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Clinical Years / Progress Test > ENT > Flashcards

ENT Flashcards

1
Q

key symptoms regarding the nose (history taking)

A

key 5 symptoms:
-Nasal obstruction
-Runny nose (anterior rhinorrhoea)
-Loss of sense of smell (hyposmia/anosmia)
-Nose bleeds (epistaxis)
-Facial pain

Other symptoms include:
-Post nasal drip
-Nasal itch
-Sneezing
-Ocular itching

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2
Q

key symptoms regarding the ear (history taking)

A

key 5 symptoms:
-Earache (otalgia)
-Ear discharge (otorrhoea)
-Hearing loss
-Tinnitus (the sensation of sound without any external stimulus)
-Dizziness

Other symptoms include:
-Aural blockage
-Itching

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3
Q

key symptoms regarding the throat (history taking)

A

key 5 symptoms:
- sore throat
- difficulty swallowing (dysphagia)
- pain on swallowing (odynophagia)
- hoarse voice (dysphonia)
- regurgitation

Other symptoms include
-A feeling of a lump in the throat
-Burning in the throat
-Weight loss

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4
Q

what systemic conditions may also affect the ears, nose and throat

A
  • Asthma - strong association with allergic chronic rhinosinusitis
  • Diabetes mellitus
  • Hypertension
  • Sarcoidosis
  • Tuberculosis
  • Granulomatosis with polyangitis (previously Wegener’s granulomatosis)
  • Neurofibromatosis type 2

+ more

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5
Q

what are the lymph node levels in the neck

A

Level 1: Submental and submandibular
Level 2: Upper deep cervical
Level 3: Mid-deep cervical
Level 4: Lower deep cervical
Level 5: Posterior triangle
Level 6: Paratracheal
Level 7: Upper mediastinal

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6
Q

what is a quinsy

how is it managed

A

also known as a peritonsillar abscess - complication of acute tonsillitis

don’t normally respond to antibiotics alone - need to be drained
done under local anaesthetic either by aspiration of pus or by incision and drainage with a knife

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7
Q

why does earache often occur with a sore throat

A

glossopharyngeal nerve supplies sensation to the throat but also to the ear

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8
Q

common causes of referred otalgia

A

dental infection
pharyngeal pathology
temporomandibular joint

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9
Q

where is the auditory cortex located?

A

superior temporal gyrus of the temporal lobe and extends in to the lateral sulcus and the transverse temporal gyri

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10
Q

how does auditory signal pass from the cochlea to the auditory cortex

A

The auditory signal passes along the cochlear nerve to the cochlear nucleus in the brainstem
Most then crosses to the contralateral side
The signal then passes up the brainstem through the superior olivary nucleus and then the lateral lemniscus in the midbrain to the inferior colliculus
Then passes through the medial geniculate body to the auditory cortex

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11
Q

what is the order of the ossicle bones from lateral to medial

A

malleus, incus, stapes

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12
Q

what is the chorda tympani

A

a branch of the facial nerve that carries taste fibres to the anterior two thirds of the tongue
also carries parasympathetic secretomotor fibres to the submandibular and sublingual glands.

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13
Q

What does otorrhoea as a symptom reflect

A

pyorrhoea/discharge from ear signifies Infection or inflammation in the middle ear

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14
Q

Acute otitis external presentation

A

Painful generalised swelling of external ear canal which is often moist and may be purulent discharge present

earache
hearing loss
history of swimming

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15
Q

Risk factors otitis external

A

Water entering ear
Skin conditions e.g. eczema or psoriasis
Instrumentation of the ear e.g. with cotton buds

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16
Q

What organisms commonly cause otitis externa

A

Staph aureus
Pseudomonas auriguinosa
Fungal; aspergillosis Niger

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17
Q

Simple otitis externa management

A

Keep ear dry
Analgesia
Topical antibiotics drop (+/- steroid containing)
- cipro or gent

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18
Q

Perichondritis due to otitis external

A

Complication of OE where the cartilage of the pinna is inflamed
If unwell with this needs referral to ENT

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19
Q

Management if OE becomes more severe I.e. external canal is swollen closed, pt systemically unwell

A

Continue topical drops via aural wick
Gentle micro suction of the ear
Admit and Start IV antibiotics

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20
Q

Complications of OE

A

Early:
Facial cellulitis
Otomycosis
Perichondritis

Late:
Canal stenosis with hearing loss
Osteomyelitis of the temporal bone

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21
Q

Osteomyelitis of the temporal bone

A

Also called necrotising otitis external - Complication of OE where infection spreads to underlying bone especially in those immunocompromised or with diabetes
Can affect cranial nerves particularly CNVII
If left untreated can cause sensorineural hearing loss and is potentially life threatening

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22
Q

Treatment of Osteomyelitis of the temporal bone

A

Topical antibiotics continued
+ IV Antibitoics for at least 6 weeks!

Causative organism is usually pseudomonas aeruginosa but liase with micro

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23
Q

Complications of Osteomyelitis of the temporal bone

A

Abscess of or around bone or cerebral abscess
CN palsy
Meningitis
Seizures

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24
Q

What can cause a hole in the tympanic membrane

A

Iatrogenic e.g. grommet insertion
Trauma
Recurrent infections

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25
Q

Chronic otitis media organisms

A

haemophillus influenza

less common:
Pseudomonas aeruginosa
Staph aureus
Streptococcus
Anaerobic bacteria

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26
Q

Treatment of chronic otitis media

A

Micro suck and inspection of the ear under microscope
Topical antibiotic and steroid drops for 7-10 days if active infection
Strict water precautions

If medical strategies not effective or the ear discharge is particularly affecting pts life then myringoplasty can be performed - surgical repair of the ear drum

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27
Q

Presentation of chronic otitis media

A

inflammatory condition affecting the middle ear for a period greater than 3 months.
Active or inactive and 2 types, mucosal and squamous epithelial COM.

Active mucosal disease - perforated tympanic membrane allows infection to develop in the middle ear
Active squamous epithelial disease results from cholesteatoma formation

Inactive mucosal disease -dry perforation
Inactive squamous epithelial -shallow self cleaning retracted tympanic membrane.

can present with Recurrent intermittent discharge arising from ear
hearing loss may be present

mucosal usually to do with pars tensa
squamous usually pars flaccida

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28
Q

What is a cholesteatoma
Symptoms
Complications

A

Deep retraction of the tympanic membrane that has keratin accumulated in it and can develop into a keratin cyst
Usually forms due to chronic Eustachian tube dysfunction

Discharge from the can be offensive
Hearing loss
Doesnt respond to antibiotic drops or oral antibiotics
Imbalance

The keratin cyst can expand and erode the ossicles and eventually damage structures adjacent to the middle ear

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29
Q

What is a glomus jugulare

A

Vascular tumour that presents as a red mass behind an intact tympanic membrane
Patient may have pulsatile tinnitus

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30
Q

initial management of cholesteatoma

A

topical abx and steroid drops if infection present

pure tone audiogram to determine degree of hearing loss

close inspection and cleaning of the ear under the microscope

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31
Q

definitive surgical management of cholesteatoma

A

mastoidectomy - opening the mastoid air cells, removing the cholesteatoma from the middle ear followed by reconstructing of the ossicles and tympanic membrane

CT guided

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32
Q

complications of middle ear surgery (for chronic otitis media or other conditions)

A

Infection
Bleeding
No improvement in hearing
Complete loss of hearing, called a dead ear (if the inner ear is damaged)
Tinnitus
Vertigo
Facial nerve injury, resulting in facial palsy
Altered taste (chorda tympani nerve damage)
Recurrence of disease needing revision surgery

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33
Q

Otitis media with effusion

A

inflammatory condition of the middle ear in which there is development of a middle ear effusion.
This causes a conductive hearing loss.
It is not an infection although it may follow an infection.

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34
Q

where in the tympanic membrane do
- retractions tend to occur
- perforations tend to occur

A

retraction - pars flaccida (attic)

perforations - pars tensa

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35
Q

intratemporal complications of Chronic Otitis Media

A

Vertigo - inflammation spread to labyrinth

Hearing loss - conductive or SN

Acute otitis externa

Facial weakness - facial nerve involvement

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36
Q

extratemporal complications of chronic otitis media

A

Meningitis - by eroding through the tegmen

Subdural abscess - spread from infection to extradural then subdural

Temporal lobe abscess

Sigmoid sinus thrombosis

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37
Q

acute otitis media presentation

A

earache
ear discharge
hearing affected
fever
often young child
often associated URTI
tympanic membrane looks inflamed

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38
Q

what investigations may be used to investigate lymph nodes after examination

A

Ultrasound Scan

Fine needle aspiration cytology

CT

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39
Q

causes of neck lumps (broadly)

A

Vascular
Infective/inflammatory
(trauma unlikely)
Autoimmune - thyroid
(metabolic none)
(iatrogenic unlikely)
Neoplastic
Congenital

40
Q

vascular neck lump causes

A

Carotid body tumours
Carotid artery aneurysms

41
Q

infective neck lump causes

A
  • Lymphadenopathy
    (Bacterial – suppurative (e.g. Streptococcus, Staphylococcus)
    Viral (e.g. Epstein Barr, Cytomegalovirus)
    Fungal
    TB
    Toxoplasmosis)
  • Neck abscess
  • Sialadenitis (salivary gland inflammation)
42
Q

inflammatory neck lump causes

A

Sarcoidosis
Kawasaki disease
Sinus histiocytosis
Castleman’s syndrome

43
Q

thyroid neck lump causes

A

Nodule
Goitre
May be benign or malignant
Thyroiditis

44
Q

Neoplastic neck lumps

A

Benign
- salivary gland tumours
- Lipoma
- Sebaceous cyst

Malignant
- Metastatic squamous cell carcinoma (SCC)
- Lymphoma
- Malignant salivary gland tumour

45
Q

Congenital neck lumps

A

Dermoids
Thyroglossal duct cyst
Branchial cysts
Teratomas
Larygocoele
Haemangloma
Plunging ranula (fluid collection under the tongue

46
Q

risk factors for squamous cell carcinoma (cancer) of the head & neck?

A

smoking
alcohol
betel nut chewing
Human Papilloma Virus (+EBV in nasopharyngeal)

47
Q

basic steps of diagnosing a head and neck cancer

A
  • Panendoscopy and biopsy ie. an examination under anaesthetic of the pharynx, laryx & upper oesophagus.
  • CT skull base to diaphragm to assess the extent of the primary tumour and to identify any regional or distant metastases
  • MDT discussion
48
Q

NICE guidelines for urgent referral head and neck cancer

A
  • hoarseness > 6 weeks
  • oral swelling > 3 weeks
  • dysphagia > 3 weeks
  • neck mass > 3 weeks
  • unilateral nasal obstruction, particularly when associated with purulent discharge
  • cranial neuropathies
  • orbital massess
49
Q

what symptoms or usually referred to maxillofacial surgery

A
  • All red or red and white patches of the oral mucosa.
  • Ulceration of oral mucosa persisting for more than three weeks.
  • Unexplained tooth mobility not associated with periodontal disease.
50
Q

Common causes of dysphonia

A

Overuse
Acute laryngitis
Chronic laryngitis secondary to reflux
Use of asthma inhalers
Smoking
Squamous cell carcinoma of the larynx
Vocal cord palsy of which there are many aetiologies inc recurrent laryngeal and vagus nerve palsies

51
Q

vocal cord polyp

A

benign inflammatory lesions of the vocal fold and usually result from overuse.
may settle with appropriate speech therapy but can be removed surgically

52
Q

Reinke’s oedema

A

oedema of the vocal folds with gelatinous material within
most common in women who are smokers
treatment is cessation of smoking, control of gastroesophageal reflux and, in refractive cases, incision of the vocal fold with evacuation of the gelatinous material.

53
Q

treatment in head and neck cancers

A

radiotherapy - curative or palliation

surgery - curative intent

chemotherapy - not usually curative for head and neck

palliative?
need for rehabilitation? swallow, voice

choices for treatment determined by patient factors (age, comorbidity, previous treatment, lifestyle) and tumour factors (site, size, staging, previous treatment)

54
Q

benign causes of a thyroid nodule

A

Follicular adenoma
Hyperplastic nodules
Thyroid cysts

55
Q

malignant causes of a thyroid nodule

A

Papillary carcinoma
Follicular carcinoma
Medullary carcinoma
Anaplastic carcinoma

56
Q

common causes of generalised thyroid swelling

A

Physiological – Pregnancy, puberty
Degenerative – Multinodular goitre
Thyroiditis – Most commonly Hashimoto’s thyroiditis
Grave’s Disease

57
Q

what symptoms associated with a thyroid lump are suspicious for malignancy

A
  • thyroid lump in a child
  • rapidly growing painless lump
  • unexplained hoarseness
  • stridor
  • enlarged cervical lymph nodes
58
Q

what are the treatment options/roles in thyroid malignancies

A

Thyroidectomy +/- lymph node resection

External beam radiotherapy or Immunotherapy - inoperable or recurrent disease or distant disease that has failed to respond to previous radioactive iodine therapy

Radioactive iodine therapy - post-operatively for larger tumours or those with unfavourable histological features / distant spread

(chemotherapy not used in thyroid malignancy)

59
Q

how can the causes of nasal obstruction be divided

A

structural
inflammatory
infective

60
Q

causes of nasal obstruction

A

rhinosinusitis

septal deviation

nasal polyps

foreign body in the nose

Granulomatosis with polyangitis - systemic disorder that can affect the cartilage of the nose

adenoids

61
Q

typical history of chronic rhinosinusitis?

A

bilateral nasal obstruction associated with anterior rhinorrhea and sneezing

often atopic history
can be worse in summer

O/E oedema of the nasal mucosa and a watery discharge in the nose.

62
Q

what test is relevant to chronic rhinosinusitis

A

RAST testing (Radioallergosorbent) - identifies allergies to specific allergens

63
Q

treatments in chronic allergic rhinosinusitis

A

Antihistamines if specific allergies identified + other allergy management techniques such as avoidance

Topical nasal steroid as a spray - mainstay as treatment

64
Q

when are decongestants used in rhinosinusitis

A

short term relief in acute rhinosinusitis (maximum 1 week)

65
Q

is surgery used in chronic rhinosinusitis

A

only if no response to medical treatment

66
Q

how is chronic rhinosinusitis with polyps managed

A

topical nasal steroid + short course of prednisolone

if not effective then Functional endoscopic sinus surgery + carry on topical steroid afterwards

67
Q

what constitutes acute or chronic rhinosinusitis

A

Acute rhinosinusitis (ARS) lasts less than 12 weeks with complete resolution of symptoms.

Chronic rhinosinusitis (CRS) lasts more than 12 weeks without complete resolution of symptoms.

68
Q

key points of nasal examination

A

external inspection

anterior nose - Thuddicums speculum

posterior nose - flexible nasal endoscope

69
Q

where is the most common side of epistaxis

A

Littles area/ Kiesselbach’s plexus - formed by 3 arteries; anterior ethmoid artery, the sphenopalatine artery and the greater palatine artery

70
Q

silver nitrate cautery

A

if a prominent vessel identified as the source of epistaxis
can only be done to one side of septum

cauterised holding the silver nitrate stick in each position for 15 seconds. The vessel itself can then be cauterised.
Antiseptic cream, such as Naspetin, should then be applied and given to the patient to apply twice daily for 2 weeks.

71
Q

advice to patients to reduce occurrence of epistaxis

A

for a few weeks;
avoid hot drinks
avoid very hot baths/showers
avoid picking the nose
avoid very hot and spicy foods

if recurrence; apply pressure for 15 mins and if this fails attend A&E

72
Q

management of epistaxis that doesn’t stop with pressure

A

A-E
check airway and breathing
circulation; IV access, haemodynamically stable? FBC, coag profile, group and save

apply pressure
if identifiable cauterise source of bleeding

continued bleeding? anterior nasal packing

continued bleeding? posterior nasal packing

continued bleeding? ligate artery in surgery

73
Q

factors that contribute to development of epistaxis in adults

A

-most common cause is trauma i.e. punching
-pmhx of hypertension, anticoagulant or antiplatelet therapy
- inflammation of the nasal mucosa
- rarely malignancy

74
Q

what nasal malignancy is most common

A

squamous cell carcinoma
most commonly occurs in individuals of Chinese origin

75
Q

most common cause of epistaxis in children

A

mainly due to bleeding from Little’s area primarily due to trauma

in most cases stops with pressure and can be prevented from bleeding recurring using cream such as naspetin or bactroban

76
Q

what is tranexamic acid

when is its use contraindicated

A

used for epistaxis sometimes
anti fibrinolytic agent.

contraindicated
- blood clots, bleeding in the brain, or urine, heart valve problems, visual problems secondary to bleeding, irregular heartbeat, irregular unexplained menstrual bleeds, using birth control medication or devices, taking medication such as clotting factors and medication containing tretinoin

77
Q

otosclerosis

A

replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window.
Otosclerosis is autosomal dominant and typically affects young adults
sometimes shows up in pregnancy

Management
hearing aid
stapedectomy

78
Q

unilateral nasal polyps management

A

urgent referral to ENT - red flag for nasopharyngeal carcinoma

79
Q

symptoms and management of nasal polyps

A

symptoms
- nasal obstruction
- rhinorrhoea, sneezing
- poor sense of taste and sme

Management
-all patients with suspected nasal polyps should be referred to ENT for a full examination
-topical corticosteroids shrink polyp size in around 80% of patients

80
Q

Ménière’s disease presentation

A

spontaneous vertigo accompanied by unilateral hearing loss and tinnitus

81
Q

sudden onset sensorineural hearing loss

A

high dose corticosteroids and referral to ENT

82
Q

red flag symptoms chronic rhino sinusitis

A

unilateral symptoms
persistent symptoms despite 3 months treatment
epistaxis

83
Q

vestibular neuronitis

A

typically develops following a viral infection with recurrent vertigo attacks lasting hours or day, usually nystagmus and sometimes associated vomiting

no hearing loss or tinnitus

treated with prochlorperazine or an antihistamine

needs to be distinguished from a posterior circulation stroke - use HINTs test

84
Q

Ramsay hunt syndrome

A

Reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.
- auricular pain progresses to include a vesicular rash around the ear, tinnitus and vertigo. Facial nerve palsy may also occur.
treatment oral aciclovir 7 days and oral prednisolone 5 days

85
Q

what kind of hearing loss does presbyacusis cause

A

sensorineural hearing loss of higher frequencies

86
Q

what kind of hearing loss does noise damage cause

A

sensorineural particularly at frequencies 3000-6000Hz

87
Q

viral labyrinthitis

A

Recent viral infection
Sudden onset vertigo
Nausea and vomiting
Hearing may be affected

88
Q

When should antibiotics be prescribed in acute otitis media

A
  • symptoms for >4 days or not improving
  • systemically unwell
  • immunocompromised or at high risk of secondary infections
  • acute otitis media with perforation

5-7 days of amoxicillin is first line

89
Q

What score on Centor criteria indicate antibiotics should be prescribed

A

3 or more

Absence of cough
Fever
Anterior cervical lymphadenopathy
Presence of tonsillar exudate

90
Q

Management chronic symptoms of vestibular neuronitis

A

Vestibular rehabilitation - make urgent referral

91
Q

What drugs can cause tinnitus

A

Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine

92
Q

acute sinusitis treatment

A

analgesia

intranasal corticosteroids if symptoms present >10 days

oral Abs not normally required but may be given for severe presentations

93
Q

positive dix-hallpike test

A

onset of vertigo and rotatory nystagmus

94
Q

Samter’s triad

A

asthma
aspirin sensitivity
nasal polyposis

95
Q

mastoiditis presentation

management

A

typically spread from a middle ear infection
pt v unwell with fever, middle ear symptoms + post auricular inflammation and ear proptosis

needs admission and IV Abx

Clinical Years / Progress Test (24 decks)

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