L1 History and Physical Exam

Question 1

NB points in ENT History?

Answer 1

PC - location, duration, frequency, quality. Agg and alliev factors. Associated symptoms (fever, chills, cough, heartburn, dizziness etc)

Question 2

5 things to ask about the ear?

Answer 2

tinnitus, otalgia, otorrhea, hearing loss, vertigo

Question 3

Unilateral ear pain Red flag?

Answer 3

if looks normal NB look in mouth, throat and refer to ENT for scope particularly if smoker or drinker… could be referred pain from malignancy etc

Question 4

5 things to ask about face?

Answer 4

swelling, pain, numbness (CN 5), cranial nerve dysfunction

Question 5

To ask about the nose?

Answer 5

“congestion, rhinorrhea, post-nasal drip,
epistaxis, impaired smell, facial pain. Unilateral symptoms / eye symptoms = red flag (complications of infection/malignancy), anosmia (no smell), hyposmia (reduction of smell)
“

Question 6

To ask about Sinuses

Answer 6

pressure and pain

Question 7

To ask about Throat?

Answer 7

odynophagia, dysphagia, globus sensation, throat clearing

Question 8

To ask about the larynx?

Answer 8

voice changes, weakness, hoarseness, stridor, dyspnea

Question 9

inspiratory stridor suggests?

Answer 9

obstruction at level of glottus or above

Question 10

expiratory stridor suggests?

Answer 10

lower resp issue more so

Question 11

biphasic stridor

Answer 11

obstruction at glottus or below

Question 12

What is otaligia?

Answer 12

“Pain of the ear

primary = from inside the ear
secondary = from outside the ear”

Question 13

What is otorrhea?

Answer 13

Drainage of liquid from the ear

Question 14

What is post nasal drip?

Answer 14

Postnasal drip is when more mucus than normal gathers and drips down the back of your throat. You may feel like you have a tickle in the back of your throat. Postnasal drip can be a bothersome condition that can lead to a chronic cough. The glands in your nose and throat are constantly making mucus.

Question 15

What is epistaxis?

Answer 15

The medical name for a nose bleed

Question 16

What are nasal red flag associated symptoms?

Answer 16

“Unilateral symptoms
eye symptoms “

Question 17

What is odynophagia?

Answer 17

Pain on swallowing

Question 18

What is globus sensation?

Answer 18

Globus pharyngis or globus sensation is the persistent but painless sensation of having a pill, food bolus, or some other sort of obstruction in the throat when there is none. Swallowing is typically performed normally, so it is not a true case of dysphagia, but it can become quite irritating.

Question 19

What is stridor?

Answer 19

High pitched wheezing sound caused by obstructed airways

Question 20

What are the components of an ear exam?

Answer 20

“1. Clean hands, intro, consent, check for oralgia
2. Inspect: Pinna, post and pre auricular area
3. Otoscopy: Ear canal, tympanic membrane
4. Tuning fork tests
5. Whisper test”

Question 21

What is an otoscopy?

Answer 21

“Medical device to look inside the ears. Potentiall gives a view of the ear canal and tympanic membrane or eardrum. The TM is the border separating the external ear canal from the middle ear and its characteristics can be indicative of various diseases of the middle ear. The presence of Cerumen (earwax), shed skin, pus, canal skin oedema, foreign body and various diseases can obscure the view of the eardrum but confirm the presence of obstructing symptoms.

examine eustachian tube function with the valsava maneouvre “

Question 22

What diseases may be diagnosed by an otoscope?

Answer 22

Otitis media (infection of the middle ear) and otitis externa

Question 23

What is an auricular haematoma?

Answer 23

“An auricular haematoma refers to a collection of blood between the cartilage of the ear and the overlying perichondrium. It is usually occurs as a result of trauma, commonly seen in contact sports (e.g. rugby).

The accumulation of blood can disrupt the blood supply to the cartilage, and requires prompt drainage. Untreated cases can result in avascular necrosis of the cartilage, resulting in a ‘cauliflower ear’ deformity.”

Question 24

What is the external acoustic meatus?

Answer 24

“a sigmoid shaped tube that extends from the deep part of the concha to the typanic membrane. The external 1/3 is made up of cartilage and the inner 2/3 are formed of temporal bone.

S shaped curve as follows:
1. initially travels in superoanterior direction
2. then turns slightly to move superoposteriorly
3. then ends by running in an inferoanterior direction “

Question 25

What is the tympanic membrane?

Answer 25

lies at the distal end of the external acoustic meatus. It is a connective tissue structure covered with skin on the outside and a mucous membrane on the inside. The membrane is connected to the surrounding termporal bone by a fibrocartilaginous ring. It is translucent so the structures within the middle ear can be observed during otoscopy.

Question 26

What is perforation of the tympanic membrane?

Answer 26

"The tympanic membrane is a relatively thin connective tissue structure, and is susceptible to perforation (usually by trauma or infection). An infection of the middle ear (otitis media) causes pus and fluid to build up behind the tympanic membrane. This causes an increase in pressure within the middle ear, and eventually the eardrum can rupture. In some cases the tympanic membrane heals itself, but in larger perforations surgical grafting may be required."

Question 27

How to describe a tympanic membrane perforation?

Answer 27

1. Size - pinhole, small, large 2. Location - quadrant, central vs marginal 3. Effusion - dry vs wet

Question 28

What is the vascular supply to the external ear?

Answer 28

"The external ear is supplied by branches of the external carotid artery: Posterior auricular artery Superficial temporal artery Occipital artery Maxillary artery (deep auricular branch) – supplies the deep aspect of the external acoustic meatus and tympanic membrane only. Venous drainage is via veins following the arteries listed above."

Question 29

What are the borders of the middle ear?

Answer 29

"The middle ear can be visualised as a rectangular box, with a roof and floor, medial and lateral walls and anterior and posterior walls. Roof – formed by a thin bone from the petrous part of the temporal bone. It separates the middle ear from the middle cranial fossa. Floor – known as the jugular wall, it consists of a thin layer of bone, which separates the middle ear from the internal jugular vein Lateral wall – made up of the tympanic membrane and the lateral wall of the epitympanic recess. Medial wall – formed by the lateral wall of the internal ear. It contains a prominent bulge, produced by the facial nerve as it travels nearby. Anterior wall – a thin bony plate with two openings; for the auditory tube and the tensor tympani muscle. It separates the middle ear from the internal carotid artery. Posterior wall (mastoid wall) – it consists of a bony partition between the tympanic cavity and the mastoid air cells. Superiorly, there is a hole in this partition, allowing the two areas to communicate. This hole is known as the aditus to the mastoid antrum."

Question 30

What is the function of the auditory tube?

Answer 30

"The auditory tube (eustachian tube) is a cartilaginous and bony tube that connects the middle ear to the nasopharynx. It acts to equalise the pressure of the middle ear to that of the external auditory meatus. It extends from the anterior wall of the middle ear, in an anterior, medioinferior direction, opening onto the lateral wall of the nasopharynx. In joining the two structures, it is a pathway by which an upper respiratory infection can spread into the middle ear. The tube is shorter and straighter in children, therefore middle ear infections tend to be more common in children than adults."

Question 31

What is otitis media with effusion?

Answer 31

"Otitis media with effusion is commonly known as glue ear. It arises from persistent dysfunction of the auditory tube. If the auditory tube is unable to equalise middle ear pressure (due to blockage, inflammation, genetic mutation), a negative pressure develops inside the middle ear This negative pressure draws out a transudate from the mucosa of the middle ear, creating an environment suitable for pathogens to replicate and cause infection. Upon inspection of a patient with otitis media with effusion, the eardrum will appear inverted, with fluid visible inside the ear."

Question 32

What is mastoiditis?

Answer 32

"Middle ear infections (otitis media) can spread to the mastoid air cells. Due to their porous nature, they are a suitable site for pathogenic replication. The mastoid process itself can get infected, and this can spread to the middle cranial fossa, and into the brain, causing meningitis. If mastoiditis is suspected, the pus must be drained from the air cells. When doing so, care must be taken not to damage the nearby facial nerve. (+ culture)"

Question 33

Whats Webers test

Answer 33

" It can detect unilateral (one-sided) conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss). Strike tuning fork and place on the base of the forhead. Ask if the sound is heard, in the middle of the head or both ears equally, towards the left or right. "

Question 34

What is conductive hearing loss?

Answer 34

Conductive hearing loss (CHL) occurs when there is a problem transferring sound waves anywhere along the pathway through the outer ear, tympanic membrane (eardrum), or middle ear (ossicles).

Question 35

What is sensorineural hearing loss?

Answer 35

"Sensorineural hearing loss (SNHL) is a type of hearing loss in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or the vestibulocochlear nerve (cranial nerve VIII). SNHL accounts for about 90% of reported hearing loss[citation needed]. SNHL is usually permanent and can be mild, moderate, severe, profound, or total. Various other descriptors can be used depending on the shape of the audiogram, such as high frequency, low frequency, U-shaped, notched, peaked, or flat. Sensory hearing loss often occurs as a consequence of damaged or deficient cochlear hair cells.[disputed – discuss] Hair cells may be abnormal at birth or damaged during the lifetime of an individual. There are both external causes of damage, including infection, and ototoxic drugs, as well as intrinsic causes, including genetic mutations. A common cause or exacerbating factor in SNHL is prolonged exposure to environmental noise, or noise-induced hearing loss. Exposure to a single very loud noise such as a gun shot or bomb blast can cause noise-induced hearing loss. Using headphones at high volume over time, or being in loud environments regularly, such as a loud workplace, sporting events, concerts, and using noisy machines can also be a risk for noise-induced hearing loss. Neural, or ""retrocochlear"", hearing loss occurs because of damage to the cochlear nerve (CVIII). This damage may affect the initiation of the nerve impulse in the cochlear nerve or the transmission of the nerve impulse along the nerve into the brainstem."

Question 36

"How do you interpret a webers test? Normal? "

Answer 36

"Symmetric hearing = normal tone is heard centrally or bilaterally "

Question 37

Conductive hearing loss?

Answer 37

heard at one side at the affected ear

Question 38

Sensorineural hearing loss?

Answer 38

Heard at one side to the better ear

Question 39

Whats Rinne's test?

Answer 39

"Primarily used to evaluate for hearing loss in one ear by comparing the perception of sound through bone conduction on mastoid to air conduction. Quick screening tool for conductive hearing loss. BC: Strike the fork and hold the base pressed against the mastoid for 2 seconds AC: immediately transfer the fork placing the tips of the tines in line with the axis of EAC"

Question 40

Rinnes test Interpretation: AC is louder than BC?

Answer 40

"Rinnes positive normal ears & most SNHL"

Question 41

Rinnes test Interpretation: BC is louder than AC

Answer 41

"Rinnes negative significant conductive element "

Question 42

Whisper test

Answer 42

"Stand arm’s length (60cm) behind the seated patient so they cannot read your lips. Rub tragus to mask non-tested ear Whisper bisyllabic numbers = 12dB Will need 2/3 correct Fail --- increase voice to conversational 50dB Fail --- loud 75dB Fail --- move closer 15 cm --- whisper 35dB Fail --- conversational 55dB "

Question 43

Answer 43

"saddle nose deformity causes trauma, untreated septal haematoma, iatrogenic if we over ressect the cartilage in a septoplasty overtime this happens, medical causes congenital, wegners, GPA, malignancy"

Question 44

Answer 44

"tip ptosis (saggy tip) dorsal hump "

Question 45

Answer 45

"Rhinophyma cause unknown subtype of severe rosacea BCCs can hide in it "

Question 46

Answer 46

Telangiectasias Hereditary Hemorrhagic Telangiectasias

Question 47

Exam Q What are the 6 subsites of the oral cavity?

Answer 47

"Buccal mucosa Alveolar margins + gingiva upper Alveolar margins + gingiva lower Hard palate Floor of mouth Anterior 2/3 Tongue Lips Retromolar trigones "

Question 48

The boundaries of the anterior triangle of the neck are:

Answer 48

Superior: the inferior border of the mandible. Medial: the midline of the neck. Lateral: the anterior border of the sternocleidomastoid.

Question 49

The boundaries of the posterior triangle of the neck are:

Answer 49

Anterior: the posterior margin of the sternocleidomastoid muscle. Posterior: the anterior margin of the trapezius muscle. Inferior: the middle one-third of the clavicle.

Question 50

What to look for when assessing a neck lump

Answer 50

"Ss Site Size Shape Surface (skin) Surround (skin) Ts Tender Transluminable Temperature Fs Fluctuance Fixed Fields "

Question 51

neck lump is soft?

Answer 51

cyst

Question 52

neck lump is hard?

Answer 52

malignancy

Question 53

neck lump is rubbery?

Answer 53

lymph node

Question 54

lump is fluid filled?

Answer 54

cyst

Question 55

lump is warm?

Answer 55

increased warmth may suggest an inflammatory or infective cause (e.g. infected epidermoid cyst).

Question 56

neck mass is pulsating?

Answer 56

suggests vascular origin (e.g. carotid body tumour, aneurysm).

Question 57

neck mass is tender?

Answer 57

may indicate infective and/or inflammatory aetiology (e.g. ruptured epidermoid cyst, infected cyst).

Question 58

apply a light source to the lump, if it is illuminated it suggests

Answer 58

the lump is fluid-filled (e.g. cystic hygroma).

Question 59

auscultate the lump to listen for a bruit suggestive of

Answer 59

vascular aetiology (e.g. carotid artery aneurysm).

Question 60

1. Start under the chin (1), then move posteriorly palpating beneath the mandible (submandibular), turn upwards at the angle of the mandible (tonsillar and parotid lymph nodes) and feel anterior (preauricular lymph nodes) and posterior to the ears (posterior auricular lymph nodes). 2. Follow the anterior border of the sternocleidomastoid muscle (anterior cervical chain) down to the clavicle, then palpate up behind the posterior border of the sternocleidomastoid (posterior cervical chain) to the mastoid process. 3. Palpate over the occipital protuberance (occipital lymph nodes). 4. Ask the patient to tilt their head (bring their ear towards their shoulder) each side in turn, and palpate behind the posterior border of the clavicle in the supraclavicular fossa (supraclavicular and infraclavicular lymph nodes).

Answer 60

submental lymph nodes

Question 61

1. Start under the chin (submental lymph nodes), then move posteriorly palpating beneath the mandible (2), turn upwards at the angle of the mandible (2b) and feel anterior (preauricular lymph nodes) and posterior to the ears (posterior auricular lymph nodes). 2. Follow the anterior border of the sternocleidomastoid muscle (anterior cervical chain) down to the clavicle, then palpate up behind the posterior border of the sternocleidomastoid (posterior cervical chain) to the mastoid process. 3. Palpate over the occipital protuberance (occipital lymph nodes). 4. Ask the patient to tilt their head (bring their ear towards their shoulder) each side in turn, and palpate behind the posterior border of the clavicle in the supraclavicular fossa (supraclavicular and infraclavicular lymph nodes).

Answer 61

submandibular tonsillar and parotid lymph nodes

Question 62

1. Start under the chin (submental lymph nodes), then move posteriorly palpating beneath the mandible (submandibular), turn upwards at the angle of the mandible (tonsillar and parotid lymph nodes) and feel anterior (preauricular lymph nodes) and posterior to the ears (posterior auricular lymph nodes). 2. Follow the anterior border of the sternocleidomastoid muscle (3) down to the clavicle, then palpate up behind the posterior border of the sternocleidomastoid (3b) to the mastoid process. 3. Palpate over the occipital protuberance (occipital lymph nodes). 4. Ask the patient to tilt their head (bring their ear towards their shoulder) each side in turn, and palpate behind the posterior border of the clavicle in the supraclavicular fossa (supraclavicular and infraclavicular lymph nodes).

Answer 62

anterior cervical chain posterior cervical chain

Question 63

What are the levels of the neck

Answer 63

Level I, submental (IA) and submandibular (IB); level II, upper internal jugular nodes; level III, middle jugular nodes; level IV, low jugular nodes; level V, posterior triangle nodes; level VI, central compartment; level VII, superior mediastinal nodes.