COMMON ENT PROBLEMS

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COMMON ENT PROBLEMS

• Eleonora Zanchin
• GPST2
• William Harvey Hospital

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Aims

• Diagnosis
• GP setting management
• Referral

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Ear

• External
• Middle
• Inner

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External Ear

• Infections
• Trauma
• Foreign bodies
• Other

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Otitis Externa

• Hx Otalgia, itchiness, otorrhoea
• O/e ear canal is swollen, red, narrow lumen
  (often unable to see TM), plenty of debris and
  secretions. Perichondritis at times.
• Investigations initially ear swab may not be
  needed
• Tx topical ABx, analgesia, aural toilet.
• If narrow ear canal wick.

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Otitis Externa - 2

• First line ciprofloxacin eye drops, Sofradex
  drops, Gentisone HC.
• Second line Locorten Vioform, Canesten drops
• Referral lack of response after initial
  management.
• Red flags malignant otitis externa in DM

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Images
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Trauma and FB

• Trauma depending on the extent of the damage
• FB very common especially in children
• batteries or chemicals ? immediate referral

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Middle Ear

• Infections
• Neoplastic
• Ossicular Pathologies
• Facial Nerve
• Other

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Tympanic membrane

• Perforation can be isolated or secondary to
  middle ear pathology
• If middle ear pathology present, treat
  accordingly
• If isolated keeping ear dry, no need for
  antibiotics, later review. If complications arise
  ? refer.

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Acute Otitis Media

• Hx pyrexia, otalgia, hearing impairment,
  systemically unwell, ear discharge.
• O/e TM hyperemic, bulging, can be perforated.
  Check facial nerve.
• Tx oral amoxicillin/ erythromycin nasal
  decongestants (otrivine spray) may be useful.
• If TM perforated treat also with topical ABx
• Referral systemically unwell, if fails to
  respond after initial management.

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Children

• Glue ear otitis media with effusion
• Almost epidemic finding
• Glue ear persists gt 3 months
• 70 revert to normal on its own in 3 mo
• Treat only if hearing loss (developmental delay),
  balance problems
• Tx grommets
• F.u. in 6 mo with audiology

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Inner Ear

• Hearing
• Balance

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Hearing impairment

• Hx congenital, trauma, drug exposure,
  occupational, family hx, recurrent infections,
  accompanying symptoms
• Assessment
• Clinical
• Tuning Fork
• Audiometry

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Hearing impairment

• Rinnes test normal AC gt BC, Rinnes positive
• Weber normally sound referred equally in each
  ear.
• Conductive loss Rinnes negative on the affected
  ear and Weber lateralises on affected ear.
• Sensorineural loss Rinnes positive, Weber
  lateralises on opposite side.
• Referral when appropriate

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Balance Disorders

• First must rule out non ENT causes e.g.
  neurological, cardiovascular problems
• Common ENT presentations
• BPPV
• Menières disease
• Ototoxic drugs
• Acute labyrinthitis

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Facial Nerve

• O/e weakness of the facial muscles,
• facial asymmetry, drooling,
• unable to close eye
• UMN vascular lesions, intracranial tumours, MS
• LMN Bells palsy, trauma, tumours, middle ear
  suppuration, Ramsay Hunt syndrome, Guillain Barré
  syndrome
• Bells palsy is a diagnosis of exclusion ?
  immediate expert advice.

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Nose and Sinuses

• Epistaxis
• Trauma
• Tumors
• Acute and Chronic Rhinosinusitis
• Foreign Bodies
• Other

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Epistaxis

• Hx trauma/spontaneous, hypertension,
  aspirin/warfarin, bleeding disorders, estimate
  blood loss
• O/e anterior/posterior, often in Littles area
• Tx
• Conservative manual pressure, ice packs,
  cauterisation with local lidocaine, nose packs
• Surgical diathermy, ligation of ethmoidal or SPA
• Refer persistent bleed, failure of initial
  conservative measures, important blood loss,
  recurrent episodes.

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Images
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Trauma

• Hx mechanism of trauma, epistaxis, CSF leak
• O/e septal haematoma, septal deviation, nasal
  deformity, nasal obstruction.
• Septal haematoma ? immediate referral
• Septal dislocation (no external deformity)? refer
  for septoplasty, wks or months
• Dislocation of nasal bones (deformity) ? refer
  for reduction of in 7 to 10 days

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Images
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Tumours

• Red flags chronic nasal obstruction, blood
  stained nasal discharge, unilateral otitis media
  with effusion, cranial nerves deficit (invasion
  of skull base), cervical lymphadenopathy, Far
  East community especially China
• Most often SCC
• Referral rapid access

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Rhinosinusitis

• Inflammation of nasal and sinuses lining
• Acute rhinorrhoea, feeling of congestion of nose
  and face, obstruction, pyrexia. Tender over
  sinuses. Usually viral but bacterial
  superinfection can follow.
  
• Tx analgesia, Cefaclor, vasoconstrictor nose
  drops as 1 ephedrine
• Refer not improving with above management, red
  flags

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Red flags/Complications

• Orbital cellulitis/abscess eyelid oedema,
  diplopia, proptosis, loss of colour
  discrimination and visual acuity
• Meningitis headache, pyrexia, neck stiffness etc
• Cerebral abscess recent frontal sinus infection,
  headache, apathy, behavioural change
• Cavernous sinus thrombosis proptosis,
  opthalmoplegia

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Rhinosinusitis

• Chronic recurrent episodes ? refer
• Underlying causes nasal septum deviation,
  ciliary dysfunction, nasal polyposis, allergic
  rhinitis
• Tx oral ABx, topical intranasal steroids e.g
  Nasonex 1 spray nocte, nasal douches.
• Might need surgery FESS
• (functional endoscopic sinus surgery).

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Foreign Bodies

• Hx unilateral nasal obstruction, unilateral
  rhinorrhoea (smelly, bloody), toy missing
• O/e with otoscope while child restrained.
• Tx Mothers kiss, child to blow, forceps,
  tweezers.
• Refer ? immediate
• Batteries or chemicals corrosive
• Other risk of inhalation

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Throat

• Oropharynx and tonsils
• Larynx
• Infections
• Tumour
• Trauma
• Foreign Bodies

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Acute Tonsillitis

• Hx sore throat, dysphagia, spitting saliva,
  voice change, pyrexia, malaise, otalgia.
• O/e enlarged erythematous tonsils, exudate,
  cervical lymphadenopathy, organomegaly.
• Tx systemic ABx, analgesia, steroids, fluids.
  
• If mononucleosis suspected avoid amoxi/ampi
• Refer unable to take oral Abx, drooling, toxic.
• Recurrent tonsillitis, in view of
  tonsillectomy.

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Images
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Quinsy

• It is a peritonsillar abscess
• Hx similar to tonsillitis but pain worse on one
  side, trismus, hot potato voice
• Tx pus draining, ABx, analgesia.
• Refer if unable to drain in GP setting,
  systemically unwell, unable to take oral Abx.

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Acute epiglottitis

• Hx acute onset, sore throat, pyrexial, difficult
  to breathe
• O/e drooling, exhaustion, cyanosis, hypoxia,
  toxic
• Refer as life threatening emergency
• Do not upset patient
• Tx humidified 02, adrenaline neb, IV dexa, IV
  ABx, IV piriton, emergency cricothyroidotomy

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Head and Neck

• Infections
• Trauma
• Neoplastic
• Other

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Thyroid mass

• Hx neck swelling
• O/e neck mass in thyroid area, LN, BP, pulse
• Investigations TFT, if abnormal auto-Ab, no need
  to USS because it does not change management.
• Risk stratification- Risk factors
• Male
• Female lt 16 yr or gt 45 yr
• Family hx thyroid Ca
• Euthyroid
• Neck irradiation

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Referral of thyroid masses

• Unchanged nodule for years, low risk patient? no
  need to refer.
• Sudden onset of pain, abnormal TFT ? non urgent
  referral.
• Refer urgently big masses (gt4 cm), dysphagia,
  odinophagia, hoarse voice, cervical LN, rapidly
  enlarging painless mass, high risk.

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Other Head and Neck Tumours

• Risk factors male, alcohol, smoke, older age
• Presentation hoarse voice, dysphagia,
  non-healing ulcer, neck mass
• SCC larynx most common
• Referral above symptoms for gt 2 weeks, urgent
  referral, rapid access
• Tx radiotherapy, surgery, palliative.