List III - Core clinical problems for the student and new doctor

Question 1

What are the signs of earchache?

Answer 1

• A young child might have earache if they:
• Rub or pull their ear
• Do not react to some sounds
• Have a temperature of 38c or above
• Are irritable or restless
• Are off their food
• Keep losing their balance
• Earache or ear pain can affect 1 or both ears

Question 2

What are the do’s and don’ts for the self management of earache?

Answer 2

Do

• Use pain killers such as paracetamol or ibuprofen (children under 16 should not take aspirin)
• Place a warm or cold flannel on the ear

Dont

• Do not put anything inside your ear, such as cotton buds
• Do not try to remove earwax
• Do not let water get inside your ear

Question 3

What is tinnitus?

Answer 3

• Perception of sound in the absence of sound from the external environment
• May be described as a ringing, hissing, buzzing, sizzling, whistling or humming and can be constant or intermittent and unilateral or bilateral

Question 4

How is tinnitus classified?

Answer 4

• Subjective tinnitus
• Objective tinnitus
• Primary tinnitus
• Secondary tinnitus

Question 5

What is subjective tinnitus?

Answer 5

• Perceived sound can only be heard by the affected individual
• Caused by abnormal activity in the inner ear or central nervous system
  (more common)

Question 6

What is objective tinnitus?

Answer 6

• Sound can be heard by the affected individual and the examiner
• Often originates from an identifiable and correctable cause that produces sound near to, or within, the ear (for example a vascular abnormality producing a pulsatile sound near to the ear, or muscle related noise)

Question 7

What is primary tinnitus?

Answer 7

• Term used to describe idiopathic tinnitus that may be associated with sensorineural hearing loss

Question 8

What is secondary tinnitus?

Answer 8

• Associated with an underlying cause or diagnosis (other than sensorineural hearing loss)

Question 9

Which disorders are associated with subjective tinnitus?

Answer 9

• Most commonly tinnitus is associated with disorders causing hearing loss
• Age related hearing loss
• Noise related
• Menieres disease (uncommon)
• Impacted wax
• Otosclerosis (rare)
• Ototoxic drugs
• Valproate
• Loop diuretics
• Aspirin and NSAIDs
• Quinine and chloroquine
• Tetracyclines
• Erythromycin (macrolides)
• Gentamicin (aminoglycosides)
• Cytotoxic drugs including cisplatin and bleomycin
• Ear infections
• Neurological disorders
• Metabolic disorders
• Psychological disorders
• Mechanical disorders - temporomandibular joint disorders

Question 10

Which disorders are associated with causing objective tinnitus (very rare)?

Answer 10

• Vascular disorders
• AV malformation and benign venous hum
• Vascular tumours
• Carotid or vertebral artery stenosis, tortuosity, dissection or aneurysm
• Aortic stenosis and mitral regurgitation
• High cardiac output states such as anaemia may also produce pulsatile sounds
• Patulous eustachian tube e.g. after adenoidectomy or weight loss; clicking sounds occur with swallowing
• Myoclonus of palatal or middle ear muscles may cause objective tinnitus by abnormal rhythmic activity, middle ear myoclonus is usually unilateral and produces a clicking or buzzing sound

Question 11

How common is tinnitus?

Answer 11

• Relatively common around 10% of UK adults experience prolonged tinnitus

Question 12

What are the consequences of tinnitus?

Answer 12

• Impaired concentration
• Interference with daily activities
• Loneliness, withdrawal and social isolation
• Sleep disturbance
• Anxiety
• Depression
• Suicide (rare)

Question 13

What is the prognosis of tinnitus?

Answer 13

• Most tinnitus is mild and improves over time

* Some cases can persist over time for many years (especially with co-existing sensorineural hearing loss)

Question 14

What are the suspected causes of unilateral tinnitus with sensorineural hearing loss?

Answer 14

• With this presentation suspect:
• Meniere’s disease - if episodes of tinnitus associated with hearing loss and vertigo generally lasting 15 minutes to 24 hours, tinnitus may be associated with a feeling of fullness in the affected ear
• Acoustic neuroma - especially if tinnitus is associated with unilateral hearing loss - dizziness may be present, signs of cranial nerve and brainstem compression and hydrocephalus may develop with large tumours

Question 15

What are the suspected causes of bilateral tinnitus with sensorineural hearing loss?

Answer 15

• With this presentation suspect tinnitus secondary to:
• Age related hearing loss
• Noise induced hearing loss
• Drug induced ototoxicity

Question 16

What are the suspected causes of bilateral or unilateral tinnitus with conductive hearing loss?

Answer 16

• With this presentation suspect:
• A disorder of the middle or outer ear
• Otosclerosis - especially if there is a family history of otosclerosis, tinnitus is characterised by a hissing sound, humming sound or discrete tones
• Suspect tinnitus secondary to head or neck injury, multiple sclerosis, diabetes or thyroid disease if these conditions are present and other causes have been ruled out

Question 17

What is the management of people with objective tinnitus?

Answer 17

• Refer all people to an ENT specialist for diagnosis of the cause

Question 18

When should a patient with tinnitus be referred to secondary care immediately?

Answer 18

• If associated with:
• High risk of suicide - refer to mental health crisis team
• Sudden onset of significant neurological symptoms e.g. facial weakness - refer for neurological assessment
• Acute uncontrolled vestibular symptoms e.g. vertigo - refer for neurological assessment
• Suspected stroke
• Sudden onset pulsatile tinnitus
• Tinnitus secondary to head trauma
• Very urgently (within 24 hours) if they have tinnitus and hearing loss that has developed suddenly over a period of 3 days or less in the past 30 days - refer to ENT or an emergency department

Question 19

How should a person with tinnitus be managed in primary care?

Answer 19

• If indicated refer for specialist assessment
• If referral not required:
• Reassure the person that tinnitus is a common condition
• May resolve itself
• Although it is commonly associated with hearing loss, it is not commonly associated with underlying physical problems
• Treat the underlying cause e.g. impacted wax, otitis media/externa
• Review medications
• Discuss using sound therapy to reduce the impact tinnitus
• Consider a stepped approach to psychological therapies for people with tinnitus related distress e.g. digital tinnitus related cognitive behavioural therapy provided by psychologists, mindfulness based CBT, group or individual
• Offer a hearing aid to people with tinnitus who have hearing loss that affects their ability to communicate
• Address any associated depression, anxiety or insomnia
• Provide information and self care advice
• What it is
• What can make tinnitus worse
• Safe listening practices
• Impact of tinnitus
• Investigations that may be required in secondary care
• Self help and coping strategies
• Management options
• Provide informations about local and national charities and support groups
• Action on hearing loss
• British Tinnitus Association
• ENT UK

Question 20

What is dizziness?

Answer 20

• Perception of disturbed or impaired spatial orientation but there is no false sense of motion
• Dizziness is commonly used as a non-specific term to describe a number of symptoms including including:
• Vertigo
• Presyncope - a sensation of being about to lose consciousness, usually caused by a decrease in global cerebral blood flow
• Disequilibrium/unsteadiness - a feeling of being unstable while sitting, standing, or walking
• Light-headedness - not clearly defined

Question 21

What is vertigo?

Answer 21

• A symptom, not a diagnosis
• Refers to a false sensation of movement (spinning or rotation) of the person or their surroundings in the absence of any actual physical movement

Question 22

What is peripheral vertigo?

Answer 22

• Peripheral vertigo is more common and is usually caused by a problem with the inner ear affecting the labyrinth or vestibular nerve (BPPV, vestibular neuronitis, labyrinthitis and Meniere’s disease)

Question 23

What is central vertigo?

Answer 23

• Central vertigo is uncommon and is usually caused by pathology in the brainstem and cerebellum (stroke, TIA, cerebellar tumour and MS)

Question 24

What should be examined on a patient with vertigo?

Answer 24

• Examination should look for facial asymmetry, examination of the ear, cranial nerves and cerebellar function, examination of the eyes and checking for signs of peripheral neuropathy and abnormal gait

Question 25

Which tests can be done for vertigo?

Answer 25

• Romburg’s test
• Dix-Hallpike manoeuvre
• Head impulse test
• Unterberger’s test and the alternate cover test can give useful information in the origin of the vertigo

Question 26

How are the causes of vertigo determined?

Answer 26

• If peripheral vertigo is suspected, the history and examination findings can be used to differentiate between conditions, in particular benign paroxysmal positional vertigo (BPPV), vestibular neuronitis and labyrinthitis, and Meniere’s disease.
• A central cause of vertigo should be suspected when the signs and symptoms do not match the features of any of the peripheral causes with reasonable accuracy.
• Features increasing suspicion of a central cause of vertigo include prolonged, severe vertigo; new-onset headache or recent trauma; focal neurological signs and symptoms; central-type nystagmus; an abnormal response to the Dix-Hallpike manoeuvre; and an inability to stand up or walk even with the eyes open