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1
Q

what is cholesteatoma?

A

abnormal collection on squamous epithelial cells in the middle ear
it is non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear
predisposes to infection

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2
Q

what is the cause of cholesteatoma?

A

not fully understood
complication of otitis media
squamous epithelial cells originate from outer surface of tympanic membrane
negative pressure in middle ear (Eustacian tube dysfunction) causes a pocket of tympanic membrane to retract to the middle ear
squamous cells continue to proliferate and can damage the ossicles > permanent damage

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3
Q

what is the presentation of cholesteatoma on history and exam?

A

history: foul discharge from ear, unilateral conductive hearing loss, otalgia, headache; also: vertigo, facial nerve palsy, infection
exam: otoscopy = an area of white debris/ crust in the attic behind the tympanic membrane

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4
Q

what are the investigations for cholesteatoma?

A

audiology assessment
CT (confirm diagnosis and plan for surgery)
MRI (can help to assess invasion and damage to local soft tissues)
referral to ENT

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5
Q

what is the treatment of cholesteatoma?

A

surgical removal of cholesteatoma

treat any discharge for infection with Abx

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6
Q

what is matoiditis?

A

inflammation of mastoid air cells within petrous temporal bone
acute = complication of acute otitis media leading to abscess formation and is life-threatening
most common in children
increased incidence in children with learning disabilities and autism

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7
Q

what is the cause of matoiditis?

A

acute is usually secondary to bacterial infection: STREP PNEUMONIAE, staph aureus, strep pyogenes, haemophilus influenzae
initially hyperaemia and oedema of mastoid air cell mucosa
inflammation and swelling leads to blockage of drainage > serous then purulent exudate collects in air cells
increased pressure in air system > bone necrosis of tiny bone septae
pus and abscess cavity forms

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8
Q

what are the RF of mastoiditis?

A 
recurrent acute otitis media
age
learning difficulties
immunocompromise
anatomical abnormalities e.g. cholesteatoma
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9
Q

what is the history and exam of mastoiditis?

A

history =
children: ear pulling, ear pain, irritability, persistent fever despite Abx, lethargy, reduced oral intake, diarrhoea
adults: severe otalgia, ottorhoea, headache, hearing loss, persistent fever despite Abx, vertigo
exam =
external: post-auricular erythema, tenderness, swelling and fluctuance, proptosed auricle, loss of post-auricular sulcus, evidence of sepsis
otoscopy: bulging tympanic membrane, bulging/sagging of posterior-superior wall of external auditory canal

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10
Q

what are the complications of mastoiditis?

A

reduced LOC
facial nerve palsy
abducens nerve palsy

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11
Q

what are the investigations for mastoiditis?

A

labs: FBC (high WCC), U&E (baseline renal function for Abx), CRP (high), lactate (high in sepsis), blood cultures (for organism and Abx choice)
send purulent middle ear fluid for MC&S
LP if intra-cranial extension
imaging: CT scan of temporal bones (progression) > mastoid air cell and middle ear opacification, loss of wall, haziness/distortion of mastoid outline, abscess formation

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12
Q

what is the management of mastoiditis?

A

immediate: ABCDE, NBM/fasted for surgery, analgesia
medical: broad-spec IV Abx e.g. IV piperacillin and tazobactam (tazocin), or metronidazole and ciprofloxacin (if penicillin allergy)
surgical: tympanocentesis, myringotomy +/- grommet/tube insertion, cortical mastiodectomy
pure-tone audiometry to exclude persistent conductive hearing loss

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13
Q

what is a Eustachian tube dysfunction?

A

when the tube between the middle ear and throat is not functioning
Eustachian tube equalises air pressure int he middle ear and drains fluid from the middle ear

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14
Q

what is the cause of Eustachian tube dysfunction?

A

when the ET is not functioning/blocked, the air pressure cannot equalise and fluid cannot drain
air pressure between the middle ear and environment is not equal
the middle ear can fill with fluid
this can be related to a viral URTI, allergies or rhinitis

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15
Q

what is the presentation of Eustachian tube dysfunction?

A

reduced hearing, popping noises or sensations in the ear, fullness sensation in the ear, pain or discomfort, tinnitus
symptoms get worse when external air pressure changes and the middle ear pressure cannot equalise
otoscopy: can be normal, but need to exclude signs of otitis media etc.

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16
Q

what are the investigations for Eustachian tube dysfunction?

A

if clear cause, no need
in persistent/severe symptoms: tympometry (peak admittance and negative pressure), audiometry, nasopharyngoscopy, CT scan to assess structural pathology

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17
Q

what is the management of Eustachian tube dysfunction?

A

none
valsalva manoeuvre (pop ears with nose)
decongestant nasal sprays
antihistamines and steroid nasal sprays for allergies/rhinitis
otovent device
surgery if severe: 1. adenoidectomy, 2. grommets, 3. balloon dilatation Eustachian tuboplasty

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18
Q

what is vertigo?

A

the hallucination of rotation due to the abnormal stimulation of hair cells of the vestibular system

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19
Q

what is the pathology of vertigo?

A

sensory inputs = 1. vision 2. propioception 3. vestibular system signals
vertigo is a mismatch between these sensory inputs
can be peripheral (affects vestibular) or central (involves brainstem/cerebellum)

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20
Q

what are the causes of vertigo?

A

peripheral: BPPV, Meniere’s disease, vestibular neuronitis, labyrinthitis; trauma, otosclerosis, Ramsey-Hunt
central: posterior circulation infarction (stroke), tumour, MS, vestibular migraine

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21
Q

what is BPPV and what is its presentation?

A

crystals of calcium carbonate called otoconia that become displaced in semicircular canals
may be displaced by a viral infection, head trauma, ageing or no clear cause
crystals disrupt the normal flow through the canals > disrupt the function of the system
features: induced by change in position, vertigo lasts from seconds to minutes, a/w nausea, torsional nystagmus and can be fatigued

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22
Q

which investigation is used for BPPV?

A

Dix Hallpike test - will be positive

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23
Q

what is Meniere’s disease and what is the presentation?

A

caused by excessive build up of endolymph in the semicircular canals, causing a higher pressure than normal, disrupting the sensory signals
features: acute episodes of = loss of hearing, tinnitus, vertigo, sensation of fullness of ear
attacks last several hours before settling
most often occurs in middle aged adults
NOT ASSOCIATED WITH MOVEMENT/POSITION
spontaneous nystagmus during attacks

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24
Q

what is vestibular neuronitis and what is the presentation?

A

inflammation of the vestibular nerve
usually URTI (viral)
features: sudden onset vertigo, lasts several days to weeks, a/w N/V, NO hearing loss/tinnitus, horizontal nystagmus

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25
what is labyrinthitis and what is the presentation?
inflammation of structures of the inner ear viral infection features: acute onset of vertigo that improves after a few weeks, causes hearing loss (different vestibular neuronitis)
26
what is posterior circulation infarction and what is the presentation?
sudden onset, a/w ataxia, diplopia, cranial nerve defects
27
what is the presentation of tumours that cause vertigo?
gradual onset, a/w cerebellar/brain dysfunction
28
what is the presentation of MS with vertigo?
may cause relapsing and remitting symptoms | a/w optic neuritis or transverse myelitis
29
what is the presentation of vestibular migraine?
symptoms last from mins to 72 hours | a/w stress, bright lights, strong smells, food, dehydration, menstruation, abnormal sleep patterns
30
which acronym is used for cerebellar signs in vertigo?
``` DANISH: Dysdiadokinesis Ataxic gait Nystagmus Intention tremor Speech (slurred) Heel to Shin test ```
31
what are the investigations for vertigo?
central vertigo: CT scan/MRI for cause
32
what is the management of vertigo?
peripheral: short term = prochlorperazine (vestibular sedative) and antihistamine (cyclizine and prometrazine) Meniere's = betahistine reduces attacks vestibular migraine = avoid triggers, medical = triptans, propanolol, topiramate or amitriptyline all prevent BPPV = Epley's
33
what are the salivary gland sections?
parotid, submandibular, sublingual
34
what is sialedenitis and what are the RF?
inflammation of salivary glands normally 2nd to stone formation (sialolithiasis) RF: poor oral hygiene/dehydration, infective (mumps) and autoimmune (sarcoidosis)
35
what is the management of sialadenitis?
IV Abx, try to express stone, surgery if recurrent, citrus and lime increases salivation
36
what is sialolithiasis and the presentation?
the presence of calculi in the glands/ducts typically calcium phosphate and hydroxyapatite intermittent pain that is worse before and during meals most involve whorton ducts
37
what is the pathology and management of salivary tumours?
80% are parotid glands (and submandibular) - most benign most sublingual tumours are malignant malignant parotid tumour will cause a facial nerve palsy if present for over 1 month REMOVE
38
what does infectious mononucleosis cause?
lymphadenopathy
39
what are the causes of infectious mononucleosis?
caused by infection of EBV most affects young adults found in saliva of infected individuals may spread by kissing or sharing cups, toothbrushes...
40
what is the presentation of infectious mononucleosis?
fever, sore throat, fatigue, lymphadenopathy | can present with an intensely itchy maculopapular rash in response to amoxicillin/cephalosporins
41
what are the investigations for infectious mononucleosis?
1st: monospot test | can also test for IgM (acute) and IgG (immunity) to EBV
42
what is the management of infectious mononucleosis?
supportive | patients should avoid alcohol (risk of liver impairment) and contact sports (risk of splenic rupture)
43
what is lymphoma?
a group of cancers that affect lymphocytes in the lymphatic system these cancerous cells proliferate within the lymph nodes and cause lymphadenopathy
44
what are the causes of lymphoma?
Hodgkin: specific disease; 1/5 are HL and has bimodal age distribution:, caused by proliferation of lymphocytes leading to malignant lymphoma > presence of Reed-Sternburg cells; RF: EBV, HIV, immunosuppression, smoking Non-Hodgkin: cause is unknown; a/w EBV (Burkitt's lymphoma) and H. pylori increases incidence of gastric MALT lymphoma; compression syndromes can be PC, can be congenital immunodeficiency and transplant
45
what is the presentation of lymphoma?
LYMPHADENOPATHY: non-tender, rubbery; some experience pain in lymph nodes when they drink alcohol B-symptoms: fever, weight loss, night sweats NHL: compression symptoms e.g. GI tract, thyroid, hepatomegaly...
46
what is the presentation difference between Hodgkin and Non-Hodgkin lymphoma?
NHL: symmetrical lymphadenopathy and B-symptoms more likely, also compression syndrome symptoms
47
what are the investigations for lymphoma?
bloods e.g. elevated ESR, normocytic anaemia CT scan LYMPH NODE BIOPSY: histology for Reed-Sternburg cells Ann-Arbor staging system
48
what is the treatment for lymphoma?
chemotherapy and radiotherapy
49
what is leukaemia?
cancer of a particular line of stem cells in bone marrow
50
what is the cause of leukaemia?
unregulated production of a certain type of blood cell 4 types: acute myeloid, acute lymphoblastic, chronic myeloid, chronic lymphocytic AML: most common acute in adults ALL: most common in children myeloid = e.g. neutrophils lymphatic = e.g. B cells
51
what is the typical presentation of leukaemia?
fever, fatigue, pallor, petechiae and abnormal bruising (thrombocytopenia), abnormal bleeding, lymphadenopathy, hepatosplenomegaly
52
what is the investigation for leukaemia?
URGENT FBC
53
what is the management of leukaemia?
chemotherapy
54
what are the characteristic differences between the following? 1. thyroid swelling 2. thyroglossal cyst 3. branchial cyst 4. cystic hygroma
1. moves up on swallowing 2. more common in <20 y.o., usually midline, moves up on protrusion 3. oval, mobile cystic mass, between sternocleidomastoid muscle and pharynx (anterior triangle), evident w. infection 4. found at brith, left posterior triangle
55
what is the cause of carotid body tumours?
it is a structure located jus above the carotid bifurcation it contains glomus cells which are chemoreceptors that detect the blood's O2, CO2 and pH groups of glomus = paraganglia they are formed by excessive growth of glomus cells = paragangliomas most are benign
56
what is the presentation of carotid body tumours?
slow-growing lump that is: in upper anterior triangle of neck, painless, pulsatile, a/w bruits, mobile side-to-side but NOT up and down they can compress CN 9, 10, 11 and 12 pressure on vagus nerve = Horner's: ptosis, miosis and anhidrosis
57
what are the investigations for carotid body tumours?
24 hour urine sample | CT contrast or MRI > splaying (separating) of internal and external carotids (lyre sign)
58
what is the management of carotid body tumours?
mostly surgical removal
59
what is a lipoma and what is the presentation?
benign tumour of fat (adipose) tissue anywhere on the body solitary, painless, rubbery, smooth mass, mobile, do NOT cause skin changes
60
what is the presentation of thyroglossal cysts?
``` midline of neck movile non-tender soft fluctuant moves w. tongue protrusion ```
61
what is the cause of branchial cysts?
congenital abnormality when the 2nd branchial cleft fails to form properly leaves a space surrounded by epithelial tissue in lateral neck this can fill with fluid
62
what is the presentation of branchial cysts?
round, soft, cystic swelling between angle of jaw and sternocleidomastoid anterior triangle present > 10yrs in young adults w. notice/ infection
63
which conditions cause deafness?
presbycusis, otosclerosis, glue ear (otitis media w. effusion), Meniere's disease, drug ototoxicity, acoustic neuroma
64
what is presbycusis?
B-related sensorineural hearing loss
65
what is the presentation of Bell's palsy?
typical: rapid onset <72 hours of unilateral facial weakness also: post-auricular pain/ ear pain, incomplete eye closure, drooling, tingling (cheeks and mouth), hyperacusis Bell's sign = upward and outward movement of eye when attempting to close it NO forehead sparing
66
what is the management of Bell's palsy?
largely supportive prednisolone can be used in those <72 hours onset anti-virals (aciclovir) can be used in combo eye-care
67
what is sinusitis?
inflammation of paranasal sinuses and nasal cavity due to infection
68
what is the cause of acute and chronic sinusitis?
acute = up to 4 weeks chronic = more than 12 weeks subacute = 4-12 weeks viral is most common (rhinovirus, influenza, parainfluenza) bacterial: most commonly occurs 2nd to infection of inflamed paranasal sinuses, following a viral infection or other clearance problems = strep pneumoniae, haemophilus influenzae, staph. aureus
69
what is the presentation of of sinusitis?
symptoms: 1. purulent nasal discharge 2. facial pressure 3. nasal obstruction others: fever, fatigue, headache, ear pressure viral is shorter and milder exam: purulent discharge in nasal cavity, facial swelling, palpable cheek tenderness, facial redness
70
what is the management of sinusitis?
viral: symptomatic relief = oral analgesics, saline nasal irrigation or intranasal corticosteroids bacterial: amoxicillin
71
what are the cause of sensorineural hearing loss?
sudden, presbycusis, noise exposure, Meniere's, labyrinthitis, acoustic neuroma, neuro (stroke, MS, brain tumours), meningitis, meds (loop diuretics, gentamicin, chemo drugs)
72
what are the causes of conductive hearing loss?
ear wax, infection (otitis media and externa), effusion, Eustachian tube dysfunction, perforated tympanic membrane, otosclerosis, cholesteatoma, exostoses, tumours
73
what are the RF for epistaxis?
rhinitis, viral/bacterial sinusitis, freq use of nasal steroids, anti-coag/platelet
74
what are the causes of epistaxis?
anterior (most in Little's area) or posterior | secondary causes: trauma, intranasal drugs, weather, deviated septum, tumours, systemic
75
what is the presentation of epistaxis?
if both nostrils > posterior > high risk of aspiration duration, uni/bilateral, previous? PMH: alcohol and drugs, PMH of bleeding, bruising/blood transfusions DH: anti-coag, intranasal sprays
76
what is the management of epistaxis?
emergency: massive haemorrhage and airway compromise, ABCDE, pinch soft cartilage and lean forward, ice pack anterior: 1. chemical/electrical cautery, local anaesthetic, topic vasoconstriction, 2. nasal packing posterior: nasal packing
77
what is a nasal septal haematoma?
blood collects in the space between the septal cartilage and overlying perichondrium
78
what is the cause of nasal septal haematoma?
rare but serious complication of trauma haematoma may deprive septal cartilage of its blood supply from overlying mucosa and can lead to permanent issues septal cartilage has no blood supply of its own, therefore it receives all its nutrients and oxygen form the perichondrium haematoma causes ischaemia and necrosis which leads to a saddle nose deformity
79
what are the symptoms of nasal septal haematoma?
symptoms: blockage in breathing, change in nose shape, painful swelling of nasal septum, nasal congestion bulging of septum
80
what is the management of nasal septal haematoma?
drain it immediately otherwise it leads to a saddle nose
81
what is the cause of tinnitus?
background sensory signal produced by cochlea that is not filtered out by auditory system primary secondary: impacted ear wax, Meniere's, noise exposure, meds, acoustic neuroma, MS, trauma, depression systemic = anaemia, diabetes, hypothyroidism, hyperlipidaemia objective: carotid artery stenosis, AS, arteriovenous malformations, Eustachian tube dysfunction
82
what are the red flags of tinnitus?
unilateral, pulsatile, a/w hearing loss, vertigo/dizziness
83
what is quinsy?
peritonsillar abscess as a complication of acute tonsillitis where pus collects in peritonsillar space if left untreated > deep neck space infection
84
what is the pathology of quinsy?
abscess collects lateral to palatine tonsils in the peritonsillar space between palatine tonsils and pharyngeal mucosa
85
what is the presentation of quinsy?
symptoms: sore throat, change in voice, inability to swallow exam: trismus (inability to open mouth fully), bulging palatine, signs of sepsis
86
what is the cause of tonsilitis?
viral (more common) or bacterial also non-infectious viral: rhinovirus! coronavirus, parainfluenza, EBV bacterial: Group A beta haemolytic strep! haemophilus influenza, moraxella catarrhalis non-inifective: GORD, NG tube
87
what is the criteria for a bacterial tonsilitis?
``` CENTOR: FLAT fever lymphadenopathy absence of cough tonsillar exudate ```
88
what is the treatment of bacterial tonsilitis?
Abx: phenoxymethylpenicillin x10 days OR clarithromycin 5 days AVOID AMOXICILLIN chronic = tonsillectomy
89
what is otitis externa?
``` inflammation of the ear canal acute < 3 weeks chronic > 3 weeks all ages increases in summer due to humidity and water exposure ```
90
what is the cause of otitis externa?
infectious: bacterial = 90%: pseudomonas aeruginosa, staph. aureus fungal = 10%: usually follow prolonged use of topical Abx +/- corticosteroids, candida albicans (white), aspergillus niger (black) non-infectious: skin conditions: atopic dermatitis, psoriasis, acne; can lead to bacterial infection
91
what are the RF of otitis externa?
humidity, increasing age, derm issues, Down's (narrow ear canal), immunosuppression and diabetes
92
what is the presentation of otitis externa?
1. otalgia, discharge, itch 2. hearing loss (only if becomes blocked), fever exam: inflammation of tympanic membrane can be hard to see due to ear canal stenosis, lympadenopathy, conductive loss on tuning fork necrotising otitis externa > facial n. palsy
93
what are the investigations for otitis externa?
clinical diagnosis | MC&S pf discharge for treatment
94
what is the management of otitis externa?
topical Abx: AVOID aminoglycosides (gentamicin) with a perforated tympanic membrane, prescribe quinolones instead; freq use gentisone = gentamicin + hydrocortisone / cirpofloxacin DO NOT USE ORAL Abx: 1. cellulitis extends beyond external ear canal 2. people with compromised immunity/severe infection 3. if recommended by ENT analgesia, remove debris (ENT)
95
what is the main complication of otitis externa?
``` necrotising otitis externa infection spreads beyond soft tissue of ear canal > osteomyelitis of temporal bone and skull base non-resolving despite topical treatment psuedomonas aeruginosa typically older and diabetic patients ```
96
what are the types of otitis media?
1. acute otitis media: inflammation of middle ear, < 3weeks, 2nd to URTI 2. acute aupprative otitis media: complication of otitis media, perforation of tympanic membrane, macropurulent (pus) discharge 3. otitis media w. effusion: GLUE EAR, middle ear infection w/o signs of infection, when fluid collects in middle ear = pain and hearing loss, 2nd to recurrent inflammation
97
what is the cause of otitis media?
bacteria: 1. strep pneumoniae 2. haemophilus influenzae, strep. pyogenes, moraxella catarrhalis viral: resp synctail virus, rhinovirus, adenovirus often preceded by URTI
98
what is the presentation of otitis media?
cold symptoms, reactive lymphadenopathy in AOM young: tugging ear, irritability, fever older: 1. otalgia and hearing loss 2. fever and ear discharge adults get hearing loss and pain until perforation, then they have discharge with some relieved pain exam: inspect pinna for otorrhoea and erythema AOM = red, bulging and tender tympanic membrane ASOM = discharge OME = dull yellow/grey bulging tympanic membrane, loss of light reflex and visible fluid level or bubbles behind tympanic membrane
99
what is the management of otitis media?
AOM: analgesia and anti-pyretics (paracetamol and ibuprofen), Abx: 1 amoxicillin 2 clarithromycin/erythromycin; resistant = co-amoxiclav OME: self-limiting, grommets +/- adenoidectomy if hearing loss

Medicine (15 decks)

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