E'N'T' PROBLEMS IN GENERAL PRACTICE

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E.N.T. PROBLEMS IN GENERAL PRACTICE

• Dr K Richmond

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EAR PROBLEMS

• 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
• Dont forget the attic

• Ask about
• Deafness
• Tinnitus (Ringing)
• Vertigo (Rotational)
• Discharge
• Otalgia (pain)

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CHILD EAR EXAM

• Get them on side try not to tower over them,
  examine Mum first
• Distract with toy
• Try Bribery
• Explain what youll do
• If all else fails ....
• pin em down!
• Childs arm under Mums axilla
• Other arm held against childs side
• Head held against Mums chest
• Pull pinna back child
• (Up back for adult)

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CHILD WITH EAR ACHE

• 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

• Ask about
• Duration
• Discharge
• URTI symptoms
• Pain relief tried
• Rashes
• Neck stiffness

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GENERAL MANAGEMENT OF EARACHE

• Regular analgesia
• No antibiotics in first 24hr
• Earache for gt24hrs 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

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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

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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

• Overall deafness if both ears affected

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Can you really tell if its 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 its
  bacterial
• Discuss the pros and cons with the patient

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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

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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)

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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

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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..its a tumour til proved otherwise
  

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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

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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

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Complications of Otitis Media

• A summary
• Glue ear / Secretory otitis media
• Perforation (central / attic)
• Tympanosclerosis (chalk patches)
• Mastoiditis
• Others

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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 dont
  work)
• - consider underlying causes if recurrent
  (diabetes/HIV)

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NOSE SYMPTOMS

• Examine for
• Linearity
• Nostril patency (sniff test/mirror)
• Littles area
• Septum (straight/deviated)
• Turbinates (swelling)
• Polyps

• Ask about
• Nasal discharge
• Headaches (frontal/maxillary)
• Sneezing
• Catarrh (post-nasal drip)

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Nose Exam In The Surgery

• When looking inside the nose look at
• Littles 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 Littles area uncomfortable
• Ask pt to breathe in before inserting speculum

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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

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RHINITIS Inflammation of nasal lining

• Symptoms
• Nasal obstruction
• Clear nasal discharge
• Bouts of sneezing
• 3 different types
• Infective (e.g. URTI)
• Allergic
• Intrinsic/Vasomotor

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Rhinitis comparing allergic and vasomotor

• 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

• 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)

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MANAGEMENT OF RHINITIS

• Medical
• Anti-histamines
• Allergen avoidance if allergic rhinitis
• Steroid nasal sprays/drops

• Surgical (refer if)
• Failure of medical therapy or
• Patients request

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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)

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ACUTE SINUSITIS Contd

• 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

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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

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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

• TURBINATES
• Three ridges on the lateral walls of the
  nose
• Only the inferior of these is visible without
  more specialist equipment
• - Turbinates look pink
• - PainFULL if prodded

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EPISTAXIS (NOSE BLEEDS)

• IN CHILDREN
• Usually bleed from Littles area (Anterior Bleed)
• May be associated with
• URTI
• Rhinitis (e.g. Hay fever)
• Digital trauma (otherwise known as nose picking
  !)
• Foreign body (foul discharge)

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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

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What to do when the bleeding has stopped? (Wait a
few days)

• Examine Littles 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

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NOSE BLEEDS IN ADULTS

• Anterior bleeds
• management same as children
• Posterior bleeds
• Tend to occur in later life
• Suspect if cant see a bleeding vessel
• Worse if BP raised
• Consider nasal packing if cant stop it
• Remember ABC call for help quickly

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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
• Dont forget to look in the ears

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HOW TO EXAMINE THE MOUTH

• Ask pt to open mouth as wide as possible
• Then stick tongue out
• Say ahh
• If you cant see enough try a tongue depressor
• Apply to front half of tongue
• Use flat and press down (dont tilt it will
  make them gag)

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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

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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

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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

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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

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2 week waits

• Quick referral for suspected malignancy
• Just be aware the system exists
• Copies of referral form should be at your
  placement surgery

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2/52 referral form
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DIFFERENTIATING NECK LUMPS ON Hx EXAM

• Branchial Cyst
• Lateral
• Congenital
• Supra-clavicular Node
• Malignant mass (e.g. lung, GI, testes) with
  spread to lymph nodes

• Lateral Lymphadenopathy
• Benign/Acute reactive
• Malignant
• Thyroglossal Cyst
• Central
• Moves on tongue protrusion
• Thyroid Lump
• Moves on swallowing

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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

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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

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• 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