Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

3 Y earENTPeershare Ryan TrimbleContents OSCEs – Historyand ExaminationsContents OSCEs– HistoryandExaminations Hearingloss Vertigo Facialnervepalsy Epistaxis Sinusitis Tonsillitis Neck lumpsHistoryT aking • WIPE (Wash hands, Introduce,Patient details, Explain (consent)) • Presenting complaint • HxPC – DOPT (Duration, Onset, Progression, Timing) • PMHx • DHx • FHx • SHxENTHistoryT akingSpecifics • HxPC– DOPT (Duration, Onset, Progression,Timing) • Nose– rhinorrhoea/post-nasaldrip,smell, congestion, facial pain • Throat – pain, dysphagia,hoarseness • General – fever, weightloss… • PMHx • Previous surgeries • FHx • Hearing loss • SHx • Smoking+alcohol • Occupation/hobbies– noiseexposureHearingLoss • Conductivevs Sensorineuralhearingloss • Conductive= outer+ middle ear • Sensorineural= innerear Clinicaltestsinhearingloss • All ENT clinicalskills demonstratedonthe portal: https://www.med.qub.ac.uk/Portal/year3/otorhino.aspx • Crudehearingtest– is there hearingloss?(not sensitive) • Rinne’s • Weber’s Conductivevs sensorineuralhearinglossCrudehearing test • Arm’s lengthbehind patient • Occludehearingin one ear • Whisper  Normalvoice  LoudvoiceRinne’sandWeber’sTests(Tuning ForkTests) Rinne’s Weber’s • Tuningforkonforehead • Compareboneconductionand air conduction–‘whichislouder?’ • ‘Doyouhearthisequallyonboth • Don’twaitforboneconductionto sidesorlouderononeside?’ stopHearingTestResults Normal Conductive Sensorineural Hearing Loss Hearing Loss Crude Hearing Whisper Reduced Reduced Test Rinne’s Test AC>BC BC>AC AC>BC Weber’s Test Equal Lateralisesto Lateralisesto BADEAR GOOD EAR Perforated Conductivehearinglosscauses tympanic membrane Earwax Acuteotitismedia Otitismedia with Foreign body effusion Otosclerosis Otitis externa Cholesteatoma Eustachiantube dysfunction • Otitis externa • Swimmers • – riskofmalignant otitis externa (emergency Mx) Conductive • Perforated tympanicmembrane HearingLoss • Recent trauma/AOM with discharge Tips • Acuteotitismedia • Signs ofinfection (pain, fever, URTIsymptoms (coryza)) • Most common bacterialcause is S. pneumoniae – delayed Abx prescriptionif no other concerning features • Otitis mediawitheffusion • V. common inchildren • Red flag ifunilateralOME inadult – Conductive ?nasopharyngeal cancer HearingLoss • Otosclerosis • Genetic – lookoutfor family Hx Tips(cont.) • Cholesteatoma • Smelly DischargeSensorineuralHearing LossCauses • Don’t Make Deafness-Inducing T 𝟐T • Degeneration(Presbycusis) • Menière’s • Drugs(AminoglycosideAbx, loopdiuretics) • Infection(Labyrinthitis,meningitis,encephalitis,HZV) • Neuro(Stroke,MS)euroma) • Noise-induced • Trauma(Basalskull#) SNHL over <72 hours ImmediateENT referral Sudden Sensorineural HearingLoss Usually idiopathic Mx= steroids(ifidiopathic)Otoscopy • Don’t forget inspection • Scars, hearing aids, skinchanges… • MAKE SURE YOU KNOW HOW TO TURN ON OTOSCOPE • Right hand for right ear, left for left • Gentle tension on pinna • Be gentle – use little finger to steady • Comment on EAM as entering • Redness, wax, discharge/pus • Comment on tympanicmembrane  Otoscopy–NormalTM Whattosay? • ‘Pearly-grey’appearance • ‘Presenceof normal landmarks’: • Lateral processofmalleus • Handleof malleus • Lightreflex • State negatives(e.g. no redness,bulgingof TM…)Otoscopy–diseasedTMs Acuteotitismedia Otitismediawith effusion PerforatedTM - Redness/inflamed - Golden-brownappearance - VisibleholeinTM - BulgingTM - Sucked-inTM–prominentLP - (Tympanosclerosisalso ofmalleus present)Vertigo • Dizziness–‘Room spinning’sensationassociatedwithnausea andvomiting • Centralcauses– Brainstem/cerebellarlesions– stroke,MS, SOL • Peripheralcauses(4): Persistent Intermittent No HearingLoss Vestibular Neuritis BPPV HearingLoss Labyrinthitis Menière’sVertigoTips Labyrinthitis/Vestibular Neuritis BPPV • Acute onset, concurrent/precedingviral • BPPV - stones in semicircularcanals URTI symptoms • Dix-Hallpike to Diagnose (rotatory • Short term Mx = nystagmus is positivetest) prochlorperazine/antihistamine • Epley manoeuvreto treat • Labyrinthitis = Loss ofhearing Menière’s disease • Vestibular Neuritis= Noloss ofhearing • Triad – attacks of: • SN Hearing loss • Vertigo • Tinnitus • Mx ofattacks = prochlorperazine/antihistamineFacialNervePalsy • Upper vs lower motor neuronelesion: • Upper = Upper sparing • Lower motor neuronelesion involves forehead • Causes – many! Here’s a mnemonicfor the key ones: • MR. BIT2S: • MS (UMN) • Ramsay HuntSyndrome (LMN) • Bell’s Palsy (LMN) • Infection(Otitis media, malignantotitis externa– LMN) • Tumour (Acousticneuroma,malignantparotid tumour,cholesteatoma– LMN) • Trauma(Basal skull #, iatrogenic) • Stroke (UMN)FacialNervePalsyTips Remembertoprotect the eye – tape eye/lubricatingeyedrops RamsayHuntSyndrome(HZV) FNPwithvesicularrasharoundEAM Mx= prednisolone+ aciclovir Mostcommoncause – idiopathic Bell’s Palsy Mx= prednisolone(+protecteye) Ifparotid tumour causesFNP –high riskof malignancyAcousticneuroma • Benign tumourofSchwanncells • At‘cerebellopontineangle’ • Associatedwith neurofibromatosistype II • nerve palsy) or vestibulocochlearnerve (rarely causingSNHLor centralvertigo) • Investigations – MRIBrainEpistaxis • Little’s area(picked by little finger) • Single nostril =anterior,both nostrils = posterior • Recurrentor prolongednose bleeds – consideranticoagulant medications,checkbloods (thrombocytopaenia/ coagulopathies)Epistaxis Management • >10-15 minutes, severe, haemodynamicallyunstable: • Ifanteriorand bleeding site observed – nasal cautery (silver nitrate stick) • OR • Ifposterior/no bleeding site tampon/gauze)sal packing(Nasal • managementreamused in post-acute • Contraindicated inpeanutandsoya allergySinusitis • Acute < 12 weeks,Chronic > 12 weeks • discharge (anterior/post-nasaldrip), facial pain, loss ofsmell • Acute sinusitis – associated w/ viral URTI • Vast majorityare viral infections • Symptoms > 10 days: intranasal steroid spray, delayed Abx prescriptionTonsillitis • Comes upmore inpaediatrics • Usuallyviral– bacterialusually groupA strep. • 2 scorestoindicatelikelihood ofbacterial infection: • Centor Criteria Learn one • Fever PAIN NeckLumps Midline Lateral • Thyroglossalcyst • Lymphnodes - Infection • Dermoidcyst - Tumour- 1° or 2° • Salivaryglands • Thyroidlumps • Branchialcyst • Thyroglossal cyst – moveswith the tongue • Dermoidcyst – maycontainhair, teeth, skin • Lymph nodes • Consider signs of infection– e.g. URTI, otitis media,eye infection • ‘B symptoms’suggest lymphoma(fever, weight loss, Neck night sweats) LumpsTips • Salivary gland enlargement commoncauses: • Submandibular– stone • Parotid – mumps • Tumours usually benign– FNP indicates malignant • Thyroid • Diffusevs nodular goitre • Multinodular, hot on radioiodinescan- ?benign • Single nodule, no radioiodineuptake -?malignantNeckLumps Examination • Remember general inspection • Bodyhabitus, clothing, unwell, cachexic • Inspection of neck • Obviouslumps, scars, skin changes • Palpation • Remember areas to palpate; submental, submandibular, cervical,supraclavicular, thyroid (remember special tests – extend tongue/swallow water) • Describe alump – 3Ss, 3Cs, 3Ts (site, size, shape, colour, countour, consistency, temperature, tenderness, tethering) The portal • Great for OSCEs! • Tutorials don’t cover allofcontent Zerotofinals Resources OSCEstop • Website • Textbook Usuallyone ENT station Don’tlistentoo muchtopredictions– they’re usuallywrong! Theinstructionsare always inthe station– if OSCETips you can’tremember,goone stepat a time Ifyoufeel like you’re nevergoingto learnall the content intime, sodoeseveryone! GOODLUCK!