1
Q
What is presbycusis?
A
Bilateral SN hearing loss of high frequencies as one gets older
2
Q
Presentation of presbycusis
A
- older
- hearing loss which is insidious and progressive
- patients won’t necessarily complain about hearing loss due to its gradual onset but may be worried about dementia (miss details in conversations/accuse of not paying attention)
- higher frequencies - female voices for example
- worse in noisy environments
- worse on the phone
-trouble hearing TV/radio - possible tinnitus
3
Q
Why and how do we manage presbycusis?
A
People with hearing loss are more likely to develop dementia
Support the person - reduce background noise, hearing aids/cochlea implants
4
Q
Investigations of presbycusis
A
Audiometry
5
Q
What is otosclerosis?
A
It is a form of conductive hearing loss, inherited in an autosomal dominant pattern which leads to the stiffening of the ossicles. In particular the base of the stapes
6
Q
Presentation of otosclerosis
A
- < 40 years old
- low pitched sounds
- loss of male voice
- tinnitus
- can hear own voice loudly and so may speak quietly
- can be uni or bi
7
Q
Management of otosclerosis
A
- conservative with hearing aids
- surgical - stapedectomy or stapedotomy, with prosthesis
8
Q
Investigations of otosclerosis
A
- audiometry
- tympanometry
- high res CT
9
Q
Causes of SSNHL
A
90% are idiopathic but:
- infection
- meniere’s
- ototoxic medications
- MS
- stroke
- migraine
- acoustic neuroma
- Cogan’s syndrome
10
Q
Investigations of SSNHL
A
Audiometry - 30dB in 3 consecutive frequencies
CT/MRI
11
Q
Management of SSNHL
A
- ENT in 24 hours
- treat the underlying cause
- if idiopathic can start steroids (oral or intratympanic)
12
Q
What is an acoustic neuroma?
A
A benign tumour of the Schwan cells surrounding the auditory nerve
If bilateral, almost certainly due to neurofibromatosis type II
13
Q
Presentation of acoustic neuroma?
A
- SSNHL
- fullness in the ear
- dizzy
- tinnitus
- unilateral
- can have associated facial nerve palsy
14
Q
Investigating acoustic neuroma
A
- audiometry
- CT or MRI
15
Q
Management of acoustic neuroma
A
- watch and wait
- surgery
- radiotherapy
16
Q
Cause of central vestibular dysfunction
A
1) Vestibular migraine
- episodes of vestibular symptoms lasting 5 minutes to 72 hours with migrainous features
- treated as migraines
2) Posterior circulation stroke
-associated with sensory and motor dysfunction
- may also have dysarthria/dysphagia, visual problems or ataxia/vertigo
17
Q
What is HINTS test?
A
1) Head impulse
Positive - corrective saccade –> peripheral (reassuring)
2) Nystagmus
Unidirectional is reassuring (beats in one direction)
3) Test of skew
Any movement –> central
18
Q
Causes of peripheral vestibular dysfunction
A
- Vestibular neuritis
- Labyrinthitis
- Meniere’s disease
- Bening paroxysmal positional veritgo
19
Q
Presentation of vestibular neuronitis
A
- vertigo (worse initially, may be constant and then triggered by or worsened by movement)
- N&V (can be severe)
- lack of balance
- recent viral URTI
- NO HEARING LOSS OR TINNITUS
20
Q
Management of vestibular neuronitis
A
- admission if dehydrated secondary to N&V
- prochlorperazine or antihistamines (only for a few days)
- self resolves in 2 to 6 weeks
- worse at the start
21
Q
Presentation of labyrinthitis
A
– vertigo (worse initially, may be constant and then triggered by or worsened by movement)
- SNHL
- Tinnitus
- Recent URTI
- Rule out bacterial - meningitis or AOM
22
Q
Management of labyrinthitis
A
- Prochlorperazine or antihistamines for a few days only
23
Q
BPPV presentation
A
- 20 to 60-second attacks of vertigo due to a change in position
- typically turning over in bed
- last a few weeks then resolves and can come back
- NO HEARING LOSS OR TINNITUS
24
Q
Investigation for BPPV
A
- Dix-Hallpike manoeuvre (ensure no neck pathology)
25
Management of BPPV
Epley manoeuvre
Brandt-Daroff exercises
26
What is Meniere's disease?
An excess of endolymph in the labyrinth
27
Presentation of Meniere's
- vertigo attacks lasting roughly 20 minutes before settling, clusters over several weeks
- hearing loss initially with attacks but then more permanent
- tinnitus as per hearing loss
- a sensation of fullness
- drop attacks
-imbalance
28
Investigations for Meniere's
Clinical but audiometry needed
29
Management of Meniere's
Acute attacks - prochlorperazine or antihistamines
Prophylaxis - betahistine
30
What is AOM?
Infection of the middle ear
31
Common causes of AOM?
- strep pneumonia
- haemophilus influenzae
- moraxella catarrhalis
- strep pyogenes
32
Presentation of AOM?
- ear pain/tugging
- reduced hearing
- fever and coryzal symptom
- possible discharge/balance issues
- bulging/red TM
33
Management of AOM
- typically resolves in 3 to 7 days
- abx can be delayed
- simple analgeisa
- abx now if:
1) > 4 days with no improvement
2) systemically unwell
3) risk of complication e.g. immunocomprimise
4) < 2 years and has bliateral
5) perforation or discharge
5 to 7 days of amoxicillin, or clarithromycin
34
Complication of AOM
- effusion
- hearing loss
- perf
- labyrinthitis
- mastoiditis
- abscess
- facial nerve palsy
- meningitis
35
What is OME?
Otitis media with effusion
In children, it is due to chronic inflammatory changes and ET dysfunction
In adults, it's due to a blockage of the ET, suspected malignancy
36
Presentation of OME
- conductive hearing loss
- fullness/popping
- aural discharge
- tinnitus
- mild intermittent ear pain
- paroxysmal sneezing/nasal itching
- absent light reflex and dull TM
37
Investigating OME
- audiometry
- tympanometry
- adults - ENT exam and flexible nasendoscopy
38
Management of OME
- surveillance, usually resolved in 3 months
- hearing aids
- grommets or myringotomy
39
What is a cholesteatoma?
collection of epithelial cells in the middle ear
negative pressures from ET dysfunction sucks in part of the TM and it coating of epithelial cells abnormally collect in the puch
40
Presentation of cholesteotoma
- foul discharge
- conductive hearing loss
- infection, CNVII palsy, vertigo and pain
- build-up of whiteish debris in upper part behind TM
41
Investigating cholesteotoma
CT
42
Management of cholesteatoma
Surgery
43
What is chronic suppurative otitis media?
Chronic inflammation of the middle ear due to perforation causing persistent otorrhoea
Chronic discharge (> 6 weeks) with no otalgia or fever
Ask about recent AOM, ear surgery and trauma
Aural toileting with topical abx/steroids
Referral to ENT if > 6 weeks for potential surgery
44
What is otitis externa?
It is an infection of the outer ear (pinna, external auditory meatus and canal
45
Presentation of otitis externa
- ear pain
- ear discharge
- itchiness
- possible conductive hearing loss
- erythema
- swelling
46
Management of otitis externa
- mild --> acetic acid 2% (Ear Calm) has antifungal and antibacterial qualities
- moderate --> topical antibiotic and steroid e.g. neomycin, dexamethasone and acetic acid (Otomize spray)
EXCLUDE PERFORATION
- severe --> oral abx +/- wick
47
Complication of otitis externa
Malignant otitis externa - progresses to osteomyelitis of the temporal bone. Look for graduation tissues at junction between cartilage and bone
Think about it in diabetes, immunocompromise or HIV
Need admission, IV abx and imaging
48
How can you tell if tonsillitis/pharyngitis is bacterial?
Centor
C - absence of cough
E - exidates
N - tender lymphadenopathy
T - fever
OR - old or young (+1 for 14 or younger or - 1 if 45 or older)
3 or more suggests bacterial
49
Antibiotic of choice if Cenotr positive
penicillin V for 10 days
50
What is scarlet fever?
A complication of GAS infection causing a sandpiper rash (red, blotchy, trunks outwards) accompanied by fever, lethargy, flushed face, and strawberry tongue. Off school in 24 hours after starting abx
51
What is rheumatic fever?
Occurs 2-4 weeks after a GAS infection
Fever, joint pain, SOB, rash, chorea, nodules, carditis,erythema marginatum
Diagnosis made using the Jones Criteria and evidence of infection (ASO abs/throat swabs)
52
When tonsillectomy?
7 episodes in the last year
5 episodes annually for the last 2 years
3 episodes annually for the last 3 years
Suspected malignancy - tonsillar asymmetry
53
Laryngitis
- hoarse/losing your voice
- irritating cough
- clear your throat
- sore throat
- can be associated with coryza/flu
Typically self-resolves in a couple of weeks; fluids, speak less, keep air moist (put out bowls of water and turn off radiators/AC, gargle with warm salty water, no smoking/caffeine/ETOH and no whispering/shouting)
54
What is quinsy?
A peritonsillar abscess
Have tonsillitis symptoms plus trismus (can't open mouth), hot potato voice and swelling/erythema besides the tonsils
Need emergency treatment - IV abx and I&D or aspiration
55
What is Lemierre syndrome?
Pharyngitis or tonsillitis spreads to lateral pharyngeal spaces and cause thrombophlebitis of the IJVs
Three stages:
1) Oropharyngeal phase - pharyngitis/tonsilitis symptoms
2) Extension with thrombophlebitis - neck pain, swelling and erythema at the mandibular angle (cord sign)
3) Septic emboli - lungs, brain, joints, kidney, liver, bone, heart, meninges
56
What is glandular fever?
Infectious mononucleosis, mono or kissing disease
EBV infection
57
Presentation of glandular fever
Fever, sore throat, fatigue, lymphadenopathy, tonsillar enlargement, splenomegaly
58
Investigating glandular fever
Heterophilic abs - monospot or Paul Benell
IgG/M abs to EBV
59
Management of glandular fever
- avoid ETOH and contact sports (reduced metabolism and increased risk of splenic rupture)
- self-resolves in 2-3 weeks but can feel fatigued for some time after
60
Presentation of sinusitis
- nasal congestion
- a feeling of fullness
- nasal discharge
- facial pain/headache
- loss of smell
- face swelling
61
Management of acute sinusitis
- High-dose steroid nasal spray for 14 days
- Delayed pen V prescription
62
Management of chronic sinusitis
- saline irrigation
- steroid spray
- surgery
- nasal endoscopy/CT may be indicated
Vascular Surgery
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