ENT

Question 1

Define benign paroxysmal positional vertigo

Answer 1

Vertigo lasting seconds to minutes on changing head position (e.g. sitting to lying down, turning head suddenly).

Question 2

Explain the aetiology / risk factors of benign paroxysmal positional vertigo

Answer 2

Displacement of otoliths (from degeneration, trauma or post-viral) into the canals (usually posterior canal) resulting in canaliths.

Most cases of BPPV do not have an identifiable cause.

If he has had a recent head injury, that could have caused the BPPV

Medications don’t cause BPPV

Question 3

Identify appropriate investigations for benign paroxysmal positional vertigo and interpret the results

Answer 3

Hallpike test

A positive test is indicated by patient report of a reproduction of vertigo and clinician observation of nystagmus when patient is lowered quickly to a supine position (lying horizontally with the face and torso facing up) with the neck extended 30 degrees below horizontal by the clinician performing the maneuver
The Hallpike (or Dix-Hallpike) test is the diagnostic test for the most common type of BPPV (viz. affecting the posterior semicircular canal).

Question 4

Management of BPPV

Answer 4

Epley or Semont manoeuvres for posterior canal BPPV;

barbeque manoeuvre for horizontal canal BPPV.

The Epley manoeuvre is a good, specific treatment for BPPV and has an 80% cure rate when used properly.

Vestibular rehabilitation (e.g. Cawthorne-Cooksey exercises) can also help.

BPPV is in most cases self-limiting so ‘watch and wait’ is a reasonable option.

(Drugs are ineffective; prochlorperazine would in principle help with the symptoms but often has side-effects, while cyclizine is only for nausea, not dizziness.)

Question 5

Why would you use metaclopramide with caution

Answer 5

Ocular gyric crisis, particularly younger patients

An acute dystonic reaction of the ocular muscles characterized by bilateral dystonic elevation of visual gaze lasting from seconds to hours.

Dystonia in general is a side effect here

Question 6

What is menieres disease

What happens to perilymph?

Answer 6

Ménière disease is an idiopathic condition affecting the inner ear, in which impaired resorption of endolymphatic fluid causes it to accumulate in the membranous labyrinth (endolymphatic hydrops).

Endolymphatic hydrops is characteristic lesion of menieres but not specific

The endolymph is rich in potassium and perilymph is rich in sodium. In Ménière disease, the concentration of potassium in the perilymph increases!

Question 7

Epidemiology

Answer 7

Female more than male

Question 8

History of menieres

Answer 8

Episodes may last from minutes to hours and decrease in frequency as patients age

Triad of symptoms: vertigo, hearing loss, tinnitus

Hearing loss tends to worsen with every episode

Question 9

Signs of menieres

Answer 9

Nystagmus can be present.

The endolymph is rich in potassium and perilymph is rich in sodium. In Ménière disease, the concentration of potassium in the perilymph increases!

N&V

Question 10

Investigation of menieres

Answer 10

Diagnositc criteria:

Two or more episodes of vertigo that last 20 minutes to 12 hours
Low-frequency to mid-frequency sensorineural hearing loss on audiometry
Fluctuating tinnitus or ear fullness
No other diagnosis is suspected

HEARING LOSS:

Weber test: lateralises to HEALTHY ear

Rinne test: bilaterally positive (i.e. normal in both ears)

Pure tone audiometry: low-frequency hearing loss

Suprathershold audiometry:

VESTIBULAR EVALUATION:
-Declining peripheral vestibular function

Imaging:
MRI or CT to rule out CNS lesions

Question 11

What is tonsillitis

Answer 11

Acute tonsillitis is an inflammation of the tonsils that frequently occurs in combination with an inflammation of the pharynx (tonsillopharyngitis).

Question 12

What is the most common cause of tonsillitis

Answer 12

Viral (50-80% of cases):

• Adenovirus
• EBV
• CMV
• Rhinovirus
• Influenza
• HIV

Bacterial (15-30% of cases):

• Strep pyogenes (GAS) is most common bacterial cause
• Rarely, N Gonorrhoea, M pneumoniaie

Question 13

What bugs are recurrent tonsillitis/chronic tonsillitis commonly caused by

Answer 13

polymicrobial infections with aerobic bacteria (typically streptococci, staphylococci, Haemophilus influenzae) and anaerobic bacteria

Question 14

Hx of bacterial tonsillitis

Answer 14

Sudden onset of symptoms
Red and swollen pharynx, tonsillar exudates  [3]
Fever, sore throat, dysphagia
Painful, swollen cervical lymph nodes
Foul breath

Question 15

Hx of viral tonsillitis

Answer 15

headache, earache, nasal congestion, and cough

Question 16

Change in voice/trismus with tonsillitis?

Answer 16

Trismus and changes in voice quality indicate the formation of potentially life-threatening peritonsillar abscess!

Question 17

Investigations for tonsillitis

Answer 17

Use the CENTOR score, to determine the risk of the throat infection being caused by GAS.

Must be older than 3 y/o
Cough ABSENT 
Exudate
Node enlargement
Temperature elevation
young OR old. 

NICE do not recommend using rapid tests for strep A infections as it does not improve anti-microbial prescribing.

So in reality, you would use CENTOR, and if it is likely to be bacterial then you would give Abx and if not then supportive care