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Otic conditions
Nasal conditions
Throat conditions
Case study
The authors
Dr Stephanie Yau
senior house officer, department
of otolaryngology — head and
neck surgery, Royal Brisbane
Hospital, Herston, Queensland.
Introduction
A LARGE proportion of ENT
problems are encountered in the
community. It is estimated that
about one-third of a GP’s workload
will comprise ENT-type problems.
Most should be relatively simple
to manage; however, relatively
innocuous symptoms can, if
not recognised early, develop
into potentially life-threatening
symptoms. It is beyond the remit of
this article to cover all the possible
ENT emergencies that may be
encountered by a GP. However,
what we have sought to do is cover a
cross-section of problems, focusing
on the salient points. The conditions
are grouped into three categories:
those largely affecting the ears,
nose, and throat respectively.
cont’d next page
Potential ENT
emergencies
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Australian Doctor
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22 March 2013 | Australian Doctor |
23
How To TREAT Potential ENT emergencies
Otic conditions
Acute otitis externa
ACUTE otitis externa (AOE) is
defined as cellulitis of the auditory
canal skin and subdermis with
inflammation and oedema (figure
1). It may involve the pinna and
tympanic membrane. It is a common condition encountered in
general practice affecting about
four in 1000 of the general population and is usually simple to
diagnose and treat.
Several factors contribute to the
development of this condition,
all of which promote the growth
of bacteria or fungus within the
ear canal. As a line of defence,
the ear produces cerumen that
creates an acidic environment to
prevent the growth of organisms.
AOE is more common in regions
with warmer climates, increased
humidity, or increased water
exposure from swimming. Activities that decrease the amount of
cerumen, such as swimming, place
patients at a higher risk of infection. Conversely, excess cerumen
can act as a barrier, leading to the
retention of water, again creating
an environment ideal for bacterial
growth. Further factors include
local physical trauma, and allergic
conditions such as dermatitis.
In the immunocompromised
patient, the possibility of a malignant otitis externa (skullbase
osteomyelitis) should be considered (figure 2), along with early
referral to a specialist if appropriate. While this condition can occur
in the immunocompetent person,
it typically affects those with diabetes or other conditions that may
affect the immune system, such as
acquired immunodeficiency syndrome, malignancy or patients
receiving chemotherapy. As the
infection spreads in the temporal
bone, it may result in cranial nerve
palsies with the facial nerve usually the first to become involved.
It is important to distinguish
other causes of the discharging ear
(eg, cholesteatoma and skullbase
osteomyelitis) from AOE. Failure
to identify other potential causes
may cause increased morbidity
or result in serious complications.
Features in the history or examination that may point to a different
diagnosis are shown in the box
Features of the AOE, right.
Uncomplicated AOE is often
polymicrobial. The most common
pathogen is Pseudomonas aeruginosa, involved in about half of
all cases. Other pathogens include
Staphylococcus aureus and fungi
such as aspergillus and candida.
Patients usually present with rapid
onset of symptoms, usually within
48 hours. Common symptoms
include otalgia, discharge from the
ear, feeling of fullness in the ear,
pruritus and decreased hearing.
The diagnosis is based on clinical exam. The tragus is classically described as being tender
on manipulation in otitis externa.
Otoscopy may reveal an erythematous and oedematous external auditory canal with purulent
discharge. Oedema narrows the
canal and often obstructs visualisation of the tympanic membrane.
If visible, the tympanic membrane
may be mildly inflamed, however,
it should be mobile on air insuf-
24
| Australian Doctor | 22 March 2013
Figure 1: Acute otitis externa, demonstrating oedematous and narrowed canal with infectious debris.
Figure 2: Malignant otitis externa demonstrating oedematous canal with
granulation tissue.
Features of AOE
• Cranial nerve palsy, unremitting
otalgia, malaise and fevers may
represent malignant otitis externa
(osteomyelitis of temporal bone)
• Purulent discharge and pain may
represent foreign object
• Pain beyond ear canal with
systemic symptoms may
represent mastoiditis or
perichondritis
jugular foramen; followed by XII
at the hypoglossal canal, can be
involved. If the disease involves the
petrous apex, then cranial nerves
V and VI can also be involved.
In about 10% of cases, fungi are
responsible for AOE. Common
pathogens include aspergillus
(90%) followed by candida. Typically, fungal infections are a result
of prolonged antibacterial treatment that alters the normal flora
of the ear canal; however, it may
occasionally be the primary pathogen. Fungal infections can be
asymptomatic, but may have evidence of hyphae on examination.
Acidifying solutions may be all
that is required; however, if there
is no response then clotrimazole
drops may be used. These also
possess some antibacterial activity.
In cases of tympanic membrane
perforation, the use of eardrops
can be fraught. Any substance that
enters the middle ear may affect
the inner ear via the round window membrane and cause adverse
effects to the cochlea and vestibular apparatus. In the presence of a
perforation with chronic middle
ear infection, the round window
membrane may become thickened
secondary to an immune response
and the deposition of connective
tissue, causing it to be less permeable. However, in uncomplicated
otitis externa, if there is a preexisting tympanic membrane perforation, ciprofloxacin drops may
be considered.
Treatment - topical therapies
Figure 3: Acute otitis media, demonstrating oedematous and erythematous
tympanic membrane.
Table 1: Topical therapies for acute otitis external
Name
Ingredients
Points of note
Sofradex
Framycetin, gramicidin,
dexamethasone
—
Kenacomb
Neomycin, gramicidin,
nystatin, triamcinolone
Not effective against P.
aeruginosa
LocacortenVioform
Flumethasone, clioquinol
Good against fungal AOE
Ciproxin HC
Ciprofloxacin, hydrocortisone
—
Ciloxan
Ciprofloxacin
Can be used with TM
perforation
flation. Cranial nerve examination is also an essential part of the
workup and if abnormal, warrants
further investigations and urgent
referral to a specialist.
In malignant otitis externa, the
facial nerve is the most commonly affected cranial nerve, usually at the stylomastoid foramen.
However as the disease advances,
cranial nerves IX, X and XI at the
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The mainstay of treatment
involves the use of topical therapies (table 1), analgesia, regular
aural toileting and patient education regarding contributing factors. The choice of these therapies
relies greatly on physical exam
findings. Cleaning of debris in the
canal allows for the direct administration of topical otic drops.
Numerous topical preparations
exist and may contain an antiseptic, antimicrobial or steroid in
combination or alone. If the ear
canal is significantly oedematous,
a gauze or foam wick should be
inserted to ensure drops are delivered to the entirety of the canal.
Meta-analysis has shown no significant differences in outcome
when different types of topical
drops are used, such as antiseptic
vs antimicrobial or steroid-antimicrobial vs antimicrobial alone.
Topical treatments are highly
efficacious and recommended as
initial therapy for uncomplicated
AOE because of safety and efficacy over placebo in randomised
trials, and excellent clinical and
bacterial outcomes in comparative
studies.
Topical therapy allows delivery
of a high concentration of antibiotic, often 100-1000 times higher
than what is possible with systemic therapy.
It is important that the patient is
educated about adequate delivery
of the drops into the ear. Patients
are often unaware how to apply
the drops, with almost 60% of
patients inappropriately using the
drops in the first three days, often
resulting in undermedication.
Drops should be used with the
patient lying down and the affected
ear upward. Circular movement of
the tragus will facilitate delivery
of the drops. The patient should
remain in this position for a few
minutes.
Oral antibiotics
Oral antibiotics are often prescribed inappropriately and should
only be used for those with complicated otitis externa or patients
with predisposing risk factors such
as diabetes or immune deficiencies.
Analgesia
The pain associated with AOE can
in most cases be controlled with
simple analgesia, although some
cases may require opioid analgesics for control. Patient education
regarding the need to keep the ear
dry during treatment and avoiding
the use of cotton buds for cleaning
is important.
Most cases of AOE will resolve
within two weeks and can be managed in the community. However, for those cases refractory to
treatment or any complications,
referral to a specialist is appropriate.
Acute otitis media
Acute otitis media (AOM) represents one of the most common
infections in infancy, and the main
reason given for using antibiotics
in children. AOM is a generic term
used to describe the symptoms and
signs seen as a result of an inflammation of the middle ear cleft (figure 3).
Studies carried out in developed countries have shown that
almost 80% of children have had
one episode of AOM by age three
and about 40% would have experienced more than six episodes
by their seventh birthday. It has
been estimated that about 80%
of acute otitis media episodes in
nursing babies are caused by bacteria, three organisms in particular: Streptococcus pneumoniae,
Moraxella catarrhalis and Haemophilus influenzae.
Eustachian tube dysfunction
underlies the primary cause of oti-
tis media. The majority of cases
of AOM are associated with a
concurrent URTI involving the
nasopharynx. Other environmental factors may also contribute
to the development of this condition such as supine bottlefeeding,
attending daycare and passive
exposure to smoking.
Diagnosis is typically made on
the history and clinical findings
(table 2). These include the development of otalgia, fever and associated symptoms in the presence of a
bulging tympanic membrane. Consider AOM in patients with preceding URTI symptoms, hearing loss,
tinnitus or vertigo. Always consider
a diagnosis of AOM in children
with non-specific symptoms such
as irritability, fever or generalised
lethargy.
Otoscopic examination is of significant importance in the diagnosis of AOM. When examining
the tympanic membrane, note the
colour of the drum. Cloudiness or
increased vascularity can suggest
AOM. Assess the position of the
drum; is it bulging, retracted or neutral? This is useful in distinguishing
between AOM where the tympanic
membrane bulges vs otitis media
with effusion where the tympanic
Table 2: Acute otitis media
features
Feature
Clinical findings
Colour
Cloudy, red
Position
Bulging
Light reflex
Absent
Mobility
Decreased
Air-fluid level
Not present
membrane takes a retracted or neutral position. A red, bulging drum
indicates disease progression from
the cloudy, bulging state.
Other features such as decreased
mobility suggest AOM. The most
specific clinical features to diagnose AOM include absence of light
reflex, bulging of the tympanic
membrane and loss of normal contour.
The tympanic membrane normally demonstrates signs of inflammation with injection and erythema
of the mucosa. There may be an
obvious purulent middle ear effusion. It may also start to bulge in
the posterior quadrants.
Treatment
The management of AOM is contentious. The use of supportive
treatment is advocated in the form
of simple analgesia and antipyretics.
In the presence of systemic symptoms or complications of acute
otitis media, antibiotics should be
considered or referral to a specialist
for further management.
In uncomplicated otitis media,
meta-analyses have shown no benefit of antibiotics over placebo in
relieving symptoms within the first
24 hours of treatment. Pain may be
reduced in 30% of cases after 2-7
days. In 80% of untreated children, the clinical condition resolved
spontaneously. Prescribing policies
vary internationally — in the Netherlands just over 30% of children
with AOM are given antibiotics,
while in the US and Australia, the
rate is over 95%.
Complications
Complications from otitis media
are rare (less than 1%), however
these potentially serious complications must always be considered.
Spread of infection to the mastoid
air cells can lead to mastoiditis.
Cholesteatoma can develop, which
is a cyst-like lesion in the temporal
bone. Other complications stem
from spreading infection including
brain abscess and meningitis.
Acute mastoiditis
Mastoiditis is inflammation of
the mastoid air cells of the temporal bone and represents a complication of acute otitis media. In
some cases of AOM, infection can
spread past the middle ear cleft
and develop osteitis of the mastoid
air cells or periosteitis of the mastoid process.
Since the introduction of antibiotics, it is a relatively rare
complication of otitis media, but
must always be considered. If left
untreated, this can lead to the
destruction of bony trabeculae
leading to coalescent mastoiditis.
This is a potentially serious complication, as infection can then
spread to intracranial spaces and
affect other structures including the facial nerve, labyrinth or
venous sinuses.
Symptoms to alert you to mastoiditis include persisting pain,
usually worse at night, and fevers.
Classic features on examination
include a bulging, erythematous
tympanic membrane, postauricular swelling and pain over the mastoid process.
CT has a high sensitivity for
mastoiditis, thus it is useful mainly
to rule out this condition. Other
imaging modalities have limited
benefit. If you suspect mastoiditis, urgent referral to a specialist is
necessary.
Treatment
Treatment will depend on the
severity of the case but most
commonly includes admission to
hospital, IV antibiotic therapy
and possible surgical intervention.
Surgery is rarely required, owing
to the availability and spectrum
of antibiotics. In cases refractory to medical treatment, surgical exploration of the ear is often
warranted, usually in the form
of some type of mastoid surgery.
This is commonly undertaken with
concomitant drainage of any middle ear infection using a grommet
insertion.
Summary
GPs are important in the first-line
management of otic conditions.
These are often simple to manage,
however they can develop serious
complications. Appropriate treatment and awareness in the community can assist greatly in reducing
disease burden for patients as well
as the number of referrals and
admissions to hospital.
Nasal conditions
Acute rhinosinusitis
ACUTE rhinosinusitis is defined
as a condition lasting less than
12 weeks with either nasal blockage, obstruction and congestion,
or nasal discharge with or without facial pain or reduction in the
sense of smell.
Sinusitis rarely occurs without
contiguous inflammation of the
nasal mucosa, thus the term ‘rhinosinusitis’ is a more accurate
term to describe this condition
(figure 4).
Rhinosinusitis is an extremely
common presenting condition
to GPs and may have significant
complications. It is the fifth most
common condition for which antibiotics are prescribed, although
the evidence supporting this treatment is controversial.
Acute rhinosinusitis can be classified into viral or bacterial causes.
Most cases are caused by viral
pathogens, most frequently rhinovirus, adenovirus, influenza virus
and parainfluenza virus. In acute
viral rhinosinusitis, symptom
duration is usually 7-10 days from
the onset of upper respiratory tract
symptoms.
If symptoms persist beyond 10
days then a diagnosis of acute
bacterial rhinosinusitis should be
considered. Common pathogens
are Streptococcus pneumoniae,
Haemophilus influenzae, Staphylococcus aureus and Moraxella
catarrhalis.
The similarity of symptoms of
acute rhinosinusitis to viral URTIs
often leads to overdiagnosis of
rhinosinusitis. Symptoms of note
include nasal discharge (which can
be purulent), nasal obstruction
and facial pain or fullness. This
symptomatology has been shown
to be specific for bacterial rather
than viral causes. Additional
symptoms include fever, cough,
fatigue and reduction of smell.
Salient points in the history are
Figure 4: Acute rhinosinusitis. Purulent nasal discharge with oedema and erythema of mucosa.
Complications of acute rhinosinusitis
Bony
Intracranial
• Osteomyelitis
• Cavernous sinus thrombosis
• Epidural abscess
• Intracranial abscess
Orbital
• Meningitis
• Inflammatory oedema and
erythema (pre-septal cellulitis)
• Subdural abscess
• Orbital cellulitis
• Superior sagittal sinus thrombosis
• Subperiosteal abscess
• Orbital abscess
immunosuppression, diabetes and
conditions affecting ciliary action,
such as cystic fibrosis, as there is a
much higher risk of complications
in these groups.
There are limitations to what
can be achieved with examination
in the general practice setting, but
important signs can be gleaned.
Anterior rhinoscopy with a good
headlight and nasal speculum will
allow evaluation of the state of
the nasal mucosa and the presence
of a nasal discharge. Assess erythematous mucosa and determine
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whether discharge is purulent. It is
important to assess for any swelling, erythema or oedema over the
cheek bones, forehead and periorbital area. Note any signs of
extrasinus involvement including
orbital cellulitis, abnormalities
of eye movement or meningism,
which may indicate complications.
In uncomplicated acute rhinosinusitis, imaging is not routinely
recommended. On the other hand,
if complications or an alternate
diagnosis are suspected, CT is the
imaging of choice. Sinus opacification, air-fluid level and mucosal
thickening can be seen on CT,
however it does not assist in distinguishing viral infection from
bacterial infection. More importantly, it may be an aid to confirm
or refute the presence of a complication of acute sinusitis.
Treatment
The management of acute rhinosinusitis aims to improve symptoms,
eradicate infection and prevent
serious but rare complications.
Pain management is an import-
ant component where analgesia
should be individualised to the
patient.
Adjunctive therapies can assist
with symptoms in both viral and
bacterial rhinosinusitis. Nasal
decongestants,
antihistamines,
saline nasal irrigation, mucolytics and intranasal steroids may
improve quality of life and obviate the need for further medical
management. In those high-risk
patients (eg, those who are immunocompromised) or in those
patients whose symptoms fail to
improve in 7-10 days, consider the
use of antibiotics.
Common pathogens include S.
pneumoniae, H. influenzae and
M. catarrhalis. Physicians should
be aware of bacterial resistance
within their community. First-line
community treatment usually is
amoxycillin, or a macrolide if the
patient is allergic to penicillin.
If patients’ symptoms fail to
improve, or worsen, the original
diagnosis should be reviewed, and
complications of acute rhinosinusitis should be considered (see
box, left). Complications occur
in about one in 1000 cases and
include orbital, intracranial or soft
tissue involvement. Referral to an
otolaryngologist or appropriate
specialist is important for further
assessment and management.
Periorbital and orbital cellulitis
Orbital cellulitis
Orbital complications are the most
common complication of acute
rhinosinusitis. Orbital infection
can be divided into pre- or postseptal. The orbital soft tissues are
divided into anterior and posterior
compartments by connective tissue known as the orbital septum.
Infection anterior to the septum
is known as pre-septal cellulitis.
Orbital cellulitis is defined as infection involving the deep soft tissues
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22 March 2013 | Australian Doctor |
25
How To TREAT Potential ENT emergencies
Figure 5: Orbital cellulitis in a child demonstrating orbital erythema and
oedema.
from previous page
around the eyeball and posterior to
the orbital septum (figure 5).
Clinically, this anatomical distinction is significant as pre-septal
conditions can expand freely anteriorly, whereas post-septal infections
are confined by the bony orbit and
orbital septum. Consequently, it is
important to differentiate between
the two. Swelling in the post-septal
area leads to increased pressure,
thereby affecting structures such as
the optic nerve and potentially causing blindness.
More than 90% of orbital cellulitis cases are due to direct
extension of acute or chronic bacterial sinusitis. Typically, infection
begins in the ethmoid sinuses and
spreads directly into the orbit. The
incidence of blindness from orbital
cellulitis is still relatively high, with
figures of just over 10% reported.
The most widely used classification method for orbital disease
was developed by Chandler and
categorised into five stages:1
1. Pre-septal disease — eyelid
swelling without proptosis,
ophthalmoplegia or loss of
vision.
2. Orbital cellulitis — inflammation of the orbital fat.
3. Subperiosteal abscess — pus
collection elevating the periosteum off the bony orbit.
4. Orbital abscess — pus collection within the orbit.
5. Cavernous sinus thrombosis.
Epistaxis: causes for concern
• Unilateral nasal blockage
• Facial pain or numbness
• Facial swelling or deformity
• South-East Asian origin (suspect
nasopharyngeal carcinoma)
• Loose teeth
The incidence of
blindness from
orbital cellulitis is still
relatively high, with
figures of just over
10% reported.
Figure 6: A: Acute epistaxis demonstrating significant haemorrhage. B: Anterior bleed from Little’s area.
B
A
systemic symptoms such as fever,
malaise and headache. If these
symptoms are present, urgent
referral to a specialist and further
investigations are warranted.
The mainstay of treatment for
orbital cellulitis is urgent admission
for IV antibiotics and treatment
of concomitant sinusitis. In most
cases, management is multidisciplinary, being guided by otolaryngologists, ophthalmologists, and
paediatricians if necessary. CT
imaging of both the orbits and
sinuses to rule out orbital or subperiosteal abscess as well as confirm
presence of sinus disease is necessary. If IV therapy is unsuccessful,
surgical treatment is warranted
with drainage of any abscess.
Epistaxis
Epistaxis is a challenging and
common condition with a lifetime
incidence as high as 60%. Most
people self-manage this condition,
which is often spontaneous and
self-limiting, and present to their
GP only when symptoms change
or worsen. Only a very small proportion of patients require specialist management.
Simple first aid measures may
be all that is required. However,
occasionally patients will need to be
transferred to the hospital for specialist treatment. As most episodes
are managed in the community,
GPs are paramount in recognising
signs and symptoms suggestive of
more sinister complications.
Periorbital cellulitis
Periorbital cellulitis is the most
common complication of acute
rhinosinusitis in children and is
defined as inflammation of the eyelid and conjunctivae. Symptoms
include orbital pain, blepharal
oedema and high fever. Antibiotic
therapy is important to prevent the
spread of infection as well as treatment of any sinusitis with topical
nasal steroids and decongestants.
Mild cases may be treated with
oral antibiotics in consultation
and review with a specialist.
Orbital cellulitis
If infection spreads beyond the
orbital septum, orbital cellulitis can develop. Orbital cellulitis
results from the spread of infection either directly through the
thin bone of the ethmoid or frontal sinus, or by thrombophlebitis
of the ethmoid veins.
Distinguishing symptoms and
signs include proptosis and limitation of ocular movements. Patients
may also develop conjunctival
chemosis, decreased vision and
26
| Australian Doctor | 22 March 2013
Nasal anatomy
The management of epistaxis has
evolved greatly in recent years
and successful treatment requires
knowledge of possible causes of
epistaxis and a detailed knowledge
of nasal anatomy.
The nose has a rich vascular
anatomy with multiple anastomoses. The arterial supply arises
from branches of the internal and
external carotid artery. Epistaxis
is most commonly classified into
anterior or posterior bleeds.
This is arbitrarily classified,
with a posterior bleed originating
from a site that cannot be seen on
anterior rhinoscopy.
More than 90% of episodes
are anterior, occurring from the
anterior nasal septum supplied by
Keisselbach’s plexus in a site called
Little’s area (figure 6).
Keisselbach’s plexus is an anastomotic network of vessels located
on the anterior cartilaginous septum. The remaining 10% of bleeds
are posterior and most commonly,
arterial in origin. They may
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Figure 7: Juvenile angiofibroma in post-nasal space.
present a greater risk of airway
compromise, aspiration and difficulty in controlling haemorrhage.
Causes
Most cases of epistaxis are idiopathic; however, identifiable
causes include local, systemic and
environmental factors, and medications. A thorough history and
examination is vital in assisting
decisions regarding further investigations and management. Local
causes include trauma, neoplasia,
septal abnormalities and inflammatory diseases. In children, nose
picking is the most common cause.
The exclusion of a sinister neoplastic cause is important. Features in
the history and examination may
raise the index of suspicion (see
box, above left).
Examples of systemic causes
include age, hypertension, bleeding diathesis and alcohol. Epistaxis
can occur in any age group, however it predominantly occurs in the
elderly (50-80 years) and in early
childhood. In the male adolescent,
juvenile nasopharyngeal angiofibroma should be considered (figure 7).
Patients with hereditary haemorrhagic telangiectasia can present
with epistaxis refractory to usual
treatment methods. It is also
common in other bleeding disorders, such as von Willebrand’s disease, for patients to present with
recurrent epistaxis.
If a bleeding diathesis is suspected, further laboratory testing
and consultation with a physician
may be warranted. The association
between hypertension and epistaxis
is often misunderstood. Hypertension itself is rarely the direct cause
of epistaxis and is perhaps related
to underlying vasculopathy in this
group of patients. It has been suggested that hypertension may be
related to anxiety, however studies
have failed to find conclusive evidence to support this.
The use of many over-the-counter and prescribed medications can
alter coagulation. NSAIDs and
aspirin are commonly used medications that can affect clotting,
thus taking a thorough medication
history is imperative. Over-warfarinised patients are also common
presenters.
Complementary and alternative
medicine use must also be considered. Their use is increasing in our
population and can interfere with
regular medications and clotting.
Ginseng and ginkgo biloba may
fall into this category.
Examination and management
Epistaxis can be distressing to
the patient and the initial assessment may warrant controlling the
bleed while taking a concomitant
focused history. Apply direct digital pressure to the soft cartilaginous part of the nose for at least
10 minutes. Have the patient sitting and leaning forward, while
breathing through their mouth.
Often this initial management may
be all that is required. The application of ice across the forehead,
behind the neck and in the mouth
is an adjuvant measure that may
help.
Once the bleeding has slowed
down or stopped, it may be possible to perform a more thorough
examination of the nasal cavity
and take a more comprehensive
history. Persistent bleeding may
suggest a more posterior cause for
the bleeding and the need for specialist input. As with all acute situations, depending on the volume
of bleeding there may be a need for
acute fluid resuscitation.
A thorough examination of the
nasal cavity requires a good headlight and suction with adequate
cont’d page 28
How To TREAT Potential ENT emergencies
from page 26
face, eye and hand protection for
the examiner.
The patient may need to blow
their nose and clear any clots to
facilitate examination. Be aware
that this may lead to a recurrence
of bleeding, which would also
assist you in identifying a bleeding point. With a nasal speculum
in one hand, attempt to view the
nasal cavity, suctioning simultaneously with your other hand. For an
anterior bleed pay particular attention to the septum and Little’s area
and look not only for a bleeding
point but also for scabbed or excoriated areas.
Preparation of the nose with adequate anaesthesia and vasoconstriction may assist the examination.
A well-primed nose is invaluable.
Apply a topical spray such as a 5%
lignocaine and 0.5% phenylephrine
combination to both nostrils. A cotton ball soaked in this solution and
carefully inserted into the nasal cavity may also help.
Posterior bleeds need to be considered if an anterior bleeding site
is not visualised on examination.
Clues to a posterior origin include
bleeding bilaterally or the presence of blood dripping down the
posterior pharyngeal wall. If direct
pressure fails and a bleeding point
is visualised, cauterisation may
be attempted. Cautery sticks are
impregnated with silver nitrate,
which reacts with the mucosal lining to produce a chemical burn.
Care must be taken during
bilateral cautery to prevent septal
perforation. Treatment should be
administered only to a small area
surrounding the bleeding point.
The oropharynx should always be
examined after treatment to ensure
there is no active bleeding down
the posterior pharyngeal wall. Inability to control the bleeding with
the above measures may require
some type of nasal packing.
Nasal packs act by applying
direct mechanical pressure on the
bleeding site. Traditional methods used lubricant or antibioticsoaked ribbon gauze, however
more modern packs have been
developed that are simple to insert
and effective.
The Rapid Rhino is composed
of an inflatable balloon coated
in a compound which acts as a
platelet aggregator. After insertion the balloon is inflated to tamponade bleeding and can be left in
for up to 3-4 days. Care must be
taken when inserting a nasal pack.
Direct the pack posteriorly, along
the floor of the nasal cavity rather
than superiorly and use a firm, but
not forceful, hand.
If the epistaxis continues despite
packing, surgical options could be
considered. These include selective
arterial ligation or embolisation.
The decision on which artery to
ligate depends on the site of bleeding and its likely source, with the
aim to ligate as close as possible to
the site of bleeding. Vessels include
the sphenopalatine, maxillary
artery and external carotid.
Figure 8: Acute tonsillitis.
THE presentation of a sore throat
in the community is very common.
The majority (75%) are viral in
aetiology. The differentiation
between a viral and bacterial cause
may be difficult clinically. Only in
about one-third of bacterial cases
is a pathogen (Group A streptococcus) identified.
Salient features in the history
include the duration of symptoms, the presence of associated
symptoms such as dysphagia and
odynophagia. A history of previous episodes may warrant a
referral to the specialist for consideration of a tonsillectomy once the
acute episode has settled.
Unilateral symptoms such as
referred otalgia, lateralised throat
pain and trismus may point to a
peritonsillar abscess, also called
quinsy.
The presence of ongoing symptoms for several weeks in addition
to other high-risk features such as
increased age, smoking and alcohol should raise the suspicion of
malignancy.
Occasionally there may be features of associated upper airway
obstruction, as a result of grossly
enlarged tonsils. This should warrant urgent referral to a hospital
for further assessment. The presence of associated significant lymphadenopathy in a young patient
may suggest glandular fever (infectious mononucleosis).
In most cases, diagnosis is
straightforward. The presence of
enlarged, erythematous, inflamed
28
| Australian Doctor | 22 March 2013
Emedicine Health — Ear Nose
and Throat Center
www.emedicinehealth.com/earnose-and-throat-conditions/center.
htm
Medscape Reference
Otolaryngology and Facial Plastic
Surgery Articles
Memedicine.medscape.com/
otolaryngology
BMJ
Ear, Nose and Throat/
Otolaryngology
www.bmj.com/specialties/earnose-and-throatotolaryngology
Reference
1. Chandler JR, et al. The
pathogenesis of orbital
complications in acute sinusitis.
Laryngoscope 1970; 80:1414-28.
Throat conditions
Tonsillitis
Online resources
Figure 9: Peritonsillar abscess left sided demonstrating deviation of uvula to
the right with erythema and oedema of the soft palate mucosa.
The presence of
ongoing symptoms
for several weeks
in addition to other
high-risk features
such as increased
age, smoking and
alcohol should raise
the suspicion of
malignancy.
tonsils should clinch the diagnosis
(figure 8). There may be a purulent exudate coating the tonsils.
The presence of significant symptoms with normal-looking tonsils
should alert the clinician to consider aetiology further down the
upper aerodigestive tract. Occasionally conditions such as supraglottitis may present in such a
fashion.
The use of throat swabs is rarely
helpful, both in terms of speed of
obtaining the result as well as differentiating between viral and bacterial.
Treatment
Generally simple analgesia and
throat gargles are all that is warranted. The use of antibiotics is
contentious. They may shorten
the duration of illness; however,
the emergence of resistant microorganisms is clearly related to the
excessive use of antibiotics and
this should be avoided unless clinically indicated.
Failure to respond to treatment
or worsening of symptoms should
warrant referral to a hospital. If
antibiotics are to be used, then
phenoxymethylpenicillin (penicillin V) remains the treatment of
choice, unless the patient is allergic. Amoxycillin and its derivatives should be avoided if possible
due to the risk of a cutaneous rash
in unsuspected infectious mononucleosis.
Infectious mononucleosis necessitates counselling of the patient
about the long duration of sympwww.australiandoctor.com.au
toms, the need to avoid contact
sports for six weeks and the need
to monitor liver function tests.
Quinsy (peritonsillar abscess)
This is one of the most common
neck-space infections in adults and
typically occurs as a complication
of tonsillitis. Traditionally, it has
been thought that the infection
spreads outside the tonsil capsule.
More recently, however, evidence
shows that it may be related to
pathology affecting the salivary
glands (Weber’s glands) at the
superior aspect of the tonsil near
the soft palate. This is supported
by its occurrence in the absence of
concurrent tonsillitis or a preceding history of tonsillitis.
Quinsy may occur at any age,
however the peak presentation is
between the third and fifth decade.
Patients typically present with lateralised throat pain, odynophagia
referred otalgia and trismus, with
a characteristic quality to their
voice.
The uvula is deviated to the contralateral side, with erythema and
swelling of the anterior tonsillar
pillar, and deviation of the tonsil
(figure 9). There may be occasions where an abscess has not yet
formed and there is simple cellulitis and erythema, the so- called
peritonsillar cellulitis. There are
occasions where the diagnosis is
not clear. The aspiration of pus
on needle aspiration or indeed the
use of cross-sectional imaging will
often clinch the diagnosis.
cont’d page 30
How To TREAT Potential ENT emergencies
from page 28
Treatment
The mainstay of treatment is drainage of the abscess, antibiotic therapy and supportive treatment with analgesia and
rehydration. Recurrence rates are undefined but thought
to be in the region of 10-20% based on current evidence.
Peritonsillar cellulitis represents a transitionary phase and
therefore should be treated similarly without the need for
drainage. Initial empiric antibiotic therapy should cover
Group A streptococcus and oral anaerobes.
The acute surgical treatment has evolved historically from
the so-called hot tonsillectomy to simple needle aspiration
or incision and drainage. Needle aspiration may be possible in the community setting by an appropriately trained
physician, but otherwise the patient should be transferred
to a specialist facility. There is little evidence to show any
difference between needle drainage and incision and drainage. Preferences are often linked to the experience of the
specialist. As with any deep neck infection, inadequate treatment carries the risk of further extension and propagation.
With any sepsis involving the upper aerodigestive tract,
airway symptoms should always be assessed for. The presence of stridor should warrant urgent specialist assessment.
Stridor is a noise produced by turbulent airflow though a
partially obstructed airway. It should be differentiated from
stertor, which is usually due to airway obstruction at the
level of the oropharynx. True stridor is an airway emergency, warranting an immediate referral to the ED where
appropriate management can be instigated.
Case study
AN eight-year year-old girl presents
to her GP with a five-day history
of increased redness, swelling and
discomfort around the left eye (figure 10). She is normally fit and well
with no premorbid history of note.
Her visual acuity is 6/6 in the right
and 6/18 on the left. There was a history of some coryzal symptoms about
two weeks ago. On examination she
has painful eye movements on the left
with mild exophthalmos.
The girl was referred urgently for
an ENT/ophthalmic opinion. A diagnosis of orbital cellulitis was made.
She was treated initially with IV antibiotics and nasal decongestants for
24 hours.
She failed to respond and returned
to her ENT specialist. Referral to CT
scanning was urgently arranged. The
CT demonstrated an orbital abscess.
The ENT specialist subsequently
drained the abscess surgically. She
rapidly improved following this, with
return of her acuity to normal.
How to Treat Quiz
Potential ENT emergencies
— 22 March 2013
1. Which TWO statements about acute otitis
externa (AOE) are correct?
a) A reduction of protective cerumen in the ear
canal is the key factor associated with acute
otitis externa development
b) Most otitis externa is due to Staphylococcus
aureus infection
c) Fungal otitis externa is typically the result of
altered flora in the ear canal, due to prolonged
antibacterial treatment
d) Cranial nerve abnormalities are red flags for
malignant otitis externa, with the facial nerve
being the most commonly affected
2. Which TWO statements about treatment of
acute otitis externa are correct?
a) There is good evidence that steroidantimicrobial drops are the most effective
topical therapy option for uncomplicated otitis
externa
b) Education about topical therapy administration,
keeping the ear dry and avoiding cotton
bud use are important for maximising the
effectiveness of therapy
c) If there is a co-existent perforation of the
eardrum in uncomplicated otitis externa, then
oral antibiotics should be chosen over topical
therapy
d) Cholesteatoma and osteomyelitis can mimic
otitis externa, and must be excluded in patients
with progressive or refractory symptoms
despite treatment
3. Which TWO statements about acute otitis
media are correct?
a) The most reliable clinical finding for detecting
otitis media is a diffusely red tympanic
membrane
b) The position of the tympanic membrane
can help distinguish between AOM (bulging
Figure 10: Redness and swelling around the girl’s left eye.
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tympanic membrane) and otitis media with
effusion (neutral or retracted tympanic
membrane)
c) Modifiable factors that can reduce the risk
of otitis media include avoidance of supine
bottlefeeding and passive smoke exposure
d) Since most acute otitis media is due to
bacterial organisms, oral antibiotic therapy is
routinely warranted to treat the condition
4. Which TWO statements about acute
mastoiditis are correct?
a) Mastoiditis is a rare but potentially serious
complication of acute otitis externa
b) Features to raise suspicion of mastoiditis
include persistent pain with nocturnal
exacerbation, postauricular swelling and a
tender mastoid process
c) MRI is the most useful imaging modality for
ruling out mastoiditis
d) Suspected mastoiditis warrants urgent ENT
review and often admission to hospital for IV
antibiotics
5. Which TWO statements about acute
rhinosinusitis are correct?
a) Nasal discharge with nasal obstruction and
facial pain or fullness should raise the suspicion
of acute rhinosinusitis rather than URTIs
b) Nasal decongestants, antihistamines,
saline nasal irrigation, mucolytics and
intranasal steroids are all suitable options
for symptomatic management in acute
rhinosinusitis
c) Due to the high risk of complications such as
orbital, intracranial or soft tissue involvement,
patients with acute rhinosinusitis should receive
oral antibiotics within 48 hours of symptom
onset
d) CT scanning is useful for distinguishing
between viral and bacterial infection in
complicated acute rhinosinusitis
6. Which TWO statements about periorbital
and orbital cellulitis are correct?
a) The incidence of blindness from orbital cellulitis
complicating acute rhinosinusitis is up to 1%
b) Proptosis, limitation of eye movements,
conjunctival chemosis or visual disturbance
associated with acute rhinosinusitis warrant
urgent specialist review to exclude orbital
cellulitis
c) Periorbital cellulitis is an immediately sightthreatening condition that always warrants
urgent hospital referral for IV antibiotics
d) Orbital pain, blepharal oedema and high fever
in a child with a history of acute rhinosinusitis
are suggestive of periorbital cellulitis
7. Which TWO statements about the aetiology
of epistaxis are correct?
a) Hypertension and anxiety are both directly
linked to the development of epistaxis
b) In young adult males presenting with epistaxis,
the possibility of an underlying juvenile
nasopharyngeal angiofibroma should be
considered
c) Red flags for a neoplastic cause for epistaxis
include bilateral nasal obstruction, superficial
otalgia and Caucasian ancestry
d) Complementary medicines such as ginseng
and ginkgo biloba have been linked to epistaxis
in some patients
8. Which TWO statements about the
management of epistaxis are correct?
a) In addition to pressure applied to the soft
cartilage of the nose, icing the forehead, nape
of neck and mouth may reduce stem blood
flow in epistaxis
b) Epistaxis usually arises from posterior, venous
vessels that cause bleeding that is easy to
control and poses little risk to the patient
c) Bilateral cautery for uncontrolled epistaxis must
be applied carefully, to avoid accidental septal
perforation
d) If nasal packing is required to control blood
flow, the pack should be inserted forcefully,
along the ceiling of the nasal cavity
9. Which TWO statements about tonsillitis
are correct?
a) It is important to perform a throat swab on
any patient with tonsillitis, to determine if the
cause is viral or bacterial
b) Prolonged symptoms in an older patient,
or one with a history of smoking or regular
alcohol use, should alert to the possibility of
underlying malignancy
c) The presence of significant symptoms
of tonsillitis with normal-looking tonsils
suggests acute infectious mononucleosis
d) Patients with infectious mononucleosisrelated tonsillitis should be advised to avoid
contact sport for six weeks
10. Which TWO statements about quinsy are
correct?
a) It is thought that quinsy may be related to
minor salivary gland pathology, rather than
extension from the tonsils
b) Quinsy is most commonly seen in
adolescents and young adults
c) Prior to abscess development, peritonsillar
cellulitis may be evident, which can be
treated with supportive measures and
antibiotics
d) Quinsy warrants prompt ENT review for
immediate tonsillectomy, under antibiotic
cover
CPD QUIZ UPDATE
The RACGP requires that a brief GP evaluation form be completed with every quiz to obtain category 2 CPD or PDP points for the 2011-13 triennium. You can
complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post or
fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.
how to treat Editor: Dr Steve Liang
Email: [email protected]
Next week Polymyalgia rheumatica is characterised by stiffness and an aching pain, predominantly in the shoulder girdle, neck, and pelvic girdle. It is particularly sensitive to corticosteroids, but
complications can arise from such therapy. The next How to Treat investigates diagnosis, treatment and potential complications of this disabling condition. The authors are Professor Lyn March, Liggins
Professor of Rheumatology and Musculoskeletal Epidemiology, University of Sydney; senior staff specialist in rheumatology, Royal North Shore Hospital, St Leonards; and Dr Premarani Sinnathurai,
rheumatology advanced trainee, Royal North Shore Hospital, St Leonards, NSW.
30
| Australian Doctor | 22 March 2013
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