ENT (B)

Question 1

Main physiological functions of nose?

Answer 1

• Humidify and warm air
• Special sense smell
• Hairs trap foreign material
• Speech - resonating chamber

Question 2

Main functions of throat and mouth?

Answer 2

• Nutrition - saliva lubricates, amylase production starts digestion, muscles mastication
• Airway - entry into lungs, epiglottis closes airway off when swallowing
• Immune - mucosal membranes are barriers, saliva contains immunoglobulins
• Special sense taste
• Speech articulation

Question 3

Symptoms you’d get from disease of the nose

Answer 3

• Visible deformity - eg saddle, deviated septum or swelling
• Epistaxis - unilateral is red flag
• Facial pressure/pain - sinusitis
• Anosmia
• CSF leak
• Rhinorrhoea
• Blocked nose
• Snoring
• Post nasal drip

Question 4

Symptoms you’d get from disease of throat and neck

Answer 4

• Hoarse voice/change in voice
• Odonophagia
• Dysphagia
• Halitosis
• Sore throat
• Bad taste in mouth
• Cough
• Palpable mass/swelling
• Enlarged lymph nodes
• Weight loss
• Referred pain to ear/jaw
• Fever
• SOB

Question 5

How to examine the nose

Answer 5

• Inspect - from front, side and below. Split nose into 1/3rds when describing Shape, deviation, symmetry, scars, skin changes, sunken
• Palpate - assess tip recoil and thickness of nasal skin
• Anterior rhinoscopy - Thudichum’s speculum and
  headlight - look for septal deviation, inflammation, swelling, polyps, prominent blood vessels
• Can do nasal misting to assess humidifcation of each nostil on Lacks cold metal depressor
• Examine oropharynx
• Can then do special tests eg flexible nasal endoscopy

Question 6

Examination of throat and neck

Answer 6

• Inspect - masses, scars
• Palpate - thyroid from behind, use fingertips, get patient to swallow water and stick out tongue. Assess if tender, temp difference, any nodules/masses
• Examine LN - anterior and posterior triangle, then begin with submental and work backwards. Don’t forget supraclavicular
• Auscultate for bruit for hyperthyroidism
• Percuss superior sternum - stoney dullness associated with retrosternal enlarge goitre

Question 7

Thyroid status exam

Answer 7

• General - appropriate dress, sweaty?
• Hands - nails for thyroid acropachy, tremor, palmar erythema, feel temp
• Radial pulse
• Face - peaches and cream for hypothyroidism, loss outer 1/3rd eyebrow?,
• Examine eye movements and check for lid lag
• Legs - pretibial myxoedema? ankle reflexes
• Pembertons test - raise arms above head, check for head and neck venous congestion and hoarse voice - shows retrosternal goitre

Question 8

Three sensory inputs of the balance system

Answer 8

• Vestibular
• Visual
• Somatosensory

Question 9

What happens once these inputs are processesd by the brain?

Answer 9

• They are processed - involves brainstem, cerebellum and cerebrum
• Efferent pathways then act on extraocular muscles to adjust eye position
• Also act on limb and trunk muscles to maintain body position

Question 10

Define vertigo

Answer 10

• A sensation that you or the environment around you is moving or spinning
• It is often described as dizziness

Question 11

How does vertigo differ from other dizziness?

Answer 11

• Vertigo is a rotational sensation
• Feels like the room is spinning
• Other dizziness descriptions may be from lightheadedness, instability, presyncope

Question 12

How to ask a patient if they have vertigo?

Answer 12

• Do you ever have the sensation that the room is spinning around you?

Question 13

Define syncope and presyncope

Answer 13

• Syncope - temporary loss of consciousness and posture usually due to decreased blood flow to the brain
• Presyncope - the feeling that one is about to faint or lose consciousness. May feel lightheaded, dizzy or nauseaous and can get tunnel vision
• Usually associated with decreased blood flow to the brain but not enough to cause syncope

Question 14

Define nystagmus

Answer 14

• Rhythmic, involuntary oscillation or movement of the eyes
• May involve horizontal, vertical or rotational movements

Question 15

What is the slow and fast phase of jerk nystagmus?

Answer 15

• Slow phase - slow and smooth movement/ drift of the eyes away from their primary position (straight ahead gaze). Considered normal/phsyiological and usually tries to reset the eyes back to primary position
• Fast phase - quick fast movement of eyes in the opposite direction. Abnormal and pathological component
• These two together create a back and forwards jerking motions

Question 16

Multifactorial causes for balance problems in older people

Answer 16

• Sensory neuropathy
• OA hips and knees
• Parkinsons
• OAB
• Stroke - altered motor function
• AF - syncope
• Postural hypotension
• Z drugs - drowsiness
• Glicazides/diabetes- hypoglycaemia
• Alcohol
• Worsening eyesight
• Anxiety
• Gout - on thiazides?
• Strong pain relief - drowsy
• Waking up at night

Question 17

Red flags for nose throat and neck symptoms

Answer 17

• Persistent hoarseness - 2WW
• Unexplained neck mass
• Dysphagia - persistent and progressive, worsening +/- weight loss
• Persistent sore throat
• Chronic nasal obstruction - esp if unilateral and associated with epistaxis
• Recurrent epistaxis
• Unexplained weight loss
• Persistent headache/facial pain
• Change in voice - persists
• Dyspnoea
• Stridor

Either referral to ENT or gastro if needed

Question 18

S

Management otitis externa

Answer 18

• Keep ears dry
• Avoid swimming and water sports for 7-10 days
• When swimming wear ear plugs and tight fitting hat
• Keep shampoo and water out of ears when showering where possible - cotton wool balls?
• Hair dryer to dry ears after shower
• Consider OTC acetic acid 2% ear drops
• Paracetamol and ibuprofen for symptom relief
• Can do ear irrigation if lots of debris
• Consider antibiotic ear drops without steroid or with steroid if lots of inflammation

Question 19

Management meniere’s disease

Answer 19

• Acute attacks - prochlorperazine (buccal or IM) or antihistamines to reduce symptoms
• Preventative - Betahistine and vestibular rehabilitation exercises
• If need hopsital admission - IV labyrinth sedatives, fluids

Question 20

Triad for Meniere’s

Answer 20

• Vertigo
• Tinnitus
• Hearing loss

Question 21

Typical presentation Meniere’s

Answer 21

• 40-50yr old
• Vertigo that lasts 20mins-few hours
• Cluster of episodes
• Hearing loss and tinnitus then start to occur even when vertigo episodes are not occuring

Question 22

Approach to assess hearing loss

Answer 22

• Unilateral vs bilateral?
• Onset - gradual or sudden

Sudden is red flag could be cancer/stroke, need high dose steroids to try and save hearing - admit that day

Question 23

Age related hearing loss and noise related hearing loss management

Answer 23

• Hearing aids
• Loop systems to aid the hearing aids - can tune into TV or have associated flashing lights/vibrations
• Cochlear implant - last resort if hearing aid not helping

Question 24

Management of perforated tympanic membrane

Answer 24

• Visualise - confirm diagnosis
• Will self resolve in 2 months usually
• Keep it dry
• Use analgesia and warm compress
• Don’t blow nose too hard
• Can fly
• If not resolving in 6-8 weeks - refer, may need myringoplasty surgery to repair

Question 25

Child/vulnerable adult with ruptured tympanic membrane

Answer 25

* Think carefully about abuse as cause * Severe trauma to side of head can cause rupture

Question 26

Management + what is supparative chronic otitis media with ruptured tympanic membrane

Answer 26

* Causes otorrhoea for more than 2 weeks * Oedematous EAM/cholesteatoma can occur alongside * Conductive hearing loss * Keep ear dry * Cotton wool mopping * Refer to ENT - DO NOT swab or initiate treatment (will often involve abx, cleaning and steroids)

Question 27

Mastoiditis

Answer 27

* Complication of recent AOM * Proptosed auricle, post auricular swelling, erythema or tenderness * Children do ear pulling * Can have associated fever, headache, otorrhoea * Bulging TM * And sagging of superior wall of EAM * A&E

Question 28

AOM management

Answer 28

* Usually goes away within 3-5 days without use of abx - analgesia and conservative * Consider prescribing in children under 2, or if bilateral AOM, or if systemically unwell * Amoxicillin is 1st line, Erythromycin/Clarithromycin if allergic * Grommets if reoccur * Review in 7 days if no improve or at any time if symptoms worsen

Question 29

Cholesteatoma management

Answer 29

* Semi-urgent referral to ENT * Surgical removal may be needed

Question 30

Causes of referred pain to ear

Answer 30

* Temporomandibular joint - CN Vc (trigemincal mandibular portion) * Diseases of oropharynx - CN IX (glossopharyngeal) * Diseases of larynx and pharynx eg cancers - CN IX and X (glossopharyngeal and vagus) Consider this if normal ear exam

Question 31

Otitis media with effusion management

Answer 31

* No hearing loss - reassure should resolve * Some hearing loss suspected - refer for tympanometry and hearing tests * ENT referral for either: watch and wait, hearing aids, myringotomy and insertion of grommets

Question 32

What happens after grommets are inserted?

Answer 32

* Falls out several months later * Allows ventilation between middle ear with eustachian tube and external environment

Question 33

Congenital deafness causes

Answer 33

* CMV or Rubella as a baby * Faulty ion channels - pH of endolymph affected * Syndrome related - down syndrome * Baby's have newborn hearing tests which detects