Nurse patients with obvious globe injury head up at 45 . Refer urgently. Provide prophylactic oral antibiotics (eg co-amoxiclav) for uncomplicated facial or orbital fractures, and arrange for maxillofacial follow-up, with advice to avoid nose-blowing in t he meantime. 537 OPHTHALMOLOGICAL TRAUMA Penetrating eye injuries Suspect intraocular foreign body if there is a history of hammerin g or work involving metal on metal. Find out if protective glasses were worn. Ascertain whe ther a small foreign body traveling at speed may have pen- etrated the orbit (eg during gri nding, hammering, chiseling). Failure to suspect and diagnose these injuries can have serio us consequences. Assessment \200 Check visual acuity. \200 Look for pupil irregularity. \200 Look for puncture/entry wounds on both aspects of the eyelids, the cornea and sclera. Corneoscleral wounds are often situated inferiorly, due to upturning of the eyeball as the patient blinks . Examine the anterior chamber. There may be a shallow anterior chamber, air bubbles, a \202 at cornea, de \202 ated globe and a positive Seidel \200\231s test (dilution of \202 uorescein by aqueous humor leaking from the ante- rior chamber). Look for a hyphaema. \200 Look for vitreous hemorrhage on fundoscopy. X-ray all patients with possible globe penetration (consider also CT or USS) Give analgesia, tetanus prophylaxis, IV antibiotics (eg 1.5g cefuroxime), and refer all pat ients with penetrating eye injuries immediately to an ophthalmologist, even if there are ot her major injuries needing attention at the same time. Never manipulate or try to remove embedded objects (eg darts). 538 CHAPTER 11 Ophthalmology Corneal trauma Conjunctival FB The typical history is of dust or grit blown into an eye by the wind. The FB usually gravitates into the lower fornix \200\224 remove with a cotton bu d. Subtarsal FB FBs may not gravitate into the lower fornix, but may remain stuck under the upper eyelid. The patient reports pain on blinking. Fluorescein staining reveals character istic vertical corneal abrasions (the cornea has been likened to an \200\230ice rink \200 \231). Evert the upper eyelid and remove the FB with a cotton bud. Discharge with topical a ntibiotic (eg chloramphenicol oint- ment qds or fusidic acid eye drops). Corneal abrasions Often result from a newspaper or \201 ngernail in the eye. Irritation, photo- phobia, and lacrimation occur. Use LA drops and \202 uorescein staining to examine the cornea. Exclu de FB or penetrating injury. Prescribe regular antibiotic ointment (eg chloramphenicol) and oral analgesia. An eye patch which seals eyelids closed will aid the symptoms and recovery . If the patient is very uncomfortable, consider instilling a drop of 1 % cyclopentolate to dilate the pupil (this reduces iris spasm) or a drop of 0.1 % diclofenac. Advise the patie nt not to drive until vision has returned to normal. Advise also to return for review if sy mptoms continue beyond 36hr. Corneal foreign body Instill LA and attempt removal with a cot ton bud. If unsuccessful, remove with a blue (23G) needle introduced from the side (ideally using a slit lamp). Ensure that the patient \200\231s head is \201 rmly \201 xed and c annot move for- wards onto the needle: it can help for the operator \200\231s hand to rest lightly on the patient \200\231s cheek. After complete removal of the FB, check that the an terior chamber is intact, instill and prescribe antibiotic ointment, and advise the patient to return if symptomatic at 36hr. Refer patients with large, deep or incompletely removed FB, or if a rust ring remains. Arc (welder \200\231s) eye/ \200\230snowblindness \200\231 E xposure to ultraviolet light can cause super \201 cial keratitis. Climbers/skiers, welders , and sunbed users who have not used protective goggles develop pain, watering, and blephar ospasm several hours later. LA drops allow examination with \202 uorescein staining, reve aling multiple punctate corneal lesions. Consider instilling a drop of 1 % cyclopentolate o r 0.1 % diclofenac into both eyes. Discharge with an eye pad, oral analgesia, and advice no t to drive until recovered. Anticipate resolution within 24hr. Do not discharge with LA dro ps. Chemical eye burns Chemical burns from alkali or acid are serious. Triage urgently ahea d, check Toxbase and provide immediate eye irrigation with lukewarm normal saline for at le ast 20min, or until the pH of tears has returned to normal (7.4). A 1L bag of 0.9 % saline with standard IV tubing is ideal. LA may be needed to enable full irrigation. Identify the substance involved and contact Poisons Unit. Refer alkali and acid burns immediately. Super glued eyelids Wash with warm water. The eye will open within 4 days. If the patient reports a FB sensation, this may represent a lump of glue, which may cause an abrasion if left unt reated: refer to the ophthalmologist. 539 CONTACT LENS PROBLEMS Contact lens problems Contact lenses are of two basic types: hard or soft. Soft lenses, com posed of hydrogels, are more comfortable to wear. Avoid using \202 uorescein with contact lenses, as permanent staining may occur. \200\230Stuck lens \200\231 Most contact lens users are adept at removing their contact le nses. New users, however, not infrequently experience dif \201 culty in their removal. Moi sten soft lenses with saline, then remove by pinching between \201 nger and thumb. Specia l suction devices are available to help remove hard lenses. \200\230Lost lens \200\231 Patients may present concerned that they are unable to \201 n d their contact lens and cannot remember it falling out. Check under both eyelids carefully (evert the upper lid if the lens is not immediately apparent) and remove the offending len s, if present. Hypersensitivity and overuse Preservatives in lens cleaning \202 uid cause itching and ma y evoke a reaction. Advise to stop using the lenses, give local antibiotic ointment and arr ange ophthalmological follow-up. Acanthamoeba keratitis This is a protozoal infection of the cornea which occurs in contact lens users, associated with poor lens hygiene or swimming whilst wearing contact lenses. Th e eye becomes painful and red. Corneal oedema and ulceration develops. If acanthamoeba infe ction is suspected, refer immediately for ophthalmological care. Other problems Treat and refer conjunctivitis, corneal abrasions, or ulcers apparently rela ted to contact lenses as outlined opposite. Advise avoidance of use of both contact lenses until the problem has resolved. 540 CHAPTER 11 Ophthalmology Sudden visual loss Sudden visual loss requires emergency assessment and treatment. Amaurosis fugax The patient describes temporary loss of vision in one eye, like a \200\230 curtain coming down \200\231, with complete recovery after a few seconds to minutes. The ca use is usually a thrombotic embolus in the retinal, ophthalmic, or ciliary artery, originat ing from a carotid atheromatous plaque. Refer urgently to the ophthalmology team. Central retinal artery occlusion The central retinal artery is an end artery. Occlusion is usually embolic (check for atrial \201 brillation and listen for carotid bruits), causing sudden painless d VA to counting \201 ngers or no light perception. The patient may have a history of amaurosis fugax. Direct pupil reaction is sluggish or absent in the affected eye, but it reacts to consensual stimulation (afferent pupillary defect). Fundoscopy reveal s a pale retina, with a swollen pale optic disc and \200\230cherry red macula spot \200 \231 (the retina is thinnest here and the underlying choroidal circulation is normal). Reti nal blood vessels are attenuated and irregular: there may be \200\230cattle-trucking \200 \231 in arteries. Treat by digitally massaging the globe for 5 \200\22315sec then release and repeat to dislo dge the embolus, whilst awaiting the urgent arrival of an ophthalmologist. If there is any delay in the patient being seen by the ophthalmologist, consider (and discu ss) the following options: \200 Giving sublingual glyceryl trinitrate (GTN). \200 Givin g IV 500mg acetazolamide (to d intra-ocular pressure). \200 Reconsider the diagnosis. In particular, consider whether or not tempo- ral arteritis is a possibility: ask about jaw cl audication, headaches, scalp tenderness. Central retinal vein occlusion This is a more frequent cause of sudden painless visual loss than arterial occlusion. Predisposing factors include: old age, chronic glaucoma, arte- ri osclerosis, hypertension, polycythaemia. Examination reveals d VA, often with an afferent p upillary defect. Fundoscopy reveals a \200\230stormy sunset \200\231 appearance: hyperaemi a with engorged veins and adjacent \202 ame-shaped hemorrhages. The disc may be obscured by hemorrhages and oedema. Cotton wool spots may be seen. Although the outcome is variable and there is no speci \201 c treatment, refer urgently as the underlying cause may be trea table, thus protecting the other eye. 541 SUDDEN VISUAL LOSS Temporal (giant cell) arteritis In \202 ammation of the posterior ciliary arteries causes ischaemic optic neu- ritis and visual loss. It is relatively common in those aged > 50 year s and is associated with polymyalgia rheumatica. The other eye remains at risk until treatm ent is commenced. Rapid and profound visual loss may be pre- ceded by headaches, jaw claudi cation, general malaise, and muscular pains. The temporal arteries are characteristically t ender to palpation. Retinal appearances have been termed \200\230pale papilloedema \200 \231: the ischaemic disc is pale, waxy, elevated and has splinter hemorrhages on it. If sus pected, give 200mg IV hydrocortisone immediately, check erythrocyte sedimentation rate (ESR ) (typically > > 40mm/hr, but can be normal) and refer urgently. Vitreous hemorrhage Occurs in diabetics with new vessel formation, in bleeding disorders an d in retinal detachment. Small bleeds may produce vitreous \202 oaters with little visual loss. Large bleeds result in painless d d VA, an absent red re \202 ex and dif \201 cult y visualizing the retina. Refer urgently. Meanwhile, elevate the head of the bed to allow b lood to collect inferiorly. Retinal detachment Occurs in myopes, diabetics, the elderly and following trauma. The rate of onset is variable: patients may report premonitory \202 ashing lights or a \200\230sn ow-storm \200\231, before developing cloudy vision. There may be a visual \201 eld defect . Macular involvement causes d VA. The affected retina is dark and opalescent, but may be d if \201 cult to visualize by standard ophthalmoscopy. Refer urgently for surgery and re-at tachment. Optic neuritis Usually presents in a young woman. Optic nerve in \202 ammation causes visu al loss over a few days. Pain on eye movement may occur. An afferent pupillary defect is as sociated with d VA, d color vision (color red looks faded) and normal/swollen optic disc. M ost recover untreated, later some develop multiple sclerosis. Refer to the ophthalmologist. Other causes Patients with chronic visual loss due to a variety of conditions may present a cutely (senile macular degeneration, glaucoma, optic atrophy, cataract, choroidoretinitis). Drugs which can cause painless visual loss include methanol ( b p.202) and quinine (in ove rdose). Refer immediately all patients in whom an acute visual loss cannot be excluded. 542 CHAPTER 11 Ophthalmology The red eye Patients commonly present with a red eye with no history of trauma, but it is c ritical not to miss certain diagnoses. Refer all patients with new \201 nd- ings of d VA, abnormal pupil reactions, or corneal abnormalities. Orbital and preseptal cellulitis This is a major infection of the orbital tissues. The infe ction is most fre- quently spread from the paranasal sinuses (ethmoid sinusitis), facial sk in or lacrimal sac. Occasionally, the infection follows direct trauma to the orbit or from haematogenous spread. Patients present with fever, eyelid swelling, erythema, and proptosis . Always assess patient for signs of severe sepsis ( b Severe sepsis and shock, p.59) and r esuscitate as necessary. Obtain venous access, take blood for cultures, commence intravenou s antibi- otics (eg co-amoxiclav) and \202 uids. Refer urgently to the ophthalmologist. S ome aggressive infections may require surgical treatment. Cavernous sinus thrombosis and me ningitis are potential complications. Acute iritis (acute uveitis) A relapsing condition of the young and middle-aged associated with anky- losing spondylitis, ulcerative colitis, sarcoid, AIDS, and Beh et \200\231s syn drome. Symptoms include Acute onset pain, photophobia, \200\230 \202 oaters \200\231, blurred vi sion and watering. Signs d VA, tender eye felt through the upper eyelid, circumcorneal eryt hema, small pupil (may be irregular due to previous adhesions). Shining a light into the \200\230good \200\231 eye causes pain in the other. Pain i as eyes converge and pupils reac t to accommodation (Talbot \200\231s test). Slit lamp may reveal hypopyon and white precipi tates on the posterior cornea. Refer urgently to the ophthalmologist for steroid eye drops, pupil dilatation, analgesia, i nvestigation, and follow-up. Acute closed angle glaucoma Long-sighted middle-aged or elderly with shallow anterior chamb ers are at risk. Sudden blocked drainage of aqueous humor into the canal of Schlemm causes intra-ocular pressure to increase from 10 \200\22320mmHg up to 70mmHg. This may be caused b y anticholinergic drugs or pupil dilatation at night (reading in dim light). Symptoms include preceding episodes of blurred vision or haloes around lights due to cornea l oedema. Acute blockage causes severe eye pain, nausea/vomiting. Signs d VA, hazy oedemato us cornea with circumcorneal erythema and a \201 xed semi-dilated ovoid pupil. The eye fe els tender and hard through the upper eyelid. Measure intraocular pressure if this facility is available. Treatment Instill a 4 % pilocarpine drop every 15min to produce ciliary muscle contraction and aqueous humor drainage. Apply prophylactic 1 % pilocarpine drops into the other eye als o. Give analgesia (eg morphine IV with anti-emetic). Arrange an emergency ophthalmology opi nion: consider giving acetazolamide 500mg IV (to d intra-ocular pressure) meantime and/ or mannitol 20 % up to 500mL intravenous infusion over 1hr. 543 THE RED EYE Conjunctivitis Caused by bacteria ( Strep. pneumoniae or H. in \202 uenza ), viruses (aden o- virus), or allergy. The sensation of a FB may involve both eyes. The con- junctiva is re d and in \202 amed, sometimes with eyelid swelling. VA and pupils are normal. Bacterial in fection classically produces sticky mucopurulent tears, viral infection copious watery tear s (associated with photophobia and pre-auricular lymphadenopathy in the highly contagious a denoviral \200\230epidemic keratoconjunctivitis \200\231). Prescribe antibiotic eye drops or oint- ment (eg fusidic acid, chloramphenicol, or gentamicin) regularly for 5 days. Advis e not to share towels or pillows. Most cases settle relatively quickly: advise patients to return if symptoms do not improve within 4 days. Ulcerative keratitis Corneal ulceration causes pain with photophobia. It is apparent on \202 uorescein staining under a slit lamp. \200 Hypopyon (pus in the anterior chamber) im plies bacterial infection. \200 Vesicles in the ophthalmic division of the trigeminal ner ve occur with herpes zoster infection. A dendritic branching ulcerative pattern suggests herpes simplex. If this is misdiagnosed a nd steroid eye drops given, ulceration can be disastrous. As a non-specialist, do not presc ribe steroid eye drops \200\224 leave this to the ophthalmologist. Whatever the infective agent, refer corneal ulceration immediately. Episcleritis In \202 ammation beneath one area of the conjunctiva is usually associated wi th a nodule and a dull aching discomfort. VA, pupils, and anterior chamber are normal. Pres cribe oral NSAIDs and advise outpatient follow- up to consider steroid eye drops if there i s no resolution. Blepharitis This chronic problem is quite common. Eyelashes are matted together and itchy. Ensure that there is no associated corneal ulceration, provide topical antibiotics (eg chlo ramphenicol) and refer for GP follow-up. External hordeolum (stye) Treat staphylococcal infections of eyelash roots with antibiotics drops. Internal hordeolum (chalazion) A chalazion is an in \202 ammatory reaction in a blocked me ibomian gland, which may become secondarily infected. Treat infected tarsal (meibomian) gla nds with topical antibiotics (eg chloramphenicol) together with oral antibiotics (eg co-amo xiclav). Refer patients who develop an abscess or nodule affecting vision. Dacrocystitis Acute infection of the lacrimal sac may follow nasolacrimal duct obstruction. Treat early infections with oral antibiotics (co-amoxiclav); later, refer for drainage. Subconjunctival hemorrhage This usually presents as a painless, well-de \201 ned area of h emorrhage over the sclera. May result from vomiting or sneezing. Following trauma, consider orbital or base of skull fracture and treat accordingly. This page intentionally left blank 545 Chapter 12 Ear, nose and throat Ear, nose, and throat foreign bodies Ear examination Vertigo Cochlear implants Earache Epis taxis Nasal fracture Sore throat Facial nerve palsy Salivary gland problems Dental emergenc ies 546 548 549 549 550 552 553 554 556 557 558 546 CHAPTER 12 Ear, nose and throat Ear, nose, and throat foreign bodies Ear foreign bodies All sorts of FBs may become lodged in the external auditory canal, including insects, vegetable matter, and various inert obje cts. The patient may present with pain, deafness, discharge or, in the case of live insects , an irritating buzzing in one ear. Diagnosis depends upon direct visualization with the auriscope. In children, remember that, as with FBs elsewhere, there may be no history of FB available. Removal \200 Many FBs can be removed under direct vision with hooks. Manipulate gently to avoid causing damage or further impaction. Drown live insects in 2 % lidocaine \201 rst. \200 Do not try to syringe out vegetable matter with water, as this may cause swelling and pain. If there is some dif \201 culty (eg ball bearing or bead in an uncooperative child), refer to ear, nose, and throat (ENT) department to consider removal under GA. Removal of beads u sing an orange stick with a tiny amount of superglue on the end has been described, but car ries some obvious dangers and requires complete patient co-operation. Embedded ear-rings The \200\230butter \202 y \200\231 piece of an ear ring may become emb edded in the posterior part of the ear lobe, causing in \202 ammation or infection. The ea r-rings are usually easily removed once adequate analgesia has been established: render the ear anesthetized with a greater auricular nerve block ( b Nerve blocks of forehead and ear , p.300), or directly in \201 ltrate local anesthetic into the lobe, remembering that this is a highly sensitive area. The butter \202 y is released by applying pressure in a poste rior direction. Occasionally, forceps and a small posterior skin incision may be required t o open up the track. If there is evidence of infection, prescribe antibiotics (eg co-amoxic lav) and arrange GP follow-up. Advise the patient not to wear ear-rings until the symptoms have settled. Nasal foreign bodies Usually affects children, who present with offensive unilateral nasal discharge. Also occurs in adults with psychotic illness or learning disabilities. Removal Remove easily accessible, anterior nasal FBs in ED. However, there is a risk of asp iration with any nasal FB, particularly in uncooperative patients. Refer such patients to a n ENT surgeon for removal with airway protection. Instruct the patient to blow their nose w hilst occluding the unaffected nostril. If unsuccessful, consider attempting removal with a nasal speculum, hook, and forceps, as appropriate. A \201 ne bore tracheal suction cathe ter attached to wall suction can also work. One technique which has been reported in cooper ative children is to ask a parent to blow into the child \200\231s mouth ( \200\230parent \200\231s kiss \200\231), having \201 rst ensured a good seal and also occluded the norma l nostril. Nasal button, batteries, or magnets ( b p.213) can cause signi \201 cant damage , so refer to ENT. 547 EAR, NOSE, AND THROAT FOREIGN BODIES Inhaled foreign bodies Aspiration causing complete upper airway obstruction is an emergency , requiring immediate intervention ( b p.324). FBs lodged in the larynx or tracheobronchial tree cause persistent coughing. There may not be a clear history \200\224 a coughing/splu ttering episode in a child should arouse suspicion of an inhaled FB. Auscultation of the ch est is often normal, but may reveal wheezes or localized absence of breath sounds. CXR may be normal or show a radio-opaque FB with distal consolidation or hyperin \202 atio n (FB acting as a ball valve). A CXR in expiration may show this more clearly. Refer to a c ardiothoracic surgeon. Ingested foreign bodies Various FBs, both radio-opaque (eg coins, rings) and non-radio-opaq ue (eg plastic pen tops, aluminum ring pulls) are frequently swallowed by children and by a dults with psychiatric disorders. Provided the FB reaches the stomach, it is likely to pass through the remainder of the gastroin- testinal tract without incident. An exception is bu tton battery ingestion ( b p.213). For radio-opaque FBs, con \201 rm with lateral neck X-r ay and CXR that it is not impacted in the esophagus. A metal detector may con \201 rm a sw allowed coin has reached the stomach. Refer patients who are symptomatic, have impacted FBs , or who have swallowed potentially dangerous items (button batteries, razor blades, open s afety pins). Note that magnets can be dangerous if two or more are ingested, since they can attract each other through tissues and cause pressure necrosis/perforation of bowel. Only discharge patients who are asymptomatic (with advice to return if they develop abdominal pa in and/or vomiting), and arrange suitable follow-up. Unless the ingested FB is valuable or of great sentimental value, examination of the stools by the patient for the FB is unnecess ary. It may take weeks to pass. Impacted \201 sh bones Fish bones often become stuck in the pharynx or esophagus. Direct visu- alization with a good light (a head torch can be useful) and wooden spatula acting as tongue depressor may reveal \201 sh bones lodged in the tonsils or base of the tongue \200\224 remove with Tilley \200\231s forceps. If no FB is seen, obtain soft-tissue lateral neck X-rays (look for prevertebral soft tissue swelling and \201 sh bone, bearing in min d not all are radio-opaque), then refer to ENT for endoscopy. Depending on local policy, th e ENT team may decide to see the patient immediately, or (provided the patient can swallow) the following day (in which case discuss the need for prophylactic antibiotics). A \201 sh bone can scratch the pharynx causing sensation of a FB to persist after it has gone. Oesophageal food bolus obstruction Usually involves a lump of meat. Patients with complete obstruction present unable to swallow solids or liquids (including their own saliva). There may be retrosternal discomfort. Refer to the surgical team for endoscopy. Glucagon (1mg IV ) relieves some episodes of food bolus obstruction, but endoscopy is still advisable to loo k for oesophageal stenosis or malignancy. 548 CHAPTER 12 Ear, nose and throat Ear examination Scope of the examination Full ear examination includes assessment of the ve stibulocochlear nerve and auroscope examination. Check for mastoid or pinna tenderness. Loo k at the external ear canal for discharge, or swelling and examine the tympanic membrane fo r color, translucency, bulging, and the cone of light. Assessing hearing Hearing can be assessed by asking the patient to place one \201 nger in their ear. Stand a foot behind the patient \200\231s unoccluded ear and whisper a two syll able word. Ask the patient to repeat the word. Weber \200\231s and Rinne \200\231s tests Weber \200\231s test \200\224 strike a 512Hz tun ing fork and place in the center of the forehead. In conductive deafness, the sound localiz es to the deaf ear, with sensorineural deafness, the sound localizes to the good ear. Rinne \200\231s test \200\224 strike a 512Hz tuning fork and place it on the mastoid proce ss. Ask the patient to tell you when they no longer hear the sound, then immediately place in front of the auditory meatus. In a normal ear, air conduction is heard for twice as long as bone conduction. In conductive deafness, bone conduction is heard for longer than air c onduction. In sensorineural deafness, air conduction is heard longer than bone conduction. Nystagmus To complete assessment of the vestibulocochlear nerve, examine for nystagmus. All forms of nystagmus can be associated with intracranial lesions, as well as peripheral caus es; however, downbeat and upbeat nys- tagmus in particular, signify a central cause. Tinnit us or deafness tends to suggest a peripheral cause. Peripheral nystagmus is exacerbated by gazing towards the side of the fast phase (Alexander \200\231s Law). Central nystagmus may change direction, depending on the side of gaze. 549 COCHLEAR IMPLANTS Vertigo Vertigo is the impression or illusion of movement when there is none. Take care to distinguish vertigo from the more general term of \200\230dizziness \200\231, which is oft en used to describe a feeling of light-headedness. Causes \200 Benign positional vertigo. Diagnosed with Hallpike \200\231s test which induc es positional vertigo. Mostly caused by posterior semicircular canal cana- lithiasis. Medic ations are ineffective. Meni re \200\231s disease: a disorder of the inner ear. Patients have recurrent vertigo, tinnitus and deafness and should be managed by ENT. Acute labyrinthitis: Caused by reactivation of herpes simplex virus. Some have an upper res piratory tract prodrome. Some individuals are unable to work or perform normal daily duties because of vertigo and vomiting. \200 Otitis media. \200 Acoustic neuroma (or vestibul ar schwannoma). This presents with slow onset deafness and tinnitus. Dizziness is less common. Cholesteatoma. \200 Stroke or transient ischaemic attack. \200 Trauma. \200 Wax or FB in the ear. Take a careful history and examine for causes of vertigo. Manage patients who present with vertigo according to the underlying cause. The cause may be unclear, in which case refer to the medical/ENT team as appropriate. Cochlear implants Cochlear implants consist of an implanted radio receiver and decoder pack age containing a magnet (above and behind the ear), together with a removable external micr ophone/radio transmitter. X-rays and CT do not damage this device, provided that the extern al microphone/transmitter is \201 rst removed and switched off. MRI can cause signi \201 cant damage to the device and the patient. If there are concerns relating to a cochlear im plant, refer to ENT. In particular, refer patients with: \200 Signi \201 cant direct tra uma, including exposure by a scalp wound. \200 Suspected otitis media of the implanted ea r. 550 CHAPTER 12 Ear, nose and throat Earache Otitis externa Often caused by Pseudomonas, Staph. aureus, Strep. pneumoniae, E. co li. Common in swimmers/surfers and after minor trauma. This causes intense itching and pain , which gradually increases. Discharge and hearing loss may be present (profuse discharge i mplies middle ear disease). On examina- tion, the external canal is in \202 amed and oedem atous. Oedema and debris may obscure the tympanic membrane. Pain is induced by pressing on the tragus or pulling the pinna. Management Prescribe topical antibiotics and topical stero ids, advise against swimming, and arrange GP follow-up. In severe cases (eg if the drum is not visible), refer to an ENT surgeon for aural toilet to remove debris from the auditory c anal. Cellulitis or furunculosis of the ear canal Cellulitis of the ear canal may be caused by sc ratching or by infection of hair follicles (furunculosis). Staph. aureus is the usual organ ism. Itching and a feeling of pressure are followed by pain in the ear, with deafness if th e ear canal is occluded by swelling. Examination shows swelling and in \202 ammation of th e ear canal, with tenderness over the tragus and pain on movement of the ear. Treat with an algesia (eg NSAID) and antibiotics (eg \202 ucloxacillin 500mg PO qds for 5 days). Arrang e follow-up by a GP (or ENT in severe cases). Acute otitis media Most common in children aged 3 \200\2236 years and may follow an upper r espi- ratory tract infection. Commonest pathogens are Strep. pneumoniae and H. in \202 uen zae. Presentation Earache may be accompanied by fever, deafness, irritability and lethargy. Typically, hearing loss precedes pain. Examination of the tympanic membrane shows evidence of in \202 ammation with loss of the light re \202 ex and bulging of the drum. Eventual perforation results in purulent discharge with some relief of pain. Look for associated swe lling/tenderness over the mastoid \200\224 this implies secondary mastoiditis (see below). Treatment Prescribe oral analgesia. The use of antibiotics remains very controversial. Oral antibiotics (eg 5-day course of amoxicillin or clarithromycin) are of questionable value, but are frequently given. Consider oral antibiotics if no improvement within 72hr, or earli er if there is deterioration or perforation. If perforation has occurred (often heralded by a sudden i pain), arrange ENT follow-up and advise not to swim. Otherwise, arrange GP foll ow-up. Acute mastoiditis This is an uncommon, but important diagnosis to make, because of the risk of intracranial spread of infection. Mastoiditis follows an episode of acute otitis media \200\224 consider it if there is no response to therapy (eg dis- charging ear for > 10 day s). Suspect it if there is pain, redness, swelling or tenderness over the mastoid process. The pinna may be pushed forwards/ outwards \200\224 swelling may mean that the drum is not visible. Refer urgently to the ENT surgeon for admission and IV antibiotics. 551 EARACHE Cholesteatoma This erosive condition affects the middle ear and mastoid. A cholest- eatoma can result in life-threatening intracranial infection. There may be an offensive discharge, with conductive hearing loss, vertigo or facial nerve palsy. Tympanic membrane examination shows granulation tissue and/or perforation with white debris. Refer to the ENT surgeon. Traumatic tympanic membrane rupture This may result from direct penetrating injury, blast i njury ( b p.389) or basal skull fracture ( b p.361). Pain is associated with d hearing. Per foration is visible on examination. Treatment Most heal spontaneously with conservative measures and advice to keep out of wate r. Arrange ENT follow-up and give prophylactic oral antibiotics according to local policy. Note that gentamicin or neomycin eardrops may cause sensorineural deafness because of ototo xicity when the tympanic membrane is ruptured. Barotrauma Sudden changes in atmospheric pressure with a blocked Eustachian tube can result in pain and hearing loss. This usually affects aircraft passengers and divers, especially if they have a cold (viral upper respiratory tract infection). Pain is often relieved by th e Valsalva maneuver (breathing out with the mouth closed, while pinching the nose). Deconge stant nasal spray may help if the problem does not resolve spontaneously. Give analgesia (N SAID). Arrange ENT follow-up if the pain persists. 552 CHAPTER 12 Ear, nose and throat Epistaxis Nasal bleeding may be idiopathic or follow minor trauma (eg nose picking). When i t occurs in patients with hypertension and coagulation disorders hemorrhage can be severe w ith signi \201 cant mortality. Epistaxis may follow isolated nasal fracture and more major facial injury. Site of bleeding Most nasal bleeding is from the anterior nasal septum in o r close to Little \200\231s area. A few patients have posterior nasal bleeding, which may b e brisk. Equipment Direct visualization of the anterior nasal cavity is aided by a headlamp (eg battery-operated head torch), \201 ne soft suction catheter, and nasal speculum. Wea r goggles to avoid blood splashes in the eyes. Initial approach Associated facial injury As sess ABC (especially pulse and BP) and resuscitate as necessary. Treat hypovolaemia vigorou sly. No associated injury Check airway patency, pulse, and BP. Treat hypovolaemia aggressiv ely. Check coagulation status of patients on anticoagulants and treat appropriately ( b p.1 70). Sit the patient up and instruct them to compress the \202 eshy part of their nose be tween \201 nger and thumb for 10min. If this stops the bleeding, the patient may be disch arged after 30min observation. Continuing bleeding after pressure Adults Apply a cotton wool pledget soaked in 4 % lidocai ne with 1 in 1000 adrenaline. Then, with a headlamp and nasal speculum, try to identify the bleeding point. Treat small anterior bleeding points with cautious cautery by applying a s ilver nitrate stick for 10 \200\22315sec. Avoid excessive cautery and never cauterize both sides of the septum \200\224 this may cause septal necrosis. If cautery stops the bleeding , observe for 15min, and discharge with GP follow- up. Advise avoidance of snif \201 ng, p icking or blowing the nose meantime. Children Applying nasal antiseptic cream (eg Naseptin ) is as effective as cautery in stopping bleeding. The cream is relatively easy to apply . Continuing bleeding despite cautery Insert a nasal pack. A specialized compressed surgical sponge nasal tampon (eg Merocel or Rapid Rhino) is ideal: gently insert a lubricated tam pon (horizontally) and \200\230in \202 ate \200\231 with a 10mL syringe of saline. Altern atively, pack the nose in a traditional way with 1.25cm wide ribbon gauze soaked in oily pa ste (eg bismuth iodoform paraf \201 n paste). Once packing has stopped the bleeding, refer to ENT for admission: observation is advisable (especially in the elderly). The pack may d islodge and obstruct the airway. Continuing bleeding despite packing Refer to the ENT surge on. The bleeding site is likely to be posterior and can cause hypovolaemic shock. In this s ituation, insert 2 large bore venous cannulae, send blood for FBC, coagulation screen, cros s-matching, and commence an IVI. Posterior nasal bleeding usually responds to tamponade wit h a Foley catheter. Remove the nasal tampon and insert a lubricated, unin \202 ated Foley catheter through the bleeding nostril into the nasopharynx. In \202 ate the balloon with a ir and gently withdraw the catheter, thus tamponading the bleeding site. Secure the cathete r to the cheek with tape, and then re-insert the anterior nasal tampon. 553 NASAL FRACTURE Nasal fracture The prominent exposed position of the nose, combined with the delicacy of it s bones, render it relatively prone to injury. Remember that the nose is part of the head, so nose injury = head injury (and potentially c ervical spine injury also). History The nose is commonly broken by a direct blow (eg from a punch) or following a fall onto the face. Nasal fracture is usually accompanied by bleeding. Search for a history of a ssociated facial/head injury (diplopia, loss of consciousness, etc.). Examination This is a clinical diagnosis based upon a history of injury with nasal swelling and tenderness. Having made the diagnosis, assess whether there is nasal deviation: it is useful to ask the patient to look in a mirror. Check and record whether the patient can bre athe through each nostril. Look for an associated septal haematoma \200\224 this will appe ar as a smooth bulging swelling, which may obstruct the nasal passage. Children are at part icular risk of septal haematoma, which predisposes to secondary infection and septal necros is. Assess for additional injuries to the head or face (eg tender mandible, diplopia, tender ma xilla). Injury to the bridge of the nose may result in persistent epistaxis and/or cerebros pinal \202 uid rhinorrhoea. Investigation Do not X-ray to diagnose a nasal fracture \200\224 the diagnosis is a clinic al one. Obtain appropriate X-rays (eg orthopantomogram (OPG) or facial views) if there is c linical suspicion of other bony injuries. Nasal fractures are often apparent on facial X-ra ys or CT scans. Treatment \200 Resuscitate and treat for associated head injury. \200 Continuing nasal hemorrhage is uncommon \200\224 refer to an ENT surgeon to consider urgent manipulation un der anesthetic (MUA) to stop the bleeding: meanwhile, insert a nasal tampon. Refer urgently to an ENT surgeon if there is a septal haematoma \200\224 this will require incision and drainage in order to prevent septal necrosis. \200 Clean and close overlyin g skin wounds: steristrips often allow good skin apposition. If there is signi \201 cant c ontamination of the wound, start a course of prophylactic oral antibiotics (eg co-amoxiclav : one tablet PO tds for 5 days). Provide oral analgesia (eg ibuprofen 400mg PO tds). \200 If the nose is deviated/distorte d, or if there is too much swelling to judge, arrange for ENT follow-up at 5 \200\2237 days , so that MUA may be performed within 10 days. It is particularly important to ensure accur ate reduction of fractures in children. Discharge with head injury instructions to the care of a relative. 554 CHAPTER 12 Ear, nose and throat Sore throat Tonsillitis Causes Acute pharyngo-tonsillitis may result from infection with a variety of viruses or bacteria: \200 Viral: Epstein \200\223Barr virus (EBV), herpes simp lex virus, adenoviruses. \200 Bacterial: group A B-haemolytic streptococcus (most common bacterial cause), mycoplasma , Corynebacterium diphtheriae . Features Sore throat is frequently accompanied by fever, headache, and mild dysphagia. Insp ection of the tonsils reveals in \202 ammation \200\224 the presence of pus on the tonsil s suggests bacterial infection. Enlarged cervical lymph nodes are found in a variety of inf ections, but generalized lymphadenopathy (sometimes also with splenomegaly) is indicative o f glandular fever (infectious mononucleosis \200\224 see b p.241). Diagnosis Despite the clinical pointers described above, it is usually impossible to distin guish clinically bacterial from viral causes. Investigation Consider throat swabs and anti-streptolysin titre in severe cases. If glandul ar fever is suspected, send blood for FBC and Paul \200\223Bunnell (or Monospot) test. Treatment Unless contraindicated, give paracetamol (1g PO qds PRN) or ibuprofen (400mg PO t ds PRN) and discharge to GP. Although frequently prescribed, oral antibiotics are rarely of bene \201 t: a sensible approach is to limit their use for patients with any of the follo wing: a history of valvular heart disease, immunosupression, diabetes, marked systemic upse t, peritonsillar cellulitis, known B \200\223haemolytic streptococci. In this case, prescr ibe penicillin 500mg PO qds for 5 days (or clarithromycin 500mg PO bd for 5 days if allergi c). Avoid ampicillin, amoxicillin, and co-amoxiclav, which cause a rash in patients infecte d with EBV. Occasionally, patients with acute tonsillitis may be unable to swallow \202 uids (this is more commonly a feature of peritonsillar or retropharyngeal abscess). In this case, refer for IV antibiotics and IV \202 uids.