1.Edoardo Cervoni, M.D. Ear Nose Throat Specialist6th March 2013 GP Trainees - Education Centre, RPH

2. Discolosures Grant/Research Support: no disclosure Consultant: no disclosure Major Shareholder: Locumdoctor4u Ltd. (Locum and Concierge Medical Services) I will not be discussing off-label uses of medications or investigations6th March 2013 GP Trainees - Education Centre, RPH 3. ENT Referrals i.Most ENT referrals are linked to Audiological and Otological problems. ii. Out of 271 consecutive referrals to the RHP ENT Department triaged in 2011, 58% could be potentially managed in Primary Care. CLPCT NHS Survey 2011 E Cervoni6th March 2013 GP Trainees - Education Centre, RPH 4. ENT Referrals i. Snoring and sleep apnoea were relatively common reasons of referrals. ii.In a rather significant proportion of cases, relevant information, with specificreference to the physical examination, were missing. iii. Among the referrals redirected to the GPwSI in ENT, deafness with wax,epistaxis and blocked nose were the most common complaints.6thCLPCT NHS Survey 2011 E CervoniMarch 2013 GP Trainees - Education Centre, RPH 5. Conditions referred Cervoni E - 20116th March 2013GP Trainees - Education Centre, RPH 6. ENT Referral Pattern is changing WHY?Ageing Sanitation -Vaccinations6th March 2013 GP Trainees - Education Centre, RPH 7. Demographics Lancashire residents grew during the decade to 2011 by 3%. There was a 5% fall in the number of 0 to 19 year olds, which was greater than the regional decrease. There was a 12% growth in people 65+ years, which was also above the regional average. The growth rate of the 65+ year olds was positive in all districts except Blackpool and the greatest in Chorley and West Lancashire.6th March 2013 GP Trainees - Education Centre, RPH 8. Sensory Presbycusis Metabolic Presbycusis High frequency down- Slowly progressivesloping SNHLFlat audiogram Speech discrimination Good speech discriminationremains goodAtropy of stria vascularis Degeneration a basalpotion of Organ of Corti Conductive Presbycusis(predominately outerThickening of basilar membranehair cells) Gradual down-sloping high Neural presbycusis frequency hearing loss Flat audiogram Rapid hearing loss Progressive Poor speechSpeech discrimination for similardiscrimination pure tone hearing is worse in older Loss of spiral ganglioncellspatients than younger patients6th March 2013 GP Trainees - Education Centre, RPH 9. Treatments Repeat testing Assistive devices Vibrating alarm clocks Flashing telephone and door signalers Television listening systems Personal amplifiers Hearing aids In U.S.A. an estimated 4.5 million hearing aid users , but only 10-20% who could use them do and 12% of people who have them dont wear them.6th March 2013 GP Trainees - Education Centre, RPH 10. Types of hearing aid circuitry Analog Digitally controlled analog Digital sound processing Body Aids Behind-the-ear (BTE) In-the-ear(ITE) In-the-canal(ITC) Completely-in-canal(CIC)6th March 2013 GP Trainees - Education Centre, RPH 11. Dysphagia Phases of swallowing Oral (reduced facial muscle strength, decreasedmasticatory strength, reduced tongue control,missing dentition) Pharyngeal (delayed in elderly subjects,decreased pharyngolaryngeal sensorydiscrimination, abnormal UES function,increased penetration and silent aspiration) Oesophageal ( decreased or absent secondaryperistalsis)6th March 2013GP Trainees - Education Centre, RPH 12. Evaluation History: Feeding problem vs. swallowing disorder Liquids vs. solids Globus, halitosis, wet vocal quality, reflux,odynophagia, recurrent pneumonia, hoarseness,dysarthria Physical Exam Oral cavity and upper aerodigestive tract, salivaquality/dentition/dentures Neurological evaluation including arousal,orientation, cognition, cranial nerves6th March 2013 GP Trainees - Education Centre, RPH 13. Investigations Barium swallow (anatomic lesions) Modified barium swallow (dinamic view) of swallowing from oral cavity to lower esophageal sphincter) FEES Functional endoscopic evaluation of swallowing Videofluoroscopic swallowing study, or VFSS test6th March 2013 GP Trainees - Education Centre, RPH 14. Causes of dysphagia Stroke Neuromuscular disease - Parkinsons disease (pill- rolling tremor, bradykinesia, cog-wheeling rigidity), Amyotrophic lateral sclerosis Medications (xerostomia, mental status change, dyskinesia, GERD, esophagitis) Cricopharyngeus dysfunction (functional, structural, bar on barium swallow) Zenkers diverticulum (regurgitation) Neoplasms6th March 2013 GP Trainees - Education Centre, RPH 15. Treatments Swallowing therapy Dietary modifications Rationalization of medications PEG Cricopharyngeal myotomy, Botox injection of cricopharyngeal bar Surgical repair of Zenkers (open vs. endoscopic)6th March 2013 GP Trainees - Education Centre, RPH 16. Balance Disorders Difficulties with sensory function, central nervous system integration, neuromuscular and skeletal function 30-50% persons 65 and older fall in a given year 50% per year fall age 80 or older 1% of falls suffer hip fractures, 5% some type of fracture Roughly half of hip fractures are estimated to never recover normal function again6th March 2013 GP Trainees - Education Centre, RPH 17. Vestibular changes with age Termed presbystasis Loss of hair cells primarily in the ampulla Total number of vestibular nerve axons is 37% thanyounger patients Loss of neurons in vestibular nuclei of 3% per decadeage 40-90 Reduction in gain of VOR, smooth pursuit, increase insaccade latencies Postural stability: Sensory (visual, hearing, vestibular, proprioceptive)/Musculoskeletal/Cognitive/Integrative function6th March 2013 GP Trainees - Education Centre, RPH 18. Other factors in balance disorders Cerebellar degeneration, Parkinsons disease, Huntingtons disease, vitamin B12 deficiency, dementia, diabetic neuropathy, brain and spinal cord tumors, postural hypotension, cerebrovascular disease, atherosclerosis, musculoskeletal disease, metabolic disorders, cardiovascular disorders, medications, visual impairment6th March 2013 GP Trainees - Education Centre, RPH 19. History Dizziness, dysequilibrium, vertigo Onset, duration, frequency, severity, provocation,associated symptoms, falls Medications, medical conditions Physical exam Examine sensory functions, posture, gait,neurological function Adjunctive testing Audiogram, electronystagmography, MRI,posturography6th March 2013GP Trainees - Education Centre, RPH 20. Treatments6th March 2013 GP Trainees - Education Centre, RPH 21. Objective -Pulsatile tinnitus Arteriovenous Cardiac murmurs malformations Pregnancy Vascular tumors Anemia Venous hum Thyrotoxicosis Atherosclerosis Pagets disease Ectopic carotid artery Benign intracranial Persistent stapedialhypertension artery Dehiscent jugular bulb Idiopathic stapedial muscle spasm Vascular loopsPalatal myoclonus Patulous eustachian tube6th March 2013 GP Trainees - Education Centre, RPH 22. Subjective tinnitus Presbycusis Noise exposure Menieres disease Otosclerosis Head trauma Acoustic neuroma Drugs Middle ear effusion TMJ problems Depression Hyperlipidemia Meningitis Syphilis6th March 2013 GP Trainees - Education Centre, RPH 23. Treatments Multiple treatments Reassurance Avoidance of dietary White noise fromstimulants: coffee, tea, radio or homecola, etc. masking machine Smoking cessation Avoid medicationsknown to cause tinnitus6th March 2013 GP Trainees - Education Centre, RPH 24. Nasal Complaints Nasal obstruction Rhinorrhea Epistaxis Olfactory dysfunction6th March 2013 GP Trainees - Education Centre, RPH 25. Causes Inflammation: decrease immune function, mucociliary dysfunction, allergy, dehydration with thickening of secretions Dystrophic changes: both atrophy of nasal mucosa and increase in vasomotor rhinitis are common Neoplasia: nasal obstruction, pain, epistaxis, rhinorrhea Trauma: old traumas, previous surgery Endocrine-metabolic disorders: hypothyroidism, decreased vitamin A and zinc Pharmacologic effects: diuretics, tricyclic antidepressants, antihistamines6th March 2013 GP Trainees - Education Centre, RPH 26. Voice changes Estimated 12% of the elderly have vocal dysfunction Fundamental frequency of the male voice tends to increase with age Fundamental frequency in females decreases with age6th March 2013 GP Trainees - Education Centre, RPH 27. Voice changes Common vocal cord findings Atrophy Bowed cords Oedema Loss of collagen and elastic fibers, decrease indensity of fibroblasts, atrophy of submucousglands, fibrosis, disorganization of collagen fibers6th March 2013 GP Trainees - Education Centre, RPH 28. Neurological disorders with voice changes Essential tremor Parkinsons disease: low volume, breathy, and monotonic Stroke Myasthenia gravis Amyotrophic lateral sclerosis6th March 2013 GP Trainees - Education Centre, RPH 29. Treatments Speech therapy Medialization thyroplasty Diagnosis and treatment of underlying disorder6th March 2013 GP Trainees - Education Centre, RPH 30. Cancer Squamous cell cancers Thyroid malignancies Well differentiated have worse course Anaplastic or undifferentiated more common Salivary gland malignancies Lymphomas6th March 2013 GP Trainees - Education Centre, RPH 31. Laryngeal Cancer UK6th March 2013 GP Trainees - Education Centre, RPH 32. Cosmetics Elderly are leading more active lives for much longer than in the past With the explosive growth of cosmetic facial plastic surgery paired with the explosive growth of the elderly population there will be many more elderly cosmetic patients6th March 2013 GP Trainees - Education Centre, RPH 33. Skin- loss of tone, dynamic and static wrinkling,thinning, pigmentary changes, gravitationaldescent of soft tissues Chemical peel, laser resurfacing Botox injection Rhytidectomy Upper third-ptosis of eyebrows and forehead Direct brow lift Pretrichial/coronal/endoscopic6th March 2013 GP Trainees - Education Centre, RPH 34. Periorbital Region - lower eyelid laxity, prolapsed lacrimal gland, ptosis(usually dermatochalasis) Dacryoadenopexy Lower lid shortening Upper/lower blepharoplasty Nose tip ptosis from loss of attachments between upper and lower lateralcartilages, loss of connections between medial crura and septum,ligamentous connections between domes of lower lateral cartilages andanterior septal angle Rhinoplasty-shorten lateral crura, place septal strut Lower third loss of premental fat pad witches chin, cheiloptosis,platysmal bands Genioplasty Lip-lift Plication, imbrication, suture suspension, Z-plasty of platysma6th March 2013GP Trainees - Education Centre, RPH 35. Conclusions With the expected explosive growth of the elderly population, this group will become a larger proportion of patients The otolaryngologist must consider the patients health and well being as a whole especially in this group of patients who often have multiple problems6th March 2013 GP Trainees - Education Centre, RPH 36. 1.Parham K, Lin FR, Coelho DH, Sataloff RT, Gates GA. Comprehensive Management of Presbycusis: Central and Peripheral. OtolaryngolHead Neck Surg. 2013 Feb 8.2.Creighton FX Jr, Poliashenko SM, Statham MM, Abramson P, Johns MM 3rd. The growing geriatric otolaryngology patient population: astudy of 131,700 new patient encounters. Laryngoscope. 2013 Jan;123(1):97-102.3.Dagan E, Wolf M, Migirov LM. Why do geriatric patients attend otolaryngology emergency rooms? Isr Med Assoc J. 2012 Oct;14(10):633-6.4.Kumar S, Rout N, Kumari P, Dey B. The conceptions of hearing impairment, causes and its management: a train survey. Int J PediatrOtorhinolaryngol. 2012 Aug;76(8):1123-6. doi: 10.1016/j.ijporl.2012.04.014. Epub 2012 May 12.5.Van Vuuren PA, Kagan SH, Chalian AA. Geriatric otolaryngology toolbox: what you and your nurse can do to improve outcomes forolder adults. Ear Nose Throat J. 2009 Oct;88(10):1162-8.6.Chalian AA. Accomplishment and opportunity in geriatric otolaryngology. Ear Nose Throat J. 2009 Oct;88(10):1156-61.7.Goldstein JC. The American Society of Geriatric Otolaryngology. Ear Nose Throat J. 2007 Dec;86(12):718-9.8.Eibenstein A, Fioretti AB, Simaskou MN, Sucapane P, Mearelli S, Mina C, Amabile G, Fusetti M. Olfactory screening test in mildcognitive impairment. Neurol Sci. 2005 Jul;26(3):156-60.9.Bora H, Bandyopadhyay SN, Basu SK, Majhi PK. Geriatric problems in otolaryngology. J Indian Med Assoc. 2004 Jul;102(7):366, 368, 370.Review.10. Vaiman M, Eviatar E, Segal S. Surface electromyographic studies of swallowing in normal subjects: a review of 440 adults. Report 1.Quantitative data: timing measures. Otolaryngol Head Neck Surg. 2004 Oct;131(4):548-55.11. Belafsky PC, Postma GN, Amin MR, Koufman JA. Symptoms and findings of laryngopharyngeal reflux. Ear Nose Throat J. 2002 Sep;81(9Suppl 2):10-3.12. Sahoo GC. Gerontology in ENT (Geriatric Otolaryngology) - an over view. Indian J Otolaryngol Head Neck Surg. 2001 Oct;53(4):267-9.13. Jiang RS, Hsu CY. Endoscopic sinus surgery for the treatment of chronic sinusitis in geriatric patients. Ear Nose Throat J. 2001Apr;80(4):230-2.6th March 2013GP Trainees - Education Centre, RPH