Primary Care - Common ENT conditions

Question 1

What is benign paroxysmal positional vertigo (BPPV)?

Answer 1

• episodic vertigo (lasting < 1 minute) that is triggered by sudden changes in the position of the head
  
  • e.g. suddenly standing up, bending forwards
• it is the most common cause of peripheral vertigo

Question 2

What causes BPPV?

Answer 2

• it is caused by otoconia dislodging and migrating into one of the semicircular canals, where it disrupts the endolymph dynamics
  
  • most commonly the posterior semicircular canal
• the exact aetiology is unknown

Question 3

What are the risk factors for BPPV?

Answer 3

• female sex
• increased age
• low vitamin D levels
• osteopenia or osteoporosis
• patients with both osteoporosis and BPPV are at increased risk of fall-related fractures

Question 4

What are the clinical features of BPPV?

What other symptoms is it associated with?

Answer 4

• episodic vertigo which is sudden and recurrent
  
  • patient describes the feeling of the room spinning
• vertigo lasts for several seconds and is triggered by sudden head movements
• associated with nystagmus, N&V and risk of falling
  
  • ​risk of N&V lower than other types of vertigo due to short duration
• does NOT typically cause cochlear (hearing loss / tinnutis) or neurological symptoms

Question 5

What manoeuvre is used to diagnose posterior canal BPPV?

Answer 5

Dix-Hallpike manoeuver

• patient sits upright on examination bed and keeps eyes open
• rotate head by 45^o towards the affected side
• keeping the neck rotated, quickly lay the patient in a supine position with the neck slightly extended and the affected ear facing downwards
  
  • their head should hang slightly off the side of the table
• hold this position for 20-30 seconds are examine eyes for nystagmus
• slowly reposition the patient into an upright posture and observe for reversal of nystagmus
• if negative, repeat the test with the head turned to the unaffected side

Question 6

What is the first-line treatment for BPPV?

Answer 6

Epley manoeuvre

• starts the same as the Dix-Hallpike manouevre
• once the patient is lying supine and affected ear is facing down, hold the position for 30 secs or until nystagmus stops
• turn patient’s head by 90^o toward unaffected side and hold this position for 30 seconds
• turn patient’s head and body by 90^o towards unaffected side so they are now lying on their side with their face turned towards the ground
• hold this position for 30 seconds
• bring them back to a seated upright position and ask them to stay there for 15 minutes

Question 7

When might vestibular suppressants be given to patients with BPPV?

What should the patients be warned about?

Answer 7

• they are not routinely indicated due to adverse side effects
  
  • e.g. falls, cognitive dysfunction, drowsiness
• they should only be used in intractable BPPV or patients who refuse to undergo canalith repositioning manoeuvres
• chronic use is contraindicated as it can exacerbate chronic gait and postural instability

Question 8

What is Wernicke encephalopathy?

What usually causes it and what can it progress to?

Answer 8

• an acute, reversible condition caused by severe thiamine (vitamin B₁) deficiency often due to chronic alcohol abuse
• it can also be caused by inadequate intake, impaired absorption or increased excretion of thiamine
• chronic thiamine deficiency can progress to Korsakoff syndrome

Question 9

What is the classical triad of symptoms associated with Wernicke encephalopathy?

Answer 9

• confusion
• oculomotor dysfunction
  
  • gaze-induced horizontal / vertical nystagmus
  • diplopia
  • conjugate gaze palsy (impaired ability of eyes to move in a single direction)
• gait ataxia - wide-based, small steps

Question 10

What are the typical symptoms of Korsakoff syndrome?

Answer 10

• this occurs in patients with persistent vitamin B1 deficiency, usually due to chronic alcohol abuse
• confabulation - patients produce fabricated memories to fill in lapses of memory
• anterograde and retrograde amnesia (long-term memory is usually preserved)
• personality changes - apathy, indifference, decrease in executive function
• hallucinations
• disorientation to time, place and person

Question 11

What is the treatment for Wernicke encephalopathy in the acute phase?

Answer 11

• immediate IV administration of high-dose thiamine (e.g. Pabrinex) until symptoms recede
• in patients with loss of consciousness, IV glucose is administered
• thiamine must be administered before glucose as glucose increases thiamine demand, so will worsen encephalopathy

Question 12

What are the long-term treatments for Wernicke encephalopathy?

Answer 12

• long-term oral replacement of vitamins B₁, B₆, B₁₂ and folic acid
  
  • this is continued until patient has adopted a balanced diet and successfully abstained from alcohol
• abstinence from alcohol

Question 13

What is vestibular neuritis?

Answer 13

• inflammation of the vestibular nerve
• typically manifests with features of vestibular hypofunction:
  
  • nausea
  • vomiting
  • vertigo
  • gait instability
• there is usually no hearing loss

Question 14

What is labyrinthitis?

Answer 14

• all the features of vestibular neuritis with ipsilateral sensorineural hearing loss
• this is caused by a viral (sometimes bacterial) infection affecting the inner ear
• both branches of the vestibulocochlear nerve are inflamed, resulting in hearing changes and vertigo

Question 15

What is Meniere disease?

Who tends to be affected?

Answer 15

• a disorder of the inner ear caused by impaired endolymph resorption
• exact aetiology unknown but linked to viral infections, autoimmunity and allergies
• tends to affect adults between 40-50 years of age

Question 16

What is the Meniere triad of symptoms?

Answer 16

• peripheral vertigo
• fluctuating unilateral sensorineural hearing loss
• unilateral tinnutis
• episodes fluctuate in severity and typically last from 20 minutes to 12 hours

Question 17

How does hearing loss in Meniere disease change over time?

What tests can be used to identify this?

Answer 17

• starts as low to mid-frequency hearing loss that progressively worsens with each episode
  
  • it can progress to deafness over several years
• tuning fork tests can be used:

Weber test - lateralisation to the healthy ear indicating SNHL in opposite ear

Rinne test - bilaterally positive as they have normal conductive hearing

Question 18

How is definite Meniere disease diagnosed?

Answer 18

must include all of the following criteria:

• 2 or more spontaneous attacks of vertigo, each lasting 20 min to 12 hrs
• low-to-mid frequency SNHL in the affected ear on audiometry
• fluctuating aural symptoms in the affected ear
  
  • hearing loss, tinnitus or ear fullness
• other suspected causes of vertigo excluded

Question 19

What is the treatment for Meniere’s disease?

Answer 19

• there is no definitive cure, but vestibular suppressants can be used to treat an acute vertigo attack
• these suppress the effects of vestibular dysfunction, such as vertigo, nystagmus and nausea
• benzodiazepines or first-generation antihistamines are used