DR Richard Isaacs, MD joined Kaiser Permanente in 1995 and he has Advanced Certification in Head and Neck Oncologic Surgery. His specialties include: orbital, nasal, and maxillofacial surgery, as well as thyroid and parathyroid surgery. Additionally, Rich is trained in Facial Plastic and Reconstr.
2. OUTLINE
Nose
− Epistaxis
− Chronic Rhinosinusitis
Throat
− Peritonsillar Abscess
− Tonsillitis
Ear
− Hearing Loss
− Vertigo
Head & Neck
Dr. Richard Isaacs, MD
3. ACUTE EPISTAXIS
Nasal mucosa: rich blood supply, anastomoses between internal
and external carotid supply
Causes
− Trauma
− Chronic irritation e.g. sinusitis, steroid spray abuse
− Coagulopathies
− Anatomical abnormalities
− Vascular malformation
− Tumour
90% anterior (capillary, venous in origin)
10% posterior (arterial in origin) – may present as haemoptysis,
melaena, haematemesis etc.
Dr. Richard Isaacs, MD
4. MANAGEMENT
D R S A B C D
Anterior vs Posterior
Achieve Haemostasis
− Pressure
− Ice
− Co-Phenylcaine/Cocaine
− Cauteurisation
− Packing
− Balloon
− Embolisation
− Antibiotics (Flucloxacillin)
Complications
Dr. Richard Isaacs, MD
5. CHRONIC RHINOSINUSITIS
Inflammation involving nasal mucosa and paranasal sinuses lasting
longer than 12 weeks
Criteria
− Anterior and/or posterior mucopurulent drainage
− Nasal obstruction
− Facial pain, pressure and/or fullness
− Decreased sense of smell
Subtypes
− With nasal polyposis
− Without nasal polyposis
− Allergic fungal rhinosinusitis
Dr. Richard Isaacs, MD
6. MANAGEMENT
Medical Therapy
− Nasal lavage – Normal Saline
− Nasal glucocorticoid sprays
− Oral glucocorticoid
− Antibiotics (Augmentin, Doxycycline)
− Antihistamines
Surgical Therapy
− Functional Endoscopic Sinus Surgery (Category of Operation)
Complications
− Recurrence
− Epistaxis
− (Very Rare) Blindness (Retrobulbar Haemorrhage)
Dr. Richard Isaacs, MD
12. HISTORY/EXAMINATION
History
− Onset/Time Course – Acute vs Chronic, Bilateral vs Unilateral
− Aggravating/Relieving Factors –
− Associated Symptoms – Tinnitus, Vertigo, Pain, Discharge
− Trauma – Physical, Barotrauma, Noise Induced
− Medications
− Past History – Stroke Risk Factors
Examination
− Otoscopy
− Whispered Voice
− Renee & Weber Tests
− Pneumoscopy/Tympanoscopy
Dr. Richard Isaacs, MD
13. INVESTIGATION
Special Tests
− Pure tone audiogram
− Speech audiometry
− Tympanogram
Imaging
− CT Temporal Bone
− +/- MRI Auditory Canal
Dr. Richard Isaacs, MD
14. CHOLESTEATOMA
Acquired vs Congential
Locally invasive overgrowth of epithelial cells – not cholesterol
Sx: Unilateral Conductive Hearing Loss, Discharge (often
discoloured and malodorous)
Cx: Local invasion, CN VII palsy, Mastoiditis, Meningitis
Management:
− Antibiotics
− CT Temporal Bone
− Surgery – Canal Wall Up vs Down
Follow Up – Local recurrence, Ossiculoplasty
Dr. Richard Isaacs, MD
15. VERTIGO
CAUSES
Seconds BPPV
Perilymphatic Fistula
Migrainous
Hours Meniere’s
Vertebrobasilar TIA
Days Vestibular Neuritis
Cerebellar Stroke
Multiple Sclerosis
PERIPHERAL CENTRAL
Unidirectional
Nystagmus
Nystagmus can
reverse direction
Horizontal +/-
Torsional
Any direction
Suppressed with visual
fixation
Not suppressed with
fixation
Hearing Loss/Tinnitus Neurological Signs
Gait preserved Severe postural
instability
16. HISTORY/EXAMINATION
Vertigo vs Dizziness
Peripheral vs Central
History
− Onset/Time Course – Seconds, Hours, Days
− Aggravating/Relieving Factors – Movement, Tullio’s
Phenomenon
− Associated symptoms – Neurology, Nystagmus
Examination
− Assess as per hearing loss
− Neurological examination
− Dix-Hallpike Test
Investigations
− CTB