This patient is displaying symptoms and signs that are consistent with a vestibular schwannoma, which is also known as an acoustic neuroma. A vestibular schwannoma typically affects the 5th and 8th cranial nerves and is characterized by the following classic presentations: gradual deterioration of hearing in one ear, facial numbness and tingling, tinnitus, and vertigo. It is also possible for the patient to have a history of headaches, and in rare cases, the 7th, 9th, and 10th cranial nerves may be affected. It is recommended that this patient be referred to either an ENT specialist or a neurosurgeon for further assessment, including an MRI of the internal auditory meatus. The main treatment options for vestibular schwannoma include surgery, radiotherapy, and stereotactic radiosurgery.

When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s condition. If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated.

Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula. Blood samples, including a full blood count, urea and electrolytes, clotting profile, and group and save (depending on the amount of blood loss), should be sent for analysis. Patients should be assigned to a majors or closely observed area, as dislodgement of a blood clot can lead to severe bleeding.

First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there is evidence of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the nasopharynx.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply, an alternative technique is to ask a relative, staff member, or use an external pressure device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones will help stop the bleeding. Applying ice to the neck or forehead does not influence nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may reduce nasal blood flow.

If bleeding stops with first aid measures, it is recommended to apply a topical antiseptic preparation to reduce crusting and vestibulitis. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.

The CENTOR score is a clinical prediction rule used to assess the likelihood of a patient having a streptococcal infection, which is commonly associated with sore throat. It is based on the presence or absence of four clinical criteria: fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough. Each criterion is assigned one point, and the total score ranges from 0 to 4. In this case, the patient has a fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and no cough, resulting in a CENTOR score of 4. A higher score indicates a higher likelihood of a streptococcal infection, and further diagnostic testing or treatment may be warranted.

Further Reading:

Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.

Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.

When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.

Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.

To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken. can

Nasal packing is recommended for cases of bilateral epistaxis (nosebleeds on both sides) and when it is difficult to locate the source of bleeding. If initial first aid measures, such as applying pressure to the soft part of the nose, do not stop the bleeding or if there is no visible bleeding point, nasal packing is necessary. In the UK, the most commonly used methods for nasal packing are Merocel nasal tampons and rapid-rhino inflatable nasal packs. If anterior nasal packing fails to control the bleeding, posterior nasal packing with a Foley catheter may be considered. Ideally, this procedure should be performed by an ENT surgeon, but if specialist input is not immediately available, a trained clinician in the emergency department can carry it out.

Further Reading:

Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

The FeverPAIN score is a scoring system recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, recommendations for antibiotic use are as follows: a score of 0-1 indicates an unlikely streptococcal infection, with antibiotics not recommended; a score of 2-3 suggests a 34-40% chance of streptococcus, and delayed prescribing of antibiotics may be considered; a score of 4 or higher indicates a 62-65% chance of streptococcus, and immediate antibiotic use is recommended for severe cases, or a short back-up prescription may be given for 48 hours.

The Fever PAIN score was developed through a study involving 1760 adults and children aged three and over. It was tested in a trial comparing three prescribing strategies: empirical delayed prescribing, score-directed prescribing, and a combination of the score with a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and reduced antibiotic prescribing by one third. The addition of the NPT did not provide any additional benefit.

According to the current NICE guidelines, if antibiotics are necessary, phenoxymethylpenicillin is recommended as the first-choice antibiotic. In cases of true penicillin allergy, clarithromycin can be used as an alternative. For pregnant women with a penicillin allergy, erythromycin is prescribed. It is important to note that the threshold for prescribing antibiotics should be lower for individuals at risk of rheumatic fever and vulnerable groups managed in primary care, such as infants, the elderly, and those who are immunosuppressed or immunocompromised. Antibiotics should not be withheld if the person has severe symptoms and there are concerns about their clinical condition.

The combination of tests points to conductive hearing loss in the right ear. There is no indication from these tests of sensorineural loss in the left ear, as a positive Rinne test (AC > BC) in the left ear is typical of normal hearing or sensorineural loss (but sensorineural loss would not result in lateralization in Weber test). Thus, the correct inference is:

Conductive hearing loss in the right ear.

Further Reading:

Hearing loss is a common complaint that can be caused by various conditions affecting different parts of the ear and nervous system. The outer ear is the part of the ear outside the eardrum, while the middle ear is located between the eardrum and the cochlea. The inner ear is within the bony labyrinth and consists of the vestibule, semicircular canals, and cochlea. The vestibulocochlear nerve connects the inner ear to the brain.

Hearing loss can be classified based on severity, onset, and type. Severity is determined by the quietest sound that can be heard, measured in decibels. It can range from mild to profound deafness. Onset can be sudden, rapidly progressive, slowly progressive, or fluctuating. Type of hearing loss can be either conductive or sensorineural. Conductive hearing loss is caused by issues in the external ear, eardrum, or middle ear that disrupt sound transmission. Sensorineural hearing loss is caused by problems in the cochlea, auditory nerve, or higher auditory processing pathways.

To diagnose sensorineural and conductive deafness, a 512 Hz tuning fork is used to perform Rinne and Weber’s tests. These tests help determine the type of hearing loss based on the results. In Rinne’s test, air conduction (AC) and bone conduction (BC) are compared, while Weber’s test checks for sound lateralization.

Cholesteatoma is a condition characterized by the abnormal accumulation of skin cells in the middle ear or mastoid air cell spaces. It is believed to develop from a retraction pocket that traps squamous cells. Cholesteatoma can cause the accumulation of keratin and the destruction of adjacent bones and tissues due to the production of destructive enzymes. It can lead to mixed sensorineural and conductive deafness as it affects both the middle and inner ear.

Patients who have acute otitis media (AOM) and are immunocompromised or systemically unwell should be given an immediate prescription for antibiotics. However, for most patients with AOM, antibiotics are not necessary or can be delayed. An immediate antibiotic prescription should be offered to patients who are systemically unwell but do not require hospitalization, patients at high risk of complications due to underlying health conditions, and patients whose symptoms have persisted for four days or more without improvement. The recommended first choice antibiotic for AOM is amoxicillin.

Further Reading:

Acute otitis media (AOM) is an inflammation in the middle ear accompanied by symptoms and signs of an ear infection. It is commonly seen in young children below 4 years of age, with the highest incidence occurring between 9 to 15 months of age. AOM can be caused by viral or bacterial pathogens, and co-infection with both is common. The most common viral pathogens include respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza virus, and parainfluenza virus. The most common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes.

Clinical features of AOM include ear pain (otalgia), fever, a red or cloudy tympanic membrane, and a bulging tympanic membrane with loss of anatomical landmarks. In young children, symptoms may also include crying, grabbing or rubbing the affected ear, restlessness, and poor feeding.

Most children with AOM will recover within 3 days without treatment. Serious complications are rare but can include persistent otitis media with effusion, recurrence of infection, temporary hearing loss, tympanic membrane perforation, labyrinthitis, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.

Management of AOM involves determining whether admission to the hospital is necessary based on the severity of systemic infection or suspected acute complications. For patients who do not require admission, regular pain relief with paracetamol or ibuprofen is advised. Decongestants or antihistamines are not recommended. Antibiotics may be offered immediately for patients who are systemically unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications. For other patients, a decision needs to be made on the antibiotic strategy, considering the rarity of acute complications and the possible adverse effects of antibiotics. Options include no antibiotic prescription with advice to seek medical help if symptoms worsen rapidly or significantly, a back-up antibiotic prescription to be used if symptoms do not improve within 3 days, or an immediate antibiotic prescription with advice to seek medical advice if symptoms worsen rapidly or significantly.

The first-line antibiotic choice for AOM is a 5-7 day course of amoxicillin. For individuals allergic to or intolerant of penicillin, clarithromycin or erythromycin a 5–7 day course of clarithromycin or erythromycin (erythromycin is preferred in pregnant women).

The Mum’s Blow technique is commonly used in cases of nasal obstruction. It requires blocking one nostril and having one of the parents, usually the mother, blow air into the child’s mouth. Alternatively, a bag valve mask can be utilized. This method is often the initial choice for young children as it is gentle and does not cause much discomfort.

Further Reading:

Foreign bodies in the ear or nose are a common occurrence, especially in children between the ages of 2 and 8. Foreign bodies in the ear are more common than those in the nose. Symptoms of foreign bodies in the ear may include ear pain, a feeling of fullness, impaired hearing, discharge, tinnitus, and vertigo. It is important to consider referral to an ENT specialist for the removal of potentially harmful foreign bodies such as glass, sharp objects, button batteries, and tightly wedged items. ENT involvement is also necessary if there is a perforation of the eardrum or if the foreign body is embedded in the eardrum.

When preparing a patient for removal, it is important to establish rapport and keep the patient relaxed, especially if they are a young child. The patient should be positioned comfortably and securely, and ear drops may be used to anesthetize the ear. Removal methods for foreign bodies in the ear include the use of forceps or a hook, irrigation (except for batteries, perforations, or organic material), suction, and magnets for ferrous metal foreign bodies. If there is an insect in the ear, it should be killed with alcohol, lignocaine, or mineral oil before removal.

After the foreign body is removed, it is important to check for any residual foreign bodies and to discharge the patient with appropriate safety net advice. Prophylactic antibiotic drops may be considered if there has been an abrasion of the skin.

Foreign bodies in the nose are less common but should be dealt with promptly due to the risk of posterior dislodgement into the airway. Symptoms of foreign bodies in the nose may include nasal discharge, sinusitis, nasal pain, epistaxis, or blood-stained discharge. Most nasal foreign bodies are found on the anterior or middle third of the nose and may not show up on x-rays.

Methods for removing foreign bodies from the nose include the mother’s kiss technique, suction, forceps, Jobson horne probe, and foley catheter. The mother’s kiss technique involves occluding the patent nostril and having a parent blow into the patient’s mouth. A foley catheter can be used by inserting it past the foreign body and inflating the balloon to gently push the foreign body out. ENT referral may be necessary if the foreign body cannot be visualized but there is a high suspicion, if attempts to remove the foreign body have failed, if the patient requires sed

When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s condition. If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated.

Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula. Blood samples, including a full blood count, urea and electrolytes, clotting profile, and group and save (depending on the amount of blood loss), should be sent for analysis. Patients should be assigned to a majors or closely observed area, as dislodgement of a blood clot can lead to severe bleeding.

First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there is evidence of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the nasopharynx.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply, an alternative technique is to ask a relative, staff member, or use an external pressure device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones will help stop the bleeding. Applying ice to the neck or forehead does not influence nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may reduce nasal blood flow.

If bleeding stops with first aid measures, it is recommended to apply a topical antiseptic preparation to reduce crusting and vestibulitis. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.

When attempting to ventilate a patient with a tracheostomy, the first approach is usually through the mouth. If this is not successful, ventilation through the tracheostomy stoma is appropriate. After removing the tracheostomy, the doctor should begin ventilating the patient through the mouth by performing standard oral manoeuvres and covering the stoma with a hand or swab. If these measures fail, the clinician should then proceed to ventilate through the tracheostomy stoma using a bag valve mask and appropriate adjuncts such as oral or nasal adjuncts or an LMA.

Further Reading:

Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.

When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.

Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.

Acute mastoiditis commonly occurs as a complication of acute otitis media (AOM). In this case, the patient exhibits symptoms indicative of acute mastoiditis. The infection typically spreads from the middle ear tympanic cavity (acute otitis media) to the mastoid antrum through a narrow canal within the petrous temporal bone.

Further Reading:

Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.

Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.

Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.

Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).

Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.

Benign paroxysmal positional vertigo (BPPV) occurs when there is dysfunction in the inner ear. This dysfunction causes the otoliths, which are located in the utricle, to become dislodged from their normal position and migrate into one of the semicircular canals over time. As a result, these detached otoliths continue to move even after head movement has stopped, leading to vertigo due to the conflicting sensation of ongoing movement with other sensory inputs.

While the majority of BPPV cases have no identifiable cause (idiopathic), approximately 40% of cases can be attributed to factors such as head injury, spontaneous labyrinthine degeneration, post-viral illness, middle ear surgery, or chronic middle ear disease.

The main clinical features of BPPV include symptoms that are provoked by head movement, rolling over, and upward gaze. These episodes are typically brief, lasting less than 5 minutes, and are often worse in the mornings. Unlike other inner ear disorders, BPPV does not cause hearing loss or tinnitus. Nausea is a common symptom, while vomiting is rare. The Dix-Hallpike test can be used to confirm the diagnosis of BPPV.

It is important to note that vestibular suppressant medications have not been proven to be beneficial in managing BPPV. These medications do not improve symptoms or reduce the duration of the disease.

The treatment of choice for BPPV is the Epley manoeuvre. This maneuver aims to reposition the dislodged otoliths back into the utricles from the semicircular canals. A 2014 Cochrane review concluded that the Epley manoeuvre is a safe and effective treatment for BPPV, with a number needed to treat of 2-4.

Referral to an ENT specialist is recommended for patients with BPPV in the following situations: if the treating clinician is unable to perform or access the Epley manoeuvre, if the Epley manoeuvre has not been beneficial after repeated attempts (minimum two), if the patient has been symptomatic for more than 4 weeks, or if the patient has experienced more than 3 episodes of BPPV.

Malignant otitis externa, also known as necrotising otitis externa, is a severe infection that affects the external auditory canal and spreads to the temporal bone and nearby tissues, leading to skull base osteomyelitis. The primary cause of this condition is usually an infection by Pseudomonas aeruginosa. It is commonly observed in older individuals with diabetes.

Further Reading:

Otitis externa is inflammation of the skin and subdermis of the external ear canal. It can be acute, lasting less than 6 weeks, or chronic, lasting more than 3 months. Malignant otitis externa, also known as necrotising otitis externa, is a severe and potentially life-threatening infection that can spread to the bones and surrounding structures of the ear. It is most commonly caused by Pseudomonas aeruginosa.

Symptoms of malignant otitis externa include severe and persistent ear pain, headache, discharge from the ear, fever, malaise, vertigo, and profound hearing loss. It can also lead to facial nerve palsy and other cranial nerve palsies. In severe cases, the infection can spread to the central nervous system, causing meningitis, brain abscess, and sepsis.

Acute otitis externa is typically caused by Pseudomonas aeruginosa or Staphylococcus aureus, while chronic otitis externa can be caused by fungal infections such as Aspergillus or Candida albicans. Risk factors for otitis externa include eczema, psoriasis, dermatitis, acute otitis media, trauma to the ear canal, foreign bodies in the ear, water exposure, ear canal obstruction, and long-term antibiotic or steroid use.

Clinical features of otitis externa include itching of the ear canal, ear pain, tenderness of the tragus and/or pinna, ear discharge, hearing loss if the ear canal is completely blocked, redness and swelling of the ear canal, debris in the ear canal, and cellulitis of the pinna and adjacent skin. Tender regional lymphadenitis is uncommon.

Management of acute otitis externa involves general ear care measures, optimizing any underlying medical or skin conditions that are risk factors, avoiding the use of hearing aids or ear plugs if there is a suspected contact allergy, and avoiding the use of ear drops if there is a suspected allergy to any of its ingredients. Treatment options include over-the-counter acetic acid 2% ear drops or spray, aural toileting via dry swabbing, irrigation, or microsuction, and prescribing topical antibiotics with or without a topical corticosteroid. Oral antibiotics may be prescribed in severe cases or for immunocompromised individuals.

Follow-up is advised if symptoms do not improve within 48-72 hours of starting treatment, if symptoms have not fully resolved

Insect removal from the ear can be quite challenging due to the distress it causes the patient and the inevitable movement of the insect during the process.

To begin, it is important to make the patient comfortable by providing analgesia. In some cases, inhaled Entonox can be helpful, and if the patient is extremely distressed or experiencing significant discomfort, sedation may be necessary.

The first step in the removal process involves immobilizing or killing the insect to prevent further movement and potential damage within the ear. This can be achieved using options such as microscope immersion oil, mineral oil, or lidocaine solution.

Once the insect is confirmed to be dead, the actual removal can be performed using forceps or the highly effective Frazier suction technique. After inspecting the ear and ensuring the insect is no longer alive, connect the Frazier suction device to low continuous suction and slowly insert it into the patient’s external ear canal. By occluding the insufflation port, the contents of the ear canal can be suctioned out. Once no more liquid returns, withdraw the catheter and verify that the insect has been successfully removed.

Patients who experience bleeding after a tonsillectomy should be treated with two primary medications. The first is IV tranexamic acid, which is given to all patients. The second is a topical vasoconstrictor, such as co-phenylcaine spray or adrenaline-soaked gauze/cotton buds. However, the use of topical vasoconstrictors is typically reserved for patients with severe bleeding until they can be reviewed by a senior medical professional or transferred to the operating theatre. Patients with mild or occasional bleeding may be instructed to gargle with hydrogen peroxide regularly during their hospital stay.

Further Reading:

Tonsillectomy is a common procedure performed by ENT surgeons in the UK, with over 50,000 surgeries performed each year. While it is considered routine, there are risks of serious complications, including post-tonsillectomy bleeding. Approximately 5% of patients experience bleeding after the procedure, with most cases being self-limiting. However, severe bleeding can lead to hypovolemia and airway obstruction from clots, which can be life-threatening.

Post-tonsillectomy bleeding can be classified as primary (reactive) or secondary (delayed). Primary bleeding occurs within 24 hours of the procedure, while secondary bleeding occurs more than 24 hours post-procedure. Secondary bleeding is often caused by factors such as sloughing of eschar, trauma from solid food ingestion, tonsil bed infection, postoperative NSAID usage, or unknown causes.

Patients may present with symptoms such as vomiting blood, coughing up blood, tasting blood in the throat, finding blood on pillows or bed sheets, or excessive swallowing (especially in children). It is important for clinicians to assess the severity of blood loss, although it can be challenging to accurately estimate in children.

The ABCDE approach should be used to assess patients, with a focus on airway compromise, hemodynamic instability, and evidence of bleeding. Clinicians may use a head torch to identify any bleeding points, which may be actively bleeding or appear as fresh red clots. It is important to note that the tonsillar fossa may appear white or yellow, which is a normal postoperative finding.

Investigations such as a full blood count, coagulation profile, group and save, and venous blood gas may be performed to assess the patient’s condition. Senior support from ENT or anesthesiology should be called if there is active bleeding.

Management of post-tonsillectomy bleeding includes positioning the patient upright and keeping them calm, establishing intravenous access, administering fluids and blood products as needed, and administering tranexamic acid to stop bleeding. Bleeding points may require gentle suction removal of fresh clots, and topical medications such as Co-phenylcaine spray or topical adrenaline may be applied to the oropharynx. All patients with post-tonsillectomy bleeding should be assessed by ENT and observed for a prolonged period, typically 12-24 hours.

If bleeding remains uncontrolled, the patient should be kept nil by mouth in preparation for surgery, and early intervention.

The most common sign of a foreign body (FB) in the nose in children is unilateral purulent nasal discharge. This discharge may have a foul smell. It is important to note that children often deny putting foreign bodies in their nose due to fear of getting in trouble. Purulent nasal discharge is more likely to occur with organic FBs, as they can absorb water and minerals, creating a breeding ground for bacterial colonization and infection. This type of discharge is more likely to occur after the FB has been in the nose for a few days.

Further Reading:

Foreign bodies in the ear or nose are a common occurrence, especially in children between the ages of 2 and 8. Foreign bodies in the ear are more common than those in the nose. Symptoms of foreign bodies in the ear may include ear pain, a feeling of fullness, impaired hearing, discharge, tinnitus, and vertigo. It is important to consider referral to an ENT specialist for the removal of potentially harmful foreign bodies such as glass, sharp objects, button batteries, and tightly wedged items. ENT involvement is also necessary if there is a perforation of the eardrum or if the foreign body is embedded in the eardrum.

When preparing a patient for removal, it is important to establish rapport and keep the patient relaxed, especially if they are a young child. The patient should be positioned comfortably and securely, and ear drops may be used to anesthetize the ear. Removal methods for foreign bodies in the ear include the use of forceps or a hook, irrigation (except for batteries, perforations, or organic material), suction, and magnets for ferrous metal foreign bodies. If there is an insect in the ear, it should be killed with alcohol, lignocaine, or mineral oil before removal.

After the foreign body is removed, it is important to check for any residual foreign bodies and to discharge the patient with appropriate safety net advice. Prophylactic antibiotic drops may be considered if there has been an abrasion of the skin.

Foreign bodies in the nose are less common but should be dealt with promptly due to the risk of posterior dislodgement into the airway. Symptoms of foreign bodies in the nose may include nasal discharge, sinusitis, nasal pain, epistaxis, or blood-stained discharge. Most nasal foreign bodies are found on the anterior or middle third of the nose and may not show up on x-rays.

Methods for removing foreign bodies from the nose include the mother’s kiss technique, suction, forceps, Jobson horne probe, and foley catheter. The mother’s kiss technique involves occluding the patent nostril and having a parent blow into the patient’s mouth. A foley catheter can be used by inserting it past the foreign body and inflating the balloon to gently push the foreign body out. ENT referral may be necessary if the foreign body cannot be visualized but there is a high suspicion, if attempts to remove the foreign body have failed, if the patient requires sed

In patients who have undergone tonsillectomy and are experiencing severe bleeding, it is recommended to apply either Co-phenylcaine spray (a combination of lidocaine and phenylephrine) or 1:10,000 adrenaline soaked gauze/dental roll to the bleeding points. This helps to constrict the blood vessels and slow down the bleeding rate.

To apply topical adrenaline, a dental roll or gauze soaked in 1:10,000 adrenaline solution is used. It is applied to the bleeding point using Magill’s forceps, with pressure directed laterally (not posteriorly). However, this may not be possible if the patient has a strong gag reflex. To minimize the risk of inhalation and facilitate suction, the patient’s head should be tilted to the side and/or forwards.

For light or intermittent bleeding, hydrogen peroxide gargles can be used. However, they are not recommended for heavy bleeds.

Further Reading:

Tonsillectomy is a common procedure performed by ENT surgeons in the UK, with over 50,000 surgeries performed each year. While it is considered routine, there are risks of serious complications, including post-tonsillectomy bleeding. Approximately 5% of patients experience bleeding after the procedure, with most cases being self-limiting. However, severe bleeding can lead to hypovolemia and airway obstruction from clots, which can be life-threatening.

Post-tonsillectomy bleeding can be classified as primary (reactive) or secondary (delayed). Primary bleeding occurs within 24 hours of the procedure, while secondary bleeding occurs more than 24 hours post-procedure. Secondary bleeding is often caused by factors such as sloughing of eschar, trauma from solid food ingestion, tonsil bed infection, postoperative NSAID usage, or unknown causes.

Patients may present with symptoms such as vomiting blood, coughing up blood, tasting blood in the throat, finding blood on pillows or bed sheets, or excessive swallowing (especially in children). It is important for clinicians to assess the severity of blood loss, although it can be challenging to accurately estimate in children.

The ABCDE approach should be used to assess patients, with a focus on airway compromise, hemodynamic instability, and evidence of bleeding. Clinicians may use a head torch to identify any bleeding points, which may be actively bleeding or appear as fresh red clots. It is important to note that the tonsillar fossa may appear white or yellow, which is a normal postoperative finding.

Investigations such as a full blood count, coagulation profile, group and save, and venous blood gas may be performed to assess the patient’s condition. Senior support from ENT or anesthesiology should be called if there is active bleeding.

Management of post-tonsillectomy bleeding includes positioning the patient upright and keeping them calm, establishing intravenous access, administering fluids and blood products as needed, and administering tranexamic acid to stop bleeding. Bleeding points may require gentle suction removal of fresh clots, and topical medications such as Co-phenylcaine spray or topical adrenaline may be applied to the oropharynx. All patients with post-tonsillectomy bleeding should be assessed by ENT and observed for a prolonged period, typically 12-24 hours.

If bleeding remains uncontrolled, the patient should be kept nil by mouth in preparation for surgery, and early intervention.

The FeverPAIN score is a scoring system recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, recommendations for antibiotic use are as follows: a score of 0-1 indicates an unlikely streptococcal infection, with antibiotics not recommended; a score of 2-3 suggests a 34-40% chance of streptococcus, and delayed prescribing of antibiotics may be considered; a score of 4 or higher indicates a 62-65% chance of streptococcus, and immediate antibiotic use is recommended for severe cases, or a short back-up prescription may be given for 48 hours.

The Fever PAIN score was developed through a study involving 1760 adults and children aged three and over. It was tested in a trial comparing three prescribing strategies: empirical delayed prescribing, score-directed prescribing, and a combination of the score with a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and reduced antibiotic prescribing by one third. The addition of the NPT did not provide any additional benefit.

According to the current NICE guidelines, if antibiotics are necessary, phenoxymethylpenicillin is recommended as the first-choice antibiotic. In cases of true penicillin allergy, clarithromycin can be used as an alternative. For pregnant women with a penicillin allergy, erythromycin is prescribed. It is important to note that the threshold for prescribing antibiotics should be lower for individuals at risk of rheumatic fever and vulnerable groups managed in primary care, such as infants, the elderly, and those who are immunosuppressed or immunocompromised. Antibiotics should not be withheld if the person has severe symptoms and there are concerns about their clinical condition.

The patient has presented with a facial palsy that affects only the left side and involves the lower motor neurons. This can be distinguished from an upper motor neuron lesion because the patient is unable to raise their eyebrow and the upper facial muscles are also affected. Additionally, the patient demonstrates a phenomenon known as Bell’s phenomenon, where the eye on the affected side rolls upwards and outwards when attempting to close the eye and bare the teeth.

Approximately 80% of sudden onset lower motor neuron facial palsies are attributed to Bell’s palsy. It is believed that this condition is caused by swelling of the facial nerve within the petrous temporal bone, which is secondary to a latent herpesvirus, specifically HSV-1 and HZV.

There are other potential causes for an isolated lower motor neuron facial nerve palsy, including Ramsay-Hunt syndrome (caused by the herpes zoster virus), trauma, parotid gland tumor, cerebellopontine angle tumor (such as an acoustic neuroma), middle ear infection, cholesteatoma, and sarcoidosis.

However, Ramsay-Hunt syndrome is unlikely in this case since there is no presence of pain or pustular lesions in and around the ear. An acoustic neuroma is also less likely, especially without any symptoms of sensorineural deafness or tinnitus. Furthermore, there are no clinical features consistent with an inner ear infection.

The recommended treatment for this patient is the administration of steroids, and appropriate follow-up should be organized.

Fibre-optic laryngoscopy is considered the most reliable method for diagnosing epiglottitis. In this case, the patient’s symptoms align with those typically seen in epiglottitis. It is crucial to prioritize the assessment of the airway before conducting any invasive procedures, such as using a tongue depressor to examine the oral cavity or performing needle aspiration of the tonsils.

Further Reading:

Epiglottitis is a rare but serious condition characterized by inflammation and swelling of the epiglottis, which can lead to a complete blockage of the airway. It is more commonly seen in children between the ages of 2-6, but can also occur in adults, particularly those in their 40s and 50s. Streptococcus infections are now the most common cause of epiglottitis in the UK, although other bacterial agents, viruses, fungi, and iatrogenic causes can also be responsible.

The clinical features of epiglottitis include a rapid onset of symptoms, high fever, sore throat, painful swallowing, muffled voice, stridor and difficulty breathing, drooling of saliva, irritability, and a characteristic tripod positioning with the arms forming the front two legs of the tripod. It is important for healthcare professionals to avoid examining the throat or performing any potentially upsetting procedures until the airway has been assessed and secured.

Diagnosis of epiglottitis is typically made through fibre-optic laryngoscopy, which is considered the gold standard investigation. Lateral neck X-rays may also show a characteristic thumb sign, indicating an enlarged and swollen epiglottis. Throat swabs and blood cultures may be taken once the airway is secured to identify the causative organism.

Management of epiglottitis involves assessing and securing the airway as the top priority. Intravenous or oral antibiotics are typically prescribed, and supplemental oxygen may be given if intubation or tracheostomy is planned. In severe cases where the airway is significantly compromised, intubation or tracheostomy may be necessary. Steroids may also be used, although the evidence for their benefit is limited.

Overall, epiglottitis is a potentially life-threatening condition that requires urgent medical attention. Prompt diagnosis, appropriate management, and securing the airway are crucial in ensuring a positive outcome for patients with this condition.

Mastoiditis occurs when a suppurative infection spreads from otitis media, affecting the middle ear, to the mastoid antrum. This infection causes inflammation in the mastoid and surrounding tissues, potentially leading to damage to the bone.

The mastoid antrum, also known as the tympanic antrum, is an air space located in the petrous part of the temporal bone. It connects to the mastoid cells at the back and the epitympanic recess through the aditus to the mastoid antrum.

The mastoid cells come in different types, varying in number and size. There are cellular cells with thin septa, diploeic cells that are marrow spaces with few air cells, and acellular cells that are neither cells nor marrow spaces.

These air spaces serve various functions, including acting as sound receptors, providing voice resonance, offering acoustic insulation and dissipation, protecting against physical damage, and reducing the weight of the cranium.

Overall, mastoiditis occurs when an infection from otitis media spreads to the mastoid antrum, causing inflammation and potential damage to the surrounding tissues and bone. The mastoid antrum and mastoid air cells within the temporal bone play important roles in sound reception, voice resonance, protection, and reducing cranial mass.

Bell’s palsy is a condition characterized by sudden weakness or paralysis of the facial nerve, resulting in facial muscle weakness or drooping. The exact cause is unknown, but it is believed to be related to viral infections such as herpes simplex or varicella zoster. It is more common in individuals aged 15-45 years and those with diabetes, obesity, hypertension, or upper respiratory conditions. Pregnancy is also a risk factor.

Diagnosis of Bell’s palsy is typically based on clinical symptoms and ruling out other possible causes of facial weakness. Symptoms include rapid onset of unilateral facial muscle weakness, drooping of the eyebrow and corner of the mouth, loss of the nasolabial fold, otalgia, difficulty chewing or dry mouth, taste disturbance, eye symptoms such as inability to close the eye completely, dry eye, eye pain, and excessive tearing, numbness or tingling of the cheek and mouth, speech articulation problems, and hyperacusis.

When assessing a patient with facial weakness, it is important to consider other possible differentials such as stroke, facial nerve tumors, Lyme disease, granulomatous diseases, Ramsay Hunt syndrome, mastoiditis, and chronic otitis media. Red flags for these conditions include insidious and painful onset, duration of symptoms longer than 3 months with frequent relapses, pre-existing risk factors, systemic illness or fever, vestibular or hearing abnormalities, and other cranial nerve involvement.

Management of Bell’s palsy involves the use of steroids, eye care advice, and reassurance. Steroids, such as prednisolone, are recommended for individuals presenting within 72 hours of symptom onset. Eye care includes the use of lubricating eye drops, eye ointment at night, eye taping if unable to close the eye at night, wearing sunglasses, and avoiding dusty environments. Reassurance is important as the majority of patients make a complete recovery within 3-4 months. However, some individuals may experience sequelae such as facial asymmetry, gustatory lacrimation, inadequate lid closure, brow ptosis, drooling, and hemifacial spasms.

Antiviral treatments are not currently recommended as a standalone treatment for Bell’s palsy, but they may be given in combination with corticosteroids on specialist advice. Referral to an ophthalmologist is necessary if the patient has eye symptoms such as pain, irritation, or itch.

The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.

If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.

The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.

Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.

The Dix-Hallpike manoeuvre is the primary diagnostic test used for patients suspected of having benign paroxysmal positional vertigo (BPPV). If a patient exhibits nystagmus and vertigo during the test, it is considered a positive result for BPPV. Other special clinical tests that may be used to assess vertigo include Romberg’s test, which helps identify instability of either peripheral or central origin but is not very effective in differentiating between the two. The head impulse test is used to detect unilateral hypofunction of the peripheral vestibular system and can help distinguish between cerebellar infarction and vestibular neuronitis. Unterberger’s test is used to identify dysfunction in one of the labyrinths. Lastly, the alternate cover test can indicate an increased likelihood of stroke in individuals with acute vestibular syndrome if the result is abnormal.

Further Reading:

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo, characterized by sudden dizziness and vertigo triggered by changes in head position. It typically affects individuals over the age of 55 and is less common in younger patients. BPPV is caused by dysfunction in the inner ear, specifically the detachment of otoliths (calcium carbonate particles) from the utricular otolithic membrane. These loose otoliths move through the semicircular canals, triggering a sensation of movement and resulting in conflicting sensory inputs that cause vertigo.

The majority of BPPV cases involve otoliths in the posterior semicircular canal, followed by the inferior semicircular canal. BPPV in the anterior semicircular canals is rare. Clinical features of BPPV include vertigo triggered by head position changes, such as rolling over in bed or looking upwards, accompanied by nausea. Episodes of vertigo typically last 10-20 seconds and can be diagnosed through positional nystagmus, which is a specific eye movement, observed during diagnostic maneuvers like the Dix-Hallpike maneuver.

Hearing loss and tinnitus are not associated with BPPV. The prognosis for BPPV is generally good, with spontaneous resolution occurring within a few weeks to months. Symptomatic relief can be achieved through the Epley maneuver, which is successful in around 80% of cases, or patient home exercises like the Brandt-Daroff exercises. Medications like Betahistine may be prescribed but have limited effectiveness in treating BPPV.

Kiesselbach’s plexus, also known as Little’s area, is formed by the connection of four or five arteries. These arteries include the greater palatine artery, anterior ethmoidal artery, superior labial artery, and sphenopalatine artery. Some sources also include the posterior ethmoidal artery as part of the plexus. The greater palatine artery is a branch of the maxillary artery, while the anterior ethmoidal artery is a branch of the internal carotid artery. The superior labial artery and sphenopalatine artery are both branches of the external carotid artery. The posterior ethmoidal artery, if included, is a branch of the ophthalmic artery.

Further Reading:

Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s airway and circulation.

If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated. Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula and collect blood samples for tests such as full blood count, urea and electrolytes, clotting studies, and blood typing and crossmatching (depending on the amount of blood loss). These patients should be closely monitored in a majors area or a designated observation area, as dislodgement of a blood clot can lead to severe bleeding.

First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there are signs of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the back of the throat.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply with pinching their own nose, an alternative technique is to ask a relative or staff member to apply external pressure using a device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones of the nose will help stop the bleeding. Applying ice to the neck or forehead has not been proven to affect nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may help reduce nasal blood flow.

If bleeding stops with first aid measures, it may be beneficial to apply a topical antiseptic preparation to reduce crusting and inflammation. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.

When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s condition. If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated.

Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula. Blood samples, including a full blood count, urea and electrolytes, clotting profile, and group and save (depending on the amount of blood loss), should be sent for analysis. Patients should be assigned to a majors or closely observed area, as dislodgement of a blood clot can lead to severe bleeding.

First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there is evidence of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the nasopharynx.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply, an alternative technique is to ask a relative, staff member, or use an external pressure device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones will help stop the bleeding. Applying ice to the neck or forehead does not influence nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may reduce nasal blood flow.

If bleeding stops with first aid measures, it is recommended to apply a topical antiseptic preparation to reduce crusting and vestibulitis. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.

Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually reach their peak within 1-3 days, with the cough often being more troublesome at night. A milder cough may persist for another 7-10 days.

Since croup is caused by a viral infection, antibiotics are not effective unless there is a suspicion of a secondary bacterial infection. It is important to note that sedation should not be used in a child experiencing respiratory distress. To reduce airway swelling, dexamethasone and prednisolone are commonly prescribed, although they do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

A barking cough is a characteristic symptom of croup, but it does not necessarily indicate the severity of the condition. Hospitalization for croup is rare and typically reserved for children who show worsening respiratory distress or signs of drowsiness/agitation.

Infectious mononucleosis is typically a self-limiting infection that is primarily caused by the Epstein-Barr virus (EBV), a member of the human herpesvirus family. About 10% of cases are caused by cytomegalovirus (CMV) infection.

This clinical infection is most commonly observed in populations with a large number of young adults, such as university students and active-duty military personnel.

The main clinical features of infectious mononucleosis include a low-grade fever, fatigue, prolonged malaise, sore throat (often accompanied by tonsillar enlargement and exudate), a transient, fine, non-itchy rash, lymphadenopathy (most commonly in the cervical region), arthralgia and myalgia, mild enlargement of the liver and spleen, and jaundice (which is less common in young adults but more prevalent in the elderly).

To diagnose EBV infectious mononucleosis, a variety of unrelated non-EBV heterophile antibodies and specific EBV antibodies can be used.

1. Heterophile antibodies:
Around 70-90% of patients with EBV infectious mononucleosis produce heterophile antibodies, which are antibodies that react against antigens from other species. False positives can occur with hepatitis, malaria, toxoplasmosis, rubella, systemic lupus erythematosus (SLE), lymphoma, and leukemia. Two main screening tests can detect these antibodies and provide rapid results within a day:
– Paul-Bunnell test: Sheep red blood cells agglutinate in the presence of heterophile antibodies.
– Monospot test: Horse red blood cells agglutinate in the presence of heterophile antibodies.

2. EBV-specific antibodies:
Patients who remain heterophile-negative after six weeks are considered heterophile-negative and should be tested for EBV-specific antibodies. These antibodies are also useful in cases where a false positive heterophile antibody test is suspected.

Other useful investigations include a full blood count, which often shows a raised white cell count with lymphocytosis and atypical lymphocytes in more than 20% of cases, an elevated erythrocyte sedimentation rate (ESR) in most patients, liver function tests (LFTs) that may show mild elevation of serum transaminases, throat swabs to rule out group A streptococci pharyngitis as a differential diagnosis, and abdominal ultrasound if splenomegaly is present.

When performing Weber’s test, if the sound lateralizes to the unaffected side, it suggests sensorineural hearing loss in the opposite ear. For example, if the sound lateralizes to the left, it indicates sensorineural hearing loss in the right ear. On the other hand, if there is conductive hearing loss in the left ear, the sound will lateralize to the affected side. Additionally, a positive Rinne test result, where air conduction is greater than bone conduction, is typically seen in normal hearing and sensorineural loss. Conversely, a negative Rinne test result, where bone conduction is greater than air conduction, is expected in cases of conductive hearing loss. In summary, these test results can help identify the presence of sensorineural loss in the opposite ear.

Further Reading:

Hearing loss is a common complaint that can be caused by various conditions affecting different parts of the ear and nervous system. The outer ear is the part of the ear outside the eardrum, while the middle ear is located between the eardrum and the cochlea. The inner ear is within the bony labyrinth and consists of the vestibule, semicircular canals, and cochlea. The vestibulocochlear nerve connects the inner ear to the brain.

Hearing loss can be classified based on severity, onset, and type. Severity is determined by the quietest sound that can be heard, measured in decibels. It can range from mild to profound deafness. Onset can be sudden, rapidly progressive, slowly progressive, or fluctuating. Type of hearing loss can be either conductive or sensorineural. Conductive hearing loss is caused by issues in the external ear, eardrum, or middle ear that disrupt sound transmission. Sensorineural hearing loss is caused by problems in the cochlea, auditory nerve, or higher auditory processing pathways.

To diagnose sensorineural and conductive deafness, a 512 Hz tuning fork is used to perform Rinne and Weber’s tests. These tests help determine the type of hearing loss based on the results. In Rinne’s test, air conduction (AC) and bone conduction (BC) are compared, while Weber’s test checks for sound lateralization.

Cholesteatoma is a condition characterized by the abnormal accumulation of skin cells in the middle ear or mastoid air cell spaces. It is believed to develop from a retraction pocket that traps squamous cells. Cholesteatoma can cause the accumulation of keratin and the destruction of adjacent bones and tissues due to the production of destructive enzymes. It can lead to mixed sensorineural and conductive deafness as it affects both the middle and inner ear.

Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.

In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.

The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.

To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.

When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.

Recurrent or chronic tonsillitis is a clear indication for tonsillectomy, which is the surgical removal of the palatine tonsils. One common complication of this procedure is bleeding, which occurs in approximately 0.5-2% of cases. The bleeding that occurs after tonsillectomy is typically venous in nature and most frequently originates from the external palatine vein. This vein drains the lateral tonsillar region and ultimately empties into the facial vein. Additionally, bleeding can also arise from the tonsillar branch of the facial artery, which supplies the inferior pole of the palatine tonsil.

This patient has experienced otic barotrauma, which is most commonly seen during aircraft descent but can also occur in divers. Otic barotrauma occurs when the eustachian tube fails to equalize the pressure between the middle ear and the atmosphere, resulting in a pressure difference. This is more likely to happen in patients with eustachian tube dysfunction, such as those with acute otitis media or glue ear.

Patients with otic barotrauma often complain of severe ear pain, conductive hearing loss, ringing in the ears (tinnitus), and dizziness (vertigo). Upon examination, fluid can be observed behind the eardrum, and in more severe cases, the eardrum may even rupture.

In most instances, the symptoms of otic barotrauma resolve within a few days without any treatment. However, in more severe cases, it may take 2-3 weeks for the symptoms to subside. Nasal decongestants can be beneficial before and during a flight, but their effectiveness is limited once symptoms have already developed. Nasal steroids have no role in the management of otic barotrauma, and antibiotics should only be used if an infection develops.

The most appropriate course of action in this case would be to provide the patient with an explanation of what has occurred and reassure them that their symptoms should improve soon.

This individual is diagnosed with an acquired cholesteatoma, which is an expanding growth of the stratified keratinising epithelium in the middle ear. It develops due to dysfunction of the Eustachian tube and chronic otitis media caused by the retraction of the squamous elements of the tympanic membrane into the middle ear space.

The most important method for assessing the presence of a cholesteatoma is otoscopy. A retraction pocket observed in the attic or posterosuperior quadrant of the tympanic membrane is a characteristic sign of an acquired cholesteatoma. This is often accompanied by the presence of granulation tissue and squamous debris. The presence of a granular polyp within the ear canal also strongly suggests a cholesteatoma.

If left untreated, a cholesteatoma can lead to various complications including conductive deafness, facial nerve palsy, brain abscess, meningitis, and labyrinthitis. Therefore, it is crucial to urgently refer this individual to an ear, nose, and throat (ENT) specialist for a CT scan and surgical removal of the lesion.

For mild cases of otitis externa, using ear drops or spray as the initial treatment is a reasonable option. The insertion of a medicated wick, known as a Pope wick, is typically reserved for patients with severely narrowed external auditory canals. Microsuction, on the other hand, is helpful for patients with excessive debris in their ear canal but is not necessary for this particular patient. In general, microsuction is usually only used for severe cases of otitis externa that require referral to an ear, nose, and throat specialist for further management.

Further Reading:

Otitis externa is inflammation of the skin and subdermis of the external ear canal. It can be acute, lasting less than 6 weeks, or chronic, lasting more than 3 months. Malignant otitis externa, also known as necrotising otitis externa, is a severe and potentially life-threatening infection that can spread to the bones and surrounding structures of the ear. It is most commonly caused by Pseudomonas aeruginosa.

Symptoms of malignant otitis externa include severe and persistent ear pain, headache, discharge from the ear, fever, malaise, vertigo, and profound hearing loss. It can also lead to facial nerve palsy and other cranial nerve palsies. In severe cases, the infection can spread to the central nervous system, causing meningitis, brain abscess, and sepsis.

Acute otitis externa is typically caused by Pseudomonas aeruginosa or Staphylococcus aureus, while chronic otitis externa can be caused by fungal infections such as Aspergillus or Candida albicans. Risk factors for otitis externa include eczema, psoriasis, dermatitis, acute otitis media, trauma to the ear canal, foreign bodies in the ear, water exposure, ear canal obstruction, and long-term antibiotic or steroid use.

Clinical features of otitis externa include itching of the ear canal, ear pain, tenderness of the tragus and/or pinna, ear discharge, hearing loss if the ear canal is completely blocked, redness and swelling of the ear canal, debris in the ear canal, and cellulitis of the pinna and adjacent skin. Tender regional lymphadenitis is uncommon.

Management of acute otitis externa involves general ear care measures, optimizing any underlying medical or skin conditions that are risk factors, avoiding the use of hearing aids or ear plugs if there is a suspected contact allergy, and avoiding the use of ear drops if there is a suspected allergy to any of its ingredients. Treatment options include over-the-counter acetic acid 2% ear drops or spray, aural toileting via dry swabbing, irrigation, or microsuction, and prescribing topical antibiotics with or without a topical corticosteroid. Oral antibiotics may be prescribed in severe cases or for immunocompromised individuals.

Follow-up is advised if symptoms do not improve within 48-72 hours of starting treatment, if symptoms have not fully resolved

If someone is suspected to have CSF rhinorrhoea, their nasal discharge should be tested for beta-2 transferrin. This test is considered the most accurate diagnostic method to confirm the presence of CSF rhinorrhoea and has replaced glucose testing.

Further Reading:

Zygomatic injuries, also known as zygomatic complex fractures, involve fractures of the zygoma bone and often affect surrounding bones such as the maxilla and temporal bones. These fractures can be classified into four positions: the lateral and inferior orbital rim, the zygomaticomaxillary buttress, and the zygomatic arch. The full extent of these injuries may not be visible on plain X-rays and may require a CT scan for accurate diagnosis.

Zygomatic fractures can pose risks to various structures in the face. The temporalis muscle and coronoid process of the mandible may become trapped in depressed fractures of the zygomatic arch. The infraorbital nerve, which passes through the infraorbital foramen, can be injured in zygomaticomaxillary complex fractures. In orbital floor fractures, the inferior rectus muscle may herniate into the maxillary sinus.

Clinical assessment of zygomatic injuries involves observing facial asymmetry, depressed facial bones, contusion, and signs of eye injury. Visual acuity must be assessed, and any persistent bleeding from the nose or mouth should be noted. Nasal injuries, including septal hematoma, and intra-oral abnormalities should also be evaluated. Tenderness of facial bones and the temporomandibular joint should be assessed, along with any step deformities or crepitus. Eye and jaw movements must also be evaluated.

Imaging for zygomatic injuries typically includes facial X-rays, such as occipitomental views, and CT scans for a more detailed assessment. It is important to consider the possibility of intracranial hemorrhage and cervical spine injury in patients with facial fractures.

Management of most zygomatic fractures can be done on an outpatient basis with maxillofacial follow-up, assuming the patient is stable and there is no evidence of eye injury. However, orbital floor fractures should be referred immediately to ophthalmologists or maxillofacial surgeons. Zygomatic arch injuries that restrict mouth opening or closing due to entrapment of the temporalis muscle or mandibular condyle also require urgent referral. Nasal fractures, often seen in conjunction with other facial fractures, can be managed by outpatient ENT follow-up but should be referred urgently if there is uncontrolled epistaxis, CSF rhinorrhea, or septal hematoma.

Gentamicin has the potential to cause a severe form of hearing loss known as sensorineural hearing loss. In cases of severe sensorineural hearing loss, the Weber’s test will show a lateralization towards the side of the unaffected ear. Additionally, the Rinne’s test may yield a false negative result, with the patient perceiving the sound in the unaffected ear.

To perform the Rinne’s test, a 512 Hz tuning fork is vibrated and then placed on the mastoid process until the sound is no longer audible. The top of the tuning fork is then positioned 2 cm away from the external auditory meatus, and the patient is asked to indicate where they hear the sound loudest.

In individuals with normal hearing, the tuning fork should still be audible outside the external auditory canal even after it can no longer be heard on the mastoid. This is because air conduction should be more effective than bone conduction.

In cases of conductive hearing loss, the patient will no longer be able to hear the tuning fork once it is no longer audible on the mastoid. This indicates that their bone conduction is greater than their air conduction, suggesting an obstruction in the passage of sound waves through the ear canal and into the cochlea. This is considered a true negative result.

However, a Rinne’s test may yield a false negative result if the patient has a severe unilateral sensorineural deficit and perceives the sound in the unaffected ear through the transmission of sound waves through the base of the skull.

In sensorineural hearing loss, the ability to perceive the tuning fork both on the mastoid and outside the external auditory canal is equally diminished compared to the opposite ear. While they will still hear the tuning fork outside the external auditory canal, the sound will disappear earlier on the mastoid process and outside the external auditory canal compared to the other ear.

To perform the Weber’s test, a 512 Hz tuning fork is vibrated and placed on the center of the patient’s forehead. The patient is then asked if they perceive the sound in the middle of the forehead or if it lateralizes to one side or the other.

If the sound lateralizes to one side, it can indicate either ipsilateral conductive hearing loss or contralateral sensorineural hearing loss.

This child has a past medical history consistent with acute purulent otitis media on the left side. The sudden improvement and discharge of pus from the ear strongly suggest a perforated tympanic membrane. It is not uncommon to be unable to see the tympanic membrane in these situations.

Initially, it is best to adopt a watchful waiting approach to tympanic membrane perforation. Spontaneous healing occurs in over 90% of patients, so only persistent cases should be referred for myringoplasty. There is no need for an urgent same-day referral in this case.

The use of topical corticosteroids and gentamicin is not recommended when there is a tympanic membrane perforation.

Salivary gland stones often cause intermittent swelling that tends to worsen during meal times. This pattern of symptoms is indicative of Sialolithiasis, which refers to the presence of stones in the salivary glands. In cases of acute sialadenitis, the affected gland or duct would typically be enlarged and tender to touch, accompanied by signs of infection such as redness or fever. While mucoepidermoid carcinoma is the most common type of salivary gland cancer, malignant salivary gland tumors are rare. On the other hand, pleomorphic adenoma is the most common benign neoplasm of the salivary glands, with an incidence rate of approximately 2-3.5 cases per 100,000 population. However, it is important to note that salivary gland stones are much more common than tumors, with an annual incidence rate that is 10 times higher.

Further Reading:

Salivary gland disease refers to various conditions that affect the salivary glands, which are responsible for producing saliva. Humans have three pairs of major salivary glands, including the parotid, submandibular, and sublingual glands, as well as numerous minor salivary glands. These glands produce around 1 to 1.5 liters of saliva each day, which serves several functions such as moistening and lubricating the mouth, dissolving food, aiding in swallowing, and protecting the mucosal lining.

There are several causes of salivary gland dysfunction, including infections (such as bacterial or viral infections like mumps), the presence of stones in the salivary ducts, benign or malignant tumors, dry mouth (xerostomia) due to medication, dehydration, or certain medical conditions like Sjögren’s syndrome, granulomatous diseases like sarcoidosis, and rare conditions like HIV-related lymphocytic infiltration. Mucoceles can also affect the minor salivary glands.

Salivary gland stones, known as sialolithiasis, are the most common salivary gland disorder. They typically occur in adults between the ages of 30 and 60, with a higher incidence in males. These stones can develop within the salivary glands or their ducts, leading to obstruction and swelling of the affected gland. Risk factors for stones include certain medications, dehydration, gout, smoking, chronic periodontal disease, and hyperparathyroidism. Diagnosis of salivary gland stones can be made through imaging techniques such as X-ray, ultrasound, sialography, CT, or MRI. Management options include conservative measures like pain relief, antibiotics if there is evidence of infection, hydration, warm compresses, and gland massage. Invasive options may be considered if conservative management fails.

Salivary gland infection, known as sialadenitis, can be caused by bacterial or viral pathogens. Decreased salivary flow, often due to factors like dehydration, malnutrition, immunosuppression, or certain medications, can contribute to the development of sialadenitis. Risk factors for sialadenitis include age over 40, recent dental procedures, Sjögren’s syndrome, immunosuppression, and conditions that decrease salivary flow. Staphylococcus aureus is the most common bacterial cause, while mumps is the most common viral cause. Ac

The most probable causative organism in this case is Streptococcus pneumoniae. This bacterium is a common cause of acute otitis media, especially in young children. It is known to cause infection in the middle ear, leading to symptoms such as ear pain (otalgia), fever, and a red, bulging tympanic membrane. Other organisms such as Escherichia coli, Candida albicans, Pseudomonas aeruginosa, and Staphylococcus aureus can also cause ear infections, but Streptococcus pneumoniae is the most likely culprit in this particular case.

Further Reading:

Acute otitis media (AOM) is an inflammation in the middle ear accompanied by symptoms and signs of an ear infection. It is commonly seen in young children below 4 years of age, with the highest incidence occurring between 9 to 15 months of age. AOM can be caused by viral or bacterial pathogens, and co-infection with both is common. The most common viral pathogens include respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza virus, and parainfluenza virus. The most common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes.

Clinical features of AOM include ear pain (otalgia), fever, a red or cloudy tympanic membrane, and a bulging tympanic membrane with loss of anatomical landmarks. In young children, symptoms may also include crying, grabbing or rubbing the affected ear, restlessness, and poor feeding.

Most children with AOM will recover within 3 days without treatment. Serious complications are rare but can include persistent otitis media with effusion, recurrence of infection, temporary hearing loss, tympanic membrane perforation, labyrinthitis, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.

Management of AOM involves determining whether admission to the hospital is necessary based on the severity of systemic infection or suspected acute complications. For patients who do not require admission, regular pain relief with paracetamol or ibuprofen is advised. Decongestants or antihistamines are not recommended. Antibiotics may be offered immediately for patients who are systemically unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications. For other patients, a decision needs to be made on the antibiotic strategy, considering the rarity of acute complications and the possible adverse effects of antibiotics. Options include no antibiotic prescription with advice to seek medical help if symptoms worsen rapidly or significantly, a back-up antibiotic prescription to be used if symptoms do not improve within 3 days, or an immediate antibiotic prescription with advice to seek medical advice if symptoms worsen rapidly or significantly.

The first-line antibiotic choice for AOM is a 5-7 day course of amoxicillin. For individuals allergic to or intolerant of penicillin, clarithromycin or erythromycin a 5–7 day course of clarithromycin or erythromycin (erythromycin is preferred in pregnant women).

The main treatment options for Bell’s palsy are oral prednisolone and proper eye care. Referral to a specialist is typically not necessary. It is recommended to start steroid treatment within 72 hours of symptom onset. Currently, NICE does not recommend the use of antiviral medications for Bell’s palsy.

Further Reading:

Bell’s palsy is a condition characterized by sudden weakness or paralysis of the facial nerve, resulting in facial muscle weakness or drooping. The exact cause is unknown, but it is believed to be related to viral infections such as herpes simplex or varicella zoster. It is more common in individuals aged 15-45 years and those with diabetes, obesity, hypertension, or upper respiratory conditions. Pregnancy is also a risk factor.

Diagnosis of Bell’s palsy is typically based on clinical symptoms and ruling out other possible causes of facial weakness. Symptoms include rapid onset of unilateral facial muscle weakness, drooping of the eyebrow and corner of the mouth, loss of the nasolabial fold, otalgia, difficulty chewing or dry mouth, taste disturbance, eye symptoms such as inability to close the eye completely, dry eye, eye pain, and excessive tearing, numbness or tingling of the cheek and mouth, speech articulation problems, and hyperacusis.

When assessing a patient with facial weakness, it is important to consider other possible differentials such as stroke, facial nerve tumors, Lyme disease, granulomatous diseases, Ramsay Hunt syndrome, mastoiditis, and chronic otitis media. Red flags for these conditions include insidious and painful onset, duration of symptoms longer than 3 months with frequent relapses, pre-existing risk factors, systemic illness or fever, vestibular or hearing abnormalities, and other cranial nerve involvement.

Management of Bell’s palsy involves the use of steroids, eye care advice, and reassurance. Steroids, such as prednisolone, are recommended for individuals presenting within 72 hours of symptom onset. Eye care includes the use of lubricating eye drops, eye ointment at night, eye taping if unable to close the eye at night, wearing sunglasses, and avoiding dusty environments. Reassurance is important as the majority of patients make a complete recovery within 3-4 months. However, some individuals may experience sequelae such as facial asymmetry, gustatory lacrimation, inadequate lid closure, brow ptosis, drooling, and hemifacial spasms.

Antiviral treatments are not currently recommended as a standalone treatment for Bell’s palsy, but they may be given in combination with corticosteroids on specialist advice. Referral to an ophthalmologist is necessary if the patient has eye symptoms such as pain, irritation, or itch.

When a patient with a tracheostomy is experiencing difficulty breathing, the first step is to assess their condition and provide them with oxygen. If there is suspected obstruction, one of the initial steps to resolve it is to remove the inner tube of the tracheostomy. After that, the mouth and tracheostomy should be examined, and if the patient is breathing, high flow oxygen should be applied to both the mouth and the tracheostomy stoma site. The next steps in managing the patient would be to pass a suction catheter. If the catheter cannot be passed, the cuff should be deflated. If the patient does not stabilize or improve, the tracheostomy tube should be removed. This order of steps is summarized in the green algorithm.

Further Reading:

Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.

When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.

Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.

Differentiating between the various causes of vertigo can be challenging, but there are several clues in the question that can help determine the most likely cause. The sudden onset of severe fixed vertigo, not related to position, following a sinus infection suggests vestibular neuronitis rather than labyrinthitis. Vestibular neuronitis is typically characterized by severe vertigo without hearing loss or tinnitus.

Here are the key clinical features of the different causes of vertigo mentioned in the question:

Vestibular neuronitis:
– Infection of the 8th cranial nerve, which can be viral or bacterial
– Often preceded by a sinus infection or upper respiratory tract infection
– Severe vertigo
– Vertigo is not related to position
– No hearing loss or tinnitus
– Nausea and vomiting are common
– Nystagmus (involuntary eye movement) away from the side of the lesion
– Episodes may recur over an 18-month period

Labyrinthitis:
– Usually caused by a viral infection
– Can affect the entire inner ear and 8th cranial nerve
– Severe vertigo
– Vertigo can be related to position
– May be accompanied by sensorineural hearing loss and tinnitus
– Nausea and vomiting are common
– Nystagmus away from the side of the lesion

Benign positional vertigo:
– Often idiopathic (no known cause)
– Can be secondary to trauma or other inner ear disorders
– Triggered by head movement, rolling over, or looking upward
– Brief episodes lasting less than 5 minutes
– No hearing loss or tinnitus
– Nausea is common, vomiting is rare
– Positive Hallpike maneuver (a diagnostic test)

Meniere’s disease:
– Idiopathic (no known cause)
– Sensorineural hearing loss
– Hearing loss usually gradually progressive and affects one ear
– Associated with tinnitus
– Vertigo attacks typically last 2-3 hours
– Attacks of vertigo last less than 24 hours
– Sensation of fullness or pressure in the ear(s)
– Nausea and vomiting are common
– Nystagmus away from the side of the lesion
– More common in individuals with migraines

Acoustic neuroma:
– Benign tumor of the 8th cranial nerve in the brain
– Gradually worsening unilateral sensorineural hearing loss
– Facial numbness and tingling

BPPV is a condition where dizziness and vertigo occur suddenly when the position of the head is changed. This is a common symptom of benign paroxysmal positional vertigo, which is characterized by episodes of vertigo triggered by head movements.

Further Reading:

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo, characterized by sudden dizziness and vertigo triggered by changes in head position. It typically affects individuals over the age of 55 and is less common in younger patients. BPPV is caused by dysfunction in the inner ear, specifically the detachment of otoliths (calcium carbonate particles) from the utricular otolithic membrane. These loose otoliths move through the semicircular canals, triggering a sensation of movement and resulting in conflicting sensory inputs that cause vertigo.

The majority of BPPV cases involve otoliths in the posterior semicircular canal, followed by the inferior semicircular canal. BPPV in the anterior semicircular canals is rare. Clinical features of BPPV include vertigo triggered by head position changes, such as rolling over in bed or looking upwards, accompanied by nausea. Episodes of vertigo typically last 10-20 seconds and can be diagnosed through positional nystagmus, which is a specific eye movement, observed during diagnostic maneuvers like the Dix-Hallpike maneuver.

Hearing loss and tinnitus are not associated with BPPV. The prognosis for BPPV is generally good, with spontaneous resolution occurring within a few weeks to months. Symptomatic relief can be achieved through the Epley maneuver, which is successful in around 80% of cases, or patient home exercises like the Brandt-Daroff exercises. Medications like Betahistine may be prescribed but have limited effectiveness in treating BPPV.

Meniere’s disease is characterized by recurring episodes of vertigo, tinnitus, and low frequency hearing loss that typically last for a few minutes to a few hours. A patient with Meniere’s disease would be expected to experience these symptoms. During the Weber test, the sound would be heard loudest in the unaffected (contralateral) side. The Romberg test would show a positive result, indicating impaired balance. Additionally, the Fukuda (also known as Unterberger) stepping test would also be positive, suggesting a tendency to veer or lean to one side while walking.

Further Reading:

Meniere’s disease is a disorder of the inner ear that is characterized by recurrent episodes of vertigo, tinnitus, and low frequency hearing loss. The exact cause of the disease is unknown, but it is believed to be related to excessive pressure and dilation of the endolymphatic system in the middle ear. Meniere’s disease is more common in middle-aged adults, but can occur at any age and affects both men and women equally.

The clinical features of Meniere’s disease include episodes of vertigo that can last from minutes to hours. These attacks often occur in clusters, with several episodes happening in a week. Vertigo is usually the most prominent symptom, but patients may also experience a sensation of aural fullness or pressure. Nystagmus and a positive Romberg test are common findings, and the Fukuda stepping test may also be positive. While symptoms are typically unilateral, bilateral symptoms may develop over time.

Rinne’s and Weber’s tests can be used to help diagnose Meniere’s disease. In Rinne’s test, air conduction should be better than bone conduction in both ears. In Weber’s test, the sound should be heard loudest in the unaffected (contralateral) side due to the sensorineural hearing loss.

The natural history of Meniere’s disease is that symptoms often resolve within 5-10 years, but most patients are left with some residual hearing loss. Psychological distress is common among patients with this condition.

The diagnostic criteria for Meniere’s disease include clinical features consistent with the disease, confirmed sensorineural hearing loss on audiometry, and exclusion of other possible causes.

Management of Meniere’s disease involves an ENT assessment to confirm the diagnosis and perform audiometry. Patients should be advised to inform the DVLA and may need to cease driving until their symptoms are under control. Acute attacks can be treated with buccal or intramuscular prochlorperazine, and hospital admission may be necessary in some cases. Betahistine may be beneficial for prevention of symptoms.

Acute epiglottitis is inflammation of the epiglottis, which can be life-threatening if not treated promptly. When the soft tissues surrounding the epiglottis are also affected, it is called acute supraglottitis. This condition is most commonly seen in children between the ages of 3 and 5, but it can occur at any age, with adults typically presenting in their 40s and 50s.

In the past, Haemophilus influenzae type B was the main cause of acute epiglottitis, but with the introduction of the Hib vaccination, it has become rare in children. Streptococcus spp. is now the most common causative organism. Other potential culprits include Staphylococcus aureus, Pseudomonas spp., Moraxella catarrhalis, Mycobacterium tuberculosis, and the herpes simplex virus. In immunocompromised patients, Candida spp. and Aspergillus spp. infections can occur.

The typical symptoms of acute epiglottitis include fever, sore throat, painful swallowing, difficulty swallowing secretions (especially in children who may drool), muffled voice, stridor, respiratory distress, rapid heartbeat, tenderness in the front of the neck over the hyoid bone, ear pain, and swollen lymph nodes in the neck. Some patients may also exhibit the tripod sign, where they lean forward on outstretched arms to relieve upper airway obstruction.

To diagnose acute epiglottitis, fibre-optic laryngoscopy is considered the gold standard investigation. However, this procedure should only be performed by an anaesthetist in a setting prepared for intubation or tracheostomy in case of airway obstruction. Other useful tests include a lateral neck X-ray to look for the thumbprint sign, throat swabs, blood cultures, and a CT scan of the neck if an abscess is suspected.

When dealing with a case of acute epiglottitis, it is crucial not to panic or distress the patient, especially in pediatric cases. Avoid attempting to examine the throat with a tongue depressor, as this can trigger spasm and worsen airway obstruction. Instead, keep the patient as calm as possible and immediately call a senior anaesthetist, a senior paediatrician, and an ENT surgeon. Nebulized adrenaline can be used as a temporary measure if there is critical airway obstruction.

Most nosebleeds, also known as epistaxis, occur at a specific area called Little’s area.

Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

The top priority when dealing with suspected epiglottitis is to assess and secure the airway. This is especially important in patients who have not been vaccinated against Haemophilus influenzae type b (HiB), as they are at risk for complications from this infection. Classic signs of epiglottitis include tripod positioning, drooling, stridor, and a muffled voice. It is crucial to avoid agitating patients, particularly children, during examination or procedures, as this can trigger laryngospasm and potentially lead to airway obstruction. In such cases, it is recommended to call in senior ENT and anaesthetic support to perform laryngoscopy and be prepared for intubation or tracheostomy if necessary to address any airway compromise. If the patient is in a critical condition, securing the airway through intubation becomes the top priority.

Further Reading:

Epiglottitis is a rare but serious condition characterized by inflammation and swelling of the epiglottis, which can lead to a complete blockage of the airway. It is more commonly seen in children between the ages of 2-6, but can also occur in adults, particularly those in their 40s and 50s. Streptococcus infections are now the most common cause of epiglottitis in the UK, although other bacterial agents, viruses, fungi, and iatrogenic causes can also be responsible.

The clinical features of epiglottitis include a rapid onset of symptoms, high fever, sore throat, painful swallowing, muffled voice, stridor and difficulty breathing, drooling of saliva, irritability, and a characteristic tripod positioning with the arms forming the front two legs of the tripod. It is important for healthcare professionals to avoid examining the throat or performing any potentially upsetting procedures until the airway has been assessed and secured.

Diagnosis of epiglottitis is typically made through fibre-optic laryngoscopy, which is considered the gold standard investigation. Lateral neck X-rays may also show a characteristic thumb sign, indicating an enlarged and swollen epiglottis. Throat swabs and blood cultures may be taken once the airway is secured to identify the causative organism.

Management of epiglottitis involves assessing and securing the airway as the top priority. Intravenous or oral antibiotics are typically prescribed, and supplemental oxygen may be given if intubation or tracheostomy is planned. In severe cases where the airway is significantly compromised, intubation or tracheostomy may be necessary. Steroids may also be used, although the evidence for their benefit is limited.

Overall, epiglottitis is a potentially life-threatening condition that requires urgent medical attention. Prompt diagnosis, appropriate management, and securing the airway are crucial in ensuring a positive outcome for patients with this condition.

Benign paroxysmal positional vertigo (BPPV) occurs when there is dysfunction in the inner ear. This dysfunction causes the otoliths, which are located in the utricle, to become dislodged from their normal position and migrate into one of the semicircular canals over time. As a result, these detached otoliths continue to move even after head movement has stopped, leading to vertigo due to the conflicting sensation of ongoing movement with other sensory inputs.

While the majority of BPPV cases have no identifiable cause (idiopathic), approximately 40% of cases can be attributed to factors such as head injury, spontaneous labyrinthine degeneration, post-viral illness, middle ear surgery, or chronic middle ear disease.

The main clinical features of BPPV include symptoms that are provoked by head movement, rolling over, and upward gaze. These episodes are typically brief, lasting less than 5 minutes, and are often worse in the mornings. Unlike other inner ear disorders, BPPV does not cause hearing loss or tinnitus. Nausea is a common symptom, while vomiting is rare. The Dix-Hallpike test can be used to confirm the diagnosis of BPPV.

It is important to note that vestibular suppressant medications have not been proven to be beneficial in managing BPPV. These medications do not improve symptoms or reduce the duration of the disease.

The treatment of choice for BPPV is the Epley manoeuvre. This maneuver aims to reposition the dislodged otoliths back into the utricles from the semicircular canals. A 2014 Cochrane review concluded that the Epley manoeuvre is a safe and effective treatment for BPPV, with a number needed to treat of 2-4.

Referral to an ENT specialist is recommended for patients with BPPV in the following situations: if the treating clinician is unable to perform or access the Epley manoeuvre, if the Epley manoeuvre has not been beneficial after repeated attempts (minimum two), if the patient has been symptomatic for more than 4 weeks, or if the patient has experienced more than 3 episodes of BPPV.

One type of brainstem infarction is characterized by the presence of complete deafness on the same side as the affected area. This condition is unlikely to be caused by a transient ischemic attack (TIA) or stroke due to the patient’s age and absence of risk factors. Benign paroxysmal positional vertigo (BPPV) causes brief episodes of vertigo triggered by head movements. On the other hand, vestibular neuronitis (also known as vestibular neuritis) causes a persistent sensation of vertigo rather than intermittent episodes.

Further Reading:

Meniere’s disease is a disorder of the inner ear that is characterized by recurrent episodes of vertigo, tinnitus, and low frequency hearing loss. The exact cause of the disease is unknown, but it is believed to be related to excessive pressure and dilation of the endolymphatic system in the middle ear. Meniere’s disease is more common in middle-aged adults, but can occur at any age and affects both men and women equally.

The clinical features of Meniere’s disease include episodes of vertigo that can last from minutes to hours. These attacks often occur in clusters, with several episodes happening in a week. Vertigo is usually the most prominent symptom, but patients may also experience a sensation of aural fullness or pressure. Nystagmus and a positive Romberg test are common findings, and the Fukuda stepping test may also be positive. While symptoms are typically unilateral, bilateral symptoms may develop over time.

Rinne’s and Weber’s tests can be used to help diagnose Meniere’s disease. In Rinne’s test, air conduction should be better than bone conduction in both ears. In Weber’s test, the sound should be heard loudest in the unaffected (contralateral) side due to the sensorineural hearing loss.

The natural history of Meniere’s disease is that symptoms often resolve within 5-10 years, but most patients are left with some residual hearing loss. Psychological distress is common among patients with this condition.

The diagnostic criteria for Meniere’s disease include clinical features consistent with the disease, confirmed sensorineural hearing loss on audiometry, and exclusion of other possible causes.

Management of Meniere’s disease involves an ENT assessment to confirm the diagnosis and perform audiometry. Patients should be advised to inform the DVLA and may need to cease driving until their symptoms are under control. Acute attacks can be treated with buccal or intramuscular prochlorperazine, and hospital admission may be necessary in some cases. Betahistine may be beneficial for prevention of symptoms.

Vestibular neuronitis is characterized by the sudden and prolonged onset of rotational vertigo. This vertigo can occur spontaneously, upon waking up, or gradually worsen throughout the day. It is particularly aggravated by changes in head position, although it remains constant even when the head is still. Unlike other conditions, vestibular neuronitis does not cause hearing loss, tinnitus, or focal neurological deficits. On the other hand, in BPPV, episodes of vertigo are usually brief, lasting less than 20 seconds, and only occur when there is a change in head position.

Further Reading:

Vestibular neuritis, also known as vestibular neuronitis, is a condition characterized by sudden and prolonged vertigo of peripheral origin. It is believed to be caused by inflammation of the vestibular nerve, often following a viral infection. It is important to note that vestibular neuritis and labyrinthitis are not the same condition, as labyrinthitis involves inflammation of the labyrinth. Vestibular neuritis typically affects individuals between the ages of 30 and 60, with a 1:1 ratio of males to females. The annual incidence is approximately 3.5 per 100,000 people, making it one of the most commonly diagnosed causes of vertigo.

Clinical features of vestibular neuritis include nystagmus, which is a rapid, involuntary eye movement, typically in a horizontal or horizontal-torsional direction away from the affected ear. The head impulse test may also be positive. Other symptoms include spontaneous onset of rotational vertigo, which is worsened by changes in head position, as well as nausea, vomiting, and unsteadiness. These severe symptoms usually last for 2-3 days, followed by a gradual recovery over a few weeks. It is important to note that hearing is not affected in vestibular neuritis, and symptoms such as tinnitus and focal neurological deficits are not present.

Differential diagnosis for vestibular neuritis includes benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere’s disease, migraine, stroke, and cerebellar lesions. Management of vestibular neuritis involves drug treatment for nausea and vomiting associated with vertigo, typically through short courses of medication such as prochlorperazine or cyclizine. If symptoms are severe and fluids cannot be tolerated, admission and administration of IV fluids may be necessary. General advice should also be given, including avoiding driving while symptomatic, considering the suitability to work based on occupation and duties, and the increased risk of falls. Follow-up is required, and referral is necessary if there are atypical symptoms, symptoms do not improve after a week of treatment, or symptoms persist for more than 6 weeks.

The prognosis for vestibular neuritis is generally good, with the majority of individuals fully recovering within 6 weeks. Recurrence is thought to occur in 2-11% of cases, and approximately 10% of individuals may develop BPPV following an episode of vestibular neuritis. A very rare complication of vestibular neuritis is ph

Malignant otitis externa (MOE), also known as necrotising otitis externa, is a rare type of ear infection that primarily affects older individuals with diabetes, particularly if their diabetes is poorly managed.

MOE initially starts as an infection in the ear canal and gradually spreads to the surrounding bone and soft tissues. In about 98% of cases, the responsible pathogen is Pseudomonas aeruginosa.

Typically, MOE presents with intense ear pain and persistent inflammation of the ear canal that does not respond well to topical antibiotics. The pain is often described as constant and tends to worsen at night. Even after the swelling of the ear canal subsides with the use of topical antibiotics, the pain may persist. Other symptoms that may be present include pus drainage from the ear and temporal headaches. Approximately 50% of patients also experience facial nerve paralysis, and cranial nerves IX to XII may also be affected.

If left untreated, MOE can be life-threatening, and serious complications may arise, such as skull base osteomyelitis, subdural empyema, and cerebral abscess.

To diagnose MOE, technetium scanning and contrast-enhanced CT scanning are typically performed. Treatment usually involves long-term administration of intravenous antibiotics.

Amoxicillin is the preferred antibiotic for treating acute otitis media (AOM). It is the first choice for patients who do not have a penicillin allergy. According to NICE guidelines, a 5-7 day course of amoxicillin is recommended for treating this condition.

Further Reading:

Acute otitis media (AOM) is an inflammation in the middle ear accompanied by symptoms and signs of an ear infection. It is commonly seen in young children below 4 years of age, with the highest incidence occurring between 9 to 15 months of age. AOM can be caused by viral or bacterial pathogens, and co-infection with both is common. The most common viral pathogens include respiratory syncytial virus (RSV), rhinovirus, adenovirus, influenza virus, and parainfluenza virus. The most common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Streptococcus pyogenes.

Clinical features of AOM include ear pain (otalgia), fever, a red or cloudy tympanic membrane, and a bulging tympanic membrane with loss of anatomical landmarks. In young children, symptoms may also include crying, grabbing or rubbing the affected ear, restlessness, and poor feeding.

Most children with AOM will recover within 3 days without treatment. Serious complications are rare but can include persistent otitis media with effusion, recurrence of infection, temporary hearing loss, tympanic membrane perforation, labyrinthitis, mastoiditis, meningitis, intracranial abscess, sinus thrombosis, and facial nerve paralysis.

Management of AOM involves determining whether admission to the hospital is necessary based on the severity of systemic infection or suspected acute complications. For patients who do not require admission, regular pain relief with paracetamol or ibuprofen is advised. Decongestants or antihistamines are not recommended. Antibiotics may be offered immediately for patients who are systemically unwell, have symptoms and signs of a more serious illness or condition, or have a high risk of complications. For other patients, a decision needs to be made on the antibiotic strategy, considering the rarity of acute complications and the possible adverse effects of antibiotics. Options include no antibiotic prescription with advice to seek medical help if symptoms worsen rapidly or significantly, a back-up antibiotic prescription to be used if symptoms do not improve within 3 days, or an immediate antibiotic prescription with advice to seek medical advice if symptoms worsen rapidly or significantly.

The first-line antibiotic choice for AOM is a 5-7 day course of amoxicillin. For individuals allergic to or intolerant of penicillin, a 5–7 day course of clarithromycin or erythromycin (erythromycin is preferred in pregnant women).

Vestibular neuritis is a common complication of vestibular neuronitis, characterized by a following of people experiencing symptoms such as persistent dizziness, unsteadiness, and fear of falling. However, a rare complication called phobic postural vertigo may also occur, where individuals experience these symptoms despite not actually falling.

On the other hand, benign paroxysmal positional vertigo (BPPV) presents with short episodes of vertigo, usually lasting less than 20 seconds, triggered by changes in head position. In contrast, vestibular neuronitis causes constant vertigo, even when at rest, which can be worsened by head movements.

Recovery from vestibular neuronitis is a gradual process that typically takes a few weeks, up to 6 weeks. It is believed that this condition is caused by inflammation of the vestibular nerve following a viral infection. On the other hand, BPPV is thought to occur due to the presence of cellular debris or crystal formation in the semicircular canals.

Further Reading:

Vestibular neuritis, also known as vestibular neuronitis, is a condition characterized by sudden and prolonged vertigo of peripheral origin. It is believed to be caused by inflammation of the vestibular nerve, often following a viral infection. It is important to note that vestibular neuritis and labyrinthitis are not the same condition, as labyrinthitis involves inflammation of the labyrinth. Vestibular neuritis typically affects individuals between the ages of 30 and 60, with a 1:1 ratio of males to females. The annual incidence is approximately 3.5 per 100,000 people, making it one of the most commonly diagnosed causes of vertigo.

Clinical features of vestibular neuritis include nystagmus, which is a rapid, involuntary eye movement, typically in a horizontal or horizontal-torsional direction away from the affected ear. The head impulse test may also be positive. Other symptoms include spontaneous onset of rotational vertigo, which is worsened by changes in head position, as well as nausea, vomiting, and unsteadiness. These severe symptoms usually last for 2-3 days, followed by a gradual recovery over a few weeks. It is important to note that hearing is not affected in vestibular neuritis, and symptoms such as tinnitus and focal neurological deficits are not present.

Differential diagnosis for vestibular neuritis includes benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere’s disease, migraine, stroke, and cerebellar lesions. Management of vestibular neuritis involves drug treatment for nausea and vomiting associated with vertigo, typically through short courses of medication such as prochlorperazine or cyclizine. If symptoms are severe and fluids cannot be tolerated, admission and administration of IV fluids may be necessary. General advice should also be given, including avoiding driving while symptomatic, considering the suitability to work based on occupation and duties, and the increased risk of falls. Follow-up is required, and referral is necessary if there are atypical symptoms, symptoms do not improve after a week of treatment, or symptoms persist for more than 6 weeks.

The prognosis for vestibular neuritis is generally good, with the majority of individuals fully recovering within 6 weeks. Recurrence is thought to occur in 2-11% of cases, and approximately 10% of individuals may develop BPPV following an episode of vestibular neuritis. A very rare complication of vestibular neuritis is ph

When performing Weber’s test, if the sound lateralizes to the unaffected side, it suggests sensorineural hearing loss. If the sound lateralizes to the right, it could mean that there is sensorineural hearing loss in the left ear or conductive hearing loss in the right ear. A positive Rinne test result indicates that air conduction is greater than bone conduction, which is normal or seen in sensorineural hearing loss. On the other hand, a negative Rinne test result suggests that bone conduction is greater than air conduction, which is typically seen in conductive hearing loss. Therefore, if there is conductive hearing loss in the left ear, a negative Rinne test result would indicate sensorineural loss on the left side.

Further Reading:

Hearing loss is a common complaint that can be caused by various conditions affecting different parts of the ear and nervous system. The outer ear is the part of the ear outside the eardrum, while the middle ear is located between the eardrum and the cochlea. The inner ear is within the bony labyrinth and consists of the vestibule, semicircular canals, and cochlea. The vestibulocochlear nerve connects the inner ear to the brain.

Hearing loss can be classified based on severity, onset, and type. Severity is determined by the quietest sound that can be heard, measured in decibels. It can range from mild to profound deafness. Onset can be sudden, rapidly progressive, slowly progressive, or fluctuating. Type of hearing loss can be either conductive or sensorineural. Conductive hearing loss is caused by issues in the external ear, eardrum, or middle ear that disrupt sound transmission. Sensorineural hearing loss is caused by problems in the cochlea, auditory nerve, or higher auditory processing pathways.

To diagnose sensorineural and conductive deafness, a 512 Hz tuning fork is used to perform Rinne and Weber’s tests. These tests help determine the type of hearing loss based on the results. In Rinne’s test, air conduction (AC) and bone conduction (BC) are compared, while Weber’s test checks for sound lateralization.

Cholesteatoma is a condition characterized by the abnormal accumulation of skin cells in the middle ear or mastoid air cell spaces. It is believed to develop from a retraction pocket that traps squamous cells. Cholesteatoma can cause the accumulation of keratin and the destruction of adjacent bones and tissues due to the production of destructive enzymes. It can lead to mixed sensorineural and conductive deafness as it affects both the middle and inner ear.

Croup, also known as laryngo-tracheo-bronchitis, is typically caused by the parainfluenza virus. Other viruses such as rhinovirus, influenza, and respiratory syncytial viruses can also be responsible. Before the onset of stridor, there is often a mild cold-like illness that lasts for 1-2 days. Symptoms usually peak within 1-3 days, with the cough being more severe at night. A milder cough may persist for another 7-10 days.

A barking cough is a characteristic symptom of croup, but it does not indicate the severity of the condition. To reduce airway swelling, dexamethasone and prednisolone are commonly used. Nebulized budesonide can be an alternative if the child is experiencing vomiting. However, it’s important to note that steroids do not shorten the duration of the illness. In severe cases, nebulized adrenaline can be administered.

Hospitalization for croup is rare and typically reserved for children who are experiencing increasing respiratory distress or showing signs of drowsiness/agitation. The Westley croup score is a useful tool for assessing the child’s condition and making appropriate management decisions. Children with moderate (score 2-7) or severe croup (score >7) may require hospital admission. On the other hand, many children with mild croup (score 0-1) can be safely discharged and treated at home.

The Westley croup score is determined based on the following criteria: the presence of stridor at rest, the severity of retractions, air entry, SaO2 levels below 92% when agitated, and the conscious level of the child. In this particular case, the child’s Westley croup score is 8 points, indicating severe croup.

Two scoring systems are suggested by NICE to aid in the evaluation of sore throat: The Centor Clinical Prediction Score and The FeverPAIN Score.

The FeverPAIN score was developed from a study involving 1760 adults and children aged three and above. The score was tested in a trial that compared three prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, or a combination of the score with the use of a near-patient test (NPT) for streptococcus. Utilizing the score resulted in faster symptom resolution and a reduction in the prescription of antibiotics (both reduced by one third). The inclusion of the NPT did not provide any additional benefit.

The score comprises of five factors, each of which is assigned one point: Fever (Temp >38°C) in the last 24 hours, Purulence, Attended rapidly in under three days, Inflamed tonsils, and No cough or coryza.

Based on the score, the recommendations are as follows:
– Score 0-1 = 13-18% likelihood of streptococcus infection, antibiotics are not recommended.
– Score 2-3 = 34-40% likelihood of streptococcus infection, consider delayed prescribing of antibiotics (3-5 day ‘backup prescription’).
– Score 4-5 = 62-65% likelihood of streptococcus infection, use immediate antibiotics if severe, or a 48-hour short ‘backup prescription.’

Mastoiditis can lead to the development of cranial nerve palsies, specifically affecting the trigeminal (CN V), abducens (CN VI), and facial (CN VII) nerves. This occurs when the infection spreads to the petrous apex of the temporal bone, where these nerves are located. The close proximity of the sixth cranial nerve and the trigeminal ganglion, separated only by the dura mater, can result in inflammation and subsequent nerve damage. Additionally, the facial nerve is at risk as it passes through the mastoid via the facial canal.

Further Reading:

Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.

Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.

Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.

Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).

Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.

Vestibular neuronitis is believed to occur when the vestibular nerve becomes inflamed, often following a viral infection like a cold. This condition causes a constant feeling of dizziness, which can worsen with head movements. On the other hand, BPPV (benign paroxysmal positional vertigo) is characterized by brief episodes of vertigo lasting around 10-20 seconds, triggered by specific head movements. To diagnose BPPV, the Dix-Hallpike test is performed, and a positive result is indicated by a specific type of eye movement called nystagmus. In contrast, vestibular neuritis typically presents with horizontal nystagmus that only occurs in one direction.

Further Reading:

Vestibular neuritis, also known as vestibular neuronitis, is a condition characterized by sudden and prolonged vertigo of peripheral origin. It is believed to be caused by inflammation of the vestibular nerve, often following a viral infection. It is important to note that vestibular neuritis and labyrinthitis are not the same condition, as labyrinthitis involves inflammation of the labyrinth. Vestibular neuritis typically affects individuals between the ages of 30 and 60, with a 1:1 ratio of males to females. The annual incidence is approximately 3.5 per 100,000 people, making it one of the most commonly diagnosed causes of vertigo.

Clinical features of vestibular neuritis include nystagmus, which is a rapid, involuntary eye movement, typically in a horizontal or horizontal-torsional direction away from the affected ear. The head impulse test may also be positive. Other symptoms include spontaneous onset of rotational vertigo, which is worsened by changes in head position, as well as nausea, vomiting, and unsteadiness. These severe symptoms usually last for 2-3 days, followed by a gradual recovery over a few weeks. It is important to note that hearing is not affected in vestibular neuritis, and symptoms such as tinnitus and focal neurological deficits are not present.

Differential diagnosis for vestibular neuritis includes benign paroxysmal positional vertigo (BPPV), labyrinthitis, Meniere’s disease, migraine, stroke, and cerebellar lesions. Management of vestibular neuritis involves drug treatment for nausea and vomiting associated with vertigo, typically through short courses of medication such as prochlorperazine or cyclizine. If symptoms are severe and fluids cannot be tolerated, admission and administration of IV fluids may be necessary. General advice should also be given, including avoiding driving while symptomatic, considering the suitability to work based on occupation and duties, and the increased risk of falls. Follow-up is required, and referral is necessary if there are atypical symptoms, symptoms do not improve after a week of treatment, or symptoms persist for more than 6 weeks.

The prognosis for vestibular neuritis is generally good, with the majority of individuals fully recovering within 6 weeks. Recurrence is thought to occur in 2-11% of cases, and approximately 10% of individuals may develop BPPV following an episode of vestibular neuritis. A very rare complication of vestibular neuritis is ph

Malignant otitis externa (MOE), also known as necrotizing otitis externa, is a rare form of ear canal infection that primarily affects elderly diabetic patients, particularly those with poorly controlled diabetes.

MOE initially infects the ear canal and gradually spreads to the surrounding bony structures and soft tissues. In 98% of cases, the responsible pathogen is Pseudomonas aeruginosa.

Typically, MOE presents with severe and unrelenting ear pain, which tends to worsen at night. Even after the swelling of the ear canal subsides with topical antibiotics, the pain may persist. Other symptoms may include pus drainage from the ear and temporal headaches. Approximately 50% of patients also experience facial nerve paralysis, and cranial nerves IX to XII may be affected as well.

To confirm the diagnosis, technetium scanning and contrast-enhanced CT scanning are usually performed to detect any extension of the infection into the surrounding bony structures.

If left untreated, MOE can be life-threatening and may lead to serious complications such as skull base osteomyelitis, subdural empyema, and cerebral abscess.

Treatment typically involves long-term administration of intravenous antibiotics. While surgical intervention is not effective for MOE, exploratory surgery may be necessary to obtain cultures of unusual organisms that are not responding adequately to intravenous antibiotics.

The most commonly found organism in patients with mastoiditis is Streptococcus pneumoniae.

Further Reading:

Mastoiditis is an infection of the mastoid air cells, which are located in the mastoid process of the skull. It is usually caused by the spread of infection from the middle ear. The most common organism responsible for mastoiditis is Streptococcus pneumoniae, but other bacteria and fungi can also be involved. The infection can spread to surrounding structures, such as the meninges, causing serious complications like meningitis or cerebral abscess.

Mastoiditis can be classified as acute or chronic. Acute mastoiditis is a rare complication of acute otitis media, which is inflammation of the middle ear. It is characterized by severe ear pain, fever, swelling and redness behind the ear, and conductive deafness. Chronic mastoiditis is usually associated with chronic suppurative otitis media or cholesteatoma and presents with recurrent episodes of ear pain, headache, and fever.

Mastoiditis is more common in children, particularly those between 6 and 13 months of age. Other risk factors include immunocompromised patients, those with intellectual impairment or communication difficulties, and individuals with cholesteatoma.

Diagnosis of mastoiditis involves a physical examination, blood tests, ear swab for culture and sensitivities, and imaging studies like contrast-enhanced CT or MRI. Treatment typically involves referral to an ear, nose, and throat specialist, broad-spectrum intravenous antibiotics, pain relief, and myringotomy (a procedure to drain fluid from the middle ear).

Complications of mastoiditis are rare but can be serious. They include intracranial abscess, meningitis, subperiosteal abscess, neck abscess, venous sinus thrombosis, cranial nerve palsies, hearing loss, labyrinthitis, extension to the zygoma, and carotid artery arteritis. However, most patients with mastoiditis have a good prognosis and do not experience long-term ear problems.

The upper part of the nose receives blood supply from the anterior and posterior ethmoidal arteries, which are derived from the internal carotid artery. On the other hand, the remaining parts of the nose and sinuses are nourished by the greater palatine, sphenopalatine, and superior labial arteries. These arteries are branches of the external carotid arteries.

In the front part of the nasal septum, there exists a network of blood vessels where the branches of the internal and external carotid artery connect. This network is known as Kiesselbach’s plexus, also referred to as Little’s area. It is worth noting that Kiesselbach’s plexus is the most common location for anterior bleeding.

The FeverPAIN score is a scoring system that is recommended by the current NICE guidelines for assessing acute sore throats. It consists of five items: fever in the last 24 hours, purulence, attendance within three days, inflamed tonsils, and no cough or coryza. Based on the score, different recommendations are given regarding the use of antibiotics.

If the score is 0-1, it is unlikely to be a streptococcal infection, with only a 13-18% chance of streptococcus isolation. Therefore, antibiotics are not recommended in this case. If the score is 2-3, there is a higher chance (34-40%) of streptococcus isolation, so delayed prescribing of antibiotics is considered, with a 3-day ‘back-up prescription’. If the score is 4 or higher, there is a 62-65% chance of streptococcus isolation, and immediate antibiotic use is recommended if the infection is severe. Otherwise, a 48-hour short back-up prescription is suggested.

The Fever PAIN score was developed from a study that included 1760 adults and children aged three and over. It was then tested in a trial that compared three different prescribing strategies: empirical delayed prescribing, using the score to guide prescribing, and combining the score with the use of a near-patient test (NPT) for streptococcus. The use of the score resulted in faster symptom resolution and a reduction in antibiotic prescribing, both by one third. However, the addition of the NPT did not provide any additional benefit.

Overall, the FeverPAIN score is a useful tool for assessing acute sore throats and guiding antibiotic prescribing decisions. It has been shown to be effective in reducing unnecessary antibiotic use and improving patient outcomes.

Kiesselbach’s plexus, also known as Little’s area, is located in the front and lower part of the nasal septum. It is the most common site of bleeding in cases of anterior epistaxis. This plexus is formed by the convergence of four arteries: the anterior ethmoidal artery, the sphenopalatine artery, the greater palatine artery, and the septal branch of the superior labial artery. It is important to note that while the posterior ethmoidal artery supplies the septum of the nose, it does not contribute to Kiesselbach’s plexus.

Epiglottitis commonly occurs in children aged 2-6 years, while adults in their 40’s and 50’s are more prone to experiencing this condition.

Further Reading:

Epiglottitis is a rare but serious condition characterized by inflammation and swelling of the epiglottis, which can lead to a complete blockage of the airway. It is more commonly seen in children between the ages of 2-6, but can also occur in adults, particularly those in their 40s and 50s. Streptococcus infections are now the most common cause of epiglottitis in the UK, although other bacterial agents, viruses, fungi, and iatrogenic causes can also be responsible.

The clinical features of epiglottitis include a rapid onset of symptoms, high fever, sore throat, painful swallowing, muffled voice, stridor and difficulty breathing, drooling of saliva, irritability, and a characteristic tripod positioning with the arms forming the front two legs of the tripod. It is important for healthcare professionals to avoid examining the throat or performing any potentially upsetting procedures until the airway has been assessed and secured.

Diagnosis of epiglottitis is typically made through fibre-optic laryngoscopy, which is considered the gold standard investigation. Lateral neck X-rays may also show a characteristic thumb sign, indicating an enlarged and swollen epiglottis. Throat swabs and blood cultures may be taken once the airway is secured to identify the causative organism.

Management of epiglottitis involves assessing and securing the airway as the top priority. Intravenous or oral antibiotics are typically prescribed, and supplemental oxygen may be given if intubation or tracheostomy is planned. In severe cases where the airway is significantly compromised, intubation or tracheostomy may be necessary. Steroids may also be used, although the evidence for their benefit is limited.

Overall, epiglottitis is a potentially life-threatening condition that requires urgent medical attention. Prompt diagnosis, appropriate management, and securing the airway are crucial in ensuring a positive outcome for patients with this condition.

This patient has developed an acute auricular subchondral haematoma. It occurs when blood and serum collect in the space between the cartilage and the supporting perichondrium due to a shearing force that separates the perichondrium from the underlying cartilage.

It is important to differentiate this condition from cauliflower ear, which is a common complication that arises when an auricular haematoma is not treated. If a subchondral haematoma is left untreated, the damaged perichondrium forms a fibrocartilage plate, leading to scarring and cartilage regeneration. This results in an irregular and thickened pinna, typically along the helical rim.

The management of an auricular haematoma involves the following steps:

1. Infiltration with a local anaesthetic, such as 1% lidocaine.
2. Drainage or needle aspiration of the haematoma.
3. Application of firm packing and compression bandaging to prevent re-accumulation.
4. Administration of broad-spectrum antibiotics.

By following these management steps, the patient can effectively address and treat the auricular haematoma.

To control nosebleeds, it is recommended to have the patient sit upright with their upper body tilted forward and their mouth open. Apply firm pressure to the cartilaginous part of the nose, just in front of the bony septum, and hold it for 10-15 minutes without releasing the pressure.

Further Reading:

Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

This area contains stones made of stone. The parotid duct opens into the vestibule of the mouth, specifically between the cheek and gums, at a spot called the parotid papilla. This papilla is located across from the second upper molar tooth.
The sublingual gland is drained by a series of 8-20 excretory ducts known as the ducts of Rivinus. The largest duct in this system is called Bartholin’s duct. It is worth noting that stones in the sublingual gland are extremely rare.

Further Reading:

Salivary gland disease refers to various conditions that affect the salivary glands, which are responsible for producing saliva. Humans have three pairs of major salivary glands, including the parotid, submandibular, and sublingual glands, as well as numerous minor salivary glands. These glands produce around 1 to 1.5 liters of saliva each day, which serves several functions such as moistening and lubricating the mouth, dissolving food, aiding in swallowing, and protecting the mucosal lining.

There are several causes of salivary gland dysfunction, including infections (such as bacterial or viral infections like mumps), the presence of stones in the salivary ducts, benign or malignant tumors, dry mouth (xerostomia) due to medication, dehydration, or certain medical conditions like Sjögren’s syndrome, granulomatous diseases like sarcoidosis, and rare conditions like HIV-related lymphocytic infiltration. Mucoceles can also affect the minor salivary glands.

Salivary gland stones, known as sialolithiasis, are the most common salivary gland disorder. They typically occur in adults between the ages of 30 and 60, with a higher incidence in males. These stones can develop within the salivary glands or their ducts, leading to obstruction and swelling of the affected gland. Risk factors for stones include certain medications, dehydration, gout, smoking, chronic periodontal disease, and hyperparathyroidism. Diagnosis of salivary gland stones can be made through imaging techniques such as X-ray, ultrasound, sialography, CT, or MRI. Management options include conservative measures like pain relief, antibiotics if there is evidence of infection, hydration, warm compresses, and gland massage. Invasive options may be considered if conservative management fails.

Salivary gland infection, known as sialadenitis, can be caused by bacterial or viral pathogens. Decreased salivary flow, often due to factors like dehydration, malnutrition, immunosuppression, or certain medications, can contribute to the development of sialadenitis. Risk factors for sialadenitis include age over 40, recent dental procedures, Sjögren’s syndrome, immunosuppression, and conditions that decrease salivary flow. Staphylococcus aureus is the most common bacterial cause, while mumps is the most common viral cause. Ac

The internal carotid artery is situated approximately 2.5 cm behind and to the side of the tonsil. When performing an aspiration procedure for a peritonsillar abscess, there is a risk of puncturing this artery. In the UK, it is common for emergency department doctors to refer the task of draining a peritonsillar abscess to the on-call ENT team due to their lack of familiarity and experience with the procedure. However, the RCEM learning platform considers the management of uncomplicated peritonsillar abscess to be within the scope of emergency department practice, making it important for doctors to be knowledgeable about the procedure and its potential complications. It is worth noting that Lemierre’s syndrome, which is infective thrombophlebitis of the jugular vein, is a complication of deep neck infections and not directly related to the aspiration procedure.

Further Reading:

A peritonsillar abscess, also known as quinsy, is a collection of pus that forms between the palatine tonsil and the pharyngeal muscles. It is often a complication of acute tonsillitis and is most commonly seen in adolescents and young adults. The exact cause of a peritonsillar abscess is not fully understood, but it is believed to occur when infection spreads beyond the tonsillar capsule or when small salivary glands in the supratonsillar space become blocked.

The most common causative organisms for a peritonsillar abscess include Streptococcus pyogenes, Staphylococcus aureus, Haemophilus influenzae, and anaerobic organisms. Risk factors for developing a peritonsillar abscess include smoking, periodontal disease, male sex, and a previous episode of the condition.

Clinical features of a peritonsillar abscess include severe throat pain, difficulty opening the mouth (trismus), fever, headache, drooling of saliva, bad breath, painful swallowing, altered voice, ear pain on the same side, neck stiffness, and swelling of the soft palate. Diagnosis is usually made based on clinical presentation, but imaging scans such as CT or ultrasound may be used to assess for complications or determine the best site for drainage.

Treatment for a peritonsillar abscess involves pain relief, intravenous antibiotics to cover for both aerobic and anaerobic organisms, intravenous fluids if swallowing is difficult, and drainage of the abscess either through needle aspiration or incision and drainage. Tonsillectomy may be recommended to prevent recurrence. Complications of a peritonsillar abscess can include sepsis, spread to deeper neck tissues leading to necrotizing fasciitis or retropharyngeal abscess, airway compromise, recurrence of the abscess, aspiration pneumonia, erosion into major blood vessels, and complications related to the causative organism. All patients with a peritonsillar abscess should be referred to an ear, nose, and throat specialist for further management.

A 512 Hz tuning fork is commonly used for both the Rinne’s and Weber’s tests. However, a lower-pitched fork, such as a 128 Hz tuning fork, is typically used to assess vibration sense during a peripheral nervous system examination. Although a 256 Hz tuning fork can be used for either test, it is considered less reliable for both.

To perform a Rinne’s test, the 512 Hz tuning fork is first made to vibrate and then placed on the mastoid process until the sound is no longer heard. The top of the tuning fork is then positioned 2 cm away from the external auditory meatus, and the patient is asked to indicate where they hear the sound loudest.

In individuals with normal hearing, the tuning fork should still be audible outside the external auditory canal even after it is no longer appreciated on the mastoid. This is because air conduction should be greater than bone conduction.

In cases of conductive hearing loss, the patient will no longer hear the tuning fork once it is no longer appreciated on the mastoid. This suggests that their bone conduction is greater than their air conduction, indicating an obstruction in the passage of sound waves through the ear canal into the cochlea. This is considered a true negative result.

However, a Rinne’s test may yield a false negative result if the patient has a severe unilateral sensorineural deficit and senses the sound in the unaffected ear through the transmission of sound waves through the base of the skull.

In sensorineural hearing loss, the ability to perceive the tuning fork on both the mastoid and outside the external auditory canal is equally diminished compared to the opposite ear. Although the sound will still be heard outside the external auditory canal, it will disappear earlier on the mastoid process and outside the external auditory canal compared to the other ear.

Migraine is a common neurological complaint, affecting approximately 16% of individuals throughout their lifetime. Vestibular migraine is characterized by the presence of migrainous symptoms along with recurring episodes of vertigo and/or unsteadiness. It is a leading cause of vertigo and the most frequent cause of spontaneous episodic vertigo. The disturbance in the vestibular system can manifest as part of the aura phase or occur independently. The duration of these episodes can range from a few seconds to several days, typically lasting for minutes to hours. Interestingly, they often occur without accompanying headaches. Diagnosing vestibular migraine is primarily based on ruling out other potential causes. For prolonged individual attacks, antivertiginous and antiemetic medications are commonly used. However, specific antimigraine drugs may not provide significant relief in rescue situations. The cornerstone of managing vestibular migraine lies in the use of prophylactic medication. In some cases, referral to a neurologist may be necessary, especially if the patient is experiencing acute symptoms for the first time.

Posterior epistaxis is characterized by bleeding from both nostrils, which is usually heavy and difficult to control. It is commonly observed in older individuals with hypertension and/or atherosclerosis. In contrast, children typically experience anterior epistaxis, which involves bleeding from the front part of the nose. One of the distinguishing features of posterior epistaxis is the inability to easily identify the source of bleeding. Additionally, the bleeding in posterior epistaxis tends to be more severe and profuse compared to anterior bleeds.

Further Reading:

Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

Malignant otitis externa (MOE), also known as necrotizing otitis externa, is a rare form of ear canal infection that primarily affects elderly diabetic patients, particularly those with poorly controlled diabetes.

MOE initially infects the ear canal and gradually spreads to the surrounding bony structures and soft tissues. In 98% of cases, the responsible pathogen is Pseudomonas aeruginosa.

Typically, MOE presents with severe and unrelenting ear pain, which tends to worsen at night. Even after the swelling of the ear canal subsides with topical antibiotics, the pain may persist. Other symptoms may include pus drainage from the ear and temporal headaches. Approximately 50% of patients also experience facial nerve paralysis, and cranial nerves IX to XII may be affected as well.

To confirm the diagnosis, technetium scanning and contrast-enhanced CT scanning are usually performed to detect any extension of the infection into the surrounding bony structures.

If left untreated, MOE can be life-threatening and may lead to serious complications such as skull base osteomyelitis, subdural empyema, and cerebral abscess.

Treatment typically involves long-term administration of intravenous antibiotics. While surgical intervention is not effective for MOE, exploratory surgery may be necessary to obtain cultures of unusual organisms that are not responding adequately to intravenous antibiotics.

Naseptin, a topical antiseptic cream containing chlorhexidine and neomycin, has been found to be just as effective as silver nitrate cautery in treating recurrent nosebleeds in children. This means that using Naseptin can help prevent future nosebleeds in children with this condition. It is important to note that silver nitrate cautery can cause more pain and should only be used if a specific bleeding vessel can be identified.

Further Reading:

Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

According to a Cochrane review conducted in 2008, it was discovered that approximately 80% of children experiencing acute otitis media were able to recover within a span of two days. However, the use of antibiotics only resulted in a reduction of pain for about 7% of children after the same two-day period. Furthermore, the administration of antibiotics did not show any significant impact on the rates of hearing loss, recurrence, or perforation. In cases where antibiotics are deemed necessary for children with otitis media, some indications include being under the age of two, experiencing discharge from the ear (otorrhoea), and having bilateral acute otitis media.

When assessing a patient with epistaxis (nosebleed), it is important to start with a standard ABC assessment, focusing on the airway and hemodynamic status. Even if the bleeding appears to have stopped, it is crucial to evaluate the patient’s condition. If active bleeding is still present and there are signs of hemodynamic compromise, immediate resuscitative and first aid measures should be initiated.

Epistaxis should be treated as a circulatory emergency, especially in elderly patients, those with clotting disorders or bleeding tendencies, and individuals taking anticoagulants. In these cases, it is necessary to establish intravenous access using at least an 18-gauge (green) cannula. Blood samples, including a full blood count, urea and electrolytes, clotting profile, and group and save (depending on the amount of blood loss), should be sent for analysis. Patients should be assigned to a majors or closely observed area, as dislodgement of a blood clot can lead to severe bleeding.

First aid measures to control bleeding include the following steps:
1. The patient should be seated upright with their body tilted forward and their mouth open. Lying down should be avoided, unless the patient feels faint or there is evidence of hemodynamic compromise. Leaning forward helps reduce the flow of blood into the nasopharynx.
2. The patient should be encouraged to spit out any blood that enters the throat and advised not to swallow it.
3. Firmly pinch the soft, cartilaginous part of the nose, compressing the nostrils for 10-15 minutes. Pressure should not be released, and the patient should breathe through their mouth.
4. If the patient is unable to comply, an alternative technique is to ask a relative, staff member, or use an external pressure device like a swimmer’s nose clip.
5. It is important to dispel the misconception that compressing the bones will help stop the bleeding. Applying ice to the neck or forehead does not influence nasal blood flow. However, sucking on an ice cube or applying an ice pack directly to the nose may reduce nasal blood flow.

If bleeding stops with first aid measures, it is recommended to apply a topical antiseptic preparation to reduce crusting and vestibulitis. Naseptin cream (containing chlorhexidine and neomycin) is commonly used and should be applied to the nostrils four times daily for 10 days.

Meniere’s disease is a condition that affects the inner ear and its cause is still unknown. It is believed to occur due to increased pressure and gradual enlargement of the endolymphatic system in the middle ear, also known as the membranous labyrinth.

Further Reading:

Meniere’s disease is a disorder of the inner ear that is characterized by recurrent episodes of vertigo, tinnitus, and low frequency hearing loss. The exact cause of the disease is unknown, but it is believed to be related to excessive pressure and dilation of the endolymphatic system in the middle ear. Meniere’s disease is more common in middle-aged adults, but can occur at any age and affects both men and women equally.

The clinical features of Meniere’s disease include episodes of vertigo that can last from minutes to hours. These attacks often occur in clusters, with several episodes happening in a week. Vertigo is usually the most prominent symptom, but patients may also experience a sensation of aural fullness or pressure. Nystagmus and a positive Romberg test are common findings, and the Fukuda stepping test may also be positive. While symptoms are typically unilateral, bilateral symptoms may develop over time.

Rinne’s and Weber’s tests can be used to help diagnose Meniere’s disease. In Rinne’s test, air conduction should be better than bone conduction in both ears. In Weber’s test, the sound should be heard loudest in the unaffected (contralateral) side due to the sensorineural hearing loss.

The natural history of Meniere’s disease is that symptoms often resolve within 5-10 years, but most patients are left with some residual hearing loss. Psychological distress is common among patients with this condition.

The diagnostic criteria for Meniere’s disease include clinical features consistent with the disease, confirmed sensorineural hearing loss on audiometry, and exclusion of other possible causes.

Management of Meniere’s disease involves an ENT assessment to confirm the diagnosis and perform audiometry. Patients should be advised to inform the DVLA and may need to cease driving until their symptoms are under control. Acute attacks can be treated with buccal or intramuscular prochlorperazine, and hospital admission may be necessary in some cases. Betahistine may be beneficial for prevention of symptoms.

Meniere’s disease is a condition that affects the inner ear due to changes in fluid volume within the vestibular labyrinth. This leads to the progressive distension of the labyrinth, known as endolymphatic hydrops, which causes damage to the vestibular system and the cochlea. The classic symptoms associated with Meniere’s disease are vertigo, hearing loss, and tinnitus.

The main clinical features of Meniere’s disease include episodes of vertigo that typically last for 2-3 hours. These episodes are usually shorter than 24 hours in duration. Hearing loss, which is often gradual and affects only one ear, is also a common symptom. Tinnitus, a ringing or buzzing sound in the ears, is frequently associated with Meniere’s disease. Other symptoms may include a sensation of fullness or pressure in the ears, as well as nausea and vomiting. Nystagmus, an involuntary eye movement, may occur away from the side of the lesion. Meniere’s disease is more prevalent in individuals who suffer from migraines.

The management of Meniere’s disease aims to alleviate acute attacks, reduce their severity and frequency, and improve hearing while minimizing the impact of tinnitus. If Meniere’s disease is suspected, patients should be referred to an ear, nose, and throat specialist.

During acute attacks, medications such as prochlorperazine, cinnarizine, and cyclizine can help reduce nausea and vertigo symptoms. If vomiting is present, buccal or intramuscular administration of these medications may be necessary. In severe cases, hospital admission may be required to prevent dehydration.

For long-term prevention, lifestyle measures can be beneficial. Avoiding caffeine, chocolate, alcohol, and tobacco is recommended. Excessive fatigue should also be avoided. Following a low-salt diet may be helpful. Betahistine, a medication that initially starts at a dose of 16 mg three times a day, can be used for prophylaxis to reduce the frequency and severity of attacks. Diuretics may also be beneficial, but they are typically not recommended for primary care use.

Overall, the management of Meniere’s disease involves a combination of lifestyle changes and medication to control symptoms and improve the patient’s quality of life.

Based on his symptoms, the most likely diagnosis is benign paroxysmal positional vertigo. The most suitable initial treatment option for this condition would be the Epley maneuver.

Further Reading:

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo, characterized by sudden dizziness and vertigo triggered by changes in head position. It typically affects individuals over the age of 55 and is less common in younger patients. BPPV is caused by dysfunction in the inner ear, specifically the detachment of otoliths (calcium carbonate particles) from the utricular otolithic membrane. These loose otoliths move through the semicircular canals, triggering a sensation of movement and resulting in conflicting sensory inputs that cause vertigo.

The majority of BPPV cases involve otoliths in the posterior semicircular canal, followed by the inferior semicircular canal. BPPV in the anterior semicircular canals is rare. Clinical features of BPPV include vertigo triggered by head position changes, such as rolling over in bed or looking upwards, accompanied by nausea. Episodes of vertigo typically last 10-20 seconds and can be diagnosed through positional nystagmus, which is a specific eye movement, observed during diagnostic maneuvers like the Dix-Hallpike maneuver.

Hearing loss and tinnitus are not associated with BPPV. The prognosis for BPPV is generally good, with spontaneous resolution occurring within a few weeks to months. Symptomatic relief can be achieved through the Epley maneuver, which is successful in around 80% of cases, or patient home exercises like the Brandt-Daroff exercises. Medications like Betahistine may be prescribed but have limited effectiveness in treating BPPV.

There are two scoring systems that NICE recommends for assessing sore throat: the Centor Clinical Prediction Score and the FeverPAIN Score.

The Centor Clinical Prediction Score was initially developed as a tool to determine the likelihood of a group A beta-haemolytic Streptococcus (GABHS) infection in adults with a sore throat. It was created and tested in US Emergency Departments, specifically for adults.

The Centor score evaluates patients based on several criteria, with one point given for each positive criterion. These criteria include a history of fever (temperature above 38°C), the presence of exudate or swelling on the tonsils, tender or swollen anterior cervical lymph nodes, and the absence of cough.

According to the current NICE guidance, the Centor score can be used to guide management in the following way:
– A score of 0 to 2 indicates a 3-17% likelihood of streptococcus isolation, and antibiotics are not recommended.
– A score of 3 to 4 suggests a 32-56% likelihood of streptococcus isolation, and immediate treatment with empirical antibiotics or a ‘backup prescription’ should be considered.

To control epistaxis, it is recommended to have the patient sit upright with their upper body tilted forward and their mouth open. Firmly pinch the cartilaginous part of the nose, specifically in front of the bony septum, and maintain pressure for 10-15 minutes without releasing it.

Further Reading:

Epistaxis, or nosebleed, is a common condition that can occur in both children and older adults. It is classified as either anterior or posterior, depending on the location of the bleeding. Anterior epistaxis usually occurs in younger individuals and arises from the nostril, most commonly from an area called Little’s area. These bleeds are usually not severe and account for the majority of nosebleeds seen in hospitals. Posterior nosebleeds, on the other hand, occur in older patients with conditions such as hypertension and atherosclerosis. The bleeding in posterior nosebleeds is likely to come from both nostrils and originates from the superior or posterior parts of the nasal cavity or nasopharynx.

The management of epistaxis involves assessing the patient for signs of instability and implementing measures to control the bleeding. Initial measures include sitting the patient upright with their upper body tilted forward and their mouth open. Firmly pinching the cartilaginous part of the nose for 10-15 minutes without releasing the pressure can also help stop the bleeding. If these measures are successful, a cream called Naseptin or mupirocin nasal ointment can be prescribed for further treatment.

If bleeding persists after the initial measures, nasal cautery or nasal packing may be necessary. Nasal cautery involves using a silver nitrate stick to cauterize the bleeding point, while nasal packing involves inserting nasal tampons or inflatable nasal packs to stop the bleeding. In cases of posterior bleeding, posterior nasal packing or surgery to tie off the bleeding vessel may be considered.

Complications of epistaxis can include nasal bleeding, hypovolemia, anemia, aspiration, and even death. Complications specific to nasal packing include sinusitis, septal hematoma or abscess, pressure necrosis, toxic shock syndrome, and apneic episodes. Nasal cautery can lead to complications such as septal perforation and caustic injury to the surrounding skin.

In children under the age of 2 presenting with epistaxis, it is important to refer them for further investigation as an underlying cause is more likely in this age group.

The Dix-Hallpike test is a straightforward examination that can be utilized to verify the diagnosis of benign paroxysmal positional vertigo (BPPV).

To conduct the Dix-Hallpike test, the patient is swiftly brought down to a supine position with the neck extended by the clinician executing the maneuver. The test yields a positive result if the patient experiences a recurrence of their vertigo symptoms and the clinician performing the test observes nystagmus.

The CENTOR score is a tool used to assess the likelihood of a patient having a streptococcal infection, which is a common cause of sore throat. It is based on four clinical criteria: presence of tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and history of fever. Each criterion is assigned one point, with a maximum score of four.

In this case, the patient has a sore throat without cough or runny nose, and her temperature is slightly elevated at 37.7°C. The examination reveals redness in the oropharynx and tonsils, but no tender neck or palpable masses. Based on this information, the patient would score one point on the CENTOR score.

Further Reading:

Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.

Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.

When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.

Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.

To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken. can

Phenoxymethylpenicillin is the preferred antibiotic for treating streptococcal sore throat, especially in patients with a CENTOR score of 3/4 and a FeverPAIN score of 4/5. In such cases, antibiotics are necessary to effectively treat the infection.

Further Reading:

Pharyngitis and tonsillitis are common conditions that cause inflammation in the throat. Pharyngitis refers to inflammation of the oropharynx, which is located behind the soft palate, while tonsillitis refers to inflammation of the tonsils. These conditions can be caused by a variety of pathogens, including viruses and bacteria. The most common viral causes include rhinovirus, coronavirus, parainfluenza virus, influenza types A and B, adenovirus, herpes simplex virus type 1, and Epstein Barr virus. The most common bacterial cause is Streptococcus pyogenes, also known as Group A beta-hemolytic streptococcus (GABHS). Other bacterial causes include Group C and G beta-hemolytic streptococci and Fusobacterium necrophorum.

Group A beta-hemolytic streptococcus is the most concerning pathogen as it can lead to serious complications such as rheumatic fever and glomerulonephritis. These complications can occur due to an autoimmune reaction triggered by antigen/antibody complex formation or from cell damage caused by bacterial exotoxins.

When assessing a patient with a sore throat, the clinician should inquire about the duration and severity of the illness, as well as associated symptoms such as fever, malaise, headache, and joint pain. It is important to identify any red flags and determine if the patient is immunocompromised. Previous non-suppurative complications of Group A beta-hemolytic streptococcus infection should also be considered, as there is an increased risk of further complications with subsequent infections.

Red flags that may indicate a more serious condition include severe pain, neck stiffness, or difficulty swallowing. These symptoms may suggest epiglottitis or a retropharyngeal abscess, which require immediate attention.

To determine the likelihood of a streptococcal infection and the need for antibiotic treatment, two scoring systems can be used: CENTOR and FeverPAIN. The CENTOR criteria include tonsillar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history of fever, and absence of cough. The FeverPAIN criteria include fever, purulence, rapid onset of symptoms, severely inflamed tonsils, and absence of cough or coryza. Based on the scores from these criteria, the likelihood of a streptococcal infection can be estimated, and appropriate management can be undertaken.

If a patient with a tracheostomy is experiencing difficulty breathing and it is not possible to pass a suction catheter, the next step is to deflate the cuff. Deflating the cuff can help determine if the tracheostomy tube is obstructed or displaced by allowing air to flow around the tube within the airway. The following steps are followed in order: 1) Remove the inner tube and any speaking cap/valve if present. 2) Attempt to pass the suction catheter. 3) If the suction catheter cannot be passed, deflate the cuff. 4) If the patient’s condition does not stabilize or improve, the tracheostomy tube may need to be removed. This process is summarized in the green algorithm.

Further Reading:

Patients with tracheostomies may experience emergencies such as tube displacement, tube obstruction, and bleeding. Tube displacement can occur due to accidental dislodgement, migration, or erosion into tissues. Tube obstruction can be caused by secretions, lodged foreign bodies, or malfunctioning humidification devices. Bleeding from a tracheostomy can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue.

When assessing a patient with a tracheostomy, an ABCDE approach should be used, with attention to red flags indicating a tracheostomy or laryngectomy emergency. These red flags include audible air leaks or bubbles of saliva indicating gas escaping past the cuff, grunting, snoring, stridor, difficulty breathing, accessory muscle use, tachypnea, hypoxia, visibly displaced tracheostomy tube, blood or blood-stained secretions around the tube, increased discomfort or pain, increased air required to keep the cuff inflated, tachycardia, hypotension or hypertension, decreased level of consciousness, and anxiety, restlessness, agitation, and confusion.

Algorithms are available for managing tracheostomy emergencies, including obstruction or displaced tube. Oxygen should be delivered to the face and stoma or tracheostomy tube if there is uncertainty about whether the patient has had a laryngectomy. Tracheostomy bleeding can be classified as early or late, with causes including direct injury, anticoagulation, mucosal or tracheal injury, and granulation tissue. Tracheo-innominate fistula (TIF) is a rare but life-threatening complication that occurs when the tracheostomy tube erodes into the innominate artery. Urgent surgical intervention is required for TIF, and management includes general resuscitation measures and specific measures such as bronchoscopy and applying direct digital pressure to the innominate artery.

An acoustic neuroma, also referred to as a vestibular schwannoma, is a slow-growing tumor that develops from the Schwann cells of the vestibulocochlear nerve (8th cranial nerve). These growths are typically found at the cerebellopontine angle or within the internal auditory canal.

The most commonly affected nerves are the vestibulocochlear and trigeminal nerves. Patients typically experience a gradual deterioration of hearing in one ear, along with numbness and tingling in the face, ringing in the ears, and episodes of dizziness. Headaches may also be present, and in rare cases, the facial nerve, glossopharyngeal nerve, vagus nerve, or accessory nerve may be affected.

It’s important to note that the trochlear nerve, which passes through the superior orbital fissure, is not impacted by an acoustic neuroma.

There are two scoring systems that NICE recommends for assessing sore throat: the Centor Clinical Prediction Score and the FeverPAIN Score.

The Centor Clinical Prediction Score was initially developed as a tool to determine the likelihood of a group A beta-haemolytic Streptococcus (GABHS) infection in adults with a sore throat. This score was created and tested in US Emergency Departments, specifically for adult patients.

The Centor score evaluates patients based on several criteria, with one point given for each positive criterion. These criteria include a history of fever (temperature above 38°C), the presence of exudate or swelling on the tonsils, tender or swollen anterior cervical lymph nodes, and the absence of cough.

According to the current NICE guidance, the Centor score can be used to guide management in the following way:
– A score of 0 to 2 indicates a 3-17% likelihood of streptococcus isolation, and antibiotics are not recommended.
– A score of 3 to 4 indicates a 32-56% likelihood of streptococcus isolation, and immediate treatment with empirical antibiotics or a backup prescription should be considered.

By utilizing these scoring systems, healthcare professionals can make more informed decisions regarding the management and treatment of patients with sore throat.

Peripheral and central vertigo can be differentiated based on certain characteristics. Peripheral vertigo typically has a sudden onset and is associated with more severe symptoms of vertigo. The vertigo symptoms may come and go intermittently. Individuals with peripheral vertigo often experience severe nausea and vomiting. Their vertigo is also affected by head movement, particularly in certain positions. Peripheral vertigo is usually not accompanied by any focal neurology. Nystagmus, which is an involuntary eye movement, tends to occur away from the side of the lesion. In some cases, hearing may also be impaired, as seen in conditions like Meniere’s disease and labyrinthitis.

On the other hand, central vertigo tends to have a gradual onset and milder symptoms of vertigo. The vertigo symptoms are constant and do not fluctuate. Nausea and vomiting may be present but are usually less severe compared to peripheral vertigo. Unlike peripheral vertigo, central vertigo is not influenced by head movement and is considered fixed. Individuals with central vertigo may experience new-onset headaches. Additionally, central vertigo is often accompanied by focal neurology, indicating involvement of specific areas of the brain. Nystagmus in central vertigo occurs towards the side of the lesion. Unlike peripheral vertigo, hearing is typically unaffected in central vertigo cases.

Based on the assessment findings, the most likely diagnosis for the 45-year-old patient with increasing hearing loss in the right ear is an acoustic neuroma. This is suggested by the lateralization of Weber’s test to the left side, indicating that sound is being heard better in the left ear. Additionally, the positive Rinne’s test in both ears suggests that air conduction is better than bone conduction, which is consistent with an acoustic neuroma. Other possible diagnoses such as otosclerosis, otitis media, cerumen impaction, and tympanic membrane perforation are less likely based on the given information.

Further Reading:

Hearing loss is a common complaint that can be caused by various conditions affecting different parts of the ear and nervous system. The outer ear is the part of the ear outside the eardrum, while the middle ear is located between the eardrum and the cochlea. The inner ear is within the bony labyrinth and consists of the vestibule, semicircular canals, and cochlea. The vestibulocochlear nerve connects the inner ear to the brain.

Hearing loss can be classified based on severity, onset, and type. Severity is determined by the quietest sound that can be heard, measured in decibels. It can range from mild to profound deafness. Onset can be sudden, rapidly progressive, slowly progressive, or fluctuating. Type of hearing loss can be either conductive or sensorineural. Conductive hearing loss is caused by issues in the external ear, eardrum, or middle ear that disrupt sound transmission. Sensorineural hearing loss is caused by problems in the cochlea, auditory nerve, or higher auditory processing pathways.

To diagnose sensorineural and conductive deafness, a 512 Hz tuning fork is used to perform Rinne and Weber’s tests. These tests help determine the type of hearing loss based on the results. In Rinne’s test, air conduction (AC) and bone conduction (BC) are compared, while Weber’s test checks for sound lateralization.

Cholesteatoma is a condition characterized by the abnormal accumulation of skin cells in the middle ear or mastoid air cell spaces. It is believed to develop from a retraction pocket that traps squamous cells. Cholesteatoma can cause the accumulation of keratin and the destruction of adjacent bones and tissues due to the production of destructive enzymes. It can lead to mixed sensorineural and conductive deafness as it affects both the middle and inner ear.