ENT

Question 1

Features of a brachial cyst

Answer 1

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx

• mobile, soft and fluctuant
• Swelling is intermittent

The cyst is filled with acellular fluid with cholesterol crystals and encapsulated by stratified squamous epithelium. Branchial cysts may have a fistula and are therefore prone to infection. They may enlarge following a respiratory tract infection.

Develop due to failure of obliteration of the second branchial cleft in embryonic development

Usually present in early adulthood

Question 2

Thyroglossal cyst features

Location

Features

Answer 2

Persistence of the thyroid duct

More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone (i.e. below the hyoid)

!Moves upwards with protrusion of the tongue!
Its connection with the foramen caecum means it will move on tongue protrusion.
May be painful if infected

Question 3

Management of sore throat

Answer 3

CENTOR criteria: 3 out of following to give abc

1) Cervical lymphadenopathy
2) Exudate on tonsils
3) No cough
4) Temp >38

If abx given
- 7-10 day course of phenoxymethylpenicillin or erythromycin (if the patient is penicillin allergic)

Question 4

Drugs that cause hearing loss

Answer 4

Aminoglycosides (e.g. Gentamicin)
Furosemide
Aspirin 
Quinine
and a number of cytotoxic agents

Question 5

Indications for tonsillectomy

Complications of tonsillectomy + management

Answer 5

NICE: Meets all criteria
• Sore throats are due to acute tonsillitis
o 7 or more significant sore throats in the preceding 12 months OR
o 5 or more episodes in each of the preceding two years OR
o 3 or more in each of the preceding three years).
• Symptoms occurring for at least a year
• The episodes are disabling and prevent normal functioning

Other indications:

• Recurrent febrile convulsions secondary to episodes of tonsillitis
• Obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
• Peritonsillar abscess (quinsy) if unresponsive to standard treatment

Complications
Primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
Secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain

Haemorrhage is a feared complication following tonsillectomy. Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.

Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in around 1-2% of all tonsillectomies.

Question 6

Red flags for epistaxis

Answer 6

Unilateral - if recurrent unilateral epistaxis, think about cancer

Question 7

Why does otitis media need urgent treatment

Answer 7

To prevent meningitis which is a complication of mastoiditis.

Other complications:
Ear drum perforation
- Spontaneously closes after 6/52
- Might see discharge => can cause secondary Otitis externa

Chronic supparative OM (chronic d/c through perf)

Chronic OM

Chronic OM with effusion (glue ear)

Mastoiditis

• Spread of infection to mastoid cavity => loss of post-auricular sulcus, mastoid
• Bogginess, pinna pushed forward and down
• Urgent op needed due to risk of infection tracking into meninges and brain

Also to prevent
CN palsies
Hearing loss
Osteomyelitis
Carotid artery spasm

Question 8

Malignant otitis externa

Who get’s it

Causative organism

Key features in history/presentation

Diagnosis

Management

Answer 8

Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics)

most commonly caused by Pseudomonas aeruginosa

Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues and into the bony ear canal
Progresses to TEMPORAL BONE OSTEOLYTIS

Key features in history
Diabetes (90%) or immunosuppression (illness or treatment-related)
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Possibly dysphagia, hoarseness, and/or facial nerve dysfunction

Diagnosis
A CT scan is IMPORTANT

Treatment
non-resolving otitis externa with worsening pain should be referred urgently to ENT
Intravenous antibiotics that cover pseudomonal infections - ciprofloxacin

Question 9

What is osteoclerosis

Cause

Features

Management

Answer 9

Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults

Onset is usually at 20-40 years - features include:

• Conductive deafness
• Tinnitus
• POSITIVE FH

Management
hearing aid
stapedectomy

*10% of patients may have a ‘flamingo tinge’, caused by hyperaemia

Question 10

Management of nasal polyps

Associated conditions

Answer 10

When bilateral, nasal polyps should be referred to ENT non-urgently for assessment. Topical corticosteroid therapy is first-line management, which shrinks polyps in 80% of cases.

Unilateral nasal polyps are a red-flag sign for nasopharyngeal cancer and therefore warrant an urgent referral to ENT

Associations
Asthma* (particularly late-onset asthma)
Aspirin sensitivity*
Infective sinusitis
Cystic fibrosis
Kartagener's syndrome
Churg-Strauss syndrome

*the association of asthma, aspirin sensitivity and nasal polyposis is known as Samter’s triad

Question 11

Features of a cytsic hygroma

Answer 11

A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age

Swelling in the subcutaneous tissue of the posterior triangle which transilluminates.

Question 12

What is black hairy tongue

Predisposing factors

Investigation

Management

Answer 12

Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour.

Predisposing factors
poor oral hygiene
antibiotics
head and neck radiation
HIV
intravenous drug use

The tongue should be swabbed to exclude Candida

Management
Tongue scraping
Topical antifungals if Candida

Question 13

Causes of vertigo

Answer 13

Viral labyrinthitis

• Recent viral infection
• Sudden onset
• Nausea and vomiting
• Hearing may be affected

Vestibular neuronitis

• Recent viral infection
• Recurrent vertigo attacks lasting hours or days
• No hearing loss

Benign paroxysmal positional vertigo

• Gradual onset
• Triggered by change in head position
• Each episode lasts 10-20 seconds

Meniere’s disease
- Associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears

Vertebrobasilar ischaemia

• Elderly patient
• Dizziness on extension of neck

Acoustic neuroma

• Hearing loss, vertigo, tinnitus
• Absent corneal reflex is important sign
• Associated with neurofibromatosis type 2

POSTERIOR CIRCULATION STROKE

Trauma

Multiple sclerosis

Ototoxicity e.g. gentamicin

Question 14

What is gingivitis

Spectrum of disease

Management

Answer 14

Gingivitis is usually secondary to poor dental hygiene. Clinical presentation may range from simple gingivitis (painless, red swelling of the gum margin which bleeds on contact) to acute necrotizing ulcerative gingivitis (painful bleeding gums with halitosis and punched-out ulcers on the gums).

If the patient has simple gingivitis
should be advised to seek routine regular review by a dentist. Antibiotics are not usually necessary

If a patient presents with acute necrotizing ulcerative gingivitis CKS recommend the following management:
refer the patient to a dentist, meanwhile the following is recommended:
Oral metronidazole* for 3 days
Chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash
Simple analgesia

*the BNF also suggest that amoxicillin may be used

Question 15

Causes of gingival hyperplasia

Answer 15

Drug causes of gingival hyperplasia
Phenytoin
Ciclosporin
Calcium channel blockers (especially nifedipine)

Other causes of gingival hyperplasia include
acute myeloid leukaemia (myelomonocytic and monocytic types)

Question 16

Submandibular triangle borders

Masses cause

Answer 16

Borders

• Mandible
• Anterior digastric
• Posterior digastric

Causes:

1) Sialolithiasis = stones
80% of all salivary gland calculi occur in the submandibular gland. 70% of these calculi are radio-opaque
- Stones are usually composed of calcium phosphate or calcium carbonate
- COLICKY pain and post prandial swelling of the gland
Investigation involves sialography to demonstrate the site of obstruction and associated other stones
- Stones impacted in the distal aspect of Wharton’s duct may be removed orally, other stones and chronic inflammation will usually require gland excision

2) Sialadenitis
Usually occurs as a result of Staphylococcus aureus infection
Pus may be seen leaking from the duct, erythema may also be noted
Development of a sub mandibular abscess is a serious complication as it may spread through the other deep fascial spaces and occlude the airway
Foul taste in mouth

3) Submandibular tumours
Only 8% of salivary gland tumours affect the sub mandibular gland
Of these 50% are malignant (usually adenoid cystic carcinoma)
Diagnosis usually involves fine needle aspiration cytology
Imaging is with CT and MRI
In view of the high prevalence of malignancy, all masses of the submandibular glands should generally be excised.

Question 17

Sudden sensorineural hearing loss

Cause

Test

Management

Answer 17

In the vast majority of cases is idiopathic.

PTA
- Both bone and air conduction reduced

There is some evidence that high dose steroids (60mg/day) for seven days improves prognosis, so all patients should start treatment as soon as possible.
ENT assessment should be arranged as soon as possible to allow pure tone audiometry testing and to arrange an MRI to exclude an acoustic neuroma.
Intra-tympanic steroids can also be given if there is no response to oral steroids.

Question 18

Otitis externa

Causes

Features

Investigations

Management

2nd line options

Answer 18

Causes of otitis externa include:
Infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal
Seborrhoeic dermatitis
contact dermatitis (allergic and irritant)

Features
Ear pain, itch, discharge, commonly 2ndary to eczema/FB
O/E: palpate pinna and tragus - pain = +ve sign
Otoscopy: red, swollen, or eczematous canal, visible discharge (swab)

Investigations

• Swabs if discharge
• Bloods

The recommended initial management of otitis externa is:
Topical antibiotic or a combined topical antibiotic with a steroid e.g. gentamycin + hydrocortisone drops
[If the tympanic membrane is perforated aminoglycosides are traditionally not used*]
If there is canal debris then consider removal (micro suction)
If the canal is extensively swollen then an ear wick is sometimes inserted

Second-line options include
Consider contact dermatitis secondary to neomycin
Oral antibiotics (flucloxacillin) if the infection is spreading
Taking a swab inside the ear canal
Empirical use of an antifungal agent

If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.

Malignant otitis externa is more common in elderly diabetics. In this condition, there is extension of infection into the bony ear canal and the soft tissues deep to the bony canal. Intravenous antibiotics may be required.

Question 19

Nasopharyngeal carcinoma

Features

Imaging

Treatment

Answer 19

SQUAMOUS CELL of the nasopharynx
Rare in most parts of the world, apart from individuals from Southern China
Associated with Epstein Barr virus infection

Features
Systemic: Cervical lymphadenopathy - painless
Local: Otalgia; Unilateral serous otitis media; Nasal obstruction, discharge and/ or epistaxis; Cranial nerve palsies e.g. III-VI

Imaging
Combined CT and MRI.

Treatment
Radiotherapy is first line therapy.

Question 20

Cholesteatoma define

Main features

Ottoscopy findings

Management

Complications

Answer 20

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. Being born with a cleft palate increases the risk of cholesteatoma around 100 fold.

Main features
foul-smelling, non-resolving discharge
hearing loss

Other features are determined by local invasion:
vertigo
facial nerve palsy
cerebellopontine angle syndrome

Otoscopy
‘attic crust’ - seen in the uppermost part of the ear drum

Management
patients are referred to ENT for consideration of surgical removal (MASTOIDECTOMY)

Complications

• Cerebrall abscess
• Meningitis
• Deafness

Question 21

Otitis media

Features

Management

Answer 21

Can be 2ndary to URTI –> Eustachian tube

Features
Most common in children and rare in adults
May present with symptoms elsewhere (e.g. vomiting) in children
Severe pain and sometimes fever
May present with discharge is tympanic rupture occurs

Management
Antibiotics (usually amoxycillin 500mg QDS for 7 days) or erythromycin

Question 22

When to 2 week wait to oral surgery

Answer 22

2 week wait referrals to oral surgery should be done in all of the following cases:

1) Unexplained oral ulceration or mass persisting for greater than 3 weeks
2) Unexplained red, or red and white patches that are painful, swollen or bleeding
3) Unexplained one-sided pain in the head and neck area for greater than 4 weeks, which is associated with ear ache, but does not result in any abnormal findings on otoscopy
4) Unexplained recent neck lump, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
5) Unexplained persistent sore or painful throat
6) Signs and symptoms in the oral cavity persisting for more than 6 weeks, that cannot be definitively diagnosed as a benign lesion

Question 23

Causes of hoarseness

Investigations

When to 2 week wait

Answer 23

Causes of hoarseness include:
voice overuse
smoking
viral illness
hypothyroidism
gastro-oesophageal reflux
laryngeal cancer
lung cancer

When investigating patients with hoarseness a chest x-ray should be considered to exclude apical lung lesions.

Suspected laryngeal cancer: referral guidelines-

A suspected cancer pathway referral to an ENT specialist should be considered for people aged 45 AND OVER with:

• Persistent unexplained hoarseness or
• An unexplained lump in the neck.

Question 24

Thyroid surgery complications

Answer 24

Anatomical such as recurrent laryngeal nerve damage.

Bleeding. Owing to the confined space haematoma’s may rapidly lead to respiratory compromise owing to laryngeal oedema.
-If a bleed occurs, the pressure behind the suture line increases and the trachea becomes compressed resulting in stridor. Thereforere remove sutures + urges Senior assistance will be required as this patient will require further surgery for haemostasis.

Damage to the parathyroid glands resulting in LOW CALCIUM.

Question 25

Perforated tympanic membrane Causes Management

Answer 25

Causes Infection. Other causes include barotrauma or direct trauma. Management No treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. NICE support this approach in the 2008 Respiratory tract infection guidelines myringoplasty may be performed if the tympanic membrane does not heal by itself

Question 26

When to 2 week wait for oral cancer

Answer 26

Unexplained ulceration in the oral cavity lasting for more than 3 weeks or a persistent and unexplained lump in the neck. Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either: A lump on the lip or in the oral cavity or A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Question 27

What is Ramsay hunt syndrome Features Management

Answer 27

Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve. Features Auricular pain is often the first feature Facial nerve palsy Vesicular rash around the ear - may also be seen on the anterior 2/3rds of the tongue and the soft palate. Other features include vertigo and tinnitus Management oral aciclovir and corticosteroids are usually given

Question 28

What is meniere's disease Features Natural history Management

Answer 28

Disorder of the inner ear of unknown cause. It is characterised by excessive pressure and progressive dilation of the endolymphatic system. It is more common in middle-aged adults but may be seen at any age. Meniere's disease has a similar prevalence in both men and women. Features Recurrent episodes of vertigo, tinnitus and hearing loss (SENSORINEURAL). - Vertigo is usually the prominent symptom - A sensation of aural fullness or pressure is now recognised as being common - other features include nystagmus and a positive Romberg test - episodes last minutes to hours - typically symptoms are unilateral but bilateral symptoms may develop after a number of years Natural history Resolve in the majority of patients after 5-10 years Majority will be left with a degree of hearing loss Psychological distress is common Management ENT assessment is required to confirm the diagnosis Patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved Acute attacks: - buccal or intramuscular Prochlorperazine. Admission is sometimes required PREVENTION: - BETAHISTAMINE and vestibular rehabilitation exercises may be of benefit

Question 29

Quincy Define Features Management

Answer 29

A peritonsillar abscess typically develops as a complication of bacterial tonsillitis. Features include: • Severe throat pain, which lateralises to one side deviation of the uvula to the unaffected side • Trismus (difficulty opening the mouth) • Reduced neck mobility • Hot potato voice • Anorexia - can't eat Patients need urgent review by an ENT specialist. Management • Needle aspiration or incision & drainage + intravenous antibiotics - LA through moth • Tonsillectomy should be considered to prevent recurrence

Question 30

Vestibular neuronitis Features Differential diagnosis

Answer 30

Vestibular neuronitis is a cause of vertigo that often develops following a viral infection. ``` Features recurrent vertigo attacks lasting hours or days nausea and vomiting may be present horizontal nystagmus is usually present no hearing loss or tinnitus ``` Differential diagnosis viral labyrinthitis posterior circulation stroke: the HiNTs exam can be used to distinguish vestibular neuronitis from posterior circulation stroke Management vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms Buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe case

Question 31

Sinusitis Investigations management Complications Name the sinuses

Answer 31

Investigations • Usually CT done • Nasal swabs? (commonly strep pneumonia, haemophillus, moraxella catarrhalis) Management of acute sinusitis - Analgesia - Intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for MORE THAN 10 DAYS Oral antibiotics are not normally required but may be given for severe presentations. The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if 'systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications' Complications • Orbital cellulitis • Frontal abscess/subdural empyema/cerebral abscess ``` Sinuses - Frontal - Maxillary - Ethmoid - Sphenoid They drain into the nose through tiny openings - mucus should go down to throat ```

Question 32

What is allergic rhinitis Types Features Management

Answer 32

Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens. It may be classified as follows, although the clinical usefulness of such classifications remains doubtful: 1) Seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever 2) Perennial: symptoms occur throughout the year 3) Occupational: symptoms follow exposure to particular allergens within the work place ``` Features sneezing bilateral nasal obstruction clear nasal discharge post-nasal drip nasal pruritus ``` Management of allergic rhinitis allergen avoidance if the person has mild-to-moderate intermittent, or mild persistent symptoms: - oral or intranasal antihistamines if the person has moderate-to-severe persistent symptoms, or initial drug treatment is ineffective - intranasal corticosteroids = 1st line e..g. fixonase - a short course of oral corticosteroids are occasionally needed to cover important life events there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline). They should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal

Question 33

Causes of sensorineural hearing loss

Answer 33

Disorders of the cochlear apparatus • Congenital disorders: from rubella or syphilis in the pregnant mother • Infection: basal meningitis, spread of infection from the middle to the inner ear, mumps or measles • Medication: aminoglycosides, diuretics, salicylates, quinine (deafness is transient with the last two but can be permanent with aminoglycosides) • Presbycusis: neuronal degeneration in the elderly causing high-frequency hearing loss • Noise-induced disorders: high-frequency hearing loss from, e.g., gun blasts or industrial machinery • Ménière disease: vertigo, fluctuating tinnitus and deafness • Head injury: fractures through the base of the skull and petrous temporal bone can lead to damage to the cochlea and eighth nerve Disorders of the cochlear nerve • Lesions of the cerebellopontine angle (CPA), e.g., vestibular schwannoma (NF2?), other tumours, granulomatous disease, arteriovenous malformation, stroke (anterior inferior cerebellar artery) • Lesions of the base of the skull e.g. infective (meningitis), inflammatory (sarcoidosis), carcinomatous meningeal seeding such as nasopharyngeal carcinoma Disorders of the brainstem • Multiple sclerosis: plaques of demyelination involving the cochlear nuclei • Infarction • Neoplastic infiltration Disorders of the supranuclear connections Unilateral lesions of the supranuclear pathways will not cause deafness as the cochlear nuclei on each side have bilateral connections projecting to the temporal cortices.

Question 34

Causes of conductive hearing loss Define

Answer 34

``` Wax Osteosclerosis Trauma FB Ottitis externa Otitis media with TM perforation ``` Sound not getting through to the cochlea for some reason

Question 35

What is glue ear Management

Answer 35

OM with effusion More common in children than adults (important to monitor effect on hearing, development, schooling) Build up of fluid in middle ear - blocked Eustachian tube Red flag in adults as could be cancer impairing drainage through Eustachian tube Mx Conservative – Valsalva maneuvers, auto-inflation in younger children, - xhearing aids Surgical – myringotomy +/- Grommet (ventilation tubes) insertion - Grommets fall out spontaneously in a year or so - Common for pts to need re-insertion Parents should stop smoking

Question 36

Define sensorineural hearing loss

Answer 36

Something happing in the cochlea, the nerve of hearing or the brain which is stopping the brain picking up that sound

Question 37

What is labrythitis Presentation Treatment

Answer 37

Most common cause of acute vertigo – usually due to viral infection getting into ear Presentation • Acute vertigo, nausea, imbalance • Nystagmus • No neurological deficit or headache. If they do  urgent investigation Treatment • Vestibular sedatives: Stemetil (asap) • Vestibular rehab after acute phase • Admit if lives alone, unable to cope, severe vomiting

Question 38

What is BPPV Test Management

Answer 38

Severe brief episodic vertigo lasting 30s on head turning (always positioning) + Nystagmus Cause - Displacement of otoliths in semicircular canals - common after head injury Causes - head injury - Idiopathic - Otosclerosis - Post viral Test = Hallpike = upbeat torsional nystagmus + dizziness Management - Epley manœuvre - Betahistine - often given but limited use

Question 39

What is ossiculoplasty

Answer 39

For conductive hearing loss with damaged or fixed ossicles • Synthetic implant or • Shaped pieces of cartilage Between the ear drum and the stapes foot plate where the sound is conducting into the cochlea

Question 40

What is an acoustic neuroma Fetaures Associated conditions Investigations Management

Answer 40

AKA Vestibular schwannomas account for approximately 5% of intracranial tumours and 90% of cerebellopontine angle tumours. The classical history of vestibular schwannoma includes a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex. Features can be predicted by the affected cranial nerves: - CN VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus - CN V: absent corneal reflex - CN VII: facial palsy Bilateral vestibular schwannomas are seen in neurofibromatosis type 2. Patients with a suspected vestibular schwannoma should be referred urgently to ENT. It should be noted though that the tumours are often slow growing, benign and often observed initially. MRI of the cerebellopontine angle is the investigation of choice. Audiometry is also important as only 5% of patients will have a normal audiogram. Management is with either - surgery - radiotherapy or observation.

Question 41

Tonsilitis Symptoms Causes Criteria Management

Answer 41

• 60-90% Viral Sore throat, fever, malaise Signs • Lymphadenopathy • Inflamed tonsils and oropharynx • Exudates Organisms • Precedes bacterial infection • Usually Streptococcal (Gp A Strep pyogenes) • Strep pneumoniae, staph, Haemophilus, • Rarely Diptheriae, Gonococcus, • EBV (Glandular Fever) – Don’t give amoxicillin else rash ``` Criteria - CENTOR Cervical lymphadenopathy Exudate No cough Temperature ``` Management • Throat Swab • Penicillin V 500mg QDS 10 days (Clarithromycin if allergy to pen) - if CENTOR 3 or more • Hydration, rest • Strong analgesia • If persists Throat swab, add metronidazole, Monospot

Question 42

Adenoidectomy Indications

Answer 42

Indications • OSA in children (+/- adults) • Glue ear with failed grommets x 1-2 • For biopsy

Question 43

Tracheostomy vs Laryngotomy

Answer 43

Tracheostomy: • Tube coming from neck into airway but still have a normal airway (voice box and airway above there so can breathe both ways) If cuffed tracheostomy: • Can only breathe through the tube Laryngectomy: • Trachea is brought out and sutured to the skin – no voice box/larynx

Question 44

Anterior neck triangle borders

Answer 44

1) Anterior Sternocleidomastoid (SCM) 2) Mandible 3) Midline Broken further down by other muscles • Digastric o Submandibular triangle o Carotid triangle

Question 45

Posterior neck triangle borders

Answer 45

1) Posterior border of SCM 2) Clavicle 3) Trapezius Further divided by the omohyoid muscle: Into upper and lower part

Question 46

Causes of anterior neck triangle lumps Investigations

Answer 46

``` Divide by pulsatility 1) Pulsatile • Carotid artery aneurysm • Tortuous carotid a. • Carotid body tumour 2) Non-Pulsatile • Branchial cyst • Laryngocele • Goitre • Parotid tumour (lump in postero-superior area) ```

Question 47

Causes of posterior Triangle neck lumps

Answer 47

``` LNs Cervical ribs Pharyngeal pouch Cystic hygromas Pancoast's tumour ```

Question 48

Causes of midline lumps

Answer 48

<20yo • Thyroglossal cyst • Dermoid cyst >20y • Thyroid isthmus mass • Ectopic thyroid tissue

Question 49

Brachial cyst What is it Presentation Management

Answer 49

Embryological remnant 2nd brachial cleft Presentation - Age <20 - Anterior margin of SCM at junction of upper and middle 3rd - May be infected --> abscess - May be associated with branchial fistula Management - Med: Abx for infection, Sclerotherapy - Surgery: Definitive Rx

Question 50

What is chronic rhinosinutisis Symtoms Investigations Management

Answer 50

Not always related to allergy • +/- Nasal polyps • Samters triad – asthma, nasal polyps and aspirin allergy • Difficult to treat Investigation • Allergy testing ``` Management • Long term steroid nasal sprays/drops o (fluticasone / mometasone) • Oral steroids occasionally • Antibiotics (azithromycin) • Endoscopic sinus surgery ```

Question 51

Epistaxis managemnet

Answer 51

* Sit up and forwards * Reassure * Mouth open (cork) * Pinch firmly cartilaginous nose * Ice over bridge of nose ``` If that doesn’t work • Calm. Reassure, fluids, bloods • Protection – apron, mask, goggles • Assistant • LA spray – cophenylcaine and wait 3-4mins ``` Consider cautery or packing. Cautery should be used if the source of the bleed is visible and cautery is tolerated- it is not so well tolerated in younger children! Packing may be used if cautery is not viable or the bleeding point cannot be visualised. If the nose is packed in primary care, the patient should be admitted to hospital for review. Cautery: Ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume. Use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect Identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of perforation. Dab the area clean with a cotton bud and apply Naseptin or Muciprocin Packing: Anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes Pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions Pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after inserting the pack. Examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as this increases pressure on the septum and offending vessel. Patients should be admitted to hospital for observation and review, and to ENT if available * Foley, Brighton Balloon – insert into postnasal space then inflate the balloon, pull it forward – puts pressure on sphenopalatine artery at back of nose * Often a combination of packing and balloon catheter Self-care advice involves reducing the risk of re-bleeding. Patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks should be avoided. The same applies for patients who have just been cauterised, as any strain on the nostril may induce a re-bleed.

Question 52

Instrumenst used to examine the nose

Answer 52

Headlight Thudicum's speculum Otoscope Nasal Endoscope (rigid or flexible)

Question 53

When to x-ray for nasal bone injury Management

Answer 53

``` Only x-ray acutely depending on: • Mechanism • Diplopia • Abnormal eye movements • Depressed zygoma • Malocclusion • LOC • Loss of facial sensation ``` Management • If seen v early release immediately pre swelling • Otherwise see in 7d for reassessment • If compound: Clean thoroughly and close (broad spectrum abx) • Septal haematoma --> refer for drainage

Question 54

Septal haematoma Cause Management

Answer 54

Blood collection between skin and lining of the nose and the nasal septum Cause • Nasal bone fractures Management • DRAIN - as blood supply from cartilage comes from perichondrium and if elevated off - they lose blood supply - Can cause necrosis and leave hole in nasal septum

Question 55

Septal deviation Causes Presentation Management

Answer 55

Causes • Trauma • Congenital (tend to be more severe) Presentation • Nasal obstruction • Snoring • Mouth breathing Management • Surgery if symptomatic = Simple endoscopic septoplasty • Combine with rhinoplasty if external deformity

Question 56

Thyroid lump investigations

Answer 56

``` Check TFTs Refer if (routine) • New lump • Increase in size • Abnormal TFTs • Sudden pain ``` ``` Refer (2ww) • Hoarseness • Cervical adenopathy • Rapidly enlarging painless mass • Thyroid nodule in child ``` Same day referral if stridor

Question 57

Thyroidectomy risks

Answer 57

Bleeding --> Airway obstruction Recurrent laryngeal n injury HYPOCALCAEMIA

Question 58

Neck lumps main caused Investigations

Answer 58

85% are LNs especially if <3 weeks - Infection/Cancer 8% are goitres 7% others e.g. sebaceous systemic or lipoma Investigation TRIPLE ASSESSMENT: Clinical, US, Cyto/Histo (apiration or biopsy)

Question 59

Laryngocele Define Characteristic feature

Answer 59

Cystic dilatation of the laryngeal saccula Anterior non-pulsatile neck lump Exacerbated by blowing

Question 60

Dermoid cysts

Answer 60

Causes Developmental inclusion of the epidermis along the lines of skin fusion Presentation - common <20yo - Found at junction of embryological fusion - neck midline - lateral angles of eyebrow - under tongue Contains ectodermal elements - Hair follicles - Sebaceous glands

Question 61

Cystic hygroma Presentation Rx

Answer 61

Congenital multiloculated lymphagioma arising from the jugular lymph sac Presentation - Infant - Lower posterior triangle lump - may extend into axilla - increases in size when kid cries - Transilluminates bilaterally Rx - Excision of hypertonic saline sclerosant

Question 62

Cervical rib neck lump Presentation

Answer 62

Overdevelopment of transverse process of C7 Presentation - Mostly asymptomatic - Hard swelling - Reduced radial pulse on abduction and external rotation of arm CAN --> vascular syndrome - compresses subclavian a. - Raynauds - Subclavian steal - Reduced venous outflow = oedema Can --> Neuro symptoms - Compresses lower trunk of brachial plexus, T1 nerve root. Wasting of intrinsic hand muscles - Paraesthesisa along medial border of hand

Question 63

Causes of salivary gland enlargement

Answer 63

1) Whole gland - Parotitis - Parotitis - Sjogrens - Sarcoid - ALL - Chronic liver disease - Anorexia/bulimia 2) localised - Tumours - Stones

Question 64

Acute parotitis causes

Answer 64

Viral: Mumps, coxsackie A, HIV Bacterial: S.aureus (associated with calculi and poor oral hygiene

Question 65

Salivary gland neoplasms

Answer 65

80% parotid 80% pleomorphic adenoma Deflection of ear outwards is classic sign CN VII palsy = malignant Classification 1) Benign a) Pleomorphic adenomas b) Adenolymphoma (Warthin's) 2) Malignant (CN7 palsy and fast growing) a) Mucoepidermoid b) Adenoid cystic Investigations - ENT exam - US +/- CT - FNAC

Question 66

Benign salivary gland lymphomas

Answer 66

1) PLEROMORPHIC ADENOMAS - Commonest salivary gland neoplasm - Presentation: 90% in parotid, middle age, F>M, Benign and slow growing - Histo: Different types - Rx: Superficial parotidectomy 2) Adenolymphomas (Warthin's tumour) - Benign cystic tumour - Older men - Enucleation

Question 67

Adenoid-cystic carcinoma Define Features Management

Answer 67

``` Highly malignant salivary tumour and one of most common = Rapid growth - Hard fixed mass - Pain - Facial n palsy ``` Surgery - Superficial or radical parotidectomy - Fascia lata face lift for facial palsy Complications - Facial palsy - Salivary fistula - Frey's syndrome (gustatory sweating - red and sweaty when thinking about food lol)