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ENT Flashcards

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1
Q

What is presbycusis?

A

Presbycusis = Age-related, bilateral, symmetrical sensorineural hearing loss affecting high frequencies first.

Commonest form of adult hearing impairment

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2
Q

Is presbycusis conductive or sensorineural?

A

Sensorineural.

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3
Q

Which frequencies are lost first in presbycusis?

A

High-frequency sounds.

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4
Q

Is presbycusis usually symmetrical or asymmetrical?

A

Symmetrical.

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5
Q

Name modifiable risk factors for presbycusis.

A

Chronic noise exposure, smoking, hypertension, diabetes, ototoxic medications

NICE emphasis: reduce modifiable risks → noise protection, CV risk factor management.

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6
Q

Which non-modifiable factors increase presbycusis risk?

A

Age, male sex, family history.

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7
Q

What symptom commonly accompanies presbycusis?

A

Tinnitus.

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8
Q

Was are the presenting features of presbycusis?

A
  • Gradual difficulty hearing conversations
  • More difficulty with high-pitched voices (female voices, children)
  • Worse in noisy environments
  • Turning up TV / asking for repetition
  • Associated tinnitus common
  • May be mistaken for cognitive decline (hearing impairment ↑ dementia risk)
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9
Q

Why might presbycusis be mistaken for cognitive decline?

A

Hearing loss can impair communication and is associated with higher dementia risk.

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10
Q

What is the investigation of choice for diagnosing presbycusis?

A

Assessment for presbycusus:

  • Otoscopy to rule out reversible causes (wax, infection).
  • Pure-tone audiometry (NICE first-line):
    • SNHL pattern
    • High-frequency drop with relatively preserved low frequencies
  • Consider tuning fork tests (Weber lateralises to better ear; Rinne positive)
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11
Q

What audiometry pattern is seen in presbycusis?

A

Sensorineural loss with preserved low frequencies and reduced high frequencies.

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12
Q

What would Rinne’s test show in presbycusis?

A

Rinne positive (air > bone).

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13
Q

What would Weber’s test show in presbycusis?

A

Sound lateralises to the better ear (sensorineural pattern).

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14
Q

Can presbycusis be reversed?

A

No, it is irreversible.

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15
Q

What is first-line management for presbycusis according to NICE?

A
  • First-line = Hearing aids
    • (Improve communication and reduce dementia risk)
  • Communication strategies
  • Cochlear implants (For severe–profound SNHL when hearing aids insufficient (ENT/audiology referral)
  • Lifestyle advice
    • Avoid loud noise exposure
    • Manage cardiovascular risk factors
    • Review ototoxic medications
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16
Q

Name communication strategies to help patients with presbycusis.

A

Reduce background noise, face-to-face conversation, good lighting, lip reading support.

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17
Q

What lifestyle measures can help prevent or reduce presbycusis progression?

A

Noise protection, CV risk factor control, avoiding ototoxic drugs.

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18
Q

When should asymmetrical hearing loss be referred for investigation?

A

Refer to ENT urgently to rule out vestibular schwannoma (MRI IAM).

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19
Q

Which occupational groups are at high risk of presbycusis from noise exposure?

A

Construction workers, woodworking, heavy industry.

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20
Q

Why is treating hearing loss important beyond communication?

A

Improves quality of life and may reduce dementia risk.

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21
Q

When do you refer for hearing loss?

A
  • Unexplained hearing loss
  • Impacting daily life
  • Asymmetrical SNHL (to rule out vestibular schwannoma)
  • Persistent unilateral tinnitus
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22
Q

Definition of sudden sensorineural hearing loss (SSNHL)

A

SSNHL: Hearing loss over less than 72 hours with no conductive cause.

More detailed:
* Sensorineural hearing loss developing over < 72 hours
* No conductive cause identified
* Otological emergency → requires immediate ENT referral (within 24 hrs) if onset within 30 days

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23
Q

Is SSNHL an emergency?

A

Yes, it is an otological emergency requiring immediate ENT referral.

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24
Q

Key features of SSNHL

A
  • Rapid unilateral hearing loss (most common)
  • May be permanent or resolve over days–weeks
  • No wax, infection, effusion, or perforation on otoscopy
  • Tuning fork tests show sensorineural pattern (Rinne positive, Weber to normal ear)
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25
Potential outcome of SSNHL
May resolve over days to weeks or become permanent.
26
Conductive causes of rapid-onset hearing loss (Mimics of SSNHL - not classed as SSNHL)
* Wax obstruction * Otitis externa * Otitis media * Middle ear effusion * Eustachian tube dysfunction * Tympanic membrane perforation
27
Proportion of SSNHL cases that are idiopathic?
About 90%.
28
Non-idiopathic causes of SSNHL
* Viral/infectious: meningitis, HIV, mumps * Ménière’s disease * Ototoxic medications (aminoglycosides, chemotherapy, loop diuretics) * Multiple sclerosis * Migraine * Stroke * Acoustic neuroma * Cogan’s syndrome (rare autoimmune inner ear + eye inflammation)
29
Investigations for SSNHL?
Investigations: 1. **Pure-tone audiometry (required for diagnosis)** - **≥ 30 dB loss** across **three consecutive frequencies** → confirms SSNHL 2. **MRI internal auditory meatus / brain** - If **acoustic neuroma** or **stroke** suspected
30
Audiometric definition of SSNHL
≥30 dB loss in three consecutive frequencies.
31
When to consider MRI or CT in SSNHL
If stroke or acoustic neuroma is suspected.
32
NICE recommendation for referral in SSNHL
Immediate ENT assessment within 24 hours for symptoms presenting within 30 days.
33
Treatment of SSNHL?
**Immediate actions:** * Urgent ENT referral within 24 hours for all suspected SSNHL * Occurring within ≤30 days of onset Treatment * If **cause identified → treat underlying issue** * **Idiopathic SSNHL → Steroids** (ENT decision): - **Oral steroids** - **Intratympanic steroid injection** * Early treatment improves recovery likelihood ## Footnote Variable: some recover fully, some partially, some permanent loss Better outcomes with early treatment, younger age, and mild–moderate loss
34
Treatment for idiopathic SSNHL
Steroids under ENT guidance ( oral OR intratympanic steroid injection)
35
What is acute otitis media (AOM)?
* **Acute otitis media (AOM)** = acute infection of the **middle ear.** * Often follows **viral URTI** → eustachian tube oedema → fluid + **secondary bacterial infection.**
36
Common bacterial causes of otitis media
* **Streptococcus pneumoniae** * **Haemophilus influenzae** * **Moraxella catarrhalis** * Staphylococcus aureus
37
Main presenting symptom of otitis media in adults
Ear pain (otalgia).
38
Presenting features of otitis media
* **Ear pain (otalgia)** = main symptom * **Reduced hearing (conductive loss)** * Systemic features: fever, malaise * URTI symptoms: cough, coryza, sore throat * Possible: - Vertigo / imbalance (if vestibular involvement) - **Otorrhoea if tympanic membrane perforates → sudden pain relief + discharge**
39
What symptom occurs if the tympanic membrane perforates?
Sudden pain relief followed by ear discharge (otorrhoea).
40
Otoscopy findings in normal tympanic membrane
Pearly grey, translucent, visible malleus, light reflex present.
41
Otoscopy findings in otitis media
* **Normal TM: pearly grey, translucent, mobile**, visible malleus + light reflex. * AOM: - **Bulging, red, opaque TM** - **Loss of normal landmarks/light reflex** - Possible **perforation + purulent discharge** * Check for: - **Mastoid tenderness / swelling (mastoiditis)** - **Cranial nerve VII (facial nerve palsy = red flag)**
42
What are 2 features to look for when examining otitis media?
* Mastoid tenderness / swelling (mastoiditis) * Cranial nerve VII (facial nerve palsy = red flag)
43
Management of otitis media in adults?
Most cases: **self-limiting in ~3 days (up to 1 week)**. Antibiotics only modestly reduce duration/complications. Supportive: * **Analgesia/antipyretics: paracetamol ± ibuprofen** * Fluids, rest * Explain natural course and safety-net. **Antibiotic Strategy** - Three approaches: * **No antibiotics** (most healthy adults with mild/moderate illness) * **Delayed prescription** (collect/use if no improvement after 3 days or worsening) * **Immediate antibiotics** if: - **Systemically unwell** (but not requiring admission) - **Significant comorbidities** (e.g. cardiac, lung, renal, liver, neuromuscular disease) - **Immunocompromised** - **Symptoms ≥4 days and not improving** - **High risk of complications** **First-Line Antibiotics (Adults):** * **Amoxicillin for 5–7 days** * If penicillin allergy: Clarithromycin (or erythromycin in pregnancy)
44
Typical course of otitis media without antibiotics
Resolves within 3 days, sometimes up to a week.
45
Three antibiotic prescribing options for otitis media
Immediate antibiotics, delayed prescription, or no antibiotics.
46
Indications for immediate antibiotics in otitis media
Systemically unwell, immunocompromised, significant comorbidities, symptoms ≥4 days without improvement.
47
First-line antibiotic for adult otitis media
Amoxicillin for 5–7 days.
48
Antibiotics for otitis media in penicillin allergy
Clarithromycin; erythromycin in pregnancy.
49
Key safety-netting advice for otitis media
* Advise urgent review / ED if: * Symptoms **worsen or no improvement after 3 days** * **New focal neurological symptoms** * **Severe headache**, photophobia, neck stiffness * Swelling/redness behind ear, protruding pinna (suspected mastoiditis) * Facial weakness * Very unwell / septic features
50
Common complications of otitis media
* **Otitis media with effusion (glue ear)** * Temporary **conductive hearing loss** * **TM perforation → otorrhoea** * **Labyrinthitis** → vertigo, imbalance * **Mastoiditis** (post-auricular swelling, tenderness, protruding pinna) * Intracranial spread: - **Brain abscess** - **Meningitis** * **Facial nerve palsy**
51
When does otitis media cause vertigo?
When the infection involves the vestibular system (labyrinthitis).
52
What finding suggests mastoiditis?
Post-auricular swelling, tenderness, or protruding pinna.
53
What is glue ear (otitis media with effusion)?
* **Non-infective fluid accumulation** in the middle ear **behind an intact tympanic membrane.** * Caused by **Eustachian tube dysfunction** → failure to drain middle-ear secretions. * Very common in children; can occur in adults.
54
What are the symptoms of glue ear?
* **Hearing loss (conductive) = main symptom** * **Speech delay** in children * No acute pain or fever (distinguishes from acute otitis media)
55
What would you find on examination for glue ear?
* **Dull** or **retracted tympanic membrane** * **Fluid level** or **air bubbles** may be seen * Can be normal-appearing, so otoscopy does not exclude OME
56
What are some complications of glue ear?
* **Acute otitis media (infection of the fluid)** * Impact on **speech/language development** in children * Learning/behavioural difficulties in chronic cases
57
Ix for glue ear (otitis media with effusion)
* **Audiometry** (hearing test) * **Tympanometry** (type B ‘flat’ trace indicates middle-ear fluid)
58
Management of glue ear
* **Conservative management first** - Majority resolve within **3 months** * **Treat contributing factors** (allergic rhinitis, adenoid hypertrophy) * ENT referral earlier in: - Children with **Down syndrome** or **cleft palate** - Persistent **bilateral** OME with hearing loss - Significant impact on **speech, learning, or behaviour** * **Grommets** - Small ventilation tubes placed into TM under GA (day case) - Allow drainage + equalisation - Usually fall out within 6–12 months - **Around 1 in 3 need repeat grommets**
59
What is the main symptom and complication of glue ear?
* The main **symptom** of glue ear = a **reduction in hearing** in that ear. * The main **complication** of glue ear = **infection (otitis media).**
60
What causes fluid build-up in glue ear?
Eustachian tube obstruction leading to retained secretions."
61
What is otitis externa?
**Otitis externa** = **Inflammation** or **infection** of the **skin** of the **external ear canal.** * May extend to the **pinna** Can be: * Acute (< 3 weeks) * Chronic (> 3 weeks)
62
Is otitis externa an infection of the middle or external ear?
External ear canal.
63
What are common triggers for otitis externa?
* **Water exposure – “swimmer’s ear”** * **Trauma** – cotton buds, scratching, earplugs, hearing aids * **Loss of protective wax** * Infective: - **Bacteria**: **Pseudomonas aeruginosa**, Staphylococcus aureus - **Fungi**: Aspergillus, Candida (esp. after multiple topical antibiotics) * **Dermatological**: - Eczema - Seborrhoeic dermatitis - Contact dermatitis (e.g. shampoos, sprays)
64
What protective role does ear wax have?
It helps prevent infection in the ear canal.
65
Infective causes of otitis externa
* **Bacterial (Pseudomonas aeruginosa, Staphylococcus aureus)** * Fungal (Aspergillus, Candida). ## Footnote For bacteria, think of staph for skin and p. aeruginosa becuase it loves water + moist environments ('Swimmer's ear')
66
What is 'Swimmer's ear'?
Otitis externa
67
Non-infective causes of otitis externa
Eczema, seborrhoeic dermatitis, contact dermatitis.
68
Why are multiple courses of topical antibiotics a risk for fungal otitis externa?
They kill commensal bacteria, allowing fungi such as Candida or Aspergillus to overgrow.
69
Typical symptoms of otitis externa
* **Ear pain** * **Itching** * **Discharge** * Conductive hearing loss (if canal is blocked).
70
Typical examination findings in otitis externa
* **Erythematous**,** swollen canal** * **Canal tenderness** on **movement of pinna or tragus** * Debris/**pus in canal** * Possible cervical/peri-auricular **lymphadenopathy** * TM may be obscured; if perforated, consider otitis media as source of discharge
71
What might it mean if the tympanic membrane is perforated and there is discharge?
The discharge may be from otitis media rather than otitis externa.
72
How is the diagnosis of otitis externa usually made?
Clinically with **otoscopy** of the ear canal. ## Footnote Ear swab only if: * Recurrent * Severe * Immunocompromised * Suspected fungal infection / treatment failure
73
When is an ear swab indicated in otitis externa?
In recurrent, severe, treatment-resistant or atypical cases.
74
First-line treatment for mild otitis externa
**Topical acetic acid 2%** (e.g. EarCalm).
75
What prophylactic measure can frequent swimmers use to prevent otitis externa?
Acetic acid 2% ear spray before and after swimming.
76
First-line treatment for moderate otitis externa
Topical antibiotic plus steroid drops or spray * **Neomycin + steroid ± acetic acid** (e.g. Otomize) * Gentamicin + hydrocortisone * Ciprofloxacin + dexamethasone **Aminoglycosides (neomycin, gentamicin) = ototoxic if they pass through a perforated TM** → **exclude perforation** or **use non-ototoxic drops.** * If canal obstructed by swelling/debris → ENT for microsuction.
77
Why must you be cautious with aminoglycoside ear drops?
They are potentially ototoxic if they pass through a perforated tympanic membrane.
78
When should you refer to ENT in otitis externa?
If the canal is very swollen/blocked, TM cannot be visualised, drops cannot reach, or symptoms are severe/systemic.
79
When are oral antibiotics used in otitis externa?
In severe disease, systemic symptoms, or spread of infection beyond the canal.
80
What is an ear wick?
A sponge or gauze wick soaked in topical treatment inserted into a swollen ear canal.
81
Management of otitis externa
**Mild**: * **Acetic acid 2% spray/drops** (e.g. EarCalm) * Can be used **prophylactically** in **swimmers**. **Moderate:** **Topical antibiotic + steroid:** * **Neomycin + steroid ± acetic acid** (e.g. Otomize) * Gentamicin + hydrocortisone * **Ciprofloxacin + dexamethasone** **Severe / systemic features:** * **Oral antibiotics (e.g. flucloxacillin or clarithromycin)** * Consider **ENT review ± admission and IV antibiotics.** **Ear Wick:** * For very **swollen canal** where drops can’t enter * Sponge/gauze wick soaked with topical treatment * Left in place ~48 h then removed; continue drops once swelling improves. **Fungal Otitis Externa:** * **Clotrimazole ear drops** (or other antifungal drops). ## Footnote ⚠️ Aminoglycosides (neomycin, gentamicin) are ototoxic if they pass through a perforated TM → exclude perforation or use non-ototoxic drops. If canal obstructed by swelling/debris → ENT for microsuction.
82
Treatment for fungal otitis externa
Topical antifungal ear drops such as clotrimazole.
83
What is malignant otitis externa?
A **severe, necrotising infection** of the external ear canal with spread to **temporal bone** (**osteomyelitis**).
84
Key risk factors for malignant otitis externa
Diabetes, immunosuppression, HIV.
85
Key symptoms of malignant otitis externa
* Severe persistent ear pain (otalgia) * **Headache** * Fever ## Footnote Granulation tissue at bone–cartilage junction in canal
86
Characteristic otoscopic finding in malignant otitis externa
Granulation tissue at the bone–cartilage junction of the ear canal.
87
Management of malignant otitis externa
* **Emergency hospital admission (ENT)** * **IV antipseudomonal antibiotics** * **Imaging (CT/MRI Head)** to assess extent
88
Potential complications of malignant otitis externa
* Facial nerve palsy * Other cranial nerve involvement * Meningitis * Intracranial thrombosis * Death
89
What is epistaxis? Types?
* Epistaxis = **bleeding** from the **nasal mucosa.** * **Anterior bleeds (90%)** → **Kiesselbach’s plexus** in **Little’s area (visible, usually mild).** * **Posterior bleeds** → from **deeper vessels** (e.g., sphenopalatine artery); more **profuse**, **bilateral**, **↑ risk of aspiration** and **airway compromise.**
90
What are some causes of epistaxis?
**Local:** * **Nose picking (most common in children)** * Nose blowing * **Trauma** * **Dry air / weather changes** * Foreign bodies * URTI / sinusitis * **Cocaine use → septal abrasion + perforation (vasoconstriction-induced necrosis)** **Systemic:** * **Coagulation disorders:** - Thrombocytopenia - Von Willebrand disease - Immune thrombocytopenia (ITP) - Haemophilia * **Blood cancers:** - **Leukaemia (especially < 2 years old)** - Waldenström’s macroglobulinaemia * **Hypertension** (exacerbates bleeding) * **Anticoagulants / antiplatelets: aspirin, warfarin, DOACs** * Hereditary haemorrhagic telangiectasia (HHT) * Granulomatosis with polyangiitis (Wegener’s) * **Tumours**: squamous cell carcinoma, juvenile angiofibroma (adolescent males)
91
How does a nosebleed (epistaxis) present?
* Usually **unilateral bleeding** * **Bilateral bleeding → suspect posterior bleed** * May swallow blood → **haematemesis** * Ask about anticoagulants, trauma, systemic disease
92
What is the first aid management for epistaxis?
Teach the patient: 1. **Sit upright + lean forward** (Prevents aspiration and swallowing blood) 2. **Pinch soft cartilaginous part of nose firmly** 3. Maintain pressure for **10–15 minutes** (some sources 15–20 min) 4. **Spit out blood; do not tilt head back** 5. **Ice pack** on nasal bridge may help If bleeding stops → aftercare.
93
What is some aftercare/preventation for epistaxis?
* ** Naseptin cream** (chlorhexidine + neomycin) **4×/day for 7–10 days** - **Avoid if peanut/soya allergy** * Alternatives: mupirocin * Avoid: - Nose blowing or picking - Hot drinks, alcohol - Heavy lifting/exercise - Lying flat - Straining
94
When you you refer / admint someone with epistaxis?
* **Bleeding >10–15 minutes despite pressure** * **Severe or posterior bleeding** * **On anticoagulants** * Recurrent unexplained epistaxis * **Haemodynamic instability** * **Children < 2 years (consider leukaemia / coagulation disorders)** * Underlying disease suspected (e.g., HHT, GPA)
95
What is the hopsital management for epistaxis?
* **Cautery (if visible anterior source)**: blow nose → Co-phenylcaine → **silver nitrate 3–10s (one side only)** → apply Naseptin/mupirocin. * **Nasal packing: if no visible source / cautery fails / posterior bleed suspected** → Co-phenylcaine → insert pack → check mouth/throat → **may pack both nostrils → admit all packed patients.** * **Posterior bleeds: profuse/bilateral → ENT, posterior packing/balloon, airway precautions, IV fluids, correct coagulopathy.** * **If persistent: sphenopalatine artery ligation (± embolisation).**
96
Exam points: Epistaxis
* Most common site of bleeding = Little’s area / Kiesselbach’s plexus * Posterior bleed clues: elderly, anticoagulants, bilateral flow, profuse bleeding * Lean forward, NOT backward * Only cauterise ONE side of the septum * Naseptin contraindicated in peanut/soya allergy * Juvenile angiofibroma → adolescent male + recurrent epistaxis * Child < 2 years (consider leukaemia / coagulation disorders) * Cocaine use → septal perforation (classic exam trick)
97
What is otosclerosis?
* **Abnormal bone remodelling of middle ear ossicles**, mainly at **stapes footplate** → causing **conductive hearing loss.** * Usually presents **before age 40**; more common in women. * Can be **autosomal dominant**, though genetics not fully defined. ## Footnote Pathophysiology: * Stapes becomes fixed at the oval window → reduced transmission of sound to cochlea. * Sensory apparatus normal → **pure conductive loss.**
98
How does otosclerosis present?
* **Progressive hearing loss** (uni- or bilateral). * **Tinnitus** = common. * Worse for **low-frequency sounds** (opposite pattern to **presbycusis**). * **Patients may speak quietly** (own voice sounds loud via bone conduction).
99
What will an examination of otosclerosis show?
* **Otoscopy = normal** * **Weber**: - Bilateral disease → central. - Unilateral → lateralises to **affected ear (conductive).** * **Rinne: negative (BC > AC).**
100
Ix for otosclerosis?
* **Audiometry**: conductive hearing loss - **Air conduction reduced**, bone conduction normal - Loss greatest at **low frequencies** * **Tympanometry**: reduced compliance (stiff TM). * **CT temporal bone**: may show bony changes (not always required).
101
Management for otosclerosis
* **Conservative**: hearing aids. * Surgical: - **Stapedectomy** – remove whole stapes, replace with prosthesis. - **Stapedotomy** – remove part of stapes, prosthesis inserted through created hole. * **Surgery = generally highly effective** and can restore near-normal hearing.
102
What is sinusitis?
* **Inflammation** of **paranasal sinuses ± nasal mucosa (rhinosinusitis).** * Acute: < 12 weeks (3 months) * Chronic: >12 weeks (3 months) - often with **polyps** Anatomy (High yield): Four paired sinuses: * **Frontal** (above eyebrows) * **Ethmoid** (between eyes) * **Maxillary** (cheeks) * **Sphenoid** (deep, behind nasal cavity) **Normal drainage occurs via ostia → obstruction → infection/inflammation.**
103
Causes of sinusitis?
* Viral URTI (most common) * Allergic rhinitis / hay fever * Obstruction: polyps, foreign body, deviated septum * Smoking * Asthma association
104
Presenting features of sinusitis
**Acute (< 12 weeks):** * Nasal congestion * Purulent nasal discharge * Facial pain/pressure * Headache * Reduced smell * Tenderness over sinuses * Fever ± systemic features **Chronic (>12 weeks):** * Similar symptoms but persistent * Often associated with **nasal polyps**
105
Ix for sinusitis
Usually not required. If persistent / severe / atypical: * **Nasal endoscopy** * **CT sinuses**
106
Management of sinusitis
Acute Sinusitis: * No antibiotics for symptoms < 10 days (usually viral). * Most resolve in 2–3 weeks. * If not improving after 10 days: - **High-dose steroid nasal spray for 14 days** (e.g., mometasone 200 mcg BD) - **Delayed antibiotics: phenoxymethylpenicillin (first-line)** - Admission if systemically unwell or septic Chronic Sinusitis: * **Saline nasal irrigation** * **Steroid nasal spray/drops** * **FESS** (Functional Endoscopic Sinus Surgery) if refractory * **Requires CT scan beforehand**
107
What is the technique for nasal spray technique?
* Head slightly forward * Spray left hand → right nostril and vice versa (away from septum) * Do not sniff hard * Gentle inhalation only * If tasted in throat → incorrect technique
108
Difference between sinusitis and rhinosinusitis
* Sinusitis = inflammation of the sinuses only (rare alone). * Rhinosinusitis = inflammation of nasal cavity + sinuses (most cases). In exams and clinical guidelines → “rhinosinusitis” is the preferred term. Sinusitis: * Inflammation/infection of the paranasal sinuses only. * Classical definition historically used. * Symptoms focus on: * Facial pain/pressure * Tenderness over sinuses * Headache * Post-nasal drip Rhinosinusitis: * **Inflammation of both the nasal cavity AND the paranasal sinuses.** * **More accurate term** because sinusitis almost always includes nasal mucosal inflammation. * **Symptoms include sinus symptoms plus nasal symptoms:** * Nasal congestion * Nasal discharge * Reduced smell * Sneezing * Rhinorrhoea ## Footnote If the nasal symptoms are present (congestion, discharge), the condition should be called rhinosinusitis.
109
What are nasal polyps?
* Benign **mucosal outgrowths** in the nasal cavity or sinuses. * Usually **bilateral; unilateral polyps = red flag** for malignancy → urgent ENT referral.
110
What conditions are associated with nasal polyps?
* **Chronic rhinitis / chronic rhinosinusitis** * **Asthma** * Samter’s triad (asthma + polyps + aspirin intolerance) * Cystic fibrosis * Eosinophilic granulomatosis with polyangiitis (Churg–Strauss)
111
How do nasal polyps present?
* **Chronic nasal obstruction** * **Mouth breathing / snoring** * **Anosmia (loss of smell)** * **Rhinorrhoea** * **Recurrent sinusitis** * **Pale grey/yellow, smooth, non-tender masses on nasal exam** * Found via **speculum exam**, **otoscope** with **large speculum**, or **nasal endoscopy**
112
Management of nasal polyps
**Red flags:** * **Unilateral polyp** → ENT urgent assessment (exclude tumour) **Medical:** * **Intranasal steroids (mometasone) (spray or drops) = first-line** * Adjuncts: saline irrigation **Surgical:** * **Intranasal polypectomy** if visible anteriorly * **Endoscopic polypectomy** for deeper or sinus polyps * Often combined with management of chronic rhinosinusitis
113
What anatomy do URTIs affect?
**URTIs** affect **mucosa** of: * Nasal cavity * Sinuses * Nasopharynx * Oropharynx * Larynx **Common terms:** * “**Cold**” – lay term for nasal discharge + sneezing * “**Coryzal symptoms**” – medical term for rhinorrhoea, sore throat, congestion etc
114
Causes of URTIs
**Viruses** (most common): * **Rhinovirus (50–80%)** * **Coronavirus** * Adenovirus * Influenza * Parainfluenza * RSV * Enteroviruses
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Epidemiology of URTIs
Adults: 2–3 episodes/year Children: 5–6 episodes/year
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Symptoms of URTIs
* Nasal discharge & obstruction * Sore throat * Headache * Cough * Malaise, fatigue * ± facial pain, ear pain, hoarseness, nausea
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Signs of URTIs
* Erythematous/injected pharynx * Nasal discharge * Tender **cervical lymphadenopathy** * Mild fever
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What assessments will you perform in an individual with a URTI?
* Full ENT exam * Resp exam to **exclude pneumonia or wheeze** * **Hydration assessment** (high-risk: children, elderly) * Basic obs: HR, BP, RR, temp, sats - **Markedly abnormal → consider sepsis, pneumonia**
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What are useful assessment tools for URTIs?
* **Children < 5: NICE Fever Traffic Light System** * **Adults** with **sore throat: FeverPAIN score** (helps assess likelihood of Strep A → guides antibiotics) - Tonsilitis
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When would you request investigations for a URTI?
Consider in: * **Infants** with fever * **Immunocompromised patients** * Atypical or severe symptoms * **Viral throat swabs** if hospital admission for suspected influenza (infection control)
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Management for URTIs
Most cases = **supportive care only**: * Reassure: **self-limiting**, resolves in **7–10 days** (may take up to 3 weeks) * **Antibiotics not indicated** for uncomplicated viral URTI * Analgesia/antipyretics: **paracetamol ± ibuprofen** * **Hydration** * Rest * OTC symptom relief if appropriate * **Consider admission for frail elderly or those with poor physiological reserve**
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Complications for a URTI?
* **Acute sinusitis** * **Otitis media** * **Secondary bacterial pneumonia** * **Exacerbation of asthma/COPD** * In infants/children: - Viral wheeze - **Bronchiolitis** - **Croup**
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What is epiglottitis?
* **Epiglottitis** = **Inflammation + swelling** of the **epiglottis** - potentially occluding the airway within hours. * **Life-threatening emergency.**
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What are the causes of epiglottitis?
* **Haemophilus influenzae type B** (rare due to vaccination) * **Streptococcus pneumoniae**
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Who is epiglottitis most likely to occur in?
Can occur at any age Typically **2–7 years**
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What is the presenting features of presentation?
**Rapid onset**, similar to croup but more severe **Symptoms**: * **sore throat**, * **dysphagia**, * odynophagia, * **high fever**, * **stridor**, * **drooling**, * **muffled “hot potato” voice** **Signs**: * scared/quiet child * toxic appearance, * **tripod position** (sat forward with a hand on each knee) * **neck/chin extended**
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What are the investigations for epiglottitis?
* Avoid routine investigations (may worsen obstruction) * **Lateral neck X-ray: “thumb sign” = swollen epiglottis**
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What is the management of epiglottitis?
* Emergency: do not upset child * **Alert senior paediatrician + anaesthetist** immediatiely * **Oxygen**: held near face, **not applied directly** * Airway management: prepare for **intubation**; tracheostomy backup if needed * **After airway secured: IV antibiotics** (e.g., **ceftriaxone**), possible **systemic steroids** ## Footnote * immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT) - endotracheal intubation may be necessary to protect the airway * if suspected do NOT examine the throat due to the risk of acute airway obstruction - the diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary * oxygen * intravenous antibiotics
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Tom Tip: Epiglottitis
TOM TIP: In exams, suspect epiglottitis in an unvaccinated child with a high fever, sore throat, dysphagia, and drooling.
130
Summary Card: Trigeminal neuralgia
**Definition:** * Severe, unilateral, brief electric-shock facial pain (V2/V3), due to vascular compression of CN V root. **Features:** * Paroxysms seconds–2 min * Triggered by touch/chewing/brushing/wind * Pain-free intervals * No neuro deficits (otherwise consider secondary cause) **Red Flags (Secondary TN):** * < 40 yrs, bilateral, sensory loss, continuous pain, poor response to carbamazepine → MRI. **Investigations:** * MRI head (exclude MS, tumour, vascular lesion) * Clinical diagnosis **Management:** * First-line: **Carbamazepine** * Alternatives: oxcarbazepine, lamotrigine, baclofen * Refractory: Microvascular decompression * ± Radiofrequency ablation / glycerol rhizolysis / stereotactic radiosurgery
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Summary card: Infectious Mononucleosis
**Definition:** * **EBV infection → fever, pharyngitis, lymphadenopathy (classically posterior cervical).** **Features:** * **Sore throat, tonsillar enlargement ± exudate** * Fever, malaise, headache * Generalised lymphadenopathy * **Splenomegaly (risk of rupture)** * **Palatal petechiae** * **Rash after amoxicillin/ampicillin** **Investigations:** * **Monospot (heterophile antibody)** – best after day 7 * **EBV serology if Monospot negative or early** * FBC: lymphocytosis ± atypical lymphocytes * LFTs: mild transaminitis **Management:** * Supportive (fluids, analgesia) * **Avoid amoxicillin (rash)** * **Avoid contact sports** for 3–4 weeks (splenic rupture risk) * **Steroids only if airway obstruction**, severe thrombocytopenia, haemolytic anaemia **Complications:** * **Splenic rupture** * **Airway obstruction** * Hepatitis * Haematological: haemolytic anaemia, thrombocytopenia
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Summary card: Influenza
**Definition:** * **Acute viral respiratory infection (Influenza A/B).** **Symptoms:** * Sudden fever, chills * Headache, myalgia, fatigue * Dry cough, sore throat, runny nose * Children: GI symptoms * Usually resolves in 2–7 days **High-Risk Groups:** * Elderly, pregnant, infants, immunosuppressed, chronic cardiac/resp disease, diabetes. **Complications:** * Pneumonia (viral/bacterial), exacerbation of comorbidities, otitis media (kids), myocarditis, encephalitis. **Diagnosis:** * Clinical in flu season; PCR if needed for management/outbreak. * Management (NICE/UK): * Supportive (fluids, rest, paracetamol/ibuprofen) * **Antivirals** (**oseltamivir**/zanamivir) for high-risk or severe disease — **start ≤48 h** * Annual vaccination for eligible groups Red Flags (seek care): * Breathlessness, chest pain, dehydration, confusion, severe comorbidity.
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Summary card: Head + neck overview
* Type: Mostly **SCC** of mucosal surfaces * Sites: Nasal cavity, sinuses, oral cavity, salivary glands, pharynx, larynx * Risks: Smoking, alcohol, betel quid, **HPV-16, EBV** * Red Flags: **Mouth ulcer >3 wks, neck lump, hoarseness, erythroplakia, oral/lip lesion** * Spread: Early → cervical nodes; may present as CUP * Tx: Surgery, radiotherapy, chemo, **cetuximab (EGFR)**, MDT-led ## Footnote CUP = cancer of unknown primary
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Summary card: Oral cavity cancer
* **Location**: Lips, anterior tongue, buccal mucosa, floor of mouth, hard palate * **Type: SCC** * **Risks**: Smoking, alcohol, HPV (less often), poor oral hygiene * **Features**: **Non-healing ulcer, leukoplakia/erythroplakia, pain, dysarthria, loosening teeth** * **Red Flags**: Ulcer >3 weeks, mass/lump, unexplained bleeding * **Tx**: Surgical resection ± neck dissection; radiotherapy ± chemo
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Summary card: Oropharyngeal / HPV-related cancer
* **Sites: Tonsils, base of tongue** * **Type: SCC** * **Risks: HPV-16 (younger, non-smokers)**, smoking/alcohol * **Features**: Sore throat, dysphagia, **unilateral tonsillar mass, neck lump** * **Prognosis: HPV+ has much better outcomes** * **Tx**: Radiotherapy ± chemotherapy; surgery in selected cases
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Summary card: Laryngeal cancer
* **Sites: Supraglottic, glottic, subglottic** * **Type: SCC** * **Risks: Smoking**, alcohol; less commonly HPV * **Features**: Persistent hoarseness, dysphonia, stridor (late), dysphagia, neck lump * **Red Flags: Hoarseness >3 weeks** * **Tx**: Early: radiotherapy or endoscopic surgery * **Advanced**: laryngectomy ± neck dissection ± chemoradiotherapy
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Summary card: Salivary card tumours
* **Sites: Parotid (most)**, submandibular, minor glands * **Types**: **Mostly benign (pleomorphic adenoma)**; malignancies = mucoepidermoid carcinoma, adenoid cystic carcinoma * **Features**: **Painless mass; facial nerve palsy = malignancy until proven otherwise** * **Investigations**: **Ultrasound + FNA** * **Tx**: Surgical excision (superficial or total parotidectomy); post-op radiotherapy if malignant ## Footnote FNA = fine needle aspiration
Phase 4
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