Transcript EVERYTHING YOU WANTED TO KNOW ABOUT ENT

ENT UPDATE
Gavin Watters FRCS FRCS(ORL)
Consultant ENT Surgeon
PRIMARY CARE
E
Vertigo BPPV
Tinnitus Otitis Externa
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Rhinosinusitis
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Globus sensation
Snoring
Dizziness
 Vertigo
 Unsteadiness
(on walking)
 Light-Headedness
Vertigo
Definition
An illusion of movement of the subject or of
his/her surroundings. Usually a sensation of
spinning or rotation.
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Central or Peripheral
Acute Peripheral Vertigo
BPPV < 5 minutes
 Meniere’s Disease/Syndrome <24 Hours
 Vertigo with migraine <24 Hours
 Vestibular/labyrinthine failure >24 Hours
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Dix-Hallpike Test
Dix-Hallpike Test
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Peripheral
Latent period
Distress +++
Rotational nystagmus
Fatigable
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Central
No latent period
Distress +/Variable nystagmus
Not fatigable
BPPV
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Calcium deposits in posterior semi-circular canal
Brandt-Daroff exercises
Epley manoeuvre
Obliterate Posterior S-CC
Singular nerve neurectomy
Brandt-Daroff Exercise
Tinnitus
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Primary/idiopathic
Secondary
Ear disease
Vascular
Neuronal
Neuromuscular
Pulsatile Tinnitus
Vascular
Vascular stenosis
AVM
Glomus tumour
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Conductive HL
Hear normal intracranial blood flow
Management
Primary
Reassurance
Advice on environmental
masking
Hearing aid
Need only refer if not
coping or unilateral
tinnitus
Hearing Therapy, masker
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Secondary
Treat underlying ear disease
Refer for further
investigation/treatment
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Otitis Externa
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Pain
Irritation/Itch
Discharge
(Hearing loss)
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Cotton buds
Skin condition
Diabetes
Middle ear disease
Anatomical
Management of OE
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Antibiotic/steroid DROPS
Water precautions
Good analgesia
Aural toilet
Steroid ointment
Swab (?Fungal OE)
Systemic antibiotics if cellulitis
Sinusitis?
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Blocked nose
Congestion
Facial pain/headache
Runny nose
Catarrh/mucous
Unpleasant smell/taste
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Puffy/swollen face
‘Bags’ under eyes
Watery/sticky eye
And many more!
Sinusitis
Cacosmia
 Purulent Rhinorrhoea
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Hyposmia/anosmia
Facial pain
Frontal headache
Nasal obstruction
Facial Pain
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Facial
neuralgia/migraine
Dental
Sinusitis
TMJ/Myofacial
pain
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Periodicity, not
constant
Well localised
Worse with colds
Responds to
antibiotics
Other sinus symptoms
Facial swelling almost
never due to sinusitis
Diagnosis of Sinusitis
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DIFFICULT!
Nasal endoscopy is the key
Plain sinus X-ray no value
CT scan limited value. 30% normal
individuals have CT changes
Facial swelling almost never due to sinusitis
Forehead and periorbital swelling probably
is due to sinus infection
Nottingham Rhinology Clinic
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973 consecutive patients
Mean follow-up 26 months
1/3 diagnosis not sinonasal
119/679(18%) with sinonasal disease had pain
43/119 pain not attributable to sinus disease
76/679(11%) had pain attributable to sinus
disease
Neurological Causes
(Nottingham Study)
Midfacial segment pain 37%
 Tension headache
23%
 Migraine
17%
 Atypical facial pain
12%
 Cluster headache
8%
 Others
3%
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Summary
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Facial pain/frontal headache is not a major
feature of sinonasal disease.
Most patients with head pain/pressure have
a neurological cause for this symptom
Be very cautious in attributing such
symptoms as being due to sinusitis,
especially in the absence of objective
evidence of sinus disease.
Rhinitis- Aetiology
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Intrinsic (vasomotor)
Allergic (seasonal, perennial)
Environmental (SMOKING)
Infective
Hormonal
Medication (Rhinitis medicamentosa)
Systemic medical disorder eg Wegner’s
Rhinitis- Management
Topical nasal steroids
Use daily
Minimum 6-8 weeks
Warn no affect for 3-4
weeks but don’t stop
 Drops more potent
than sprays
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Stop nasal
decongestants
Stop smoking
Add antihistamines?
Ipratropium Bromide?
Allergen avoidance
After allergy testing
Immunotherapy
Gastro-oesophageal reflux
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Effects 25-40% of British population each week
Atypical manifestations are common
Laryngeal
Pharyngeal
Laryngopharyngeal Symptoms
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Hoarse voice (usually fluctuating)
Globus sensation
Mild dysphagia
Post nasal drip
Chronic cough
Chronic sore throat (mild)
Pathophysiology
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Inflammation due to direct action of acid
Laryngitis, pharyngitis
Increase in cricopharyngeus muscle tone
Globus sensation, dysphagia, pharyngeal pouch
Vagal hypersensitivity
Globus sensation, chronic cough
Ciliary damage
Post nasal drip
THERAPEUTIC TRIAL WITH A
PPI IS WELL WORTH WHILE,
PROVIDED THERE ARE NO
CLEAR ‘CANCER SYMPTOMS’
Cancer symptoms
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Pain, especially odynophagia
True dysphagia
Change in diet
Weight loss
Food regurgitation
Is symptom more noticeable when
eating/drinking?
SNORING
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Obesity
Oropharyngeal
Palate
Tongue base ? Retrognaethia
Tonsils
Nasal
Treatment
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Non-Surgical
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Surgical
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LOSE WEIGHT
Mandibular splint
Treat rhinitis
Avoid alcohol in evening
Avoid sedatives
Stop smoking
Sleep on side
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Palatal surgery (LAUP)
Must exclude OSA
Tonsillectomy
Nasal surgery
Orthognaethic
procedures
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Laser assisted palatoplasty
AND FINALLY
Questions ?