Surgery - Ear, nose and throat Flashcards
(240 cards)
1
Q
What is a normal result in pure tone audiometry?
A
All results above 20dB line
2
Q
What is Rinne’s test? Describe the results
A
tuning fork placed over mastoid process until sound no longer heard, followed by repositioning just over external acoustic meatus
+ve: AC > BC bilaterally = normal or SNHL
-ve: BC > AC = conductive deafness
3
Q
What is Weber’s test? Describe the results
A
Tuning form placed in middle of forehead, equidistant from ears
patient asked which side is loudest
Normal: equal
Unilateral SNHL: localises to unaffected ear
Unilateral conductive HL: sound localises to affected ear
4
Q
What is the difference between SNHL, conductive HL and mixed HL?
A
SNHL = both air + bone conduction are impaired (AC better than BC)
Conductive: only air conduction impaired
Mixed: air + bone conduction both impaired, but BC better than AC
5
Q
How can middle ear function be evaluated?
A
Tympanometry - measures stiffness of ear drum
6
Q
What is automated auditory brainstem response audiometry?
A
Auditory stimulus with measurement of elicited brain response by surface electrode
7
Q
What are the components of the child hearing exams?
A
All babies get evoked otoacoustic emission testing
If not normal –>
Automated auditory brainstem response audiometry
8
Q
What are the signs and symptoms of TMJ dysfunction?
A
Otalgia (referred pain from auriculotemporal nerve) Facial pain TMJ joint clicking/popping Bruxism (teeth grinding) Stress
9
Q
What condition does ‘swimmer’s ear’ refer to?
A
Acute diffuse otitits externa
10
Q
How should necrotising otitis externa be managed?
A
Urgent ENT referral
CT head
IV ciprofloxacin
11
Q
What is acute otitis media?
A
Inflammation in the middle ear a/w effusion accompanied by rapid onset S/S of ear infection
12
Q
What is the most common pathogen implicated in acute otitis media? Name 2 others
A
S. pneumoniae (as secondary to URTI)
Haemophilus influenzae
Moraxella catarrhalis
13
Q
List 3 viral causes of acute otitis media
A
Respiratory syncytial virus (RSV)
Rhinovirus
Adenovirus
14
Q
Give 4 risk factors specific to infants for acute otitis media
A
Nursery
Formula feeding
Use of a dummy
Bottle feeding supine
15
Q
List 3 general risk factors for acute otitis media
A
Smoking/ passive smoking
FH
Craniofacial abnormalities e.g. cleft palate
16
Q
Give 5 signs/ symptoms of acute otitis media
A
Otalgia +/- tugging/ rubbing
Fever
Conductive HL
Recent viral URTI Sx
Discharge if TM perforates
17
Q
List 4 features found on otoscopy in acute otitis media
A
Bulging TM: loss of light reflex
Air-fluid level behind TM indicates effusion
Opacification/ erythema of TM
Perforation with purulent otorrhoea
18
Q
How should acute otitis media without perforation be managed?
A
Analgesia
Delayed/ no script Abx unless:
- Sx >4 days + not improving
- systemically unwell but not requiring admission
- Immunocompromised
- <2y with BL OM
- Perforation / discharge in canal
19
Q
If antibiotics are indicated in acute otitis media, what is firstline?
A
Amoxicillin
If Pen allergy: erythromycin or clarithromycin
20
Q
Describe 3 common sequalae to acute otitis media
A
TM perforation + otorrhoea
Hearing loss
Labyrinthitis
21
Q
What may unresolved acute otitis media with perforation progress to?
A
Chronic suppurative otitis media: perforation of TM with otorrhoea for >6w
22
Q
List 4 complications of acute otitis media
A
Mastoiditis
Meningitis
Brain abscess
Facial nerve paralysis
23
Q
How should acute otitis media with perforation be managed?
A
Oral amoxicillin 5 days
Review in 6w
24
Q
What condition is known as ‘glue ear’?
A
Otitis media with effusion
25
List 6 risk factors for glue ear
Male
Siblings with glue ear
Winter/ Spring
Bottle feeding
Day care attendance
Parental smoking
26
What is the peak age of glue ear?
2y
Most common cause of CHL + elective surgery in childhood
27
How does glue ear usually present? What secondary problems may also be seen?
Hearing loss
Speech + language delay
Behavioural problems
Balance problems
28
How should glue ear be managed?
If no comorbidities: active observation for 6-12w, If no improvement: ENT referral
If co-existent cleft palate/ Down's: ENT referral
29
What surgical options are available for glue ear?
Grommet insertion: allows air to pass into middle ear + do job normally done by Eustachian tube
Adenoidectomy
30
How long do grommets last?
10-12 months
31
What are the signs and symptoms of cholesteatoma?
Foul smelling, non-resolving discharge from ear
Hearing loss
Vertigo
Facial nerve palsy
Cerebellopontine angle syndrome
32
What is cholesteatoma?
Non-cancerous growth of squamous epithelium trapped in skull base causing local destruction
Most common in 10-20y
RF: Cleft palate
33
What do cholesteatomas often result from?
Chronic ear infections
Eustachian tube dysfunction
34
What is seen on otoscopy in cholesteatoma?
'Attic crust' seen in uppermost part of ear drum
35
How should cholesteatoma be managed?
Refer for surgery
36
Recall 4 drugs that can cause tinnitus
Aspirin
Aminoglycosides
Loop diuretics
Ethanol
37
What is the most concerning cause of unilateral tinnitus?
Acoustic neuroma
38
Recall 3 vestibular causes of vertigo
Meniere's
BPPV
Labyrinthitis
39
Recall 5 central causes of vertigo
```
Vestibular schwannoma
MS
Stroke
Head injury
Inner ear syphillis
```
40
What is Meniere's?
Dilatation of endolymph spaces of membranous labyrinth
41
What are the symptoms of Meniere's?
Clustered attacks lasting mins-hours
Recurrent episodes of vertigo, tinnitus + SNHL
Aural fullness/ pressure
N+V
Nystagmus + positive Romberg test
42
How is Meniere's managed?
ENT assessment to confirm Dx
Patients should inform DVLA + stop driving until satisfactory control of Sx
Acute: Buccal/ IM Prochlorperazine
Prevention: Betahistine + vestibular rehabilitation
43
What are the symptoms of viral labyrinthitis/ vestibular neuronitis?
Severe vertigo, nystagmus + vomiting following an URTI
44
How can you differentiate between vestibular neuronitis and viral labyrinthitis clinically?
Hearing may be affected in viral labyrinthitis but isn't in vestibular neuronitis
45
How can vestibular neuronitis be differentiated from posterior circulation stroke?
HiNTS exam
(Head impulse, Nystagmus and Test of Skew)
Peripheral vertigo: abnormal Hi, no/ unidirectional N + no vertical skew
Central vertigo: normal Hi, vertical/ saccadic N, vertical skew
46
How should viral labyrinthitis/ vestibular neuronitis be managed?
If severe: IV prochlorperazine
| If less severe: PO cyclizine and prochlorperazine
47
Give 4 signs and symptoms of vestibular neuronitis
Recurrent vertigo attacks: hours-days
N+V
Horizontal nystagmus
NO hearing loss or tinnitus
48
Describe management of vestibular neuronitis
Mild: Short course PO Prochlorperazine/ antihistamine e.g. cyclizine, promethazine
Severe: Buccal/ IM Prochlorperazine (rapid relief)
Chronic Sx: vestibular rehabilitation exercises
49
What is BPPV? What is the pathophysiology?
disorder of inner ear characterised by repeated episodes of positional vertigo
Otoconia (crystals) dislodge + migrate into semi-circular canals, disrupting endolymph dynamics, causing motion of fluid, inducing vertigo
Posterior semi-circular canal affected in 85-95%
50
List 3 precipitants to BPPV
Head injury
Ear surgery
Post-inner ear pathology e.g. Meniere's, labrynthitis, vestibular neuronitis
51
Describe the vertigo in BPPV
Sx brought on by specific movements/ positions of head
Transient; <60s
N+V may occur
Lightheadedness/ imbalance persist
52
Name 2 symptoms that do NOT occur in BPPV
Hearing loss
Tinnitus
53
How can BPPV be diagnosed?
Dix-Hallpike manoevre:
Rapidly lower patient to supine position with extended neck
Provokes vertigo + torsional (rotatory) upbeating nystagmus
54
How can BPPV be managed?
Resolves in weeks-months
Symptomatic relief with:
* Epley manoevre
* Vestibular rehabilitation (patient exercises e.g. Brandt-Daroff)
55
What medication is often prescribed in BPPV, but is of limited value?
Betahistine
Vasodilates + improves blood flow to inner ear
56
Prognosis in BPPV
Often relapsing-remitting
~50% have recurrence 3-5y after dx
57
What is acoustic neuroma also known as?
Vestibular schwannoma
58
What are acoustic neuromas?
Benign tumours arising from Schwann cells
Primarily originate within vestibular portion of CN VIII
Form in internal acoustic canal with variable extension into cerebellopontine angle
59
What are the symptoms of acoustic neuroma?
Slow-onset, unilateral SNHL
Tinnitus
Vertigo
Absent corneal reflex
60
How can clinical features of acoustic neuroma be predicted by cranial nerve involvement?
CN V: absent corneal reflex
CN VII: Facial palsy
CN VIII: Vertigo, unilateral SNHL, unilateral tinnitus
61
In which condition are bilateral acoustic neuromas seen in?
Neurofibromatosis type 2
62
How should possible acoustic neuroma be investigated?
Contrast MRI of cerebellopontine angle
Pure tone audiometry: >90% have some type of HL
63
Describe management of acoustic neuromas
Observation (MRI every 6-12m): small tumours/ minimal HL
Surgery/ Radiotherapy: large tumours/ significant hearing los
64
Give 4 signs and symptoms of impacted earwax
Pain
Conductive HL
Tinnitus
Vertigo
65
Describe management of impacted ear wax
Olive oil drops
(or sodium bicarbonate 5% or almond oil)
Irrigation (ear syringing)
66
What is otosclerosis?
Replacement of normal bone by vascular spongy bone
Causes progressive conductive HL due to fixation of the stapes at the oval window
Autosomal dominant
Onset 20-40y
67
What are the symptoms of otosclerosis?
BL conductive HL
Tinnitus
Hearing loss improves with noise but worsens with pregnancy, menstruation, menopause
68
69
Describe the appearance of the tympanic membrane in otosclerosis
Majority normal
10% have 'flamingo tinge' caused by hyperaemia
70
How should otosclerosis be managed?
Hearing aid, stapes implant
71
What is Presbycusis?
Age related sensorineural hearing loss
High freq. hearing affected bilaterally- difficulty in conversation in noisy environments
Progresses slowly- atrophy of sensory hair cells + neurones in cochlea over time
72
List 6 contributory factors to Presbycusis
Arteriosclerosis: diminished perfusion + oxygenation of cochlea
Diabetes: acceleration of arteriosclerosis
Accumulated exposure to noice
Drugs: salicylates, chemo
Stress
Genetics: predisposed to early ageing of auditory system
73
Give 5 features of presentation of presbycusis
Speech difficult to understand
Need for increased vol on TV/ radio
Difficulty using phone
Loss of directionality of sound
Worsening of Sx in noisy environments
74
What are 2 less common symptoms of presbycusis?
Hyperacusis: heightened sensitivity to certain freq of sound
Tinnitus
75
What sign may be found in presbycusis?
Possible Weber's test BC localisation to 1 side if SNHL not completely bilateral
76
What 4 investigations should be performed in presbycusis?
Otoscopy: Normal, to r/o otosclerosis, cholesteatoma + conductive HL (FB, impacted wax etc.)
Tympanometry: Normal middle ear function with hearing loss (Type A)
Audiometry: Bilateral SNHL pattern
Blood tests inc. inflammatory markers + specific antibodies: Normal
77
Give 3 features of audiogram in presbycusis
Bilateral impairment
High frequency hearing loss
Downward-sloping pure tone thresholds
78
How should sudden SNHL be managed?
Refer to ENT in <24h
High dose PO prednisolone
MRI to r/o vestibular schwannoma
79
Give 5 causes of sudden onset sensorineural hearing loss
Idiopathic (most common)
AI: Behcets, SLE
Infection: bacterial meningitis, mumps, Lyme
Metabolic: diabetes, hypothyroidism
Neoplasm
80
In which patients are auricular haematomas most common? Why is prompt treatment needed? What does this involve?
Rugby players + wrestlers
To avoid formation of Cauliflower ear
Mx: same day ENT assessment + incision + drainage
81
What is chronic rhinosinusitis?
Inflammatory disorder of paranasal sinuses + linings of nasal passages >,12w
82
Give 5 pre-disposing factors for chronic rhinosinusitis
Atopy: hay fever, asthma
Nasal obstruction e.g. septal deviation, polyps
Recent local infection e.g. Rhinitis, dental extraction
Swimming/ diving
Smoking
83
Give 4 signs and symptoms of chronic rhinosinusitis
Facial pain: frontal pressure pain, worse on bending forward
Nasal discharge: clear if allergic/ vasomotor. thicker, purulent if secondary infection
Nasal obstruction: "mouth breathing"
Post-nasal drip: may produce chronic cough
84
How should recurrent/ chronic rhinosinusitis be managed?
Avoid causative allergen
Nasal irrigation with saline
Mild Sx: PRN oral antihistamine (eg cetirizine) + PRN intranasal antihistamine (eg azelastine)
Severe Sx:
Intranasal CS (eg beclomethasone)
85
What is acute sinusitis?
Inflammation of mucous membranes of paranasal sinuses
Most common organisms: Streptococcus pneumoniae, Haemophilus influenzae + rhinoviruses
86
List 4 predisposing factors to acute sinusitis
Nasal obstruction e.g. septal deviation/ polyps
Recent local infection e.g. rhinitis/ dental extraction
Swimming/ diving
Smoking
87
Give 3 signs and symptoms of acute sinusitis
Facial pain: frontal pressure pain, worse on bending forward
Nasal discharge: usually thick + purulent
Nasal obstruction
88
What are the red flags in sinusitis that would prompt an urgent ENT referral?
Unilateral Sx
Persistent Sx >3m despite Tx
Epistaxis
89
What are the indications for admission to hospital with sinusitis?
```
Severe systemic infection
Signs of dangerous complications of sinusitis eg:
Periorbital/orbital cellulitis
Meningitis
Brain abscess
```
90
How should acute sinusitis be managed?
If Sx <10d: analgesia, advice + safety-netting
If Sx >10d: 14 day course of high-dose nasal corticosteroid
Abx PO for severe cases: phenoxymethylpenicillin
91
What is a 'double-sickening'?
Initial period of recovery from viral sinusitis followed by worsening of Sx due to secondary bacterial sinusitis
92
What are nasal polyps?
benign lesions of nasal mucosa or paranasal sinuses due to chronic mucosal inflammation
93
Epidemiology of nasal polyps
1% adults
M > F
Not common in kids/ elderly
94
List 6 conditions associated with nasal polyps
Asthma (esp. late onset)
Aspirin sensitivity
Infective sinusitis
Cystic fibrosis
Kartagener's syndrome
Churg-Strauss syndrome
95
What are 4 symptoms of nasal polyps?
Nasal obstruction
Watery anterior rhinorrhoea +/- post nasal drip
Sneezing
Poor sense of taste + smell
96
Describe management of nasal polyps
Refer all to ENT for assessment
Topical CS shrink polyps in 80%
97
What is Samter's triad?
Triad of nasal polyps, asthma + aspirin hypersensitivity
If person has nasal polyps + asthma, advise to avoid NSAIDs + aspirin as could cause a life-threatening reaction
98
What would make nasal polyps seem concerning?
If single + unilateral
Assumed neoplastic until proven otherwise
99
How should nasal polyps be managed?
- Routine referral to ENT for exam
- Medical: 4-6w course of topical steroids
- Surgically: can be removed endoscopically
100
What is a septal haematoma?
Complication of nasal trauma
Untreated nasal fracture --> septal necrosis + nasal collapse as cartillage blood supply comes from the mucosa
Haematoma between septal cartilage + overlying perichondrium.
101
Give 3 signs and symptoms of nasal septal haematoma
Sensation of nasal obstruction (most common Sx)
Pain + rhinorrhoea
Classically a bilateral, red swelling arising from the nasal septum
102
How is a nasal septal haematoma differentiated from a deviated septum?
Gently probing the swelling.
Nasal septal haematomas = boggy
Septums = firm
103
What is the management for nasal septal haematoma?
Surgical drainage
IV Abx
104
What results if nasal septal haematoma goes untreated?
Irreversible septal necrosis develops within 3-4 days
Due to pressure-related ischaemia of cartilage resulting in necrosis
May result in a 'saddle-nose' deformity
105
How should all nosebleeds be initially managed?
Sit up
Lean forwards
Mouth open
Compress nasal cartilage for 15 mins
106
Describe the aetiology of tonsillitis
Viral 50-80%
Bacterial 15-30%
107
What are the 2 most common causes of tonsilitis?
Viral: EBV
Bacterial: GAS
| GAS: Streptococcus pyogenes
108
List 4 s/s of bacterial tonsillitis
Sudden onset fever, sore throat, dysphagia
Inflamed pharynx: erythema, oedema, exudates
Cervical lymphadenitis
Absence of cough
109
Give 5 s/s of viral tonsillitis
Coryza: cough, runny nose
Absence of fever
Conjunctivitis
Diarrhoea
Oral ulcers, anterior stomatitis
110
When can the Centor criteria be used?
Only with recent onset (,<3 days) acute pharyngitis
111
Describe the Centor criteria
Cough absent
Exudate/ swelling on Tonsils
Node enlargement (Tender/ swollen anterior cervical LNs)
Temperature >38
OR young (3-14y= +1) or old (>44y = -1)
## Footnote
M-CENTOR
M= Must be older than 3y + have presented in ,<3 days
112
What does each score in the Centor criteria indicate?
0-2: 3-17% likelihood. No Abx.
3-4: 32-56% likelihood. Rapid strep test + Abx
113
Describe the components of the FeverPAIN score
FEVER: during previous 24h
PURULENCE: pharyngeal/ tonsilar exudate
ATTEND rapidly: within 3 days
INFLAMED: severely inflamed tonsils
NO Cough or coryza (inflammation of mucous membranes in nose)
114
What does each score in FeverPain indicate?
0-1: 13-18% likelihood. No Abx
2-3: 34-40% likelihood. Delayed Abx
4-5: 62-65% likelihood. Immediate Abx
| Likelihood of isolating streptococci
115
What investigations may be used in suspected bacterial tonsillitis?
Rapid strep test if >3y + Centor >2
Throat culture in kids to r/o GAS
## Footnote
Throat culture deferred in adults w/o RFs for GAS infection since their risk of subsequent acute rheumatic fever is low.
116
What is the most common cause of infectious mononucleosis?
Epstein-Barr virus
117
What is the classic triad of signs/ symptoms seen in infectious mononucleosis?
Sore throat
Pyrexia
Lymphadenopathy: anterior + posterior triangles of neck
118
In addition to the classic triad, what are 5 other symptoms/ signs of infectious mononucleosis?
Malaise
Anorexia
Headache
Petechiae on soft palate
Splenomegaly
119
What investigations are used for infectious mononucleosis?
Heterophil antibody test (Monospot test)
FBC
| NICE suggest FBC + monospot in 2nd week of illness
120
Give 3 abnormalities/ features of bloods in infectious mononucleosis
Hepatitis: transient rise in ALT
Lymphocytosis with at least 10% atypical lymphocytes
Haemolytic anaemia secondary to cold agglutins (IgM)
121
Describe management of infectious mononucleosis
Supportive
Rest, fluids
Simple analgesia
Avoid alcohol
Avoid contact sports for 4w to reduce risk of splenic rupture
122
What reaction occurs to patients given a certain antibiotic whilst they have infectious mononucleosis? What is the antibiotic?
Maculopapular, pruritic rash
Ampicillin/ Amoxicillin
123
What antibiotic is used in bacterial tonsilitis? What is given to penicillin-allergic individuals?
Phenoxymethylpenicillin
Clarithromycin if pen allergic
7-10 days
124
How does diptheria classically appear?
Pseudomembranous 'web' at back of throat
125
When would you admit for tonsilitis?
- Difficulty breathing
- Clinical dehydration
- Peri-tonsillar abscess (quinsy) or cellulitis
- Marked systemic illness or sepsis
- Suspected rare cause (e.g. Kawasaki disease, diphtheria)
126
Name 3 complications of tonsilitis
Peritonsillar abscess (Quinsy)
Otitis media
Rheumatic fever + glomerulonephritis (very rarely)
127
Give 4 signs and symptoms of quinsy
Severe throat pain which lateralises to 1 side
Deviation of uvula to unaffected side
Trismus (difficulty opening mouth)
Reduced neck mobility
128
What is the management for quinsy?
Urgent ENT review
Needle aspiration or I+D
IV Abx
Tonsillectomy considered to prevent recurrence
129
How frequent does tonsilitis have to be to indicate tonsillectomy?
7 bouts in 1y
5 bouts/ year for 2y
3 bouts/year for 3y
130
Other than number of episodes of tonsillitis, give 3 indications for tonsillectomy
Recurrent febrile convulsions secondary to tonsillitis
OSA, stridor or dysphagia secondary to large tonsils
Quinsy unresponsive to standard Tx
131
What are the complications of tonsillectomy?
Primary (<24h): haemorrhage (mostly due to inadequate haemostasis), pain
Secondary (>24h-10d): haemorrhage (mostly due to infection), pain
132
How should post-tonsillectomy haemorrhage be managed?
All assessed by ENT
Primary (<24h, mostly 6-8h): Immediate return to theatre
Secondary (>24h, mostly 5-10d): often a/w wound infection. Admission + co-amoxiclav. May require surgery
133
What are the signs that GAS infection has progressed to scarlet fever?
Rash ('sandpaper')
| Strawberry tongue
134
What is the risk of scarlet fever?
May progress to rheumatic fever with a week latency period
135
How should scarlet fever be managed?
Notify PHE
| Phenoxymethylpenicillin
136
What is the main RF for tonsilar SCC?
HPV infection
137
What are the symptoms of Bell's palsy?
UL facial weakness
Otalgia
Ageusia (loss of taste)
Hyperacusis (due to stapedius palsy)
138
What is Bell's sign?
Failure of eye closure --> dryness and conjunctivitis
| Seen in Bell's palsy
139
How should Bell's palsy be investigated?
Serology, possible LP
140
How should Bell's palsy be managed?
Eye care
| Prednisolone (50mg PO OD for 10 days)
141
What is the aetiology of RamsayHunt syndrome?
Reactivation of the varicella zoster virus in the genticulate ganglion of CNVII
142
What are the symptoms of Ramsay Hunt syndrome?
Otalgia
Facial nerve palsy
Vesicular rash around ear
Vertigo + tinnitus
143
Where a re vesicular lesions seen in Ramsay hunt syndrome?
External auditory canal + pinna (classically)
Anterior 2/3 of tongue + soft palate (less common)
144
How should Ramsay Hunt syndrome be managed?
Aciclovir/ Valaciclovir PO
Steroids PO
If treated within 72h, 75% recover, otherwise only 1/3 fully recover
145
If a small parotid lump enlargens very quickly, what is the likely cause?
Stone that has blocked parotid duct
146
Give 3 causes of a perforated tympanic membrane
Infection (most common)
Barotrauma
Direcr trauma
147
How long after a TM perforation should a referral to ENT be made if it hasn't healed? What may be performed in this case?
6-8w (avoid getting water in ear)
Myringoplasty (closes hole)
148
Recall some differentials for the cause of salivary gland swelling
```
Infective (TB/mumps)
Neoplastic
Calculi blockage
Autoimmune (Sjogren's/IgG4)
Sarcoidosis
```
149
How is a pharyngeal pouch managed?
Surgical repair with minimally-invasive stapling (Dohlman's procedure)
150
What are the symptoms of pharyngeal pouch?
Hallitosis
| Food getting stuck
151
What are the FeverPAIN criteria?
Fever (during previous 24h)
Purulence (pus on tonsils)
Attend rapidly (within 3 days after onset of Sx)
severely Inflamed tonsils
No cough or coryza
152
Recall the 2 most common pathogens in otitis externa
Staph aureus
Pseudomonas aeruginosa
153
Give 4 symptoms of otitis externa
Itch of ear canal
Ear pain
Discharge
Conductive HL (less common)
154
Give 4 signs of otitis externa
Tenderness of tragus +/- pinna
Red, oedematous, eczematous canal
TM erythema
Cellulitis of pinna + adjacent skin
155
Describe initial management of otitis externa
TOP Abx or combined TOP Abx + steroid 7-14d
If TM perforated, dont use aminoglycoside
Consider removal of canal debris
Insert ear wick if canal v swollen
156
Describe second line management of otitis externa
Refer to ENT
Consider contact dermatitis secondary to neomycin
Flucloxacillin PO if infection spreading
Swab inside canal
Antifungal empirically
157
How should necrotising otitis externa be managed?
Admit
Tazocin
158
Name 3 complications of otitis media
Facial nerve palsy
Chronic perforation
Mastoiditis
159
When does mastoiditis typically develop? What is the most common causative organism?
When an infection spreads from the middle ear to mastoid air spaces
Strep pneumoniae
160
Give 6 signs and symptoms of mastoiditis
Otalgia: severe, classically behind ear
Fever, v unwell
Post-auricular inflammation + erythema
Ear proptosis
Discharge if eardrum perforated
+/- Hx of recurrent otitis media
161
How is mastoiditis diagnosed? Describe management
Clinical dx
+/- CT if complications suspected
Emergency Tx with IV Abx
162
List 3 complications of mastoiditis
Facial nerve palsy
Hearing loss
Meningitis
163
What is Ludwig's angina?
Rapidly spreading infection of submandibular space
Classically "woody" to touch
Causes neck pain and drooling
164
6 predisposing factors to otitis externa
Swimming
Skin conditions Seborrhoeic dermatitis, eczema, psoriasis
Contact dermatitis (allergic + irritant): neomycin, shampoos, ear buds
Diabetes
FB, hearing aids, ear plugs
Trauma inc. cotton buds
165
What type of mouth ulcer is typically described as centralised white ulcer and erythematous “halo”?
Apthous ulcers
166
What is this a typical history for?
"an indurated ulcer involving the lateral tongue in a patient with a long-term smoking history"
Squamous cell carcinoma
167
What is Heerfordt's syndrome?
Rare manifestation of sarcoidosis characterized by the presence of facial nerve palsy, parotid gland enlargement, anterior uveitis, + low grade fever
Source: Capsule case 145
168
What is the most common type of parotid malignancy in adults?
Mucoepidermoid tumours
169
What is Warthin’s tumour?
Benign parotid tumour that typically appears in older male smokers
170
What is a pleomorphic adenoma?
benign tumour of parotid gland.
most common tumour of parotid
Typically in 40-60y.
aka: benign mixed tumour
171
Describe the pathophysiology of pleomorphic adenoma
Proliferation of epithelial + myoepithelial cells of the ducts + an increase in stromal components
Slow-growing, lobular, + not well encapsulated
172
Give 2 features of pleomorphic adenoma
Gradual onset, painless unilateral swelling of parotid gland
Mobile OE (rather than fixed)
173
Describe management and prognosis of pleomorphic adenoma
Mx: surgical excision
Prognosis:
Recurrence rate 1-5% with parotidectomy
Malignant transformation if not removed in 2-10%
174
Describe anterior bleed epistaxis
Visible source; usually due to insult to network of capillaries that form Kiesselbach's plexus
175
Give 4 features of posterior bleed epistaxis
More profuse
Originate from deeper structures
More common in elderly
Higher risk of aspiration + airway compromise
176
Describe the first aid measures used for epistaxis in a haemodynamically stable patient
Sit with torso forward + mouth open- decreases blood flow to nasopharynx, allows patient to spit blood + reduces risk of aspiration
Pinch soft area of nose firmly for 20 mins
Breathe through mouth
177
What topical antiseptic may be used alongside first aid measures for epistaxis? Why? What are contraindications to this?
Naseptin (Chlorhexidine + Neomycin)
Reduces crusting + risk of vestiubulitis
CI: peanut, soy or neomycin allergy
Alternative: Mupirocin
178
In which patients with controlled epistaxis should admission be considered?
If comorbidity present (e.g. coronary artery disease, severe HTN)
If <2y as more likely due to haemophilia or leukaemia
179
What self-care advice should be given to reduce risk of re-bleeding after epistaxis?
Avoid:
- blowing/ picking nose
- heavy lifting
- exercise
- lying flat
- alcohol + hot drinks
180
When is cautery indicated for epistaxis?
If continuous bleeding after 10-15 mins pressure + if source is visible
181
Describe cautery for epistaxis
Ask to blow their nose to remove any clots (bleeding may resume)
Use LA spray (e.g. Co-phenylcaine) and wait 3-4 mins for it to take effect
Identify bleeding point + apply silver nitrate stick for 3-10s until it becomes grey-white.
Avoid touching areas which do not require Tx
Only cauterise 1 side of septum (risk of perforation)
Dab area clean with a cotton bud + apply Naseptin or Muciprocin
182
Describe packing for epistaxis
Anaesthetise with LA spray (e.g. Co-phenylcaine) + wait for 3-4 mins
Pack nose while they sit with their head forward, following manufacturer’s instructions
Pressure on cartilage around nostril can cause cosmetic changes + should be reviewed after inserting the pack.
Examine mouth + throat for any continuing bleeding, + consider packing other nostril as this increases pressure on the septum + offending vessel.
Admit for observation + review, + to ENT if pos
183
What surgical management can be used for epistaxis that has failed all emergency management?
Sphenopalatine ligation
184
List 3 products that can be used for nasal packing
Nasal tampon
Inflatable pack e.g. Rapid-Rhino
Ribbon gauze impregnated with vaseline
185
What is binocular vision post-facial trauma indicative of?
Depressed fracture of zygoma
186
What intranasal treatments are used for the treatment vs prophylaxis of sinusitis?
Tx: intranasal decongestant
Prophylaxis: intranasal corticosteroid
187
4 features of Thyroglossal cyst
Midline
Non-tender (can be tender if infected)
Mobile
Moves up with protrusion of tongue
188
What are exostoses?
Benign bony growths in external auditory canal
Due to repeated exposure to cold water + wind
Causes conductive hearing loss
189
List 3 potential complications following thyroid surgery
Anatomical: recurrent laryngeal nerve damage
Bleeding: owing to confined space, haematomas may lead to rapid respiratory compromise due to laryngeal oedema
Damage to parathyroid glands resulting in hypocalcaemia
190
List 6 indications to refer make 2ww referral to oral surgery
ue oral ulceration/ mass persisting >3w
ue red/ red+ white patches that are painful, swollen or bleeding
ue 1 sided pain in H+N area >4w a/w earache but no abnormal findings on otoscopy
ue recent neck lump/ previously undiagnosed lump that has changed over 3-6w
ue persitent sore/ painful throat
S/S in oral cavity persisting >6w that can't be definitively diagnosed as a benign lesion
| UE = unexplained
191
What abnormality in ECG timing may be caused by hypocalcaemia?
Prolonged QT interval
192
Give 2 indications to refer under 2ww for potential laryngeal cancer
Persistent unexplained HOARSENESS
Unexplained LUMP in the neck
193
Give 2 indications to refer under 2ww for potential oral cancer
Unexplained ULCERATION in oral cavity lasting >3w
Persistent + unexplained LUMP in neck
194
Give 2 indications to refer to a DENTIST under 2ww for potential oral cancer
LUMP on lip or in oral cavity
Red or Red + white patch in oral cavity consistent with erythroplakia or erythroleukoplakia
195
Give 1 indications to refer under 2ww for potential thyroid cancer
Unexplained thyroid lump
196
Give 1 indication to refer under 2ww for potential nasopharyngeal cancer
Hearing loss + unilateral middle ear effusion not related to URTI in a Chinese or SE Asian patient
197
What is malignant otitis externa?
Uncommon type of otitis externa
Infection commences in soft tissues of external auditory meatus, progresses to temporal bone osteomyelitis
198
What is the most common cause of malignant otitis externa?
Pseudomonas aeruginosa
199
Give 2 risk factors for malignant otitis externa
Diabetes (90% cases)
Immunosuppression
200
Give 8 signs and symptoms of malignant otitis externa
Severe, unrelenting, deep-seated otalgia
Purulent otorrhea
Profound conductive HL
Vertigo
Ipsilateral facial nerve palsy
Temporal headaches
Systemically unwell, fever
+/- Dysphagia + Hoarseness
201
What investigation is used for malignant otitis externa?
CT
202
Describe management of malignant otitis externa
Urgent referral to ENT
IV Abx that cover pseudomonal infections
203
4 causes of epiglottitis
Haemophilus influenzae B (traditionally)
Streptococcus pyogenes
Streptococcus pneumoniae
Staphylococcus aureus
204
Give 8 signs and symptoms of epiglottitis
Rapid onset sore throat
Fever
Inspiratory stridor
Drooling of saliva
Dysphagia
'Tripod' position
Toxic appearance
"Hot potato" voice
205
What investigations are performed in epiglottitis?
Clinical dx
Do NOT examine throat
If X-ray is performed, lateral view: swelling of epiglottis = 'thumb sign'
206
Describe management of epiglottitis
Immediate senior involvement: anaesthetists, ENT
+/- endotracheal intubation
IV Abx: Cefotaxime, Ceftriaxone
O2
207
Describe the epidemiology of epiglottitis
Adults > Children (since HiB vaccine)
Peak in kids 6-12y
Peak in adults 40-50y
208
What is a Branchial cyst?
Benign developmental defect in branchial arches
Filled with acellular fluid with cholesterol crystals
Encapsulated by stratified squamous epithelium
209
When do branchial cysts usually present?
Late childhood-early adulthood
210
Give 6 features of branchial cysts
Unilateral (typically LHS)
Lateral, anterior to sternocleidomastoid
Slowly enlarge
Smooth, soft, fluctuant
Non tender
Fistula may be seen (RF for infection)
211
Give 2 features on examination of a branchial cyst
No movement on swallowing
No transillumination
212
Describe investigations and management for branchial cysts
Consider + r/o malignancy
USS
ENT referral
FNA
Mx: conservative/ surgical excision
Abx for infections
213
What is the most common cause of neck swellings?
Reactive lymphadenopathy
Hx local infection or generalised viral illness
214
Give 3 features of lymphoma neck lumps
Rubbery, painless
Pain on drinking alcohol is RARE
+/- night sweats + splenomegaly
215
Give 2 features of thyroid swellings
Hypo-, Eu- or Hyper-thyroid
Moves UP on swallowing
216
Give 4 features of thyroglossal cyst neck lumps
More common in <20s
Usually midline, between isthmus of thyroid + hyoid bone
Moves up with protrusion of tongue
+/- pain if infected
217
In which group is pharyngeal pouch more common?
Older men
218
What does a pharyngeal pouch represent?
Posteromedial herniation between thyropharyngeus + cricopharyngeus muscles
219
Describe the appearance of pharyngeal pouches
Usually not seen
If large: midline lump that gurgles on palpation
220
Give 4 signs/ symptoms experienced with a pharyngeal pouch
Dysphagia
Regurgitation
Aspiration
Chronic cough
221
What is a cystic hygroma?
Congenital lymphatic lesion (Lymphangioma) typically in neck on LHS
Most evident at birth: 90% present before 2y
222
If a cystic hygroma was aspirated, what would be found?
Lymph
223
Give 2 features of cervical ribs
More common in adult females
~10% develop thoracic outlet syndrome
224
Describe the appearance of a carotid aneurysm
Pulsative lateral neck mass
Doesn't move on swallowing
225
What type of hearing loss is seen in:
* tympanic membrane perforation
* base of skull fracture
| (after trauma to the head)
TM perforation: CHL
Base of skull #: SNHL
226
What is Wallenberg syndrom? How does it present?
Posterior inferioer cerebellar artery stroke
Vertigo
Nystagmus
Ipsilateral facial pain
Contralateral loss of temperature sensation
227
Describe obstructive sleep apnoea
recurrent episodes of complete or partial obstruction of upper airway during sleep, causing apnoea (complete airflow obstruction with temporary absence or cessation of breathing) or hypopnoea (decreased airflow)
228
How does obstructive sleep apnoea differ from obstructive sleep apnoea syndrome?
OSA: irregular breathing at night, no Sx
OSAS: irregular breathing at night + excessive daytime sleepiness
229
Give 6 predisposing factors for obstructive sleep apnoea
Male
Obesity
FH
Macroglossia: acromegaly, hypothyroidism, amyloidosis
Adenotonsillar hypertrophy
Craniofacial abnormalities
230
List 3 lifestyle factors that may contribute to obstructive sleep apnoea
Smoking
Alcohol
Sleeping supine
231
List 3 consequences of obstructive sleep apnoea
Daytime somnolence
Compensated respiratory acidosis
HTN
232
How can sleepiness be assessed in suspected obstructive sleep apnoea?
Epworth Sleepiness scale: questionnaire
STOP-Band questionnaire
Multiple Sleep Latency Test: measures time to fall asleep in dark room
233
What investigations are used in obstructive sleep apnoea?
Refer to sleep clinic
Sleep studies (polysomnography)
234
List 3 specialist treatments for obstructive sleep apnoea in adults
CPAP (mod-sev)
Mandibular advancement device (mild)
Upper airway surgery (if nasopharyngeal obstruction causing Sx)
235
Name 2 specialist treatments for obstructive sleep apnoea in children
Adenotonsillectomy: if hypertrophy- usually curative
CPAP
236
List 4 conservative measures for obstructive sleep apnoea
Weight loss
Smoking cessation
Reducing alcohol intake
Avoid sleeping on back (use pillows to prop on side)
237
What is allergic rhinitis?
Inflammatory disorder of nose where nose becomes sensitised to allergens e.g. house dust mites + grass, tree + wood pollens
238
How can allergic rhinitis be classified?
Seasonal: Sx occur around same time each year
Perennial: Sx throughout year
Occupational: Sx following exposure to allergens in workplace
239
Give 5 s/s of allergic rhinitis
Sneezing
Bilateral nasal obstruction
Clear nasal discharge
Post-nasal drip
Nasal pruritis
240
Describe management of allergic rhinitis
Allergen avoidance
Mild-mod: Antihistamines PO/ intranasal
Mod-sev: CS intranasal
Important life events: short course CS PO
