ENT

Last updated on July 14, 2020 at 16:21

Shout-out to Mische 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

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

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