ENT UPDATEENT UPDATE

Gavin Watters FRCS Gavin Watters FRCS FRCS(ORL)FRCS(ORL)

Consultant ENT SurgeonConsultant ENT Surgeon

PRIMARY CAREPRIMARY CARE

EEVertigo BPPV Tinnitus Otitis Vertigo BPPV Tinnitus Otitis

ExternaExterna

NNRhinosinusitisRhinosinusitis

TTGlobus sensation SnoringGlobus sensation Snoring

DizzinessDizziness

VertigoVertigoUnsteadiness (on walking)Unsteadiness (on walking)Light-HeadednessLight-Headedness

VertigoVertigo

DefinitionDefinition

An illusion of movement of the subject An illusion of movement of the subject or of his/her surroundings. Usually or of his/her surroundings. Usually a sensation of spinning or rotation.a sensation of spinning or rotation.

Central or PeripheralCentral or Peripheral

Acute Peripheral VertigoAcute Peripheral Vertigo

BPPV < 5 minutesBPPV < 5 minutes Meniere’s Disease/Syndrome Meniere’s Disease/Syndrome

<24 Hours<24 Hours Vertigo with migraine <24 Vertigo with migraine <24

HoursHours Vestibular/labyrinthine failure Vestibular/labyrinthine failure

>24 Hours>24 Hours

Dix-Hallpike TestDix-Hallpike Test

Dix-Hallpike TestDix-Hallpike Test

PeripheralPeripheral Latent periodLatent period Distress +++Distress +++ Rotational Rotational

nystagmusnystagmus FatigableFatigable

CentralCentral No latent periodNo latent period Distress +/-Distress +/- Variable Variable

nystagmusnystagmus Not fatigableNot fatigable

BPPVBPPV

Calcium deposits in posterior semi-Calcium deposits in posterior semi-circular canalcircular canal

Brandt-Daroff exercisesBrandt-Daroff exercises Epley manoeuvreEpley manoeuvre Obliterate Posterior S-CCObliterate Posterior S-CC Singular nerve neurectomySingular nerve neurectomy

Brandt-Daroff ExerciseBrandt-Daroff Exercise

TinnitusTinnitus

Primary/idiopathicPrimary/idiopathic SecondarySecondary

Ear diseaseEar disease

VascularVascular

NeuronalNeuronal

NeuromuscularNeuromuscular

Pulsatile TinnitusPulsatile Tinnitus

VascularVascular

Vascular stenosisVascular stenosis

AVMAVM

Glomus tumourGlomus tumour

Conductive HLConductive HL

Hear normal Hear normal intra-cranial intra-cranial blood flowblood flow

ManagementManagement

PrimaryPrimary

ReassuranceReassurance

Advice on Advice on environmental environmental maskingmasking

Hearing aidHearing aid

Need only refer if not Need only refer if not coping or unilateral coping or unilateral tinnitustinnitus

Hearing Therapy, Hearing Therapy, maskermasker

SecondarySecondary

Treat underlying ear Treat underlying ear diseasedisease

Refer for further Refer for further investigation/treatinvestigation/treatmentment

Otitis ExternaOtitis Externa

PainPain Irritation/ItchIrritation/Itch DischargeDischarge (Hearing loss)(Hearing loss)

Cotton budsCotton buds Skin conditionSkin condition DiabetesDiabetes Middle ear Middle ear

diseasedisease AnatomicalAnatomical

Management of OEManagement of OE

Antibiotic/steroid DROPSAntibiotic/steroid DROPS Water precautionsWater precautions Good analgesiaGood analgesia Aural toiletAural toilet Steroid ointmentSteroid ointment Swab (?Fungal OE)Swab (?Fungal OE) Systemic antibiotics if cellulitisSystemic antibiotics if cellulitis

Sinusitis?Sinusitis? Blocked noseBlocked nose CongestionCongestion Facial Facial

pain/headachepain/headache Runny noseRunny nose Catarrh/mucousCatarrh/mucous Unpleasant Unpleasant

smell/tastesmell/taste

Puffy/swollen facePuffy/swollen face ‘‘Bags’ under eyesBags’ under eyes Watery/sticky eyeWatery/sticky eye And many more!And many more!

SinusitisSinusitis

CacosmiaCacosmia Purulent RhinorrhoeaPurulent Rhinorrhoea Hyposmia/anosmiaHyposmia/anosmia Facial painFacial pain Frontal headacheFrontal headache Nasal obstructionNasal obstruction

Facial PainFacial Pain Facial Facial

neuralgia/migrneuralgia/migraineaine

DentalDental SinusitisSinusitis TMJ/Myofacial TMJ/Myofacial

painpain

Periodicity, not Periodicity, not constantconstant

Well localisedWell localised Worse with coldsWorse with colds Responds to Responds to

antibioticsantibiotics Other sinus Other sinus

symptomssymptoms Facial swelling Facial swelling

almost almost nevernever due to due to sinusitissinusitis

Diagnosis of SinusitisDiagnosis of Sinusitis

DIFFICULT!DIFFICULT! Nasal endoscopy is the keyNasal endoscopy is the key Plain sinus X-ray no valuePlain sinus X-ray no value CT scan limited value. 30% normal CT scan limited value. 30% normal

individuals have CT changesindividuals have CT changes Facial swelling almost never due to Facial swelling almost never due to

sinusitissinusitis Forehead and periorbital swelling Forehead and periorbital swelling

probably is due to sinus infectionprobably is due to sinus infection

Nottingham Rhinology Nottingham Rhinology ClinicClinic

973 consecutive patients973 consecutive patients Mean follow-up 26 monthsMean follow-up 26 months 1/3 diagnosis not sinonasal1/3 diagnosis not sinonasal 119/679(18%) with sinonasal disease 119/679(18%) with sinonasal disease

had painhad pain 43/119 pain not attributable to sinus 43/119 pain not attributable to sinus

diseasedisease 76/679(11%) had pain attributable to 76/679(11%) had pain attributable to

sinus diseasesinus disease

Neurological CausesNeurological Causes((Nottingham Study)Nottingham Study)

Midfacial segment painMidfacial segment pain37%37% Tension headacheTension headache 23%23% MigraineMigraine 17%17% Atypical facial painAtypical facial pain 12%12% Cluster headacheCluster headache 8%8% OthersOthers 3%3%

SummarySummary Facial pain/frontal headache is not a Facial pain/frontal headache is not a

major feature of sinonasal disease.major feature of sinonasal disease. Most patients with head Most patients with head

pain/pressure have a neurological pain/pressure have a neurological cause for this symptomcause for this symptom

Be very cautious in attributing such Be very cautious in attributing such symptoms as being due to sinusitis, symptoms as being due to sinusitis, especially in the absence of objective especially in the absence of objective evidence of sinus disease.evidence of sinus disease.

Rhinitis- AetiologyRhinitis- Aetiology

Intrinsic (vasomotor)Intrinsic (vasomotor) Allergic (seasonal, perennial)Allergic (seasonal, perennial) Environmental (SMOKING)Environmental (SMOKING) InfectiveInfective HormonalHormonal Medication (Rhinitis medicamentosa)Medication (Rhinitis medicamentosa) Systemic medical disorder eg Wegner’sSystemic medical disorder eg Wegner’s

Rhinitis- ManagementRhinitis- Management

Topical nasal Topical nasal steroidssteroids

Use dailyUse daily

Minimum 6-8 weeksMinimum 6-8 weeks

Warn no affect for Warn no affect for 3-4 weeks but 3-4 weeks but don’t stopdon’t stop

Drops more potent Drops more potent than spraysthan sprays

Stop nasal Stop nasal decongestantsdecongestants

Stop smokingStop smoking Add Add

antihistamines?antihistamines? Ipratropium Ipratropium

Bromide?Bromide? Allergen avoidanceAllergen avoidance

AfterAfter allergy allergy testingtesting

ImmunotherapyImmunotherapy

Gastro-oesophageal Gastro-oesophageal refluxreflux

Effects 25-40% of British population Effects 25-40% of British population each weekeach week

Atypical manifestations are commonAtypical manifestations are common

LaryngealLaryngeal

PharyngealPharyngeal

Laryngopharyngeal Laryngopharyngeal SymptomsSymptoms

Hoarse voice (usually fluctuating)Hoarse voice (usually fluctuating) Globus sensationGlobus sensation MildMild dysphagia dysphagia Post nasal dripPost nasal drip Chronic coughChronic cough Chronic sore throat (mild)Chronic sore throat (mild)

PathophysiologyPathophysiology Inflammation due to direct action of acidInflammation due to direct action of acid

Laryngitis, pharyngitisLaryngitis, pharyngitis Increase in cricopharyngeus muscle toneIncrease in cricopharyngeus muscle tone

Globus sensation, dysphagia, pharyngeal Globus sensation, dysphagia, pharyngeal pouchpouch

Vagal hypersensitivityVagal hypersensitivityGlobus sensation, chronic coughGlobus sensation, chronic cough

Ciliary damageCiliary damagePost nasal dripPost nasal drip

THERAPEUTIC TRIAL THERAPEUTIC TRIAL WITH A PPI IS WELL WITH A PPI IS WELL

WORTH WHILE, WORTH WHILE, PROVIDED THERE ARE PROVIDED THERE ARE

NO CLEAR ‘CANCER NO CLEAR ‘CANCER SYMPTOMS’SYMPTOMS’

Cancer symptomsCancer symptoms

Pain, especially odynophagiaPain, especially odynophagia TrueTrue dysphagiadysphagia Change in dietChange in diet Weight lossWeight loss Food regurgitationFood regurgitation

Is symptom more noticeable when Is symptom more noticeable when eating/drinking?eating/drinking?

SNORINGSNORING

ObesityObesity Oropharyngeal Oropharyngeal

PalatePalate

Tongue base ? RetrognaethiaTongue base ? Retrognaethia

TonsilsTonsils NasalNasal

TreatmentTreatment

Non-SurgicalNon-Surgical LOSE WEIGHTLOSE WEIGHT Mandibular splintMandibular splint Treat rhinitisTreat rhinitis Avoid alcohol in Avoid alcohol in

eveningevening Avoid sedativesAvoid sedatives Stop smokingStop smoking Sleep on sideSleep on side

SurgicalSurgical Palatal surgery Palatal surgery

(LAUP)(LAUP)

Must exclude OSAMust exclude OSA TonsillectomyTonsillectomy Nasal surgeryNasal surgery Orthognaethic Orthognaethic

proceduresprocedures

Laser assisted Laser assisted palatoplastypalatoplasty

AND FINALLYAND FINALLY

Questions ?Questions ?