Peripheral Peripheral Latent period Latent period Distress +++ Distress +++ Rotational nystagmus Rotational nystagmus Fatigable Fatigable Central No latent period Distress +/- Variable nystagmus Not fatigable
Management Primary PrimaryReassurance Advice on environmental masking Hearing aid Need only refer if not coping or unilateral tinnitus Hearing Therapy, masker Secondary Treat underlying ear disease Refer for further investigation/treatment
Management of OE Antibiotic/steroid DROPS Antibiotic/steroid DROPS Water precautions Water precautions Good analgesia Good analgesia Aural toilet Aural toilet Steroid ointment Steroid ointment Swab (?Fungal OE) Swab (?Fungal OE) Systemic antibiotics if cellulitis Systemic antibiotics if cellulitis
Sinusitis? Blocked nose Blocked nose Congestion Congestion Facial pain/headache Facial pain/headache Runny nose Runny nose Catarrh/mucous Catarrh/mucous Unpleasant smell/taste Unpleasant smell/taste Puffy/swollen face ‘Bags’ under eyes Watery/sticky eye And many more!
Facial Pain Facial neuralgia/migraine Facial neuralgia/migraine Dental Dental Sinusitis Sinusitis TMJ/Myofacial pain TMJ/Myofacial pain Periodicity, not constant Well localised Worse with colds Responds to antibiotics Other sinus symptoms Facial swelling almost never due to sinusitis
Diagnosis of Sinusitis DIFFICULT! DIFFICULT! Nasal endoscopy is the key Nasal endoscopy is the key Plain sinus X-ray no value Plain sinus X-ray no value CT scan limited value. 30% normal individuals have CT changes CT scan limited value. 30% normal individuals have CT changes Facial swelling almost never due to sinusitis Facial swelling almost never due to sinusitis Forehead and periorbital swelling probably is due to sinus infection Forehead and periorbital swelling probably is due to sinus infection
Nottingham Rhinology Clinic 973 consecutive patients 973 consecutive patients Mean follow-up 26 months Mean follow-up 26 months 1/3 diagnosis not sinonasal 1/3 diagnosis not sinonasal 119/679(18%) with sinonasal disease had pain 119/679(18%) with sinonasal disease had pain 43/119 pain not attributable to sinus disease 43/119 pain not attributable to sinus disease 76/679(11%) had pain attributable to sinus disease 76/679(11%) had pain attributable to sinus disease
Summary Facial pain/frontal headache is not a major feature of sinonasal disease. Facial pain/frontal headache is not a major feature of sinonasal disease. Most patients with head pain/pressure have a neurological cause for this symptom Most patients with head pain/pressure have a neurological cause for this symptom Be very cautious in attributing such symptoms as being due to sinusitis, especially in the absence of objective evidence of sinus disease. Be very cautious in attributing such symptoms as being due to sinusitis, especially in the absence of objective evidence of sinus disease.
Rhinitis- Management Topical nasal steroids Topical nasal steroids Use daily Minimum 6-8 weeks Warn no affect for 3-4 weeks but don’t stop Drops more potent than sprays Drops more potent than sprays Stop nasal decongestants Stop smoking Add antihistamines? Ipratropium Bromide? Allergen avoidance After allergy testing Immunotherapy
Gastro-oesophageal reflux Effects 25-40% of British population each week Effects 25-40% of British population each week Atypical manifestations are common Atypical manifestations are commonLaryngealPharyngeal
Pathophysiology Inflammation due to direct action of acid Inflammation due to direct action of acid Laryngitis, pharyngitis Increase in cricopharyngeus muscle tone Increase in cricopharyngeus muscle tone Globus sensation, dysphagia, pharyngeal pouch Vagal hypersensitivity Vagal hypersensitivity Globus sensation, chronic cough Ciliary damage Ciliary damage Post nasal drip
THERAPEUTIC TRIAL WITH A PPI IS WELL WORTH WHILE, PROVIDED THERE ARE NO CLEAR ‘CANCER SYMPTOMS’
Cancer symptoms Pain, especially odynophagia Pain, especially odynophagia True dysphagia True dysphagia Change in diet Change in diet Weight loss Weight loss Food regurgitation Food regurgitation Is symptom more noticeable when eating/drinking?
SNORING Obesity Obesity Oropharyngeal Oropharyngeal Palate Palate Tongue base ? Retrognaethia Tongue base ? Retrognaethia Tonsils Tonsils Nasal Nasal
Treatment Non-Surgical Non-Surgical LOSE WEIGHT LOSE WEIGHT Mandibular splint Mandibular splint Treat rhinitis Treat rhinitis Avoid alcohol in evening Avoid alcohol in evening Avoid sedatives Avoid sedatives Stop smoking Stop smoking Sleep on side Sleep on side Surgical Palatal surgery (LAUP) Must exclude OSA Tonsillectomy Nasal surgery Orthognaethic procedures