1
Q
What is found in the anterior triange of the neck?
A
- Larynx
- Hypopharynx
- Carotid sheath
- Thyroid gland
- Deep cervical lymph nodes
2
Q
What is found in the Posterior triangle of the neck?
A
- Lymph nodes
- Accessory nerve
- Subclavian artery
3
Q
What are the lymph node levels of the neck, what is found in each level?
Level 1
Level 2
Level 3
Level 4
Level 5
Level 6
Level 7
A
- Level 1 – Submental & Submandibular lymph nodes
- Level 2 – Upper deep cervical
- Level 3 – Mid deep cervical
- Level 4 – Lower deep cervical
- Level 5 – Posterior triangle
- Level 6 – Paratracheal
- Level 7 – Upper mediastinal
4
Q
What are the subdivisions of the anterior triangle?
A
- Carotid triangle
- Submental triangle
- Digastric triangle
5
Q
When taking a Hx concerning a patient with problems with their nose, what are the key questions to ask?
A
- Nasal obstruction
- Runny nose (Also called anterior rhinorrhoea)
- Loss of sense of smell (Also called hyposmia)
- Nose bleeds (Also called epistaxis)
- Facial pain
Other symptoms include:
- Post nasal drip
- Nasal itch
- Sneezing
- Ocular itching
6
Q
When taking a Hx concerning a patient with problems with their ear, what are the key questions to ask?
A
- Earache (Also called otalgia)
- Ear discharge (Also called otorrhoea) – Colour/Smell/Consistency
- Hearing loss – How does it affect you?
- Tinnitus (the sensation of sound without any external stimulus)
- Dizziness
- Any problems with balance?
Other symptoms can occur and include:
- Aural blockage
- Itching
7
Q
When taking a Hx concerning a patient with problems with their throat, what are the key questions to ask?
A
- Sore throat
- Difficulty swallowing (Also called dysphagia)
- Pain on swallowing (Also called odynophagia)
- Hoarse voice (Also called dysphonia)
- Regurgitation
Other symptoms include:
- A feeling of a lump in the throat
- Burning in the throat
- Weight loss
8
Q
You are asked to perform an ear examination, what does this involve?
A
[Introduction]
- Wash hands & Introduce self
- Ask Patient name & DOB & Age
- Today I am going to be doing an examination of your ear, having a look at it from the outside, then using a scope to look inside the ear, this will involve me getting close to your ears
- Does that sound ok?
- Do you have any pain at the moment?
- Would you like some painkillers?
- For the examination I will need to have access to both your ears, so can you please tie your hair back, and remove any piercings that might obstruct your ears/canal?
- I’ll need you sitting comfortably on a chair please
[General Inspection]
- Where exactly is the pain?
- Is it in a specific area/generalised?
- Look at the patient sat in the chair, assess for:
- Signs of pain
- Discomfort
- Look in ear
- Any hearing aid/cotton wool needs to be removed for the examination
[Inspection]
- Assess R & L ear:
- Size & shape of the Pinna
- Extra cartilage tags
- Pre-auricular sinuses or pits
- Signs of trauma
- Perichondral haematoma
- Lesions, Massess
- Condition of the skin
- Inflammation around the ear
- Eryspelas
- Mastoiditis
- Discharge
- Scars of previous surgery
- Assess other ear
[Palpation]
- Gently palpate, for tenderness:
- Tragus
- Around the mastoid
- Gentle tug on pinna
- Assess lymph nodes
- Pre-auricular
- Post auricular
[Otoscope]
- Prepare: Attach the speculum (New speculum for each patient)
- Correct size for patients ear canal
- Ensure it is attached firmly
- Put otoscope on
- Check light is working correctly
- Insert otoscope into the test ear Hold near head of otoscope like holding a pen
- Left ear - Left hand with handle facing left
- Right ear - Right hand with handle facing right
- Gently pull up and back on pinna – To straighten the external auditory meatus
- Stabilise otoscope by using little finger to rest on patients temple
- Gradually insert speculum into the external auditory meatus
- Look in ear canal:
- Skin changes
- Foreign body
- Wax (Normal)
- Discharge
- Assess the tympanic membrane
- Handle
- Lateral process of the malleus
- Light reflex/Cone of light
- Pars tensa
- Pars flaccida
- Look in ear canal:
- Comment on any abnormalities
- Otitis externa (Acute/chronic/fungal)
- Otitis Media
- Cholesteatoma
- Perforation
- Tympanosclerosis
[Conductive & Sensorineural hearing loss]
- Basic hearing test
- Ask patient to put finger in one of their ears
- Whisper letters/numbers into patients other ear
- Can you repeat what I just said?
- Repeat in other ear
- Use different letters/numbers
- Note:
- If there is a hearing impairment it is a conductive problem/sensorineural
- Conductive -> Outer ear/TM/Middle ear
- Sensorineural -> Inner ear or CN 8
Rinne’s
- Rinne’s test Place vibrating 512Hz tuning fork firmly on patients mastoid process of test ear
- Can you hear the tuning fork?
- Transfer to in front of the ear canal
- Which is louder
- Note:
- Normal -> In front of the ear should be louder than the mastoid process
- Air conduction is > Bone conduction
- Rinnes test POSITIVE:Normal + Hearing impairment
- Sensorineural hearing loss
- Rinnes test NEGATIVE:Abnormal + Hearing impairment
- Conductive hearing loss
- Normal -> In front of the ear should be louder than the mastoid process
- It is possible to have a Rinnes negative result - but have sensorineural deafness
- Because if the sensorineural deafness is complete then the vibration from the test ear -> transfers to the non-test ear via the bone
- That’s why you use Webers test to confirm this, as the sound should lateralise to the non-test ear
Weber’s test
- Place the vibrating 512Hz tuning fork centrally and firmly on patients forehead
- Ask patient - where can you hear the sound?
- Centrally
- Left
- Right
- If the patient has Conductive hearing loss
- Localises TOWARDS the Abnormal ear
- Sensorineural hearing loss
- Localises AWAY from affected ear
[Complete exam]
- Thank patient & Wash hands
- “This is patient x who is a x year old Male/Female with the following findings”
- I would take a full Hx + examine any other systems – Nose/Throat
- I would consider the differentials
- I would order relevant investigations
- Observations
- Bloods
- Imaging
- I would initiate management of the most likely differential
9
Q
You are asked to perform a nasal examination, what does this involve?
A
[Introduction]
- Wash hands & Introduce self
- Ask Patient name & DOB & Age
- Today I am going to be doing an examination of your ear, having a look at it from the outside, then using a scope to look inside the nose
- Does that sound ok?
- Do you have any pain at the moment?
- Would you like some painkillers?
- For the examination I will need to have access to your nose so can you please remove your glasses for me?
- I’ll need you sitting comfortably on a chair please
[General Inspection]
- Where exactly is the pain?
- Is it in a specific area/generalised?
- Look at the patient sat in the chair, assess for:
- Signs of pain
- Discomfort
- Runny nose
- Do they look systemically well?
[Inspection]
- Examine the external nose:
- Size and shape
- Obvious bend or deformity
- Swelling
- Bruising
- Scars
- Abnormal creases
- Redness
- Skin changes
- Discharge/crusting
- Offensive smell
- Examine the nose internally
- Can you please lift the tip of your nose with your thumb?
- Use pen torch to look, note:
- Abnormalities
- Septal deviation
[Palpation]
- Gently palpate the nasal bone & cartilage, assess for:
- Tenderness
- Alignment
- If signs of trauma then palpate the:
- Nasal process
- Facial surface
- Frontal process of maxilla
- Infra-orbital ridges
- If signs of trauma then palpate the:
- What im going to do next is just to block one of your nostrils and can you just breathe through the other one
- Assess difference in airflow
- Block other nostril
[Otoscope]
- Attach new speculum to otoscope
- Examine R nostril
- Hold R nostril otoscope in L hand
- Examine L nostril
- Hold L nostril with otoscope in R hand
- Insert speculum gently into nostril & open up nasal cavity
- Examine nasal cavity
- Septum
- Turbines (Inferior turbine should be visible)
- Signs of inflammation
- Any polyps or foreign body
[Complete exam]
- Thank patient & Wash hands
- “This is patient x who is a x year old Male/Female with the following findings”
- I would take a full Hx + examine any other systems
- I would consider the differentials
- I would order relevant investigations
- Observations
- Bloods
- Imaging
- I would initiate management of the most likely differential
10
Q
You are asked to perform a neck/throat examination, what does this involve?
A
[Introduction]
- Wash hands & Introduce self
- Ask Patient name & DOB & Age
- Today I am going to be doing an examination of your throat, having a look at it from the outside, then using a scope to look inside your throat
- Does that sound ok?
- Do you have any pain at the moment?
- Would you like some painkillers?
- For the examination I will need you to be able to see your neck, so please take off your scar or top if blocking neck
- I’ll need you sitting comfortably on a chair please
[General Inspection]
- Where exactly is the pain?
- Is it in a specific area/generalised?
- Look at the patient sat in the chair, assess for:
- Signs of pain
- Discomfort
- Systemically well at rest?
- Cachexia
- Hoarse voice
[Inspection]
- Look externally
- Scars
- Visible lymph nodes
- Massess on neck If midline - Can you swallow some water for me?
- Thyroglossal cyst & thyroid mass -> Move up
- Can you please stick your tongue out for me
- Thyroglossal cyst -> Moves UP, Thyroid mass will NOT
- Look internally
- Can you please remove any dentures if you have any?
- Put gloves on and get pen torch & tongue depressors
- Im going to just ask you to open your mouth, so that I can have a look at your throat. I’m going to be using these wooden spatula to push your tongue down
- Asses - Mouth
- Mucosa of the cheeks
- Condition of tongue
- Ask them to move tongue out
- Move tongue to the R & L to check the sides
- Back of tongue and tonsils - with tongue depressor
- Exudate
- Quinsy
- Uvula
- Soft palate
- Ask patient to tip head back -> Insepct the hard palate
- Buccal area
- Gingivolabial sulcus (Space b/w cheek and gums)
- Asses - Mouth
- Can you stick your tongue up for me
- Examine floor of mouth
[Palpation]
- I’m just going to have a feel of your tongue now
- Palpate base of tongue for
- Tumours
- Remove gloves, and stand behind patient - Palpate lymph nodes:
- Submental - Submandibular - Preauricular - Postauricular - Anterior cervical - Posterior cervical
- Palpate structures in neck
- Parotids - Tail of parotid (Anterior and inferior to mastoid process)
- Submandibular glands (Singular swelling)
- Palpate neck -Tip of chin - submandibular - submental - mastoid process - anterior SCM - Thyroid gland - Larynx - Posteiror triangle - Supraclavicular fossae
- Massess
- Tenderness
[Complete exam]
- Thank patient & Wash hands
- “This is patient x who is a x year old Male/Female with the following findings”
- I would take a full Hx + examine any other relevant systems
- I would consider the differentials
- I would order relevant investigations
- Observations
- Bloods
- Imaging
- I would initiate management of the most likely differential
11
Q
How do you differentiate between a thyroglossal v thyroid cyst?
A
- Massess on neck If midline - Can you swallow some water for me?
- Thyroglossal cyst & thyroid mass -> Move up
- Can you please stick your tongue out for me
- Thyroglossal cyst -> Moves UP
- Thyroid mass will NOT
12
Q
You are asked to take a throat swab from a patient, how do you go about this procedure?
A
[Introduction]
- Wash hands & Introduce self
- Ask Patient name & DOB & Age
- Today I am going to be doing a swab of your throat is that what you were expecting?
[Prepare equipment]
- Wash hands
- Put on apron
- Open procedure pack on to clean surface
- Partially open swab packaging
- Wear gloves
[Position patient]
- Use good light source
- I will need you to be seated with your head back and mouth wide open
- Stick your tongue out and say ahhh
[Take swab]
- Use tongue depressor to flatten tongue
- Roll swab over suspect area
- Remove swab -> Place in medium
- Remove gloves
- Wash hands
[Complete]
- Thank patient
- Explain when they will receive results
- Label sample
- Place in hazards bag - fill out paper work
- Send to microbiology
13
Q
What is the following showing? What are the items labelled?
A
Normal throat O/E, from top to bottom
- Hard palate
- Soft palate
- Uvula
- Palatine Tonsils
- Tongue
14
Q
What is the following showing? What do the arrows point to?
A
Normal ear O/E
- Top left – Pars flaccida
- Top right – Lateral process of malleus
- Bottom Left – Pars tensa
- Bottom right – Cone of light
15
Q
Label the following diagram of the ear
A
- Tympanic membrane
- Pinna
- Helix
- Outer ear/External acoustic meatus
- Cartilage
- Earlobe
- Malleus - Incus - Stapes (Lateral to medial)
- Semicircular canals
- Cochlea
- 10 + 11. Vestibulococclear nerve
- 12 + 13. Eustachian tube
- Bone
16
Q
How are sound waves conducted from outside into the ear?
A
- Sound waves – external auditory canal
- Hit the Typmanic membrane
- Transfer to ossicles (Malleus + Incus + Stapes) to the inner ear
- Hit the Oval window
- Tranfer to the cochlea
17
Q
What is the cochlea?
How is it divided?
A
Spiral shaped cannal within the temporal bone
3 membranous compartments filled with Perilymph:
- Scala tympani
- Scala media – Filled with Endolymph
- Basilar membrane
- Organ of corti
- Scala Vestibuli
18
Q
What is the function of the organ of corti?
A
Organ of corti = Detects sound waves – converts it into electrical signal for brain via CN8
19
Q
Where is sound transmitted to in the central nervous system?
A
- Cochlear nerve – Cochlear nucleus in brainstem
- Decussation to contralateral side
- Up brainstem via Superior Olivary nucleus
- Through lateral leminiscus (Midbrain) – Inferior Colliculus
- Medial geniculate body
- Auditory cortex (Superior Temporal gyrus of temporal lobe)
20
Q
What are the 2 types of hearing loss?
A
- Conductive – Problem with transmission of sound waves from external ear – middle ear
- Sensorineural – Problem with the cochlear - Cochlear nerve - Brainstem leading to abnormal/absent neurosensory impulses
- Most common in adults
21
Q
Who typically gets deafness/hearing loss in adults?
A
- People >50yrs (Due to age related damage)
- Men
- Those exposed to excessive noise
22
Q
What can cause conductive hearing loss in adults?
A
- Occlusion – Cerumen/Foreign body/Oedema
- Infection – Otitis externa/Otitis media/Sinusitis
- Tympanic membrane perforation
- Growths – Benign cysts/Benign or Malignant tumours
- Cholesteatoma
- Adenoids blocking the eustachian tube
23
Q
What can cause sensorineural hearing loss in adults?
A
- Presbyacusis (Age related hearing loss)
- Noise induced hearing loss
- Ototoxic hearing loss
- Acoustic neuroma
- Menieres disease
24
Q
What are the risk factors for hearing loss in children?
A
- FHx of deafness
- Infection – Congenital/MMR/Meningitis
- Ototoxic medications
- Low birth weight/prematurity
- Head injury
25
What are the common causes of hearing loss in children?
* Congenital
* Otitis Media with effusion
26
What is Tympanosclerosis?
Calcification of the tissue in the tympanic membrane + middle ear
Classified as:
* **Myringosclerosis** -- Only tympanic membrane is involved
* **Intratympanic tympanosclerosis** -- Involving ossicles/mastoid cavity
27
Why does tympanosclerosis develop?
* May be due to an abnormal healing response
* Most commonly develops secondary to acute & chronic otitis media
* Increased risk in children with grommet insertion for OM
28
How does Tympanosclerosis typically develop?
* Asymptomatic
* O/E: Chalky white patches on inspection
* May have conductive hearing loss
29
What does the following otoscope exam show?
Tympanosclerosis
30
If you suspect a person has tympanosclerosis, how should this be investigaited?
* Not usually required if visualised O/E
* Audiometry - if hearing loss
31
How is Tympanosclerosis managed?
* Only if there is hearing loss
* Hearing aids
* Surgery -- Excision of sclerotic areas + reconstruction of ossicles
32
What are the differential diagnoses for otalgia (Ear pain)?
External ear
* Otitis externa
* Foreign body -- Object/Impacted cerumen
* Trauma
Middle ear
* Otitis media
* Mastoiditis
* Trauma
* Obstruction of eustachian tube
Referred pain
* Adenoidectomy/Infection
* CN referred pain
* TMJ
33
What is acute otitis media?
* Middle ear infection
* Common in children
* Commonly caused by H.Influenzae + Streptococcus pneumoniae (Bacteria)
* Rhinovirus + RSV (Viruses)
34
How do patients develop acute OM?
* Upper respiratory viruses infect the nasal passages/eustachian tube/middle ear
* Impairs mucocilliary clearance of eustachian tube to clear the middle ear
35
What are Chronic OM and Recurrent OM?
Chronic OM:
* Inflammation of the middle ear for \>3months
Recurrent OM:
* \>4 episodes of OM in 6 months
36
Who typically gets Acute OM?
* Children
* Smoking - Passive or Active
* During the winter months
Patients with:
* Eustachian tube dysfunction
* URTI
* Sinusitis
* Craniofacial abnormalities
37
What is the classic Hx of Acute OM?
* Hearing loss
* Otalgia
* Fever
* Preceeding URTI e.g. Flu/Sinusitis/Pneumonia/Tonsilitis
* In children:
* Irritability/Crying/Poor feeding
* Coryza/Rhinorrhea
* Vomiting
Signs:
* Fever
* Red/Yellow/Cloudy tympanic membrane
* Bulging of TM
* May have discharge in auditory canal secondary to perforation of TM
38
Why is Acute OM in adults a red flag?
* Because it signifies esutachian tube dysfunction which could be caused by malignancy
* Especially if unilateral
39
A patient presents with the following Hx, what is the most likely diagnosis? What are the differentials?
An 18-month-old toddler presents with 1 week of rhinorrhoea, cough, and congestion. Her parents report she is irritable, sleeping restlessly, and not eating well. Overnight she developed a fever. She attends day care and both parents smoke. On examination signs are found consistent with a viral respiratory infection including rhinorrhoea and congestion. The toddler appears irritable and apprehensive and has a fever. Otoscopy reveals a bulging, erythematous tympanic membrane and absent landmarks.
* **Acute otitis media**
* Mastoiditis
* Migraine
* Herpes Zoster
* Trauma
* Foreign body in ear
40
What does the following otoscope image demonstrate?
**Acute otitis media**
* Erythema
* Bulging membrane
41
A patient presents with the following Hx suggestive of AOM, what investigations should be done?
An 18-month-old toddler presents with 1 week of rhinorrhoea, cough, and congestion. Her parents report she is irritable, sleeping restlessly, and not eating well. Overnight she developed a fever. She attends day care and both parents smoke. On examination signs are found consistent with a viral respiratory infection including rhinorrhoea and congestion. The toddler appears irritable and apprehensive and has a fever. Otoscopy reveals a bulging, erythematous tympanic membrane and absent landmarks.
* Examination of ear w/otoscope
* Clinical diagnosis based on findings
* Culture of discharge if any
* Audiometry - if chronic hearing loss suspected (Not during acute infection)
* CT/MRI - in adults to exclude complications
42
How do you manage a patient with confirmed AOM?
* Analgesics -- Paracetamol ± NSAIDs (Ibuprofen)
* If bacterial -- Avoid prescribing ABx, unless systemically unwell or symptoms not improving within 4 days
* Amoxicillin for 5 days, If allergic - Erythromycin/Clarithromycin
* Immediate ABx if - systemically unwell/risk of complications
Consider admission:
* Admission for immediate assesment -- If complications of AOM, e.g. Meningitis/mastoiditis/facial nerve paralysis
* If \<3 months with Fever
* Consider admission -- If systemically unwell
* \<3 months, or 3-6months with Fever
43
What are the red flags in a patient presenting with symptoms of AOM?
Urgent referral to ENT, due to suspecting nasopharyngeal cancer
* Persistent symptoms not responsive to treatment
* Persistent cervical lymphadenopathy
* Unilateral epistaxis
44
What is Otitis Media with effusion?
* AKA - Glue ear
* Collection of fluid in the middle ear
* Chronic inflammation, usually follows AOM in children
* Can cause hearing impairment
* Uncommon in adults - Usually due to eustachian tube dysfunction or suspicious cause e.g. tumours
Can be caused by:
* Eustachian tube dysfunction
* Chronic colonisation of the adenoids/hypertrophy
45
Who classically gets OME?
What are the symptoms/Signs?
* Most common cause of aquired hearing loss in childhood
* Common in ages 1-6yrs
* Less common in adulthood
* Male \> Females
* Contact with people with infections/Smokers
Symptoms/Signs:
* Hearing loss
* Otalgia, may have fullness ± popping
* Hx of recurrent ear infection/URTI/Nasal obstruction
* May have balance problems
Otoscope:
* Opacification of the tympanic membrane
* No inflammation/Discharge
* Loss of light reflex
* Fullness/bulging of the typmanic membrane
* Crackling/popping tinnitus
46
How is a patient with OME investigated & Managed?
Investigations:
* Refer for hearing test/ENT
* May have mild conductive hearing loss
* May have spontenous resolution so active observation for 3 months
Adults:
* If unilateral - suspicious finding, MRI to rule out tumour
* Full evaluation
Management:
* Patient education -- Self limiting illness
* Smoking cessation
* Assist with hearing loss
* Hearing aids if required
Surgery:
* Only if bilateral present for \>3 months
* Insertion of Grommets (Ventillation tubes)
* Adenoidectomy - if recurrent URTI
* Usually resolution in 6-10 wks
47
Why are children particularly vulnerable to AOM?
* Vulnerable to the transer of organisms from the nasopharynx to the ear
* Angle b/w eustachian tube + wall of pharynx is wide so doesnt close shut with coughing or sneezing -- avenue for transfer of pathogens
Usually caused by:
* Preceeding URTI -- Haemophilus Influenzae/Strep Pneumoniae
* Viral -- RSV/Rhinovirus
48
What is Chronic Suppurative Otitis Media?
* Chronic inflammation in the middle ear + mastoid cavity
* TM is perforated
Safe -- Tubotympanic perforation (Centre of TM)
Unsafe -- Atticoantral perforation (Top of TM) + Cholesteatoma
49
Who classically gets CSOM?
What are the symptoms/Signs?
* Uncommon in both children & adults
* Male = Females
* Patients with multiple episodes of AOM
* Children attending daycare/with craniofacial abnormalities
Symptoms/Signs:
* Chronically draining ear \>2wks
* Hx of recurrent AOM
* Traumatic perforation/Insertion of grommets
* Otorrhoea without Otalgia + fever
* Hearing loss -- Conductive
* Mixed hearing loss -- Extensive disease
* External auditory canal - oedematous ± tender
* Discharge from the ear
* Middle ear mucosa visible on examination
50
In a patient with CSOM, what investigations should be ordered?
How should they be managed?
Investigations:
* NO EAR SWAB
* Audiogram -- Conductive hearing loss
* MRI -- if intratemporal/intracranial complications suspected
Management:
* Urgent assessment/admission to ENT -- If Mastoiditis (Postauricular tenderness/swelling) or facial paralysis or vertigo or evidence of intracranial infection
* If not urgent - routine referral to ENT
* Microsuction exudate from ear canal
* Keep ear dry, avoid swimming
* Aural toilet + ABx (Topical):
* Antibiotic + Steroid combination for 3-4wks until otorrhea resolves
51
What is Otitis Externa?
* Inflammation of the outer ear (Auricle + External auditory canal + Outer TM)
* Can be localised or diffuse
* AKA Swimmers ear
* Due to disturbance of lipid/acid balance of the ear canal
Usually caused by:
* Infection - Most common
* Allergies/Irritants/Inflammatory conditions
52
How does the ear canal clean itself normally?
* Self cleaning via epithelial migration
* Skin surface moves laterally from the TM towards the ear canal opening
* Ear wax (Cerumen) - assists with cleaning & lubrication and protection from bacteria/dust/insects
53
What are the causes of Otitis Externa?
Infection:
* 90% Bacterial -- Staph Aureus ± Pseudomonas Aureginosa
* Fungal -- Aspergillus/Candida, usually following prolonged ABx/steroids
* May also be caused by Herpes Zoster -- Ramsey Hunt syndrome
Skin inflammation:
* Sebhorrheic dermatitis/Psoriasis
* Acne
* Atopic eczema
* SLE
Irritants:
* Topical medications/Hearing aids/Ear plugs
* Ear trauma -- Foreign bodies/Cotton buds
* Swimming
54
Who classically gets Otitis Externa?
What are the symptoms/signs?
* Common condition
* People who swim/immunocompromised
* Trauma to ear canal
* Foreign body/Wax build-up
Symptoms/Signs:
* Otalgia
* Itching
* Ear canal with erythema
* May have exudate/oedema
* May have discharge - can become bloody
* Mobile TM
* Pain with movement of tragus/auricle
* Pre-auricular lymphadenopathy
* Fever
55
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 35-year-old man presents with a 2-day history of rapid-onset severe ear pain and fullness. The patient complains of otorrhoea and mild decreased hearing. He reports that his symptoms started after swimming. No fever is reported. On physical examination the external ear canal is diffusely swollen and erythematous. He has tenderness of the tragus and pain with movement of the auricle. The tympanic membrane was partially visualised due to the swelling. The concha and the pinna look normal. Neck examination fails to reveal any lymphadenopathy.
* **Otitis externa**
* Foreign bodies
* Impacted wax
* CSOM
* OM
* Malignancy
56
A patient presents with the following Hx, suggestive of otitis externa. How would you investigate? And manage the patient?
A 35-year-old man presents with a 2-day history of rapid-onset severe ear pain and fullness. The patient complains of otorrhoea and mild decreased hearing. He reports that his symptoms started after swimming. No fever is reported. On physical examination the external ear canal is diffusely swollen and erythematous. He has tenderness of the tragus and pain with movement of the auricle. The tympanic membrane was partially visualised due to the swelling. The concha and the pinna look normal. Neck examination fails to reveal any lymphadenopathy.
Investigations:
* Swabs of ear canal -- Microscopy + Culture
* Examination of ear + CN + Neck for cervical lymphadenopathy
Management:
* Urgent Referral if malignant otitis media suspected
* Referral to ENT if -- Cellulitis/Extreme pain/Considerable discharge/Systemic symptoms
* Manage with topical ear drops
* Ear Wicking (Coated in ABx + Steroid) ± removal of debris
* Keep ear dry
* If there is Cellulitis/cervical lymphadenopathy -- Oral ABx
* Flucloxacillin/Erythromycin (If allergy)
57
What is Malignant Otitis Externa?
* Life threatening extension of Otitis externa into the mastoid & temporal bones
* Due to Pseudomonas A. or Staph A
* Affects elderly pts, those with DM/immunocompromised
Symptoms/Signs:
* Pain + Headache (Severe)
* Facial nerve palsy
* Oedema/Exudate
Investigations:
* CT to determine extent of involvement
Management:
* Urgent referral to ENT
* Oral + Topical treatment with quinolones for 6-8 weeks
58
What is a Cholesteatoma?
* Collection of epidermal + connective tissues in the middle ear
* Grows independently - Locally invasive + destructive
Can be:
* Congenital -- When squamous epithelium is trapped within the temporal bone during embryo development, expansion causes local damage
* Primary acquired -- Eustachian tube dysfunction causes TM to be sucked back and retracted leads to erosion of the TM epithelium and creates a pocket which can continue to erode
* Secondary acquired -- Due to perforation/trauma on the TM, squamous epithelium implanted and triggers growth + expansion
59
What are the symptoms/Signs of cholesteatoma?
* Depend on the size of the growth
* Small lesion -- Progressive conducting hearing loss
* Erosion -- Vertigo/Headache/Facial nerve palsy
* Otorrhoea + Hearing impairment
* Total deafness + Impaired facial movement
* Frequent unremitting painless otorrhoea - may be foul smelling
* Recurrent otitis - unresponsive to ABx
60
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 37-year-old man presents with hearing loss and a painful intermittent purulent discharge from his right ear. He also reports intermittent dizziness, and tinnitus in the right ear. On otoscopy, he has an attic crust on his right tympanic membrane. Examination with an otomicroscope and micro-suctioning reveals keratin in an attic retraction pocket. An audiogram demonstrates a conductive hearing loss on the right side.
* **Cholesteatoma**
* Myringosclerosis -- Thickening + calcification of TM secondary to inflammation
* CSOM
* Otitis externa
* Benign Necrotising Otitis externa
61
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 12-year-old girl presents with a history of a recurrently discharging left ear for several months. She complains of an offensive discharge and hearing loss. She reports a previous history of grommet insertion. Otoscopy reveals a posterosuperior perforation of the tympanic membrane with a white keratin-like discharge. She has a conductive hearing loss on audiometry.
* **Cholesteatoma**
* Myringosclerosis -- Thickening + calcification of TM secondary to inflammation
* CSOM
* Otitis externa
* Benign Necrotising Otitis externa
62
A patient presents with the following Hx, suggestive of cholesteatoma. How would you investigate? How would you manage it?
A 12-year-old girl presents with a history of a recurrently discharging left ear for several months. She complains of an offensive discharge and hearing loss. She reports a previous history of grommet insertion. Otoscopy reveals a posterosuperior perforation of the tympanic membrane with a white keratin-like discharge. She has a conductive hearing loss on audiometry.
Investigations:
* Ear examination
* Hearing tests - Audiometry
* CT imaging -- Extent of lesion + bony defects
* If soft tissue involvement possible -- MRI
Management:
If surgery not possible:
* Regular ear cleaning with treatment of infections
Surgery:
* Remove the cholesteatoma -- Tympanomastoidectomy/Tympanoplasty
63
What is Mastoiditis?
* When supparative infection from the middle ear (OM) spread to the mastoid air cells
* Causing inflammation of the mastoid & may lead to bony destruction
* Rare complication of AOM
* Can spread to cause meningitis/cerebral abscess
* Typically caused by Strep Pneumoniae/Strep Pyogenes/Pseudomonas A
64
Who classically gets mastoiditis?
What are the symptoms/Signs?
* More common in you children
* Patients with immunocompromise or Cholesteatoma
Symptoms/Signs:
* Hx of acute/recurrent AOM
* Intense otalgia + pain behind the ear
* Fever
* Children -- irritability/crying/feeding problems
* Swelling redness/bogygy tender mass behind the ear
* External ear may protrude forwards
* May have ear discharge + Perforated eardrum
* TM membrane bulges + erythematous
* Patient is systemically well
* Local neurological involvement -- CN 5 or 7 plsy
* May have conductive deafness
65
A patient presents with a Hx suggestive of mastoiditis, how would you investigate + manage them?
Investigations:
* FBC -- Increased WCC
* ESR -- Elevated
* Blood cultures
* Ear swabs if no perforation -- Culture + Microscopy
* CT ± MRI -- to look for Intracranial spread
* If intracranial spread suspected -- LP
Management:
* Referral to ENT in hospital
* High dose IV ABx for at least 1-2 days
* Oral ABx after this
* Paracetamol ± Ibuprofen
* Myringotomy ± Tympanostomy tube -- if required
* Mastoidectomy Immediately -- if subperiosteal abscess formation/Intracranial extension/Cholesteatoma
66
What are the possible complications of mastoiditis?
* Conductive/Sensorineural hearing loss
* Labrynthitis
* Osteomyelitis/bone erosion
* Extension to local bone
* Subperiosteal abscess -- Abscess b/w periosteum and mastoid (Protruding ear)
* CN palsy
* Cerebral abscess/Meningitis/Subdural Empyema
67
What is Perichondritis?
* Infection of the connective tissue of the ear (Auricle ± Pinna)
* Requires immediate treatment as it can worsen into liquefying chondritis -- disfigurement ± Loss of external ear
Causes:
* Minor trauma/Burns/Ear piercing causing infection
* Pseudomonas A/E.coli/Staph A are all common organisms that cause Perichondritis
68
How is Perichondritis diagnosed + Managed?
Clinical diagnosis via:
* Physical exam
Patient has:
* Dull pain - gradually developing to severe otalgia
* Purulent discharge
* Erythema/Swelling
* Tenderness of auricle
* Lobule is unaffected (Otitis externa if affected)
Management:
* ABx with anti-pseudomonal activity
* Incission + drainage by ENT if necrotic cartilage
* Oral therapy with Ciprofloxacin
69
What is a Pinna Haematoma?
* Traumatic collection of blood b/w the cartilage + Perichondrum (Source of blood supply)
* Requires prompt treatment to prevent permanent deformity (Cauliflower ear)
Symptoms:
* Otalgia
* Swollen ear
* Fluctuant collection
Management:
* Asceptiv evaluation of haematoma + Compression (Prevent re-collection)
70
What is a thyrolossal cyst?
* Most common congenital abnormality of the neck
* Arise from persistent thyroglossal duct (Formed from descent of thyroid from foramen cecum to front of neck)
* Can lead to sinuses/fistula/cysts
* Most common cysts are Infrahyoid + Suprahyoid
71
Who classically gets thyroglossal cysts?
What are the symptoms/signs?
* Commonly \<10yrs old but also seen in adults
Symptoms/Signs:
* Fluctuant swelling in midline of neck
* Moves up when tongue is protruded (Attached to the larynx)
* Non-tender + Mobile
* If infected may be tender
Associated with:
* Dysphagia/Dysphonia
* Fever/Increasing neck mass
72
How are thyroglossal cysts investigated + managed?
Investigations:
* Hx taking
* Neck and lymph node examination
* Thyroid examination - to distinguish if thyroid or thyroglossal
* USS
* CT Scan
* TFTs -- Normal
Management:
* Surgical removal of the cyst
73
What is a Dermoid cyst?
* Contains dermal structures
* Found in midline
Diagnosis + treatment:
* Excision biopsy
74
If a patient presents with a neck lump, how would you go about taking a Hx + examination?
Most commonly caused by inflammatory lymph nodes (Reactive
[History]
* How long has the lump been present?
* Is it painful?
* Has it changed? If so, over what time frame?
* Are there symptoms of recent infection of nearby structures (cough, cold, sore throat, earache, toothache, skin problems, head lice, bites)?
* Has there been a fever?
* Does eating affect the lump?
* Is there pain on swallowing?
* Is there any effect on voice?
* Does the person smoke?
* Is there a history of travel?
* Is there a past history of cancer?
Are there red flag symptoms of systemic illness such as:
* Night sweats.
* Weight loss.
* Unexplained bruising or bleeding.
* Persistent fatigue.
* Breathlessness
Examination
Examine the:
* Anterior triangle (bordered by the midline, the body of the mandible and the anterior border of sternocleidomastoid).
* Posterior triangle (bordered by the posterior border of sternocleidomastoid, the clavicle and the trapezius).
* Midline.
Whether it is:
* tender, hot, red, inflamed.
* Consistency.
* Size.
* Mobility.
* How deep the lump is: whether it is intradermal (suggesting sebaceous cyst with a central punctum, or a lipoma), subcutaneous or within deeper tissue.
* Whether it is pulsatile.
* Whether it is a solitary lump or if there is more than one.
* Whether it moves on swallowing (thyroid, thyroglossal cysts).
* Whether it moves when the person sticks out their tongue (thyroglossal cysts)
Examination of the skin of the head and neck for rashes, lesions or infection.
Examination of the ears, nose and throat.
Examination of the mouth - for malignancy, dental issues. If parotid disease is suspected, identify the orifice of parotid duct and palpate with the patient's head tilted backwards.
Examination of the chest.
Examination for lymphadenopathy or organomegaly elsewhere.
Checking for compression of the airway or vasculature.
Taking note of general clues of systemic illness, such as jaundice, pallor, petechiae, bruising, excoriation
75
In a patient with a neck lump, what are the differentials that should be considered?
* most common cause is reactive lymph nodes:
* Bacterial causes, such as beta haemolytic streptococci, staphylococcus aureus, tuberculosis and secondary syphilis.
* Viral causes, such as common viruses causing upper respiratory tract infections, Epstein-Barr virus (EBV), cytomegalovirus, HIV, herpes simplex virus
* Non-infective causes, such as sarcoidosis and connective tissue disease
* Malignant lymph nodes: leukaemia, lymphoma, metastases.
* Infections of the skin: abscess, infected sebaceous cyst.
* Lipomas and other benign tumours
* Thyroid swelling
76
How would you investigate a neck lump?
* FBC and ESR (within 48 hours if generalised lymphadenopathy to exclude leukaemia).
* TFTs.
* Viral serology - eg, EBV, cytomegalovirus, toxoplasmosis.
* Throat swab.
* CXR (within two weeks for supraclavicular lymph node swelling or persistent cervical node in a person over 40 years old)
* Endoscopy
* Ultrasound scan - for thyroid swellings and as a first-line imaging option where diagnosis is unclear, with or without a view to ultrasound-guided fine-needle aspiration biopsy.
* Radionucleotide scanning (if masses of parathyroid or thyroid glands).
* CT or MRI scan.
* Any new neck mass persisting beyond six weeks should be referred
77
What are the neck lump red flags for 2WW referral?
* The person has lost weight.
* There is associated hoarseness, difficulty swallowing (dysphagia), or dyspnoea for three weeks or more.
* There has been haemoptysis.
* There are associated symptoms suggestive of lymphoma (weight loss, night sweats, fever, breathlessness, pruritus or bleeding)
* An unexplained enlarged lymph node is persistent.
78
What is the most common head & neck cancer?
Squamous cell carcinoma
Such as:
* Oral cavity cancer
* Cancers of the pharynx
* Larynx
* Salivary gland
79
What are the key risk factors for head & neck cancers?
* Smoking
* Alcohol
* Poor diet
* HPV 16 -- Oral/Pharyngeal/Laryngeal cancer
80
What is Tonsillitis?
* Inflammation of the palatine tonsils due to infection
Typically caused by:
* Rhinovrisu/Coronavirus/Adenovirus (Most common)
* EBV -- Infectious Mononucleosis
* Beta haemolytic streotococci/Grou A strep
81
Who classically gets tonsillitis?
What are the symptoms/signs?
* Common condition in children + young adults
* Pts with immunodeficiency
* FHx of tonsillitis/atopy
Symptoms/Signs:
* Pain in throat
* Pain on swallowing
* May have referred otalgia
* Headache
* Loss of voice or voice change
* Erythema at back of throat
* Swollen - may be coated with pus (White/Yellow)
* Fever
* Cervical lymphadenopathy
82
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 6-year-old previously healthy boy presents with acute onset of fever of 39°C (102°F), severe throat pain that is exacerbated by swallowing, headache, and malaise. On examination his tonsils are symmetrically enlarged and red, with purulent exudate. He has multiple enlarged, painful anterior neck lymph nodes, but no other lymphadenopathy and no splenomegaly. He has no runny nose or cough, and no difficulty breathing.
* **Tonsillitis**
* Coryza
* Infectious Mononucleosis
* Epiglottitis -- Emergency
* If unilateral enlargement -- Malignancy
83
What do patients with infectious mononucleosis get that distinguishes it from tonsillitis?
* Hepatosplenomegaly
* Sexual activity/Kissing/Contact with infected person
* Cervical/generalised lymphadenopathy
* Fever
* Pharyngitis
84
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 16-year-old student presents with fever, sore throat, and fatigue. She started feeling ill 1 week ago. Her symptoms are gradually getting worse, and she has difficulty swallowing. She has had a fever every day, and she could hardly get out of bed this morning. She does not remember being exposed to anybody with a similar illness recently. On physical examination she is febrile and looks ill. Enlarged cervical lymph nodes, exudative pharyngitis with soft palate petechiae and faint erythematous macular rash on the trunk and arms are found.
* **Infectious mononucleosis**
* Tonsillitis
* Coryza
* Epiglottitis
* Malignancy
85
A patient presents with the following Hx suggestive of tonsillitis, how do you investigate this? How would you manage it?
A 6-year-old previously healthy boy presents with acute onset of fever of 39°C (102°F), severe throat pain that is exacerbated by swallowing, headache, and malaise. On examination his tonsils are symmetrically enlarged and red, with purulent exudate. He has multiple enlarged, painful anterior neck lymph nodes, but no other lymphadenopathy and no splenomegaly. He has no runny nose or cough, and no difficulty breathing.
Investigations:
* CENTOR Criteria to determine if viral or bacterial:
* No cough
* Tender Cervical lymphadenopathy
* Fever
* Exudate O/E
Management:
Urgent referral to A&E if:
* Breathing difficulty/Dehydration/Peritonsillar abscess
If \>3 CENTOR criteria:
* Avoid social contact due to risk of spread
* Self limiting condition
* Paracetamol ± Ibuprofen
* ABx -- Phenoxymethylpenicillin 5-10 days
* If allergy -- Clarithromycin/Erythromycin 10 days
If \<3 criteria:
* Avoid social contact due to risk of spread
* Self limiting condition
* Paracetamol ± Ibuprofen
* Watchful wait for 3-5 days for resolution or symptom change:
* If no resolution then ABx
May require - Tonsillectomy if recurrent
86
A patient presents with the following Hx suggestive of infectious mononucleosis, how do you investigate this? How would you manage it?
A 16-year-old student presents with fever, sore throat, and fatigue. She started feeling ill 1 week ago. Her symptoms are gradually getting worse, and she has difficulty swallowing. She has had a fever every day, and she could hardly get out of bed this morning. She does not remember being exposed to anybody with a similar illness recently. On physical examination she is febrile and looks ill. Enlarged cervical lymph nodes, exudative pharyngitis with soft palate petechiae and faint erythematous macular rash on the trunk and arms are found.
Investigations:
* Abdominal exam -- Hepatosplenomegaly
* FBC -- Increased WCC
* EBV specific antibodies -- Positive
* PCR -- Positive
Management:
* Paracetamol ± Ibuprofen
* Refrain from physical activity and contact sports for 8 weeks after (Risk of splenic rupture)
* Prednisolone if breathing diffiulty due to obstruction
87
What is a Peritonsillar abscess?
* Complication of acute tonsillitis or Infectious mononucleosis
* Pus becomes trapped between the tonsillar capsule + lateral pharyngeal wall
* Can arise w/o prior tonsillitis
88
What are the symptoms/signs of peritonsillar abscess?
* Severe throat pain which may become unilateral.
* Fever.
* Drooling of saliva.
* Foul-smelling breath.
* Swallowing may be painful.
* Trismus (difficulty opening the mouth).
* Altered voice quality ('hot potato voice') due to pharyngeal oedema and trismus.
* Earache on the affected side.
* Neck stiffness symptoms.
* Headache and general malaise
O/E:
* Breath is fetid.
* There may be drooling and salivation
* Tender, enlarged ipsilateral cervical lymph nodes
* unilateral bulging, usually above and lateral to one of the tonsils; occasionally the bulging is inferiorly.
* There is medial or anterior shift of the affected tonsil and the tonsil may be erythematous, enlarged and covered in exudate
* Displaced uvula
89
How would you investigate + manage a patient with peritonsillar abscess?
Investigations:
* Throat examination
* Clinical diagnosis
Management:
* Urgent referral to ENT
* IV fluids - correct dehydration
* Paracetamol ± Ibuprofen
* IV ABx:
* Benzylpenicillin + Metronidazole
* Needle aspiration + Incision + drainage
90
What are the causes of congenital nasal problems?
* Chromosomal abnormalities
* Diseases related to prenatal infection
* Maternal drug use
* Environmental factors
* Iatrogenic causes
91
What is Arhinia?
What is it associated with?
How is it managed?
* Absence of external nose + Nasal cavity + Olfactory system
* v. rare
* Evident at birth
* Associated with Trisomy 9
* Requires surgical repair
92
What is Choanal atresia?
* Prescence of bony septum b/w nose - pharynx
* Most common nasal congenital abnormality
* Females \> Males
* Can be lethal if bilateral
* Confirm diagnosis via CT Scan
* Treated with surgery
93
How should a nasal injury be investigated and managed?
Investigation:
* Examination of the nose:
* If Rhinorrhoea with CSF leakage or epistaxis
* Septal deviation/malposition
* Any facial # or injury
* Opthalmoplegia
Management:
* Refer to ENT if:
* Marked deviation in septum
* Epistaxis that doesnt settle
* CSF leakage - via cribiform plate
* CT scan + Referral to neurosurgery
* Facial anaesthesia -- Immediate referral to maxfax
* ICE + Paracetamol + Ibuprofen
* Review in 5 days
94
How is a nasal foreign body investigated + managed?
Investigation:
Refer to ENT if:
* Hx of prolonged unilateral nasal discharge
* Foreign body is in posterior position
* Patient is uncooperative/agitated
Management:
* Topical anaesthetic + vasocontrictor spray in affected nostril
* Blow positive pressure - Patient closing off opposite nostril and you blow sharply into childs mouth
* Use nasal speculum + hook or thin forceps to remove object
* Balloon catheter past FB, inflate and remove catheter to bring FB with it
95
What is Septal perforation?
What can cause it?
How does it present?
How is it managed?
* Defect through any portion of the cartilaginous or bony septum
Causes:
* Traumatic/Nose picking
* Septal surgery/inflammation
* Infection
* Cocaine sniffing
Symptoms/Signs:
* Nasal whistling sound
* Discharge from nose
* Nasal congestion
* Infection -- Cellulitis/fever/discharge
* Epistaxis
Management:
* Endoscope to visualise the perforation
* Nasal douching + saline -- Keep mucosa moist
* Nasal emollients to inside of nose before bedtime
* Surgical closure only if severe QoL impact
96
What is Non-allergic rhinitis?
profuse chronic watery rhinorrhoea which is not allergic
* encompassing a number of conditions:
* Vasomotor rhinitis.
* Occupational rhinitis.
* Hormonal rhinitis.
* Drug-induced rhinitis.
* Non-allergic rhinitis with eosinophilia syndrome (NARES)
97
Who classically gets rhinitis?
What are the symptoms/signs of rhinitis generally?
* very common condition in adults
* Associated with -- Asthma/Nasal polyps/Otitis media/Sinusitis
Symptoms/Signs:
* rhinorrhoea
* sneezing
* itchy nose
* nasal congestion
* acute rhinosinusitis by causing blockage of intranasal passages
98
What is Vasomotor rhinitis?
* excessive vascular engorgement of the nasal mucosa and profuse, watery rhinorrhoea
* triggered by chemical irritants, changes in weather, excess humidity or a very dry atmosphere, and stress
* nasal mucosa can vary in colour from bright red to purple. Symptoms are usually intermittent
Management:
* Topical antihistamines are the usual first-line medical treatment
99
What is Occupational rhinitis?
* Symptoms occur only in the workplace
* Common inhaled irritants which trigger the condition include metal salts, animal dander, latex, wood dust and chemicals
Management:
* Avoidance of the trigger irritant is the ideal treatment but cannot always be achieved in reality.
* Nasal corticosteroids and second-generation antihistamines
100
What is Hormonal Rhinitis?
How is it managed?
* Rhinorrhoea and nasal congestion are the principal symptoms
* linked to increases in oestrogen levels
* pregnancy, menstruation and puberty
Management:
* Pregnant patients may present with vasomotor rhinitis and may benefit from nasal saline solution, exercise and topical pseudoephedrine.
* Hormonal contraceptives might protect young women from allergies including rhinitis
101
What is Non-allergic rhinitis with eosinophilia syndrome (NARES)?
How is it managed?
* eosinophilic inflammation of the nasal mucosa, without evidence of an allergy or other nasal pathologies
* symptoms are rhinorrhoea, sneezing, nasal pruritus and hyposmia
Management:
* Steroid nasal sprays are useful, as they appear to have a direct action on eosinophils, preventing the activation of the allergic cascade which leads to inflammation
102
What is Allergic rhinitis?
* Seasonal allergic rhinitis/hay fever: this occurs at certain times of the year. When due to tree pollen or grass it is known as hay fever. Other allergens include mould spores and weeds.
* Perennial rhinitis (persistent): this occurs throughout the year. Allergens commonly include house dust mites and domestic pets.
* Occupational rhinitis: symptoms occur due to exposure to allergens at work (eg, flour, wood dust, latex gloves)
Pathology:
* immunoglobulin E (IgE)-mediated inflammation of the nasal mucosa following exposure to allergens.
* This gives rise to a release of preformed mediators (of which histamine appears to be the most important) and chemotactic factors from the mast cells in the nasal mucosa
103
Who classically gets Allergic rhinitis?
What are the symptoms/signs?
* common problem
* School-aged children and adolescents are more likely to have seasonal allergic rhinitis, whereas adults tend to have persistent allergic rhinitis
* FHx of atopy or rhinitis
Symptoms/Signs:
* Seasonal rhinitis tends to occur in the spring or summer
* occupational symptoms will be worse at work, improving on days off or during holidays
* Sneezing.
* Rhinorrhoea and nasal congestion
* anterior or posterior, leading to postnasal drip.
* Clear - infection unlikely
* Itchy nose and/or palate.
* Symptoms tend to be bilateral, and worse on waking.
* Usually associated symptoms in the eyes, with watering, itching, redness or swelling
* nasal mucosa looks swollen and greyish
* eyes for signs of conjunctivitis
104
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 45-year-old male presents with chronic post-nasal drainage, cough, and nasal congestion that began approximately 2 years ago but has been getting progressively worse over the past few months. He snores, which results in sore throats in the morning. He experiences pressure over his forehead and behind his eyes, along with ear plugging and popping. His symptoms are aggravated by strong odours, such as perfumes/fragrances and tobacco smoke, and by weather changes. He is not bothered by cats, dogs, freshly cut grass, or dust. He never had these symptoms as a child and has no family history of allergies. These symptoms interfere with his work, as he has to make presentations to clients and is concerned that the constant clearing of his throat is diminishing his effectiveness.
* **Non-allergic rhinitis**
* Allergic rhinitis
* Nasal polyposis
* Deviated septum
* Foreign body
105
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 22-year-old student presents with a 5-year history of worsening nasal congestion, sneezing, and nasal itching. Symptoms are year-round but worse during the spring season. On further questioning it is revealed that he has significant eye itching, redness, and tearing as well as palate and throat itching during the spring season. He remembers that his mother told him at some point that he used to have eczema in infancy.
* **Allergic rhinitis**
* Non-allergic rhinitis.
* Infective rhinitis.
* Nasal polyps.
* Sinusitis.
* Adenoidal hypertrophy.
* Cystic fibrosis
106
A patient presents with the following Hx suggestive of allergic rhinitis, how would you investigate + Manage?
A 22-year-old student presents with a 5-year history of worsening nasal congestion, sneezing, and nasal itching. Symptoms are year-round but worse during the spring season. On further questioning it is revealed that he has significant eye itching, redness, and tearing as well as palate and throat itching during the spring season. He remembers that his mother told him at some point that he used to have eczema in infancy.
Investigations
* History and examination should be sufficient to make the diagnosis
* allergy testing may be helpful
Management
* education, allergy avoidance, antihistamines and topical steroids
* Topical nasal antihistamines
* Oral antihistamines -- Once-daily, non-sedating antihistamines such as cetirizine, loratadine or fexofenadine are recommended
* Topical intranasal steroids
107
What are nasal polyps?
* lesions arising from the nasal mucosa
* part of the spectrum of chronic rhinosinusitis
* If they occur in children, cystic fibrosis testing is merited
* Associated with: Asthma/Aspirin sensitivity/Cystic fibrosis/Churg Strauss
108
Who classically gets nasal polyps?
What are the symptoms/signs?
* Male \> Females
Symptoms/Signs:
* history of recurring acute or chronic sinusitis
* Symptoms depend on the size of the polyp (small polyps may be asymptomatic)
* Nasal airway obstruction.
* Nasal discharge:
* Watery anterior rhinorrhoea, sneezing, postnasal drainage.
* Green secretions suggest infection due to a polyp blocking the sinus ostia
* Unilateral, blood-tinged secretion suggests a tumour
* Dull headaches.
* Snoring and obstructive sleep symptoms.
* Hyposmia or anosmia (decreased smell) and reduced taste
109
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 35-year-old man presents with a 1 year history of bilateral nasal obstruction and congestion. He also reports frequent nasal discharge, mucus in the throat, and coughing bouts. He suffers from intermittent facial discomfort, characterised by a feeling of pressure and fullness in the nose and paranasal sinuses. He complains of an absent sense of smell and reduced ability to taste his food.
* **Nasal polyps**
* Foreign body - particularly if there is unilateral, blood-tinged discharge in young children.
* Chronic rhinosinusitis without polyps.
* Sinusitis.
* Allergic fungal rhinosinusitis.
* Tumours, benign and malignant -- if unilateral
110
A patient presents with the following Hx suggestive of nasal polyps, how would you investigate + manage?
A 35-year-old man presents with a 1 year history of bilateral nasal obstruction and congestion. He also reports frequent nasal discharge, mucus in the throat, and coughing bouts. He suffers from intermittent facial discomfort, characterised by a feeling of pressure and fullness in the nose and paranasal sinuses. He complains of an absent sense of smell and reduced ability to taste his food.
Investigations
* Rigid or flexible endoscopy (rhinoscopy) carried out by specialists - this allows localisation and determination of the extent of the polyps
Management:
* Unilateral polyps may be a sign of malignancy and should always be referred to ENT
* Medical management is first-line, unless the nature of the polyp is uncertain
* Topical corticosteroids -- Fluticasone, mometasone and budesonide
* Surgery if refractory to treatment
111
What is Sinusitis?
* inflammation of the membranous lining of one or more of the sinuses
* Viral disease is said to last less than 10 days, whereas worsening symptoms after 5 days or symptoms extending beyond 10 days suggest bacterial infection
Acute: an infection lasting 7-30 days
Chronic: symptoms persist for \>90 days (these may be caused by irreversible changes in the mucosal lining of the sinuses), with or without acute exacerbations
112
How are the sinuses assessed clinically?
* Palpation for tenderness
* Percussion for dullness
* Transillumination
113
What classically causes Acute sinusitis?
* tends to arise as a result of a viral infection and a diagnosis of acute sinusitis is made if there is sinus drainage obstruction and subsequent secondary bacterial infection
* most commonly caused by Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis
*
114
What are the symptoms/Signs of acute sinusitis?
How is it diagnosed?
How is it managed?
Symptoms/signs:
* non-resolving cold (\>1 week or worsening symptoms over 4-5 days)
* Facial discomfort (eg, a feeling of congestion or fullness, often unilateral and worse when bending forwards) or pain
* Nasal obstruction or (purulent) nasal discharge or postnasal drip
* pyrexia, purulent nasal discharge ± decreased or absent smell
* pain on palpation of the sinuses.
* Erythema and oedema of the nasal mucosa may also be found
* Headache.
* Halitosis.
* Fatigue.
* Dental pain.
* Cough.
* A feeling of pressure or fullness in the ears.
Investigations:
* Clinical diagnosis
Management:
* Most patients can be reassured that this is generally a viral infection similar to a cold but which takes a little longer to resolve (about 2.5 weeks)
* Paracetamol/ibuprofen for pain/fever.
* Intranasal decongestant
* Adequate fluids and rest
* Antibiotics are reserved for severe or prolonged infections (\>5 days) -- amoxicillin/doxycycline/clarithromycin
* If chronic sinusitis -- Beclometasone 50 micrograms nasal spray (two sprays per nostril twice a day)
115
What is Epistaxis?
* Nose bleeding usually when nasal mucosa is eroded and vessels are exposed and break
* Due to trauma or Malignancy/Tumour
Can either be Anterior/Posterior
Anterior haemorrhage:
* Source of bleeding visible
* From nasal septum (Kiesselbachs plexus)
Posterior haemorrhage:
* More common in older people
* More profuse + Increased risk of airway compromise
116
What is the normal blood supply to the nose?
Internal Carotid artery + External Carotid artery
Internal:
* Anterior ethmoid artery
* Posterior ethmoid artery
External:
* Sphenopalatine artery
* Branch of internal maxillary artery
117
What are the causes of epistaxis?
* Trauma to the nose - most common e.g. nose picking/insertion of foreign body/Excess nose blowing
* Disorders of platelet function -- Thrombocytopenia/Splenomegaly/ITP
* Drugs -- Aspirin/Anticoagulants
* Hereditary haemorrhagic telangectasia
* Malignancy of the nose
* Cocaine abuse
* Wegeners granulomatosis
118
What are the classic symptoms/signs of epistaxis?
* Blood running out of nose + one nostril -- Anterior
* Blood running into the throat from both nostrils -- Posterior
* Hx of trauma to the nose/Malignancy
* FHx of clotting disorders/HTN
* DHx of warfarin/Aspirin/Clopidogrel use
* Rule out nasopharyngeal tumour -- Facial pain + Otalgia + Young male pt
* Juvenile nasopharyngeal angiofibroma -- Nasal obstruction + headache + rhinorrhea + anosmia
119
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 7-year-old girl presents with frequent nosebleeds, worse on the left. There is no active bleeding on presentation. Her mother reports previous treatment with clinic cautery using silver nitrate. She has concerns about the cautery being repeated as it was painful for the child. Examination shows small blood vessels in the most anterior septal mucosa, bilaterally.
* **Epistaxis**
* Haemoptysis
* Haematemesis
120
A patient presents with the following Hx, what is the most likely diagnosis? what are the differentials?
A 50-year-old man arrives at the emergency department with an active nosebleed. This began on the right side but now he has blood in both nares as well as in the throat. He carries a towel partly covered with blood, which he uses to catch blood dripping from the nose and expectorated from the throat. He appears anxious with a pulse of 96 bpm and a BP of 165/95 mmHg.
* **Epistaxis** - Posterior
* Haemoptysis
* Haematemesis
121
A patient presents with the following Hx suggestive of Epistaxis. How would you investigate it and manage it?
A 7-year-old girl presents with frequent nosebleeds, worse on the left. There is no active bleeding on presentation. Her mother reports previous treatment with clinic cautery using silver nitrate. She has concerns about the cautery being repeated as it was painful for the child. Examination shows small blood vessels in the most anterior septal mucosa, bilaterally.
Investigations:
If mild:
* None required
If recurrent/Severe:
* Referral to ENT
* FBC
* Coagulation studies
* Blood type
If suspected malignancy:
* Referral to ENT
* CT scan
Management:
* ABCDE assesment
* Monitor BP + Pulse
* If bleeding stopped -- Inspect with nasal speculum
* Ice pack + pressure on bridge of nose for 20mins -- Sit upright + lean slightly forward + breathe through mouth
* Nose packing
* Silver nitrate cautery/Electrocautery after bleeding has stopped
* Nasopharyngoscopy
122
What are the complications of Epistaxis?
* Anosmia
* Continued bleeding
* Breathing difficulties
* Increased risk of infection with packing
* Hypotension secondary to severe bleeding
123
What are the following areas of the neck?
* Level 1 -- Submental & Submandibular lymph nodes
* Level 2 -- Upper deep cervical
* Level 3 -- Mid deep cervical
* Level 4 -- Lower deep cervical
* Level 5 -- Posterior triangle
* Level 6 -- Paratracheal
* Level 7 -- Upper mediastinal
124
What can be seen in the following on otoscopy?
**Cholesteatoma**
125
What can be seen in the following on otoscopy?
**Unsafe CSOM**
**Safe CSOM**
126
What can be seen in the following otoscopy image?
Grommet
127
What can be seen in the following otoscopy image?
Otitis Media with effusion
128
What can you see in the following image?
Otitis Externa
129
What can you see in the following image?
**Malignant otitis externa**
Granulation tissue on floor of cartilaginous ear canal
Meatus filled with purulent discharge
130
What can you see in the following image?
**Mastoiditis**
131
Which ear is each image?
Right eardrum
Left eardrum
132
What hearing loss is shown here?
Conductive hearing loss
133
What hearing loss is shown here?
Sensorineural hearing loss
134
What hearing loss is shown here?
Normal hearing
135
What can be seen in the following image?
**Tonsillitis**
* Erythema
* Exudate on tonsils
* Swollen tonsils
136
What can be seen in the following image?
**Peritonsillar abscess**
* Swollen tonsils
* Deviated uvula
137
What can be seen in the following image?
**Perichondritis**
Year 4 M&M
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Decks in class (7)
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