Phase 3B ENT Part 2 EARS: VERTIGO - PowerPoint Presentation

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Phase 3B ENT

Part 2

EARS: VERTIGO - Illusion of movement  dizziness

Peripheral: BPPVMeniere’s DiseaseLabyrinthitisVestibular Neuritis

Causes:

Central: Acoustic NeuromaMultiple SclerosisHead Injury

DRUGS:

Gentamicin

Metronidazole

Diuretics

EARS: VERTIGO - BPPV

Very common, any age, F>M

Most = idiopathic cause

Sx

: SHORT EPISODES OF VERTIGOWORSE IN AMSUDDEN ONSETLAST ~20-30s, RAPID RESOLUTIONPROVOKED BY HEAD MOVEMENTSNO HEARING LOSS/TINNITUSDx = clinicalo/e – DIX HALLPIKE TEST (+ve = BPPV)Mgmt = usually self limitingPromote – slowly get out of bed, alcohol and head movements EPLEY’S MANOEUVRE Meds – PROCHLORPERAZINE (antiemetic/antipsychotic)

Otoliths detach into semi-circular canals

Detached otoliths continue to move once head movement stopped

DIZZINESS = VERTIGO

Differentials?

Acute labyrinthitis, Menieres, Acoustic Neuroma, RH syndrome, otosclerosis

EARS: VERTIGO – MENIERE’S DISEASE

Increase in fluid volume (endolymph) in membranous labyrinth - aka endolymphatic hydropsProgressive distension of membranous labyrinth Unknown cause, ~40-60yrsSx: Unilateral or bilateralVERTIGO +- N&VTINNITUSHEARING LOSSSENSATION OF AURAL PRESSUREDx = clinical + audiometry Mgmt = 1) Acute attack:Best rest & reassurance, antihistamine (eg cinnarizine), prochlorperazine buccal/IV2) Prophylaxis: BETAHISTINE (decrease frequency and severity)

FLUCTUATING, EPISODIC PATTERN:

ACUTE ATTACKS

= MINS-HRS, CLUSTERS (6-11/YR)Remission of sx = vary (usually months)

MUST INFORM DVLA!!

EARS: VERTIGO – LABYRINTHITIS AND VESTIBULAR NEURITIS

Labyrinthitis

Inflammation of membranous labyrinth AND vestibular nerve

Usually follows URTIF>M, adults ~30-60yrsSx:SUDDEN, SEVERE, INCAPACITATING ROTATIONAL VERTIGONOT TRIGGERED BY MOVEMENTHEARING LOSSN&VPRECEDING URTI SXDx: clinical  audiometry + o/e HINTSMgmt: SELF LIMITING (1-3wks)Antihistamine – cerazine, cyclizine Prochlorperazine Corticosteroids (eg Pred)Bed rest + oral fluidsDO NOT DRIVE!

Vestibular Neuritis

Inflammation of

VESTIBULAR NERVE ONLY

Usually follows

URTI OR REACTIVATION OF LATENT HSV

F>M, adults ~40-50yrs

Sx

:

SUDDEN, SEVERE, INCAPACITATING ROTATIONAL VERTIGO

NOT TRIGGERED BY MOVEMENT

GAIT INSTABILITY

NO HEARING LOSS!!

N&V

PRECEDING URTI SX

Dx:

clinical

 audiometry + o/e HINTS

Mgmt

:

SELF LIMITING

(1-3wks)

Antihistamine –

cerazine

,

cyclizine

Prochlorperazine

Corticosteroids (

eg

Pred

)

Bed rest + oral fluids

DO NOT DRIVE!

EARS: OTALGIA – OTITIS EXTERNA

Inflammation

of

outer ear Aetiology:Infectious  90% bacterial, 10% fungal Irritants/inflammation  psoriasis, dermatitis, hearing aids, ear plugs, swimming etcPresentation: Otalgia Itching  ear canal erythema, oedema, exudateHearing loss +- Fever, preauricular lymphadenopathyIx – clinical diagnosis +- swab  MC&SRx – a) Topical Abx or combined abx + steroid, remove canal debris + analgesia b) PO Abx if spreading + empirical use of antifungal

WATCH OUT!!...NECROTISING OTITS EXTERNA

Life-threatening!! RARE

OE extends to mastoid and temporal bones

 erodes bone + cartilage

Usually P. aeruginosa or

S.aureus

Sx

: pain + oedema, fever, headache, exudate, RED FLAG = FACIAL NERVE PALSY

Signs: abscess, granulation tissue

Ix: CT/MRI

Rx: ABX

 IV gentamicin/ciprofloxacin/flucloxacillin

EARS: OTALGIA - ACUTE OTITIS MEDIA

Inflammation of middle ear  usually follows URTI VERY COMMON – children mainlyWinter>summerRFs: Children = young age, household smoking, craniofacial abnormality (eg cleft palate)Adults = smoking, ET dysfunction, URTI, allergies, chronic sinusitis, immunosuppression

Clinical presentation: OtalgiaFever + malaiseCoryzal sxIrritability, poor feeding, restlessnessHearing loss (conductive)

Ix: CLINICAL DIAGNOSIS Audiometry if chronic hearing loss CT/MRI – complications (eg meningitis, mastoiditis, facial nerve palsy)

Rx: Sx relief – analgesia and antipyretics = Para, NSAIDSPO ABX – Amoxicillin 5days (if pen allergic = erythromycin/clarithromycin)Recurrent AOM = ENT referral

O/E

- pyrexial, red/yellow bulging TM, red pinna, +- discharge

COMPLICATIONS:

OME, TM perforation

Infratemporal infection = labyrinthitis, mastoiditis, facial nerve palsy

Intracranial infection = meningitis, encephalitis, brain abscess

EARS: OTALGIA – OTITIS MEDIA WITH EFFUSION

AKA

GLUE EAR = collection of fluid in middle ear Due to chronic inflammation = AOMCommonly children***NB – middle ear fluid in adults SUSPICIOUS  MUST exclude head/neck tumour*** Presentation:CONDUCTIVE HEARING LOSSMild intermittent otalgiaAural fullness sensation +- crackling/poppingHx of recurrent URTI, AOM, +- balance problems O/E – opaque (yellow), intact, retracted TM – no signs of inflammation or discharge, loss of light reflex, presence of bubblesIx - Audiometry, Tympanogram = flat, underlying causes excludedRx:Reassure parents  self limiting within ~1yr, recurrence commonGrommet insertion (surgery) Hearing aids

EARS: MASTOIDITIS

Suppurative infection of middle ear

Infection of mastoid air cells

Inflammation of mastoid

Bony destruction

Risk Factors:

young children (6-13m), IC, cholesteatoma, AOM/OME

Infecting organisms:

Strep pneumoniae

Strep pyogenesStaph aureusPseudomonas aeurginosaH.influenzae

Clinical Presentation:OTALGIA PAIN BEHIND EARSWOLLEN, TENDER RED MASS BEHIND EARPROTRUSION OF PINNAFEVERo/e – bulging, red TM+- discharge, perforation

Ix: bloods, blood cultures, discharge culture, audiogram, skull xray +- LP, CT/MRI

Mgmt: IV abx – 3rd gen cephalosporin 1-2 daysPara, NSAIDOral abx 1-2wksSurgery – mastoidectomy

Complications:Hearing loss, osteomyelitis, subperiosteal abscess, CN palsies (V, VI, VII), intracranial spread

NOSE (AND FACE): SINUSITIS

Acute = <4wksUsually viral causeSx: Non-resolving URTI sx >1wkFacial tendernessFeeling of facial pressure – worse on bending forwardsDecreased sense of smellRx: Antipyretic – ParacetamolIntranasal decongestantNasal douching + warm face packs**ABX if severe/prolonged**Completely resolves

Sinusitis = inflammation of membranous lining of one or more sinuses

Risk Factors:

URTIAllergic rhinitisAsthmaImmunocompromisedDental ProblemsChurg-StraussWegner’s

Chronic = >12wksOften assoc with nasal polypsSx: Dull ache on palpationNasal purulenceLoss of smell Rx: Nasal corticosteroids (eg beclomethasone)

Complications:

Orbital cellulitis

Meningitis

Osteomyelitis

Cavernous venous thrombosis

Intracranial abscess

NOSE (AND FACE): BELL’S PALSY

CN VII  controls muscles of faceACUTE, UNILATERAL, IDIOPATHIC FACIAL NERVE PARALYSISAny age, peak 20-40yrsLMN PALSY = FOREHEAD AFFECTED Sx: vary mild - severeFacial sagging with weak muscles of facial expressionDrooping eyelid Drooping corner of mouthLoss of nasolabial foldHyperacusis Dry mouth, altered tasteDecreased tear productionDx = clinical Rx - Prednisolone PO 10 days within 72 hours - Artificial tears Prognosis – commonly spontaneous resolution

RAMSAY HUNT SYNDROME

Varicella zoster LMN facial nerve palsy

Peripheral facial neuropathy +

erythematous rash/vesicles on ipsilateral ear (+- hard palate, ant 2/3rds tongue)

Sx

– PAIN PROMINENT, HEARING LOSS +

sx

of CNVII palsy

Rx:

Acyclovir within 72hours

THROAT: SORE THROAT

Pharyngitis Aetiology = viral/bacterial (strep pyogenes - GABS)Presents: FeverOdynophagiaURTI Sx - cough, rhinorrhoea, headache, malaise+- hoarse voice GABS = SCARLET FEVER  red, punctate skin eruption, strawberry tongue, flushed faceIx – only if sx persist Rx – reassure self-limiting (~1wk), antipyretics + fluids

Laryngitis

Inflammation of vocal cords and larynx

Acute <3wks

 bacterial/viral/fungal infection

Chronic >=3weeks

 reflux, asthma, smoking, trauma, meds, AI disease

Sx

:

Fever/malaise

Hoarse voice

Ant neck pain

Dysphagia

Globus (lump in throat)

Ix:

Laryngoscopy,

bloods, sputum culture, laryngeal swab,

xray

neck

Rx:

Acute = self limiting

 vocal hygiene +-

abx

(if purulent sputum or IC)

Chronic = vocal hygiene + voice therapy

THROAT: SORE THROAT - TONSILLITIS

ANY AGE – commonly children 5-14yrs or young adults 15-25yrs

Causative Organisms:

GROUP A STREP = STREP PYOGENESStaph, Moraxella catarrhalis, Haemophilus influenzae, Mycoplasma

Clinical Presentation:Sx:SORE THROAT >= 48 HRSHIGH GRADE FEVERODYNOPHAGIAHEADAHCELOSS OF VOICE/CHANGESPREFERRED OTALGIAADBO PAINSigns:ERYTHEMATOUS THROATSWOLLEN, COATED TONSILSSWOLLEN REGIONAL LNS

Ix:

clinical dx +- bloods (FBC, CRP), throat swab

Management:Reassurance RestFluidsAntipyretic - paracetamolABX or no ABX?!  CENTOR CRITERIA**>= 3 = ABX**PHENOXYMETHYLPENICILLIN PO 10 DAYSSurgery = TONSILLECTOMY

Complications:

peritonsillar abscess, acute OM, RF, glomerulonephritis, scarlet fever, sleep apnoea

THROAT: SORE THROAT – GLANDULAR FEVER

INFECTIOUS MONONUCLEOSIS

 caused by EBV

Usually adolescents

Clinical Presentation:

Sx

:

Low-grade feverFatigue/Malaise  may persist for months post acute infection resolutionSore throatNausea/AnorexiaSigns:Tonsillar enlargement  exudatePalatal petechiaeFine, macular non-pruritic rash Lymphadenopathy LATER - hepatosplenomegaly

Associated with Burkitt’s lymphoma, B-cell lymphoma, undifferentiated carcinomas

Ix:

IM heterophil antibodies

MONOSPOT TESTEBV specific antibodiesViral capsid antigensEBV nuclear antigenBloods – FBC, ESR, LFTsThroat swab

Management:SUPPORTIVE:PARABED RESTFLUIDS PO/IV

AVOID AMOXICILLIN IN ANYONE WITH SUSPECTED IM

WIDESPREAD ITCHY MACULOPAPULAR RASH

WATCH OUT!!!

AVOID CONTACT SPORT 8WKS POST IM…

AT RISK OF SPLENIC RUPTURE

THROAT: SORE THROAT - QUINSY

Pus trapped between tonsillar capsule and lateral pharyngeal wallUsually complication of acute tonsillitis or glandular fever Most commonly teensCausative organisms:Strep pyogenesStaph aureusHaemophilus influenzaeSx:SEVERE SORE THROATFEVER/MALAISEDROOLING SALIVAFOUL-SMELLING BREATHOYDNOPHAGIATRISMUS  due to pterygoid muscle spasmALTERED VOICE QUALITYOTALGIANECK STIFFNESS

Signs: Cervical lymphadenopathyUvula deviated AWAY from lesionUnilateral tonsil bulgingDx: clinical Management:AnalgesiaIV fluidsIV abx  benzylpenicillin/amoxicillin Surgery  NEEDLE ASPIRATION or INCISION AND DRAINAGEQuinsy tonsillectomy (6wks post quinsy)

THROAT: SALIVARY GLAND SWELLINGS

PAROTITIS:

Viral/bacterial

Presents:

Painful, tender swelling near ear

Dry mouth

Difficulty opening mouth

Pain on eating

Fever

Foul taste

N.B MUMPS = bilateral swelling >=1 + low grade pyrexia

Ix – Bloods, viral serology, salivary antibody testing, pus swab cultures,

USS, sialography

, CT/MRI

Rx – MUMPS = self-limiting

Suppurative =

abx

+- incision and drainage

THROAT: SALIVARY GLAND SWELLINGS

ObstructionStones most common causeSubmandibular or parotid gland usuallySx: colicky pain + swelling at meal timesIx: USS, sialography (contrast + xray)Rx: may pass spontaneously – hydration, warm compress, gland massage Surgical removal

Sialadenosis

Generalised non-inflammatory,

painless bilateral swelling of gland

(usually parotid)

Caused by

hypertrophy

of

acinar

component

ASSOCIATED WITH SYSTEMIC DISEASE

– Sjogren's, sarcoid, malnutrition - anorexia, endocrine disorders

Ix:

Sialography

– sialectasis (cystic dilatation of ducts), biopsy, autoantibodies,

Rx:

Pilocarpine

- for hyposalivation, ? refer to

rheumatology