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ENT slidesNose History taking • 5 key Qs • Bleeding • Rhinorrhoea • Facial pain • Hyposmia/anosmia • Blocked nose • Also: sneezing, unilateral symptoms, otalgia2ww for nose • Unilateral nasal symptoms - obstruction + purulent dischargeKey nose conditions • - Rhinosinusitis • - Septal deformity of the nose • - Unilateral nasal polyp • - Recurrent epistaxis • -Acute epistaxisAcute Epistaxis • Key points in History • Establish side • Ant. vs Post. • Frequency • Est. blood loss • Trauma • PMHx • HTN, anticoag, drug abuseAcute Epistaxis - Management • Pinch nose for 20 mins • See source > silver nitrate cautery • Anterior nasal pack • Posterior pack • catheter or rapid rhinos • Then theatre • Manage in A&E resus as can be severe • Give advice - for 24hrs avoid hot drinks, heavy lifting, blowing nose • ?nasal septal haematoma – emergency, must be drainedNasal Septum HaematomaRecurrent Epistaxis • Rule out malignancy + clotting disorders • Some are easily reversible • Drug abuse, anticoagRhinosinusitis • Symptoms • Rhinorrhoea • Sneezing • Blocked nose • Itching • Post-nasal drip • Allergic vs Non-allergicAllergic rhinosinusitis • IgE mediated immune response • Key Symptoms– watery + itchy eyes • Triggers • PMHx – atopic triad • Investigations – skin prick, RAST • Management + advice • high temp wash, shower before bed • Antihistamines – cetirizine • Nasal steroidsAcute rhinosinusitis • <12 weeks • Typically viral infection – rhinovirus, or bacterial (double sickening) • Strep. Pneumoniae, H. Influenzae • Key Symptoms – Facial pain, nasal congestion, coloured discharge • Systemic • Management – Analgesia, Steroids if >10 days • Complications • Osteomyelitis • Pre septal/orbital cellulitis – emergency • Requires urgent High definition Contrast CT orbitsChronic Rhinosinusitis • >12 weeks • Risk factors - smoking • Investigation – Nasal endoscopy, CT • Management • Saline irrigation, • anti histamine, • steroids, • Functional Endoscopic Sinus Surgery • Avoid overuse of nasal decongestants– QDS for 7 DaysNasal polyps • Common, usually bilateral • If unilateral, consider malignancy • Rare in children • Management • Refer to ENT non urgent (2ww if unilateral) • Steroids – short course PO then topicalPossible OSCE stations • Nose history + exam – epistaxis • Prescribing – Antihistamines (non-sedating), topical nasal steroidsThroat History taking • 5 key Qs • Persistent sore throat • Odynophagia • Dysphagia • Dysphonia • Regurgitation • Also: • weight loss, lump in throat, ear pain, fever, night sweats2ww for Throat • for >3 weeks • Hoarse voice OR • Dysphagia OR • Unresolving neck mass • 45yo+ with unexplained neck lump • <45yo with persistent neck lumpKey throat conditions • - Tonsillitis • - Quinsy • - Reactive lymph node • - Thyroid nodules • - Goitre • - Thyroid malignancyTonsillitis • Key Scoring systems (viral vs bacterial) • CENTOR • Fever, Exudate, NO cough, Cervical lymph nodes • FeverPAIN • Fever, Exudate (Pus), Attend in 3 days, Inflamed tonsils, No cough • Initial management based on score • <3 - No abx, or delayed prescription, • 3+ score - Abx phenoxymethylpenicillinor clarithromycin, 7-10 day • Repeated episodes > tonsillectomy • >7 eps in 1yr, • 5+ across 2 yrs, • 3+ across 3 years • Complications – sinusitis, otitis media, quinsyQuinsy (peritonsillar abscess) • Emergency – requires URGENT ENT review • Large unilateral swelling • pain, systemic sx, trismus, “hot potato” voice • Management: • Drain + Abx • Consider tonsillectomy in 6 weeks • Tonsillectomy bleed management • Assess by ENT • <24hrs - Primary (usually 6-8hrs) return to theatre • >24hrs - Secondary (5-10 days) infection assoc. > admit + AbxLymph Nodes • Red flags– rubbery, non tender, night sweats, weight loss, splenomegaly • Mets – axilla, groin • Reactive • painful, systemic signs of infectionsThyroid • Malignancy • Papillary commonest • Goitre – TMG, Hot nodule, Autoimmune – Graves, Hashimotos • Investigations –Thyroid Exam, TFTs, USS, Biopsy – FNAC, SPECT • Management – surgical, radiotherapy, radioiodine • Complications – damage to parathyroid glands > hypocalcaemiaNeck lumps – pattern recognition • Pharyngeal pouch - halitosis, regurg, dysphagia, gurgle on palpation • Thyroid – up on swallow • Thyroglossal cyst – up on tongue out, midline • Branchial cyst – non tender, smooth round cyst • Carotid aneurysm– pulsatile • Cervical rib – thoracic outlet syndrome, unilateral neuro sx. • Reactive lymphadenopathy – tender, assoc. viral illness • Lymphoma– rubbery, painless, night sweats, splenomegalyPossible OSCE stations • Neck Hx and examQ1 • 14 year old boy is brought into the GP practice by his mother. She says he has been feeling unwell for the past few days with a cough and a sore throat. On examination his tonsils appear inflamed but there is no pus visible. He is pyrexial and there is noted tenderness of his cervical lymph nodes on palpation. • What is his Centor score? What is the initial management?Q2 • 25 year old man attends A&E after being punched in the face. He initially suffered a nose bleed but this has resolved. On examination the right side he feels well, and his obs are normal.t to the touch. Aside from some pain • What should his initial management be? a) Anterior Nasal pack b) Discharge with safety netting c) Silver Nitrate Cautery d) Immediate ENT referral e) Routine ENT referralThank you for listening! • Any further questions? • QR code for Feedback form: