ENT

Question 1

what can the causes of vertigo be differentiated into?

Answer 1

central
peripheral

Question 2

what are the main causes of peripheral vertigo?

Answer 2

BPPV
Vestibular neuritis
Labyrinthitis
Meniere’s disease
Acoustic neuroma

Question 3

what are the main causes of central vertigo?

Answer 3

stroke/TIA (usually cerebellar)
Vestibular migraines
MS

Question 4

what is BPPV?

Answer 4

condition caused by the displacement of calcium carbonate crystals within the semi-lunar canals.

Question 5

what are the classical features of BPPV?

Answer 5

short episodes of vertigo
caused by movement such as turning head
sudden onset symptoms
not associated with tinnitus/hearing loss
causes nystagmus
vertigo resolves spontaneously

Question 6

how can you test for BPPV?

Answer 6

with the dix-hallpike manouver

Question 7

how is the dix hallpike manoeuvre performed?

Answer 7

place patient on the bed, turn their head to 45 degrees and then ask them to lay back with head still in that position. Observe for any nystagmus - if present - positive.

Question 8

what is the first line management of BPPV?

Answer 8

Provide them with the Brandt-Daroff exercises - advised to perform these for 4 weeks.
Consider Epley manoeuvre if able to perform.
If no improvement after 4 weeks and Epley manoeuvre, then referral to ENT for vestibular rehab.

Question 9

what is vestibular neuritis?

Answer 9

inflammation of the vestibular nerve supplying the semi-lunar canals and utricle. This can often follow a recent viral illness, but not always.

Question 10

what are the typical symptoms of vestibular neuronitis?

Answer 10

symptoms are usually of sudden onset
prolonged vertigo for several days
worse with movement
hearing and tinnitus are not present

Question 11

what are the typical symptoms of labrynthitis?

Answer 11

similar to vestibular neuronitis - start with prolonged vertigo, nausea, nystagmus for several days, then improves
can have hearing loss and tinnitus

Question 12

what is labrynthitis?

Answer 12

inflammation of the labyrinth

Question 13

management of labrynthitis or vestibular neuronitis?

Answer 13

Reassurance that symptoms would settle over the next few weeks without treatment
Advise to avoid alcohol, tiredness or intercurrent illness
short term symptomatic relief can be offered with oral prochlorperazine, cinnarizine, cyclizine or promethazine - for up to 3 days
Advise patients not to drive during acute phase

Question 14

what to do if patient with vestibular neuronitis or labrynthitis do not improve after 1 week?

Answer 14

urgent referral to ENT for consideration of vestibular rehab

Question 15

What are the red flags for hearing loss?

Answer 15

sudden onset unilateral or bilateral hearing loss (developing within 72 hours), which cannot be explained by external or middle ear causes
unilateral hearing loss with focal neurology
unilateral hearing loss with facial/head/beck injury
rapidly progressing hearin gloss

Question 16

what is eustachian tube dysfunction?

Answer 16

Build up of fluid in the middle ear after - can cause conductive hearing loss

Question 17

management of eustachian tube dysfunction?

Answer 17

option 1: do nothing - often resolves on its own
option 2: deongestants - max 5-7 days (any longer can cause rebound congestion)
option 3: antihistamines
option 4: steroid nasal spray - takes up to 1 month to work

Question 18

management of otitis media - in otherwise well child/adult?

Answer 18

option 1: no antibioticsn and safety netting advice to return if symptoms worsen rapidly or significantly - return if not better after 3 days.

option 2: back up antibiotics to use if not better after 3 days PLUS safety netting to seek medical attention

abc: amoxicillin for 5-7 days
or clari/erythromycin if allergic

safety netting

lower threshold for abx in patients who are <2 years or have bilateral symptoms

Question 19

what signs may cause admission in otitis media?

Answer 19

severe systemic infection
red flags such as mastoiditis or facial nerve paralysis
< 3 months with fever > 38 degrees

consider admission if <3 months but temp normal, or 3-6 months with temp > 39 degrees

Question 20

what is the treatment plan for otitis externa?

Answer 20

1: advice - keep ears clean and dry, use analgesia, if over 12 years can buy acetic acid 2% ear drops for max 7 days

2: consider topical antibiotics +/- topical steroid for 7-14 days: Otomize (dexamethasone and neomycin) - avoid in perforation due to risk of ototoxicity
If concern of perforation - ciprfloxacin +/- dexamethasone

safety net - improvement in 48-72 hours, if no improvement or resolution within 2 weeks - needs review

Question 21

what are the red flags of vertigo?

Answer 21

isolated persitent vertigo of hyperacute onset (came on over a few seconds)
normal head impulse test
new onset headache
new onset unilateral deafness
any cranial nerve/neurology on examination

Question 22

how to examine for cerebellar signs?

Answer 22

Dysdiadochokinesia
Ataxia (gait and posture)
Nystagmus
Intention tremor
Slurred, staccato speech
Hypotonia/heel-shin test

Question 23

management of chronic rhinitis?

Answer 23

consider referral for specialist allergy testing - house dust mite, pollen, animal dander

Advise patient to consider saline nasal irrigation e.g. sterimar - very helpful!
prescribe nasal spray: start with steroid nasal spray e.g. mometasone - takes 2-4 weeks to gain maximal benefit

If not helping can consider steroid/atnihistamine combination spray

Advice against decongestant

Question 24

management of recurrent epistaxis?

Answer 24

naspetin cream - apply QDS for 10 days - contraindicated if peanut allergy

if not settling or any concerns of red flag features - refer to ENT

Question 25

examination of suspected sinusitis?

Answer 25

check of facial tenderness
cest for postnasal pharyngeal secretions
look in ears for middle ear effusion
look in nostrils
vital signs

Question 26

management of acute sinusitis?

Answer 26

if symptoms for < 10 days:
self management with analgesia, nasal saline or deoncgestants

if symptoms > 10 days or worsening of 5 days:
- consider nasal spray e.g. mometaonse
- back up abx e.g. phenoxymethypenicillin