Common ENT problems

Otitis externa (infection of the outer ear)

Irritants, including cotton buds, can cause this common and very painful condition. The outer ear canal is often swollen and filled with debris.



Treatment requires regular suctioning of debris from the ear canal (microsuction) combined with appropriate ear drops (commonly a steroid and antibiotic combination). Drops alone may not settle the infection until all the debris has not been removed.

When the external ear canal is very swollen, a pope wick (sponge) is inserted which allows instillation of drops.

It is essential to keep the ear dry and to avoid using cotton buds.

Acute otitis media (recurrent middle ear infections)

Inflammation of the middle ear commonly affects young children as part of an upper respiratory tract infection. Children develop symptoms of irritability, have a raised temperature and often pull at their ears. There is usually an associated hearing loss. If the ear drum ruptures, pus leaks out of the ear. Oral antibiotics such as amoxicillin or clarithromycin are prescribed. Recurrent otitis media may be treated by grommet insertion.

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Chronic otitis media ("Glue ear")

Persistent otitis media with bilateral effusions are the most common cause of hearing loss in children. This may cause speech delay, language problems and even behavioural issues (children often feel isolated or frustrated).

Removing the "glue" in addition to grommet insertion allows air to re-enter the middle ear to restore hearing. The grommets usually fall out after 18 months in this age group.

Adults with a persistent middle fluid ear should undergo examination of the postnasal space under general anaesthesia. A biopsy should be taken from the Fossa of Rosenmüller, just medial to the Eustachian tube, to exclude the rare possibility of a tumour obstructing the Eustachian tube orifice.

Foreign Bodies – Ear

Foreign bodies within the external ear canal may be difficult to remove. Children will need to be held by a parent or nurse; the first attempt at removal is the best. However, if the foreign body cannot be removed, patients require a short general anaesthetic to allow removal. Objects can be removed using a hook, microsuction or irrigation. Insects can be drowned using olive oil and then removed.

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Tympanic membrane perforation (hole in the ear drum)

Infection, pressure changes or direct trauma to the ear canal may result in a hole in the ear drum.



If this does not heal of its own accord, patients may suffer from recurrent ear infections or a hearing loss, and surgical closure may be required (tympanoplasty). This is performed under a general anaesthetic. A graft is harvested from behind the ear and placed under the hole. The ear drum skin then grows over the graft to allow the hole to close.


Facial paralysis (weakness of one side of the face)

There are a wide variety of causes for facial nerve palsy.

Ramsay-Hunt syndrome
Acute facial paralysis occurring in association with herpetic blisters of the skin of the ear canal, auricle, or both is referred to as the Ramsay Hunt syndrome. Onset is rapid, characterized by pain and the appearance of vesicles. Treatment requires a thorough assessment, and treatment with oral steroids and antivirals.

Acute otitis media (Acute middle ear infection)
Middle ear inflammation may cause a facial nerve palsy, typically if the bony canal of the facial nerve is absent within the middle ear. Treatment includes intravenous antibiotics, oral steroids and nasal decongestants. A CT or MRI scan are helpful in some situations. If there is no clinical improvement after 24-48 hours, surgery may be required to release the pus within the middle ear and restore the function to the nerve.

Bell’s palsy
This cause of facial paralysis is a diagnosis by exclusion. Patients require a thorough examination and a hearing test. Treatment requires antivirals, oral steroids and eye protection. An MRI is only indicated if the nerve does not recover.

Tumour
Rarely, a tumour may press or damage the facial nerve and cause a paralysis. A scan may be required if the nerve does not recover despite treatment.


Sudden hearing loss

The cause of sudden inner ear hearing loss is usually unknown. Causes include labyrinthine viral infection, labyrinthine vascular compromise, intracochlear membrane ruptures, and immune-mediated inner ear disease. Appropriate blood tests, an MRI scan and serial audiograms are performed. If sudden sensorineural hearing loss is bilateral, admission is required. Consideration must be given to treatment with acyclovir and oral steroids.

Perichondritis

This is a common infection of the pinna. Patients are prone to this if the ear has been pierced through the cartilage. The infection is usually bacterial, Pseudomonas is often involved and requires treatment with a combination of oral and intravenous antibiotics. A swab should always be taken.

If the infection persists the cartilage of the ear may die and patients can be left with an ugly “cauliflower ear”.



Pinna Haematoma (“Cauliflower ear”)

Blunt trauma to the pinna may result in a subperichondral haematoma. Untreated, this can cause a ‘cauliflower ear’ deformity. Treatment is by surgical incision and drainage with pressure dressing or quilting sutures to prevent recollection. Oral antibiotics should be prescribed while sutures are in place.

Nasal trauma

A fractured nose should be seen approximately 5 to 7 days after injury when the swelling has decreased. However, a septal haematoma should be excluded at the time of initial presentation. X-rays of the nasal bones are not required. Intervention should only be undertaken if there is an obvious cosmetic problem. The nasal bones can be manipulated under local or general anaesthetic, ideally within 14 days from the time of injury.



An injury to the nose may cause a fracture of the cartilage within the nose. This will cause the nose to become blocked. If required, the septum may be straightened with an operation, septoplasty.

Foreign Bodies - Nose

These require prompt removal as there is a risk of inhaling the object. Children commonly insert sponge, paper and other small objects in their nostrils or ears! There can be a foul smelling discharge from the nose.

A parent or nurse will need to hold the child. A hook is used, passed above and behind the object, to draw it out. Always remember that the first attempt is the best attempt. If unsuccessful, the child should undergo a general anaesthetic to allow removal.

Acute sinusitis

Patients usually complain of fever, purulent nasal discharge and facial pain. Confirming the presence of mucopus draining from the sinuses supports the diagnosis. Decongestants together with broad-spectrum antibiotics are essential. A CT scan of the sinuses is useful if symptoms recur or are persistent.

Periorbital cellulitis

This is an ENT emergency as patients may become blind within just a few hours. Orbital cellulitis is an acute sinus infection that spreads to involve the eye lids and eye. Patients develop swelling and redness of the eye lids and the globe of the eye is pushed forwards.

A CT scan must be performed. These patients will require intravenous antibiotics and surgery to decompress the orbit if there is an abscess in order to save the eye.

Regular bedside assessment of their visual acuity and colour vision should be carried out as these are the earliest signs of orbital compromise.

Acute pharyngitis

This is most commonly due to a viral infection involving the tonsils and adenoids. This may be difficult to distinguish clearly from acute tonsillitis. Treatment consists of supportive measures and antibiotics if a secondary bacterial infection is present.

Tonsillitis

Tonsillitis is very common amongst children and young adults. The tonsils become red and swollen. Patients find it difficult to swallow and may need admission to hospital for intravenous antibiotics. Patients who suffer 4-5 episodes of tonsillitis over 12 months are likely to benefit from removal of the tonsils. This procedure (tonsillectomy) is performed under a general anaesthetic.

Quinsy (peritonsillar abscess)

Defined as a localized collection of pus between the tonsillar capsule and the superior constrictor muscle, this condition mainly occurs in young adults, either spontaneously or as a complication of acute tonsillitis. This condition is extremely painful and is treated by aspirating the abscess under local anaesthetic. Two or more episodes of quinsy is an indication for tonsillectomy.

Infectious mononucleosis (“Mono”, Glandular Fever)

This condition mainly occurs in young adults and is caused by the Epstein-Barr virus (EBV). Glandular fever causes a severe tonsillitis and patients are often unable to eat or drink. Treatment is with intravenous antibiotics. All contact sports and alcohol must be avoided in the first few weeks after the onset of symptoms.

Unilateral tonsillar enlargement (one tonsil enlarged)

In the absence of active infection a unilateral tonsillar enlargement should be treated with suspicion of malignancy. A tonsillectomy is required to exclude the presence of a cancer.

Hoarseness

Hoarsness is common amongst adults. It may be caused by voice strain but any patient who is hoarse for three weeks or longer must have their throats examined to make certain that a vocal cord tumour is not the cause of the voice change.

Globus sensation (a feeling of a mass in the throat)

This is a common problem and is often caused by acid reflux. Acid can rise up into the throat and cause a caustic burn that leaves a feeling of a lump in the throat. It is essential to formally examine the throat with a flexible nasolaryngoscope to make certain that a cancer is not the underlying cause. A barium swallow is often also required.

Most patients respond well to anti-acid medication. If symptoms do not settle, a formal examination under general anaesthetic is required.


Acknowledgement: The illustarions included on these pages were generously donated to the author by Ms S Leighton.