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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
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