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ENT Flashcards

1
Q

Vertigo differentials and investigations

A 
BPPV
Meniere's
Vestibular neuronitis
Labyrinthitis
Acoustic neuroma
Stroke - PICA - Lateral medullary syndrome

Investigations

  • Audiometry
  • CN exam
  • CT/MRI
  • HiNTS exam
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2
Q

HiNTS exam

A

Patients presenting with…

  • Persistent vertigo over hours/days
  • Nystagmus
  • Normal neuro exam

Head impulse test - Ipsilateral vestibulocochlear nerve pathology

  • Positive - Eyes move with head before returning to point of fixation
  • Must be performed when patient symptomatic

Nystagmus

  • Unidirectional - Peripheral
  • Bidirectional or vertical - Central - E.g. stroke

Test of skew

  • Cover the patients eye
  • Quickly swap to cover the other eye
  • Positive - Abnormal movement or diplopia - Suggests central cause
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3
Q

BPPV aetiology / presentation / red flags

A

Loose otoliths
Post-infection or head trauma
More common in older women

Presentation

  • Vertigo - 10-20 seconds, occurs with head movement
  • No hearing loss
  • N/V

Red flags

  • Headache
  • Pain
  • Deafness
  • Tinnitus
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4
Q

BPPV investigations and management

A

Investigations - Dix-Hallpike manoeuvre

  • Turn head 45 degrees then lay down
  • Positive = Dizziness / Nystagmus

Otoscopy - Infection?
CN exam

Management - Epley’s manoeuvre

  • Betahistine
  • Advised not to drive
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5
Q

Meniere’s aetiology and presentation

A

Increased pressure and dilatation of endolymphatic system

  • Idiopathic
  • Trauma
  • Infection

Presentation

  • Vertigo
  • “Fullness” in the ear
  • Tinnitus
  • SN deafness - Low frequency sounds
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6
Q

Meniere’s investigations and management

A

Romberg’s +ve - Unable to maintain balance with eyes closed
CN exam - SN deafness
Audiometry - Loss of low frequency sounds
CT - SOL?

Management

  • Acute - IM Prochlorperazine / Admision
  • Low salt diet
  • Diuretics - Hydrochlorothiazide
  • Antihistamine - Betahistine
  • Meniett device
  • Advised not to drive
  • Surgery - Drain endolymph sac
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7
Q

Vestibular neuronitis

A

Post-infection - HSV

Vertigo - Non-positional - Hours-days
No hearing loss
Horizontal nystagmus
N/V

Investigations

  • HiNTS
  • Gait - Fall to side of lesion

Management

  • Vestibular rehabilitation exercises
  • Acute - IM Prochlorperazine
  • PO Prochlorperazine / Cyclizine
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8
Q

Labyrinthitis

A

Inflammation of membranous labyrinth
Vestibular and cochlear organs affected

Usually viral - Post-infectious - URTI

Clinical features

  • Vertigo - Not triggered by movement
  • SN deafness
  • Nystagmus- Unidirectional
  • Tinnitus
  • N/V

Investigations

  • HiNTS
  • Gait - Falls to side of lesion

Management

  • Prochlorperazine
  • Prednisolone
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9
Q

Vestibular neuronitis vs Labyrinthitis

A

VN only affects vestibular nerve - Vertigo WITHOUT hearing loss

Labyrinthitis affects vestibular nerve and labyrinth - Vertigo WITH hearing loss

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10
Q

Acoustic neuroma

A

Associated with NF2 - Bilateral

CN5 - Absent corneal reflex
CN7 - Facial palsy
CN8 - Vertigo, SN deafness, tinnitus

Nystagmus - Bidirectional

Investigations

  • HiNTS
  • MRI cerebellopontine angle - 2ww referral

Management - Surgery + Chemo/Radio

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11
Q

Conductive deafness aetiology

A 
Occlusive - Wax / Foreign body
Infection - OM / Sinusitis
Perforation - Trauma / Surgery
Cholesteatoma
Otosclerosis
Growth - Fibroma
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12
Q

SN deafness aetiology

A

Noise
Trauma
MS

Meningitis
Mumps
VZV - Ramsay Hunt syndrome - CN7/8
HIV

Labyrinthitis
Meniere’s
Acoustic neuroma

Animoglycosides - Gent
Thiazides
Quinines

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13
Q

Rinne’s and Weber’s

A

Rinne’s

  • Place tuning fork at external ear canal
  • Then place on mastoid process
  • Conductive hearing loss is louder by bone
  • Positive = Normal = Louder in air

Weber’s

  • Place tuning fork in middle of forehead
  • SN deafness - Sound localised to unaffected side
  • Conductive deafness - Sound localised to affected side
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14
Q

Facial pain differentials

A

GCA
Trigeminal neuralgia
Cluster headache

Cellulitis
Shingles

Mastoiditis
Sinusitis
OE/OM

Mumps
Dental abscess

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15
Q

Parotid swelling differentials

A

Parotid cancer - Pleomorphic adenoma - Warthrin tumour

Frey’s syndrome post-surgery

  • Sweating
  • Erythema - Post-prandial

Stones

  • Colicky pain - Post-prandial
  • Investigation - Sialography

Sarcoidosis
Sjogren’s
Mumps
HIV

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16
Q

Submandibular swelling differentials

A

Stones
Cancer
Cervical lymphadenopathy - Including EBV

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17
Q

Nasal blood supply

A

Anterior and posterior ethmoidal - Branch of internal carotid

Sphenoidal artery - Branch of maxillary - From internal carotid

Keisselbach’s plexus / Little’s area - Most common area for epistaxis

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18
Q

Epistaxis

A

Usually Keisselbach’s plexus

Aetiology - Trauma and nose picking

  • Blood disorders
  • Anticoagulants
  • Hereditary telangiectasia
  • Wegener’s
  • Malignancy
  • Cocaine

Management - ABCDE

  • Holding - Pinch anterior nose and lean forwards - Sit upright
  • Topical antiseptic - Naseptin
  • Packing
  • If still bleeding after 15 minutes
  • Silver nitrate
  • Electrocautery
  • Treat cause
19
Q

Nasal polyps

A

Lesions from the mucosa - Middle meatus

Aetiology - AACCCChu - That’s a sneeze

  • Asthma
  • Aspirin
  • CF
  • Churg Strauss
  • Cancer
  • Chronic sinusitis

Samter’s triad

  1. Asthma
  2. Aspirin sensitivity
  3. Nasal polyposis

Presentation

  • Bilateral
  • Obstruction / Apnoea
  • Hyposmia
  • Rhinorrhoea
  • Unilateral - Suggests malignancy - 2ww referral

Investigations - 2ww referral - Rhinoscopy

Management - Topical steroids

20
Q

Nasal trauma

A

Red flags - BOPSS on the nose

  • Basal skull fracture - CSF rhinorrhoea, Battle’s sign, raccoon eyes
  • Signs of facial fracture
  • Prolonged / profuse epistaxis
  • Septal haematoma - Boggy on probing
  • Ophthalmoplegia - Orbital blow out fracture

Investigations - Imaging - XR/CT

Management - Re-alignment surgery

Complications

  • Septal haematoma
  • Needs surgical drain and abx
  • Risk of AVN / abscess formation
21
Q

OSA aetiology and clinical features

A

Intermittent and transient upper airway collapse

Aetiology

  • Family history
  • Obesity
  • Smoking / alcohol
  • Macroglossia - Acromegaly, hypothyroid, amyloidosis
  • Large tonsils
  • Sedatives

Clinical features

  • Daytime sleepiness
  • Collateral history - Snoring and periods of apnoea
22
Q

OSA investigations and management

A

Polysomnography - Sleep studies
Epworth sleepiness score
FBC - Secondary polycythaemia

Management

  • Lose weight
  • CPAP
  • Intra-oral device
  • Tonsillectomy if large tonsils
  • Inform DVLA
23
Q

Otitis externa aetiology and clinical features

A

Increased risk with DM
Seborrhoeic dermatitis
Contact dermatitis

Infection

  • Staph A
  • Pseudomonas - diabetics
  • Fungal - Aspergillus

Clinical features

  • Ear pain - Pain on moving the tragus
  • Discharge
  • Pre-auricular lymphadenopathy
24
Q

Otitis externa investigations / management / complications

A

Investigations - Otoscopy

  • Red
  • Oedematous
  • Pre-auricular lymphadenopathy

Management

  • Abx/steroid drops - Cipro / Dex
  • Oral abx - Cipro
  • ENT referral if not responding

Complications - Malignant necrotising OE

  • Presents with deterioration / Not responding to abx
  • Urgent ENT referral + IV abx
  • Can cause CN7/8 palsy + Osteomyelitis
25
OM aetiology
May be preceded by viral URTI - Rhinovirus / RSV Nasopharyngeal microbiome is disturbed Bacteria infect middle ear via eustachian tube - Strep P - H. Influenzae - Moraxella Catarhalis Risk factors - Winter - Immunocompromise - Sinusitis - 6-12 months - ET shorter and more horizontal
26
OM clinical features and investigations
Pain - Children may pull at ear Conductive hearing loss Fever Discharge - Perforated TM ``` Investigations - Otoscopy - Bulging TM - Loss of light reflex - TM opacification and erythema - Possible TM perforation - Purulent discharge + Swab for MC&S + CT - Exclude mastoiditis ```
27
OM criteria / management
1. Acute onset of symptoms 2. Presence of middle ear infection 3. Inflammation of tympanic membrane - Erythema Management - Amoxicillin - Criteria... - Symptoms > 4 days - Age < 2 + Bilateral - Perforation / Discharge
28
OM complications
Chronic suppurative OM - Chronic infection + Inflammation + Ruptured TM + Cholesteatoma = Perforation + Conductive deafness OME - Glue ear - Fluid in middle ear - Conductive deafness - Management - Supportive + Grommets CN7 palsy Perforation Local spread - Mastoiditis / Meningitis
29
Cholesteatoma
Non-cancerous growth of squamous epithelium Causes local destruction Aetiology - Chronic ear infections - Risk x 100 with cleft palate Clinical features - Foul smelling discharge - Non-resolving - Conductive hearing loss - Vertigo - Facial nerve palsy - Cerebellopontine angle syndrome Investigations - Otoscopy - Attic crust - Perforation of pars flaccida Management - Surgical removal
30
Tonsillitis
Bacterial - Strep Viral - Rhinovirus Diagnosis - FeverPAIN score - Fever - Pus on tonsils - Attend rapidly < 3 days from onset of symptoms - Inflamed tonsils - No cough 1 - No abx 2-3 - Consider back-up abx prescription 4-5 - Prescribe abx Management - Penicillin V - CI if suspected EBV - Gargle saltwater - Increase fluid intake
31
Tonsillectomy referral criteria Tonsillitis complications
> 5 episodes in 1 year Recurrent febrile convulsions Obstruction - OSA, stridor, dysphagia, etc. Peritonsillar abscess Complications - OM - Quinsy - Peritonsillar abscess - Rheumatic fever / Glomerulonephritis
32
Quinsy
Jugulodigastric lymph node ``` Severe throat pain "Hot potato" voice Drooling Dysphagia Uvula deviation Trismus - Difficulty opening mouth Reduced neck mobility ``` Management - Urgent ENT referral - Needle aspiration / I&D - IV abx - Consider tonsillectomy
33
Pharyngitis aetiology / clinical features / DDx
Bacterial - Strep Viral - CRAPI - Coronavirus - Rhinovirus - Adenovirus - Parainfluenza - Influenza Clinical features - Sore throat - Fever - URTI symptoms DDx - Epiglottitis - Tripod sign, muffled voice, drooling - Scarlet fever - Strawberry tongue, rash
34
Pharyngitis investigations / management / complications
If prolonged... - Throat swab MC&S - ASO titre - Monospot for EBV Management - Penicillin V Complications 1. Bacterial - Strep - Rheumatic fever - PSGN - Scarlet fever 2. Local sprea - Mastoiditis - Sinusitis - OM
35
Mastoiditis aetiology and clinical features
Local spread from OM Strep pneumonia Strep pyogenes Clinical features - Ear protrudes anteriorly - Boggy mastoid process - Facial pain - Behind the ear - Fever - CN palsy - 6/7/8
36
Mastoiditis investigations / management / complications
CT Blood cultures Tympanoscentesis Management - IV Cef - Analgesia - Mastoidectomy Complications - Meningitis - Osteomyelitis - CN palsy
37
Sinusitis aetiology
Inflammation of mucosal lining of sinuses - Frontal - Maxillary - Ethmoidal - Sphenoid Strep pneumonia H. Influenza Rhinovirus Nasal obstruction - Septal deviation / polyps Recent local infection - Rhinitis / dental extraction Swimming / Diving Smoking
38
Sinusitis clinical features / investigations / management / complications
``` Facial pain - Worse bending forward Nasal discharge - Thick and purulent Nasal obstruction Headache Fever ``` Investigations - Nasal swab MC&S - CT if severe Management - Analgesia - Intranasal decongestants / Saline - Intranasal CS - If symptoms > 10 days - Mometasone - Oral abx - Penicillin V Complications - OM - Meningitis - Osteomyelitis
39
Laryngitis aetiology
Acute - Infection Bacterial - Strep + HiB Viral - CRAPI - Coronavirus - Rhinovirus - Adenovirus - Parainfluenza - Influenza Chronic - Asthma / allergies - Trauma - Reflux - SLE / RA
40
Laryngitis clinical features / investigations / management
Hoarse voice Dysphagia / Globus Pain - Anterior neck Investigations - Laryngoscopy if chronic Management - Humidification - Steam inhalation - Stop smoking - Voice rest
41
Neck lump differentials
Thyroid - Goiter Thyroglossal cyst - Midline, moves with tongue Pharyngeal pouch - Dysphagia, regurg, halitosis Cancer - Pharyngeal Lymphoma - Rubbery, painless Abscess - Lipoma - Smooth, mobile, painless Cervical lymphadenopathy - EBV - Infection - Tonsillitis - HIV Weird and wonderful... - Cyst hygroma - LEFT, congenital - Branchial cyst - Oval, SCM to pharynx - Cervical rib - Adult females
42
Oropharyngeal cancer aetiology and clinical features
Alcohol HPV Smoking Hot drinks Clinical features - Neck lump - Hoarseness - Persistent sore throat - Persistent mouth ulcer
43
Oropharyngeal cancer investigations
2ww referral criteria... Laryngeal cancer - Aged > 45 + Persistent unexplained hoarseness + Unexplained neck lump Oral cancer - Unexplained ulceration > 3 weeks - Persistent unexplained neck lump - Lip or oral lump - Red/white patch in oral cavity Thyroid cancer - Unexplained thyroid lump Investigations - Examination under anaesthetic - Biopsy + HPV testing - CT/MRI Management - Surgery + Chemo/Radio

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