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Phase 4 - GR > ENT > Flashcards

ENT Flashcards

1
Q

Nmae 3 common DDx of cervical lymphadenopathy

A

EBV: fever, pharyngitis, lymphadenopathy: posterior cervical
HIV: flu-like etc. cervical, axillary and occipital
Adenovirus: cold or flu/RTI axillary, cervical, occipital
CMV: immunocompromised, nt sweats, pneumonia
HZV: shingles - axillary, cervical, occipital
Streptococcal pharyngitis (pyogenes): cervical lymphadenopathy, enlarged tonsils
NHL, HL, CLL - generalised etc

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2
Q

What travels through parotid

A

facial nerve (if this is affected = malignant)

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3
Q

Name 3 causes of parotid swelling

A

viral parotitis (mumps), stone, sarcoidosis, tumours, HIV, wegners

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4
Q

Pt comes in with Bilateral swelling of parotids lasting one week, associated by low grade pyrexia… What Ix ? name 3

A

FBC, ESR/CRP, UE, blood culture, viral serology,
salivary antibody testing (*salivary mumps IgM)

Pus swab culture and sensitivities

USS

Sialography for blockage (contrast into gland + X-ray)

CT/MRI scan to exclude neoplasm

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5
Q

Which salivary gland do you normally get obstruction?

A

submandibular (parotid wider / more water)

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6
Q

Parotid Pain + swelling at meal times, colicky, relapse and remit…What is it likely? Ix?

A

obstruction

USS + contrast sialography

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7
Q

Mx of obstruction

A

Many pass spontaneously: good hydration, warm compress, gland massage, oral hygiene

Surgical removal

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8
Q

Most tumours of salivary glands are benign (75%) but name 3 red flags that might indicate malignancy

A

Rapid increase in size, ulceration, fixation, paresthesia of associated nerves, past Hx skin cancer, Sjogren’s, *facial nerve weakness,

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9
Q

Specific Ix of salivary gland tumour

A

USS if first line
+ Fine needle aspiration - cytology
+ Core biopsy if tumour is seen

MRI for tumour staging or margins (*sublingual = high malignancy risk)

CT for metastatic spread

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10
Q

Post surgical removal of a salivary tumour what is the main complications

A

Damage to facial nerve

recurrence

Freys syndrome 
(redness or swelling on cheek when eating/salivating from autonomic nerves)
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11
Q

Most common cause of vertigo?

A

Benign paroxysmal positional vertigo

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12
Q

Who gets BPPV

A

50 year old women with anxiety + Menieres

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13
Q

BPPV what type of vertigo? how long does it last”?

A

Vertigo provoked by head movement, worse when head tilted one way

Sudden onset attacks: 20-30 seconds

Assoc nausea

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14
Q

Name any Sx you might think were red flags in BPPV

A

hearing loss, tinnitus, pain or headache

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15
Q

What test confirms BPPV?

2 other examinations?

A

Dix-Hallpike test
(turn head to one side and quickly lay them down
-> vertigo and rotary nystagmus)

Otoscopy: for exclude cholesteatoma and vesicles (VZV)

Cranial nerve exam: palsies/hearing loss

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16
Q

In BPPV the dix hallpike test is only positive on 1 side - what might it suggest if its bilateral?

A

vestibular neuritis, central cause

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17
Q

Name 3 DDx of BPPV

A

Acute vestibular labyrinthitis, MS, Menieres, acoustic neuroma, Ramsay Hunt syndrome (varicella zoster oticus - pain within ear radiates to pinna, vertigo, tinnitus, facial weakness, rash)

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18
Q

Mx of BPPV ? ADVICE?

A

Get out of bed slowly, reduce head movements

Epley’s manoeuvre

Advise not to drive when dizzy

High risk of recurrence

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19
Q

What is this and cause?…Episodic auditory and vestibular disease characterised by sudden onset vertigo, hearing loss, tinnitus (*low frequency roaring) and fullness in ear - *unilatera

A

menieres

overproduction / lack of absorption of endolymph

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20
Q

Meniers presentation

A

Recurrent vertigo - 30 mins
Unilateral hearing loss: fluctuating and worsening around vertigo *sensorineural
Tinnitus: unilateral and roaring
Aural fullness
Drop attacks
Positive Romberg’s
Hearing loss: pure tone air and bone conduction (low frequency loss early in disease), otoacoustic emissions absent in low frequency

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21
Q

The Ix in menieres is mostly about exclusion - name2

A

MRI normal,
TFT normal,
lyme disease/syphillis serology - normal

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22
Q

Acoustic neuroma and menieres present quite similarly - what is an easy difference?

A

Hearling loss - menieres is low frequency (in early disease )

Neuroma - high frequency

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23
Q

Mx of menieres

A

Low salt diet and diuretics

Symptomatic vertigo:
Meniett device: delivers pressure pulses to ear canalmeclozine (vestibular suppressant) ± intratympanic corticosteroids,

Hearing aids

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24
Q

What if mx of menieres fails?

A

endolymphatic sac surgery

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25
Q

How to tell the difference between Vestibular neuritis and labyrinthitis

A

Presentation - Acute vertigo (AN/L) + hearing loss (L only)

This is because vestibular neuritis only affects the vestibular nerve whereas labyrinthitis is a disorder affecting the inner ear as a whole or CN 8 as a whole.

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26
Q

Cause of vestibular neuritis?

A

Most causes are a viral infeciton e.g. measles, flu, rubella.
reactivation of HSV in vestibular ganglion

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27
Q

What usually precedes labarynthitis

A

post viral URTI (50%) - bronchitis

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28
Q

Presentation of VN / L

A

VERTIGO

Sudden, severe incapacitating vertigo (illusion of moving)
assoc N+V

Not triggered by mvmt, but may be exacerbated (dizzy at rest) - *No Dix-Hallpike!!!!!

Hearing loss = labyrinthitis (unilateral/bilateral) ± tinnitus

URTI symptoms

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29
Q

Name 3 things you would do OE of VN/L ?

A

External ear and TM : herpes zoster oticus, cholesteatoma

Herpes zoster IS VZV.

CN exam - to look for hearing loss

Mastoid tenderness, nuchal rigidity, high fever

Assess gait - fall towards affected side

Hearing test: 256 Hz Weber’s - nerve = quieter in affected, conductive = louder in affected

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30
Q

How to differentiate VN/L from stroke

A

HINTS test: Head impulse, nystagmus type, skew

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31
Q

What result of HINTS test would indicate VN/L? stroke?

A
  • VN or LN
    unidirectional nystagmus, no vertical skew (cover/uncover)

Stroke
bidirectional nystagmus, vertical skew - sensitive for ischaemic stroke esp PICA - posterior inferior cerebellar artery syndrome

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32
Q

specific Ix for VN/L

A

Culture and sensitivity of middle ear perfusions

CT scan for mastoiditis

Pure tone audiometry in hearing loss

Vestibular function testing

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33
Q

Mx of vertigo in VN/L

A

prochlorperazine

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34
Q

What is an acoustic neuroma

A

CN8 tumour of Schwann cells at cerebellopontine angle

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35
Q

What presentation is always an acoustic neuroma until proven otherwise

A

Unilateral hearing loss

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36
Q

Pres of acoustic neuroma

A

Unilateral or asymmetrical hearing loss or tinnitus - progressive

Impaired facial sensation (involvement of trigeminal nerve loss of corneal reflex)

Balance problems

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37
Q

Bilateral acoustic neuroma seen when?

A

Neurofibromatosis T2

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38
Q

2 key Ix in acoustic neuroma

A

audiology

MRI

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39
Q

Mx acoustic neuorma

A

treatment of choice is microsurgery

Conservative: if small tumour with good preserved hearing

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40
Q

What nerve innervates the maxiliary sinus ? what does this mean?

A

infraorbital - can get referred pain to upper jaw pain, toothache, pain in skin

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41
Q

Basic exam of sinus ?

A

palpate

simple assessment of nose

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42
Q

Name 2 bugs that usually are the cause of sinusitis

A

strep pneumoniae, h. Influenza, moraxella catarrhalis (children)

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43
Q

Mx of sinusitis

A

Paracetamol/ibuprofen - pain/fever
Intranasal decongestant (max 7 days)
Nasal douching
Warm face packs

Abx if bacterial - amox

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44
Q

Complications of sinusitis

A

Orbital cellulitis, meningitis, osteomyelitis

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45
Q

Chronic sinusitis Mx

A

topical nasal steroids: beclomethasone

Good dental hygiene, stop smoking

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46
Q

If a pt has facial pain associated with getting Worse with fatigue or stress, often linked with depression or mood disturbance…..
Mx/

A

TCA - amitryptiline ± CBT

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47
Q

triad in TMJ dysfunction

A

pain, limited mouth opening, joint noises

48
Q

What is the pain in TMJd

A

typically in front of tragus (lil ting on inner side of external ear) radiating to ear, temple, cheek, mandible

49
Q

Mx of TMJ dysfuction

A

Explanation and reassurance (mainly benign and self-limiting)

Rest, education: limit chewing, massage, relaxation

Manage pain psychologically

Drugs: NSAIDs, muscle relaxants, TCA (2-4 weeks)

50
Q

2 causes of congenital hearing loss ? Post natal?

A

rubella
CMV
malformation

Mumps
measles

51
Q

What are rinnes and webers

A

Weber’s:
in conductive = louder in affected ear
in sensorineural = quieter in affected ear

Rinne’s: start at mastoid then to ear
+ve both retained
-ve air lost = conductive
Both lost = sensorineural - also +ve

52
Q

What to examine in deafness

A

Inspection of external ear andexamination of tympanic membrane

Rinne’s and Weber’s

53
Q

Deafness Ix

A

Audiometry
Tympanometry
otoacoustic emission testing

54
Q

Sudden hearing loss - whatcha do?

A

urgent referral to ENT

55
Q

Qs to differentiate otitis externa and acute otitis media with pt presenting with otorrhoea

A

Is there pain?
Y = otitis externa
There was pain but it is now settled = acute otitis media

Well + unilateral - otitis externa

Pain then discharge late - AOM

[Basically - Media has pain and then discharge later]

56
Q

Pres of otitis externa

A

Erythematous ear canal with oedema and exudate
Mobile tympanic membrane
Pain on move tragus
Pre-auricular lymphadenopathy

57
Q

What are the 3 main types of otitis externa and usual cause

A

acute diffuse otitis externa (Swimmer’s ear)
-bacterial

chronic otitis externa
-fungal

necrotising otits externa
p.aeruginosa (gets to mastoid / temporal bones)

58
Q

Mx of necrotising otitis externa

A

Use oral and topical quinolones (6-8 weeks)

eg ciprofloxacin

59
Q

Mx of otitis externa

A

Pain management
Cure infection
Prevent complications

60
Q

Mx of acute Otitis externa? When oral Abx?

A

Topical drops - *neomycin (also covers fungal)

Oral ABX if cellulitis or cervical lymphadenopathy

61
Q

Mx if you suspect fungal cause of otitis externa

A

clotrimazole

62
Q

Mx of chronic otits externa with no apparent cause

A

acetic acid and corticosteroid ear drops (hydrocortisone)

63
Q

Advice to prevent recurrence of otitis externa. Name 3

A

Keep ear dry

Use ear plugs when swimming

Do not use cotton swabs for wax

Olive oil to prevent waxy build up

64
Q

Presentation of acute otitis media

A

Hearing loss (not in OE), otalgia, otorrhoea, fever

65
Q

ix in otitis media? if worried about comps?

A

Culture of discharge if chronic / perforation

CT or MRI to exclude complications

66
Q

Mx of otitis mediA

A

Analgesics
nasal steroids - if allergy based
abx if sx >5 days

67
Q

What is otitis media with effusion called?

A

glue ear

68
Q

how does glue ear present/

A

conductive hearing loss
Feeling of aural fullness
Cracking tinnitus

69
Q

What is being described?
Which nerves can be involved?

: Intense pain behind ear, fever, boggy mass behind ear, external ear protrudes forwards

A

mastoiditis

VI (petroud apex) or VII CN palsy

70
Q

ix in mastoiditis

A

FBC (WCC), blood cultures,
CT/MRI for Dx and comp
LP if suspect IC spread
fluid extraction - tympanocentesis for gram stain and culture

71
Q

mx of mastoiditis

A

High dose broad spec IV ABX: 3rd generation cephalosporin (2 days)

Then oral ABX for 2 weeks

72
Q

What to do if cranial extension of mastoiditis ?

A

Mastoidectomy + tympanoplasty

73
Q

What is a cholesteatoma?

A

Keratinising squamous epithelium within the middle ear cleft

74
Q

Whats the issue with cholesteatoma?

A

may be locally invasive affecting bones of middle ear.

Erodes bones with *osteolytic enzymes

75
Q

how does Cholesteatoma present?

A

progressive conductive hearing loss

Features of erosion - vertigo, headache, CN7 palsy, meningitis

Frequent otorrhoea (foul smelling) + progressive unilateral hearing loss + tympanic membrane perforation or TM retraction

76
Q

Ix for Cholesteatoma

A

CT

MRI

77
Q

mX Cholesteatoma

A

surgical removal

78
Q

what nerve runs over temporal bone

A

abducens

79
Q

Where can refer pain to ear?

A

Cervical spine (C2, C3) - worse at night

Laryngo-pharynx (CN10) - in carcinoma of pyriform fossa

Upper molars/TMJ/parotid gland (CN5 mandibular)

Oropharynx (CN9) (tonsillitis or carcinoma of posterior ⅓ tongue)

80
Q

Dx and staging of oral Ca

A

fibre optic endoscopy, fine needle aspiration/biopsy (neck masses)

CT/MRI for spread and nodal metastasis

CT thorax for all with head and neck cancers

81
Q

Mx of early oral Ca

A

Surgical resection or brachytherapy

If no neck disease - prophylactic radiotherapy

Postoperative radiotherapy ± CISPLATIN

82
Q

Rfs oral / pharyngeal Ca

A

Tobacco, HPV, alcohol, too hot drinks

83
Q

Big Rf for nasopharyngeal Ca? common issue?

A

EBV
(smoking too obvs)

50% have cervical mets at presentation

84
Q

Pres of layngeal Ca?

A

Chronic hoarseness* +

PERSISTENT COUGH, pain, dysphagia, lump in neck, sore throat, earache, breathlessness, aspiration, weight loss, *stridor

85
Q

What Ix in chronic hoarseness

A

urgent CXR to decide if lung or ENT

86
Q

When would you Ix sore throat

A

Only if prolonged, FBC and glandular fever screen, ASO (antistreptolysin O titres)

87
Q

What things would you advise about for saftey net of sore throat

A

stridor, drooling, muffled voice, severe pain

88
Q

Cause of epiglottitis and presentation?

A

HIB

Sore throat, unable to swallow (drooling), muffled voice (hot potato voice), fever, ear pain, high temp, tachycardia, *tripod sign - patient leaning forward
*Stridor and respiratory distress

89
Q

Seen on lateral Xray of epiglotitis?

A

thumbprint sign

90
Q

Mx of epliglotitis

A

IV or oral abx ± intubation/tracheostomy

91
Q

Usual cause of quinsy?

A

s pyogenes

92
Q

Mx of quinsy?

A

IV fluids, analgesia, IV abx (penicillin/cephalosporin/co-amoxiclav)

Needle aspiration, incision and drainage

93
Q

Ix in reccurent epistaxis ?

A

FBC, coagulation studies

If ?malignancy - to ENT ± CT ± nasopharyngoscopy

94
Q

Mx reccurent / severe epistaxis?

A

Nasal cautery with caustic agent e.g. silver nitrate or electrocautery

95
Q

What features would cause you to refer a nasal injury immediately

A 
Marked deviation, prolonged epistaxis, 
septal haematoma (requires incision and drainage) 
CSF rhinorrhoea - breach of cribiform plate -> for CT and neurosurgery
96
Q

Ix of nasal polyps

A

Rigid or flexible rhinoscopy by ENT -

97
Q

Mx of nasal polyps

A 
topical corticosteroids (beclomethasone may affect growth) 
\+ saline douche

2nd - functional endoscopic sinus surgery

98
Q

What is congenital lymphatic lesion, lymphangioma, classically found on left side
90% are evident at birth

A

Cystic hygroma

99
Q

what is oval, mobile mass between sternocleidomastoid and pharynx
Develop due to failure of obliteration of second branchial cleft
Usually present in adulthood

A

brancial cyst

100
Q

What is? Dysphagia, regurgitation, aspiration, chronic cough, weight loss. Gurgling lump on palpation, halitosis from decaying food

key Ix?

A

pharyngeal pouch

barium swallow

101
Q

DDx of swallowing difficulties…name 3

A

Obstructive
GORD, oesophagitis, oesophageal/gastric cancer, pharyngeal cancer, oesophageal stricture

Neuro
CVA, achalasia, oesophageal spasm, MND, MS, Parkinson’s

Other
Pharyngeal pouch, globus hystericus, external compression (mediastinal tumour), inflammation (tonsillitis, laryngitis), CREST syndrome

102
Q

Rfs of obstructive sleep apnea

A

Obesity, male, middle age, smoking, sedatives, alcohol, family history

103
Q

Pres of obstructive sleep apnea

A

Hx of snoring and witnessed apnoeas + excessive daytime sleepiness + macroglossia, apnoea

104
Q

how to assess sleepiness?

A

epworth sleeiness score

105
Q

mx obstructive sleep apnea

A

Behavioural: smoking, wt loss, alcohol

CPAP (gold standard)

?modafinil for daytime sleepiness

Surgical for tonsils etc….

106
Q

What is bells palsy? features?

A

Acute, unilateral, idiopathic facial nerve paralysis
20-40yrs

LMN palsy - forehead affected

Hyperacusis (hearing), altered taste

107
Q

Mx bells palsy

A

Prednisolone 1mg/kg for 10 days within 72 hours

+ artificial tears (for eyecare)

108
Q

What should normal ear look like down an otoscope?

A

“pearly-grey“, translucent and slightly shiny

should be able to visualise the malleolus through the membrane and a “cone of light” in reflection to the otoscope light.

109
Q

33y complains of poor hearing in the left ear, which has become worse in the past year. She has a family history of uncle and father going deaf in their 40’s
Examination reveals normal ear drums and tuning-fork testing shows Weber test localising to the right and a negative Rinne test on that side.

Diagnosis?
mx?

A

Otosclerosis
ADominant

Observation – if mild
Hearing Aid – if symptomatic

Stapedectomy – if large conductive loss
stapes replaced with a prosthetic Teflon piston

110
Q

Comp of stapedectomy in otosclerosis?

A

5% may become completely deaf if surgery fails

111
Q

61 year old female presents with left sided hearing loss over the past 48h. No PMHx
Otoscopy NAD

Dx?
Mx?

A

Acoustic neuroma

Observation if small and slow-growing

Surgical excision

112
Q

3 year old presented with fever, irritability, ear tugging, not responding when called by mum

OE: bulging, erythematous TM with a absence of light reflex

Dx?
Key comp?

A

Acute Otitis Media

Mastoiditis

Matsoiditis /AOM can
lead to intracranial infection
and death

113
Q

A 24-year old has had problems with his ears for most of his life. He has had three sets of grommets for glue ear and numerous ear infections. However, he now has a constant discharge from his right ear for 3 months, which is foul-smelling.
Examination shows the ear canal to be full of debris and mucus. Once this had been removed, a polyp was seen to be filling most of the ear canal, obscuring the tympanic membrane.

Dx?
Mx?
3 comps?

A

Cholesteatoma
Surgical removal
Atticotomy – if small and limited to the attic

Radical Mastoidectomy – if more advanced and extends into mastoid

Complications can arise if the sac erodes into:
Ossicles – causing conductive deafness

Facial Nerve – causing facial palsy

Labyrinth – causing vertigo

Tegmen (roof of middle ear) – causing intracranial sepsis

Cochlea – causing sensorineural deafness

Sigmoid Sinus – causing it to thrombosis

114
Q

discharging ear and VII nerve palsy

A

cholesteatoma until proven otherwise

115
Q

3 Dx for CNVII palsy

A

Trauma:
Fractured temporal bone

Vascular:
CVA (Rapid onset, forehead unaffected)

Infection:
Ramsay Hunt Syndrome (Rapid onset, vesicles in ear)

Cholesteatoma (Ear discharge + CHL)
Otitis Media

Neurological:
MS

Neoplasm: 
Parotid Carcinoma (Gradual onset, facial pain)

Intracranial

Idiopathic
Bells Palsy

116
Q

Bells palsy vs ramsay hunt

Cause?
Sx Different?
Mx?

A

Bells - Idiopathic

RH - Reactivation of varacella zoster virus in geniculate ganglion

RH Sx
More pain
Hearing loss
Vesicles

Mx
BP - eye care / corticosteroid

RH - Eye care / Acyclovir

Phase 4 - GR (22 decks)

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