Final ENT Flashcards

Question

What is important to distinguish with a patient who presents with vertigo? [1] How do you do this? [1]

Answer 1

It is **essential to differentiate between peripheral (inner ear) and central (brain) causes** when a patient presents with **vertigo**. **Any neurological signs or symptoms should make you consider a central** cause of **vertigo** rather than **vestibular neuronitis**. This may require urgent management, particularly if **posterior circulation infarction (stroke) is suspected.**

Answer 2

The head impulse test involves the patient sitting upright and fixing their gaze on the examiner’s nose. The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose. The head is slowly moved back to the centre before repeating in the opposite direction. Ensure they have no neck pain or pathology before performing the test. A patient with a normally functioning vestibular system will keep their eyes fixed on the examiner’s nose. In a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis), the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner. The head impulse test helps diagnose a peripheral cause of vertigo but will be normal if the patient has no current symptoms or a central cause of vertigo.

Answer 3

**Patients may need admission** if they are becoming **dehydrated due to severe nausea and vomiting.** For peripheral vertigo, short-term options for managing symptoms include: * **Prochlorperazine** (buccal / IM) * **Antihistamines** (e.g., **cyclizine, cinnarizine and promethazine**) **NICE advise that symptomatic treatment can be used for up to 3 days.** More extended use may slow down the recovery.

Answer 4

NICE also recommend **referral if the symptoms do not improve after 1 week or resolve after 6 weeks**, as they may require further investigation or **vestibular rehabilitation therapy (VRT).**

Answer 5

posterior circulation stroke: the **HiNTs** exam can be used to distinguish vestibular neuronitis from posterior circulation stroke **PoCS** is a **central cause of vertigo**, whereas **vestibular** **neuronitis** is a **peripheral cause of vertigo.** * In **peripheral causes you have abnormal head impulse and none or unidirectional nystagmus**, and **no findings on test of skew**. I always think abnormal, normal, normal = peripheral. * In **central** you have a **normal head impulse** (which is actually a really bad finding), a **bidirectional or vertical nystagmus, and a vertical skew.** So, normal abnormal, abnormal = central. Central causes are worse than peripheral and require acute, time-sensitive management.

Answer 6

HiNTS exam is composed of 3 tests: **head impulse test + assess nystagmus + test of skew**

Answer 7

**Peripheral vertigo:** - abnormal head impulse test (catch-up saccade) - no/unidirectional nystagmus - no vertical skew **Central vertigo:** - normal head impulse test - vertical/saccadic/bidirectional nystagmus - vertical skew

Answer 8

The first step in investigating suspected cholesteatoma is **Otoscopy**. - This allows direct visualisation of the tympanic membrane and middle ear, which can r**eveal signs suggestive of cholesteatoma such as retraction pockets, perforations or white keratin debris**. - However, otoscopy alone may not be sufficient to confirm the diagnosis due to limitations in visualising deep structures of the ear. **Audiometry** is another essential first-line investigation that provides information about hearing function. **It can identify conductive, sensorineural or mixed hearing loss associated with cholesteatoma**. - **Pure tone audiometry (PTA)** is typically used for this purpose. **A CT head** can be used to **confirm the diagnosis** and plan for surgery. MRI may help assess invasion and damage to local soft tissues.

Answer 9

**Chronic Otitis Media with Effusion (COME)** * COME is characterised by a persistent middle ear effusion for more than three months without signs of infection. **Unlike cholesteatoma, COME usually presents bilaterally** and is common in children. * Clinically, patients may report hearing loss or aural fullness but lack the **recurrent otorrhoea seen in cholesteatoma**

Answer 10

**Surgical Management** * **Canal Wall Up (CWU) Mastoidectomy:** This procedure aims to eradicate the disease while preserving the posterior canal wall. It has a lower rate of post-operative cavity problems but a higher recurrence risk. * **Canal Wall Down (CWD) Mastoidectomy:** This approach offers better disease eradication but results in a mastoid cavity that requires regular cleaning.

Answer 11

**Ossicular chain erosion**: This is the most frequent complication, leading to conductive hearing loss. The incus is usually the first ossicle to be affected . also **Labyrinthitis**: Cholesteatoma can erode into the labyrinth leading to sensorineural hearing loss, vertigo or both.

Answer 12

**Meningitis**: This is a serious complication that results from direct spread of infection through dural erosion. It presents with symptoms like headache, fever, neck stiffness and photophobia. **Brain abscess:** This occurs due to spread of infection into the brain parenchyma. Symptoms include focal neurological deficits and altered mental status . **Sigmoid sinus thrombosis:** Thrombus formation in the sigmoid sinus can lead to increased intracranial pressure presenting as headaches, vomiting and seizures.

Answer 13

If **antibiotics** are indicated or a patient is unable to attend a dentist amoxicillin or **phenoxymethylpenicillin** are **first line** (clarithromycin if there is a history of true penicillin allergy). - If the i**nfection is severe or spreading**, or the patient has systemic signs of infection **metronidazole should also be prescribed.** Analgesia may be necessary: ibuprofen and paracetamol are first-line (if not contraindicated).

Answer 14

**Auditory symptoms:** These are the most common presenting features. They include: * **Hearing loss:** This is typically mild to moderate, bilateral and conductive in nature. It may be fluctuating depending on the severity and chronicity of middle ear effusion. * **Tinnitus**: Some patients, especially older children and adults, may complain of ringing or buzzing noises in the ears. **Non-auditory symptoms:** These are less specific but can provide additional clues towards the diagnosis: * **Speech and language delay**: Particularly in younger children where early detection and intervention are paramount for normal development. * **Behavioural changes:** Including reduced attention span, frustration or irritability due to difficulty in hearing. * **Balance problems**: Rarely, patients might report episodes of imbalance or clumsiness due to vestibular involvement. ## Footnote NB: glue ear presents with hearing loss or speech delay without signs of acute inflammation

Answer 15

**Chronic Suppurative Otitis Media (CSOM):** - CSOM is defined as **persistent purulent otorrhoea through a perforated tympanic membrane for more than two weeks**. It **differs from OME** in its chronicity and **presence** of **active** infection. - The most common symptom is a **continuous foul-smelling discharge from the affected ear** - **Hearing loss** may also occur due to damage to the ossicles or cochlea but it's typically more severe than in glue ear. - **Otoscopic findings include a perforated tympanic membrane and purulent discharge within the middle ear or external auditory canal.**

Answer 16

**Conservative Management** **Watchful waiting**: In the majority of cases, glue ear resolves spontaneously within three months without intervention. Therefore, watchful waiting is often recommended as the initial management approach for uncomplicated cases. During this period, it is essential to monitor the patient's symptoms and provide regular follow-up appointments to assess changes in hearing status. **Medical treatment:** - While there is limited evidence supporting pharmacological interventions for glue ear, some studies suggest that systemic or topical nasal corticosteroids may have a modest effect on resolution rates. However, these benefits should be weighed against potential side effects before prescribing such treatments. **Autoinflation**: - Encouraging patients to perform autoinflation techniques such as Valsalva manoeuvre or Politzerisation may help improve Eustachian tube function and promote resolution of glue ear; however, further research is needed to confirm their efficacy. **Surgical intervention may be considered if conservative management fails or if there are complications such as persistent hearing loss or recurrent acute otitis media episodes**. **Myringotomy and grommet insertion:** - This procedure involves making a small incision in the tympanic membrane (myringotomy) and inserting a ventilation tube (grommet) into the middle ear to equalise pressure and facilitate drainage of accumulated fluid. Grommets typically fall out spontaneously after 6-12 months, during which time they must be monitored for complications such as otorrhoea, tympanic membrane perforation or scarring. **Adenoidectomy**: - In cases of recurrent glue ear or when concurrent adenoidal hypertrophy is present, adenoidectomy may be beneficial in reducing the frequency of otitis media episodes by improving Eustachian tube function. **Tympanostomy and balloon dilation:** - This procedure involves inserting a tympanostomy tube through the eardrum and inflating a small balloon to dilate the Eustachian tube. While some studies have shown promising results, further research is required to establish its efficacy and safety profile.

Answer 17

**Most likely complications:** **Hearing loss:** The presence of a thick, sticky fluid in the middle ear can cause **conductive hearing loss**. This is usually **temporary but chronic OME may result in permanent damage to the middle ear structures** leading to long-term hearing impairment. **Speech and language delay**: Prolonged periods of hearing loss in children can lead to delays in speech and language development. This may have further impacts on academic performance and social interaction.

Answer 18

However, **nocturnal symptoms are more common in LPR** than in GERD due to the **absence of swallowing during sleep** which normally helps clear any refluxate from the oesophagus.

Answer 19

Management * lifestyle measures * possible triggers include fatty foods, caffeine, chocolate and alcohol * proton pump inhibitor * sodium alginate liquids (e.g. Gaviscon)

Answer 20

**Risk Factor Modification:** * **Smoking Cessation**: Encourage patients to quit smoking through counselling, nicotine replacement therapy or pharmacological interventions. * **Alcohol Reduction**: Advise patients on reducing alcohol intake within recommended limits. **Biopsies** are usually performed to **exclude alternative diagnoses such as squamous cell carcinoma and regular follow-up is required to exclude malignant transformation** to squamous cell carcinoma, which occurs in around 1% of patients.

Answer 21

**Ludwig's angina** is a type of **progressive cellulitis that invades the floor of the mouth and soft tissues of the neck**. Most cases result from **odontogenic infections** which spread into the submandibular space. It is a **life-threatening emergency as airway obstruction can occur rapidly as a result**. Urgent medical treatment and airway assessment is required.

Answer 22

For acute attacks, short-term options for managing symptoms include: * **Prochlorperazine** * **Antihistamines** (e.g., cyclizine, cinnarizine and promethazine) Prophylaxis is with: * **Betahistine**

Answer 23

Uncommon type of otitis externa that is found in **immunocompromised individuals (90% cases found in diabetics)** - Infective organism is usually **Pseudomonas aeruginosa** Infection **commences** in the soft tissues of the **external auditory meatus**, then **progresses to involve the soft tissues and into the bony ear canal** - Progresses to **temporal bone osteomyelitis** Pulsenotes: - **Malignant otitis externa is a serious condition where infection spreads from the external auditory canal to the skull base.**

Answer 24

* **Diabetes** (90%) or immunosuppression (illness or treatment related) * **Severe, unrelenting, deep-seated otalgia** * **Temporal headaches** * **Purulent otorrhea** * **Possibly dysphagia, hoarseness, and/or facial nerve dysfunction**

Answer 25

**Cranial Nerve Involvement**: The most common complication, often starting with the **facial nerve** (cranial nerve VII), leading to **facial palsy**. Other cranial nerves such as IX, X, XI, and XII may also be affected.

Answer 26

**Mastoiditis** is inflammation of the **mastoid antrum and the lining of the mastoid air cells** - **mastoid process** is the area of **bone formed of the petrous temporal and occipital bones** which is **present posterior and inferior to the external auditory meatus**

Answer 27

The key features usually found in the history are: * **Recent** or **concurrent acute otitis media** in around 50% of cases. * **Deep** **otalgia** on the **affected** side in nearly all cases. * **Recent loss of hearing** (progressive) on affected side. * **Generally unwell** with young children often not eating or drinking as normal. * **Seizures and symptoms of intracranial infection** are rarely the presenting symptoms.

Answer 28

They key findings on examination are: **Fever**. **Usually bulging tympanic membrane** with **clear fluid level** or **perforation with purulent discharge from the ear.** **Erythema** and **swelling** over **mastoid process behind the ear in up to 75% of cases.** **Mastoid tenderness.** **Cervical lymphadenopathy** on affected side.

Answer 29

**Inverted papilloma** is a **benign** **tumour** that arises from the **lateral nasal wall and paranasal sinuses**. In contrast to the smooth appearance of nasal polyps, inverted papillomas are often **irregular and lobulated.**

Answer 30

**Medical management** * Initial management typically involves **topical** **corticosteroids** to reduce inflammation. * **Oral corticosteroids** may be considered in severe cases or if topical treatment is ineffective. * **Intranasal saline irrigations** can aid in symptomatic relief. **Surgical intervention** * **Endoscopic sinus surgery (ESS)** is the preferred surgical method for removing nasal polyps. Surgery should be considered if medical therapy fails or in case of complications such as mucoceles or orbital involvement. **Biological therapies** * Newer biological therapies targeting specific inflammatory pathways (e.g., anti-IL5, anti-IL4Rα) may be considered in refractory cases.

Answer 31

**Intranasal polypectomy** is used where the polyps are **visible close to the nostrils** **Endoscopic nasal polypectomy** is used where the **polyps** are **further in the nose or the sinuses**

Answer 32

**Mild otitis externa** may be treated with **acetic acid 2%** (available over the counter as EarCalm). Acetic acid has an antifungal and antibacterial effect. This can also be used prophylactically before and after swimming in patients that are prone to otitis externa. **Moderate otitis externa** is usually treated with a **topical antibiotic and steroid** An **ear wick** may be used if the **canal is very swollen, and treatment with ear drops or sprays will be difficult** - An ear wick is made of sponge or gauze. They contain topical treatment for otitis externa (e.g., antibiotics and steroids). Wicks are inserted into the ear canal and left there for a period of time (e.g., 48 hours). As the swelling and inflammation settle, the ear wick can be removed, and treatment can continue with drops or sprays. **Fungal infections** can be treated with **clotrimazole ear drops.**

Answer 33

The typical presentation is a patient **under 40 years** presenting with **unilateral or bilateral:** * **Hearing loss** * **Tinnitus** It tends to affect the **hearing of lower-pitched sounds** more than **higher-pitched sounds**. Female speech may be easier to hear than male speech (due to the generally higher pitch). This is the reverse of the pattern seen in presbycusis. Due to **conductive hearing loss with intact sensory hearing**, the patient **can experience their voice as being loud compared to the environment** (due to bone conduction of their voice). **This can lead to them talking quietly.**

Answer 34

**Audiometry is the initial investigation of choice**. - Otosclerosis will show a **conductive hearing loss pattern.** - **Bone conduction readings** will be **normal** (between 0 and 20 dB). - However, **air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart.** - Hearing loss tends to be greater at lower frequencies. **Tympanometry** will show **generally reduced admittance (absorption) of sound**. The tympanic membrane is stiff and non-compliant and does not absorb sound, reflecting most of it back. **High-resolution CT** scans can detect boney changes associated with otosclerosis, although they are not always required.

Answer 35

The options for management are: **Conservative**, with the use of **hearing aids** **Surgical** (stapedectomy or stapedotomy): * **Stapedectomy** involves removing the entire stapes bone and replacing it with a prosthesis. The prosthesis attaches to the oval window and hooks around the incus, transmitting the sound from the incus to the cochlea in the same way the stapes normally would. * **Stapedotomy** involves removing part of the stapes bone and leaving the base of the stapes (the footplate) attached to the oval window. A small hole is made in the base of the stapes for the prosthesis to enter. A prosthesis is added to transmit sound from the incus to the cochlea.

Answer 36

**Antibiotic therapy:** - **Empirical antibiotics** are **initiated** **before** **culture** results are available. - The first-line treatment typically includes a **penicillin combined with a beta-lactamase inhibitor.** **Analgesia**: - Pain management is crucial due to severe sore throat associated with quinsy. Non-steroidal anti-inflammatory drugs (NSAIDs) or paracetamol can be used for this purpose. **Steroids**: - While not universally agreed upon, some clinicians advocate for the use of steroids to reduce inflammation and potentially expedite recovery. **Surgical Management** - **Needle aspiration**: This is often the f**irst line surgical intervention**, especially if there is significant trismus preventing oral examination. - **Intraoral incision and drainage:** This procedure may be performed if needle aspiration fails or if the abscess is large. * **Quinsy tonsillectomy:** This is a more radical approach and is usually reserved for recurrent cases or if other interventions fail. The procedure involves removal of the tonsil along with the abscess.

Answer 37

When a patient presents with sudden onset hearing loss it is important to examine them carefully to differentiate between conductive and sensorineural hearing loss → sudden-onset sensorineural hearing loss (SSNHL) requires urgent referral to ENT. The majority of **SSNHL** cases are **idiopathic**. An **MRI scan** is usually performed to exclude a **vestibular schwannoma** **High-dose oral corticosteroids** are used by ENT for all cases of SSNHL.

Answer 38

**Cetuximab** is an example of a monoclonal antibody used in treating squamous cell carcinomas of the head and neck. It may also be used to treat bowel cancer. It targets epidermal growth factor receptor, blocking the activation of this receptor and inhibiting the growth and metastasis of the tumour.

Answer 39

The classical history of vestibular schwannoma includes a combination of vertigo, hearing loss, tinnitus and an absent corneal reflex. Features can be predicted by the affected cranial nerves: * **cranial nerve VIII**: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus * **cranial nerve V**: absent corneal reflex * **cranial nerve VII:** facial palsy

Final ENT Flashcards

(63 cards)