E.N.T. PROBLEMS IN GENERAL PRACTICE

1. E.N.T. PROBLEMS IN GENERAL PRACTICE Dr K Richmond

2. EAR PROBLEMS Ask about Deafness Tinnitus (Ringing) Vertigo (Rotational) Discharge Otalgia (pain) Examine for Scars (e.g. mastoidectomy) Look at pinna External auditory canal Ear drum (tympanic membrane or T.M.) Remember to look at all quadrants of the T.M. and for Handle of malleus Light reflex Don’t forget the attic

3. CHILD EAR EXAM Get them on side – try not to tower over them, examine Mum first Distract with toy Try Bribery Explain what you’ll do If all else fails .... pin ‘em down! Child’s arm under Mum’s axilla Other arm held against child’s side Head held against Mum’s chest Pull pinna back – child (Up & back for adult)

4. CHILD WITH EAR ACHE Ask about Duration Discharge URTI symptoms Pain relief tried Rashes Neck stiffness Examine for Appearance of TM Colour(red/normal/honey coloured) Shape (swollen/retracted) Light reflex (split/absent) Handle of malleus (flush/tilt) Fluid behind TM (glue ear) Appearance of ear canal discharge/swelling Consider taking a swab

5. GENERAL MANAGEMENT OF EARACHE Regular analgesia No antibiotics in first 24hr Earache for >24hrs needs review Antibiotics if suspect bacterial O.M. Review in 2/52 to exclude glue ear (IF parents worried about deafness) When and what to refer? Secretory otitis media with persistent deafness Recurrent otitis media with GP or parental concern Earache with underlying ear disease

6. POINTS IN THE HISTORY(IS IT VIRAL OTITIS MEDIA OR BACTERIAL???) In viral O.M. you would expect… URTI Recent onset – less than 36hrs Mild fever One or both ears Associated with D and V in younger children Discharge of liquid wax In bacterial O.M. you would expect….. May follow viral O.M. May be a complication of tonsillitis Marked fever Infrequent vomiting Purulent/bloody discharge with relief of pain Usually unilateral

7. FINDINGS ON OTOSCOPY In viral O.M. you would expect… Handle of malleus flush Bubbles sometimes seen behind TM Dull TM Peripheral vessels Discharge of liquid wax In bacterial O.M. you would expect….. Red and bulging Haemorrhagic areas on membrane Marked fever Central perforation with pulsatile discharge of pus

8. Can you really tell if it’s viral or bacterial otitis media? Probably not! One study which took samples from the middle ear found it was impossible to tell if the infection was viral or bacterial just by looking Some studies have shown antibiotics do not make a difference, to complication rates, even if it’s bacterial Discuss the pros and cons with the patient

9. OTALGIA Causes Wax Referred pain (e.g. dental problems, TMJ dysfunction, sinusitis) Infections of TM – otitis media (viral/bacterial) Infections of the ear canal – otitis externa

10. Complications of Otitis Media Perforation = a hole in the eardrum May be central or in the attic If attic refer (?cholesteatoma) If central Review to see if getting smaller Refer for repair if not Avoid swimming underwater (pressure increase due to water in middle ear can damage ossicles)

11. Other complications of Otitis Media Glue ear = an effusion in the middle ear Also called… Otitis media with effusion Serous otitis media Secretory otitis media May see bubbles/air-fluid meniscus behind TM TM can look ‘honey coloured’ or dull TM may also be retracted - retraction is shown by prominent malleus and - split light reflex

12. MANAGEMENT OF GLUE EAR CHILDREN 50% resolve within 6/52 Try decongestants and antibiotics Refer if deafness persists developmental delay suspect cholesteatoma ADULTS As above if bilateral Usually follows an URTI and settles within 6/52 If Unilateral – needs examination of the nasopharynx…..it’s a tumour ‘til proved otherwise

13. FURTHER COMPLICATIONS OF Otitis Media Tympanosclerosis (chalk patches on TM) - if deaf refer to exclude other problems - otherwise no need to do anything - happens after recurrent ear infection

14. FURTHER COMPLICATIONS OF Otitis Media  Mastoiditis is an ‘Inflammatory condition of the middle ear cleft’ The mastoids are air filled bones near the middle ear – so can be infected as a consequence of otitis media How would you diagnose and treat it? pinna displaced outwards forward abnormal TM on exam, with tenderness over the mastoid process, in an unwell patient ADMIT FOR IV ANTIBIOTICS

15. Complications of Otitis Media A summary Glue ear / Secretory otitis media Perforation (central / attic) Tympanosclerosis (chalk patches) Mastoiditis Others

16. Problems with the ear canal Otitis externa (O.E.) Patient complains of itchy ears and discharge Ask about hobbies e.g. swimming/travel (more common in hot climates) Also ask about use of cotton buds as these can exacerbate/cause OE Treatment -Steroid and antibiotic drops - Aural toilet (refer to ENT for discharge to be ‘sucked out’ of ear canal – if drops don’t work) - consider underlying causes if recurrent (diabetes/HIV)

17. NOSE SYMPTOMS Ask about Nasal discharge Headaches (frontal/maxillary) Sneezing Catarrh (post-nasal drip) Examine for Linearity Nostril patency (sniff test/mirror) Little’s area Septum (straight/deviated) Turbinates (swelling) Polyps

18. Nose Exam In The Surgery When looking inside the nose look at Little’s area (red/crusts) Septum (straight/deviated) Turbinates (swollen/increased vascularity) Polyps Ways to examine Lift nose tip and shine light up nose or Use auroscope with large speculum Look back not up when examining inside the nose Try not to touch Little’s area – uncomfortable Ask pt to breathe in before inserting speculum

19. NASAL BLOCKAGE CAUSES Mucosal swelling URTI (infective rhinitis) Rhinitis (allergic/vasomotor) Polyps Septal deviation Idiopathic Traumatic 3) Nasal collapse On inspiration 4) Nasopharyngeal obstruction enlarged adenoids polyps tumour

20. RHINITIS= Inflammation of nasal lining  Symptoms Nasal obstruction Clear nasal discharge Bouts of sneezing 3 different types Infective (e.g. URTI) Allergic Intrinsic/Vasomotor

21. Rhinitis – comparing allergic and vasomotor Allergic Rhinitis can be seasonal (e.g. hay fever) or perennial Lots of sneezing May be related to house dust mites/animal dander/pollen Allergen testing positive (sometimes) Vasomotor Rhinitis (also called Non-specific) Imbalance parasym/symp nerve supply nasal mucosa Symptoms with change in temp and humidity Can also occur due to hormonal changes e.g. Puberty Pregnancy

22. MANAGEMENT OF RHINITIS Medical Anti-histamines Allergen avoidance if allergic rhinitis Steroid nasal sprays/drops Surgical (refer if) Failure of medical therapy or Patient’s request

23. ACUTE SINUSITIS Patient presents with : Facial pain over upper nose / cheek (s) Tenderness on palpation Nasal blockage Associated fever Muco-purulent nasal discharge Pain varies with position (e.g. head down = worse) Cacosmia (patient smells something unpleasant)

24. ACUTE SINUSITIS Cont’d… May also get constitutional symptoms Sensation of congestion in face/head/ears Light-headedness How would you treat acutely? Menthol and steam inhalation Pain relief Antibiotics – to provide aerobic and anaerobic cover – however some studies show no benefit with antibiotics

25. CHRONIC SINUSITIS When should you refer for recurrent sinusitis? Failure of medical therapy Large polyps Septal deviation One-sided blood stained nasal discharge ? Neoplasia Refer urgently

26. STRUCTURES YOU MAY SEE IN THE NOSE POLYPS ‘Pedunculated mass’ attached to the nasal lining Herniated mucosa and oedema from the lateral nasal wall Polyps look grey PainLESS if prodded

27. EPISTAXIS (NOSE BLEEDS) IN CHILDREN Usually bleed from Little’s area (Anterior Bleed) May be associated with URTI Rhinitis (e.g. Hay fever) Digital trauma (otherwise known as nose picking !) Foreign body (foul discharge)

28. HOW TO STOP A NOSE BLEEDACUTE MANAGEMENT Pinch the soft part of nose Put head forward NOT back Avoid tissues Avoid nose blowing TOP TIP : get pt to lean forward with arms on desk. Use both thumbs to apply pressure Ensure they compress for at least 5mins

29. What to do when the bleeding has stopped? (Wait a few days) Examine Little’s area - ? Bleeding vessel present Use lignocaine applied with a cotton bud Wait 5 mins Cauterise with a silver nitrate stick NEVER do both sides at one go If no vessel obvious try naseptin (antibiotic cream) for 7 days If keeps bleeding…… ? Clotting abnormal (warfarin, aspirin, haemophilia) Check bloods - clotting

30. NOSE BLEEDS IN ADULTS Anterior bleeds management same as children Posterior bleeds Tend to occur in later life Suspect if can’t see a bleeding vessel Worse if BP raised Consider nasal packing if can’t stop it Remember ABC – call for help quickly

31. THE PATIENT WITH A SORE THROAT(What to look for on examination) Well or ill Hydration status Fever Lymphadenopathy Associated symptoms e.g. URTI Halitosis Exudate on tonsils Don’t forget to look in the ears

32. HOW TO EXAMINE THE MOUTH Ask pt to open mouth as wide as possible Then stick tongue out Say ‘ahh’ If you can’t see enough try a tongue depressor Apply to front half of tongue Use flat and press down (don’t tilt – it will make them gag)

33. MOUTH/THROAT EXAMINATION Look at the tongue Inspect the palatine tonsils and the uvula – is it central/displaced? Look at the salivary gland openings Inspect the teeth – dental hygiene/mobility Mucosa – ulcers Red and white patches

34. THINGS YOU MAY SEE ON EXAM Exudate on the tonsils May indicate bacterial tonsillitis Could also indicate glandular fever How would you treat? Analgesia/Anti-pyretics Penicillin V Avoid amoxicillin – if the patient has glandular fever they will develop a rash

35. THINGS YOU MAY SEE ON EXAM Displaced uvula - May indicate a peri-tonsillar abscess - Refer to ENT for IV antibiotics/drainage White patches on the palate - Candida/Thrush - Take a swab if unsure - Treat with topical anti-fungal e.g. Nystatin

36. ACUTE SORE THROAT Most are viral in origin Antibiotics only shorten the course of true bacterial tonsillitis In teenagers consider glandular fever In adults with chronic symptoms consider malignancy (especially if smoke/drink) General treatment : analgesia, rest, fluids

37. 2 week waits… Quick referral for suspected malignancy Just be aware the system exists Copies of referral form should be at your placement surgery

38. 2/52 referral form

39. DIFFERENTIATING NECK LUMPS ON Hx & EXAM Lateral Lymphadenopathy Benign/Acute reactive Malignant Thyroglossal Cyst Central Moves on tongue protrusion Thyroid Lump Moves on swallowing Branchial Cyst Lateral Congenital Supra-clavicular Node Malignant mass (e.g. lung, GI, testes) with spread to lymph nodes

40. HOMEWORK – mgt of ear wax Pt lies with ear to be treated uppermost Someone else pulls pinna up and back Fill ear with drops (8-10) using either Warm olive oil Sodium bicarbonate Stay in this position for 10mins Place cotton wool in ear – pt can the sit up – leave in place for 20-30mins just in the edge of the ear canal –stops leakage but does not soak up drops

41. QUIZ SECRETORY OTITS MEDIA What is the surgical management for glue ear Grommet What should the patient not do? (e.g. activities) - Swim under water PATIENT REPEATEDLY WIPES END OF NOSE (in an upwards direction) What name do the ENT doctors give to this mannerism? - Nasal salute What symptom are they trying to alleviate? -Nasal blockage What external change to the nose might be seen? - Skin crease across ‘bridge’ of nose

42. THE PATIENT COMPLAINS OF EARACHE / CLICKY JAW What is the diagnosis? - TMJ dysfunction How would you manage? Anti-inflammatories Refer for maxillo-facial opinion if suspect dental cause