| E |

Key features

Key history

Assess the site of pain and radiation, details of the onset of pain, nature of the pain, aggravating or relieving factors and associated features such as vertigo, tinnitus, sore throat and irritation of the external ear. Ask about trauma, especially the use of a cotton bud to clean the ear.

Key examination

• The external ear with manipulation of the ear

• Check helix for chondrodermatitis nodularis helicis.

• Palpate the face and neck to include the parotid glands, regional lymph nodes and skin and temporomandibular joint (TMJ).

• Inspect both empty ear canals and tympanic membrane (TM) with the auroscope using the largest possible earpiece.

• Look for causes of referred pain: cervical spine, nose, postnasal space and mouth including teeth.

Key investigations

Seldom necessary.

• Consider hearing tests, audiometry

• Any ear discharge for MC but swabs of no value if the TM is intact

Otitis media in children

Features

• Two peaks of incidence: 6–12 mths of age and school entry

• Seasonal incidence coincides with URTIs.

• The commonest organisms are viruses (adenovirus and enterovirus) and the bacteria S. pneumoniae, H. influenzae and Moraxella catarrhalis.

• Fever, irritability, otalgia and otorrhoea may be present.

• The main symptoms in older children are increasing earache and hearing loss.

• Pulling at the ears is a common sign in infants.

• Viral cause indicated by reddening and dullness of tympanic membrane (without mucopus) associated with URTI.

• Antibiotics not warranted for viral causes, most improve within 48 hrs.

• Bacterial OM is suggested by acute onset of ear pain/tugging, hearing loss, irritability and fever. Suppurative OM has progressive erythema and bulging of OM with loss of landmarks ± vomiting. Treat with ABs that are most beneficial in children <2 yrs with bilateral OM, for devt. of more serious symptoms or if the fever, pain and other symptoms do not resolve within 2–3 d (see box below).

Treatment

• Rest patient in warm room with adequate humidity

• Paracetamol suspension for pain (high dosage)

• Decongestants only if nasal congestion

For bacterial OM the antibiotic of choice is:

• amoxycillin 15 mg/kg (to max. 500 mg) (o) tds for 5 d or

• amoxycillin 30 mg/kg bd for 5 d (for compliance)

If β-lactamase producing bacteria are suspected or documented or initial treatment fails, use:

• cefaclor 10 mg/kg (to max. 250 mg) (o) tds for 7 d (cefaclor is second choice irrespective of cause) or

• (if resistance to amoxycillin is suspected or proven) amoxycillin/potassium clavulanate

Follow-up:

• report if no improvement in 72 h

• re-evaluate at 10 d

Complications

• Middle-ear effusion: an effusion up to 2 mths is relatively normal and antibiotics not warranted. If the effusion persists beyond 3 mths refer for an ENT opinion.

• Acute mastoiditis: pain, swelling and tenderness developing behind the ear with deterioration of the child requires immediate referral

• Chronic otitis media

Recurrent acute otitis media (AOM)

Prevention of AOM is indicated if it occurs more often than every other mth or for ≥4 episodes in 12 mths.

• Chemoprophylaxis (for about 4 mths) amoxycillin 20 mg/kg (o) once daily or cefaclor bd

• Check pneumococcal vaccination.

Otitis media in adults

Treatment of acute episode

• Analgesics to relieve pain

• Adequate rest in a warm room

• Nasal decongestants for nasal congestion

• Antibiotics for evidence of bacterial infection

• Treat associated conditions (e.g. adenoid hypertrophy)

• Follow-up: review and test hearing audiometrically

Antibiotic treatment

First choice:

• Amoxycillin 750 mg (o) bd for 5 d or

• 500 mg (o) tds for 5 d

Alternatives:

• Doxycycline 100 mg (o) bd for 5–7 d (once/d for milder infections) or

• Cefaclor 375 mg (o) bd for 5–7 d or

• (If resistance to amoxycillin is suspected or proven) amoxycillin/potassium clavulanate 875/125 mg (o) tds for 5–7 d (the most effective antibiotic)

Chronic otitis media

There are two types of chronic suppurative otitis media and they both present with deafness and discharge without pain. The discharge occurs through a perforation in the TM: one is safe, the other unsafe.

If an attic perforation is recognised or suspected, specialist referral is essential. Cholesteatoma cannot be eradicated by medical means.

Otitis externa

Clinical features

• Itching at first

• Pain (mild to intense)

• Fullness in ear canal

• Scant discharge

• Hearing loss

• Pain on moving pinna

Obtain culture, esp. if resistant Pseudomonas sp. suspected, by using small ear swab.

Management

Aural toilet

The cornerstone of treatment. Dry mopping.

Syringing

This is appropriate in some cases but the canal must be dried meticulously afterwards. For most cases it is not recommended.

Dressings

After cleaning and drying, insert 10–20 cm of 4 mm Nufold gauze impregnated with a steroid and antibiotic cream.

For severe otitis externa a wick is important and will reduce the oedema and pain in 12–24 h. It needs replacement daily until the swelling has subsided.

Topical antimicrobials

The most effective, esp. when the canal is open, is an antibacterial, antifungal and corticosteroid preparation (e.g. Ciprox HC, 3 drops bd, Kenacomb or Sofradex drops or ointment, 2–3 drops tds or flumethasone 0.02% with clioquinol (locacorten–vioform) 1% 2–3 drops bd).

Other measures

• Strong analgesics are essential.

• ABs have little place in treatment unless a spreading cellulitis has developed.

• Prevent scratching and entry of water.

• Prevention: keep ear dry; protect with cotton wool soaked with petroleum jelly. Use an antiseptic drying agent (e.g. ethanol) after swimming and showering.

Practice tip for severe ‘tropical ear’

• Prednisolone (o) 15 mg statim then 10 mg 8 hrly for 6 doses followed by

• Merocel ear wick

• Topical Kenacomb, Ciprox HC or Sofradex drops

Furunculosis

This is usually S. aureus infection of a hair follicle just inside the canal opening.

Management

• If pointing, incise after local or topical anaesthetic

• Warmth—use hot face washer

• If cellulitis or fever—di(flu)cloxacillin orally

Perichondritis

Perichondritis is infection of the cartilage of the ear characterised by severe pain of the pinna which is red, swollen and exquisitely tender.

Treatment: ciprofloxacin

Infected earlobe

The cause is most likely a contact allergy to nickel in an earring, complicated by an S. aureus infection.

Management

• Remove earrings.

• Clean the site to eliminate residual traces of nickel.

• Swab the site, then commence antibiotics (e.g. di(flu)cloxacillin or erythromycin).

• Instruct the patient to clean the site daily, then apply the appropriate ointment.

• Use a ‘noble metal’ stud to keep the tract patent.

• Advise the use of only gold, silver or platinum studs in future.

Otic barotrauma

Barotrauma affects scuba divers and aircraft travellers. The symptoms include temporary or persisting pain, deafness, vertigo, tinnitus and perhaps discharge.

Inspection of the TM may reveal (in order of seriousness): retraction; erythema; haemorrhage (due to extravasation of blood into the layers of the TM); fluid or blood in the middle ear; perforation. Perform conductive hearing loss tests with tuning fork.

Treatment

Most cases are mild and resolve spontaneously in a few days, so treat with analgesics and reassurance. Menthol inhalations are soothing and effective. Refer if any persistent problems.

Ear exostoses (‘surfer's ear’)

These bony overgrowths are initiated by water retention in the ear.

Prevention

• Use plugs to waterproof ear.

• Dry thoroughly with hair dryer after swimming.

• Requires surgical repair (local anaesthetic).

• Use a mild ointment prior to surgery.

Assessment of and the establishment of rapport with the elderly patient is a special skill. Age-associated deterioration of health and function occurs especially with hearing, vision, glucose tolerance, systolic blood pressure, kidney, pulmonary and cardiac function, immune function, bone density, cognitive function, mastication and bowel and bladder function.

‘Rules of 7’ for assessment of the non-coping elderly patient

If your elderly patient presents with non-specific symptoms, unexpected deterioration in health and/or an inability to cope with the activities of daily living, consider the following checklist (Table E3) in your assessment.

Apart from confusion, other non-specific symptoms include drowsiness, poor concentration, apathy, fatigue/weakness/tiredness/lethargy, anorexia, nausea, weight loss, dyspnoea, immobility, ‘stuck in bed or chair’, stumbles or falls. It is also important to consider infections including pneumonia and the masquerades.

The mini-mental state examination

Evidence of memory difficulty remains the best single indication of dementia and should always be evaluated by formal memory testing. A number of screening tests are available but the mini-mental state examination (MMSE), particularly the Folstein MMSE (Appendix 2) is commonly used and recommended.

Consider behavioural changes using the following checklist.

D: drugs and alcohol, depression

E: ears, eyes

M: metabolic (e.g. hyponatraemia, diabetes mellitus, hypothyroidism)

E: emotional problems (e.g. loneliness)

N: nutrition: diet (e.g. vitamin B group deficiency, teeth problems)

T: tumours, trauma (of CNS)

I: infection

A: atherosclerotic disease → cerebral insufficiency

Electrolyte/metabolic disorders

The following disorders tend to occur in patients with medical problems requiring polypharmacy.

• DxT: malaise +muscle weakness—but usually asymptomatic until cardiac toxicity, e.g. arrhythmia, cardiac arrest; ECG-peaked T waves, small P waves

• → hyperkalaemia: K > 6mmol/L; >7—a medical emergency

• DxT: lethargy + muscle weakness/hypotonia + muscle cramps + impaired cognition/confusion ± cardiac arrhythmia esp. ectopics

• → hypokalaemia: K < 2.5 mmol/L (severe symptoms); 2.5–3.5 usu asymptomatic

• DxT: lethargy + muscle weakness + personality changes ± confusion ± seizures

• → hyponatraemia Na < 125–135 mmol/L

• DxT: thirst = oliguria + confusion + muscle twitching & cramps + orthostatic hypotension ± seizures/coma

• → hypernatraemia: Na > 145+ mmol/L

Falls in the elderly

Falls are a major problem as at least 5% of falls result in a fracture particularly Colle's and femoral neck. The death rate is significant.

The main causes are:

• neurological (e.g. cerebrovascular disease, Parkinson disease)

• sensory impairment (e.g. visual, vestibular)

• cardiovascular (e.g. postural hypotension)

• musculoskeletal (e.g. arthritis, foot disorders)

• fluid and electrolyte imbalance

• cognitive and psychological conditions (e.g. dementia, delirium)

• medication/drug related (e.g. sedatives, alcohol)

• physiological changes (e.g. gait disorders)

• environmental factors (e.g. slipping or tripping)

• combinations of the above

The most significant clinical risk factors for falls have been shown to be visual impairment, impaired general function, postural hypotension, hearing impairment, low morale/depression, drug usage, especially sedatives, decreased lower limb strength including arthritis, and impaired balance and gait.

Management and prevention involves correction of any medical disorders and risk factors. Refer patients of concern to a multidisciplinary team that includes occupational therapists and physiotherapists. Strategies include walking aids, home hazard control, exercise training and medication reduction.

Encopresis is the involuntary passage of formed or semi-formed stools into clothing occurring repeatedly for at least 1 month, in children 4 yrs and over. Inadequate toileting and poor diet are features. The key feature is significant faecal retention → rectal dilatation. PR reveals poor anal tone, capacious rectum overload with firm faeces.

Assessment

• History inc. development

• Examination inc. check underwear

• Consider abdominal X-ray (serves as baseline)

Management

The majority are cured with the following strategies. The initial task is to empty the bowel of faeces (can take months).

Laxative medication:

• Stool softener (e.g. paraffin oil) 20–40 mL daily

• Macrogol 3350 (Movicol) sachets 1 bd day 1, 2 bd day 2, 3 bd day 3 and so on until desired result

• Consider Microlax enema, then Senokot granules, one teaspoon daily

If severe faecal impaction:

• Admit to hospital (day care).

• Consider abdominal X-ray.

• Macrogel 3350: double usual dosage

• Microlax enema

If unsuccessful, sodium phosphate (Fleet) enema (not <2 y)

If oral medication refused, sodium sulphate (ColonLYTLEY) via nasogastric tube.

General care:

• Ongoing interest and support (critical)

• Education and counselling

• A good normal diet, adequate fluids and exercise

• Structured toileting program (e.g. regular sitting on toilet for at least 10 mins, 3 times/d after each meal)

• Regular follow-up with encouragement, e.g. star-chart diary

• Avoid punitive methods, criticism and undue focus on the problem

• Consider encopresis clinic if problematic

Warning signs

• Unexplained fever and cardiac murmur

• Febrile illness after instrumentation or minor and major surgical procedures

Classic tetrad: signs of infection, heart disease, embolism and immunological phenomenon, e.g. arthritis.

Only 50% have previously known heart disease. Consider the possibility in IV drug users.

Main test is blood culture: at least 3 sets of samples within first hour.

Echocardiography (TOE more sensitive than TTE).

Antimicrobial treatment

There are two important principles of management:

• Treatment must be given IV for at least 2 wks.

• Treatment is prolonged—usually 4–6 wks.

Consultation with an infectious disease physician or clinical microbiologist should be sought. Once cultures have been taken prompt empirical antimicrobial treatment should be commenced, esp. in fulminating infection suspected to be endocarditis. Benzylpenicillin + gentamicin di(flu)cloxacillin are recommended. Vancomycin needs to be considered if hospital acquired, MRSA suspected or prosthetic cardiac valve.

Prevention of endocarditis

Value of prophylaxis unclear.

Low-risk patients (no prosthetic valves or previous attack of endocarditis): prophylaxis not recommended

High-risk patients (prosthetic values, all acquired valvular disease, past history, most congenital heart disease, mitral valve prolapse with regurgitation) having invasive dental procedures, oral or upper respiratory tract surgery, GIT or GU surgery: (consult an infectious disease physician)

• Amoxycillin 2 g (50 mg/kg up to adult dose) orally, 1 h beforehand (if not on long-term penicillin) or

• (Amoxy) ampicillin 2 g (50 mg/kg up to adult dose) IV just before procedure commences or IM 30 mins before; if having a general anaesthetic plus (depending on circumstances)

• Gentamicin IV (just before) or IM (30 mins before) or vancomycin IV

Triads/tetrads for syndromes related to pituitary hormones

Thyroid

Hypothyroidism

tiredness + husky voice + cold intolerance physical slowing + mental slowing + facial puffiness

Hyperthyroidism

anxiety + weight loss + muscle weakness sweaty hands + loose frequent bowel motions + palpitations

Adrenal

Addison disease

fatigue/weakness + anorexia & nausea + dizziness ± skin discolouration ± abdominal pain, weight loss, loose bowels (diarrhoea)

Cushing disease

plethoric moon face + thin extremities + muscle weakness hirsutism + abdominal striae + hypertension

Primary hyperaldosteronism

usually asymptomatic—any symptoms are features of hypokalaemia, e.g. weakness, paraesthesia, cramps

Phaeochromocytoma

headache + palpitations + sweating + anxiety

Congenital adrenal hyperplasia

sexual ambiguity + clitoral hypertrophy + virulisation + salt losing state

Pituitary

Acromegaly

nasal problems + fitting problems (shoes, gloves, rings) + weakness + sweating

Hypopituitarism

(female) amenorrhoea + loss of axillary and pubic hair + breast atrophy, (male) reduced libido + impotence + loss of body hair

Diabetes insipidus

weakness + polyuria + polydipsia (intense craving for ice water)

Hyperprolactinaemia

symptoms common to both sexes—reduced libido + subfertility + galactorrhoea

+ females—amenorrhoea/oligomenorrhoea

+ males—ED, reduced facial hair

Other endocrine related

Hyperparathyroidism

Classic mnemonic: bones, moans, stones, abdominal groans

Due to hypercalcaemia

Hypercalcaemia

weakness + constipation + polyuria

Hypoparathyroidism

neuromuscular excitability + tetany + neuropsychiatric features, e.g. confusion

Due to hypocalcaemia

Diabetes mellitus

fatigue & tiredness + polydipsia + polyuria + weight loss (indicates type 1)

Clinical features

• 10% incidence

• Puberty to menopause, peak 25–35 yrs

• Secondary dysmenorrhoea

• Premenstrual spotting

• Infertility

• Dyspareunia

• Non-specific pelvic pain

• Menorrhagia

• Acute pain with rupture of endometrioma

DXT: dysmenorrhoea + menorrhagia + dyspareunia + pelvic pain

Diagnosis

• Can be made only by direct visual inspection at laparoscopy or laparotomy

• Ultrasound scan helpful

Treatment

• Careful explanation—point out risk of infertility

• Basic analgesics

• Treatment can be surgical or medical

Medical:

To induce amenorrhoea—options:

• levonorgestrel-releasing IUCD—5 yrly

• danazol (Danocrine)—for 3–6 mths

• combined oestrogen–progestogen oral contraceptive: once daily continuously for about 6 mths or longer

• progestogens (e.g. medroxy-progesterone acetate (Depo Provera))

• GnRH analogues (e.g. goserelin)

Surgical: Surgical measures depend on the patient's age, symptoms and family planning. Laser surgery and microsurgery can be performed either via laparoscopy or laparotomy to ablate endometrial deposits and uterine nerve.

Note: Pregnancy beneficial but endometriosis can recur.

If unsuitable for surgery, use a strip of hypo-allergenic, non-woven surgical tape (1 cm × 3 cm) to evert lid and secure to cheek (see Fig. E5). It should be changed as often as necessary by a carer.

Nocturnal enuresis

It is considered a problem if regular bed-wetting occurs in children 6 yrs and older, although many boys do not become dry until 8 yrs.

After the age of 6, investigations including an intravenous urogram or US are necessary to exclude urinary tract abnormalities and diabetes.

Advice for parents on managing the child

• Do not scold or punish the child.

• Praise the child often, when appropriate.

• Consider a star-chart diary with a star/dry night.

• Do not stop the child drinking after the evening meal.

• Do not wake the child at night to visit the toilet.

• Use a night-light to help the child who wakes.

• Some parents use a nappy to keep the bed dry but try using special absorbent pads beneath the bottom sheet rather than a nappy.

• Make sure the child has a shower or bath before going to kindergarten or school.

• Reassure the child there is nothing wrong; it is a common problem that will go away.

Treatment

Many methods have been tried, but the bed-wetting alarm system is generally regarded to be the most effective. If the child has emotional problems, counselling or hypnotherapy may be desirable. Desmopression acetate is effective and very useful on school camps.

Stepwise management trial

1. Conditioning therapy:

   • pad or bell alarm or

   • body worn alarm (e.g. Malem night-trainer)

   If a trial fails, have a 3-mth break and try again with close supervision.

2. Desmopressin acetate tablets or nasal spray each night (avoid water load before bed)

3. Desmopressin + alarm

4. Planned waking

The above is preferred to tricyclic antidepressants such as imipramine.

Epilepsy is defined as a ‘tendency to recurrence of seizures’. It is a symptom, not a disease. A person should not be labelled ‘epileptic’ until at least two attacks have occurred. Use monotherapy for prescribing if possible.

Types of epilepsy

Epileptic seizures are classified in general terms as generalised and partial (Table E5). Partial seizures are about twice as common as generalised seizures and usually due to acquired pathology.

Tonic-clonic seizures

Formerly called grand mal seizure, it is the classic convulsive seizure with muscle jerking. Typical features (in order):

• initial rigid tonic phase (up to 60 secs)

• convulsion (clonic phase) (seconds to minutes)

• mild coma or drowsiness (15 mins to several hrs)

A typical tonic-clonic seizures

These variants of tonic-clonic seizures are more common than realised:

• stiffen and fall = tonic

• floppy and fall = atonic

• shaking only = clonic

Diagnosis

• Check short-term aggravating factors (e.g. lack of sleep, medications, drugs inc. alcohol)

• Investigate and treat any cause. Usual tests—EEG, CT or MRI (preferable) scan, basic biochemistry and haematology

Management

Note: Do not usually treat on one fit (chance of a further seizure is about 70%). Refer to Fig. E6 (flow chart for initial management of epilepsy).

• Profound psychosocial support

• Education, counselling, advocacy

• Appropriate referral

Medication

• Sodium valproate (first choice)

• Adults: 500 mg (o)/d for 1 wk, then bd for 1 wk, ↑ every 2–4 wks to achieve control (up to 2–3 g/d)

Some prefer carbamazepine in young women because of risk of teratogenicity with valproate which, however, is less sedating.

• Carbamazepine (2nd choice)

• Other choices: phenytoin, lamotrigine, topiramate, levetiracetam (usually added on to achieve optimal control—check interactions)

Continue treatment until fit-free for at least 2 yrs.

Avoid use of prochlorperazine and benzodiazepines. Monitor with annual LFTs and FBE.

Absence seizure

This type of generalised epilepsy typically affects children from 4 yrs up to puberty. It is subclassified as childhood absence epilepsy (formerly known as petit mal) usually 4–9 yrs and juvenile absence epilepsy usually 10–15 yrs.

• Child ceases activity and stares suddenly.

• Child is motionless.

• No warning.

• Sometimes clonic (jerky) movement of eyelids, face, fingers.

• May be lip-smacking or chewing (called complex absence).

• Only lasts a few seconds—usually 5–10 secs.

• Child then carries on as though nothing happened.

• Usually several per day (not just one or two).

• May lead to generalised seizures in adulthood.

Diagnosis

Best evoked in the consulting room by hyperventilation.

EEG:

• Classic 3 Hz wave and spike

• May be normal

• Always include hyperventilation

Medication

• Ethosuximide (1st choice) or

• Sodium valproate (2nd choice): first line if associated other seizure type

Other choices: clonazepam, lamotrigine, clobazam

Complex partial seizures

It is the commonest type of focal epilepsy and the attacks vary in time from momentary to several minutes (av. 1–3 mins).

Possible manifestations

• Commonest: slight disturbance of perception and consciousness

• Hallucinations—visual, taste, smell, sounds

• Absence attacks or vertigo

• Affective feelings—fear, anxiety, anger

• Dyscognitive effects, e.g. deja vu (familiarity), jamais vu (unreality)

• Objective signs:

  • lip-smacking

  • swallowing/chewing/sucking

  • unresponsive to commands or questions

  • pacing around a room

Unreal or detached feelings and post-ictal confusion are common in complex partial seizures. There can be permanent short-term memory loss.

Diagnosis

• EEG-diagnostic in 50–60% of cases

• EEG/video telemetry helpful with frequent attacks

• CT or MRI scan—to exclude tumour when diagnosis confirmed

Medication

• Carbamazepine (1st choice) 200 mg/d ↑ gradually by 100 mg/wk to control or

• Sodium valproate

Other choices: phenytoin, lamotrigine, gabapentin, vigabatrin, tiagabine

Simple partial seizures

In simple partial seizures there is no loss of consciousness. These include focal seizures which may proceed to a generalised tonic-clonic seizure or to motor seizures—Jacksonian epilepsy.

Jacksonian (motor seizure)

Typically, jerking movements begin at the angle of the mouth or in the thumb and index finger and ‘march’ to involve the rest of the body, e.g. thumb → hand → limb → face ± leg on one side and then on to the contralateral side. A tonic-clonic or complex partial seizure may follow.

Medication: As for complex partial seizures.

Status epilepticus

Status is >1 seizure without regaining consciousness or fitting >20 mins.

Focal status

• A high index of suspicion is needed to diagnose

• Oral medication usually adequate

• Avoid overtreatment

Generalised status

Absence attack (petit mal)

• Hospitalisation

• IV diazepam

Tonic-clonic (dangerous!)

• Ensure adequate oxygenation: attend to airway (e.g. Guedel tube); give O₂ 8 L/min

• Midazolam 5–10 mg (child 0.15–0.2 mg/kg up to 10 mg) IV or IM over 2–5 min or 5–10 mg bucally (between gums and cheek) with syringe or intranasally. Repeat in 15 mins if necessary or

• Diazepam 0.05 mg/kg/min (or 0.2 mg/kg stat) IV until the seizures cease or respiratory depression begins (beware of respiratory depression and other vital parameters); usually give 10–20 mg bolus in adult or

• Clonazepam 1–2 mg IV statim then 0.5–1 mg/min IV until seizures cease or respiratory depression begins or

• Followed by (for all of above benzodiazepines) phenytoin 1000 mg IV over 20–30 mins

Other drugs to consider: phenobarbitone; thiopentone; paraldehyde; sodium valproate (can use rectally).

Note: Midazolam is suitable for all types of seizures, and can be given (preferentially) intranasally or bucally.

Diazepam can be given rectally by solution, suppository or gel. In an adult, 10 mg is diluted in 5 mL, of isotonic saline and introduced via the nozzle of the syringe into the rectum. The dose in children is 0.5 mg/kg.

Simple tamponade

• Pinch ‘soft’ part of nose between thumb and finger for 5 mins.

• Apply ice packs to bridge of nose.

Simple cautery of Little's area

(Under LA, e.g. Cophenylcaine forte nasal spray ± 5% cocaine solution.) Use one of three methods: electrocautery, trichloracetic acid or silver nitrate stick (preferred).

Persistent anterior bleed

• Merocel (surgical sponge) nasal tampon or Kaltostat pack or BIPP with ribbon gauze

‘Trick of the trade’ for recurrent anterior epistaxis:

• apply Nasalate nose cream tds for 7–10 d or

• Rectinol ointment

Severe posterior epistaxis

Use a Foley's catheter or an Epistat catheter with or without Kaltostat.

Erectile dysfunction (impotence) is the inability to achieve or maintain an erection of sufficient quality for satisfactory intercourse. It does not refer to ejaculation, fertility or libido. Look for a cause (e.g. psychogenic, hormonal—uncommon, drug-induced, vascular disease).

Investigations

First-line blood tests:

Others: nocturnal penile tumescence, LFTs, esp. GGT (alcohol effect)

Management

Treat cause. If psychogenic, refer for personal or sexual counselling.

If androgen deficiency step-wise trial:

1. oral: testosterone undecanoate (Andriol)

2. IM: testosterone enanthate (Primoteston Depot) or testosterone esters (Sustanon)

3. subcutaneous implantation: testosterone implants (last 5–6 mths)

If functional: oral mediation (PDE-5 inhibitors)

• sildenafil (Viagra) 50–100 mg (o) 1/2–1 h before sex

• tadalafil (Cialis) 10–20 mg (o) 1–2 h before sex

• vardenafil (Levitra) 10–20 mg (o) 1/2–1 h before sex

Avoid in those on nitrates for angina.

Intrapenile injection prostaglandin E (alprostadil):

• intracavernosal injections

• self-administered after supervised teaching

• max. of 3/wk (use 2 pseudoephedrine tabs for prolonged erection >2 h)

• Superficial cellulitis of skin

• Involves face in at least 80%—spread from nose, facial or dental infection

• Invariably caused by Streptococcus pyogenes

• More common in the elderly

• Abrupt onset

• Rapidly spreading red patch of skin

• Lymphatic and lymph node involvement

• Heat, pain and oedema of lesion

• Systemic effect (e.g. fever, malaise)

• Recurrence is common

Treatment

• Phenoxymethylpenicillin 500 mg (o) qid or IM procaine penicillin once daily for 7–10 d

• Benzylpenicillin 600 mg (IV) 4 hrly (if severe)

Usually elderly patient complaining of a chronic gritty sensation—due to reduced tear secretion. Three main preparations for treatment:

• lubricating drops (e.g. polyvinyl alcohol solution or hypromellose 0.5%)

• lubricating gels or ointments (e.g. Poly Vise, Duratears)

• tear stimulating drops (e.g. Thera Tears, Cellufresh)

Other tips:

• Bathe regularly with clean water.

• Use room humidifiers where there is dry heating.

• Acute conjunctivitis accounts for over 25% of all eye complaints seen in general practice ( Conjunctivitis).

• Pain and visual loss suggest a serious condition such as glaucoma, uveitis (inc. acute iritis) or corneal ulceration.

• Beware of the unilateral red eye—think beyond bacterial or allergic conjunctivitis. It is rarely conjunctivitis and may be a corneal ulcer, keratitis, foreign body, trauma, uveitis or acute glaucoma.

The clinical approach

The five essentials of the history are:

• history of trauma (esp. as indicator of IOFB)

• vision

• the degree and type of discomfort

• presence of discharge

• presence of photophobia

When examining the unilateral red eye, keep the following diagnoses in mind:

• trauma

• foreign body, inc. IOFB

• corneal ulcer

• iritis (uveitis)

• viral conjunctivitis (commonest type)

• acute glaucoma

Red eye in children

Of particular concern is orbital cellulitis, which may present as a unilateral swollen lid and can rapidly lead to blindness if untreated. Bacterial, viral and allergic conjunctivitis are common in all children. Conjunctivitis in infants is a serious disorder because of the immaturity of tissues and defence mechanisms.

Neonatal conjunctivitis (ophthalmia neonatorum)

This is conjunctivitis in an infant less than 1 month old and is a notifiable disease. Chlamydial and gonococcal infections are uncommon but must be considered if a purulent discharge is found in the first few days of life. Chlamydia trachomatis usually presents 1 or 2 wks after delivery, with moderate mucopurulent discharge.

Treatment is with oral erythromycin for 21 d and local sulfacetamide.

N. gonorrhoeae conjunctivitis, which usually occurs within 1 or 2 days of delivery, requires vigorous treatment with intravenous cephalosporins or penicillin and local sulfacetamide drops.

Trachoma

Trachoma is a chlamydial conjunctivitis that is prevalent in outback areas and in the Indigenous population. C. trachomatis is transmitted by human contact and by flies, esp. where hygiene is inadequate. It is the most common cause of blindness in the world. It is important to start control of the infection in childhood as outlined above.

For adults (and children >6 kg): azithromycin 1 g (o) once

Blocked nasolacrimal duct

Excessive eye watering in infants ± mucus/mucopus is the key sign. Usually obvious 3–12 wks. In the majority of infants spont. resolution occurs by 6 mths.

Management

• Local antibiotics for infective episodes, warm cotton wool for minor infection

• Bathing with normal saline

• Frequent finger massage over the lacrimal sac towards tip of nose

• Referral for probing and dilation of the lacrimal passage before 6 mths if the watering/discharge is profuse and irritating or between 6–12 mths if not self-corrected

Orbital cellulitis

Orbital cellulitis includes two basic types—periorbital (or preseptal) and orbital (or post-septal) cellulitis and is usually found in children.

Orbital (post-septal) cellulitis

Features

• A potentially blinding and life-threatening condition

• In children blindness can develop in hours

• Unilateral swollen eyelids; may be red

• An unwell patient

• Tenderness over the sinuses (see Fig. E7)

• Restricted and painful eye movements

• Usually secondary to ethmoiditis

• Usually caused by H. influenzae

Periorbital (pre-septal) cellulitis

• Similar presentation

• Usually follows an abrasion but

• No pain or restriction of eye movement

Management (both types)

• Immediate specialist referral

• IV cefotaxime until afebrile, then amoxycillin/clavulanate or di(flu) cloxacillin for 7–10 d

Red eye in adults

Conjunctivitis

See Conjunctivitis

Episcleritis and scleritis

Episcleritis and scleritis present as a localised area of inflammation. Both may become inflamed but episcleritis is essentially self-limiting while scleritis (which is rare) is more serious as the eye may perforate.

History

A red and sore eye is the presenting complaint. There is usually no discharge but there may be reflex lacrimation. Scleritis is much more painful than episcleritis and tender to touch.

Management

An underlying cause such as an autoimmune condition should be identified. Refer the patient, esp. for scleritis. Corticosteroids or NSAIDs may be prescribed.

Uveitis (iritis)

Anterior uveitis (acute iritis or iridocyclitis) is inflammation of the iris and ciliary body and this is usually referred to as acute iritis. The pupil may become small because of adhesions and the vision is blurred.

The affected eye is red with the conjunctival injection being particularly pronounced over the area covering the inflamed ciliary body (ciliary flush). The patient should be referred to a consultant.

Causes include auto-immune diseases such as the spondyloarthropathies, e.g. AS, sarcoidosis and some infections.

Management involves finding the underlying cause. Treatment includes pupil dilation with atropine drops and topical steroids to suppress inflammation. Systemic corticosteroids may be necessary.

Posterior uveitis (choroiditis) may involve the retina and vitreous and also requires referral.

Acute glaucoma

Acute glaucoma should always be considered in a patient over 50 yrs presenting with an acutely painful red eye. Permanent damage will result from misdiagnosis. The attack characteristically strikes in the evening when the pupil becomes semidilated.

Features

• Patient >50 yrs

• Pain in one eye

• ± Nausea and vomiting

• Impaired vision

• Haloes around lights

• Fixed semi-dilated pupil

• Eye feels hard

Management

Urgent ophthalmic referral is essential since emergency treatment is necessary to preserve eyesight. If immediate specialist attention is unavailable, treatment can be initiated with acetazolamide (Diamox) 500 mg IV and pilocarpine 4% drops to constrict the pupil.

Herpes zoster ophthalmicus

Herpes zoster ophthalmicus (shingles) affects the skin supplied by the ophthalmic division of the trigeminal nerve. The eye may be affected if the nasociliary branch is involved.

Immediate referral is necessary if the eye is red, vision is blurred or the cornea cannot be examined. Apart from general eye hygiene, treatment usually includes oral aciclovir, famciclovir or valaciclovir (provided this is commenced within 3 d of the rash appearing), and topical aciclovir 3% opth. ointment 4 hrly.

Flash burns

Eyelid and lacrimal disorders

There are several inflammatory disorders of the eyelid and lacrimal system that present as a ‘red and tender’ eye without involving the conjunctiva. Any suspicious lesion should be referred.

Stye

Chalazion (meibomian cyst)

May resolve spont. or require incision.

Blepharitis

Dacryocystitis

Acute dacryocystitis is infection of the lacrimal sac secondary to obstruction of the nasolacrimal duct at the junction of the lacrimal sac. The problem may vary from being mild (as in infants) to severe with abscess formation.

Management

• Local heat: steam or a hot, moist compress

• Analgesics

• Systemic antibiotics (best guided by results of Gram stain and culture) but initially use dicloxacillin or cephalexin (if sensitive to penicillin)

• Measures to establish drainage are required eventually. Recurrent attacks or symptomatic watering of the eye are indications for surgery such as dacryocystorhinostomy.

Dacroadenitis

This is infection of the lacrimal gland presenting as a tender swelling on upper outer margin of eyelid. Many causes but usually viral (e.g. mumps). Treat conservatively with warm compresses. Antibiotics for a bacterial cause.

When to refer the patient with a red eye

• Uncertainty about the diagnosis

• Deep central corneal and intraocular foreign bodies

• Sudden swelling of an eyelid in a child with evidence of infection suggestive of orbital cellulitis—this is an emergency

• Emergency referral is also necessary for hyphaemia, hypopyon, penetrating eye injury, acute glaucoma, severe chemical burn.

Summary for urgent referral

• Trauma (significant)/penetrating injury

• Hyphaema >3 mm

• Corneal ulcer

• Severe conjunctivitis

• Uveitis/acute iritis

• Behcet syndrome

• Acute glaucoma

• Giant cell arteritis/temporal arteritis

• Orbital cellulitis

• Acute dacryocystitis

• Keratitis

• Episcleritis/scleritis

• Herpes zoster ophthalmicus

• Endophthalmitis

Note: As a general rule, never use corticosteroids or atropine in the eye before referral to an ophthalmologist.

Practice tips for eye management

• Avoid long-term use of any medication, esp. antibiotics (e.g. chloramphenicol: course for a maximum of 10 days).

• As a general rule avoid using topical corticosteroids or combined corticosteroid/antibiotic preparations.

• Never use corticosteroids in the presence of a dendritic ulcer.

• To achieve effective results from eye ointment or drops, remove debris such as mucopurulent exudate with bacterial conjunctivitis or blepharitis by using a warm solution of saline (dissolve a teaspoon of kitchen salt in 500 mL boiled water) to bathe away any discharge from conjunctiva, eyelashes and lids.

• Beware of the contact lens ‘overwear syndrome’, which is treated in a similar way to flash burns.

Perform epilation using eyebrow tweezers (available from chemists). Regular epilation may be necessary. Severe cases: electrolysis of hair roots.

Could be a nervous condition or a focal dystonia. Advise that cause is usually stress or fatigue. Reassure and counsel. Consider prescribing clonazepam if severe.

Blepharospasm may be treated with botulinum toxin injection into the orbicularis oculi muscle.

Cause: intense ultraviolet light burns to corneas (keratitis) (e.g. arc welding, UV lamps, snow reflection)

Precautions: foreign bodies; continued use of topical anaesthetics (once only)

Treatment

• Topical long-acting LA drops (e.g. amethocaine) once only

• Homotropine 2% eye drops, 1–2 drops statim

• Broad-spectrum antibiotic eye ointment, bd in lower fornix (48 h)

• Analgesics (e.g. codeine + paracetamol)

• Eye padding for 24 h then review

The eye usually heals completely in 48 h. If not, check for a foreign body.

Note: Contact lens ‘overwear syndrome’ gives the same symptoms.