ENT Flashcards
(124 cards)
1
Q
What are the main differentials for vertigo?
A
- benign paroxysmal positional vertigo
- menieres disease
- vestibular neuronitis /labrynthitis
- iron deficiency anaemia
2
Q
describe the features of BPPV?
A
episodic vertigo - lasts for seconds
occurs when turn head e.g. in bed
relapsing remitting
3
Q
What is BPPV precipitated by?
A
upper resp viral infection
head injury
inner ear pathology e.g. vestibular neuronitis
ear surgery
4
Q
How is BPPV diagnosed?
A
dix hallpike manoeuvres - nystagmus if +ve
5
Q
How is BPPV managed?
A
Epley Manoevres - by specialist
or Brandt Daroff exercises at home
6
Q
Describe the features of menieres disease?
A
- episodic vertigo - lasts for 20 mins - 12 hours
- tinnitus - precedes the attack
- aural fullness “pressure, warm feeling in ear”
- hearing loss
-> leads to chronic unsteadiness and hearing loss
7
Q
How can menieres disease be managed through lifestyle?
A
salt restriction
stop smoking
caffeine restriction
consider risks before driving, swimming, diving or operating machinery
8
Q
How can menieres disease be managed with medication?
A
- anti emetic and anti histamine (e.g. cyclizine) for nausea
- betahistine for reducing endolymphatic fluid imbalance in inner ear
- IV labarynthe sedatives and fluids
9
Q
Define vestibular neuronoitis?
A
inflammation of the vestibular nerve, usually by viral infection
10
Q
Define labarythitis?
A
inflammation of the labarinth
11
Q
how does vestibular neuronitis present?
A
sudden onset debilitating vertigo for 2-3 days + gradual recovery over few weeks
nausea and vomiting
unsteadiness
unwell for first few days
12
Q
What sign can you see on examination of vestibular neuronitis?
A
Head Impulse Nystagmus Type Skew deviation test
13
Q
How is vestibular neuronitis managed?
A
- supportive care - for nausea and vomiting can give oral /IM cyclizine or prochlorperazine but delays recovery time as interferes with cerebral compensatory mechanisms
- if persist for >6 weeks, consider referral
14
Q
List the differentials for a sore throat?
A
tonsilitis pharyngitis glandular fever quinsy laryngitis epiglottitis diphtheria
15
Q
What are the causes of tonsilitis?
A
- VIRAL (80%) - epstein barr virus **, herpes simplex, adenovirus
- BACTERIAL (20%) - streptococcus pyogenes** , strep pneumonia, staph aureus
16
Q
What are the common features of tonsilitis?
A
- sore throat
- fever
- malaise
- cervical upper anterior lymphadenopathy
+ anorexia, dysphagia, halitosis
bacterial infection is a MORE SEVERE ILLNESS
17
Q
Which criteria is used to assess the likelihood that the tonsilitis is a bacterial infection?
A
CENTOR CRITERIA
- fever
- tonsillar exudate
- tender anterior cervical adenopathy
- no cough
18
Q
How is the centor criteria calculated and what does each score mean?
A
1 pt for each criteria + 1pt for age <15 y/o (subtract 1pt if > 44y/o)
0-1 pt = no antibiotics needed
2-3 pts = throat culture + antibiotic if culture +ve
4-5 pts = treat with antibiotic
19
Q
Describe the appearance of tonsilitis on examination?
A
oedematous + yellow +/- white pustules
20
Q
How is a bacterial tonsilitis treated?
A
phenoxymethylpenicillin (or erythromycin) for 7-10 days
supportive care - bed rest, hydration, analgesia
21
Q
What are the complications of tonsilitis?
A
peritonsillar abscess (quinsy) otitis media rheumatic fever scarlet fever glomerulonephritis
22
Q
What are the indications for a tonsillectomy?
A
> 7 bacterial infections in 12 months
1 quinsy
suspected malignancy
sleep disordered breathing e.g. sleep apnoea
23
Q
What are the complications of tonsillectomy?
A
haemorrhage, pain
24
Q
What is the most common cause of chronic sore throat?
A
pharyngitis- caused by adenovirus, enterovirus, rhinovirus
25
How is pharyngitis treated?
paracetemol or ibuprofen
bed rest
plenty of fluids
26
What is the cause of glandular fever?
Epstein Barr virus (HHV4)
27
How does glandular fever present?
FOR 2-4 WEEKS:
1. sore throat
2. fever
3. cervical lymphadenopathy - anterior and posterior triangles
+ anorexia, tiredness, headache, hepatosplenomegaly
28
How is glandular fever investigated and diagnosed?
1. MONOSPOT *test - confirms in week 2
2. FBC *
+ UandE , LFTS (causes hepatitis)
29
what would you find on examination of someone with glandular fever?
tonsils greatly enlarged and covered by membranous exudate
+ petechial haemorrhages + hepatosplenomegaly
30
How is glandular fever managed and what advice should be given?
1. supportive care - bed rest, analgesia, fluids
2. avoid alcohol
3. avoid contact sports for 8 weeks (at risk of splenic rupture)
31
What happens if you take amoxicillin whilst having glandular fever?
maculopapular pruritic rash
32
What is quinsy?
= peritonsillar abscess
abscess/ pus forms between the tonsil capsule and superior constrictor muscle from a bacterial tonsillitis
33
How does a peritonsillar abscess typically present?
usually after bacterial tonsilitis
```
severe unilateral sore throat
"hot potato" voice
dysphagia -> can result in dribbling
trismus = difficulty opening mouth
cervical adenopathy
reduced neck mobility
```
34
Explain the findings on examination of quinsy?
uvula deviation
unilateral tonsillar inflammation
cervical adenopathy
reduced neck mobility
35
How is quinsy managed?
1. refer to hospital
2. IV penicillin
3. surgical aspiration under local anaesthetic
4. tonsillectomy
36
List the differentials for facial pain?
1. atypical facial pain
history of depression, vague history, unresponsive to medications
2. trigeminal neuralgia
sharp pain in maxillary and mandibular regions,
Rx: carbamazepine
3. giant cell arteritis
+ jaw claudication, scalp tenderness, fever, amaurosis fugax, polymyalgia rheumatica
Rx: high dose pred
4. sinusitis
5. dental causes
e. g. abscess
6. migraine
+ severe unilateral pulsating throbbing pain, nausea
Rx: NSAIDS, triptans
7. ENT malignancy e.g. malignant pleomorphic adenoma
37
Define sinusitis?
inflammation of the mucous membranes of paranasal sinuses
38
List the 4 paranasal sinuses
1. frontal sinus
2. ethmoidal sinus
3. sphenoidal sinus
4. maxillary sinus
39
What is the common cause of sinusitis?
viral / bacterial infection - strep pneumonia **, h. influenza*, rhinovirus
40
What are the risk factors for sinusitis?
```
recent local infection
smoking
swimming / diving
nasal polyposis
deflected nasal septum or turbinate hypertrophy
```
41
List the features of acute sinusitis?
diffuse throbbing headache and facial pain - pressure in the forehead, between eyes and occipital ***
pain worse on bending forward
post coryzal nasal congestion and discharge
recurrent
halitosis
42
How is sinusitis treated?
1. analgesia e.g. paracetemol, codeine
2. intranasal decongestant or nasal drops e.g. oxymetazoline
3. saline irrigation
4. steam or menthol inhalations
if severe and suspect bacterial cause, give phenoxymethylpenicillin
43
What is a possible complication of sinusitis?
periorbital cellulitis, brain abscess, meningitis
44
When would a pt with sinusitis be referred to surgery?
refer if >3 antibiotics needed throughout the year, if suspected intracranial/ orbital involvement , refer for CT
1. intranasal polypectomy
2. septal correction
45
List the LOCAL causes of epistaxis?
```
idiopathic **
trauma e.g. injury, nose picking, surgery
foreign body
infection
neoplasia
```
46
List the GENERAL causes of epistaxis?
coagulation disorders e.g. thrombocytopenia, ITP, splenomegaly
drugs e.g. aspirin, warfarin, cocaine use
malignancy e.g. leukaemia
Hypertension
hereditary haemorrhagic telangiectasia
47
What are two areas that can bleed in epistaxis?
ANTERIOR (90%) - epistaxis occurs in Kiesselbachs plexus (littles area)
POSTERIOR - more profuse bleeding and from deeper structures (higher risk of aspiration and airway compromise)
48
How are nose bleeds initially managed?
ABC + Trotters method = nostrils pinched together, patient leans forward, mouth open
+ topical anti septic (Naseptin) - to reduce crusting and vestibular risk
49
If epistaxis continues after initial first aid measures, what should you do?
1. assess blood loss - BP, pulse, signs of shock, FBC, clotting screen and cross matched
2. cauterize with local anaesthetic spray and silver nitrate
3. if continue to bleed, use anterior nasal pack -> POSTNASAL PACK
4. if continues need to examine under anaesthetic with arterial ligation
50
after epistaxis, what lifestyle advice is given?
avoid picking nose
avoid hot drinks, alcohol
avoid heavy lifting or exercise
avoid lying flat
51
List the differentials for cervical lymphadenopathy / lump in neck?
MALIGNANCY - lymphoma (single neck lump), metastaic spread of cancer, primary cancer (thyroid carcinoma)
INFECTION - TB, glandular fever, mumps, hIV
AUTOIMMUNE - Sjogrens, SLE, scleroderma, RA
OTHER - sarcoidosis, branchial arch cyst , thyroglossal cyst
52
How should a thyroid swelling be assessed?
1. examination - differentiate between goitre or a nodular single mass, determine size, associated symptoms
2. TSH *
3. thyroid ultrasound scan * - determine if cystic or solid
53
How should a thyroid swelling be treated?
thyroidectomy or thyroid lobectomy
54
List the main risk factors for head and neck cancers?
smoking **
alcohol **
viruses - HPV 16, Epstein Barr virus **
55
What is the main type of head and neck cancers?
* squamous cell carcinoma *
56
How are head and neck cancers investigated?
1. examination - palpate lymph nodes, use flexible fibroptic endoscopy
2. CT scan
3. PET scan
4. biopsy
57
What are general features of head and neck cancers?
1. neck lump
2. persistent sore throat
3. hoarseness
4. persistent mouth ulcers
58
How are head and neck cancers managed?
1. surgery - quick local clearance of disease
2. radiotherapy - can be option on its own
+ establish nutritional status, refer for dental assessment, correct anaemia, encourage smoking cessation, refer to SALT
59
What are the main features of laryngeal cancer?
2nd most common head and neck cancer
hoarse voice, persistent irritating cough, dysphagia, dyspnoea
60
What are the main features of cancer of the oral cavity?
high incidence world wide
persistent mouth ulcers, dental problems, dysphagia, numbness, referred ear pain
61
What are the main features of cancer of the pharynx?
nasopharyngeal - cervical lymphadenopathy, nasal symptoms, unilateral hearing loss
oropharyngeal - sore throat, lump in throat
hypopharyngeal - dysphagia, odynophagia, hoarse voice
62
What are the features of tumours of salivary gland?
painless lump in neck - difficult to distinguish between benign and malignant
facial pain, facial nerve palsy, infiltration of surroundings
63
What are the different types of thyroid cancers?
1. papillary * - good prognosis
2. follicular * - good prognosis
3. medullary
4. anaplastic - poor prognosis
64
Describe the presentation of papillary or follicular thyroid cancer?
painless neck lump **
younger females
10% have spread to lymph nodes
65
Describe the features of anaplastic thyroid cancer?
```
elderly females
rapidly enlarging painful neck lump
bilateral lymphadenopathy
90% have distant/ regional spread at diagnosis
aggressive
```
66
Describe who is more likely to get medullary thyroid cancer and how are they present?
MEN !! - familial
painless unilateral neck lump
cervical lymphadenopathy
67
Describe the pathology of medullary thyroid cancers?
neuroendocrine tumour arising from the parafollicular C cells -> secrete calcitonin !!!
68
How is a neck lump that is suspected to be thyroid cancer investigated?
1. thyroid ultrasound * and fine needle aspiration
2. calcitonin - high in medullary cancers, used to monitor disease
3. TFT, FBC, LFTS, U&Es
4. CT and PET scan
69
How is papillary and follicular cancer managed?
total thyroidectomy + radioiodine (I-131) + yearly thyroglobulin levels to detect recurrence
70
What are the risks with a thyroidectomy?
hypoparathyroidism
recurrent laryngeal nerve injury - hoarse voice, bovine cough
bleeding
71
How is anaplastic thyroid cancer managed?
palliation with radiotherapy, resection if possible
72
What are the different types of salivary gland neoplasia?
BENIGN
benign pleomorphic adenoma - painless lump
Warthins tumour - usually in parotid, mobile mass
VARIABLE
mucoepidermoid tumour - in paroid gland
acinic cell tumour
MALIGNANT
malignant pleomorphic adenoma - panful lump with facial pain
adenoid cystic carcinoma - swelling and facial pain
squamous cell carcinoma
73
List the differentials for stridor?
```
croup
acute epiglottitis
foreign body inhalation
laryngomalacia
congenital tumours e.g. supraglottis haemangioma
anaphylaxis
subglottis stenosis
acute laryngitis
laryngeal carcinoma
```
74
What are the main features of croup?
cause: parainfluenza
s+s : fever, stridor, painful barking cough
who: 6 months - 3 years old
75
How is croup treated?
high flow oxygen + nebulised dexamethasone +/- nebulised adrenaline
76
How does acute epiglottitis present?
cause: group B haemophilus influenza
| s+s: stridor, fever, severe sore throat, dribbling, breathing with open mouth
77
How is acute epiglottitis managed?
1. emergency - do not examine throat
2. IV cefuroxime
3. nebulised adrenaline
4. extubate - call anaesthetist
78
How does inhalation of foreign body present?
acute sudden onset coughing/ wheezing/ stridor
| well in themselves
79
How is anaphylaxis managed?
1. high flow oxygen
2. adrenaline 1:1000 0.5ml IM
3. fluid bolus 500ml 0.9% saline
4. stop causative drug
5. IV chlorphenamine 10mg
6. 200mg IV hydrocortisone
80
List the differentials for otalgia (ear pain)
```
EAR RELALTED CAUSES
otitis media
otitis externia
malignant otitis externa
mastoiditis
ramsay hunt syndrome
neoplasia
perichronditis
otosclerosis
acute otitis barotrauma
```
```
NON EAR RELATED CAUSES
tonsilitis
TMJ disorders
neoplasmas of oropharyngeal
dental problems
foreign body
```
81
Define otitis externa
inflammation of the external ear canal (between the outer ear and ear drum)
82
What are the risk factors for otitis externa?
```
swimming "swimmers ear"
eczema in the ear canal
contact dermatitis
seborrhoeic dermatitis
trauma with cotton wool buds
```
83
What are the common infective agents of otitis externa?
staphylococcus aureus
pseudomonas aeruginosa
fungi
84
How does otitis externa present?
painful discharging ear **
| itching and irritation of ear
85
How does ear look on examination in otitis externa?
red, swollen, tender ear
pain when pressing tragus or moving the pinna
discharge visible
86
How is otitis externa treated?
1. topical antibiotics
2. removal of any canal debris +/- otowick if ear v swollen
3. precautions: avoid swimming, keep ears dry, don't touch
87
Define otitis media
inflammation of the middle ear
88
How is otitis media caused?
1. VIRUS- RSV**, rhinovirus
| 2. BACTERIA - streptococcus pneumonia, h. influenzae
89
How does otitis media present?
rapid onset of painful ear
rubbing/ tugging of ear
+ fever, systemic upset, irritable
often after a resp tract infection
90
How is viral otitis media managed?
paracetemol and ibuprofen + nasal decongestants
91
When should children with otitis media be prescribed antibiotics?
1. <6 months old
2. < 2y/o with bilateral OM
3. immunocompromised
4. increasingly unwell, decreased oral intake
5. no improvement after 4 days
92
What does the ear look like o/e in otitis media
tympanic membrane is red, yellow or cloudy and can be bulging
93
What should be given if suspect bacterial otitis media?
5 days of amoxicillin (erythyromycin if allergic)
94
What are the possible complications of otitis media?
```
mastoiditis
hearing loss
recurrence of infection
perforation of tympanic membrane
intracranial complications: meningitis, extradual abscess
```
95
Define otitis media with effusion and what can it cause?
glue ear= collection of fluid within the middle ear space with no signs of inflammation
most common cause of hearing loss in children
96
What are the risk factors for otitis media with effusion?
cleft lip, downs syndrome, CF, recurrent otitis media, allergic rhinitis
97
When is mastoiditis common and what is it?
inflammation of the mastoid lining
common after otitis media infection and in young children
98
How does mastoiditis present?
painful ear
fever
systemically unwell
99
What signs on examination points towards a diagnosis of mastoiditis?
sagging ear canal wall
swelling, tenderness, redness over the mastoid and zygomatic
pinna pushed down
drum head bulges / discharging pus
100
How is mastoiditis treated?
IV antibiotics prolonged
101
who does malignant otitis externa affect?
elderly diabetics ***
| immuncompromised
102
What is malignant otitis externa?
infection of the external ear canal that spreads into the temporal and mastoid bone - dangerous
103
which organism causes malignant otitis externa?
pseudomonas aeruginosa **
104
How does malignant otitis externa present?
severe unremitting ear pain
temporal headaches
purulent discharge
105
What are the complications of malignant otitis externa?
meningitis
cerebral abscess
dural sinus thrombosis
106
How is malignant otitis media diagnosed and treated?
1. CT scan *
2. oral/ IV flucloxacillin
3. surgical debridement?
107
what is ramsay hunt syndrome?
facial nerve infection by varicella zoster (shingles)
108
How does ramsay hunt syndrome present?
unilateral severe facial pain
vesicles on tM/ pinna
facial palsy
+ vertigo, deafness
109
How is ramsay hunt syndrome managed?
1. oral acyclovir and corticosteroids
| 2. analgesia
110
What is conductive deafness?
when there is impediment / obstruction to the passage of sound waves between the external ear and footplate of the stapes
-> so there is decreased transmission of sound to the cochlea via air conduction
111
What are the possible causes of conductive deafness?
1. obstruction of the ear canal e.g. wax, oedema, foreign body
2. perforation of the tympanic membrane
3. otosclerosis
4. infection
5. trauma
112
What is sensorineural deafness?
when there is fault in the cochlea or the cochlear nerve but sound transmitted normally to inner ear
113
What are the causes of sensorineural deafness?
1. drug ototoxicity e.g. gentamicin, chemotherapy, aspirin, furosemide
2. noise damage
3. menieres disease
4. acoustic neuroma
5. viral infections e.g. mumps
114
How is acute deafness investigated?
1. examination - ear, cranial nerves and neuro exam
2. pure tone audiogram
3. MRI
115
Describe the webers test
put tuning fork in middle of head and asked which side is loudest
unilateral sensorineural deafness = sound localised to unaffected ear
unilateral conductive deafness = sound localised to affected ear
116
Describe the Rinnes test
put tuning fork on mastoid process and when no longer heard, then reposition to over external acoustic meatus
normal = air conduction > bone conduction
conductive deafness= bone conduction > air conduction
117
what are the signs of acoustic neuroma?
associated with type 2 neurofibromatosis
cancer of the vestibulocochlear nerve (CN 8) so causes:
1. hearing loss
2. tinnitus
3. vertigo
if causes cancer of CN7 then facial paralysis or CN5 absent corneal reflex
118
What is otosclerosis?
autosominal dominant condition where normal bone replaced with spongy bone
119
What are the features of otosclerosis and how is it managed?
conductive hearing loss, tinnitus, "flamingo tinge" to tympanic membrane
Rx: stapedectomy
120
What is presbycusis?
age related sensorineural hearing loss causing difficulty to follow conversations
121
what are the complications of quinsy?
airway obstruction
necrotising fasciitis
mediastinitis
122
what is a branchial cyst?
most common midline cyst in children
asymptomatic, moves on tongue protrusion
located below hyoid bone
123
what is a branchial arch cyst?
lateral cysts and located in the anterior triangle in front of sternomastoid
non tender lump, does NOT MOVE on tongue protrusion
aspirate and surgical excise
124
What is a cholesteoma?
Cholesteatoma is a non-cancerous growth of squamous epithelium that is 'trapped' within the skull base causing local destruction. It is most common in patients aged 10-20 years
causes hearing loss and discharge
