ENT Flashcards
What is Bell’s palsy?
An acute unilateral peripheral facial nerve palsy, consisting of deficits affecting all facial zones equally that fully evolve within 72 hours
What is the aetiology of Bell’s palsy?
Viral aetiology which is strongly associated with the herpes simplex virus (type 1)
What are the risk factors for Bell’s palsy?
Pregnancy (x3)
Diabetes (x5)
Intranasal influenza vaccination (no longer in clinical use)
What is the epidemiology of Bell’s palsy?
Bell’s palsy is the most common aetiology of unilateral facial palsy among those 2 years of age or older
Affects 15–40/100 000/yr
It is most prevalent in people between 15 and 45 years of age and equal in men and women
What are the presenting symptoms of Bell’s palsy?
Complete unilateral facial weakness
Quick onset (e.g. overnight or after a nap)
Ipsilateral numbness or pain around the ear
Reduced taste - anterior 2/3rds (ageusia)
Hyperacusis- hypersensitivity (from stapedius palsy)
Unilateral sagging of the mouth
Drooling of saliva
Food trapped between gum and cheek
Speech difficulty
Failure of eye closure may cause a watery or dry eye
What are the signs of Bell’s palsy on physical examination?
Unable to complete or resist on facial nerve actions
Unable to wrinkle their forehead (no forehead sparing which occurs in UMN lesions e.g. stroke) confirming LMN pathology
What are the appropriate investigations for Bell’s palsy?
1st Line:
-Clinical diagnosis: acute, unilateral facial palsy, with an otherwise normal physical examination
Rule out other causes:
-Blood: ESR; glucose; raised Borrelia antibodies in Lyme disease, raised VZV antibodies in Ramsay Hunt syndrome
- CT/MRI: Space-occupying lesions; stroke; MS
-CSF: (Rarely done) for infections.
What differentiates Lyme disease, Guillain–Barré, sarcoid, and trauma from Bell’s palsy?
They all often present with bilateral weakness
What is the management for Bell’s palsy?
Drugs:
-If given within 72h of onset, prednisolone speeds recovery, with 95% making a full recovery.
-Antivirals (eg aciclovir) can be used in the cases associated with HSV-1
Protect the eye:
-Dark glasses and artificial tears (eg hypromellose) if evidence of drying
-Encourage regular eyelid closure by pulling down the lid by hand
-Use tape to close the eyes at night
Surgery: Consider if eye closure remains a long-term problem (lagophthalmos) or ectropion is severe (eyelid turns outward)
What are the possible complications of Bell’s palsy?
Keratoconjunctivitis sicca: dry eye
Ectropion: sagging eyelid
Synkinesis: increased neural irritability and aberrant regeneration of motor axons e.g. eye blinking causes synchronous upturning of the mouth
Gustatory hyperlacrimation: (crocodile tears) misconnection of parasympathetic fibres can produce crocodile tears (gusto–lacrimal reflex) when eating stimulates unilateral lacrimation, not salivation
What is the prognosis for patient’s with Bell’s palsy?
Incomplete paralysis: without axonal degeneration usually recovers completely within a few weeks.
Complete paralysis: ~80% make a full spontaneous recovery, but ~15% have axonal degeneration in which case recovery is delayed
- Some evidence suggests pregnancy-associated Bell’s palsy is associated with worse long-term outcomes
What is benign paroxysmal positional vertigo (BPPV)?
A peripheral vestibular disorder that presents as sudden, short-lived episodes of vertigo elicited by specific head movements e.g. sitting to lying down
(one of the most common causes of vertigo)
What is the aetiology of BPPV?
Approximately 50% to 70% of BPPV occurs without a known cause and is referred to as primary (or idiopathic) BPPV.
Secondary BPPV is associated with a range of underlying conditions (migraines, head trauma, labyrinthitis, Ménière’s disease)
What is the epidemiology of BPPV?
Primary BPPV is more common between 50 and 70 years, but can occur at any age.
Migraine and head trauma are more common in younger patients with secondary BPPV compared with older patients with secondary disease.
What are the presenting symptoms of BPPV?
Specific provoking positions causing dizziness Episodic dizziness Sudden onset of dizziness Nausea Light headedness
What are the signs of BPPV on physical examination?
Normal neurological examination
Absence of associated neurological/ otological symptoms e.g. hearing loss, tinnitus (makes alternative diagnoses more likely)
What are the appropriate investigations for BPPV?
Dix- Hallpike test: If the test is positive the patient will complain of vertigo and you should be able to directly observe nystagmus
What are the different types of nystagmus that you could observe in the Dix-Hallpike test and what does it indicate?
Rotary nystagmus is the most common type and suggests the involvement of the superior semicircular canal
Horizontal nystagmus suggests the involvement of the lateral semicircular canal
What is the Epley manoeuvre?
It is used to treat BPPV (usually of the posterior canal) once it has been diagnosed using the Dix-Hallpike test
What is infectious mononucleosis?
A clinical syndrome most commonly caused by Epstein Barr virus (EBV) infection, also known as glandular fever
What is the aetiology of infectious mononucleosis?
Epstein Barr virus (EBV), also known as human herpes virus 4, is the aetiological agent in approximately 80% to 90% of cases
Other causes: Herpes virus 6, cytomegalovirus and HSV-1
What are the risk factors for infectious mononucleosis?
Close contact e.g. kissing, sharing eating utensils, sexual behaviour
What is the epidemiology of infectious mononucleosis?
Common (UK annual incidence 1 in 1000)
Has two peaks:
1. 1–6 years (usually asymptomatic)
2. 14–20 years
What are the presenting symptoms of infectious mononucleosis?
Incubation period: 4–8 weeks
May have abrupt onset: sore throat, fever, fatigue, headache, malaise, anorexia, sweating, abdominal pain
What are the signs of infectious mononucleosis on physical examination?
Pyrexia.
Oedema and erythema of pharynx, fauces and soft palate, with white/creamy exudate on the tonsils which becomes confluent within 1–2 days, palatal petechiae. Cervical/generalized lymphadenopathy
Splenomegaly (50–60%), hepatomegaly (10–20%).
Jaundice (5–10%)
What are the appropriate investigations for infectious mononucleosis?
1st line:
- Bloods: FBC (leukocytosis), LFT (raised aminotransferases)
- Blood film: Lymphocytosis (>20% atypical lymphocytes)
- Heterophile antibodies: produced in response to EBV infection
- EBV specific antibodies
- Throat swab: exclude streptococcal tonsilitis
Consider: CT of abdomen (splenic rupture)
What is Ménière’s disease?
An auditory disease characterised by an episodic sudden onset of vertigo, low-frequency hearing loss (in the early stages of the disorder), low-frequency roaring tinnitus, and sensation of fullness in the affected ear
What is the aetiology of Ménière’s disease?
Underlying cause is unknown
What are the risk factors for Ménière’s disease?
Recent viral infection
Genetic predisposition
Autoimmune disease e.g. rheumatoid arthritis (especially likely when MD presents bilaterally)
What are the presenting symptoms of Ménière’s disease?
Vertigo (recurrent episodes) Tinnitus Hearing loss (unilateral in affected ear) Nausea Headaches Aural fullness
What are the signs of Ménière’s disease on physical examination?
Positive Romberg’s test: Swaying or falling when asked to stand with feet together and eyes closed
Fukuda’s stepping test: Turning towards the affected side when asked to march in place with eyes closed
What are the appropriate investigations for Ménière’s disease?
1st line:
- Pure-tone audiometry and bone conduction: unilateral sensorineural hearing loss (early stages= low frequency, as disease progresses= middle and high frequencies are affected)
- speech audiometry: assess the degree of hearing loss
- EEG: abnormally large summating potential amplitude
- Vestibular evoked myogenic potential (VEMP): increased amplitude in early disease, attenuated or absent in later stages
What is the management for Ménière’s disease?
There is no cure for MD.
Reduce endolymphatic pressure to control vertigo:
-Dietary changes (low salt)
-Diuretics
Symptomatic treatments:
-Vertigo: vestibular suppressants and anti-emetics
-Tinnitus: sound based therapies, tinnitus maskers
-Sudden hearing loss: corticosteroids (intratympanically or orally)
What are the goals of treatment for Ménière’s disease?
Vertigo control
Prevention of further deterioration in hearing whenever possible
Amelioration (improvement) of tinnitus
Balance control
What are the complications of Ménière’s disease?
Falls
Profound hearing loss
What is the prognosis for patients with Ménière’s disease?
Symptoms tend to get worse over time regardless of medical intervention
MD goes into periods of remission that are variable in duration and frequency
The progression of hearing loss over time is unpredictable for the individual patient
What is the management for infectious mononucleosis?
Generally a self-limiting condition with no specific treatment.
The mainstay of therapy is supportive care:
Good hydration
Antipyretics
Analgesics
What is the management for infectious mononucleosis in severe cases?
Systemic corticosteroids should be reserved for patients with severe airway obstruction, severe thrombocytopenia (<20,000 platelets/mm3), or haemolytic anaemia
What are the complications of Infectious Mononucleosis?
Splenic rupture- infiltration of lymphocytes (LOW)
Encephalitis (LOW)
Chronic active EBV infection (LOW)
Fatigue (MEDIUM)
What is the prognosis for a patient with infectious mononucleosis?
The prognosis for healthy people with IM is very good. Death occurs rarely, and is usually caused by airway obstruction, splenic rupture, neurological complications, haemorrhage, or secondary infection
What is the management for BPPV?
The initial step in managing BPPV is patient education and reassurance.
Particle repositioning manoeuvre e.g. Epley to clear the affected semicircular canal of debris
What are the complications of BPPV?
Sudden head movements an precipitate an episode of BPPV and result in accidents/ falls
Falls- particularly in older patients
What is the prognosis for a patient with BPPV?
BPPV is highly treatable, but recurrences are common even after successful treatment with repositioning manoeuvres, so further treatments may be required
What are thyroglossal cysts?
Fluid-filled sac which can be a remnant of the development of the thyroid gland
What is the aetiology of thyroglossal cysts?
- During fetal development, the thyroid gland is located at the back of the tongue.
- It migrates down the neck, passing through the hyoid bone
- As the thyroid gland descends, it forms a small channel called the thyroglossal duct.
- This duct usually disappears once the thyroid gland reaches its final position in the neck.
- Sometimes part of the duct remains and leaves a pocket. A thyroglossal cyst will form when fluid collects in this pocket.
What is the epidemiology of thyroglossal cysts?
Are present at birth and often occur in children (mean age of presentation is around 5 years)
What are the presenting symptoms of thyroglossal cysts?
Usually a painless, soft, round lump in the front centre of the neck
May also be asymptomatic and go unnoticed until they become infected
(If the cyst becomes infected, it can become tender, red and swollen)
*Some patients may find it difficult to swallow or to breathe or experience recurring infection, excessive swelling, or pressure symptoms.
Sometimes mucus may seep out of a small opening in the skin near the lump
What are the signs of thyroglossal cysts on physical examination?
On examination of the neck: soft, round lump in the front centre of the neck
They will typically move when the person swallows or sticks their tongue out
What are the appropriate investigations for thyroglossal cysts?
Bloods: infection markers (WCC), TFTs Ultrasound examination Thyroid scans Fine needle aspiration X-rays with a contrast dye
What is the management for thyroglossal cysts?
Surgery is a standard treatment option (for the comfort of the patient)- low risk of recurrence
Antibiotics if the cyst is infected
What makes up the lining of a thyroglossal cyst?
Epithelium
What is an important sign to elicit to diagnose thyroglossal cyst?
It will move upwards on tongue protrusion
What is tonsillitis?
An acute infection of the parenchyma of the palatine tonsils
What is the aetiology of tonsillitis?
Tonsillitis is usually viral but the most common bacterial pathogen is Group A beta-haemolytic streptococci.
Local inflammatory pathways result in oropharyngeal swelling, oedema, erythema, and pain
RF: contact with infected people in enclosed spaces
What is the epidemiology of tonsillitis?
Acute tonsillitis is more common in children between the ages of 5-15 years.
More common in winter and early spring although can occur at any time of the year
What are the presenting symptoms of tonsillitis?
Sudden onset of sore throat
Headache
Fever
Pain on swallowing
Presence of cough or runny nose
Tonsillar enlargement
Associated nausea and vomiting
What are the signs of tonsillitis on physical examination?
Tonsillar exudate (purulent “discharge/pus milky looking”)
-particularly when caused by Group A beta-haemolytic streptococci
Tonsillar erythema
Tonsillar enlargement
Enlarged anterior cervical lymph nodes
What are the appropriate investigations for tonsillitis?
Throat culture
Rapid streptococcal antigen test
Bloods: WCC, CRP, ESR
*Important to establish whether the patient has acute tonsillitis and not another cause of sore throat (retropharyngeal abscess or infectious mononucleosis)
What is the management of tonsillitis?
Analgesia
Antibiotics- penicillin is still first choice
Corticosteroids (dexamethasone)
Tonsillectomy may be considered for patients who have recurrent symptoms of tonsillitis and no other explanation for recurrent symptoms
What are the complications of tonsillitis?
Scarlet fever (diffuse erythematous rash from delayed skin reactivity produced by Streptococcus species)
Acute sinusitis
Acute Otitis media
What are the features of the rash produced by Scarlet fever?
The rash blanches with pressure and has multiple small papules.
It generally starts on the head and neck, and is associated with circumoral (around mouth) pallor and a strawberry tongue.
It subsequently spreads to the trunk, sparing the palms and soles, and is more marked over the skin folds
What is the prognosis for a patient with tonsillitis?
Acute tonsillitis is an acute, self-limiting infective condition that normally resolves completely within 1 week.
In vulnerable people tonsillitis may run a more severe course. Antibiotics and/or admission to hospital for a limited period of time may be advisable
Some patients may also develop recurrent tonsillitis; tonsillectomy may be considered in these cases
