ent for gps for gps jan 2019.pdf · deafness • sudden sensorineural = emergency • forget tuning...
TRANSCRIPT
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ENT for GPsChris Webb
Consultant ENT SurgeonRoyal Liverpool and Broadgreen Hospitals
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Topics (learning outcomes)
• Dizziness• Tinnitus• Deafness• Ear discharge• OME in kids• Rhinosinusitis• Reflux• Head and Neck cancer
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DizzinessDiagnosis Duration Other symptoms
(excluding nausea/vomiting)
BPPV Few seconds up to a couple of minutes
No
Meniere’s Hours Aura (increasing tinnitus, pressure in ear)Deafness
Vestibular Neuronitis Days No
Labyrinthitis Days Occasionally tinnitusOccasionally deafness
Migraine Hours HeadachesHyperacusisVisual disturbances
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Dizziness
• Primary care tests• Otoscopy• Hearing tests• Balance• Hallpike’s• Gait• Cranial nerves (nystagmus)• Cerebellar tests• Peripheral nerves
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Dizziness
• Epley Manoeuvre
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Dizziness
Brandt-Daroff
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Dizziness
• Meniere’s• Often preceding warning e.g. increasing tinnitus• Sensorineural deafness during attack• Aural fullness• Rotatory vertigo• Episodes last few hours – a day or two• Recurrent episodes over a few weeks• Remission for months
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Dizziness
• Meniere’s• Reduced salt intake?• Reduced caffeine?• Reduced alcohol?• Betahistine hydrochloride?• (Prochlorperazine)• Transtympanic steroid injection• Natural history of ‘burnout’ in 80%
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Dizziness
• Labyrinthitis• Preceding URTI or similar in some cases• Sudden onset• Occ deafness• Occ tinnitus• Very severe for a week or so• Subsides after six weeks• Stemetil helpful in first week only
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Dizziness
• Vestibular neuronitis• Preceding URTI or similar in some cases• Sudden onset• No deafness• No tinnitus• Very severe for a week or so• Subsides after six weeks• Stemetil helpful in first week only
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Dizziness
• Remember non-ENT causes:• Cardiac
• Palpitations• Syncope “light-headedness”• Postural effects
• Neurological• Vertical nystagmus• Headaches (migraine)
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Dizziness
• Migraine• Aura• Headache• Visual disturbance• Lasts up to 24 hours• Can be recurrent over a few days• Remission for a few months• Hormonal
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Dizziness
• Urgent ENT referral• Sudden deafness• Middle ear suppuration• Facial palsy
• Which conditions need advice about driving• Any sudden and disabling dizziness – Patient must inform DVLA
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Tinnitus
• Bilateral/unilateral• Pulsatile/non-pulsatile• Constant/intermittent• Onset gradual/sudden• Other ear symptoms
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Tinnitus
• Primary care tests• Otoscopy• Neck/heart auscultation• Hearing tests
• Management• Reassurance• Sound enrichment (apps)• CBT
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Deafness
• Conductive• Wax• Infection• FB• Perforated TM• OME• Otosclerosis
• Sensorineural• Mixed
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Deafness
• Conductive• Sensorineural
• Presbyacusis• NIHL• Ototoxicity• TORCHES• Acoustic neuroma
• Mixed
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Deafness
• Sudden sensorineural = emergency• Forget tuning forks!• Ask patient to hum• If heard in deaf ear = conductive• If heard in good ear = sensorineural
• Oral prednisolone 60mg od 1/52 (taper by 10mg every 3 days thereafter)• Refer to emergency ENT clinic (via on-call SpR)
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Discharging ear
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Discharging ear
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Discharging ear
• Microbiology of Otitis Externa• Psuedomonas aeruginosa• S. aureus• Enterococcus sp• Fungi
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Discharging ear
• Antibiotics
• http://www.microbiologynutsandbolts.co.uk/how-to-choose-an-antibiotic.html
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Discharging ear
• Microbiology of Otitis Externa• Psuedomonas aeruginosa• S. aureus• Enterococcus sp• Fungi
• Amoxicillin is NOT the correct choice• Don’t forget ear calm• Ciprofloxacin is better
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Otitis media (in kids)
• Persisting OM guidelines• https://cks.nice.org.uk/otitis-media-with-effusion#!scenario
• Parental smoking increases risk of OME• Observe 3/12 (except Down’s/cleft palate)• If OME persists at 3/12 refer to ENT
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Ear questions?
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Rhinosinusitis
• Rhinosinusitis – Inflammation of the nose and paranasal sinuses characterised by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge
• +/- facial pain/pressure• +/- reduction or loss of smell
• Endoscopic findings of nasal polyps/middle meatal oedema or pus• CT evidence of mucosal disease affecting the OMC or paranasal
sinuses
EPOS pocket guide 2012
www.rhinologyjournal.com
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EPOS pocket guide 2012
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Management – Adults CRS
EPOS pocket guide 2012
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Management – Adults CRS
EPOS pocket guide 2012
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Management – Adults CRS• Beware total daily dose of steroids
• beclomethasone (beconase) 44% (6+)• budesonide (rhinocort) 33% (12+)• fluticasone furoate (avamys) 0.5% (6+)• fluticasone propionate (flixonase) 0.5% (4+)• mometasone furoate (nasonex) 0.1% (6+)
• Saline nasal douching• Neilmed Sinusrinse - bd
• 240mls previously boiled water• ½ teaspoon of salt• 2-3 drops of baby shampoo
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Management – Adults CRS
EPOS pocket guide 2012
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Management – Adults CRS
Webb, Leong, Liverpool CCG 2018
Re-evaluate after 4 weeks
Improvement No improvement
Continue saline nasal douching and intranasal steroid spray
Prescribe maximal medical therapy
Re-evaluate after 3months
Improvement No improvement
Refer to ENT
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Management – Adults CRS
EPOS pocket guide 2012
• Maximal medical therapy• CRS without nasal polyps
• Saline nasal douching bd• (NeilMed sinus rinse)
• Fluticasone propionate nasules 400mcg½ nasule each nostril bd 3/12
• Clarithromycin 250mg bd 3/12• (then continue nasal spray and saline douche long term or refer)
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Management – Adults CRS
EPOS pocket guide 2012
• Maximal medical therapy• CRS with nasal polyps
• Prednisolone 0.5mg/kg ~ 30 – 40 mg od 1/52• Saline nasal douching bd
• (NeilMed sinus rinse)• Fluticasone propionate nasules 400mcg
½ nasule each nostril bd 3/12• Doxycycline 100mg od 3/52• (then continue nasal spray and saline douche long term or refer)
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Management – Surgery
• Useful in• Medical treatment failure• Deviated nasal septum• Inferior turbinate hypertrophy• Unilateral nasal polyposis?• Fungal sinusitis• Complications of acute or chronic rhinosinusitis
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Nose/sinus questions?
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Laryngopharyngeal reflux
• Gastric refluxate (liquid or aerosolised) reaches larynx• Not GORD• Contents?
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Laryngopharyngeal reflux
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Laryngopharyngeal reflux
• Pepsin• Proteolytic enzyme• Active at pH <6.5• Stable at pH 8• Denatured at pH >8• Active transport into laryngeal epithelium• Intracellular pH ~5
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Laryngopharyngeal reflux
• “Heartburn” needs 350 reflux episodes per week• LPR needs only 3 episodes > 30 seconds per week
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Laryngopharyngeal reflux
• Risk factors: reduced competence of LOS• Hiatus hernia• Smooth muscle relaxants• Alcohol• Caffeine• Spicy foods• Fatty foods• Smoking
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Laryngopharyngeal reflux
• Symptoms• Cough/throat clearing• Choking episodes (esp. night)• Hoarseness• Globus pharyngeus• Dry throat• Sore throat• Dysphagia to small items e.g. rice/tablets
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Laryngopharyngeal reflux
• Management• Self help• Medical• Surgical
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Laryngopharyngeal reflux
• Self help• Reduce alcohol, caffeine, spicy or fatty food• Avoid cola, fruit juices, tomatoes• Stop smoking• Lose weight• “Tooth whitening” chewing gum• Raise head of bed (not pillows)
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Laryngopharyngeal reflux
• Medical treatment• PPI• Gaviscon advance
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Laryngopharyngeal reflux
• Surgical treatment• Nissen fundoplication• Endoscopic techniques
• Radiofrequency ablation• Endoscopic fundoplication
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Laryngopharyngeal refluxHigh dose PPI ½ hour before breakfast and evening meal. 10 ml (one tab) gavisconadvance at night and after meals
High dose PPI ½ hour before breakfast and evening meal. 10 ml (one tab) gavisconadvance at night and after meals
Low dose PPI ½ hour before breakfast and evening meal. 10 ml (one tab) gavisconadvance at night and after meals
Low dose PPI ½ hour before breakfast and evening meal. 10 ml (one tab) gavisconadvance at night and after meals
Low dose PPI ½ hour before evening meal. 10 ml (one tab) gaviscon advance at night and after meals
Low dose PPI ½ hour before evening meal. 10 ml (one tab) gaviscon advance at night and after meals
2/12
2/12
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Laryngopharyngeal reflux
PRN low dose PPI. Gavisconadvance 10ml (one tab) nocte and
after meals. Lifestyle changes
PRN low dose PPI. Gavisconadvance 10ml (one tab) nocte and
after meals. Lifestyle changes
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Head and Neck Cancersuspected cancer referral criteria 2015
http://www.nwcscnsenate.nhs.uk/index.php/download_file/view/2070/1672/
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Head and Neck Cancersuspected cancer referral criteria 2015
http://www.nwcscnsenate.nhs.uk/index.php/download_file/view/2070/1672/
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Head and Neck Cancer
• Note that unilateral deafness/tinnitus are NOT part of current guidelines (not since 2003)
• Acoustic neuroma is benign and very slow growing
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Head and Neck Cancer
• Laryngeal cancer• Persistent unexplained hoarseness in over 45s• Or unexplained neck lump
• How long is persistent?• What about “explained”, is this the cause?
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Head and Neck Cancer
• Concerns...• No inclusion of dysphagia or odynophagia• Dysphagia now on upper GI pathway• Risk of delay in diagnosis/treatment for e.g. hypopharyngeal cancer• Persistent sore throat not on any pathway I can find!
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Head and Neck Cancer
• Suggest instead suspected cancer referral to ENT for…• ALL persistent hoarseness lasting >3/52• ALL persistent sore throat lasting >3/52• ALL persistent neck lumps >3/52
(be aware that primary care arranged USS never includes FNA and incurs delay in referral/diagnosis)
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Head and Neck Cancer questions?