ENT: Ear Problems 2 Flashcards
What is tinnitus?
Tinnitus is the perception of sound in the absence of sound from the external environment. It may be described as a ringing, hissing, buzzing, sizzling, whistling, or humming, and can be constant or intermittent, and unilateral or bilateral
NOTE: thought to be due to cochlea producing a background sensory signal and the signal not being filtered out by central auditory system
What is primary tinnitus?
- Tinnitus with no identifiable cause
- Often occurs with sensorineural hearing loss
Secondary tinnitus refers to tinnitus with an identifiable cause; state some example causes
Example causes:
- Impacted ear wax
- Ear infection
- Ménière’s disease
- Presbyacusis
- Noise exposure
- Medications (e.g., loop diuretics, gentamicin and chemotherapy drugs such as cisplatin)
- Acoustic neuroma
- Multiple sclerosis
- Trauma
- Depression
- TMJ disorders
Tinnitus may also be associated with systemic conditions:
- Anaemia
- Diabetes
- Hypothyroidism or hyperthyroidism
- Hyperlipidaemia
What is subjective tinnitus and what is objective tinnitus?
State some example causes of objective tinnitus
- Subjective tinnitus (more common) if the perceived sound can only be heard by the affected individual. This is caused by abnormal activity in the inner ear or central nervous system.
-
Objective tinnitus (affecting 1% of people with tinnitus) if the sound can be heard by the affected individual and the examiner (by auscultating with a stethoscope around ear); This often originates from an identifiable and correctable source that produces sound near to, or within, the ear. Example causes:
- Carotid artery stenosis (pulsatile carotid bruit)
- Aortic stenosis (radiating pulsatile murmur sounds)
- Arteriovenous malformations (pulsatile)
- Eustachian tube dysfunction (popping or clicking noises)
When asking a pt about tinnitus, state some questions you should ask (focused around characteristics/pattern of symptoms)
- Uni or bilateral
- Frequency
- Duration
- Severity
- Pulsatile or non-pulsatile
- Additional symptoms such as hearing loss, dizziness, vertigo, balance problems, jaw pain or clicking, facial weakness, or sensitivity to loud noises
Then also ask:
- Impact on life
- PMH & past surgical history
- Medications
What investigations may be done for someone with tinnitus?
NICE suggest:
- Blood tests:
- FBC (anaemia)
- Glucose (diabetes)
- TSH (thyroid disorders)
- Lipids (hyperlipidaemia)
- Audiology (assess hearing)
- CT or MRI imaging (not often required but may be required to investigate e.g. acoustic neuroma)
State some tinnitus red flags that could indicate serious underlying pathology that needs specialist assessment
- Unilateral tinnitus
- Pulsatile tinnitus
- Hyperacusis (hypersensitivity, pain or distress with environmental sounds)
- Associated unilateral hearing loss
- Associated sudden onset hearing loss
- Associated vertigo or dizziness
- Headaches or visual symptoms
- Associated neurological symptoms or signs (e.g., facial nerve palsy or signs of stroke)
- Suicidal ideation related to the tinnitus
Discuss the management of tinnitus
- Reassure that it to tends to improve & resolve over time without intervention
- Treat identifiable underlying causes e.g. wax
- Measures to help improve & manage symptoms:
- Hearing aids
- Sound therapy (add background noise to mask tinnitus)
- CBT
- Support groups
What is vertigo?
A false sensation of movement (spinning or rotation) of the person or their surroundings in the absence of any actual physical movement.
Remind yourself of the 3 sensory inputs for maintaining balance and posture
- Vision
- Proprioception
- Signals from vestibular system
Remind yourself of the structure of the vestibular system and how it works to maintain balance and posture
Structure
- Vestibular apparatus in inner ear
- Made up of the semi-circular canals, utricle and saccule
- Stereocilia in utricle & saccule respond to linear acceleration and static pull of gravity
- Stereocilia in semicicrucular canals respond to rotational acceleration in 3 different planes
- Semi-circular canals filled with endolymph and are orientated in different directions to detect various head movements
- When head moves, fluid in the canals moves
- Fluid movement is detected by stereocilia
- Stereocilia generate action potential
- Signal carried, by vestibular nerve, to the vestibular nucleus in brainstem and to the cerebellum
- Vestibular nucleus sends signals to oculomotor, trochlear and abducens nuclei that control eye movements and also to the thalamus, spinal cord and cerebellum
- Cerebellum helps coordinate movement throughout the body
Vertigo can be caused by a peripheral or a central problem; explain what we mean by each
- Peripheral: due to problem with vestibular system
- Central: due to problem with brainstem or cerebellum
State some peripheral causes of vertigo (highlighting the 4 most common)
Four most common
- Benign paroxysmal positional vertigo
- Ménière’s disease
- Vestibular neuronitis
- Labyrinthitis
Others
- Trauma to the vestibular nerve
- Vestibular nerve tumours (acoustic neuromas)
- Otosclerosis
- Hyperviscosity syndromes
- Herpes zoster infection (often with facial nerve weakness and vesicles around the ear – Ramsay Hunt syndrome)
State some central causes of vertigo
Central problems disrupt signals from vestibular system and cause sustained, non-positional vertigo.
Most common causes
- Posterior circulation infarction (stroke)
- Tumour
- Multiple sclerosis
- Vestibular migraine
What is the first thing you must establish in a patient presenting with ‘dizziness’?
Whether it is vertigo (rotatory or spinning symptoms) or a non-rotatory dizziness e.g. light-headedness, off-balance
**NICE states to consider asking:
- ‘When you have dizzy spells, do you feel light-headed or do you see the world spin around you as if you had just got off a playground roundabout?’
- If the person has nystagmus it is likely that their dizziness is vertigo.
Discuss how you can distinguish between peripheral and central vertigo based on:
- Onset
- Duration
- Hearing loss
- Tinnitus
- Coordination
- Nausea
Alongside features of vertigo, there are other things you can enquire about in history to try and determine cause; state these
- Recent viral illness (labyrinthitis or vestibular neuronitis)
- Headache (vestibular migraine, cerebrovascular accident or brain tumour)
- Typical triggers (vestibular migraine)
- Ear symptoms, such as pain or discharge (infection)
- Acute onset neurological symptoms (stroke)
If a pt presents with vertigo, what examinations must you do? (5)
- Ear examination including otoscopy & hearing tests (infection or other pathology)
- Neurological examination (assess for central causes)
- Cardiovascular examination (assess for cardiovascular causes of dizziness)
- Cerebellar examination
- Special tests:
- Romberg’s test (looks for sensory ataxia)
- Dix-Hallpike manoeuvre (diagnose BPPV)
- HINTS examination
What is the HINTS examination used for?
What does it involve?
Used to distinguish between central and peripheral vertigo. It stands for:
- HI – Head Impulse
- N – Nystagmus
- TS – Test of Skew
Explain how to perform the head impulse test and explain what the results mean
How to perform
- Sit pt upright and ask to look at examiners nose (and continue looking at it throughout)
- Examiner holds pt’s head and rapidly jerks it 10-20 degrees in one direction
- Slowly return head back to centre and repeat in opposite direction
Results
- Normal vestibular system: eyes remain fixed on examiners nose
- Abnormal vestibular system/peripheral cause of vertigo: eyes will make a corrective saccade before eventually fixating back on examiners nose
Explain how to check for nystagmus and what the results mean
How to perform
- Get pt to look to the left or right and hold the gaze
- Observe eye movements
Results
- Unilateral/unidirectional horizontal nystagmus: more likely peripheral
- Bilateral horizontal or vertical nystagmus: more likely central
Explain how to perform the test of skew (also know as alternate cover test) and explain what the results mean
How to perform
- Sit pt upright and ask pt to fixate/look at examiners nose
- Examiner covers one eye at a time, alternating between the two eyes
Results
- Eyes should remain fixed on examiners nose
- If there is vertical correction when eye is uncovered (meaning eye has drifted up or down when covered so needs to move vertically to re-fixate on nose) = indicates central cause of vertigo
Summarise HITT examination findings in peripheral and central causes of vertigo
Remind yourself of features of cerebellar disease (and hence what to assess in cerebellar examination)
- D – Dysdiadochokinesia
- A – Ataxic gait (ask the patient to walk heel-to-toe)
- N – Nystagmus (see below for more detail)
- I – Intention tremor
- S – Speech (slurred)
- H – Heel-shin test
Discuss the management of vertigo (brief overview)
- May need further investigations to establish underlying cause
-
Symptom control in peripheral vertigo:
- Prochlorperazine
- Antihistamines (e.g. cyclizine, cinnirazine)
-
Treat underlying cause:
- Ménière’s disease: betahistine to reduce attacks
- BPPV: Epley manouevre
- Vestibular migraine: avoid triggers, triptans for acute symptoms, betablockers/amitriptyline/topiramate for prophylaxis
- MS: medications
- Tumours: surgical removal
What is BPPV?
Benign paroxysmal positional vertigo
Get recurrent episodes of sudden onset vertigo triggered by head movement
Describe pathophysiology of BPPV
- Otoconia (crystals of calcium carbonate) are usually found in utricle & saccule above the stereocilia; they are displaced in response to movement and cause depolarisation of hair cells- which is perceived as movement
- In BPPV, otoconia get into the semicircular canals (most commonly in the posterior semicircular canal)
- Displacement/movement into semicircular canals may be caused by viral infection, head trauma, ageing or idiopathically
- Crystals disrupt normal flow of endolymph in canals; they can continue to stimulate hair cells even after head movement has ceased leading to vertigo
Describe typical presentation of BPPV
Average age of onset is 55yrs:
- Vertigo triggered by head movements (commonly by turning over in bed or looking up)
- Episodes last 10-20 seconds
- Associated nausea
What test can be done to diagnose BPPV?
Explain how it is done
What is a positive results?
Dix-Hallpike test
Head movements move the endolymph through semicircular canals and triggers vertigo in pts with BPPV.
- The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
- Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
- Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
- Watch the eyes closely for 30-60 seconds, looking for nystagmus
- Repeat the test with the head turned 45 degrees in the other direction
In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).
Discuss the management of BPPV
Usually resolves spontaneously within a few weeks to months hence pt has option of waiting; however, there are a couple options to relieve symptoms:
- Epley manoeuvre (sucessful in ~80%)
- Brandt-Daroff exercises
Describe how to perform the Epley manoeuvre
Idea is to move otoconia in the semicircular canals to a position that doesn’t cause symptoms. Maintain each head position for at least 30 seconds and wait for any nystagmus or vertigo to settle
- Start with the person sitting upright with their head turned 45 degrees to the affected side, then lie them back (with their head still turned 45 degrees) until the head is dependent 30 degrees over the edge of the couch (as if performing the Dix-Hallpike manoeuvre)
- With the face upwards, but still tilted backwards by 30 degrees, rotate the head through 90 degrees to the opposite side.
- Hold the head in this position for about 20 seconds and ask the person to roll onto the same side as they are facing.
- Rotate the person’s head so that they are facing obliquely downward with their nose 45 degrees below the horizontal.
- Sit the person up sideways while the head remains rotated and tilted to the side.
- Rotate the head to the central position and move the chin downwards by 45 degrees.
Briefly outline what Brandt-Daroff exercises involve
Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.
Discuss the management of vestibular neuronitis
- Treatments for symptom relief- can be used for up to 3 days:
- Prochlorperazine (can be given IM or buccal in severe, PO in mild)
- Antihistamines (e.g. cyclizine, cinnirazine, promethazine)
- Admit pts if they are becoming dehydrated due to severe nausea & vomiting
- Refer to ENT if symptoms not improved after 1/52 or resolved after 6/52 (may need further investigation or vestibular rehabilitation therapy which involves tailored exercises specific to pt)
Discuss the management of labyrinthitis
Management similar to vestibular neuronitis & like vestibular neuronitis it usually resolves in a few weeks
- Treatments for symptom relief- can be used for up to 3 days:
- Prochlorperazine (can be given IM or buccal in severe, PO in mild)
- Antihistamines (e.g. cyclizine, cinnirazine, promethazine)
- If chronic, refer to ENT as may benefit from vestibular rehabilitation therapy
What might you find on otoscopy in otitis media?
- Bulging, red tympanic membrane (like a doughnut)
- May see perforation in tympanic membrane
Describe typical presentation of otitis externa
- Similar, but more severe, to those of otitis externa with additional features such as headache, severe pain, fever
- Granulation tissue at junction between bone & cartilage in ear canal (~ ½ way along)= key finding
Discuss the management of glue ear
Non-surgical
- Active observation for 3 months (should have audiology assessments and assess impact on life)
- Auto inflation using nasal balloon or Valsalva manoeuvre (useful in older children- may do in the active observation period)
- Hearing aids (if surgery not suitable or acceptable)
Surgical
- Grommets: allow air to pass into middle ear and hence do the job normally done by Eustachian tube. Majority stop functioning after 10 months & fall out on their own in time
- Adenoidectomy: if adenoids obstructing Eustachian tube
For Ramsey Hunt syndrome, discuss:
- What it is
- What else it is called
- Cause
- Features/presentation
- Management
- Peripheral facial nerve palsy accompanied by an erythematous vesicular rash on the ear (zoster oticus) or in the mouth
- Also called herpes zoster oticus
- Caused by reactivation of varicella zoster virus in the geniculate ganglion of CNVII
- Features:
- Auricular pain
- Facial nerve palsy
- Vesicular rash around ear on affected side (can extend to anterior ⅔ of tongue and hard palate)
- Vertigo
- Tinnitus
- Management:
- PO aciclovir and corticosteroids
- Lubricating eydrops
For perichondritis, discuss:
- What it is
- Presentation
- Management
- Infection of perichondrium (tissue that covers cartilage) in ear
- Presentation:
- Erythema
- Pain
- Swelling
- Management:
- Antibiotics & corticosteroids
- If abscess, incision & drainage
- Simple analgesia
- Complications:
- Cauliflower ear
State some common causes of hearing loss in children
- Acute otitis media (most common)
- Glue ear
- Other infections e.g. mumps, meningitis
- Ear wax blockage
- Foreign body
- Genetics
