2022/2023 Revision Session Dr Dalton Barham
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20222023 Revision Session Dr Dalton Barham 19012023 Ear, Nose, and Throat The Peer Teaching Society is not liable for false or misleading information Well aim to cover: Basic Facts about Basic ENT conditions Emergent facts about ENT
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01
2022/2023<br>
02
Revision Session
Dr Dalton Barham
19/01/2023 Ear, Nose, and Throat The Peer Teaching Society is not liable for false or misleading information…<br>
Dr Dalton Barham
19/01/2023 Ear, Nose, and Throat The Peer Teaching Society is not liable for false or misleading information…<br>
03
We'll aim to cover:
Basic Facts about Basic ENT conditions
Emergent facts about ENT Emergencies
Bits people commonly struggle with The Peer Teaching Society is not liable for false or misleading information… Aims and Objectives<br>
Basic Facts about Basic ENT conditions
Emergent facts about ENT Emergencies
Bits people commonly struggle with The Peer Teaching Society is not liable for false or misleading information… Aims and Objectives<br>
04
Welcome to the ENT ward! You are the new F1!
You've just been handed a bleep and a headlamp....and let loose!
Let's see some patients!<br>
You've just been handed a bleep and a headlamp....and let loose!
Let's see some patients!<br>
05
You are the F1 asked to see John, an 86M, on warfarin for AF. His INR is 2.0. His nose has been bleeding for 30 minutes.
What is most appropriate initial management?
Pinch the fleshy part of the nose and lean forward.
Bipolar nasal cautery
Insert a rapid rhino nasal tampon
Insert a foley catheter into the nose
Sphenopalatine artery ligation Epistaxis The Peer Teaching Society is not liable for false or misleading information…<br>
What is most appropriate initial management?
Pinch the fleshy part of the nose and lean forward.
Bipolar nasal cautery
Insert a rapid rhino nasal tampon
Insert a foley catheter into the nose
Sphenopalatine artery ligation Epistaxis The Peer Teaching Society is not liable for false or misleading information…<br>
06
Bleeding is usually unilateral and anterior
Posterior bleeds may come out of both nostrils. We worry about aspiration.
Approach these patients in an ABCDE manner
Naseptin Cream is great... What must you ask before prescribing? Epistaxis Facts The Peer Teaching Society is not liable for false or misleading information… Diagram from www.aliem.com Common
Stuff<br>
Posterior bleeds may come out of both nostrils. We worry about aspiration.
Approach these patients in an ABCDE manner
Naseptin Cream is great... What must you ask before prescribing? Epistaxis Facts The Peer Teaching Society is not liable for false or misleading information… Diagram from www.aliem.com Common
Stuff<br>
07
You see Tina, a 8 year old female next who is really struggling for breath, while listening in you can hear a stridorous sound.... you treat her in an ABCDE fashion and her breathing improves.
You perform fine nasal endoscopy and this is what you see..... Spot Diagnosis! The Peer Teaching Society is not liable for false or misleading information… Image from laryngopaedia.com<br>
You perform fine nasal endoscopy and this is what you see..... Spot Diagnosis! The Peer Teaching Society is not liable for false or misleading information… Image from laryngopaedia.com<br>
08
Inflammation of the upper airway.
Absolute emergency
Not that Common… thanks to which vaccine?
Beware the unvaccinated febrile child, struggling to breathe and drooling in exams.
Can you think of some specific management?
Stridor is a late sign! Epiglottitis/Supraglottitis facts The Peer Teaching Society is not liable for false or misleading information… Emergencies/Important Image from radiopaedia.org<br>
Absolute emergency
Not that Common… thanks to which vaccine?
Beware the unvaccinated febrile child, struggling to breathe and drooling in exams.
Can you think of some specific management?
Stridor is a late sign! Epiglottitis/Supraglottitis facts The Peer Teaching Society is not liable for false or misleading information… Emergencies/Important Image from radiopaedia.org<br>
09
Your Registrar Calls you and tells you to look at the scan. She bets you a £5 you can’t guess what systemic condition this patient has?
Kartagener’s
Neurofibromatosis 2
Neurofibromatosis 1
Bells Palsy
Multiple Endocrine Neoplasia 1
Multiple Endocrine Neoplasia 2 The Exception that proves the rule The Peer Teaching Society is not liable for false or misleading information…<br>
Kartagener’s
Neurofibromatosis 2
Neurofibromatosis 1
Bells Palsy
Multiple Endocrine Neoplasia 1
Multiple Endocrine Neoplasia 2 The Exception that proves the rule The Peer Teaching Society is not liable for false or misleading information…<br>
10
Tumour of the Schwann cells surrounding the vestibular nerve.
Benign
Occur at cerebellopontine angle
Presents with gradual:
SNHL, tinnitus, fullness, dizziness & facial nerve palsy.
Treated conservatively, or with surgery or radiotherapy. Vestibula Schwannoma = Acoustic Neuroma The Peer Teaching Society is not liable for false or misleading information…<br>
Benign
Occur at cerebellopontine angle
Presents with gradual:
SNHL, tinnitus, fullness, dizziness & facial nerve palsy.
Treated conservatively, or with surgery or radiotherapy. Vestibula Schwannoma = Acoustic Neuroma The Peer Teaching Society is not liable for false or misleading information…<br>
11
General Principle Beware the Unilateral in ENT<br>
12
Which of the following do you perform to diagnose benign paroxysmal positional vertigo in Margret?
1).Epley Manoeuvre
2).Dix-Halpike test
3).Rhine’s test
4).Barary’s Caloric manoeuvre
5).Barlow’s manoeuvre BPPV The Peer Teaching Society is not liable for false or misleading information… Common
Stuff Image from upliftingtoday.com<br>
1).Epley Manoeuvre
2).Dix-Halpike test
3).Rhine’s test
4).Barary’s Caloric manoeuvre
5).Barlow’s manoeuvre BPPV The Peer Teaching Society is not liable for false or misleading information… Common
Stuff Image from upliftingtoday.com<br>
13
BPPV is the most common cause of vertigo.
Otoconia disrupt normal endolymph flow (posterior canal)
It is a peripheral cause of vertigo.
Attacks are short (10-60s), and are commonly triggered by movement.
No hearing loss or tinnitus
Diagnosed with Dix-Hallpike, and treated with Epley’s manouver BPPV facts The Peer Teaching Society is not liable for false or misleading information… From bodywise.net.au<br>
Otoconia disrupt normal endolymph flow (posterior canal)
It is a peripheral cause of vertigo.
Attacks are short (10-60s), and are commonly triggered by movement.
No hearing loss or tinnitus
Diagnosed with Dix-Hallpike, and treated with Epley’s manouver BPPV facts The Peer Teaching Society is not liable for false or misleading information… From bodywise.net.au<br>
14
Next up is Tim, an 18 year old student with glandular fever. What specific advice do you enthusiastically give him?
1). Smoking is protective!
2). Don’t take amoxicillin!
3). Keep active and play contact sports!
4). Alcohol is okay, if you feel up to it!
5). This is viral, so you don’t need time off from university! Infectious Mononucleosis The Peer Teaching Society is not liable for false or misleading information… Entspecialist.sg Confusing!<br>
1). Smoking is protective!
2). Don’t take amoxicillin!
3). Keep active and play contact sports!
4). Alcohol is okay, if you feel up to it!
5). This is viral, so you don’t need time off from university! Infectious Mononucleosis The Peer Teaching Society is not liable for false or misleading information… Entspecialist.sg Confusing!<br>
15
Image from wikicommons IM is usually caused by Epstein Barr Virus.
Most people get it as a child, but those who get it later get it worse, 95% have it by adulthood.
Usually self limiting, and you should give sensible advice
Virus replicates in pharynx epithelial cells> then in B cells. CD8 cells attack the B lymphocytes and cause an increase in large atypical lymphocytes (look like monocytes) on a blood film. Infectious Mononucleosis facts The Peer Teaching Society is not liable for false or misleading information…<br>
Most people get it as a child, but those who get it later get it worse, 95% have it by adulthood.
Usually self limiting, and you should give sensible advice
Virus replicates in pharynx epithelial cells> then in B cells. CD8 cells attack the B lymphocytes and cause an increase in large atypical lymphocytes (look like monocytes) on a blood film. Infectious Mononucleosis facts The Peer Teaching Society is not liable for false or misleading information…<br>
16
The Peer Teaching Society is not liable for false or misleading information… Name the condition Hearing Loss
Vertigo
Tinnitus Confusing!<br>
Vertigo
Tinnitus Confusing!<br>
17
Meniere's/Labyrinthitis/Vestibular Neuronitis The Peer Teaching Society is not liable for false or misleading information… Confusing!<br>
18
Central VS Peripheral Vertigo Emergencies/Important The stroke F1 refers a patient to you. Jim is a 75 year old, hypertensive man with vertigo.
Which of the following is a worrying sign of central vertigo?
Saccades on the Head Impulse Test.
Jim recovers from his attacks quickly.
Vertigo comes on at night, when Jim rolls over in bed.
He’s struggling with coordination since this happened.
He’s just recovered from a sore throat.<br>
Which of the following is a worrying sign of central vertigo?
Saccades on the Head Impulse Test.
Jim recovers from his attacks quickly.
Vertigo comes on at night, when Jim rolls over in bed.
He’s struggling with coordination since this happened.
He’s just recovered from a sore throat.<br>
19
Peripheral=Vestibular system
E.g. Vestibular neuritis, Ramsey Hunt Syndrome.
Attacks, Positional, acute
Coordination intact Central = Brainstem or cerebellum
E.g. Posterior Stroke, vestibular migraine, tumour
Sustained, non-positional, gradual onset (except stroke)
Coordination impaired Central Vs Peripheral Vertigo Emergencies/Important What do you mean when you say vertigo?<br>
E.g. Vestibular neuritis, Ramsey Hunt Syndrome.
Attacks, Positional, acute
Coordination intact Central = Brainstem or cerebellum
E.g. Posterior Stroke, vestibular migraine, tumour
Sustained, non-positional, gradual onset (except stroke)
Coordination impaired Central Vs Peripheral Vertigo Emergencies/Important What do you mean when you say vertigo?<br>
20
Can you name 3 treatments for obstructive sleep apnoea? Obstructive Sleep Apnoea The Peer Teaching Society is not liable for false or misleading information… Image from www.nqsurgicaldentistry.com.au Common
Stuff<br>
Stuff<br>
21
What is it?
Collapse of the pharynx during sleep, resulting in apnoeic episodes, the patient is usually un aware
How do we diagnose it?
Epworth sleepiness scale (daytime sleepiness)
Sleep studies (home respiratory polygraphy is first line)
How do we manage it?
All OSA: Lifestyle modification
Moderate OSA: CPAP or Mandibular advancement device
Severe OSA: Surgical Intervention considered OSA facts The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
Collapse of the pharynx during sleep, resulting in apnoeic episodes, the patient is usually un aware
How do we diagnose it?
Epworth sleepiness scale (daytime sleepiness)
Sleep studies (home respiratory polygraphy is first line)
How do we manage it?
All OSA: Lifestyle modification
Moderate OSA: CPAP or Mandibular advancement device
Severe OSA: Surgical Intervention considered OSA facts The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
22
Image from Sydneyentclinic.com Arminda, a 56F with DM, presents with ear pain and discharge. She has already had 3/7 Amoxicillin PO. How should you treat initially? Otoscopy shown.
Topical Ciprofloxacin
Admit for IV Abx
Topical Gentamycin
PO Ciprofloxacin
Pope Wick While rounding, you get a call from a GP friend of yours… The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
Topical Ciprofloxacin
Admit for IV Abx
Topical Gentamycin
PO Ciprofloxacin
Pope Wick While rounding, you get a call from a GP friend of yours… The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
23
Mild: acetic acid drops
Moderate: Abx and steroid drops (such as Otomize, most are equally effective).
Oral antibiotics do not work for all but the mildest cases of AOE Inflammation of the EAC.
Most commonly bacterial, but may be Eczematous or fungal.
Pseudomonas Aeruginosa
Staph Aureus
Pain, erythema, discharge and conductive hearing loss. Acute Otitis Externa The Peer Teaching Society is not liable for false or misleading information…<br>
Moderate: Abx and steroid drops (such as Otomize, most are equally effective).
Oral antibiotics do not work for all but the mildest cases of AOE Inflammation of the EAC.
Most commonly bacterial, but may be Eczematous or fungal.
Pseudomonas Aeruginosa
Staph Aureus
Pain, erythema, discharge and conductive hearing loss. Acute Otitis Externa The Peer Teaching Society is not liable for false or misleading information…<br>
24
From ENTOPA.com What is the most common cause of Otitis Media?
HHV 8
Covid-19
Strep Pneumoniae
Staph Aureus
E. Coli You watch the SHO perform Nasal endoscopy, he highlights the below structure…. The Peer Teaching Society is not liable for false or misleading information…<br>
HHV 8
Covid-19
Strep Pneumoniae
Staph Aureus
E. Coli You watch the SHO perform Nasal endoscopy, he highlights the below structure…. The Peer Teaching Society is not liable for false or misleading information…<br>
25
Ear Pain
Fever
URTI symptoms
Hearing loss
More common in kids (short/flat ET)
Most cases resolve with analgesia, but you can give PO Abx if unwell or there are lots of comorbidities (Amoxicillin) Otitis Media The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
Fever
URTI symptoms
Hearing loss
More common in kids (short/flat ET)
Most cases resolve with analgesia, but you can give PO Abx if unwell or there are lots of comorbidities (Amoxicillin) Otitis Media The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
26
Mastoiditis Image from Entdocs.net Feared (But thankfully rare)
Complication of OM
Tender swelling
Erythema
Bogginess on palapation
Needs an urgent assessment by ENT to r/o or treat with IV ABx<br>
Complication of OM
Tender swelling
Erythema
Bogginess on palapation
Needs an urgent assessment by ENT to r/o or treat with IV ABx<br>
27
Image from Radiopaedia.org
Note the fluid in the mastoid air cells<br>
Note the fluid in the mastoid air cells<br>
28
Cholesteatoma Not related to Cholesterol or a tumour!
Build up of squamous epithelial cells behind the TM.
Negative pressure causes the TM to retract and epithelial cells then proliferate in the middle ear.
Build up damages the ossicles
=Hearing loss and discharge
Diagnose with a CT
Needs surgical removal. Confusing Stuff<br>
Build up of squamous epithelial cells behind the TM.
Negative pressure causes the TM to retract and epithelial cells then proliferate in the middle ear.
Build up damages the ossicles
=Hearing loss and discharge
Diagnose with a CT
Needs surgical removal. Confusing Stuff<br>
29
Types of Hearing Loss Sensorineural vs Conductive
Make sure you can come up with some differentials for each example.
Acute hearing loss typically needs ENT referral for audiogram Common and Confusing!<br>
Make sure you can come up with some differentials for each example.
Acute hearing loss typically needs ENT referral for audiogram Common and Confusing!<br>
30
Spot Diagnosis? The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
Stuff<br>
31
What is it?
Idiopathic LOWER motor neurone lesion of the facial nerve.
Differential:
Wide differential.
R/O UMNL
Ramsey Hunt is common in Exams
Treat: Prednisolone and Eye drops Bell’s Palsy The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
Idiopathic LOWER motor neurone lesion of the facial nerve.
Differential:
Wide differential.
R/O UMNL
Ramsey Hunt is common in Exams
Treat: Prednisolone and Eye drops Bell’s Palsy The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
32
Tonsillitis or Quinsy? The Peer Teaching Society is not liable for false or misleading information…<br>
33
Tonsillitis or Quinsy? The Peer Teaching Society is not liable for false or misleading information…<br>
34
Centor Criteria:
Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
>3 = 40-60 % chance of bacterial tonsilitis 95% of tonsilitis is viral
Manage this according to Centor score.
Where appropriate, give delayed prescriptions.
Pen V is first line Tonsillitis facts The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
Fever over 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
>3 = 40-60 % chance of bacterial tonsilitis 95% of tonsilitis is viral
Manage this according to Centor score.
Where appropriate, give delayed prescriptions.
Pen V is first line Tonsillitis facts The Peer Teaching Society is not liable for false or misleading information… Common
Stuff<br>
35
We’ve covered some common and complex topics.
Any questions?
Best Resources for ENT
ENTsho.com
Zerotofinals.com/surgery/ent/
Oxford handbook
Surgical Talk (Tutorial style)
Blackbourne’s Surgical Recall for facts
Anything in-depth/next level: Bailey and Love Conclusion The Peer Teaching Society is not liable for false or misleading information…<br>
Any questions?
Best Resources for ENT
ENTsho.com
Zerotofinals.com/surgery/ent/
Oxford handbook
Surgical Talk (Tutorial style)
Blackbourne’s Surgical Recall for facts
Anything in-depth/next level: Bailey and Love Conclusion The Peer Teaching Society is not liable for false or misleading information…<br>
36
Some things we haven’t covered (ENT IS BROAD) Sinusitis
Head and Neck Cancer
Front of neck access
Otitis Media With Effusion
Rare ENT conditions
Audiometry<br>
Head and Neck Cancer
Front of neck access
Otitis Media With Effusion
Rare ENT conditions
Audiometry<br>