“Some common topics”VP VIJAY

Topics• Otitis media – acute

• Otitis media with effusion

• Otitis media – chronic suppurative

• Otitis externa

• Epistaxis

Otitis media - acute• infection of middle ear

• common problem in general practice, – mostly younger children – more often in children who

– are subject to passive smoking, – attend daycare (nursery), – use formula milk (rather than breast milk), – have craniofacial syndromes (such as Down's syndrome and cleft palate),

and – in boys

Otitis media - acute• in older children, usually presents with earache

• younger children – may pull or rub their ear, – may have non-specific symptoms such as

– fever, – irritability, – crying, – poor feeding, – restlessness at night, – cough, or – a runny nose

Otitis media - acute• on examination

– ear drum distinctly red, yellow, or cloudy – occasionally bulging

Otitis media - acute• pain and fever – can manage with paracetamol or ibuprofen

• most do not need antibiotics – symptoms resolve spontaneously after a few days

• antibiotics may be necessary for children if:– younger than 3 months– systemically unwell– no improvement ≥ 4 days– infection in both ears– present with perforation and/or discharge in ear canal

• if antibiotic required, 5-day course of amoxicillin recommended

Otitis media - acute• hospital admission for immediate specialist assessment in:

– children < 3 months with temp ≥ 38°C– children 3–6 months with temp ≥ 39°C– if suspect acute complications

– meningitis, – mastoiditis, or – facial paralysis

Otitis media - acute• some patients have recurrent episodes

– treat each as acute episode – long-term antibiotics not recommended

• measures that may help prevent recurrence include:– avoid exposure to passive smoking– avoid dummies– not feeding child while lying flat– pneumococcal vaccination as part of routine immunisation

Otitis media with effusion• characterized by

– collection of fluid within middle ear space – without signs of acute inflammation

• also known as 'glue ear'

Otitis media with effusion• most common cause of hearing impairment in childhood

• most common in children 1 - 6 yrs old, especially in winter

• symptoms vary with time and age

• hearing loss usually resolves over several weeks or months, – but may be more persistent, – if bilateral, may lead to

– educational problems– language problems– behavioural problems

Otitis media with effusion• presence of coexisting medical conditions may increase

impact of OME on child, e.g., – hearing loss otherwise unrelated to OME, – uncorrectable visual impairment, – speech and language delay or disorder, – other causes of developmental delay

Otitis media with effusion• exact cause uncertain,

– but over 50% of cases thought to follow an episode of acute otitis media, especially in children < 3 years of age

• persistence may occur because of:– impaired Eustachian tube function causing poor aeration of middle

ear– low-grade viral or bacterial infection– persistent inflammatory reaction– adenoidal infection or hypertrophy

Otitis media with effusion• more common in children with

– cleft palate, – Down's syndrome, – cystic fibrosis, – primary ciliary dyskinesia, – allergic rhinitis

• several environmental factors may chance of children developing OME, e.g. – low socioeconomic group– frequent upper-respiratory infections

• parental smoking – risk

Otitis media with effusion• complications:

– conductive hearing loss– educational, developmental, behavioural, and social difficulties– chronic damage to tympanic membrane

Otitis media with effusion• screening children in general population: no value in

identifying OME

• however, children with Down’s syndrome or cleft palate should be regularly assessed by a specialist

• suspicion based on – suspected hearing loss, – clinical history, – examination, – confirmed with

– audiometry, and – tympanometry, as appropriate

Otitis media with effusion• diagnosis:

– detailed history; – examine ears; – consider need for wider examination of respiratory system,

– including nose and throat;

– exclude alternative diagnoses – e.g. acute otitis media, – foreign body, – impacted wax, – balance disorders

Otitis media with effusion• spontaneous resolution common,

– for most children active observation over 6–12 weeks is appropriate management.

• if signs and symptoms persist, refer– for hearing test or – to ENT specialist if direct referral not available

Otitis media with effusion• referral to ENT also if:

– Down's syndrome or cleft palate– severe hearing loss and/or associated with significant impact on

child's quality of life– significant hearing loss persists on two documented occasions– tympanic membrane structurally abnormal– alternative diagnosis suspected

• if persistent, foul-smelling discharge suggestive of possible cholesteatoma — urgent referral (within 2 weeks).

Otitis media – chronic suppurative• defined as

– chronic inflammation of middle ear, and mastoid cavity, – presents with recurrent ear discharges (otorrhoea) – through tympanic perforation

• assumed to be a complication of acute otitis media– WHO: AOM considered to be CSOM after ≥ 2 weeks of discharge, – whereas some experts suggest ≥ 6 weeks of discharge as cut-off

point

Otitis media – chronic suppurative• true prevalence unknown, but in UK estimated to be < 1%.

• if left untreated, may spread – extracranially, causing

– facial paralysis, – mastoiditis, or – cholesteatoma) or

– intracranially, causing – meningitis, or – cerebral abscess, (rare - 0.7% to 3.2%)

Otitis media – chronic suppurative• tympanic perforation will usually close spontaneously,

– but may persist, leading to – permanent hearing loss and – (in children) problems with language development

• symptoms supporting diagnosis of CSOM:– ear discharge (for 2 weeks) without pain and fever.– history of AOM (ear pain, fever, irritability), ear trauma, or previous

glue ear and grommet insertion– painless ear examination (unlike AOM or acute otitis externa), with

evidence of tympanic membrane perforation.– possible hearing loss

Otitis media – chronic suppurative• assessment should include:

– checking for – postauricular swelling (tenderness), facial paralysis, or vertigo, and – signs or symptoms of intracranial infection (requiring admission)

– asking about – hearing loss, and – if appropriate, effect of CSOM on daily activities (e.g. school or work), and – language development

– excluding alternative causes for persistent ear discharge such as – otitis externa (suggested by an inflamed, eczematous canal without a

perforation), – a foreign body (particularly in children), – impacted ear wax, and – neoplasm (ear canal swelling that bleeds on contact).

Otitis media – chronic suppurative• admit if signs of infection beyond ear, e.g.

– postauricular swelling or tenderness, – headache, – facial paralysis, or – vertigo

• if CSOM suspected, refer to ENT specialist (for diagnosis, treatment, and follow up):– the ears should not be swabbed– treatment should not be initiated

• give reassurance that any hearing loss will usually return when perforation heals, – but hearing test may be done in secondary care.

Otitis externa• inflammation of external ear canal

• can be classed as – acute (lasting < 3 weeks) or – chronic (lasting > 3 months).

Otitis externa• localized otitis externa

– infection of hair follicle – can progress to become a boil

• diffuse otitis externa – more widespread inflammation of skin and subdermis of external ear

canal

• malignant otitis externa – extension into bone surrounding ear canal

– i.e. mastoid and temporal bones – fatal without treatment

– osteomyelitis progressively involves mastoid, temporal, and basal skull bones, – spreads to CSF causing meningitis.

Otitis externa• slightly more common in women than men

• prevalence peaks – in women aged 45–54 years– in men aged 65–74 years

Otitis externa• direct causes:

– infection– dermatitis.

• precipitating factors: – ear trauma – excessive moisture

• risk factors – diabetes – radiotherapy to head and neck.

Otitis externa• complications:

– abscess, – inflammation of tympanic membrane, – malignant otitis.

Otitis externa• diagnosis

– based on characteristic symptoms and signs.

• alternative diagnoses, e.g.– otitis media, – earwax– neoplasm– usually differentiated by history, e.g.

– rapidity of onset, – duration, – pattern of symptoms– clinical examination.

Otitis externa• management

– assess symptom severity (e.g. pain, itch, hearing loss, and ear discharge).

– remove/treat aggravating/precipitating factors (such as diabetes, dermatitis, trauma to ear)

– paracetamol/ibuprofen for symptom relief (codeine for severe pain)– treat infection, if necessary, usually topical preparation

Otitis externa• management

– consider need for investigations – rarely useful but may be necessary if persistent/recurrent symptoms

– appropriate self-care advice – to aid recovery– reduce risk of recurrence– e.g. keep ears dry and clean, – avoid use of cotton buds, – treat generalized skin conditions such as eczema

Otitis externa• for localized otitis externa:

– application of local heat (e.g. from a warm flannel) may be sufficient – as folliculitis usually mild and self limiting

• if pus causing severe pain and swelling, consider I&D – usually requires referral,

– although small pustule near entrance to ear canal may be drained by incision with surgical needle.

• if malignant otitis is suspected, urgent admission indicated

Otitis externa• consider specialist advice if

– persistent symptoms, or– contact sensitivity is suspected, or – ear canal is occluded

• consider referral to secondary care if – extensive cellulitis, or– extreme pain or discomfort, or– considerable discharge or extensive swelling of auditory canal, or – sufficient earwax or debris to obstruct topical medication

Otitis externa• follow up:

– not usually needed; – however, recommended:

– after completion of course of treatment, to review response– diabetes or compromised immunity– severe otitis externa with accompanying cellulitis which has spread

outside auditory canal.

Epistaxis• bleeding from nose

• caused by damage to blood vessels of nasal mucosa.

Epistaxis• most epistaxis self-limiting and harmless

– cause of damage to blood vessels often not identified

• local causes of damage to blood vessels – trauma, – inflammation, – topical drugs, surgery, – vascular causes

– hereditary haemorrhagic telangiectasia, – Wegener's granulomatosis, or

– tumours – such as squamous cell carcinoma

Epistaxis• more general causes:

– hypertension; – atherosclerosis; – increased venous pressure from mitral stenosis; – haematological disorders

– thrombocytopenia, – leukaemia, and – haemophilia;

Epistaxis• more general causes:

– environmental factors such as – temperature, – humidity, or – altitude; – systemic drugs

– anticoagulants and – antiplatelets; and

– excessive alcohol consumption.

Epistaxis• complications of epistaxis

– rare, – hypovolaemia, – anaemia – complications from nasal packing treatment.

• if haemodynamic compromise, – managed as emergency– immediate transfer to hospital

Epistaxis• if haemodynamically stable,

– usually managed with first aid measures: – sit with upper body tilted forward and mouth open; – soft part of nose pinched firmly and held for 10–15 minutes.

• if suspect posterior bleed (profuse, from both nostrils, and cannot identify site on examination), – hospital admission may be necessary

Epistaxis• if stops with first aid measures,

– may apply topical antiseptic such as Naseptin® cream to prevent re-bleeding

• if does not stop after 10–15 minutes of pressure, – nasal cautery or packing may be used to stop bleeding– otherwise immediate ED admission recommended

Epistaxis• investigations rarely needed in primary care following

acute epistaxis, but may include:– FBC

– if bleeding heavy or recurrent, or – anaemia suspected

– coagulation studies, if– clotting diathesis suspected or – patient on warfarin therapy.

Epistaxis• management of recurrent epistaxis includes:

– topical antiseptic treatment such as Naseptin® cream – to reduce crusting and vestibulitis, or

– nasal cautery– referral to ENT if

– recurrent epistaxis despite treatment, or – high risk of serious underlying cause

Sore throat• symptom of pain at back of mouth.

• clinical descriptions– acute pharyngitis: inflammation of part of throat behind soft palate

(oropharynx).– tonsillitis: inflammation of tonsils.

Sore throat• acute sore throat commonly caused by viral or bacterial

infection.

• non-infectious causes uncommon – physical irritation, e.g.,

– gastro-oesophageal reflux disease, – chronic irritation from

– cigarette smoke, – alcohol, or

– hayfever

Sore throat• acute infections most common in

– children 5–10 years – young adults 15–25 years.

• complications – otitis media (most common), – peri-tonsillar abscess (quinsy), – parapharyngeal abscess, – mastoiditis.

Sore throat• sore throat due to viral or bacterial cause

– self-limiting condition – symptoms resolve within

– 3 days in 40% – 1 week in 85%, – irrespective of whether or not sore throat is due to streptococcal infection

– symptoms of infectious mononucleosis usually resolve within 1–2 weeks – although mild cases may resolve within days

– however lethargy continues for some time afterwards – in rare cases may continue for months or years.

• throat swabs – should not be carried out routinely in primary care management of

sore throat.

Sore throat• common causes of sore throat in primary care

– usually not life-threatening; – common cold, – influenza, – streptococcal infection, and – infectious mononucleosis 

• less common causes include – HIV, – gonococcal pharyngitis, and – diphtheria.

Sore throat• management involves:

– identify need for admission or referral.– admit immediately if

– stridor, – breathing difficulty, or – dehydration.– immediately life-threatening condition, e.g.

– acute epiglottis or – Kawasaki disease

Sore throat• management involves:

– simple advice, if appropriate, e.g. – regular use of paracetamol or ibuprofen to relieve pain and fever, – avoidance of hot drinks, – adequate fluid intake to avoid dehydration, and the – use of simple mouthwashes (e.g. warm salty water) at frequent intervals

until the discomfort and swelling subside.

– antibiotic treatment, if appropriate. – Centor clinical prediction score should be used to assist decision

– identifying and manage patients at risk of immunosuppression.

Sore throat• urgent referral if:

– suspected throat cancer – persistent sore throat,

– especially if neck mass

– sore or painful throat lasts for 3 to 4 weeks– red, or red and white patches, or ulceration or swelling of

oral/pharyngeal mucosa for > 3 weeks.– pain on swallowing or dysphagia for > 3 weeks

• other conditions may require referral or expert advice should be sought e.g., – consideration of tonsillectomy for recurrent tonsillitis