ENT B presentations

Question 1

BPPV presentation

Answer 1

• Variety of head movements trigger vertigo
• Typical trigger is turning over in bed
• Settle after 20-60s
• Episodes occur overal several weeks then resolve but can reoccur
• NO hearing loss or tinnitus

Question 2

Diagnosis and management of BPPV

Answer 2

• Diagnose with Dix Hallpike maneuvre
• Treat with Epley

Question 3

Cause of allergic rhinitis

Answer 3

• Inflammatory condition of nasal mucosa
• Caused by IgE mediated response to allergens within environment eg pollen/dust mites
• Can show seasonal variation

Question 4

Signs and symptoms of allergic rhinitis

Answer 4

• Nasal pruritis
• Sneezing
• Rhinorrhoea
• Nasal congestion
• May be associated with allergic conjuctivitis = eye redness, puffiness and watery dishcarge

Question 5

Diagnosis for allergic rhinitis

Answer 5

• Clinical and pt history based
• If needed can refer for skin prick test or blood tests for specific IgE antibodies to identify allergen

Question 6

Investigations if diagnosis doubt or failure to respond to treatment in allergic rhinitis

Answer 6

• Nasal endoscopy
• Nasal allergy challenge
• Evaluation of nasal nitric oxide and ciliary beat frequency
• Analysis of nasal fluid
• CT scan

Question 7

What are nasal polyps?

Answer 7

• Growths of nasal mucosa that occur in nasal cavity/sinuses
• Often associated with inflammation, eg chronic rhinitis
• Grow slowly and gradually obstruct passage
• More common in men esp those 40+

Question 8

Polyps patten

Answer 8

• Bilateral usually
• Unilateral is red flag - tumour?

Question 9

Presentation of nasal polyps

Answer 9

• Chronic rhinosinusitis
• Difficulty breathing through nose
• Snoring
• Nasal discharge
• Hypo or anosmia
• Post nasal drip = cough

Question 10

Investigations for nasal polyps

Answer 10

• Examine with nasal speculum to hold nostrils open
• Otoscope + large speculum attached
• Specialist can do nasal endoscopy
• Appear as round, pale/grey/yellow growrht on mucosal wall

Question 11

When to refer polyps?

Answer 11

Unilateral - 2WW

Question 12

Management polyps

Answer 12

• Intranasal steroid drops or sprays
• Surgery - intranasal polypectomy (when polyps are visibilt OR
• Endoscopic nasal polypectomy (polyps are further in nose or in sinuses)

Question 13

Infective cervical lymphadenopathy characteristics

Answer 13

• Tender
• Mobile
• Associated fever, cough, sore throat

Question 14

Maligmant cervical lymphadenopathy characteristics

Answer 14

• Irregular
• Hard
• Tethered to surrounding tissues
• Painless
• Larger than 2cm
• Associated systemic symptoms - weight loss, night sweats, fatigue
• Other symptoms - change in voice, dysphagia, haemoptysis, rapidly growing

Question 15

Investigations for cervical lynphadenopathy

Answer 15

• Depends
• May just resolve if viral
• Can do EBV, cyomegalovirus and HIV serology
• Urgent CXR if suspect TB or lung cancer (within 2 weeks)
• If suspect leukaemia need FBC

Question 16

Management cervical lymphadenopathy

Answer 16

• Viral - self limiting
• Bacterial - assess need for abx,
• If unresolved after 2-4 weeks consider urgent ENT referral
• If suspect cancer 2WW pathway for cancer

Question 17

Acute sinusitis presentation

Answer 17

• Lasting less than 4 weeks
• Facial pain
• Anosmia
• Purulent discharge

Question 18

Investigations for chronic sinusitis

Answer 18

• Nasal endoscopy
• Nasal and sinus cultures
• CT if indicated - complications and extent of disease
• Skin prick testing

Question 19

Management acute sinusitis

Answer 19

• Analgesia
• Intranasal decongestants or nasal saline
• Intranasal corticosteroids if symptoms present for more than 10 days
• Oral abx if severe presentation and suspect bacterial - phenoxymethylpenicillin, co-amoxiclav is systemically very unwell

Question 20

What is double sickening?

Answer 20

• Viral sinusitis worsens due to secondary bacterial infection - get better and then worse

Question 21

When to refer to ENT acute sinusitis?

Answer 21

• No improvement after 7-14 days or red flag

Question 22

Red flag for sinusitis

Answer 22

• Eye signs - periorbital swelling or erythema, displaced globe, visual changes, opthalmoplegia
• Severe unilateral headache
• Bilateral frontal headache
• Frontal swelling
• Neurological signs or reduced conc level

Question 23

Chronic sinusitis - what is it?

Answer 23

• Inflammation of the paranasal sinuses in the face for more than 12 weeks
• Rhinosinusitis if nasal cavity is also inflamed
• Can last several months

Question 24

Underlying cause chronic sinusitis

Answer 24

More likely to be inflammatory rather than infection (acute more likely to be infection)

Question 25

RF for chronic sinusitis

Answer 25

* Allergic rhinitis * Asthma * Cystic fibrosis * Immunocompromised * Smoking * Previous sinus surgery * Nasal polyps - blocks drainage

Question 26

Signs and symptoms chronic sinusitis

Answer 26

* Nasal blockage * Nasal discharge with facial pain/pressure or headache * +/- reduced sense of smell * Cough

Question 27

Management chronic sinusitis

Answer 27

* Good control of asthma or any allergic rhinitis * Avoid triggers * Smoking cessation * Nasal irrigation with saline solution * Consider course intranasal corticosteroids for up to 3 months (esp if allergic cause) - reduces swelling

Question 28

When to refer chronic sinusitis?

Answer 28

* Persistent symptoms past 3 months * Unilateral symptoms (cancer?) * Interefering with QOL * Allergic/immunologic factors that need investigating

Question 29

Thyroid nodules - presentation

Answer 29

* Identified on routine examination/incidentally on imaging * If large can be palpable * Move upwards on swallowing * Can present with hyper or hypothyroidism or compressive symptoms

Question 30

Compressive symptoms of thyroid nodules

Answer 30

On oesophagus or trachea: * Dysphagua * Stridor * Voice changes (hoarseness) * SVCO - face/neck swelling, distended neck veins and dyspnoea

Question 31

Causes of thyroid nodules

Answer 31

* Most benign - adenoma, multinodular goitre, hashimotos thyroiditis or cysts (colloid, simple, haemorrhagic) * Malignancy - PFAM, lymphoma * Mets - breast, kidney, prostate

Question 32

Invetsigations for thyroid nodules

Answer 32

* TFTs * Thyroid USS - solid, irregular, hyperechoic, >1cm, rapid growth and central vascularity suggests cancer * Thyroid scintigraphy (radioisotope scanning) * Fine needle aspiration and histological diagnosis

Question 33

Thyroid scintigraphy findings and meanings

Answer 33

* Non-functioning cold nodule, no uptake of iodine - malignant * Autonomous hot nodule, increased uptake - unlikely malignancy eg adenoma * Hot and cold areas, patchy uptake - toxic multinodular goitre

Question 34

What is thyroid scintigraphy?

Answer 34

Radioactive labelled iodine is given to pt Measure thyroid uptake using nuclear scan

Question 35

Management thyroid nodules options

Answer 35

* Emergency hospital admission if signs of obstruction * Urgent referral to endocrinology (2weeks) * Serum TFTs * Routine endo referral * Monitor

Question 36

When to urgent refer thyroid nodules to endo?

Answer 36

* Unexplained thyroid lump * Unexplained hoarseness/voice change * Cervical lymphadenopathy or supraclavicular * Sudden onset and rapidly expanding painless thyroid mass - increased in size over days/weeks * Compressive symptoms

Question 37

When to routine endo referral thyroid nodule?

Answer 37

* Non-suspicious nodule with abnormal TFTs and normal TFTs * Sudden onset, painful expansion in pre-existing lump - haemorrhage into benign cyst? * Non suspcious incidental finding on imaging more than 1cm

Question 38

When to just monitor thyroid lump in primary care?

Answer 38

* Long standing unchanging over several years * Non-palpable, asymptomatic incidental finding on imaging less than 1cm * Non palpable cervical lymphadenopathy and no red flags for malignancy

Question 39

Acute labyrinthitis vs vestibular neuronitis

Answer 39

* Labyrinthitis = vestibule, semicircular canals and cochlea inflamed * VN - vestibular portion of CN8th inflamed so no hearing loss/tinnitus present

Question 40

Cause of AL and VN

Answer 40

* Viral URTI is usually cause (can be otitis media or meningitis too)

Question 41

Presentaiton of AL and VN

Answer 41

* Acute onset of vertigo, nausea and vomitting * Can have symptoms of URTI - cough, sore throat, blocked nose etc * AL can have tinnitus and hearing loss also

Question 42

Diagnosing AL and VN

Answer 42

* Clinical * Can do head impulse test to distinguish between peripheral and central causes of vertigo

Question 43

Management acute labyrinthitis/VN

Answer 43

* Supportive - settles over several weeks * Advise not to drive if very dizzy * Short term (up to 3 days) of prochlorperazine or antihistamines (cyclizine, cinnarizine and promethazine) to relieve symptoms * Abx used if suspect bacterial cause (more likely in otitis media or meningitis)

Question 44

Hearing loss after acute labyrinthitis

Answer 44

* Rarely have permanent hearing loss * More common following bacterial infection esp from meningitis * All patients after meningitis recovery should have audiology assessment