ENT Flashcards
Weber’s test?
512Hz tuning fork placed in middle of forehead, ask which ear is loudest
Normal
- both equal
Sensorineural
- sound louder in normal ear
Conductive
- sound louder in affected ear
Rinne’s test
- flat end of tuning fork on mastoid, when pt can no longer hear, move to 1cm away from ear, wait until not heard again
Normal
- pt can hear sound in air - AC>BC - Rinne’s positive
Abnormal
- Can’t hear sound in air - BC>AC - Rinne’s negative - conductive hearing loss
Audiometry interpretation
Normal - anything above 20db line
Sensorineural - both air and bone conduction reduced
Conductive - bone normal, air reduced
Mixed - both air and bone reduced, >15db difference between - air often worse than bone
Vertigo
sensation of movt between pt + environment - feel like they are spinning / room is spinning
mismatch of sensory inputs for balance / posture - vision / proprioception / vestibular issues
Vertigo causes
Peripheral - vestibular
- BPPV
- Meniere’s
- vestibular neuronitis
- labyrinthitis
- Ramsay-Hunt, trauma to vestibular nerve, acoustic neuroma, otosclerosis
Central - brainstem / cerebellum
- posterior circulation infarct
- tumour
- MS
- vestibular migraine
Benign paroxysmal positional vertigo (BPPV)
recurrent episodes of vertigo, triggered by head movt
BPPV Patho
Calcium carbonate crystals displaced into semicircular canals
disrupt endolymph flow, confusing vestibular system
head movt creates flow of endolymph - triggers vertigo
Causes - viral infection, head trauma, aging, no cause
BPPV Px
vertigo triggered by head movt
- 10-20s episode
- nausea
- asym between attacks
- episodes occur over several weeks, resolve, can recur later
- no hearing loss / tinnitus
BPPV Dx
Dix-Hallpike manoeuvre
BPPV Mx
Epley manoeuvre
Brandt-Daroff exercises
Betahistine
Vestibular neuronitis
inflammation of vestibular nerve - usually viral
Vestibular neuronitis Px
acute onset vertigo
- URTI hx
- most severe at start (constant), then triggered by head movt
- N+V
- balance issues
- horizontal nystagmus
- no neuro sx
- no tinnitus / hearing loss
Vestibular neuronitis Dx
Head impulse test
Vestibular neuronitis Mx
Buccal / IM prochlorperazine
Cyclizine, cinnarizine, promethazine
Maybe vestibular rehab therapy
Labyrinthitis
Inflammation of semicircular canals, vestibule, cochlear
Usually after URTI / bacterial infection (eg meningitis, OM)
Labyrinthitis Px
- acute onset vertigo, exacerbated by movt
- hearing loss - sensorineural
- tinnitus
- N+V
- viral sx
- gait - may fall to affected side
- nystagmus
Labyrinthitis Dx
H/E
Head impulse test - abnormal
Labyrinthitis Mx
- prochlorperazine
- cyclizine, cinnarizine, promethazine
- abx for bacterial cause
Meniere’s disease
Long term inner ear disorder
excessive endolymph in labyrinth - disrupt sensory signals
Meniere’s disease Px
- unilateral, maybe bilateral after years
- vertigo, 20mins-hrs episodes, in clusters
- hearing loss - sensorineural
- tinnitus
- fullness in ear
- drop attacks
- imbalance
- nystagmus in attack
Meniere’s disease Dx
clinical dx - by ENT
Audiology
Meniere’s disease Mx
Acute attacks
- prochlorperazine
- cyclizine, cinnarizine, promethazine
Prophylaxis
- betahistine
- vestibular rehab exercises
Inform DVLA - don’t drive until sx controlled
Otitis externa (OE)
inflammation of external ear canal
bacterial, fungal, eczema, contact dermatitis, trauma, swimming….
OE Px
- ear pain, itch, discharge
- red, swollen ear canal
- lymphadenopathy
oe Ix
Can do swab
OE Mx
Mild;
- OTC acetic acid
Moderate:
- otomize spray - neomycin + dex + acetic acid
- oral abx (cipro / fluclox) - if immunocompromised, severe infection, spread beyond canal
- ear wick - sponge/gauze with topical tx
- fungal - clotrimazole
malignant OE?
- severe life-threatening form of OE
- commonly pseudomonas
- spreads to bones - osteomyelitis of temporal bone
Px
- OE and more severe
- headache, pain, fever
- purulent ear discharge
- granulation tissue in ear canal
- facial nerve palsy, hoarse voice, dysphagia
Mx
- admit under ENT
- IV abx
- CT / MRI head
Otitis media (OM)
infection of middle ear
often after viral URTI
also bacterial - strep pneumoniae….
OM Px
- ear pain
- reduced hearing
- URTI sx
- balance issues, vertigo
- discharge - if tympanic membrane perf
- young pts - fever, vomiting, irritable, lethargy, poor feeding…
OM Ix
Otoscopy - bulging tympanic membrane (effusion), red, inflamed, discharge
OM Mx
- paeds - admit if high fever…
- analgesia
- most self resolve
Immediate Abx if: systemically unwell, immunocompromised or significant comorbidities
Offer delayed prescription to pick up after 3 days if symptoms unresolved
- amoxicillin 5d
- erythromycin - if pregnant + pen allergy
- clarithromycin - if pen allergy
Mastoiditis?
- infection in mastoid air spaces of temporal bone (spread from middle ear)
Px
- otalgia - behind ear
- hx of OM
- fever, unwell
- swelling, red, tender over mastoid process
Ix
- CT
Mx
- IV abx
Presbycusis - Px, Ix and Mx
- age-related sensorineural hearing loss - high pitches first
Px
- gradual, insidious hearing loss
- speech difficult to hear
- tinnitus
Ix
- audiometry
- otoscopy - r/o ddx
- tympanometry
- bloods
Mx
- hearing aids
- cochlear implants
Otosclerosis
- remodelling of base of stapes - becomes stiff - conductive hearing loss
- <40yo
Px
- uni/bilateral
- hearing loss - lower pitches affected more
- tinnitus
Ix
- otoscopy - normal
- Weber’s / Rinne’s
- audiometry
- tympanometry
- ?CT
Mx
- hearing aids
- surgical - stapedectomy / stapedotomy - replace whole / part of stapes with prosthesis
Eustachian tube dysfunction?
- tube not working properly / blocked - eg URTI, allergies, smoking
Px
- reduced hearing
- popping in ear
- fullness
- pain, tinnitus
Ix
- otoscopy - r/o OM
Mx
- Valsalva
- decongestant nasal sprays
- antihistamines, steroid nasal spray
- Otovent - OTC
- surgery if severe
Glue ear? Px, Ix and Mx
OM + effusion -> loss of hearing
- eustachian tube blocked
Px
- reduction of hearing
- peak 2yo
Ix
- otoscopy - dull tympanic membrane, air bubbles / fluid level
- audiometry
Mx
- resolves alone <3mo
- hearing aids
- grommets
- ?adenoidectomy
Sudden sensorineural hearing loss (SSNHL): definition, Ix and Mx
- unexplained hearing loss <72hrs - ENT emergency
Ix
- audiometry
- MRI / CT head
Mx
- ENT referral
- tx cause
- idiopathic - steroids - oral / intra-tympani
Conductive causes of acute hearing loss
- ear wax
- infection - OM / OE
- middle ear effusion
- eustachian tube dysfunction
- perforated tympanic membrane
Causes of SSNHL
- 90% idiopathic
- infection - meningitis, HIV, mumps
- Meniere’s
- ototoxic meds
- MS
- migraine
- stroke
- acoustic neuroma
Tinnitus
persistent ringing in ears
Tinnitus causes
- idiopathic
- meniere’s
- otosclerosis
- SSNHL
- acoustic neuroma
- hearing loss
- drugs
- ear wax
- anaemia, DM, hypo/hyperthyroid, hyperlipidaemia
- objective tinnitus - carotid artery stenosis, AS, AV malformation
Tinnitus Ix
- otoscopy
- Rinne, Weber
- Bloods - FBC, glucose, TSH, lipids
- audiology
- CT / MRI if needed
Tinnitus red flags
- unilateral
- pulsatile
- hyperacusis - hypersensitive to sounds
- sudden hearing loss
- vertigo / dizziness
- visual / neuro sx
- suicidal ideation from tinnitus
tinnitus mx
treat underlying cause
symptom managment:
- hearing aids
- sound therapy (background noise to mask tinnitus)
- CBT
ear wax?
Px
- conductive hearing loss
- ear discomfort, feels full, pain
- tinnitus
Ix
- otoscopy
Mx
- ear drops - olive oil / sodium bicarb
- ear irrigation
- microsuction - by ENT