ENT for General Practice

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ENT for General Practice

• George Vattakuzhiyil
• MBBSMS(ENT)FRCS

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Objectives

• Detailed examination of ENT/HN
• Learn to diagnose treat common ENT pathology
• Recognise serious complication, request
  additional tests, specialty referral

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Quick recap of ear anatomy
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Hearing testsRinne and Weber testsRinne Ac
better than BC
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Weber 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

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Otitis 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

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Otitis externa

• Extension to pre/post auricular area
• Microsuction/IV antibiotics
• Diabetic patient/ Pseudomonas inf
• ? Malignant otitis externa

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Acute otitis media

• Common in children
• otalgia/discharge
• Unwell/pyrexia
• TM red, bulging,oedematous
• Streptococcus/Haemophilus
• Amoxycillin 5-7 days

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complications

• Acute mastoiditis
• Chronic otitis media
• Intracranial complications

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CSOM

• Recurrent ear discharge
• Hearing loss
• Perforation of the TM central
• Presence of cholesteatoma
• Marginal, Attic perforation
• Offensive discharge, bleeding, granulations

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Complications

• Vestibular symptoms
• Facial palsy
• Intracranial complications

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Management

• Medical Dry mopping,suction clearance,/ Ear
  drops, rarely systemic antibiotics
• Surgical
• Myringoplasty/ Tympanoplasty
• Combined Mastoidectomy/Tympanoplasty

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Otitis mediaeffusion-Glue ear

• Common in children
• Reduced hearing noticed by parents/teacher
• Recurrent ear infection
• Unsteadiness- child falling over
• Effusions persist for weeks after AOM
• 80 clear at 8 weeks

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Signs of OME

• Dull retracted TM
• May show air-fluid level
• Conductive hearing loss(whisper test, Rinne/weber
  tests)
• OME persistant over 3 months ENT referral

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Treatment

• Failed audio
• Flat tympanograms
• h/o gt3 episodes in 6/12 or gt4 in 12/12
• Grommet insertion
• Evaluate adenoids, especially in recurrent
  grommet insertions

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Syringing the ear

• Which ear needs syringing?

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Occlusive cerumen

• Causing pain
• Hearing loss
• Tinnitus

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Avoid syringing

• Non occlussive cerumen
• Previous ear surgery
• Only hearing ear
• Perforated TM
• Kerotosis obturans

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Acute/Chronic tonsillitis

• Sorethroat, fever, malaise
• Tender cervical lymph nodes
• Enlarged congested tonsils with pus
• Analgesia
• Penicillin
• Prolonged course, worsening symptoms consider
  glandular fever

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Quincy (peritonsillar abscess)

• ? pain trismus
• Swelling of the soft palate
• Displacement of uvula
• Refer for I/V antibiotics ? drainage

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Allergic rhinitis

• Seasonal allergen usually outdoor
• perennial indoor dust, mite, cat dander
• O/E pale mucosa, boggy turbinate
• Avoid allergen, antihistamines, topical
  vasoconstrictors, steroids
• Surgery- SMD, laser, Turbinectomy

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sinusitis

• Facial pain/ pressure/ fullness
• Nasal obstruction/ discharge
• Altered smell
• Pyrexia in acute sinusitis
• Headache, halitosis, dental pain
• Minor factors cough,ear pressure, fatigue

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sinusitis

• Acute sinusitis lt 4/52
• Chronic gt4/52 or 4 or more episodes
• O/E nasal congestion, polyps, pus in MM
• Structural changes DNS, concha bullosa

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sinusitis

• Sinus X ray usually unhelpful
• CT sinuses
• Acute amoxicillin ? clavulonate, oxymetazoline
• Chronic Pus c/s, augmentinmetronidazole, Treat
  the cause allergy, surgery(FESS)

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CT sinuses
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Epistaxis

• Most common site littles area
• Cause Idiopathic, trauma (nose picking), dry
  mucosa, hypertension, coagulopathy, NSAID,
  Warfarin, tumours
• Try naseptin cream for a short course
• Silver nitrate cautery
• Electrocautery/ packing/ surgery

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Common PathologyViral laryngitis

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

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Hoarseness

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

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Vocal cord nodules

• Singer / teacher / children /
• Often B/L Junction ant/ middle 1/3
• Voice rest / speech therapy
• Rarely MLS excision

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Laryngitis - GORD

• Hx of GORD
• Inflammation of Post larynx
• Treatment for reflux
• Raising head end of cot

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Vocal polyp/Reinkes oedema

• Male Smoker
• Irritant exposure
• Hoarseness
• Dyspnoea
• Irritant cough
• Treatment Voice rest, speech therapy,stop
  smoking, Microlaryngoscopy and vc stripping

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Sq papilloma

• Anterior commissure/ true VC
• Complete excision
• Laser treatment

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Laryngeal Malignancy

• Risk factors
• Smoking
• Alcohol
• Radiation exposure
• HPV
• Nickel exposure

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Symptoms

• Hoareseness associated with
• Dysphagia
• Odynophagia
• Otalgia
• Haemoptysis

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Signs

• Dysplasia/Ca in situ Leukoplakia
• Ulcero/Exophytic growth
• Neck mass
• URGENT REFERRAL

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Cord paralysis

• Breathy voice (air escape)
• B/L airway compromise
• P/H of thyroid, cardiovascular Sx
• Cord in paramedian position
• Refer for investigations and treatment

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Functional aphonia

• Psychogenic Only able to speak in forced whisper
• Normal cough
• Spastic dysphonia strained/strangled voice
• Onset related to major life stress
• Hyperadduction of true/false cord
• Speech therapy, ? Botulinum toxin inj

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Dysphagia

• Progressive dysphagia for solids structural
  lesion
• Dysphagia for liquids Neurological
• Painful swallow spasm of cricopharynx, ulcer
• Signs of reflux
• Signs of aspiration

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Examination-key points

• Oral cavity Tongue, gag reflex,soft palate
• Pharynx pooling, lesions
• larynx Elevation of larynx, scopy
• Neck masses

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Investigations

• Ba meal
• Video fluroscopy
• Oesophagoscopy
• Imaging CT/MRI

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Salivary glands

• Painful diffuse swelling sailadinitis
• Plus fluctuation with meals calculi
• Non painful swelling Tumour

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Examination

• Unilateral/bilateral ?
• Diffuse/well circumscribed?
• Is it tender?
• Any discharge from the ducts?
• Enlarged nodes?
• Palpable calculi?

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Investigations

• Plain X-ray lateral view
• FNAC
• CT scan
• Sialogram

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Tinnitus

• SNHL
• Drugs-NSAID, Aminoglycosides, Antidepressants
• Tumors- Acoustic neuroma, Temporal lobe tumor
• Anxiety/ Depression

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Tinnitus

• If unilateral refer MRI
• Serology FTA
• Haematocrit
• Lipids
• Audiogram/ ABR
• Consider hearing therapy referral councilling/
  tinnitus masker

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Thankyou