ENT Flashcards
1
Q
Where is the inner ear located? 2 main components of the inner ear? 2 openings into the middle ear covered by membranes?
A
Within the petrous part of the temporal bone between the middle ear and internal acoustic meatus lying laterally and medially
Bony and membranous labyrinthes
Oval window + round window: oval= between middle ear and vestibule + round window between middle ear from scala tympani
2
Q
What does the bony labyrinth consist of? Membranous labyrinth?
A
A series of bony cavities= the cochlea, vestibule and 3 semi-circular canals, lined internally with periosteum and contains perilymph
Lies within the bony labyrinth= cochlear duct, semi-circular ducts, utricle and the saccule, contains endolymph
3
Q
The vestibule communicates anteriorly with what and posteriorly with what? 2 parts of the membranous labyrinth contained within the vestibule?
A
The cochlea and semi-circular canals
The saccule and utricle
4
Q
The cochlea houses what? It twists upon itself around what producing a cone shape which points in what direction? What’s found at the base of the modiolus?
A
The cochlea duct of the membranous labyrinth
The modiolus
Branches from the cochlear portion of the vestibulocochlear nerve
5
Q
What extends outwards from the modiolus and attaches to the cochlear duct? Two perilymph-filled chambers above and below this?
A
Spiral lamina
1) Scala vestibuli= superiorly
2) Scala tympani= inferiorly terminating at the round window
6
Q
3 semi-circular canals? Contain what? Swelling at one end called what?
A
Anterior, lateral and posterior
Semi-circular ducts for balance- along with utricle and saccule
Ampulla
7
Q
Lateral wall of the cochlear duct formed by what? The roof formed by what which separates it from the scala vestibuli? The floor formed by a membrane which separates it from the scala tympani? The basilar membrane housing the epithelial cells of hearing called what?
A
Thickened periosteum- the spiral ligament
Reissner’s membrane
The basilar membrane
The Organ of Corti
8
Q
The utricle receives what? The saccule receives what? Endolymph drains from here into what? Travels through what to the posterior aspect of the petrous part of the temporal bone? The saccule detects linear acceleration in what plane? The utricle?
A
The 3 semi-circular ducts
The cochlear duct
The endolymphatic duct
The vestibular aqueduct
The vertical plane without tilting
The horizontal plane without tilting
9
Q
Sensory receptors where detect change in speed and/ or direction of flow of endolymph within the semi-circular ducts? The semi-circular ducts detect what?
A
Sensory receptors in the ampullae of the semi-circular canals
Rotational movement in any direction
10
Q
The bony labyrinth receives its blood supply from what 3 arteries? Membranous labyrinth? Venous drainage?
A
1) Anterior tympanic branch
2) Petrosal branch
3) Stylomastoid branch
Labyrinthine artery(branch of the inferior cerebellar artery)–> cochlear branch + x2 vestibular branches
The labyrinthine vein–> the sigmoid sinus/ inferior petrosal sinus
11
Q
Inner ear is innervated by what? Vestibular nerve enlarges and splits into what to supply what? Cochlear nerve?
A
The vestibulocochlear nerve via the internal acoustic meatus–> vestibular + cochlear nerve
The vestibular ganglion–> superior and inferior parts to supply the utricle, saccule and 3x semi-circular ducts
The base of the modiolus through the lamina to supply the receptors of the Organ of Corti
12
Q
Main function of the middle ear? 2 main parts of the middle ear? Tympanic cavity contains what 3 small bones?
A
To transmit vibrations from the tympanic membrane to the inner ear via the auditory ossicles
1) Tympanic cavity- medial to the tympanic membrane: malleus, incus and stapes
2) Epitympanic recess= space superior to the tympanic cavity next to the mastoid air cells, the malleus and incus partially extend upwards into the epitympanic recess
13
Q
Roof of the middle ear separates it from what? Floor? Lateral wall made up of what? Medial wall? Anterior wall has two openings for what? Separated from what? Posterior wall consists of what? Hole in this superiorly?
A
Thin bone from petrous part of temporal bone- middle cranial fossa
“Jugular wall”- from internal jugular vein
The tympanic membrane and lateral wall of the epitympanic recess
Lateral wall of the internal ear- prominent bulge from the facial nerve
For the auditory tube and tensor tympanic muscle, from the inner carotid artery
Between the tympanic cavity + mastoid air cells
The aditus to the mastoid antrum
14
Q
Which bone is the largest and most lateral attaching to the tympanic membrane via what? The head of this lies where and articulates with what? Consists of what and what articulates with the malleus, posterior wall of the middle ear and the stapes?
A
The malleus via the handle of malleus
In the epitympanic recess–> the incus
A body and two limbs
The body, the short limb and the long limb
15
Q
The stapes consists of what?
A
Joins the incus to the oval window, is stirrup-shaped, has a head, 2 limbs and a base
Head–> the incus, base–> the oval window
16
Q
The mastoid air cells are located where? They are what? Act as what?
A
Posterior to the epitympanic recess
Collection of air-filled spaces in the mastoid process of the temporal bone, contained within the mastoid antrum–> middle ear via the aditus
A buffer system of air- releasing air into the tympanic cavity when the pressure is too low
17
Q
2 muscles serving a protective function in the middle ear? Contract in response to what? Known as what? The tensor tympanic originates where? Innervated by what? Stapedius muscle?
A
1) Tensor tympanic + stapedius
Loud noise
Acoustic reflex
From the auditory tube–> the handle of malleus pulling it medially
Tensor tympanic nerve(branch of the mandibular nerve)
Facial nerve- attaches to the stapes
18
Q
What connects middle ear to the nasopharynx? Acts to do what? Lined with what? Innervated by what? Blood supply?
A
Eustachian tube
Equalise the pressure of the middle ear to that of external auditory meatus
Mucous membrane
Branches of tympanic plexus
Ascending pharyngeal artery from ex car artery, middle meningeal artery + artery of the pterygoid canal(branches of maxillary artery)
Drains into pterygoid venous plexus
19
Q
2 parts of external ear? Ends where?
A
Auricle/ the pinna
External acoustic meatus
Tympanic membrane
20
Q
Outer curvature of the auricle? Second innermost curvature? Divides into what? Hollow depression in the middle? Continues as what? Opposite the tragus?
A
Helix
Antihelix
Inferoanterior and superoposterior crus
Concha
External acoustic meatus
Antitragus
21
Q
Walls of external 1/3 of ex ac meatus formed by what? Inner 2/3? Direction of path?
A
Cartilage–> the temporal bone
Superoanterior direction–> turns slightly to move superoposteriorly- ends by running inferoanterior
22
Q
Structure of tympanic membrane? Attaches to the handle of malleus at what? What can be seen at handle of malleus’ highest point? Parts moving away from the lateral process?
A
Covered with skin and mucous membrane on the inside
Connected to the temporal bone by a fibrocartilaginous ring (annulus)
A point called the umbo of tympanic membrane
The lateral process of the malleus
Anterior and posterior malleolar folds
23
Q
Supply of external ear? Sensory innervation of auricular skin?
A
Posterior auricular artery, superficial temporal artery, occipital artery, maxillary artery
Great auricular nerve, lesser occipital nerve, auriculotemporal nerve, branches of facial and vagus nerves
24
Q
Functions of the nose?
A
Conditioning the air to maximise gas exchange, raising temperature + humidity
Hairs catch large foreign particles
Defence function= cilia take particulates backwards to be swallowed
25
Structure of nasal cavity?
Anterior= nasals--> enlarged vestibule, skin lined with stiff thick hairs
Turbinates= soft vascular tissue within nose increases SA of nasal cavity to warm + moisten air
Superior meatus: olfactory epithelium, cribriform plate, sphenoid sinus
Middle meatus: sinus openings
Inferior meatus: nasolacrimal duct- drains tears from eye to be swallowed
26
Epithelium lining nasal entrance? Rest?
Keratinised columnar
Non-keratinised columnar
27
4 paranasal sinuses? Each is lined by what?
Frontal
Maxillary
Ethmoid
Sphenoid
Ciliated pseudostratified epithelium interspersed with mucus- secreting goblet cells
28
Bone of frontal sinus? Position? Nerve? Drainage?
Frontal
Above the eyes into 2 by midline septum
Ophthalmic div of V(V1)
Hiatus semilunaris of middle meatus
29
Bone of maxillary sinus? Position? Nerve? Drainage?
Body of maxilla
Just under the eyes/ orbit--> pyramidal shape
Hiatus semilunaris of the middle meatus
30
Bone of ethmoid sinus? Position? Nerve? Drainage?
Labyrinth of air cells between the eyes
3 types= anterior, middle and posterior
Ethmoid bone
V1
Anterior = hiatus semilunaris into the middle meatus, middle= ethmoid bullar, posterior = superior meatus
31
Bone of sphenoid sinus? Position? Nerve? Drainage?
Medial to cavernous sinus
Sphenoid bone
V1
Sphenoethmoidal recess lateral to attachment of the nasal septum
32
3 divisions of the nasal cavity?
Vestibule= area surrounding anterior external opening
Respiratory region= lined by ciliated pseudostratified epithelium interspersed with mucus-secreting goblet cells
Olfactory region at apex of cavity- lined by olfactory cells with olfactory receptors
33
Curved shelves of bone that project out of the lateral walls of the nasal cavity? Create what for air to flow? Function of conchae?
Conchae= inferior, middle and superior
Inferior, middle + superior meatus and spheno-ethmoidal recess recess
Increase SA of cavity + disrupts fast air flow--> air more humidified
34
Other 2 structures that open into the nasal cavity other than the sinuses?
Nasolacrimal duct- opens into inferior meatus
Auditory tube= opens into nasopharynx at level of inferior meatus
35
Internal and external carotid branches supplying the nose?
Internal= anterior
and posterior ethmoidal arteries(branches of ophthalmic artery descend through cribriform plate)
Sphenopalatine, greater palatine, superior labial and lateral nasal sinuses
36
Special and general innervation of the nose?
Olfactory nerves
Nasopalatine (branch of maxillary) nerve + nasociliary(branch of ophthalmic) nerve, external= trigeminal nerve
37
General sensation in the anterior 2/3 of the tongue is supplied by what? Taste? Touch and taste of posterior 1/3 by what nerve?
Sensation= trigeminal nerve
Taste= facial nerve
Glossopharyngeal nerve
38
Where does the pharynx start and finish? 3 parts?
From the base of the skull--> the inferior border of the cricoid cartilage
Nasopharynx, oropharynx, laryngopharynx
39
Where is the nasopharynx found? Lined with what? Posterosuperior part contains what?
Between the base of the skull and the soft palate- continuous with the nasal cavity
Ciliated pseudostratified columnar epithelium with goblet cells
The adenoid tonsils- grow between 3-8 years of age then regress
40
What is the oropharynx bounded by anteriorly and posteriorly? Contains what structures? Ring of lymphoid tissue in naso and oropharynx formed by paired palatine tonsils, adenoids and lingual tonsil?
Soft palate and constrictor muscles
Posterior 1/3 of the tongue
Lingual tonsils- lymphoid tissue at the base of the tongue
Palatine tonsils= lymphoid tissue in the tonsillar fossa
Superior constrictor muscle
Waldeyer's ring
41
What is the arch across the oropharynx that runs on either side, lateral and forward to the side of the base of the tongue? Formed by the projection of what muscle?
Palatoglossal fold
Palatoglossus muscle
42
Where is the laryngopharynx located? Communicates with the larynx via what? Lateral to which what can be found? Contains what muscles?
Between the superior border of the epiglottis and inferior border of the cricoid cartilage
The laryngeal inlet
Piriform fossae
The middle and inferior pharyngeal constrictors
43
3 circular pharyngeal constrictor muscles of the pharynx? All innervated by what nerve? All fuse together on what? Arterial supply?
Superior, middle and inferior
Vagus nerve
Pharyngeal artery
44
Origin of superior pharyngeal constrictor? Inserts into what?
Pterygomandibular ligament, alveolar process of mandible and medial pterygoid plate + pterygoid hamulus of the sphenoid bone
Into the pharyngeal tubercle of the occiput and median pharyngeal raphe
45
Origin of middle pharyngeal constrictor? Inserts into what?
Stylohyoid ligament + horns of the hyoid bone
Into the pharyngeal raphe
46
Origin of inferior pharyngeal constrictor? Inserts into what?
Superior component= oblique fibres--> thyroid cartilage
Inferior= horizontal fibres--> the cricoid cartilage
47
Longitudinal muscles of the pharynx?
Stylopharyngeus, palatopharyngeus, salpingopharyngeus
48
Origin, insertion and innervation of stylopharyngeus?
Palatopharyngeus? Salpingopharyngeus?
Styloid process
Thyroid cartilage
CN IX
From Eustachian tube
CN X
From Eustachian tube
CN X
49
Motor and sensory innervation of the majority of the pharynx? Overlies which muscle?
Pharyngeal plexus: pharyngeal branches from CN IX, pharyngeal branch of the vagus nerve, branches from the external laryngeal nerve, sympathetic fibres from the superior cervical ganglion
Sensory= CN IX
Motor= CN X, except for stylopharyngeus which is CN IX
50
Arterial supply to the pharynx? Venous drainage?
Branches of the external carotid artery
Ascending pharyngeal artery
Branches of the facial artery
Branches of the lingual and maxillary arteries
Pharyngeal venous plexus--> internal jugular vein
51
What are the carotid sheaths? Contents? Fascia of the sheath? Column of fascia runs between where?
Paired structures on either side of the neck, which enclose an important neurovascular bundle of the neck
1) Common carotid artery
2) Internal jugular vein
3) Vagus nerve
4) Accompanying cervical lymph nodes
Contributions from the pretracheal, prevertebral, and investing fascia layers
Base of the skull--> thoracic mediastinum
52
Functions of the larynx? Situated where?
Protects the lower airway, voice production, coughing, sensory organ + controls ventilation
Below the tongue and the hyoid bone and between the great vessels of the neck between C3-C6
53
Larynx covered anteriorly by what? Laterally? Posteriorly? What is Sellick's manoeuvre?
Infrahyoid muscles
Thyroid gland lobes
Oesophagus
Pressure applied to the cricoid cartilage of the larynx to occlude the oesophagus to prevent regurgitation of gastric contents during emergency intubation
54
Internal larynx can be divided into what 3 sections?
Supraglottis= from inferior epiglottis--> vestibular folds
Glottis= contains vocal cords and 1cm below them
Subglottis= from inferior glottis--> inferior border of the cricoid cartilage
55
Interior surface of the larynx is lined by what?
Pseudostratified ciliated columnar epithelium
True vocal cords= stratified squamous epithelium
56
Vasculature and drainage of the larynx?
1) Superior laryngeal artery= branch of superior thyroid artery(external carotid,) follows superior laryngeal nerve
2) Inferior laryngeal artery= branch of inferior thyroid artery (thyrocervical trunk,) follows recurrent laryngeal nerve
Superior + inferior laryngeal veins- superior= into internal jugular vein, inferior= into left brachiocephalic vein
57
Innervation of the larynx?
1) Recurrent laryngeal nerve= sensory--> infraglottis + motor innervation--> internal muscles of the larynx (except cricothyroid)
2) Superior laryngeal nerve- internal branch sensory--> supraglottis, external branch= motor--> cricothyroid
58
How many cartilages within the larynx? 3 unpaired? 6 paired?
9; 3 unpaired + 6 paired
Epiglottis, thyroid, cricoid
Cuneiform, corniculate, arytenoid
59
2 sheets join anteriorly for the thyroid cartilage to form what? Posterior border of each sheet project superiorly and inferiorly to form what? Superior horns connect to hyoid bone via what? Inferior horns?
Laryngeal prominence
Superior + inferior horns
Lateral thyrohyoid ligament
Cricoid cartilage
60
Cartilage type of the cricoid cartilage? Marks the inferior border of the larynx at what level? Articulates with what posteriorly to change what?
Hyaline
C6
Arytenoid cartilages- length of vocal cords affecting the sound produced
61
Cartilage type of the epiglottis? Its 'stalk' is attached to the back of anterior of what?
Elastic covered in a mucous membrane
Thyroid cartilage
62
Arytenoid cartilages consist of what? Where are the cuneiform cartilages located?
Apex--> corniculate cartilage
Base--> superior cricoid cartilage
Vocal process= attaches vocal ligament
Muscular process= for posterior and lateral cricoarytenoid muscles
Within the aryepiglottic folds- act to strengthen them
63
Function of extrinsic and intrinsic laryngeal ligaments?
Attach components to external structures e.g. hyoid and cricoid cartilage
Holds cartilages of the larynx together
64
4 extrinsic laryngeal ligaments?
Thyrohyoid membrane= between superior thyroid cartilage and hyoid bone
a) Median thyrohyoid ligament= anteromedial thickening
b) Lateral thyrohyoid ligaments= posterolateral thickenings
Hyo- epiglottic ligament= hyoid bone--> anterior epiglottis
Cricotracheal ligament= cricoid cartilage--> trachea
Median cricothyroid ligament= connects cricoid and thyroid cartilages
65
2 intrinsic laryngeal ligaments?
1) Cricothyroid ligament- forms vocal ligament, attached anteriorly to thyroid cartilage, posteriorly to arytenoid cartilage
2) Quadrangular membrane= anterolateral arytenoid cartilage--> lateral epiglottis, lower margin= thickened--> vestibular ligament
66
The 2 important soft tissue folds within the larynx? How are the true vocal cords structured? Space between the folds?
Vestibular + vocal folds
Non-keratinised stratified squamous epithelium
Reinke's space= watery layer rich in glycosaminoglycans
Vocal ligament= at free upper edge of cricothyroid ligament
Vocalis muscle= fine fibres lateral to vocal ligaments
Rima glottidis
67
Vestibular folds lie where? Consist of?
Superiorly to true vocal cords
Vestibular ligament covered by mucous membrane- pink, fixed folds act to provide protection to larynx
68
All intrinsic muscles of the larynx are innervated by what? Cricothyroid muscle?
Inferior laryngeal nerve
External branch of the superior laryngeal nerve
69
Function of cricothyroid muscle? Attachments, actions and innervation?
Stretches and tenses vocal ligaments- creates forceful speech + altering tone
Cricoid cartilage--> inferior horn thyroid cartilage
External branch of superior laryngeal nerve
70
Function of thyroarytenoid muscle? Attachments, actions and innervation?
Relaxes vocal ligament--> softer voice
Inferoposterior thyroid cartilage--> anterolateral arytenoid cartilage
Inferior laryngeal nerve
71
Function of posterior cricoarytenoid muscle? Attachments, actions and innervation?
Sole abductors of the vocal folds- widens rima glottidis
From posterior cricoid cartilage--> muscular arytenoid cartilage
Inferior laryngeal nerve
72
Function of lateral cricoarytenoid muscle? Attachments, actions and innervation?
Major adductors of the vocal folds- narrows the rima glottidis- modulating tone + volume of speech
From arch of cricoid cartilage--> muscular arytenoid cartilage
Inferior laryngeal nerve
73
Function of transverse and oblique arytenoid muscles? Attachments, actions and innervation?
Adduct the arytenoid cartilages closing posterior rima glottidis- narrowing laryngeal inlet
From one arytenoid--> opposite arytenoid
Inferior laryngeal nerve
74
Function of vocalis muscle? Attachments, actions and innervation?
Reduces tension on vocal cords during speech--> decreases pitch
From inner surface of thyroid--> anterior arytenoid
Inferior laryngeal
75
Where and what do the aryepiglottic folds do?
Triangular opening at the laryngeal entrance
Bound in front by the epiglottis and behind by the arytenoid cartilages, corniculate cartilages and interarytenoid notch
Involved in phonation
76
What is conductive hearing loss a problem with? Sensorineural hearing loss?
Sound travelling from the environment to the inner ear
The sensory system or vestibulocochlear nerve in the inner ear
77
Other things to consider with hearing loss?
Tinnitus, vertigo, pain, discharge, neurological symptoms
78
Where is the tuning fork placed in Weber's test? What is a normal result? What about conductive or sensorineural hearing loss?
Middle of the forehead
Sound is heard equally in both ears
Conductive= louder on AFFECTED side
Sensorineural= louder on INTACT side
79
Where is the tuning fork placed in Rinne's test? Normal result? Rinne's also positive in what hearing loss? Negative in what?
On the mastoid process, ask when they can no longer hear the noise, hover it 1cm from the same ear- repeat on the other side
Rinne's positive= air> bone conduction(sound heard again when bone conduction ceases and moved next to ear)
Sensorineural hearing loss
Conductive hearing loss
80
Causes of sensorineural hearing loss? Medications?
Sudden<72 hours
Presbycusis
Noise exposure
Meniere's disease
Labyrinthitis
Acoustic neuroma
Neurological conditions
Infections
Loop diuretics, aminoglycoside antibiotics e.g. gentamicin, chemotherapy drugs
81
Causes of conductive hearing loss?
Ear wax, infection, fluid in the middle ear, Eustachian tube dysfunction, perforated tympanic membrane, otosclerosis, cholesteatoma, exostoses, tumours
82
Symptoms of presbyacusis? Refer for what, then what if appropriate?
Bilateral symmetrical sensorineural deafness in over 50s, gradual in onset, high frequencies= more severely affected- speech discrimination lost first
Examination= normal
Audiogram, hearing aid/ cochlear implants if not sufficient
83
What causes otosclerosis? Avoid prescribing what? Ix and tx?
Bilateral conductive deafness due to adherence of the stapes footplate--> the bone around the oval window
May be FH(50%)- autosomal dominant, usually between the ages of 15-35 y/o, F>M
Hearing loss, speaking softly, hearing better in noisy surroundings, hearing sounds from within your body, dizziness and balance issues
Combined contraceptives if deteriorates in pregnancy
Audiometry
Medical= bilateral hearing aids, surgical= stapedectomy/ stapedotomy
84
Refer to ENT within 24 hours if there's what?
Sudden unilateral/ bilateral hearing loss within the past 30 days not explained by external/ middle ear causes
Asymmetrical deafness to exclude acoustic neuroma, cholesteatoma with focal neurology
Associated with head/ neck injury
Otalgia + otorrhoea that hasn't responded to tx within 72 hours in a person with immunosuppression
85
Urgent referral--> ENT within 2 weeks if what?
Sudden onset unilateral/ bilateral >30 days ago and cannot be explained
Rapidly progressive over 4-90 days which cannot be explained by external/ middle ear causes
Suspected head/ neck malignancy
86
Routine referral to ENT if what?
Unilateral/ asymmetrical and of gradual onset
Fluctuating and not associated with URTI
Ass w/ hyperacusis (sound sensitivity)
Ass w/ persistent unilateral, pulsatile, changed/ distressing tinnitus
Ass w/ persistent or recurrent vertigo
Not thought to be age-related
87
What is a cholesteatoma? Aetiology? Symptoms? Ix? Rx?
Abnormal, longstanding skin growth in the middle ear
Retraction pocket of tympanic membrane that sheds layers of old skin
Extends by pressure--> slowly eroding bone
Recurrent middle ear infections, perf ear drum, congenital
Unilateral watery, smelly discharge from ear, gradual conductive hearing loss, unilateral ear discomfort, vertigo, facial paralysis
Otoscopy, CT head can confirm + help plan for surgery, MRI may help assess invasion
Surgical removal
88
What is mastoiditis? Ix and tx? Organisms?
Rare complication of acute OM
Persistent throbbing earache; creamy; profuse ear discharge, increasing conductive deafness; fever + general malaise
Tenderness+/- swelling over mastoid; ear may stick out; drum is red/ bulging/ perforated
ENT as emergency--> bloods, cultures, discharge culture, audiogram, skull XR +/- LP, CT/ MRI
IV ABx- 3rd gen cephalosporin 1-2 days--> oral ABx 1-2 weeks
Mastoidectomy
S.pneumoniae, s.pyogenes, s.aureus, pseudomonas aeroginosa, h.influenzae
89
SSx of tympanic membrane perforation? Rx?
Sudden painful hearing loss & suggestive history
O/E: perforated ear drum
1) Small< 2mm= heal spontaneously + topical Abx cover
2) Larger>2mm= myringoplasty (ear drum replacement)
90
Pathology behind noise-induced hearing loss? SSx? Dx? Rx?
Exposure to excessive sounds>85 dB
Leads to permanent increased stimuli threshold for outer hair cells in cochlea
Gradual bilateral hearing loss +/- tinnitus
Hx + audiometry- difficulty hearing sounds w/ frequency 4000Hz
Hearing aids
91
What is an acoustic neuroma? SSx? Tx? Bilateral acoustic neuromas associated with what?
Slow-growing neurofibroma arising from the acoustic nerve- arise from Schwann cells of nerve myelin sheath
Unilateral sensorineural deafness, tinnitus +/- facial palsy
Refer to ENT--> audiology= sensorineural, MRI/ CT
TX= surgical
i) W+W
ii) Stereotactic radiosurgery- single large dose of radiation
iii) Microsurgery
Neurofibromatosis type II
92
What is sudden sensorineural hearing loss defined as? Conductive causes of rapid-onset hearing loss?
Hearing loss< 72 hours unexplained by other causes--> on-call ENT tea
NOT SSNHL= ear wax, infection, effusion, Eustachian tube dysfunction, perforated tympanic membrane
93
% cases of SSNHL are idiopathic? Other causes? Ix? Tx?
90%
Infection, Meniere's disease, ototoxic meds, MS, migraine, stroke, acoustic neuroma, Cogan's syndrome(AI condition inflames eyes and inner ear)
Audiometry- loss of at least 30Db in x3 consecutive frequencies, MRI/ CT for stroke/ acoustic neuroma
ENT referral within 24 hours, idiopathic= steroids- oral, intra-tympanic(injection through membrane)
94
In terms of otalgia, what external ear causes are there? Middle ear? Referred pain?
Otitis externa, foreign body, trauma, impacted cerumen, bullous myringitis, furuncle, herpes zoster, neoplasm, otomycosis, perichondritis of pinna, Sjogren's syndrome
Otitis media, effusion ass w/OM, acute mastoiditis, barotrauma, acute obstruction of Eustachian tube, neoplasm, trauma
Nasopharynx, cranial nerve, salivary glands, teeth+ jaw, base of skull, petrous aneurysms, oesophagus, inflammation/ neoplasm of oropharynx, tongue/ larynx, temporal arteritis, thyroiditis
95
What is otitis externa? Aetiology? Presentation? Ix? Rx?
Inflammation of outer ear- acute<6 weeks, chronic> 3 months
a) Infectious- 90% bacterial, 10% fungal
b) Irritants/ inflammation--> psoriasis, dermatitis, hearing, ear plugs, swimming etc.
Otalgia, itching--> erythema, oedema, hearing loss, +/- fever, preauricular lymphadenopathy
Clinical Ix +/- swab--> MC&S
a) Topical Abx/ combined Abx + steroid, remove canal debris + analgesia
b) PO Abx if spreading + empirical use of antifungal(flucloxacillin/ clarithromycin + clotrimazole)
96
Common bacterial/ fungal causes of otitis externa? Mild OE can be tx with? Topical ABx + steroid for moderate OE? What are potentially ototoxic?
Pseudomonas aeruginosa + s. aureus/ candida albicans + aspergillus niger
Acetic acid 2%(EarCalm)- can be used prophylactically before + after swimming
Neomycin, dex + acetic acid
Neomycin + betamethasone
Gentamicin + hydrocortisone
Ciprofloxacin + dex
Aminoglycosides e.g. gentamicin + neomycin(exclude perforated tympanic membrane)
97
What is malignant otitis externa? Related to what? Sx? Tx? Comps?
Infection spreads to surrounding--> osteomyelitis of the temporal bone
Diabetes, immunosuppressant meds e.g. chemo, HIV
More severe than otitis externa- persistent headache, severe pain + fever
Granulation tissue= between bone and cartilage in ear canal
Admission--> hospital under ENT, IV ABx, imaging to assess extent
Facial nerve palsy, other CN involvement, meningitis, IC thrombosis, death
98
What is otitis media? Common causes of this?
Middle ear infection
S.pneumoniae
H.influenzae, moraxella catarrhalis, s.aureus
99
SSx and O/E for otitis media?
Main= otalgia, reduced hearing in affected ear, feeling generally unwell i.e. fever, URTI symptoms, can cause vestibular symptoms, may be discharge if membrane perforated
Bulging, red, inflamed looking membrane
100
Tx of otitis media?
Most resolve within 3 days without ABx, simple analgesia
Immediate ABx in significant co-morbidities, systemically unwell/ immunocompromised
Delayed prescription= symptoms not improved/ worsened after 3 days (amoxicillin 5-7 days 1st-line, clarithromycin if allergy, erythromycin in pregnant allergic), recurrent= ENT referral
101
Exclude what in adults with middle ear fluid? Presentation of OM w/ effusion? O/E? IX? RX?
Head/ neck tumour
Conductive hearing loss, mild intermittent otalgia, aural fullness sensation +/- crackling/ popping, hx of recurrent URTI, AOM, +/- balance issues
Opaque, intact, retracted TM- no signs of inflammation/ discharge, loss of light reflex, presence of bubbles
Audiometry, tympanogram
Reassure, grommet insertion, hearing aids
102
Presentation and tx for sinusitis?
Infection of >1 paranasal sinus usually following URTI, 10% due to tooth infection
Frontal headache/ facial pain, typically worse on movement/ bending +/- purulent nasal discharge +/- fever
Most resolve after 7-10 days, analgesia + fluids, steam inhalation, steroid nasal sprays, Abx= frontal sinusitis, severe symptoms, symptoms> 2.5 weeks, high risk of serious comps
103
How long is chronic sinusitis for? Tx?
>12 weeks/ >3 episodes in any year, ass w/ nasal polyps and vasomotor rhinitis
Nasal corticosteroids e.g. beclometasone
104
What is rhinitis? Presentation and tx?
Inflammation of the nasal mucosa- may be allergic/ non- allergic
Nasal discharge, itching, sneezing +/- nasal blockage/ congestion, may be seasonal; intermittent or persistent
Moderate/ severe if>=1 of troublesome symptoms, abnormal sleep, impairment of daily activities/ sport/ leisure; problems at work/ school, intrusive/ difficult to control
Reduce allergen exposure; nasal douching with saline nasal drops +/- steam inhalation
105
Tx for allergic rhinitis?
a) Nasal steroids: effective if applied properly and can be used safely long-term, takes several days to work, often started at high dose
b) Oral steroids: only rarely needed, for: severe nasal obstruction; short-term rescue medication= 20-30mg prednisolone PO for 5-7 days+ nasal steroids
c) Oral antihistamines: e.g. loratadine 10mg OD, alone/ + nasal steroids
d) Topical antihistamines: e.g. azelastine nasal drops, useful as rescue therapy, faster acting than oral antihistamines, onset=<15min
e) Leukotriene receptor antagonists e.g. Montelukast 10mg OD, concurrent asthma, combination with antihistamines
f) Topical/ oral decongestants e.g. Ephedrine nasal drops tds/ qds
g) Topical anticholinergics e.g. Ipratropium bromide nasal spray tds
h) Topical chromones
106
Technique for nasal sprays?
Tilting the head slightly forward, using 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
107
What is Eustachian tube dysfunction? Presentation?
When the tube between the middle ear and throat is not functioning properly, may be related to a URTI, allergies, or smoking
Reduced/ altered hearing, popping noises/ sensations in the ear, fullness sensation in the ear, pain/ discomfort, tinnitus
Worse with flying, climbing a mountain/ scuba diving
108
Ix and tx for Eustachian tube dysfunction?
Persistent, problematic/ severe symptoms: tympanometry, audiometry, nasopharyngoscopy, CT
No tx- recovering from URTI, valsalva manoeuvre, decongestant nasal sprays, antihistamines and steroid nasal spray, surgery, otovent= OTC device
109
Tympanometry involves what? Amount of sound absorbed by tympanic membrane and middle ear? What pressure is equal to that in healthy ears? In ETD?
Inserting device into external auditory canal, creating different air pressures in the canal, sending a sound in the direction, measuring the amount of sound reflected back, plotting a tympanogram absorbed at different air pressures
Admittance
Ambient air pressure
Middle ear air pressure< ambient air pressure- tympanogram= peak admittance with negative ear canal pressures
110
Surgical tx for ETD?
1) Adenoidectomy
2) Grommets
3) Balloon dilatation Eustachian tuboplasty
Grommets= uses local anaesthetic, typically fall out within 18 months
BDET= deflated balloon--> ET, inflating for short period , then deflating and removing under GA
111
Causes of unilateral anosmia? Central causes of bilateral anosmia? Taste disturbance?
Head injury, frontal lobe lesion
CNS tumours, after head injury, meningitis, hydrocephalus, Kallman's syndrome
Drugs e.g. ACEi, glossopharyngeal nerve palsy(posterior 1/3,) facial nerve palsy, chronic adrenal insufficiency, malignancy e.g. metallic w/ pancreatic cancer
112
Ix for persistent blood stained discharge? Clear fluid from the nose after trauma?
Tumour of the nose/ post-nasal sinus--> refer to ENT
Fracture of the roof of the ethmoid labyrinth and CSF leak, +ve for glucose--> refer for head injury assessment, persists= refer to neurosurgery for dural closure
113
Persistent unilateral nasal blockage? Causes of nasal obstruction?
Neoplastic--> refer to ENT
Mucosal swelling, septal deviation, tumour, enlarged adenoids, foreign body
114
Presentation and tx for deviated nasal septum?
Usually secondary to injury, may be ass w/ external deformity, nasal blockage= unilateral, tx mucosal swelling due to rhinitis first, unsuccessful= refer--> surgery(submucous resection)
115
Presentation of septal haematoma?
May occur after injury and causes nasal blockage--> bilateral soft bulging of the septum, refer--> ENT for evacuation to prevent cartilage destruction
116
What is post-nasal drip?
Draining of nasal secretions down the back of the throat, tx as for chronic sinusitis
Feeling of mucus in the back of the throat, chronic cough, morning sore throat, nasty taste in the mouth/ bad breath
Causes= URTI, sinusitis, allergic and/ or vasomotor rhinitis, nasal polyps, deviated nasal septum
117
What are nasal polyps?
Growths of the nasal mucosa that can occur in the nasal cavity/ sinuses, often ass w/ inflammation, particularly chronic sinusitis, grow slowly and gradually obstruct the nasal passage
Usually bilateral- unilateral= RED FLAG
118
Nasal polyps ass w/?
Chronic rhinitis/ sinusitis, asthma, Samter's triad(w/ asthma + aspirin intolerance/ allergy,) CF, eosinophilic granulomatosis with polyangiitis
119
Presentation of nasal polyps?
Chronic rhinosinusitis, difficulty breathing through the nose, snoring, nasal discharge, anosmia, change in voice
Use nasal speculum/ otoscope, specialist= nasal endoscopy
Round pale grey/ yellow growths on the mucosal wall
120
Tx for nasal polyps?
Intranasal topical steroids drops e.g. fluticasone nasal drops OD, then spray to reduce recurrence
Fails--> intranasal polypectomy- visible close to nostrils
Endoscopic nasal polypectomy= further in the nose/ sinuses
121
Tx for undisplaced nasal fractures? Ass injuries? Reassess 7-10 days after injury and refer with what?
No intervention, XR= unhelpful, analgesia, feel blocked for 1-2 weeks
Head injury: fractures of zygoma/ maxillary bones--> maxillofacial surgeons if present
Significant deformity/ if patient is unhappy with appearance to ENT-->reduction <3 weeks after fracture
Deviated septum= may not be correctable at the time of manipulation, if symptomatic--> submucous resection later on
122
Nosebleeds usually originate from what? Common triggers? Bilateral?
Kiesselbach's plexus in Little's area
Nose picking, colds, sinusitis, vigorous nose-blowing, trauma, changes in weather, coagulation disorders, anticoagulant medication, snorting cocaine, tumours
May indicate bleeding posteriorly in the nose
123
Check what in person with epistaxis? Most can be stopped how?
If on anticoagulants, aspiring, or NSAIDs and enquire about bleeding issures
BP- review prior to starting tx, watch for signs of shock and airway problems
Pinching soft tip of nose for >10 minutes- don't let go, ice pack to bridge of the nose, sitting the patient up + leaning forward
124
If anterior bleeding point is visualised, try what?
Cautery with a silver nitrate stick, if stops- prescribe antiseptic cream e.g. Naseptin bd for 1 week
125
2/3 people have what with tinnitus? Ringing/ hissing/ buzzing suggests what cause? Popping/ clicking? Pulsatile is what?
Sensorineural hearing loss
Inner ear/ central cause
External/ middle ear/ the palate
Objective- can reflect increased awareness of blood flow in the ear
126
Causes of secondary tinnitus? Systemic conditions?
Impacted ear wax, ear infection, Meniere's disease, noise exposure, medications e.g. Loop diuretics, gentamicin and chemotherapy e.g. cisplatin, acoustic neuroma, MS, trauma, depression
Anaemia, diabetes, hypothyroidism/ hyperthyroidism, hyperlipidaemia
127
What is objective tinnitus? Actual additional sounds?
Patient can objectively hear an extra sound within their head- can be auscultated around the ear
Carotid artery stenosis, aortic stenosis, arteriovenous malformations, ETD
128
Ix, red flags and tx for tinnitus?
Bloods: FBC, glucose, TSH, lipids
Audiology, imaging- CT/ MRI
Unilateral tinnitus, pulsatile, hyperacusis, unilateral hearing loss, sudden onset hearing loss, vertigo/ dizziness, headaches/ visual symptoms, neurological symptoms/ signs, suicidal ideation
Hearing aids loss>35 dB, sound therapy, CBT
129
What is vertigo? Can be caused by what?
Sensation that there is movement between the patient and their environment- they're/ the environment is moving
Ass w/ N+V, vomiting, sweating and feeling unwell
Peripheral problem affecting vestibular system, central problem involving brainstem/ cerebellum
130
Peripheral causes of vertigo?
BBPV, Meniere's, vestibular neuronitis, labyrinthitis, trauma to the vestibular nerve, acoustic neuromas, otosclerosis, VSV infection
131
Central causes of vertigo?
Posterior circulation infarction, tumour, MS, vestibular migraine--> sustained non-positional vertigo
132
Onset, duration, hearing loss/ tinnitus, coordination and nausea in peripheral vertigo? Central?
Sudden, short duration, often present, intact, more severe
Gradual, persistent, usually not, impaired coordination, mild nausea
133
Key features pointing to cause of vertigo?
Recent viral illness--> labyrinthitis/ vestibular neuronitis
Headache--> vestibular migraine, CVA/ tumour
Typical triggers--> vestibular migraine
Ear symptoms= infection
Acute symptoms= stroke
134
4 things to examine with vertigo?
1) Ear exam
2) Neurological exam + cerebellar
3) CV exam
4) Special tests: Romberg's test, Dix-Hallpike manoeuvre for BPPV, HINTS= central vs peripheral
135
HINTS exam for central vs peripheral exam?
Head impulse, nystagmus, test of skew
Head impulse= eyes saccade(rapidly move back and forth and eventually fix back on examiner) in peripheral causes
Unilateral horizontal nystagmus= peripheral, bilateral/ vertical= central
Test of skew= eyes should remain fixed on examiner's nose with no deviation
136
Short-term tx for peripheral vertigo? Ix for central vertigo? What reduces attacks in patients diagnosed with Meniere's disease? Manoeuvre to tx BPPV? Tx for vestibular migraine?
Prochlorperazine, antihistamines e.g. cyclizine, cinnarizine and promethazine
CT/ MRI head
Betahistine
Epley
Avoiding triggers and lifestyle changes, triptans for acute and propanolol/ topiramate/ amitriptyline for prevention
137
Causes of episodic vertigo lasting few seconds/ minutes, minutes to hours or prolonged>24 hours?
BPPV
Meniere's disease
Peripheral lesion e.g. viral labyrinthitis/ trauma/ central lesion e.g. MS/ stroke/ tumour
138
Presentation of BPPV? Diagnosis? Tx?
F>M, most= idiopathic
Common after head injury/ viral illness, possibly caused by otoliths in the labyrinth
Short episodes of vertigo, worse in AM, last 20-30 seconds, provoked by head movements/ change in posture, NO hearing loss/ tinnitus
Dix Hallpike Test +ve--> rotational nystagmus towards the affected ear and vertigo symptoms, normal tympanic membrane
Slowly out of bed, reduced alcohol + head movements, Epley's from ENT and/ or refer to physio for exercises/ vestibular rehabilitation, prochlorperazine
139
Crystals of what in BPPV? Most often in what? Exercises that can help to relieve BPPV symptoms?
CaCO3, posterior semicircular canal
Brandt- Daroff exercises
140
Cause and presentation of Meniere's disease? Ix? Tx?
Increase in endolymph in membranous labyrinth, progressive distension of membranous labyrinth
Unilateral/ bilatteral vertigo +/- N+V, tinnitus, sensorineural hearing loss may be progressive, sensation of aural pressure(fluctuating, episodic pattern, acute attacks= mins- hours, clusters 6-11/ year)
Clinical + audiometry
141
Tx for Meniere's disease?
Refer all suspected cases to ENT/ neurology to confirm diagnosis
Bed rest + reassurance, antihistamines e.g. cinnarizine, prochlorperazine buccal/ IV
Prophylaxis= betahistine (decrease frequency + severity)
INFORM THE DVLA
142
Who is vertebro-basilar insufficiency common in?
Older patients
Hx of dizziness on extension and rotation of the neck, normal tympanic membrane, may have associated cervical spondylosis + neck pain
Lifestyle advice
143
Labyrinthitis usually follows what? Presentation, Ix and tx?
URTI
Inflammation of membranous labyrinth AND vestibular nerve
F>M, adults 30-60 y/o
Sudden, severe rotational vertigo, not triggered by movement, hearing loss, N&V, tinnitus, preceding URTI sx
Clinical--> audiometry + o/e HINTS
Anti-histamine= cerazine, cyclizine, prochlorperazine, corticosteroids e.g. pred, bed rest + oral fluids, ABx for bacterial, DON'T DRIVE
144
Causes of congenital deafness?
Usually on neonatal screening
Genetic=50%, birth asphyxia, meningitis, severe neonatal jaundice, intrauterine infection e.g. rubella, drugs in pregnancy e.g. streptomycin
145
What is vestibular neuritis? Usually follows what? In who? Sx? Dx? Tx?
Inflammation of vestibular nerve only
URTI/ reactivation of latent HSV
F>M, adults 40-50 y/o
Sudden, severe rotational vertigo, NOT triggered by movement, gait instability, NO hearing loss, N&V, preceding URTI sx
Clinical + audiometry + O/E HINTS
Antihistamine - cerazine, cyclizine, prochlorperazine, corticosteroids, bed rest + oral fluids
146
Other name for ear wax? Presentation? 3 main methods for removal? CI to ear irrigation?
Cerumen
Conductive hearing loss, discomfort in the ear, feeling of fullness, pain, tinnitus
Ear drops- olive oil/ sodium bicarbonate 5%, ear irrigation- using water, microsuction- tiny suction device to suck out wax
Perforated tympanic membrane/ infection--> microsuction by specialist ENT services
147
Peak age for Bell's palsy? Causes what? Ix and tx?
20-40 y/o
LMN palsy= forehead affected
Mild-->severe= facial sagging with weak muscles of facial expression, drooping eyelid, drooping of corner of mouth, loss of nasolabial fold, hyperacusis, dry mouth, altered taste, decreased tear production
Clinical Ix
Pred PO 50mg 10 days within 72 hours, artificial tears, commonly spontaneous resolution
148
Cause of Ramsey- Hunt syndrome? Tx within?
VZV--> unilateral LMN
Painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side, can extend--> anterior 2/3 of the tongue and hard palate
Prednisolone + aciclovir within 72 hours, lubricating eye drops
149
Infective causes of LMN facial nerve palsy? Systemic disease? Tumours? Trauma?
Otitis media, malignant otitis externa, HIV, Lyme's disease
Diabetes, sarcoidosis, leukaemia, MS, GBS
Acoustic neuroma, parotid tumours, cholesteatomas
Direct nerve trauma, damage during surgery, base of skull fractures
150
What is obstructive sleep apnoea caused by? RFs and features?
Collapse of the pharyngeal airway= episodes of apnoea during sleep, the person stops breathing periodically for up to a few minutes
Middle age, male, obesity, alcohol, smoking
Apnoea episodes, morning headache, snoring, waking up unrefreshed from sleep, concentration issues, daytime sleepiness, reduced oxygen saturation during sleep
Severe--> HTN, HF and increased MI and stroke risk
151
Scale used for obstructive sleep apnoea? Tx?
Epworth Sleepiness Scale
Referral to ENT specialist/ specialist sleep clinic
Stop drinking alcohol, smoking and lose weight
CPAP
Surgery= reconstruction of the soft palate and jaw= uvulopalatopharyngoplasty
152
Urgent referral involving the mouth to exclude malignancy? Non-urgent?
Mouth ulcers> 3 weeks, lumps in mouth> 3 weeks, red/ white patches in the mouth that are painful, swollen or bleeding
Unexplained red and/ or white patches of the oral mucosa not painful, swollen or bleeding inc suspected lichen planus
153
Causes of a sore mouth? Mouth ulcers?
Oral thrush, aphthous ulcers, HSV, dry mouth, trauma, side effects of chemo/ radiotherapy, anaemia, HF+M disease, gingivitis
Aphthous ulcers, trauma, Crohn's/ UC, coeliac disease, drugs, Reiter's disease, Behcet's disease, HSV, herpes zoster, vincent's angina, erythema multiforme, self-inflicted e.g. burns
154
What is leukoplakia? Refer or not? Tx?
Thick whitish, grey patch usually on the inside of the cheek, tongue or gum
Yes(to oral surgery)= early sign of oral cancer(SCC)
Stop smoking, reducing alcohol, close monitoring, laser removal or surgical excision
155
What is erythroplakia? Less/ more ominous predictor of oral cancer than leukoplakia?
Like leukoplakia except red lesions
More ominous
156
What is lichen planus? In who mostly? 3 patterns in the mouth? Tx?
An autoimmune condition that causes localised inflammation of the skin
Shiny, purplish, flat-topped raised areas with white lines across the surface= Wickham's striae
>45 y/o, F>M
Reticular, erosive, plaque
Good oral hygiene, stopping smoking and topical steroids
157
What is gingivitis? How does acute necrotising ulcerative gingivitis present? Cause of this? RFs? Tx?
Inflammation of the gums--> swollen gums, bleeding after brushing, painful gums and halitosis, can lead to periodontitis
Rapid onset of more severe inflammation, painful= anaerobic bacteria
Plaque build-up on the teeth, smoking, diabetes, malnutrition, stress
Good oral hygiene, stopping smoking, hygienist to remove plaque and tartar, chlorhexidine mouthwash, ABx for AUG, dental surgery
158
What is gingival hyperplasia? Possible causes?
Abnormal growth of the gums= notably enlarged around the teeth
Gingivitis, pregnancy, vitamin C deficiency, AML, medications i.e. CCBs, phenytoin and ciclosporin
159
What are aphthous ulcers? Causes? Indication of what? Tx?
Very common, small, painful ulcers of the mucosa in the mouth
Well-circumscribed, punched-out, white appearance
Stress, trauma to the mucosa/ foods, IBD, coeliac disease, Behcet disease, vitamin deficiency, HIV
Usually heal within 2 weeks
Topical: choline salicylate e.g. Bonjela, benzydamine e.g. Difflam spray, lidocaine
160
Topical corticosteroids for aphthous ulcers? Guidelines for suspected oral cancer?
Hydrocortisone buccal tablets, betamethasone soluble tablets, beclomethasone inhaler spray
2- week wait in unexplained ulceration > 3 weeks
161
What is glossitis? Causes?
An inflamed tongue, the papillae atrophy--> smooth
Iron deficiency anaemia, B12 deficiency, folate deficiency, coeliac disease, injury/ irritant exposure
162
3 top causes of angioedema of the tongue?
Allergic reactions, ACEi, C1 esterase inhibitor deficiency(hereditary)
163
Presentation of oral candidiasis? Predisposing factors? Tx options?
White spots/ patches that coat the surface of the tongue and palate
Inhaled corticosteroids, antibiotics, diabetes, immunodeficiency, smoking
Miconazole gel, nystatin suspension, fluconazole tablets= severe/ recurrent cases
164
What is geographic tongue? Can be related to what? Tx?
Irregular smoother redder patches that change position over time on the dorsum of the tongue
Condition= relapses and remits
Stress, psoriasis, atopy and diabetes
None- topical steroids/ antihistamines in discomfort/ burning
165
What is strawberry tongue?
Becomes red and swollen, papillae--> enlarged, white and prominent
1) Scarlet fever
2) Kawasaki disease
166
Black hairy tongue results from what? Causes and tx?
Decreased shedding of keratin from tongue's surface, papillae elongate and take on appearance of hairs, bacteria + food--> dark pigmentation
Some= sticky saliva and a metallic taste
Dehydration, dry mouth, poor oral hygiene and smoking
Adequate hydration, gentle brushing of the tongue and stopping smoking
167
Short-term halitosis ass w/ what?
Acute illness e.g. tonsillitis, appendicitis, gastroenteritis, DKA
168
Causes of bleeding gums? Hypertrophied gums? Blue line? Gum inflammation?
Peridontal disease, pregnancy, leukaemia, bleeding disorders, scurvy
Phenytoin use
Lead poisoning
Gingivitis- immunodeficiency; vitamin C deficiency, DM, leukaemia; drugs, e.g. phenytoin, nifedipine, ciclosporin
169
What is Vincent's angina, tx?
Pharyngeal infection with ulcerative gingivitis
Pen V 250mg QDS PO + metronidazole 400mg tds po
170
Issues ass w/ cleft palate? Detected at what?
Feeding difficulties with associated poor weight gain, aspiration pneumonia, hearing problems, speech and dental problems
Routine antenatal USS
171
What is temporomandibular joint (TMJ) dysfunction? What in hx? Examine what?
Pain- duration, location, and nature; precipitating/ relieving factors; joint noises; restricted jaw function, e.g. locking, poor bite; non-specific symptoms e.g. headache, earache, and tinnitus
The head and neck- TMJ + mandibular movement
172
3 patterns of TMJ dysfunction disease? Tx? Specialist tx?
1) Myofacial pain + dysfunction- usually worse in the morning
2) Internal derangement- restriction, pain usually continuous and exacerbated by jaw movement
3) Osteoarthrosis- degeneration of the joint seen on older patients, crepitus and sounds from the joint on movement
Analgesia, resting, avoiding stress
Bite appliance helps 70%, physio, behavioural therapy, exercises, surgery if failure
173
Most common cause of bacterial tonsillitis? Second most common? Tonsils infected in tonsillitis?
Group A strep, s. pneumoniae
Palatine tonsils
174
What score gives 40-60% probability of bacterial tonsillitis? Point is given for what features? Alternative to the CENTOR criteria? ABx with what score?
3 or more
Fever>38 degrees, tonsillar exudates, absence of cough, tender anterior cervical lymph nodes
FeverPAIN Score: fever during previous 24 hours, purulence, attended within 3 days of symptom onset, inflamed tonsils, no cough or coryza
>=4
175
Consider admission for sore throat if what? Return when after safety netting? Delayed prescription when?
Immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress, evidence of a peritonsillar abscess/ cellulitis
Not settled after 3 days/ fever above 38.3 degrees
If symptoms worsen/ do not improve in the next 2-3 days
176
1st line for bacterial tonsillitis? Comps?
Penicillin V for 10 days, allergy= clarithromycin
Quinsy, retropharyngeal abscess, otitis media, scarlet fever, rheumatic fever, post-strep GN, post-strep reactive arthritis
177
Urgent referral for sore throat? For tonsillectomy(under GA as a day case)?
>1 month
>5 attacks a year for 2 years, airway obstruction--> sleep apnoea, chronic tonsillitis>3 months + halitosis, recurrent quinsy, unilateral enlargement
178
Main significant complication after a tonsillectomy? Tx? Before going back to theatre, 2 options?
Post tonsillectomy bleeding
Call ENT registrar, IV access + send FBC, clotting screen, group and save and crossmatch, analgesia, spit out blood, NBM, IV fluids for maintenance and resus
Bleeding/ airway compromise= call anaesthetist
Hydrogen peroxide gargle, adrenalin soaked swab applied topically
179
Additional symptoms indicating peritonsillar abscess? Common causes? Tx?
Trismus= unable to open mouth
Change in voice- 'hot potato voice'
Swelling and erythema
Group A strep, s. aureus and h.influenzae
Needle aspiration / surgical incision and drainage, some surgeons= dexamethasone to settle inflammation + help recovery
180
Incubation period of glandular fever? Presentation? Ix? Tx?
4-14 days
Sore throat, malaise, fatigue, lymphadenopathy, enlarged spleen, palatal petechiae, and/ or rash
FBC and antibodies- Monospot or Paul Bunnell
Rest, fluids, paracetamol, avoid alcohol, salt water/ aspirin gargles if >16 y/o, severe= short course pred, secondary infection= ABx
181
What is hoarseness? Causes?
Change in quality of the voice affecting pitch, volume, or resonance- vocal cord function is affected by a change in the cords, a neuro/ muscular problem
Local= URTI, laryngitis; trauma, carcinoma, hypothyroidism, acromegaly
Neuro= laryngeal nerve palsy; MND; MG; MS
Muscular dystrophy, functional issues
182
Assessment of hoarseness/ stridor? Refer urgently for CXR if what? What if there's a positive or negative finding?
Weight reduction, dysphagia/ neck lumps, TFTs in weight gain
Hoarseness>3 weeks- particularly smokers>50 y/o and heavy drinkers
+ve= refer to a team specialising in lung cancer tx
-ve= refer to a team specialising in tx of head and neck cancer
183
Presentation of laryngitis? Management?
Hoarseness, malaise +/- fever and/or pain on using voice, usually viral + self-limiting(1-2 weeks) but occasionally secondary bacterial infection occurs
Advise rest to voice, take OTC analgesia e.g. paracetamol and/or ibuprofen, try steam inhalations, ABx if bacterial suspected e.g. phenoxy 250mg QDS for 1 week
184
Presentation and how vocal cord nodules visualised? Tx?
Usually precipitated by overuse of voice- typically in singers, can be visualised at laryngoscopy, initial tx= resting voice, sometimes= surgical removal
185
Functional disorders of larynx? Management?
Hysterical paralysis of the vocal cord adductors due to psychological stress, can cause voice to reduce to a whisper/ be lost completely, more common in young women
Refer--> laryngoscopy to exclude organic cause, speech therapy and psych support might help
186
Signs of laryngeal carcinoma? Management?
Hoarseness, stridor, dysphagia + pain
Refer to RNT urgently, IX= laryngoscopy and biopsy, tx= surgery +/- radiotherapy, early confined to vocal cord= 80-90% 5y survival
187
Post-laryngectomy issues?
After= permanent tracheostomy and need practical + psych support
Issues= excessive secretions, recurrent pneumonia, stenosis of tracheostomy site(refer to ENT/ oral surgery,) communication difficulties- refer to speech therapy, maintenance of diet
188
Signs of narrowing airways? Causes? Refer for what in adult epiglottitis?
Increased RR, pallor and cyanosis, use of accessory muscles and tracheal tug
Congenital abnormalities of the larynx; epiglottis; croup, inhaled foreign body(refer to ENT); trauma; laryngeal paralysis
IV ABx
189
What to ask with neck lumps? Regarding neck lumps, urgent referral to ENT when? Check what in lymphadenopathy?
Local sx in head/ neck and systemic symptoms, site, onset, size + growth, any changes + timescale; red flags= dysphagia/ odynophagia, persistent cough, sore throat/ hoarseness, haemoptysis, fatigue, night sweats, unexplained fever, weight loss, RFs, co-morbidities, smoking/ alcohol, family hx
Any unexplained lump in the neck of recent onset, any previously undiagnosed lump that has changed over 3-6 weeks
FBC, blood film + ESR (or CRP/ viscosity)
190
Consider further investigation, discussion with a specialist, and/ or referral if what in lymphadenopathy?
Present>/=6 weeks, LNs= increasing in size, associated with weight loss, night sweats, and/or splenomegaly, LN>2cm insize, widespread lymphadenopathy
191
Causes of lymphadenopathy? Single neck lumps often due to what?
Benign infective= viral infection, e.g. EBV, CMV, adenovirus, HIV; bacterial infection e.g. strep throat, TB; toxoplasmosis; syphilis
Benign non-infective= sarcoid, CND; skin disease, drugs e.g. phenytoin
192
What is a branchial cyst? Presentation + tx?
From embryonic remnants of the second brachial cleft in the neck, most common= young adults, smooth swelling in front of the anterior border of the sternomastoid at junction of upper and middle thirds- often during viral URTI
Fluctuant lump does not move on swallowing
Excision- ENT referral
193
What is a thyroglossal cyst? Presentation + tx?
Portion of the thyroglossal duct remains patent, in young adults normally- peak= 15-30 y/o
Painless, smooth, cystic midline swelling between isthmus of thyroid and hyoid cartilage/ just above hyoid cartilage/ if inflamed- painful, tender lump with localised swelling
Cyst rises as patient sticks out his tongue
Refer to ENT for excision
194
80% salivary gland calculi seen where? Less frequently? Strictures occur how? Presentation?
In the submandibular duct system, less frequently in the parotid duct system + rarely in other salivary glands
As a complication of pre-existing calculi due to mucus plugs/ following trauma to duct wall e.g. cheek biting
Pain + swelling on eating due to saliva flow obstruction, gland may be normal/ tender + swollen, sometimes= stones at salivary duct orifice/ on bimanual palpation, both= predispose to gland infection
195
Tx for salivary stones/ strictures?
Refer to ENT/ oral surgery for confirmation- stones= on plain XRs or sialography(contrast + XR,) some pass spontaneously/ most require surgical removal, whole gland may be removed to prevent recurrent problems, strictures can often be dilated
196
What is acute parotiditis? Mumps? Predisposing factors? Precipitating factors? Ix? Tx? If not settling consider what?
Unilateral parotid swelling and pain caused by bacterial infection- painful, tender swelling near ear, dry mouth, difficulty opening mouth, pain on eating, fever, foul taste
Bilateral swelling>=1 + low grade pyrexia
DM, immunosuppression/ compromise, local fibrosis following radiotherapy, AI destruction
Bloods, viral serology, salivary antibody testing, pus swab cultures, USS, sialography, CT/ MRI
Surgery, dehydration, salivary stones/ strictures, and poor oral hygiene
ABx e.g. amoxicillin 500mg TDS for 1 week + rehydration, consider abscess formation--> ENT/ oral surgery for drainage
197
Presentation of salivary gland tumours? 80% where? Tx? Refer urgently to ENT/ oral surgery if what?
Lump/ swelling in salivary gland- parotid gland, surgery +/- radiotherapy
Unexplained swelling in parotid/ SM gland for >1 month, sooner if pain, rapid growth, hard fixed mass, weight reduction/ facial nerve palsy
198
Assessing neck lumps?
Assess for signs of stridor, superior SVC compression, or dysphagia with aspiration
Examine the position, size, pulsatility, consistency, tenderness, mobility, and nodularity of the lumps(s); and overlying skin appearance
Examine for localised/ generalised lymphadenopathy
Head + neck general examination of the skin, ears, nose, throat, oral cavity, chest, abdomen
199
NICE criteria for 2 week wait for neck lumps? Head and neck cancers? Urgent USS in lumps what? Within how long for 25 y/o and older and how long for under 25 y/o? 2 WW if USS suggestive of what?
Unexplained neck lump in someone aged 45 or above/ persistent unexplained neck lump at any age
Growing in size- 2 weeks/ 48 hours
Soft tissue sarcoma
200
Blood tests for neck lumps? Imaging options? Methods for biopsy?
FBC + blood film for leukaemia and infection, HIV test, monospot test/ EBV antibodies for infectious mononucleosis, TFTs for goitre/ thyroid nodules, ANA antibodies for SLE, LDH= non-specific for Hodgkin's lymphoma
USS= often 1st line
CT/ MRI scans
Nuclear medicine scan
Fine needle aspiration cytology, core biopsy, incision biopsy, removal of the lump
201
What is sialadenosis? Caused by what? Associated with what? Ix? Rx?
Generalised non-inflammatory, painless bilateral swelling of gland(usually parotid)
Caused by hypertrophy of acinar component
Systemic disease- Sjogren's, sarcoid, malnutrition- anorexia, endocrine disorders
Sialography- sialectasis, biopsy, autoantibodies
Pilocarpine- for hyposalivation, ? refer to rheumatology
202
Head and neck cancers are usually what? Red flag Sx? What is MAB used in treating SCC? It targets what?
SCCs
Smoking, chewing tobacco, chewing betel quid, alcohol, HPV, EBV infection
Lump in the mouth or on the lip, unexplained ulceration in the mouth lasting >3weeks, erythroplakia/ erythroleukoplakia
Cetuximab- epidermal growth factor receptor- blocks the activation of this receptor and inhibiting the growth and metastasis of the tumour
