ENT Flashcards
Hallmarks of Facial Nerve Palsy ??
Main nerve supplying the str. of 2nd Embryonic Branchial arch
- Predominantly an EFFERENT nerve to muscles of Facial expression, Digastric muscle & also glandular str.
- Few Afferent fibres: Originate in Geniculate ganglion & are concerned with Taste
SUPPLY (Face, Ear, Taste, Tear)
- Face: facial expression muscles
- Ear: Nerve to Stapedius
- Taste: Supplies to anterior 2/3rd
- Tear: Parasympathetic fibres to lacrimal glands & Salivary glands
Causes of B/L CN-7 palsy ??
Sarcoidosis
GBS
Lyme’s Disease
B/L Acoustic Neuroma (as in NF-2)
BELL’S Palsy (25% of B/L cases but this represents 1% of total Bell’s palsy cases)
Causes of U/L CN-7 palsy ??
LMN Lesions
- Bell’s Palsy
- Ramsay-Hunt syndrome (HZV)
- U/L Acoustic Neuroma
- Parotid Tumour
- HIV, - MS, - DM
UMN Lesion
- Stroke
- MS
UMN vs LMN lesion ??
UMNL ‘spares’ upper face ie Forehead
LMNL affects all facial muscles
Facial Nerve Course/ Path
SUBARACHNOID Path
- Origin: Motor- Pons, Sensory- Nervus Intermedius
- Pass through Petrous Temporal bone into Internal Auditory Meatus with CN-8.
- Here it combines to become FN
FACIAL CANAL Path
- Canal passes superior to vestibule of inner ear
- At the middle part of middle ear, it gets wider, contains Geniculate G
- 3 branches: Greater Petrosal N, Nerve to Stapedius, Chorda tympani (Sensory Taste)
STYLOMASTOID Foramen
- Passes through SMF (Tympanic cavity anterior & Mastoid antrum posteriorly)
- Posterior Auricular N & Branch to POSTERIOR Belly of Digastric & Stylohyoid muscle
Hallmarks of Bell’s Palsy ??
Acute U/L, Idiopathic, CN-7 palsy
- HSV might be the cause
- Peak Incidence: 20-40 yrs
- MC in Pregnant women
C/F -
LMN Lesion of FN- Forehead affected
Post-auricular pain (may precede paralysis), Altered taste, Dry eyes, Hyperacusis
Rx. of Bell’s Palsy ??
Oral Predinosolone within 72 hrs of onset of Bell’s palsy
NICE
- Anti-Viral Rx. with CS may have a small benefit, but seek specialist advice if this is being considered
UpToDate : recommends addition of Anti-virals for Severe FN Palsy
Eye Care (to prevent E Keratopathy)
- Artificial tear & Eye lubricants
- Taping with micropore: If unable to close eye at bedtime
Follow up & Prognosis of Bell’s Palsy ??
If paralysis shows NO sign of improvement after 3 wks
- Urgent referral to ENT
If more long standing weakness (for several months)
- Plastic Sx. referral
Most people fully recover in 3- 4 months
- If untreated, 15% of pts. have permanent moderate to severe weakness
What is Ramsay Hunt Syndrome ??
Herper Zoster OTUCUS is caused by
- Reactivation of VZV in the Geniculate ganglion of CN-7
C/F-
- 1st c/f : Auricular pain
- FN palsy
- Vesicular Rash around Ear
- Vertigo, Tinnitus
Rx.- Oral Aciclovir + Corticosteroids
Rinne’s & Weber’s test
Rinne’s Test
- Tuning fork is placed over the mastoid process until the sound is no longer heard, followed by repositioning just over EAM
- (+)ve Rinne’s: AC normally better than BC
- (-)ve Rinne’s: BC > AC then Conductive deafness
Weber’s Test
- U/L SNHL : Sound localised to NORML Ear
- U/L Conductive deafness: Localised to Affected ear
Interpretation of Rinne’s & Weber’s test ??
Type = Rinne’s = Weber’s
1) Normal = AC>BC = Midline
2) Conductive HL = BC>AC in affected ear & AC>BC in normal ear = Lateralised to Affected ear
3) SNHL = AC>BC = Lateralised to Unaffected/ Normal ear
Hallmarks of Otosclerosis ??
Replacement of Normal bone by VASCULAR Spongy Bone.
- Causes Progressive conductive deafness due to Stapes fixation to Oval window
- A D & Typically affects Young adults
- FHx present
- Previous Measles infection is a RF
Features of Otosclerosis ??
Onset at 20-40 yrs:
- Conductive HL
- Tinnitus
- Normal T Memb.: 10% pts. may have ‘Flamingo tinge’ due to Hyperaemia
Rx.-
- Hearing aid
- Stapedectomy
Hallmarks of Otitis Externa ??
Causes
- Infection: Bacterial (Staph. aureus, P aeruginosa) or Fungal
- Seborrhoeic Dermatitis
- Contact Dermatitis (allergic or Irritant)
- Recent Swimming (common trigger)
Features
- Ear pain
- ITCH & Discharge
- Otoscopy: Red, swollen, or Eczematous
Rx. of Otitis Externa ??
Initial Rx.-
- Topical Abx. or Topical Abx. + Steroids
- If T memb. is perforated, Aminoglycosides are not used
- Remove if any canal debris
- Canal extensively swollen: Insert an ear wick
SECOND Line Rx.-
- Consider Contact dermatitis 2ndary to Neomycin
- Oral FLUCLOXACILLIN (if spreading)
- Take Ear swabs from ear canal
- Empirical use of Anti-Fungals
If FAILS to respond to Topical Abx., pt. should be REFERRED to ENT
Malignant Otitis Externa ??
MC in Elderly DM pts.
In this condition, there is
- Extension of infection into bony ear canal &
- Soft tissues deep to bony canal involved
Rx.- IV Antibiotics required
Hallmarks of Tinnitus ??
Perception of sounds in the ears or head with no external stimuli
CAUSES
Idiopathic (cause will not be found in majority of pts.)
Meniere’s Disease
- a/w HL, Tinnitus, Aural fullness or pressure
Otosclerosis
Sudden Onset SNHL (SSNHL)
Hearing Loss
- Excessive loud noise & Presbycusis
DRUGS
Impacted wax
Assessment of Tinnitus ??
Audiological assessment
- Detect underlying HL
IMAGING
MRI Scan
- Non-pulsatile + U/L or other Neuro./ Otological signs
MRA
- Pulsatile Tinnitus
Rx. of Tinnitus ??
Ix. & Treat any underlying Cause
Amplification Devices
- More beneficial if a/w HL
Psychological therapy - CBT
Tinnitus Support group
What is Sudden onset SNHL ??
Seen in
- Acoustic neuroma
HL, Vertigo, Tinnitus
ABSENT Corneal reflex
a/w NF-2
Drug causes of Tinnitus ??
Aspirin or NSAIDs
Aminoglycosides
Loop Diuretics
Quinine
Hallmarks of Meniere’s Disease ??
Excessive pressure + Progressive Dilation of Endolymphatic system
- MC in Middle-aged adults
Features
- Recurrent episodes of D(SNHL)VT
- Aural Fullness
- Nystagmus + (+)ve Romberg’s
- Episodes last: Min to Hrs
- Typically U/L features but B/L can also occur after several years
Rx. of Meneire’s Disease ??
Resolve in maj. pts. after 5- 10 yrs & will be left with a degree of HL
Rx
- ENT assessment ro confirm Dx.
- Pt. should inform DVLA (Stop driving till satisfactory control of c/f achieved.
ACUTE attacks:
- Prochlorperazine (Buccal or IM)
- Admission may be required sometimes
PREVENTION
- Betahistine & Vestibular rehabilitation exercises
Hallmarks of Vestibular Neuronitis ??
Vertigo seen after a Viral infection
Features
- Recurrent Vertigo
- Lasts for Hrs. to Days
- Horizontal Nystagmus
- NO HL or Tinnitus
DDs
- Viral Labyrinthitis
- Posterior Circulation Stroke
Rx. of Vestibular Neuronitis ??
1) Acute Rx. for Severe cases
- Prochlorperazine (Buccal or IM)
2) Less severe cases
- Short oral course of Prochlorperazine or Antihistamine (Cinnarizine, Cyclizine, Promethazine)
3) Chronic symptoms
- Vestibular Rehabilitation Exercises
Hallmarks of BPPV ??
Sudden onset of Dizziness & Vertigo triggered by changes in Head position
- Age of onset: 65 yrs
Rx.-
Symptomatic Relief
- EPLEY Manoeuvre (successful in 80%)
- Brandt-Daroff exercise (self exercise at home- Vestibular rehabilitation)
Medications
- Betahistine (limited value)
How to distinguish b/w Peripheral & Central causes of Acute Vestibular syndrome particularly to exclude Posterior circulation stroke ??
HiNTS examination (100% sensitive & 96& specific for Peripheral causes of vertigo)
1) Head impulse
A (+)ve test [corrective saccade (+)ve] indicates a Disruption in Vestibulo-Ocular reflex, ie., it is a peripheral cause of Vertigo
- Peripheral Vertigo: Abnormal
- Central vertigo: Normal
2) Nystagmus
- PV : None/ Unidirectional
- CV : Bi-directional or Vertical
3) Test of Skew
Abnormal eye movt. such as Vertical Diplopia
- PV : No Vertical Skew
- CV : Vertical Skew
