1. E N T Gerard Kelly cases and update The Spire Hospital Leeds
The Leeds Teaching
Hospitals NHS Trust
Gerard Kelly
MD MEd FRCS (ORL-HNS) FRCS (Ed)
ENT surgeon, Spire Hospital Leeds and Leeds Teaching Hospitals NHS Trust
Tuesday, March 19th 2019
Yorkshire Healthcare Practitioners Association

2. Ear
6 symptoms
otorrhoea
otalgia
itch
hearing
tinnitus
balance

3. Nose 6 symptoms nasal obstruction rhinorrhoea facial pain smell
epistaxis
post nasal drip

4. Throat 6 symptoms dysphagia dysphonia odynophagia pain neck lumps
weight loss

5. Vertigo

6. The Leeds Teaching Hospitals NHS Trust
vertigo is the hallucination of movement
it is usually but not always rotatory
The Leeds Teaching Hospitals NHS Trust

7. The Leeds Teaching Hospitals NHS Trust
what is the most important factor in diagnosis in a patient with vertigo?
The Leeds Teaching Hospitals NHS Trust

8. The Leeds Teaching Hospitals NHS Trust
examination of the tympanic membranes
audiogram
stapedial reflexes
BSERA
unterberger’s
calorics
ENG
cranial nerve examination
MR head
CT scan
The Leeds Teaching Hospitals NHS Trust

9. The Leeds Teaching Hospitals NHS Trust
history
The Leeds Teaching Hospitals NHS Trust

10. The Leeds Teaching Hospitals NHS Trust
what do you want to get out of the history?
The Leeds Teaching Hospitals NHS Trust

11. The Leeds Teaching Hospitals NHS Trust
what the sensation is like?
movement?
drunk?
light headed?
The Leeds Teaching Hospitals NHS Trust

12. The Leeds Teaching Hospitals NHS Trust
how long does it last?
seconds?
minutes?
hours?
any warning that it is going to happen?
The Leeds Teaching Hospitals NHS Trust

13. The Leeds Teaching Hospitals NHS Trust
any exacerbating or reliving factors?
staying still?
medication?
standing up quickly?
The Leeds Teaching Hospitals NHS Trust

14. The Leeds Teaching Hospitals NHS Trust
any associated features?
tinnitus?
hearing?
tingling in the arms and hands?
The Leeds Teaching Hospitals NHS Trust

15. Vertigo summary

16. vertigo
Benign paroxysmal positional vertigo (BPPV). Intense, brief vertigo immediately with a change in head position, turning over in bed, sitting up in morning, or bending down. Common. Can follow vestibular neuronitis.
Vestibular neuronitis / labyrinthitis. Sudden intense, constant vertigo, days. Nausea, vomiting. Bedbound. Hearing loss = labyrinthitis. Generally subsides on its own. Vestibular rehabilitation = speeds recovery.
Meniere's disease. Build up of fluid in the inner ear. Sudden episodes of vertigo lasting as long as several hours, accompanied by fluctuating hearing loss, ringing in the ear and a feeling of fullness in the affected ear.
Vestibular migraine. More than a headache. Visual "aura“ and vertigo episodes without a severe headache. Such vertigo episodes can last hours to days and may be associated with headache as well as light and noise sensitivity.
Acoustic neuroma. (vestibular schwannoma) benign growth on the vestibular nerve. Symptoms of an acoustic neuroma generally include progressive hearing loss and tinnitus on one side accompanied by dizziness or imbalance.
Other causes. Rarely, vertigo can be a symptom of a more serious neurological problem such as a stroke, brain haemorrhage or multiple sclerosis = other neurological symptoms.

17. case – ear not getting better

18. 41 year old male right otorrhoea 6 weeks itch foul smelling
reduced hearing
treated with several courses of gentisone

19. fungal spores in the ear

20. Diagnosis?

21. Otitis externa - fungal
itch
otorrhoea
previous or recurrent symptoms

22. Otitis externa
treatment?

23. Otitis externa
treatment?
nothing
medical
aural toilet

24. ear infection emergencies

25. 3 year old male distressed 2 day post URTI temperature 39.2°C
pulling left ear

26. diagnosis?

27. acute otitis media
treatment?

28. antibiotic use for acute otitis media varies from 31% in the Netherlands to 98% in the USA and Australia

29. acute otitis media and antibiotics

30. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days.

31. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain.

32. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics.

33. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics. Antibiotics are most useful in children under two years of age, with bilateral AOM, and with both AOM and discharging ears.

34. Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics. Antibiotics are most useful in children under two years of age, with bilateral AOM, and with both AOM and discharging ears. For most other children with mild disease, an expectant observational approach seems justified. We have no data on populations with higher risks of complications.

35. we overuse antibiotic in acute otitis media a trial of withholding antibiotics is usually effective – either because it works or because with time and aging there is natural resolution

36. sudden hearing loss emergencies

37. 64 year old woman presents
2 day history of hearing loss in the right ear

38. 64 year old woman presents
2 day history of hearing loss in the right ear
what do you ask?

40. sudden sensorineural loss
definition
at least 30dB hearing loss
over 3 contiguous frequencies
a period of a few hours to 3 days

41. sudden sensorineural loss
incidence
5 – 20 per people per year
1 in people per year
0.01% people per year

42. sudden sensorineural loss
typical patient
40 – 50 years
M=F
30% have balance symptoms

43. sudden sensorineural loss
aetiology?

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

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

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

47. topical papers

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.

49. steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980

50. steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980

51. steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980

52. steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980

53. steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980

54. steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
Kaiser-Permanente, Oakland, California and
Massachusetts Eye and Ear Infirmary
dexamethasone and
methylprednisolone

55. steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
% recovery
steroids %
placebo %

56. steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
% recovery
steroids %
placebo %
controls (no treatment patients,
not in the study) 55.8% .

57. steroids
Cinamon et al. Steroids, carbogen or placebo for SSNHL: a prospective double-blind study. Eur Arch Otolaryngology 2001
41 patients randomized
5 days 54% improved
1 month 73% improved

58. steroids
Cinamon et al. Steroids, carbogen or placebo for SSNHL: a prospective double-blind study. Eur Arch Otolaryngology 2001
41 patients randomized
5 days 54% improved
1 month 73% improved
in all groups

59. evidence based medicine
vasodilators unproven
steroids unproven
antivirals protocol
intratympanic steroids unproven

60. evidence based medicine
so, if there is no good evidence for the treatment of SSNHL, should we not treat anyone with SSNHL?

61. evidence based medicine
we know there is no evidence but patients expect some form of treatment
currently idiopathic sudden sensorineural hearing loss tends to be treated like Bell’s palsy with oral steroids (eg 40mg daily Prednisolone)

62. acoustic neuromas

63. acoustic neuromas
benign tumours of the hearing and balance nerve, but with growth there can be a threat to life due to brain stem compression and raised intracranial pressure
diagnosed by MR scanning and scanning is necessary when there is a 15 dB difference at 2 frequencies in an audiogram
treated often by serial rescanning by MR
other options surgery (major operation with at least 7 days admission) and the gamma knife (single dose radiation, out patient procedure)