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Managing common ENT problems in primary care

16 Jan 2017

There are various ear, nose, and throat (ENT) conditions which present to the GP’s clinic. Pearl Toh spoke with Dr Jason Hwang, an ENT Consultant from the Department of Otolaryngology at Gleneagles Hospital in Singapore, on how the majority of the conditions can be effectively managed at the primary care level seeing that these can be treated medically without the need for surgical intervention.

 

Otitis externa

Otitis externa usually presents with otalgia and ear discharge. If the discharge occludes the ear canal, patients will also report hearing loss. Diabetic patients with severe otalgia may have malignant otitis externa due to Pseudomonas infection. This can potentially spread along the skull base as a form of osteomyelitis and usually requires ENT referral and intravenous antibiotic treatment.

Examination shows purulent discharge in the ear canal and there may be oedema and erythema of the ear canal. In otomycosis, there is often a creamy layer of debris with fungal spores seen.  In patients with recurrent or refractory symptoms, taking a swab for bacterial and fungal culture can be useful.

Otitis externa generally responds to eardrops without the need for oral medication. However, if the ear canal is obstructed, either due to a swollen ear canal or if filled with discharge, ear drops are unable to penetrate deep into the ear canal. Aural toilet for cleaning the ear canal by an ENT specialist may be required to allow effective use of ear drops. In patients with oedematous ear canals, an ear wick may be used to help with penetration of the ear drops. A 2010 Cochrane review analysed 19 randomized controlled trials and concluded that (i) topical treatment is sufficient for uncomplicated cases (ii) most topical treatments are equally effective (iii) choice of treatment is determined by various factors including risk of ototoxicity, cost and availability. [Cochrane Database Syst Rev 2010;(1):CD004740] 

Otitis media

Acute otitis media. (Photo courtesy of Dr Jason Hwang)

Acute otitis media. (Photo courtesy of Dr Jason Hwang)

Middle ear infections present as acute otitis media (AOM) or chronic suppurative otitis media (CSOM). AOM is often associated with an upper respiratory tract infection (URTI) and fever. Besides URTI symptoms, the patients commonly experience otalgia (often severe) and hearing loss. The tympanic membrane tends to be erythematous and bulging, which may result in tympanic membrane perforation with the relief of pain and onset of ear discharge. These perforations are usually small and heal spontaneously with resolution of the infection. In patients with persistent infection, it can result in nonhealing and CSOM.

Most AOM start as a viral inflammation and may not require antibiotics in the initial period. The associated URTI can be treated symptomatically. However, the American Academy of Paediatrics recommends that antibiotics should be initiated for young patients with definite AOM who are under 2 years of age. For children above 2 years old, they can be monitored and started on antibiotics if there is no improvement after 48 to 72 hours.

In children, it is common for middle ear effusion to occur after resolution of AOM. Though 90 percent resolve spontaneously, these patients require follow up to ensure resolution. A persistent middle ear effusion can affect speech development and requires drainage via a grommet tube.

Left middle ear effusion with fluid level. (Photo courtesy of Dr Jason Hwang)

Left middle ear effusion with fluid level. (Photo courtesy of Dr Jason Hwang)

Sudden sensorineural hearing loss (SSNHL)

SSNHL is defined as a hearing impairment occurring over 72 hours, in one or both ears. The majority of cases (up to 90 percent) are idiopathic. Patients with bilateral sudden hearing loss, neurological signs or recurrent episodes should be flagged for possible central causes.

Oral steroids should be given as early as possible after the onset of hearing loss in order to reverse the condition. There is no good evidence to support the use of antivirals, antioxidants or supplements, though these are often given in an attempt to salvage hearing. Patients with incomplete recovery after oral medication should be referred to an ENT specialist for second-line treatment with intratympanic steroid injections. This can be done under local anaesthesia and gives an additional 30–40 percent chance of hearing recovery.

 

Tonsils and adenoid      

Together with the adenoid, the tonsils form the mucosa associated lymphoid tissue in the pharynx. Not surprisingly, they are inflamed during periods of infection, resulting in swelling and pain. The most common issues with the tonsils and adenoid are: (i) infection or (ii) size.

Tonsillitis

The clinical features of acute tonsillitis are fairly typical and make diagnosis straightforward. Fever, sore throat, and swallowing difficulty will quickly alert the physician to examine the throat. This will show inflamed tonsils, sometimes with purulent exudate in the tonsillar crypts. The adenoids are likely to be inflamed as well, but remain tucked away in the nasopharynx and usually not visible.

Treatment includes antibiotics, hydration, and symptomatic treatment. Antibiotics from the penicillin group or macrolides (for patients with penicillin allergy) can be given orally. Patients with severe symptoms may require hospital admission for intravenous hydration and antibiotics. Symptomatic treatment would include topical preparations (eg, gargle, sprays, lozenges) as well as paracetamol and ibuprofen for fever and pain control. The use of amoxicillin may cause a rash in cases of infectious mononucleosis.

A peritonsillar abscess (quinsy) is a collection of pus between the tonsil and the pharyngeal muscles. This presents with fever, trismus and unilateral or asymmetrical throat pain. Examination reveals swelling not of the tonsil itself but mainly in the adjacent superolateral area of the oropharynx. The abscess requires transoral incision and drainage, often under general anaesthesia in young children and under local anesthesia in older children and adults.

Endoscopic view of a large tonsil. (Photo courtesy of Dr Jason Hwang)

Endoscopic view of a large tonsil. (Photo courtesy of Dr Jason Hwang)

Almost complete airway obstruction due to large tonsils during inspiration revealed by Muller's manoeuvre. (Photo courtesy of Dr Jason Hwang)
Almost complete airway obstruction due to large tonsils during inspiration revealed by Muller's manoeuvre. (Photo courtesy of Dr Jason Hwang)

Snoring and Obstructive Sleep Apnoea (OSA)

Breathing through a narrow air passage leads to turbulent airflow, vibration and snoring. This can be due to one or more areas of the upper airway, including large inferior turbinates, a floppy, low lying palate or large tonsils and adenoid. Complete obstruction of the airway results in OSA. Weight gain and decreased muscle tone can further worsen the narrow airway.

In OSA, the poor airflow leads to a drop in oxygen levels in the body, resulting in interrupted, restless sleep as the patient struggles to maintain oxygen levels. A patient with OSA is rarely aware of having difficulty breathing and is often brought to medical attention by the partner. Apnoea episodes are characterized by snoring, followed by a period of silence as airflow ceases. This leads to choking or gasping as the patient tries to breathe to restore oxygen levels in the body. This can occur repeatedly throughout the night, leading to poor sleep quality and daytime fatigue. The fluctuating oxygen levels result in increased risks of stroke, hypertension and ischemic heart disease. In children, OSA may manifest differently and they may be hyperactive with poor memory, learning difficulties and failure to thrive.

Evaluation of snoring and OSA requires a sleep study to determine the presence and severity of OSA as well as an upper airway evaluation with endoscopy to identify the narrow areas. Treatment is dependent on severity, involving weight loss for patients who are overweight. Definitive options would need to be individualized depending on the severity of the OSA, daytime fatigue and snoring noise. This can range from minor surgical procedures under local anaesthesia for mild cases to CPAP (continuous positive airway pressure) devices and comprehensive surgical options for severe OSA. Factors to consider about undergoing surgery include the risks versus the long-term benefits of surgery. In some adults, there may be multilevel areas of narrowing. In some cases, surgery is used to facilitate more comfortable use of CPAP instead of being curative.

 

Acute rhinosinusitis (ARS)

Sinusitis is often loosely used to mean bacterial rhinosinusitis. Strictly speaking, amajority of rhinosinusitis are due the viral infections, with secondary bacterial infection occurring in only 2 percent at most. The diagnosis of bacterial rhinosinusitis in primary care is mainly symptom-based. In ARS, there is a sudden onset of two or more of the following symptoms lasting for up to 4 weeks:

i)      Nasal obstruction or congestion

ii)      Purulent nasal discharge (anterior or postnasal drip)

iii)      Facial pain or pressure

iv)      Hyposmia or anosmia

In a primary care setting, we expect the common cold (viral rhinosinusitis) to resolve within 5 days. As such, an increase in symptoms after 5 days or persistent symptoms after 10 days (Figure 1) can be presumed to be due to bacterial rhinosinusitis, requiring antibiotics. Examination often shows thick mucopus coming from the sinuses. Imaging is generally not required for the diagnosis of ARS. Plain X-rays should not be done as they lack sensitivity and specificity. In patients with unilateral maxillary sinusitis, a dental cause needs to be excluded.

Figure 1: EPOS guidelines. (Adapted from Rhinol Suppl. 2005;18:1)

Figure 1: EPOS guidelines. (Adapted from Rhinol Suppl. 2005;18:1)

Complications of ARS

ARS may lead to orbital and neurological complications. Though uncommon, sinusitis patients with warning signs like drowsiness, eye swelling, diplopia and reduced visual acuity require urgent assessment. Ethmoid sinusitis can cross the thin lamina papyracea leading to orbital cellulitis, orbital abscess, subperiosteal abscess or cavernous sinus thrombosis. Intracranial spread of sinusitis can cause meningitis, epidural abscess and subdural abscess. These orbital and intracranial complications are emergencies, requiring immediate attention of the ENT specialist.

Medical treatment in ARS

When indicated, antibiotics should be given for 5 to 10 days.  Amoxicillin with or without clavulanate should be considered as the first-line antibiotic in ARS.

In addition to antibiotics, nasal steroid spray twice daily has been shown to help improve symptoms. Routine use of oral steroids in ARS should be avoided.  Anti-histamines are generally not recommended but may be useful in patients with allergic rhinitis. Though there is no clear evidence, topical decongestants and saline irrigation can be useful for symptomatic relief.

Patients with persistent symptoms despite treatment should be referred to an ENT specialist for further management.  This may include taking an endoscopic guided swab for bacterial culture and the use of second-line antibiotics. Should symptoms persist, the patient may benefit from endoscopic sinus surgery to drain the trapped mucopus and ventilate the sinuses.

Acute sinusitis with pus streaming out of left middle meatus. (Photo courtesy of Dr Jason Hwang)

Acute sinusitis with pus streaming out of left middle meatus. (Photo courtesy of Dr Jason Hwang)

Allergic rhinitis

Allergic rhinitis is characterized by symptoms of nasal obstruction, watery rhinorrhoea, sneezing and nasal itch. It is important that patients understand that treatment does not change the underlying allergy but is targeted at reducing and controlling the symptoms of the allergy.

The most common allergen in South East Asia is undoubtedly the house dust mite. This is often confirmed using skin prick tests. Environmental measures include keeping the house and bedroom clean, removal of carpets and soft toys, use of a vacuum cleaner with a HEPA filter and antidust mite covers for the mattresses and pillows.

Medications for allergic rhinitis are broadly divided into steroid sprays and antihistamines. Steroid spray is the first-line treatment for monotherapy as it has a better overall effect on all symptoms of allergic rhinitis. Antihistamines work well for rhinorrhoea and sneezing but have minimal effect on nasal obstruction. Nasal decongestants are helpful for the initial treatment period but keep in mind the risk of rhinitis medicamentosa with prolonged use.  It is important to explain to patients that the medication does not change the underlying allergy and symptoms will recur on cessation of medication.

Immunotherapy involves the exposure of patients to previously identified allergen. The sublingual route has significantly less risk of adverse effects compared with the subcutaneous route. However, it requires substantial commitment from the patient, as the beneficial effect only starts 6-12 months after starting treatment and requires 4 years of daily treatment for optimal effect. Despite this, long-term data shows recurrence of symptoms after 8 years, with a need for additional booster doses. These issues should be clearly explained to patients before they commit to a long and relatively expensive treatment regime.

Surgery can relieve the symptoms of allergic rhinitis. However, it must be made clear to the patient that it does not change the fact that they have an allergy. For those who are noncompliant or unhappy with the use of medication, surgery may be considered. This may include radiofrequency turbinate reduction, turbinoplasty and septoplasty. 

Dr Jason Hwang, ENT Consultant of the Department of Otolaryngology, ​Gleneagles Hospital, Singapore.
Dr Jason Hwang, ENT Consultant of the Department of Otolaryngology, ​Gleneagles Hospital, Singapore.
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