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Conflict of interest
• None
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The patient with a discharging ear
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Differential Diagnoses
• Otitis Externa
• Otitis Media
– Acute
– Chronic
• Cholesteatoma
• Skull base lesion
– Glomus, CSF
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History
• Otorrhoea
• Otalgia
• Deafness
• Tinnitus
• Vertigo
• Time-line
• Provocation
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Otorrhoea & Otalgia
• Watery, mucoid, purulent, bloody, itchy
• Dull, deep, systemic upset-fever, radiation, chewing/TMJ, relieved by discharge, worse with tragal pressure or pinna movement
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Deafness &Tinnitus & Vertigo
• Onset of hearing loss
– Expect a conductive HL with discharge
• Accompanied by tinnitus
– Pulsatile?
• Dysequilibrium or vertigo
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Otoscopy : otitis externa
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Management
• Topical antibiotic/steroid drops – Swab
• Microsuction
• Pope wick
• When to refer: – Pain management, spreading cellulitis, necrotising OE,
exostoses surgery
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Otoscopy: otitis media
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Management • Acute OM:
– Role of oral antibiotics: amoxycillin – 6x AOM in 6-12 months: consider grommet insertion – With perforation: microscution & topical drops – Ciloxan
(HC) - ? refer for myringoplasty – Removal of grommet
• Chronic OM: – Perforation, Retraction, Cholesteatoma – Refer for specialist management
• Skull base lesions: refer to specialist for Ix • Formal audiometry helpful
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Red Flags: discharge with…
• Chronic pain in elderly diabetic immuno-compromised patient
= Necrotising Otitis Externa
• Any cranial nerve palsy/palsies
= Skull base lesion
• Pinna displacement/erythema and unwell child
= Mastoiditis or intracranial complication
• Polyp in deep ear canal
= Cholesteatoma
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The snoring child
• Loudness of snoring not necessarily correlates with severity of problem
• Frequency better indicator
• Video recording best
• Parental reporting not always accurate
– OSA during REM ( early hours of morning)
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History – young child / infant
• Snuffly ?
• Airway issues when feeding / crying ?
• Positional ?
• Cranio-facial abnormality ?
• Frequent URTI’s ?
• With rec AOM / OME hearing loss?
• Less likely to be simple adenotonsil hypertrophy….
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History – older child
• Snoring
• Noisy Breathing
• Restless sleep
• Mouth breathing
• Frequent URTI
• Ear infections
• Hearing and speech problems
• Morning headaches
• Daytime fatigue • Excessive daytime
sleepiness • Abnormal/ difficult
behaviour • Impaired school
performance • Attention problems • Developmental delay • Impaired growth • Enuresis
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• Cognitive • Behavoural • Social
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OSA
• 2-4% population
• Impacted by obesity levels
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Examination
• Facial morphology
• Bite
• Tonsils
• Adenoids
• Allergy
• Nasal airway – Rhinitis
• BMI
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Tonsil hypertrophy – grade 4
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Adenoidal hypertrophy
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Polysomnography: sleep study
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Adenotonsillectomy
• Usually Day procedure
– 2 weeks off school
• 3-5% chance of post op bleed
• Suction-diathermy adenoidectomy
• Treat any rhinitis: nasal steroid
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