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ENT Update 7th Feb 08 David Strachan ENT Consultant, Bradford Royal Infirmary

David Strachan ENT Consultant, Bradford Royal Infirmary

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Page 1: David Strachan ENT Consultant, Bradford Royal Infirmary

ENT Update 7th Feb 08

David StrachanENT Consultant,BradfordRoyalInfirmary

Page 2: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 3: David Strachan ENT Consultant, Bradford Royal Infirmary

Basic Questions1. Draw a normal eardrum2. What normal structures can you see up a

nose3. What is a cholesteatoma4. What is the commonest way for an

acoustic neuroma to present5. What may cause a facial palsy

Page 4: David Strachan ENT Consultant, Bradford Royal Infirmary

TOPICS • TAKING A HISTORY• (EXAMINATION)• AUDIOGRAMS & HEARING LOSS• CHRONIC EAR DISEASE• VERTIGO• TINNITUS• GLUE EAR (TARGET STUDY)• RHINITIS / SINUSITIS• NECK & THROAT SYMPTOMS

– HOARSE VOICE– DYSPHAGIA– THYROID / NECK LUMP

• ANYTHING ELSE

Page 5: David Strachan ENT Consultant, Bradford Royal Infirmary

Back to basics

Page 6: David Strachan ENT Consultant, Bradford Royal Infirmary

Audiology courseDiagnostic Strategy

David Strachan FRCSENT Consultant

Bradford Royal Infirmary

Page 7: David Strachan ENT Consultant, Bradford Royal Infirmary

The History

•The most important part of the strategy

• Take timeBe thoroughBe structured

Page 8: David Strachan ENT Consultant, Bradford Royal Infirmary

HISTORY TAKING: SUGGESTED SEQUENCE

• Introduction• Presenting complaint• History of current illness• Systemic enquiry• Past medical history• Drugs and allergies• Family history• Social and personal history• Patient’s ideas, concerns and expectations.

Page 9: David Strachan ENT Consultant, Bradford Royal Infirmary

Diagnostic strategy …

• History taking

• Examination• Investigation

a differential diagnosis is already in mind

Page 10: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMINATION - EAR

Page 11: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMINATION - EAR

• External Inspection• Palpation• Auriscope• (Hearing assessment)

Page 12: David Strachan ENT Consultant, Bradford Royal Infirmary

ExternalInspection

Is there anexternaldeformity?

Page 13: David Strachan ENT Consultant, Bradford Royal Infirmary

ExternalInspection

Are there any scars?

Endaural

Postauricular

Page 14: David Strachan ENT Consultant, Bradford Royal Infirmary

EXTERNAL EXAMINATIONOF EAR

Palpation

Is it tender?

Tragus Postaural

Page 15: David Strachan ENT Consultant, Bradford Royal Infirmary

Auriscope Examination

Page 16: David Strachan ENT Consultant, Bradford Royal Infirmary

Auriscope Examination

ChildPosterior

AdultPosterior-Superior

Page 17: David Strachan ENT Consultant, Bradford Royal Infirmary

Auriscope Examination

CartilagenousExternal Auditory Canal

Page 18: David Strachan ENT Consultant, Bradford Royal Infirmary

Auriscope Examination

BonyExternal Auditory Canal

Page 19: David Strachan ENT Consultant, Bradford Royal Infirmary

Auriscope Examination

Bony External Auditory Canal& Tympanic Membrane

Page 20: David Strachan ENT Consultant, Bradford Royal Infirmary

Auriscope Examination

Wax

Page 21: David Strachan ENT Consultant, Bradford Royal Infirmary

Epithelial Migration

Page 22: David Strachan ENT Consultant, Bradford Royal Infirmary

Epithelial Migration

2 months

4 months

Page 23: David Strachan ENT Consultant, Bradford Royal Infirmary

Auriscope Examination

Tympanic Membrane

incus

Roundwindow

Lightreflex

malleus

Page 24: David Strachan ENT Consultant, Bradford Royal Infirmary

The ear

Page 25: David Strachan ENT Consultant, Bradford Royal Infirmary

malleus

incus

roundwindow

Page 26: David Strachan ENT Consultant, Bradford Royal Infirmary

Auriscope Examination

Tympanic Membrane

incuslightreflex

malleusroundwindow

Page 27: David Strachan ENT Consultant, Bradford Royal Infirmary

TOPICS • TAKING A HISTORY• (EXAMINATION)• AUDIOGRAMS & HEARING LOSS• CHRONIC EAR DISEASE• VERTIGO• TINNITUS• GLUE EAR (TARGET STUDY)• RHINITIS / SINUSITIS• NECK & THROAT SYMPTOMS

– HOARSE VOICE– DYSPHAGIA– THYROID / NECK LUMP

• ANYTHING ELSE

Page 28: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 29: David Strachan ENT Consultant, Bradford Royal Infirmary

HEARING DISABILITY

NORMAL

MILD HEARING LOSS

MODERATE HEARING LOSS

SEVERE HEARING LOSS

PROFOUND HEARING LOSS

TOTAL LOSS

Page 30: David Strachan ENT Consultant, Bradford Royal Infirmary

NIHL - Audiological findings

Page 31: David Strachan ENT Consultant, Bradford Royal Infirmary

High frequency

hearing loss

VowelsConsonants

Page 32: David Strachan ENT Consultant, Bradford Royal Infirmary

High frequency hearing loss

__e _a_ _a__a_ o_ __e _a_

Page 33: David Strachan ENT Consultant, Bradford Royal Infirmary

High frequency hearing loss

th_ f_t c_ts_t _n th_ m_t

Page 34: David Strachan ENT Consultant, Bradford Royal Infirmary

High frequency hearing loss

the fat catsat on the mat

Page 35: David Strachan ENT Consultant, Bradford Royal Infirmary

Moderate hearing loss

VowelsConsonants

Disability issues

Page 36: David Strachan ENT Consultant, Bradford Royal Infirmary

TOPICS • TAKING A HISTORY• (EXAMINATION)• AUDIOGRAMS & HEARING LOSS• CHRONIC EAR DISEASE• VERTIGO• TINNITUS• GLUE EAR (TARGET STUDY)• RHINITIS / SINUSITIS• NECK & THROAT SYMPTOMS

– HOARSE VOICE– DYSPHAGIA– THYROID / NECK LUMP

• ANYTHING ELSE

Page 37: David Strachan ENT Consultant, Bradford Royal Infirmary

Otitis externa

WicksDrops / Spray

Regular toilet

Page 38: David Strachan ENT Consultant, Bradford Royal Infirmary

Chronic Ear

Disease

Page 39: David Strachan ENT Consultant, Bradford Royal Infirmary

Chronic Ear

Disease

Page 40: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 41: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 42: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 43: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 44: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 45: David Strachan ENT Consultant, Bradford Royal Infirmary

Cholesteatoma

“skin in the wrong place”

Page 46: David Strachan ENT Consultant, Bradford Royal Infirmary

Cholesteatoma – diagnosis (can be difficult)

Page 47: David Strachan ENT Consultant, Bradford Royal Infirmary

Complications of middle ear disease

Page 48: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 49: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 50: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 51: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 52: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 53: David Strachan ENT Consultant, Bradford Royal Infirmary

TOPICS • TAKING A HISTORY• (EXAMINATION)• AUDIOGRAMS & HEARING LOSS• CHRONIC EAR DISEASE• VERTIGO• TINNITUS• GLUE EAR (TARGET STUDY)• RHINITIS / SINUSITIS• NECK & THROAT SYMPTOMS

– HOARSE VOICE– DYSPHAGIA– THYROID / NECK LUMP

• ANYTHING ELSE

Page 54: David Strachan ENT Consultant, Bradford Royal Infirmary

What is Vertigo

Page 55: David Strachan ENT Consultant, Bradford Royal Infirmary

Vertigo

• Sensation of rotation• Not ‘unsteadiness’• Not ‘lightheadedness’• History is key

Page 56: David Strachan ENT Consultant, Bradford Royal Infirmary

History is key

Page 57: David Strachan ENT Consultant, Bradford Royal Infirmary

good

bad

? Symptoms with time

Page 58: David Strachan ENT Consultant, Bradford Royal Infirmary

good

bad

• Lasts hours• Variable attacks• Other symptoms• ? menieres

Page 59: David Strachan ENT Consultant, Bradford Royal Infirmary

good

bad

Severe initial attackSlow improvement

? Vestibularneurolabyrinthitis

Page 60: David Strachan ENT Consultant, Bradford Royal Infirmary

good

bad

lasts secondsrelated to head posn? BPPV

Page 61: David Strachan ENT Consultant, Bradford Royal Infirmary

Dix Hallpike

• BPPV & Epley manoeuvre

Page 62: David Strachan ENT Consultant, Bradford Royal Infirmary

TOPICS • TAKING A HISTORY• (EXAMINATION)• AUDIOGRAMS & HEARING LOSS• CHRONIC EAR DISEASE• VERTIGO• TINNITUS• GLUE EAR (TARGET STUDY)• RHINITIS / SINUSITIS• NECK & THROAT SYMPTOMS

– HOARSE VOICE– DYSPHAGIA– THYROID / NECK LUMP

• ANYTHING ELSE

Page 63: David Strachan ENT Consultant, Bradford Royal Infirmary

A symptom not a diagnosis

Page 64: David Strachan ENT Consultant, Bradford Royal Infirmary

Tinnitus

• Diagnosis explained• Investigate as appropriate

– Audio– ? MRI

• Treatment options– Nil– Simple strategies– TRT (Tinnitus Retraining Therapy)

Page 65: David Strachan ENT Consultant, Bradford Royal Infirmary

Key point

• Persistent unilateral symptoms

Page 66: David Strachan ENT Consultant, Bradford Royal Infirmary

Unilateral hearing loss +/- tinnitus

Page 67: David Strachan ENT Consultant, Bradford Royal Infirmary

TOPICS • TAKING A HISTORY• (EXAMINATION)• AUDIOGRAMS & HEARING LOSS• CHRONIC EAR DISEASE• VERTIGO• TINNITUS• GLUE EAR (TARGET STUDY)• RHINITIS / SINUSITIS• NECK & THROAT SYMPTOMS

– HOARSE VOICE– DYSPHAGIA– THYROID / NECK LUMP

• ANYTHING ELSE

Page 68: David Strachan ENT Consultant, Bradford Royal Infirmary

Diagnosing OME

Page 69: David Strachan ENT Consultant, Bradford Royal Infirmary

Diagnosing OME

Audio + tymps

Page 70: David Strachan ENT Consultant, Bradford Royal Infirmary

Treating OME

Page 71: David Strachan ENT Consultant, Bradford Royal Infirmary

TARGET STUDY• MRC funded randomised controlled trial• Surgery v non-surgery

Page 72: David Strachan ENT Consultant, Bradford Royal Infirmary

OME leading to 20 dB + loss > 12 weeks

Page 73: David Strachan ENT Consultant, Bradford Royal Infirmary

? Watch - ? Grommets

Page 74: David Strachan ENT Consultant, Bradford Royal Infirmary

TARGET STUDY• Benefit in surgery group …

– hearing disability improved– Q of L scores– non-aggressive behaviour problems– (NOT Aggressive behaviour problems)

Page 75: David Strachan ENT Consultant, Bradford Royal Infirmary

Basic Point

• A child that ‘cant hear’ cant hear till proved otherwise

• Hearing loss is underestimated

Page 76: David Strachan ENT Consultant, Bradford Royal Infirmary

TOPICS • TAKING A HISTORY• (EXAMINATION)• AUDIOGRAMS & HEARING LOSS• CHRONIC EAR DISEASE• VERTIGO• TINNITUS• GLUE EAR (TARGET STUDY)• RHINITIS / SINUSITIS• NECK & THROAT SYMPTOMS

– HOARSE VOICE– DYSPHAGIA– THYROID / NECK LUMP

• ANYTHING ELSE

Page 77: David Strachan ENT Consultant, Bradford Royal Infirmary

Back to basics

Page 78: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMINATION - NOSE

Page 79: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMINATION - NOSE

• External Inspection• Airway• Nasal Cavity

– Auriscope– (Thudicums/ Head light)

Page 80: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMINATION - NOSE

External Inspection

Page 81: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMINATION - NOSE

The Airway

Page 82: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMINATION OF NASAL CAVITY

Look for …

Septumposition

Little’s area

InferiorTurbinate

Page 83: David Strachan ENT Consultant, Bradford Royal Infirmary

Septum - position

Page 84: David Strachan ENT Consultant, Bradford Royal Infirmary
Page 85: David Strachan ENT Consultant, Bradford Royal Infirmary

Septum - Little’s area

Page 86: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMNOF

NASALCAVITY

Page 87: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMNOF

NASALCAVITY

SeptumInferiorTurbinate

Page 88: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMINATION OF NASAL CAVITY

Look for …

• InferiorTurbinate

•? ? MiddleTurbinate

Page 89: David Strachan ENT Consultant, Bradford Royal Infirmary

EXAMNOF

NASALCAVITY

SeptumInferior

Turbinate

MiddleTurbinate

Page 90: David Strachan ENT Consultant, Bradford Royal Infirmary

RHINITIS (Rhinosinusitis) –SYMPTOMS & TREATMENTS

IN PRIMARY CARE

Page 91: David Strachan ENT Consultant, Bradford Royal Infirmary

RHINITIS (Rhinosinusitis) –SYMPTOMS

• Nasal blockage• Rhinorrhoea• Post nasal discharge• Facial pain / headache – not always sinuses• Facial pressure• Snoring / Cheek swelling / etc

Page 92: David Strachan ENT Consultant, Bradford Royal Infirmary

Rhinosinusitis – investigations in primary care

• Allergy testing

• Sinus Xray

Page 93: David Strachan ENT Consultant, Bradford Royal Infirmary

RHINITIS (Rhinosinusitis) – Possible Treatments

• Antihistamines – oral• Steroid sprays (drops)• Antihistamine spray• Antibiotics• Ipratropium bromide spray• Sodium cromoglycate spray

- ? decongestants

Page 94: David Strachan ENT Consultant, Bradford Royal Infirmary

PERENNIAL RHINITIS SINUSITISSummary

• ? Triggers / allergy• Facial pain – not always sinuses• Try antihistamines• Try steroid nasal spray (4 weeks minimum)• Refer in cases not responding to medical

therapy• Endoscopic sinus surgery possible

Page 95: David Strachan ENT Consultant, Bradford Royal Infirmary

TOPICS • TAKING A HISTORY• (EXAMINATION)• AUDIOGRAMS & HEARING LOSS• CHRONIC EAR DISEASE• VERTIGO• TINNITUS• GLUE EAR (TARGET STUDY)• RHINITIS / SINUSITIS• NECK & THROAT SYMPTOMS

– HOARSE VOICE– DYSPHAGIA– THYROID / NECK LUMP

• ANYTHING ELSE

Page 96: David Strachan ENT Consultant, Bradford Royal Infirmary

•HOARSE VOICE

•DYSPHAGIA

•THYROID / NECK LUMPS

Page 97: David Strachan ENT Consultant, Bradford Royal Infirmary

? Cancer !!!!!!!

Page 98: David Strachan ENT Consultant, Bradford Royal Infirmary

Ear Nose & Throat problems -common in Primary Care

12 patients / week on average(excluding URTI)

10-20% of all Consultations in GP

Page 99: David Strachan ENT Consultant, Bradford Royal Infirmary

“ all patients with possible cancer will be seen in 2 weeks”

Page 100: David Strachan ENT Consultant, Bradford Royal Infirmary

What can be a sign of ‘CANCER’

Page 101: David Strachan ENT Consultant, Bradford Royal Infirmary

OTALGIA

BLEEDING

OTORRHOEA

HEARING LOSS

Page 102: David Strachan ENT Consultant, Bradford Royal Infirmary

NASAL OBSTRUCTION

FACIAL PAIN RHINORRHOEA

EPISTAXIS

Page 103: David Strachan ENT Consultant, Bradford Royal Infirmary

HOARSENESS

DYSPHAGIANECK LUMP

SENSATION IN THROAT

Page 104: David Strachan ENT Consultant, Bradford Royal Infirmary

HOARSENESS

DYSPHAGIANECK LUMP

SENSATION IN THROAT

NASAL OBSTRUCTION

RHINORRHOEAFACIAL PAIN

EPISTAXIS

OTALGIA OTORRHOEA

BLEEDING HEARING LOSS

C

Page 105: David Strachan ENT Consultant, Bradford Royal Infirmary

Referrals

Page 106: David Strachan ENT Consultant, Bradford Royal Infirmary

HOARSENESS

DYSPHAGIANECK LUMP

SENSATION IN THROAT

NASAL OBSTRUCTION

RHINORRHOEAFACIAL PAIN

EPISTAXIS

OTALGIA OTORRHOEA

BLEEDING HEARING LOSS

C

Page 107: David Strachan ENT Consultant, Bradford Royal Infirmary

Telling the difference

Dang

er

Danger

Page 108: David Strachan ENT Consultant, Bradford Royal Infirmary

OTALGIA- Intractable& Progressive

BLOODSTAINEDOTORRHOEA

Dang

er

Danger

Page 109: David Strachan ENT Consultant, Bradford Royal Infirmary

BLOODSTAINEDRHINORRHOEA

Dang

er

Danger UNILATERAL SYMPTOMS

FACIALSWELLING

Page 110: David Strachan ENT Consultant, Bradford Royal Infirmary

PERSISTENTHOARSENESS

PROGRESSIVEDYSPHAGIA

ASSOCIATEDNECK LUMP

THROATPAIN WITHOTALGIA

Dang

er

Danger

Page 111: David Strachan ENT Consultant, Bradford Royal Infirmary

Neck LumpsThink ENT

Page 112: David Strachan ENT Consultant, Bradford Royal Infirmary

Neck LumpsNeed upper airway

i.e. ENT assessment

Page 113: David Strachan ENT Consultant, Bradford Royal Infirmary

HOARSE VOICEDYSPHAGIA

• Progressive• Never normal• High risk patient• Associated pain / otalgia

• Consider fast-track

Page 114: David Strachan ENT Consultant, Bradford Royal Infirmary

Common things are common

Page 115: David Strachan ENT Consultant, Bradford Royal Infirmary

Communication

Page 116: David Strachan ENT Consultant, Bradford Royal Infirmary

The End

Discussion

Page 117: David Strachan ENT Consultant, Bradford Royal Infirmary

Basic Questions1. Draw a normal eardrum2. What normal structures can you see up a

nose3. What is a cholesteatoma4. What is the commonest way for an

acoustic neuroma to present5. What may cause a facial palsy

Page 118: David Strachan ENT Consultant, Bradford Royal Infirmary

Any questions

We’re all ears!We’re all ears!