COMMON PROBLEMS IN ENT

Dr. Richard Isaacs, MD

OUTLINE

Nose
Epistaxis
Chronic Rhinosinusitis
Throat
Peritonsillar Abscess
Tonsillitis
Ear
Hearing Loss
Vertigo
Head & Neck

Dr. Richard Isaacs, MD

ACUTE EPISTAXIS

Nasal mucosa: rich blood supply, anastomoses between internal

and external carotid supply
Causes
Trauma
Chronic irritation e.g. sinusitis, steroid spray abuse
Coagulopathies
Anatomical abnormalities
Vascular malformation
Tumour
90% anterior (capillary, venous in origin)
10% posterior (arterial in origin) may present as haemoptysis,
melaena, haematemesis etc.

Dr. Richard Isaacs, MD

MANAGEMENT

D RSABC D
Anterior vs Posterior
Achieve Haemostasis
Pressure
Ice
Co-Phenylcaine/Cocaine
Cauteurisation
Packing
Balloon
Embolisation
Antibiotics (Flucloxacillin)
Complications

Dr. Richard Isaacs, MD

CHRONIC RHINOSINUSITIS

Inflammation involving nasal mucosa and paranasal sinuses lasting

longer than 12 weeks
Criteria
Anterior and/or posterior mucopurulent drainage
Nasal obstruction
Facial pain, pressure and/or fullness
Decreased sense of smell
Subtypes
With nasal polyposis
Without nasal polyposis
Allergic fungal rhinosinusitis

Dr. Richard Isaacs, MD

MANAGEMENT

Medical Therapy
Nasal lavage Normal Saline
Nasal glucocorticoid sprays
Oral glucocorticoid
Antibiotics (Augmentin, Doxycycline)
Antihistamines
Surgical Therapy
Functional Endoscopic Sinus Surgery (Category of Operation)
Complications
Recurrence
Epistaxis
(Very Rare) Blindness (Retrobulbar Haemorrhage)

Dr. Richard Isaacs, MD

Untreated

WITHOUT
POLYP

WITH POLYP

ALLERGIC
FUNGAL

Oral Steroids

Oral Steroids

Surgery

Topical Steroids

Topical Steroids

Oral Steroids

Steroid Instillation

Steroid Instillation

Steroid Instillation

+/- Antihistamine

+/- Antihistamine

+/- Oral
Antifungals

Oral Antibiotics
Maintenance

+/Antileukotriene

TONSILLITIS/TONSILLECTOMY

Indications controversial in adult population

Management
Analgaesia
+/- Antibiotics (GAS coverage)
Tonsillectomy
Contraindications Velopharyngeal, Acute Tonsillitis
Knife vs Unipolar vs Bipolar
Complications: Haemorrhage, Haemorrhage, Haemorrhage,
Pain (Otalgia)
Post tonsillectomy haemorrhage requires representation
Management involves vasoconstriction, pressure

Dr. Richard Isaacs, MD

PERITONSILLAR ABSCESS

Risk factors
Tonsillitis
Smoking
Symptoms
Trismus
Dysphagia
Systemically Unwell
Management
Drainage (Needle Aspiration vs Surgery)
Antibiotics (Not amoxicillin)
Analgaesia
Tonsillectomy (Acute vs Chronic)
+/- Glucocorticoids
Complications Recurrence (10-15%)

Dr. Richard Isaacs, MD

HEARING LOSS

Sensorineural vs Conductive vs Mixed

Dr. Richard Isaacs, MD

CAUSES
CONDUCTIVE
External Ear

Middle Ear

SENSIRONEUR
AL
Congenital

Bilateral

Noise Induced

Foreign Body

Presbycusis

Tumour

Autoimmune

Infection

Drug Mediated

Trauma

Unilateral

Trauma

Infection

Perilymphatic
Fistula

Cholesteatoma

Acoustic Neuroma

Otosclerosis

Menieres Disease

Glomus Tumour

Idiopathic

HISTORY/EXAMINATION

History
Onset/Time Course Acute vs Chronic, Bilateral vs Unilateral
Aggravating/Relieving Factors
Associated Symptoms Tinnitus, Vertigo, Pain, Discharge
Trauma Physical, Barotrauma, Noise Induced
Medications
Past History Stroke Risk Factors
Examination
Otoscopy
Whispered Voice
Renee & Weber Tests
Pneumoscopy/Tympanoscopy

Dr. Richard Isaacs, MD

INVESTIGATION

Special Tests
Pure tone audiogram
Speech audiometry
Tympanogram
Imaging
CT Temporal Bone
+/- MRI Auditory Canal

Dr. Richard Isaacs, MD

CHOLESTEATOMA

Acquired vs Congential
Locally invasive overgrowth of epithelial cells not cholesterol
Sx: Unilateral Conductive Hearing Loss, Discharge (often
discoloured and malodorous)
Cx: Local invasion, CN VII palsy, Mastoiditis, Meningitis
Management:
Antibiotics
CT Temporal Bone
Surgery Canal Wall Up vs Down
Follow Up Local recurrence, Ossiculoplasty

Dr. Richard Isaacs, MD

VERTIGO
PERIPHERAL

CENTRAL

Unidirectional
Nystagmus

Nystagmus can
reverse direction

Horizontal +/Torsional

Any direction

Menieres

Suppressed with
visual fixation

Not suppressed
with fixation

Vertebrobasilar
TIA

Hearing
Loss/Tinnitus

Neurological Signs

Vestibular Neuritis

Gait preserved

Severe postural
instability

CAUSES
Seconds

BPPV
Perilymphatic
Fistula
Migrainous

Hours

Days

Cerebellar Stroke
Multiple Sclerosis

HISTORY/EXAMINATION

Vertigo vs Dizziness
Peripheral vs Central
History
Onset/Time Course Seconds, Hours, Days
Aggravating/Relieving Factors Movement, Tullios
Phenomenon
Associated symptoms Neurology, Nystagmus
Examination
Assess as per hearing loss
Neurological examination
Dix-Hallpike Test
Investigations
CTB

MANAGEMENT

Non-pharmacological
Vestibular Rehabilitation
Pharmacological
Antiemetics Prochlorperazine (Stemetil), Metoclopramide
(Maxolon), Promethazine (Phenergan)
Vestibular Suppressants Clonazepam (Rivotril), Amitriptyline
(Endep)
Specific
BPPV Epleys Manoeuvre
Vestibular Neuritis Vestibular Suppressants
Menieres Disease Na restrict, Diuretics (HCT), Surgical
Migraine Pizotifen, Amitriptyline, Aspirin
Stroke As per Stroke

HEAD & NECK TUMOURS

Fifth most common cancer worldwide

Most common histology squamous cell carcinoma
Field Cancerization
multiple primary and secondary tumours in upper aerodigestive
tract
tobacco (smoked or smokeless) +/- alcohol synergistic
HPV
betel nut chewing
previous radiation exposure
periodontal disease
occupational exposure e.g. wood-dust

Dr. Richard Isaacs, MD

Thank You

Dr. Richard Isaacs, MD