EENT TEST 2! Flashcards
What are the 4 types of Peripheral vertigo
Meniere’s vestibular neuritis
labyrinthitis
BPPV
migainous, Cervicogenic
What are some features of vestibular neuronitis?
- Common, usually follows URI.
- Sudden, severe vertigo with N/V
- Affects CN 8
- No tinnitus or change in hearing
- head impulse test +
- Unidirectional nystagmus
- Hypoactive vestibular apparatus
- Vertigo is frequent too constant, spontaneous, and worse with movement
What is the prognosis for vestibular neuronitis?
Resolves in days to weeks down to mild positional vertigo.
How is labyrinthitis different from vestibular neuronitis?
It involves both the cochlea and the labyrinth and hearing is often effected.
Where does the nystagmus go in labyrinthitis?
Spontaneously to the unaffected side.
What is the prognosis of labyrinthitis?
May resolve in days to weeks but unsteadiness and positional vertigo may persist for months.
What causes labyrinthitis
Lots of things: ototoxic drugs, infection, autoimmune, treatment of TB.
Most commonly concomitant to acute infection like OM or sinusitis.
What is LABYRINTHITIS?
inflammatory d/o of inner ear or labyrinth.
Disturbance of balance & hearing to varying degrees & mb u/l or b/l.
MB: infx acute inflmtn of labyrinth, AI d/o, ototoxic drugs, TB tx.
What are the features of viral labyrinthitis?
sudden, u/l loss of vestibular fxn & hearing;
acute onset of severe vertigo, n/v, resolves usu several days-wks; but BPPV may persist for several mo;
Involves cochlea & labyrinth,
balance & hearing both affected. Mb concurrent acute URI
What are the red flags that may indicate CNS stroke
hyperacute onset vertigo, occipital headache or gait ataxia.
What is BPPV?
brief episode of vertigo that is ALWAYS and only positional.
Does BPPV have hearing loss or tinnitus?
No it does not.
What can cause BPPV?
Head trauma, dental surgery, middle ear infection, otoliths.
Otoliths roll across hairs when head moves and sends aberrant signals to brain causing vertigo.
What test is diagnostic for BPPV?
Dix-Halpike
How does one cure BPPV?
Epley Maneuvers
What is the difference between central and positional vertigo?
The primary differentiating feature is downbeat or pure tortional nystagmus on Dix-Hallpike.
Recurrent episodic vertigo caused by endolymphatic hydrops (edema) is what disease?
Meniere’s Disease
What are some symptoms of Meniere’s disease?
- Episodic attacks (with dread)
- Severe to violent vertigo with N/V
- Aural fullness
- Fluctuating hearing loss
- Loud, roaring, tinnitus
- Sensitivity to loud noises
- Usually middle-aged women
- Autoimmune?
Who does Menier’s classically affect?
Middle aged women
Will Menieres present with hearing loss
fluctuating sensorineural hearing loss, and rarely recruitment, resulting in hypersensitivity to loud noises.
What will the head impulse test reveal?
lateralized vestibular dysfunction to the symptomatic ear.
When should one consider a brainstem stroke?
patients with acute audiovestibular loss who do not have typical Ménière’s symptoms.
When should one consider an acute ischemic attack is present
consider when episodes get worse in a crescendo pattern.
Assess stroke risk factors (HTN, DB, hyperlipidemia)
look for focal neurologic deficits.
Mb brainstem stroke w/acute audiovestibular loss
What is bilateral vestibular failure due to?
Mostly seen in hospital settings.
Bilateral vestibular failure is due to aminoglycoside toxicity.
.
What are the two most common causes of bilateral vestibular failure?
Gentamicin and streptomycin are the common causes
What do you do with any vague dizziness or vertigo with unilateral or asymmetric sensory hearing loss?
acoustic neuroma
What is an uncommon but dangerous condition that only causes vertigo in 50% of pts?
Assume it’s an acoustic neuroma until proven otherwise.
What are some features of acoustic neuroma?
- Tinnitus
- Facial weakness
- Slowly progressive, unilateral hearing loss.
What is a perilymphatic fistula
Breach between the middle and inner ear. Secondary to trauma from a direct blow or sudden barotraumas, occaisionally heavy weight bearing or straining.
Disruption of the oval window allowing perilymph to leak into the middle ear space.
What will happen upon insufflation if a perilymphatic fistula is present?
Symptoms will be made worse by insufflation.
What happens in superior canal dehiscence
bone overlying the superior aspect of the superior semicircular canal becomes thin or even absent, thereby allowing pressure to be transmitted to the inner ear.
migranious vertigo?
Episodic moderate dizziness, N hearing, hx of migraine;
Look for environmental, food, or lifestyle triggers; stimuli - light, sound, or motion, can trigger or aggravate sx.
Dx of exclusion.
What are the symptoms of migranious vertigo
N Head impulse test.
If new sx - other dx = stroke or TIA should still be considered if sx do not fit a peripheral vestibular d/o;
Avoid- chocolate, aged cheese, coffee
What is the Neuhauser Criteria for Migrainous Vertigo for definite results?
Definite
1. Episodic vestibular symptoms of at least moderate severity
a. Vertigo; positional dizziness and head motion intolerance
2. Migraine according to the International Headache Criteria
3. One or more of the following features during at least two vertigo attacks
a. Migrainous headache
b. photophobia
c. phonophobia
d. migraine aura
4. Other diagnoses excluded by appropriate tests
Probable
What is the Neuhauser Criteria for Migrainous Vertigo for probable results?
Criteria for Other diagnoses excluded by appropriate tests and Episodic vestibular symptoms of at least moderate severity
plus at least ONE of the following
1. Migrainous headache
2. Migraine symptoms during vertigo
3. Migraine specific triggers of vertigo (specific foods like red wine)
Response to the anti-migraine treatments
What endocrine/metabolic conditions should be on your DDx when treating inner ear disorders?
-Hypothyroid
-Hyperlipidemia
-Electrolytes (specifically Na/K)
-Diabetic and dysglycemia
What is cervicogenic vertigo triggered by?
somatosensory input (position sense) in the cervical joints from head and neck movement
What red flags suggest central vertigo?
Hyper acute onset of vertigo,
risk factors for stroke
normal head impulse tests,
focal neurological deficits,
new onset headache in a patient without previous migraine,
onset associated with Valsalva.
What type of hearing loss is present in BPV?
None
What type of hearing loss is present in Vestibular
Neuronitis?
is tinnitus present?
None and no
What type of hearing loss is present in Labrynthitis?
is tinnitus present?
Yes w/ Tinnitus
What type of hearing loss is present in Ménière’s Disease
Sensorineurral 90% unilateral
What type of hearing loss is present in Cholesteatoma
Conductive
What type of hearing loss is present in Perilymphatic
Fistula
mixed sensorineural
What type of hearing loss is present in Acoustic Neuroma
Sensorineural
How does BPV present?
Paroxysmal, brief, always positional vertigo
How does Vestibular Neuritis present?
Sudden onset, constant,
< Movement, Often follows antecedent viral infection
How does labrynthitis present?
Mild to severe vertigo/imbalance accompanied by a concomitant Ear, sinus or nose infection
How does Menieres disease present
Episodic attacks of severe vertigo usually with aural fullness and hearing loss
How do cholesteatomas present
Recurrent vertigo with history of ASOM with perforation
How does a perilymphatic fistula present
History of trauma
How does acoutstic neuroma present
Progressive unilateral hearing loss, with vertigo
How do you DX BPV
History, Positive Dix- Hallpike, therapeutic response to Epley Maneuver
How do you DX vestibular neuritis
History, normal hearing, spontaneous horizontal nystagmus, resolves in hours to days, Abnormal VOR
How do you DX labrynthitis
ENT examination, Abnormal VOR
How do you DX menieres
History, with recurrences, ABR, Abnormal VOR
How do you DX cholesteatoma
Usually visible on otoscopic exam
How do you DX a perilymphatic fistula
Positive fistula test (insufflation) < Valsalva
How do you DX an acoustic neuroma
Auditory Brainstem Response, MRI
If Weber Lateralize to bad ear then…
= conductive hearing loss
If Weber Lateralize to bad ear then…Lateralizes to good ear =
sensorineural hearing loss
AC > BC =
Normal
BC > AC =
Conductive hearing loss
AC > BC, but both diminished =
Sensorineural hearing loss
Speech audiometry
measures the threshold that speech can be accurately heard.
Usually the greater cochlear hearing loss the poorer word recognition score.
Typanometry
is a measure of tympanic membrane mobility (impedance) and an indirect measure of middle ear pressure.
Electrocohleography:
is a method for recording the electrical potentials of the cochlea. It is particularly helpful in the diagnosis of Meniere’s disease/endolymphatic hydrops and screening for hearing loss in infants.
Auditory Brainstem Response:
This resembles a nerve conduction study. The time taken for an impulse to get from the cochlea to the brainstem is measured.
The time is prolonged with acoustic neuroma (example page 11). Can also be used as an objective hearing test in young children.
What is Schwartze’s sign?
A pinkish blue hue to TM associated with otosclerosis
What might you notice in office about your pt with conductive hearing loss?
They may be very soft spoken and hear better in a noisy environment.
What kind of tympanogram are you likely to see in conductive hearing loss?
AS (still)
What is the history of a patient with otosclerosis
Progressive conductive hearing loss, usu w/ well preserved speech discrimination; mb sensorineural hearing loss w/ cochlear involvement.
Clinical Pearl: Pts often soft spoken and aware they seem to hear better in noisy environments
what is the most common pe in otosclerosis
Stapes & malleus fusing = m/c.
Review what the tympanogram for otosclerosis looks like
type a look at a chart!
What is Schwartze’s sign:
Pinkish/blue hue on TM promontory upon otoscopic exam
associated with otosclerosis
What is Carhart’s notch
A dip in bone conductive threshold at 2000 Hz. on audiometric testing
associated with otosclerosis
What are the three main causes of conductive hearing loss?
inflammatory
otosclerosis
traumatic
What are the four main causes of sensorineural hearing loss?
congential
trumatic
neoplastic
inflammatory
What is the history of a patient with traumatic sensorineural hearing loss
Head injury or Noise
Occupations: Farmers, construction, machinists, military, musicians
What is the history of a patient with congenital sensorineural hearing loss
Genetic: FHx of deafness
Non-genetic: dz & injury
What is the history of a patient with neoplastic sensorineural hearing loss
9 & malignant neoplasms can affect hearing granulomas, meningiomas, and acoustic neuroma;
What is the physical exam findings of sensorineural congenital hearing loss
Waadenburg’s Syndrome – genetic hearing loss w/ white patch of hair
Non-genetic: dt Rubella, jaundice or anoxia at birth, brain injury
What is the physical exam findings of traumatic sensorineural hearing loss
Initial complaint = tinnitus: is reversible until hairs in Organ of Corti are damaged beyond repair, then loss is permanent
What is the physical exam findings of inflammatory sensorineural hearing loss
Strep -endotoxins that pass through oval window & damage the hair cells; Other infx damage nerves (measles, syphilis)
What is the physical exam findings of neoplastic sensorineural hearing loss
u/l hearing loss
Document w/ audiometry. r/o w/ MRI.
What does audiology show for neoplastic sensorineural hearing loss?
Acoustic Neuroma, hearing loss localized in high frequencies
Retro-cochlear pattern = tumor, behind cochlear. “V wave” is delayed in bad (R) ear
What does audiology show for traumatic sensorineural hearing loss?
In noise induced hearing loss there is a characteristic drop off in ↑frequencies
What does audiology show for congenital sensorineural hearing loss?
loud volumes usu resonate @ 4k Hz
What does Audiology test?
Air and bone conduction between 250-8,000 Hz
What kind of tympanogram are you likely to see in conductive hearing loss?
AS (Stiff)
look at this!
What does speech audiometry measure?
the threshold at which speech is accurately heard
What does auditory brainstem response measure?
the time it takes for impulses to get from the cochlea to the brainstem
What minerals are helpful for presbycusis
zinc and copper (if long term)
What are a few ototoxic substances?
- Aspirin
- Quinine
- Aminoglycosides
- Erythromycin (high dose)
- Loop and thiazide diuretics
- Platinum based chemo
- CO2
- Nicotine
- Alcohol
- Heavy metals
- Interferon a
How can you improve circulation to the middle ear?
Oral: Gingko, vaccinium bilberry, vinca minor.
Local: Hypericum oil, cimicifuga
According to the article in american family physician, what are some causes of acute tinnitus?
Infection Meds Trauma Loud noises Wax Change in BP or metabolism
According to the article in american family physician, what are some causes of chronic tinnitus?
Damage to auditory cortex from aging
According to the article in american family physician, what are some causes of objective tinnitus?
Vascular abnormalities
Mechanical disorders
According to the article in american family physician, what are some treatments for tinnitus?
-Acoustic therapy - hearing aids, sound pillows.
- Hearing protection
- Manage insomnia, anxiety, depression
- Manage metabolic disorders
Which supplements help stabilize cell membranes?
Antioxidants - Strength cell membranes.
- Quercetin - Stabilize mast cells
- EFAs - Stabilize cell membranes
Which bioflavonoid helps by inhibiting the degranulation of mast cells?
Quercetin!
Which bioflavonoid inhibits histidine carboxylase and is also a potent antioxidant?
Catechin
Which class of EFAs do atopic patients have trouble converting to PGE1?
Linoleic acid, which is an omega 6.
EPO, borage, and black currant all have GLA and avoid this step.
Which foods should allergic patients avoid?
Dairy, citrus, animal fat, TFAs.
All food allergens.
What are some ways to support the adrenals?
Standard Process: Drenotrophin, Antronex, Corrhyzadyn, Isocort, Multi B vitamins,
-DHEA if indicated by testing.
-Pantothenic acid (B5) precursor to coenzyme A
PE for DDx of Perilymphatic Fistula:
insufflations, pressing on tragus – makes it worse
PE for Dx of BPV:
dicks/hallpike, brief upbeat the fatigues and then diminishes over time if test repeated– when to suspect central vertigo? Downbeat nystagmus, doesn’t fatigue
How sensitive is Rinne test for Conductive hearing loss –
not very, but is specific
Differential diagnosis of noninflammatory rhinitis: Structural anomalies
Deviated septum
Hypertrophic turbinates (mechanism undefined)
Ostiomeatal complex (OMC) anatomic variants
Concha bullosa
Paradoxical curvature of the middle turbinate
Choanal atresia
Tumors
Adenoidal hypertrophy with recurrent infections
Complications of excessive surgical excision of mucosa
Strictures
Fracture of cribriform plate
Cerebrospinal rhinorrhea (high glucose)
Hypertrophy of fleshy components of the anterior nasal valve
Rhinophyma , Foreign body
Differential diagnosis of noninflammatory rhinitis: hormonal and drug related
Pregnancy (estrogen and progesterone)
Hypothyroidism
Acromegaly
Chlorpromazine (neuroleptic)
Adrenergic dysfunction
Antihypertensive agents
Beta Blockers
Reserpine
Rhinitis medicamentosa : Chronic topical α-adrenergic agonist abuse (afrin), Cocaine abuse
Side effects of eye drops delivered via nasolacrimal ducts Glaucoma medicationsDifferential diagnosis of noninflammatory Rhinitis:
Neural dysfunction and other conditions
absent symp fxn (no vasoconstriction)
Horner’s syndrome
Hyperactive cholinergic parasymp fxn (XS mucus production)
Cholinergic rhinitis (vasomotor rhinitis)
Trigeminal neuralgia
Gustatory rhinitis, ‘salsa sniffles’
Nociceptive rhinitis/irritant rhinitis
weather changes, perfume, tobacco smoke, & inhalants
Nonallergic rhinitis of CFS, fibromyalgia,
Loss of parasympathetic & sympathetic innervation
Lab tests to Dx rhinitis lab results on CBC, nasal smear, scratch tests w/different czs of rhinitis
- CBC - may show eosinophilia
- Nasal smear/cytology (GenSa eosinophilic stain) eosinophils is suggestive, if hx matches
- Scratch tests: Pollen extracts are placed on broken skin wheal & flare = IgE rxn to Ag; 1-4+ grading
- RAST/ELISA tests-in vitro serum test: Measure IgE in relation to Ag; Expensive test, use for anaphylaxis or bad eczema/rxn
- Total serum IgE - not a particularly sensitive or specific, mb increased
- (-) findings if vasomotor/cholinergic rhinitis
When is the best time ti implement a nutritional program for prophylaxis of allergic rhinitis?
2 months before allergy season.
Is urtica dioica good for everyone with hay-fever?
it helps about 58% of the time.
What’s a good herbal formula for hay-fever?
Urtica Butterbur Sambucus Euphrasia
What are some ways you can help your patients abort a cold?
Nature cure Rest Water Simple diet Hydrotherapy
Is echinacea effective for the prevention and treatment of URIs?
Apparently yes. It decreases the incidence and duration of the common cold.
However, it’s usually used in conjunction with other treatments.
What are a few ND sinusitis treatments?
Botanicals: achillea, euphrasia, hydrasits.
Rest, water, simple diet, garlic, etc.
Hydro: Nasal lavage, steam inhalation.
When should you order imaging for sinusitis?
Never for acute sinusitis.
If you have persistent sinusitis and you suspect orbital cellulitis or brain abscess.
CT is probably the most accurate.
Fiberoptic visualization of the ostia may reveal obstruction from polyps or anomalies.
Are ABX indicated for acute sinusitis?
Rarely, 1 in 8 cases will respond.
How do you assess and treat epistaxis?
Assess by PE, look for bleeding site.
Frontal epistaxis is usually controlled with pressure or cold.
If uncontrolled, use topical anesthetic and silver nitrate.
When is epistaxis potentially dangerous?
If it’s a posterior bleed. Refer to an ENT!
Also dangerous if bleeding doesn’t stop or if the site of bleeding can’t be found.
What are a few of the risk factors for sinusitis?
VRI Allergies Anatomy MEds Irritants Many, many more.
What is the pathophysiology of sinusitis?
Viran infection leads to blockage of the ostia. Oxygen is absorbed from the enclosed space leading to negative pressure (pain from vacuum). Then transudate and bacteria invade the space leading to inflammation, ciliary dyskinesis, and positive pressure. This causes a second stage of pain.
What’s the prognosis for sinusitis?
May take 3-4 days for relief.
-Continue Tx for 10-14 days to avoid relapse.
-Refer: persistent HA, high fever, lethargy, orbital swelling.
What are some good physmed and hydro options for sinusitis?
Nasal specific Craniosacral Nasal lavage Steam inhalation
What’s the DDx for inflammatory rhinosinusitis with mostly eosinophils?
Allergic
- Non-allergic
- Asthma
- Fungal
What’s the DDx for inflammatory rhinosinusitis with mostly neutrophils?
-Acute bacterial
-Foreign body
-Nasal polyps
-Primary ciliary dyskinesia
What do you think about inflammatory rhinosinusitis with complex infiltrates?
common cold
What’s the general DDx for non-inflammatory rhinosinusitis?
-Structural
-Hormonal
-Drug induced
-Neural dysfunction
-Other (sick building, alzheimer’s)
What would you expect on CBC, scratch, nasal smear (eos) for allergic rhinitis?
- CBC +
- Scratch +
- Nasal smear (eos) +
What would you expect on CBC, scratch, nasal smear (eos) for NARES?
- CBC Neg
- Scratch Neg
-Nasal smear (eos) +
What would you expect on CBC, scratch, nasal smear (eos) for vasomotor rhinitis?
- CBC Neg
- Scratch Neg
-Nasal smear (eos) Neg
What’s the immune pathophysiology of allergic rhinitis?
Some Ag diffuses across the mucus membrane ->Th2 response ->IL-4, IL-13 stimulate B cells to make IgE.
Mast cells -> Histamine, PGL D2, Leukotrienes, Kinins, TNFa.
What does degranulation of mast cells eventually lead to in allergic rhinitis?
Contraction of smooth muscle.
Capillary dilation, increased permeability of capillary walls.
Glandular hyper-secretion.
Should you give urtica to every patient with hayfever?
No, it’s CI for diabetic pts (increases blood glucose) and people with fluid retention secondary to cardiac or kidney disease.
What’s Herbal Ed’s formula for hayfever?
Hydrastis Achillea Euphrasia Cochlearia
What can you give for recurrent epistaxis?
Vitamin C
Bioflavinoids
Homeopathy
What are three conditions (besides pharyngitis) that can cause sore throat?
Cardiovascular disease (aortic dissection)
Systemic disease
Other head and neck disorder.
Should you always do a quick ENT exam on all patient with a sore throat?
Yep
What are some oral lesions that can cause sore throat?
- Necrotizing gingivitis
- Herpes simplex
- Hand, foot, mouth
- Apthous ulcers
- Oral candida
- Mononucleosis
What are the signs and symptoms of mono?
-Posterior cervical and auricular LA
-Exhaustion and myalgia
-Tonsillar exudates
-Petechia on back of pharynx
-Hepatosplenomegaly (maybe)
How do you confirm mono with labs?
- Peripheral smear shows 80-100 atypical lymphocytes.
- Positive monospot.
-Elevated liver transaminases.
What is the CENTOR criteria for strep culture?
- Temp over 100
- No cough
- Swollen tender anterior cervical LA
- Tonsillar swelling or exudate
What are some cases in which you can safely decline to do a strep culture?
-Close contacts are positive.
-Scarlet fever is evident.
-In strep epidemics.
-Prior ABX
What is a strep carrier? Are they at risk for non-suppurative complications of strep throat?
Pts who are GABHS + but ASO titer negative.
They’re not at risk, they don’t mount an Ab response.
