What to do and What not to do in ENT
In spite of undergoing some training in ENT during the undergraduate days it is quite common to find some doctors not knowing the best course of action that needs to be taken in certain circumstances.
A Suspected Traumatic Perforation of the Ear Drum
It is far too easy to perforate an ear drum than one thinks. A few examples are given below.
1. a slap or blow which covers the ear - the "assailant" may even be an infant!
2. head hitting any solid object occluding the ear canal
3. trauma by cotton buds, sticks or any material introduced to the ear
4. blowing or sucking on the ear
5. lightening strikes
6. head trauma as in accidents
In all these instances a perforation must be suspected. This is collaborated by other evidence such as bleeding, deafness, fullness in the ear, vertigo, tinnitus etc.
Inspection of the ear drum will confirm the diagnosis, but this may not be possible due to various reasons. E.g.: blood in the ear, uncooperative child, more serious injuries etc.
What to Do
1. Explain to the patient or parent the presence / possibility of a perforation
2. Start on antibiotic cover if contamination is suspected
3. Keep ear dry
4. Do ear cleaning if indicated with or without anaesthesia
5. Check hearing levels clinically and also by audiometry if possible
6. Keep good records with diagrams - may be important medico-legally
7. Follow up closely to check on healing and hearing levels
What not to do
1. Do not put any medications into the ear
2. Do not syringe ear to remove debris
3. Do not give prognostic predictions too early to the patient
A foreign body in the nose
Usually a foreign body (FB) in the nose in not an emergency except in a few circumstances such as;
1. a toxic FB e.g. button-battery, corrosive material
2. the FB is causing bleeding or serious obstruction
3. possibility of swallowing a harmful FB; e.g. poisonous seed
What to do
1. Find out what the foreign body is
2. Examine the nose and confirm the FB
3. Decide on when to remove the FB
4. Remove with least discomfort and safety to the patient; e.g. under GA
5. Reassure parents
What not to do
1. Do not assume a FB is not present; follow-up if in doubt
2. Do not delay if it needs immediate removal
3. Do not physically or mentally hurt the patient (child) trying to remove the FB
4. Do not attempt to remove unless proper lighting and instruments are available.
A fish bone stuck in the throat
A fish bone stuck in the throat is usually a very painful situation and clinically it is easy to diagnose. However sometimes the symptoms maybe vague.
What to do
1. If in doubt always do an X ray; most bones are seen on a neck lateral view
2. If x ray is normal let the clinical situation be the deciding factor in the final diagnosis
3. Examine the mouth, palate and pharynx carefully for small bones; especially the tonsils
4. Examination under anaesthesia with endoscopy should be done once diagnosed
What not to do
1. Do not ignore the patients symptoms; after all he is the one who feels it
2. Do not give antibiotics for the sake of doing something
3. Do not send the patient away unless you are convinced about the absence of a bone
A foreign body in the ear
A foreign body in the ear is often not a dangerous situation unless it is mismanaged.
If the FB is superficial it can be removed with appropriate instruments or syringing.
If it is deep and stuck anaesthesia is needed with magnification
What to do
1. Identify the FB - this is important to decide what course of action to take
2. Decide whether it is possible to remove it immediately
3. If not does it need intervention immediately - a live insect will cause discomfort and further damage to the ear43. A live insect causing discomfort should be killed with clean water or edible oil
4. The ear drum should be inspected for damage and appropriate treatment given
5. Advice the patient and/or parents how to avoid this happening
6. Always get specialist advice if in doubt
What not to do
1. If you do not have proper instruments do not try to take the FB out
2. If you are not confident to remove it do not attempt
3. Do not syringe an insect, large piece of vegetable matter or if a perforation is suspected
4. Do not hurt a child in attempting to remove a FB without anaesthesia.
5. Do not delay in getting expert opinion if needed.
Acute Otitis Media
Acute otitis media should be treated with care until completely resolved.
What to do
1. AOM should be diagnosed by seeing the ear drum.
2. Antibiotics can be withheld if
the patient can be monitored on a daily basis with the parents full
understanding of when to start
antibiotics.
3. If antibiotics are given, give full dosage for at least one week.
4. Check hearing levels after treatment
5. Get an ENT during / after the episode.
What not to do
1. Do not diagnose AOM and treat unless the eardrum is clearly seen
2. Do not give suboptimal antibiotic courses
3. Do not diagnose a normal ear without a tympanometry test.
Unilateral Deafness
Unilateral deafness is highly significant as it could be due to a neoplasm such as an acoustic neuroma, or autoimmune causes which can come suddenly: the latter needs urgent intervention
What to do
1. Take unilateral deafness seriously whether acute or chronic
2. If an obvious cause such as wax impaction is seen tackle it.
3. If you cannot find the
definite cause for the deafness refer to ENT surgeon immediately in acute cases
and electively in gradual
onset cases.
4. If ENT opinion is unavailable urgently start on prednisolone 60 mg daily in adult in sudden onset deafness.
What not to do
1. Do not reassure the patient and send him home
2. Do not give treatment unless you know the cause