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