ENT Flashcards
Define BPPV
Peripheral vestibular disorder that manifests as sudden, short-lived episodes of vertigo triggered by certain head movements which is often self-limiting. It occurs due to calcium carbonate crystals from utricle entering semicircular canal and obstructing endolymph flow.
Summarise the aetiology of BPPV
OFTEN IDIOPATHIC
Occurs due to displacement of Otoliths into the semicircular canals (usually posterior) resulting in canaliths.
Primary BPPV: IDIOPATHIC (50-70%)
Secondary BBPV: Degeneration Head Trauma Migraine Post-viral infection i.e. Labyrinthitis, Vestibular neuronitis
What are the risk factors of BPPV?
Increasing age Female Head trauma Vestibular neuritis Labyrinthitis Inner Ear Surgery Meniere’s disease Hypertension Hyperlipidaemia Diabetes Giant Cell Arteritis
Summarise the epidemiology of BPPV
Peak incidence between 50 and 70 years old
More likely in females
Most common cause of peripheral vertigo
Migraine and head trauma are more common in younger patients with secondary disease compared with older patients
What are the presenting symptoms of BPPV?
Short-lived sudden vertigo triggered by specific head movement Vertigo lasts less than 1 minute Nausea Vomiting Specific and predictable changes in head position cause it Imbalance Dizziness NO HEARING LOSS OR TINNITUS
What are the signs on physical examination of BPPV?
POSTIVE Dix-Hallpike Manoeuvre provokes BPPV and Nystagmus
POSITIVE supine lateral head turn
- Patient lies supine and lifts head to 30 degrees
- Turns head slowly to right and left
- Provokes BPPV and Nystagmus
Normal neurological ontological examination
Patients ONLY experience nystagmus during the positional tests
What are the appropriate investigations for BPPV?
Clinical diagnosis
Dix-Hallpike Test - positive (causes BPPV)
Positive supine lateral head turn
Investigations to consider:
Audiogram: indicated in patients with hearing loss to diagnose cause
Brain MRI: to diagnose or exclude CNS conditions i.e. MS, Tumours
Define infectious mononucleosis
A clinical syndrome caused by Epstein Barr Virus infection
Summarise the aetiology of infetious mononucleosis
Infectious mononucleosis is often caused by Epstein Barr Virus infection or Human Herpes Virus 4
EBV is a double stranded DNA virus
It is spread via saliva or respiratory droplets - sharing food or drinks, kissing
EBV infection of the epithelial cells of the oropharynx leads to B cell infection
The infected B cells disseminate EBV across the body causing a humoral and cellular response
EBV remains latent in lymphocytes
Reactivation may occur following stress or immunosuppression
Summarise the epidemiology of infectious mononucleosis
Most common in teenagers aged 15-24 years old
Past EBV infection in 90% of adults by the age of 40
COMMON
What are the presenting symptoms of infectious mononucleosis?
Incubation period 30-50 days Abrupt onset of symtoms Fever Sore throat Enlarged lymph nodes Fatigue Headache Malaise Anorexia Sweating Abdominal pain
What are the signs on physical examination of infectious mononucleosis?
Fever
Posterior cervical lymphadenopathy
Hepatosplenomegaly
Tonsillar exudates (white/creamy)
Pharyngitis - oedema and erythema of the pharynx
Palatal petechiae
Widespread maculopapular rash (in patients who have received ampicillin or amoxicillin)
What are the appropriate investigations for infectious mononucleosis?
Clinical signs
Bloods:
FBC - lymphocytosis
Blood film - atypical lymphocytosis
Heterophil antibody monospot test - blood causes agglutination with animal (sheep or horse) RBC
If negative heterophil monospot test - EBV specific antibodies
IgM Viral Caspid Antigen - acute infection
IgG EBNA - shows latent infection
PCR - EBV DNA detection
USS abdo - splenic enlargement
What is the management of infectious mononucleosis?
Often uncomplicated recovery within 3-21 days
Paracetamol and aspirin - pain and fever relief
Rest
Avoid contact with others
Avoid contact sports for 3-4 weeks to avoid splenic rupture
If severe, can use corticosteroids
DO NOT USE AMOXICILLIN OR AMPICILLIN - causes widespread itchy maculopapular rash
What are the possible complications of infectious mononucleosis?
Long-term fatigue Antibiotic induced rash Splenic rupture B cell cancer Hodgkin and non-Hodgkin lymphoma Nasopharyngeal carcinoma Oral hairy leukoplakia if HIV positive patient
Summarise the prognosis of infectious mononucleosis?
Most make uncomplicated recovery within 3 to 21 days
Immunodeficiency and death are very rare
Define Meniere’s disease
A disorder of the inner ear due to excessive endolymph, causing recurrent episodes of vertigo, tinnitus and sensorineural hearing loss.
Summarise the aetiology of Meniere’s disease
Idiopathic however due to excessive endolymph in the semicircular canals due impaired absorption or overproduction - endolymphatic hydrops
Allergic responses (especially to food) Congenital or acquired syphilis Lyme disease Hypothyroidism Stenosis of the internal auditory canal Acoustic or physical trauma Viral infection Immune-mediated mechanisms affecting the absorption of endolymph Endolymphatic sac/duct blockage Vestibular aqueduct hypoplasia Vascular constriction
Summarise the epidemiology of Meniere’s disease
Onset usually in 40s
50% of patients have family history
Slightly more common in females
What are the presenting symptoms of Meniere’s disease?
Recurrent episodes of rotary vertigo lasting 20 mins-24 hours
Sensorineural hearing loss - initially to low frequency sounds but eventually permanent loss
Low frequency tinnitus
Feeling of ear fullness or pressure
Nausea and vomiting
May be triggered by caffeine, alcohol, high salt diet, nicotine
Drop attacks: Sudden loss of balance without loss of consciousness or other autonomic or neurological symptoms
What are the signs on physical examination of Meniere’s disease?
Positive Romberg’s test - swaying or falling when asked to stand with feet together with eyes closed
Fukuda’s stepping test - when marching on spot with eyes closed, turns towards affected side
Nystagmus seen in acute attacks
Inability to walk heel-to-toe in straight line
What are the appropriate investigations for Meniere’s disease?
Mainly a clinical diagnosis and diagnosis of exclusion
Audiometry - shows sensorineural hearing loss
Electronystagmography
Vestibular evoked myogenic potential
MRI
Lyme disease and syphilis serology - normal, excludes these as causes for hearing loss
Define tonsillitis
An acute inflammation of the parenchyma of the palatine tonsils
Summarise the aetiology of tonsillitis
Viral (most common): rhinovirus, coronavirus, adenovirus
Rarely - influenza virus, parainfluenza, enterovirus, herpes virus. EBV in tonsillitis associated with infectious mononucleosis
Bacterial: group A beta-haemolytic streptococcus (15-30% of cases in children aged 5-15)
Can distinguish between the two using FeverPAIN or CENTOR criteria
Fever Purulence Attend urgently Inflammed tonsils No cough
Can't cough Exudate Nodes Temperature OR - age <15 increases score by 1, age over 44 decreases score by 1
For both FeverPAIN and CENTOR, higher score suggests more likely due to bacterial cause
