1
Q
GO REVISE SEM 3: HEAD & NECK ANATOMY OF MOUTH & NOSE
A
2
Q
Label the following structures on the diagram:
- Nares
- Septum (body & cartilaginous)
A
3
Q
Label the following structures on the diagram:
- Superior, middle & inferior conchae/turbinates
- Sinuses (frontal, maxillary, sphenoid, ethomoid)
- Hard & soft palate
- Post-nasal space/nasopharynx
- Cribriform plate
- Opening of Eustachain tube
A
4
Q
Where is Little’s/Keisselbach’s area?
Why is it clinically relevant?
A
Anastomoses of 5 arteries- common site of bleeding for anterior nasal bleeds
5
Q
Label the following on the diagram:
- Anterior & posterior pillars
- Tonsils
- Uvula
- Posterior pharyngeal wall
A
6
Q
Label the following on the diagram:
- Parotid salivary galnds
- Submandibular salivary glands
- Sublingual salivary gland
- SCM
- Hyoid bone
*
A
7
Q
Label the following on the diagram:
- Cricoid cartilage
- Thyroid cartilage
- Thyroid gland
- Parathyroid galnds
A
8
Q
Discuss how you would examine the nose
A
- Inspect external nose: inspect for skin changes, deformity
- Nasal cavity inspection: ask pt to look forward keeping their head in neutral position, elevate tip of nose with thumb so that nasal cavity becomes visible and use a light to illuminate cavity. Inspect muscosa and septum
- Further inspection of internal nose: use otoscope with large speculum attached or nasal speculum with a light to look further into nose. Assess nasal vestibule for inflammation, ucleration, oedea. Inspect nasal septum for polyps, deviation, perforation, haematoma. Inspect inferior turubinates for any asymmetry, inflammation or polyps.
- Palpate nasal bone & cartilage: palpate nasal bones assessing for alignment, tenderness, irregularity. Palpate nasal cartilage assessing for alignment and tenderness. Palpate infraorbital ridges and assess eye movement if there is history of orbital blow out fracture.
- Assess air flow of both nostrils:either feel for air with your finger or use metal prong and look for misting as pt breathes out
** SEE GEEKY MEDICS FOR FULL
9
Q
Discuss how you would examine the throat/oral cavity
A
- General inspection: inspect face for any swelling e.g. parotid, submandibular
- Closer inspection: ask pt to open mouth and use light source to illuminate. Inspect lips for angular stomatitis, hyperpigmentated macules, ulceration. Inspect teeth for any missing teeth, decay, nicotine staining. Inspect gums for gingivitis, periodonitis, ulceration. Inspect tongue for oral candidiasis, glossitis, ulceration, hairy leukoplakia. Inspect buccal mucosa for apthous ulcers or other ulcers, parotid duct. Inspect palate and uvula for candiadiasis, ulceration, papillomas. Inspect tonsils enlargement, asymmetry, ulceration, stones. Inspect pharyngeal arches. Inspect uvula for deviation. Ask pt to life tongue and insepct floor of mouth for further ulceration & salivary gland pathology.
- Palpation: palpate any lumps, the paraotid gland, sublingual and submandibular gland. Note size, thickness, colour, consistency & tenderness of any lumps.
**SEE GEEKY MEDICS FOR FULL
10
Q
Discuss how you would examine the neck
A
- General inspection: scars, cachexia, hoarse voice, dyspnoea or stridor, behaviour, clothing, exophthalmos
- Inspect neck lump from front and side noting its location
- If lump is in midline, do some further tests: ask pt to swallow, ask pt to protrude tongue
- Palpate neck lump: assess for size, shape, consistency, mobility, flucutance, temperature, overling skin changes, pulsatility, tenderness, transillumination, vascular bruit
- Assess lymph nodes: palpate all cervical lymph nodes noting size, shape, consistency, tenderness, mobility, overlying skin changes
- Palpate thyroid: stand behind pt, ask to tilt chin slightly down, place 3 middle fingers of each hand along midline below chin. Start at thyroid cartilage, move down to cricoid cartilage, then move down to first 2 rings of trachea to find isthmus. Palpate isthmus then move out laterally to palpate lobes. Ask pt to swallow and feel for symmetrical elevation of thyroid gland. Ask pt to stick out their tongue. Note size, symmetry, consistency, any massess of thyroid, any thrills. Listen for thyroid bruits
11
Q
What 3 sensory inputs aid the balance system?
A
- Vision
- Proprioception
- Vestibular system
These sensory inputs are processed by brain and the efferent pathways then act on extra-occular muscles to adjust eye position and limb & trunk muscles to maintain body position.
12
Q
Define vertigo
A
Feels like you, or everything around you, is spining
13
Q
Define syncope
Define pre-syncope
A
- Syncope, also known as fainting, is a loss of consciousness and muscle strength characterized by a fast onset, short duration, and spontaneous recovery
- Pre-syncope: sensation that you are going to faint/syncope
14
Q
Define nystagmus
Explain what is meant by the slow phase and fast phase of jerk nystagmus
A
- Nystagmus= involuntary eye movements
- Jerk nystagmus is a rhythmic eye oscillation characterized by a slow drift of the eyes in one direction that is repeatedly corrected by fast movements in the reverse direction. Slow phase is when eyes drift in one direction, fast phase is fast movement of eyes to correct the slow drift. We refer to nystagmus by describing the direction of the fast phase
15
Q
For acute sinusitis, discuss:
- What it is
- Causes
- Symptoms & signs
A
- Sinusitis= symptomatic inflammation of paranasal sinuses
- Usually triggered by viral upper respiratory tract infection however can also be bacterial sinusitis
- Signs & symptoms:
- Nasal blockage or discharge
- Facial pain/pressure/headahce
- Reduction in sense of smell (adults)
- Cough (child)
- Nasal inflmmation
- Mucosal oedema
- Mucopurulent nasal discharge
16
Q
Discuss how to differentiate between viral and bacterial sinusitis/when so to suspect bacterial sinusitis
A
Suspect acute bacterial sinusitis when symptoms:
- Last longer than 10 days
- Include discoloured or prurulent nasal discharge
- Severe local pain
- Fever greater than 38 degrees celcius
- Deterioration after an initial mild illness
17
Q
State the ‘time frames’ for acute and chronic sinusitis
A
- Acute <12 weeks
- Chronic >12 weeks
18
Q
Discuss the management of acute sinusitis in primary care
A
Usually self-limiting therefore:
- Advice that will get better on its own (2-3 weeks)
- Analgesia for fever or pain
- Consider need for antibiotics if suspect bacterial- phenoxymethylpenicillin or doxycycline if penicillin allergic. If symptoms still worsening can try co-amoxiclav
- Consider high dose intranasal corticosteroids in adults with severe or more prolonged symptoms (>10 days)
- Safety net: if symptosm worsen rapidly or significantly or become systemcially unwell seek medical attention
19
Q
Discuss the management of chronic sinusitis
A
- Advise that chronic sinusitis may last several months
- Control any associated conditions e.g. allergic rhinitis, asthma
- Other advise:
- Avoid allergic triggers
- Stop smoking
- Good dental hygience (reduce risk of dental infection- which is associated with chronic sinusitis)
- Consider nasal irrigation
- Consider course of intranasal steroids e.g. mometasone, fluticasone for 3 months (particularly if allergic cause)
- Consider need for long-term antibiotics; only start after consultation with specialist
20
Q
When would arrange urgent hospital admission for someone with sinusitis?
A
- Severe systemic infection
- Complications developed e.g. orbital or intracranial involvement
21
Q
State some predisposing factors for sinusitis
A
- Asthma
- Allergic rhinitis
- Smoking
- Anatomical variations e.g. deviated nasal septum, nasal polyps, trauma, foreign body
- Impaired ciliary motility e.g. cystic fibrosis
- Immunocompromised
22
Q
Discuss how thyroid nodules may present
A
Usually asymptomatic hoever if nodules become large enough patient may present with:
- Visible swelling
- SOB (compression of trachea)
- Dysphagia (compression of oesophagus)
If nodules are producing thyroxine may present with features of hyperthyroidism e.g:
- Unexplained weight loss
- Tremor
- Sweating
- Diarrhoea
- Tachycardia/palpitations
- Oligo- or amenorrhoea
- Loss of libido
23
Q
What investigations would you do if you suspect thyroid nodule (in a patient that doesn’t need urgent referral)?
A
- TFTs
- Referral to endocrinology for further investigations e.g. USS, needle aspiration biopsy
24
Q
When would you arrange emergency admission to hospital for thyroid lump?
When you would arrange urgent referral to specialist for a thyroid lump?
A
- Emergency hospital admission= airway obstruction
- Urgent referral to specialist (within 2 weeks):
- An unexplained thyroid lump.
- A thyroid mass associated with unexplained hoarseness or voice change.
- A thyroid mass associated with cervical lymphadenopathy or supraclavicular lymphadenopathy.
- Sudden onset of a rapidly expanding painless thyroid mass, significantly increasing in size over days and weeks.
- A suspected thyroid nodule with other red flags or risk factors for malignancy.
- Child
25
Remind yourself of some red flags for neck lumps
* Persisting \>6 weeks
* Fixed, hard, irregular
* Rapidly growing in size
* Associated with generalised lymphadenopathy
* Associated systemic symptoms e.g. weight loss, night sweats
* Associated with persistent unexplained change in voice/hoarseness or difficulty swallowing
26
For allergic rhintis, discuss:
* What it is
* Symptoms and signs
* If any investigations are required
* Management
* Inflammation of nasal mucosa due to allergy; IgE mediated
* Symptoms & signs:
* Nasal congestion
* Rhinorrhoea
* Nasal itching
* Sneezing
* Associated conditions: allergic conjunctivitis, eczema, asthma
* May refer to specialist for allergy testing but this if condition is refractory to treatment
* Management:
* **Allergen avoidance**
* **Nasal irrigation**
* **Intranasal antihistamines** (e.g. aelastine)
* **Oral antihistamines** (e.g. loratadine, cetirizine)
* **Intranasal corticosteroid** e.g. beconase spray
* Local cromone (prevent histamine release from mast cells)
* Intranasal antimuscuranic
* Leukotriene receptor antagonist
* Short course of oral corticosteroids for severe uncontrolled symptoms that are significantly impacting life
27
Discuss the different types of allergic rhinitis
* **Seasonal** — symptoms occur at the same time each year. If caused by grass and tree pollen allergens, it is also known as 'hay fever'.
* **Perennial** — symptoms occur throughout the year, typically due to allergens from house dust mites and animal dander.
* **Intermittent** — symptoms occur for less than four days a week, or less than four consecutive weeks.
* **Persistent** — symptoms occur for more than four days a week and for more than four consecutive weeks.
* **Occupational** — symptoms due to exposure to allergens in the work environment, for example, flour allergy in a baker.
28
For nasal polyps, discuss:
* What they are
* Risk factors
* Symptoms & signs
* Benign growth/tumour of nasal mucosa
* Risk factors:
* Asthma
* Aspirin sensitivty/allergy
* Symptoms & signs:
* Nasal blockage
* +/- change in smell
* Rhinorrhoea
* Post-nasal drip (may describe as constant need to swallow)
* Snoring
* Epistaxis
* Yellow/grey fleshy growths of mucosa upon rhinoscopy- bilateral!
29
Discuss the management of nasal polyps, consider medical & surgical management
_Medical Management_
1. Intransal steroids
2. If polyps are large or intranasal treatment hasn't worked can give short course (1-2 week) of oral steroids (e.g. prednisolone 0.5mg per kg) followed by maintenance intranasal steroid spray e.g. mometasone
_Surgical Management_
* Removal of polyps (e.g.. via simple endoscopic nasal polypectomy or functional endoscopic sinus surgery)
30
Discuss the difference between inflammatory/allergic polyps and anto-choanal polyps
* **Inflammatory/allergic**: multiple polyps associated wtih chronic rhinosinusitis
* **Anto-choanal**: single polyp arising from maxillary sinus extending outwards towards nasopharynx causing unilateral nasal obstruction
31
A single unilateral polyp is....
Cancer until proven otherwise
Refer to ENT
32
Remind yourself of the cervical lymph nodes; include the superficial (regional) and deep (terminal) lymph nodes
Superficial nodes are found in superficial fascia. Deep noes are deep to the investing layer of fascia. Superficial nodes drain into deep nodes.
_Regional lymph nodes_
* Submental
* Submandibular
* Pre-auricular
* Post-auricular/mastoid/retroauricular
* Occipital
* Superficial cervical (along EJV)
* Posterior cervical (along EJV)
* Anterior cervical (along AJV)
_Deep lymph nodes *(closely related to IJV)*_
* Jugulo-digastric
* Jugulo-omohyoid
* Supraclavicular
33
Dicuss what structures/regions drain in to the following lymph nodes
_Regional lymph nodes_
* **Submental:** *tip of tongue & lip*
* **Submandibular:** *middle & part deeper tongue, mouth, lateral nose NOTE: deeper tongue will also drain into jugulo-diagrastic*
* **Pre-auricular:** *eye and anterior to the ear*
* **Post-auricular/mastoid/retroauricular:** *posterior to ear*
* **Occipital:** *occiptal region/back of head*
* **Superficial cervical (along EJV):** *s**uperficial surfaces of neck*
* **Posterior cervical (along EJV): ???**
* **Anterior cervical (along AJV): ????**
_Deep lymph nodes (closely related to IJV)_
* **Jugulo-digastric:** *tonsils, oral cavity, deep/posterior tongue*
* **Jugulo-omohyoid:** *deep/posterior tongue,* *oral cavity, oesphagus, trachea, thyroid*
* **Supraclavicular:** *lung ca, GI ca,*
34
What is benign paroxysmal positional vertigo (BPPV)?
Discuss the pathophysiology of BPPV
* Disorder of the inner ear characterized by repeated episodes of positional vertigo that lasts a few seconds and is often triggerd by head movement or bending down
* Otoconia are biocrystals present in the utricle and saccule of vestibular apparatus. They are located above stereocilia and kinocilia (hair cells that detect movement) and are displaced in response to movement; this causes depolarisation of hair cells and is perceived as movement. When these otoconia get into the semi-circular canals- most commonly the posterior canal- the detached otoconial debris, in addition to the endolymph, may continue to stimulate hair cells even after head movements have ceased. This leads to an abnormal sensation of vertigo and nystagmus when the head moves in the plane of the affected semi-circular canal. Process called **canalolithiasis.**
35
BPPV is the most common cause of vertigo; true or false?
True
36
Who does BPPV most commonly present in, include age and gender
* 50-70yrs
* Women \> men
37
State some potential causes/risk factors for BPPV
* Head injury
* Prolonged recumbent position
* Ear surgery
* Following episode of inner ear pathology
38
Discuss the typical presentation of BPPV
* Episodes of vertigo lasting \<1 min
* Symptoms brought on by specific movements e.g. lying down, turning over in bed etc...
* +/- nausea & vomitting
39
Discuss how to diagnose BPPV
Dix-Hallpike manoeuvre
* Get patient to sit facing forwards, stand at side of them
* Turn their head 45 degrees towards you and observe eyes for 30 seconds
* Lie them down so that head is extended 20-30 degrees and observe eyes for up to 1 minute to see if nystagmus is present
* Do this on both sides
40
Discuss the management of BPPV
* Watch & wait to see if symptoms settle without treatment however must explain that treament may help resolve problem quicker
* Treatment options include:
* Epley manoeuvre
* Brandt-Daroff exercises
* Follow up in 4 weeks if symptoms not resolved
41
Describe the Epley manoeuvre
* Turn head 45 degrees towards affected side
* Lie pt down and extend by 20-30 degrees
* After 30-60secs turn head to other side and hold for same amount of time
* Turn pt onto side and turn head 45 degrees from horizontal
* Have patient sit up
*\*Trying to manipulate crystal to move towards canal opening*
42
Describe Brandt-Daroff exercises
1. Start sitting upright on the edge of the bed
2. Turn your head 45 degrees to the left, or as far as is comfortable
3. Lie down on your right side
4. Remain in this position for 30 seconds or until any dizziness has subsided
5. Sit up and turn head back to centre
6. Turn your head 45 degrees to the right, or as far as is comfortable
7. Lie down on your left side
8. Remain in this position for 30 seconds or until any dizziness has subsided
9. Sit up and turn head back to centre.
The above description is one repetition. The exercises should be performed in a set of **5 repetitions**. They should be performed **three times a day for two weeks.**
43
When would you consider referral to ENT specialist for BPPV?
* Cannot provide Epley manoeuvre in primary care
* Physical limitations affect safety or practicality of carrying out Epley manoeuvre
* Canalith repositioning procedures have been performed and repeated but symptoms still present
* Symptoms and signs are atypical
* Symptoms & signs not resolved in 4 weeks
* Three or more periods in which person has experienced vertigo
44
Discuss the prognosis of BPPV
* Relapsing & remitting course; around half of people with BPPV will have recurrence of symptoms 3-5yrs after diagnosis
* 20% people recover spontaneously after 1 month, 50% after 3 months
45
For deviated nasal septum, discuss:
* Possible causes
* Signs & symptoms
* Diagnosis
* Possible causes: *impact trauma, congenital compression, genetic connective tissue disorders*
* Signs & symptoms:
* Nasal obstruction
* Recurrent sinus infections
* Recurrent otits media
* Nose bleeds
* May see septum deviated when do rhinoscopy
* Diagnosis: mainly based on history and examination
*\*NOTE: some degree of septal deviation is common; symptoms only occur in more severe cases*
46
Discuss the management of septal deviations
No treatment necessary if minor deviation and minimal symptoms. Treatment options for symptomatic releif includes:
* Decongestants
* Antihistamines
* Nasal strips
Surgical management inlcudes septoplasty which may be combined with rhinoplasty (cosmetic surgery)
47
What is a potential serious complication of septal deviation?
Septal haematoma
48
For nasal fracture, discuss:
* Signs & symptoms
* Investigations
* Signs & symptoms:
* Obvious deformity/deviation
* Instability & crepitus
* Swelling & bruising
* Epistaxis
* Rhinnorrhoea (clear, watery, one nostril)
* Investigations: *diagnosis largely based on history and clinical examination as x-rays miss ~50% of these fractures. X-rays generally ony used to rule out involvement of other important facial structures e.g. orbit, cheek bones, jaw etc...*
49
Discuss the management of nasal fracture
Management depends on if complicated or uncomplicated:
_Uncomplicated_
* Advise healing time 2-3weeks
* Ice packs
* Analgesia & anti-inflammatories: paracetamol & ibruprofen
* Abx if laceration overlying fracture or haematoma has been lanced & drained as may pre-dispose ot infection
* Follow up with ENT in 5-7 days where they will reset nose
* Safety net: if get worsening nasal obstruction & pain seek medical attention as may be septal haematoma
_Complicated_
* Refer to specialist straight away
*
50
For vestibular migraines, discuss:
* What they are
* Cause
* Triggers
* Management
* Dizziness or verigo associated with migraines
* Symptoms can include those of migraines and dizziness or vertigo
* Exact cause is unknown however thought that genetics have a role
* Triggers: *stress/anxiety, food or drink, lack of sleep, environmental factors, hormonal changes*
* Management:
* Avoid triggers
* Analgesia e.g. paracetamol, ibruprofen or triptans
* Antiemetics
* Prophylactic treatment e.g. beta blockers or antidepressants
51
What is vestibulopathy?
State some potential causes of vestibulopathy
Discuss potential presentation of vestibulopathy
* Vestibulopathy= disorder of vestibular function of inner ear
* Causes:
* Ototoxic medications
* Inflammation or infection e.g. vestibular neuronitis, labyrinthitis
* Tumour e.g. acoustic neuroma
* Old age
* Ear surgery
* Presentation:
* Vertigo
* Imbalance
* Nausea/vomitting
* Migraine
52
What investigations would you do for vestibular neuroma
* Audiometry
* Balance tests
* Visual tests
* MRI/CT
53
Discuss the management of vestibulopathy
* **TREAT UNDERLYING CAUSE**
* Vestibular rehabilitation therapy
* Medication for symptom relief e.g. antiemetics, antihhistamines
* Surgery if required
54
For tonsillitis, discuss:
* What it is
* Common causes
* Who is it common in
* Symptoms & signs
* **Inflammation of tonsils**
* **Most commonly caused by viral infection** but can be caused by bacteria. Most common causative bacteria is **group A Streptococcus (Streptococus pyogenes)**. Second most common bacterial cause= **Streptococcus pneumoniae.**
* Children aged 5-10yrs, then another peak aged 15-20yrs
* Symptoms & signs:
* Sore throat
* Painful swallowing
* Fever
* Headache
* Red, inflamed & enlarged tonsils
* May see exudate on tonsils
* Note: younger children may present with vague symptoms
55
What must you also examine someone presents with a sore throat?
* Throat
* Cervical lymph nodes
56
What two criteria can we use to estimate the probability that tonsilitis is due a bacterial infection and will benefit from antibiotics?
* Centor criteria
* FeverPAIN score
57
58
Describe the centor criteria
A **score of 3 or more gives a 40-60%** probability of bacterial tonsilitis and it is appropriate to offer antibiotics. A point is given for each of following:
* Fever \>38 degrees
* Tonsillar exudates
* Absence of cough
* Tender anterior cervical lymph nodes
59
Describe the FeverPAIN score
A score of 2-3 gives 34-40% probability and a score of 4-5 gives 62-65% probability of bacterial tonsilitis. A point is given for each of the following:
* Fever during previous 24hrs
* Purulence on tonsils
* Attended within 3 days of onset of symptoms
* Inflamed tonsils (severely inflamed)
* No cough or coryza
60
Discuss the management of tonsillitis
* **Education:** mot likey viral cause and will improve on its own
* **Analgesia**: paracetamol & ibruprofen
* **Safety net:** seek help if pain not improved in 3 days or fever raises above 38.3 degrees.
* Consider abx (**phenoxymethylpenicilin for 10 days, or clarithromycin if penicillin allergic**) if Centor =/\>3 or FeverPAIN =/\>4, immunocompromised, significant co-morbidity or history of rheumatic fever
* May consider **delayed prescription of abx**
61
State some potential complications of tonsillitis
* Peritonsillar absess (quinsy)
* Otitis media
* Scarlet fever
* Rheumatic fever
* Post-streptococcal glomerulonephritis
* Post-streptococcal reactive arthritis
* Chronic tonsillitis
Yr3: GP
flashcards
Decks in class (21)
# Cards
-
Remote Consulting9
-
Acute Emergencies & Pre-hospital Care61
-
Safeguarding26
-
MSK47
-
Paediatrics96
-
Minor Illness36
-
Health Promotion54
-
Men's & Women's Health76
-
Dermatology123
-
ENT79
-
Contraception & Sexual Health93
-
Mental Health81
-
Diabetes61
-
Hypertension, CKD & Hyperlipidaemia76
-
Asthma & COPD76
-
IHD & Heart Failure54
-
Palliative Care25
-
Medicines Optimisation16
-
ENT 261
-
STIs42
-
Scoring Systems & Emergency Drugs52
