13: EAR, NOSE AND THROAT

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CHAPTER 13 EAR, NOSE AND THROAT

The discharging ear

Cervical lymphadenopathy

DEAFNESS

Ear wax is the commonest cause of reduced hearing in general practice but it rarely causes deafness.

Diagnosis

History.

Ask the patient:

• whether the deafness is unilateral or bilateral, and whether the deafness was of sudden or gradual onset

• if there are any associated symptoms, such as tinnitus or vertigo, which may suggest a labyrinthine disorder

• whether any drugs have been taken which may affect the acoustic nerve, such as streptomycin and gentamicin.

In the case of children, the parents’ account of hearing loss or delayed speech development must be taken seriously.

Examination

• Test the hearing with a whispered voice in each ear in turn.

• Examine to exclude wax, otitis media and a perforated eardrum. (The canal needs to be completely blocked before wax can be held responsible for the hearing loss.)

• Decide whether the problem is conductive or sensorineural using Weber’s and Rinne’s tuning fork tests.

Weber’s test.

Place the foot of a vibrating tuning fork on the vertex of the patient’s skull and ask in which ear the sound is loudest. An asymmetrical Weber’s test indicates conductive deafness on the loud side or sensorineural deafness on the quiet side.

Rinne’s test.

Place the foot of a vibrating tuning fork on the patient’s mastoid process. As soon as the sound fades away, hold the tines of the same tuning fork by the external auditory meatus. The normal ear should be able to hear the noise from the tines after the sound from the foot has faded. If bone conduction is louder than air conduction, a conductive loss is likely.

Management

Children with hearing loss and glue ear need considering for grommet insertion.

Referral

Unilateral sensorineural hearing loss, of recent onset, should be referred urgently in case of acoustic neuroma.

If the principal symptom is bilateral hearing loss and there is no external or middle ear problem to account for it, refer to ENT outpatients. In the elderly this is the commonest scenario and is due to the presbyacusis of old age. It can be helped by a hearing aid, which may be obtained by referral to the ENT outpatient department, or by direct referral to a hearing aid department, according to local policy.

Administration

Referral to a social worker for the deaf may be helpful, if this has not been done by the hospital.

THE DISCHARGING EAR

The commonest cause of discharging ear in general practice is otitis externa. It is usually unilateral.

EARACHE

Earache can be very painful and makes children miserable. Parents of small children soon learn the importance of keeping a stock of paediatric paracetamol in the house.

Diagnosis

Examination.

If the eardrum is red, bulging or dull, middle ear infection is suspected. If the eardrum is normal, eustachian tube dysfunction is likely, i.e. increased pressure in the middle ear due to a blocked eustachian tube.

• a boil in the canal

• the vesicular rash of shingles

• inflammation behind the earlobe, suggesting mastoiditis.

Investigations.

Take a swab of any discharge from the ear and send it to bacteriology.

Management

Otitis media.

Treat with regular analgesia, e.g. paracetamol. Antibiotics, e.g. amoxicillin 125 mg tds under 3 years of age, 250 mg tds over 3 years, may be given if symptoms persist >48 hours.

Eustachian tube dysfunction.

For eustachian tube dysfunction advise regular analgesia and warm drinks. (The action of swallowing helps.) The role of decongestants is more controversial.

Otitis externa.

For otitis externa prescribe an antibiotic eardrop, such as Gentisone HC eardrops, with or without an oral antibiotic, such as amoxicillin. If there has been no response in 1 week, try an alternative eardrop, e.g. Otosporin or Locorten-Vioform, with or without oral erythromycin. Refer for aural toilet if there is no response.

Wax.

Ear wax can be painful, but usually responds to the use of olive oil eardrops for 1–2 weeks. Syringing may be necessary if the wax persists.

Boil.

A boil in the ear canal requires analgesics. Antibiotics or incision and drainage may be necessary if the pain is severe.

Shingles.

If mastoiditis is suspected, refer the patient to ENT urgently.

Temporomandibular joint dysfunction.

This also requires analgesics. Reassure the patient that the condition is self-limiting. Advise a dental opinion if the pain persists.

Toothache.

This is best dealt with by prescribing analgesics and advising patients to contact their dentist. For dental abscesses prescribe penicillin V and metronidazole (see p. 221).

Perforated eardrum.

TINNITUS

Tinnitus is a ringing, buzzing, hissing or pulsating in the ears.

Management

• Patients with tinnitus often present for the first time with fear of a sinister underlying disease, such as a brain tumour or high blood pressure. Reassure the patient if appropriate.

• Treat associated depression.

• The majority of cases resolve. Distraction techniques, such as increasing background noise, are often useful.

• Treat wax or otitis if present.

• If there is no response and the patient is still suffering, referral to ENT outpatients is indicated.

• ‘Maskers’ are available through ENT outpatients.

• Suggest the Tinnitus Association for educational support (see pp. 355–356).

In persistent, unilateral tinnitus of recent onset, refer to ENT to exclude acoustic neuroma.

In Ménière’s disease and other longstanding causes of tinnitus, patients should be told that drug treatment is mainly ineffective and that, while the ringing will not go away, they will gradually become less aware of it.

HAY FEVER

In some areas hay fever is the commonest condition presenting to GPs in May and June.

EPISTAXIS

Patients with nose bleeds present in general practice both acutely, with bleeding, and afterwards, for the prevention of recurrence.

Diagnosis

History.

Ask how much blood has been lost, which nostril the blood comes from and whether the patient has any disorder of blood clotting.

Examination.

Measure BP. Look up the nose to try and identify a bleeding point. Little’s area, on the nasal septum just inside the nostril, often contains some large, delicate blood vessels.

Management

Nose bleeds are very common in young children and are often recurrent. No specific preventive treatment is necessary, as the tendency often remits spontaneously.

To stop acute bleeding

• Advise the patient or parent to squeeze the nose just below the bony part of the nasal bridge. The pressure needs applying continuously for 15 minutes, and it is best if this is timed with a watch. This stops most bleeds.

• If the bleeding does not stop within 15 minutes of continuous pressure and the bleeding is heavy, admit the patient. Alternatively, pack the nose with an adrenaline-soaked wick by pushing it gently towards the back of the nasal cavity with McGill forceps. A nasal balloon catheter may be used instead. Admit the patient if this does not control the bleeding.

To prevent further bleeding

• The recurrent bleeding nose is probably best cauterised. If a bleeding point can be identified in Little’s area the blood vessel can be touched with the tip of a silver nitrate stick.

• Consider referral for nasal cautery if the bleeding point cannot be identified or controlled.

BLOCKED NOSE

Nasal obstruction can be either bilateral or unilateral, although distinguishing between the two is of little diagnostic use in general practice, except when a foreign body in the nose is suspected. A more useful distinction is between acute blockage (of a few days) and chronic blockage (of, say, more than 3 weeks).

ACUTE BLOCKAGE

Management

If symptoms warrant treatment in an URTI, advise normal saline nose drops. Failing this, xylometazoline nose drops will help if used for a short while.

Hay fever.

Sinusitis.

The blocked nose of acute sinusitis is associated with yellow, green or blood-streaked nasal discharge and facial tenderness. Treat with amoxicillin or doxycycline. For chronic sinusitis, treat initially with steroid sprays or decongestants, e.g. beclometasone two sprays bd per nostril. Otherwise, refer for sinus X-rays or CT and antral lavage if indicated.

CHRONIC BLOCKAGE

Management

Nasal steroid sprays, e.g. beclometasone, may provide partial relief, as will treatment of acute infective exacerbations with antibiotics.

Referral.

Referral for e.g. adenoidectomy should be considered for nasal speech, recurrent infections or glue ear in children, and for e.g. submucous resection or polypectomy, if appropriate, on failure of medical treatment in adults. For snoring/obstructive sleep apnoea advise weight loss and alcohol reduction if appropriate. Consider referral if symptoms are severe or daytime somnolence is significant (see p. 221).

SORE THROAT

Acute viral or streptococcal sore throats are a very common feature of general practice. Glandular fever, quinsy and the sore throat of postnasal drip in sinusitis are less common.

Diagnosis

History.

• The duration of the symptoms: most acute viral and streptococcal sore throats get better spontaneously within 5–7 days.

• Symptoms of systemic illness: fever, sweating, myalgia and fatigue all suggest a more severe infection.

• The patient’s expectations: some patients expect a prescription for antibiotics; others want reassurance or a medical certificate.

Examination

• Examine the throat with a good light.

• Look for the presence of pus on the tonsils, suggesting tonsillitis, and for the creamy white film of glandular fever.

• Palpate the cervical lymph nodes.

Investigations.

Investigations are usually unnecessary and unhelpful in the majority of cases of sore throat. Throat swabs take at least 3 days to give a result, by which time most patients are better.

Blood-testing for glandular fever becomes more sensitive after the first 3 weeks, so repeat the test if a first early test is negative and the patient is no better 1–2 weeks later.

Management

Viral infections.

Viral throat infections are best treated with analgesics. Antiseptic or analgesic mouthwashes may also help.

Bacterial infections.

In streptococcal throat infections the duration of the illness can probably be shortened by 24 hours with the use of penicillin. (Unfortunately there is no quick way of distinguishing between viral and bacterial throat infections. The use of antibiotics is therefore difficult to justify.) If the patient is toxic, prescribe an antibiotic that is effective against streptococci, e.g. penicillin V, or erythromycin, 250 mg qds for 5 days.

Quinsy.

Painful, marked swelling of a single tonsil suggests a quinsy, especially if a collection of pus can be seen to point from within the tonsil. Refer the patient to ENT casualty for incision and drainage.

Glandular fever.

Chronic sore throat.

Consider physical causes of irritation of the throat, such as snoring, dust inhalation, gastro-oesophageal reflux.

Recurrent sore throat.

Reinfection within families is a cause of recurrent throat infection, particularly with Streptococcus pyogenes. Send a throat swab and treat the family with penicillin or erythromycin if positive. Consider referral for tonsillectomy if more than five episodes of tonsillitis a year and/or significant snoring or apnoea.

If a patient on carbimazole develops a sore throat, consider neutropenia. Check an FBC urgently.

Mouth ulcers.

CERVICAL LYMPHADENOPATHY

The isolated, enlarged lymph node in the neck is usually an associated finding with URTIs. Enlarged lymph nodes occasionally present alone, either with tenderness or without.

Management

• Often the cause is a non-specific viral illness and the gland returns to its normal state after a few weeks.

• Treat any underlying infection, as appropriate.

• If no infection can be found it is reasonable to wait and see for 3–4 weeks in the absence of other symptoms.

• If the gland remains enlarged, an FBC with differential white count, ESR and a glandular fever test will reveal most haematological malignancies and glandular fever. If the blood tests are negative, refer the patient to the ENT outpatient department for a biopsy to exclude tuberculosis or malignancy.

HOARSENESS

Hoarseness and loss of voice commonly present in general practice as acute problems in association with URTIs. Acute viral laryngitis is the usual cause, for which the treatment is symptomatic: analgesia for the sore throat and resting the voice.

GUM DISEASE

DENTAL ABSCESS

A dental abscess produces a painful tender swelling of the cheek adjacent to an infected tooth root. Often the carious tooth can be identified. It is worth excluding a parotid gland swelling by making sure the angle of the jaw is palpable.

Management

Prescribe analgesia, e.g. co-codamol, 1–2 tablets 4–6-hourly (max = 8 tabs/24 hours), and antibiotics, such as penicillin V 500 mg 6-hourly and metronidazole 800 mg 8-hourly.

Refer patients to their dentist.

GINGIVITIS

Gingivitis is inflammation of the gums, making them fragile and prone to bleeding on brushing. It occurs in the presence of dental caries, although not exclusively.

Management

Advise patients on general dental hygiene and suggest they see a dental hygienist. Chlorhexidine oral rinse 0.2% is useful in some cases.

MOUTH ULCERS

Painful acute ulceration is nearly always benign, but consider carcinoma of the oral cavity for ulcers that do not resolve over 4 weeks.

Management

• Mouth ulcers are usually aphthous, but can occasionally be viral. Most respond to symptomatic treatment with an analgesic oral gel.

• Prescribe nystatin oral suspension 1 ml qds if thrush is likely.

• Adcortyl in Orabase applied to the ulcers often speeds up the healing.

• Benzydamine spray is useful for ulcers of the tongue.

SNORING

Snoring affects everyone some of the time, and some people most of the time! Most requests for medical help come from partners whose sleep is affected by the patient’s snoring.

In most cases of snoring the cause is unknown, or due to obesity.

Management

• Advise weight loss if the BMI is greater than 26 or if the collar size is >17 inches.

• Advise alcohol moderation in drinkers.

• Encourage patients to sleep on side and avoid excess pillows.

• Consider beclometasone nasal spray for nasal congestion.

• For nasal obstruction advise the use of AirFlow nasal plasters, or Nozovent. Both these are devices for holding the nostrils open at night, and are available from most pharmacies.

Referral.

Refer to ENT for consideration for surgery, e.g. septal straightening, polypectomy, turbinate reduction, tonsillectomy or uvulopalatopharyngoplasty.

Refer to a sleep clinic or local chest physician if the patient complains of daytime somnolence. Sleep apnoea can be a complication of snoring, especially in patients with a collar size >17 inches. This condition is treatable with continuous positive pressure ventilation via a nasal mask at night.

Related

Churchills Pocketbook of General Practice