Ear, Nose and Throat

Question 1

audiometry

Answer 1

Quantify loss and determine nature

Question 2

Pure tone audiometry

Answer 2

headphones at different frequencies and strengths in soundproofed room

pt indicates when sound appears and siappears

mastoid vibrator - bone conduction threshold

threshold at different frequencies plotted to give audiogram

Question 3

Tympanometry

Answer 3

Measures stiffness of ear drum
- evaluates middle ear function

flat tympanogram - mid ear fluid or perforation

Shifted tympanogram - +/- mid ear pressure

Question 4

Evoked response audiometry

Answer 4

auditory stimulus w measurement of elicited brain response by surface electrode

used for neonatal screening if otoacoustic emission testing negative

Question 5

Otitis Externa

Answer 5

Presentation (otalgia)

• watery discharge
• itchy
• pain + tragal tenderness

Causes
 Moisture: e.g. swimming
 Trauma: e.g. fingernails
 Absence of wax
 Hearing aid

Organisms
 Mainly pseudomonas
 Staph aureus

Management
Aural toilet w drops
 Betamethasone for non-infected eczematous OE
 Betamethasone w neomycin
 Hydrocortisone w gentamicin
 Acidifying drops

Question 6

Malignant Otitis Externa

Answer 6

Life-threatening infection which can > skull osteomyelitis
90% pt diabetic (or other immunocompromisation)

Presentation
 Severe otalgia which is worse @ night
 Copious otorrhoea
 Granulation tissue in the canal

Rx
 Surgical debrdement
 Systemic Abx

Question 7

Bullous Myringhitis

Answer 7

 Painful haemorrhagic blisters on deep meatal skin and TM.

 Assoc. c¯ influenza infection

Question 8

TMJ Dysfunction

Answer 8

Sx - otalgia (earache) - referred pain from auriculotemporal nerve

• facial pain
• joint clicking/popping
• teeth-grinding (burxism)
• stress (assw depression)

Signs
- joint tenderness exacerbated by lateral movement of open jaw

Ix - MRI

Mx - NSAIDs
- stabilising orthodontic occlusal prostheses

Question 9

Otitis Media

Classification

Answer 9

Classification
 Acute: acute phase
 Glue ear / OME: effusion after symptom regression
 Chronic: effusion > 3mo if bilat or > 6mo if unilat
 Chronic suppurative OM: Ear discharge c¯ hearing
loss and evidence of central drum perforation.

Organisms

• Viral
• Pneumococcus
• Haemophilus
• Moraxella

Question 10

Acute Otitis Media

Answer 10

Presentation
 Usually children post viral URTI
 Rapid onset ear pain, tugging @ ear.
 Irritability, anorexia, vomiting
 Purulent discharge if drum perforates

o/e
 Bulging, red TM
 Fever

Rx
 Paracetamol: 15mg/kg
 Amoxicillin: may use delayed prescription

Question 11

Acute Otitis Media Compliciations

Answer 11

Intratemporal
 OME
 Perforation of TM
 Mastoiditis
 Facial N. palsy

Intracranial
 Meningitis / encephalitis
 Brain abscess
 Sub- / epi-dural abscess

Systemic
 Bacteraemia
 Septic arthritis
 IE

Question 12

Otitis MEdia Externa (glue ear)

Answer 12

Presents

• inattention at school
• poor speech development
• hearing impairment

O/E - retracted dull TM
- fluid level

Ix - audiometry flat tympanogram

Rx - usually resovles spontaneously
- consider grommets if persistent hearing loss
> SE infections, tympanosclerosis

Question 13

Chronic Suppurative OM

Answer 13

Presentation - painless discharge and hearing

O/E - TM perforation

Rx - aural toilet
- abx/steroids ear drops

Complications - cholesteatoma

Question 14

Mastoiditis

Answer 14

Middle-ear inflam > destruction of mastoid air cells + abscess formation

Presentation - fever, mastoid tenderness, protruding auricle

Imaging CT

Rx - IV abx
- myringotomy +/- mastoidectomy

Question 15

Cholesteatoma

Answer 15

Locally destructive expansion of stratified squamous epithelium within middle ear

Classification

• congenital
• acquired 2ndary to attic perforation in chronic suppurative OM

Presentation 
- Foul smelling white discharge
- headache, pain
- CN involvement 
  > vertigo, deafness, facial paralysis

O/E - appears pearly white w surrounding inflammation

Mx - Surgery

Question 16

Cholesteatoma Complications

Answer 16

Deafness (ossicle destruction)
Meningitis
Cerebral abscess

Question 17

Tinnitus

Answer 17

Sensation of sound w/o external sound stimulation

Causes
Specific
 Meniere’s
 Acoustic neuroma
 Otosclerosis
 Noise-induced
 Head injury
 Hearing loss: e.g. presbyacusis

General
 ↑BP
 ↓Hb

Drugs
 Aspirin
 Aminoglycosides
 Loop diuretics
 EtOH

Question 18

Tinnitus History

Answer 18

 Character: constant, pulsatile
 Unilateral: acoustic neuroma
 FH: otosclerosis
 Alleviating/exacerbating factors: worse @ night?

Associations
 Vertigo: Meniere’s, acoustic neuroma
 Deafness: Meniere’s, acoustic neuroma

Cause: head injury, noise, drugs, FH

Question 19

Tinnitus Examination Ix Mx

Answer 19

Examination
 Otoscopy
 Tuning fork tests
 Pulse and BP

Ix
 Audiometry and tympanogram
 MRI if unilateral to exclude acoustic neuroma

Mx
 Treat any underlying causes
 Psych support: tinnitus retraining therapy
 Hypnotics @ night may help

Question 20

Vertigo

Causes

Answer 20

Illusion of movement

Cause

Peripheral/vestibular

• Meniere’s
• BPV
• Labyrinthitis

Central
- Acoustic neuroma
- MS
- vertebrobasilar insufficiency/stroke 
head injury
- inner ear syphilis 

Drugs (central/ototoxic)
 Gentamicin
 Loop diuretics
 Metronidazole
 Co-trimoxazole

Question 21

Veritogo Hx + Examination + tests

Answer 21

Hx
 Is it true vertigo or just light-headedness?
> Which way are things moving?
 Timespan
 Assoc. symptoms: n/v, hearing loss, tinnitus, nystagmus

Examination and Tests
 Hearing
 Cranial nerves
 Cerebellum and gait
 Romberg’s +ve = vestibular or proprioception
 Hallpike manouvre
 Audiometry, calorimetry, LP, MRI

Question 22

Meniere’s Disease

presentation

Answer 22

Dilatation of endolymph space of membranous labryrinth (endolymphatic oedema)

Presentation

• Attacks occur in clusturs + last up to 12 hours
• progressive SNHL (sensnorineural hearing loss)
• vertigo + N/v
• tinnitus
• aural fullness

Question 23

Meniere’s Disease

Ix Rx

Answer 23

Ix - audiometry shows low-freq SNHL which fluctuates

Rx
Medical - vertigo, cyclizine, betahistine

Surgical - gentamicin instillation via grommets
- Saccus decompression

Question 24

Vestibular Neuronitis/Viral labyrinthitis

Answer 24

Presentation

• following febrile illness (URTI)
• sudden vomiting
• severe vertigo exacerbated by head movement

Rx

• Cyclizine
• Improvement in days

Question 25

Benign positional vertigo (BPV)

Answer 25

Displacement of otoliths in semicircular canals - common after head injury Presents - sudden rotational vertigo for <30s > provoked by head turning - nystagmus Causes - idiopathic - head injury - otosclerosis - post-viral Dx - hallpike manoeuvre > upbeat torsional nystagmus Rx - self-limiting - epley manoeuvre - betahistine - histamine analogue

Question 26

Conductive Adult Hearing Loss

Answer 26

Impaired conduction between auricle and round window External canal obstruction  Wax  Pus  Foreign body TM perforation  Trauma  Infection Ossicle defects  Otosclerosis  Infection  Trauma Inadequate eustachian tube ventilation of middle ear

Question 27

Sensorineural Adult Hearing Loss

Answer 27

Defects of cochlrea, cochlear Nerve or brain Drugs - aminoglycosides - vancomycin Post-infective - meningitis - measles - mumps - herpes Misc - Meniere's - Trauma - MS - CPA lesion (acoustic neuroma) - low B12

Question 28

Acoustic Neuroma/Vestibular Schwannoma

Answer 28

Benign slow growing tumour of superior vestibular nerve Acts as SOL > cerebellar pontine angle syndrome assw NF2

Question 29

Acoustic Neuroma/Vestibular Schwannoma Presentation

Answer 29

 Slow onset, unilat SNHL, tinnitus ± vertigo  Headache (↑ICP)  CN palsies: 5,7 and 8  Cerebellar signs

Question 30

Acoustic Neuroma/Vestibular Schwannoma | Ix DDx Rx

Answer 30

Ix  MRI of cerebellopontine angle >MRI all pts. c¯ unilateral tinnitus / deafness  PTA Differential  Meningioma  Cerebellar astrocytoma  Mets Rx  Gamma knife  Surgery (risk of hearing loss)

Question 31

Otosclerosis

Answer 31

AD fixation of stapes at oval window F>M Presents - early adult life bilateral conductive deafness + tinnitus - HL improved in noisy places - Willis paracousis - worsened by pregnancy menstruation/menopause Ix - PTA shows dip Caharts notch at 2kHz Rx - hearing aid or stapes implant

Question 32

Presbyacussis

Answer 32

Age related hearing loss Presentation - >65y - bilateral slow onset - +/- tinnitus Ix PTA Rx - hearing aid

Question 33

Congenital Hearing loss in Children

Answer 33

Conductive  Anomalies of pinna, external auditory canal, TM or ossicles.  Congenital cholesteatoma  Pierre-Robin SNHL  AD - Waardenburgs: SNHL, heterochromia + telecanthus AR  Alport’s: SNHL + haematuria  Jewell-Lange-Nielson: SNHL + long QT  X-linked - Alport’s Infections: CMV, rubella, HSV, toxo, GBS Ototoxic drugs

Question 34

Perinatal causes of hearing loss

Answer 34

anoxia cerebral palsy kernicterus infection - meningitis

Question 35

Acquired causes of hearing loss in children

Answer 35

OM/OME infection - meningitis, measles head injury

Question 36

Universal Neonatal Hearing Tests

Answer 36

Detection + Mx of hearing loss before 6mo improves language Tests - otoacoustic emissions - audiological

Question 37

Congenital Anomalies

Answer 37

 1st and 2nd branchial arches form auricle while 1st branchial groove forms external auditory canal.  Malfusion → accessory tags/auricles and preauricular pits, fistulae or sinuses.  Sinuses may get infected, mimicking a sebaceous cyst.

Question 38

Pinna Haematoma

Answer 38

Blunt trauma > subperichondrial haematoma Can > ischaemic necrosis of cartilage + subsequent fibrosis > cauliflower ears Mx - aspiration + firm packing to auricle contour

Question 39

Exostoses

Answer 39

Smooth symmetrical bony narrowing of external canals Bony hypertrophy due to cold exposure - from swimming/surfind Sx - ASx unless narrowing occludes > conductive deaf

Question 40

Wax: Cerum Auris

Answer 40

Secreted in outer 3rd of canal to prevent maceration Wax accumulation can > conductive deafness Mx - suction under direct vision w microscope - syringing after 1 wk softening wth oil

Question 41

Tympanic Membrane Perforation | causes

Answer 41

OM Foreign Body Barotrauma Trauma

Question 42

Allergic Rhinosinusitis

Answer 42

Classification - seasonal (hay-fever) - perennial T1HS IgE mediated inflam from allergen exposure > mediator release from mast cells Allergens - pollen, house dust mites Sx - sneezing, pruritis, rhinorrhoea Signs - swollen, pale, boggy turbinates - nasal polyps Ix - skin prick testing to find allergens (not if prone to eczema - RAST tests

Question 43

Allergic Rhinosinusitis Mx

Answer 43

Allergen Avoidance  Regularly washing bedding (inc. toys) on high heat or use acaricides.  Avoid going outside when pollen count high. 1st Line  Anti-histamines: cetirazine, desloratidine  Or, beclometasone nasal spray  Or, chromoglycate nasal spray (children) 2nd Line: intranasal steroids + anti-histamines 3rd Line: Zafirlukast 4rd Line: Immunotherapy  Aim to induce desensitisation to allergen  OD SL grass-pollen tablets → ↑ QOL in hay-fever  Injection immunotherapy Adjuvants  Nasal decongestants: Pseudoephedrine, Otrivine

Question 44

Sinusitis

Answer 44

 Viruses → mucosal oedema and ↓ mucosal ciliary actions → mucus retention ± 2O bacterial infection  Acute: Pneumococcus, Haemophilus, Moraxella  Chronic: S. aureus, anaerobes Causes  Majority are bacterial infection 2O to viral  5% 2O to dental root infections  Diving / swimming in infected water  Anatomical susceptibility: deviated septum, polyps Systemic Disease  PCD / Kartagener’s  Immunodeficiency

Question 45

Sinusitis Sx, Imaging

Answer 45

Symptoms Pain  Maxillary (cheek/teeth)  Ethmoidal (between eyes)  ↑ on bending / straining Discharge: from nose → post-nasal drip c¯ foul taste Nasal obstruction/congestion Anosmia or cacosmia (bad smell w/o external source) Systemic symptoms: e.g. fever Imaging  Nasendoscopy ± CT

Question 46

Sinusitis Mx

Answer 46

Acute / Single Episode  Bed-rest, decongestants, analgesia  Nasal douching and topical steroids  Abx (e.g. clarithro) of uncertain benefit ``` Chronic / recurrent  Usually a structural or drainage problem.  Stop smoking + fluticasone nasal spray  Functional Endoscopic Sinus Surgery  If failed medical therapy ```

Question 47

Sinusitis Complications

Answer 47

 Mucoceles → pyoceles  Orbital cellulits / abscess  Osteomyelits – e.g. Staph in frontal bone Intracranial infection  Meningitis, encephalitis  Abscess  Cavernous sinus thrombosis.

Question 48

Nasal Polyps Sites Sx Signs

Answer 48

M 40 Sites - Middle turbinates, middle meatus, ethmoids Sx - Watery anterior rhinorrhoea - purulent post nasal drip - Nasal obstruction - sinusitis - headaches - snoring Signs - Mobile, pale, insensitive

Question 49

Nasal polyp associations

Answer 49

 Allergic / non-allergic rhinitis  CF  Aspirin hypersensitivity  Asthma

Question 50

Single Unilateral Polyp

Answer 50

May be sign of rare sinister pathology ```  Nasopharyngeal Ca  Glioma  Lymphoma  Neuroblastoma  Sarcoma ``` Do CT and get histology

Question 51

Nasal Polyp in children

Answer 51

Rare <10yrs old  Must consider neoplasms and CF ``` Mx  Drugs  Betamathasone drops for 2/7  Short course of oral steroids  Endoscopic Polypectomy ```

Question 52

Fractured Nose

Answer 52

Anatomy - upper 1/3 of nose has bony support - lower 2/3 and septum cartilaginous ``` Hx  Time of injury  LOC  CSF rhinorrhoea  Epistaxis  Previous nose injury  Obstruction ``` Consider facial #, check for  Teeth malocclusion  Piplopia (orbital floor #)

Question 53

Fractured Nose

Answer 53

Ix - cartilaginous injury won't show and radiographs don't alter Mx Mx - exclude septal haematoma - re-examine after 1 wk (decreased swelling) - reduction under GA w post-op splinting best w/i 2 weeks

Question 54

Septal Haematoma

Answer 54

Septal necrosis + nasal collapse if untreated  Cartilage blood supply comes from mucosa Boggy swelling and nasal obstruction Needs evacuation under GA c¯ packing ± suturing.

Question 55

Epistaxis Causes

Answer 55

 80% unknown  Trauma: nose-picking / #s  Local infection: URTI Pyogenic granuloma  Overgrowth of tissue on Little’s area due to irritation or hormonal factors.  Osler-Weber-Rendu / HHT  Coagulopathy: Warfarin, NSAIDs, haemophilia, ↓plats, vWD, ↑EtOH  Neoplasm

Question 56

Epistaxis Initial Mx

Answer 56

Wear PPE Assess for shock and manage accordingly If not shocked  Sit up, head tilted down  Compress nasal cartilage for 15min. If bleeding not controlled remove clots w suction or by blowing and try to visualise bleed by rhinoscopy

Question 57

Anterior Epistaxis

Answer 57

``` Usually septal haemorrhage: Little’s area / Kisselbach’s plexus  Ant. Ethmoidal A.  Sphenopalatine A.  Facial A. ``` Insert gauze soaked in vasoconstrictotr + LA  Xylometazoline + 2% lignocaine  5min Bleeds can be cauterised w silver nitrate sticks Persistent bleeds should be packed with Mericel pack  Refer to ENT if this fails or if you can’t visualise the bleeding point.  They may insert a posterior pack or take pt. to theatre for endoscopic control.

Question 58

Posterior/Major epistaxis

Answer 58

Posterior packing (+ anterior pack)  Pass 18/18G Foley catheter through the nose into nasopharynx, inflate w 10ml water and pull forward until it lodges.  Admit pt. and leave pack for ~48hrs. Gold standard is endoscopic visualisation and direct control: e.g. by cautery or ligation.

Question 59

Epistaxis After bleed

Answer 59

```  Don’t pick nose  Sit upright, out of the sun  Avoid bending, lifting or straining  Sneeze through mouth  No hot food or drink  Avoid EtOH and tobacco ```

Question 60

Osler-Weber-Rendu/HHT

Answer 60

AD 5 Genetic Subtypes Features - Telangiectasias in mucosae  Recurrent spontaneous epistaxis  GI bleed (usually painless) - Internal telangiectasias and AVM  Lungs  Liver  Brain Rarely  Pulmonary HTN  Colon polyps: may → CRC

Question 61

Tonsilitis Sx Signs Organisms

Answer 61

Symptoms  Sore throat  Fever, malaise Signs  Lymphadenopathy: esp. jugulodigastric node  Inflamed tonsils and oropharynx  Exudates ``` Organisms  Viruses are most common (consider EBV)  GAS: Pyogenes  Staphs  Moraxella ```

Question 62

Tonsilitis Mx

Answer 62

Swabbing superficial bacteria is irrelevant and can → overdiagnosis. Analgesia: Ibuprofen / Paracetamol ± Difflam gargle Consider Abx only if ill: use Centor Criteria  Pen V 250mg PO QDS (125mg TDS in children) or erythromycin for 5/7 NOT AMOXICILLIN → MACPAP RASH IN EBV

Question 63

Centor Criteria

Answer 63

Guideline for admin Abx in acute sore throat/tonsilitis/pharyngitis 1 point for 1. Hx of fever 2. Tonsillar exudates 3. Tender anterior cervical adenopathy 4. No cough Mx  0-1: no Abx (risk of strep infection <10%)  2: consider rapid Ag test + Rx if +ve  ≥3: Abx

Question 64

Tonsillectomy Indications

Answer 64

Recurrent tonsillitis if all the below criteria are met  Caused by tonsillitis  5+ episodes/yr  Symptoms for >1yr  Episodes are disabling and prevent normal functioning Airway obstruction: e.g. OSA in children Quinsy Suspicion of Ca: unilateral enlargement or ulceration

Question 65

Tonsillectomy method + complications

Answer 65

Cautery or cold steel.. ``` Complications  Reactive haemorrhage  Tonsillar gag may damage teeth, TMJ or posterior pharyngeal wall.  Mortality is 1/30,000 ```

Question 66

Strep throat complications Peritonsillar Abscess

Answer 66

Quinsy Typically occurs in adults Symptoms  Trismus  Odonophagia: unable to swallow saliva  Halitosis ``` Signs  Tonsillitis  Unilateral tonsillar enlargement  Contralateral uvula displacement  Cervical lymphadenopathy ``` Rx  Admit  IV Abx  I&D under LA or tonsillectomy under GA

Question 67

Strep throat complications Retropharyngeal Abscess

Answer 67

Rare Presents - unwell child w stiff, extended neck who refuses to eat + drink - fails to improve w IV abx - unilateral swelling of tonsil of tonsil + neck Ix - lateral neck XR show soft tissue swelling - CT from skull-base to diaphragm Rx - IV abx - I+D (incision and drainage)

Question 68

Strep Throat Complications Lemierre's Syndrome

Answer 68

IJV thrombophlebitis c¯ septic embolization most commonly affecting the lungs. Organism: Fusobacterium necrophorum Rx  IV Abx: pen G, clinda, metro

Question 69

Strep Throat Complications Scarlet Fever

Answer 69

12-48h after pharyngotonsillitis Sandpaper like rash on chest, axillae or behind ears Circumoral pallor Strawberry tongue Rx - Start pen V/G and notify HPA

Question 70

Strep throat complications Rheumatic Fever

Answer 70

```  Carditis  Arthritis  Subcutaneous nodules  Erythema marginatum  Sydenham’s chorea ```

Question 71

Strep throat complications Post-Streptococcal glomerulonephritis

Answer 71

Malaise + smoky urine 1-2 weeks after a pharyngitis

Question 72

Larynx Function

Answer 72

 Phonation  Positive thoracic pressure: inc. auto-PEEP  Respiration  Prevention of aspiration

Question 73

Laryngitis

Answer 73

Usually viral and self-limiting 2O bacterial infection may develop Symptoms: pain hoarseness and fever o/e: redness and swelling of the vocal cords Rx: Supportive, Pen V if necessary

Question 74

Laryngeal Papilloma

Answer 74

Pedunculated vocal cord swellings caused by HPV Present w hoarseness Usually occur in children Rx: laser removal

Question 75

Recurrent Laryngeal Nerve Palsy

Answer 75

Supplies all intrinsic muscles of the larynx except for cricothyroideus.  Ext. branch of sup laryngeal N. Responsible for ab- and ad-uction of vocal folds

Question 76

Recurrent Laryngeal Nerve Palsy Sx

Answer 76

Hoarseness Breathy voice w bovine cough Repeated coughing from aspiration (↓ supraglottic sensation) Exertional dyspnoea (narrow glottis)

Question 77

Recurrent Laryngeal Nerve Causes

Answer 77

30% are cancers: larynx, thyroid, oesophagus, hypopharynx, bronchus 25% iatrogenic: para- / thyroidectomy, carotid endarterectomy Other: aortic aneurysm, bulbar / pseudobulbar palsy

Question 78

Laryngeal Squamous Cell Cancer

Answer 78

Assw alcohol, smoking ``` Presentation  Male smoker  Progressive hoarseness → stridor  Dys-/odono-phagia  Wt. loss ``` Ix - laryngoscopy + biopsy (inc nodes) - MRI staging Mx - based on stage - radiotherapy - laryngectomy

Question 79

Laryngeal SCC After total Laryngectomy

Answer 79

Pts have permanent tracheostomy - speech valve - electrolarynx - oesophageal speech (swallowed air) Regular follow up for recurrence

Question 80

Laryngomalacia Paeds airway issues

Answer 80

Immature and floppy aryepiglottic folds and glottis → laryngeal collapse on inspiration Presentation  Stridor: commonest cause in children Presents w/i first wks of life. Noticeable @ certain times  Lying on back,  Feeding  Excited/upset Problems can occur w concurrent laryngeal infections or w feeding. Mx  Usually no Rx required but severe cases may warrant surgery

Question 81

Epiglottitis Paeds Airway Issues

Answer 81

``` Symptoms  Sudden onset  Continuous stridor  Drooling  Toxic ``` Pathogens: haemophilus, GAS Rx  Don’t examine throat  Consult w anaesthetists and ENT surgeons  O2 + nebulised adrenaline  IV dexamethasone  Cefotaxime  Take to theatre to secure airway by intubation

Question 82

Foreign Body Paeds airway issues

Answer 82

 Sudden onset stridor in a previously normal child.  Back slaps and abdominal thrusts.  Needle cricothyrotomy in children  Can only exclude foreign body in bronchus by bronchoscopy

Question 83

Subglottic Stenosis paeds airway issues

Answer 83

 Subglottis is narrowest part of respiratory tract in children. Symptoms: stridor, FTT Causes  Prolonged intubation  Congenital abnormalities Rx  Mild: conservative  Severe: Tracheostomy or partial tracheal resection

Question 84

Bell's Palsy path + features

Answer 84

Inflammatory oedema f CN7 in narrow facial canal - probs viral origin (HSV1) - 75% of facial nerve palsies Features  Sudden onset: e.g. overnight Complete, unilateral facial weakness in 24-72h  Failure of eye closure (Bell’s Sign) → dryness and conjunctivitis  Drooling, speech difficulty Numbness or pain around ear ↓ taste (ageusia) Hyperacusis: stapedius palsy

Question 85

Bell's Palsy Ix Mx

Answer 85

Ix  Serology: Borrelia or VZV Abs  MRI: SOL, stroke, MS  LP Mx - protect eyes (dark glasses, artificial tears, tape closed at night) - give prednisolone w/i 72h >60mg PO for 5 days followed by tapering - valciclovir if zoster suspected - plastic surgery may helpif no recovery

Question 86

Bell's Palsy Prognosis

Answer 86

Incomplete paralysis usually recovers completely w/i wks. With complete lesions: 80% full recovery 20% delayed recovery or permanent neurological / cosmetic abnormalities.

Question 87

Bell's Palsy Complications

Answer 87

Synkinesis: e.g. blinking causes up-turning of mouth Crocodile tears: eating stimulates unilateral lacrimation, not salivation

Question 88

Ramsay Hunt Syndrome path + Features

Answer 88

Reactivation of VZV in geniculate ganglion of CNVII Features - preceding ear pain or stiff neck - vesicular rash in auditory canal (+/- TM, pinna, tongue, hard palate) - no rash is zoster sine herpete - ipsilateral facial weakness, aguesia, hyperacusis - may affect CN7 > vertigo, tinnitus, deafness

Question 89

Ramsay Hunt Syndrome

Answer 89

Mx - valaciclovir + prednisolone w/i 72h Prognosis - treated w/i 72h 75% recovery - otherwise 1/3 recovery, 1/3 partial, 1/3 poor

Question 90

Other facial palsy | not bell's, ramsay hunt

Answer 90

 Bilateral symptoms (Lyme, GBS, leukaemia, sarcoid)  UMN signs: sparing of frontalis and orbicularis oculi  Other CN palsies (but seen in 8% of Bell’s)  Limb weakness  Rashes

Question 91

Intracranial lesions and facial palsy

Answer 91

Vascular, MS, SOL (space occupying lesion)  Motor cortex → UMN signs  Brainstem nuclei → LMN signs Cerebello-pontine angle lesion  May be accompanied by 5th, 6th, and 8th CN palsies

Question 92

Intratemporal/infratemporal lesions + facial palsy

Answer 92

Intratemporal lesions Otitis media Cholesteatoma Ramsay Hunt Infratemporal lesions - parotid tumours - trauma

Question 93

Systemic facial nerve palsy

Answer 93

Peripheral neuropathy  Demyelinating: GBS  Axonal: DM, Lyme, HIV, Sarcoid Pseudopalsy: MG, botulism