Chapter 13: Ear, Nose and Throat

Eliciting sinus tenderness is important in the diagnosis and follow-up of sinusitis.

Firm pressure over any facial bone, particularly in the patient with an upper respiratory infection, may cause pain. It is important to differentiate sinus tenderness from non-sinus bone tenderness.

Method

1. This is best done by palpating a non-sinus area first and last (Fig. 13.1), systematically exerting pressure over the temporal bones (T), then the frontal (F), ethmoid (E) and maxillary (M) sinuses, and finally zygomas (Z), or vice versa.

2. Differential tenderness both identifies and localises the main sites of infection.

A simple way to assess the presence or absence of fluid in the frontal sinus, and in the maxillary sinus (in particular), is the use of transillumination. It works best when one symptomatic side can be compared with an asymptomatic side.

It is necessary to have the patient in a darkened room and to use a small, narrow-beam torch.

Frontal sinuses

Shine the torch above the eye in the roof of the orbit and also directly over the frontal sinuses, and compare the illuminations.

Maxillary sinuses

Remove dentures (if any). Shine the light inside the mouth, on either side of the hard palate, pointed at the base of the orbit. A dull glow seen below the orbit indicates that the antrum is air-filled. Diminished illumination on the symptomatic side indicates sinusitis.

Simple inhalations for upper respiratory tract infections (including upper airways obstruction from the oedema and secretions of rhinitis and sinusitis) can promote symptomatic relief and early resolution of the problem. The positive effect of making the patient responsible for active participation in management often helps to counterbalance the occasional disappointment when no antibiotic is prescribed.

The old method of towel over the head and inhalation bowl can be used, but it is better to direct the vapour at the nose.

Equipment

• Container. This can be an old disposable bowl, a wide-mouthed bottle or tin, or a plastic container.

• The inhalant. Several household over-the-counter preparations are suitable: e.g. Friar’s Balsam (5 mL), Vicks^® VapoRub (one teaspoon), Euky Bear™, eucalyptus oil or menthol (5 mL).

• Cover. A paper bag (with its base cut out), a cone of paper (Fig. 13.2a) or a small cardboard carton (with the corner cut away; Fig. 13.2b).

Method

1. Add 5 mL or one teaspoon of the inhalant to 0.5 L (or 1 pint) of boiled water (allow to cool for 5 to 10 minutes) in the container.

2. Place the paper or carton over the container.

3. Get the patient to apply nose and mouth to the opening to breathe the vapour in deeply and slowly through the nose, and then out slowly through the mouth.

4. This should be performed for 5 to 10 minutes, 3 times a day, especially before retiring.

After inhalation, upper airway congestion can be relieved by autoinsufflation.

Hot water bottle method

A relatively safe and convenient way is to use a hot water bottle for inhalations. The top fits neatly over the mouth and nose.

Vacuum flask method

An old vacuum flask (thermos) is an ideal container to fill with very hot/boiling water and the inhalant. It is also portable.

Warning: Avoid using these hot water methods in children.

A practical inhalation method for busy workers

Dr Tony Dicker claims great success using a coffee cup for inhalations. By placing the inhalant, e.g. Vicks^®, on a teaspoon then adding boiling water, an inhalation bowl is made by placing the hands over the cup to suit the nose and mouth. People find this easy to use during meal/coffee breaks.

Nasal polyps are small ‘bags’ of fluid and mucus following engorgement of the mucosa of the sinuses usually due to allergic rhinitis. They pop out through the sinus openings into the nasal cavity (Fig. 13.3). They are best treated by medical polypectomy using topical nasal hydrocortisone solution or corticosteroid sprays for small polyps and oral corticosteroids for extensive polyps, e.g. prednisolone 50 mg per day for 5 to 7 days (avoid aspirin). Antibiotics may be needed for infection.

Surgery is usually reserved for failed medical treatment. Polyps can be simply removed under local anaesthetic by snaring the base or stalk with a loop of cutting wire. More severe cases may require sophisticated surgery.

The age of the digital watch has meant a decline in the use of the ‘ticking watch’ test as a rough screening procedure for hearing loss.

In children and in adults with a reasonable amount of hair, an alternative method can be used.

Method

1. Grasp several scalp hairs close to the external auditory canal lightly between the thumb and index finger.

2. Rub lightly together (Fig. 13.4) to produce a relatively high-pitched ‘crackling’ sound.

If this sound cannot be heard, a moderate hearing loss is likely (usually about 40 dB or greater). If a hearing loss is detected, tuning fork assessment and other investigations will then be required.

The whispered voice test

The whispered voice test has been proved as an accurate screening test for hearing impairment. It is less accurate in children than in adults.

It is important to exhale quietly before whispering.

Method

1. Stand 60 cm behind the patient.

2. Mask the non-test ear by gently occluding the auditory canal and rubbing the tragus in a circular motion.

3. Exhale quietly before whispering a combination of numbers and letters (e.g. ‘5, M, 2, A’).

4. If the patient responds correctly (i.e. repeats at least 3 out of 6 numbers and letters correctly), hearing is considered normal.

5. If the patient responds incorrectly, repeat the test using a different number-and-letter combination.

6. Test each ear individually, beginning with the better ear. Use a different number–letter combination each time.

Crumpled paper test

Another simple rapid test is to use the sound of paper. Gently rub two pieces of paper together about 1–2 cm from the ear and request the patient to indicate if they hear the sound. For infants, crush a piece of paper behind the ear and note their response.

Waterproofing ears with Blu-Tack

An excellent earplug can be made with Blu-Tack, which can be gently moulded to the external auditory canal. It is ideal for children if they need to keep an ear dry when swimming or showering, for example those with perforations, ventilating grommets and recurrent otitis externa (‘swimmer’s ear’). Ideally, a swimming cap should also cover the ear and diving should be advised against.

The Blu-Tack provides excellent waterproofing, stays in place and is reusable. Do not use in hot saunas, where it softens easily.

Children should be instructed not to keep poking the ‘tack’ into their ears with their fingers.

Be prepared to remove retained bits of Blu-Tack sometimes.

New type of ear plug

A new form of ear protection is the expanding ear plug. The plugs can be used during exposure to excessive noise and for middle ear protection while swimming, especially for children with ventilating tubes inserted in their ears.

Made of compressible foam, when cut in half the plug can be rolled into a cylindrical shape that fits neatly in a child’s ear. Keeping a finger on the outer part of the ear canal allows the plug to expand and fill the canal. A small coating of petroleum jelly and a standard rubber bathing cap make them waterproof, but the child should not dive under water.

Parents who have tried to use a full-sized ear plug for a child have sometimes found that the bathing cap rubbed on the end of it, pulling it out of the ear—hence the reason for cutting them in half. (E.A.R. Plugs are available from most acoustic services for approximately $1.00 a pair. They are washed easily in warm, soapy water, and a pair will last between 6 and 12 months.)

The debris from otitis externa and the discharge from otitis externa or media can be mopped out with ‘spears’ fashioned from toilet paper or other tissue. They are widely used in Indigenous children. In otitis externa this toileting can be followed by acetic acid 0.25% washout—then topical steroid and antibiotic ointment if necessary.

Get patients to rinse ears out with fresh water (possibly using a 5 mL syringe) and then dry with a hair dryer on moderate heat.

Treatment and prevention of swimmer’s ear

Use a drying topical medication, e.g. Aquaear^® or Ear Clear^® (acetic acid and isopropyl alcohol). An alternative less expensive preparation is a ‘homebrew’ mixture of acetic acid (vinegar) and methyl alcohol (methylated spirits), 3 parts to 7. Instil 2 to 3 drops daily during the swimming season.

Wash the canal with dilute povidone-iodine (Betadine^®) 5% solution using a 20 mL syringe with plastic tubing 1, 2 or 3 times daily. Dry mop with rolled toilet paper ‘spears’. Teach this method to family members. If available, suction kits are useful.

This simple method of ear piercing (for the insertion of ‘sleepers’) requires only an 18- or 19-gauge sterile needle. Local anaesthesia is optional. A freezing spray can be used.

Method

1. Carefully place marks on the ear lobe (this is better done by the patient or patient’s parents).

2. Introduce the needle through the selected site (Fig. 13.5a). One can use a cork or piece of potato on the exit side.

3. Insert the pointed end of the sleeper into the bore of the needle, ensuring that it fits tightly, and withdraw the needle (Fig. 13.5b).

Ear syringing is a simple and common procedure, but it should be performed with caution and by an experienced professional. Cautionary advice: Medical negligence claims related to complications of ear syringing are common.¹

Contraindications

Syringing should not be performed in the acute stages of otitis media or when perforation of the tympanic membrane cannot be excluded. In these instances, wax should be cleared with a hook or curette under direct vision (Fig. 13.6a).

In otitis externa, syringing may be performed to remove debris from the canal. Meticulous drying after the procedure is mandatory.

Wax softeners

The average wax production is 2.81 mg/week. Most ear wax clears spontaneously without treatment. Proprietary preparations may be used as an alternative to syringing or to assist removal. These include hydrogen peroxide, carbamide peroxide (Ear Clear^®) and docusate sodium (Waxsol^®), but dioctyl sodium sulphosuccinate should not be used if perforation is suspected. Sodium bicarbonate (available on prescription) or olive oil drops may also be used. Culinary vegetable oil can be used by the patient prior to visiting the office.

A study by Kamien led to the conclusion ‘that the most effective, cheapest and least messy cerumenolytic is a 15% solution of sodium bicarboonate’.² It can be readily made by dissolving ¼ teaspoon of sodium bicarbonate in 10 mL of water. Apply it with a dropper.

Another simple method is to fill the ear with liquid soap. Request the patient to ‘pump’ their tragus for a couple of minutes then attempt syringing.

Ear syringing

Method 1

The syringe should have a properly fitting nozzle and an airtight plunger. Friction in a metal syringe can be reduced by coating the inner plunger with petroleum jelly; it can also be primed with liquid soap. Water at body temperature (37°C) is a satisfactory solution (vertigo, nausea and vomiting may be precipitated by excessively hot or cold fluid coming in contact with the tympanic membrane).

The nozzle of the syringe should rest just inside the auditory meatus and the syringe should be angled slightly upwards (Fig. 13.6b). Water directed along the roof of the external auditory canal cascades around and behind the plug of wax. Pulling the pinna upward and slightly backward straightens the canal, and may assist partial separation of the wax plug.

While a kidney dish is the traditional collecting vessel for the syringed fluid, an empty plastic ice cream ‘bucket’ is a practical alternative: the pliable sides mould easily into the shape of the neck. Another improvised ear ‘cup’ can be cut out from a used hospital 1 L plastic bottle. A small recess can be made for the ear (Fig. 13.6c).

Method 2

This is a very effective system that provides a constant flow of water, maximum safety, and a free hand when syringing the ear.

The apparatus consists of:

• a Higginson syringe

• a heavy metal washer (acts as a weight)

• a metal eustachian catheter

• additional tubing.

The washer maintains the rubber syringe in the basin of water during the ear syringing. The metal eustachian catheter provides an ‘accurate’ jet of water, which is aimed superiorly above the wax in the usual, recommended manner (Fig. 13.6b).

Post-syringing

If the patient complains of deafness due to water retention, instil acetic acid-alcohol drops (Aquaear^® or Ear Clear^®). This gives instant hearing. Some doctors routinely use these drops after syringing out the wax.

A ‘gentle’ ear syringe

A simple ear syringe can be improvised from a 20 mL or 50 mL syringe and a plastic ‘butterfly’ intravenous cannula. The apparatus is also useful for instilling ointment to treat otitis externa.

Method

Firmly attach the ‘butterfly’ cannula to the syringe and cut off the tubing, leaving it about 3–4 cm long (Fig. 13.7).

Use

This ‘ear syringe’ is flexible, safe and easy to use, especially for children. The curve at the end of the tubing permits good positioning in the ear canal.

Note: Some doctors testify to the value of adding a small quantity of povidone-iodine solution to the water, especially if otitis externa is present. Others prefer hydrogen peroxide (100 mL bottles of 30 mg/mL are available in supermarkets) for ear toilet, especially with low-grade otitis externa.

Hair spray and hard wax

People who use hair sprays are prone to developing hard wax if it finds its way into the ear canal. Advise these people to cover their ears when they use the spray.

Keratosis obturans—a pearly white plug of keratin—can develop.

Examination of an infected ear should include inspection of the attic region, the small area of drum between the lateral process of the malleus, and the roof of the external auditory canal immediately above it. A perforation here renders the ear ‘unsafe’ (Fig. 13.8a); other perforations, not involving the drum margin (Fig. 13.8b), are regarded as ‘safe’.

The status of a perforation depends on the presence of accumulated squamous epithelium (termed cholesteatoma) in the middle ear, because this erodes bone. An attic perforation contains such material; safe perforations do not.

Cholesteatoma is visible through the hole as white flakes, unless it is obscured by discharge or a persistent overlying scab. Either type of perforation can lead to a chronic infective discharge, the nature of which varies with its origin. Mucus admixture is recognised by its stretch and recoil when this discharge is being cleaned from the external auditory canal. The types of discharge are compared in Table 13.1.

Management

If an attic perforation is recognised or suspected, specialist referral is essential. Cholesteatoma cannot be eradicated by medical means: surgical removal is necessary to prevent a serious intratemporal or intracranial complication.

Ear pain during descent can be helped by instilling a nasal decongestant such as Drixine^® 1 hour beforehand, and also by chewing gum during descent.

Small ear lobe cysts can be removed by simple excision with the aid of ring forceps (meibomian clamps). Such forceps are especially useful when they can be applied over accessible areas, such as eyelids, lips, webbing, scrotum and ear lobes. They enable a firm hold over a small cyst and help to control haemostasis.

Method

1. For a small ear lobe cyst, apply the forceps over the ear and clamp so that the surface chosen for excision occupies the open ring.

2. Make an incision over the cyst with a small scalpel blade and dissect the cyst gently away from adherent tissue (Fig. 13.9).

3. Once it is relatively free, it may be possible to squeeze out the entire cyst by digital pressure on either side.

The cause is most likely a contact allergy to nickel in the jewellery, complicated by a Staphylococcus infection.

Management method

1. Discard the earrings.

2. Clean the site to eliminate residual traces of nickel.

3. Swab the site, then commence antibiotics (broad-spectrum antistaphylococcus).

4. Get the patient to clean the site daily, then apply the appropriate ointment.

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

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

The embedded earring stud can be difficult to remove, but a simple technique using curved mosquito artery forceps can disimpact the stud easily. The typical stud consists of a post that slots into a butterfly clip.

Method

1. Insert the tips of the mosquito artery forceps into the two openings of the butterfly clip.

2. Open the forceps, thus gently springing apart the butterfly clip (Fig. 13.10). This manoeuvre removes the pressure on the post, and the stud can then be separated.

For severe painful otitis externa, which is common in tropical areas:

• prednisolone (orally) 15 mg statim, then 10 mg 8 hourly for six doses, followed by

• Merocel^® ear wick or ichthammol and glycerine wick

• topical Locacorten^®-Vioform^® or Sofradex^® drops for 10 days.

Otic ointment can be instilled into the ear canal, starting from deep near the tympanic membrane, by using the ‘gentle’ ear syringe described on pp. 184–5 for ear syringing. A more economical way is to use a small 1 or 2 mL syringe to squirt in 0.5–1 mL of cream, e.g. a mixture of hydrocortisone and clotrimazole.

Avoid cotton buds to instil ointment and other material in the ear. Don’t use cotton buds to clean the ear. They tend to impact wax and other debris.

Remember to use protective eyewear if there is significant bleeding.

Simple tamponade

In most instances, haemostasis can be obtained by pinching the ‘soft’ part of the nose between a finger and thumb for 5 minutes and applying ice packs to the bridge of the nose (Fig. 13.11).

Other simple office methods

• Remove any clots—blow nose and then apply 5–6 sprays of a decongestant nasal spray (e.g. Drixine^®).

• A cotton wool ball soaked in Xylocaine^® with adrenaline or a decongestant is also a useful method.

Matchstick tamponade

Several practitioners claim excellent results using a matchstick (¾ of its length) jammed up in a horizontal position under the upper lip to the roof of the gum reflection on the teeth. Leave it in place for several minutes. It compresses the superior labial arteries that also supply the nasal septum.

Note: Dental packing (hard cotton wool roll) is ideal and preferable to a matchstick.

Simple cautery of Little’s area

Local anaesthetic

Co-Phenylcaine™ Forte nasal spray—leave 5 minutes;

or

an equal mixture of 10% cocaine HCl and adrenaline 1:1000 (0.5 mL of each) soaked in a small piece of cotton wool about the size of a 5 cent piece. This pledget is gently compressed against the area and left for 2 minutes.

Cautery methods

The three methods of cautery are:

• electrocautery

• trichloroacetic acid (pure)

• silver nitrate stick (preferred).

Fashion cotton wool onto the end of the silver nitrate stick to dry the treated site. Put the silver nitrate directly onto the small vessels. Beware of silver nitrate stains. Apply Vaseline^® twice daily to the cauterised area.

Use of dental broach for treatment of epistaxis

A dental broach can be modified to pick up a small but adequate amount of trichloroacetic acid (TCA) for nasal cautery.

Method

1. A small loop can be made in the broach by bending the wire around the tip of fine forceps.

2. The loop is placed in the TCA so that a small amount fits neatly in the loop.

3. The loop is then applied to the appropriate site on Little’s area in the nasal septum (Fig. 13.12). The small amount of acid is delivered accurately and cauterises a specific area, without spillage to the healthy adjacent tissue.

Intermittent minor nose bleeds

If not actively bleeding:

• avoid nose blowing

• avoid digital trauma

• apply petroleum jelly (e.g. Vaseline^®) or an antibiotic ointment twice daily for 2 to 3 weeks.

Recurrent anterior epistaxis

For patients with recurrent epistaxis from Little’s area, especially in the presence of localised rhinitis, several topical options are available:

• Nasalate^® cream tds for 7 to 10 days, or

• Aureomycin^® or Nemdyn^® otic ointment bd or tds for 10 days, or

• Rectinol ointment.

Rectal ointment containing local anaesthetic and a vasoconstrictor, e.g. Rectinol, is a very useful topical agent.

Persistent anterior bleed

Use Merocel^® (surgical sponge) nasal tampon or a Kaltostat^® pack or a vaginal tampon.

Severe posterior epistaxis

Occasionally, severe posterior nasal bleeding cannot be controlled by an anterior pack. Insertion of a nasopharyngeal pack via the oropharynx is technically difficult and distressing for the patient. A simple and effective method of applying postnasal pressure uses a Foley catheter.

The traditional ribbon nasal pack with bismuth iodoform paraffin paste (BIPP) can still be used, or glycerine can be used instead of BIPP.

Method

1. Anaesthetise the nasal passage.

2. Select a small Foley catheter (no. 10, 12, 14 or 16) with a 30 mL balloon and self-sealing rubber stopper.

3. Lubricate the deflated catheter and pass it directly into the nasal passage along the floor of the nose until resistance is felt in the nasopharynx (the tip might be visible behind the soft palate).

4. Using a 20 mL syringe, partially inflate the balloon with 5–8 mL of saline or, preferably, air.

5. Gradually withdraw the catheter until resistance is felt; inject another 5 mL of saline or air.

6. Draw the catheter taut so that the balloon fits snugly in the nasopharynx against the choana (Fig. 13.13).

7. Pack the anterior chamber with ribbon gauze in the usual manner.

Note: The patient should be admitted to hospital. Administration of oxygen might be necessary for the elderly patient whose respiration is compromised.

The Epistat catheter: A special catheter called the Epistat has been developed specifically for this method. It is ideal but relatively costly. It has two inflatable balloons, one to act as a stay posteriorly and a wider ‘anterior’ balloon. There is a central airway in the device. This catheter can be autoclaved for further use.

To achieve the best results from nasal drops instil as follows:

• to insert into the left side, incline the head to the left

• for the right side, incline the head to the right.

Ensure no foreign body present.

Treatment

• mupirocin 2% nasal ointment instil 2 to 3 times a day or

• Kenacomb^® ointment instil 2 to 3 times a day

Treatment

• Blow nose hard into disposable paper tissue or handkerchief until clear.

• Nasal decongestant for 2 to 3 days only.

• Steam inhalations with Friar’s Balsam or menthol.

• Simply take promethazine (Phenergan^®) 25 mg nocte.

This is used to flush out excess mucus and other ‘debris’ with hypertonic sterile saline. A suitable solution can be prepared with 2 cups of warm water (distilled water or previously boiled water) with 1/4 to 1/2 teaspoon of non-iodised salt and a pinch of baking soda.

Method

Lean to one side over a basin and forwards about 30–40 degrees. Introduce the wash on one side of the nose with a squeeze bottle, large plastic syringe or bulb spray with the tip just inside the nose. The fluid drains out through the other nostril. Gently blow the nose. Perform about 3 times a week.

Follow-up: corticosteroid nebuliser or nasal inhaler twice daily.

This is a common, distressing problem in the elderly, caused by failure of the vasomotor control of the mucosa. It may be associated with a deviated septum and dryness of the mucosa. The treatment is to keep the nasal passages lubricated with an oil-based preparation e.g. insufflation with an oily mixture (a commercial preparation is Nozoil^®, which is sesame oil based). Topical decongestants can cause serious side effects in the elderly.

Use of Nozoil^® (sesame oil preparation)

This can be used when temporary relief of dry and crusting nasal tissue is required. This can be caused by:

• dry air

• CPAP and oxygen

• drugs such as isotretinoin

• age-related dryness ± rhinorrhoea

• post-surgery including cautery for epistaxis

• nasal steroid use

• nasal crusting from colds and influenza.

Fractures of the nose can occur in isolation or combined with fractures of the maxilla or zygomatic arch. They may result in nasal bridge bruising, swelling, non-alignment and epistaxis. Always check for a compound fracture or head injury and, if present, leave alone and refer. If the patient is seen immediately (such as on a sport’s field) with a straightforward lateral displacement, reduction may be attempted ‘on the spot’ with digital manipulation before distortion from soft tissue swelling. This involves simply using the fingers to push laterally on the outside of the nose towards the injured side to realign the nose.

Tips

• X-rays are generally unhelpful unless excluding other facial skeletal injuries.

• If a deformity is present, refer the patient within 7 days, ideally from days 3 to 5.

• Skin lacerations (i.e. a compound fracture) usually require early repair.

• The optimal time to reduce a fractured nose is about 10 days after injury. There is a window period of 2 to 3 weeks before the fracture unites.

• Closed reduction under local or general anaesthetic is the preferred treatment.

• Open reduction is more suitable for bilateral fractures with significant septal deviation, bilateral fractures with major dislocations or fractures of the cartilaginous pyramid.

Refer

• Uncontrolled epistaxis

• Recurrent epistaxis

• Concern about cosmetic alignment

Ideal hands-free lights to examine the ears, nose and throat include the Vorotek headlight kit or the Welch Allyn portable binocular microscope, the LumiView™—a headband flat surface magnifier.

A less expensive alternative is a caving headlamp, which can be obtained at a camping shop at a reasonable cost.

This method works well for patients with persistent catarrh and sinus problems.

Equipment

You will need:

• a drinking straw

• a tea cup

• warm water with 1 teaspoon of salt and 1 teaspoon of sodium bicarbonate.

Method

1. Place the straw in the water and the other end in the nostril.

2. Holding the other nostril closed with a finger, the patient inhales the fluid rapidly into the nostril and then expectorates.

This preparation is a sinus douche of physiological ‘extracellular fluid’. It can be delivered as a nasal metered pump, which limits the distribution to the nose only, or as a 200 mL douche bottle to thoroughly wash nasal and sinus cavities.

Hiccoughs (singultus) is due to involuntary repetitive diaphragmatic spasms and if prolonged can have serious consequences especially in infants.

For simple brief episodes, try any of the following.

• Rebreathe air in a paper bag (as for hyperventilation).

• Hold the breath.

• Suck ice/swallow iced water.

• Plug both ears and drink a glass of cold water without pause.

• Swallow a teaspoon of table sugar (some practitioners add vinegar to the sugar; others, whisky or gin).

• Swallow 20 mL of spirits (37% or more alcohol) e.g. Benedictine or Sambucca.

• Insert a catheter quickly in and out of the nose.

• Apply pressure on the eyeballs.

When persistent (assuming exclusion of the organic diseases):

• chlorpromazine orally or IV, or

• valproic acid.

Consider acupuncture, hypnosis or phrenic nerve block.

Newborn

Tend to occur during feeding, especially with a bottle. Advise mother to take a break and facilitate burping to expel air.

Toddlers

Lie the child prone and apply natural pressure to the epigastrium. Apply quick downward (gentle) pressure movements and try and coincide it with the hiccoughs (not evidence based).

Nasal catheter for hiccoughs

Persistent hiccoughs can be arrested quickly by irritation of the nose with a soft rubber or plastic nasal catheter. The method is particularly useful for the post-operative patient.

A catheter is introduced into one of the nasal passages and withdrawn as soon as the patient shows irritation.

Worth a try?

Ask the patient what they ate for breakfast 2 days ago. The thoughtful pause that ‘freezes’ the diaphragm may work!

Important strategies to prevent snoring include:

• avoid sleeping on the back

• weight reduction to ideal weight

• no alcohol in the evening.

Otherwise refer to a medical consultant in sleep disorders. Continuous positive airway pressure (CPAP) delivered through a special face mask may be prescribed.

Nasal device

A device suitable to prevent ‘collapsing’ of the front of the nose is ‘Nozovent^®’, which is a simple medical-grade plastic device that fits into the nose. The device, invented by a Swedish ENT surgeon, increases the diameter of the nostrils and prevents them from collapsing on inhalation. An Australian version is the Breathing Wonder^®, which is inexpensive and freely available.

Precautions

• Exclude drugs (including marijuana), vascular disease, depression, aneurysm and vascular tumours.

• Be mindful of lonely elderly people living alone (suicide risk).

Management

• Educate and reassure the patient.

• Encourage the patient to use relaxation techniques.

• Encourage background ‘noise’, e.g. music playing during night.

• Tinnitus maskers.

• Hearing aids.

Drug trials to consider (limited efficacy)

• Betahistine (Serc^®) 8–16 mg daily (max 32 mg)

• Carbamazepine (Tegretol^®)

• Antidepressants

• Sodium valproate (Epilim^®, Valpro, Valprease^®)

Acute severe tinnitus

Slow IV injection of 1% lidocaine (as for migraine—see Intravenous lidocaine). Up to about 5 mL is very effective.

Rather than painful sipping of fluids, advise the patient to fill the mouth with as much fluid as possible and then swallow.

This common condition, particularly in children, causes discomfort in the affected ear or ears. These include muffled or dull hearing, ear ‘fullness’, buzzing, ringing or ‘popping’ noises. One consequence, particularly in younger children, is glue ear.

Treatment strategy

Physical

If the problem is mild, as often follows an URTI, no treatment apart from clearing the snuffly nose is required. All cases can be helped by inhalations of steam with menthol (or similar) added to the water.

Auto-sufflation (auto-inflation) can be used with good effect. This involves Valsalva manoeuvres in which you breathe out slowly with your mouth closed several times and then, while pinching your nose, blow out hard against the back of your hand. This may unblock mucus in the tube.⁴

Proprietary devices

These include the balloon-based device Otovent^® (see also ‘Snoring’ in this chapter) and an air-pump device such as Ear Popper™.

Otovent^® consists of a balloon attached to a nosepiece. The child with a glue ear holds the nosepiece to the nostril and inflates the balloon to the size of a grapefruit while keeping the other nostril compressed with a finger and the mouth firmly closed. It acts as a Valsalva manoeuvre to open up the Eustachian tube. The balloon is then allowed to deflate while the child swallows. It is performed 2 to 3 times a day for 2 to 3 weeks.³

Decongestants: these agents such as pseudoephedrine and phenylephrine taken by mouth or as a spray or drops (5 to 7 days) can be effective.

Antihistamines: these taken orally or used as a nasal spray are effective for allergic causes such as hay fever.

Corticosteroids: nasal steroids are commonly used particularly if there is an allergic basis to the problem. Steroids taken orally for short periods, especially if the symptoms are severe with considerable congestion and swelling, can be effective.

An auriscope with the widest possible attachment will allow an excellent view of the nasal cavity. The patient should mouth breathe during the inspection.

For patients complaining of loss of the sense of smell following an upper respiratory infection, prescribe a nasal decongestant such as Spray-Tish^® Menthol for 5 to 7 days (maximum).

For an irritated persistent ticklish throat instruct the patient to make a trilling musical sound like an opera singer for 2 to 3 minutes.

Theory⁵

This condition is considered to be caused by displacement of floating crystalline calcium carbonate deposits (otoconia) in the posterior semicircular canal. This creates the illusion of motion. The Brandt–Daroff exercises can be performed by the patient at home. The particle repositioning manoeuvres of Semont and Epley can be performed as office procedures by the therapist.

The Epley manoeuvre⁶

This exercise should be tried first. The basic manoeuvres are (Fig. 13.14):

• move the patient’s head into four different positions

• hold the head in each postural position for 1 minute

• after doing this sit still for 10 minutes to allow the crystals to settle.

Method (right-sided ear problem shown)

1. The patient sits on the bed with the head slightly extended and turned 45° in the direction that precipitated the vertigo (Fig. 13.14a).

2. Lie the patient on their back with the head hanging over a pillow placed at the shoulder level (this is the basic Hallpike test). Wait 1 minute (Fig. 13.14b).

3. Once the provoked vertigo and nystagmus settles, from this position turn the head through 90° to the opposite side and wait 1 minute (Fig. 13.14c).

4. Turn the head through a further 90° and roll onto that side so that the ear is parallel to the floor. Wait another minute (Fig. 13.14d).

5. Slowly sit the patient upright and still for 10 minutes (Fig. 13.14e).

Follow up: Get the patient to sleep in a semi-upright position. Repeat until the attacks abate.

The Semont manoeuvre (Fig. 13.15)

1. Sit the patient upright in the middle and on the edge of the bed or couch. Turn the head 45° to the side opposite to that which precipitated the vertigo (the unaffected ear).

2. While maintaining the head position, tip the patient to the affected side so that they are lying on the affected side (with nose up) and wait 1 minute.

3. Move the patient quickly 180° through the upright position (maintaining the original head position) and lower to the other side (nose now pointing down). Wait 1 minute.

4. Slowly return the patient to the upright position and then rotate the head to the normal position. Sit still in this position for 10 minutes.