PASSMEDICINE TEXT BOOK (DOWNLOADED 28/01/2022)

ENT

Acute otitis media

Acute otitis media is extremely common in young children, with around half of children having three or more
episodes by the age of 3 years.

Pathophysiology

 whilst viral upper respiratory tract infections (URTIs) typically precede otitis media, most infections are
secondary to bacteria, particularly Streptococcus pneumonaie, Haemophilus influenzae and Moraxella
catarrhalis
 viral URTIs are thought to disturb the normal nasopharyngeal microbiome, allowing bacteria to infect the
middle ear via the Eustachian tube

Clinical features and diagnosis

Features

 otalgia

+ some children may tug or rub their ear

  fever occurs in around 50% of cases
 hearing loss
 recent viral URTI symptoms are common (e.g. coryza)
 ear discharge may occur if the tympanic membrane perforates

Possible otoscopy findings:

 bulging tympanic membrane → loss of light reflex

 opacification or erythema of the tympanic membrane
 perforation with purulent otorrhoea
 decreased mobility if using a pneumatic otoscope

Whilst guidelines vary, the majority use the following criteria to diagnose otitis media:

 acute onset of symptoms

o otalgia or ear tugging
 presence of a middle ear effusion
o bulging of the tympanic membrane, or
o otorrhoea
o decreased mobility on pneumatic otoscopy
 inflammation of the tympanic membrane
o i.e. erythema

Management
Acute otitis media is generally a self-limiting condition that does not require an antibiotic prescription. There are
however some exceptions listed below. Analgesia should be given to relieve otalgia. Parents should be advised to
seek medical help if the symptoms worsen or do not improve after 3 days.

Antibiotics should be prescribed immediately if:

 Symptoms lasting more than 4 days or not improving

 Systemically unwell but not requiring admission
 Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or
neuromuscular disease
 Younger than 2 years with bilateral otitis media
 Otitis media with perforation and/or discharge in the canal

If an antibiotic is given, a 5-7 day course of amoxicillin is first-line. In patients with penicillin allergy, erythromycin
or clarithromycin should be given.

Sequelae and complications

Common sequelae include:

 perforation of the tympanic membrane → otorrhoea

o unresolved with acute otitis media with perforation may develop into chronic suppurative otitis media
(CSOM)
o CSOM is defined as perforation of the tympanic membrane with otorrhoea for > 6 weeks
 hearing loss
 labyrinthitis
Complications:

 mastoiditis
 meningitis
 brain abscess
 facial nerve paralysis

Acute sinusitis

Sinusitis describes an inflammation of the mucous membranes of the paranasal sinuses. The sinuses are usually sterile - the
most common infectious agents seen in acute sinusitis are Streptococcus pneumoniae, Haemophilus influenzae and
rhinoviruses.

Predisposing factors include:

 nasal obstruction e.g. septal deviation or nasal polyps

 recent local infection e.g. rhinitis or dental extraction
 swimming/diving
 smoking

Features

 facial pain
o typically frontal pressure pain which is worse on bending forward
 nasal discharge: usually thick and purulent
  nasal obstruction

Management of acute sinusitis

 analgesia
 intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited
 NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for more
than 10 days
 oral antibiotics are not normally required but may be given for severe presentations.
o The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if 'systemically very unwell, signs and
symptoms of a more serious illness, or at high-risk of complications'
o 'double-sickening' may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial
infection

Allergic rhinitis

Allergic rhinitis is an inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust
mites and grass, tree and weed pollens. It may be classified as follows, although the clinical usefulness of such classifications
remains doubtful:

 seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is
known as hay fever
 perennial: symptoms occur throughout the year
 occupational: symptoms follow exposure to particular allergens within the work place

Features
  sneezing
 bilateral nasal obstruction
 clear nasal discharge
 post-nasal drip
 nasal pruritus

Management of allergic rhinitis

 allergen avoidance
 if the person has mild-to-moderate intermittent, or mild persistent symptoms:
o oral or intranasal antihistamines
 if the person has moderate-to-severe persistent symptoms, or initial drug treatment is ineffective
o intranasal corticosteroids
 a short course of oral corticosteroids are occasionally needed to cover important life events
 there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline). They should not be used for
prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound
hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal

Aphthous mouth ulcers

Aphthous mouth ulcers are painful, clearly defined, round or ovoid, shallow ulcers that are confined to the mouth and are not
associated with systemic disease. They are often recurrent, with onset usually in childhood.

Single ulcers, or recurrent ulcers in the same place, may be caused by damage to the mouth, for example biting the cheek, or
damage to the buccal mucosa with a toothbrush or a sharp tooth or filling.

People with recurrent ulcers may have a genetic predisposition. Precipitating factors include:
  Oral trauma (for example excessive tooth brushing).
 Anxiety or stress.
 Certain foods (typically chocolate, coffee, peanuts, almonds, strawberries, cheese, tomatoes, and wheat flour).
 Stopping smoking.
 Hormonal changes related to the menstrual cycle.

Aphthous ulcers present as one or more rounded or ovoid mouth ulcers with a clearly-defined margin, a floor of yellowish-
grey slough, and an erythematous periphery. They generally occur on non-keratinized mucosal surfaces such as the inside of
the lips, the inside of the cheeks, the floor of the mouth, or the undersurface of the tongue.

Investigations are generally unnecessary. Investigations should be considered (for example full blood count, erythrocyte
sedimentation rate, ferritin, folate and vitamin B12) if an underlying systemic disease is suspected based on history and
examination findings.

Most aphthous ulcers heal within 10-14 days without scarring.

Management of aphthous ulcers includes:

 Avoidance of precipitating factors, and

 Symptomatic treatment for pain, discomfort, and swelling e.g. a short course of a low potency topical corticosteroid
(hydrocortisone lozenges), an antimicrobial mouthwash, or a topical analgesic.
 People with a mouth ulcer that persists for more than 3 weeks should be referred urgently to a specialist

Audiograms

Audiograms are usually the first-line investigation that is performed when a patient complains of hearing difficulties. They are
relatively easy to interpret as long as some simple rules are followed:
  anything above the 20dB line is essentially normal (marked in green on the audiogram below)
 in sensorineural hearing loss both air and bone conduction are impaired
 in conductive hearing loss only air conduction is impaired
 in mixed hearing loss both air and bone conduction are impaired, with air conduction often being 'worse' than bone

This audiogram is essentially normal. Note all the values are above the 20dB line, highlighted in green on this image

Auricular haematomas
Auricular haematomas are common in rugby players and wrestlers. Prompt treatment is important to avoid the formation of
'cauliflower ear'.

Management

 auricular haematomas need same-day assessment by ENT

 incision and drainage has been shown to be superior to needle aspiration

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo encountered. It is characterised by
the sudden onset of dizziness and vertigo triggered by changes in head position. The average age of onset is 55 years and it
is less common in younger patients.

Features

 vertigo triggered by change in head position (e.g. rolling over in bed or gazing upwards)
 may be associated with nausea
 each episode typically lasts 10-20 seconds
 positive Dix-Hallpike manoeuvre, indicated by:
o patient experiences vertigo
o rotatory nystagmus

BPPV has a good prognosis and usually resolves spontaneously after a few weeks to months. Symptomatic relief may be
gained by:

 Epley manoeuvre (successful in around 80% of cases)

  teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-
Daroff exercises

Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.

Around half of people with BPPV will have a recurrence of symptoms 3–5 years after their diagnosis

Black hairy tongue

Black hairy tongue is relatively common condition which results from defective desquamation of the filiform papillae. Despite
the name the tongue may be brown, green, pink or another colour.

Predisposing factors

 poor oral hygiene

 antibiotics
 head and neck radiation
 HIV
 intravenous drug use

The tongue should be swabbed to exclude Candida

Management

 tongue scraping
 topical antifungals if Candida
Branchial cyst

A branchial cyst is a benign, developmental defect of the branchial arches. The cyst is filled with acellular fluid with
cholesterol crystals and encapsulated by stratified squamous epithelium. Branchial cysts may have a fistula and are therefore
prone to infection. They may enlarge following a respiratory tract infection.

They typically present in late childhood or early adulthood and present as asymptomatic neck lateral neck lumps and are
usually located anterior to the sternocleidomastoid muscle. There is a slight male predisposition and account for around 20%
of paediatric neck masses.

Typical examination features:

 unilateral, typically on the left side

 lateral, anterior to the sternocleidomastoid muscle
 slowly enlarging
 smooth, soft, fluctuant
 non-tender
 a fistula may be seen
 no movement on swallowing
 no transillumination

Differential diagnosis of a neck lump in children:

 congenital: branchial cyst, thyroglossal cyst, dermoid cyst, vascular malformation

 inflammatory: reactive lymphadenopathy, lymphadenitis,
 neoplastic: lymphoma, thyroid tumour, salivary gland tumour
Diagnosis and investigations:

 consider and exclude other malignancy

 ultrasound
 referral to ENT
 fine-needle aspiration

Branchial cysts are treated by Ear Nose and Throat (ENT) surgeons and can be treated conservatively or surgically excised.
Antibiotics are required for acute infections.

References
1. Meier JD, Grimmer JF. Evaluation and management of neck masses in children. Am Fam Physician. 2014 Mar 1;89(5):353–8.

Cholesteatoma

Cholesteatoma is a non-cancerous growth of squamous epithelium that is 'trapped' within the skull base causing local
destruction. It is most common in patients aged 10-20 years. Being born with a cleft palate increases the risk of
cholesteatoma around 100 fold.

Main features

 foul-smelling, non-resolving discharge

 hearing loss

Other features are determined by local invasion:

  vertigo
 facial nerve palsy
 cerebellopontine angle syndrome

Otoscopy

 'attic crust' - seen in the uppermost part of the ear drum

Management

 patients are referred to ENT for consideration of surgical removal

Chronic rhinosinusitis

Chronic rhinosinusitis affects up to 1 in 10 people. It is generally defined as an inflammatory disorder of the paranasal sinuses
and linings of the nasal passages that lasts 12 weeks or longer.

Predisposing factors include:

 atopy: hay fever, asthma

 nasal obstruction e.g. Septal deviation or nasal polyps
 recent local infection e.g. Rhinitis or dental extraction
 swimming/diving
 smoking
Features

 facial pain: typically frontal pressure pain which is worse on bending forward
 nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection
 nasal obstruction: e.g. 'mouth breathing'
 post-nasal drip: may produce chronic cough

Management of recurrent or chronic sinusitis

 avoid allergen
 intranasal corticosteroids
 nasal irrigation with saline solution

Red flags symptoms

 unilateral symptoms
 persistent symptoms despite compliance with 3 months of treatment
 epistaxis

Cochlear implant

A cochlear implant is an electronic device that may be offered to patients with severe-to-profound hearing loss.
Suitability for a cochlear implant is determined by:

 In children, audiological assessment and/or difficulty developing basic auditory skills.

 In adults, patients should have completed a trial of appropriate hearing aids for at least 3 months which they have
been objectively demonstrated to receive limited or no benefit from.

Causes of severe-to-profound hearing loss:

In children

 Genetic (accounts for up to 50% of cases).

 Congenital e.g. following maternal cytomegalovirus, rubella or varicella infection.
 idiopathic (accounts for up to 30% of childhood deafness).
 Infectious e.g. post meningitis.

In adults

 Viral-induced sudden hearing loss.

 Ototoxicity e.g. following administration of aminoglycoside antibiotics or loop diuretics.
 Otosclerosis
 Ménière disease
 Trauma

Prior to an assessment for the cochlear implant, patients should have exhausted all medical therapies aimed at targeting any
underlying pathological process contributing to the loss of hearing. In addition, they should have explored 'conventional'
amplification strategies i.e. hearing aids and found the devices insufficient to allow functioning within daily life and/or support
language development/maintenance.
Whilst implants are necessitated by the destruction or degeneration of the organ of Corti, it is essential that there are
surviving spiral ganglion neurons to ensure the success of the implant. An assessment of the patient anatomy should be
undertaken by an experienced otolaryngologist/skull base surgeon.

Surgical implantation may be complicated by infection, facial paralysis due to nerve injury intra-operatively, cerebrospinal
fluid (CSF) leakage, and meningitis. To reduce the risk of meningitis as far as possible, it is recommended that all patients
should have up-to-date vaccinations against Streptococcus and Haemophilus.

Patients are discharged for the post-operative physical recovery of the implantation site and generally return to outpatient
clinic 3-5 weeks post-op for device stimulation.

Contraindications to consideration for cochlear implant:

 Lesions of cranial nerve VIII or in the brain stem causing deafness

 Chronic infective otitis media, mastoid cavity or tympanic membrane perforation
 Cochlear aplasia

Relative contraindications:

 Chronic infective otitis media or mastoid cavity infections

 Tympanic membrane perforation
 Patients that may be seen to demonstrate a lack of interest in using the implant to develop enhanced oral
communication skills.

In addition, patients should demonstrate an understanding of what to expect from cochlear implantation including
comprehension of the likely limitations of the device.

The device has both internal and external components.

Externally, the microphone recognises the environmental sound and sends it to the sound processor. This, in turn, transforms
the impulses received into a digital signal that which is then transferred to the transmitter coil. The transmitter coil conveys
the signal to the internal components. Internally, a receiver, which magnetically connected to, and sits directly above the
transmitter coil, and receives the impulses from the external apparatus which are then processed by a set of electrodes. The
electrodes do the work that would be performed by the inner ear hair cells in a 'normal' ear. The brain can then process these
signals to comprehend sound. Rechargeable batteries can be used to power the apparatus and life span depends upon usage
and the individual device.

Hearing link describes cochlear implants as '...the world’s most successful medical prostheses in that less than 0.2% of
recipients reject it or do not use it and the failure rate needing reimplantation is around 0.5%.'

Deafness

The most common causes of hearing loss are ear wax, otitis media and otitis externa. The table below details some of the
characteristic features of other causes:

Condition Key features

Presbycusis Presbycusis describes age-related sensorineural hearing loss. Patients may describe difficulty following
conversations

Audiometry shows bilateral high-frequency hearing loss

Otosclerosis Autosomal dominant, replacement of normal bone by vascular spongy bone. Onset is usually at 20-40
years - features include:

 conductive deafness
 tinnitus
 Condition Key features

 tympanic membrane - 10% of patients may have a 'flamingo tinge', caused by hyperaemia
 positive family history

Glue ear Also known as otitis media with effusion

 peaks at 2 years of age

 hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive
hearing loss and elective surgery in childhood)
 secondary problems such as speech and language delay, behavioural or balance problems may
also be seen

Meniere's disease More common in middle-aged adults

 recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the
prominent symptom
 a sensation of aural fullness or pressure is now recognised as being common
 other features include nystagmus and a positive Romberg test
 episodes last minutes to hours

Drug ototoxicity Examples include aminoglycosides (e.g. Gentamicin), furosemide, aspirin and a number of cytotoxic
agents

Noise damage Workers in heavy industry are particularly at risk

Hearing loss is bilateral and typically is worse at frequencies of 3000-6000 Hz

Acoustic neuroma (more correctly called Features can be predicted by the affected cranial nerves
vestibular schwannomas)
 Condition Key features

 cranial nerve VIII: hearing loss, vertigo, tinnitus

 cranial nerve V: absent corneal reflex
 cranial nerve VII: facial palsy

Bilateral acoustic neuromas are seen in neurofibromatosis type 2

Dental abscess

With the increasing privatisation and cost of dental treatment, many people do not regularly see a dentist. Therefore, it is not
surprising that GPs are seeing more patients presenting with dental problems. GPs have an ethical responsibility to offer help
in an emergency, even where the underlying cause might be a dental problem.

A dental abscess or tooth abscess can occur in the teeth, supporting structures of the teeth (ligaments and bones), or the
gums. An abscess is a localised collection of pus most commonly caused by a bacterial infection. Tooth decay can enable
bacteria to invade the dental pulp inside the tooth. An abscess at the end of the tooth (root canal) is called a periapical
abscess and an abscess in the gum is called a periodontal abscess.

Complications include loss of the infected tooth, the formation of a fistula or sinus tract, or spread of infection. The spread of
infection can include local structures eg maxillary sinus, osteomyelitis, cellulitis, brain abscess or generalised sepsis.

Epidemiology

 The lifetime prevalence has been reported as 5–46% 1 (there is limited data).
 The vast majority of healthy patients have localised infections which can be managed in the community.
 Dental abscesses are rare in infants because they do not form until teeth erupt.
  In children, periapical abscesses are more common, due to the combination of thinner enamel, increased blood supply
and poor hygiene.
 In adults, periodontal abscesses are more common than periapical.

Risk factors

 Poor dental hygiene: Enquire about the frequency of brushing and flossing and their diet (how much sugar they
consume?)
 Dental caries.
 Periodontal disease.
 Partially erupted or impacted tooth.
 Dental trauma: Have they had previous dental procedures e.g. fillings, root canals and extractions?
 Alcohol or drug misuse.
 Malnutrition.
 Immunocompromise.
 Previous radiotherapy.
 Medications causing a dry mouth (e.g. anticholinergics, antihistamines, and antidepressants).

Patients typically present with a subacute onset of:

 Pain: typically the pain is intense and throbbing and starts suddenly and gets worse over hours to days. The pain may
wake the patient from sleep and the tooth may be tender and cause pain when eating.
 Temperature sensitivity (e.g. to hot or cold drinks).
 Foul taste.
 Fever.
 General malaise.
 Trismus (inability to open the mouth).
 Dysphagia (in severe cases).
Signs:

 Facial swelling
 Gum swelling
 Altered tooth appearance (the affected tooth have signs of decay, be elevated or broken).
 Local lymphadenopathy.
 Gum swelling.
 Pus may be visible (it can be intra or extra-oral).
 If you palpate the tooth it might wobble and may well be tender.
 The gum may also be tender or warm to palpate.
 Signs of severe infection include signs of cardio-respiratory compromise or airway obstruction.

Investigations:

 If a patient presents to their doctor with a tooth abscess a diagnosis is made on the clinical history and examination
findings.
 Patients should be encouraged to attend their dentist for definitive diagnosis and treatment unless they require
emergency admission to a hospital due to severe complications or sepsis.

Treatment:

 Definitive treatment can only be given by a dentist and antibiotics will not eliminate the source of infection.
 Serious complications can occur if a patient is not treated by a dentist.
 Antibiotics are generally not indicated in an otherwise healthy individual unless they are systemically unwell or have
signs of severe infection.
  If antibiotics are indicated or a patient is unable to attend a dentist amoxicillin or phenoxymethylpenicillin are first line
(clarithromycin if there is a history of true penicillin allergy).
 If the infection is severe or spreading, or the patient has systemic signs of infection metronidazole should also be
prescribed.
 Analgesia may be necessary: ibuprofen and paracetamol are first-line (if not contraindicated).

Ear wax

Ear wax is a normal physiological substance which helps protect the ear canal. Impacted ear wax is extremely common and
may cause a variety of symptoms including:

 pain
 conductive hearing loss
 tinnitus
 vertigo

The main treatment options in primary care are ear drops or irrigation ('ear syringing'). Treatment should not be given if a
perforation is suspected or the patient has grommets. The following drops may be used:

 olive oil
 sodium bicarbonate 5%
 almond oil

Epistaxis
Epistaxis (nose bleeds) is split into anterior and posterior bleeds, whereby the former often has a visible source of bleeding
and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s plexus. Posterior haemorrhages, on
the other hand, tend to be more profuse and originate from deeper structures. They occur more frequently in older patients
and confer a higher risk of aspiration and airway compromise.

Causes

 most cases of epistaxis tend to be benign and self-limiting. Exacerbation factors include:
o nose picking
o nose blowing
 trauma to the nose
 insertion of foreign bodies
 bleeding disorders
o immune thrombocytopenia
o Waldenstrom’s macroglobulinaemia
 juvenile angiofibroma
o benign tumour that is highly vascularised
o seen in adolescent males
 cocaine use
o the nasal septum may look abraded or atrophied, inquire about drug use. This is because inhaled cocaine
o cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.
 hereditary haemorrhagic telangiectasia
 granulomatosis with polyangiitis

Management

If the patient is haemodynamically stable, bleeding can be controlled with first aid measures. This involves:
  Asking the patient to sit with their torso forward and their mouth open
o avoid lying down unless they feel faint
o his decreases blood flow to the nasopharynx and allows the patient to spit out any blood in their mouth
o it also reduces the risk of aspirating blood
 Pinch the cartilaginous (soft) area of the nose firmly
o this should be done for at least 20 minutes
o also ask the patient to breathe through their mouth.

If first aid measures are successful

 consider using a topical antiseptic such as Naseptin (chlorhexidine and neomycin) to reduce crusting and the risk of
vestibulitis
o cautions to this include patients that have peanut, soy or neomycin allergies
o Mupirocin is a viable alternative
 admission and follow up care may be considered in patients under if
o a comorbidity (e.g. coronary artery disease, or severe hypertension) is present, an underlying cause is
suspected
o they are aged under 2 years (as underlying causes such as haemophilia or leukaemia are more likely in this age
group)
 self-care advice involves reducing the risk of re-bleeding
o patients should be informed that blowing or picking the nose, heavy lifting, exercise, lying flat, drinking alcohol
or hot drinks should be avoided

If bleeding does not stop after 10-15 minutes of continuous pressure on the nose consider cautery or packing

 cautery should be used initially if the source of the bleed is visible and cautery is tolerated
o it is not so well-tolerated in younger children!
o ask the patient to blow their nose in order to remove any clots. Be wary that bleeding may resume.
o use a topical local anaesthetic spray (e.g. Co-phenylcaine) and wait 3-4 minutes for it to take effect
 o identify the bleeding point and apply the silver nitrate stick for 3-10 seconds until it becomes grey-white. Avoid
touching areas which do not require treatment, and only cauterise one side of the septum as there is a risk of
perforation.
o dab the area clean with a cotton bud and apply Naseptin or Muciprocin
 packing may be used if cautery is not viable or the bleeding point cannot be visualised
o anaesthetise with topical local anaesthetic spray (e.g. Co-phenylcaine) and wait for 3-4 minutes
o pack the patient’s nose while they are sitting with their head forward, following the manufacturer’s instructions
o pressure on the cartilage around the nostril can cause cosmetic changes and this should be reviewed after
inserting the pack.
o examine the patient’s mouth and throat for any continuing bleeding, and consider packing the other nostril as
this increases pressure on the septum and offending vessel.
o patients should be admitted to hospital for observation and review, and to ENT if available

Patients that are haemodynamically unstable or compromised should be admitted to the emergency department

 control bleeding with first aid measures in the interim

 patients with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum,
bleeding from both nostrils or profuse) should be admitted to hospital.

Epistaxis that has failed all emergency management

 may require sphenopalatine ligation in theatre

Facial pain

The table below gives characteristic exam question features for conditions causing facial pain
 Condition Characteristic exam feature
Sinusitis Facial 'fullness' and tenderness
Nasal discharge, pyrexia or post-nasal drip leading to cough
Trigeminal neuralgia Unilateral facial pain characterised by brief electric shock-like pains, abrupt in onset and termination
May be triggered by light touch, emotion
Cluster headache Pain typical occurs once or twice a day, each episode lasting 15 mins - 2 hours
Clusters typically last 4-12 weeks
Intense pain around one eye
Accompanied by redness, lacrimation, lid swelling, nasal stuffiness
Temporal arteritis Tender around temples
Raised ESR

Geographic tongue

Geographic tongue is a benign, chronic condition of unknown cause. It is present in around 1-3% of the population and is
more common in females.

Features

 erythematous areas with a white-grey border (the irregular, smooth red areas are said to look like the outline of a map)
 some patients report burning after eating certain food

Management

 reassurance about benign nature

Gingival hyperplasia

Drug causes of gingival hyperplasia

 phenytoin
 ciclosporin
 calcium channel blockers (especially nifedipine)

Other causes of gingival hyperplasia include

 acute myeloid leukaemia (myelomonocytic and monocytic types)

Gingivitis

Gingivitis is usually secondary to poor dental hygiene. Clinical presentation may range from simple gingivitis (painless, red
swelling of the gum margin which bleeds on contact) to acute necrotizing ulcerative gingivitis (painful bleeding gums with
halitosis and punched-out ulcers on the gums).

If the patient has simple gingivitis

 should be advised to seek routine regular review by a dentist. Antibiotics are not usually necessary

If a patient presents with acute necrotizing ulcerative gingivitis CKS recommend the following management:
  refer the patient to a dentist, meanwhile the following is recommended:
 oral metronidazole* for 3 days
 chlorhexidine (0.12% or 0.2%) or hydrogen peroxide 6% mouth wash
 simple analgesia

*the BNF also suggest that amoxicillin may be used

Glue ear

Glue ear describes otitis media with an effusion (other terms include serous otitis media). It is common with the majority of
children having at least one episode during childhood

Risk factors

 male sex
 siblings with glue ear
 higher incidence in Winter and Spring
 bottle feeding
 day care attendance
 parental smoking

Features

 peaks at 2 years of age

 hearing loss is usually the presenting feature (glue ear is the commonest cause of conductive hearing loss and elective
surgery in childhood)
 secondary problems such as speech and language delay, behavioural or balance problems may also be seen
Treatment options include:

 grommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the
Eustachian tube. The majority stop functioning after about 10 months
 adenoidectomy

Head and neck cancer

Head and neck cancer is an umbrella term. It typically includes:

 Oral cavity cancers

 Cancers of the pharynx (including the oropharynx, hypopharynx and nasopharynx)
 Cancers of the larynx

Features

 neck lump
 hoarseness
 persistent sore throat
 persistent mouth ulcer

NICE suspected cancer pathway referral criteria (for an appointment within 2 weeks)
Laryngeal cancer

 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for laryngeal cancer in people aged
45 and over with:
o persistent unexplained hoarseness or
o an unexplained lump in the neck

Oral cancer

 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with
either:
o unexplained ulceration in the oral cavity lasting for more than 3 weeks or
o a persistent and unexplained lump in the neck.
 Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in
people who have either:
o a lump on the lip or in the oral cavity or
o a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Thyroid cancer

 Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for thyroid cancer in people with an
unexplained thyroid lump.

Hoarseness
Causes of hoarseness include:

 voice overuse
 smoking
 viral illness
 hypothyroidism
 gastro-oesophageal reflux
 laryngeal cancer
 lung cancer

When investigating patients with hoarseness a chest x-ray should be considered to exclude apical lung lesions.

Suspected laryngeal cancer: referral guidelines-

A suspected cancer pathway referral to an ENT specialist should be considered for people aged 45 and over with:

 persistent unexplained hoarseness or

 An unexplained lump in the neck.

Laryngopharyngeal reflux

Laryngopharyngeal reflux (LPR) is a condition caused by gastro-oesophageal reflux resulting in inflammatory changes to the
larynx/hypopharynx mucosa. It is a common diagnosis and thought to account for around 10% of ear, nose and throat
referrals.
Features

 around 70% of patients have the sensation of a lump in the throat - 'globus'
o typically felt in the midline
o typically worse when swallowing saliva rather than eating or drinking
 other features
o hoarseness (70%)
o chronic cough (50%)
o dysphagia (35%)
o heartburn (30%)
o sore throat
 examination findings
o the external examination of the neck should be normal, with no masses
o the posterior pharynx may appear erythematous

Diagnosis

 in the absence of red flags a clinical diagnosis of LPR can be made without further investigations
 the NICE cancer referral guidelines should be reviewed for red flags, examples of which include:
o persistent, unilateral throat discomfort
o dysphagia, odynophagia (i.e. with food rather than just saliva)
o persistent hoarseness

Management

 lifestyle measures
o possible triggers include fatty foods, caffeine, chocolate and alcohol
 proton pump inhibitor
  sodium alginate liquids (e.g. Gaviscon)

Ludwig's angina

Ludwig's angina is a type of progressive cellulitis that invades the floor of the mouth and soft tissues of the neck. Most cases
result from odontogenic infections which spread into the submandibular space.

Features

 neck swelling
 dysphagia
 fever

It is a life-threatening emergency as airway obstruction can occur rapidly as a result.

Management

 airway management
 intravenous antibiotics

Malignant otitis externa

Basics
  Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics)
 most commonly caused by Pseudomonas aeruginosa
 Infection commences in the soft tissues of the external auditory meatus, then progresses to involve the soft tissues
and into the bony ear canal
 Progresses to temporal bone osteomyelitis

Key features in history

 Diabetes (90%) or immunosuppression (illness or treatment-related)

 Severe, unrelenting, deep-seated otalgia
 Temporal headaches
 Purulent otorrhea
 Possibly dysphagia, hoarseness, and/or facial nerve dysfunction

Diagnosis

 A CT scan is typically done

Treatment

 non-resolving otitis externa with worsening pain should be referred urgently to ENT
 Intravenous antibiotics that cover pseudomonal infections

Meniere's disease
Meniere's disease is a disorder of the inner ear of unknown cause. It is characterised by excessive pressure and progressive
dilation of the endolymphatic system. It is more common in middle-aged adults but may be seen at any age. Meniere's
disease has a similar prevalence in both men and women.

Features

 recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
 a sensation of aural fullness or pressure is now recognised as being common
 other features include nystagmus and a positive Romberg test
 episodes last minutes to hours
 typically symptoms are unilateral but bilateral symptoms may develop after a number of years

Natural history

 symptoms resolve in the majority of patients after 5-10 years

 the majority of patients will be left with a degree of hearing loss
 psychological distress is common

Management

 ENT assessment is required to confirm the diagnosis

 patients should inform the DVLA. The current advice is to cease driving until satisfactory control of symptoms is
achieved
 acute attacks: buccal or intramuscular prochlorperazine. Admission is sometimes required
 prevention: betahistine and vestibular rehabilitation exercises may be of benefit
Mouth lesions

2 week wait referrals to oral surgery should be done in all of the following cases:

 Unexplained oral ulceration or mass persisting for greater than 3 weeks

 Unexplained red, or red and white patches that are painful, swollen or bleeding
 Unexplained one-sided pain in the head and neck area for greater than 4 weeks, which is associated with ear ache, but
does not result in any abnormal findings on otoscopy
 Unexplained recent neck lump, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeks
 Unexplained persistent sore or painful throat
 Signs and symptoms in the oral cavity persisting for more than 6 weeks, that cannot be definitively diagnosed as a
benign lesion

The level of suspicion should be higher in patients who are over 40, smokers, heavy drinkers and those who chew tobacco or
betel nut (areca nut).

Erythroplakia is defined as any erythematous area on a mucous membrane, that cannot be attributed to any other
pathology. Leukoplakia is used to describe a white area on a mucous membrane without a known cause. Both are types
of premalignant lesion in the mouth. Lesions containing both red and white areas are called erythroleukoplakia.

Erythroplakia presents as a red macule or plaque with well-demarcated, raised borders which is often painless and
grows slowly. It is most commonly found in elderly men and both tobacco smoking and alcohol consumption are
recognised risk factors.

Erythroplakia is much less common than leukoplakia, however carries a significantly higher risk of transforming into
invasive squamous cell carcinoma (50%). Leukoplakia carry a 5% risk of malignancy Any lesion suspicious of
erythroplakia or leukoplakia in the oral cavity warrants urgent further investigation.

For more information visit http://publications.cancerresearchuk.org/downloads/product/GP1.pdf

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.

Associations

 asthma (particularly late-onset asthma)

 aspirin sensitivity
 infective sinusitis
 cystic fibrosis
 Kartagener's syndrome
 Churg-Strauss syndrome

The association of asthma, aspirin sensitivity and nasal polyposis is known as Samter's triad.

Features

 nasal obstruction
 rhinorrhoea, sneezing
 poor sense of taste and smell

Unusual features which always require further investigation include unilateral symptoms or bleeding.
Management

 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

Nasal septal haematoma

Nasal septal haematoma is an important complication of nasal trauma that should always be looked for. It describes the
development of a haematoma between the septal cartilage and the overlying perichondrium.

Features

 may be precipitated by relatively minor trauma

 the sensation of nasal obstruction is the most common symptom
 pain and rhinorrhoea are also seen
 on examination, classically a bilateral, red swelling arising from the nasal septum
 this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are
typically boggy whereas septums will be firm

Management

 surgical drainage
 intravenous antibiotics
If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia
of the cartilage resulting in necrosis. This may result in a 'saddle-nose' deformity

Nasopharyngeal carcinoma

Basics

 Squamous cell carcinoma of the nasopharynx

 Rare in most parts of the world, apart from individuals from Southern China
 Associated with Epstein Barr virus infection

Presenting features

Systemic Local

Cervical lymphadenopathy Otalgia

Unilateral serous otitis media

Nasal obstruction, discharge and/ or epistaxis

Cranial nerve palsies e.g. III-VI

Imaging

Combined CT and MRI.

Treatment

Radiotherapy is first line therapy.

Neck lumps

The table below gives characteristic exam question features for conditions causing neck lumps:

Condition Notes
Reactive By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral
lymphadenopathy illness
Lymphoma Rubbery, painless lymphadenopathy
The phenomenon of pain whilst drinking alcohol is very uncommon
There may be associated night sweats and splenomegaly
Thyroid swelling May be hypo-, eu- or hyperthyroid symptomatically
Moves upwards on swallowing
Thyroglossal cyst More common in patients < 20 years old
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
Pharyngeal pouch More common in older men
 Condition Notes
Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough
Cystic hygroma A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
Most are evident at birth, around 90% present before 2 years of age
Branchial cyst An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
Develop due to failure of obliteration of the second branchial cleft in embryonic development
Usually present in early adulthood
Cervical rib More common in adult females
Around 10% develop thoracic outlet syndrome
Carotid aneurysm Pulsatile lateral neck mass which doesn't move on swallowing

Otitis externa

Otitis externa is a common reason for primary care attendance in the UK.

Causes of otitis externa include:

 infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal

 seborrhoeic dermatitis
 contact dermatitis (allergic and irritant)
 recent swimming is a common trigger of otitis externa

Features
  ear pain, itch, discharge
 otoscopy: red, swollen, or eczematous canal

The recommended initial management of otitis externa is:

 topical antibiotic or a combined topical antibiotic with a steroid

 if the tympanic membrane is perforated aminoglycosides are traditionally not used*
 if there is canal debris then consider removal
 if the canal is extensively swollen then an ear wick is sometimes inserted

Second-line options include

 consider contact dermatitis secondary to neomycin

 oral antibiotics (flucloxacillin) if the infection is spreading
 taking a swab inside the ear canal
 empirical use of an antifungal agent

If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.

Malignant otitis externa is more common in elderly diabetics. In this condition, there is extension of infection into the bony
ear canal and the soft tissues deep to the bony canal. Intravenous antibiotics may be required.

*many ENT doctors disagree with this and feel that concerns about ototoxicity are unfounded

Otosclerosis
Otosclerosis describes the replacement of normal bone by vascular spongy bone. It causes a progressive conductive deafness
due to fixation of the stapes at the oval window. Otosclerosis is autosomal dominant and typically affects young adults

Onset is usually at 20-40 years - features include:

 conductive deafness
 tinnitus
 normal tympanic membrane*
 positive family history

Management

 hearing aid
 stapedectomy

*10% of patients may have a 'flamingo tinge', caused by hyperaemia

Perforated tympanic membrane

The most common cause of a perforated tympanic membrane is infection. Other causes include barotrauma or direct trauma.

A perforated tympanic membrane may lead to hearing loss depending on the size and also increase the risk of otitis media.

Management
  no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is
advisable to avoid getting water in the ear during this time
 it is common practice to prescribe antibiotics to perforations which occur following an episode of acute otitis media.
NICE support this approach in the 2008 Respiratory tract infection guidelines
 myringoplasty may be performed if the tympanic membrane does not heal by itself

Post-operative complications of tonsillectomy

Pain

The pain may increase for up to 6 days following a tonsillectomy.

Haemorrhage

Haemorrhage is a feared complication following tonsillectomy. All post-tonsillectomy haemorrhages should be

assessed by ENT.

Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed
by immediate return to theatre.

Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound
infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary
haemorrhage occurs in around 1-2% of all tonsillectomies.

Presbycusis
Presbycusis is a type of sensorineural hearing loss that affects elderly individuals. Typically, high-frequency hearing is
affected bilaterally, which can lead to conversational difficulties, particularly in noisy environments. Presbycusis progresses
slowly, as sensory hair cells and neurons in the cochlea atrophy over time. Although certain factors are associated with
presbycusis, it is distinct from noise-related hearing loss.

Epidemiology

 In the USA, it is estimated that 25-30% of 65-74 year-olds have impaired hearing. For those over 75 years, the
incidence is 40-50%
 The age of presentation varies, however, prevalence increases with age
 Males are at slightly higher risk of developing presbycusis compared to females (55%:45%)

Causes

 The precise cause is unknown however is likely multifactorial

 Arteriosclerosis: May cause diminished perfusion and oxygenation of the cochlea, resulting in damage to inner ear
structures
 Diabetes: Acceleration of arteriosclerosis
 Accumulated exposure to noise
 Drug exposure (Salicylates, chemotherapy agents etc.)
 Stress
 Genetic: Certain individuals may be programmed for the early ageing of the auditory system

Patients typically present with a chronic, slowly progressing history of:

 Speech becoming difficult to understand

 Need for increased volume on the television or radio
 Difficulty using the telephone
  Loss of directionality of sound
 Worsening of symptoms in noisy environments
 Hyperacusis: Heightened sensitivity to certain frequencies of sound (Less common)
 Tinnitus (Uncommon)

Signs:

 Possible Weber's test bone conduction localisation to one side if sensorineural hearing loss not completely bilateral

Investigations:

 Otoscopy: Normal, to rule out otosclerosis, cholesteatoma and conductive hearing loss (Foreign body, impacted wax
etc.)
 Tympanometry: Normal middle ear function with hearing loss (Type A)
 Audiometry: Bilateral sensorineural pattern hearing loss
 Blood tests including inflammatory markers and specific antibodies: Normal

Ramsay Hunt syndrome

Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate
ganglion of the seventh cranial nerve.

Features

 auricular pain is often the first feature

  facial nerve palsy
 vesicular rash around the ear
 other features include vertigo and tinnitus

Management

 oral aciclovir and corticosteroids are usually given

Rinne's and Weber's test

Performing both Rinne's and Weber's test allows differentiation of conductive and sensorineural deafness.

Rinne's test

 tuning fork is placed over the mastoid process until the sound is no longer heard, followed by repositioning just over
external acoustic meatus
 'positive test': air conduction (AC) is normally better than bone conduction (BC)
 'negative test': if BC > AC then conductive deafness

Weber's test

 tuning fork is placed in the middle of the forehead equidistant from the patient's ears
 the patient is then asked which side is loudest
 in unilateral sensorineural deafness, sound is localised to the unaffected side
 in unilateral conductive deafness, sound is localised to the affected side
Interpretation of Rinne and Weber tests

Rinne result Weber result

Normal Air conduction > bone conduction bilaterally Midline

Conductive hearing loss Bone conduction > air conduction in affected ear Lateralises to affected ear
Air conduction > bone conduction in unaffected ear

Sensorineural hearing loss Air conduction > bone conduction bilaterally Lateralises to unaffected ear

Sore throat

Sore throat encompasses pharyngitis, tonsillitis, laryngitis

Clinical Knowledge Summaries recommend:

 throat swabs and rapid antigen tests should not be carried out routinely in patients with a sore throat

Management

 paracetamol or ibuprofen for pain relief

 antibiotics are not routinely indicated
 there is some evidence that a single dose of oral corticosteroid may reduce the severity and duration of pain, although
this has not yet been incorporated into UK guidelines
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

Scoring systems

The Centor criteria are: score 1 point for each (maximum score of 4)

 presence of tonsillar exudate

 tender anterior cervical lymphadenopathy or lymphadenitis
 history of fever
 absence of cough

Centor score Likelihood of isolating Streptococci

0 or 1 or 2 3 to 17%

3 or 4 32 to 56%

The FeverPAIN criteria are: score 1 point for each (maximum score of 5)
  Fever over 38°C.
 Purulence (pharyngeal/tonsillar exudate).
 Attend rapidly (3 days or less)
 Severely Inflamed tonsils
 No cough or coryza

FeverPAIN score Likelihood of isolating Streptococci

0 or 1 13 to 18%

2 or 3 34% to 40%

4 or 5 62% to 65%

If antibiotics are indicated then either phenoxymethylpenicillin or clarithromycin (if the patient is penicillin-allergic) should be
given. Either a 7 or 10 day course should be given

Sudden-onset sensorineural hearing loss

When a patient presents with sudden onset hearing loss it is important to examine them carefully to differentiate
between conductive and sensorineural hearing loss → sudden-onset sensorineural hearing loss (SSNHL)
requires urgent referral to ENT.

The majority of SSNHL cases are idiopathic.

An MRI scan is usually performed to exclude a vestibular schwannoma.

High-dose oral corticosteroids are used by ENT for all cases of SSNHL.
Surfer's ear (exostosis)

Surfer's ear is a condition seen secondary to repeated exposure to cold water- often seen in surfers, divers, and
kayakers. It is more common in New Zealand and the USA. Some areas of the United Kingdom such as Cornwall
may see cases. Patients with this condition may suffer from repeated ear infections, decreased hearing and water
plugging. It is a progressive condition and preventative measures ought to be taken to prevent repeated exposure
- hoods, ear plugs or swim caps can be used. Surgery may be undertaken.

Temporomandibular joint dysfunction

Features

 pain: at the TMJ or may radiate to the head, neck or ear

 restricted jaw motion: chewing may cause pain
 the patient may notice clicks and other noises whilst moving the jaw

Management options include:

 recommending soft foods

 simple analgesia including paracetamol and NSAIDs
 short-courses of benzodiazepines may be helpful
 review by a dentist

Thyroglossal cyst
The key to understanding thyroglossal cysts is to think about the name; thyro (thyroid) and glossal (tongue).

Embryology

The thyroid develops from the floor of the pharynx and descends into the neck during its development. It is connected to the
tongue by the thyroglossal duct. The foramen cecum is the point of attachment of the thyroglossal duct to the tongue. The
thyroglossal duct normally atrophies but in some people may persist and give rise to a thyroglossal duct cyst.

Presentations

More common in patients < 20 years old.

Features

 usually midline, between the isthmus of the thyroid and the hyoid bone
 moves upwards with protrusion of the tongue
 may be painful if infected

Tinnitus

Tinnitus is the perception of sounds in the ears or head that do not come from an outside source. Around 1 in 10 people will
experience an episode of tinnitus at some point in their life. Although sometimes considered a 'minor' symptom of 'ringing in
the ears' it can be distressing to patients and may occasionally be a sign of a serious underlying condition.
Causes of tinnitus include:

Idiopathic An underlying cause will not be found in the majority of patients.

Meniere's disease Associated with hearing loss, vertigo, tinnitus and sensation of fullness or
pressure in one or both ears

Otosclerosis Onset is usually at 20-40 years

Conductive deafness
Tinnitus
Normal tympanic membrane although 10% of patients may have a 'flamingo
tinge', caused by hyperaemia

Positive family history

Sudden onset sensorineural hearing Around 80% of Hearing loss, vertigo, tinnitus
loss (SSNHL) Acoustic neuroma Absent corneal reflex is important
sign
Associated with
neurofibromatosis type 2

Hearing loss Causes include excessive loud noise and presbycusis

Drugs Aspirin/NSAIDs
Aminoglycosides
Loop diuretics
Quinine

Impacted ear wax Usually obvious on otoscopy

Assessment

 audiological assessment
o detect underlying hearing loss
 imaging
o not all patients will require imaging. Generally, non-pulsatile tinnitus does not require imaging unless it is
unilateral or there are other neurological or ontological signs. MRI of the internal auditory meatuses (IAM) is first-
line
o pulsatile tinnitus generally requires imaging as there may be an underlying vascular cause. Magnetic resonance
angiography (MRA) is often used to investigate pulsatile tinnitus

Management

 investigate and treat any underlying cause

 amplification devices
o more beneficial if associated hearing loss
 psychological therapy may help a limited group of patients
o examples include cognitive behavioural therapy
 tinnitus support groups

Tonsillitis and tonsillectomy

Complications of tonsillitis include:

 otitis media
 quinsy - peritonsillar abscess
  rheumatic fever and glomerulonephritis very rarely

The indications for tonsillectomy are controversial. NICE recommend that surgery should be considered only if the person
meets all of the following criteria

 sore throats are due to tonsillitis (i.e. not recurrent upper respiratory tract infections)
 the person has five or more episodes of sore throat per year
 symptoms have been occurring for at least a year
 the episodes of sore throat are disabling and prevent normal functioning

Other established indications for a tonsillectomy include

 recurrent febrile convulsions secondary to episodes of tonsillitis

 obstructive sleep apnoea, stridor or dysphagia secondary to enlarged tonsils
 peritonsillar abscess (quinsy) if unresponsive to standard treatment

Complications of tonsillectomy

 primary (< 24 hours): haemorrhage in 2-3% (most commonly due to inadequate haemostasis), pain
 secondary (24 hours to 10 days): haemorrhage (most commonly due to infection), pain

Vertigo
Vertigo may be defined as the false sensation that the body or environment is moving.

The table below lists the main characteristics of the most important causes of vertigo

Disorder Notes

Viral labyrinthitis Recent viral infection

Sudden onset
Nausea and vomiting
Hearing may be affected

Vestibular neuronitis Recent viral infection

Recurrent vertigo attacks lasting hours or days
No hearing loss

Benign paroxysmal positional vertigo Gradual onset

Triggered by change in head position
Each episode lasts 10-20 seconds

Meniere's disease Associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears

Vertebrobasilar ischaemia Elderly patient

Dizziness on extension of neck

Acoustic neuroma Hearing loss, vertigo, tinnitus

Absent corneal reflex is important sign
Associated with neurofibromatosis type 2

Other causes of vertigo include

 posterior circulation stroke
 trauma
 multiple sclerosis
 ototoxicity e.g. gentamicin