Common ENT Conditions PwPT2008

7/29/2019 Common ENT Conditions PwPT2008

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Common Ear Conditions

F Bhatti ST2Group B9/12/08


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Outline of the presentation

Few common presentations in general practice related toears. Examining the ears. Ear Wax and syringing. Otitis Externa

. Otitis Media( Acute and Chronic)

. Eustacian tube dysfunction

. Perforations ( Safe vs. Unsafe)

Treatment ( Evidence based)

Lots of pictures!

Few questions( AKT based)


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Sources (With hyperlinks)

GP Notebookhttp://www.gpnotebook.co.uk/homepage.cfm

CKS

http://cks.library.nhs.uk/home

ENT USA

http://www.entusa.com/index.html Passmedicine

http://www.passmedicine.com/index.php

University of Bristol, Otoscopy tutorialhttp://www.bris.ac.uk/Depts/ENT/otoscopy_tutorial.htm

You Tube

BMJ Learning

Bradford VTS website ( With thanks to Dr R Mehay)
http://www.gpnotebook.co.uk/homepage.cfmhttp://cks.library.nhs.uk/homehttp://www.entusa.com/index.htmlhttp://www.passmedicine.com/index.phphttp://www.bris.ac.uk/Depts/ENT/otoscopy_tutorial.htmhttp://www.bris.ac.uk/Depts/ENT/otoscopy_tutorial.htmhttp://www.passmedicine.com/index.phphttp://www.entusa.com/index.htmlhttp://cks.library.nhs.uk/homehttp://www.gpnotebook.co.uk/homepage.cfm


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ENT Examination

You tube video of ENT examination in an OSCE situation.http://www.youtube.com/watch?v=mDbwAPr5RvU

Ear examination- You tube videohttp://uk.youtube.com/watch?v=I3sa2W83iuo&NR=1

NB:

. The canal may be partly straightened by pulling the pinna backwards

and upwards during examination.. In infants pull the pinna more horizontally backwards as the shape of

the ear canal is different.
http://www.youtube.com/watch?v=mDbwAPr5RvUhttp://uk.youtube.com/watch?v=I3sa2W83iuo&NR=1http://uk.youtube.com/watch?v=I3sa2W83iuo&NR=1http://www.youtube.com/watch?v=mDbwAPr5RvU


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Normal

Anterior

direction

Inferior

Posterio

r

Anterio

r

- Consider the malleus as

an arrow; pointing inthe forward direction.

- The normal tympanicmembrane shouldappear

. pearly grey

. have a light reflex

. generally concave

. and malleus should bevisible

Abnormals:

. Retraction( bones more prominent)

. Perforations

. Bubbles (glue ear, resolving infection)

. White patches (tympanosclerosis orcholesteatoma)

. Granulations

. Red lesion at tip of malleus (glomustumour)

. Grommets/FBs

Attic


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Ear Drum-normal Landmarks

An annulus fibrosus or morecommonly referred to as

the eardrum margin. This isimportant. Note howsmooth and how ever soslightly blurry it is.

Um umbo - the end of themalleus handle and usuallymarks the centre of thedrum

Lr light reflex or Cone oflightis usually seen antero-inferioirly

At Attic also known as parsflaccida. Any perforationshere are serious and needreferral.

Lp Lateral process of themalleusHm handle of the malleusLpi long process of incus -sometimes visible through ahealthy translucent drum


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Go systematically

External:

Pinna (shape, colour, position, tenderness, haematoma) etc

Mastoid (tenderness in AOE or mastoid abscess)

Internal:

The Canal ( skin, furuncle, scales,spores,FBs,discharge, debris, wax)

The Tympanic membrane (look ant, post, superior/ attic and inferior of malleus)

. Colour( opaque, white, red, patches & translucency)

. Retraction( landmarks behind it more visible)

. Perforation ( safe/ unsafe)

. Discharge (purulent, mucopurulent)

Behind the Eardrum. Fluid behind the drum( meniscus, air fluid levels, colour, bubbles?..can ask for avalsalva if appropriate)

. Any red bits( glomus tumour, granulations or blood?, white- cholesteotoma)


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Ear Wax

Wax is produced in the outer halfof the ear canal and migratesoutwards along with the canalskin. Inappropriateinstrumentation can cause

impaction. Wax impaction can causehearing loss, pain, tinnitus,vertigo, or chronic cough butnot usually discharge.

Sudden expansion after getting

water in can cause suddendeafness or pain, but needscareful exclusion of otherpathology behind it e.g.cholesteotoma

Be mindful of other possibilities FB(crayon) in a childs ear


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Ear Wax.contd

Management:. Educate about non instrumentation of their ear canals.If Symptomatic. Syringing (with use of drops) or wax hook.. Different preparations available none superior to other.

Sodium bicarbonate drops might be better at disintegrating wax, butcan cause dryness of the canal and/ or irritation

. Instructions for use:e.g. Olive oil drops warmed on a warm spoon.Put 2-3 drops in theear and lie on the opposite side for 3-5 mins. Use BD. Get syringed in5-7 days.

. When to refer to ENT clinic:. Patients known to have a tympanic membrane perforation or

previous ear surgery (need microsuction), only hearing ear

. Syringing fails

. Causes pain or vertigo,

. Hearing loss persists after wax removal.

. Keratosis Obturans


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Otitis Externa

Infection of the external auditory canal. Mediterraneanear/Swimmers ear

Usually unilateral Gradual onset pruritis, pain, hearing loss, and ear discharge which

varies in consistency and colour. Discharge not mucoid inconsistency as no mucin glands are present in the ext aud canal.

The pt is usually well. Can result in a featureless ext aud canal Risk factors: trauma, water, Immunosuppression, eczema Can be fungal- spores might not always be visible If treatment fails or otitis externa recurs

frequently consider sending an ear swab

for bacterial and fungal microscopyand culture


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Management

Remove or treat any precipitating or aggravating factors. Analgesic A topical ear preparation for 7 days. Options include preparations containing:

a. Both a non-aminoglycoside antibiotic + a corticosteroid e.g. flumetasoneclioquinol (LocortenVioform) ear drops.b. Both an aminoglycoside antibiotic and a corticosteroid (contraindicated if

the tympanic membrane is perforated).c. Topical preparations containing only an antibiotic (gentamicin ear dropsare contraindicated if the tympanic membrane is perforated).d. Antifungal or ? something containing all three

Aural toilet: if earwax or obstruct topical medication (mayrequire referral).

If there is extensive swelling of the auditory canal, considerinserting an ear wick (may require referral). Provide appropriate self-care advice


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Current Evidence Topical corticosteroids are at least as effective as topical antibiotics

combined with corticosteroids. However, because ofmethodological weaknesses in the clinical trials and because acutediffuse otitis externa is thought to be caused by an infection, topicalcorticosteroids on their own are not generally recommended as first-line treatment

Clioquinol is antibacterial and antifungal and has lower risks of skinreactions and ototoxicity than aminoglycosides. Therefore, ontheoretical grounds, the combination flumetasoneclioquinol mightbe slightly preferred.

Oral Abx: usually where furunculosis and/or extensive spreadingcellulitis- In 1997, GPs prescribed oral antibiotics for 21% of first

episodes of otitis externa. Amoxicillin/ampicillin was the mostfrequently prescribed antibiotic (34%)

Flucloxacillin narrower spectrum but good tissue diffusion

Erythromycin wider spectrum- effective for most sensitive Gram +cocci and some Gramve cocci and anaerobes; Clarithromycin lessGI side effects but more expensive


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Malignant Otitis Externa

"Malignant" otitis externa is a severe infection due to Pseudomonasaeruginosa and anaerobes causing osteomyelitis of the skull basecharacterised by severe pain, involvement of the floor of the earcanal, sometimes with granulation tissue. If untreated, it can involvethe cranial nerves and brain. It is not a neoplastic process.

Facial nerve palsy occurs in 50% of patients, IX to XII may also beinvolved. immunocompromised patients, especially elderly diabetics.It may be life threatening.

What to look for:Elderly, DM, earotalgia, otorrhoea, hoarseness,puffiness , trismus, failure to respond to drops, granulations, CN palsiesetc

Mx:-Refer

-Intensive local and systemic antibiotics against Pseudomonas arerequired if malignant otitis externa is present, e.g. ciprofloxacin orceftazidime, plus suitable anaerobic cover e.g. metronidazole.


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Question 1

23 yr old man, 4 days Hx of itchy sore Rt ear; returned recentlyfrom holiday in Spain

O/E= Rt ext auditory canal is inflamed but no debris seen.T.membrane is visible and unremarkable. What is the mostappropriate management?

A. Topical corticosteroid + Aminoglycoside

B. Topical corticosteroid

C. Tell him serves him right for going on a holiday while you work!

D. Topical corticosteroid +Clotrimazole

E.. Oral Flucloxacillin


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Answer 1

Correct Answer is A.

Dx- Otitis externa- Topical antibiotic or

combined Antibiotic + corticosteroidpreparation


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Question 2 53 year old man, fastidiously

clean, previously normal

hearing, currently recentonset strange sensation inme ear! + slightlyreducedhearinghave been trying topop them. Perchance; youhad a brilliantpresentation

on ENT conditions from afellow registrar on the last VTShalf day release and yourecognise the cone of light isnormal, but what is this

A. Normal ear drum

B. Otitis Externa secondary toear buds use

C. Serous Otitis Media

D. Time waster/ Hidden agenda


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Answer 2

Serous Otitis media because of Eustaciantube dysfunction

Has normal cone of light, mild rednessexternally likely normal, fluid level, and mildlyretracted ear drum


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Question 3

A 28 year old woman presents witha 5 day Hx of pain in her Rt ear,reduced hearing, and yellowcoloured discharge.

A. Keeping this picture in mindwhat test on physical exam could

have given you a clue about thediagnosis.

B. What is the likely diagnosis

a. Acute Otitis Media

b. Acute Otitis Externa

c. Chronic Suppurative Otitismedia

d. Its actually a picture from acolposcopy examination!


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Answer 3

Tragal tenderness

Answer is Acute Otitis Externa( for those who thought it was a picture from a colposcopy, may be itstime for you to move on to your next job!)


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Question 4

Which of the following statements aboutotitis externa is correct?

a. You should avoid removing canal debris

b. Its common in people not wearing ear protection whileworking with loud power tools as a divine punishment.

c. It may result in a featureless tympanic membrane

d. It is usually due to a Staphylococcus aureus infection


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Answer 4

Correct answer- It may result in a featureless tympanicmembrane

Commonest causative organism for infective otitis externa is

Pseudomonas

Could be difficult to eradicate in someone wearing earprotection in certain occupations e.g. forge/factory workers


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Question 5

Which of the following statements about the use of topicaleardrops is correct?

a. Only use topical ear drops if the tympanic membrane is visible

b. Topical eardrops are contraindicated in children under the age of12years

c. Topical eardrops cannot be used in the presence of a perforatedtympanic membrane

d. Topical eardrops can worsen otitis externa

e. If its difficult putting them in your ears, they are equally effectiveputting them in your nose and standing on your head for 3.37 mins.


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Answer 5

Correct answer- Topical eardrops can worsen otitis externa if there issensitivity to them

The use of ototoxic drops in the presence of a perforated tympanicmembrane is controversial due to reports of sensorineural hearing loss

as a result of their application. Reports of this association are rare andoften the validity of such reports is questionable. Certainly the risks ofsensorineural hearing loss or of major complications of otitis mediaare of more significance. Limiting the course of treatment andensuring that they are not used in healthy ears can reduce anypotential risks from the administration of ototoxic medicines.

There is no quality evidence supporting putting ear drops in your noseand standing on your head; but there is certainly none to refute it.


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Otitis Media

Can be acute or chronic

Can be with or without serous effusion (acute orchronic)

Can be Acute or chronic suppurative

Can co-exist with Otitis externa

Otitis media with serous effusion= Glue Ear


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Acute Otitis Media

Common in children

Unwell/pyrexia, otalgia/discharge there may be tenderness over the mastoid

discharge in meatus

loss of outline of drum and landmarks

TM: red, bulging,oedematous or perforation.

Mostly viral but can be Streptococcus/Haemophilus

Risk factors: Passive smoker

Male

Family history of otitis media.

In day care

On formula feed


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Current evidence for AOM

80% of children get better by day 3 without antibiotics

It is reasonable to prescribe analgesia.-

Antibiotics should not be used routinely and prescribing them justincreases parental belief and re-attendance rates

Use delayed scripts if necessary

Adenoidectomy, as the first surgical treatment of children aged 10 to24 months with recurrent acute otitis media, is not effective in

preventing further episodes. Neither is Chemoprophylaxis.

Current Evidence for CSOM

Randomised controlled trials (RCTs) found limited evidence thattopical quinolone antibiotics versus placebo improved otoscopic

appearances. RCTs found no clear evidence of significantdifferences between topical antibiotics.

No benefits from anything else.


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AOM (pus behind the eardrum)


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AOM continued..

Analgesia: For most children, this is the mainstay of treatment.

Antibiotics should not beroutinely prescribed for uncomplicatedAOM.

Some children may significantly benefit from antibiotics. All children aged 6 months and under

. Children aged between 6 months and 2 years where the diagnosis is reasonably

certain.. Children older than 2 years where there aresevere symptoms:. Moderate or severe ear pain (otalgia) with a fever of 39C or above, orsystemic features such as vomiting. Severe local signs, such as perforation with purulent discharge. Bilateral AOM

Choice of antibiotic:Amoxicillin is the usual first-line for 5 days. If severe symptoms present,or there has been a previous episode of AOM within the last month,use high doses (double the standard dose)..Erythromycin (use high doses) or Clarithromycin (use standarddoses) are alternative antibiotics if documented allergy to penicillin.


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AOM contd 2.

A good compromise is to use issuing a delayed prescription to beredeemed within 72 hours only if the condition has not adequately

improved. Active Follow up for:

. under 2 years of age.

. systemic symptoms such as high temps (> 39C) or vomiting.

. There is discharge from the ear. Visualisation of the tympanicmembrane can be difficult. Re-examine after 2 weeks to assess the

integrity of the membrane and to check for complications. If there is aperforation still present, monitor the situation and considerreferral if ithas not healed after 6 weeks.

Persistent AOM:Pt returning within 2 weeks with same complaints

.Analgesia

.If not had Abx-give Abx e.g. Amoxicillin double the standard dosefor 5/7

. If had Abx-check compliance-If good then try 2nd line Abx e.g. Co-Amoxiclav at double the standard dose for 5/7.
http://cks.library.nhs.uk/otitis_media_acute/management/quick_answers/scenario_first_line_treatment/should_i_refer_or_investigatehttp://cks.library.nhs.uk/otitis_media_acute/management/quick_answers/scenario_first_line_treatment/should_i_refer_or_investigate


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Complications from AOM

Complications from otitis media is extremely low.

> Progression to glue ear and associated hearing impairment> Perforation. In one study 29.5 % children with AOM eardrum perfs.But spontaneously closed in 94 % of the patients within one month.

Rarely to mastoiditis, labyrinthitis, meningitis, intracranial sepsis orfacial nerve palsy.

Recurrent episodes may lead to atrophy and scarring of theeardrum, chronic perforation and otorrhoea, cholesteatoma,permanent hearing loss, chronic mastoiditis and intracranial sepsis.


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Serous Otitis Media


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Serous Otitis Media/Secretory

Glue ear, commonest cause of deafness, and the commonestindication for surgery, in children.

The condition is most frequent in early childhood,

Peaks prevalence at 2 and 5 years.

Half of 3-year-olds have at least one effusion in a year, and inthe UK, 1 in 200 children is operated on for the condition.

Ninety thousand operations are performed in England andWales annually, at an estimated cost of 30 million


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Serous otitis media with retraction


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A hearing test is not appropriate at the initial presentation if there isno evidence of significant hearing loss or developmental delay. Ifsigns and symptoms of OME continue, hearing should be assessedafter 3 months, where OME can be regarded as persistent.

Consider setting a lower threshold for referral for a hearing test in

younger children (e.g. children aged less than 3 years old) as

communication is more difficult


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Otitis media+effusion-Glue ear

Features

Dull retracted TM

May show air-fluid level

Conductive hearing loss(whisper test, Rinne/weber tests)

Notes Common in children; often after AOM and can persist for

weeks

Reduced hearing noticed by parents/teacher

Unsteadiness- child falling over

80% clear at 8 weeks


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Management

Adults presentation - the nasopharynx is examined to excludetumour. Secretory otitis media is uncommon in adults. It usually followsa cold and spontaneously resolves; this may take up to 6 weeks

In Children- 50% of cases will resolve spontaneously within 6 weeks

Persistence of bilateral Otitis media with effusion (OME) and hearingloss in a child should be confirmed over a period of 3 months beforeintervention is considered

Surgery: adenoidectomy or myringotomy and grommet insertion.however a systematic review suggests that the role of grommets inthe management of glue ear is unclear.

Hearing aids: persistent OME, not for surgery

Treatments not recommended are antihistamines,decongestants, steroids ,homeopathy,cranial osteopathy, acupuncture,dietary modification, including

probiotics,immunostimulants, massage


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About glue ear

A unilateral serous effusion in an adult is due to nasopharyngealtumour until proven otherwise.

Secretory otitis media, or `glue ear', is the most frequent cause ofhearing problems in children. May produce pain or a conductivehearing loss, or may remain symptomless. There is concern thatimpaired hearing in early childhood may interfere with educationand normal development, but the magnitude of these effects is not

clearly established. Over 50% of effusions resolve spontaneously within 8 weeks, but

bilateral hearing loss, persisting 12 months, occurs in 5% of cases


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Glue Ear vs. Otitis Media

Factors suggestive of a diagnosis of glue ear include:

. frequent attacks of otitis media

. it is unusual for children to get multiple resolving episodes ofotitis media

prolonged signs. otitis media will usually resolve within 6 weeks and certainlywithin three months

Other risk factors: cleft palate ,Down's syndrome, allergy, familyhistory


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Eustachian Tube Dysfunction

a severely retractedeardrum. Margins are

very clear as is the

malleus and it looks

very sunken.


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Eustachian Tube dysfunction

Chronic blockage of the Eustachian tube is called Eustachian tubedysfunction. The eustachian tube becomes congested and swollenso that it may temporarily close; this prevents air flow behind the eardrum and causes ear pressure, pain or popping just as youexperience with altitude change when travelling on an airplane oran elevator.

This can occur when the lining of the nose becomes irritated andinflamed, narrowing the Eustachian tube opening or its passageway.

1. Illnesses like the common cold or influenza.

2. Others: pollution, cigarette smoke, allergic rhinitis, obesity

3. Rarely nasal polyps, cleft palate, skull base tumour


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Eustachian Tube Dysfunction

. Chronic ETD may reveal retraction pockets or collapsed middle eardisease with erosion of incus/stapedius. Difficulty auto-inflating the

ear drum

. Generally the fluid clears spontaneously over a period of severalweeks

. The efficacy of treatments such as nasal decongestants, oraldecongestants, antihistamines is unclear

. Antibiotics may help prevent infection in cases of severebarotrauma


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ETD & Children

Young children (esp 1 to 6 years) at particular risk because of verynarrow Eustachian tubes. Also, they may have adenoid enlargementthat can block the opening of the Eustachian tube. Since children indaycare are highly prone to getting URTIs, they tend to get more earinfections compared to children that are cared for at home.

Eustachian tube in infants and young children runs horizontally, ratherthan sloping downward from the middle ear. Thus, bottle-feedingshould be performed with the infants head elevated, in order toreduce the risk of milk entering the middle ear space. The horizontalcourse of the Eustachian tube also permits easy transfer of bacteriafrom the nose to the middle ear space.

Most children older than 6 years have outgrown this problem andtheir frequency of ear infections should drop substantially.


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Chronic Otitis Media

Recurrent ear discharge Hearing loss, painless

Perforation of the TMcentral

Presence of cholesteatoma

Marginal, Attic perforation

Offensive discharge,bleeding, granulations

Complications:

. Vestibular symptoms

. Facial palsy

. Intracranial complications


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Ear drum Perforations

Safe vs Unsafe Perforations

Safe perforations

. may allow infection to enter the middle ear

. conductive deafness

Unsafe perforations

. in fact represent a retraction of the tympanic membrane.

. essentially a part of the drum becomes sucked inwards and maygradually enlarge.

.when the retraction becomes extensive, keratinous debris builds up

in the retraction and may become infected and an acquiredcholesteatoma develops


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UNSAFE SAFESource Cholesteatoma Mucosa

Odour Foul Inoffensive

Amount Usually scant,never profuse Can be profuse

Nature Purulent Mucopurulent


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Unsafe perforations are

a)In the attic or

b)In the posterior region. These are

often linear rather than oval

c)Or involve the eardrum margin

Anything else is generally Safe.

i.e.

a) In the anterior region orb) In the inferior region

c) And not involving the eardrum

margin

MAKE SURE YOU ALWAYS INSPECTTHE ATTIC AREA ON OTOSCOPY!


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Safe anterior perforation

Perforations in

this position is a

persistent defect

after the

extrusion of a

grommet.


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Safe inferior perforation

This is more likely to

be as a result of

chronic middle earinfection.


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Unsafe posterior perforation

Posterior perforation.

Although posterior

perforations may

represent more

serious disease such

as cholesteatoma,

this is well described

and dry. It is possible

to make out the

posterior margin of

this

defect. Traumatic

perforations (e.g

barotrauma) are often

posterior and linear,like a tear rather than

a round hole.

Theres also some

tympanosclerosis in

this picture.


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Unsafe attic perforation

Any defect or

apparent perforation

in the attic must be

considered unsafe

and should be

referred for ENT

assessment. This

crust in the attic

represents a large

underlying

cholesteatoma sac.

Note the bulging

eardrum too.


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Marginal perforation plus cholesteatoma formation

Unsafe because it is a

perforation involving the

drum margin (the yellowy

white flakes indicating a

cholesteatoma also gives

it away!).


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Cholesteotoma


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Cholesteatoma

Cholesteatoma is "a three dimensional epidermoid structure

exhibiting independent growth, replacing middle ear mucosa,resorbing underlying bone, and tending to recur afterremoval." There is usually a persistent or recurrent scantycream coloured offensive discharge and progressive hearingloss due to ossicular destruction or toxin induced sensoryhearing loss.

Otoscopy : a pearly white mass usually in the pars tensa +/-discharge and sometimes erosion of the bone. A perforation is usuallypresent, but is not always visible due to overlying keratin. Granulationtissue or polyps may be seen due to chronic inflammation andsometimes retraction pockets are present.

A crust adherent to the tympanic membrane is indicative of acholesteatoma until proved otherwise. They can be reviewedafter a short course of steroid or ceruminolytic ear drops, but ifit is persistent or reveals an underlying abnormality then youshould refer


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Why is it important to diagnose it?

Cholesteatoma is an important diagnosis asit can cause irreversible hearing loss fromossicular destruction as well as facial nervepalsy, labyrinthitis, lateral sinus thrombosis,meningitis, intracranial abscess, and otitichydrocephalus. It is more easily treated in its

earlier stages. While waiting for their ENT appointment

patients should keep the ear dry and anyinfective discharge can be treated with atwo week course of antibiotic ear drops,with or without steroids. Aural toilet is also

advised if there is debris.


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Another cholesteotoma
http://www.entusa.com/ear_photographs_html/cholesteatoma-1.htm


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Serous Otitis media


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Normal ear drum

t th h l t t


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Yet another cholesteotoma


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Question 6

A 31 year old man with a history ofrecurrent Otitis media in childhoodsees you on a Tuesday afternoonwith his wife. C/O unilateral leftsided hearing loss. Possibilities are:

a. Cholesteatoma

b. Tympanic membrane retractionpocket

c. He doesnt get along well with theMissus.

d. Tympanic membrane perforation


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Correct answer-Tympanic membrane retraction pocket

This is a pars tensa retractionpocket which is clean. It isretracted onto the longprocess of the incus. There issome incidentaltympanosclerosis.

Generalised tympanicmembrane retraction andretraction pockets are thoughtto be caused by thinning of thetympanic membrane andnegative middle ear pressure.

Thinning of the tympanicmembrane can be caused bymiddle ear fluid or infections, apoorly healed perforation, orafter extrusion of a grommet

Retraction+ serous OM


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Haemorrhagic blister on ear drum surface fromshingles


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Grommet

This grommet is in

the correct position

but is covered in

infectivegranulation and

blocked up. This

will not be doing

any good and may

be responsible for

a chronic

discharge. Notealso the extensive

tympanosclerosis

on the drum.


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Glomus tumour

. Rare vascular tumour

. Causes pulsatile tinnitus

. Needs surgical removal

. Can erode bone etc over time


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Glomus tumour


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Chronic otitis externa


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Serous Otitis Media


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Slag caused injury

Despite what conclusions mightbe drawn from the title, it wasclaimed to be sustained whilewelding and when a sparkentered Pts ear. He complainedof pain and slightly muffled

hearing. The picture to the rightshows an eardrum one weekafter the injury. The eardrum isstill red and had a crust on it. Asmall metal ball is seen at thebottom of the canal.


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Haemotympanum


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Middle ear FB

The moulding materialentered middle ear whiletaking a cast for an elderlyladys hearing aid.


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Granulations

Granulations like this are

often associated with

underlying disease,

particularly if they arise in

the attic.


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AOM (Purulent)


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Question 7

A mother brings her 4 year old son to see you. He is complaining ofpain in his ear and his mother thinks that he pushed a button batteryinto it. You try to examine him but the child is horsing around . Whatshould you do?

a. Bribe the child with sweets/ Smack him when mums not lookingb. Tell the mother to come back in a few days time when the child is

calmer

b. Refer him for immediate removal of the suspected foreign body

c. Refer him to the ENT clinic routinely

d. Prescribe waxol drops(I seem to remember something along thoselines from the ENT job.)


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Answer 7

Correct Answer- Refer him urgently for FB removal.( Mum happy, thekids out of your surgery, good clinical practice and the ENT peopleyou dislike are stuck with him- a definite win win situation).

Usually inert non organic FBs can be extracted over a number of

days .Indications for referral are pain, infection, organic FB, youngchild, yourself not having the necessary equipment etc.

Button batteries are a definite no-no for drops, because the electriccurrent can catalyse chemical reactions and release alkalis causingnasty chemical burns; hence need to be extracted ASAP.


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The End (finally..)

Documents

Common ENT Conditions PwPT2008