Ear, Nose + Throat Flashcards
what is pure tone audiometry / tympanometry / evoked response audiometry?
Pure tone audiometry (PTA)
• Headphones deliver tones at different
frequencies and strengths in a sound-proofed
room.
• Pt. indicates when sound appears and
disappears.
• Mastoid vibrator → bone conduction threshold.
• Threshold at different frequencies are plotted to
give an audiogram.
Tympanometry
• Measures stiffness of ear drum
- Evaluates middle ear function
• Flat tympanogram: mid ear fluid or perforation
• Shifted tympanogram: +/- mid ear pressure
Evoked response audiometry
• Auditory stimulus ¯c measurement of elicited
brain response by surface electrode.
• Used for neonatal screening (if otoacoustic
emission testing negative)
otitis externa
Otitis Externa Presentation • Watery discharge • Itch • Pain and tragal tenderness Causes • Moisture: e.g. swimming • Trauma: e.g. fingernails • Absence of wax • Hearing aid Organisms • Mainly pseudomonas • Staph aureus
steroid +/- abx ear drops
malignant otitis externa
Malignant Otitis Externa • Life-threatening infection which can → skull osteomyelitis • 90% of pts. are diabetic (or other immune compromise) • Presentation § Severe otalgia which is worse @ night § Copious otorrhoea § Granulation tissue in the canal • Rx § Surgical debridement § Systemic Abx
TMJ dysfunction
TMJ Dysfunction Symptoms • Earache (referred pain from auriculotemporal N.) • Facial pain • Joint clicking/popping • Teeth-grinding (bruxism) • Stress (assoc. ¯c depression) Signs • Joint tenderness exacerbated by lateral movements of an open jaw. Investigation • MRI Management • NSAIDs • Stabilising orthodontic occlusal prostheses
acute otitis externa vs acute otitis media
otitis externa - more likely in summer, tragus movement painful, ear canal swollen, eardrum NORMAL, discharge, fever, hearing may be normal
otitis media - more likely winter, tragus not painful, ear canal normal, eardum bulging or perforated, fever, hearing always worse
classify otitis media
Classification
• Acute: acute phase
• Glue ear / OME: effusion after symptom regression
• Chronic: effusion > 3mo if bilat or > 6mo if unilat
• Chronic suppurative OM: Ear discharge ¯c hearing
loss and evidence of central drum perforation
Organisms • Viral • Pneumococcus • Haemophilus • Moraxella
acute otitis media summary
Acute OM Presentation • Usually children post viral URTI • Rapid onset ear pain, tugging @ ear. • Irritability, anorexia, vomiting • Purulent discharge if drum perforates o/e • Bulging, red TM • Fever Rx • Paracetamol: 15mg/kg • Amoxicillin: may use delayed prescription
complications of otitis media
Complications • Intratemporal § OME § Perforation of TM § Mastoiditis § Facial N. palsy • Intracranial § Meningitis / encephalitis § Brain abscess § Sub- / epi-dural abscess • Systemic § Bacteraemia § Septic arthritis § IE
otitis media with effusion
OME Presentation • Inattention at school • Poor speech development • Hearing impairment o/e • Retracted dull TM • Fluid level Ix • Audiometry: flat tympanogram Rx • Usually resolves spontaneously, • Consider grommets if persistent hearing loss § SE: infections and tympanosclerosis
chronic supparative otitis media
Chronic Suppurative OM Presentation • Painless discharge and hearing loss o/e • TM perforation Rx • Aural toilet • Abx / Steroid ear drops Complications • Cholesteatoma
mastoiditis
Mastoiditis • Middle-ear inflam → destruction of mastoid air cells and abscess formation. Presentation • Fever • Mastoid tenderness • Protruding auricle Imaging: CT Rx • IV Abx • Myringotomy ± mastoidectomy
cholesteatoma presentation
Definition • Locally destructive expansion of stratified squamous epithelium within the middle ear. Classification • Congenital • Acquired: 2O to attic perforation in chronic suppurative OM Presentation • Foul smelling white discharge • Headache, pain • CN Involvement § Vertigo § Deafness § Facial paralysis
cholesteatoma o/e treat
o/e • Appears pearly white ¯c surrounding inflammation Complications • Deafness (ossicle destruction) • Meningitis • Cerebral abscess Mx • Surgery
tinnitus causes
Tinnitus • Sensation of sound w/o external sound stimulation Causes • Specific § Meniere’s § Acoustic neuroma § Otosclerosis § Noise-induced § Head injury § Hearing loss: e.g. presbyacusis • General § ↑BP § ↓Hb • Drugs § Aspirin § Aminoglycosides § Loop diuretics § EtOH
hx and exam tinnitus
Hx • Character: constant, pulsatile • Unilateral: acoustic neuroma • FH: otosclerosis • Alleviating/exacerbating factors: worse @ night? • Associations § Vertigo: Meniere’s, acoustic neuroma § Deafness: Meniere’s, acoustic neuroma • Cause: head injury, noise, drugs, FH Examination • Otoscopy • Tuning fork tests • Pulse and BP
inv and manage tinnitus
Ix
• Audiometry and tympanogram
• MRI if unilateral to exclude acoustic neuroma
Mx
• Treat any underlying causes
• Psych support: tinnitus retraining therapy
• Hypnotics @ night may help
vertigo causes
Definition • The illusion of movement Causes Peripheral / Vestibular Central • Meniere’s • Acoustic neuroma • BPV • MS • Labyrinthitis • Vertebrobasilar insufficiency / stroke Head injury • Inner ear syphilis Drugs (central/ototoxic) • Gentamicin • Loop diuretics • Metronidazole • Co-trimoxazol
hx, exam, tests vertigo
Hx • Is it true vertigo or just light-headedness? § Which way are things moving? • Timespan • Assoc. symptoms: n/v, hearing loss, tinnitus, nystagmus Examination and Tests • Hearing • Cranial nerves • Cerebellum and gait • Romberg’s +ve = vestibular or proprioception • Hallpike manouvre • Audiometry, calorimetry, LP, MRI
meniere’s presentation
Ménière’s Disease Pathology • Dilatation of endolymph spaces of membranous labyrinth (endolymphatic oedema) Presentation • Attacks occur in clusters and last up to 12h. • Progressive SNHL • Vertigo and n/v • Tinnitus • Aural fullnes
meniere’s inv and manage
Ix • Audiometry shows low-freq SNHL which fluctuates Rx • Medical § Vertigo: cyclizine, betahistine • Surgical § Gentamicin instillation via grommets § Saccus decompression
vestibular neuronitis
Vestibular Neuronitis / Viral Labyrinthitis Presentation • Follows febrile illness (e.g. URTI) • Sudden vomiting • Severe vertigo exacerbated by head movement Rx • Cyclizine • Improvement in days
BPPV presentation
Pathology • Displacement of otoliths in semicircular canals • Common after head injury. Presentation • Sudden rotational vertigo for <30s - Provoked by head turning • Nystagmu
BPPV inv and treat and causes
Causes • Idiopathic • Head injury • Otosclerosis • Post-viral Dx • Hallpike manoeuvre → upbeat-torsional nystagmus Rx • Self-limiting • Epley manoeuvre • Betahistine: histamine analogue
categorise conductive causes of adult hearing loss
Conductive • Impaired conduction anywhere between auricle and round window. External canal obstruction • Wax • Pus • Foreign body TM perforation • Trauma • Infection Ossicle defects • Otosclerosis • Infection • Trauma
categorise sensineural causes of adult hearing loss
Sensorineural • Defects of cochlea, cohlear N. or brain. Drugs • Aminoglycosides • Vancomycin Post-infective • Meningitis • Measles • Mumps • Herpes Misc. • Meniere’s • Trauma • MS • CPA lesion (e.g. acoustic neuroma) • ↓B12
acoustic neuroma present
Acoustic Neuroma / Vestibular Schwannoma
Pathology
• Benign, slow-growing tumour of superior vestibular N.
• Acts as SOL → Cerebellopontine angle syndrome
§ 80% of CPA tumours
• Assoc. ¯c NF2
Presentation
• Slow onset, unilat SNHL, tinnitus ± vertigo
• Headache (↑ICP)
• CN palsies: 5,7 and 8
• Cerebellar signs
acoustic neuroma inv and manage
Ix • MRI of cerebellopontine angle § MRI all pts. ¯c unilateral tinnitus / deafness • PTA Differential • Meningioma • Cerebellar astrocytoma • Mets Rx • Gamma knife (RadioT) • Surgery (risk of hearing loss)
otosclerosis summary
Otosclerosis
• AD condition characterised by fixation of stapes at the
oval window.
• F>M=2:1
Presentation
• Begins in early adult life
• Bilateral conductive deafness + tinnitus
• HL improved in noisy places: Willis’ paracousis
• Worsened by pregnancy/ menstruation/ menopause
Ix
• PTA shows dip (Caharts notch) @ 2kHz
Rx
• Hearing aid or stapes impla
presbyacusis
Presbyacussis • Age-related hearing loss Presentation • >65yrs • Bilateral • Slow onset • ± tinnitus Ix: PTA Rx: hearing aid
hearing loss in a child
Hearing Loss in Children Congenital Causes Conductive • Anomalies of pinna, external auditory canal, TM or ossicles. • Congenital cholesteatoma • Pierre-Robin SNHL • Autosomal Dominant § Waardenburgs: SNHL, heterochromia + telecanthus • Autosomal recessive § Alport’s: SNHL + haematuria § Jewell-Lange-Nielson: SNHL + long QT • X-linked § Alport’s • Infections: CMV, rubella, HSV, toxo, GBS • Ototoxic drugs Perinatal • Anoxia • Cerebral palsy • Kernicterus • Infection: meningitis Acquired Causes • OM/OME • Infection: meningitis, measles • Head injury
neonatal hearing testing
Universal Neonatal Hearing Tests • Detection and Mx of hearing loss before 6mo improves language. • Tests § Otoacoustic emissions § Audiological brainstem responses.
tympanic membrane perforation
TM Perforation Causes • OM • Foreign body • Barotrauma • Trauma
allergic rhinitis presentation
Allergic Rhinosinusitis Classification • Seasonal: hay-fever (prev = 2%) • Perennial Pathology • T1HS IgE-mediated inflam from allergen exposure → mediator release from mast cells. • Allergens: pollen, house dust mites (perennial) Symptoms • Sneezing • Pruritus • Rhinorrhoea Signs • Swollen, pale and boggy turbinates • Nasal polyps
allergic rhinitis inv and manage
Ix
• Skin-prick testing to find allergens
- Don’t perform if prone to eczema
• RAST tests
Mx
Allergen Avoidance
• Regularly washing bedding (inc. toys) on high
heat or use acaricides.
• Avoid going outside when pollen count high.
1st Line
• Anti-histamines: cetirazine, desloratidine
• Or, beclometasone nasal spray
• Or, chromoglycate nasal spray (children)
2nd Line: intranasal steroids + anti-histamines
3rd Line: Zafirlukast
4rd Line: Immunotherapy
• Aim to induce desensitisation to allergen
• OD SL grass-pollen tablets → ↑ QOL in hay-fever
• Injection immunotherapy
Adjuvants
• Nasal decongestants: Pseudoephedrine,
Otrivine
sinusitis causes
Sinusitis
Pathophysiology
• Viruses → mucosal oedema and ↓ mucosal ciliary
actions → mucus retention ± 2O bacterial infection
• Acute: Pneumococcus, Haemophilus, Moraxella
• Chronic: S. aureus, anaerobes
Causes
• Majority are bacterial infection 2O to viral
• 5% 2O to dental root infections
• Diving / swimming in infected water
• Anatomical susceptibility: deviated septum, polyps
• Systemic Disease
§ PCD / Kartagener’s
§ Immunodeficiency
symptoms and inv of sinusitis
Symptoms • Pain § Maxillary (cheek/teeth) § Ethmoidal (between eyes) § ↑ on bending / straining • Discharge: from nose → post-nasal drip ¯c foul taste • Nasal obstruction / congestion • Anosmia or cacosmia (bad smell w/o external source) • Systemic symptoms: e.g. fever Imaging • Nasendoscopy ± CT
managment sinusitis
Mx Acute / Single Episode • Bed-rest, decongestants, analgesia • Nasal douching and topical steroids • Abx (e.g. clarithro) of uncertain benefit Chronic / recurrent • Usually a structural or drainage problem. • Stop smoking + fluticasone nasal spray • Functional Endoscopic Sinus Surgery - If failed medical therapy Complications (rare) • Mucoceles → pyoceles • Orbital cellulits / abscess • Osteomyelits – e.g. Staph in frontal bone • Intracranial infection § Meningitis, encephalitis § Abscess § Cavernous sinus thrombosi
nasal polyps
The Patient • Male, > 40yrs Sites • Middle turbinates • Middle meatus • Ethmoids Symptoms • Watery, anterior rhinorrhoea • Purulent post-nasal drip • Nasal obstruction • Sinusitis • Headaches • Snoring Signs • Mobile, pale, insensitive Associations • Allergic / non-allergic rhinitis • CF • Aspirin hypersensitivity • Asthma
manage nasal polyp
Single Unilateral Polyp • May be sign of rare but sinister pathology § Nasopharyngeal Ca § Glioma § Lymphoma § Neuroblastoma § Sarcoma • Do CT and get histology Nasal Polyps in Children • Rare <10yrs old • Must consider neoplasms and CF Mx • Drugs § Betamethasone drops for 2/7 § Short course of oral steroids • Endoscopic polypectomy
fractured nose inv hx
Anatomy • Upper 3rd of nose has bony support • Lower 2/3 and septum are cartilaginous. Hx • Time of injury • LOC • CSF rhinorrhoea • Epistaxis • Previous nose injury • Obstruction • Consider facial #, check for § Teeth malocclusion § Diplopia (orbital floor #) Ix • Cartilaginous injury won’t show and radiographs don’t alter Mx.
nose fracture manage
Mx
• Exclude septal haematoma
• Re-examine after 1wk (↓ swelling)
• Reduction under GA ¯c post-op splinting best w/i 2wks
Septal haematoma
• Septal necrosis + nasal collapse if untreated
§ Cartilage blood supply comes from mucosa
• Boggy swelling and nasal obstruction
• Needs evacuation under GA ¯c packing ± suturing.
causes and classification epistaxis
Causes • 80% unknown • Trauma: nose-picking / #s • Local infection: URTI • Pyogenic granuloma § Overgrowth of tissue on Little’s area due to irritation or hormonal factors. • Osler-Weber-Rendu / HHT • Coagulopathy: Warfarin, NSAIDs, haemophilia, ↓plats, vWD, ↑EtOH • Neoplasm Classification • Anterior • Posterior
initial management nosebleed
Initial Mx
• Wear PPE
• Assess for shock and manage accordingly
• If not shocked
§ Sit up, head tilted down
§ Compress nasal cartilage for 15min.
• If bleeding not controlled remove clots ¯c suction or by
blowing and try to visualise bleed by rhinoscopy
anterior epistaxis
Anterior Epistaxis
• Usually septal haemorrhage: Little’s area /
Kisselbach’s plexus
§ Ant. Ethmoidal A.
§ Sphenopalatine A.
§ Facial A.
• Insert gauze soaked in vasoconstrictor + LA
§ Xylometazoline + 2% lignocaine
§ 5min
• Bleeds can be cauterised ¯c silver nitrate sticks
• Persistent bleeds should be packed with Mericel pack
§ Refer to ENT if this fails or if you can’t visualise
the bleeding point.
§ They may insert a posterior pack or take pt. to
theatre for endoscopic control.
posterior epistaxis
Posterior / Major Epistaxis
• Posterior packing (+ anterior pack)
§ Pass 18/18G Foley catheter through the nose
into nasopharynx, inflate ¯c 10ml water and pull
forward until it lodges.
§ Admit pt. and leave pack for ~48hrs.
• Gold standard is endoscopic visualisation and direct
control: e.g. by cautery or ligation.
post nosebleed advice
After the Bleed • Don’t pick nose • Sit upright, out of the sun • Avoid bending, lifting or straining • Sneeze through mouth • No hot food or drink • Avoid EtOH and tobacco
Osler Weber Rendu / Hereditary hemorrhagic telangiectasia
Osler-Weber-Rendu / HHT • Autosomal dominant • 5 genetic subtypes Features • Telangiectasias in mucosae § Recurrent spontaneous epistaxis § GI bleed (usually painless) • Internal telangiectasias and AVMs § Lungs § Liver § Brain • Rarely § Pulmonary HTN § Colon polyps: may → CRC
tonsillitis presenation
Symptoms • Sore throat • Fever, malaise Signs • Lymphadenopathy: esp. jugulodigastric node • Inflamed tonsils and oropharynx • Exudates Organisms • Viruses are most common (consider EBV) • Group A Strep: pyogenes • Staphs • Moraxella
tonsillitis manage
Mx
• Swabbing superficial bacteria is irrelevant and can
→ overdiagnosis.
• Analgesia: Ibuprofen / Paracetamol ± Difflam
gargle
• Consider Abx only if ill: use Centor Criteria
§ Pen V 250mg PO QDS (125mg TDS in
children) or erythromycin for 5/7
• NOT AMOXICILLIN → MACPAP RASH IN EBV
tonsillits criterai
Centor Criteria • Guideline for admin of Abx in acute sore throat / tonsillitis / pharyngitis 1 Point for each of • Hx of fever • Tonsillar exudates • Tender anterior cervical adenopathy • No cough Mx • 0-1: no Abx (risk of strep infection <10%) • 2: consider rapid Ag test + Rx if +ve • ≥3: Abx
tonsillectomy indications and complications
Tonsillectomy Indications • Recurrent tonsillitis if all the below criteria are met § Caused by tonsillitis § 5+ episodes/yr § Symptoms for >1yr § Episodes are disabling and prevent normal functioning • Airway obstruction: e.g. OSA in children • Quinsy • Suspicion of Ca: unilateral enlargement or ulceration Methods • Cold steel • Cautery Complications • Reactive haemorrhage • Tonsillar gag may damage teeth, TMJ or posterior pharyngeal wall. • Mortality is 1/30,000
strep throat complications
quinsy - peritonsillar abscess Retropharyngeal Abscess Lemierre’s Syndrome Scarlet Fever Rheumatic Fever post strep GN
quinsy
Peritonsillar Abscess (Quinsy) • Typically occurs in adults • Symptoms § Trismus § Odonophagia: unable to swallow saliva § Halitosis • Signs § Tonsillitis § Unilateral tonsillar enlargement § Contralateral uvula displacement § Cervical lymphadenopathy • Rx § Admit § IV Abx § I&D under LA or tonsillectomy under GA
retropharyngeal abscess
Retropharyngeal Abscess • Rare • Presentation § Unwell child ¯c stiff, extended neck who refuses to eat or drink § Fails to improve ¯c IV Abx § Unilateral swelling of tonsil and neck • Ix § Lat. neck x-rays show soft tissue swelling § CT from skull-base to diaphragm. • Rx § IV Abx § I&D
Lemierre’s syndrome
Lemierre’s Syndrome • IJV thrombophlebitis ¯c septic embolization most commonly affecting the lungs. • Organism: Fusobacterium necrophorum • Rx § IV Abx: pen G, clinda, metro
scarlet fever
Scarlet Fever • “Sandpaper”-like rash on chest, axillae or behind ears 12-48h after pharyngotonsillitis. • Circumoral pallor • Strawberry tongue • Rx § Start Pen V/G and notify HPA.
rheumatic feve
Rheumatic Fever • Carditis • Arthritis • Subcutaneous nodules • Erythema marginatum • Sydenham’s chorea
post strep GN
Post-streptococcal Glomerulonephritis
• Malaise and smoky urine 1-2wks after a pharyngitis
laryngitis
Laryngitis • Usually viral and self-limiting • 2O bacterial infection may develop • Symptoms: pain, hoarseness and fever • o/e: redness and swelling of the vocal cords • Rx: Supportive, Pen V if necessary
larygneal papilloma
Laryngeal Papilloma • Pedunculated vocal cord swellings 2O to HPV • Present ¯c hoarseness • Usually occur in children • Rx: laser removal
recurrent larygneal nerve palsy
Recurrent Laryngeal N. Palsy
• Supplies all intrinsic laryngeal muscles except for
cricothyroideus.
§ Ext. branch of sup laryngeal N.
• Responsible for ab- and ad-uction of vocal folds
Symptoms
• Hoarseness
• “Breathy” voice ¯c bovine cough
• Repeated coughing from aspiration (↓ supraglottic
sensation)
• Exertional dyspnoea (narrow glottis)
Causes
• 30% are cancers: larynx, thyroid, oesophagus,
hypopharynx, bronchus
• 25% iatrogenic: para- / thyroidectomy, carotid
endarterectomy
• Other: aortic aneurysm, bulbar / pseudobulbar
palsy
laryngeal SCC
Laryngeal SCC • Incidence: 2000/yr in uk • Associations: smoking, EtOH Presentation • Male smoker • Progressive hoarseness → stridor • Dys-/odono-phagia • Wt. loss Ix • Laryngoscopy + biopsy (inc. nodes) • MRI staging Mx • Based on stage • Radiotherapy • Laryngectomy After total laryngectomy • Pts have permanent tracheostomy § Speech valve § Electrolarynx § Oesophageal speech (swallowed air) • Regular f/up for recurrence
laryngomalacia child
Laryngomalacia
• Immature and floppy aryepiglottic folds and glottis →
laryngeal collapse on inspiration
Presentation • Stridor: commonest cause in children § Presents w/i first wks of life. • Noticeable @ certain times § Lying on back, § Feeding § Excited/upset • Problems can occur ¯c concurrent laryngeal infections or ¯c feeding. Mx • Usually no Rx required but severe cases may warrant surger
epiglottitis
Epiglottitis Symptoms • Sudden onset • Continuous stridor • Drooling • Toxic Pathogens: haemophilus, Group A Strep Rx • Don’t examine throat • Consult ¯c anaesthetists and ENT surgeons • O2 + nebulised adrenaline • IV dexamethasone • Cefotaxime • Take to theatre to secure airway by intubation
foreign body in throat child
Foreign Body
• Sudden onset stridor in a previously normal child.
• Back slaps and abdominal thrusts.
• Needle cricothyrotomy in children
• Can only exclude foreign body in bronchus by
bronchoscopy
subglottic stenosis
Subglottic Stenosis • Subglottis is narrowest part of respiratory tract in children. • Symptoms: stridor, FTT • Causes § Prolonged intubation § Congenital abnormalities • Rx § Mild: conservative § Severe: Tracheostomy or partial tracheal resectio
Bell’s palsy presentation
Bell’s Palsy • Inflammatory oedema from entrapment of CNVII in narrow facial canal • Probably of viral origin (HSV1). • 75% of facial palsy Features • Sudden onset: e.g. overnight • Complete, unilateral facial weakness in 24-72h § Failure of eye closure (Bell’s Sign) → dryness and conjunctivitis § Drooling, speech difficulty • Numbness or pain around ear • ↓ taste (ageusia) • Hyperacusis: stapedius palsy
inv manage Bell’s palsy
Ix • Serology: Borrelia or VZV Abs • MRI: SOL, stroke, MS • LP Mx • Protect eye § Dark glasses § Artificial tears § Tape closed @ night • Give prednisolone w/i 72hrs § 60mg/d PO for 5/7 followed by tapering • Valaciclovir if zoster suspected (otherwise antivirals don’t help). • Plastic surgery may help if no recovery
Bell’s palsy prognosis and complications
Prognosis
• Incomplete paralysis usually recovers completely
w/i wks.
• With complete lesions, 80% get full recovery but
the remainder have delayed recovery or permanent
neurological / cosmetic abnormalities.
Complications: Aberrant Neural Connections
• Synkinesis: e.g. blinking causes up-turning of
mouth
• Crocodile tears: eating stimulates unilateral
lacrimation, not salivation
Ramsay Hunt Syndrome
• Reactivation of VZV in geniculate ganglion of CNVII
Features
• Preceding ear pain or stiff neck
• Vesicular rash in auditory canal ± TM, pinna,
tongue, hard palate (no rash = zoster sine herpete)
• Ipsilateral facial weakness, ageusia, hyperacusis,
• May affect CN7 → vertigo, tinnitus, deafness
Mx
• If Dx suspected give valaciclovir and prednisolone
w/i first 72h
Prognosis
• Rxed w/i 72h: 75% recovery
• Otherwise: 1/3 full recovery, 1/3 partial, 1/3 poor
other causes of facial palsy aside from main 2
May be suggested by • Bilateral symptoms (Lyme, GBS, leukaemia, sarcoid) • UMN signs: sparing of frontalis and orbicularis oculi • Other CN palsies (but seen in 8% of Bell’s) • Limb weakness • Rashes Intracranial Lesions • Vascular, MS, SOL § Motor cortex → UMN signs § Brainstem nuclei → LMN signs • Cerebellopontine angle lesion § May be accompanied by 5th, 6th, and 8th CN palsies Intratemporal Lesions • Otitis media • Cholesteatoma • Ramsay Hunt Syndrome Infratemporal • Parotid tumours • Trauma Systemic • Peripheral neuropathy § Demyelinating: GBS § Axonal: DM, Lyme, HIV, Sarcoid • Pseudopalsy: MG, botulism
