1
Q
Most common bacteria causing bacterial otitis media?
A
Haemophilus Influenzae
2
Q
List some causes of conductive hearing loss
A
- Foreign body
- Otitis media
- Otitis externa
- Perforated ear drum
- Otosclerosis
3
Q
List some causes of otitis externa
A
- Infection: bacterial (Staph aureus, Pseudomonas aeruginosa) or fungal
- Serborrheic dermatitis
- Contact dermatitis (allergic and irritant)
- Recent swimming
4
Q
Features of otitis externa?
A
- Otalgia, itch, discharge
- Otosocopy - red, swollen or eczematous ear canal
5
Q
Outline management for otitis externa
A
- Topical antibiotic or combined antiobitic with a steroid (note if TM is perforated typically aminoglycosides are not used). If you suspect fungal otitis externa use canesten drops
- If there is canal debris - consider removal
- If the canal is extensively swollen sometimes a pope ear wick is used
- Swab the ear
SECOND LINE: - Oral antibiotics e.g. fluclox if infection is spreading
- Empirically use antifungal agent
In suspected otitis malignant otitis externa (elderly diabetics, cranial nerve involvement etc)
- IV antibiotics
6
Q
List some complications of tonsillitis
A
- Otitis media
- Quinsy
- Rheumatic fever and glomerulonephritis very rarely
7
Q
Outline the indications for tonsillectomy
A
- 7,5,3 rule - 7 episodes per year for one year
- 5 episodes per year for 2 years
- 3 episodes per year for 3 years
- Suspected malignancy (irregular often asymmetrical tonsillar enlargement, etc)
- Recurrent febrile convulsions secondary to episodes of tonsillitis
- Obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
- Peritonsillar abscess (quinsy) if unresponsive to standard treatment
8
Q
When is a primary post-tonsillectomy bleed and when is secondary?
Also what are primary and then what are secondary bleeds most commonly caused by?
A
Primary = < 24 hours - most commonly due to inadequate haemostasis
Secondary = 24 hours to 10 days - most commonly due to infection
9
Q
What is the most common symptom in nasal septal haematoma?
Then list some more features
A
Sensation of nasal obstruction
Pain
Rhinorrhoea
Bilateral, red swelling arising from the nasal septum
Can be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm
10
Q
How can nasal septal haematomas be differentiated from nasal deviation?
A
Surgical drainage
IV antibiotics
11
Q
What is the complication that happens when you don’t manage nasal septal haematoma?
A
If untreated, irreversible septal necrosis may develop within 3-4 days. Due to pressure related ischaemia of the cartilage resulting in necrosis. Can result in saddle-nose deformity
12
Q
What decibel level is normal in audiograms?
A
0-20dB
13
Q
List some differentials for facial pain
A
- Trigeminal neuralgia - severe lancinating pain along one or more branches of the trigeminal nerve
- Sinusitis - facial pain accompanied by symptoms such as nasal discharge or congestion suggesting sinusitis
- Dental problems - dental caries or abscesses can cause localised facial pain
- Tension type headache
- Migraine
- GCA
14
Q
Triad of symptoms in Meniere’s disease?
A
Vertigo, tinnitius and hearing loss (sensorineural)
15
Q
What pattern of hearing loss can occur in Meniere’s disease?
A
Sensorineural hearing loss
16
Q
Apart from the triad of vertigo, tinnitus and hearing loss, what other features can be present in Meniere’s disease?
A
Nystagmus
Romberg’s +ve
Sensation of aural fullness or pressure
17
Q
Outline the management of Meniere’s disease, including advice, what is given for acute attacks and what is given for prevention of attacks?
A
- Inform the DVLA - cease driving until satisfactory control of symptoms
- Acute attacks - buccal or IM prochlorperazine
- Betahistine and vestibular rehabilitation exercises
18
Q
What 3 -itis s can be involved in sore throat?
A
- Pharyngitis
- Tonsillitis
- Laryngitis
19
Q
NICE indications for antibiotics in sore throat?
A
- Feature of marked systemic upset secondary to the acute sore throat
- Unilateral peritonsillitis
- History of rheumatic fever
- Increased risk from acute infection (e.g. child with diabetes mellitus or immunodeficiency)
- Patients with acute sore throat / acute pharyngitis / acute tonsillitis when 3+ centor criteria are present
20
Q
What are the 4 different categories that score a point on the Centor criteria?
A
- Presence of tonsillary exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- History of fever
- Absence of cough
Note 3+ - give antibiotics
21
Q
What are the different categories that score a point in the FeverPAIN criteria?
A
- Fever > 38C
- Purulence (pharyngeal / tonsillar exudate)
- Attend rapidly ( 3 days or less)
- Severely inflamed tonsils
- No cough of coryza
22
Q
Which antibiotics are given in people who fulfill Centor or FeverPAIN criteria?
A
- Phenoxymethylpenicillin OR clarithromycin if penicillin allergic
23
Q
List some causes of vertigo
A
- Viral labyrinthitis
- Vestibular neuronitis
- BPPV
- Meniere’s disease
- Vertebrobasilar ischaemia
- Acoustic neuroma
- Posterior circulation stroke
- Trauma
- MS
- Ototoxicity e.g. gentamicin
24
Q
Nasal polyps more common in men or women?
A
2-4x more common in men
25
List some associations for nasal polyps
- Asthma (particularly late-onset asthma)
- Aspirin sensitivity
- Infective sinusitis
- Cystic fibrosis
- Kartagener's syndrome
- Churg-Strauss sydrome
26
What is the triad in Samter's triad?
- Nasal obstruction
- Rhinorrhoea, sneezing
- Poor sense of taste and smell
27
What features require further investigation in nasal polyps?
- Unilateral symptoms
- Bleeding
28
What are the treatment options in nasal polyps?
- Topical corticosteroids shrink polyps size in around 80% of patients
- Polypectomy
29
Asthma, aspirin sensitivity and nasal polyposis are part of what triad?
Samter's triad
30
What to do with someone with unexplained unilateral otalgia for > 4 weeks with unremarkable otoscopy?
Refer under 2 week wait
31
Features of head and neck cancer?
- Neck lump
- Hoarseness
- Persistent sore throat
- Persistent mouth ulcer
32
NICE guidelines for suspected cancer pathwar referral criteria under 2WW for laryngeal cancer?
45 + yrs with:
- Persistent unexplained hoarseness
- Unexplained lump in the neck
33
NICE guidelines for suspected cancer pathwar referral criteria under 2WW for oral cancer?
- Unexplained ulceration in the oral cavity for more than 3 weeks
- Persistent and unexplained lump in the neck
- Lump on the lip or in the oral cavity
- Red or red and white patch in the oral cavity consistent with eryroplakia or erythroleukoplakia
34
NICE guidelines for suspected cancer pathwar referral criteria under 2WW for thyroid cancer?
Unexplained thyroid lump
35
Features of post-nasal drip?
Mucus accumulates in the throat or in the back of the nose resulting in a chronic cough and bad breath
36
A 44-year-old man comes to see you describing a constant feeling of mucus in the back of the throat. He also describes that he has had a cough for 6 months and often has bad breath -especially in the mornings. He reports that he is otherwise well but admits to smoking 10 cigarettes a day.
On examination, the ears appear normal and the throat appears slightly erythematous with no tonsillar swelling.
What is the most likely diagnosis?
Post-nasal drip
37
What is the prognosis of BPPV?
Good prognosis - usually resolves spontaneously after a few weeks to months
However roughly half of people with BPPV will have a recurrence of symptoms 3-5 years after their diagnosis
38
Average age of onset of BPPV?
55yrs
39
What is the Dix Hallpike manouevre, and how is it done?
- Test to diagnose BPPV
- Rapidly lower the patient to the supine position with an extended neck
40
Management options for BPPV?
Epley manoeuvre (succesful in ~ 80% of cases)
Vestibular rehabilitation e.g. Brandt-Daroff exercises
41
List of causes of tinnitus?
- Idiopathic
- Meniere's disease
- Otosclerosis
- Sudden onset sensorineural hearing loss
- Acoustic neuroma
- Hearing loss
- Drugs
- Impacted ear wax
42
In what cases do you do imaging in tinnitus, and what are the imaging options you use?
- Non-pulsatile tinnitus does not require imaging unless unilateral or there are other neurological or otological signs - MRI of internal auditory meatus is first line
- Pulsatile tinnitus requires imaging to rule out vascular cause - MRA (magnetic resonance angiography)
43
Management options for tinnitus?
Depends on the cause, but otherwise in general:
- Amplification devices - more beneficial if associated hearing loss
- Pyschological therapy e.g. CBT
- Tinnitus support groups
44
What is a key clinical examination finding in acoustic neuroma? Note this examination finding also helps differentiate it from Meniere's disease (as both otherwise present with hearing loss, vertigo and tinnitus)?
Absent corneal reflex
45
List some drugs / drug classes that can cause tinnitus
Aspirin NSAIDs
Aminoglycosides
Loop diuretics
Quinine
46
When to consider admission in epistaxis?
- Comorbidity e.g. Coronary Artery Disease, or severe hypertension is present, an underlying cause suspected
-Age < 2 years (as underlying causes e.g. haemophilia or leukaemia more likely in this age group)
- Haemodynamically unstable - admit to ED
- Bleeding from unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital
47
What is the last line consideration for management of epistaxis - surgical option?
Sphenopalatine ligation in theatre
48
What is a risk factor associated with cholesteatoma that increases the risk by around 100x?
Congenital cleft palate
49
Features of cholesteatoma?
Foul smelling, non-resolving discharge
Hearing loss
There may be a history of chronic otitis media
Other features determined by local invasion:
- Vertigo
- Facial nerve palsy
- Cerebellopontine angle syndrome
Otoscopy - 'attic crust' seen in uppermost part of the ear drum
50
True or false, cholesteatoma is not a cancerous growth?
True - it is a non-cancerous growth of squamous epithelium trapped within the skull base causing local destruction
51
What age group do cholesteatomas typically present in?
10-20 year olds
52
What is this?
Cholesteatoma - 'attic crust'
53
What is the pathological process in otosclerosis?
Replacement of normal bone with vascular spongy bone. Causes progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant
54
What is the inheritance patter in otosclerosis?
Autosomal dominant - so typically affects young adults
55
Features of otosclerosis?
- Conductive deafness
- Tinnitus
- Tympanic membrane - normal in most patients, but 10% may have a 'flamingo tinge' caused by hyperaemia
- Positive family history
56
What are the management options in otosclerosis?
- Hearing aid
- Stapedectomy
57
3 most common bacteria that can cause acute otitis media?
Strep pneumoniae, Haemophilus Influenzae, Moraxhella Catarrhalis
58
Features in acute otitis media?
- Otalgia
- Fever in 50% of cases
- Hearing loss
- Recent viral URTI symptoms e.g .coryza
- Ear discharge may occur if the tympanic membrane perforates
59
Possible otoscopy findings in otitis media?
- Bulging tympanic membrane - loss of light reflex
- Opacification or erythema of the tympanic membrane
- Perforation with purulent otorrhoea
- Decreased mobility if using a pneumatic otoscope
60
After how long to advise parents to seek help in suspected otitis media?
3 days
61
When to prescribe antibiotics in otitis media?
- Symptoms lasting > 4 days or not improving
- Systemic unwell but not requiring admission
- Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver or neuromuscular disease
- < 2 yrs old with bilateral otitis media
- Otitis media with perforation and / or discharge in the canal
62
Which antibiotic is given for otitis media?
5-7 day course of amoxicillin
If allergic - erythromycin or clarithromycin is given
63
What are some common sequelae of otitis media, and some other complications?
- Perforation of the tympanic membrane - which can develop into chronic suppurative otitis media
- Hearing loss
- Labyrinthitis
Complications:
- Mastoiditis
- Meningitis
- Brain abscess
- Facial nerve paralysis
64
What is the definition of chronic suppurative otitis media?
Perforation of the tympanic membrane with otorrhoea for > 6 weeks
65
List some causes of hoarseness
- Voice overuse
- Smoking
- Viral illness
- Hypothyroidism
- GORD
- Laryngeal cancer
- Lung cancer
66
When investigating patients with hoarseness, what investigation must be done?
Chest x-ray, to exclude apical lung lesions
67
Presbycusis is sensorineural or conductive hearing loss?
Sensorineural
68
What will be seen in the following in Presbycusis?
Otoscopy?
Tympanometry?
Audiometry?
- Otoscopy - Normal, to rule out otosclerosis, cholesteatoma, and conductive hearing loss
- Tympanometry - Normal middle ear function with hearing (type A)
- Audiometry - Bilateral sensorineural pattern hearing loss
69
Key different clinical sign between viral labyrinthitis / vestibular neuronitis?
Hearing may be affected in viral labyrinthitis vs no hearing loss in vestibular neuronitis
70
In vertebrobasilar ischaemia, dizziness is particularly marked on what movement
Extension of the neck
71
True or false, in black hairy tongue the tongue can only be black?
False - can be brown, green, pink or another colour
72
List some predisposing factors for black hairy tongue
- Poor oral hygiene
- Antibiotics
- Head and neck radiation
- HIV
- IVDU
73
How to manage black hairy tongue?
Swab the tongue to exclude Candida
Tongue scraping
Topical antifungals if Candida
74
List causes of bilateral parotid gland swelling
Viruses: mumps
Sarcoidosis
Sjogren's
Lymphoma
Alcoholic liver disease
75
List causes of unilateral parotid swelling
Tumour - pleiomorphic adenomas
Stones
Infection
76
Risk factors for glue ear?
- Male sex
- Siblings with glue ear
- Higher incidence in Winter and Spring
- Bottle feeding
- Day care attendance
- Parental smoking
77
Features of glue ear?
- Hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood)
- Secondary problems such as speech and language delay, behavioural or balance problems may also be seen
78
Glue ear peaks at what age?
2
79
Treatment options for glue ear?
- Active observation - first presentation of OME - observe for 3 months
- Grommet insertion - to allow air to pass into the middle ear - doing the job the eustachian tube normally does
- Adenoidectomy
80
In which salivary glands are tumours most commonly present?
Parotid
81
In which salivary glands are stones most common?
Submandibular
82
80% rule of tumours of the salivary glands?
80% Parotid, 80% of these = Pleiomorphic adenomas, 80% Superficial lobe
83
Features of malignant salivary gland tumours?
Short history, painful, hot skin, hard, fixation, CN VII involvement
84
What is the greatest risk with superficial parotidectomies?
CN VII damage
84
.... .... make up 80% of salivary gland tumours, whereas .... .... make up 10%
A good way to differentiate them clinically is?
Pleiomorphic adenomas make up 80% of salivary gland tumours, whereas Warthin's tumours make up 10%
Warthin's tumours are softer, more mobile and fluctuant
85
Features of stones in salivary glands?
Recurrent unilateral pain and swelling on eating
May become infected - Ludwig's angina
86
What is the key investigation for stones in salivary glands?
Plain X-rays, Sialography
87
Management of stones in salivary glands?
Surgical removal
88
Apart from tumours, stones give some other causes of enlargement of the salivary glands
- Acute viral infection e.g. mumps
- Acute bacterial infection e.g. 2nd to dehydration diabetes
- Sicca syndrome and Sjogren's (e.g. RA)
89
How long after tonsillectomy may pain increase?
6 days
90
What is the timeline for how soon after surgery primary then secondary post-tonsillectomy haemorrhage occurs?
Primary - first 6-8 hours following surgery
Secondary - 5-10 days after surgery
91
How to manage secondary post-tonsillectomy bleeds?
Secondary haemorrhage is often associated with wound infection.
Treatment = admission and antibiotics, severe bleeding may require surgery
92
MSRA
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