Other problems in the ear, nose, and throat

Here are some other ENT problems which you might meet; most of them are rare. Respiratory obstruction will cause you much anxiety. Dysphagia and hoarseness come second. Some laryngeal emergencies are part of a general illness.

OTHER ENT PROBLEMS For carcinoma of the maxillary antrum, see Section 32.39.

THE EAR If a patient develops SLOWLY PROGRESSIVE DEAFNESS IN ONE EAR, becomes unsteady on his feet, and has rare attacks of severe vertigo, suspect an ACOUSTIC NEUROMA (rare). Look for a loss of corneal sensation, slight facial paralysis, and an increased protein in his CSF. Refer him.

THE NOSE [s7]AND PARANASAL SINUSES If a patient has a SWELLING ON HIS NASAL SEPTUM it may be a HAEMATOMA or an ABSCESS. The same incision is suitable for both. Move the tip of his nose from side to side; you will see that swelling is continuous with the columella on both sides, and is fluctuant. Soak a length of 1 cm ribbon gauze in 4% lignocaine, mixed with a few drops of adrenalin, and place it over the red mucosal part of his septum. Wait a few minutes, and then make a vertical incision over the swelling. Remove a small piece of mucosa to enlarge the hole, and insert a drain. Or try aspirating it.

THE LARYNX[md]STRIDOR Here are some causes of stridor with the most important causes first. The later ones are all rare. Stridor is always worse on inspiration, unless otherwise stated. Remember also retropharyngeal (5.7) and peritonsillar abscesses (5.6).

If a patient of any age has the RAPID ONSET OF HOARSENESS AND STRIDOR, worse on inspiration, suspect ACUTE LARYNGITIS (not uncommon). Steam and antibiotics will usually cure him. Tracheostomy may occasionally be necessary, but avoid it if possible, especially in a young child. If there is a membrane in his throat, he is likely to have a streptococcal infection (common), or DIPHTHERIA (uncommon).

If a child, particularly, has PROGRESSIVE DYSPHAGIA, continual drooling from his mouth, STRIDOR, COUGH, a red swollen epiglottis, and is ill and febrile, suspect ACUTE EPIGLOTTITIS (not uncommon), which is much more serious than acute laryngitis. If he is old enough to speak, he may have the characteristic ''hot potato' speech, which is different from the hoarseness of laryngitis. Give him chloramphenicol or ampicillin intravenously. Be prepared to intubate him, followed if necessary by tracheostomy. If he is not rapidly and correctly treated, his chances of death are considerable.

If a patient of any age has SLOW PROGRESSIVE HOARSENESS, leading to STRIDOR which is worse on expiration, suspect a papilloma of his larynx, or a carcinoma in older smokers (both not uncommon, 32.39). Tracheostomy and endoscopic removal may be necessary. Biopsy an adult's lesion, and look for malignant change. Recurrence is more common in children, and deaths have occurred.

If a patient of any age has SUDDEN STRIDOR, particularly on inspiration, AFTER INGESTING FOOD, suspect a foreign body (not uncommon). Remove it (25.12).

If a child (usually) has HOARSENESS and variable progressive STRIDOR of RAPID ONSET AFTER FEVER, with severe dysphagia and a bleeding mouth and nose (rare), suspect GANGRENOUS PHARYNGITIS. Give him antibiotics and oxygen. Feed him through a small nasogastric tube, and aspirate his pharynx periodically to remove blood and slough. Mortality is high.

If a baby has STRIDOR SOON AFTER BIRTH, worse on any exertion or crying, but he looks well and his cry is normal, suspect LARYNGOMALACIA (rare). Endoscopy shows a markedly folded epiglottis, with its aryepiglottic folds sucked in towards the larynx during inspiration to cause stridor. Reassure his parents that he will probably recover spontaneously between 3 and 5 years.

If an INFANT OR YOUNG CHILD has sudden, spasmodic STRIDOR, usually at night, which ends spontaneously with another deep inspiratory effort and collapse, suspect LARYNGISMUS AND TETANY (rare). He is normal between attacks. Give him parathyroid hormone and calcium between attacks, and his prognosis will be good.

If a child has had STRIDOR and DYSPNOEA ON EXERTION SINCE BIRTH, perhaps with hoarseness which is progressive with his growth, suspect a LARYNGEAL WEB (rare). Symptoms depend on the degree of stenosis. Tracheostomy may be necessary. Expert surgery can give good results.

If a patient of any age has SUDDEN STRIDOR, worse on expiration, following food, medicine or a sting, suspect ANGIONEUROTIC OEDEMA (rare). Give him an antihistamine or intravenous hydrocortisone. Tracheostomy may be necessary. His prognosis with treatment is good.

If a patient of any age has SUDDEN SEVERE STRIDOR, usually without much hoarseness (rare), suspect LARYNGEAL PARALYSIS due to infection, trauma, poliomyelitis, or nutritional deficiencies. Give him vitamin B complex. Occasionally, a permanent tracheostomy is necessary.

THE OESOPHAGUS If, after a heavy meal, a patient, who is usually between 20 and 40, VOMITS, AND HAS AN INTENSE PAIN IN HIS LEFT (rarely his right) CHEST radiating to his neck, suspect that he has RUPTURED HIS OESOPHAGUS during the act of vomiting. Feel and listen with a stethoscope for surgical emphysema (a fine crackling) in his neck or chest. He is intensely thirsty, but sips of water make the pain worse. If one lung is hyperresonant with no breath sounds, his pleura has perforated, and he has a hydropneumothorax. One differential diagnosis is a perforated peptic ulcer, but here the pain comes before the vomiting. When he ruptures his oesophagus the pain comes as he vomits. Other differential diagnoses include a spontaneous pneumothorax, acute pancreatitis, and coronary thrombosis. Take a chest X-ray; it may show a pneumothorax, perhaps with a fluid level; if so aspirate this. Confirm a rupture by asking him to swallow 10 or 20 ml of ''Gastrographin', avoid barium. This may show a leak. Many of these patients are mistakenly operated on for a perforated peptic ulcer.

CAUTION ! (1) His upper abdomen is usually rigid. (2) Early, he has no clinical or X-ray signs in his chest; these come later when treatment may be too late.

Before you refer him, resuscitate him and pass a nasogastric tube (check radiologically that it is not in his mediastinum). Insert a chest drain with an underwater seal (65.2).

If you cannot refer him, a feeding gastrostomy (11.8) will keep him alive, and a wide bore intercostal tube will evacuate his pleura, and hopefully allow it to seal on to his oesophageal tear.

If you ever find a DISTAL TEAR in the oesophagus, consider mobilizing the stomach, suturing it over the tear as a diamond-shaped patch, and then wrapping the stomach round the oesophagus and suturing them as in Fig. 25-12.

Fig. 25-12. A DISTAL TEAR IN THE OESOPHAGUS is being patched with the stomach, which is wrapped round it. After ''Hamilton Bailey's Emergency Surgery'', edited by HAF Dudley, Fig. 22.4. John Wright, with kind permission. 26 Dental and oral surgery