Day 4 ENT Flashcards
A 5-year-old boy presents with his mother to the GP surgery with a 5-day history of right-sided otalgia and reduced hearing. On examination, he has a temperature of 38.5ºC and a heart rate of 120 bpm. There is swelling around his right ear and the ear appears to be displaced anteriorly. The canal appears normal however the tympanic membrane is red and bulging.
What is the most appropriate next step in management?
This child is unwell and has signs of mastoiditis. He should be referred urgently to ENT for admission and further assessment.
A 32-year-old lady presents with episodes of vertigo that come on at random. These ‘dizzy spells’ last for a few minutes to hours, and during this time she also experiences difficulty hearing and ringing in her ear. What is the most likely diagnosis?
In Meniere’s disease, vertigo occurs spontaneously. Episodes last for minutes to hours, and are accompanied by unilateral hearing loss and tinnitus
A 67-year-old man presents to you with difficulty hearing in his left ear, that has occurred over the past month. He states that recently he has found it difficult to follow telephone conversations and frequently has to increase the volume on his television. He is otherwise well, with no significant past medical history.
Examination reveals a normal oropharynx with no cervical lymphadenopathy. Rinnes test shows bone conduction greater than air conduction left side. Weber’s test lateralises to the left side. Otoscopy shows compacted earwax in the left external canal. Right tympanic membrane and canal appear normal.
Given the diagnosis, what is the appropriate first-line management?
Olive oil drops are a commonly used first-line treatment for impacted ear wax
A 22-year-old man complains of hearing problems. You perform an examination of his auditory system including Rinne’s and Weber’s test:
Rinne’s test:
- Left ear: bone conduction > air conduction
- Right ear: air conduction > bone conduction
Weber’s test: Lateralises to the left side
What do these tests imply?
Left conductive deafness
A 19-year-old woman presents with hearing problems for the past six months. She initially thought it was due to wax but her hearing has not improved after ear syringing. You perform an examination of her auditory system including Rinne’s and Weber’s test:
Rinne’s test:
Left ear: air conduction > bone conduction
Right ear: air conduction > bone conduction
Weber’s test:
Lateralises to the left side
What do these tests imply?
Right sensorineural deafness
A 48-year-old woman is admitted to the acute medical unit with sudden-onset dizziness, which she describes as the room spinning around. The dizziness is persistent and does not settle with rest. It is associated with severe nausea and vomiting. She also complains of hearing loss in her left ear. Other than a recent cough and coryza episode, she has been well with no past medical history.
On examination, Rinne’s test shows air conduction is greater than bone conduction in both ears. Weber’s test lateralises to her right ear. She has a normal range of eye movements with mild horizontal nystagmus on lateral gaze. Her coordination is intact.
What is the most likely diagnosis?
Viral labyrinthitis stereotypical history: recently developed an upper respiratory tract infection presents with vertigo and vomiting. Hearing is also affected. The symptoms came on suddenly
The parents of a 2-year-old child are concerned after he develops a lump in his neck. On examination there is a swelling in the subcutaneous tissue of the posterior triangle which transilluminates.
The correct answer is: Cystic hygroma
This is a classical description. Collection of dilated lymphatic sacs which are fluctuant and brilliantly transilluminable. Recurrence is common.
A 10-year-old child presents with enlarged tonsils that meet in the midline. Oropharyngeal examination confirms this finding and you also notice peticheal haemorrhages affecting the oropharynx. On systemic examination he is noted to have splenomegaly.
Infectious mononucleosis
A combination of pharyngitis and tonsillitis is often seen in glandular fever. Antibiotics containing penicillin may produce a rash when given in this situation, leading to a mistaken label of allergy.
A 54-year-old man presents with a 2-day history of sudden onset left-sided hearing loss. On further questioning, there is no history of trauma and he has otherwise been well in himself. He describes some tinnitus in his left ear alongside vertigo.
On examination, he has a moderate amount of ear wax bilaterally. He has no pinna, tragal or mastoid tenderness. The small amount of tympanic membrane you can see bilaterally appears normal. There is evident hearing loss on his left side.
Whilst performing Weber’s test, he localises the sound to his right side. Rinnes test is positive bilaterally (air conduction better than bone).
What is the most appropriate next management step?
Acute sensorineural hearing loss is an emergency and requires urgent referral to ENT for audiology assessment and brain MRI
A 59-year-old woman presents to the urgent care centre with a 1-day history of facial paralysis. She also complains of some mild ear pain over the last 2 days. On examination, she has a fixed half-smile on the left side of her face. She is unable to raise her left eyelid and has increased sensitivity to sound in her left ear. She denies dizziness or vertigo. The remainder of her cranial nerve examination is normal. ENT examination shows an erythematous left ear canal and vesicles over her soft palate.
Given the likely diagnosis, which of the following is the most appropriate treatment to initiate?
Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
A 64-year-old woman with a one week history of pain above and lateral to her left eye. On examination she is tender over that area.
Temporal arteritis
A 70-year-old inpatient on the geriatrics ward who is on warfarin complains of a nosebleed. He is not known to have any nasal pathology or coryzal symptoms.
What is the most likely anatomical origin of the epistaxis?
Little’s area in the nasal septum is a common site for epistaxis to originate because it is the confluence of 4 arteries
Little’s area in the anterior nasal septum is the site of Kiesselbach’s plexus, supplied by 4 arteries. Epistaxis therefore most commonly originates from the anterior of the nose.
A 51-year-old female with a 3 week history of recurrent attacks of vertigo, right ear tinnitus and the sensation of fullness in her right ear. On testing, there is noted to be right-sided hearing loss affecting low frequencies.
Meniere’s disease
Mr Zhang, a 56-year-old Mandarin-speaking patient, attends with his daughter, who translates for him. He has had reduced hearing and mild discomfort in his left ear for about two weeks which he attributes to an ear infection, and he is asking for antibiotics. He describes the hearing as being a bit muffled, and he hears clicking and popping at times, especially when swallowing. He says he hasn’t had a cold recently. He is a current smoker. On examination, the right tympanic membrane appears normal, and the left tympanic membrane looks dull and retracted. The oral cavity looks normal and there are no enlarged cervical lymph nodes.
How should you manage Mr Zhang?
What is the likely diagnosis?
Unilateral middle ear effusion in an adult can be a presenting symptom of nasopharyngeal cancer, especially in smokers and people of Chinese or South-East Asian origin.
Drug ototoxicity examples (3)
aminoglycosides (e.g. Gentamicin)
furosemide
aspirin
A 19-year-old man has had a sore throat for the past 5 days. Over the past 24 hours he has noticed increasing and severe throbbing pain in the region of his right tonsil. He is pyrexial and on examination is noted to have a swelling around the right tonsillar region
Quinsy
Unilateral swelling and fever is usually indicative of quinsy. Surgical drainage usually produces prompt resolution of symptoms.
Key features of acoustic neuroma
Features can be predicted by the affected cranial nerves
cranial nerve VIII: hearing loss, vertigo, tinnitus
cranial nerve V: absent corneal reflex
cranial nerve VII: facial palsy
Cause of low frequency hearing loss
Otoscleritis
What is the Eppley manouvre?
The Epley manoeuvre is used to treat BPPV (usually of the posterior canal) once it has been diagnosed by the previously mentioned Dix-Hallpike test.
A 64-year-old woman presents to her GP with a five-day history of feeling right earache and feeling generally unwell. In the last day she has developed painful blistering around the ear and her husband has told her that her facial movements appear different. Her past medical history includes hypertension, for which she takes amlodipine.
On examination, a vesicular rash is noted around the right ear and the patient has a visible right-sided facial palsy. Her observations are normal and she is apyrexial.
Given the likely diagnosis, which of the following is the most appropriate treatment plan?
Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
A 25-year-old lady presents with an swelling located at the anterior border of the sternocleidomastoid muscle. The swelling is intermittent and on examination it is soft and fluctuant.
Branchial cyst
Branchial cysts are remnants of the branchial cleft. They may become infected.
James, 40, has presented to his GP with weakness of the right side of his face, which examination confirms. James also reveals that he has experienced pain in his ear and otoscopy reveals the presence of vesicles on his tympanic membrane. Which of the following is the likely diagnosis?
Ramsay Hunt syndrome, type 2, is a condition where reactivation of pre-existing Varicella Zoster virus occurs in the geniculate ganglion.
A 62-year-old woman presents with a two week history of shooting pains across her left cheek. The pain is sometimes triggered by touching her face. She has no past medical history note
Trigeminal neuralgia
Characteristics of Otoscleritis (4)
- Otosclerosis is a genetic condition which is inherited in an autosomal dominant fashion.
- It causes irregular bony formation in the middle ear, causing dysfunction of the ossicular chain.
- This leads to a progressive conductive deafness, which typically presents in middle age.
- Tinnitus and vertigo may also be present, but are less common.
What does the audiogram show?
Normal hearing
A 33-year-old with coryzal symptoms presents with a one day history of vertigo and nausea. There is no hearing loss on examination
Vestibular neuronitis
How do you perform the eppley manouvre?
- The Epley manoeuvre typically follows on from a positive Dix-Hallpike test, so we will assume the patient is still positioned lying flat, with the head hanging over the end of the bed, turned 45º away from the midline.
- Turn the patient’s head 90º to the contralateral side, approximately 45º past the midline, still maintaining neck extension over the bed. Keep the patient in this position for 30 seconds.
- Whilst maintaining the position of the patient’s head, ask the patient to roll onto their shoulder (on the side their head is currently turned towards).
- Once the patient is on their side, rotate the patient’s head so that they are looking directly towards the floor. Maintain this position for 30 seconds to a minute.
- Sit the patient up sideways, whilst maintaining head rotation.
- Once the patient is sitting upright, the head can be re-aligned to the midline and the neck can be flexed so that the patient is facing downwards (chin to chest). Maintain this position for 30 seconds.
45-year-old female presents to the general practitioner with a two-week history of progressive paraesthesia of the fingers, toes and peri-oral area, associated with muscle cramps and spasms. She recently underwent a thyroidectomy for Graves’ disease but is otherwise well with no drug allergies.
Given the likely diagnosis, what is this patient’s ECG likely to show?
Complications of thyroid surgery - damage to parathyroid glands can result in hypocalcaemia
A 76-year-old-man was seen by one of your colleagues one month previously complaining of right ear otalgia and discharge. He was diagnosed with otitis externa and started on antibiotic ear drops.
He was next seen by an out of hours doctor one week ago who prescribed further antibiotic drops and tramadol. He has come to see you reporting that his symptoms are no better and the pain is becoming unbearable.
He has a past medical history of type-2 diabetes mellitus and hypertension. His regular medicines are metformin, gliclazide, ramipril and atorvastatin. He has no drug allergies. He has never smoked and rarely drinks alcohol.
On examination there is debris in the right ear canal but the tympanic membrane remains visible. There was no erythema of the pinna or mastoid swelling. Examination of the cranial nerves is normal.
Non-resolving otitis externa with worsening pain should be referred urgently to ENT
Long courses of intravenous antibiotics are needed and urgent ENT assessment is required.
A 33-year-old male presents to the GP complaining of a 4 month history persistent nasal discharge on his left hand side and facial pressure which is worse on bending forward. He often finds he has to breath through his mouth due to his nose being blocked. He has a past medical history of asthma and is a smoker with a 5 pack-year history.
What is the most appropriate management?
Unilateral symptoms are a red flag for patients with chronic rhinosinusitis
A 54-year-old woman presents with a neck swelling. She is systemically well apart from some recent weight loss. On examination she is noted to have a midline, non-tender neck swelling which moves upwards when she swallows.
Goitre
Patients with a goitre are often euthyroid or have minor symptoms. A thyroglossal cyst would be unusual at this age - they typically present in patients < 20 years old
A 78-year-old man complains of difficultly following conversations. His wife says he has the TV turned up too loud. Audiometry shows sensorineural hearing loss at the higher frequencies.
The correct answer is: Presbycusis
- Presbycusis describes age-related sensorineural hearing loss.
- Patients may describe difficulty following conversations
- Audiometry shows bilateral high-frequency hearing loss
A 62-year-old male presents with right ear pain and a longstanding purulent discharge from his right ear. On examination, you notice he has a facial nerve palsy.
Which of the following is the biggest risk factor for malignant otitis externa?
Malignant otitis externa is most common in patients with diabetes
A 78-year-old man is brought to a same-day emergency appointment by his wife. He had a dental extraction 5 days previously but overnight has developed worsening pain and a new fever. He is usually fit and well.
On assessment he is febrile with a temperature of 38.3ºC and a heart rate of 92 bpm but other parameters are normal. He has a tender swelling to the left submandibular region around the site of his dental extraction. He has mild trismus. His tongue is slightly displaced upwards and he is unable to protrude it. He has no stridor or respiratory distress.
What is the diagnosis?
Ludwig’s Angina, a rare infection of the floor of the mouth and soft tissues of the neck.
This is most commonly odontogenic but may also result from any form of soft tissue neck infection.
A 28-year-old Bangladeshi woman presents with a three day history of sweats, headache, lethargy and muscle aches. On examination she has bilateral tender swellings in the submandibular region.
Reactive lymph nodes
By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness
A 27-year-old male presents to the GP with intense left-sided ear pain which he has had for 24 hours. On examination, you see that the left ear is protruding forward, with a tender, boggy mass behind the ear. The tympanic membrane is bulging and erythematous. He is tachycardic and his temperature is 37.9 ºC.
Urgent treatment of this condition is necessary to prevent which complication?
Mastoiditis is a medical emergency due to the potential risk of meningitis
A 67-year-old gentleman comes in to your practice complaining of ‘dizziness’. He has a past medical history of hypertension, hypercholesterolaemia and hay fever. He is an ex-smoker with a forty pack-year history.
On closer questioning, he describes a sudden onset of a sensation at 9am this morning - ‘like the room is spinning’ - accompanied by nausea but no vomiting. The dizziness has persisted and is constant.
On examination he looks well, blood pressure 170/120 mmHg, with other observations in normal range. Cardiac, respiratory and ENT examination is unremarkable. On neurological examination he has normal power, tone, sensation and reflexes throughout both upper and lower limbs bilaterally. There is notable nystagmus on cranial nerve testing. There is also mild past pointing and dysdiadochokinesis.
This gentleman has a history suggestive of vascular disease, and has presented with acute onset of symptoms suggesting a posterior stroke
Jamie is a 13-year-old girl who presents to her general practitioner complaining of right ear pain over the last three days, with slightly worse hearing over this time. She also complained of fluid leaking from her ear this morning. Jamie’s past medical history includes recurrent otitis media as a child (approximately two episodes per year until the age of 5), and had grommets inserted once at age 4.
On examination, Jamie’s blood pressure is 120/80mmHg, heart rate 85/min and temperature 37.4ºC. On otoscopy, the right external auditory canal appears swollen and erythematous. The tympanic membrane is slightly erythematous with no effusion is present. There is no pain on mastoid palpation, however when the GP pulls on the right tragus there is significant tenderness.
Which of the following is the most likely diagnosis?
Otitis externa: pain on palpation of the tragus, itching, discharge and hearing loss
The answer is otitis externa. Classical symptoms of otitis externa include pain on palpation of the tragus, itching, discharge and hearing loss
You diagnose a right-sided sudden sensorineural hearing loss (SSNHL) in a normally fit and well 38-year-old woman who has come to see you in your GP clinic. She developed her symptoms over a few hours yesterday and now can not hear at all through her right ear. Her examination shows no obvious external or middle ear causes.
What is your next step?
Acute sensorineural hearing loss is an emergency and requires urgent referral to ENT for audiology assessment and brain MRI
A 50-year-old man presents with right-sided ear pain and facial weakness. He had flu-like symptoms of fever and headache for three days before the rash appeared.
On examination, there is a right-sided facial nerve palsy. A vesicular rash is seen on otoscopy.
How should this patient be managed?
What is the diagnosis?
Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
herpes zoster oticus
A 25-year-old male has come to the emergency department after sustaining an injury in a rugby game earlier that morning. When he was tackled and went to ground, another player’s boot impacted his left ear. He did not lose consciousness and only had some ear pain immediately after. In the ensuing minutes the pain worsened and he noticed a persistent ringing. When he felt his ear it was tender and swollen, with other players telling him it looked very red and puffy.
On examination, the patient does not exhibit any neurological deficit or pain other than in his left ear. The ear is ecchymotic and swollen with loss of normal anatomy to the anterosuperior pinna.
What is the diagnosis?
What is the most appropriate next step?
Auricular haematomas are common in rugby players and wrestlers. Prompt treatment is important to avoid the formation of ‘cauliflower ear’.
Auricular haematomas need same day assessment by ENT
Auricular haematomas occur after direct trauma to the ear and is due to a build up of blood between the cartilage and perichondrium.
This can restrict blood supply and lead to necrosis of the connective tissue. ENT must therefore assess the patient quickly to decide how to manage it. Treatment is usually incision and drainage +/- a draining wick depending on the size.
A 61-year-old woman with a history of cardiac problems develops hearing loss after a prolonged admission in hospital. Drug toxicity is suspected.
Furisemide Toxicity
What is vestibular neuronitis?
Vestibular neuronitis is a cause of vertigo that often develops following a viral infection.
Features
- recurrent vertigo attacks lasting hours or days
- nausea and vomiting may be present
- horizontal nystagmus is usually present
- no hearing loss or tinnitus
A 40-year-old female attends your practice complaining of a history of sudden episodes of dizziness over the last few weeks. The episodes can last several hours and then improve for a few days before recurring again. She is worried about ‘ear cancer’ as her mother had suffered from this but she is unsure of any further information.
On further questioning, she admits the attacks also cause a ‘pressure’ in her ears, and, at times, she hears buzzing noises in both ears. She has no other past medical history. She is, however, a smoker of 20 pack years.
Meniere’s disease
BPPV usually lasts a few seconds and is typically positional. It is not generally associated with tinnitus.
In this case, the most likely diagnosis is Meniere’s disease.
Acoustic neuromas tend to present more insidiously with hearing loss and symptoms are generally unilateral. Vertigo is an uncommon symptom, although not entirely impossible.
A 23-year-old man presents to his GP with a swollen pinna of the left ear.
On examination, his neurological examination is completely normal. However, the upper half of the left pinna is hot, red, swollen and exquisitely tender to touch. His observations are normal.
What is the most appropriate course of action?
Auricular haematomas need same day assessment by ENT
A 64-year-old woman presents to the GP with worsening hearing loss. The GP performs Weber’s test and Rinne’s test.
Weber’s test - Sound heard loudest in the left ear
Rinne’s test right ear - Air sound greater than bone
Rinne’s test left ear - Bone sound greater than air
In this case, the results test indicate that there is a conductive hearing loss in the left ear.
Exostosis affecting the left ear
A 35-year-old woman presents to her GP with hearing loss which has slowly progressed over the last year. She also reports tinnitus that has worsened over the same time period. She is otherwise well and has no significant medical history. Her father also suffered from hearing loss at a young age.
Her neurological examination reveals mild bilateral conductive hearing loss but is otherwise normal. On inspection, the tympanic membrane appears normal.
What is the likely cause of this patient’s symptoms?
This presentation (slowly progressive bilateral conductive hearing loss in a young patient with a positive family history) is most consistent with otosclerosis.
Otosclerosis is an autosomal dominant cause of deafness affecting young adults
A 32-year-old woman presents with a long history of chronic ear infections. She complains of an offensive discharge from her right ear with associated hearing loss for months. She has had severe vertigo for the last 48 hours.
What is the most likely diagnosis?
The past medical history of chronic ear infections and offensive discharge are suggestive of cholesteatoma. A large cholesteatoma can invade the inner ear resulting in sensorineural hearing loss and vertigo, as seen in this case.
You see a 3-year-old boy as a follow-up appointment. Two weeks ago he presented with left-sided otalgia associated with a purulent discharge. You prescribed amoxicillin and arranged to see him today. His mum reports that he is much better and says she has managed to keep the ear dry. On examination of the left side a perforation of the tympanic membrane is noted. What is the most appropriate action?
Advise to keep ear dry and see in a further 4 weeks time
A 25-year-old woman presents with a slowly enlarging mass on the side of the face. Clinical examination demonstrates that the mass is located in the tail of the parotid gland. There is no evidence of facial nerve involvement. What is the most likely cause?
Pleomorphic adenomas are the commonest tumours of the parotid gland and are often slow growing, smooth and mobile.
A 34-year-old lady presents with a long standing offensive discharge from the ear and on examination is noted to have a reduction in her hearing of 40 decibels compared to the opposite side.
Cholesteatoma
A 37-year-old lady, Mrs Halen is referred to the emergency department by her GP. She reports that when she awoke in the morning her eyes felt like they were moved to one side. Since then, she has felt very dizzy as if the room is spinning and she has been vomiting almost non-stop. She has a dull headache generally around the whole head which came on gradually this morning and is 4/10 severity. She has not experienced photophobia, phonophobia or a rash. She has a history of migraines which present as severe right-sided throbbing head pain but reports that pain to be different from this.
She reports being well prior to this episode, other than a mild cold a week ago. She reports a 3 day history of ringing in her right ear and slight muffling of her hearing. She has not noticed any feeling of pressure in the ear. She says that the ear is not painful. Otoscopy examination is normal.
Mrs Halen is given promethazine which improves her symptoms of vertigo and vomiting.
Which condition is the likely cause of her symptoms?
Acute viral labrynthitis: sudden onset horizontal nystagmus, hearing disturbances, nausea, vomiting and vertigo
An 18-month-old girl is brought to her general practitioner with a three-day history of poor feeding and pulling at their ears. Her observations are as follows:
- Respiratory rate of 26 breaths/min
- Pulse of 123 beats/min
- Temperature of 37.1ºC
- Blood pressure of 94/58mmHg
- Oxygen saturations of 97%
On examination, you note bulging tympanic membranes with surrounding erythema bilaterally.
What is the appropriate first-line management in this patient?
If antibiotics are required for otitis media, amoxicillin is first-line
What are the characteristics of Meniere’s disease?
(5)
- recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
- a sensation of aural fullness or pressure is now recognised as being common
- other features include nystagmus and a positive Romberg test
- episodes last minutes to hours
- typically symptoms are unilateral but bilateral symptoms may develop after a number of years
You are working in general practice, a 5-year-old boy is brought in by his mum due to a 3-day history of ear pain. On examination, you suspect a diagnosis of otitis media.
What is the most common cause of bacterial otitis media?
Haemophilus influenzae is a common cause of bacterial otitis media
A 37-year-old cello player complains of a three month history of vertigo and hearing loss on the left side. On examination he has an absent corneal reflex on the left eye.
Acoustic neuroma
A 25-year-old cat lover presents with symptoms of abdominal pain, lethargy and sweats. These have been present for the past two weeks. On examination she has lymphadenopathy in the posterior triangle.
Bartonella infection may occur following a cat scratch. The organism is intracellular. Generalised systemic symptoms may occur for a week or so prior to clinical presentation
Where are the parotid glands?
There are 3 main salivary glands:
the parotid glands are anterior and inferior to each ear
the submandibular glands lies below the angle of the jaw
the sublingual glands lie beneath the tongue
What is Meniere’s disease?
Meniere’s disease is a disorder of the inner ear of unknown cause.
It is characterised by excessive pressure and progressive dilation of the endolymphatic system.
A 24-year-old patient attends their general practitioner with an earache. They complain of being unable to hear clearly and have had difficulty sleeping due to the pain. They noticed feeling hot at home and recorded a temperature of 38ºC. On examination, the tympanic membrane appears to be bulging and opacified.
Of the following, what is the most likely causative organism of this presentation?
Haemophilus influenzae is a common cause of bacterial otitis media
A 6-year-old boy is brought to surgery. His mother says he has been complaining of left sided otalgia for the past three days. Otoscopy demonstrates the following:
Acute otitis media
The bulging nature of the tympanic membrane strongly suggests a diagnosis of otitis media. The colour of the tympanic membrane alone has a low predictive value for otitis media as it may be reddened by coughing, nose blowing, and fever.
A 17-year-old female presents to her GP with a sore throat and fevers for the past 3 days. She has no past medical history and takes no regular medication. On examination her throat is red with bilateral tonsillar swelling and bilateral cervical lymphadenopathy. Her pulse rate is 83 bpm and her blood pressure is 124/76 mmHg.
Which of the following features would be suggestive of a diagnosis of bacterial tonsillitis?
The likelihood that a diagnosis of pharyngitis or tonsillitis is due to a bacterial source is decided based on the Centor criteria. The criteria are as follows:
• Temperature >38ºC
• Tender anterior cervical lymphadenopathy
• Absence of a cough
• Exudate present on tonsils
A 25-year-old man presents with an acute history of sudden intense vertigo on waking, with loss of balance affecting his right side and pain in the right ear. There is no associated deafness or tinnitus. On examination he has a nystagmus with the rapid component to the right.
Which one of the following is the likely diagnosis?
Sudden and near-complete loss of vestibular function in a young patient is suggestive of vestibular neuronitis, a condition assumed due to a self-limiting viral infection of the vestibular nerve.
Hearing is normal in vestibular neuronitis
A 57=year-old male presents in the emergency department with a 12-hour history of sudden onset left-sided hearing loss. His hearing loss is accompanied by new onset tinnitus.
He denies any trauma or exposure to loud sounds and feels well in himself. He denies any weight loss, night sweats, or fever. He has no past medical or surgical history. He does not take any medication regularly apart from an over-the-counter vitamin D supplement.
You perform a full cranial nerve examination and note the below findings for assessment of CN VIII (vestibulocochlear nerve):
- Weber test - Louder in right ear
- Rinne test - Positive
Following urgent referral to ENT, what is the most appropriate next step in management?
Following referral to ENT, patients with sudden-onset sensorineural hearing loss are treated with high-dose oral corticosteroids
A 41-year-old complains of some difficulties with his hearing which have got gradually worse over the past few weeks. An audiogram is arranged:
Right conductive hearing loss
A 27-year-old woman complains of recurrent ear discharge. Otoscopy is as follows:
Cholesteatoma
‘attic crust’ - seen in the uppermost part of the ear drum
A 19-year-old man presents with a swelling on the left side of his neck. On examination he has a smooth swelling in between the sternocleidomastoid muscle and the pharynx. It is fluctuant but doesn’t transilluminate or move during swallowing.
Branchial cysts often present during intercurrent upper respiratory tract infection
What does the audiogram show?
Right sensorineural hearing loss
What is the most likely diagnosis?
Cholesteatoma is a non-cancerous growth of squamous epithelium that is ‘trapped’ within the skull base causing local destruction. It is most common in patients aged 10-20 years. Being born with a cleft palate increases the risk of cholesteatoma around 100 fold.
