ENT and Maxillofacial Emergencies




(1)
Royal Free NHS Foundation Trust, London, UK

 




Approach to the patient with vertigo

Vertigo is an illusory sensation of motion, that can be rotatory, linear, or vertical.

Spontaneous



  • Single prolonged episode: vestibular neuronitis (associated hearing loss: labyrinthitis); labyrinthine concussion; lateral medullary or cerebellar infarction


  • Recurrent episodes: Meniere disease (severe vertigo with tinnitus and progressive hearing loss); perilymph fistula; vestibular migraine (recurrent attacks of vertigo or dizziness lasting minutes to hours; associated with headache or other migrainous symptoms; postural imbalance; personal history of migraine); posterior circulation ischaemia

Positional



  • Peripheral: benign paroxysmal positional vertigo


  • Central


Causes of peripheral (labyrinthine) vertigo





  • Trauma: head injury, barotrauma, perilymph fistula (vertigo triggered by straining); tympanic membrane rupture; round window rupture; labyrinthine concussion


  • Iatrogenic: middle and inner ear surgery


  • Infection: acute viral labyrinthitis (acute onset of sustained peripheral vertigo, nausea and vomiting, recent upper respiratory tract infection in 50%, symptoms predominantly with head movement, hearing loss, postural imbalance with falls toward affected side), herpes zoster, syphilis, suppurative labyrinthitis after suppurative otitis media; mastoiditis; vestibular neuronitis


  • Metabolic: Meniere’s disease (tetrad of recurrent attacks of vertigo lasting more than 20 min, fluctuating sensorineural hearing loss, tinnitus and subjective sensation of aural fullness; vestibular drop attacks may rarely occur), cochlear otosclerosis


  • Ototoxic drugs: aminoglycosides (vestibular nerve); quinine, salicylates (vestibular)


  • Degenerative: benign paroxysmal positional vertigo (repeated short-lived episodes of vertigo (<60 s), induced by positional change such as rolling over in bed, lying back in bed or sitting up from a supine position, and associated with transient rotatory nystagmus; caused by canalithiasis with free floating otoconia within the endolymph of the membranous labyrinth; particle repositioning manoeuvres such as the Epley manoeuvre can lead to symptom resolution)


  • Tumour: acoustic neuroma


  • Drugs: quinine, salicylates


  • Otitis media


  • Motion sickness


Causes of central vertigo

(brainstem, cerebellar or temporal lobe lesions)



  • Cerebrovascular disease: vertebrobasilar insufficiency; cerebellar or brainstem stroke; cerebellar haemorrhage; vertebral artery dissection; subclavian steal syndrome; basilar artery migraine


  • Cerebellar degeneration


  • Multiple sclerosis


  • Alcohol intoxication


  • Posterior cranial fossa tumours of the brain stem or cerebellum


  • Craniovertebral junction disorders: Arnold-Chiari malformations


  • Trauma: basal skull fractures; vertebral artery injury


  • Syringobulbia


  • Temporal lobe epilepsy


Features suggesting central vertigo





  • Gradual onset


  • New onset headache


  • Associated brainstem symptoms: dysarthria, dysphagia, diplopia


  • Central neurological signs: gait ataxia; down-beat, vertical or changing-direction nystagmus


  • Cranial nerve deficts


Features suggesting peripheral vertigo





  • Acute onset


  • Severe intensity of symptoms, especially with head movement to one side


  • Positional symptoms


  • Hearing loss, usually unilateral


  • Tinnitus


  • Otalgia


  • Frequently severe autonomic symptoms


  • Unidirectional, horizontal or rotatory jerk nystagmus on lateral gaze opposite side of lesion


  • Visual fixation inhibits nystagmus


  • Head movement increases symptoms

    Absence of cranial nerve palsies


Examination for balance

includes consideration of



  • Stance and gait tests


  • Romberg sign


  • Dix-Hallpike manoeuvre


  • Oculomotor examination


  • Vestibulo-ocular reflex


  • Visual-vestibular interaction


  • Dizziness-provoking manoeuvres


Dix-Hallpike manoeuvre

(rapid movement from sitting to head hanging position)



  • The patient sits upright, facing forwards with eyes open, and with legs extended


  • Rotate head 45° to one side


  • Lie down backwards rapidly with head extended 20°, hanging over the end of the table


  • Hold in this position for 30 s


  • The development of torsional nystagmus, with a latency of 5–10 s and with the fast phase directed towards the affected ear (closest to the ground) indicates benign paroxysmal positional vertigo. Nystagmus fades if the head is held in the provoking position


  • Sit upright and then repeat with the head rotated 45° towards the other side


  • The manoeuvre is contraindicated in the presence of cervical spine instability, prolpased intervertebral disc with radiculopathy, cervical myelopathy, previous cervical spine surgery, or vascular dissection syndromes


Localisation of vestibular lesions





  • Inner ear: otalgia; tinnitus; aural fullness; hearing loss


  • VIII nerve (internal auditory meatus): poor speech discrimination; facial weakness


  • Cerebello-pontine angle: facial weakness; facial sensory loss; dysarthria; incoordination


  • Brainstem: hemiparesis; hemi-sensory loss; dysphagia; dysarthria


  • Cerebellum: incoordination; dysarthria


  • Cortex: olfactory or gustatory hallucinations; vertiginous seizures


Differential diagnosis of dizziness





  • Near syncope or presyncope (sensation of impending faint or loss of consciousness): postural hypotension; cardiogenic hypotension (cardiac arrhythmia, valvular heart disease); vasovagal attack; carotid sinus hypersensitivity


  • Dysequilibrium (sensation of impaired balance and gait): multiple sensory deficits (peripheral neuropathy; visual impairment); cerebellar lesions


  • Vertigo (sensation of rotation of patient or environment, related to a mismatch of the vestibular, visual and somatosensory symptoms)


  • Light headedness: hyperventilation; hypoglycaemia; panic attack


Characteristics of cardiovascular dizziness





  • Dizziness is described as light-headedness


  • Associated with syncope, pallor, the need to sit/lie down


  • Symptoms occur with prolonged standing


Causes of imbalance or vertigo on looking up





  • Benign paroxysmal positional vertigo


  • Posterior circulation ischaemia caused by cervical osteophytes leading to vertebral artery compression


  • Chiari type 1 syndrome


  • Parkinsonism


  • Polyneuropathy


Types of nystagmus

Spontaneous, involuntary periodic and rhythmical oscillations of the eyes in which a slow phase alternates with a fast phase in the opposite direction.

Repetitive rapid (saccadic) eye movements, often alternating with a slow drift in the opposite direction; named for the direction of the fast component

Spontaneous



  • Pendular (opposing movements of equal speed and amplitude): vertical; horizontal; see saw


  • Horizontal


  • Torsional (rotary)


  • Downbeat (vertical jerk nystagmus with downward fast phase): cranio-cervical junction disorder (Chiari malformation); bilateral lesions of cerebellar flocculus or medial longitudinal fascicle


  • Upbeat (vertical jerk nystagmus with upward fast phase): pontine lesions, along ventral tegmental tract; anterior cerebellar vermis (vestibulocerebellum)


  • Periodic alternating: horizontal jerk nystagmus in which direction of fast phase changes spontaneously and cyclically with an intervening neutral period


  • See saw: vertical-torsional oscillation of both eyes in which one eye rises and intorts and the other falls and extorts; rostral midbrain including midbrain-thalamic junction


  • Dissociated (horizontal nystagmus that is greater in the abducting than inthe adducting eye)


  • Medial longitudinal fasciculus lesion (inter-nuclear ophthalmoplegia)

Gaze-evoked (identified with patient fixating with both eyes)



  • Gaze-evoked nystagmus: horizontal; vertical


  • Optokinetic


  • Endpoint: extreme lateral gaze

Clinical categorization of nystagmus



  • Monocular


  • Binocular asymmetrical or dissociative


  • Binocular symmetrical:



    • Dysconjugate: seesaw; horizontal


    • Conjugate: pendular; jerk (fast corrective component)


Check list for evaluation of nystagmus





  • Anomalous head posture


  • Visual acuity: uniocular; binocular


  • Laterality


  • Latent/manifest


  • Type; direction (horizontal, vertical, rotatory); frequency (fast; slow); amplitude (large, small); plane


  • Conjugate (same in both eyes)/dysconjugate


  • Dissociation


  • Occurrence in primary position (at rest) or gaze evoked


Causes of facial paralysis

Supranuclear (sparing of frontalis because of bilateral innervation)



  • Stroke


  • Tumour


  • Multiple sclerosis

Infranuclear (unilateral facial weakness, including inability to wrinkle forehead, brow ptosis with inability to raise eyebrow, drooping of the angle of the mouth, asymmetrical smile, upper eyelid retraction, incomplete eyelid closure with risk of exposure keratopathy, lower eyelid atony leading to ectropion, inability to purse lips and to show teeth; aberrant regeneration may lead to gustatory epiphora and facial synkinesiae)



  • Geniculate ganglion: Bell’s palsy (herpes simplex type 1); Ramsay Hunt syndrome (herpes zoster of geniculate ganglion)- otalgia, vesicles in the external auditory canal, pinna or anterior 2/3rds of the tongue


  • Middle ear: cholesteatoma; otitis media


  • Parotid salivary gland: infection; tumour


  • Lyme disease


  • Granulomatous disorders: sarcoidosis


  • GuillainBarre syndrome


  • Temporal bone: fracture; tumour

The types of presentation of facial paralysis include



  • Unilateral lower motor neuron: Bell’s palsy


  • Bilateral lower motor neuron: myasthenia gravis


  • Unilateral upper motor neuron: hemispheric stroke


  • Bilateral upper motor neuron: brainstem stroke (pseudobulbar palsy)


Causes of upper airway obstruction





  • Trauma: laryngeal stenosis, acute laryngeal injury, airway burn, haemorrhage; retropharyngeal haematoma (associated with Capp’s triad of tracheal or oesophagel compression, anterior displacement of the trachea, and subcutaneous bruising over the neck and anterior chest)


  • Foreign bodies: teeth; dentures; fish bones


  • Infection: retropharyngeal abscess (sore throat, fever, neck stiffness, dysphagia, odynophagia, stridor); peritonsillar abscess, Ludwig’s angina (fever, trismus, lower facial and neck cellulitis, stridor, induration of floor of mouth; may complicate dental infection or tongue piercing), epiglottitis (high fever, sore throat, dysphagia, adoption of a position of leaning forward with mouth open, muffled voice, drooling of saliva), laryngitis, viral laryngotracheobronchitis (croup) (barking cough, hoarse voice, intermittent inspiratory stridor, retractions-often worse at night, variable respiratory distress; usually a benign, self-limited disease), diphtheria,bacterial tracheitis


  • Vocal cord paralysis


  • Tumours: benign and malignant laryngeal tumours; laryngeal papillomatosis


  • Iatrogenic: post-intubation or post-tracheostomy sub-glottic stenosis


Features of inhalational burn injury





  • Entrapment


  • Fire in enclosed space


  • Loss of consciousness at scene


  • Carbonacous sputum


  • Soot around mouth


  • Singed nasal hairs


  • Facial burns


  • Pharyngeal oedema


  • Stridor


Stridor

Stridor is a high-pitched, harsh noise, secondary to turbulent flow through a partially obstructed upper airway.

Stertor is a coarse inspiratory noise through a narrowed nose/pharynx.

Causes of stridor

Acute, febrile

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Nov 20, 2017 | Posted by in Uncategorized | Comments Off on ENT and Maxillofacial Emergencies

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