--- module: 056-02 language: en chapter: 56 title: "Ear, Nose, Throat, Hearing, Balance, Voice, and Swallowing" module_title: "Auditory localisation, vestibular syndromes, deep-neck danger, and airway protection" source_sha256: 249011c57e36e05218aef6571c72a5c4223db536721eb0e1042152fd0fd3f6f4 --- # Localisation, vestibular syndromes, deep neck, airway ## Time-dependent syndromes ### Stridor, drooling, enlarging neck swelling ### Deep-neck sepsis, severe epistaxis ### Sudden hearing loss, vertigo with central signs ### Compact anatomy speeds progression #### Airway obstruction, intracranial spread, aspiration ## Hearing pathway and testing ### Conductive loss attenuates before the cochlea ### Sensorineural: hair cells, nerve, central ### Air conduction includes both pathways #### Bone conduction bypasses external and middle ear #### Air-bone gap supports conductive loss ### Poor speech discrimination suggests neural cause ### Tuning forks modify probability #### Conductive: Weber toward, bone exceeds air #### Sensorineural: Weber away, air exceeds bone #### Technique and bilateral disease mislead ## Sudden loss and ear infection ### Sudden loss mistaken for wax or congestion #### Steroid benefit is time-sensitive #### Normal otoscopy is not reassuring ### Otitis externa confined to canal skin #### Wick or cleaning when canal closed #### Aminoglycoside drops injure inner ear if perforated ### Nocturnal pain, cranial neuropathy: skull-base osteomyelitis ### Bulging membrane, not redness, for otitis media ### Adult unilateral effusion: examine nasopharynx ### Cholesteatoma erodes bone despite modest pain ## Tinnitus and hearing function ### Pulsatile or not, unilateral or bilateral ### Pulse-synchronous suggests vascular mechanisms ### Unilateral with asymmetric loss: retrocochlear ### Rehabilitation reduces distress, percept persists ### Function not set by pure-tone thresholds ### Aids adjust frequency and binaural input ### Implant delivers electrical nerve stimulation ## Vestibular mechanisms and syndromes ### Paired labyrinths give balanced resting signal #### Unilateral loss read as rotation ### Reflex moves eyes opposite the head #### Catch-up saccade: peripheral deficit #### Central lesions may preserve the reflex ### Classify by timing and triggers #### Seconds, positional: benign positional vertigo #### Minutes to hours: migraine, Meniere, ischaemia #### Days, continuous: neuritis or stroke #### Worse with movement is nonspecific ### Otoconia in canal, repositioning manoeuvre ### Non-fatigable vertical nystagmus: central ### Impulse-nystagmus-skew valid only when continuous #### Early posterior-fossa MRI can be negative ## Nose, sinuses, and foreign bodies ### Allergic rhinitis is IgE-mediated ### Steroid spray regular, aimed off septum ### Unilateral obstruction, blood: tumour concern ### Thin orbital walls, valveless veins permit spread #### Emergency imaging, antibiotics, drainage ### Compress soft nose, not nasal bones #### Bilateral septal cautery risks perforation #### Posterior bleed threatens airway, circulation ### Button battery causes rapid necrosis #### Blind attempts push objects deeper ## Deep-neck infection and airway crisis ### Infection spreads along fascial planes ### Peritonsillar abscess: trismus, palatal bulge ### Ludwig angina elevates the tongue #### Sedation removes compensatory tone ### Stridor phase localises obstruction ### Severity from work and fatigue, not loudness #### Quieter stridor can mean exhaustion ### Normal saturation is not reassuring #### Oxygenation falls abruptly before obstruction ### Prepare expert, equipment, surgical airway ## Voice and vocal-fold paralysis ### Persistent hoarseness needs fold visualisation ### Recurrent laryngeal nerve, skull base to chest #### Thyroid, lung, aortic, mediastinal disease ### Bilateral paralysis threatens airway ## Swallowing safety and aspiration ### Alertness, closure, sensation, cough needed ### Aspiration silent when sensation impaired ### Endoscopy views pharynx, residue ### Videofluoroscopy shows mechanics across strategies ### Safety measures can cost hydration, pleasure ### Aspiration pneumonia is multifactorial #### Saliva aspirated despite nil by mouth #### Mouth care, upright posture, bolus size ### Share texture as real consistency