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ENT - Level 2 Flashcards

1
Q

Definition of otitis externa?

A
  • Inflammation of external ear canal
    o Localised = folliculitis that can progress to become boil in canal
    o Diffuse = inflammation of skin and sub-dermis in canal and tympanic membrane
  • Acute (<3 weeks), chronic (>3 months)
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2
Q

Defintion of malignant otitis externa?

A

o Aggressive infection affecting immunocompromised or DM or elderly which spreads to bone surrounding ear canal

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3
Q

Epidemiology of otitis externa?

A
  • Prevalence increases at end of summer
  • Common >1% diagnosed per year
  • Women > Men
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4
Q

Causative organisms of otitis externa?

A 
-	Bacterial
o	S.Aureus
o	Pseudomonas sp.
-	Fungal
o	Aspergillus
o	Candida Albicans
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5
Q

Other causes of otitis externa?

A
  • Seborrhoeic Dermatitis
  • Contact dermatitis (irritant or allergen)
  • Trauma (scratching, aggressive, ear syringing, foreign objects, cotton buds)
  • Swimming
  • High humidity
  • Narrow ear canal
  • Hearing aids
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6
Q

Symptoms of otitis externa?

A
  • Minimal discharge
  • Itch
  • Pain – made worse by moving pinna
  • Hearing Loss
  • Tender regional lymphadenitis
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7
Q

Signs of otitis externa?

A 
-	Otoscopy
o	Red canal with swelling, shedding of scaly skin
o	White or yellow pus in canal
o	Struggle to see tympanic membrane
-	Lymphadenopathy of pre-auricular nodes
-	Pyrexia
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8
Q

Symptoms of chronic otitis externa?

A
  • Lack of earwax
  • Dry hypertrophic skin, partial stenosis of canal
  • Pain on manipulation of external ear canal
  • Constant itch and discomfort
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9
Q

Symptoms of malignant otitis externa?

A
  • Granulation tissue at bone-cartilage junction of ear canal
  • Facial nerve palsy
  • Temperature >39
  • Severe pain and headache
  • Vertigo
  • Profound hearing loss
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10
Q

Diagnosis of otitis externa?

A
  • Clinical Diagnosis
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11
Q

When to swab ear in otitis externa?

A

o Treatment fails, recurrent or chronic

o Infection spread or severe enough for oral antibiotics

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12
Q

Management of otitis externa - general measures?

A 
	Self-Care Advice
•	Avoid swimming, cotton buds, foreign objects down ear
•	Keep ears clean and dry
	Paracetamol and ibuprofen PRN
	Local heat with warm flannel
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13
Q

Management of otitis externa - medical therapy?

A

 Acetic Acid 2%
• For mild cases
 Topical antibiotic with/without topical corticosteroid
• Gentamicin, neomycin or Chloramphenicol with steroid (Otomize, Betnesol)
• 7-14 days
 Oral antibiotics if cellulitis beyond ear canal to pinna, fever, systemic signs of infection, DM or immunocompromised:
• 7-day course of flucloxacillin (or clarithrymycin)

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14
Q

Management of otitis externa - when to ear swab?

A 
	Treatment failure
	Recurrent or chronic
	Topical treatment cannot be delivered
	Infection spread beyond EAC
	Need oral antibiotics
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15
Q

Management of otitis externa - when to refer?

A

 Symptoms not improved despite treatment
 Cellulitis extensive
 Pain extreme
 Micro-suction or ear wick insertion required
 Requiring incision and drainage of furuncle

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16
Q

Management of otitis externa - when to refer urgently?

A

o Referral urgently if malignant otitis externa suspected:
 Unremitting pain, otorrhoea, fever or malaise
 Granulation tissue at bone-cartilage joint of ear canal
 Facial nerve paralysed
 Temperature >39

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17
Q

Management of chronic otitis externa - if fungal nfection suspected?

A

 Topical clotrimazole 1% solution/acetic acid 2% spray/

 Seek specialist advice if inadequate response

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18
Q

Management of chronic otitis externa - if irritant or allergic dermatitis?

A

 Advise person to avoid contact with irritant or allergen

 Give topical corticosteroid

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19
Q

Management of chronic otitis externa - if seborrheoic dermatitis?

A

 Topical antifungal/corticosteroid combination

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20
Q

Management of chronic otitis externa - if no evident cause?

A

 7 days topical corticosteroid with acetic acid spray

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21
Q

Management of chronic otitis externa - when to refer?

A

 Does not respond to treatment
 Contact sensitivity suspected
 Ear canal occluded
 Malignant otitis is suspected

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22
Q

Complications of otitis externa?

A
  • Abscess
  • Chronic otitis externa
  • Fibrosis
  • Myringitis
  • Tympanic membrane perforation
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23
Q

Prognosis of otitis externa?

A
  • Symptoms usually improve within 48-72 hours of initiation of treatment
  • Resolves within 7-10 days
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24
Q

What is ear wax?

A
  • Ear wax = normal physiological substance that protects ear canal
  • Combination of sheets of desquamated keratin squames (dead, flattened cells on outer layer of skin), cerumen (wax-like substance produced by ceruminous glands), sebum and foreign substances
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25
Q

Function of ear wax?

A

o Aids removal of keratin
o Cleans, lubricates and protects lining of ear canal – trapping dirt and repelling water
o Antibacterial properties

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26
Q

Epidemiology of ear wax?

A
  • Most common ENT procedure in primary care – ear wax removal
  • Dry wax is dry, flaky and golden-yellow and common in Asian people
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27
Q

Risk factors of ear wax?

A 
o	Narrow or deformed ear canal
o	Hairs in ear canal
o	Osteomata
o	Dermatological disease in peri-auricular area
o	Elderly
o	Recurrent otitis externa
o	Cotton wool bud use/Hearing aids
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28
Q

Symptoms of ear wax?

A
  • Mainly asymptomatic
  • Symptoms include:
    o Blocked ears
    o Ear discomfort
    o Feeling of fullness in ear
    o Tinnitus
    o Itchiness
    o Vertigo
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29
Q

Signs of ear wax?

A
  • Signs on otoscopy

o Wax in ear canal (may occlude whole canal)

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30
Q

Management of ear wax - when to remove?

A

o Totally occluding canal and symptoms present
o If tympanic membrane is obscured by needs to be viewed to establish diagnosis
o If hearing aid impression needing to be fit

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31
Q

Management of ear wax - general advice?

A

o Do not insert anything into ear as can damage structures

o Ear candles has no benefit in management

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32
Q

Management of ear wax - safety net?

A

o If develop earache, itching, discharge from ear, swelling of ear canal come back

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33
Q

Management of ear wax - how to remove ear wax?

A

o Ear drops (olive oil 3-4 times a day for 3-5 days) to soften wax
o Ear irrigation
• Electronic ear irrigator
• Angle so flow is along top of posterior wall

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34
Q

Management of ear wax - contraindications of removing ear wax?

A
  • Hx of previous problem
  • Current perforation or in last 12 months
  • Grommets in place
  • Hx of ear surgery
  • Mucous discharge from ear
  • Middle ear infection in previous 6 weeks
  • Acute otitis externa
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35
Q

Management of ear wax - complications of removing ear wax?

A

• Failure, otitis externa, perforation, pain, vertigo

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36
Q

Management of ear wax - if irrigation unsuccessful?

A

o Use drops for further 3-5 days and return for repeat irrigation
o Instil water into ear – then irrigate after 15 minutes
o Refer to ENT specialist

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37
Q

Management of ear wax - when to refer?

A

o Before irrigation if – chronic perforation, history of ear surgery, foreign body
o If irrigation unsuccessful
o Severe pain, deafness or vertigo
o Infection present

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38
Q

Management of ear wax - recurrent ear wax?

A

o Ear drops regularly (sodium bicarbonate, sodium chloride, olive oil, almond oil)
o Irrigation or referral for manual extraction if needed

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39
Q

Complications of ear wax?

A

o Conductive hearing loss

o Discomfort

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40
Q

Categories of hearing loss?

A

o Conductive – occurs due to abnormalities of outer or middle ear which impairs conduction of sound waves from external ear (pinna, ear canal or tympanic membrane) through ossicles to cochlear
o Sensorineural – abnormalities in cochlear, auditory nerve or structures in neural pathway leading to auditory cortex
o Mixed

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41
Q

Severity of hearing loss?

A

o Mild – 25-39dB
o Moderate 40-69dB
o Severe – 70-94dB
o Profound - >95dB

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42
Q

Epidemiology of hearing loss?

A
  • Prevalence increases with age

- Most common is age related hearing loss

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43
Q

Causes of conductive hearing loss?

A

 Impacted earwax
 Foreign Bodies
 Tympanic membrane perforation
 Infection (otitis media and externa)
 Middle ear effusion
 Cholesteatoma
 Otosclerosis (abnormal bone growth affecting ossicles)
 Neoplasms (SCC of external ear, vascular glomus tumour)
 Exostoses (hard, bony growths in ear canal)

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44
Q

Causes of sensorineural hearing loss?

A

 Age-related (presbycusis) – most common
 Noise exposure
 Sudden sensorineural hearing loss (within 72 hours)
 Meniere’s disease
 Ototoxic substances (gentamicin, bumetanide, furosemide, NSAIDs, aspirin, quinine, chloroquine, cisplatin, bleomycin, cigarettes, mercury, lead)
 Labyrinthitis
 Vestibular Schwannoma (Acoustic Neuroma)
 MS, stroke
 Malignancy (intracranial or nasopharyngeal)
 Infections (CMV, toxoplasmosis, syphilis, meningitis, HIV, Lyme disease HZV)
 Autoimmune (RA, SLE, sarcoidosis, Wegeners granulomatosis)
 Hereditary (Alports syndrome)

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45
Q

Symptoms of prebycusis?

A

o Bilateral high-frequency hearing loss after 50 years old

o May be unaware and need TV higher or cannot hear people

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46
Q

Symptoms of noise-related hearing loss?

A

o Hx of exposure to persistent high levels of noise

o Associated with tinnitus

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47
Q

Symptoms of sensorineural hearing loss?

A

o Bilateral hearing loss within 72 hours

o May have tinnitus, sensation of fullness in ear and vertigo

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48
Q

Symptoms of labyrinthitis?

A

o Tinnitus and vertigo common

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49
Q

Symptoms of acoustic neuroma?

A

o Gradual onset, unilateral hearing loss associated with tinnitus and vertigo

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50
Q

Assessment of hearing loss?

A 
o	History
o	Examination
o	Otoscopy
o	Weber Test
o	Rinne’s Test
o	Cranial Nerve and Cerebellar tests
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51
Q

Weber test used in hearing loss? what is positive test?

A

 512Hz tuning fork, strike one side on padded surface or ball of hand
 Place vibrating tuning fork on person’s forehead for 4 seconds
 Ask person where tone is heard – centrally, left or right
• If centrally – suggests symmetrical hearing loss
• In poorer ear – suggests asymmetrical conductive hearing loss
• In better ear – suggests asymmetrical sensorineural hearing loss

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52
Q

Rinne’s test used in hearing loss? What is positive test?

A

 512Hz tuning fork, strike one side on padded surface or ball of hand
 Hold tuning fork 2.5cm from entrance to ear canal for 2s then press footplate firmly over mastoid and hold for 2s
 Ask person if tone is louder next to ear or behind ear
• If better/louder by air conduction (next to ear) – Rinne’s positive and suggests sensorineural hearing loss or normal hearing
• If better/louder by bone conduction (held on mastoid) – Rinne’s negative and suggests conductive hearing loss in that ear

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53
Q

Further investigations in hearing loss?

A

o Audiology assessment if underlying systemic condition

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54
Q

Management of hearing loss - when to refer immediately?

A

o Sudden onset (<72 hours) unilateral or bilateral hearing loss within 30 days and not explained by external or middle ear causes
o Unilateral hearing loss associated with focal neurology
o Hearing loss with head/neck injury
o Necrotising otitis externa or Ramsay Hunt Syndrome

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55
Q

Management of hearing loss - when to refer within 2 weeks?

A

o Sudden onset (<72 hours) unilateral or bilateral hearing loss over 30 days ago and not explained by external or middle ear causes
o Rapidly progressive hearing loss not explained by external or middle ear cause
o Suspected head and neck malignancy

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56
Q

Management of hearing loss - when to refer routinely?

A

o Unilateral or asymmetric gradual onset hearing loss
o Fluctuating hearing loss not with URTI
o Hearing loss associated with hyperacusis
o Hearing loss associated with persistent tinnitus which is:
 Unilateral – acoustic neuroma, Meniere’s disease, otosclerosis
 Pulsatile – intracranial vascular tumours, aneurysms, carotid atherosclerosis
 Changed significantly
 Causing distress
o Hearing loss with persistent or recurrent vertigo
o Hearing loss not age related

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57
Q

Management of hearing loss in primary care - initial management?

A

Exclude/treat ear wax, acute ear infection, middle ear effusion due to URTI

Audiological Assessment
	If sensorineural confirmed and no underlying causes requiring further investigation by ENT
•	Hearing aids
•	Assisted listening devices (ALDs)
•	Cochlear implants
	Follow up 6-12 weeks

Refer for diagnostic assessment

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58
Q

Management of hearing loss in primary care - general measures?

A

 Reduce competing noises
 Soft furnishings improve sound quality if hearing aid used
 Ensure adequate lighting to help with communicating

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59
Q

Management of hearing loss in secondary care - investigations?

A

 MRI to adults with hearing loss and localising symptoms or signs (facial nerve weakness) indicating vestibular schwannoma
 Audiology assessment
• Bloods – FBC, ESR, CRP, U&E, LFT, TSH, autoimmune profile, clotting, glucose
• Audiometry and brainstem responses
• High-dose steroids

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60
Q

Management of hearing loss in secondary care - non-induced hearing loss?

A
  • Reduced occupational risk

* Tinnitus retraining therapy

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61
Q

Management of hearing loss in secondary care - otosclerosis?

A
  • Hearing aid

* Surgery – stapedectomy, stapedotomy

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62
Q

Management of hearing loss in audiological services - what hearing devices are available?

A

 Hearing Aids
• If hearing loss affects ability to communicate and hear
• Offer 2 if both ears affected

 Assisted Listening Devices
• Personal loops, personal communicators, TV amplifiers, telephones devices, smoke alarms, doorbell sensors

 Implantable Devices
• Cochlear Implants

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63
Q

Follow up in audiological services?

A

 6-12 weeks after hearing aids fitted

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64
Q

Definition of acoustic neuroma?

A
  • Tumour of vestibulocochlear nerve (CN8) arising from Schwann cells of nerve sheath
  • Typically benign and slow-growing
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65
Q

Risk factors of acoustic neuroma?

A

o Neurofibromatosis

o High-dose ionising radiation

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66
Q

Presentation of acoustic neuroma?

A

o Unilateral sensorineural hearing loss – considered acoustic neuroma until proven otherwise
 Progressive onset
o Impaired facial sensation
o Balance problems
o Large tumours give cerebellar signs or raised ICP

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67
Q

Investigations of acoustic neuroma?

A

o Audiology assessment

o MRI scan – for all with unilateral hearing loss

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68
Q

Management of acoustic neuroma - observation?

A

 Small neuromas and good preserved hearing

 Annual scans to monitor growth – if detected then active management

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69
Q

Management of acoustic neuroma - surgery?

A

 Microsurgery – removal of tumour

 Stereotactic radiosurgery – single large dose of radiation using high-energy X rays or gamma rays

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70
Q

What are the most common causes of vertigo?

A

BPPV, Meniere’s and vestibular neuronitis

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71
Q

Definition of vertigo?

A
  • Vertigo is false sensation of movement (spinning or rotating) of the person or their surroundings in absence any actual physical movement
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72
Q

Peripheral causes of vertigo?

A 
	BPPV
	Labryrinthitis
	Meniere’s Disease
	Perilymphatic fistula
	Ototoxicity
	Syphilis
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73
Q

Central causes of vertigo?

A

 Migraine

 Stroke

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74
Q

Tests to perform in vertigo?

A
  • Romberg’s test
  • Dix-Hallpike manoeuvre
  • Head impulse test
  • Unterberger’s test
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75
Q

What is Romberg’s test in vertigo?

A

o Stand up straight with feet together and shut their eyes
o If person cannot maintain balance when eyes closed, test if positive
o Problem with proprioception or vestibular function

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76
Q

What is Dix-Hallpipe manoeuvre in vertigo?

A

o Caution if neck/back problems, carotid sinus syncope
o Keep eyes open and look straight ahead
o Sit upright on couch and head turned 45o to one side
o From this position, lie person down rapidly supporting head and neck until head is extended 20-30 degrees over end of couch and maintain for 30 seconds
o Observe eyes closely for 30 seconds for nystagmus
o If Dix-Hallpipe positive with vertigo and torsional upbeating nystagmus - BBPV

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77
Q

What is Head impulse test in vertigo?

A

o Sit upright and fix gaze on examiner
o Rapidly turn head 10-20o to one side and watch person’s eyes
o Normal = eyes stay fixed
o Abnormal = eyes are dragged off target by head turn, corrective abnormal movement (saccade) – positive test

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78
Q

What is Unterberger’s test in vertigo?

A

o March on spot with eyes closed

o Person will rotate to side of affected labyrinth

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79
Q

Common features of peripheral vertigo?

A

 Prolonged, severe vertigo
 New-onset headache or recent trauma
 CV risk factors

80
Q

Common features of central vertigo?

A

 Normal neurological examination
 Severe N&V
 Hearing loss

81
Q

Management of central vertigo?

A

o Admit or urgently refer to ENT

o Prochlorprazine, cyclizine, promethazine whilst awaiting referral

82
Q

Management of peripheral vertigo?

A

o Admit urgently if severe N&V, central neurological symptoms
o Refer to ENT if undetermined cause
o Prochlorprazine, cyclizine, promethazine whilst awaiting referral for no longer than 1 week

83
Q

Description of acute vestibular syndrome?

A 
	Acute onset dizziness and/or vertigo
	Intolerance of head movement
	Continuous dizziness of 24 hours to several weeks duration
	Nystagmus
	Unsteady gait
	Nausea and/or vomiting
84
Q

Definition of BPPV?

A
  • Disorder of inner ear characterised by repeated episodes of positional vertigo and positional nystagmus on performing diagnostic manoeuvres
85
Q

Epidemiology of BPPV?

A
  • Most common cause of vertigo
  • Women more commonly
  • Posterior semi-circular canal most commonly affected 85-90%
86
Q

Risk Factors of BPPV?

A

o Head injury
o Prolonged recumbent position (vet, hairdresser)
o Ear surgery
o Ear pathology (labyrinthitis, Meniere’s)

87
Q

Pathology of BPPV?

A

o Loose calcium carbonate debris (otoconia) in semi-circular canals of inner ear (canalithiasis)
o When head moves, otoconia move into semi-circular canals causing motion of fluid of inner ear (endolymph) which induces symptoms

88
Q

Symptoms of BPPV?

A
  • Vertigo
    o Brought on by movements (lying down, turning over in bed, looking upwards, bending over)
    o Lasts <1 minute, preceded by position change
    o Asymptomatic between attacks
  • Nausea and vomiting
  • Hearing and tinnitus NOT affected
89
Q

Classical vetigo symptoms in BPPV?

A

o Brought on by movements (lying down, turning over in bed, looking upwards, bending over)
o Lasts <1 minute, preceded by position change
o Asymptomatic between attacks

90
Q

Tests in BPPV?

A
  • Dix-Hallpipe manoeuvre
    o Diagnose posterior BPPV if torsional upbeating nystagmus (left ear = clockwise, right ear = anticlockwise)
    o Latent period 5-20s until symptoms and increase in intensity and then decline
    o If negative – repeat in one week
91
Q

Management of BPPV - general advice?

A

o Most people recover over several weeks, but may last or recur
o Get out of bed slowly and avoid tasks looking upwards
o Do not drive when dizzy and inform DVLA if ‘sudden unprovoked or unprecipitated episodes of disabling dizziness’

92
Q

Management of BPPV - if mild?

A

o Watchful waiting

93
Q

Management of BPPV - moderate/severe?

A

o Epley Maneouvre
 If symptoms do not settle after 1 week – return for repeat

o Brandt-Daroff exercises if Epley manoeuvre not performed
 Sit on edge of couch with eyes closed
 Lie down sideways on one side with head looking up at ceiling
 Rest for 30 seconds, keep eyes closed and then sit upright
 Repeat 3-4 times until symptoms free and 3-4 times a day

o Follow up in 4 weeks if not resolved

94
Q

Management of BPPV - when to admit?

A

o If severe N&V unable to tolerate oral fluids

95
Q

Management of BPPV - when to refer to ENT?

A

o Epley manoeuvre not available in primary care
o Epley manoeuvre not worked
o Symptoms not resolved in 4 weeks

96
Q

Complications of BPPV?

A
  • Falls

- Difficulty performing ADLs

97
Q

Prognosis of BPPV?

A
  • Relapsing and remitting pattern

- Recurrence is common (about 15%)

98
Q

Definition of vestibular neuronitis?

A
  • Acute, isolated, prolonged vertigo of peripheral origin

Inflammation of vestibular nerve and no hearing loss and may occur after viral infection

99
Q

Definition of labyrinthitis?

A

inflammation of labyrinth, hearing loss a feature

100
Q

Epidemiology of vestibular neuronitis?

A
  • 30-60
  • Spring or early summer most likely
  • 2nd most common cause of vertigo
101
Q

Symptoms of vestibular neuronitis?

A

o Preceded by viral illness
o Rotational vertigo occurs spontaneously
 Sudden, on waking and may worsen over course of day
 Exacerbated by head position but initially constant
o Nausea and vomiting
o Malaise
o Balance affected
o HEARING LOSS AND TINNITUS IN LABYRINTHITIS ONLY

102
Q

Signs of vestibular neuronitis? What test can be performed?

A

o Nystagmus – fine horizontal
o Head impulse test positive
 Sit upright and fix gaze on examiner
 Rapidly turn head 10-20o to one side and watch person’s eyes
 Normal = eyes stay fixed
 Abnormal = eyes are dragged off target by head turn, corrective abnormal movement (saccade) – positive test

103
Q

Diagnosis of vestibular neuronitis?

A
  • Clinical diagnosis
104
Q

Management of vestibular neuronitis - general advice?

A

o Symptoms will settle over 2-6 weeks, even with no treatment
o Avoid alcohol, tiredness, illness which worsen it
o Bed rest during acute phase
o Do not drive when dizzy and inform DVLA if ‘sudden unprovoked or unprecipitated episodes of disabling dizziness’

105
Q

Management of vestibular neuronitis - symptomatic management?

A

o Rapidly relieve severe N&V – buccal prochlorperazine
o Alleviate N&V and vertigo
 3-day oral course of prochlorperazine or antihistamine (cinnarizine, cyclizine, promethazine)
o Return if symptoms worsen or not resolved after 1 week

106
Q

Management of vestibular neuronitis - when to admit?

A

o If severe N&V who cannot tolerate oral fluids

107
Q

Management of vestibular neuronitis - when to refer to ENT?

A

o Symptoms not typical (neurological symptoms)
o Symptoms persist without improvement for >1 week despite treatment
o Symptoms persist >6 weeks

108
Q

Complications of vestibular neuronitis?

A
  • BPPV can develop after Vestibular neuronitis in 10%
  • Risk of falls
  • Worse ADLs and QoL
109
Q

Prognosis of vestibular neuronitis?

A
  • Severe initial symptoms usually last 2-3 days, and recover gradually over weeks (by 6)
  • Recurrence is possible but rare and consider vestibular migraine or BPPV
110
Q

Definition of Meniere’s Disease?

A
  • Disorder of inner ear which can affect balance and hearing
  • Clinical syndrome characterised by episodes of vertigo, fluctuating hearing loss and tinnitus
  • Associated with feeling of fullness in ear
111
Q

Epidemiology of Meniere’s Disease?

A
  • Uncommon

- Women, 30-60

112
Q

Risk factors of Meniere’s Disease?

A 
o	Autoimmune
o	FHx
o	Metabolic disturbances – sodium, potassium
o	Viral infection
o	Head trauma
113
Q

Pathology of Meniere’s Disease?

A

o Abnormal endolymph production and/or absorption
o Volume of endolymph in membranous labyrinth increases and volume of perilymph filling bony labyrinth decreases
o Swelling of vestibular system lead to classic symptoms

114
Q

Classic symptoms of Meniere’s Disease?

A

o Vertigo
 Spontaneous, with or without nausea and vomiting
 Unsteadiness can persist for several days after acute attack

o Tinnitus
 ‘Roaring’, may become permanent

o Sensorineural hearing loss
 Fluctuating, initially low frequencies and then permanent

o Aural Fullness (sensation of pressure in ear)

115
Q

Acute attacks of Meniere’s Disease?

A

o Preceded by change in tinnitus, increased hearing loss or aural fullness before vertigo for few hours
o Vertigo and symptoms for 20 minutes to a few hours

116
Q

Other problems in Meniere’s Disease?

A

o Otholitic crises of Tumarkin – drop attack without LoC without warning and normal activity resumed immediately
o Gait problems
o Postural instability

117
Q

Diagnosis of Meniere’s Disease?

A
  • Diagnosis is clinical and need the following criteria:
    o Vertigo – 2 or more spontaneous episodes lasting 20 minutes to 12 hours
    o Fluctuating hearing loss, tinnitus and/or perception to aural fullness in affected ear
    o Hearing loss confirmed by audiometry as sensorineural, low-to-mid frequency
118
Q

When is Meniere’s Disease the probable diagnosis?

A
  • Probable diagnosis if all of above without audiometry
119
Q

Management of Meniere’s Disease - when to admit?

A

o If severe symptoms for IV labyrinthine sedatives and fluids

120
Q

Management of Meniere’s Disease - when to refer to ENT?

A

o To confirm diagnosis

121
Q

Management of Meniere’s Disease - when to refer to audiology?

A

o If signs suggestive of hearing loss

122
Q

Management of Meniere’s Disease - general advice?

A

o Long-term condition but vertigo usually improves
o Acute attack usually settle within 24 hours
o Do not drive when dizzy and inform DVLA if ‘sudden unprovoked or unprecipitated episodes of disabling dizziness’

123
Q

Management of Meniere’s Disease - symptomatic treatment of acute attacks?

A

o Severe – admission for IV labyrinthine sedatives
o Rapidly relieved severe N&V – buccal prochlorperazine
o Alleviate N&V and vertigo
 7 days (14 days if required before) of prochlorperazine or antihistamine (cyclizine, promethazine, cinnarizine)
 If symptoms don’t improve within 5-7 days – reassess

124
Q

Management of Meniere’s Disease - prevention of recurrent attacks??

A 
o	Oral Betahistine
o	Specialist management:
	Vestibular rehabilitation
	Diuretics
	Intratympanic gentamicin or steroids
	Endolymphatic shunts or sac surgery
	Labyrinthectomy
125
Q

Prognosis of Meniere’s Disease?

A
  • Symptoms can initially fluctuate, resolving completely between episodes
  • Later in course, hearing loss progresses and tinnitus becomes persistent
  • After years, vertigo is no longer experienced
126
Q

Definition of epistaxis?

A
  • Bleeding from the nose
127
Q

Epidemiology of epistaxis?

A
  • Up to 60% have nosebleeds but rarely do people need medical attention
  • Common in children
  • Posterior epistaxis more common in elderly
128
Q

Patholgoy of epistaxis?

A

o 80-90% originate from Little’s area on anterior nasal septum, contains Kiesselbach plexus of vessels
o Less commonly from branches of sphenopalatine artery in posterior nasal cavity

129
Q

Causes of epistaxis?

A

o Trauma – nose-picking, nasal fractures, septal ulcers, foreign body, blunt trauma
o Inflammation – infection, allergic rhinosinusitis, nasal polyps
o Topical drugs – cocaine, decongestants, corticosteroids
o Vascular – Wegener’s granulomatosis
o Post-operative bleeding
o Tumours – benign (angiofibroma) or malignant (SCC)
o Nasal oxygen therapy
o Clotting disorders – thrombocytopenia, platelet dysfunction, von Willebrand disease, leukaemia, haemophilia
o Drugs – anticoagulants, antiplatelet drugs
o Excessive alcohol consumption

130
Q

Symptoms of epistaxis?

131
Q

Assessment of epistaxis?

A
  • Assess how much blood, any temporary measures performed, previous epistaxis and treatment
  • Examine – both nasal passages (with nasal speculum)
    o Look for bleeding point
132
Q

When to suspect posterior epistaxis?

A

o Profuse, from both nostrils, bleeding site not identified and goes down throat

133
Q

Investigations if secondary cause suspected in epistaxis?

A

o FBC (if heavy or recurrent), coagulation (if clotting disease suspected)

134
Q

Management of epistaxis - when to transfer immediately to A&E?

A

o Haemodynamic compromise

135
Q

Management of epistaxis - when to admit to hospital?

A

o Posterior bleed - Bleeding profuse, from both nostrils and site cannot be identified
o Children <2
o Underlying cause (bleeding predisposition, haemophilia, leukaemia)

136
Q

Management of epistaxis - acute management - first aid measures?

A

 Sit with upper body tilted forward and mouth open – avoid lying down
 Pinch cartilaginous (soft) part of nose firmly and hold for 10-15 minutes without releasing pressure, breathe through mouth

137
Q

Management of epistaxis - acute management - if stops with first aid?

A

 Topical antiseptic (Naseptin cream QDS for 10 days)

138
Q

Management of epistaxis - acute management - if does not stop in 10-15 minutes?

A

Either admit to hospital (A&E) or perform in primary care if possible:
 Nasal Cautery – if site identified
• Topical LA spray (Co-phenylcaine), wait 3-4 minutes and apply silver nitrate stick to bleeding point for 3-10 seconds until grey
• Need Naseptin after

 Nasal packing – if cautery ineffective
• Topical LA spray (Co-phenylcaine), wait 3-4 minutes
• Options: Nasal tampons (Merocel), inflatable packs (Rapid-Rhino)
• Need admission to ENT afterwards

139
Q

Management of epistaxis - general measures after nosebleed?

A

 Avoid blowing nose, picking nose, heavy lifting, strenuous exercise, lying flat, drinking alcohol

140
Q

Management of epistaxis - secondary care of severe epistaxis?

A

 Resuscitate if BP low, dizzy on sitting
 Apply pressure for 20 minutes, sit forward and breathe through mouth
 Cautery – encourage patient to blow out clots
• LA soaked for 2 minutes
• Apply cautery on bleeding point – moving in a circle
• Never cauterise both sides of septum
 If continues:
• Anterior nasal pack – Rapid Rhino, Merocel
• Posterior nasal pack – Foley urinary catheter and inflate balloon

141
Q

Management of epistaxis - secondary care treatments?

A 
	Resuscitation if needed
	Formal packing
	Endoscopic assessment and electrocautery
	EUA
	Arterial ligation/embolisation
	IV transexamic acid
142
Q

Management of epistaxis - recurrent epistaxis?

A

o First aid measures when bleeds

o Avoid blowing/picking nose, heavy lifting, strenuous exercise and lying flat for 24 hours after

o Determine underlying cause:
 FBC, clotting

o Referral to ENT if recurrent with signs of underlying conditions such as:
 Angiofibroma (nasal obstruction, severe epistaxis)
 Cancer (nasal obstruction, facial pain, hearing loss, eye symptoms)
 Telangiectasia (red spots on fingertips, lips, lining of nose)

143
Q

Complications of epistaxis?

A

o Hypovolaemia, anaemia, aspiration
o Nasal packing treatment – sinusitis, septal haematoma, pressure necrosis, toxic shock syndrome
o Nasal cautery treatment – septal perforation

144
Q

How common is nasal injury?

A

o Nasal bone most commonly fractured bones of face

o Seen in 15-30

145
Q

Causes of nasal injury?

A 
o	Motor vehicle
o	Sports
o	Falls
o	Abuse
o	Punches, clash of heads
146
Q

Symptoms and signs of nasal injury?

A

o Usually high-impact injury
o Swelling becomes apparent
o CSF Rhinorrhoea
 CSF contains glucose and B2 tau transferrin
 If traumatic – 7-10 bed rest, lumbar drain, avoid coughing/sneezing, antibiotic cover
o Epistaxis
o Septal deviation/haematoma

147
Q

When to refer nasal injury to ENT immediately?

A 
o	Marked deviation
o	Epistaxis not settling
o	Septal haematoma
o	CSF rhinorrhoea
o	Widening intercanthal distance
o	Facial anaesthesia
148
Q

Management of nasal injury?

A 
o	If significant swelling:
	Ice, simple analgesia
	Review in 5 days by GP
o	Usually heal within 2-3 weeks
o	Manipulation under anaesthetic (MUA) performed within 5-10 days in adults
149
Q

Common causes of nasal foreign body?

A 
o	Beads
o	Buttons
o	Sweets
o	Nuts
o	Seeds
o	Peas
150
Q

Presentation of nasal foreign body?

A

o Self-inserted and often observed
o May produce nasal obstruction
o Purulent unilateral discharge suggests organic material

151
Q

When to refer to ENT a nasal foreign body?

A

o If prolonged unilateral nasal discharge
o FB in posterior position
o Patient agitated
o Not experienced

152
Q

Management of nasal foreign body?

A

o Topical anaesthetic and vasoconstrictor spray
o Ask child to blow nose
o Ask parent to blow sharply though patients mouth whilst obstructing unaffected nostril (success rate >70%)
o Nasal speculum and thin forceps to hold object (avoid pushing deeper)
o Refer to ENT if two unsuccessful attempts

153
Q

Definition of allergic rhinitis?

A
  • IgE mediated inflammatory disorder of nose

- Due to nasal mucosa sensitised to allergens, triggers histamine release to produce symptoms

154
Q

Epidemiology of allergic rhinitis?

A
  • Prevalence increasing

¼ of adults

155
Q

Classifications of allergic rhinitis?

A

o Seasonal – occur at same time each year (hayfever)
o Perennial – throughout year, typically due to house dust mites, animal dander
o Intermittent - <4 days a week or <4 consecutive weeks
o Persistent - >4 days a week and >4 consecutive weeks

156
Q

Causes of allergic rhinitis?

A 
o	FHx
o	House dust mites
o	Grass, tree and weed pollen
o	Mould
o	Animal dander (cats and dogs most common)
o	Occupational
157
Q

Symptoms of allergic rhinitis?

A

o Sneezing
o Nasal Itching
o Nasal discharge (rhinorrhoea)
o Nasal congestion
o Eye itching, redness, tearing
o Bilateral and usually develop within minutes of exposure to allergen
o Other – postnasal drip, cough, mouth breathing

158
Q

Signs of allergic rhinitis?

A

o Nasal voice
o Darkened eye shadows
o Horizontal nasal crease
o Discharge – usually clear

159
Q

Management of allergic rhinitis - general measures?

A

o Nasal irrigation with saline – OTC
o Allergen avoidance
 Grass pollen allergy – avoid grassy, open spaces, particularly early in morning or late at night, avoid drying washing outdoors, keep windows shut
 House dust mite – synthetic pillows, keep furry toys off bed, wash bedding frequently, wooden floors preferable
 Animal allergy – Restrict areas of house animal can go, wash animal regularly
 Occupational – reduce exposure, adequately ventilated work environment

160
Q

Management of allergic rhinitis - drug treatment for mild-to-moderate?

A

 PRN intranasal antihistamines (azelastine) OR
 PRN oral antihistamines (loratadine or certirizine)
• If antihistamines CI or not tolerated – PRN intranasal sodium cromoglicate

161
Q

Management of allergic rhinitis - drug treatment for moderate-to-severe?

A

 Regular intranasal corticosteroid during periods of exposure (mometasone, fluticasone)

162
Q

Management of allergic rhinitis - other treatments?

A

 If nasal congestion – short-term intranasal decongestant (ephedrine)
 If watery rhinorrhoea – intranasal anticholinergic (ipratropium bromide)
 If itching or sneezing – regular antihistamine

163
Q

Management of allergic rhinitis - severe symptoms or uncontrolled?

A

 Oral prednisolone for 5-10 days

164
Q

Management of allergic rhinitis - follow up?

A

o Review after 2-4 weeks of treatments

165
Q

Management of allergic rhinitis - when to refer to ENT?

A

o Red flag features – unilateral, blood stained mucous, nasal pain, recurrent epistaxis – 2-week wait
o Nasal obstruction/structural abnormality which makes intranasal treatment difficult
o Persistent symptoms despite ongoing management
 Allergy Testing – skin prick or IgE levels to allergens
 Immunotherapy

166
Q

Complications of allergic rhinitis?

A

o Impaired QoL
o Asthma
o Sinusitis
o Nasal Polyps

167
Q

Definition of sinusitis?

A
  • Inflammation of paranasal sinuses

o Frontal, maxillary, sphenoid, ethmoidal

168
Q

Classifications of sinusitis?

A
  • Acute – resolves within 12 weeks
  • Recurrent – 4 or more annual episodes of sinusitis with persistent symptoms in intervening periods
  • Chronic – symptoms lasting >12 weeks
169
Q

Epidemiology of sinusitis?

A
  • Acute – common in adults

- Chronic – increases with age, women, asthma/COPD

170
Q

Causes of acute sinusitis?

A

 Viral URTI which can be followed by bacterial infection
• S.pneumoniae, H,influenza, Moraxella catarrhalis and S.aureus
 Also associated with asthma, allergic rhinitis, smoking, anatomical variation, seasonal variation, CF

171
Q

Causes of chronic sinusitis?

A

 Multifactorial
 Usually S.aureus, enterobacteriaeceae
 Predisposing conditions: atopy, asthma, CF, aspirin sensitivity, immunocompromise, smoking

172
Q

Symptoms and signs of acute sinusitis?

A 
o	Usually follows viral illness
o	Diagnostic with (<12 weeks):
	Nasal obstruction/congestion
	Nasal discharge (anterior, posterior) 
	Facial pain/pressure
	Reduced/Loss of smell
o	Altered speech, tender cheekbones, cough
173
Q

When to suspect bacterial sinusitis?

A

o >10 days
o Discoloured or purulent nasal discharge
o Severe local pain
o Fever >38

174
Q

Symptoms and signs of chronic sinusitis?

A
  • Chronic Sinusitis (>12 weeks):
    o Nasal obstruction/congestion
    o Nasal discharge (anterior, posterior)
    o Facial pain/pressure
175
Q

Examination performed in sinusitis?

A

o Inspect and palpate maxillofacial area to elicit swelling/tenderness
o Perform anterior rhinoscopy to identify:
 Nasal inflammation, mucosal oedema, purulent nasal discharge, nasal polyps
o Pulse rate, blood pressure, temperature

176
Q

Management of sinusitis - when to refer to ENT?

A 
o	If not typical or diagnosis in doubt
o	Frequent recurrent episodes
o	Treatment failure
o	Anatomical defect
o	Immunocompromise
o	Nasal polyps
177
Q

Management of sinusitis - when to refer urgently?

A

o Systemically unwell, intra/periorbital complications, intracranial complications

178
Q

Management of sinusitis - acute sinusitis - if symptoms <10 days?

A

 Usually caused by virus and should take 2-3 weeks, most people will get better without antibiotics
 PRN paracetamol + ibuprofen
 Nasal saline or nasal decongestants
 Seek medical advice if symptoms worsen or do not improve after 3 weeks

179
Q

Management of sinusitis - acute sinusitis - if symptoms >10 days with no improvement?

A

 High-dose nasal corticosteorids for 14 days (mometasone 200mcg BDS)
 Backup prescription used if no improvement after 7 days
• Phenoxymethylpenicillin 500mg QDS for 5 days (doxycycline)
• 2nd line if not working – Co-amoxiclav

180
Q

Management of sinusitis - chronic sinusitis?

A

o Avoid allergic triggers
o Stop smoking
o Good dental hygiene
o Avoid underwater diving
o Nasal irrigation with saline solution
o Intranasal steroids (mometasone/fluticasone) for up to 3 months
o Seek specialist advice on long-term antibiotics

181
Q

Complications of sinusitis?

A 
o	Acute (rare) – orbital cellulitis/abscess, meningitis, encephalitis, osteomyelitis
o	Chronic – sleep problems, depression, impact on work, reduced QoL
182
Q

Definition of viral croup?

A

 Mucosal inflammation affecting the nose to the LRT

 Due to parainfluenza, influenza and RSV in children aged 6 months – 6 years

183
Q

Definition of spasmodic or recurrent croup?

A

 Barking cough and hyperreactive upper airways

 No respiratory tract symptoms

184
Q

Definition of acute epiglottitis?

A

 Life-threatening swelling of the epiglottis and septicaemia due to H. Influenzae type B infection
 Now rare due to Hib immunization

185
Q

How common is viral croup?

A
  • Viral croup= 95% of the laryngotracheal infections
  • Most common in autumn
  • Peak at 2yrs old, in children aged 6M-6yrs
186
Q

How common is acute epiglottitis?

A

most commonly in ages 1 – 6 years, rare due to Hib immunisation

187
Q

Causative organisms in viral croup?

A

o MOST COMMONLY due to parainfluenza

o Others include Influenza and RSV

188
Q

Causative organisms in acute epiglottitis?

A

o H. Influenzae type B infection

189
Q

Symptoms of croup?

A

o Barking cough
o Harsh stridor
o Hoarseness preceded by fever & coryza

190
Q

Symptoms of acute epiglottitis?

A 
o	High fever, toxic-looking child
o	Intensely painful throat
	Stops swallowing or speaking
o	Saliva drooling
o	Respiratory difficulty
o	Child sitting immobile, upright, with open mouth
191
Q

Examination in croup/epiglottitis?

A

DO NOT EXAMINE THE THROAT—assess severity:
o Degree of stridor and subcostal recession
o RR
o HR
o LOC (drowsy?), tired, exhausted
o Pulse oximetry

192
Q

Diagnosis of acute epiglottitis?

A
  • Anaesthetist makes diagnosis by laryngoscopy – cherry-red swollen epiglottis
  • Electively intubate before obstruction occurs
193
Q

Scoring system used in croup?

A
  • Westley Croup Score
    o Assesses stridor, retractions, air entry, SpO2 and level of consciousness
    o Those with moderate – severe >2 need admission
194
Q

Initial management of croup/epiglottitis?

A
  • LEAVE CHILD ALONE - DO NOT DISTRESS (especially in epiglottitis)
  • Immediate Management:
    o Differentiate between croup and acute epiglottitis
    o Stabilise child, give oxygen and keep airway open
195
Q

Management of mild croup?

A

o Mild illness can be managed at home
 Usually resolves after 48hours
 Take paracetamol/ibuprofen PRN
o If there is recession and stridor at rest, then return to hospital

196
Q

Management of severe croup?

A

Moist or humidified air
• Ease breathing

Steroids
• Oral dexamethasone (0.15mg/kg stat dose) or oral prednisolone (1-2mg/kg stat) or nebulised budesonide (2mg stat dose)

Nebulised adrenaline (epinephrine)
• Transient relief of Sx (airway obs)
• Driven by 8L/O2

My need endotracheal intubation

197
Q

Management of epiglottits?

A

o Nebulised adrenaline may buy time
o Manage in ICU after endotracheal intubation
o Once procedure completed take blood cultures and start IV Abx
 Cefotaxime IV for 7-10 days
o Rifampicin prophylaxis to close contacts

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