ENT Flashcards
1
Q
Paranasal Cancers
A
Suspect when Chronic Sinusitis presents for first time in later life
o Blood stained nasal discharge, nasal obstruction, cheek swelling; Squamous cell
(50%), Lymphoma (10%), Adenocarcinoma, Adenoid-cystic, Olfactory NB etc
o Mgmt with RT ± radical surgery
2
Q
Nasopharyngeal Carcinoma
A
Rare in UK
o P/c Neck Lump, 90% have cervical LNadenopathy, Unilateral CHL due to Eustachian
blockage, CN palsy due to skull base extension
o Dx with Endoscopy/Biopsy, staging by MRI
o Mgmt with RT ± CT ± Radical neck dissection; Good survival if stage I
3
Q
Differential for Voice Hoarseness: Common
A
• Acute and Chronic Laryngitis • Reflux Laryngitis • Vocal fold nodule, cyst, polyps, scars • Reinke’s Oedema (Chronic irritation causes gelatinous fusiform enlargement; Typically, hypothyroid, elderly, female smokers) • Disorders of Speech Articulation
4
Q
Differential for Voice Hoarseness: Uncommon
A
- Laryngeal Cancer
- Granuloma/Contact ulcers
- Unilateral and bilateral VF paresis
- Leucoplakia
- Vocal fold cancer
5
Q
HEAD AND NECK SQUAMOUS CELL CARCINOMAS
A
• 90% Head and neck cancer are squamous cell carcinoma – Lining of upper aerodigestive tract;
Oral cavity, Oropharynx, Hypopharynx, Larynx and Trachea
o >80% arise in >50y, incidence in young increasing; Spreads via lymphatics
o RF: Smoking 10x, Alcohol, Vitamin A and C deficiency, Nitrosamines, HPV, GORD
• Present as Neck pain/lump, Hoarseness or Sore throat >6/52, Mouth bleeding and numbness,
Sore tongue, Painless ulcers, Oral patches, Otalgia/Effusion, Speech change and Dysphagia
• Dx: FNE, FNA/ Biopsy of masses, CT/MRI for staging of primary and nodal disease, MDT
o Staging by TNM (<2cm = T1, T4 extends to
bone/muscle/skin/antrum/neck; Nodes in
the neck are divided into 6 areas of the
neck; Mets)
6
Q
Oral and Lingual Carcinomas
A
Rare in UK; P/c Persistent, painful ulcers; White/red patches on tongue, gum or mucosa,
Otalgia, Odynophagia, LNadenopathy
o Surgery/RT >80% 5y survival if early disease
7
Q
Oropharyngeal Carcinoma
A
• Often Advanced presentation; 5:1 M, Older patient, Smokers, Referred Otalgia/Fullness in
throat; RF: Pipe/chewing tobacco; 20% node positive at ppt
o Ix: MRI; Mgmt: Surgery and RT; RT first line if ≤T2
o Tonsillar cancer has better prognosis; 5y Survival 50% if stage I
o High risk HPV (especially HPV16) linked to Lingual, Tonsillar and Pharyngeal cancer;
Vaccination might reduce risk
8
Q
Hypopharyngeal Carcinoma
A
• Hypopharynx – Hyoid bone to lower edge of Cricoid
• Rare, present as lump in throat, dysphagia, odynophagia, referred otalgia, hoarseness
• Mgmt: RT and surgery; Very poor prognosis
o Pre-malignant conditions – Leukoplakia (Hyperparakeratosis ± Underlying epithelial
hyperplasia), Plummer-Vinson (Pharyngeal web associated with Fe deficiency); 2%
risk post-cricoid cancer
9
Q
Laryngeal Cancer
A
• Typically, older patient; Progressive hoarseness to Stridor, difficulty/pain on swallowing,
haemoptysis, otalgia; If in younger patient, tends to be HPV +ve
o Described as Supra, Infra or Glottic; Glottic tumours cause hoarseness earlier = Better
prognosis; Spread to nodes occurs typically late
• Ix: Laryngoscopy, Biopsy, HPV status; Staging by MRI
• Mgmt: Radical RT for small tumours, Partial/Total Laryngectomy for larger tumours ± block
dissection of neck glands
o 5y survival rate 66%
10
Q
Post-Laryngectomy Management
A
• Voice restoration if larynx is removed, and trachea is brought to skin as end-stoma on neck
• Post-Laryngectomy, Oesophagus and Trachea are no longer united; New swallowing
technique required, breathing through stoma
• NGT initially post-op as pharynx heals + Analgesia; SALT-led rehabilitation, Stoma care
o Trans-oesophageal puncture – One-way valve (Voice prosthesis) between trachea
and pharynx/oesophagus; Valve activated when patient occludes stoma and breathes
o Artificial Larynx (Servox) – Artificial vibrating larynx held against neck
11
Q
The Lump in the Neck
A
• Duration – <3/52 likely Reactive LNadenopathy from self-limiting infection
• Tissue Layer – Intradermal: Sebaceous cyst with central punctum, Lipoma
• Imaging: Ultrasound – Architecture, Vascularity, Guidance for FNAC; CT – Anatomy; CXR for
malignancy or sarcoid (Bihilar LNadenopathy)
o Virology and Mantoux test
12
Q
Midline Lumps
A
If <20yrs – Likely dermoid cyst If moves up with protruding tongue, and is Infrahyoid – Thyroglossal cyst If bony hard – Chondroma
13
Q
Submandibular
Triangle
A
If <20yrs – Likely reactive LNadeno; If >20 exclude Malignancy: Firm, Non-tender, B-sym Is TB likely? Other Dx: Stone, Submand Tumour, Sialadenitis
14
Q
Anterior Triangle
A
LNadenopathy B-sym? Lymphoma Upper third junction of SCM – Brachial cyst (Squamous lined, Cholesterol) Parotid Ca esp if >40y; Other Dx: Laryngocoele, Carotid pathology
15
Q
Posterior Triangle
A
Pharyngeal pouch Cystic Hygroma (Lymphatic malformations, very transilluminable) LNadenopathy if many small lumps (TB, HIV, EBV; if >20y think Lymphoma or mets Cervical Ribs
16
Q
EMERGENCY MANAGEMENT OF UPPER AIRWAY OBSTRUCTION
A
• Positioning – Let patient to sit or lie down to position most comfortable
• Oxygen or Heliox (79% He, 21% O2); Less dense than air, more laminar flow
• Nebulised Racemic Adrenaline, IV Dexamethasone or Hydrocortisone
• Crash Bleep to ENT Registrar and Anaesthetist; Get Crash Tracheostomy kit ready
• Discern History where possible and identify based on common reasons for Stridor
o Acute DDx: Anaphylaxis, Laryngotracheobronchitis, Epiglottitis, Laryngitis,
Oesophageal Foreign Body, Vocal Cord Paralysis
• ABG where possible without delay or stress; if Stridor improves, Flexi Nasoendoscopy to
identify cause and visualise airway
• AP plus lateral XR Neck and Chest
• Definitive Airway – Needle Cricothyrotomy in
Children (15L/min Oxygen through 14G cannula; 1
sec oxygenating jet, 4 sec expiratory pause);
Surgical Cricothyroidectomy (>12yrs)
• Tracheostomy in Theatre within 30 mins as Jet
insufflation oxygenates rather than ventilates;
CO2 build up can occur
17
Q
VOCAL CORD PARALYSIS
A
• Superior Laryngeal Nerve splits into External (Supplies Cricothyroideus muscle) and Internal
(Supplies sensation above the vocal folds); Recurrent Laryngeal Nerve supplies most of the
intrinsic muscles of the Larynx
o Posterior Cricoarytenoid muscles – Only muscle to open the vocal folds
• Vocal Cord Paralysis can present as Hoarseness with a ‘Breathy’ voice and Weak Cough;
Repeating Coughing and Aspiration (Due to weak sphincter and poor supraglottic sensation),
Exertional Dyspnoea (Due to airway narrowing; At rest, a unilateral paralysis can be
compensated by contralateral abduction)
o 30% due to Cancer (Laryngeal, Thyroid, Oesophageal, Hypopharynx, Bronchus), 25%
Iatrogenic; Also, due to CNS disease, TB; 15% Idiopathic
• Investigate with CXR, Barium swallow, MRI, Endoscopy
• Treat underlying tumour; If no additional pathology, SALT opinion regarding whether
spontaneous recovery can occur
o Non-resolving paresis – Injection
Medialisation (allows vocal fold to contact
contralateral fold, allowing better
phonation); Medialisation Thyroplasty
18
Q
EPISTAXIS
A
• Described as anterior or posterior bleeds; Anterior easily seen with rhinoscopy, simpler to treat, less severe than posterior • General principles: Resuscitate (IVI, O2, etc) • Hx: Trauma, Quantity of loss, On anticoagulation, other PMHx • Pinch lower part of nose 20 minutes, breathe through nose, sit forward and spit blood into bowl; Ice pack on nasal dorsum • Strategies – Cauterise with Ag Nitrate, 1: 200,000 adrenaline soaked cotton balls, local anaesthetic spray (Lidocaine) o Never cauterise both sides of septum – Risk perforation; If unable to see bleeding point, refer to ENT o Anterior Nasal pack (e.g. Rapid Rhino, Merocel) if bleeding continues despite; Remove after 24h if bleeding stops; If failed, apply Postnasal pack/Foley catheter
• Anterior Epistaxis – Almost invariably septal
• Serious posterior bleed requires EUA, Endoscopic Arterial Ligation or Embolisation of e.g.
Internal Max, Facial Artery (however, risk of causing stroke)
19
Q
Aetiology of Epistaxis
A
RF: Allergic Rhinitis, Chronic Sinusitis, HTN, Haem malignancies, Coagulopathy
20
Q
Epistaxis: Local
A
- Trauma – Most common cause
- Mucosal Irritation/Infection/ Topical Rx
- Septal Abnormality
- Inflammatory Diseases
- Tumour
21
Q
Epistaxis: Systemic
A
• Dyscrasias – E.g. Haemophilia, von-
Willebrand’s disease
- Arteriosclerosis
- Anticoagulation
- HHT (Osler-Weber-Rendu)
22
Q
Retained Nasal Foreign Body
A
- Mainly self-inserted by children; Organic material presents early with purulent discharge
- Auroscopic Examination; If possible, removal by Crocodile forceps; Batteries = Urgent
- Ask child to blow nose, or ‘Parental kiss’ technique (>70% success rate)
23
Q
Nasal Fracture
A
• Exclude HI or C-spine; Most commonly direct trauma or fall, often with brief/short-lived
epistaxis; P/c New nasal deformity, facial swelling/contusion
• XR can help exclude other facial #; Treat Epistaxis, + Analgesia, Ice, closure of skin injuries
• If MUA required, perform 10-14d after injury before nasal bones set
• Septal Haematoma – Boggy swelling of septum; near-total obstruction; Requires urgent I+D
24
Q
Xerostomia
A
can result from a variety of causes, including Sjögren’s Syndrome, Drugs
(Antimuscarinics, Antiparkinsonian, Antihistamines, MAOIs, TCAs and Clonidine);
Radiotherapy, Dehydration, Shock and CKD
o Simulation and Replacement (Glycerine, Lemon Mouthwash, Artificial Saliva)
25
Sialadenitis
Acute Sialadenitis is typically Viral
(Mumps) or Bacterial; Bacterial Sialadenitis is painful
ascending infection (S aureus, S pyogenes or
pneumoniae); Pus can be expressed
o DDx: TB, HIV, ALL, Heerfordt’s Syndrome
(Uveoparotid Fever of Sarcoidosis)
26
Salivary Duct Obstruction
Usually due to calculus;
Painful swelling of Submandibular gland, especially
after eating; Plain XR and Sialography will show
calculus; Endoscopic removal
27
Parotid Tumours
• Salivary Neoplasia accounts for 3% of all tum ours worldwide, majority in Parotid gland
o Pleomorphic Adenoma is the most common (80%), of which 15% undergo Malignant
transformation; Classically results in CN VII signs
o Recurrence after surgical incision is common
o Other DDx includes Warthin’s Tumour (Benign Adenolymphoma), Haemangioma or
Lymphangioma (In Children), Mucoepidermoid Tumours (Intermediate)
o Malignancies include Adenoid Cystic, Adenocarcinoma or Squamous Cell Carcinoma
• Lumpectomy is inadequate; Partial Parotidectomy required due to risk of seeding
• Sialograms and CT are useful for pre-operative planning
28
Primary Sjögren’s Syndrome
• Dry Eyes (Keratoconjunctivitis Sicca) in absence of RA or other autoimmune disease;
Association with HLA-N8/DR3; Dryness of Mouth, Skin or Vagina; Salivary and Parotid
Enlargement; Other Autoimmune Phenomena (Arthralgia, Raynaud’s, Dysphagia and
abnormal motility, Other Organ-specific disease)
• Biopsy of Salivary gland shows focal infiltration with Lymphocytes and Plasma cells
• Raised Ig, Circulating Immune Complexes and AutoIg; RF typically positive, ANA 80%, Anti-
Mitochondrial 10%; Anti-Ro (SSA) 60-90%
o Anti-Ro can cross placenta; Potentially cause Congenital Heart Block
• Symptomatic Management with Artificial tears and Saliva replacement; Hydroxychloroquine
may help Fatigue and Arthralgia; Corticosteroids rarely needed, but used in treating
Persistent Salivary Gland Swelling or Neuropathy
29
Transduction of Sound Waves
• Sound vibrates the Tympanic membrane due to changes in air pressure; Conducted to the
oval window in the Tympanic cavity by the Ossicles (Malleus → Incus → Staples)
o Stapedius, Tensor tympani regulate the transmission of sound
• The Oval window is the interface between the air filled Tympanic cavity, and the fluid-filled
Cochlear. The sensitive hair-cells, corresponding to each frequency of sound as arranged,
release neurotransmitters in response to kinetic energy. These neurotransmitters arrive at
the synapse, leading to firing of action potentials at the vestibulocochlear nerve
• Sound information is transmitted via the auditory nerve to the cochlear nucleus of brainstem
o Projected to the inferior colliculus – Involved in auditory reflexes e.g. Startle response
o First consciously experienced in the Primary Auditory Cortex
30
Causes of Hearing Loss: Conductive
```
• Middle ear – O Media, Acquired or
Congen Cholesteatoma (K Squamous
Epithelialisation), Otosclerosis, Tumour,
Trauma, Congenital deformity
• Tympanic Membrane – Perf Eardrum
• External Ear – Wax, O Externa,
Tumour/Growths, Barotrauma
```
31
Causes of Hearing Loss: Sensorineural
```
• Prebyacusis – Affects higher
frenquencies first; Most common cause
• NIHL – Drop out centred at 4kHz
• Labyrinthitis/ O Interna
• Tumour
• Meniere’s Disease
• Ototoxic Rx – Aminogly, Loop, NSAIDs
• Congenital Inf – Rubella, CMV, Toxo
• Genetic – DFNB1, Stickler,
Waardenburg, Pendred, Usher
```
32
Sudden Hearing Loss
• >30dB hearing reduction over three contiguous frequencies over 72hr or less
o Typically, plus Tinnitus; Vestibular symptoms in 40%
o NB only 10-15% have identifiable cause
• DDX: Infection, Trauma, Autoimmune, Ototoxic Rx, Vascular, Malignant, Neurological Disease,
Disorders of the Inner Ear (E.g. Meniere’s disease)
o Diagnosed by PTA
• Ix: Clinical exam, Bloods for systemic/infective causes, Imaging (MRI Head)
• Mgmt: Oral or Intratympanic Corticosteroids; NB clinical benefit not established
33
Reversible Causes of Hearing Loss
• CHL – Cerumen, Otitis externa and media, Foreign object, Tumour, Perforated drum,
Cholesteatoma, Barotrauma
• SNHL – Otitis interna, Tumour compression, Meningitis, Mumps (epidemic parotiditis),
Ramsay-hunt Syndrome type II (HZ Oticus), Ototoxic drugs (if stopped early), Hypothyroid
34
Treatment for Hearing Impairment
• Removing ear wax blockage
• Surgical intervention – E.g. Grommet insertion, CN VIII nerve decompression
• Hearing aids – Behind-the-ear, Open/Receiver-in-canal, In-the-ear/canal
• Cochlear implant – Sound processor worn behind-the-ear, which transmits to internal
implant; Internal implant stimulates cochlear nerve via electrodes
35
Speech for patients with Hearing Loss
• Hearing Loss on Development – Delay in receptive and expressive communication skills, leads
to learning problems; Social isolation and poor self-concept; Affects vocational choices
• Requires early family-centred intervention; Audiologist as part of MDT
• Slow vocabulary acquisition, learn concrete (Cat, Jump, Five) words faster than abstract
(Before, After) words, difficulty with function words (The, an, are, a)
• Comprehend and produce shorter and simpler sentences
• Difficulty understanding longer sentences or in the passive voice
• Cannot hear word endings – Misunderstand or misuse verb tense, pluralisation
• Cannot hear quiet speech sounds – S, Shh, F, T, K
36
Foreign Body Obstruction
• Usually children >9mo due to pincer grip development; Adults: Insects most commonly
• Removal indicated if object is well visualised, and uncomplicated first attempt anticipated; CI
if TM perforation, if object in contact with TM, or if auditory canal cannot be fully visualised
o For speculum and operative microscopic removal instead
o Liquefaction necrosis is possible if batteries involved
o Local anaesthetic not generally used due to complex innervation of ext canal
• Pinna retracted, Techniques used: Mechanical extraction, Irrigation and Suction
o Friable objects removed by suction > forceps better; Live insects should be
immobilised before retrieval (Oil, viscous lidocaine)
37
Ear Irrigation
• Cerumen comprises dead epithelium, dust and oily secretions of sebaceous and ceruminous
glands; Lubricates and moisturises ear canal
• Alternatively: Pharmacists can supply dissolving ear-drops; CI Perf TM
o Seek help if haven’t cleared 5/7 or bad blockage/total hearing loss
• 20-ga angiocatheter attached to syringe; Cannula advanced into EAC gently; Direct stream of
water along roof of meatus, aiming for posterior wall
o If patient suddenly swallows, Perf TM
o After removal of wax/debris, dry mop excess water under direct supervision
o Syringing should cause discomfort but never cause pain
• CI: Organic matter that might swell through osmosis, Hx Perf TM, recent Otalgia, Otitis Media,
Grommet in-situ, Mastoid cavity
• Complications – Otitis Media, Perf TM, Tinnitus, Vertigo, Deafness
38
Otitis Externa
• Otalgia and inflammation of the EAC; Might report CHL; Acute 95%, <6/52 otherwise Chronic
o Acute typically Bacterial infection; Chronic – Allergy, Autoimmune
o Acute commonly due to Swimming (‘Swimmer’s Ear’), Trauma from cleaning,
Hearing-aid and Earplug use, Skin conditions (Psoriasis, Dermatitis); Other causes are
Fungal (Otomycosis)
• Rx: Antibiotic ED (e.g. Ofloxacin), Steroid ED, Oral Analgesia
o No more than 1/52 (Will exacerbate fungal infection); 5/7 usually improvement
o Oral Abx not recommended unless poor immune function, or wider skin infection
o Preventative Acetic acid (Vinegar diluted thirds) ear drops
39
Malignant Otitis Externa (MOE)
• =Necrotising Externa Otitis; Severe Otitis; Patient with
DM at risk, especially elderly; Also in severely
compromised immune system
• Extending infection into bony-ear canal and soft-tissues;
Skull Base Osteomyelitis
o Multiple nerve palsies – CN VII, Recurrent
Laryngeal, Cochlear
• P/c unrelenting pain that interferes with sleep, persists
even after swelling resolved with topical Abx treatment
• Rx: Oral or IV Abx; Nearly always Pseudomonas but can
also be Fungal (Asp); Diabetic control
o Not amenable to surgery; Most common
surgical finding: Diffuse cellulitis without
localised abscess formation
o Empirically Ciprofloxacin is used as anti-Pseudomonal macrolide
40
OTITIS MEDIA
Main Types: Acute Otitis Media, Otitis Media with Effusion, Chronic Suppurative Otitis Media
o AOM – Acute onset presenting with Otalgia; in younger children, presents with
pulling of ear, increased crying, poor sleep, febrile
▪ Commonly pneumococcus, haemophilus, moraxella
o OME – Not typically associated with symptoms; sometimes feeling of fullness
▪ Non-infectious fluid in the Middle Ear for >3/12
▪ Frequently occurs after AOM and viral URTI, exposure to smoke or allergies
▪ May improve with Abx
o CSOM – Middle Ear inflammation >2/52 with discharge; Can be complication AOM
▪ Pain is rarely present
41
Acute Otitis Media
• 11% of people per year worldwide; Half involve
children <5yrs, M>F
o About 5% develop CSOM
• O/E: Bulging/lack of movement of TM from puff
of air; New discharge not related to OE
• Risk can be reduced by Pneumococcal and
Influenza vaccination, Breastfeeding for first 6/12
of life, Avoiding smoke
• Rx: Analgesia (Paracetamol, Ibuprofen,
Benzocaine ED, Opioids); Abx – For severe disease
or patients <2y age; systemically unwell,
immunocompromised
o Abx for less severe disease is no improvement after 4/7;
o Abx of choice typically Amoxicillin; Erythromycin if pen allergic
• Continuing discharge indicates complications – Mastoiditis (rare), other rare complications
include petrositis, Labyrinthitis, facial nerve palsy, meningitis and intracranial abscess
• Recurrence and Risk factors – First episode within 6/12 of life, male, day-care, not breastfed,
bilateral disease, smoking exposure, winter, sibling with recurrent AOM, craniofacial
abnormalities (trisomy 21), use of pacifiers
o For frequent infections, Tympanostomy tubes (Grommet) can decrease recurrence
42
Chronic Otitis Media
• Ear infection or inflammatory conditions; TM perforation in setting of recurrent/chronic
• Hearing loss, otorrhea, fullness, otalgia
o Benign – Dry tympanic membrane perforation without active infection
o Chronic serous – Continuous, straw coloured drainage
o Chronic suppurative – Persistent purulent drainage
• Rx: Topical/systemic Abx, aural cleaning, water precautions, follow-up
o Surgery – Myringoplasty, Mastoidectomy
• Complications – Prolonged low middle ear pressure – Retraction pocket formation and
cholesteatoma in the longer term
• Surgery for CSOM – Myringoplasty (graft often temporalis fascia or tragal perichondrium) and
Mastoidectomy (if mastoiditis or advanced cholesteatoma)
43
Otitis Media with Effusion (Glue Ear)
• Noticed by parents is mode of p/c in 80%;
Dysfunction of Eustachian tubes; associated with
URTI, Adenoids, nasopharyngeal dimensions,
infections etc
o Similar RF to recurrent AOM
o Chief cause of hearing loss in children –
Learning and behavioural problems
• Active observation 3/12, Autoinflation of
Eustachian tube by Otovent
• Consider grommet if persistent, or worsening over
3/12: Complications of grommet insertion include
infection and tympanosclerosis
o Infections mgmt by aural cleaning and topical Abx/steroid ED
o Hearing aids for persistent bilateral OME and hearing loss if not for surgery
44
Grommet insertion
Chronic OM – ≥3 acute infections of middle ear in
6/12 period, or ≥4 per year; Clinical evidence
suggests benefit for first 6/12 to maintain
symptom-free state
o Grommet falls out naturally between 6-
12/12 of insertion
45
Cholesteatoma
• Keratinising squamous epithelium formation
within retraction pocket of pars tensa or flaccida,
narrowing of pocket neck results in cholesteatoma
• Serious but rare complications – Meningitis, Cerebral abscess, Hearing loss, Mastoiditis, Facial
nerve dysfunction
• 1:10,000; Foul discharge, deafness, headache, pain, facial paralysis and vertigo indicate
impending CNS complications
o Mastoiditis – Destruction of air cells in mastoid bone with possible abscess formation;
Fever, tenderness, swelling and erythema over mastoid process
▪ CT head, admit for IV Abx, Myringotomy and definitive Mastoidectomy
46
Referred Otalgia
Secondary Otalgia – Most commonly dental, pharyngitis, TMJ disorders, cervical spine
arthritis and neuralgias
o External Ear – Helix: Auriculotemporal (Br Trigeminal); Antitragus, Antihelix and
Lobule: Greater Auricular (C2-3); Conchal bowl supplied by CN VII, IX and X
▪ Auricular Br of Vagus – Arnold’s ear-cough reflex
o Middle Ear – CN IX component of tympanic plexus (Jacobson’s br=Tympanic nerve);
Medial portion of TM by Chorda Tympani
o Inner ear does not have nociceptor fibres; however, CN VIII is sensitive to strength;
Meniere’s disease has enlargement of membrane labyrinth, leading to stretching of
nerves, causing ‘sense of fullness’
47
TINNITUS
• Perception of sound typically in absence of auditory stimulation; Might be symptom of
underlying abnormality; 15% prev; 0.5% severe; 2/3 have SNHL, 1/3 no identifiable cause
• Characterisation – Uni/bilateral, Pulsatile/non-pulsatile
o Ringing, hissing or buzzing suggests Inner Ear or Central causes
o Popping or clicking suggests External, Middle or Palatine issues
o Objective Tinnitus – Vascular (e.g. AV malformation, high-output cardiac states),
Myoclonus of ossicular muscles, Eustachian abnormalities
o Subjective Tinnitus – Most commonly Prebyacusis and NIHL, Meniere’s (Unilateral),
Ototoxic drugs (Bilateral); Cisplatin and Aminogly can cause permanent loss, NSAIDs,
Quinine, Macrolides and Loops likely reversible
• Spontaneous oto-acoustic emissions, altered/increased spontaneous auditory nerve activity,
inappropriate feedback from descending pathways, auditory-limbic interactions
• Ix: Audiometry and Tympanogram
o Unilateral Tinnitus urgently requires MRI head for Schwannoma (10% p/c)
• Mgmt: Hearing aids (if loss >35dB, hearing aid improve perception of background noise,
making tinnitus less apparent), Psychoeducation and sound therapy, CBT
o Improves with time following habituation; Mgmt psych and insomnia; Treatment
aimed at reducing impact of symptoms
48
VERTIGO
• Sensation that individual, or world around is moving or spinning
o Vestibular (peripheral) vertigo – Severe, accompanied by loss of balance, N+V,
hearing loss, tinnitus, nystagmus (typically horizontal)
o Central vertigo – Less commonly has hearing loss or tinnitus; usually less severe,
nystagmus can be vertical or horizontal
o Duration important – Short lasting (Meniere’s or Migraine), >day to week Acute
Vestibular failure
• O/E CN and ears; Cerebellar function and reflexes; Nystagmus, gait and Romberg’s test
(worse balance with eyes shut); Provocation tests (Head thrust, Hallpike); Audiometry,
Nystagmography, MRI
49
Benign Paroxysmal Positional Vertigo (BPPV)
• Commonest cause of Peripheral Vertigo; Attacks of sudden rotational vertigo lasting >30s
provoked by head turning, other ear symptoms rare
o Displacement of otoliths stimulating the Semicircular canals; Idiopathic, trauma
o No persistent vertigo, no speech/visual/motor/sensory problems, no tinnitus,
headache, ataxia, facial numbness or dysphagia, no vertical nystagmus
• Hallpike Positive – Patient looks straight, head turned 45 deg towards test ear, lie 30 deg
below level of couch quickly; look for nystagmus, ask if dizzy
• Typically, Self-limiting; Epley’s, Home repositioning manoeuvres; Surgery (rare) for last resort
50
Home Management of BPPV
• Modified Epley useful for patients with frequent
recurrence, or do not respond quickly to therapist-led
manoeuvres
• Brandt-Daroff exercises – Believed to work by
repositioning, dispersing or dissolving inner ear debris and
habituation by exposure; used with repositioning
unsuccessful, effective in few
• Combination of both effective for longer term recovery
51
Meniere’s Disease
• Dilatation of Endolymphatic spaces of membranous labyrinth; leads to sudden attacks of
vertigo lasting 2-4hrs; Nystagmus always present
o Fullness of ears, tinnitus following vertigo possibly
o Symptoms often become bilateral
• Dx by Electrocochleography or MRI head
• Rx – Prochlorperazine acutely, Prophylaxis by Betahistine
• Gentamicin instillation via grommet for persistent symptoms; Labyrintectomy 95% effective
in controlling vertigo; Vesticular neurectomy 90% effective but mostly keeps hearing intact
52
Acute Vestibular Failure (=Vestibular Neuronitis, Labyrinthitis)
Acute Vestibular Failure (=Vestibular Neuronitis, Labyrinthitis)
53
Rhinosinusitis
Inflammation of nose and paranasal sinuses with at least 2 symptoms
o *Must have nasal blockage/obstruction/congestion or discharge
o Facial pain/pressure, Reduced/loss of smell, Endoscopic or CT imaging changes
o Acute or Chronic (>12/52); Classed as Mild, mod, severe
54
Acute Rhinosinusitis (= Common cold)
Self-limiting; If >5/7, consider intranasal steroids (non-systemic bioavail); Avoid Abx unless
severe or worsening symptoms; 80% resolve without Abx in 2/52
o Acute post-viral sinusitis – Increase in symptoms after 5/7, or persistent 10/7
55
Chronic Rhinosinusitis without Nasal Polyps
• Mgmt with Intranasal steroids and saline irrigation;
• If no improvement after 4/52, and moderate/severe endoscopic findings, consider Culture +
Long term Abx if IgE is normal (= Non-allergic Rhinitis)
o CT and if poor response, consider surgery
56
NASAL POLYPS
• Swellings of nasal/sinus mucosa prolapsing into
nasal cavity; 2% prevalence
• Typically, in male patients >40yrs; Usually
bilateral, most commonly middle meatus; P/c
watery rhinorrhoea, sneezing, purulent post-nasal
drip, nasal obstruction, sinusitis, mouth-breathing,
snoring and headaches
• Nasal polyps rare if <10y; Rule of Neoplasms, CF,
Meningocoele/Encephalocoele
• Associated with Allergic and Non-Allergic Rhinitis,
Chronic Ethmoid Sinusitis, CF, Aspirin
Hypersensitivity, and Non-Atopic Asthma
o *NB: Single unilateral polyp requires urgent biopsy; NPC, Lymphoma
• Ix: Rhinoscopy, FNE; Polyps appear as pale, mobile, insensitive to gentle palpation; Consider
allergy testing (IgE); Mgmt: Topical steroids; consider long-term Abx
• Endoscopic Sinus Surgery – CT imaging might be required; Complications rare but include CN
II damage and CSF leak; Do not blow nose post-op, watch out for bleeding to epistaxis advice
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Differential for Rhinitis
• Child – Adenoids, Choanal Atresia, Post-nasal space tumour, Foreign body obstruction,
• Adult – Septal deviation, Granulomatous disease (TB, Syphilis, GPA, Leprosy), Topical
vasoconstrictor use, TCA
• Refer urgently if – Numbness, Tooth loss, Bleeding, Unilateral mass
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ALLERGIC RHINITIS
• Seasonal (e.g. Hayfever) or perennial (more common in adults); IgE mediated inflammation
from allergen exposure (e.g. HDM, Pollens, animal dander) leading to Mast cell degranulation
• Sneezing, pruritus, nasal discharge, bilateral itchy red eyes; O/E Turbinates might be swollen,
• Mgmt: Allergen avoidance, Nasal saline irrigation, Antihistamines
o If moderate/persistent – Intranasal steroid sprays; severe consider Short course Pred
o Sodium Cromoglycate – Inhibition of Mast cell degranulation (? Ca ion blockade)
• Immunotherapy – Sublingual Immunotherapy (SLIT), Allergy vaccines
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ACUTE BACTERIAL RHINOSINUSITIS
• Presence of at least three of the following: Discoloured discharge with unilateral prominence
and purulent secretion in nasal cavity, Severe local pain with unilateral prominence, Fever
>38deg, Inflammatory markers, Deterioration after initial mild illness
• DDx: Migraine, TMJD, Dental, Neuropathic, TA, HZV
• Mostly follows viral illness; Other causes: Direct spread from other bacterial infection,
Anatomical abnormalities, Mechanical ventilation/NGT, Biofilm formation
o Commonly S pneumo, HiB, S aureus, Moraxella, and fungi
• Ix: Clinical Dx; O/E mucosal inflammation, oedema, nasal discharge, polyps, septal deviation
o CT and FNE confirms diagnosis, plan surgery and identify anatomy o In recurrent acute sinusitis, CT may be normal if no acute infection
• Mgmt: Simple analgesia, nasal saline irrigation, intranasal decongestants
o Antihistamines not used routinely; Thickens secretes = inadequate drainage
o Abx if bacterial infection suspected – Amox or Doxy
• If recurrent – Refer for imaging or surgery; If no imaging evidence poor results post-op
o Endoscopic sinus surgery tailed for specific sinus affected
o Smoking cessation – Tobacco irritates mucosa, reduced ciliary function
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Complications of Sinusitis
• Orbital Cellulitis/Abscess –
• Intracranial Involvement – Meningitis, Encephalitis, Cerebral abscess, CS Thrombosis
• Mucocoeles infected → Pyocoeles
• Osteomyelitis – Classically Staph infection;
Pott’s Puffy Tumour – Subperiosteral abscess
arising from frontal osteomyelitis
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Anatomy of Paranasal Sinuses
• Lined with ciliated respiratory mucosa; Sweeps
debris and mucous towards osteomeatal
complex into nostrils
o Obstruction can be due to anatomical
factors or mucosal problems
• Middle meatus – Drains Maxillary, Anterior and
Middle Ethmoidal; Also, Frontal
• Superior meatus – Drains Posterior Ethmoidal
• Sphenoid drains into Sphenoethmoidal recess
• Nasolacrimal duct drains into Inferior meatus
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GRANULOMATOSIS POLYANGIITIS
• Small/Medium Vessel Vasculitis; Autoimmune condition characterised by c-ANCA (Anti-
Proteinase 3); Rhinitis is the first sign in most patients
• Nasal pain, Stuffiness, Nosebleeds, Rhinitis, Saddle-nose Deformity due to Perforated Septum
• Conductive Hearing Loss due to Auditory Tube Dysfunction, Also SNHL, Strawberry Gingivitis,
Bone destruction leading to poor dentition; Scleritis, Conjunctivitis, Uveitis, Arthritis (60%) etc
• Mortality mostly occurs through Renal Failure (Rapidly Progressive GN in 75%) or Respiratory
Disease (Pulmonary ‘Coin lesions’, Infiltrates, Cavitary Lesions, Haemorrhage)
• Diagnosis by Serum, Biopsy (Renal, Pulmonary); Treated with Cyclophosphamide and High
Dose steroids to induce Remission; Maintenance with Steroid-sparing agents; Other measures
include Plasma Exchange or Renal Transplantation
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Acute Pharyngitis and Tonsillitis
• Inflammation of the Oropharynx/Tonsils; Commonly bacterial/viral, generally self-limiting
illness; Symptoms resolve in 1/7 in majority
• Viral – Rhinovirus, Coronavirus, Parainfluenza in 25%; Influenza A/B in 4%, Adenovirus 4%,
HSV 2%; only 1% is due to Ebstein-Barr
• Bacterial – GABHS (Also, Scarlet Fever); 15-30% of sore throats in children, 10% in adult
o Typically, no routine tests required; ASO only to confirm PSGN or RF
• DDx Unilateral Tonsillar Enlargement –? Quinsy, Parapharyngeal Abscess, HNSCC
o Rule-out Malignancy by Excision Biopsy
• Mgmt: Ibuprofen, Paracetamol, Mouthwashes/sprays
o Centor >2 – Pen V for 10/7 to lower relapse; If pen-allergic use Clari or Erythro
o *NB: Avoid Amox as can cause rash in EBV
o If Immunosuppressed – Seek urgent
specialist advice; If on DMARDs or
Carbimazole, check FBC urgently
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Complications of Tonsillitis
• Otitis Media, Sinusitis
• Peritonsillar Abscess (Quinsy) – Sore Throat,
Dysphagia, Peri-tonsillar bulge, Uvular deviation,
Trismus and Muffled voice (Hot potato)
o Abx, Aspiration or surgical drainage
• Parapharyngeal Abscess – Diffuse neck swelling;
Ultrasound to identify site, I+D under GA
• Lemierre (Rare) – Acute Septicaemia and JV
Thrombosis, Septic emboli; secondary to
infection with Fusobacterium
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Scarlet Fever
• Exotoxins from Strep pyogenes; Rash on chest,
axilla, post-auricular 12-48h after initial sore
throat and fever = Scarlet
o Red pin-prick blanching rash, Facial
flushing with Oral pallor, Strawberry tongue
* Pen V (Clari if Pen-allergic) for 10/7
* Complications – Sydenham’s Chorea, Post-infectious Demyelinating Disorders
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The Centor Criteria
* Tonsillar Exudate, Tender Anterior Cervical LN, Febrile Hx, Absence of Cough
* If >2 criteria = 50% PPV of Strep throat, may benefit from antibiotics, If 0 = 80% NPV
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STRIDOR
• High-pitched inspiratory noise from partial obstruction of Larynx or Large airways; Most
common in children due to narrower airways
• Red Flags: Dysphagia, Drooling, Pallor/Cyanosis, Respiratory distress, Tracheal tug
• Causes – Congenital malformations, Inflammation (Laryngitis, Epiglottitis, Croup,
Anaphylaxis), Tumours (Haemangiomas, Papillomas), Trauma/Intubation
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Laryngotracheobronchitis (=Croup)
• Leading cause of Stridor (predominantly Inspiratory) – Barking cough, respiratory distress due
to upper airway obstruction
o Often worse at night; 95% viral e.g. Parainfluenza
o Mild – No stridor at rest; Moderate – Stridor at rest; Severe – Plus respiratory distress
• Children with Croup = Single dose Dexamethasone (Alt: Pred); Advise that self-limiting and
resolves within 48h; Seek help if severe signs; Admit if moderate and unsettling, or severe
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OBSTRUCTIVE SLEEP APNOEA
• Affects 1-2% Population; Most often Overweight, Middle-aged Males; Can occur in Children
especially in enlarged tonsils
o Symptoms include Snoring (95%), Daytime Sleepiness (90%), Unrefreshed or Restless
Sleep, Morning Headache etc
• Activity of Respiratory Muscles reduced in sleep; In REM, practically dependent on Diaphragm
• Apnoea occurs when airway at back of throat is sucked closed in inspiration during sleep;
Hypotonia of opening muscles of the upper airway in sleep; Partial narrowing leads to snoring
o Apnoea leads to Hypoxia – Increasingly Strenuous effort; Central Hypoxic Stimulation
and Effort leads to brief waking; Patient might not be aware
o Unaware waking leads to sleep
deprivation, especially REM sleep,
leading to daytime sleepiness
• Risk Factors – Obesity, Narrow Pharyngeal
Openings, Nasal Obstruction, Enlarged Tonsils,
COPD, Acromegaly, Respiratory Depressants
(ETOH, Sedatives, Analgesia)
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Management of Obstructive Sleep Apnoea
• Relatives often provide good Hx of Snore-Silence-Snore cycle; Quantify using Epworth
Sleepiness Scale (7 daily activities, 0 – 3 points for chance of dozing; 5-4/21 Normal,
Narcolepsy 17/21)
• Diagnosis by Overnight Pulse Oximetry (Characteristic Cyclical desaturation leading to
sawtooth appearance); Inpatient Sleep Studies if undiagnostic
o Confirmed Diagnosis if >10-15 Apnoeas or Hypopnoeas in any 1hr of sleep
• Treatment of Correctable Factors; Nasal Mask CPAP during sleep (Improves symptoms, QOL,
Daytime alertness, Survival); NB: 50% cannot tolerate CPAP
• Modafinil – CNS stimulant; Useful short-term alternative
