Definition: When symptoms of sinusitis persist for more than 3 months (> 12 weeks) chronic state develops. Most important cause of chronic sinusitis is failure of acute infection to resolve

Clinical features are often vague and similar to those of acute sinusitis but of lesser severity.

Anosmia: Loss of smell

Blockage/obstruction of Nasal

Congestion/Cough

Discharge: Purulent discolored nasal discharge

Ear pressure/Ear fullness

Facial pain, Fever

Generalized malaise/Fatigue

Headache/Halitosis

Investigation:

> X-Ray PNS: The involved sinus may show mucosal thickening or opacity.

> X-rays after injection of contrast material may show soft tissue changes in the sinus mucosa.

> CT scan PNS: Particularly useful in ethmoid and sphenoid sinus infections and has replaced studies with contrast materials.

> Aspiration and irrigation: Finding of pus in the sinus is confirmatory

It is essential to search for underlying aetiological factors which obstruct sinus drainage and ventilation.

A work-up for nasal allergy may be required.

Culture and sensitivity of sinus discharge helps in the proper selection of an antibiotic.

Initial treatment of chronic sinusitis is conservative, including antibiotics, decongestants, antihistamines and sinus irrigations.

Surgical: Indication: If medical treatment given for a period of 3-4 weeks fails.

1. Tab. Fexofenadine 60 mg, 120mg, 180mg (Fexet, Telfast) 0-0-1(OD)

Or Tab. Loratidine 10mg (Softin, Loril, Lorin-NSA)

0-0-1(OD), 1-0-1(BD)

2. Tab. Co-Amoxiclav 375mg, 625mg, 1g (Augmentin)

1-1-1 (TDS), 1-0-1 (BD)

Or Cap. Cefixime 400mg (Cefspan, Cefim)

Or Tab. Moxifloxacin 400mg (Moxiget, Avelox, Maxlox)

0-0-1(OD) 250mg (Ponstan, Mefnac)

3. Tab. Mefenamic Acid 500mg (Ponstan forte, Mefnac DS)

Or Tab. Paracetamol 500mg (Panadol, Calpol, Febrol) 1-1-1 (TDS)

Or Tab. Aceclofenac 100mg (Acenac, Acelo)

Or Tab. Flurbiprofen 50mg, 100mg (Tab Froben) 1-0-1(BD)

4. Steam inhalation - Vicks balm (Vaporization) at night

SURGERIES FOR CHRONIC SINUSITIS

For Chronic Maxillary Sinusitis:

1. Antral lavage: Done by performing antral puncture in inferior meatus with the help of Tilley Lichtwitz trocar and cannula.

2. Intranasal Antrostomy: Done by making a window in inferior meatus to facilitate drainage through gravity.

3. Caldwell-Luc operation: Discussed later.

4. FESS: These days all sinus surgeries have been replaced by FESS-discussed later

Chronic Frontal Sinusitis:

1. Trephination of frontal sinus:

Done in acute frontal sinusitis if pain persists or exacerbates or there is fever in spite of antibiotic treatment for 48 hrs.

Also done in chronic frontal sinusitis.

A 2 cm long horizontal incision is made in the superomedial part of the eye to expose the frontal sinus.

» A hole is made and PUS is drained.

2. External frontal ethmoidectomy (Howarth's or Lynch operation): Frontal sinus is entered via inner margin of the orbit.

3. Other surgeries: Paterson operation, osteoplastic flap operation.

These surgeries are seldom done now and are replaced by FESS.

4 ACUTE RHINITIS Rx

C/C:

Etiology: It is caused by a virus.

The infection is usually contracted through airborne droplets. Several viruses (adenovirus, picornavirus and its subgroups such as rhinovirus, coxsackie virus and enteric cytopathic human orphan virus) are responsible.

Incubation period is 1-4 days and illness lasts for 2-3 weeks.

Clinical features:

> To begin with, there is a burning sensation at the back of the nose soon followed by nasal stuffiness, rhinorrhoea and sneezing.

> Patient feels chilly and there is a low-grade fever.

> Initially, nasal discharge is watery and profuse but may become mucopurulent due to secondary bacterial invasion.

Secondary invaders include Streptococcus haemolyticus, pneumococcus, Staphylococcus, Haemophilus influenzae, Klebsiella pneumoniae and Moraxella Catarrhalis

Bed rest is essential to cut down the course of illness Plenty of fluids are encouraged

Symptoms can be easily controlled with antihistamines and nasal decongestants.

Analgesics are useful to relieve headache, fever and myalgia.

Non-aspirin containing analgesics are preferable as aspirin causes increased shedding of virus.

Antibiotics are required when secondary infection supervenes.

(Fexet, Telfast, Fexo)

1. Tab Fexofenadine 60 mg, 120mg, 180mg OR Tab Fexofenadine 60mg + Pseudoephedrine 120mg 0-0-1(OD) (Fexet-D, Telfast-D, Fexo-D)

250mg (Ponstan, Mefnac)

2. Tab. Mefenamic Acid 500mg (Ponstan forte, Mefnac DS) OR Tab Paracetamol 500mg (Panadol, Calpol, Febrol)

1-1-1 (TDS)

3. Sodium chloride 0.9% nasal spray (Normal saline, Norsaline-P) Intranasal sprays - 3 nostril 2-3 times a day

4. Tab. Co-Amoxiclav 375mg, 625mg, 1g (Augmentin, Amoxiclave) Or Cap. Cephalexin 250mg, 500mg (Ceporex, Keflex) Or Cap. Cefadroxil 250mg, 500mg (Cedrox, Duricef)

1-1-1 (TDS), 1-0-1 (BD)

1. Tab. Cetirizine 10mg (T-day, Zyrtec, Rigix) Or Tab. Loratidine 10mg (Softin, Loril, Lorin-NSA) 0-0-1(OD), 1-0-1 (BD)

2. Tab. Aceclofenac 100mg (Acenac, Acelo) Or Tab. Flurbiprofen 50mg, 100mg (Froben, Ansaid)

1-0-1 (BD)

(Azomax, Zetro, Azitma)

3. Cap. Azithromycin 250 mg, Tab. Azithromycin 500mg 1-0-1(BD), 0-0-1(OD)

Or Tab. Clarithromycin 250mg, 500mg (Claritek, Klaricid) 1-1-1(TDS), 1-0-1(BD)

4. Rhinosone nasal spray OR Xynosine nasal spray (Intranasal sprays) 2-3 nostril 2-3 times a day Note: Nasal decongestants- They should not be given for longer period else patient may develop Rhinitis medicamentosa

5 CHRONIC SIMPLE RHINITIS Rx

C/C:

>>> Nasal obstruction: Usually worse on lying and affects the dependent side of nose.

>>>> Nasal discharge: It may be mucoid or mucopurulent, thick and viscid and often trickles into the throat as postnasal drip.

>>> Patient has a constant desire to blow the nose or clear the throat.

>>> Headache: It is due to swollen turbinates impinging on the nasal septum.

>>> Swollen turbinates: Nasal mucosa is dull red in color. Turbinates are swollen; they pit on pressure and shrink with application of vasoconstrictor drops (this differentiates the condition from hypertrophic rhinitis). Middle turbinate may also be swollen and impinge on the septum.

>>> Postnasal discharge: Mucoid or mucopurulent

discharge is seen on the posterior pharyngeal wall.

1. Treat the cause with particular attention to sinuses, tonsils, adenoids, allergy, personal habits (smoking or alcohol indulgence), environment or work situation (smoky or dusty surroundings).

2. Nasal irrigations with alkaline solution help to keep the nose free from viscid secretions and also remove superficial infection.

3. Nasal decongestants help to relieve nasal obstruction and improve sinus ventilation. Excessive use of nasal drops and sprays should be avoided because it may lead to rhinitis medicamentosa. A short course of systemic steroids helps to wean the patients already addicted to excessive use of decongestant drops or sprays.

4. Antibiotics help to clear nasal infection and concomitant sinusitis.

5. Symptomatic Rx are same as Acute Rhinitis

6 HYPERTROPHIC RHINITIS (CHRONIC) Rx

It is characterized by thickening of mucosa, submucosa, Seromucinous glands, periosteum and bone. Changes are more marked on the turbinates.

C/C:

ETIOLOGY

Common causes are recurrent nasal infections, chronic sinusitis, chronic irritation of nasal mucosa due to smoking, industrial irritants, prolonged use of nasal drops and vasomotor and allergic rhinitis.

SYMPTOMS

Nasal obstruction is the predominant symptom. Nasal discharge is thick and sticky. Some complain of headache, heaviness of head or transient anosmia.

SIGNS

Examination shows hypertrophy of turbinates. Turbinal mucosa is thick and does not pit on pressure. It shows little shrinkage with vasoconstrictor drugs due to presence of underlying fibrosis. Maximum changes are seen in the inferior turbinate. It may be hypertrophied in its entirety or only at the anterior end, posterior end or along the inferior border giving it a mulberry appearance.

Attempts should be made to discover the cause and remove it.

Nasal obstruction can be relieved by reduction in size of turbinates.

The various methods are:

1. Linear cauterization.

2. Submucosal diathermy.

3. Cryosurgery of turbinates.

4. Partial or total turbinectomy. Hypertrophied

inferior turbinate can be partially removed at

its anterior end, inferior border or posterior

end. Middle turbinate, if hypertrophied, can

also be removed partially or totally. Excessive

removal of turbinates should be avoided as it

leads to persistent crusting.

5. Submucous resection of turbinate bone. This removes bony obstruction but preserves turbinal mucosa for its function.

6. Lasers have also been used to reduce the size of turbinates.

7 ALLERGIC RHINITIS Rx

C/C:

Recurrent episodes of:

Sneezing

Nasal congestion

Rhinorrhea

Post-nasal drip

* Itchy nose and throat

Pale, boggy nasal mucosa with hypertrophic turbinates, and/or nasal polyps may be seen in long-standing cases of allergic rhinitis.

* Cobblestone appearance of the posterior pharyngeal wall

* Associated allergic conditions Allergic conjunctivitis

Atopic dermatitis and/or bronchial asthma

* Long-standing allergic rhinitis can predispose the patient to recurrent sinusitis and/or otitis media.

* Excessive use of nasal drops and sprays should be avoided because it may lead to rhinitis medicamentosa

1. Avoid exposure to the putative allergen (e.g., Allergen, dust)

2. Tab Cetirizine 10mg (T-day, Zyrtec, Rigix) Or Tab Loratidine 10mg (Softin, Loril, Lorin-NSA) 0-0-1(OD), 1-0-1 (BD)

250mg (Ponstan, Mefnac)

3. Tab. Mefenamic Acid 500mg (Ponstan forte, Mefnac DS) Or Tab Paracetamol 500mg (Panadol, Calpol, Febrol) 1-1-1(TDS)

4. Rhinosone nasal spray OR Xynosine nasal spray (Intranasal sprays) 2-3 nostril 2-3 times a day

2nd ALTERNATIVE Rx

1. Avoid exposure to the putative allergen (e.g., allergen, dust)

(Fexet, Telfast, Fexo)

2. Tab Fexofenadine 60 mg, 120mg, 180mg Or Tab Fexofenadine 60mg + Pseudoephedrine 120mg 0-0-1(OD) (Fexet-D, Telfast-D, Fexo-D)

3. Tab Aceclofenac 100mg (Acenac, Acelo) Or Tab Flurbiprofen 50mg, 100mg (Froben, Ansaid) 1+0+1(BD)

4. Rhinosone nasal spray Or Xynosine nasal spray (Intranasal sprays) 2-3 nostril 2-3 times a day

If Severe Or Hx of allergy, asthma then add 5. Fluticasone propionate 0.05% (Flixonase, Flexosone) (Intranasal sprays) 3 nostril 2/3 times a day

ALTERNATIVE DRUGS

ANTIALLERGIC DRUGS

Fexofenadine + Pseudoephedrine (FEXET-D, TELFAST-D)

Fexofenadine 60, 120, 180mg (FEXET, TELFAST)

Loratadine 10mg (LORIN NSA, SOFTIN)

Desloratadine 5mg (DESLORA)

Cetirizin: Tab Rigix 3mg

ANALGESIC/ANTIPYRETIC

Aceclofenac: Tab Acenac 100mg

Diclofenac potassium: Tab Caflam 50mg

Flurbiprofen: Froben 50mg, 100mg, Cap Froben 200mg (SR)

Mefenamic acid (ponstan/ponstan forte)

Nimesulide: Tab Nims 100mg

Nasal spray

1. Fluticasone propionate 0.05%: (Flixonase/Flexosone)

2. Fluticasone Furoate 27.5 Mcg: Avamys Nasal Spray

3. Ephedrine 5 mg/ml + Fluprednisolone 0.025mg/ml + Naphazoline 1.25mg/ml: Rhinosone nasal spray

4. Xylometazoline HCL 0.1%: Xynosine / Xolisan nasal spray

5. Azelastine Hydrochloride 0.1%: Azosin

6. Flunisolide 0.025%: Tarisin nasal spray

7. Mometasone Furoate 50 mcg: Hivate

8. Sodium Cromoglycate 4%: Oxycrom-P

9. Na Cromoglycate 2% + Xylometazoline HCI 0.025%: Oxycrom

8 DEVIATED NASAL SEPTUM (DNS) Rx

C/C:

* Difficulty breathing (typically in only one nostril)

Nasal congestion/obstruction

Snoring or noisy breathing during sleep

Headaches or facial pain

* Sinusitis: Deviated septum may obstruct sinus ostia resulting in poor ventilation of the sinuses.

* Epistaxis (nosebleeds)

Anosmia: Failure of the inspired air to reach the olfactory region may result in total or partial loss of sense of smell.

* External deformity

Middle ear infection: DNS also predisposes to middle ear infection.

Diagnostics

Anterior rhinoscopy: A nasal speculum and external light source are used to visualize the septum.

CT scan: for more detailed evaluation of the nasal septum (and adjacent structures)

TYPES OF DNS

Deviation may involve only the cartilage, bone or both the cartilage and bone.

1. Anterior dislocation: Septal cartilage may be dislocated into one of the nasal chambers. This is better appreciated by looking at the base of nose

when patient's head is tilted backwards

2. C-shaped deformity: Septum is deviated in a simple curve to one side. Nasal chamber on the concave side of the nasal septum will be wider and may show compensatory hypertrophy of turbinates.

3. S-shaped deformity: Either in vertical or anteroposterior plane. Such a deformity may cause bilateral nasal obstruction.

4. Spurs: A spur is a shelf-like projection often found at the junction of bone and cartilage. A spur may press on the lateral wall and give rise to headache. It may also predispose to repeated epistaxis from the vessels stretched on its convex surface

5. Thickening: It may be due to organized haematoma or overriding of dislocated septal fragments.

No treatment is required, if it is not causing any symptoms.

Give symptomatic or correct underlying cause

Nasal congestion/Obstruction

1. Tab Cetirizine 10mg (T-day, Zyrtec, Rigix) Or Tab Loratidine 10mg (Softin, Loril, Lorin-NSA) 0-0-1(OD), 1-0-1(BD) Or Tab Fexofenadine 60 mg, 120mg, 180mg x OD

Plus/minus add

2. Rhinosone nasal spray OR Xynosine nasal spray (Intranasal sprays) 2-3 nostril 2-3 times a day

Headache/Facial pain

3. Tab Aceclofenac 100mg (Acenac, Acelo) Or Tab Flurbiprofen 50mg, 100mg (Froben, Ansaid) 1+0+1 (BD)

Sinus infection/ear infection

4. Cap Amoxicillin 250mg, 500mg (Zeemox, Amoxil) Or Tab Co-Amoxiclave 375, 625, 1g (Augmentin) Or Cap Cefadroxil 250mg, 500mg (Duricef, Cedrox) 1-1-1 (TDS), 1-0-1 (BD)

Surgical management is the treatment of choice.

SEPTOPLASTY:

Conservative surgery as most of the septal framework is retained. Only the most deviated parts are removed. Rest of the septal framework is corrected and re-posited by plastic means. It is the preferred operation

SUBMUCOUS RESECTION (SMR) OPERATION

Here apart from a thin dorsal and caudal strip, the rest of the entire septum is removed.

It is generally done in adults under local anesthesia.

It consists of elevating the mucoperichondrial and mucoperiosteal flaps on either side of the septal framework by a single incision made on one side of the septum, removing the deflected parts of the bony and cartilaginous septum, and then repositioning the flaps.

Note: Septal surgery is usually done after the age of 17 so as not to interfere with the growth of the nasal skeleton. Only if a child has severe septal deviation causing marked nasal obstruction, septoplasty should be done.

9 SEPTAL HAEMATOMA Rx

It is a collection of blood under the perichondrium or periosteum of the nasal septum It often results from nasal trauma or septal surgery. In bleeding disorders, it may occur spontaneously.

C/C:

Bilateral nasal obstruction is the commonest presenting symptom.

This may be associated with frontal headache and a sense of pressure over the nasal bridge.

Examination reveals smooth rounded swelling of the septum in both the nasal fossae.

Palpation may show the mass to be soft and fluctuant.

Duration: 5 days

COMPLICATIONS

Septal haematoma, if not drained, may organize into fibrous tissue leading to a permanently thickened septum. If secondary infection supervenes, it results in septal abscess with necrosis of cartilage and depression of nasal dorsum.

Small haematomas can be aspirated with a wide bore sterile needle.

Larger haematomas are incised and drained by a small anteroposterior incision parallel to the nasal floor.

Excision of a small piece of mucosa from the edge of the incision gives better drainage.

Following drainage, the nose is packed on both sides to prevent re-accumulation.

Systemic antibiotics should be given to prevent septal abscess.

1. Tab. Co-Amoxiclav 375, 625, 1g (Augmentin, Amclav) 1-1-1 (TDS), 1-0-1 (BD)

Or Cap. Cefixime 400mg (Cefspan, Cefim)

0-0-1(OD)

250mg (Ponstan, Mefnac) 2. Tab. Mefenamic acid 500mg (Ponstan forte, Mefnac DS) 1-1-1(TDS)

10 SEPTAL ABSCESS Rx

Septal abscess mostly, it results from secondary infection of septal haematoma. Occasionally, it follows the furuncle of the nose or upper lip. It may also follow acute infection such as typhoid or measles

C/C:

30 Severe B/L nasal obstruction with pain and tenderness over the bridge of the nose.

Patients may also complain of fever with chills and frontal headache. Skin over the nose may be red and swollen.

> Internal examination of nose reveals smooth bilateral swelling of the nasal septum, Fluctuation can be elicited in this swelling.

Septal mucosa is often congested. Submandibular lymph nodes may also be enlarged and tender.

Abscess should be drained as early as possible. Incision is made in the most dependent part of the abscess and a piece of septal mucosa excised.

Pus and necrosed pieces of cartilage are removed by suction. Incision may require to be reopened daily for 2-3 days to drain any pus or to remove any necrosed pieces of cartilage.

Systemic antibiotics are started as soon as diagnosis has been made and continued at least for a period of 10 days.

11 ADULT/CHILDERN WITH EAR DISCHARGE/INFECTION Rx

C/C:

Ear Pain

Ear Discharge

Fever

Headache

Duration: 5 days

1. Cap. Amoxicillin 250mg, 500mg (Zeemox, Amoxii) Or Tab. Co-Amoxiclav 375, 625, 1g (Augmentin, Amclave) 1-1-1(TDS), 1-0-1(BD)

250mg (Ponstan, Mefnac)

2. Tab. Mefenamic acid 500mg (Ponstan fort, Mefnac DS) Or Tab. Paracetamol 500mg (Calpol, Panadol) 1-1-1(TDS)

3. Polymyxin + Lidocaine Ear Drop (Otocain, Lidosporin) Or Polymyxin + Neomycin + Hydrocortisone Ear drop (Otosporin)

2-3-drops 3-4 time a day

2nd Alternative Rx

1. Cap. Cefadroxil 250mg, 500mg (Duricef, Cedrox) Or Cap. Cephalexin 250mg, 500mg (Ceporex, Keflex) 1-1-1(TDS), 1-0-1 (BD)

2. Tab. Flurbiprofen 50mg, 100mg (Froben) Or Tab. Aceclofenac 100mg (Acenac)

1-0-1 (BD)

3. Ciprofloxacin + Lidocaine Ear drops (Cipocain, Zeprocaine) Or Ciprofloxacin + Dexamethasone Ear drops (Cipotic-D, Dexcip)

3rd Alternative Rx

1. Cap. Cefixime 400mg (Cefiget, Cefim) Or Tab. Moxifloxacin 400mg (Moxiget, Avelox) 0-0-1(OD)

2. Tab. Diclofenac sodium 50mg, 100mg (Voren, Voltral) Or Tab. Naproxen sodium 250mg, 500mg (Neoprox/Flexin) 1-0-1(BD)

3. Tobramycin + Dexamethasone Ear drops (Dexatob 0.3%, Dexatob 0.6%)

Rx for childern

1. Syp Augmentin/Syp Augmentin DS OR

Syp Cefadroxil 125mg/250mg (Duricef)

1-2 teaspoon BD/TDS

2. Syp Brufen / Brufen DS OR

Syp Dollor / Dollar DS

1-2 teaspoon BD/TDS

3. Cipocain OR Otocain Ear drop 2-3-drops 3-4 time a day

12 ACUTE SUPPURATIVE OTITIS MEDIA (ASOM)Rx

ASOM is an acute inflammation of the middle ear cleft < 3 weeks, infective in origin.

Organism

Bacterial: Streptococcus pneumoniae (Most common), H. influenzae (2nd most common), Moraxella catarrhalis Viral: Syncytial virus, Influenza virus, Rhino and adenovirus

One of the most common infectious disease seen in children

Peak incidence - first 2 years of life

Stages of ASOM

1. Stage of tubal occlusion

2. Stage of pre-suppuration

3. Stage of suppuration

4. Stage of resolution

5. Stage of complication

C/C:

>>> Ear Pain: Adults most frequently report

General symptoms

Otalgia/Earache, commonly described as throbbing pain.

Hearing loss in the affected ear

Fever

Otorrhea (Ear Discharge) in the case of a ruptured tympanic membrane.

Examination findings

Otoscopy

>> Bulging tympanic membrane (TM) with loss of landmarks

>>> Opacification and loss of light reflex

>> Retracted and hypomobile TM

>> Purulent/serosanguineous discharge in the external auditory canal or visible perforation

>>> Distinct erythema of the TM

>>> Additional findings that may be present:

Yellow spot on the TM

Cartwheel TM

Blisters/bullae on the TM

Tuning fork test

The Weber test and Rinne test can be performed to verify conductive hearing loss secondary to an effusion.

Weber test: Sound localizes to the affected ear.

Rinne test: Air conduction is impaired in the affected ear, while bone conduction remains intact.

CBC: Leukocytosis maybe present Gram stain and culture of middle ear fluid - if patient not responded to Rx

Blood cultures: indicated only in severe infection

1. Cap. Amoxicillin 250mg, 500mg (Zeemox, Amoxil)

Or Tab Co-Amoxiclave 375, 625, 1g (Augmentin) 1-1-1 (TDS), 1-0-1 (BD)

(Froben 50mg, 100mg, 200mg)

2. Tab. Flurbiprofen 100mg (Froben, Synalgo, Ansaid) Or Tab. Naproxen sodium 500mg (Neoprox, Flexin) 1-0-1(BD)

3. Polymyxin + Lidocaine Ear drops (Otocain) Or Ciprofloxacin + Lidocaine Ear drops (Cipocain)

2-3-drops 3-4 time a day

No sufficient evidence to support the routine use of opioids, decongestants, antihistamines, steroids

2ND ALTERNATIVE Rx

1. Cap. Cefadroxil 250mg, 500mg (Duricef, Cedrox) 1-1-1 (TDS), 1-0-1 (BD) Or Cap. Cefixime 400mg (Cefspan, Cefiget, Cefim) Or Tab. Moxifloxacin 400mg (Maxlox, Moxiget) 0-0-1(BD)

2. Tab. Diclofenac sodium 50mg, 100mg (Voren, Voltral) Or Tab. Naproxen sodium 250mg, 500mg (Neoprox, Flexin) 1-0-1(BD)

3. Tobramycin + Dexamethasone Ear drops (Dexatob) Or Ciprofloxacin + Dexamethasone Ear drops (Cipotic-D) 2-3-drops 3-4 time a day

13 CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM) Rx

CSOM is a chronic infection of the middle ear and mastoid. It is characterized by a permanent perforation in the Tympanic membrane. Generally, a perforation of TM heals by 6-12 weeks. Therefore any perforation which persists for > 12 weeks is considered as permanent and leads to CSOM.

TYPES OF CSOM

Clinically, it is divided into two types:

1. Tubotympanic: Also called the safe or benign type; it involves anteroinferior part of middle ear cleft, i.e. eustachian tube and mesotympanum and is associated with a central perforation. Most common organisms isolated are - P. aeruginosa, S.aureus and proteus species. Here perforation occurs in any part of parstensa except margins. There is no risk of serious complications. Most common in children.

2. Atticoantral: Also called unsafe or dangerous type; it involves postero-superior part of the cleft (i.e. attic, antrum and mastoid) and is associated with an attic or a marginal perforation. The disease is often associated with a bone eroding process such as cholesteatoma, granulations or osteitis. Risk of complications is high in this variety

Complications: In long standing cases of Tubotympanic variety of CSOM, necrosis of ossicles can occur due to repeated infection. The Most common ossicle to necrosis is Incus (long process)

Differences between tubotympanic and atticoantral type of CSOM

Features	Tubotympanic or safe type	Atticoantral or unsafe type
Discharge	Profuse, mucoid, odorless	Scanty, purulent, foul smelling
Perforation	Central	Attic or marginal
Granulations	Uncommon	common
Polyp	Pale	Red and fleshy
Cholesteatoma	Absent	Present
Complications	Rare	common
Audiogram	Mild to moderate conductive deafness	Conductive or mixed deafness

Tubotympanic type of CSOM

C/C:

>> Ear discharge: It is non-offensive, mucoid or mucopurulent, constant or intermittent. The discharge appears mostly at time of upper RTI or on accidental entry of water into the ear.

> Conductive type hearing loss

> Perforation: always central, it may

lie anterior, posterior or inferior to the handle of malleus. It may be small, medium or large or extending up to the annulus, i.e. subtotal

Middle ear mucosa: seen when the perforation is large

Tubotympanic type of CSOM

Medical Treatment (Treatment of Choice)

Aural toilet: It is an important step in treatment and should not be missed.

Remove all discharge and debris from the ear.

>> It can be done by dry mopping with absorbent cotton buds, suction clearance under microscope or irrigation (not forceful syringing) with sterile normal saline.

Ear must be dried after irrigation.

Topical ear drops:

Ciprofloxacin + Lidocaine Ear drops (Cipocain, Zeprocaine)

Or Ciprofloxacin + Dexamethasone Ear drops (Cipotic-D, Dexcip) Or Tobramycin + Dexamethasone Ear drops (Dexatob)

2-3-drops 3-4 times a day

Systemic antibiotics: Limited role, can be given in early, acute cases.

Tab Co-Amoxiclave 375, 625, 1g (Augmentin, Amclav) Or Cap Cefadroxil 250mg, 500mg (Duricef, Cedrox)

Or Cap Cephalexin 250mg, 500mg (Ceporex, Keflex) 1-1-1 (TDS), 1-0-1(BD)

#Precautions: Patients are instructed to keep water out of the ear during bathing, swimming and hair wash. Rubber inserts can be used. Hard nose blowing can also push the infection from nasopharynx to middle ear and should be avoided

Treatment of contributory causes: Attention should be paid to treat concomitantly infected tonsils, adenoids, maxillary antra and nasal allergy.

Surgical Treatment

Surgical treatment is done at a later stage to correct the hearing loss

Prerequisites

Ear dry for 6 weeks without antibiotics

Eustachian tube function normal

Normal middle ear mucosa

Procedure of choice:

Myringoplasty - if ossicle chain is intact

Tympanoplasty - if ossicular chain is disrupted

▲ Atticoantral type of CSOM

C/C:

Ear discharge: Usually scanty, but always foul-smelling due to bone destruction.

Hearing loss: Hearing is normal when ossicular chain is intact or when cholesteatoma, having destroyed the ossicles, bridges the gap caused by destroyed ossicles (cholesteatoma hearer). Hearing loss is mostly conductive but sensorineural element may be seen

>> Bleeding: may occur from granulations or the polyp when cleaning the ear.

>> Perforation: Either attic or posterosuperior marginal type

>> Retraction pocket: An invagination of tympanic membrane is seen in the attic or posterosuperior area of pars tensa. Degree of retraction and invagination varies. In early stages, pocket is shallow and self-cleansing but later when pocket is deep, it accumulates keratin mass and gets infected

> Cholesteatoma: Pearly-white flakes of cholesteatoma can be sucked from the retraction pockets

Atticoantral type of CSOM

Surgical: It is the mainstay of treatment.

Primary aim is removal of disease by mastoidectomy to make ear safe followed by reconstruction of hearing at a later stage.

Two types of surgical procedures are done to deal with cholesteatoma:

Canal wall down procedures.

Canal wall up procedures.

Surgery of choice: Modified Radical mastoidectomy

14 TINNITUS Rx

Tinnitus is a common condition in which sound (whistling, hissing, buzzing, ringing, and pulsating) is perceived in the absence of an external source. It can be unilateral or bilateral, acute or chronic, and intermittent or constant. Tinnitus is not a specific disease but a symptom that can be connected to a wide variety of etiologies, most commonly conditions associated with hearing loss.

Most people will experience tinnitus at some point in their lifetime.

Increases with age, More common in men and smokers

Associations: hearing loss, hyperacusis

Etiology

Tinnitus is a symptom, not a specific disease, and its presence can indicate an underlying abnormality. Objective tinnitus: tinnitus that can perceived by others, which is due to sounds created by the body (e.g., carotid artery stenosis, stapedial myoclonus)

Subjective tinnitus: tinnitus that is only perceived by the affected individual, which can be due to a wide range of etiologies (e.g., otosclerosis, tumor, infections, temporomandibular joint dysfunction)

Tinnitus

C/C:

>> Perceived sound without an external source (whistling, hissing, buzzing, ringing and pulsating)

>> Symptoms of an underlying disease may be present as well (hearing loss)

Diagnosis

History: characterize the tinnitus (e.g., unilateral vs. bilateral, symptom duration, quality) and risk factors (sound exposure, chronic illness, and recent use of ototoxic medication)

Initial exam

>>> Otoscopic examination: exclude infection, impacted cerumen

>> Head and neck auscultation to assess for bruits or hums

>>> Neurologic examination to look for focal deficits

>> Audiological examination for all patients presenting with tinnitus

>> Imaging (CT/MRI) is recommended for patients with one or more of the following: unilateral tinnitus, asymmetric tinnitus, pulsatile tinnitus, and/or focal neurological deficits

>>> Routine blood test if a treatable cause of tinnitus is suspected CBC (Anemia), TSH (hypothyroidism)

>>> Infectious workup (FTA-ABS for syphilis) and autoimmune workup (ANA, ESR, rheumatoid factor) if suspected

After symptom onset, treatment should be started as early as possible to prevent the condition from becoming chronic.

Treat any underlying conditions.

Supportive treatment: counseling, stress reduction, cognitive behavioral therapy, sound therapy etc...

Stress Reduction: This includes using biofeedback, Deep breathing exercises, Relaxation to music etc...

Cognitive behavioral Therapy: The more the patient understands what tinnitus is and is not the less negative effect. Once the patient fully cognizes - understands that tinnitus is similar to itching, the symptoms are reduced.

Masking: When the body hears the same sound from the cell phone or sound device, this reduces the symptoms. There are various forms of masking. Essentially these masking sounds take the attention away from the internal tinnitus sound and replace it with relaxing sounds.

Introduction of the same sound

Introduction of an altered sound

Music with the tinnitus sound removed

White noise or pleasant sounds

Sleep improvement: Tinnitus can affect normal sleep and therapy should be directed to better sleep hygiene.

1. Tab. Alprazolam 0.5mg (Alp, Xanax)

Tab. Diazepam 5mg (Valium) Or Tab. Clonazepam 0.5mg (Revotril, Naze) 0-0-1(HS)

2. Softgel. Cod liver oil (Seven seas, Seamega) 0-0-1(OD)

Antidepressants may be indicated for patients who do not respond to protocol therapy

3. Tab. Amitriptyline 25mg (Sensival) x HS titrated the dose if not responded. (Maximum dose: 25mg-150mg/day) Or Cap. Fluoxetine 20mg (Depex, Flux) x OD after breakfast

15 VERTIGO Rx

Definition: Vertigo is the sensation of spinning or swaying of oneself (internal vertigo) or of one's surroundings (external

vertigo) while stationary.

Vertigo are divided into:

1. Peripheral vertigo: Involve vestibular end organs and their 1st order neurons (i.e. the vestibular nerve).

The cause lies in the internal ear or the 8th nerve.

They are responsible for 85% of all cases of vertigo.

2. Central vertigo: Involve central nervous system after the entrance of vestibular nerve in the brainstem and involve vestibulo-ocular, vestibulospinal and other central nervous system pathways

DIFFERENTIATING PERIPHERAL VERTIGO FROM CENTRAL VERTIGO

Characteristics	Peripheral vertigo	Central vertigo
Etiology	Ménière's disease (endolymphatic hydrops) Benign paroxysmal positional vertigo (semicircular canal debris) Vestibular neuronitis Labyrinthitis Vestibulotoxic drugs Head trauma Perilymph fistula Syphilis Acoustic neuroma	Vertebrobasilar insufficiency Posterior inferior cerebellar artery syndrome Basilar migraine Demyelination (multiple sclerosis) Brainstem ischemia (vestibular nuclei stroke) Tumors of brainstem and fourth ventricle Epilepsy Cervical vertigo
Location of the underlying disorder	Lesions of Inner ear: vestibulocochlear nerve, semicircular canals)	Lesions of CNS (cerebellum, brainstem)
HINTS Head Impulse, Nystagmus, and Test of Skew)	Head impulse test: usually abnormal in vestibular neuritis Nystagmus >> Typically horizontal Vertical or torsional nystagmus may be seen or elicited in BPPV Direction of nystagmus does not change with gaze change Skew deviation:absent	Head impulse test: normal Nystagmus >>> May be torsional, horizontal, or vertical >> Direction of nystagmus changes with gaze change. >>> Gaze fixation does not reduce nystagmus Skew deviation: present
Associated cerebellar symptoms (e.g., ataxia, dysmetria)	Absent or mild	marked
Sense of motion	severe	mild
Associated hearing loss and/or tinnitus	Common (e.g., Ménière's disease, labyrinthitis)	rare
Associated focal neurological findings (e.g., diplopia)	rare	common

▲ Vertigo

C/C: ********

Diagnostics

>> Diagnosis is clinical

>> Dix-Hallpike maneuver

>> supine head roll test

Vestibular rehabilitation therapy (Brandt-Daroff exercise, Cawthorne-Cooksey exercise), training on maintaining balance based on visual and proprioceptive clues

Lifestyle recommendations: avoiding caffeine, salt and alcohol, avoiding triggers

Canalith repositioning procedure: Epley maneuver

1. Tab. Betahistine 8mg, 16mg or 24mg (Serc, Enier, Setspin) x 8mg to 48mg x TDS/BD Or Tab. Prochlorperazine 5mg (Stemetil) x TDS, increasing up to 30mg if not respond Or Tab. Dimenhydrinate 50mg (Gravinate) x TDS (maximum dose 400 mg/day)

2. Tab. Alprazolam 0.5mg (Alp, Xanax) Or Tab. Diazepam 5mg (Valium) Or Tab. Clonazepam 0.5mg (Revotril, Naze)

0-0-1(HS)

16 BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)Rx

Definition: Episodic vertigo triggered by certain changes in the position of the head

Prevalence

BPPV is the most common type of peripheral vestibular vertigo with a prevalence of ~ 2%.

BPPV is the underlying cause in approx. 40% of geriatric patients presenting with dizziness

Sex: female > male

Age: peak incidence between 50-60 years

Clinical features:

" Episodic vertigo (spinning sensation)

Sudden ("paroxysmal") and recurrent episodes

Lasts several seconds (typically ≤1 min)

Triggered by certain head movements (positional vertigo) after a latency of a few seconds.

Associated with: Nystagmus, Risk of falls and subsequent injury, Nausea and vomiting

Triggers: Quick rotation of the head relative to gravity is the main trigger of BPPV

Lying down, reclining, or standing up quickly

. Rolling over in bed

Bending forwards

Suddenly jerking the head to look up or down

Diagnostic approach

Dix-Hallpike maneuver

The Dix-Hallpike maneuver should be performed in all patients with suspected BPPV to identify posterior canal BPPV

If the Dix-Hallpike maneuver is negative, the supine head roll test should be performed to assess for lateral canal BPPV

Indication

First-line test for suspected BPPV

Gold standard test to diagnose suspected posterior semicircular canal BPPV

Suspected anterior semicircular canal BPPV

Characteristic findings

Positive Dix-Hallpike test: positional vertigo and nystagmus triggered during the maneuver

Direction of nystagmus

Posterior canal BPPV: upbeat nystagmus with ipsiversive torsional nystagmus component

- Anterior canal BPPV: downbeat nystagmus with ipsiversive torsional nystagmus

Procedure of Dix-Hallpike maneuver

1. Ask the patient to sit upright on the examination bed and to keep their eyes open during the procedure.

. Rotate the head by 45° towards the affected side.

2 3. Keeping the neck rotated, quickly lay the patient in a supine position with the neck slightly extended (approx.

20°) and the affected ear held down at 45°.

4. Hold this position for 20-30 seconds.

Examine the eyes for nystagmus; if present note latency, direction, and duration of nystagmus

Inquire if the patient is experiencing vertigo

Wait for resolution of nystagmus and vertigo

5. Slowly reposition the patient into an upright posture with neck in neutral position and observe for reversal of nystagmus.

6. If negative (that is, no nystagmus/vertigo), repeat the maneuver with the head turned to the unaffected side in step 2.

Supine Head Roll Test

Characteristic findings

Positional vertigo and nystagmus triggered during the maneuver

Direction of nystagmus in lateral canal BPPV:

Bilateral horizontal nystagmus with eyes beating toward the ground (geotropic nystagmus)

Bilateral horizontal nystagmus with eyes beating toward the ceiling (apogeotropic nystagmus)

Procedure of supine head roll test

1. Ask the patient to lie in a supine position and to keep their eyes open during the procedure.

2. Position the patient's head in neutral position.

3. Quickly turn the patient's head by 90° to one side and examine for nystagmus.

4. Wait for nystagmus to subside.

5. Reposition the patient's head to neutral position, reassess for nystagmus; allow nystagmus to subside.

6. Repeat steps on the opposite side.

BPPV

C/C:******

Diagnostics

>>> Diagnosis is clinical

>> Dix-Hallpike maneuver

>>> supine head roll test

Vestibular rehabilitation therapy (Brandt-Daroff exercise, Cawthorne-Cooksey exercise), training on maintaining balance based on visual and proprioceptive clues

Lifestyle recommendations: avoiding caffeine, salt and alcohol, avoiding triggers

Canalith repositioning procedure: Epley maneuver

1. Tab. Betahistine 8mg, 16mg or 24mg (Serc, Enier, Setspin) 8mg or 16mg = 1-1-1 (TDS), 24mg = 1-0-1 (BD)

Or Tab. Prochlorperazine 5mg (Stemetil)

1-1-1 (TDS) titrated up to 30mg if not respond.

Or Tab. Cinnarizine (Tab. Stugeron 25mg) or Cap. Stugeron 75mg)

Tablets-1-1-1 (TDS) or Capsules = OD/BD per day

Or Tab. Dimenhydrinate 50mg (Gravinate)

1-1-1 (TDS) Maximum Dose: <400mg/day

2. Tab. Alprazolam 0.5mg (Alp, Xanax, Praz)

Or Tab. Diazepam 5mg (Valium) 0-0-1(HS)

Or Tab. Clonazepam 0.5mg (Revotril, Naze)

Surgical treatment Indication

Intractable BPPV

Severe and frequent recurrences

Options

Singular neurectomy

Posterior semicircular canal occlusion

Canalith Repositioning Maneuvers (CRM)

Definition: Set of specific sequential maneuvers performed to mobilize the otoconia out of the involved semicircular canal and back into the vestibule

Indication: first-line treatment for BPPV

General Considerations

CRM can be performed immediately after identifying the affected canal on a provoking maneuver.

« A trained general practitioner can perform the Dix- Hallpike maneuver and Epley maneuver.

ENT referral is recommended in patients with persistent or recurrent symptoms.

>> Potential side effects include nausea, vomiting, and postural instability lasting for approximately 24 hrs.

Antiemetics or vestibular suppressants may be given prophylactically before performing CRM.

>> Patients with frequent recurrences can be taught to perform these maneuvers themselves at home.

Outcome

>> Up to 80-90% success rate, patients will be cured by a single maneuver.

>> Recurrences requiring repeat CRM are expected.

>>> Canal conversion

Procedure of Epley Maneuver

1. The initial steps are the same as those of the Dix- Hallpike maneuver

Ask the patient to sit upright on the examination table and to keep their eyes open during the procedure.

Rotate the head by 45° towards the affected side.

Keeping the neck rotated, quickly lay the patient in a supine position with the neck slightly extended (approx. 20°) & the affected ear facing down at 45°

2. Hold this position for 30 seconds or until the resolution of nystagmus.

3. Turn the patient's head by 90° toward the unaffected side; hold this position for 30 seconds or until resolution of nystagmus

4. Turn the patient's head and body by 90° towards the unaffected side such that the patient is now lying on their side with their face turned toward the ground.

5. Hold this position for 30 seconds or until the resolution of nystagmus.

6. Bring the patient back to a seated, upright position with the head in the neutral position.

7. After completion of the maneuver, ask the patient to remain in this position for about 15 minutes.

EAR NOSE THROAT (ENT) OPD RX GUIDE

1 ACUTE TONSILLITIS /ACUTE PHARYNGITIS Rx

2 ACUTE SINUSITIS (ACUTE SINUS INFECTION) Rx

3 CHRONIC SINUSITIS Rx

4 ACUTE RHINITIS Rx

5 CHRONIC SIMPLE RHINITIS Rx

6 HYPERTROPHIC RHINITIS (CHRONIC) Rx

7 ALLERGIC RHINITIS Rx

8 DEVIATED NASAL SEPTUM (DNS) Rx

9 SEPTAL HAEMATOMA Rx

10 SEPTAL ABSCESS Rx

11 ADULT/CHILDERN WITH EAR DISCHARGE/INFECTION Rx

12 ACUTE SUPPURATIVE OTITIS MEDIA (ASOM)Rx

13 CHRONIC SUPPURATIVE OTITIS MEDIA (CSOM) Rx

14 TINNITUS Rx

15 VERTIGO Rx

16 BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)Rx

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