ENT

Question 1

How do auricular haematomas form and how do you manage them?

Answer 1

They occur after direct trauma to the ear and is due to a build up of blood between the cartilage and perichondrium. This can restrict blood supply and lead to necrosis of the connective tissue.

Management: same day ENT referral ± incision and drainage (preferred over fine needle aspiration)

Question 2

What are risk factors for tonsilar squamous cell carcinoma?

Answer 2

Smoking
High levels of alcohol intake
Poor oral hygiene

*Also associated to HPV (especially HPV-16)

Question 3

What is the most common cause of sudden-onset sensorineural hearing loss

Answer 3

Idiopathic

However you need to do an urgent referral to ENT where they will perform an MRI to rule out vestibular schwannoma. High-dose oral corticosteroids are also given.

Question 4

What is Ménière’s disease?

Answer 4

It is a disorder of the inner ear whereby there is excessive pressure and progressive dilation of the endolymphatic system.

Question 5

What are the features of Ménière’s disease?

Answer 5

• Recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
• A sensation of aural fullness or pressure is now recognised as being common
• Other features include nystagmus and a positive Romberg test
• Episodes last minutes to hours
• Typically symptoms are unilateral but bilateral symptoms may develop after a number of years

Question 6

What is the management of perforated tympanic membrane?

Answer 6

No specific treatment as it will heal after 6-8 weeks. Advise to keep ear dry and avoid getting water in the ear.

Myringoplasty can be performed if the tympanic membrane does not heal itself.

Question 7

Do you give antibiotics in acute sinusitis?

Answer 7

Not unless it is complicated where you would use phenoxymethylpenicillin first. If they are more systemically unwell, then consider Co-amoxiclav.

Question 8

What symptoms should warrant an urgent ENT referral in patients 45 and over?

Answer 8

Persistent unexplained hoarseness or an unexplained lump in the neck.

Question 9

What are the features of osteosclerosis?

Answer 9

Onset at 20-40 years
Progressive conductive deafness
Tinnitus
Normal tympanic membrane (but 10% will have a flamingo tinge caused by hyperaemia)
Positive family history

*caused by replacement of normal bone by vascular spongy bone

Question 10

What are red flag symptoms of nasal polyps?

Answer 10

Unilateral polyps
Bleeding polyps

Question 11

What is prebycusis?

Answer 11

Presbycusis describes age-related sensorineural hearing loss. Patients may describe difficulty following conversations

Audiometry shows bilateral high-frequency hearing loss

Question 12

What is glue ear?

Answer 12

aka otitis media with effusion

• Peaks at 2 years of age
• Hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood)
• Secondary problems such as speech and language delay, behavioural or balance problems may also be seen

Question 13

What is a nasal septal haematoma?

Answer 13

Complication of nasal trauma - development of a haematoma between the septal cartilage and the overlying perichondrium

Management:
* Surgical drainage
* Intravenous antibiotics

Question 14

What is Ludwig’s angina?

Answer 14

Cellulitis that occurs on the floor on the mouth of the patient. This is deadly as it can spread in fascial spaces on the head and neck. It can eventually cause enough inflammation to push the floor of the mouth upwards and block air entry

Question 15

What is vertebrobasilar ischaemia?

Answer 15

It is commonly seen in elderly patients with dizziness on extension of the neck.

Risk factors include cardiovascular disease

Question 16

What drugs can cause tinnitus?

Answer 16

Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine

Question 17

How many episodes of tonsillitis do you need to have to be considered for a tonsillectomy?

Answer 17

Seven in 1 year

Or five per year in 2 years

Or 3 per year in 3 years

Question 18

What ECG changes is associated with hypocalcaemia (i.e. post-thyroidectomy)?

Answer 18

Isolated QTC elongation

Question 19

What is the management of mastoiditis and what are its complications?

Answer 19

Management: IV ABx

Complications: facial nerve palsy, hearing loss, meningitis

Question 20

What are some causes of bilateral nasal polyps?

Answer 20

Chronic rhinosinusitis
Aspirin sensitivity
Asthma
Eosinophilic granulomatosis with polyangiitis (Wegener’s)

Question 21

What is the feverPAIN scoring system?

Answer 21

1 point for each (maximum score of 5):
* Fever over 38°C.
* Purulence (pharyngeal/tonsillar exudate).
* Attend rapidly (3 days or less)
* Severely Inflamed tonsils
* No cough or coryza

*the higher the number, the greater the chance of isolating Streptococci

Question 22

What are common complications of thyroid surgery?

Answer 22

• Anatomical such as recurrent laryngeal nerve damage.
• Bleeding: haematomas may rapidly lead to respiratory compromise owing to laryngeal oedema (due to confined space).
• Damage to the parathyroid glands resulting in hypocalcaemia.

Question 23

When should you do 2WW referrals to oral surgery?

Answer 23

• Unexplained oral ulceration or mass persisting for greater than 3 weeks
• Unexplained red, or red and white patches that are painful, swollen or bleeding
• Unexplained one-sided pain in the head and neck area for greater than 4 weeks, which is associated with ear ache, but does not result in any abnormal findings on otoscopy
• Unexplained recent neck lump, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
• Unexplained persistent sore or painful throat
• Signs and symptoms in the oral cavity persisting for more than 6 weeks, that cannot be definitively diagnosed as a benign lesion

Question 24

What are the features of vestibular neuronitis?

Answer 24

• Recurrent vertigo attacks lasting hours or days
• Nausea and vomiting may be present
• Horizontal nystagmus is usually present
• No hearing loss or tinnitus

Question 25

What is the management of vestibular neuronitis?

Answer 25

• Vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms
• Buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases

Question 26

What are causes of non-allergic chronic rhinitis?

Answer 26

Weather changes
Tobacco smoke
Automotive emission fumes
Irritants such as chemicals with strong odors (e.g., perfumes, chlorine)

Question 27

What cancer is HPV associated with?

Answer 27

Oropharyngeal cancer

Question 28

What cancer is EBV associated with?

Answer 28

Nasopharyngeal cancer

Question 29

What are features of quinsy?

Answer 29

• Unilateral sore throat
• Hot potato voice
• Severe dysphagia/odynophagia
• Fevers

Question 30

What is the management of quinsy?

Answer 30

• IV fluids
• Analgesia
• IV abx - amoxicillin with clindamycin or metronidazole
• Steroids

Question 31

Risk factors for head and neck cancers

Answer 31

Men
Alcohol
Smoking
Air pollution
Radiation exposure
Betel nut

Question 32

What are features of otosclerosis?

Answer 32

Autosomal dominant condition causing replacement of normal bone by vascular spongy bone –> progressive conductive deafness due to fixation of the stapes at the oval window

Features:
* Onset is usually at 20-40 years
* Tinnitus
* Tympanic membrane - 10% of patients may have a ‘flamingo tinge’, caused by hyperaemia
* Positive family history

Question 33

What is the management of otosclerosis

Answer 33

Hearing aids
Stapedectomy

Question 34

What is tympanosclerosis?

Answer 34

Calcification of tissue in the eardrum and middle ear

This causes conductive hearing loss

Question 35

Name causes of conductive hearing loss

Answer 35

Ear wax
Otitis externa and media
Otosclerosis
Tympanosclerosis
Perforated ear drum
Foreign bodies

Question 36

Name causes of sensorineural hearing loss

Answer 36

Presbycusis (aging)
Noise-induced hearing loss
Drugs i.e. gentamicin
Acoustic neuromas
Viral infections
Head trauma

Question 37

What is malignant otitis externa?

Answer 37

• Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics)
• Most commonly caused by Pseudomonas aeruginosa
• Can infect soft tissues and cause osteomylitits

Patients will require urgent referral to ENT due to non-resolving otitis externa + IV abx for pseudomonas cover

Question 38

What are features of nasopharyngeal carcinomas?

Answer 38

• Squamous cell carcinoma of the nasopharynx
• Rare in most parts of the world, apart from individuals from Southern China
• Associated with Epstein Barr virus infection

Signs/symptoms:
* Cervical lymphadenopathy
* Otalgia
* Unilateral serous otitis media
* Nasal obstruction, discharge and/or epistaxis

Question 39

What is the first-line treatment of nasopharyngeal carcinomas?

Answer 39

Radiotherapy

Question 40

What is the management of recurrent or chronic sinusitis?

Answer 40

• Avoid allergen
• Intranasal corticosteroids
• Nasal irrigation with saline solution

Question 41

How do you manage haemorrhage post-tonsillectomy?

Answer 41

All haemorrhages need assessment by ENT

Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours post-surgery: requires immediate return to theatre

Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection: requires admission and treatment with abx ± surgery