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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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128
DEAFNESS
The GP overview
Deafness is a frustrating symptom. In children it creates educational diculties and parental
worry. In adults, everyday life is fraught with diculties, and there may be stigmatisation. ree
million adults in the UK suer some degree of persistent deafness. Congenital causes acquired
in utero are not included here.
Differential diagnosis
COMMON
earwax
otitis media (OM)
otitis externa (OE)
glue ear (serous otitis media)/Eustachian dysfunction
presbyacusis (senile deafness)
OCCASIONAL
Ménière’s disease
otosclerosis
noise damage to cochlea
barotrauma
viral acoustic neuritis
large nasal polyps or nasopharyngeal tumour
drugs: streptomycin, gentamicin, aspirin overdose
RARE
vascular (haemorrhage, thrombosis of cochlear vessels)
acoustic neuroma
vitamin B
12
deciency
CNS causes (e.g. multiple sclerosis, cerebral secondary carcinoma)
cholesteatoma
Paget’s disease
traumatic (e.g. to tympanic membrane or ossicles)
https://t.me/med1917
DEAFNESS 129
Ready reckoner
Earwax OM OE Glue ear/ET Presbyacusis
Pain Possible Ye s Ye s No No
Pinna traction painful No No Ye s No No
Discharge from EAM Possible Possible Ye s No No
Conductive deafness Ye s Ye s Ye s Ye s No
Fluid level on drum No No No Ye s No
Possible investigations
LI KE LY: (In children) audiogram and tympanometry.
POSSIBLE: Ear swab.
SMALL PRINT: FBC/B
12
levels, skull X-ray, further imaging.
Audiometry quanties loss and distinguishes sensorineural from conductive hearing loss.
Tympanometry measures the compliance of the eardrum. Fluid in the middle ear attens
the compliance curve.
Swab of ear discharge: Discharge can be swabbed to guide treatment in refractory otitis
externa.
FBC/B
12
levels: To conrm B
12
deciency.
Skull X-ray: For Paget’s disease.
Further imaging: e.g. CT and MR I scans may be arranged by specialist for suspected acoustic
neuroma, multiple sclerosis or cerebral pathology.
TOP TIPS
Take parents seriously if they suspect their child is deaf. ere may be no physical signs in
glue ear, and tympanometry will yield the diagnosis.
Warn patients with otitis media that hearing may take a few weeks to return completely to
normal – this saves unnecessar y attendances with patients complaining that ‘e antibiotics
haven’t worked’.
In a case with no immediately alarming features and no past history of signicant ear disease,
it is reasonable to defer a comprehensive history and examination – instead, take a quick look
at the ear canals. If the diagnosis appears to be earwax, arrange syringing. Assess in more
detail only if there is no earwax or syringing doesn’t solve the problem.
Remember how to perform and interpret Rinne’s and Weber’s tests – these are invaluable in
assessing the less straightforward cases.
https://t.me/med1917
130 SYMPTOM SORTER
Remember the possibility of acoustic neuroma if there is progressive unilateral sensorineural
deafness – especially if there is accompanying tinnitus, vertigo or neurological symptoms or
signs.
Otherwise unexplained and persistent serous otitis media in adults may be due to
nasopharyngeal carcinoma – refer for urgent examination of the nasopharyngeal space.
Sudden onset of profound sensorineural deafness is usually viral or vascular and requires
same-day ENT assessment.
Otosclerosis requires early diagnosis for eective treatment. Consider the diagnosis in
otherwise unexplained conductive deafness in young adults, especially if there is a family
history.
NOTES:
https://t.me/med1917
131
EARACHE
The GP overview
is the commonest reason for an out-of-hours call for a child. Parental distress is oen as great
as the child’s, and appropriate advice can do much to relieve this – even over the telephone.
Causes in adults are far more varied than for children and can originate in the pinna, ear canal,
middle ear and from neighbouring structures (referred pain).
Differential diagnosis
COMMON
infective otitis media (OM): bacterial/viral
infective otitis externa (OE): bacterial/fungal/viral
boils and furuncles of the canal and pinna
trauma (especially cotton buds) and foreign bodies (including earwax)
throat problems: tonsillitis/pharyngitis/quinsy
OCCASIONAL
temporomandibular joint (TMJ) dysfunction
dental abscess
impacted molar
trigeminal neuralgia
ear canal eczema/seborrhoeic dermatitis
chondrodermatitis nodularis helicis externa
RARE
necrotising (or malignant) otitis externa
mastoiditis
cervical spondylosis
cholesteatoma
malignant disease
barotrauma
https://t.me/med1917
132 SYMPTOM SORTER
Ready reckoner
OM OE Boils Trauma Throat problems
Discharge Possible Ye s Possible Possible No
Pain on pulling pinna and pressing tragus No Yes Ye s Possible No
Red, bulging eardrum Yes No No No No
Deafness Ye s Possible No Possible No
Pain on swallowing No No No No Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: Ear swab.
SMALL PRINT: X-rays of TMJ, teeth and mastoid bone, FBC, Paul–Bunnell test.
Swab of ear canal useful if discharge present, aer failure of empirical rst-line treatment.
X-ray of mastoid bone excludes mastoiditis if mastoid clear – usually arranged by specialist.
X-rays of TMJ and teeth are the remit of the dentist or oral surgeon.
FBC and Paul–Bunnell test usefu l if glandular fever suspected. e diagnosis provides a label
and guides further advice, though no specic treatment exists.
Further specialist investigations may include CT/MRI as the only way adequately (non-
invasively) to investigate the inner ear and temporal bone anatomy.
TOP TIPS
Persistent debris in the ear canal will prevent resolution of OE and mask possible underlying
causes. Aural toilet is essential.
If inserting the aural speculum causes pain, the diagnosis is likely to be otitis externa or a
furuncle.
Don’t forget to ask about trauma – especia lly the use of a cotton bud. Excavating earwax with
a bud tends to produce an inamed canal and drum, mimicking infection.
Earache can be excruciating: Don’t underestimate the need for adequate analgesia while you
establish and treat the cause.
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EARACHE 133
Consider mastoiditis if foul-smelling discharge is present for more than 10 days. Look for
swelling behind the ear and downward displacement of the pinna.
Consider necrotising (or malignant) otitis externa in elderly diabetics or the
immunocompromised with ota lgia apparently out of proportion to their otitis externa. ey
may have a high fever and a facial palsy too. Refer urgently.
Don’t be too ready to diagnose otitis media in children – URTIs and crying inevitably result
in some redness of the drum. Indiscriminate prescribing may lead to iatrogenic problems or
the masking of the true diagnosis.
Beware the elderly patient with intractable, unexplained earache – refer to exclude a
nasopharyngeal carcinoma.
NOTES:
https://t.me/med1917
134
EAR DISCHARGE
The GP overview
is is oen seen in swimmers and returned tropical travellers. It is frequently a sequel to water
trapped behind earwax in the ear canal, which swells and encourages stasis and subsequent
infection. e vast majority of cases seen settle with simple treatment, but be wary of rarer
serious causes.
Differential diagnosis
COMMON
boil
acute suppurative otitis media (OM)
infective otitis externa (OE): viral, bacterial and fungal
chronic suppurative otitis media
reactive otitis externa: seborrhoeic dermatitis, eczema, psoriasis
OCCASIONAL
cholesteatoma
trauma: oen a result of over-vigorous attempts to clean the ear
bullous myringitis (otitis externa haemorrhagica)
infection with foreign body (insects, beads in toddlers)
liquefying excess earwax
RARE
mastoiditis
necrotising (or malignant) otitis externa
squamous and basal cell (rarer) carcinoma of the EAM
keratosis obturans (bolus of abnormally desquamated epithelium and earwax: associated
with chronic bronchitis and bronchiectasis)
herpes zoster oticus
cerebrospinal uid (CSF) otorrhoea
https://t.me/med1917
EAR DISCHARGE 135
Ready reckoner
Boil OM Infective OE Chronic OM Reactive OE
Painless No No Possible Ye s Possible
Other skin disease Possible No No No Ye s
Tender tragus Ye s No Ye s No Yes
Drum perforated No Ye s No Ye s No
Ipsilateral deafness No Ye s Possible Ye s Possible
Possible investigations
LI KE LY: None.
POSSIBLE: Swab, urinalysis.
SMALL PRINT: Skull/mastoid X-rays, CT or MRI scan, audiometry.
Swab of ear discharge: Helps guide treatment in refractory cases.
Urine for glucose: To exclude underlying diabetes if infections are recurrent (especially boils).
X-ray of the mastoid process will show a cloudy appearance in the mastoid air cells in
mastoiditis.
CT or MRI scan is the best way to investigate possible invasion of temporal bone by tumour,
cholesteatoma.
Audiometry may be required to assess baseline hearing loss in chronic OM, so improvement
aer denitive surgical treatment can be measured.
Skull X-ray: May show middle cranial fossa fracture in CSF otorrhoea (performed in hospital
aer signicant trauma).
TOP TIPS
Otitis externa is oen recurrent: To minimise future problems, advise the patient to avoid
getting water in the ear and stop using cotton buds. Also treat any underlying skin disease.
In the presence of ear discharge, pain on moving the tragus suggests otitis externa or a boil;
in the case of the former, the patient tends to present with itching rather than pain.
Most cases of otitis externa and media settle with empirical treatment and so don’t require a
swab. Only investigate if they do not respond to rst-line treatment.
If the diagnosis is not certain, be sure to follow up aer initial treatment to visualise the
drum; if persistent discharge makes th is impossible, refer to the ENT outpatients department
for aural toilet and further assessment.
https://t.me/med1917
136 SYMPTOM SORTER
Heat, tenderness and swelling over the mastoid process suggests mastoiditis: Refer urgently.
If ear discharge does not clear with usual therapy, refer for microsuction of debris (aural
toilet) to speed resolution and exclude signicant middle-ear disease.
Very rarely, middle-ear infection causing discharge can progress centrally, causing, for
example, mening itis or cerebral abscess – so refer immediately any patient with ear discharge
who becomes confused or develops neurological signs.
e use of aminoglycoside or polymyxin drops in the presence of a perforated tympanic
membrane carries a risk of ototoxicity (though some specialists do use such drops even if
perforation is present). When using potentially ototoxic drops, be as certain as you can about
what you are treating.
Beware severe otitis externa in elderly diabetics or the immunocompromised – it may be the
necrotising (‘malignant’) form.
NOTES:
https://t.me/med1917
137
TINNITUS
The GP overview
is means noises heard (nearly always subjectively) in the ears or head. ey are oen described
as being like a whistling kettle, an engine, or in time with the heartbeat. As a short-lived
phenomenon, it is very common (oen with URTIs) – such cases do not usually present to the
GP. More serious, persistent tinnitus occurs in up to 2% of the population. It is very distressing
and can cause secondary depression and insomnia. Objective tinnitus is very rare.
Differential diagnosis
COMMON
earwax
hearing loss (20% of cases: chronic noise damage and presbyacusis)
suppurative otitis media (also chronic infection and serous OM)
otosclerosis
Ménière’s disease
OCCASIONAL
aer a sudden loud noise (e.g. gunre)
head injury (especially basal skull fracture)
impacted wisdom teeth and TMJ dysfunction
drugs: aspirin overdose, loop diuretics, aminoglycosides, quinine
hypertension and atherosclerosis
RARE
acoustic neuroma
palatal myoclonus (objectively detectable)
arteriovenous stulae and arterial bruits (objectively detectable)
severe anaemia and renal failure
glomus jugulare tumours (objectively detectable)
https://t.me/med1917
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