1
Q
Which drugs are associated with tinnitus?
A
- NSAIDs incl. Aspirin
- Aminoglycosides
- Loop diuretics
- EtOH
- Quinine
2
Q
What are causes of tinnitus?
A
- Meniere’s disease (associated with vertigo)
- Otosclerosis
- Acoustic neuroma (absent corneal reflex, vertigo)
- Hearing loss (excessive loud noise, presbycusis)
- Durgs
3
Q
What is otosclerosis?
A
Otosclerosis describes the replacement of normal bone by vascular spngy bone.
It causes a progressive hearing loss due to fixation of the stapes at the oval window.
- Autosomal dominant
- Onset in 20-40s with
- Conductinve hearing loss
- Tinnitus
- Normal timpanic membrane or flamingo tinge
- Positive FHx
4
Q
What is labyrinthtis?
How does it present?
A
Labyrinthitis is inflammation of the membranous labyrinth affecting both vestibular and cochlear end organs. (Cf. vestibular neuritis
It can be viral, bacterial or 2° to systmic disease.
It presents with sudden onset of:
- Symptoms:
- Vertigo - not triggered, but exacerbated by movement
- Nausea and vomiting
- Hearing loss (unilateral or bilateral
- Tinnitus
- Preceding URTI symptoms
- Signs:
- Unidirectional horizontal nystagmus
- Sensorineural hearing loss
- Gait disturbance
5
Q
What are causes of vertigo?
A
Peripheral/Vestibular:
- Meniere’s Disease
- Benign paroxysmal positional vertigo
- Labyrinthitis (both hearing and vertigo) or vestibulr neuronitis (hearing not affected)
Central:
- Acoustic neuroma
- MS
- Vertobasilar stroke
May also be caused by drugs (gentamycin, loop diuretics)
6
Q
What is benign paroxysmal positional vertigo?
A
BPPV is a condition where there are calcium carbonate crystals within the semilunar canals of the labyrinth, as a result of age, viral infection, head traum or idiopathic.
This impairs the normal detection of head movement by the steatocilia.
Symptoms:
- Positional - symptoms only on movement
- Attacks last around 1 minute before they settle
- Typically periods of several weeks, then self-resolve, but can reoccur
7
Q
What test can be used to diagnose BPPV?
How can it be treated?
A
The Hallpike test. (see image)
There, the patient’s head is twisted and then rapidly brought down onto a pillow - watch the patients eyes for nystagmus (upbeat, torsional) and ask for symptoms of vertigo.
It can be treated with the Epley maneuvre.
8
Q
What are causes of conductive hearing loss?
A
- External canal obstruction (wax, pus, foreign body)
- Tympanic membrane perforation (trauma, infection)
- Ossicle defects (otosclerosis, infection, trauma)
9
Q
What are causes of sensorineural hearing loss?
A
This occurs due to damage to the cochlea, the cochlear nerve or the brain.
- Drugs (aminoglycosides, vancomycin)
- Post-infective (meningitis, measles, mumps, herpes)
- Miscellaneous:
- Meniere’s
- Trauma
- Multiple Sclerosis
- Cerebropontine angle lesion
10
Q
What is an acoustic neuroma?
How does it present?
A
This is a slow gorwing tumour of the vestibular nerve. It acts as a SOL and causes cerebellopontine angle syndrome. (80% of CPA tumours are acoustic neuromas).
Presentation:
- Slow onset
- Sensorineural hearing loss on the site of lesion
- Headache (2° to raised ICP)
- CN palsy ov 5 (V1, V2), 7 and 8
- Cerebellar signs may be seen
11
Q
What is Alport syndrome?
A
Alport syndrome is a genetic condition (most commonly X-linked recessive but can also be autosomal recessive) affecting collagen IV, leading to:
- Sensorineural hearing loss
- Haematuria
12
Q
What is Meniere’s Disease?
A
This is an excessive endolymph in the labyrinths, leading to attacks of hearing loss, vertigo, fullness. These often occur in middle aged adults.
They are NOT associated with movement.
Spontaneous nystagmus occurs during the attacks.
Over time, hearing will deteriorate.
13
Q
What is versibular neuronitis?
A
This is inflammation of the vestibular part of the 8th cranial nerve, usually 2° to a viral infection. It leads to sudden onset vertigo WITHOUT hearing loss.
This lasts for several weeks before improving.
14
Q
What is Ramsay Hunt syndrome.
A
This is Herpes Zoster reactivation of facial nerve near ear.
It can also affect hearing and vestibular function, leading to tinnitus, hearing problems and vertigo.
There often is a vesicular rash in the auditory canal and pinna.
Treat with valaciclovir and prednisolone
15
Q
What are the symptoms of a posterior circulation stroke?
A
- Ataxia
- Vertigo
- Diplopia
- Limb weakness
- Cranial nerve abnormalities
These will be sudden onset.
16
Q
What are vestibular migraines?
A
These are sudden onset vertigo episodes lasting minutes - hours; often associated with visual auras and headaches.
17
Q
How can epistaxis be classified?
A
Anterior:
- Bleeding due to insult to capillaries of Kiesselbach’s plexus (aka. Little’s area)
Posterior:
- More common in older patients
- Higher risk of aspiration
18
Q
What are causes of epistaxis?
A
- Majority unknown
- Trauma (including nosepicking)
- Local infection
- Juvenile angiofibroma (in young people)
- Pyogenic granuloma in Little’s area
- GPA
- Cocaine use (vasoconstriction can obliterate septum)
- Hereditary haemorrhagic telangectasia (Osler-Weber-Rendu)
- Coagulopathy
- Neoplasm
19
Q
Summarise the management for a patient with epistaxis who is haemodynamically stable.
A
- Sit patient up, mouth open torso forwards - reduces blood flow to the nose and risk of aspiration
- Pinch cartilagenous area of nose for 15 monites, breathing through mouth
If the bleeding doesn’t stop after 15 minutes:
- Cautery with silver nitrate sticks if lesion is visible and can be tolerated; uses local anaesthetic spray
- Packing - put lots of gauze into the nasal cavity that is soaked in vasoconstrictor + LA. Admit for review.
20
Q
Summarise the management for a patient with epistaxis who is haemodynamically unstable.
A
These patients need to be admitted to the ED - control bleeding with first-aid measures in the interim and admit to hosptial if unsuccessful for ENT management.
21
Q
What are self-care advices you can give patients with nose bleeds?
A
- Avoid immedately after bleed (or treatment)=:
- Blowing nose
- nose picking
- heavy liftin
- exercise
- Drinkng EtOH
- Lying flat
22
Q
What is hereditary haemorrhagic telangectasia?
A
This is an autosomal dominant disease with:
- telangectasia in mucosae leading to:
- recurrent spontaneous epistaxis
- GI bleeds (usually painless)
- internal telangectasia and AVMs (can be massive):
- Lungs
- Liver
- Brain
23
Q
What are the clinical features of acute tonisllitis?
A
Signs:
- Sore throat
- Fever
Signs:
- Lymphadenopathy
- Inflammed tonsils and oropharynx
- Exudates - white of yellow pustules may be present
24
Q
What is the most common infectious agent implicated in tonsillitis?
A
Streptococcus pyogenes (GAS). - this may form a quinsy.
The condition is frequently mimicked by Infectious mononucleosis.
25
What are potential complications of tonsillitis?
* Otitis media
* Quinsy - peritonsillar abscess
* Rheumatic Fever
* Post-strep glomerulonephritis
* Scarlet Fever
26
Summarise the management for tonsilitis.
* Paracetamol/Ibuprofen for pain relief
* ABx if:
* Features ofr systemic upset 2° to acute sore throat
* History of rheumatic fever
* Increased risk of acute infection (DM or immunodeficiency)
* ≥3 Centor criteria (alternatively the FeverPAIN score can be used)
* **7-10 days** of **phenoxymethylpenicllin** or **erythromycin**
Centor criteria:
* **C** ough absent
* **E** xudate present
* **N** odes enlarged
* **T** emperature
* (Young **OR** old) - not really counted
27
Why don't you give amoxicillin to patients with tonsillitis?
The risk of causing a maculopapular rash in patients that are actually infected with EBV.
28
What are indications for a tonsillectomy?
Controversial topic. NICE recommends if all of the following are met:
* Sore throats due to tonsillitis (and not URTIs)
* ≥5 episodes/year
* Symptoms for at least one year
* Episodes of sore throat are disabling and prevent normal functioning
Other indications include:
* Recurrent febrile convulsions 2° to tonsillitis
* Obstructive sleep apnoea due to enlarged tonsils
* Quinsy unresponsive to standard treatment
29
What are the specific complications of tonsillectomy?
Imediate:
* Haemorrhage (reactive) -\> **required immediate return to theatre**
* pain
* Damage to teeth, TMJ or posterior pharyngeal wall due to instruments used
Early:
* Haemorrhage (due to infection) - requires ABx therapy
* Pain
30
What is Quinsy?
What are its features?
Quinsy is **peritonsillar abscess**. Often a complication of tonsillitis.
This presents with:
* Severe throat pain, lateralising to one side
* **Deviation of the uvula** to the unaffected side
* **Lymphatenopathy**
* Trismus (difficulty opening the mouth)
* Reduced neck mobility
31
What is the managment of a peritonsillar abscess?
* **Needle aspiration** or **incision and drainage** + **IV ABx**
* Tonsillectomy to prevent recurrence (considered)
32
What are features of scarlet fever?
How is this diagnosed and treated?
Features:
* Strawberry tongue
* Rash - fine, punctuate erythema, starting on the torso and sparing the soles and palms. **Sandpaper texture**
* Desquamation may occur in later parts of the illness
Diagnosis is with a throat swab, isolating GAS.
Treatment is with **oral phenoxymethylpenicillin** for **10 days** (azithromycin as alternative). Children can go to school 24h after ABx. **Notifiable disease**.
33
What structures constitute the larynx?
The epiglottis, supraglottis (space above glottis), glottis (vocal cords) and the subglottis.
Below this is the trachea.
34
What is a laryngeal papilloma?
This is a small papilloma on the vocal cords, usually 2° to HPV infection.
Presents with **hoarseness.**
Treated with **laser removal**
35
What are the features of recurrent laryngeal nerve problems?
The recurrent laryngeal nerve supplies all intrinsic muscles of the larynx except for cricothyroideus. It is therefore responsible for **ab- and adduction of the vocal cords**.
Features of problems include:
* Hoarseness
* Breathy voice with "bovine" cough
* Repeated coughing from aspiration
* Exertional dyspnoa due to narrow glottis
36
What are causes of recurrent laryngeal nerve problems?
* **Cancers**: 30% - **larynx**, thyroid, **oesophagus**, **bronchus**
* **Iatrogenic**: (para-) thyroidectomy, carotid endarterectomy
* Other: aortic aneyurysm, bulbar/pseudobulbar palsy
37
Summarise the NICE 2-week referral criteria for head and neck cancers.
Laryngeal:
* \>45 and:
* Persistent, unexplained hoarseness
* Unexplained lump in neck
Oral cancer:
* Unexplained ulceration in oral cavity \>3 months
* Persistent unexplained lump in neck
* Lump on the lip
* Red or red+white patch in roal cavity
Thyroid:
* Unexplained thyroid lump
38
What is the most common cause of laryngeal cancer?
Laryngeal SCC is most commonl ycuased by **smoking** but there is also an association with **alcohol**.
39
What is epiglottitis?
What are the clinical features and how is it managed?
This is inflammation of the epiglottis, mostly due to **Haemophilus** **influenzae** infection.
It presents with:
* Sudden onset
* Continuous **stridor**
* **Drooling**
* Patient looking toxic
DO NOT examine the throat, immediately call an anaesthetist and give O2 with nebulised adrenaline. IV dexamethasone + cefotaxime. Take to theatre if intubation required.
40
What is a cause of tonsillar SCC?
HPV - specifically 16, has been linked to tonsillar SCC.
41
What is leukoplakia?
Leukoplakia is a **premalignant** **condition** presenting as a **white hard spot** on the mucous membranes of the mouth. More common in **smokers**.
Diagnoses of exclusion:
* Candidiasis and lichen planus should be considered (lesion can be rubbed off)
* Biopsies are usually performed to **exclude SCC**
* In HIV positive individuals, **hairy leukoplakia** 2° to EBV can occur (not scraped off, benign lesion)
Regular F/U to exclude transformation to SCC is required.
42
What are causes of facial nerve palsy?
* Unilateral:
* Idiopathic (aka. Bell's Palsy)
* Intratemporal lesions: Ramsay Hunt Syndrome, otitis media, cholesteatoma
* Infratemporal: Parotid tumours, trauma
* UMN: stroke/MS (sparing of frontalis and orbicularis oculi)
* Bilateral:
* Lyme disease
* GBS
* DM
* Pseudopalsy: MG
43
Summarise the management of facial nerve palsy.
* Give prednisolone within 72 hours
* If zoster suspected give antivirals, otherwise they have shown no benefit.
* Provide protection to the eye: dark glasses, artificial tears and tape closed.
44
How can allergic rhinitis be classified?
Allergic rhinitis is an inflammatory disorder of the nose where the nose becomes sensitised to allergens:
* Seasonal: symptoms at same time each year - hay fever if due to pollen
* Perennial: symptoms throughout the year
* Occupational: exposure to particular allergens at workplace
45
What are the clinical features of allergic rhinitis?
* Sneezing
* Bilateral nasal obstruction
* Clear nasal discharge
* Post-nasal drio
* Nasal pruritus
46
Summarise the management of allergic rhinitis
* Allergen avoidance
* **Oral** or **intranasal** **antihistamines**
* Offer **intranasal** **corticosteroids** if more severe
* Oral steroids may be required to cover during important life events
* **Short** courses of topical decongestants
Immunotherapy (**desensitisaion**) can be used in some cases.
47
Why should decongestants only be used short term?
They can cause **rhinitis medicamentosa** - swelling on whithdrawal as incraseing doses are required to have the same effect (resistance).
48
What are agents implicated in sinusitis?
* Viral: the oedema and decreased mucociliary clearance often lead to 2° bacterial infection
* **Acute**: Strep penumoniae, haemophilus, maroxella
* **Chronic**: Staph aureus, anaerobes
49
What are the underlying causes for sinusitis?
* Majorits 2° to viral infection
* Dental root infections
* Diving/swimming in infected waters
* Anatomical: deviated septum/polyps
* Systemic disease:
* Primary ciliary dyskinesia
* Immunodeficiency
* CF
50
What are the clinical features of sinusitis?
* Facial pain: typically frontal
* Nasal discharge: thick and purulent
* Nasal obstruction
51
What is the management of acute sinusitis?
* Analgesia
* Intranasal decongestants or nasal saline
* **Intranasal** **corticosteroids** may be considered if the symptoms have been present for **\>10 days**
* Oral ABx are NOT usually required, but may be given with severe presentations (phenoxymethylpenicillin, co-amoxiclav)
52
What is the managment of chronic sinusitis?
This is usuallyy 2° to a structural or drainage problem:
* Stop smoking (enhances clearance)
* Fluticasone nasal spray
* Functional surgery
In case of systemic underlying illness (e.g. PCD) regular suction and ABx may be required.
53
What are potential complications of sinusitis?
These are rare:
* Orbital cellulitis
* Osteomyelitis
* Intracranial infection (cavernous sinus thrombosis, meningitis, abscess)
54
What are nasal polyps?
What are the clinical features?
These are non-cancerous growths within the nose or sinuses.
Clinical features include:
* Watery, anterior rhinorrhoea
* Post-nasal drip
* Nasal obstruction, predisposing to frequent sinusitis. Poor sense of smell/taste
* Snoring
The masses are **mobile, pale and insensitive**.
55
What conditions are nasal polyps associated with?
* Asthma
* Aspirin sensitivity
* Infective sinusitis
* CF
* Primary Ciliary Dyskinesia
* eGPA
56
Summarise the managment of nasal polyps.
* Refer to ENT if **unilateral, large or cause complete obstruction**
* Topical corticosteroids shrink polyp size
* Short course of oral steroids may help further
* Endoscopic polypectomy
57
Summarise the gross anatomy of the nose
* Upper 1/3rd is bone
* Lower 2/3rd and the septum are cartellaginous.
58
What do you need to ALWAYS check for in someon that had nasal injury?
Nasal septal haematoma:
* This can lead to septal necrosis and nasal collapes if intreated, as the cartilage blood supply comes from the mucose.
* It reqruies urgent evacuation under GA and packing + suturing.
Facial injury:
* Any CSF rhinorrhoea?
* Diplopia? (orbital floor #)
* New Teeth malocclusion?
59
When should you refer someone for a mouth ulcer?
If a mouth ulcer persists for longer than 3 weeks, refer under the 2 weeks wait.
60
How does sialolithiasis present?
* 80% of salivary gland calculi occur in submandibular gland
* Patients develop pain (colicky) and post-prandial swelling of the gland
61
How do you investigate Sialolithiasis?
70% of stones are radio-opaque, so **sialography** is used instead.
62
What is Sialadenitis?
* Usually occurs as a result of ***Staphylococcus* *aureus* infection**
* **Pus** may be seen **leaking** **from** **the** **duct**, erythema may also be noted
* Development of a **sub mandibular abscess is a serious complication** as it may spread through the other deep fascial spaces and occlude the airway
63
What does a positive Rinne's test indicate?
Positive Rinne's is **normal**. I.e. air conduction \> bone conduction
64
Summarise the managment for otitis externa-
Mild (mild discomford ± pruritus, no deafness/discharge):
* Acetic acid 2% topical spray
More severe:
* Topical ABx ± topical steroid
* If there is debris -\> Remove
* If canal is swollen: insert ear wick
65
In audiometry, what is considered normal hearing?
Anything below 20 dB is considered normal hearing.
66
How can you distinguish between vertigo due to BPPV and vertebrobasilar ischaemia (e.g. stroke)?
In vertebrobasilar ischaemia there is **dizziness on _extension of teh neck_** which is very specific.
67
When are ABx prescribed in acute otitis media?
* Symptoms lasting **longer than 4 days**
* **Systemically** **unwell** but not requiring admission
* **Immunosuppression**
* **Younger than 2 years** with **bilateral** otitis media
* Otitis media with **perforation** or **discharge** into the canal
68
What is the name for the operation that repairs a perforated ear drum?
Myringoplasty
69
What are the investigations of choice for a patient with suspected recurrent laryngeal nerve compression due to malignancy?
* CXR as apical lung cancer can cause it
* Neck and chest CT
* Flexible fibre-optic laryngoscopy ± FNA
70
What is the significance of a unilateral middle ear effusion in an **adult**?
Unilateral middle ear effusion in an adult can be a presenting symptoms of nasopharngeal cancer.
These patients should therefore be referred under the 2 week wait to ENT.
71
How long should you wait before referring someone with a perforated ear drum?
If it persists beyon 6 weeks -\> Refer.
in this time, it is advisable to avoid getting water in the ear.
72
What is mastoiditis?
Acute mastoiditis is a **serious** **condition** which is characterised by **severe pain and protrusion of the ear forwards**, with a tender, boggy and often reddened mass behind the ear. It needs **urgent** **treatment** due to its many complications. One of these is **_meningitis due to intracranial spread_**; others include cranial nerve palsies, hearing loss, osteomyelitis and carotid artery spasm.
Acute mastoiditis begins when acute otitis media spreads out from the middle ear.
73
Which drugs are associated with gingival hyperplasia?
* Phenytoin
* Ciclosporin/tacrolimus
* CCBs
Note that AML is also assicuated wtih hyperplasia.
74
75
Where in the nose do bleeds most commonly originate from?
Little's area - this is aka. Kiesselbach's Plexus - is located in the anterior nasal septum; 4 arteries supply this area and epistaxis therefore most commonly originates from the anterior of the nose.
76
What is the most common tumour of the parotid gland?
Pleimorphic adenoma (80%).
They are benign, and should NOT invade strutures such as the facial nerve.
77
What drug can be given to prevent the onset of Meniere's disease symptoms?
Betahistine.
78
Which ENT cancer would quickly spread to local lymphnodes?
Where would you expect the draining LNs to be?
Nasopharnygeal carcinoma.
This typically spreads to the LNs in the **posterior** **triangle**.
79
What is the management of the acute phase ofo vetsibular neuronitis?
**Vestibular rehabilitation exercises** are the rpeferred treatment for patients who ecperience chronic symptoms.
**Prochlorperazine** (buccal, IM or oral) may be used in the acute phase, btu should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms.
80
What is a common cause of otitis externa in diabetics?
Pseudomonas.
Hence first line in these patients is ciprofloxacin.
81
name the part of the eardrum that you would see during otoscopy.
Passmed Surgery
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