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13.03.19 ENT + Audiology notes

Tonsillitis
  • Long term effects:
    • Somnolence, FTT, Bed wetting
    • Kid with doctor dad
  • Can't operate if <15 kg
  • Things to check if you can't operate:
    • FBC
    • Ig screen for missing bands
    • Functional antibody tests (for failure of vaccination):
      • Tetanus
      • Pneumococcus
      • Haemophilus


Patterns of hearing loss

  • Low frequency
    • Otitis media
    • Wax
    • Developmental
    • Trauma
    • Collapsed canal
    • Perforations
    • Infection
    • Exostosis (benign bony outgrowth)
    • Otosclerosis
  • Carhart's notch (dip around 2 kHz)
    • Otosclerosis (often see a conductive loss elsewhere)
  • High frequency
    • Presbycusis
    • Ototoxicity
  • 4 kHz dip
    • Noise exposure (often get a compensatory tinnitus at this frequency)
  • Sensoryneural everywhere (try steroids)
    • Virus
    • Meningitis
    • Ototoxins
    • Trauma

Tinnitus
  • Associations
    • Stress
    • Anxiety
  • Mechanism
    • Unsure
    • May affect many different bits of the auditory pathway
    • Compensation for sensorineural loss?
  • Management
    • Treat the underlying cause
      • Give a hearing aid
    • Retraining therapy
      • Sound therapy
      • Low-noise generators
    • Medication (for severe cases)
      • GABA agonists (benzodiazepines, baclofen)
      • Antidepressants (SSRIs, amitryptyline)
    • Surgery (cut CN VIII) not used any more


Hearing aids

  • BAHA (bone anchored hearing aid)
  • Middle ear vibrators
  • Brainstem implants
    • Poor frequency response - Just allows awareness of sound
    • e.g. For vestibular schwannoma excision


Localising balance problems

  • Direction of veer when walking (with eyes closed): TOWARDS the problem
  • Nystagmus: AWAY FROM the problem
  • Side you lie on the causes dizziness: TOWARDS the problem


Hallpike test

  • Performed with the patient sitting upright with the legs extended
  • Rotate head 45 degrees and lie down quickly to 20 degrees head extension
  • Observe eyes for 45 seconds (characteristic 5–10 second period of latency)
  • If rotational nystagmus occurs then the test is considered positive for benign positional vertigo
    • Fast phase of the rotatory nystagmus is toward the affected ear, which is the ear closest to the ground
    • The direction of the fast phase is defined by the rotation of the top of the eye, either clockwise or counter-clockwise


ROSIER

  • Questions:
    • Has there been loss of consciousness or syncope?
      • Yes -1
    • Has there been seizure activity?
      • Yes -1
    • Is there a NEW ACUTE onset (or on awakening from sleep) of:
      • Asymmetric facial weakness
        • Yes +1
      • Asymmetric arm weakness
        • Yes +1
      • Asymmetric leg weakness
        • Yes +1
      • Speech disturbance
        • Yes +1
      • Visual field defect
        • Yes +1
  • Stroke is likely if total scores are > 0
  • Scores of </= 0 have a low possibility of stroke but not completely excluded


Unterberger test
  • The patient is asked to walk on the spot with their eyes closed
  • If the patient rotates to one side they may have a labyrinthine lesion on that side
  • Should not be used to diagnose lesions without the support of other tests


Notes
  • Sodium bicarbonate drops for blocked grommets
  • Parental smoking => OME
  • Hyperaccusis
    • ?Pre-tinnitus
    • ++ OAEs
    • ++ Spontaneous auditory activity
  • Facial nerve ALL goes through the ear, then divides in the parotid
  • Tympanosclerosis
  • Atherosclerosis => Loss of balance (vestibular system requires good blood supply)
  • The direction of nystagmus is where the jump is to (i.e. the second, faster movement)
  • Vestibular rehab is the management for pretty much all balance problems
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