ENT Questions for Applied Knowledge Test Dr Azhar Siddiqui GPST1 2009

Causes of Neck Lumps > Branchial Cyst > Ludwigs Angina > Parotitis > Thyroglossal Cyst > Dermoid Cyst > Parapharyngeal Abscess > Thyroid Swelling > Laryngocele > Pharyngeal pouch > Reactive lymphadenitis 45 yr old clarinet player presents with neck swelling that expands with forced expiration

Causes of Neck Lumps > Branchial Cyst > Ludwigs Angina > Parotitis > Thyroglossal Cyst > Dermoid Cyst > Parapharyngeal Abscess > Thyroid Swelling > Laryngocele > Pharyngeal pouch > Reactive lymphadenitis 45 yr old clarinet player presents with neck swelling that expands with forced expiration Laryngocele

Causes of Neck Lumps Laryngocele : Air filled sac associated with larynx becomes dilated High pressure in larynx pushes laryngeal mucosa through thyrohyoid membrane Found in wind instrument players Symptoms include: Neck mass Hoarseness Stridor Treatment usually surgical – dependant upon size

Causes of Neck Lumps > Branchial Cyst > Ludwigs Angina > Parotitis > Thyroglossal Cyst > Dermoid Cyst > Parapharyngeal Abscess > Thyroid Swelling > Laryngocele > Pharyngeal pouch > Reactive lymphadenitis 4 yr old boy presents with small midline neck swelling that moves on swallowing. It is painless, mobile, transilluminates and fluctuates

Causes of Neck Lumps > Branchial Cyst > Ludwigs Angina > Parotitis > Thyroglossal Cyst > Dermoid Cyst > Parapharyngeal Abscess > Thyroid Swelling > Laryngocele > Pharyngeal pouch > Reactive lymphadenitis 4 yr old boy presents with small midline neck swelling that moves on swallowing. It is painless, mobile, transilluminates and fluctuates Thyroglossal Cyst

Causes of Neck Lumps Thyroglossal Cyst : Arise from persistent epithelial thyroid duct formed with the descent of thyroid from foramen caecum to its final position in the front of the neck Occur at any age, but commonly between 15 – 30 yrs of age Presents with painless smooth cystic midline swelling in region of hyoid bone Cyst rises when the patient protrudes their tongue

Causes of Neck Lumps > Branchial Cyst > Ludwigs Angina > Parotitis > Thyroglossal Cyst > Dermoid Cyst > Parapharyngeal Abscess > Thyroid Swelling > Laryngocele > Pharyngeal pouch > Reactive lymphadenitis 30 yr old male presents with 5cm neck swelling anterior to the sterno-mastoid muscle on the left in its upper third. He states the swelling has been treated with antibiotics for infections in the past

Causes of Neck Lumps > Branchial Cyst > Ludwigs Angina > Parotitis > Thyroglossal Cyst > Dermoid Cyst > Parapharyngeal Abscess > Thyroid Swelling > Laryngocele > Pharyngeal pouch > Reactive lymphadenitis 30 yr old male presents with 5cm neck swelling anterior to the sterno-mastoid muscle on the left in its upper third. He states the swelling has been treated with antibiotics for infections in the past Branchial Cyst

Causes of Neck Lumps Branchial Cyst: Arises from embryonic remnants of second branchial cleft in the neck Most common in young adults Presents as smooth swelling in front of the anterior border of sternomastoid, at the junction of upper and middle thirds Treatment is by excision Treatment may need to be delayed if cyst is acutely infected, leading to branchial fistula

Diagnosis of ENT Diseases > Malignant Otitis Externa > Otitis Externa > Rhinocerebral mucormycosis > Quinsy > Lymphoma > Acute Otitis Media > Nasal Polyposis > Otitis media with glue ear > Rhinosinusitis > Glandular Fever A 25 yr old man presents with worsening sore throat. On examination he has trismus and unilateral enlargement of his right tonsil.

Diagnosis of ENT Diseases > Malignant Otitis Externa > Otitis Externa > Rhinocerebral mucormycosis > Quinsy > Lymphoma > Acute Otitis Media > Nasal Polyposis > Otitis media with glue ear > Rhinosinusitis > Glandular Fever A 25 yr old man presents with worsening sore throat. On examination he has trismus and unilateral enlargement of his right tonsil. Quinsy

Diagnosis of ENT Diseases Quinsy :

Diagnosis of ENT Diseases Quinsy : Aka peritonsillar abscess Complication of acute tonsillitis Usually due to streptococcal infection Collection of pus arising outside tonsil capsule. Symptoms include: sore throat, fever, halitosis, dysphagia, trismus, referred ear ache. Uvula may be very oedematous and displaced downwards and medially by the infected tonsil Treatment is with penicillin based antibiotics ( IV Benzylpen, or oral penicillin V, + IV hydrocortisone) Drainage of abscess by aspiration or incision Consider tonsillectomy 6 weeks post acute infection

Diagnosis of ENT Diseases > Malignant Otitis Externa > Otitis Externa > Rhinocerebral mucormycosis > Quinsy > Lymphoma > Acute Otitis Media > Nasal Polyposis > Otitis media with glue ear > Rhinosinusitis > Glandular Fever A 60 yr old woman noted to have unilateral tonsillar enlargement. She denies having sore throat

Diagnosis of ENT Diseases > Malignant Otitis Externa > Otitis Externa > Rhinocerebral mucormycosis > Quinsy > Lymphoma > Acute Otitis Media > Nasal Polyposis > Otitis media with glue ear > Rhinosinusitis > Glandular Fever A 60 yr old woman noted to have unilateral tonsillar enlargement. She denies having sore throat Lymphoma

Diagnosis of ENT Diseases Lymphoma : Varied presentation – mainly painless lump or swelling Not conclusive without histology Be wary of lymphoma for unilateral tonsillar enlargement, or unresolving / recurrent lymphadenopathy

Diagnosis of ENT Diseases > Malignant Otitis Externa > Otitis Externa > Rhinocerebral mucormycosis > Quinsy > Lymphoma > Acute Otitis Media > Nasal Polyposis > Otitis media with glue ear > Rhinosinusitis > Glandular Fever 30 year old woman complaining of otalgia and purulent discharge from right ear. External auditory meatus is swollen and inflammed and filled with white discharge

Diagnosis of ENT Diseases > Malignant Otitis Externa > Otitis Externa > Rhinocerebral mucormycosis > Quinsy > Lymphoma > Acute Otitis Media > Nasal Polyposis > Otitis media with glue ear > Rhinosinusitis > Glandular Fever 30 year old woman complaining of otalgia and purulent discharge from right ear. External auditory meatus is swollen and inflammed and filled with white discharge Otitis Externa

Diagnosis of ENT Diseases Otitis Externa :

Diagnosis of ENT Diseases Otitis Externa : Causes : Infection – bacteria (esp staph), fungi Allergy – eczema, contact allergy Iatrogenic – frequent ear syringing, trauma Swimmers more commonly affected Symptoms – irritation, discharge, pain, hearing loss Refer to hospital if : Malignant otitis externa Uncontrolled symptoms Previous history of complex ear problems Treatment: Antibiotic eardrops +/- oral fluclox Aural toilet If symptoms not resolving after 1/52, consider alternative drops +/- erythromycin

Diagnosis of ENT Diseases > Malignant Otitis Externa > Otitis Externa > Rhinocerebral mucormycosis > Quinsy > Lymphoma > Acute Otitis Media > Nasal Polyposis > Otitis media with glue ear > Rhinosinusitis > Glandular Fever A 60 yr old diabetic woman complains of severe otalgia. On examination, she has granulation tissue in ear

Diagnosis of ENT Diseases > Malignant Otitis Externa > Otitis Externa > Rhinocerebral mucormycosis > Quinsy > Lymphoma > Acute Otitis Media > Nasal Polyposis > Otitis media with glue ear > Rhinosinusitis > Glandular Fever A 60 yr old diabetic woman complains of severe otalgia. On examination, she has granulation tissue in ear Malignant Otitis Externa

Diagnosis of ENT Diseases Malignant Otitis Externa : Otitis externa that has spread to cause osteomyelitis of skull base Due to Pseudomonas aeruginosa and anaerobes Facial nerve involved in 50% of cases Granulation tissue - diagnostic indicator Ix – swabs for cultures, and CT/MRI to show invasion IV cipro or ceftazidine + metronidazole Surgical removal of granulated tissue may be needed

Diagnosis of ENT Diseases Otitis Media

Diagnosis of ENT Diseases Otitis Media : Inflammation of middle ear Classified as : Acute suppurative – caused by viral or bacterial infection. Causes pain and tenderness Chronic suppurative – persistent drainage from ear associated with TM perforation. Not usually painful due to chronic nature Serous/secretory – Middle ear effusion without TM perforation. Associated with dysfunction/obstruction of eustachian tube. Important cause of hearing loss in children. Antibiotics used in AOM – Amoxicillin Tympanoplasty in safe CSOM Aural toilet, antibiotics, exploration of the ear in unsafe CSOM

Diagnosis of Hearing Loss > Acoustic neuroma > Ototoxicity > Blast injury > Fracture base of skull > Petrous temporal bone fracture > CSOM > Wax impaction > Glue ear > Acute otitis media > Herpes Zoster Man treated with gentamicin for peritonitis for 10/7 presents with deafness

Diagnosis of Hearing Loss > Acoustic neuroma > Ototoxicity > Blast injury > Fracture base of skull > Petrous temporal bone fracture > CSOM > Wax impaction > Glue ear > Acute otitis media > Herpes Zoster Man treated with gentamicin for peritonitis for 10/7 presents with deafness Ototoxicity

Diagnosis of Hearing Loss Ototoxicity : Various drugs can damage inner ear and cause sensorineural deafness and tinnitus Ototoxic drugs : Aminoglycoside antibiotics Diuretics Antimalarials Cytotoxic drugs Analgesics – salicylates, ibuprofen Chemicals – alcohol, tobacco, marijuana

Diagnosis of Hearing Loss > Acoustic neuroma > Ototoxicity > Blast injury > Fracture base of skull > Petrous temporal bone fracture > CSOM > Wax impaction > Glue ear > Acute otitis media > Herpes Zoster A woman presents with deafness and corneal numbness. MRI showed widened internal auditory meatus

Diagnosis of Hearing Loss > Acoustic neuroma > Ototoxicity > Blast injury > Fracture base of skull > Petrous temporal bone fracture > CSOM > Wax impaction > Glue ear > Acute otitis media > Herpes Zoster A woman presents with deafness and corneal numbness. MRI showed widened internal auditory meatus Acoustic neuroma

Diagnosis of Hearing Loss Acoustic Neuroma : Benign slow growing neoplasm of the schwann cells of CN VIII Lesions located in internal auditory canal or cerebellopontine angle causing compression of vestibular nerve Clinical features Occipital pain on side of tumour CN VIII damage - Unilateral senssorineural deafness CN V damage – depression of corneal reflex, facial pain, numbness CN VII, IX, X, XI damage - rare Ix – audiometry, CT with contrast, MRI Treatment Conservative – watch and wait Radiosurgery – small to medium sized tumours Microsurgery – large neuromas

Diagnosis of Hearing Loss

Diagnosis of Hearing Loss > Acoustic neuroma > Ototoxicity > Blast injury > Fracture base of skull > Petrous temporal bone fracture > CSOM > Wax impaction > Glue ear > Acute otitis media > Herpes Zoster A 20 yr old male presents with head injury, bruising to right side of the head with hearing loss

Diagnosis of Hearing Loss > Acoustic neuroma > Ototoxicity > Blast injury > Fracture base of skull > Petrous temporal bone fracture > CSOM > Wax impaction > Glue ear > Acute otitis media > Herpes Zoster A 20 yr old male presents with head injury, bruising to right side of the head with hearing loss Petrous temporal bone fracture

Diagnosis of Hearing Loss Petrous temporal bone fracture : Head injury can cause hearing loss due to: Ossicular disruption Haemotympanum CSF otorrhoea CN VIII nerve palsy All these can occus in fractures petrous temporal bone Complaint of reduced hearing in one ear after trauma poits to haemotympanum Blood in external auditory meatus caused by basal skull fracture

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