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REVIEW ARTICLE

Common Ear, Nose and Throat Infections in India

Meenesh R Juvekar

 
Introduction
Infections in the Ear, Nose and Throat can be variable, toublesome and dangerous. Complete examination of the Ear, Nose and Throat with necessary investigations is required for the diagnosis and treatment of these conditions.
Ear : The ear is divided into the external ear, the Middle ear and the Inner ear.
 
External Ear infections
Perichondritis : This is an infiammation of the pinna often extending upto the external ear canal.
 
Aetiology
• Commonly seen after a haematoma of the pinna
• Extension of the furuncle from the posterior
• Post exposure of the cartilage to burns, irradiation and frostbite.
Pathology :
The pus gets collected between the perichondrium and the underlying cartilage. The cartilage often undergoes ischaemic changes and there is necrosis. If untreated it can lead to a bad deformity of the pinna. The most commonly found organisms are pseudomonas aeruginosa and streptococcus.
Clinically :
a) Early stage : The pinna becomes red, infiamed and tender.
b) Late stage : There is generalised swelling of the pinna and formation of subperichondrial abscess.
Treatment :
Local : Ichthyol 20% in water for local application.
 
Medical
• Antibiotics depending on the organism involved.
• Analgesics and Anti-pyrectics if required.
Surgical :
Incision and drainage of the subperichondrial abscess with wide incision on the lateral aspect of the auricle.
 
Otitis Externa
This is a generic name applied to all infiammatory conditions of the external meatal skin. Otitis externa could be of bacterial, fungal or viral aetiology.
 
Predisposing factors
1.Narrow canal, excessive wax.
2. Ear pricking with sharp infected objects.
3. Heat, humidity and swimming in unclean waters.
4. Badly fitting hearing aids.
 
Clinical features
a) Pain aggravated by jaw movement.
b) Ear discharge purulent and blood stained.
c) Deafness due to blockage of the external auditory canal.
Pathology : There is an infiammatory process in the external canal, which may also spread to the pinna. The organisms usually affecting the acute stage are staphylococcal or streptococcus. Pseudomonas, proteus are more seen in chronic otitis externa.
 
Treatment
• Glycerin - Icthamol drops in the ear.
• Antibiotics are useful to reduce the oedema and control the infection.
• Analgesics and local heat application.
 
Viral infections causing Otitis Externa
1. Herpes simplex : Commonly occurs on lips spreading to the ear canal. There is no specific treatment. Anti-viral drugs can be used in
severe cases.
2. Bullus myringitis : It is characterised by formation of purplish blebs due to haemorrhagic effusion in the tympanic membrane and the
deep meatal skin.
Treatment : The ear is kept dry and analgesics are given.
 
Fungal infections causing Otitis externa
Otomycosis : It is one of the common causes for Otitis externa. Whitish fungal growth with black spores are often seen. It occurs in diabetics and other immunocompromised patients and persons having exposure to infected waters. The causative organism is Candida albicans and Aspergillus niger.
Treatment : Epithelial debris is removed. 1% Clotrimazole ear drops are given. Antibiotics may be required in case of secondary infection.
 
Acute Suppurative Otitis media
It is an inflammation of the middle ear cleft comprising the eustachian tube, tympanic membrane and mastoid air cells by pus forming organisms. This condition is usually a sequel to upper respiratory tract infection.
 
Aetiology
•One can get an infection of the middle ear via the eustachian tube or the perforated eardrum.
•Unhygienic conditions and malnutrition play a very important role.
• It is seen more in colder climates and winter.
• Nasopharyngeal masses, allergy. Immunodeficiency syndromes all predispose to acute suppurative otitis media.
 
Clinical symptoms
1. Pain is most common complaint. It is very severe and throbbing.
2. Deafness or heaviness of the ear may be present in some cases.
3. Ear discharge starts as the disease gradually progresses.
Pathology : After a bout of upper respiratory tract infection there is mucosal oedema and paralysis of the ciliary action. As a result there is blockage of the eustachian tube and negative middle ear pressure created. The organism is usually staphylococcal or
B-haemolytic streptococcus.
 
Treatment
• Aural toilet.
• Boro spirit or antibiotic-steroid ear drops.
• Antibiotics according to the organism involved.
• Analgesics and antihistaminics.
• Nasal decongestants.
• Myringotomy of the tympanic membrane to drainout the middle ear effusion.
Recent advances : Myringotomy by KTP or Argon laser is very effective due to its precision of incision and the bloodless field.
 
Acute Mastoiditis
Acute mastoiditis is a complication of acute suppurative Otitis media. The accumulation of pus in the mastoid air cells may remain walled off causing coalescent mastoiditis. The disease if untreated eventually spreads outside the mastoid bone.
 
Aetiology
• Low resistance of the patient.
• Virulent organism.
• Improper or inadequate treatment.
 
Clinical Features
1. Pain, fever and tenderness in the post aural region.
2. Ear discharge often increasing rapidly.
3. Sagging of the posterior canal wall.
4. Tympanic membrane may show a perforation, granulations or a polyp.
Complications : The pus may trickle out of the mastoid bone causing various abscesses, intracranial and extracranial complications.
 
Treatment
• Local antibiotic and steroid therapy.
• Systemic antibiotics, which pass the blood, brain barrier.
• Surgical drainage of the mastoid or other abscesses may be required.
• Mastoidectomy : The disease is cleared from the mastoid bone and the type of surgery depends on the extent of the disease.
 
CHRONIC SUPPURATIVE OTITIS MEDIA
This is a persistent condition after an acute attack causing severe destruction of the middle ear cleft.
 
Clinical features
• Ear discharge is present. It can be unilateral or bilateral, painless, foul smelling and scanty.
• Deafness is usually gradually progressing.
• A presence of facial palsy, pain, vertigo, and headache is a sign of complications.
Pathology : Depending on the status of the tympanic membrane CSOM can be divided into safe type and unsafe type. Both aerobic and anaerobic organisms can be present in CSOM. Commonly present organisms are staphylococcus aureus, pseudomonas aeruginosa, escherichia coli, proteus and bacteroides.
Treatment : The modern concept of treatment of chronic suppurative otitis media includes a careful assessment of the extent of the disease and functional assessment.
Medical treatment : a) Aural toilet. b) Broadspectrum antibiotics. seen.
Surgical treatment : Myringoplasty or Mastoidectomy depending on the type and extent of disease.
 
INFECTIONS OF THE NASAL CAVITIES
The nasal cavities are prone to a variety of organisms due to the high pollution levels and infective agents. Jacobson and Dick (1941) found staphylococcus albus, diphtheroid bacilli and staphylococcus aureus as the most commonly infecting organisms.
Vestibulitis : The vestibule is the skin lined anterior compartment of the nose. When the skin of this area becomes excoriated and infected one gets vestibulitis.
 
Aetiology
• Nose pricking or trauma.
• Immunocompromised conditions.
• A dislocated columella in the vestibule.
 
Clinical features
• Pain, swelling, malaise and fever are commonly
• Facial cellulitis and Cavernous sinus thrombosis are the most dangerous complications.
 
Management
• Broad-spectrum antibiotics.
• Local anti-inflammatory application with magnesium sulphate powder.
Sinusitis : It is the infiammation of the paranasal sinuses. There can be various causes of sinusitis with the infective agents being bacterial, fungal or viral origin.
 
Aetiology
• Anatomical obstruction due to deviated nasal septum or hypertrophied turbinate.
• Dental infections and abscesses going into the maxillary sinus.
• Swimming in infected waters.
• Tumours causing an anatomical blockage of the sinus.
 
Infective agents
Bacterial : pneumococci, staphylococcus, streptococcus and Escherichia coli.
Viral : parainfluenza virus, rhinovirus, and adenovirus.
Fungi : mucormycosis, aspergillosis, and rhinosporidium seeberi.
Pathology of sinusitis : Whenever there is stagnation of secretions there is loss of ciliary action and secondary infection. This causes sinusitis.
 
Clinical features
• Headache, malaise, fevers,
• Pain around the maxillary sinus area.
• Loss of normal vocal resonance.
• Occasional epistaxis.
 
Treatment
Medical : It basically depends on the type of infective organism.
1. Antibiotics : Amoxycillin, Sparfloxacin are commonly effective.
Recent Advances : Combination of Amoxycillin and Clavulanic acid is very effective against the newer strains of bacterial organisms.
2. Oxymetazoline or Neb ephedrine nasal drops.
3. Steam inhalation : Useful for clearing out the secretions.
4. Antihistaminics are given as per the symptoms of the patient.
 
Surgical treatment
Antral puncture : It is the procedure used to drain out the secretions from the maxillary sinus.
Recent Advances : Functional endoscopic sinus surgery (FESS) is one of the best surgical methods to clear the disease from the sinuses. The surgery is performed through a sinoscope of different angulations usually under local anaesthesia.
 
Common cold (Coryza)
It is the commonest infection. Mode of ransmission is usually by contact or droplets. Viruses are the cause of this condition though
secondary bacterial infection commonly occurs.
 
Clinical features
• Prodromal stage : This lasts a few hours’. The patient get malaise and sometimes nasal irritation. There is watery discharge and nasal blockage.
• Secondary infection : The discharge is purulent. Then nasal obstruction and toxaemia sets in.
• Resolution : The symptoms gradually diminish after 5-10 days.
 
Management
a) Rest
b) Antibiotics and analgesics in cases of secondary infection.
c) Nasal decongestants and steam inhalation to clear out the secretions.
Rhinosporidiosis : This is a chronic infestation of the nasal cavities by a fungus rhinosporidium seeberi.
 
Aetiology
• Usually seen in adult males.
• Common in endemic areas in India and Sri Lanka especially in farmers.
 
Clinical features
• Nasal mass causes blockage, headache and epistaxis.
• The mass looks like a strawberry with spores in it.
 
Treatment
Surgical : Excision of the mass is performed with a cauterization of the base.
Recent advances have shown that laser excision has lesser chances of recurrence and less bleeding.
Medical : Dapsone 100 mg twice daily increases the fibrosis and reduces recurrence.
 
ORAL CAVITY AND THROAT
 
Tonsillitis
The tonsil is a subepithelial lymphatic tissue associated with the production of lymphocytes and plasma cells. Infiammation or infection of this tissue causes tonsillitis. Tonsillitis can be acute or chronic. Most common organisms infecting it are beta-haemolytic streptococcus, staphylococcus, haemophilus and anaerobic organisms.
 
Aetiology
• Seen in children upto 12-14 years of age.
• Persons who consume unhygienic food stuffs.
• Low body resistance and immunocompromised conditions.
 
Clinical features
• Throat pain and swelling.
• Fever with malaise.
• Neck swelling with enlargement of the cervical lymph nodes.
 
Treatment
Medical
1. Bed rest with a bland clean diet.
2. Antibiotics to control the infection.
3. Oral antiseptic gargles
4. Analgesics and antipyretics.
Surgical : Tonsillectomy is advised in patients, who have recurrent attacks of acute tonsillitis, or patients having local or systemic complications of tonsillitis.
Ludwig’s Angina : This is a rapidly progressing cellulitis of the fioor of the mouth and the submandibular space.
 
Aetiology
• Dental infections and improper tooth extractions are the most common cause of Ludwig’s angina.
• Submandibular sialadenitis.
• Mucosal infections.
 
Clinical features
1. Fever and Odynophagia which is rapidly progressing.
2. Breathlessness with trismus.
3. Neck swelling which is tender and progressing.
 
Treatment
• Systemic antibiotics.
• Incision and drainage of the abscess.
• Tracheostomy may be required in cases of severe stridor.
Retropharyngeal abscess : It is an infection of the retropharyngeal space. It could be acute or chronic in onset.
 
Aetiology
• Occurs after oropharyngeal or nasopharyngeal infections.
• Chronic retropharyngeal abscess is seen due to tuberculous cervical spine.
• Trauma of the pharyngeal wall by a fish bone or similar sharp body.
 
Clinical features
• Odynophagia
• Fever with restriction of neck movements.
• Change of voice.
• Breathlessness.
 
Treatment
1. Antibiotics and Anti-infiammatory drugs.
2. Incision and drainage of the abscess by Trans - oral route under local anaesthesia.
3. Anti-tuberculous treatment in cases of caries spine.
4. Tracheostomy may be required in severe breathlessness.
Laryngitis : It is an infiammation of the any part larynx especially the vocal cords. Laryngitis may present as an acute or chronic condition.
 
Causes of acute laryngitis
1. Epiglottitis
2. Laryngitis
3. Diphtheritic laryngitis
4. Voice abuse.
 
Causes of chronic laryngitis
1. Voice abuse
2. Leprosy
3. Scleroma
4. Tuberculosis
5. Syphilis
Acute Epiglottitis : It is an infiammation of the epiglottis. Children are more commonly affected. Haemophilus influenzae is the most common organism.
 
Clinical features
• History is short and starts with a bout of upper respiratory tract infection.
• Stridor is often present and is rapidly progressing.
• Change to voice with croupy cough.
• Severe pain with malaise or fever.
• On examination a red, oedematous, swollen epiglottis.
 
Treatment
This condition should be tackled on an emergency basis
1. Oral antibiotics
2. Steroid inhalers and oral steroids.
3. Analgesics and antipyretics.
4. Tracheostomy in cases of severe breathlessness.
Acute Laryngitis : It is the infiammation of the laryngeal mucosa.
 
Aetiology
• Infections extending from an upper respiratory tract.
• Trauma, voice abuse.
• Inhalation of toxic fumes.
 
Clinical features
1. Hoarseness of voice.
2. Discomfort in the throat.
3. Odynophagia.
4. Fever.
 
Treatment
The treatment for laryngitis is similar except in cases of specific infections. This includes:
• Voice rest.
• Steam inhalation
• Antibiotics
• Steroids
• Oxygen in cases of severe stridor.
 
Diphtheritic laryngitis
Laryngeal diphtheria usually follows pharyngeal infections. Variable strains of corynebacterium diphtheria have been isolated from the larynx. Corynebacterium diphtheria gravis is the most fulminant strain and causes epidemics.
 
Clinical features
1. Sore throat, malaise, fever.
2. Tonsils may show a characteristic greyish membrane, which bleeds, on touch.
3. Palatal paralysis is the commonest of the peripheral neuropathies.
4. Cough.
 
Treatment
• Diphtheritic Antitoxin 20000 to 120000 units depending on the age.
• Injection Benzyl Penicillin 600-1200 mg every 6 hourly.
• Steroids to reduce oedema.
• Tracheostomy in cases of stridor with oxygen supplementation.
 
Recent Advances
Fibre-optic laryngoscopy is one of the safest methods to visulise the vocal cords under magnification. This procedure is routinely done on an OPD basis and under local anaesthesia.
 
REFERENCES
1. Joselen Ransome. ‘Acute suppurative otitis media and acute mastoiditis’. Scott-Browns Otolaryngology 3 : 203-14.
2. Logan Turners diseases of the Ear, Nose and Throat, 6th edition. Chapter 36 and 37.
3. Shenoi PM. Management of chronic suppurative otitis
 
RHABDOMYOLYSIS

Rhabdomyolysis is defined as an acute increase in serum concentrations of creatine kinase to more than five times the uppernormal limit and when myocardial infarction has been excluded as a cause (CK-MB fraction less than 5%). Visible yoglobinuria (tea or cola coloured urine) occurs when urinary myoglobin eceeds 250 µg/ml (normal < 5 ng/ml). Single episodes are most commonly caused by infections (viral, bacterial, or other), drugs, or physical factors such as compartment syndromes, schaemia, reperfusion (including surgical procedures), and pressure from hard surfaces in comatose patients. Bywaters and Beall described the development of acute renal failure following crush injuries sustained in the London Severe or unaccustomed exertion, particularly in extremes of heat, is a common precipitant and has been reported in Alcohol and opiates are the drugs implicated most often, but all potentially myotoxic drugs (particularly mixtures Statins are of particular concern because of their widespread and increasing use. Myotoxicity occurs in about 0.1% of cases, although cerivastatin was withdrawn in 2001 because the incidence of myotoxicity with this drug was some 10 times greater. Drug interactions particularly with fibrates or drugs that interfere with cytochrome. Reassuringly, fatal rhabdomyolysis dur to The immediate consequences of rhabdomyolysis include hyperkalaemia, which may cause fatal cardiac dysrhythmia, and hypocalcaemia due to calcium binding by damaged muscle proteins and phosphate. Acute renal failure results from renal vasoconstriction, intraluminal myoglobin cast formation, and haem protein nephrotoxicity..

Russell Lane, Maclon Phillips, BMJ, 2003; 327 : 115-16.


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