ENT

Question 1

Acoustic neuromas

Sometimes called cerebellopontine angle tumour, as they occur there

Answer 1

Benign tumours of the Schwann cells (provides myelin sheath around neurones) surrounding the auditory nerve (CN VIII) that innvervates the inner ear

Usually unilateral, bitlateral - neurofibromatosis type II

Question 2

Presentation of acoustic neuroma

Answer 2

Typically 40 - 60, gradual onset of:

• Unilateral sensorineural hearing loss (often first symptom)
• Unilateral tinnitus
• Dizziness/imbalance
• Fullness feeling in ear
• Facial nerve palsy if tumour large enough to compress CN VII

Question 3

Investigations and management of acoustic neuroma

Answer 3

• Audiometry - sensorineural pattern of hearing loss
• Brain imaging (MRI/CT) - confirm dx

Management:

• Conservative if no symptoms or tx inappropriate
• Surgerical removal
  Radiotherapy to reduce growth

Risks with surgery:

• Vestibulocochlear nerve injury - permanent hearing loss or dizziness
• Facial nerve injury + facial weakness

Audiometry

X = Left air conduction
] = Left bone conduction
O = Right air conduction
[ = Right bone conduction

Question 4

Acute epiglottitis

Answer 4

• Inflammation and swelling of the epiglottis (a flap of cartilage that covers trachea when swallowing)
• Life-threatening emergency
• Key cause: haemophilus influenzae type B (rare now due to vax), strep pneumoniae
• Typically 2 - 7yo, but any age

Question 5

Presentation of acute epiglottitis

Answer 5

SImilar to croup but more rapid onset, additional features and appear more ill!

• Sore throat
• Difficulty swallowing
• Painful swallowing
• High fever
• Stridor
• Drooling
• Muffled voice

On inspection:

• Scared and quiet
• Tripod position
• Extending neck and chin
• Looks toxic

EXAMS: suspect epiglottitis in unvax child with high fever, sore throat, dysphagia and drooling

Question 6

Management of acute epiglotitis

Answer 6

Do not examine as might upset child and further obstruct airway

Lateral x-ray of neck = “thumbprint sign”

Emergency as immediate risk of airway closing, invovle most senior paediatrician and anaesthetist available

Secure airway, and preparations to intubate or tracheostomy if needed

Once airway secure, IV abx (e.g. cefotaxime) +/- systemic steroids

Question 7

Ménière’s Disease

Answer 7

Long-term inner ear disorder that causes recurrent attacks of:

Classic triad for exams:

• Hearing loss
• Vertigo
• Tinnitus

Caused by excess endolymph buildup in the labyrinth of the inner ear = higher pressure (endolymphatic hydrops) = disruption in sensory signals

Question 8

Presentation of Ménière’s Disease

Answer 8

Typically 40 - 50 yo with unilateral episodes of vertigo, hearing loss and tinnitus

Vertigo = episodes of 20 mins to several hours, clusters then prolonged periods with no vertigo

Sensorineural hearing loss > fluctuating associated with vertigo then more permanent

Similar pattern with tinnitus

Question 9

DIagnosis and management of Ménière’s Disease

Answer 9

Diagnosed by ENT specialist, audiology assessment to assess hearing loss

Management:

Acute attack:

• Prochlorperazine
• Antihistamines (cyclizine, cinnarizine or promethazine)

Prophylaxis:

• Betahistine

Question 10

Rhinosinusitis

Answer 10

• Inflammation of the paranasal sinuses in the face
• Acure (< 12 weeks)
• Chronic ( > 12 weeks)

Four paranasal sinuses:

• Frontal
• Maxillary
• Ethmoid
• Sphenoid

Causes:

• URTI
• Allergies e.g. hayfever (with allergic rhinitis)

Question 11

Presentation of sinusitis

Answer 11

Typically patient with recent URTI

• Nasal congestion
• Nasal discharge
• Facial pain/heachache/pressure/swelling
• Loss of smell

Examination:

• Tenderness in affected areas
• Inflammation and oedema of nasal mucosa
• Fever

Chronic = similar but > 12 weeks

If persistent despite tx then nasal endoscopy and CT scan

Question 12

Management of rhinosinusitis

Answer 12

aAcute

• < 10 days, see if self-resolve
• > 10 days - high dose steroid nasal spray 14 days (e.g. mometasone 200mcg x2 daily)
• Delayed abx prescription if no better in 7d - 1st line is phenoxymethylpencillin

Chronic

• Saline nasal irrigation
• Steroid nasal sprays or drops (e.g. mometasone or fluticasone)
• Functional endoscopic sinus surgery (FESS)

Question 13

Functional endoscopic sinus surgery (FESS)

Answer 13

Insertion of small endoscope through nostril and sinuses

Obstructions removed (caused by swollen mucosa, bone, polyps or deviated septum (septoplasty)

Ballons to dilate sinus opening

CT scan beforehand to confirm dx

Question 14

Vertigo

Answer 14

Sensation of movement between the patient and environment, may feel like they or environment is moving or horizontal spinning sensation

Often associated with nausea, vomitting, sweating and feeling unwell

Causes:
Peripheral problem affecting the vestibular system

• BPPV
• Meniere’s disease
• Vestibular neuronitis
• Labyrinthitis

Central problem affecting the brainstem or cerebellum (causes sustained, non-positional vertigo)

• Posterior circulation infarction
• Tumour
• Multiple sclerosis
• Vestibular migraine

Question 15

History in vertigo

Answer 15

• Important to distinguish between veritgo and lightheadedness
• “Room moving? (vertigo)” or “lightheadedness”
• Differentiate between central and peripheral vertigo, see table below

Key features that may point to a specific cause are:

• Recent viral illness (labyrinthitis or vestibular neuronitis)
• Headache (vestibular migraine, cerebrovascular accident or brain tumour)
• Typical triggers (e.g. bright lights) (vestibular migraine)
• Ear symptoms, such as pain or discharge (infection)
  Acute onset neurological symptoms (stroke)

Question 16

Examinations in veritgo

Answer 16

• Ear
• Neuro (central causes)
• Cadiovascular (arrhythmias or valve disease)
• Cerebellar exam

Special tests:

• Romberg’s test - problems with proprioception or vestibular function
• Dix-Hallpike manoeuvre - BPPV
• HINTS - Head Impluse (HI), Nystagmus (N), Test of Skew (TS)-

Cerebellar exam: DANISH - Dysdiadochokinesia, Ataxic (ask pt to walk heel to toe), Nystagmus, Intention tremor, Slurred speech, Heel-shin test

Question 17

HINTS examinations for vertigo

Answer 17

• Head impluse - examiner jerks patient’s head in one direction for 10 - 20s, repeat on opp side, patient fix on examiner nose
• Normal = central cause or no symptoms - - Positive = eyes saccade (rapidly move back and forth) as they eventually fix on examiner = peripheral cause (e.g. labyrinthitis)
• Nystagmus - unilateral horizontal = peripheral cause, bilateral/vertical = central
• Test of Skew (alternate cover test) - pt fix gaze on examiner nose, cover one eye alternating between eyes, if vertical correction when uncover = central cause

Question 18

Management of vertigo

Answer 18

• Suspected central vertigo = CT/MRI to establish cause
• Peripheral vertigo short term: prochlorperazine, antihistamines (e.g. cyclizine, cinnarizine and promethazine)
• Ménière’s disease - Betahistine
• BPPV - Epley manoeuvre
• Vestibular migraine: avoid triggers, triptans for acute attack and propranolol, topiramate or amitriptyline prophylaxis
• DVLA guide - patients must not drive AND must inform DVLA if sudden and unprovoked episodes of disabling dizziness

Question 19

Vestibular neuritis

Answer 19

• Inflammation of vestibular nerve, hx of ?URTI
• Acute vertigo, N+V, balance problems
• No hearing loss and tinnitus
• Labyrinthitis = loss of hearing and tinnitus
• Head impulse test, dx peripheral vertigo
• Positive = eyes saccade, negative = normal or central cause

Management:

• Prochloperizine 3d
• Antihistamines (cyclizine, promethazine) 3d
• Refer for vestibular rehab therapy if ineffective