What to do for the best? Doctors are called on to make decisions about every patient they m eet: few are curable at once, so making a plan for what to do for the best is the secret of success at the bedside. The aim here is to explain this secret, to enable you to \202 ou rish in the clinical world, and to keep you out of lawyers \200\231 offi ces. 532 Let us look at the steps of the history, physical, or mental examination, and investigations. By the end of taking the history, you need to have acquired 3 things: 1 Rap port with the patient. 2 A diagnosis or diff erential diagnosis. 3 The placement of the dia gnosis in the context of the patient \200\231s life. Rapport: Consultations are shorter whe n rapport is good. 295(N=116) The patient is con \201 dent that he or she is getting the f ull attention of the doctor, and these patients are more understanding, and more forgiving when things go wrong. Doctors are far from infallible, so we need to have con \201 dence t hat the patient will feel able to come back if things are not right, tell us what has happe ned, agree on an adjustment of the treatment, and, by giving feedback, improve our clinical acumen. Diagnosis: Studies have shown that skilled physicians have made a provision- al di agnosis soon after the consultation starts, and they spend the rest of the history in con \201 rming or excluding it. What happens if you are not skilled, and you have no hint as to the diagnosis? You need to get more information. \200 Pursue the main symptom: \200\234 tell me more about the headache \200 \200\235 \200 Elicit other symptoms \200\224eg chan ge of weight or appetite, fevers, fatigue, un- e r a c y r a m i r P explained lumps, itching, jaundice, or anything else odd? Get help from a colleague or even a diagnostic system \200\224eg Mentor, p502. \200 Check you still have rapport with the patient. Are you searching for a physi- cal diagnosis when a psychological diagnosis would be more appropriate? Here you might ask questions such as \200\234How is your mood? \200\235 \200\234What would your wife or partner say is wrong? \200\235 \200\234Would they say you are depressed? \200\235 \200\234What would have to ch ange for you to feel better? \200\235. \200\207Do not proceed to the physical examination until you have a working diagno- sis: the answer is rarely found there (<10%). Placing the diagnosis in the context of the patient \200\231s life: If you do not do this, you will not know what will count as a cure, and, more speci \201 cally, dif- ferent patients need dif f erent treatments \200\224see p241. Some factors to focus on might be: the motivation of t he patient to get better ( \200\234I \200\231ve got to get my knee better so that I stay st rong enough to lift my wife onto the commode \200\235); their general health; social situat ion; drugs (not forgetting nicotine and alcohol); is help available at home; work (yes/no; type)? At the end of the history, occasionally there is enough information to start treatment. Usu ally you may be only, say, 70% sure of the diagnosis, and more information is needed before treatment is commenced. Fig 1. It is time for the physical examination. This aims to gain evidence to con \201 rm or exclude the hypothesis, to de \201 ne the extent of some process, or to assess the prog ress of known disease. At each step, ask \200\234What do I need to know? \200\235 Followin g the examination the diagram may look like this: 533 Fig 2. Investigations If the action threshold has not been crossed, further informa- tion i s need. Action thresholds vary from doctor to doctor, and from disease to disease. When the treatment is dangerous, the action threshold will be high (eg leukemia). In self-limiting illnesses, eg pharyngitis, the action threshold will be lower. Note that \200\230action \200\231 may be that, in agreement with such a patient, only symptomatic treatment is neede d, and future episodes could be man- aged without medical input. e r a c y r a m i r P Similarly, it may be important to move the probability of a serious but un- likely disease beyond the exclusion threshold. Once the probability of a disease passes the action threshold, treatment can commence, if the patient wishes. Fig 3. Supposing neither the action threshold nor the exclusion threshold is exceed- ed, th en more information is needed, eg from pathology, imaging, or the pas- sage of time. Time i tself is an investigation: it may reveal sinister causes or the benign nature of the diseas e. To use time this way, you need to be reasonably sure that immediate treatment is not req uired. If there is still not enough certainty to initiate management, get further in- formation, e g from books, computers, colleagues, further tests \200\224or you may feel it appropriate t o refer the patient at this stage. Or go round the process again, starting with the history \200\224from a diff erent viewpoint. Once above the action threshold, it is time to decide what to do for the best. This is a de cision shared by the doctor and the patient. It entails informed consent and consideration of: 296 \200 The probability of the diagnosis. \200 The likelihood of the diff erent po ssible outcomes. \200 The costs and side-eff ects of treatment. \200 The hope and value s of those aff ected, particularly the patient. \200 What is possible, considering the sk ills, resources, and time available. Finally, tell your patient how they will know if they are on the path to improve- ment or relapse, and if so, at what point to seek help (critica l action threshold, below; record this in the notes) \200\224eg if your peak \202 ow fall s by 40%, start this prescription for prednisolone, and come and see me. Fig 4. 7 Ear, nose and throat diseases \200 Prevalence of ENT symptoms 536 ENT examination 536 The ear 538 Hearing tests audiology 540 \200\2231 Painful ears 542 Discharging ears 544 Fluid in the middle ear 546 Who to refer wi th glue ear? 547 Childhood deafness 548 Issues with cochlear implants 549 Deafness in adult s 550 Tinnitus 552 Acoustic neuroma 553 Dangers of excessive noise 553 Vertigo 554 Rhinosin usitis & Nasal polyps 556 \200\2237 The paranasal sinuses 558 Nasal injury & foreign bodies 560 Nosebleed (epistaxis) 562 Throa t infections 564 Tonsillar tumors 564 \200 Stridor 566 Hoarseness 568 Laryngeal nerve pals y 569 Head & neck cancers 570 Dysphagia 572 (OHCM p233) Facial palsy 574 Lumps in the neck 576 The salivary glands 578 Dry mouth (xerostomia) 579 Dentistry for doctors 580 Transmitter Receiver Oval window Vestibular apparatus Round window External ear Multiple electrodes Tympanic membrane Sound processor attached by magnet Cochlea z 3000 H Fig 1. An electrode from a cochlea implant is strug- gling to reach the core of the cochlea \200\231s spiral, but un- less it negotiates the ever tightening bends, lower tones (encod ed near its core) are unheard, and speech will be distorted. 1 \200\2233 Its spirals vary a mong mammals depending (per- haps!) on how much low-fre- quency sounds in their habi- tat m ost need ampli \201 cation via the whispering chamber eff ect ( \201 g 3, whereby sound t raveling along a curved wall in a big room remains strong enough to be well- heard on its o pp osite side). Hz 00 2 0 0 5 0 Fig 3. Why is the coch- lea \200\231s spiral (blue) dif- ferent to sim ple spirals based on Fib onacci se- quences (black)? Low-tone hearing rang- es from mice to whales in step with the pitch of the spiral; the tighter it is, the more sound en- ergy in low-frequency waves is forced against the cochlea \200\231s outer wall. Trials show that this \200\230whisper ing chamber eff ect \200\231 augmen t s low- freq uency sound by 20dB.5-7 0 H z Cochlea ( \201 g 2) is Latin for snail. Fig 2. Our cochlea is a tapering spiral tube with 2.5 turns. Some- times after an accident in the 7th embryonic week a child is born with only 1.5 turns (basal turn intact; Mondini \200\231s malformation). What is the result? No low-tone hearing. How is it di agnosed? Spi - ral CT, of course. 4 Ideally, read this chapter with a good supply of ENT patients, ENT teachers and audiologist s to hand. If una- vailable, guides to ENT examination are found at www.ispub.com/ostia/ind ex.php?xml \201 lepath=journals/ ijorl/current.xml. Free full text ENT journals/videos: ww w.entusa.com/qt_wmv1.htm. For those inspired to learn more, try www.bcm.edu/oto/othersa.htm l. We thank Mr Chris Potter FRCS, our ENT Reader. 535 Reissner \200\231s membrane \200 Stria vascularis Scala media Scala vestibuli s e s a e s i d T N E Basilar membrane Scala tympani Fig 1. A cross-section of the cochlea. The basilar membrane is stiff at the broad, outer en d and \202 exible the core, so diff erent fre- quencies peak at diff er- ent positions al ong it. Tectorial membrane towards Outer hair cells Rods of Corti Inner hair cell Nerve \201bres entering epithelium of organ of Corti Fig 2. Inside the spiral: the organ of Cor- ti. Hearing and balance rely on the abil- ity o f hair cells to sense tiny mechanical stimuli. Outer hair cells are actively mo- tile struc tures that feed energy into the vibration of the inner ear and enhance sensitivity to sound and movement. The sounds they produce are called otoacoustic emissions (OAE). Detecting OA E is a good test of a healthy inner ear. OAE are detected in neonatal screening tests.8 OAE and other hair cell functions are impaired by inner ear stressors, by various types of her editary deafness, syndromic hearing loss, 9 and inner ear disease (eg M ni re \200\231s d isease). OUP Active listening Within a few millisec- onds of hearing sounds that might be meaningful speech (vs the same sounds played in reverse) we send impulses to the cochlear via medial olivocochlear eff erents to improve perception of the speech-associated sounds. This eff ect is arises thanks in part to eff erent eff ects on OAE. For other aspects of ac tive lis- tening, see \201 g 1, p371.10 From the index ENT emergencies \200 Airway obstruction: Complete (no breath sounds; aphonia); Heimlich manoeuvreetc p795 \200 Incomplete (with, fo r example, wheeze or stridor) p566 \200 Laryngeal oedema/anaphylaxis p237 \200 Foreign body in the ear p538 \200 Sudden sensorineural hearing loss p550 \200 Peric hondritis p536 \200 Epiglottitis p566 \200 Epistaxis p562 \200 Nasal fractures p560 \200 Nasal foreign body p560 \200 Retropharyngeal abscess p564 \200 Orbital cellulitis p4 20 \200 Sudden parotid enlargement p578 \200 Facial nerve palsy p574 \200 Quinsy p564 \200 Post-tonsillectomy bleeding p565 Prevalence of ENT symptoms In one UK community study (n=15,788), 20% reported current hear ing troubles, eg diffi culty with speech in background noise (few wore a hearing aid regula rly). 20% reported tinnitus lasting >5 minutes. 15% reported hayfever et al in the last ye ar, 7% sneezing or voice problems, and 31% had severe sore throat/tonsillitis. 21% re- por ted ever having had dizziness in which things seemed to spin around the individual, 29% un- steadiness/light-headedness, and 13% reported dizziness in which the person seemed to move .11 Nasal polyp symptoms (p567): 2%.12 536 \200 Cardinal ear symptoms \200 Ear pain/discharge: p542 \200\2234 \200 Hearing loss: p551 \200 Tinnitus/vertigo: p554 Cardinal nose symptoms \200 Nasal congestion: p556 \200 Ep istaxis: p562 Cardinal throat symptoms \200 Stridor: p566 \200 Hoarseness: p568 \200 Dysphagia: p572 \200 Neck lumps: p576 ENT examination Examination in ENT diff ers from some other specialties in that its regions are rather inaccessible. Illumination by a headlight (self-contained or with a sepa- rate light source and cable) has replaced the traditional head mirror with light source position ed behind the patient. Hands-free stereoscopic view of cavities is the aim. Patient positio ning is also important. Rod lens and \202 exible \201 bre- optic scopes for nasendoscop y and laryngoscopy are now routine. The ear (Position yourself to one side of the patient; begin on the better side, if applicable (otherwise you may forget to examine it at all). In spect for scars (postauricular and endaural suggest mastoid and middle ear surgery respecti vely) and other abnormalities, eg perichondritis, which is a serious infection of the pinna , eg with pseudomonas after cosmetic piercing (vascu- lar supply is impaired, leading to a cauli \202 ower ear, ie neocartilage from dis- rupted perichondrium, unless urgent referra l for abscess drainage is made). To examine the auditory meatus, pull the pinna up and back to straighten the bend. (In infants, the bony canal has not formed fully, so pull the pinn a back and down.) Swab any discharge; remove wax carefully. Insert the largest comfortable aural speculum (don \200\231t probe too far \200\224it \200\231s sensitive). Any infec- tio n/in \202 ammation, stenosis, or exostoses (p538)? Otoscopy: Practice is the key, ( \201 g 3, p539). Examine quadrants in turn. Identify the pars tensa, pars \202 accida, the han dle of the malleus and the cone of light (light re \202 ex) that points to the toes (anter oinferior). Note color, translucency, and any bulging or retraction of the drum \200\224and perforations (size; position; site: marginal or central?). Perforation/retraction of the p ars \202 accida is seri- ous (p544). Assess drum mobility using a pneumatic attachment fo r the oto- scope or a special Siegle speculum. Lack of movement suggests perforation or mid dle ear eff usion. On squeezing the balloon, the drum should move. Drum movement on a Valsa lva maneuver means a patent Eustachian tube. Also: free \201 eld voice testing (whisper a t 40cm); tuning fork test; VII nerve tests. The nose (Testing smell is often omitted, but o ften fascinating.1) Sit face-to- face (knees together, to the patient \200\231s right). Ins pect the external nose: size, s e s a e s i d T N E 1 Smell, sweat, darkness, dirt, and lust Smells are as hard to name as emotions: when we ar e told by a novelist or a chef, we say \200\234Yes: that \200\231s it! \200\235 Smells and emotions go hand in hand with mem- ory. Engrams are the brain \200\231s map of memorable e vents; they include smells which can be the key to accessing the memory. Unrelated word pai rs (eg butter and church) are recalled better if the smells at their encoding are re-presen ted when we try to recall them. MRI shows the olfactory cortex and ant erior hippocampus me diate olfactory routes to hidden memory, and their attendant emotions.13 So when we test th e sense of smell we are testing consciousness itself \200\224which is no more or less than the interaction of emotion, memory, and sensation. When we re-smell the smells of youth, or re-smell a perfume from a distant affaire de coeur, we are transported, de-realized, and m oved back to our former selves. For a mom ent we re-inhabit lands of lost content (p468) or torment. Olfaction plugs directly into the limbic system, enabling us to smell and interpr et the dark. This expanding of the sense of smell to encompass all things struck Kipling on revisiting Lahore: \200\230the heat and smell of oil and spices, and puffs of temple ince nse, and sweat and darkness, and dirt and lust and cruelty. \200\23114 shape, deviations, or deformity. Lift the nose tip to inspect the vestibule. Check patency of each side either with a cold metal tongue depressor or by occluding each nostril in turn with the \202 at of your thumb: don \200\231t press the side in (distorts the other nost ril). \200\234Please sniff \200\235. Thudicum speculum (anterior rhinoscopy): Insert gent ly; assess mucosa, septum position, and the front of inferior and middle turbinates. Any po lyps? Examine the rest of the nasal cavity with rigid endoscopy after spraying with xylomet azoline & lidocaine. The middle meatus is a key nasal area as most of the sinuses ventilate via this cleft (between the middle and inferior conchae). The postnasal space (nasopharynx ) contains the Eus- tachian tube ori \201 ces & the pharyngeal recess (of Rosenmuller), an d may contain adenoids or naso-pharyngeal cancer. A postnasal mirror helps ex- amine the na sopharynx via the oral cavity (these mirrors are usually only seen in clinical exams!). Exa mine the palate (it \200\231s the \202 oor of the nose). The throat \200 Position yours elf as above; remove any dentures \200 Inspect lips and perioral region. Ask him to open his mouth without protruding the tongue. Then use a tongue depressor (with light) to retrac t each cheek: in- spect the buccal mucosa, the parotid duct opening (opposite the upper 2nd molar), gums, teeth, \202 oor of the mouth, and the retromolar trigone (muc osa behind t he 3rd molar over the ramus of the mandible, a site of tumors that often involve periostium ) \200 Depress the tongue; say \200\234ah then aye \200\235 (checks pal- ate movement an d exposes more mucosa) \200 Examine the tonsils (prominent tonsils aren \200\231t always enlarged; deep crypts with debris can be normal) \200 Put on a glove for bimanual examina tion of the \202 oor of the mouth; any submandibu- lar gland stones or masses? \200 Pal pate the tongue for early invisible tumors. Free \201 eld voice testing NB: not so suitab le in children. 15 Other tests: p540. \200 Explain what you are about to do. Stand behind the patient. \200 To test the right ear, use your left hand to rub the patient \200\231s left tragus to mask that ear, then 2ft (60cm), whisper a simple polysyllable, eg \200\234 41 \200\235 or \200\234chicken \200\235. \200 The patient should be able to repeat what is said at least \200\223 \205\224 of the time; failure represents hearing impairment. T his is clari \201 ed by (a) coming closer (15cm) and (b) raising the voice to conversation al levels \200\224or a shout. 537 \200 s e s a e s i d T N E Indirect laryngoscopy (Now rarely done.) The posture is with head extend- ed ( \200\234snif fi ng the morning air \200\235). It is vital to explain what you are about to do. \200 An esthetize the throat with a rather unpalatable topical 2% lidocaine spray; warn the patient not to eat anything hot for 1 \200\2232h after. Hold the protruded tongue with a swab with slight forward tension. With the other hand warm a mirror (not too hot!). Ask to mouth breathe, and place the mirror up to the uvula/soft p alate. Examine epiglottis and false cords (ventricular folds). On saying \200\234hee \200 \235, assess vocal cords and their movement. Flexible nasendoscopy (4mm) is now preferred to indirect laryngoscopy. Fig 1. Vocal cords abducted for inspiration (above) and ad- ducted for low (a), and high pi tch phonation (b): NB elong- ation to raise pitch is done by the cric o thyroid muscle. (a) Low pitch (b) High pitch Courtesy of James Thomas. The ear 538 \200 The external ear ( \201 g 1). The auricle is \201 broelastic cartilage, covered b y skin. The ear drum ( \201 gs 1, 3) is set obliquely, the external auditory canal is 3cm anterior- l y and 2.5cm posteriorly. The canal \200\231s outer \205\223 is cartilage, having hairs an d ceru- minous (wax) glands in the skin; its inner \205\224 is bony and lined with sensiti ve skin. Congenital anomalies The auricle develops from 6 hillocks derived from the 1st and 2nd branchial arches that appear at 4 \200\2236 wks with the intervening 1st branchi- al g roove forming the external auditory canal. Any malfusion may give rise to accessory tags/au ricles or a preauricular pit, sinus, or \201 stula. An infected sinus may be mistaken for an infected sebaceous cyst, but there is often a deep tract that lies close to the facial nerve. It must be removed to avoid further infection. \200\207Auricular anomalies are freq uently associated with middle ear anomalies. Chondrodermatitis nodularis chronica helicis e t antihelicis This Latin describes an exquisitely tender cartilaginous in \202 amed nodule dwelling on the upper helix \200 or antihelix \200 ( \201 g 2). A more convenient name is Winkler \200\231s dis- ease.16 It is commoner in men who work outdoors. Causes: ?poor bl ood \202 ow (avascular chondritis) from pressure (eg phone addicts)17 or vasoconstriction from cold. A pressure-relieving prosthesis may help.18 If not, excise skin and underlying cartilage (eg \200\230wide excision \200\231 or \200\230deep shave \200\231).19 Pinna hae matoma Blunt trauma may cause bleeding in the subperichondrial plane elevating the perichon drium to form a haematoma. Arrange prompt evac- uation. Aspiration is rarely adequate: \201 rm packing conforming to the contours of the auricle may prevent reaccumulation. 20 So metimes haematoma is found to be within the cartilage itself, which tends to be refractory. 21 Poor treatment leads to ischaemic necrosis, then \201 brosis (a cauli \202 ower ear). Secondary infection may cause major loss of cartilage. Exostoses These are smooth multiple bilateral swellings of the bony canals and said to represent local bony hypertrophy from c old exposure, eg in aquatic sports. Symptoms: none, so long as the lumen is suffi cient for sound conduc- tion (so they are often picked up incidentally). When they hinder migration of wax or debris, or when they occlude the canal to cause conductive deafness, surgical rem oval is indicated. Osteomas (p699) are usually solitary. Wax (cerumen) Wax is secreted in t he outer \205\223 of the canal, to protect against maceration. Due to epithelial migration , the ear is self-cleaning; cotton buds are unnecessary and lead to deafness and discomfort if the wax impacts. Optimal treatment is suction under direct vision using a microscope \200\224but syringing usu- ally works too, using water at 37 C; eg after softening with o live oil or bicar- bonate drops daily for a week;22 warn of post-op dizziness. Use of drops 30mins pre-syringing is just as good.23 Or you can instill warm water 15min pre-op in un-o iled ears; this more than halves duration of syringing required.24 But as 40% of the time o iling is all that is needed, the longer regimen has advantages. At sy- ringing, direct the jet back and up. Give up after 3 attempts.25 Dry the ear after. \200\207Avoid syringing if the drum is perforated, if grommets (or within 1 yrs), cleft palate, or after mastoid sur gery. Complications: Pain; otitis externa; vertigo (0.2%); perforated drum ( \200\2050.2%). 25,26 Ear FBs Foreign bodies are common if <5yrs old and in adults with learning dif- \201 culty. Organic FBs cause much in \202 ammation. Many methods of removal de- scribed i n the literature: syringing can be successful, eg with small objects; take care with object s that almost \201 ll the canal as these may impact, and organic material may swell. Suct ion ( specially designed ends with soft \202 anges \200\224may prevent FBs penetrating ever deeper), glue, gum, and hooks have their uses. \200\207Batteries (eg from hearing aid s) need urgent removal. Suction methods: \200\207Always use instrumentation under direct v ision. Diffi cult patients (eg young children; the anxious) are best referred directly, wit hout inexpert attempts at removal to \200\200chance of successful removal with few complic ations. s e s a e s i d T N E 539 Fig 1. Left drum. The 4 arbitrary quadrants are indicated by solid lines and by the handle of the malleus. The light re \202 ex points to the feet. Fig 2. The pinna. s e s a e s i d T N E Fig 3. Normal right drum. If only patients could see how beautiful and delicate the drum is , amateur instru- mentation of the ear would be far less common! Fig 4. The left drum is re- tracted, along with the han- dle of the malleus (appears short) . The lateral process will also become more prominent than normal. Fig 5. (Right drum) This crust in the attic repre- sents a large underlying cholesteatoma. Fig 6. The (right) drum is opaque. There is prominence of blood vessels suggesting a middle ear eff usion. This is one of several appearances of glue ear. Fig 7. (Right drum) White patches are usually tym- panosclerosis (calcium de- posits), eg a fter infection or trauma. They are often of no signi \201 cance; if severe can cause mild conductive hearing loss. Fig 8. (Right drum) Poste- rior perforation. Posterior perforations may be serious, but thi s one is dry, and its posterior margin is de \201 ned. Traumatic perforations (eg barotrau ma) are often pos- terior and linear, like a tear rather than a hole. Fig 9. Posterior perforation exposing incudostapedial joint. The irregular shape is suggest s trauma. These images may look surprisingly clear: this is because they were taken through a Hopkins rod, rather than an otoscope. the cause Figs 3 \200\2238 courtesy ofMichael Saunders FRCS. Fig 9 cour- tesy of Rory Herdman FRCS. Hearing tests and audiology When assessing suspected hearing loss, determine its nature (co nductive or sensorineural), its severity and its cause: is it treatable, and is it part of some other disease process \200\224eg unilateral sensorineural hearing loss (SNHL) in acous tic neuroma? Remember also to assess the degree of disability. Rinne tuning fork test See O HCM p468. If +ve in sudden sensori-neural deafness (air conduction > bone) \200\207refer s ame day (p550). Free \201 eld voice testing p537. Audiometry This quanti \201 es loss an d determines its nature. Pure tone au- diometry is the standard measure \200\224 \201 gs 1 \200\2237. Headphones deliver electroni- cally generated tones at diff erent strengths ove r frequencies of 250 \200\2238000Hz in a sound-proofed room. The patient says when he hears sounds 50% of the time at threshold. This intensity is recorded in decibels (dB) by the te ster as the air conduction threshold. A bone conduction threshold is obtained by us- ing a transducer over the mastoid process. Masking ( \200\203narrowband noise to the untested ear ) prevents cross-stimulation of the non-test ear by raising its threshold. Speech audiometr y examines speech discrimination above the threshold by asking patients to repeat words pre sented via headphones. It is assesses disability, and can predict whether a hearing aid wou ld help. 540 \200 s e s a e s i d T N E Both pure tone and speech audiometry are subjective tests, acoustic imped- ance audiometry (tympanometry) is objective. A probe with an airtight seal is introduced into the meatus; i t measures the proportion of an acoustic signal re \202 ected back at varying pressures an d generates a graph of compliance \200\224see \201 g 3, p547. Tympanometry provides a use ful measure of middle ear pressure. A normal ear shows a smooth bell-shaped compliance curv e (type A). Fluid in the middle ear \202 attens the curve (type B). Negative middle ear p ressure shifts the peak to the negative side or left (type C). 125 125 500 2000 8000 500 2000 8000 250 1000 4000 250 1000 4000 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 Fig 1. Normal hearing. \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 AIR UM NOT REACHED UNCERTAIN AIR M BONE UM BONE M UCL UM R CONTRA Fig 2. Bilateral middle ear congestion. 125 500 2000 8000 125 500 2000 8000 250 1000 4000 250 1000 4000 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 Fig 3. Right-sided M ni res. Fig 4. Noise-induced hearing loss. 125 125 500 2000 8000 500 2000 8000 541 250 1000 4000 250 1000 4000 \200\22310 \200\22310 0 0 10 10 20 20 30 30 40 40 50 50 60 60 70 70 80 80 90 90 100 100 1 10 110 120 120 Fig 5. Right-sided otosclerosis, with Carhaarts notch at 2kHz on masked bone conduction. \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 s e s a e s i d T N E Fig 6. Typical presbyacusis \200\224bilateral, symmetrical, high-frequency SNHL. 125 500 2000 8000 Fig 7. Cookie-bite loss (as if someone took a bite out of the top of the audio- gram (isola ted mid-range hearing loss). It is likely to be hereditary. Test siblings. Referral to a ge neticist may be indicat- ed. (In \200\230reverse cookie-bite \200\231 loss the bite is out of the lower edge.) Abbreviations m = masked um = unmasked 250 1000 4000 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 \200\22310 0 10 20 30 40 50 60 70 80 90 100 110 120 Figs 1 \200\2237 C Potter When to refer for speech therapy 0 \200\2231 years old: Feeding diffi culty eg from cleft lip/cerebral palsy. 2 years old: If vocabulary is <30 words or no phrases (but not if good com- munication skills without speech, and he or she seems on the edge of talking). 3 year s old: Unintelligible speech, eg oromotor or verbal dyspraxia (with a quiet voice, poor lip control, with mouth always open and dribbling). Also consider if: \200 Using sentences o f 2 words only. \200 No descriptive words or pronouns used. \200 Comprehension \200\201 , eg cannot identify ball or pen by \200\230which do we draw with? \200\231 \200 Parenta l anxiety, if the child is going through a stage of non- \202 uency. 4 years old: Unclear speech/diffi culty in carrying out simple commands. \200 Sentences used are less than 3 w ords; vocabulary is limited. \200 Stammering. The Lidcombe program is best started pre-sc hool.27 In this technique, parents provide verbal contingencies for periods of stutter-free conversation and moments of stuttering. Waiting for natural recovery is not acceptable bec ause of negative social and cognitive consequences. 5 years old: Problems with \200\230r \200\231, \200\230th \200\231, and lisps or articulation diffi culties. Also: \200 Diffi culty understanding simple sentences. \200 Diffi culty in giving direct answers to simpl e questions. \200 Diffi culty with sentence structure; immature sentences; word order. 6 years and older: Persisting articulation or comprehension problem. Also: \200 Diffi culty with verbal expression or other signi \201 cant voice problems. \200\207Refer hoarseness and excessive nasality at whatever age they present. Delay in talking: p215 Painful ears (otalgia) 542 \200 The cause is often non-otological (in 50%); look for sources of referred pain (OPPOSITE), eg throat and teeth: does grinding/tapping hurt? \200\224see p580. Otitis exter na (OE) Minimal discharge, itch, pain and tragal tenderness due to an acute in \202 ammati on of the skin of the meatus, eg caused by moisture (swim- ming), trauma eg \201 ngernail s (a consequence from conditions causing itch, eg ec- zema/psoriasis), high humidity, an ab sence of wax, a narrow ear canal, and hear- ing aids.28 Pseudomonas is the chief organism i nvolved, though Staphylococcus aureus is another common off ender. Hearing loss and canal s tenosis (making hearing aids diffi cult to wear) can be sequelae. \201\231 \201\231 : Cont act eczema ( \201 g 1). Aural toilet is the key to treatment. If severe, the meatus is narrowed. A thin Pope wick c an be inserted and hydrated with eardrops, eg Sofradex (framy- cetin + dexametasone). An alternative is a strip of ribbon gauze soaked in ich- thammol glycerin (very soothing) or a luminum acetate (astringent). After a few days, the meatus will open up enough for either m icrosuction or careful cleansing with cotton wool. Commercial Qtips or cotton buds should n \200\231t be used: they are too large; instead thin out or make one yourself by wrapping a small piece of cotton wool gently around an orange stick. Use drops only short-term, as t roublesome fungal infections can arise. Non-specialists should not syringe the ear. s e s a e s i d T N E \200\207Beware persistent unilateral otitis externa in diabetics/immunosup- pressed/ the e lderly: the risk is malignant/necrotizing otitis externa (see BOX). \200\207OE which is re sistant to treatment can be a sign of malignancy. Do biopsy. Furunculosis This is a very pa inful staphylococcal abscess arising in a hair follicle. Pathologically it is identical to a boil anywhere else; if there is cellulitis consider \202 ucloxacillin. Diabetes is an i mportant predisposing factor. Bullous myringitis These are very painful haemorrhagic bliste rs on deep meatal skin and on the drum ( serosanginous \202 uid behind it). Classically as- sociated with in \202 uenza infection, but Mycoplasma pneumoniae has also been implic ated as have a variety of other organisms. It may simply represent a variant of acute otiti s media. Sensorineural hearing loss is much more frequent than previously thought. Treatmen t is generally supportive only, eg pain relief; oral antibiotics can be considered in cases with middle ear eff usions. Barotrauma (aerotitis) If the Eustachian tube is occluded, mid dle ear pres- sure cannot be equalized during descent in an aircraft or diving, so causing damage. Risk factors: Conditions inhibiting function of the Eustachian tube eg in \202 amm ation/infection. Symptoms: Severe pain as the drum becomes indrawn, eg from transudation or bleeding into middle ear. Barotrauma to the inner ear causes vertigo, tinnitus, and deafne ss. Prevention: Not \202 ying with a URTI, de- congestants into the nose (eg xylometazoli ne every 20min), repeated yawns, swallows/jaw movements. In \202 ating an Otovent device is eff ective (it is recom- mended to air passengers with problems clearing the ears.)29 P ositive pressure (higher than Eustachian tube resistance) through mask to the nasopharynx c an also help.30 \200\224: Supportive if simple barotrauma; eff usions usually clear sponta ne- ously, and most perforations heal. Temporomandibular joint (TMJ) dysfunction Symptoms: Earache, facial pain, and joint clicking/popping related to malocclusion, teeth-grinding (b rux- ism) or joint derangement, and, importantly, stress, making this a biopsycho- social d isorder which may become a chronic pain syndrome (p636).31,32 Signs: Joint tenderness exace rbated by lateral movement of the open jaw, or trigger points in the pterygoids. Imaging: M RI. Associations: Depression;33 Ehlers \200\223 Danlos, p642.3 4 \200\224: NSAIDs (PO or t opical, eg diclofenac);35 stabilizing orthodontic occlusal prostheses;36 cognitive therapy (p374); physiotherapy; biofeedback; surgery (eg reconstruction),37 acupuncture.32 543 Performing aural toilet (learn by watching an expert at work) \200 Tools: otoscope, cotto n wool, Jobson Horne probe, Crocodile forceps, which must be used under a direct headlight. Pull the pinna back and up to straighten the canal, and under direct vision, dry mop with J obson Horne probe with a small piece of cotton wool on its serrated end. \200 Clean the a uditory meatus with a gentle rotary action; don \200\231t touch the drum. \200 Replace th e cotton wool as becomes soiled. Attend to the anterior-inferior recess, which often harbors debris. Intermittently re-examine the meatus, using the otoscope, during cleaning. \200 Patients who have mastoid cavities (a surgical widened canal done to treat infec- tion) should be fo llowed up in the ENT department for irrigation and drying. Cavi- ties repeatedly infected m ay need surgical repair of the posterior wall. s e s a e s i d T N E Take swabs as needed and advise on ear care. Referred otalgia: when the cause is not in the ear Referred (secondary) pain can arise from disease processes in the territories of the sensory nerves supplying the ear: \200 V: Th e auriculotemporal nerve (a branch of the trigeminal nerve which sup- plies lateral upper h alf of pinna) may refer pain from dental disease and TMJ dysfunction (temporomandibular joi nt dysfunction, opposite). VII: A sensory branch of the facial nerve (supplies lateral surface of drum) refers pain in geniculate herpes (Ramsay Hunt syndrome, p652). IX: Primary glossopharyngeal neuralgia is a rare cause of pain often in- duced by talking or swallowing. \200 IX & X: The tympanic branch of the glossopharyngeal nerve and the au- ricular branch of the vagus (supplies medial surface of drum) refer pain from the cancer of the posterior \205\223 of the tongue, pyriform fossa, or larynx, or fro m the throat to the ear, eg in tonsillitis or quinsy. Otalgia is common post-tonsillectomy (esp. in adults), so it is worth warning all patients. \200 c2, 3: The great auricular ne rve (C2, 3, supplying lower of pinna) refers pain from soft tissue injury in the neck an d from cervical spondylosis/arthritis. Use of eardrops in otitis externa \200\207Take a swab \201 rst, and do aural toilet. Is there chronic otitis externa that needs specialist attention? If not and no perforation, tr y local drops: \200 Betamethasone 0.1% cheap and good for non-infected eczema. \200 Fra mycetin + dexametasone = Sofradex . \200 Polymyxin B + neomycin+hydrocortisone=Otosporin . \200 Gentamicin 0.3%+hydrocortisone 1% = Gentisone HC drops; more costly than betam ethasone but can be good: advised by some only as a 2nd-line agent, eg in Pseudomonas infec tions. To minimize risks of gentamicin oto- toxicity, use for <2wks, and after baseline aud iometry (if possible); explain risks and bene \201 ts of gentamicin esp. if tympanic perfo ration. 38 \200 Clioquinol 1% + \202 umetasone=Locorten-Vioform , not if iodine sensit ive). \200 Sodium bicarbonate 5% drops are useful if wax is an additional problem. \200 \200\207Over-treating may lead to fungal infection: if suspected, try clotrimazole 1% sol ution/8 \200\22312h, continued for \211 2weeks after disappearance of infection. Malignant/necrotizing otitis externa This is aggressive, life-threatening infection of the external ear that can lead to temporal bone destruction and base-of-skull osteomyelitis. 90 % are diabetic. Immunosuppression (and probably aural irrigation)39 are other risk factors. The cause is usually Pseudomonas aeruginosa (also Proteus and Klebsiella). Treatment is by surgical debridement, systemic antibiotics, speci \201 c immuno- globulins, and, possibly , hyperbaric oxygen therapy.40 Discharging ears and otitis media 544 \200 The character of the discharge provides clues Causes of discharge to consider \200 Otitis externa/media. \200 Cholesteatoma to its source and cause: \200 External ear: In \202 ammation, ie otitis externa (OE) pro duces a scanty watery discharge, as there are no mucinous glands \200\224see p542. Blood ca n result from trauma to the canal. Liquid wax can sometimes \200\230leak \200\231 out. (rare but imp ortant). NB: crust in the attic/postero-superior quadr- ant often hides patho logy, so remove it. Middle ear: Mucous discharges are almost always due to middle ear disease. Serosanguinous d ischarge suggests a granular mucosa of chronic otitis media (COM). An off ensive discharge suggests cholesteatoma.