ENT Flashcards
(39 cards)
Acute epiglossitis
Cause: Hib infection
Presentation: Adults (severe sore throat and dysphagia). Children (irritable, fever, leaning forward, drooling, muffled voice/cry, heaving breathing)
Investigation: Clinical diagnosis. Do not do throat exam.
Management: Leaning patient forwards –> Get ENT surgeon and anaesthetist –> Intubation + IV dex and ceftriaxone
Tonsillitis
Infection agent: >50% due to streptococcus pyogeens
Diagnosis: Clinical. No throat swab.
Scoring: Centor criteria (ant lymphadenopathy, no cough, tonsillar exudate, history of fever).
Management:
- 1st line Antibiotics (7-10 days phenoxymethylpenicillin. If pen allergic, give erythromycin). Indications: Centor criteria met OR systemic upset OR immunocompromised OR history of rheumatic fever.
- 2nd line Tonsillectomy. Indications: Recurrent tonsillitis (>7 eps a year), sore throat, symptoms for >1 year. Complications of haemorrhage (Primary due to inadequate haemostasis. Secondary due to infection) and pain
Absess
Two type: Peritonsillar abscess and Parapharyngeal abscess
Severity: ENT emergencies!!
Cause: Complications of tonsillitis
Peritonsillar abscess
- Px: Sore throat, uvular deviation, peritonsillar bulge, dysphagia
- Mx: Abx and aspiration
Parapharyngeal abscess
- Px: Diffuse swelling of the neck
- Mx: Us to location and drainage under GA
Laryngitis
Cause: Viral mostly. Can be secondary to bacterial infection (staph or strep), GORD (“reflux laryngitis”), autoimmune e.g. RA
Progression: Self-limiting
Presentation:
- Hoarseness
- Fever
- Pain (hypopharyngeal, dysphagia, on phonation)
Ix: No throat swab. Clinical Dx
Management:
1st line- Conservative
2nd line- 1 week of phenoxymethylpenicillin
Indications to admit:
- Stridor
- Breathing difficulties
- Life threatening emergency e.g. epiglossitis, kawasaki
- Clinical dehydration
Acute sinusitis
Causes:
- Obstruction e.g. septal deviation, polyps
- Swimming /diving
- Recent local infection
- Smoking
Causative agents
- Bacteria (Hib, strep pneomoniae)
- Viral (rhinoviruses)
Presentation
- Facial pain (frontal, worse on bending forwards)
- Nasal discharge (purulent and thick)
- Nasal obstruction
Management:
1st line: Analgesia. If symptoms >10 days, take inhaled corticosteroids
2nd line: Oral phenoxymethylpenicillin. If severe symptoms, oral co-amoxiclav
Acute rhinosinusitis
What? i.e. Common cold
Presentation: Nasal discharge, nasal obstruction, facial pain/ pressure, reduced smell, endoscopic/CT signs
Duration: <12 weeks
Progression: 80% self-limiting
Management:
1st line: If <5 days, nothing
2nd line: If >5 days, corticosteroids (mometasone or fluticasone)
Chronic rhinosinusitis
What? RS for >12 weeks. Most commonly inflammation at the middle meatus.
Presentation: Water, anterior rhinorrhoea, purulent post-nasal drip, sneezing, snoring, nasal obstruction, mouth breathing, headaches
Investigations: Anterior rhinoscopy or nasal endoscopy. (Polyps = Pale, mobile, insensitive to touch)
Classification? With or without polyps
Management:
WITH POLYPS
1st line- Steroids (Topical beclometasone for 2 weeks then fluticasone nasap spray for 3 months)
2nd line - Add Abx (Doxy long term)
3rd line - Surgery for ESS (endoscopic sinus surgery) Risk of CSF leakage or CN II damage
WITHOUT POLYPS
1st line- Steroids or saline nasal irrigation
2nd line - If no improvement after 4 weeks, culture and start >12 weeks Abx
3rd line- CT scan and consider surgery
Septal perforation
Cause: Septal surgery, infections, drugs, trauma, SCC
Risk: Progressive enlargement
Management:
1st line- Symptomatic treatment (Saline nasal irrigation, petroleum jelly around edges)
2nd line- Septal prosthesis (“button surgery”)
Foreign body in nasal cavity
Presentation: Organic material –> Purulent unilateral dischage. Inorganic material –> Can remain unnoticed for years
Management:
1st line- Blow nose / parental kiss / removal with forceps. Batteries require URGENT removal
2nd line- ENT referral
Nasal fractures
Cause: Trauma **
Presentation: Facial swelling, nasal deformity, epistaxis , black eyes.
Investigation: Nasal examaintion. Exclude head an c-spine injury. X-ray NOT required. Check for nasal haematoma (risk of complete nasal obstruction. Urgent treatment required if present)
Management:
1st line- Treat epistaxis, analgesia, ice –> Reassess in 5 days. If MUA required, perform 10-14 days after injury
2nd line- Urgent drainage and incision
CSF leakage
Cause: Ethmoid bone fractures, neoplasm
Investigation
1st line: Lab testing for nasal CSF (positive for glucose)
Gold standard: Lumbar puncture (contains high B2 tau transferrin)
Management (if traumatic)
1st line- 7-10days bed with head elevation + Avoid sneezing/coughing/blowing nose + Abx + pneumococcal vaccine +/- lumbar drain
Allergic rhinitis
Presentation: Bilateral red itchy eyes, nasal discharge, pruritis, atopy, sneezing
Signs of auroscope: Mucosa pale, turbinates swollen, nasal polyps present
Management: 1st line- Allergen or irritant avoidance. Saline nasal irrigation 2nd line (mild-mod intermittent or mild persistent symptoms)- Loraditine OD 3rd line (mod-severe intermittent or 2nd line ineffective) - intranasal corticosteroids e.g. mometasone, fluticasone 4th line (cover big life events) - 5-10 days course of prednisolone
Prevention: OD SLIT (sublingual immunotherapy) or allergy vaccine Inj
Epistaxis
Cause:
- Direct trauma
- Injury
- Illicit drug use
- Bleeding disorders e.g. (thrombocytopaenia, leukaemia, haemophilia, ITP, splenomegaly)
- Cold and dry weather
Emergency management
- Gown up and ABCDE
- Pinch lower part of nose for 20 mins + lean forwards
- Ice of dorsum of nose
- Patient to blow out clots. or remove clots gently with forceps
- Vasoconstriction using adrenaline soaked cotton wool for 2 mins OR lidocaine
- Silver nitrate cautery (not of actively bleeding areas. If you cannot see bleeding origin, refer)
- Anterior nasal pack
- Postnasal pack
Management of serious posterior bleed
Options:
- EUA: If bleeding source found, the diathermy or repacking
- Arterial ligation via endoscopy e.g. of sphenopalatine artery
- Embolisation of internal maxillary or facial artery (e.g. lifesaving in stroke risk patients)
Periorbital / preseptal cellulitis
Cause: Infection spread from nearby structures (cellulitis, RTI, sinusitis,
Epidemiology: Children >. Winter months >
Pathogen: Staph aureus, streptocci
Presentation: Eye swelling/pain/redness + fever. *Absent orbital signs * (e.g. pain on movement, RAPD, chemosis, restricted movements, visual disturbance)
DDx: Orbital cellulitis, allergic reaction
Investigation: Bloods (raised ESR and CRP). Culture any discharge. If needing to exclude orbital cellulitis, contrast CT head required.
Management: Refer to secondary care for assessment. Microguide abx = 5 days of flucloxacillin (if pen allergic, doxy or clarithromycin)
Risk: Orbital cellulitis
Labyrinthitis
What? Viral infection of the labyrinth (cochlear and vestibular end organs)
Duration: Acute onset for 1-2 days, then improves over week
Who? 40-70y/o
Presentation:
- Vertigo (exacerbated by movement)
- N/V
- Hearing loss (can be bilateral or unilateral)
- Tinnitus
Signs:
- SNHL
- Abnormal head impulse test
- Unidirectional horizontal nystagmus
DDx:
- Hearing loss excludes vestibular neuritis
Investigation: History and exam. Check BM to exclude hypoglycaemia
Management: Vestibular suppressants e.g. Buccastem oral
Pinna Haematoma
What? Bleeding into the sub-perichondrial plane typically due to blunt trauma
Management: Surgery (incision + primary closure with packing ) AND antibiotic cover with ciprofloxacin
Complications:
- Cauliflower ear due to ischaemic necrosis and subsequent fibrosis
- Infection and loss of cartilage
Acute otitis media
What? Inflammation of the middle ear.
Organisms: Most commonly Streptococcus Pneumonia, haemophilis, moraxella
Presentation:
Symptoms: Rapid onset of pain + Fever. +/- anorexia, vomiting and irritability
Progression: Most cases resolve in 24hrs. If there is sudden relief of pain and purulent discharge, think TM perforation
Investigation:
1st line - Otoscopy (TM bulging, erythma, dilatation of the circumferential vessels)
Management:
1st line- Conservative
2nd line- Antiobiotics. Indications: Systemically unwell, immunocompromised, <3 months old, <2 years old with bilateral OM, perforation + discharge, symptoms for 4 days. What? Amoxicillin for 5 days.
Complications:
Present with continuous discharge
1. Perforation and discharge (Mx: Top Abx)
2. Recurrent AOM (Mx: Expectant treatment, long term Abx, grommet)
3. Acute mastoiditis (Mx: Urgent ENT referral for IV Abx and Surgical drainage)
4. Intracranial sepsis or meningitis (Mx: Urgent referral for IV Abx
5. Facial falsy (Mx: Urgent referral for grommet insertion)
Chronic otitis media
What? Perforation of the TM likely due to recurrent or prolonged infections
Presentation: Otalgia, hearing loss, fullness, otorrhoea
Classification
- Squamous or mucosal
- Active or inactive.
Management:
1st line: Abx (systemic or topical), aural cleaning, water precautions
2nd line: Surgery
Complications:
- Cholesteatoma due to retraction of pars flaccida or tensa leading to epithelium build up
Otitis Externa
What? Inflammation to external ear and canal
Cause: Bacterial infection e.g. Pseudomonas aeruginosa, staph aureus
Precipitating factors:
- Excessive moisture
- Trauma
- Dermatitis (contact or seborrheic )
R/F
- DM
- Radiotherapy to head and neck
Classification:
Timing: <3 months is acute, >3 months is chronic
Severity: Diffuse, localised and malignant
Presentation:
- Hearing loss
- ITCH
- Ear pain
- Discharge
Signs: Red, swollen, eczematous ear canal / external ear
Diagnosis: By examination
Management;:
1st line: Risk factor management. Analgesia. Topical ABx
2nd line: Referral to ENT if… excessive cellulitis / extreme pain / excessive swelling / obstruction to topical Abx. URGENT referral for malignant OE as IV abx required.
Complication:
- Abscess
- Malignant OE
- TM inflammation i.e. OM
Vestibular neuronitis
What? Acute, spontaneous, prolonged, isolated vertigo
Cause? Viral infection leads to inflammation of the vestibular nerve
Presentation
Progression: Acute spontaneous onset. Severe Sx for 1-2 days followed by a few weeks of recovery and improvement
Symptoms:
- Vertigo
- N/V
- NO hearing loss
- NO tinnitus
- NO focal neurology
Signs: Fine horizontal nystagmus
DDx:
- Labyrinthitis
- BPPV
- Meniere’s disease
- Central causes: Migraine, stroke, MS, cerebellar tumour
Investigation: Clinical diagnosis (HiNTs tests excludes posterior circulation stroke)
Management:
Hospital admission indications: Cannot tolerate oral intake. No improvement with 1st line medication after 1 week. Focal neurology. 6 weeks of symptoms
Acute- 1st line Symptomatic relief with antiemetics (if N/V is severe then IM or Buccal prochlorperazine or cyclizine. If moderate N/V then oral prochlorperazine, cinnarazine, cyclizine).
Chronic: Vestibular rehab exercises
Meniere’s disease
What? Disease of the inner ear from an unknown case, associated with endolymph hydrops which would increase pressure
Risk factors: Autoimmunity, female gender, FH, metabolic abnormalities, vascular factor
Presentation:
Symptoms- Vertigo, fluctuating hearing loss and tinnitus in episodes lasting minutes-hrs.
Signs- Nystagmus present. Romberg’s positive
Progression: Most symptoms resolve after 5-10 years but patients left with some degree of HL.
Investigation: Clinical examination/history + audiometry to confirm SNHL
Mangement
In primary care: Refer to ENT for formal audiometry assessment
In secondary care: Audiometry assessment. Prescribe medications for acute attack of N/V and vertigo (Prochlorperazine or anti-histamine). Patient to inform DVLA and take care operating machinery
Hospital admission: Required for severe symptoms to give IV labyrinthine sedative + fluids
Prevention: Beta-histamine trial or vestibular rehab exercises
SNHL
What? Loss of hearing to the defect in the oval window of the cochlea or the cochlear nerve
Cause:
Vascular (Cochlear vascular disease)
Inf (Meningitis, Meniere’s, measles, mumps, herpes, TB, syphilis)
Trauma
Autoimmune (MS)
Idiopathic (Presbycusis)
Drugs (ABx e.g. streptomycin, gentamicin, vancomycin. -“Quines”
Presentation: Onset can vary depending on cause. Usually unilateral hearing loss.
DDx: CHL, OPE
Investigations:
In primary care: Detailed history, esp drugs. Rinnes shows AC>BC in affected ear. Weber’s is louder in non-affected ear. Exam EAM and do otoscopy
In secondary care: Formal audiology +/- audiological BS response
Management:
1st line: If inflammatory cause then 4 days oral prednisolone and taper for 8 days
2nd line: If inflammatory cause then intratympanic dexamethasone
Prognosis: Good with 30-65% getting complete/partial resolution
BPPV
What? Benign paroxysmal positional vertigo
Who? Women> in 50-70s
Precipitating factors: Head injury, ear surgery, prolonge recumbent postition, past inner ear pathology (meniere’s, labyrinthitis, vestibular neuronitis)
Presentation: Repeated episodes of vertigo. Likely to recur and have spontaneous resolution
Diagnosis: Positive Dix-Hallpike manoeuvre
Management:
1st line in primary care: Watchful waiting or Epley manoeuvre. Follow-up in 4 weeks
2nd line: Refer balance specialist if persistent symptoms, S/S atypical, 3+ episodes, Epley manoeuvre cannot be performed or was unsuccessful
Admission to hospital: If N/V prevent oral intake.
Acoustic Schwannoma
Aka acoustic neuroma
What? Indolent, benign subarachnoid tumour. Acts are SoL leading to pressure issues. Forms 90% of cerebellopontine tumours
Presentation:
- Ipsilateral > (if bilateral, think neurofibromatosis type 2)
- Symptoms dependent on CN involved (CN V = Absent corneal reflex. CN VII= Facial palsy. CN VIII = Vertigo, SNHL and tinnitus.
Investigation:
1st line: MRI of cerebellopontine angle + Audiometry
Management:
1st line: Urgent ENT referral. Watchful waiting initially to monitor growth.
