COMMON ENT CONDITIONS

ENCOUNTERED IN PRACTICE
SIAMANI BRIAN
 Objectives
• Appreciate the various ENT conditions which
could be encountered in one’s practice
• Make correct diagnosis and institute
appropriate management
• Institute timely referral for further and
specialized management of the patient
• Highlight complications of these disease
pathologies
 Introduction
• ENT/otolaryngology
– Specialized field of surgery involving the ear, nose
and throat i.e. looking at
• Hearing
• Balance
• Airway/passage
• Humidification of air
• Immunity
• Phonation
 Anatomy-Ear

• Divided into three anatomic parts

 Anatomy-nasal area & sinuses
• One of two primary
entry points for oxygen
• Nasal septum:
separation between the
nostrils
• Turbinates: layers of
bone within each nasal
chamber

© Jones & Bartlett Learning

 Anatomy-sinuses

• Frontal sinuses are

above the nose.
• Paranasal sinuses
– Cavities within
several bones
associated with the
nose
Anatomy-sinuses
 Diagnosis of these conditions
• History
• Physical examination:
– Otoscopy
– Nose
– Pharynx
– IDL/ DL
– Conduction tests
– Audiogram
– Radiological: X-Rays, CT scan, MRI scan
• Microbiology
• Histopathology
 Summary of conditions
• Congenital abnormality • Polyps
• FB-ear, nose, throat, • Sinusitis
trachea • Deafness
• LTB/croup • Otitis media
• Tonsillitis • Tumours-laryngeal,
• Adenoditis pharyngeal, nasal
• Otitis-external, media, • Mucoceles
chronic • Congenital problems-
• Sinusitis deafness
• Mastoditis • Craniopharyngioma
• Trauma
 Otitis externa/OE
• Otitis Externa- a painful inflammation of the
membranous lining of the external auditory canal
and/or contiguous structures.
– May be acute(<3wks) subacute (3wks-3months) or chronic
(>3months) inflammatory process
– It may be diffuse or localized
– Is largely benign and self-limiting
– Invasive otitis externa is potentially life threatening
• Malignant OE-- now know as Necrotizing OE
 Otitis externa/OE
• Pathology;
– Inflammation most commonly caused by microbial
infection. Colonization of the external ear is
prevented immune and anatomic mechanisms
• Squamous epithelia of the canal constantly slough,
• while hair follicles sweep laterally, cleaning and act as a
barrier.
• The canal maintains an acidic pH and repels moisture
and the presence of normal flora inhibit the
overgrowth of virulent bacteria.
• If any of this is broken compromised there may be
colonization by bacteria
 Otitis externa/OE
• Microbiology;
– Pseudomonas aeruginosa is most common of
diffuse infections and most cases of invasive OE
– Staphylococcus aureus typically causes a localized
infection from a hair follicle
– Streptococcus pyogenes associated with local
infection presenting as folliculitis
– Polymicrobial infection found in up to 1/3 of cases
of diffuse disease
 Otitis externa/OE
• Other causes of OE
– Fungal agents
• Aspergillus niger- usually local infection, but can cause
invasive infection
• Pityrosporum
• Candida albicans
– Hyperkeratotic processes
• Eczema, psoriasis, seborrheic, or contact dermatitis
 Otitis externa/OE
• Necrotizing OE is the most severe infectious
form of OE
– Bacterial infection extends from the skin of canal
into soft tissue or bone
– Cranial nerves may be involved
– Pseudomonas is most common
– May have bad outcomes!
 Otitis externa/OE

– Presenting complaints
• severe ear pain (otalgia) of sudden or acute onset
• Pain worse at night
• Worse with pulling on the pinna or earlobe or pushing on tragus
• Severe cases- pain with chewing
• May have purulent discharge may be noted
• Chronic OM
– May present with dryness and itching
 Otitis externa/OE

– Physical findings
• Tenderness with palpation
• Otoscopic exam- canal appears swollen and red with drainage with
bacterial infections
• Diffuse cases present with complete involvement
• Localized cases present with focal lesion
• Pseudomonas produces a copious green exudate
• Staphylococcal produces yellow crusting in purulent exudate
• Fungal infections presents as a fluffy, white or black malodorous
growth
• Except in invasive disease there is no lymphadenopathy
• TMJ pain indicates invasive disease
 Otitis externa/OE

– Diagnostic testing
• Rarely needed
• Cultures may be done of discharge if indicated in
healthy patients
• CT or MRI may be needed if suspect invasive disease
 Otitis externa/OE
• Management and Treatments
– Pain meds
– Heat or ice
– Keep dry- no swimming ECT… for 7 days
– Treatment for basic OE
• Irrigation if indicated
• Pain drops
• Antibiotic drops
– Ciprodex, Floxin Cortisporin
– May need a wick if very swollen
 Otitis Media
• Otitis Media;
– Inflammation of the structures in the middle ear.
• Types
– Acute: Acute Otitis Media is infection in the
middle ear (<3wks)
– Subacute (3wks-3months)
– Chronic (>3months)
– Otitis media with effusion: involves the
transudation of plasma from middle ear blood
vessels leading to chronic fluid, can be chronic
 Otitis Media
• Contributing factors include;
– Allergies, rhinitis, pharyngitis due to swelling of upper
airway membranes.
– Most common factor is upper airway infections
(colds), caused by many different viruses.
– Influenza,
– RSV,
– Pneumovirus,
– Adenovirus
– Streptococcus pneumoniae, haemophilus influenzae,
Moraxella catarrhalis are most common. Less
common are streptococcus pyogenes and aureus
– Up to ½ are viral
 Otitis Media
• AOM Symptoms
– Stuffiness,
– fullness,
– decreased hearing,
– pain is rare
– Rarely vertigo
• Usually a history of recent URI, allergies
• Deep pain, fever, sometimes decreased hearing,
discharge with a perforation, sometimes dizziness or
ringing in the ear
• Recurrent AOM means there is clearing of the infection
between episodes
 Otitis Media
• COM;
– presents with history of repeated bouts of AOM
followed by effusion with hearing loss being the
biggest concern
• OME;
• mucous membranes of nose and mouth
red/swollen,
• with recent history of URI.
• TM may be dull
 Otitis Media
• AOM physical examination
– Yellow-orange, maybe fiery red and bulging with
an area of yellow noted.
– Bone landmarks and cone of light are not seen.
– Grayish/white collection of tissue on or behind the
TM may be a cholesteatoma.
– There may be adenopathy of the preauricular
and/posterior cervical.
– With an infected ear and pain at the mastoid bone
 Otitis Media
• Otitis Management/Follow-up
– OM
• If over 2 years, watchful waiting for three days
• If present longer than three days treat for most common organism
• Recheck children in 2-3 weeks, adults if pain or other symptoms
return
– OME
• Watchful waiting is indicated, recheck every 4-6 weeks for 3-4
months
• Steroids are sometimes used for 7 days
• Nasal steroids used more often for 3 months
• Rarely an antibiotic is tried
• Refer patient for specialized treatment
 Cholesteatoma
• Condition where there is retraction of ear drum
due to negative pressure in the Eustachian tube
• There is desquamation of epithelial lining of TM
• Involvement of ossicles of the middle ear
• Can erode into the bone structures leading to
hearing loss, loss of balance and meningitis
• Management:
– Refer patient
– Will need surgical treatment
– Ototopical Abx beneficial
 Rhinitis
• Rhinitis/coryza-acute or chronic
– Inflammation of the nasal mucosa with congestion,
rhinorrhea, sneezing, pruritus, post nasal drip
– Allergic
• Seasonal or perennial
– Nonallergic
• Infectious, irritant related, vasomotor, hormone-related,
associated with medication, or atrophic
– May be chronic or acute
– Most common types
• Viral
• Perennial (hay fever)
 Ear Wax/Cerumen impaction
• Etiology-ear wax is a mixture of secretions from
ceruminous and pilosebaceous glands, squames
of epithelium, dust, and debrisRisk Factors
• Hairy or narrow ear canals, in-the-ear hearing
aids, cotton swab usage, osteomata
• Clinical features-hearing loss (conductive), ±
tinnitus, vertigo, otalgia, aural fullness
• Treatment-ceruminolytic drops (bicarbonate
solution, olive oil, glycerine, syringing, manual
debridement by MD
 Rhinitis

• Epidemiology/Causes
– Atrophic rhinitis affects older adults, but symptoms may begin
in the teens
– VIRAL URI’s are more frequent in families with young children
– Exposure to offending allergens is the main risk factor of
allergic rhinitis
– Vasomotor rhinitis is aggravated by low humidity, sudden
temperature or pressure change, cold air, strong odors, stress,
smoke
– Certain drugs may precipitate rhinitis- ACE, beta-adrenergic
antagonists, some anti-inflammatory agents, even asa
 Rhinitis
• Rhinitis Patho
– Etiologic agents
– Rhinovirus, influenza, parainfluenza, respiratory syncytial,
coronavirus, adenovirus, echovirus, coxsackievirus
– Most rhinosinusitis is viral
» Bacterial super-infection rarely occurs
– Allergic rhinitis
• results from immunoglobulin E (IgE) mediated type I hypersensitivity
to airborne irritants affecting the eyes, nose, sinuses, throat, and
bronchi
– Vasomotor rhinitis is chronic, noninfectious process of
unknown etiology without accompanying
eosinophilia, characterized by periods of abnormal
autonomic responsiveness and vascular engorgement
unrelated so specific allergens
 Rhinitis
• Rhinitis – symptoms
– Viral-malaise, HA, substernal tightness, rare fever,
sneezing and coughing
– Allergic-itching of all upper air way mucosa,
watery eyes, sore throat, sneezing, coughing
– Vasomotor-watery nasal discharge, nasal speech,
mouth breathing, nasal obstruction that switches
sides
 Rhinitis
• Rhinitis treatments
– Centers on
• relieve of symptoms
• Self care measures
• Environmental issues
– HA- acetaminophen
– Rhinorrhea- decongestants
– Coughs -dextromethorphan ? , Or codeine
 Rhinitis
• Treatments continued
– Allergic rhinitis
• Avoid the triggers
• Antihistamines
– Allegra, Claritin, Clarinex, Zyrtec, Astelin
• Nasal steroids
– Flonase, Nasonex, Nasacort
• Leukotriene receptor antagonists
– Singular
• Desensitizing immunotherapy
– Atrophic- bacitracin to nares, saline, irrigation
 Sinusitis
• Sinusitis is an inflammation of the mucous
membranes of one or more of the paranasal sinuses;
frontal, sphenoid, posterior ethmoid, anterior
ethmoid, and maxillary
– Acute-abrupt onset of infection and post-therapeutic
resolution lasting no more than four weeks
– Subacute with a purulent nasal discharge persist despite
therapy, lasting 4-12 weeks
– Chronic, with episodes of prolonged inflammation with
repeated or inadequately treated acute infection lasting
greater than 12 consecutive weeks
 Sinusitis
• Sinusitis – Patho
– Vast majority of acute sinusitis are caused by the same viruses
found in URI’s
• Viral rhinosinusitis is most common
– Which is the most common cause for acute bacterial sinusitis, from
complications in about 2%
– Sneezing sends fluid from the nares and nasal cavity into the sinuses
which is a great place for microbial replication
– The only reliable way of identifying causative organisms in acute
sinusitis is direct sinus aspiration
– Pathogens
• Streptococcus pneumoniae, haemophilus influenzae,
Moraxella catarrhalis, streptococcus pyogenes, staph aureus
 Sinusitis
• Clinical presentation
– Gradual onset of symptoms
• Pain over the affected sinus, with increasing pain
• Pain is worse with coughing
• Area of pain corresponds the sinus affected
• Develop over at least 2 weeks of URI symptoms
• Nasal congestion, runny nose, pressure, cough, sore
throat, eye pain, malaise, and fatigue, headache,
cough, fever
 Sinusitis

• Sinusitis objective findings

– Purulent secretions, red swollen nasal mucosa, purulent
secretions from middle meatus
– On palpation there is tenderness
• Sinusitis testing
– None is usually indicated
– X-rays or CT’s may be very helpful
• Shows air-fluid levels and more than 4mm of mucosal thickening
– CBC to look for leukocyte elevation
– Stains or cultures of mucus may be indicated
– Allergy testing
 Sinusitis
• Sinusitis Management
– Remember this is usually VIRAL!
– Supportive care is most helpful
• Sinus rinse
– Few meds are helpful
• Nasal spray, expectorants,
– Rarely use steroids –po, or antihistamines
• Localized sinus infections are self limited
– Abx-Penicillin, Cephalosporin
 Sinusitis
• Sinusitis follow up
– Varies per provider
• With increase symptoms recheck
• If no better in 5-7 days recheck
• With reoccurrence of symptoms shortly after completing
medication
– Complications to watch for
• Visual changes, cellulites, severe fever, aphasia, palsy, seizures,
altered mental status, osteomyelitis, swelling, meningitis,
empyema, abscess
 Pharyngitis
• Pharyngitis and tonsillitis are generalized
inflammatory process of both infectious and
non infectious etiology
– Most cases are viral and self-limiting
– Most cases of pharyngitis are contagious
– All cases of tonsillitis are contagious
 Pharyngitis
• Epidemiology
– 8% of all office visits
– Viral more common in cold weather
– GABHS increases from 10% in fall to 40% in winter
• Causes
– Herpangina, EBV, URI, postnasal drip, sinusitis, chronic
illnesses, leukemia, stress, alcohol, gonorrhea, syphilis,
herpes, diphtheria, candida, tobacco, marijuana
 Pharyngitis
Clinical presentation
– Cough and congestion are rarely present
– Allergic pharyngitis does not present with fever
– Mono has a gradual onset of low grade fever and
fatigue
– Influenza will have abrupt onset with headache
and body pain also, then followed by a cough….
 Tonsillitis
• Inflammation/infection of tonsils
• Mainly disease of childhood
• Causative organisms:
– Streptococcus, staphylococcus, Haemophilus,
Pneumococcus
• Can be acute or chronic
• May complicate into peritonsillar abscess,
parapharyngeal abscess
 Tonsillitis
• Clinical presentation • Halitosis
– Throat discomfort • Sore throat
– Malaise • Odynophagia
– Fever
– anorexia
– Halitosis
 Tonsillitis
• Management
– Diagnosis
– Abx- Penicillin drug of choice
– Plenty of fluids
– Antipyretic and analgesia
– Follow up
– May need Tonsillectomy after age of 4
 Acute Epiglotitis
• Occurs in both adults and children
• In children it is a life-threatening disease
• Young children symptoms can progress rapidly
• Due to haemophilus influenzae infection
• Presents with stridor and drooling
• Patient may require intubation or tracheostomy
• Insertion of spatula may precipitate complete
airway obstruction
• Also require humidified oxygen and antibiotics
 Foreign Bodies
• These are commonly seen in children
• Types can be anything;
– Seeds
– Toy parts
– Vegetation
– Insects
– Metallic/coins objects
– Bones-fish bones
 FB
• Diagnosis
– History
– Clinical examination
– Radiological-Neck X-Ray
– Endoscopic
• Management
– ABC
– Calm the patient
– Remove object if competent and have equipment
– Refer appropriately
 Tumours
• Primary cancers of involving ENT are from
– Larynx
– Nasal
– Oral
– Ear
– Hypopharnyx
– Paranasal sinuses
– Salivary glands
• Found commonly in smokers, alcohol consumers
 Tumours
• Divided into;
– Benign: Polyps, papilloma
– Malignant: SCC, BSC, melanoma, acoustic
neuroma
• Common type of cancer is SCC-95%. Others
are;
• Oropharyngeal Ca on an increase, attributed
to HPV (types 6, 11)
 Symptoms of ENT cancers
• A mass in the neck
• Hoarseness for two weeks or more
• Pain in the ear (otalgia),
• Pain in the throat on swallowing (odynophagia),
• Difficulty swallowing (dysphagia)
• A lump below or in front of the ear
• A persistent oral ulcer
• Unilateral serous otitis media
 Epistaxis
• Nose bleeding
• Occurs commonly in an called Little’s area-
Kiesselbach’s plexus-anteriorly
• Posteriorly in an area called Woodruff’s area
• Causes;
– Trauma: habitual nose picker
– Hypertension
– Infection: vestibulitis, rhinitis
– Bleeding disorders-leukaemia
– Tumours of the nose
 Epistaxis-management
• General assessment of patient
• ABC
• Clean the nose
• Pinch nose for 5-10minutes
• Available treatment modalities;
– Adrenaline pack –no dry gauze packing
– Cauterisation
– Rubber catheters
– Ligation of Blood vessel
• Bed rest with head end of bed elevated
• Treat primary associated cause
Epistaxis