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Finals > ENT > Flashcards

ENT Flashcards

1
Q

Risk factors for otitis externa

A 
Mechanical injury to the skin - cleaning, foreign objects (hearing aids, earplugs), itching
Increased moisture - swimming
Skin disease
DM
Prolonged use of topical antibiotics
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2
Q

Clinical features of otitis externa

A 
Otalgia - particularly at night
Otorrhea
Tender tragus
Moving auricle causes pain
Conductive hearing loss
Diffuse oedema and erythema
Purulent debris
Peri-auricular lymphadenopathy
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3
Q

Possible complications of acute otitis externa

A

Perichondritis (infection of the cartilage)
Cellulitis
Malignant otitis externa
Otomycosis (fungal ear infection usually following use of topical abx)
Late: canal stenosis, hearing loss

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4
Q

What is malignant/necrotising otitis externa

A

When otitis externa spreads and causes osteomyelitis of the temporal bone

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5
Q

Causative organisms of otitis externa

A

Staph aureus
Pseudomonas aeruginosa (swimming, abx drop resistance)
Aspergillus niger - itching > otorrhea, looks like cotton wool speckled with black dots
Herpes zoster
Influenza viruses

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6
Q

Management of otitis externa

A

Keep ear dry
Oral analgesia
Topical drops - antibiotic + steroid: Sofradex, Gentisone, Otomise

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7
Q

What features would make you think of perichondritis rather than otitis externa

A

Symptoms worsening or not responding to treatment
Pyrexial
Tachycardic
Hearing loss

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8
Q

Features of malignant otitis externa

A 
Severe pain
Granulation tissue - at junction of cartilage and bony part of ear canal
Red/swollen periauricular tissue
Otorrhea
Conductive hearing loss
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9
Q

Possible complications of malignant otitis externa

A

Facial nerve palsy
Osetomyelitis of skull base which in turn can cause extradural abscess, venous sinus thrombosis, paralysis of other cranial nerves

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10
Q

Who gets malignant otitis externa

A

The immunocompromised

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11
Q

Management of malignant otitis externa

A 
Continue with topical antibiotics
PLUS 
6 weeks of IV antibiotics (Ciprofloxacin)
CT head to identify bone destruction
MRI to identify intracranial extension
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12
Q

Most common causative organism of acute otitis media

A

Streptococcus pneumoniae

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13
Q

Presentation of acute otitis media

A 
Acute onset of earpain, usually with a throbbing character
Fever
Loss of appetite
Bulging TM
Red TM
Purulent discharge if ruptured TM
Conductive hearing loss
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14
Q

Risk factors for acute otitis media

A 
Bottle/formula feeding
Pacifier use
Passive cigarette smoking
Day care
Poor socioeconomic status
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15
Q

What is the definition of recurrent acute otitis media

A

More than 4 episodes in a 6 month period

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16
Q

How does otitis media happen

A

Eustachian tube dysfunction –> negative middle ear pressure –> retracted TM
Accumulation of middle ear secretions –> bacterial superinfection –> bulging TM

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17
Q

Predisposing factors for eustachian tube obstruction

A

ET mucosal inflammation - viral URTI, allergic rhinitis
Enlarged adenoids
Nasal polyps
Cleft palae
Young - the ET of infants is short, wide and horizontal so nasopharyngeal secretions easily reflux into the ET and so infants are more prone to developing acute otitis media

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18
Q

Management of acute otitis media

A

Paracetamol and ibuprophen

Antibiotics if: bilateral/lasted over 2 days/systemic illness

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19
Q

Antibiotic of choice in acute otitis media

A

Amoxicillin

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20
Q

What is chronic otitis media

A

Inflammation of the middle ear for >3 months

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21
Q

Most common causative organisms of chronic otitis media

A

Pseudomonas aeruginosa

Staph aureus

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22
Q

What is chronic suppurative otitis media

A

Persistent drainage from the middle ear through a perforated tympanic membrane lasting >6-12 weeks

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23
Q

How does chronic suppurative otitis media present

A

Painless recurrent otorrhea that is odourless and mucoid/serous
Conductive hearing loss
May develop concurrent cholesteatoma

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24
Q

Management of chronic suppurative otitis media

A

Topical antibiotics and steroids

Consider tympanoplasty or graft insertion

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25
Q

What is otitis media with effusion (glue ear)

A

Chronic mucoid or serous effusion in the middle ear, in the absence of infection, lasting for >3 months

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26
Q

What is thought to cause otitis media with effusion

A

Eustachian tube dysfunction

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27
Q

Otoscopy findings of otitis media with effusion

A

Opaque/yellow TM

Air-fluid level behind TM

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28
Q

Management of otitis media with effusion

A

Tympanostomy tubes

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29
Q

Possible complications of chronic otitis media a) intra-temporal, b) extra-temporal

A

Intra-temporal complications of COM = vertigo (inflammation spreads to labyrinth + vestibular system), hearing loss (conductive due to ossicle/membrane damage, sensorineural due to cochlear inflammation), acute otitis externa (due to discharge irritating skin), facial weakness (erosion of middle ear bony canal exposes facial nerve, gets inflamed)
Extra-temporal complications = meningitis/subdural abscess/temporal lobe abscess (erodes through tegmen and expose dura), sigmoid sinus thrombosis (direct infective process or retrograde venous spread)

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30
Q

Possible complications of inner ear surgery

A

Infection
Bleeding
No improvement in hearing
Complete loss of hearing if inner ear damaged
Tinnitus
Vertigo
Facial nerve injury
Altered taste - chorda tympani nerve damange
Recurrence of disease and need for further surgery

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31
Q

What is cholesteatoma

A

A form of chronic otitis media in which keratinizing squamous epithelium grows from the tympanic membrane or the auditory canal into the middle ear mucosa. Deep retraction of the tympanic membrane, keratin accumulation (originates from skin cells that line the outer surface of the normal tympanic membrane – usually migrate out of ear canal with wax but if there is a deep retraction the keratin cant escape the pocket and develops into a keratin cyst

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32
Q

Potential complications of cholesteatoma

A

Middle ear invasion and ossicle erosion
Erosion of temporal bone –> extradural abscess, meningitis, sigmoid sinus thrombosis
Facial nerve paralysis

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33
Q

Clinical features of cholesteatoma

A

May be asymptomatic
Painless otorrhea
Scant, foul smelling discharge
Conductive hearing loss

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34
Q

Primary vs secondary causes of acquired cholesteatoma

A

Primary acquired - eutsachian tube dysfunction and formation of a retraction pocket
Secondary acquired - epithelium migrates inwards through a perforated tympanic membrane

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35
Q

Appearance of primary acquired cholesteatoma Vs appearance of congenital and secondary acquired cholesteatoma

A

Primary acquired: retraction pocket with squamous epithelium and debris that often appears as a brownish, irregular mass.
Congenital and secondary acquired: white or pearly mass behind the tympanic membrane

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36
Q

Imaging options for cholesteatomy

A

XR mastoid process
CT temporal bone
MRI is suspected intracranial extension

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37
Q

What is the definitive treatment of cholesteatoma

A

Mastoidectomy - open mastoid air cells, remove cholesteatoma from middle ear, reconstruct ossicles and tympanic membrane

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38
Q

What is a glomus jugulare

A

A vascular tumour in the middle ear. Usually benign but can be locally destructive

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39
Q

Symptoms of glomus jugulare

A

Hearing loss
Pulsatile tinnitus
Vertigo
Otorrhoea

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40
Q

Management of perichondritis

A

Gentle microsuction
Insert an aural wick
Continue topical drops
If systemically unwell then admit for IV antibiotics

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41
Q

Why are oral antibiotics not really used for treating perichondritis

A

The cartilage has a relatively poor blood supply

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42
Q

Causes of tympanic membrane perforation

A

Trauma - NAI, foreign body, ear irrigation
Infection - otitis media
Barotrauma - slap, diving, explosion
Iatrogenic - grommet insertion

43
Q

Signs/symptoms of tympanic membrane perforation

A

Whistling sounds when sneezing.blowing nose
Decreased hearing
Tendency to infection
Purulent discharge
Pain usually only if concurrent infection

44
Q

Management of tympanic membrane perforation

A

Water precautions - no swimming, ear plugs or vaseline on cotton balls when showering
Topical abx + steroid drops if infection also present (e.g. Sofradex, Gentisone)
If recurrent/persitent then consider myringoplasty

45
Q

Differentials for otorrhea

A 
Otitis externa
Chronic suppurative otitis media
Acute otitis media with TM perforation
CSF otorrhea
External or middle ear tumours
Granulomatous disease - granulomatosis with polyangitis (Wegeners)
Perichondritis 
Cholesteatoma
46
Q

Differentials for otorrhea + facial pain

A 
Malignant otitis externa
Chronic suppurative otitis media
Cholesteatoma
Malignancy
Ramsay Hunt Syndrome
Skull base fracture
47
Q

Neck lumps red flags

A 
Persistent sore throat
Hoarseness
Dysphagia 
Odynophagia
Horner's syndrome
SVC obstruction
Weight loss
Fevers
Night sweats
History of radiation to the neck
Rapidly enlarging painless mass
Stridor
48
Q

Differentials for a midline neck lump

A 
Thyroid nodule - adenoma, cyst, carcinoma
Goitre
Lipoma
Thyroglossal cyst
Dermoid cyst
Cervical lymphadenopathy
49
Q

What are the 2 main investigations use to assess neck lumps

A

USS

FNAC

50
Q

What is meant by a ‘functioning’ thyroid nodule

A

A thyroid nodule that is associated with hyperthyroidism

51
Q

When assessing for thyroid cancer, what do the ‘U’ and ‘TH’ grades refer to

A 
U = USS 
TH = FNAC

Both are graded 1-5

52
Q

Differentials for a solitary thyroid nodule

A

Benign;

  • Follicular adenoma
  • Hyperplastic nodule
  • Thyroid cyst

Malignant;

  • Papillary carcinoma
  • Follicular carcinoma
  • Medullary carcinoma
  • Anaplastic carcinoma
53
Q

Differentials for a generalised thyroid swelling/goitre

A

Physiological - Pregnancy, puberty
Multinodular goitre
Hashimotos thyroiditis
Graves disease

54
Q

Risk factors for head and neck SCC

A 
HPV
EBV (nasopharyngeal carcinoma)
Betel nut chewing (oropharyngeal)
Alcohol
Smoking
55
Q

What does a panendoscopy look at

A

The upper aerodigestive tract - pharynx, larynx, upper trachea and oesophagus

56
Q

Differentials for dysphonia/hoarseness

A 
Overuse (e.g. singers)
Acute laryngitis
Chronic laryngitis secondary to reflux 
Inhalers
Smoking
SCC of the larynx
Vocal cord paralysis 
Recurrent laryngeal nerve damage (e.g. in surgery)
57
Q

Differentials for vocal cord lesions

A

Vocal cord polyp - result from overuse
SCC of the larynx
GORD
Reinke’s oedema - common in female smokers, oedema and accumulation of gelatinous material

58
Q

Dysphonia - indications for urgent referral

A 
Hoarsness lasting >6 weeks
Oral swellings lasting >3 weeks
Dysphagia lasting >3 weeks
Unilateral nasal obstruction
Neck mass lasting >3 weeks
Cranial neuropathies
Orbital masses
59
Q

Neck lump - rubbery, painless lymphadenopathy, may be night sweats and splenomegaly

A

Lymphoma

60
Q

Neck lump - common in patients <20 years old, midline, moves upwards with tongue protrusion, may be painful if infected

A

Thyroglossal cyst

61
Q

Neck lump - common in older men, midline lump if large, gurgles on palpation. Typical symptoms are dysphagia, regurgitation, aspiration, chronic cough

A

Pharyngeal pouch

62
Q

Neck lump - congenital lymphatic lesion, classically on the left side of the neck, most present at birth/before age 2

A

Cystic hygroma

63
Q

Neck lump - oval, mobile, cystic mass between SCM and pharynx, usually presents in early adulthood

A

Branchial cyst

64
Q

Neck lump - pulsatile lateral neck mass that doesn’t move on swallowing

A

Carotid aneurysm

65
Q

What conditions/lumps are only really found in the anterior triangle of the neck

A

Salivary gland swelling
Carotid artery aneurysm
Laryngocele

66
Q

What conditions/lumps are only really found in the posterior triangle of the neck

A

Pharyngeal pouch

Cystic hygroma

67
Q

What happens to a) thyroid mass b) thyroglossal cyst if you get a patient to swallow

A

Both will rise

68
Q

What happens to a) thyroid mass b) thyroglossal cyst if you get a patient to stick their tongue out

A

a) thyroid mass won’t move

b) thyroglossal cyst will rise

69
Q

When is rhinosinusitis classed as chronic

A

If it’s >12 weeks without complete resolution of symptoms

70
Q

Risk factors for rhinosinusitis

A 
URTI
Polyps
Allergies
Granulomatosis with polyangitis
Septal deviation
71
Q

What are the main symptoms of rhinosinusitis

A 
Purulent rhinorrhea
Facial pain - worse when leaning forwards
Nasal blockage/congestion/obstruction
Reduced sense of smell
With or without polyps
72
Q

What kind of test can you do if someone has allergic rhinosinusitis

A

RAST testing - blood test for specific allergens

73
Q

Management of allergic rhinosinusitis

A

Avoid allergen triggers
Saline nasal irrigation
Nasal steroid spray (e.g. Flixonase)
Antihistamines

74
Q

Management for rhinosinusitis with polyps

A

Topical nasal steroid - drops if severe but usually spray

Functional endoscopic sinus surgery (FESS) to remove polyps

75
Q

Risks of FESS (functional endoscopic sinus surgery)

A 
Recurrence
Orbital damage
Damage to optic nerve
CSF leak if skull base breached, carries risk of meningitis
Synechiae (adhesions in nasal cavity)
Bleeding
Change in sense of smell
Damage to nasolacrimal duct can cause watery eye
Infection
76
Q

What do you advise patients regarding their nasal steroid spray after having polyp surgery

A

Keep on using it even if the symptoms are better.
It can be explained by thinking of the surgery as a method of opening up the sinus drainage & creating a route of access for the steroids.

77
Q

Antibiotic of choice if you suspect infected rhinosinusitis

A

Clarithromycin

78
Q

Nasal steroid sprays

A

Fluticasone (Flixonase)
Beclomethasone (Beconase)
Mometasone (Nasonex)

79
Q

Risk factors for nasal polyps

A

Chronic rhinosinusitis
Cystic fibrosis
Aspirin induced respiratory disease

80
Q

Clinical features/symptoms of nasal polyps

A 
Long history (years)
Bilateral nasal obstruction
Post nasal drip
Hyposmia/anosmia
Worse around allergens
No preceding symptoms
Rhinorrhea
No nasal sprays work
May have associated cheek pain
81
Q

Which vasculitis commonly affects the nose

A

Granulomatosis with polyangitis (Wegeners)

82
Q

Effects of granulomatosis with polyangitis on the nose

A

Inflammation of nasal mucosa
Large amounts of crusting
Can cause septal perforation and nasal dorsal collapse

83
Q

Causes of nasal septal deviation

A

Congenital
Infective
Inflammatory - GPA, sarcoidosis
Trauma

84
Q

Symptoms of septal deviation

A 
Difficulty breathing through one nostril
Nasal congestion
Snoring
Headaches
Facial pain
Epistaxis
85
Q

What test can be used to assess nasal mucocilliary function

A

Saccharine test

86
Q

A common cause of nasal obstruction in children

A

Large adenoids

87
Q

Two ways of visualising the nose properly

A

Anterior rhinoscopy

Nasal endoscopy

88
Q

What happens if patients use nasal decongestant too much

A

You get rebound congestion

89
Q

Most nose bleeds come from which anatomical region

A

Little’s area - located in the anterior nasal septum

90
Q

What is the name of the plexus of vessels in Little’s area

A

Kiesselbach’s plexus

91
Q

Which 3 blood vessels form Kiesselbach’s plexus

A

Anterior ethmoid artery
Sphenopalatine artery
Greater palatine artery

92
Q

Name of the plexus of vessels that causes posterior epistaxis

A

Woodruf’s plexus

93
Q

Causes of epistaxis

A 
Trauma
Inflammatory - Granulomatosis with polyangitis, sarcoidosis
Acute/chronic rhinosinusitis
Anticoagulation
Hypertension
Haematological disorder - ITP
Neoplasia of nasal cavity - SCC, adenocarcinoma, papilloma, juvenile angiofibroma
Iatrogenic - recent surgery
94
Q

Management of epistaxis

A

Naseptin ointment - for 1-2 weeks, caution peanut allergy
General advice regarding nose bleeds
Silver nitrate cautery

95
Q

What general advice can you give to patients about nose bleeds

A

Try not to blow your nose for a week
Don’t try and clean the node
Avoid hot baths and showers
Don’t drink/eat anything really hot for 72 hours
Try to avoid strenuous exercise for a week
Avoid picking the nose
Apply firm pressure for 15 minutes - if this fails to work then attend A+E

96
Q

Acute management of epistaxis lasting >15 minutes or that is profuse

A

ABCDE approach
IV access with cannula
PPE - gloves, eye shield, apron
Use headlight + Thuddicums speculum - if you can see the vessel cauterise it, if not then apply pressure and pack
Order FBC, coagulation profile, group and save
Admit to ENT ward
Anterior nasal packing - if continuing to bleed or spitting out blood then need posterior pack (often using foley catheter)
Posterior packs should stay in for 48hours, consider prophylactic abx
If continuing to bleed may need artery ligation

97
Q

What are the CENTOR criteria

A 
Used to see how likely it is that tonsillitis is caused by streptococcal bacteria
Absence of cough
Exudate
Nodes
Temp (38)
98
Q

Vertigo - recent viral infection, sudden onset, nausea and vomiting, hearing may be affected

A

Viral labyrinthitis

99
Q

Vertigo - recent viral infection, recurrent attacks lasting hours or days, no hearing loss

A

Vestibular neuronitis

100
Q

Vertigo - gradual onset, triggered by change in head position, each episode lasts 10-20 seconds

A

Benign paroxysmal positional vertigo (BPPV)

101
Q

Vertigo - associated with hearing loss, tinnitus, and a sensation of fullness/pressure in one or both ears

A

Meniere’s disease

102
Q

Vertigo - elderly patient, dizziness on extension of the neck

A

Vertebrobasilar ischaemia

103
Q

Vertigo - hearing loss, vertigo, tinnitus, absent corneal reflex, may also have NF type 2

A

Acoustic neuroma

Finals (32 decks)

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