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