Presentations Flashcards
What is the first question you should ask if a pt tells you they are experiencing vertigo or dizziness?
What do you mean by dizzy/vertigo?
Tell me exactly what you experience.
How will true vertigo feel to the pt?
As if the room is spinning around them.
What will dizziness that isn’t vertigo be described as?
Light-headedness Shakiness (like with low blood sugar) Weakness Unsteadiness Feeling faint Visual disturbance Other funny turns
A pt describes recurrent episodes of dizziness. They describe it as the room appears to spin around them.
What are the main differentials you want to consider in this patient?
BPPV Vestibular migraine Labyrinthitis Vestibular neuronitis Ménière’s disease
May have a central cause
A pt describes recurrent episodes of dizziness. They describe it as a light-headed feeling, but no room spinning occurs.
What are the main differentials you want to consider in this patient?
Cardiovascular cause e.g. postural hypotension, arrhythmia, vertebrobasilar insufficiency etc.
Neurological cause e.g. head injury, epilepsy, peripheral neuropathy etc.
Metabolic cause e.g. hypoglycaemia, adrenal insufficiency, hypothyroidism.
Psychogenic e.g. anxiety
Iatrogenic (esp. in older polypharmacy pts)
What are the main neurological causes of vertigo?
MS
Posterior stroke
Migraine
Intracranial space occupying lesion
What is vertigo the result of?
Conflict between vestibular input and other sensory inputs of balance (vision and proprioception).
A pt describes recurrent episodes of dizziness. They describe it as the room appears to spin around them.
What would make you suspect BPPV over other otological causes of vertigo?
- Triggered by head movement e.g. getting out of bed, bending to pray etc.
- Last a few seconds, may not be immediate after movement (small latency).
- No other ear symptoms e.g. tinnitus, pain, fullness, hearing loss.
A pt describes recurrent episodes of dizziness. They describe it as the room appears to spin around them.
What would make you suspect Ménières disease over other otological causes of vertigo?
- Classic triad - severe paroxysmal vertigo, sensorineural hearing loss, and tinnitus.
- Unilateral symptoms, with remission between attacks
- Aural fullness in affected ear
- Lasts minutes to hours
A pt describes recurrent episodes of dizziness. They describe it as the room appears to spin around them.
What would make you suspect vestibular neuronitis over other otological causes of vertigo?
- Last for days
- Preceding URTI
- Incapacitating
- Associated N+V
What is tinnitus?
The perception of sound without an external auditory stimulus.
How might a patient describe tinnitus?
Intermittent or continuous sounds, such as ringing, buzzing, clicking, whistling, but with nothing making the noise in the environment.
What is primary tinnitus often associated with?
Sensorineural hearing loss
A pt presents with ringing ears.
What systems do you need to ask about to try and find a cause?
Ears Medications Metabolic conditions Neurological symptoms Psychological Vascular risk factors
What otological causes of tinnitus are there, and how can they be divided?
Conductive problems - cerumen impaction, otosclerosis, otitis media.
Sensorineural problems - presbycusis, Ménières disease, acoustic neuroma
What are the medications that can cause tinnitus?
NSAIDs Tetracyclines Quinine Sodium Valproate Chemotherapy
To help differentiate between the different causes of tinnitus, wht questions do we need to ask?
SQITARS it up!!
S - both ears or just one?
Q - what does it sound like? Is it always the same? Onset - sudden or gradual?
I - How much does it impact their life? Associated hearing loss?
T - how long does it last, when does it come on?
A - Any head trauma? Drugs hx? Stress?
R - If chronic, is it better in less stressful times?
S - Hearing loss? Pain? Focal neurology? Vertigo? Anything else?
What are the red flags that make tinnitus an otological emergency?
- Sudden onset, pulsatile tinnitus
- Significant neurological symptoms
- Severe vertigo
- Head trauma -> tinnitus
- Sudden hearing loss (unexplained)
When examining a pt with tinnitus, what should we look at?
Otoscopy
Audiometry
Cranial nerve examination
TMJ for focal neurology
What is otalgia?
Aching or pain in the ear
What are the 3 sources of otalgia?
External ear
Middle ear
Referred pain from local structures
What are the possible causes of otalgia relating to the external ear?
- Infection/Inflammation - otitis externa, bullous myringitis, herpes zoster, perichondritis
- Trauma or a foreign body
- Neoplasm
- Sjögren’s syndrome
What are the possible causes of otalgia relating to the middle ear?
- Infection/Inflammation - otitis externa, otitis media with effusion, acute mastoiditis
- Barotrauma
- Eustachian tube obstruction
- Trauma
- Neoplasm
Conditions in which local structures might cause referred otalgia?
- Nasopharynx
- Cranial nerves
- Salivary glands
- Teeth/jaw
- Oesophagus
- Thyroid
- Temporal ateritis
- Tongue
Are most cases of otalgia transient?
Yes
What are the important factors to elicit from a HPC of otalgia?
The usual, SQITARS! Most importantly:
- Onset
- Precipitating factors
- Duration
- Discharge
- Fever
- Swallowing
- Dental history
When might auroscopy not visualise a problem causing otalgia?
If the otalgia is due to referred pain.
Which cranial nerves might otalgia be referred from in particular?
Cranial nerves V, IX, and X.
What red flags would suggest a neoplastic cause of otalgia?
- Persistent otalgia
- Weight loss
- Voice change
- Lymphadenopathy
- Dysphagia
How can otalgia be managed?
Simple analgesia
Treat the cause
If no cause found, wait and review in a few days.
How common is talgia with spontaneous resoluation and no obvious cause?
Very - makes up 50% of patients that present with otalgia.
Are the causes of hearing loss in children and in adults different r the same?
Different
How is hearing loss graded?
By decibels hearing loss (dB HL), graded into 4 categories - mild, moderate, severe, and profound.
What is the most common cause of hearing loss in children?
Glue ear
What kind of hearing loss does glue ear cause?
Conductive hearing loss
Is permanent childhood hearing loss more likely to be conductive or sensorineural?
Sensorineural
Which infections can predispose to hearing loss in a child?
Congenital e.g. Rubella, CMV, toxoplasmosis, herpes…
Mumps
Meningitis
How might hearing loss in a child present?
With parent or teacher concerned about the child’s hearing, speech or language, or a general delay in development.
When might the different degrees of congenital/perinatally acquired hearing loss in a child present?
- Profound - Newborn hearing screen or up to 6-9 months.
- Mild/moderate - later, usully at school with speech/language/development issues.
A child presents with hearing loss that you assess to be conductive. What should you examine for?
- Evidence of glue ear
- Adenoidal hypertrophy - mouth breathing, persistent cough
How can chronic infections cause hearing loss?
- Perforation or scarring of tympanic membrane
- Cholesteatoma formation
- Fluid behind the ear drum
A child presents with hearing loss after starting school. The teachers also wonder if there is an underlying condition as the child has some facial stigmata. What tests can be done to confirm this?
Chromosomal studies to look for specific genetic syndromes
What are the specific tests for hearing loss?
- Rinne’s and Webers
- Auditory brainstem response
- Otoacoustic emissions
- Audiometry
- Tympanometry
How should hearing loss in a child be managed?
Treat the cause if possible.
Advice and support for family.
Communication support
School involvement
What neonatal risk factors are there for hearing loss in a child?
RFs include:
- Premature birth
- Low birth weight
- Intraventricular haemorrhage/meningitis/encephalitis
- Neonatal jaundice
- Neonatal hypoxia
What kind of trace is seen on tympanometry of a glue ear?
Flat trace i.e. tympanic membrane is immobile
An adult presents with hearing loss. What conductive causes might there be for this?
- Wax
- Keratosis obturans
- Exostoses
- Perforated eardrum
- Otosclerosis
- Ossicle discontinuity
An adult presents with hearing loss. What sensorineural causes might there be for this?
- Presbyacusis
- Idiopathic hearing loss
- Noise exposure
- Inflammation
- Ototoxic drugs
- Tumours of CNVIII
Which structures can cause facial pain?
Name one and you won’t be wrong…
- Sinus
- Nose
- Ear
- Mastoid
- Teeth
- Soft tissues of face
- Nerves
- Parotid gland
- Eye
- Joints of head
- Nasopharynx
- Bone of face
- Brain (headaches)
- Upper lobe lung cancer
- Idiopathic/stress-related
How should a facial pain history be taken?
Like any other pain hx, SQITARS! S- unilateral, bilateral, where, Q - sharp, dull, cyclical etc. I - scale, has this changed over time? T - continuous or comes and goes, how long for, worse at different times? A - what makes it worse? Triggers R - what makes it better? Pain relief? S - any problems with structures local to pain, if not do systemic H+N review.
What would a history of neuralgic facial pain sound like?
Pain in the distribution of a nerve or dermatome, intermittent, sharp, severe.
What would a history of facial pain caused by a bone/ear/teeth problem sound like?
Dull, aching pain, usually constant or aggravated by eating etc.
What symptom of facial pain might suggest temporal arteritis?
Tenderness of superficial temporal artery.
Jaw claudication.
What is dysphagia?
Difficulty in swallowing.
What 3 broad causes are there for dysphagia?
- Neurological
- Pharyngeal
- Oesophageal
What might dysphagia be associated with?
Odynophagia a.k.a. painful swallowing
What pattern of dysphagia would suggest malignancy?
Worsening over a few weeks, especially in an older patient.
What symptoms might a pt with dysphagia report?
- Regurgitation of food
- Vomiting
- Coughing
- Choking
What might the cause of dysphagia be in a pt with a long history of heartburn?
Inflammatory stricture from long-term acid reflux.
What question can help differentiate between the broad categories of dysphagia causes?
What is harder to swallow - solids or liquids? Or is it equally a problem?
What cancers might cause dysphagia?
Oesophageal ,gastric, or pharyngeal.
What obstructive cause of acute dysphagia is there?
Acute foreign body
What neurological causes could there be for dysphagia?
CVA/brain injury
- Achalasia
- Spasm
- Myasthenia gravis
- MS
- MND
- Myopathy
- Parkinson’s disease
- Dementia
What investigations are usually done to help diagnose a cause of dysphagia?
- FBC and ESR
- Barium swallow
- Endoscopy with biopsy
- CT/MRI if neurological or malignancy
What general advice can be given to pts with dysphagia?
- Chew food well
- Drink plenty with food and at other times
- Modify diet consistency if necessary
Where can we refer pts with a neurological swallowing problem?
SALT (speech and language therapist) for assessment.
What complications can occur secondary to dysphagia?
- Malnutrition
- Aspiration pneumonia
- Perforation (iatrogenic due to investigation e.g. endoscopy)
What symptoms might a pt with a hoarse voice report?
Voice is: -Breathy -Harsh -Tremulous -Weak -Reduced to a whisper Vocal fatigue
When would a pt with hoarse voice need to be referred for exclusion of malignancy?
After 3 or more weeks of unexplained hoarseness
What emergency might sudden onset hoarseness indicate?
Laryngeal obstruction
What infective causes of laryngeal obstruction could cause a hoarse voice?
- Acute epiglottitis
- Diptheria
- Croup
- Laryngeal abscess
What risk factors are there for developing a hoarse voice?
- Smoking
- Excess alcohol consumption
- GORD
- Professional voice use
- Environment e.g. poor acoustics, irritants, dry
- Type 2 DM
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