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3B > ENT > Flashcards

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
Q

OM aetiology

A

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
Q

OM clinical features and investigations

A

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
Q

OM criteria / management

A
  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
Q

OM complications

A

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
Q

Cholesteatoma

A

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
Q

Tonsillitis

A

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
Q

Tonsillectomy referral criteria

Tonsillitis complications

A

> 5 episodes in 1 year
Recurrent febrile convulsions
Obstruction - OSA, stridor, dysphagia, etc.
Peritonsillar abscess

Complications

  • OM
  • Quinsy - Peritonsillar abscess
  • Rheumatic fever / Glomerulonephritis
32
Q

Quinsy

A

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
Q

Pharyngitis aetiology / clinical features / DDx

A

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
Q

Pharyngitis investigations / management / complications

A

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
Q

Mastoiditis aetiology and clinical features

A

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
Q

Mastoiditis investigations / management / complications

A

CT
Blood cultures
Tympanoscentesis

Management

  • IV Cef
  • Analgesia
  • Mastoidectomy

Complications

  • Meningitis
  • Osteomyelitis
  • CN palsy
37
Q

Sinusitis aetiology

A

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
Q

Sinusitis clinical features / investigations / management / complications

A 
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
Q

Laryngitis aetiology

A

Acute - Infection

Bacterial - Strep + HiB

Viral - CRAPI

  • Coronavirus
  • Rhinovirus
  • Adenovirus
  • Parainfluenza
  • Influenza

Chronic

  • Asthma / allergies
  • Trauma
  • Reflux
  • SLE / RA
40
Q

Laryngitis clinical features / investigations / management

A

Hoarse voice
Dysphagia / Globus
Pain - Anterior neck

Investigations - Laryngoscopy if chronic

Management

  • Humidification - Steam inhalation
  • Stop smoking
  • Voice rest
41
Q

Neck lump differentials

A

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
Q

Oropharyngeal cancer aetiology and clinical features

A

Alcohol
HPV
Smoking
Hot drinks

Clinical features

  • Neck lump
  • Hoarseness
  • Persistent sore throat
  • Persistent mouth ulcer
43
Q

Oropharyngeal cancer investigations

A

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

3B (23 decks)

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