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

Objectives 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 anatomy

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

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

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

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

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

complications Acute mastoiditis Chronic otitis media Intracranial complications

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

Intracranial complications Vestibular symptoms Facial palsy Intracranial complications

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

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

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

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

Which ear needs syringing? Syringing the ear Which ear needs syringing?

Occlusive cerumen Causing pain Hearing loss Tinnitus

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

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

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

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

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

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

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

CT sinuses

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

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

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,

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

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

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

Sq papilloma Anterior commissure/ true VC Complete excision Laser treatment

Laryngeal Malignancy Risk factors Smoking Alcohol Radiation exposure HPV Nickel exposure

Symptoms Hoareseness associated with Dysphagia Odynophagia Otalgia Haemoptysis

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

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

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

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

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

Investigations Ba meal Video fluroscopy Oesophagoscopy Imaging CT/MRI

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

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

Investigations Plain X-ray lateral view FNAC CT scan Sialogram

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

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

Thankyou