ENT Update 7th Feb 08. David Strachan ENT Consultant, Bradford Royal Infirmary

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1 ENT Update 7th Feb 08 David Strachan ENT Consultant, Bradford Royal Infirmary

2

3 Basic Questions 1. Draw a normal eardrum 2. What normal structures can you see up a nose 3. What is a cholesteatoma 4. What is the commonest way for an acoustic neuroma to present 5. What may cause a facial palsy

4 TOPICS TAKING A HISTORY (EXAMINATION) AUDIOGRAMS & HEARING LOSS CHRONIC EAR DISEASE VERTIGO TINNITUS GLUE EAR (TARGET STUDY) RHINITIS / SINUSITIS NECK & THROAT SYMPTOMS HOARSE VOICE DYSPHAGIA THYROID / NECK LUMP ANYTHING ELSE

5 Back to basics

6 Audiology course Diagnostic Strategy David Strachan FRCS ENT Consultant Bradford Royal Infirmary

7 The History The most important part of the strategy Take time Be thorough Be structured

8 HISTORY TAKING: SUGGESTED SEQUENCE Introduction Presenting complaint History of current illness Systemic enquiry Past medical history Drugs and allergies Family history Social and personal history Patient s ideas, concerns and expectations.

9 Diagnostic strategy History taking a differential diagnosis is already in mind Examination Investigation

10 EXAMINATION - EAR

11 EXAMINATION - EAR External Inspection Palpation Auriscope (Hearing assessment)

12 External Inspection Is there an external deformity?

13 External Endaural Inspection Postauricular Are there any scars?

14 EXTERNAL EXAMINATION Palpation OF EAR Is it tender? Tragus Postaural

15 Auriscope Examination

16 Auriscope Examination Child Posterior Adult Posterior- Superior

17 Auriscope Examination Cartilagenous External Auditory Canal

18 Auriscope Examination Bony External Auditory Canal

19 Auriscope Examination Bony External Auditory Canal & Tympanic Membrane

20 Auriscope Examination Wax

21 Epithelial Migration

22 Epithelial Migration 2 months 4 months

23 Auriscope Examination Light reflex incus malleus Round window Tympanic Membrane

24 The ear

25 malleus incus round window

26 Auriscope Examination light reflex incus malleus round window Tympanic Membrane

27 TOPICS TAKING A HISTORY (EXAMINATION) AUDIOGRAMS & HEARING LOSS CHRONIC EAR DISEASE VERTIGO TINNITUS GLUE EAR (TARGET STUDY) RHINITIS / SINUSITIS NECK & THROAT SYMPTOMS HOARSE VOICE DYSPHAGIA THYROID / NECK LUMP ANYTHING ELSE

28

29 HEARING DISABILITY NORMAL MILD HEARING LOSS MODERATE HEARING LOSS SEVERE HEARING LOSS PROFOUND HEARING LOSS TOTAL LOSS

30 NIHL - Audiological findings

31 High frequency hearing loss Vowels Consonants

32 High frequency hearing loss e _a a a_ o e _a_

33 High frequency hearing loss th_ f_t c_t s_t _n th_ m_t

34 High frequency hearing loss the fat cat sat on the mat

35 Disability issues Moderate hearing loss Vowels Consonants

36 TOPICS TAKING A HISTORY (EXAMINATION) AUDIOGRAMS & HEARING LOSS CHRONIC EAR DISEASE VERTIGO TINNITUS GLUE EAR (TARGET STUDY) RHINITIS / SINUSITIS NECK & THROAT SYMPTOMS HOARSE VOICE DYSPHAGIA THYROID / NECK LUMP ANYTHING ELSE

37 Otitis externa Wicks Drops / Spray Regular toilet

38 Chronic Ear Disease

39 Chronic Ear Disease

40

41

42

43

44

45 Cholesteatoma skin in the wrong place

46 Cholesteatoma diagnosis (can be difficult)

47 Complications of middle ear disease

48

49

50

51

52

53 TOPICS TAKING A HISTORY (EXAMINATION) AUDIOGRAMS & HEARING LOSS CHRONIC EAR DISEASE VERTIGO TINNITUS GLUE EAR (TARGET STUDY) RHINITIS / SINUSITIS NECK & THROAT SYMPTOMS HOARSE VOICE DYSPHAGIA THYROID / NECK LUMP ANYTHING ELSE

54 What is Vertigo

55 Vertigo Sensation of rotation Not unsteadiness Not lightheadedness History is key

56 History is key

57 good? Symptoms with time bad

58 good Lasts hours Variable attacks Other symptoms? menieres bad

59 good Severe initial attack Slow improvement? Vestibular neurolabyrinthitis bad

60 good lasts seconds related to head posn? BPPV bad

61 Dix Hallpike BPPV & Epley manoeuvre

62 TOPICS TAKING A HISTORY (EXAMINATION) AUDIOGRAMS & HEARING LOSS CHRONIC EAR DISEASE VERTIGO TINNITUS GLUE EAR (TARGET STUDY) RHINITIS / SINUSITIS NECK & THROAT SYMPTOMS HOARSE VOICE DYSPHAGIA THYROID / NECK LUMP ANYTHING ELSE

63 A symptom not a diagnosis

64 Tinnitus Diagnosis explained Investigate as appropriate Audio? MRI Treatment options Nil Simple strategies TRT (Tinnitus Retraining Therapy)

65 Key point Persistent unilateral symptoms

66 Unilateral hearing loss +/- tinnitus

67 TOPICS TAKING A HISTORY (EXAMINATION) AUDIOGRAMS & HEARING LOSS CHRONIC EAR DISEASE VERTIGO TINNITUS GLUE EAR (TARGET STUDY) RHINITIS / SINUSITIS NECK & THROAT SYMPTOMS HOARSE VOICE DYSPHAGIA THYROID / NECK LUMP ANYTHING ELSE

68 Diagnosing OME

69 Diagnosing OME Audio + tymps

70 Treating OME

71 TARGET STUDY MRC funded randomised controlled trial Surgery v non-surgery

72 OME leading to 20 db + loss > 12 weeks

73 ? Watch -? Grommets

74 TARGET STUDY Benefit in surgery group hearing disability improved Q of L scores non-aggressive behaviour problems (NOT Aggressive behaviour problems)

75 Basic Point A child that cant hear cant hear till proved otherwise Hearing loss is underestimated

76 TOPICS TAKING A HISTORY (EXAMINATION) AUDIOGRAMS & HEARING LOSS CHRONIC EAR DISEASE VERTIGO TINNITUS GLUE EAR (TARGET STUDY) RHINITIS / SINUSITIS NECK & THROAT SYMPTOMS HOARSE VOICE DYSPHAGIA THYROID / NECK LUMP ANYTHING ELSE

77 Back to basics

78 EXAMINATION - NOSE

79 EXAMINATION - NOSE External Inspection Airway Nasal Cavity Auriscope (Thudicums/ Head light)

80 EXAMINATION - NOSE External Inspection

81 EXAMINATION - NOSE The Airway

82 EXAMINATION OF NASAL CAVITY Look for Septum position Little s area Inferior Turbinate

83 Septum - position

84

85 Septum - Little s area

86 EXAMN OF NASAL CAVITY

87 EXAMN OF NASAL CAVITY Inferior Turbinate Septum

88 EXAMINATION OF NASAL CAVITY Look for Inferior Turbinate?? Middle Turbinate

89 EXAMN OF NASAL CAVITY Middle Turbinate Inferior Turbinate Septum

90 RHINITIS (Rhinosinusitis) SYMPTOMS & TREATMENTS IN PRIMARY CARE

91 RHINITIS (Rhinosinusitis) SYMPTOMS Nasal blockage Rhinorrhoea Post nasal discharge Facial pain / headache not always sinuses Facial pressure Snoring / Cheek swelling / etc

92 Rhinosinusitis investigations in primary care Allergy testing Sinus Xray

93 RHINITIS (Rhinosinusitis) Possible Treatments Antihistamines oral Steroid sprays (drops) Antihistamine spray Antibiotics Ipratropium bromide spray Sodium cromoglycate spray -? decongestants

94 PERENNIAL RHINITIS SINUSITIS Summary? Triggers / allergy Facial pain not always sinuses Try antihistamines Try steroid nasal spray (4 weeks minimum) Refer in cases not responding to medical therapy Endoscopic sinus surgery possible

95 TOPICS TAKING A HISTORY (EXAMINATION) AUDIOGRAMS & HEARING LOSS CHRONIC EAR DISEASE VERTIGO TINNITUS GLUE EAR (TARGET STUDY) RHINITIS / SINUSITIS NECK & THROAT SYMPTOMS HOARSE VOICE DYSPHAGIA THYROID / NECK LUMP ANYTHING ELSE

96 HOARSE VOICE DYSPHAGIA THYROID / NECK LUMPS

97 ? Cancer!!!!!!!

98 Ear Nose & Throat problems - common in Primary Care 10-20% of all Consultations in GP 12 patients / week on average (excluding URTI)

99 all patients with possible cancer will be seen in 2 weeks

100 What can be a sign of CANCER

101 OTALGIA OTORRHOEA BLEEDING HEARING LOSS

102 NASAL OBSTRUCTION EPISTAXIS FACIAL PAIN RHINORRHOEA

103 HOARSENESS SENSATION IN THROAT NECK LUMP DYSPHAGIA

104 HOARSENESS SENSATION IN THROAT NASAL OBSTRUCTION EPISTAXIS OTALGIA FACIAL PAIN C OTORRHOEA RHINORRHOEA BLEEDING NECK LUMP HEARING LOSS DYSPHAGIA

105 Referrals

106 HOARSENESS SENSATION IN THROAT NASAL OBSTRUCTION EPISTAXIS OTALGIA FACIAL PAIN C OTORRHOEA RHINORRHOEA BLEEDING NECK LUMP HEARING LOSS DYSPHAGIA

107 Telling the difference Danger Danger

108 Danger Danger OTALGIA -Intractable & Progressive BLOOD STAINED OTORRHOEA

109 Danger Danger UNILATERAL SYMPTOMS BLOOD STAINED RHINORRHOEA FACIAL SWELLING

110 Danger Danger PERSISTENT HOARSENESS PROGRESSIVE DYSPHAGIA THROAT PAIN WITH OTALGIA ASSOCIATED NECK LUMP

111 Neck Lumps Think ENT

112 Neck Lumps Need upper airway i.e. ENT assessment

113 HOARSE VOICE DYSPHAGIA Progressive Never normal High risk patient Associated pain / otalgia Consider fast-track

114 Common things are common

115 Communication

116 The End Discussion

117 Basic Questions 1. Draw a normal eardrum 2. What normal structures can you see up a nose 3. What is a cholesteatoma 4. What is the commonest way for an acoustic neuroma to present 5. What may cause a facial palsy

118 Any questions We re all ears!

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