1. ENTENT

2. Sinusitis Acute sinusitis Starts with a cold then: Purulent nasal discharge, unilateral maxillary pain, pain in the upper teeth, pain when chewing, post-nasal drip, or pain on bending forward. Duration of more than 7 days. Do they need antibiotics?

3. Sinusitis Antibiotics ?? NNT 18 on most outcomes but no effect on pain / ADLs or return to work NNH = 8 (antibiotic side effects) Cochraine review of evidence recommends avoiding prescription Red flags = fever / sepsis + these patients were excluded from studies.

4. Sinusitis Chronic > 28 days. Common in asthmatics / smokers Often with nasal polyps Nasal congestions, loss of smell, rhinorrhoea, pressure, pain (though less common – consider dental causes esp if facial swelling) Refer if – unilateral, blood stained, epiphoria, unremitting, diplopia, neurology or proptosis Beware unilateral polyp.

5. Nasal steroids – no difference in efficacy between brands. Drops allow higher dose of steroid to be administered. Limited evidence for antibiotics (12 weeks macrolide). Refer if poor response at 4 weeks Little evidence for benefits of FESS

6. Rhinitis Serious impact on quality of life (similar to asthma) Poor exam performance Assoc with sinusitis / asthma Allergic (often with allergic conjunctivitis) or non-allergic

7. Deviated septum Pregnancy Polyps Menstrual cycle Foreign body Acromegaly Adenoidal hypertrophy Hypothyroidism Choanal atresia Aspirin and NSAID Churg–Strauss Oral contraceptives Wegener's granulomatosis Rhinitis medicamentosa Sarcoidosis Antihypertensives SLE Cocaine 'Neurogenic' rhinitis (gustatory, emotional, cold air) Gastro-oesophageal reflux Idiopathic Postural

8. Avoid allergens (can RAST if likely precipitant) – in practice rarely possible – tree/ grass pollens / house dust mite/ smoke Mild = non sedating antihistamine (NNT 15) Moderate to severe nasal steroid (NNT 4) Consider topical nasal antihistamine if watery consider nasal ipatropium

9. If not working + esp if asthmatic / atopic = trial of leukotriene receptor antag (monteleukast) Consider short course oral steroids (i.e. for exam) AVOID im steroids due to side effects Refer ENT if blockage or sinusitis or considering immunotherapy

10. Common cold Zinc!!! Take every 2 hours for 5 days daily dose of zinc acetate of 75 mg reduces cold by 1 day If taken throughout the winter 36% reduction in risk of cold + school absences (0.4 of a day) (daily dose prob needs to be over 75 mg).

11. Vertigo Central Vs peripheral. Central = brain related i.e. tumour/ cerebellar stoke etc Peripheral = ear related. BPPV, meniere’s, labyrinthitis

12. Central vertigo Persistent, severe, or prolonged New-onset headache. Focal neurological symptoms and signs (visual disturbance, visual field defects, dysarthria, weakness, numbness, and gait ataxia). Central-type nystagmus (for example vertical nystagmus). Abnormal response to the Hallpike manoeuvre (for example vertical nystagmus without latency, adaptation, or fatiguability; excessive nausea and vomiting). Prolonged, severe imbalance (an inability to stand up even with the eyes open). Nausea and vomiting are usually less severe Hearing is usually normal, except in acute brainstem stroke, when a unilateral hearing loss can occur.

13. Latency – initial delay before symptoms/ nystagmus kick in after hallpike’s Fatiguability – reduction in symptoms each time hallpike’s is performed

14. Peripheral vertigo In (BPPV), episodes of are induced by moving the position of the head and episodes last for seconds (but may be described as minutes). In meniere’s episodes of occur spontaneously, are not provoked by position change, and last much longer (30 minutes to several hours) than in BPPV. Tinnitus, hearing loss, and fullness in the ear are present in Meniere's disease, but not usually in BPPV or vestibular neuronitis. In vestibular neuronitis /labyrinthitis - usually persists for several days and gradually improves with time + there is no hearing loss or tinnitus. Horizontal / rotational nystagmus.

15. Labyrinthitis = massively overdiagnosed and q rare Often misdiagnosis of BPPV or vestibular migraine (more common)

16. Look at the person's face for signs of asymmetry suggestive of peripheral facial nerve involvement or a cerebrovascular event. Examine the ear — look for infection, discharge, vesicular eruptions, and signs of cholesteatoma. Perform a neurological examination: Test cranial nerves and cerebellar function. Examine the eyes for nystagmus: Perform fundoscopy. Check for signs of peripheral neuropathy. Examine the person's gait and their ability to stand unaided.

17. Romberg’s test — to identify instability of either peripheral or central cause (although it is not a sensitive test for differentiating between them). http://www.youtube.com/watch?v=U5a4lbmwmOw Hallpike’s test — to help make a diagnosis of benign paroxysmal positional vertigo (latency/ rotational) vs central cause (vertical, no latency). http://www.youtube.com/watch?v=YPIN9MDsBqo http://www.youtube.com/watch?v=cZlXvRlxrRE Head impulse test — test for vestibular problems (positive in peripheral vertigo due to vestibular cause but negative in BPPV) http://www.youtube.com/watch?v=CZXDNLLGG8k Unterberger’s test — to identify damage to one of the labyrinths. http://www.youtube.com/watch?v=XGUNTS_Z2UM

18. Cannalith repositioning manoeuvres Epley http://www.youtube.com/watch?v=Zq okxZRbJfwhttp://www.youtube.com/watch?v=Zq okxZRbJfw Bradnt Daroff exercises http://www.youtube.com/watch?v=nI EguL0AaEwhttp://www.youtube.com/watch?v=nI EguL0AaEw

19. Central = hallpikes – instant symptoms / nystagmus often continues > 1 minute. Non fatiguable. head impulse – negative. Often fall on walking, rarely hearing loss or tinnitus, often other neurology Peripheral = hallpikes – latency (symptoms and nystagmus kick in within 30 secs after initial delay) + settle q quickly, fatiguability (reduce each time done). Head impulse positive if acute unilateral vestibular loss (-ve in BPPV). Mild instability often able to walk though. No neurology. May have hearing loss or tinnitus.

20. Chronic dizziness Common problem Often coexists with anxiety Evidence that rehabilitation exercises / some CBT techniques help www.menieres.org.uk can access book of vestibular exercises on linewww.menieres.org.uk

21. Discharging ear Beware cholesteotoma / foreign body (attic perforation) Often hard to tell if OE or OM with perforation. Don’t worry re amioglycoside drops with perforation – risk low if just 1-2 week course + not repeated excessively (commonly used by ENT) If not responding consider swab If canal v narrow or debris ++ consider referral for microsuction / ear wick General advice to patient to avoid recurrence (i.e no fish hooks)

22. Otitis media Basically little benefit to abx Slightly more benefit if otorrhoea or aged <2 and bilateral Systemic upset = more likely to benefit but delayed script still appropriate (48 hours as most get better) If giving abx = 5 day amox 25% of infections = H influenzae which erythromycin is not effective for so clarithromycin

23. Glue ear Impaired speech, language, behaviour Observe for 3 months after diagnosis before referral with general advice (unless other problems i.e. Down’s, cleft) Consider autoinflation devices (otovent – available most pharmacies – nasal balloon!) No role for abx, decongestants, nasal steroids