MRCS ENT Flashcards
1
Q
Criteria for treatment of glue ear?
A
Hearing level in better ear of 25db-30db or worse averaged at 500, 1000, 2000 and 4000 Hz for more than 3 months
2
Q
Management options for glue ear? (3)
A
Watchful waiting 3-6 months
Hearing aid
Grommet +/- adenoidectomy
3
Q
Which muscle opens the eustachian tube when swallowing?
A
Tensor veli palatini
4
Q
What is Trotter’s triad?
A
Decreased mobility of ipsilateral palate due to direct infiltration, glue ear due to involvement of eustachian tube, pain in trigeminal area due to trigeminal nerve irritation
5
Q
Presentation of NPC?
A
Trotters triad, neck nodes
6
Q
Which structure is thought to rupture in meniere’s disease?
A
Reissner’s membrane (vestibular membrane)
7
Q
List 4 symptoms of a vestibular schwannoma?
A
Unilateral hearing loss, unilateral tinnitus, vertigo, facial pain due to trigeminal nerve involvement
8
Q
Management of vestibular schwannoma?
A
Watchful waiting with serial MRI scans
Stereotactic surgery (gamma knife)
Surgery
9
Q
What are the 3 surgical approaches to vestibular schwannoma?
A
Middle cranial fossa
Translabyrinthine/transmastoid
Retrosigmoid/suboccipital
10
Q
Which investigation to rule out glandular fever?
A
Paul-Bunnell or Monospot test
11
Q
Which antibiotic to avoid in EBV and why?
A
Amoxicillin - type IV hypersensitivity reaction rash
12
Q
SIGN guidelines for tonsillectomy due to recurrent tonsillitis?
A
7 episodes/1 year
5 episodes/2 consecutive years
3 episodes/3 consecutive years
13
Q
List three ways in which a tonsillectomy can be performed?
A
Cold steel dissection
Bipolar diathermy
Coblation
Laser
14
Q
List 4 instruments used in a tonsillectomy
A
Boyle-Davis mouth gag with Doughty split tongue blade
Draffin rods
Dennis-Browne tonsil holding forceps
Mollison pillar retractor
15
Q
Management of subperiosteal abscess? (Orbital cellulitis)
A
IV antibiotics as per hospital’s antimicrobial policy
Nasal decongestants and steroid drops
Urgent ophthalmology review and regular eye observations
Surgery - open ethmoidectomy via modified Lynch Howarth incision
If any maxillary sinus disease to perform endoscopic maxillary antrostomy at the same time
Take pus swabs for cultures
16
Q
List at least 2 intracranial complications of orbital abscess?
A
Epidural empyema
Subdural empyema
Cerebral abscess
Venous thrombosis
Osteomyelitis
17
Q
Where is Killian’s dehiscence?
A
Between thyropharyngeus and cricopharyngeus
18
Q
Name 5 presenting symptoms of Zenker’s diverticulum?
A
Dysphagia
Halitosis
Regurgitation of undigested food
Weight loss
Cough
Recurrent chest infection due to aspiration
Neck lump
19
Q
Management of pharyngeal pouch?
A
Conservative
Open surgery
Endoscopic stapling
20
Q
Define stridor
A
Noise from disrupted airflow due to partial obstruction of the respiratory tract at or below the larynx
21
Q
List 5 causes of stridor
A
Laryngomalacia, laryngeal web, laryngeal cyst
Vocal cord paralysis
Subglottic stenosis
Epiglottitis
Foreign body
Allergy
Neoplasia (benign or malignant)
22
Q
Describe the initial management of stridor
A
Humidified O2
Nebulised adrenaline (1ml 1:1000 in 2ml NACL)
Heliox (21%oxygen and 79% helium - generates less airway resistance than air so reduced work of breathing)
Dexamethasone
23
Q
Describe the landmarks for an elective tracheostomy
A
Horizontal incision made halfway between cricoid cartilage and suprasternal notch, lateral borders of incision are marked by medial borders of SCM
24
Q
Tests you can perform on fluid to check for CSF?
A
Glucose
Beta-2 transferrin
Beta-trace protein
25
Otoscopy findings in temporal bone fractures? 3
Haemotympanum
Stepping of EAC
Traumatic TM perforation
26
5 symptoms of a cholesteatoma?
Recurrent foul smelling otorrhoea
Hearing loss
Tinnitus
Vertigo/dysequilibrium
Pain
Facial nerve weakness
27
5 complications of chloesteatoma if left untreated?
Hearing loss (conductive/SN/mixed)
Facial nerve palsy
Vertigo
Cerebral abscess
Meningitis
28
Management of cholesteatoma?
Get a baseline PTA
Get a CT temporal bones - optional
Conservative - regular aural toiler, topical ear drops +/- steroids
Surgery - atticotomy, combined approach tympanoplasty, modified radical mastoidectomy
29
List 4 complications of parotidectomy
Frey's syndrome (gustatory sweating)
Numbness to lower half of pinna due to division of great auricular nerve
Salivary fistula
Facial weakness
Bleeding
Haematoma
Infection
Scar
30
Explain the pathophysiology of Frey's syndrome
Neo-innervation of parasympathetic secretomotor nerves distributed via auriculotemporal nerve into sympathetic fibres supplying facial sweat glands
31
List 5 conditions which may cause parotid enlargement
Viral parotitis - mumps, HIV related lymphocytic infiltration, parainfluenza, parovirus B19
Acute and chronic bacterial parotitis (usually staph aureus)
Stone in salivary duct
Neoplasia (benign or malignant)
Autoimmune - Sjogrens syndrome
Sarcoidosis
32
Where do you find the parotid duct opening?
Buccal mucosa, opposite 2nd upper molar tooth
33
List two differential diagnosis of a thyroglossal duct cyst
Dermoid cyst
Thyroid goitre
34
Which investigations can you perform for a thyroglossal duct cyst?
TFTs
US neck
MRI/CT neck
Radioactive iodine scan
35
How to treat a thyroglossal duct cyst?
Treat any acute infections with aspiration and antibiotics
Formal excision with Sistrunk's procedure
36
What is this structure and label the diagram
This is a membranous labyrinth
a saccule
b utricle
c cochlear duct
d endolymphatic duct
e lateral scc
f posterior scc
g superior scc
37
Which structures of the inner ear detect linear acceleration?
vertical - macula of saccule
horizontal - macula of utricle
38
which structures of inner ear detect angular acceleration?
Lateral, posterior and superior semicircular canals
39
which structures are tested in the caloric test?
lateral semicircular canal
40
which structures play a role in pathophysiology of BPPV
Utricle and posterior scc
41
What is the temperature of water in caloric testing?
cold - 30 degrees C
warm - 44 degrees C
ice - 10 degrees C
42
What does BPPV stand for
benign paroxysmal positional vertigo
43
Describe the pathophysiology of BPPV
stimulation of posterior scc by otoconia dislodged from the macula in the utricle
44
History of vertigo in BPPV?
Lasts seconds
Brought on by sudden head movements
45
List 3 features of the nystagmus provoked by dix hallpike in BPPV
if left ear - anticlockwise, if right ear - clockwise
Torsional
Latency period
Fatigable
Lasting 20-40 seconds
46
What can you recommend as home treatment for BPPV
Brandt-Daroff exercises
47
Complications following nasal polypectomy/FESS
Orbital - loss of vision, double vision, orbital haematoma
CSF leak, meningitis, frontal lobe abscess
Epistaxis, infection, adhesions
48
Diagnostic criteria for CRS
2 or more of:
- nasal congestion/blockage/nasal discharge anterior/posterior (must be present)
- facial pain/pressure
- Anosmia/hyposmia
>12 weeks
49
What is aspirin exacerbated respiratory disease
also known as samter's triad
asthma
aspirin sensitivity
nasal polyps
50
What are three structures preserved in a modified radical neck dissection
spinal accessory nerve
SCM
internal jugular vein
51
What are the anatomical boundaries for level V neck dissection?
Boundaries of the posterior triangle!
posterior border SCM, anterior border trapezius, superior border clavicle
52
What structures can be damaged in level V neck dissection?
Spinal accessory nerve
53
What nerves can be damaged in level 3 neck dissection?
greater auricular nerve
vagus nerve
hypoglossal nerve
54
Label this
a septal cartilage
b maxilla
c palatine bone
d vomer
e perpendicular plate of ethmoid
55
How may a patient with an anterior septal perforation present?
bleeding
crusting
whistling
asymptomatic
56
list 5 causes of septal perforation
trauma - nose picking, nasal inhalers, following septal haematoma/abscess
Iatrogenic - post septoplasty, excessive cautery
Drugs - intranasal cocaine
Systemic disease - GPA, sarcoidosis, SLE, syphilis (usually posterior perforation), TB
Neoplasm - SCC, BCC, T-cell lymphoma
57
List some investigations for a septal perforation
FBC, U&E, ESR
ANCA
ACE
VDRL for syphilis (veneral disease research laboratory)
CXR
urine dip
?biopsy if malignancy suspected
58
Which age group presents with laryngomalacia?
neonates - symptoms usually start at 2 weeks to resolve by 2 years
59
How will a child with laryngomalacia present
inspiratory stridor
Worse on exertion (e.g. feeding)
normal cry when supine
60
Muscle and nerve supply for abduction of VCs?
posterior cricoarytenoid. RLN
61
Muscle and nerve supply for adduction of VCs?
lateral cricoarytenoid muscle mostly, RLN
62
Muscle and nerve supply for tensing of VCs?
cricothyroid muscle, external branch of superior laryngeal nerve
63
Which bones form the lateral nasal wall?
maxilla
perpendicular plate of palatine bone
medial pterygoid plate
ethmoid labyrinth
inferior concha
64
Where does the frontal sinus open into?
middle meatus
65
Where does the anterior ethmoidal sinus open into?
middle meatus
66
Where does the posterior ethmoidal sinus open into?
superior meatus
67
Where does the maxillary sinus open into?
middle meatus
68
where does the sphenoid sinus open into?
sphenoethmoidal recess
69
How may a quinsy present?
odonyphagia
halitosis
trismus
fever
referred otalgia
hot potato voice
drooling of saliva
70
Initial management of a quinsy
resuscitation and pain control
abscess drainage
IV antibiotics and steroids
antiseptic mouthwash
71
list two differentials of acute mastoiditis
infected post auricular lymph node
infected epidermoid cyst
72
how to manage acute mastoiditis?
resuscitatoin
assess for neurological signs
start IV antibiotics as per hospital antimicrobial policy
CT with contrast of temporal bone with brain windows
surgery - cortical mastoidectomy +/- ventilation tube
73
list 5 complications of acute mastoiditis
intracranial abscess
venous sinus thrombosis (lateral sinus thrombosis)
meningitis
Bezolds abscess
citellis abscess
facial nerve palsy
74
What is a Bezold's abscess?
abscess within sheath of SCM forming a fluctuant mass along anterior border
75
What is a Citelli's abscess
Abscess in the digastric fossa
76
list 5 causes of a facial nerve palsy
trauma - temporal bone fracture, facial wounds
iatrogenic - parotid or ear surgery
infection - AOM, NOE, lyme disease (borreliosis), cholesteatoma
Viral - herpes zoster oticus, HIV
Neoplasia - skull base, parotid
Idiopathic - bell's palsy
77
Describe the grading system for facial nerve palsies?
House Brackmann scale
1 - normal function
2 - slight weakness on close inspection but complete eye closure
3 - obvious weakness, still has complete eye closure. Strong but asymmetrical mouth. Can move with maximal effort.
4 - inability to lift brow/close eye/asymmetry of mouth
5 - motion barely perceptible, slight movement of corner of mouth
6 - no movement
78
Management of an idiopathic facial nerve palsy?
explanation and reassurance
eye care - artificial tears, eye taping, ophthalmology review
steroids - pred 1mg/kg for 7-10 days and then wean down
follow up in clinic
79
what are the 5 branches of the facial nerve?
temporal, zygomatic, buccal, marginal mandibular, cervical
80
which muscle does the temporal branch of the facial nerve supply and how do you test?
frontalis (frontal belly of occipitofrontalis muscle) + corrugator supercilii, raise eyebrows/frown
81
which muscle does the zygomatic branch of the facial nerve supply and how do you test?
orbicularis oculi, close eyes tightly
82
which muscle does the buccal branch of the facial nerve supply and how do you test?
buccinator, puff cheeks out
83
which muscle does the marginal mandibular branch of the facial nerve supply and how do you test?
depressor labii inferioris, depressor anguli oris - show me bottom teeth
84
which muscle does the cervical branch of the facial nerve supply and how do you test?
platysma - tense your neck
85
Other than the muscles of facial expression, which other muscles does the facial nerve supply?
posterior belly of digastric
stylohyoid
stapedius
86
Mechanism of orbital haematoma after FESS?
breach of lamina paprycea during surgery, injury to orbital veins if slow symptoms, injury to anterior and posterior ethmoidal arteries if rapid symptoms
87
How may an orbital haematoma present?
proptosis
reduced visual acuity
increasing swelling of eye
88
How to manage an orbital haematoma
remove any nasal packs
consider IV mannitol and steroids
urgent ophthalmology review
senior help
lateral canthotomy and inferior cantholysis under LA
If eye remains proptosed, needs superior canthotomy and medial orbital decompression/ligation of any bleeding vessels under GA
89
label
a - superior crus of lateral canthal tendon
b - lateral canthal tendon
c - inferior crus of lateral canthal tendon
90
List complications of FESS
Orbital harmorrhage
Diplopia due to injury to medial rectus and superior oblique muscles
Epiphora due to nasolacrimal duct injury
Optic nerve injury and blindness due to haematoma
CSF leak
meningitis
Adhesions
Epistaxis
Infection
recurrence
91
How may bony exostoses of the ear present?
wax impaction
otitis externa
Hearing loss
asymptomatic
92
Management of exostosis?
conservative - treat infections and wax impaction
surgical - canaloplasty
93
Which tuning fork to use for Rinne and Weber's test
512 Hz
94
What does masking mean?
presenting a constant noise to the non test ear to prevent the non test ear from detecting sound presented by the test ear by crossover
95
what are the following symbols in PTAs?
o
X
^ (triangle)
[
]
o - right air conduction threshold
X - left air conduction threshold
^ - unmasked bone conduction
[ - right bone conduction threshold
] - left ear bone conduction threshold
96
Describe mild, moderate, severe, profound hearing loss thresholds
mild - 20-40
moderate - 41-70
severe - 71-95
profound - >95dB
97
What are risks of nasal cautery
burn to upper lip
septal perforation
98
what does BIPP stand for
bismuth iodoform paraffin paste
99
what do you need to check before giving naseptin nasal cream?
allergy to peanuts/neomycin/chlorhexadine
100
what is the blood supply to the nasal septum?
ICA: anterior and posterior ethmoidal ateries from the ophthalmic artery
ECA: sphenopalatine artery (terminal branch of maxillary), greater palatine artery (from descending palatine artery from maxillary artery), superior labial artery (from facial artery)
101
Which vessels contribute to the anastomosis in Little's area?
SPA
greater palatine
superior labial
anterior ethmoidal
102
list 5 causes of epistaxis
trauma (nose picking, facial injuries, foreign body)
inflammatory (sinusitis, rhinitis)
drugs (aspirin, clopi, warfarin, cocaine)
neoplasm (SCC, juvenile angiofibroma)
GPA
HHT
vWD
103
Two pathogens in OE?
pseudomonas aeruginosa
staphylococcus aureus
104
Presentation of OE
tragal tenderness
otorrhoea
hearing loss
erythema and oedema of EAC
aurual fullness
cellulitis spreading to surrounding skin
105
List 3 risk factors for OE
swimming
skin conditions (eczema, psoriasis, atopic dermatitis)
trauma (cotton buds)
Diabetes
medications e.g. steroids
106
List two species causing otomycosis
aspergillus niger/flavus/fumigatus
candida albicans
107
How to treat otomycosis?
regular aural toilet
antifungal ear drops (1% clotrimazole)
keep ear dry
ear swab
108
What are the advantages of cuffed tracheostomy tubes?
inflated cuff descreases risk of aspirate into lungs
inflated cuff enables positive pressure ventilation
109
what are the disadvantages of cuffed tracheostomy tubes?
pressure trauma
if cuff inflated and tracheostomy lumen is occluded, no airflow
swallowing can be impaired due to pressure against oesophagus
110
list 3 indications for tracheostomy
facilitate weaning from positive pressure ventilation (reduced dead space)
minimise risk of aspiration in absence of laryngeal reflexes
obtain/secure airway in patients with upper airway obstruction
111
What layers does surgeon go through in a tracheostomy
skin
subcutaneous tissue
platysma
investing layer of deep cervical fascia
strap muscles (usually pulled aside)
pretracheal fascia
thyroid isthmus (usually ligated and then divided)
trachea (window usually placed between 2nd and 4th ring)
112
list 5 complications of tracheostomy
bleeding
airway obstruction
misplacement
pneumothorax
damage to oeseophagus
damage to recurrent laryngeal nerve
tracheoesophageal/trachea cutaneous/ tracheo innominate artery fistula
113
Advantages of uncuffed trachey ?
patients can breathe around trache tube if it gets blocked
suitable for long term use because decreased risk of pressure trauma
can speak with an uncuffed tube
114
what is the advantage of an inner cannula
facilitates cleaning of crusted secretions whilst outer tube maintains the airway but it does reduce the diameter of inner lumen therefore increasing the work of breathing
115
what is tympanometry?
measurement of acoustic compliance of eardrum as a function of change in pressure in ear canal
116
what information can you obtain from tympanogram? 3
volume of ear canal
middle ear pressure
compliance of eardrum
117
3 causes of a type B tympanogram
glue ear
perforation/patent grommet is ear canal volume above normal limits
inaccurate reading if ear canal volume below normal limits
118
list two causes of an As tympanogram
shallow peak i.e. decreased compliance and normal middle ear pressure
suggests a normal middle ear fucntion or a stiff middle ear system from ossicular fixation or tympanosclerosis
119
list two causes of an Ad tympanogram
high peak i.e. increased compliance and normal middle ear pressure, indicating a hyper mobile/flaccid middle ear system
Suggests ossicular discontinuity, flaccid tympanic membrane e.g. healed tympanic membrane perforation
120
which three nerves can be injured during submandibular gland excision
lingual nerve
hypoglossal nerve
marginal mandibular branch of facial nerve
121
list the structures lying within the substance of the parotid gland from superficial to deep
facial nerve
retromandibilar vein (maxillary vein +superficial temporal vein)
carotid artery giving off terminal branches (maxillary artery and superficial artery)
lymph nodes
122
what causes laryngeal papillomatosis
HPV 6 and 11
123
list 5 symptoms of supraglottic cancer
dysphagia
odonophagia
referred otalgia
hoarseness
neck lump
124
risk factors for supraglottic cancer
smoking
alcohol
HPV 16 and 18
125
label this
a - epiglottis
b - aryepiglottic fold
c - anterior commisure
d - true vocal vord
e - false vocal cord
f - arytenoid cartilage
g - piriform fossa
h - rima glottis
126
Type of laser for HHT treatment
NdYAG, KTP532 or argon laser
127
Unit of x axis on tympanogram
daPa
128
Unit of y axis on typamnogram
ml
129
what is a normal middle ear pressure in adults
-50 to 50 daPa in adults
150 daPa in children
130
why can a cholesteatoma cause both CH and mixed HL?
conductive - erosion of ossicular chain
mixed - erosion into labyrinth/inner ear
131
dizziness with cholesteatoma is suggestive of?
labyrinthine fistula of lateral SCC
132
Causes for a CT temporal bone for a cholesteatoma?
plan approach
check for anatomical abnormalities - especially if syndromic
check if facial nerve is dehiscent
check for bony destruction or fistula
revision cases
133
two muscles which attach to mastoid process
SCM
posterior belly of digastric muscle
134
what are branchial cysts
cysts which contain lymphoid tissue and are lined by squamous epithelial tissue
135
name the intrinsic laryngeal muscles
cricothyroid
thyroarytenoid (vocalis) - paired
lateral cricoarytenoid -paired
posterior cricoarytenoid - paired
transverse arytenoid - unpaired
136
coughing during microsuction - which nerve
arnolds nerve
137
describe hearing loss seen in menieres
fluctuating SNHL, initially seen in the lower frequencies
138
2 surgical options for menieres
myringotomy tube insertion
endolymphatic sac surgery
139
management of menieres
dietary - limit salt and caffeine, eat at regular intervals
lifestyle - stop smoking, reduce stress
medical - stemetil during acute attacks, vestibular rehabilitation, hearing aids
surgical - grommets, steroid inection, IT gent, endolymphatic sac surgery, vestibular nerve section
140
side effects of moffetts solution
tachycardia
arryhthmias
HTN
hyperthermia
sweating
anxiety
141
which theory are the rules of masking based on
theory on interaural attenuation
142
Q-5 : Describe the first rule of masking.
Air conduction audiometry: masking is needed at any frequency where the difference between the left and right not-masked air conduction thresholds is 40 dB or more (55dB if using insert earphones).
143
what is the second rule of masking
Bone conduction audiometry: masking is needed at any frequency where the non-masked bone conduction threshold is more acute than the air conduction threshold (on either side) by 10dB or more.
144
how does dabigatran work
direct inhibitor of free thrombin, fibrin bound thrombin and thrombin induced platelet aggregation
145
how does rivaroxaban work
inhibitor of activated factor Xa
146
what does gentisone HC contain
gentamicin
hydrocortisone
147
what should a patient be warned of prior to undergoing tracheostomy insertion
initial inability to talk after surgery
need for humidification
possibility of going home with trache after appropriate training
148
what is the function of a heat moisture exchanger
It provides humidification of the airway and is used when no extra oxygen is needed. It is very useful when patient is out of bed and mobilising.
149
3 causes of type B tympanogram - consider the ear canal volumes
If the earcanal volume is within the normal limits, type B tympanogram indicates the presence of fluid behind the eardrum, usually due to otitis media with effusion (OME) - ‘glue ear’.
If the ear canal volume is above the normal limits, type B tympanogram indicates presence of perforation / patent grommet.
If the ear canal volume is below the normal limits, type B tympanogram suggessts an innacurate reading due to a misplacement of the tympanometer probe tip (pushed against the canal wall).
150
Describe briefly what tympanogram ‘As’ and list two possible causes of this type of tympanogram.
Type ‘As’ tympanogram is characterised by a shallow peak (decreased compliance) and normal middle ear pressure.
It can represent normal middle ear function or a ‘stiff’ middle ear system with normal Eustachian tube function, resulting from:
Ossicular fixation (e.g., in otosclerosis).
Tympanosclerosis (restricted movements of the tympanic membrane).
151
Describe briefly what tympanogram ‘Ad’ is and list two possible causes of this type of tympanogram.
Type ‘Ad’ tympanogram is characterised by a high peak (increased compliance) and normal middle ear pressure. It indicates flaccid or hyper-mobile middle ear system.
Ossicular discontinuity (partial or full).
Flaccid tympanic membrance (e.g., healed tympanic membrane perforation).
152
where on the VC are singers nodules usually found
Pale lesions at the junction of anterior one third and posterior two thirds of the true vocal cords
153
a Ear mould
b Connecting tube
c Battery
d Volume control
e On / Off button
154
explain cleft lip
It involves the lip, alveolus and hard palate anterior to the incisive foramen (premaxilla). There is a failure of fusion between medial nasal, maxillary and lateral nasal prominences. If extending posterior to the incisive foramen, it is called cleft lip and palate (impaired palatal shelf fusion).
155
Q-3. What are the challenges in patients with cleft lip/palate? List three.
a. Difficulty feeding.
b. Ear infections and hearing loss (cleft lip and palate)
c. Dental problems
d. Speech difficulties
e. Challenges of coping with a medical condition
156
surgical management of cleft palate
repair of soft palate at 6 months, hard palate at 9 months, further palatal surgery depending on treatment needs, alveolar bone grafts from 7 years
157
label
a. tectorial membrane
b. outer hair cells
c. inner hair cells
d. basilar membrane
e. VIII th nerve fibres f. stereocilia
158
Sound transmitted via the oval window creates a wave in the ............................... Movement of the .................causes shearing forces between the ......................and the ____________, causing the movement of the hair cells’ ____________. The ____________ depolarize, releasing neurotransmitters at their bases, which generates action potential in the ______________.
Sound transmitted via the oval window creates a wave in the basilar membrane (d). Movement of the basilar membrane (d) causes shearing forces between the basilar membrane (d) and the tectorial membrane (a), causing the movement of the hair cells’ stereocilia (f). The inner hair cells (c) depolarize releasing neurotransmitters at their bases, which generates action potential in the VIII th nerve fibres (e).
159
3 characteristic features of downs syndrome
small nose, flat nasal bridge
upslating palpebral fissures
epicanthal fold
macroglossia
low set, small pinna
160
issues with grommet insertion in children with downs syndrome
narrower eustachian tubes
defects in tensor palatini muscles so insertion of grommets is more challenging and child may require multiple sets of grommets
161
3 factors which contribute to increased severity of OSA in downs syndrome children
midfacial and mandibular hypoplasia
macroglossia
narrowing of oropharynx/nasopharynx
generalised hypotonia
increased secretions
162
what to consider before adenotonsillectomy in downs syndrome children
a. atlantoaxial joint instability- careful and limited neck extension , cautious use of the monopolar suction diathermy (see also question 3d, station 7); if suspicion- consider pre operative neck x-ray /MRI, neurologic examination.
b. Reported increased incidence of velopharyngeal dysfunction and hypernasal speech.
163
signs of food bolus on lateral soft tissue neck XR
preservation of the cervical lordosis (loss of the cervical lordosis may be due to pain or inflammation of the preverterbal muscles secondary to impacted foreign body/abscess)
b. swelling of the prevertebral tissues*
c. presence of any radioopaque objects
d. presence of high oesophageal bubble/air/fluid level (suggestive of food bolus obstruction)
e. presence of free air (secondary to perforation)
164
which levels of assess width of prevertebral space
C3 < than 1/3 AP width of C3 vertebral body
C6 < than the AP width of C6 vertebral body
165
how to get FB at level of cricopharyngeus
rigid oesophagoscopy
could try flexible gastroscopy but harder for high fbs
166
Management of soft FBs
IV buscopan
rectal diazepam
fizzy drinks
167
initial management of oesophageal perforation
NBM
NG insertion
IV fluid and antibiotics
gastrograffin swallow study
168
symptoms of oesophageal perforation
a. tachycardia
b. tachypnoe
c. spiking temperatures
d. pain between scapulae
e. surgical emphysema
169
what distance from incisors to cricopharyngeus, aortic arch, left bronchus and gastric inlet
15 cm to the cricopharyngeus
22 cm to the aortic arch
27.5 cm to the left bronchus
40 cm to the gastric inlet
170
pit in anterior neck (along anterior border SCM) with recurrent mucinous discharge?
second branchial cleft sinus/fistula
171
4 nerves that need to be infiltrated for anaesthesia of the external node
external nasal nerve - over nasal dorsum
nasopalatine nerve - at base of columella and nasal top
infraorbital nerve
infratrochlear nerve - near medial canthus area
172
walsham forceps
173
a. Jobson Horne probe
b. Wax hook
c. Myringotome/myringotomy knife
d. Crocodile forceps (Cawthorne/Hartman silver)
e. Cawthorne needle f. Shah grommet
174
is the eustachian tube usually open or closed?
closed - swallowing or yawning opens to ET
175
list the 4 muscles of the eustachian tube
levator veli palatini
salpingopharyngeus
tensor tympani
tensor veli palatini
176
childs eustachian tube compared to adults?
shorter straighter course in children
177
function of hypoglossal nerve
motor supply to all intrinsic and extrinsic muscles of tongue except palatoglossus
178
grading system for subglottic stenosis
Cotton myer classification
Grade 1: 0-50% obstruction
Grade 2: 51-70% obstruction
Grade 3: 71- 99% obstruction
Grade 4 : No detectable lumen
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how to grade subglottic stenosis practically
endoscopically - use a uncuffed ETT and compare the size with expected size of ETT of healthy child of same age
180
treatment of subglottic stenosis?
mild - endoscopic balloon dilation, excision with cold steellaser
severe - laryngotracheal reconstruction +/- surgcial trache
181
what is the narrowest part of the paediatric airway
cricoid
182
what is the narrowest part of the adult airway
glottis
183
Q-6 : How would you calculate the internal diameter of an age appropriate uncuffed paediatric tube for children 1-10 years of age?
Uncuffed endotracheal tube size (mm ID) =(age in years/4) + 4
184
post grommet insertion instructions
water precautions for 2 weeks
follow up with audiogram in 1 year
185
complications of grommets
otorrhoea
infection
tympanosclerosis
perforation persists
cholesteatoma
bleeding
