What causes sinusitis?
- Infection → viral URTI
- Allergies → allergic rhinitis
- Obstruction of drainage → polyps, foreign body, trauma
- Smoking → impairs normal mucociliary clearance
How does sinusitis present?
- Nasal congestion & discharge
- Facial pain, headache, pressure
- Facial swelling over affected areas
- Loss of smell
- Tenderness on palpation of affected areas
How is acute sinusitis managed?
<10 days:
- Do not offer antibiotics → most cases are viral & will clear up within 2-3 weeks
- Paracetamol for pain
If symptoms haven’t improved after 10 days:
- High-dose steroid nasal spray for 14 days (mometsone)
- Delayed abx prescription, used if worsening or not improving within 7 days → phenoxymethylpenicillin
How is chronic sinusitis managed?
- Saline nasal irrigation
- Steroid nasal sprays or drops
- Functional endoscopic sinus surgery → clear any obstructions to the sinuses.
What is otitis externa, and what are the risk factors?
= inflammation of the skin in the external ear canal.
Risk Factors:
- Swimming → often referred to as ‘swimmers ear’
- Trauma to the ear canal → cotton buds or ear plugs
- Removal of ear wax
- Highest incidence in 7-12 year olds → however can affect all ages
- Hot & humid climates
- Dermatological issues
What are the common causes of otitis externa?
- Bacterial (90% cases): pseudomonas aeruginosa, s.aureus
- Fungal: aspergillis, candida, especially if extensive topical abx or steroid use
- atopic dermatitis
- Psoriasis
How does otitis externa present?
- Significant ear pain → progressive. The inflammation & swelling in the ear canal causing a rising pressure.
- Itch
- Discharge
- If fungal → Looks like wet newspaper, can see spores
- Sometimes conductive hearing loss → can present without hearing loss, helpful to differentiate between OE & AOM.
How is otitis externa managed?
Supportive:
- Keep the ear dry → can roll a ball of cotton in vaseline & gentle place in the eye when bathing. Very important to advise this!
- Avoid itching or using cotton buds.
Medical:
- Mild OE → acetic acid 2% (EarCalm OTC), which has an antibacterial & antifungal effects.
- Moderate → topical antibiotic & steroid
- Otomize spray → neomycin, dexamethasone, acetic acid
- If the tympanic membrane is perforated, then avoid these drops & others with aminoglycosides → if unable to visualise the TM then refer to ENT for microsuction.
- Severe/systemic symptoms → oral antibiotics (flucloxacillin) and potential admission.
What is malignant otitis externa? How does it present?
= a severe & life-threatening form of OE, where the infection has spread beyond the soft tissue, resulting in osteomyelitis of the temporal bone & skull base.
Presentation:
- Non-resolving OE despite adequate topical treatment
- Persistent headache
- Severe pain
- Fever
What is the most common cause of Acute Otitis Media?
Streptococcus pneumoniae
How does Acute Otitis Media present?
- Recent onset ear pain → irritability & ear pulling noted in non-verbal children.
- Fever, cough, coryzal symptoms, sore throat, anorexia
- Aural fullness, hearing loss
- Discharge from the ear → when the tympanic membrane has perforated.
- Balance issues & vertigo
How is Acute Otitis Media managed?
AOM is a self-limiting disease lasting 3 days-1 week & often does not require antibiotics.
Systemically Well:
- Reassurance & safety-netting
- Analgesia & antipyretic agents → paracetamol or ibuprofen
- If failure to improve within 48hrs, consider antibiotics (delayed prescription)
Unwell Child:
- Consider hospital admission (rare)
- Antibiotics → 5-7 days amoxicillin, then co-amoxiclav if worsening symptoms or first choice taken for 2-3 days without benefit.
What antibiotics are given for tonsillitis if they are required?
Phenoxymethylpenicillin for 10 days, or clarithromycin if there is a penicillin allergy.
What are the indications for tonsillectomy?
- If recurrent episodes, refer for tonsillectomy if the following criteria has been met:
- > 7 documented, adequately treated, sore throat episodes in 1 year
- > 5 episodes per year for 2 years
- > 3 episodes per year for 3 years
- Other indications:
- Recurrent tonsillar abscesses (2 episodes)
- Enlarged tonsils causing difficulty breathing, swallowing, or snoring
What are the causes of central & peripheral vertigo?
- Peripheral
- Benign Paroxysmal Positional Vertigo → most common
- Meniere’s disease
- Vestibular Neuronitis
- Labyrinthitis
- Central → uncommon
- Vestibular migraine → most common
- Posterior circulation infarct
- Tumour
- MS
What are some differing features of peripheral vs central vertigo presentation?
Peripheral:
- sudden onset
- short duration (seconds, minutes)
- hearing loss or tinnitus often present
- coordination intact
- severe nausea
Central:
- gradual onset (except stroke)
- persistent
- usually no tinnitus or hearing loss
- impaired coordination
- mild nausea
When is a Dix-Hallpike Test performed, and what are the findings if this is positive?
Indicated in someone with paroxysmal vertigo in who BPPV is considered
If positive:
- pt will feel the vertigo & nausea
- you will observe nystagmus directly
Typical findings in BPPV:
- up to 20s latent period followed by onset of torsional (rotary) or horizontal nystagmus
What is Meniere’s disease, and how does it present?
= a long-term inner ear disorder that causes peripheral vertigo.
- Exact aetiology/physiology is not fully understood.
- Associated with the excessive build-up of endolymph in the labyrinth of the inner ear
Triad of symptoms:
- Hearing loss → progressive, fluctuating. Sensorineural, unilateral, affects low frequencies first.
- Vertigo → recurrent, spontaneous episodes. 20 minutes→ several hours. Not triggered by movement or posture.
- Tinnitus → initially occurs with episodes of vertigo, before eventually becoming more permanent.
Other symptoms:
- Aural fullness
- Unexplained falls (”drop attacks”) without LOC
- Imbalance, which can persist after episodes of vertigo resolve.
How is meniere’s disease managed?
Acute Attacks:
- Prochlorperazine
- Antihistamines → cyclizine
Prophylaxis:
- Betahistine
What is BPPV? Why does it occur?
= an inner ear disorder, characterised by recurrent brief attacks of positional vertigo.
- Canalolithiasis is most commonly accepted theory → there is displacement of free-floating otoconia particles from the macula that then become trapped in the posterior canal.
- The detached otoconial debris, in addition to the endolymph may continue to stimulate hair cells even after head movements have ceased.
- This leads to abnormal sensation of vertigo & nystagmus when the head moves in the plane of the affected semi-circular canal.
How does BPPV present?
- Brief episodes of vertigo → 30s - 1 minute
- Symptoms provoked by head movements → turning over in bed, gazing upwards, bending forwards.
- No hearing loss of tinnitus
Dix-Hallpike Test:
- Used to diagnose BPPV
- It involves moving the patient’s head in a way that moves endolymph through the semi-circular canals, and triggers vertigo in patients with BPPV.
- Check the patient has no neck pain or pathology beforehand.
How is BPPV managed?
Conservative:
- Often self-limiting, & symptoms may subside within 6 months of onset.
- Patients should be advised to:
- Avoid positions that may provoke vertigo symptoms
- Counsel that symptoms may re-occur.
- Do not drive when they feel dizzy or if this provokes episodes & inform their employer if there is an occupational hazard
Medical:
- If symptoms persist, vestibular rehabilitation should be performed.
- Repositioning techniques
- Medications:
- Anti-emetics → prochlorperazine, cyclizine
- Vestibular sedatives → betahistine
What is an acoustic neuroma? How do they present?
= benign tumours of the schwann cells surrounding the vestibulocochlear nerve
The typical patient is aged 40-60 years presenting with a gradual onset of:
-Unilateral sensorineural hearing loss (often the first symptom)
-Unilateral tinnitus
-Dizziness or imbalance
-A sensation of fullness in the ear
They can also be associated with a facial nerve palsy if the tumour grows large enough to compress the facial nerve.
How is acoustic neuroma managed?
Conservative- monitoring if no symptoms or unable to treat
Surgery -> partial or total removal
Radiotherapy - to reduce growth
