SSSM: COMMON PROBLEMS IN ENT

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SSSM COMMON PROBLEMS IN ENT

• PETER TAO
• INTERN

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OUTLINE

• Nose
• Epistaxis
• Chronic Rhinosinusitis
• Throat
• Peritonsillar Abscess
• Tonsillitis
• Ear
• Hearing Loss
• Vertigo
• Head Neck

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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.

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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

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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

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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)

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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
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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

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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)

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HEARING LOSS

• Sensorineural vs Conductive vs Mixed

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CAUSES
CONDUCTIVE SENSIRONEURAL
External 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 Menieres Disease
Glomus Tumour Idiopathic
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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

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INVESTIGATION

• Special Tests
• Pure tone audiogram
• Speech audiometry
• Tympanogram
• Imaging
• CT Temporal Bone
• /- MRI Auditory Canal

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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

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VERTIGO
CAUSES
Seconds BPPV
Perilymphatic Fistula
Migrainous
Hours Menieres
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
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HISTORY/EXAMINATION

• Vertigo vs Dizziness
• Peripheral vs Central
• History
• Onset/Time Course Seconds, Hours, Days
• Aggravating/Relieving Factors Movement,
  Tullios Phenomenon
• Associated symptoms Neurology, Nystagmus
• Examination
• Assess as per hearing loss
• Neurological examination
• Dix-Hallpike Test
• Investigations
• CTB

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MANAGEMENT

• Non-pharmacological
• Vestibular Rehabilitation
• Pharmacological
• Antiemetics Prochlorperazine (Stemetil),
  Metoclopramide (Maxolon), Promethazine
  (Phenergan)
• Vestibular Suppressants Clonazepam (Rivotril),
  Amitriptyline (Endep)
• Specific
• BPPV Epleys Manoeuvre
• Vestibular Neuritis Vestibular Suppressants
• Menieres Disease Na restrict, Diuretics (HCT),
  Surgical
• Migraine Pizotifen, Amitriptyline, Aspirin
• Stroke As per Stroke

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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

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