(I) RHINOLOGY

 

 EPISTAXIS

 A. General Measures:

• Calm the patient, firmly pinch patient's entire nose ( may stop anterior nosebleeds).
•  Sitting preferable b/c reduces nasal arterial pressures & risk of blood aspiration.

 

      1. Recognise and treat hypovolaemia

• • Look for evidence of shock: weak pulse, cool, pale skin; disordered mentn etc
    • If significant blood loss, treat for hypovolemia .
    • Insert a large-bore (> 16-gauge) intravenous catheter.
    • Blood for XM, Hb, clotting factors, EUC’s
    • IV infusion of crystalloid solutions

      2. Look for underlying cause

• • PF’s: hypertension, bleeding diathesis, anticoagulants or aspirin, hematologic disease. 

 B.      Control of Haemorrhage;

 

     1. Determine the site of bleeding-

• • Bright light (headlight or head mirror), nasal speculum, adequate suction device.
  •  Systematically examine lateral & medial walls of nasal cavity for bleeding pts

    2. Stop the bleeding-

         The site of bleeding varies with the age of patient

                a. Children

• •  Often in Little’s (Kiesselbach's) area, located anteriorly on nasal septum

                b.Adults

• •  usually more posteriorly than Little’s area.

                c.Elderly patient

• • most difficult
  • bleeding source usually high & posterior ( on the lateral wall ).
  •  may be difficult to visualise by conventional anterior rhinoscopy.
  • Calcified arteriosclerotic vessels (inelastic ineffective vasospasm).

*Bleeding can be stopped by:

 

  Chemical (eg silver nitrate) or Electrical cautery, or packing tightly against bleeding point

            Preparing the nose

                        a.Adequate illumination

                        b.Suction all visible clot

                        c.LA:

                                    (i) Cophenylcaine Forte (V/C & L/A)

                                    (ii) Cotton-wool pledgets soaked in either:

                                                -Cophenylcaine Forte  or

                                                -4% lignocaine & adrenaline (max dose 7 mg/kg)                                                                

                        NB:  adequate systemic analgesia (eg morphine)

           

            (i) To perform chemical cautery, use silver nitrate-tipped sticks

                            *under direct vision , bleeding point only.

                  - Caution: Do not cauterise wide area of nasal mucosa, and do not cauterise

                                    both sides of nasal septum since septal necrosis may result.

                                               

           (ii)To place an anterior pack,

                         * Continuous strip of petroleum-impregnated gauze into anterior nares firmly

                         -Remember floor is horizontal & post choanae are 6 - 7.5 cm deep.

                         * If bleeding continues, pack other nostril . 

                         *If entire nasal chamber is packed & bleeding persists posteriorly

                                                => posterior pack

            (iii)To place a posterior pack,

                * Simpson’s balloon or Foley urethral catheter is inserted back along nasal  floor   

                * Inflate balloons (water) & tape catheter to cheek

         .            *Then insert anterior nasal pack

 After A&E

            NBM,  IV fluids and antibiotic cover

            Strict bed rest

            TED stockings

            Sedation (if no signif resp disease)

            Rpt Hb in  6hrs (if concerned re ongoing bleeding) and 24 hrs

           NB: A posterior pack may be left in place for 3-4 days.

 

 NASAL FOREIGN BODY

1.    May be asymptomatic or => serosanguinous, offensive, unilateral nasal discharge.

2.    If easily accessible in anterior part of nose, attempt removal with a bent hook or pair of forceps.

3.    However (as with the foreign body in the ear), if removal is difficult, or child is uncooperative => GA. Sudden posterior dislodgment with inhalation of the foreign body is a real danger.

FRACTURED NOSE

Diagnosis

1.       Swelling, deformity and epistaxis.

2.       Exclude more serious facial bone fracture,

                        (eg. CSF rhinorrhoea from cribriform plate damage)

3.       Look carefully for septal haematoma,

            *Nasal passage is blocked by dull-red swelling replacing septum

            *If not drained may => septal collapse.

Management

     Refer to ENT team < 2 to 3  days 

 

NASAL DISCHARGE

            *Most => allergy, vasomotor rhinitis, or  URTI

Diagnostic Clues of Potential emergencies

 *CSF rhinnorhea :   - Hx head trauma;

                              - high glucose level in discharge

*Foreign body         - children

                               - unilateral air-flow obstruction

*Sinusitis                - purulent discharge.

                                - sinuses tender;

                               -often a past Hx

                               -abNormal sinus x-rays,

*Tumour                 -primarily adults;

                                -unilateral airflow obstruction & bloody discharge.

 

Non-emergencies

Allergy                         -history of allergic rhinitis

                                    - pale boggy rnucosa

Viral URTI                   -red, swollen nasal mucosa

                                    -systemic symptoms

 

Hx  &  Examination.

            * Symptoms of viral URTI

            * Palpate frontal & maxillary sinuses for signs of tenderness or swelling

            * Nasal airway for unilateral obstruction,

            * ?? foreign bodies or tumours,

  Ix:    * Sinus CT

 

Treatment

            * if  suspected acute CSF rhinorrhea => urgent ENT & Neurosurgical R/V.

            * foreign bodies should be removed

            * if the obstruction is thought to be due to tumour, urgent ENT referral

            * if sinusitis is suspected, obtain sinus CT, and treat with A/B’s, decongestants &

                 analgesia

 

(II) OTOLOGY

                                  OTALGIA

(PAIN IN THE EAR)

 

 

Hx  &  Examination

     Swimming (otitis externa), trauma (chondritis),

     Palpate pinna & Xmn for chondritis. 

     Otoscopy => EAM & TM

     Test hearing

      Examine other facial structures (teeth, TMJetc)  ??referred

     Examine CN’s  (esp VII )

 

VERTIGO

Diagnosis

.*Two groups:

i.     Central vertigo: => lesions in CNS,

        (eg  vertebrobasilar TIA, cerebellar or brainstem CVA, tumour, demyelination,

               vertebrobasilar migraine & drug toxicity).

ii.    Peripheral vertigo: => lesions in vestibular n & inner ear

      (eg vestibular neuritis, Meniere's disease,  BPPV, acoustic neuroma, otosclerosis,        

           cholesteatoma and ototoxic drugs).

 

Management

1. Incapacitating vertigo

                => Diazepam 2.5-5-10 mg IM  OR  Prochlorperazine (Stemetil)12.5 mg IM.

2.  Central causes of vertigo => medical team

3. Pperipheral causes of vertigo => ENT team.

 

  

SUBPERICHONDRIAL HAEMATOMA

Diagnosis

       *Defn: Blunt trauma to ear => bleeding b/w auricular cartilage & perichondrium. 

            *If left untreated => cauliflower ear.

Management

            *Aspirate small clots under local anaesthesia and apply pressure by head bandage.

               If large bleed may need OT

            *ENT R/V since the bleeding may recur

            *Protect against perichondritis with flucloxacillin orally qid. for 7 days.

 

OTITIS EXTERNA

(swimmer's ear)

Diagnosis

            *Staphylococci or Pseudomonas aeruginosa or fungal infection

            *Infection often follows exposure to water.

            *Trauma associated with cleaning may also precipitate the disease,

            *Swelling & purulent discharge from EAM with tenderness elicited by movement of

                 the pinna       

Treatment

            *Aural toilet using  cotton wick

            *Small cotton wick should placed EAM

            *Combined steroid/antibiotic otic preparations

            *Adequate analgesia !!!

            *Wick removed 2-3 days

            *Systemic antibiotics for moderate to severe cases (Rx: Ciprofloxacin.  Not for kids)

   

FOREIGN BODIES IN THE EAR

Diagnosis & Treatment

 

       1.Pain, deafness & discharge if left.

        2 Do not attempt maneuvers if:

                        * object is not freed instantly, or

                        * patient is uncooperative,

               Live insects should be suffocated with oil & removed with large metal suction tip

 

 PERFORATED TYMPANIC MEMBRANE (DRUM)

 Diagnosis

1.    Causes: direct injury from  sharp object , or

                        indirect pressure from slap, blast injury, SCUBA diving, fracture of skull base

2.    Pain, conductive deafness and sometimes bleeding.

3.    Severe vertigo or complete hearing loss => suspect inner ear involvement.

 Management

1.    Immediate ENT referral if inner ear damage is suspected.

2.    Otherwise, do not put anything into the ear or attempt to clean it out.

        Advise the patient to keep water out of the ear canal.

3.    Amoxycillin 500 mg orally t.d.s. and refer the patient

 

ACUTE OTITIS MEDIA

Diagnosis

1.    Common in children due to pneumococcus or Haemophilus influenzae

        ( children < 6 yrs)

2.    Intense earache, conductive deafness, fever

3     TM exm’n:  loss of light reflex, injected vessels around malleus.

4.    As infection progresses => bulging drum => may perforate & discharge pus.

 Management

1.    Early stages: Augmentin Duo orally bd for 10 days & analgesia

2.    If the drum is bulging or has perforated and the child is unwell, notify  ENT team.

  

MASTOIDITIS

Diagnosis and Management

1.    Extension of acute otitis media into mastoid air-cell system.

2.    Patient is ill, febrile, tender over the mastoid

3.    Immediate ENT referral ,CT scan and IV antibiotics .

4.    Complications: CN palsy, meningitis & subperiosteal abscess.

  

FACIAL NERVE PARALYSIS

Diagnosis

1.    Upper motor neurone paralysis

i.        Weakness of lower facial muscles, +\-  other neurological signs

ii.       Cause is usually a CVA

2.    Lower motor neurone paralysis

i.      Weakness of whole side of face (including  forehead muscles).

ii.     Causes:

1.  Bell's palsy
2.  temporal bone trauma or facial laceration in parotid area
3. tumours (eg acoustic neuroma or parotid )
4. infection (eg acute OM, chronic OM +\- cholesteatoma, geniculate HZ, Ramsay Hunt)
5. miscellaneous (including Guillain-Barre syndrome, sarcoidosis, diabetes).

Examination: assessment of the external auditory canal, eardrum, parotid region & full CNS exmn.

 

Management

       Refer cases => medical, or ENT team according to  likely aetiology.

  

SUDDEN DEAFNESS & TINNITUS

    Must be seen as an emergency ASAP.

     All conditions that => SNHL may also => tinnitus.

     Primary importance of tinnitus => possibility of significant SNHL

     Acoustic neuroma must be ruled out as well.

 

(III) OROPHARYNGEAL

  

TONSILLITIS

 Diagnosis

       1. Viral or bacterial, (usually beta-haemolytic streptococcus).

       2. Sore throat, dysphagia, fever & foetor

       3. Clinically may be impossible to distinguish  viral Vs  bacterial cause.

         NB:  Remember that glandular fever ( a grey, exudative tonsillitis).

 

Management

       *.Assess airway, hydration status, analgesic requirement, overall patient condition.

           If  these are abnormal admit:       

            otherwise

       *Penicillin V 500mg orally q i.d. for 10 days and an antipyretic analgesic   

       *GP  f/up

  

PERITONSILLAR ABSCESS ( QUINSY)

 Diagnosis and Management

1.    More common in adults.

2.    Spiking temperatures, muffled voice, dysphagia, referred earache & trismus.

3.    Examination : unilateral swelling of soft palate, displacement of the tonsil down & medially 

4.         Start benzylpenicillin 1.2 grams  i.v. qid

            ENT team R/V for operative drainage.

 

 

FOREIGN BODY IN THE PHARYNX

 Diagnosis

 1.         Fish or meat bones most common

 2.         Fish bone will impact in the tonsil, base of the tongue, or posterior pharyngeal wall

 3.         If no bone is seen despite symptoms (including indirect laryngoscopy),

               request a lateral soft tissue x-ray of the neck

 4.         Coins are the most common objects swallowed by preschool children, although

               small children swallow almost anything and the elderly may swallow their dentures.

 5.         Oesophageal impaction, usually around the cricopharyngeus at the level of C6 is

               suggested by dysphagia, excessive salivation, local tenderness or retrosternal pain.

NB: Batteries pose a particular risk as they may cause local mucosal erosion and

                    toxicity from mercury release, thus urgent removal is required.

 Management

1.    Removal fish bone from tonsil or the back of tongue using Tilley's curved forceps.

i.      If this fails in patient with pain or salivating excessively, refer immediately to ENT team.

ii.     Occasionally pharyngeal mucosa has only been scratched, and if symptoms are minimal, prescribe an antibiotic (eg amoxycillin ), and ask patient to return in 24 hours for review.

 2.    Immediate ENT R/V for oesophagoscopy, if oesophageal impaction with dysphagia,

                 excessive salivation, local tenderness or retrosternal pain is suspected