ENT for General Practice
George Vattakuzhiyil
MBBS;MS(ENT);FRCS
Objectives

Detailed examination of ENT/H&N

Learn to diagnose & treat common ENT
pathology

Recognise serious complication, request
additional tests, specialty referral
Quick recap of ear anatomy
Hearing tests
Rinne and Weber tests
Rinne Ac better than BC
Hearing
loss
< 15db
256Hz
512HZ
1024Hz



15-30db
x
x

30-45db
45-60db
x
x
x
x

x
Weber test

Hold the base of the tuning fork in the
midline (forehead, incisor teeth)

Laterelising to the left: conductive loss on
left or SNHL on right
Otitis Externa

Inflammatory disorder of
skin lined EAC
 Acute/Chronic
 Generelised skin disorder
 Pathogens: staph,
pseudomonas, Fungus
 Topical antibiotic/steroid
 Sofradex,otomize
spray,otosporin,GHC,
locorten- vioform
Otitis externa

Extension to pre/post auricular area
 Microsuction/IV antibiotics
 Diabetic patient/ Pseudomonas inf
 ? Malignant otitis externa
Acute otitis media
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Common in children
otalgia/discharge
Unwell/pyrexia
TM: red,
bulging,oedematous
Streptococcus/Haemo
philus
Amoxycillin 5-7 days
complications

Acute mastoiditis
 Chronic otitis media
 Intracranial
complications
CSOM
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Recurrent ear discharge
Hearing loss
Perforation of the TM –
central
Presence of cholesteatoma
Marginal, Attic perforation
Offensive discharge,
bleeding, granulations
Complications

Vestibular symptoms

Facial palsy

Intracranial complications
Management

Medical: Dry mopping,suction clearance,/
Ear drops, rarely systemic antibiotics
 Surgical
 Myringoplasty/ Tympanoplasty
 Combined Mastoidectomy/Tympanoplasty
Otitis media+effusion-Glue ear

Common in children
 Reduced hearing noticed by parents/teacher
 Recurrent ear infection
 Unsteadiness- child falling over
 Effusions persist for weeks after AOM
 80% clear at 8 weeks
Signs of OME

Dull retracted TM
 May show air-fluid level
 Conductive hearing loss(whisper test,
Rinne/weber tests)
 OME persistant over 3 months ENT referral
Treatment
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Failed audio
Flat tympanograms
h/o >3 episodes in
6/12 or >4 in 12/12
Grommet insertion
Evaluate adenoids,
especially in recurrent
grommet insertions
Syringing the ear
Which ear needs syringing?
Occlusive cerumen

Causing pain
 Hearing loss
 Tinnitus
Avoid syringing
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Non occlussive
cerumen
Previous ear surgery
Only hearing ear
Perforated TM
Kerotosis obturans
Acute/Chronic tonsillitis

Sorethroat, fever, malaise
 Tender cervical lymph nodes
 Enlarged congested tonsils with pus
 Analgesia
 Penicillin
 Prolonged course, worsening symptoms
consider glandular fever
Quincy (peritonsillar abscess)
 pain + trismus
 Swelling of the soft
palate
 Displacement of uvula
 Refer for I/V
antibiotics  drainage

Allergic rhinitis

Seasonal : allergen usually outdoor
 perennial: indoor dust, mite, cat dander

O/E pale mucosa, boggy turbinate
 Avoid allergen, antihistamines, topical
vasoconstrictors, steroids
 Surgery- SMD, laser, Turbinectomy
sinusitis

Facial pain/ pressure/ fullness
 Nasal obstruction/ discharge
 Altered smell
 Pyrexia in acute sinusitis
 Headache, halitosis, dental pain
 Minor factors: cough,ear pressure, fatigue
sinusitis

Acute sinusitis < 4/52
 Chronic >4/52 or 4 or more episodes

O/E nasal congestion, polyps, pus in MM
 Structural changes: DNS, concha bullosa
sinusitis

Sinus X ray usually unhelpful
 CT sinuses
 Acute: amoxicillin  clavulonate,
oxymetazoline
 Chronic: Pus c/s, augmentin+metronidazole,
Treat the cause: allergy, surgery(FESS)
CT sinuses
Epistaxis
Most common site – littles area
 Cause: Idiopathic, trauma (nose picking),
dry mucosa, hypertension, coagulopathy,
NSAID, Warfarin, tumours
 Try naseptin cream for a short course
 Silver nitrate cautery
 Electrocautery/ packing/ surgery

Common Pathology
Viral laryngitis




Viral URTI preceding aphonia
Hx sorethroat
B/L V.c. oedema/erythema
voice rest, antibiotics
Hoarseness
 Symptom of
both local, systemic pathology
 Often the early symptom of ca larynx
 Persistent > 2/52 or worsening
 Associated with loss of weight, smoking,
Vocal cord nodules
 Singer
/ teacher / children /
 Often B/L – Junction ant/ middle 1/3
 Voice rest / speech therapy
 Rarely – MLS excision
Laryngitis - GORD

Hx of GORD
 Inflammation of Post larynx
 Treatment for reflux
 Raising head end of cot
Vocal polyp/Reinkes oedema

Male Smoker
 Irritant exposure
 Hoarseness
 Dyspnoea
 Irritant cough
 Treatment: Voice rest, speech therapy,stop
smoking, Microlaryngoscopy and vc
stripping
Sq papilloma

Anterior commissure/ true VC
 Complete excision
 Laser treatment
Laryngeal Malignancy

Risk factors
 Smoking
 Alcohol
 Radiation exposure
 HPV
 Nickel exposure
Symptoms

Hoareseness associated with
 Dysphagia
 Odynophagia
 Otalgia
 Haemoptysis
Signs

Dysplasia/Ca in situ Leukoplakia

Ulcero/Exophytic growth
 Neck mass

URGENT REFERRAL
Cord paralysis

Breathy voice (air escape)
 B/L airway compromise
 P/H of thyroid, cardiovascular Sx
 Cord in paramedian position
 Refer for investigations and treatment
Functional aphonia

Psychogenic Only able to speak in forced
whisper
 Normal cough
 Spastic dysphonia strained/strangled voice
 Onset related to major life stress
 Hyperadduction of true/false cord
 Speech therapy, ? Botulinum toxin inj
Dysphagia

Progressive dysphagia for solids structural
lesion
 Dysphagia for liquids Neurological
 Painful swallow spasm of cricopharynx,
ulcer
 Signs of reflux
 Signs of aspiration
Examination-key points

Oral cavity Tongue, gag reflex,soft palate
 Pharynx pooling, lesions
 larynx Elevation of larynx, scopy
 Neck masses
Investigations

Ba meal
 Video fluroscopy
 Oesophagoscopy
 Imaging CT/MRI
Salivary glands

Painful diffuse swelling sailadinitis
 Plus fluctuation with meals calculi
 Non painful swelling Tumour
Examination
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Unilateral/bilateral ?
Diffuse/well
circumscribed?
Is it tender?
Any discharge from
the ducts?
Enlarged nodes?
Palpable calculi?
Investigations

Plain X-ray lateral
view
 FNAC
 CT scan
 Sialogram
Tinnitus

SNHL
 Drugs-NSAID, Aminoglycosides,
Antidepressants
 Tumors- Acoustic neuroma, Temporal lobe
tumor
 Anxiety/ Depression
Tinnitus

If unilateral refer: MRI
 Serology: FTA
 Haematocrit
 Lipids
 Audiogram/ ABR
 Consider hearing therapy referral
councilling/ tinnitus masker