SSSM: COMMON PROBLEMS IN ENT

PETER TAO INTERN

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)

Untreated

WITHOUT POLYP

Oral Steroids Oral Antibiotics

WITH POLYP

Oral Steroids

ALLERGIC FUNGAL

Surgery Maintenance Topical Steroids Steroid Instillation +/- Antihistamine Topical Steroids Steroid Instillation +/- Antihistamine +/- Antileukotriene Oral Steroids Steroid Instillation +/- Oral Antifungals

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

External Ear Middle Ear Congenital Foreign Body Tumour Infection Trauma Infection Cholesteatoma Otosclerosis Glomus Tumour

SENSIRONEURAL

Bilateral Unilateral Noise Induced Presbycusis Autoimmune Drug Mediated Trauma Perilymphatic Fistula Acoustic Neuroma Meniere’s Disease 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

CAUSES

Seconds Hours Days BPPV Perilymphatic Fistula Migrainous Meniere’s Vertebrobasilar TIA Vestibular Neuritis Cerebellar Stroke Multiple Sclerosis

PERIPHERAL

Unidirectional Nystagmus Horizontal +/ Torsional Suppressed with visual fixation Hearing Loss/Tinnitus Gait preserved

CENTRAL

Nystagmus can reverse direction Any direction Not suppressed with fixation Neurological Signs 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