21.7 — Skin, Eyes, Ears, Nose and Throat

A red eye is usually conjunctivitis and occasionally the start of permanent blindness.

Telling those apart takes about four questions, and this chapter is largely a collection of distinctions like that one — the ones where knowing which side you are on changes what you do in the next hour.

The eye

Red eye — the distinction that matters

Almost always harmless when: vision is normal, there is no significant pain, the pupil reacts normally, and the redness is diffuse and worse toward the outside of the eye.

Needs same-day assessment when: vision is reduced, there is real pain rather than grittiness, there is sensitivity to light, the pupil looks abnormal, the redness is concentrated in a ring around the cornea, or the person wears contact lenses.

Conjunctivitis — gritty, discharge, vision normal.

Viral is commonest, watery, often with a cold, highly contagious for up to two weeks, and needs no antibiotics.

Bacterial — stickier discharge, lids stuck together in the morning. Most cases resolve without treatment; antibiotic drops shorten it slightly.

Allergic — itchy, both eyes, with other allergy symptoms. Itch is the key word — bacterial and viral conjunctivitis are gritty rather than itchy.

Acute angle-closure glaucoma — and this is the emergency.

Severe eye pain, headache, blurred vision, haloes around lights, nausea and vomiting, a red eye, and a fixed mid-dilated oval pupil. The eye feels hard.

The drainage angle closes, pressure rises rapidly, and the optic nerve is damaged within hours.

And the trap: the nausea and vomiting frequently lead to a diagnosis of a stomach problem or migraine while the eye is being lost. Immediate ophthalmology.

Uveitis — inflammation inside the eye. Pain, light sensitivity, blurred vision, redness worst around the cornea. Associated with autoimmune conditions (Chapter 21.5). Needs urgent assessment and steroid drops.

Corneal ulcer — pain, watering, light sensitivity, and a visible white spot on the cornea. In a contact lens wearer this is an emergency, because it can perforate.

Subconjunctival haemorrhage — a dramatic-looking patch of blood on the white of the eye, painless, with normal vision. Harmless, and it resolves over two weeks. Worth checking blood pressure if recurrent.

Sudden loss of vision

All of these need emergency assessment, and the pattern points to the cause.

Painless, sudden, complete, in one eye — retinal artery occlusion, which is a stroke of the eye. Time-critical, and it means an urgent search for the source, because the same clot could go to the brain next.

Sudden loss with flashes, a shower of new floaters, and a curtain coming across the vision — retinal detachment. Surgery within days saves the sight; delay does not.

Painless loss, often on waking, described as a dense shadow — retinal vein occlusion, or anterior ischaemic optic neuropathy — and in someone over 50 with headache, scalp tenderness or jaw pain, giant cell arteritis, which needs steroids the same day to save the other eye (Chapter 20.1).

Gradual central blurring with straight lines appearing wavy — wet age-related macular degeneration, which is treatable with injections into the eye that have transformed the outlook, and the treatment works far better if started early.

Temporary loss like a curtain descending and lifting within minutes — amaurosis fugax, a warning of stroke (Chapter 18.6). Urgent assessment.

The long-term eye conditions

Cataract — clouding of the lens. Gradual blurring, glare, haloes at night, and colours appearing faded. Surgery replaces the lens and is among the most effective operations in medicine, typically taking under half an hour with rapid recovery.

Glaucoma — chronic open-angle type.

Painless, symptomless, and it destroys peripheral vision so gradually that people do not notice until a substantial amount is permanently gone.

Which makes it the argument for routine eye tests, because it is detected by measuring pressure, examining the optic nerve and testing the visual field, not by how the person feels. Treated with drops that lower pressure, and laser or surgery when needed. Damage already done cannot be reversed, and further damage can be prevented.

Diabetic retinopathy — damage to retinal blood vessels (Chapter 18.7). Also silent until advanced, which is why annual screening for everyone with diabetes exists and why it works. Treated with laser, injections and surgery, and prevented by glucose and blood pressure control.

Dry eye — extremely common, worse with screen use because blink rate falls, and with age and some medications. Lubricating drops, warm compresses for the oil glands in the lids, and deliberate blinking breaks.

The ear

Hearing loss

Two kinds, and separating them determines everything that follows.

Conductive — sound cannot reach the inner ear. Wax, fluid behind the eardrum, perforation, or problems with the small bones. Often correctable.

Sensorineural — the cochlea or the nerve. Age-related, noise-induced, or from disease. Usually permanent, and helped by aids.

Sudden sensorineural hearing loss is an emergency, and it is one of the least known.

Sudden loss of hearing in one ear over hours to days, without pain. Steroids started within days give a real chance of recovery; started after a few weeks they do very little.

And the common error is assuming it is wax or a blocked ear from a cold. The distinguishing test is simple: if a tuning fork or a humming sound is heard louder in the good ear, that suggests a nerve cause and needs same-day assessment.

Age-related hearing loss — gradual, both sides, worst for high frequencies, so consonants blur and speech in noisy places becomes hard while volume seems adequate. "I can hear you but I can't understand you" is the characteristic complaint.

And treating it matters beyond hearing: untreated hearing loss is the largest single modifiable risk factor for dementia (Chapter 20.4), and it drives social withdrawal and low mood. Hearing aids are used by a small fraction of those who would benefit, mostly because of stigma and cost.

Noise-induced loss — entirely preventable and entirely permanent once it happens. Hearing protection, volume limits, and breaks from loud environments.

Tinnitus — sound without a source, usually accompanying hearing loss. Mostly benign. Pulsatile tinnitus that beats with the heart, or tinnitus in one ear only, needs investigation. Treated with hearing aids where there is hearing loss, sound therapy, and CBT, which reduces the distress reliably even though it does not remove the sound.

Ear infections and dizziness

Otitis media — middle ear infection, mostly in children. Ear pain, fever, and reduced hearing. Most resolve without antibiotics, which are reserved for young infants, severe cases, or failure to improve.

Otitis externa — outer ear canal infection. Pain on pulling the ear, itch, and discharge. Treated with drops and by keeping the ear dry. Do not use cotton buds, which cause it as often as they relieve it.

Vertigo — the sensation that the world is spinning, which is different from lightheadedness.

BPPV — benign paroxysmal positional vertigo — brief spinning, lasting under a minute, triggered by head position change, particularly rolling over in bed or looking up.

Caused by displaced crystals in a semicircular canal (Chapter 11.8), and treated by the Epley manoeuvre — a sequence of head positions that moves them back — which resolves it in a single session for most people. It is one of the most satisfying treatments in medicine and it is badly under-used.

Vestibular neuritis — sudden severe vertigo lasting days, with nausea, no hearing loss. Improves over weeks, helped by vestibular rehabilitation exercises, which work better than prolonged use of sedating anti-sickness drugs.

Ménière's disease — episodes of vertigo lasting hours, with fluctuating hearing loss, tinnitus and a sensation of fullness in the ear.

And the important distinction: vertigo with any new neurological sign — double vision, slurred speech, weakness, numbness, severe unsteadiness with an inability to walk — may be a stroke of the brainstem or cerebellum, not an inner ear problem. That combination is an emergency.

The nose and throat

Allergic rhinitis — sneezing, itch, blocked and runny nose. Treated with nasal steroid sprays, which are more effective than antihistamine tablets for blockage and are frequently used incorrectly — aim away from the septum, and do not sniff hard after spraying. They take days to weeks to reach full effect.

Sinusitis — facial pain and pressure, blocked nose, and discoloured discharge.

Most are viral and resolve. Antibiotics are considered when symptoms persist beyond around 10 days or worsen after initially improving. Nasal saline rinsing and steroid sprays help.

And the red flags: swelling around the eye, vision changes, severe headache, or confusion — infection spreading beyond the sinus, which is an emergency.

Sore throat — mostly viral.

Bacterial tonsillitis is suggested by fever, tonsillar exudate, tender neck glands and the absence of a cough. The more of those, the more likely. Antibiotics shorten it by around a day and are given mainly to prevent complications in higher-risk cases.

And the ones that are not ordinary sore throats: difficulty breathing, drooling and inability to swallow saliva, a muffled voice, severe one-sided pain with the uvula pushed to one side — quinsy or a deep neck infection, both needing urgent assessment.

Hoarseness lasting more than three weeks needs the larynx examined, particularly in a smoker, because that is how laryngeal cancer presents and it is very treatable when caught early.

Nosebleeds — pinch the soft part of the nose, not the bridge, lean forward, and hold continuously for 10 to 15 minutes without checking. Leaning back sends blood down the throat. Seek help if it does not stop after 20 minutes, if it follows injury, or if the person is on anticoagulants.

Obstructive sleep apnoea appears here too, since it is frequently an airway problem (Chapter 20.11).

The skin

Eczema — dry, itchy, inflamed skin, often in the elbow and knee creases, associated with asthma and hay fever.

A barrier problem as much as an immune one — filaggrin gene variants weaken the skin barrier, so irritants and allergens get in and water gets out.

Which is why emollients are the foundation and not an optional extra: used generously and frequently, including when the skin looks fine.

Steroid creams for flares, matched in strength to the site — mild on the face, stronger on the body. And under-treatment from fear of steroids is a bigger practical problem than over-treatment, because untreated eczema means broken skin, infection and sleepless nights.

Then: calcineurin inhibitors, and biologics such as dupilumab for severe disease, which have been genuinely transformative.

Psoriasis — well-defined red plaques with silvery scale, on the elbows, knees, scalp and lower back (Chapter 14.5). Immune-driven with rapid skin cell turnover. Treated with vitamin D analogues, steroids, phototherapy, and biologics for severe disease, which can clear the skin completely. Associated with arthritis, and with cardiovascular risk.

Acne — blocked follicles with bacterial involvement and inflammation (Chapter 14.5). Treated with topical retinoids and benzoyl peroxide, antibiotics, hormonal treatment, and isotretinoin for severe or scarring acne, which is highly effective and requires strict pregnancy prevention because it causes severe birth defects.

Treat early to prevent scarring, because scars are permanent and acne is not.

Urticaria — hives, weals that come and go within hours. Treated with antihistamines, sometimes at higher than standard doses. With swelling of the lips, tongue or throat, or with breathing difficulty, it is anaphylaxis and an emergency (Chapter 23.5).

Cellulitis — spreading bacterial infection of the skin. Red, hot, tender, expanding, usually on a leg, with fever. Needs antibiotics, and marking the edge with a pen is a simple way to tell whether it is advancing.

Shingles — reactivated chickenpox virus in one nerve territory. A painful band of blisters on one side, not crossing the midline.

Antivirals within 72 hours reduce the pain and the risk of persistent nerve pain afterwards.

And two specific warnings: shingles involving the tip of the nose suggests eye involvement and needs urgent ophthalmology; shingles in or around the ear with facial weakness is Ramsay Hunt syndrome (Chapter 20.6).

The vaccine substantially reduces both shingles and the lingering nerve pain, and it is one of the more worthwhile vaccines in later life.

Fungal infections — athlete's foot, ringworm, nail infections. Treated with antifungals, topical for skin and usually oral for nails, which take months because the nail has to grow out.

Skin cancer — what to look at

Basal cell carcinoma — a pearly nodule with visible small vessels, sometimes ulcerating. Slow-growing, essentially never spreads, and needs treating because it destroys locally.

Squamous cell carcinoma — a scaly or crusted growing lump, sometimes tender. Can spread, so treated promptly.

Melanoma — the one that matters most.

The ABCDE checklist: Asymmetry; Border irregular; Colour varied; Diameter over 6 mm; Evolving — changing in size, shape, colour, or starting to itch or bleed.

And the single most useful sign is change, plus the "ugly duckling" — a mole that looks different from all your others.

Caught early, melanoma is usually cured by excision alone. Caught late it was until recently almost untreatable — and immunotherapy has changed advanced melanoma more than almost any other cancer (Chapter 19.7).

Prevention: sun protection, shade in the middle of the day, and no sunbeds, which are a proven carcinogen.

The theme

Most skin, eye and ear complaints are benign and self-limiting.

A small number are emergencies, and they are recognisable: sudden vision loss, a painful red eye with reduced vision, sudden hearing loss in one ear, vertigo with neurological signs, a spreading skin infection with fever, and a changing mole.

Knowing that short list is most of what a non-doctor needs, because it tells you when the answer is "wait a few days" and when it is "today".

What the next page fixes

Chapter 21.8 covers rare diseases — why they matter far more than their individual rarity suggests, and what to do when nothing fits.