ENT Masterclass: Otitis Externa/ Tonsillitis

Mr Ali KalanMr Anooj Majithia25th Jan 2011

Otitis Externa: inflammation of external ear canal, due to: o infection (usually bacteria, e.g. Pseudomonas aeruginosa or Staphylococcus aureus or, rarely, fungi or yeasts, especially after antibacterial therapy) o allergies o irritants o can occur as a complication of eczema, psoriasis or other skin conditions

• Epidemiology: life-time prevalence 10%, typically affects females age 45- 54 years and males age 65-74 years

Otitis ExternaOtitis Externa

Clinical presentation: • pain, fullness or pressure in ear • decreased hearing – which is usually mild • itching in external ear canal • tenderness in ear canal • scanty discharge - there are no mucous secreting glands in the external ear; profuse discharge suggests middle ear disease • pain and purulent discharge- only if secondary bacterial infection occurs

The condition may be generalised (diffuse) throughout ear canal (may be acute, acute-recurrent or chronic); or localised inflammation (furuncle) within ear canal.

Otitis ExternaOtitis Externa

History: • nature and duration of symptoms; pain may not be prominent with chronic OE, which rather may be associated with itch and discomfort, whether recurrent, whether unilateral or bilateral • nature of any discharge • whether there is bleeding • presence of risk factors for OE: water exposure, e.g. swimmers, divers, humid environments • over-use of cotton buds • history of eczema or psoriasis • possible contact dermatitis, e.g. from shampoo or soap, earrings, hair dye, hearing aid • diabetes mellitus • Immuno-compromised, e.g. steroids, HIV • systemic symptoms suggestive of sepsis • malignant otitis externa is more common in the elderly diabetic

On examination: On examination:

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pain on gentle pulling on external ear, narrowed, oedematous mepain on gentle pulling on external ear, narrowed, oedematous meatus atus

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meatal debris meatal debris

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tenderness on moving jaw tenderness on moving jaw

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+/+/--

tender regional lymph nodes tender regional lymph nodes

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assess for facial nerve palsy (may complicate severe OE such asassess for facial nerve palsy (may complicate severe OE such as

necrotising necrotising OE or herpetic OE) OE or herpetic OE)

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temperature temperature

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signs of dermatitis around the pinna signs of dermatitis around the pinna

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on otoscopy: on otoscopy:

o erythema, oedema and debris in ear canal o erythema, oedema and debris in ear canal

o scanty white discharge o scanty white discharge

o eardrum inflamed but intact o eardrum inflamed but intact

••

if chronic, the following features may be present: if chronic, the following features may be present:

o thickened abnormal skin in ear canal o thickened abnormal skin in ear canal

o reduced production of ear wax o reduced production of ear wax

o bloody or mucoo bloody or muco--purulent discharge purulent discharge

o

narrowing

of

the

ear

canalo

narrowing

of

the

ear

canal

InvestigationsInvestigations

screen for Diabetes Mellitus (important predisposing factor for screen for Diabetes Mellitus (important predisposing factor for OE in OE in adults) in recurrent or chronic OE or in suspected malignant OE adults) in recurrent or chronic OE or in suspected malignant OE

••

ear swab for Gram stain and culture of ear canal discharge is near swab for Gram stain and culture of ear canal discharge is not ot routinely required routinely required unless there is evident discharge and/or unless there is evident discharge and/or condition is chronic or previous treatment has failedcondition is chronic or previous treatment has failed

(Tuning fork tests may demonstrate mild conductive deafness) (Tuning fork tests may demonstrate mild conductive deafness)

Management 1Management 1

prescribe suitable eardrops containing antibiotic and antiprescribe suitable eardrops containing antibiotic and anti--inflammatory: inflammatory: GentisoneGentisone--HC contains gentamicin and hydrocortisone appropriate for HC contains gentamicin and hydrocortisone appropriate for most bacteria including anaerobes such as pseudomonas most bacteria including anaerobes such as pseudomonas

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note that review of the evidence suggests no clinical benefit wnote that review of the evidence suggests no clinical benefit with the ith the use of oral antibiotics plus topical antiuse of oral antibiotics plus topical anti--infective agents compared with infective agents compared with topical antitopical anti--infective agents alone infective agents alone

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fungal infection fungal infection

o if persistent otitis externa then consider the possibility of o if persistent otitis externa then consider the possibility of a fungal a fungal infection and treat with topical preparation containing an antifinfection and treat with topical preparation containing an antifungal, ungal, such as clotrimazole 1% ear drops (Canestensuch as clotrimazole 1% ear drops (Canesten®®), or flumetasone ), or flumetasone pivalate 0.02%, clioquinol 1% ear drops (Locortenpivalate 0.02%, clioquinol 1% ear drops (Locorten--VioformVioform®®) )

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Refer for aural toilet if there is no response Refer for aural toilet if there is no response

Management 2Management 2

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Educate the patient re general principles of prevention: Educate the patient re general principles of prevention:

o not to poke the ear at all o not to poke the ear at all

o to use olive oil for wax removal and minor irritation o to use olive oil for wax removal and minor irritation

o not to rub ears when drying after washing/swimming o not to rub ears when drying after washing/swimming

�� after bathing or swimming, all water in the ear canals should bafter bathing or swimming, all water in the ear canals should be e drained out by tilting the head to the sides drained out by tilting the head to the sides

�� the external ear canal should be then dried using a hair dryer the external ear canal should be then dried using a hair dryer on the on the lowest heat setting. lowest heat setting.

�� acidifying drops (vinegar) with alcohol drops can be used as acidifying drops (vinegar) with alcohol drops can be used as prophylactic after each swim (2) prophylactic after each swim (2)

o can be prevented by maintaining a dry ear and avoiding the mano can be prevented by maintaining a dry ear and avoiding the many y above mentioned precipitants above mentioned precipitants

o insertion of cotton swabs into the ear canal and any manipulato insertion of cotton swabs into the ear canal and any manipulation of ion of the canal should be avoided the canal should be avoided

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If no response in one week then consider an alternative eardropIf no response in one week then consider an alternative eardrop

(if (if swab

taken

on

initial

visit

then

prescribe

based

on

result)swab

taken

on

initial

visit

then

prescribe

based

on

result)

Referral Threshold Referral Threshold

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Refer otitis externa to hospital if: Refer otitis externa to hospital if:

o Aural toilet is required o Aural toilet is required

o Previous history of complex ear problems o Previous history of complex ear problems

o o Erysipelas (Erysipelas is a rapidly spreading Streptococcal infeErysipelas (Erysipelas is a rapidly spreading Streptococcal infection ction of the skin and of the skin and subcutaneous tissue characterized by cellulitis and subcutaneous tissue characterized by cellulitis and lymphangitis) lymphangitis)

o o Malignant otitis externa (Malignant otitis externa is otitis extMalignant otitis externa (Malignant otitis externa is otitis externa erna which has spread to cause osteomyelitis of the skull base. It iswhich has spread to cause osteomyelitis of the skull base. It is due to due to Pseudomonas aeruginosa and anaerobes causing a mound of tissue iPseudomonas aeruginosa and anaerobes causing a mound of tissue in n the external canal. A facial nerve palsy occurs in 50% of patienthe external canal. A facial nerve palsy occurs in 50% of patients with ts with this condition, and nerves IX to XII may also be involved. It afthis condition, and nerves IX to XII may also be involved. It affects fects immunocompromised patients, especially elderly diabetics) immunocompromised patients, especially elderly diabetics)

THE EAR

1. Helix2. Antihelix3. Triangular Fossa4. Tragus5. Anti Tragus6. Lobule7. Ext. Acoustic Meatus

RELATIONS OF THE EXTERNAL, MIDDLE AND INNER EAR

Middle earTympanic membrane, 3 ossicles (Malleus, Incus & Stapes)For amplification of sound waves

Inner EarCochlear mechanism for hearingLabyrinthine mechanism of fluid filled semicircular canals for balance and equilibrium

To obtain a good view of the tympanic membrane, pull the ear backwards and outwards.

Steady the auriscope by resting your little finger against the patients cheek.

HOW TO EXAMINE THE EAR DRUM

Collapsing ear canalCollapsing ear canal

Oedematous External Ear Canal

Bloody otorrhoeaBloody otorrhoea

Secondary to Secondary to trauma/infection etc.trauma/infection etc.

RxRx::

No water/suction/ No water/suction/ cleaning or ear dropscleaning or ear drops

Admit under HI teamAdmit under HI team

Oral antibiotics Oral antibiotics

ENT referral: Non ENT referral: Non urgent unless VII urgent unless VII Nerve palsyNerve palsy..

Aural polypAural polyp

From From middle/external earmiddle/external ear

May be associated May be associated with cholesteatomawith cholesteatoma

Rx:Rx:

Initially topical ear Initially topical ear drops helpsdrops helps

May require May require mastoid approachmastoid approach

Furuncle in External Ear Canal

Chronic Otitis externaChronic Otitis externa

May be result of May be result of bacterial, fungal or bacterial, fungal or mixed infectionmixed infection

Meatus filled with Meatus filled with moist, macerated moist, macerated keratin squameskeratin squames

Treatment includes Treatment includes preventative and preventative and medical measuresmedical measures

Referral: if canal Referral: if canal oedematous/non oedematous/non responsive/aural responsive/aural toilettoilet

Chronic otitis externaChronic otitis externa

OtomycosisOtomycosis

Dark spores of Dark spores of Aspergillus niger Aspergillus niger and white and white mycelium of mycelium of Candida albicans.Candida albicans.

Thorough aural Thorough aural toilet and long toilet and long term antifungal term antifungal dropsdrops

Treat underlying Treat underlying otitis media if otitis media if presentpresent

Otomycosis of EAC – fungal infection

Dermatitis of EAC

Herpes ZosterHerpes Zoster

Malignant otitis Malignant otitis externaexterna

Hematoma in canalHematoma in canal

Questions?Questions?

Tonsillitis Tonsillitis -- HistoryHistory

symptom duration symptom duration

absence or presence of trismus absence or presence of trismus

symptoms of systemic upset e.g. fever, malaise symptoms of systemic upset e.g. fever, malaise

symptoms of dysphagia? symptoms of dysphagia?

rash? rash?

history of previous episodes?history of previous episodes?

ExaminationExamination

Assessment of how ill patient is e.g. pulse, temperature. Assessment of how ill patient is e.g. pulse, temperature.

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Examine trunk for rash Examine trunk for rash --

scarlet fever rash generally starts on the scarlet fever rash generally starts on the chest and spreads to involve the neck and face; there may be spachest and spreads to involve the neck and face; there may be sparing ring of the circumoral area. The rash associated with infectious of the circumoral area. The rash associated with infectious mononucleosis tends to be generalized. mononucleosis tends to be generalized.

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Examine the neck for cervical lymphadenopathy. Examine the neck for cervical lymphadenopathy.

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Note any trismus or dribbling. Note any trismus or dribbling.

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Inspect the tongue and throat. In streptococcal disease there mInspect the tongue and throat. In streptococcal disease there may be ay be a 'strawberry tongue'. In cases of infectious mononucleosis thera 'strawberry tongue'. In cases of infectious mononucleosis there may e may be petichiae on the palate. be petichiae on the palate.

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Examine the tonsils. There may be halitosis. Examine the tonsils. There may be halitosis. If there is stridor then If there is stridor then do not examine the throat because acute airways obstruction do not examine the throat because acute airways obstruction

from epiglottitis may be provokedfrom epiglottitis may be provoked

InvestigationsInvestigations

Throat swabs Throat swabs --

in general, throat swabs are of little value in the in general, throat swabs are of little value in the management of sore throat as up to 20% of patients carry strep. management of sore throat as up to 20% of patients carry strep. pyogenes as a commensal; there are no criteria for distinguishinpyogenes as a commensal; there are no criteria for distinguishing g between carriage and infection between carriage and infection

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Full blood count and monospot may be helpful if glandular feverFull blood count and monospot may be helpful if glandular fever

or or

blood dyscrasia is suspected blood dyscrasia is suspected

Management PrinciplesManagement Principles

establish the duration of the illness establish the duration of the illness --

infections usually resolve within infections usually resolve within five five ––

ten days ten days

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consider aetiology of sore throat consider aetiology of sore throat --

most frequently look for features most frequently look for features suggesting: suggesting:

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an infective cause or other risk factors an infective cause or other risk factors

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an indication for antibiotics (see Centor criteria below) an indication for antibiotics (see Centor criteria below)

CENTOR CriteriaCENTOR Criteria

The The Centor criteria may be useful to predict patients (both adults aCentor criteria may be useful to predict patients (both adults and children) nd children) who are at higher risk of Group A betawho are at higher risk of Group A beta--haemolytic streptococcus (GABHS) and haemolytic streptococcus (GABHS) and complications, who may benefit from antibiotics complications, who may benefit from antibiotics

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tonsillar exudate tonsillar exudate

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tender anterior cervical lymph nodes tender anterior cervical lymph nodes

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absence of cough absence of cough

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history of fever history of fever

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presence of three or four of these clinical signs suggests thatpresence of three or four of these clinical signs suggests that

the chance of the patient the chance of the patient having GABHS is between 40% and 60%, so the patient may benefit having GABHS is between 40% and 60%, so the patient may benefit from antibiotic from antibiotic treatment treatment

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absence of three or four of the signs suggests that there is anabsence of three or four of the signs suggests that there is an

80% chance that the 80% chance that the patient doesn't have the infection, and antibiotics are unlikelypatient doesn't have the infection, and antibiotics are unlikely

to be necessary to be necessary

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In patients with tonsillitis who are unwell, and have In patients with tonsillitis who are unwell, and have three out of four of these criteria, three out of four of these criteria, the risk of quinsy is 1:60 compared with 1:400 in those who are the risk of quinsy is 1:60 compared with 1:400 in those who are not unwell. not unwell.

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If antibiotics are clinically indicated, phenoxymethylpenicilliIf antibiotics are clinically indicated, phenoxymethylpenicillin is an appropriate first choice n is an appropriate first choice (adult dose: 500mg two to four times a day for 10 days) (see end(adult dose: 500mg two to four times a day for 10 days) (see end

of Section for guidance) of Section for guidance)

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Offer advice and reassurance, and recommend analgesics (ParacetOffer advice and reassurance, and recommend analgesics (Paracetamol is the drug of amol is the drug of

choice; NSAIDs are not routinely recommended)for symptom relief choice; NSAIDs are not routinely recommended)for symptom relief in all patients in all patients

Referral ThresholdReferral Threshold

Paediatric group Paediatric group

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H/O sleep apnoea, daytime somnolence or failure to thrive H/O sleep apnoea, daytime somnolence or failure to thrive

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H/O 5 or more episodes of acute sore throat in the preceding 12H/O 5 or more episodes of acute sore throat in the preceding 12

months months documented by the parent or doctor, and which have been severe edocumented by the parent or doctor, and which have been severe enough to nough to disrupt the childdisrupt the child’’s normal behaviour or days normal behaviour or day--toto--day activity day activity

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Associated with guttate psoriasis (a type of Associated with guttate psoriasis (a type of psoriasis that looks like small, psoriasis that looks like small, salmonsalmon--pink drops on the skin) which is exacerbated by recurrent tonsilpink drops on the skin) which is exacerbated by recurrent tonsillitis litis

Other groups Other groups

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recurrent tonsillitis recurrent tonsillitis

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blood dyscrasias (diseases of the blood forming organs) associablood dyscrasias (diseases of the blood forming organs) associated with ted with

recurrent infections recurrent infections

TonsilsTonsils

Lymphoid tissueLymphoid tissue

rolerole

Inflammation + Infection frequentInflammation + Infection frequent

ViralViral

BacterialBacterial

Ind for Sx: >5 episodes a year for 2 yrs Ind for Sx: >5 episodes a year for 2 yrs or 7 episodes in 1 yr; Or > 2 episodes of or 7 episodes in 1 yr; Or > 2 episodes of quinsy quinsy

Or OSA (adenotonsillectomy)Or OSA (adenotonsillectomy)

The OropharynxThe Oropharynx

THE TONSILS AND OROPHARYNX

• Waldeyers Ring• “Tonsil enlargement”• Examination of the oropharynx (should include dentition, hard/soft palate, openings of parotid and submandibular ducts, and neck)

THE TONSILS AND OROPHARYNX (2)

Common ProblemsAcute TonsillitisPeritonsillar Abscess (Quinsy)Glandular FeverForeign bodies / Fish bonesPost Tonsillectomy Bleeding

COMMON TONSILLAR PATHOLOGIES

Acute tonsillitisCharacterised by sore throat, dysphagia and pyrexia.Appearance of the tonsil varies.The tonsillar lymph nodes near the angle of the mandible are large and tender.

When to admit:

• SOB / Stridor• Unable to swallow saliva• Not able to eat or drink• Not responding to oral antibiotics• Systemically unwell

NB. MONOSPOT test is always required

AcuteTonsillitisAcuteTonsillitis

GpABHS commonest GpABHS commonest Strep PneumoniaeStrep Pneumoniae

H InfluenzaH Influenza Moraxella catarrhalisMoraxella catarrhalis

Staph aureusStaph aureus OthersOthers

Viral, EBVViral, EBV60% undetermined60% undeterminedPenicillinPenicillinBroad spectrum antibioticBroad spectrum antibioticAirwayAirway

AcuteTonsillitisAcuteTonsillitis

Quinsy

Quinsy (Peritonsillar abscess)Collection of pus above the tonsil.Dysphagia, otalgia, trismus, fever.Uvula deviated and swollenNeeds Aspiration or I+DCo-phenylcaine spray and spinal needlePus should be sent for MC+S. Admit for IV antibiotics.

SymptomsSymptoms (Symptoms appear 2(Symptoms appear 2--8 days prior to abscess 8 days prior to abscess formation)formation)

Unilateral sore throatUnilateral sore throat

DysphagiaDysphagia

OdynophagiaOdynophagia

Distortion of vowels Distortion of vowels ‘‘Hot Hot potato voicepotato voice’’

HalitosisHalitosis

TrismusTrismus

Drooling of salivaDrooling of saliva

Referred ear painReferred ear pain

FeverFever

MalaiseMalaise

HeadacheHeadache

Glandular Fever

Infectious Mononucleosis (Glandular Fever)Suspect if sore throat and malaise persist despite antibiotic treatment.A white membrane is characteristic.AVOID Ampicillin.Confirmation of diagnosis with Monospot test.Treatment is supportive. Avoidance of contact sports for 3 months.

Post tonsillectomy slough

Normal post tonsillectomy appearance

Post tonsillectomy bleedingAffects 2-4% of all tonsillectomies.Commonly occurs as a result of infection 5-15 days post op.Admit ALL cases for IV antibiotics.

Tonsillar hypertrophyTonsillar hypertrophy

In children almost invariably assoc with In children almost invariably assoc with adenoidal enlargementadenoidal enlargement

Snoring/Stertor/OSASnoring/Stertor/OSA

Questions?Questions?

Otitis Externa

Inflammation of the skin of the EAMUsually EAM sterilePredisposing factors – heat, humidity, swimming, trauma, narrow ear canal, eczemaMost common causative factor – P.aeruginosa, S.Aureus, Proteus (NB. Fungal and viral causes)

Presenting features – Otalgia, Deafness, Oedema/Swelling of canal.An ear swab should be taken.If debris seen in the canal or oedema is obstructing canal – patient should be referred to ENT for microsuction clearance.Antibiotics of choice – Sofradex ear drops or Gentisone HC drops.