ENT

Question 1

Allergic rhinitis

Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens

Answer 1

It may be classified as follows, although the clinical usefulness of such classifications remains doubtful:

seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever
perennial: symptoms occur throughout the year
occupational: symptoms follow exposure to particular allergens within the work place

Features

sneezing

bilateral nasal obstruction

clear nasal discharge

post-nasal drip

nasal pruritus

Management of allergic rhinitis

allergen avoidance

if the person has mild-to-moderate intermittent, or mild persistent symptoms:

oral or intranasal antihistamines

if the person has moderate-to-severe persistent symptoms, or initial drug treatment is ineffective

intranasal corticosteroids

a short course of oral corticosteroids are occasionally needed to cover important life events

there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline). They should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal

Question 2

Audiograms

Answer 2

Audiograms are usually the first-line investigation that is performed when a patient complains of hearing difficulties. They are relatively easy to interpret as long as some simple rules are followed:

anything above the 20dB line is essentially normal (marked in red on the blank audiogram below)

in sensorineural hearing loss both air and bone conduction are impaired

in conductive hearing loss only air conduction is impaired

in mixed hearing loss both air and bone conduction are impaired, with air conduction often being ‘worse’ than bone

Question 3

Benign paroxysmal positional vertigo

Answer 3

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterised by the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it is less common in younger patients.

Features

vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)

may be associated with nausea

each episode typically lasts 10-20 seconds

positive Dix-Hallpike manoeuvre

BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be gained by:

Epley manoeuvre (successful in around 80% of cases)

teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises

Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.

Around half of people with BPPV will have a recurrence of symptoms 3–5 years after their diagnosis

Question 4

Black hairy tongue

Answer 4

Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite the name the tongue may be brown, green, pink or another colour.

Predisposing factors

poor oral hygiene, antibiotics, head and neck radiation, HIV

intravenous drug use
The tongue should be swabbed to exclude Candida
Management

tongue scraping

topical antifungals if Candida

Question 5

Cholesteatoma

Cholesteatoma is a non-cancerous growth of squamous epithelium that is ‘trapped’ within the skull base causing local destruction. It is most common in patients aged 10-20 years. Being born with a cleft palate increases the risk of cholesteatoma around 100 fold.

Answer 5

Main features

foul-smelling, non-resolving discharge

hearing loss

Other features are determined by local invasion:

vertigo

facial nerve palsy

cerebellopontine angle syndrome

Otoscopy

‘attic crust’ - seen in the uppermost part of the ear drum

Management

patients are referred to ENT for consideration of surgical removal

Question 6

Hearing Loss

Answer 6

Presbycusis

Presbycusis describes age-related sensorineural hearing loss. Patients may describe difficulty following conversations

Audiometry shows bilateral high-frequency hearing loss

Otosclerosis

Autosomal dominant, replacement of normal bone by vascular spongy bone. Onset is usually at 20-40 years - features include:

conductive deafness

tinnitus

tympanic membrane - 10% of patients may have a ‘flamingo tinge’, caused by hyperaemia

positive family history

Glue ear

Also known as otitis media with effusion, peaks at 2 years of age

hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood)

secondary problems such as speech and language delay, behavioural or balance problems may also be seen

Meniere’s disease

More common in middle-aged adults

recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom

a sensation of aural fullness or pressure is now recognised as being common

other features include nystagmus and a positive Romberg test

episodes last minutes to hours

Drug ototoxicity

Examples include aminoglycosides (e.g. Gentamicin), furosemide, aspirin and a number of cytotoxic agents

Noise damage

Workers in heavy industry are particularly at risk
Hearing loss is bilateral and typically is worse at frequencies of 3000-6000 Hz

Acoustic neuroma (more correctly called vestibular schwannomas)

Features can be predicted by the affected cranial nerves

cranial nerve VIII: hearing loss, vertigo, tinnitus

cranial nerve V: absent corneal reflex

cranial nerve VII: facial palsy

Bilateral acoustic neuromas are seen in neurofibromatosis type 2

Question 7

Ear wax

Answer 7

Ear wax is a normal physiological substance which helps protect the ear canal. Impacted ear wax is extremely common and may cause a variety of symptoms including:

pain

conductive hearing loss

tinnitus

vertigo

The main treatment options in primary care are ear drops or irrigation (‘ear syringing’). Treatment should not be given if a perforation is suspected or the patient has grommets. The following drops may be used:

olive oil

sodium bicarbonate 5%

almond oil

Question 8

Facial pain

Answer 8

Sinusitis

Facial ‘fullness’ and tenderness
Nasal discharge, pyrexia or post-nasal drip leading to cough

Trigeminal neuralgia

Unilateral facial pain characterised by brief electric shock-like pains, abrupt in onset and termination
May be triggered by light touch, emotion

Cluster headache

Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
Clusters typically last 4-12 weeks
Intense pain around one eye
Accompanied by redness, lacrimation, lid swelling, nasal stuffiness

Temporal arteritis

Tender around temples
Raised ESR

Question 9

Geographic tongue

Answer 9

Geographic tongue is a benign, chronic condition of unknown cause. It is present in around 1-3% of the population and is more common in females.

Features

erythematous areas with a white-grey border (the irregular, smooth red areas are said to look like the outline of a map)

some patients report burning after eating certain food
Management

reassurance about benign nature

Question 10

Gingival hyperplasia

Answer 10

Drug causes

phenytoin

ciclosporin

calcium channel blockers (especially nifedipine)

Other causes of gingival hyperplasia include

acute myeloid leukaemia (myelomonocytic and monocytic types)

A patient presents with gum problems. His dentist has told him that the appearances may be related to his long-term medication.

Question 11

Glue ear

Answer 11

Glue ear describes otitis media with an effusion (other terms include serous otitis media). It is common with the majority of children having at least one episode during childhood

Risk factors

male sex

siblings with glue ear

higher incidence in Winter and Spring

bottle feeding

day care attendance

parental smoking

Features

peaks at 2 years of age

hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective surgery in childhood)

secondary problems such as speech and language delay, behavioural or balance problems may also be seen

Treatment options include:

grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months

adenoidectomy

A 5-year-old girl presents with her mother and complains of left sided otalgia and reduced hearing over the past 4 weeks. Her teacher reports she is struggling compared to the other children. On examination, she has a temperature of 36.7ºC and the canal appears normal. The tympanic membrane is retracted. What treatment should be initiated?

Question 12

Head and neck cancer

Answer 12

Head and neck cancer is an umbrella term. It typically includes:

Oral cavity cancers

Cancers of the pharynx (including the oropharynx, hypopharynx and nasopharynx)

Cancers of the larynx
Features

neck lump

hoarseness

persistent sore throat

persistent mouth ulcer

NICE suspected cancer pathway referral criteria (for an appointment within 2 weeks)

Laryngeal cancer

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged 45 and over with:

persistent unexplained hoarseness or

an unexplained lump in the neck

Oral cancer

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:

unexplained ulceration in the oral cavity lasting for more than 3 weeks or

a persistent and unexplained lump in the neck.

Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:

a lump on the lip or in the oral cavity or

a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Thyroid cancer

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an unexplained thyroid lump.

Question 13

Hoarseness

Answer 13

Causes of hoarseness include:

voice overuse

smoking

viral illness

hypothyroidism

gastro-oesophageal reflux

laryngeal cancer

lung cancer

When investigating patients with hoarseness a chest x-ray should be considered to exclude apical lung lesions.

Suspected laryngeal cancer: referral guidelines-

A suspected cancer pathway referral to an ENT specialist should be considered for people aged 45 and over with:

persistent unexplained hoarseness or

An unexplained lump in the neck.

Question 14

Macroglossia

Answer 14

Causes

hypothyroidism

acromegaly

amyloidosis

Duchenne muscular dystrophy

mucopolysaccharidosis (e.g. Hurler syndrome)

Patients with Down’s syndrome are now thought to have apparent macroglossia due to a combination of mid-face hypoplasia and hypotonia

Question 15

Epistaxis

Answer 15

Epistaxis that has failed all emergency management may require sphenopalatine ligation in theatre

Important for meLess important

Emergency management of epistaxis includes the following:

adequate first aid for 20 minutes (squeeze both nasal ala firmly and sit forward. Ice in the mouth can help)

topical adrenaline/local anaesthetic

topical tranexamic acid

nasal packing (e.g. with Rapid Rhino. Initially insert into the affected nostril. If unsuccessful, a pack in the other nostril may help. Posterior bleeds can be packed with a posterior pack, or with a Foley catheter).

surgical intervention (sphenopalatine artery ligation).

Question 16

Meniere’s disease

Answer 16

Meniere’s disease is a disorder of the inner ear of unknown cause. It is characterised by excessive pressure and progressive dilation of the endolymphatic system. It is more common in middle-aged adults but may be seen at any age. Meniere’s disease has a similar prevalence in both men and women.

Features

recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom

a sensation of aural fullness or pressure is now recognised as being common

other features include nystagmus and a positive Romberg test

episodes last minutes to hours

typically symptoms are unilateral but bilateral symptoms may develop after a number of years

Natural history

symptoms resolve in the majority of patients after 5-10 years

the majority of patients will be left with a degree of hearing loss

psychological distress is common

Management

ENT assessment is required to confirm the diagnosis

patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is achieved

acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required

prevention: betahistine and vestibular rehabilitation exercises may be of benefit

Question 17

Mouth lesions

Answer 17

2 week wait referrals to oral surgery should be done in all of the following cases:

Unexplained oral ulceration or mass persisting for greater than 3 weeks

Unexplained red, or red and white patches that are painful, swollen or bleeding

Unexplained one-sided pain in the head and neck area for greater than 4 weeks, which is associated with ear ache, but does not result in any abnormal findings on otoscopy

Unexplained recent neck lump, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks

Unexplained persistent sore or painful throat

Signs and symptoms in the oral cavity persisting for more than 6 weeks, that cannot be definitively diagnosed as a benign lesion

The level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers and those who chew tobacco or betel nut (areca nut).

Question 18

Nasal polyps

Answer 18

Around in 1% of adults in the UK have nasal polyps. They are around 2-4 times more common in men and are not commonly seen in children or the elderly.

Associations

asthma* (particularly late-onset asthma)

aspirin sensitivity*

infective sinusitis

cystic fibrosis

Kartagener’s syndrome

Churg-Strauss syndrome

Features

nasal obstruction

rhinorrhoea, sneezing

poor sense of taste and smell

Unusual features which always require further investigation include unilateral symptoms or bleeding.

Management

all patients with suspected nasal polyps should be referred to ENT for a full examination

topical corticosteroids shrink polyp size in around 80% of patients

*the association of asthma, aspirin sensitivity and nasal polyposis is known as Samter’s triad

Question 19

Nasal septal haematoma

Answer 19

Nasal septal haematoma is an important complication of nasal trauma which should always be looked for. It describes the development of a haematoma between the septal cartilage and the overlying perichondrium.

Features

may be precipitated by relatively minor trauma

the sensation of nasal obstruction is the most common symptom

pain and rhinorrhoea are also seen

on examination, classically a bilateral, red swelling arising from the nasal septum

this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm20

Management

surgical drainage

intravenous antibiotics

If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia of the cartilage resulting in necrosis. This may result in a ‘saddle-nose’ deformity

Question 20

Neck lumps

Answer 20

Reactive lymphadenopathy

By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness

Lymphoma

Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly

Thyroid swelling

May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing

Thyroglossal cyst

More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected

Pharyngeal pouch

More common in older men
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Cystic hygroma

A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age

Branchial cyst

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood

Cervical rib

More common in adult females
Around 10% develop thoracic outlet syndrome

Carotid aneurysm

Pulsatile lateral neck mass which doesn’t move on swallowing

14.

A 19-year-old man presents with a swelling on the left side of his neck. He has recently had an upper respiratory tract infection. On examination he has a smooth swelling in between the sternocleidomastoid muscle and the pharynx. It is fluctuant but doesn’t transilluminate or move during swallowing.

Lymphoma
The correct answer is: Branchial cyst 41%

Brachial cysts often present during intercurrent upper respiratory tract infection

15.

A 28-year-old Bangladeshi woman presents with a three day history of sweats, headache, lethargy and muscle aches. On examination she has bilateral tender swellings in the submandibular region.

Cervical rib
The correct answer is: Reactive lymph nodes 44%

This patient probably has the ‘flu

16.

A 17-year-old girl presents with a painless swelling in the neck. She is currently well. A midline, cystic swelling is noted in the region of the hyoid bone. It moves upwards when she swallows or sticks her tongue out.

Cervical rib
The correct answer is: Thyroglossal cyst 88%

Question 21

Otitis externa

Answer 21

Otitis externa is a common reason for primary care attendance in the UK.

Causes of otitis externa include:

infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal

seborrhoeic dermatitis

contact dermatitis (allergic and irritant)

Features

ear pain, itch, discharge

otoscopy: red, swollen, or eczematous canal

The recommended initial management of otitis externa is:

topical antibiotic or a combined topical antibiotic with a steroid

if the tympanic membrane is perforated aminoglycosides are traditionally not used*

if there is canal debris then consider removal

if the canal is extensively swollen then an ear wick is sometimes inserted

Second-line options include

consider contact dermatitis secondary to neomycin

oral antibiotics (flucloxacillin) if the infection is spreading

taking a swab inside the ear canal

empirical use of an antifungal agent

If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.

Question 22

Otitis media

Answer 22

Antibiotics should be prescribed immediately if:

Symptoms lasting more than 4 days or not improving

Systemically unwell but not requiring admission

Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease

Younger than 2 years with bilateral otitis media

Otitis media with perforation and/or discharge in the canal

If an antibiotic is given, a 5-day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin or clarithromycin should be given

Otitis media

Question 23

Otosclerosis

Answer 23

Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults

Onset is usually at 20-40 years - features include:

conductive deafness

tinnitus

normal tympanic membrane*

positive family history

Management

hearing aid

stapedectomy

Question 24

Parotid gland swelling

Answer 24

Swelling of this gland is either unilateral or bilateral. Disorders of the gland cause swelling and pain which may be pronounced on eating or talking. There may be associated fever and a foul taste in the mouth.

Bilateral causes

viruses: mumps

sarcoidosis

Sjogren’s syndrome

lymphoma

alcoholic liver disease

Unilateral causes

tumour: pleomorphic adenomas

stones

infection

Question 25

Perforated tympanic membrane

Answer 25

The most common cause of a perforated tympanic membrane is infection. Other causes include barotrauma or direct trauma.

A perforated tympanic membrane may lead to hearing loss depending on the size and also increase the risk of otitis media.

Management

no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time

it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media. NICE support this approach in the 2008 Respiratory tract infection guidelines

myringoplasty may be performed if the tympanic membrane does not heal by itself

Question 26

Ramsay Hunt syndrome

Answer 26

Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.

Features

auricular pain is often the first feature

facial nerve palsy

vesicular rash around the ear

other features include vertigo and tinnitus

Management

oral aciclovir and corticosteroids are usually given

A 66-year-old woman comes to the GP surgery complaining of a droop in the left side of her face for the past 3 days. This is associated with dizziness and deafness. She has also noticed that her eyes and mouth are very dry.

Question 27

Rinne’s and Weber’s test

Answer 27

Performing both Rinne’s and Weber’s test allows differentiation of conductive and sensorineural deafness.

Rinne’s test

tuning fork is placed over the mastoid process until the sound is no longer heard, followed by repositioning just over external acoustic meatus

‘positive test’: air conduction (AC) is normally better than bone conduction (BC)

‘negative test’: if BC > AC then conductive deafness

Weber’s test

tuning fork is placed in the middle of the forehead equidistant from the patient’s ears

the patient is then asked which side is loudest

in unilateral sensorineural deafness, sound is localised to the unaffected side

in unilateral conductive deafness, sound is localised to the affected side

Question 28

Salivary glands

Answer 28

parotid (serous) - most tumours

submandibular (mixed) - most stones

sublingual (mucous)

Pathology

tumours: ‘80% parotid, 80% of these = pleomorphic adenomas, 80% superficial lobe

malignant rare: short hx, painful, hot skin, hard, fixation, CN VII involvement

Pleomorphic adenomas (benign, ‘mixed parotid tumour’, 80%)

middle age

slow growing, painless lump

superficial parotidectomy; risk = CN VII damage

Warthin’s tumour (benign, ‘adenolymphomas’, 10%)

males, middle age

softer, more mobile and fluctuant (although difficult to differentiate)

Stones

recurrent unilateral pain & swelling on eating

may become infected → Ludwig’s angina

80% are submandibular

plain x-rays; sialography

surgical removal

Other causes of enlargement

acute viral infection e.g. mumps

acute bacterial infection e.g. 2nd to dehydration diabetes

sicca syndrome and Sjogren’s (e.g. RA)

Question 29

Sore throat

Answer 29

Sore throat encompasses pharyngitis, tonsillitis, laryngitis

Clinical Knowledge Summaries recommend:

throat swabs and rapid antigen tests should not be carried out routinely in patients with a sore throat

Management

paracetamol or ibuprofen for pain relief

antibiotics are not routinely indicated

there is some evidence that a single dose of oral corticosteroid may reduce the severity and duration of pain, although this has not yet been incorporated into UK guidelines

NICE indications for antibiotics

features of marked systemic upset secondary to the acute sore throat

unilateral peritonsillitis

a history of rheumatic fever

an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency)

patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present

Question 30

Scoring systems

Answer 30

The Centor criteria are: score 1 point for each (maximum score of 4)

presence of tonsillar exudate

tender anterior cervical lymphadenopathy or lymphadenitis

history of fever

absence of cough

Centor score

Likelihood of isolating Streptococci

0 or 1 or 2

3 to 17%

3 or 4

32 to 56%

The FeverPAIN criteria are: score 1 point for each (maximum score of 5)

Fever over 38°C.

Purulence (pharyngeal/tonsillar exudate).

Attend rapidly (3 days or less)

Severely Inflamed tonsils

No cough or coryza

FeverPAIN score

Likelihood of isolating Streptococci

0 or 1

13 to 18%

2 or 3

34% to 40%

4 or 5

62% to 65%

Question 31

Tinnitus

Answer 31

Meniere’s disease

Associated with hearing loss, vertigo, tinnitus and sensation of fullness or pressure in one or both ears

Otosclerosis

Onset is usually at 20-40 years
Conductive deafness
Tinnitus
Normal tympanic membrane*
Positive family history

Acoustic neuroma

Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2

Hearing loss

Causes include excessive loud noise and presbycusis

Drugs

Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine

Question 32

Tonsillitis and tonsillectomy

Answer 32

Complications of tonsillitis include:

otitis media

quinsy - peritonsillar abscess

rheumatic fever and glomerulonephritis very rarely

The indications for tonsillectomy are controversial. NICE recommend that surgery should be considered only if the person meets all of the following criteria

sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)

the person has five or more episodes of sore throat per year

symptoms have been occurring for at least a year

the episodes of sore throat are disabling and prevent normal functioning

Other established indications for a tonsillectomy include

recurrent febrile convulsions secondary to episodes of tonsillitis

obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils

peritonsillar abscess (quinsy) if unresponsive to standard treatment

Complications of tonsillectomy

primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain

secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain

Question 33

Vertigo

Answer 33

Vertigo may be defined as the false sensation that the body or environment is moving.

The table below lists the main characteristics of the most important causes of vertigo

Disorder

Notes

Viral labyrinthitis

Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected

Vestibular neuronitis

Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss

Benign paroxysmal positional vertigo

Gradual onset
Triggered by change in head position
Each episode lasts 10-20 seconds

Meniere’s disease

Associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears

Vertebrobasilar ischaemia

Elderly patient
Dizziness on extension of neck

Acoustic neuroma

Hearing loss, vertigo, tinnitus
Absent corneal reflex is important sign
Associated with neurofibromatosis type 2

Other causes of vertigo include

posterior circulation stroke

trauma

multiple sclerosis

ototoxicity e.g. gentamicin

Question 34

Vestibular neuronitis

Answer 34

Vestibular neuronitis is a cause of vertigo that often develops following a viral infection.

Features

recurrent vertigo attacks lasting hours or days

nausea and vomiting may be present

horizontal nystagmus is usually present

no hearing loss or tinnitus

Differential diagnosis

viral labyrinthitis

posterior circulation stroke: the HiNTs exam can be used to distinguish vestibular neuronitis from posterior circulation stroke

Management

vestibular rehabilitation exercises are the preferred treatment for patients who experience chronic symptoms

buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases

a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases