affected side

Answer 95

1. 'positive test': air conduction (AC) is normally better than bone conduction (BC) 2. 'negative test': if BC \> AC then **conductive deafness** 3. **Air conduction \> bone conduction = sensorineural hearing loss**

Answer 96

1. Exotosis 2. Cholesteatoma 3. Perforated eardrum 4. Ear wax

Answer 97

1. Acoustic neuromas 2. Age-related hearing loss 3. Noise-related hearing loss

Answer 98

1. Watch and wait - if persists beyond 6 weeks then ENT referral 2. **Myringoplasy**

Answer 99

Barrett's refers to the metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium. There is an increased risk of oesophageal adenocarcinoma, estimated at 50-100 fold

Answer 100

1. gastro-oesophageal reflux disease (GORD) is the single strongest risk factor 2. male gender (7:1 ratio) 3. smoking 4. central obesity

Answer 101

1. Endoscopic surveillance with biopsies 2. high-dose proton pump inhibitor: whilst this is commonly used in patients with Barrett's the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited **Endoscopic surveillance** 1. for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years **If dysplasia of any grade is identified endoscopic intervention is offered. Options include:** 1. Endoscopic mucosal resection 2. Radiofrequency ablation

Answer 102

1. may be precipitated by relatively minor trauma 2. the sensation of nasal obstruction is the most common symptom 3. pain and rhinorrhoea are also seen 4. on examination, classically a bilateral, red swelling arising from the nasal septum 5. this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm

Answer 103

Urgent ENT referral 1. Surgical drainage 2. IV antibitoics

Answer 104

High-dose oral corticosteroids are used by ENT for all cases of SSNHL.

Answer 105

1. Otosclerosis describes the replacement of normal bone by vascular spongy bone. 2. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. 3. Otosclerosis is autosomal dominant and typically affects young adults

Answer 106

1. conductive deafness 2. tinnitus 3. normal tympanic membrane\* 4. positive family history

Answer 107

1. hearing aid 2. stapedectomy

Answer 108

A peritonsillar abscess typically develops as a complication of bacterial tonsillitis.

Answer 109

1. severe throat pain, which lateralises to one side 2. deviation of the uvula to the unaffected side 3. trismus (difficulty opening the mouth) 4. reduced neck mobility

Answer 110

1. Patients need urgent review by an ENT specialist. 2. Management * needle aspiration or incision & drainage + intravenous antibiotics * tonsillectomy should be considered to prevent recurrence

Answer 111

Presbycusis is a type of sensorineural hearing loss that affects elderly individuals. Typically, high-frequency hearing is affected bilaterally, which can lead to conversational difficulties, particularly in noisy environments.

Answer 112

1. Otoscopy: Normal, to rule out otosclerosis, cholesteatoma and conductive hearing loss (Foreign body, impacted wax etc.) 2. Tympanometry: Normal middle ear function with hearing loss (Type A) 3. Audiometry: Bilateral sensorineural pattern hearing loss 4. Blood tests including inflammatory markers and specific antibodies: Normal

Answer 113

1. Small epithelial defect anterior to the left ear 2. Produce foul mselling discharge

Answer 114

Left, has a longer course, therefore, more susceptable to damage

Answer 115

1. Temporal 2. Zygomatic 3. Buccal 4. Mandibular 5. Cervical

Answer 116

1. Infectious mononucleosis (glandular fever) is caused by the Epstein-Barr virus (EBV, also known as human herpesvirus 4, HHV-4) in 90% of cases. Less frequent causes include cytomegalovirus and HHV-6. It is most common in adolescents and young adults.

Answer 117

1. sore throat 2. lymphadenopathy: may be present in the anterior and posterior triangles of the neck, in contrast to tonsillitis which typically only results in the upper anterior cervical chain being enlarged 3. pyrexia

Answer 118

1. malaise, anorexia, headache 2. palatal petechiae 3. splenomegaly - occurs in around 50% of patients and may rarely predispose to splenic rupture 4. hepatitis, transient rise in ALT 5. lymphocytosis: presence of 50% lymphocytes with at least 10% atypical lymphocytes 6. haemolytic anaemia secondary to cold agglutins (IgM) 7. a maculopapular, pruritic rash develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis

Answer 119

1. heterophil antibody test (Monospot test) - NICE guidelines suggest FBC and Monospot in the 2nd week of the illness to confirm a diagnosis of glandular fever.

Answer 120

1. rest during the early stages, drink plenty of fluid, avoid alcohol 2. simple analgesia for any aches or pains 3. consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture

ENT Flashcards

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