ENT surgeon Spire Hospital Leeds and Leeds Teaching Hospitals NHS Trust Tuesday March 19 th 2019 Yorkshire Healthcare Practitioners Association E N T cases and update The Leeds Teaching Hospitals NHS Trust ID: 774689
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Gerard Kelly MD MEd FRCS (ORL-HNS) FRCS (Ed)ENT surgeon, Spire Hospital Leeds and Leeds Teaching Hospitals NHS TrustTuesday, March 19th 2019Yorkshire Healthcare Practitioners Association
E N Tcases and update
The Leeds Teaching Hospitals NHS Trust
The Spire Hospital Leeds
Slide2Ear
6 symptoms
otorrhoea
otalgia
itch
hearing
tinnitus
balance
Slide3Nose
6 symptoms
nasal obstruction
rhinorrhoea
facial pain
smell
epistaxis
post nasal drip
Slide4Throat
6 symptoms
dysphagia
dysphonia
odynophagia
pain
neck lumps
weight loss
Slide5Vertigo
Slide6The Leeds Teaching Hospitals NHS Trust
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vertigo is the hallucination of movement
it is usually but not always rotatory
Slide7The Leeds Teaching Hospitals NHS Trust
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what is the most important factor in diagnosis in a patient with vertigo?
Slide8The Leeds Teaching Hospitals NHS Trust
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examination of the tympanic membranes
audiogram
stapedial reflexes
BSERA
unterberger’s
calorics
ENG
cranial nerve examination
MR head
CT scan
Slide9The Leeds Teaching Hospitals NHS Trust
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history
Slide10The Leeds Teaching Hospitals NHS Trust
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what do you want to get out of the history?
Slide11The Leeds Teaching Hospitals NHS Trust
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what the sensation is like?
movement?
drunk?
light headed?
Slide12The Leeds Teaching Hospitals NHS Trust
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how long does it last?
seconds?
minutes?
hours?
any warning that it is going to happen?
Slide13The Leeds Teaching Hospitals NHS Trust
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any exacerbating or reliving factors?
staying still?
medication?
standing up quickly?
Slide14The Leeds Teaching Hospitals NHS Trust
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any associated features?
tinnitus?
hearing?
tingling in the arms and hands?
Slide15Vertigo summary
Slide16Benign paroxysmal positional vertigo (BPPV). Intense, brief vertigo immediately with a change in head position, turning over in bed, sitting up in morning, or bending down. Common. Can follow vestibular neuronitis.Vestibular neuronitis / labyrinthitis. Sudden intense, constant vertigo, days. Nausea, vomiting. Bedbound. Hearing loss = labyrinthitis. Generally subsides on its own. Vestibular rehabilitation = speeds recovery. Meniere's disease. Build up of fluid in the inner ear. Sudden episodes of vertigo lasting as long as several hours, accompanied by fluctuating hearing loss, ringing in the ear and a feeling of fullness in the affected ear. Vestibular migraine. More than a headache. Visual "aura“ and vertigo episodes without a severe headache. Such vertigo episodes can last hours to days and may be associated with headache as well as light and noise sensitivity. Acoustic neuroma. (vestibular schwannoma) benign growth on the vestibular nerve. Symptoms of an acoustic neuroma generally include progressive hearing loss and tinnitus on one side accompanied by dizziness or imbalance. Other causes. Rarely, vertigo can be a symptom of a more serious neurological problem such as a stroke, brain haemorrhage or multiple sclerosis = other neurological symptoms.
vertigo
Slide17case – ear not getting better
Slide1841 year old male
right otorrhoea 6 weeks
itch
foul smelling
reduced hearing
treated with several courses of gentisone
Slide19fungal spores in the ear
Slide20Diagnosis?
Slide21Otitis externa - fungal
itch
otorrhoea
previous or recurrent symptoms
Slide22Otitis externa
treatment?
Slide23Otitis externa
treatment?
nothing
medical
aural toilet
Slide24ear infection
emergencies
Slide253 year old male
distressed
2 day post URTI
temperature 39.2°C
pulling left ear
Slide26diagnosis?
Slide27acute otitis media
treatment?
Slide28antibiotic use for acute otitis media varies from 31% in the Netherlands to 98% in the USA and Australia
Slide29acute otitis media and antibiotics
Slide30Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days.
Slide31Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain.
Slide32Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics.
Slide33Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics. Antibiotics are most useful in children under two years of age, with bilateral AOM, and with both AOM and discharging ears.
Slide34Antibiotics slightly reduce the number of children with acute middle ear infection experiencing pain after a few days. However, most (78%) settle spontaneously in this time, meaning 16 children must be treated to prevent one suffering ear pain. This benefit must be weighed against the possible harms: 1 in 24 children experience symptoms caused by antibiotics. Antibiotics are most useful in children under two years of age, with bilateral AOM, and with both AOM and discharging ears. For most other children with mild disease, an expectant observational approach seems justified. We have no data on populations with higher risks of complications.
Slide35we overuse antibiotic in acute otitis media
a trial of withholding antibiotics is usually effective – either because it works or because with time and aging there is natural resolution
Slide36sudden hearing loss
emergencies
Slide3764 year old woman
presents
2 day history of hearing loss in the right ear
Slide3864 year old woman
presents
2 day history of hearing loss in the right ear
what do you ask?
Slide39Slide40sudden sensorineural loss
definition
at least 30dB hearing loss
over 3 contiguous frequencies
a period of a few hours to 3 days
Slide41sudden sensorineural loss
incidence
5 – 20 per 100 000 people per year
1 in 10 000 people per year
0.01% people per year
Slide42sudden sensorineural loss
typical patient
40 – 50 years
M=F
30% have balance symptoms
Slide43sudden sensorineural loss
aetiology?
Slide44sudden sensorineural loss
Infection
Bacterial postmeningitis, bacterial
labyrinthitis, syphilis
Viral mumps, cytomegalovirus
Inflammation
Autoimmune
Cogan’s syndrome, systemic lupus erythematosus
Multiple sclerosis
Trauma
Temporal bone fracture
Acoustic trauma
Perilymph fistula
Tumor
CPA tumour
Temporal bone metastasis
Carcinomatosis meningitis
Toxins
Aminoglycosides
Aspirin
Vascular
Thromboembolism
Macroglobulinemia, sickle cell disease, post-CABG, vasculitides
Slide45sudden sensorineural loss
Infection
Bacterial postmeningitis, bacterial
labyrinthitis
, syphilis
Viral
mumps, cytomegalovirus
Inflammation
Autoimmune
Cogan’s syndrome, systemic lupus erythematosus
Multiple sclerosis
Trauma
Temporal bone fracture
Acoustic trauma
Perilymph fistula
Tumor
CPA tumour
Temporal bone metastasis
Carcinomatosis meningitis
Toxins
Aminoglycosides
Aspirin
Vascular
Thromboembolism
Macroglobulinemia, sickle cell disease, post-CABG,
vasculitides
Slide46sudden sensorineural loss
Infection
Bacterial postmeningitis, bacterial
labyrinthitis
, syphilis
Viral
mumps, cytomegalovirus
Inflammation
Autoimmune
Cogan’s syndrome, systemic lupus erythematosus
Multiple sclerosis
Trauma
Temporal bone fracture
Acoustic trauma
Perilymph fistula
Tumor
CPA tumour
Temporal bone metastasis
Carcinomatosis meningitis
Toxins
Aminoglycosides
Aspirin
Vascular
Thromboembolism
Macroglobulinemia, sickle cell disease,
post-CABG,
vasculitides
Slide47topical papers
Slide48stroke and SSNHL
Stroke. 2008 Oct;39(10):2744-8. Epub 2008 Jun 26.
Sudden sensorineural hearing loss increases the risk of stroke: a 5-year follow-up study. Lin HC, Chao PZ and Lee HC
CONCLUSIONS: Our findings suggest that SSNHL can be an early warning sign of impending stroke. We suggest that SSNHL patients should undergo a comprehensive hematologic and neurological examination to help clinicians identify those potentially at risk for stroke developing in the near future.
Slide49steroids
Wilson et al.
The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
Slide50steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
Slide51steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
Slide52steroids
Wilson et al. The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
Slide53steroids
Wilson et al.
The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
Slide54steroids
Wilson et al.
The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
Kaiser-Permanente, Oakland, California and
Massachusetts Eye and Ear Infirmary
dexamethasone and
methylprednisolone
Slide55steroids
Wilson et al.
The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
% recovery
steroids 60.6%
placebo 32.4%
Slide56steroids
Wilson et al.
The efficacy of steroids in the treatment of idiopathic SSNHL. Arch Otolaryngology 1980
% recovery
steroids 60.6%
placebo 32.4%
controls (no treatment patients,
not in the study) 55.8%
Slide57steroids
Cinamon et al.
Steroids, carbogen or placebo for SSNHL: a prospective double-blind study. Eur Arch Otolaryngology 2001
41 patients randomized
5 days 54% improved
1 month 73% improved
Slide58steroids
Cinamon et al.
Steroids, carbogen or placebo for SSNHL: a prospective double-blind study. Eur Arch Otolaryngology 2001
41 patients randomized
5 days 54% improved
1 month 73% improved
in all groups
Slide59evidence based medicine
v
asodilators
unproven
steroids unproven
antivirals
protocol
intratympanic
steroids unproven
Slide60evidence based medicine
so, if there is no good evidence for the treatment of SSNHL, should we not treat anyone with SSNHL?
Slide61evidence based medicine
we know there is no evidence but patients expect some form of treatment
currently idiopathic sudden sensorineural hearing loss tends to be treated like Bell’s palsy with oral steroids (eg 40mg daily Prednisolone)
Slide62acoustic neuromas
Slide63acoustic neuromas
benign tumours of the hearing and balance nerve, but with growth there can be a threat to life due to brain stem compression and raised intracranial pressure
diagnosed by MR scanning and scanning is necessary when there is a 15 dB difference at 2 frequencies in an audiogram
treated often by serial rescanning by MR
other options surgery (major operation with at least 7 days admission) and the gamma knife (single dose radiation, out patient procedure)