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EAR, NOSE AND THROA T Rachelle Rachmat OSCEazy Sponsored byContent • Ear pathology • History • Examinations • Common Cases • Nose pathologies • History • Epistaxis management • Rhinitis and sinusitis (prescribing station / counselling) • Throat pathology • Tonsillitis , Quinsy • Neck lumps – History, exam , causes OSCEazy Sponsored byEar Pathologies OSCEazy Sponsored by • Ear pain • Make sure you ask the Ear History nose and throat questions • Discharge too! Taking • Hearing loss • Tinnitus • SOCRATES all complaints • Dizziness • Fullness OSCEazy Sponsored by • Weber’s • Rinne’s • Otoscopy Examination • Audiogram OSCEazy Sponsored byWeber’s and Rinne’s 1. What would someone’s results be for a conductive hearingproblem in their left ear? 2. Weber’s sound lateralizes to right Rinne’s: AC >BC in left ear, AC > BC in right ear OSCEazy Sponsored byAudiogram OSCEazy Sponsored byAudiogram Interpretation OSCEazy Sponsored by Audiogram OSCEazy Sponsored by Case 1 O/E: History: • 54 year old male • Left ear pain (2/7) • Tenderness Treatment: • Itching • Aural fullness • Abx drops • Hearing loss • Analgesia eg. • Enjoys swimming Paracetamol Otitis Externa • PmHx: T2DM - Careful of Malignant Otitis Externa OSCEazy Sponsored by Case 2 Symptoms: • Ear dischargethat has an unpleasant odor- tends to be resistant to abx • Hearing loss • Potentially: tinnitus, otalgia, altered taste and dizziness - Choleasteatoma Investigations: Management: • Topical abx • Otoscopy • Urgent if associated with facial nerve palsy • Audiogram • Surgery • CT petrous temporal bones OSCEazy Sponsored byCase 3 O/E: History: • 1 year old child • Irritable • Keeps pulling Treatment: 1. Analgesia right ear • Vomiting 2. Delayed abx • No discharge prescription Pmhx: Diagnosis: Otitis Media (with effusion) • Frequently gets thesesx OSCEazy Sponsored byComplications of Acute Otitis Media • Perforation of tympanic membrane • Mastoiditis- boggy swelling behind ear • Facial nerve palsy • Sigmoid sinus thrombosis OSCEazy Sponsored by Dizziness Symptoms Test/ Examination Management BPPV • Room spins Dix-Hallpike Manoeuvre • Epley Manoeuvre • Worse on moving head • Positive= vertigo with • No ear pain or nystagmus discharge • Recurring, transient vertigo • Hearing normal • Vertigo • Audiometry • Low salt diet Meniere’s • Hearing loss (at low • Rinne’s • Triamterene/ frequencies)- usually • Weber’s hydrochlorothiazide unilateral sensorineural • Or Acetazolamide • Tinnitus • Fullness in affected ear OSCEazy Sponsored byPerichondritis • Causes: • Usually injury eg. ear piercing, surgery • Most common causative agent= P. aeruginosa • Symptoms/signs: • Induration • Pruritus • Oedema • Crusting and weeping • Pain over pinna key in Perichondritis pinna hematoma • Management • Abx eg. Ciprofloxacin OSCEazy Sponsored by Sudden onset or rapidly progressivehearing loss: • With or without tinnitus • Must exclude acoustic neuroma Sudden, complete unilateral hearing loss with vertigo: Red Flags • Exclude acute ischemic episode for Ear episodic vertigo:-aged patient who has atypical Complaints • Exclude MS Pain or bleeding from the ear: • Exclude trauma • Referred ota- common in head and neck malignancies OSCEazy Sponsored by Nose Pathologies OSCEazy Sponsored by • SOCRATES • Site- Unilateral or bilateral? • How long have sx lasted? • Constant or intermittent? History of • Associated symptoms Nasal • Any blockage? If so, ever clear? Symptoms • facialpain, rhinorrhea (pain), PND, epistaxis. • Hx of trauma? • PMH and prev ENT history • Any previous nasal surgery? • Drug history - meds? OSCEazy Sponsored by Epistaxis History Not a trivial condition - can potentially be life threatening Unilateral/bilateral Duration, frequency Nb. neoplasm of the nasal cavity eg. SCC, Frequency adenocarcinoma Severity/quantify estimated blood loss Any contributing/inciting factors FH of bleeding disorder PMH Current medications Examination •Identify whether bleed is anterior or posterior •Suggested by failure to visualise anterior source/bleeding from both nostrils/visualisation of blood in pharynx •Encourage gentle blowing/suction the nose to clear clots •Use nasal speculum, good light source •Can use a rigid endoscope OSCEazy Sponsored by Primary/idiopathic Spontaneous bleed without any identified precipitant Trauma (including nose picking) Local factors Mucosal irritation Foreign bodies Age (2-10 + 45-65) HTN Causes of Systemic factors Alcohol use Liver disease Epistaxis Hereditary disorders - HHT, haemophilia, vWB Platelet function- thrombocytopenia Antiplatelets- aspirin, clopidogrel Medications Anticoagulants - warfarin, NOACs Intranasal steroids OTC/complementary Cold/dry air > mucosal irritation - presentations increase Environmental in winter Prolonged inhalation of dry air (oxygen) OSCEazy Sponsored by • Vital signs • A-E • Get IV access if: • Older • On anticoagulants • Hemodynamically compromised Management • Bleeding profusely of Epistaxis • Bleeding for more than 20 mins • Bloods: • FBC, G&S, • Clotting studies eg. INR, PT, APTT, platelet function • LFT (only if pt has chronic liver disease) • Position forwards for comfort + to avoid swallowing/aspirating blood • Tamponade vessels by pinching anterior nose 15-20 mins OSCEazy Sponsored byManagement of Epistaxis OSCEazy Sponsored by Rhinitis and Sinusitis Rhinitis Acute Rhinosinusitis • Inflammation of mucous membranes of nose • Inflammation of mucous membranes of nose and • Sx: nasal congestion, rhinorrhea, sneezing, paranasal sinuses itching, PND • Divided into allergic vs. non allergic causes • Tx: steroid nasal spray, antihistamines (only in allergic), nasal irrigation Chronic Rhinosinusitis • >12 weeks • Clinical symptoms + endoscopic/CT changes • Divided into CRS with polyps or CRS without polyps OSCEazy Sponsored by Rhinosinusitis (also known as Sinusitis) • Acute vs. chronic (>12 weeks) • With or without polyps • Causes • Acute= bacterial or viral cause • Chronic= allergy, structural abnormality, bacterial • Need to have 2 or more symptoms plus 1 sign: • 2 or more symptoms plus 1 sign • Symptoms: 1. Blockage/obstruction/congestion 2. Discharge: anterior/posterior 3. Facial pain, pressure 4. Reduction of sense of smell • Signs: 1. Endoscopic (polyp) 2. Discharge OSCEazy Sponsored by Management of Sinusitis • If sx <10 days: • No abx • Advise that usually caused by a virus • Paracetamol or ibuprofen for fever and pain • If sx >10 days: • High dose nasal corticosteroid for 14 days • worsen no abx or a back up prescription if no improvement within 7 days or symptoms • Self care • Chronic Sinusitis: • Manage associated disorders eg. allergic rhinitis or asthma • Advice on exacerbating factors such as allergic triggers • Relievesx through nasal irrigation with saline • Intranasal corticosteroids • Long term abx (need ENT input) OSCEazy Sponsored by 30 year old came in with 2 weeks Prescribing history of nasal blockage, discharge Exercise and pain across his forehead • What would you prescribe? OSCEazy Sponsored by • Unilateral symptoms of obstruction Red Flags for Nose with blood stained discharge • Persistent(>3weeks) unilateral and Sinus symptoms of obstruction Complaints • Unilateral or bleeding polyps • Polyps in children • Persistent unexplained epistaxis OSCEazy Sponsored byThroat pathologies OSCEazy Sponsored byHistory for Throat • Pain /sore throat- SOCRATES • Hoarseness in voice • Dysphagia + odynophagia • Neck lumps • Persistentcough OSCEazy Sponsored byRed Flags for Head and Neck • Persistent sore throat • Hoarseness >6 weeks • Dysphagia >3 weeks • Odynophagia • Weight loss, fevers and night sweats • Oral swellings > 3 weeks • Neck mass >3 weeks OSCEazy Sponsored by T onsillitis/ Sore Throat • FeverPAINscore • 0-1: no abx • 2-3: delayed prescription • 4-5: abx prescription • Management: • Analgesia • If they can’t swallow and are clinically dry, will need to be admitted • Abx or not – phenoxymethylpenicillin for 7- 10 days OSCEazy Sponsored by Quinsy • Symptoms: • Severe pain – often unilateral • Trismus • Otalgia • Signs: • Uvula deviation • Fever • Anterior arch pushed towards the midline Treatment: • Drainage • Admission for IV abx OSCEazy Sponsored by Laryngitis • Inflammation of the voice box- usually viral cause • Symptoms: • Dysphonia (hoarseness)- beware if >3 weeks • Difficulty speaking • Sore throat • Mild fever • Dry cough • Constant need to clear your throat • Can become chronic if due to GORD, excessive alcohol use, smoking etc. OSCEazy Sponsored by Neck Examination Assess lump’s: • Inspection -Overlying skin appearance • Size • Position • Mobility • Consistency (hard/ firm/ soft) • Pulpability • Tenderness • Further investigations – USS, FNA, Bloods- TFTs Examine lymph nodes Examine the oral cavity and the nose OSCEazy Sponsored by • Rubbery= reactive • Fluctuant= reactive Examination • Painful= reactive Findings • Hard and irregular= possibly malignant (Generally) • Size increasing= possibly malignant • If you can feel an enlarged left supraclavicular node (Virchow’s node)- ?gastric cancer OSCEazy Sponsored by Infection Benign Lymphadenopathy Causes of Benign tumour eg. lipoma Neck Lump Congenital and developmental lumps eg. thyroglossal cyst OSCEazy Sponsored by If a neck lump has not Sinister gone after 3 weeks, 2ww Causes of Neck Most common= Lumps lymphoma, thyroid cancer and soft tissue sarcoma OSCEazy Sponsored by Thyroid Nodules • Differentials: • Thyroglossal cyst Most common type of thyroid cancer= papillary • Thyroid goiter thyroid carcinoma • Cervical lymphadenopathy • Dermoid cyst • Thyroid cancer • Investigations: • FNAC Be suspicious of a thyroid • USS lump if: • TFTs • In a child • Rapidly enlarging and painless • If you suspect cancer, will have a fiberoptic laryngoscopy • Associated with cervical lymphadenopathy • Management: • Associated with stridor • Thyroidectomy • Unexplained hoarseness • Removal of lymph nodes OSCEazy Sponsored by Lymphoma Lymphocyte problem- will usually have multiple lumps - EBV associated Non- Hodgkin’s Lymphoma eg. Hodgkin’s lymphoma - Immunosuppression Burkitt lymphoma, Diffuse • B lymphocytes affected associated • Reid Sternberg cells seen large B cell lymphoma May see: - Anaemia - Thrombocytopenia - Neutropenia OSCEazy Sponsored byTHANK FOR LISTENING ANY QUESTIONS OSCEazy Sponsored by