ENT Differential diagnosis and history taking notes PDF

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ENT Differential diagnosis and history taking notes Part I - Ear A. Ear discharge [Otorrhea] 1. Infective External ear: Otitis externa Middle ear: Chronic supportive OM (or late-stage acute OM) 2. CSF Trauma Skull base fracture 3. Blood Trauma Barotrauma - AOM = 3 months [CSOM = persistent, non-healing eardrum perforation] B. Hearing loss I. Paediatric Conditions Hereditary/ Congenital

Syndromic (20%)*

Non syndromic (80%)*

Environmental/ Others Acquired

Maternal

1. 2. 3. 4. 5. 6. 1. 2. 3. 1. 2. 3. 4. 1. 2.

Conductive Apert syndrome Crouzon syndrome Treacher Collin syndrome Pierre-Robin sequence Goldenhar syndrome Down’s syndrome Microtia Aural atresia Ossicular malformation Otitis media with effusion (OME) Chronic supparative otitis media Congenital cholesteatoma Wax impaction, trauma

Sensorineural* Pendred’s syndrome Usher’s syndrome Waardenburg’s syndrome

(Mondini vs Michelle malformation)

Cochlear dysplasia Auditory neuropathy Ototoxicity Metabolic e.g. hypothyroidism Autoimmune Trauma noise-induced/fractured tb Intrauterine infection - TORCH, syphilis Illnesses - Fetal alcohol syn, maternal DM, drugs

Perinatal insults - hypoxia, hyperbil, low BW, premat 2. Post-natal infections - meningitis, CSOM - OME causes = Congenital *Cleft palate, Down’s syndrome, craniofacial abnormality, mucociliary dysf, IgG deficiency+ Acquired [URTI, acute OM, nasal polyp, nasopharyngeal mass] Neonatal

1.

II. Adult Conditions Conductive External Auditory Canal

1. Wax 2. Foreign body 3. EAC stenosis 4. Otitis externa (Benign outgrowth cartilage on bone) 5. Exostosis 6. Osteoma/ Tumour Middle ear 1. Chronic supparative otitis media 2. OME -> think NPC! 3. Cholesteatoma 4. Otosclerosis 5. Haemotympanum 6. Tympanosclerosis 7. Ossicular Chain abnormality 8. Tumour - Otosclerosis: CDHL, Tinnitus, Vergio

Sensorinerual 1. Prebyscusis 2. Idiopathic sudden SNHL 3. Ototoxicity 4. Acoustic neuroma 5. Transverse fracture of temporal bone 6. Noise-induced SNHL 7. Ramsay-hunt syndrome 8. Syphilis 9. Meniere’s disease 10. Hypothyroidism

C. Vertigo [Central vs Peripheral vs Functional2] Peripheral Central* 1 1. BPPV 1. Central-Vestibular Vertigo3 Vestibule (Canalolithiasis/Capulolithiasis) (Brainstem/Cerebellum) 2. Meniere’s disease5 2. Vestibular migraine4 3. Perilymph fistula8 & Sup canal dehiscence 3. Medication e.g. phenytoin 4. Labyrinthitis 4. Metabolic - Thyroid 5. Ototoxicity - Anaemia 6. Trauma - Electrolyte 1. Vestibular neuritis6 (Post-URTI, Viral) Vestibular nerve - hypoglycaemia (Vascular compression of CN8) 2. Vestibular paroxysmia7 - Dix-Hallpike’s manoeuvre = Diagnostic for BPPV - Epley’s manoeuvre = Therapeutic for BPPV [posterior SCC] (Alternate cover test for skew deviation - HINTS test* = Head impulse (VOR fc) + Nystagmus (observe R&L gaze) + Test of skew - Romberg’s test = Test for proprioception (sensory ataxia) [Also sensitive for vestibular cause] (NOT cerebellar!) D. I. 1. 2. 3. 4. 5. 6.

Facial pain & Otalgia Facial pain Local diseases around facial region Skin infections (cellulitis, herpes zoster) Acute/Chronic sinusitis OR Paranasal sinus tumours Dental infection, Malocclusion Pain of nervous origins (trigeminal neuralgia, migraine) Referred pain (NPC -> CN V2 V3 [pinna spared if only V2])

Key = Differentiate Central from Peripheral causes [+ve HINTS tests 100% sensitive; 96% specific]

II. Otalgia (Ear pain) Ear External Ear

Referred Pain 1. NPC Otitis externa (skin congestion, eryth) V3 Furunculosis (infection of follicles) 2. Dental conditions Perichondritis +- Abscess 3. TMJ Pinna skin infection (e.g. erysipelas) 4. Salivary glands (e.g. parotitis) Fungal infection [colonization = painless] 5. Post-adenoidectomy Herpes Zoster infection* 6. Sino-nasal conditions CN9&10 Foreign body 1. Pharyngitis Tumour at EAC (SCC) 2. Tonsillitis Middle Ear Acute OM -> throbbing pain due to bulging TM 3. Quinsy (peritonsillar abscess) Active chronic supparative OM 4. Post-tonsillectomy Carcinoma of Middle ear 5. Tumour of tongue base/piriform fosssa CPA tumour 1. Cervical spondylosis Inner Ear C2&C3 - Vestibular schwannoma 2. Arthritis - Meningioma 3. Soft tissue injury - Ramsay Hunt syndrome type 2* = Reactivation of VZV at the geniculate nucleus [Triad of 1. Otalgia (excruciating pain) 2. Ipsilateral facial palsy 3. Vesicles (e.g. face ear)] - Referred pain from regions that share same sensory nervous supply with the ear: 1. 2. 3. 4. 5. 6. 7. 8. 1. 2. 3. 1.

To Pinna: 1. Lower: Great Auricular Nerve (C2,C3) 2. Upper Lat: Lesser Occipital Nerve (C2) 3. Upper Med: Auriculotemporal Nerve (V3) To EAM + Lateral TM 1. Ant TM: 2. Post TM:

Auriculotemporal Nerve (V3) Auricular br of Vagus Nerve

To Medial TM = Glossopharyngeal Nerve History taking: 1. Associated Ear symptoms x5 [Ear discharge, Hearing loss*, Tinnitus, Otalgia, Vertigo] 2. Fever (+ other constitutional Sx) + Neurological Sx 3. 1 cause = Otorrhoea vs 2 cause = Rhinorrhoea, post-nasal drip, sore throat, dysphagia, hoarseness [Otalgia] 4. Onset (sudden vs progressive)* 5. Involvement (unilateral vs bilateral)* 6. PMH (Systemic disease, NPC, previous RT, previous ear OT) 7. Medication e.g. antibiotics 8. Family Hx (Osteosclerosis and Cancer e.g. NPC) 9. Social Hx = Occupation, noise exposure* + Risk factors [Swimming (may expand impacted ear wax) +using Q-tip] 10.Paediatric patient (Antenatal + Perinatal/birth Hx = trauma, infection, neonatal jaundice, birth complication) Hearing rehabilitation (hearing aids vs implant) 1. Hearing aid [Design, Technology of amplification, Special features] -

Transmission of vibration by titanium implant on skull to cochlear

vs Bone anchored Hearing aid (Semi-implantable)

(1) Behind the ear (BTE) (2) In the ear/In the canal (ITC) (3) Completely in canal (CIC); Analog vs Digiatal; e.g. Feedback suppression Indications BAHA: 1. Hearing loss but conventional ACHA cannot be used/inserted (aural atresia) 2. Unmanageable feedback from ACHA 3.UNILATERAL severe to profound SNHL (NOT bil -> cross over hearing by BC)

4. NPC hearing rehabilitation

2. Cochlear implant (Place electrode along scala tympani of cochlear to stimulate auditory nerves) BEFORE 5 yo for speech dev (Neural plasticity)

Vertigo 1. 2. 3. 4. -

Supine lateral sleep on specific side [BPPV] Bright light [Vestibular migraine] URTI [Vestibular neuronitis] Ototoxic drugs (Aminogly,TB drug, Cispl) [Induced vestibulopathy] Loud sound/ear pressure [Superior canal dehiscence] Head injury [Fractured temporal bone]

Type [Pre-syncopy vs Vertigo] Timing Trigger Associated symptoms Meniere’s disease : Triad of (1) Vertigo (2) Tinnitus (3) Hearing loss +- Aural fullness Central : Diplopia, ataxia, paresis Vestibular migraine: Headache, sound/light hypersensitivity

Common conditions and treatment 1. -

1. 2. 3. 4. 5. 6.

[Particulate from otoconia dislodge & lodge in commonly posterior SCC]

BPPV = Most common cause of periph vertigo, due to Canalotithiasis or Cupulolithiasis [Densities adh to cupula of ampulla ONLY vertigo lasting for sec to min, provoked by postural change, usually self limiting (3 weeks), common recurrence Diagnosis by Dix-Hallpike’s manoeuvre [Lower px quickly from seated to side-lying, Then head rotated 45d to side tested: Nystagmus + vertigo] Treatment by (1) Reassurance (2) Epley’s manoeuvre *Therapeutic+ (3) Vestibular sedatives (4) Surgery x

Meniere’s disease = Idiopathic syndrome of endolympathic hydrops [malabs of endoly], so distortion of membranous labyrint Triad of (1) Tinnitis (2) Vertigo 20mins to 12 hr (3) (NS)Hearing loss +- Aural fullness [Fluctuating course] or aural fullnes Diagnosis (1) At least one audiometrically documented hearing loss (2) Two or more definite episodes of at least 20 mins (3) Tinnitis Treatment by (1) Rest (2) Antiemetics (3) Vestibular sedatives (4) Betahistine [inner ear vasodilation/relief pressure] (Acute (5) Diuretics (6) Low-salt diet (7) Meniett device (8) Intratympanic gentamicin injection (Chronic High spontaneous remission (50% in 2 years), some with poor balance and hearing; Surgical if me tx fails 3. Vestibular migraine = (1) ≥ 5 episodes(5 mins to 72 hrs) (2) Hx of migraine (3) ≥ migraine features in >50% of vertigo episode

2. -

4. Otitis externa (Swimmer’s ear) [RF: 1. Narrow ear canal 2. Impacted wax 3. Foreign b 4. Humidity 5. Abrasion 6. DM] - Pain (Worsened by pushing tragus -> Diagnostic)& itchiness + Otorrhoea + Temporary CDHL + Infected skin e.g. furunculo - Treatment by (1) Local cleansing (2) Keep dry (3) Local Abx eardrops (4) Systemic Abx (if furunculosis) 5. AOM = Inflammation of middle ear [AOM = Rapid onset of Sx < 3weeks course vs SubacuteOM 3w-3m vs Chronic >3m] - Pain + CDHL + Constitutive Sx + Otorrhoea (ONLY if eardrum is perforated) (Tiny incision created to relieve pressur - Treatment by (1) PO Abx 7-10 days + Sx relief (2) Myringotomy + Grommet insertion [if persist ≥3months bilat OME] (Paed 6. OME (in adult -> must consider NPC) = Presence of effusion ≥6w from initial AOM / Sterile ME effusion for ≥3month CSOM = Persistent, non-healing eardrum perforation [Tubotympanic/Central vs Atticoantral (Marginal) =unsafe] Recurrent otorrhoea + CD/Mixed HL (need Audiological assessment) COMPLICATIONS Extracranial: 1. CN7 palsy 2. Ossicular chain erosion 3. Labyrinthitis 4. Lateral SCC fistula 5. SC abscess 6. Subperiosteal absces Intracranial: 1. Extradural abscess 2. Subdural abscess 3. Brain abscess 4. Meningitis 5. Sigmoid sinus thrombophl 6. Otitic hydrocephalus Treatment [Safe] (1) Tympanoplasty to improve hearing (2) Otorrhoea prevention (Aural toilet + Abx drops + Ear ventilation) [Unsafe] (1) Mastoidectomy (Definitive surgical tx) -> Eradicate infection & Prevent Cx (2) Dx of any Cx 8. Cholesteatoma (congenital vs acquired) = Collection of squamous epithelium within middle ear and mastoid [Cx: locally invasive] - Treatment by Tympanotomy, Removal + Mastoidectomy [During embryogenesis vs from chronic infection or surgery] 9. Microtia = Failure of six hillocks to form a normal pinna (Smaller than normal auricle); Autogenous rib cartilage reconstruction or Prosthesis 10.Aural atresia = Hypoplasia or absence of EAC; (1) Surgical opening of atresia (2) Hearing aid (Bone conduction/anchored) 11.Otosclerosis = Focal osseous dysplasia of bone derived from otic capsule, abnormal bone absorption & deposition, with fibrous replacement & sclerosis - Treatment: Conservative, Hearing aid, Stapedectomy (AD incomplete penetrance, onset 20-30, 80% bilateral, 50% FHx) 12.Sudden sensorineural hearing loss = ≥ 30dB SNHL in >3 contiguous frequency occurred within 3 days [40-60, mostly idiopathic] T O l i l R f l ENT S id (S i i i ) 7. -

Part II - Nose A. Nasal obstruction Congenital Inflammation

Infection

Trauma Neoplasm

1. 2. 1. 2. 3. 4. 5. 1. 2. 3. 1. 2. 1. 2.

Choanal atresia Deviated nasal septum (DNS) Allergic rhinitis Nasal polyp [usu bilateral, from middle meatus] Antrochoanal polyp [usu unilateral, from maxillary antral mucosa, extrude via ostium into NP] Vasomotor rhinitis Rhinitis medicamentosa [due to abuse of topical nasal decongestants esp oxymetazoline (Afrin) ] Rhinitis [infective] Adenoiditis/ Adenoid hypertrophy Sinusitis Septal hematoma/ DNS Bone fracture Benign: Junvenile angiofibroma, inverted papilloma [risk to SCC] Malignant: SCC, adenocarcinoma, NPC

History taking: 1. 2. 3. 4. 5. 6.

Age [neonate -> Choanal atresia vs children -> AR, adenoid vs Adults -> AR, polyps, DNS vs elderly -> rhinitis, neoplasm] Unilteral vs Bilateral [Unilteral -> DNS, neoplasm] History of atopy Onset/timing Associated symptoms [Epistaxis + ear symptoms => think Neoplasm! Vs Only nasal obstruction + rhinnorhea] Trauma

B. Upper airway obstruction [Ddx by commonality] [History taking refer to medical notes]

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Neonate/Infants Laryngomalacia Congenital tumour/cyst (Vallecula, Laryngeal) Subglottic stenosis Subglottic haemangioma Vocal cord palsy (unilateral) Vocal cord palsy (bilateral) Vascular malformation Lymphatic malformation = Cystic hygroma Tracheal anomaly Laryngeal cleft Craniofacial abnormalities Choanal atresia

Toddlers/Children Croup Epiglottitis Retropharyngeal abscess Respiratory papillomatosis OSA Foreign body aspiration

Adults Tumour Infection (x4) Trauma Anaphylaxis OSA Foreign body aspiration

Common conditions and treatment 1. 2. 3. 4. 5. 6.

Infective rhinitis (Mostly caused by virus) Tx: Antihistamine, steroid nasal spray Allergic rhinitis = Type I hypersensitivity to specific allergens [Recurrent nasal obstruction, rhinorrhoea, sneezing, atopic Sx] Vasomotor rhinitis = ANS dysfunction presentation similar to allergic rhinitis without specific allergens (seasonal, perennia Rhinitis medicamentosa = Abuse of topical nasal decongestants esp Oxymetazoline (Afrin) maybe ulcerative Treatment by AVOID long-term use [discontinuation of decongestants lead to severe rebound of obstruction atrophic mucosa Nasal polyp = Edematous mucosa due to fluid retention in lamina propria, originate from middle meatus, usu Bilateral Antrochoanal polyp = Dumb-bell shape polyp (restricted), originate from maxillary antral mucosa extrudes through ostium into N

1. Laryngomalacia = Weak/crowded supraglottic framework, 80% of Infantile laryngeal stridor, within first 2 weeks of life - Inspiratory stridor worse on supine (alleviated by prone/sit/hyperextend neck) + Feeding difficulty [Normal cry, no cyanosis - Treatment by CO2 supraglottoplasty/ Laser aryepiglottoplasty (removal redundant tissue ) if Cx [OSAS, Cor pulmonale Chest deformity, Failure to thrive]; vs Monitor feeding + BW in Self-limiting (resolution by 12-18m) 2. Vallecula & laryngeal cyst = Stridor from D1 + signs of respiratory distress; Tx by URGENT intubation + cyst remova 3. Subglottic stenosis = Subglottic diameter Acute tonsillitis, Peritonsillar abscess (Quinsy), Infectious mononucleosis (Glandular fever), Ludwig angina, Acute epiglottitis Tumour -> Oropharngeal carcinoma (85% SCC, 50% @ tonsil, 25% tongue base) vs Parapharngeal space tumour (80% benign) Hypopharyngeal carcinoma (60% piriform fosssa 30% postcricroid 10% post pharyngeal wall)

Common conditions and treatment 1. Vocal cord nodules = Chronic Vocal trauma (OVERUSE) -> Localised edema -> Fibrosis -> Nodules (Breathy voice) - At mid-pt OR junction of ant/mid 1/3rd of vocal cord + Bilateral symmetrical - Treatment by Speech therapy ± Excision (Early stage nodules may regress) 2. Vocal polyps = Acute Vocal trauma (OVERUSE) -> Haemorrhage cyst -> Polyp (Breathy voice too) - Same common location + Unilateral - Treatment by Excision (to exclude Ca) (Low rough voice 3. Reinke’s edema = Fluid colletion in Reinke’s space (superficial l. propria) [Smoking, Laryngeal reflux, Hypothyroidism 4. Recurrent respiratory papillomatosis = HPV infection (type 6 &11) from in-utero transfer, birth contact, oral sex - Complication = Malignant change and tracheobronchial spread [May spontaneously regress upon puberty] - Treatment by Surgical debulking ± Adjuvant medical therapy [Hoarseness + Airway obstruction] 5. A. B. C. D. A. B. -

Ca Larynx (SCC) [Main risk factor = Smoking, M:F 10:1] [Hoarseness, Airway obstruction, Cervical LN met] Location: Glottic 59%, Supraglottic 40%, Subglottic 1% Investigation: Flexible endoscopy + Biopsy [Extent of T + Histological Dx] Upper panendoscopy (Broncho/esophagoscopy) [Risk of synchronous Ca 10%] USG neck ± FNAC [Extent of N as cervical lymphadenopathy] CT/MRI [Extent of TNM] Treatment: T1 T2 Early stage Ca Larynx (Stage 1,2) = Either Surgery (consider Partial) OR Radiotherapy as single modality therapy Partial Laryngectomy: (Endoscopic) microlaryngeal surgery, Hemilarygectomy, Supraglottic, supracricoid, near total RT has adv of better voice quality BUT disadv of ST： Odynophagia + Laryngeal edema & LT: Sarcoma, fibrosis, necrosis, hypo Advanced Ca Larynx (Stage 3,4) = Multi(Dual)modality with Surgery (Total laryngectomy) + Adj (chemo)RT Total Larynectomy: Remove entire larynx (thyroid + cricoid cartilage, ± hyoid bone & tracheal rings) ± neck dissectio Tracheal stump anastomosed to neck opening -> Permanent tracheostomy!

Inspection of larynx 1. 2. 3. -

Indirect Laryngoscopy -> LA, only visualisation of larynx by reflected image xxx Direct (rigid) Laryngoscopy [Indication: 1. Intubation 2. Foreign body removal] -> GA, diagnostic + therapeutic Rigid: Trans-oral [Microlaryngoscopy = Operation under microscopy -> e.g. CO2 laser] (Direct) Flexible (Fibreoptic) Laryngoscopy ± Stroboscopy (Slow motion) -> NA/LA [Commonly seen in OPD!] Fibreoptic: Trans-Nasal, less gag reflex, inferior image quality, limited light

Voice rehabilitation 1. 2. 3. 4.

Electrolarynx (Artificial):Voice restoration immediately, last 10yr minimal maintenance, easy to use vs Unnatural robotic voic Pneumatic voice (External assistant speech aid): better voice quality vs Need gd manual dexterity and co-ordination TES: Need greatest manual dexterity & co-ordination (Press thumb when speak to force air via prosthesis) +surgery, need regular change Esophageal speech: Very difficult to learn, delay speech acquisition (vs TES 2 week) due to blockag

Part IV - Others A. Trismus (Inability of mouth opening ‘locked jaw’) TMJ and Mandible 1. Systemic RA 2. TMJ fibrosis

3. Local arthritis from repeated trauma

Usu presents as Trigeminal neuralgia first

Muscles of mastication* Fibrosis from RT or OT Neoplasm - Primary [rhabdomyosarcoma] - Tumour invasion [NPC, Ca Tonsil] Inflammation (Spread from adj str) - Dental - Peritonsilar, Parapharyngeal

Neurological Trigeminal ganglion lesion Apical petrositis from acute OM

Tetanus (esp IVDU)

4. Mandibular condyle fracture 5. Malignant otitis externa with TMJ - P/E = Palpate TMJ + CN exam + Intraoral exam + Dental gap [Max distance between U&L incisors = Trismus if UMN lesion, frontalis sparing (e.g. stroke) 2. [Facial nucleus] -> LMN lesion (MS, stroke, tumour at pons) Temporal bone 1. Tumour (Internal acoustsic meatus, Cerebellopontine angle esp meningioma) 2. Fracture (Temporal bone fracture) Middle ear 1. AOM 2. CSOM (cholesteatoma) 3. Bell’s palsy (swollen nerve, neuropraxia) 4. Ramsay Hunt Syndrome (Herpes Zoster Oticus) 5. Tumour (Glomus, Carcinoma) Beyond stylomastoid foramen 1. Trauma (Blunt vs Penetrating) -> may affect one branch only 2. Neoplasm (Malignant parotid tumour, Met intraparotid LN from skinCa) 1. Facial nerve schwannoma/neurofibroma Others [Along the nerve] [By order of frequency] 2. Surgical injury 3. CNS demyelinating disease - Grading = House and Brackman Facial Paralysis Grading System [Grade I to VI – normal fc to total paralysis] C. Intraoral ulcer & mass White lesion Red lesion Pigmented Ulcerative Mass Pigemented nevi Infection/Stomatitis Traumatic Benign: 1. Leukoplakia (5% Ca risk) Lentigo Aphthous 2. Lichen planus (low Ca risk) Trauma Fibroma Lentigo maligna 3. Allergy Lipoma Candidiasis (creamy removable) Infective Melanoma 4. Linea alba (occlusal line) Immunological Ranula Neoplasm Erythroplakia/ Pre-malign (15%) Nevus of Ota 5. Leukoedema (intracelledema) Torus Smoker’s Melanosis 6. Papilloma (HPV) Malignancy/ SCC Malignant: Systemic disease (SLE/Reiter) Addison disease 7. Verrucous carcinomaSCC Minor salivary Peutz-Jeghers syn 8. SCC (low grade SCC,HPV) Vascular gland tumour (Hereditary haemorrhagic 9. Geographic tongue(welldemarked) telangiectasia) 10. Hairy tongue(markd acc keratin) - Leukoplaia = White patch firmly attached to oral mucosa cannot be rubbed off [smoking, alcohol, chronic friction, Candid - Lichen planus = White lines + skin pruritic papules on flexors [common T cell mediated AI, chronic inflam] Biopsy for any suspicious mass persists for over 3 weeks Imaging by OP...