Necrotising (Malignant) Otitis Externa
Overview
People who are immunocompromised or have a history of diabetes mellitus presenting with severe, unrelenting ear pain that is out of proportion to clinical findings should raise suspicion of necrotising (malignant) otitis externa.
Initial steps
- Immediately refer to ENT
- Investigations may involve:
- CT with IV contrast
- MRI brain and internal auditory canal
Vestibular Schwannoma (Acoustic Neuroma)
Overview
Vestibular schwannomas classically present with:
- Vertigo
- Hearing loss
- Tinnitus
- Involvement of other cranial nerves which may include:
- The trigeminal nerve (CN V): absent corneal reflex
- The facial nerve (CN VII): facial nerve palsy
It may present with sudden sensorineural hearing loss.
Initial steps
- Urgently refer to ENT
- MRI of the cerebellopontine angle – the investigation of choice
Laryngeal Cancer
Overview
A 2-week wait referral should be considered for patients ≥45 years old with a persistent and unexplained hoarse voice or an unexplained lump. The risk is higher in those that smoke.
Neck Lumps
Overview
Although reactive lymphadenopathy can occur following infection, lumps that are >2cm, firm, non-tender, and tethered to surrounding structures may be malignant.
A 2-week wait referral should be considered for patients ≥45 years old with a persistent and unexplained hoarse voice or an unexplained lump. The risk is higher in those that smoke.
Epiglottitis
Overview
Epiglottitis may still occur in patients who have been immunised against Haemophilus influenzae B (Hib). Symptoms usually come on rapidly and patients appear very unwell. Features include:
- Stridor
- Drooling
- Very sore throat
- Tripod position – the patient finds it easier to breathe leaning forward and extending their neck while sitting down
Initial steps
- Do not examine the throat as this can worsen stridor and precipitate airway closure
- Refer immediately to the emergency department for consideration of airway management (e.g. endotracheal intubation)
Peritonsillar Abscess (Quinsy)
Overview
A peritonsillar abscess can develop as a complication of bacterial tonsillitis. Key features are:
- Severe throat pain
- Deviation of the uvula away from the affected side
- Trismus
- ‘Hot potato voice’ – muffled speech due to impaired tongue movement
Initial steps
- Immediately refer to hospital for ENT assessment
- Management involves incision and drainage with IV antibiotics
Nasal Tumours and Nasal Foreign Bodies
Overview
Unilateral nasal obstructive symptoms such as epistaxis, discharge, or obstruction may suggest nasal tumours. Associated symptoms may be present such as blood-stained discharge or altered facial sensation.
In children, this may also suggest a nasal foreign body.
Initial steps
- Urgently refer to ENT if tumour suspected
- Refer to the emergency department if a nasal foreign body is suspected
