Phase 4 Question Knowledge > ENT > Flashcards

ENT Flashcards

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1
Q

Weber’s test

A
  • 512Hz tuning fork placed in middle of forehead, ask which ear is loudest

Normal
- both equal

Sensorineural
- sound louder in normal ear

Conductive
- sound louder in affected ear

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2
Q

Rinne’s test

A
  • flat end of tuning fork on mastoid, when pt can no longer hear, move to 1cm away from ear, wait until not heard again

Normal
- pt can hear sound in air - AC>BC - Rinne’s positive

Abnormal
- Can’t hear sound in air - BC>AC - Rinne’s negative - conductive hearing loss

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3
Q

Audiometry interpretation

A

Normal - anything above 20db line

Sensorineural - both air and bone conduction reduced

Conductive - bone normal, air reduced

Mixed - both air and bone reduced, >15db difference between - air often worse than bone

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4
Q

Vertigo

A

sensation of movt between pt + environment - feel like they are spinning / room is spinning

mismatch of sensory inputs for balance / posture - vision / proprioception / vestibular issues

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5
Q

Vertigo causes

A

Peripheral - vestibular
- BPPV
- Meniere’s
- vestibular neuronitis
- labyrinthitis
- Ramsay-Hunt, trauma to vestibular nerve, acoustic neuroma, otosclerosis

Central - brainstem / cerebellum
- posterior circulation infarct
- tumour
- MS
- vestibular migraine

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6
Q

Benign paroxysmal positional vertigo (BPPV)

A

recurrent episodes of vertigo, triggered by head movt

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7
Q

BPPV Patho

A

Calcium carbonate crystals displaced into semicircular canals

disrupt endolymph flow, confusing vestibular system

head movt creates flow of endolymph - triggers vertigo

Causes - viral infection, head trauma, aging, no cause

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8
Q

BPPV Px

A
  • vertigo triggered by head movt
  • 10-20s episode
  • nausea
  • asym between attacks
  • episodes occur over several weeks, resolve, can recur later
  • no hearing loss / tinnitus
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9
Q

BPPV Dx

A

Dix-Hallpike manoeuvre

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10
Q

BPPV Mx

A

Epley manoeuvre

Brandt-Daroff exercises

Betahistine

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11
Q

Vestibular neuronitis

A

inflammation of vestibular nerve - usually viral

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12
Q

Vestibular neuronitis Px

A
  • acute onset vertigo
  • URTI hx
  • most severe at start (constant), then triggered by head movt
  • N+V
  • balance issues
  • horizontal nystagmus
  • no neuro sx
  • no tinnitus / hearing loss
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13
Q

Vestibular neuronitis Dx

A

Head impulse test

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14
Q

Vestibular neuronitis Mx

A

Buccal / IM prochlorperazine

Cyclizine, cinnarizine, promethazine

Maybe vestibular rehab therapy

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15
Q

Labyrinthitis

A

Inflammation of semicircular canals, vestibule, cochlear

Usually after URTI / bacterial infection (eg meningitis, OM)

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16
Q

Labyrinthitis Px

A
  • acute onset vertigo, exacerbated by movt
  • hearing loss - sensorineural
  • tinnitus
  • N+V
  • viral sx
  • gait - may fall to affected side
  • nystagmus
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17
Q

Labyrinthitis Dx

A

H/E
Head impulse test - abnormal

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18
Q

Labyrinthitis Mx

A
  • prochlorperazine
  • cyclizine, cinnarizine, promethazine
  • abx for bacterial cause
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19
Q

Meniere’s disease

A

Long term inner ear disorder

excessive endolymph in labyrinth - disrupt sensory signals

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20
Q

Meniere’s disease Px

A
  • unilateral, maybe bilateral after years
  • vertigo, 20mins-hrs episodes, in clusters
  • hearing loss - sensorineural
  • tinnitus
  • fullness in ear
  • drop attacks
  • imbalance
  • nystagmus in attack
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21
Q

Meniere’s disease Dx

A

clinical dx - by ENT

Audiology

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22
Q

Meniere’s disease Mx

A

Acute attacks
- prochlorperazine
- cyclizine, cinnarizine, promethazine

Prophylaxis
- betahistine
- vestibular rehab exercises

Inform DVLA - don’t drive until sx controlled

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23
Q

Otitis externa (OE)

A

inflammation of external ear canal

bacterial, fungal, eczema, contact dermatitis, trauma, swimming….

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24
Q

OE Px

A
  • ear pain, itch, discharge
  • red, swollen ear canal
  • lymphadenopathy
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25
OE Ix
Can do swab
26
OE Mx
- OTC acetic acid - otomize spray - neomycin + dex + acetic acid - oral abx (cipro / fluclox) - if immunocompromised, severe infection, spread beyond canal - ear wick - sponge/gauze with topical tx - fungal - clotrimazole
27
Malignant OE
- severe life-threatening form of OE - commonly pseudomonas - spreads to bones - osteomyelitis of temporal bone Px - OE and more severe - headache, pain, fever - purulent ear discharge - granulation tissue in ear canal - facial nerve palsy, hoarse voice, dysphagia Mx - admit under ENT - IV abx - CT / MRI head
28
Otitis media (OM)
infection of middle ear often after viral URTI also bacterial - strep pneumoniae....
29
OM Px
- ear pain - reduced hearing - URTI sx - balance issues, vertigo - discharge - if tympanic membrane perf - young pts - fever, vomiting, irritable, lethargy, poor feeding...
30
OM Ix
Otoscopy - bulging tympanic membrane (effusion), red, inflamed, discharge
31
OM Mx
- paeds - admit if high fever... - analgesia - amoxicillin 5d / erythromycin / clarithromycin - abx if sx not improving >4d, perf, co-morbidities.... - consider delayed prescription - eg after 3d if sx worsen
32
Mastoiditis
- infection in mastoid air spaces of temporal bone (spread from middle ear) Px - otalgia - behind ear - hx of OM - fever, unwell - swelling, red, tender over mastoid process Ix - CT Mx - IV abx
33
Presbycusis
- age-related sensorineural hearing loss - high pitches first Px - gradual, insidious hearing loss - speech difficult to hear - tinnitus Ix - audiometry - otoscopy - r/o ddx - tympanometry - bloods Mx - hearing aids - cochlear implants
34
Otosclerosis
- remodelling of base of stapes - becomes stiff - conductive hearing loss - <40yo Px - uni/bilateral - hearing loss - lower pitches affected more - tinnitus Ix - otoscopy - normal - Weber's / Rinne's - audiometry - tympanometry - ?CT Mx - hearing aids - surgical - stapedectomy / stapedotomy - replace whole / part of stapes with prosthesis
35
Eustachian tube dysfunction
- tube not working properly / blocked - eg URTI, allergies, smoking Px - reduced hearing - popping in ear - fullness - pain, tinnitus Ix - otoscopy - r/o OM Mx - Valsalva - decongestant nasal sprays - antihistamines, steroid nasal spray - Otovent - OTC - surgery if severe
36
Glue ear
- OM + effusion -> loss of hearing - eustachian tube blocked Px - reduction of hearing - peak 2yo Ix - otoscopy - dull tympanic membrane, air bubbles / fluid level - audiometry Mx - resolves alone <3mo - hearing aids - grommets - ?adenoidectomy
37
Sudden sensorineural hearing loss (SSNHL)
- unexplained hearing loss <72hrs - ENT emergency Ix - audiometry - MRI / CT head Mx - ENT referral - tx cause - idiopathic - steroids - oral / intra-tympanic
38
Conductive causes of acute hearing loss
- ear wax - infection - OM / OE - middle ear effusion - eustachian tube dysfunction - perforated tympanic membrane
39
Causes of SSNHL
- 90% idiopathic - infection - meningitis, HIV, mumps - Meniere's - ototoxic meds - MS - migraine - stroke - acoustic neuroma
40
Tinnitus
persistent ringing in ears
41
Tinnitus causes
- idiopathic - meniere's - otosclerosis - SSNHL - acoustic neuroma - hearing loss - drugs - ear wax - anaemia, DM, hypo/hyperthyroid, hyperlipidaemia - objective tinnitus - carotid artery stenosis, AS, AV malformation
42
Tinnitus Ix
- otoscopy - Rinne, Weber - Bloods - FBC, glucose, TSH, lipids - audiology - CT / MRI if needed
43
Tinnitus red flags
- unilateral - pulsatile - hyperacusis - hypersensitive to sounds - sudden hearing loss - vertigo / dizziness - visual / neuro sx - suicidal ideation from tinnitus
44
Tinnitus mx
- tx cause - hearing aids - sound therapy - CBT - tinnitus support groups
45
Ear wax
Px - conductive hearing loss - ear discomfort, feels full, pain - tinnitus Ix - otoscopy Mx - ear drops - olive oil / sodium bicarb - ear irrigation - microsuction - by ENT
46
Acoustic neuroma
- vestibular schwannoma - benign tumour of Schwann cells around vestibulocochlear nerve - 5% intracranial, 90% cerebellopontine angle tumours - Bilateral - NF2
47
Acoustic neuroma Px
- 40-60yo - CN8 - vertigo, unilateral sensorineural hearing loss, tinnitus - CN5 - absent corneal reflex - CN7 - facial palsy, forehead not spared
48
Acoustic neuroma Ix
- urgent ENT referral - audiometry - CT / MRI
49
Acoustic neuroma Mx
- surgery - radiotherapy - W+W
50
Cholesteatoma
- non-cancerous growth of squamous epithelium in skull base -> local destruction, infections Px - foul-smelling discharge - hearing loss - local invasion -> vertigo, facial nerve palsy, pain.... Ix - otoscopy - attic crust - CT / MRI Mx - ENT - surgery
51
Auricular haematoma
- blood in auricle after trauma - ENT assessment - incision + drainage - prevent cauliflower ear
52
Perforated tympanic membrane
- eg from infection, barotrauma, direct trauma - may have hearing loss Mx - 6-8wks to heal alone - avoid water - abx for perf after acute OM - myringoplasty - surgery to close perforation
53
Epistaxis
- nosebleed - anterior - Kiesselbach's plexus, in Little's area - posterior - deeper - risk of aspiration / airway compromise
54
Epistaxis causes
Local - nose picking, trauma - FB - colds, sinusitis - cocaine - topical drugs - steroids - vascular, tumours General - coag disorders, blood thinners - HTN, atherosclerosis - weather changes - excessive alcohol
55
Epistaxis Px
- unilateral - if bilateral - may indicate posterior - vomiting blood - if swallowed
56
Epistaxis Ix
FBC, coag, G+S
57
Epistaxis Mx
- A-E, cannulate if needed First aid - sit up, tilt head forwards - squeeze soft part of nostrils 10-15mins - spit out blood, don't swallow Next - nasal packing - nasal tampons / inflatable packs - cautery - silver nitrate sticks - only one side of septum After - naseptin cream - chlorhexidine + neomycin - 10d QDS Admission - if uncontrolled / posterior - ?balloon catheter - if unstable - ?splenopalatine artery ligation in theatre (for posterior)
58
Sinusitis
- inflammation of mucous membranes in paranasal sinuses - eg strep pneumoniae, H influenzae, rhinoviruses - RFs - nasal obstruction, recent local infection, swimming, diving, smoking
59
Sinusitis Px
- recent URTI - facial pain, frontal, worse bending forward - nasal discharge, nasal obstruction - loss of smell - fever Red flags - unilateral - persistent despite tx for 3mo - epistaxis
60
Sinusitis Ix
- in chronic (>12wks) - nasal endoscopy, CT
61
Sinusitis Mx
- analgesia - intranasal decongestants - intranasal corticosteroids - oral abx - if severe - phenoxymethylpenicillin, co-amox (if systemically unwell)
62
Allergic rhinitis
- inflammatory disorder of nose - to allergens - seasonal / perennial / occupational Px - sneezing, blocked nose, itchy - clear discharge, also at back of throat Mx - avoid allergen - antihistamines - oral / intranasal - intranasal corticosteroids - topical nasal decongestants
63
Nasal polyps
- growth of nasal mucosa - usually bilateral - unilateral = ?tumour associated with - chronic rhinitis, sinusitis - asthma - Samter's triad - CF - granulomatosis with polyangiitis - Kartagener's syndrome
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Nasal polyps px
- ?chronic rhinosinusitis - difficulty breathing through nose - snoring - nasal discharge - anosmia
65
Nasal polyps Ix
- examine with nasal speculum - nasal endoscopy
66
Nasal polyps Mx
- intranasal steroid drops / spray - surgery - intranasal polypectomy / endoscopic if further back
67
Nasal septal haematoma
- haematoma between septal cartilage and overlying perichondrium - cx of nasal trauma Px - nose blocked, pain, rhinorrhoea - bilateral, red swelling arising from nasal septum - boggy Mx - surgical drainage - IV abx Cx - septal necrosis -> saddle nose deformity
68
Tonsillitis
Inflammation in tonsils Causes - viral - most common - Group A strep - strep pyogenes - strep pneumonia...
69
Tonsillitis Px
- fever - sore throat - painful swallowing - lymphadenopathy - younger children - fever, poor oral intake, headache, vomiting, abdo pain
70
Tonsillitis Ix
- examine - red, inflamed, enlarged +/- exudates - examine ears - palpate for lymphadenopathy - rapid antigen for group A strep - if immunocompromised, old/young, severe sx - throat culture if antigen test negative
71
Centor criteria
Probability of bacterial infection >3 of the following - indicates abx - fever >38 - tonsillar exudates - absence of cough - tender anterior cervical lymph nodes
72
FeverPAIN score
score /5, gives % chance of strep infection 2-3 is 34-40%, 4-5 is 62-65% - fever in past 24hrs - pus - attend <3d of sx onset - inflamed tonsils - no cough / coryza
73
Tonsillitis Mx
- paracetamol, ibuprofen, Difflam - abx - penicillin V / clarithromycin - consider delayed prescription - admit if needed - eg unwell...
74
Quinsy
- peritonsillar abscess - bacterial infection with trapped pus - most commonly strep pyogenes (GAS), also S aureus, H influenzae
75
Quinsy Px
- sore throat - painful swallowing - fever, neck pain, referred ear pain - swollen lymph nodes - trismus - hot potato voice - swelling / erythema beside tonsils
76
Quinsy Mx
- ENT admission - incision / drainage - Co-amoxiclav - ?dex for inflammation
77
Tonsillectomy indications
- 7+ cases in 1yr - 5/yr for 2yrs - 3/yr for 3yrs - Recurrent tonsillar abscesses (2 episodes) - Enlarged tonsils causing - difficulty breathing, swallowing, snoring - Recurrent febrile convulsions secondary to tonsillitis
78
Tonsillectomy Cx
- pain, sore throat - damage to teeth - infection - risks of GA - post-tonsillectomy
79
Post-tonsillectomy bleeding Mx
- ENT registrar - IV access, send FBC, coag, G+S/C - keep child calm, analgesia - spit blood out - NBM for GA - IV fluids / bloods - hydrogen peroxide gargle - adrenaline soaked gauze
80
Thyroid surgery cx
- recurrent laryngeal nerve damage - bleeding - parathyroid gland damage -> hypocalcaemia
81
Laryngopharyngeal reflux
- inflammatory changes in larynx / hypopharynx due to GORD Px - sensation of lump in throat - midline, worse swallowing saliva (rather than food/drink) - hoarse voice, chronic cough, dysphagia, heartburn, sore throat Ix - clinical dx - if red flags, 2ww referral - persistent unilateral discomfort, dysphagia, odynophagia, persistent hoarseness Mx - diet chages - PPI, gaviscon
82
Ludwig's angina
- progressive cellulitis which invades floor of mouth, soft tissues of neck - from dental infections Px - neck swelling - dysphagia - fever Mx - mx airway - IV abx
83
Salivary gland tumours
80% parotid, 80% of these - pleomorphic adenomas, 80% superficial lobe
84
Pleomorphic adenoma
- benign mixed parotid tumour Px - slow growing painless lump, moveable - middle aged Mx - superficial parotidectomy
85
Warthin's tumour
- benign, adenolymphoma, 10% - males, middle aged - softer, more mobile, fluctuant
86
Salivary gland stones
- 80% submandibular Px - recurrent unilateral pain / swelling on eating Ix - XR - sialography - XR + contrast Mx - surgical removal
87
Neck lumps DDx
- Bony prominence - hyoid bone, cervical rib - lymphadenopathy - tumour - lipoma - goitre, thyroid nodules - salivary gland stones / infection - carotid body tumour - haematoma - thyroglossal cyst - branchial cyst - cystic hygroma - dermoid cyst - haemangioma - venous malformation
88
Neck lump H/E
Hx - SOCRATES - fever, wt loss, night sweats - FHx, smoking Exam - lump exam - lymph nodes - skin changes - focal chest sounds - cancer - clubbing - HSM
89
Neck lump 2ww referral criteria
- unexplained neck lump >45yo - persistent unexplained neck lump any age USS with growing lump: - <2wks if >25yo, <48hrs if <25yo
90
Neck lump Ix
- bloods - eg FBC, blood film, HIV, EBV ABs, TFTs, ANA, LDH (Hodgkin's) - USS, CT/MRI, nuclear medicine scan - Biopsy - fine needle / core, incision
91
Lymphadenopathy causes
Reactive - URTIs, dental infections, tonsillitis Infective - TB, HIV, IM Inflammatory - SLE, sarcoidosis Malignancy - lymphoma, leukaemia, mets, chest/abdo (supraclavicular)
92
Lymphadenopathy sx suggesting malignancy
unexplained persistently >3xm abnormal shape - oval hard / rubbery non-tender tethered / fixed to skin / underlying tissues night sweats, wt loss, fatigue, fever
93
Carotid body tumour
- glomus cells (grouped into paraganglia) just above carotid bifurcation - benign tumour of this Px - slow growing lump, near angle of mandible - painless, pulsatile - bruit - mobile side-to-side, not up/down - may compress nerves - eg Horner's Ix - imaging - splaying of internal / external carotids - lyre sign Mx - surgical removal
94
Pharyngeal pouch
- older men - posteromedial herniation between thyropharyngeus + cricopharyngeus muscles - Px - dysphagia, regurg, aspiration, cough
95
Head/neck cancer
usually SCC Locations - nasal cavity, paranasal sinuses, mouth, salivary glands, pharynx, larynx usually spread to lymph nodes first RFs - smoking, chewing tobacco, alcohol, HPV 16, EBV
96
Head/neck cancer Px
- lump in mouth / lip - unexplained mouth ulcer >3wks - erythroplakia, erythroleukoplakia - persistent neck lump - unexplained hoarse voice - unexplained thyroid lump - CN palsies, nasal obstruction, epistaxis, otalgia
97
Head/neck cancer referral criteria
Laryngeal - >45yo with persistent unexplained hoarseness / lump in neck Oral - unexplained mouth ulcer >3wks / lump in neck - lump on lip / oral cavity / red or red/white patch - dentist to see Thyroid - unexplained thyroid lump
98
Head/neck cancer Ix
- Scans, biopsy - TNM staging
99
Head/neck cancer Mx
- chemo / radio - surgery - MAbs
100
Glossitis
- inflammation of tongue - red, sore, swollen - papillae atrophy - smooth tongue Causes - iron deficiency - B12 anaemia - folate anaemia - coeliac - injury / irritants
101
Angioedema
fluid build up in tissues Causes - allergic reactions - ACEi - hereditary angioedema
102
Oral candidiasis
- oral thrush - white spots / patches on tongue / palate RFs - ICS - abx - DM, HIV, smoking Mx - miconazole gel - nystatin suspension - fluconazole tablets
103
Geographic tongue
- inflammatory - patches of tongue lose epithelium + papillae - irregular shapes - related to - stress, mental illness, psoriasis, atopy, diabetes - benign - topical steroids / antihistamines for sx control
104
Strawberry tongue
tongue swollen, red papillae enlarged + white Scarlet fever / Kawasaki's
105
Black hairy tongue
- defective exfoliation of keratin from tongue's surface, papillae elongate + look like hairs Causes - dehydration, poor oral hygiene, smoking, abx, HIV, IVDU, radiation Ix - swab to r/o candida Mx - hydrate - gently brush tongue - stop smoking
106
Leukoplakia
- white patches on tongue, inside of cheeks - precancerous to SCC Px - asym, irregular, slightly raised Ix - biopsy Mx - stop smoking, alcohol - potential surgical excision
107
Erythroplakia
Red patches in mouth, like leukoplakia
108
Lichen planus
- autoimmune - local chronic inflammation of skin Px - shiny, purplish, raised areas with white lines - bright red, sore - plaques - often only mouth, but can affect all mucosal membranes Mx - oral hygiene, stop smoking - topical steroids
109
Gingivitis
- inflammation of gums - acute necrotising ulcerative version - rapid onset RFs - plaque, smoking, diabetes, malnutrition, stress Px - swollen gums, bleeding, painful, bad breath Mx - hygiene, stop smoking, dental hygienist clean - chlorhexidine mouth wash - abx for acute necrotising ulcerative - metronidazole, amoxicillin
110
Gingival hyperplasia
abnormal growth of gums Causes - gingivitis - pregnancy - vit deficiency - scurvy - AML - meds - CCBs, phenytoin, ciclosporin
111
Aphthous ulcers
- small, painful ulcers of mucosa in mouth Causes - stress, trauma, foods - IBD, coeliac, Behcet, vit deficiency, HIV Mx - if unexplained >3wks, refer for 2ww - bonjela - difflam spray - lidocaine - more severe - hydrocortisone buccal tablets, betamethasone, beclometasone
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