1. Common ENT Conditions in Adults
Paul Chatrath
Consultant ENT/Head & Neck Surgeon
Charing Cross Hospital (Imperial Healthcare NHS Trust)
Honorary Senior Lecturer
Anglia Ruskin University, Chelmsford
Visiting Professor of Rhinology
Canterbury Christ Church University, Kent
6th September 2016

2. Objectives Ear: Nose Head & Neck Otitis Externa Sinusitis
Blocked nose / allergies
Head & Neck
Tonsillitis
Globus

3. THE EAR

4. The infected ear
A 28 year old man presents with a 6 month history of a recurrent smelly discharge from the right ear
O/E: infected discharge ear canal
What is the likely diagnosis?
(A) Otitis externa
(B) Acute otitis media with perforated ear drum
(C) Cholesteatoma
(D) Don’t know

5. The infected ear Predisposing factors to consider Causes to consider
Diabetes
Water exposure
Occupation
Sinonasal infection
Instrumentation
Causes to consider
Otitis externa
Variants
Otitis media with perforated ear drum
Cholesteatoma
SCC

6. The infected ear Initial management Subsequent management
Swab
Topical toilet
Antibiotics
Topical
Systemic
Subsequent management
Review patient
Identify and treat underlying cause
Key message: Ultimately must be able to see the ear drum

8. Otitis Externa - Features
Discharge, pain, hearing loss, itching
Commonest organisms:
S Aureus
Ps Aeruginosa
Proteus
Predisposing factors:
Water
Cotton buds
Eczema
Treatment:
Topical antibiotics
Aural toilet
Analgesia

9. Otitis Externa - Variants
Fungal
Malignant OE
Diabetes
VII palsy

10. Otitis Externa – when to refer
Refer if: Non responsive
Canal oedematous
Needs aural toilet
Suspicion of malignant OE

11. Why visualise ear drum if you think it is otitis externa?
Exclude perforation
Exclude cholesteatoma

12. THE NOSE

13. Case
A 36 year old lady presents with a 6/12 history of a blocked nose, facial pressure, a bad smell in the nose and lethargy
She has recently had a cold
Examination confirms a low grade temperature, considerably blocked nose with rhinitis and some thick yellow mucus
Q: Would you give antibiotics?
Y/N

14. Rhinosinusitis Symptoms
European position paper on rhinosinusitis (EP3OS) 2007 & 2012
Two or more symptoms:
One MUST be
nasal block +/- nasal discharge
Plus any of the following
Facial pain/pressure
Hyposmia/anosmia
Polyps
CT scan changes in sinuses
Definition sharpened to include nasal block +/- discharge

15. Diagnosis: CT scanning
History
Examination including nasendoscopy
Allergy tests
Radiology

16. Possible Strategies for CRS
Infectious
Treat
Aetiology
Allergen Avoidance
Antibiotics
Surgery
Anatomic
Allergy
Attenuate
Inflammation
Steroids
Immunotherapy
Antileukotrienes
Macrolides
IL-5, IL-4
IL-8, IF-
GM-CSF
Slide 73—Possible Strategies for Treating CRS (chronic rhinosinusitis)
Reference
Adapted by Bradley Marple from Benninger M, Ferguson B, Hadley J, Hamilos D, Jacobs M, Kennedy D, Lanza D, Marple B, Osguthorpe J, Stankiewicz J, Anon J, Denneny J, Emanuel I, Levine H. Adult Chronic Rhinosinusitis: Definitions, Diagnosis, Epidemiology, and Pathophysiology. Otolaryngol Head Neck Surg 2003;129(suppl 3):S1-32.
CRS

17. Sinusitis: Tips for a clear nose
Clear mucus:
Aggressive douching
Sinus rinse
Sprays (Sterimar)
Steaming
Reduce inflammation
Decongestant 7/7
Reduce infection
Antibiotics
7/7: symptom relief
14/7: reduce inflammation
28/7: reduce osteitis
Type of antibiotic important?

18. Surgical Management FESS (Functional Endoscopic Sinus Surgery)
Accepted surgical procedure for CRS with or without polyps
Failed medical management or in presence of structural abnormalities
Some controversy exists
Not universally successful
Complications
Reversible (mucosal) changes on CT

19. Balloon sinuplastyTM
New(ish) technique involving minimally invasive surgery to access the paranasal sinuses
Principle based on angioplasty
Involves placement of a guidewire
Railroading of deflated balloon then inflation to create opening

20. Allergic Rhinitis: key points
Allergy avoidance
Commence topical steroid before season starts
Remember saline douching
Increased mucociliary flow
Brief vasoconstrictive effect
Alkaline medium thins mucus
Remember asthma (& vice versa)
Topical steroid choice:
Bioavailability
Cost
Compliance
Device
Aftertaste
Side effects (few)

21. Effect of mometasone and fluticasone on nasal congestion in PAR
Mean % improvement from baseline
Mean % change from baseline in patient-rated symptom score for congestion 70 60 50 40 30
Mometasone 200 mcg od Fluticasone 200 μg od Placebo 20
Patient diary data demonstrated that patients receiving Nasonex® experienced significantly greater improvements from baseline in nasal congestion compared with their counterparts receiving placebo. The difference between Nasonex® and placebo was statistically significant at all time points (p<0.01). At Day 29 and Week 8, Nasonex® was superior to fluticasone for the treatment of nasal congestion (p=0.04).
Reference
Mandl et al Study Group. Ann Allergy Asthma Immunol 1997; 79: 10
Days 1-15
Days 1-15
Days 1-15
Days 1-15
Days 1-15
Days 1-15
p<0.01 at all time points for mometasone and fluticasone relative to placebo
Mandl et al 1997

22. Head & Neck / Throat

23. Normal tonsils
Acute tonsillitis

24. Tonsillitis What history would point towards tonsillitis?
A 16 year old girl presents with a long history of recurrent severe sore throats. She requires antibiotics and has had some time off school on several occasions
Examination reveals large unhealthy looking tonsils
What history would point towards tonsillitis?
Severe pain/odynophagia
Pyrexia
Lymphadenopathy
Referred otalgia
Time off school

25. Acute tonsillitis Bloods
FBC + differential
Monospot test
U+Es
If not swallowing - admit for iv fluids and antibiotics (benzylpen)
If swallowing OK – send home on oral antibiotics (pen V)

26. Glandular fever / Infectious Mononucleosis
Clinically
Greyish sloughing over tonsil surface
Bloods
FBC – mononuclear cells
Heterophile antibodies / Monospot test
LFTs
Supportive management as for tonsillitis
Avoid amoxycillin owing to maculopapular rash associated with IM

27. ‘Feeling of a lump in my throat’
Majority due to globus pharyngeus
Globus:
feeling of something / lump in throat with no organic or structural abnormality detected on examination
Associated features – GORD, anxiety/stress
Typically no true dysphagia demonstrated
Key point is to discriminate globus from any cause of true dysphagia

28. Globus Pharyngeus (‘Feeling of a lump in my throat’)
Feeling occurs at any time
Usually inbetween meals
Better on eating solids
Associations
Anxiety
Acid reflux
True dysphagia
Due to a physical obstruction
Difficulty in swallowing liquids or solids
Usually no symptoms inbetween meals
Often weight loss

29. Summary Ear: Nose Head and Neck Otitis Externa Sinusitis
Blocked nose / allergies
Head and Neck
Tonsillitis
Globus

30. Paul Chatrath Consultant Rhinologist / ENT Surgeon
Common ENT Conditions
Questions
Paul Chatrath
Consultant Rhinologist / ENT Surgeon