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GP block (Y3) > Week 3: ENT (clinical approach to ear symptoms) > Flashcards

Week 3: ENT (clinical approach to ear symptoms) Flashcards

1
Q

key symptoms of the ear

A
  • Hearing loss
  • Tinnitus
  • Otalgia
  • Otorrhoea
  • Dizziness and vertigo
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2
Q

history questions to ask in someone with hearing loss

A
  • Sudden or gradual
  • Unilateral or bilateral
  • Associated otologigical or neuro-otological symptoms
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3
Q

investigation for hearing loss

A
  • Pure tone audiogram (PTA) and tuning fork test (Rinnes and weber)- should be used together
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4
Q

types of hearing loss

A

conductive vs sensorineural

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5
Q

conductive hearing loss involves either

A

the external or middle ear

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6
Q

causes of conductive hearing loss

A
  • wax
  • acute otitis media
  • otitis media with effusion
  • otosclerosis
  • TM perforation
  • cholesteotoma
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7
Q

Wax- additional symptoms to hearing loss

A
  • Additional symptoms: feeling blocked
  • Signs: wax on otoscopy
  • Investigations: n/a
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8
Q

otitis media with effusion -additional symptoms to hearing loss

A
  • Additional symptoms: popping, clicking/pressure
  • Signs: dull/ staw TM/ fluid level, bubbles on otoscopy
  • Investigations: tympanogram will show flat trace
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9
Q

otosclerosis - additional symptoms to hearing loss

A
  • Additional symptoms: can be unilateral or bilateral
  • Signs
    • Usually none
    • Schwartz sign: red tinge to TM= flamingo sign
    • Investigations: CT, PTA-2kHz raised BC threshold (carhart notch)
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10
Q

TM perforation- additional symptoms to hearing loss

A
  • Additional symptoms- may have middle ear discharge if active infection
  • Signs – TM perforation
  • Investigations: n/a
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11
Q

cholesteatoma- additional symptoms to hearing loss

A
  • Associated symptoms: chronic smelly discharging ear
  • Signs: deep retraction pocket with keratin collection
  • Investigations- CT
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12
Q

sensorineural hearing loss

A

pathology involving the inner ear structures or CN VIII

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13
Q

causes of sensorineural hearing loss

A
  • presbucysus
  • noise related hearing loss
  • menieres disease
  • acoustic neuroma
  • ototic mediations
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14
Q

presbycusis - additional symptoms to hearing loss

A
  • Symptoms: bilateral, gradual
  • Signs: normal otoscopy
  • Investigations: PTA
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15
Q

noise related hearing loss- additional symptoms to hearing loss

A
  • Symtpoms: often tinnitus
  • Signs: normal otoscopy
  • Investigation: PTA
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16
Q

menieres disease - additional symptoms to hearing loss

A
  • Symptoms: tinnitus and vertigo
  • Signs: normal otoscopy
  • Investigation: MRI, autoimmune screen
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17
Q

acoustic neuroma -additional symptoms to hearing loss

A
  • Symptoms: asymmetrical hearing loss
  • Signs: normal otoscopy
  • Investigation: MRI
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18
Q

Management of hearing loss

A

Audiological

  • Hearing aids for mild to prfound hearing loss

Surgical

  • Tympanoplasty - Cartilage or temporalis fascia is used to repair a perforation in tympanic membrane.
  • Stapedectomy - Prosthesis used to bypass fixed stapes/footplate in otosclerosis and allow transmission of sound into inner ear
  • Bone anchored hearing aid – a transcutaneous or percutaneous device can be surgically implanted under general or local anaesthesia for a conductive, mixed conductive /sensorineural hearing loss or unilateral dead ear
  • Cochlear implantation- sensorineural hearing loss.
  • Middle ear implant – suitable for conductive and mixed hearing loss

Management of excessive ear wax

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19
Q

Management of excessive ear wax

A
20
Q

tinnitus

A
  • Perception of sound when no external sound is present*
  • ‘sound of silence’- all people if sat in silence in a sound proof room will hear tinnitus
21
Q

causes of tinnitus

A
  • No identifiable cause in most cases
  • Usually associated with hearing loss
22
Q

types of tinnitus

A
  • Non-pulsatile
  • Pulsatile
23
Q

Non-pulsatile tinnitus

A
  • False perception of sound that is heard by affected individual only
  • E.g. buzzing, high pitched tone
  • Associated with noise induced hearing loss, presbycusis, Meniere’s, head injury, otitis media, drug related (salicylates, NSAIDs, loops)
24
Q

pulsatile tinnitus

A
  • Sound heard by individual that is synchronous with their heartbeat
  • Cause is turbulent blood flow that reaches cochlear
  • Vascular causes
    • Atherosclerosis on internal carotid
    • Vascular malformation
    • Glomus tumours
    • Non vascular causes
    • Paget’s
    • Otosclerosis
    • Myoclonus of the muddle ear muscles (clicking noise)
25
Q

investigations for tinnitus

A
  • MRI
    • If unilateral and associated with hearing loss (exclude acoustic neuroma)
  • MRI or CT angiography
    • If pulsatile tinnitus
26
Q

treatment of tinnitus

A
  • Reassurance that tinnitus is common and they will adapt to it
    • Usually worse at quiet times e.g. at night and worrying about it generally makes it worse
  • Addressing any underlying causes e.g. hypertension, carotid stenosis, side effects of mediation
  • Behavioural therapy coping strategies
  • A noise generator can be helpful with sleep
  • Hearing aid may help if hearing loss is present through a masking effect
27
Q

Otalgia

A

Otalgia is ear pain that can originate from the ear itself or can also be referred from elsewhere in the head or neck

28
Q

Otalgia causes

A
29
Q

Referred otalgia

A

Any pathology involving the cranial nerves V, VII, IX, and X and the upper cervical nerves C2 and C3 can cause the sensation of referred otalgia.

  • Ask about other general symptoms
    • Dental, nasal and throat symptoms
    • Indicators of malignancy
30
Q

which condition is the most common cranial neuralgia linked to referred otalgia

A

Trigeminal neuralgia

31
Q

otorrhoea

A
  • The ear can discharge wax, pus, blood, mucus and even cerebrospinal fluid.*
  • Remember discharging wax should be reassured as normal.
32
Q

The common bacterial pathogens in a discharging ear that can cause an infection include:

A
  1. Pseudomonas aeruginosa
  2. Staphylococcus aureus
  3. Proteus spp.
  4. Streptococcus pneumonia
  5. Haemophilus influenza
  6. Moraxella catarrhalis
33
Q

history taking in pt with otorrhea

A
  • Duration of discharge – If chronic, think chronic otitis media including cholesteatoma especially if unilateral
  • Is there associated otalgia (ear pain)?
  • Associated fever or systemic symptoms indicates an infective aetiology
  • Is there associated hearing loss or dizziness?
  • Do not miss a history of putting foreign bodies in the ear especially in children
  • Facial nerve palsy - May occur with acute or chronic otitis media especially if the facial nerve is dehiscent along its course in the middle ear (10% of the population)
  • Check for history of trauma - CSF otorrhoea
  • Has there been any recent history of topical antibiotics? This can in itself cause discharge or predispose to antifungal ear infections if there is prolonged usage
34
Q

DD for otorrhea

A
35
Q

Dizziness and vertigo

A

True vertigo is most often associated with a sensation of ‘spinning’ and movement of the surrounding environment. It is important to distinguish this from the more generalised dizziness of disequilibrium.

36
Q

epidemiology of vertigo

A

Epidemiology: male: female 1:3

History

  • Need to ascertain that this is true vertigo
  • Duration and frequency of attacks
37
Q

causes of vertigo

A
38
Q

Benign Paroxysmal Positional Vertigo (BPPV)

A
  • most common cause of true vertigo with typical age of onset 40-60 years
    • Dix-hallpike test positive
    • Rotatory vertigo on moving head
39
Q

Vestibular neuritis

A
  • Rotatory vertigo that is continuous for over 24 hours often associated with nausea and vomiting
  • Confined to bed and takes days to weeks to recover
40
Q

Meniere’s Disease

A
  • Rotatory vertigo associated with fluctuating hearing loss often with low frequency threshold affected
  • Tinnitus usually gets worse during an attack
  • Patients classically gen an aural fullness before onset of vertigo
41
Q

Vestibular migraine

A
  • Rotatory vertigo can last minutes to hours to days
    • Headaches
    • Photophobia
    • Visual disturbance
    • Phonophobia
    • Not always a headache or visual symptoms
    • Can sometimes overlap (e.g. hearing loss) – hard to differentiate between conditions such as Meniere’s
42
Q

invesrtigations for vertigo

A

Investigations

  • Full neurological examination
  • Pure tone audiometry
  • Dix-Hallpike test
  • MRI of internal auditory meatus may be appropriate with asymmetrical sensorineural loss to exclude an acoustic neuroma
  • Video head impulse testing (vHiT) – this is performed using specialist equipment and can be used to assess the function of the semi-circular canals by measuring visual ocular reflex (VOR) function. It takes around 15minutes to perform and is a quick and sensitive measure of labrythine function
43
Q

treatment of BBPV

A

Epley’s manoeuvre can be curative in up to 90% by repositioning of the displaced otoconia crystals. In persistent cases, Brandt-Daroff exercises may be advised. Surgical management is rarely required but posterior semi-circular canal occlusion is useful in resistant cases.

44
Q

treatment of vestibular neuronitis

A

Treatment is expectant with anti-emetics during the acute phase

45
Q

treatment of menieres disease

A

The underlying pathophysiology is thought to be endolymphatic hydrops.

Therefore “pressure reducing” therapies include:

  • low salt diet,
  • medications such as betahistine and diuretics although the

second line

  • Intratympanic injection of steroid or gentamicin is used for those that fail conservative management.

other treatments

  • saccus decompression, labyrinthectomy and vestibular nerve section.
46
Q

treatment of vestibular migraine

A

Common trigger factors include dehydration, foods (classically chocolate, cheese), anxiety and a poor sleep pattern.

A symptom diary can help identify these. In those that do not respond to avoidance measures, there are a variety of migraine-preventative medications available.

GP block (Y3) (39 decks)

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