ENT Flashcards
referred ear pain
As a result of the large amount of nerves passing nearby the ear it is possible for stimuli residing within the sensory net of cranial nerves V, VII, IX, X and upper C2 and C3 can potentially cause pain in the ear.
Rinne and Weber hearing test
Rinne test - conduction hearing loss (bone conduction is greater than air conduction)
sensorineural hearing loss will test NORMAL for this (bone louder than air)
Webers test - tests for sensorineural hearing loss (will be loudest in NORMAL ear)
and conductive hearing loss (will be loudest in AFFECTED ear)
normal should be heard equally
acute otitis media (AOM)
Background:
Most common in children ages <4
Complications include recurrence of infection, hearing loss, tympanic membrane perforation, mastoiditis, intracranial abscess, sinus thrombosis and facial nerve paralysis
Pathology:
Acute inflammation in the middle ear (cochlear, vestibular apparatus and nerves) associated with effusion and rapid onset of ear infection presentation
Bacteria can enter from the back of the throat through the eustachian tube
Viral causes are often preceded by a viral upper respiratory tract infection
Aetiology:
Viruses and bacteria (most commonly strep. Pneumoniae, H/ influenza, moraxella catarrhalis)
AOM risk factors and presentation
Risk factors: Passive smoke Daycare or nursery Formula feeding Craniofacial abnormalities
Presentation:
Earache
Rubbing or holding the ears
Fever, crying, poor feeding, restlessness, cough or rhinorrhea, clinginess
Tympanic membrane is distinctly red, yellow or cloudy and may be bulging
Ear discharge (if perforated)
Balance issues and vertigo is vestibular system affected
AOM Ix and management
Investigation/diagnosis:
Ear examination
vitals
Management:
Many cases resolve spontaneously within a few days (95% cases)
Pain and fever - paracetamol or ibuprofen
Encourage regular fluids
Antibiotics for those who are systemically unwell, have presentation of more serious illness/condition or who are high risk of complications (clinical judgement)
First line 5-7 days of amoxicillin (clarithromycin for erythromycin for allergy or pregnancy)
Presenting with severe systemic infection, suspected complications (meningitis, mastoiditis, intracranial abscess etc.) or children <3 YO with temperature of >38 degree C need hospitalisation
Safety net to come back if worsening or persisting longer than 48 hours if antibiotics prescribed
otitis externa
Otitis externa/swimmer’s ear:
Background:
Acute (<3 weeks)
Chronic (>3months)
Very common and more than 1% of people will be diagnosed with the conditions each year
Affects all ages but incidence peaks between ages 7-12
Complications can include abscess, inflammation of tympanic membrane, malignant otitis
Pathology:
Inflammation of the external ear canal +/- infection
Aetiology:
Bacterial infection
Disturbing/damaging cell lining of the ear canal e.g. excessive cotton bud use or hot tubs causing inflammation
otitis externa risk factors and presentation
Risk factors:
Diabetes or radiotherapy to the head/neck increase the risk of malignant otitis
Presentation:
Ear pain, itching, discharge and hearing loss
Swollen, red or eczematous ear canal and/or external ear
Usually systemically well and not bothered by infection
Ear may leak fluids, look wet and crusty and may smell
Screen for red flags - fever, swelling or hot to touch beyond ear, regional LAP, hearing loss
otitis externa Ix and Mx
Investigation/diagnosis:
History/clinical diagnosis
Ear examination
Ear swab for persistent or recurrent symptoms
Management:
Paracetamol or ibuprofen (codeine for severe pain) analgesia
Topical preparation (Otomize spray) containing dexamethasone, antibacterial spray. Also can use steroid eye drops for simple otitis externa cases. Use for 7 days but up to 14 if symptoms persist, 2-3 drops 3-4x daily. Tilt ear up and back (or back and down if child <3 years), press tragus and keep head tilted to the side for a few moments to help keep fluid in the ear
Topical acetic acid for 1 week
Topical antibiotics for mod-severe cases - clioquinol
Antibiotic ear drops (otomize CI in TM perforation - use gentamicin with no steroid)
Oral antibiotics only in severe infection or those at high risk of severe infection (diabetes, immunocompromised, systemic signs of infection) - amoxicillin.
Surgery to repair tympanic membrane, ossicles, remove cholaestoma etc.
General advice to keep ears clean, dry, avoid using cotton buds, moisturising any eczema etc.
Follow up recommended for those with severe otitis externa, chronic OE, diabetes or are immunocompromised
Suspected ,malignant otitis - urgent admission
cerumen impaction
Pathology:
Earwax is a normal physiological substance made from dead flattened cells, cerumen (waxy substance), sebum and various foreign substances
It cleans, lubricates and protects the lining of the ear canal, trapping dirt, dust and hair and repelling water. It is acidic and normally coats the walls of the ear canal, inhibiting growth of bacteria and fungi
It is normally spontaneously removed from the ear via natural jaw movement. If this is inadequate or disrupted then the wax is retained in the canal and may become impacted
Aetiology:
Inadequate or disrupted clearing of earwax from ear canal
cerumen impaction presentation, Ix
Presentation: Reduced hearing Feeling of blocked ear or irritation Found incidentally on hearing aid assessment Tinnitus
Investigation/diagnosis:
Clinical history
Ear examination
cerumen impaction management and referrals
Should remove the ear wax if: person is symptomatic, tympanic membrane is obscured or person wears a hearing aid and impression is needed for a mould or the wax is causing the hearing aid to whistle
Ear drops (olive oil) for 3-5 days BD initially to soften wax (CI for suspected eardrum perforation)
Consider ear irrigation if symptoms persist (must have olive oil for at least 5 days BD before irrigation)
Referral to ENT:
Chronic perforation of eardrum
Past history of ear surgery
Foreign body in ear canal
Used ear drops but not successful and irrigation is CI
Unsuccessful irrigation
Had multiple attempts to remove impacted earwax including combination of treatments
Persistent symptoms despite resolution of impaction
mastoiditis
Background:
Serious infection, more common in children
Most people recover quickly with no complications if diagnosed and treated promptly
Pathology:
Inflammation of the mastoid bone behind the ear
Aetiology:
Can occur secondary to otitis media or externa so always important to palpate the mastoid bone behind the ear for every ear assessment - causes pain or is swollen
mastoiditis presentation, Ix and Mx
Presentation:
Earache (persistent and throbbing)
Creamy, often profuse ear discharge
History of increasing deafness
Pyrexial and unwell
Marked tenderness over mastoid antrum
Pinna may be pushed down and forward due to swelling in post-auricular region
Tympanic membrane either red and bulging or perforated (if neither of these it is NOT mastoiditis)
Rinne test negative and Weber’s test positive for conductive hearing loss (sound loudest in affected ear)
Investigation/diagnosis: Vitals - temperature, BP, oxygen Ear examination Mastoid palpation Rinne and Weber’s test
Management:
Same day referral to ENT
tonsilitis
Background:
Very common presentation in children and adults
Self limiting condition often resolving within 3 days in 40% of people and within 1 week in 85% of cases
Pathology:
Inflammation of the tonsils +/- an infection
Aetiology:
Viral or bacterial infection (streptococcal most commonly)
tonsillitis presentation and Ix
Viral - runny nose, cough, feeling generally unwell, earache
Bacterial - isolated sore throat, smelly breath, not eating or drinking well, feeling generally unwell
Ix:
throat examination
centor score
fever pain score
centor score (tonsillitis)
each scores 1 pt (max 4). Score of <2 is low risk and score of 3 or 4 thought to be associated with 32-56% likelihood of isolating strep infection
tonsillar exudate,
tender anterior cervical LAP or lymphadenitis,
history of fever >38 degrees,
absence of cough
fever pain score (tonsillitis)
each scores 1 pt. <2 thought to be more likely a viral cause. Score of 3 considers delayed antibiotic script. 4 or 5 prescribe antibiotics are likelihood of bacterial infection is higher
Fever during last 24 hours Purulence Attend rapidly within 3 days onset Inflammation of tonsils No cough or coryza (inflammation of mucous membranes in the nose)
management of tonsillitis
Viral - document, reassure that it should self resolve within the next few days/one week and to come back if this is not the case or they begin to show systemic symptoms (high fever etc). Paracetamol or ibuprofen for analgesia
Difflam spray for soothing throat inflammation (not routinely prescribed)
Corsodyl mouthwash (daily wash for long term OR acute bacterial wash for use during infection ONLY as can stain teeth), regular fluids, small amounts of regular foods that are easy to swallow (ice cream, soups)
Consider delayed antibiotic prescription for more vulnerable patients without severe symptoms and feverpain score of 2 or 3 (phenoxymethylpenicillin - penicillin V - first line for 10 days, clarithromycin for allergy, erythromycin for pregnancy with allergy). Treated for 10 days to reduce risk of recurrence.
NEVER prescribe amoxicillin (because you can never tell the difference clinically between glandular fever and tonsillitis, amoxicillin can cause nasty rash with glandular fever)
pharyngitis and presentation
Background:
Very common presentation in children and adults
Self limiting condition often resolving within 3 days in 40% of people and within 1 week in 85% of cases
Pathology:
Inflammation of the oropharynx
Aetiology:
Viral infection most commonly
Bacterial infection
Presentation:
Localised more just to the oropharynx less the tonsils
redness, skin changes, swelling
pharyngitis Ix and Mx
Investigation/diagnosis:
Throat examination
Management:
Symptoms control only using paracetamol/ibuprofen
Corsodyl mouthwash (daily mouthwash for long term OR for infection ONLY used during acute infection or can stain teeth)
Good fluid intake and small regular meals (soups, ice cream)
NO ABX NEEDED
infectious mononucleosis
glandular fever:
Background:
Self limiting illness
Spread via contact with saliva (especially kissing - AKA kissing virus), sharing cups, toothbrushes etc.
Can take up to 6 weeks to present with symptoms
Most common in young adults and teens
Have lifelong immunity post-infection
Complications can include damaged spleen, rash, jaundice, malaise and depression
Pathology:
Viral infection
Aetiology:
Epstein-Barr virus
glandular fever presentation
Symptoms occur for a week or so then settle over the next week Sore throat Swollen glands and tonsils Flu like symptoms Malaise and fatigue Swelling around the eyes Splenomegaly (temporary) Asymptomatic (subclinical infection common in children and >40 YO)
glandular fever Ix and Mx
Investigation/diagnosis: Clinical history Throat examination Lymph node examination Vitals - temperature Bloods - epstein-barr viral antibody
Management:
Encourage good fluid intake, small easy to swallow foods
Do not share contaminated items with household persons, avoid kissing and close bodily contact with others while symptomatic
Paracetamol or ibuprofen for fever and analgesia
Avoid drinking alcohol this will worsen symptoms
approach to looking at the throat
Is there any erythema? Where is it located?
Can you see the tonsils? Are they enlarged? Bilaterally or unilaterally?
Is there exudate?
Is the uvula central or deviated?
quinsy
peritonsillar abscess:
Background:
The bad boy of throat infections
Predominantly common in teenagers and young adults
Complications - necrotising fasciitis, mediastinitis, pericarditis, pleural effusions, airway compromise, aspiration, haemorrhage after tonsillectomy, recurrence of peritonsillar abscess
Pathology: Weber glands (salivary glands immediately above the tonsillar area in soft palate) are thought to play a minor role in clearing trapped debris from the tonsillar area. An infection resulting in trapped pus and abscess formation. Tissue necrosis and scarring and obstruction of the ducts draining the glands causing swelling.
Aetiology:
Secondary to acute tonsillitis, progresses to peritonsillitis and results in formation of a peritonsillar abscess or can arise from primary infection
Usually caused by strep. Pyogenes (group A strep) or staph. Aureus and H. influenzae
quinsy presentation
Unilateral tonsil swelling Fever Drooling Foul smelling breath Painful to swallow Trismus (difficulty opening the mouth) Altered voice (hot potato voice) due to pharyngeal oedema and trismus Earache on affected side (referred pain) Neck stiffness symptoms Headaches and general malaise Displaced uvula Severe - airway compromise or spontaneous rupture leading to aspiration
quinsy Ix and Mx
Investigation/diagnosis: Clinical diagnosis Throat examination Vitals - temperature CT scan for atypical presentations (inferior pole abscess) or high risk for drainage procedure (bleeding disorders etc) or to guide drainage in difficult cases Culture of pus/throat swab
Management:
Refer same day to hospital/ENT surgery for surgical intervention
IV fluids for dehydration
Analgesia
IV antibiotics of penicillin, cephalosporins, amoxicillin + clavulanic acid and clindamycin or metronidazole + penicillin depending on cultures
IV Igs (rare)
Single dose IV steroids may help reduce inflammation
Surgery - if conservative management is not successful, needle aspiration and drainage (USS guided if needed). Interval tonsillectomy if there is a background of chronic or recurrent tonsillitis
parotitis
Background:
The most commonly affected salivary gland affected by inflammation
Pathology:
Inflammation of the parotid glands (one or both)
Aetiology:
Tumours
Viral - mumps
Obstruction (stones or thickened saliva - more risk on hot days)
Sarcoidosis - Heerfordt’s syndrome (sarcoidosis with parotid enlargement, fever, anterior uveitis and facial nerve palsy)
Bacterial infection
HIV related lymphocytic infiltration
parotitis presentation and Mx
Swelling of parotid glands (uni or bilateral)
Loss of jaw angle (parotid swelling)
Accessory lobe may swell causing lump anterior to the ear
Displaced ipsilateral tonsils
Mx
Investigate and manage underlying cause
Mumps - self limiting, supportive treatment only
Salivary gland blockage (stone or thickened saliva) - drink lots of water, eat lemon, sherbert etc. to stimulate salivation and encourage flushing out of blockage
Acute suppurative infection - antibiotics and incision and drainage for abscess
Salivary flow encouragement using warm compress, sialogogues (lemon drops, gum, vitamin C lozenges), hydration, salivary gland massage and good oral hygiene
Chronic infections - duct obstruction by stone or structure needs removal, gland decision for recurrent or severe problems.
parotitis investigations
Investigation/diagnosis:
Bloods - FBC, inflammatory markers, U+Es, blood cultures, viral serology and salivary antibody testing, HIV screen
Pus swabs for culture and sensitivities
Sialography
USS
CT/MRI to exclude neoplasm
Fine needle aspiration or incisional biopsy if malignancy suspected
throat/gland examination:
Inspect deep lobe through the mouth
Ask patient to clench teeth to allow palpation of masseter - feel parotid across anterior border of masseter muscle
Inspect orifice of duct in the mouth opposite second upper molar by retracting teeth with spatula
Pressure on parotid gland may cause pus extrusion from orifice
Examine facial nerve for weakness or asymmetry (malignancy)
Vertigo
Background:
A type of dizziness referring to a false sensation that oneself or the surroundings are moving or spinning, usually accompanied by nausea and loss of balance
It is a mismatch between vestibular, visual and somatosensory systems
Can be classified into central or peripheral vertigo based on the cause
Majority of cases seen are viral or benign positional vertigo
Prevalence of vertigo and dizziness in those aged 60+ reaches 30%
Pathology:
Varies depending on cause
Aetiology:
Central - cerebral cortex, cerebellum, brain stem pathology e.g. cerebrovascular disease, migraine, MS, acoustic neuroma, diplopia and alcohol intoxication
Peripheral - vestibular labyrinth, semicircular canals or vestibular nerve pathology e.g. viral labyrinthitis, vestibular neuritis, benign paroxysmal positional vertigo (BPPV), meniere’s disease, motion sickness, ramsay hunt syndrome (herpes zoster)
Vertigo presentation
Feeling of rotatory or spinning symptoms
Symptoms of underlying cause..
Ear symptoms - hearing loss, ear discharge, tinnitus, history of recent URTI or ear infection
Neurological - headache, diplopia, visual disturbance, dysarthria or dysphagia, paraesthesia, muscle weakness or ataxia
Autonomic symptoms - N+V, sweating, palpitations
Migraine aura - visual or olfactory symptoms
History of recent head trauma may indicate BPPV
Anxiety and depression can aggravate vertigo
Acute intoxication with alcohol
Nystagmus common in acute vertigo
Vertigo investigations
Full Neurological examination (Romberg’s test)
Ear examination
Eye examination
Dix-hallpike maneuvers - used to confirm BPPV
Head impulse test - determine if cause of vertigo is peripheral or central (not sensitive)
Unterberger’s test - identifies damage to one of the labyrinths. Patients should march on the spot for 30 seconds with eyes closed, observing for lateral rotation. Rotate to the AFFECTED labyrinth side.
Audiometry - cochlear function
Electronystagmography, calorimetry and brain-stem evoked responses - Vestibular function
CT/MRI
EEG - epilepsy
Lumbar puncture - MS
Syphilis serology
Vertigo management
Identify and treat underlying cause
Explain and reassure for anxiety related exacerbations
Advise not to drive while dizzy or likely to experience an episode (DVLA states those liable to sudden attacks should stop driving)
Advise them to inform their employer if it poses a risk in the workplace (ladders, heavy machinery, driving etc)
Discuss risk of falling in the home
Consider symptomatic drug management for one week (must stop 48 before seeing a specialist) - prochlorperazine, cinnarizine, cyclizine or promethazine
Leaflets and support advice on chronic dizziness, rehabilitation
vertigo referrals
Referrals:
Severe N+V, inability to tolerate fluids, symptomatic drug treatment needs hospitalisation
Very sudden onset vertigo not provoked by positional change and is persistent refer urgently to neurologist or balance specialist (ENT)
Central neurological presentation e.g. new headache, gait disturbance, truncal ataxia refer urgently to neurologist
Acute deafness without typical features of Meniere’s diseases refer urgently to ENT
Undetermined cause refer to balance specialist (ENT) urgency dependent on clinical presentation
Bengin paroxysmal positional vertigo BPPV
Background:
Most common cause of vertigo (illusion of movement)
Can affect any age but is common around age 50
Younger people may develop BPPV as a consequence of head trauma
Women are twice as affected as men
Pathology:
Otoliths become detached from the macula (utricle-based receptor for detecting head position and movement) into the semicircular canals (posterior most commonly, inferior and then anterior rarely).
Detached otoliths may continue to move after movement ceases resulting in vertigo sensation of ongoing movement with other sensory inputs
BPPV cause and risk factors
Aetiology: Mostly idiopathic Heady injury Spontaneous degeneration of labyrinth Post-viral illness (viral neuritis) Complication of stapes surgery Chronic middle ear disease
Risk factors: Increasing age (40-60 most commonly) Women (2:1 ratio) Meniere’s disease Anxiety disorders Migraine - particularly in children
BPPV presentation
Vertigo provoked by head movements (rolling over in bed, lying down, sitting up, leaning forward, turning head to side etc.)
Symptoms are worse when head is tilted to one particular side
Sudden onset and lasting 20-30 seconds with rapid resolution if head is kept still
Brief latent period of 5-20 seconds between head movement and vertigo symptoms
Nausea (vomiting is rare)
Symptoms worse in the mornings
Light-headedness lasting several minutes or hours
BPPV investigations
Detailed history
Ear examination
Cranial nerve examination
Dix-hallpike test - confirms posterior canal BPPV
CT/MRI for diagnostic uncertainty
HINTS exam - head impulse test, nystagmus type and skew
BPPV management
Advise symptoms are usually self limiting over several weeks but may recur
Advise getting out of bed slowly and reducing head movements
Offer period of observation or immediate treatment (Epley’s manoeuvre or Brandt-Daroff exercises)
Advise against driving whilst dizzy or if provoked attack is likely (DVLA must be notified if person is liable to sudden and unprovoked or unpredicted episodes of disabling giddiness)
Follow up in four weeks to assess resolution of symptoms
Referral to specialist if Epley’s manoeuvre cannot be done in primary care, has been performed and repeated without success, uncertain diagnosis, symptoms have not resolved in four weeks or there are three or more recurrences of vertigo
Epleys manoeuvre
Most widely used repositioning manoeuvre for BPPV
Aims to move otoliths back into utricles from posterior semicircular canals.
Sit patient upright on couch with head turned to 45 degrees to the affected side (positive from Dix-Hallpike test)
Place hands on either side of the patients head and guide patient to lie down with head dependent 30 degrees over the edge (same as Dix-Hallpike)
Rotate head to 90 degrees opposite side with patients face upwards and head remaining dependent
Roll patient onto their side whilst holding their head in this position then rotate the head so it is facing downwards (tell patient to look at the ground)
Sit patient up sideways while maintaining head rotation
Simultaneously rotate the head centrally (should be no nystagmus now and otoliths should be repositioned)
Each position should be maintained until full symptom resolution and nystagmus has been achieved for at least 30 seconds
Symptoms can resolve quickly after treatment but full recover ycan take days-weeks
If not settled within a week diagnosis of BPPV is likely, consider repeating manoeuvre
Can be taught to be self-performed at home for patients
Brandt-Daroff exercises
Series of home exercises to loosen and disperse inner ear debris
Not as effective as Epley’s
Sit on side of the bed with head rotated 45 degrees
Close eyes
Quickly lie down to opposite side until head touches the bed, nose up, lateral occiput resting on the bed
Stay in position for 30 seconds then sit up
Turn head to other side and repeat
One session should include 6 repetitions to each side repeated 3 times daily until vertigo free for at least 2 consecutive days
Labyrinthitis and vestibular neuritis
Background:
Vestibular neuritis - confirmed cases where only the vestibular nerve is involved and is a common cause of vertigo. Peak onset of 40-50 YOs
Labrynthitis - the vestibular nerve and labyrinth are affected, also a cause of vertigo but less common than vestibular neuritis. Most commonly viral, between the ages of 30-60 years.
Pathology:
Vestibular neuropathy from herpes simplex most commonly affects the superior division of the nerve (longer than the inferior division and travels through a bony passage so is more vulnerable to swelling or ischaemic effects)
Labyrinthitis is caused by inflammation of the membranous labyrinth and damage to the vestibular and auditory end organs. Hearing loss is always present to some degree due to cochlear involvement
labyrinthitis and vestibular neuritis causes and risk factors
Aetiology:
Vestibular neuropathy is caused by reactivation of latent type 1 herpes simplex virus in the vestibular ganglion or can be caused by autoimmune and microvascular ischaemic insults
Labyrinthitis is caused by viral infection and URTI most commonly. Bacterial is a dangerous disorder, can also be associated with systemic disease
Risk factors: Female (2:1) Viral infection Chronic suppurative and acute otitis media Cholesteatoma Meningitis Inner ear malformations
Labyrinthitis presentation
Detailed history Sudden onset severe vertigo Not triggered by movement but may be exacerbated by movement N+V Hearing loss and tinnitus (with labyrinthitis but NEVER vestibular neuritis) can be uni or bilateral Preceding URTI symptoms Otalgia suggests herpes zoster Nystagmus Positive head impulse test
labyrinthitis and vestibular neuritis investigations
Ear examination
Cranial nerve exam
Gait assessment
HINTS examination - Head impulse test, Nystagmus Type and Skew
Swab of ear effusions if present
CT/MRI
Vestibular function tests - caloric testing, electronystagmogram and vestibular evoked myogenic potentials
labyrinthitis and vestibular neuritis management
Sudden onset unilateral hearing loss - refer to ENT urgently as may indicate acute ischaemia of labyrinth or brainstem
Safety net to seek medical attention for worsening symptoms, neurological symptoms (diplopia, slurred speech, gait disturbance etc)
Reassure patient this can usually be managed at home, lie still during attacks with eyes closed, encourage activity as soon as possible after to speed up development of vestibular compensation
Prochlorperazine or antihistamines for vertigo, N+V symptoms taken for the most minimal time possible
Labyrinthitis may need surgical management depending on cause (effusion, mastoiditis, cholesteatoma)
Vestibular rehabilitation exercises
Falls risk assessment
meniere’s disease and risk factors
Background:
Uncommon condition roughly 1:1000-1:2000
Disorder of the inner ear
Pathology:
Increased pressure within the endolymphatic system resulting in a swelling of the membranous labyrinth of the inner ear
Aetiology:
Changed in fluid volume in the labyrinth due to increased pressure within the endolymphatic system
Risk factors: Autoimmune conditions Family history Metabolic disturbances of sodium and potassium levels in inner ear Migraine Viral infections Head trauma
meniere’s disease presentation and Ix
Vertigo
Fluctuating hearing loss
Tinnitus
Typical attack begins with cochlear symptoms, followed by vertigo
Investigations/diagnosis:
Clinical diagnosis (rule out red flags for brainstem stroke)
Examination to rule out other vertigo causes (Dix-Hallpike manoeuvre)
Audiometry to assess hearing loss (sensorineural loss)
Balance test - ENG or video nystagmography
Bloods - eGFR, glucose, U+Es, FBC, CRP, ESR, TFTs
acute episodes of vertigo should be differentiated from non-rotatory dizziness
Meniere’s disease management
Lifestyle intervention - diet control Trial of betahistines Medical ablation (aminoglycoside) Pressure pulse treatment (provide positive pressure through pulse generator into ear canal) Psychological management for symptoms
Acute attack: Lie down on firm surface Avoid spinning drinks (causes vomiting) Cinnarizine, promethazine or cyclizine Oral steroid or intratympanic injections effective for acute and chronic symptoms
epistaxis
Background:
Most common ENT emergency, usually minor and self limiting
Anterior bleeding is most common (90% cases),
Posterior bleeding is in around 10% of cases, common in more elderly patients and often more severe
Pathology:
Anterior - bleeding occurs in the anterior septal area supplied by Keisselback’s plexus in Little’s area
Posterior - Usually arises from posterior nasal cavity at the following sites: behind posterior part of middle turbinate or posterior superior roof of the nasal cavity, supplied by the sphenopalatine artery
epistaxis causes and risk factors
Aetiology Trauma Chronic sinusitis Irritants (smoke, drugs) Drugs - topical corticosteroids Rhinitis Vascular malformation (telangiectasia) Neoplastic cause
Risk factors:
Hot, dry climates (causes skin to dry and crack)
Deviated nasal septum altering airflow pattern causing dryness
Colds and allergies (inflammation)
Medical causes - kidney failure, thrombocytopenia, hypertension, hemophilia
Alcohol
Drugs - anticoagulants, NSAIDs
