ENT

Question 1

Conductive hearing loss - def and causes

Answer 1

D - Impaired sound transmission via external canal or inner ear.

C - Caused by external obstruction, drum perforation, ossicular degeneration (otosclerosis, infection, trauma) and inadequate eustachian ventilation e.g. nasopharyngeal carcinoma).

Question 2

Sensorineural hearing loss - def and cause

Answer 2

D - Defects central to the oval window.

C - Caused by drugs (the mycins, chloroquine), post-infective (meningitis, measles, mumps, flu, herpes, syphilis). More rarely - acoustic neuroma, B12 def, MS, brain mets.

Question 3

Otosclerosis - def, cause, sy, mx

Answer 3

D - New bone forms around stapes footplate.

C - AD, incomplete penetrance, 50% have FH.

Sy - Conductive deafness, hearing made better with background noise, worse in preg. +- vertigo and pink tinge to drum.

Mx - Hearing aid or stapedectomy.

Question 4

Presbyacusis - def, when worst, Mx

Answer 4

D - Age-related, high freq SNHL due to loss of hair cells. Normal is -10 to 25dBHL

Most affected when there is background noise.

Mx - Hearing aids

Question 5

Benign paroxysmal positional vertigo - def, Sy, Ix, Mx

Answer 5

D - otoconia stimulate semicircular-canals.

Sy - sudden 30s attack evoked by head turning. No other sy.

Ix - Dix-Hallpike test.

Mx - Usually self-limiting. Epley manoeuvre.

Question 6

Meniere’s disease - Def, Sy, Mx.

Answer 6

D - Dilation of endolymphatic spaces of the labyrinth.

Sy - Sudden attack of vertigo 2-4hrs, nystagmus, tinnitus, fullness. +- fluctuating SNHL.

Mx - Prochlorperazine and betahistine for prophylaxis.

Question 7

Acute vestibular failure - AKA vestibular neuronitis / labarynthitis - Sy, Mx.

Answer 7

Sy - sudden attcks of vertigo and vomiting following infection, often UTI. Lasts 1-2dys. Nystagmus away from affected side.

Mx - Prochlorperazine

Question 8

Head and neck SCC - RF, Sy, Mx.

Answer 8

RF - smoking, alcohol, vit A/C def, nitrosamines in salted fish, HPV, GORD.

Sy - usually in hypopharynx. Neck lump/pain, >6wks hoarse voice/sore throat, mouth bleeding, numbness, sore tongue, ulcers, speech change, dysphagia.

Mx - Endoscopy then CT and MRI. Surgery. If mets can do block neck dissection to remove all the lymph nodes.

Question 9

Oropharyngeal carcinoma - RF, Sy, Mx.

Answer 9

RF - Pipe smoking, chewing tobacco, HPV esp 16 (oral sex).

Sy - Older smoker with sore throat, sensation of lump, referred otalgia.

Question 10

Laryngeal cancer - Sy, Ix, Mx.

Answer 10

Sy - either older smoker with progressive hoarseness then stridor, dysphagia, haemoptysis OR younger with HPV.

Ix - Laryngoscopy for biopsy, MRI, HPV status.

Mx - If small radiotherapy, if large laryngectomy. Post-laryngectomy can use voice prosthesis or artificial larynx.

Question 11

Stridor - def, causes, Mx

Stertor - def

Answer 11

D - high pitched inspiritory noise caused by partial obstuction of larynx or large airways.

C - Congenital (laryngomalacia, vascular ring), inflammation (laryngitis, epiglottitis, croup, anaphylaxis), tumours, trauma.

Mx - Give O2 or heliox (helium and O2), neb adrenaline, consider intubation, or cricothyroidotomy.

Stertor - inspiratory snoring noise caused by obstruction of pharynx.

Question 12

Croup - Cause, Sy, severity, Mx.

Answer 12

C - Viral URTI. Parainfluenza virus (esp T1), RSV.

Sy - MOST COMMON CAUSE OF STRIDOR, barking cough, resp distress.

S - Mild no stridor at rest, mod freq cough stridor at rest, severe resp distress.

Mx - Dexamethasone 0.15mg/Kg, nebulised 1:1000 adrenaline if severe. Admit and observe if moderate or severe.

Question 13

Acute epiglottitis - Sy, Mx.

Answer 13

Sy - Short hx of fever, irratability, sore throat, drooling, no cough. Now rare due to HIb vaccine.

Mx - Do not examine, diagnosis made by laryngoscopy in theatre.

Question 14

Acute otitis media - Sy, Mx, complications.

Answer 14

Sy - Rapid onset otalgia, fever, irritability, often after viral infection. If tympanic membrane perfs will releave pain but cause purulent d/c.

Mx - Analgesia. Amox if systemically unwell.

C - Glue ear - usually resolves, refer for audiogram, observe for 3m, can insert grommet. Chronic OM - perf with chronic infection, Mx topical Abx.

Question 15

Cholesteatoma - Def, Sy, Mx.

Answer 15

D - A locally destructive pocket of epithelia.

Sy - Foul d/c, deafness, headache, pain, facial paralysis. Can be post-chronic OM.

My - mastoid surgery.

Question 16

Facial fracture

Answer 16

Nasal - drain septal haemoatoma, reassess one week after injury, can manipulate if fracture.

Mandible - order orthopantogram and refer to maxfax.

Question 17

Bells palsy - RF, Sy

Answer 17

RF - pregnancy, diabetes.

Sy - sudden onset paralysis of one side of the face. Mouth sags, dribbling, watery eyes. Idiopathic, most common cause of facial palsy.

Mx - 25mg pred for 10days if present within a few days of onset. Refer to ENT if recurrent, bilateral, or does not improve in 1month.

DDX - Ramsay Hunt, check ear!

Question 18

Rhinosinusitis - acute, chronic, allergic.

Answer 18

D - Inflammation of the nose/sinuses with 2+ sy.

Sy - Congestion, nasal discharge, facial pressure/pain, loss of smell.

Acute - common cold, consider nasal steroids if persists.

Chronic - Can be due to polyps or not. Give 4 weeks mometasone or fluticasone (head down on insertion). Mouth breathing, snoring, obstruction makes polyps more likely. If does not improve consider endoscopy and surgery. N.B. rare in children, rule out neoplasms.

Question 19

Acoustic neuroma - Def, Sy, Mx.

Answer 19

D - Indolent benign tumour that causes problems by mass effect.

Sy - Progressive ipsilateral tinnitus, +- deafness, giddiness.

Mx - stereotactic radiosurgery. Difficult.

Question 20

Salivary gland tumours - Histology, RF, Sy, Ix, Mx.

Answer 20

H - 80% occur in parotid, 80% are benign pleomorphic adenomas, 80% superficial lobe.

RF - Radiation to the neck, smoking.

Sy - Increased risk of malignancy if hard, fixed, painful, does not vary in size when eating, facial nerve palsy.

Ix - US/MRI, FNAC/biopsy.

Mx - surgery/radiotherapy.

Question 21

Salivary gland obstruction - name the 3 pairs of glands, sialadenitis, sialolithiasis, differentials.

Answer 21

Pairs - parotid, submandibular, sublingual.

Sialadenitis - infection of the glands usually in elderly with poor oral hygiene. Swelling of the gland with fever, pus may be seen. Mx - Abx, lemon drops to stimulate salivation.

Salivary stones - usually submandibular gland as thicker secretions, pain and swelling of the gland during and after meals. Ix - USS, sialogram. Mx - lemon juice (sialogogues) or surgery if large.

If no stones - Sjogrens syndrome (dry mouth and eyes), mumps, HIV, TB and sarcoid.

Question 22

Cervical lymphadenopathy - Acute, persistent

Answer 22

Acute - usually a local infection, also Kawasaki disease.

Persistent - eczema, infections (EBV, cytomegalovirus, TB, HIV), lymphoma/leukaemia, arthritis, lupus. Follow up with bloods if concerned.

Question 23

Midline lumps - younger patient, moves on swallowing only, moves when protrude tongue, bony hard.

Answer 23

Dermoid cyst - younger patient, embryological remnant, removed surgically when older as can have malignant core.

Thyroglossal cyst - between hyoid and thyroid.

Thyroid mass - Within thyroid, seen in older patients.

Chondroma - benign cartilage tumour.

Question 24

Submandibular triangle

Answer 24

Reactive lymphadenopathy

Malignant lymphadenopathy - firm, non-tender, fever, night sweats, weight loss.

Submandibular stone, tumour or infection.

Question 25

Anterior triangle - lymphadenopathy, branchial cyst, laryngoceles, carotid body.

Answer 25

Lymphadenopathy - Common.

Branchial cyst - ant border of SCM where upper 1/3 meets middle 1/3. Lines with squamous epi and contain cholesterol crystals. Mx - excision.

Laryngoceles - painless, worse when blowing.

If pulsatile - could be carotid aneurysm, tortuous artery, carotic body tumour. Rare, move side to side not up and down.

Question 26

Posterior triangle - Cervical ribs, pharyngeal pouch, cystic hygromas.

Answer 26

Cervical ribs - enlarged C7 can cause neuro sy on brachial plexus or Raynauds.

Pharyngeal pouch - protrude on swallowing.

Cystic hygromas - lymphatic malformations that transluminate brightly. Mx - surgery or hypertonic saline to sclerose.

Question 27

Mouth ulcers - local causes, infective, systemic causes.

Answer 27

Local - mechanical, thermal or chemical trauma. Recurrent aphthous ulceration (AKA Canker sores) - clearly defined shallow ulcers caused by trauma or stress. SCC (may be leukoplakia or erythroplakia).

Infective - HHV 1/2, HHV-8 Kaposi’s sarcoma, candida albicans, Coxsackie A virus (hand/foot/mouth disease).

Systemic - Bechets, Kawasaki, Lichen planus, pemphigoid, chrohns.

Question 28

Leukoplakia - def, cause.

Answer 28

D - White patch which cant be rubbed off, premalignant lesion.

C - Chronic irritation, candidiasis, vit A/B def.

Mx - Biopsy if suspicious. Surgical or cryotherapy removal.

Question 29

Temporal mandibular joint dysfunction - Sy, Si, Mx.

Answer 29

Sy - Otalgia, facial pain, joint clicking, stress (psychiatric, may become chronic pain).

Si - tender on lateral movement of open jaw.

Mx - analgesia, reassure, CBT.

Question 30

Epistaxis - anterior, posterior, Mx

Answer 30

Ant - most common, less severe, usually Little’s area of the septum.

Posterior - harder to assess and may be more severe.

Mx - Pinch nose for 20m and lean forward +- ice pack on dorsum of the nose. Suck out clots, apply cotton ball with 1:20,000 adrenaline or use LA, cauterise with silver nitrate. Apply anterior nasal pack (remove after 24hrs). If continues try postnasal pack e.g. foley 16G and clamp to stop falling into airway.

Question 31

Anaphylaxis - Sy, Mx.

Answer 31

Sy - Sudden onset progressive ABC problems, urticaria, angioedema.

Mx - High flow O2, adrenaline 1:1000 500 micrograms IM, IV fluid challenge, also give IM/IV chlorphenamine (antihistamine) and hydrocortisone. Observe for 8hrs as can have biphasic attack. Send home with 3 days of pred and chlorphenamine. Refer to allergy, consider giving epipen.

Congenital angioedema - low C1 esterase inhib.

Question 32

Audiometry

Answer 32

Tests hearing using headphones and bone conductor from 250-8000Hz and compared to normal hearing (-10 - 25dBHL).

Question 33

Tympanometry

Answer 33

Measures pressure of the middle ear to Ix conductive deafness. Peak compliance happens when external and middle ear pressures are equal. If peak is increased - ossicle disruption of flaccid TM. If flat and low - fluid in ear, if flat and high - grommets or perf.

Question 34

Vestibular sedatives - Name, mechanism, use.

Answer 34

Prochlorperazine / cinnarizine - D2 antagonists, used to decrease N + V in Menieres.

Question 35

Otitis externa Mx

Answer 35

7dys erythromycin with steroid topical. Avoid gent if perforation!!!

Question 36

Hearing aids -

Answer 36

Types - May be behind ear or in ear. Bone anchored - transmit via bone conduction. Cochlear implant - profound SNHL with normal cochlear structure.

Question 37

Vestibular rehab - def

Answer 37

Exercise helps reduce vertigo and unteadiness in vestibular problems by compensating with other modalities (vision balance training).