ent update gavin watters frcs frcs(orl) consultant ent surgeon
TRANSCRIPT
ENT UPDATEENT UPDATE
Gavin Watters FRCS Gavin Watters FRCS FRCS(ORL)FRCS(ORL)
Consultant ENT SurgeonConsultant ENT Surgeon
PRIMARY CAREPRIMARY CARE
EEVertigo BPPV Tinnitus Otitis Vertigo BPPV Tinnitus Otitis
ExternaExterna
NNRhinosinusitisRhinosinusitis
TTGlobus sensation SnoringGlobus sensation Snoring
DizzinessDizziness
VertigoVertigoUnsteadiness (on walking)Unsteadiness (on walking)Light-HeadednessLight-Headedness
VertigoVertigo
DefinitionDefinition
An illusion of movement of the subject An illusion of movement of the subject or of his/her surroundings. Usually or of his/her surroundings. Usually a sensation of spinning or rotation.a sensation of spinning or rotation.
Central or PeripheralCentral or Peripheral
Acute Peripheral VertigoAcute Peripheral Vertigo
BPPV < 5 minutesBPPV < 5 minutes Meniere’s Disease/Syndrome Meniere’s Disease/Syndrome
<24 Hours<24 Hours Vertigo with migraine <24 Vertigo with migraine <24
HoursHours Vestibular/labyrinthine failure Vestibular/labyrinthine failure
>24 Hours>24 Hours
Dix-Hallpike TestDix-Hallpike Test
Dix-Hallpike TestDix-Hallpike Test
PeripheralPeripheral Latent periodLatent period Distress +++Distress +++ Rotational Rotational
nystagmusnystagmus FatigableFatigable
CentralCentral No latent periodNo latent period Distress +/-Distress +/- Variable Variable
nystagmusnystagmus Not fatigableNot fatigable
BPPVBPPV
Calcium deposits in posterior semi-Calcium deposits in posterior semi-circular canalcircular canal
Brandt-Daroff exercisesBrandt-Daroff exercises Epley manoeuvreEpley manoeuvre Obliterate Posterior S-CCObliterate Posterior S-CC Singular nerve neurectomySingular nerve neurectomy
Brandt-Daroff ExerciseBrandt-Daroff Exercise
TinnitusTinnitus
Primary/idiopathicPrimary/idiopathic SecondarySecondary
Ear diseaseEar disease
VascularVascular
NeuronalNeuronal
NeuromuscularNeuromuscular
Pulsatile TinnitusPulsatile Tinnitus
VascularVascular
Vascular stenosisVascular stenosis
AVMAVM
Glomus tumourGlomus tumour
Conductive HLConductive HL
Hear normal Hear normal intra-cranial intra-cranial blood flowblood flow
ManagementManagement
PrimaryPrimary
ReassuranceReassurance
Advice on Advice on environmental environmental maskingmasking
Hearing aidHearing aid
Need only refer if not Need only refer if not coping or unilateral coping or unilateral tinnitustinnitus
Hearing Therapy, Hearing Therapy, maskermasker
SecondarySecondary
Treat underlying ear Treat underlying ear diseasedisease
Refer for further Refer for further investigation/treatinvestigation/treatmentment
Otitis ExternaOtitis Externa
PainPain Irritation/ItchIrritation/Itch DischargeDischarge (Hearing loss)(Hearing loss)
Cotton budsCotton buds Skin conditionSkin condition DiabetesDiabetes Middle ear Middle ear
diseasedisease AnatomicalAnatomical
Management of OEManagement of OE
Antibiotic/steroid DROPSAntibiotic/steroid DROPS Water precautionsWater precautions Good analgesiaGood analgesia Aural toiletAural toilet Steroid ointmentSteroid ointment Swab (?Fungal OE)Swab (?Fungal OE) Systemic antibiotics if cellulitisSystemic antibiotics if cellulitis
Sinusitis?Sinusitis? Blocked noseBlocked nose CongestionCongestion Facial Facial
pain/headachepain/headache Runny noseRunny nose Catarrh/mucousCatarrh/mucous Unpleasant Unpleasant
smell/tastesmell/taste
Puffy/swollen facePuffy/swollen face ‘‘Bags’ under eyesBags’ under eyes Watery/sticky eyeWatery/sticky eye And many more!And many more!
SinusitisSinusitis
CacosmiaCacosmia Purulent RhinorrhoeaPurulent Rhinorrhoea Hyposmia/anosmiaHyposmia/anosmia Facial painFacial pain Frontal headacheFrontal headache Nasal obstructionNasal obstruction
Facial PainFacial Pain Facial Facial
neuralgia/migrneuralgia/migraineaine
DentalDental SinusitisSinusitis TMJ/Myofacial TMJ/Myofacial
painpain
Periodicity, not Periodicity, not constantconstant
Well localisedWell localised Worse with coldsWorse with colds Responds to Responds to
antibioticsantibiotics Other sinus Other sinus
symptomssymptoms Facial swelling Facial swelling
almost almost nevernever due to due to sinusitissinusitis
Diagnosis of SinusitisDiagnosis of Sinusitis
DIFFICULT!DIFFICULT! Nasal endoscopy is the keyNasal endoscopy is the key Plain sinus X-ray no valuePlain sinus X-ray no value CT scan limited value. 30% normal CT scan limited value. 30% normal
individuals have CT changesindividuals have CT changes Facial swelling almost never due to Facial swelling almost never due to
sinusitissinusitis Forehead and periorbital swelling Forehead and periorbital swelling
probably is due to sinus infectionprobably is due to sinus infection
Nottingham Rhinology Nottingham Rhinology ClinicClinic
973 consecutive patients973 consecutive patients Mean follow-up 26 monthsMean follow-up 26 months 1/3 diagnosis not sinonasal1/3 diagnosis not sinonasal 119/679(18%) with sinonasal disease 119/679(18%) with sinonasal disease
had painhad pain 43/119 pain not attributable to sinus 43/119 pain not attributable to sinus
diseasedisease 76/679(11%) had pain attributable to 76/679(11%) had pain attributable to
sinus diseasesinus disease
Neurological CausesNeurological Causes((Nottingham Study)Nottingham Study)
Midfacial segment painMidfacial segment pain37%37% Tension headacheTension headache 23%23% MigraineMigraine 17%17% Atypical facial painAtypical facial pain 12%12% Cluster headacheCluster headache 8%8% OthersOthers 3%3%
SummarySummary Facial pain/frontal headache is not a Facial pain/frontal headache is not a
major feature of sinonasal disease.major feature of sinonasal disease. Most patients with head Most patients with head
pain/pressure have a neurological pain/pressure have a neurological cause for this symptomcause for this symptom
Be very cautious in attributing such Be very cautious in attributing such symptoms as being due to sinusitis, symptoms as being due to sinusitis, especially in the absence of objective especially in the absence of objective evidence of sinus disease.evidence of sinus disease.
Rhinitis- AetiologyRhinitis- Aetiology
Intrinsic (vasomotor)Intrinsic (vasomotor) Allergic (seasonal, perennial)Allergic (seasonal, perennial) Environmental (SMOKING)Environmental (SMOKING) InfectiveInfective HormonalHormonal Medication (Rhinitis medicamentosa)Medication (Rhinitis medicamentosa) Systemic medical disorder eg Wegner’sSystemic medical disorder eg Wegner’s
Rhinitis- ManagementRhinitis- Management
Topical nasal Topical nasal steroidssteroids
Use dailyUse daily
Minimum 6-8 weeksMinimum 6-8 weeks
Warn no affect for Warn no affect for 3-4 weeks but 3-4 weeks but don’t stopdon’t stop
Drops more potent Drops more potent than spraysthan sprays
Stop nasal Stop nasal decongestantsdecongestants
Stop smokingStop smoking Add Add
antihistamines?antihistamines? Ipratropium Ipratropium
Bromide?Bromide? Allergen avoidanceAllergen avoidance
AfterAfter allergy allergy testingtesting
ImmunotherapyImmunotherapy
Gastro-oesophageal Gastro-oesophageal refluxreflux
Effects 25-40% of British population Effects 25-40% of British population each weekeach week
Atypical manifestations are commonAtypical manifestations are common
LaryngealLaryngeal
PharyngealPharyngeal
Laryngopharyngeal Laryngopharyngeal SymptomsSymptoms
Hoarse voice (usually fluctuating)Hoarse voice (usually fluctuating) Globus sensationGlobus sensation MildMild dysphagia dysphagia Post nasal dripPost nasal drip Chronic coughChronic cough Chronic sore throat (mild)Chronic sore throat (mild)
PathophysiologyPathophysiology Inflammation due to direct action of acidInflammation due to direct action of acid
Laryngitis, pharyngitisLaryngitis, pharyngitis Increase in cricopharyngeus muscle toneIncrease in cricopharyngeus muscle tone
Globus sensation, dysphagia, pharyngeal Globus sensation, dysphagia, pharyngeal pouchpouch
Vagal hypersensitivityVagal hypersensitivityGlobus sensation, chronic coughGlobus sensation, chronic cough
Ciliary damageCiliary damagePost nasal dripPost nasal drip
THERAPEUTIC TRIAL THERAPEUTIC TRIAL WITH A PPI IS WELL WITH A PPI IS WELL
WORTH WHILE, WORTH WHILE, PROVIDED THERE ARE PROVIDED THERE ARE
NO CLEAR ‘CANCER NO CLEAR ‘CANCER SYMPTOMS’SYMPTOMS’
Cancer symptomsCancer symptoms
Pain, especially odynophagiaPain, especially odynophagia TrueTrue dysphagiadysphagia Change in dietChange in diet Weight lossWeight loss Food regurgitationFood regurgitation
Is symptom more noticeable when Is symptom more noticeable when eating/drinking?eating/drinking?
SNORINGSNORING
ObesityObesity Oropharyngeal Oropharyngeal
PalatePalate
Tongue base ? RetrognaethiaTongue base ? Retrognaethia
TonsilsTonsils NasalNasal
TreatmentTreatment
Non-SurgicalNon-Surgical LOSE WEIGHTLOSE WEIGHT Mandibular splintMandibular splint Treat rhinitisTreat rhinitis Avoid alcohol in Avoid alcohol in
eveningevening Avoid sedativesAvoid sedatives Stop smokingStop smoking Sleep on sideSleep on side
SurgicalSurgical Palatal surgery Palatal surgery
(LAUP)(LAUP)
Must exclude OSAMust exclude OSA TonsillectomyTonsillectomy Nasal surgeryNasal surgery Orthognaethic Orthognaethic
proceduresprocedures
Laser assisted Laser assisted palatoplastypalatoplasty
AND FINALLYAND FINALLY
Questions ?Questions ?