1. history ears otorrhoea otalgia itch hearing tinnitus balance noses
nasal obstruction
rhinorrhoea
facial pain
smell
epistaxis
post nasal drip
throats
dysphagia
dysphonia
odynophagia
pain
neck lumps
weight loss

2. common nose mistakes

3. Case

5. rhinitis vs polyps rhinitis with inflamed turbinates vs nasal polyps
polyps more likely with asthma and anosmia

6. audiograms

7. normal audiogram

8. normal audiogram
Normal hearing

14. tinnitus

15. case

16. tinnitus 67 year old woman tinnitus for 6 months, getting worse
anxious
hearing not problem

17. audiometry

18. tinnitus
hearing loss compatible with aging

19. tinnitus
treatment?

20. tinnitus
treatment?
distraction
hearing aids
tinntius therapy
CBT

21. tinnitus treatment? distraction hearing aids tinntius therapy CBT
the truth is there is no treatment which can cure tinnitus

22. tinntius
MRC, 2000 (Davis 2000) longitudinal study of 48,313 people; 10.1% described tinnitus arising spontaneously and lasting for five or more minutes at a time and 5% described it as moderately or severely annoying However, only 0.5% reported tinnitus having a severe effect on their life

23. tinntius
tinnitus which severely affects people, such people will often have other life stress events or psychological issues

24. nasal polyps

25. nasal examination

26. nasal polyps - treatment
medical
steroids
surgical
polypectomy

27. case – ear not getting better

28. 41 year old male right otorrhoea 6 weeks itch foul smelling
reduced hearing
treated with several courses of gentisone

30. Diagnosis?
fungal otitis externa

31. Otitis externa
itch
otorrhoea
previous or recurrent symptoms

32. Otitis externa
treatment?

33. Otitis externa treatment? nothing medical aural toilet
antifungal medication needs to be used for at least 14 days

34. new techniques

35. Balloon sinuplasty
can be used for frontal sinus where access would otherwise be difficult

36. sudden hearing loss emergencies

37. 64 year old woman presents
2 day history of hearing loss in the right ear
Most experts would define sudden sensorineural hearing loss as an inner ear loss of at least 30dB, over 3 contiguous frequencies, occurring over a period of anything up to a few days.

38. 64 year old woman presents
2 day history of hearing loss in the right ear
what do you ask?
Most experts would define sudden sensorineural hearing loss as an inner ear loss of at least 30dB, over 3 contiguous frequencies, occurring over a period of anything up to a few days.

39. But, in the catastrophic situation, both ears can be affected..

40. sudden sensorineural loss
definition
at least 30dB hearing loss
over 3 contiguous frequencies
a period of a few hours to 3 days
Most experts would define sudden sensorineural hearing loss as an inner ear loss of at least 30dB, over 3 contiguous frequencies, occurring over a period of anything up to a few days.

41. sudden sensorineural loss
incidence
5 – 20 per people per year
1 in people per year
0.01% people per year
Most experts would define sudden sensorineural hearing loss as an inner ear loss of at least 30dB, over 3 contiguous frequencies, occurring over a period of anything up to a few days.

42. sudden sensorineural loss
typical patient
40 – 50 years
M=F
30% have balance symptoms
Most experts would define sudden sensorineural hearing loss as an inner ear loss of at least 30dB, over 3 contiguous frequencies, occurring over a period of anything up to a few days.

43. sudden sensorineural loss
aetiology?
There are many potential causes for sensorineural hearing loss of sudden onset. The treatment of hearing loss due to a cerebello-pontine angle tumour is clearly very different to treatment of an auto-immune hearing loss (if such an entity actually exists).

44. sudden sensorineural loss
Infection
Bacterial postmeningitis, bacterial
labyrinthitis, syphilis
Viral mumps, cytomegalovirus
Inflammation
Autoimmune
Cogan’s syndrome, systemic lupus erythematosus
Multiple sclerosis
Trauma
Temporal bone fracture
Acoustic trauma
Perilymph fistula
Tumor
CPA tumour
Temporal bone metastasis
Carcinomatosis meningitis
Toxins
Aminoglycosides
Aspirin
Vascular
Thromboembolism
Macroglobulinemia, sickle cell disease, post-CABG, vasculitides
There are many potential causes for sensorineural hearing loss of sudden onset. The treatment of hearing loss due to a cerebello-pontine angle tumour is clearly very different to treatment of an auto-immune hearing loss (if such an entity actually exists).

45. sudden sensorineural loss
Infection
Bacterial postmeningitis, bacterial
labyrinthitis, syphilis
Viral mumps, cytomegalovirus
Inflammation
Autoimmune
Cogan’s syndrome, systemic lupus erythematosus
Multiple sclerosis
Trauma
Temporal bone fracture
Acoustic trauma
Perilymph fistula
Tumor
CPA tumour
Temporal bone metastasis
Carcinomatosis meningitis
Toxins
Aminoglycosides
Aspirin
Vascular
Thromboembolism
Macroglobulinemia, sickle cell disease, post-CABG, vasculitides
Here I am going to confine myself to the treatment of sudden sensorineural hearing loss

46. sudden sensorineural loss
Infection
Bacterial postmeningitis, bacterial
labyrinthitis, syphilis
Viral mumps, cytomegalovirus
Inflammation
Autoimmune
Cogan’s syndrome, systemic lupus erythematosus
Multiple sclerosis
Trauma
Temporal bone fracture
Acoustic trauma
Perilymph fistula
Tumor
CPA tumour
Temporal bone metastasis
Carcinomatosis meningitis
Toxins
Aminoglycosides
Aspirin
Vascular
Thromboembolism
Macroglobulinemia, sickle cell disease, post-CABG, vasculitides
where the aetiology is uncertain. There have been many hypotheses advanced to explain the aetiology of sensorineural hearing loss of sudden onset: viral, vascular, allergic, rupture of intralabyrinthine membranes, local histamine production and autoimmune disease are just some theories, but in about three quarters of cases the cause of this condition is unknown and no clear diagnosis is ever made.

47. topical papers
where the aetiology is uncertain. There have been many hypotheses advanced to explain the aetiology of sensorineural hearing loss of sudden onset: viral, vascular, allergic, rupture of intralabyrinthine membranes, local histamine production and autoimmune disease are just some theories, but in about three quarters of cases the cause of this condition is unknown and no clear diagnosis is ever made.

48. stroke and SSNHL
Stroke Oct;39(10): Epub 2008 Jun 26.
Sudden sensorineural hearing loss increases the risk of stroke: a 5-year follow-up study. Lin HC, Chao PZ and Lee HC
CONCLUSIONS: Our findings suggest that SSNHL can be an early warning sign of impending stroke. We suggest that SSNHL patients should undergo a comprehensive hematologic and neurological examination to help clinicians identify those potentially at risk for stroke developing in the near future.
Carbogen, a mixture of carbon dioxide and oxygen. If I was being sceptical about any of these, equally good contenders for treatment, I would ask where was the evidence for treatment?

49. otitis externa and mastoiditis emergencies

51. otitis externa & mastoiditis
how to tell the difference?
history
examination

52. otitis externa & mastoiditis
how to tell the difference?
URTI
unwell
Pyrexia (or history)
discharge

53. how to tell the difference?
mastoiditis
otitis externa
URTI unwell pyrexia (or history) discharge position of pain swelling mastoid swelling in ear canal ear drum
longer history past history not systemically unwell itch position of pain discharge both ears swelling in ear canal ear drum