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ENT Flashcards

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1
Q

what can the causes of vertigo be differentiated into?

A

central
peripheral

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2
Q

what are the main causes of peripheral vertigo?

A

BPPV
Vestibular neuritis
Labyrinthitis
Meniere’s disease
Acoustic neuroma

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3
Q

what are the main causes of central vertigo?

A

stroke/TIA (usually cerebellar)
Vestibular migraines
MS

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4
Q

what is BPPV?

A

condition caused by the displacement of calcium carbonate crystals within the semi-lunar canals.

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5
Q

what are the classical features of BPPV?

A

short episodes of vertigo
caused by movement such as turning head
sudden onset symptoms
not associated with tinnitus/hearing loss
causes nystagmus
vertigo resolves spontaneously

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6
Q

how can you test for BPPV?

A

with the dix-hallpike manouver

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7
Q

how is the dix hallpike manoeuvre performed?

A

place patient on the bed, turn their head to 45 degrees and then ask them to lay back with head still in that position. Observe for any nystagmus - if present - positive.

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8
Q

what is the first line management of BPPV?

A

Provide them with the Brandt-Daroff exercises - advised to perform these for 4 weeks.
Consider Epley manoeuvre if able to perform.
If no improvement after 4 weeks and Epley manoeuvre, then referral to ENT for vestibular rehab.

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9
Q

what is vestibular neuritis?

A

inflammation of the vestibular nerve supplying the semi-lunar canals and utricle. This can often follow a recent viral illness, but not always.

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10
Q

what are the typical symptoms of vestibular neuronitis?

A

symptoms are usually of sudden onset
prolonged vertigo for several days
worse with movement
hearing and tinnitus are not present

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11
Q

what are the typical symptoms of labrynthitis?

A

similar to vestibular neuronitis - start with prolonged vertigo, nausea, nystagmus for several days, then improves
can have hearing loss and tinnitus

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12
Q

what is labrynthitis?

A

inflammation of the labyrinth

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13
Q

management of labrynthitis or vestibular neuronitis?

A

Reassurance that symptoms would settle over the next few weeks without treatment
Advise to avoid alcohol, tiredness or intercurrent illness
short term symptomatic relief can be offered with oral prochlorperazine, cinnarizine, cyclizine or promethazine - for up to 3 days
Advise patients not to drive during acute phase

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14
Q

what to do if patient with vestibular neuronitis or labrynthitis do not improve after 1 week?

A

urgent referral to ENT for consideration of vestibular rehab

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15
Q

What are the red flags for hearing loss?

A

sudden onset unilateral or bilateral hearing loss (developing within 72 hours), which cannot be explained by external or middle ear causes
unilateral hearing loss with focal neurology
unilateral hearing loss with facial/head/beck injury
rapidly progressing hearin gloss

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16
Q

what is eustachian tube dysfunction?

A

Build up of fluid in the middle ear after - can cause conductive hearing loss

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17
Q

management of eustachian tube dysfunction?

A

option 1: do nothing - often resolves on its own
option 2: deongestants - max 5-7 days (any longer can cause rebound congestion)
option 3: antihistamines
option 4: steroid nasal spray - takes up to 1 month to work

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18
Q

management of otitis media - in otherwise well child/adult?

A

option 1: no antibioticsn and safety netting advice to return if symptoms worsen rapidly or significantly - return if not better after 3 days.

option 2: back up antibiotics to use if not better after 3 days PLUS safety netting to seek medical attention

abc: amoxicillin for 5-7 days
or clari/erythromycin if allergic

safety netting

lower threshold for abx in patients who are <2 years or have bilateral symptoms

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19
Q

what signs may cause admission in otitis media?

A

severe systemic infection
red flags such as mastoiditis or facial nerve paralysis
< 3 months with fever > 38 degrees

consider admission if <3 months but temp normal, or 3-6 months with temp > 39 degrees

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20
Q

what is the treatment plan for otitis externa?

A

1: advice - keep ears clean and dry, use analgesia, if over 12 years can buy acetic acid 2% ear drops for max 7 days

2: consider topical antibiotics +/- topical steroid for 7-14 days: Otomize (dexamethasone and neomycin) - avoid in perforation due to risk of ototoxicity
If concern of perforation - ciprfloxacin +/- dexamethasone

safety net - improvement in 48-72 hours, if no improvement or resolution within 2 weeks - needs review

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21
Q

what are the red flags of vertigo?

A

isolated persitent vertigo of hyperacute onset (came on over a few seconds)
normal head impulse test
new onset headache
new onset unilateral deafness
any cranial nerve/neurology on examination

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22
Q

how to examine for cerebellar signs?

A

Dysdiadochokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/heel-shin test

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23
Q

management of chronic rhinitis?

A

consider referral for specialist allergy testing - house dust mite, pollen, animal dander

Advise patient to consider saline nasal irrigation e.g. sterimar - very helpful!
prescribe nasal spray: start with steroid nasal spray e.g. mometasone - takes 2-4 weeks to gain maximal benefit

If not helping can consider steroid/atnihistamine combination spray

Advice against decongestant

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24
Q

management of recurrent epistaxis?

A

naspetin cream - apply QDS for 10 days - contraindicated if peanut allergy

if not settling or any concerns of red flag features - refer to ENT

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25
examination of suspected sinusitis?
check of facial tenderness cest for postnasal pharyngeal secretions look in ears for middle ear effusion look in nostrils vital signs
26
management of acute sinusitis?
if symptoms for < 10 days: self management with analgesia, nasal saline or deoncgestants if symptoms > 10 days or worsening of 5 days: - consider nasal spray e.g. mometaonse - back up abx e.g. phenoxymethypenicillin
27
what is the pathophysiology of epistaxis?
bleeding from anterior or posterior part of the nasal tract anterior - more common, bleeding from Kiesselbachs plexus posterior - woodruff plexus, bleeding from deeper structures, rare
28
what are the causes of epistaxis?
nasal picking/blowing nose trauma bleeding disorders cocaine use angiofibroma - benign tumour in young males FB imsertion hereditary haemorrhagic telangiectasia
29
management of epistaxis?
initial management - ask patient to lean forwards, pinch soft part of nose for 20 mins if not stopping and can see source of bleeding = cauterise with silver nitrate stick if not stopping but unable to see source of bleeding = nasal packing if still ongoing = surgery
30
who should be admitted due to epistaxis?
if not stopping with emergency measures if HTN +++ if comorbidity if Ca suspected < 2 years - more likely to be due to bleeding disorder if needed packing
31
what does persistent blood stained nasal discharge indicate?
tumour until proven otherwise
32
what are some causes of persistent nasal discharge?
clear discharge - physiological / allergy / viral clear after trauma - CSF leak green - bacterial yellow - viral blood stained - tumour
33
what can cause a CSF leak?
trauma - due to perforation of the ethmoid labyrinth
34
how can you differentiate CSF leak from other types of nasal discharge?
CSF tests positive for glucose on dip
35
management of CSF leak post trauma?
needs urgent ref to AE usually does spontaneously heal on its own, but needs monitoring in case not healing and needs dural closure
36
what are some causes of nasal obstruction?
mucosal swelling - rhinitis/nasal polyps septal deviation - trauma or congenital other - tumour, enlarged edenoids, FB
37
management of septal deviation?
treated underlying rhinitis with steroid nasal spray initially as that may be sufficient to manage symptoms if ongoing - routine ref to ENT
38
how does septal haematoma present?
presents as acute bilateral soft bulging of the septum after trauma
39
management of septal haematoma
urgent ref to ENT - needs evacuation to prevent cartilage destruction
40
what is the management of allergic rhinitis
first line- oral antihistamine or nasal antihistamine second line - add nasal steroid spray third line - add intranasal anticholinergic fourth line - consider LTRA if asthma features, short course of decongestant nasal spray or oral steroids if still poorly controlled - ref to ENT
41
what is an example of antihistamine nasal spray?
azelastine hydrochloride
42
management of suspected nasal polyps?
if air entry good - then trial of steroid nasal spray , if no improvement refer to ENT if air entry poor - ENT ref , can try fluticasone fumarate drops for 6 weeks then review
43
how quickly should reduction of nasal fracture be done after an injury?
should be done < 3 weeks afterwards
44
what are the names of the different sinuses of the face?
frontal maxillary ethmoid sphenoid
45
what are the symptoms of acute sinusitis?
facial pain tenderness over sinuses purulent discharge can sometimes be hard to distinguish from toothache
46
what is the usual length of acute sinusitis without treatment/
usually 10 days improves without intervention usually whether caused by bacteria of virus
47
what is the initial management of acute sinusitis ?
advise re self-management strategies - trial of nasal saline or nasal decongestants - can consider trial of steroid nasal spray (off label use) - could cause systemic effects if patient already taking steroids
48
who should be offered abx for acute sinusitis?
if has had the symptoms for > 10 days with no improvement or symptoms increase after 5 days
49
if antibiotics are indicated, then what abx should be prescribed for acute sinusitis?
phenoxymethylpenicillin 500mg QDS for 5 days if pen allergy - doxycyline 200mg first day then 100mg for 4 further days or clarithromycin 500mg BD for 5 days
50
who abx should be prescribed in pregnancy for acute sinusitis?
erythromycin 500mg QDS for 5 days
51
what should be prescribed as second line abx for acute sinusitis if no improvement with first line after 2-3 days?
co-amox 500/125mg TDS for 5 days
52
what are some potential complications of acute sinusitis?
orbital cellulitis intracranial abscess osteomyelitis / potts puffy tumour
53
management of chronic sinusitis?
trial of nasal steorid spray if no improvement in 6-12 weeks - ref
54
who should be referred for chronic sinusitis?
if symptoms affecting QoL immunocompromised anatomic deficit suspected allergy cacosomia - needs immediate ref
55
what are the red flags for oral cancer?
ulcer/lesions > 3 weeks in the mouth unexplained lump in neck / mouth red/white patches that are bleeding/blistering
56
differentials for mouth ulcers?
aphthous ulcers trauma crohns disease coeliac disease drugs - steroids/gold reiters disease behcets disease HSV erythma multiforme self inflicted - e.g. burns
57
what is leukoplakia?
thin grey/white patch on the mouth and inside of the cheek, tongue or gum
58
what are the causes of leukoplakia?
usually caused due to smoking, ill fitting dentures or chewing of gums can be an early sign of Ca
59
management of leukoplakia?
ref to exclude Ca in all cases
60
what is geographic tongue?
irregular smooth redder patches on the tongue that change position over time on the dorsum of the tongue
61
what causes geographic tongue?
due to papillae loss - usually asymptomatic
62
management of painful aphthous ulcers?
investigate and treat underlying cause symptmoatic management with hydrocortisone lozenges QDS
63
what is the most common type of oral cancer?
squamous cell cancer
64
what are the risk factors for oral cancer?
smoking alcohol intake ++
65
what is the prognosis of oral cancer
poor- thought to be due to poor public awareness so presents late rather than aggressive nature
66
what is lichen planus?
chronic inflammatory condition that affects mucous membranes - genital area and can affect the mouth
67
management of suspected oral lichen planus?
refer to derm
68
what is gingivitis?
inflammation of the gum margin - painless, red swelling
69
management of gingivitis?
needs ref to dentist antibiotics not routinely needed
70
what is TMJ disorder?
common disorder - affecting 70% of the population
71
what are the symptoms of TMJ disorder?
pain at the TMJ , which may radiate to head/neck/ear restricted jaw motion patient may notice clicks and other noises
72
what are the management options for TMJ?
soft foods simple analgesia/NSAIDs physiotherapy short course of benozodiazepines can be helpful review by dentist night gaurd
73
what is acute otitis media?
infection of middle ear, can be associated with TM perforation / discharge
74
what are the symptoms of otitis media?
pain ++, fever, viral / coryzal symptoms
75
at what age is OM most common?
0- 4 years
76
who should be admitted for OM?
consider if < 3 months if 3-6 months with T 39 or more
77
how long is the usual course of OM?
3-7 days
78
first line treatment for uncomplicated OM?
if uncomplicated - advise no abx needed, expected to improve on its own
79
if abx indicated, which should be given for OM?
amoxicillin for 5-7 days or clarithromycin/erythromycin if allergic or pregnant
80
what is glue ear?
otitis media with effusion
81
what is otitis media with effusion?
collection of fluid within the middle ear space without signs of acute inflammation
82
what are the symptoms of glue ear?
persistent conductive hearing loss speech and language development issues communication skills can cause chronic damage to the TM
83
what is the management of glue ear?
if no hearing loss and otherwise well - reassure that will get better with time if hearing loss suspected- refer to ENT - can consider grommets if needed
84
what is otitis externa?
diffuse inflammation of the external skin of the eustachian tube
85
what causes otitis externa?
infection - baterial (staph aureus/pseudomonas) fungal seborrhoeic dermatitis contact dermatitis recent swimming
86
symptoms of otitis externa?
ear pain - itching, discharge
87
what can be seen on otoscopy of otitis externa?
red, swollen, eczematous canal
88
management of otitis externa?
consider topical abx prescription - such as otomize for 7-14 days if immunocompromised or has spread to adjacent tissues - consider adding oral abx for cellulitis ie. flucloaxillin
89
what is the definition of chronic otitis externa?
ongoing for > 3 months
90
management of chronic otitis externa?
trial of antifungal clotriamzole 1% for 14 days after infection settled trial of prednisolone drops until sx improve if no improvement or ongoing for 2-3 months - refer to ENT
91
what is mastoiditis?
infection of the mastoid air cells of the temporal bone - found behind the ear
92
what are the symptoms of mastoiditis?
post-auricular swelling, pain, fever, loss of pinna
93
management of suspected mastoiditis?
referral to ENT same day emergency
94
what is malignant otitis externa?
invasive infection of the base of the skull - similar to mastoiditis but usually only in the immunocompromised and elderly
95
what are the symptoms of malignant otitis externa?
severe ear pain, worse at night, otorrohea, grannulation tissue at base of ear
96
management of malignant otitis externa?
immediate ref to ENT
97
who is more at risk of malignant otitis externa?
elderly immunocompromised
98
what is a cholesteatoma?
non-cancerous growth of squamous cell epithelium that is trapped in the base of the skull causing local destruction
99
what age is cholesteatoma most common?
age 10-20 years
100
what increases risk of cholesteatoma?
being born with a cleft palate
101
what are the symptoms of cholesteatoma?
foul smelling discharge from ear no pain hearing loss - conductive vertigo occasional facial nerve palsy depending on the location
102
management of cholesteatoma?
needs ENT ref - surgical removal
103
what are causes of conductive hearing loss?
impacted wax debris/FB in the ear cancal perforation of the ear drum middle ear effusion (glue ear) otosclerosis
104
what are causes of sensorineural hearing loss?
presbyacusis infections - measles/meningitis menieres disease drugs acoustic neuroma noise induced deafness
105
what is ramsay hunt syndrome?
reactivation of the VZV virus - causing shingles type rash in the facial (7th cranial) nerve
106
how does ramsay hunt present?
vesicular rash around the ear facial paralysis unilateral ear pain sensorineural hearing loss sometimes causes vertigo
107
management of ramsay hunt?
oral aciclovir if presents within 72 hours oral prednisolone
108
which medications can cause gingival hyperplasia?
phenytoin ciclosporin calcium channel blockers i.e. nifedipine
109
what are the DVLA rules around menieres disease?
must inform the DVLA cannot drive until symptoms well controlled
110
sensitivity to what medication is associated with nasal polyps?
aspirin
111
what type of nystagmus indicates a central cause of vertigo?
vertical nystamgus
112
what are common medications that can cause tinnitus?
aspirin naproxen / strong NSAIDs aminogylocisdes - gentamicin loop diuretics quinine
113
which medications can cause rhinitis as a side effect?
Alpha blockers (tamsulosin), beta blockers, aspirin and other anti-inflammatory medicines, angiotensin converting enzyme (ACE) Inhibitors, the contraceptive pill, chlorpromazine and alcohol.
114

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