entcheck Flashcards
(29 cards)
History questions in vertigo?
Helenka should be asked about the time course of her vertigo, onset, duration, potential triggers and associated symptoms such as aural pressure, tinnitus and hearing loss.
Potential triggers of vertigo include sudden head movement or change in position (benign paroxysmal positional vertigo [BPPV]), recent viral illness (vestibular neuritis), preceding migraine (vestibular migraine) and high-sodium meals (Ménière’s disease).11
The presence of vascular risk factors such as pre-existing cardiovascular disease, smoking history, alcohol intake and hypertension should be elicited when considering cerebrovascular causes of vertigo.
The impact of Helenka’s vertigo episodes on work, school and leisure should be explored, as this will influence the aggressiveness of the treatment approach.
Features of peripheral vertigo?
Nystagmus
Unidirectional in horizontal plane
Beats towards the normal ear
Suppressed by visual fixation
Otological Symptoms
Hearing loss
Tinnitus
Neurological signs
Unidirectional instability, walking usually preserved
Positive head impulse test
Features of central vertigo?
Nystagmus
Horizontal, vertical or torsional
Not suppressed by visual fixation
Otological symptoms
Absent
Neurological signs
Severe instability, unable to walk
Focal neurological signs may be present
What is the Fukada stepping test?
During the Fukuda stepping test (also the Unterberger test), the patient is asked to walk on the spot with their eyes closed. When there is asymmetry of labyrinthine function, the patient will often rotate towards the side of the lesion.
Positive in Menieres - localises to affected side
Clinical features of Menieres disease?
Vertigo
Lasts minutes to hours; usually nausea/vomiting; attacks tend to cluster
Hearing loss
Fluctuating, typically low-frequency sensorineural hearing loss; worsens during episodes; progressive
Tinnitus
Low-frequency roaring; unilateral
Aural fullness
Ipsilateral; worse during or before attack
Drop attacks
Elderly; late stages; uncommon
Presence of risk factors
Family history; autoimmune disease; recent viral illness
Examination
Positive Romberg test
Swaying or flailing when standing with feet together and eyes closed
Fukuda stepping test
Turning towards affected side when stepping in place with eyes closed
Nystagmus
Unidirectional; seen during acute attacks
Heel-toe
Inability to walk heel-to-toe in a straight line
DDx of peripheral vertigo
Benign paroxysmal positional vertigo
Ménière’s disease
Ramsay Hunt syndrome (Herpes zoster oticus)
Labyrinthitis
Vestibular neuritis or labyrinthitis
Acoustic neuroma
Superior semicircular canal dehiscence
Cholesteatoma
Ddx of central vertigo?
Cerebellar infarction
Cerebellar haemorrhage
Vertebrobasilar insufficiency
Vestibular migraine
Multiple sclerosis
Hereditary ataxia
Tests for MEnieres
Audiological evaluation
Complete audiological evaluation includes pure-tone air and bone conduction with appropriate use of masking, speech audiometry, tympanometry and otoacoustic emissions.
Gadolinium-enhanced magnetic resonance imaging of the head should be performed for patients presenting with significant asymmetry of sensorineural hearing to exclude retrocochlear pathology, such as acoustic neuroma or demyelinating disease.
An autoimmune screen should be considered for patients who present with bilateral disease that is unresponsive to conventional therapy. Recommended tests include anti-nuclear antibody, anti-neutrophil cytoplasmic antibody and rheumatoid factor.20,21
Diagnostic criteria for menieres
Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours
Audiometrically documented low- to medium-frequency sensorineural hearing loss in one ear, defining the affected ear on at least one occasion before, during or after one of the episodes of vertigo
Fluctuating aural symptoms (hearing, tinnitus or fullness) in the affected ear
Not better accounted for by another vestibular diagnosis
Management of Menieres
Dietary salt restriction and diuretics
limit her dietary salt intake to 2000 mg per day.
This can be achieved by not adding salt to meals and avoiding foods high in sodium. Bananas and orange juice can be added to the diet to increase potassium intake. Such dietary changes may be all that is required in the early stages of disease
DIURETICS
Recommended diuretic regimens for Ménière’s disease:
Hydrochlorothiazide 25 mg orally daily; increase up to 50 mg daily if necessary
Hydrochlorothiazide/amiloride 50/5 mg daily
Hydrochlorothiazide/triamterene 25/50 mg daily; increase up to 50/100 mg daily if necessary
WEANING
If the patient remains symptom free for six months, diuretics may be slowly tapered and re-started if required. If the response to treatment is inadequate, an alternative diuretic combination should be tried. These medications should not be used for patients with known or suspected reactions to sulphonamides.
Amplification and assistive hearing devices can be used to treat hearing loss, and use of these devices can be commenced in consultation with an audiologist.
If diet and diuretic therapy prove ineffective, referral to an otologist should be sought for consideration of other treatment modalities.
What are specilist treatment options for menieres
Further specialist treatment options include intratympanic injections, positive pressure therapy (insertion of tympanostomy tubes) and surgery.
SURG
Surgical interventions are divided into destructive and non-destructive categories.
Non-destructive procedures, such as endolymphatic sac decompression, preserve residual hearing and allow drainage of endolymph to address hydrops. This may be considered for patients with bilateral Ménière’s disease
Vestibular neurectomy selectively severs the vestibular portion of the vestibulocochlear nerve, leaving the cochlear portion intact. It can potentially preserve hearing; however, it should be avoided for patients with bilateral disease and in patients for whom central compensation may be impaired (ie those with cerebellar dysfunction, physiological ageing, multiple sclerosis). Vertigo control rates are as high as 90%.37
Labyrinthectomy involves the surgical removal of the inner ear neuroepithelium and can be considered for patients without serviceable hearing. As with vestibular neurectomy, it should be avoided for patients with bilateral disease, as loss of bilateral vestibular inputs result in oscillopsia and permanent disequilibrium.10 Vertigo control rates are highest for this procedure (97%) for appropriately selected patients.38
Rhinitis history?
Nasal symptoms
Rhinorrhoea is anterior and clear, and results in sniffing and blowing. Purulent rhinorrhoea would suggest a non-allergic cause such as foreign body, upper respiratory tract infection or chronic rhinosinusitis.
Sneezing and pruritus are both common in allergic rhinitis. Itching may affect not only the nose but also the palate, face, eyes and ears.
Nasal obstructions may be described more often as intermittent in allergic rhinitis, but the patient may have a fixed obstruction such as a deviated septum. Allergic rhinitis can coexist with a fixed obstruction, and this will be determined by the examination. If a fixed obstruction is suspected, the patient should be referred to an ear, nose and throat specialist.
Hyposmia can occur if the congestion is severe.
Ocular symptoms
Redness, itching, epiphora or lacrimation and burning of the eyes often coexist with nasal symptoms.
Otological symptoms
The patient may have intermittent ear popping, crackling or fullness due to eustachian tube inflammation/mucus in the postnasal space.
Time course
It is important to establish if the symptoms occur at a specific time of the year (and are therefore intermittent/seasonal) or whether they are they present throughout the entire year and persistent/perennial.
Associated conditions
History-taking should ascertain if the patient may have associated conditions of asthma or allergic dermatitis.
Family history
A family history of atopy (allergic rhinitis, asthma, dermatitis) can strengthen the diagnosis of allergic rhinitis, because a positive family history makes it more likely that the patient’s nasal symptoms are allergic in nature.
Rhinitis examination
nterior rhinoscopy may be performed to look for septal deformity, turbinate hypertrophy (including congested or bluish coloured turbinates) and nasal mucosal bridging (suggesting sticky mucus). Decongestant may be sprayed to assess response, as allergic hypertrophy of turbinates should be reversible; however, this may also be observed in other causes of rhinitis. It is important to examine the external nose for transverse creases, which can be an indication of chronic nose wiping, and the conjunctiva and periorbital region for redness and puffiness.41,42
The systemic examination should include assessment of the ears for effusion (from eustachian tube dysfunction), the lungs for wheeze (given the potential for coexisting asthma) and the skin (for rash of allergic dermatitis).41,42
Testing for rhinitis?
Total IgE is often used as a screening test but is nonspecific. Allergen-specific IgE (radioallergosorbent test [RAST]) directly measures the quantity of a specific IgE to a particular antigen. Currently, the Medicare Benefits Schedule rebate for blood tests is limited to four tests at once. Hence, dust mite mix, Alternaria mould, grass pollen mix and animal dander mix may be appropriate to screen. These tests are readily available to general practitioners. Patients can continue antihistamines prior to these tests.
Skin testing requires referral to an allergist, immunologist or rhinologist who is trained in skin testing.
Treatment of rhinitis in primary care?
Avoidance
Recommendations for avoidance of allergens include:
dust – purchase a dust mite–resistant mattress or cover and foam pillows; dust and vacuum frequently; consider synthetic carpets
pollen – keep windows closed; avoid cutting grass; air conditioning of the environment should be minimised
mould – disinfect bathrooms floors and walls; reduce humidity; address potential sources of mould such as plants, old showers and old curtains
animals – remove if possible; keep out of bedrooms.
Pharmacotherapy
Intranasal steroids can be prescribed to improve symptoms. These agents are most effective if used regularly and accompanied by the use of a nasal douche, the latter being used 15 minutes prior to intranasal steroids. The nasal douche cleanses the nasal cavity of stagnant mucus, with the benefit of reducing the burden of the allergen present in the mucus.
Intermittent use of non-sedating antihistamine tablets or antihistamine nasal sprays is recommended for breakthrough symptoms, particularly itch, sneeze and epiphora.
The use of nasal decongestant sprays should be discouraged because of a high likelihood of dependence (rhinitis medicamentosa).
HOw is inferior turbinate hypertrophy managed
If inferior turbinate hypertrophy is detected in the setting of response to initial management strategies, referral to an otorhinolaryngologist for turbinate reduction may be indicated
Subcut vs sublingual immunotherapy for allergic rhinitis
subcut - lots of different allergens
sublingual - limited to a few allergens
subcut - monthly injections -less suitable for kids
sublingual daily
sublingual lower risk of anaphylaxis but unpleasant taste and can cause stomatitis
History on patient with nasal obstruction?
Anosmia
Hyposmia
Mid facial pain (character, frequency, anterior rhinorrea)
frequency and type
RED FLAGS
Unilateral symptoms
Bleeding
Cacosmia (perceived malodorus smell)
Signs of meningitis (neck stiffness, photophobia)
Altered neurology
Frontal swelling
Any orbital involvement:
diplopia
decreased visual acuity
painful ophthalmoplegia
periorbital oedema and erythema
globe displacement
PMHx - asthma
what is samters triad
nonsteroidal anti-inflammatory drug sensitivity, asthma and CRS with nasal polyposis.
How is rhinosinusitis defined?
Characterised by two or more symptoms:
one of which must be either nasal blockage/obstruction/congestion or nasal discharge (anterior or posterior drip)
+/– facial pain/pressure
+/– reduction or loss of smell
And either endoscopic signs:
polyps and/or
mucopurulent discharge primarily from middle meatus and/or
oedema/mucosal obstruction primarily in middle meatus
And/or computed tomography (CT) changes:
mucosal change within the osteomeatal complex and/or sinuses.
Chronic sinusitis requires symptoms to be present for at least 12 weeks’ duration
Investigation of Chronic Rhinosinusitis
blood tests – immunoglobulin (Ig) E levels, radioallergosorbent test panel if questioning allergic triggers
nasal swab considered for culture if mucopurulent discharge is present
CT of paranasal sinuses – to confirm the diagnosis, define the burden of disease, identify anatomical factors relevant to surgery and review for complications secondary to sinus disease
Management of CRS
medical management trial
intranasal corticosteroids (Level 1a evidence; Grade A recommendation)
nasal irrigations (Level 1a evidence; Grade A recommendation)
potential course of oral prednisolone if polyposis is seen on imaging (Level 4 evidence; Grade C recommendation)
short-term oral antibiotic therapy for acute exacerbations (Level 2 evidence; Grade B recommendation) or macrolide antibiotic for ≥12 weeks’ use for CRS with low IgE levels (Level 1b evidence; Grade C recommendation)
allergy avoidance in allergic patients (Level 4 evidence; Grade D recommendation)
Indications for specialist referral in CRS
appropriate for patients considering surgical intervention for management, if there is ambiguity of diagnosis, if symptoms are significantly affecting quality of life or if simple medical management is ineffective. Specialist review is recommended for patients who require oral corticosteroids for control or are undergoing regular antibiotic treatment, or if the primary carer considers a need for long-term antibiotic therapy.
