ENT Flashcards
Features of a brachial cyst
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
Thyroglossal cyst features
Location
Features
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
Management of sore throat
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)
Drugs that cause hearing loss
Aminoglycosides (e.g. Gentamicin) Furosemide Aspirin Quinine and a number of cytotoxic agents
Indications for tonsillectomy
Complications of tonsillectomy + management
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.
Red flags for epistaxis
Unilateral - if recurrent unilateral epistaxis, think about cancer
Why does otitis media need urgent treatment
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
Malignant otitis externa
Who get’s it
Causative organism
Key features in history/presentation
Diagnosis
Management
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
What is osteoclerosis
Cause
Features
Management
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
Management of nasal polyps
Associated conditions
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
Features of a cytsic hygroma
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.
What is black hairy tongue
Predisposing factors
Investigation
Management
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
Causes of vertigo
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
What is gingivitis
Spectrum of disease
Management
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
Causes of gingival hyperplasia
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)
Submandibular triangle borders
Masses cause
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.
Sudden sensorineural hearing loss
Cause
Test
Management
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.
Otitis externa
Causes
Features
Investigations
Management
2nd line options
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.
Nasopharyngeal carcinoma
Features
Imaging
Treatment
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.
Cholesteatoma define
Main features
Ottoscopy findings
Management
Complications
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
Otitis media
Features
Management
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
When to 2 week wait to oral surgery
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
Causes of hoarseness
Investigations
When to 2 week wait
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.
Thyroid surgery complications
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.
Perforated tympanic membrane
Causes
Management
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
When to 2 week wait for oral cancer
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.
