ENT 525/16

Question 1

1. Sore Throat History

Answer 1

A targeted history should include

• the duration of the sore throat and
• other associated symptoms such as
  
  • earache,
  • trouble breathing,
  • problems with swallowing, or
  • cough.
• Problems with swallowing can be divided into dysphagia (difficulty in swallowing) or odynophagia (painful swallowing).
  
  • Difficulty swallowing may suggest an obstruction, stricture or motility issues, whereas painful swallowing may be due to ulcers, oropharynx pathology or infection.
• A history of voice change is also important to elicit as it can be a symptom of quinsy, epilglottis or tracheal pathology.
• Associated headache, the duration, onset and nature of the headache and other neurological symptoms should be elicited to exclude red flags of serious neurological pathology.
  
  • should also be asked about photophobia, neck stiffness, and the presence of vomiting or nausea to exclude meningitis or encephalitis.
• Associated anorexia, a history of his fluid intake is important so he can be assessed for his state of hydration.
• A history of rashes should be sought, especially about the red maculopapular rash of scarlet fever or a petechial rash of meningitis.

There are certain patient groups who are at higher risk of having a streptococcal pharyngitis/tonsillitis.

• Patients should be asked specifically if they identify as Aboriginal or Torres Strait Islander, Maori or Pacific Islander, or
• if they are immunocompromised.

A history of acute rheumatic fever (ARF) also increases the risk substantially that a patient will have another episode of ARF.

The risk of ARF after the first attack of Group A streptococcal (GAS) pharyngitis is approximately 0.3–3%, but with subsequent infection in someone who has already had ARF this risk rises to 25–75%.

Question 2

1. Sore throat Examination

Answer 2

Examination should include

• general appearance,
• skin (including specifically looking for rashes),
• difficulty breathing,
• stridor or
• a change in voice.
• Jaw muscles spasm (trismus) and reduced mouth opening should be looked for as if a patient has severe unilateral throat pain, high fever and/or change in voice it is a strong indicator of quinsy or other abscess formation (Therapeutic guidelines).
• Observations such as temperature and respiratory rate are needed.
• Ears, throat, chest and heart should be examined.
• Lymphadenopathy should be checked in the cervical, axilla and groin region. If there are multiple areas of lymphadenopathy, an abdominal examination looking for organomegaly would be appropriate.
• If appropriate should also be examined for neck stiffness and photophobia.

Question 3

1. Sore throat DDx

Answer 3

• viral upper respiratory tract infection
• bacterial pharyngitis/tonsillitis
• glandular fever.

Sore throat is a very common complaint in general practice and, although it is often a viral self-limiting condition, it can be a feature of more serious conditions.

GAS pharyngitis/tonsillitis is found in 15–30% of children and 10% of adults with sore throat. The peak incidence is three to 15 years of age.

Bacterial causes of sore throat other than GAS are rare. Streptococcal infections can cause

• suppurative (otitis media, quinsy, sinusitis and cellulitis) and
• non-suppurative complications (acute rheumatic fever [ARF], acute glomerulonephritis). ARF is a delayed autoimmune response to a throat infection caused by GAS bacteria, which results in an illness that mainly affects the heart, joints, brain and skin.

Another important condition to consider is Epstein–Barr virus (EBV), which presents as infectious mononucleosis (glandular fever). EBV infects more than 90% of the population. The syndrome of infectious mononucleosis typically occurs when primary infection occurs in adolescents or adults and consists of the triad of fever, sore throat and generalised lymphadenopathy.

Question 4

1. Sore throat Inx

Answer 4

• A full blood evaluation (FBE),
• liver function tests (LFTs) and
• EBV serology should be ordered to assess if the cause is infectious mononucleosis, which could show a raised white cell count, atypical lymphocytes, elevated liver enzyme and positive EBV serology.
• A throat swab for microbiology, culture and sensitivity (MC&S) is recommended to identify if the sore throat is due to a streptococcal infection.

Question 5

1. Strep Throat

Answer 5

Streptococcal tonsillitis.

Several studies have looked at criteria or features that may help doctors to identify when patients are more likely to have a bacterial infection. In one such study, the Centor criteria suggest that GAS infection is present if a patient has at least three of the following:

• pus
• cervical nodes
• history of fever
• no history of cough.

Other researchers have suggested that short duration and severe inflammation should be included in the Centor criteria. However, these criteria have low specificity for bacterial infection.

Question 6

1. Strep Throat vs EBV

Answer 6

It can also be difficult to differentiate EBV from streptococcal infection. Although there are no specific criteria or guidelines for the diagnosis of EBV or streptococcal infections, there are associated clinical features that might help to differentiate EBV infection.

• In infectious mononucleosis, the cervical nodes in the posterior triangle are more likely to be involved, whereas in streptococcal infection, the submandibular nodes are more likely to be very tender.
• EBV is also more common in older children and adolescents.
• EBV-related palatal petechia located at the junction of the hard and soft palates occurs in 25–60% of cases
• Splenomegaly occurs in about half of the cases and hepatomegaly is present in 10–15% of cases.

Question 7

1. Strep Throat Rx

Answer 7

There is controversy regarding the need for antibiotic therapy for streptococcal infections in populations where ARF is rare.

In Australia, ARF persists among children in rural and remote settings, but also among those living in disadvantaged urban areas.

Aboriginal and Torres Strait Islander peoples and Pacific Islander children are over-represented among these children.

It has been found that antibiotics do confer relative benefits in the treatment of sore throat in low-risk groups.

However, the absolute benefits are modest. Protecting those with a sore throat against suppurative and non- suppurative complications in low-risk populations requires treating many with antibiotics for one to benefit.

Antibiotics shorten the duration of symptoms by about 16 hours overall in low-risk groups.

In most cases, antibiotics are not needed, but a delayed prescription strategy is likely to provide similar benefits to an immediate antibiotic prescription.

Streptococcal infection remains highly susceptible to penicillin.

If treatment is indicated, use phenoxymethylpenicillin 500 mg (children: 15 mg/kg up to 500 mg) orally, 12-hourly for 10 days. Dosing with phenoxymethylpenicillin 12-hourly is effective for the treatment of streptococcal pharyngitis and is preferred due to improved adherence.

For non-adherent patients, or if oral therapy is not tolerated, use benzathine penicillin 900 mg (children: 3–6 kg: 225 mg; 6–10 kg: 337.5 mg; 10–15 kg: 450 mg; 15–20 kg: 675 mg; 20 kg or more: 900 mg) intramuscular (IM), as a single dose.

For patients with non-immediate hypersensitivity to penicillins, use cephalexin 1 g (children: 25 mg/kg up to 1 g) orally, 12-hourly for 10 days.

If patients have immediate hypersensitivity, then use azithromycin 500 mg (children: 12 mg/kg up to 500 mg) orally, daily for five days

Amoxycillin/ampicillin is contraindicated in glandular fever and should be avoided when prescribing for sore throats as it can precipitate a maculopapular rash, which can be confused with hypersensitivity to penicillins

Question 8

1. Tonsellectomy and recurrent infections

Answer 8

A systematic review has found that adeno-/tonsillectomy leads to a reduction in the number of episodes of sore throat and days with sore throat in children in the first year after surgery, compared with non-surgical treatment.

Children who were more severely affected were more likely to benefit as the procedure had a small reduction in moderate/severe sore throat episodes. The size of the effect is very modest. Insufficient information was available on the effectiveness of adeno-/tonsillectomy versus non-surgical treatment in adults to draw a firm conclusion.

The potential ‘benefit’ of surgery must be weighed against the risks of the procedure as adeno-/tonsillectomy is associated with a small but significant degree of morbidity in the form of primary and secondary haemorrhage and, even with good analgesia, is particularly uncomfortable for adults.

Several guidelines have suggested that the following features, called the Paradise Criteria, in children aged 1–18 years identify those children who are more likely to benefit from a tonsillectomy. The

criteria state that tonsillectomy may be considered in patients with

recurrent throat infections if they have had at least:

• seven documented episodes of sore throat in the previous year
• five documented episodes in each of the previous two years, or
• three documented episodes in each of the previous three years.

They must also have a temperature of greater than 38.3°C, cervical lymphadenopathy, tonsillar exudate, or a positive culture for group A beta-hemolytic streptococcus.

It would be reasonable to refer for an ear, nose and throat specialist opinion for further discussion about the risks and benefits of tonsillectomy.

Question 9

2. Otitis Media- History

Answer 9

• General acute pain and URTI Hx
• hearing,
• speech,
• behaviour or inattention,
• recurrence of ear infection or upper respiratory tract infections,
• balance problems and
• poor education progress.
• Second-hand smoke is a particular risk factor that should be enquired about.

Question 10

2. Otitis media History and examintation

Answer 10

The NICE guidelines suggest that examination should focus on

• otoscopy,
• tympanometry,
• general upper respiratory tract health and developmental status.
• Hearing tests, if required, should be carried out by trained staff.

Hearing tests are indicated as part of the formal assessment. It is important to use tests appropriate for the child’s developmental stage. According to NICE guidelines, a formal assessment involves:

• clinical history – focus on:
– poor listening skills
– indistinct speech or delayed language development
– inattention and behaviour problems
– hearing fluctuation
– recurrent ear infections or upper respiratory tract infections – balance problems and clumsiness
– educational progress

• clinical examination – focus on:

– otoscopy

– general upper respiratory health

– general development

– hearing testing – use tests appropriate for child’s developmental stage

– tympanometry.

Important hearing loss causes need to be considered, such as sensoneural, permanent or non-organic causes.

Question 11

2. Otitis media- key features

Answer 11

Key features of acute otitis media include

• pain,
• fever,
• acuteness and
• a bulging, red tympanic membrane, with or without effusion.

Question 12

2. OM causes

Answer 12

Acute otitis media is a common problem in early childhood, and the majority of children have at least one episode before starting school. Causes of otitis media include the following:

• viruses (25%)
• Streptococcus pneumoniae (35%)
• non-typable strains of Haemophilus influenza (25%)
• Moraxella catarrhalis (15%).

Aboriginal and Torres Strait Islander patients require particular attention for acute otitis media. A helpful algorithm has been made available by the Department of Health (Figure 1).

Question 13

2. Sudden onset hearing loss

Answer 13

Sudden-onset hearing loss can be a particular concern; the differential diagnosis can be classified into anatomical regions:

• outer ear: conductive hearing loss from foreign body, wax, otitis externa, ear canal pathology or trauma
• middle ear: conductive hearing loss from otitis media with effusion,
• haemotympanum, ossicular chain discontinuity, trauma, iatrogenic, tympanic membrane perforation or choleostatoma
• inner ear: sensorineural hearing loss from noise, ototoxic medications, infection, trauma, tumours, vascular causes, autoimmune causes or other causes.

Red flags associated with sudden-onset hearing loss include:

• concurrent head trauma
• neurological signs or symptoms
• unilateral middle ear effusion (post-nasal space must be examined).

Question 14

2. OM complications

Answer 14

Sequelae of acute otitis media include

• mastoiditis,
• facial nerve paralysis,
• meningitis,
• intracanial abscess,
• lateral sinus thrombosis.

Question 15

2. OM pathophysiology

Answer 15

Question 16

2. OM with effusions pathophysiology

Answer 16

Question 17

2. OM treatment

Answer 17

The Therapeutic Guidelines suggests avoiding antibiotic therapy for non-suppurative acute otitis media in the low-risk patient, because the number to treat is 20 to prevent pain in one child at two to seven days.

Antibiotic therapy is considered for children who do not improve with symptomatic treatment or develop systemic features, such as high fever, vomiting or lethargy.

Amoxycillin 15 mg/kg (max 500 mg) every eight hours for five days or, for patients suspected to be non- adherent 30 mg/kg (max 1 g) every 12 hours for five days are the recommended treatment regimens.

Those not responding adequately can be changed to amoxycillin and clavulanic acid or trimethoprim and sulfamethoxazole.

Question 18

2. OM with effusion treatment

Answer 18

Otitis media with effusion has often been treated with a combination of antibiotics and steroids. However, there is no evidence for the long- term benefits of steroids, although resolution of the otitis media with effusion may be faster.

Equally so, antibiotic therapy should not be commenced automatically.

A recent Cochrane review does not support the use of antibiotics for children up to 18 years of age with otitis media with effusion. The review found that the greatest effects of antibiotics were seen with continuous treatment for four weeks or three months, but suggested that benefits should be weighed against potential side effects and the emergence of bacterial resistance.

Autoinflation is a technique used to re-open the Eustachian tube by raising pressure in the nose to equalise pressure and facilitate fluid drainage. Raised pressure can be achieved by forced exhalation with mouth and nose closed, blowing up a balloon through each nostril or using an anaesthetic mask.

Autoinflation may be a reasonable measure (low cost, absence of adverse effects) while awaiting natural resolution of otitis media with effusion.

A recent Cochrane review suggested no benefit and some harm from the use of antihistamines or decongestants, either alone or in combination, in the management of otitis media with effusion, and recommend against using these.

Question 19

2. OM with grommets

Answer 19

Treatment in this particular situation needs to consider ototoxicity, development of bacterial resistance and the overall systemic health of the patient.

Recent evidence suggests that topical fluoroquinolones (+/– corticosteroids) offer the most effective treatment. Aminoglycoside agents should not be used because of the potential ototoxicity.

Question 20

2. Chronic suppurative OM

Answer 20

Chronic suppurative otitis media (CSOM) is more common in Aboriginal and Torres Strait Islander peoples. It requires cleaning
of the external ear canal by dry mopping the ear with rolled tissue spears or similar, every six hours until the external canal is dry (dry aural toilet).10 Ciprofloxacin ear drops (0.3%, five drops instilled every 12 hours for at least three days) is the antibiotic of choice. Systemic antibiotics may be indicated if perforation was recent or if it is clear that the patient is not adhering to the management plan. In the latter situation it may be necessary to balance the risk and benefits of oral antibiotic therapy (twice daily dosing).17 Persistent discharge may require referral to an ear, nose and throat (ENT) specialist to exclude cholesteatoma or chronic osteitis.

An algorithm for management
of otitis media in high-risk populations is shown in Figure 6. Key messages for primary care providers are shown in Box 1.

Question 21

2. CSOM and GP management

Answer 21

Question 22

2. Referral to ENT

Answer 22

Referral to an ENT specialist should be considered for recurrent acute otitis media with

• three or more episodes in six months or
• four or more episodes in 12 months.

Other indications for immediate referral are complications such as

• mastoiditis,
• nerve involvement, or
• high-risk patients who are not improving despite multiple courses of antibiotics.

Specialist input should also be sought for hearing loss (>30 dB) or if there is any impact on education, speech or behaviour, or if symptoms are chronic in nature (>three months). However, anything ‘worse than normal hearing’ should be considered for referral and 20–30 db loss or more is very significant.

A recent qualitative study suggested a discrepancy between evidence- based treatment guidelines and parents’ expectation and perception of what should be done. This provides an opportunity to identify concerns and misconceptions, and address these in an appropriate manner.

Generally speaking, antibiotics have no early effect on pain in acute otitis media, but have a modest effect in some children with tympanic perforations. In countries like Australia, recovery is uneventful
without treatment or complications. A Cochrane review reportedthat antibiotics were most useful in children under the age of two years with bilateral acute otitis media, or with acute otitis media and otorrhoea. Adverse events, including vomiting, diarrhoea and rash, occurred in one out of every 14 children treated with antibiotics. This review recommended that patients should be given advice about adequate analgesia and the limited role of antibiotics in the management of otitis media.

Avoidance of cigarette smoking and overcrowding in households can reduce the risk of ear infections. For infants, breastfeeding has been shown to be beneficial as well.

Swimming, flying and diving should be avoided during an acute otitis media phase.

Cotton buds should not be used in the ears as these can damage the external ear canal and contribute to infections.

General risk factors for acute otitis media are

• younger age and
• day care settings.

Prophylactic administration of xylitol has been shown to reduce the occurrence of acute otitis media in healthy children attending day care centres.

Question 23

2. OM general info

Answer 23

A recent qualitative study suggested a discrepancy between evidence- based treatment guidelines and parents’ expectation and perception of what should be done. This provides an opportunity to identify concerns and misconceptions, and address these in an appropriate manner.

Generally speaking, antibiotics have no early effect on pain in acute otitis media, but have a modest effect in some children with tympanic perforations. In countries like Australia, recovery is uneventful
without treatment or complications. A Cochrane review reportedthat antibiotics were most useful in children under the age of two years with bilateral acute otitis media, or with acute otitis media and otorrhoea. Adverse events, including vomiting, diarrhoea and rash, occurred in one out of every 14 children treated with antibiotics. This review recommended that patients should be given advice about adequate analgesia and the limited role of antibiotics in the management of otitis media.

Avoidance of cigarette smoking and overcrowding in households can reduce the risk of ear infections. For infants, breastfeeding has been shown to be beneficial as well.

Swimming, flying and diving should be avoided during an acute otitis media phase.

Cotton buds should not be used in the ears as these can damage the external ear canal and contribute to infections.

General risk factors for acute otitis media are

• younger age and
• day care settings.

Prophylactic administration of xylitol has been shown to reduce the occurrence of acute otitis media in healthy children attending day care centres.

Question 24

2. OM and vaccinations

Answer 24

The pneumococcal vaccine and influenza vaccination may be useful at reducing the risk of recurrent infections, although trials are still ongoing.

Current evidence on whether zinc supplementation can reduce the incidence of otitis media in healthy children under the age of five years living in low- and middle-income countries is mixed. Its role for those above age five is unknown.

Question 25

3. Hoarse voice history

Answer 25

Hoarseness (dysphonia) is a disorder characterised by altered vocal quality, pitch, loudness or vocal effort that impairs communication or reduces voice-related quality of life (QoL).

The duration of hoarseness is important to ascertain.

• For example, acute laryngitis, caused by an upper respiratory tract infection or short-term vocal abuse, is a common and self-limiting cause of hoarseness and usually resolves within two weeks.

It is important to enquire about any associated symptoms.

Upper respiratory allergies often involve the larynx and cause hoarseness in addition to rhinitis and conjunctivitis.

The presence of heartburn may suggest reflux of stomach contents into the larynx, a recognised cause of hoarseness.

Hoarseness can be a symptom of various neurological conditions, such as Parkinson’s disease, multiple sclerosis (MS) and cerebrovascular accidents; and of systemic diseases such as hypothyroidism, sarcoidosis and acromegaly.

Weight loss, dysphagia, odynophagia, haemoptysis, or symptoms of airway obstruction such as stridor, raise the possibility of malignancy.

Medications can have an adverse effect on voice quality. In a 2007 study of the hazardous effects of inhaled corticosteroids on voice quality, higher doses and frequency of use were associated with more voice problems.

Other medications that can potentially affect voice quality include antipsychotics (laryngeal dystonia), angiotensin converting enzyme inhibitors (when causing chronic cough) and bisphosphonates (which can cause a chemical laryngitis).

You should ask about smoking and excessive alcohol consumption, as they are both risk factors for laryngeal problems.

• While smoking did not independently increase the risk of voice disorders in a population study, hoarseness in tobacco smokers is associated with an increased frequency of polypoid vocal fold lesions, and head and neck cancers.

Ascertain pattern of voice use and the vocal demands of occupation.

Dysphonia has been shown to be more common in singers, teachers, clergy, lawyers and operators at call centres.

For professional voice users, chronic or recurring dysphonia may have severe career and economic consequences.

Question 26

3. Hoarse Voice Management

Answer 26

Provided no alarm symptoms or signs, such as

• haemoptysis,
• dysphagia,
• stridor,
• abnormal cervical lymph nodes or
• a neck mass,

Addressing risk factors would be appropriate initial management.

Patients should be counselled on the benefits of quitting smoking, and provided advice on effective ways to do this.

If asthma is well controlled, and it is reasonable to trial stopping the inhaled corticosteroid, as this was found to be the most effective treatment for voice disorders associated with inhaled steroid use.

Asthma will then require close monitoring, as patients with well-controlled asthma who stop taking regular inhaled steroids have an increased risk of flare-ups.

Both caffeine and alcohol use are associated with gastric reflux, which may be silent and a contributor to hoarseness, so advice to modify these is sensible.

Voice protection can also help with voice recovery. This may involve taking some time off work and/or modifying her voice use at work.

Patients should not be routinely prescribed antibiotics. Bacterial infection is a very rare cause of either acute or chronic hoarseness, and clinical guidelines state that the clinician should not routinely prescribe antibiotics to manage hoarseness.

Patients should not be prescribed anti-reflux medication if they has no symptoms or signs of reflux. Studies have shown that up to 55% of patients presenting with hoarseness have laryngopharyngeal reflux.

However, a 2006 Cochrane review found that the benefit of anti-reflux treatment for hoarseness in patients without symptoms of oesophageal reflux (heartburn and regurgitation) or evidence for oesophagitis was unclear, mainly because of a lack of good-quality studies.

Current guidelines recommend that the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastro-oesophageal reflux disease (GORD).

Patients should also not be prescribed steroids, as there is no evidence to support the empirical use of oral corticosteroids in the treatment of hoarseness.

Timely review of the patient is important to check whether these measures have helped with the hoarseness.

Question 27

3. Persistent Hoarse Voice Inx/Management

Answer 27

Current guidelines recommend that laryngoscopy be performed by someone skilled in the technique, when hoarseness fai

ls to resolve after a maximum of three months of onset, or irrespective of duration if a serious underlying cause is suspected.

Serious causes include

• laryngeal malignancy,
• fungal infection, and
• neurological diseases such as myasthenia gravis and motor neurone disease.

Smoking history puts patient at higher risk of laryngeal cancer than the general population, and early laryngoscopy allows for prompt institution of appropriate management if a cancer is found.

Laryngoscopy is also the most effective way to diagnose many other types of chronic hoarseness:

Unilateral vocal fold paralysis – this causes breathy hoarseness. It is often caused either by surgical damage to nerves, or by thoracic, cervical or brain tumours that compress or invade the vagus nerve or its branches.

Stroke may also present with hoarseness due to vocal fold paralysis. Vocal fold paralysis is routinely identified, characterised and followed by laryngoscopy.

Benign vocal fold lesions – these include vocal fold cysts, vocal cord nodules and vocal cord polyps, and they are readily detected on laryngoscopy.

In addition, there is significant evidence for
the usefulness of laryngoscopy in planning voice therapy and in documenting the effectiveness of voice therapy when treating vocal lesions.

Laryngopharyngeal reflux – this term is used when GORD affects the pharynx and larynx. Visualisation of the larynx may demonstrate changes suggesting the diagnosis of laryngopharyngeal reflux,
such as arytenoid erythema, mucosal oedema, contact ulcers and granulomas.

Neurologic disease

• Parkinson’s disease,
• amyotrophic lateral sclerosis and
• MS
• may affect the muscles of the larynx.*
• Spasmodic dysphonia is a distinct neuromuscular disorder of unknown aetiology that results in uncontrolled contraction of the laryngeal muscles and focal laryngeal spasm.

Question 28

3. Benign vocal cord nodules Mx

Answer 28

Vocal hygiene

There is evidence that vocal hygiene education can be effective in the management of hoarseness.

Vocal hygiene programs evaluated included

• education in environmental changes (eg humidification of the air, and avoidance of smoke, dust, and other inhaled irritants);
• behavioural changes (eg avoidance of frequent coughing or throat clearing);
• vocal habit changes (eg avoidance of shouting or speaking loudly for prolonged periods); and
• dietary changes (eg increased fluid intake, and avoidance of large meals, excessive caffeine and alcohol use, and spicy foods).2

Voice therapy

Voice therapy refers to a variety of non-surgical techniques used to improve or modify voice quality.2 For example, the accent method uses rhythmic exercises to facilitate the coordination of vocal fold vibration with appropriate air pressure and air flow. Digital laryngeal manipulation, also called laryngeal massage, aims to decrease excessive contraction of the muscles of the larynx.

• Vocal function exercises involve three components:
  
  • warm up
  • pitch glides (high to low and low to high)
  • sustained vowel phonation at selected pitches.

Evidence from clinical trials documents the efficacy of voice therapy for a spectrum of voice disorders in adults and children, including benign vocal cord lesions and spasmodic dysphonia.

Referral to an appropriately qualified and experienced speech pathologist is an important component of management.

Surgery

Many benign, soft tissue lesions of the vocal folds are self-limited or reversible after instituting appropriate vocal hygiene and voice therapy measures. Surgery is reserved for benign vocal fold lesions when a satisfactory voice result cannot be achieved with conservative management. In cases in which surgery is necessary, pre- and post- operative voice therapy may shorten the postoperative recovery time, allowing faster return to work and limiting scar tissue and permanent dysphonia.

Other treatment considerations

Hoarseness can have significant implications for patients’ QoL, and patients may suffer social isolation and depression. Hoarseness may also impair work-related function.

In the general population, 7.2% of individuals surveyed in America missed work for one or more days within the preceding year because of a problem with their voice.

Among teachers, this rate increases to 20%

Question 29

4. Allergic Rhinitis History

Answer 29

S&S

• runny nose,
• itchy nose and eyes,
• cough,
• sneezing, and
• headache on and off
• no fevers

Additional history-taking should include

• family history,
  
  • Allergic rhinitis has a significant genetic component, so a positive family history for atopy makes the diagnosis more likely.
• exposure to allergens and
  
  • A thorough history of environmental exposures helps to identify specific allergic triggers. This should include investigation of risk factors for exposure to perennial allergens (eg dust mites, mould, pets).
• other comorbid conditions.
  
  • such as asthma
  • or atopic dermatitis.
  • Of patients with allergic rhinitis, 20% also have symptoms of asthma. Uncontrolled allergic rhinitis may cause worsening of asthma or even atopic dermatitis.

Question 30

4. Allergic Rhinitis DDx

Answer 30

Other possible causes are rhinitis due to other causes (vasomotor, gustatory, hormonal, anatomical), nasal polyps, acute sinusitis and chronic sinusitis.

Sinusitis and anatomical causes such as deviated nasal septum and nasal polyps can be further excluded from clinical examination and imaging

Question 31

4. Allergic Rhinitis Inx

Answer 31

Testing for reaction to specific allergens can be helpful to confirm the diagnosis of allergic rhinitis and determine specific allergic triggers.

Knowledge of specific allergens will be very useful in management, such as avoidance and immunotherapy.

The most commonly used methods for identifying an allergy to a particular substance are skin testing (testing for immediate hypersensitivity reactions) and RAST, which indirectly measures the quantity of specific immunoglobulin E (IgE) to a particular antigen.

General practitioners (GPs) can order a RAST test but, in Australia, referral to a specialist or allergy clinic is required for skin prick tests. The RAST test is subsidised by the Medicare Benefits Schedule (MBS) with restrictions (MBS item 71079); up to four tests in a 12-month period can be claimed through the MBS.

Total IgE may be raised in people with allergies. High total IgE antibody levels are also found in people with parasite infections, eczema and some rare medical conditions such as allergic bronchopulmonary, aspergillosis, Hodgkin’s lymphoma, systemic vasculitis (especially Churg–Strauss syndrome), primary immunodeficiencies (especially hyper-IgE syndrome, Wiskott–Aldrich syndrome) and IgE myeloma.

High IgE levels do not prove that symptoms are due to allergy, and a normal IgE level does not exclude allergy. Therefore, measuring total IgE levels is not routinely recommended in allergy testing.

Eosinophils are specialised white blood cells that are designed to kill worms and parasites. They can also cause tissue inflammation in allergies. High levels of eosinophils are sometimes seen in blood samples from people with allergic rhinitis, asthma and eczema, as well as in a number of less common conditions.

However, a high eosinophil count does not prove that symptoms are due to an allergy, and a normal eosinophil count does not exclude allergy. Therefore, measuring eosinophil counts has a limited role to play in allergy testing.

Question 32

4. Allergic Rhinitis Mx

Answer 32

The management of allergic rhinitis consists of three major categories of treatment:

• allergen avoidance

• pharmacological management

• immunotherapy.

Allergen avoidance and environmental controls requires identification of the specific allergen(s).

Pharmacological management consists of the following:

• oral or intranasal antihistamines
• intranasal nasal corticosteroids
• leukotriene receptor antagonists
• intranasal decongestants.

Intranasal corticosteroids medication is the mainstay of treatment and probably the most effective option.

The Australian asthma handbook recommends intranasal corticosteroids for adults and children with persistent allergic rhinitis or moderate-to-severe intermittent allergic rhinitis, even if the person is already taking regular inhaled corticosteroids for asthma.

Further, if symptoms are troublesome to the patient, consider initially adding an agent with a more rapid onset of action (eg oral or intranasal

H1-antihistamine or short-term intranasal decongestant). Warn patients not to take intranasal decongestants for more than five days, and only occasionally.

For young children with mild allergic rhinitis or intermittent allergic rhinitis, or those who will not tolerate intranasal medicines, consider an oral H1-antihistamine. Avoid older, sedating antihistamines. If allergic rhinitis symptoms do not resolve within three to four weeks, consider allergy testing and review the diagnosis.

Immunotherapy reduces the patient’s immunoreactivity to harmless environmental antigens (allergens). It is indicated for severe allergic rhinitis that is not responsive to pharmacotherapy. It is available in subcutaneous and sublingual administration forms and requires care by an allergy specialist or immunologist.13

There is evidence from meta-analyses for the efficacy of subcutaneous and sublingual immunotherapy in the management of allergic rhinitis and asthma.

Subcutaneous immunotherapy is widely available for various types of allergens, whereas sublingual immunotherapy is limited to a few allergens.

Subcutaneous immunotherapy is associated with local adverse effects, which may occur in up to 10% of patients (eg injection- site swelling) and, less frequently, with serious systemic adverse effects (eg anaphylaxis).

Subcutaneous immunotherapy is generally not suitable for younger children (eg less than seven years of age) because they may not be able to tolerate frequent injections.

Sublingual immunotherapy is available for a limited number of allergens in Australia. Higher doses of allergen are required, compared with subcutaneous immunotherapy. The cost of sublingual immunotherapy has been reported to be $250 for six months.

Local adverse effects include an unpleasant taste, localised swelling in the mouth, abdominal pain and nausea. Local adverse effects are common in children receiving sublingual immunotherapy.

Systemic adverse reactions, such as anaphylaxis, are very rare (estimated as 1.4 serious adverse events per 100,000 doses). The majority of adverse events occur soon after beginning treatment.

An allergic rhinitis action plan may be helpful for management of Dilan’s condition at home and at school. The Australasian Society of Clinical Immunology and Allergy (ASCIA) provides templates for allergic rhinitis plans.

Question 33

5. Vertigo - Hx

Answer 33

A thorough history of the ‘dizziness’ itself should be taken, including

• light-headedness,
• the duration of episodes,
• aggravating factors and associated symptoms (hearing loss, tinnitus, aural fullness, visual disturbance, aura).

Given that the range of diagnoses is broad and covers many sub-specialties, it is important to take a thorough history, look for common patterns and directly rule out conditions associated with different organ systems (Table 2).

Consider neurological, cardiovascular and endocrine disorders, as well as disorders
of otology that may present with dizziness, disequilibrium, presyncope or syncope.

An accurate history can determine if the dizziness is related to a vestibular disorder. If the patient’s symptoms do not fit common patterns, then you should explore rarer causes

• (eg vestibular migraine or hypotension resulting in dizziness and ataxia).

For elderly patients, although age-related vestibular impairment (presbystasis) is possible, the common causes of dizziness should always be explored, as well as red flags, before presuming that dizzy spells are simply due to ageing.

Question 34

5. Dizziness Red Flags

Answer 34

Dizziness is a complex symptom with a broad differential that commonly presents in primary care.1 Although most of the conditions presenting with dizziness are benign, there are more sinister conditions that need to be directly explored (Table 1).

Ataxia is also a generalised symptom that needs thorough evaluation. Alone it may direct to a neurological cause, but when associated with other symptoms, may suggest more complex disease.

Question 35

5. Vertigo- Examination

Answer 35

Physical examination provides an adjunct to your findings in history and should be focused on the key symptoms.

All patients should have their ears, nose and throat examined.

Dix–Hallpike manoeuvre should be performed in patients with episodic dizziness to diagnose BPPV. This manoeuvre is performed by taking a patient from a sitting to supine position while the head is laterally rotated at 45 degrees, then guiding the head a further 15–20 degrees from horizontal

while maintaining the rotation for at least 60 seconds. It is essential to ensure there is enough room at the end of the bed to allow for effective tilting of the head and it is useful for the examiner to place a seat for themselves at this position to safely maintain the orientation of the patient’s head. Patients should be advised that their symptoms may be reproduced but that they will pass and, despite any nausea, they are extremely unlikely to vomit. Patients must also keep their eyes open to allow examination of the movements of the eyes as part of the interpretation of the test. Nystagmus that is rotational, has a latent period and is fatigable is characteristic of BPPV.9

Basic cardiovascular and neurological testing, including postural blood pressures, cranial nerve examination, examination of sensation and motor function, as well as reflexes, should also be assessed in all patients. Further neurological examination including observing for nystagmus and Romberg’s test should also be performed. This test is performed by having the patient stand with feet together and hands by their sides. On closing eyes a positive test is seen with swaying – indicating a loss of balance.

Question 36

5. Vertigo and balance

Answer 36

Physical examination provides an adjunct to your findings in history and should be focused on the key symptoms.

All patients should have their ears, nose and throat examined. Dix–Hallpike manoeuvre should be performed in patients with episodic dizziness to diagnose BPPV. This manoeuvre is performed by taking a patient from a sitting to supine position while the head is laterally rotated at 45 degrees, then guiding the head a further 15–20 degrees from horizontal while maintaining the rotation for at least 60 seconds. It is essential to ensure there is enough room at the end of the bed to allow for effective tilting of the head and it is useful for the examiner to place a seat for themselves at this position to safely maintain the orientation of the patient’s head. Patients should be advised that their symptoms may be reproduced but that they will pass and, despite any nausea, they are extremely unlikely to vomit. Patients must also keep their eyes open to allow examination of the movements of the eyes as part of the interpretation of the test. Nystagmus that is rotational, has a latent period and is fatigable is characteristic of BPPV.

Basic cardiovascular and neurological testing, including postural blood pressures, cranial nerve examination, examination of sensation and motor function, as well as reflexes, should also be assessed in all patients.

Further neurological examination including observing for nystagmus and Romberg’s test should also be performed. This test is performed by having the patient stand with feet together and hands by their sides.

On closing eyes a positive test is seen with swaying – indicating a loss of balance.

Question 37

5. Dizziness vs Vertigo

Answer 37

The traditional characterisation of vertigo as a spinning sensation, versus dizziness as a different perceived sensation, can be somewhat unreliable.

More importantly, a lack of spinning should not exclude diseases that cause vertigo.

The complex neurological pathways involved in the coordination of balance are below the patient’s level of awareness, which makes symptoms particularly difficult to describe.

It should be emphasised that timing and triggers are more reliable historic factors that should be investigated. Additionally, other significant causes of dizzy episodes have been reported as vertiginous episodes by patients.

• Therefore, over-reliance on the characterisation of a spinning sensation may miss red flag conditions.

Question 38

5. Vertigo Rx

Answer 38

The best treatment is aimed at the underlying cause. However, a patient can be supported through an acute episode of vertigo with short-term use of vestibular sedatives such as prochlorperazine, antihistamines or benzodiazepines (Box 1). These can give the patient comfort, while allowing time to undergo investigations to clarify the cause. These medications should be used as temporary management as there is a possibility of adverse neurological effects and possible dependence.

Medications for acute vertigo attacks

• Prochlorperazine – 12.5 mg intramuscular (IM), followed in six hours by 5–10 mg orally as a single dose if required
• Prochlorperazine – 5–10 mg orally, 3–4 times daily
• Promethazine – 25–50 mg orally, 8–12 hourly for 48 hours
• Diazepam – 5–10 mg orally, three times daily when required

Question 39

5. Meniere’s Disease

Answer 39

Ménière’s disease should be considered in a patient with episodic attacks of vertigo, sensorineural hearing loss (SNHL), which usually fluctuates, and tinnitus, with or without a sensation of aural fullness. It is a diagnosis of exclusion after consideration of other causes of dizziness and vertigo.

Patients with Ménière’s disease have hearing loss that is often, initially, in the low frequencies and fluctuating, but can be progressive in the involved ear.

The hallmark of Ménière’s disease is thought to be primary endolymphatic hydrops – an abnormality in the fluid within the inner ear resulting in fluctuation in pressure.

The aetiology is unclear, although a number of theories, including abnormal endolymph drainage and immune dysfunction,

have been postulated.7 Other pathologies can also result in endolymphatic hydrops, such as otosclerosis and trauma – these are considered secondary causes.

Baseline tests should be performed to rule in Ménière’s disease and exclude other diagnoses.

• Office-based audiogram,
• ECG and
• blood tests, including fasting glucose, should be considered when a patient first presents with dizziness.

Meniere’s disease will usually show normal results to these initial investigations and is therefore usually, initially, diagnosed on clinical grounds alone.

Formal balance testing supports the diagnosis, but can have false negatives (these tests are discussed in another question).

Neuroimaging should be considered to investigate for cerebrovascular disease and a lesion causing mass effect such as a vestibular schwannoma, particularly in patients who have progressive symptoms, unilateral hearing loss, and should not otherwise be a routine initial investigation.

Question 40

5. Dizziness Specialist Referral

Answer 40

Consider referrals to a neurologist and otolaryngologist to assist in clarifying the diagnosis for prolonged or concerning dizziness.

Referral to an otolaryngologist is indicated for persistent vertigo or dizziness that is resistant to conservative measures (diet and lifestyle) and does not resolve within two to three months, or is associated with other otolaryngology symptoms such as hearing loss.

All patients should have formal audiometry done before the referral is made.

Question 41

5. Audiometry Testing

Answer 41

Formal pure-tone audiometry is required; a patient should be referred in the primary care setting if there are any other otological symptoms associated with vertigo.

Formal vestibular assessment by an audiologist can often be performed by professional audiology centres, and an ENG and VEMP tests (usually ordered by otolaryngologist) may assist in the initial evaluation of balance function.

Question 42

5. Meneire’s disease management

Answer 42

It is important to advise patients that there is no cure for Ménière’s disease, but symptoms can often be well controlled.

Symptom control from Ménière’s disease should involve lifestyle management

Lifestyle management of vertigo

• Salt restriction to 3 g per day
• Avoid caffeine
• Avoid stress
• Regular sleep
• Remain physically active, avoid excessive fatigue

and medications that can reduce the frequency and duration of vertigo in most people.

Tinnitus and hearing loss are less responsive to these conservative treatments.

Spontaneous resolution of symptoms occurs in 60% of patients at two years.

Medications are used to reduce endolymphatic pressure by reducing sodium and water content of the endolymph.

First-line prophylactic treatment is a thiazide diuretic. Most often, hydrochlorothiazide 25 mg orally, once daily, is prescribed.

Alternatively, combination therapy with a thiazide diuretic and a potassium-sparing diuretic (eg amiloride, triamterene) may be used. When using thiazide diuretics, electrolytes should be monitored and replaced if required.

Betahistine (Serc) is a vasodilator that has been used on the basis that it may increase blood supply to the inner ear, although this may not be its only mechanism of action in Ménière’s disease. The starting dose of betahistine is 8 mg orally, increasing to 16 mg, two or three times per day.

Specialist otolaryngologist management includes office procedures and surgery, which are reserved for patients in whom episodes of vertigo become intractable or disease progresses despite conservative management.

Consideration may be given for the insertion of tympanostomy tubes, and middle ear infusion with either gentamicin or dexamethasone, or surgery to destroy the inner ear. Gentamicin infusions and surgeries that destroy the inner ear are considered for patients who already have poor hearing on that ear.

Referral to allied health professionals such as physiotherapists or audiologists who have an interest in vestibular disorders should
only be done after consideration of potential diagnoses, to avoid inadvertently referring a patient with a sinister cause of their disorder.

Ménière’s support groups are a helpful resource for patients (refer to ‘Resources for patients and doctors’).

Question 43

6. Hearing impairment

Answer 43

History:

• Which ear is better at hearing?
• What was the onset and progression of your hearing loss?
• Have you had any ear discharge (otorrhoea)?
• Have you had any ear pain (otalgia)?
• Do you get vertigo?
• Do you get tinnitus?
• Have you had any ear operations or head trauma in the past?
• Do you have any exposure to loud noises?
• Do you have a family history of hearing loss?
• Do you have any past or current medical conditions?
• Are you on any medications (ototoxic potential)?

Question 44

6. Hearing impairment

Answer 44

Non-pulsatile, high-pitched tinnitus is generally benign.

For pulsatile tinnitus, an MRI to exclude causes such as arteriovenous malformations or high-riding jugular bulb is considered.

Physical examinations should include:

• otoscopy
• tuning fork tests (Rinnes and Weber)
  
  • Rinne test – using a tuning fork, strike the tuning fork lightly and place it first on the base of the mastoid bone, then in the air beside the ear. Normal hearing AC should be louder than BC. If BC > AC, then this indicates a conductive hearing loss. In SNHL AC>BC
  • Weber test – using a tuning fork, strike the tuning fork lightly and place it high on the forehead in the midline. Ask the patient if the sound is louder in one ear or another. If the sound lateralises there is either a conductive loss in the ear, which it lateralises, or an SNHL in the opposite ear
• cranial nerve examination
• pure tone audiometry
• tympanometry.

Question 45

6. SNHL DDx

Answer 45

Sensorineural hearing loss may have the following underlying causes:

• presbycusis (age-related SNHL)
• noise-induced hearing loss
• acoustic neuroma
• autoimmune disease of the inner ear
• genetic SNHL
• Ménière’s disease
• congenital SNHL
• enlarged vestibular aqueduct
• temporal bone fracture.

Question 46

6. Hearing loss INx and DDx

Answer 46

Investigations should include:

• computed tomography (CT) scan of the temporal bone
• magnetic resonance imaging (MRI) of the brain and temporal bone.

Specialist referral (when the patient presents with hearing loss impacting on his daily living):

• otolaryngologist
• audiologist.

Noise-induced hearing loss could be detected in the history.

Acoustic neuroma could be associated with central signs such as vertigo, tinnitus, and nystagmus and would be excluded with an MRI of the brain.

Autoimmune disease is usually relapsing-remitting, associated with other neurological abnormalities (visual changes, gait disturbances).

Genetic SNHL is suggested by a strong family history of hearing loss.

Ménière’s is associated with vertigo, tinnitus, aural fullness and a fluctuating usually low frequency SNHL.

Congenital SNHL presents in the history; a younger person who has failed the newborn hearing screening program or someone who has not developed speech well indicates congenital loss.

Testing of children for congenital deafness is done soon after birth and an abnormal test result warrants prompt referral to a specialist for further investigation.

Question 47

6. Presbycusis/ age related SNHL

Answer 47

Presbycusis or age-related SNHL.

It is generally a diagnosis of exclusion of other causes of SNHL.

Age-related hearing loss is typically worse for high frequencies and is more severe in men.

The hearing loss is usually progressive and the rate at which hearing deteriorates accelerates with time.

Question 48

6. Cochlear Ear Implant

Answer 48

The cochlear implant program consists of a multidisciplinary team including:

• ear, nose and throat surgeons • audiologists
• social workers
• speech pathologists

• administrative staff.

The program also provides access to additional hospital clinics, such as anaesthetics departments and occupational therapy.

In patients who do not receive adequate amplification from hearing aids, cochlear implantation is a management option.

Current literature supports the use of cochlear implants in the elderly and has been shown to improve quality of life, cognition and social functions in the elderly. With improvements in technology, surgical procedures are shorter and associated with fewer complications and lower device failure rates. There are no reported differences between older and younger patients.

Advanced age is not a contraindication for a cochlear implant and all patients should be referred to an otolaryngologist for assessment.

The eligibility criteria for a cochlear implant vary between different centres but are based primarily on speech perception scores and must meet audiometric criteria.

Question 49

6. Audiometry

Answer 49

Question 50

6. Audiometry

Answer 50

Otoscopy shows normal external auditory canals and intact tympanic membranes. Ralph’s middle ears are aerated and there are no signs of middle ear effusions. His Weber test lateralises to the right and Rinnes demonstrates air conduction is greater than bone conduction bilaterally. His cranial nerve examination is normal.

Pure tone audiometry (Figure 1) reveals a right SNHL and a left severe, sloping-to-profound SNHL.

Question 51

6. Tympanometry

Answer 51

Tympanometry (Table 1) demonstrates normal tympanic membrane and middle ear function.