ENT AS Flashcards

Question

Presentation of cholesteatoma?

Answer 1

``` **Foul smelling white discharge** Headache, pain CN involvement - Vertigo - Deafness - Facial paralysis ```

Answer 2

Appears pearly white with surrounding inflammation. Any crusting or ear wax obscuring the attic is a cholesteatoma until proven otherwise. The attic is extremely important to visualise to see attic crust. Never trust an attic crust.

Answer 3

Deafness --> ossicle destruction Meningitis Cerebral abscess

Answer 4

Sensation of sound without external sound stimulation

Answer 5

Specific - Meniere's - Acoustic neuroma (hearing loss, vertigo, tinnutis, Absent corneal reflex). NF2. - Otosclerosis (20-40yrs, conductive deafness, tinnitus, normal tympanic membrane) - Noise-induced - typically high range (3,000-6,000) - head injury - Hearing loss - presbyacusis General - Increased BP - decreased Hb ``` Ototoxicity is my FAV.Q&A Furosemide Aminoglycoside (gentamicin, neomycin) Vancomycin Quinine Aspirin ```

Answer 6

Character: constant, pulsatile Unilateral: acoustic neuroma FH: otosclerosis Alleviating/exacerbating factors: worse @ night Associations - Vertigo: Meniere's, acoustic neuroma - Deafness: Meniere's, acoustic neuroma Cause: head injury, noise, drugs, FH

Answer 7

Otoscope Tuning fork tests Pulse and BP

Answer 8

Audiometry and tympanogram | MRI if unilateral to exclude acoustic neuroma

Answer 9

Treat any underlying causes Psych support: tinnitus retraining therapy Hypnotics @ night may help.

Answer 10

The illusion of movement

Answer 11

Peripheral/Vestibular? Meniere's = Hearing loss, tinnitus, sensation of fullness or pressure in one or both ears. >30 mins but lasts few hours. BPPV = Gradual onset, triggers by change in head position. Each episodes lasts 10-20 s. Viral Labyrinthitis = Recent viral infection. Sudden onset, N+V. Hearing may be affected. = Days. Vestibular neuronitis (No Hearing loss) = Recent viral infection, recurrent vertigo attacks lasting hours or days. No hearing loss. Central causes of vertigo? - Acoustic neuroma - MS - Vertebrobasilar insufficiency/stroke - Inner ear syphilis Drugs - Gentamicin - Loop diuretics - Metronidazole - Co-trimoxazole

Answer 12

Is it true vertigo or just light-headedness - Which way are things moving Timespan Associated symptoms: n/v, hearing loss, tinnitus, nystagmus

Answer 13

- Hearing - Cranial nerves - Cerebellum and gait - Rombergs +ve = vestibular or proprioception - Hallpike manoeuvre - Audiometry, calorimetry, LP, MRI.

Answer 14

Dilatation of endolymph space of membranous labyrinth (endolymphatic oedema) Presents with - Attacks occur in clusters up to 12hrs - Progressive SNHL (sensorineural hearing loss) - vertigo and n/v - Tinnitus - Aural fullness - Romberg's test +ve. - Lasts minutes to hours Ix - Audiometry shows low-freq SNHL which fluctuates Management - Medical = Vertigo: Cyclizine, betahistine acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required prevention: betahistine and vestibular rehabilitation exercises may be of benefit - Surgical = Gentamicin instillation via grommets, saccus decompression.

Answer 15

Vestibular neuritis = only vestibular nerve so no hearing impairment Labyrinthitis = vestibular nerve and labyrinth are involved. Both - Follows febrile illness - Sudden vomiting - Horizontal nystagmus - No hearing loss of tinnitus - Severe vertigo exacerbated by head movement DDx - Viral labyrinthitis (includes hearing loss) /posterior circulation stroke (HiNTs exam helps to tell apart) Management - Vestibular rehabilitation exercises are preferred treatment for patients who experience chronic symptoms - A short oral course of prochlorperazine or an antihistamine (cinnarize, cyclizine, promethazine) may be used to alleviate less severe cases. - Buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases. FOR THE ACUTE PHASE. Delays recovery.

Answer 16

Displacement of otoliths in semicircular canals Common after head injury Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients. Features - vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards) may be associated with nausea - each episode typically lasts 10-20 seconds - positive Dix-Hallpike manoeuvre Management - Epley manoeuvre - Teaching patient exercises they can do themselves.

Answer 17

Sudden rotational vertigo for <30s - Provoked by head turning Nystagmus Causes by: idiopathic, head injury, otosclerosis, post-viral Diagnosis - Hallpike manoeuvre --> Upbeat-torsional nystagmus Management - Self-limiting - Epley manoeuvre - Betahistine: histamine analogue

Answer 18

Impaired conduction anywhere between auricle and round window

Answer 19

External canal obstruction - Wax, pus, foreign body TM perforation - trauma, infection Ossicle defects - Otosclerosis - Infection - Trauma

Answer 20

Defects in the cochlea, cohlear nerve or brain. Drugs - Aminoglycosides - Vancomycin Post-infective - Meningitis - Measles - Mumps - Herpes Misc - Meniere's - Trauma - MS - CPA lesion (acoustic neuroma) - Decreased B12

Answer 21

Benign, slow-growing tumour of superior vestibular nerve Acts as SOL --> CPA - Associated with NF2

Answer 22

Should also be considered in patients with unilateral sensorineural deafness or tinnitus. - Slow onset, unilateral SNHL, tinnitus ± vertigo. Absent corneal reflex. - Headache (Increased ICP) - CN palsies: 5, = Absent corneal reflex 7, = Facial palsy 8. = vertigo, unilateral sensorineural hearing loss, unilateral tinnitius. - Cerebellar signs Investigations - MRI of cerebellopontine angles (Gadolinium-enhanced) - MRI all patients with unilateral tinnitus/deafness PTA (pure tone audiometry) Differential - Meningioma - Cerebellar astrocytoma - Mets Management Refer urgently to ENT. - Gamma knife - Surgery (risk of hearing loss)

Answer 23

AD condition characterised by fixation of stapes at the oval window F>M = 2:1

Answer 24

Begins in early adult life Bilateral conductive deafness + tinnitus. Key is bilateral. HL improved in noisy places: Willis' paracousis Worsened by pregnancy/menstruation/menopause

Answer 25

PTA shows dip (Caharts notch) @ 2kHz

Answer 26

Hearing aids or stapes implant

Answer 27

Age-related hearing loss - SNHL Presentation - >65 yrs old - Bilateral - Slow onset - ± tinnitus High freqeuncy hearing loss. Ix: PTA Management: hearing aid

Answer 28

Anomalies in pinna, external auditory canal, ossicles | Pierre-Robin syndrom

Answer 29

AD: Waardenburgs AR: Alports or Jewell-Lange-Nielson X-linked: alports Infections: CMV, Rubella, HSV Ototoxic drugs May be perinatal - anorxia, cerebral palsy, kernicterus, infection

Answer 30

Congenital anomalies - 1st and 2nd branchial arches form auricle while 1st brachial groove forms external auditory canal. - Malfusion --> accessory tags auricles and preauricular pits, fistulae, sinuses. - Sinuses may get infected, mimicking a sebaceous cyst

Answer 31

BLunt trauma --> Subperichondrial haematoma Can --> Ischaemic necrosis of cartilage and subsequent fibrosis to cauliflower ears. Management: aspiration + firm packing to auricle contour.

Answer 32

Smooth symmetrical bony narrowing of external canals. path - Bony hypertrophy due to cold exposure. Eg. from swimming/surfing. Symptoms - Asymptomatic unless narrowing occludes --> conductive deafness Management: conservative or surgical widening.

Answer 33

Secreted in outer 3rd of canal to prevent maceration Wax accumulation can --> conductive deafness Management - Suction under direct vision with microscope - Syringing after 1 week softening with olive oil.

Answer 34

``` Causes - OM - Foreign body - Barotrauma Trauma ``` No treatment needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. Advisable to avoid getting water in the ear during this time, Common practise is to prescribe antibiotics to perforations which occur following an episode of acute otitis media. Myringoplasty may be performed if the tympanic membrane does not heal by itself. Myringoplasty is the closure of the perforation of pars tensa of the tympanic membrane. When myringoplasty is combined with ossicular reconstruction, it is called tympanoplasty.

Answer 35

Classification - Seasonal: hay-fver - Perennial Pathology - T1HS IgE mediated inflammatory from allergen exposure --> Mediator release from mast cells Allergens: pollen, house dust mites Symptoms - Sneezing - Pruritis - Rhinorrhoea - Post nasal drip Signs - Swollen, pale, boggy tubinates - Nasal polyps Ix - Skin prick test to find allergens - RAST test

Answer 36

Washing bedding on high Avoid going outside when pollen count is high 1st line - Cetirazine, desloratidine - beclometasone nasal spray 2nd lin: intranasal steroids 3rd line : Zarfirlukast Topical nasal decongestant = oxymetazoline. Prolonged periods not used as increasing doses required to achieve same effect. 4th line: immunotherapy - Aim to induce densensitiation to allergen - OD SL grass-pollen tablets

Answer 37

Virusus --> mucosal oedema and decreased mucosal ciliary actions --> Mucus retention ± 2ndry bacterial infection Acute: Pneumococcus, Haemophilus, Moraxella Chronic: s.aureus, anaerobes

Answer 38

Bacterial infection secondary to viral 5% secondary to dental root infection Diving/swimming in infected water Smoking Anatomical susceptibility: deviated septum, polyps Systemic disease - PCD/Kartagener's - Immunodeficiency

Answer 39

Pain - Maxillary (cheek/teeth) - Ethmoidal (between eyes) increased on bending/straining Discharge: from nose --> post-nasal drip with foul taste Nasal obstruction/congestion Anosmia. Imaging - Nasendoscopy + CT

Answer 40

Acute/Single Episode - Bed-rest, decongestants, analgesia - Nasal douching and topical steroids. Treat with intra-nasal corticosteroids if symptoms of sinusitis are severe or have lasted for period of 10 days or more. Antibiotics NOT recommended (can sometimes give if symptoms present more than 10 days) Chronic/recurrent - Usually a structural or drainage problem - Stop smoking + fluticasone nasal spray - Functional endoscopic sinus surgery

Answer 41

``` Mucoceles --> pyoceles Orbital cellulitis/abscess Osteomyelitis - Staph in frontal bone Intracranial infection - Meningitis - ABscess - Cavernous sinus thrombosis ```

Answer 42

Patient male, >40yrs Sites - Middle turbinates - Middle meatus - Ethmoids Symptoms - Watery, anterior rhinorrhoea - Purulent post-nasal drip - Nasal obstruction - Sinusitis - Headache - Snoring Signs - Mobile, pale, insensitive

Answer 43

Allergic/non-allergic rhinitis CF Aspirin hypersensitivity Asthma

Answer 44

May be sign of rare or sinister pathology - Nasopharyngeal Ca - Glioma - Lymphoma - Neuroblastoma - Sarcoma Do CT and get histology Nasal polyp in children - Must consider neoplasm and CF Must do urgent ENT referral for examination.

Answer 45

Betamethasone drops for 2/7 Short course of oral steroids Endoscopic polypectomy

Answer 46

Anatomy - Upper 3rd of nose has bony support - Lower 2/3 and septum are cartilaginous ``` History - Time of injury - Loss of Consciousness - CSF rhinorrhoea - Epistaxis - Previous nose injury - Obstruction - Consider facial £ check for Teeth malocclusion Piplopia (orbital floor) ```

Answer 47

Radiographs dont change management

Answer 48

Exclude septal haematoma Re-examine after 1wk (reduced swelling) Reduction under GA with post-op splinting best within 2 weeks

Answer 49

Septal necrosis + nasal collapse if untreated - Cartilage blood supply come from mucosa Boggy swelling and nasal obstruction Needs evacuation under GA with packing + suturing.

Answer 50

``` 80% Unknown Trauma: nose-picking Local infection: URTI Pyogenic granuloma - Overgrowth of tissue on Little's area due to irritation or hormonal factors. This is in the anterior of the nasal septum in the site of Kiesselbach's plexus. ``` Osler-Weber-Rendu/HHT Coagulopathy: warfarin, NSAIDs, haemophilia, decreased platelets, vWD, increased alcohol Neoplasms

Answer 51

Anterior | Posterior - more serious and originate from deeper structures, more common in older patients.

Answer 52

Wear PPE Assess for shock and manage accordingly IF not shocked - Sit up, head tilted down - Compress nasal cartilage for 15 mins If bleeding not controlled remove clots with suction or by blowing and try to visualise bleed by rhinoscopy

Answer 53

Usually septal haemorrhage: Little's area/Kisselbach's plexus. - Anterior Ethmoidal A - Sphenopalatine A - Facial A - Sit forward - open mouth. Pinch cartilaginous area of nose for 15 mins -> if successful, consider topical antiseptic. Insert gauze soaked in vasoconstriction + LA. Xylometazoline + 2% lignocaine - 5mins Bleeds can be cauterised with silver nitrate sticks. If there is no visible bleeding side. Ask patient to blow nose. Use local anaesthetic spray and wait 3-4 mins. Persistent bleeds should be packed with mericel pack - Refer to ENT if this fails or if you can't visualise the bleeding point They may insert a posterior pack or take patient to theatre for endoscopic control.

Answer 54

Postior packing + anterior packing Pass 18/18G foley catherer through nose into nasopharynx, inflate with 10ml water and pull forward until it lodges. - Admit patient and leave pack for 48hrs. Gold standard is endoscopic visualisation and direct control: e.g by cautery or ligation.

Answer 55

``` Don't pick nose Sit upright out of the sun Avoid bending, lifting or straining eense through mouth No hot food or drink Avoid ETOH and tobacco ``` Can use intranasal epinephrine to prevent re-bleeding once the initial bleeding has stopped.

Answer 56

Telangiectasias in mucosa - Recurrent spontaneous epistaxis - GI Bleed INternal telangioectasis and AVMs - Lungs - Liver - Brain Rarely - Pulmonary HTN - Colon polyps: may --> CRC

Answer 57

- Sore throat Fever, malaise - Lymphadenopathy, esp jugulodigastric node - Inflamed tonsils and oropharynx - Exudates

Answer 58

Viruses are most common (consider EBV) GAS: Pyogenes Staphs Moraxella

Answer 59

Swabbing superficial bacteria overdiagnosis therefore not routine. Analgesia: Ibuprofen/paracetamol + Difflam gargles Consider Abx only if ill: use Centor Criteria - Pen V 250mg PO QDS or erythromycin - Phenoxymethylpenicillin or erythromycin. 7 or 10 day course. - If allergic give erythromycin 250mg QDS for 7 days. NOT AMOXICILLIN --> MACPAP rash in EBV

Answer 60

Guideliens for admin of Abx is acute sore throat/ tonsillitis/pharyngitis 1 point for each of - 1. hx of fever - 2. Tonsillar exudate - 3. Tender anterior cervical adenopathy - 4. No cough

Answer 61

0-1: no abx (risk of strep infection <10%) - 2: consider rapid Ag test + Rx if +ve - >3: abx

Answer 62

Recurrent tonsillitis if all the below criteria are met - Caused by tonsillitis - 5+ episodes a year - Symptoms for >1yrs - Episodes are disabling and prevent normal functioning Airway obstruction: e.g OSA in children Quinsy Suspicious of Ca: unilateral enlargement or ulceration

Answer 63

Cold steel | Cautery

Answer 64

- Reactive haemorrhage: Haemorrhage 5-10 days after tonsillectomy is commonly associated with wound infection and should therefore be treated with antibiotics. Primary haemorrhage within hours after tonsillectomy requires immediate return to theatre. - Tonsillar gag may damage teeth, TMJ or posterior pharygeal wall.

Answer 65

``` Peritonsillar abscess (quinsy) - Typically occurs in aduls SYmptoms - Trismus (lockjaw) - Odonophagia: unable to swallow saliva - Halitosis ``` Signs - Tonsillitis - Unilateral tonsillar enlargement - Trismus (difficulty opening mouth) - Uvula deviated to unaffected side. - Cervical lymphadenopathy Management - Admit - IV abx - I+D under LA or tonsillectomy under GA.

Answer 66

Rare Presents with unwell child with stiff, extended neck who refused to eat or drink. Fails to improve with IV Abx Unilateral swelling of tonsil and neck Ix: Lateral neck x-ray show soft tissue swelling. CT from skull-base to diaphragm Management - IV Abx - ID

Answer 67

IJV thrombophlebitis with septic embolisation - caused by fusobacterium necrophorum Management - IV abx: pen G, clinda, metro.

Answer 68

Sandpaper like rash on chest, axillae or behind ears 12-48hrs after pharyngotonsillitis. Circumoral pallor Strawberry tongue Management - Start Pen V/G and notify HPA.

Answer 69

``` Arthritis Carditis - Subcut Nodules Erythema marginatum Sydenham's chorea ```

Answer 70

Phonation Positive thoracic pressure Respiration Prevention of aspiration

Answer 71

Usually viral and self-limiting 2ndry bacterial infection may develop - Symptoms: pain hoarseness and fever - o/e: redness and swellign of vocal cords - Management: supportive, Pen V if necessary

Answer 72

Pedunculated vocal cord swellign caused by HPV. Presents with hoarseness Usually occur in children Manage: laser removal

Answer 73

Supplies all intrinsic muscle of the larynx except for cricothyroideus. Responsible for ab + aduction of vocal folds.

Answer 74

Hoarseness Breathy voice with bovine cough Repeated coughing from aspiration (decreased supraglottic sensation) Exertional dyspnoea (narrow glottis)

Answer 75

cancer - larynx, thyroid, oesophagus, hypopharynx, bronchus 25% iatrogenic: parathyroidectomy, carotid endartectomy Othe: aortic aneurysm, bulbar/pseudobulbar palsy.

Answer 76

Incidence: 2000/ yr. | Associated with smoking, ETOH.

Answer 77

Male smoker Age over 45 Progressive hoarseness --> Stridor. If unexplained needs 2WW. Dys/odonophagia Weight loss

Answer 78

Do a chest x-ray to exclude an apical lung lesion. A normal chest x-ray does not rule out the diagnosis of a lung malignancy. Laryngoscopy + biopsy (in nodes) MRI staging

Answer 79

Based on stage Radiotherapy Laryngectomy After total laryngectomy - Pts have permanent tracheostomy - Speech valve - Electrolarynx - Oesophageal speech (swallowed air) Regular f/up

Answer 80

Asthma Aspirin Sensitivity Nasal polyposis Avoid aspirin.

Answer 81

``` Asthma Aspirin Sensitivity Infective sinusitis Cystic fibrosis Kartagener's Churg-Strauss ``` Management - All patients should be referred to ENT for full examination - Topical corticosteroids shrink size in 80% of patients.

Answer 82

Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour. ``` Predisposing factors poor oral hygiene antibiotics (penicillin, erythromycin, tetracycline ) head and neck radiation HIV intravenous drug use ``` The tongue should be swabbed to exclude Candida Management tongue scraping topical antifungals if Candida

Answer 83

ABCDE Patient has a compromised airway and breathing. Each patient is returned to the ward with a suture blade. In the event of post-operative bleed, the pressure behind the suture line increases and the trachea becomes compressed resulting in stridor

Answer 84

Air conduction is superior to bone conduction. This is because they are both affected equally, but AC is better.

Answer 85

Bone conduction is superior to air conduction.

Answer 86

Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve. Features auricular pain is often the first feature facial nerve palsy vesicular rash around the ear other features include vertigo and tinnitus Management oral aciclovir and corticosteroids are usually given

Answer 87

Centre. if sound is louest in one ear, there is either conductive hearing loss of the left ear or SNHL of the right ear.

Answer 88

Fork is struck causing it to vibrate. Conductive hearing loss is if bone is louder than air.

Answer 89

Some evidence that high dose steroids for seven daus improves prognosis. ENT checks for pure tone audiometry testing to arrange an MRI to exclude acoustic neuroma.

Answer 90

Phenytoin Cyclosporin CCB - Nifidepine AML CIA - CCB (nifedipine), immunosuppressants (ciclosporin), anticonvulsants - phenytoin.

Answer 91

SCC of the nasopharynx Rare in most parts of the world. Associated with EPV. Presenting features - Systemically = Cervical Lymphadenopathy - Local = Otalgia, unilateral serous otitis media, nasal obstruciton, discharge and epistaxis, cranial nerve palsies III-VI. Referred pain through V-X Image = CT and MRi Radiotherapy = First line Presents with a painless lymphadenopathy with a tendency to spread early. Remember the nasopharynx drains to the posterior triangle Larynx, buccal mucosa and tonsillar fossa drains to anterior triangle.

Answer 92

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either: unexplained ulceration in the oral cavity lasting for more than 3 weeks or a persistent and unexplained lump in the neck. Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either: a lump on the lip or in the oral cavity or a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Answer 93

Vertigo upon neck extension = characteristic for this condition and results in falls in elderly patients. RF: atherosclerosis etc.

Answer 94

Inflammation of the salivary gland likely secondary to obstruction by a stone impacted in the duct. Usually due to Staph A. Duct from the submandibular gland drain into the floor of the mouth. Purulent discharge causes a foul taste in mouth. 3 main salivary glands - Parotid glands, submandibular glands, sublingual glands. Disorders of glands occur due to infection, inflammation , obstruction or malignancy.

Answer 95

Haematoma is a complication of surgery that is typically resolved by placement of a drain. Emergency management is to remove the surgical clips

Answer 96

Cellulitis which occurs on the floor of the mouth of a patient. Deadly, as it spreads into the fascial spaces of the head and neck. Swelling ensues from the inflammation begins to push the floor of the mouth upwards and blocks air entry. Patient has compromised immune system (IVDU puts risk for HIV and AIDS) and poor dentition.

Answer 97

Complications following surgery: - Anatomical such as recurrent laryngeal nerve damage - Bleeding. Confined space haematoma's may rapidly lead to respiratory compromised owing to laryngeal oedema. - Damage to the parathyroid glands resulting in hypocalcaemia.

Answer 98

White film covering tonsils = Diphtheria however patients are NOT systemically well.

Answer 99

Secondary to poor dental hygiene. Ranges from simple gingivitis (Painless red swelling of gum margin which bleeds on contact) to necrotizing ulcerative gingivitis (painful bleeding gums with halitosis and punched out ulcers on gums). Simples = Review by dentist. Patient presents with acute necrotising ulcerative gingivitis - Refer patient to dentist - Oral metronidazole 3 days. - Chlorhexidine or hydogen peroxide - Simple analgesia

Answer 100

Can be presenting symptoms of nasopharyngeal cancer. Unilateral middle ear effusion in an adult can be a presenting symptom of nasopharyngeal cancer, especially in smokers and people of Chinese or South-East Asian origin. A tumour may cause obstruction of the eustachian tube. NICE advises you should consider a two week wait referral for patients of Chinese or South-East Asian origin with unilateral ear effusion, if not associated with an upper respiratory tract infection.

Answer 101

Tonsils are most common site for SCC in the oropharynx. Presents at an advanced stage. RF = Smoking, high levels of alcohol intake and poor oral hygiene. HPV (HPV-16) linked to development of tonsillar SCC. EBV is associated with nasopharyngeal in origin of lymphoma.

Answer 102

Rebound nasal congestion brought on by extended use of topical decongestants. Withdrawal of offending nasal spray (cold turkey).

ENT AS Flashcards

(127 cards)