ENT Flashcards

Question

LPR features?

Answer 1

Laryngopharyngeal reflux (LPR) is a condition caused by gastro-oesophageal reflux resulting in inflammatory changes to the larynx/hypopharynx mucosa. It is a common diagnosis and thought to account for around 10% of ear, nose and throat referrals. Features around 70% of patients have the sensation of a lump in the throat - 'globus' typically felt in the midline typically worse when swallowing saliva rather than eating or drinking other features hoarseness (70%) chronic cough (50%) dysphagia (35%) heartburn (30%) sore throat examination findings the external examination of the neck should be normal, with no masses the posterior pharynx may appear erythematous Diagnosis in the absence of red flags a clinical diagnosis of LPR can be made without further investigations the NICE cancer referral guidelines should be reviewed for red flags, examples of which include: persistent, unilateral throat discomfort dysphagia, odynophagia (i.e. with food rather than just saliva) persistent hoarseness Management lifestyle measures possible triggers include fatty foods, caffeine, chocolate and alcohol proton pump inhibitor sodium alginate liquids (e.g. Gaviscon)

Answer 2

The indications for tonsillectomy are controversial. NICE recommend that surgery should be considered only if the person meets all of the following criteria sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections) the person has 7 episodes per year for one year, 5 per year for 2 years, or 3 per year for 3 years, and for whom there is no other explanation for the recurrent symptoms) the episodes of sore throat are disabling and prevent normal functioning Other established indications for a tonsillectomy include recurrent febrile convulsions secondary to episodes of tonsillitis obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils peritonsillar abscess (quinsy) if unresponsive to standard treatment

Answer 3

In adults, patients should have completed a trial of appropriate hearing aids for at least 3 months which they have been objectively demonstrated to receive limited or no benefit from.

Answer 4

erythematous areas with a white-grey border (the irregular, smooth red areas are said to look like the outline of a map) some patients report burning after eating certain food Management reassurance about benign nature

Answer 5

- More common in patients < 20 years old. - Usually midline, between the isthmus of the thyroid and the hyoid bone - Moves upwards with protrusion of the tongue - May be painful if infected

Answer 6

- More common in older men - Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles - Usually not seen but if large then a midline lump in the neck that gurgles on palpation - Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Answer 7

- A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side. - Most are evident at birth, around 90% present before 2 years of age.

Answer 8

- An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx. - Develop due to failure of obliteration of the second branchial cleft in embryonic development - Usually present in early adulthood

Answer 9

- Aspirin/NSAIDs - Aminoglycosides - Loop diuretics - Quinine

Answer 10

1. Analgesia 2. Intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited. 3. Intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days. 4. Oral antibiotics are not normally required but may be given for severe presentations. The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if 'systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications'. 'double-sickening' may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection

Answer 11

******************** - In sensorineural hearing loss both air and bone conduction are impaired. - In conductive hearing loss only air conduction is impaired. - In mixed hearing loss both air and bone conduction are impaired, with air conduction often being 'worse' than bone.

Answer 12

Glue ear describes otitis media with an effusion (other terms include serous otitis media). Features: - Peaks at 2 years of age - Hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood). - Secondary problems such as speech and language delay, behavioural or balance problems may also be seen Treatment options include: - Active observation: the management for a child with a first presentation of otitis media with effusion is active observation for 3 months - no intervention is required - Grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months - Adenoidectomy

Answer 13

The most common cause of a perforated tympanic membrane is infection. Other causes include barotrauma or direct trauma. A perforated tympanic membrane may lead to hearing loss depending on the size and also increase the risk of otitis media. Management: - No treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time. - It is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. NICE support this approach in the 2008 Respiratory tract infection guidelines. - Myringoplasty may be performed if the tympanic membrane does not heal by itself

Answer 14

Definitive treatment can only be given by a dentist and antibiotics will not eliminate the source of infection. Antibiotics are generally not indicated in an otherwise healthy individual unless they are systemically unwell or have signs of severe infection. 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 infection is severe or spreading, or the patient has systemic signs of infection metronidazole should also be prescribed.

Answer 15

- Sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections) - The person has 7 episodes per year for one year, 5 per year for 2 years, or 3 per year for 3 years, and for whom there is no other explanation for the recurrent symptoms). - The episodes of sore throat are disabling and prevent normal functioning Other established indications for a tonsillectomy include: - recurrent febrile convulsions secondary to episodes of tonsillitis obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils - peritonsillar abscess (quinsy) if unresponsive to standard treatment

Answer 16

A reactivation of varicella-zoster virus (VZV) in the geniculate ganglion of the facial nerve (CN VII). Causes a triad of: 1. Ipsilateral facial paralysis (like Bell’s palsy) 2. Vesicular rash in the ear canal/pinna/tympanic membrane 3. Ear pain Other features include vertigo and tinnitus Management: oral aciclovir and corticosteroids are usually given

Answer 17

Phenytoin Ciclosporin Calcium channel blockers (especially Nifedipine)

Answer 18

Laryngeal cancer - Consider a suspected cancer pathway referral for laryngeal cancer in people aged 45 and over with: persistent unexplained hoarseness or an unexplained lump in the neck Oral cancer Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either: unexplained ulceration in the oral cavity lasting for more than 3 weeks or a persistent and unexplained lump in the neck. Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either: a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia. Thyroid cancer Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump.

Answer 19

Horizontal nystagmus

Answer 20

Management options include: - recommending soft foods - simple analgesia including paracetamol and NSAIDs - short-courses of benzodiazepines may be helpful - review by a dentist

Answer 21

Haemorrhage is a feared complication following tonsillectomy. All post-tonsillectomy haemorrhages should be assessed by ENT!! Even if the bleed has stopped by the time of assessment the patient is at risk of further haemorrhage and will usually need same day ENT assessment. Often these patients are admitted for 24 hours for observation to allow prompt surgical management of any non-resolving bleeds. Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre. Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in around 1-2% of all tonsillectomies.

Answer 22

Fever in last 24 hours Purulence (purulent tonsils) Attend rapidly (3 days or less from onset) Inflamed tonsils No cough or coryza Score 0 - 1: No Abx Score 2 -3: Consider delayed script Score 4 -5: Consider antibiotics

Answer 23

Penicillin V for 10 days If allergic: Clarithromycin/erythromycin for 5 days

Answer 24

Leukoplakia is a premalignant condition which presents as white, hard spots on the mucous membranes of the mouth. It is more common in smokers. Leukoplakia is said to be a diagnosis of exclusion. Candidiasis and lichen planus should be considered, especially if the lesions can be 'rubbed off' 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 25

Urgent referral 2WW for suspected laryngeal cancer for patients over the age of 45 with: - Persistent unexplained hoarseness >3 weeks - An unexplained lump in the neck

Answer 26

Recent guidance suggests considering immediate antibiotic prescribing in: - Children under two years of age with bilateral AOM. - Children with otorrhoea and AOM who are systemically unwell or at high risk of complications (e.g. the immunosuppressed or those with diabetes).

Answer 27

First-line Phenoxymethylpenicillin . or if the patient is allergic/intolerant to penicillin then doxycycline, clarithromycin or erythromycin can be used. Co-amoxiclav is given if there are signs of severe illness or after no improvement with first-line antibiotics.

Answer 28

For people presenting within 72 hours of the onset of symptoms, consider prescribing prednisolone. Options include: - Giving 50 mg daily for 10 days or - Giving 60 mg daily for 5 days followed by a daily reduction in dose of 10 mg (for a total treatment time of 10 days) if a reducing dose is preferred. Antiviral treatments alone are not recommended. Antiviral treatment in combination with a corticosteroid may be of small benefit, but seek specialist advice if this is being considered. This patient has potential prodromal features of a herpes infection - it's possible that the rash has not yet developed, so discussion about the use of antivirals may be helpful.

Answer 29

Sialolithiasis which is diagnosed using sialogram. In sialogram, the ductal opening is cannulated, and the radiopaque dye is administered into the gland. Plain radiographs are taken at different time intervals to visualise the ductal system, the glandular parenchyma as well as filling defects and strictures.

Answer 30

It can present as a cystic swelling below or at the level of the hyoid bone within the midline. On examination, the cyst moves superiorly on protrusion of the tongue or on swallowing. They have a tendency to present following an upper respiratory tract infection. Elective surgical intervention is usually indicated to reduce the risk of future infection.

Answer 31

Guidelines recommend offering tonsillectomy to children with seven or more documented severe sore throats in one year; five or more yearly in two successive years; or three or more yearly in three successive years (the Paradise criteria).

ENT Flashcards

(56 cards)