Otology 2

Question 1

What is Otitisd media with effusion

Answer 1

Fluid, no symptoms/signs of acute inflammation (if in an older person unilaterally then consider a tumour)

Question 2

What is chronic suppurative otitis media

Answer 2

Inflammation, TM perforation

Question 3

What is cholesteatoma

Answer 3

Squamous epithelium in middle ear

Question 4

Management of TM perforation

Answer 4

Keep dry
GP follow up in 6 weeks
Give abx drops if perforated ear drum with infection signs
Refer to ENT if severe bleeding or significant symptoms: deafness, tinnitus, vertigo, facial palsy

Question 5

Management of acute otitis media with no perforation

Answer 5

Oral abx

Question 6

When is a bone anchored hearing aid used

Answer 6

Chronic otitis externa, COngenital absence of pinna etc.

Its mechanism of action: instead of sound going as sound wave via ear canal, sound is transmitted to bone by vibration and reaches cholera via bone conduction

Question 7

Factfile of BPPV

Answer 7

Positional: e.g. occurs when roll in bed. Dizziness lasts for seconds

Question 8

Factfile of Ménière’s disease

Answer 8

SNHL, tinnitus, fullness in ears and dizziness. Dizziness lasts for minutes/hours

Question 9

Factfile of vestibular neuritis

Answer 9

Dizziness lasts for days. Occurs usually in young adults with URTI

Question 10

Factfile of migrainous vertigo

Answer 10

Variable duration of dizziness
Migrainous (common, photophobia, personal of Fox migraine)

Question 11

What to do if someone presents with vertigo

Answer 11

Check other CN/ cerebellum/ hearing/ nystagmus (Horizontal nystagmus is usually associated with ENT except for BPPV which presents with other nystagmus when lying down)

Question 12

IF someone presents with acute vertigo, nystagmus, gait unsteadiness and neurological signs what should you be worried about

Answer 12

POsterior fossa stroke

Question 13

Concept of visual preference and how to manage it

Answer 13

People with vestibular hypo function compensate with their vision. Therefore if you take away their vision then it will make them feel off balance i.e. Romberg’s test or if dizziness is worse with patterned/irregular surroundings that disturb visual input.

Treatment: Vestibular rehabilitation with Cawthorne Cooksey exercises

Question 14

Examinations to do when pt presents with dizziness

Answer 14

Cranial neves
Nystagmus
Smooth pursuit (track examiner’s finger and eye movements should be smooth. If not then problem with cerebellum)
Saccades (examiner puts one finger to the left and one tot he right. Ask pt to look from one to the other. Eye movement should be smooth. if not then problem with cerebellum
Rhomberg’s test
Unterberger’s test (ask patient to march for a minute and look for any twisting >30 degrees or falling)
Hallpike test (Tests for BPPV. Get patient to turn head to 45* then quickly move from seated to supine with their head 20* below horizontal. Observe for latency, direction and duration of nystagmus. Nystagmus would be mixed torsional with vertical components. Should resolve within 60s if not then cerebellar cause. Sit up and repeat contralateral ear)
Lying and standing BP

Question 15

treatment of BPPV

Answer 15

Employ manoeuvre: (this is for left posterior canal BPPV)
-Turn head 45 degrees left
-Quickly lie back with head below horizontal
-Turn head right
-Turn whole body right and look at floor
-Sit up on right side

Question 16

Management of Ménière’s disease

Answer 16

MRI to exclude vetibular schwannoma (acoustic neuroma)
Dietary: low salt, caffeine
medical: betahistine, bendroflumethiazide
Grommets
Intratympanic gentamycin or steroid
Pressure devices

Question 17

What do unilateral inner ear symptoms need (SNHL, tinnitus)

Answer 17

MRI to exclude vestibular scwannoma

Question 18

What Are vestibular sedatives used for and their contraindications

Answer 18

Used to prevent overactivity of vestibular system to help with balance issues and dizziness/vomiting. Useful in acute management but not in long term as they stop vestibular system recovery and they mask clinical findings

Question 19

House Brackman scores for the facial nerve

Answer 19

I: normal
II: mild weakness on movement
III: obvious weakness, can close eye
IV: can’t close eye
V: only a flicker of movement
VI: no movement

Question 20

Causes of facial palsy LMN

Answer 20

Bells palsy
Ramsay Hunt Syndrome (also has vesicles in ear)
Middle ear disease (acute otitis media, cholesteatoma)
Trauma
tumour
Infection, Lyme disease
Central cause

Question 21

Factfile of Bell’s palsy and management

Answer 21

Idiopathic facial nerve palsy. Sy,ptoms appear over a few hours then stabilise and improve over weeks.

High dose oral steroids (prednisolone). Eye care: viscotears, lacrilube, night protection with eye shield or tape)

Question 22

What can cause sudden sensorineural hearing loss

Answer 22

Idiopathic
Viral
Tumours
Temporal one fractures
Meniere’s disease
Ototoxic drugs
Central cause e.g. CVA
Autoimmune.

Question 23

Treatment of sudden sensorineural hearing loss

Answer 23

Oral steroids asap
do a turning fork exam and look inside ear
If unsure, refer to ENT

Question 24

When are cochlear implants used

Answer 24

For severe/ profound SNHL when hearing aids are ineffective

Question 25

What to do if pulsatile tinnitus

Answer 25

Look for bruits, anaemia, hyperthyroidism, consider CT/MR angiogram esp if unilateral

Question 26

What to do with non pulsatile tinnitus

Answer 26

Scan only if unilateral.

Question 27

Management of tinnitus

Answer 27

Symptomatic management
Explain: information reaching the brain is incorrect; the ear sends wrong information, or the brain hearing pathways don’t transmit information accurately
Sound enrichment (TV on, music at night)
Hearing aids work well if associated hearing loss
Tinnitus masker plays noise into ear, which for some patients is less annoying than tinnitus
Tinnitus therapy: psychological techniques based on information giving and strategies to avoid stress response

Tell patient several options available, even though no easy cure