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*RACS ENT Fellowship > ENT Differential lists > Flashcards

ENT Differential lists Flashcards

1
Q

LARYNGOTRACHEAL STENOSIS x

A

Congenital

Acquired

  • Traumatic
  • Internal- intubation (90% of paed stenosis)
  • External- penetrating, blunt
  • Iatrogenic
  • Tracheostomy, glottic web, supraglottic collapse
  • Infection
  • Tb, syphilis
  • Inflammatory
  • Wegener’s, sarcoidosis, SLE, pemphigus
  • Neoplastic

Pathogenesis of post-intubation stenosis: ETT —> pressure necrosis and mucociliary stasis —> mucosal oedema and ulceration —> exposed cartilage —> infection/perichondritis —> cartilage necrosis —> granulation tissue —>- fibrous tissue deposition

Management:

  • Medical- PPI, antibiotics, steroids
  • Surgical
  • Endoscopic - cold steel, KTP laser, balloon dilatation
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2
Q

PAROTID LUMP x

A

Neoplastic:

  • Benign
  • Monomorphic- Warthin’s, basal cell adenoma, oncocytoma
  • Pleomorphic- Pleo
  • Malignant
  • Primary- MEC, Acinic, ACC, AdenoCa, carcinoma ex-pleo
  • Secondary- metastatic SCC (MC parotid malignancy in Australia)

Non-neoplastic:

  • Sjogren’s
  • Sarcoid
  • HIV
  • Lymhpadenopathy
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3
Q

BILATERAL PAROTID SWELLING x

A
  1. Sialadenosis nutritional/hormonal disturbances
    - Enlarged acini + glandular hypertrophy
    - Malnutrition
    - Obesity
    - DM
    - Alcoholism
    - Liver disease
    - Eating disorders
    - Recurrent Parotitis of Childhood
  2. Infective
    - Viral- Mumps, HIV assoc lymphoepithelial cysts - Mumps vaccine has only moderate efficacy, thus can still get it after vaccination
    - HIV may be- hyperplastic lymphadenopathy, benign lymphoepithelial cysts, diffuse infiltrative lymphocytosis syndrome
    - Bacterial- acute suppurative parotitis, bilateral parotid abscesses
    - Mycobacterial- TB
  3. Autoimmune/Granulomatous
    - Sjogren’s — primary vs secondary
    - Sarcoidosis
    - Wegener’s- may be an early presentation of limited disease
  4. Neoplastic
    - Warthin’s tumour
    - Lymphoma- associated with Sjogren’s, HIV, chronic sialadenitis
  5. Iatrogenic
    - Anaesthesia mumps
    - Iodide mumps- following radiologic investigations
    - Hypersensitivity vs toxic accumulation
    - Radiation sialadenitis - RAI, EBRT
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4
Q

PARAPHARYNGEAL SPACE LESION x

A
  1. Primary PPS lesion
    - Salivary gland 50%
    - Prestyloid (ICA posteriorly displaced), parotid > minor glands, benign = pleomorphic, malignant = MEC - Fat plane between mass and parotid differentiates minor salivary gland origin
    - Neurogenic 20%
    - Schwannoma - MC, X then SNS, IX, XI, XII. Cartoid anteriorly displaced
    - Paraganglioma - vagale, carotid body, inferior extension of jugulare
    - Neurofibroma - Multiple lesions suggests NF-1 (15% malignancy in NF-1, rare if sporadic)
    - Miscellaneous 30% (LNs 50%, other 50%)
    - Lipoma, rhabdomyosarcoma, haemangioma, haemangiopericytoma, lymphoma, teratoma, dermoid etc
  2. Metastatic disease
    - H&N sites - Maxillary, Thyroid- papillary, medullary, NPC
    - Distant sites - Breast, osteogenic sarcoma
  3. Direct extension at least as common as primary PPS lesion
    - Mandible, maxilla, nasopharynx, neck, oral cavity, oropharynx, temporal bone
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5
Q

HYPERCALCAEMIA x

A
  1. PTH-mediated
    a. Primary- elevated PTH and Ca 1:1,000
    b. Secondary - CRF —> chronic stim of PT glands due to subtle ionized hypocalcaemia for many years
    c. Tertiary - Long-standing CRF —> PT glands autonomous

—> Ca low, PTH elevated

  1. non-PTH-mediated
    a. Malignancy-
    - PTHrP secretion (lung, oesoph, H&N, kidney, ovary, bladder, breast)
    - Ectopic PTH secretion (SCLC, Lung SCC, ovary, thymoma, PTC, HCC)
    - Ectopic 1,25-dihydroxycholecalciferol
    - Bone lytic lesions (multiple myeloma, lymphoma, breast, sarcoma)
    b. Non-malignant- benign tumours, granulomatous, meds (thiazides, lithium)
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6
Q

DENTAL LESION x

A

Cysts

  • radicular (periapical) cyst
  • dentigerous cyst
  • odontogenic keratocyst

Neoplasms

  • Odontoma
  • Ameloblastoma
  • Odontogenic Myxoma
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7
Q

EPIPHORA

A
  1. Excessive tear production
    a. Primary
    b. Secondary- FB, trichiasis, entropion/ectropion, conjunctivitis, dry eye syndrome, blepharitis, Crocodile tears syndrome
  2. Lacrimal pump failure
  3. Poor drainage through lacrimal system
    a. Upper system obstruction- puncal/canalicular stenosis
    b. Obstruction within lacrimal sac- tumours/dacryoliths/dacrocystitis/mucocele/pyocele
    c. Lower system obstruction- NLD stenosis/obstruction
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8
Q

NASOLACRIMAL DUCT OBSTRUCTION

A
  1. Congenital
    a. Dacryostenosis
    b. Absence of valves
    c. Sac anomalies
    d. Anomalies of the puncta
    e. Anomalies of the canaliculi
  2. Acquired
    a. Primary
    b. Secondary
    - Infections- bacterial, viral, fungal, parasitic
    - Inflammatory- Wegener’s, Sarcoidosis, Histiocytosis, Kawasaki, Scleroderma
    - Traumatic- iatrogenic, non-iatrogenic
    - Mechanical- FB, external compression/occlusion - Toxic- eye drops, radiation, chemo, bone marrow transplantation
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9
Q

NASAL POLYP

A

Intracranial:

  • Meningocele
  • Encephalocele
  • Glioma

Nasal/sinuses:

  • Congenital
  • Thornwaldt’s cyst
  • Dermoid
  • Infectious
  • Adenoiditis
  • Bacterial incl atypical
  • Inflammatory
  • Granulomatous
  • Specific - Tb, Syphilis, Lyme
  • Non-specific- Sarcoidosis, Wegener’s, Churg-Straus - Non-granulomatous - Neoplastic - Benign
  • Malignant- Primary vs Secondary
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10
Q

EPISTAXIS

A

LOCAL: Idiopathic Traumatic- nose picking, foreign body, nasal fracture Iatrogenic- post-operative Inflammatory/Infectious- ARS/CRS, granulomatous disease, environmental irritants Neoplastic- haemangioma, haemangiopericytoma, JNA, pyogenic granuloma, sinonasal malignancy Structural- septal deformity, septal perforation Drugs- INCS, cocaine

GENERAL: Hypertension Atherosclerosis Coagulopathy- platelet dysfunction/deficiency, Warfarin, liver disease Leukaemia, von Willebrand’s disease HHT Medications- NSAIDs, Aspirin, Clopidogrel, Warfarin, Heparin/Clexane Alcohol- assoc with alcohol intake within last 24 hours

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11
Q

RHINITIS

A

Allergic: 50% of rhinitis

  • Seasonal
  • Perennial
  • Occupational

Non-allergic: 50% of rhinitis. I/M rhinorrea, NAO, congestion unrelated to allergy

Atrophic replacement of ciliated columnar epi with stratified squamous

  • Primary- e.g. aging, hereditary, nutrition, infectious - Secondary- surgery, cocaine, radiation, infectious (syphilis, rhinoscleroma)

Induced

  • Exercise
  • Gustatory- profuse watery rhinorrhea, esp spicy foods
  • Hormone- e.g. pregnancy, hypothyroidism, acromegaly
  • Pregnancy: Lasts > 6 weeks, no other cause - Worse in 2nd trimester (highest oestrogen), resolves after delivery
  • Medication- Anti-HT, antipsychotics, antidepressants, NSAID
  • Rhinitis medicamentosa- a-adrenergic agonists (e.g. oxymetazoline) .
  • Rebound congestion with characteristic nasal mucosa, prone to bleeding
  • Irritant- Cocaine, perfumes
  • Occupational- IgE and non-IgE dependent mechanisms. Freq assoc with occupational asthma - Can be either a new rhinitis at work or an exacerbation of existing rhinitis
  • Medicolegal implications

Systemic disorder

  • Granulomatous- Wegener’s, Sarcoid, Churg-Strauss, Tb
  • Autoimmune- SLE, Sjogren’s, Pemphigoid
  • Ciliary- CF, PCD

Idiopathic = vasomotor rhinitis

NARES- non-allergic rhinitis with eosinophilia syndrome

  • Symptoms similar to AR. Allergy tests -ve. Prominent eosinophils
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12
Q

SYSTEMIC DISEASE AFFECTING NOSE

A

Neoplastic

  1. Benign
  2. Malignant
    - Epithelial- SCC, Adenocarcinoma, SNUC
    - Non-epithelial- chondrosarcoma, rhabdomyosarcoma, lymphoma (incl NK-T cell), melanoma, neuroendocrine (Esthesio), vascular

Non-neoplastic

  1. Granulomatous disease- WG, CSS, Sarcoidosis have a predilection for the nose
    - Specific (Tb, foreign body) vs non-specific (WG, Sarcoid)
  2. Infectious- viral, bacterial (typical e.g. T.pallidum, K. rhinoscleromata or atypical e.g. Tb), fungal (immune competent vs compromised)
  3. Autoimmune - pemphigus, pemphigoid, Behcet’s
  4. Mucociliary - CF, PCD
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13
Q

SEPTAL PERFORATION

A

Traumatic:

  • Iatrogenic
  • Septoplasty, cautery, nasal packing
  • Radiation
  • Non-iatrogenic
  • Haematoma/abscess
  • Foreign body
  • Gunshot/stab

Non-Traumatic:

  • Irritant
  • Cocaine, Decongestants, Arsenic, Fumes
  • Infective
  • Tb, syphilis, leprosy, rhinoscleroma, diptheria
  • Fungal- incl Mucor
  • Inflammatory
  • Sarcoid, WG, RPC, SLE, RA, Crohns
  • Neoplastic
  • Epithelial- SCC, Adenocarcinoma
  • Non-epithelial- Lymphoma (NK-T cell), Melanoma, Metastasis
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14
Q

FIBRO-OSSEOUS LESIONS

A

3 recognised benign fibro-osseous diseases

  1. Fibrous dysplasia
    - Mono, poly, MAS
  2. Ossifying fibroma
    - A benign neoplastic disease
  3. Osseous dysplasia (periapical, focal, florid)
    - Close association with tooth roots

Other diseases that may be included in DDx: - Paget’s disease - Osteoid osteoma - Aneurysmal bone cyst - Cherubism - Brown tumour - Renal osteodystrophy - Low grade osteosarcoma

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15
Q

ANOSMIA

A
  1. Conductive
    - Tumour
    - CRSwNP
    - Allergic Rhinitis
    - Nasal packing
    - Anatomical deformities
  2. Sensory-Neural
    - URTI
    - CRSwNP
    - Neurodegenerative disorder
    - Traumatic Head Injury
    - Toxins
    - Congenital disorders (Kallman’s)
    - Iatrogenic
    - Miscellaneous
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16
Q

UNILATERAL MAXILLARY SINUS OPACIFICATION F MEN: Fungal Mucocele Encephalocele Neoplasia

A
  1. Neoplastic
    - Benign
    - Papilloma- IP
    - Fibro-osseous lesion- osteoma, FD, ossifying fibroma
    - Salivary gland tumour- pleomorphic adenoma, oncocytoma
    - Mesenchymal- fibroma, lipoma, myxoma
    - Vascular- haemangiopericytoma, JNA, pyogenic granuloma
    - Malignant
    - Epithelial- SCC, adenocarcinoma, adenoid cystic carcinoma
    - Non-epithelial- lymphoma, melanoma, sarcoma
  2. Non-neoplastic - Infective- Bacterial (ARS), fungal - Silent sinus syndrome
    - Mucosal cyst
    - Antrochoanal polyp
    - Cholesterol granuloma
    - Mucocele
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17
Q

UNILATERAL SPHENOID SINUS OPACIFICATION x

A
  1. Within the sinus
    - Sinusitis- bacterial, fungal
    - Mucocele
    - Fibrous dysplasia
    - Neoplasm
    - Benign (IP is rare)
    - Malignant (SCC, adenocarcinoma)
  2. Outside of sinus
    - Pituitary (adenoma, meningioma)
    - Clivus (chordoma, craniopharyngioma)
    - Meningoencephalocele
    - ICA aneurysm
    - Nasopharyngeal mass (NPC, JNA etc)
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18
Q

BENIGN SINONASAL TUMOURS

A
  1. Epithelial - Papilloma - Schneiderian papilloma (inverting, cylindrical, fungiform)
  2. Mesenchymal - Osteoma - Chondroma - Fibroma - JNA
  3. Neural - Schwannoma - Neurofibroma - Meningioma
  4. Fibro-osseous - Fibrous dysplasia - Ossifying fibroma - Aneurysmal bone cyst - Giant cell tumour/giant cell granuloma
  5. Vascular - Haemangioma - Haemangiopericytoma - Pyogenic granuloma
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19
Q

TELANGIECTASIA

A
  1. Congenital - HHT - Sturge-Weber syndrome - Ataxia-telangiectasia
  2. Acquired - Acne roasacea - Sun/cold exposure - Radiotherapy/chemotherapy - Carcinoid syndrome - Chronic steroids Rx
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20
Q

CONGENITAL VII PALSY

A
  1. Developmental:
    - Mobius syndrome (see Syndromes cards)
    - Goldenhar
    - Congenital unilateral lower lip paralysis
    - Dystrophia myotonica
    - CHARGE
    - Alberg-Shoenberg disease (osteopetrosis)
    - Melkersson-Rosenthal
    - Relapsing peripheral VII palsy
    - Chronic orofacial swelling
    - Furrowed tongue dorsum (lingua plicata)
  2. Traumatic: Most common
    - Risks: prolonged labour, forceps delivery
    - Compression of VII s it exits SM foramen
    - Soft TB, superficial location at SMF in neonate
    - 90% spontaneous recovery rate
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21
Q

VOICE DISORDERS IN CHILDREN

A
  1. Organic
    - Voice quality disorders
    - VC paralysis (see separate DDx card)
    - Vocal fold pathology
    - Granuloma
    - Nodules, cysts, sulcus, polyp
    - Web, stenosis, papilloma, malignant tumour
    - Resonance disorders
    - Hypernasality- esp VPI
    - Hyponasality
    - Choanal atresia
    - Adenoid hypertrophy
    - DNS/IT hypertrophy/nasal polyps
  2. Functional

This algorithm can guide treatment

  • Web/stenosis/papilloma/malignancy- surgery then voice therapy
  • Nodules, cysts, sulcus, polyp- voice therapy +/- surgery if not improving
  • Granuloma- medical Rx +/- surgery
  • Resonance disorders- treatment specific for underlying pathology
  • Functional- psych evaluation

Key differences in paediatric voice disorders:

  • Inability to cooperate
  • Lack of awareness of the problem
  • Lack of motivation for change
  • Surgery undertaken cautiously - larynx not mature and surgery more difficult
  • Voice therapy is the mainstay
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22
Q

VOCAL CORD PARALYSIS IN CHILDREN

A

2nd most common cause of congenital stridor

  • 10% of congenital anomalies of the larynx

Idiopathic 30%

  • Onset birth- 8 weeks. U/L > B/L
  • Recovery in 20%. May take years

Neurologic 50%

  • 50% of cases
  • Arnold-Chiari malformation MC
  • Small posterior fossa causes cerebellar herniation and kinking of medulla
  • 1/3 present with U/L VC palsy
  • B/L VC palsy: intubation/trache. Decompression. If in 24 hrs, VC fxn returns in 2/52

Birth trauma 15%

  • Complicated delivery requiring LSCS/forceps. U/L or B/L

Surgical trauma rare

  • TOF repair or congenital heart disease repair (incl PDA)

Infectious rare

  • Syphilis

Congenital - Scant reports with variable postulated inheritance patterns

50% are bilateral Overall 50% will recovery

  • Secure airway while minimising detriment to vocal function
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23
Q

CONGENITAL NASAL DISORDERS

A
  1. Anterior Neuropore
    - Meningocele/encephalocele
    - Faulty closure of foramen caecum — persistent CSF connection
    - Glioma
    - Premature closure of foramen caecum
    - Nasal dermoid
    - Irrevocably attached ectoderm pulled towards foramen caecum
  2. Central midface
    - Cleft palate/lip
    - Arhinia, polyrhinia
    - Congenital pyriform aperture stenosis
    - Nasolacrimal duct cysts (dacrocystoceles)
  3. Nasobuccal membrane
    - Choanal atresia
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24
Q

AIRWAY OBSTRUCTION

A

Considered in terms of the level of obstruction:

  1. Nasal
    - Congenital pyriform aperture stenosis
    - Choanal atresia
  2. Oropharyngeal
    - Macroglossia/glossoptosis
  3. Supraglottis
    - Laryngomalacia
  4. Glottis
    - Vocal cord palsy
    - Glottic web
    - RRP
  5. Subglottis
    - SG stenosis
    - SG haemangioma
  6. Trachea
    - Tracheomalacia
    - Vascular compression
    - Complete tracheal rings
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25
Q

PAEDIATRIC NECK MASS


Central

A
  1. Central
    - TGDC
    - Dermoid
    - Teratoma (need to excise as will enlarge
    - Arise from pluripotent cells, tissues foreign to the site from which they arise
    - Carinomatous or sarcomatous change occurs in 10-35% - Plunging ranula
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26
Q

PAEDIATRIC NECK MASS


Lateral

A
  1. Lateral
    - Branchial cleft cyst
    - Pseudotumour of infancy- not present at birth. Onset 1-8 weeks
    - Fibrous tissue, aetiology unknown ? birth trauma - Mid-portion of SCM, fusiform swelling
    - U/S for Dx, physio. Increase 2-3/12 then regress over 4-8/12 (disappear in 80%)
    - Lymphadenopathy
    - Viral- adenovirus, rhinovirus, enterovirus, EBV, CMV, HIV
    - Suppurative- S. aureus, Group A B-streptococci - Cat scratch- Bartonella henselae. Cervical adenopathy in >90%
    - Most patients have a Hx of cat exposure (90%) and cat scratch (50%)
    - Malaise, fever, aches, anorexia
    - Dx = serology, Rx = Azithromycin/Ciprofloxacin - Toxoplasmosis- Toxoplasma gondii. Adenitis in 90% - Serology is Dx, Sulfonamide is Rx. Oocytes excreted in cat faeces
    - Dx = serology, Rx = Sulfonamide - Mycobacterium- 80% tuberculous, 20% NTM (MAC, kansaii, scrofulaceum)
    - Ant/sup neck, overlying skin discolouration, 50% fluctuant, 10% fistula
    - Dx = Mantoux (strong = tub, weak = non-tub). Rx: tub= 2 drug, non-tub=excision
    - Kawasaki’s- Fever / Erythema lips - oral / Rash / Red hands / feet / Coronary Aneurysms
    - Vascular malformation- Lymphoma, RMS - Neoplastic- Lymphoma, RMS
27
Q

VASCULAR ANOMALIES Muliken and Glowacki

A
  1. Vascular Tumours endothelial cell hyperplasia - Haemangioma of Infancy
    - MC tumour of infancy (10% of infants, 60% in H&N) - Localised (75%) vs Segmental (25%)
    - Congenital haemangioma- RICH vs NICH
    - Kaposiform Haemangioepithelioma
    - Tufted angioma
    - Pyogenic granuloma
  2. Vascular Malformations error of vasculogenesis - High flow
    - AVM (intracranial:extracranial = 20:1)
    - Arterial
    - Low flow
    - Capillary
    - Venous- soft compressible, increase size with straining and IJV compression
    - Rx with PDL laser
    - Lymphatic- macrocystic (>2cm3) vs microcystic (<2cm3) vs mixed
28
Q

Pediatric stridor

A

Differential by anatomical subsite: Pharynx/hypopharynx

Glossoptosis

Laryngopharyngeal reflux

Vascular malformation

Vallecular cyst

Supraglottis Laryngomalacia

Laryngocele

Stenosis

Vascular malformation

Neck mass

Glottis Vocal cord paralysis (bilateral>unilateral)

Intubation injury

Laryngeal cleft

Glottic web

Stenosis

Laryngeal trauma/fracture

Subglottis

Croup

Intubation granulation/edema

Acquired stenosis

Hemangioma

Cysts

Congenital cricoid malformation

Foreign body

Tracheobronchus

Tracheobronchomalacia

Foreign body

Complete tracheal rings

Vascular compression

Stenosis

Bacterial tracheitis

Neck/chest mass

29
Q

CONDUCTIVE HEARING LOSS

A

Congenital

Anotia/microtia, EAC atresia Syndromes- Treacher-Collins, PRS, Crouzon’s/Apert’s, Goldenhar’s Otosclerosis, Paget’s, Osteogenesis imperfecta

Acquired Inflammatory/Infectious OE, AOM, OME, Cholesteatoma, Tympanosclerosis, Myringitis, Syphilis

Iatrogenic Surgical complication/failure, traumatic ear cleaning, trauma, burns, FB, Barotrauma, TB fracture, Penetrating injury

Neoplasia SCC, BCC, Melanoma, Pleomorphic adenoma

Metabolic/Systemic Cerumen, Wegener’s, Relpasing Polychondritis, Fibrous dysplasia, Polyarteritis nodosa, Sarcoidosis, Keratosis obturans

Other Canal osteoma, canal exostosis, haemotympanum

30
Q

WHITE MIDDLE EAR MASS

A

Cholesteatoma

Tympanosclerosis

Endostosis

Graft/prosthesis

Tumour

31
Q

BLUE/RED MIDDLE EAR MASS

A

Normal variant- high jugular bulb, dehiscent ICA, persistent Stapedial artery

Tumour- glomus, minor salivary gland, schwannoma, Histiocytosis X, carcinoid

Inflammation- cholesterol granuloma, Schwartze’s sign

Trauma- haemotympanum

32
Q

PINNA INFLAMMATION

A

Infective

Bacterial

Viral- HZV

Inflammatory Allergy (hearing aid/topical med)

Relapsing polychondritis

SLE

Dermatologic disorders

33
Q

EAC ULCER or BONY EROSION x

A

Neoplasia

SCC

Adenoid cystic

BCC

MSG

Lymphoma

Choelsteatoma/KO

Malignant OE

Irradiation- ORN

Others 1st arch anomaly

dermatologic disorders

Trauma- burns, chemical

Viral. fungal inflam

34
Q

MIDDLE EAR EFFUSION

A

Infective- bacterial vs viral

Traumatic- barotrauma

Inflammatory- Wegener’s, Sarcoid

Neoplasia

35
Q

CPA MASS - location-based

A

Extra-axial

  • Vestibular schwannoma
  • Meningioma
  • Epidermoid (or other cysts- arachnoid, dermoid)
  • Non-acoustic neuromas (V, VII, IX, X, XI, XII) - Vascular lesions (loops, aneurysms, malformations)

Extradural

  • Paraganglioma
  • Bone lesions (benign vs malignant, primary vs secondary)

Intra-axial

  • Astrocytoma, Ependymoma, Papilloma, Haemangioblastoma
36
Q

CPA MASS - Complete list

- mnemonic for most common

A
  1. Schwannoma
    - Fusiform, intracanalicular, acute angle at porous
  2. Meningioma
    - dural tail, obtuse angle with porous
    - Arise from arachnoid villi (present at porous)
    - More likely to be incompletely excised but better chance of hearing preservation
  3. Arachnoid cyst/aneurysm
  4. Epidermoid cyst/ependymoma
  5. Facial neuroma
  6. Petrous apex cholesteatoma
  7. Metastatic disease
  8. Haemangiopericytoma

Pnemonic for the common lesions is AMEN

A: acoustic schwannoma (~80%)

M: meningioma (~10%)

E: ependymoma (~5%)

N: neuroepithelial cyst (arachnoid/epidermoid) (~5%)

37
Q

PETROUS APEX LESION

A
  1. Inflammatory PA effusion>PACG>PA cholesteatoma
    - Cholesterol granuloma MC primary lesion of PA - Petrous apex effusion
    - Cholesteatoma- congenital vs acquired
    - Mucocele
  2. Infectious
    - Petrous apiciits
    - Skull base osteomyelitis
  3. Neoplastic
    - Benign- Schwannoma, Meningioma, Glomus
    - Malignant- Primary vs Secondary (breast, lung, kidney, prostate)
    - Epithelial- chordoma, NPC
    - Non-epithelial- chondrosarcoma, rhabdomyosarcoma
  4. Other
    - Asymmetrical pneumatisation
    - Giant air cell
    - ICA aneurysm- congenital weakness vs trauma vs infectious
38
Q

AURAL POLYP

A

Divide it anatomically:

  1. External ear
  2. TM
  3. Middle ear
  4. From outside (e.g. meningoencephalocele, parotid tumour e.g. SCC, TMJ fistula)

Also then use surgical seive for each location: Infective- viral, bacterial, fungal, parasitic

Inflammatory:

  • Chronic granulomatosis
  • Specific- Tb, Fungal, Syphilis, Leprosy
  • Non-specific- WG, PAN, SLE, Sarcoidosis

Neoplastic

  • Benign- incl Histiocytosis
  • Malignant
  • Epithelial (SCC, adenoCa)
  • Non-epithelial (incl Lymphoma)

Traumatic

39
Q

SUBJECTIVE TINNITUS

A
  1. Otologic- noise, NIHL, SNHL, Otosclerosis, Meniere’s
    - Tinnitus may be related to hearing loss at the same frequency
  2. Neurologic- VS, MS, head injury
  3. Infectious- OM, meningitis, syphilis
  4. Iatrogenic- surgery, medications- Aspirin, NSAID, aminoglycoside, quinine
  5. Metabolic- B12 deficiency, Zinc deficiency, Hypo/hyperthyroid, anaemia
  6. Psychogenic- Depression, Anxiety
  7. Other- TMJ / somatic

Neurophysiologic model of tinnitus (Jastreboff):

  • Auditory perception due to aberrant spontaneous neural activity (altered state of excitation/inhibition within auditory system)
  • Limbic system responsible for development of tinnitus annoyance
40
Q

PULSATILE TINNITUS 
Clinical exam and management

A

History:

  • Vascular risk factors: HT, Hyperchol, smoking, DM, FHx
  • BIH risk factors: obese, female, steroid use. H/A, visual change, aural fullness, dizziness

Examination:

  • Compression of IJV (reduce venous tinnitus)
  • Auscultation of neck/cranium (carotid bruit/AVM). Dural AVF — retroauricular bruit
  • Otoscopy- glomus, high riding jugular bulb
  • Oropharyngeal exam- palatal myoclonus
  • Increase HR (e.g. run up stairs) to differentiate myoclonus from vascular cause

Investigation:

  • Tympanometry- patulous ET = fluctuating trace
  • PTA- CHL (ME mass)
  • Bloods- hyperdynamic state- FBE, TFTs, BSL
  • Rarely required
  • Imaging
  • Suspicion of atherosclerosis Ultrasound (carotids, Echo)
  • Venous tinnitus- MRI/MRV
  • BHI: empty sella, small ventricles, flattening of posterior globes
  • Arterial tinnitus- CTA
  • Abnormal otoscopy- CTA
  • Cerebral angiography- if strong suspicion of AVM/AVF

Management: Treat underlying cause

BIH- weight loss, ? Acetazolamide Surgery- based on cause

41
Q

PULSATILE TINNITUS 
causes

A
  1. Vascular Arterial vs Venous Arterial - Atherosclerotic disease (ICA) - Vascular tumours (glomus, haemangioma) - Vascular malformations (AVM, aneurysm- AICA, ICA, vertebral, fistulae e.g. dural AVM/AV fistula) - Dural AVF accounts for 15% of intracranial AVMs. Retroauricular bruits - Pulsatile tinnitus is MC manifestation of AVMs and dural AVFs - Dural AVFs — risk of haemorrhage or ischaemic stroke (10%/year) — mortality 20% - Management with transvenous + transarterial coiling - Transmitted cardiac murmurs - Hyperdynamic states - Superior canal dehiscence - Otosclerosis Venous - Increased ICP (venous hum)- MC cause of venous pulsatile tinnitus - Jugular bulb abnormalities


  2. Myogenic - twitching or clicking sounds - Palate, stapedius, tensor tympani
  3. Patulous ET - To and fro movt of TM (synchronous with nasal respiration)
  4. TMJ dysfunction - Audible vibratory sound arising from jaw clenching
  5. Spontaneous OAEs - Extremely rare
42
Q

VII PALSY

Exam
investigation Theories synkinesis

A

Examination: - Tone - Voluntary movement - Synkinesis (aberrant regeneration)

Investigation: - Audio - Topodiagnostic testing (historical) - Electrophysiologic testing - NET, MST, ENoG, EMG

Synkinesis Theories: - Cross re-innervation - Focal demyelination —> lateral transmission btwn adj nerve fibres allowing depolarisation of adjacent nerve fibres - Facial nucleus hyperactivity secondary to continuous irritation

43
Q

VII PALSY

differential

A

Congenital - See separate card

Acquired

  1. Infectious
    - Bell’s (50%)
    - Pain around ear in 2/3, dysguesia, change in facial sensation
    - Normal audio (if abnormal, have to think of another diagnosis)
    - Complete recovery 85%, partial recovery 95% - Recovery: 60% by 3 months, 90% by 6 months
    - Viral - e.g. HZV, Gullian-Barre, EBV, HIV
    - Ramsey-Hunt (10%) order of Sx: severe pain, complete VII palsy, vesicles
    - May also have cochleovestibular disturbance
    - Bacterial- incl AOM, CSOM/cholesteatoma, MOE
    - Atypical- Tb, Lyme (can be B/L), Syphilis
  2. Iatrogenic
    - Surgery, Anaesthesia
    - Surgical complication or planned (e.g. facial rerouting


  3. Neoplastic
    - Benign - schwannoma, meningioma, neuroma, haemangioma
    - Malignant - SCC, adenoid cystic ca
  4. Trauma
    - TB trauma, extracranial lacerations
  5. Toxic
    - Thalidomide, Lead
  6. Inflammatory
    - Sarcoidosis - MC otologic manifestation
    - In isolation or aprt of uveoparotid fever (Heerfordt’s disease)
    - WG - middle ear involvement with dehiscent Fallopian Canal
44
Q

VERTIGO

A

Can differentiate by sieve or by timing of Sx

VERTIGO acronym:

Vascular - CNS causes - VBI, CVA

Epilepsy

Rx - Ototoxic drugs- Aminoglycosides, Cisplatin, Quinine, Salicylates (Aspirin), Diuretics (Frusemide)

Trauma - TB #, PLF, Acoustic trauma

Infection - TORCHS - Vestibular neuronitis

General med - Hypo/hypertension - Hyper/hypoglycaemia - Cardiac- incl WPW

Otologic (COMA) - Cholesteatoma - Otosclerosis - Meniere’s - Acoustic Neuroma &

Other - SSCC dehiscence

45
Q

CSF OTORRHEA

A

Congenital - Meningoencephalocele - Perilymph fistula

Acquired - Traumatic - Iatrogenic- e.g. cholesteatoma surgery - Non-iatrogenic- TB #, PLF - Non-traumatic - Idiopathic- see Pathogenesis - Infectious- e.g. CSOM/cholesteatom - Neoplastic

46
Q

COMPLICATIONS OF AOM

Contributing factors

A

Factors contributing to a rise in complications:

  1. Changing antibiotic resistance patterns
    - S. pneumo now 50-60%
  2. S. pneumo and H. flu vaccinations
    - Reduction in vaccine serotype infections (esp 19F) - Increase in non-serotype infections (now 19A most common, rare prior to vaccine)
  3. Changing antibiotic prescribing practices for AOM - Guidelines to hold antibiotics for AOM initially (? compliance with this though)
47
Q

COMPLICATIONS OF AOM


Complications diferrential

A
  1. Intracranial
    - Sigmoid sinus thrombosis
    - 5-15% of advanced mastoiditis cases. MC intracranial complication
    - Neuro signs (H/A, nuchal rigidity, photophobia, papilloedema, VI palsy) may predominate over otologic signs if ABx prescribed
    - Mastoidectomy + VT insertion. Opening sinus controversial.
    - No clear role for anti-coagulants. Only if extended (IJV/CST)
    - Brain abscess and subdural/extradural empyema - Combined ENT/Neurosurgical intervention
    - Otitic hydrocephalus**
    - Meningitis **Inc CSF pressure (nausea, vomiting, optic nerve head swelling)


  2. Extracranial
    a. Intratemporal - VII Palsy - SNHL/CHL - Dizziness/Tinnitus - Petrous apicitis
    b. Extratemporal - Subperiosteal abscess - Bezold’s abscess = deep to SCM - Citelli’s abscess = PBD - Luc’s abscess = zygomatic root

Griesinger’s sign: erythema/oedema over mastoid process due to septic thrombosis of mastoid emissary vein and thrombophlebitis of the sigmoid sinus

48
Q

SYSTEMIC DISORDERS OF THE TEMPORAL BONE

A

1. Granulomatous/Infectious - Langerhan’s Cell Histiocytosis - Tuberculosis - Wegener’s granulomatosis - Sarcoidosis - Syphilis - Lyme disease - Mycotic disease

  1. Neoplastic - Multiple myeloma - Leukaemia - Metastasis


  2. Bone diseases - Paget’s disease - Fibrous dysplasia - Osteogenesis imperfecta
  3. Storage/Metabolic - Mucopolysaccharidoses - Gout
  4. Collagen vascular/autoimmune
  5. Immunodeficiency - Congenital - Acquired
49
Q

BILATERAL SSNHL

A
  1. Infectious - HZV, HIV - Lyme, Syphilis - Meningitis
  2. Autoimmune/granulomatous - AIED - Sarcoidosis - Cogans
  3. Other - Trauma - Ototoxicity - NF-2 - Genetic (e.g. MELAS, other mitochondrial disorders
  4. Hyperviscosity
50
Q

UNILATERAL SSNHL

A
  1. Idiopathic- 90% of all SSNHL
  2. Neoplastic- benign (VS, meningioma) vs malignant
  3. Traumatic
  4. Iatrogenic
  5. Infectious- Syphilis, HIV, HZV, HSV, mumps, rubella
  6. Inflammatory- WG, SLE, Sarcoid,
51
Q

PARAGANGLIOMA 1. Vernet syndrome 2. Villaret syndrome 3. Brown’s sign 4. Aquino sign

A

VERNET SYNDROME AKA Jugular foramen syndrome CN IX, X, XI palsy 50% have PCF disease (if CN XII included too, 75%)

VILLARET SYNDROME Vernet + Horner’s syndrome 50% have MCF involvement (via the ICA) Collet-Sicard IX - XII palsy

BROWN’S SIGN Blanching of the middle ear mass on pneumatic otoscopy AQUINO SIGN Ipsilateral carotid compression leads to reduced pulsatile tinnitus

52
Q

OSSICULAR FIXATION

A

Congenital - congenital ossicular fixation

Acquired - Tympanosclerosis - Bony fixation - Infectious - cholesteatoma / CSOM - Surgical trauma - Temporal bone # - Bony lesions (Paget’s)

53
Q

PROGRESSIVE SNHL CHILDHOOD

A

Tends to be bilateral, asymmetric, often fluctuating Hereditary cause most common




Hereditary

  • Syndromic - Alport’s / Pendred
  • Non syndromic (MCC PSNHL) - tend to be AD - Present 1st / 2nd decade (AR tend to be prelingual hearing loss)

Developmental - Mondini / EVAS / ECA

Infectious

  • Congenital - CMV, Rubella, Syphilis, Toxoplasmosis - Acquired - Meningitis / Other viruses - HIV / HSV

Metabolic - Hyperlipidaemia / hypothyroidism / Alport’s Toxic - Ototoxic eg aminoglycosides esp if A1555G Autoimmune - Kawasaki / Cogan’s Traumatic - PLF (congenital or acquired), CHI Vascular

54
Q

BLEEDING DISORDER

A

INCREASED VESSEL FRAGILITY

Infections (e.g. meningococcal)

Drug reactions

Scurvy, Ehlers-Danlos syndrome

Henoch-Schonlein purpura

HHT

Perivascular amyloidosis

PLATELET DEFICIENCY/DYSFUNCTION

Reduced production- aplastic anaemia, leukaemia, chemo, NSAIDs, CRF

Decreased survival- ITP, TTP, connective tissue disorders

Sequesteration- Spleen normally sequesters 30%, splenomegaly = 80-90%

DERANGEMENT OF COAGULATION

Congenital typically a single factor

  • Haemophilia A and B- VIII and IX respectively
  • Von Willebrand’s Disease- platelet function defects and VIII deficiency

Acquired rarely affects a single factor

  • Vit K deficiency- inadequate stores, malabsorption, oral anticoagulants
  • Liver failure- Vit K deficiency, reduced synthesis, thrombocytopenia, functional abnormalities, DIC
  • DIC- consumption coagulopathy
  • Massive transfusion
55
Q

VOICE DISORDERS DDx

A
  1. Organic
    a) Anatomical
    - Epithelium
    - Leukoplakia
    - Hyperkeratosis
  • CIS/Carcinoma
  • Lamina propria
  • Diffuse = Reinke’s
  • Focal = nodules, polyp, scar, cyst, sulcus, vascular, reactive
  • Arytenoid
  • Vocal fold granuloma
  • Infection
  • Other
  • Laryngeal web
  • Stenosis
    b) Movement disorder
  • Vocal cord paralysis/paresis
  • Paradoxical vocal fold motion
  • Muscle tension
  • Spasmodic dysphonia (adductor, abductor, mixed) - Essential tremor of the larynx
    2. Non-organic
  • Psychogenic
  • Conversion
56
Q

VOICE DISORDERS Janet Baker, 2002 Diagnostic Classification System for Voice Disorders (DCSVD)

A

Organic vs Functional (muscle tension vs psychogenic)

Organic disorders

  1. Mass lesions or changes
  2. Laryngeal trauma
  3. Neurologic- LMN: VC paralysis
  4. Neurologic- adductor/abductor spasmodic dysphonia
  5. Neurologic UMN and assoc dysarthrophonia (wekaness/incoord of muscles of articulation/respiration/resonation/phonation)

Muscle tension disorders

Type 1: no secondary pathology

Type 2: secondary pathology

  • 2a- mod hoarseness. Abuse inciduced inflam, oedema, nodule, ulcer
  • 2b- Severe hoarseness. Diffuse erythema and chronic laryngitis
  • 2c- Severe hoarseness. Reinke’s oedema

Psychogenic disorders

  1. Aphonia
  2. Dysphonia
  3. Psychogenic spasmodic dysphonia
  4. Puberphonia/mutational falsetto

Functional Voice Disorders: aphonia/dysphonia with no organic pathology or, if there is, it is insufficient to account for nature/severity or is secondary to the functional problem

Functional Voice Disorders consist of 2 main areas:

  • Muscle tension: disrupted vocal behaviours lead to poor vocal habits and susbsequent development of organic changes to the vocal folds
  • Psychogenic: disturbed psychological processes leading to loss of volitional control over voice
57
Q

RLN PALSY IN ADULTS 1/3 tumour 1/3 trauma 1/3 idiopathic

A

Neoplastic 25% - Bronchogenic Ca (50%) - Thyroid Ca - Upper oesophageal Ca - Laryngeal Ca

Surgical trauma 20% - Thyroid (MC), carotid endarterectomy, ant approaches to cervical spine, skull base surgery, lung, heart, oesophagus, mediastinum

Idiopathic 13% - Dx of exclusion. ? viral aetiology

Inflammatory 13% - Tb

Traumatic 11% - Enlargement of left atrium - Aortic aneurysm - Neck trauma

Neurologic 7% - CHI, CVA, MS, Parkinsons, encephalitis, Bulbar palsy, Wallenber syndrome (PICA occlusion)

Miscellaneous 11% - RA, haemolytic anaemia, Syphilis, Collagen diseases

L = 75%, R = 25% (longer course of left RLN) - 10% bilateral

58
Q

BILATERAL VOCAL CORD PALSY

A
  1. Traumatic - Surgical - Non-surgical
  2. Non-laryngeal malignancy
  3. Neurologic
  4. Intubation
  5. Idiopathic
  6. RA/CT disorder

Vocal fold immobility may be: \

  1. Paralysis
  2. Synkinesis
  3. CAJ fixation (trauma, arthritis, tumours)
  4. Interarytenoid scar
59
Q

HALITOSIS

A
  1. Local 90%
    - Oral- gingivitis, periodontitis, tongue coating (bacterial, fungal), ulceration, malignancy - Pharyngeal- chronic tonsillitis, tonsoliths, deep neck space infection (retropharyngeal, peritonsillar)
  2. Systemic 10%
    - Sinonasal disease- sinusitis, foreign body, PND - Gastrointestinal- pharyngeal pouch, reflux oesophagitis, hiatus hernia, achalasia
    - Hepatic- liver cirrhosis, cholecystitis
    - Respiratory- chronic bronchitis, bronchial carcinoma, bronchiectasis
    - Other- renal impairment, DKA - Psychogenic
60
Q

ORAL ULCER

A
  1. Benign
    - Drugs - Stevens-Johnson Syndrome
    - Traumatic
    - Infectious
    - Bacterial - Staph / Strep / TB / Diptheria / Gonorrhoea
    - Viral (HSV, VZV, HHV, EBV, CMV, HIV, Coxsackie, Adenovirus)
    - Fungal - Candidiasis / Actinomyces
    - Parasitic/Spirochete - Syphilis
    - Inflammatory .
    - Sarcoidosis, Wegener’s Granulomatosis, SLE, Crohn’s
    - OLP, PV, MMP, Crohn’s, Erythema Multiforme, Behcet’s
    - Melkersson- Rosenthal = lip swelling / fissured tongue / VII palsy
    - Dental / periodontal
    - Necrotizing sialometaplasia
    - Recurrent Aphthous Stomatitis
    - Systemic disease
    - Nutritional
    - Immunosuppression- Leukaemia, HIV, Chemotherapy, Radiotherapy
  2. Malignant
    - Primary
    - Epithelial
    - Non-epithelial
    - Secondary
61
Q

SYSTEMIC EOSINOPHILIA

A

1. Allergic disorders

  • Asthma
  • Hay fever
  • Drug allergies
  • Allergic skin disease (pemphigus, dermatitis herpetiform)
    2. Parasitic infection
    3. Malignancy
  • Hodgkin’s +/- NHL
    4. Systemic autoimmune disease (SLE)
    5. Vasculitis
  • Churg-Strauss
    6. Cholesterol embolus (transient)
    7. Hyperimmunoglobulin E syndrome
62
Q

TONGUE LESION x

A

Ulcerative

Benign

  1. Erosive OLP
  2. Median rhomboid glossitis
  3. Amyloidosis

Malignant

  1. SCC
  2. Minor salivary gland tumour

Non-Ulcerative

63
Q
A

*RACS ENT Fellowship (19 decks)

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