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1
Q

What is vertigo

A

An illusion of movement, usually rotatory

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2
Q

What happens if balance goes wrong?

A

Can’t stand up or walk straight
Nystagmus
Vomiting

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3
Q

What is nystagmus? 2 different types

A

Periodic rhythmic ocular oscillations - everyone gets at the extremes of gaze
Pendular - both directions at same speed
Jerk - fast and slow phase

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4
Q

Inputs of balance system

A

Eyes
Proprioception
Vestibular system

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5
Q

Central connections

A

Brainstem

Cerebellum

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6
Q

Output

A

Musculoskeletal

Eye movements

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7
Q

Things that can go wrong with central connections of balance

A

Migraine associated vertigo
Brain stem infarct
Cerebellum infarct
Tumours

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8
Q

Problems with output of vestibular system

A

PD

Arthritis

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9
Q

Problems with inputs of vestibular system

A

Eyes - blind
Neuropathy - proprioception
Vestibular - BPPV, labrynthitis, Ménière’s disease

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10
Q

What is BPPV?

A

Benign paroxysmal positional vertigo

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11
Q

Occurance of BPPV

A

Common, easily treatable

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12
Q

Presentation of BBPV

A

Short episodes of vertigo lasting seconds to minutes

Commonly precipitated by rolling over in bed - couple seconds later the room starts to spin

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13
Q

Pathology of BPPV

A

Debris in the posterior semicircular canal
Canalolithiasis
Loose in canal and cause excessive stimulation of hair cells

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14
Q

Dx of BPPV

A

History

Hallpikes test

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15
Q

Treatment of BPPV

A

Epleys manoeuvre

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16
Q

What is labyrinthitis

A

Single episode of vertigo lasting for several days

Often precipitated by URTI

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17
Q

Symptoms of labrynthitis

A

Vertigo, nausea and vomiting
So bad can’t get out of bed
No hearing loss

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18
Q

Nystagmus with labyrinthitis

A

Eyes will flick towards the affected ear - paralytic nystagmus
Or eyes will flick away from affected side - irritating nystagmus

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19
Q

Management of labyrinthitis

A 
Hydration
Benzodiazepines - vestibular sedatives
Prochlorperazine - antiemetic 
Steroids if severe
Antibiotics if bacteria cause suspected
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20
Q

What is menieres disease?

A

Attacks of vertigo, tinnitus, hearing loss and feeling of aural fullness/pressure
Multiple episodes often occur in clusters

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21
Q

Additional feature of Ménière’s disease

A

Drop attacks - tumarkin crisis
Suddenly fall to the ground with no loss of consciousness
Feel as though being pushed
Activations of hair cells - don’t know why
Not everyone gets them

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22
Q

Pathology of Ménière’s disease?

A

endolymphatic Hydrops - build up of endolymphatic fluid in the inner ear
Aetiology unknown

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23
Q

Dx of Ménière’s disease

A

History

Electrocochleography

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24
Q

Prevention of Ménière’s disease attacks

A

Low salt diet
Reduce caffeine and chocolate
Diuretics
Betahistamine

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25
To abort Ménière's disease attacks
Antiemetics - prochlorperazine or ondansetron | Antihistamines - Meclozine or drimethobenzamide
26
Treatment of Ménière's disease
Intratympanic gentamicin (ototoxic therefore chemical labyrinthectomy- have severe vertigo for 2 weeks until body compensates for lack of vestibular input from that ear) Intratympanic steroids Endolymphatic surgery Vestibular neurectomy Labyrinthectomy
27
Features of migraine associated vertigo
Hearing normal Not always a headache Duration variable Prophylactic agents work - acute migraine treatments don't
28
What is dizziness?
The feeling that you are about to fall, instability and tendency to lose ones balance
29
What is otorrhoea
Discharging ear
30
Which hand do you use to hold the auroscope to examine the right ear
Your right hand
31
Where is ear wax produced and where should it normally be found?
Outer 1/3 of EAC and that is where it should be found | Shouldn't see ear wax on the TM
32
Type of skin in EAC
Migratory epithelium - forms in centre of TM and then moves outwards Cannot be normal skin because if you shed dead skin then the ear canal would get bunged up
33
Functions of ear wax
Natural protective layer Keeps ear waterproof Conditions the skin Mild antibacterial
34
When does ear wax become pathological
When it gets completely compacted and occludes the ear canal
35
Treatment of pathological ear wax
Syringing it out - flood it with water - aim behind the wax - don't aim at eardrum Microsuction
36
What is otitis externa?
Acute inflammation of the skin of the EAC
37
Symptoms of otitis externa
``` Otalgia Itchy Otorrhoea Oedema Erythema Severe swelling can cause hear loss ```
38
Predisposing factors of otitis externa
``` Anatomical Occlusion (FB, hearing aid) Moisture (humidity or swimming) Skin condition such as eczema - lose the protective layer DM COM ```
39
Common bacteria in otitis externa and other common ones
Pseudomonas aeruginosa (pungent otorrhoea) + other gram negatives
40
When do you suspect fungal otitis externa?
When discharge is resistant to Ab ear drops
41
What is appearance of fungal otitits externa?
Fluffy "cotton wool" type debris or black spots (aspergillus niger)
42
How do you treat fungal otitis externa?
Can take several weeks of therapy to clear | Don't stop anti-fungal therapy when you can't see any more - need to do it for weeks or it will reoccur
43
What is furunculosis
Reccurent infected boil in the ear Acute and really painful Causes conductive hearing loss Treated with systemic ab's
44
Treatment of otitis externa
Keep it dry and do not put things down it | Topical antibiotic/steroid combination (steroids because it is inflammatory not just infectious)
45
If no improvement initially with medical treatment of otitis externa?
Microsuction or aural toilet
46
What is necrotising otitis externa? What organism causes it and symptoms?
Life threatening invasive pseudomonal infection of the bone | Severe constant pain
47
Who gets necrotising otitis externa?
Diabetics, elderly and immunocompromised
48
Treatment of necrotising otitis externa?
Antipseudomonal ab long term and ciprofloxacin ear drops
49
What can cause perforated ear drum?
Acute OM Traumatic - blast injury Iatrogenic
50
What does ear drum perforation cause
Hearing loss with recurrent discharge (OM )
51
Management of perforated ear drum
Keep it dry Small and acute - wait and encourage healing and prevent infection If larger - myringoplasty or tympanoplasty - surgical repair
52
What is cholesteatoma?
Keratinizing squamous epithelium in the middle ear - ball of skin trapped there Can't go anywhere therefore gets infected
53
Presentation of cholesteatoma
Foul-smelling otorrhoea | Hearing loss
54
What does examination of cholesteatoma show?
Tympanic membrane full of white cheesy material
55
Compliction of cholesteatoma
It grows and destorys structures - produces enzymes which break down bone eg. ossicles and inner ear Can erode into facial nerve - cause palsy Can also cause vertigo
56
Management of cholesteatoma
Mastoidectomy
57
Discharge in neoplastic lesions in the ear
Chronic pink (blood-stained) discharge
58
Usually presentation of neoplastic lesions
Very rare. Previous hx of skin cancer and they are painful
59
5 questions to ask if any ear symptoms
Tinnitus, hearing loss, pain, discharge and vertigo
60
When is fhx relavant in hearing loss
Significant HL before age of 60
61
What drugs are ototoxic?
``` Aminoglycosides Cisplatin Diuretics - furosemide Aspirin Quinine ```
62
Rhine's normal test
AC > BC, also present if mild SN HR
63
Rhine's negative test
Conductive hearing loss | BC > AC
64
Weber's normal test
Can hear a faint buzzing everywhere
65
Weber's if SN hearing loss
Bone conduction preferentially to side which is not affected
66
Weber's if CH R
Bone conduction to the side with conductive HR
67
What is tympanometry
Measures the pressure across the tympanic membrane | Will be altered if perforation of compacted middle ear infection
68
Causes of congenital conductive hearing loss
Anotia - no outer ear Atresia of ear canal - canal hasn't opened up yet Ossicular malformation
69
Management of congenital conductive hearing loss
Cochlear is frequently normal Therefore rehab with hearing aid Reconstruction surgery has poor results
70
Causes of acquired hearing loss
1) Wax/FB 2) Otitis Externa 3) TM perforation 4) Otitis media (because compacted and ossicles can't move) 5) Glue ear 6) Otosclerosis 7) Ossicular discontinuity
71
Signs of OM
Severe pain and conductive hearing loss Tinnitus Children may get systemic symptoms Otorrhoea if ear drum perforates
72
Commonest cause of OM
Viral eg. following cold
73
Bacterial causes of OM
Strep.pneumoniea H/influenzae Moraxella
74
Treatment of OM
Most settle within 72hours without treatment | If systemic features after 72 hours then give amoxicillin
75
What treatment is of no value in OM
Topical therapy
76
Complications of OM
Perforation (no more pain and otorrhoea) | Infection of mastoid bone - tenderness and swelling over mastoid bone
77
What is glue ear?
Otitis media with secondary effusion causing mucous plug in eustachian tube Serous otitis media Common in children because of Eustachian tube dysfunction
78
Normal development of glue ear
Usually resolves naturally but can persist giving HL | Also predisposes to reccurent attacks of OM
79
Treatment of glue ear
Grommet - tympanostomy tube - inserted into TM and ventilates the middle ear cavity - taking over eustachian tube function Usually extruded from TM as it heals (over 6months to 2 years)
80
After what age to eustachian tube dysfunctions become rare
7-14 when middle 1/3 of face grows
81
What is otosclerosis?
Usually a hereditary disorder associated with new bony deposits within the stapes footplate and cochlea
82
When does otosclerosis present?
Normally 20-30s F>M Worse in pregnancy
83
Treatment of otosclerosis
Hearing aid OR Stapedectomy
84
Causes of congenital SN HR
Cochlear dysplasia | Auditory nerve aplasia
85
Most common acquired cause of SN HR
Presbyacusis degenerative disorder of cochlea of old age Can be due to loss of any part of SN pathway
86
Which sound frequencies most commonly affected in presbyacusis?
High frequency - consonants - therefore speech intelligible Treat with high frequency hearing aid
87
Other causes of acquired SN HL
``` Noise exposure Ototoxic drugs (overdose or normal dose in susceptible individuals - eg. renal failure, pre-existing SN HR or old age) ``` Menieres disease Vestibular schawannoma

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