ENT Flashcards
1
Q
Name the auditory ossicles
A
Stapes
Incus
Malleus
2
Q
What is otitis externa?
A
Acute inflammation of the skin of the auditory meatus
3
Q
What are the characteristic features of otitis externa?
A
Discharge, itch, pain (otalgia) and tragal tenderness
4
Q
What organism is the most common cause of otitis externa?
A
Pseudomonas
Occasionally staph. aureus
5
Q
Describe the different clinical entities of otitis externa; mild, moderate and severe
A
Mild - scaly erythematous skin, no narrowing of the external auditory canal
Moderate - painful ear, narrowing of external auditory canal, cream-white discharge
Severe - occluded external auditory canal
6
Q
What is auditory furunculosis?
A
A very painful staphylococcal abscess arising from a hair follicle within the canal often with concurrent pinna cellulitis
7
Q
What is malignant/necrotising otitis externa?
A
An aggressive, life-threatening infection of the external ear that can lead to temporal bone mass loss and base of skull osteomyelitis
8
Q
What organism is the most common cause of malignant/ necrotising otitis externa?
A
Pseudomonas
9
Q
What is auditory barotrauma?
A
Damage to the ear when the Eustachian tube is closed - due to pressure
10
Q
What is temporomandibular joint dysfunction?
A
Dysfunction of the temporomandibular leading to facial, ear and mandibular pain
Stress-induced teeth grinding is thought to be the major aetiological factor
11
Q
What is acute otitis media?
A
Inflammation of the midlle ear
12
Q
How does otitis media present?
A
Rapid onset of otalgia, fever, irritability, nausea and vomiting and anorexia
13
Q
What organisms are commonly responsible for otitis media?
A
Pseudomonas, haemophilus and moraxella
14
Q
What complications may arise following an acute bout of otitis media?
A
Effusion
Chronic otitis media
15
Q
What is cholesteatoma?
A
An abnormal, noncancerous skin growth that can develop in the middle section of your ear, behind the eardrum. It may be a birth defect, but it’s most commonly caused by repeated middle ear infections
16
Q
What are the classical symptoms indicative of cholesteatoma?
A
Foul discharge Deafness Headache Pain Facial paralysis and vertigo (may indicate CNS infiltration)
17
Q
How is cholesteatoma treated?
A
Mastoid surgery may be needed to remove disease and make the skull safe from potential secondary complications (hearing preservation is a secondary consideration)
18
Q
What complications can arise from cholesteatoma?
A
Meningitis, cerebral abscess, facial nerve dysfunction
19
Q
What is mastoiditis?
A
Middle ear inflammation leading to air cell destruction in the mastoid bone with/without abscess formation
20
Q
What are the signs of mastoiditis?
A
Fever, mastoid tenderness, protruding auricle and erythema
21
Q
For patients with chronic suppurative otitis media, there are a few surgical options, describe both myringoplasty and mastoidectomy.
A
Myringoplasty - repair of the tympanic membrane alone
Mastoidectomy (for patients with mastoiditis/cholesteatoma) - mastoid surgery and tympanoplasty (surgical repair of tympanic membrane and ossicles)
22
Q
What are the most common risk factors for otitis media?
A
URTI
Bottle-feeding
Passive smoking
Dummy/pacifier use
23
Q
Explain conductive hearing loss
A
Impaired sound transmission via the external canal and middle ear ossicles to the foot of the stapes through a variety of causes
24
Q
List some causes of conductive hearing loss:
A
External canal obstruction
Drum perforation
Ossicular chain dysfunction
Eustacian tube dysfunction
25
Explain sensorineural hearing loss
Resulting from defects central to the oval window inthe cochlear (sensory) and chochlear nerve (neural)
26
List some causes of sensorineural hearing loss:
- Ototoxic drugs (e.g. streptomycin , gentamicin, vancomycine etc.)
- Post-infective (meningitis, measles, flu etc.)
- Cochlear vascular disease
- Multiple scleroisis
27
What is the range of frequency for normal human hearing?
Between 20-20,000 Hz
Sound frequencies between 250-8000 Hz are most important for speech interpretation
28
What is presbyacusis?
Age-related bilateral high-frequency sensorineural hearing loss
29
What is tinnitus?
Perception of sound in the absence of auditory stimuli
30
What are the two types of tinnitus?
Objective (audible to the examiner) - due to AV malformations, high-output cardiac conditions etc.
Subjective (audible only to the patient) - due to conditions causing sensoroneural hearing loss i.e. Menieres disease
31
What is an acoustic neuroma?
Indolent and typically benign subarachnoid tumour that causes problems due to direct pressure
Arising most commonly from the superior vestibular nerve schwann cell layer
32
What symptoms may arise from an acoustic neuroma?
Progressive ipselateral tinnitus +/- sensorineural deafness
Nearby cranial nerves at risk of compression are V, VI, VII with dysfunction resulting in either facial numbness, ocular/facial paralysis respectively
33
What is vertigo?
Vertigo is a symptom - the sensation of the world moving around you/spinning
34
What is benign paroxysmal positional vertigo?
Commonest cause of peripheral vertigo. Episodes of sudden vertigo lasting >30s provoked by head-turning
35
What is the pathophysiology of benign paroxysmal positional vertigo?
Displacement of the otoliths stimulating the semi-circular canals
36
How is benign paroxysmal positional vertigo diagnosed and treated?
Diagnosis by the Dix-Hallpike manoeuvre
Treatment by vestibular habituation exercises and rarely vestibular nerve resection
37
What is Meniere's disease?
Dilatation of the endolymphatic spaces of the membraneous labyrinth causes sudden attacks of vertigo lasting around 2-4hrs
38
How is Meniere's disease treated?
Acute management : Prochlorperazine
Prophylaxis: Betahistine
If severe and intractable - labyrinthectomy (causes total ipselateral deafness)
39
What is acute vestibular failure/vestibular neuronitis?
Sudden attacks of unilateral vertigo and vomiting in a previously well person.
Often following an URTI
40
How is acute vestibular failure/vestibular neuronitis treated?
Vestibular suppressants - cyclizine and/or prochlorperazine
41
What symptoms should be screened for in a history regarding the nose?
```
Nasal obstruction
Nasal discharge
Epistaxis
Facial pain
Nasal deformity
AnosmiaSneezing
```
42
What aspects of past medical history are of importance when discussing the nose?
```
Medical treatment
Nasal surgery
Nasal trauma
Asthma
Aspirin sensitivity
```
43
What occupation history may be of particular importance for rhinology?
Woodworkers
44
What social history may be of particular impotence for rhinology?
Cocaine use (degenerates nasal septum)
45
What instruments are used in a nasal examination?
Otoscope and endoscope for posterior cavity
46
What investigations can be carried out when a nasal pathology is suspected?
Bloods (FBC, ANCA in small blood vessel damage, ESR, ACE, RAST)
CT (gold standard)
Skin tests
Nasal smear
Rhinomanometry (not often used - assesses smell) Flexible/rigid nasendoscopy
47
List some common nasal disorders; Include traumatic, vascular, infectious, malignant and congenital
```
Nasal trauma
Epistaxis (nose bleeds)
Rhinosinusitis (very common)
Nasal polyps/tumour
Choanal atresia - nasal cavity not open in posterior aspect - leads to breathing issues
```
48
What is the treatment for nasal trauma?
Rhinoplasty
49
What is septal haematoma? How can it occur?
Swelling/bruising of the nasal septum. Can occur due to trauma of anterior nasal septum
50
What is the potential complication for septal haematoma?
If left untreated can become septic (therefore requires draining) Can lead to chronic nasal congestion Can cut off blood supply to cartilage -> necrosis -> saddle-nose deformity
51
What are the aetiologies of nasal polyps?
```
Idiopathic
Chronic inflammation
Autonomic dysfunction
Genetic predisposition
Allergic vs non-allergic
```
52
Nasal polyps are associated with which allergic conditions?
>20-50% have asthma
8-26% have aspirin intolerance
50% have alcohol intolerance
53
What conditions may cause secondary polyposis to occur in the nose?
```
Cystic fibrosis (6-48% have polyps)
Allergic fungal sinusitis (85% have polyps)
Churg-Strauss syndrome (autoimmune vasculitis)
```
54
What components are there to a nasal smear test; what can these reveal?
Microbiology - indicates infection
Eosinophils - indicates allergic component
Neutrophils - indicates chronic sinusitis
55
What is the treatment of polyps?
Oral and nasal steroids - high dose prednisolone
Surgical - polypectomy or microdebrider
56
What are the classifications and characteristics of adult sinusitis?
Acute - fast onset, duration of symptoms <12 weeks, completely resolves
Recurrent acute - 1-4 episodes of rhinosinusitis per year, complete recovery between episodes
57
What is the difference between sinusitis and rhinosinusitis?
Sinusitis is the inflammation of the paranasal air sinuses
Rhinosinusitis is the inflammation of the nasal cavity and paranasal air sinuses
58
What are the classifications and characteristics of adult rhinosinusitis?
Chronic - duration >12 weeks, persistent inflammation on imaging after a month of appropriate treatment
Acute exacerbation of chronic - worsening of existing symptoms/appearance of new symptoms
59
What are the two most common microbes responsible for acute rhinosinusitis?
Strep. pneumoniae (31%)
| H. influenzae (21%)
60
New guidelines for the diagnosis of rhinosinusitis are based on:
Nasal blockage/discharge plus the addition of reduced sense of smell/headache
61
What anitmicrobial therapy is available for the treatment of rhinosinusitis?
Beta-lactams - penicillins, cephalosporins
Macrolides - erythromycin, clarithromycin
62
What class of antibiotics shows greater penetration into the sinuses?
Macrolides
63
What treatment options are there for sinusitis?
Nasal decongestants, antibiotics (co-amoxiclav, clarithromycin), steroid nasal spray, steam inhalations
64
What is Potts Puffy Tumour?
A life threatening complication of infectious sinusitis which develops into osteomyelitis of the frontal bone with associated subperiosteal abscess causing swelling and oedema over the forehead and scalp.
65
What is the treatment protocol for PPT?
Emergancy referral for frontal sinus surgery
66
Sinusitis can lead to the development of mucous filled cysts in the ethmoid air sinus, what is this called? What complications can arise?
Ethmoidal mucocele; presses on orbit causing double vision
67
What is the treatment for ethmoidal mucoceles?
Endoscopic Sinus Surgery (ESS)
68
What is the commonest cause of epistaxis?
Idiopathic
69
What are other common causes of epistaxis?
Infectious, traumatic, allergic, hypertension, hereditary haemorrhagic telangiectasia, tumour
70
Outline the management of epistaxis
ABCsCompression of nose - soft tissue for 20-30mins + can use ice packs for vasoconstriction
Vitals management - cannula + fluids
Bloods: Group + save, clotting
Physical exam of Little's area (anterior rhinoscopy or posterior endoscopy)
Cauterisation - silver nitrate
Nasal Packs
Surgery
71
What are nasal packs?
Either anterior or posterior
Used when bleeding has not stopped despite first aid/therapy to stop bleeding
Nose balloon inflated to physically stop bleeding
72
What is the surgical intervention for epistaxis?
Ligation of artery to stop bleeding
Usually sphenopalatine artery (main blood supply of the nose)
73
What is hereditary haemorrhagic telangiectasia?
Autosomal dominant disorder causing abnormal blood vessel development around the face (including the nose)
74
What is the treatment for HHT?
Not standard epistaxis treatment; laser treatment and skin grafts are indicated
75
What causes are there of nasal obstruction?
```
Foreign body
Septal deviation
Septal haematoma
Tumour
Choanal atresia
Nasal congestion - infection
```
76
What three things must you distinguish when presented with a child who has hearing loss?
Congenital vs acquired
Unilateral vs bilateral
Conductive vs sensorineural
77
List the subjective assessments of hearing loss
6-18 months old: distraction test
12 months - 3 years old: visual reinforced audiometry
3-5 years old: play audiometry
5 years+ : pure tone audiometry
78
List the objective assessment of the auditory system
```
Otoacoustic emissions (all newborns have this screening hearing test)
Auditory brainstem response
Tympanometry (middle ear pressure)
```
79
What is the most common cause of hearing loss in children?
Otitis media with effusion
80
What are the risk factors for OM with effusion?
Infections at day care, smoking, cleft palate, Downs syndrome
81
What is the treatment for OM with effusion?
Most resolve spontaneously
Hearing aids/grommets and adenoidectomy
82
What are the signs and symptoms of OM with effusion?
Symptoms - hearing loss, speech delay, behavioural problems, academic decline, imbalance
Signs - dull tympanic membrane, fluid bubbles
83
What is the cause of OM with effusion?
Eustachian tube failure
Muscular immaturity
Adenoidal hypertrophy
Resolving acute OM
84
What is otitis externa?
Discharging ear caused by inflammation around the external auditory canal
85
What is the treatment for otitis externa?
Aural micro-suction (drain and clean)
| Topical antibiotics Water precautions (keep it dry)
86
What are the principle microbes responsible for causing acute OM?
H. influenzae, strep pneumoniae, moraxella catarrhalis
87
How is acute OM treated?
Co-amoxiclav
| Grommets/ Adenoidectomy if recurrent
88
What are the symptoms of acute OM?
Pain, fever, discharge
89
What are the complications of acute OM?
Mastoiditis leading to brain abscess
90
What is chronic OM and how is it treated?
Recurrent/persistent infection of middle ear caused, most commonly, by cholesteatoma.
Treated with mastoidectomy (open antrum and clean out)
91
What are the clinical features of chronic OM?
Chronic discharge and hearing loss despite grommets in place
92
What is the normal development time to aeration of the sinuses in children?
Ethmoids/maxillary: 0-4 months
Sphenoid: 3-7 years
Frontal: 8 years to adolescence
93
When should you be suspicious of a foreign body in the nose?
Unilateral discharge
94
What is choanal atresia?
Congenital bilateral blockage of the nasal passage
95
What is the treatment for non-acute tonsillitis?
Viral - symptomatic treatment Bacterial - 24hrs IV antibiotics if persistent
96
What is the treatment for acute tonsillitis?
Difficulty to breath requires steroids and IV antibiotics
97
What complications can occur from tonsillitis?
Peritonsilar abscess (quincy)
98
What is laryngomalacia?
Congenital condition caused by collapsing of soft immature cartilage of epiglottis so when they breathe it obstructs the airway
99
What is the treatment for larygnomalacia?
Normally maintain saturation and eat well so just let them grow out of it (2/3 years)
100
What is a branchial cyst?
A cyst formed from epithelial tissue of the lateral neck
101
What is cystic hygroma?
Blockage of lymphatic drainage in the left posterior triangle of the neck; leading to cyst formation
102
What is infective pharyngitis?
Pharyngeal inflammation, with sore throat
103
What causes pharyngitis?
Usually viral cause: influenza, parainfluenza, rhinovirus
Bacterial: strep. pneumococcus
104
What are the symptoms of tonsillitis?
Sore throat, difficulty swallowing, pyrexia, malaise, lymphadenopathy, exudative inflammation, tonsil enlargement
105
What organisms cause tonsillitis?
Beta haemolytic streptococcus, pneumococcus, haemophilus influenza
106
What is the management of tonsillitis?
Rest, analgesia, fluids, antibiotics (penicillin/ erythromycin)
Tonsillectomy if recurrent acute/ chronic tonsillitis
107
What is quinsy?
Peritonsillar abscess
Due to the spread of infection from tonsils to lateral tissues
108
What are the features of quinsy?
Drooling, trismus (pain opening mouth), patient appears more unwell
O/E: lateral swelling, displacement of uvula away from midline
109
Treatment for quinsy?
Aspiration/ incision of abscessAntibioticsTonsillectomy if 2+ episodes
110
What are the indications for tonsillectomy?
```
Recurrent quinsy (2+ episodes)
Recurrent tonsillitis (5+ episodes in 1 year)
Malignancy
Obstructive sleep apnoea
```
111
What conditions can an enlarged adenoid cause in children?
```
Nasal obstruction
Glue ear (compromises Eustachian tube function)
Sleep apnoea
```
112
What is obstructive sleep apnoea?
Upper airway collapse, snoring and episodes of breathing cessation
113
What are the risk factors for sleep apnoea?
Obesity, large neck, alcohol, smoking, adenoid hypertrophy
114
How do you investigate sleep apnoea?
Sleep study (polysomnography): monitors blood oxygen saturations, rest rate, heart rate
Epworth questionnaire
Nasendoscopy
115
What are the symptoms of sleep apnoea?
Chronic snoring, daytime sleepiness, lethargy, poor concentration, poor memory, loss of libido
116
Management of sleep apnoea?
1. Lifestyle measures: Weight loss, reduce alcohol, withdraw any sedatives
2. CPAP
3. Nasal splint, mandibular advancement device
4. Surgery (adenectomy in children)
Plus Treat any other nasal conditions reducing airflow
117
What are the complications of sleep apnoea?
Pulmonary HTN, RV strain, heart failure, falling asleep whilst driving, road traffic accidents, negative effect on schooling in children
118
What is stridor?
High pitched Noisy breathing on INSPIRATION due to disrupted airway flow
119
What causes of stridor?
Due to instruction in larynx or trachea, due to:
```
Foreign body
Epiglottitis
Croup
Vocal cord palsy
Trauma
```
120
What is the definition of allergy?
Hypersensitive disorder of the immune system
121
How do hypersensitive allergic reactions occur?
Reaction occur to normally harmless substances known as allergens; these reactions are acquired
122
```
Give an example of an allergic:
Skin reaction
URT reaction
LRT reaction
Systematic reaction
```
Skin - Urticaria/angioedema
Upper respiratory: Rhinitis
Lower respiratory - asthma
Systematic - anaphylaxis
123
What is the pathophysiology of type 1 (hypersensitivity reactions)?
Sensitisation - Plasma cells produce IgE (binds to mast cells)
Re-exposure - mast cells degranulate releasing histamine, leukotrienes, prostaglandins and chemotactic factors
124
What is the physiological effect of mast cell degranulation?
Causes vasodilation, increased vascular permeability, leukocyte infiltration (especially eosinophils)
125
What is allergic rhinitis?
Allergic inflammation of the nasal airways
126
What are the risk factors for allergic rhinitis?
Atopy, FHx, environmental factors
127
What are the immediate and latent effects of allergic rhinitis?
Immediate - sneezing, itching, nasal blockage, rhinorrhoea
Latent - chronic obstruction, hyposmia, hyperactivity
128
What are the two classifications of duration of allergic rhinitis?
Intermittent (symptoms lasting <4 days/week or < 4 consecutive weeks)
Persistent (>4 days/week and >4 consecutive weeks)
129
What are the classifications of severity of allergic rhinitis?
Mild - symptoms present but not troublesome
| Moderate-severe - sleep disturbance, impairment of activities, issues at school/work, troublesome symptoms
130
What principle investigations are appropriate for allergic rhinitis?
Skin test - tests response to known allergens
RAST - tests presence of specific allergen IgE ni serum
131
What other investigations are indicated for allergic rhinitis?
Total serum IgE
Nasal Allergen challenge
Nasal cytology
132
What is the treatment of allergic rhinitis?
| 5
```
Education about allergen avoidance
Topical intranasal steroids/ oral steroids
Antihistamines
Sodium cromoglycate (anti-allergen)
Allergen immunotherapy Anti-IgE
```
133
What are the symptoms of rhinitis?
Nasal congestion, rhinorrhoea, postnasal drip, sneezing, nasal irritation
