ENT

Question 1

Define BPPV

Answer 1

Peripheral vestibular disorder that manifests as sudden, short-lived episodes of vertigo triggered by certain head movements which is often self-limiting. It occurs due to calcium carbonate crystals from utricle entering semicircular canal and obstructing endolymph flow.

Question 2

Summarise the aetiology of BPPV

Answer 2

OFTEN IDIOPATHIC

Occurs due to displacement of Otoliths into the semicircular canals (usually posterior) resulting in canaliths.

Primary BPPV: IDIOPATHIC (50-70%)

Secondary BBPV:
Degeneration 
Head Trauma 
Migraine
Post-viral infection i.e. Labyrinthitis, Vestibular neuronitis

Question 3

What are the risk factors of BPPV?

Answer 3

Increasing age
Female
Head trauma
Vestibular neuritis
Labyrinthitis 
Inner Ear Surgery 
Meniere’s disease 
Hypertension
Hyperlipidaemia 
Diabetes 
Giant Cell Arteritis

Question 4

Summarise the epidemiology of BPPV

Answer 4

Peak incidence between 50 and 70 years old
More likely in females
Most common cause of peripheral vertigo
Migraine and head trauma are more common in younger patients with secondary disease compared with older patients

Question 5

What are the presenting symptoms of BPPV?

Answer 5

Short-lived sudden vertigo triggered by specific head movement
Vertigo lasts less than 1 minute
Nausea
Vomiting
Specific and predictable changes in head position cause it 
Imbalance
Dizziness
NO HEARING LOSS OR TINNITUS

Question 6

What are the signs on physical examination of BPPV?

Answer 6

POSTIVE Dix-Hallpike Manoeuvre provokes BPPV and Nystagmus

POSITIVE supine lateral head turn

• Patient lies supine and lifts head to 30 degrees
• Turns head slowly to right and left
• Provokes BPPV and Nystagmus

Normal neurological ontological examination
Patients ONLY experience nystagmus during the positional tests

Question 7

What are the appropriate investigations for BPPV?

Answer 7

Clinical diagnosis
Dix-Hallpike Test - positive (causes BPPV)
Positive supine lateral head turn

Investigations to consider:
Audiogram: indicated in patients with hearing loss to diagnose cause
Brain MRI: to diagnose or exclude CNS conditions i.e. MS, Tumours

Question 8

Define infectious mononucleosis

Answer 8

A clinical syndrome caused by Epstein Barr Virus infection

Question 9

Summarise the aetiology of infetious mononucleosis

Answer 9

Infectious mononucleosis is often caused by Epstein Barr Virus infection or Human Herpes Virus 4
EBV is a double stranded DNA virus
It is spread via saliva or respiratory droplets - sharing food or drinks, kissing
EBV infection of the epithelial cells of the oropharynx leads to B cell infection
The infected B cells disseminate EBV across the body causing a humoral and cellular response
EBV remains latent in lymphocytes
Reactivation may occur following stress or immunosuppression

Question 10

Summarise the epidemiology of infectious mononucleosis

Answer 10

Most common in teenagers aged 15-24 years old
Past EBV infection in 90% of adults by the age of 40
COMMON

Question 11

What are the presenting symptoms of infectious mononucleosis?

Answer 11

Incubation period 30-50 days
Abrupt onset of symtoms
Fever
Sore throat
Enlarged lymph nodes 
Fatigue
Headache 
Malaise 
Anorexia 
Sweating 
Abdominal pain

Question 12

What are the signs on physical examination of infectious mononucleosis?

Answer 12

Fever
Posterior cervical lymphadenopathy
Hepatosplenomegaly
Tonsillar exudates (white/creamy)
Pharyngitis - oedema and erythema of the pharynx
Palatal petechiae
Widespread maculopapular rash (in patients who have received ampicillin or amoxicillin)

Question 13

What are the appropriate investigations for infectious mononucleosis?

Answer 13

Clinical signs

Bloods:
FBC - lymphocytosis
Blood film - atypical lymphocytosis

Heterophil antibody monospot test - blood causes agglutination with animal (sheep or horse) RBC

If negative heterophil monospot test - EBV specific antibodies
IgM Viral Caspid Antigen - acute infection
IgG EBNA - shows latent infection

PCR - EBV DNA detection
USS abdo - splenic enlargement

Question 14

What is the management of infectious mononucleosis?

Answer 14

Often uncomplicated recovery within 3-21 days
Paracetamol and aspirin - pain and fever relief
Rest
Avoid contact with others
Avoid contact sports for 3-4 weeks to avoid splenic rupture
If severe, can use corticosteroids

DO NOT USE AMOXICILLIN OR AMPICILLIN - causes widespread itchy maculopapular rash

Question 15

What are the possible complications of infectious mononucleosis?

Answer 15

Long-term fatigue
Antibiotic induced rash
Splenic rupture
B cell cancer
Hodgkin and non-Hodgkin lymphoma
Nasopharyngeal carcinoma
Oral hairy leukoplakia if HIV positive patient

Question 16

Summarise the prognosis of infectious mononucleosis?

Answer 16

Most make uncomplicated recovery within 3 to 21 days

Immunodeficiency and death are very rare

Question 17

Define Meniere’s disease

Answer 17

A disorder of the inner ear due to excessive endolymph, causing recurrent episodes of vertigo, tinnitus and sensorineural hearing loss.

Question 18

Summarise the aetiology of Meniere’s disease

Answer 18

Idiopathic however due to excessive endolymph in the semicircular canals due impaired absorption or overproduction - endolymphatic hydrops

Allergic responses (especially to food)
Congenital or acquired syphilis
Lyme disease
Hypothyroidism
Stenosis of the internal auditory canal
Acoustic or physical trauma
Viral infection 
Immune-mediated mechanisms affecting the absorption of endolymph 
Endolymphatic sac/duct blockage
Vestibular aqueduct hypoplasia
Vascular constriction

Question 19

Summarise the epidemiology of Meniere’s disease

Answer 19

Onset usually in 40s
50% of patients have family history
Slightly more common in females

Question 20

What are the presenting symptoms of Meniere’s disease?

Answer 20

Recurrent episodes of rotary vertigo lasting 20 mins-24 hours
Sensorineural hearing loss - initially to low frequency sounds but eventually permanent loss
Low frequency tinnitus
Feeling of ear fullness or pressure
Nausea and vomiting

May be triggered by caffeine, alcohol, high salt diet, nicotine

Drop attacks: Sudden loss of balance without loss of consciousness or other autonomic or neurological symptoms

Question 21

What are the signs on physical examination of Meniere’s disease?

Answer 21

Positive Romberg’s test - swaying or falling when asked to stand with feet together with eyes closed
Fukuda’s stepping test - when marching on spot with eyes closed, turns towards affected side
Nystagmus seen in acute attacks
Inability to walk heel-to-toe in straight line

Question 22

What are the appropriate investigations for Meniere’s disease?

Answer 22

Mainly a clinical diagnosis and diagnosis of exclusion
Audiometry - shows sensorineural hearing loss
Electronystagmography
Vestibular evoked myogenic potential
MRI
Lyme disease and syphilis serology - normal, excludes these as causes for hearing loss

Question 23

Define tonsillitis

Answer 23

An acute inflammation of the parenchyma of the palatine tonsils

Question 24

Summarise the aetiology of tonsillitis

Answer 24

Viral (most common): rhinovirus, coronavirus, adenovirus
Rarely - influenza virus, parainfluenza, enterovirus, herpes virus. EBV in tonsillitis associated with infectious mononucleosis
Bacterial: group A beta-haemolytic streptococcus (15-30% of cases in children aged 5-15)

Can distinguish between the two using FeverPAIN or CENTOR criteria

Fever
Purulence
Attend urgently
Inflammed tonsils
No cough

Can't cough
Exudate
Nodes
Temperature
OR - age <15 increases score by 1, age over 44 decreases score by 1

For both FeverPAIN and CENTOR, higher score suggests more likely due to bacterial cause

Question 25

Summarise the epidemiology of tonsillitis

Answer 25

Most common in children aged 5-15 years old
Group A streptococci - 15-30% of children, 5-10% of adults
More common in winter and early spring

Question 26

What are the presenting symptoms of tonsillitis?

Answer 26

ACUTE ONSET
Fever
Pain on swallowing
Sore throat
Fatigue
Pain may be referred to ears
Abdominal pain (in small children)
Headache 
Loss of voice or changes in voice
Cough if viral cause

Question 27

What are the signs on physical examination of tonsillitis?

Answer 27

Red throat
Fever >38 degrees
Anterior cervical lymphadenopathy
Tonsillar exudate (white or yellow flecks on tonsils)
Tonsillar enlargement and erythema

Question 28

What are the appropriate investigations for tonsillitis?

Answer 28

Usually no investigations
Throat swab and culture
Rapid streptococcal antigen testing - positive if group A beta haemolytic streptococci is causative agent

Question 29

Define thryoglossal cyst

Answer 29

A fibrous cyst that forms from a persistent thyroglossal duct

Question 30

Summarise the aetiology of thyroglossal cyst

Answer 30

Congenital disorder
Usually the thyroglossal duct closes and is obliterated. If this fails to occur, the thyroglossal duct can grow and fill with mucous, forming a thyroglossal cyst

Question 31

Summarise the epidemiology of thyroglossal cyst

Answer 31

90% of cases present in children before the age of 10

70% of neck abnormalities are from thyroglossal cysts

Question 32

What are the presenting symptoms of a thyroglossal cyst?

Answer 32

Painless midline neck in the lump above or below the hyoid bone
Dysphagia
Dyspnoea
Dyspepsia
Neck or throat pain if cyst becomes infected
Red neck lump if infected

Question 33

What are the signs on physical examination of a thyroglossal cyst?

Answer 33

Midline suprahyoid or subhyoid neck lump
Neck lump which rises on swallowing and protruding tongue
Soft, round, non-tender neck lump
If infected: swollen, red, tender neck lump

Question 34

What are the appropriate investigations of a thyroglossal cyst?

Answer 34

USS or CT
FNA
TFTs
Thyroid Scan – using radioactive iodine or technetium