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
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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
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45 Cholesteatoma skin in the wrong place
46 Cholesteatoma diagnosis (can be difficult)
47 Complications of middle ear disease
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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
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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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