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ENT Flashcards

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1
Q

What is the centor criteria?

A

Predicts risk of infection with Group A beta-haemolytic streptococci

  • Absence of cough
  • Exudate
  • Fever > 38
  • Anterior cervical lymphadenopathy
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2
Q

How are sore throats managed?

A
  • Analgesia
  • Anti-pyretics (paracetemol/ibuprofen)
  • Increase fluid intake
  • Salt water gargles
  • Antibiotics (penicillin or erythromycin) if:
    • >/=3 on centor criteria
    • Systemically unwell
    • Signs of serious complication
    • Risk of complication due to co-morbidity
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3
Q

Name some complications of a sore throat

A
  • Quinsy (peritonsillar abscess) = unilateral peritonsillar swelling
    • Difficulty swallowing and opening jaw
  • Retropharyngeal abscess (children)
    • Inability to swallow and fever
  • Rheumatic fever
  • Glomerulonephritis
  • Lemierre’s syndrome = pharyngotonsilitis, internal jugular vein thrombophlebitis + septic emboli
    • Fusobacterium necrophorum
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4
Q

Name the indications for a tonsillectomy

A
  • Recurrent acute tonsilitis
    • >7/year, >5/year for 2 years, >3/year for 3 years
  • Airway obstruction (sleep apnoea)
  • Chronic tonsiltis > 3 months + halitosis
  • Recurrent quinsy
  • Unilateral tonsillar enlargement
  • Risk of malignancy
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5
Q

Describe glandular fever, including symptoms, cause and diagnosis

A

Infectious mononucleosis

  • Symptoms = sore throat > 1 week, malaise, fatigue, lymphadenopathy, enlarged spleen, palatal petachiae
  • Caused by Epstein-Barr virus and spread by droplet infection/direct contact
  • Diagnosed with FBC (lymphocytes) and glandular fever antibodies (Monospot/Paul Bunnell)
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6
Q

How is glandular fever managed?

A
  • Rest
  • Fluids
  • Regular paracetemol
  • Avoid alcohol
  • Salt water/aspirin gargles
  • Consider short course of prednisolone if severe
  • Antibiotics if secondary infection
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7
Q

What is stridor? Name some causes

A

Noise created on inspiration due narrowing of the larynx or trachea

  • Epiglottitis
  • Croup (laryngotracheobronchitis)
  • Inhaled foreign body
  • Trauma
  • Laryngeal paralysis
  • Congenital abnormalities
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8
Q

What is croup? What are the clinical signs?

A

Viral infection of the larynx/trachea, commonly seen in young children

  • Fever
  • Runny nose
  • Barking cough
    • Worse at night
    • Exacerbated by crying
  • Inspiratory stridor
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9
Q

How is croup managed?

A
  • Steam
  • Steroids - oral dexamethasone or prednisolone
  • Admit as paediatric emergency if:
    • Intercostal recession
    • Cyanosis
    • Carers unable to cope
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10
Q

What is CSF rhinorrhoea? What is it an indication of?

A

Clear fluid dripping from the nose after trauma can indicated a fracture of the roof of the ethmoid labyrinth/cribriform plate which disrupts dura and arachnoid mater causing consequent CSF leak

  • CSF contains ß2 (tau) transferrin on immunoelectrophoresis
  • Differentiate from nasal discharge as +ve for glucose
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11
Q

Name some causes of earache

A
  • Local
    • Otitis externa/media
    • Impacted wax
    • Malignancy
    • Barotrauma
    • Mastoiditis
  • Referred
    • Trigeminal nerve (dental abscess/TMJ)
    • Facial nerve
    • Vagus nerve (larynx)
    • Glossopharyngeal nerve (tonsilitis/quinsy)
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12
Q

Name some risk factors for developing otitis externa

A
  • Swimming
  • Narrow ear canal
  • Hearing aid use
  • Mechanical trauma
    • Cotton buds
    • Syringing
  • Itching
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13
Q

How is otitis externa managed?

A
  • Analgesia (paracetemol +/- ibuprofen)
  • Aural toilets
  • Ear drops (if no perforation)
    • Antibiotics (gentamicin)
    • Steroid (betamethasone)
    • Aluminium acetate
  • Refer to ENT if no response - microsuction
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14
Q

How does acute otitis media present?

A

Often after a viral URTI

  • Unilateral ear pain
  • Fever
  • Ear purulent discharge (drum perforation)
    • Associated with pain relief
  • Red, bulging ear drum
  • If perforated - external canal filled with pus
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15
Q

How is acute otitis media managed?

A
  • Fluids
  • Paracetemol/ibuprofen
  • Delayed prescription of antibiotics (after 4 days)
    • Amoxicillin immediately if child with bilateral or otorrhoea
    • Immediately if systemically unwell or at high risk of complications
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16
Q

What are the different types of hearing loss?

A
  • Conductive = blockage of outer/middle ear interferes with sound transmission to inner ear
    • Wax
    • Infection (glue ear)
    • Perforated ear drum
    • Otosclerosis
  • Sensorineural = damage to cochlea and/or auditory nerve
    • Noise-induced
    • Infection (measles, meningitis)
    • Aging (presbyacusis)
    • Acoustic neuroma
    • Ototoxic drugs (streptomycin, quinines)
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17
Q

What is glue ear?

A

Accumulation of non-infected fluid in the middle ear due to dysfunction/obstruction of the Eustachian tube

  • Secondary to throat or ear infection
  • Presents with deafness, ear pain, difficulties with speech, behavioural problems
  • Usually resolves <3 months
  • Treated with grommets
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18
Q

What is mastoiditis?

A

Infection from otitis media spreads to the mastoid bone

  • Presents with presistent, throbbing earache with creamy, profuse discharge, conductive deafness
  • Swelling over mastoid causes ear to stick out
  • Drum is red, bulging or perforated
  • Refer to ENT as emergency - need mastoidectomy
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19
Q

What is cholesteatoma?

A

Skin or stratified squamous epithelium growing in the middle ear, thought to result from formation of a retraction pocket in the pars flaccida of the eardrum

  • Local expansion damages adjacent strutures
    • Facial nerve
    • Semicircular canals (vertigo)
  • Refer to ENT - microsuction/antiobiotic drops/mastoid surgery
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20
Q

Name some causes of congential deafness

A
  • Genetic
  • Birth asphyxia
  • Intrauterne infection (rubella)
  • Meningitis
  • Drugs during pregnancy - streptomycin
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21
Q

Describe hearing tests

A
  • Simple (whispering etc)
  • Rinne’s = base of vibrating tuning fork (512) on mastoid process then near external acoustic meatus
    • If air conduction > bone conduction = positve, normal
    • If BC > AC = negative, conductive deafness
  • Weber’s = vibrating tuning fork on forehead
    • If normal = not louder on either side
    • If on the right
      • right conductive
      • left sensorineural
  • Audiometry - quantifies loss and determines nature (subjective)
  • Acoustic impedence audiometry (objective)
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22
Q

Label this ear drum

A

RIGHT (cone of light towards feet)

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23
Q

Describe anatomy of ear

A
  • External ear = pinna/auricle + external auditory canal
  • Middle ear
    • Ossicles = malleus, incus, stapes
    • Eustachian tube (middle ear to back of nose)
  • Inner ear
    • Cochlea (hearing) - bony
      • Organ of Corti (hair cells)
    • Vestibule (balance) / labyrinth
    • Semicircular canals 3 (balance) - saccule + utricle
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24
Q

How is sudden sensorineural deafness managed?

A
  • ENT help
  • Investigate cause - WR, ANA, INR, TSH, gluc, chol, ESR, FBC, LFT, viral
  • Audiology + evoked response audiometry
  • Imaging - gondolium MRI, CT
  • Prednisolone 80mg/24 hours PO for 4 days
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25
How is sudden sensorineural deafness defined?
Loss of \>/= 30 DB in 3 contiguous pure tone frequencies over = 72 hours
26
What is otosclerosis? Name some symptoms
Vascular spongy bone replaces normal lamellar bone around the oval window - fixes stapes footaplate * Conductive deafness (better with background noise) * Tinnitus * Mild, transient vertigo * Pink tinge to drum Symptoms worse with pregnancy, menstruation and menopause
27
How is otosclerosis managed?
* Fluoride * Hearing aid * Cochlear implant * Surgery
28
What is presbyacusis?
Age-related hearing loss from accumulated environmental noise toxicity, starting with high frequency sounds * Most affected with background noise * Treat with hearing aids
29
What is tinnitus? Name some causes
Sensation of non-verbal sound not due to stimuli outside the body * Inner ear/central = ringing/hissing/buzzing * External/middle ear = popping/clicking * Drugs - aminoglycosides, aspirin, loop diuretics * Psychological (anxiety) * Benign intracranial hypertension
30
How is tinnitus managed?
* Treat the treatable * Hearing aid if loss \> 35 dB * Psychological support - tinnitus retraining therapy/cognitive therapy * Music, massage * Drugs * melatonin * Betahistine (menieres) * Baclofen * Intratympanic dexamethasone?
31
What is an acoustic neuroma?
Indolent subarachnoid tumours of the superior vestibular nerve * Progressive ipsilateral tinnitus +/- sensorineural deafness * +/- ipsilateral cerebellar signs * RICP * Numb face Investigate with MRI
32
Organisms in otitis externa
* Pseudomonas * Staph aureus * Fungal
33
Risk factors for chronic otitis media
* URTI * Oversized adenoids * Bottle-feeding * Asthma * Passive smoking * Malformations * Dummy
34
History in glue ear
* Poor listening/sppech/behaviour * Language delay * Inattention * Balance * School work * URTI
35
Signs of glue ear
* Retracted bulging ear drum - dull/grey/yellow * Decreased drum mobility * Bubbles of fluid level * Superficial vessels * Impedence audiometry - flat tympanogram (type B) * Audiograms= conductive defect
36
What is vertigo?
Sensation of environment/person moving or spinning * World seem to spin? Which way? - vertigo * If not - vascular, ocular, MSK, metabolic, claustrophobic * Duration of vertigo * Seconds to minutes - BPPV * 30 mins to 30 hours - Menier's or migraine * 30 hours to 1 week = acute vestibular failure
37
Name some causes of vertigo
* Peripheral * Menieres * Benign paroxysmal positional vertigo * Vestibular failure * Labyrinthitis * Cholesteatoma * Central * Acoustic neuroma * MS * Head injury * Drugs (gentamicin, diuretics, co-trimaxazole, metronidazole)
38
What is menieres disease?
Dilatation of the endolymphatic spaces of membranous labyrinth causes vertigo for around 12 hours * Extreme weakness * Nausea/vomiting * Feeling of full ears * Unilateral tinnitus * +/- fluctuating sensorineural deafness * Attacks in clusters
39
How is menieres managed?
* Investigate - endolymphatic space MRI, electrocochleography * Prochlorperazine if vomiting * Betahistine * Thiazides * Surgical (vestibular neurectomy) * Psychological * Advice - lie down, close eyes, don't turn head quickly
40
What is acute vestibular failure?
Vestibular neuronitis * Follows febrile illness in adults (HSV) * Sudden vertigo * Vomiting * Prostration (severe weakness) exacerbated by head movements Managed with cyclizine, methylprednisolone
41
What is benign paroxysmal positional vertigo?
Attacks of sudden rotational vertigo lasting \> 30 seconds provoked by head turning * Displacement of otoconia in semicircular canals * Other otological symptoms rare * Diagnosis with Hallpike test
42
How is BPPV managed?
* Vestibular habituation exercises * Drugs * Betahistine * Prochlorperazine * Antidepressants * Epley manoevres * Posterior semicircular canal denervation (risk of deafness)
43
What is rhinosinusitis? How is it managed?
Inflammation in the nose and paranasal sinuses with more than 2 symptoms (1 must be nasal congestion or discharge) including facial pain/pressure, decreased olfaction and nasal polyps * Acute management - topical corticosteroids and oral antibiotics * Chronic management - topical corticosteroids and nasal douching
44
What is allerigc rhinosinusitis? How is it managed?
IgE-mediated inflammation from allergen exposure to nasal mucosa causing histamine release from mast cells * Antihistamine (loratadine) * Systemic decongestants (pseudoephedrine) * Nasal sprays/nasal steroids (beclometasone \< 1 month) * Oral steroids * Immunotherapy
45
What are nasal polyps? Name some associations
Ciliated columnar epithelium with thickened basement membrane and avascular oedematous stroma (90% eosinophilic) * Rhinitis * Chronic ethmoid sinusitis * Cystic fibrosis * Aspirin sensitivity * Asthma
46
Symptoms and signs of nasal polyps
* Watery anterior rhinorrhoea * Purulent postnatal drip * Nasal obstruction * Change of voice * Taste disturbance * Mouth-breathing * Snoring * Signs = pale, mobile, insensitive to gentle palpation
47
Management of nasal polyps
* 1% betamesthasone drops * Beclometasone spray (maintenance) * Oral prednisolone 1-2 weeks * Anti-leukotrienes and low dose clarithromycin 2 weeks * Endoscopic polypectomy If single unilateral polyp +/- epistaxis = prompt CT and histology
48
Causes of epistaxis
Anterior septum (Little's area) or posterior * Trauma * Infection * Hypertension * Haemophilia * High alcohol * Septal perforation * Neoplasm
49
How is epistaxis managed?
* Resuscitate if needed (hypotension/dizzy) + ABCDE * Patient pitch lower part of nose for 15 mins sitting forward * Fully decongest (ephedrine 0.5% drops) * Ice pack on dorsum of nose * Silver nitrate cautery (after lidocaine and phenylephrine) * Anterior nasal pack (paraffin gauze) 24 hours * Posterior nasal pack (foley catheter) * Diathermy * Arterial ligation (sphenopalatine/maxillary)
50
Symptoms of sinusitis
* Pain - maxillary (teeth/cheek) or ethmoid (between eyes) * Worse on bending * Discharge from nose * Nasal congestion * Ansomia * Fever
51
Causes of bacterial sinusitis
* Direct spread (dental root, swimming) * Odd anatomy (septal deviation, polyps, large ethmoidal bulla) * ITU - mechanical ventilation, NG tubes * Biofilms Organisms = strep pneumonia, haemophilus influenza, moraxella catarrhalis
52
Management of sinusitis
* Acute (if after 5 days not resolved): * Nasal douching * Topical steroids/decongestants * +/- amoxicillin * Chronic (\> 12 weeks) * Functional Endoscopic Sinus Surgery (FESS) * Suction cleaning 1 weel post-op * Fluticasone spray 6 weeks post-op * Smoking cessation
53
Complications of sinusitis
* Mucocoeles (cysts) - infected pyocoeles * Orbital cellulitis/abscess * Osteomyelitis * Intracranial infection - meningitis, encephalitis, abscess
54
Name sinuses and drainage
55
Emergency management of acute airway obstruction
* O2 or heliox * Nebulised racemic adrenaline * Dexamethasone/hydrocortisone IV * ENT+anaesthetics help * Tracheostomy kit ready * ABG * Flexible nasendoscopy (ENT) * AP + lateral x-rays of neck and chest
56
Name some causes of dysphonia (hoarseness)
* Laryngitis (viral) * Reinke's oedema (vocal cord oedema) * Functional disroders (aphonia) * Intrinsic - decreased lubrication (Sjogrens, granulomas) * Extrinsic - goitre, carotid body tumour, neoplasia * Bacteria - epiglottitis, aortitis, abscess * CNS - vagus lesion, myasthenia gravis, laryngeal nerve palsy
57
Symptoms of laryngeal nerve palsy
* Hoarseness * Breathy voice * Weak cough * Repeated cough/aspiration * Exertional dyspnoea (glottis too narrow)
58
Causes of laryngeal nerve palsy
* Cancer (larynx, thyroid, oesophagus, bronchus) * Iatrogenic (parathyroidectomy) * TB * Aoritc aneurysm * Idiopathic
59
Causes of dysphagia
* Malignant - oesophageal, pharyngeal, gastric, lung * Neuro - bulbar palsy, myasthenia gravis * Benign strictures * Pharyngeal pouch * Achalasia
60
Dysphagia history
* Dyspepsia * Weight loss * Lumps * Fluid be drunk as fast as usual? Yes = stricture. No = motility disorders * Difficulty making swallowing movement? Yes = bulbar palsy * Dysphagia constant and painful? Yes = malignant stricture * Neck bulge or gargle on drinking? Yes = pharyngeal pouch (+ choking, chronic cough, regurgitation, halitosis)
61
Investigations for dysphagia?
* FBC, ESR * Barium swallow * Endoscopy with biopsy * Oesophageal motility studies * CXR
62
Causes of facial nerve palsy
* Intracranial = brainstem tumours, stroke, MS, meningitis * Intratemporal = otitis media, shingles, cholesteatoma * Infratemporal = parotid tumours, trauma * Herpes * Diabetes * Bell's palsy
63
How to examine facial nerve?
* Inspect at rest - forehead wrinkles, nasolabial folds * Movements * Raise eyebrows * Close eyes * Blow out cheeks * Smile * Pursed lips (whistle) * Inspect external acoustic meatus - shingles (Ramsay-Hunt) * Hearing or taste changes?
64
Contents of anterior and posterior neck triangles
Anterior: * Supra/infrahyoid muscles * Common carotid bifurcation * Internal jugular * CN VII, IX, X, XI, XII Posterior: * Omohyoid * External jugular + subclavian vein * CN XI * Phrenic nerve
65
Causes of neck lumps
* Midline * If \< 20 = dermoid cyst * If \> 20 = thyroid mass * Moves on protruding tongue? Thyroglossal cyst * Submandibular triangle * If \< 20 = self-limiting lymphadenopathy * If \> 20 = malignant? * Salivary stone * Sialadenitis (salivary gland infection) * Anterior triangle * Nodes * Branchial cyst (\<20) * Parotid tumour * Carotid body paraganglioma (pulsatile) * Posterior triangle * Nodes * Lymphoma/mets
66
How are neck lumps investigated?
* US - lump consistency * CT - anatomical position * Nasendoscopy * Virology + Mantoux test * CXR - malignancy or hilar lymphadenopathy * Fine needle aspiration
67
Name the salivary glands
68
Name some causes of salivary gland lumps based on acute/chronic/uni/bilateral
* Acute unilateral = mumps, acute parotitis (post-op) abscess * Acute bilateral = mumps, staph, TB, HIV, ALL * Recurrent unilateral = stones * Pain/swelling worse with eating * Sialography x-ray * Chronic bilateral = Sjogrens * Fixed swelling = malignant, idiopathic, sarcoidosis
69
What is xerostomia? How is it managed?
Dry, atrophic, fissured oral mucosa causing discomfort when eating and speaking * Increase oral fluids * No acidic foods/drinks * Chewing gum (sugar free) * Saliva substitute
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