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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
< 15db
256Hz
512HZ
1024Hz
15-30db
x
x
30-45db
45-60db
x
x
x
x
x
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/Haemo
philus
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
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
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