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The dizzy patient 117
Answers
Clinical cases
CASE 2.14 –
Dizziness
A1: What is the likely differential diagnosis?
Benign positional vertigo
Ménière’s disease
Vestibular neuronitis/labyrinthitis
A2: What additional features in the history would you like to elicit?
Determine whether the patient has true vertigo, rather than unsteadiness. Vertigo is the hallucination
of movement; either the environment moves or the patient moves. Ask the patient whether she has
had similar attacks before and whether the attacks are episodic. Ask how long each attack is. If it is for
a few seconds without hearing loss and tinnitus, it is likely to be benign positional vertigo. Ménière’s
disease tends to present with tinnitus and hearing loss, together with the vertigo, over a period of
hours. Vestibular neuronitis lasts for days and will not be associated with other ear symptoms. Ask
about unconsciousness. Patients with peripheral lesions are conscious whereas those with central
nervous system problems, which may be vascular in origin, can lose consciousness. Ask whether
epileptic attacks occur. A full general history should be taken for all patients with dizziness, including
cardiovascular, respiratory, central nervous and gastrointestinal symptoms. Many patients with vascular
disease and hypertension feel unsteady when they stand up.
Investigations include audiometry and occasionally caloric testing if there is any diagnostic doubt. If
the diagnosis is benign positional vertigo, no further investigation is required. If there is asymmetrical
hearing, MRI of the internal auditory meatus should be arranged.
A3: What should one look for in the examination?
A full otoneurological examination should be undertaken; this includes examination of the ears, plus
tests to exclude central pathology – examination of the cranial nerves, pursuit and tests for cerebellar
signs. Pulse and blood pressure should be measured. If a patient has good mobility of the cervical spine,
positional tests should be undertaken. The most likely diagnosis here is benign positional paroxysmal
vertigo. This is conrmed by Dix-Hallpike testing – lying the patient down from a seated position with
the patient’s head rotated 30 degrees to the affected side. The patient develops geotropic rotational
nystagmus with an additional downbeat component (Figure2.4). If the patient has cervical spine
problems then a Dix-Hallpike is contraindicated.
A4: What investigations would be most helpful and why?
An audiogram should be performed. If benign positional paroxysmal vertigo (BPPV) is conrmed on Dix-
Hallpike testing, then no further investigations are required.
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118 Ear, nose and throat (ENT)
A5: What are the treatment options?
Treatment for benign positional vertigo is to perform a particle repositioning manoeuvre (the Epley
manoeuvre) (Figure2.5), although often the symptoms settle spontaneously. Ménière’s disease is
typically treated in a stepwise manner, commencing with conservative measures – low-salt diet,
caffeine and alcohol avoidance – which are successful in controlling symptoms in 60 per cent of
patients. In those who fail conservative measures, medical therapy with Betahistine (a histamine
analogue which effects microcirculation within the cochlea and vestibular system) is attempted, again
this is successful in approximately 60 per cent of patients. Finally destruction of the labyrinth, either
chemically with gentamycin or surgically, stops almost all attacks of Ménière’s, although patients may
develop a chronic imbalance due to unilateral labyrinthine failure. Vestibular neuronitis presents with a
picture identical to unilateral vestibular loss and can be treated with vestibular therapy.
A
B
Figure 2.4 Dix-Hallpike test for benign positional paroxysmal vertigo.
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The dizzy patient 119
A
B
C
D
E
Figure 2.5 Epley manoeuvre for benign positional paroxysmal vertigo.
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120 Ear, nose and throat (ENT)
OSCE Counselling case
OSCE COUNSELLING CASE 2.13 –
The patient is obviously worried that
there is something sinister going on.
What is your advice?
As it is very easy to make the diagnosis, you can inform the patient that the disease is coming from the
inner ear and that he does not have a serious brain condition. Patients are often worried about this and
they may not volunteer the information, so mention it. State that the condition is often self-limiting but
relapses in 50 per cent and a further Epley manoeuvre can be undertaken if the symptoms return. If
they have a lot of problems driving they should not do so until the condition has resolved.
REVISION PANEL
The diagnosis of BPPV can typically be made on eliciting a classic history of vertigo lasting seconds
occurring on head movement, with no other otological symptoms.
BPPV diagnosis is conrmed by a positive Dix-Hallpike test.
BPPV is treated by an Epley manoeuvre in the rst instance.
Classic BPPV is not associated with other intracranial pathology and the patient can be reassured
of this.
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Acute facial palsy 121
ACUTE FACIAL PALSY
Questions
Clinical cases
For the clinical case scenario given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What is the important nding on examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.15 –
Acute facial palsy
An adult aged 32 presents with a droopy face on the left side.
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122 Ear, nose and throat (ENT)
OSCE Counselling case
OSCE COUNSELLING CASE 2.14 –
A patient who has an acute Bell’s
palsy that is partial and occurred 3
days previously is concerned about
recovery. What is your advice?
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Acute facial palsy 123
Key concepts
Assess upper and lower motor neuron function.
House-Brackmann classication of facial nerve palsy
I. Normal
II. Mild dysfunction
− Gross: Slight weakness on close inspection; may have synkinesis
− Motion: Forehead – moderate to good, eye – complete closure with effort, mouth – slightly
weak on maximal effort
III. Moderate dysfunction
− Gross: Obvious, but not disguring between sides; noticeable but not severe synkinesis or
spasm; at rest normal symmetry and tone
− Motion: Forehead – slight to moderate movement, eye – complete closure with effort,
mouth – slightly weak with maximal effort
IV. Moderately severe
− Gross: Obvious weakness and/or disguring asymmetry; at rest normal symmetry and
tone
− Motion: Forehead – none, eye – incomplete closure, mouth – asymmetry with maximal
effort
V. Severe dysfunction
− Gross: Only barely perceptible motion; at rest, asymmetry
− Motion: Forehead – none, eye – incomplete closure, mouth – slight movement
VI. Total paralysis
No movement at all
Corticosteroids demonstrated to improve the outcome from a facial palsy if begun within 2 weeks of
onset
Antivirals may be benecial
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124 Ear, nose and throat (ENT)
Answers
Clinical cases
CASE 2.15 –
Acute facial palsy
A1: What is the likely differential diagnosis?
Bell’s palsy is a diagnosis of exclusion.
A2: What additional features in the history would you like to elicit?
Ask whether the palsy came on suddenly and whether it is painful, particularly pain in the ear. Ask
about hearing, taste and lacrimation.
A3: What is the important nding on examination?
Perform an otoneurological examination plus audiometry. Examine the neck for parotid masses.
Determine whether it is an upper or a lower motor neuron lesion – upper motor neuron lesions spare
the forehead. The vast majority at this age will be lower motor neuron lesions. Try to grade the palsy. If
you cannot determine the severity, note whether it is partial or complete.
Lower motor neuron facial nerve palsies can be caused by pathology in the following:
Cerebellopontine (CP) angle – typically acoustic neuromas (see Case 2.10)
Middle ear – temporal bone fracture, acute otitis media, cholesteatoma
Parotid – malignant parotid neoplasms
Globally – Bell’s palsy, Ramsey Hunt, Lyme disease
Hence the diagnosis of Bell’s palsy is a diagnosis of exclusion. Middle-ear conditions can be excluded by
a combination of history and otoscopic ndings. Parotid pathology can be excluded by neck palpation.
The CP angle lesions cannot be excluded initially, and if there is no complete resolution of symptoms
within 3 months then an MRI is undertaken. The presence of pain and vesicles on the soft palate, tonsil
area, or ear canal and drum are diagnostic of Ramsay Hunt syndrome. This is the sensory supply of the
seventh cranial nerve. Lyme disease may present with bilateral facial palsies with a history of exposure to
the tick of Borrelia species. If all of the above is normal, then a presumptive diagnosis of Bell’s is made.
The single most important observation is whether the patient can cover the cornea when she tries to
close her eyes. The eye is most at risk from corneal damage with a facial palsy. Lacrimation may well be
reduced as well.
A4: What investigations would be most helpful and why?
A simple case of Bell’s palsy requires no investigation except audiometry. If the palsy does not improve
completely after 3 months, then an MRI is required to exclude an acoustic neuroma.
A5: What are the treatment options?
Corticosteroids have been demonstrated to improve the outcome from a facial palsy if begun within
2 weeks of onset. Antivirals may be benecial. The most important aspect of treatment is corneal
protection. If there is any doubt, the patient should be referred to the eye surgeon. In the meantime
articial tears and tape, to ensure the eye remains closed at night, should be provided.
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Acute facial palsy 125
OSCE Counselling case
OSCE COUNSELLING CASE 2.14 –
A patient who has an acute Bell’s
palsy that is partial and occurred 3
days previously is concerned about
recovery. What is your advice?
Approximately 95 per cent of Bell’s palsies recover completely by 9 months. If the palsy is partial and
there is good eye closure, the recovery may well be quicker, often a few weeks. Some patients are
concerned that they have had a stroke and you will be able to reassure them that this is not the case
(a cerebrovascular accident (CVA) would present with an upper motor neuron lesion). Others may be
concerned that there is something serious going on within the brain, and again you can stress that it is
the nerve that supplies the face that is affected rather than anything more serious.
REVISION PANEL
Evaluation of facial nerve palsies includes both determining the degree of the palsy and examining
the course of the facial nerve to establish an underlying cause.
Symptomatic treatment of the eye requires articial tears and taping the eye closed at night.
Bell’s palsies resolve completely in 95 per cent of patients; this success rate is achieved if oral
corticosteroids are administered within the rst 2 weeks of onset.
If the palsy does not resolve completely, an MRI of the course of the facial nerve is required.
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126 Ear, nose and throat (ENT)
THROAT
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What is the important nding on examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.16 –
Child with sore throat
A mother presents with a child who has a recurrent sore throat causing constitutional symptoms.
CASE 2.17 –
Adolescent with acute sore throat
An adolescent aged 17 comes to the surgery with an acute sore throat, feeling unwell.
CASE 2.18 –
Smoker with continuous sore throat
A smoker aged 65 presents with a continuous sore throat, which is progressive, and complains of pain
when swallowing.
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