ENT Flashcards
1
Q
Weber’s test?
A
512Hz tuning fork placed in middle of forehead, ask which ear is loudest
Normal
- both equal
Sensorineural
- sound louder in normal ear
Conductive
- sound louder in affected ear
2
Q
Rinne’s test
A
- flat end of tuning fork on mastoid, when pt can no longer hear, move to 1cm away from ear, wait until not heard again
Normal
- pt can hear sound in air - AC>BC - Rinne’s positive
Abnormal
- Can’t hear sound in air - BC>AC - Rinne’s negative - conductive hearing loss
3
Q
Audiometry interpretation
A
Normal - anything above 20db line
Sensorineural - both air and bone conduction reduced
Conductive - bone normal, air reduced
Mixed - both air and bone reduced, >15db difference between - air often worse than bone
4
Q
Vertigo
A
sensation of movt between pt + environment - feel like they are spinning / room is spinning
mismatch of sensory inputs for balance / posture - vision / proprioception / vestibular issues
5
Q
Vertigo causes
A
Peripheral - vestibular
- BPPV
- Meniere’s
- vestibular neuronitis
- labyrinthitis
- Ramsay-Hunt, trauma to vestibular nerve, acoustic neuroma, otosclerosis
Central - brainstem / cerebellum
- posterior circulation infarct
- tumour
- MS
- vestibular migraine
6
Q
Benign paroxysmal positional vertigo (BPPV)
A
recurrent episodes of vertigo, triggered by head movt
7
Q
BPPV Patho
A
Calcium carbonate crystals displaced into semicircular canals
disrupt endolymph flow, confusing vestibular system
head movt creates flow of endolymph - triggers vertigo
Causes - viral infection, head trauma, aging, no cause
8
Q
BPPV Px
A
vertigo triggered by head movt
- 10-20s episode
- nausea
- asym between attacks
- episodes occur over several weeks, resolve, can recur later
- no hearing loss / tinnitus
9
Q
BPPV Dx
A
Dix-Hallpike manoeuvre
10
Q
BPPV Mx
A
Epley manoeuvre
Brandt-Daroff exercises
Betahistine
11
Q
Vestibular neuronitis
A
inflammation of vestibular nerve - usually viral
12
Q
Vestibular neuronitis Px
A
acute onset vertigo
- URTI hx
- most severe at start (constant), then triggered by head movt
- N+V
- balance issues
- horizontal nystagmus
- no neuro sx
- no tinnitus / hearing loss
13
Q
Vestibular neuronitis Dx
A
Head impulse test
14
Q
Vestibular neuronitis Mx
A
Buccal / IM prochlorperazine
Cyclizine, cinnarizine, promethazine
Maybe vestibular rehab therapy
15
Q
Labyrinthitis
A
Inflammation of semicircular canals, vestibule, cochlear
Usually after URTI / bacterial infection (eg meningitis, OM)
16
Q
Labyrinthitis Px
A
- acute onset vertigo, exacerbated by movt
- hearing loss - sensorineural
- tinnitus
- N+V
- viral sx
- gait - may fall to affected side
- nystagmus
17
Q
Labyrinthitis Dx
A
H/E
Head impulse test - abnormal
18
Q
Labyrinthitis Mx
A
- prochlorperazine
- cyclizine, cinnarizine, promethazine
- abx for bacterial cause
19
Q
Meniere’s disease
A
Long term inner ear disorder
excessive endolymph in labyrinth - disrupt sensory signals
20
Q
Meniere’s disease Px
A
- unilateral, maybe bilateral after years
- vertigo, 20mins-hrs episodes, in clusters
- hearing loss - sensorineural
- tinnitus
- fullness in ear
- drop attacks
- imbalance
- nystagmus in attack
21
Q
Meniere’s disease Dx
A
clinical dx - by ENT
Audiology
22
Q
Meniere’s disease Mx
A
Acute attacks
- prochlorperazine
- cyclizine, cinnarizine, promethazine
Prophylaxis
- betahistine
- vestibular rehab exercises
Inform DVLA - don’t drive until sx controlled
23
Q
Otitis externa (OE)
A
inflammation of external ear canal
bacterial, fungal, eczema, contact dermatitis, trauma, swimming….
24
Q
OE Px
A
- ear pain, itch, discharge
- red, swollen ear canal
- lymphadenopathy
25
oe Ix
Can do swab
26
OE Mx
Mild;
- OTC acetic acid
Moderate:
- otomize spray - neomycin + dex + acetic acid
- oral abx (cipro / fluclox) - if immunocompromised, severe infection, spread beyond canal
- ear wick - sponge/gauze with topical tx
- fungal - clotrimazole
27
malignant OE?
- severe life-threatening form of OE
- commonly pseudomonas
- spreads to bones - osteomyelitis of temporal bone
Px
- OE and more severe
- headache, pain, fever
- purulent ear discharge
- granulation tissue in ear canal
- facial nerve palsy, hoarse voice, dysphagia
Mx
- admit under ENT
- IV abx
- CT / MRI head
28
Otitis media (OM)
infection of middle ear
often after viral URTI
also bacterial - strep pneumoniae....
29
OM Px
- ear pain
- reduced hearing
- URTI sx
- balance issues, vertigo
- discharge - if tympanic membrane perf
- young pts - fever, vomiting, irritable, lethargy, poor feeding...
30
OM Ix
Otoscopy - bulging tympanic membrane (effusion), red, inflamed, discharge
31
OM Mx
- paeds - admit if high fever...
- analgesia
- most self resolve
Immediate Abx if: systemically unwell, immunocompromised or significant comorbidities
Offer delayed prescription to pick up after 3 days if symptoms unresolved
- amoxicillin 5d
- erythromycin - if pregnant + pen allergy
- clarithromycin - if pen allergy
32
Mastoiditis?
- infection in mastoid air spaces of temporal bone (spread from middle ear)
Px
- otalgia - behind ear
- hx of OM
- fever, unwell
- swelling, red, tender over mastoid process
Ix
- CT
Mx
- IV abx
33
Presbycusis - Px, Ix and Mx
- age-related sensorineural hearing loss - high pitches first
Px
- gradual, insidious hearing loss
- speech difficult to hear
- tinnitus
Ix
- audiometry
- otoscopy - r/o ddx
- tympanometry
- bloods
Mx
- hearing aids
- cochlear implants
34
Otosclerosis
- remodelling of base of stapes - becomes stiff - conductive hearing loss
- <40yo
Px
- uni/bilateral
- hearing loss - lower pitches affected more
- tinnitus
Ix
- otoscopy - normal
- Weber's / Rinne's
- audiometry
- tympanometry
- ?CT
Mx
- hearing aids
- surgical - stapedectomy / stapedotomy - replace whole / part of stapes with prosthesis
35
Eustachian tube dysfunction?
- tube not working properly / blocked - eg URTI, allergies, smoking
Px
- reduced hearing
- popping in ear
- fullness
- pain, tinnitus
Ix
- otoscopy - r/o OM
Mx
- Valsalva
- decongestant nasal sprays
- antihistamines, steroid nasal spray
- Otovent - OTC
- surgery if severe
36
Glue ear? Px, Ix and Mx
OM + effusion -> loss of hearing
- eustachian tube blocked
Px
- reduction of hearing
- peak 2yo
Ix
- otoscopy - dull tympanic membrane, air bubbles / fluid level
- audiometry
Mx
- resolves alone <3mo
- hearing aids
- grommets
- ?adenoidectomy
37
Sudden sensorineural hearing loss (SSNHL): definition, Ix and Mx
- unexplained hearing loss <72hrs - ENT emergency
Ix
- audiometry
- MRI / CT head
Mx
- ENT referral
- tx cause
- idiopathic - steroids - oral / intra-tympani
38
Conductive causes of acute hearing loss
- ear wax
- infection - OM / OE
- middle ear effusion
- eustachian tube dysfunction
- perforated tympanic membrane
39
Causes of SSNHL
- 90% idiopathic
- infection - meningitis, HIV, mumps
- Meniere's
- ototoxic meds
- MS
- migraine
- stroke
- acoustic neuroma
40
Tinnitus
persistent ringing in ears
41
Tinnitus causes
- idiopathic
- meniere's
- otosclerosis
- SSNHL
- acoustic neuroma
- hearing loss
- drugs
- ear wax
- anaemia, DM, hypo/hyperthyroid, hyperlipidaemia
- objective tinnitus - carotid artery stenosis, AS, AV malformation
42
Tinnitus Ix
- otoscopy
- Rinne, Weber
- Bloods - FBC, glucose, TSH, lipids
- audiology
- CT / MRI if needed
43
Tinnitus red flags
- unilateral
- pulsatile
- hyperacusis - hypersensitive to sounds
- sudden hearing loss
- vertigo / dizziness
- visual / neuro sx
- suicidal ideation from tinnitus
44
tinnitus mx
treat underlying cause
symptom managment:
- hearing aids
- sound therapy (background noise to mask tinnitus)
- CBT
45
ear wax?
Px
- conductive hearing loss
- ear discomfort, feels full, pain
- tinnitus
Ix
- otoscopy
Mx
- ear drops - olive oil / sodium bicarb
- ear irrigation
- microsuction - by ENT
46
acoustic neuroma?
- vestibular schwannoma
- benign tumour of Schwann cells around vestibulocochlear nerve
- 5% intracranial, 90% cerebellopontine angle tumours
- Bilateral - NF2
47
acoustic neuroma Px
-typical patient is aged 40-60 years presenting with a gradual onset of:
Unilateral sensorineural hearing loss (often the first symptom)
Unilateral tinnitus
Dizziness or imbalance
A sensation of fullness in the ear
NB can be associated with facial nerve palsy
48
acoustic neuroma Ix
- urgent ENT referral
- audiometry
- CT / MRI
49
acoustic neurone mx
* Conservative management with monitoring may be used if there are no symptoms or treatment is inappropriate
* Surgery to remove the tumour (partial or total removal)
* Radiotherapy to reduce the growth
50
Cholesteatoma
- non-cancerous growth of squamous epithelium in skull base -> local destruction, infections
Px
- foul-smelling discharge
- hearing loss
- local invasion -> vertigo, facial nerve palsy, pain....
Ix
- otoscopy - attic crust
- CT / MRI
Mx
- ENT - surgery
51
auricular haematoma
- blood in auricle after trauma
- ENT assessment - incision + drainage - prevent cauliflower ear
52
perforated tympanic membrane
- eg from infection, barotrauma, direct trauma
- may have hearing loss
Mx
- 6-8wks to heal alone - avoid water
- abx for perf after acute OM
- myringoplasty - surgery to close perforation
53
Epistaxis: what is it and most common area affected?
nosebleeds
usually originates from Kiesselbach’s plexus, which is located in Little’s area
54
epistaxis causes
Local
- nose picking, trauma
- FB
- colds, sinusitis
- cocaine
- topical drugs - steroids
- vascular, tumours
General
- coag disorders, blood thinners
- HTN, atherosclerosis
- weather changes
- excessive alcohol
55
epistaxis px
- unilateral
- if bilateral - may indicate posterior
- vomiting blood - if swallowed
56
epistaxis Ix
FBC, coag, G+S
57
epistaxis mx
- A-E, cannulate if needed
First aid
- sit up, tilt head forwards
- squeeze soft part of nostrils 10-15mins
- spit out blood, don't swallow
Next
- nasal packing - nasal tampons / inflatable packs
- cautery - silver nitrate sticks - only one side of septum
Admission
- if uncontrolled / posterior - ?balloon catheter
- if unstable
- ?splenopalatine artery ligation in theatre (for posterior)
58
sinusitis?
- inflammation of mucous membranes in paranasal sinuses
- eg strep pneumoniae, H influenzae, rhinoviruses
- RFs - nasal obstruction, recent local infection, swimming, diving, smoking
59
sinusitis Px?
- recent URTI
- facial pain, frontal, worse bending forward
- nasal discharge, nasal obstruction
- loss of smell
- fever
Red flags
- unilateral
- persistent despite tx for 3mo
- epistaxis
60
sinusitis Ix
- in chronic (>12wks) - nasal endoscopy, CT
61
sinusitis mx
- analgesia
- intranasal decongestants
- intranasal corticosteroids
- oral abx - if severe - phenoxymethylpenicillin, co-amox (if systemically unwell)
62
allergic rhinitis
- inflammatory disorder of nose - to allergens
- seasonal / perennial / occupational
Px
- sneezing, blocked nose, itchy
- clear discharge, also at back of throat
Mx
- avoid allergen
- antihistamines - oral / intranasal
- intranasal corticosteroids
- topical nasal decongestants
63
nasal polyps?
- growth of nasal mucosa
- usually bilateral - unilateral = ?tumour
associated with
- chronic rhinitis, sinusitis
- asthma
- Samter's triad
- CF
- granulomatosis with polyangiitis
- Kartagener's syndrome
64
nasal polyps Px
- ?chronic rhinosinusitis
- difficulty breathing through nose
- snoring
- nasal discharge
- anosmia
65
nasal polyps Ix
examine with nasal speculum
- nasal endoscopy
66
nasal polyps Mx
- intranasal steroid drops / spray
- surgery - intranasal polypectomy / endoscopic if further back
67
nasal septal haematoma? Px, Mx and key complication?
- haematoma between septal cartilage and overlying perichondrium - cx of nasal trauma
Px
- nose blocked, pain, rhinorrhoea
- bilateral, red swelling arising from nasal septum - boggy
Mx
- surgical drainage
- IV abx
Cx
- septal necrosis -> saddle nose deformity
68
tonsillitis
Inflammation in tonsils
Causes
- viral - most common
- Group A strep - strep pyogenes
- strep pneumonia...
69
tonsillitis px
- fever
- sore throat
- painful swallowing
- lymphadenopathy
- younger children - fever, poor oral intake, headache, vomiting, abdo pain
70
CENTOR criteria
Probability of bacterial infection
>3 of the following - indicates abx
- fever >38
- tonsillar exudates
- absence of cough
- tender anterior cervical lymph nodes
71
FeverPAIN score
score /5, gives % chance of strep infection
2-3 is 34-40%, 4-5 is 62-65%
- fever in past 24hrs
- pus
- attend <3d of sx onset
- inflamed tonsils
- no cough / coryza
72
tonsillitis Mx
- paracetamol, ibuprofen, Difflam
- abx - penicillin V / clarithromycin
- consider delayed prescription
- admit if needed - eg unwell...
73
Quinsy
- peritonsillar abscess
- bacterial infection with trapped pus
- most commonly strep pyogenes (GAS), also S aureus, H influenzae
74
Qunisy Px
- sore throat
- painful swallowing
- fever, neck pain, referred ear pain
- swollen lymph nodes
- trismus
- hot potato voice
- swelling / erythema beside tonsils
75
Quinsy Mx
- ENT admission - incision / drainage
- Co-amoxiclav
- ?dex for inflammation
76
Indication for tonsillectomy?
- 7+ cases in 1yr
- 5/yr for 2yrs
- 3/yr for 3yrs
- Recurrent tonsillar abscesses (2 episodes)
- Enlarged tonsils causing - difficulty breathing, swallowing, snoring
- Recurrent febrile convulsions secondary to tonsillitis
77
complications of tonsillectomy
- pain, sore throat
- damage to teeth
- infection
- risks of GA
- post-tonsillectomy
78
Post-tonsillectomy bleeding Mx
- ENT registrar
- IV access, send FBC, coag, G+S/C
- keep child calm, analgesia
- spit blood out
- NBM for GA
- IV fluids / bloods
- hydrogen peroxide gargle
- adrenaline soaked gauze
79
thyroid surgery complications
- recurrent laryngeal nerve damage
- bleeding
- parathyroid gland damage -> hypocalcaemia
80
Laryngopharyngeal reflux
- inflammatory changes in larynx / hypopharynx due to GORD
Px
- sensation of lump in throat - midline, worse swallowing saliva (rather than food/drink)
- hoarse voice, chronic cough, dysphagia, heartburn, sore throat
Ix
- clinical dx
- if red flags, 2ww referral - persistent unilateral discomfort, dysphagia, odynophagia, persistent hoarseness
Mx
- diet chages
- PPI, gaviscon
81
ludwig's angina?
- progressive cellulitis which invades floor of mouth, soft tissues of neck
- from dental infections
Px
- neck swelling
- dysphagia
- fever
Mx
- mx airway
- IV abx
82
salivary gland tumours?
80% parotid, 80% of these - pleomorphic adenomas, 80% superficial lobe
83
pleomorphic adenoma
- benign mixed parotid tumour
Px
- slow growing painless lump, moveable
- middle aged
Mx
- superficial parotidectomy
84
warthin's tumour
- benign, adenolymphoma, 10%
- males, middle aged
- softer, more mobile, fluctuant
85
salivary gland stones?
- 80% submandibular
Px
- recurrent unilateral pain / swelling on eating
Ix
- XR
- sialography - XR + contrast
Mx
- surgical removal
86
neck lumps DDx
- Bony prominence - hyoid bone, cervical rib
- lymphadenopathy
- tumour
- lipoma
- goitre, thyroid nodules
- salivary gland stones / infection
- carotid body tumour
- haematoma
- thyroglossal cyst
- branchial cyst
- cystic hygroma
- dermoid cyst
- haemangioma
- venous malformation
87
Neck lump Hx and Ex
Hx
- SOCRATES
- fever, wt loss, night sweats
- FHx, smoking
Exam
- lump exam
- lymph nodes
- skin changes
- focal chest sounds - cancer
- clubbing
- HSM
88
Neck lump 2ww referral criteria
- unexplained neck lump >45yo
- persistent unexplained neck lump any age
USS with growing lump:
- <2wks if >25yo, <48hrs if <25yo
89
neck lump ix
bloods - eg FBC, blood film, HIV, EBV ABs, TFTs, ANA, LDH (Hodgkin's)
- USS, CT/MRI, nuclear medicine scan
- Biopsy - fine needle / core, incision
90
Lymphadenopathy causes
Reactive - URTIs, dental infections, tonsillitis
Infective - TB, HIV, IM
Inflammatory - SLE, sarcoidosis
Malignancy - lymphoma, leukaemia, mets, chest/abdo (supraclavicular)
91
Lymphadenopathy sx suggesting malignancy
unexplained
persistently >3xm
abnormal shape - oval
hard / rubbery
non-tender
tethered / fixed to skin / underlying tissues
night sweats, wt loss, fatigue, fever
92
carotid body tumour
- glomus cells (grouped into paraganglia) just above carotid bifurcation - benign tumour of this
Px
- slow growing lump, near angle of mandible
- painless, pulsatile
- bruit
- mobile side-to-side, not up/down
- may compress nerves - eg Horner's
Ix
- imaging - splaying of internal / external carotids - lyre sign
Mx
- surgical removal
93
pharyngeal pouch
- older men
- posteromedial herniation between thyropharyngeus + cricopharyngeus muscles
- Px - dysphagia, regurg, aspiration, cough
94
head/neck cancer
usually SCC
Locations
- nasal cavity, paranasal sinuses, mouth, salivary glands, pharynx, larynx
usually spread to lymph nodes first
RFs
- smoking, chewing tobacco, alcohol, HPV 16, EBV
95
head/neck cancer Px
- lump in mouth / lip
- unexplained mouth ulcer >3wks
- erythroplakia, erythroleukoplakia
- persistent neck lump
- unexplained hoarse voice
- unexplained thyroid lump
- CN palsies, nasal obstruction, epistaxis, otalgia
96
head/neck cancer referral criteria
Laryngeal
- >45yo with persistent unexplained hoarseness / lump in neck
Oral
- unexplained mouth ulcer >3wks / lump in neck
- lump on lip / oral cavity / red or red/white patch - dentist to see
Thyroid
- unexplained thyroid lump
97
head/neck cancer Ix
- Scans, biopsy
- TNM staging
98
Head/neck cancer Mx
- chemo / radio
- surgery
- MAbs
99
glossitis
- inflammation of tongue
- red, sore, swollen
- papillae atrophy - smooth tongue
Causes
- iron deficiency
- B12 anaemia
- folate anaemia
- coeliac
- injury / irritants
100
angioedema
fluid build up in tissues
Causes
- allergic reactions
- ACEi
- hereditary angioedema
101
Oral candidiasis
- oral thrush - white spots / patches on tongue / palate
RFs
- ICS
- abx
- DM, HIV, smoking
Mx
- miconazole gel
- nystatin suspension
- fluconazole tablets
102
Geographic tongue
- inflammatory - patches of tongue lose epithelium + papillae - irregular shapes
- related to - stress, mental illness, psoriasis, atopy, diabetes
- benign
- topical steroids / antihistamines for sx control
103
strawberry tongue?
tongue swollen, red
papillae enlarged + white
Scarlet fever / Kawasaki's
104
black hairy tongue
- defective exfoliation of keratin from tongue's surface, papillae elongate + look like hairs
Causes
- dehydration, poor oral hygiene, smoking, abx, HIV, IVDU, radiation
Ix
- swab to r/o candida
Mx
- hydrate
- gently brush tongue
- stop smoking
105
leukoplakia
- white patches on tongue, inside of cheeks - precancerous to SCC
Px
- asym, irregular, slightly raised
Ix
- biopsy
Mx
- stop smoking, alcohol
- potential surgical excision
106
erythroplakia
Red patches in mouth, like leukoplakia
107
lichen planus
- autoimmune - local chronic inflammation of skin
Px
- shiny, purplish, raised areas with white lines
- bright red, sore
- plaques
- often only mouth, but can affect all mucosal membranes
Mx
- oral hygiene, stop smoking
- topical steroids
108
gingivitis
- inflammation of gums
- acute necrotising ulcerative version - rapid onset
RFs
- plaque, smoking, diabetes, malnutrition, stress
Px
- swollen gums, bleeding, painful, bad breath
Mx
- hygiene, stop smoking, dental hygienist clean
- chlorhexidine mouth wash
- abx for acute necrotising ulcerative - metronidazole, amoxicillin
109
gingival hyperplasia
abnormal growth of gums
Causes
- gingivitis
- pregnancy
- vit deficiency - scurvy
- AML
- meds - CCBs, phenytoin, ciclosporin
110
aphthous ulcers
abnormal growth of gums
Causes
- gingivitis
- pregnancy
- vit deficiency - scurvy
- AML
- meds - CCBs, phenytoin, ciclosporin
111
Common bacterial causes of OE?
Pseudomonas aeruginosa
Staphylococcus aureus
112
which infection is commonly known as swimmers ear?
OE
113
what can you consider prescribing after an acute nosebleed? who is this contraindicated in?
Naseptin nasal cream (chlorhexidine and neomycin) QDS for 10 days
C/I in peanut or soya allergy
