ENT

Question 1

Define Benign paroxysmal positional vertigo (BPPV)

Answer 1

peripheral vestibular disorder causing sudden short-lived episodes of vertigo elicited by certain head movements

Question 2

Cause of BPPV

Answer 2

movement of otolith (crystals) from utricle + saccule => semi-circular canals causing movement of endolymph even when head has stopped moving.

Question 3

Presenting symptoms of BPPV

Answer 3

• sudden severe episodic vertigo provoked by specific head movements
• nausea
• imbalance
• lightheadedness

Question 4

Examination findings of BPPV

Answer 4

• normal neurological exam
• BUT positive DIX-HALLPIKE manoeuvre -sitting => supine positions => head tilted back and 45 degrees =>see nystagmus (eyes jumping) within 30s.

Question 5

Investigations for BPPV

Answer 5

• Dix-hallpike maneouvre
• audiogram- exclude sensorineural hearing loss (meniere’s disease/ labrynthitis)
• MRI brain- exclude MS, tumours

Question 6

Management for BPPV

Answer 6

• educate patient about condition and to continue exercise
• 3- position particle repositioning manoeuvre (PRM)
• if not- vestibular rehabilitation

Question 7

define Meneiere’s

Answer 7

disorder of the inner ear causing sudden vertigo due to increased pressure and dilation of endolymphatic system

Question 8

symptoms for Meniere’s

Answer 8

• spontaneous vertigo (20mins-12hours)
• tinitus
• ear fullness
• fluctuating sensorineural hearing loss
• nausea/vomiting

Question 9

signs of Meniere’s

Answer 9

• nystagmus
• positive Romberg’s test (poor proprioception - ataxia is sensory in nature not cerebellar)

Question 10

Risk factors for Meniere’s

Answer 10

• viral infections
• head trauma
• genetics
• autoimmune
• metabolic disturbances (changes to Na+/K+ in ear)

Question 11

Management of Meniere’s disease

Answer 11

Severe => refer to hospital for IV labrynthite, fluids and nutrition

Medical:

• acute attacks => prochlorperazine- anti-emetic
• prevention => betahistine (anti-histamine)- anti-emetic, treats vertigo

MDT approach

• refer to ENT for diagnosis
• refer to audiology for hearing loss

Lifestyle:

• keep medication nearby, vertigo usually gets better with treatment and symptoms usually resolve within 24hrs
• caution of operating heavy mahcinery/ driving
• inform DVLA

Question 12

define epistaxis

Answer 12

nose bleeds due to damage of vessels in nasal mucosa

• usually self-limiting

Question 13

causes of epistaxis

Answer 13

• Nose trauma (picking/blowing nose, allergies /surgery)
• nasal polyps/ tumours (SCC)
• Hypertension/ atherosclerosis
• Haematological (leukaemia, haemophillia, thrombocytopenia)
• Environmental factors (low humidity, high altitude)
• Drugs (anticoagulants, antiplatelets)
• XS alcohol
• vascular causes (hereditary haemorrhagic telangiectasia/ Wegener’s granulomatosis

Question 14

investigations for epistaxis

Answer 14

• rarely done
• FBC - Hb (anaemia)
• coagulation studies (clottting disorders)

Question 15

Management of epistaxis

Answer 15

Acute epistaxis

• Lean forward, mouth open and hold nose for 10-15 mins
• if posterior bleed (profuse, bleeding from both nostrils => A&E)
• apply naseptin (antiseptic) to prevent re-bleeding
• after bleeding- advise to not heavy lift/pick nose for >24hrs

Recurrent epistaxis:

1. topical antiseptic (naseptin- chlorohexidine + neomycin)- prevent crusting/vestibulitis
2. nasal cautery
3. referral to ENT

Question 16

complications of epistaxis

Answer 16

• rare
• anaema
• hypovolaemia

Question 17

define rhinosinusitis

Answer 17

• inflammation of nasal cavity + paranasal sinuses (frontal,nasal, ethmoid, maxillary sinuses) usually viral infection but can be followed by bacterial infection (uncommon)

1. acute - symptoms <3 months
2. chronic - symptoms >3 months

Question 18

causes of rhinosinusitis

Answer 18

acute

• triggered by viral respiratory tract infection (influenza, RSV) =>followed by bacterial infection
• allergies, asthma, seasonal variation
• smoking
• CF
• anatomical obstruction (deviated nasal septum, nasal polyps, trauma, foreign body)

chronic

• inflammatory cause
• triggers: allergies, asthma, smoking, CF,
• immunocompromised

Question 19

symptoms of rhinosinusitis

Answer 19

Adults:

• nasal blockage/nasal discharge + face pain (around sinuses)
• headache
• fever
• loss of smell
• cough
• red,tender, swollen cheeks/periorbital areas

Child:

• nasal blockage/ discoloured nasal discharge
• fever
• face pain / pressure
• cough

Examination => nasal inflammation, nasal disharge, mucosal oedema

Signs of bacterial infection

• discoloured discharge
• high fever
• followed a mild illness

Question 20

investigations for rhinosinusitis

Question 21

Differentials for rhinosinusitis

Answer 21

nasal blockage/discharge

• URTI
• tonsilitis
• tumour
• foreign body

face pain

• migraine
• giant cell/temporal arteritis
• dental pain
• temperomandibular disorders
• trigeminal neuralgia

Question 22

management for rhinosinusitis

Answer 22

If signs of orbital/bone/neuro complications => hospital

AB use is not encouraged as bacterial infection is rare

Acute

• if symptoms <10 days - no further action needed, should resolve on own
• if > 10 days => high dose nasal corticosteroids + (backup antibiotics?)
• recurrent/ ABs don’t help => refer to ENT (rare)

Chronic

• avoid triggers, stop smoking
• nasal irrigation with saline
• high dose nasal corticosteroids
• refer to ENT

Question 23

complications of rhinosinusitis

Answer 23

acute:

• Orbital complications — orbital cellulitis, orbital abscess, cavernous sinus thrombosis.
• Intracranial complications —meningitis, encephalitis, abscess, venous thrombosis.
• Bony complications — osteomyelitis.
• Progression to chronic sinusitis.

Chronic

• poor sleep, fatigue, depression