Tinnitus, Otalgia + Facial Nerve Palsy

Question 1

What is tinnitus?

Answer 1

Perception of sound in the absence of an external auditory stimulus

Question 2

Which features is it important to ask about when taking a history from a patient with tinnitus?

Answer 2

Intermittent vs constant
Pulsatile vs non-pulsatile
Affect on QOL --> sleep, attention, mood
Symmetry
Hearing loss
Focal neurology

Question 3

Which examinations should be done in a patient with tinnitus?

Answer 3

Otoscopy
Pure tone audiometry
Cranial nerves
Examine TMJ

Question 4

Which features would be an indication for emergency referral in a patient with tinnitus?

Answer 4

Sudden onset pulsatile tinnitus
Significant neurology
Severe vertigo
Secondary to head trauma
Unexplained sudden hearing loss

Question 5

Which investigations should be done for tinnitus?

Answer 5

Pure tone audiometry + tympanometry
BP check
FBC, TFTs, lipids and glucose
Contrast CT (if persistent unilateral pulsatile tinnitus)
MRI (if unilateral SNHL)

Question 6

Why is pulsatile tinnitus worrying?

Answer 6

Vascular cause e.g. AVM, intracranial hypertension, gloms jugulare

Question 7

How is tinnitus managed?

Answer 7

Usually conservative + reassurance –> most are mild and resolve in time
Tinnitus retraining therapy + CBT may reduce impact
Hearing aids
Treat any identified cause

Question 8

Describe the course of the facial nerve within the cranium

Answer 8

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

Question 9

What is the most common cause of facial nerve palsy and how is it diagnosed?

Answer 9

Bell’s palsy (idiopathic)

Diagnosis of exclusion

Question 10

How can you differentiate between UMN and LMN causes of facial nerve palsy?

Answer 10

UMN causes present with forehead sparing

Question 11

What are some UMN causes of facial nerve palsy?

Answer 11

Stroke
Subdural haematoma
Brain tumour

Question 12

What are some LMN causes of facial nerve palsy?

Answer 12

Infective e.g. AOM, cholesteatoma, virus (HSV, CMV, EBV)
Ramsay-Hunt syndrome (shingles)
Neoplasm e.g. parotid malignancy
Trauma/iatrogenic
Lyme disease

Question 13

What are some risk factors for Bell’s palsy?

Answer 13

Viral infection (HSV, CMV, EBV)
Diabetes
Pregnancy

Question 14

What are the clinical features of a facial nerve palsy?

Answer 14

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)

Question 15

Which investigations should be done for facial nerve palsy?

Answer 15

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

Question 16

How is a facial nerve palsy managed?

Answer 16

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

Question 17

What are the complications of facial nerve palsy?

Answer 17

Corneal scarring –> blindness if eye care not given
Wasting of facial muscles
Psychological

Question 18

What is the difference between primary and secondary otalgia?

Answer 18

Primary –> direct stimulation of sensory nerve due to ear pathology
Secondary –> referred pain

Question 19

What are some causes of primary otalgia?

Answer 19

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)

Question 20

Which nerves may be responsible for referred pain in the ear?

Answer 20

C2 + C3
CN V
CN IX
CN X

Question 21

What might cause referred pain in the ear from C2/C3?

Answer 21

Arthritis/cervical spondylosis

Soft tissue injury

Question 22

What might cause referred pain in the ear from CN V?

Answer 22

Sinusitis
Trigeminal neuralgia
Dental disease
TMJ dysfunction
Nasopharyngeal disease e.g. viral infection, tumour or post adenoidectomy

Question 23

What might cause referred pain in the ear from CN IX?

Answer 23

Any oropharyngeal infection –> pharyngitis, tonsillitis, quincy, post-tonsillectomy
Tongue base tumour

Question 24

What might cause referred pain in the ear from CN X?

Answer 24

Carcinoma of larynx or hypopharynx

Question 25

Which examinations should be done for otalgia?

Answer 25

Otoscopy
Temporomandibular joint
Oral cavity + oropharynx
Neck
CN exam
Flexible endoscopy --> post nasal space, tongue base, pharynx, larynx

Question 26

When does primary otalgia require an urgent ENT referral?

Answer 26

Perichondritis
Complicated herpes zoster
Severe otitis externa
Mastoiditis
Facial nerve palsy (AOM, cholesteatoma)
Sudden hearing loss
Cranial nerve palsy

Question 27

When does secondary otalgia (referred pain) require an urgent ENT referral?

Answer 27

Associated dysphagia, dysphonia, neck lump
Unilateral glue ear in adults (nasopharyngeal carcinoma)
Stridor, dyspnoea, hoarseness, dysphagia, drooling –> supraglottitis
Peritonsillar abscess

Question 28

How should TMJ dysfunction be managed?

Answer 28

Dentist
NSAIDs
Soft diet
Dental guard
Maxillofacial referral