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Ear , Nose and Throat By Alasdair Silverberg and Charlie DerbyshireHistory taking Ear Nose Throat • Discharge/otorr hea • Any bleeding --> • Pain on swallowing how much blood (odynophagia) • Hearing • Change in smell • Struggling to swallow --> changes/loss • Pain liquids or solids or both • Tinnitus • Nasal obstruction • Change/Hoarseness in voice • Pain/otalgia • Rhinorrhea • Regurgitation • Dizziness • Sore throat Don’t forget about red flagsExaminationEar pain 85-year-old male presents with ear pain. It has been ongoing for 4 days. White thick fluid is coming out of the ear. Not systemically unwell. No change in hearing, no dizziness, no tinnitus. Patient is a keen swimmer. What is the diagnosis? A – Otitis media with effusion B – Otosclerosis C – Otitis Externa D – Ear wax impaction E – Otitis media with perforation Don’t forget about referred/secondary pain: Otitis types - Dental - TMJ - Pharyngeal Otalgia No Otorrhea Otorrhea Acute otitis Otitis media Malignant Glue ear media ----------> perforation Otitis externa Otitis externa Symptoms - Otalgia - Otorrhea Otitis Externa - Pruritus Risk factors - Foreign bodies in ear - Swimming - Instrumentation of the ear - Immunocompromised– elderly Ear swabs may be useful if Treatment complicated/unresolving Topical antibiotics with steroids - ?Gentamycin - Ciprofloxacin with dexamethasone Malignant otitis externa – immunocompromised--> Patient advice: keep dry, use oral analgesia progression to temporal bone osteomyelitis = CT scan required. Signs and symptoms • Ear pain (tugging/rubbing ear) Acute otitis media • Reduced hearing • URTI infection Risk factors/demographics • young children • Recent URTI– more often bacterial than viral Treatment 1st = simple analgesia 2nd = Antibiotics if meet criteria: - More than 4 days, not improving, systemically unwell, immunocompromised, bilateral and less than 2 years perforationAcute otitis media perforation Treatment: 1st line: Supportive – generally heals spontaneously – keep dry, will heal in 6-8 weeks 2nd line: not healing = MyringoplastyMastoiditis Urgent referral for IV antibiotics Complications - facial nerve pain - hearing loss - meningitisDeafness • 82-year-old female complaining of progressively increasing deafness. Started 3-4 years ago and has started to frustrate her husband as he now has to shout next to her ear to get her to understand anything and he has osteoarthritis and so it is difficult for him to mobilize to her. No otalgia, no tinnitus, no otorrhea, no dizziness. Weber's– no lateralisation Rinne's – air conduction is better than bone conduction A – Presbycusis D – Otosclerosis B – Meniere's disease E – Acoustic Neuroma C – Noise damage hearing lossPresbycusis High pitch hearing loss that is progressively getting worse Hearing loss to below 20 Treatment= Hearing aids if patient's Hz hearing loss of below 20/25 dBGlue ear/Otitis media with effusion/Secretory otitis media Symptoms/Signs - Reduced hearing in affected ear - Mild otalgia - Aural fullness - URTI previous, however no current active infection is ongoing - previous AOM Demographics similar to AOM - Hearing aids - autoinflation - Myringotomy and grommet Treatment insertion 1st line - Watchful waiting for 3 months with pure tone audiometry 2nd line – Refer to ENT if: • Down's syndrome/cleft palate • Hearing loss affecting quality of life • Abnormal tympanic membrane structure • ?Cholesteatoma Otosclerosis Symptoms Bilateral progressive deafness (often starts on one side) Demographics 20–40-year-olds Autosomal dominant Pregnancy Treatment Hearing aids Stapedectomy Ear wax impaction Symptoms Treatment - otorrhea Olive oil drops/sodium bicarbonate/almond oil, sodium - progressive deafness chloride – use 3/4 times a day for 3-5 - previous cotton bud days use/foreign object Ear irrigation Possibly: otalgia, aural Refer if meets criteria fullness, pruritus, tinnitus Demographics Typically, older peopleCholesteatoma Treatment Symptoms Surgical (tympanomastoidectomy) --> Otorrhea – foul smelling (classically painless this may not restore hearing to otorrhea) normal. (may even decline) Hearing loss Otalgia Can reoccur Dizziness Recurrent infections CT scan may be used to assess Acoustic neuroma Symptoms Hearing loss Investigations Tinnitus MRI scan with Dizziness contrast Other cranial nerves may be compressed: 5,7, 9 and 10 Raised ICP Demographics - Treatment Neurofibromatosis type 2 1st – Hearing aids (AD) although most are 2nd – Stereotactic sporadic radiotherapy 30-50 years old 3rd – SurgeryDizziness • 74-year-old male complains of dizziness when turning his head in bed. Attacks last for a couple of minutes and then dissipate. No otalgia, no otorrhea, no change in hearing, no aural fullness, no tinnitus A – Acoustic neuroma B – Meniere's disease C – Benign positional paroxysmal vertigo D – Acute otitis media E – Ear wax impactionBenign positional paroxysmal vertigo Symptoms: Investigations - Dizziness when turning Dix-Hallpike manoeuvre head – attacks that subsequently resolve after 20-30 seconds Demographics - elderly Migraines, vestibular neuronitis, viral Treatment labyrinthitis 1st - Epley manoeuvre 2nd - Vestibular rehabilitation 3rd - Surgical treatments Meniere's disease Management Refer to ENT Symptoms Aural fullness Informing DVLA – stop driving until symptoms are Dizzy attacks controlled: Reduced hearing Control symptoms: Tinnitus Prochlorperazine for acute Nystagmus and attacks positive Rhomberg's Betahistine/vestibular rehab for prevention Demographics Middle aged adults Symptoms resolve in -10 years - patients may lose some hearing permanentlyViral labyrinthitis Vestibular neuronitis Symptoms Symptoms Hearing loss Vertigo Recurrent vertigo attacks N+V N+V Tinnitus Prochlorperazine or antihistamine Prochlorperazine, vestibular rehabilitation