Transcript ENT - My Surgery Website

E.N.T. – (Illustrated!)
Dr Katie Bleksley GPST1
Aims


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

To be able to recognise infections of the ear: OE, furunculosis, HZV,
OM. Understand the use of antibiotics in treating ear infections

Understand what to do with foreign bodies in the ear, and which
substances require urgent removal.

Understand the risks/complications of ear trauma and how
lacerations/haematomas and bites should be managed.

Assess deafness and appreciate the importance of sudden deafness.

Brief coverage of DDx for vertigo and tinnitus
Otalgia

Primary
–
–
–

Otitis Externa
Otitis Media
Furuncle
Secondary/Referred pain
–
–
–
–
–
–
No obvious cause
TMJ
Dental
Throat pathology
Sinuses
LNs
Facial Nerve
The normal TM

Long process of the incus
G

Handle of the malleus
D

pars tensa
A

Long arm of the malleus

pars flaccida
E
F
Otitis Externa
Otitis Externa

Features





Pain – on movement of pinna
Itching
Deafness
Swollen / Inflamed canal
Discharge / Debris
Otitis Externa

Management





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%)

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.


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





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)





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




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

Management


Analgesia
Consider oral antibiotics: amoxil tds (pen all.: erythro qds) for
5days if….
–
–
–
–
–

Age <2 with bilat acute OM
If perforation present
?? If >3days duration ??
If sig. comorbidities
Or give a delayed script
Refer ENT if..
–
–
–
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

LOOK FOR A PERFORATION IN ANY
DISCHARGING EAR
–
–
–
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

Left TM central perforation
Attic perforation with cholesteatoma
Problematic OM

Recurrent acute OM:
–

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

Pinna Lacerations


Human Bites


Refer all but the most trivial
Refer all
Haematoma of the Pinna

Refer urgently to prevent cartilage necrosis
Ear Injuries
Deafness


Temporary deafness is common due to OM
Persistent hearing problems:
–
–
–

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:
–
–
–
Sudden onset deafness
Conductive hearing loss with no obvious cause
Asymmetrical deafness
Sudden onset SN deafness is an ENT emergency
Persistent Deafness - causes

Conductive:
–
–
–
–

Wax / FB
OME
Chr supp OM and cholesteatoma
Otosclerosis (bilat may be a FH, refer for surgery)
Sensorineural:
–
–
Presbyacusis (gradual bilat symm high freq loss in ppl >50y)
Acoustic neuroma (unilat/asymmet deafness)
Wax in the ear


Olive oil tds for 5d
microsuction
Foreign Bodies in the Ear
What needs urgent removal?





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





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




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

Secs-mins : BPPV (postural, dix hallpike +ve)
Reasssure. Don’t give labyrinthine sedatives.
Epley’s, usually self limiting,
–

Mins-hours: meniere’s (vertigo, SN deafness, tinnitus, aural fullness)
–

overdiagnosed so refer all suspected cases to ENT to confirm the diagnosis
>24h
–
peripheral lesion: trauma / viral labyrinthitis
(URTI, sudden onset vertigo, n+v, prostration, hearing normal, TM normal). Rx =
cyclizine/prochlorperazine
–

Central pathol: CVA/tumour/MS…
On neck extension and rotation in elderly: VB insuff
Summary

We have covered:
– infections of the ear: OE, furunculosis, HZV, OM and know
when ABx are appropriate plus other measures which
maybe required.
–
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.
–
Brief insight into the common DDx for tinnitus and vertigo.
Questions ?