18: ENT

Published on 23/06/2015 by admin

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Last modified 23/06/2015

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Section 18 ENT

Edited by Peter Cameron

18.1 Ears, nose and throat

Foreign body

Foreign bodies in the ear are most common in children under the age of 5 and in mentally handicapped adults. Animate objects such as insects in the ear can affect all ages, especially adults who enjoy the outdoors, particularly at dusk.

Accidental foreign bodies, such as the end of a cotton bud or a matchstick, occur in people obsessed with cleaning their ears with such objects.

Removal of a live foreign body

This is a true ENT emergency. The insect should be killed as a matter of urgency, as considerable damage is being done to the sensitive skin of the bony meatus and the tympanic membrane by the flapping wings and appendages of the desperate insect trying to escape.

The movement of the insect also causes intense pain and tinnitus, thereby creating further anxiety and distress.

Any liquid used to kill the insect should be carefully chosen so as to avoid damage to the sensitive skin and tympanic membrane: strong corrosive agents, knockdown spray or alcohol should be avoided. The common agents of choice are lignocaine 2%, olive oil, water for injection or normal saline.

One of the preferred methods is to instil some water for injection from a 10 mL plastic ampoule and leave an examination light on the pinna. The insect swims up to surface towards the light and can be helped to safety by holding the tip of the ampoule.1

Removal of a foreign body in a child or a mentally handicapped adult may be done in one of two ways. The patient is either cooperative and unrestrained or fully restrained. It is vital not to attempt any procedure with partial restraint, as any movement of the patient during the attempt could cause trauma to the ear canal and the tympanic membrane.

There are two techniques used to remove a foreign body. The dry method is by using a Jobson Horne probe for solid objects such as beads or alligator forceps for an insect or a cotton bud. The wet method is by syringing the ear canal with tepid water. The water should be close to body temperature to avoid a caloric effect, which produces nystagmus and vertigo.

The key to success is good lighting, preferably through a head lamp, a cooperative or fully restrained patient, and a patient, gentle approach by the clinician, who knows when to stop if unsuccessful.

Trauma

Trauma to the ear canal requires the ear to be kept dry for about a week with antibiotic ear drops for 4–5 days in severe cases to avoid progressing into otitis externa.

Penetrating trauma can cause perforation of the eardrum and occasionally disruption of the ossicular chain. Dislocation of the footplate of the stapes following such an injury can cause permanent sensorineural hearing loss. Referral to an ENT specialist is essential in all cases of traumatic perforation with suspected ossicular chain disruption.

Infection

Otitis externa

Infection of the external ear is common and affects between 3 and 10% of the patient population.2 It can be localized (furuncle) or diffuse. The symptoms are pain, itching and tenderness to palpation, followed by aural fullness, hearing loss and discharge. The common pathogens responsible are Pseudomonas aeruginosa, Proteus spp. and Staphylococcus aureus.3

The diagnosis is usually self-evident, but the diagnostic signs of otitis externa are tragal tenderness or pain on pulling the pinna. This is a disease of the cartilaginous ear canal, with swelling and discharge causing occlusion of the meatus. It may be extremely painful to pass the ear speculum and often the tympanic membrane is not able to be visualized.

Management

The most important step in the treatment is thorough and atraumatic cleansing of the ear canal.4 Tolerance and cooperation between the patient and the clinician is vital. Pope Otowick (Xomed)® is very useful in the management of this condition. This is a semirigid foam wick that, when inserted into the ear canal, swells, absorbing moisture to increase the size of the ear canal. Topical otic drops, such as Sofradex® (Roussel), are used three to four times a day and the patient is reviewed on a daily basis to change the wick and continue the ear toilet. Occasionally oral antibiotics such as ciprofloxacin or flucloxacillin may be required,5 particularly if there is evidence of cellulitis. The patient is advised to keep the ear clear of any water. Strong analgesics are usually required.

Fungal otitis externa (otomycosis) tends to be not that painful and is treated with ear toilet as described and topical antifungal ear drops such as Loco corten vioform.