Dr C K KrishnaswamyMB;BS; MS(ENT). DLO RCS (Eng.).PG Dip (ENT) Primary Care.

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How to examine ENT patients in Primary Care

Instruments required:Otoscope*Metal tongue depressor / SpatulaHead mirror / head light / pen torchTuning fork 512

Clinical ENT ExaminationHistory Examine Ear, Nose , Throat and Neck Hearing tests/TFTs

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Anatomy of the Ear

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Ear diagram B.Shannon (2010) Scottish sensory centre

Normal Tympanic Membrane

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EAR CONDITIONS

Impacted wax Earache Deafness Tinnitus Aural Discharge Otitis Externa Otitis Media Dizziness/Vertigo/ BPPV

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Impacted WaxWhat ?SiteDiagnosis*Treatment- Wax solvents Removal- Syringing. ContraindicationsMicrosuctionHospital care

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Earache (Otalgia)Causes-Otological causes

Acute O E, Furunculosis, Perichondritis, ViralAOM, Barotrauma, FB, Tumours

Non-otological (Referred Otalgia)C S Impacted molarsTMJ DysfunctionCa- upper GI & Airway

Treatment Ref: Dhillon and East (1999)

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DeafnessTypes- Conductive (EAM & Middle ear) Sensori-neural ( Inner ear) MixedCauses- • Congenital• Trauma – HI, FB, Surgery, drugs• Inflammatory – Labyrinthitis, Mumps, Measles, Myringitis Bullosa, Otitis • Externa, Otitis Media• Neoplastic – ANF, Neurological / Vascular• Miscellaneous – Wax, Otosclerosis, Meniere’s ,• ENT Exam- Tests- TFTs, Audiometry Treatment• treat the cause, • HA, BAHA. Cochlear implants• aural care• surgery

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Tinnitus

  

Definition- Types- Subjective –

wax, middle ear disease, NIHL, Presbyacusis, Meniere’s disease, Trauma (surgery & HI) Ototoxic drugs, Labyrinthitis

Objective - ICA. CB tumours, TMJ, FB ENT Exam Tests – TFTs, Audiometry Treatment-

Reassurance HA, Tinnitus maskers Psychotherapy Unilateral- needs more tests (MRI scan, Angiography etc)Ref: Dhillon and East (1999)

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Aural discharge

Nature- purulent, mucoid, watery, foul smellingCauses- OE, COM. Mastoid cavities, FB, Fracture Temporal bone, Malignant tumoursExamination-

TM perforation, Safe (TT) & Unsafe ear (AA)Mastoid tenderness, Fistula sign, Facial N

Ix- Ear swab for C/S,* Hearing tests, X Ray (CT) Mastoid Treatment-

Conservative- aural toilet, antibiotic. Surgery

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Otitis Externa Definition Clinical features- Very painful Diffuse or localised (furuncle ) swelling Discharge- thick and scanty Blocked meatus, deafness, tenderness, spreading cellulitis Causative organisms-

Bacterial Fungal

‘Malignant’ Otitis Externa- Rare occurs in elderly DM Ps aeruginosa very painful Ref hospital if suspected

Treatment- Antibiotic- oral and aural Ear pack (ribbon gauze) Pope wick Analgesics Recurrence- to rule out DM

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OTITIS MEDIA

Diagnosis Treatment Discharge-

profuse, muco-purulent or purulent

Deafness, tinnitus, vertigoPerforation- TT & AA Mastoid tenderness* Fistula sign* Facial N* Complications *

Conservative-Antibiotic- Aural toiletAnalgesic

Hearing testsCT ScanSurgical-

AA immediateTT if conservative fails

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Perforated Ear drum

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Perforated ear drum – ENT uk

Inner Ear

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Image from Graphicshunt.com 2009

Dizziness/Vertigo/ BPPV

Causes

Cervical Spondylosis Ageing Migraine TIA/ MS/ CVA HI Epilepsy Hyperventilation

Diagnosis

Middle ear diseases Drugs Labyrinthitis Vestibular neuritis Menierre's BPPV ANF Miscellaneous - Cholesteotoma

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Definition

GeneralENT

Benign Paroxysmal Positional Vertigo

Definition- brief but intense periods of vertigoProvoked by- neck movementsturning in bedlooking upbending forwardlying downMechanism-No obvious cause May follow HIThe symptoms- lesion of the crista of the posterior semi-circular canal, otolith crystals becomes displaced, finding its way into the canalWhen patient rotates the head an abnormally strong signal from the canal produces transient rotatory vertigoNo hearing lossSymptom may reoccur or disappears spontaneously after 3-6 months

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Positional testing- Dix Hall pike test for Nystagmus- Patient sitting on the bedHead turned to one sideHave patient lay supine in bedHead hangs, over the edge of the bedObserve for 30 seconds

Characteristic features-brief latent period10 to 30 seconds of nystagmus and vertigo (dizzy and feels ill)Fatigue on repeat testingDirection of nystagmus may reverse direction when patient sits up

Contraindications-on-going CNS diseases (TIA/Stroke)Unstable heart diseaseHigh grade carotid stenosisSevere cervical Spondylosis

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Epley’s ManoeuvreProcedure- First-sitting positionhead turned to one sidehave patient lay supine in bedhead hangs head over the edge of bedobserve for nystagmus Second-turn head to opposite side 90 degobserve for nystagmusThird-Turn the body and head 90 deg

Sit up back again and observe for nystagmus

http://www.youtube.com/watch?v=7ZgUx9G0uEs

Johns P (2010)

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Epley’s Manoeuvre (cont.)

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Burton 2000

Questions

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Community ENT ServiceGP Specialist ENT Service Criteria

The service is ONLY for patients aged 5 years and upwards. Patients will be seen by the GPSI in the community clinic for the following conditions:

Inclusion Criteria:

EARImpacted WaxEaracheDeafnessAural DischargeOtitis MediaOtitis ExternaTinnitusVertigoForeign Body in the ears

NOSENasal ObstructionNasal PolypsRhinosinusitisEpistaxisSnoring

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Community ENT Services (Continued)THROATSore ThroatRecurrent TonsillitisGlobus

Exclusion of the ServiceChildren under 5 years oldGlue Ears in the childrenHoarsenessNeck LumpsSudden Hearing LossDysphagiaPatients with symptoms indicating serious conditions where an urgent or two week referral would be more appropriateWhen it is likely that surgery is necessaryEmergency cases

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Advantages of referring to Community ENT ServicesLocal service at the patients door stepsProvides quality service for patients with Ear, Nose

Throat conditionsEasy AccessibilityAppointment made and seen within 2 weeks thereby

reducing waiting timeProvide guidance on patient management to GP

colleaguesCost effective

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Procedures Performed Removal of impacted wax Ear irrigation ( Ear syringing ) EUM-Examination under microscope Micro suction of ears Foreign Body removal Clearance of Mastoid Cavity Hearing tests – Pure tone Audiometry Tympanometry Nasal Endoscopy Cautery to nose Skin Prick Tests for allergy

Clinic locations:Goldthorpe Centre, Goldthorpe Roundhouse Centre, Athersley

Contact: Phone: 01709 886325Email: medicmartuk@gmail.comWebsite: www.medicmartuk.co.uk

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How to book Patients into This ServiceLog into choose and book Enter Speciality: Ear, Nose and Throat Enter Clinic type: Ear conditions ( including Tinnitus, Deafness,

Balance / Dizziness) book under Aural care clinics. Nose, Sinus, Throat, Snoring (excluding Sleep Apnoea) and not

specified conditions book under GPSI ENT clinic Enter patients residential postcode: Select SearchFrom the list displayed .Book patient in the aural care clinic in Athersley or Goldthorpe. If other ENT problems, please book with GPSI ENT clinics at Goldthorpe

Wednesday am. If you have any problem ring Community ENT Services on 01709 886325

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Case studies

Case study 1I would be grateful if you could see this 19 year old lady who has been having nose bleed for the past few weeks. I have treated with Naseptin cream with no success. She tells me that she has had cauterisation in the past.I would appreciate your input and assessment.

Allergies: Hay fever

Past Medical history:Asthma (2010)

Discussion

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Case study 2I would be grateful if you see this 11 year old boy who is having recurrent nose bleed, I wonder whether he needs Nasal Cautery. I would appreciate your opinion.

Allergies: NilMedication – nonePast Medical History: nil significant

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Epistaxis Causes- Systemic- Hypertension, nephritis Drugs Blood disorders Hereditary telangiectasia Local- Idiopathic- Injuries, Nose picking, FB, surgery, Inflammatory- Rhinitis, sinusitis, polyps, Neoplastic- Papilloma, JNA, Ca Vascular- aneurysm Miscellaneous- e g Wegener’s granuloma Tests- blood tests, coagulation screen Treatment- Medical Local & General Nasal cautery- Nasal Pack-

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Case Study 3I would be grateful if you could see this 63 year old gentleman who has persistent hard wax both ears, my practice nurse tried to syringe the ears but not successful. I would appreciate if you can see and advice.

Allergies: noneMedication – as listed.Past Medical History: Hypertension (2007)

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Case study 4I would be grateful if you could see this 18 year old gentleman who complains of tinnitus both ears, but more so on the left ear for the past 4 months.He is a vocalist in a local band and uses ear plugs. When he removes the ear plugs the tinnitus is more than before. He says he has no problem with hearing and it is not painful.

I would appreciate your opinion and further management.

Past Medical History: nil significantAllergies: noneMedications: noneAlcohol intake: moderation

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Case Study 5

Dear Dr KThis girl has bilateral wax, hard wax which is causing her a

little bit discomfort. I think there may be some cotton buds that have moved the wax onto her drum causing the pain. Her mother will apply Olive oil, to both ears, diligently until such time as she is able to see you

Thank you

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Case Study 6Dear Dr KThank you for seeing this 16-year old who has an

intermittent history over the past three months or so of irritation, discharge and discomfort in the right ear. She has been treated with Otomize ear spray on several occasions and initially the ear was syringed to remove wax.

On examination today, the left ear is completely normal, the right shows a very narrow meatus with thickened flaky skin, some white debris and some thin discharge.

She has no particular illness lately. She does not do swimming or diving.

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Case Study 7Dear Dr KMany thanks for seeing this 54 year old gentleman Mr W

has had Mastoid surgery in 1994 and since then he is getting recurrent ear infection in the left ear

On examination left ear is filled with wax and debrisI wonder if he needs aural toilet?

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Case Study 8

Dear Dr KCould you please see this 23 year old lady for skin prick test. She is

complaining of constant blocked nose and sneezing even after using Beconase spray and cetirizine.

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Blocked NosePhysiological-Causes- Congenital- Choanal atresia, Ads, DNS Trauma- injury, surgery, FB, sprays, drugs Inflammatory- Rhinitis, Sinusitis, Polyps Neoplastic- Papilloma, JNA, Ca Vascular- Haematoma, aneurysm Miscellaneous- e g Wegener’s granuloma, SarcoidosisENT Exam- AR & PNETests- Nasal swab, blood tests, SPT, RAST, CT scan Treatment- Medical-Surgical-

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RhinosinusitisDefinition- 8wk persistent symptomsCauses- Systemic- URTI, Allergy, C F Immune disordersLocal- DNS, Trauma, swimming/ diving, drugs

ENT Exam- AR & PNETests- Nasal swab, blood tests, SPT, RAST, CT scan Treatment- Medical-Surgical-

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Case Study 9

Dear Dr K Thank you for seeing this 30 year old lady who has on-going problems with

recurrent sore throat. She has Chronic fatigue and is currently off sick as she is unable to work with her symptoms. She gets recurrent problems, sometimes looks infective and we treat with Penicillin or other occasion looks like candida and she has been treated with Nystatin.

She is also slightly iron deficient. Really run down, recurrent glands in her neck and generally feeling unwell. She has been under ENT previously but I would like your opinion?

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THROATRecurrent Sore ThroatDefinition- Causes- Infective- Viral, bacterial, fungal Infectious mononucleosis, HIV Smoking, spirits, sepsis, radiotherapy- Neoplastic- e. g Leukaemia. Cancer Vascular- e. g Agranulocytosis, Anaemia Endocrine- DM Miscellaneous- ME GORD ENT examination- Full Investigation-Throat swabEndoscopy-Blood tests FBC, blood film, Monospot, EBV serology CXR Barium swallow Treatment- Analgesic. Rest, Antibiotic, Life style changes

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Case Study 10Dear Dr KI would be grateful if you could see this 38 year old

anxious lady and advise Mrs J Smith is complaining of ‘lump in the throat’ for three months since she lost her mother who suffered Ca Throat

Thank you

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Globus‘Lump’ in the throat, discomfort or FB. No other obvious symptoms. Age- 40 years Anxious FH- similar related disease Reflux Oesophagitis, Pharyngeal or oesophageal mobility dysfunction

ENT examination Endoscopy CXR Ba swallow Treatment- Reassurance, Life style changes, PPI, Relaxation therapy, anti-cholinergicSurgery-

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References ENT UK Perforated ear drum British Otorhinolaryngology Head & Neck surgery [online] Available from http://www.entuk.org/patient_info/ear/surgery_perf_html [Accessed 8 February 2012] Burton M (2000) Diseases of the Ear, Nose and Throat – 15th edition. London: Churchill Livingstone Dhillon R S and East C A (1999) Ear, Nose and Throat – 2nd Edition. London: Churchill Livingstone Graphichunt.com (2009) Graphichunt [online] Available from

http://www.graphicshunt.com/health/images/inner_ear-1732.htm [Accessed 8 February 2012]

Johns P (2010) How to do Epley Maneuver? You tube [online] Available fromhttp://www.youtube.com/watch?v=7ZgUx9G0uEs [Accessed 8 February 2012]

Robb P and Watson A (2007) ENT in Primary Care. London: Rila M Saunders The normal eardrum Bristol ENT Partnerships [online] Available

fromhttp://www.entbristol.co.uk/otoscopy.php#normal_eardrum [Accessed 8 February 2012] B. Shannon (2010) Scottish Sensory centre [online]

Available fromhttp://www.ssc.education.ed.ac.uk/courses/deaf/dnov10i.html [Accessed 8 February 2012]

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