List III - Core clinical problems for the student and new doctor Flashcards
1
Q
What are the signs of earchache?
A
- 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
2
Q
What are the do’s and don’ts for the self management of earache?
A
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
3
Q
What is tinnitus?
A
- 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
4
Q
How is tinnitus classified?
A
- Subjective tinnitus
- Objective tinnitus
- Primary tinnitus
- Secondary tinnitus
5
Q
What is subjective tinnitus?
A
- Perceived sound can only be heard by the affected individual
- Caused by abnormal activity in the inner ear or central nervous system
(more common)
6
Q
What is objective tinnitus?
A
- 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)
7
Q
What is primary tinnitus?
A
- Term used to describe idiopathic tinnitus that may be associated with sensorineural hearing loss
8
Q
What is secondary tinnitus?
A
- Associated with an underlying cause or diagnosis (other than sensorineural hearing loss)
9
Q
Which disorders are associated with subjective tinnitus?
A
- 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
10
Q
Which disorders are associated with causing objective tinnitus (very rare)?
A
- 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
11
Q
How common is tinnitus?
A
- Relatively common around 10% of UK adults experience prolonged tinnitus
12
Q
What are the consequences of tinnitus?
A
- Impaired concentration
- Interference with daily activities
- Loneliness, withdrawal and social isolation
- Sleep disturbance
- Anxiety
- Depression
- Suicide (rare)
13
Q
What is the prognosis of tinnitus?
A
- Most tinnitus is mild and improves over time
* Some cases can persist over time for many years (especially with co-existing sensorineural hearing loss)
14
Q
What are the suspected causes of unilateral tinnitus with sensorineural hearing loss?
A
- 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
15
Q
What are the suspected causes of bilateral tinnitus with sensorineural hearing loss?
A
- With this presentation suspect tinnitus secondary to:
- Age related hearing loss
- Noise induced hearing loss
- Drug induced ototoxicity
16
Q
What are the suspected causes of bilateral or unilateral tinnitus with conductive hearing loss?
A
- 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
17
Q
What is the management of people with objective tinnitus?
A
- Refer all people to an ENT specialist for diagnosis of the cause
18
Q
When should a patient with tinnitus be referred to secondary care immediately?
A
- 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
19
Q
How should a person with tinnitus be managed in primary care?
A
- 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
20
Q
What is dizziness?
A
- 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
21
Q
What is vertigo?
A
- 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
22
Q
What is peripheral vertigo?
A
- 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)
23
Q
What is central vertigo?
A
- Central vertigo is uncommon and is usually caused by pathology in the brainstem and cerebellum (stroke, TIA, cerebellar tumour and MS)
24
Q
What should be examined on a patient with vertigo?
A
- 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
25
Q
Which tests can be done for vertigo?
A
- 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
26
Q
How are the causes of vertigo determined?
A
- 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
