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 • • • Should not be routinely offered AOM is self limiting, serious complications are rare. Strategy of watchful waiting, delayed prescriptions and paracetamol/ibuprofen • Useful in those under 2, systemically unwell, recurrent infections • • Ist line –Amoxicillin – 5 days Alt –Erythromycin 2nd line Clarithromycin • Reduction in middle ear effusions 3 months post treatment • What antibiotics do not affect –recurrence rate, referral rate, effusions at 1 month • • Weak evidence for decreasing severity and duration of symptoms. Except in children under2. Delayed prescriptions. Secretory Otitis Media • Unilateral serous effusion in adult is nasopharyngeal tumour until proven otherwise • Results in conductive hearing loss, most common cause of hearing loss in children. Also impairments of speech, language and cognitive development. • 50% resolve in 3 months, 95% in 1 year. 5% have bilateral hearing loss at 1 year • 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. • Always refer children with Downs syndrome/ cleft palate(affects 92-97% in first year) Secretory OM - Treatment • Children – 50% resolve in 6 weeks • • • • 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 • Adults – refer for nasopharynx examination • • 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 • Chronic Otitis Media • Otorrhoea for >1 month • 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) • Complications of unsafe COM – acute mastoiditis, meningitis, extra dural abscess, brain abscess, subdural abscess, labyrinthitis, lateral sinus thrombosis, facial nerve paralysis, petrositis. • • • • • 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 • Unsafe ear must be rendered harmless- surgery - radical mastoidectomy / tympanoplasty Hearing testing/screening in young children • Permanent hearing loss 1 in 1000 newborns, 9-16 yrs 2 in 1000 • • 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. • School entry hearing test – pure tone sweep test • Other tests that can be done by audiology, Toy test, pure tone audiometry, tympanometry. • 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 • Rapid loss of hearing occurring suddenly or over a period up to 72 hours. Can be associated with tinnitus and vertigo. 85% idiopathic • More than 30db loss in three connected frequencies • A medical or ENT emergency • Common between ages 30-60 • Causes include infections, trauma, immunological, toxins, ototoxic drugs, MS, Menieres • Investigations – Audiogram, MRI brain, Bloods • Hearing returns to near normal 70%. Treatments – antivirals, steroids Cochlear implants • • • • • 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 • 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. • Vertigo is not synonymous with dizziness. Only 30% people with dizziness will have vertigo. • • Dizziness should be categorised into 4 subtypes Vertigo, Pre-syncope, Disequilibrium, light headedness • Is central (brain stem, cerebellum) or peripheral (inner ear ) • • Central causes – MS, Acoustic neuroma, cerebral tumour, HI, epilepsy Peripheral causes – Menieres, Viral labyrinthitis, BPV, Middle ear disease, Otosclerosis, Trauma, Drugs Benign Positional Vertigo • Brief recurrent attacks of vertigo provoked by changes in head position with respect to gravity. • One of the most common causes • 30% vertigo referrals • Often caused by rolling over in bed, bending over, looking upwards • Affects the semicircular canals in the inner ear • • • Treatment – self limiting – observe. Avoid provocative positions Medical – anti emetics or vestibular sedatives. Particle repositional manoeuvers (Eply) Surgery- rarely done Menieres Disease • • • • • • • • 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) • 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 • • • • 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 • Most cases are benign • 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 • • • Referral/Treatment for tinnitus • • • • • • • 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 • • • • • Treatments Counselling/relaxation/cbt Hearing aids Sound therapy – maskers, music Medical – sedatives/antidepressants. Surgery limited Rhinosinusitis • • • • • • • • • • 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) • 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 • Infection -viral (common cold) -bacterial – strep Pneumonia/ haemophilus, moraxella – mucopurulent secretions -fungal – 4 types- inc fulminant type in immunocompromised • Vasomotor - imbalance of autonomic system. Parasympathetic action inc nasal gland secretion , congestion of nasal lining by altered vascular tone • Hormonal – emotion, pregnancy, puberty, hypothyroidism Drug induced – aspirin, OC pill, B blockers, ACE. Overuse of topical nasal decongestants sinex Rhinosinusitis (3) • Investigations - allergy tests – skin prick, RAST -FBC/ eosinophils, immunoglobulin's -test children for CF -MC&S - Plain xr has no use. CT sinuses • Sinister signs – Unilateral symptoms, , bloody discharge, crusting, cacosmia, systemic symptoms • Treatment – – – – – – – 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 • Antibiotics unnecessary for most patients – self limiting and resolves within a week in 85% of cases whether Strep infection or not • Serious complications are rare • 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 • • • • 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 • Be aware of underlying psychological influences in patients presenting with sore throats • Throat swabs should not be carried out routinely • Analgesia – ibuprofen for adults, Paracetamol 1st line in children • Echinacea not recommended for prevention • Antibiotics should not be given specifically to prevent the development of acute glomerulonephritis or rheumatic fever. • Referral criteria for tonsillectomy in adults. (SIGN) Watchful waiting better in children. – – – – – 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 • • Oral malodour is common Bad breath on wakening is common and not abnormal. • 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 • 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. • Management -good oral hygiene - avoiding certain foods and drinks -antimicrobial toothpastes and mouthwashes – chlorhexidine, hydrogen peroxide - antibiotics of little use psychological evaluation Snoring • • 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. • Excessive snoring may be secondary to conditions causing an encroachment on the pharynx conditions causing nasal obstruction • • 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 • 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 • Head and Neck Cancer • • • • • • • • • • • • • 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) • 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