ENT

Page created on January 4, 2020. Last updated on February 10, 2022 at 20:46

Shout-out to Mishe Katanchi and my boy Hatem Abo Obaid

1. Pure tone audiometry, speech audiometry

• Subjective audiometry
  • Involve attention, reaction time, cooperation, etc
• Pure tone audiometry
  • The patient is played various frequencies through a headphone (air conduction) and a bone oscillator on mastoid bones
  • Various frequencies are played -> patient gives signal when hearing the sound
  • Auditory threshold is determined for each frequency for each modality
• Speech audiometry
  • Increasingly loud words are played, which the patient should repeat
    • The percentage of syllables, words or sentences heard is plotted on audiogram
  • Also involves speech recognition
• Conductive hearing loss
  • Impaired conduction of sound through outer ear, tympanic membrane or middle ear
  • Children and young adults
  • Etiology
    • Tympanic membrane perforation
    • Otitis media
    • Barotrauma
    • Otosclerosis
  • Diagnosis
    • Pure tone audiometry
      • Auditory threshold increased for air conduction
      • Auditory threshold normal for bone conduction
    • Speech audiometry
      • Increasing loudness eventually leads to 100% speech comprehension
    • Rinne test
      • Unable to hear tuning fork after moving it from mastoid to outer ear
• Sensorineural hearing loss
  • Lesion of cochlea, vestibulocochlear nerve or central auditory pathways
  • Adults and elderly
  • Etiology
    • Congenital
    • Acquired
      • Presbycusis (aging) (most common cause)
        • Especially high frequencies
      • Ototoxicity
      • Meniere disease
      • Acoustic neuroma
      • Noise-induced hearing loss
      • Trauma
      • Otitis interna
      • Diabetic otopathy
  • Diagnosis
    • Pure tone audiometry
      • Auditory threshold increased for both air and bone conduction
    • Speech audiometry
      • Increasing loudness never leads to 100% speech comprehension
• Combined hearing loss
  • Diagnosis
    • Pure tone
      • Auditory threshold is increased for both air and bone conduction, but it is increased more for air conduction
• Tuning fork tests
  • Distinguish conductive and SNHL
  • Weber test
    • Tests for lateralization (sound is louder in one ear)
    • Base of tuning fork on the middle of forehead – bone conduction to cochlea
    • Interpretation
      • Lateralization to one ear = contralateral sensorineural HL or ipsilateral conductive HL
      • No lateralization = normal hearing or bilateral HL
  • Rinne test
    • Tests for air conduction and bone conduction
    • Base of tuning fork on the mastoid process
      • -> which side is louder?
      • -> when the patient no longer hears the tone, move front of the fork to the outer ear and ask if the patient still hears it
        • Air conduction is greater than bone, so patient should still hear the fork
    • Interpretation
      • Sound is louder with air than bone conduction (positive Rinne) = no conductive HL in examined ear
      • Sound is louder with bone than with air conduction (negative Rinne) = conductive HL in examined ear

2. Otoacoustic emissions, brainstem evoked response audiometry

• Objective audiometry
  • Doesn’t depend on cooperation and subjective responses of patient
• Otoacoustic emissions
  • Vibrations of hair cells in cochlea are transmitted back through the conducting apparatus
  • Test can only be performed if the middle ear function is normal
  • A microphone in the ear canal can detect otoacoustic emissions
  • Test reflects functional integrity of cochlea
  • Indications
    • Screening for cochlear function in newborns
      • Cochlear lesions are the major cause of hearing loss in this population
  • Two types
    • Spontaneous otoacoustic emissions
      • Spontaneous, without external stimulus
    • Evoked otoacoustic emissions
      • Stimulated externally
      • Transient evoked OAEs
        • Brief stimulus
      • Distortion product OAEs
        • Two continuous stimuli which distort each other
• Brainstem evoked response audiometry
  • EEG above mastoid detects the activity of the auditory brainstem response in response to short stimuli
    • Five characteristic waves are seen on the averaged EEG
  • Infants must be sleeping or sedated
  • Indications
    • Determine auditory threshold objectively
    • Intraoperative monitoring
    • Differentiate cochlear and retrocochlear hearing loss

3. Diseases of the pinna and the external ear canal

• Auricle (pinna)
  • Elastic cartilage
  • Collects sound waves
  • Diseases
    • Malformations
      • Protruding ears
      • Auricular appendages
      • Congenital auricular fistulas
        • Infections
      • Microtia
      • Anotia
      • Stenosis of ear canal
      • Creased lobule (CAD)
    • Inflammation (often bacterial/viral)
      • Often with otitis externa
      • Acute
        • Herpes zoster oticus
        • Cellulitis, dermatitis
        • Perichondritis
      • Chronic
        • Eczema
    • Trauma
      • Perichondral haematoma (cauliflower ear)
        • Accumulation of blood in perichondrium
      • Frostbite
      • Piercings
• External ear canal
  • Outer third is cartilage, inner 2/3 is bone
  • Thin keratinized stratified squamous epithelium
  • Contains ceruminous glands -> produce cerumen
  • Diseases
    • Swimming, Q-tip use, scratching
    • Acute
      • Diffuse otitis externa
      • Circumscribed otitis externa
      • Bullous otitis externa
    • Chronic
      • Necrotizing otitis externa (pseudomonas)
      • Eczema
      • Fungal infection (otomycosis)
      • Cholesteatoma
  • Symptoms
    • Otorrhoea
    • Pain
    • Conductive hearing loss

4. Diseases of the tympanic membrane, tumours of the external ear (benign, malignant tumours)

• Tympanic membrane
  • Divided into four quadrants be the longitudinal axis of the handle of the malleus and a line perpendicular to it
  • Anterosuperior quadrant
    • Pars tensa
  • Posterosuperior quadrant
    • Vessels
    • Nerves
    • Middle ear bones
  • Anteroinferior quadrant
    • Light reflex
  • Posteroinferior quadrant
    • Nothing
  • Surgery
    • Paracentesis – needle puncture to drain fluid
    • Myringotomy – incision, insertion of tube
    • Anteroinferior or posteroinferior quadrant!
  • Diseases
    • Perforation, rupture
    • Myringitis granulosa
      • Type of otitis externa where granulation tissue forms in the tympanic membrane
    • Myringitis bullosa
      • Bulla on membrane
    • Barotrauma
      • Airplane
      • Divers
    • Retraction
      • Negative pressure in middle ear
      • Flat membrane, no light reflex
      • Due to eustachian tube closing
• Tumours of external ear
  • Auricle
    • Most are epithelial
    • Kerato-acanthoma
    • Rheumatoid nodules
    • Epidermal cyst
    • Haemangioma
    • Seborrheic keratosis
    • Atheroma
    • Actinic keratosis
    • Cutaneous horn
    • BCC
    • SCC
    • Malignant melanoma

5. Serous otitis media (acute, chronic)

• Serous otitis media = otitis media with effusion
  • Middle ear fluid without acute signs of infection
  • Due to obstruction of Eustachian tube -> air absorbed in middle ear -> negative pressure in middle ear -> exudate in middle ear
  • Usually resolves by itself
  • Risk factors
    • Cleft palate and other midface anomalies
    • 6 – 18 months
    • Impaired ventilation of middle ear
      • Upper respiratory viral infection with swelling
      • Obstruction of eustachian tube by tumor or adenoid hyperplasia
      • Tensor veli palatini dysfunction
    • Acute – up to 3 weeks
    • Subacute – 3 weeks – 3 months
    • Chronic – longer than 3 months
      • Cholesteatoma may form
  • Clinical features
    • Mostly asymptomatic
    • Conductive hearing loss
    • Pressure in ear
    • Tinnitus
    • Balance problems
    • Retracted tympanic membrane
  • Treatment
    • Conservative
      • Decongestants
      • Valsalva manoeuvre
    • Surgical
      • For chronic OME
      • Paracentesis
      • Myringotomy
      • Adenectomy

6. Suppurative otitis media (acute, chronic)

• Acute (suppurative) otitis media
  • Epidemiology
    • Infants
    • Small children
    • 80% by 3 years of age
  • Etiology
    • Bacterial superinfection (on viral URTI) which ascends through eustachian tube
    • S. pneumoniae
    • H. influenzae
  • Risk factors
    • Previous AOM
    • Chronic otitis media
    • Parental smoking
  • Protective factors
    • Prolonged breastfeeding
    • Pneumococcal vaccine
  • Clinical features
    • Ear pain
      • Infants repeatedly touch the ear
    • Fever
    • Discharge from ear
      • Only if there is spontaneous tympanic perforation
    • Conductive hearing loss
  • Diagnosis
    • Early: Retracted, hypomobile tympanic membrane
    • Then: Bulging tympanic membrane
      • Due to accumulation of pus
    • Loss of light reflex
  • Treatment
    • NSAIDs
    • Not decongestants! – prolong course
    • Antibiotics
      • Only in < 2 years, or > 2 years if bilateral, no resolution in 2 days
      • Amoxicillin
      • Clavulanic acid added if treatment failure
• Chronic suppurative otitis media
  • Persistent drainage from middle ear through perforated tympanic membrane lasting > 6 weeks
    • Perforated tympanic membrane usually heals within weeks
    • No healing -> sign of chronic inflammation
  • Older children
  • Bacteria enter through perforated TM
  • Clinical features
    • 3 yes 1 no
    • Yes: Perforation of TM
    • Yes: Ear discharge
    • Yes: Conductive hearing loss
    • No: No pain
  • Two types
    • Mesotympanic
      • Central perforation
      • Treatment: tympanoplasty
    • With cholesteatoma
      • Cholesteatoma: keratinizing squamous epithelium found in bony spaces, and the bone is destroyed by inflammatory osteoclastic process
        • In TM, auditory canal or mastoid
      • Can become infected
      • Marginal perforation
      • Brown irregular mass
      • Imaging to assess bone destruction
      • Treatment: surgery

7. Complications of suppurative otitis media

• Intratemporal complications
  • Mastoiditis
    • Children
    • Infection spread to mastoid -> collection of pus -> destruction of air cells -> empyema
    • Antibiotics
      • Always!
      • Vancomycin
    • Mastoidectomy in severe cases
  • Peripheral facial nerve palsy
  • Labyrinthitis
    • Inflammation of inner ear
    • Vertigo
    • Nystagmus
    • Sensorineural hearing loss
• Intracranial complications
  • Meningitis
  • Otogenic abscess
    • Epidural, subdural or cerebral
    • Headache
  • Sinus thrombosis
• Extracranial complications
  • Bezold abscess
    • Deep to sternocleidomastoid, pus from mastoiditis erodes through the mastoid part of the temporal bone

8. Idiopathic facial nerve palsy, Bell palsy

• Facial nerve palsy
  • Loss of function of facial nerve
  • Idiopathic, peripheral facial palsy = Bell palsy
  • Etiology
    • Idiopathic
    • Secondary
      • Trauma
      • Otitis
      • Herpes zoster oticus
      • Tumor
      • Diabetes
      • Guillain-Barre syndrome
      • Sarcoidosis
      • Stroke
  • Types
    • Central
      • Unilateral lesion between cortex and brainstem nuclei
      • Muscles of eyelids and forehead are preserved
      • Paralysis of contralateral lower facial muscles
    • Peripheral
      • Unilateral lesion between brainstem nuclei and muscles
      • Paralysis of eyelids and forehead
      • Paralysis of ipsilateral lower facial muscles
  • Clinical features
    • Sensory disturbances
      • Painful sensations around ear
      • Numbness of face
      • Abnormal taste
      • Hyperacusis
    • Dry mouth
    • Lagopthalmos
      • Can’t fully close their eyelids
      • Dehydration -> keratitis
    • Involuntary movements of facial muscles
  • Prognosis
    • Idiopathic: 90% recover within 3 weeks
  • Bell’s phenomenon
    • Reflexive movement of the eye upward and outward when the eyelid is kept open but the patient tries to close it
• Bell palsy
  • Oral glucocorticoids (e.g., prednisone): should be administered within 72 hours from the disease onset
  • In severe cases: add antivirals (acyclovir, valacyclovir) for 1 week 
  • Eye care: artificial tears, sleeping masks
• Secondary facial nerve palsy: management of the underlying cause

9. Disorders of the inner ear, congenital malformations, hereditary deafness

• Disorders of the inner ear
  • Benign paroxysmal positional vertigo
  • Trauma
  • Labyrinthitis
    • Complication of AOM
    • Hearing loss
    • Vertigo
  • Vestibular neuritis
    • Idiopathic
    • Possibly viral
    • No hearing loss
    • Vertigo
    • Positive head thrust test
  • Acoustic neuroma
  • Meniere syndrome
• Congenital malformations
  • Michel aplasia = complete labyrinthine aplasia
  • Mondini aplasia
    • 1,5 turns of cochlea instead of 2,5
    • Sensorineural hearing loss
  • Congenital CSF otorrhoea
    • Fistula of oval window
  • Thalidomide embryopathy
• Hereditary deafness
  • Syndromic hereditary hearing loss
    • Down syndrome
  • Non-syndromic hereditary hearing loss
    • Congenital form
      • Autosomal recessive
      • Only lack of hearing
      • Symmetrical
      • Present at birth
    • Later-onset form
      • Hearing loss occurs later
      • Autosomal dominant

10. Trauma of the temporal bone (longitudinal, transverse fractures)

• Temporal bone fracture
  • Often with fractures of calvaria and brain injury
  • Thin-slice CT
  • Complications
    • CSF leak
      • Air in intracranial cavity
      • CSF otorrhoea
      • CSF rhinorrhoea
      • Meningitis
      • Brain abscess
      • Surgery only if it persists
    • Cochleovestibular symptoms
      • Conductive (fluid in middle ear)
      • Sensorineural (fracture of labyrinth)
        • Vertigo
        • Nausea
    • Facial nerve symptoms
  • Types
    • Longitudinal fractures
      • Fracture runs along the external auditory canal and the anterior border of the petrous pyramid
      • Most common
      • Lateral trauma
      • Clinical features
        • Ear discharge with blood and/or CSF
        • Hearing loss
        • Delayed facial paralysis
        • Tearing of meatal skin and TM
      • Complications
        • Fracture of auditory ossicles
        • Meningitis
        • Otitis media
      • Treatment
        • Conservative
        • Surgery if complications
    • Transverse fractures
      • Fracture runs across the petrous pyramid along the internal auditory canal and/or through the labyrinth
      • Vestibule, cochlea destroyed
      • Frontal trauma
      • Much less common
      • Clinical features
        • Vestibular symptoms
        • Hearing loss
        • Immediate facial paralysis
        • No otorrhoea
        • Haemotympanum
      • Complications
        • Higher risk of meningitis
        • Hearing and vestibular function never recovers
      • Treatment
        • Conservative
        • Surgery if CSF leak

11. Otosclerosis, tympanosclerosis

• Otosclerosis
  • Abnormal bone growth of the bony labyrinth
  • The stapes becomes increasingly fixated to the oval window -> progressive conductive HL
  • Can also affect cochlea
  • Epidemiology
    • Whites
    • Females
    • Adults
  • 50% autosomal dominant, 50% sporadically
  • Diagnosis
    • Decreased air conduction on pure tone
    • Carhart notch on audiogram
    • Normal otoscopy
  • Treatment
    • Stapes replaced by prosthesis – stapedotomy
• Tympanosclerosis
  • Scarring of tympanic membrane and cavity due to recurrent otitis externa or media
  • Asymptomatic or conductive hearing loss due to fixation of ossicles
  • White calcified plaques on otoscopy
  • Myringosclerosis – only tympanic membrane
    • Rarely symptoms
  • Treatment
    • Surgical removal of sclerosis
      • Usually recurs

12. Fluid systems of the labyrinth, Meniere’s disease, toxic lesions of the inner ear

• Fluid systems of the labyrinth
  • Membranous labyrinth
    • Filled with K-rich endolymph
    • Contains hair cells
    • Divided into vestibule and cochlear duct
  • Bony labyrinth
    • Contains membranous labyrinth in Na-rich perilymph
    • Three cavities
      • Scala media (cochlear duct)
        • Filled with endolymph
        • Basilar membrane forms the floor of it
      • Scala vestibuli
        • Filled with perilymph
        • Above and separated from scala media
        • Connected to scala tympani at helicotrema
      • Scala tympani
        • Filled with perilymph
        • Below and separated from scala media
        • Runs downward from helicotrema to the round window
  • Oval window vibrates -> sound waves transmitted in perilymph in scala vestibuli
    • -> sound waves vibrate the vestibular membrane and basilar membrane, thus stimulating hair cells
    • -> sound waves travel through helicotrema -> down the scala tympani -> to the round window
  • Low frequency waves act at apex of cochlea
  • High frequency waves act at base of cochlea
• Meniere disease (idiopathic endolymphatic hydrops)
  • Impaired resorption of endolymph causes accumulation
  • Epidemiology
    • Females
    • Older adults
  • Clinical features
    • Meniere triad
      • Episodes lasting from minutes to hours
      • 3 yes 1 no
      • Yes: Sensorineural HL
      • Yes: Repeated attacks of vertigo
      • Yes: Tinnitus
      • No: No neurological signs
  • Diagnosis
    • Criteria
      • >1 episode that lasts 20 minutes to 12 hours
      • Low-mid frequency SN hearing loss
      • Tinnitus
  • Treatment
    • Avoid triggers (stress, alcohol, caffeine)
    • Low sodium diet
    • Rehabilitation
    • Bed rest
    • Drugs
      • First generation antihistamines
      • Histamine analogues
      • Gentamycin in ear – destroy vestibule
    • Surgery
      • Labyrinthectomy
      • Sacculotomy
      • Vestibular neurectomy
• Toxic lesions
  • Etiology
    • Endogenous
      • Metabolic diseases
        • Diabetes mellitus
        • Uraemia
      • Bacterial toxins
    • Exogenous
      • Aminoglycosides
      • Loop diuretics
      • Cytostatic drugs
      • Salicylates
      • Industrial solvents
      • Heavy metals
      • Alcohol
      • Illegal drugs
  • Serous labyrinthitis
    • Bacterial toxins from chronic otitis media

13. Acoustic tumours, noise induced hearing losses

• Acoustic neuroma = vestibular schwannoma
  • In internal acoustic canal or cerebellopontine angle
  • Benign tumor of Schwann cells
  • Older adults
  • Unilateral – spontaneous
  • Bilateral – NF2
  • Clinical features
    • Early symptoms
      • Unilateral SNHL
      • Tinnitus
      • Dizziness
      • Unsteady gait
    • Late symptoms – compression of cerebellopontine angle
      • Trigeminal nerve – paraesthesia or facial pain
      • Facial nerve – facial palsy
      • Cerebellum – ataxia
      • 4th ventricle – hydrocephalus
  • Diagnosis
    • Pure tone audiometry – SNHL of higher frequencies
    • Brainstem-evoked audiometry
    • Contrast MRI
  • Treatment
    • Surgery or radiation – if large or significant symptoms
    • Observation
• Noise-induced hearing loss
  • Excessive noise causes direct mechanical and metabolic injury
  • Types
    • Acute acoustic trauma
      • < 1,5 ms sound of >140 dB
      • Gunshot, airbags, fireworks
    • Blast injury
      • Pressure wave ruptures tympanic membrane
    • Acute noise-induced hearing loss
      • Seconds – hours
      • Jet engine, concerts, power tools
      • Often reversible
    • Chronic noise-induced hearing loss
      • Chronic exposure to loud sounds
      • Loud music, party
  • Clinical features
    • Muffled sensation
    • Tinnitus
  • Diagnosis
    • Hearing threshold decreased at all frequencies, especially 3 – 6 kHz

14. Tinnitus

• An auditory sensation that occurs in the absence of external acoustic or electrical stimulus
• Nonspecific symptom of an auditory system abnormality
• Types
  • Subjective tinnitus
    • Conductive tinnitus
      • Obstruction of the ear canal
      • Middle ear disease
    • Sensorineural tinnitus
      • Damage to cochlea
      • Damage to cochlear nerve
    • Central tinnitus
      • Damage to central auditory pathway
  • Objective tinnitus
    • Vascular tinnitus
      • Vascular malformations
      • AV fistulas
    • Myogenic tinnitus
      • Velopharyngeal myoclonus
      • Middle ear myoclonus
• Compensated – if it doesn’t compromise life quality
• Decompensated – if it causes disability or suffering
• Worsening factors
  • Stress
  • Caffeine
  • Alcohol
  • Nicotine
  • Sleeping problems
• Classification according to time
  • Acute – < 3 months
  • Subacute – 4 – 12 months
  • Chronic > 12 months
• Diagnosis
  • Patient history
  • Audiometry
  • Neurological examination
  • MRi – if unilateral, asymmetric or pulsatile
• Treatment
  • IV lidocaine (temporary)
  • Tinnitus retraining therapy
    • Break link between tinnitus and negative emotions
  • Masking with white noise

15. Cochlear implantation

• Cochlear implants are prosthetic devices surgically implanted into the temporal bone
• They stimulate the auditory nerve directly via intracochlear electrodes
• A microphone and speech processor behind the hear picks up and processes the sound
• The sound is then sent wirelessly through the skin to the cochlear implant
• Prerequisite: Functional auditory nerve and central auditory pathway
  • Promontory test – direct stimulation of promontory reveals whether the auditory nerve and central auditory pathway work
• Indications
  • Moderate – severe SNHL
  • Lack of benefit from hearing aids
• Follow-up
  • Technical check of implant function and speech processor
  • Adjusting the speech processor
  • Auditory training – the patient must learn to interpret the electrical impulses as speech
  • Sign language and lip reading should also be taught

16. Sleep apnoea

• Sleep apnoea – respiratory arrest for > 10 seconds during sleep
• Obstructive sleep apnoea
  • Collapse of pharyngeal muscles during sleep
  • Epidemiology
    • Male
    • Old age
  • Risk factors
    • Obesity, especially around the neck
    • Enlarged
      • Tonsils
      • Uvula
      • Tongue
      • Soft palate
    • Smoking
    • Family history
    • Alcohol
  • Pathophysiology
    • Hypoxaemia
      • -> Sympathetic activity -> secondary hypertension
      • -> pulmonary vasoconstriction -> cor pulmonale
      • -> EPO -> polycythaemia
      • -> arrhythmia
    • Hypercapnia
      • -> Respiratory acidosis
  • Clinical features
    • Loud, irregular snoring
    • Third party witness periods of apnoea
    • Daytime sleepiness
    • Cognitive dysfunction
  • Diagnosis
    • Polysomnography
  • Treatment
    • Weight loss
    • Avoid risk factors
    • Esmarch splint – keeps airway open
    • CPAP
    • Surgery – to remove enlarged parts
• Central sleep apnoea
  • Impaired function of respiratory centre
  • Etiology
    • Heart failure
    • Stroke
    • Brainstem tumor
    • Idiopathic
  • Features and treatment similar to OSAS

17. Benign/malignant tumours of the paranasal sinuses

• Diagnosis
  • Histology
  • CT to determine extent
• Benign
  • Clinical features
    • Nasal airway obstruction
      • Sinusitis
    • Headache
    • Epistaxis
    • Anosmia
  • Inverted papilloma
    • Epithelial tumor
    • Endophytic growth
    • Locally aggressive
    • Can transform into SCC
    • Surgical removal
  • Fungiform papilloma
    • Exophytic growth
  • Osteoma
    • Asymptomatic until they obstruct drainage of paranasal sinuses
    • Surgical removal when it becomes symptomatic
• Malignant
  • More common than benign
  • 80% are epithelial
  • 20% adenocarcinoma, lymphoma, melanoma, sarcoma
  • Nasal cavity > maxillary sinus > ethmoid cells
  • Older adults
  • Clinical features
    • Nasal airway obstruction
    • Bloody rhinorrhoea
    • Nasal odour
    • Refractory unilateral sinusitis
    • Advanced
      • Swelling
      • Pain
      • Numbness of cheek
      • Orbital infiltration
  • Diagnosis
    • Endoscopy
    • Search for lymph node metastases
    • CT/MRi
  • Treatment
    • Surgery and postoperative radiation
    • Facial reconstruction
    • Neck dissection if metastases (only 20% of cases)

18. Obstruction of the nasal airway, rhinitis (forms of rhinitis, except allergic rhinitis)

• Nasal airway obstruction
  • Clinical features
    • Difficulty in nasal breathing, eating, sleeping
    • Nasal congestion
    • Headache
    • Epistaxis
  • Differential diagnosis
    • Acute rhinitis
    • Chronic rhinitis
    • Rhinosinusitis
    • Deviated septum
    • Septal perforation
    • Adenoids (pharyngeal tonsil hyperplasia)
    • Turbinate hyperplasia
    • Nasal polyp
    • Tumours of nose, paranasal sinuses
    • Foreign bodies
    • Nasal decongestant abuse
• Rhinitis
  • Acute rhinitis (common cold)
    • Etiology
      • Rhinovirus
      • Coronavirus
      • Influenzavirus
      • Adenovirus
    • Droplet infection
    • Risk factors
      • Cold exposure
    • Clinical features
      • Initial dry stage
        • Malaise
        • Headache
        • Fever
      • Catarrhal stage
        • Watery, serous rhinorrhoea
        • Nasal obstruction due to swelling
      • (Bacterial superinfection)
        • Mucopurulent rhinorrhoea
    • Treatment
      • Nasal decongestants
      • Steam inhalation
  • Chronic rhinitis
    • Non-specific
      • Etiology
        • Recurrent acute rhinitis with progressive mucosal damage
        • Septal deviation
        • Septal spur
        • Nasal polyps
        • Nasal cavity tumours
      • Clinical features
        • Nasal obstruction
        • Mucous nasal discharge
        • Hoarseness
      • Treatment
        • Remove offending irritant
        • Surgically correct pathology
        • Nasal decongestants (temporary benefit)
    • Specific
      • Tuberculosis
      • Sarcoidosis
      • Actinomycosis
      • Syphilis
      • Aspergillosis
  • Rhinitis medicamentosa
    • Rebound nasal congestion due to nasal decongestant withdrawal

19. Allergic rhinitis

• Type I hypersensitivity
• Types
  • Seasonal (hay fever)
    • Pollen
    • February – September
    • No symptoms the rest of the year
  • Perennial
    • Indoor allergens
    • House dust
    • Pets
    • Moulds
    • Latex
• Clinical features
  • Nasal airway obstruction
  • Sneezing
  • Watery rhinorrhoea
  • Itchy nose and eyes
• Diagnosis
  • History
  • Examination of nose
    • Bluish-purple mucosa in seasonal
    • Red mucosa in perennial
  • Allergy testing
    • Prick test
    • Radioallergosorbent test
• Treatment
  • Avoid allergen
  • Medical
    • Intranasal or oral
    • Antihistamines
    • Decongestants (xylometazoline)
    • Local steroids
    • Sodium cromoglycate
    • Muscarinic antagonists (ipratropium)
    • Antileukotrienes
  • Immunotherapy – hyposensitization
  • Resection of turbinates

20. Fractures of the paranasal sinuses. Fronto-basal, maxillo-facial, blow-out fractures, Le Fort fractures

• Fronto-basal fractures
  • Trauma to frontal bone or roof of nose
    • Car accidents
  • Escher classification
    • Escher 1 – High fracture (forehead, calvaria)
    • Escher 2 – Central fracture (low forehead)
    • Escher 3 – Low fracture (along nasal cavity? – midface separated from skull base)
    • Escher 4 – latero-orbital fracture (above and lateral to orbit)
  • Clinical features
    • CSF rhinorrhoea
    • Cranial nerve palsy
    • Raccoon eyes – haematoma around eyes
  • Diagnosis
    • High-resolution CT
  • Complications
    • Ascending infection -> meningitis, brain abscess
    • Vision loss
    • Oculomotor palsy
  • Treatment
    • All fractures should be surgically treated
• Maxillo-facial fractures
  • Etiology
    • Car accident
    • Assault
    • Fall
  • Le Fort classification
    • Le Fort 1 – separates maxilla from mid-face
    • Le Fort 2 – separates nasomaxillary complex (goes above nose)
    • Le Fort 3 – separates mid-face from skull
  • Clinical features
    • Facial oedema
    • CSF rhinorrhoea
    • Epistaxis
    • Mobile maxilla
    • Hypoesthesia of infraorbital nerve
    • Raccoon eyes
  • Treatment
    • Ensure airways
    • Facial reconstruction
• Blowout fracture
  • Isolated fracture of the orbital floor with herniation of orbital content into maxillary sinus
  • Etiology
    • High-velocity blunt trauma to the eye
    • Punch
    • Tennis ball
  • Clinical features
    • Periorbital pain, oedema, ecchymosis
    • Posteriorly depressed eye
    • Hypoesthesia of infraorbital nerve
    • Epistaxis
  • Treatment
    • Urgent stabilization

21. Acute and chronic rhinosinusitis

• Sinusitis rarely occurs without rhinitis – rhinosinusitis
• Pansinusitis – all sinuses
• Acute rhinosinusitis
  • < 4 weeks
  • Maxillary sinus > ethmoidal cells
  • Etiology
    • Spread of rhinitis
    • Viruses
      • Rhinovirus
      • Coronavirus
    • Bacteria
      • S. pneumoniae
      • H. influenzae
    • Spread of dental root infection
  • Clinical features
    • Symptoms of rhinitis
    • Pain over sinus
    • Headache – worsens when bending over
  • Diagnosis
    • Rhinoscopy/endoscopy – pus, swollen mucosa
    • Sinus radiography – partial opacification of affected sinus or fluid level
  • Treatment
    • Conservative
      • Ventilation, drainage improvement
        • Decongestants
      • Antibiotics
    • Surgery
      • Puncture of wall
• Chronic rhinosinusitis
  • > 12 weeks
  • Etiology
    • Impaired ventilation due to obstruction
    • Anatomical abnormalities
      • Septal deviation
      • Septal spur
    • Untreated acute rhinosinusitis
    • Chronic allergy
  • Clinical features (4 major signs, 4 minor)
    • 4 major signs
      • Nasal obstruction
      • Purulent nasal discharge (ant/post)
      • Anosmia
      • Facial pain
    • 4 minor signs
      • Cough
      • Dental pain
      • Fever
      • Halitosis
  • Diagnosis
    • Rhinoscopy/endoscopy
    • CT
  • Treatment
    • Conservative (symptomatic)
      • Decongestants
      • Antibiotics
    • Functional endoscopic sinus surgery (FESS) (definitive)

22. Tumours of the salivary glands (benign and malignant)

• 70% are benign
• Most are in parotid
• Ultrasound – modality of choice for salivary gland
• The smaller the gland, the higher risk that the tumor is malignant
• Lateral parotidectomy
  • Superficial – with large margin
  • As early as possible
  • Complete
  • Complications:
    • Facial nerve injury
    • Gustatory sweating
    • Gustatory hyperlacrimation
• Benign tumours
  • Clinical features
    • Slow growth
    • Painless
    • Soft or tense
    • Mobile nodule
    • No additional symptoms
  • Pleiomorphic adenoma
    • 85% of benign
    • Radiation, occupational exposure
    • Firmer tumour
    • Diagnosis
      • Histology – pleiomorphic cells
    • 5% can turn malignant
    • 5% recur
    • Treatment
      • Superficial parotidectomy
  • Warthin tumor
    • Older males
    • 10% of benign
    • Etiology
      • Radiation
      • Smoking
    • Softer tumour
    • Treatment
      • Complete surgical excision while preserving facial n.
• Malignant tumours
  • Etiology
    • Radiation
  • Clinical features
    • Rapid growth
    • Painless, fixed nodule
    • Enlarged lymph nodes
    • Infiltration of facial nerve
  • Diagnosis
    • FNAB
    • CT for infiltration
  • Types
    • Mucoepidermoid carcinoma
      • Most common in children
      • Most are low-grade
      • Painless swelling -> later becomes painful
    • Acinar cell carcinoma
      • Locally invasive
      • Older women
    • Adenoid cystic carcinoma
      • Locally invasive
      • Poor radiosensitivity
  • Treatment
    • As complete as possible removal -> radiation

23. Differential diagnosis of the neck masses (neck regions I-VII, origin of metastases)

• Children
  • 90% of neck masses in children are benign/inflammatory/congenital
  • Most common cancer – lymphoma
• Adults
  • 80% of neck masses in adults are neoplastic
  • Most common cancer – SCC
• DD neck mass
  • Congenital
    • Branchial cleft cyst
    • Thyroglossal duct cyst
  • Inflammatory (lymphadenopathy)
    • Reactive viral lymphadenopathy
      • Mononucleosis
    • Bacterial lymphadenopathy
  • Neoplastic
    • Metastasis from aerodigestive tract
    • Tumor of tonsils, tongue base, thyroid, submandibular, paraganglioma
• Diagnosis
  • CT with contrast
  • FNAB – best diagnostic test for neck mass without known origin
• Metastases
  • Origin
    • Upper GI tract
    • Upper respiratory tract
    • Skin
    • Salivary glands
    • Thyroid
  • Clinical features
    • Dysphagia
    • Dysphonia
    • Recurrent laryngeal n. paralysis
    • Pain
• Neck dissection
  • Radical neck dissection
    • Regions I – V
    • En bloc removal of everything in the neck except carotid artery, vagus, phrenic nerve, hypoglossal nerve
    • Metastatic disease of the neck
  • Modified neck dissection
    • Preserves SCM, internal jugular vein OR accessory nerve
    • Metastatic disease of the neck where the aforementioned structures are not infiltrated
  • Selective neck dissection
    • Preservation of certain regions
    • I – III or II – IV
• Neck regions
  • Region I – submental and submandibular region
    • Lips
    • Tongue
    • Oral cavity
    • Sublingual gland
    • Submandibular gland
  • Region II – superior (internal) jugular region or superior parajugular region
    • Oral cavity
    • Nasal cavity
    • Pharynx
    • Larynx
    • Parotid
  • Region III – middle (internal) jugular region or middle parajugular region
    • Oral cavity
    • Pharynx
    • Larynx
  • Region IV – inferior (internal) jugular region or inferior parajugular region
    • Thyroid
    • Larynx
    • Hypopharynx
    • Upper oesophagus
  • Region V – posterior triangle
    • Nasopharynx
    • Posterior scalp
    • Ear
  • Region VI – central or anterior compartment
    • Thyroid
    • Larynx
    • Hypopharynx

You can be asked about the borders of these regions. I was.

24. Infectious diseases of the oral cavity and the pharynx (peritonsillar abscess)

• Oral cavity
  • HSV
    • Labial herpes
    • Topical acyclovir (early)
  • VZV
    • Antivirals
  • Herpangina
    • Coxsackie A
    • Herpes-like lesions
    • Sore throat, fever
  • Candidiasis
    • White plaque in oral cavity, can be scraped off
    • Cottony feeling in mouth
    • Loss of taste
    • Antifungal
  • Oral floor abscess
    • From teeth
    • Swelling in region I
  • Lingual abscess
• Pharynx
  • Acute tonsillitis
    • S. pyogenes
    • Palatine tonsils
    • Children, adolescents
    • Clinical features
      • Pain on swallowing – radiates to ear
      • High fever
    • Diagnosis
      • Swollen, bright red, coated tonsils
      • Rapid streptococcal test
    • Treatment
      • Penicillin V
  • Scarlet fever
    • S. pyogenes
    • Clinical features
      • Strawberry tongue
      • Swollen red tonsils
      • Rash on trunk
    • Diagnosis
      • Rapid streptococcal test
    • Treatment
      • Penicillin V
  • Acute viral pharyngitis
    • Influenza, parainfluenza
    • Clinical features
      • Fever
      • Sore throat
      • Headache
    • Diagnosis
      • Red and coated pharyngeal mucosa
  • Infectious mononucleosis
    • EBV
    • Clinical features
      • Tonsillitis
        • Pain on swallowing
      • Headache
      • Fatigue
      • Mild fever
      • Fatigue
    • Diagnosis
      • Many palpable lymph nodes enlarged
        • Tonsillar
        • Nuchal
        • Axillary
        • Inguinal
      • Red, swollen, coated tonsils
  • Peritonsillar abscess
    • Unilateral inflammation of the tonsillar parenchyme and peritonsillar tissue
    • Polymicrobial
    • Clinical features
      • Unilateral swelling of soft palate
      • Muffled speech
      • Trismus
    • Treatment
      • Removal or incision of affected tonsil
      • Drainage, many days
      • Antibiotics
  • Diphtheria
    • Clinical features
      • Moderate fever
      • Swallowing difficulties
      • Malaise
      • Headache
    • Diagnosis
      • Grayish-yellow pseudomembranes on tonsils
    • Treatment
      • Diphteria antitoxin
      • Penicillin G
  • TB

25. Precancerous disorders in the oral cavity, pharynx, larynx and oesophagus

• Oral cavity
  • Leukoplakia
    • Etiology
      • Denture
      • Alcohol
      • Nicotine
    • White plaque which cannot be scraped off
    • Always biopsy
    • Surgical removal
  • Bowen disease
    • Similar to leukoplakia
    • Chronic inflammation
• Larynx
  • Leukoplakia
  • Erythroplakia
  • Pachydermia
• Oesophagus
  • Barret oesophagus
    • Etiology
      • Decreased tone in lower oesophageal sphincter -> gastric acid reflux
      • Smoking
      • Alcohol
      • Caffeine
      • Obesity
      • Stress
    • Chronic acidic injury -> intestinal metaplasia
    • -> adenocarcinoma
    • Treatment
      • PPI
      • Endoscopic resection/ablation

26. Malignant tumours in the oral cavity and pharynx (+ nasopharyngeal tumours)

• Oral cavity
  • SCC of lips
    • Lower lip
    • Ulceration
    • Pipe smokers
  • SCC of oral mucosa
    • Nicotine
    • Alcohol
    • Clinical features
      • Bloody saliva
      • Painful swallowing
      • Halitosis
    • Diagnosis
      • Visual inspection
      • Lymph node palpation
    • Treatment
      • Surgical
      • Radiation after
  • Kaposi sarcoma
    • in HIV
• Nasopharynx
  • EBV
  • Clinical features
    • Unilateral conductive hearing loss
    • Middle ear effusion
    • Lymph node metastasis at mandibular angle
  • Types
    • SCC
    • Lymphoepithelial carcinoma
  • Treatment
    • Radiotherapy
      • Very radiosensitive
      • Surgery difficult
• Oropharynx
  • SCC
  • 80% in palatine tonsils or tongue base
  • Alcohol
  • HPV
  • Nicotine
  • Clinical features
    • Dysphagia
    • Odynophagia
    • Bloody saliva
    • Halitosis
  • Treatment
    • Surgical removal
    • Radiation afterwards
• Hypopharynx
  • SCC
  • Alcohol
  • Nicotine
  • Clinical features
    • Come late! Diagnosed at advanced stage
    • Dysphagia
    • Halitosis
    • Cervical lymph node metastasis
    • Referred ear pain
  • Treatment
    • Local surgical excision
    • Neck dissection
    • Often laryngectomy

27. Clinical symptoms and signs of benign and malignant diseases of the larynx, hypopharynx and base of the tongue

• Persistent hoarseness!
• Hoarse > 2 weeks -> laryngoscopy
• Benign diseases of the larynx
  • Majority of laryngeal neoplasms
  • Clinical features
    • Coughing
    • Hoarseness
    • Wheezing
    • Dyspnoea
    • Inspiratory stridor
    • Frequent throat clearing
• Malignant diseases of the larynx
  • Most common head and neck cancers (40%)
  • Clinical features
    • Foreign body sensation
    • Frequent throat clearing
    • Dysphagia
    • Haemoptysis
    • Hoarseness
      • Early in glottic
      • Late in supraglottic, subglottic
    • Referred ear pain
• Clinical features of diseases of the hypopharynx
  • Come late! Diagnosed at advanced stage
  • Dysphagia
  • Halitosis
  • Cervical lymph node metastasis
  • Referred ear pain
• Clinical features of diseases of the base of the tongue (oropharynx)
  • Difficulty moving tongue
  • Pain
  • Ear pain
  • Dysphagia
  • Sore throat
  • Hoarseness

28. Acute and chronic infections of the larynx, acute epiglottitis, phlegmonous epiglottitis, abscess of the epiglottis

• Acute laryngitis
  • < 3 weeks
  • Etiology
    • Descended URTI
    • Viral
      • Rhinovirus
      • Adenovirus
    • Bacterial superinfection
    • Vocal strain
    • Airborne irritants
  • Clinical features
    • Hoarseness
    • Dry cough
  • Subtypes
    • Croup – laryngotracheitis
    • Epiglottitis
  • Diagnosis
    • Laryngoscopy – erythema, oedema
  • Treatment
    • Vocal rest
    • Steam inhalation
    • Antibiotics if bacterial
• Chronic laryngitis
  • > 3 weeks
  • Etiology
    • Ascending or descending inflammation
    • GERD
    • Smoking
    • Recurring URTI (postnasal drip)
• Acute epiglottitis
  • Etiology
    • H. influenzae
    • S. pneumoniae
  • Clinical features
    • High fever
    • Inspiratory stridor
    • Odynophagia
  • Intubation
  • Complications
    • Phlegmon
    • Abscess

29. Benign tumours of the larynx

• Majority of laryngeal neoplasms
• Clinical features
  • Coughing
  • Hoarseness
  • Wheezing
  • Dyspnoea
• Vocal cord polyps
  • Adults in speaking professions
  • Etiology
    • Vocal overuse
    • Chronic inflammation
  • Unilateral
  • Mucosal hyperplasia
  • Hoarseness
  • Microsurgical removal
• Cysts and mucoceles
  • Originate in small glands
  • Hoarseness
  • Microsurgical removal
• Laryngeal papilloma
  • Most common in children
  • HPV 6, 11
  • Hoarseness
  • Inspiratory stridor
  • CO₂ laser surgery
• Vocal nodules
  • Etiology
    • Vocal overuse
    • Screamers
    • Professional speakers
    • Singers
  • Fibrosis, CT proliferation
  • Bilateral
  • Hoarseness
  • Voice therapy

30. Laryngeal cancer (supraglottic, glottic, subglottic), TNM stage

• Older men
• 40% of head and neck cancers
• SCC
• Etiology
  • Smoking
  • Alcohol
• Types
  • Supraglottic
    • 40% of cases
  • Glottic
    • Best prognosis
    • Early symptoms (hoarseness)
    • Limited lymphatic drainage
    • 60% of cases
  • Subglottic
    • Dyspnoea
    • Stridor
• Clinical features
  • Hoarseness
  • Foreign body sensation
  • Dyspnoea
  • Dysphagia
  • Stridor
• Staging
  • TNM
    • T1 – confined to one part of larynx
    • T2 – invades another part of larynx
    • T3 – tumor confined to larynx
    • T4 – tumor invades outside the larynx
    • N1 – single regional ipsilateral lymph node
    • N3 – large regional lymph node
    • M1 – distant metastasis
  • AJCC stage
    • 0 – in situ
    • I – T1, N0, M0
    • II – T2, N0, M0
    • III – T3, N0, M0
    • IV – T4 OR N1 OR M1
• Treatment
  • Early – radiotherapy, laser resection
  • Late – laryngectomy
  • Neck dissection

31. Congenital malformations of the neck, benign tumours of the neck

• Congenital malformations of the neck
  • Thyroglossal duct cyst
    • Remnant of thyroglossal duct
    • Diagnosis in first years of age
    • Painless, firm midline neck mass
      • Moves when swallowing or moving tongue
    • Dysphagia
    • Surgical excision
    • Complication
      • Abscess formation
  • Branchial cleft cyst
    • Remnant of second branchial cleft
    • Undiagnosed cyst in young adults becomes infected
    • Painless, firm lateral/midline mass
      • Does not move when swallowing
    • Surgical excision
  • Lymphangioma
    • Consists of cyst-like cavities containing lymph
    • Soft, compressible, painless neck mass
    • In region V/posterior triangle
    • Dysphagia
    • Surgical excision
• Benign tumours of the neck
  • Rare
  • Lipoma
    • Painless, soft
    • Surgery for cosmetic
  • Madelung disease
    • In alcoholics
    • Surgical removal
    • Cancer risk
  • Carotid paraganglioma
    • Painless, pulsatile mass at the carotid bifurcation
    • Clinical features
      • Dry cough (vagus irritation)
      • Hoarseness (vagus irritation)
    • Surgical removal

32. Thyroiditis, malignant tumours of the thyroid gland

• Thyroiditis
  • Hashimoto thyroiditis
    • Most common autoimmune thyroiditis
    • Initially hyperthyroid, then hypothyroid
    • Females
  • Subacute granulomatous thyroiditis
    • After viral infection
    • Painful goitre
    • Self-limiting
  • Subacute lymphocytic thyroiditis
    • Postpartum
    • Drugs
    • Painless goitre
    • Self-limiting
• Thyroid carcinoma
  • Women
  • Adults
  • Etiology
    • Radiation
    • MEN2
  • Types
    • Well-differentiated
      • Papillary – most common (80%)
      • Follicular
    • Poorly differentiated
      • Medullary
      • Anaplastic
  • Clinical features
    • Late onset of symptoms
    • Firm, painless thyroid nodules
    • Dysphagia
    • Hoarseness
    • Horner syndrome
  • Diagnosis
    • Ultrasound
    • Thyroid scintigraphy
    • FNAB
  • Treatment
    • Thyroidectomy/hemithyroidectomy
    • Radioiodine therapy
      • Only differentiated

33. Clinical signs of obstructions of the upper airways (upper airway stenosis), coniotomy, tracheotomy

• Upper airway obstruction
  • Etiology
    • Tumor
    • Inflammation
    • Infections
      • Croup
      • Epiglottitis
      • Tracheitis
      • Peritonsillar abscess
      • Retropharyngeal abscess
    • Oedema
      • Anaphylaxis
      • Angioedema
    • Trauma
    • Foreign body
  • Clinical features
    • Dyspnoea
    • Stridor
      • Inspiratory if larynx or above
      • Expiratory if trachea or below
    • Respiratory distress
    • Coughing
    • Haemoptysis
    • Cyanosis
• Coniotomy/cricothyrotomy
  • Airway is opened through cricothyroid ligament between the thyroid and cricoid cartilage
  • Should be converted to tracheotomy when possible
  • Indications
    • Angioedema
    • Foreign body in upper airway
    • Severe facial trauma
  • Procedure
    • Transverse surgical incision into skin between thyroid and cricoid cartilages
    • Incision through skin, spf cervical fascia, deep cervical fascia, pre-tracheal fascia, median cricothyroid ligament
    • Insertion of catheter
• Tracheotomy
  • Permanent or temporary stoma between cricoid cartilage and sternal notch
  • Indication
    • Long-term mechanical ventilation
    • Obstruction outside larynx or trachea
      • Struma
      • Cervical or mediastinal tumor
    • Obstruction in the wall of larynx or trachea
      • Laryngeal oedema
      • Foreign body
    • Prophylactic
  • Procedure
    • Vertical skin incision between cricoid cartilage and sternal notch
    • Separation of pre-laryngeal muscles
    • Cut thyroid isthmus
    • Insertion and fixation of tracheostomy tube
    • X-ray to confirm placement

34. Foreign bodies in the bronchial system, foreign bodies of the oesophagus

• Foreign body aspiration
  • Children < 3
  • 4x more often in the right main bronchus
  • Peanuts, tablets, seeds
  • Clinical features
    • Coughing
    • Choking
    • Stridor
    • Dyspnoea
  • Complete obstruction – atelectasis
  • Partial obstruction – distal hyperinflation
  • Diagnosis
    • Chest X-ray
    • Bronchoscopy
  • Treatment
    • Heimlich
    • Removal with bronchoscopy
• Foreign body in oesophagus
  • Children
  • Coins, nuts, toys, button batteries, magnets
  • Fish bones, dentures
  • Hypopharynx or upper part of oesophagus
  • Clinical features
    • Pain
    • Feeling of pressure
    • Dysphagia
  • Diagnosis
    • X-ray
    • Oesophagoscopy
  • Treatment
    • Nothing (if asymptomatic, low-risk)
    • Endoscopic removal if not passed within 24 hours

35. Tumours of the oesophagus, dysphagia

• Oesophageal cancer
  • Older males
  • Clinical features
    • Asymptomatic early
    • Dysphagia
    • Weight loss
    • Pain
    • Haematemesis
  • Adenocarcinoma
    • Developed world
    • Lower third
    • GERD -> Barrett
    • Etiology
      • Obesity
      • Smoking
      • Alcohol
      • Stress
  • SCC
    • Developing world
    • Upper two thirds
    • Etiology
      • Alcohol
      • Tobacco
      • Diet
  • Diagnosis
    • Endoscopy
    • Barium swallow
  • Treatment
    • Endoscopic resection
    • Oesophagectomy
    • Chemoradiation
    • Palliative
• Dysphagia
  • Oropharyngeal type
    • Etiology
      • Tumor in oropharynx
      • Pharyngitis
      • Parkinson
      • Stroke
    • Clinical features
      • Coughing
      • Inability to initiate swallow
      • Nasal regurgitation
  • Oesophageal type
    • Etiology
      • Oesophagitis
        • HSV
        • Candida
      • Oesophageal cancer
      • Oesophageal diverticula
      • Achalasia
      • (Nutcracker oesophagus)
      • (Diffuse oesophageal spasm)
      • Scleroderma
      • Autonomic neuropathy
      • Oesophageal web
      • Oesophageal stricture
        • GERD
    • Clinical features
      • Food feeling stuck behind sternum seconds after swallow
      • Regurgitation

36. Vertigo in otolaryngologic practice

• Vertigo
  • The sensation that you are moving, or everything moves around you
  • Types
    • Systematic (definite directional or rotational component)
    • Non-systematic (no motion components)
  • Examination
    • Nystagmus testing
  • Differential diagnosis
    • Vertigo lasts seconds
      • During head movements -> peripheral vestibular disorder
      • At rest -> central vestibular disorder
    • Vertigo lasts for minutes
      • Position-dependent -> BPPV
      • Position-independent -> Central vestibular disorder
    • Vertigo lasts for hours or days
      • Intensity diminishing -> peripheral vestibular disorder
      • Intensity increasing -> central vestibular disorder
  • Non-ENT causes
    • Orthostatic hypotension
    • Hypertension
    • Heart disease
    • Anaemia
  • Tests
    • Head impulse test
      • Patient maintains fixation on a fixed target
      • Move patient’s head rapidly and randomly
      • Negative: Gaze stays on fixated target
      • Positive: Eyes move with head, afterwards corrects
• Peripheral vestibular disorders
  • Vestibular neuritis
    • Loss of peripheral vestibular function on one side
    • HSV of vestibular nerve?
    • Clinical features
      • Sudden onset vertigo
      • Severe attack with nausea, vomiting
      • Lasts for days
    • Head impulse test positive on affected side
    • Nystagmus toward healthy side
    • Treatment
      • Hydration
      • Steroids
      • Antihistamines
      • Antiemetics
  • Benign paroxysmal positional vertigo
    • Otoliths dislodging in endolymph into semi-circular canals
    • Clinical features
      • Episodes of vertigo (< 1 minute)
      • Triggered by specific movements (positional)
      • Nystagmus toward affected side
    • Diagnosis
      • Dix-Hallpike/Supine roll test
    • Treatment
      • Epley/BBQ repositioning manoeuvre
  • Meniere disease
  • Bilateral vestibulopathy
    • Rare
    • Positional vertigo
    • Positive head impulse test
  • Acoustic neuroma
    • One-sided tinnitus, hearing loss
    • Diagnosis
      • Brainstem evoked response audiometry
      • MRI
    • Treatment
      • Surgery
      • Gamma knife
      • Wait and see
  • Migraine
  • Trauma
  • Herpes zoster oticus
• Central vestibular disorders
  • Brainstem injury
• Acute vestibular syndrome
  • Vertigo > 24 hours + nausea + intolerance to head movement + nystagmus
  • Vestibular neuronitis
  • MS
  • Stroke of cerebellum/brainstem
  • HINTS plus
    • A bedside examination technique to distinguish between central and peripheral
      • If any of the four are negative -> central disorder
    • Head Impulse
    • Nystagmus
    • Test of Skew
    • plus hearing loss

II. A. Clinical tests

• Weber and Rinne test
  • Weber – on forehead
  • Rinne – mastoid -> ear
• Spontaneous vestibular signs
  • Head impulse test
  • Romberg test
    • Stand with eyes closed for 30 seconds without sway
  • Unterberger stepping test
    • 50 steps with eyes closed
  • Finger to nose test
  • Walking with eyes closed
  • Smooth eye tracking of objects
  • Horizontal and vertical tracking test
  • Hallpike-Dix manoeuvre
• Examinations of the neck, lymph nodes, thyroid
• Examinations of facial nerve
  • Forehead wrinkling
  • Closing eyes tightly
  • Nose wrinkling
  • Inflate cheeks
  • Smiling
  • Whistling
  • Taste
• Examinations of meningeal signs
  • Triad
    • Nuchal rigidity (inability to flex neck forward)
    • Headache
    • Photophobia
  • Kernig sign
    • Supine patient
    • Flexion of hip joint with knees in 90 degrees -> painful passive extension of the knee joint
  • Brudzinski sign
    • Supine patient
    • Passive flexion of the neck -> patient involuntarily lifts legs