ENT Flashcards
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
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
Audiograms
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
Benign paroxysmal positional vertigo
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
Black hairy tongue
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
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.
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
Hearing Loss
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
Ear wax
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
Facial pain
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
Geographic tongue
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
Gingival hyperplasia
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.
Glue ear
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?
Head and neck cancer
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.
Hoarseness
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.
Macroglossia
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
Epistaxis
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).
Meniere’s disease
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
Mouth lesions
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).
Nasal polyps
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
Nasal septal haematoma
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
Neck lumps
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%
Otitis externa
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.
Otitis media
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
Otosclerosis
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
Parotid gland swelling
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
Perforated tympanic membrane
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
Ramsay Hunt syndrome
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.
Rinne’s and Weber’s test
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
Salivary glands
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)
Sore throat
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
Scoring systems
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%
Tinnitus
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
Tonsillitis and tonsillectomy
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
Vertigo
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
Vestibular neuronitis
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
