ENT Flashcards
What is Bell’s palsy?
An acute unilateral peripheral facial nerve palsy, consisting of deficits affecting all facial zones equally that fully evolve within 72 hours
What is the aetiology of Bell’s palsy?
Viral aetiology which is strongly associated with the herpes simplex virus (type 1)
What are the risk factors for Bell’s palsy?
Pregnancy (x3)
Diabetes (x5)
Intranasal influenza vaccination (no longer in clinical use)
What is the epidemiology of Bell’s palsy?
Bell’s palsy is the most common aetiology of unilateral facial palsy among those 2 years of age or older
Affects 15–40/100 000/yr
It is most prevalent in people between 15 and 45 years of age and equal in men and women
What are the presenting symptoms of Bell’s palsy?
Complete unilateral facial weakness
Quick onset (e.g. overnight or after a nap)
Ipsilateral numbness or pain around the ear
Reduced taste - anterior 2/3rds (ageusia)
Hyperacusis- hypersensitivity (from stapedius palsy)
Unilateral sagging of the mouth
Drooling of saliva
Food trapped between gum and cheek
Speech difficulty
Failure of eye closure may cause a watery or dry eye
What are the signs of Bell’s palsy on physical examination?
Unable to complete or resist on facial nerve actions
Unable to wrinkle their forehead (no forehead sparing which occurs in UMN lesions e.g. stroke) confirming LMN pathology
What are the appropriate investigations for Bell’s palsy?
1st Line:
-Clinical diagnosis: acute, unilateral facial palsy, with an otherwise normal physical examination
Rule out other causes:
-Blood: ESR; glucose; raised Borrelia antibodies in Lyme disease, raised VZV antibodies in Ramsay Hunt syndrome
- CT/MRI: Space-occupying lesions; stroke; MS
-CSF: (Rarely done) for infections.
What differentiates Lyme disease, Guillain–Barré, sarcoid, and trauma from Bell’s palsy?
They all often present with bilateral weakness
What is the management for Bell’s palsy?
Drugs:
-If given within 72h of onset, prednisolone speeds recovery, with 95% making a full recovery.
-Antivirals (eg aciclovir) can be used in the cases associated with HSV-1
Protect the eye:
-Dark glasses and artificial tears (eg hypromellose) if evidence of drying
-Encourage regular eyelid closure by pulling down the lid by hand
-Use tape to close the eyes at night
Surgery: Consider if eye closure remains a long-term problem (lagophthalmos) or ectropion is severe (eyelid turns outward)
What are the possible complications of Bell’s palsy?
Keratoconjunctivitis sicca: dry eye
Ectropion: sagging eyelid
Synkinesis: increased neural irritability and aberrant regeneration of motor axons e.g. eye blinking causes synchronous upturning of the mouth
Gustatory hyperlacrimation: (crocodile tears) misconnection of parasympathetic fibres can produce crocodile tears (gusto–lacrimal reflex) when eating stimulates unilateral lacrimation, not salivation
What is the prognosis for patient’s with Bell’s palsy?
Incomplete paralysis: without axonal degeneration usually recovers completely within a few weeks.
Complete paralysis: ~80% make a full spontaneous recovery, but ~15% have axonal degeneration in which case recovery is delayed
- Some evidence suggests pregnancy-associated Bell’s palsy is associated with worse long-term outcomes
What is benign paroxysmal positional vertigo (BPPV)?
A peripheral vestibular disorder that presents as sudden, short-lived episodes of vertigo elicited by specific head movements e.g. sitting to lying down
(one of the most common causes of vertigo)
What is the aetiology of BPPV?
Approximately 50% to 70% of BPPV occurs without a known cause and is referred to as primary (or idiopathic) BPPV.
Secondary BPPV is associated with a range of underlying conditions (migraines, head trauma, labyrinthitis, Ménière’s disease)
What is the epidemiology of BPPV?
Primary BPPV is more common between 50 and 70 years, but can occur at any age.
Migraine and head trauma are more common in younger patients with secondary BPPV compared with older patients with secondary disease.
What are the presenting symptoms of BPPV?
Specific provoking positions causing dizziness Episodic dizziness Sudden onset of dizziness Nausea Light headedness
What are the signs of BPPV on physical examination?
Normal neurological examination
Absence of associated neurological/ otological symptoms e.g. hearing loss, tinnitus (makes alternative diagnoses more likely)
What are the appropriate investigations for BPPV?
Dix- Hallpike test: If the test is positive the patient will complain of vertigo and you should be able to directly observe nystagmus
What are the different types of nystagmus that you could observe in the Dix-Hallpike test and what does it indicate?
Rotary nystagmus is the most common type and suggests the involvement of the superior semicircular canal
Horizontal nystagmus suggests the involvement of the lateral semicircular canal
What is the Epley manoeuvre?
It is used to treat BPPV (usually of the posterior canal) once it has been diagnosed using the Dix-Hallpike test
What is infectious mononucleosis?
A clinical syndrome most commonly caused by Epstein Barr virus (EBV) infection, also known as glandular fever
What is the aetiology of infectious mononucleosis?
Epstein Barr virus (EBV), also known as human herpes virus 4, is the aetiological agent in approximately 80% to 90% of cases
Other causes: Herpes virus 6, cytomegalovirus and HSV-1
What are the risk factors for infectious mononucleosis?
Close contact e.g. kissing, sharing eating utensils, sexual behaviour
What is the epidemiology of infectious mononucleosis?
Common (UK annual incidence 1 in 1000)
Has two peaks:
1. 1–6 years (usually asymptomatic)
2. 14–20 years
What are the presenting symptoms of infectious mononucleosis?
Incubation period: 4–8 weeks
May have abrupt onset: sore throat, fever, fatigue, headache, malaise, anorexia, sweating, abdominal pain
