ENT Flashcards
1
Q
What is tonsillitis?
A
Inflammation due to infection of the tonsils
2
Q
What are the most common causative organisms of tonsillitis?
A
Mostly viral- HSV, adenovirus, rhinovirus, influenza, coronavirus, RSV, EBV
Bacterial- staph aureus, strep pneumoniae, mycoplasma pneumoniae
GpA B-haemolytic strep (Strep pyogenes)
3
Q
What criteria can be used to assess the need for antibiotics in tonsillitis?
A
FeverPAIN or CENTOR
4
Q
What are the FeverPAIN criteria?
A
Fever > 38 Purulence- exudate Attends rapidly- 3 days or less severely Inflamed tonsils No cough or coryza 2 or more- consider antibiotics
5
Q
What are the CENTOR criteria?
A
Likelihood of a bacterial infection in patients with sore throat 1. Hx of fever 2. Tonsillar exudate 3. Tender anterior cervical adenopathy 4. Absence of cough Age < 15 (+1) or > 44 (-1)
6
Q
Management of tonsillitis
A
Fluids, analgesia
Abx- Phenoxymethylpenicillin V for 10 days
7
Q
What is the most common causative organism for Glandular fever/Infectious mononucleosis?
A
EBV
10% CMV
8
Q
Presentation of Glandular fever/Infectious mononucleosis
A
Fever, malaise, headache, sore throat, photophobia, red/swollen tonsils with white patches, lymphadenopathy, cough, splenomegaly, abdo pain, nausea
9
Q
Investigations for Glandular fever/Infectious mononucleosis
A
Monospot/EBV serology
Throat swab
10
Q
Management of Glandular fever/Infectious mononucleosis
A
Usually self-limiting
11
Q
Causes of 8th nerve lesions
A
Paget’s disease of bone, Meniere’s disease, Herpes zoster, neurofibroma, acoustic neuroma, CVA, lead, aspirin, furosemide
12
Q
Presentation of 8th nerve lesions
A
Unilateral sensorineural deafness and tinnitus
13
Q
Aetiology of conductive deadfness
A
Impediment to passage of sound waves between external ear and footplate of stapes
14
Q
Aetiology of sensorineural deafness
A
Fault in cochlea or cochlear nerve
15
Q
What is presbyacusis?
A
Age-related hearing loss
16
Q
What is the most common cause of acquired deafness??
A
Otitis media with effusion
17
Q
Is air or bone conduction better in conductive and sensorineural deafness?
A
Conductive: air > bone
Sensorineural: air + bone conduction bad
18
Q
Causes of conductive hearing loss
A
Obstruction of external ear canal: wax, inflammatory oedema, debris, atresia, FB
Perforated TM
Fixation/Discontinuity of ossicular chain- infection/trauma
Middle ear effusion
19
Q
Causes of sensorineural deafness
A
Bilateral progressive loss- presbyacusis, drug ototoxicity, noise damage
Unilateral progressive loss- Meniere’s disease, acoustic neuroma
Sudden loss- trauma, viral, CVA, acoustic neuroma, barotrauma
20
Q
What is Acoustic neuroma/Vestibular Schwannoma?
A
Tumour of vestibulocochlear nerve arising from Schwann cells of the nerve sheath
Slow-growing but mass effect
21
Q
Risk factors for Acoustic neuroma/Vestibular Schwannoma
A
Neurofibromatosis type 2
Radiation
22
Q
Presentation of Acoustic neuroma/Vestibular Schwannoma
A
Unilateral sensorineural hearing loss, tinnitus, impaired facial sensation, balance problems
Later- facial pain, earache, ataxia
23
Q
Investigation of suspected Acoustic neuroma/Vestibular Schwannoma
A
MRI
24
Q
Management of Acoustic neuroma/Vestibular Schwannoma
A
Microsurgery
Stereotactic radiotherapy
25
What is Otitis Externa?
Inflammation of the outer ear
26
Most common causative organism of Otitis Externa
Pseudomonas aeruginosa
| Also fungal- Aspergillus/Candida
27
Risk factors for Otitis Externa
Hot humid climates, swimming, immunocompromise, DM, over-cleaning, eczema, obstruction of meatus
28
Presentation of Otitis Externa
Pain + itching, hearing loss, ear canal erythema, oedema, exudate, mobile tympanic membrane, pain with movement of tragus, pre-auricular lymphadenopathy
29
Management of Otitis Externa
Acute: topical drops, oral/IV Abx- Flucloxacillin or Ciprofloxacin in diabetes
Chronic: Acetic acid + corticosteroid drops; Fungal: Clotrimazole drops
30
What is Malignant Otitis Externa?
Osteomyelitis of EAM + bony tympanic plate (necrotising)
31
Presentation of malignant Otitis Externa
Severe unremitting otalgia, purulent aural discharge, granulaitons
32
Management of malignant Otitis Externa
Quinolones 6-8wks
33
Complications of Otitis Externa
Meningitis, Cerebral abscess, dural sinus thrombosis
34
What is Mastoiditis?
Suppurative infection in the middle ear which spreads to the mastoid air cells
--> inflammation --> bony destruction
35
Risk factors for Mastoiditis
Immunocompromised
Cholesteatoma
Age 6-13
36
What is the most common causative organism for Mastoiditis?
Strep pneumoniae
37
Presentation of Mastoiditis
Intense otalgia, pain behind ear, fever, tender boggy swelling behind ear, external ear protrudes forwards, bulging TM
Conductive deafness
38
Which type of deafness does Mastoiditis cause?
Conductive
39
Investigation of Mastoiditis
CT/MRI
40
Management of Mastoiditis
Broad-spectrum IV antibiotics for 1-2 days then oral
- Cefotaxime/Ceftriaxone
Myringotomy +/- tympanostomy tube
41
Complications of Mastoiditis
Hearing loss
CN palsies- VI/VII or trigeminal opthalmic
Osteomyelitis
42
What is a Thyroglossal duct cyst?
Occurs from a persistent epithelial tract from descent of the thyroid from the foramen caecum
43
Types of Thyroglossal duct cyst
```
Infrahyoid
Suprahyoid
Juxtahyoid
Intralingual
Suprasternal
Intralaryngeal
```
44
Presentation of Thyroglossal duct cyst
Midline lump in neck, moves on swallowing and tongue protrusion, non-tender
45
What is the typical age for presentation of Thyroglossal duct cyst?
Age 10 ish
46
Management of Thyroglossal duct cyst
Surgically removed to diagnose and prevent infection
47
Causes of Acute Pharyngitis
Influenza, mononucleosis, adenovirus, measles, chicken pox, croup, whooping cough, GpA Strep
48
What is Acute Pharyngitis?
Inflammation of the oropharynx but not the tonsils
49
Presentation of Acute Pharyngitis
Pharyngeal exudate, cervical lymphadenopathy, difficulty swallowing, fever, chills, headache
50
Investigations for Acute Pharyngitis
Throat culture for Strep throat
51
Which tools can be used to assess the need for antibiotics in Acute Pharyngitis
FeverPAIN/CENTOR
52
Management of Acute Pharyngitis
Phenoxymethylpenicillin if bacterial
| Fluids, paracetamol
53
What is the typical age of presentation with Epiglottitis?
Age 2-5
54
Causes of Epiglottitis
Used to be Hib but now vaccine
Strep, Staph aureus, Moraxella catarrhalis, HSV
Reactive epiglottitis to radiotherapy
55
Presentation of Epiglottitis
Sore throat, odynophagia, drooling, muffled 'hot potato' voice, fever
Stridor, respiratory distress
56
Investigation of Epiglottitis
DO NOT examine airway
| Fibre optic laryngoscopy- gold standard
57
Management of Epiglottitis
DO NOT examine airway
Medical emergency
IV/Oral antibiotics
Intubation/surgical tracheostomy?
58
Causes of chronic laryngitis
Allergy, asthma, trauma, smoking, sarcoidosis, ACE inhibitors
59
How long is classified as chronic laryngitis?
> 3 weeks
60
Presentation of laryngitis
Hoarse/breathy voice, pain/discomfort in neck, URTI symptoms, dysphagia, globus pharyngeus, throat clearing, fever
61
Management of laryngitis
Acute: mostly self-limiting, voice rest, hydration, antibiotics if fever > 48hrs, purulent sputum, immunocompromised
Chronic: voice therapy, treat underlying condition
62
What is Quinsy?
Peri-tonsillar abscess, complication of acute tonsillitis, pus between tonsillar capsule and lateral pharyngeal wall
63
Causative organisms of Peri-tonsillar abscess (Quinsy)
Strep pyogenes, Staph aureus, HiB
64
Presentation of Peri-tonsillar abscess (Quinsy)
Severe unilateral throat pain, fever, drooling, foul breath, painful swallowing, trismus (lockjaw), earache, unilateral bulging superior and lateral to tonsil
Medial/anterior shift of tonsil + uvula
65
Management of Peri-tonsillar abscess (Quinsy)
IV Fluids, analgesia
IV antibiotics- eg Ceftriaxone
Surgical aspiraton
66
What is Ménière's disease?
Increase in fluid (endolymph) in membranous labyrinth --> endolymphatic hydrops
67
What is the peak age for Ménière's disease?
Age 40-60
68
Risk factors for Ménière's disease
Allergy, autoimmune conditions, migraine, viral infections
69
Presentation of Ménière's disease
- Vertigo
- Tinnitus
- Fluctuating hearing loss
- Sense of aural pressure
70
Management of Ménière's disease
- Vertigo- Prochlorperazine
- Prophylaxis- betahistine
- Endolymphatic sac surgery
- DVLA
71
Patient presents with vertigo, tinnitus, fluctuating hearing loss and a sense of aural pressure, what is the most likely diagnosis?
Ménière's disease
72
What is the most common cause of vertigo?
Benign Paroxysmal Positional Vertigo
73
What is Benign Paroxysmal Positional Vertigo?
Otoliths become detached from macula into semicircular canals
--> hair cells are stimulated
Mostly posterior
74
Causes of Benign Paroxysmal Positional Vertigo
Idiopathic
| Head injury, post-viral infection, complication of surgery
75
Presentation of Benign Paroxysmal Positional Vertigo
Episodes of vertigo provoked by head movements, attacks sudden onset with rapid resolution once head is kept still
Worse in morning
No hearing loss or tinnitus
76
Patient presents with episodes of vertigo provoked by head movements and which resolve once head kept still, what is the most likely diagnosis?
Benign Paroxysmal Positional Vertigo
77
How is Benign Paroxysmal Positional Vertigo diagnosed?
Dix-Hallpike maneouvre
78
Management of Benign Paroxysmal Positional Vertigo
Usually self-limiting over weeks
Epley maneouvre
DVLA- can drive once symptoms resolved
Surgery last resort
79
What is the aetiology of Vestibular Neuronitis?
Likely a neuropathy caused by reactivation of latent HSV1 in vestibular ganglion
80
Presentation of Vestibular Neuronitis
Sudden, spontaneous, severe and incapacitating vertigo, spontaneous nystagmus
NEVER hearing loss or tinnitus
81
How can you differentiate central from peripheral vertigo?
HINTS examination:
Head impulse
Nystagmus type
Skew
Peripheral: head impulse abnormal, nystagmus unidirectional or absent, no vertical skew
Central: head impulse normal, nystagmus bidirectional, vertical skew
82
Management of Vestibular Neuronitis
Prochlorperazine/antihistamines for vertigo
| Reassurance
83
Management of Ramsay-Hunt syndrome
Aciclovir + Prednisolone
84
What is the cause of Ramsay-Hunt syndrome?
Herpes zoster virus
85
Presentation of Ramsay-Hunt syndrome
Unilateral lower motor neuron facial nerve palsy
Painful and tender vesicular rash in ear canal, pinna and around ear, can extend to anterior 2/3 of tongue and hard palate
86
Causes of Acute Otitis Media
Viral: RSV, Rhinovirus, Parainfluenza, Influenza
Bacterial: Strep pneumoniae, H influenzae, Moraxella catarrhalis, Strep pyogenes
87
Which age group is most at risk of Acute Otitis Media
Children as short and more horizontal eustachian tube
88
Risk factors for Acute Otitis Media
Young, male, smoking (+ passive), contact with other children, GORD, prematurity, immunodeficiency
89
Presentation of Acute Otitis Media
Inflammation of middle ear
| Earache, tugging at ear, fever, irritability, cough, rhinorrhoea
90
What is found on otoscopy in Acute Otitis Media?
Red/yellow/cloudy TM, bulging TM, perforated TM
91
Management of Acute Otitis Media
Pain relief
Antibiotics if < 6mths or unwell or no improvement by 72hrs- 5-7 days Amoxicillin
Admission if < 3mths with temp > 38 or systemically unwell
92
Management of recurrent Acute Otitis Media
Grommets
| Prophylactic antibiotics
93
Complications of Acute Otitis Media
Post-auricular abscess, mastoiditis, meningitis etc
94
What is the most common cause of hearing impairment in children?
Otitis media with effusion
95
What is the most common age of presentation with Otitis media with effusion?
Age 2-5
96
Risk factors for Otitis media with effusion
Cleft palate, Down's syndrome, Primary Ciliary Dyskinesia, Allergic rhinitis, AOM, Household smoking, Bottle feeding
97
Presentation of Otitis media with effusion
Hearing loss, foul-smelling aural discharge, recurrent ear infections, mild ear pain, popping sensation
98
What is seen on otoscopy in Otitis media with effusion?
Abnormal colour of drum, loss of light reflex, air bubbles/air-fluid level, retracted/concaved drum
99
Management of Otitis media with effusion
Active observation 6-12wks
Hearing aids
Autoinflation
Myringotomy + grommets
100
What is Cholesteatoma?
3D collection of connective and epidermal tissue in middle ear
--> Bone erosion
101
Types of Cholesteatoma
1. Congenital
2. Primary acquired
3. Secondary acquired- from trauma to TM
102
What is the aetiology of Congenital Cholesteatoma?
Squamous epithelium trapped in temporal bone in embryogenesis
103
Risk factors for Cholesteatoma
Ear trauma, cleft palate, grommets
104
Presentation of Cholesteatoma
Progressive conductive hearing loss
Erode into structures --> vertigo, headache, facial nerve palsy
Infection --> sigmoid sinus thrombosis, meningitis etc
Grows into auditory canal --> deafness, impaired facial movement
Acquired --> frequent painless foul-smelling otorrhoea
105
What type of hearing loss does Cholesteatoma cause?
Progressive conductive hearing loss
106
What is seen on otoscopy in Cholesteatoma?
Pearly white mass behind tympanic membrane
107
At what age does congenital Cholesteatoma typically present?
6 months - 5 years
108
What is the gold standard investigation in Cholesteatoma?
CT
109
Management of Cholesteatoma
Surgery- tympanomastoidectomy/tympanoplasty
| Treat infections
110
Differentials of facial pain
```
Rhinosinusitis
Tension headache
Migraine
Cluster headache
Trigeminal neuralgia
TMJ dysfunction
Atypical facial pain
```
111
How is atypical facial pain managed?
Amitriptylline, Gabapentin, Pregabalin
112
What is Sinusitis?
Inflammation of the membranous lining of 1 or more sinuses
113
Name the Paranasal sinuses
1. Maxillary
2. Sphenoidal
3. Frontal
4. Ethmoidal
114
Risk factors for Sinusitis
URTI, asthma, allergy, smoking, DM, immunocompromise
115
How is acute vs chronic Sinusitis classified?
Acute < 4 weeks
| Chronic > 90 days
116
Most common causative organisms of Acute Sinusitis
Strep pneumoniae, H influenzae, M catarrhalis
117
Presentation of Acute Sinusitis
Non-resolving cold, pain over sinuses, purulent nasal discharge, reduced sense of smell, headache
118
Management of Acute Sinusitis
Symptom relief: paracetamol, intranasal decongestant, fluids, nasal saline irrigation
Antibiotics if > 10 days or immunocompromised
- Phenoxymethylpenicillin
119
Causes of Chronic Sinusitis
Allergic rhinitis, nasal polyps, ciliary dysfunction, immunodeficiency
120
Presentation of Chronic Sinusitis
Non-resolving cold, pain over sinuses, purulent nasal discharge, reduced sense of smell, headache
Ache on palpation of sinuses
121
Management of Chronic Sinusitis
Modulate triggers, stop smoking
Nasal steroids
Antibiotics for 3 weeks
122
What are the criteria for diagnosis of Sinusitis?
1. Facial discomfort/pain
2. Nasal obstruction/discharge/post-nasal drip
3. Decreased or absent sense of smell
123
What is Trigeminal Neuralgia?
Compression of the trigeminal nerve
124
Causes of Trigeminal Neuralgia
Compression of trigeminal nerve by...
- Loop of artery or vein
- MS
- Tumours
- AV malformation
125
Presentation of Trigeminal Neuralgia
Sudden unilateral brief stabbing pain in distribution of 1 or more branches of the trigeminal nerve, electric shocks
126
What are the common triggers for Trigeminal Neuralgia?
Vibration, skin contact, brushing teeth, oral intake, exposure to wind
127
Management of Trigeminal Neuralgia
Reassurance
Carbamazepine
Surgery to relieve pressure
128
Investigationsfor diagnosis of Trigeminal Neuralgia
None- clinical diagnosis
129
What is the most common site of bleeding in epistaxis?
Anterior- Little's area- Kiesselbach's plexus
130
Causes of epistaxis
Idiopathic
| Coagulopathy, rhinitis, trauma, aspirin, warfarin
131
Investigations in epistaxis
Anterior + posterior rhinoscopy to identify bleeding point
132
Management of epistaxis
```
Acute: ABCDE
Nasal cautery- silver nitrate
Nasal packing- anterior packing
Ligation of vessels under GA
Angiography + embolisation
```
133
What is the temporomandibular joint?
TMJ formed by mandibular condyle inserting into mandibular fossa of the temporal bone
134
Risk factors for Temporomandibular Joint Disorders
Disc displacement, TMJ hypo/permobility, trauma, bruxism (grinding teeth), stress, anxiety, gout
135
Presentation of Temporomandibular Joint Disorders
3 cardinal features:
1. Facial pain
2. Restricted jaw function
3. Joint noise
136
Management of Temporomandibular Joint Disorders
```
Rest + self care
Bite guards
Analgesics, NSAIDs, Muscle relaxants
IA steroids
Surgery
```
137
What is the most common type of Pharyngeal cancer?
Squamous cell crcinoma
138
Risk factors for Pharyngeal cancer
SCC: tobacco, HPV
| Nasopharyngeal carcinoma: EBV, heavy alcohol intake
139
Presentation of Pharyngeal cancer in oropharynx
Persistent sore throat, lump in throat or mouth, ear pain
140
Presentation of Pharyngeal cancer in hypopharynx
Problems with swallowing, ear pain, hoarseness
141
Presentation of Pharyngeal cancer in nasopharynx
Lump in neck, nasal obstruction, deafness, post-nasal discharge
142
2 week wait criteria for Pharyngeal cancer
Unexplained ulceration > 3 weeks
Oral red/white patched
Persistent and unexplained lump in neck
143
Management of Pharyngeal cancer
External beam radiotherapy main treatment
| Surgery, chemo
144
What is the most common type of Laryngeal cancer?
Almost all Squamous cell carcinoma
145
Cancer in which areas is classified as Pharyngeal cancer?
Oropharynx/Nasopharynx/Hypopharynx
146
Cancer in which areas is classified as Laryngeal cancer?
Supraglottis, Glottis, Subglottis
147
Risk factors for Laryngeal cancer
Smoking, alcohol, asbestos, formaldehyde, nickel, sulphuric acid, HPV16
148
Which strain of HPV is associated with Laryngeal cancer?
HPV16
149
Presentation of Laryngeal cancer
Chronic hoarseness, pain, dysphagia, lump in neck, sore throat, earache, persistent cough, breathlessness, haemoptysis
150
2 week wait criteria for Laryngeal cancer
Persistent unexplained hoarseness
| Unexplained lump in neck
151
Management of Laryngeal cancer
Total/partial laryngectomy, chemo + radiotherapy
152
What investigation should be done in all people with chronic hoarseness?
Chest x-ray
153
Which side does Weber's test localise to in:
i) conductive deafness;
ii) sensorineural deafness?
Conductive deafness- affected side
| Sensorineural- unaffected side
154
In Rinne's test, if Bone conduction > Air conduction, what type of deafness is present?
Conductive deafness
155
Aetiology of Branchial cysts
Benign developmental defect in branchial arches
| Filled with acellular fluid with cholesterol crystals and encapsulated by stratified squamous epithelium
156
Lump in neck filled with acellular fluid with cholesterol crystals and encapsulated by stratified squamous epithelium, what is the most likely diagnosis?
Branchial cyst
157
When do branchial cysts usually present?
Late childhood/early adulthood
158
How do branchial cysts present?
Painless lateral neck lump, anterior to sternocleidomastoid
| Smooth, soft, fluctuant, non-tender, no transillumination
159
Management of Branchial cyst
Refer to ENT, USS, Fine needle aspiration
