COMMON ENT PROBLEMS IN EVERYDAY PRACTICEbreatheright.co.za/files/Medical Practitioners... · F...
Transcript of COMMON ENT PROBLEMS IN EVERYDAY PRACTICEbreatheright.co.za/files/Medical Practitioners... · F...
Azgher M Karjieker 086 127 5337
2011
Azgher Karjieker
086 1275 337 [email protected]
Chris Barnard Hospital
Rondebosch Med Centre
Tokai Medicross
Constantiaberg Mediclinic (July 2010)
F Dhansay Audiology
0800 12 4324 [email protected] 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 [email protected]
Chris Barnard Hospital
Rondebosch Med Centre
Tokai Medicross
Constantiaberg Mediclinic (July 2010)
F Dhansay Audiology
0800 12 4324 [email protected] Chris Barnard Hospital Rondebosch Med Centre