ENT Flashcards
Dry tympanic perforation
Key clinical features (symptoms, signs (including otoscopy)
If indicated, what would audiograms and/or other investigations show?
Management
Unilateral
hearing loss (might not take place with smaller perforations), tinnitus, otalgia, itching in your ear
Red flags - Headache, Nystagmus, Vertigo, Fever, Labyrinthitis, Facial paralysis, Swelling/tenderness behind the ear.
Signs- Can see perforation of the TM on otoscopy. There can be fogging of the otoscope. Conductive hearing loss.
Management - water exclusion - cotton bud covered with Vaseline in shower and no swimming
Painkillers
gets better on its own within 2 months and hearing returns to normal.
May prescribe antibiotics if there is an ear infection, or to stop getting an ear infection while the TM heals.
Sometimes, surgery (myringoplasty) may be needed if it is not healing by itself.
Don’t give ototoxic drops
Referral - Traumatic perforation - Consider referral at 6 weeks if not healed or hearing not recovered.
Non-traumatic - Consider referral if persists more than 6 months and either causing otalgia, discharge, hearing loss or restriction in activity due to water exclusion.
Cholesteatoma - Refer urgently if possible cholesteatoma - more likely in marginal TM perforations
Mastoiditis
Mastoiditis involves inflammation of the mastoid air cells within the petrous temporal bone.
Acute mastoiditis is a complication of acute otitis media (AOM) with the infection spreading from the middle ear into the mastoid air cells. This can result in abscess formation.
Symptoms- ottorhoea, severe throbbing pain, progressive hearing loss
Signs - Pyrexia, Swelling and redness in the postauricular region; the pinna is pushed down and forward. Marked tenderness over the mastoid, The tympanic membrane is either perforated and the ear discharging, or it is red and bulging.
Investigations
Treatment
When the diagnosis of acute mastoiditis has been made, do not delay.
• Admit the patient to hospital.
• Commence IV antibiotics immediately. If the organism is not known start with a cephalosporin and metronidazole
•Surgery - Immediate mastoidectomy to treat actue mastoiditis with subperiosteal abscess formation.
Mastoidectomy ± tympanoplasty, is also usually suggested if there is:
Mastoid osteitis, Intracranial extension, Co-existing cholesteatoma, Limited improvement after IV antibiotics.
Mastoidectomy can be:
Simple: infected mastoid air cells are removed.
Radical: the tympanic membrane and most middle ear structures are removed and the Eustachian tube is closed.
Modified: the ossicles and part of the tympanic membrane are preserved.
AOM
Diagnosis if:
Acute onset of symptoms - In older children and adults — earache.
In younger children — tugging, or rubbing of the ear, or non-specific such as fever, crying, poor feeding, restlessness, cough, or rhinorrhoea.
On otoscopic examination:
A red, yellow, or cloudy tympanic membrane.
Bulging of TM and an air-fluid level behind the TM (indicates a middle ear effusion).
Perforation of the tympanic membrane and/or discharge in the external auditory canal.
Management- usual course is about 3 days, but can be up to 1 week.
Paracetamol or ibuprofen for pain. Where immediate antibiotics are not prescribed, prescribe ear drops containing an analgesic and anaesthetic people under the age of 18 where there is no ear drum perforation or otorrhoea.
No evidence to support decongestants or antihistamines.
Children may return to school once they are afebrile and the otalgia has resolved.
Safety netting - seeking medical help if symptoms worsen significantly, do not improve after 3 days, or the person becomes systemically very unwell
If antibiotic - amoxicillin
Otitis externa
Suspect a diagnosis if:
At least one typical symptom (usually rapid-onset within 48 hours):
Itch of the ear canal.
Ear pain and tenderness of the tragus and/or pinna (often severe), with possible jaw pain.
Ear discharge.
At least two typical signs:
Tenderness of the tragus and/or pinna.
The ear canal is red and oedematous, and there may be debris and ear discharge.
Tympanic membrane erythema
Management
Provide advice on self-care measures - Avoid damage to the external ear canal, Keep the ears clean and dry. Consider use of over-the-counter acetic acid ear drops or spray for after swimming or bathing, for a maximum of 7 days.
Paracetamol or ibuprofen for symptom relief, if needed.
Consider cleaning the external auditory canal (‘aural toilet’), to enable topical treatments to be applied effectively.
Consider prescribing a topical antibiotic preparation with or without a topical corticosteroid for 7–14 days, depending on clinical judgement and symptom response.
Arrange follow up to reassess the person if:
Symptoms are not improving within 48–72 hours of starting initial treatment.
Symptoms have not fully resolved after 2 weeks of starting initial treatment.
Symptoms are severe
If recurrent = consider candida - white discharge
If topical don’t work flucoxacillin
Complications - malignant OE
RF - diabetes, 65 over, male, immunocompromised
Noise-related hearing loss
Destruction of hair cells which cannot regenerate
Sensorineural
Typically a history of previous exposure to persistent high levels of noise or sudden loud noises (such as machinery, gunfire, or loud music). May be associated with tinnitus. Examination is usually normal.
Examine:
Assessment may include the finger rub test or whispered voice test. Rinne and Weber.
Audiogram , speech audiometery in secondary.
Management - Hearing aids, cochlear implant (electric signals to directly stimulate cochlear nerve). Give support and info. Noise reduction.
Two type - acoustic trauma - instant
Chronic - gradual
Ménière’s disease
Aetiology - unknown - endolymphatic accumulation in cochlea causing sensorineural hearing loss.
Diagnosis:
A definite diagnosis requires all of the following criteria:
Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours.
Audiometrically documented low-to-medium frequency sensorineural hearing loss in one ear, locating to the affected ear on at least one occasion before, during, or after an episode of vertigo.
Fluctuating aural symptoms (hearing loss, tinnitus, or fullness) in the affected ear.
Not better accounted for by an alternative vestibular diagnosis.
Usually unilateral
Clusters in few weeks
Other symptoms:
Drop attacks without loss of consciousness that occur without warning (Otholitic crises of Tumarkin). Normal activities can be resumed immediately afterwards. They affect fewer than 1 in 10 people.
Balance or gait problems, Postural instability.
NV
Examine:
Head and neck examination findings are usually normal.
Horizontal and/or rotatory nystagmus that can be suppressed by visual fixation may be present.
Positive Romberg’s test (have to push) and cannot walk heel-to-toe in a straight line.
If asked to march on the spot with their eyes closed (Unterberger’s test), the person may be unable to maintain their position and will turn to the affected side.
Management - refer to ENT services.
In primary care:
Provide appropriate information and advice- long-term condition but vertigo usually improves with treatment.
Consider risks before undertaking activities such as driving, operating dangerous machinery etc.
To help alleviate nausea, vomiting, and vertigo:
Consider prescribing a short course (up to 7 days) of prochlorperazine or an antihistamine (such as cyclizine).
Consider prescribing a trial of betahistine to reduce the frequency and severity of attacks of hearing loss, tinnitus, and vertigo.
If the person’s symptoms deteriorate or do not improve after 5–7 days -
Reassess to exclude an alternative diagnosis.
Hearing loss towards end of disease.
Red flags for central pathology that require immediate hospital admission:
New unilateral hearing loss.
Focal neurological signs (facial weakness, diplopia, or limb weakness).
New-onset headache.
Normal head thrust test.
Congenital deafness - add how it might present
Rare - one in a thousand newborns
Take family history, maternal alcohol and infection history
Causes:
Inherited - most common autosomal recessive- Connexin 26
Syndromes - eg Down’s, Treacher Collins’, Waardenburg’s syndrome.
Intrauterine infection - eg, TORCH (toxoplasmosis, rubella, CMV, herpes, HIV)
Perinatal causes: eg prematurity, low birth weight, perinatal hypoxia, severe hyperbilirubinaemia and sepsis.
Management - early diagnosis and early intervention.
Offered a newborn hearing test before being discharged from hospital after birth. Or done by a healthcare profession in the first 4 to 5 weeks.
OAE test - how well cochlea, works. It measures otoacoustic emissions. Hair cells in the inner ear that respond to sound by vibrating. The vibration produces a very quiet sound that echoes back into the middle ear. This sound is the OAE that is measured.
ABR - measures brain activity to sounds
Do history and physical exam, diagnostic imaging, genetic testing etc.
Treatment consists of hearing aids and cochlear implantation (needs brain training so give young), combined with speech and language therapy.
Presbycusis
Get from history - TV louder, group conversations and background noise they can’t hear, keep repeating myself.
Bilateral gradual sensorineural hearing loss which may be caused by loss of receptor hair cells at the basal aspect of the cochlea resulting in characteristic high-frequency hearing loss.
Determining whether the pattern of hearing loss is sensorineural or conductive is an important first step - Weber and the Rinne test.
Presbycusis is characterized by bilateral hearing loss above 2000 Hertz.
Stop smoking
Avoid loud noises
Keep ears clean
Hearing aids, education
cholesteatoma
Diagnosis:
Unilateral usually
Recurrent purulent aural discharge, which may be unresponsive to antibiotic therapy.
Discharge is malodorous
Hearing loss or tinnitus
Less commonly, otalgia, vertigo, or facial nerve (VII) involvement (altered taste or facial weakness), indicating more advanced disease.
People with unilateral vertigo - suspect
Risk factors:
Male
Middle ear disease
Eustachian tube dysfunction
Otological surgery or traumatic blast to ear
Family History
Examine:
Evidence of ear discharge.
Presence of a deep retraction pocket in the tympanic membrane, with or without granulation tissue and skin debris.
Crust or keratin in the upper part of the tympanic membrane.
The tympanic membrane may be perforated.
Congenital cholesteatoma (rare) may appear as a white mass behind an intact tympanic membrane, in a person with no prior history of ear discharge, tympanic membrane perforation, or surgical procedures on the ear.
Management:
For all people with suspected cholesteatoma, arrange semi-urgent referral to an ear, nose, and throat specialist.
Investigations carried out in secondary care will include an audiology assessment and a CT scan.
Prior to surgical treatment, aural discharge may be treated with topical antibiotics.
Red flags - emergency admission:
A facial nerve palsy or vertigo.
Other neurological symptoms (including pain) or signs of an intracranial abscess or meningitis.
Referred ear pain - find common conditions that cause this
Ear pain with ear normal - eg no discharge
The auricle is innervated by cranial nerves V, VII, and X, and C2 and C3.
The ear canal is innervated by cranial nerves V, VII, and X.
The tympanic membrane is innervated by cranial nerves VII, IX, and X.
The middle ear is innervated by cranial nerves V, VII, and IX.
The trigeminal nerve provides sensory innervation to the face, and teeth and controls the mastication muscles. Auriculotemporal branch innervates the temporomandibular joint.
Dental and TMJ pathology = secondary otalgia.
CN VII provides taste sensation to the tongue’s anterior two-thirds via the chorda tympani nerve. The nervus intermedius is CN VII’s sensory portion. Inflammatory nervus intermedius pain is known as geniculate neuralgia (nerve synapses at geniculate ganglion).
CN IX provides taste and sensation to the tongue’s posterior third and afferents to the carotid body and oropharynx. Also controls the stylopharyngeus muscle.
CN X innervates thyroid gland, pharynx, and larynx. The vagus nerve’s superior laryngeal branch innervates the vocal cords. The vagus nerve also innervates distant organs such as the heart, lungs, and parts of the GI tract.
So pharyngeal and laryngeal disorders. Lung disease. Cardiac disease eg MI. GI disease eg GORD.
C2 and C3 are cervical plexus branches innervating the auricular lobule, cervical paraspinal muscles, and posterior head.
So MSK disorders eg cervical disc degeneration
Tonsillitis, Eustachian tube dysfunction, cold and coughs - most common
Otitis media with effusion
Retracted
Not infective
RF - Asthma
Cleft palate, Down’s
Management- better within 3months
Grommet insertions - will fall out - immediate improvement in hearing - prevent speech and development difficulties
Hearing aids
Wet tympanic perforation
Red flags - look at cks hearing loss
SSHL - steroid injections
Facial nerve palsy - could be stroke
Tenderness of mastoid
Intracranial - severe headache, visual impairment, vomiting
Trauma
Unexplained hearing loss
Necrotising OE
Less urgent
Progressing unexplained hearing loss
Cholesteatoma
Routine
Very gradual
Tinnitus, vertigo
People with cognitive impairment
Acute sinusitis
Diagnose - sinonasal inflammation lasting less than 12 weeks and associated with the sudden onset of at least two diagnostic symptoms - Nasal congestion or discharge, Facial pain (or headache), Reduction of sense of smell.
Other features - sore throat, hoarseness, and cough.
Non-specific systemic symptoms, such as malaise, fatigue, and fever.
Suspect acute bacterial sinusitis if at least three are present - more than 10 days, Discoloured nasal discharge, Severe localized pain (often unilateral pain over teeth and jaw), Fever greater than 38°C, Marked deterioration after an initial milder phase (double sickening).
Management:
caused by a virus, resolves within 12 weeks
Self-management - Paracetamol or ibuprofen for pain or fever.
Consider nasal saline or nasal decongestants (evidence is lacking) - tachyfalaxsis
If symptoms more than 10 days or worsening after 5 days - consider high-dose nasal corticosteroid for 14 days (or if polyps, enlarged turbinates).
Consider no antibiotic prescription or a back-up antibiotic prescription (look if bacterial cause likely).
Safety-netting - reassess if symptoms worsen rapidly or significantly or do not improve after treatment.
Red flags (admit to hospital) - Signs of sepsis.
Intraorbital or periorbital complications, including periorbital oedema or cellulitis, a displaced eyeball, double vision, ophthalmoplegia, or newly reduced visual acuity.
Intracranial complications eg swelling over the frontal bone, meningitis, severe frontal headache, or focal neurological signs.
Reduced consciousness.
Neoplasm - persistent unilateral such as nasal obstruction, discharge or nosebleeds,
Examination - general obs
Rhinoscopy
Otoscope - effusion
Allergic rhinitis
Allergic rhinitis - IgE-mediated - nasal mucosa becomes exposed to allergens, to produce symptoms of sneezing, nasal itching, rhinorrhoea, and congestion.
Usually begins in childhood.
Most common - pollen, dust, animal dander
Related to eczema and asthma
Complications - possible development of asthma, sinusitis, and nasal polyps.
Assessment:
Timing, persistence, severity, impact of symptoms.
Housing conditions, pets, and occupation.
Any drugs that may effect.
FH of atopy.
Management:
Possible use of saline nasal irrigation.
Allergen avoidance techniques -avoid wali g in grass, keep windows shut when pollen high
As-needed intranasal antihistamine or non-sedating oral antihistamine for symptoms that are mild, intermittent - ask about potential sedation, pregnant or breastfeeding.
Regular intranasal corticosteroids during periods of allergen exposure for moderate to severe persistent symptoms.
A short course of oral corticosteroid for severe, uncontrolled symptoms in adults that are significantly affecting quality of life.
Follow-up:
Review after 2–4 weeks if symptoms persist.
Swelling of throat, rapid breathing, pale, stridor, accessory muscles
Bloody rhinorea, unilateral nasal polyps - 2 week wait to ENT
Referral:
Persistent symptoms, allergy testing may be needed.
Deviated nasal septum
Cause - usually result of trauma, either recent or in the past, including at birth.
One acquired in a young child may become more pronounced as the septum grows.
Presentation - Difficulty breathing through one or both nostrils, Nosebleeds, Sinus infections, Noisy breathing during sleep in infants, Mouth-breathing during sleep in adults
Management - Septoplasty for nasal obstruction associated with septal deviation
If trauma - manual realignment first
Chronic sinusitis
Diagnosis - if sinonasal inflammation lasts 12 weeks or longer
with a combination of at least two diagnostic symptoms (nasal blockage, facial pain, loss of smell)
and objective evidence of sinonasal inflammation ( mucopurulent mucus, oedema, or polyps on examination or, radiographic/endoscopic evidence of sinonasal inflammation).
Examine - Inspect and palpate the maxillofacial area to elicit swelling or tenderness.
Perform an anterior rhinoscopy (using an otoscope or a nasal speculum and headlight) to identify:
Nasal signs (such as inflammation, mucosal oedema, and mucopurulent nasal discharge).
Associated pathology (such as nasal polyps).
Anatomical abnormalities (such as septal deviation).
If the person is systemically unwell, record pulse rate, blood pressure, and temperature.
Management:
Avoid allergic triggers.
Stop smoking
If the person has an associated disorder eg allergic rhinitis or asthma - good control is likely to benefit their symptoms.
Nasal irrigation with saline solution to relieve congestion.
Course (up to 3 months) of intranasal corticosteroid (for example, mometasone), especially if suspicion of allergic cause.
Red flags - same as acute sinusitis
CT scan - enlarged tissue in maxillary sinus needs surgery
Nasal polyps
Symptoms - depend on the size of the polyp (small polyps may be asymptomatic) and include:
Nasal airway obstruction, Nasal discharge, Watery anterior rhinorrhoea, sneezing.
Green secretions suggest infection (due to a polyp blocking the sinus ostia), Dull headaches, Snoring and obstructive sleep symptoms, decreased smell and taste.
Examination - tend to be bilateral. nasal speculum for visualisation.
Nasal polyps can be distinguished from the inferior turbinate by their lack of sensitivity, their yellowish-grey colour and ability to get between them and the side wall of the nose.
Using an aural speculum, look for single, or clusters of, grape-like structures.
Management - topical corticosteroids and then surgery (polypectomy)
Red flags:
Unilateral
Nasal fracture
Symptoms + signs - nose is obviously misshapen and out of place
It wobbles (unstable) and clicks, cuts around nose, swelling and/or bruising around nose, nose bleed (needs packing), blocked nose
History:
● How and when the injury was sustained
● Nasal obstruction (with persisting pain may indicate a septal haematoma)
● Change in appearance
Examination:
● Inspect the external nose, looking for obvious nasal bone deviation
● Inspect both sides of the internal nose using a pen torch
o Look for a red, fluctuant swelling on the septum that may indicate a septal haematoma or septal abscess
● Inspect the remainder of the face for obvious deformities – pay attention to the orbit and jaw
Management - A broken nose usually heals on its own within three weeks.
Simple break with no problems - use ice packs and take painkillers such as paracetamol and ibuprofen, to reduce the swelling and ease any pain.
Antibiotics if there is a cut over the area of the break.
If nose bleeds, pinch the fleshy part of the nose firmly for 20 minutes, breathe through mouth and lean forward in a sitting position.
Do not try to straighten nose if it’s changed shape, don’t blow nose until it’s healed, don’t do strenuous exercise for the first two weeks or play sports where face might be hit for at least six weeks.
Red flags - Skull base injury: watery rhinorrhoea or hyposmia
● Orbital trauma: visual disturbance, diplopia, ecchymosis
● Temporomandibular joint injury: altered bite, loose teeth, cheek paraesthesia
Epistaxis does not stop.
Loss of consciousness, vomiting or loss of memory of the injury.
Bleeding from one of the ears
Neck pain with or without tingling down arms/legs
Refer to ENT:
Fracture reduction required - <3 hours after injury have potential for good results (if minimal oedema is present) OR 7-10 days after injury (after swelling has resolved and before the setting of fracture fragments).
Refer to ENT surgeon:
● Attempts to reduce deformity or improve nasal obstruction are not always successful
● Epistaxis
● Septal haematoma
Thyroid nodules - look at classification of thyroid nodules
Symptoms - often asymptomatic. Sometimes cause pain and rarely present with features of compression of the trachea. Hyper,hypothyroidism
Signs - Ask the patient to drink some water and note the thyroid move as they swallow.
Note lumps, asymmetry, size and tenderness.
Check for regional lymphadenopathy.
Ultrasound
Management:
Hospital admission if upper airway obstruction such as stridor.
Arrange serum TFTs in primary care.
Arrange a routine endocrinology referral if:
non-suspicious thyroid nodule
Sudden-onset painful expansion in a pre-existing thyroid lump (likely to be due to haemorrhage into a benign thyroid cyst).
A thyroid nodule picked up incidentally on an ultrasound scan, CT, or MRI, which is more than 1 cm in diameter + no suspicious features.
Monitor in primary care depending on clinical judgement, if there is:
An adult with a history of a longstanding unchanging thyroid nodule over several years and no other red flags.
A non-palpable, asymptomatic thyroid nodule picked up incidentally on a scan which is less than 1 cm in diameter, with no red flags.
Red flags:
Persistent or rapidly-growing neck masses.
HN cancers - Dysphagia or odynophagia, Cough, or haemoptysis, hoarseness, Ipsilateral otalgia, Nasal obstruction, or epistaxis, loose or misaligned teeth
Risk factors for malignancy, such as smoking, excess alcohol intake, betel nut use; history of Hashimoto’s thyroiditis (increased risk of lymphoma).
RF:
Low iodine consumption.
The risk of malignancy in a thyroid nodule is higher under the age of 20 and over the age of 70.
Thyroid nodules and cancers are more common after exposure to radiation. This includes therapeutic radiotherapy.
Smoking increases the risk of nodular goitre.
Family history.
Medication such as amiodarone and lithium.
Cervical lymphadenopathy
Abnormal enlarged lymph nodes in neck
Infection, malignancies, autoimmune
Painful or not,
Hard, tethered, rubbery - malignant
Bacterial - antibiotics
Biopsy
Serology
Neck USS
Red flags - cough, weight loss, night sweats
Fixed hard irregular, rapidly growing
Dysphagia, hoarse
Vestibular migraine
Diagnostic criteria:
At least five episodes of vestibular symptoms AND
Associated with at least one of the following:
Headache with at least two of Unilateral location, Pulsating quality, Moderate or severe intensity, Aggravation by routine physical activity
Photophobia and phonophobia
Visual aura
History of motion sickness
Management:
Find triggers, food diary
Abortive treatment—use less than 10 days per month:
Simple analgesics/NSAIDs/triptans for headache
Vestibular sedatives (cyclizine, prochlorperazine) for vertigo
Consider prochlorperazine for nausea
Preventative treatment—Tricyclics (amitriptyline)
Red flags:
Direction-changing, or vertical nystagmus
Skew deviation and normal head impulse test
Neurological deficits including:
Acute unilateral deafness
Dysarthria
Limb weakness, numbness, or incoordination
Severe gait ataxia
Acute labyrinthitis
Symptoms - Acute vertigo, hearing loss, symptoms of URTI
Investigate ear for discharge, vesicles
Head impulse test - positive
Ease after few days, manage URTI, antihistamines for dizziness, vertigo, NV
First - line - prochloperazine
Not if pregnant or breastfeeding
Look at BP meds - hypotension
Physio if long term balance
Avoid alcohol
Don’t drive if dizzy
Sudden unilateral hearing loss- hospital
Benign paroxysmal positional vertigo
Repeated episodes of positional vertigo - loose calcium debris
Relapsing and remitting course
Symptoms - vertigo with head movement, dizzy, balance, NV
Exam - Dix-hallpike manoeuvre
Management - Epley manoeuvre
RF - Head injury, ear pathology or surgery
Vestibulopathy
Causes:
viral infection of the inner ear - acute symptoms - last for a few days or weeks.
restriction to the normal flow of blood to the inner ear can cause damage.
Some drugs can affect the balance system and can cause a weakness on one or both sides.
Other vestibular or neurological conditions e.g. MS or Stroke.
Common symptoms:
Vertigo: At the start it may be severe and will be constant. As time passes the dizziness is likely to be present only with head movements.
Nausea and vomiting - at the start of symptoms but the nausea can persist and is usually related to movement of the head.
Decreased balance. Initially may have problems walking unaided.
Veer sideways or lose balance with quick head or body movements.
Blurry vision
Hearing loss: trouble hearing conversations in busy places of have to
turn up the volume on the television.
Management:
Severe nausea and vomiting and cannot tolerate oral fluids - admit
Reassure that symptoms will usually settle over several weeks even if no treatment given. The brain will recognise there is an imbalance in the system and will make adjustments for it over time and so the symptoms improve - compensation - occurs if you keep as active as possible despite feeling dizzy.
To alleviate less severe nausea, vomiting, and vertigo, consider prescribing a short oral course of prochlorperazine, or an antihistamine - min amount of time possible so it does not delay compensation.
Vertigo on head movement - offer the Hallpike manoeuvre to check for BPPV if a healthcare professional is trained in its use. If BPPV is diagnosed, offer a canalith repositioning manoeuvre (eg Epley manoeuvre) if healthcare professional is trained.
Follow-up:
Advise the person to return if their symptoms deteriorate or have not fully resolved after 1 week.
Red flags:
Sudden-onset dizziness with a focal neurological deficit (such as vertical or rotatory nystagmus, new-onset unsteadiness or new-onset deafness) - could be posterior circulation stroke.
Sudden-onset acute vestibular syndrome with signs of stroke on HINTS test (normal head impulse test, direction-changing nystagmus or skew deviation) or it is not accounted by BPPV or postural hypotension.
Recurrent fixed-pattern dizziness with alteration of consciousness - epilepsy
