ENT Flashcards
(103 cards)
1
Q
Risk factors for otitis externa
A
Mechanical injury to the skin - cleaning, foreign objects (hearing aids, earplugs), itching Increased moisture - swimming Skin disease DM Prolonged use of topical antibiotics
2
Q
Clinical features of otitis externa
A
Otalgia - particularly at night Otorrhea Tender tragus Moving auricle causes pain Conductive hearing loss Diffuse oedema and erythema Purulent debris Peri-auricular lymphadenopathy
3
Q
Possible complications of acute otitis externa
A
Perichondritis (infection of the cartilage)
Cellulitis
Malignant otitis externa
Otomycosis (fungal ear infection usually following use of topical abx)
Late: canal stenosis, hearing loss
4
Q
What is malignant/necrotising otitis externa
A
When otitis externa spreads and causes osteomyelitis of the temporal bone
5
Q
Causative organisms of otitis externa
A
Staph aureus
Pseudomonas aeruginosa (swimming, abx drop resistance)
Aspergillus niger - itching > otorrhea, looks like cotton wool speckled with black dots
Herpes zoster
Influenza viruses
6
Q
Management of otitis externa
A
Keep ear dry
Oral analgesia
Topical drops - antibiotic + steroid: Sofradex, Gentisone, Otomise
7
Q
What features would make you think of perichondritis rather than otitis externa
A
Symptoms worsening or not responding to treatment
Pyrexial
Tachycardic
Hearing loss
8
Q
Features of malignant otitis externa
A
Severe pain Granulation tissue - at junction of cartilage and bony part of ear canal Red/swollen periauricular tissue Otorrhea Conductive hearing loss
9
Q
Possible complications of malignant otitis externa
A
Facial nerve palsy
Osetomyelitis of skull base which in turn can cause extradural abscess, venous sinus thrombosis, paralysis of other cranial nerves
10
Q
Who gets malignant otitis externa
A
The immunocompromised
11
Q
Management of malignant otitis externa
A
Continue with topical antibiotics PLUS 6 weeks of IV antibiotics (Ciprofloxacin) CT head to identify bone destruction MRI to identify intracranial extension
12
Q
Most common causative organism of acute otitis media
A
Streptococcus pneumoniae
13
Q
Presentation of acute otitis media
A
Acute onset of earpain, usually with a throbbing character Fever Loss of appetite Bulging TM Red TM Purulent discharge if ruptured TM Conductive hearing loss
14
Q
Risk factors for acute otitis media
A
Bottle/formula feeding Pacifier use Passive cigarette smoking Day care Poor socioeconomic status
15
Q
What is the definition of recurrent acute otitis media
A
More than 4 episodes in a 6 month period
16
Q
How does otitis media happen
A
Eustachian tube dysfunction –> negative middle ear pressure –> retracted TM
Accumulation of middle ear secretions –> bacterial superinfection –> bulging TM
17
Q
Predisposing factors for eustachian tube obstruction
A
ET mucosal inflammation - viral URTI, allergic rhinitis
Enlarged adenoids
Nasal polyps
Cleft palae
Young - the ET of infants is short, wide and horizontal so nasopharyngeal secretions easily reflux into the ET and so infants are more prone to developing acute otitis media
18
Q
Management of acute otitis media
A
Paracetamol and ibuprophen
Antibiotics if: bilateral/lasted over 2 days/systemic illness
19
Q
Antibiotic of choice in acute otitis media
A
Amoxicillin
20
Q
What is chronic otitis media
A
Inflammation of the middle ear for >3 months
21
Q
Most common causative organisms of chronic otitis media
A
Pseudomonas aeruginosa
Staph aureus
22
Q
What is chronic suppurative otitis media
A
Persistent drainage from the middle ear through a perforated tympanic membrane lasting >6-12 weeks
23
Q
How does chronic suppurative otitis media present
A
Painless recurrent otorrhea that is odourless and mucoid/serous
Conductive hearing loss
May develop concurrent cholesteatoma
24
Q
Management of chronic suppurative otitis media
A
Topical antibiotics and steroids
Consider tympanoplasty or graft insertion
25
What is otitis media with effusion (glue ear)
Chronic mucoid or serous effusion in the middle ear, in the absence of infection, lasting for >3 months
26
What is thought to cause otitis media with effusion
Eustachian tube dysfunction
27
Otoscopy findings of otitis media with effusion
Opaque/yellow TM
| Air-fluid level behind TM
28
Management of otitis media with effusion
Tympanostomy tubes
29
Possible complications of chronic otitis media a) intra-temporal, b) extra-temporal
Intra-temporal complications of COM = vertigo (inflammation spreads to labyrinth + vestibular system), hearing loss (conductive due to ossicle/membrane damage, sensorineural due to cochlear inflammation), acute otitis externa (due to discharge irritating skin), facial weakness (erosion of middle ear bony canal exposes facial nerve, gets inflamed)
Extra-temporal complications = meningitis/subdural abscess/temporal lobe abscess (erodes through tegmen and expose dura), sigmoid sinus thrombosis (direct infective process or retrograde venous spread)
30
Possible complications of inner ear surgery
Infection
Bleeding
No improvement in hearing
Complete loss of hearing if inner ear damaged
Tinnitus
Vertigo
Facial nerve injury
Altered taste - chorda tympani nerve damange
Recurrence of disease and need for further surgery
31
What is cholesteatoma
A form of chronic otitis media in which keratinizing squamous epithelium grows from the tympanic membrane or the auditory canal into the middle ear mucosa. Deep retraction of the tympanic membrane, keratin accumulation (originates from skin cells that line the outer surface of the normal tympanic membrane – usually migrate out of ear canal with wax but if there is a deep retraction the keratin cant escape the pocket and develops into a keratin cyst
32
Potential complications of cholesteatoma
Middle ear invasion and ossicle erosion
Erosion of temporal bone --> extradural abscess, meningitis, sigmoid sinus thrombosis
Facial nerve paralysis
33
Clinical features of cholesteatoma
May be asymptomatic
Painless otorrhea
Scant, foul smelling discharge
Conductive hearing loss
34
Primary vs secondary causes of acquired cholesteatoma
Primary acquired - eutsachian tube dysfunction and formation of a retraction pocket
Secondary acquired - epithelium migrates inwards through a perforated tympanic membrane
35
Appearance of primary acquired cholesteatoma Vs appearance of congenital and secondary acquired cholesteatoma
Primary acquired: retraction pocket with squamous epithelium and debris that often appears as a brownish, irregular mass.
Congenital and secondary acquired: white or pearly mass behind the tympanic membrane
36
Imaging options for cholesteatomy
XR mastoid process
CT temporal bone
MRI is suspected intracranial extension
37
What is the definitive treatment of cholesteatoma
Mastoidectomy - open mastoid air cells, remove cholesteatoma from middle ear, reconstruct ossicles and tympanic membrane
38
What is a glomus jugulare
A vascular tumour in the middle ear. Usually benign but can be locally destructive
39
Symptoms of glomus jugulare
Hearing loss
Pulsatile tinnitus
Vertigo
Otorrhoea
40
Management of perichondritis
Gentle microsuction
Insert an aural wick
Continue topical drops
If systemically unwell then admit for IV antibiotics
41
Why are oral antibiotics not really used for treating perichondritis
The cartilage has a relatively poor blood supply
42
Causes of tympanic membrane perforation
Trauma - NAI, foreign body, ear irrigation
Infection - otitis media
Barotrauma - slap, diving, explosion
Iatrogenic - grommet insertion
43
Signs/symptoms of tympanic membrane perforation
Whistling sounds when sneezing.blowing nose
Decreased hearing
Tendency to infection
Purulent discharge
Pain usually only if concurrent infection
44
Management of tympanic membrane perforation
Water precautions - no swimming, ear plugs or vaseline on cotton balls when showering
Topical abx + steroid drops if infection also present (e.g. Sofradex, Gentisone)
If recurrent/persitent then consider myringoplasty
45
Differentials for otorrhea
```
Otitis externa
Chronic suppurative otitis media
Acute otitis media with TM perforation
CSF otorrhea
External or middle ear tumours
Granulomatous disease - granulomatosis with polyangitis (Wegeners)
Perichondritis
Cholesteatoma
```
46
Differentials for otorrhea + facial pain
```
Malignant otitis externa
Chronic suppurative otitis media
Cholesteatoma
Malignancy
Ramsay Hunt Syndrome
Skull base fracture
```
47
Neck lumps red flags
```
Persistent sore throat
Hoarseness
Dysphagia
Odynophagia
Horner's syndrome
SVC obstruction
Weight loss
Fevers
Night sweats
History of radiation to the neck
Rapidly enlarging painless mass
Stridor
```
48
Differentials for a midline neck lump
```
Thyroid nodule - adenoma, cyst, carcinoma
Goitre
Lipoma
Thyroglossal cyst
Dermoid cyst
Cervical lymphadenopathy
```
49
What are the 2 main investigations use to assess neck lumps
USS
| FNAC
50
What is meant by a 'functioning' thyroid nodule
A thyroid nodule that is associated with hyperthyroidism
51
When assessing for thyroid cancer, what do the 'U' and 'TH' grades refer to
```
U = USS
TH = FNAC
```
Both are graded 1-5
52
Differentials for a solitary thyroid nodule
Benign;
- Follicular adenoma
- Hyperplastic nodule
- Thyroid cyst
Malignant;
- Papillary carcinoma
- Follicular carcinoma
- Medullary carcinoma
- Anaplastic carcinoma
53
Differentials for a generalised thyroid swelling/goitre
Physiological - Pregnancy, puberty
Multinodular goitre
Hashimotos thyroiditis
Graves disease
54
Risk factors for head and neck SCC
```
HPV
EBV (nasopharyngeal carcinoma)
Betel nut chewing (oropharyngeal)
Alcohol
Smoking
```
55
What does a panendoscopy look at
The upper aerodigestive tract - pharynx, larynx, upper trachea and oesophagus
56
Differentials for dysphonia/hoarseness
```
Overuse (e.g. singers)
Acute laryngitis
Chronic laryngitis secondary to reflux
Inhalers
Smoking
SCC of the larynx
Vocal cord paralysis
Recurrent laryngeal nerve damage (e.g. in surgery)
```
57
Differentials for vocal cord lesions
Vocal cord polyp - result from overuse
SCC of the larynx
GORD
Reinke's oedema - common in female smokers, oedema and accumulation of gelatinous material
58
Dysphonia - indications for urgent referral
```
Hoarsness lasting >6 weeks
Oral swellings lasting >3 weeks
Dysphagia lasting >3 weeks
Unilateral nasal obstruction
Neck mass lasting >3 weeks
Cranial neuropathies
Orbital masses
```
59
Neck lump - rubbery, painless lymphadenopathy, may be night sweats and splenomegaly
Lymphoma
60
Neck lump - common in patients <20 years old, midline, moves upwards with tongue protrusion, may be painful if infected
Thyroglossal cyst
61
Neck lump - common in older men, midline lump if large, gurgles on palpation. Typical symptoms are dysphagia, regurgitation, aspiration, chronic cough
Pharyngeal pouch
62
Neck lump - congenital lymphatic lesion, classically on the left side of the neck, most present at birth/before age 2
Cystic hygroma
63
Neck lump - oval, mobile, cystic mass between SCM and pharynx, usually presents in early adulthood
Branchial cyst
64
Neck lump - pulsatile lateral neck mass that doesn't move on swallowing
Carotid aneurysm
65
What conditions/lumps are only really found in the anterior triangle of the neck
Salivary gland swelling
Carotid artery aneurysm
Laryngocele
66
What conditions/lumps are only really found in the posterior triangle of the neck
Pharyngeal pouch
| Cystic hygroma
67
What happens to a) thyroid mass b) thyroglossal cyst if you get a patient to swallow
Both will rise
68
What happens to a) thyroid mass b) thyroglossal cyst if you get a patient to stick their tongue out
a) thyroid mass won't move
| b) thyroglossal cyst will rise
69
When is rhinosinusitis classed as chronic
If it's >12 weeks without complete resolution of symptoms
70
Risk factors for rhinosinusitis
```
URTI
Polyps
Allergies
Granulomatosis with polyangitis
Septal deviation
```
71
What are the main symptoms of rhinosinusitis
```
Purulent rhinorrhea
Facial pain - worse when leaning forwards
Nasal blockage/congestion/obstruction
Reduced sense of smell
With or without polyps
```
72
What kind of test can you do if someone has allergic rhinosinusitis
RAST testing - blood test for specific allergens
73
Management of allergic rhinosinusitis
Avoid allergen triggers
Saline nasal irrigation
Nasal steroid spray (e.g. Flixonase)
Antihistamines
74
Management for rhinosinusitis with polyps
Topical nasal steroid - drops if severe but usually spray
| Functional endoscopic sinus surgery (FESS) to remove polyps
75
Risks of FESS (functional endoscopic sinus surgery)
```
Recurrence
Orbital damage
Damage to optic nerve
CSF leak if skull base breached, carries risk of meningitis
Synechiae (adhesions in nasal cavity)
Bleeding
Change in sense of smell
Damage to nasolacrimal duct can cause watery eye
Infection
```
76
What do you advise patients regarding their nasal steroid spray after having polyp surgery
Keep on using it even if the symptoms are better.
It can be explained by thinking of the surgery as a method of opening up the sinus drainage & creating a route of access for the steroids.
77
Antibiotic of choice if you suspect infected rhinosinusitis
Clarithromycin
78
Nasal steroid sprays
Fluticasone (Flixonase)
Beclomethasone (Beconase)
Mometasone (Nasonex)
79
Risk factors for nasal polyps
Chronic rhinosinusitis
Cystic fibrosis
Aspirin induced respiratory disease
80
Clinical features/symptoms of nasal polyps
```
Long history (years)
Bilateral nasal obstruction
Post nasal drip
Hyposmia/anosmia
Worse around allergens
No preceding symptoms
Rhinorrhea
No nasal sprays work
May have associated cheek pain
```
81
Which vasculitis commonly affects the nose
Granulomatosis with polyangitis (Wegeners)
82
Effects of granulomatosis with polyangitis on the nose
Inflammation of nasal mucosa
Large amounts of crusting
Can cause septal perforation and nasal dorsal collapse
83
Causes of nasal septal deviation
Congenital
Infective
Inflammatory - GPA, sarcoidosis
Trauma
84
Symptoms of septal deviation
```
Difficulty breathing through one nostril
Nasal congestion
Snoring
Headaches
Facial pain
Epistaxis
```
85
What test can be used to assess nasal mucocilliary function
Saccharine test
86
A common cause of nasal obstruction in children
Large adenoids
87
Two ways of visualising the nose properly
Anterior rhinoscopy
| Nasal endoscopy
88
What happens if patients use nasal decongestant too much
You get rebound congestion
89
Most nose bleeds come from which anatomical region
Little's area - located in the anterior nasal septum
90
What is the name of the plexus of vessels in Little's area
Kiesselbach's plexus
91
Which 3 blood vessels form Kiesselbach's plexus
Anterior ethmoid artery
Sphenopalatine artery
Greater palatine artery
92
Name of the plexus of vessels that causes posterior epistaxis
Woodruf's plexus
93
Causes of epistaxis
```
Trauma
Inflammatory - Granulomatosis with polyangitis, sarcoidosis
Acute/chronic rhinosinusitis
Anticoagulation
Hypertension
Haematological disorder - ITP
Neoplasia of nasal cavity - SCC, adenocarcinoma, papilloma, juvenile angiofibroma
Iatrogenic - recent surgery
```
94
Management of epistaxis
Naseptin ointment - for 1-2 weeks, caution peanut allergy
General advice regarding nose bleeds
Silver nitrate cautery
95
What general advice can you give to patients about nose bleeds
Try not to blow your nose for a week
Don't try and clean the node
Avoid hot baths and showers
Don't drink/eat anything really hot for 72 hours
Try to avoid strenuous exercise for a week
Avoid picking the nose
Apply firm pressure for 15 minutes - if this fails to work then attend A+E
96
Acute management of epistaxis lasting >15 minutes or that is profuse
ABCDE approach
IV access with cannula
PPE - gloves, eye shield, apron
Use headlight + Thuddicums speculum - if you can see the vessel cauterise it, if not then apply pressure and pack
Order FBC, coagulation profile, group and save
Admit to ENT ward
Anterior nasal packing - if continuing to bleed or spitting out blood then need posterior pack (often using foley catheter)
Posterior packs should stay in for 48hours, consider prophylactic abx
If continuing to bleed may need artery ligation
97
What are the CENTOR criteria
```
Used to see how likely it is that tonsillitis is caused by streptococcal bacteria
Absence of cough
Exudate
Nodes
Temp (38)
```
98
Vertigo - recent viral infection, sudden onset, nausea and vomiting, hearing may be affected
Viral labyrinthitis
99
Vertigo - recent viral infection, recurrent attacks lasting hours or days, no hearing loss
Vestibular neuronitis
100
Vertigo - gradual onset, triggered by change in head position, each episode lasts 10-20 seconds
Benign paroxysmal positional vertigo (BPPV)
101
Vertigo - associated with hearing loss, tinnitus, and a sensation of fullness/pressure in one or both ears
Meniere's disease
102
Vertigo - elderly patient, dizziness on extension of the neck
Vertebrobasilar ischaemia
103
Vertigo - hearing loss, vertigo, tinnitus, absent corneal reflex, may also have NF type 2
Acoustic neuroma
