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EAR, NOSE & THROAT Sophia Wong, Y6 Med Student sophiawch14@gmail.comOtitis media ➔ Middle ear infection, typically in children after URTI. Viral 60% RSV, rhinovirus, enterovirus. Bacterial 40% strep. pneumoniae, H. influenzae,M. catarrhalis ➔ Sx: Coryza, otalgia, hearing loss +/- N&V ➔ Ix: Otoscopy (bulging TM, loss of light reflex, +/- perforation), MC&S if discharge, CT if C/ ➔ Rx: ◆ Analgesia + delayed prescription/ review if >3 days ◆ Immediate abx (oral amox 500mg TDS for 5-7 days. Doxy if pen allergic) if >4 days, systemically unwell, immunocompromised, <2yrs old with bilat. AOM, AOM + perf ◆ Consider abx steroid drops eg. ciprodex ➔ C/: CSOM (if >6wks), hearing loss, labyrinthitis, mastoiditis, facial nerve paralysis, petrositis, tympanosclerosis, meningitis, brain abscess, lateral sinus thrombosisOtitis externa ➔ External ear infection, typically swimmers (staph. aureus, pseudomonas), tropical climate (fungal), patients with dermatitis, immunosuppressed ➔ Sx: Otalgia, itch, custard-like discharge +/- conductive hearing loss ➔ Ix: Otoscopy (red, swollen canal), MC&S, CT if NOE ➔ Rx: ◆ Mild: Topical abx+steroid drops eg. ciprodex, gentamix, OR 2% acetic acid spray, OR clotrimazole. Consider aural toilet (microsuction) if debris. Refer to ENT if no resolution ◆ Severe: Pope wick soaked in gentamicin ◆ Admit if pinna cellulitis, CN palsy, complete stenosis ➔ C/: Malignant NOE in elderly diabetics, peri-auricular cellulitisAcoustic neuroma ➔ Rare, 90% of cerebellopontine tumours, if bilateral -> NF2 ➔ Sx: Progressive vertigo, sensorineural hearing loss, unilateral tinnitus, absent corneal reflex ➔ Ix:MRI cerebellopontine angle/ internal auditory meatus, audiogram ➔ Rx: ◆ Urgent referral to ENT for observation (slow-growing), surgery, radiotherapyMénière’s disease ➔ ?Endolymphatic hydrops, middle aged adults ➔ Sx: Mins-hours of recurrent vertigo, sensorineural hearing loss, unilateral tinnitus, nystagmus, aural fullness ➔ Ix: +ve romberg’s test ➔ Rx: ◆ Acute attack: buccal/IM prochlorperazine ◆ Prevention: low salt diet, betahistine, (diuretics), vestibular exercises ◆ Specialist: steroid injections, saccus decompression, labyrinthectomy, vestibular nerve section ◆ Advice on driving - contact DVLA ➔ C/: A degree of hearing loss after resolutionBPPV ➔ Common, middle-aged patients, good prognosis ➔ Sx: Seconds of vertigo triggered by head movement +/- nausea ➔ Ix: Dix-hallpike (+ve rotatory nystagmus, don’t perform if neck pathology) ➔ Rx: ◆ Epley manoeuvre +/- betahistine ◆ Brandt-Daroff exercises if persistent ◆ Posterior semi-circular canal occlusion if resistant ➔ C/: Recurrence after 3-5 yearsDizziness & Vertigo BPPV Vestibular Meniere’s Vestibular neuritis migraine Onset Sudden Sudden/ gradual Gradual Sudden/ gradual Hearing loss No No Fluctuating Sometimes Investigations Full neuro exam, pure tone audiometry, Dix-Hallpike OR vHiT, MRI to exclude acoustic neuroma Treatment Epley Anti-emetics: Treat: anti- Avoid triggers Brandt-Daroff cinnarizine, emetics Surgery prochlorperazine Prevent: Low salt diet, betahistine, steroid injectionEpistaxis ➔ Anterior (common, bleeding from Kiesselbach’s plexus/ Little’s area), posterior (more profuse bleeding). Caused by dry air, trauma, bleeding disorders, hypertension, cocaine use. Can be fatal. ➔ Sx: Unilateral bleed if anterior, bilateral and runs down throat if posterior ➔ Ix: Thudicum speculum examination +/- nasendoscopy ➔ Rx: ◆ 1st line: sit forward with mouth open, pinch nostrils for at least 20 mins, spit out blood +/- suck on ice cubes +/- naseptin BD for 2wks (ask about peanut or soy allergy!). Advice to avoid hot drinks, blowing nose, strenuous activity ◆ 2nd line: unilateral nasal cautery with silver nitrate if obvious bleeding point, nasal packing with adrenaline soaked gauze if no obvious bleeding point. Refer to ENT ?sphenopalatine ligation under GA. ◆ Admit if haemodynamically unstable, underlying cause suspected, <2yrs old. If trauma, beware septal haematoma, r/v for deformity 5 days after swelling, consider septoplastyEpistaxisRhinosinusitis ➔ Allergic (atopy) or non-allergic - > acute (usually viral infection - rhinovirus, RSV) or chronic (>3months due to nasal polyps eg. samter’s triad, smoking, spicy food, GPA) ➔ Sx: Allergic -> frontal pressure pain worse on leaving forward, clear discharge, post-nasal drip + cough. Non-allergic -> mucopurulent nasal discharge, nasal blockage, loss of smell ➔ Ix: Allergic -> SPT/ RAST. Non-allergic -> Bloods, swabs, CT sinuses + brain with contrast ➔ Rx: ◆ Allergic: Avoid allergen, oral non-sedating antihistamine, intranasal steroids, nasal douching ◆ Non-allergic: -> Acute: analgesia, nasal douching, 5-days decongestant, intranasal steroids if >10days. Abx if severe pain, fever, elevated ESR/CPR, double sickening). -> Chronic: all of the above (EPOS Guidelines) +/- FESS ◆ Refer if unilateral symptoms, persistent despite 3months compliance, epistaxis ➔ C/: If infection, risk of spread esp. Periorbital cellulitisFESS ➔ Indication: Refractory sinusitis, nasal polyps, endonasal tumour, access to skull base ➔ Pre-op: Nasal endoscopy, CT+/- MRI paranasal sinuses ➔ Procedure: ◆ Patient prepped & draped, under GA ◆ Insert 0 degree endoscope, perform uncinectomy, suction and clearance of relevant sinuses +/- swabs for MC&S ➔ Post-op: Immediate: analgesia, nasal douching BD +/- intranasal steroids +/- abx. Long-term: intranasal steroid spray ➔ C/: General: pain, infection, bleeding. Specific: intra-cranial/orbital complications, recurrenceFESS Functionalendoscopicsinus surgery (FESS)-3Danimation This medicalanimationdescribes the functionalendoscopicsinus surgery (FESS), orcommonly knownas sinus surgery, is minimally invasive surgicalprocedure forserious sinus conditions. Medicalprofessionaluse the term “functional”because the surgery is done torestore howyoursinuses work, orfunction. Healthcare providers use nasalendoscopes —thintubes withlights andlens —toease yoursinus symptoms withoutmaking incisions inoraroundyournose. Studies showbetween80%and90%ofpeople who’ve hadthis surgery feelitsolvedtheirsinus issues. Howis functionalendoscopicsurgery performed? A decongestantmedicationis insertedinyournose, followedby a nasalendoscopy. Aninjectionofa numbing solutionis insertedintoyournose, andthe endoscope is insertedgently. Surgicaltools are usedalongside the endoscope toremove bone, diseasedtissue orpolyps thatmay be blocking yoursinuses. Mostfunctionalendoscopicsurgeries lastabouttwohours. This 3danimationis licensable forhealthcare providers toassistwiththeirpatienteducation. Formore informationaboutlicensedorcustom 3Danimations, visithttps://www.amerra.com/. Watchadditionalmedicalanimations: Craniectomy brainsurgery -3Danimation: https://youtu.be/1RkseDeYS9g Accessing animplantable porttraining -3Danimation: https://youtu.be/xSTpxjyv4O4 OpenSuctioning witha Tracheostomy Tube -3Danimation: https://youtu.be/wamB7jpWCiQ Ventriculostomy BrainSurgery -3danimation: https://youtu.be/pUy0YDzVNzs Suctioning the endotrachealtube -medicalanimation: https://youtu.be/pN6-EYoeh3g Howtoinserta nasogastrictube forNGintubation-3danimation: https://youtu.be/Abf3Gd6AaZQ Oralairway insertion-oropharyngealairway technique -3Danimation: https://youtu.be/caxUdNwjt34 Nasotrachealsuctioning (NTS)-3Danimation: https://youtu.be/979jWMsF62c Learnabouthemorrhoids with#3d#animation: https://youtu.be/R6NqlMpsiiY LASIKeye surgery -3Danimation: https://youtu.be/Bb8bnjnEM00 CPRcardiopulmonary resuscitation-3Danimation: https://youtu.be/G87knTZnhks Whatare warts (HPV)? -3Danimation: https://youtu.be/guJ1J7rRs1w HowMacularDegenerationAffects YourVision-3Danimation: https://youtu.be/ozZQIZ_52YY NeoGrafthairtransplantprocedure – animation: https://youtu.be/C-eTdH2UPXIEpiglottitis ➔ Rare but serious H. influenzae infection ➔ Sx: Stridor (late sign), rapid onset aphagia + drooling + tripod position, rapid onset voice change ➔ Ix: DO NOT EXAMINE IF EPIGLOTTITIS SUSPECTED. (Thumb sign on X-ray lateral view) ➔ Rx: ◆ Immediate senior support (anaesthetics, ENT) -> endotracheal intubation ◆ O2, IV high dose steroids, IV broad spec abx, PRN adrenaline nebs ➔ C/: If infection, risk of spread esp. Periorbital cellulitis. Consider CTObstructive sleep apnoea ➔ Periods of abnormal breathing assoc. obesity, large tonsils, acromegaly, marfan’s syndrome, hypothyroidism, ➔ Sx: excessive snoring, apnoea ➔ Ix: Epworth sleepiness scale, polysomnography (gold standard) ➔ Rx: ◆ Conservative: weight loss, inform DVLA ◆ CPAP, mandibular advancement ◆ Adenotonsillectomy if indicated ➔ C/: Daytime somnolence, hypertensionTonsillitis ➔ Infection of palatine tonsils, 70% viral, 30% bacterial Group A strep beta-haemolytic. ➔ Sx: sore throat, odynophagia, systemic upset, bilateral cervical lymphadenopathy. If quinsy -> hot potato voice, trismus, uvular deviation ➔ Ix: Monospot test, Bloods (FBC, U&Es, LFTs, CRP). Centor criteria/ FeverPAIN score. ➔ Rx: ◆ IV fluids, abx (benzylpenicillin), analgesia (regular IV/PO paracetamol, ibuprofen + PRN topical difflam benzydamine spray) ◆ Refer for tonsillectomy if meet criteria ◆ Admit if quinsy for aspiration ➔ C/: Quinsy, parapharyngeal/ retropharyngeal abscessCentor/ Fever PAIN criteria Fever >38 Give abx if >2 criteria. Tonsillar exudate Tender anterior cervical lymphadenopathy (Modified: +1 if Age 3-14 years old) No coughTonsillectomy criteria (SIGN 2010) ➔ Indications: ◆ >7/year for 1 year; >5/year for 2 years, >3/year for 3 years ◆ Obstructive sleep apnoea/ dysphagia 2ary to enlarged (adeno)tonsils ◆ Refractive quinsy (best to avoid in acute infection) ◆ Severely disabling ➔ Procedure: cold method (dissection along avascular plane), hot method (cautery) ➔ Complications: haemorrhage, <24hrs: inadequate haemostasis, 24hrs-10days: infection. Beware of herald bleedsInfectious mononucleosis ➔ Aka. glandular fever, caused by EBV/ HHV4, common in adolescents ➔ Sx: sore throat, lymphadenopathy, pyrexia. Maculopapular, pruritic rash after taking amox. Usually very large tonsils (Grade 4) with thick cheesy exudate ➔ Ix: Monospot test, Bloods (FBC, LFTs) ➔ Rx: ◆ Supportive for 2-4 weeks: analgesia, fluids. Advise avoiding alcohol, contact sports for 4wks ➔ C/: Splenic ruptureNeck lumps ➔ Differential: Lymphadenopathy Thyroids Thyroglossal cyst Cystic hygroma Branchial cyst Parapharygneal pouchMalignancy Symptoms Possible cancer Lip/oral lump, persistent neck lump Oral Erythroplakia, erythroleukoplakia Oral ulcer >3wks Unexplained thyroid lump Thyroid Unexplained neck lump in >45yo Laryngeal Unexplained hoarseness in >45yo Unilateral serous OM Nasopharyngeal carcinoma Unilateral nasal obstruction/discharge CN III-VI palsy: History PAIN INFECTION SWELLING DISCHARGE HeariEAR balance Breathing, speaking, eating THROATExam Normal left tympanic membraneExam Normal throat exam Bone conduction Investigations Air conduction ● [ = Right ear masked ● ] = Left ear masked ● O = Right ear unmasked ● X = Left ear unmasked Normal audiogramThank you for listening! Please leave Recommended feedback at the reading: end of the - entsho.com session. - entUK booklet - NICE CKS Sophia Wong sophiawch14@gmail.com