Ear, Nose & Throat Flashcards
(39 cards)
Define Bell’s palsy
Idiopathic lower motor neurone facial nerve palsy
Explain the aetiology/risk factors of Bell’s palsy
- IDIOPATHIC
- 60% are preceded by an upper respiratory tract infection
- This suggests that it has a viral or post-viral aetiology
Summarise the epidemiology of Bell’s palsy
Most cases: 20-50 yrs
Recognise the presenting symptoms of Bell’s palsy
• Prodrome of pre-auricular pain (in some cases)
• This is followed by unilateral facial weakness and droop
• Maximum severity: 1-2 days
• 50% experience facial, neck or ear pain or numbness
• Hyperacuisis
o This is due to stapedius paralysis
• Loss of taste (uncommon)
• Tearing or drying of exposed eye
o Because it may be difficult to close the eye fully
Recognise the signs of Bell’s palsy on physical examination
• Lower motor neurone weakness of facial muscles
o Affects ipsilateral muscles of facial expression
o Does NOT spare the muscles of the upper part of the face (unlike upper motor neurone facial nerve palsy)
• Bell’s Phenomenon
o Eyeball rolls up but the eye remains open when trying to close their eyes
• Despite reporting unilateral facial numbness, clinical testing of sensation is normal
• Examine the ears to check for other causes of facial nerve palsy (e.g. otitis media, herpes zoster infection)
Identify appropriate investigations for Bell’s palsy
- Usually unnecessary (except for excluding other causes)
* EMG - may show local axonal conduction block
Generate a management plan for Bell’s palsy
• Protection of cornea with protective glasses/patches or artificial tears
• High-dose corticosteroids is useful within 72 hrs
o Only given if Ramsey-Hunt Syndrome is excluded
• Surgery - lateral tarsorrhaphy (suturing the lateral parts of the eyelids together)
o Performed if imminent or established corneal damage
Identify possible complications of Bell’s palsy
• Corneal ulcers
• Eye infection
• Aberrant reinnervation
o E.g. Blinking may cause contraction of the angle of the mouth due to aberrant sympathetic innervation of orbicularis oculi and oris
o Crocodile Tears Syndrome - parasympathetic fibres may aberrantly reinnervate the lacrimal glands causing tearing whilst salivating
Summarise the prognosis for patients with Bell’s palsy
85-90% recover function within 2-12 weeks with or without treatment
Define BPPV
Vertigo lasting seconds to minutes on changing head position (e.g. sitting to lying down or turning the head suddenly)
Explain the aetiology/risk factors for BPPV
Displacement of otoliths (from degeneration, trauma or post-viral) into the semi-circular canals
Recognise the presenting symptoms of BPPV
- Dizziness
- Vertigo
- Loss of balance or unsteadiness
- Nausea/vomiting
Recognise the signs of BPPV on physical examination
No signs
Identify appropriate investigations for BPPV
Hallpike test
Define infectious mononucleosis
• Clinical syndrome caused by primary EBV infection
o AKA glandular fever
Explain the aetiology/risk factors of infectious mononucleosis
- EBV is a gamma-Herpes virus (dsDNA)
- It is found in the pharyngeal secretions of infected individuals and is transmitted by close contact (e.g. kissing, sharing eating utensils)
- EBV infection of the epithelial cells of the oropharynx leads to B cell infection
- The infected B cells disseminate EBV across the body leading to a humoral and cellular immune response
- Atypical lymphocytes in the peripheral blood are a classic feature of infectious mononucleosis
- EBV remains latent in lymphocytes
- Reactivation may occur following stress or immunosuppression
Summarise the epidemiology of infectious mononucleosis
• COMMON
• TWO age peaks:
o 1-6 yrs
o 14-20 yrs
Recognise the presenting symptoms of infectious mononucleosis
• Incubation period: 4-8 weeks • Abrupt onset of symptoms: o Sore throat o Fever o Fatigue o Headache o Malaise o Anorexia o Sweating o Abdominal pain
Recognise the signs of infectious mononucleosis on physical examination
- PYREXIA
- Oedema and erythema of the pharynx
- White/creamy exudate on the tonsils
- Palatal petechiae
- Cervical/generalised lymphadenopathy
- Splenomegaly
- Hepatomegaly
- Jaundice (5-10%)
- Widespread maculopapular rash (in patients who have received ampicillin)
Identify appropriate investigations for infectious mononucleosis
• Bloods
o FBC - leucocytosis
o LFTs - high AST/ALT
• Blood Film - lymphocytosis with atypical lymphocytes
• Heterophil Antibody Test (aka Monospot Test, Paul Bunnell Test)
o Based on EBV antigens being similar to antigens on RBCs of many animals but NOT humans
o Mixing blood of an EBV-positive human with animal blood will make the animal’s red cells aggregate and precipitate out of solution
o May give false-negatives in the early stages of infection before antibodies are generated
• Throat swabs - exclude streptococcal tonsillitis
• IgM or IgG to EBV viral capsid antigen
• IgG against Epstein-Barr nuclear antigen (EBNA)
Generate a management plan for infectious mononucleosis
- Bed rest
- Paracetamol and NSAIDs - helps with fever, malaise
- Corticosteroids in SEVERE cases
- IMPORTANT: do NOT give AMPICILLIN or AMOXICILLIN if infectious mononucleosis is suspected - nearly 100% of patients with glandular fever develop a maculopapular rash
- Advice - avoid contact sports for 2 weeks (because of risk of rupturing your spleen)
Identify possible complications of infectious mononucleosis
- Lethargy for several months
- Respiratory - airway obstruction from oedematous pharynx, secondary bacterial throat infection, pneumonitis
- Haematological - haemolytic or aplastic anaemia, thrombocytopenia
- GI/Renal - splenic rupture, fulminant hepatitis, pancreatitis, mesenteric adenitis, renal failure
- CNS - Guillain-Barre syndrome, encephalitis, viral meningitis
- EBV-associated malignancy - Burkitt’s lymphoma (in sub-Saharan Africa), nasopharyngeal cancer, Hodgkin’s lymphoma
Summarise the prognosis for patients with infectious mononucleosis
- Most make uncomplicated recovery (within 3 weeks)
* Immunodeficiency and death are VERY RARE
Define Meniere’s disease
Recurrent episodes of tinnitus, paroxysmal vertigo and unilateral fluctuating hearing loss
