Notes from Dr. Monique Parkin via HMRI ENT Update 2023

Ear

Otitis externa

Cause

• Wetness and trauma = Staph

• Wetness = Pseudomonas

Treatment

1. Swab first

2. Strict water precautions

   • Blutak - Large piece, external, don’t reuse

   • Extend 1-week beyond the resolution of symptoms

   • No syringing

3. Antibiotics

   • Sofradex (skin)

   • Ciprofloxacin HC (water)

   • Minimise duration to 5 days due to the risk of fungal infection being high

   • Systemic ABx only if extension of cellulitis e.g. pinna, immunosuppressed

4. Steroids

   1. Prednisolone 3 days ff canal swollen shut

Persistence

• If symptoms return after resolution return to step 1 and start from scratch

• Reswab

• Be aware itch ear can be a fungal infection

  • Locacorten-Viaform (Compounded)

  • Canestan

  • Kenacomb

• Fungal infections are more dependent on toileting than bacterial

Grommet care

• Variable advice

  • No additional precautions

  • Bluetak swimming

• Discharge is not normal

  • Needs Swab and treatment

  • Tissue spears first

• Topical not oral antibiotics unless concurrent URTI

  • Ciprofloxacin vs Sofradex (safe enough)

  • Tissue spears prior

  • Pump in after with tragus

SSNHL

• Sudden loss of hearing

• Ideally hearing tests quickly

• 2-week window for PO steroids

• ASAP 50mg max daily up to 14 days and wean

• Beware side effects

• Consider intraTM steroid injection if not improvement

• MRI to exclude retro-cochlear pathology

• ? autoimmune screen

• Ongoing

  • Protect hearing, tinnitus advice, amplifications vs Cochlear implant (Next sense referral)

Nose

Epistaxis

• Cause

  • 90% anterior

  • Dry of the nose in Winter

  • Anticoagulants

  • Septal deviation

• Treatment

  • DRABC first

    • Sit up, head forward

    • Apply pressure to the site of bleeding by squeezing the anterior cartilaginous nose

    • 10 minutes

  • 2nd line is a moisturiser

    • FESS nasal gel hourly, when awake for 2 weeks

    • Avoid vaseline

    • May resolve the issue

  • 3rd line nasal cautery

    • Headlight, nasal speculum, cophenylate, cotton ball, silver nitrate

Sinusitis vs headache

• Headache is not sinusitis

• Acute rhinosinusitis

  • Purulent nasal discharge

  • Nasal obstruction

  • Facial pain

  • Persistent for more than 10 days

  • <10 days is viral

  • 10 days to 4 weeks is bacterial

• Chronic rhinosinusitis > 12 weeks

  • Mucopurulent drainage, nasal obstruction, facial pain, hyposmia

  • Inflammation

    • Needs CT to scan to demonstrate

  • Trial treatment

    • Swab

    • Flo douche BD

      • Helps cilia recover

    • ABx

    • Steroids

  • Must have a CT

    • Diagnostic, prognostic, required

  • Refer only if the diagnosis is confirmed and treatment failed

Paediatric rhinitis

• Rhinorrhoea, sneezing, Itching, congestion, obstruction

• Medical issue

• Secondary effects

  • Ear - ETD, rAOM, OME, atelectasis

  • Nose - Mouth-breathing, craniofacial growth

  • Throat - Snoring, SDB

  • Brain - Sleep quality, poor concentration

  • Lower airways - Asthma

• Every needs a trial of medial therapy, surgery does not help in the long-erm

• Treatment

  • Avoid trigger

  • Steroids

    • INCS / Dymsita / Ryaltria / Avamys / Omanris / Nasonex

    • Minimum 2 to 3 months of daily use

    • Safe to use up to 9 months of a year lifelong

      • Side effects epistaxis, ocular safety, HPPA

  • Antihistamines

    • Oral or IN

  • Montelukast

  • Immunotherapy

Throat

Indications for tonsillectomy

• Recurrent tonsillitis 7 in 1 year, 5 in 2 years, 3 in 3 years, twice yearly indefinite

• Complicated tonsillitis

  • Quinsy = 30% chance of recurrence

  • Febrile convulsions

• Chronic tonsilloliths

  • Surgery only cure

  • Impact greatly understated, can greatly reduce QoL

• SDB/OSA

• Cancer

Tonsillitis

• High impact on patients and families and community

Snoring/OSA

• Primary snoring

  • Noise only that doesn’t disturb sleep

  • No gas exchange abnormalities

  • No need ENT referral

• SDB/UARS

  • Disturbed sleep

  • Microawakenings

  • Gasping episodes

  • Restlessness

  • Sweating

  • Enuresis

  • Daytime somnolence

  • Behavioural distrubances

  • Hyperactivity

  • Headaches

  • Irritability

  • Poor concentration

• OSA

  • Complete upper airway obstruction

  • Witnessed apnoeas

  • Hypoxaemia

  • refer ENT

  • Resp/PSG only if suspect severe or discordant parental vs medical opinion