ENT Flashcards
Is an inferior relation of the pituitary gland
Sphenoid sinus
Is a medial relation of the nasolacrimal duct
Inferior concha
A posterior relation to the supra ciliary arch
Frontal sinus
Is related inferiorly to the molar teeth
Maxillary sinus
Is a medial relation of the orbit
Ethmoid sinus
The anatomy of the nose and nasal sinuses are important in both ENT and neurosurgery - particularly pituitary surgery.
The important relations of the pituitary and surgical axis to the pituitary should be understood, together with the relations of the sinuses to the orbit, teeth and their neurovascular contents.
A 10-year-old boy presents with hoarseness of voice. On examination of the larynx, there are two pedunculated swellings over the vocal cords. He is otherwise well.
Laryngeal papillomata
Laryngeal papillomata, caused by papilloma virus, occur mainly in children but can also present in adults. They are commonly found over the vocal folds but sometimes may spread throughout the larynx and the tracheo-bronchial tree. These papillomas can be successfully treated by laser surgery.
A 42–year-old market trader presents with hoarseness of two months duration. He is a social drinker and smokes 10 cigarettes a day. On examination of the larynx, both cords are slightly red with small swellings on each cord. He is systemically well.
Singer’s nodules
Singer’s nodules are associated with overuse or misuse of voice. Resting the vocal cords is usually adequate to treat small lesions. Larger lesions may require surgical removal.
A 65-year-old known chronic obstructive pulmonary disease patient on steroid inhalers and who smokes 20 cigarettes per day presents with hoarseness of voice of three months duration. On examination, the throat appears inflamed with white patches. In addition, the larynx and vocal cords also appear red and beefy.
A 65-year-old known chronic obstructive pulmonary disease patient on steroid inhalers and who smokes 20 cigarettes per day presents with hoarseness of voice of three months duration. On examination, the throat appears inflamed with white patches. In addition, the larynx and vocal cords also appear red and beefy.
Candidiasis of larynx
Candidiasis of the larynx is common in patients using steroid inhalers. Very young or old, diabetics, immuno-suppressed (cytotoxics, steroids, haematological malignancies, AIDS) are at an increased risk. These lesions appear as creamy white patches on the mucosa, surrounded by a thin margin of erythema. Patches are hard to remove and they bleed if scraped. Antifungal agents such as nystatin or amphotericin B are useful to treat this condition, and antibiotics should be withdrawn if possible.
A mother is concerned regarding the incessant screaming of her 24-hour-old female infant. On examination, the baby has a temperature of 37.8°C and has an inflamed right tympanic membrane.
Cefotaxime IV
The neonate has features suggestive of otitis media with an inflamed tympanic membrane.
In newborns, Gram negative enteric bacilli, particularly Escherichia coli, and Staphylococcus aureus cause suppurative otitis media. The most appropriate treatment for the neonate is IV cefotaxime to ensure appropriate coverage of these organisms that may be resistant to penicillins.
A 12-year-old boy presents with earache following an air journey a week ago. On examination the drum is not inflamed, but fluid is noted in the middle ear.
Analgesia
This boy has features of serous otitis media and requires only simple analgesia with paracetamol.
A 3-year-old boy is brought to clinic with a history of tugging at his ear. He has a temperature of 36.7°C, and examination reveals a red inflamed ear canal but the eardrum cannot be observed due to pain.
Analgesia
This child has otitis externa with ear pain and redness of the canal preventing observation of the eardrum.
He needs adequate analgesia, and it may be possible to clean the ear canal with a cotton bud or gentle suction. The ear canal needs to be visualised in order to exclude otitis media, and this should be done before topical antibiotic and/or corticosteroid is used. Risk factors associated with otitis externa include swimming and cleaning the ears with cotton wool buds.
A 3-year-old girl presents with a two day history of fever and mild nausea. On examination she has a temperature of 39.5°C and her left tympanic membrane appears red and inflamed with fluid behind it.
Amoxicillin oral
This girl with fever and nausea also has otitis media and should be treated with oral antibiotics. Adequate analgesia will be helpful in improving symptoms and fever, and oral antibiotics can then be trialled in the first instance. Amoxicillin is regarded as the first line treatment for this condition.
A 45-year-old male presents with headaches and is diagnosed with acromegaly.
Macroglossia
Acromegaly is associated with enlargement of hands, tongue, feet and typical facial appearance. The condition is also associated with hypertension and diabetes and is due to excess GH secretion from a pituitary tumour.
Other causes of macroglossia include Down’s syndrome and hypothyroidism.
A 23-year-old female with a longstanding history of epilepsy for which she takes phenytoin.
Gingival hyperplasia
Phenytoin is associated with gingival hyperplasia as a well recognised side effect. Other causes include calcium antagonists (rarely), cyclosprin and pregnancy.
A 45-year-old female presents with tiredness and menorrhagia. She is found to have an iron deficiency anaemia.
Angular stomatitis
Iron deficiency anaemia, like pernicious anaemia, is associated with angular stomatitis.
There is inflammation and erythema of the corners of the mouth.
Other causes are multiple and include inflammatory bowel disease.
A 32-year-old male presents with weight loss, fever and fatigue. He is diagnosed with AIDS.
Hairy leukoplakia
AIDS is associated with numerous oral signs including
Oral candidiasis
Oral, gingival regression
Kaposi’s sarcoma
and, like the latter, hairy leukoplakia is classically associated.
A 34-year-old man presents with painful ears headache, fever and nasal discharge.
Sphenoid sinusitis
Sphenoid sinusitis. Ear pain is referred via the greater auricular branch of the trigeminal nerve (C2,3). Pain from the teeth may also be similarly referred to the ears.
A 5-year-old boy complains of pain in his right ear. he has hearing loss, a low grade fever and has had repeated right middle ear infections. There is a swelling behind his ear.
Mastoiditis complicates partially or untreated otitis media. Classically there is also a swelling behind the affected ear. Treatment is with antibiotics.
A 40-year-old business executive presents with painful ears and a hearing loss after disembarking from a transatlantic flight. He had been suffering with a ‘cold’ for one week.
Barotrauma
Barotrauma is due to damage to the tympanic membrane by changes in atmospheric pressure especially in presence of an occluded (Eustachian)tube. Divers and air travellers are most at risk. Clinical features include ear pain, feeling of pressure in ears and conductive deafness.
A 72-year-old lady is being treated for myocardial infarction in the coronary care unit. She has been thrombolysed 72 hours ago and is being anticoagulated for a refractory atrial fibrillation. She has developed epistaxis. Her observations are all normal but the nurse has noticed that she bruises very easily.
Drug induced
Splenomegaly in the boy gives the clue to the suggested diagnosis of ITP.
An 8-year-old boy presents with epistaxis. He has multiple bruises which according to the parents result from seemingly trivial injuries. He has a cousin with a similar problem who is receiving steroids for it. On examination, he is also found to have splenomegaly.
Idiopathic thrombocytopenic purpura (ITP)
Epistaxis or nasal bleed is a very common condition.
Causes for epistaxis, like most conditions, could be classified into:
Traumatic - fractures of the nasal bones, maxilla, and floor of the cranial cavity or soft tissue injury around the nasal cavity. Nose picking is the most common cause of epistaxis in children.
Neoplastic - include both benign (angiofibroma of nasal cavity) and malignant (maxillary or other paranasal sinus carcinoma, Kaposi sarcoma). Nasal polyps are a common cause of epistaxis but these are generally produced by mucosal hypertrophy rather than true hyperplasia and so are not strictly neoplastic.
Infective - are rare causes of epistaxis. However, severely congested conchae could bleed with very trivial trauma. Orf is one infective cause of infective epistaxis. Ulcers due to sexually transmitted disease are also described.
Systemic illnesses - a variety of systemic illnesses could give rise to nasal bleed. The common ones for a spontaneous epistaxis are hypertension, bleeding diathesis including haematological malignancies.
Miscellaneous - these include medications including anticoagulants.
In the patient with myocardial infarction, epistaxis is probably due to thrombolysis and/or anticoagulation.
A 55-year-old carpenter presented to his GP with recurrent episodes of spotty bleeding from his right nostril. He also states that the right nostril seems to be perpetually blocked for the last six months in spite of all the decongestants he has bought off the counter. On examination, right maxillary prominence is noted. Anterior rhinoscopy reveals a fleshy mass obstructing the right nasal cavity. He has associated unilateral diplopia on the right side.
Maxillary adenocarcinoma
The gentleman’s symptoms, his occupation and the examination findings of fleshy mass, maxillary lump and unilateral diplopia point to the obvious cause of his epistaxis.
A 12-year-old boy hit his head on a pole on the school playground. His nurse sent him to the emergency department as he had a small nasal bleed that stopped spontaneously. In the intervening two hours, he has noticed a watery discharge from his nose. On examination there is considerable bruising on his nose and forehead.
Ethmoid bone fracture
Epistaxis or nasal bleed is a very common condition.
Causes for epistaxis, like most conditions, could be classified into:
Traumatic - fractures of the nasal bones, maxilla, and floor of the cranial cavity or soft tissue injury around the nasal cavity. Nose picking is the most common cause of epistaxis in children.
Neoplastic - include both benign (angiofibroma of nasal cavity) and malignant (maxillary or other paranasal sinus carcinoma, Kaposi sarcoma). Nasal polyps are a common cause of epistaxis but these are generally produced by mucosal hypertrophy rather than true hyperplasia and so are not strictly neoplastic.
Infective - are rare causes of epistaxis. However severely congested conchae could bleed with very trivial trauma. Orf is one infective cause of infective epistaxis. Ulcers due to sexually transmitted disease are also described.
Systemic illnesses - a variety of systemic illnesses could give rise to nasal bleed. The common ones for a spontaneous epistaxis are hypertension, bleeding diathesis including haematological malignancies.
Miscellaneous - these include medications including anticoagulants.
Ethmoid bone fracture is the only traumatic cause in this list of differentials provided and so is the cause of epistaxis in the boy.
An 80-year-old male presents with a history of epistaxis of two hours duration. He states that he feels light headed on occasions and is aware of tiredness. He has otherwise been quite well.
Hypertension
In the absence of any other signs or features in the 80-year-old man who presents with headaches and tiredness, the most likely cause for these symptoms and epistaxis would be hypertension- particularly common in the elderly and usually isolated systolic hypertension - systolic above 140, diastolic below 90.
