ENT UPDATE

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ENT UPDATE

• Gavin Watters FRCS FRCS(ORL)
• Consultant ENT Surgeon

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PRIMARY CARE

• E
• Vertigo BPPV Tinnitus Otitis Externa
• N
• Rhinosinusitis
• T
• Globus sensation Snoring

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Dizziness

• Vertigo
• Unsteadiness (on walking)
• Light-Headedness

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Vertigo

• Definition
• An illusion of movement of the subject or of
  his/her surroundings. Usually a sensation of
  spinning or rotation.
• Central or Peripheral

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Acute Peripheral Vertigo

• BPPV lt 5 minutes
• Menieres Disease/Syndrome lt24 Hours
• Vertigo with migraine lt24 Hours
• Vestibular/labyrinthine failure gt24 Hours

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Dix-Hallpike Test
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Dix-Hallpike Test

• Peripheral
• Latent period
• Distress
• Rotational nystagmus
• Fatigable

• Central
• No latent period
• Distress /-
• Variable nystagmus
• Not fatigable

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BPPV

• Calcium deposits in posterior semi-circular canal
• Brandt-Daroff exercises
• Epley manoeuvre
• Obliterate Posterior S-CC
• Singular nerve neurectomy

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Brandt-Daroff Exercise
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Tinnitus

• Primary/idiopathic
• Secondary
• Ear disease
• Vascular
• Neuronal
• Neuromuscular

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Pulsatile Tinnitus

• Vascular
• Vascular stenosis
• AVM
• Glomus tumour

• Conductive HL
• Hear normal intra-cranial blood flow

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Management

• Primary
• Reassurance
• Advice on environmental masking
• Hearing aid
• Need only refer if not coping or unilateral
  tinnitus
• Hearing Therapy, masker

• Secondary
• Treat underlying ear disease
• Refer for further investigation/treatment

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Otitis Externa

• Pain
• Irritation/Itch
• Discharge
• (Hearing loss)

• Cotton buds
• Skin condition
• Diabetes
• Middle ear disease
• Anatomical

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Management of OE

• Antibiotic/steroid DROPS
• Water precautions
• Good analgesia
• Aural toilet
• Steroid ointment
• Swab (?Fungal OE)
• Systemic antibiotics if cellulitis

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Sinusitis?

• Blocked nose
• Congestion
• Facial pain/headache
• Runny nose
• Catarrh/mucous
• Unpleasant smell/taste

• Puffy/swollen face
• Bags under eyes
• Watery/sticky eye
• And many more!

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Sinusitis

• Cacosmia
• Purulent Rhinorrhoea
• Hyposmia/anosmia
• Facial pain
• Frontal headache
• Nasal obstruction

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Facial Pain

• Facial neuralgia/migraine
• Dental
• Sinusitis
• TMJ/Myofacial pain

• Periodicity, not constant
• Well localised
• Worse with colds
• Responds to antibiotics
• Other sinus symptoms
• Facial swelling almost never due to sinusitis

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Diagnosis of Sinusitis

• DIFFICULT!
• Nasal endoscopy is the key
• Plain sinus X-ray no value
• CT scan limited value. 30 normal individuals
  have CT changes
• Facial swelling almost never due to sinusitis
• Forehead and periorbital swelling probably is due
  to sinus infection

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Nottingham Rhinology Clinic

• 973 consecutive patients
• Mean follow-up 26 months
• 1/3 diagnosis not sinonasal
• 119/679(18) with sinonasal disease had pain
• 43/119 pain not attributable to sinus disease
• 76/679(11) had pain attributable to sinus disease

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Neurological Causes(Nottingham Study)

• Midfacial segment pain 37
• Tension headache 23
• Migraine 17
• Atypical facial pain 12
• Cluster headache 8
• Others 3

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Summary

• Facial pain/frontal headache is not a major
  feature of sinonasal disease.
• Most patients with head pain/pressure have a
  neurological cause for this symptom
• Be very cautious in attributing such symptoms as
  being due to sinusitis, especially in the absence
  of objective evidence of sinus disease.

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Rhinitis- Aetiology

• Intrinsic (vasomotor)
• Allergic (seasonal, perennial)
• Environmental (SMOKING)
• Infective
• Hormonal
• Medication (Rhinitis medicamentosa)
• Systemic medical disorder eg Wegners

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Rhinitis- Management

• Topical nasal steroids
• Use daily
• Minimum 6-8 weeks
• Warn no affect for 3-4 weeks but dont stop
• Drops more potent than sprays

• Stop nasal decongestants
• Stop smoking
• Add antihistamines?
• Ipratropium Bromide?
• Allergen avoidance
• After allergy testing
• Immunotherapy

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Gastro-oesophageal reflux

• Effects 25-40 of British population each week
• Atypical manifestations are common
• Laryngeal
• Pharyngeal

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Laryngopharyngeal Symptoms

• Hoarse voice (usually fluctuating)
• Globus sensation
• Mild dysphagia
• Post nasal drip
• Chronic cough
• Chronic sore throat (mild)

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Pathophysiology

• Inflammation due to direct action of acid
• Laryngitis, pharyngitis
• Increase in cricopharyngeus muscle tone
• Globus sensation, dysphagia, pharyngeal pouch
• Vagal hypersensitivity
• Globus sensation, chronic cough
• Ciliary damage
• Post nasal drip

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THERAPEUTIC TRIAL WITH A PPI IS WELL WORTH WHILE,
PROVIDED THERE ARE NO CLEAR CANCER SYMPTOMS
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Cancer symptoms

• Pain, especially odynophagia
• True dysphagia
• Change in diet
• Weight loss
• Food regurgitation
• Is symptom more noticeable when eating/drinking?

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SNORING

• Obesity
• Oropharyngeal
• Palate
• Tongue base ? Retrognaethia
• Tonsils
• Nasal

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Treatment

• Non-Surgical
• LOSE WEIGHT
• Mandibular splint
• Treat rhinitis
• Avoid alcohol in evening
• Avoid sedatives
• Stop smoking
• Sleep on side

• Surgical
• Palatal surgery (LAUP)
• Must exclude OSA
• Tonsillectomy
• Nasal surgery
• Orthognaethic procedures

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Laser assisted palatoplasty
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AND FINALLY
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Questions ?