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EN1.2 | Pathophysiology of Common ENT Disorders — SDL Guide (Part 4)

Principles of Management

The management principles for each EN1.2 disease follow directly from the pathophysiology. For chronic inflammatory diseases, treatment targets the mechanism of inflammation. For structural mechanical disease (otosclerosis), treatment targets the mechanical consequence (stapes fixation). For obstructive diseases (adenoid hypertrophy, nasal polyposis), treatment addresses the obstruction. The following management principles should be understood as pathophysiological logic, not memorised as arbitrary rules.
In practice this means: (1) for tubotympanic CSOM, start with medical management and reserve surgery for persistent dry perforations; (2) for atticoantral CSOM, refer immediately for surgical assessment — never delay for a course of topical antibiotics; (3) for otosclerosis, offer the patient a choice between hearing amplification and surgical restoration; (4) for adenoid hypertrophy with OME, consider the time course — watchful waiting for 3 months before intervening surgically in a child without significant disability; (5) for nasal polyps, escalate from topical to systemic steroids to endoscopic surgery based on disease burden, and never forget that recurrence of ethmoidal polyps is the expected outcome, not a surgical failure.

Chronic Otitis Media — Tubotympanic Type
Medical management first (only appropriate for tubotympanic/safe type):
- Aural toilet (dry mopping or gentle suction of the EAC and the mucous discharge through the perforation) to reduce bacterial colonisation of the middle ear mucosa.
- Topical antibiotics: ciprofloxacin otic drops are preferred (broad-spectrum, effective against Pseudomonas; does NOT have ototoxicity risk when applied to a perforated ear). Aminoglycoside drops (gentamicin, neomycin) should be used with caution or avoided in perforated ears — they can cause cochlear ototoxicity via round window absorption.
- Surgical: myringoplasty (repair of the TM perforation using a temporalis fascia graft) is indicated when the ear has been dry for at least 3 months and the patient desires hearing improvement or protection from recurrent infection.

Chronic Otitis Media — Atticoantral Type (Cholesteatoma)
Always surgical — no medical treatment is appropriate as the primary management:
- Mastoidectomy: the cholesteatoma sac must be completely surgically excised. Two main surgical approaches:
- Canal wall up mastoidectomy (combined approach tympanoplasty, CAT): preserves the posterior EAC wall; better cosmesis; retains the potential for hearing reconstruction; but higher risk of residual/recurrent cholesteatoma (the sac may not be fully visualised).
- Canal wall down mastoidectomy (modified radical mastoidectomy): removes the posterior EAC wall, creating a wide-open mastoid bowl that is inspectable for residual disease; lower recurrence rate; requires lifelong cavity maintenance (prevents water entry, annual cleaning).

Otosclerosis
- Hearing aid: effective, non-invasive; appropriate for patients who prefer non-surgical management or are poor surgical candidates.
- Surgical: stapedectomy (removal of the fixed stapes and replacement with a prosthesis connecting the incus to the oval window membrane) or stapedotomy (small hole in the footplate with a piston prosthesis). Surgical success rate >90% for experienced surgeons; risks include sensorineural hearing loss (perilymph gush), labyrinthitis, tinnitus, taste disturbance (chorda tympani nerve).
- Sodium fluoride was historically prescribed as a medical measure to slow cochlear otosclerosis progression — evidence is limited and it is not routinely recommended.

Adenotonsillitis and Adenoid Hypertrophy
- Acute tonsillitis: supportive care + phenoxymethylpenicillin (penicillin V) for suspected GABHS (10 days); amoxicillin avoided if EBV suspected (risk of drug rash); erythromycin for penicillin-allergic patients.
- Peritonsillar abscess: incision and drainage (or needle aspiration) + IV antibiotics + interval tonsillectomy 6 weeks later.
- Tonsillectomy indications: recurrent tonsillitis (Paradise criteria), peritonsillar abscess, obstructive sleep apnoea from tonsillar hypertrophy.
- Adenoidectomy: for OME with hearing loss (± grommets for middle ear ventilation), symptomatic OSA from adenoid obstruction, recurrent rhinosinusitis from adenoid bacterial reservoir.

Nasal Polyposis
- Ethmoidal polyps: first-line: topical intranasal corticosteroids (mometasone furoate, fluticasone propionate) — reduce polyp size and symptoms; short courses of oral prednisolone for acute exacerbations ('medical polypectomy'). Surgical: FESS (functional endoscopic sinus surgery) for large polyps, bilateral anosmia, or unresponsive disease; recurrence is the rule and long-term topical steroid post-FESS is mandatory. Aspirin desensitisation in Samter's triad patients (specialist-supervised gradual aspirin rechallenge) can reduce polyp recurrence.
- Antrochoanal polyp: endoscopic polypectomy including wide middle meatal antrostomy and removal of the antral base (the root of the stalk in the maxillary sinus); when complete, does not recur. Simple nasal polypectomy (without the antral base) results in recurrence.

Self-Assessment

Test your understanding of the pathophysiology and clinical reasoning for the four EN1.2 diseases by answering these questions without consulting your notes. Each tests a different level of clinical reasoning — from factual recall to applied differential diagnosis to management decision.
These five questions span the full range of clinical reasoning required by EN1.2 — from pathophysiology mechanism to clinical diagnosis to management principle. They are written to mirror the format of final-year assessments: some are purely factual (Carhart notch, Samter's triad), some require you to apply a mechanism to an unfamiliar case (the child with OME), and some test your ability to reason from first principles (why does antrochoanal polyp not recur). If you can answer all five confidently without notes, you are at the KH (Knowledge and How) level that EN1.2 requires.

1. A 15-year-old boy has a 6-year history of right ear discharge and hearing loss. On otoscopy, you see a white pearly mass in the right attic with a small marginal perforation and foul-smelling discharge. What is the diagnosis? What is the single most important management step?
2. A young woman with bilateral progressive hearing loss has a completely normal otoscopic examination in both ears. What is the most likely diagnosis? What two audiometric and tympanometric findings would you expect?
3. A 6-year-old child is brought in by parents who are worried about his hearing. He also snores loudly and seems to breathe through his mouth all the time. Otoscopy shows an amber-coloured retracted TM bilaterally with Type B tympanograms. What is the underlying anatomical mechanism causing the hearing loss? What management might improve both the hearing loss and the snoring?
4. Explain in two sentences why ethmoidal nasal polyps recur after surgery but an antrochoanal polyp does not, provided the antral base is completely removed.
5. A 45-year-old woman with asthma and bilateral nasal polyposis reports that her nose blocks severely and she develops an asthma attack within 2 hours of taking ibuprofen for a headache. What triad does this represent? What pharmacological class should she avoid?

If you cannot answer Question 1 — specifically that atticoantral CSOM with cholesteatoma ALWAYS requires surgery, NEVER just topical treatment — re-read the cholesteatoma section immediately. This is the highest-stakes differential in ENT.