Week 5/6 - ENT - Vertigo & Nasal Conditions

Question 1

Allergic Rhinitis

Clinical Features
Management

Answer 1

1. ) Clinical Features
   - sneezing, rhinorrhea, nasal congestion, itchy nose
   - post-nasal drip, itchy palate, cough
   - allergic conjunctivitis, FH of atopy
2. ) Management - avoid allergens
   - 1: intra-nasal antihistamines (azelastine hydrochloride)
   - 2: oral antihistamines (cetirizine or loratadine)
   - 3: intranasal corticosteroid (beclometasone)

Question 2

Sinusitis (acute and chronic)

What is it?
Clinical Features
Management
Red Flags

Answer 2

1. ) What is it? - inflammation of paranasal sinuses
   - acute: triggered by viral URTI, lasting <12wks
   - chronic: >12wks w/ sinonasal inflammation on exam
2. ) Cinical Features
   - nasal blockage, purulent discharge, (cough in kids)
   - facial pain/headache w/ tenderness over sinuses
   - reduced sense of smell and mucosal oedema
3. ) Management
   - if sx <10d reassure takes 2-3wks to resolve
   - if >10 days, can prescribe nasal corticosteroid (fluticasone)or antibiotic (not advised), Penicillin V or co-amoxiclav
   - chronic: may last several months and can also receive intranasal corticosteroids
4. ) Red Flags - refer to hospital immediately
   - severe systemic infection, intraorbital complictation
   - intracranial complications

Question 3

Deviated Nasal Septum

What is it?
Clinical Features
Management

Answer 3

1. ) What is It? - displacement of the nasal septum, making one of the nasal passages smaller
   - if severe, can make it difficult to breathe
   - occurs often due to injury to the nose
2. ) Clinical Features
   - nasal obstruction, nosebleeds, facial pain, noisy breathing during sleep
3. ) Management
   - nasal obstruction: decongestants and antihistamines
   - improve sleep: nasal dilators (reduce snoring)
   - surgery is required to correct a deviated septum

Question 4

Nasal Fracture (Broken Nose)

Clinical Features
Management

Answer 4

1. ) Clinical Features
   - nasal deviation, instability/crepitus, nasal obstruction
   - swelling or bruising, nosebleeds, nasal discharge
2. ) Management - usually heals within 2-3 weeks
   - ensure no signs of basilar skull fracture or involvement of eye orbit, cheek or jaw bones
   - treat nosebleeds by sitting/standing upright and leaning forward whilst pinching nose bridge
   - ice packs and regular painkillers

Question 6

Nasal Polyps

What is it?
Clinical Features
Investigations
Management

Answer 6

1. ) What is it? - benign flesh swellings often found at the middle meatus (sometimes in sinuses)
   - caused by inflammation → oedema
2. ) Clinical Features - depends on size
   - nasal obstruction, rhinorrhoea, post-nasal drip
   - ↓smell, ↓taste, dull headaches, snoring/sleep issues
3. ) Investigations
   - nasal speculum/rhinoscopy to locate polyps
   - CT scan if severe
   - if unilateral, referral for cancer 2WW
   - test children for cystic fibrosis
4. ) Management
   - intranasal corticosteroids to shrink
   - functional endoscopic sinus surgery (gold standard)

Question 7

Vestibular Migraine

What is it?
Clinical Features
Management

Answer 7

1.) What is it? - repeated dizziness/vertigo in people with a history of migraine symptoms

2. ) Clinical Features
   - headaches, dizziness/vertigo (mins), sensitivity to motion and sound
3. ) Management
   - abortive therapy: triptans, vestibular supressants (lorazepam, promethazine, antihistamines)
   - avoid all known triggers e.g. alcohol, MSG
   - MRI and hearing and balance tests to rule out stroke or menieres

Question 8

Bilateral Vestibulopathy

What is it?
Clinical Features
Management

Answer 8

1. ) What is it? - when the balance portions of both inner ears are damaged
   - idiopathic (50%), ototoxic drugs (e.g. gentamycin)
2. ) Clinical Features
   - imbalance, worse in dark or uneven terrain
   - oscillopsia (visual disturbance when moving head)
   - vertigo is rare
3. ) Management
   - avoid ototoxic drugs or vestibular suppressants
   - vestibular rehabilitation

Question 8

5 inner ear conditions causing vertigo

Benign Paroxymal Postional Vertigo (BPPV)
Meniere's Disease
Acute Labrynthitis
Acute Vestibular Neuronitis
Acoustic Neuroma

Answer 8

1. ) BPPV - short episodes (seconds) of vertigo triggered by movement of the head
   - caused by dislodged calcium crystals in the inner ear
   - Dix-Hallpike test (trigger torsional geotropic nystagmus) to confirm (sit upright then lay down, hang head off the bed, tilt head)
   - Epley Manoeuvre to remove symptoms

2.) Meniere’s Disease - recurrent episodes of vertigo,
unilateral hearing loss, and tinnitus, +/- N/V
- symptoms last 30 mins up to 24 hours
- hearing deteriorates overtime

3. ) Acute Labyrinthitis - history of URT infection w/ vertigo, hearing loss, tinnitus and vomiting
   - involvement of all inner ear structures
4. ) Acute Vestibular Neuronitis - history of URTI w/ severe vertigo and sudden onset of vomiting
   - usually no hearing disturbance or tinnitus
   - managed using vestibular suppressants to ↓N/V
5. ) Acoustic Neuroma - vestibular schwannoma, overproduction of Schwann cells
   - CN VIII compression: vertigo, unilateral tinnitus, unilateral sensorineural hearing loss
   - CN V compression: absent corneal reflex
   - CN VII compression: facial nerve palsy
   - requires urgent referral to ENT