Tinnitus, Otalgia + Facial Nerve Palsy Flashcards
What is tinnitus?
Perception of sound in the absence of an external auditory stimulus
Which features is it important to ask about when taking a history from a patient with tinnitus?
Intermittent vs constant Pulsatile vs non-pulsatile Affect on QOL --> sleep, attention, mood Symmetry Hearing loss Focal neurology
Which examinations should be done in a patient with tinnitus?
Otoscopy
Pure tone audiometry
Cranial nerves
Examine TMJ
Which features would be an indication for emergency referral in a patient with tinnitus?
Sudden onset pulsatile tinnitus Significant neurology Severe vertigo Secondary to head trauma Unexplained sudden hearing loss
Which investigations should be done for tinnitus?
Pure tone audiometry + tympanometry BP check FBC, TFTs, lipids and glucose Contrast CT (if persistent unilateral pulsatile tinnitus) MRI (if unilateral SNHL)
Why is pulsatile tinnitus worrying?
Vascular cause e.g. AVM, intracranial hypertension, gloms jugulare
How is tinnitus managed?
Usually conservative + reassurance –> most are mild and resolve in time
Tinnitus retraining therapy + CBT may reduce impact
Hearing aids
Treat any identified cause
Describe the course of the facial nerve within the cranium
Pons –> internal acoustic meatus –> facial canal (temporal bone)
Gives off branches: greater petrosal nerve, nerve to stapedius + chorda tympani
The exits facial canal (and cranium) via stylomastoid foramen
What is the most common cause of facial nerve palsy and how is it diagnosed?
Bell’s palsy (idiopathic)
Diagnosis of exclusion
How can you differentiate between UMN and LMN causes of facial nerve palsy?
UMN causes present with forehead sparing
What are some UMN causes of facial nerve palsy?
Stroke
Subdural haematoma
Brain tumour
What are some LMN causes of facial nerve palsy?
Infective e.g. AOM, cholesteatoma, virus (HSV, CMV, EBV) Ramsay-Hunt syndrome (shingles) Neoplasm e.g. parotid malignancy Trauma/iatrogenic Lyme disease
What are some risk factors for Bell’s palsy?
Viral infection (HSV, CMV, EBV)
Diabetes
Pregnancy
What are the clinical features of a facial nerve palsy?
Weak facial muscles Dry painful eye if closure impaired Drooling from side of mouth, difficulty eating Hyperacusis (nerve to stapedius) Metallic taste (chorda tympani) Reduced lacrimation (greater petrosal)
Which investigations should be done for facial nerve palsy?
Otoscopy --> AOM, cholesteatoma Head + neck exam --> parotid tumour PTA --> conductive loss (cholesteatoma) or SNHL (acoustic neuroma) MRI if suspecting central cause Bell's palsy diagnosis of exclusion
How is a facial nerve palsy managed?
Eye care –> artificial tears, tape/patch eye
- refer to ophthalmology
Oral steroids for Bell’s palsy/Ramsay Hunt - if presenting within 72 hours of onset
+ antivirals for Ramsay Hunt
ENT surgeon if doubt over diagnosis, recurrent, bilateral or not improving after 1 month
What are the complications of facial nerve palsy?
Corneal scarring –> blindness if eye care not given
Wasting of facial muscles
Psychological
What is the difference between primary and secondary otalgia?
Primary –> direct stimulation of sensory nerve due to ear pathology
Secondary –> referred pain
What are some causes of primary otalgia?
External ear:
- conditions affecting pinna or external canal
- chronic pain: malignancy, necrotising otitis externa
Middle ear:
- AOM
- mastoiditis
- deep temporal bone + infra temporal fossa petrous apex erosion (MRI if chronic earache but normal ENT + dental exam)
Which nerves may be responsible for referred pain in the ear?
C2 + C3
CN V
CN IX
CN X
What might cause referred pain in the ear from C2/C3?
Arthritis/cervical spondylosis
Soft tissue injury
What might cause referred pain in the ear from CN V?
Sinusitis Trigeminal neuralgia Dental disease TMJ dysfunction Nasopharyngeal disease e.g. viral infection, tumour or post adenoidectomy
What might cause referred pain in the ear from CN IX?
Any oropharyngeal infection –> pharyngitis, tonsillitis, quincy, post-tonsillectomy
Tongue base tumour
What might cause referred pain in the ear from CN X?
Carcinoma of larynx or hypopharynx
Which examinations should be done for otalgia?
Otoscopy Temporomandibular joint Oral cavity + oropharynx Neck CN exam Flexible endoscopy --> post nasal space, tongue base, pharynx, larynx
When does primary otalgia require an urgent ENT referral?
Perichondritis Complicated herpes zoster Severe otitis externa Mastoiditis Facial nerve palsy (AOM, cholesteatoma) Sudden hearing loss Cranial nerve palsy
When does secondary otalgia (referred pain) require an urgent ENT referral?
Associated dysphagia, dysphonia, neck lump
Unilateral glue ear in adults (nasopharyngeal carcinoma)
Stridor, dyspnoea, hoarseness, dysphagia, drooling –> supraglottitis
Peritonsillar abscess
How should TMJ dysfunction be managed?
Dentist NSAIDs Soft diet Dental guard Maxillofacial referral
