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T oday’s Session Plan: “Doctor,I recently had anupper respiratory tract infection andnow I have problems with my balance for the past 2-3 days. Myhearing is unaffected and I’m sure if you tested for cerebellarsigns and did the HINTSexam these wouldbe negative”T oday’s Session Plan: “Doctor,I recently had “Ihave been dizzy” anupper respiratory tract infection andnow “It started gradually over I have problems with the last couple ofdays” my balance for the past 2-3 days. “Ihave had acold” Myhearing is ”Ihaven’t noticed anything wrongwith my unaffected and I’m sure hearing” if you tested for cerebellarsigns and did + “Ihavenoticeda the HINTSexam these strange rashinmy ear” wouldbe negative” + ”Ihaven’t had any recent night sweats, MCQ Skills weight loss” + “I have few CV risk factors” … OSCE SkillsT oday’s Session Plan: Use a logical structureto narrow down diagnoses efficiently “Doctor,I recently had “Ihave been dizzy” anupper respiratory tract infection andnow “It started gradually over I have problems with the last couple ofdays” my balance for the past 2-3 days. “Ihave had acold” Myhearing is ”Ihaven’t noticed anything wrongwith my unaffected and I’m sure hearing” if you tested for cerebellarsigns and did + “Ihavenoticeda the HINTSexam these strange rashinmy ear” wouldbe negative” + ”Ihaven’t had any recent night sweats, MCQ Skills weight loss” + “I have few CV risk factors” … OSCE SkillsT oday’s Session Plan: Use a logical structureto narrow down diagnoses efficiently “Doctor,I recently had “Ihave been dizzy” anupper respiratory tract infection andnow “It started gradually over I have problems with the last couple ofdays” my balance for the past 2-3 days. “Ihave had acold” Myhearing is ”Ihaven’t noticed Ask questions to weigh moreor anything wrongwith my less likelihood amongst your unaffected and I’m sure hearing” differentials if you tested for cerebellarsigns and did + “Ihavenoticeda the HINTSexam these strange rashinmy ear” wouldbe negative” + ”Ihaven’t had any recent night sweats, MCQ Skills weight loss” + “I have few CV risk factors” … OSCE SkillsT oday’s Session Plan: Use a logical structureto narrow down diagnoses efficiently “Doctor,I recently had “Ihave been dizzy” anupper respiratory tract infection andnow “It started gradually over I have problems with the last couple ofdays” my balance for the past 2-3 days. “Ihave had acold” Myhearing is ”Ihaven’t noticed Ask questions to weigh moreor anything wrongwith my less likelihood amongst your unaffected and I’m sure hearing” differentials if you tested for cerebellarsigns and did + “Ihavenoticeda the HINTSexam these strange rashinmy ear” wouldbe negative” + ”Ihaven’t had any recent night sweats, MCQ Skills weight loss” Safeguardimportant redflags + “I have few CV risk factors” What would makethispresentation … dangerous? Or requireurgent specialist OSCE Skills RV/admission?T oday’s Session Plan: Part 1: 45mins Lecture + Discussion Learning intention: Discussing a prioritized approach to discriminating 5 key symptoms, and important negatives to elicitT oday’s Session Plan: Part 1: 45mins Lecture + Discussion Learning intention: Discussing a prioritized approach to discriminating 5 key symptoms, and important negatives to elicit 1. Acute Sore Throat 2. Dizziness 3. Swallowing Difficulties/Dysphagia 4. Ear Pain 5. Discharging earT oday’s Session Plan: Part 2: 15 mins Other MLA Content Learning intention: Provide high-yield information of MLA content not covered in Part 1. Part 1: 45mins Lecture + Discussion - Emergencies Learning intention: Discussing a prioritized - Neck Lumps, Sinusitis, OSA approach to discriminating 5 key symptoms, and important negatives to elicit Part 3: 30 mins OSCE Practice 1. Acute Sore Throat Learning intention: Apply and give feedback to peers 2. Dizziness using 3. Swallowing Difficulties/Dysphagia - In person (groups of 3) 4. Ear Pain - Virtual (MedAll/Teams) 5. Discharging ear Breakout roomsAcute Sore Throat PC/Basic Questions: 19y male, Sore throat - 2 days Worse when swallowing and felt at back of mouth. Recent fevers and general malaise Additional Questions to ask?Acute Sore Throat PC/Basic Questions: 19y male, Sore throat - 2 days Worse when swallowing and felt at back of mouth. Recent fevers and general malaise Additional Questions to ask? 1) What Can the patient swallow? 2) Voice change? 3) Trismus? 5) Immunocompromised or other risk factors?Acute Sore Throat PC/Basic Questions: 19y male, Sore throat - 2 days Worse when swallowing and felt at back of mouth. Recent fevers and general malaise Additional Questions to ask? 1) What Can the patient swallow? 2) Voice change? 3) Trismus? 4) Fever? Systemically unwell? 5) Immunocompromised or other risk factors? Tonsillar Exudate +1 Fever (last 24h) +1 Tender anterior cervical Purulence (pus on tonsils) lymphadenopathy or lymphadenitis +1 +1 Fever (>38) +1 Attend rapidly (within 3 days of +1 symptom onset) Absence of cough +1 Inflamed tonsils (severely) +1 No cough or coryza +1 *Modified CENTOR criteria FeverPAIN Score 2-3 = 34-40% probability of bacterial tonsilitis >3 = 40-60% probability of bacterial tonsilitis 4-5 = 62-65% probability of bacterial tonsilitis 1. Airway obstruction (stridor, Acute Sore Throat dyspnoea, drooling, dysphonia) PC/Basic Questions: 19y male, Sore throat - 2 days 2. Trismus Worse when swallowing and felt at back of mouth. 1. Voice changes: Hot Recent fevers and general malaise potato voice Additional Questions to ask? 2. Pain opening the jaw 3. Difficulty swallowing 4. Unilateral tonsillar deviation 1) What Can the patient swallow? 5. Not coping/systemically unwell 2) Voice change? 6. If: Sore throat with normal throat 3) Trismus? examination + severe pain or stiffness 4) Fever? Systemically unwell? on neck movements + airway 5) Immunocompromised or other risk factors? obstruction --> think Deep space neck infection Tonsillar Exudate +1 Fever (last 24h) +1 Tender anterior cervical Purulence (pus on tonsils) lymphadenopathy or lymphadenitis +1 +1 Fever (>38) +1 Attend rapidly (within 3 days of +1 symptom onset) Absence of cough +1 Inflamed tonsils (severely) +1 No cough or coryza +1 *Modified CENTOR criteria FeverPAIN Score 2-3 = 34-40% probability of bacterial tonsilitis >3 = 40-60% probability of bacterial tonsilitis-5 = 62-65% probability of bacterial tonsilitis 1. Airway obstruction (stridor, Acute Sore Throat dyspnoea, drooling, dysphonia) PC/Basic Questions: 19y male, Sore throat - 2 days 2. Trismus Worse when swallowing and felt at back of mouth. 1. Voice changes: Hot Recent fevers and general malaise potato voice Additional Questions to ask? 2. Pain opening the jaw 3. Difficulty swallowing 4. Unilateral tonsillar deviation 1) What Can the patient swallow? 5. Not coping/systemically unwell 2) Voice change? 6. If: Sore throat with normal throat 3) Trismus? examination + severe pain or stiffness 4) Fever? Systemically unwell? on neck movements + airway 5) Immunocompromised or other risk factors? obstruction --> think Deep space neck infection Tonsillar Exudate +1 Fever (last 24h) +1 To Complete the exam: Examine throat, observations… Tender anterior cervical Purulence (pus on tonsils) DDx: Tonsilitis, Quinsy, Infective mononucleosis (EBV), head and neck lymphadenopathy or lymphadenitis +1 +1 malignancy, haematological malignancy, Fever (>38) +1 Attend rapidly (within 3 days of +1 symptom onset) Absence of cough +1 Inflamed tonsils (severely) +1 No cough or coryza +1 *Modified CENTOR criteria FeverPAIN Score 2-3 = 34-40% probability of bacterial tonsilitis >3 = 40-60% probability of bacterial tonsilitis-5 = 62-65% probability of bacterial tonsilitis 1. Airway obstruction (stridor, Acute Sore Throat dyspnoea, drooling, dysphonia) PC/Basic Questions: 19y male, Sore throat - 2 days 2. Trismus Worse when swallowing and felt at back of mouth. 1. Voice changes: Hot Recent fevers and general malaise potato voice Additional Questions to ask? 2. Pain opening the jaw 3. Difficulty swallowing 4. Unilateral tonsillar deviation 1) What Can the patient swallow? 5. Not coping/systemically unwell 2) Voice change? 6. If: Sore throat with normal throat 3) Trismus? examination + severe pain or stiffness 4) Fever? Systemically unwell? on neck movements + airway 5) Immunocompromised or other risk factors? obstruction --> think Deep space neck infection Tonsillar Exudate +1 Fever (last 24h) +1 To Complete the exam: Examine throat, observations… Tender anterior cervical Purulence (pus on tonsils) DDx: Tonsilitis, Quinsy, Infective mononucleosis (EBV), head and neck lymphadenopathy or lymphadenitis +1 +1 malignancy, haematological malignancy, Tonsillitis Management: Fever (>38) +1 Attend rapidly (within 3 days of +1 - Consider admission if the patient symptom onset) is immunocompromised, systemically unwell, dehydrated, Absence of cough +1 Inflamed tonsils (severely) has stridor, respiratory distress or evidence of a peritonsillar +1 abscess or cellulitis. No cough or coryza +1 •ABx if the Centor score is ≥ 3, or the FeverPAIN score is ≥ 4. - Penicillin antibiotics preferred. (amoxicillin generally, co- amox. In severe (rare)) - GroupA strep (most common) > S. pneumoniae (other *Modified CENTOR criteria FeverPAIN Score common) 2-3 = 34-40% probability of bacterial tonsilitis •Consider delayed prescription for -1 criteria if specific concerns >3 = 40-60% probability of bacterial tonsilitis 4-5 = 62-65% probability of bacterial tonsilitis (Immunocompromised, Diabetes, young infants) •Tonsillectomy: at least 7 in 1 year, 5/year for 2 years, 3/year for 3 yearDizziness (1) First attack 5 days ago, 3 since then. spells” Otherwise fit and well Additional Questions to ask?Dizziness (1) PC/Basic Questions: 50y female, “Dizzy spells” First attack 5 days ago, 3 since then. Otherwise fit and well Additional Questions to ask? 1) Nature of episodes Duration of attacks? Onset? What were they doing? Screen Other symptoms at onset? Relief period? Any medicationsDizziness (1) PC/Basic Questions: 50y female, “Dizzy spells” First attack 5 days ago, 3 since then. Otherwise fit and well Additional Questions to ask? 1) Nature of episodes Duration of attacks? Onset? What were they doing? Screen Other symptoms at onset? Relief period? Any medications 2) Is it Vertigo? 3) Hearing 4) Aural fullness 5) Recent illnesses or other PMHxDizziness (1) PC/Basic Questions: 50y female, “Dizzy spells” First attack 5 days ago, 3 since then. Otherwise fit and well Additional Questions to ask? 1) Nature of episodes Duration of attacks? Onset? What were they doing? Screen Other symptoms at onset? 2) Is it Vertigo?period? Any medications 3) Hearing 4) Aural fullness 5) Recent illnesses or other PMHx Red Flags: 1. Systemically Unwell 2. Focal neurology: • Facial weakness (CNVII) • Facial numbness (CNV) (vertigo in acoustic neuroma) 3. Signs of raised ICP or Space occupying lesion 1. Focal neurology or concerns of a central cause? Dizziness (1) Consider emergency admission: Raised ICP/ SOL, Stroke, Need for CT/MRI First attack 5 days ago, 3 since then. spells” Otherwise fit and well 2. Is it actually vertigo (hallucination of movement)? If not: do a general/ neurological assessment; ddx of nausea or syncope Additional Questions to ask? 3. How long does it last? 1) Nature of episodes Constant: Labyrinthitis Duration of attacks? Onset? What were they doing? Episodic (seconds): BPPV Screen Other symptoms at onset? Relief period? Any medications Episodic (hours-days): Vestibular migraine 2) Is it Vertigo? Episodic (without warning): Meniére’s (aural sx); Acoustic neuroma (nil 3) Hearing 4) Aural fullness aural sx) 5) Recent illnesses or other PMHx 4. Does positioning cause the attack (BPPV, posterior circulation syndrome), 5. Hearing affected? Red Flags: Hearing loss is usually peripheral cause (BPPV and viral labrynthitis 1. Systemically Unwell are the exceptions) 2. Focal neurology: • Facial weakness (CNVII) • Facial numbness (CNV) (vertigo in acoustic neuroma) 3. Signs of raised ICP or Space occupying lesionDizziness (1) 1. Focal neurology or concerns of a central cause? PC/Basic Questions: 50y female, “Dizzy spells” Consider emergency admission: Raised ICP/ SOL, Stroke First attack 5 days ago, 3 since then. Otherwise fit and well Need for CT/MRI – HiNTS Exam (next slide) Additional Questions to ask? 2. Is it actually vertigo (hallucination of movement)? 1) Nature of episodes If not: do a general/ neurological assessment; DDx of nausea or Duration of attacks? syncope Onset? What were they doing? Relief period? Any medications? 3. How long does it last? 2) Is it Vertigo? 3) Hearing Constant: Labyrinthitis 4) Aural fullness Episodic (seconds): BPPV 5) Recent illnesses or other PMHx Episodic (hours-days): Vestibular migraine/neuronitis Red Flags: Episodic (without warning): Meniére’s / Vestibular schwannoma Does positioning cause the attack (BPPV, posterior circulation 1. Systemically Unwell 2. Focal neurology: syndrome) • Facial weakness (CNVII) 4. Hearing affected? • Facial numbness (CNV) (vertigo in vestibular schwanomma) Hearing loss is usually peripheral cause (BPPV/Viral 3. Signs of raised ICP or Space occupying labrynthitis/Lateral Pontine Syndrome are exceptions) lesion Management Principles: Dizziness (2) 1. Exclude cerebrovascular event or space occupying lesion 2. Examination is incredibly important Ear exam, Neuro, CV exam, DANISH, Romberg’s test, Dix Halpike, HINTS 3. Bedside hearing assessment + consider formal audiology assessment 4. Symptomatic relief (prochlorperazine > antihistamines – cyclizine, promethazine) 5. Specific Rx: Vest. rehab; Meniere’s: Betahistine, BPPV: Epley’s 6. Protection/advice (No driving, heavy machinery, heights) 7. Supportive management for vomiting/illness 8. CT head required when central cause not excludedDysphagia PC/Basic Questions: 65y male, lump in throat Difficulties eating Additional Questions to ask? Dysphagia PC/Basic Questions: 65y male, lump in throat Difficulties eating Additional Questions to ask? • What consistency can the patient swallow and how has this changed? • Time duration? Progressive? • Odynophagia or aphagia? • Globus • Reflux Dysphagia PC/Basic Questions: 65y male, lump in throat Difficulties eating Additional Questions to ask? • What consistency can the patient swallow and how has this changed? • Time duration? Progressive? • Odynophagia or aphagia? • Globus • Reflux • Lump on lip or ulceration on mouth • Hoarseness • Thyroid lump • Systemic: malaise, weight loss fevers, night sweats Pain anywhere • Skin changes • Recurrent ear infections Dysphagia PC/Basic Questions: 65y male, lump in throat Difficulties eating Additional Questions to ask? • What consistency can the patient swallow and how has this changed? • Time duration? Progressive? • Odynophagia or aphagia? • Globus • Reflux • Lump on lip or ulceration on mouth • Hoarseness • Thyroid lump • Systemic: malaise, weight loss fevers, night sweats Pain anywhere • Skin changes • Recurrent ear infections • Tobacco, tobacco snus, chewing betel, khat • Other RFs:Alcohol, HPV vaccination, HPV infection, MSM Dysphagia PC/Basic Questions: 65y male, lump in throat Difficulties eating Additional Questions to ask? • What consistency can the patient swallow and how has this changed? • Time duration? Progressive? • Odynophagia or aphagia? • Globus RED FLAGS • Reflux 1. Progressive dysphagia to • Lump on lip or ulceration on mouth liquids → solids • Hoarseness 2. Smoker with any neck lumps • Thyroid lump 3. Recurrent otitis media • Systemic: malaise, weight loss fevers, night sweats Pain anywhere • Skin changes 4. Mouth ulcer >3 weeks 5. Hoarseness • Recurrent ear infections 6. Thyroid lump • Tobacco, tobacco snus, chewing betel, khat 7. White lessions in mouth or throat (erythroplakia) • Other RFs:Alcohol, HPV vaccination, HPV infection, MSM 8. StridorDysphagia PC/Basic Questions: 65y male, lump in throat Difficulties eating Additional Questions to ask? RED FLAGS Oral Cavity Cancer Most commonly oral cavity cancers will present as a mass, typically painless, being felt on the inner lip, tongue, floor 1. Progressive dysphagia to of the mouth, or hard palate. Less commonly, these cancers will present in more non-specific means*, such as oral liquids → solids cavity bleeding, localised painwithinthe oral cavity, orjaw swelling. *Premalignant conditions (erythroleukoplakia) may be noticed initially, prompting further investigations which reveal 2. Smoker with any neck themalignant transformation lumps Pharyngeal Cancer 3. Recurrent otitis media Many cases of pharyngeal cancer can present* initially as odynophagia, dysphagia, stertor, or referred otalgia. Nasopharyngeal carcinoma patients can present initiallywitha neck lump. 4. Mouth ulcer >3 weeks Majority of these tumours, specifically of the hypopharynx, frequently will have an advanced stage at the time of 5. Hoarseness *Trotters Syndrome is a triad of clinical features suggestive of nasopharyngeal malignancy, comprised of (1) unilateral 6. Thyroid lump conductive deafness (secondary to middle ear effusion), (2) trigeminal neuralgia (secondary to perineural invasion), and (3) defective mobility of thesoft palate 7. White lessions in mouth or Laryngeal Cancer throat (erythroplakia) The clinical features of a laryngeal malignancy can include hoarse voice, stridor (if advanced), dysphagia, persistent 8. Stridor cough, or referred otalgia. Laryngeal cancers are divided anatomically (mainly for the purpose of tumour staging) into glottis, supraglottis, and subglottis, withmost malignancies originating in the glottis region. Patients with glottic tumours have better prognosis as they present earlier with hoarse voice and there is no lymphatic drainage from the glottis, hence limits any metastatic spread locally. Dysphagia PC/Basic Questions: 65y male, lump in throat Difficulties eating Additional Questions to ask? • What consistency can the patient swallow and how has this changed? • Time duration? Progressive? Oral Cavity Cancer • Stridor. Breathlessness? typically painless, mass (inner lip, the mouth, or hard palate). Less • Odynophagia or aphagia? cavity bleeding, localised pain with • Globus 1. Airway obstruction (stridor, or jaw swelling. • Reflux dyspnoea, drooling, Pharyngeal Cancer dysphonia) Initiallyas odynophagia, dysp • Lump on lip or ulceration on mouth 2. Trismus or referred otalgia. Nasopharyn 1. Voice changes: Hot patients can present initially with a ne • Hoarseness Majority of these tumours, will prese potato voice stage (often metastatic) at the time • Thyroid lump 2. Pain opening the jaw they will often metastasise early due • Systemic: malaise, weight loss fevers, night sweats Pain anywhere 3. Difficulty swallowing lymphatic network. 4. Unilateral tonsillar deviation Laryngeal Cancer • Skin changes hoarse voice, str 5. Not coping/systemically unwell advanced), dysphagia, persi • Recurrent ear infections 6. If: Sore throat with normal throat or referred otalgia. Laryngeal can on neck movements + airwayor stiffness anatomically • Tobacco, tobacco snus, chewing betel, khat obstruction --> think Deep space neck Patients with glottic tumours infection prognosis as they present earlier w • Other RFs: Alcohol, HPV vaccination, HPV infection, MSM and there is no lymphatic drainage hence limits any metastatic spread loEar PainEar Pain Key Questions: 1. Which Side? 2. Appearance (what parts of ear) 3. Is there Ear Discharge? Colour? Blood? Suggestive of tympanic membrane rupture. 3. Hearing? Effusion 4. Fever 5. Coryzal symptoms 6. Balance issues Yes: Suggests media > externa 3. Otoscopy Normal? Yes: consider referred pain from tonsils, TMJ , neuropathic. 4. Is the tympanic membrane opaque, bulging, and red? Yes: AOM No: AOM with Effusion 1. Down Syndrome (eustachian) Ear Pain 2. Recurrent infections ?nasopharyngeal cancer 3. Systemically unwell patients Key Questions: 4. <3 months old 1. Which Side? 5. Bilateral under 2y 2. Appearance (what parts of ear) 6. Complications 3. Is there Ear Discharge? Temporary hearing loss Colour? Blood? Suggestive of tympanic membrane rupture. External: Mastoiditis (retroauricular boggy 3. Hearing? Effusion 4. Fever swelling), Labyrinthitis, Petrositis, Facial Nerve 5. Coryzal symptoms Palsy Internal: Meningitis, Intracranial Abscess, 6. Balance issues Venous thrombosis Yes: Suggests media > externa DDx: 3. Otoscopy Normal? 1. Acute Otitis Media with Effusion Yes: consider referred pain from tonsils, TMJ , neuropathic. 2. Chronic Suppurative Otitis Media 4. Is the tympanic membrane opaque, bulging, and red? Yes: AOM 3. Trauma No: AOM with Effusion 4. Otitis Externa - ?Necrotising/Malignant 5. Referred: Tonsils, TMJ, Neuropathy + Above mentioned complications 1. Down Syndrome (eustachian) Ear Pain 2. Recurrent infections ?nasopharyngeal cancer 3. Systemically unwell patients Key Questions: 4. <3 months old 1. Which Side? 5. Bilateral under 2y 2. Appearance (what parts of ear) 6. Complications 3. Is there Ear Discharge? Temporary hearing loss Colour? Blood? Suggestive of tympanic membrane External: Mastoiditis (retroauricular boggy rupture. swelling), Labyrinthitis, Petrositis, Facial Nerve 4. Hearing affected? Effusion Palsy 5. Fever? Internal: Meningitis, Intracranial Abscess, 6. Coryzal symptoms Venous thrombosis 7. Balance issues Yes: Suggests media > externa DDx: 8. Otoscopy Normal? 1. Acute Otitis Media +/- Effusion Yes: consider referred pain from tonsils, TMJ, neuropathic 2. Chronic Suppurative Otitis Media 3. Trauma 9. Is the tympanic membrane: opaque, bulging, and red? – AOM 4. Otitis Externa - ?Necrotising/Malignant fluid level visible, but nil acute – OME (Glue Ear) 5. Referred: Tonsils, TMJ, Neuropathy + Above mentioned complications Management (AOM): 1. Simple analgesia alone 2. Oral/Topical Antibiotics, can offer delayed prescription: Amoxicillin 5-7 days, (clarithromycin if allergic) Co-amoxiclav in very comorbid patients 3. Reassurance that eardrum ruptures usually heal (keep dry!!)Discharging Ear: Key Questions:Discharging Ear: Key Questions: 1. Which Side? 2. Is it Painful? Painless: Consider chronic causes of discharge 3. Painful: Adult or Child Adult: Acute Otitis Externa Child: Otitis Media with Effusion 4. Discharge? Purulent: Bacterial AOM/OME Serous: CSOM, Cholesteatoma (smelly) Cottage cheese: Fungal Infection 5. Hearing Loss Conductive or non-conductive? Typically Conductive = Cholesteatoma, ear wax etc.Discharging Ear: Key Questions: 1. Which Side? 2. Is it Painful? Painless: Consider chronic causes of discharge 3. Painful: Adult or Child Adult: Acute Otitis Externa Child: Otitis Media with Effusion 4. Discharge? Purulent: Bacterial AOM/OME Serous: CSOM, Cholesteatoma (smelly) DDx: Cottage cheese: Fungal Infection 1. AOM/OME + Perforation 5. Hearing Loss 2. Chronic Suppurative Otitis Media Conductive or non-conductive? 3. Otitis Externa Typically Conductive = Cholesteatoma, ear 4. Cholesteatoma wax etc. RED FLAGS 1. Systemically Unwell 2. Further spread: External: Mastoiditis, Labyrinthitis, Petrositis, Facial Nerve Palsy Internal: Meningitis, IC Abscess, Venous Sinus ThrombosisDischarging Ear: Key Questions: 1. Which Side? 2. Is it Painful? Painless: Consider chronic causes of discharge 3. Painful: Adult or Child Adult: Acute Otitis Externa Child: Otitis Media with Effusion 4. Discharge? Purulent: Bacterial AOM/OME Serous: CSOM, Cholesteatoma (smelly) DDx: Cottage cheese: Fungal Infection 1. AOM/OME + Perforation 5. Hearing Loss 2. Chronic Suppurative Otitis Media Conductive or non-conductive? 3. Otitis Externa Typically Conductive = Cholesteatoma, ear 4. Cholesteatoma wax etc. RED FLAGS 1. Systemically Unwell Management: 2. Further spread: 1. ENT Referral if non-responsive (CT/MRI + Surgery for External: Mastoiditis, Labyrinthitis, Cholesteatoma). Petrositis, Facial Nerve Palsy 2. Otitis Externa: Topical antibiotics +/- Steroid +/- wick/suction Internal: Meningitis, IC Abscess, 2% Acetic acid (over the counter) Venous Sinus Thrombosis Other MLAAKT ENT Topics Neck Lumps Sinusitis 1. Malignancies – SCC/Thyroid, also ?Lymphoma (B-symptoms) Acute – Rhinovirus, Strep. Pneumoniae, Haem. Influenza 2. Infection – Cervical lymphadenopathy vs Neck lump infection Rhinorrhoea, Frontal pressure, Nasal Obstruction 3. Central Neck – Goitre vs Thyroglossal Duct Cyst Analgesia; if >10days -> Steroids 4. Lateral Neck – Cystic Hygroma: @birth, transilluminates If severe -> Pen V/Co-amox. -> orbital cellulitis Branchial Cyst: childhood, no transilluminate 5. Pharyngeal Pouch – Older, Regurgitation/Dysphagia Chronic - >12 wks, 6. Parotid disease Similar Sx – post-nasal drip & cough, polyps Allergen avoidance, Saline Irrigation, Steroids Benign – Pleomorphic Adenoma (common), Warthin’s (smoker/bilat.) Prolonged decongestants: tachyphylaxis & medicamentosa Malignant – Many types, can arise from PA, CNVII involvement Sialolithiasis – Colicky pain, stone OSA – Common+++, Obesity, Large tonsils, Marfan’s Sialadenitis – Infection; Bilateral & non-vaccinated - ?Mumps Sx: Daytime sleepiness, Hypertension, Resp. acidosis Other – HIV, Sjogren’s, Sarcoid Ix: Epworth Sleepiness Scale, Polysomnography Rx: Weight loss, CPAP; ?Surgery; DVLAEmergencies – Remaining MLA content • Epistaxis • Post-tonsillectomy bleed • SSNHL • Epiglottitis Emergencies – Epistaxis Anterior =Generally Kisselbach’s plexus with a visiblebleeding point. Generally ligher Posterior – Woodruff or other posterior structure. Generally heavier and presents with posterior drip. Key principles - Everyone → A-E and First aid: Sit up, leaning slightly forward + head tilt. Pinch cartilaginous area of nose15/20 minutes mins. Encouragespitting out blood. Ask to breathe through nose - haemotological causesal in <2 years, very frail (may diewith another bleed) or ?underlying causesuch as - Admission (>30mins) ifcomorbid condition (Severe HTN, CAD, anaemia) - Septal haematoma or blunt trauma needs same dayENTreview for incision and drainage(risk of septal necrosis) - When discharged: - Naseptine to reduce crusting (Caution: Peant, soy or neomycin allergy → mupirocin) - Avoid blowing or picking nose,heavy lifting,strenuous exercise, lying flat, alcohol or hot drinks - Management (Going deeper) • A-E assessment • First aid trial (if haemodynamically stable, if not proceed to packing or cautery) • Can you Visualise? • Visualised → CAUTERISE (Never blind cauterise,local anaestheticspray, not fit for young children ?specialist in cocaine ingestion) • Not visualised → ADMIT and ANTERIOR PACK (Unilateral) (Local anaestheric spray) • Then…If still bleeding → Posterior pack • Then reassess for bilateral packing • If fails: → ENT specialist (for endoscopic cauteryor spheropalatine ligation) Recurrent epistaxis or underlying cause workup suspected if<2 years, angiofibroma (nasal obstruction) cancer (facial pain, hearing loss, nasal obstruction, South Chinese origin), telangiectasia on fingertips face or nose(hereditary telangectasia) Emergency - Post-tonsillectomy bleed Pain normal up to 6 days All reviewed by ENT/admission Primary haemorrhage = <8 hours → immediate return to theatre Secondary haemorrhage = >24 hours - generally 5-10 days = Infection main cause (1-2% rate of occurrence) Source: Wikimedia commons → Admit + antibiotics. May require surgical re- operation Emergencies – SSNHL Definition: Onsent <72hours loss of >30dB at three consecutive frequencies. Majority unilateral. Generally older patients and common to have another ear condition or CV risk factors. Emergencyreferral to ENT Some are excluded as conductive causes such as wax, eardrum rupture etc. (these are not SSNHL) >90% idiopathic.Other causes– viral infections,meningitis), ménière’s disease,ototoxic drugs,MS, stroke, acoustic neuroma,cogan’s syndrome Audiometry +/- MRI orCT head Stroke needsto be excluded/thought of if presenting to primarycare Steroids (oral or intra-tympanic under ENT decision) – around 60-70% treatment success Emergencies – Epiglottits Source ENTUK https://www.entuk.org/resources/169/adult_acute_severe_sore_throat_management_guidelines_for_emergency_department_doctors/We will now do Peer OSCE simulation If Leaving now… please leave Feedback OSCE Cases 2 then 3 then 6