All - ( About Health )

The nose and sinuses condition (septal perforation)

2008-01-24T03:56:00.000-08:00

Septal perforation

There are several reasons why a patients's septum may be perforated.
These include:

Trauma or accident
Post septal surgery
Nose picking
Granulomatous disease- must be excluded before treating perforation.

wegener's
sarcoidosis
TB
syphilis

Cocaine addiction

Signs and symptoms

whistling - if there is a small anterior perforation.
bleeding from the nose
crusting of the nose at the site of the perforation.

Treatment

apply vaseline to the edge of the perforation
treat epistaxis expectantly.
septal button- this is a plastic prosthesis fitted into the hole in the septum. only half the patients find it tolerable and continue using it long term.
surgical septum repair- the results of surgery are variable even in experienced hands.

The Mouth, Tonsils, and Adenoids Condition (Glandular fever)

2007-08-03T07:21:00.000-07:00

What is Glandular fever?

Glandular fever is also known as infectious mononucleosis or EpsteinBarr virus infection. It is common in teenagers and young adults. Patients with glandular fever may present a similar picture to patients with acute bacterial tonsillities, but with a slightly longer of symtoms. Diagnosis relies upon a positive monospot or Paul-Bunnell blood test, but early in the course of the disease this test can still show up negative.

Signs and Symptoms

- Sore throat
- Pyrexia
- Cervical Lymphadenopathy
- White slough on tonsils
- Petechial haemorrhages on the palate
- Marked widespread lymphadenopathy
- Hepatosplenomegaly

Treatment

This is self limiting condition for which there is no cure as such. Treatment is largely supportive with painkillers, although patients may appreciate a short course of corticosteroids to decrease swelling. IV fluids may be necessary if they cannot drink enough.

Complications

Patients should be advised to refrain from contact sports for six weeks because of the risk of a ruptured spleen. This can lead to life threatening internal bleeding.

The Mouth, Tonsils, and Adenoids Condition (Tonsillectomy)

2007-06-09T01:37:00.000-07:00

What is Tonsillectomy?

Tonsillectomy is one of the most commonly performed operations. Patients usually stay in the hospital for one night, so that bleeding may be recognized and treated appropriately. Tonsils are removed by dissection under general anaesthetic. Haemostasis is achieved with diathermy or ties.

What is going to happen after your surgery? (Post op)

Tonsillectomy is very painful and regular simple analgesia is always required afterwards. Patients should be advised that referred pain to the ear is common. Until the tonsillar fossae are completely healed, eating is very uncomfortable. The traditional jelly and ice cream has now been replaced with crisps, biscuits, and toast, since chewing and swallowing after tonsillectomy is very important for recovery and in helping to prevent infection.
In the immediate postoperative period the tonsillar fossae become coated with a white exudate, which can be mistaken as a sign of infection.

Complications

Postoperative haemorrhage is a serious complication for between 5-15% of patients after a tonsillectomy.

A reactive haemorrhage can occur in the first few hours after the operation, this will frequently necessitate a return trip to the operating theatre (OT).

A secondary haemorrhage can occur any time within two weeks of the operation. It occur less than 10% of cases and may result from an infection of the tonsillar fossa.

Neck Condition (Neck Hernias)

2007-05-10T23:41:00.001-07:00

What is Neck hernias?

Laryngocoele
This is caused by expansion of the saccule of the larynx. The saccule is a blind-ending sac arising from the anterior end of the laryngeal ventricle. A laryngocoele is an air-filled herniation of this structure. This can expand, and either remains within the laryngeal framework (internal laryngocoele), or part of it may extend outside the larynx (external laryngocoele). It escapes through a point of weakness in the thyrohyoid membrane.
There is a rare association with a laryngeal cancer of the saccule, and all patients should have this area examined and biopsied.
There is little evidence to support the supposition that this condition is more frequent in trumpet players and glass blowers.

Sign and symptoms
- Lump in the neck which may vay in size
- Hoarseness
- A feeling of something in the throat FOSIT
- Swallowing difficulties
- Airway problems
If the laryngocoele become infected and full of pus ( laryngo-pyo-coele) then they may rapidly increase in size and cause additional pain.

Neck Condition (Neoplastic Lymphadenopathy)

2007-04-11T22:54:00.000-07:00

What is neoplastic lymphadenopathy?

Lymphoma
This is a primary malignant tumour of the lymphatic tissues.

Sign and Symptoms

Multiple nodes of a rubbery consistency. The patient may or may not experience night sweats, weight loss, axillary or groin nodes, and lethargy.

Investigations

FNAC may be suspicious but an excision biopsy is often required to confirm the diagnosis and allow for sub typing. A CXR and/or a chest CT scan may be done, or, for staging, a CT scan of the abdomen or pelvis. Bone marrow may be needed for staging.

Treatment

May involve chemotherapy and/or radiotherapy. The patient may need a lymphoma multi-Disciplinary Team review.

What is squamous cell carcinoma

This a primary muco-cutaneous malignancy which commonly spreads to local lymph nodes. It can affect single or multiple nodes.

Signs and Symptoms

The patient may have ENT-related symptoms such as a sore throat, a hoarse voice or otalgia. The nodes may have a firm or hard consistency. The patient may have a history of smoking.

Investigations

These may include FNAC , ENT examination looking for ENT primary carcinoma, a CT or MRI scan of the neck, a CT scan of the chest and/or CXR (metatases), a liver USS (metatases), a panendoscopy and biopsy.
Where no ENT primary is seen on examination, a rigorous search should be done for a silent tumor. This will usually involve imaging as above with ipsilateral tonsillectomy, biopsy of the tongue base, post nasal space and piriform fossa as a minimum.

Treatment

This depends on the stage, the size and the site of the primary. Options for treatment include:
Radiotherapy: this involves 4-6 weeks of daily treatment with a total dose of 50-60Gy.

Radical neck dissection: this involves removing the affected nodes as well as all the other nodal groups and lymph-bearing structures on that side od the neck. This includes the lymph nodes at level 1, 2, 3, 4, and 5, the internal jugular vein (IJV), the Sternomastoid and the accessory nerve.

Modified radical neck dissection: this takes all the nodal levels (1, 2, 3, 4, 5) but preserves one or all of the IJV, the sternomastoid and the accessory nerve.

Selective neck dissection: Instead of all the nodal groups being removed, those groups thought to be at most risk are selectively dissected and removed. All other structures are preserved.

N staging of the neck

N1 - a single node< 3cm
N2a - a single node>3cm but <6cm
N2b - >1 ipsilateral node <6cm
N2c - Bilateral or contralateral nodes <6cm
N3 - Any node >6cm

Neck Condition (Lymph node enlargement)

2007-03-30T22:27:00.000-07:00

What is lymph node enlargement?

-The majority of neck nodes in children are benign
-The majority of neck nodes in adults are malignant
-Neck nodes may be involved secondarily in an infection of any part of the ENT system.

Infective lymphadenopathy
This secondary lymphadenopathy is extremely common in children. An example is jugulo-digastric node enlargement during or following tonsillitis. A single node or a group of nodes may be enlarged. There may be tenderness and symptoms related to the primary infection.

Specific infections presenting with lymph node enlargement (priamary lymphadenopathy) include:
- Glandular fever
- TB
- Toxoplasmosis
- Brucellosis
- Cat- scratch fever
- HIV
The diagnosis in these cases will often be made following the appropriate screening blood test and CXR. FNAC and even excision biopsy may be needed to exclude malignancy

Neck Condition (Neck infections)

2007-03-09T06:12:00.001-08:00

Parapharyngeal abscess

This is a deep seated infection of the parapharyngeal space. It often results from a primary infection in the tonsil or is an extension from a parapharyngel abscess (or quinsy). It is more common in children than in adult.

Signs and symptoms

Include pyrexia, neck swelling deep to sternomastoid muscle and a patient who seems unwell. There may be trismus, or a reduced range of neck movements. The tonsil and the lateral pharyngeal wall may be pushed medially. Airway compromise is a late and ominous sign.
If the diagnosis is in doubt, a CT scan will often distinguish between lymphadenitis and an abscess.

Treatment

This will involve a high dose of IV broadspectrum antibiotics (Augmentin), in addition to surgical drainage via a lateral neck approach.

Retropharyngeal abscess

This is a very rare infection of the retropharyngeal space. It is much more common in children and infants than in adults.

Signs and symptoms

An unwell patient, with pyrexia, often with preceding URTI or swallowing difficulty. There may be shortness of breath or stridor, or torticollis-due to prevertebral muscle irritation.

Treatment

A high dose of IV broad spectrum antibiotics (Augmentin). Where necessary the airway will be secured and surgical incision and drainage may be performed via the mouth.

Lugwig's angina

This is a rare infection of the submandibular space, it usually occurs as a result of dental infection. It is more common in adults than in children.

Signs and symptoms

These include pyrexia, drooling, trismus, airway compromise due to backward displacement of the tongue. There may be firm thickening of the tissues of the floor of mouth-best appreciated on bi-manual palpation.

Treatment

High doses of IV broad spectrum antibiotics (Augmentin). Secure the airway (try a naso-pharyngeal airway first since this will often suffice, but were necessary consider a tracheostomy). Surgical incision is often unsatisfying since little pus may drain away.

Skull Base Condition (Sinonasal malignancy)

2007-02-11T01:00:00.000-08:00

What is Sinonasal malignancy?

This term describes a diverse group of malignant tumours affecting the nose and sinus system. SCC account for 70% of sinonasal malignancy, adenocarcinoma 10% and adenoid cystic carcinoma 10%.
Nickel workers are at risk of developing SCC, woodworkers are at risk of adenocarcinoma. This is often delayed up to 20 years after exposure. The prognosis is poor with less than 50% of patients surviving for 5 years.

Common sites for sinonasal malignancy are:
-Maxillary sinus
-Nasal cavity
-Ethmoid sinus

Presentation
Some or all of the following features may be seen:
-Nasal obstruction
-Epistaxis
-Sinusitis
-Maxillary symptoms
-Loose teeth
-Ulcer on palate
-Cheek swelling
-Ethmoid symptoms
-Unilateral obstruction
-Diplopia
-Headache.

Investigations
-CT and/or MRI
-Endoscopy and biopsy
-FNA if cervical metastases

Treatment
Surgical resection and/or radiotherapy may be required. Treatment decisions should be made by an MDT in a specialist head and neck clinic taking into account the type of tumour and the staging.

TNM Staging of sinonasal malignancy
Maxillary sinus
-T1-Tumour limited to antral mucosa.
-T2-Tumour causing erosion or destruction into hard plate/lateral nasal wall.
-T3-Tumour eroding posterior wall/subcutaneous/cheek/medial orbit
-T4-Intracranial extension/orbital apex/skin of nose.

Ethmoid sinus
-T1-Confined to ethmoid
-T2-Extends to nasal cavity
-T3-Extemds to anterior orbit/maxillary sinus.
-T4-Intracranial extension

Skull Base Condition (Juvenile Angiofibroma)

2007-01-19T06:51:00.000-08:00

What is Juvenile Angiofibroma?

This is a rare tumour almost exclusively seen in males. (If the patient is female consider chromosomal analysis.) It originates from the sphenopalatine foramen and is locally invasive but not malignant. It is a combination of fibrous tissue with endothelial spaces in vascular tissue.

Presentation
->Recurrent epistaxis in young male (average age 14)
->Large posterior nasal mass
->Pulsatile mass palpated prior to adenoidectomy
->Nasal obstruction

Investigations
->Clinical examination with endoscope
->CT scan and MRI
->Angiography
->Do not do a biopsy for fear of life threatening haemorrhage

Management

The treatment is surgical removal, with pre-operative embolisation to reduce the blood loss during the operation. There are several ways to gain accessto the area, but the most common is via the midface in an operation called midfacial degloving.

Skull Base Condition (Nasopharyngeal Carcinoma(NPC))

2007-01-06T01:44:00.000-08:00

What is Nasopharyngeal Carcinoma?

There are two distinct types of this types of this cancer of the back of the nose:
->Undiffenrentiated non-keratinizing squamous cell carcinoma (SCC)- this is more common in
people from Southern China and Chinese people from Hong Kong. It is associated with EBV.
->Differentiated keratinizing SCC- this has similar at risk groups to the majority of head and
neck cancers.

Presentation
->Epistaxis
->Nasal obstruction
->Lymph node metastasis
->Middle ear effusion
->Extensive tumours can involve the skull base and cause cranial nerve palsies.

Investigations
Patients will be given a CT and/or an MRI scan

--*Important*--
Every patient presenting with a unilateral middle ear effusion must have their postnasal space visualized to exclude an NPC.

Treatment
Radiotherapy is given for all stages. Neck dissection may be necessary if there are extensive lymph node metastases.

Skull Base Condition (Acoustic Neuroma)

2006-12-23T07:20:00.000-08:00

What is Acoustic Neuroma?

An acoustic neuroma is a benign, slow growing tumour. It is more correctly called the vestibular schwannoma, because of its origin on the vestibular nerve. Post mortem data shows that this tumour is under-diagnosed. An acoustic neuroma may be an incidental finding on MRI.
Acoustic neuromas account for 6% of all intracranial neoplasms, the majority of which are sporadic (95%). 5% are genetic-part of the inherited condition of NF2 (neurofibromatosis type 2) on chromosome 22.

Presentation

The patient may experience some of the following:
-Sudden SNHL or progressive high frequency SNHL
-Vertiginous episodes-but these are rare as the patient unknowingly compensates.
-Symptoms of raised intracranial pressure such as headache or visual disturbance.
-Brainstem compression-ataxia is a late symptom of this.

Investigations

-PTA.
-MRI scan with gadolinium contrast.
-Full otoneurological exam.
-Hitselbergers sign-postauricular numbness due to facial nerve compression.
-Reduced corneal reflex.
-Unterberger's test positive-patient marches on the spot with the eyes closed. A positive test is a rotation to one side or the other.

Management

Management options balance the risk of hearing loss, facial nerve palsy and surgical morbidity. There are several possibilities:
-Watchful waiting-with serial MRI scans for slow growing tumours.
-Retrosigmoid approach-preserves the hearing
-Translabyrnthine approach-destroys the hearing but is an easier approach. It is useful if there is little hearing to preserve.
-Middle fossa approach-is technically challenging as it involves opening the middle fossa. No driving for one year due to the risk of fitting.
-Intracapsular removal-useful to decompress large rumours in elderly patients with brainstem compression.
-Stereotactic radiosurgery-this multiplanar radiotherapy is useful in small tumours as it avoids surgery.

Complications

-Any intracranial procedure e.g. craniotomy-carries a 1% risk of mortality.
-Facial nerve palsy
-Total hearing loss

Complications of ear surgery

2006-12-13T20:54:00.000-08:00

There are risks with all surgical procedures. The degree of risk is related to both the specific procedure and to the underlying pathology. The patient should be given an indication of the likely risk in a sensitive way, so that they are not frightened into abandoning surgery.
A full explanation of the underlying condition will highlight the risks of leaving an ear disease untreated. Risks should be documented in the case notes and on the consent form.
The list of complications for CSOM is similar to that of the operation-the untreated disease carries similar risks as the operation.

These are:
-Hearing loss-temporary and permanent. Always obtain an audiogram at least within 3 months
of surgery, but preferably nearer to surgery and perform pre-op tuning fork tests and
document your findings
-Tinnitus-temporary and permanent.
-Vertigo and unsteadiness-temporary and permanent
-Facial nerve palsy-temporary and permanent
-Wound infection
-Need for further surgery
-Formation of mastoid cavity
-Need for ongoing care e.g. aural toilet for mastoid cavities

Inter-operative considerations
These can be avoided by taking precautions, e.g. always setting up and checking items such as facial nerve monitors yourself. The precaution undertaken in theatre, such as the use of a facial nerve monitor, should be recorded on the operation note. An inter-operative unusual finding or complications shold be witnessed and recorded by a senior colleague if available.

Immediate post-operative period
Check for facial nerve palsy in recovery.

Post-operative ward review
Facial nerve function should be checked, along with the eye movements for nystagmus. Webber's tuning fork test should be done. The patient should localise to the operated ear.

Inner Ear Condition (Benign Paroxysmal Positional Vertigo(BPPV))

2006-12-04T01:54:00.000-08:00

What is Benign Paroxysmal Positional Vertigo?

BPPV is the most common cause of vertigo (80%) in patients who present in a dizzy clinic. Its pathogenesis is the displacement of otoliths from the macula of the utricle. Otoliths are calcium cabonate-containing particles that that migrate by the force of gravity towards the semicircular canals depending on the head position of the patient. The most common semicircular involved is the posterior one (95%). The aetiology can be idiopathic (50%), from infection (20%) and from head trauma (30%).

Symptoms and Signs

Typically, the patient complains of spinning vertigo when the head is placed in a particular position. Usually, this involves lying down, lifting the head looking upwards or bending down and looking upwards. The vertigo generally lasts 10 to 30 seconds. It becomes less intense with repeated manoeuvres (fatiguability). Hearing is not affected. The condition is self-limiting and resolves spontaneously in the majority of patients over a few weeks to months but can persist up to two years. It can recur, especially in the elderly.
The pathognomonic sign is seen on the Dix-Hallpike manoeuvre. This involves placing the supine patient on a couch and tilting the head backwards over the edge of the couch such that the neck is extended 30 degrees and rotated 45 degrees to one side. In this position, the ampulla of the posterior semicircular canal, which contains the end organ, is most dependent. When positive, nystagmus will be noted after a latency period of a few seconds. The nystagmus will last for up to 30 seconds and will become less noticeable with repeated manoeuvres. On sitting up, some patients demonstrate a reversal of nystagmus. This feature of reversal is not required to make the diagnosis.

Investigations

No investigations are essential but as this is an inner ear condition some routinely do an audiogram.

Management

Medications are of little benefit as the spells are episodic and short-lasting. As the condition is self-limiting, patients may experience total resolution of symptoms over time. However, in 1992, John Epley demonstrated the particle repositioning manoeuvre (PRM) which aims at returning the displaced otoliths to the utricle. The success rate is quoted at 80% after one treatment and up to 95% after repeated manoeuvres.
If conservation methods fail, occlusion of the posterior canal can be performed via a transmastoid approach with good success. It comes with a 4 to 5% risk of hearing. Fortunately, with the high success rate of PRM, surgery is rarely performed nowadays.

Inner Ear Condition (Meniere's Disease)

2006-11-21T03:12:00.000-08:00

What is Meniere's Disease?

In 1861, Prosper Meniere identified the inner ear as the source of the triad of symptoms that now bears his name. Although much research has been done to elucidate the aetiology of this condition, it has resulted in little new understanding and generated much controversy. Many theories have been postulated, including viral, autoimmune and allergy. The histopathophysiology of this condition shows a swelling of the endolymphatic compartment within the inner ear and is termed endolymphatic hydrops. The pathogenesis is unknown and could be either overproduction or reduced absorption of endolymph.

Clinical Symptoms

The classic triad of Meniere's Disease is vertiginous (spinning) dizziness, tinnitus and deafness. The majority of patients suffer unilateral disease although some studies report that in up to 35% of patients the second ear becomes involved.
Vertigo--the patient experiences sudden onset of spinning lasting from 20 minutes to 24 hours. This is incapacitating and is associated with nausea and vomiting. The patient prefers to lie down with eyes closed, keeping the head still. Some patients experience a prodrome of ear fullness or tinnitus before the spell starts. Most patients are perfectly well between attacks
Hearing loss--in the early stages, the hearing loss is mainly in the low frequencies and fluctuates (returning to normal between attacks of dizziness). As the disease progresses, all thresholds become involved and the deafness can become severe to profound in the late stages.
Tinnitus--a symptom accompanying the hearing loss which varies in intensity but tends to increase as the hearing deteriorates.
Tumarkin Crisis--a very rare condition where the patient falls spontaneously to the ground without vertigo, hearing loss, tinnitus, nausea and vomiting. Some have described it as a push to the ground. Unless there is injury, the patient is able to resume the previous activity. This crisis is thought to be a sudden, undefined change in the otolithic organs. If patients suffer from this condition, they should not be allowed to drive.
The clinical course of Meniere's disease is unpredictable, with periods of activity separated by periods of quiescence. During the active times there may be frequent attacks which can suddenly settle. The vertiginous spells tend eventually to become less frequent and intense as the condition 'burns' itself out over 10 to 20 years. In the late stages, the hearing loss and tinnitus can be severe.

Investigations

An audiogram will reveal the nature of any hearing loss. In the early stages, a mild low-tone sensorineural deafness may be seen which may fluctuate with thresholds returning to normal when the patient is asymptomatic.
Electronystagmography (ENG) is sometimes performed to confirm the level of function of the diseased ear. In about 50% of patients, a caloric weakness is found confirming a hypofunctioning labyrinth in the suspected ear.

Imaging

All patients with Meniere's disease should have an MRI done to exclude on acoustic nerve tumour.

Management

Acute attacks

The acute attack is best managed by giving the patient bed rest. The only medication that is required at this time is a labyrinthine sedative drug. Many of these patients will vomit and therefore the drug is usually more effective if given intramuscularly or rectally. Stemetil (prochlorperazine) is probably the most useful drug as it has the additional benefit of being an anxiolytic agent.

Prevention of attacks

The long-term management of Meniere's disease is fraught with controversy. Many claims have been made for various regimes but none has been shown to influence the course of the condition in a long-term controlled trial. Vasodilators (betahistine 8 mg tds), oxygen-carrying molecules (Duxaril 1 tab bd), diuretics (hydrochlorthiazide 50 mg OM), sedatives (valium 2 mg tds) are some examples in the literature.
Patients should also be advised to reduce salt and caffeine intake. Stress management should be advocated if possible.

Surgical Treatment

Surgery is indicated only very rarely in Meniere's disease and also tends to be surrounded by controversy. The only indication is to control the attacks of dizziness when they have become incapacitating. All surgical procedures carry some risk to the hearing but they are subdivided into those aimed at perserving hearing and those where the hearing is deliberately sacrificed.

Inner Ear Conditions (Sudden Onset Sensorineural Hearing Loss)

2006-11-14T06:57:00.000-08:00

What is Sudden Onset Sensorineural Hearing Loss?

Sudden onset sensorineural hearing loss (SSNHL) is defined as loss of hearing of more than 30 dB over three contiguous frequencies within three days. The pathogenesis is thought to be viral in origin. The incidence is reported to be about 20 per 100000 population, more common with increasing age. The natural history of the condition is for 65 to 70% of patients to recover a significant degree of their hearing. SSNHL is thought to be the result of a viral infection (of cochlea or VII nerve), vascular problems (ischaemia or occlusion) or inner ear membrane rupture. This condition should be considered an emergency and the patient should be referred immediately.

Symptoms and Signs

Typically, patients present with a unilateral hearing loss over 24 to 48 hours. Commonly, there is no preceding or predisposing factor. A proportion will give a history of an upper respiratory tract infection. The degree of hearing loss can range from mild to profound. About 70 to 75% will complain of associated tinnitus and 50% will have concomitant vertigo.
The ear examination is likely to be normal. Tuning fork test will reveal sensorineural hearing loss in the affected ear. The Weber test will show lateralisation to the normal ear. The Rinne test can reveal bone conduction (due to cross-over hearing from the other ear) that is better than air conduction.

Investigations

An audiogram should be performed to confirm the diagnosis and determine the severity and shape of the deafness. Many authors have suggested that the following blood tests be performed in idiopathic SSNHL:
FTA-Abs, ANA, Rheumatoid factor, Autoimmune screen, ESR, Coagulation profile, Full Blood Count (FBC), TSH, Fasting Glucose, Cholesterol and Triglycerides.
However, it is uncommon for any of these tests to reveal the cause of hearing loss.
An MRI to exclude acoustic neuroma can be performed if no recovery of hearing thresholds is seen after six months.

Management

This condition should be treated as a semi-emergency. An audiogram should be performed within the first 48 hours. Many medications have been used but there are no adequate randomised controlled trials to substantiate any treatment except possibly for the use of steroids (Prednisolone 1mg/kg/day for 10 days). Preferably, steroid therapy should be instituted as soon as possible from the onset of hearing loss (patients with mild hearing loss are likely to recover without medication, those with severe hearing loss are unlikely to recover despite treatment). Significant poor prognostic factors include age (less than 15 years, more than 65 years, poorer prognosis) and the presence of vertigo. Good prognostic factors include early commencement of treatment and low-frequency hearing loss.
Surgery is indicated only when a perilymph fistula is suspected.

Middle Ear Conditions (Atticoantral disease)

2006-11-13T06:44:00.000-08:00

What is Atticoantral Disease?

This form involves the attic (or epitympanum) of the middle ear and the antrum of the mastoid air cell system and is usually associated with a cholesteatoma. There are many theories of the pathophysiology but the most favoured one is the Theory of Negative Pressure. This purports that chronic negative pressure in the middle ear space results in retraction of the tympanic membrane. The cause of chronic negative pressure is usually some form of Eustachian tube dysfunction. The part of the tympanic membrane that first retracts is the pars flaccida, situated superiorly. Initiall, the retraction pocket is shallow and remains a self-cleaning pocket. As the pocket deepens, squames, debris and wax become trapped and a cholesteatoma forms. This is another term for atticoantral disease. Cholesteatoma is the presence of squamous epithelium in the middle/inner ear with erosive change. The pocket generally progresses posteriorly to the antrum but can also involve the Eustachian tube anteriorly and hypotympanum inferiorly. As it enlarges, it erodes surrounding structures through a combination of pressure and enzymatic erosion. This makes the condition potentially dangerous.

Symptoms and Signs

Like tubotympanic disease, the most common symptons are discharge and deafness. The discharge is foul-smelling as a result of the nature of the infecting organisms and dead skin trapped in the ear. Hearing loss is conductive in nature. Pain is not a distinct feature of this condition.

Investigation

An audiogram is performed to determine the nature of the hearing loss. As all patients are recommended surgical intervention, a CT scan of the temporal bone is ordered for two main reasons. One is to assess the anatomy of the temporal bone prior to surgery and the other is to exclude complications that may exist but are not clinically obvious prior to surgery.

Management

All patients with cholesteatoma are recommended surgery to remove the disease. This is because if the disease is allowed to progress, complications can occur. Surgery is aimed at excising the cholesteatoma and exteriorising the mastoid cavity so that it cannot recur. There are many ways of dealing with the disease that are beyond the scope of this chapter.

Complications

Most of the complications from CSOM result from atticoantral disease. They can be divided broadly into two classes-Extracranial and Intracranial complications.

(A) Extracranial

a. The most common extracranial complication is ossicular chain disruption. The most common site affected is the joint between the incus and stapes bones.

b. Labyrinthine fistula-the lateral semicircular canal makes an impression on the antrum on its medial wall. Like other proccesses, the bone over it can be eroded resulting in exposure of the lateral semicircular canal to the antrum. When this happens, a fistula is created. Patients will experience vertigo on straining and pressure on the ear canal. If allowed to progress, sensorineural hearing loss can result.

c. Cholesteatoma can erode the facial nerve canal resulting in facial palsy. Most commonly, the tympanic portion is affected.

d. Lateral Sinus Thrombosis-The lateral sinus is a venous structure that is situated posteriorly to the mastoid cavity. The bone over the sinus can be eroded and the sinus can be infected resulting in thrombus formation.

(B) Intracranial

The bone separating the middle ear and mastoid cavity from the intracranial cavity is called the tegmen. This thin plate of bone can be eroded and infected from the temporal bone can spread to the intracranial cavity resulting in extradural abscess, subdural abscess, meningitis, encephalitis and cerebral absesses. The most commonly affected areas are the temporal lobes and the cerebellum. With improving standards of medical care and better imaging techniques, these complications have become fairly uncommon.

*ALL THE INFORMATIONS REGARDING THE EAR CONDITIONS ARE PROVIDED BY DR GERARD CHEE HSIEN. copyright reserved.

Middle Ear Conditions (Chronic Suppurative Otitis Media(CSOM))

2006-11-09T06:36:00.000-08:00

As the name suggests this condition should have symptoms lasting more than three months, be the result of infection and involve the middle ear cleft. There are two types of CSOM, namely tubotympanic and atticoantral.

What is Tubotympanic Disease?

This type involve the Eustachian tube (tubo-) and the tympanum (middle ear). The classical feature is a central perforation of the tympanic membrane. In general, perforations secondary to ASOM heal spontaneously, but when the acute infection is inadequately treated or if chronic infection sets in, then the perforation may not heal, resulting in a chronic perforation, and hence the name. The bacteria found include Pseudomonas, beta- haemolytic Streptococcus and Haemophilus influenzae.

Symptoms and Signs

The most common symptoms are ear discharge and deafness. Pain is uncommon although itchiness can occur due to secondary external otitis. The discharge is usually odourless and mucoid in nature. Tuning fork tests will point to a conductive hearing loss in the affected ear.

Investigation

Culture and sensitivity of the discharge is taken in cases where treatment is resistant or protracted. An audiogram is always performed prior to any surgical intervention.

Management

Concurrent infection is best treated with combined steroid and antibiotic ear drops (Framycetin, Ciprofloxacin HC, Ofloxacin). Once the infection has settled down for at least one month, surgical closure of the perforation under GA is advised. It is important to be aware of the risks of inner ear damage resulting from the use of aminoglycoside antibiotic ear drops in the presence a perforation and prolonged use is hazardous.

Complications

This form of CSOM is generally not associated with long-term complications. The most common complication is disruption of the ossicular chain which can be repaired during surgical closure of the perforation.

Middle Ear Conditions (Acute Suppurative Otitis Media (ASOM))

2006-11-06T07:22:00.000-08:00

What is Acute Suppurative Otitis Media?

ASOM is an infection of the middle ear space. Children are more commonly affected although adults are susceptible. The pathophysiology of ASOM is typically an ascending infections from the nasopharynx up the Eustachian tube to the middle ear. The primary infection can take the form of a viral upper respiratory tract infection (URTI), an acute sinusitis or a lower respiratory tract infection. The purported reasons why children are most susceptible include ineffective Eustachian tube function, chronic adenoidal infection and frequent URTI as a result of schooling. The pathogens include Haemophilus influenzae, Beta-haemolytic Streptococcus and Moxarella catarrhalis.

Symptoms and Signs

In the early stages, there will be some discomfort, sensation of blockage and deafness. As the condition progresses, otalgia becomes the principal complaint, associated with fever and toxicity. There is usually a history of preceding URTI.
On examination, the patient will look ill, with a fever of more than 38 Celsius. The appearance of the eardrum differs during the stages of ASOM. In the first 48 hours, the eardrum is erythematous with some retraction. From two to seven days, there will be accumulation of pus and a bulging tympanic membrane, with pus clearly seen in the middle ear. From then on, as te conditions resolves, the eardrum appears more opaque and less erythematous and bulging.

Investigations

In an acute infection, no investigations are generally warranted. If the infection ruptures the eardrum, a culture and sensitivity of the discharge can be taken.

Management

The management of ASOM is mainly conservative. Pain relief and antipyretics (paracetamol, codeine) are usually required. Antibiotics (Augmentin, Klacid) are generally prescribed although some studies have questioned their efficacy. The symptoms and signs should resolve over three to five days after commencement of treatment. If the symptoms are present after one week, or worsen, a myringotomy should be performed and drainage established.

Complications

Complications from ASOM are uncommon with prompt and effective treatment. The most common complication is perforation of the tympanic membrane resulting in ear discharge and relief of pain. Infection can also spread medially to the inner ear, causing labyrinthitis with deafness and vertigo. It can also spread posteriorly, resulting in an acute mastoiditis with postauricular swelling and pain. Meningitis and facial paralysis are very rare complications.

External Ear Conditions (Malignant Otitis Externa (MOE))

2006-11-03T22:07:00.000-08:00

What is Malignant Otitis Externa?

The organism involved in MOE is invariably Pseudomonas aeruginosa. It is a condition that occurs primarily in diabetics who are generally elderly. The Pseudomonas subtype involved produces an exotoxin which in an immunocompromised environment allows the external ear infection to extend beyond the soft tissue confines of the external ear. Hence, the bony external ear becomes infected (osteomyelitis). If left unchecked, the infection spreads into the skull base and its soft tissues. At thia stage, the condition will progress rapidly towards the midline and involve the lower cranial nerves, brainstem, and ultimately result in death.

Clinical Features

The most notable feature is excessive pain in the presence of mild to moderate signs. The pain can interfere with sleep and the ability to function. The patients can look unwell or even toxic. Otorrhoea is usually scant and hearing is at mostly mildly affected. On examination, there is granulation tissue, usually at the bony-cartilaginous junction, scant discharge and an intact eardrum. The lower cranial nerves can be affected. The most common is the facial nerve. Hence, an external ear infection with an ipsilateral facial palsy implies malignant otitis externa.

Investigations

Investigation for MOE are aimed at confirming the diagnosis and determining the extent of disease. Culture and sensitivity and biopsy of granulations are taken. A CT scan of the temporal bone is performed to determined the extend of bony destructon. An MRI scan is crucial in revealing the extent of soft tissue involvement and helpful in differentiating between inflammaton and tumour, e.g. nasopharyngeal cancer. Serial MRIs are done to assess the efficacy of treatment. Occasionally, a bone scan (Gallium) is done. This will reveal hyperintensity of the infected area if osteomyelitis is present.

Management

All patients with suspectedof confirmed MOE are admitted. The aim is to start intensive pharmacological therapy, monitor progression (or resolution) and control predisposing conditions (e.g. diabetes). An anti-pseudomonal antibiotic (Ciprofloxacin, Ceftazidine) is started intravenously for a minimum of eight weeks. Whether combination therapy improves outcome is still a subject of debate. Pain relief and control of diabetes mellitus is also important. The external ear canal is cleared regularly using microsuction. Surgical intervention is limited to clearance of sequestra within the external ear canal and facial nerve decompression when indicated.
*Note: The importance of early diagnosis in patients with MOE cannot be over-emphasised. The early institution of treatment leads to reduced morbidity and mortality. When in doubt, refer patients

*ALL THE INFORMATION REGARDING THE EAR CONDITIONS ARE PROVIDED BY DR GERARD CHEE HSIEN. copyright reserved.

External Ear Conditions (Furunculosis)

2006-11-01T05:22:00.000-08:00

What is Furunculosis?

The pathology of furunculosis is an infection of a hair follicle. The causative organism is Staphylococcus aureus.

Clinical Features

The main symptoms is otalgia. Generally there is no otorrhoea or deafness. The patient will complain of pain on tugging the pinna and compression of the tragus. On examination, there is localized swelling with surrounding erythema in the hair-bearing area of the external ear canal.

Management

If the furuncle is not pointing, an antibiotic impregnated wick can be inserted into the canal over the furuncle for about three to five days. If it is pointing , an incision and drainage can be performed in the clinic. A course of antibiotics (Cloxacillin 250 mg qds for one week) can be prescribed. Analgesics will be required for the pain.

External Ear Conditions (Diffuse External Otitis)

2006-10-30T06:36:00.000-08:00

What is Diffuse External Otitis?

An infection of the external ear canal is a very common condition. The most common causes include trauma, such as from digging and scratching; swimming (also known as Swimmer's ear); and overuse of antibiotic eardrops. Patients suffering from eczema of the external ear canal are predisposed to infection, usually as a result of hypersensitivity and trauma. The pathogens involved include bacteria such as Pseudomonas aeruginosa and Staphylococcus aureus and fungi such as Aspergillus niger and Candida albicans.

Clinical Features

The patient's main complaints include otalgia (pain), otorrhoea (discharge) and deafness. Acute infections that do not settle within three weeks are then considered to be chronic. When examining the ear, the canal is swollen and filled with debris and discharge (greenish suggests Pseudomonas, creamy suggsts fungal). The tympanic membrane may not be visible but is usually intact although it may be swollen with granulations (granular myringitis).

Investigation

Generally, investigations are not warrented in a simple acute infection. If the condition becomes protracted with little improvement, the discharge should be cultured and sensitivities determined. Rarely is it necessary to biopsy granulation tissue to exclude more sinister conditions.

Management

The key to sucess in managing external ear conditions is regular and meticulous aural toilet. The best method for this is microsuction. If the canal is very swollen, a pope wick is inserted to hasten recovery. Once the ear canal is cleaned, antibacterial or antifungal ear drops should be prescribed, ideally with the addition of a steroid (e.g. Sofradex 5 drops tds for 10 days, or Canesten 5 drops tds for 10 days). Patients should be advised not to swim during the treatment period and to avoid water entering the ear canal during bath time. I recommend using some cotton wool mixed with hand lotion as an earplug during baths. Patients should be reviewed at two-week intervals, and more often for severe infections. Education is also important in preventing future episodes.

External Ear Conditions (Wax)

2006-10-28T08:02:00.000-07:00

Introduction

A famous otologist in the mid-nineteenth century classified all cases of deafness into two categories: that due to wax, which could be cured; and all the others which were incurable. Happily, we have come a long way since then, but removal of occluding wax from the ear canal can still be a very rewarding procedure.

What is Wax?

Wax is produced only in the outer half of the meatus and normally it migrates out of the ear along with the desquamating cells of the canal skin. However those who 'dig at' their ears tend to push it back in again until either the build up occludes the canal, or almost occluded canal becomes completely occluded when water, or ear drops, complete the closure. It is only when the canal is completely occluded that wax causes significant hearing loss, which can be very disturbing.

Management

The treatment is removal of the wax and usually this can be done by simple syringing, so long as there are no contraindications such as a known pre-existing perforation. This is best carried out by using water at body temperature, directing the flow along the posterior canal wall, not directly at the ear drum, and ensuring that the water pressure is not dangerously high. This procedure usually produces an immediately grateful patient.
If syringing is unsuccessful or if there is a pre-existing perforation, manual removal is requried. This is best done by visualization under a microscope and extration of the wax either with a hook or, if the wax is soft, a sucker.
It has to be acknowledged that many doctors use ear drops to soften wax or partially dissolve it before either syringing or manually removing it. In actual fact, this is almost never necessary.

Complications

Careless syringing or inexperienced probing of the ear canal can cause innumerable problems, ranging from a simple perforation to a dead ear. Most of these can be avoided. It is important to be aware of the dangers from the patient moving the head at an inappropriate time.

External Ear Conditions (Keloid)

2006-10-27T08:50:00.000-07:00

What is Keloid?

Keloids are overgrowth of fibrous or scar tissue resulting from trauma. They are raised and reddish and are the result of excessive activity of fibroblasts after injury. In general, the darker skinned races are genetically predisposed to the development of keloids.

Symptoms and Signs

Patients will present with painless raised nodules over an injury site, usually a pierced ear hole. The keloid can be itchy and bleed and may become pigmented.

Management

The effective treatment is a topic of controversy. Many modalities have been employed and include excision, steriod injection, cryosurgery, laser surgery and radiation therapy. I have found it most effective to excise the keloid with a cold knife and inject the wound with steriods every few weeks for up to six months post-excision.

External Ear Conditions (Pinna Haematoma)

2006-10-27T08:27:00.000-07:00

What is Pinna Haematoma?

Pinna haematoma is a collection of blood between the cartilage and the covering perichondrium. Trauma is the usual cause. Contact sports such as boxing, rugby and soccer are commonly associated with this condition.

Symptoms and Signs

There is swelling of the ventral aspect of the pinna, generally located at the superior part although any portion can be involved. Unless very tense, the swelling is not very tender or warm to the touch.

Management

The principle in the treatment is to remove blood collection. This can be done either by aspiration or incision and drainage. The latter is more commonly employed as it gives better results although the former is easily performed in a clinic setting. Once teh blood has been evacuated, firm dressing or sutures are used to keep the skin and perichondrium in contact with the cartilage. This is important to prevent re-accumulation of blood. Unless infected, antibiotics need not be prescribed.

Complications

"Cauliflower ear" results from secondary organization of a residual blood clot or devascularization of cartilage and can be cosmetically deforming.

External Ear Conditions (Perichondritis)

2006-10-27T02:04:00.000-07:00

What is Perichondritis?

Perichondritis is an infection involving the lining (perichondrium) of the cartilage of the pinna. Common causes include injury, insect bites, pierced ears and burns. These infections are more common in patients with diabetes mellitus and weakened immune systems. The most common organism is Pseudomonas aeruginosa although Staphylococcus aureus sometimes can be found. The condition results in inflammation and swelling of the perichondrium.

Symptoms and Signs

Pain, warmth and swelling are the usual complaints. The swelling and erythema are generally limited to the cartilaginous portion of the pinna, leaving the lobule untouched. The pinna is tense, warm and tender to touch. Generally, there is no fluctuation. The cause can sometimes be seen in the form of a puncture wound or burn.

Management

In the early stages, oral antibiotics may suffice. Ciprofloxacin 250 mg bd for 10 days can be prescribed in addition to medication for pain relief. For more severe infections, itravenous antibiotics may be required. Occasionally, the infection is complicated by a collection of pus between the cartilage and the perichondrium (subperichondrial abscess) which requires surgical drainage.

Complications

The cartilage of the pinna derives its nutrients from its perichondrium. When the perichondrium is infected or, worse, separated from the cartilage by pus, the cartilage begins to degenerate. If this process is allowed to progress, the cartilage may shrivel and die, resulting in a "cauliflower ear".