Ear and Nose Conditions Overview

Epistaxis (Nosebleed)

• Bleeding from inside the nose.
• Common sites: Little's area, above and below the middle turbinates, posterior nasal wall, nasopharynx.
• Causes: Local (trauma, infections, sinusitis, TB), Generalized (blood disorders, liver disease, drugs, infections), Idiopathic.
• Management:
  • Assess mode of onset, duration and frequency of bleeding, site of bleeding, history of bleeding tendencies, medical ailments, drug intake.
  • Procedures: Cauterization, anterior nasal packing, posterior nasal packing

Otitis Externa (Swimmer's Ear)

• Inflammation of the external ear.
• Classified by aetiology:
  • Infective: Bacterial (Localized, Diffused, Malignant Otitis Externa), Viral (Herpes zoster oticus, Otitis externa haemorrhagia), Fungal (Otomycosis)
  • Reactive: Eczematous OE, Seborrhoeic OE, Neurodermatitis

Localized OE (Furunculosis)

• Staphylococcal infection of the hair follicle.
• Symptoms: Ear pain, meateal swelling, serous discharge, itching (in diffuse otitis externa).
• Treatment: Ear toileting, medicated wicks, localized steroid drops, antibiotics, analgesics.

Otomycosis

• Fungal infection of the ear canal.
• Presents as filamentous growths in the canal.
• Common organisms: Aspergillus niger, Aspergillus fumigatus, Candida albicans.
• Clinical features: Intense itching, ear pain/discomfort, watery discharge, ear blockage.
• Treatment: Ear toileting, antifungal agent (ketoconazole cream), antibiotics (if bacterial infection), steroid preparation (to reduce inflammation and edema).

Adenoids (Nasopharyngeal Tonsils)

• Lymphoid tissues located at the junction of the roof and posterior wall of the nasopharynx.
• Present at birth, enlarge physiologically up to age 6, tend to atrophy at puberty and disappear in early adulthood.
• Aetiology: Lymphoid hyperplasia, Upper respiratory tract allergy, Recurrent upper respiratory tract infection.

Clinical Features of Adenoids

• Nasal: Nasal obstruction, nasal discharge, sinusitis, voice changes, snoring, mouth breathing.
• Aural: Eustachian tube obstruction, recurrent OE, otitis media with effusion (OME), chronic suppurative otitis media (CSOM).
• General: Adenoid facies, pulmonary hypertension.

Diagnosis of Adenoids

• Detailed history (including snoring and mouth breathing).
• Post-nasal space (PNS) x-ray showing enlarged adenoids and the extent of nasopharyngeal air space occupied.

Treatment of Adenoids

• Nasal decongestants, antihistamines (for co-existing nasal allergy), breathing exercises.
• Definitive treatment: Adenoidectomy

Tonsillitis

• Palatine tonsils are two ovoid tissues located on the lateral wall of the oropharynx.
• Functions: Local immunity, surveillance mechanism.
• Types: Acute tonsillitis, Chronic tonsillitis

Acute Tonsillitis

• Types: Acute Catarrhal/Superficial tonsillitis, Acute follicular tonsillitis, Acute parenchymal tonsillitis, Acute membranous tonsillitis.

Aetiology of Acute Tonsillitis

• Haemolytic Streptococcus is the most common organism. Others include staphylococci, pneumococci, H. influenza.

Symptoms of Acute Tonsillitis

• Sore throat, difficulty swallowing, fever, headache, malaise, earache.

Signs of Acute Tonsillitis

• Inflamed tonsils, foetid breath, hyperaemia of pillars, soft palate and uvula, yellowish spots of purulence at the opening of crypts (Acute follicular tonsillitis).

Treatment of Acute Tonsillitis

• Liberal oral fluid intake, analgesics, antimicrobial therapy.

Chronic Tonsillitis

• Aetiology: Complication of acute tonsillitis, subclinical infection of tonsils without an acute attack, chronic infection in sinuses/teeth.
• Occurs mostly in children and young adults.
• Types: Chronic follicular tonsillitis, Chronic parenchymal tonsillitis, Chronic fibroid tonsillitis.

Clinical Features of Chronic Tonsillitis

• Recurrent sore throat, halitosis, chronic throat irritation with cough, obstructive sleep apnea, dysphagia.

Examination of Chronic Tonsillitis

• Tonsillar enlargement, yellowish beads of pus on the medial surface (chronic follicular tonsillitis), flushing of anterior pillars.

Definitive Treatment of Chronic Tonsillitis

• Tonsillectomy

Complications of Tonsillitis

• Peritonsillar abscess, parapharyngeal abscess, intratonsillar abscess, tonsilloliths, tonsillar cysts.

Allergic Rhinitis

• IgE-mediated immunological response of the nasal mucosa to airborne allergens.
• Characterized by watery discharge, nasal obstruction, sneezing, itching in the nose.
• Symptoms can be seasonal or perennial.

Aetiology of Allergic Rhinitis

• Allergens, genetic predisposition.

Clinical Features of Allergic Rhinitis

• Nasal: Sneezing, nasal obstruction, watery nasal discharge, nasal itching, loss of sense of smell, post nasal drip, allergic salute, enlarged turbinates.
• Occular: Edema of the eyelids, cobble-stone appearance of the conjunctiva, dark circles under the eye (allergic salute).
• Otologic: Retracted tympanic membrane, serous otitis media (secondary to Eustachian tube blockage).
• Pharyngeal: Pharyngitis from hyperplasia of submucosal lymphoid tissues.
• Laryngeal: Hoarseness, edema of the vocal cord.

Diagnosis of Allergic Rhinitis

• Based on duration of symptoms (intermittent < 4 days/week or < 4 weeks, persistent > 4 days/week or > 4 weeks), severity of symptoms (mild, moderate, severe), detailed history and physical examination.

Investigations for Allergic Rhinitis

• FBC (eosinophilia), nasal smear (shows aggregation of eosinophils), skin prick test, specific IgE measurement, nasal provocation test.

Treatment of Allergic Rhinitis

• Avoidance of allergen, drug therapy (antihistamine, leukotriene receptor antagonist (montelucast), corticosteroids, anticholinergics), immunotherapy.

Complications of Allergic Rhinitis

• Recurrent sinusitis, nasal polyps, serous otitis media, bronchial asthma.

Foreign Body/Trauma in the Ear

• Non-vegetative materials: Cotton buds, beads, eraser, biro tips, sticks, colour pencils, etc.
• Vegetative materials: Beans, maize.
• Live insects: Cockroaches, moths.
• Treatment: Removal with instruments (Jobson-Horne probe, crocodile forceps) or ear irrigation. Removal under general anesthesia may be necessary for impacted foreign bodies and uncooperative children. Foreign bodies can be pushed into the middle ear by untrained hands.