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ENT UPDATE

ENT UPDATE. Gavin Watters FRCS FRCS(ORL) Consultant ENT Surgeon. PRIMARY CARE. E Vertigo BPPV Tinnitus Otitis Externa N Rhinosinusitis T Globus sensation Snoring. Dizziness. Vertigo Unsteadiness (on walking) Light-Headedness. Vertigo. Definition

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ENT UPDATE

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  1. ENT UPDATE Gavin Watters FRCS FRCS(ORL) Consultant ENT Surgeon

  2. PRIMARY CARE • E Vertigo BPPV Tinnitus Otitis Externa • N Rhinosinusitis • T Globus sensation Snoring

  3. Dizziness • Vertigo • Unsteadiness (on walking) • Light-Headedness

  4. Vertigo • Definition An illusion of movement of the subject or of his/her surroundings. Usually a sensation of spinning or rotation. • Central or Peripheral

  5. Acute Peripheral Vertigo • BPPV < 5 minutes • Meniere’s Disease/Syndrome <24 Hours • Vertigo with migraine <24 Hours • Vestibular/labyrinthine failure >24 Hours

  6. Dix-Hallpike Test

  7. Peripheral Latent period Distress +++ Rotational nystagmus Fatigable Central No latent period Distress +/- Variable nystagmus Not fatigable Dix-Hallpike Test

  8. Calcium deposits in posterior semi-circular canal Brandt-Daroff exercises Epley manoeuvre Obliterate Posterior S-CC Singular nerve neurectomy BPPV

  9. Brandt-Daroff Exercise

  10. Tinnitus • Primary/idiopathic • Secondary Ear disease Vascular Neuronal Neuromuscular

  11. Vascular Vascular stenosis AVM Glomus tumour Conductive HL Hear normal intra-cranial blood flow Pulsatile Tinnitus

  12. Primary Reassurance Advice on environmental masking Hearing aid Need only refer if not coping or unilateral tinnitus Hearing Therapy, masker Secondary Treat underlying ear disease Refer for further investigation/treatment Management

  13. Pain Irritation/Itch Discharge (Hearing loss) Cotton buds Skin condition Diabetes Middle ear disease Anatomical Otitis Externa

  14. Management of OE • Antibiotic/steroid DROPS • Water precautions • Good analgesia • Aural toilet • Steroid ointment • Swab (?Fungal OE) • Systemic antibiotics if cellulitis

  15. Blocked nose Congestion Facial pain/headache Runny nose Catarrh/mucous Unpleasant smell/taste Puffy/swollen face ‘Bags’ under eyes Watery/sticky eye And many more! Sinusitis?

  16. Sinusitis • Cacosmia • Purulent Rhinorrhoea • Hyposmia/anosmia • Facial pain • Frontal headache • Nasal obstruction

  17. Facial neuralgia/migraine Dental Sinusitis TMJ/Myofacial pain Periodicity, not constant Well localised Worse with colds Responds to antibiotics Other sinus symptoms Facial swelling almost never due to sinusitis Facial Pain

  18. Diagnosis of Sinusitis • DIFFICULT! • Nasal endoscopy is the key • Plain sinus X-ray no value • CT scan limited value. 30% normal individuals have CT changes • Facial swelling almost never due to sinusitis • Forehead and periorbital swelling probably is due to sinus infection

  19. Nottingham Rhinology Clinic • 973 consecutive patients • Mean follow-up 26 months • 1/3 diagnosis not sinonasal • 119/679(18%) with sinonasal disease had pain • 43/119 pain not attributable to sinus disease • 76/679(11%) had pain attributable to sinus disease

  20. Neurological Causes(Nottingham Study) • Midfacial segment pain 37% • Tension headache 23% • Migraine 17% • Atypical facial pain 12% • Cluster headache 8% • Others 3%

  21. Summary • Facial pain/frontal headache is not a major feature of sinonasal disease. • Most patients with head pain/pressure have a neurological cause for this symptom • Be very cautious in attributing such symptoms as being due to sinusitis, especially in the absence of objective evidence of sinus disease.

  22. Rhinitis- Aetiology • Intrinsic (vasomotor) • Allergic (seasonal, perennial) • Environmental (SMOKING) • Infective • Hormonal • Medication (Rhinitis medicamentosa) • Systemic medical disorder eg Wegner’s

  23. Topical nasal steroids Use daily Minimum 6-8 weeks Warn no affect for 3-4 weeks but don’t stop Drops more potent than sprays Stop nasal decongestants Stop smoking Add antihistamines? Ipratropium Bromide? Allergen avoidance After allergy testing Immunotherapy Rhinitis- Management

  24. Gastro-oesophageal reflux • Effects 25-40% of British population each week • Atypical manifestations are common Laryngeal Pharyngeal

  25. Laryngopharyngeal Symptoms • Hoarse voice (usually fluctuating) • Globus sensation • Mild dysphagia • Post nasal drip • Chronic cough • Chronic sore throat (mild)

  26. Pathophysiology • Inflammation due to direct action of acid Laryngitis, pharyngitis • Increase in cricopharyngeus muscle tone Globus sensation, dysphagia, pharyngeal pouch • Vagal hypersensitivity Globus sensation, chronic cough • Ciliary damage Post nasal drip

  27. THERAPEUTIC TRIAL WITH A PPI IS WELL WORTH WHILE, PROVIDED THERE ARE NO CLEAR ‘CANCER SYMPTOMS’

  28. Cancer symptoms • Pain, especially odynophagia • Truedysphagia • Change in diet • Weight loss • Food regurgitation Is symptom more noticeable when eating/drinking?

  29. SNORING • Obesity • Oropharyngeal Palate Tongue base ? Retrognaethia Tonsils • Nasal

  30. Non-Surgical LOSE WEIGHT Mandibular splint Treat rhinitis Avoid alcohol in evening Avoid sedatives Stop smoking Sleep on side Surgical Palatal surgery (LAUP) Must exclude OSA Tonsillectomy Nasal surgery Orthognaethic procedures Treatment

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