ENT Flashcards
Benign Paroxysmal Positional Vertigo
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Peripheral vestibular disorder that manifests as sudden, short-lived episodes of vertigo elicited by specific head movement
One of the most common causes of vertigo
Common in women, 50-70years
Causes:Either idiopathic or Otoliths/canaliths dislodging and moving into one of the semicircular canals (posterior, lateral or anterior) where it disrupts endolymph dynamics
RF:
- Head trauma
- Vestibular neuronitis- treat with prochlorperazine in the acute phase (should be stopped after a few days as it delays recovery)
- Labyrinthitis
- Migraines
- Inner ear surgery
- Meniere’s disease
CLINICAL FEATURES
- Vertigo provoked by specific head movements
- Brief duration of vertigo (<1 min)
- Episodic and sudden onset vertigo (sensation of head spinning)
- Nausea
- Imbalance
- Light-headedness
INVESTIGATIONS
Dix-Hallpike manoeuvre: if delayed onset rotatory/torsional nystagmus unilaterally and vertigo then positive sign for BPPV (both must be present)
Rotatory nystagmus indicates posterior canal BPPV
Lateral nystagmus indicates lateral canal BPPV
Vertical nystagmus indicates superior canal BPPV
(the patient is rapidly moved from a sitting to the supine posture with the head turned 45 degrees to the right. After 20 to 30 seconds, the patient is brought back to the sitting position)
MANAGEMENT
Canalith repositioning manoeuvres (CRM) → set of specific sequential manoeuvres to move otoconia out of semicircular canal and back into vestibule (Epley manoeuvre)
Rotatory nystagmus= Epley manouvre
Lateral nystagmus = Lempert manouver
Vertical nystagmus= Head hanging manouvre
At home patients can do Brandt-Daroff exercises → 3 to 4 times per day until there’s been 2 consecutive days without symptoms.
3 position particle repositioning manouevre
Semont repositioning manouevre
If mild or infrequent: observation and waitful watching
Meds: vestibular suppressant medication : benzodiazepines like lorezepam and diazepam, antihistamines like meclozine and promethazine)
Surgery is rare as most recover from repositioning manouvres or spontaneously
COMPLICATIONS
falls in elderly
What findings would suggest that the issue is not BPPV and what are the differentials
Consider another diagnosis if:
- If vertigo lasts >1min
- If associated hearing loss
- If associated neurological symptoms
- If elderly patient dizzy when extending their neck think Vertebrobasilar ischaemia
- Vestibular Neuritis : presents as vertigo lasting hours to days, N+V, balance problems, horizontal nystagmus, no hearing loss of tinnitus
- Viral labyrinthitis : vestibular neuritis but with hearing loss and tinnitus
- Acoustic neuroma (schwannoma): vertigo, hearing loss, tinnitus and absent corneal reflex
Epistaxis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Nosebleed.
Most common site is Kiesselbach plexus (littles area where vessels supplying nasal mucose anastomose with each other.]Most common in children and the elderly
2 types:
1) Anterior epistaxix 90%: blood flowing out of nostrils
2) Posterior epistaxis: blood running down throat, high risk of apiration and airway compromise
RF:
- Dry weather
- Minor nasal trauma (nose picking or rubbing)
- Primary coagulopathy (haemophilia)
- Familial hereditary haemorrhagic telangiectasia: auto dominant, mutliple telangiecasia (small dilated broken blood vessels) over skin and mucous membranes. Causes spontaneous, recurrent nosebleeds, a first degree relative will also have it
- Granulomatosis with polyangiitis: epistxis, sinusitis, dyspnoea, saddle shaped nose, rapidly progressive glomerulonephritis, cANCA positive
- Thombocytopenias: (Idiopathic thrombocytopaneia purapura is a thrombocytopenia in a well person causing petechiae and purapura- give oral prednisolone) (Thrombotic thrombocytopenia purapura is in an unwell person such as having fever, neurological signs or HUS (type of AKI))
CLINICAL FEATURES
- blood in 1 nostril or on both sides of nose
- Recurrent epistaxis → suggests anterior vessel on affected side- common in children
- Septal deviation- increased likelihood for epistaxis
INVESTIGATIONS
clinical diagnosis
MANAGEMENT
If haemodynamically unstable: fluid resus
1st Pinch the cartilaginous (soft) area of the nose firmly and bend their head forward (NOT BACK as blood may go into pharynx and cause haematemesis)
If blood doesnt stop within 10-15 mins:
1st - nasal cautery
2nd nasal packing (choose this if bleeding point difficult to localise
Recurrent epistaxis: naseptin (antiseptic cream)
Posterior epistaxis: ENT specialist (bleeds over 20 mins or occurs due to trauma of throat or neck or head)
COMPLICATIONS
- Acute bacterial rhinosinusitis
- Aspiration pneumonia
- Recurrent epistaxis
PROGNOSIS
respond well, especially to nasal packing
Infections Mononucleosis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Mono or kissing disease or glandular fever
Epstein Barr Virus (EBV)
Highly contagious and spreads via bodily secretions esp saliva (hence kissing disease). Common in 15-24 year olds
RF:
kissing and sexual activity
CLINICAL FEATURES
Incubation period is 6 weeks
Symptoms lasts 2-4 weeks in adults, children asymptomatic
- Fever
- Fatigue/malaise
- Splenomegaly
- Tonsilitis (sore throat) or pharyngitis
- Bilateral cervical lymphadenopathy
- Abdo pain
- Hepatomegaly and jaundice
- Maculopapular rash: develops in people who take amoxicillin/ampicilling whilst thy have mononucleosis
INVESTIGATIONS
Monospot test (heterophile antibody test) → positive heterophile antibodies
Also: Positive EBV-specific antibodies → IgG to EBV nuclear antigens appears 6-12 weeks after infection and are lifelong
Bloods: high AST and ALT, lymphocytosis and neutropenia
Blood film - atypical lymphocytes
MANAGEMENT
Supportive mainly:
- Rest
- Fluids
- Avoid alcohol
- Avoid physical activity due to risk of splenic rupture
- Analgesics / Antipyretics → acetaminophen (paracetamol)
- Corticosteroids in severe cases (prednisolone)
COMPLICATIONS
- Antibiotic-induced purapura rash if given amoxicillin
- Chronic fatigue
PRGNOSIS: good in healthy people
Death occurs rarely, and is caused by airway obstruction, splenic rupture, neurological complications, haemorrhage, or secondary infection
Meniere’s Disease
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
An episodic auditory and vestibular disease characterised by sudden onset of vertigo, hearing loss, tinnitus, and sensation of fullness in the affected ear. Due to impaired endolymph resorption in the inner ear → excess fluid in inner ear
Occurs in females 40-50 years old
Causes:
- Idiopathic
- Viral infections
- Autoimmunity
- Allergies
RF:
- Family history
- Recent viral illness
- Autoimmune disorders
CLINICAL FEATURES
1) Vertigo : recurrent episodes of spinning sensations lasting minutes to hours, assoiated with N+V, attacks in cluster in groups
2) Hearing loss that wosens around vertigo spells and unilateral in affected ear
3) Tinnitus in affected ear
- aural fullness
- fukudas stepping test
- Nystagmus
- Positive Rombergs test
If only foul smelling non-resolving discharge and hearing loss= cholesteatoma
INVESTIGATIONS
Pure tone audiometry for unilateral sensorineural hearing loss
- Rinne’s Test → air conduction > bone conduction bilaterally if positive
- Weber’s Test → localises to contralateral ear
Will show sensorineural hearing loss in acute Meniere disease or advanced disease.
Speech audiometry
MANAGEMENT
Acute attacks: Buccal or IM prochlorperazine
Prevention and to reduce attack frequency: Betahistine
Maintenance: Thiazide diuretics to reduce volume of endolymph
PROGNOSIS
Symptoms tend to worsen over time regardless of medical intervention
COMPLICATIONS
- Falls
- Profound hearing loss
Obstructive sleep apnoea
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Sleep-related breathing disorder in which airflow significantly decreases or ceases due to an upper airway obstruction
Sleep → Decreased Muscle Tone → Upper Airway Collapse → Apnoea (Intermittent Hypoxia) → Arousal (Fragmented Sleep, Sleepiness and Cognitive Dysfunction) → Airway Reopens
Men, older, overweight middle aged men
Classifications
- Mild (5-15 events/hr)
- Moderate (15-30 events/hr)
- Severe (>30 events/hr)
Causes:
- Obesity
- Acromegaly (causes macroglossia)
- Hypothyroidism (causes macroglossia)
- Large tonsils
- Alcohol
- Smoking
CLINICAL FEATURES:
- Excessive daytime sleepiness- measured by Epworth sleepiness scale (14 is moderate sleepiness and 18 is severe)
- Episodes of apnoea and gasping
- Restless sleep
- Chronic, loud snoring
- Signs of complications
- Impaired cognitive function
- Depression
- Decreased libido
- Hypertension with increased pulse pressure
Partner often complains of loud snoring
Not sleeping well can lead to:
daytime somnolence
compensated respiratory acidosis
hypertension
INVESTIGATIONS
Polysomnography (PSG)
Assess risk of OSA: STOP-BANG score (>3 means you should do PSG)
Assessment of sleepiness
Epworth Sleepiness Scale - questionnaire completed by patient +/- partner
Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria)
MANAGEMENT:
address weight loss first
1st line after lifestyle= CPAP at night
If CPAP not tolerated -> intra-oral devises (mandibular advancement)
If OSA is causing excessive daytime sleepiness then DVLA
COMPLICATIONS
- impaired glucose metabolism
- cardiovascular disease
- depression
- motor vehicle accidents
- cognitive dysfunction
- increased mortality
PRONGOSIS
patients efficiently treated may report improvements in alertness and some improvement in quality of life, mood, and cognitive function
Rhinosinusitis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Symptomatic inflammation of the lining of the nasal cavity (rhinitis) and paranasal sinuses (sinusitis). Usually women and usually in colder months
2 causes:
Viruses: rhinovirus, coronavirus, adenovirus
Bacteria: strep pneumonia, H.influencae
- Symptoms <10 days → viral
- Symptoms >10 days but <4 weeks → bacterial
3 categories:
- Acute ≤4 weeks
- Subacute 4-12 weeks
- Chronic ≥12 weeks
RF:
- pre-existing viral URTI can lead to superimposed bacterial infections
- atopy (hay fever/asthma)
- nasal obstruction
- smoking
CLINICAL FEATURES
- Frontal facial pain/pressure worse on bending forwards
- Purulent nasal discharge- discoloured nasal mucus
- Nasal obstruction (congestion/stuffiness/blockage)
- Cough
- Myalgia
- Sore throat
- Anosmia
INVESTIGATIONS
clinical diagnosis
if suspect complications: Sinus CT, may see:
- Opacification
- Mucosal thickening
- Air-fluid levels
- Soft tissue swelling
Can also do Nasal endoscopy- provides good visualisation for the nasal cavity and sinuses
Sinus culture can help to plan appropriate management
MANAGEMENT
Supportive: analgesics or antipyretics
Treatment:
- Decongestants
- Intranasal corticosteroid: If lasted >10 days
- Ipratropium (anticholinergics)
+
Nasal irrigation with intranasal saline
If severe: penoxymethylpenicillin with the above measures
PROGNOSIS
generally self-limiting and resolves within 1 month. Complications are more commonly seen in the paediatric population, and occur due to direct extension of the infection into neighbouring structures.
COMPLICATIONS
- chronic sinusitis
- bacterial meningitis
- brain abscess
- peri-orbital or orbital cellulitis
Tonsilitis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Inflammation of the tonsils- specifically an infection of the parenchyma of the palatine tonsils. Common in children 5-15 years old
Infectious condition and can be spread by exposure to an infected person (hence predominantly a disease of school children)
2 causes:
1) Viral:
- Rhinovirus
- Coronavirus
- Adenovirus
- Mono (EBV)
2) Bacterial:
Streptococcus pyogenes
CLINICAL FEATURES
- Pharyngitis (sore throat)
- Fever >38°C
- Malaise
- Purulent tonsillar exudate (yellow or white pustules may be present)
- Pain on swallowing
- Tonsillar enlargement + erythema
- Enlarged anterior cervical lymph nodes (lymphadenopathy)
INVESTIGATIONS
Throat culture fir bacterial: not so useful as limits come back in 48 hours.
Instead, Rapid streptococcal antigen test: lower sensitivity but immediate results.
Use this test is suspect group A beta haemolytic strep pyogenes (GABHS)
Centor Criteria (criteria for likelihood of GABHS
- Presence of tonsillar exudate
- Tender anterior cervical lymphadenopathy or lymphadenitis
- Fever 38°C
- Absence of cough
(1 point for each and 3 or more indicates strep pyogenes
MANAGEMENT:
Acute no GABHS: Analgesics (paracetamol main one or ibuprofen/aspirin/naproxen)
Acute with GABHS or 3/4 centor: Analgesics + 7-10 days Abx (phenoxymethylpenicillin) + corticosteroids (dexamethasone).
if allergic to penicillin switch to clarithromycin
If:
Sore throats are due to tonsillitis (i.e., tonsils are erythematous, oedematous and may have exudates)
Episodes for at least one year
Episodes are disabling and prevent normal function
Seven or more well documented, clinically significant sore throats in preceding year OR
Five or more episodes in each of the preceding two years OR
Three or more episodes in each of the preceding three years
This patient has been given a tonsillectomy information leaflet
Six months watchful waiting has not resulted in significant improvement ( particularly relevant in children and teenagers)
then tonsillectomy
- common complication is haemorrhage (if is within 24 hours of surgery must undergo another surgery),, (if happens 5-10 days after surgery indicates infection so ABx
COMPLICATIONS
- Scarlet fever
- Acute sinusitis
- Acute otitis media
PROGNOSIS
Acute, self limiting, usually better in 1 year.
Some patients may have recurrent so consider tonsillectomy
Weber and Rinne results interpretation
Normal=
rinne: air condution> bone BILATERALLY= rinne positive
weber: midline, equal in both
CONDUCTIVE HEARING LOSS (problem with sound travelling to inner ear)
rinne:
bone conduction> air in AFFECTED EAR (rinne regative)
air conduction> bone in normal
weber: side of affected ear
conductive: negative rinne and weber on affected ear
SENSORINEURAL LOSS (problem with auditory nerve or cochlea)
rinne: air conduction> bone conuction bilaterally
Weber: lateralises to unaffected ear
Sensorneural: positive rinnes, webers heard more in opposite ear
