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
• DRSABCD
• 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
WITH POLYP
ALLERGIC FUNGAL
Oral Steroids
Oral Steroids
Surgery
Topical Steroids
Topical Steroids
Oral Steroids
Steroid Instillation
Steroid Instillation
Steroid Instillation
+/- Antihistamine
+/- Antihistamine
+/- Oral Antifungals
Oral Antibiotics
Maintenance
+/- Antileukotriene
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
SENSIRONEURAL
Congenital
Bilateral
Noise Induced
Foreign Body
Presbycusis
Tumour
Autoimmune
Infection
Drug Mediated
Trauma
Unilateral
Trauma
Infection
Perilymphatic Fistula
Cholesteatoma
Acoustic Neuroma
Otosclerosis
Meniere’s Disease
Glomus Tumour
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
BPPV
Perilymphatic Fistula
Migrainous
Hours
Meniere’s
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
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