1. ENT for General Practice
George Vattakuzhiyil
MBBS;MS(ENT);FRCS

2. Objectives Detailed examination of ENT/H&N
Learn to diagnose & treat common ENT pathology
Recognise serious complication, request additional tests, specialty referral

3. Quick recap of ear anatomy

4. Hearing tests Rinne and Weber tests Rinne Ac better than BC
Hearing loss
256Hz
512HZ
1024Hz
< 15db 
15-30db x
30-45db
45-60db

5. 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

6. 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

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

8. Acute otitis media Common in children otalgia/discharge Unwell/pyrexia
TM: red, bulging,oedematous
Streptococcus/Haemophilus
Amoxycillin 5-7 days

9. complications Acute mastoiditis Chronic otitis media
Intracranial complications

10. CSOM
Recurrent ear discharge
Hearing loss
Perforation of the TM – central
Presence of cholesteatoma
Marginal, Attic perforation
Offensive discharge, bleeding, granulations

11. Intracranial complications
Vestibular symptoms
Facial palsy
Intracranial complications

12. Management
Medical: Dry mopping,suction clearance,/ Ear drops, rarely systemic antibiotics
Surgical
Myringoplasty/ Tympanoplasty
Combined Mastoidectomy/Tympanoplasty

13. Otitis media+effusion-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

14. 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

15. Treatment 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

16. Which ear needs syringing?
Syringing the ear
Which ear needs syringing?

17. Occlusive cerumen
Causing pain
Hearing loss
Tinnitus

18. Avoid syringing Non occlussive cerumen Previous ear surgery
Only hearing ear
Perforated TM
Kerotosis obturans

19. Acute/Chronic tonsillitis
Sorethroat, fever, malaise
Tender cervical lymph nodes
Enlarged congested tonsils with pus
Analgesia
Penicillin
Prolonged course, worsening symptoms consider glandular fever

20. Quincy (peritonsillar abscess)
 pain + trismus
Swelling of the soft palate
Displacement of uvula
Refer for I/V antibiotics  drainage

21. 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

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

23. sinusitis Acute sinusitis < 4/52
Chronic >4/52 or 4 or more episodes
O/E nasal congestion, polyps, pus in MM
Structural changes: DNS, concha bullosa

24. sinusitis Sinus X ray usually unhelpful CT sinuses
Acute: amoxicillin  clavulonate, oxymetazoline
Chronic: Pus c/s, augmentin+metronidazole, Treat the cause: allergy, surgery(FESS)

25. CT sinuses

26. 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

27. Common Pathology Viral laryngitis
Viral URTI preceding aphonia
Hx sorethroat
B/L V.c. oedema/erythema
voice rest, antibiotics

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

29. Vocal cord nodules Singer / teacher / children /
Often B/L – Junction ant/ middle 1/3
Voice rest / speech therapy
Rarely – MLS excision

30. Laryngitis - GORD Hx of GORD Inflammation of Post larynx
Treatment for reflux
Raising head end of cot

31. Vocal polyp/Reinkes oedema
Male Smoker
Irritant exposure
Hoarseness
Dyspnoea
Irritant cough
Treatment: Voice rest, speech therapy,stop smoking, Microlaryngoscopy and vc stripping

32. Sq papilloma Anterior commissure/ true VC Complete excision
Laser treatment

33. Laryngeal Malignancy Risk factors Smoking Alcohol Radiation exposure
HPV
Nickel exposure

34. Symptoms Hoareseness associated with Dysphagia Odynophagia Otalgia
Haemoptysis

35. Signs Dysplasia/Ca in situ Leukoplakia Ulcero/Exophytic growth
Neck mass
URGENT REFERRAL

36. 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

37. 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

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

39. Examination-key points
Oral cavity Tongue, gag reflex,soft palate
Pharynx pooling, lesions
larynx Elevation of larynx, scopy
Neck masses

40. Investigations
Ba meal
Video fluroscopy
Oesophagoscopy
Imaging CT/MRI

41. Salivary glands Painful diffuse swelling sailadinitis
Plus fluctuation with meals calculi
Non painful swelling Tumour

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

43. Investigations
Plain X-ray lateral view
FNAC
CT scan
Sialogram

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

45. Tinnitus If unilateral refer: MRI Serology: FTA Haematocrit Lipids
Audiogram/ ABR
Consider hearing therapy referral councilling/ tinnitus masker

46. Thankyou