Dr C K Krishnaswamy
MB;BS; MS(ENT). DLO RCS (Eng.).PG Dip (ENT)
Primary Care.
Medicmart UK Ltd
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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
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Anatomy of the Ear
Ear diagram B.Shannon (2010)
Scottish sensory centre
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Normal Tympanic Membrane
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EAR CONDITIONS
 Impacted wax
 Earache
 Deafness
 Tinnitus
 Aural Discharge
 Otitis Externa
 Otitis Media
 Dizziness/Vertigo/ BPPV
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Impacted Wax
 What ?
 Site
 Diagnosis*
 Treatment- Wax solvents
 Removal- Syringing. Contraindications
 Microsuction
 Hospital care
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Earache (Otalgia)
 Causes-
 Otological causes
 Acute O E, Furunculosis,
 Perichondritis, Viral
 AOM, Barotrauma, FB, Tumours
 Non-otological (Referred Otalgia)
 CS
 Impacted molars
 TMJ Dysfunction
 Ca- upper GI & Airway
 Treatment
Ref: Dhillon and East (1999)
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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
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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)
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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
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Otitis Externa
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Definition
Clinical featuresVery painful
Diffuse or localised (furuncle ) swelling
Discharge- thick and scanty
Blocked meatus, deafness, tenderness, spreading cellulitis
Causative organisms
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‘Malignant’ Otitis Externa
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Bacterial
Fungal
Rare
occurs in elderly DM
Ps aeruginosa
very painful
Ref hospital if suspected
Treatment
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Antibiotic- oral and aural
Ear pack (ribbon gauze)
Pope wick
Analgesics
Recurrence- to rule out DM
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OTITIS MEDIA
Diagnosis
Treatment
 Discharge profuse,
 muco-purulent or purulent
 Deafness, tinnitus, vertigo
 Perforation- TT & AA
 Conservative Antibiotic Aural toilet
 Analgesic
 Hearing tests
 Mastoid tenderness*
 CT Scan
 Fistula sign*
 Surgical AA immediate
 TT if conservative fails
 Facial N*
 Complications *
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Perforated Ear drum
Perforated ear drum – ENT uk
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Inner Ear
Image from Graphicshunt.com 2009
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Dizziness/Vertigo/ BPPV
Definition
Causes
General
ENT
 Cervical Spondylosis
 Middle ear diseases
 Ageing

 Migraine

 TIA/ MS/ CVA

 HI

 Epilepsy

 Hyperventilation

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Drugs
Labyrinthitis
Vestibular neuritis
Menierre's
BPPV
ANF
Miscellaneous - Cholesteotoma
Diagnosis
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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
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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
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Epley’s Manoeuvre
ProcedureFirst 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)
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Epley’s Manoeuvre (cont.)
Burton 2000
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Questions
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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
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Impacted Wax
Earache
Deafness
Aural Discharge
Otitis Media
Otitis Externa
Tinnitus
Vertigo
Foreign Body in the ears
NOSE
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Nasal Obstruction
Nasal Polyps
Rhinosinusitis
Epistaxis
Snoring
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Community ENT Services (Continued)
THROAT
 Sore Throat
 Recurrent Tonsillitis
 Globus
Exclusion of the Service
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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
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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
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Procedures Performed
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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
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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,

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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
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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
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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
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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-
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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)
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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
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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
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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.
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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?
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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.
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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
TreatmentMedicalSurgicalMedicmart UK Ltd
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Rhinosinusitis
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Definition- 8wk persistent symptoms
CausesSystemic- 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
TreatmentMedicalSurgicalMedicmart UK Ltd
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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?
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THROAT
Recurrent Sore Throat
 DefinitionCauses
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

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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
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Globus
 ‘Lump’ in the throat, discomfort or FB. No other obvious symptoms.

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Age- 40 years
Anxious
FH- similar related disease
Reflux Oesophagitis, Pharyngeal or oesophageal mobility dysfunction

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ENT examination
Endoscopy
CXR
Ba swallow
Treatment- Reassurance, Life style changes, PPI, Relaxation therapy,
anti-cholinergic
 SurgeryMedicmart UK Ltd
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References
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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
Dhillon R 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 Epley Maneuver? 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]
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