ENT for General PracticeENT for General Practice

George VattakuzhiyilMBBS;MS(ENT);FRCS

ObjectivesObjectives

Detailed examination of ENT/H&N

Learn to diagnose & treat common ENT pathology

Recognise serious complication, request additional tests, specialty referral

Quick recap of ear anatomyQuick recap of ear anatomy

Hearing testsHearing testsRinne and Weber testsRinne and Weber tests

Rinne Ac better than BCRinne Ac better than BC

Hearing loss

256Hz 512HZ 1024Hz

< 15db

15-30db x x

30-45db x x 45-60db x x x

Weber testWeber test

Hold the base of the tuning fork in the midline (forehead, incisor teeth)

Laterelising to the left: conductive loss on left or SNHL on right

Otitis ExternaOtitis Externa Inflammatory disorder of

skin lined EAC Acute/Chronic Generelised skin disorder Pathogens: staph,

pseudomonas, Fungus Topical antibiotic/steroid Sofradex,otomize

spray,otosporin,GHC, locorten- vioform

Otitis externaOtitis externa

Extension to pre/post auricular areaMicrosuction/IV antibioticsDiabetic patient/ Pseudomonas inf? Malignant otitis externa

Acute otitis mediaAcute otitis media

Common in children otalgia/discharge Unwell/pyrexia TM: red,

bulging,oedematous Streptococcus/

Haemophilus Amoxycillin 5-7 days

complicationscomplications

Acute mastoiditis Chronic otitis media Intracranial

complications

CSOMCSOM

Recurrent ear discharge Hearing loss Perforation of the TM –

central Presence of cholesteatoma Marginal, Attic

perforation Offensive discharge,

bleeding, granulations

ComplicationsComplications

Vestibular symptoms

Facial palsy

Intracranial complications

ManagementManagement

Medical: Dry mopping,suction clearance,/ Ear drops, rarely systemic antibiotics

SurgicalMyringoplasty/ TympanoplastyCombined Mastoidectomy/Tympanoplasty

Otitis media+effusion-Glue earOtitis media+effusion-Glue ear

Common in childrenReduced hearing noticed by parents/teacherRecurrent ear infectionUnsteadiness- child falling overEffusions persist for weeks after AOM80% clear at 8 weeks

Signs of OMESigns of OME

Dull retracted TMMay show air-fluid levelConductive hearing loss(whisper test,

Rinne/weber tests)OME persistant over 3 months ENT referral

TreatmentTreatment

Failed audio Flat tympanograms h/o >3 episodes in

6/12 or >4 in 12/12 Grommet insertion Evaluate adenoids,

especially in recurrent grommet insertions

Syringing the earSyringing the ear

Which ear needs syringing?

Occlusive cerumenOcclusive cerumen

Causing pain Hearing loss Tinnitus

Avoid syringingAvoid syringing

Non occlussive cerumen

Previous ear surgery Only hearing ear Perforated TM Kerotosis obturans

Acute/Chronic tonsillitisAcute/Chronic tonsillitis

Sorethroat, fever, malaiseTender cervical lymph nodesEnlarged congested tonsils with pusAnalgesiaPenicillinProlonged course, worsening symptoms

consider glandular fever

Quincy (peritonsillar abscess)Quincy (peritonsillar abscess)

pain + trismus Swelling of the soft

palate Displacement of uvula Refer for I/V

antibiotics drainage

Allergic rhinitisAllergic rhinitis

Seasonal : allergen usually outdoor perennial: indoor dust, mite, cat dander

O/E pale mucosa, boggy turbinateAvoid allergen, antihistamines, topical

vasoconstrictors, steroidsSurgery- SMD, laser, Turbinectomy

sinusitissinusitis

Facial pain/ pressure/ fullnessNasal obstruction/ dischargeAltered smellPyrexia in acute sinusitisHeadache, halitosis, dental painMinor factors: cough,ear pressure, fatigue

sinusitissinusitis

Acute sinusitis < 4/52Chronic >4/52 or 4 or more episodes

O/E nasal congestion, polyps, pus in MMStructural changes: DNS, concha bullosa

sinusitissinusitis

Sinus X ray usually unhelpfulCT sinuses Acute: amoxicillin clavulonate,

oxymetazolineChronic: Pus c/s,

augmentin+metronidazole, Treat the cause: allergy, surgery(FESS)

CT sinusesCT sinuses

EpistaxisEpistaxis

Most common site – littles areaCause: Idiopathic, trauma (nose picking),

dry mucosa, hypertension, coagulopathy, NSAID, Warfarin, tumours

Try naseptin cream for a short courseSilver nitrate cauteryElectrocautery/ packing/ surgery

Common PathologyCommon PathologyViral laryngitisViral laryngitis

Viral URTI preceding aphonia Hx sorethroat B/L V.c. oedema/erythema voice rest, antibiotics

HoarsenessHoarseness

Symptom of both local, systemic pathology Often the early symptom of ca larynx Persistent > 2/52 or worsening Associated with loss of weight, smoking,

Vocal cord nodulesVocal cord nodules

Singer / teacher / children /Often B/L – Junction ant/ middle 1/3Voice rest / speech therapyRarely – MLS excision

Laryngitis - GORDLaryngitis - GORD

Hx of GORDInflammation of Post larynxTreatment for refluxRaising head end of cot

Vocal polyp/Reinkes oedema Vocal polyp/Reinkes oedema Male SmokerIrritant exposureHoarseness DyspnoeaIrritant coughTreatment: Voice rest, speech therapy,stop

smoking, Microlaryngoscopy and vc stripping

Sq papillomaSq papilloma

Anterior commissure/ true VCComplete excisionLaser treatment

Laryngeal MalignancyLaryngeal Malignancy

Risk factorsSmokingAlcoholRadiation exposureHPV Nickel exposure

SymptomsSymptoms

Hoareseness associated withDysphagiaOdynophagiaOtalgiaHaemoptysis

SignsSigns

Dysplasia/Ca in situ Leukoplakia

Ulcero/Exophytic growthNeck mass

URGENT REFERRAL

Cord paralysisCord paralysis

Breathy voice (air escape)B/L airway compromiseP/H of thyroid, cardiovascular SxCord in paramedian positionRefer for investigations and treatment

Functional aphoniaFunctional aphonia

Psychogenic Only able to speak in forced whisper

Normal coughSpastic dysphonia strained/strangled voiceOnset related to major life stressHyperadduction of true/false cordSpeech therapy, ? Botulinum toxin inj

DysphagiaDysphagia

Progressive dysphagia for solids structural lesion

Dysphagia for liquids NeurologicalPainful swallow spasm of cricopharynx,

ulcerSigns of refluxSigns of aspiration

Examination-key points Examination-key points

Oral cavity Tongue, gag reflex,soft palatePharynx pooling, lesionslarynx Elevation of larynx, scopyNeck masses

InvestigationsInvestigations

Ba mealVideo fluroscopyOesophagoscopyImaging CT/MRI

Salivary glandsSalivary glands

Painful diffuse swelling sailadinitisPlus fluctuation with meals calculiNon painful swelling Tumour

ExaminationExamination

Unilateral/bilateral ? Diffuse/well

circumscribed? Is it tender? Any discharge from

the ducts? Enlarged nodes? Palpable calculi?

InvestigationsInvestigations

Plain X-ray lateral view

FNAC CT scan Sialogram

TinnitusTinnitus

SNHLDrugs-NSAID, Aminoglycosides,

AntidepressantsTumors- Acoustic neuroma, Temporal lobe

tumorAnxiety/ Depression

TinnitusTinnitus

If unilateral refer: MRISerology: FTA HaematocritLipidsAudiogram/ ABRConsider hearing therapy referral

councilling/ tinnitus masker