ENT

Last updated on January 22, 2021 at 21:21

Shout-out to Mische and my boy Hatem Abo Obaid

Table of Contents

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

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