Assess and manage ear presentations:
- hearing loss:
- from various causes (eg conductive and sensorineural loss, malignancy)
- occupation-related
- in children, including speech and developmental delay
- outer ear:
- auricular disease (eg perichondritis)
- canal disease (eg exostoses)
- ear wax
- otitis externa
- foreign body
- trauma
- canal eczema
- middle ear disease
- otitis media
- tympanic perforation
- bullous myringitis
- other (eg otosclerosis)
- labyrinthitis
- Meniere’s disease
- referred pain/non-aural causes of ear pain:
- dental problems (abscess, impacted molar)
- temporomandibular joint syndrome
- pharyngeal disorders (eg malignancy, foreign body)
- carotidynia
- cervical spine problems, including osteoarthritis and spondylosis
- neurological problems (herpes zoster, trigeminal neuralgia, glossopharyngeal neuralgia)
- Bell’s palsy
- any cranial nerve lesion affecting nerves V, VII, IX or X
- upper cervical lesions
- ear malignancies (eg acoustic neuroma, cholesteatoma)
- facial nerve paralysis (Bell’s palsy)
- vertiginous syndromes:
- benign paroxysmal vertigo
- chronic vertiginous syndrome (eg tinnitus, Meniere’s disease)
- vestibular neuritis
- Ramsay Hunt syndrome.
| Presentation | Clinical Assess | High Yield Features | Management |
| Hearing Loss | |||
| – Conductive & Sensorineural Loss | History, tuning fork tests, audiometry | Aetiology: Otosclerosis, noise exposure, aging, infections Risk Factors: Loud noise exposure, age, infections Signs/Symptoms: Decreased hearing, tinnitus, dizziness | Address underlying cause hearing aids surgery (e.g., stapedectomy for otosclerosis) cochlear implants for severe sensorineural loss |
| – Malignancy | History, otoscopic exam, biopsy, imaging | Aetiology: Primary or metastatic tumors Risk Factors: Smoking, chronic otitis media, radiation exposure Signs/Symptoms: Unilateral hearing loss, otalgia, otorrhea, facial nerve weakness | Surgical resection radiotherapy |
| – Occupational-Related | History, audiometry, noise exposure assessment | Aetiology: Prolonged exposure to loud noise Risk Factors: Work in noisy environments Signs/Symptoms: Progressive hearing loss, tinnitus | Hearing protection noise control measures regular hearing tests hearing aids |
| – In Children | History, developmental assessment, audiometry | Aetiology: Congenital, infections, ototoxic medications Risk Factors: Family history, prematurity Signs/Symptoms: Delayed speech and language development, inattentiveness | Treat underlying conditions (e.g., antibiotics for infections) Early intervention, speech therapy, hearing aids, cochlear implants |
| Outer Ear | |||
| – Auricular Disease | History, physical exam, culture | Aetiology: Trauma, infections (perichondritis) Risk Factors: Piercings, surgery Signs/Symptoms: Pain, redness, swelling, drainage | Flucloxacillin 500 mg orally, 6-hourly for 7-10 days Drainage of abscesses, wound care |
| – Canal Disease | History, otoscopic exam, imaging | Aetiology: Exostoses, infections, foreign bodies Risk Factors: Cold water exposure (exostoses) Signs/Symptoms: Hearing loss, pain, discharge | Ciprofloxacin eardrops 0.3%, 3 drops twice daily for 7 days (if infection present) Removal of exostoses or foreign bodies |
| – Ear Wax | History, otoscopic exam | Aetiology: Accumulation of cerumen Risk Factors: Use of cotton swabs Signs/Symptoms: Hearing loss, fullness in ear, tinnitus | Cerumenolytics (e.g., olive oil drops, sodium bicarbonate drops) Ear irrigation, manual removal |
| – Otitis Externa | History, otoscopic exam, culture | Aetiology: Bacterial, fungal infections Risk Factors: Water exposure, trauma Signs/Symptoms: Ear pain, itching, discharge, hearing loss | Topical ciprofloxacin 0.3% with hydrocortisone 1%, 3 drops twice daily for 7 days; oral flucloxacillin 500 mg 6-hourly for 7 days (if severe) Keep ear dry pain management with NSAIDs |
| – Foreign Body | History, otoscopic exam | Aetiology: Insertion of objects Risk Factors: Young children Signs/Symptoms: Pain, discharge, hearing loss | Removal of foreign body, treat any secondary infection |
| – Trauma | History, physical and otoscopic exam, imaging | Aetiology: Blunt or penetrating trauma Risk Factors: Accidents, assaults Signs/Symptoms: Pain, bleeding, hearing loss, deformity | |
| – Canal Eczema | History, physical exam | Aetiology: Allergic reactions, dermatitis Risk Factors: Allergies, irritants Signs/Symptoms: Itching, redness, flaking skin | Topical hydrocortisone 1% cream, apply twice daily |
| Middle Ear | |||
| – Otitis Media | History, otoscopic exam, tympanometry | Aetiology: Bacterial, viral infections Risk Factors: Upper respiratory infections, allergies Signs/Symptoms: Ear pain, fever, hearing loss, otorrhea | Pharmacological: Amoxicillin 500 mg orally, 8-hourly for 5-7 days (adults); 15 mg/kg/dose 8-hourly for 5-7 days (children) Non-Pharmacological: Analgesics myringotomy with or without tube placement |
| – Tympanic Perforation | History, otoscopic exam, audiometry | Aetiology: Infection, trauma, barotrauma Risk Factors: Chronic otitis media, trauma Signs/Symptoms: Hearing loss, otorrhea, tinnitus | Pharmacological: None specific unless secondary infection (e.g., amoxicillin) Non-Pharmacological: Observation, surgical repair (tympanoplasty) |
| – Bullous Myringitis | History, otoscopic exam | Aetiology: Viral infections (e.g., Mycoplasma) Risk Factors: Upper respiratory infections Signs/Symptoms: Severe ear pain, bloody otorrhea, hearing loss | Pharmacological: Azithromycin 500 mg on day 1, then 250 mg daily for 4 days Non-Pharmacological: Pain management with NSAIDs |
| – Other (e.g., Otosclerosis) | History, otoscopic exam, audiometry | Aetiology: Abnormal bone growth Risk Factors: Family history, age Signs/Symptoms: Progressive conductive hearing loss, tinnitus | Hearing aids stapedectomy |
| – Labyrinthitis | History, physical exam, vestibular tests, audiometry | Aetiology: Viral or bacterial infections Risk Factors: Recent upper respiratory infection Signs/Symptoms: Vertigo, hearing loss, tinnitus, nausea, vomiting | Pharmacological: Prednisolone 1 mg/kg (max 60 mg) orally daily for 10-14 days if bacterial, amoxicillin/clavulanate 875/125 mg 12-hourly for 10-14 days Non-Pharmacological: Bed rest, vestibular rehabilitation, hydration |
| – Meniere’s Disease | History, physical exam, audiometry, vestibular tests | Aetiology: Endolymphatic hydrops Risk Factors: Genetic predisposition, autoimmune diseases Signs/Symptoms: Episodic vertigo, fluctuating hearing loss, tinnitus, aural fullness | Pharmacological: Betahistine 16 mg three times daily diuretics (e.g., hydrochlorothiazide 25 mg daily) Non-Pharmacological: Low-salt diet vestibular rehabilitation, intratympanic steroids or gentamicin surgery in refractory cases |
| Referred Pain and Aural Causes | |||
| – Dental Problems | History, dental exam, imaging | Aetiology: Abscess, impacted molar Risk Factors: Poor oral hygiene, dental caries Signs/Symptoms: Tooth pain, swelling, fever | Pharmacological: Amoxicillin 500 mg orally, 8-hourly for 5-7 days; metronidazole 400 mg 8-hourly for 5 days (if anaerobic infection suspected) Non-Pharmacological: Dental treatment (extraction, drainage), pain management |
| – TMJ Syndrome | History, physical exam, imaging | Aetiology: Bruxism, arthritis Risk Factors: Stress, jaw clenching Signs/Symptoms: Jaw pain, clicking, limited mouth opening | Pharmacological: NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours), muscle relaxants (e.g., diazepam 2-5 mg at night) Non-Pharmacological: Dental appliances, physical therapy, stress management |
| – Carotidynia | History, physical exam, imaging | Aetiology: Inflammation of the carotid artery Risk Factors: Unknown Signs/Symptoms: Neck pain, tenderness over carotid artery | Pharmacological: NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours), corticosteroids (e.g., prednisolone 20-40 mg daily for 7-10 days) |
| – Cervical Spine Problems | History, physical exam, imaging | Aetiology: Osteoarthritis, spondylosis Risk Factors: Age, neck injury Signs/Symptoms: Neck pain, radiating pain to the ear | Pharmacological: NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours), muscle relaxants Non-Pharmacological: Physical therapy, surgical intervention in severe cases |
| – Neurological Problems | History, physical exam, neurological exam, imaging | Aetiology: Herpes zoster, trigeminal neuralgia, glossopharyngeal neuralgia Risk Factors: Viral infections, nerve compression Signs/Symptoms: Sharp, stabbing pain, rash (in herpes zoster), nerve dysfunction | Pharmacological: Acyclovir 800 mg 5 times daily for 7 days (for herpes zoster); carbamazepine 100 mg twice daily, increase as needed for trigeminal neuralgia Non-Pharmacological: Pain management, physical therapy |
| – Bell’s Palsy | History, physical exam, neurological exam | Aetiology: Idiopathic, viral infections (e.g., HSV) Risk Factors: Recent viral illness Signs/Symptoms: Unilateral facial paralysis, ear pain, altered taste | Pharmacological: Prednisolone 1 mg/kg (max 60 mg) daily for 10 days, valacyclovir 1000 mg 3 times daily for 7 days (if viral) Non-Pharmacological: Eye care (artificial tears, eye patch) physical therapy |
| – Upper Cervical Lesions | History, physical exam, imaging | Aetiology: Trauma, tumors Risk Factors: Injury, cancer Signs/Symptoms: Neck pain, radiating pain to the ear, neurological deficits | |
| Ear Cancers | |||
| – Acoustic Neuroma | History, audiometry, MRI | Aetiology: Benign tumor of the vestibulocochlear nerve Risk Factors: Genetic predisposition (e.g., NF2) Signs/Symptoms: Unilateral hearing loss, tinnitus, vertigo, facial numbness | Observation (for small, asymptomatic tumors) surgical removal stereotactic radiosurgery |
| – Cholesteatoma | History, otoscopic exam, CT scan | Aetiology: Abnormal skin growth in the middle ear Risk Factors: Chronic otitis media Signs/Symptoms: Hearing loss, ear discharge, ear fullness, dizziness | Pharmacological: Antibiotics for secondary infection (e.g., amoxicillin/clavulanate 875/125 mg 12-hourly for 7-10 days) Non-Pharmacological: Surgical removal |
| Facial Nerve Paralysis | |||
| – Bell’s Palsy | History, physical exam, neurological exam | Aetiology: Idiopathic, viral infections (e.g., HSV) Risk Factors: Recent viral illness Signs/Symptoms: Unilateral facial paralysis, ear pain, altered taste | Pharmacological: Prednisolone 1 mg/kg (max 60 mg) daily for 10 days, valacyclovir 1000 mg 3 times daily for 7 days (if viral) Non-Pharmacological: Eye care (artificial tears, eye patch), physical therapy |
| Vertigo Syndromes | |||
| – Benign Paroxysmal Vertigo | History, Dix-Hallpike test | Aetiology: Displacement of otoliths in the inner ear Risk Factors: Age, head injury Signs/Symptoms: Brief episodes of vertigo triggered by head movements | Epley maneuver Brandt-Daroff exercises |
| – Chronic Vertiginous Syndrome | History, physical exam, audiometry, vestibular tests | Aetiology: Meniere’s disease, vestibular migraine Risk Factors: Genetic predisposition, stress Signs/Symptoms: Persistent or recurrent vertigo, tinnitus, hearing loss | Pharmacological: Betahistine 16 mg three times daily (for Meniere’s); propranolol 40-80 mg twice daily (for vestibular migraine) Non-Pharmacological: Vestibular rehabilitation, low-salt diet (for Meniere’s) |
| – Vestibular Neuritis | History, physical exam, vestibular tests, audiometry | Aetiology: Viral infection affecting the vestibular nerve Risk Factors: Recent upper respiratory infection Signs/Symptoms: Acute onset of vertigo, nausea, vomiting, no hearing loss | Pharmacological: Prednisolone 1 mg/kg (max 60 mg) daily for 10-14 days; antiemetics (e.g., prochlorperazine 5-10 mg 8-hourly) Non-Pharmacological: Vestibular rehabilitation bed rest hydration |
| – Ramsay Hunt Syndrome | History, physical exam, neurological exam, viral testing | Aetiology: Reactivation of varicella-zoster virus in the geniculate ganglion Risk Factors: Immunosuppression, age Signs/Symptoms: Severe ear pain, vesicular rash around the ear, facial paralysis, hearing loss | Pharmacological: Acyclovir 800 mg 5 times daily for 7 days; prednisolone 1 mg/kg (max 60 mg) daily for 10 days Non-Pharmacological: Pain management, eye care, physical therapy |
Assess and manage nose presentations:
- rhinitis, including allergic rhinitis
- sinusitis
- epistaxis
- nasal polyps
- foreign bodies.
| Presentation | Clinical Assess | High Yield Features | Management |
| Rhinitis | |||
| – Allergic Rhinitis | History, physical exam, allergy testing | Aetiology: Allergens (pollen, dust mites, pet dander) Risk Factors: Family history, atopy Signs/Symptoms: Sneezing, nasal congestion, rhinorrhea, itching | Pharmacological: Antihistamines (e.g., cetirizine 10 mg daily), intranasal corticosteroids (e.g., fluticasone propionate 1-2 sprays per nostril daily), leukotriene receptor antagonists (e.g., montelukast 10 mg daily) Non-Pharmacological: Allergen avoidance, nasal irrigation |
| – Non-Allergic Rhinitis | History, physical exam | Aetiology: Irritants (smoke, pollution), hormonal changes, infections Risk Factors: Exposure to irritants, hormonal changes (pregnancy) Signs/Symptoms: Nasal congestion, rhinorrhea, postnasal drip | Pharmacological: Intranasal corticosteroids (e.g., fluticasone propionate 1-2 sprays per nostril daily) nasal decongestants (e.g., oxymetazoline 0.05% spray twice daily for short-term use) Non-Pharmacological: Avoidance of triggers, nasal irrigation |
| Sinisutis | |||
| – Acute Sinusitis | History, physical exam, nasal endoscopy, imaging | Aetiology: Bacterial (Streptococcus pneumoniae, Haemophilus influenzae), viral infections Risk Factors: Recent upper respiratory infections, allergies Signs/Symptoms: Facial pain/pressure, nasal congestion, purulent discharge, fever | Pharmacological: Amoxicillin/clavulanate 875/125 mg orally twice daily for 7-10 days (first-line), doxycycline 100 mg twice daily for 7-10 days (if penicillin allergic) Non-Pharmacological: Saline nasal irrigation, steam inhalation, pain management with NSAIDs |
| – Chronic Sinusitis | History, physical exam, nasal endoscopy, imaging | Aetiology: Chronic inflammation, bacterial infections, fungal infections Risk Factors: Nasal polyps, allergies, asthma Signs/Symptoms: Nasal congestion, postnasal drip, facial pain/pressure, hyposmia | Pharmacological: Intranasal corticosteroids (e.g., fluticasone propionate 1-2 sprays per nostril daily) saline nasal irrigation, long-term antibiotics (e.g., doxycycline 100 mg daily for 3-6 weeks) Non-Pharmacological: Functional endoscopic sinus surgery (FESS) if refractory |
| Epistaxis | History, physical exam, nasal endoscopy | Aetiology: Trauma, dry air, hypertension, anticoagulant use Risk Factors: Nasal trauma, use of anticoagulants, bleeding disorders Signs/Symptoms: Nosebleed (anterior or posterior), nasal congestion | Pharmacological: Topical vasoconstrictors (e.g., oxymetazoline 0.05% spray) tranexamic acid soaked in cotton (for anterior bleeds) Non-Pharmacological: Direct pressure, nasal packing cauterization treatment of underlying conditions (e.g., hypertension control) |
| Nasal Polyps | History, physical exam, nasal endoscopy, imaging | Aetiology: Chronic inflammation (e.g., chronic rhinosinusitis), allergic rhinitis, asthma Risk Factors: Asthma, aspirin sensitivity, cystic fibrosis Signs/Symptoms: Nasal obstruction, anosmia, recurrent sinusitis | Pharmacological: Intranasal corticosteroids (e.g., mometasone furoate 2 sprays per nostril daily) short course of oral corticosteroids (e.g., prednisolone 30 mg daily for 5 days) Non-Pharmacological: Endoscopic sinus surgery if refractory |
| Foreign Bodies | History, physical exam, nasal endoscopy | Aetiology: Insertion of objects (common in children) Risk Factors: Young children Signs/Symptoms: Unilateral nasal discharge, foul odor, nasal obstruction, epistaxis | Pharmacological: None unless secondary infection (then use antibiotics as appropriate) Non-Pharmacological: Remove of foreign body (positive pressure technique, direct instrumentation), treat any secondary infection |
Assess and manage oral presentations
- acute:
- gingivitis
- periodontitis
- dental abscess
- mouth ulcers (aphthous)
- leucoplakia
- lichen planus
- angular cheilitis
- tongue changes (eg smooth, geographical, sore tongue)
- acute parotitis and salivary stones
- acute manifestation of systemic disease (eg systemic lupus erythematosus)
- chronic:
- oral mucosal lesions
- benign ulcers
- oral cancers (mouth, lip and tongue)
- salivary gland tumours
- xerostomia.
- oral mucosal lesions
| Presentation | Clinical Assess | High Yield Features | Management |
| Acute | |||
| – Gingivitis | History, physical exam, dental exam | Aetiology: Plaque accumulation, poor oral hygiene Risk Factors: Smoking, diabetes, certain medications Signs/Symptoms: Red, swollen gums, bleeding gums, bad breath | Pharmacological: Chlorhexidine mouthwash 0.2%, rinse twice daily for 1-2 weeks Non-Pharmacological: Improved oral hygiene, professional dental cleaning |
| – Periodontitis | History, physical exam, dental exam, X-rays | Aetiology: Bacterial infection, progression from gingivitis Risk Factors: Smoking, diabetes, genetic predisposition Signs/Symptoms: Gum recession, pocket formation, tooth mobility, bad breath | Pharmacological: Systemic antibiotics if severe (e.g., amoxicillin 500 mg orally, 8-hourly for 7 days) Non-Pharmacological: Scaling and root planing, improved oral hygiene, regular dental follow-up |
| – Dental Abscess | History, physical exam, dental exam, imaging | Aetiology: Bacterial infection Risk Factors: Poor oral hygiene, untreated cavities, trauma Signs/Symptoms: Severe toothache, swelling, fever, pus discharge | Pharmacological: Amoxicillin 500 mg orally, 8-hourly for 7 days; metronidazole 400 mg 8-hourly for 7 days if anaerobic infection suspected Non-Pharmacological: Incision and drainage, root canal treatment, tooth extraction if necessary |
| – Mouth Ulcers (Aphthous) | History, physical exam | Aetiology: Unknown, possibly immune-mediated Risk Factors: Stress, trauma, certain foods Signs/Symptoms: Painful, recurrent ulcers on mucosal surfaces | Pharmacological: Topical corticosteroids (e.g., triamcinolone acetonide 0.1% paste), topical anesthetics (e.g., lidocaine gel) Non-Pharmacological: Avoidance of trigger foods, good oral hygiene |
| – Leucoplakia | History, physical exam, biopsy | Aetiology: Chronic irritation, tobacco use Risk Factors: Smoking, alcohol use, HPV infection Signs/Symptoms: White patches on the oral mucosa that cannot be scraped off | Pharmacological: None specific Non-Pharmacological: Smoking cessation, regular monitoring, biopsy of suspicious lesions |
| – Lichen Planus | History, physical exam, biopsy | Aetiology: Immune-mediated Risk Factors: Hepatitis C infection, genetic predisposition Signs/Symptoms: Lacy white patches, painful sores | Pharmacological: Topical corticosteroids (e.g., clobetasol propionate 0.05% gel), systemic corticosteroids for severe cases Non-Pharmacological: Regular monitoring, good oral hygiene |
| – Angular Cheilitis | History, physical exam | Aetiology: Fungal (Candida), bacterial (Staphylococcus) infection Risk Factors: Denture use, nutritional deficiencies Signs/Symptoms: Cracks, redness, and soreness at the corners of the mouth | Pharmacological: Topical antifungal (e.g., miconazole cream), topical antibacterial (e.g., fusidic acid cream) Non-Pharmacological: Address underlying causes improve oral hygiene use of emollients |
| – Tongue Changes | History, physical exam | Aetiology: Nutritional deficiencies, infections, systemic diseases Risk Factors: Poor diet, underlying systemic conditions Signs/Symptoms: Smooth tongue, geographic tongue, soreness | Pharmacological: Nutritional supplements (e.g., vitamin B12, iron) antifungal agents if candidiasis (e.g., nystatin oral suspension) Non-Pharmacological: Address underlying cause dietary improvements good oral hygiene |
| – Acute Parotitis & Salivary Stones | History, physical exam, imaging | Aetiology: Bacterial infection, dehydration, ductal obstruction Risk Factors: Reduced salivary flow, chronic illness Signs/Symptoms: Swelling, pain, pus discharge (if infected), dry mouth | Pharmacological: Antibiotics for bacterial infection (e.g., amoxicillin/clavulanate 875/125 mg orally twice daily for 7-10 days) Non-Pharmacological: Hydration, sialogogues (e.g., sour candies), massage, stone removal if necessary |
| – Systemic Disease Manifestation | History, physical exam, relevant systemic work-up | Aetiology: Systemic lupus erythematosus, other autoimmune diseases Risk Factors: Genetic predisposition, known autoimmune conditions Signs/Symptoms: Oral ulcers, other systemic symptoms (e.g., rash, arthritis) | Pharmacological: Immunosuppressive therapy (e.g., hydroxychloroquine for SLE), corticosteroids for severe flares Non-Pharmacological: Regular monitoring, management of systemic disease, patient education |
| Chronic | |||
| – Oral Mucosal Lesions | History, physical exam, biopsy | Aetiology: Chronic irritation, autoimmune diseases Risk Factors: Tobacco use, chronic trauma Signs/Symptoms: Persistent lesions, may be white, red, or ulcerated | Pharmacological: Depends on underlying cause (e.g., topical corticosteroids for inflammatory lesions) Non-Pharmacological: Regular monitoring, biopsy of suspicious lesions, smoking cessation |
| – Benign Ulcers | History, physical exam, biopsy | Aetiology: Trauma, infections Risk Factors: Ill-fitting dentures, viral infections Signs/Symptoms: Painful ulcers, usually resolve spontaneously | Pharmacological: Topical corticosteroids (e.g., triamcinolone acetonide 0.1% paste), topical anesthetics (e.g., lidocaine gel) Non-Pharmacological: Address underlying cause, good oral hygiene |
| – Oral Cancers | History, physical exam, biopsy, imaging | Aetiology: Tobacco use, alcohol use, HPV infection Risk Factors: Smoking, heavy alcohol use, HPV infection Signs/Symptoms: Persistent sores, lumps, white or red patches, difficulty swallowing | Pharmacological: As per oncologist’s protocol (chemotherapy, targeted therapy) Non-Pharmacological: Surgical resection, radiotherapy, regular follow-up |
| – Salivary Gland Tumours | History, physical exam, imaging, biopsy | Aetiology: Benign or malignant tumors Risk Factors: Radiation exposure, genetic factors Signs/Symptoms: Painless lump, facial nerve involvement (if malignant) | Pharmacological: As per oncologist’s protocol (chemotherapy for malignant tumors) Non-Pharmacological: Surgical removal, radiotherapy if indicated |
| – Xerostomia | History, physical exam | Aetiology: Medications, systemic diseases (e.g., Sjögren’s syndrome), radiation therapy Risk Factors: Use of anticholinergic drugs, autoimmune diseases Signs/Symptoms: Dry mouth, difficulty swallowing, dental decay | Pharmacological: Saliva substitutes, pilocarpine 5 mg orally three times daily Non-Pharmacological: Good oral hygiene, frequent sips of water, sugar-free chewing gum, avoid caffeine and alcohol, regular dental check-ups |
Identify, and appropriately manage, ear, nose and throat emergencies:
- barotrauma
- sudden hearing loss
- tympanic perforation
- temporal bone fractures
- foreign bodies in ear
- mastoiditis
- epistaxis
- nasal trauma
- septal haematoma
- nasal fracture
- post-tonsillectomy bleed
- palatal/laryngeal trauma
- quinsy.
| Condition | Clinical Features | Management |
| Barotrauma | – Ear pain, hearing loss, tinnitus, vertigo, sensation of fullness in the ear | Pharmacological: – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day) – Nasal decongestants: Oxymetazoline 0.05% spray twice daily for 3 days Non-Pharmacological: – Valsalva maneuver, avoid diving/flying until resolved, use of nasal decongestants before flying or diving, keep ear dry |
| Sudden Hearing Loss | – Rapid onset (within 72 hours) of unilateral hearing loss, tinnitus, ear fullness, dizziness | Pharmacological: – Corticosteroids: Prednisolone 1 mg/kg (max 60 mg) orally daily for 1-2 weeks, tapering dose – Antivirals if viral etiology suspected: Valacyclovir 1000 mg orally 3 times daily for 7 days Non-Pharmacological: – Urgent ENT referral, audiometry to confirm diagnosis, hyperbaric oxygen therapy (if available), keep ear dry, avoid water exposure |
| Tympanic Perforation | – Sudden ear pain, hearing loss, otorrhea, tinnitus, vertigo (if inner ear involved) | Pharmacological: – Topical antibiotics if contaminated: Ciprofloxacin 0.3% ear drops, 3 drops twice daily for 7 days Non-Pharmacological: – Keep ear dry, avoid water exposure, ENT follow-up for potential surgical repair, avoid blowing nose forcefully, consider tympanoplasty if persistent perforation or significant hearing loss |
| Temporal Bone Fractures | – Hearing loss, vertigo, facial nerve paralysis, hemotympanum, Battle’s sign (bruising behind the ear) | Pharmacological: – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day) – Antibiotics if CSF leak present: Ceftriaxone 2 g IV daily Non-Pharmacological: – CT scan to assess fracture, urgent ENT referral, facial nerve monitoring, prevent CSF leak (bed rest, head elevation), avoid blowing nose forcefully, possible surgical intervention for facial nerve decompression, CSF leak repair |
| Foreign Bodies in Ear | – Ear pain, hearing loss, visible foreign object in ear canal | Pharmacological: – None unless secondary infection (then use antibiotics as appropriate): Amoxicillin 500 mg orally, 8-hourly for 7 days Non-Pharmacological: – Removal under direct visualization (irrigation for non-organic objects, suction, instrumentation), ENT referral if difficult to remove or for potential complications (e.g., perforation, deep impaction), avoid using cotton swabs in the ear |
| Mastoiditis | – Ear pain, fever, postauricular swelling and tenderness, protruding auricle, otorrhea | Pharmacological: – IV antibiotics: Ceftriaxone 1-2 g IV daily, add metronidazole 500 mg IV every 8 hours if anaerobic infection suspected Non-Pharmacological: – Urgent ENT referral, possible surgical drainage (mastoidectomy), CT scan of temporal bones to assess extent, myringotomy for culture and drainage, hospital admission for severe cases, pain management with paracetamol or ibuprofen |
| Epistaxis | – Anterior: bleeding from the nostril – Posterior: bleeding into the throat, difficulty controlling bleeding | Pharmacological: – Topical vasoconstrictors: Oxymetazoline 0.05% spray, 2 sprays per nostril – Tranexamic acid 500 mg orally three times daily for 5 days (for severe cases) Non-Pharmacological: – Direct pressure to the nostrils (pinch the soft part of the nose for 10-15 minutes), nasal packing with vaseline gauze or nasal tampon, cauterization with silver nitrate sticks (if bleeding site identified), consider posterior packing or balloon catheter for posterior epistaxis, treat underlying conditions (e.g., hypertension control), avoid nose picking and blowing |
| Nasal Trauma | – Nasal deformity, swelling, bruising, epistaxis, nasal obstruction | Pharmacological: – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day) Non-Pharmacological: – Ice packs to reduce swelling, closed reduction of nasal fracture (within 7-10 days if no septal hematoma), ENT referral if septal hematoma or significant deformity, avoid further trauma to the nose, head elevation to reduce swelling |
| Septal Haematoma | – Nasal obstruction, pain, swelling of the nasal septum, difficulty breathing through the nose | Pharmacological: – Antibiotics to prevent abscess formation: Amoxicillin/clavulanate 875/125 mg orally twice daily for 7-10 days Non-Pharmacological: – Urgent drainage of the hematoma, anterior nasal packing to prevent re-accumulation, ENT referral for follow-up, ice packs to reduce swelling, avoid further trauma to the nose |
| Nasal Fracture | – Pain, nasal deformity, epistaxis, swelling, bruising | Pharmacological: – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day) Non-Pharmacological: – Ice packs to reduce swelling, closed reduction of nasal fracture (within 7-10 days if no septal hematoma), ENT referral if septal hematoma or significant deformity, avoid further trauma to the nose, head elevation to reduce swelling |
| Post-Tonsillectomy Bleed | – Hemorrhage from tonsillar bed, may occur within 24 hours (primary) or 5-10 days post-op (secondary) | Pharmacological: – None specific Non-Pharmacological: – Urgent ENT referral, apply direct pressure with gauze soaked in adrenaline (1:10,000), patient positioning (head forward to prevent aspiration), IV fluids for resuscitation, blood transfusion if significant blood loss, return to operating theatre for hemostasis if necessary, monitor for signs of hypovolemia (tachycardia, hypotension), hospital admission for observation |
| Palatal/Laryngeal Trauma | – Dysphagia, hoarseness, stridor, subcutaneous emphysema, visible wounds or hematoma in the oropharynx | Pharmacological: – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day) – Antibiotics if infection risk: Amoxicillin/clavulanate 875/125 mg orally twice daily for 7-10 days Non-Pharmacological: – Secure airway if compromised (intubation or tracheostomy), imaging (CT scan) to assess injury, urgent ENT referral, possible surgical intervention for repair, hospital admission for observation and airway management |
| Quinsy (Peritonsillar Abscess) | – Severe sore throat, dysphagia, trismus, “hot potato” voice, uvular deviation, swelling and redness of the soft palate | Pharmacological: – IV antibiotics: Penicillin G 2-4 million units IV every 4 hours, Metronidazole 500 mg IV every 8 hours (if anaerobic infection suspected) – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day) Non-Pharmacological: – Needle aspiration or incision and drainage of the abscess, supportive care (hydration, pain management), ENT follow-up, consider tonsillectomy if recurrent, monitor for airway obstruction |
This detailed table provides an overview of the clinical features and management of common ear, nose, and throat emergencies, including specific pharmacological and non-pharmacological management strategies according to Australian guidelines.
Competently carry out certain ear, nose and throat procedures:
- use of auroscope
- Weber and Rinne tests (demonstration and interpretation)
- removal of foreign bodies
- nasal packing
- ear wax removal (syringing versus suction)
- interpretation of audiograms
- demonstration of use of nasal sprays.
Weber and Rinne tests.
| Test | Demonstration | Normal Result | Interpretation for Conductive Hearing Loss | Interpretation for Sensorineural Hearing Loss |
|---|---|---|---|---|
| Weber | 1. Strike a tuning fork (512 Hz) and place its base on the midline of the patient’s skull or forehead. 2. Ask the patient where they hear the sound best: in the left ear, right ear, or equally in both ears. | Sound is heard equally in both ears. | Sound is heard louder in the affected ear (conductive hearing loss). | Sound is heard louder in the unaffected ear (sensorineural hearing loss). |
| Rinne | 1. Strike a tuning fork (512 Hz) and place its base on the mastoid process behind the patient’s ear. 2. Ask the patient to tell you when they no longer hear the sound (bone conduction). 3. Move the tuning fork near the ear canal (air conduction) without touching it. 4. Ask the patient if they can hear the sound again and when they no longer hear it. | Air conduction (AC) is greater than bone conduction (BC). The patient hears the fork next to the ear longer than on the mastoid process (AC > BC). | Bone conduction is greater than air conduction in the affected ear (BC > AC). | Air conduction is greater than bone conduction, but both are reduced in the affected ear (AC > BC, but both diminished). |
Notes:
- Weber Test: Helps differentiate between conductive and sensorineural hearing loss. The lateralization of sound indicates the type of hearing loss.
- Rinne Test: Compares air conduction and bone conduction of sound. Helps confirm the presence of conductive hearing loss when BC > AC.
Steps for Weber and Rinne Tests
Weber Test:
- Explain the procedure to the patient.
- Strike the tuning fork gently against your hand.
- Place the base of the tuning fork on the midline of the patient’s skull or forehead.
- Ask the patient where they hear the sound (left, right, or both equally).
Rinne Test:
- Explain the procedure to the patient.
- Strike the tuning fork gently against your hand.
- Place the base of the tuning fork on the mastoid process behind one ear.
- Ask the patient to tell you when they no longer hear the sound.
- Immediately move the tuning fork to the front of the ear canal.
- Ask the patient if they can hear the sound again and when they no longer hear it.
By following these steps and interpreting the results as shown in the table, you can accurately assess the type of hearing loss present in a patient.
Interpreting an audiogram
involves understanding the various components and how they relate to hearing loss. Here’s a step-by-step guide to interpreting an audiogram in table format.
| Component | Description | Interpretation |
|---|---|---|
| Frequency (Hz) | X-axis on the audiogram, ranging from low frequencies (250 Hz) to high frequencies (8000 Hz). | Lower frequencies represent bass sounds (e.g., vowel sounds), and higher frequencies represent treble sounds (e.g., consonants like “s” and “th”). |
| Hearing Level (dB) | Y-axis on the audiogram, ranging from -10 dB to 120 dB. Lower numbers indicate softer sounds, and higher numbers indicate louder sounds. | The level at which a person can barely hear a tone. Normal hearing is between -10 dB and 20 dB. Values above 20 dB indicate some degree of hearing loss. |
| Air Conduction (AC) | Represented by circles (right ear) and Xs (left ear) connected by a line. Tested using headphones or ear inserts. | Measures the ability to hear sounds through the air. Poor AC thresholds indicate hearing loss, but further tests are needed to determine the type (conductive vs. sensorineural). |
| Bone Conduction (BC) | Represented by brackets (< or >) or sometimes arrows. Tested using a bone oscillator placed on the mastoid bone. | Measures the ability to hear sounds through bone vibrations. Poor BC thresholds with good AC thresholds indicate conductive hearing loss. Poor BC and AC thresholds indicate sensorineural hearing loss. |
| Air-Bone Gap | The difference between air conduction and bone conduction thresholds at the same frequency. | An air-bone gap greater than 10 dB indicates a conductive component to the hearing loss. If no gap exists, the hearing loss is sensorineural. |
| Speech Reception Threshold (SRT) | The lowest intensity level (dB) at which a person can correctly repeat 50% of common spondee words (two-syllable words with equal stress). | Should be consistent with the pure-tone average (PTA) of the thresholds at 500, 1000, and 2000 Hz. Significant differences might indicate non-organic hearing loss or a need for re-testing. |
| Word Recognition Score (WRS) | Percentage of words correctly repeated at a comfortable loudness level above the SRT. | High scores (90-100%) indicate good speech understanding, while lower scores suggest difficulties understanding speech, especially in background noise. |
Interpreting Types of Hearing Loss
| Type of Hearing Loss | Audiogram Pattern | Characteristics |
|---|---|---|
| Normal Hearing | AC and BC thresholds between -10 dB and 20 dB across all frequencies. | Indicates no significant hearing loss. |
| Conductive Hearing Loss | AC thresholds are elevated (worse) while BC thresholds are within normal limits, showing an air-bone gap. | Indicates an issue in the outer or middle ear, such as earwax blockage, otitis media, or otosclerosis. |
| Sensorineural Hearing Loss | Both AC and BC thresholds are elevated (worse) equally without an air-bone gap. | Indicates an issue in the inner ear or auditory nerve, such as presbycusis, noise exposure, or ototoxic medications. |
| Mixed Hearing Loss | Both AC and BC thresholds are elevated (worse), but there is a significant air-bone gap. | Indicates a combination of conductive and sensorineural components, such as chronic otitis media with presbycusis. |
Steps to Interpret an Audiogram
- Examine the Frequency (Hz):
- Check the X-axis to see the range of frequencies tested (250 Hz to 8000 Hz).
- Check the Hearing Level (dB):
- Look at the Y-axis to understand the decibel levels (loudness) where thresholds are plotted.
- Compare Air Conduction (AC) and Bone Conduction (BC) Thresholds:
- Identify AC thresholds (circles for the right ear, Xs for the left ear).
- Identify BC thresholds (brackets or arrows).
- Analyze the Air-Bone Gap:
- Determine if there is a gap between AC and BC thresholds. An air-bone gap greater than 10 dB suggests conductive hearing loss.
- Review Speech Reception Threshold (SRT) and Word Recognition Score (WRS):
- SRT should align with the pure-tone average (PTA).
- WRS provides insight into the patient’s ability to understand speech.
- Determine the Type and Degree of Hearing Loss:
- Use the patterns in the thresholds to classify the hearing loss as normal, conductive, sensorineural, or mixed.
- Assess the severity based on the decibel levels (mild, moderate, severe, profound).
By following these steps and using the table, you can systematically interpret an audiogram and identify the type and extent of hearing loss in a patient.
show me example chart of an audiogramChatGPT
Sure, here is an example of an audiogram chart to help visualize how audiograms are plotted and interpreted:
Example Audiogram Chart
| Frequency (Hz) | 250 | 500 | 1000 | 2000 | 4000 | 8000 |
|---|---|---|---|---|---|---|
| Right Ear (AC) | 10 | 15 | 20 | 25 | 30 | 35 |
| Right Ear (BC) | 10 | 15 | 20 | 25 | 30 | 35 |
| Left Ear (AC) | 10 | 20 | 25 | 30 | 35 | 40 |
| Left Ear (BC) | 10 | 20 | 25 | 30 | 35 | 40 |
Audiogram Interpretation
- Right Ear:
- Air Conduction (AC): Thresholds are between 10 dB and 35 dB.
- Bone Conduction (BC): Thresholds are the same as AC (10 dB to 35 dB).
- Interpretation: No air-bone gap. This indicates sensorineural hearing loss that is mild to moderate.
- Left Ear:
- Air Conduction (AC): Thresholds are between 10 dB and 40 dB.
- Bone Conduction (BC): Thresholds are the same as AC (10 dB to 40 dB).
- Interpretation: No air-bone gap. This indicates sensorineural hearing loss that is mild to moderate.
Degree of Hearing Loss (Example)
- Normal Hearing: -10 to 20 dB
- Mild Hearing Loss: 21 to 40 dB
- Moderate Hearing Loss: 41 to 55 dB
- Moderately Severe Hearing Loss: 56 to 70 dB
- Severe Hearing Loss: 71 to 90 dB
- Profound Hearing Loss: >90 dB
Example Audiogram Chart
Symbols Used:
- O: Right ear air conduction (AC)
- X: Left ear air conduction (AC)
- <: Right ear bone conduction (BC)
- >: Left ear bone conduction (BC)
Explanation:
- Right Ear (AC): Circles (O) are plotted at thresholds 10 dB, 15 dB, 20 dB, 25 dB, 30 dB, and 35 dB across different frequencies.
- Left Ear (AC): Crosses (X) are plotted at thresholds 10 dB, 20 dB, 25 dB, 30 dB, 35 dB, and 40 dB across different frequencies.
- Right Ear (BC): Brackets (<) could be plotted at the same points as AC for right ear if indicated.
- Left Ear (BC): Brackets (>) could be plotted at the same points as AC for left ear if indicated.
Example Interpretation
- Right Ear: Mild to moderate sensorineural hearing loss, as indicated by the O symbols ranging from 10 dB to 35 dB without any significant air-bone gap.
- Left Ear: Mild to moderate sensorineural hearing loss, as indicated by the X symbols ranging from 10 dB to 40 dB without any significant air-bone gap.
This graphical representation helps in quickly identifying the type and degree of hearing loss by visually inspecting the plotted points on the audiogram chart.