ENT Flashcards
(212 cards)
1
Q
What characteristics of a hoarse voice would be more worrying for cancer?
A
If it was constantly hoarse rather than being worse in the evening
or if there is a neck lump
2
Q
What is the best imaging modality for the nature of a neck lump?
What is the best investigation in general?
A
Ultrasound, as very accessible.
Definitive diagnosis requires fine needle aspiration (best initial investigation)
3
Q
What type of cancer do head and neck cancers tend to be?
A
Squamous cell carcinoma
4
Q
If you want to know tumour grade in head and neck tumour, how should it biopsied?
What should be avoided?
A
Ultrasound guided fine needle aspiration
NOT excision
risk of seeding cancer or compromising margins and creating scarring
5
Q
When is a barium swallow useful in head and neck cancers?
A
If suspecting lower oesophageal tumours as well
6
Q
Why do vocal nodules form?
A
In people who use their voice alot and shout, the constant impact of speaking smacks chords together leading to nodules forming
7
Q
How do you treat vocal nodules?
A
Vocal therapy (not surgery)
8
Q
Risk Factors for head and neck cancers
A
Smoking Alcohol Betel nut chewing (tobacco) Male Publicans- who are exposed to smoke
9
Q
In TNM staging for head and neck tumours, what characteristics determine the N score?
A
Nodes- size, unilateral/bilateral, multiple/single
10
Q
40 year old presents with throat cancer, has never smoke or drunk to excess. What might be the cause? What puts you at risk?
A
Human papillomavirus 16 +18
Oral sex with multiple partners
11
Q
A patient with severe tonsillitis can’t swallow, can’t take antibiotics, how to treat?
A
Admit as they can’t swallow so can give IV antibiotics
plus dexamethosone
12
Q
Epstein Barr virus = glandular fever
why should you avoid amoxicillin?
A
Gives an erythematous rash
13
Q
When should tonsils be removed in children?
A
In children, if they get tonsillitis
7x year for 1 year
5x year for 2 years
3x year for 3 years
14
Q
What are the complications of tonsillitis?
A
Abscesses
Upper airway compromise (very rare)
15
Q
In sleep studies of obstructive sleep apnoea patients, what variables are measured?
A
Apnoea = cessation of sleep for 10 seconds
Hypoapnoea = reduction in ventilation by 50% for 10 seconds
Or drop in 02 sats 4% blow baseline
16
Q
Where are most salivary glands found?
A
80% in parotid gland
17
Q
What pathological type of tumour are salivary gland tumours?
A
80% benign- pleomorphic adenoma
18
Q
Cheek and earlobe numb unilaterally and a cheek swelling.
Diagnosis?
A
Salivary gland tumour of parotid
numbness is due to compression of auricular nerve as it passes over parotid
19
Q
What is Frey’s syndrome?
A
Auriculotemporal nerve damage causes erythema and sweating in the cutaneous distribution of the auriculotemporal nerve, usually in response to gustatory stimuli.
20
Q
Which viruses cause tonsillitis?
A
herpes simplex Epstein- Barr Cytomegalovirus Other herpes Adenovirus Measles
21
Q
Bacterial causes of tonsillitis
A
Group A beta haemolytic strep- strep pyogenes
steph pneumoniae
staph aureus
haemophilus influenzae
22
Q
Unilateral tonsil enlargement + loss of weight
whats the possible cause?
A
Lymphoma
23
Q
Types of squint
A
esotropia = eye turns in, convergent squint
exotropia = eye faces out, divergent squint
accommodative convergent squint- corrects with glasses for near vision
24
Q
Imaging for foreign body in the orbit?
A
CT
25
Which wall of the eye is most commonly fractured?
Referral?
The orbital floor- often with squash balls impact
Refer maxfax + avoid blowing nose
26
In a ruptured globe what is the treatment in A+E?
eye shield NOT cotton pad
27
The accessory nerve innervates what?
CNXI- trapezius and sternocleidomastoid
28
Palsy of CN III causes what abnormal eye movement?
Looking down and out
29
40 year old man has severe and recurrent nose bleeds, he gets nosebleeds during sleep sometimes, his lips have av malformations visible as red splodges on them. What could a rare cause be? And complication?
Osler-Weber-Randu
Autosomal dominant hereditary haemorrhagic telangiectasia
May become anaemic requiring transfusion
30
What is the blood supply to the nose broadly?
External carotid a:
Maxillary a (sphenopalatine)
Facial
```
Internal carotid a:
Ophthalmic a (ethmoid a)
```
31
Where do most nosebleeds occur?
What type of haemorrhage do these cause
```
Kisselbachs plexus (little's area)
Where internal carotid and external carotid branches anastamose
Anterior haemorrhage
```
10% sphenopalatine a (from maxillary + eca)
Posterior haemorrhage
32
How can anterior and posterior haemorrhage in nosebleeds be differentiated?
Anterior hameorrhages have a visible source with rhinoplasty
33
Person with asthma complains of a chronic cough and constantly blocked nose? Treatment?
Allergic rhinitis + asthma:
nasal steroids + antileukotrine (zafirlukast)
(stops rhinitis triggering asthma)
34
Rx for allergic rhinitis:
1st line:
1. Oral antihistamines
2. Oral decongestants
3. Nasal antihistamines or steroids (for 1 MONTH at a time MAX)
2nd line:
Oral steroids
35
How can rhinitis be differentiated from a csf leak?
Nasal dipsticks: csf is +ve for glucose
But not that accurate
Send to lab for better results, csf has b2-transferrin
36
Gentleman has a blow to the nose, a few days later he has a big red cherry in the middle of his nose where the septum is, what is it? What are the risks of it?
Septal haematoma
Drain in theatre and pack
Risk: septal necrosis, nasal collapse
37
How soon does a nasal fracture need to be reduced before it sets in place?
Aim to reduce under general anaesthetic before two weeks
Sets by three weeks
38
What is the management of different types of foreign body put in nostrils or ear holes?
Inorganic- can leave a little while, may not get discharge
Organic- remove quickly (one day or so), purulent discharge
Button batterys- remove immediately, erodes, causes death
39
How can you differentiate between a nasal polyp and inflamed inferior turbinate if you're a gp?
Nasal polyps are pale (greyish) and insensitive, mobile
| Whereas a swollen inferior turbinate will be sore
40
Medical Rx for nasal polyps?
Betamethasone sodium phosphate drops (polyps are eosinophilic in 90%) for 2 days
Beclometasone spray
41
Doctor notices a nasal polyp in his 8 year old patient. Whats most likely diagnosis?
Polyps are rare in the under 10s
Commoner is:
Neoplasms
Meningocele/encephalocele (herniation of cranial contents)
Especially if under 2 + unilateral
Cystic fibrosis
42
Unilateral nasal polyp in 54 year old patient. Investigations?
As unilateral, could be malignant
CT
Biopsy for histology
43
Common causes of tonsillitis?
Sore throat
Group A streps- strep pyogenes
```
Staphs
Moraxella catarrhalis
Mycoplasma
Chlamydia
Haemophilius
```
44
Differential of tonsillitis (sore throat + lymphadenopathy)
Infectious mononucleosis- Epstein Barr (HHV-4)
doesn't resolve in one week, systemic symptoms
Agranulocytosis- low WCC
leukaemia
Diptheria- Corynebacteria
grey green membrane over oropharynx
45
Child has a very sore throat that is not resolving and a small neck lump, what Ix to exclude retropharyngeal abscess?
Lateral xray to look for soft tissue swelling
46
30 year old had a sore throat for a week and now cannot swallow saliva due to pain, on ehx the uvula is displaced to the left. Diagnosis?
Other typical symptoms?
```
Peritonsillar abscess (quinsy)
Can be a life threatening complication of acute tonsillitis
```
Odynophagia (pain on swallowing)
Hot potato voice
Trismus (jawlock)
47
Name that syndrome:
Pharyngotonsillitis
+ internal jugular vein phlebitis
+ septic embolization (often lungs)
And causative pathogen
Lemierres syndrome
Fusobacterium necrophorum
High dose benpen, clindamycin, metronidazole
48
Difference between scarlet fever and rheumatic fever?
Both caused by group a strep:
Scarlet fever- strep pharyngitis + sandpaper rash
Rheumatic fever- post-infectuous sequelae of strep pharyngitis according to jones criteria
(Jones= carditis, polyarthritis, erythema marginatum, chorea, nodules)
49
What is the pathophysiology of post-infectious demyelinating disorder or chorea following strep throat?
Demyelinating: antigen mimicry leading to antibodies forming against cns epitopes
(Can occur with mycoplasma, streps + ebv)
Chorea: antibodies against corpus striatum in basal ganglia causing jerky uncoordinated movements
50
How many episodes of tonsillitis a year warrant a tonsillectomy?
5 or more
51
Commonest cause of barking cough and stridor in children?
Laryngotracheobronchitis/croup
95% is viral like parainfluenza
Especially if no drooling
Much commoner than epiglossitis- tend to drool
52
What is the severity grading for croup?
```
1 = barking cough + inspiratory stridor
2 = 1+ expiratory stridor
3 = 2 + pulsus paradoxus
4 = 3 + cyanosis or decreased consciousness
```
53
Child has barking cough and stridor, what xray sign would confirm croup (laryngotracheobronchitis)?
Steeple sign (trachea tapering around the thyroid area)
54
Rx for severe croup?
| Mild croup is self-limiting
Antibiotics
Humidified o2
Adrenaline 5mL 1:1000 neb
Steroid PO or NEB
55
Someone who doesn't have the haemophilus vaccine is at risk of...?
Acute epiglottitis
56
Newborn baby has some stridor, whats the cause and treatment?
laryngomalacia
Immature and floppy aryepiglottic folds leads to larynx collapse on inspiration
Generally self limiting, improves by age 2
57
How do laryngomalacia and laryngeal paralysis present different in neonates in classical presentations?
Laryngomalacia (floppy larynx) = stridor
Laryngeal paralysis = hoarse breathy cry
58
If someone has airway obstruction, and you can hear the stridor, once stable what IHx can help identify the cause?
Flexible nasendoscopy
AP + lateral xrays of neck and chest
Causes: inflammation, tumour, trauma, foreign body, vocal cord paralysis
59
Patient complains of a hoarse voice and pain after eating sometimes, likely cause and rx?
Reflux laryngitis (from gastro-oesophageal reflux disease)
PPI
+/- surgical fundoplication
60
Reinke's oedema is...?
| And is associated with...?
A gelatinous enlargement of the vocal cords
Associated with smoking and hypothyroidism
61
How can you distinguish between partial and complete cord paralysis when looking with a scope?
Partial- cords fixed in midline as abductors tend to be damaged more often than adductors so muscles are unopposed
Complete- fixed mid-way (abductors and adductors wiped out)
62
What risk factors is nasopharyngeal cancer (squamous cell) associated with?
```
HLA-A2 allele
Human papillomavirus virus (oral sex)
Epstein barr virus
Tobacco, formaldehyde, wood dust exposure
Salted fish
```
63
What is the mainstay of treatment for nasopharyngeal squamous cancers?
Radiotherapy
+/- chemotherapy or surgery
64
What is the histology of oropharyngeal cancers?
85% are squamous
Adenocarcinoma of salivary glands
Lymphoma
Melanoma
65
Patient has increasing hoarseness and smokes, what investigations?
Want to exclude squamous cell laryngeal cancer:
Laryngoscopy + biopsy
Hpv +ve
Mri for staging
66
Child has barking cough and stridor, what xray sign would confirm croup (laryngotracheobronchitis)?
Steeple sign (trachea tapering around the thyroid area)
67
Rx for severe croup?
Antibiotics
Humidified o2
Adrenaline 5mL 1:1000 neb
Dexamethosone po / budesonide neb
68
Someone who doesn't have the haemophilus vaccine is at risk of...?
Acute epiglottitis
69
Newborn baby has some stridor, whats the cause and treatment?
Immature and floppy aryepiglottic folds leads to larynx collapse on inspiration
Generally self limiting, improves by age 2
70
How do laryngomalacia and laryngeal paralysis present different in neonates in classical presentations?
Laryngomalacia (floppy larynx) = stridor
Laryngeal paralysis = hoarse breathy cry
71
If someone has obstruction, once stable what IHx can help?
Flexible nasendoscopy
AP + lateral xrays of neck and chest
Causes: inflammation, tumour, trauma, foreign body, vocal cord paralysis
72
Patient complains of a hoarse voice and pain after eating sometimes, likely cause and rx?
Reflux laryngitis (from gastro-oesophageal reflux disease)
PPI
+/- surgical fundoplication
73
Reinke's oedema is...?
| And is associated with...?
A gelatinous enlargement of the vocal cords
Associated with smoking and hypothyroidism
74
How can you distinguish between partial and complete cord paralysis when looking with a scope?
Partial- cords fixed in midline as abductors tend to be damaged more often than adductors so muscles are unopposed
Complete- fixed mid-way (abductors and adductors wiped out)
75
What risk factors is nasopharyngeal cancer (squamous cell) associated with?
```
HLA-A2 allele
Human papillomavirus virus (oral sex)
Epstein barr virus
Tobacco, formaldehyde, wood dust exposure
Salted fish
```
76
Patient has increasing hoarseness and smokes, what investigations?
Want to exclude squamous cell laryngeal cancer:
Laryngoscopy + biopsy
Hpv +ve
Mri for staging
77
Arteries making up the littles area
Legs
Superior Labial
Ethnoidal (anterior and posterior)
Greater palatine
Sphenopalatine
78
Common causes of otitis externa?
Staph and pseudomonas
79
Old man has foul smelling discharge coming from his ear and pain, not responding to antibiotics. Diagnosis?
Cholesteatoma
| Chronic otitis media would respond to antibiotics
80
What is the different typical demographic of adenocarcinoma of the maxillary sinus vs nasopharygneal cancer?
Adenocarcinoma- lumberjack, wood particle inhalation
Nasopharyngeal- southern chinese man who eats salted fish
81
If a child has a thyroglossal cyst what must you do before removing it and why?
Radioactive isotope scan incase the cyst is the only functional thyroid tissue they have
82
15 year old has a lump around his sternocleidomastoid muscle, he is fit and well. What could be the cause and its derivative
Branchial cyst, occurs when the second branchial cleft doesn't obliterate
83
What are the benign tumours of the parotid gland?
Pleomorphic adenoma
Adenolymphoma
84
How many episodes of apnoea (10 secs no breathing) or hypapnoea (50% decreased ventilation) per hour would define mild, moderate or severe obstructive sleep apnoea in adults?
Mild: 5-15
Moderate: 15-30
Severe: 30+
85
How do you classify different bleeding after surgery?
Intra-operative
Primary (within 24hours)
Secondary (after 24hours)
For tonsillectomy most bleeding occurs 5 days later
86
What things in the history suggest neurological vs stricture (benign or malignant) causes of dysphagia- swallowing difficulty?
Fluids can be swallowed still- suggests stricture rather than neuro cause (bulbar palsy/ lat medullary syndrome)
Difficult to do swallowing movement + causes coughing (neuro)
Constant + painful (stricture)
Neck bulge or gurgle on drinking (pharyngeal pouch)
87
60 year old man has had swallowing difficulty, has a bulge in their neck and can hear gurgling upon swallowing fluid and bad breath. What imaging modality will help plan management?
Rx?
Pharyngeal pouch- barium meal
At increased risk of oesophageal perforation.
Can do endoscopic stapling
88
Which branch of the facial nerve runs through the middle ear and what structures does it run between?
```
Chorda tympani (2/3rds taste anterior tongue)
Between malleus and incus and tensor tympani muscle
```
89
What are the bones of the middle ear and which connect to the tympanic membrane?
Mis
Malleus (connects with tympanic membrane)
Incus and stapes
90
What tests could you do to determine the level of a facial nerve lesion?
Above geniculate ganglion, loss of lacrimation (parasympathetic, greater petrosal nerve)
Above middle ear, loss of stapedius dampening noise
Loss of taste to ant 2/3rds tongue- electrogustometry
And submandibular salivation (chorda tympani)
91
Patient has fever, ear pain and has noticed the side of her face is drooping, she can't raise her eyebrows. No vesicles noted in the ear or surround.
Ehx: tympanic membrane is bulging
Diagnosis and rx?
Otitis media, facial nerve palsy due to compression in middle ear
(Vesicles would suggest herpes zoster/ramsay hunt)
Amoxicillin
92
If a patient has bells palsy with severe paralysis, what three symptoms would suggest a herpes zoster cause and indicate highdose antivirals like valaciclovir?
Ear pain
Stiff neck
Red auricle
(Also vesicles around ear)
93
Rx for bells palsy onsetting in last 24 hours?
Prednisolone if in the last 24 hours
Valaciclovir (higher dose if prodrome of virus)
Artificial tears
94
Likely diagnosis of a midline lump in someone under 20
```
Dermoid cyst (teratoma)
Thyroglossal cyst (fluctuant that moves onto protruding tongue)
```
95
What are branchial cysts?
Found at the upper third of sternocleidomastoid
Lined by squamous epithelium
Filled with cholesterol crystals
In under 20s
96
Describe the course and branches of the facial nerve
1. Medulla- internal acoustic meatus- facial canal
2. Forms geniculate ganglion, gives off greater petrosal nerve with parasympathetic to lacrimal gland
3. Middle ear, gives off nerve to stapedius and chorda tympani
4. Stylomastoid foramen
5. Nerve to occipitofrontalis
Nerve to post belly of digastric and stylohyoid
Nerves to face (ten zebras broke my car)
97
Patient has fever, ear pain and has noticed the side of her face is drooping, she can't raise her eyebrows. No vesicles noted in the ear or surround.
Ehx: tympanic membrane is bulging
Diagnosis and rx?
Otitis media, facial nerve palsy due to compression in middle ear
(Vesicles would suggest herpes zoster/ramsay hunt)
Amoxicillin
98
Acute bilateral parotid gland swelling with dry mouth. Differential diagnosis?
Mumps
Staph infections
HIV
TB
Acute lymphoblastic leukaemia
Heerfordt's syndrome- acute sarcoid with fever, uveitis, salivary gland swelling
99
Patient who has sarcoid develops:
Fever
Uveitis
Salivary gland swelling
Name the syndrome and the mechanism
Heerfordt's syndrome: uveoparotid fever
100
Investigations to look at a red, swollen tender lump under the chin. Pain is worse on eating. Keeps happening and resolving.
Salivary gland stones- 80% submandibular
| Plain radiograph/sialography
Contrast injected into salivary glands
101
Rx for chronic infection of the salivary glands?
Prolonged oxyetracycline
102
Freys syndrome?
Thinking of food or eating food causes a rashy redness and swelling of the cheek.
Due to a mix up between the parasympathetic to parotid salivary glands and synpathetic input to facial sweat glands.
Normally auriculo-temporal nerve of Trigeminal carries parasympathetics to parotid
103
Patient has tooth pain, what features suggest whether the tooth is alive, dead or with an abscess?
Character:
Intermittent = alive
Constant = dead
Exacerbating:
Worse with sugar, heat or cold = alive
Worse on percussion = dead
Worse on movement with finger or thumb = abscess
104
Causes of gum swelling (fibrous hyperplasia)
Pen, knife, spoon
```
Phenytoin, nifedipine, ciclosporin
Pregnancy
AML- leukaemic infiltrate
HIV
Scurvy
```
105
What kind of analgesia and antibiotics does tooth pain and infection tend to respond to?
Nsaids- not opioids
| Penicillin + metronidazole
106
Gardener has a very tender inflamed nodule on the helix of his ear. Name the condition and treatment?
Chondrodermatitis nodularis helicis
Excise skin and underlying cartilage
107
Why do people get cauliflower ear, how can it be prevented?
From ischaemic necrosis following a pinna haematoma.
| Drain and pack the ear to avoid this
108
When should syringing of the ear be avoided?
If the eardrum is perforated (keep it dry)
Or grommets
Cleft palate or mastoid surgery
109
What does tympanometry and audiometry measure?
Typanometry: Middle ear pressure and tympanic membrane compliance
Audiometry: Lowest dBs that can be heard with each ear
110
What age should children be referred to speech therapy by if they have a stammer or a lisp/difficulty with 'r' or 'th' sounds?
Stammer- age 4
| Lisps etc- age 5
111
A child has an itchy painful ear and tenderness of the tragus. What is the diagnosis and possible causes?
In an adult, if resistant to rx what should be done?
Otitis externa
Pseudomonas
Staph aureus
Resistant- biopsy incase its malignant
112
Carbuncles (collection of boils) or furunculosis (infected hair follicle) are caused by...?
Staph aureus
| Strep pyogenes typically
113
A patient has pain of the jaw, she often grinds her teeth and in her pmh she has depression. What may be the cause? And Rx?
Temporomandibular joint dysfunction
Lateral movement of open jaw makes it worse
Rx nsaids, stabilizing orthodontic prostheses, cognitive therapy etc
114
What nerves refer pain to the pinna of the ear and what areas are the real source of injury?
Upper half pinna- V (auriculotemporal nerve) refers dental or TMJ dysfunction pain
Lower half pinna- C2,3 (auricular nerve) in neck injury and cervical spondylosis
115
What nerves refer pain to eardrum and what is the real site of injury?
Lateral drum- VII refers in geniculate herpes
Medial drum- IX (tympanic) + X (auricular) refers posterior tongue, larynx, throat in tonsillitis, quinsy
116
Which patients are most at risk of necrotizing otitis externa?
90% occurs in diabetic patients
=life threatening infection that can destroy temporal bone and base of skull.
Requires surgical debridement, abx, IV Ig
117
First line Rx of acute otitis media?
Amoxicillin 7days
118
How does chronic and acute otitis media present differently?
Acute- pain, fever +/- irritability, anorexia, vomiting
Often after viral URTI
Chronic- discharge, reduced hearing, little pain
EHx if discharge can't drain retraction of pars tensa/flaccida occurs
119
Foul smelling discharge from the ear with pain suggests...? Rx?
Cholesteatoma- squamous cell overgrowth eroding bone etc
| Mastoid surgery to remove the disease
120
Imaging if suspect mastoiditis?
CT scan
121
A tympanometry study on an adult found there was middle ear fluid, what needs to be excluded and how?
Postnasal space tumour incase it is blocking the eustacian tube
Use nasendoscopy to visualise
122
What are the risk factors for glue ear?
Boys, winter
PMH: downs, atopy, primary ciliary dyskinesia
SHx: passive smoking
123
When would you give surgery for glue ear?
(Chronic serous/secretory otitis media)
What do patients need to know about their grommets?
Persistent bilateral otitis media for 3 months +
With hearing in better ear below 25-30dB
No diving, use cotton wool and vaseline to plug ear when using shampoo
124
Pierre robin syndrome?
Micrognathia (short chin)
+/- cleft palate, eye abnormality, conductive deafness
125
Treacher collins syndrome?
Autosomal dominant
Eyes slant down, notch in lower eyelid, underdeveloped facial bones
Associated with deafness
126
Autosomal dominant causes of sensorineural hearing loss?
WAK
Waardenburg- hearing loss and odd coloured eyes/blue eyes
Alport- kidney disease, hearing loss, misshapen lens in eye or retinal defects
Klippel-Fiel - fused cervical vertebrae so short neck, restricted neck turning,n
127
Baby has sensorineural hearing loss, which autosomal recessive syndrome would they have if they also had:
A) goitre
B) retinitis pigmentosa (rod degeneration)
C) long qt interval
A) goitre = pendred
B) retinitis pigmentosa = ushers
C) long QT= jervell and lange-nielisen
128
Which x linked conditions may cause sensorineural hearing loss?
Alports- pyelonephritis, haematuria, renal failure
(Can also be autosomal recessive)
Turners- short stature, webbed neck
129
What screening tests can you do on a newborn to check for deafness?
Otoacoustic emissions-
Detects the sounds of fluid moving in the basilar membranes in response to auditory stimuli
Audiological brainstem responses-
Measure brain wave activity in response to earphones producing soft clicks
130
In what types of deafness will cochlear implants not help with?
What can cause this congenitally?
The h's
Central deafness-
hyperbilirubinaemia
hypoxia
intraventricular haemorrhage
131
When would you c...c...consider a bone anchored hearing aid?
3 C's
Can't use traditional hearing aids:
draining ear
mastoid cavity
topical sensitivity
Congenital malformations:
Microtia (no pinna)
Atresia (no external ear canal)
Can hear on one side (unilateral deafness)
132
What are the dangerous causes of unilateral deafness that need to be excluded?
Acoustic neuroma
Cholesteatoma
Nasopharyngeal cancer effusion
133
What is the definition of sudden sensorineural deafness in an adult?
(Rule of 3s)
Loss of more than 30dB
in three neighbouring pure tone frequencies
in 3 days
134
Gentleman comes in with sudden sensorineural deafness, he mentions he started antibiotics recently, what antibiotic could be the cause?
Gentamycin (ototoxicity)
135
What audiometry finding suggests otosclerosis?
| What is otosclerosis?
Cahart's notch: a dip dB threshold for bone conduction at 2kHz.
(85% bilateral)
Otosclerosis- replacement of lamellar bone with vascular spongy bone around the stapes footplate fixing it in place
136
Rx of otosclerosis?
Fluoride may inhibit sclerotic progression
Surgery to replace the adherent stapes with an artificial implant
Hearing aid
137
What are the ototoxic drugs to look out for on a drug chart?
| Will cause difficulties watching VHS of Gangsta's + Cowboys
Vancomycin
Hydrochloroquine (DMARD)
Streptomycin
Gentamycin
Chloroquine (malaria)
138
Postinfective causes of sensorineural deafness?
| Mmm, her philis flew
Meningitis
Mumps
Measles
Herpes
Syphilis
Flu
139
How are severe and significant hearing loss defined?
Severe- more than 100-120dB loss
| Significant- more than 35dB loss
140
Causes of pulsating tinnitus sounds in the ear?
Vascular causes: Tumours- glomus or carotid body
Vessel shape- Aneurysm, aortic stenosis, AV malformations
Cardio- hypertension, high output cardiac states (hyperthyroid, Pagets)
Anxiety
Benign intracranial hypertension
141
How does the type of tinnitus sound help point towards to the site of the problem?
Hissing, buzzing or ringing = inner ear or central
Popping or clicking = middle or external ear
Pulsatile = vascular/anxiety
142
Drug causes of tinnitus?
| Daaa
Loop diuretics
Aspirin
Aminoglycosides
Alcohol excess
143
Type of tumour in acoustic neuromas?
| Origin
Tumour of the schwann cell layer of the superior vestibular nerve (CN VIII)
144
Which cranial nerves may be affected in acoustic neuromas?
```
CN V (facial numbness)
CN VI (abducting eye)
CN VII
CN VIII (giddiness, deafness, tinnitus)
```
145
What is vibroacoustic disease?
An occupational disease occurring in workers
exposed to large pressure or low frequency noise
leading to abnormal growth of extracellular matrices in blood vessels, thickening pericardium and lung fibrosis etc
146
How do peripheral causes of vertigo differ in presentation from central causes?
Peripheral- often hearing loss, tinnitus, nausea, vomiting
| Central- hearing loss and tinnitus less common, tends to be less severe
147
Audiometry shows bilateral hearing loss of high frequencies, what is the likely cause in adults?
Presbycusis
| From death to hair cells with age
148
Inheritance pattern of otosclerosis?
Autosomal dominant
149
What signs may occur in Meniere's disease?
Nystagmus
| Rhomberg's sign +ve (fall over when closing eyes)
150
What inherited condition is associated with bilateral acoustic neuromas?
Other symptoms?
Neurofibromatosis type 2
```
Auto-dominant
Early cataracts (juvenile posterior subcapsular lenticular opacity)
May get meningiomas also
```
151
Signs of neurofibromatosis type 1?
```
Cafe-au-lait spots
Freckling in skin folds- axillae, groin
Dermal neurofibromas- skin coloured moles
Lisch nodules- brown mounds in iris
Short stature
```
152
Rx for trigeminal neuralgia?
Carbamazepine (antiepileptic)
153
Baby has a massive lump on the side of her neck that transilluminates brightly and is soft and fluctuant, likely diagnosis?
Cystic hygroma
| Congenital lymphatic lesion
154
A patient has a red eye, how do glaucoma and uveitis present differently?
Glaucoma- severe pain, halos, semi-dilated pupil, cloudy pupil
Uveitis- small fixed oval pupil, ciliary flush (ring of red spreading out from the cornea)
155
How does the duration of vertigo help indicate the possible cause?
Seconds to minutes- benign positional vertigo
Up to 30 minutes- Menieres
30 hours to a week- acute vestibular failure (follows febrile illness)
156
First line Rx for meniere's disease where the patient is throwing up?
Prochlorperazine (D2 receptor antagonist)
Betahistine may help (H3 histamine antagonist)
157
What causes benign positional vertigo?
Dislodged calcium carbonate crystals (otoconia) going from being embedded in cells, floating into the semicircular canal fluid
158
What test differentiates benign positional vertigo and a central cause of vertigo (and how?)
Hallpike manoeuvre:
Rotate the head 45 degrees, lie down suddenly with head extended 20 degrees, wait 45 secs. Look for nystagmus
CNS cause suggested if
If up and down beating nystagmus with no rotational nystagmus
No latency of 15-20 seconds before onset of nystagmus on lying
Nystagmus isn't fatiguable on repetitions
No dizziness
Electronystagmography
159
What happens to lines on a amsler grid in macular disease?
Intersecting lines appear wavy and squares distorted
160
Young guy has unilateral hearing loss, examination of ear is normal, possible diagnosis to exclude?
Acoustic neuroma
161
Retraction of the ear drum in the 'attic' commonly occurs with what?
Cholesteotoma, as the attic is the weakest thinnest part of the tympanic membrane and so more prone to retraction
162
Common cause of acute otitis media in children?
Viruses
Strep pneumo
Haemophilis
Moraxella catarrhalis
163
Describe the course and branches of the facial nerve
1. Pons- internal acoustic meatus- facial canal
2. Forms geniculate ganglion, gives off greater petrosal nerve with parasympathetic to lacrimal gland
3. Middle ear, gives off nerve to stapedius and chorda tympani
4. Stylomastoid foramen
5. Nerve to occipitofrontalis
Nerve to post belly of digastric and stylohyoid
Nerves to face (ten zebras broke my car)
164
Name for benign outgrowth of cartilage in the ear?
Exostosis
165
On ear examination what test can identify a patent eustacian tube?
Valsalva manoeuvre- check the ear drum moves
166
Why do accessory tags or fistulas/sinuses form congenitally in the ear?
Malfusion of the 1st and 2nd branchial arches
167
White patches on an eardrum are due to?
Tympanpsclerosis- calcium deposits following trauma or infection
Often of no significance unless severe (may cause conductive loss then)
168
Rx for severe otitis externa?
Meatus may be narrowed, take swab + scoop out wax/debris
Non-infected eczema = steroid drops
Infection = Steroid + antibiotic drops (sofradex)
Resistent pseudomonas = gent + hydrocortisone drops (max 2 weeks)
169
Patient has been using antibiotic and steroid drops for otitis externa for the last few weeks. What are they at risk of?
Fungal infection- clotrimazole Rx
170
What is the risk of diabetic or immunocompromised ear infection and Rx?
Necrotizing otitis externa- can lead to temporal bone destruction + osteomyelitis
Rx: surgical debridement, systemic antibiotics, Ig
171
Name for a very painful haemorrhagic blister deep in the ear canal + likely causative agent?
Bullous myringitis
Influenza
Rx: supportive
172
Drops that can be added in if wax is a problem in an otitis externa infection?
Sodium bicarbonate 5% drops
173
1st line investigation for someone with ear pain + redness with fever and a tender mastoid?
Mastoiditis
CT
Rx: IV antibiotics, incision of tympanic membrane (myringotomy)
174
Risk factors for otitis media?
Bottle feeding, use of a dummy
PC: Adenoids or cleft palate
PMH: URTI or GORD or Asthma
SHx: increased BMI in adults, passive smoking
175
Risk factors for otitis media with effusion (glue ear)?
Boys, winter season
PMH: atopy, Down's syndrome, primary ciliary dyskinesia
SHx: parents smoke
(Not infectious)
176
What are the indications for grommets?
Bilateral persistent hearing loss
| Where better ear hears
177
What do you need to tell parents if their child has grommets about what they can or can't do?
Swimming yes
Diving no (forces water into middle ear)
Ear plugs when washing hair
Grommets extrude after 3-12 months
178
What are the syndromes associated with congenital conductive hearing loss.
NB note conductive not sensorineural
Pierre Robin: small jaw, cleft palate
| Treacher Collins: small jaw, slanting eyes, malformed/absent ears
179
Autosomal dominant causes of sensorineural hearing loss?
WAK
Waardenburg: heterochromia, white lock of hair, wide set eyes
Alport: haematuria, cataracts
Klippel-Feil: limited movement of neck, scoliosis, cleft palate, short stature
180
Autosomal recessive causes of sensorineural hearing loss?
PUJ
Pendred: goitre
Usher's: retinitis pigmentosa
Jervell + Lange-Nielson: long QT interval
181
X linked causes of sensorineural hearing loss?
Alport's- haematuria, cataracts
| Turner's- webbed neck, short stature, XO
182
What hearing tests does a baby undergo and at what age?
Newborn hearing screening: within hours of birth
(Otoacoustic emissions + brainstem responses)
7 months: distraction testing
2-4 years: speech discrimination, conditioned response audiometry
5 years: pure tone audiogram
183
What imaging can damage cochlear implants?
MRI
184
Cause of gradual hearing loss with old age?
Presbycusis: loss of high-frequency sounds as hair cells are destroyed.
Problems encountered when high frequency vibrations of consonants cannot be heard.
185
What imaging can help to elucidate a cause in adults with hearing loss?
MRI- MS or Schwannoma
| CT- cholesteatoma
186
What is the difference between vestibular neuritis and viral labyrinthitis?
Both tend to be viral, often proceeded by URTI and may have vertigo and vomiting.
Neuritis = nerve inflammation, labyrinthitis = inner ear
Neuritis affects vestibular branch, doesn't cause hearing loss
Labyrinthitis affects cochlear nerve also so hearing loss
187
What determines 1st line Rx in Meniere's disease?
Salt restriction
If vomiting: prochlorperazine (Dr antagonist)
If not: betahistine (histamine analogue)
188
Red flags that should not be present in a likely benign positional vertigo diagnosis?
1. Persistent vertigo
2. Speech, visual, motor or sensory problems
3. Tinnitus, headache, ataxia, facial numbness, dysphasia
4. Vertical nystagmus
189
What is the Hallpike test and what is it used to diagnose?
Benign positional vertigo
Patient sitting, examiner extends their neck and turns head to one side
Rapidly lower patient so laying flat with head hanging over the edge of the bed
Nystagmus after 5 seconds that lasts for 1 min is +ve
190
Rx for benign positional vertigo?
Epley manoeuvres:
Rapidly lower patient to supine
Rotate head quickly to the left, wait 30 seconds
Patient rolls onto left side, turn head to face floor
Patient is rapidly repositioned to sitting position
Or drugs (prochlorperazine/betahistine)
191
Difference between Rx for acute and chronic rhinosinusitis?
NB- not allergic rhinosinusitis
Acute- less than 12 weeks
Topical corticosteroids + oral antibiotics
Chronic- more than 12 weeks
Topical steroids + nasal douching
192
Difference in presentation between allergic rhinosinusitis and infectious rhinosinusitis
Allergic: sneezing, pruritis, atopy
Infectious: loss of smell, facial pain/pressure
193
Histology of nasal polyps?
Ciliated columnar epithelium
| thickened basement membrane
194
Rx to get rid of nasal polyps?
Steroid drops
Oral steroids
Antileukotrienes + ciprofloxacin
195
IHx for a unilateral single polyp?
CT + biopsy
| May be malignant
196
What investigation is used to identify the presence of tau transferrin in clear nasal discharge to determine the presence of a CSF leak?
Immunoelectrophoresis
+ a lab glucose (+ve in CSF)
197
In managing a nosebleed what protective layers should be worn?
Gloves
Gown
Goggles
198
Steps of nosebleed management:
1. Gloves, gown, goggles
2. 15 mins of pinching nose
3. 0.5% ephedrine drops + ice on dorsum nose
4. Remove clots, spray lidocaine
5. Silver nitrate cautery for bleeding points
199
Nosebleed, silver nitrate hasn't worked, next steps?
1. Pack nose (lubricate pack)- remove after 24 hours
2. Postnasal pack (foley catheter, filled with water)
Admit patients with packs.
3. Serious posterior bleeds: endoscopic ligation of maxillary or sphenopalatine artery
200
Child has tonsillitis, you note that they have some skin peeling. What do you need to be thinking of?
```
Kawasaki-
5 day fever + 4 of:
Non-purulent conjunctivitis
Lymph nodes
Dry lips/strawberry tongue
Rash on trunk
Joint pain, palmar erythema
```
201
Rx for tonsillitis fulfilling the centor criteria?
Penicillin
Allergic: erythromycin
Not amoxicillin
202
Rx for quinsy (peritonsillar abscess)?
Antibiotics: penicillin + metronidazole
+ Fine needle aspiration
NB preferred to surgical drainage but requires a cooperative child
203
What is distinctive about Scarlet fever?
Rash on chest, axilla or behind the ears
Accentuated in skin folds
+ strawberry tongue
204
Which infections can cause acute disseminated encephalopmyelitis because of their antigenic mimicry to CNS epitopes?
Mycoplasma (hence Guillian Barré)
Streps (post-scarlet fever)
EBV
205
Children under what age can't have a surgical cricothyrotomy?
Under 12 years
206
Management of salivary gland swellings?
Remove if present for 1 month +
| Or examine with fine needle aspiration, unlike neck lumps less fear of seeding tumour cells
207
Rx of pleomorphic adenoma?
1st: superficial parotidectomy
2nd: radiotherapy if recurrent or residual disease post-surgery
208
What symptoms makes a parotid tumour more likely to be malignant than an adenoma?
CN VII palsy
209
Children under what age can't have a surgical cricothyrotomy?
Under 12 years
210
Management of salivary gland swellings?
Remove if present for 1 month +
| Or examine with fine needle aspiration, unlike neck lumps less fear of seeding tumour cells
211
Rx of pleomorphic adenoma?
1st: superficial parotidectomy
2nd: radiotherapy if recurrent or residual disease post-surgery
212
What symptoms makes a parotid tumour more likely to be malignant than an adenoma?
CN VII palsy
