Ent (3) 11

ENT
Aims
• Assess the ear, nose and throat
• Case studies
The Ear
The Ear
• Organ of hearing and balance
• External ear
• Middle ear
• Inner ear
Anatomy of
the Ear
Outer Ear
Tympanic
Membrane
Symptoms
• Hearing loss
• Tinnitus
• Vertigo
• Discharge
• Itching
• Sensorineural • Conduction
Hearing • Presbyacusis • Wax
Loss • Acoustic neuroma

• Occupation
•
•
Otosclerosis
Infection/effusion
• Tumour
• Infection
• Menieres disease
• Hearing loss,
vertigo, tinnitus
Tinnitus
• Ringing sensation
• No external source
• History
• When did it start?
• Unilateral or bilateral?
• Associated symptoms?
• Red flag?
Vertigo
‘False sensation that oneself or the surroundings are moving or

spinning (usually accompanied by nausea and loss of balance) that is a
result of a mismatch between vestibular, visual and somatosensory
systems’
Della-Morte D, Rundek T; Dizziness and vertigo. Front Neurol Neurosci. 201230:22-5. Epub 2012 Feb 14.
Vertigo
• Sensation of movement
• BPPV, labyrinthitis, vestibular neuronitis, Menieres
• History
• Duration
• Vertigo vs dizziness/light headedness
• Precipitating factors
• Exacerbating factors
• Associated symptoms
Discharge and Itching
• Colour of discharge
• Purulent
• Blood stained
• Clear/mucoid
• Offensive
• Pain
• Fever
Examination
• Inspection
• Swelling
• Deformity
• Skin changes
• Discharge
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Examination
• Otoscopy
• Check light is working
• Use widest speculum possible
• Pull pinna up and back GENTLY
• Either pencil or hammer grip but protect canal
• Examine canal
• Oedema
• Wax
• Discharge
Examine tympanic membrane
Examination
• Hearing
• Whispering test
• Tuning fork tests
• Weber
• Rinne
Examination
Weber Rinne
• Place on centre of head • Place on mastoid then near EAM
• Normal - middle • Normal – air > bone
• Conductive – towards • Conductive – bone > air
• Sensorineural - away
To complete
• Audiometry
• Imaging e.g MRI
• Vestibular testing
Ear wax (cerumen)
• Antifungal and antibacterial properties
• Amount produced varies
• Rik factors for impaction:
• Hearing aids
• Elderly
• Cotton buds
Ear wax and blocked ears
• Hearing loss
• Feeling of fullness
• Ear ache
• Itching
• Tinnitus
Examination
Ear wax treatment
• Eardrops
• Olive oil/almond oil
• Sodium bicarbonate/urea hydrogen peroxide
• Irrigation
• Use softening drops prior
• Microsuction
• Curettage
Otitis externa
• Outer ear infection
• Common – 1% of all GP presentations
• Risk factors:
• Swimming
• Elderly
• Diabetes
• Wax
• Trauma
• Allergies/skin conditions
Otitis externa
• Pain and itching
• Discharge
• Hearing loss
• Swelling
• Exudate
• Erythema
• Lymphadenopathy
• Look for cellulitis
Otitis externa
Otitis externa treatment
• Topical
• Acetic acid (mild)
• Neomycin/clioquinol
• Steroids
• Ear wick
• Aural toilet
• Oral antibiotics
The Nose
Anatomy
Symptoms
• Blocked nose
• Epistaxis
• Sneezing
• Nasal discharge
• Abnormalities of smell
Symptoms
• Blocked nose
• Bilateral or unilateral
• Nasal discharge
• History of atopy
• Anatomical – septal defect

• Obstruction – polyp, hypertrophied turbinate/rhinitis
Symptoms
• Epistaxis
• Spontaneous or trauma
• Bilateral or unilateral
• Previous history
• Risk factors
• Coagulopathy
• Liver disease
• Iatrogenic
• Substance misuse
• Malignancy
Examination
• Inspection
• From front and behind
• Skin changes
• Asymmetry
• Septal defect
• Nasal mucosa
• Use otoscope with speculum to visualise turbinates
Examination
• Palpation
• Nasal bones
• Sinuses – frontal and maxillary
• Cervical lymph nodes
• Assess nostril patency

• Occlude nostril and sniff
• Metal spatula looking for condensation
• Smell – usually assessed in ENT clinic

Further Investigations
• Usually done in secondary care
• Nasal endoscopy
• CT
• X-rays
Throat
And Mouth
Anatomy
Symptoms
• Sore throat
• Change in voice
• Pain in mouth
• Dysphagia
Symptoms
• Sore throat Red Flags
• Timing • Hoarseness >3/52
• Associated symptoms ? • Weight loss
systemically unwell
• Difficulty breathing • Dysphagia
• Treatment so far • Odynophagia
• Risk factors
• Smoking
• HPV
Pharyngitis –
inflammation of
the pharynx
• Viral/bacterial
• Sore throat/neck pain
• URTI symptoms
• Fever/lethargy
• Hoarseness (larynx)
Viral vs bacterial
Centor Criteria (3-4 >40%) FeverPAIN

• Tonsillar exudate • Fever during previous 24 hours
• Tender anterior cervical lymph • Purulence
nodes • Rapid onset (<= 3 days)
• Absence of cough • Very inflamed tonsils
• History of fever • No cough/coryza
Examination
• Inspect lips and buccal mucosa
• Touch top of mouth/upper incisor and inspect back of tongue
• Stick out tongue an inspect
• Inspect hard palate + uvula
• Inspect soft palate
• Inspect pharyngeal wall/tonsils (use tongue depressor)
• Palpate cervical lymph nodes
To complete
• Examine neck
• Bloods
• Throat swab
• Imaging as required

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ENT

Loss • Acoustic neuroma

‘False sensation that oneself or the surroundings are moving or

• Anatomical – septal defect

• Assess nostril patency

• Smell – usually assessed in ENT clinic

Centor Criteria (3-4 >40%) FeverPAIN

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