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ENT for General Practice

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.

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ENT for General Practice

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  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 testsRinne and Weber testsRinne Ac better than BC

  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. 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. 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 PathologyViral 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

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