Download Common Problems in ENT

Common Problems in ENT
DR NEIL A L SMITH
MSc MBBS DRCOG MRCGP MFOM
Consultant in Occupational Medicine, AGH
and GP Silsden Group Practice
Antibiotics in acute otitis media
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Should not be routinely offered
AOM is self limiting, serious complications are rare.
Strategy of watchful waiting, delayed prescriptions and paracetamol/ibuprofen
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Useful in those under 2, systemically unwell, recurrent infections
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Ist line –Amoxicillin – 5 days Alt –Erythromycin
2nd line Clarithromycin
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Reduction in middle ear effusions 3 months post treatment
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What antibiotics do not affect –recurrence rate, referral rate, effusions at 1 month
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Weak evidence for decreasing severity and duration of symptoms. Except in children under2.
Delayed prescriptions.
Secretory Otitis Media
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Unilateral serous effusion in adult is nasopharyngeal tumour until proven otherwise
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Results in conductive hearing loss, most common cause of hearing loss in children. Also
impairments of speech, language and cognitive development.
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50% resolve in 3 months, 95% in 1 year. 5% have bilateral hearing loss at 1 year
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Referral if marked hearing difficulty, indistinct speech or delayed language development,
repeated ear infections, recurrent urtis/nasal obstruction, behaviour problems, poor
educational progress and balance difficulties/tinnitus.
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Always refer children with Downs syndrome/ cleft palate(affects 92-97% in first year)
Secretory OM - Treatment
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Children – 50% resolve in 6 weeks
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Treatments not recommended – antibiotics, antihistamines, decongestants, steroids,
homeopathy, cranial osteopathy, acupuncture, dietary modification, immunostimulants,
massage
Hearing aids can be offered –bil OME and hearing loss
Otovent
Surgical treatment- adenoidectomy, myringotomy and grommet insertion
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Adults – refer for nasopharynx examination
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OME and hearing loss should be confirmed over 3 months before intervention
Surgery if persistent bil OME over 3 months with hearing loss or impact on development,
social or educational status.
Role of grommets – unclear –effects diminish over 1 year/risk of tympanosclerosis
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Chronic Otitis Media
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Otorrhoea for >1 month
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Two types
– Safe tubotympanic or mucosal disease
– Unsafe – attico antral or bony disease - if headache/earache/vertigo/facial weakness present
this may suggest an intracranial problem – urgent referral
Predisposing factors
-otitis media not promptly treated
- inappropriate or inadequate antibiotic therapy
-sepsis upper airway
- lowered resistance to infection
- virulent infection- measles
Safe disease – Discharge is mucoid/mucopurulent ,perforation often central in tympanic
membrane. Often hearing impairment- conductive .
Unsafe disease- Discharge is foul smelling continuous - due to cholesteatoma formation –
perforation in attico-antral area. Bones are affected plus there is proximity to a number of
important structures
Chronic Otitis Media (2)
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Complications of unsafe COM – acute mastoiditis, meningitis, extra dural abscess, brain
abscess, subdural abscess, labyrinthitis, lateral sinus thrombosis, facial nerve paralysis,
petrositis.
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Treatment – of safe ears – eliminate discharge and assist hearing deficit.
aural toilet/ keep ear dry
Treat infection in upper resp tract
Antibiotic drops – quinolone antibiotic drops
Once dry – inactive chronic OM
Hearing loss – HA/reconstruct the drum - myrigoplasty
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Unsafe ear must be rendered harmless- surgery - radical mastoidectomy / tympanoplasty
Hearing testing/screening in young
children
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Permanent hearing loss 1 in 1000 newborns, 9-16 yrs 2 in 1000
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Neonatal screening –routine since 2006
For babies not requiring SCBU –AOAE test (Automated otoacoustic emissions test) If failed
move on to Automated auditory brainstem responses test , AABR.
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School entry hearing test – pure tone sweep test
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Other tests that can be done by audiology, Toy test, pure tone audiometry, tympanometry.
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Who to refer – children with suspected hearing loss, parental concern, didn't pass screening
test, after meningitis/septicaemia, after temporal bone fracture, delayed speech or language,
Ototoxic drugs, Downs syndrome, cleft palate, family history of childhood S/N loss, SCBU
treatment, jaundice, congenital infection, neurodevelopment disorders.
Sudden Sensori-neural hearing loss
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Rapid loss of hearing occurring suddenly or over a period up to 72 hours. Can be associated
with tinnitus and vertigo. 85% idiopathic
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More than 30db loss in three connected frequencies
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A medical or ENT emergency
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Common between ages 30-60
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Causes include infections, trauma, immunological, toxins, ototoxic drugs, MS, Menieres
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Investigations – Audiogram, MRI brain, Bloods
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Hearing returns to near normal 70%. Treatments – antivirals, steroids
Cochlear implants
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Used in patients with profound hearing loss – to stimulate residual nervous tissue
Has internal and external components
Internal – Body containing a decoder and a magnet, and a band of electrodes inserted into cochlea –
which deliver sounds of varying pitch and loudness.
External – microphone worn behind ear, speech processor and receiver
Indications
bil profound sensorineural hearing loss (hearing only sounds that are 90 db or louder at frequencies of 2 &
4 K Hz without aids)
no benefit from other hearing aids – for at least 3 months
no surgical contraindication
patient must be well motivated.
full assessment by multidisciplinary team
Bilateral simultaneous cochlear implantation is recommended especially for children or adults who are blind or
have other disabilities.
Vertigo
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Is an hallucination of movement of the environment about the patient or of the patient with
respect to the environment caused by disorders of the brain stem or labyrinth.
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Vertigo is not synonymous with dizziness. Only 30% people with dizziness will have vertigo.
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Dizziness should be categorised into 4 subtypes
Vertigo, Pre-syncope, Disequilibrium, light headedness
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Is central (brain stem, cerebellum) or peripheral (inner ear )
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Central causes – MS, Acoustic neuroma, cerebral tumour, HI, epilepsy
Peripheral causes – Menieres, Viral labyrinthitis, BPV, Middle ear disease, Otosclerosis,
Trauma, Drugs
Benign Positional Vertigo
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Brief recurrent attacks of vertigo provoked by changes in head position with respect to
gravity.
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One of the most common causes
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30% vertigo referrals
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Often caused by rolling over in bed, bending over, looking upwards
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Affects the semicircular canals in the inner ear
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Treatment – self limiting – observe. Avoid provocative positions
Medical – anti emetics or vestibular sedatives. Particle repositional manoeuvers (Eply)
Surgery- rarely done
Menieres Disease
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Endolymphatic hydrops
Episodic attacks of vertigo, hearing loss, tinnitus – lasting many hours. Vertigo is often severe
accompanied by nausea and vomiting. Sensorineural deafness initially fluctuant, later progressive.
Tiinitus often worse during attacks.
May be feeling of fullness or pressure in ear and nystagmus away from affected ear.
Attacks occur intermittently in clusters – anything from daily to yearly
After attack patients are exhausted, sleepy, off balance
Usually affects one ear, both ears 15% M=F 35-55
Cause unknown. Often overdiagnosed.
Investigations
– -audiometry
- ENG (electronystagmography) – Electrodes near eyes, warm and cold water introduced into
ear canal. Measurement of eye mvmts to test balance system. Balance function reduced in
affected ear
- Auditory brain stem response
- MRI to exclude acoustic neuroma
- Syphillis serology
Menieres disease (2)
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Treatment
– Medical – acute – antiemetics – prochlorperazine , cinnarazine
– Longer term – vasodilators – Betahistine, Nicotinic acid
– Salt restricted diet, diuretics
Surgery - Decompression of the endolymphatic sac and vestibular neurectomy.
- Labyrinthectomy –left with no hearing
Tinnitus
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An unwanted auditory perception of internal origin which is usually localised and may rarely
heard by others
Ringing, buzzing, hissing, roaring, clicking
Can vary form soft to unbearable
Can be unilateral or bilateral
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Most cases are benign
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Unilateral is more serious , as is pulsatile tinnitus and tinnitus associated with unilateral
otological symptoms - need to exclude acoustic neuroma
Classified as objective or subjective
Objective – vascular bruits, muscle clonus, respiratory, cochlear – can be heard by examiner
as well
Subjective – Presbycusis, wax, secretory OM, otosclerosis, Menieres, loud noise, drugs
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Referral/Treatment for tinnitus
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Unilateral or pulsatile tinnitus
Tinnitus with unilateral hearing impairment, sudden or fluctuating hearing loss, vertigo and
imbalance
Severe distressing tinnitus
Tinnitus causing problems in noisy backgrounds or in sound localisation
Tinnitus associated with systemic disease or neurological problems
Objective tinnitus
Tinnitus with hearing loss where a HA may help
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Treatments
Counselling/relaxation/cbt
Hearing aids
Sound therapy – maskers, music
Medical – sedatives/antidepressants. Surgery limited
Rhinosinusitis
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Inflammation of the lining of the nose and sinuses
Two or more of symptoms- nasal blockage/congestion, discharge, anterior or PND, facial pain
or pressure and loss of smell.
Up to 12 weeks acute, >12 weeks chronic.
Many causes – mostly allergic. Also infective(viral, bacterial, fungal) vasomotor, hormonal,
drug induced.
Nasal polyposis – part of spectrum, 4% population. Male over 50, bilateral
Complications – periorbital cellulitis, intracranial infection, cavernous sinus thrombosis,
meningitis, extra and sub dural, frontal lobe abscess.
Treatment – analgesia, topical decongestant, topical steroid, antibiotics
Allergy very common – seasonal /perennial
Frequent disabling symptoms, not responding to treatment- refer
Surgery (FESS) for right case with experienced surgeon gives good results
Rhinosinusitis (2)
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Allergic rhinosinusitis – perennial, seasonal, occupational
-Perennial – frequently HDM. Also cat, dog dander,
-Seasonal – pollens – grass, tree, weed.
-Occupational – latex, flour dust, wood dust
-IgE mediated allergy leads to mucosal oedema
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Infection
-viral (common cold)
-bacterial – strep Pneumonia/ haemophilus, moraxella – mucopurulent secretions
-fungal – 4 types- inc fulminant type in immunocompromised
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Vasomotor - imbalance of autonomic system. Parasympathetic action inc nasal gland
secretion , congestion of nasal lining by altered vascular tone
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Hormonal – emotion, pregnancy, puberty, hypothyroidism
Drug induced – aspirin, OC pill, B blockers, ACE. Overuse of topical nasal decongestants sinex
Rhinosinusitis (3)
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Investigations
- allergy tests – skin prick, RAST
-FBC/ eosinophils, immunoglobulin's
-test children for CF
-MC&S
- Plain xr has no use. CT sinuses
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Sinister signs – Unilateral symptoms, , bloody discharge, crusting, cacosmia, systemic
symptoms
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Treatment
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There are some good algorithms in ABC of ENT.
Analgesia, decongestants
Allergy avoidance, topical steroids, antihistamines
Nasal douches
Antibiotics
Referral, ct scan
Surgery -FESS
Managing sore throats
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Antibiotics unnecessary for most patients – self limiting and resolves within a week in 85% of cases
whether Strep infection or not
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Serious complications are rare
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Centor criteria useful to predict patients at higher risk of Group A beta haemolytic strep and
complications
-tonsillar exudate
-tender ant cervical LNs
-absence of cough
-HO fever
3 out of 4 features increases risk of Quinsy from 1:400 to 1:60
Antibiotic – Pen V 500mg qds 10 days. Alt – Erythromycin.
A prescription means they're more likely to attend again. Use of delayed presciption if getting
worse after 3 days
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Otherwise offer advice, reassurance, analgesics.
Always ask why they came – as most patients with a sore throat don’t see a doctor.
Other points about sore throats and
referral for Tonsillectomy
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Be aware of underlying psychological influences in patients presenting with sore throats
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Throat swabs should not be carried out routinely
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Analgesia – ibuprofen for adults, Paracetamol 1st line in children
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Echinacea not recommended for prevention
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Antibiotics should not be given specifically to prevent the development of acute
glomerulonephritis or rheumatic fever.
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Referral criteria for tonsillectomy in adults. (SIGN) Watchful waiting better in children.
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The sore throats are due to acute tonsillitis
The episodes of sore throat are disabling and prevent normal functioning
Seven or more well documented, clinically significant, adequately treated sore throats in the preceding year.
Five or more such episodes in each of the preceding two years
Three or more such episodes in each of the preceding three years.
Halitosis
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Oral malodour is common
Bad breath on wakening is common and not abnormal.
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Genuine halitosis
-Physiological
-Pathological – Oral causes
- Non oral causes
Pseudo halitosis- not perceived by others
Halitophobia
Oral causes
-commonest cause is poor oral hygiene
-other oral causes include acute necrotising ulcerative gingivitis, acute gingivitis,
periodontitis, pericoronitis, dry socket, oral ulceration and oral malignancy
Halitosis
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Non oral causes
-respiratory disease – foreign bodies, sinusitis, tonsillitis, lung disease
- gastrointestinal disease – diverticulum, GI reflux, pyloric sternosis, HP infection
- systemic disease – hepatic failure, renal failure, diabetic ketoacidosis, leukaemia
- drugs – solvents, amphetamines, disulphiram, nitrates, cytotoxic agents
Transient halitosis - tobacco, alcohol, foods- onion, garlic, betel nut products.
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Management
-good oral hygiene
- avoiding certain foods and drinks
-antimicrobial toothpastes and mouthwashes – chlorhexidine, hydrogen peroxide
- antibiotics of little use
psychological evaluation
Snoring
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Common – prevalence of up to 40%
The area where the tongue and upper throat meet the soft palate and uvula is the collapsible part
of the airway . Snoring occurs when these come into contact with each other when breathing.
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Excessive snoring may be secondary to
conditions causing an encroachment on the pharynx
conditions causing nasal obstruction
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May be associated with sleep apnoea, but only 4%
Aetiology – age, men, obesity, craniofacial abnormalities, adenotonsillar hypertrophy, obstruction
of the nasal airway – turbinate, septum, polyps. Smoking, alcohol
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Treatment – ear plugs/ sleep on side, weight loss
Lifestyle changes
Avoid sedative medications
intra oral devices
Nasal surgery, uvulopalatopharyngoplasty, laser assisted uvulopalatoplasty
Adeno tonsillectomy in children
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Head and Neck Cancer
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Increasing as population ages (27% increase from 1995 to 2003)
Males and deprivation
Squamous cell carcinoma of the mucous membrane is the most common cancer
3rd most common in men, 4th in women.
Not exclusively smoking and alcohol related. Occurring increasingly in men in their 40s
onwards
Other risk factors- betel nut, poor dental hygiene infective agents (HIV, HPV, Herpes)
Occupational exposure to hard wood (sinuses)
Mortality rate 50%
Most common sites- oral cavity and larynx (70%)
Other sites – Nasal cavity, pharynx , middle ear, salivary , thyroid,.
Lymphomas and secondaries from breast, lung, kidney and prostate occur.
Oral cavity cancer presents most commonly on the lateral border of the tongue with
ulceration and pain.
Laryngeal cancer presents with painless hoarseness because of the involvement of the vocal
cord (glottis)
Second primary head and neck cancers occur – 4%/year
Head and Neck Cancer (2)
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NICE guidelines for urgent referral
-an unexplained red or white patch on the oral mucosa- painful swollen and/or bleeding
-an unexplained ulceration or mass of the oral mucosa for more than 3 weeks
-unexplained tooth mobility > 3 wks
-persistent hoarseness for more than 3 weeks with a normal CXR
-unexplained lump in the neck, recently appeared or a lump that has changed over a period
of 3 weeks
-persistence of an unexplained swelling of the parotid or submandibular gland
-an unexplained or persistent sore or painful throat
-a persistent or unexplained pain in the head and neck area for more than 4 weeks associated
with otalgia (with normal otoscopy)
Audiograms