Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

MENTI: 26909867 Ayesha Duhra ad1621@ic.ac.uk ENT Conditions MedEd Y3 Written Exam Lectures 2025SESSION STRUCTURE ENT Presentations: ENT Conditions: ✓ Dizziness ✓ BPPV ✓ Vertigo ✓ Meniere’s disease ✓ Nasal discharge ✓ Rhinosinusitis ✓ Epistaxis ✓ Thyroglossal cyst ✓ Tinnitus ✓ Hearing lossSESSION STRUCTURE Background Investigations Management Complications = Gold Standard = High Yield SBA 1 A 64-year-old female presents to her local GP explaining they have had several episodes where it feels like the ‘world is spinning’. She mentions that this happens 2-3 times a day and especially when turning over in bed. She says that these usually last 20 seconds and reports no over symptoms. What would be the next appropriate step that the GP can take? A. Betahistine B. Referral to balance specialist C. CT Head D. Epley manoeuvre E. Dix Hallpike manoeuvre Adapted from slide byAlistair Ovenell Dizziness + Vertigo Dizziness: Umbrella term for a range of different sensations Presyncope Hypotension Light-headedness Vertigo: Specific feeling of room spinning/ whirling Psychiatric disorders Disequilibrium (ataxia) Hyperventilation Adapted from slide byAlistair Ovenell Dizziness + Vertigo History: Examinations: - Nature of ‘dizziness’ - Neuro/ CN exams - Length of episodes - Recurrence? - HINTS examination* - Provoking events (e.g., on movement/ recent illness…) - Gait/ Balance - Associated symptoms: - Neuro deficits - Hearing changes - Gross hearing - Tinnitus - Headaches - SOB etc. - Special tests (e.g., Dix Hallpike) Adapted from slide byAlistair Ovenell HINTS Exam Purpose: Determine origin of acute vestibular syndrome (i.e. acute onsets of dizziness/ vertigo/ nystagmus/ N+V) Head Impulse Peripheral: Impaired VOR with corrective saccade Nystagmus Peripheral: Unidirectional + Horizontal + Fatiguable Test of Skew Peripheral: No vertical skew when covering/ uncovering eye If all 3 present highly likely peripheral. If not consider central cause for AVS. Adapted from slide byAlistair Ovenell Peripheral VS Central Central HINTS Peripheral HINTS ± neuro deficit ± hearing changes VERTIGO PERIPHERAL CENTRAL Posterior Vestibular BPPV Meniere’s Vestibular Other: Stroke/TIA Migraine Neuritis Ramsay Hunt, Neurological Episodic Episodic Days Episodic Medicine side deficits effects (e.g., Headache 10-20 secs Post viral Hours gentamicin/ Risk factors illness Photophobia Positional Ear fullness cisplatin), ±Abnormal ± Hearing Loss Vestibular MRI ±Aura Positive Dix + Tinnitus Sensorineural Hallpike hearing loss nerve trauma BPPV Definition: (benign paroxysmal positional vertigo) Brief recurrent periods of vertigo that are triggered by specific changes to the position of your head. Pathophysiology: - Disease of the inner ear - Displacement of calcium carbonate crystals from the utricle (where they normally reside) to the semi-circular canals BPPV Causes: - Old age - Trauma/ Ear surgery - Viral infection - Other conditions affecting the inner ear BPPV Signs and Symptoms: - Vertigo (head spinning) - Triggered by (certain) movement - ± Nausea - 10 – 20 seconds - Sudden onset Typical patient: - ≥ 55 years - “Head spinning” e.g., after lying down/ sitting up - (more common in female patients) BPPV Investigations: Dix-Hallpike manoeuvre (diagnostic) Positive test: (i.e. has BPPV) - Nystagmus (rotatory + fatigable) - Patient will feel symptoms BPPV Management: - Spontaneous resolution (weeks to months) - Epley manouvere / Semont - Brandt-Daroff exercises - According to NICE: drug treatment not usually helpful - Refer to specialist clinic if repeated clinic visits for manoeuvres fail to resolve symptoms/ atypical symptoms/ unable to perform manoeuvre BPPV Complications: - Recurrence (common) - Alternative diagnosis for recurrent/ persistent vertigo - Accidents (e.g., BPPV event when driving) - May experience nausea during repositioning manoeuvres - Can consider giving anti-emetic prior MENTI: 26909867 SBA 1 A 64-year-old female presents to her local GP explaining they have had several episodes where it feels like the ‘world is spinning’. She mentions that this happens 2-3 times a day and especially when turning over in bed. She says that these usually last 20 seconds and reports no over symptoms. What would be the next appropriate step that the GP can take? A. Betahistine B. Referral to balance specialist C. CT Head D. Epley manoeuvre E. Dix Hallpike manoeuvre SBA 1 A 64-year-old female presents to her local GP explaining they have had several episodes where it feels like the ‘world is spinning’. She mentions that this happens 2-3 times a day and especially when turning over in bed. She says that these usually last 20 seconds and reports no other symptoms. What would be the next appropriate step that the GP can take? A. Betahistine B. Referral to balance specialist C. CT Head D. Epley manoeuvre E. Dix Hallpike manoeuvre Ménière’s disease Definition: Excessive pressure and progressive dilation of the endolymphatic system leading to issues with hearing and balance. Pathophysiology: - Disease of the inner ear - Unknown cause Ménière’s disease Symptoms: - Episodes of (minutes to hours): - Recurrent vertigo (most prominent symptom) - Hearing loss* (sensorineural) - Tinnitus * - Ear fullness * - * Usually unilateral - Can become bilateral after years Signs: - Nystagmus - +ve Romberg’s Typical patient: - Middle-aged (but can be any age) Adapted from slide byAlistair Ovenell Ménière’s disease Clinical Examination Investigations Loss of low > high frequencies Romberg’s +ve Fukuda +ve Audiometry (Air = Bone conduction) DifficultyTandem walking Otoscopy Peripheral HINTS MRI Head Refer urgently if asymmetrical tinnitus/ hearing loss (to exclude acoustic neuroma) Sensorineural Rinne +Weber Ménière’s disease Management: Lifestyle modifications: - Decrease intake of - Salt - Caffeine Acute Attack: - Alcohol Prevention: - Nicotine - Rapid relief of severe N+V: Buccal/ IM prochlorperazine - Betahistine - Avoid specific triggers - Alleviation of N+V + vertigo: - Vestibular rehabilitation Prochlorperazine/ antihistamine - If no success -> ENT referral exercises - Inform DVLA + cease driving until satisfactory symptom control Ménière’s disease Complications: - Patients tend to resolve after 5– 10 years - Can be left with hearing loss - Psychological distress from symptoms SBA 2 A 55-year-old male presents to his GP practice with sudden hearing loss in their right ear which has persisted for the last 11 days. He describes a high-pitched ringing sound in the same ear that Started at the same time. On otoscopy no abnormalities were detected.The GP decided to perform Rinne andWeber’s test.They found: LHS: RHS: Rinne: Air conduction > Bone conduction Rinne:Air conduction > Bone conduction Weber: Localises in left ear Weber: Localises in left ear What would be the next appropriate step that the GP can take? A. Refer to nurse for ear syringing B. Urgent referral (ENT assessment + MRI) C. Reassure patient and discharge D. Routine referral to general ENT clinic E. Refer for audiology testing Adapted from slide byAlistair Ovenell Hearing Loss - Issue with conduction from auricles to ossicles 1) CONDUCTIVE Adapted from slide byAlistair Ovenell Hearing Loss - Issue with conduction from auricles to ossicles Tympanic membrane: Otitis 1) CONDUCTIVE Ear canal:Wax compaction, foreign body, tumour, otitis externaedia, glue ear, cholesteatoma, ruptured ear drum Adapted from slide byAlistair Ovenell Hearing Loss - Issue with conduction from auricles to ossicles 1) CONDUCTIVE Ear canal:Wax compaction, Tympanic membrane: Otitis foreign body, tumour, otitis externaedia, glue ear, cholesteatoma, ruptured ear drum - Issue with inner ear (cochlea) to brainstem 2) SENSORINEURAL Adapted from slide byAlistair Ovenell Hearing Loss - Issue with conduction from auricles to ossicles Ear canal:Wax compaction, T ympanic membrane: Otitis 1) CONDUCTIVE foreign body, tumour, otitis externa media, glue ear, cholesteatoma, ruptured ear drum - Issue with inner ear (cochlea) to brainstem 2) SENSORINEURAL Unilateral: MS, brainstem stroke, Bilateral:Age (presbycusis), Meniere’s, acoustic neuroma ototoxicity (e.g., aminoglycosides, tetracyclines, chemotherapy), noise = urgent MRI + ENT referral exposure Adapted from slide byAlistair Ovenell Hearing Loss Can clinically differentiate (AC) TIP: Conductive VS 512 Hz Sensorineural with Rinne & Weber test Toremember: 51Tune (128 Hz for vibration sensation UL/LL: 128 (BC) make your legs shake) Normal Sensorineural Conductive RINNE AC > BC AC > BC BC >AC WEBER Same in both ears Localises to Localises to affected unaffected ear earConductive Sensorineural Adapted from slide byAlistair Ovenell Right Conductive Hearing Loss: Adapted from slide byAlistair Ovenell Bilateral Sensorineural Hearing Loss: Adapted from slide byAlistair Ovenell Bilateral Sensorineural Hearing Loss: Meniere’s sensorineural worse at lower frequencies: SBA 2 MENTI: 26909867 A 55-year-old male presents to his GP practice with sudden hearing loss in their right ear which has persisted for the last 11 days. He describes a high-pitched ringing sound in the same ear that Started at the same time. On otoscopy no abnormalities were detected.The GP decided to perform Rinne andWeber’s test.They found: LHS: RHS: Rinne: Air conduction > Bone conduction Rinne:Air conduction > Bone conduction Weber: Localises in left ear Weber: Localises in left ear What would be the next appropriate step that the GP can take? A. Refer to nurse for ear syringing B. Urgent referral (ENT assessment + MRI) C. Reassure patient and discharge D. Routine referral to general ENT clinic E. Refer for audiology testing SBA 2 A 55-year-old male presents to his GP practice with sudden hearing loss in their right ear which has persisted for the last 11 days. He describes a high-pitched ringing sound in the same ear that Started at the same time. On otoscopy no abnormalities were detected.The GP decided to perform Rinne andWeber’s test.They found: LHS: RHS: Rinne: Air conduction > Bone conduction Rinne:Air conduction > Bone conduction Weber: Localises in left ear Weber: Localises in left ear What would be the next appropriate step that the GP can take? A. Refer to nurse for ear syringing B. Urgent referral (ENT assessment + MRI) Suspect acoustic neuroma!!! C. Reassure patient and discharge D. Routine referral to general ENT clinic E. Refer for audiology testing Thyroglossal Cyst Definition: Rare, benign congenital fluid filled cyst in the neck Pathophysiology/Aetiology: - Embryological structure ‘thyroglossal duct’ attaches tongue and thyroid - Usually duct atrophies but can persist in some and lead to cyst Thyroglossal Cyst Signs and Symptoms: Midline lump - Usually between thyroid and hyoid bone - Moves up with tongue protrusion + swallowing - Pain if infected (but otherwise painless) Typical Patient: - < 20 years old - Slow growing (but can be rapid growing following URTI) Thyroglossal Cyst Investigations: Examinations/ Clinical Bloods Special tests Investigations - History - Thyroid - Ultrasound function - Thyroid tests - ~ If indicated exam fine needle - ~ PTH/ serum aspirate Ca2+ Thyroglossal Cyst Investigations: Examinations/ Clinical Bloods Special tests Investigations Management: - ENT/ Head- History surgeon referra- Thyroidx is surgical - Ultrasound function tests - Thyroid - ~ If indicated exam fine needle - ~ PTCa2+erum aspirateThyroglossal Cyst Complications: - Infections Surgery is recommended to prevent - Enlargement these complications - Fistulae SBA 3 Emma is a 22-year-old that has been suffering from nasal congestion and a mucopurulent discharge for the past 15 days. She mentions that she has had some facial pain over the same period and a mild fever. When asked by the GP , Emma says that she has not seen any blood in the nasal discharge. Her GP has seen her prior to this and advised Emma to take paracetamol, try nasal douching and gave her 1 week of oral decongestants. What should be offered to the patient next? a) Referral to ENT for nasoendoscopy b) Prescribe course of co-amoxiclav c) Send bloods for CRP & ESR d) Offer topical glucocorticoid spray and doxycycline e) Send for routine sinus CT scan Slide byAlistair Ovenell Nasal Discharge Nasal discharge is a very common symptom often caused by common colds or allergies BUT if presenting with red flagsymptoms e.g persistent, unilateral & bloodstained – can be sign of serious illness Slide byAlistair Ovenell Nasal Discharge Consistency & colour Weight loss, night sweats, (bloody, mucopurulent, Ear Sx (discharge, pain & clear) lymphadenopathy hearing) Timingand exacerbating factors (allergens, Key features in history Medicines irritants…) Coryza, fever & illness Nasal obstruction and Atopy, asthma, allergic facial pain conjunctivitis &“itchy Sx” Slide byAlistair Ovenell Nasal Discharge Discharge type Mucopurulent Clear & watery Slide byAlistair Ovenell Nasal Discharge Clear & watery Hx of head injury / Elderly patient excluding Coryza ± fever Headache & unilateral head surgery neurology seriouspathology Consider CSF Consider migraine OR Consider senile (age- Consider common cold rhinorrhoea cluster headache related) rhinorrhoea History of allergy/atopy ± itchy eyes ± itchy nose Consider allergic rhinitis Slide byAlistair Ovenell Nasal Discharge Non-bloody discharge Mucopurulent Bloody (serosanguinous) discharge Septal perforation ± Obstruction ± anosmia ± crusting ± nasal collapse facial pain Nasal obstruction (unilateral) Consider granulomatosis < 7days > 7daysbut < 12 > 12 weeks with polyangiitis (formerly symptoms weeks ± fever symptoms Wegner’s) Consider sinus / nasopharyngeal Consider acute Consider acute Consider neoplasm rhinosinusitis rhinosinusitis chronic (viral) (bacterial) rhinosinusitis Child / psychiatric Consider nasal adult foreign body Rhinosinusitis Definition: Inflammation of nasal cavity (‘rhino-’) and sinuses (’-sinusitis) leading to symptoms. Aetiology: > 12 weeks of symptoms = Chronic rhinosinusitis VIRAL BACTERIAL More common Less common < 7 days 7 Days – 12 weeks Rhinoviruses, influenzaS. pneumoniae, H. influenzae, parainfluenza Moraxella catarhallis Rhinosinusitis Risk factors: Swimming/ Smoking Diving Nasal obstruction Recent local e.g., polyps/ infections Atopy deviated septum e.g., dental (chronic) extraction Rhinosinusitis Signs and Symptoms: Viral Bacterial Headache Same symptoms as viral Facial pain/ forehead pain • Pain especially when leaning forward/ Can have more intense facial pain coughing May see chronic productive cough (postnasal Nasal congestion/ obstruction drip) Mucopurulent nasal discharge (clear but can be coloured) Thicker and purulent especially if 2° infection Obstruction ±Anosmia ± Facial pain for <7 Obstruction ±Anosmia ± Facial pain for >7 days days/ <12 weeks Rhinosinusitis Signs and Symptoms: Other General Symptoms: o cough o productive - pale yellow sputum o fever/ feeling hot Rhinosinusitis Investigations: CLINICAL DIAGNOSIS May see: If red flags present, investigate w/ anterior rhinoscopy: o Mucosal oedema • Serosanguinous (bloody nasal discharge), o Inferior turbinate hypertrophy • Visual/ orbital symptoms e.g., orbital cellulitis • Focal neurology o Rhinorrhoea • Unilateral symptoms o For chronic: ± nasal polyps Rhinosinusitis Management: ACUTE CHRONIC - Paracetamol/ ibuprofen (for pyrexia/ pain) • Lifestyle • avoid triggers - For nasal congestion: • stop smoking - nasal saline irrigation (nasal • dental hygiene douching) • steaming - oral nasal decongestant e.g., phenylephrine for 1 wk - if >10 days consider Intranasal • Nasal douching glucocorticoid • Intranasal glucocorticoids (up to 3 - Antibiotics: months) - If >10 days/ high suspicion of bacterial cause 1st line: Referral to specialist if: phenoxymethylpenicillin 1. RED FLAG SYMPTOMS 2. Symptoms despite 3 months intranasal steroids - If systematically unwell (severe pain/ 3. Polyps complicating treatment fever/ high ESR or CRP OR high risk 4. Significant impact on QOL complications) = empirical co- Adapted from slides by Alistair Ovenell Rhinosinusitis Complications: Rhinosinusitis Orbital complications Intracranial complications Orbital / Cavernous preseptal Orbital abscess Meningitis sinus cellulitis thrombosis SBA 3 MENTI: 26909867 Emma is a 22-year-old that has been suffering from nasal congestion and a mucopurulent discharge for the past 15 days. She mentions that she has had some facial pain over the same period and a mild fever. When asked by the GP , Emma says that she has not seen any blood in the nasal discharge. Her GP has seen her prior to this and advised Emma to take paracetamol, try nasal douching and gave her 1 week of oral decongestants. What should be offered to the patient next? a) Referral to ENT for nasoendoscopy b) Prescribe course of co-amoxiclav c) Send bloods for CRP & ESR d) Offer topical glucocorticoid spray and doxycycline e) Send for routine sinus CT scan SBA 3 Emma is a 22-year-old that has been suffering from nasal congestion and a mucopurulent discharge for the past 15 days. She mentions that she has had some facial pain over the same period and a mild fever. When asked by the GP , Emma says that she has not seen any blood in the nasal discharge. Her GP has seen her prior to this and advised Emma to take paracetamol, try nasal douching and gave her 1 week of oral decongestants. What should be offered to the patient next? a) Referral to ENT for nasoendoscopy b) Prescribe course of co-amoxiclav c) Send bloods for CRP & ESR d) Offer topical glucocorticoid spray and doxycycline e) Send for routine sinus CT scan Slide byAlistair Ovenell Orbital & periorbital (pre-septal) celluitis Pre-septal (periorbital) Orbital Slide byAlistair Ovenell Orbital & periorbital (pre-septal) celluitis Pre-septal (periorbital) Orbital Rare BUT more common in children and may threaten vision!!! Assess with ABCDE, look for any sepsis / intracranial infection and assessfor eye compromise Eye red flags O/E: Nasoendoscopy to inspect mucosa + neurological 1. Diplopia (double vision) examination with cranial nerves 2. Pain eye of movement 3. Decreased visual acuity 4. Loss of colour vision discrimination IF red flags admit, urgent CT sinus & brain, broad- 5. Chemosis (oedema of sclera) spectrum antibiotics and keep NBM SBA 4 A 79-year-old male presents toA+E profusely bleeding from the nose.The doctors are informed that this has not stopped despite pinching and holding the nose for 20 minutes whilst leant forward.There are no signs that he is hypovalaemic. Observations are all normal however, on nasoendoscopy it is found that there are a number of foci bleeding covering a large area of the anterior mucosa. What is the next best step for this patient’s management? a) Tranexamic acid IV b) Cauterise with silver nitrate c) Sphenopalatine ligation in theatre d) Anterior nasal packing e) Continue observation Epistaxis Definition: Nosebleeds POSTERIOR BLEEDS Pathophysiology: ANTERIOR BLEEDS - Anterior bleeds (more common) (Little’s are - Posterior bleeds (blood in back of throat + continues despite anterior packing) Epistaxis Definition: Nosebleeds POSTERIOR BLEEDS Pathophysiology: ANTERIOR BLEEDS - Very common - Anterior bleeds (more common) - Bimod- <10 yearsribution (Little’s are - Poster- 45 – 65 yearsod in back of throat + continues despite anterior - Posterior more common in elderly (can lead to significant blood loss) Adapted from slide byAlistair Ovenell Epistaxis Less common Common aetiologies: Rarer aetiologies: aetiologies: • Idiopathic • Sinonasal neoplasm • Nose picking • Irritants (e.g., nasal O2) • Coagulopathy • Hereditary • Trauma (e.g., fracture) • Anticoagulants / haemorrhagic • Age-related changes antiplatelets telangiectasia (avoid (drying) packing) Take history for frequency, duration, red flags ABCDE approach + examine with thudicum (obstruction, serosanguinous discharge), anticoagulant medications speculum ± endoscopy Adapted from slide byAlistair Ovenell Epistaxis Less common Common aetiologies: Rarer aetiologies: aetiologies: • Idiopathic • Sinonasal neoplasm • Nose picking • Irritants (e.g., nasal O2) • Coagulopathy • Hereditary • Trauma (e.g., fracture) • Anticoagulants / haemorrhagic • Age-related changes antiplatelets telangiectasia (avoid (drying) packing) Take history for frequency, duration, red flags ABCDE approach + examine with thudicum (obstruction, serosanguinous discharge), anticoagulant medications speculum ± endoscopy Adapted from slide byAlistair Ovenell Epistaxis Management: 1 4 Anterior packing with nasal Assess with ABCDE approach ± manage and tampon orgauze in paraffin + hypovolaemia (IV access &crystalloids) refer to ENT for admission 5 2 Hippocratic method = lean forward + pinch Bilateral anterior packing ± anterior nares (nearLittle’s) + hold 20mins posterior packing (Foley catheter) 3 6 Examine with thudicum & cauterise anterior point bleedswith silver nitrate ifvisible (+ Unresolvingbleeds need arterial ligation in can tolerate + not bilateral) theatre (e.g ,sphenopalentine ligation) Epistaxis Complications: - Can lead to acute bacterial rhinosinusitis e.g., because of anterior packing disrupting normal sinus clearance - Recurrence SBA 4 MENTI: 26909867 A 79-year-old male presents toA+E profusely bleeding from the nose.The doctors are informed that this has not stopped despite pinching and holding the nose for 20 minutes whilst leant forward.There are no signs that he is hypovalaemic. Observations are all normal however, on nasoendoscopy it is found that there are a number of foci bleeding covering a large area of the anterior mucosa. What is the next best step for this patient’s management? a) Tranexamic acid IV b) Cauterise with silver nitrate c) Sphenopalatine ligation in theatre d) Anterior nasal packing e) Continue observation SBA 4 A 79-year-old male presents toA+E profusely bleeding from the nose.The doctors are informed that this has not stopped despite pinching and holding the nose for 20 minutes whilst leant forward.There are no signs that he is hypovalaemic. Observations are all normal however, on nasoendoscopy it is found that there are a number of foci bleeding covering a large area of the anterior mucosa. What is the next best step for this patient’s management? a) Tranexamic acid IV b) Cauterise with silver nitrate c) Sphenopalatine ligation in theatre d) Anterior nasal packing e) Continue observationThank You for Listening! Please scan the QR code to fill out the feedback form! If you have any questions, feel free to email: ad1621@ic.ac.uk