ENT1

Question 1

Red flags for malignancy in epistaxis?

Answer 1

unilateral nasal blockage

facial pain

headaches

facial swelling/deformity

South-East Asian origin (nasopharyngeal carcinoma)

loose teeth

deep otalgia.

Question 2

Causes of epistaxis?

Answer 2

LOCAL - Trauma, structural abnormalities (Septal deviation). inflammatory disease (granulomatous disease, infection, allergy) tumours, vascular malformations.

Environmental - Low humidity, Temperature (cooler months)

Drugs - intranasal steroids, anticoagulant therapy, cocaine, asprin, antiinflamms

Systemic - coagulopathy, CARDIOPULMONARY disease (more severe), vasculitis

Question 3

Recurrent profuse nose bleeds with mucocutaneous telangiectasia (tongue tge’s)

Answer 3

Hereditary haemorrhagic telangiectasia - Oslers disease

Question 4

Management approach for Epistaxis

Answer 4

Simple:

First AID

Apply Pressure to anterior littles area

Ice to nasal bridge

Persistent bleeding - ABC

Nasal decongestant and adminstration of cophenylcaine anaesthetic.

Once stopped - DONT blow nose, drink alcohol or hot beverage for 12 hours

PERSISTENT

Cautery - sticks impregnated with silver nitrate - (Apply nasal moisturiser post such as kenacomb)

Packing of the nose after decongestant and cophenylcaine administration

Consider antibiotic cover for staph. aureus to prevent toxic shock syndrome if leaving packs in situ

RECURRENT EPISTAXIS - REFER TO ENT

Question 5

Red flags in hoarseness?

Answer 5

Red flags include

a history of smoking,

dysphagia,

odynophagia or otalgia,

stridor,

haemoptysis and recent fevers,

night sweats and unexplained weight loss

Question 6

Causes of hoarseness based on description?

Answer 6

Deep

Reinke’s oedema

Hypothyroidism

Raspy

Laryngopharyngeal reflux

Intermittent

Functional dysfunction

Gravelly

Vocal cord mass

Inflammatory arthritis

Soft

Parkinson’s disease

Vocal cord paralysis

Fatiguable

Muscle tension dysphonia

Myaesthenia gravis

Parkinson’s disease

Phonotrauma

Strained or strangled

Spasmodic or muscle tension dysphonia

Question 7

When would you refer persistent hoarseness?

Answer 7

recommended that any persistent hoarseness, present for more than three weeks, requires referral for direct visualisation

OR

redflags

Question 8

Causes of hoarseness?

Answer 8

Structural - malignant - laryngeal ca

benign - nodules

Irritation - from inhaled steroids/smoke/dust

Post nasal drip

Gastro oesophageal reflux

Autoimmune disease - wegners, SLE, sarcoidosis

Infections - candida, staph aureus

Allergy

Trauma

Question 9

History questions for hoarseness?

Answer 9

Nature and duration of the change in voice?

Respiratory symptoms - eg cough

Constitutional symptoms - weight loss, night sweats

Associated: Symptoms of HYPOTHYROIDISM

Reflux? Allergies

Recent surgery?

Overuse: Excessive straining of voice, public speaking/singing/

Drug hx: Inhaled corticosteroids?

Exposures: Smoking/Dust?

Question 10

Examination findings for hoarseness?

Answer 10

VOICE:

listen to the voice and note the quality, pitch and volume

ask the patient to sustain the vowel sound ‘ah’ for as long as they can and time it. This maximal phonation time can vary, but if less than eight seconds it often indicates an organic pathology.

Listen for effective cough?

RESPIRATORY Examination - Stridor on auscultation?

ENT examination

LYMPHADENOPATHY

Question 11

Investigations for hoarseness?

Answer 11

if persists longer than 3 weeks - needs direct laryngoscopic evaluation

FBE

ESR/CRP

CXR

TSH

Question 12

Most common pharyngeal or laryngeal malignancy?

Answer 12

SCC

Risk factors:

smoking,

Heavy ETOH intake

less common : immunosupression, exposure to asbestos

Question 13

Hoarseness following a surgery where Endotracheal tube or Laryngeal mask was used?

Answer 13

NEEDS REFERAL to ENT for investigation with flexible laryngoscopy

1. Laryngeal oedema - sponateous recover in 6 weeks
2. Vocal cord granuloma - voice therapy, acid suppression and surgical excision -

Question 14

Causes of intermittent hoarseness?

Answer 14

Gastroesophageal reflux

Post nasal drip

Muscle tension dysphonia (responds well to voice therapy)

Question 15

What vocal problems can bisphosphonates cause?

Answer 15

A chemical laryngitis

Question 16

Clinical Features of BPPV?

Answer 16

More females

All ages (Esp elderly)

Each attack is BRIEF - 10-60seconds (rapid resolution)

Positive Hallpike

Continues for several days

Recovery in weeks

THERE IS NO Vomiting, tinnitus, or deafness

Question 17

Management of BPPV?

Answer 17

1. Reassure that its a benign - recovery in few weeks.
2. Avoid movements that cause dizziness
3. Stemetil 5mg orally three times daily prn
4. Brandt-Daroff exercises three times daily
5. If not settling -referral to physio for epley manoeuvres

Question 18

What is an acoustic neuroma?

Answer 18

Its a benign schawnnoma

Question 19

Sensorineural Deafness, tinnitus and Ataxia?

Answer 19

Acoustic neuroma (ataxia, not actually vertigo)

Question 20

What symptoms can present in an acoustic neuroma?

Answer 20

If only affecting 8th nerve -then sensorineural deafness, tinnitus and fullness of the ear

cerebellum - (cerebellopontine angle) - ATAXIA

but it can spread to involve

5th - numbness in ipsilateral face

6th -diplopia

7th - Facial palsy

Question 21

Investigations for a cerebellopontine angle tumour (acoustic neuroma?)

Answer 21

MRI Brain

Auditory Brainstem Responses

Also do audiometry (as part of your workup)

Question 22

Treatment of acoustic neuroma?

Answer 22

Neurosurgical

Question 23

How can anxiety lead to light headedness?

Answer 23

Hyperventialtion syndrome -

Can have lightheadedness

AND breathing off too much CO2 - respiratory alkalosis - which can lead to hypocalcaemic tetany.

Office test: breathe heavily sitting and walking for 2 minutes. raise hand if dizziness occurs

Mx: Reassure,

Anxiety management

Consciously slow down when this happens

breathe into cupped hands or paper bag

Question 24

Clinical features of MENIERES

Answer 24

Minutes to Hours

Recurrent

VERTIGO and Associated AURAL FULLNESS, TINNITUS, HEARING LOSS
Peripheral nystagmus

Low frequency sensorineural hearing loss

Question 26

Differential diagnosis of peripheral vertigo?

Answer 26

Question 27

Which two types of stroke can give rise to central vertigo?

Answer 27

Vertebrobasillar insufficiency and Posterior cerebellar artery syndrome PICA syndrome **Associated symptoms** - Central nystagmus, dysphagia, hiccoughs, ipsilateral cranial nerve dysfunction, contralateral sensory loss,

Question 28

How can you tell difference between labyrinthitis and vestibular neuronitis?

Answer 28

Both after an URTI both have peripheral vertigo ( few days - 2 weeks) Labyrinthitis - CAN get deafness or tinnitis (labrynths are complex) Vestibular neuronitis - no deafness, no tinnitus, but vertigo after an URTI

Question 29

Central vs Peripheral causes of vertigo

Answer 29

Question 30

What is Rhombergs sign? In a cerebellar infarct - would rhombergs be positive or negative?

Answer 30

If rhombergs is negative (that means the unsteadiness does not worsen with loss of visual input). That means its - cerebellar. If Rhombergs is positive - symptoms worsen with closing eyes - this means peripheral neuropathy (proprioception) or a vestibular problem (brain).

Question 31

key differences between central and peripheral nystagmus?

Answer 31

Visual fixation - suppresses in peripheral, does not suppress in central. Hearing symptoms - tend to be absent in central, and present in peripheral Walking is usually preserved in peripheral and in central they can be unable to walk

Question 32

Investigations in dizziness/vertigo?

Answer 32

1. ECG 2. Office based audiogram 3. Blood sugar Further testing 4. Neuroimaging - if central cause a consideration 5. Audiometry eg Pure tone audiogram ENT specialist would do - Electro nystagmo gram (ENG) VEMP - vestibular evoked myogenic potentials

Question 33

What is the head impulse test?

Answer 33

Test for peripheral versus central lesion. Focus on spot between doctors eyes move head quickly to side - if corrective saccade - positive. - this is indicative of a peripheral lesion

Question 34

Red flags for stroke or central lesion in patient with vertigo?

Answer 34

Vertical nystagmus acute unaccustomed headache inability to stand or walk spontaneous direction changing nystagmus NORMAL head impulse focal neurological signs

Question 35

Dizziness - history questions?

Answer 35

Continuous/episodic? Vertigo? vomiting? hearing loss? tinnitus? visual disturbance? Anxiety/depression? Meds - etoh? antiepileptics? gentamycin head injury? URTI? Neck pain? Neuro symptoms? Ataxia?

Question 36

Dizziness - examination?

Answer 36

General posture? Fever? CVS - BP lying and standing, PR - rate and rhythm, carotid pulses Rhombergs? Cerebellar signs? Full Neuro incl cranial nerves Ear examination Cervical spine examination

Question 37

Differential diagnosis for exertional syncope in young - middle aged ppl?

Answer 37

HOCM AS Arrhythmia (Due to WPW or HOCM) Hyperventialation and anxiety drugs of abuse MS

Question 39

Syncope in older person? DDx

Answer 39

1. Postural hypotension 2. CVS (AMI, AS, Arrhythmia 3. CVS (verteberobasilar insufficency and PICA) 4. Malignancy (primary or secondary - cerebellar or brainstem) 5. WAX in ears 6. MS 7. BPPV, Menieres 8. Acoustic Neuroma

Question 40

Which drugs can cause dizziness?

Answer 40

Antihypertensives Aspirin (salicylates) Quinine Antidepressants Tranquilisers Diuretics

Question 41

Short attacks of vertiginous symptoms with systemic neurological symptoms eg weakness or tingling

Answer 41

Vertebro-basilar insufficency - TIA's in the vertebro-basilar territory DDx - basilar migraine - family history of migraines Urgent referral to Stroke Unit MRI CT angio FBE/Lipids/Glucose/UEC

Question 42

CLinical features of vestibular migraine?

Answer 42

Central cause Vascular phenomenon Lasts minutes to days Can occur with or without a headache only transient neuo signs (when you examine they be normal) Can have triggers Responds to anti migraine therapy FHx of migraines No hearing/auditory features

Question 43

What are the causes of tinnitus?

Answer 43

1. **PRIMARY** 2. **Secondary**: 3. Drug induced (Asprin, salicilyates, gentamycin, quinine) 4. Venous Hums 5. Arterial aneurysms 6. Vascular tumour - glomus tumour (pulsatile) 7. Viral cochleitis 8. Acoustic neuroma (asymetrical hearing loss) Can be pulsatile or continuous

Question 44

What investigations are warranted in tinnitis?

Answer 44

1. **Formal audiological assessment in all** (PTA and Tympanogram) 2. **Unilateral tinnitus or asymetrical SN hearing loss**- needs MRI CPA/IM (cerebellopontine angle and internal acoustic meatus) - ?acoustic neuroma 3. **Pulsatile Tinnitus** - could be vascular anomaly - carotidocavernous or AV fistula or glomus tumour - Needs CT angiogram of head 4. Progressive unilateral **CONDUCTIVE** hearing loss and tinnitus in 3rd or 4th decade - Otosclerosis - CT temporal bone

Question 45

What are the treatments of tinnitus?

Answer 45

If there's hearing loss on audiometric assessment - then refer to audiology for **hearing aids** **Sound therapy** - if distressing (prescribed by audiologist) If there's psycholgical distress - **CBT** is useful