1. ENT Questions for Applied Knowledge Test
Dr Azhar Siddiqui
GPST1 2009

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. Diagnosis of ENT Diseases
Quinsy :

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. Diagnosis of ENT Diseases
Otitis Externa :

21. 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

22. 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

23. 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

24. 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

25. Diagnosis of ENT Diseases
Otitis Media

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Diagnosis of Hearing Loss

34. 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

35. 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

36. 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

37. Thank you