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.

1. Dr. Richard Isaacs, MD
COMMON PROBLEMS IN ENT

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

7. WITHOUT POLYP WITH POLYP ALLERGIC FUNGAL
Untreated Oral Steroids Oral Steroids Surgery
Oral Antibiotics
Maintenance Topical Steroids Topical Steroids Oral Steroids
Steroid Instillation Steroid Instillation Steroid Instillation
+/- Antihistamine +/- Antihistamine +/- Oral Antifungals
+/- Antileukotriene

8. TONSILLITIS/TONSILLECTOMY

Indications – controversial in adult population

Management
− Analgaesia
− +/- Antibiotics (GAS coverage)

Tonsillectomy
− Contraindications – Velopharyngeal, Acute Tonsillitis
− Knife vs Unipolar vs Bipolar
− Complications: Haemorrhage, Haemorrhage, Haemorrhage,
Pain (Otalgia)
− Post tonsillectomy haemorrhage requires representation
− Management involves vasoconstriction, pressure
Dr. Richard Isaacs, MD

9. PERITONSILLAR ABSCESS

Risk factors
− Tonsillitis
− Smoking

Symptoms
− Trismus
− Dysphagia
− Systemically Unwell

Management
− Drainage (Needle Aspiration vs Surgery)
− Antibiotics (Not amoxicillin)
− Analgaesia
− Tonsillectomy (Acute vs Chronic)
− +/- Glucocorticoids

Complications – Recurrence (10-15%)
Dr. Richard Isaacs, MD

10. HEARING LOSS

Sensorineural vs Conductive vs Mixed
Dr. Richard Isaacs, MD

11. CAUSES
CONDUCTIVE SENSIRONEURAL
External Ear Congenital Bilateral Noise Induced
Foreign Body Presbycusis
Tumour Autoimmune
Infection Drug Mediated
Middle Ear Trauma Unilateral Trauma
Infection Perilymphatic Fistula
Cholesteatoma Acoustic Neuroma
Otosclerosis Meniere’s Disease
Glomus Tumour Idiopathic

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

18. MANAGEMENT

Non-pharmacological
− Vestibular Rehabilitation

Pharmacological
− Antiemetics – Prochlorperazine (Stemetil), Metoclopramide
(Maxolon), Promethazine (Phenergan)
− Vestibular Suppressants – Clonazepam (Rivotril), Amitriptyline
(Endep)

Specific
− BPPV – Epley’s Manoeuvre
− Vestibular Neuritis – Vestibular Suppressants
− Meniere’s Disease – Na restrict, Diuretics (HCT), Surgical
− Migraine – Pizotifen, Amitriptyline, Aspirin
− Stroke – As per Stroke

19. HEAD & NECK TUMOURS

Fifth most common cancer worldwide

Most common histology squamous cell carcinoma

“Field Cancerization”
− multiple primary and secondary tumours in upper aerodigestive
tract
− tobacco (smoked or smokeless) +/- alcohol – synergistic
− HPV
− betel nut chewing
− previous radiation exposure
− periodontal disease
− occupational exposure e.g. wood-dust
Dr. Richard Isaacs, MD

20. Thank You
Dr. Richard Isaacs, MD