12 Ear, nose and throat

All sorts of FBs may become lodged in the external auditory canal, including insects, vegetable matter, and various inert objects. The patient may present with pain, deafness, discharge or, in the case of live insects, an irritating buzzing in one ear.

Diagnosis

depends upon direct visualization with the auriscope. In children, remember that, as with FBs elsewhere, there may be no history of FB available.

The ‘butterfly’ piece of an ear ring may become embedded in the posterior part of the ear lobe, causing inflammation or infection. The ear-rings are usually easily removed once adequate analgesia has been established: render the ear anaesthetized with a greater auricular nerve block ( Nerve blocks of forehead and ear, p.300), or directly infiltrate local anaesthetic into the lobe, remembering that this is a highly sensitive area. The butterfly is released by applying pressure in a posterior direction. Occasionally, forceps and a small posterior skin incision may be required to open up the track. If there is evidence of infection, prescribe antibiotics (eg co-amoxiclav) and arrange GP follow-up. Advise the patient not to wear ear-rings until the symptoms have settled.

Usually affects children, who present with offensive unilateral nasal discharge. Also occurs in adults with psychotic illness or learning disabilities.

Remove easily accessible, anterior nasal FBs in ED. However, there is a risk of aspiration with any nasal FB, particularly in uncooperative patients. Refer such patients to an ENT surgeon for removal with airway protection. Instruct the patient to blow their nose whilst occluding the unaffected nostril. If unsuccessful, consider attempting removal with a nasal speculum, hook, and forceps, as appropriate. A fine bore tracheal suction catheter attached to wall suction can also work. One technique which has been reported in cooperative children is to ask a parent to blow into the child's mouth (‘parent's kiss’), having first ensured a good seal and also occluded the normal nostril.

Nasal button, batteries, or magnets (  p.213) can cause significant damage, so refer to ENT.

Aspiration causing complete upper airway obstruction is an emergency, requiring immediate intervention (  p.324). FBs lodged in the larynx or tracheobronchial tree cause persistent coughing. There may not be a clear history—a coughing/spluttering episode in a child should arouse suspicion of an inhaled FB. Auscultation of the chest is often normal, but may reveal wheezes or localized absence of breath sounds.

may be normal or show a radio-opaque FB with distal consolidation or hyperinflation (FB acting as a ball valve). A CXR in expiration may show this more clearly. Refer to a cardiothoracic surgeon.

Various FBs, both radio-opaque (eg coins, rings) and non-radio-opaque (eg plastic pen tops, aluminium ring pulls) are frequently swallowed by children and by adults with psychiatric disorders. Provided the FB reaches the stomach, it is likely to pass through the remainder of the gastrointestinal tract without incident. An exception is button battery ingestion (  p.213). For radio-opaque FBs, confirm with lateral neck X-ray and CXR that it is not impacted in the oesophagus. A metal detector may confirm a swallowed coin has reached the stomach. Refer patients who are symptomatic, have impacted FBs, or who have swallowed potentially dangerous items (button batteries, razor blades, open safety pins). Note that magnets can be dangerous if two or more are ingested, since they can attract each other through tissues and cause pressure necrosis/perforation of bowel. Only discharge patients who are asymptomatic (with advice to return if they develop abdominal pain and/or vomiting), and arrange suitable follow-up. Unless the ingested FB is valuable or of great sentimental value, examination of the stools by the patient for the FB is unnecessary. It may take weeks to pass.

Fish bones often become stuck in the pharynx or oesophagus. Direct visualization with a good light (a head torch can be useful) and wooden spatula acting as tongue depressor may reveal fish bones lodged in the tonsils or base of the tongue—remove with Tilley's forceps. If no FB is seen, obtain soft-tissue lateral neck X-rays (look for prevertebral soft tissue swelling and fish bone, bearing in mind not all are radio-opaque), then refer to ENT for endoscopy. Depending on local policy, the ENT team may decide to see the patient immediately, or (provided the patient can swallow) the following day (in which case discuss the need for prophylactic antibiotics). A fish bone can scratch the pharynx causing sensation of a FB to persist after it has gone.

Usually involves a lump of meat. Patients with complete obstruction present unable to swallow solids or liquids (including their own saliva). There may be retrosternal discomfort. Refer to the surgical team for endoscopy. Glucagon (1mg IV) relieves some episodes of food bolus obstruction, but endoscopy is still advisable to look for oesophageal stenosis or malignancy.

Full ear examination includes assessment of the vestibulocochlear nerve and auroscope examination. Check for mastoid or pinna tenderness. Look at the external ear canal for discharge, or swelling and examine the tympanic membrane for colour, translucency, bulging, and the cone of light.

Hearing can be assessed by asking the patient to place one finger in their ear. Stand a foot behind the patient's unoccluded ear and whisper a two syllable word. Ask the patient to repeat the word.

—strike a 512Hz tuning fork and place in the centre of the forehead. In conductive deafness, the sound localizes to the deaf ear, with sensorineural deafness, the sound localizes to the good ear.

—strike a 512Hz tuning fork and place it on the mastoid process. Ask the patient to tell you when they no longer hear the sound, then immediately place in front of the auditory meatus. In a normal ear, air conduction is heard for twice as long as bone conduction. In conductive deafness, bone conduction is heard for longer than air conduction. In sensorineural deafness, air conduction is heard longer than bone conduction.

To complete assessment of the vestibulocochlear nerve, examine for nystagmus. All forms of nystagmus can be associated with intracranial lesions, as well as peripheral causes; however, downbeat and upbeat nystagmus in particular, signify a central cause. Tinnitus or deafness tends to suggest a peripheral cause. Peripheral nystagmus is exacerbated by gazing towards the side of the fast phase (Alexander's Law). Central nystagmus may change direction, depending on the side of gaze.

Vertigo is the impression or illusion of movement when there is none. Take care to distinguish vertigo from the more general term of ‘dizziness’, which is often used to describe a feeling of light-headedness.

Take a careful history and examine for causes of vertigo. Manage patients who present with vertigo according to the underlying cause. The cause may be unclear, in which case refer to the medical/ENT team as appropriate.

Cochlear implants consist of an implanted radio receiver and decoder package containing a magnet (above and behind the ear), together with a removable external microphone/radio transmitter. X-rays and CT do not damage this device, provided that the external microphone/transmitter is first removed and switched off. MRI can cause significant damage to the device and the patient. If there are concerns relating to a cochlear implant, refer to ENT. In particular, refer patients with:

Often caused by Pseudomonas, Staph. aureus, Strep. pneumoniae, E. coli. Common in swimmers/surfers and after minor trauma. This causes intense itching and pain, which gradually increases. Discharge and hearing loss may be present (profuse discharge implies middle ear disease). On examination, the external canal is inflamed and oedematous. Oedema and debris may obscure the tympanic membrane. Pain is induced by pressing on the tragus or pulling the pinna.

Prescribe topical antibiotics and topical steroids, advise against swimming, and arrange GP follow-up. In severe cases (eg if the drum is not visible), refer to an ENT surgeon for aural toilet to remove debris from the auditory canal.

Cellulitis of the ear canal may be caused by scratching or by infection of hair follicles (furunculosis). Staph. aureus is the usual organism. Itching and a feeling of pressure are followed by pain in the ear, with deafness if the ear canal is occluded by swelling. Examination shows swelling and inflammation of the ear canal, with tenderness over the tragus and pain on movement of the ear.

with analgesia (eg NSAID) and antibiotics (eg flucloxacillin 500mg PO qds for 5 days). Arrange follow-up by a GP (or ENT in severe cases).

Most common in children aged 3–6 years and may follow an upper respiratory tract infection. Commonest pathogens are Strep. pneumoniae and H. influenzae.

Earache may be accompanied by fever, deafness, irritability and lethargy. Typically, hearing loss precedes pain. Examination of the tympanic membrane shows evidence of inflammation with loss of the light reflex and bulging of the drum. Eventual perforation results in purulent discharge with some relief of pain. Look for associated swelling/tenderness over the mastoid—this implies secondary mastoiditis (see below).

Prescribe oral analgesia. The use of antibiotics remains very controversial. Oral antibiotics (eg 5-day course of amoxicillin or clarithromycin) are of questionable value, but are frequently given. Consider oral antibiotics if no improvement within 72hr, or earlier if there is deterioration or perforation. If perforation has occurred (often heralded by a sudden ↑ pain), arrange ENT follow-up and advise not to swim. Otherwise, arrange GP follow-up.

This is an uncommon, but important diagnosis to make, because of the risk of intracranial spread of infection. Mastoiditis follows an episode of acute otitis media—consider it if there is no response to therapy (eg discharging ear for >10 days). Suspect it if there is pain, redness, swelling or tenderness over the mastoid process. The pinna may be pushed forwards/outwards—swelling may mean that the drum is not visible. Refer urgently to the ENT surgeon for admission and IV antibiotics.

This erosive condition affects the middle ear and mastoid. A cholesteatoma can result in life-threatening intracranial infection. There may be an offensive discharge, with conductive hearing loss, vertigo or facial nerve palsy. Tympanic membrane examination shows granulation tissue and/or perforation with white debris. Refer to the ENT surgeon.

This may result from direct penetrating injury, blast injury (  p.389) or basal skull fracture (  p.361). Pain is associated with ↓ hearing. Perforation is visible on examination.

Most heal spontaneously with conservative measures and advice to keep out of water. Arrange ENT follow-up and give prophylactic oral antibiotics according to local policy. Note that gentamicin or neomycin eardrops may cause sensorineural deafness because of ototoxicity when the tympanic membrane is ruptured.

Sudden changes in atmospheric pressure with a blocked Eustachian tube can result in pain and hearing loss. This usually affects aircraft passengers and divers, especially if they have a cold (viral upper respiratory tract infection). Pain is often relieved by the Valsalva manoeuvre (breathing out with the mouth closed, while pinching the nose). Decongestant nasal spray may help if the problem does not resolve spontaneously. Give analgesia (NSAID). Arrange ENT follow-up if the pain persists.

Nasal bleeding may be idiopathic or follow minor trauma (eg nose picking). When it occurs in patients with hypertension and coagulation disorders haemorrhage can be severe with significant mortality. Epistaxis may follow isolated nasal fracture and more major facial injury.

Most nasal bleeding is from the anterior nasal septum in or close to Little's area. A few patients have posterior nasal bleeding, which may be brisk.

Direct visualization of the anterior nasal cavity is aided by a headlamp (eg battery-operated head torch), fine soft suction catheter, and nasal speculum. Wear goggles to avoid blood splashes in the eyes.

Assess ABC (especially pulse and BP) and resuscitate as necessary. Treat hypovolaemia vigorously.

Check airway patency, pulse, and BP. Treat hypovolaemia aggressively. Check coagulation status of patients on anticoagulants and treat appropriately (  p.170). Sit the patient up and instruct them to compress the fleshy part of their nose between finger and thumb for 10min. If this stops the bleeding, the patient may be discharged after 30min observation.

Apply a cotton wool pledget soaked in 4% lidocaine with 1 in 1000 adrenaline. Then, with a headlamp and nasal speculum, try to identify the bleeding point. Treat small anterior bleeding points with cautious cautery by applying a silver nitrate stick for 10–15sec. Avoid excessive cautery and never cauterize both sides of the septum—this may cause septal necrosis. If cautery stops the bleeding, observe for 15min, and discharge with GP follow-up. Advise avoidance of sniffing, picking or blowing the nose meantime.

Applying nasal antiseptic cream (eg Naseptin^®) is as effective as cautery in stopping bleeding. The cream is relatively easy to apply.

Insert a nasal pack. A specialized compressed surgical sponge nasal tampon (eg Merocel^® or Rapid Rhino) is ideal: gently insert a lubricated tampon (horizontally) and ‘inflate’ with a 10mL syringe of saline. Alternatively, pack the nose in a traditional way with 1.25cm wide ribbon gauze soaked in oily paste (eg bismuth iodoform paraffin paste). Once packing has stopped the bleeding, refer to ENT for admission: observation is advisable (especially in the elderly). The pack may dislodge and obstruct the airway.

Refer to the ENT surgeon. The bleeding site is likely to be posterior and can cause hypovolaemic shock. In this situation, insert 2 large bore venous cannulae, send blood for FBC, coagulation screen, cross-matching, and commence an IVI.

Posterior nasal bleeding usually responds to tamponade with a Foley catheter. Remove the nasal tampon and insert a lubricated, uninflated Foley catheter through the bleeding nostril into the nasopharynx. Inflate the balloon with air and gently withdraw the catheter, thus tamponading the bleeding site. Secure the catheter to the cheek with tape, and then re-insert the anterior nasal tampon.

The prominent exposed position of the nose, combined with the delicacy of its bones, render it relatively prone to injury.

Remember that the nose is part of the head, so nose injury = head injury (and potentially cervical spine injury also).

The nose is commonly broken by a direct blow (eg from a punch) or following a fall onto the face. Nasal fracture is usually accompanied by bleeding. Search for a history of associated facial/head injury (diplopia, loss of consciousness, etc.).

This is a clinical diagnosis based upon a history of injury with nasal swelling and tenderness. Having made the diagnosis, assess whether there is nasal deviation: it is useful to ask the patient to look in a mirror. Check and record whether the patient can breathe through each nostril. Look for an associated septal haematoma—this will appear as a smooth bulging swelling, which may obstruct the nasal passage. Children are at particular risk of septal haematoma, which predisposes to secondary infection and septal necrosis.

Assess for additional injuries to the head or face (eg tender mandible, diplopia, tender maxilla). Injury to the bridge of the nose may result in persistent epistaxis and/or cerebrospinal fluid rhinorrhoea.

Do not X-ray to diagnose a nasal fracture—the diagnosis is a clinical one. Obtain appropriate X-rays (eg orthopantomogram (OPG) or facial views) if there is clinical suspicion of other bony injuries. Nasal fractures are often apparent on facial X-rays or CT scans.

Acute pharyngo-tonsillitis may result from infection with a variety of viruses or bacteria:

Sore throat is frequently accompanied by fever, headache, and mild dysphagia. Inspection of the tonsils reveals inflammation—the presence of pus on the tonsils suggests bacterial infection. Enlarged cervical lymph nodes are found in a variety of infections, but generalized lymphadenopathy (sometimes also with splenomegaly) is indicative of glandular fever (infectious mononucleosis—see  p.241).

Despite the clinical pointers described above, it is usually impossible to distinguish clinically bacterial from viral causes.

Consider throat swabs and anti-streptolysin titre in severe cases. If glandular fever is suspected, send blood for FBC and Paul–Bunnell (or Monospot) test.

Unless contraindicated, give paracetamol (1g PO qds PRN) or ibuprofen (400mg PO tds PRN) and discharge to GP. Although frequently prescribed, oral antibiotics are rarely of benefit: a sensible approach is to limit their use for patients with any of the following: a history of valvular heart disease, immunosupression, diabetes, marked systemic upset, peritonsillar cellulitis, known β–haemolytic streptococci. In this case, prescribe penicillin 500mg PO qds for 5 days (or clarithromycin 500mg PO bd for 5 days if allergic). Avoid ampicillin, amoxicillin, and co-amoxiclav, which cause a rash in patients infected with EBV.

Occasionally, patients with acute tonsillitis may be unable to swallow fluids (this is more commonly a feature of peritonsillar or retropharyngeal abscess). In this case, refer for IV antibiotics and IV fluids.

Otitis media, sinusitis, retropharyngeal abscess, peritonsillar abscess.

Typically, preceded by a sore throat for several days, the development of a peritonsillar abscess is heralded by high fever, pain localized to one side of the throat, and pain on swallowing. Difficulty swallowing can result in drooling. Trismus may make inspection difficult, but if visualized there is tense bulging tonsil, pushing the uvula away from the affected side. Group A β-haemolytic streptococci are frequently implicated.

Insert an IV cannula and give IV benzyl penicillin 1.2g (clarithromycin 500mg if allergic to penicillin), and refer immediately to an ENT surgeon for aspiration or formal drainage.

Spread of infection from adjacent lymph nodes may occasionally cause a retropharyngeal abscess, particularly in children aged <3 years.

It is characterized by a sore throat, difficulty swallowing, fever, and dehydration. In children, cough is typically absent from the history (unlike in croup and other viral causes of upper airway obstruction). There may be evidence of airway compromise (stridor, neck hyperextension, signs of hypoxia). The differential diagnosis includes acute epiglottitis (  p.677). Lateral X-rays of the neck show soft tissue swelling (obtain these in the resuscitation room, rather than moving the patient to the X-ray department).

Get senior ED, ENT, and anaesthetic help. If the patient is a child with evidence of respiratory distress, do not upset them further. Airway obstruction may be precipitated by examination of the throat, so avoid this until appropriate staff and equipment are ready to cope with airway problems. The child can sit on mum's knee in the resuscitation room. On suspicion of a retropharyngeal abscess in an adult, insert an IV cannula, take bloods and blood cultures, give IV fluids and IV co-amoxiclav 1.2g, and refer immediately to an ENT surgeon.

Smoking cocaine can result in dangerous burns of the throat, since the drug acts as a local anaesthetic. Swelling of the epiglottis may result in airway obstruction.

Bacterial infection may result from direct spread from infected tooth roots or (more usually) be secondary to viral upper respiratory tract infection (URTI).

Provide analgesia. Despite a lack of convincing evidence, oral antibiotics (eg amoxicillin, doxycycline or erythromycin) and nasal decongestant (eg 1% ephedrine) are commonly given. Advise GP follow-up. In severe cases, refer to ENT.

The facial (VII) nerve supplies the muscles of facial expression. Clinical examination reveals whether facial nerve palsy is of upper motor neurone or lower motor neurone type.

is usually due to a stroke (  p.144), resulting in unilateral facial muscle weakness, but with sparing of the muscles of the forehead. If stroke is the cause, there may be additional evidence elsewhere (eg hemiparesis affecting the limbs).

of the facial nerve results in weakness of the muscles of one side of the face. The facial nerve arises from its nucleus in the pons, emerges from the pons to travel past the cerebello-pontine angle, through the petrous part of the temporal bone, to emerge from the stylomastoid foramen and thence into the parotid gland, where it divides into branches. During its passage through the petrous temporal bone, the facial nerve is accompanied by the chorda tympani (carrying taste fibres from the anterior 2/3 of one half of the tongue) and gives off the nerve to stapedius. Lesions of the facial nerve in the temporal bone therefore produce loss of taste and hyperacusis (noise is distorted and sounds loud) on the affected side.

Bell's palsy is the commonest cause of sudden onset isolated lower motor neurone facial nerve palsy. It is believed to result from viral infection, producing swelling of the facial nerve within the temporal bone: there may be associated hyperacusis and loss of taste of the anterior two-thirds of one half of the tongue. The absence of involvement of other cranial nerves is a reassuring feature, helping to secure this clinical diagnosis.

Most patients recover completely over several months without treatment—a small percentage are left with permanent weakness. Recovery is quicker if prednisolone is started within 72hr of the onset of symptoms (prednisolone 60mg daily for 5 days, then 10mg less each day; total of 10 days of treatment). Antiviral drugs do not seem to be helpful. Advise the use of artificial tears and an eye patch at night, to prevent corneal drying, and refer for ENT follow up.

This is due to herpes zoster infection of the geniculate ganglion. Clinical features of Bell's palsy are present, together with (painful) herpetic vesicles present in the external auditory meatus and occasionally also, the soft palate. Refer to an ENT specialist for aciclovir and follow up.

Saliva is a mixture containing water, various ions, mucin, and amylase, produced by the parotid, submandibular, and sublingual salivary glands. The problems most commonly affecting the salivary glands are infection and calculous disease.

Painful swelling of both parotid glands in children is most frequently due to mumps infection (  p.222). In adults, painless bilateral parotid swelling may be due to Sjögren's syndrome, sarcoidosis, hypothyroidism, lymphoma, drugs (eg oral contraceptive). In each of these cases, there are often other features, which will help in diagnosis.

Painful unilateral parotid swelling may occur as part of mumps infection, but also in other circumstances (eg poor oral hygiene, post-operatively). Refer to an ENT surgeon for admission and IV antibiotics. Chronic painless unilateral parotitis is often neoplastic (mostly benign) in origin.

Mechanical obstruction of the flow of saliva is most commonly due to salivary gland stones, affecting the submandibular gland. Obstruction may also occur from neoplasms or strictures.

Blockage of a salivary duct causes pain and swelling of the affected gland on eating. Bimanual palpation of the floor of the mouth may reveal a stone—occasionally this may be visible intra-orally at the duct orifice. If there is superimposed infection, it may be possible to express pus from the duct.

Obtain X-rays of the floor of the mouth. If the patient presses down with the tongue when the X-ray is taken the stone may be seen more easily below the mandible on a lateral view or OPG.

Refer to an oral or ENT surgeon. If an immediate consultation is not available, discuss the use of antibiotics in the meantime (these are often reserved for situations where there is evidence of salivary gland infection).

The primary teeth erupt between 6 months and 2 years—they are replaced by permanent teeth which first start to appear at ≈6 years (Table 12.1). There are 20 primary and 32 permanent teeth. The permanent teeth are made up of 4 quadrants of 8 teeth: right upper, left upper, right lower, left lower. Each quadrant comprises (from medial to lateral): central incisor, lateral incisor, canine, first premolar, second premolar, first molar, second molar, and third molar (‘wisdom tooth’).

do not require immediate attention: redirect the patient instead to their dentist. Specialist ‘sensitive teeth’ toothpaste rubbed over the broken area of tooth may ↓ pain.

present with a small area of bleeding and are exquisitely tender to the touch. Refer to the on-call dentist.

need to be stabilized as soon as possible—advise the patient to avoid manipulating the tooth and to refer to the dentist.

need to be accounted for (especially in the unconscious patient) in order to exclude the possibility of aspiration. Obtain a postero-anterior (PA) and lateral CXR to search for both the tooth and secondary problems, such as pulmonary collapse and air trapping distal to the obstruction. Ensure that there is adequate tetanus prophylaxis.

brought to the ED may be suitable for re-implantation. Avulsed primary teeth are usually not suitable. A history of rheumatic fever, valvular heart disease, or immunosuppressive treatment are contraindications to re-implantation. Milk is the best easily available transport medium to advise a patient to bring a tooth in. The best chance of success lies with early re-implantation (within the first few hours). Handle the tooth as little as possible. Hold it by the crown to clean it gently with 0.9% saline. Orientate the tooth, and then replace it within the socket using firm pressure (this may be easiest after LA—see Dental anaesthesia  p.302). Refer immediately to the on-call dentist for stabilization and prophylactic antibiotics (eg clarithromycin). Ensure tetanus prophylaxis.

may respond to simple measures. Ask the patient to bite on a rolled up piece of gauze placed over the socket for 10min. If this is unsuccessful, consider stopping the bleeding by inserting a horizontal mattress suture (eg using ‘Vicryl’), placed under LA using lidocaine with adrenaline (Fig. 12.4). If bleeding continues despite these measures, apply direct pressure, send a coagulation screen and refer to the on-call dentist.

may follow tooth extraction (typically 3–8 days later) when bone is exposed in the empty socket. Gently irrigate the socket with warm saline. Prescribe oral antibiotics (eg penicillin or erythromycin) and analgesia and refer to the dentist.

Toothache without associated local or systemic symptoms/signs usually responds to analgesia (eg ibuprofen 400mg PO tds with food). Add antibiotics (eg penicillin or clarithromycin) if there is a suspicion of local infection. Advise follow-up with a dentist.

Toothache with associated swelling, trismus, dysphagia, or systemic evidence of infection requires immediate referral to a maxillofacial surgeon for IV antibiotics and surgical drainage.