ENT Flashcards

Question

Dry tympanic perforation

Answer 1

Causes - barotrauma, direct trauma, sudden loud noise Symptoms - sudden hearing loss, otalgia, tinnitus Diagnosed on otoscopy Treatment - most self-limiting, will heal in 6-8 weeks, avoid submerging ear in water, do not put anything in the ear (incl. ear drops), analgesia to reduce pain

Answer 2

Causes - infection (otitis media - increased pressure in the middle ear cavity) Symptoms - sudden hearing loss, otalgia, tinnitus Otoscopy - diagnostic, will have presence of discharge in the auditory canal (differentiates from dry) Treatment - antibiotics to treat underlying cause (amoxicillin for AOM)

Answer 3

Middle ear and mastoid are the same cavity so otitis media often causes a degree of mastoiditis -> the inflammation within the air cells can progress to necrosis and subperiosteal abscess, causing concern

Answer 4

Tender, boggy, erythematous swelling behind the ear Can push the pinna forward if left untreated Otorrhoea, headaches, hearing loss in affected ear Fever

Answer 5

Bulging, erythematous tympanic membrane May have fluid level behind membrane Discharge may be present

Answer 6

All should be managed in a hospital setting, high-dose broad-spectrum IV antibiotics for at least 1-2 days, followed by oral for 1-2 weeks (typically cephalosporins), analgesia and anti-pyretics May need myringotomy (drainage of middle ear) as therapeutic or for culture If subperiosteal abscess is present or severe symptoms with no improvement on IV anitbiotics - immediate mastoidectomy

Answer 7

A migraine accompanied by vertigo, dizziness or balance problems

Answer 8

Typical migraine symptoms - nausea, vomiting, photophobia, phonophobia (sensitivity to sound), sensitivity to movement, visual disturbances Associated vestibular symptoms - vertigo, dizziness, balance disturbances

Answer 9

Exact causes unknown Certain triggers - stress, tiredness, hormones, eye strain, tension in neck or shoulders, irregular meals or lack of food, dehydration, caffeine, food additives, bright lights and flickering, loud noises, strong smells

Answer 10

At least 5 episodes Present or past history of migraines Vestibular symptoms lasting between 5 mins and 72 hrs Migraine headache or associated symptoms in at least half of the episodes

Answer 11

Prevention - identify and avoid triggers, antidepressants, beta-blockers and antiepileptic medications Acute treatment - analgesia, triptan medications, anti-emetics, avoid opiates

Answer 12

Inflammation of the palatine tonsils as a result of either a bacterial or viral infection

Answer 13

Viruses – adenovirus and EBV Bacterial – strep pyogenes (group A strep)

Answer 14

Smoking – second hand from parents or personal smoking in older children

Answer 15

In general last between 5-7 days, symptoms lasting longer than 7 days may be due to glandular fever Odynophagia Fever Reduced oral intake Halitosis New onset snoring SoB Examination: red, inflamed tonsils, white exudate spots on the tonsils, cervical lymphadenopathy

Answer 16

Differentiate between bacterial and viral tonsillitis 1) Tonsillar exudate 2) Tender anterior cervical lymphadenopathy or lymphadenitis 3) Fever/history of fever 4) Absence of cough Score of 3 or more = highly suggestive of bacterial infection

Answer 17

Fever (during previous 24 hours) Purulence Attend rapidly (within 3 days after onset of symptoms) Severely inflamed tonsils No cough/coryza Score 0-1 = 13-18%, score 2-3 = 34-40%, score 4-5 = 62-65%

Answer 18

Quinsy/peritonsillar abscess Pharyngitis Glandular fever Tonsillar malignancy Epiglottitis

Answer 19

Initial – inpatient admission/not: respiratory compromise, unable to eat or drink, patients not getting better with abx Antibiotics – 7-10 days of penicillin V Analgesia Steroids Operative treatment - In one year: 7 or more episodes - In two years: 5 or more episodes per year - In three years: 3 or more episodes per year

Answer 20

Spread of the infection into the peritonsillar space = peritonsillar abscess Spread into the retropharyngeal/parapharyngeal spaces – requires prolonged IV abx and sometimes surgical drainage Recurrent tonsillitis

Answer 21

Post streptococcal glomerulonephritis – more common in children (6-8), classic triad of hypertension, haematuria and oedema, often proteinuria as well Rheumatic fever – autoimmune response to GAS which typically affects children aged 5-14, develops 2-5 weeks after the initial infection and causes a variety of symptoms: prolonged fever, anaemia, arthritis & pancarditis

Answer 22

Caused by EBV Presents as a sore throat with associated fever and lymphadenopathy Most common – 1-6 and 18-22

Answer 23

Exchange of saliva – incubation period is around 6 weeks Blood transfusion Stem cell and solid organ transplant

Answer 24

Sore throat (worst they’ve ever had), snoring & sleep apnoea, swollen neck Systemic – feverish, headaches, N&V, tired all the time, generalised aches and pains in the muscles and joints Examination – enlarged inflamed tonsils (often meeting in the middle), significant cervical lymphadenopathy, abdominal tenderness & splenomegaly, hepatomegaly, palatal petechiae

Answer 25

Tonsilitis – generally shorter-lived and tends to have fewer of the systemic symptoms Quinsy – tends to be unilateral with swelling predominantly superior to the tonsil

Answer 26

Routine bloods – FBC (raised lymphocytes), LFTs – elevation of liver enzymes, should resolve in week 5 Monospot test in immunocompetent adults More specific ELISA based immunoassays and anti-viral capsid antigen IgG

Answer 27

Symptomatic relief with paracetamol or ibuprofen Condition is usually self limiting Encouraging the person to return to normal activities as soon as possible, exclusion from work or school is not required Avoid heavy lifting and contact sports for the first month of the illness – reduce the risk of splenic rupture Advising on ways to limit the spread of the disease – avoid kissing, not sharing eating utensils

Answer 28

Post-viral fatigue Upper airways obstruction Splenic rupture Neutropenia Immunocompromised people – may result in malignant disease eg. hodgkin’s lymphoma & nasopharyngeal carcinoma

Answer 29

Acute, unilateral facial nerve weakness or paralysis of rapid onset (< 72 hours) and unknown cause

Answer 30

Rapid onset Facial muscle weakness involving upper & lower parts of the face -> reduction in movement on the affected side, often with drooping of the eyebrow & corner of the month and loss of nasolabial fold Ear and postauricular region pain on affected side Difficulty chewing, dry mouth & changes in taste Incomplete eye closure, dry eye, eye pain or excessive tearing

Answer 31

Caused by VZV Presents as a unilateral lower motor neurone facial nerve palsy Painful and tender vesicular rash in the ear canal, pinna and around the ear on affected side Treatment should be initiated within 72 hours: prednisolone & aciclovir, lubricating eye drops

Answer 32

Most people make a full recovery within 3-4 months Important to keep eye lubricated – lubricating eye drops For people presenting within 72 hours of the onset of symptoms = prednisolone Antiviral treatments alone are not recommended

Answer 33

Common respiratory disease that typically occurs in children aged between 6 months and 3 years Most commonly caused by a virus (parainfluenza virus types 1 or 3)

Answer 34

A child with a sudden onset of a seal-like barking cough Hoarse voice Symptoms typically worse at night & increase with agitation Non-specific URT symptoms, progressive upper airway obstruction can result in the development of stridor and respiratory distress

Answer 35

Bacterial tracheitis – following a viral-like respiratory illness from which the person appears to be recovering then becomes acutely worse Epiglottitis – preferred posture is sitting upright with head extended, rarely seen since widespread immunisation against haemophilus influenzae B Foreign body in upper airway Peritonsillar abscess

Answer 36

Single dose of oral dexamethasone to be taken immediately Advise parents/carers: - Symptoms usually resolve within 48 hours - Use paracetamol/ibuprofen for fever/pain - Fluids regularly - Take child to hospital if respiratory distress

Answer 37

Inflammation of the paranasal sinuses in the face Usually triggered by a viral upper respiratory tract infection & defined by symptoms that last less that 12 weeks

Answer 38

Adults – presence of nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip) with facial pain/pressure and/or reduction of sense of smell - Other features: altered speech, tenderness, swelling or redness over the cheekbone, cough Children – presence of nasal blockage or discoloured nasal discharge with facial pain/pressure and/or cough O/E – inspect and palpate maxillofacial area to elicit swelling and tenderness, performing anterior rhinoscopy

Answer 39

Symptoms > 10 days Discoloured/purulent nasal discharge Severe local pain Fever > 38 Marked deterioration after an initial milder form of the illness Elevated ESR/CRP

Answer 40

Symptoms < 10 days – self-care measures Symptoms > 10 days with no improvement – consider prescribing a high-dose nasal corticosteroid for 14 days, consider a back-up abx prescription (not necessary)

Answer 41

Symptoms > 12 weeks with objective evidence of sinonasal inflammation on examination

Answer 42

Lasting longer than 12 weeks Adults – presence of nasal blockage/nasal discharge with facial pain/pressure and/or reduction of the sense of smell Children – presence of nasal blockage/nasal discharge with facial pain/pressure and/or cough O/E – evidence of sinonasal inflammation: inspecting and palpating the maxillofacial area, performing anterior rhinoscopy (nasal inflammation, mucosal oedema, mucopurulent nasal discharge)

Answer 43

Allergic rhinitis Asthma Immunosuppression

Answer 44

Inform that chronic sinusitis may last several months Advise the person – avoid allergic triggers, stop smoking, good dental hygiene, avoid underwater diving Consider nasal irrigation with saline solution Consider a course of intranasal corticosteroids for up to 3 months, especially if suspicion of an allergic cause

Answer 45

Normal result – patient hears the sound equally in both ears Sensorineural hearing loss – sound will be louder in the normal ear Conductive hearing loss – sound will be louder in the affected ear

Answer 46

Normal – AC > BC Abnormal – BC > AC - Suggests a conductive cause for the hearing loss

Answer 47

Age-related presbycusis Meniere’s disease Labyrinthitis Acoustic neuroma Neurological conditions – stroke, MS, brain tumours Medications – loop diuretics, aminoglycoside abx, chemotherapy drugs (cisplatin)

Answer 48

Ear wax Infection – otitis media or otitis externa Fluid in the middle ear Eustachian tube dysfunction Perforated tympanic membrane Otosclerosis Cholesteatoma

Answer 49

Age-related hearing loss Type of sensorineural hearing loss that occurs as people get older Tends to affect high-pitched sounds first and more notably than lower-pitched sounds Gradual and symmetrical

Answer 50

Age Male gender Family history Loud noise exposure (hearing protection should be worn in occupations such as woodworking/construction) Diabetes Hypertension Ototoxic medications Smoking

Answer 51

Gradual and insidious hearing loss Female voices more difficult to understand May be associated tinnitus Patients with hearing loss are more likely to develop dementia & treating the hearing loss may reduce the risk

Answer 52

Audiometry - Sensorineural hearing loss pattern - Normal/near-normal hearing at lower frequencies - Worsening hearing loss at higher frequencies

Answer 53

Effects cannot be reversed Optimising the environment eg. reducing the ambient noise during conversations Hearing aids Cochlear implants (hearing aids are not sufficient)

Answer 54

Inflammation of the skin in the external ear Acute (< 6 weeks) and chronic (> 3 months) Exposure to water whilst swimming can lead to inflammation in the ear canal, trauma another predisposing factor, removal of ear wax can increase the chances of infection

Answer 55

Bacterial infection Fungal infection – think in patients that have had multiple courses of topical abx Eczema Seborrheic dermatitis Contact dermatitis

Answer 56

Pseudomonas aeruginosa – gram-negative aerobic rod-shaped bacteria Staph aureus

Answer 57

Ear pain Discharge Itchiness Conductive hearing loss Examination: erythema and swelling in the canal, tenderness, pus/discharge in the ear canal, lymphadenopathy

Answer 58

Can be made clinically with an examination of the ear canal Ear swab can be used to identify the causative organisms but not usually required

Answer 59

Mild – acetic acid 2%, can also be used prophylactically before and after swimming in patients that are prone to otitis externa Moderate – topical abx and steroid (eg. neomycin, dexamethasone and acetic acid = otomize) - Aminoglycosides are potentially ototoxic, therefore essential to exclude a perforated tympanic membrane Severe – may need oral antibiotics (flucloxacillin or clarithromycin) Ear wick may be used if canal is very swollen & treatment with ear drops/sprays will be difficult (left there for a period of time and then removed when swelling settles) Fungal infections – can be treated with clotrimazole

Answer 60

Severe and potentially life-threatening form of otitis externa Infection spreads to the bones surrounding the ear canal and skull -> osteomyelitis of the temporal bone of the skull Underlying risk factors – diabetes, immunosuppressant medications, HIV Symptoms – persistent headache, severe pain and fever Granulation tissue at the junction between the bone and cartilage in the ear canal is a key finding Emergency management – admission under ENT, IV abx, imaging to assess extent of infection Complications – facial nerve damage and palsy, other CN involvement, meningitis, intracranial thrombosis, death

Answer 61

Long-term inner ear disorder that causes recurrent attacks of vertigo, symptoms of hearing loss, tinnitus & feeling of fullness

Answer 62

Associated with the excessive build-up of endolymph in the labyrinth of the inner ear, causing an increased pressure and disrupting the sensory signals Increased pressure of the endolymph = endolymphatic hydrops

Answer 63

40-50 years old, presenting with unilateral episodes of vertigo, hearing loss and tinnitus Vertigo – comes in episodes, can come in clusters over several weeks followed by prolonged periods without vertigo symptoms, not triggered by movement or posture Hearing loss – fluctuates (associated with vertigo attacks) then gradually becomes more permanent, sensorineural hearing loss, generally unilateral & affects low frequencies first Tinnitus – occurs with episodes of vertigo before eventually becoming more permanent, usually unilateral Other – fullness in the ear, unexplained falls without loss of consciousness, imbalance Spontaneous nystagmus can be seen during an acute attack (usually in one direction)

Answer 64

Clinical, based on signs and symptoms Made by an ENT specialist Need an audiology assessment to evaluate hearing loss

Answer 65

Acute attacks – prochlorperazine, antihistamines (cyclizine, cinnarizine and promethazine) Prophylaxis – betahistine

Answer 66

Common cause of recurrent episodes of vertigo triggered by head movement Peripheral cause of vertigo (problems is located in the inner ear)

Answer 67

Variety of head movements can trigger attacks of vertigo Symptoms settles after around 20-60 seconds and patients are asymptomatic between attacks Often episodes occur over several weeks and then resolve but can reoccur weeks or months later Do NOT cause hearing loss/tinnitus

Answer 68

Crystals of calcium carbonate that become displaced into the semicircular canals Occurs most often in the posterior semi-circular canal Crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system Head movement creats the flow of endolymph in the canals, triggering episodes of vertigo

Answer 69

Can be used to diagnose BPPV 1) Patient sits upright on a flat examination couch with their head turned 45 degrees to one side 2) Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees 3) Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch 4) Watch the eyes closely for 30-60 seconds, looking for nystagmus, repeat the test with the head turned 45 degrees in the other direction Will trigger rotational nystagmus (towards the affected ear) and symptoms of vertigo

Answer 70

Can be used to treat BPPV, idea is to move the crystals in the semi circular canal into a position that does not disrupt endolymph flow 1) Have patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees 2) Rotate the patient’s head 90 degrees past the central position 3) Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction 4) Have the patient sit up sideways with the legs off the side of the couch 5) Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest 6) At each stage, support the patient’s head in place for 30 seconds & wait for any nystagmus/dizziness to settle

Answer 71

Can be performed by the patient at home to improve the symptoms of BPPV Involve sitting on the end of a bed and lying sideways, from one side to the other, whilst rotating the head slightly to face the ceiling Exercises are repeated several times a day until symptoms improve

Answer 72

Inflammation of the vestibular nerve Usually attributed to a viral infection

Answer 73

Inflammation of the vestibular nerve, viral infection may trigger this Distorts the signals travelling from the vestibular system to the brain, confusing the signal required to sense movements of the head Results in episodes of vertigo where the brain thinks the head is moving when it is not

Answer 74

Acute onset of vertigo May be history of a recent viral URTI Most severe for the first few days, initially vertigo constant, after which it is triggered or worsened by head movement; associated with: - N&V - Balance problems NO loss of hearing

Answer 75

Can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system 1) Patient sitting upright and fixing gaze on examiner’s nose 2) Holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose 3) Head is slowly moved back to the centre before repeating in the opposite direction Eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner Will be normal if patient has no current symptoms/central cause of vertigo

Answer 76

Prochlorperazine Antihistamines (eg. cyclizine, cinnarizine and promethazine) Symptomatic treatment can be used for up to 3 days, more extended use may slow down recovery Referral if symptoms do not improve after 1 week/resolve after 6 weeks -> may require further investigation or vestibular rehabilitation therapy

Answer 77

Inflammation of the bony labyrinth of the inner ear, including the semi circular canals, vestibule & cochlea Usually attributed to a viral URTI Rarely – can be caused by a bacterial infection, secondary to otitis media/meningitis

Answer 78

Acute onset vertigo Hearing loss Tinnitus May have symptoms of causative virus – cough, sore throat and blocked nose

Answer 79

Clinical diagnosis Head impulse test

Answer 80

Supportive care and short-term use of medication to suppress the symptoms Prochlorperazine Antihistamines Abx for bacterial labyrinthitis Rarely have lasting symptoms (but can have permanent hearing loss -> more common after bacterial labyrinthitis, particularly associated with meningitis)

Answer 81

Abnormal collection of squamous epithelial cells in the middle ear Non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear Can predispose to significant infections

Answer 82

Negative pressure in the middle ear (caused by eustachian tube dysfunction) causes a pocket of the tympanic membrane to retract into the middle ear Small area of the tympanic membrane gets sucked inwards Squamous epithelial cells of this pocked continue to proliferate and grow into the surrounding space, bones and tissues Can damage the ossicles resulting in permanent hearing loss

Answer 83

Foul discharge from the ear Unilateral conductive hearing loss Further symptoms – infection, pain, vertigo and facial nerve palsy Otoscopy – abnormal bild-up of whitish debris or crust in the upper tympanic membrane

Answer 84

CT head can be used to confirm the diagnosis and plan for surgery Surgical removal of the cholesteatoma

Answer 85

Growths of the mucosa that occur in the nasal cavity or sinuses Often associated with inflammation, particularly with chronic rhinitis Grow slowly and gradually obstruct the nasal passage Unilateral polyps – red flag and should raise suspicions of tumours

Answer 86

Chronic rhinitis/sinusitis Asthma Samter’s triad – nasal polyps, asthma & aspirin intolerance/allergy CF Eosinophilic granulomatosis with polyangiitis (churg-strauss syndrome)

Answer 87

Unilateral polyps should be referred for specialist assessment to exclude malignancy Medical management – intranasal topical steroid drops or spray Surgical treatment where medical management fails - Intranasal polypectomy – polyps are visible close to the nostrils - Endoscopic nasal polypectomy – where polyps are further in the nose or the sinuses