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COMMUNITY ENT SERVICE

COMMUNITY ENT SERVICE. Dr C K Krishnaswamy MB;BS; MS(ENT). DLO RCS (Eng.).PG Dip (ENT) Primary Care. How to examine ENT patients in Primary Care. Instruments required: Otoscope * Metal tongue depressor / Spatula Head mirror / head light / pen torch Tuning fork 512 Clinical ENT Examination

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COMMUNITY ENT SERVICE

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  1. COMMUNITY ENT SERVICE Dr C K KrishnaswamyMB;BS; MS(ENT). DLO RCS (Eng.).PG Dip (ENT) Primary Care. Medicmart UK Ltd

  2. How to examine ENT patients in Primary Care Instruments required: • Otoscope* • Metal tongue depressor / Spatula • Head mirror / head light / pen torch • Tuning fork 512 Clinical ENT Examination • History • Examine Ear, Nose , Throat and Neck • Hearing tests/TFTs Medicmart UK Ltd

  3. Anatomy of the Ear Ear diagram B.Shannon (2010) Scottish sensory centre Medicmart UK Ltd

  4. Normal Tympanic Membrane Medicmart UK Ltd

  5. EAR CONDITIONS • Impacted wax • Earache • Deafness • Tinnitus • Aural Discharge • Otitis Externa • Otitis Media • Dizziness/Vertigo/ BPPV Medicmart UK Ltd

  6. Impacted Wax • What ? • Site • Diagnosis* • Treatment- Wax solvents • Removal- Syringing. Contraindications • Microsuction • Hospital care Medicmart UK Ltd

  7. Earache (Otalgia) • Causes- • Otological causes • Acute O E, Furunculosis, • Perichondritis, Viral • AOM, Barotrauma, FB, Tumours • Non-otological (Referred Otalgia) • C S • Impacted molars • TMJDysfunction • Ca- upper GI & Airway • Treatment Ref: Dhillon and East (1999) Medicmart UK Ltd

  8. Deafness Types- • Conductive (EAM & Middle ear) • Sensori-neural ( Inner ear) • Mixed Causes- • 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 Medicmart UK Ltd

  9. 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) Medicmart UK Ltd

  10. Aural discharge • Nature- purulent, mucoid, watery, foul smelling • Causes- OE, COM. Mastoid cavities, FB, Fracture Temporal bone, Malignant tumours • Examination- • 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 Medicmart UK Ltd

  11. 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 Medicmart UK Ltd

  12. OTITIS MEDIA Diagnosis Treatment • Discharge- • profuse, • muco-purulent or purulent • Deafness, tinnitus, vertigo • Perforation- TT & AA • Mastoid tenderness* • Fistula sign* • Facial N* • Complications * • Conservative- • Antibiotic- • Aural toilet • Analgesic • Hearing tests • CT Scan • Surgical- • AA immediate • TT if conservative fails Medicmart UK Ltd

  13. Perforated Ear drum Perforated ear drum – ENT uk Medicmart UK Ltd

  14. Inner Ear Image from Graphicshunt.com 2009 Medicmart UK Ltd

  15. Dizziness/Vertigo/ BPPV Definition Causes ENT General • Cervical Spondylosis • Ageing • Migraine • TIA/ MS/ CVA • HI • Epilepsy • Hyperventilation Diagnosis • Middle ear diseases • Drugs • Labyrinthitis • Vestibular neuritis • Menierre's • BPPV • ANF • Miscellaneous - Cholesteotoma Medicmart UK Ltd

  16. Benign Paroxysmal Positional Vertigo Definition- brief but intense periods of vertigo Provoked by- neck movements • turning in bed • looking up • bending forward • lying down Mechanism- • No obvious cause • May follow HI • The symptoms- lesion of the crista of the posterior semi-circular canal, otolith crystals becomes displaced, finding its way into the canal • When patient rotates the head an abnormally strong signal from the canal produces transient rotatory vertigo • No hearing loss • Symptom may reoccur or disappears spontaneously after 3-6 months Medicmart UK Ltd

  17. Positional testing- Dix Hall pike test for Nystagmus- • Patient sitting on the bed • Head turned to one side • Have patient lay supine in bed • Head hangs, over the edge of the bed • Observe for 30 seconds Characteristic features- • brief latent period • 10 to 30 seconds of nystagmus and vertigo (dizzy and feels ill) • Fatigue on repeat testing • Direction of nystagmus may reverse direction when patient sits up Contraindications- • on-going CNS diseases (TIA/Stroke) • Unstable heart disease • High grade carotid stenosis • Severe cervical Spondylosis Medicmart UK Ltd

  18. Epley’s Manoeuvre Procedure- First- • sitting position • head turned to one side • have patient lay supine in bed • head hangs head over the edge of bed • observe for nystagmus Second- • turn head to opposite side 90 deg • observe for nystagmus Third- • 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) Medicmart UK Ltd

  19. Epley’s Manoeuvre (cont.) Burton 2000 Medicmart UK Ltd

  20. Questions Medicmart UK Ltd

  21. Community ENT Service GP 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: EAR • Impacted Wax • Earache • Deafness • Aural Discharge • Otitis Media • Otitis Externa • Tinnitus • Vertigo • Foreign Body in the ears NOSE • Nasal Obstruction • Nasal Polyps • Rhinosinusitis • Epistaxis • Snoring Medicmart UK Ltd

  22. Community ENT Services (Continued) THROAT • Sore Throat • Recurrent Tonsillitis • Globus Exclusion of the Service • Children under 5 years old • Glue Ears in the children • Hoarseness • Neck Lumps • Sudden Hearing Loss • Dysphagia • Patients with symptoms indicating serious conditions where an urgent or two week referral would be more appropriate • When it is likely that surgery is necessary • Emergency cases Medicmart UK Ltd

  23. Advantages of referring to Community ENT Services • Local service at the patients door steps • Provides quality service for patients with Ear, Nose Throat conditions • Easy Accessibility • Appointment made and seen within 2 weeks thereby reducing waiting time • Provide guidance on patient management to GP colleagues • Cost effective Medicmart UK Ltd

  24. 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 886325 Email: medicmartuk@gmail.com Website: www.medicmartuk.co.uk Medicmart UK Ltd

  25. How to book Patients into This Service • Log 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 Search • From 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 Medicmart UK Ltd

  26. Case studies Case study 1 I 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 Medicmart UK Ltd

  27. Case study 2 I 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: Nil Medication – none Past Medical History: nil significant Medicmart UK Ltd

  28. 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- Medicmart UK Ltd

  29. Case Study 3 I 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: none Medication – as listed. Past Medical History: Hypertension (2007) Medicmart UK Ltd

  30. Case study 4 I 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 significant Allergies: none Medications: none Alcohol intake: moderation Medicmart UK Ltd

  31. Case Study 5 • Dear Dr K • This 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 Medicmart UK Ltd

  32. Case Study 6 • Dear Dr K • Thank 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. Medicmart UK Ltd

  33. Case Study 7 • Dear Dr K • Many 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 debris • I wonder if he needs aural toilet? Medicmart UK Ltd

  34. Case Study 8 • Dear Dr K • Could 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. Medicmart UK Ltd

  35. Blocked Nose • Physiological- • 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, Sarcoidosis ENT Exam- AR & PNE Tests- Nasal swab, blood tests, SPT, RAST, CT scan Treatment- Medical- Surgical- Medicmart UK Ltd

  36. Rhinosinusitis • Definition- 8wk persistent symptoms • Causes- • Systemic- URTI, Allergy, C F • Immune disorders • Local- DNS, Trauma, swimming/ diving, drugs ENT Exam- AR & PNE Tests- Nasal swab, blood tests, SPT, RAST, CT scan Treatment- Medical- Surgical- Medicmart UK Ltd

  37. 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? Medicmart UK Ltd

  38. THROAT Recurrent Sore Throat • Definition- 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 swab • Endoscopy- • Blood tests FBC, blood film, Monospot, EBV serology • CXR • Barium swallow • Treatment- Analgesic. Rest, Antibiotic, Life style changes Medicmart UK Ltd

  39. Case Study 10 • Dear Dr K • I 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 Medicmart UK Ltd

  40. 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-cholinergic • Surgery- Medicmart UK Ltd

  41. 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 • DhillonR 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 EpleyManeuver? 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] Medicmart UK Ltd

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