Surgery - Ears, Nose and Throat Flashcards

Question

There are a large number of medications that can cause sensorineural hearing loss. Some of the more common to remember are:

Answer 1

* Loop diuretics (e.g., furosemide) * Aminoglycoside antibiotics (e.g., gentamicin) * Chemotherapy drugs (e.g., cisplatin

Answer 2

* Ear wax (or something else blocking the canal) * Infection (e.g., otitis media or otitis externa) * Fluid in the middle ear (effusion) * Eustachian tube dysfunction * Perforated tympanic membrane * Otosclerosis * Cholesteatoma * Exostoses * Tumours

Answer 3

Presbycusis is described as age-related hearing loss. It is a type of **sensorineural hearing loss** that occurs as people get older. It tends to affect **high-pitched** sounds first and more notably than lower-pitched sounds. The hearing loss occurs gradually and symmetrically.

Answer 4

There are several different mechanisms, including loss of the **hair cells** in the cochlea, **loss of neurones** in the **cochlea**, **atrophy** of the **stria vascularis** and reduced **endolymphatic potential**.

Answer 5

* Age * Male gender * Family history * Loud noise exposure * Diabetes * Hypertension * Ototoxic medications * Smoking

Answer 6

**Hearing loss** in presbycusis is **gradual and insidious**. The gradual onset may mean patients do not notice the change in their hearing. The loss of **high-pitched** sounds can make speech difficult to hear and understand, particularly in loud environments. Male voices may be easier to hear than female voices (due to the generally lower pitch). Patients may present after others have noticed they are not paying attention or missing details of conversations. Sometimes patients can present with concerns about dementia, when in fact, the issue is hearing loss. There may be associated **tinnitus** (ringing in the ears).

Answer 7

Audiometry Presbycusis will give a sensorineural hearing loss pattern, with normal or near-normal hearing at lower frequencies and worsening hearing loss at higher frequencies.

Answer 8

The effects of presbycusis cannot be reversed. Management involves supporting the person to maintain normal functioning: * Optimising the environment, for example, reducing the ambient noise during conversations * Hearing aids * Cochlear implants (in patients where hearing aids are not sufficient)

Answer 9

Otitis media is the name given to an infection in the middle ear. The middle ear is the space that sits between the **tympanic membrane** (eardrum) and the inner ear.

Answer 10

cochlea, vestibular apparatus and nerves

Answer 11

A **viral upper respiratory tract** infection often precedes **bacterial** infection of the middle ear.

Answer 12

streptococcus pneumoniae

Answer 13

rhino-sinusitis and tonsillitis.

Answer 14

Haemophilus influenzae Moraxella catarrhalis Staphylococcus aureus

Answer 15

**Ear pain** is the primary presenting feature of otitis media in adults. It may also present with: * **Reduced hearing** in the affected ear * Feeling generally unwell, for example with **fever** * Symptoms of an upper airway infection such as **cough, coryzal symptoms** and **sore throat** When the infection affects the vestibular system, it can cause **balance issues** and **vertigo**. When the tympanic membrane has perforated, there may be **discharge** from the ear

Answer 16

Otitis media will give a bulging, red, inflamed looking membrane. When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane..

Answer 17

A normal tympanic membrane is **“pearly-grey”, translucent and slightly shiny**. You should be able to visualise the malleus through the membrane. Look for a **cone of light** reflecting the light of the otoscope.

Answer 18

Most otitis media cases will resolve** without antibiotics **within around** three **days, sometimes up to a week **Simple analgesia** (e.g., paracetamol or ibuprofen) can be used for pain and fever. There are three options for prescribing antibiotics: * Immediate antibiotics * Delayed prescription * No antibiotics

Answer 19

Consider **immediate antibiotics** at the initial presentation in patients who have significant co-morbidities, are systemically unwell or are immunocompromised. Consider a **delayed prescription** that can be collected and used after three days if symptoms have not improved or have worsened at any time. This can be a helpful strategy in patients pressing for antibiotics or where you suspect the symptoms might worsen

Answer 20

* Amoxicillin for 5-7 days first-line * Clarithromycin (in pencillin allergy) * Erythromycin (in pregnant women allergic to penicillin)

Answer 21

* Otitis media with effusion * Hearing loss (usually temporary) * Perforated tympanic membrane (with pain, reduced hearing and discharge) * Labyrinthitis (causing dizziness or vertigo) * Mastoiditis (rare) * Abscess (rare) * Facial nerve palsy (rare) * Meningitis (rare)

Answer 22

Otitis externa is inflammation of the skin in the external ear canal. Oto- refers to ear, -itis refers to inflammation, and externa refers to the external ear canal. The infection can be localised or diffuse. It can spread to the external ear (pinna). It can be acute (less than three weeks) or chronic (more than three weeks).

Answer 23

Otitis externa is sometimes called **“swimmers ear”**, as exposure to water whilst swimming can lead to inflammation in the ear canal. **Trauma** from the ear canal (e.g., from cotton buds or earplugs) is another predisposing factor. **Ear wax** (cerumen) has a protective effect against infection, and the removal of ear wax can increase the chances of infection.

Answer 24

Bacterial infection Fungal infection (e.g., aspergillus or candida) Eczema Seborrhoeic dermatitis Contact dermatitis

Answer 25

Pseudomonas aeruginosa Staphylococcus aureus

Answer 26

* gram-negative aerobic rod-shaped bacteria * grow in moist, oxygenated environments * can colonise the lungs in patients with cystic fibrosis * naturally resistant to many antibiotics, * It can be treated with aminoglycosides (e.g., gentamicin) or quinolones (e.g., ciprofloxacin).

Answer 27

Ear pain Discharge Itchiness Conductive hearing loss (if the ear becomes blocked)

Answer 28

* **Erythema** and **swelling** in the ear canal * **Tenderness** of the ear canal * **Pus** or **discharge** in the ear canal * **Lymphadenopathy** (swollen lymph nodes) in the neck or around the ear

Answer 29

The diagnosis can be made clinically with an examination of the ear canal **(otoscopy)**. An **ear swab** can be used to identify the causative organism but is not usually required

Answer 30

**Mild otitis externa** may be treated with **acetic acid 2%** (available over the counter as EarCalm). Acetic acid has an antifungal and antibacterial effect. This can also be used **prophylactically** before and after swimming in patients that are prone to otitis externa. **Moderate otitis externa** is usually treated with a **topical antibiotic** and steroid, for example: * Neomycin, dexamethasone and acetic acid (e.g., Otomize spray) * Neomycin and betamethasone * Gentamicin and hydrocortisone * Ciprofloxacin and dexamethasone

Answer 31

Aminoglycosides (e.g., gentamicin and neomycin) are potentially **ototoxic**, rarely causing hearing loss if they get past the tympanic membrane. Therefore, it is essential to exclude a **perforated tympanic membrane** before using topical aminoglycosides in the ear.

Answer 32

An **ear wick** may be used if the canal is very swollen, and treatment with ear drops or sprays will be difficult

Answer 33

Fungal infections can be treated with **clotrimazole** ear drops.

Answer 34

Malignant otitis externa is a severe and potentially life-threatening form of otitis externa. The infection spreads to the bones surrounding the ear canal and skull. It progresses to osteomyelitis of the temporal bone of the skull

Answer 35

Diabetes Immunosuppressant medications (e.g., chemotherapy) HIV

Answer 36

Granulation tissue at the junction between the bone and cartilage in the ear canal (about halfway along)

Answer 37

Admission to hospital under the ENT team IV antibiotics Imaging (e.g., CT or MRI head) to assess the extent of the infection

Answer 38

* Facial nerve damage and palsy * Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves) * Meningitis * Intracranial thrombosis * Death

Answer 39

Tonsillitis refers to inflammation of the tonsils.

Answer 40

viral infection

Answer 41

**Group A streptococcus** (Streptococcus pyogenes). The second most common bacterial cause of tonsillitis is **Streptococcus pneumoniae.**

Answer 42

penicillin V (phenoxymethylpenicillin)

Answer 43

adenoids, tubal tonsils, palatine tonsils and the lingual tonsil

Answer 44

The palatine tonsils

Answer 45

Sore throat Fever (above 38°C) Pain on swallowing

Answer 46

Examination of the throat will reveal red, inflamed and enlarged tonsils, with or without exudates. **Exudates** are small white patches of pus on the tonsils. There may be **anterior cervical lymphadenopath**y, which refers to swollen, tender lymph nodes in the anterior triangle of the neck (anterior to the sternocleidomastoid muscle and below the mandible). The **tonsillar lymph nodes** are just behind the angle of the mandible (jawbone).

Answer 47

The **Centor criteria** can be used to estimate the probability that tonsillitis is due to **bacterial** infection and will benefit from antibiotics. A score of 3 or more gives a 40 – 60 % probability of **bacterial tonsillitis**, and it is appropriate to offer antibiotics. A point is given if each of the following features are present: * **Fever** over 38ºC * **Tonsillar exudates** * **Absence** of cough * **Tender** anterior cervical lymph nodes (lymphadenopathy)

Answer 48

The FeverPAIN score is an alternative to the Centor criteria. A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 62 – 65% probability of **bacterial tonsillitis:** * Fever during previous 24 hours * P – Purulence (pus on tonsils) * A – Attended within 3 days of the onset of symptoms * I – Inflamed tonsils (severely inflamed) * N – No cough or coryza

Answer 49

* Consider admission if the patient is immunocompromised, systemically unwell, dehydrated, has stridor, respiratory distress or evidence of a peritonsillar abscess or cellulitis. * Safety net if it is viral tonsilitis * Consider prescribing antibiotics if the Centor score is ≥ 3, or the FeverPAIN score is ≥ 4.

Answer 50

Advise simple analgesia with paracetamol and ibuprofen to control pain and fever. NICE clinical knowledge summaries suggest advising patients to return if the pain has not settled after 3 days or the fever rises above 38.3ºC. Starting antibiotics or an alternative diagnosis should be considered.

Answer 51

**Penicillin V** (also called **phenoxymethylpenicillin**) for a **10-day course** is typically first-line. It has a relatively narrow spectrum of activity and is effective against **Streptococcus pyogenes**. Clarithromycin is the usual first-line choice in true penicillin allergy.

Answer 52

* Peritonsillar abscess, also known as quinsy * Otitis media, if the infection spreads to the inner ear * Scarlet fever * Rheumatic fever * Post-streptococcal glomerulonephritis * Post-streptococcal reactive arthritis

Answer 53

Tonsillectomy

Answer 54

The SIGN guidelines (2010) give the indications for tonsillectomy. The **number of episodes** of acute sore throat they specify for a tonsillectomy are: * 7 or more in 1 year * 5 per year for 2 years * 3 per year for 3 years Other indications are: * Recurrent tonsillar abscesses (2 episodes) * Enlarged tonsils causing difficulty breathing, swallowing or snoring

Answer 55

* **Sore throat** where the tonsillar tissue has been removed (this can last 2 weeks) * Damage to teeth * Infection * **Post-tonsillectomy bleeding** * Risks associated with a general anaesthetic

Answer 56

Post tonsillectomy bleeding is the main significant complication after a tonsillectomy. Significant bleeding can occur in up to 5% of patients who have had a tonsillectomy requiring urgent management. This can happen up to 2 weeks after the operation. Bleeding can be severe and, in rare cases, **life-threatening** due to aspiration of blood

Answer 57

* Call the ENT registrar and get them involved early * Get IV access and send bloods including an FBC, clotting screen, group and save and crossmatch * Keep the patient calm and give adequate analgesia * Sit them up and encourage them to spit out the blood rather than swallowing * Make the patient **nil by mouth** in case an anaesthetic and operation is required * IV fluids for maintenance and resuscitation, if required If there is severe bleeding or airway compromise, call an anaesthetist. Intubation may be required. Before going back to theatre there are two options for stopping less severe bleeds: * **Hydrogen peroxide** gargle * **Adrenalin** soaked swab applied topically

Answer 58

Cholesteatoma is an abnormal collection of squamous epithelial cells in the middle ear. It is non-cancerous but can invade local tissues and nerves and erode the bones of the middle ear. It can predispose to significant infections.

Answer 59

The pathophysiology is not fully understood. **Squamous epithelial cells** originate from the outer surface of the **tympanic membrane.** The main theory is that **negative pressure** in the **middle ear**, caused by **Eustachian tube dysfunction**, causes a pocket of the tympanic membrane to retract into the middle ear. Essentially, a small area of the tympanic membrane gets sucked inwards. The squamous epithelial cells of this pocket continue to proliferate and grow into the surrounding space, bones and tissues. It can damage the **ossicles** (the tiny bones of the middle ear involved in hearing), resulting in permanent hearing loss.

Answer 60

The typical presenting symptoms are: * **Foul discharge** from the ear * **Unilateral conductive hearing loss**

Answer 61

Infection Pain Vertigo Facial nerve palsy

Answer 62

Otoscopy can show an abnormal build-up of whitish debris or crust in the upper tympanic membrane. However, it may not be possible to visualise the eardrum if discharge or wax are blocking the can

Answer 63

A CT head can be used to confirm the diagnosis and plan for surgery. MRI may help assess invasion and damage to local soft tissues. Treatment involves **surgical removal** of the cholesteatoma.

Answer 64

Acoustic neuromas are benign tumours of the **Schwann cells** surrounding the **auditory nerve** (vestibulocochlear nerve) that innervates the inner ear.

Answer 65

unilateral

Answer 66

neurofibromatosis type II TOM TIP: Bilateral acoustic neuromas almost certainly indicate neurofibromatosis type II. This is a popular association in exams, so worth remembering

Answer 67

The typical patient is aged 40-60 years presenting with a gradual onset of: * Unilateral sensorineural hearing loss (often the first symptom) * Unilateral tinnitus * Dizziness or imbalance * A sensation of **fullness** in the ear

Answer 68

They can also be associated with a **facial nerve palsy** if the tumour grows large enough to compress the facial nerve.

Answer 69

**Audiometry** is used to assess hearing loss. There will be a sensorineural pattern of hearing loss. **Brain imaging (MRI or CT)** is used to establish the diagnosis and features of the tumour. MRI provides more detail than CT.

Answer 70

ENT specialist management options include: * **Conservative** management with monitoring may be used if there are no symptoms or treatment is inappropriate * **Surgery** to remove the tumour (partial or total removal) * **Radiotherapy** to reduce the growth

Answer 71

* **Vestibulocochlear nerve injury**, with permanent hearing loss or dizziness * **Facial nerve injury,** with facial weakness

Answer 72

Ménière’s disease is a long-term inner ear disorder that causes recurrent attacks of vertigo, and symptoms of hearing loss, tinnitus and a feeling of fullness in the ear.

Answer 73

TOM TIP: Remember the typical triad of symptoms in Ménière’s disease, as this is commonly tested in exams: Hearing loss Vertigo Tinnitus

Answer 74

Ménière’s disease is associated with the excessive buildup of **endolymph** in the **labyrinth** of the **inner ear**, causing a higher pressure than normal and disrupting the sensory signals. This increased pressure of the endolymph is called **endolymphatic hydrops**.

Answer 75

The typical patient is 40-50 years old, presenting with unilateral episodes of **vertigo, hearing loss, and tinnitus.** Other symptoms can include: * A sensation of **fullness** in the ear * **Unexplained falls** (“drop attacks”) without loss of consciousness * **Imbalance**, which can persist after episodes of vertigo resolve

Answer 76

**Vertigo** in Ménière’s disease comes in episodes. These last for 20 minutes to several hours before settling. These episodes can come in clusters over several weeks, followed by prolonged periods (often months) without vertigo symptoms. Vertigo is not triggered by movement or posture. **Hearing loss** in Ménière’s disease typically fluctuates at first, associated with vertigo attacks, then gradually becomes more permanent. It is sensorineural hearing loss, generally unilateral and affects low frequencies first. **Tinnitus** initially occurs with episodes of vertigo before eventually becoming more permanent. It is usually unilateral.

Answer 77

Management involves: * Managing symptoms during an acute attack * Prophylactic medication to reduce the frequency of attacks For acute attacks, short-term options for managing symptoms include: * **Prochlorperazine** * **Antihistamines **(e.g., cyclizine, cinnarizine and promethazine) Prophylaxis is with: * **Betahistine**

Answer 78

Tinnitus refers to a persistent addition sound that is heard but is not present in the surrounding environment. It may be described as a “ringing in the ears”, but it can also be a buzzing, hissing or humming noise.

Answer 79

Primary tinnitus has no identifiable cause and often occurs with sensorineural hearing loss

Answer 80

Secondary tinnitus refers to tinnitus with an identifiable cause. Causes include: * Impacted ear wax * Ear infection * Ménière’s disease * Noise exposure * Medications (e.g., loop diuretics, gentamicin and chemotherapy drugs such as cisplatin) * Acoustic neuroma * Multiple sclerosis * Trauma * Depression

Answer 81

Anaemia Diabetes Hypothyroidism or hyperthyroidism Hyperlipidaemia

Answer 82

Objective tinnitus refers to when the patient can objectively hear an extra sound within their head. This sound can also be observable on examination by auscultating with a stethoscope around the ear

Answer 83

Carotid artery stenosis (pulsatile carotid bruit) Aortic stenosis (radiating pulsatile murmur sounds) Arteriovenous malformations (pulsatile) Eustachian tube dysfunction (popping or clicking noises)

Answer 84

I think of primary tinnitus as the ears trying to “turn up the volume” when they cannot hear the surrounding noises as well. This is a helpful way of explaining it to patients who have tinnitus associated with hearing loss. Using hearing aids allows the ears to pick up noises better and “turn the volume down”, improving the tinnitus. The actual cause of tinnitus is not entirely understood, so this is not entirely accurate, but it is a helpful analogy

Answer 85

Ask about the pattern of symptoms: * Unilateral or bilateral * Frequency and duration * Severity * Pulsatile or non-pulsatile (pulsatile may indicate a cardiovascular cause, such as carotid artery stenosis with a bruit) A focused history and examination can be used to identify any underlying causes, including: * Contributing factors, such as hearing loss or noise exposure * Associated symptoms (e.g., hearing loss, vertigo, pain or discharge) * Stress and anxiety * Otoscopy to look for causes such as ear wax or infection * Weber’s and Rinne’s tests for hearing loss

Answer 86

The NICE clinical knowledge summaries (updated March 2020) suggest considering blood tests for possible underlying causes: * Full blood count (anaemia) * Glucose (diabetes) * TSH (thyroid disorders) * Lipids (hyperlipidaemia) **Audiology** can be used to assess the hearing in detail and help establish the underlying cause. **Imaging** (e.g., CT or MRI) may be rarely required to investigate for underlying causes such as vascular malformations or acoustic neuromas.

Answer 87

Red flags that could indicate a serious underlying cause and the need for specialist assessment include: * Unilateral tinnitus * Pulsatile tinnitus * Hyperacusis (hypersensitivity, pain or distress with environmental sounds) * Associated unilateral hearing loss * Associated sudden onset hearing loss * Associated vertigo or dizziness * Headaches or visual symptoms * Associated neurological symptoms or signs (e.g., facial nerve palsy or signs of stroke) * Suicidal ideation related to the tinnitus

Answer 88

Tinnitus tends to improve or resolve over time without any interventions. Underlying causes of tinnitus can be treated, such as impacted ear wax or infection. Several measures can be used to help improve and manage symptoms: * Hearing aids * Sound therapy (adding background noise to mask the tinnitus) * Cognitive behavioural therapy

Answer 89

Vestibular neuronitis describes inflammation of the vestibular nerve. This is usually attributed to a viral infection.

Answer 90

The inner ear contains the **bony labyrinth**, a complex bony structure containing fluids (**perilymph** and **endolymph**).

Answer 91

Semicircular canals Vestibule (middle section) Cochlea

Answer 92

The semicircular canals and otolith organs within the vestibule (the utricle and saccule) are responsible for detecting movement of the head. Together they form the vestibular system: * The semicircular canals detect rotation of the head * The otolith organs detect gravity and linear acceleration

Answer 93

acute onset of vertigo history of a recent viral upper respiratory tract infection. It is often associated with: * Nausea and vomiting (may be severe) * Balance problems

Answer 94

It is essential to differentiate between peripheral (inner ear) and central (brain) causes when a patient presents with vertigo**. Any neurological signs or symptoms** should make you consider a central cause of vertigo rather than vestibular neuronitis. This may require urgent management, particularly if posterior circulation infarction (stroke) is suspected.

Answer 95

FALSE Tinnitus and hearing loss are not features of vestibular neuronitis, as the cochlea and cochlear nerve are not affected. If tinnitus and hearing loss are also present, consider labyrinthitis or Ménière’s disease as differential diagnoses. You can remember this with: Labyrinthitis – Loss of hearing Neuronitis – No loss of hearing

Answer 96

The **head impulse test** involves the patient sitting upright and fixing their gaze on the examiner’s nose. The examiner holds the patient’s head and rapidly jerks it 10-20 degrees in one direction while the patient continues looking at the examiner’s nose. The head is slowly moved back to the centre before repeating in the opposite direction. Ensure they have no neck pain or pathology before performing the test. A patient with a normally functioning vestibular system will keep their eyes fixed on the examiner’s nose. In a patient with an abnormally functioning **vestibular system** (e.g., vestibular neuronitis or labyrinthitis), the eyes will **saccade** (rapidly move back and forth) as they eventually fix back on the examiner. The head impulse test helps diagnose a **peripheral** cause of vertigo but will be normal if the patient has no **current symptoms** or a central cause of vertigo.

Answer 97

Patients may need admission if they are becoming dehydrated due to severe nausea and vomiting. For peripheral vertigo, short-term options for managing symptoms include: *** Prochlorperazine * Antihistamines (e.g., cyclizine, cinnarizine and promethazine)** NICE advise that symptomatic treatment can be used for up to 3 days. More extended use may slow down the recovery. NICE also recommend **referral** if the symptoms do not improve after 1 week or resolve after 6 weeks, as they may require further investigation or vestibular rehabilitation therapy (VRT).

Answer 98

Labyrinthitis refers to inflammation of the bony labyrinth of the inner ear, including the semicircular canals, vestibule (middle section) and cochlea. The inflammation is usually attributed to a **viral upper respiratory tract infection.**

Answer 99

otitis media or meningitis.

Answer 100

Labyrinthitis presents with **acute onset vertigo**, similarly to vestibular neuronitis. Unlike vestibular neuronitis, labyrinthitis can also be associated with: ** * Hearing loss * Tinnitus** Patients may have symptoms associated with the causative virus, such as a cough, sore throat and blocked nose

Answer 101

A clinical diagnosis is based on history and examination findings. It is important to exclude a central cause of the vertigo. The **head impulse test** can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g., vestibular neuronitis or labyrinthitis).

Answer 102

Management is the same as with vestibular neuronitis, with supportive care and short-term use (up to 3 days) of medication to suppress the symptoms. Options for managing symptoms are: *** Prochlorperazine * Antihistamines (e.g., cyclizine, cinnarizine and promethazine)** Antibiotics are used to treat bacterial labyrinthitis. The underlying infection (e.g., otitis media or meningitis) needs appropriate treatment.

Answer 103

Remember **hearing loss** as a key complication of meningitis. All patients with meningitis are offered audiology assessment as soon as they are recovered to assess for hearing impairment. This complication comes up often in exams and is worth remembering

Answer 104

Benign paroxysmal positional vertigo (BPPV) is a common cause of recurrent episodes of **vertigo** triggered by head movement. It is a **peripheral** cause of vertigo, meaning the problem is located in the inner ear rather than the brain. It is more common in older adults.

Answer 105

A variety of head movements can trigger attacks of vertigo. A common trigger is turning over in bed. Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks. Often episodes occur over several weeks and then resolve but can reoccur weeks or months later. BPPV does not cause** hearing loss or tinnitus**.

Answer 106

BPPV is caused by** crystals of calcium carbonate** called otoconia that become displaced into the **semicircular canals.** This occurs most often in the **posterior semicircular canal**. They may be displaced by a viral infection, head trauma, ageing or without a clear cause. The crystals disrupt the normal flow of **endolymph** through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo

Answer 107

The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis). It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV. Check the patient can do the manoeuvre safely before performing it, for example, ensuring they have no neck pain or pathology.

Answer 108

To perform the manoeuvre: * The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear) * Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees * Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch * Watch the eyes closely for 30-60 seconds, looking for nystagmus * Repeat the test with the head turned 45 degrees in the other direction In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).

Answer 109

The Epley manoeuvre can be used to **treat** BPPV. The idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow

Answer 110

To perform the manoeuvre: * Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees * Rotate the patient’s head 90 degrees past the central position * Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction * Have the patient sit up sideways with the legs off the side of the couch * Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest * At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle

Answer 111

Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve

Answer 112

Facial nerve palsy refers to isolated dysfunction of the **facial nerve**. This typically presents with a **unilateral facial weakness.** It is important to understand some basics about the pathway and function of the facial nerve

Answer 113

The facial nerve exits the **brainstem** at the **cerebellopontine angle**. On its journey to the face, it passes through the **temporal bone** and **parotid gland**. It then divides into five branches that supply different areas of the face: * Temporal * Zygomatic * Buccal * Marginal mandibular * Cervical

Answer 114

There are three functions of the facial nerve: **motor, sensory and parasympathetic.**

Answer 115

It supplies the muscles of facial expression, the stapedius in the inner ear and the posterior digastric, stylohyoid and platysma muscles in the neck.

Answer 116

It carries taste from the anterior 2/3 of the tongue

Answer 117

It provides the parasympathetic supply to the: * Submandibular and sublingual salivary glands * Lacrimal gland (stimulating tear production)

Answer 118

It is essential to make this distinction because, in a patient with a new-onset upper motor neurone facial nerve palsy, you should be referring immediately with a suspected **stroke**

Answer 119

UMN lesion

Answer 120

Each side of the forehead has upper motor neurone innervation by both sides of the brain. However, each side of the forehead only has lower motor neurone innervation from one side of the brain. In an **upper motor neurone** lesion, the forehead will be **spared**, and the patient can move their forehead on the affected side. In a **lower motor neurone lesion**, the forehead will **NOT be spared, **and the patient cannot move their forehead on the affected side

Answer 121

Cerebrovascular accidents (strokes) Tumours

Answer 122

Pseudobulbar palsies Motor neurone disease

Answer 123

unilateral LMN lesion

Answer 124

The majority of patients fully recover over several weeks, but recovery may take up to 12 months. A third are left with some residual weakness.

Answer 125

prednisolone as treatment, either: * 50mg for 10 days * 60mg for 5 days followed by a 5-day reducing regime of 10mg a day Patients also require lubricating eye drops to prevent the eye on the affected side from drying out and being damaged. If they develop pain in the eye, they need an ophthalmology review for **exposure keratopathy.** The eye can be taped closed at night

Answer 126

Ramsay-Hunt syndrome is caused by the varicella zoster virus (VZV). It presents as a unilateral lower motor neurone facial nerve palsy. Patients stereotypically have a painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side. This rash can extend to the anterior two-thirds of the tongue and hard palate.

Answer 127

Treatment should ideally be initiated within 72 hours. Treatment is with: * Prednisolone * Aciclovir Patients also require lubricating eye drops

Answer 128

Ramsay-Hunt syndrome is a very popular presentation in your MCQ exams. Look out for that patient with a facial nerve palsy and vesicular rash around their ear.

Answer 129

Otitis media Malignant otitis externa HIV Lyme’s disease

Answer 130

Diabetes Sarcoidosis Leukaemia Multiple sclerosis Guillain–Barré syndrome

Answer 131

Acoustic neuroma Parotid tumours Cholesteatomas

Answer 132

Direct nerve trauma Damage during surgery Base of skull fractures

Answer 133

Otosclerosis is a condition where there is remodelling of the small bones in the middle ear, leading to conductive hearing loss. Oto- refers to the ears, and -sclerosis means hardening. It usually presents before the age of 40 years.

Answer 134

autosomal dominant

Answer 135

The typical presentation is a patient under 40 years presenting with unilateral or bilateral: * Hearing loss * Tinnitus It tends to affect the hearing of lower-pitched sounds more than higher-pitched sounds. Female speech may be easier to hear than male speech (due to the generally higher pitch). This is the reverse of the pattern seen in presbycusis.

Answer 136

Weber’s test is normal if the otosclerosis is bilateral, meaning that when the tuning fork is applied to the centre of the forehead, they will hear the sound equally in both ears. If the otosclerosis is unilateral or affects one ear more than the other, the sound will be louder in the more affected ear.

Answer 137

Rinne’s test will show conductive hearing loss. The sound will be easily heard when the tuning fork is applied to the mastoid process (bone conduction). When the patient stops being able to hear the sound during bone conduction, and the tuning fork is removed from the mastoid process and held close to the ear canal, they will still not hear the sound (air conduction is worse than bone conduction).

Answer 138

**Audiometry** is the initial investigation of choice. Otosclerosis will show a conductive hearing loss pattern. **Bone conduction** readings will be normal (between 0 and 20 dB). However, air conduction readings will be greater than 20 dB, plotted below the 20 dB line on the chart. Hearing loss tends to be greater at lower frequencies. **Tympanometry** will show generally reduced admittance (absorption) of sound. The tympanic membrane is stiff and non-compliant and does not absorb sound, reflecting most of it back. **High-resolution CT** scans can detect boney changes associated with otosclerosis, although they are not always required.

Answer 139

use of hearing aids