Ear, Nose, Throat and Dental Problems
Ear, nose and throat (ENT) examination needs patience and practice to master. Patients may cough or sneeze, showering you with their body fluids, so protect yourself with gloves, apron, mask and eye protection. Adequate light and topical anaesthesia makes examination easier and your patient more comfortable.
Ear pain is usually caused by infection in the middle ear – otitis media. The eardrum appears dull with prominent blood vessels. Sinusitis presents as headache and a feeling of pressure in the face. These are self-limiting conditions caused by a viral upper respiratory tract infection, blocking drainage from airspaces within the head. Analgesics and decongestant drugs are helpful; antibiotics are not.
Otitis externa or ‘swimmer’s ear’ is a localised infection of the ear canal, which becomes congested with discharge and debris. Otitis externa is treated with topical antibiotics and steroids, applied using a wick of cotton wool.
Ruptured ear drum
Commonly caused by trauma, barotrauma or infection, a ruptured ear drum normally heals within 2 months. Patients should avoid immersing the ear in water.
Vertigo causes a sensation of spinning; it is not just ‘feeling faint/ light-headed’. Vertigo is caused by conflicting sensory information from ears, eyes and joints. The problem is usually due to peripheral (sensory) problems rather than central (brain) ones.
• A peripheral cause is likely if the patient has hearing loss, tinnitus, ear infection, headache, nausea and vomiting.
• A central cause is likely if the patient has motor symptoms or cardiovascular risk factors, e.g. atrial fibrillation.
Use the Dix-Hallpike test to differentiate central from peripheral causes. If there are central signs, check blood glucose and ECG – consider transient ischaemic attack (TIA)/stroke or other neurological cause (Chapter 42).
If the patient has no hearing loss, the most common cause of vertigo is vestibular neuronitis, usually caused by a (viral) upper respiratory tract infection. Prochlorperazine (an anti-emetic) +/− intravenous fluids is particularly effective. Antihistamines are structurally similar drugs and can also be used. Vestibular labyrinthitis is similar, but patients may have hearing loss and tinnitus.
Nose and face Common presentations Nosebleed
Most patients bleed from venous plexi in the anterior part of the nose – Little’s area. Some (usually elderly) patients may have bleeding from the posterior part of their nasal cavity. Ask about warfarin and antiplatelet drugs such as aspirin and clopidogrel. Check FBC/clotting in older patients. Pack the nose and admit according to local protocols.
Assess stability of upper teeth and mandible, and sensation over the face. If there is a fracture of the orbital floor, examine the eye movements (Chapter 22). Radiographic facial views are necessary, but are difficult to interpret – look for asymmetry. If there is mandibular injury, request XR OPG (oral pantomogram): fractures of the neck of the mandible can be difficult to spot.
A patient with a painful swollen nose following trauma is likely to have broken their nose. X-rays do not change management. The patient should be discharged and reviewed in 5–7 days in an Ear, Nose and Throat clinic.
Do not miss
Septal haematoma – a swelling from the medial side of a fractured nose, usually in a young adult. This requires urgent drainage to prevent avascular necrosis of the cartilage.
Pharyngitis and tonsilitis can be caused by bacteria or viruses. Viral pharyngitis is more likely if the patient has runny nose/ conjunctivitis/diarrhoea. Group A B-haemolytic Streptococcus (GAβHS) is responsible for 10% of pharyngitis, and is treated by penicillin/erythromycin if three or more of the following criteria are present.
• Exudate on the tonsils.
• Tender anterior neck lymph nodes.
• Lack of cough.
If two or more criteria are present, rapid antigen tests can be used to identify those patients with GAβHS. Complications of untreated GAβHS are uncommon, and over-treatment with antibiotics is self-reinforcing. Patients who are systemically unwell with extensive bacterial pharyngitis need admission for intravenous penicillin and fluids.
Foreign body in throat/oesophagus
The site of pain suggests location of the foreign body.
• Unilateral pain – foreign body above cricopharyngeus.
• Pain in submandibular region – foreign body in tonsillar fossa.
• Pain around larynx – foreign body in posterior tongue.
If there is pain on every swallow, the foreign body is probably still there; if there is just vague discomfort, the foreign body has probably gone. Radiography is useful for bones, but fishbones, a common cause, are not very radio-opaque.
If there is no danger of the foreign body causing obstruction were it to be pushed into the trachea, it may be removed under direct vision using forceps or suction. Otherwise it is likely the foreign body will need to be removed under general anaesthesia.
Foreign bodies stuck in the oesophagus will often move with a combination of glucagon (which relaxes the lower oesophageal sphincter) and fizzy drink. Failure necessitates endoscopy.
Diagnoses not to miss
Quinsy (peritonsillar abscess)
Quinsy causes a painful, asymmetrically swollen throat with difficulty opening the mouth or swallowing and a ‘plummy’ voice. Treated by aspiration or drainage in theatre, together with antibiotics.
Epiglottitis, retropharyngeal abscess, Ludwig’s angina
These rare but dangerous infections can cause upper airway obstruction, giving stridor, a whistling sound worse on inspiration. Patients are unwell with high fever, sitting forward, with a stiff neck, drooling saliva they are unable to swallow. Treatment is urgent anaesthetic and ENT airway assessment and antibiotics.
Postoperative bleeding is often a result of infection: these patients should always be reviewed by the Ear, Nose and Throat team.
Dental pain is usually caused by dental caries leading to local infection (pulpitis) and abscesses. Affected teeth are tender to percussion and temperature. Treatment is analgesia and advice to see a dental practitioner. Antibiotics are not normally indicated.
Wounds inside the mouth rarely need treatment as they heal very rapidly, and saliva has a natural antibacterial action. Exceptions are ‘through and through’ lacerations (through oral mucosa, muscle and facial skin) or lacerations involving the tip of the tongue.
An avulsed tooth should be replaced in the socket immediately if it is to survive. If this is not possible, the patient should carry the tooth between cheek and teeth. A dentist can place a splint to the tooth in place.