1
Q
What is BPPV?
A
Vertigo that is thought to occur when otoconia (tiny Ca(CO3)2 crystals) are dislodged from the utricle into the semicircular canals
2
Q
Symptoms of BPPV?
A
vertigo that is precipitated by head movements usually to a particular position e.g. turning in bed or sitting up
onset is distressing but attacks last only seconds
3
Q
Test for BPPV?
A
Hallpike manoeuvre: patient sits on couch, head turned towards 1 year, examiner supports head and then leans them backward with head off the couch, positive tests involves nystagmus when the head is turned towards the affected ear, need to do test both sides https://www.youtube.com/watch?v=8RYB2QlO1N4
4
Q
Management of BPPV?
A
Epley manoeuvre https://www.youtube.com/watch?v=jBzID5nVQjk
5
Q
In BPPV vertigo lasts ___1__
In Meniere’s disease vertigo lasts ____2_____
In vestibular neuritis and labyrinthitis vertigo lasts ___3_____
A
- seconds
- recurring episodes that last 30 mins to hours
- vertigo lasts days
6
Q
Meniere’s disease is also associated with?
A
low frequency sensorineural hearing loss, aural fullness, loss of balance, tinnitus and vomiting
7
Q
Are there other symptoms associated with vestibular neuritis and labyrinthitis?
A
vestibular neuritis - no as only vestibular nerve
labyrinthitis - both nerves are affected so can also get tinnitus and hearing loss
8
Q
What are features of vestibular migraine?
A
vertigo lasting 5 minutes to 72 hours associated with other migraine features e.g. triggers, photophobia, photophobia, nausea, headache
9
Q
What is infectious mononucleosis and how is it spread?
A
- Infection with EBV causes increased levels of monocytes (technically are other infections that can cause this but EBV is classically what causes infectious mononucleosis)
- EBV is spread by touch and close contact and viral shedding can occur for up to 6 months in infected individuals (ie can be shedding the virus even when asymptomatic)
10
Q
Presentation of infectious mononucleosis?
A
- Fever
- Sore throat (may have tonsillitis)
- Lymphadenopathy (usually posterior cervical chain)
- Palatal petechiae and a transient macular rash are common
- Splenomegaly is noted in 50%
- Can get mild hepatitis in some individuals
- Fatigue
11
Q
What do you need to tell those with EBV and splenomegaly?
A
no contact sports due to risk of splenic rupture
12
Q
Complications of EBV?
A
Splenic rupture, aplastic anaemia, increased future risk of Hodgkin lymphoma
13
Q
Diagnosis of EBV?
A
- Should be suspected in those who have atypical mononuclear cells in large numbers in the peripheral blood
- Serology testing – Paul Bunnel or Monospot test
14
Q
Management of EBV?
A
Self-limiting so supportive treatment
15
Q
What is otitis externa and what is it usually caused by?
A
- Inflammation of the skin in the ear canal, usually infective, often bacterial and then develop a fungal infection
- Common organisms are pseudomonas and Staph
- May occur in swimmers – explains why pseudomonas as this is commonly found in soil and water
- Other causes are trauma by cotton buds or susceptibility due to skin conditions e.g. psoriasis and eczema
16
Q
Presentation of otitis externa?
A
- Redness and swelling of ear canal
- Itchy progressing to sore and painful
- Discharge and/or increased amounts of wax
- If canal becomes blocked by swelling or secretions, hearing can be affected
17
Q
Management of otitis externa?
A
- Topical treatments– antibiotic drops in combination with steroid and/ or acetic acid
- May get topical gentamicin (want to check TM membrane is still intact if giving this)
- For fungal – clotrimazole
- Refer to ENT if associated cellulitis
- May need ear canal cleared out
18
Q
What is acute otitis media and what causes it?
A
- Acute otitis media is inflammation of the middle ear
- It is extremely common in children
- Most common cause is infection (usually viral) and then secondary bacterial infection can occur (strep pneumoniae, strep pyogenes, haemophilus influenzae
- Infection usually comes from the nose or pharynx via the Eustachian tube which in children is shorter, wider and more horizontal so infection can track upwards more easily
19
Q
Presentation of acute otitis media?
A
- Usually have just had a cold, then get a temperature and pain in ear
- Otalgia, fever and loss of hearing is followed by otorrhoea (discharge from ear), this is caused by burst of the ear drum which relieves pain
- On otoscopy: bulging, opaque, erythematous tympanic membrane
20
Q
Management of acute otitis media?
A
- Treatment of acute otitis media is usually with NSAIDs, it is usually viral in origin and will settle within 72 hours without antibacterial treatment
- Admit to hospital if: signs of serious complications, severe systemic infection, younger than 3 months of age with temperature of 38 degrees or more (this suggests severe illness as you wouldn’t expect those under 3 months to get so ill as still have maternal antibodies)
- Consider antibiotics if: have ottorhoea (as ear drum has perforated so at risk of bacterial infection even if initial infection is viral), those aged less than 2 years with bilateral infection
- Antibiotics taken for 5-7 days, amoxicillin is first line antibiotic, clarithromycin is second line
21
Q
What causes otitis media with effusion/ glue ear?
A
- Eustachian tube dysfunction leads to a poorly ventilated middle ear, the vacuum created by poor ventilation leads to a non-inflammatory effusion
- The effusion resolves naturally in majority of cases but can persist or recur causing a hearing loss that can impact on speech and education
- Common in children due to eustachian tube dysfunction
22
Q
Presentation of otitis media with effusion/ glue ear?
A
- Eustachian tube dysfunction leads to a poorly ventilated middle ear, the vacuum created by poor ventilation leads to a non-inflammatory effusion
- The effusion resolves naturally in majority of cases but can persist or recur causing a hearing loss that can impact on speech and education
- Common in children due to eustachian tube dysfunction
23
Q
Presentation of otitis media with effusion/ glue ear?
A
- Hearing loss or speech delay but little association with otalgia
- Can result in poor performance in school
- On otoscopy: dull tympanic membrane with loss of light reflex and occasionally fluid with air bubbles visible in the middle ear
- Frequently adenoidal hypertrophy and nasal blockage are present in children (adenoids hypertrophy due to bacterial and viral infections, generally they will atrophy as children get older)
24
Q
Management of otitis media with effusion/ glue ear?
A
- Active observation over 3 months should be done in most children as spontaneous resolution is common
- If no resolution, grommets/ ventilation tubes may be inserted allowing ventilation of the middle ear cavity
- Grommets are extruded from the tympanic membrane as it heals over 6 months to 2 years
- They may need reinserted but often effusion has resolved
25
List some causes of rhinitis?
infective rhinitis
non infective allergic rhinitis e.g. seasonal allergic or persistent allergies
non infective non allergic - vasomotor rhinitis or nasal polyps
26
Investigations and management of allergic rhinitis?
* Allergy testing can be done by skin prick or IgE for 4 main allergens – house dust mites, grass pollen, dog and cat
* Advice on allergy avoidance for everyone
* Step 1: intranasal or oral antihistamines
* Step 2: regular intranasal corticosteroids
* Step 3: should be referred
27
What is vasomotor rhinitis and what is it treated with?
* Nose seems more easily irritated than normal, may react to changes in air quality e.g. temperature, pollen, dust, but it is not an allergic response
* Treated with topical anticholinergics
28
Where are nasal polyps most commonly found?
sinuses
29
Development of nasal polyps is associated with?
seasonal allergies, frequent asthma exacerbations, chronic sinusitis, genetic links with cystic fibrosis and primary ciliary dyskinesia
30
Symptoms of nasal polyps?
sinus infections, decreased sense of smell, snoring, sleep apnoea
31
Diagnosis of nasal polyps?
visually with nasal endoscopy, or CT scan
32
Management of nasal polyps?
shrink with steroid sprays or surgery if fails
polyps often return and may need treated regularly
33
What causes acute sinusitis?
* Infection of paranasal sinuses
* This usually follows a common cold, usually bacterial infection e.g. strep pneumoniae or haemophilus influenzae
34
Symptoms of acute sinusitis?
* Frontal headache, purulent rhinorrhoea, facial pain with tenderness and fever
35
Management of acute sinusitis?
* Refer to hospital if signs of severe systemic infection, any intraorbital or periorbital complications, a displaced eyeball, double vision, ophthalmoplegia or newly reduced visual acuity, intracranial complications
* If person is systemically very unwell and/ or is at high risk of complications offer antibiotics
* If person has symptoms 10 days or less advise that likely viral and will get better in a couple of weeks, self care e.g. paracetamol/ ibuprofen, nasal decongestants
* If more than 10 days and no improvement, consider high dose nasal corticosteroid, still withhold antibiotics
* 1st line antibiotic is Penicillin V, and 2nd line is doxycycline
36
What is chronic sinusitis?
* Chronic inflammation of sinuses
* Predisposing factor to chronic sinusitis include allergic rhinitis, asthma and immunosuppression
37
Symptoms of chronic sinusitis?
* Nasal blockage and/ or discharge
* Facial pain/ pressure
* Reduction in sense of smell
38
Management of chronic sinusitis?
* Refer to hospital if signs of severe systemic infection, any intraorbital or periorbital complications, a displaced eyeball, double vision, ophthalmoplegia or newly reduced visual acuity, intracranial complications
* Good control of associated disorders e.g. asthma is likely to benefit sinusitis symptoms
* Consider nasal irrigation with saline solution, course of intranasal steroids
39
What is post nasal drip? What are common causes?
* Occurs when excess mucus builds up and drips down the back of the throat
* Generally mucus is swallowed unconsciously but if more is being produced can start to notice it and irritate the throat
* Common causes are colds, flu, allergies, sinusitis, pregnancy, some medications, deviated septum, changing temperatures, certain foods, fumes and other irritants
40
Presentation of post-nasal drip?
* Cough
* Feeling of mucus in back of throat
* Frequent swallowing
* Urge to clear throat
* Halitosis
41
Management of post-nasal drip?
* Treat the cause
* Measures to allow mucus secretions to pass more easily: drinking more water, nasal sprays, saline nasal irrigations
42
Majority of tonsillitis is ___
viral infection
EBV, rhinovirus, influenza, parainfluenza, enterovirus and adenovirus
43
Most common cause of bacterial tonsillitis is ____
other causes ______
group A strep (strep progenes
second most common is strep pneumoniae, other causes are staph A and HiB
44
Why is it important to rule out GABHS as a cause of tonsillitis?
due to risks of acute rheumatic fever, rheumatic heart disease, poststreptococcal glomerulonephritis, peritonsillar abscesses and retropharyngeal abscesses
45
Presentation of tonsillitis?
VIRAL: malaise, sore throat, temperature, possible lymphadenopathy but able to undertake normal activity, lasts 3-4 days, cough
BACTERIAL: systemic upset, fever, odynophagia, halitosis, lymphadenopathy, unable to work, lasts about a week, absence of cough, presence of exudates
46
Management of tonsillitis?
* FeverPAIN score for determining whether to give antibiotics
* Eat, drink, rest, paracetamol, NSAIDs
* If need antibiotic, penicillin V for 10 days, clarithromycin if allergic
47
Tonsillectomy guidelines?
* Sore throat due to tonsillitis
* Episodes are disabling
* 7 or more well documented, clinically significant, adequately treated in preceding year or 5 episodes a year in 2 years or 3 episodes a year in 3 years
48
Presentation of Quinsy?
* Unilateral throat pain and odynophagia, 3-7 days preceding acute tonsillitis, medial displacement of tonsil and uvula, concavity of palate lost
49
Management of Quinsy?
aspiration and antibiotics
50
Why dont you give amoxicillin for tonsillitis?
if the cause is EBV will get a rash
