ENT UPDATE Gavin Watters FRCS FRCS(ORL) Consultant ENT Surgeon

PRIMARY CARE E Vertigo BPPV Tinnitus Otitis Externa NRhinosinusitis T Globus sensation Snoring

Dizziness Vertigo Vertigo Unsteadiness (on walking) Unsteadiness (on walking) Light-Headedness Light-Headedness

Vertigo Definition Definition An illusion of movement of the subject or of his/her surroundings. Usually a sensation of spinning or rotation. Central or Peripheral Central or Peripheral

Acute Peripheral Vertigo BPPV < 5 minutes BPPV < 5 minutes Meniere’s Disease/Syndrome <24 Hours Meniere’s Disease/Syndrome <24 Hours Vertigo with migraine <24 Hours Vertigo with migraine <24 Hours Vestibular/labyrinthine failure >24 Hours Vestibular/labyrinthine failure >24 Hours

Dix-Hallpike Test

Peripheral Peripheral Latent period Latent period Distress +++ Distress +++ Rotational nystagmus Rotational nystagmus Fatigable Fatigable Central No latent period Distress +/- Variable nystagmus Not fatigable

BPPV Calcium deposits in posterior semi-circular canal Calcium deposits in posterior semi-circular canal Brandt-Daroff exercises Brandt-Daroff exercises Epley manoeuvre Epley manoeuvre Obliterate Posterior S-CC Obliterate Posterior S-CC Singular nerve neurectomy Singular nerve neurectomy

Brandt-Daroff Exercise

Tinnitus Primary/idiopathic Primary/idiopathic Secondary Secondary Ear disease VascularNeuronalNeuromuscular

Pulsatile Tinnitus Vascular Vascular Vascular stenosis AVM Glomus tumour Conductive HL Hear normal intra- cranial blood flow

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

Otitis Externa Pain Pain Irritation/Itch Irritation/Itch Discharge Discharge (Hearing loss) (Hearing loss) Cotton buds Skin condition Diabetes Middle ear disease Anatomical

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!

Sinusitis Cacosmia Cacosmia Purulent Rhinorrhoea Purulent Rhinorrhoea Hyposmia/anosmia Hyposmia/anosmia Facial pain Facial pain Frontal headache Frontal headache Nasal obstruction Nasal obstruction

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

Neurological Causes (Nottingham Study) Midfacial segment pain37% Midfacial segment pain37% Tension headache23% Tension headache23% Migraine17% Migraine17% Atypical facial pain12% Atypical facial pain12% Cluster headache8% Cluster headache8% Others3% Others3%

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- Aetiology Intrinsic (vasomotor) Intrinsic (vasomotor) Allergic (seasonal, perennial) Allergic (seasonal, perennial) Environmental (SMOKING) Environmental (SMOKING) Infective Infective Hormonal Hormonal Medication (Rhinitis medicamentosa) Medication (Rhinitis medicamentosa) Systemic medical disorder eg Wegner’s Systemic medical disorder eg Wegner’s

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

Laryngopharyngeal Symptoms Hoarse voice (usually fluctuating) Hoarse voice (usually fluctuating) Globus sensation Globus sensation Mild dysphagia Mild dysphagia Post nasal drip Post nasal drip Chronic cough Chronic cough Chronic sore throat (mild) Chronic sore throat (mild)

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

Laser assisted palatoplasty

AND FINALLY

Questions ?