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E.N.T. – (Illustrated!)
Dr Katie Bleksley GPST1
Aims
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To recognise and proficiently manage
common ear conditions presenting to GP
Be aware of the some of the red flags to look
out for wrt ear problems.
Objectives
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To be able to recognise infections of the ear: OE, furunculosis, HZV,
OM. Understand the use of antibiotics in treating ear infections
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Understand what to do with foreign bodies in the ear, and which
substances require urgent removal.
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Understand the risks/complications of ear trauma and how
lacerations/haematomas and bites should be managed.
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Assess deafness and appreciate the importance of sudden deafness.
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Brief coverage of DDx for vertigo and tinnitus
Otalgia
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Primary
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Otitis Externa
Otitis Media
Furuncle
Secondary/Referred pain
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No obvious cause
TMJ
Dental
Throat pathology
Sinuses
LNs
Facial Nerve
The normal TM
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Long process of the incus
G
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Handle of the malleus
D
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pars tensa
A
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Long arm of the malleus
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pars flaccida
E
F
Otitis Externa
Otitis Externa
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Features
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Pain – on movement of pinna
Itching
Deafness
Swollen / Inflamed canal
Discharge / Debris
Otitis Externa
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Management
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Aural toilet needed in all but
mild cases
Keep ear dry
Topical Antibiotic / Steroid:
Analgesia
Preventative advice: keep dry
when swimming/bathing, no FBs
in ear..
Otitis Externa: ABx
1.
Locorten vioform (flumethasone and clioquinol and iodine) 2-3drops
bd 7-10days
2.
Sofradex (dex and framycetin and gramicidin) 2-3drops tds/qds or
Otomize (dex and neomycin): 1 spray tds or
Ciloxan eye drops (cipro 0.3%)
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Treat for > 7days
Swab before starting any second line treatment (?candida/aspergillus)
and check sensitivities
For fungal OE use Clotrimazole 1% (canesten) drops tds for 14d after
the infection has resolved.
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Caution, OE in diabetics….
Caution – Diabetics – Malig OE
Malignant OE
 Infection of the EAC with pseudomonas
 Infection can spread to soft tissues and
bones
Furunculosis
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Infection of hair follicles in outer third of ear
canal.
Severe pain
O/E: Boil in the ear canal
Need to r/o DM
Rx: analgesia, gentisone HC drops 3 drops
qds 7 days. Oral fluclox 7days if cellulitis
Ramsey Hunt Synd (HZV)
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Severe pain in ear precedes facial palsy
vesicles in the EAC/around the ext ear and
on the soft palate.
+/- dizziness / vertigo
Aciclovir 800mg 5x/day for 1 wk if Dx <24h
Postherpetic neuralgia can be a problem
Otitis Media
Acute Otitis Media
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Infection of the middle ear.
Bacterial/viral but impossible to distinguish
clinically
Presentation: Pain, Deafness, URTI Sxs
O/E: Red, Bulging TM, +/- perforation and
discharge
Acute Otitis Media
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Management
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Analgesia
Consider oral antibiotics: amoxil tds (pen all.: erythro qds) for
5days if….
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Age <2 with bilat acute OM
If perforation present
?? If >3days duration ??
If sig. comorbidities
Or give a delayed script
Refer ENT if..
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Signs of complications/spread of infection
OM recurs/fails to respond give augmentin and refer.
acute perf. fails to heal within 1 month.
Otitis Media – red flags 1
SIGNS OF COMPLICATIONS
- mastoid tenderness / swelling
- sudden deafness
- dizziness with nystagmus
- malaise / headache
Mastoiditis
Refer Immediately
Otitis Media – red flags 2
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LOOK FOR A PERFORATION IN ANY
DISCHARGING EAR
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Acute central perf. is okay (but needs review in 1
month),
Attic perf. suggests cholesteatoma and merits
referral.
If you can’t visualise the drum review the patient.
Tympanic Perforation
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Left TM central perforation
Attic perforation with cholesteatoma
Problematic OM
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Recurrent acute OM:
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Trimethoprim 1-2mg/kg od for 3months
Chr supp. OM
If ear d/c in presence of chr (central) perforation treat as OE:
– Gentisone HC 2 drops qds or Cipro 0.3% eye drops 2 drops
tds
– Red flags: persistent discharge despite the above or
deafness/vertigo/attic perf. -> Refer ENT.
Ear Injuries
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Pinna Lacerations
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Human Bites
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Refer all but the most trivial
Refer all
Haematoma of the Pinna
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Refer urgently to prevent cartilage necrosis
Ear Injuries
Deafness
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Temporary deafness is common due to OM
Persistent hearing problems:
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Hx and Ex
pay attention to developmental assessment in children,
take seriously and refer for audiology (formal audiometry
possible if >3y)
Refer to ENT if:
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Sudden onset deafness
Conductive hearing loss with no obvious cause
Asymmetrical deafness
Sudden onset SN deafness is an ENT emergency
Persistent Deafness - causes
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Conductive:
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Wax / FB
OME
Chr supp OM and cholesteatoma
Otosclerosis (bilat may be a FH, refer for surgery)
Sensorineural:
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Presbyacusis (gradual bilat symm high freq loss in ppl >50y)
Acoustic neuroma (unilat/asymmet deafness)
Wax in the ear
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Olive oil tds for 5d
microsuction
Foreign Bodies in the Ear
What needs urgent removal?
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Batteries
Biological material (eg dead insect*)
Signs of secondary infection
Urgent = same day
Non-urgent = within 3days
* insects can be drowned in oil and then suctioned out
OME
OME
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Hearing loss, +/- earache, developmental delay
Dull retracted drum with visible peripheral vessels,
fluid level/air bubbles may be visible behind the drum
75% resolve in <3months
Refer if persistent esp if causing speech/lang delay
Grommets: can swim/bathe, but avoid diving. If
dicharge from ear treat with aural toilet and
AB/steroid drops as for OE.
Tinnitus
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Severe tinnitus affects 2% of pop
DDx: may accompany hearing loss, meniere’s, noise
exposure, head injury, HTN, drugs (loop diuretics,
TCAs, aminoglycosides, aspirin, NSAIDs) but often
no cause found.
Ix: audiometry if deafness
Rx: reassure, +/- refer to hearing therapist and
tinnitus support group, masking.
Unilat tinnitus (?acoustic neuroma), objective/pulsatile tinnitus (?vasc
malformation)
Vertigo – Hx gives Dx, Neuro Ex (esp
cerebellar ex) essential to r/o pathol
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Secs-mins : BPPV (postural, dix hallpike +ve)
Reasssure. Don’t give labyrinthine sedatives.
Epley’s, usually self limiting,
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Mins-hours: meniere’s (vertigo, SN deafness, tinnitus, aural fullness)
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overdiagnosed so refer all suspected cases to ENT to confirm the diagnosis
>24h
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peripheral lesion: trauma / viral labyrinthitis
(URTI, sudden onset vertigo, n+v, prostration, hearing normal, TM normal). Rx =
cyclizine/prochlorperazine
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Central pathol: CVA/tumour/MS…
On neck extension and rotation in elderly: VB insuff
Summary
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We have covered:
– infections of the ear: OE, furunculosis, HZV, OM and know
when ABx are appropriate plus other measures which
maybe required.
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Understand which foreign bodies require urgent removal.
–
Understand the risks/complications of ear trauma and how
lacerations/haematomas and bites should be managed.
–
Know how to assess/investigate deafness and understand
that sudden deafness merits urgent ENT review.
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Brief insight into the common DDx for tinnitus and vertigo.
Questions ?