Medical Lectures

ENT for Primary Care: A Practical Guide

Quintin M. Cappelle, MD
Cappelle, MD breaks down serious ENT diagnoses, from sudden hearing loss, rhinosinusitis, and others that can become permanent if not treated properly.
11/18/2021
Family Medicine & Primary Care
GIBLIB
OVERVIEW
1. EAR
  • Sudden Hearing Loss
  • Otitis Media
2. RHINOSINUSITIS
  • Sinus Headache
  • Epistaxis
3. TONSILLECTOMY GUIDELINES
4. THYROID GUIDELINES
5. HEAD AND NECK CANCER


ENT CASE 1. WHAT IS IDIOPATHIC SUDDEN HEARING LOSS? 

We do consider that to be an emergency. Not in the sense that if it's in the middle of the night/ over the weekend that you have to deal with it. But within a matter of a couple of days, the patient should be treated. And you should refer this patient to ENT to get formal ideologic testing completed, as well as to be started on treatment. 


Idiopathic sudden hearing loss oftentimes gets missed because patients aren't very clear in what they're experiencing. So, they don't come in and say, “I have hearing loss.” Oftentimes, we'll just describe it as your fullness or pressure sensation. Things feel muffled. They might have some ringing in their ears, but they don't necessarily say that they had that hearing loss. 


They may or may not have vertigo with it. If there is vertigo, we actually consider that Labyrinthitis. So, the cochlea and the semicircular canals have been affected by the process that's going on. If there's that vertiginous component, if it's isolated to just a sudden hearing loss, it's really whatever process, and we don't feel we know what's going on – it’s happening just within the cochlea itself. 


HOW HEARING LOSS GETS CONFUSED

The key component in the history is that patients are often very clear at the onset of symptoms. They'll say, “I woke up this morning, and all of a sudden, I had this symptom in my ear,” or, “It was two o'clock in the afternoon, and all of a sudden, my ear felt full.” So, when they have that sudden change and a symptom in their ear, you have to consider a sudden hearing loss. 


The other thing is, a lot of times, they think it gets missed, being treated as an otitis media because we see that fullness or muffled sensation with otitis media. 


Obviously, a cerumen impaction. Patients say they're cleaning their ear, and they jam something in there. The impact of the wax further is certainly a foreign body, but that's usually clear with the history of barotrauma. 


HOW TO DIAGNOSE AND TREAT YOUR PATIENT WITH HEARING LOSS

The ear exam is normal, so trust your exam. The patients complain of hearing symptoms, but if you look and the ear looks totally normal, trust that and consider sudden hearing loss in your diagnosis. 


And this is where you can do something for the patient. They've looked at studies and steroids is the best thing that we can offer them. And it's a high-dose steroid. So, typically what I do is I do 60 milligrams of prednisone for 7 days and then taper down about 20 milligrams every 2 days after that. The other option is to then do inter tympanic steroid injections. 


So, when patients come into our clinic, if they have failed their oral steroids, and they're still having symptoms or they only got a partial response, we'll then proceed to inserts in panic, steroid injections. And that is typically a course of three or a series of three antivirals are not indicated, even though we think this might be a viral etiology. It has not been shown that it actually improves the recovery of hearing. 


HOW TO DIAGNOSE HEARING LOSS, AND WHAT TO DO IF IT'S TOO LATE

The first thing is the greater the magnitude of hearing loss, the less likely that hearing will be restored back to their baseline. So, that's important for counseling the patient. And then the second component is the longer the interval before treatment, the less likely the hearing will be restored. 


So, patients who come in and it's been a month that they've had their muffled hearing loss, they've been put on potentially antibiotics, thinking that it might be a bacterial otitis media if they come into me. 


And if they come in and they have this sudden hearing loss, which is sensory neural in nature and not a conductive component, steroids are going to be helpful for them. But, by that time they've come to see me. I can't really even offer them steroids because they're not can get any benefit out of it at that time. The damage to the nerve has already occurred. 


REASONS TO PLACE AN EAR TUBE

Studies have shown that if a fusion has not resolved within three months, it's typically not going to on its own. We've actually gotten a little bit more lax in letting those effusions sit there. And if the patient doesn't really have any symptoms, could potentially just leave it there. 


STRUCTURAL ABNORMALITIES RELATED TO THE FUSION

If you see a retraction to the eardrum, there'd be a reason to put in a tube recurrent acute otitis media with effusions. So this is where you have your three infections within six months or four infections over a year with persistent effusions or associated hearing loss would be an indication to refer. And then obviously, any perceived developmental delay and language development would be a reason to consider tympanostomy tube placement. 


INSTRUCTIONS TO GIVE PATIENTS WITH RECURRENT OTITIS MEDIA 

What is not an indication is recurrent otitis media without effusions. And this is where it gets a little tricky with parents. So, you have a parent who's coming in with their child, and it's the fourth time that they've been in to get treated for an ear infection. And so they really want those tubes because they hate having to keep coming back in to be seen. 


But there isn't really an indication to place a tube if there's documentation that in between the ear infections, the child clears that fluid because what that is demonstrating is that the child has good Eustachian tube function. And he or she has had unfortunate luck getting exposed. So, putting it at two doesn't necessarily then decrease their exposures and decrease their symptoms. 


Also, following tube placements, there are no water precautions necessary. So, when two kids get their ear tubes placed or even adults who get tubes placed, they can shower, bathe all the same. Swimming is the same. I personally am still a little bit cautious when they ask about swimming in like lakes and rivers, but there hasn't been shown to be an increase in the number of infections with tubes in place. And wearing earplugs does not decrease the number of infections. 


In general, tendency to reduce the number of infections by about three per year. So that's the benefit of having the tubes in place. Another benefit of having tubes in place is the treatment. 

 

HOW TO TREAT A PATIENT WITH A EAR TUBE VERSUS WITHOUT ONE

Once there's a tube in place, you can just treat it topically with OTC ear drops, so they no longer need systemic oral medicines. And typically, ofloxacin works very well for clearing these up. So, in your patients who have a history of tube placement, one of the great benefits is how we administer the antibiotics by giving them locally down the ear canal. They no longer have the issues with the GI upset or the side effects from oral antibiotics. 


I try to really educate the family on that so that, if they show up in like in urgent care and E.R. with a draining ear, they can hopefully advocate for themselves that they only need eardrops because they think this is something we encounter a lot, where I see a child who has tubes in and then they've been placed on amoxicillin. And again, ofloxacin is doing is actually more effective than amoxicillin at that time.


ENT CASE 2. RHINOSINUSITIS

So, moving on to rhinosinusitis. You meet the definition of rhinosinusitis. If you have two major criteria or one major criterion and two minor criteria. It's considered acute if its symptoms are less than four weeks subacute. If it's between 4 to 12 and chronic if greater than 12. The typical course of your situs is viral and then proceeds bacterial. So, if this patient is only been having symptoms for three to five days, it's usually just supportive therapy for them without actual treatment, with any antibiotics. And the transition to bacteria, you just mainly rely on your time course. 


So, if it's five to seven days, and the symptoms are not getting better, that would be an appropriate time to consider antibiotics. Or, if the patient was feeling bad, got better, and then is starting to feel bad again, that's usually a sign that it's turned into bacterial, and you can treat with antibiotics. 


In general, rarely, do you see sinusitis before kids hit puberty and become teenagers. In part, the sinuses aren't really fully developed until that time. So, more often than not, they're having rhinitis. And often supportive therapy is all that's necessary without antibiotics. 


WHAT DOES SINUS SURGERY LOOK LIKE?

Patients who get sinus surgery, and it's all done with anoscopy these days, with cameras and instruments through the nose. The patient's right side is a normal anatomy. So, you still see kind of bony divisions here within the sinuses. And then the left is an operated side. So, what ends up happening is you remove the bone to open up the drainage pattern out of the maxillary sinus, and you remove the tiny substations that divide up the anterior cells, trying to leave some normal landmarks so the middle turbinate is left in place. 


Patients often are fearful of sinus surgery because 15, 20 years ago, we used to do all sorts of nasal packing, which was terribly painful. And then it had to get pulled out in clinic and get stuck on low bone spike heels, and you just be yanking it out of their base. So a lot of patients are fearful of having that done. 


Nowadays, we don't really pack anymore. And it's actually not a very painful procedure. So, these patients are just going home on Tylenol for a couple of days. The biggest thing is they just have congestion from the swelling, which is oftentimes not too different than what they have pre-op anyway.


WHAT IS A SINUS HEADACHE? 

So, a true sinus headache is a headache that occurs in association with an acute sinusitis or other viral or bacterial and resolves with the sinusitis. So, it's not a sinus headache if it's persistent. Now, unless you have a demonstration of chronic sinus symptoms on imaging, that's a different story. But the patients who come in and say, “I have sinus headaches all the time,” and they want to be treated for sinusitis, you have to really tease out to be clear – are they having inflammatory viral or bacterial response with it? 


Because if it's not if it's just a persistent headache that's located over their mid-face or their sinuses, it's probably just an old-fashioned headache, either an atypical headache or a migraine. And so, this requires a lot of patient education. I spent a fair amount of time with my patients educating them that their prior symptoms for the past 10, 15 years that they have thought is a sinusitis is really just a headache, and we need to treat their headache. So, a true sinus headache is one that comes with a sinusitis and then resolves. 


EPISTAXIS REVIEW AND YOUR PATIENT’S NOSEBLEEDS

Greater than 90 percent of nosebleeds occur anteriorly in what we call Kiesselbach’s plexus. So, it's the confluence of different contributing arteries on the septum just at the front part, which you can see when you look in the person's nose. The cause of epistaxis is primarily dry nasal mucosa. So, similarly, like you have a crack or a scab somewhere else on your skin, you have dry skin, it cracks open and bleeds, and then that becomes cyclical. Midwest winters are notorious for that. The number of patients we see for up this Texas in the winter close up. 


Certainly, patients who are on anticoagulation are at increased risk. Digital trauma, otherwise known as nose-picking, you have some people who get a scab in there, and that's really irritating to them. And so it's bothersome. So they keep picking at it to try and relieve it and feel get rid of that obstruction that they feel and then that leads to the nose bleed. 


Certainly, a facial trauma can cause it. Patients with septic perforation, the number one cause of septal perforation is a prior septal plasty. So, if they have that in their history and you look and you see a hole that can certainly be too recurrent nose bleeds and everyone likes to talk about cocaine use. But the actual reality is that's a pretty small number of patients that get a perforation from sniffing cocaine. 


HOW TO CONTROL YOUR PATIENT’S NOSEBLEED

Direct pressure is your best bet. So, most of these can be stopped just by holding pressure. Most patients do it incorrectly, so they grab the top part of their nose and tip their head back and they think it's going to stop. And really, where they need to hold is over the soft part of their nose, pinching off that Kiesselbach’s plexus and stopping the nose bleed. 


Typically, they should have their head just either upright or forward. Tilting that head back just makes the blood go into their throw, and they swallow and get nauseous, and there's no need for that. If they're actively bleeding or they're in the clinic with you, you can try and remove the clot. If you have silver sticks of silver nitrate available, you can try and just apply that to the septum right over the side of bleeding. Usually, you'll need anywhere from two to five sticks of silver nitrate to stop the bleeding. And then Urgent Cares or ER oftentimes use packing if they can't control it. 


The E r literature nowadays is going to not placing these patients on antibiotics. And I think there's a difference between their literature and our literature as to the indication. And I think it has to do with how we're packing. So, in the ER, they're using more of these plastic products with balloons, whereas oftentimes the EA, people are packing with tampon-type materials like mirror cells. 


And so, for those who have the tampon, like packing, we do place patients on antibiotics to prevent toxic shock. Typically, we like to leave the packing in for at least three days to allow time for the patient to develop a clot underneath it, so that when we go to pull that packing out, they don't rebleed on us. 


ENT CASE 3. TONSILLECTOMY GUIDELINES

We'll move on to tonsillectomy guidelines. So, indications for tonsillectomy is a history of peritonsillar abscess, at least two. We give the patient a pass if they've had one period, you don't need your tonsils out yet. But if they have that second one, then we say, “OK, you've had a bad enough tonsils tonsillitis.” They've gotten a complication from it, and now, it's time to take out the tonsils. 


CHRONIC OR RECURRENT TONSILLITIS 

This is based on the Paradise Criteria, which states that you need to have 7 episodes of acute tonsillitis within a year, 10 over 2 years, or 9 over 3 years to meet the criteria to get your tonsils out. Now, can you imagine parents bringing in their child 7 times within a year before they say, “Let's take out the tonsils?” So, I personally think there's some wiggle room as long as we have that honest conversation with the family. Yes, you don't quite need criteria for it yet, but we can still take them out. 


And the reason why that criterion is so strict is that we found that taking off the tonsils for recurrent tonsillitis does not actually really reduce the incidence. There's a short-term benefit for about a year or two, but there's not a long-term benefit from it. Patients will still be exposed to viral tonsillitis or bio pharyngitis. And oftentimes, kids will have a period where they might be a carrier until they'll have repeated infections, but then their body clears it. And so it's not a lifelong issue that they have fighting off tonsillitis. 


PEDIATRIC OBSTRUCTIVE SLEEP APNEA VERSUS ADULT SLEEP APNEA

The more frequent indication for taking out tonsils is pediatric obstructive sleep apnea. As a side note, the mainstay of therapy for adults with obstructive sleep apnea is c-pap. Taking out the tonsils has really fallen by the wayside because we found that it doesn't actually change their apnea hypothecate index. It's not a very effective surgery. That's different for kids. So, for adults, it tends to be multifactorial, but for kids, it often is just because of enlarged tonsils or adenoids. 


So, any kid who has an HIV one or greater meets indications to have their tonsils or adenoids out, which basically equates if the kids snore, or if the parents notice that they have an ethnic event or our gasping, they should have their tonsils out. Kids, really, when they sleep, should be completely silent. So, that's the private number one reason why we're taking out tonsils these days. And obviously, for malignancy, that tends to be in your adult population.


RELATIVE INDICATIONS FOR TAKING YOUR TONSILS

Chronic bad breath or halitosis, pain or difficulty with swallowing or feeling like food gets caught or hung up in the back of their throat. Tonsil stones. So, patients will say they've got these little crumb leaves that they pick out. They often have pretty descriptive stories of how they get them out. And that would be a relative indication to take them out as a quality of life reason.


Sometimes, for antibiotic allergies, if kids only have had tonsillitis two or three times what they have had pretty severe antibiotic allergies, and we can't really treat it, I'll have put the paradise criteria by the wayside as a reason to maybe intervene sooner. PFAPA (Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis) Syndrom. So, these are these cyclical fevers that kids get every usually three weeks. They respond with steroids and immediately improve within about a day. However, steroids decrease the cycle until the cycles become more frequent. 


There's some evidence to say that taking out the tonsils then eliminates or decreases those cycles. That's pretty. Not as common. Certainly growth delay. So, they're spending all their time and energy at night trying to breathe, so they can’t actually grow. So, if you see a really small child who's kind of behind on the growth curve but is otherwise healthy and normal. Take a look in their mouth or inquire about if there's any snoring at night. 


WHY SOMETIMES TAKING OUT TONSILS CAN HELP KIDS WITH ADHD-LIKE SYMPTOMS

And then, ADHD-like symptoms. So, kids who get poor sleep, unlike adults, tend to be more hyperactive or inattentive and can't focus during the day. Whereas, if they get that quality sleep at night, they tend to be able to have improved behavior during the day. It's not a direct link, and we certainly can't guarantee it by taking up the tonsils, but certainly, something to consider. 


LARGE TONSILS DON’T NECESSARILY NEED SURGERY

And finally, large tonsils do not equal tonsillectomy. So, if a child doesn't really have any snoring symptoms, doesn't have recurrent tonsillitis, but has really large tonsils,they can just be observed. You don't have to come out tonsils the size of the tonsils does not equate with the degree of symptoms. You want to be taking out tonsils based on their symptoms. All right. 


ENT CASE 4. THYROID GUIDELINES

What do you do with those pesky incidental thyroid nodules that you find? Cause you've got to test for some other reason, and then the radiologist comments that there's a thyroid nodule. The first thing you do is follow up with that thyroid ultrasound. So, that's the imaging of choice.  


The nice thing, at least within the Mayo system, is that they're they've become pretty standardized as to how they're reporting on the thyroid ultrasound, which is actually quite helpful. It's broken down into risk categories. So, you have your high, intermediate, low, very low, and benign categories. 


The high has about a seven. If the thyroid nodule falls into the high category as a 70 and 90 percent chance, that it's probably malignant. If it's in the intermediate, it drops off dramatically, so you're at that 10 to 20 percent range of being malignant. And then low and very low, it keeps dropping down from there. 


WHAT MAKES A THYROID NODULE CONCERNING?

Typically, it's irregular margins, microcalcifications, whereas macrocalcifications are considered benign, but microcalcifications, extra thyroid extension, or if the shape of the nodules is taller than wide. Those are your concerning features. 


Because of the risk stratification, we tend to intervene sooner if it's in the higher, even intermediate category. So anything that's sub-centimeter does not need to have a final aspiration. But if it's one centimeter or more, then you should recommend a final aspiration if it's in the higher any immediate grade. For low-risk thyroid nodules, we recommend final aspiration if it's one point five centimeters or greater. Very low if it's two centimeters or greater. And if it's benign, do not need to recommend for final aspiration at all. 


INDICATIONS FOR THYROIDECTOMY 

Malignancy if it's determined on that final aspiration, or if you've had repeat biopsies that are inconclusive, then you can do a thyroidectomy for diagnostic purposes. And certainly compressive symptoms. So, if a patient has a thyroid go goiter, they have voice changes or difficulty breathing or swallowing, that be a reason to take out the thyroid. 


ENT CASE 5. HEAD AND NECK CANCER RED FLAGS

If a patient has hoarseness for a month or greater, they should get evaluated with a laryngoscopy to see if there's any reason. If the patient has a neck mass for a month or greater, they should be evaluated with a head and neck exam. If it's a reactive cervical lymphadenopathy from a viral URI, that neck mass should be resolved within a month. If it doesn't, it needs to be pursued and evaluated. 


CANCER AND HPV EPIDEMIC

There's an HPV epidemic going on with head and neck cancer, particularly oropharyngeal cancer. So, cancer of the tonsil and tongue base in it. I think it's important to be aware of as kind of screening. So, the demographic of patients with head and neck cancer is changing. It's no longer you're 60, or 70-year-old male who has been a lifetime smoker. We're now seeing much younger patients in their 20s and 30s who have cancer. No history of smoking. And oftentimes, the only symptom they have is a neck mass. Usually level 2, not painful at all.


This site or the origin of cancer, if it's mediated by the HPV virus, is often microscopic and the only present with just a neck mass. So, it's already become a regional disease. The good thing, fortunately, for these patients is that is radiosensitive. So, radiation therapy is the treatment for it. And they tend to have a better prognosis than your patients who have squamous cell carcinoma. 

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ENT for Primary Care: A Practical Guide
Cappelle, MD breaks down serious ENT diagnoses, from sudden hearing loss, rhinosinusitis, and others that can become permanent if not treated properly.
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