Azgher M Karjieker 086 127 5337

2011

Azgher Karjieker

086 1275 337 drk@drkarjieker-ent.co.za

Chris Barnard Hospital

Rondebosch Med Centre

Tokai Medicross

Constantiaberg Mediclinic (July 2010)

F Dhansay Audiology

0800 12 4324 ann@drkarjieker-ent.co.za Chris Barnard Hospital Rondebosch Med Centre

RECOGNISE AND TREAT

MAXIMUM MEDICAL THERAPY

KNOW WHEN TO REFER

COMMON ENT PROBLEMS

AUDIOLOGY ESSENTIALS

ASK QUESTIONS ANYTIME

Seasonal vs Perennial

Sneezing

Nasal blockage

Rhinorrhea

Nasal saline spray essential - EARLY

Dimetap(or equiv) for runny nose

Paed Iliadin for blocked nose

No response: Prelone 1mg/kg (15mg/5ml) ◦ Max 3 times per year (all ages)

Nasal Saline spray

Demazin NS or Equivalent 5 days

Vibrocil 2 puffs tds 5 days max or equiv

Mucolytic: ACC 200 or Mucospect/ Mistabron

No response: Prednisone (F)40-(M)60mg after breakfast 5 days

Facial Pain

Fever

LOA

Green / yellow Nasal Mucus

Progression to infection - add Antibiotic

Allergen test / avoidance – not easy

Cigarette smoke avoidance

Dairy??? – last resort

Antihistamine : itchy eyes/nose/sneezing ◦ Allecet , Deselex or equiv

◦ AS NEEDED OR CHRONIC

Nasal Steroid: pure nasal symptoms ◦ AROUND CHANGE OF SEASON OR CHRONIC

Beclate

Budesonide (Inflanaze)

Fluticasone (Flomist,Flixonase, Avamys)

Mometasone (Nexomist, Nasonex)

Steroid Absorption

Cost

Chronic Medication Med Aid Cover – limited unless asthma as well (J45.0 – PMB)

Singulair (leukotriene inhibitor)

Gaining freq use in combination with Nasal steroid

Great for nasal Polyps (J33.9)

Again – better funded if patient asthmatic as well (PMB)

Same as for control of allergies

Add Paracetamol 10-20mg/kg 120mg/5ml

Ibuprofen 5mg/kg 100mg/5ml

Voltaren Suppository 1mg/kg bd

Saline spray at 1st hint of runny nose

Freq URTI – regular saline spray Mon to Fri after creche

Educate Parents

Adenoids central cause

Water Intake (esp excessive talkers)

Tea/Coffee intake (diuretic effect)

NO response in 2 weeks – add Nasal steroid

?Scan

Unable to Valsalva

Blocked ear – after URTI

Increase water intake

Mucolytic

Oral Steroids

r

Inflamed lining blocks natural drainage pathways - symptoms

Vibrocil or equiv EARLY + Saline spray

Amoxil 1gr tds 10 days

Amox/Clavulanate 2gr bd 10 days

Ketek 800mg dly 5 days

Avelon 400mg dly 7 days

Oral Steroids (for late presentation)

Chronic Facial Pain/Pressure, Headaches

Worse on bending forward

Nasal Steroid

Short course Prednisone

Erythromycin 250mg BD for 3 months

Recurs or Persists – Refer for surgical solution

Oral Steroids

Betnesol Nose drops (2 drops BD 5 days)

Nasal Steroid spray

Singulair

Surgery

OSA symptoms: awakes unrefreshed, daytime somnolence

Open Nose to reverse mouthbreathing

More floppy tissue in mouth to reverberate

Prevent progression to OSA

Start Nasal Steroid early

Weightloss – diet + exercise – review 3 months until goal achieved

Mandibular Advancement splint

Affects daytime productivity

Prevent complications

Heart Disease

CVA

Impotence

Nasal Steroid

Splint

Sleep Study

CPAP

Septoplasty

Tonsillectomy

Palatal Stiffening

Less invasive Tongue suspension (NEW)

Tracheostomy (Last Resort)

MOUTH BREATHING

NEGATIVE IMPACT ON HEALTH

Recurrent URTI

Mouth breathing

Rec Ear Infections

Snoring

Betnesol N 2 drops bd for 5 days

Regular Nasal Saline

4 or more infections per year

Quinsy

Asymmetry ?sinister pathology (lymphoma)

Upper airway obstruction (snoring-OSA)

Prophylaxis Pen VK daily for 3 months <20kg 250mg >20kg 500mg

Longer history

Trismus

Unilateral Swelling

PR or IM Voltaren

High Dose Amoxil

Regular Genpayne

Exclude EBV (Paul Bunnell Test)

Reliant on thin runny mucus

Affected by ◦ Dryness

◦ Thick mucus

◦ Acid irritation

◦ Cig smoke

Sore throat / discomfort

Normal pharynx

Ask about: ◦ Late nibbling

◦ Morning discomfort

◦ Excessive clearing of throat

◦ Recurrent hoarseness

◦ Dyspepsia only in 40%

Increase water intake

Last 2 hours before sleeping – water only

PPI BD before meals for 2-6 months

Gaviscon if eats late for any reason

WAX

Encourage water in ears

Avoid cotton buds

Syringing

Start ear drops early – NOT oral Antibiotic

Covomycin D / Sofradex / Ciloxan / Cilodex

Keep dry 2 months

NSAID

Swollen tight - Refer

Otitis media

Treat adenoiditis + ear infection

Otitis media

If recurrent – same principle

Grommets +Adenoidectomy

Mastoiditis - RARE

Perforation

Keep dry

Safe drops – Ciloxan / Cilodex 4 drops BD

Audiogram + surgery

Sudden hearing loss

Bell’s Palsy

Vertigo

Wax

Mid Ear effusion post URTI +- airtravel

Viral inner Ear infection ◦ Oral Steroids

◦ Antiviral

◦ Disprin

Viral origin Look for vesicles in Ear Oral steroids, protect eye(gel or patch) Antiviral?? Resolves 6-8 weeks

It’s all in the history

Rotatory Vertigo

Postural Hypotension

Few seconds = BPPV

Worse to one side

Loose crystals in Inner Ear

Epley Manouvre

Few minutes to hours, episodic with hearing loss/aural fullness and tinnitus = Meniere’s Disease

Low salt diet, HCTZ 12.5mg daily

? Longterm anti emetic

Few days at a time with no hearing loss = Vestibular neuronitis

1st few days severe – then abates

IMI Stemetil

Serc 24mg BD 5 days then wean

Few days at a time with hearing loss = Labyrinthitis

IMI Stemetil

Serc 24mg BD

Oral Steroids

Other – Anaemia, Thyroid Dysfxn, CVA

Other symptoms/signs

Blood tests

Refer – any atypical features

Excise if recurrently infected

Exclude septal Haematoma

Palpate facial bones

Loss of Consciousness – refer to casualty

Fracture needs manipulation within 2 weeks

Xray not necessary

Earache – sharp, shooting H92.0

Eardrum normal

Jaw clicks

Celebrex + Refer physio & Max Fac

Pinch Correctly

Vibrocil

Cyclokapron 3tabs stat then 1tab tds

Pack nose

Alternatively WHEN ENCOUNTERED WITH MILD OR MODERATE BLEEDING FROM THE NOSE THE TREATMENT IS SIMPLE, APPLY AN ICE-PACK TO THE TESTICLE OR BREAST-NEW ENGLAND JOURNAL OF MEDICINE 1874

Adequate Tools

Hands free

Limited opportunity to get it out

Get behind object with hook if hard

Use crocodile if soft

If a mother says her child can’t hear it is almost always true

unilateral nasal discharge – foreign body

inflamed swollen cheek – dental abscess

Look at ear in cases of facial palsy

refer if hoarse voice >1 month

sun should never set on a foreign body in nose

beware of the old man with sore throat and

cottonwool in his ear

adult with Mid Ear Effusion – Post Nasal Space growth/ HIV

unilateral neck swelling

only thing you can put in your ear is your elbow

AUDIOLOGY

Just the basics

Air Conduction Bone Conduction

Normal Effusion Negative Pressure

Bone conduction > Air conduction

Bone and air conduction equally affected

Personal Music

Players

Work

Dip at 4000hz diagnostic

Azgher Karjieker

086 1275 337 drk@drkarjieker-ent.co.za

Chris Barnard Hospital

Rondebosch Med Centre

Tokai Medicross

Constantiaberg Mediclinic (July 2010)

F Dhansay Audiology

0800 12 4324 ann@drkarjieker-ent.co.za Chris Barnard Hospital Rondebosch Med Centre