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ENT in

Primary Care

A Concise Guide

Edoardo Cervoni
Kim Leech

123
ENT in Primary Care
Edoardo Cervoni • Kim Leech

ENT in Primary Care


A Concise Guide
Edoardo Cervoni Kim Leech
ENT Specialist Advanced Nurse Practitioner
Central Park Surgery Central Park Surgery
Leyland Leyland
Lancashire Lancashire
UK UK

ISBN 978-3-319-51986-9    ISBN 978-3-319-51987-6 (eBook)


DOI 10.1007/978-3-319-51987-6

Library of Congress Control Number: 2017935364

© Springer International Publishing AG 2017


This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
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Preface

ENT disease represents a significant percentage of the day-to-day cases seen in ­primary
care – approximately 1 in 4 consultations. Research suggests this figure is between
23% (Cross and Rimmer 2007) and 25% (Lloyd et al. 2014) of all primary care presen-
tations. Unfortunately, the educational curriculum of the medical schools and family
doctor/GP training programs do not parallel the high prevalence of ENT disease. As a
result, health care professionals such as GPs and nurse practitioners (NPs) may refer
many patients to secondary care with ENT problems when they could handle them in
primary care. It is legitimate to assume that a better understanding of the clinical his-
tory, clinical examination and accurate management of ENT disease might lead to a
better management of the ENT patient and a reduction in the number of specialist
appointments requested in general practice. This book is not a complete compendium
of otolaryngology. Instead, it is intended to be a practical guide for the primary care
provider. The topics covered are common and the ENT disease management is the one
you would expect to take place in a primary care setting. The use of ENT diagnostic
instrumentation refers to what should be available in any GP surgery. We think this
book is a useful addition to the library of medical students, GPs in training, board certi-
fied family physicians and NPs. Its format is simple and the text is minimal. The topics
are organized in such a way as to highlight when a patient should be sent to a specialist
immediately and when they can be efficiently managed in general practice.

Leyland, Lancashire, UK Edoardo Cervoni


Leyland, Lancashire, UK Kim Leech

References

1. Cross S, Rimmer M (2007) Nurse practitioner manual of clinical skills, 2nd edn. Elsevier,
London
2. Lloyd S, Tan ZE, Taube MA, Doshi J (2014) Development of an ENT undergraduate curricu-
lum using a Delphi survey. Clin Otolaryngol 39:281–288

v
Acknowledgements

We would wish to personally thank the following people for their contributions to
our inspiration and knowledge and other help in creating this book.
Dr. Cervoni would like to thank the many people who have brought him this far.
They are his relatives, teachers, and colleagues he had the pleasure to work with
over the years, but especially his very much loved children, Oliver Alessandro and
Francesca, with the infinite love that they give every day.
Mrs. Kim Leech would like to acknowledge her parents, Mark and Brenda
Jagger, for her upbringing, their support and encouragement, her husband, Ashley,
for his continued support and constant belief and her beautiful daughter, Maddison.
Finally, we would like to thank the patients for their trust and for having shared
their experience of living with the most diverse ENT pathologies.

vii
Abbreviations

AIDS Acquired immune deficiency syndrome


AOM Acute otitis media
BD Twice a day
BPPV Benign paroxysmal positional vertigo
CHL Conductive hearing loss
CSF Cerebrospinal fluid
EAC External auditory canal
ENT Ears, nose and throat
HIV Human immunodeficiency virus
NSAID Nonsteroidal anti-inflammatory drug
RAST Radioallergosorbent test
SNHL Sensorineural hearing loss
TDS Three times a day
TIA Transient ischaemic attack
TMJ Temporomandibular joint

ix
Contents

1 E
 NT Anamnesis������������������������������������������������������������������������������������������   1
The ENT Consultation ��������������������������������������������������������������������������������   1
ENT History��������������������������������������������������������������������������������������������   1
History of Presenting Complaint ������������������������������������������������������������   2
Past Medical History��������������������������������������������������������������������������������   2
Drug History��������������������������������������������������������������������������������������������   2
Social History������������������������������������������������������������������������������������������   2
References����������������������������������������������������������������������������������������������������   3
2 O
 tology��������������������������������������������������������������������������������������������������������   5
Organ Targeted History��������������������������������������������������������������������������������   5
The Ear����������������������������������������������������������������������������������������������������   5
Ear Equipment ��������������������������������������������������������������������������������������������   6
Otoscope��������������������������������������������������������������������������������������������������   6
Tuning Forks��������������������������������������������������������������������������������������������   8
Frenzel Goggles ��������������������������������������������������������������������������������������   8
Ear Syringe����������������������������������������������������������������������������������������������   9
Otological Examination ����������������������������������������������������������������������������   10
Otalgia����������������������������������������������������������������������������������������������������������  11
Causes of Referred Otalgia��������������������������������������������������������������������������  11
Local Causes��������������������������������������������������������������������������������������������  12
Otitis Externa ����������������������������������������������������������������������������������������������  12
Acute Otitis Media��������������������������������������������������������������������������������������  14
Consequences of Viral and Bacterial Otitis Media����������������������������������  16
Ear Secretions����������������������������������������������������������������������������������������������  18
Otitis Externa ������������������������������������������������������������������������������������������  19
Middle Ear Pathology������������������������������������������������������������������������������  19
Trauma or Foreign Body��������������������������������������������������������������������������  19

xi
xii Contents

Management of Ear Secretions��������������������������������������������������������������������  19


Perforation of Tympanic Membrane������������������������������������������������������������  20
Cholesteatoma����������������������������������������������������������������������������������������������  22
Child Deafness ��������������������������������������������������������������������������������������������  23
With Otalgia��������������������������������������������������������������������������������������������  23
Without Otalgia����������������������������������������������������������������������������������������  23
Adult Deafness��������������������������������������������������������������������������������������������  25
Hearing Tests������������������������������������������������������������������������������������������������  25
Rinne Test������������������������������������������������������������������������������������������������  25
Weber Test������������������������������������������������������������������������������������������������  27
Contraindications ������������������������������������������������������������������������������������  29
Precautions����������������������������������������������������������������������������������������������  29
Evaluation of Auditory Function by GP��������������������������������������������������  30
Services for Patients with Hearing Loss��������������������������������������������������  30
Vestibular System����������������������������������������������������������������������������������������  31
Smooth Pursuit����������������������������������������������������������������������������������������  31
Saccades��������������������������������������������������������������������������������������������������  31
Head-Shaking Nystagmus������������������������������������������������������������������������  31
Fukuda Stepping Test������������������������������������������������������������������������������  32
Hallpike Test��������������������������������������������������������������������������������������������  32
Tinnitus��������������������������������������������������������������������������������������������������������  33
Subjective Tinnitus����������������������������������������������������������������������������������  33
Objective Tinnitus������������������������������������������������������������������������������������  33
Vertigo����������������������������������������������������������������������������������������������������������  33
Objective Vertigo��������������������������������������������������������������������������������������  36
Subjective Vertigo������������������������������������������������������������������������������������  37
Fistula Test ��������������������������������������������������������������������������������������������������  37
Benign Paroxysmal Positional Vertigo (BPPV)��������������������������������������  38
References����������������������������������������������������������������������������������������������������  38
3 R
 hinology����������������������������������������������������������������������������������������������������  39
The Nose������������������������������������������������������������������������������������������������������  39
Nose Assessment������������������������������������������������������������������������������������������  40
Dentist Mirror or a Cosmetic Mirror ������������������������������������������������������  41
Silver Nitrate Sticks ��������������������������������������������������������������������������������  41
Nose Inspection����������������������������������������������������������������������������������������  42
Epistaxis������������������������������������������������������������������������������������������������������  42
Epistaxis in the Child ����������������������������������������������������������������������������������  42
Epistaxis in Adults ��������������������������������������������������������������������������������������  44
Nasal Obstruction����������������������������������������������������������������������������������������  45
Allergic Rhinitis������������������������������������������������������������������������������������������  45
Vasomotor Rhinitis��������������������������������������������������������������������������������������  47
Nasal Polyps������������������������������������������������������������������������������������������������  48
Allergy Testing��������������������������������������������������������������������������������������������  50
Contents xiii

Septal Deviation������������������������������������������������������������������������������������������  50


Inspiratory Nasal Valve Collapse ����������������������������������������������������������������  50
Nasopharyngeal Obstruction������������������������������������������������������������������������  50
Sinusitis��������������������������������������������������������������������������������������������������������  52
Recurring Rhinosinusitis��������������������������������������������������������������������������  53
References����������������������������������������������������������������������������������������������������  54
4 L
 aryngology������������������������������������������������������������������������������������������������  55
The Throat����������������������������������������������������������������������������������������������������  55
Mouth and Throat Assessment��������������������������������������������������������������������  56
Sore Throat��������������������������������������������������������������������������������������������������  57
Pharyngitis ����������������������������������������������������������������������������������������������  57
Other Causes of Pharyngitis��������������������������������������������������������������������  57
Tonsillitis��������������������������������������������������������������������������������������������������  58
Hoarseness ��������������������������������������������������������������������������������������������������  62
Dysphagia����������������������������������������������������������������������������������������������������  63
Acute Dysphagia��������������������������������������������������������������������������������������  63
Progressive Dysphagia����������������������������������������������������������������������������  64
Other Causes��������������������������������������������������������������������������������������������  64
Globus Pharyngeus����������������������������������������������������������������������������������  64
Snoring��������������������������������������������������������������������������������������������������������  65
Key Anamnestic Points����������������������������������������������������������������������������  66
References����������������������������������������������������������������������������������������������������  67
5 H
 ead and Neck ������������������������������������������������������������������������������������������  69
The Oral Cavity and the Neck���������������������������������������������������������������������  69
Neck Lump��������������������������������������������������������������������������������������������������  69
Salivary Gland Lump ����������������������������������������������������������������������������������  70
Facial Palsy��������������������������������������������������������������������������������������������������  70
Herpes Zoster ������������������������������������������������������������������������������������������  70
Bell’s Palsy��������������������������������������������������������������������������������������������������  72
Other Causes������������������������������������������������������������������������������������������������  73
References����������������������������������������������������������������������������������������������������  73
6 P
 ost-operative ORL ����������������������������������������������������������������������������������  75
Adenoidectomy��������������������������������������������������������������������������������������������  75
Trans-tympanic Tubes����������������������������������������������������������������������������������  75
Nasal Surgery����������������������������������������������������������������������������������������������  76
Tonsillectomy����������������������������������������������������������������������������������������������  76
Oncology ORL��������������������������������������������������������������������������������������������  77
Neoplastic Suspect in ENT����������������������������������������������������������������������  77
7 P
 harmacology��������������������������������������������������������������������������������������������  79
Antibiotic Prescribing����������������������������������������������������������������������������������  79
Common ENT Antibiotic Prescribing in Primary Care ��������������������������  79
xiv Contents

Common Prescriptions��������������������������������������������������������������������������������  79


Rhinitis����������������������������������������������������������������������������������������������������  79
Vertigo������������������������������������������������������������������������������������������������������  80
Otitis Externa ������������������������������������������������������������������������������������������  80
Sore Throat/Mouth����������������������������������������������������������������������������������  80
Glue Ear ��������������������������������������������������������������������������������������������������  82
Reference ����������������������������������������������������������������������������������������������������  82
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Index��������������������������������������������������������������������������������������������������������������������  85
Chapter 1
ENT Anamnesis

The ENT Consultation

There are many well-documented consultation models such as Helman’s Folk Model
(1981), Pendleton et al. (1984), Neighbour (1987) and Calgary-Cambridge (1996) to
name but a few. Many of which, designed in Primary Care. The use of consultation
models helps to add structure to the consultation and ensure all relevant aspects are
explored. It is not the intention of this book to specify a preferred model or whether
a clinician devises their own model. However, there is a common factor in that all
models which includes presenting complaint, past medical history, drug history,
social history, examination, differential diagnosis, investigations and treatment.

ENT History

Undertaking an effective clinical history is an essential part of the ENT consultation, as


it is with any aspect of medical practice. The content explored will vary from clinician
to clinician and depend upon the patient’s past medical history, social history and drug
history, as well as previous experiences. It is essential that the clinician has good com-
munication skills, both verbal and non-verbal and may notice any cues given by the
patient. Smith (2003) suggests that if the clinician listens to the patient, they will tell
you the diagnosis. The information collected in the history will enable the clinician to
target their questions to a certain line of enquiry and will guide the clinician to which
investigations may be appropriate. During the history taking, the physician-patient
relationship takes shape. It allows the clinician to get to know their patient, gain their
confidence and trust and develop an understanding of any external influences that
might affect their health. It also allows the clinician to explore the patient’s ideas, con-
cerns and expectations. This is a crucial element of the clinical encounter for several
reasons, including understanding of their condition and compliance to treatments.

© Springer International Publishing AG 2017 1


E. Cervoni, K. Leech, ENT in Primary Care,
DOI 10.1007/978-3-319-51987-6_1
2 1  ENT Anamnesis

History of Presenting Complaint

When a patient presents with an ENT complaint, it is important to ascertain factors


such as onset, frequency and duration of symptoms, whether the patient has any
other associated symptoms and what treatments, if any they have already tried. At
this point, the physician should address questions specific to the system or systems.
In relation to ENT, whether the patient has experienced any dizziness, congestion,
decreased smell, hoarseness, odynophagia, swellings or lymphadenopathy, pain or
discharge (to name a few ENT symptoms.) Corbridge (2011) suggests that, in gen-
eral, unilateral symptoms should increase the clinician’s suspicion because most of
the conditions that have serious consequences, such as tumours and cancers, are
unilateral, at least initially.

Past Medical History

The clinician should ascertain a patient’s past medical history. This may help the
clinician determine if it is a recurring health problem. A history should include
allergies. This is especially important in ENT presentations. Any history of asthma
or respiratory conditions, neurology or rheumatology may also be significant.
Undertaking a past medical history may affect a patient’s treatment plan or options
for surgery and anaesthesia.

Drug History

Reviewing patient prescribed medications may alert a clinician to pre-existing ENT


complaints or the presenting complaint may be because of a current medication. For
example, a patient who presents with epistaxis who is prescribed apixaban or a
patient presenting with hearing loss or tinnitus who is prescribed a macrolide or
maybe quinine. A clinician should ascertain if the patient is taking any other medi-
cations, prescribed, over-the-counter or otherwise obtained.

Social History

Many clinicians utilise physician-centred approaches to social history, which can be


limiting to smoking, drinking alcohol and the use of drugs. However patient-centred
approaches are often more in-depth and incorporate a wider range of social factors
such as place of birth, qualifications/education, occupation, home environment,
diet, exercise, sexual history, religion, tobacco, alcohol and drug use. In some cases,
the details of the patient’s household may also be relevant (Fig. 1.1).
References 3

Ototoxic

Anticoagulants
s
ug
Dr Affecting the vestibular system

Affecting BP

Alcohol

Smoking

Social history Occupation


Past ENT history
ENT anamnesis No
is e
Current ENT signs and e x p os Occupation
ure
symptoms
Hobbies

Endocrinology
G
en Allergology
er
a lc
on Immunology
diti
ons
Cardiology

Mental Health

Rheumatology

Infectious diseases

Fig. 1.1  ENT anamnesis map

References

Corbridge RJ (2011) Essential ENT. 2nd edn. CRC Press, London


Helman CG (1981) Disease versus illness in general practice. J R Coll Gen Pract 31:548–562
Kurtz SM, Silverman JD (1996) The Calgary-Cambridge Referenced Observation Guides: an aid
to defining the curriculum and organising teaching in communication training programmes.
Med Educ 30:83–89
Neighbour R (1987) The inner consultation. Lancaster, MTP
Pendleton D, Schofield T, Tate P, Havelock P (1984) The consultation: an approach to learning and
teaching. Oxford University Press, Oxford
Smith R (2003) Thoughts for new medical students at a new medical school. BMJ.
327(7429):1430–1433
Chapter 2
Otology

Organ Targeted History

The Ear

Hearing loss is a very common presenting symptom of ear disease. It is estimated


that ten million people in the UK suffer with this complaint. Hearing loss can occur
in the external, middle or inner ear and can be conductive, sensorineural in nature or
both. The clinician should ask the patient how long they have been experiencing the
symptoms, was it a sudden loss or gradual and whether it is unilateral or bilateral.
Unilateral loss could indicate important pathology. Family history of hearing loss
can be relevant, and gaining an understanding of any professional or recreational
noise the patient has been exposed to could be significant. In a child, it is important
to enquire about previous infections, trauma at birth or anoxia, and other medical
conditions. Ear problems can very often result in otalgia (ear pain).
Due to the distribution of cranial nerves and shared innervations such as of tem-
poromandibular joint, mouth, teeth, salivary glands and throat; otalgia can quite
often be because of referred pain. Therefore, the clinician needs to determine if the
pain is from a direct or a referred cause. The clinician should explore whether the
pain is acute or chronic and whether it has been a recurrent problem. The patient may
describe the pain as sharp, dull, a discomfort, a deep penetrating pain or diffuse ante-
rior pain. The clinician should ascertain what the exacerbating and alleviating factors
are and whether there are any associated symptoms such as fever, congestion, nasal
or ear discharge, sinus pain or headaches. As mentioned, otalgia can be because of
referred pain for example tonsillitis. Fifty percent of ear pain is from a dental or TMJ
causes, therefore a comprehensive history should assess ear, dental, sinus, jaw, neck,
tongue, mouth and neurological disorders that can affect the head and neck.
Otorrhoea is a common presentation in primary care, especially in children. The
clinician should ask the patient about onset, duration, amount and quality of
­otorrhoea. A purulent discharge could indicate infection, whilst a blood-stained

© Springer International Publishing AG 2017 5


E. Cervoni, K. Leech, ENT in Primary Care,
DOI 10.1007/978-3-319-51987-6_2
6 2 Otology

o­ torrhoea may indicate trauma. Likewise, patients with a mucous discharge may
have a perforated tympanic membrane and patients with a clear fluid following a
head or skull injury could have a CSF leak. A foul-smelling otorrhoea is character-
istic of cholesteatoma. However, there are other infections leading to extremely
malodorous ear secretion such as infection caused by Proteus. The history should
investigate any childhood illness, trauma, foreign bodies, respiratory symptoms,
any ENT surgery or excessive exposure to water e.g. swimmers. Associated symp-
toms such as hearing loss, tinnitus, pain, vertigo and facial palsy should also be
explored. Vertigo and facial palsy associated with otorrhoea require urgent
referral.
Patients complaining of ear noise (tinnitus) often indulge in a very detailed
description of what they hear. Most of this is useless in making the diagnosis.
Tinnitus has many causes, including hearing loss, loud noise exposure, head
injury or surgery and side effects of medications. Aspirin, NSAIDs, furosemide
and quinine have all been associated with tinnitus. The clinician should ascer-
tain the patient’s symptoms, whether they are experiencing a ringing, any aural
fullness, fluctuating hearing loss, vertigo, otalgia or vestibular symptoms.
However, it is important to recognize if the tinnitus is non-pulsating or pulsating
since the latter may occur with severe vascular tumours or malformations. Ear
popping and cracking are suggestive of Eustachian tube dysfunction, as it is a
feeling of pressure inside the ear. Subjects suffering from Ménière’s syndrome
may report a similar experience. Dizziness accounts for 2.5% of primary care
presentations and of which 50% of dizziness presentations have an ontological
cause. When obtaining the clinical history, the clinician should ascertain onset,
duration and associated symptoms. Hain (1997) suggests duration can help to
diagnose the complaint: BPPV (usually lasts seconds), TIA (minutes), Ménière’s
(hours), vestibular neuronitis (days) and ototoxins (years). Associated head
movement or change in head position, hearing disturbance, headache, cognitive
symptoms and stress are helpful to explore. If after picking up the history you
do not have a suspect, it is unlikely that diagnostic clinical examination and
further investigations may bring to fruitful results. The facial nerve is in close
anatomic relationship with the ear and it can be involved in its pathology.
Therefore, the patient may experience change in sense of taste or facial weak-
ness. The clinician should explore this, as the patient may fail to recognise the
link and its relevance (Fig. 2.1).

Ear Equipment

Otoscope

It is a fundamental tool that can be fitted with or without sliding lens (this allowing
the use of instruments such as the Jobson Horne for removal of earwax), and pneu-
matic pump for assessment of tympanic membrane mobility. Best visualisation of
the external auditory canal (EAC) is achieved positioning your head at the same
Ear Equipment 7

Aminoglicosides

Affecting the vestibular system

Quinine

s Salicylates
r ug
D
Loop diuretics

Cisplatin

Erythromycin

Neurofibromatosis
ry
isto Deafness
lt h
Blood mi
Fa

Aqueous Disch Referred


arge Pain
Serous
Direct Seconds

Purulent Otological Days


Duration anamnesis Duration
Ve Minutes
Onset ing rtig
Type if hearing loss Hear o
Hours
Progression Symmetry
Positional

Triggers Spontaneus
Fe Induced by stimulation
ve
r
Hypertermia

Hyperpyrexia

Ti Low
nn Pitch
itu
s High

Pulsation
Type
Non-pulsation
Severity

Fig. 2.1  Otological anamnesis map

Fig. 2.2 Otoscope

level as the patient’s head. With the free hand, the clinician should straighten the
external auditory meatus (ear canal) by gently pulling the auricle upward and back-
ward in the adult and downwards and backwards in the child. The clinician should
choose the widest speculum that will comfortably fit into the patient’s ear, as this
would provide the best view of the ear structures. The clinician should choose the
largest speculum that will comfortably fit into the patient’s ear, as this would pro-
vide the best view of the ear structures (Fig. 2.2).
8 2 Otology

Tuning Forks

In ENT, tuning forks are used to assess hearing loss and ascertain whether the
hearing loss is conductive or sensorineural in nature. Each tuning fork carries a
number (128, 256, 512 and 1024  Hz.) This is the frequency at which the fork
vibrates.

Diapason at 512 Hz

The 512 Hz tuning fork is the most effective in the range of clinical diapasons avail-
able as the patient may not recognize a lower frequency (128, 256 Hz), and higher
frequencies have a shorter duration making the Rinne test difficult to perform. The
tuning fork may be made of steel or aluminium, the latter being a much cheaper
material, but is suitable to clinical use (Fig. 2.3).
The easiest and most useful hearing tests to perform are the Rinne and the
Weber test. The Rinne and Weber test are used to differentiate between
­conductive hearing loss (CHL) and sensorineural hearing loss (SNHL). Both
should be carried out and the Rinne test should be done first. We shall address
the details of both tests in a separate section of this book dedicated to hearing
evaluation.

Frenzel Goggles

The Frenzel goggles are helpful to assess nystagmus, a condition of involuntary


movement of the eyes, the assessment of which is often extremely helpful to
­diagnose pathologies affecting the vestibular system (Fig. 2.4).

Fig. 2.3  Tuning fork sets


Otological Examination 9

Fig. 2.4  Frenzel goggles

Fig. 2.5  Electronic syringe

Ear Syringe

Ear syringing is the most common ENT procedure carried out in primary care. Its
purpose is the removal of cerumen. There are many types of ear syringe, including
metallic, glass or made of plastic and electric with automatic pressurization
(Propulse II.) The Medical Device Agency advocates the use of the Propulse II as
the safest device (Fig. 2.5).
10 2 Otology

Otological Examination

In addition to the clinical anamnesis we have described in the previous sections, the
complete otological examination comprises a physical examination and testing
which includes:
• Inspection
• Otoscopy
• Removal of cerumen if present
• Use of tuning forks
• Pneumatic otoscopy/“fistula test”
• Vestibular system assessment
• Cranial nerve exam
• Head and neck exam
It is common practice to examine the unaffected or least affected ear first. This
will set a baseline for the clinician to compare the other ear to. The clinician should
start by assessing the pinna, reviewing the skin around, behind and adjacent to it.
Evaluate for the presence of scars, as this may be significant in framing the clini-
cal scenario (Figs. 2.6 and 2.7).
The clinician should assess whether there is a deformity of the pinna, or any skin lesions.
The clinician should then assess the appearance of EAC. The otoscope is funda-
mental to this providing magnification and illumination. The otoscope will be used
in conjunction with a speculum of the largest size that can fit in the  EAC  of the
patient without causing discomfort. Pulling the pinna upwards  and  ­backwards
straightens the ear canal, and the clinician should assess:
• Normal findings such as hair, and cerumen
• Abnormal findings such as dry flaky skin suggestive of eczema, inflamed or
swollen ear canal, discharge, impacted cerumen or foreign body
• The appearance of tympanic membrane – this includes analysing the m ­ obility of
the TM, any retraction pockets, the presence of keratinous a­ ccumulations, any
erosion of the ossicular chain, any perforations or scars (Fig. 2.8)

Temporal
fascia grafting
site

Retroauricular
approach
Retroauricular
approach

Grafting
site

Fig. 2.6  Surgical scars


Causes of Referred Otalgia 11

Fig. 2.7  The ear Helix

Triangular fossa
Scaphoid fossa

Crus of helix Crura of antihelix

Tragus
Concha cava

Antihelix

Antitragus

Lobule

Fig. 2.8  Intact tympanic


membrane

Otalgia

Earache is a common presenting complaint in primary care. Often, but not always,
it is indicative of an ear infection. When the otoscopic examination is normal, the
ear pain is a referred pain. In addition, the healthcare professional has to be aware
that catarrhal otitis can lead to chronic acute otitis media and vice versa. When con-
sidering an ear infection, in conjunction with the clinical history, the diagnostic
elements illustrated in the following paragraphs are of extreme relevance.

Causes of Referred Otalgia

There are several possible causes of otalgia. Among them are:


• Tonsillitis
• Mononucleosis
12 2 Otology

• TMJ syndrome
• Cervical spondylosis
• Cancers of the throat, mouth and nasopharynx
• Odontogenic
In the following sections we shall explore the local causes of otalgia, whilst some
of the conditions causing referred otalgia will be discussed in other sections of the
book instead.

Local Causes

The main local causes of otalgia are trauma, or pathology of the pinna, otitis externa,
and otitis media.

Otitis Externa (Fig. 2.9)

Clinical Presentation
Otitis externa may be due to acute or chronic eczema, psoriasis, seborrhoeic derma-
titis, skin infection of the EAC or pinna.
Examination
• Itching and/or ear pain
• Watery secretion
• Some deafness, or blocked ear
• Pain that radiates towards neck and adenopathy
Clinical Management
• Antibiotic and topical steroid drops for 5 days
• Cream and/or antibiotic drops with steroid and gauze
• Ear swab for microbiological examination
• Diabetic control if applicable
• Consider shampooing
• Acetic acid in drops or spray
• Use of ear plugs to avoid water entering the ear canal

Key Points
Refer to a specialist if marked stenosis of the EAC, or in case of ear obstruction
due to exostosis of the EAC, keratin debris, facial cellulitis, persistent symp-
toms resistant to medical treatment, and infections interfering with the use of
hearing devices. Other causes of otitis externa are boils, which are very painful
especially to traction of the pinna; shingles; myringitis bullosa haemorrhagica;
and perichondritis, which require hospitalization for appropriate therapy.
Otitis Externa 13

Fig. 2.9  Otitis externa

RED FLAGS

Painless secretion

Pain which does not parallel clinical observation

Non resolving otalgia especially in the diabetic patient

Recurrent/Persistent unilateral infection

Facial nerve deficit


14 2 Otology

Acute Otitis Media

The acute otitis media, or AOM, may be viral or bacterial.


Viral Otitis Media (Fig. 2.10)
Clinical Presentation
Viral otitis media may be secondary to upper respiratory tract infection, there
may be the absence of fever, or mildly raised temperature and one of both ears
may be affected. Children may present in combination with vomiting and
diarrhoea.
Examination
• Hyperaemia of the handle of the hammer
• Bubbles and fluid behind a tympanic membrane flushed, but intact
• The absence or decrease of luminous triangle
• Hypervascularisation of the tympanic membrane
Clinical Management
• Acetaminophen during the 24 h, when the pain is more accenuated.
• NSAIDs, such as ibuprofen, may be particularly helpful at night.
• If the ear pain persists for more than 24  h, review pain control and
­consider  antibiotic therapy, particularly if fever, age less than 3  years old,
yellow tinged middle ear secretions, or perforation of the tympanic
membrane.
• Check in 2 weeks to prevent relapse.

Fig. 2.10  Viral otitis media


Acute Otitis Media 15

Key Points
Refer to the ENT specialist recurring otitis media if cause for concern for the
patient, family, or GP.  Also refer to the ENT consultant if chronic otalgia,
recurrent or from otological causes.

Acute Bacterial Otitis Media (Fig. 2.11)


Clinical Presentation
Patients may present following a viral otitis media. It can be a complication of
tonsillitis and be associated with a high fever. Vomiting may also be present. If a
perforation is present, there may be a discharge of purulent fluid with or without
blood, and pain.
Examination
• Tympanic membrane is red and bulging
• Central perforation with presence of pus
• Haemorrhagic areas
Clinical Management
• First-line treatment is ibuprofen or paracetamol. Observe. If no improvement
after 72 h, amoxicillin 500 mg tds for 5 days.
• For people who are allergic to penicillin, prescribe a 5-day course of clarithro-
mycin bd.
• Treat pain and fever with paracetamol or NSAID such as ibuprofen.
• Admit for immediate paediatric assessment, any child younger than 3 months of
age with the presence of a temperature of 38 °C or more and any child 3–6 months
of age with the presence of a temperature of 39 °C.

Fig. 2.11  Acute bacterial


otitis media
16 2 Otology

• Admit for immediate specialist assessment, adults and children with acute com-
plications of acute otitis media such as meningitis, mastoiditis, or facial nerve
paralysis.
• Consider admitting patients who are systemically unwell.
• Consider admitting people with significant, persistent symptoms on high-dose
amoxicillin/clavulanic acid, or azithromycin.

Consequences of Viral and Bacterial Otitis Media

• Full resolution: no action to follow.


• Persistent otalgia: refer to specialist.
• Serous otitis media: if asymptomatic, observation; if painful or cause of deaf-
ness, refer to ENT.
• If associated with acute tympanic membrane perforation, suggest avoiding the
entrance of water in the ear canal and review the patient in 1 month; refer to the
specialist if the perforation has not closed.
• Myringosclerosis (white limestone plaques in the context of the tympanic
­membrane): no further action required unless this is associated with significant
hearing loss. In that case, ENT referral is indicated (Fig. 2.12).
• Chronic tympanic perforation: ENT referral (Fig. 2.13).

Fig. 2.12 Myringosclerosis
Acute Otitis Media 17

Fig. 2.13  Chronic tympanic


membrane perforation

Key Points
Acute otitis media in adults is uncommon in those subjects that have not been
already prone at a young age and as such it should be followed-up carefully.
Refer to specialist in the absence of a speedy resolution, or in case of
recurrence.
Any child younger than 2  years old that is unwell needs otoscopic
examination.
The level of concern of relatives often goes in parallel with the severity of the
ENT pathology.
Treating otitis media with analgesia for 24 h does not harm the patient’s
health.
An exudative otitis media in an adult without previous history of ontological
problems should trigger special attention.
A mastoid abscess should not be diagnosed in the presence of normal tym-
panic membrane, or almost normal.
A mastoiditis requires hospital admission if evidence of complications.
18 2 Otology

RED FLAGS

Children < 3 monthes of age with a temperature > 38ºC

Children 3-6 months of age with a temperature > 39ºC

Swelling or pain to the mastoid process

Symptoms and signs suggestive of meningitis

Facial nerve deficit

Ear Secretions (Fig. 2.14)

The presence of ear discharge is a common finding in general practice. The presence
of secretions in the EAC does challenge the clinician’s ability to visualize the tym-
panic membrane without the help of a suctioning device. As such, the clinician
should be particularly careful in their proposed management. In the presence of
history of ear surgery, or surgical incision, the patient should be referred to the ENT
specialist. Ear discharge, or otorrhoea, may be due to several causes, ranging from
an otitis externa to pathology of the middle ear.

Fig. 2.14 Otorrhoea
Management of Ear Secretions 19

Otitis Externa

We have already discussed otitis externa as being a cause of otalgia. In fact, earache
is the prominent feature of otitis externa and the presence of discharge in the absence
of pain should suggest the possibility of a perforated otitis media instead. Otitis
externa can be due to a variety of causes, including a trauma, boils, pseudomonas,
or rarely a neoplasm. The use of cotton buds is a common trigger of otitis externa.
Otitis externa is often associated with pruritus, sensation of ear fullness because of
the accumulations of keratin scales and exudate, and a slight hearing loss.

Middle Ear Pathology

It can lead to ear discharge only in the presence of tympanic membrane perforation.
Pathologies of the middle ear that can cause discharge include the already discussed
AOM, chronic otitis media, some fractures of the temporal bone and granulations of
the tympanic membrane.

Trauma or Foreign Body

It is uncommon for a GP to see an ear trauma or a foreign object in the external


auditory canal during surgery times. However, should this be the case, a referral
to the local A&E Department is generally required. This may not be the case only
if the GP can fully visualise the external and middle ear establishing the absence
of lesions or foreign bodies. The presence of deafness, tinnitus, or vertigo should
warrant further specialist assessment. A GP may also attempt removal of foreign
objects by means of ear stringing, or using otoscope and Jobson Horn
instrument.

Management of Ear Secretions

Clinical Management
• Antibiotic and topical steroid drops for 5 days.
• If the patient is diabetic, obtain an ear swab to exclude Pseudomonas aeruginosa
infection which, if present, would demand ENT referral.
• Suggest avoiding shampoo, conditioner, swimming, and sauna.
• Repeat otoscopic examination if the above measures do not bring benefit.
• In the presence of tight and swollen ear canal, use gauze or other guide.
• Analgesia.
• Oral antibiotics if adenopathy present.
• Anti-histamine if itching.
• If abundant keratin debris, refer to ENT? cholesteatoma.
20 2 Otology

RED FLAGS

Facial nerve injury or deficit of other cranial nerves

Vertigo suggestive of cholesteatoma

Foul-smelling secretion suggestive of cholesteatoma

Otorrhoea by cerebrospinal fluid leakage

Previous ontological surgery

Perforation of Tympanic Membrane (Fig. 2.15)

Tympanic membrane perforations can be handled in the large part by primary care.
They occur when a hole or tear develops in the tympanic membrane.
These are divided into:
• Peripheral
• Of the attic
• Central

Fig. 2.15 Tympanic
perforation
Perforation of Tympanic Membrane 21

Each type has different management plans.


Clinical Presentation
• Otalgia
• Discharge from the ear
• Temperature of 38 °C or above
• Tinnitus
Examination
• Undertake otoscopy to identify a perforation with or without granulation
tissue
• Look for retraction pockets and keratinic debris, which may hint the presence of
cholesteamtoma
• Be alerted by foul-smelling debris or discharge, which may suggest Pseudomonas
or other bacterial infection
Clinical Management of Central Perforations
• Prescription drops if secretions obscure the tympanic membrane. Most antibiotic
ear drops contain aminoglycosides that are ototoxic. They are often still pre-
scribed by the ENT consultant, but in primary care the use of non-ototoxic drugs
such as ofloxacin drops with or without topical steroid could be preferable. When
the perforation is dry, observe and advise patient to avoid getting water in the
entrance of the ear canal using cotton with wax or Vaseline.
• Pain relief such as paracetamol or ibuprofen.
• Review the patient after 6 weeks.
• Very often central perforations resolve spontaneously.
Clinical Management of Peripheral Perforations and Perforation of the
Attic
• All peripheral perforations and perforations of the attic require ENT referral in
view of the higher risk of chronic middle ear disease and in particular
cholesteatoma.

Key Points
Consider referring patient in case of:
• Recurring/persistent otorrhoea
• Otalgia resulting from secondary otitis externa
• Deafness
• Vertigo
• Persistent perforation
22 2 Otology

RED FLAGS

Facial nerve deficit

Headache

Vertigo

High fever

Fig. 2.16 Cholesteatoma

Cholesteatoma (Fig. 2.16)

Cholesteatoma is a less common finding in general practice. It occurs when a col-


lection of cells grow on the inside of the ear drum. Left untreated, it can damage the
structures of the middle ear and lead to deafness, ear infections, vertigo, tinnitus and
facial nerve damage.
Clinical Presentation
The presence of symptoms and conditions that should trigger the suspect of choles-
teatoma are:
Child Deafness 23

• Deafness
• Smelly otorrhoea
• Otalgia
• Facial nerve deficit
• Vertigo
• Mastoid abscess
• Meningitis

Examination
• The presence of cholesteatoma is typically suggested by the presence of abun-
dant keratinic debris with or without smelly discharge and tympanic mem-
brane perforation. The latter is most common, but it may not be present on
occasions such as in the case or a retraction pocket or a congenital
cholesteatoma.

Clinical Management
• The presence or suspect of cholesteatoma dictates ENT referral for further
management.

Child Deafness

If a parent suspects that his child has difficulty hearing, the GP should consider a
request for visiting an ENT specialist. In general, the perception of deafness in a
child indicates the presence of bilateral hearing loss. The first question to consider
is if deafness is associated with ear pain.

With Otalgia

Consider:
• Acute otitis media
• Upper respiratory tract infection

Without Otalgia

Consider:
• Earwax
• Bilateral exudative otitis media
24 2 Otology

• History of pre-, peri-, post-natal complications or that might suggest the pres-
ence of sensorineural hearing impairment
• History of meningitis, or severe rash
• History of head trauma
• Congenital malformations
Examination
• Presence of earwax: sodium bicarbonate 5% drops for 48–72 h, eventually fol-
lowed by irrigation of the EAC.  However, this would not be advisable in the
young child.
• Glue ear which is very common and is determined by:
–– Vascularisation of the tympanic membrane
–– Golden colour of tympanic membrane
–– Absence of bright reflex triangle
–– Almost blue reflex of tympanic membrane
–– Presence of fluid, or air-water levels/bubbles behind an intact tympanic
membrane
–– Horizontal handle of the hammer
Clinical Management of Deafness with Otalgia
• Acetaminophen for 24 h in the presence of acute otitis media
• Symptoms lasting longer than 24h, 5 days of antibiotic therapy
• If the ear pain resolves but the deafness remains, treat as deafness without ear pain
• Note: Nasal drops don’t help
Clinical Management of Deafness Without Otalgia
• It is important to get a good clinical history from the relatives and clarify what,
when and how the suspect of deafness was established.
• Evaluate speech and the ability to read; in the event of a delay request ENT and
Paediatric assessment.
In the clinical management of “glue ear”, or chronic otitis media exudative,
consider:
• Otitis media and exudative otitis media can be linked to each other.
• In the case of a speech delay, refer to a specialist.
• In the absence of a delay in speech, observe for a couple of months before
referring.
• Lack of improvement after 2 weeks, should lead to referral.
• In the presence of auditory fluctuations, reviewing every 2 months.
• In older children, spontaneous resolution is more likely.
• Nasal drops, mucolytic and antibiotics should help.
Auditory assessment of a child can usually take place in a GP surgery using the
Leeds Picture Discrimination Cards and whispered voice a metre away.
• 0–3 years: refer
• 3–6 years: Leeds Picture Discrimination Cards
• 6 years: whispered voice
Hearing Tests 25

If parents believe that a child has hearing problems, refer. Always refer a child
with marked hearing loss even when this is possibly due to the presence of serous
otitis media, or glue ear.

RED FLAGS

Speech delay

Marked hearing loss

Chronic ear discharge

Malformations

Adult Deafness

Usually, deafness in adulthood has a slow onset and evolution. It can be uni-/bilat-
eral, affecting the understanding of speech, especially on the phone and in noisy
environments.
Key anamnestic points
• Past medical history of ear surgery
• Infantile exanthema
• Head trauma
• Severe systemic diseases that have required the use of ototoxic medications
• History of occupational exposure to noise
• Hobbies such as hunting, or music
• Family history of deafness
• Diabetes
• Autoimmune disease

Hearing Tests

Rinne Test

The Rinne test is used to evaluate CHL.  CHL occurs when there is a problem
conducting the sound waves to the inner ear anywhere along the route through the
outer ear, tympanic membrane, ossicular chain, up to the oval window (or fenstra
vesibuli). CHL may occur in conjunction with SNHL or in isolation. The Rinne
26 2 Otology

Fig. 2.17 Rinne
+

>

<

False

<

test is performed by placing a 512 Hz diapason to the patient’s mastoid bone. A


person with intact hearing should be able to hear the tuning fork by air after he can
no longer hear the sound through the bone. If the person being examined is not
able to hear the tuning fork when it is quickly repositioned near to the external
acoustic meatus that means his bone conduction is greater than the air conduction.
In turn, this indicates that there is some kind of problem that inhibits the move-
ment of sound waves to the cochlea (i.e. there is a hearing loss). In the case of
hearing loss of a sensorineural type, the ability to perceive the diapason via con-
duction through bone is also diminished, therefore the conduction of sound
through the air will still be more effective (Fig. 2.17).
Hearing Tests 27

Neg CHL
SNHL

Fig. 2.18 Weber

Weber Test

The Weber test is used to detect either unilateral hearing loss of transmissive type or
unilateral sensorineural hearing loss (SNHL). When undertaking the Weber test, the
512 Hz diapason is placed in the centre of the patient’s forehead. Patients with uni-
lateral hearing loss (or predominantly unilateral) perceive the sound from the dis-
eased side if suffering from conductive hearing loss, or from the healthy side – or
less sick – if suffering from a perceptive hearing loss. In transmissive deafness, if
deafness is bilateral and there is a difference in the threshold between the two ears,
the sound will be lateralized in the worst ear; if deafness is symmetrical, to the cen-
tre (Fig. 2.18).

Obstruction of the Auditory Canal

• Benign lesion/exostoses of the EAC


• Earwax
Exostoses are common is scuba divers and swimmers in cold waters. Their man-
agement requires ENT referral. Wax can be removed by means of ear drops, such as
sodium bicarbonate 3%, 3–4 drops to be applied for 3–4 days and to be followed, if
necessary, by ear syringing.

Ear Syringing

Ear Irrigation Procedure

It is important that a comprehensive history has been undertaken before performing ear
irrigation to determine if there are any contraindications why it should not be performed.
28 2 Otology

Also an understanding of the basic anatomy of the ear is essential, so that the clinician
examining the patient understands what constitutes normal and when there are devia-
tions to this. Patients should be advised to use olive oil for at least 7 days, to soften the
wax prior to irrigation. The procedure for ear irrigation should follow the NHS
Modernisation Guidelines written by Harkin (2007) and is as follows.
• Explain the procedure to the patient, outlining risks associated with it such as
dizziness, perforation, otitis externa. If the patient is happy to proceed, gain con-
sent and document.
• Check whether the patient has had ear irrigation before.
• Sit the patient in a chair appropriate for the procedure with the ear to be irrigated
facing you.
• Inspect both ears with the otoscope.
• Place the protective cape and disposable towel in position, and ask the patient to
hold the receiver under the ear. It is advisable the patient tilt their head slightly
towards the affected side.
• Check your head light or mobile light is in place.
• Check the temperature of the water using a thermometer to approximately 37 °C.
• Remember any variation by more than a few degrees may cause the patient to
feel dizzy. If this occurs, stop irrigating, and ask the patient to fix his gaze on
some object for a few minutes until the dizziness passes.
• You should be sitting at the same level as the patient when carrying out this
procedure.
Use of an electronic syringe (Propulse II irrigator)
• Fill the reservoir of the Propulse II irrigator with warm water of 37 °C. Set the
pressure to minimum.
• Connect disposable jet tip applicator to the tubing of machine with firm push/
twist action. Push until click is felt.
• Direct the tip of the jet into the reservoir and switch on the machine for 10–20 s.
This distributes the water through the system to expel any trapped air or cold
water. This also enables the patient to accept the noise the machine makes.
• Gently pull the pinna upwards and outwards to straighten the meatus.
• Place the tip of the nozzle into the external auditory meatus entrance. Nothing
should be inserted into the ear further than the part that can be seen from the
outside. Inform the patient that you are about to begin and that they should make
you aware of any symptoms of pain, dizziness or nausea. Switch the machine on
(using either foot or hand control).
• Direct the stream of water onto the posterior wall of the canal (11 o’clock in the
right ear and 1 o’clock in the left ear). Increase the pressure switch as determined
by the aural condition. It is advisable that a maximum of two reservoirs of water
be used in any one irrigation procedure.
Hearing Tests 29

• If the clinician has not managed to remove the wax within 5 min of irrigation,
switch to the other ear if indicated; allow approximately 15 min before returning
to first ear.
• Periodically inspect the meatus with the otoscope and inspect the solution run-
ning into the receiver.
• After removal of the wax, ask the patient to dry mop the excess water from the
meatus. Dry mop excess water from meatus under direct vision because stagna-
tion of water and any abrasion of the skin during the procedure may predispose
the otitis externa to infection.
• Examine ear, both meatus and tympanic membrane, and refer to ENT if there is
severe inflammation or trauma. Record all findings and treatment in the patients’
notes.
NB: Irrigation should never cause pain. If the patient complains of pain – stop
immediately.

Contraindications

Irrigation should not be carried out when the patient:


• Has a history of a perforation or there is a history of mucous discharge in the last
year
• Has had a history of middle ear infection in the last 6 weeks
• Has had an untoward experience following this procedure in the past
• Has had previous ear surgery
• Has a grommet in place
• Has evidence of otitis externa
• The patient has a cleft palate (repaired or not)
• Has epilepsy

Precautions

• Tinnitus – people with troublesome tinnitus may notice that when the wax is
removed and their hearing improves the tinnitus may increase in severity; dis-
cuss the procedure with the patient in detail and document consent in patients’
records
• Healed perforation – discuss on an individual basis – consider referral for suction
removal
• Dizziness
30 2 Otology

Evaluation of Auditory Function by GP

• Whispered voice at 1 metre with contra lateral masking


• Conversation at 1 metre with contra lateral compression of tragus
• General conversation with lip masking
• Test with the diapason: Weber and Rinne with 512 Hz tuning fork
• Pure tone audiometry if available

Key Points
Consider referral if:
• Removing the earwax doesn’t solve the deafness
• Sudden onset of deafness in the absence of earwax
• Unilateral symptoms
• Other symptoms in addition to ear tinnitus
• Tympanic membrane abnormalities

RED FLAGS

Unilateral hearing loss

Sudden hearing loss

Deficits of cranial nerves

Services for Patients with Hearing Loss

• ENT departments
• Audiologists
• Special schools
• Adapted television and telephone
Vestibular System 31

Vestibular System

The use of Frenzel goggles may be particularly helpful to look and assess for the
presence of nystagmus. This may be spontaneous, gaze evoked, post-headshake,
positional, triggered by the Dix-Hallpike manoeuvre, by pneumatic otoscopy, or by
other techniques. Smooth pursuit, saccades, gait, and head-shaking nystagmus
should be assessed. The Romberg test, the Fukuda step test and the hyperventilation
test are also helpful.

Smooth Pursuit

Smooth pursuit is a movement of the eyes allowing us to follow a moving target. We


can also shift the gaze voluntarily by means of saccadic eye movements. Pursuit is
triggered by a moving visual signal and it would be very difficult, if possible, to be
initiated in its absence. Smooth pursuit and saccades work together. If a target
moves faster than 30°/s, the pursuit tends to require catch-up saccades. Smooth
pursuit is asymmetric in so far that we are better at horizontal than vertical smooth
pursuit, that is we can follow a moving target without making catch-up saccades
horizontally rather than vertically. We are also better at downward rather than
upward pursuit. Smooth pursuit may be affected by a variety of conditions as it
requires the coordination of different brain areas also far away from each other.

Saccades

As briefly mentioned above, a saccade is quick, coordinated movement of both eyes


between two positions of fixation in the same direction. Saccades are involved in
fixation, rapid eye movement, and in the fast phase of optokinetic nystagmus.

Head-Shaking Nystagmus

Head-shaking nystagmus, or HSN, is a latent spontaneous vestibular nystagmus


which can be provoked by rapid passive head shaking around a vertical axis.
Typically HSN is triggered by means of horizontal sinusoidal head oscillations of
30° each side, for at least 20 cycles, and then abruptly interrupted. Ideally, the head
of the subject should be 20° downward with respect to the vertical axis, so that the
32 2 Otology

axis of rotation could be parallel to one of the semicircular lateral canals. HSN is
absent in normal subjects; hence its identification with Frenzel’s glasses in a dark
room or a video camera (videonystagmoscopy) can be helpful. In fact, passive head
shaking is an effective way of triggering nystagmus in patients with peripheral and
central vestibular lesions.

Fukuda Stepping Test

The Fukuda stepping test (FST) is another particularly useful test in the limited
space of a consulting room. In the FST, also known as Unterberger’s stepping test,
the patient is asked to walk in place with their eyes closed. There are two variants to
the test, with 50 and 100 steps, the latter being somewhat more sensitive. Abnormal
deviation towards the side of the lesion, that means >45° deviation, occurs in most
cases, but in about 1/4 of the patients this could be towards the intact side, and in
another 1/4 it can remain within the normal range. Hence, if the patient rotates to a
particular side they may have a labyrinthine lesion on that side, but this test should
not be used in isolation of other tests to diagnose lesions.

Hallpike Test

Also known as the Dix-Hallpike test, it is probably one of the most helpful test that
can be performed in primary care to make diagnosis of BPPV. The British Society of
Audiology (2014) suggests the clinician should begin by explaining the procedure to
the patient and demonstrating if necessary. Make sure the patient is aware that he/she
may experience vertigo with eventual nausea and/or vomiting, but that this is likely
to be short-lived. Also, the clinician should be aware of the absolute contraindica-
tions to the test; these are: recent cervical spine fracture, atlanto-axial subluxation,
cervical discopathy, confirmed vertebro-basilar insufficiency and recent neck trauma
that restricts torsional movements of the neck. The test is performed with the patient
sitting upright on the examination table, or on their bed during a home visit, with the
legs extended. The patient’s head is then rotated to one side by 45°. The examiner
helps the patient to lie down backwards quickly with the head held in 20° extension.
This extension may either be achieved by having the examiner supporting the head
as it hangs off the table/bed, or by placing a pillow under their upper back. The
patient must be reminded to keep the eyes open staring straight ahead, and endeav-
ouring to suppress blinks, as their eyes are then observed for about 45 s. There is a
characteristic 5–10 s period of latency prior to the onset of nystagmus. If rotational
nystagmus occurs then the test is considered positive for benign positional vertigo.
During a positive test, the fast phase of the rotatory nystagmus is towards the affected
ear, which is the ear closer to the ground. The direction of the fast phase is defined by
the rotation of the top of the eye, either clockwise or counter-clockwise.
Tinnitus 33

Key Points
• Good lighting
• Practice your technique
• Correct equipment
• Be methodical

Tinnitus

Tinnitus is the hearing of sound when no external sound is present. It can be


described in various ways, but most often as a whistle or hum, in the head; in some
cases, the noise is described as pulsating and synchronized with the heartbeat.

Subjective Tinnitus

It is more often associated with a sensory deficit. A disease of the middle ear that inhib-
its masking ambient sounds, such as an otitis media, can exacerbate it. Many adults are
extremely anxious about tinnitus. Often the patient fears a brain tumour causes tinnitus.
A reduction of the anxiety levels may be surely beneficial. When this is present, the
patient will probably be willing to have an MRI scan, but rather rarely this would bring
any valuable information. Many patients are aware of a certain level of deafness.
• Refer to a specialist if deafness has a social impact
• Refer if the tinnitus is unilateral
• If mild, reassure the patient about the benign nature of tinnitus

Objective Tinnitus

Objective tinnitus occurs when the examiner can hear it as well. Objective tinnitus
is rare and it demands further investigations via ENT referral.

Vertigo

The patient uses various terms to describe dizziness such as unsteadiness, light-­
headedness, giddiness or vertigo. It is up to the clinician to determine if it is an
episode of true vertigo or not. Vertigo is a sensation of spinning and as such, to make
a diagnosis of vertigo, the patient needs to have experienced a rotational movement
34 2 Otology

of the surroundings clockwise or counter-clockwise, depending on the side being


affected and the type of disorder. If the patient does not describe such roundabout
experience, we cannot talk about vertigo (Fig. 2.19).
Lemajic-Komazec and Komazec (2006) suggest that balance control depends
on receiving afferent sensory information from several sensory systems: vestibu-
lar, optical and proprioceptive. Bioelectric signals, generated by endolymphatic
fluid movements in the semicircular canals and in the otolithic apparatus, are
transmitted via the vestibular nerve to the vestibular nucleus. All four vestibular
nuclei, located bilaterally in medial longitudinal fasciculus, are connected with
several central nervous system structures. These central nervous system structures
are involved in maintaining visual fixation, spatial orientation and balance con-
trol. Therefore, afferent signals balance disorders will lead to nystagmus that is an
involuntary movement of the eyes.
Nystagmus due to peripheral lesions is conjugate nystagmus, because there is a
bilateral central connection.
Lesions above the vestibular nuclei induce deficits in synchronization and conju-
gation of eye movements, thus the nystagmus is dissociated.
In peripheral vestibular disorders, spontaneous nystagmus is rhythmic, associ-
ated, horizontal-rotatory or horizontal, with vertigo which decreases with time, and
harmonic signs. Harmonic signs are so called when their direction coincides with
the slow phase of nystagmus.

Cardiovascular pathology
Rheumatological disease
High pitch
Tinnitus Neurological pathology
Low pitch
Infective disease
SNHL
Endocrinological pathology
Conductive Deafness
Immunological disease
Mixed General conditions
Depression
Purulent
Fear of serious disease
Acqueus Secretions Mental Health Anxiety
Hyperventilation
Serous Ear
Stress
Head
Surgical Positional
Ear
Accidental Trauma Objective Spontaneus
Acustic Provoked
Barotrauma Positional
Vertigo Fainting feeling Induced by physical exercis
Seconds
Palpitations
Minutes
Type Vomiting
Hours Subjective
Duration Duration
Days Headache
Severity

Absent Triggers
Spontaneus Confusion

Positional
Ear diseases
Gaze Triggered Nystagmus
Previous episodes
Induced by stimulation
Ototoxic
Drugs Hypotensive
Anamnesis
Affecting the vestibular system
Smoke, alcohol, abuse drugs

Fig. 2.19  Vertigo mind map


Vertigo 35

Spontaneous nystagmus in central vestibular lesions is severe, dissociated, hori-


zontal, rotatory or vertical, without changes related to optical suppression; if ves-
tibular symptoms are present, they are non-harmonic.
In central disorders, findings after peripheral, caloric stimulation – which can
be carried out by a clinical audiologist – are either normal or pathological, with
dysrhythmias and inhibition in pendular stimulation (Fig. 2.20).

Jerk nystagmus
convergence-
retraction nystagmus
refers to the irregular
jerking of the eyes back
into the orbit during up-
ward gaze. It can indicate
midbrain tegmental dam-
age.

Downbeat nystagmus
refers to the irregular
downward jerking of the
eyes during downward
gaze. It can signal lower
medullary damage.

Vestibular nystagmus,
the horizontal or rotary
movement of the eyes,
suggests vestibular dis-
case or cochlear dysfunc-
tion.

Pendular nystagmus
Horizontal, or pendu-
lar, nystagmus refers to
oscillations of equal ve-
locity around a center
point. It can indicate con-
gential loss of visual acu-
ity or multiple sclerosis.

Vertical, or seesaw,
nystagmus is the rapid,
seesaw movement of the
eyes; on eye appears to
rise while the other ap-
pears to fall. It suggests
an optic chiasm lesion.

Fig. 2.20  Jerk vs. pendular nystagmus


36 2 Otology

Objective Vertigo

Ménière’s Syndrome

This is probably diagnosed more often than it should be. It is an idiopathic disease
of the inner ear characterized by hearing loss, tinnitus and dizziness. Endolymphatic
hydrops, that is an increase of the inner ear fluids pressure, mostly sharp, is believed
to be responsible for the onset of the symptoms and signs.
Clinical Presentation
• Vertigo and nausea
• Hearing fluctuation with vertigo
• Feeling of ear fullness, or pressure
• Tinnitus
• Cluster episodes, of variable duration ranging from several hours to days
Ménière’s syndrome must be referred to a specialist for an appropriate diagnostic
and therapeutic management.
Clinical Management
• Medical: diuretics, hypo-saline diet, sedatives, anti-vertiginous, antiemetic, any
correction of metabolic dysfunctions and vasculopathy.
• Surgery: surgical therapy is indicated in those cases that do not benefit from
medical treatment. It can be divided into conservative and destructive: the latter
should be reserved for the terminal stages of the disease and unilateral forms.
The conservative treatment or functional treatment aims for the improvement of
the vestibular symptoms with hearing preservation: sacculotomy and endolym-
phatic shunt. The most radical intervention does not take into account the conse-
quences for the hearing, in an attempt to achieve the highest success rate: it
consists of the labyrinthectomy and in the section of the vestibular nerve.

Viral Labyrinthitis

It is characterized by the presence of:


• Recent viral upper respiratory tract infection
• Accompanied by nausea and vomiting
• Often lack of hearing impairment
• Normal otoscopic examination
• Beginning as vertigo then later changes into imbalance and resolves
Clinical Management
• Reassure the patient that symptoms generally resolve within a few days, some-
times weeks, occasionally months
• Use of vestibular suppressant if necessary
• Vestibular physiotherapy
• Refer to a specialist if symptoms persist for more than 6 weeks
Vertigo 37

Subjective Vertigo

Vertebrobasilar Insufficiency

The diagnosis is suggested by:


• Association with the neck extension and rotation
• Normal tympanic membrane
• Association with cervical pain from spondylosis
• May be associated with other diseases due to atherosclerosis
• Occasional episodes of cerebral ischemia
Clinical Management
• Cervical collar – rarely proposed nowadays
• Lifestyle changes
• Treatment of osteoarthritis

Fistula Test

Key Points
Refer urgently to specialist in case of:
• Cholesteatoma
• Otorrhoea
• Deafness
• Facial paralysis
• Headaches and other neurological abnormalities
• Previous otological surgery
• Recent head injury

In the case of a cholesteatoma with or without otorrhoea, you might encounter an


erosion of lateral semi-circular canal. In the case of cholesteatoma and vertigo, fis-
tula test can sometimes confirm the diagnosis. To perform the fistula test, you are
squeezing the tragus with the finger, and the patient, in case of a positive test, expe-
riences the presence of objective vertigo with nystagmus directed towards the oppo-
site side. Alternatively, you can use the pneumatic otoscope to achieve the same
objective.
38 2 Otology

2 1 3 4

Fig. 2.21  Vestibular exercises for BPPV

Benign Paroxysmal Positional Vertigo (BPPV)

Patients suffering with BPPV experience short bursts of severe dizziness when they
move their head in certain directions.
Clinical Presentation
• Vertigo generally appears when the patient gets up from bed, or lies down; when
looking up to a shelf, or lacing shoes.
• Typically one side is affected and the patient learns to avoid this position, most
notably the recumbent on one side when in bed.
• Can be cured with appropriate clinical examination.
• Otoscopy is normal.
Clinical Management
• Reassure the patient
• Vestibular exercises (Fig. 2.21)
• Refer to a specialist if it does not resolve within 1 month

References

British Society of Audiology (2014) Recommended procedure for hallpike maneuver [online].
http://www.thebsa.org.uk/wp-content/uploads/2014/04/HM.pdf
Hain TC (1997) Approach to the Vertigo. In: Practical neurology. Lippincott-Raven, Philadelphia
Harkin H (2007) Ear care guidance from the NHS Modernisation Agency. NHS Modernisation,
London
Lemajic-Komazec S, Komazec Z (2006) Initial evaluation of vertigo. Med Pregl 59(11–12):
585–590
Chapter 3
Rhinology

The Nose

Undertaking a history of the nose should include questions aiming to establish


whether any of its functions – smelling, conditioning, warming, humidification of
inhaled air and voice resonance – is impaired or not. Change of airway resistance
and sense of smell are key indicators of nasal pathology. Also common presenta-
tions seen in primary care are rhinorrhoea, epistaxis, facial pain or sense of pressure,
and a nasal voice. Rhinorrhoea is perhaps the most frequent sign reported and
observed by the clinician when dealing with nasal problems. Like otorrhoea, the
clinician should ascertain whether the discharge is watery, purulent, mucousy or
blood stained as this will help determine the cause. Rhinorrhoea can be chronic,
acute or recurrent; so gaining an understanding of the duration may be pertinent.
The patient should be asked if it is linked to any allergies or whether it is seasonal.
Associated symptoms that the patient may describe include watering eyes, itchy
eyes, sore throat and facial pain or pressure.
Many patients complain of nasal obstruction. This can be unilateral or bilateral.
The clinician should determine the duration it has been occurring for, whether it is
constant, intermittent or related to seasons or allergies. Any associated symptoms
should also be explored including facial pain, sneezing, headache, post-nasal drip,
sore throat, otalgia and asthma. If a patient presents with epistaxis, the clinician
must prioritise significant bleeding over undertaking a history. However, once the
bleeding is controlled, then the clinician should enquire as to whether the epistaxis
was unilateral or bilateral, anterior or posterior. Foreign bodies can lead to epistaxis
and should be ruled out, especially in children. It is important to ask the patient if
the bleed was spontaneous or post trauma. The onset, duration and recurrence are
also of significance.
Associated symptoms should be reviewed along with medications prescribed and
past medical history. For example, the patient may be prescribed anti-­coagulants or
suffer from hypertension or renal disease. Symptoms that may direct the clinician to

© Springer International Publishing AG 2017 39


E. Cervoni, K. Leech, ENT in Primary Care,
DOI 10.1007/978-3-319-51987-6_3
40 3 Rhinology

Degree
Laterality
Nasal obstruction
Duration
Duration Fever
Onset
Hyposmia
Change of voice Hyponasal
Anosmia
resonance
Olfaction changes
Change of taste Hypernasal
Trauma

Pain
Laterality Facial Surgical
Nose
Accidental
Headache
Unilateral Laterality Laterality

Bilateral Amount
Duration Nasal discharge
Serous Epistaxis Duration
Aqueous Type
Frequency Triggers
Purulent
Anticoagulants
Drugs
Blood stained Triggers
NSAIDs

General conditions

Fig. 3.1  Rhinological anamnesis mind map

suspect sinusitis include pressure or pain in the patient’s cheeks or forehead, nasal
congestion, a sense of heaviness in the head heaviness and sometimes facial pain.
Determining the severity of the pain and the length of time a patient has experi-
enced the symptoms will establish appropriate management. If the sinusitis has
lasted up to 10 days it is likely to be viral. For symptoms lasting longer than 10 days
it is more likely to be a bacterial sinusitis. Symptoms lasting for more than 12 weeks
are suggestive of chronic sinusitis, and lasted >12 weeks is chronic sinusitis. Patients
may describe fever, purulent discharge, nasal obstruction, post-nasal drip, chronic
unproductive cough, malaise and facial pain.
Nasal voice may be distinguished in hyponasal and hypernasal speech, otherwise
respectively known as rhinolalia clausa and rhinolalia aperta. The first is typical of
nasal congestion, the latter of cleft palate and velopharyngeal insufficiency. The doc-
tor should be informed about the presence of defects of smell, such as loss of smell
(anosmia), its reduction (hyposmia), and unpleasant odours, particularly putrefactive
odours (cacosmia). A thorough patient history is essential in determining any olfac-
tory disorders such as sense of smell and sense of taste can often be confused by
patients. Patients may also present with hyposmia, which is partial loss of smell. The
clinician should ascertain the time the loss occurred and if there were any other con-
tributing factors, such as trauma or illness. Intra-nasal obstruction, allergic rhinitis,
head trauma and also type II diabetes and Alzheimer’s have been linked to anosmia.
Drug and alcohol history should be taken as long term alcohol misuse can lead to
anosmia. Certain medications such as metronidazole can also cause it (Fig. 3.1).

Nose Assessment

An otoscope can be used to make a rhinoscope with a wide speculum. The patient
should be asked to breathe with his mouth during the examination to prevent the
otoscope lens fogging during the procedure. The otoscope gives a good view of the
anterior nasal cavity (Fig. 3.2).
Nose Assessment 41

Fig. 3.2  Otoscope being


used to perform nasal
examination

Fig. 3.3  Silver nitrate sticks

Dentist Mirror or a Cosmetic Mirror

Useful to evaluate the nasal flow, particularly in newborns.

Silver Nitrate Sticks

Silver nitrate sticks can be used for nasal cauterization to treat recurring nose bleeds.
Frequent nose bleeds are likely to be a result of an exposed blood vessel in the nasal
cavity; therefore cauterizing it may prevent further bleeding. Silver nitrate sticks
look like large matches and are dipped in water before being applied to the lesion
for a few seconds (Fig. 3.3).
42 3 Rhinology

Fig. 3.4  Little’s area,


otherwise known as
Valsalva area

Nose Inspection

• Symmetry
• Septal deviations
• Deformity of the nasal pyramid
• Patency of the nostrils
• Little’s area (varices, crusting, bleeding) (Figs. 3.4 and 3.5).
• Septal perforations
• Nasal vestibule
• Turbinates
• Osteo-meatal complex
• Injury or growths in the nasal cavity

Epistaxis

Patients do often experience recurring spontaneous nasal bleeding, from one or


both nostrils. Sometimes, the GP is called to deal with epistaxis at the surgery,
but much more frequently this pathology is handled in the Emergency Room.

Epistaxis in the Child

Children tend to bleed from the nose more easily than adults and from the front of
the septum, otherwise known as Little or Valsalva area. Establishing the severity of
bleeding should take precedence over the history taking.
Epistaxis in the Child 43

Anterior ethmoid artery


Posterior ethmoid artery
Sphenopalatine artery

Kiesselbach’s
plexus

Superior
labial artery

Greater
palatine artery

Fig. 3.5  Vascularisation of the Little’s area

Clinical Presentation
The child may present with symptoms of a cold or as an exacerbation of allergic rhinitis.
In a child this may be accompanied by a foul-smelling discharge; this may indicate a
foreign body. Likewise a unilateral bleed or discharge may also indicate a foreign body.
Examination
• Look for foreign body
• Prodromal sign of exanthema
• Inflammation of nasal vestibule
• If appropriate, get child to blow nose; this will help to remove clots and give a
better view of the nasal cavity
• External nasal deformity
Clinical Management
• Anterior nasal bleeding can usually be stopped with a compression of the nos-
trils. At the same time, the child should bend the head forward.
• Cauterization of eventual varicosities of the Little’s area with silver nitrate fol-
lowed by application of antibiotic nasal cream, more often mupirocin or
chlorhexidine dihydrochloride 0.1% / neomycin sulphate 0.5%, for up to 10 days.
• If there is no obvious varicosity, or crusting, nasal topical antibiotic application
for a week, and control.
• In case of absence of a specific site of bleeding, consider a haemostatic disorder
and arrange further investigations to explore this possibility.
• For recurrent nosebleeds, refer to the specialist.
44 3 Rhinology

RED FLAGS

Bleeding non resolving with direct pressure

Recurrent idiopathic epistaxis

Signs of shock

Epistaxis in Adults

Clinical Presentation
Like children, establishing the severity of the bleed should take precedence over the
history taking. Once this has occurred it is important to establish whether the epi-
staxis is unilateral or bilateral. A good history should enquire about previous epi-
staxis, history of hypertension, other systemic diseases, family history or any
bruising. In adults, a medication review may prove helpful looking for anti-­
coagulants, aspirin, NSAIDs and dipyridamole.
Examination
• Consider anterior nasal bleeding as in children. Approximately 90% of bleeds
are anterior in nature.
• Posterior nasal bleeding should be suspected when a specific point of bleeding is
not clearly identifiable, or stopped with the compression of the nostrils.
Posterior epistaxis is:
• More frequent in old age
• More severe when associated with hypertension
• May stop spontaneously, but is usually very copious
• Should be handled within the scope of first aid emergency ENT
Clinical Management
• Treat the anterior nasal bleeding as in children
• In case of posterior nasal bleeding
–– Check blood pressure
–– Refer to a specialist if recurring, or if associated with visible nasal lesion

Key Points
Check if the patient takes anticoagulants.
Check haematocrit and coagulation.
Consider angiofibroma in a young man with nasal obstruction. In this case,
refer to the specialist.
Allergic Rhinitis 45

RED FLAGS

Bleeding not stopped by direct pressure

Suspected shock

Recurrent unilateral bleed

Associated symptoms such as facial pain, numbness or


diplopia

Anticoagulants or anything to suggest blood disorder

Nasal Obstruction

Nasal obstruction refers to the feeling of a reduction of nasal flow, uni- or bilateral.
It is generally divided into:
• Mucosal oedema due to:
–– Viral rhinitis
–– Allergic rhinitis
–– Vaso-motor rhinitis
–– Nasal polyps
• Septal deviation:
–– Post-traumatic
–– Idiopathic
–– Nasal valve insufficiency with collapse of one or both nostrils
• Rhino-pharyngeal obstruction due to:
–– Hypertrophy of adenoids
–– Polyp(s)
–– Neoplasm

Allergic Rhinitis

Often characterized by the presence of the triad: sneezing, aqueous nasal secretions
and itching of palate, eyes, nose and/or throat (Fig. 3.6).
46 3 Rhinology

Fig. 3.6  Swollen inferior


turbinate in allergic rhinitis

Clinical Presentation
When taking the medical history, you should also look for data that can identify the
potential allergen(s) such as:
• Dust
• Pollens
• Feathers
• Mould
• Spore
• Animal dander

Examination
Typical findings at the clinical examination are:
• Oedema of the inferior turbinate
• Pale colour of the nasal mucosa
• Wet nasal mucosa
• Choanal space reduction
• Allergic dermatitis
Clinical Management
• Medicinal products for topical use.
• Steroids for nasal use. They are also available in aqueous forms that cause less
easily nasal bleeding.
• Allergen(s) avoidance.
• Anticholinergics for topical use if the rhinorrhoea is predominantly watery.
• In the case of cacosmia and facial pain, a study of the paranasal sinuses is essen-
tial before starting the steroid use.
Vasomotor Rhinitis 47

• Oral therapy supports topical treatment. In case of nasal symptoms or persistence


of non-nasal symptoms, their use is particularly recommended and relies on:
–– Anti-histamine
–– Pseudo-ephedrine
–– Anti-histamine and sympathomimetics
• Inhalation therapy. Perhaps not as popular in the UK as it may be in the rest of
Europe, it is based on the use of:
–– Menthol
–– Steam
–– Eucalyptol
–– Inhalations reduce pain in sinuses and reduce nasal obstruction most often, up to 2 h.
• Immunotherapy – This is still not widely available. Fujisawa (2015) suggests that
to make the therapy more effective, it is preferable to start it as early as possible,
hopefully in infancy. But it is still difficult at present because of relatively fre-
quent adverse events and invasive manner of administering allergen extracts for
young children. It would need a referral to an allergologist.
• Surgery – Surgical interventions aim to reduce the volume of the turbinate which
is recommended when:
–– Nasal obstruction is severe.
–– Medical treatment does not give good results.
–– Turbinate reduction improves airflow and the distribution of medicines for
topical use.

Vasomotor Rhinitis (Fig. 3.7)

Clinical Presentation
Vasomotor rhinitis in many ways resembles allergic rhinitis, but it is not triggered
by an allergen and its cause is currently unknown. It can be exacerbated by:
• Perfumes
• Spray
• Air temperature changes
• Tobacco smoke or other irritants
In addition:
• There is not usually an associated itch
• The obstructed side is generally alternating
• Can co-exist with an allergic form
• Sometimes it is associated with puberty and hormonal changes
• Its onset may be associated with anxiety and frustration
• Watery nasal discharge is typical
48 3 Rhinology

Fig. 3.7 Vasomotor
rhinitis with watery
discharge

Examination
• Vasomotor rhinitis can be sub-classed as ‘runners’ that exhibit wet rhinorrhea
• Dry vasomotor rhinitis – with airflow resistance and nasal obstruction with lim-
ited rhinorrhea
Clinical Management
Clinical management mirrors that of allergic rhinitis. The distinction between aller-
gic rhinitis and vasomotor rhinitis may be clinically challenging and it is most often
dictated by history data rather than by the appearance of the nasal mucosa.

Nasal Polyps (Fig. 3.8)

Clinical Presentation
Symptoms develop in a gradual, progressive way and are very often in the context
of an allergic rhinitis or vasomotor rhinitis. In addition, there is often a history of:
• Previous nasal polypectomy
• Decreased sense of smell
• Recurrent sinusitis
Examination
• Alterations in facial appearance
• Assess inferior turbinate, anterior septum and middle meatus
• Assess posterior wall for polyposis
• Undertake otoscopy – extensive polyposis can lead to Eustachian tube dysfunc-
tion and cause otitis media
Clinical Management
• In the case of mild symptoms, intra-nasal drops such as Beclomethasone should
be applied twice daily with the head in extended position.
Nasal Polyps 49

MT MT MT MT MT

IT IT IT IT IT

0 1 2 3 4

Fig. 3.8  Nasal polyposis and its grading (Lund and Mackay 1993)

• Alternatively, you can use a steroid spray.


• An x-ray of the sinuses may be useful to detect possible hydro-air levels, but it is
nowadays rarely requested as CT and MRI scan are easily available and do offer
significant diagnostic advantages.

• An oedema or thickening of the mucosa of the paranasal sinuses is acceptable, if


minimal.
• We recommend smoking cessation.
• ENT specialist advice should be sought when:
–– Drug therapy does not produce acceptable results
–– Severe nasal obstruction
–– A neoplastic pathology is suspected due to the presence of unilateral polyp,
with or without nasal bleeding

Key Points
In the case of nasal polyps, one must always keep in mind that this is a recur-
rent disease, so the topical steroid therapy should be maintained.

RED FLAGS

Bloody discharge

Unilateral growth

Facial swelling

Polyps in children could mean cystic fibrosis


50 3 Rhinology

Allergy Testing

The allergy testing can be made via cutaneous stimulation, the patch and the prick
test, or via blood collection using the RAST test. The latter can be directly arranged
by GPs. The skin tests require the support of a Resuscitation Department and the
patient should stay in observation for a couple of hours. A referral should be
arranged, but the purpose of skin tests is limited and often impractical. Even from a
commercial point of view, the advantages are much reduced, and because of this it
is not easy to find the necessary kit. The RAST test (radio absorbent sensitivity test)
is easily obtainable, although expensive; it can be carried out on a sample of venous
blood.

Septal Deviation

Examination
• May be associated with deformity of the nasal pyramid.
• There may be a history of trauma of the nasal pyramid.
• Unilateral nasal obstruction is often present.
• There are often coexisting changes of the nasal mucosa, such as compensatory
hypertrophy of the turbinates.
Clinical Management
• Refer to a specialist if nasal obstruction is only due to septal deviation.
• In case of co-existence of rhinitis, treat the rhinitis first, and if that’s not enough,
refer to a specialist.

Inspiratory Nasal Valve Collapse

A certain degree of movement of the nostrils during inhalation is normal. However,


a collapse of the nostril(s) is pathological and leading to nasal obstruction. In this
case, the patient should be referred to an ENT specialist (Fig. 3.9).

Nasopharyngeal Obstruction

The causes of nasopharyngeal obstruction include:


• Hypertrophic adenoids in children (Fig. 3.10)
• Antro-coanal polyps
• Craniosynostosis
Sinusitis 51

Fig. 3.9  Collapse of the nasal valve

Fig. 3.10 Adenoids
hypertrophy

• Post-surgical scarring
• Tumours
Examination
• Look for dysmorphic features
• Perform anterior rhinoscopy
• Assess oropharynx
• Both in adults and in children look for possible ear pathology
• Cervical lymph nodes: palpate for any inflammatory or neoplastic pathology
Clinical Management
• This highly depends on the cause of the obstruction. Referral to the ENT special-
ist is required and if the adenoids are deemed to be responsible for the obstruc-
tion, they may require adenoidectomy.
52 3 Rhinology

Sinusitis

Sinusitis it is common presentation in primary care (Fig. 3.11).


Clinical Presentation
The following symptoms suggest the possibility of sinusitis:
• Cacosmia
• Facial pain and tenderness of the maxillary and frontal sinuses
• Nasal obstruction
• Mucopurulent rhinorrhoea
• Fever associated with symptoms listed above, peri-orbital oedema or swelling of
face (or Pott’s oedema) can occur as a complication of sinusitis but it is unusual
with proper medical treatment
• Sensation of congestion of upper respiratory tract, head, and ears
• Dizziness
• Hyposmia

Examination
• Rhinoscopy to ascertain the presence of nasal discharge
• Assess for fever
• Facial tenderness
Clinical Management
• In the event of Pott’s oedema, refer immediately to the ENT specialist
• Antibiotic therapy may be indicated if sinusitis does not respond to home reme-
dies or symptoms are severe
• Analgesia

Fig. 3.11 Purulent
sinusitis
Sinusitis 53

• Menthol/inhalations
• Refer to the specialist in case of non-resolution of symptoms

Recurring Rhinosinusitis

Examination
• A minimum mucosal thickening without hydro-air levels is common and not
necessarily pathological, and a diagnosis of rhinitis, rather than of sinusitis,
should be taken into account.
• Bone erosions are suggestive of neoplastic disease and require urgent specialist
clinical evaluation.
• Small cystic lesions of maxillary sinuses are common and do not require
treatment.
Clinical Management
• Imaging may help to assess the presence of chronic disease. GP may request
x-rays with chin-occipital view to evaluate the maxillary, frontal and ethmoid
sinuses.
• An acute exacerbation of a recurring form requires the use of metronidazole and
penicillin, or macrolide.
• Analgesia.
• Menthol/inhalations.
• In an allergic rhinitis, nasal steroid are useful.
• Nasal polyposis can respond to the nasal steroid spray or drops.
• Referring to a specialist is required in case of:
• Frequent recurrences
• Large nasal polyps
• Large septal deviation
• Suspect of neoplastic pathology
In the absence of radiographic abnormalities, diagnosis of sinusitis is highly
unlikely. The clinician should consider other possible causes of facial pain and in
particular the contact between nasal concha and septum.

Key Points
Rhinitis medicamentosa is a disease that results from prolonged use of decon-
gestants. If a patient presents with nasal obstruction and nasal mucosa oedema
after a period of prolonged use of decongestants, refer to a specialist as may
require surgical correction.
Unilateral nasal secretion in a child is believed to be due to the presence of
a foreign body until proven otherwise and it requires an urgent ENT referral.
Children are not prone to nasal polyps and their presence should trigger the
suspect of cystic fibrosis.
54 3 Rhinology

Patients from tropical regions, or sub-tropical, may take a couple of years


before showing signs of dust allergy.
Nasal polyps should always trigger an ENT referral if unilateral.
Steroid drops should be avoided in the long term in favour of spray.
Remember nasal valve incompetence as a cause of nasal obstruction.
Posterior nasal drainage is a nonspecific symptom.
Facial oedema is always indicative of complications and the patient should
be referred to a specialist.
Unilateral nasal bleeding with obstruction, or facial pain, should be sent to
a specialist with a suspect of neoplastic pathology.

References

Fujisawa T (2015) Allergen immunotherapy in children. Arerugi 64:787–794


Lund VJ, Mackay IS (1993) Staging in rhinosinusitus. Rhinology. 31:183–184
Chapter 4
Laryngology

The Throat

Voice problems and sore throat are two of the most common complaints associated
with the throat, larynx and hypopharynx regions. Voice disorders should be distin-
guished in problems with the articulation of the voice, or dysarthria, and hoarseness,
or dysphonia, when there is a change in the quality of the voice instead.
Hoarseness is the most frequent among the two. It is important to determine if
hoarseness has been of a gradual onset or sudden onset. Gradual onset may be as a
result of smoking or drinking alcohol, whilst sudden onset may be as a result of an
infection or vocal abuse. Smoking and alcohol should be documented in all cases. A
patient’s occupation may provide vital information to the history, especially if they
use their voice in a professional way such as a singer. In these cases it is worth ask-
ing the patient if they have experienced a change in their pitch or abnormal pitch
range. The clinician should determine if their hoarseness is constant, or whether it
changes throughout the day. Any exposure to chemicals or corrosive substances
may also be important. Previous trauma, surgery or endotracheal intubation should
be ascertained. Patients may describe their voice disturbances as breathy, hoarse,
low-pitched, strained, and trembling or a feeling of vocal fatigue. Clinicians should
be aware that specific voice disturbances could help the focus on a differential diag-
nosis. For example, breathy complaints could indicate functional dysphonia, vocal
cord paralysis or abductor spasmodic dysphonia.
Dysarthria results from a neurological injury of the phonation system. As such,
the causes may be several, including multiple sclerosis, Parkinson’s disease,
Parkinson plus syndromes, stroke, motor neuron disease and others. A sore throat
itself is actually a symptom. Other common presenting symptoms include a feeling
of a lump in throat, mucus in the throat and general discomfort. Sore throat is usu-
ally caused by viral infection; however, the most common bacterial infection affect-
ing the throat is Group A beta-haemolytic streptococcus. The clinician should
ascertain the duration and severity of the symptoms, any dysphagia, rash or stridor,

© Springer International Publishing AG 2017 55


E. Cervoni, K. Leech, ENT in Primary Care,
DOI 10.1007/978-3-319-51987-6_4
56 4 Laryngology

Ageusia
Ulcerations
Parageusia
Oral Taste
Blisters muco
sa
Dysgeusia
Bullae
Hypogeusia

Referred
Pain Mouth Saliv Reduced
a
Local tenderness
Increased

Odynophagia
General conditions and
medications

Fig. 4.1  Mouth anamnesis map

whether the patient feels systemically unwell and whether there is the presence of
trismus. Associated symptoms may include malaise, headache, rhinitis, cough and
hoarseness. These symptoms are often benign in nature. However, can also be
symptoms of malignancy. Patients with acid reflux may present with throat prob-
lems. If this is linked with symptoms of dyspepsia or gastro-oesophageal reflux it
should be investigated (Fig. 4.1).

Mouth and Throat Assessment

Tongue depressors, (Fig. 4.2) typically a disposable wooden spatula, are used to
depress the tongue to allow the clinician to inspect the patient’s mouth and throat
structures. Again an otoscope can be used as a torch to improve visualisation of the
mouth and throat. A clinician should always wear gloves when performing an oral
examination.

Fig. 4.2  Tongue depressor


Sore Throat 57

Mouth, throat and neck examination

• Scars and nodularity


• Symmetry of the face and lips
• Speech quality
• Teeth
• Soft and hard palate
• The oral mucosa and the retro-molar trigon
• Palpation of the floor of the mouth, neck, and salivary glands

Sore Throat

It is a frequent symptom and often associated with viral upper respiratory tract
infection.

Pharyngitis

Clinical Presentation
• Sore throat or dryness of the throat
• Worse in the morning
• Absence of systemic impairment
• The patient may have sense of nasal obstruction especially at night
• Cold symptoms
–– Acutes
–– Chronic (Fig. 4.3)
Examination
• Check the nasal passages
• Check the sinuses
• Check oropharynx, mouth, and tonsils
• Assess cervical lymph nodes
Clinical Management
• Invite to stop smoking
• Advise to stop or reduce to recommended limits alcohol intake
• Refer to a specialist in case of failure to respond to previous approaches

Other Causes of Pharyngitis

• Iatrogenic, from prolonged use of antibiotics or topical steroid


• Anti-inflammatory causing agranulocytosis
• Dental caries
58 4 Laryngology

Fig. 4.3 Chronic
pharyngitis

• Tobacco
• GORD
• Alcohol
• Occupational irritants
• Vocal abuse
• Venereal diseases

RED FLAGS

Presence of traces of blood

Smoker/ Age greater than 40 years

Unilaterality

Tonsillitis (Fig. 4.4)

Clinical Presentation
• Major general prostration
• Fever
• Cervical adenopathy
• Otalgia
• Halitosis
Sore Throat 59

Fig. 4.4 Bacterial
tonsillitis

Examination
The Centor criteria are particularly useful to corroborate the diagnostic suspect giv-
ing an indication of the likelihood of a sore throat being due to bacterial infection.
The criteria are:
• Tonsillar exudate
• Tender anterior cervical adenopathy
• Fever over 38 °C (100.5 °F) by history
• Absence of cough
If 3 or 4 of Centor criteria are met, the positive predictive value is 40–60%.
The absence of 3 or 4 of the Centor criteria has a fairly high negative predictive
value of 80%. Also of good clinical value is the streptococcal score card. This
gives an indication of the likelihood of a sore throat being due to infection with
group A beta-­haemolytic streptococci (GABHS). The criteria are (Centor et al.
1981):
• Age 5–15 years
• Season (late autumn, winter, early spring)
• Fever (≥38.3 °C [≥101 °F])
• Cervical lymphadenopathy
• Pharyngeal erythema, oedema, or exudate
• No symptoms of a viral upper respiratory infection (conjunctivitis, rhinorrhoea,
or cough)
If 5 of the criteria are met, a positive culture for GABHS is predicted in 59% of
children; if 6 of the criteria are met, a positive culture is predicted in 75% of
children.
60 4 Laryngology

Peri-tonsillar Cellulitis

• Peri-tonsillar redness and oedema


• Lock of the jaw, but not marked

Peri-tonsillar Abscess

• Evolution of peri-tonsillar cellulitis


• Symptoms and signs of peri-tonsillar cellulitis
• Lockjaw
Examination
The appearance of the tonsils between episodes of acute tonsillitis does not help
much the diagnosis. At times, the tonsils are hypertrophic, sometimes to the point to
cause snoring, or airway obstruction. In other cases, they may be cryptic. Some
caseous material may be found in the cryptae of the tonsils, hinting chronic inflam-
mation with dysfunctional tonsils. During periods of acute sore throat, in case of
viral infection, you may observe:
• Redness and oropharyngeal mucosa and oedema with or without
ulcerations
• In the case of unilateral ulceration of the pharynx, consider herpetic
infection
• Petechiae of the palate
• Oedema of the uvula
• Cold sores of the nostril
In case of tonsillitis, you can demonstrate:
• Limited redness, swelling of the tonsils and of the tonsillar pillars
• Pus in the tonsillar crypts
• Halitosis
• “Hot potato voice”
• Redness of the face
• Fever
• Painful cervical adenopathy
• General malaise
In the case of mononucleosis:
• Halitosis
• “Hot potato voice”
• Petechiae on the palate
• Tonsils swollen with whitish patina
• Fever
• Adenopathy
• Liver and spleen may be enlarged
• Jaundice may be present
• General malaise
Sore Throat 61

Fig. 4.5  Glandular fever

Clinical Management of Tonsillitis


• In sore throats without lockjaw, or other complications, soluble aspirin is a good
option in the adult only. In children, paracetamol and ibuprofen should be preferred.
• The majority of patients with sore throat may have already tried to manage their
disease for at least a day with analgesia before presenting to the family physician.
• At this point, having made a diagnosis of tonsillitis, antibiotic therapy, preferably
with penicillin V, erythromycin, or clarithromycin, for 10 days rather than 5 or 7
days, is an option (Little et al. 1997).
• Refer to the specialist in case of recurrent tonsillitis requiring antibiotic therapy in
line with local referring policy.
Clinical Management of Infectious Mononucleosis
• Do not advise antibiotic therapy as this would not help.
• It may require a prolonged period of rest.
• Liver disease may occur, but often it is not clinically significant (Fig. 4.5).

• The Monospot test or blood smear on a slide helps to confirm the diagnostic
suspect
• Supra-infection may require specific treatment

RED FLAGS

Trismus (reduced mouth opening)

Hot potato voice

Patients unable to swallow their own saliva or small


amounts of fluid

Quinsy/abscess
Meningism
62 4 Laryngology

Key Points
Refer to ENT asymmetrical swelling of tonsils, particularly if this is not asso-
ciated with acute inflammatory condition.
Ampicillin/amoxicillin should not be used in a suspected mononucleosis.
Recurrent pharyngitis in a debilitated and worsening patient requires blood
test to exclude hematologic pathology.

Hoarseness

An anomaly of the voice:


• Tone
• Quality
• Pitch
• Volume
Hoarseness is often associated with upper respiratory tract infection in otherwise
healthy individuals, and viral causes in most cases (Fig. 4.6).
Examination
• Weight loss: report immediately to a specialist for suspect neoplastic pathology
• Weight gain: investigation for suspect of myxoedema
• Associated with dysphagia: refer immediately to exclude malignancy
• Otalgia: can suggest neoplastic pathology
• Cervical adenopathy: can indicate neoplastic pathology
• History of bronchitis and sinusitis
• History of dyspepsia and GORD
• Chemical trauma or smoke
• Vocal abuse

Days

Weeks
ion
rat

Months
Du

Years

Dysphagia solid>fluids
ing
Swallow
Dysphagia solid<fluids
Cough History taking in
General conditions Dysphagia solid=fluids
neck & throat
Fever disease Pho Type
nati
on
Weight loss
Duration
Other pathologies and ory
medications i st Onset
lh
Pa

cia
in

So Referred Progression
Smoking
Local tenderness

Alcohol

Fig. 4.6  Laryngology map


Dysphagia 63

Clinical Management
It depends on the cause. Referral to a specialist is often required to exclude neoplas-
tic pathology if hoarseness persists for more than 3 weeks.
• Restrict use of the voice (vocal cords rest)
• Analgesia
• Fumigation and vapours
• Refer to a specialist hoarseness persisting for more than 3 weeks to exclude neo-
plastic pathology, nodules, or polyps
• Chest x-rays

RED FLAGS

Persistence over 3 weeks duration

Pain

Dysphagia

Haemoptsis

Otalgia

Lump/neck mass

Smoker/age greater than 40 years

Dysphagia

Dysphagia is defined as difficulty swallowing (aphagia is its extreme form when


swallowing becomes impossible) of fluids, solids, or both.

Acute Dysphagia

The most common causes are:


• Supraglottic inflammation (epiglottitis); this condition requires immediate refer-
ral to the ENT specialist.
• Tonsillitis that causes pain, obstruction, or both.
• Tonsillar abscess, which demands urgent ENT referral with hospitalization.
• Mononucleosis, which may require hospitalization for fluid and steroid therapy.
• Foreign bodies tend to show up in emergency rooms rather than at GP Surgery.
In case of this suspect, refer to a specialist urgently.
64 4 Laryngology

Progressive Dysphagia

This should always trigger the suspect of oesophageal or pharyngeal neoplastic


pathology in particular when associated to:
• History of weight loss and fatigue
• First to solids and then to both fluids and solids
• Hoarseness
Cough when drinking may suggest the possibility of aspiration. Anamnestic data
suggesting a benign cause of progressive dysphagia are:
• Regurgitation: a barium swallow allows you to confirm a pharyngeal or oesopha-
geal diverticulum. Refer to the specialist.
• A history of GORD suggests the possibility of a stricture due to oesophageal
mucosal ulceration. Even in this case, refer to the specialist.

Other Causes

• Neurogenic dysphagia
• Connective tissue disorders such as systemic sclerosis

Globus Pharyngeus

The sense of obstruction in the throat is a functional problem and it is otherwise


known as globus pharyngeus, or hystericus. The term ‘pseudo-dysphagia’ also
describes adequately the problematic.
• The knot in the throat improves swallowing, but returns immediately after.
• It is variable.
• There are no signs of obstruction.
• There is often anxiety.
The patient should be referred to the specialist for endoscopic evaluation.
Examination
General examination should be looking for abnormal findings such as:
• Pallor
• Weight loss
• Abdominal masses
• Abnormal chest examination
• Cranial nerve abnormalities
Snoring 65

Local/district examination:
• Angular cheilitis
• Glossitis
• Neck masses
• Masses of the oral cavity
• Movements of the tongue, palate and pharynx
• Sensory examination of mouth and pharynx
Clinical Management
The investigations should include:
• X-ray of the neck with side view
• Chest x-ray
• Barium
• Basic blood tests
In case of a suspect neurological disorder, refer immediately to a specialist.

RED FLAGS

Ear Pain

Sore Throat

Symptoms of lateralization

Persistent hoarseness

Snoring

Snoring is the snorting or rattling noise some people may do when breathing during
sleep. The noise comes from the vibration of the soft palate due to a turbulent air
flow. Also the vibration for the mouth tissues, nose and throat can contribute signifi-
cantly to its generation. Some people snore infrequently and the sound they make are
not particularly loud, while others may snore every night loudly enough to disturb
other people. From an anatomical point of view snoring is due to loss of tone of the
muscles of the soft palate, including those of the uvula, but there are many contribut-
ing factors to it, all of them contributing to the speed and turbulence of the air flow,
or the capacity of vibrating of the soft tissues of the upper aero-digestive tract.
66 4 Laryngology

Fig. 4.7  OSAS and sites


of obstructions of the
upper airways

Key Anamnestic Points

Apnoea: snoring may be associated with apnoeic episodes. Few, short episodes of
apnoea may occur also in normal individuals, but apnoeic episodes that last more
than 10 s and ending with a loud snoring, or heave with awakening, often temporary
and partial, are suggestive of obstructive sleep apnoea syndrome (OSAS).
Epworth Sleeping Score: reference scale that makes possible to evaluate the
severity of daytime sleepiness. With a score 10 < ESS the OSAS is unlikely.
Sometimes children with OSAS may be hyperactive during the day (Fig. 4.7).
Examination
General examination
• Obesity
• Arterial hypertension
Localized/district examination
• Nasal obstruction
• Soft palate ptosis
• Short, large neck
• Mandibular retrognathism
• Hypertrophy of tonsils
• Hypertrophy of adenoids
• Hypertrophy of lingual tonsil
Clinical Management
• Weight loss.
• Smoking cessation.
• Avoid alcoholic drinks for 4 h before bedtime.
References 67

• Do not use hypnotics, or muscle relaxers at night.


• Trial of mandibular snore ban type pusher. Optionally, refer the patient for poly-
somographic studies. A respiratory physician may advise continuous positive
airway pressure (CPAP).
CPAP is a small machine that delivers a constant and steady air pressure through
a hose to a mask or nose piece. Remember to tell the patient it is its obligation to
inform the Driving Vehicles Licensing Authority.

RED FLAGS

Daytime sleepiness

Sleep apnoea observed by another person

References

Little P, Gould C, Williamson I, et al. (1997) Reattendance and complications in a randomised trial
of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ
315:350–352
Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K (1981) The diagnosis of strep throat
in adults in the emergency room. Med Decis Making. 1(3):239–246
Chapter 5
Head and Neck

The Oral Cavity and the Neck

Any of the structures of the mouth may be involved in local disease or may be part of
wider systemic pathology. Therefore a thorough history is needed to determine
between the two. Certain symptoms such as xerostomia (dry mouth) should not be
considered in isolation. This may be as a result of drugs, gland dysfunction or diabe-
tes. Ulcerations of the oral mucosa could be as a result of local disease such as poor
dental hygiene, gingivitis or systemic illnesses including anaemia, AIDS or HIV. Any
ulceration that is red, white or pigmented lasting for longer than 3 weeks should be
investigated. Angular stomatitis and tongue/mouth soreness could be from a haema-
tological cause or iron deficiency. Any intraoral swellings that increase in size or pain
associated with eating are usually as a result of salivary gland pathology. Patients
who present with any lumps in the neck should be referred to an ENT specialist, so
that they can be appropriately investigated to determine if they are secondary lymph
nodes and the likely primary source. In patients presenting with a neck lump, it is
worth investigating any symptoms of the tongue, mouth, nose or throat as these may
identify the primary site. Enlarged lymph nodes may be a result of a previous infec-
tion, so the clinician should determine if the patient has had any recent illnesses or
infections. Symptoms associated with under-active or over-active thyroid should be
determined. Associated symptoms such as weight loss, night sweats and malaise are
suggestive of systemic diseases such as AIDS or lymphoma.

Neck Lump

All patients with an unexplained lump in neck that recently appeared, or a lump that
was not diagnosed before and has changed during a period from 3 to 6  weeks,
should be referred urgently to an ENT specialist.

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70 5  Head and Neck

Salivary Gland Lump

Patients with persistent unexplained swelling of a parotid, sublingual, or subman-


dibular gland should be referred urgently to ENT.

Facial Palsy

The facial nerve controls the muscles of the facial expression and stapedius, the lac-
rimal and submandibular glands, and the sensory function of the anterior 2/3 of the
tongue. Hence, as well as facial droop, patients may present with drooling, hyperacu-
sis, altered taste, speech issues, earache, dry eye and reduced corneal reflex. Facial
palsy can be classified in central or peripheral. The two forms are differentiated clini-
cal examination since the facial motors nuclei are two, one top and one bottom bilat-
erally innervated that receives only a contra-lateral innervations. It follows that:
• Central facial palsy is incomplete, affecting only the lower half of the contra-­
lateral face.
• Peripheral facial paralysis is complete and ipsilateral and its severity can be clas-
sified according to House and Brackmann (1985) (Fig. 5.1).

Herpes Zoster

Herpes affects the ear, mouth, pharynx and facial nerve. Even the acoustic nerve
may be affected and is otherwise known by the name of Ramsay-Hunt.
Clinical Presentation
• Ramsay-Hunt syndrome presents with severe otalgia Hunt JR (1907).
• Burning pain several hours before onset of typical herpetic blistering.
• Blistering rash will appear around the ear, face and sometimes in the oral
cavity.
• The syndrome generally causes more severe symptoms and has a worse progno-
sis than Bell’s palsy has. Even if the latter, of which the exact reasons remain
unclear, maybe likewise ascribed to herpetic infection.
• Accompanying vestibular symptoms such as vertigo, nausea and vomiting may
be present.
Facial Palsy 71

Fig. 5.1  Peripheral facial paralysis

• Hearing can be reduced, with or without tinnitus.


• The eye and mouth may be affected; the latter with alteration to taste, known as
disgeusia.
Examination
• Examination will demonstrate a vesicular rash
• Examination of facial nerves
• Assessment of taste
• Otoscope and hearing assessment
• Pain and/or paraesthesia
• If the vestibular system is affected, vestibular testing would show a deficit on the
same side of the lesion.
• Middle ear pathology – The involvement of the facial nucleus lower motor neu-
ron is associated with ipsilateral otorrhoea and/or cholesteatoma.
• Post-traumatic causes – Most often occur in the emergency room while occa-
sionally patients seek advice from part of GP. In this case, the patient should be
reported immediately to the specialist. They may be: a temporal bone fracture,
post-surgical, sharp/blunt facial trauma, or a birth canal trauma
Clinical Management
• Analgesics
• Acyclovir (topical or oral) if onset of symptoms is within 48 h
• Protection of the cornea
• EMG evaluation
72 5  Head and Neck

RED FLAGS

Suspect of stroke

Suspect of mastoiditis

Head trauma

Severe otitis externa

Bell’s Palsy

Bell’s palsy is a diagnosis of exclusion.


Clinical Presentation Complete
• Can be preceded by otalgia.
• Often the patient is believed to have had a stroke.
Examination Complete
• The sense of taste in the front 2/3 of the tongue is affected, and the patient may
have watery eye and reduced corneal reflex. However, their recovery is often
faster than the recovery of the motor function.
Clinical Management
• In 75% of the cases, it resolves within 3 weeks from the onset and the lack of a
resolution within that span of time should suggest a request for specialist visits.
• ACTH and corticosteroids have not been confirmed as effective. However, it is
believed that steroid tablets such as prednisolone help to reduce inflammation
and are normally taken for 10 days.
• The eye should be protected and artificial drops prescribed.
• In the case of a suspicion of damage to the cornea, refer to ophthalmologist.
• In the case of a slow recovery, suggest physiotherapy with transcutaneous elec-
trical stimulation.
• Consider alternative diagnoses in case of multiple neuropathies.

RED FLAGS

Otitis media

Cholesteatoma

Parotid tumour

Malignant otitis externa

Bilateral onset
References 73

Other Causes

Other causes may be an acoustic neuroma, a parotid gland malignancy, a malignant


otitis externa or Lyme disease.

References

House JW, Brackmann DE (1985) Facial nerve grading system. Otorlaryngol Head Neck Surg
93(2):146–147
Hunt JR (1907) On herpetiform inflammation of the geniculate ganglion: a new syndrome and its
complications. Nerve Ment Dis 34:73
Chapter 6
Post-operative ORL

Adenoidectomy

After adenoidectomy, the patient may experience post-operative bleeding and pain.
Post-operative Bleeding
Bleeding after adenoidectomy surgery requires immediate hospitalization, with
posterior nasal tamponade, if necessary.
Post-operative Pain
It is in general minimal. If otalgia, perform otoscopy to exclude ear infection.

Trans-tympanic Tubes

It is not uncommon for a GP to be consulted by parents alarmed by the appearance


of ear discharge from the very same ear where a drainage tube, this being a grommet
or a T-tube, had been positioned by the ENT specialist some weeks or months
before. The discharge may follow an upper respiratory tract infection or a bath with
subsequent infection due to contaminated water, for example, penetrated in the mid-
dle ear. It is reasonable to suggest topical antibiotic therapy as eardrops, or an oral
antibiotic. The GP should be mindful of the ototoxicity of the aminoglycosides usu-
ally present in the eardrops. Eye drops with ofloxacin or ciprofloxacin may be very
helpful in similar circumstances. There is no conclusive evidence that swimming is
risky for the child with trans-tympanic drainage. It is preferable to avoid shampoo
and conditioner in your ear (Fig. 6.1).

© Springer International Publishing AG 2017 75


E. Cervoni, K. Leech, ENT in Primary Care,
DOI 10.1007/978-3-319-51987-6_6
76 6  Post-operative ORL

Fig. 6.1  Grommet in place

Nasal Surgery

Pain
Generally present in post-transplantation, especially because of nasal swabs inserted
to prevent adhesions. In the absence of infection, use analgesia. In case of oedema
or infection, the patient should be admitted to hospital.
Post-operative Epistaxis
An epistaxis after nasal surgery should be sent to a specialist immediately although
a mupirocin cream like Naseptin can help.

Tonsillectomy

Post-operative Bleeding
Most often it occurs within the first 48 h. Generally, the patient is readmitted immedi-
ately, in case he had been already discharged. Minor bleeding can occur up to 10 days
after surgery and are most often caused by infection or detachment of granulation
tissue from the loggia of the tonsils. Hospital readmission is required (Fig. 6.2).
Post-operative Pain
Although the patient is discharged with analgesia, sore throat in the subsequent days
has to be expected and the patient may attend the GP surgery. It is on this occasion
that the GP may confuse the granulation tissue with pus and infection. It may
Oncology ORL 77

Fig. 6.2 Tonsillectomy

happen that the GP replaces an antibiotic that the ENT department initiated, assum-
ing that this was not working. In addition, we must be cautious in the use of soluble
aspirin for the risk of bleeding associated with NSAIDs. Paracetamol, codeine and
ibuprofen are all valuable alternatives.
It is helpful to assure patients and their relatives that within a couple of weeks the
situation will be resolved. As for the food, hard foods like nuts and chips should be
avoided in favour of a liquid or soft diet. Eating little and often can be beneficial.
Avoid a two-large-meals diet.

Oncology ORL

Neoplastic Suspect in ENT

The request for an urgent ENT appointment is recommended whenever you suspect
a malignancy. Several signs and symptoms may be the trigger and they shall be
illustrated in the following paragraphs.

Hoarseness

If hoarseness persists for more than 3 weeks, particularly in smokers over 50 years
old and heavy drinkers, we recommend an urgent CXR.  Patients with positive
results must be sent urgently to a team specialized in the management of lung can-
cer. Patients with a negative result must be sent urgently to a team that specializes
in cancer of the head and neck.
78 6  Post-operative ORL

Sore Throat

In patients with sore throat unexplained and persistent, it is recommended that a


request for an urgent ENT assessment should be arranged.

Otalgia with Sore Throat or Neck

In patients with unilateral unexplained pain in the area of the head and neck for
more than 4 weeks, associated with ear pain (otalgia), but with normal otoscopy,
you should formulate a request for urgent ENT assessment.
Chapter 7
Pharmacology

Antibiotic Prescribing

When prescribing, or considering prescribing antibiotics, it is advisable to:


• Document the indication/rationale for antimicrobial therapy, including clinical
criteria relevant to this.
• Review and document the patient’s allergy status.
• Ensure the choice of antibiotic complies with the antibiotic guidelines whenever
possible and to keep a record of any clinical criteria relevant to the choice of agent.
• Document a management plan including duration of the treatment or review
date.
• Where relevant, consider drainage of pus or surgical debridement/removal of
foreign material. To this aim, immediate ENT referral may be required.

Common ENT Antibiotic Prescribing in Primary Care (Fig. 7.1)

Common Prescriptions

Rhinitis

Beclometasone nasal spray


Budesonide nasal spray (Rhinocort Aqua)
Betamethasone nose drops (Betnesol, Vistamethasone)
Ipratropium bromide 21 μg/metered spray (Rinatec)
Xylometazoline hydrochloride 0.1% (Otrivine)
Fluticasone propionate 50 μg
Azelastine hydrochloride 137 μg/metered spray (Dymista)

© Springer International Publishing AG 2017 79


E. Cervoni, K. Leech, ENT in Primary Care,
DOI 10.1007/978-3-319-51987-6_7
80 7 Pharmacology

Vertigo

Betahistine
Cinnarizine tablets (Stugeron)

Otitis Externa

Clotrimazole for ear infections (Canesten)


Betamethasone ear drops (Betnesol, Vistamethasone)
Dexamethasone (as sodium metasulphobenzoate) 0.05%, framycetin sulphate 0.5%,
gramicidin 0.005%. (Sofradex)
Dexamethasone 0.1%, neomycin sulphate 3250  units/mL, glacial acetic acid 2%
(Otomize)
Ofloxacin 0.3% (Exocin)

Sore Throat/Mouth

Benzydamine spray (Difflam)


Chlorhexidine mouthwash (Corsodyl)
Mucoadhesive buccal tablets of hydrocortisone 2.5 mg (as sodium succinate)
Clinical diagnosis Treatment advice Comments and guidelines
for lab testing
Acute sore throat Centor>3 Centor score 3 or above treat
Phenoxymethylpenicillin with antibiotics. < 3 no
500mg qds for 10 days In antibiotics
penicillin allergy: Take a throat swab in
Clarithromycin 500mg bd for persistent infections lasting
5 days 3-4 weeks (CKS). Treatment
advice also applies to Scarlet
Fever but for 10 days

Acute viral sore throat No antibiotic indicated Issue Use CENTOR to guide
Patient Information Leaflet diagnosis If 3 or 4 present
(PIL) on viral sore throats If treat as for bacterial sore
in doubt, use of deferred throat
prescription is an option N.B. If symptoms persist
refer to ENT
Acute laryngitis No antibiotic indicated Issue
Patient Information Leaflet
(PIL) on viral sore throats
Acute sinusitis Use symptomatic relief Avoid antibiotics as 80%
(analgesia) before resolve in 14 days without,
prescribing antibiotics and they only offer marginal
Amoxicillin 500mg tds for 7 benefit after 7 days
days or Doxycycline 200mg
stat. then 100mg od for 7
days in total (for children

Fig. 7.1  2016 Antimicrobial Guide and Management of Common Infections in Primary Care
(From the Pan Mersey Area Prescribing Committee NHS 2016)
Common Prescriptions 81

under 12 use clarithromycin


instead of doxycycline) For
persistent symptoms Co-
amoxiclav 500/125mg tds for
7 days
Chronic sinusitis Refer to ENT and treat
according to advice
Labyrinthitis Antibiotics not indicated
Bacterial Parotid gland Flucloxacillin 500mg qds for Ensure the patient is hydrated
infection (usually 7 days In penicillin allergy:
unilateral) Clindamicin 450mg qds for
7 days
Acute otitis media First line treatment is 80% of cases will resolve in
paracetamol or ibuprofen and 72 hours. If no vomiting and
observe If no improvement temp < 38.5 use paracetamol
after 72 hours; Amoxicillin or ibu profen.
500mg tds: for 5 days In
penicillin allergy:
If in doubt, use a delayed
Clarithromycin 500mg bd for
prescription.
5 days

Immediate antibiotic
treatment should be Acute
(AOM) considered for
bilateral AOM in 3 episodes
in 6 months or >5 episodes in
12 months
Chronic otitis media Refer to ENT
Otitis externa First use aural toilet If cellulitis or disease
(if available) and analgesia. extending outside ear canal,
First line: Acetic acid 2% start oral antibiotics and
(EarCalm®) 1 spray tds for refer. In severe infection of
7 days. Second line: Neomycin the pinna, swab to exclude
sulphate with corticosteroid pseudomonas Caution:
and acetic acid (Otomize®) Topical neomycin has been
1 metered spray tds known to cause ototoxicity
Third line: Ciprofloxacin and must not be used if there
0.3% eye drops (Ciloxan) is a suspicion of ear drum
2 drops three times a day as perforation. See third line
ear drops for 7 days if: swelling recommendation (unlicensed
is so severe that topical indication)
treatment cannot be
administered in the form of a
spray or there is confirmed or
suspected tympanic
membrane perforation
Intermittent or prolonged
(>7 days) use should be
avoided in primary care.
For cellulitis or extensive
infection to outside ear canal:
Flucloxacillin 500mg qds for
5 days In penicillin allergy:
Clarithromycin 500mg bd for
5 days For fungal infections
use clotrimazole solution
1%, apply 2-3 times daily until
14 days after cure

Fig. 7.1 (continued)
82 7 Pharmacology

Glue Ear

Autoinflation nasal balloon (Otovent)

Reference

Pan Mersey Area Prescribing Committee NHS (2016) Antimicrobial guide and management of
common infections in primary care 11–14
References

BMJ Best Practice (2016) Tonsilitis [online]. http://bestpractice.bmj.com/best-practice/mono-


graph/598/diagnosis/criteria.html
British Society of Audiology (2014) Recommended procedure for Hallpike maneuver [online].
http://www.thebsa.org.uk/wp-content/uploads/2014/04/HM.pdf
Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K (1981) The diagnosis of strep throat
in adults in the emergency room. Med Decis Making 1(3):239–246
Corbridge RJ (2011) Essential ENT. 2nd edn. CRC Press, London
Cross S, Rimmer M (2007) Nurse practitioner manual of clinical skills, 2nd edn. Elsevier, London
Fujisawa T (2015) Allergen immunotherapy in children. Arerugi 64:787–794
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Helman CG (1981) Disease versus illness in general practice. J R Coll Gen Pract 31:548–562
House JW, Brackmann DE (1985) Facial nerve grading system. Otorlaryngol Head Neck Surg
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Hunt JR (1907) On herpetiform inflammation of the geniculate ganglion: a new syndrome and its
complications. Nerve Ment Dis 34:73
Kurtz SM, Silverman JD (1996) The Calgary-Cambridge Referenced Observation Guides: an aid
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using a Delphi survey. Clin Otolaryngol 39:281–288
Neighbour R (1987) The inner consultation. Lancaster, MTP
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327(7429):1430–1433

© Springer International Publishing AG 2017 83


E. Cervoni, K. Leech, ENT in Primary Care,
DOI 10.1007/978-3-319-51987-6
Index

A H
Adenoidectomy, 51, 75 Halitosis, 58, 60
Adult deafness, 25 Hallpike test, 32–33
Allergic rhinitis, 40, 43, 45–48, 53 Head-shaking nystagmus, 31, 32
Hearing tests, 8, 25–30
Herpes zoster, 70–72
B Hoarseness, 2, 55, 56, 62–65, 77–78
Bell’s palsy, 70, 72

N
C Nasal obstruction, 39, 40, 44, 45, 47–50, 52,
Child deafness, 23 53, 57, 66
Nasal polyps, 45, 48–50, 53, 54

D
Dysphagia, 55, 62–64 O
Otalgia, 5, 6, 11–12, 15, 16, 19, 21, 23–25,
39, 58, 62, 70, 75, 78
E Otitis externa, 12–13, 18, 19, 28, 29, 73, 80,
Ear syringe, 9 81
Epistaxis, 2, 39, 42–44, 76 Otoscope, 6, 7, 10, 19, 28, 29, 37, 40, 41, 56,
71

F
Facial palsy, 6, 70–71 P
Fistula test, 10, 37–38 Pharyngitis, 57–58, 62
Frenzel goggles, 8, 9, 31
Fukuda stepping test (FST), 32
R
Recurring rhinosinusitis, 53–54
G Rhinitis, 45, 53, 56, 79
Globus pharyngeus, 64–65 Rhinosinusitis, 53–54
Glue ear, 24, 25, 82 Rinne, 8, 25–27, 30

© Springer International Publishing AG 2017 85


E. Cervoni, K. Leech, ENT in Primary Care,
DOI 10.1007/978-3-319-51987-6
86 Index

S Tonsillitis, 5, 11, 15, 58–63


Saccades, 31 Trans-tympanic tubes, 75–76
Septal deviation, 42, 45, 50, 53 Tuning forks, 8, 9, 26, 30
Sinusitis, 40, 48, 52–54, 62, 80, 81
Smooth pursuit, 31
Snoring, 60, 65–66 V
Sore throat, 39, 55–62, 76, 78, 80–81 Vasomotor rhinitis, 47–48
Vertigo, 6, 19, 21, 22, 33–38, 70, 80

T
Tinnitus, 2, 6, 19, 21, 22, 29–36, 70 W
Tonsillectomy, 76–77 Weber, 8, 27–30