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DIZZINESS History • Spinning • History of 1st episode • Predisposing factors • Associated symptoms • How long? • Single or recurrent Dizziness Vertigo Disequilibrium INNER EAR Presyncope Single episode Multiple episodes Other able: Summary of typical clinical features of common causes of vertigo Vestibular neuronitis (neuritis) Onset Duration Precipitants Associations Sudden Constant for many hours or even a day Viral illness (occasionally) Nausea and vomiting able: Summary of typical clinical features of common causes of vertigo BPPV Ménière's disease Intermittent Intermittent Recurrent Intermittent vestibulopathy Episodes up to 60 seconds Unpredictable, episodes may last hours Head movements - Episodes lasting minutes to hours None Onset Vestibula Sudden r neuroniti Deafness s Tinnitus Aural fullness (neuritis) BPPV Intermitt ent - Duration Precipita Associati nts ons Constant for many hours or even a day Viral Nausea illness and (occasion vomiting ally) Episodes Head None up to 60 moveme seconds nts Ménière' Intermitt Unpredic s disease ent table, episodes may last hours Deafness Tinnitus Aural fullness Recurren Intermitt Episodes t ent lasting vestibulo minutes pathy to hours - Homework • Chondrodermatitis nodularis chronica helicis • Hallpike test • Epley’s manouver The Nose Anatomy Anatomy # nasal bones Epistaxis Septal perforation Septal perforation • Trauma ,iatrogenig,Wegner’s ,sarcoidosis,TB,Syphilis, COCAINE,NEOPLASTIC. • Asynptomatic, wistling,blockage,epistaxis • FBC,ESR,CANCA,ACE level?VDRL.Biopsy • Saline nasal douches ,surgical Rhinitis • 2 out of 3 for >1 hour every day for >2 weeks. -Nasal congestion -rhinorrhoea (Ant. Or Post.) -sneezing - itching (nasal cavity),facial pain ,anosmia *RAST *steroides (beclomethazone,fluticasone,mometasone) *Antihistaminics *Oral steroides *Montelukast *saline douches *surgical NB Rhinits and sinusits usually coexist and are concurrent in most individuals; thus, the correct terminology is now rhinosinusits. Sinusitis • Acute:<4 weeks 1-Broad spectrum antibiotics 2-Betnesol nasal drops(2 drops BD) 3-Steam inhalation 4-Xylometazoline 0.5% 2 drops tds • Chronic >12 weeks RAST ,ESR,CANCA,ACE,CT scan Sinuses Medical treatment for 3 months mild :fluticasone 2 puffs OD Severe (polyps) :Betamethasone 2 drops for 6 weeks followed by steroides spray Oral antihistaminics (if allergic) Oral steroids (very severe) Oral antibiotics (clarythromycin) Surgical: FESS Referral: failure of treatment red flags patient willing to have surgery. Periorbital cellulitis Nasal polyps Around in 1% of adults in the UK have nasal polyps. They are around 2-4 times more common in men and are not commonly seen in children or the elderly. • What are they? • Paediatric polyps? • ?Unilateral polyps?( neoplastic until proven otherwise) • Associated with Asthma (particularly late-onset asthma) Aspirin sensitivity.......... Samter's triad infective sinusitis cystic fibrosis Kartagener's syndrome Churg-Strauss syndrome • all patients with suspected nasal polyps should be referred to ENT for a full examination • topical corticosteroids shrink polyp size in around 80% of patients Red flags Unilateral blockage Unilateral discharge Blood stained discharge Eye signs /symptoms Facial swelling (smokers, elderly) SNORING • Causes • Epworth sore...?sleep apnoea(is it witnessed) • Day time somnolesence • Treatment Wight loss Surgical UVPPP CPAP • DLVA Patient’s responsibility to inform DVLA when OSA suspected/investigated. Doctors responsibility to inform DVLA if untreated OSA pt is witnessed driving Homework • CSF rhinorrhoea Throat Anatomy Acute tonsillitis Acute tonsillitis NICE indications for antibiotics • features of marked systemic upset secondary to the acute sore throat • unilateral peritonsillitis • a history of rheumatic fever • an increased risk from acute infection (such as a child with diabetes mellitus or immunodeficiency) • patients with acute sore throat/acute pharyngitis/acute tonsillitis when 3 or more Centor criteria are present • WHICH ANTIBIOTICS? Presence of tonsillar exudate Tender anterior cervical lymphadenopathy or lymphadenitis History of fever Absence of cough Quinsy Glandular fever Laryngology Hoarseness • Causes: URTI (Most common) Trauma(shouting/nodules). Iatrogenic tumour neurological (?) functional(young women) Ask about ? Reflux symptoms , Wight loss, inhalers use, voice misuse, stress ,swallowing, breathing • Investigations :TFT,weight ,indirect laryngoscopoy. • • • • Urgent Chest XRAY (IF SYMPTOMS >3 WEEKS) If X-ray shows positive signs ..urgent referral to chest physician If X-ray shows negative signs ..urgent referral to ENT Early laryngeal tumours confined to vocal cords have 80-90% 5 Y survival . 2WW Red flags Persistent hoarseness > 3 weeks Pain Dysphagia Haemoptysis Otalgia Neck lump Especially in - smokers - over 40yrs Croup versus epiglottitis Features CROUP Epiglottitis Organism Para influanze virus H Influanza Age < 2 years 2-6 Onset gradual rapid Previous attack often no Cough Parking no Dysphagia NO +++ stridor inspiratory Insp/expiratory Pyrexia + ++ position Lying Down Sitting forward drooling No +++ nodes +++ + behavior struggling Quiet voice hoarse muffled colour pink grey Neck lumps • • • • • Lymphadenopathy Branchial cyst Thyroglossal cyst Salivary glands Refer urgently to ENT Urgent referral • • • • • • • • Mouth ulcers> 3weeks. Lumps in mouth >3 weeks Ubexplained sore throat>1 month Hoarseness >3 weeks, negative CXR. Unexplained salivary gland swelling>4 weeks Unilateral unexplained ear ache with normal otoscopy Asymmetrical /unilateral deafness Unilateral tinnitus The ear http://www.youtube.com/watch?feature=play er_embedded&v=0kEKoQ33dB0