SSSM: COMMON PROBLEMS IN ENT

PETER TAOINTERN

OUTLINE

• Nose– Epistaxis– Chronic Rhinosinusitis

• Throat– Peritonsillar Abscess– Tonsillitis

• Ear– Hearing Loss– Vertigo

• Head & Neck

ACUTE EPISTAXIS

• Nasal mucosa: rich blood supply, anastomoses between internal and external carotid supply

• Causes– Trauma– Chronic irritation e.g. sinusitis, steroid spray abuse– Coagulopathies– Anatomical abnormalities– Vascular malformation– Tumour

• 90% anterior (capillary, venous in origin)• 10% posterior (arterial in origin) – may present as haemoptysis, melaena,

haematemesis etc.

MANAGEMENT

• D R S A B C D• Anterior vs Posterior• Achieve Haemostasis

– Pressure– Ice– Co-Phenylcaine/Cocaine– Cauteurisation– Packing– Balloon– Embolisation– Antibiotics (Flucloxacillin)

• Complications

CHRONIC RHINOSINUSITIS

• Inflammation involving nasal mucosa and paranasal sinuses lasting longer than 12 weeks

• Criteria– Anterior and/or posterior mucopurulent drainage– Nasal obstruction– Facial pain, pressure and/or fullness– Decreased sense of smell

• Subtypes– With nasal polyposis– Without nasal polyposis– Allergic fungal rhinosinusitis

MANAGEMENT

• Medical Therapy– Nasal lavage – Normal Saline– Nasal glucocorticoid sprays– Oral glucocorticoid– Antibiotics (Augmentin, Doxycycline)– Antihistamines

• Surgical Therapy– Functional Endoscopic Sinus Surgery (Category of Operation)

• Complications– Recurrence– Epistaxis– (Very Rare) Blindness (Retrobulbar Haemorrhage)

WITHOUT POLYP WITH POLYP ALLERGIC FUNGAL

Untreated Oral Steroids Oral Steroids Surgery

Oral Antibiotics

Maintenance Topical Steroids Topical Steroids Oral Steroids

Steroid Instillation Steroid Instillation Steroid Instillation

+/- Antihistamine +/- Antihistamine +/- Oral Antifungals

+/- Antileukotriene

TONSILLITIS/TONSILLECTOMY

• Indications – controversial in adult population• Management

– Analgaesia– +/- Antibiotics (GAS coverage)

• Tonsillectomy– Contraindications – Velopharyngeal, Acute Tonsillitis– Knife vs Unipolar vs Bipolar– Complications: Haemorrhage, Haemorrhage, Haemorrhage, Pain

(Otalgia)– Post tonsillectomy haemorrhage requires representation– Management involves vasoconstriction, pressure

PERITONSILLAR ABSCESS

• Risk factors– Tonsillitis– Smoking

• Symptoms– Trismus– Dysphagia– Systemically Unwell

• Management– Drainage (Needle Aspiration vs Surgery)– Antibiotics (Not amoxicillin)– Analgaesia– Tonsillectomy (Acute vs Chronic)– +/- Glucocorticoids

• Complications – Recurrence (10-15%)

HEARING LOSS

• Sensorineural vs Conductive vs Mixed

CAUSES

CONDUCTIVE SENSIRONEURALExternal Ear Congenital Bilateral Noise Induced

Foreign Body Presbycusis

Tumour Autoimmune

Infection Drug Mediated

Middle Ear Trauma Unilateral Trauma

Infection Perilymphatic Fistula

Cholesteatoma Acoustic Neuroma

Otosclerosis Meniere’s Disease

Glomus Tumour Idiopathic

HISTORY/EXAMINATION

• History– Onset/Time Course – Acute vs Chronic, Bilateral vs Unilateral– Aggravating/Relieving Factors – – Associated Symptoms – Tinnitus, Vertigo, Pain, Discharge– Trauma – Physical, Barotrauma, Noise Induced– Medications– Past History – Stroke Risk Factors

• Examination– Otoscopy– Whispered Voice– Renee & Weber Tests– Pneumoscopy/Tympanoscopy

INVESTIGATION

• Special Tests– Pure tone audiogram– Speech audiometry– Tympanogram

• Imaging– CT Temporal Bone– +/- MRI Auditory Canal

CHOLESTEATOMA

• Acquired vs Congential• Locally invasive overgrowth of epithelial cells – not cholesterol• Sx: Unilateral Conductive Hearing Loss, Discharge (often discoloured and

malodorous)• Cx: Local invasion, CN VII palsy, Mastoiditis, Meningitis• Management:

– Antibiotics– CT Temporal Bone– Surgery – Canal Wall Up vs Down

• Follow Up – Local recurrence, Ossiculoplasty

VERTIGO

CAUSESSeconds BPPV

Perilymphatic Fistula

Migrainous

Hours Meniere’s

Vertebrobasilar TIA

Days Vestibular Neuritis

Cerebellar Stroke

Multiple Sclerosis

PERIPHERAL CENTRAL

Unidirectional Nystagmus

Nystagmus can reverse direction

Horizontal +/- Torsional

Any direction

Suppressed with visual fixation

Not suppressed with fixation

Hearing Loss/Tinnitus Neurological Signs

Gait preserved Severe postural instability

HISTORY/EXAMINATION

• Vertigo vs Dizziness• Peripheral vs Central• History

– Onset/Time Course – Seconds, Hours, Days– Aggravating/Relieving Factors – Movement, Tullio’s Phenomenon– Associated symptoms – Neurology, Nystagmus

• Examination– Assess as per hearing loss– Neurological examination– Dix-Hallpike Test

• Investigations– CTB

MANAGEMENT

• Non-pharmacological– Vestibular Rehabilitation

• Pharmacological– Antiemetics – Prochlorperazine (Stemetil), Metoclopramide

(Maxolon), Promethazine (Phenergan)– Vestibular Suppressants – Clonazepam (Rivotril), Amitriptyline (Endep)

• Specific– BPPV – Epley’s Manoeuvre– Vestibular Neuritis – Vestibular Suppressants– Meniere’s Disease – Na restrict, Diuretics (HCT), Surgical– Migraine – Pizotifen, Amitriptyline, Aspirin– Stroke – As per Stroke

HEAD & NECK TUMOURS

• Fifth most common cancer worldwide• Most common histology squamous cell carcinoma• “Field Cancerization”

– multiple primary and secondary tumours in upper aerodigestive tract– tobacco (smoked or smokeless) +/- alcohol – synergistic– HPV– betel nut chewing– previous radiation exposure– periodontal disease– occupational exposure e.g. wood-dust

Thank You