ENT Flashcards
(137 cards)
1
Q
What options do you have for analgesia in a child with otitis media where antibiotics are not indicated?
A
Paracetamol/ ibuprofen for ALL
Analgeisic ear drops for a few who are struggling - OTIGO (Phenzone is NSAID and lidocaine)
- Drops reduce ABx use and give good pain relief
2
Q
How do you describe the natural history of otitis media?
A
Most better in 3 days
Very few persist past 7 days
3
Q
What features make a child higher risk in otitis media?
A
Bilateral infection <2
Child with otorrhoea
Anyone else low risk
4
Q
When could you not use otigo ear drops?
A
TM perforation
Otorrhoea
Immediate ABx precription
5
Q
What is first line ABx for otitis media?
A
1st: Amoxicillin for 5-7 days
2nd: Clarithomycin for 5-7 days
6
Q
If a child has 2-3 days of ABX for otitis media and is getting worse, what is the next approrpiate ABx management step?
A
Co-amoxiclav
7
Q
How do you distinguish between otitis media and otitis externa? Name 3 features for each.
A
Both: Pain, discharge, reduced hearing
Otitis externa: Hurts to touch ear or tragus, discharge/ pain similar time
+ Itch
+ More common in adults
swimming/ ear plugs/ hearing aids/ eczema. instrumentation
Otitis media: Pain comes first, discharge a few days later
+ Preceeding UTRI
+ More common children
8
Q
How do you manage treatment failure in otitis externa?
A
Swab
- Consider fungal infection and treat for this also
9
Q
Name 3 signs of malignant otitis externa?
A
Infection spreads (can cause osteomyelitis of temporal bone)
- Unremitting disproportionate ear pain, headache, purulent otorrhoea, fever, or malaise.
Vertigo.
Profound conductive hearing loss.
- Fever + systemically unwell, facial nervy palsy, granulation tissue/ bone visible in TM
ENT emergency - same day referral
10
Q
In addition to malignant otitis externa name 3 indications for referral to ENT in otitis externa?
A
Complete canal stenosis - wick needed
Complete occlusion with debris
Cholesteatoma with attic perforation
(May not need to be seen same day)
Maligant otitis externa - seen same day
11
Q
What are the NICE criteria for a diagnosis of otitis externa?
A
1 symptom (Pain, pain on tragus or pinna, jaw pain, ear discharge, itch or hearing loss)
2 signs (Tenderness tragus or pinna, red and oedmatous ear canal, debris and discharge, TM erythem, tender lymphadenitis, conductive hearing loss)
12
Q
What is the definition of sudden sensorineural hearing loss and how should it be managed?
A
Develops in under 3 days, no other cause found
< 30 days ago - Same day ENT review
> 30 days - ENT 2ww referral
13
Q
Which way does webes test localise in conductive/ sensorineural hearing loss?
A
Webers test lateralises to:
- Same side as a conductive loss
- Opposite side to a sensorineural loss
14
Q
What is the role of steroids in sudden sensorineural hearing loss?
A
Helpful if within 48 hours onset
Unlikely to be beneficial after 14 days
15
Q
What % of sore throats improve within 7 days (viral and bacterial)
A
85%
(1% complication rate, ABx don’t change this)
16
Q
What is the optimal scoring system to use for sore throat?
A
FeverPain - Better, gives lower ABx prescription rates
17
Q
What are the red flags in tonsilitis?
A
Unilateral symptoms
Smoking
Tonsilitis is rare in over 45’s
(Possible oropharangeal cancer, linked with HPV infection)
18
Q
How may quinsy (peritonsilar abscess) present? Name 5 possible symptoms and 2 signs
A
Often complication tonsilitis
Sore throat, fever, offensive breath, voice changes, difficulty opening mouth (trismus), drooling, neck pain, earache
Signs: Uvula deviation, unilateral swelling (often can’t see pus)
19
Q
How should quinsy (peritonsilar abcess) be managed?
A
Same day ENT review (often IVABx, needle aspiration)
20
Q
What is geographic tongue - how should patients be advised to manage?
A
Loss of hair/ papillae from tongue
Leads to red patches of different sizes
Self resolves in days-weeks up to years. Not an infection
21
Q
Name 3 differentials for loss of smell/ taste?
A
Viral URTI
Head trauma
Chronic sinus inflammation
Nasal polys
Radiotherapy/ chemical/ drug exposure
Alzeihmers
22
Q
What is the definition of otitis media with effusion?
A
Otitis media with effusion (OME), also known as ‘glue ear’, is characterized by a collection of fluid within the middle ear space without signs of acute inflammation.
23
Q
What age is OME most common and how does it usually present?
A
6mths-4yrs
Presents with hearing loss, mild intermittent pain with fullness or popping
Over 50% may follow episode of otitis media
24
Q
Name 3 otoscopy findings in OME?
A
Can be normal
OR
- Abnormal (yellow/ amber or blue) color to drum
- Loss of light reflex
- Air bubbles/ fluid level
- Retracted, concave or (less often) bulging drum
25
Name 3 risk factors for OME
Cleft palpate, downs syndrome, cystic fibrosis, allergic rhinitis
Parental smoking, pollution
Allergies, reflux disease
Frequent URTI's/ otitis media
26
Name 3 indications to refer OME to ENT?
Child has down's/ cleft palate
Hearing loss is severe/ affecting QoL
TM structually abnormal
Persistent foul smelling discharge suggestive of cholesteatoma (should be 2ww referral)
27
What is the definition of a cholesteatoma?
An abnormal sac of keratinizing squamous epithelium and accumulation of keratin within the middle ear or mastoid air cell spaces which can become infected and also erode neighbouring structures
28
How does cholesteatoma typically present?
Persistent or recurrent discharge from the ear that is often foul smelling. An associated conductive hearing loss may also occur.
Later > Vertigo, sensorineural loss, facial nerve palsy
(NB: In a practice with 10,000 patients may only see 1 per year - rare)
29
Name indications for emergency and 2ww referrals for cholesteatoma?
Emergency:
- Facial nerve palsy or vertigo
- Other neurological signs consistent with intercranial abscess or meningitis
2ww:
- All other cholesteatoma's
30
Name 3 possible presenting symptoms of mastoiditis?
What is the main risk factor?
Fever/ systemically unwell
Marked hearing loss
Mastoid tenderness or swelling
Headache
Discharge from ear
Main RF: Otitis media or externa (peak incidence 6-13months)
31
How should suspected mastoiditis be managed?
Same day admission
32
What are the main risk factors for perforation of the ear drum?
Infection
Injury to ear (i.e. physical trauma)
Barotrauma (pressure)
Sudden loud noise (from shock/ pressure waves)
Foreign objects
33
What should patients be advised regarding management of perforated ear drum?
Usually self resolves in 6-8weeks
Avoid getting wet (cotton wool ball covered in vaseline into outer ear whilst showering)
(if not healed at 2 months may need to consider surgical referral). Note ABx may be needed but avoid ototoxic ear drops.
34
A patient presents with subjective tinnitus - what is your differential diagnosis? (Name at least 5)
Unilateral wIth SN hearing loss:
- Meniere's (Episodic 15min-24hrs), may have fullness in ear
- Acoustic neuroma (vestibular schwannoma). May also have vertigo
Bilateral with SN hearing loss:
- Drug induced
- Noise induced
- Age related
- Secondary to MS/ diabetes/ thyroid disease
With conductive hearing loss:
- Middle/ outer ear problem (otitis media, cholestetoma, wax)
- Otosclerosis (Fhx
35
Name 3 drugs which can cause tinnitus?
Aspirin
NSAIDS
Loop diuretics
Cytotoxic drugs
ABx (Gentamycin)
36
Name 3 indications for immediate referral (within a few hours) in tinnitus?
If tinnitus +:
- Sudden onset neurology (i.e. facial weakness)
- Acute uncontrolled vergio
- Suspect stroke
- Sudden onsent pulsatile tinnitus
- Tinnitus secondary to head trauma
37
Name 1 indication for very urgent referral (within 24 hours) in tinnitus?
Anyone with tinnitus and hearing loss that has developed suddenly (<3 days) within the last 30 days
38
Name 3 indications for urgent referral (2ww) in tinnitus?
Distress affecting mental wellbeing
Hearing loss that developed suddenly (<3days) more than 30 days ago
Hearing loss rapidly worsening (over 4-90 days)
Persistent otalgia or otorrhoea that does not resolve with tx
38
How should tinnitus be managed in primary care (assuming referral not indicated)
Reassure (common, can resolve by self)
Treat underlying cause (i,e. wax etc)
Review medications - stop ototoxic
Discuss sound therapy (continuous low level background sound)
Consider stepped approach to pyschological therapies
Treat depression, anxiety or insomnia
Offer hearing aids if affects ability to communicate
38
Name 3 risk factors for cleft palate?
Drugs: Isotretanoin, valproate, benzo's and steroids
Materal smoking and alcohol
Genetic (parental or sibling) increases risk
Chromosomal abnormalities
38
How is cleft palate usually managed?
Primary lip closure at 3 months post birth
Palate closure 6-12 months
Further corrective surgery until growing complete at 18
39
What is the most common congenital abnormality in the neck and how does it present?
How are they managed?
Thyroglossal duct cyst
Fluctuant swelling in midline of neck, non tender, mobile
- Cyst moves up when patient protrudes tongue
Mx: USS, then CT and surgical removal
40
Your patient has cervical lymphadenopathy you think is related to infection. What do you advise?
Should settle within 4 weeks - if not resolved in 4 weeks to come back
41
Name 3 possible indications for 2ww if you find unexplained cervical lymphadenopathy?
Infection
Leukaemia (all have FBC within 48hrs)
Lymphoma (2ww if over 25yrs, 48 hour review if under 25yrs)
Lung cancer
Oral cancer (think if ulceration)
Laryngeal cancer (hoarseness)
42
How do you manage an unexplained persistent cervical lymphadenopathy?
If over 25yrs - 2ww
If under 25yrs - Review within 48 hours
43
What are the NICE 2ww criteria for laryngeal cancers?
People over 45 with:
- Persistent unexplained hoarseness
- Unexplained neck lump
44
What are the NICE 2ww criteria for oral cancers? (3)
Unexplained oral ulceration lasting over 3 weeks
Peristent and unexplained neck lump
By a dentist:
- Lump in lip or oral cavity
- Erythroplakia, erythroleukoplakia or leukoplakia
45
What is Ramsey Hunt Syndrome?
Chickenpox (Varicella zoster) becames reactivated in 7th (facial) nerve
Symptoms: Facial paralysis, loss of taste, vestibulocochlear dyfunction (vertigo/ tinnitus) and pain deep within the ear
Rash/ blisters - Skin, ear canal, auricle or both
46
What distinguishes shingles and Ramsey Hunt syndrome?
Shingles is a disease of sensory nerves but Ramsay Hunt syndrome is distinctive in that there is a motor component (facial nerve palsy)
47
What is the distinguishing features between Ramsey Hunt and Bells palsy?
Bells - no pain or rash
RH- Painful and rash
48
How is Ramsey Hunt syndrome managed?
HIV test etc to look for immunocompromise
Prompt anti-viral (acivlovir) and steroid (prednisolone) treatment within 72 hours
49
How does Bell's palsy typically present?
Rapid (<72hr) onset of unilateral facial nerve weakness/ paralysis
Possible difficulty chewing/ dry mouth/ dry eye/ hyperacusisis
Most common 15-45yrs
50
How should Bell's palsy be managed?
If presenting within 72 hours - prednisolone 50mg daily for 10 days or 60mg daily for 5 days then reduce down 10mg daily for 5 days
Thought to be caused by HSV so occasional antivirals should be used but only if specialist advice
51
How do you distinguish between stroke and bells palsy?
Stroke - Forehead spared
Bells - Forehead affected
52
How does trigemial neuralgia classically present?
Pain in distribution trigeminal nerve (usually cheek or lower jaw)
- Shooting, unilateral, short (seconds to 2mins), recurrent, episodic
Provoked by touch, eating, talking, cold air etc
53
Name 3 possible red flags that would suggest serious cause of pain in trigeminal nerve distribution other than TN?
Sensory changes
Deafness/ ear problems
Skin or oral lesions
Pain in opthalmic divison only (Herpes)
Optic neuritis (MS)
FHx of MS
Age onset before age 40
54
What is the treatment for trigeminal neuralgia?
1st: Carbamazepine (only one licenced). Start 100mg BD and titrate every 2 weeks (max 1600mg daily)
Reduce dose back down until pain in remission
DO NOT offer any other treatments unless advised by a specialist, any other treatments should be under shared care
55
Name 4 common side effects of carbemazepine - when do they tend to occur?
N+V
Sedation
Dizziness
Ataxia
Skin reactions common (at worst can be SJS)
Leucopenia
Usually dose related, most common at the start of treatment
56
What ethnicity should be screened before taking carbamazepine?
People who are of Han Chinese, Hong Kong Chinese, or Thai origin should be screened for the presence of the HLA-B*1502 allele before taking carbamazepine.
Should also be considered in people originating from Malaysia and the Philippines.
57
What is the indication for cochlear implants or bone conduction hearing implants?
Sensorineural hearing loss which has become too severe for hearing aids
58
What is the indication for fitting of hearing aids?
How can you advise patients to facilitate good hearing?
Sensorineural hearing loss with no underlying cause
1) Reduce competing and background noise
2) Improve environment acoustics (i.e. more soft furnishing)
59
What is the differential diagnosis of conductive hearing loss? (5)
Impacted wax
Foreign bodies
TM perforation
Infection (OM, OE)
Cholesteatoma
Middle ear effusion (OME)
Otoscloerosis
Neoplasm
60
What is the differential diagnosis of sensorineural hearing loss?
Age related (presbycusis)
Noise exposure
SSHL (sudden sensorineural hearing loss - idopathic, over 30dB HL)
Meniere's disease
Ototoxic substances
Labyrinthitis
Vestibular schwanomma (acoustic neuroma)
Malignancy. trauma, MS/ Stroke
61
What are the management options for globus oharyngeus?
No agreed standards
- Trial PPI if possible reflux
- Referral to SALT can be helpful
CBT/ antidepressants if concomitant pyschiatric issues
62
What is burning mouth syndrome?
Burning, mainly on tongue or lips, often worse later in the day
Mouth appears normal
Generally pyschological stress related
63
What is first aid management advice for epistaxis?
Sit with upper body tilted forward
Pinch soft part of nose and hold firmly for 10-15 mins
For 24hrs avoid nose blowing, heavy lifting, picking nose, alcohol or hot drinks
64
Name three factors that suggest epistaxis from posterior aspect of nose?
Profuse bleeding
From both nostils
Bleed site can't be identified
> Admit to hospital
65
What is the recommended management of recurrent epistaxis including referral criteria?
Check for referral criteria (angiofibroma in young men, cancer in over 50's, telangiectasia, anyone under 2)
1) Naseptin QDS for 10 days (chlorhexadine and neomycin)
- Not if allergic to penut or soya (give mupirocin)
2) Refer for nasal cautery only if bleeding point identified can be done in primary care
66
When should a nasal bone fracture be reduced if significant deviation?
Within 3 hours (before swelling)
If not possible 7-10 days post surgery (give time for swelling to go down)
67
Define Allergic rhinitis? - IgE or non IgE mediated?
IgE mediated inflammatory disorder of the nose
68
Name 4 classical allergic rhinitis symptoms?
Sneezing
Nasal itching
Rhinoorhoea
Congestion
69
How can allergic rhinitis be classified?
Seasonal — symptoms occur at the same time each year (hay fever)
Perennial - symptoms occur throughout the year, (house dust mites and animal dander)
Intermittent — symptoms occur for less than four days a week, or less than four consecutive weeks.
Persistent — symptoms occur for more than four days a week and for more than four consecutive weeks.
Occupational — due to allergens in the work environment
70
What is first line treatment for allergic rhinitis in children and adults?
Intranasal corticosteroid (fluticasone) <
OR
Intranasal antihistamine (azelastine)
OR
Intranasal steroid + oral antihistamine
OR
Both inhaler in combination (most effective)
71
How long do intranasal antihistamines/ intranasal steroids take to work?
INAH - Works within minutes but less effective
INS - Works within 6-8 hours but up to 2 weeks for full effect
72
Allergic rhinitis - how to manage if symptoms despite regular intranasal corticosteroid?
If nasal congestion - Intranasal decongestant (xylometazoline) for 6-7 days
If watery rhinorrhoea - intranasal anticholinergic (ipratropium)
If nasal itching/ sneezing - Add oral antihistamine (either alone or with intra nasal depending)
Asthma hx - Consider LTA (montelukast)
73
What is the role of oral corticosteroid in the management of allergic rhinitis?
If an adult has severe, uncontrolled symptoms that are significantly affecting quality of life, consider prescribing a short course of oral corticosteroids to provide rapid symptom relief, such as:
Adults — prednisolone 0.5 mg/kg in the morning for 5–10 days.
74
Name 3 red flag features in allergic rhinitis?
Unilateral symptoms
Blood stained nasal discharge
Recurrent epistaxis
Nasal pain
(All 2ww)
75
What is first line management for post nasal drip (Upper airway cough syndrome)?
Oral antihistamine and decongestant (pseudoephedrine)
- Resolution usually in 2 weeks but up to several months
76
Name three symptoms that may suggest a diagnosis of post nasal drip (Upper airway cough syndrome)?
Frequent throat clearing
Unpleasant sensation in throat
Nasal congestion/ nasal discharge/ sneezing
77
What is management for nasal polyps?
Long term topical nasal steroid
78
Name 5 risk factors for oral candidiasis?
Diabetes
Immuocompromise (chem, HIV etc)
Smoking
Use of broad spectrum ABx
Inhaler corticosteroids
Poor hygeine/ malnutrition
Severe anaemia
79
How should oral candidiasis be managed 1st line? What ages may this change ?
Miconazole oral gel first line for age 4 months and over
If unsuitable nystatin
Both- 7-14 days (7 days after cleared)
(unlicenced if used under age of 4 months for both)
80
If topical candidasis treatment is ineffective/ extensive or severe/ px significantly immunocompromised how should oral thrush be treated?
If >16 yrs - Oral fluconazole for at least 14 days
81
What is gingivitis and how may it present?
How does it differ from peridontitis?
Inflammation of gums - presents as reddening and swelling or gums, bleeding from brushing, flossing or gentle probing
Peridontitis - chronic inflammation of the above, largely irreversible tissue damage
82
What is ANUG?
Acute necrotizing ulcerative gingivitis (ANUG) is an acute, atypical, progressive, and painful bacterial infection of the gums with ulceration and necrosis of the dental papillae and bleeding.
- Urgent dental assessment and management
83
What is oral herpes - which two areas are commonly affected?
What strain of herpes causes syx?
Herpes labialis - cold sores
Oral (gingivostomatitis) is of oral mucosa
90% are HSV 1
84
How should oral or lip herpes be managed?
Self limiting (10-14days if labialis, 2-3 weeks if oral mucosa)
Oral antiviral if persistent, recurrent, severe or immunocompromised
85
How does oral herpes simplex present?
(may have prodrome of fever, sore throat, lymphadenopathy)
Initial symptoms of pain, burning, tingling, and itching may precede visible lesions and typically last 6–48 hours
86
In sialolithiasis what gland is most commonly affected?
Submandibular
87
How does sialolithiasis usually present?
Swelling and tenderness worsens when the person is eating due to an increase in saliva production.
Symptoms may last for a few minutes or hours before settling.
If symptoms last for a few days, suspect secondary infection
88
How may sialadenitis present?
Acute sialadenitis most commonly affects the parotid gland and is more likely in older people with dehydration or following recent dental procedures.
Rapid onset pain, swelling, erythema, odema and tenderneness
89
How does mumps classically present?
Bilateral parotid swelling, which may be tender, with possible associated otalgia and trismus
(Viral illness so other viral symptoms)
90
What is the most common cause of salivary gland infection?
Mumps
(A notifiable disease)
91
What is sjorgrens syndrome an association of?
Keratoconjunctivitis sicca (Dry eyes) and/or xerostomia (Dry mouth)
- With
rheumatoid arthritis or other connective tissue disorder
92
What is a pleomorphic adenoma and how does it present?
Benign salivary gland tumour
- Most commonly affects parotid gland
- Slow growing and generally asymptomatic
93
Name 5 possible differential diagnosis for hoarseness
Laryngeal cancer (any unexplained persistent hoarseness)
Acute laryngitis/ chronic laryngitis
Voice overuse (common)
Benign vocal cord lesions (nodules)
Laryngeal nerve palsy (lung ca, thoracic AA)
MND
Thyroid ca/ lymphoma
94
When is laryngitis classed as chronic?
If persisting beyond 3 weeks
95
How may laryngitis present?
Hoarseness
Pain in anterior neck
Possible: URTI syx, dysphagia, globus, throat clearing, fever etc
96
How is acute laryngitis treated?
Most viral, mild and slef limiting
Rest avoid, humidification can be helpful
ABx only if persistent fever (>48hrs), or immunocompromised
97
Name 3 possible causes of chronic (>3 weeks laryngitis)
GORD
Cancer
Allergy
Trauma
Autoimmune
98
How is sinusitis defined?
Inflammation of mucosal lining of paranasal sinus' and nasal cavity (rhinosinusiti)
Acute viral - Syx <10 dyas
Acute post viral - Worsen after 5 days, last more than 10 but under 12 weeks
Chronic - Syx over 12 weeks
(Acute bacterial is a secondary infection that develops in approx 1%)
99
Name three features that would raise suspicion of bacterial cause sinusitis?
Syx over 10 days
Discoloured/ purulent nasal discharge
Severe local pain
Fever over 38
Dehydration
Diagnose bacterial if at least three are present
100
Name three features that would raise suspicion of allergic cause sinusitis?
Itchy/ watery eyes
Itchy nose
Other atopic features
101
What are the diagnostic criteria for chronic sinusitis?
At least two symptoms:
- Nasal blockage, obstruction, congestion, discharge, post nasal drip
- Facial pain or headaches
- Reduction in loss of smell
1x objective evidence:
- Mucus/ oedema/ polyps on examination
- Radiographic evidence inflammation
102
A patient presents to you saying they have sinusitis - what features would cause suspicion of neoplasm instead?
Persistent unilateral symptoms, such as nasal obstruction, nasal discharge or nosebleeds, crusting, or facial swelling
- 2ww
103
In acute sinusitis, name 3 indications for (non-2ww) referral?
- Immunocompromised
- Anatomical defect
- Polyps or asthma complicating management
- No improvement after 10 days of antibiotic treatment
104
What is first line treatment for sinusitis lasting <10 days?
Paracetamol/ ibuprofen
Nasal saline or decognestant can help but no evidence
105
What is first line treatment for sinusitis lasting >10 days?
Supportive as per <10 days
PLUS
High dose nasal steroid for 14 days (mometasone 200mcg BD) - off label
+/- Back up ABx prescription (advise to take if not improved in further 7 days)
106
What antibiotic is used for sinusitis when indicated?
PenV 500mg QDS for 5 days
If high risk, very unwell etc co-amox 500/125 TDS for 5 days
107
What antibiotic is used for sinusitis when indicated if penacillin allergy?
Doxycycline 200mg then 100mg daily (5 days)
Clarithromycin 500mg BD for 5 days
108
You prescribed PenV for a sinusitis which has now gone on for 16 days. The patient has been taking the ABx for 3/7 and says symptoms are getting worse - how do you manage?
If symptoms are worsening after the first-line antibiotic has been taken for at least 2–3 days:
Prescribe co-amoxiclav 500/125 mg three times daily for 5 days.
109
What are the indications for referral in chronic sinusitis?
- Cacosmia (abhorrent, obnoxious smell inhaling - likely fungal infection)
- Syx persist despite 3 months tx
+ all those for acute sinusitis
110
What does a HINTS exam consist of an what would findings imply in each area?
1) Head impulse: +ve (saccades as eyes flick back to nose) suggests peripheral cause (likely labyrinthitis/ neuronitis). Normal in central causes
2) Nystagmus: None/ unidirectional can be peripheral vertigo. Bidirectional or vertical nystagmus is very specific for central cause (think stroke)
3) Test of skew (alternatively cover eyes whilst look at your nose): Normal in peripheral causes of vertigo. If any vertical skew suggestive of central cause.
111
A patient presents with vertigo, name some key features of the following that would make you consider them?
a) BPPV
b) Vestibular neuronitis
c) Labrynthitis
d) Menieres
a) Lasts seconds - mins, initiated (not just worse with) head movement
b) Sudden, severe onset, lasts days with gradual improvement, NO hearing loss/ tinnitus/ fullness - head impulse +ve
c) Sudden, severe onset, lasts days with gradual improvement, MAY have hearing loss/ tinnuts but NO fullness - head impulse +ve
d) Episodes 30mins-hours, likely fluctuating hearing loss, tinnitus AND FULLNESS
112
A patient presents with new vertigo - what features would suggest need for an urgent same day referral to hospital?
Concern about new acute central cause (I.e. stroke)
- Sudden onset (seconds), not precipitated by head movement
- Any neurology, cranial nerve abnormalities, cerebellar signs
- Vertical nystagmus, vertical skew
- Sudden onset deafness (without other menieres signs)
V.severe N+V unable to keep fluids down and needing rehydration
113
A patient presents with new sudden onset true vertigo, there is no hearing loss, tinnitus or feeling of fullness in the ear and no neurology. Head impulse test is positive, there is no nystagmus and test of skew is negative.
How do you manage?
Likely vestibular neuronitis
1) Advise likely settle in first few days a little, can take up to 6 weeks to resolve, may need bed rest in this time
2) If need rapid antiemetic - buccal prochlorperazine, if not vomiting (oral prochlorperazine 5-10mg TDS, or cyclzine 50mg TDS or promethazine 25mg ON)
114
How would you distinguish between labyrinthitis and Meniere's disease?
Meniere's: Episodes usually 30mins to hours, roaring tinnitus, aural fullness and fluctuating hearing loss
Labyrinthitis: Episodes last several days and gradually improve rather than being as episodic as menieres. Hearing loss and tinnitus often present, but aural fullness is not.
115
How would you distinguish between labyrinthitis and vestibular neuronitis?
Both sudden onset, last days, gradually improve between 3 days and 6 weeks. Both head impulse +ve likely. Neither have aural fullness.
VN: No hearing loss or tinnitus
Labrinth: Likely both hearing loss and tinnitus
116
How would you distinguish between an acoustic neuroma and menieres/ vestibular neuronitis?
Acoustic neuroma - GRADUAL onset hearing loss - may have tinnitus and or vertigo
Others: More episodic, hearing loss if present is usually fluctuating and more sudden onsets
117
In addition to acute treatments, what preventative medications could be considered to prevent recurrent attacks of menieres disease?
Trial of betahistine 16mg TDS with food
118
What is the indication for dix-hallpike and how is it performed?
To diagnose BPPV
1) Sit up - head at 45degrees
2) Lie down onto back with head still at 45 degrees - hold 1-2 mins
3) Observe for nystagmus
119
When is the epley manouvre indicated and how is it done?
To treat BPPV
1) Lie down on bed, head at 45 degrees (to affected side)
2) Turn 90 degrees to contralateral side - hold 30s
3) Ask patient to roll onto shoulder of side currently on - head to the floor (30-60s)
4) Sit patient up whilst maintaining head rotation
120
What is the management of vestibular neuronitis or labrynthitis?
- Usually self resolves in a few days
Prochlorperazine, cyclizine or promethazine can all be used
(Stematil buccal or IM if need rapid/ severe, oral otherwise)
121
What is the management of an acute episode of menieres disease?
Prochlorperazine, cyclizine or promethazine can all be used
(Stematil buccal or IM if need rapid/ severe, oral otherwise)
Up to 7 days course
122
What is the preventative management of Menieres disease?
Betahistine 16mg TDS with food
123
Name 3 red flag features of a central cause of vertigo which require urgent brain imaging?
Isolated, persistent vertigo (>24hrs) of hyperacute (seconds) onset
Normal head impulse
New onset unilateral deafness
Any other neurology
New onset headache with vertigo
124
What is:
a) A normal audiogram result
b) The pattern of sensorineural loss
c) The pattern of conductive loss?
a) Above 20dB in all frequencies
b) No air/ bone gap
c) Conductive loss shows a gap between air (reduced) and bone (normal) conduction
125
How is OSA defined?
'Obstructive sleep apnoea/hypopnoea syndrome' (OSAHS) is a sleep-related breathing disorder characterized by recurrent episodes of complete or partial obstruction of the upper airway during sleep, causing apnoea (complete airflow obstruction with temporary absence or cessation of breathing) or hypopnoea (decreased airflow)
126
Name 3 presenting features of sleep apnoea?
Snoring
Irregular breathing at night
Daytime sleepiness/ fatigue
Unrefreshing sleep/ impaired concentration
Witnessed apnoeas
Nocturnal awakenings
127
Name 5 risk factors for OSA?
Increasing age
Male
Obesity
Neck > 40.6cm circumference
FHx OSA
Smoking/ alcohol
T2DM/ PCOS/ Stroke/ Asthma/ Arrythmia/ Heart Failure etc
128
What features would indicate urgent (<4 weeks) referral in OSA? What about non urgent referral?
- Affecting role as professional (driver, pilot, machines)
- Co-morbid condition (COPD, HF, tx resistent HTN etc)
- Pregnant
- Undering assessment for major surgery
All others routine referral
129
How is OSA investigated and managed in secondary care?
Sleep studies (Polysomonography +/- oxygen desaturation index)
Tx: CPAP, intra-oral devices, surgery
(Adenotonsillectomy may be offered to children)
130
What is the Group 1 DVLA guidance for sleep apnoea?
Suspected or confirmed mild: Must not drive if excessive sleepiness
- Can resume once syx control
- If not controlled in 3 months must notify DVLA
Confirmed mod/ severe: Must not drive and must notify DVLA (may be able to drive later on with conditions)
131
What is the Group 2 DVLA guidance for sleep apnoea?
Suspected or confirmed mild: Must not drive if excessive sleepiness
- Can resume once syx control
- If not controlled in 3 months must notify DVLA
Confirmed mod/ severe: Must not drive and must notify DVLA (may be able to drive later on with conditions)
SAME AS GROUP ONE FOR OSA
132
Name 3 presenting features of TMJ dysfunction?
Pain in TMJ/ surrounding
- Increase by jaw movements
Limitation jaw movements
Clicking/ popping/ grating/ crepitusY
133
You suspect a patient has TMJ disorder - name 5 other differentials for jaw pain?
GCA
Dental problems
Trigeminal neuralgia
Herpes zoster
Salivary gland stone/ infection
Cancer
Migraine
134
How is TMJ dysfunction managed?
When would you refer?
Paracetamol/ NSAID/ local Ice or heat
Soft diet
Manage stress
Avoid big yawning or clenching
- If very severe consider low dose benzo for maximum of 2 weeks
Refer max fax if trauma or marked limited mouth opening
