7. Anatomy and physiology of the vestibular system. Harmonic and disharmonic vestibular syndrome.
8. Fundamental examination tools of otoneurology.
20. Ménière’s syndrome and Ménière’s disease. Therapeutic options.
21. Differential diagnosis of BPPV, vestibular neuronitis and Ménière’s disease.
Labyrinth
Vestibular nerve
Vestibular nuclei
Vestibular pathways Vestibulocerebellar
Vestibulospinal
Vestibuloocular
Vestibuloreticular
Cortical, hippocampal
pathways
Ear drum examination Hearing tests Pure tone audiometry
Vestibular system tests Statokinetic (vestibulospinal) Spontaneous nystagmus (vestibulo-ocular reflex tests) Positional nystagmus tests Head impulse test
Vestibular provocation tests: Optokinetic tests
Caloric irrigation tests
Rotational tests
Previous diseases: heart diseases, blood-pressure, renal failures, drugs, ear diseases, neurological diseases, neck vertebra problems
Types of vertigo: rotatory vertigo, unsteadiness, light-headedness, imbalance
Length of vertigo: seconds, minutes, hours, days, constant dizziness
Single recurrent attacks
Concomitant symptoms: hearing loss, tinnitus, discharge from ear, nausea, vomitus, loss of consciousness, headache
Horisontal
Vertical
Rotatory
Horisontorotatory
Verticorotatory
Retraction
Romberg’s test Past pointing tests Blind walking test
Patient history: ◦ Type of vertigo (sensation of spinning or falling);
◦ Vegetative symptoms, nausea, vomiting.
Examination: ◦ deviation, tilting;
◦ spontaneous nystagmus and nystagmus provoked by head movements.
Minimum criteria for the ENT exam - essential ENT knowledge for a
physician
Torsional (Causse)-latero-retroflexion of the neck
Positional and positioning nystagmus
Dix-Hallpike manouvre
More than 24 hours long severe vertigo with nausea,
vomitus, motion intolerance, balance disorder and
nystagmus.
1. Vestibular neuronitis
2. Stroke
Differential diagnosis: head impulse test in the ED
Not a specific diagnosis! Rotatory vertigo with sudden onset
Nystagmus, vomitus, sometimes tinnitus
Peripheral or central origin True Meniere’s disease
Other inner ear disorders
Vascular lesions of brainstem or inner ear
Vestibular neurectomy
Saccotomy Intratympanal gentamycin
Vasoactive drugs, intratympanal dexametasone
Parenteral vasoactive drugs
Betahistine, salt-free diet, saluretics
III. Stadium II. Stadium I. Stadium
A
Diseases Lenth of attacks
Head
position
influence
Hearing loss
Ménière’s disease Hours NO YES
Vestibular neuronitis Days NO NO
BPPV Seconds, but
recurrent
YES NO
14. Differentiation of central and peripheral facial nerve palsy. Causes of peripheral facial nerve palsy, differential diagnosis.
No wrinkles on face, on
forehead
No eye-closure, Bell’s
phenomenon
No movements on face
Nasolabial assymmetry
Lacrimation or dry eye
Hyperacusia,
Tasting disorder
Herpes eruptions in the auricle
Sensorineural hearing loss
Vertigo Facial palsy
Bell’s palsy;
Herpes zoster oticus;
Other viral or bacterial infections (HSV, EBV, Lyme);
Acute and chronic middle ear diseases (acute and chronic middle ear infections, cholesteatoma, rarely tumors);
Tumors of the pontocerebellar angle, vestibular schwannoma;
Cranial traumas (pyramid bone fractures), extratemporal traumas;
Malignant tumors of parotid gland.
Minimum criteria for the ENT exam - essential ENT knowledge for a physician
Otoscopy
Audiometry, tympanometry, stapedial reflex
Imaging methods (Schüller, CT, MR)
Parotid gland palpation (ultrasonography)
Blood tests (diabetes!), blood pressure
Topical diagnosis n. petrosus- lacrimation -Shirmer teszt
n. stapedius-hyperacusis- stapedial reflex
chorda tympani –tasting disorders- gustometria
Electrodiagnostic tests
Casual therapy in secondary palsies
Corticosteroid and antiviral treatment in Bell’s palsy.
In every palsy case: Psychical support of patients
Ophthalmological control (keratitis)
Covering the eye-ball, eyedrops
Electrotherapy, selective stimulation of the nerve or the muscles to prevent atrophy.
In the recovery stadium -active movement .
Primary headaches
Migraine, tension headache, cluster headache, chronic
paroxysmal hemicrania
Secondary headaches
Headaches due to neurological reasons:
Posttraumatic, vascular, infectious headaches,
metabolic headaches
Otolaryngological and ophthalmological headaches
Neuralgias
Outer and middle ear diseases
Diseases of nasal and paranasal
sinuses
Nasopharyngeal diseases
13. Complications of purulent acute and chronic otitis media.
34. Complications of sinusitis.
35. Benign and malignant tumors of the paranasal sinuses. Principles of treatment.
38. Diseases of the nasopharynx. Symptoms adenoid hyperplasia.
Viral infection of the upper airways;
Inflammation of nasal sinuses: (acute and chronic);
Benign and malignant tumors of nasal sinuses;
Cervical: cervical vertebra disorders, spondylosis, myalgia;
Complications of otitis and sinusitis: mastoiditis, meningitis, brain abscess, inflammation of the petrous pyramid;
Neuralgias;
Pain of temporomandibular joint.
Minimum criteria for the ENT exam - essential ENT knowledge for a physician
Temporomandibular joint disorders (Costen
syndrome):
Unilateral headache, earache, chewing problems
Mastoiditis
Subperiosteal abscess
Labyrinthitis
Peripheral facial palsy
Thrombosis of sigmoideal sinus
Petrositis
Meningitis
Brain abscess
◦ Extracranial Intratemporal
Acute mastoiditis; Zygomaticitis; Petrositis; Facial nerve palsy; Labyrinthitis;
Extratemporal Abscess: subperiosteal, preauricular, suboccipital, Bezold's abscess;
◦ Intracranial Extradural abscess; Sinus phlebitis - sinus thrombosis; Subdural abscess; Meningitis, encephalitis; Brain abscess;
◦ General: sepsis.
Minimum criteria for the ENT exam
- essential ENT knowledge for a physician
Frontal sinusitis – forehead;
Maxillary sinusitis – face;
Ethmoidal sinusitis –periorbitally, between the eyes;
Sphenoid sinusitis – crown of the head, referring to the occipital area;
All forms of sinusitis can cause diffuse headache.
Minimum criteria for the ENT exam - essential ENT knowledge for a physician
Orbital cellulitis
Orbital abscess
Osteomyelitis
Thrombophlebitis
of cavernosal sinus
Meningitis
Brain-abscess
Extracranial complications ◦ Periorbital cellulitis;
◦ Subperiosteal abscess;
◦ Orbital phlegmone / abscess;
◦ Osteomyelitis;
◦ Sepsis;
Intracranial complications ◦ Meningitis;
◦ Epi/subdural or brain abscess, encephalitis;
◦ Cavernous sinus thrombosis.
Minimum criteria for the ENT exam - essential ENT knowledge for a physician