Ear, Nose,
Throat and Dental Problems
Ear, nose and throat (ENT) examination needs
patience and practice to master. Patients may cough or sneeze, showering you
with their body fluids, so protect yourself with gloves, apron, mask and eye
protection. Adequate light and topical anaesthesia makes examination easier and
your patient more comfortable.
Ear
Common diagnoses
Otitis media/sinusitis
Ear pain is usually caused by
infection in the middle ear – otitis media. The eardrum appears dull with
prominent blood vessels. Sinusitis presents as headache and a feeling of
pressure in the face. These are self-limiting conditions caused by a viral
upper respiratory tract infection, blocking drainage from airspaces within the
head. Analgesics and decongestant drugs are helpful; antibiotics are not.
Otitis externa
Otitis externa or ‘swimmer’s ear’
is a localised infection of the ear canal, which becomes congested with
discharge and debris. Otitis externa is treated with topical antibiotics and
steroids, applied using a wick of cotton wool.
Ruptured ear drum
Commonly caused by trauma,
barotrauma or infection, a ruptured ear drum normally heals within 2 months.
Patients should avoid immersing the ear in water.
Vertigo
Vertigo causes a sensation of spinning;
it is not just ‘feeling faint/ light-headed’. Vertigo is caused by conflicting
sensory information from ears, eyes and joints. The problem is usually due to
peripheral (sensory) problems rather than central
(brain) ones.
• A peripheral
cause is likely if the patient has hearing loss, tinnitus, ear infection,
headache, nausea and vomiting.
• A central
cause is likely if the patient has motor symptoms or cardiovascular risk
factors, e.g. atrial fibrillation.
Use the Dix-Hallpike test to
differentiate central from peripheral causes. If there are central signs, check
blood glucose and ECG – consider transient ischaemic attack (TIA)/stroke or
other neurological cause (Chapter 42).
If the patient has no hearing
loss, the most common cause of vertigo is vestibular neuronitis, usually caused
by a (viral) upper respiratory tract infection. Prochlorperazine (an
anti-emetic) +/− intravenous fluids is particularly effective. Antihistamines
are structurally similar drugs and can also be used. Vestibular labyrinthitis
is similar, but patients may have hearing loss and tinnitus.
Nose and face Common presentations Nosebleed
Most patients bleed from venous
plexi in the anterior part of the nose – Little’s area. Some (usually elderly)
patients may have bleeding from the posterior part of their nasal cavity. Ask
about warfarin and antiplatelet drugs such as aspirin and clopidogrel. Check
FBC/clotting in older patients. Pack the nose and admit according to local
protocols.
Facial fractures
Assess stability of upper teeth
and mandible, and sensation over the face. If there is a fracture of the
orbital floor, examine the eye movements (Chapter 22). Radiographic facial
views are necessary, but are difficult to interpret – look for asymmetry. If
there is mandibular injury, request XR OPG (oral pantomogram): fractures of the
neck of the mandible can be difficult to spot.
Fractured nose
A patient with a painful swollen
nose following trauma is likely to have broken their nose. X-rays do not change
management. The patient should be discharged and reviewed in 5–7 days in an
Ear, Nose and Throat clinic.
Do not miss
Septal haematoma
Septal haematoma – a swelling
from the medial side of a fractured nose, usually in a young adult. This
requires urgent drainage to prevent avascular necrosis of the cartilage.
Throat
Common presentations
Tonsillitis/pharyngitis
Pharyngitis and tonsilitis can be
caused by bacteria or viruses. Viral pharyngitis is more likely if the patient
has runny nose/ conjunctivitis/diarrhoea. Group A B-haemolytic Streptococcus (GAβHS) is responsible for
10% of pharyngitis, and is treated by penicillin/erythromycin if three or more
of the following criteria are present.
•
Fever.
•
Exudate
on the tonsils.
•
Tender
anterior neck lymph nodes.
•
Lack of
cough.
If two or more criteria are
present, rapid antigen tests can be used to identify those patients with GAβHS. Complications of
untreated GAβHS are uncommon, and over-treatment with antibiotics is self-reinforcing.
Patients who are systemically unwell with extensive bacterial pharyngitis need
admission for intravenous penicillin and fluids.
Foreign body in throat/oesophagus
The site of pain suggests
location of the foreign body.
•
Unilateral
pain – foreign body above cricopharyngeus.
•
Pain in
submandibular region – foreign body in tonsillar fossa.
•
Pain
around larynx – foreign body in posterior tongue.
If there is pain on every
swallow, the foreign body is probably still there; if there is just vague
discomfort, the foreign body has probably gone. Radiography is useful for
bones, but fishbones, a common cause, are not very radio-opaque.
If there is no danger of the
foreign body causing obstruction were it to be pushed into the trachea, it may
be removed under direct vision using forceps or suction. Otherwise it is likely
the foreign body will need to be removed under general anaesthesia.
Foreign bodies stuck in the
oesophagus will often move with a combination of glucagon (which relaxes the
lower oesophageal sphincter) and fizzy drink. Failure necessitates endoscopy.
Diagnoses not to miss
Quinsy (peritonsillar abscess)
Quinsy causes a painful,
asymmetrically swollen throat with difficulty opening the mouth or swallowing
and a ‘plummy’ voice. Treated by aspiration or drainage in theatre, together
with antibiotics.
Epiglottitis, retropharyngeal abscess, Ludwig’s angina
These rare but dangerous
infections can cause upper airway obstruction, giving stridor, a whistling
sound worse on inspiration. Patients are unwell with high fever, sitting
forward, with a stiff neck, drooling saliva they are unable to swallow.
Treatment is urgent anaesthetic and ENT airway assessment and antibiotics.
Postoperative bleeding
Postoperative bleeding is often a
result of infection: these patients should always be reviewed by the Ear, Nose
and Throat team.
Dental
Dental pain is usually caused by
dental caries leading to local infection (pulpitis) and abscesses. Affected
teeth are tender to percussion and temperature. Treatment is analgesia and
advice to see a dental practitioner. Antibiotics are not normally indicated.
Wounds inside the mouth rarely
need treatment as they heal very rapidly, and saliva has a natural
antibacterial action. Exceptions are ‘through and through’ lacerations (through
oral mucosa, muscle and facial skin) or lacerations involving the tip of the
tongue.
An avulsed tooth should be
replaced in the socket immediately if it is to survive. If this is not
possible, the patient should carry the tooth between cheek and teeth. A dentist
can place a splint to the tooth in place.
