1. E. N.T. – (Illustrated!) Dr Katie Bleksley GPST1

2. Aims To recognise and proficiently manage common ear conditions presenting to GP Be aware of the some of the red flags to look out for wrt ear problems.

3. Objectives To be able to recognise infections of the ear: OE, furunculosis, HZV, OM. Understand the use of antibiotics in treating ear infections Understand what to do with foreign bodies in the ear, and which substances require urgent removal. Understand the risks/complications of ear trauma and how lacerations/haematomas and bites should be managed. Assess deafness and appreciate the importance of sudden deafness. Brief coverage of DDx for vertigo and tinnitus

4. Otalgia Primary – Otitis Externa – Otitis Media – Furuncle Secondary/Referred pain – TMJ – Dental – Throat pathology – Sinuses – LNs – Facial Nerve No obvious cause

5. The normal TM Long process of the incusincus Handle of the malleusmalleus pars tensa Long arm of the malleusmalleus pars flaccida GDAEFGDAEF

6. Otitis Externa

7. Features Pain – on movement of pinna Itching Deafness Swollen / Inflamed canal Discharge / Debris

8. Otitis Externa Management Aural toilet needed in all but mild cases Keep ear dry Topical Antibiotic / Steroid: Analgesia Preventative advice: keep dry when swimming/bathing, no FBs in ear..

9. Otitis Externa: ABx 1. Locorten vioform (flumethasone and clioquinol and iodine) 2-3drops bd 7-10days 2. Sofradex (dex and framycetin and gramicidin) 2-3drops tds/qds or Otomize (dex and neomycin): 1 spray tds or Ciloxan eye drops (cipro 0.3%) Treat for > 7days Swab before starting any second line treatment (?candida/aspergillus) and check sensitivities For fungal OE use Clotrimazole 1% (canesten) drops tds for 14d after the infection has resolved.

10. Caution, OE in diabetics…. Malignant OE Infection of the EAC with pseudomonas Infection can spread to soft tissues and bones Caution – Diabetics – Malig OE

11. Furunculosis Infection of hair follicles in outer third of ear canal. Severe pain O/E: Boil in the ear canal Need to r/o DM Rx: analgesia, gentisone HC drops 3 drops qds 7 days. Oral fluclox 7days if cellulitis

12. Ramsey Hunt Synd (HZV) Severe pain in ear precedes facial palsy vesicles in the EAC/around the ext ear and on the soft palate. +/- dizziness / vertigo Aciclovir 800mg 5x/day for 1 wk if Dx <24h Postherpetic neuralgia can be a problem

13. Otitis Media

14. Acute Otitis Media Infection of the middle ear. Bacterial/viral but impossible to distinguish clinically Presentation: Pain, Deafness, URTI Sxs O/E: Red, Bulging TM, +/- perforation and discharge

15. Acute Otitis Media Management Analgesia Consider oral antibiotics: amoxil tds (pen all.: erythro qds) for 5days if…. – Age <2 with bilat acute OM – If perforation present – ?? If >3days duration ?? – If sig. comorbidities – Or give a delayed script Refer ENT if.. – Signs of complications/spread of infection – OM recurs/fails to respond give augmentin and refer. – acute perf. fails to heal within 1 month.

16. Otitis Media – red flags 1 SIGNS OF COMPLICATIONS - mastoid tenderness / swelling - sudden deafness - dizziness with nystagmus - malaise / headache

17. Mastoiditis Refer Immediately

18. LOOK FOR A PERFORATION IN ANY DISCHARGING EAR – Acute central perf. is okay (but needs review in 1 month), – Attic perf. suggests cholesteatoma and merits referral. – If you can’t visualise the drum review the patient. Otitis Media – red flags 2

20. Tympanic Perforation Left TM central perforation Attic perforation with cholesteatoma

21. Problematic OM Recurrent acute OM: – Trimethoprim 1-2mg/kg od for 3months Chr supp. OM If ear d/c in presence of chr (central) perforation treat as OE: – Gentisone HC 2 drops qds or Cipro 0.3% eye drops 2 drops tds – Red flags: persistent discharge despite the above or deafness/vertigo/attic perf. -> Refer ENT.

22. Ear Injuries Pinna Lacerations Refer all but the most trivial Human Bites Refer all Haematoma of the Pinna Refer urgently to prevent cartilage necrosis

23. Ear Injuries

24. Deafness Temporary deafness is common due to OM Persistent hearing problems: – Hx and Ex – pay attention to developmental assessment in children, – take seriously and refer for audiology (formal audiometry possible if >3y) Refer to ENT if: – Sudden onset deafness – Conductive hearing loss with no obvious cause – Asymmetrical deafness Sudden onset SN deafness is an ENT emergency

25. Persistent Deafness - causes Conductive: – Wax / FB – OME – Chr supp OM and cholesteatoma – Otosclerosis (bilat may be a FH, refer for surgery) Sensorineural: – Presbyacusis (gradual bilat symm high freq loss in ppl >50y) – Acoustic neuroma (unilat/asymmet deafness)

26. Wax in the ear Olive oil tds for 5d microsuction

27. Foreign Bodies in the Ear

28. What needs urgent removal? Batteries Biological material (eg dead insect*) Signs of secondary infection Urgent = same day Non-urgent = within 3days * insects can be drowned in oil and then suctioned out

29. OME

30. Hearing loss, +/- earache, developmental delay Dull retracted drum with visible peripheral vessels, fluid level/air bubbles may be visible behind the drum 75% resolve in <3months Refer if persistent esp if causing speech/lang delay Grommets: can swim/bathe, but avoid diving. If dicharge from ear treat with aural toilet and AB/steroid drops as for OE.

31. Tinnitus Severe tinnitus affects 2% of pop DDx: may accompany hearing loss, meniere’s, noise exposure, head injury, HTN, drugs (loop diuretics, TCAs, aminoglycosides, aspirin, NSAIDs) but often no cause found. Ix: audiometry if deafness Rx: reassure, +/- refer to hearing therapist and tinnitus support group, masking. Unilat tinnitus (?acoustic neuroma), objective/pulsatile tinnitus (?vasc malformation)

32. Vertigo – Hx gives Dx, Neuro Ex (esp cerebellar ex) essential to r/o pathol Secs-mins : BPPV (postural, dix hallpike +ve) – Reasssure. Don’t give labyrinthine sedatives. Epley’s, usually self limiting, Mins-hours: meniere’s (vertigo, SN deafness, tinnitus, aural fullness) – overdiagnosed so refer all suspected cases to ENT to confirm the diagnosis >24h – peripheral lesion: trauma / viral labyrinthitis (URTI, sudden onset vertigo, n+v, prostration, hearing normal, TM normal). Rx = cyclizine/prochlorperazine – Central pathol: CVA/tumour/MS… On neck extension and rotation in elderly: VB insuff

33. Summary We have covered: – infections of the ear: OE, furunculosis, HZV, OM and know when ABx are appropriate plus other measures which maybe required. – Understand which foreign bodies require urgent removal. – Understand the risks/complications of ear trauma and how lacerations/haematomas and bites should be managed. – Know how to assess/investigate deafness and understand that sudden deafness merits urgent ENT review. – Brief insight into the common DDx for tinnitus and vertigo.

34. Questions ?