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ENT Flashcards

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1
Q

What causes obstructive hearing loss?

A

Outer and middle ear defects

E.g. wax, cholesteatoma, otitis media/externa, osteosclerosis

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2
Q

What causes sensorineurial hearing loss?

A

Cochlear or CN8 pathology

E.g. prebyacusis, labyrinthitis, menieres, acoutstic neuromas, meningitis

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3
Q

What is the most common cause of sudden onset sensorineural hearing loss?

A

Idiopathic

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4
Q

What investigation is used in sudden onset sensorineural hearing loss?

A

Careful exam
MRI scan to exclude vestibular schwannoma

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5
Q

How is sudden onset sensorineural hearing loss managed?

A

Urgent ENT referral
High dose oral corticosteroids

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6
Q

How do you perform Rinne’s test?

A

Place tuning fork over mastoid process until sound is no longer heard then reposition ovr external acoustic meatus

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7
Q

What is a positive Rinne’s test?

A

air conduction normally better than bone conduction

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8
Q

What is a negative Rinne’s test?

A

bone conduction better than air conduction-> conductive deafness

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9
Q

How do you perform Weber’s test?

A

Tuning fork in middle of forehead, ask patient whish side is louders

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10
Q

Describe the interpretation of Weber’s test?

A

Sound localised to unaffected side: unilateral sensorineural deafness

Sound localised to affected side: unilateral conductive deafness

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11
Q

Describe what results of Rinne’s and Weber’s would indicate normal hearing?

A

Rinne’s:
-Air conduction>bone conduction bilaterally

Weber’s:
-Midline

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12
Q

Describe what results of Rinne’s and Weber’s would indicate conductive hearing loss?

A

Rhinne’s:
-Bone conduction >air conduction in affected ear
-Air conduction >bone conduction in unaffected ear

Weber’s:
-Lateralises to affected ear

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13
Q

Describe what results of Rinne’s and Weber’s would indicate sensorineural hearing loss?

A

Rinne’s:
-Air conduction >bone conduction bilaterally

Weber’s:
-Lateralises to unaffected ear

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14
Q

What is a cholesteatoma?

A

Non-cancerous growth of squamous epithelium trapped within skull base causing local destruction

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15
Q

What age group is a cholesteatoma mc in?

A

10-20 yrs

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16
Q

What is a major risk factor for cholesteatoma

A

Cleft palate

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17
Q

Describe the signs and symptoms of cholesteatoma

A

Foul-smelling, non-resolving discharge
Hearing loss (conductive)

Local invasion sx:
-Vertigo
-Facial nerve palsy
-Cerebellopontine angle syndrome

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18
Q

What is seen on otoscopy in cholesteatoma

A

‘Attic crust’-> uppermost part fo eardrum

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19
Q

How is cholesteatoma managed?

A

Patients referred to ENT for consideration of surgical removal

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20
Q

What is otosclerosis?

A

Replacement of normal bone by vascualr spongy bone-> progressive conductive deafness due to fixation of stapes at oval window

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21
Q

What age group is affected by otosclerosis?

A

20-40yrs

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22
Q

Describe the aetiology of otosclerosis

A

Autosomal dominant

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23
Q

How do patients with otosclerosis present?

A

Progressive hearing loss-> often starts unilateral then affects btoh ears-conductive

Tinnitus

Positive family history

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24
Q

How is otosclerosis diagnosed?

A

History
Audiometry-> conductive hearing loss
Otoscopy-> some will have ‘flamingo tinge’-> hyperaemia

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25
How is otosclerosis managed?
Hearing aids Stapedectomy
26
What is Meniere's disease?
Disorder of inner ear-> excessive pressure and progressive dilation of endolymphatic system
27
What age group is Meniere's seen in?
Middle-aged adults But can be any age
28
Describe the presentaiton of Meniere's
Recurrent episodes of vertigo, tinniuts and sensorineural hearing loss Sensation of arual fulness/pressure Episodes last minutes-hours Usually unilateral but bilateral after years Drop attacks
29
What are the signs of Meniere's
Nystagmus-horizontal Positive Romberg's
30
How is Meniere's diagnosed?
ENT referal Need: 1) >=2 definitive vertigo attacks 2) Flucutating otological sx: aurul fullness, tinnitus, etc 3) Audiometry: sensorineural hearing loss
31
How is Meniere's managed?
ENT assessment Inform DVLA and stop driving Acute attacks: buccal/IM prochlorperazine Prevention: Betahistine
32
Name some causes of vertigo
BPPV Acute labytrinthitis Ototoxicity Acoustic neuroma Trauma Ramsay Hunt Syndrome Others: MS, Stroke/TIA, migraine, motion sickness, alcohol
33
What is benign paroxysmal positional vertigo?
Sudden episodic attacks of vertigo induced by changes in head position due to detachemnt of otoliths in inner ear
34
Describe the pathophysiology of BPPV
Detachment of otoliths from utricle of inner ear-> migrate into semicircular canals-> stimular hair cells-> vertigo
35
What is the increasing prevalence of BPPV attributed to?
Accumulation of calcium deposits (cholelithiasis) in semi circular canals of inner ear
36
Describe the presentation of BPPV
<1 minute epidoses of vertigo attacks provoked by specific head movements like turning head to one side or looking uo May have n+v No auditory symptoms
37
How is BPPV diagnosed?
Dix-Hallpike manouevre-> sit pt up, turn head L/R then lie pt down with head off bed and observe for rotatory nystagmus and vertigo
38
How is BPPV managed?
Epley manouvre Brandt-Daroff exercises-> vestibular rehab Betahistine prescribed but not that useful
39
What is vestibular neuronitis
Cause of vertigo that develops post viral infection-> affects vestibular nerve component only of CN8
40
Describe the presentation of vestibular neuronitis
Recurrent vertigo attacks lasting hours-> days Nause and vomiting Horizontal nystagmus No hearing loss/tinnitus
41
What are the main differentials for vestibular neuronitis
Vital labyrinthitis Posterior circulation storke-> HINTS exam
42
Describe the management of vestibular neuronitis
Buccal/IM prochloperazine short term for severe Less severe: short course prochlorperazie/anihistamine (cyclizine or promethazine) Vestibular rehab exercises if chronic
43
What is labyrinthitis?
Inflammatory disorder of membranous lanyrinth -> affects both the vestibular nerve and cochlear end organs
44
What are the different types of labyrinthitis
Viral -mc Bacterials Associated with systemic diseases
45
What si the difference between labyrinthitis and vestibular neuritis?
Vestibular neuritis-> only vestibular nerve involved so no hearing impairment labyrinthitis-> vestibular nerve and labyrinth involved-> vertigo +hearing impairment
46
What age group is affected most by labyrinthitis
40-70yrs
47
Describe the sx of labyrinthitis
Acute onset of: -Vertigo )not triggered by movement but worse with movement) -Nausea and vomiting -Hearing loss-> unilatera/bilateral -Tinnitus -Preceding sx of UTRI
48
Describe the signs of labyrinthitis
Spontaneous unidirectional horizontal nystagmus towards unaffected side Sensorineural hearing loss Abnormal head impulse test (impaired vestibulo-ocular reflex) Gait disturbance-> may fall towards affected side
49
How is labyrinthitis diagnosed?
Hx and exam mostly
50
Describe the management of labyrinthitis
Usually self-limiting Can use antihistamines or prochloperazine
51
What things are assessed in the HINTS exam?
Head impulse Nystagmus Test of skew
52
What is the HINTS exam used for?
Vertigo-> central vs peripheral origin Used when: -Sudden onset vertigo for hours/days Nystagmus Normal full neuro exam
53
How do you perform the head impulse test of the HINTS exam
-Gently move head side to side ensuring relaxed neck muscles -Aks patient to keep looking at nose whilst turning head leaft and right -Turn heard 10-20 degrees to each side quickly then back to midpoint
54
How do you interpret the head impulse part of the HINTS exam?
Positive: Eyes move with head then saccade rapidly back to point of fixation ('corrective saccade')-> disruption to vstibulo-ocular reflec spo peripheral problem
55
What are some contraindications to doing the head impulse test?
Neck.head trauma Severe cervical spine osteoarthritis
56
How do you assess nystagmus in HINTS exam
Observe primary gaze whilst looking straight ahead Ask to look to left and right without fixating on obkect
57
How do you interpret the nystagmus part of the HINTS exam
Unidirectional nystagmus-> reassuring-> peripheral Nystagmus changes direction/vertical-> central Bidirectional (beats in direction patient is looking and changed with gaze )-> STROKE
58
How do you perform the test of skew in the HINTS exam?
-Ask pt to look at nose and cover one of their eyes -Move hand to cover other eye and observe uncovered eye for vertical/diagnosal corrective movemebt -Repeat on other eye
59
How do you interpret the test of skew test in HINTS exam
Any abnormal movement (often verticla diplopia too)-> central
60
What is an acoustic neuroma?
Benign subarachnoid tumour that exerts local pressure on the 8th cranial nerve
61
What should bilateral vestibular schwannomas prompt consideration of?
Neurofibromatosis type 2
62
Describe the presentation of a vestibular schwannoma?
Vertigo Hearing loss Tinnitus Absent corneal reflex Affected cranial nerves: CN 8: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus CN5: absent corneal reflex CN7: facial palsy
63
How is acoustic neuroma investigated?
Urgent ENT referrla MRI of cerebellopontine angle-GS Audiometry
64
How is acoustic neuroma treated?
Observation (slow growing initially) Surgery Radiotherapy
65
What is Ramsay Hunt syndrome?
Reactivation of varicella zoster virus in geniculate ganglion of 7th cranial nerve
66
Describe the presentation of Ramsay Hunt syndrome
Auricular pain-often comes first Facial nerve palsy Vesicular rash around ear Vertigo, tinnitus
67
How is ramsay hunt syndrome managed?
Oral aciclovir and corticosteroids
68
What group of people do you often find auricular haematomaas in?
Contact sports-> rugby players/wrestlers
69
What can auricular haematomas develop into?
Cualiflower ear
70
Describe the management of auricular haematomas?
Same day assessment by ENT Incision and drainage
71
Describe the aetiology of acute otitis media
Viral URTI-precede Most infections secondary to bacteria@ -S penumoniae -H influenzae -Morazella catarrhalis
72
How do viral URTI's cause otitis media?
Disturb normal nasopharyngeal microbiome-? bacteria infect middle ear via Eustachian tube
73
Describe the symptoms of otitis media
Otaligia (children may rub/tug er) Fever Hearing loss Recent viral URTI sx Ear discharge if tympanic membrane perfs
74
What might be seen on otoscopy in otitis media
Bulging tympanic reflex-> loss of light reflex Opacification/erythema of tympanic membrane Perforation with purulent otorrohea
75
How is otitis media diagnosed?
Presence of: -Acute onset of sx -Presence of middle ear effusion (tymp membrane bulging, otorrhoea, decreased mobility) -Inflammation of tympanic membrane
76
How is otitis media managed?
-Usually self limiting not requiring abx -Simple anaglesia -Safety netting if sx worsen/don;t improve within 3 days
77
When should abx be used in patients with otitis media?
43210 4: >4 days sx no improvement 3: NEWS>3 (systemically unwell) 2: <2yrs and bilateral 1: Immunocompromised 0: Looks like a hole (perfOration)
78
What abx are used for otitis media
5-7 day course amoxicillin 1st line If allergy: erythromycin/clarithromycin
79
What are common sequelae post otitis media
Perforation of tympanic membrane-> otorrhoea-> may develop into chronic suppurative otitis media Hearing loss Labyrinthitis
80
What is chronic suppurative otitis media?
Perforation of the tympanic membrane with otorrhoea for >6 weeks
81
What are some complications following otitis media
Mastoiditis Meningitis Brain abscess Facial nerve paralysis
82
What is malignant otitis externa?
Uncommon type of otitis externa in immunocompromused patients (diabetes)-> progressess to temporal bone osteomyelitits
83
What is the most common causative organism for malignant otitis externa?
Pseudomonas aeruginosa
84
What key features in history would indicate malignant otitis externa
Diabetes/immunosuppression Severe, unrelenting deep seater otalgia Temporal headaches Purulent otorrrhoea Possible dysphagia, hoarseness and/or facial nerve dysfunction
85
How is malignant otitis externa diagnosed?
CT scan
86
How is malignant otitis externa managed?
Non resolved otitis externa with worsenign pain-> urgent ENT referral IV abx that cover pseudomonal infections
87
What are the main causes.trigger of otitis externa
Infection: (s aureus, pseudomonals aeruginosa) or fungal Seborrheic dermatitis Contact dermatitis (allergic/irritant) Recent swimming-common trigger
88
Descrobe the symptoms and otoscopy finding for otitis externa
Ear pain Itching Discharge Otoscopy: red, swollen or eczematous canal
89
Describe the initial management of otitis externa
Topical abx or combined topical abx with a steroid If debris-consider removal
90
What are the 2nd line options for otitis externa management
Consider contact dermatitis secondary to neomycin Oral abx (fluclox )-> spreding infection Swabs Empiriacl use of antifungal
91
When should a patient with otitis externa be referred ot ENT?
Fails to respod to topical abx
92
What is the difference between ottitis externa and malignant otitis externa?
Malignant: elderly diabetics: extension of infection into bony ear canal and soft tissues deep to the bony canal
93
What is the most common cause of conductive hearing loss in childhood?
Otitis media with effusion/glue ear
94
Name some risk factors for glue ear?
Male Siblings wiht glue ear Hihg incidence in winter/spring Bottle feeding Daycare attendance Parental smoking Down's syndrome
95
What age group msot commonly gets glue ear?
2-5 years
96
How do patients with otitis media with effusion present?
Hearing loss-> wathcing TV with loud volume, can't hear teachers
97
What is seen on otoscopy and audiography in otitis media with effusion
Otoscopy: yellow tympanic membrane, aid fluid level, tympanic membrane retracted Audiography: conductive hearing loss
98
How is otitis media with effusion managed?
Observation for 3 months Grommet insertion-> allows air to pass through into middle ear and do the job done by Eustachian tube Adenoidectomy
99
What should be considered in adults presenting with glue ear?
Nasopharyngeal carcinoma-> especially if unilateral (Trotter's triad)
100
When does mastoidits develop?
Infection spreads from middle to mastoid air spaces of temporal bone (s pneumonia)
101
Describe the features of mastoiditis
Otalgia-> severe, behind the ear Hx of recurrent otitis media Fever Systemically unwell Swelling, erythema and tenderness over mastoid process External ear may protrude forward Ear discharge if eardrum perfed
102
How is mastoiditis diagnosed?
Clinical CT if complications suspected
103
How is mastoiditis diagnosed?
IV antibiotics
104
What complications can arise from mastoidits
Facial nerve palsy Hearing loss Meningitis
105
Name some risk factors for obstructive sleep apnoea
Obesity Magroglossia-> acromegaly, hypothyroidism, amyloidosis Large tonsils Marfan's syndrome
106
What are the consequences of obstructive sleep apnoea
Daytime somnolence Compensated respiratory acudosis Hypertension Right heart failure
107
What are the symptoms of obstructive sleep apnoea
Excessive snoring Apnoea reported by partner daytime tiredness
108
What is used to diagnose obstructive sleep apnea?
Epworth sleepiness scale-questionnaire Multi Sleep Latency Test-time taken to fall asleep GS: Sleep studies (PSG)
109
Describe the management of obstructive sleep apnoea
Weight loss CPAP Intra-oral devices like mandibular advancment Inform DVLA if causing excessive sleepiness
110
What is cerumen?
Wax impaction
111
Name some risk factors for cerumen
Cotton ear bud use Earplug use
112
What are the symptoms of cerumen
conductive hearing loss Fullness in ear Pain Tinnitus
113
How is cerumen diagnosed?
Otoscopy-> Tympanic membrane not visible due to wax
114
How is cerumen treated?
Soften wax-> olive oil drops If recurrent: suction and irrigation
115
What is chondrodermatitis nodularis helicis?
Common benign condition characterised by a painful nodule on the ear
116
Describe the epidemiology of chondrodermatitis nodularis helicis
Men Increasing age
117
Name some causes/risk factors for chondrodermatitis nodularis helicis
Persistent pressure on the ear-> e.g. sleep, headsets Trauma Exposure to cold
118
Describe the management of chondrodermatitis nodularis helicis
Pressure relief-> 'ear protectors' or specialised cushions Itralesonal corticosteroid injection Collagen injecyion Surgical excision-> if refractory (recurrence common)
119
What is rhinosinusitis
Inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer
120
Name some predispoing factors for rhinosinusitis
Atopy : hayfever, asthma Nasal obstruction-> septal deviation or nasal polyps Recent local infection-> rhinitis or dental extraction Swimming/diving Smoking
121
Describe the presentation of rhinosinusitis
Facial pain: frontal pressure, worse on bending forward Nasal discharge (clear=allergic/vasomotor, purulent = secondary infection) Nasal obstruction-> mouth breathing Post-nasal drip-> chronci cough
122
How is chronic rhinosinusitis managed?
Avoid allergen Intranasal corticosteroids Nasal irrigation with saline solution
123
What are the red flag symptoms in a patient with rhinosinusitis
Unilateral symptoms Persistent sx despite complicance with 3 months of treatment Epistaxis -Cancer
124
What conditions are associated with nasal polyps
Asthma Aspirin sensitivity Infective sinusitis Cystic fibrosis (suspicious if in children) Kartagener's syndrome Churg-Strauss syndrome
125
What is Samter's triad?
Asthma Aspirin sensitivity Nasal polyposis
126
Describe the symptoms of nasal polyps
Nasal obstruction Rhinorrhoea Sneezing Poor sense of taste and smell
127
What features of nasal polyps would promt further investigation?
Unilateral sx Bleeding
128
How are nasal polyps treated?
Refer to ENT for full exam Topical corticosteroids
129
What is a nasal haematoma?
Complication of nasal trauma Development of haematoma between septal cartilage and overlying perichondrium
130
Describe the presentation of a nasal septal haematoma
May be precipitated by minor nasal trauma Nasal obstruction sensation-mc sx Pain and rhinorrhoea
131
What is sen on examination of a patient with a nasal septal haematoma
Bilateral red swelling arising from nasal septum
132
How can a deviated septum be differentiated from a nasal septal haematoma
Probe the swelling: nasal spetal haematoma: boggy deviated septums: firm
133
How are nasal septal haematomas managed?
Surgical drainage IV abx
134
What is the main complication of untreated nasal septal haematomas
Irreversible septal necrosis within 3-4 days from pressure related ischaemia of the cartilage-> necrosis Can result in saddle nose deformity
135
What are the sx of a nasal fracture
Hypermobile, deformed nose Bruising Pain Epistaxis
136
How are nasal fractures treated?
Minor: no tx required if no function sx If sx/cosmetic concerns-> rhinoplasty
137
What typoe of cancer is most commonly found n head and neck cancers
Squamous cell ca with fast spread to lymoh nodes
138
What are the broad symptoms of head and neck cancers
Neck lump Hoarseness Persistent sore throat Persisten mouth ulcer
139
What are the 2 week wait pathway criteria for a referral for laryngeal cancer?
>=45yrs with: -Unexplained persistent hoarseness -Unexplained lump in neck
140
What are the 2 week wait pathway criteria for a referral for oral cancer
-Unexplained ulceration in oral cavity lasting >=3 weeks or -Persistent/unexplained lump in neck COnsider referral if: -Lump on lip or in oral cavity or -Red or red/whtoe patch consistent with erythroplakia or erythroleukoplakia
141
What are the 2 week wait pathway criteria for a referral for thyroid cancer
-Unexplained thyroid lump
142
Name some risk factors for head and neck cancers
HPV-16 Smoiking Alcohol EBV GORD
143
What are the symptoms of nasopharyngeal cancer
Unilateral effusive otitits media Unilateral nasal obstruction Nasal/neck mass Epistaxis Crusting
144
What are the sx of oropharyngeal cancer
>3 weeks non healing ulcer Neck lump Erhythro/erythroleukoplakia
145
What are the symptoms of laryngeal cancer
Dysphagia Odonophagia Hoarseness Neck lump Stridor
146
What investigations are done for head and neck cancers
1.Flexible laryngoscope with fine needle aspiration biopsy GS: Rigid laryngoscopy with core needle biopsy under GA CT/MRI/PET for TNM staging
147
What is Ludwig's angina?
Type of progressive cellulitis that invades the floor of the mouth and soft tissues of the neck Mc from odontogenic infections whcih spread into submandibular space
148
Descrobe the symtpoms of Ludwig's angina
Neck swelling Dysphagia Fever
149
How is Ludwig's angina managed?
Airway management-> life-threatenig as can cause airway obstruction IV abx
150
What is pleomorphic adenoma?
Benign tumour of parotid gland
151
What age group is pleomorphic adenoma mc in?
40-60yrs
152
Describe the pathophysiology of pleomorphic adenoma
Proliferation of epitherlial and myoepithelial cells of the ducts and increase ins tromal components Slow growing, lobular and not well encapsulated
153
Descirbe the sx of pleomorphic adenoma
Gradual onset, painless, unilateral swelling of the parotid gland Typically moveable on examination
154
How is pleomorphic adenoma amanged?
Surgical excision
155
What is the prognosis of pleomorphic adenoma
Recurrence rate of 1-5% with excision
156
What is the main complication of pleomorphic adenoma
Malignant transformation-> adenocarcinoma
157
What are the features of MEN1
Pancoast tumour Pituitary adenoma Parathyroid hyperplasia
158
What are the features of MEN 2a
Medullary thyroid carcinoma Phaeochromocytoma Parathyroid hyperplasi
159
What are the features of MEN 2b
Medullary thyroid carcinoma Phaeochromocytoma Mucosal neuromas
160
What is the most comon cause of neck swelings?
Reactive lymphadenopathy
161
Describe the features of a neck lump indicating lymphoma
Rubbery painless lymphadenopathy Associated with night sweats and splenomegaly
162
Describe the features of a neck lump indicating thyroid swelling
Moves upwards on swallowing Thyroid sx
163
Describe the features of a neck lump indicating a thyroglossal cyst
<20 yrs Midline between isthmus of thyroid and hyoid bone Moves upwards on protrusion of tongue May be painful if infected
164
Describe the features of a neck lump indicating a pharyngeal pouch
If large enough to see-> midline lump on neck that gurgles on palpation Sx of dysphagia, regurg, aspiration, chronic cough Older men
165
Describe the features of a neck lump indicating a cystic hygroma
Evident at birth, <2yrs of age Congenital lymphatic lesion found in neck on left side
166
Describe the features of a neck lump indicating a branchial cyst
Oval bonile cystic mass between sternocleidomastoid muscle and pharynx Early adulthood Failure of obliteration of 2nd branchial cleft in embryonic development
167
What are the features of a cervical rib
Adult females Throacic outlet syndrome in 10%
168
Describe the features of a neck lump indicating a carotid aneurysm
Pulsatile lateral neck mass that doesn;t move on swallowing
169
What are the complications of tonsillitis
Otitis media Quinsy-peritonsillar abscess Rheumatic fever and glomerulonephritis-> rare
170
What are the indications for a tonsillectomy
Sore throats due to tonsillitis that are disabling and prevent normal functioning and occur either: 7 episodes/year for 1 year or 5 per year for 2 years or 3 per year for 3 years Others: Recurrent febrile convulsions Obstructive sleep apnoea, stridor or dysphagia seocndary to enlarged tonsils Peritonsillar abscess and unresponsive to tx
171
What are the complicaitons of tonsillectomy
Haemorrhage (due to inadequate haemostasis or infection) Pain
172
Name some risk factors for tonsillitis
5-15 years Immunodeficiency Fhx Close contact with infected individual
173
What are the common causative organisms for tonsillitis
Group A strep-strep pyogenes EBV
174
What 2 criterias can be used to assess the likelihood of bacterial tonsillitis?
CENTOR criteria FEVERPain score
175
Describe the CENTOR score
Tonsillar exudate Tender anterior cervical lymphadenopathy Fever >38 degrees Absence of a cough Score of 3/4: 32-56% likelihood
176
Describe the FeverPAIN score
Fever Pus on tonsils Attended within 3 days of sx onset Inflamed tonsils No cough or coryza
177
Descrobe the management of bacterial tonsillitis:
Abx: -Indicated if CENTOR 3/4 or FeverPAIN 4/5 or systemic upset/immunosuppression -1st line: penicillin V PO QDS 5-10 days -2nd line: clarithromycin/erythromycin CENTOR 0-2/FeverPAIN score 0/1: -Abx not needed Analgeisa and flud intake Admit if systemically unwell
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