Ear, Nose and Throat problems are frequently encountered in Primary care and A&E departments both in children and adults. Most conditions require an office based treatment. A detailed assessment is needed to confidently diagnose and treat all ENT complaints. On occasions, blood test and radiological investigations are required to diagnose an underlying condition. Some common conditions are mentioned below:
Symptoms include itch, ear discharge, temporary dulled hearing, and pain.
Otitis externa is common and often occurs 'out of the blue' for no apparent reason.
Treatment: Usually include local (Topical) drops and suction to clear the debris. Occasionally it requires oral or intravenous antibiotics.
Allergic rhinitis is a common condition characterized by an IgE-mediated inflammation of the nasal mucosa following exposure to allergens.
Sneezing occurs within minutes of exposure due to stimulation of afferent nerve endings .
Increase in nasal secretion follows shortly afterwards, to peak 15-20 minutes after contact with the allergen.
Characterized by nasal obstruction, Sneezing, Rhinorrhoea.
Allergens commonly include tree pollen (spring time), grass / weed pollens (summer) and occasionally, mould spores (late summer / autumn), house dust mites and domestic pets.
Severity is measured by assessing effect of symptoms on sleep and normal daily activities (including school, work, sport and leisure). If one or more is affected, the condition is deemed to be moderate or severe.
A large, swollen, edematous inferior or middle turbinate can easily be confused with a polyp; polyps, however, unlike turbinate, are usually pale grey, translucent and mobile and lack any sensation on gentle.
Examine eyes for signs of conjunctivitis.
Rule out other associated conditions.
1. Topical nasal antihistamines:
They have superior effects to oral antihistamines for rhinitis symptoms, but do not reduce symptoms at other sites e.g. eyes.
They are fast acting (less than 15 minutes) so are a useful 'rescue'.
2. Oral antihistamines:
Regular therapy is more effective than 'as required'.
3. Most patients will attain good control on intranasal steroids and a large body of data shows that they are effective for all symptoms of allergic perennial rhinitis, including nasal obstruction, itching, sneezing and watery rhinorrhoea.
Modern intranasal steroids are safe for long term use in adults when used within the recommended dosage.
4. In children, they should be used at the lowest dose that controls symptoms, particularly when used concurrently with other inhaled or intranasal steroids.
5. Topical nasal decongestants may be useful at the start of treatment to "open up" the nose and should be used for less than two weeks to avoid the risk of developing "rhinitis medicamentosa".
Oral steroids should be used only as a last resort when other treatments have failed.
When drugs fail and a structural abnormality exists, surgery may be indicated:
Surgical reduction of the inferior turbinate or correction of a deviated nasal septum or nose may be needed to improve the airway or at least to improve access for topical medical treatment.
This is administered by the subcutaneous or sublingual route (SLIT) and has been shown to be effective in both seasonal and perennial allergic rhinitis in patients with proven IgE mediated disease and a limited spectrum of allergies.
Its use is confined to those patients in whom a perennial allergen is the dominant cause and in whom avoidance measures and medical treatment are either not effective or not tolerated owing to side effects.
The presence of chronic bronchial asthma is a contraindication to immunotherapy in the United Kingdom.
The common site for a nosebleed to start is from just inside the entrance of the nostril, on the nasal septum (the middle harder part of the nostril). Here the blood vessels are quite fragile and can rupture easily for no apparent reason. This happens most commonly in children. This delicate area is also more likely to bleed with the following.
In the above situations, the bleeding tends to last only a short time and is usually easy to control. The bleeding may last longer and be harder to stop if you have: heart failure; a blood clotting disorder; are taking 'blood thinning' drugs (anticoagulants) such as warfarin or aspirin.
Bleeding sometimes comes from other areas further back in the nose. It is sometimes due to uncommon disorders of the nose, or to serious injuries to the nose.
For most nosebleeds, simple first aid can usually stop the bleeding.
If you are not feeling faint, sit up and lean slightly forward.
With a finger and thumb, pinch the lower fleshy end of the nose completely blocking the nostrils. It is useless to put pressure over the root of the nose or nose bones. Usually, if you apply light pressure for 10-20 minutes, the bleeding will stop.
If available, a cold flannel or compress around the nose and front of face will help. The cold helps the blood vessels to close down (constrict) and stop bleeding.
Once the nosebleed has stopped, do not pick the nose or try and blow out any of the blood remaining in the nostrils. This may cause another nosebleed.
If you feel faint it is best to lie flat on your side.
Get medical help quickly if bleeding is heavy, or it does not stop within 20-30 minutes. Sometimes the nose needs to be packed by a doctor to stop the bleeding. Rarely, a nosebleed is so heavy that a blood transfusion is needed, and surgery may be required to stop it.
Snoring is noisy breathing caused by vibration of relaxed soft tissues of the nose, soft palate or pharynx whilst sleeping or drowsy.
It affects up to 40% of the UK population.
It is more common in men.
Obstructive sleep apnoea (OSA) occurs in 1% of people who snore: there is total upper airway collapse, with cessation of airflow for at least 10 seconds, occurring >5 times per hour. The snoring sound can be generated at one or more levels:
1. Encourage weight loss as appropriate.
2. Lifestyle advice: more exercise, less alcohol, less sedatives, stop smoking Posture adjustment and sleep position training: e.g. tennis ball taped to back to stop patient rolling onto back. Bed wedges and pillows may also help.
3. Ear plugs for partner.
4. Decongestants and steroid nasal sprays can help nasal congestion.
5. Devices that splay the nasal alae may help nasal.
6. Oral appliances can advance the soft palate, tongue or mandible and therefore open the airway. 7. Mandibular advancement devices may help if snoring is generated from tongue base or in mouth breathers (best fitted by dentist).
8. Continuous positive airway pressure (CPAP) often works well in most circumstances but may not be readily available for those without OSA.
Those with normal anatomy and near normal BMI do best. Procedure performed depends on level of obstruction:
1. Nasal surgery
2. Septoplasty
3. Polypectomy
4. Turbinate reduction
5. Sometimes the above procedures are carried out in combination
6. Tongue base reduction (laser)
Obstructive sleep apnoea syndrome (OSAS) is a condition where your breathing stops for short spells when you are asleep. The word apnoea means 'without breath', that is, the breathing stops. In the case of OSAS, the breathing stops because of an obstruction to the flow of air down your airway. The obstruction to the airflow occurs in the throat at the top of the airway.
You may also have episodes where your breathing becomes abnormally slow and shallow. This is called 'hypopnoea'. Because there can also be these episodes of hypopnoea, doctors sometimes use the term 'obstructive sleep apnoea/hypopnoea syndrome'.
OSAS can occur at any age, including in children. However, it most commonly develops in middle aged men who are overweight or obese. It is thought that as many as 4 in 100 middle aged men and 2 in 100 middle aged women develop OSAS.
Factors that increase the risk of developing OSAS, or can make it worse, include the following. They all increase the tendency of the narrowing in the throat at night to be worse than normal.
Overweight and obesity. Particularly if you have a thick neck as the extra fat in the neck can squash the airway.
Drinking alcohol in the evening. Alcohol relaxes muscles more than usual and makes the brain less responsive an apnoea episode. This may lead to more severe apnoea episodes in people who may otherwise have mild OSAS.
Enlarged tonsils.
Taking sedative drugs such as sleeping tablets or tranquilisers.
Sleeping on your back rather than on your side.
Having a small or receding lower jaw (a jaw that is set back further than normal).
Smoking.
You may also have a family history of OSAS.
People with OSAS may not be aware that they have this problem as they do not usually remember the waking times at night. It is often a sleeping partner or a parent of a child with OSAS that is concerned about the loud snoring and the recurring episodes of apnoea that they notice.
One or more of the following also commonly occur:
Daytime sleepiness. This is often different to just being 'tired'. People with severe OSAS may fall asleep during the day with serious consequences. For example, when driving, especially on long monotonous journeys such as on a motorway. A particular concern is the increased frequency of car crashes involving drivers with OSAS. Drivers with OSAS have a 7-12 increased risk of having a car crash compared to average. You should not drive or operate machinery of you feel sleepy.
Poor concentration and mental functioning during the day. This can lead to problems at work.
Not feeling refreshed on waking.
Morning headaches.
Depression.
Being irritable during the day.
Some people with OSAS find that they get up to pass urine frequently during the night. Less common symptoms also include night sweats, reduced sex drive, and gastro-oesophageal reflux disease.
People with untreated OSAS also have an increased risk of developing high blood pressure. Having high blood pressure can increase your risk of having a heart attack or stroke. People with untreated OSAS may also have an increased risk of developing problems with blood sugar regulation.
If you have daytime tiredness, sometimes a questionnaire is used to measure where you are on the Epworth Sleepiness Scale. This helps to gauge the level of sleepiness that you feel during the daytime. A high score indicates that you may have a sleeping disorder such as OSAS. See separate leaflet called 'Epworth Sleepiness Scale' for more details.
If you have symptoms that suggest OSAS, or a high score on the Epworth Sleepiness Scale, your GP may refer you to a specialist for tests. There are various types of test that can be done whilst you sleep. The ones done may be determined by local policies and availability of equipment. For example: Your airflow may be measured whilst you sleep by using a probe placed under your nose.
A sensor may record snoring volume and body movement whilst you sleep.
The oxygen level in your blood can be monitored by a probe clipped onto your finger.
Breathing can be monitored and recorded by the use of special belts placed around the chest and abdomen.
A video of you sleeping may be helpful.
You may be asked to spend a night in hospital for the tests to be done. However, some of the tests may be done in your own home from equipment supplied by the specialist. The information gained from the tests can help a specialist to firmly diagnose or rule out OSAS.
You doctor will usually check your blood pressure. (OSAS is associated with high blood pressure.) They may also suggest other tests to exclude other causes of your sleepiness. For example, a blood test can check for an underactive thyroid gland.OSAS, driving and operating machinery
If you have OSAS and you are a driver, you must not drive and you must inform the DVLA (Driver and Vehicle Licensing Agency). For normal car drivers, you will usually be allowed to resume driving after you have had treatment so that you no longer have daytime sleepiness. However, special rules apply if you have an HGV or similar license.
Equally, if you have daytime sleepiness, you should not operate heavy machinery as this can also be dangerous.
Things that can make a big difference include:
Losing some weight if you are overweight or obese.
Not drinking alcohol for 4-6 hours before going to bed.
Not using sedative drugs.
Stopping smoking if you are a smoker.
Sleeping on your side or in a semi-propped position.
This is the most effective treatment for moderate or severe OSAS. It may be used to treat mild OSAS if other treatments are not successful. This treatment involves wearing a mask when you sleep. A quiet electrical pump is connected to the mask to pump room air into your nose at a slight pressure. The slightly increased air pressure keeps the throat open when you are breathing at night and so prevents the blockage of airflow. The improvement with this treatment is often very good, if not dramatic.
If CPAP works, (as it does in most cases) then there is an immediate improvement in sleep. Also, there is an improvement in daytime wellbeing as daytime sleepiness is abolished the next day. Snoring is also reduced or stopped. The device may be cumbersome to wear at night, but the benefits are usually well worth it. Comments like "I haven't slept as well for years" have been reported from some people after starting treatment with CPAP.
Lifelong treatment is needed. Sometimes you can have problems with throat irritation or dryness or bleeding inside you nose. However, newer CPAP machines tend to have a humidifier fitted which helps to reduce these problems.
Ear wax forms a protective coating of the skin in the ear canal. Small amounts are made all the time. Flakes or crusts of wax break off and fall out of the ear from time to time.
The quantity of ear wax made varies greatly from person to person. Plugs of wax form in some people. This may cause a feeling of fullness and dulled hearing. A doctor or nurse can look into the ear canal and confirm a plug of wax has formed.
Ear drops alone will often clear a plug of wax. You can buy drops from pharmacies. For example, sodium bicarbonate, almond oil, or olive oil ear drops. Warm the drops to room temperature before using them. (Let the bottle stand in the room for about half an hour.) Pour a few drops into the affected ear. Lie with the affected ear uppermost when putting in drops. Stay like this for 2-3 minutes to allow the drops to soak into the wax. The wax is softened, and it often breaks up if you put drops in 3-4 times a day for 5-7 days. Flakes or crusts of wax usually fall out bit by bit.
This may be needed if ear drops do not work. Syringing will usually clear wax. But, it will usually only work if the plug of wax has been softened. Therefore, use ear drops to soften wax 2-3 times a day for five days prior to syringing. Ear syringing is usually painless. Lukewarm water is squirted into the ear canal. This dislodges the softened plug which then falls out with the water.Some people feel dizzy after ear syringing, but this quickly settles. Some people develop an inflammation in the ear canal following ear syringing. This causes itch and discomfort, but can be treated with ear drops. Rarely, ear syringing can cause serious damage to the ear or eardrum.
Ear syringing may not be advised if you have certain ear problems. In particular, if you:
1. Have had surgery for some types of ear problems.
2. Have recurring infection of the ear canal (recurring otitis externa).
3. Have or have had a perforated ear drum.
4.Are deaf in your other ear (as there is a very small risk that syringing can cause deafness in your good ear and so make you deaf in both ears.)
Tinnitus is an abnormal noise (or noises) that you can hear. However, the noise does not come from outside your ear. The sort of noises that people hear include: ringing, buzzing, whistles, roaring, humming, machine type noises, etc. Sometimes the noise pulsates at the same rate as your pulse. Tinnitus can be either constant or 'come and go'. It can vary in loudness and character from time to time. You can hear the noise or noises in one ear, in both ears, or it may be difficult to pinpoint where the noise seems to come from.
The noise is often more prominent when you are in a quiet place. For example, when you are in bed and trying to get to sleep. It may also be more noticeable when you are tired. Some people with tinnitus are also more sensitive to normal everyday sounds. For example, some people with tinnitus find that a radio or TV is painfully loud when it is at a normal volume for most people.
Tinnitus is common and can occur at any age. Most people have an occasional episode of tinnitus after going to a load concert or disco. For most people, this is temporary and soon goes. As many as 1 in 6 people have persistent tinnitus that is mild and not very troublesome. However, about 1 in 100 people have tinnitus which persists most of the time, and severely affects their quality of life.
In many people with tinnitus, the cause is not known. The ear is otherwise fine. What seems to happen is that signals are sent from the ear down the ear nerve to the hearing part of the brain. The brain interprets these signals as noise. It is not clear why these signals are sent from the ear. The noise may also originate somewhere else in the hearing nerve pathways in the brain.
Sometimes the tinnitus is caused by another condition. For example, meniers disease, otosclorsis, after head injury, deafness, infection, anxiety and some rare disorders.
A doctor will usually examine your ears, and the nerves around your face and ears. A hearing test is usually done. An underlying ear problem can usually be ruled out by this examination and hearing test.
Further tests such as a brain scan are done in some cases. For example, this may be advised if you have one-sided tinnitus and an underlying brain disorder is suspected.
In most cases there is no easy cure. Some people are helped by understanding the problem and knowing that they do not have a serious underlying condition. With time, the tinnitus may become less of a problem as you adjust to it. In addition, background noise e.g radio, hearing aids for deafness, help with anxiety and depression, may all help in reduction of tinnitus.
In severe cases a treatment called tinnitus retraining therapy (TRT) may be used. Some studies show that this can help in up to 3 in 4 cases. TRT aims to help the brain learn to ignore the tinnitus. (The tinnitus is not stopped, but the aim is to become less bothered by it). TRT involves wearing a sound generator (described above). This therapy is accompanied by regular counseling sessions which aim to help you cope with the tinnitus. TRT can take as long as a year where you gradually learn not to focus on your tinnitus until it becomes much less bothersome, even without using the sound generator.
Nasal irrigation is also known as “nasal lavage “and “nasal douching “is a very and widely practiced method of “cleaning “ the nose.
Nasal irrigation is most commonly prescribed for one of three reasons :1. to reduce swelling (edema), 2.to help clear mucus and 3.to reduce dryness.
There are no known risk associated with this treatment , other than the possibility of allergic reaction to one of the components Nasal irrigation can alter the environment of the nasal cavities and sinuses, making them more conducive to the growth of certain water-loving bacteria such as Pseudomonas. Also, irrigation should not be performed if you are suffering from acute sinusitis (an acute bacterial infection of the sinuses), since it could facilitate spread of the infection to the other sinuses, the eyes or throat.
1 teaspoon salt , 1 teaspoon baking soda ,1 pint of water (use distilled or filtered water if you have any concerns about the quality of your tap water.) Home-made solutions should be discarded after one week (then prepare a fresh batch.) If the solution looks cloudy, or if you see particulate matter floating in it, do not use it- make yourself a fresh batch.
In the first few days try and irrigate three times per day, however when symptoms improve this can be reduced to once or twice daily.
