ENT
PART 2
Treat
ENT
Dr Peter Ryan
PART 2
‘ Unsafe ’ perforations
ANIKA , 54 , has a known chronic left tympanic membrane perforation , and has been poorly compliant with follow-up and management for many years . She presents complaining of a painful , discharging left ear .
Dr Ryan is an ENT registrar at Royal North Shore Hospital , Sydney , NSW .
THE QUIZ
oesophageal varices and only moderate internal haemorrhoids .
Discussion Mark was ultimately diagnosed with hepatorenal syndrome . The syndrome is a diagnosis of exclusion , made when other causes for acute renal injury ( for example , vasculitis and glomerulonephritis ) are not found . Hepatorenal syndrome occurs when portal hypertension triggers arterial vasodilation , particularly in the splanchnic circulation . The fall in systemic vascular resistance reduces kidney perfusion and results in a decreased glomerular filtration rate .
Hepatorenal syndrome occurs in both chronic and acute liver disease . It can be precipitated by acute insults including infection or gastrointestinal bleeding .
Treatment is dependent on the cause of hepatic
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IT seems the Apple and Play stores have hundreds , maybe thousands , of relaxation apps .
But Treat is different , it claims , because it is “ made for health professionals by health professionals ”.
Alfred Health in Melbourne developed the app to complement its de-stressing program for doctors and nurses . It has a list of different spoken-word recordings — ranging from 40 seconds to 45 minutes — to help users relax .
Users can pick a specific recording , or let the app recommend one , based on the time they have and the type of destressing they need .
The categories include resting ,
impairment . In untreatable hepatic failure , transplant is the mainstay of therapy .
Treatment of alcoholic liver disease is with abstinence from alcohol , and with IV fluid management to increase kidney perfusion pressure . Viral hepatitis is best managed with antiviral drugs .
Interestingly , however , hepatorenal syndrome potentiated by acute bacterial infection , such as spontaneous bacterial peritonitis , does not improve with antibiotics alone . Judicious fluid resuscitation and tertiary hospital care is required .
Following his hospital stay , Mark has remained essentially abstinent from alcohol . Perhaps surprisingly , his liver and kidney function have improved to better than his previous baseline .
Mark is aware of the low reserves of his cirrhotic liver and is embracing lifestyle changes to prolong his life . ● recalibrating , recovering or reducing tension . Treat is an intuitive , pleasant and unpretentious app , standing out even in a hugely crowded field .
Specifications
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Q . Which of the following makes this perforation ‘ unsafe ’? a . Tympanosclerosis of the intact portion of the tympanic membrane b . Perforation extends to / involves the annulus of the tympanic membrane anteriorly ( marginal perforation ) c . Mucopus within the middle ear d . Irregular squamous epithelium at the inferior margin of the perforation A . The answer is b and d . Tympanosclerosis is scarring of the eardrum from recurrent infections . The white appearance seen behind the tympanic membrane in this image likely reflects squamous epithelium on the medial surface of the tympanic membrane , a sinister sign .
The most concerning features in this image are the extension of the perforation to and involving the annulus ( marginal perforation ) and irregular squamous epithelium at the inferior margin of the perforation .
The natural direction of the tympanic membrane ’ s epithelial migration is from internal to external . A marginal perforation can disrupt this process and allow epithelial migration into the middle ear , forming a cholesteatoma . Marginal and attic perforations warrant further investigation to exclude a cholesteatoma .
Chronic discharge or bleeding through a perforation suggests a sinister middle ear pathology that warrants urgent referral . The mucopus in the middle ear here suggests an acute infective process that does not make the perforation ‘ unsafe ’ in isolation . However , ototopical antibiotics should be started immediately .
Q . Which of the following ototopical agents are appropriate for the management of this middle ear infection ? a . Dexamethasone 0.05 %, framycetin
0.5 %, gramicidin 0.005 % b . Ciprofloxacin 0.3 % c . Triamcinolone 0.1 %, neomycin 0.25 %, gramicidin 0.025 %, nystatin 100 000 units / g d . Oral ciprofloxacin A . The answer is b . The presence of a tympanic membrane perforation in the setting of a middle ear infection facilitates direct application of ototopical agents to the site of infection .
Where a perforation exists or a grommet is in place and patent , addition of oral antibiotics is unnecessary unless there is evidence of systemic infection or other spread of infection beyond the middle ear .
Framycetin is an aminoglycoside with potential ototoxicity , particularly when instilled into a middle ear unprotected by an intact tympanic membrane .
These agents should be avoided where an effective alternative is available .
‘ I look into the chest ’
Medical history
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IT was 1816 , and French physician Dr René Laennec was faced with a woman ’ s chest and a dilemma .
The patient presented “ labouring under general symptoms of diseased heart ”, but the shy doctor could not bring himself to put his ear against the woman ’ s breasts to confirm the diagnosis .
He found the percussion technique equally inappropriate , not least because of her “ great degree of fatness ”.
Finally , Dr Laennec found a solution to his moral quandary , a way of listening to the heart and lungs without all the awkwardness of direct auscultation :
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“ I rolled a quire of paper into a sort of cylinder and applied one end of it to the region of the heart and the other to my ear .”
Dr Laennec experimented with various shapes and materials to achieve optimum acoustics , settling on a wooden telescope-like device that he called a stethoscope — literally meaning ‘ I look into the chest ’.
But while his newfound instrument allowed him to catalogue diseases like never before , it was not without its detractors .
Scottish physician Dr John Forbes said
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it was “ ludicrous ” to listen to the chest “ as if the disease within were a living being that could communicate its condition to the sense without ”.
However , the device eventually gained acceptance in the medical community and was modified by others into the iconic binaural neckwear we know today .
As fate would have it , Dr Laennec was diagnosed with TB — the disease that had killed his mother , brother and uncle — with the aid of his own invention , dying in 1826 at the age of 45 . He left his personal stethoscope to his nephew .
Sophie Attwood
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www . australiandoctor . com . au 2 June 2017 | Australian Doctor | 15