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ENT in Primary Care PDF
ENT in Primary Care PDF
Primary Care
A Concise Guide
Edoardo Cervoni
Kim Leech
123
ENT in Primary Care
Edoardo Cervoni • Kim Leech
ENT disease represents a significant percentage of the day-to-day cases seen in primary
care – approximately 1 in 4 consultations. Research suggests this figure is between
23% (Cross and Rimmer 2007) and 25% (Lloyd et al. 2014) of all primary care presen-
tations. Unfortunately, the educational curriculum of the medical schools and family
doctor/GP training programs do not parallel the high prevalence of ENT disease. As a
result, health care professionals such as GPs and nurse practitioners (NPs) may refer
many patients to secondary care with ENT problems when they could handle them in
primary care. It is legitimate to assume that a better understanding of the clinical his-
tory, clinical examination and accurate management of ENT disease might lead to a
better management of the ENT patient and a reduction in the number of specialist
appointments requested in general practice. This book is not a complete compendium
of otolaryngology. Instead, it is intended to be a practical guide for the primary care
provider. The topics covered are common and the ENT disease management is the one
you would expect to take place in a primary care setting. The use of ENT diagnostic
instrumentation refers to what should be available in any GP surgery. We think this
book is a useful addition to the library of medical students, GPs in training, board certi-
fied family physicians and NPs. Its format is simple and the text is minimal. The topics
are organized in such a way as to highlight when a patient should be sent to a specialist
immediately and when they can be efficiently managed in general practice.
References
1. Cross S, Rimmer M (2007) Nurse practitioner manual of clinical skills, 2nd edn. Elsevier,
London
2. Lloyd S, Tan ZE, Taube MA, Doshi J (2014) Development of an ENT undergraduate curricu-
lum using a Delphi survey. Clin Otolaryngol 39:281–288
v
Acknowledgements
We would wish to personally thank the following people for their contributions to
our inspiration and knowledge and other help in creating this book.
Dr. Cervoni would like to thank the many people who have brought him this far.
They are his relatives, teachers, and colleagues he had the pleasure to work with
over the years, but especially his very much loved children, Oliver Alessandro and
Francesca, with the infinite love that they give every day.
Mrs. Kim Leech would like to acknowledge her parents, Mark and Brenda
Jagger, for her upbringing, their support and encouragement, her husband, Ashley,
for his continued support and constant belief and her beautiful daughter, Maddison.
Finally, we would like to thank the patients for their trust and for having shared
their experience of living with the most diverse ENT pathologies.
vii
Abbreviations
ix
Contents
1 E
NT Anamnesis������������������������������������������������������������������������������������������ 1
The ENT Consultation �������������������������������������������������������������������������������� 1
ENT History�������������������������������������������������������������������������������������������� 1
History of Presenting Complaint ������������������������������������������������������������ 2
Past Medical History�������������������������������������������������������������������������������� 2
Drug History�������������������������������������������������������������������������������������������� 2
Social History������������������������������������������������������������������������������������������ 2
References���������������������������������������������������������������������������������������������������� 3
2 O
tology�������������������������������������������������������������������������������������������������������� 5
Organ Targeted History�������������������������������������������������������������������������������� 5
The Ear���������������������������������������������������������������������������������������������������� 5
Ear Equipment �������������������������������������������������������������������������������������������� 6
Otoscope�������������������������������������������������������������������������������������������������� 6
Tuning Forks�������������������������������������������������������������������������������������������� 8
Frenzel Goggles �������������������������������������������������������������������������������������� 8
Ear Syringe���������������������������������������������������������������������������������������������� 9
Otological Examination ���������������������������������������������������������������������������� 10
Otalgia���������������������������������������������������������������������������������������������������������� 11
Causes of Referred Otalgia�������������������������������������������������������������������������� 11
Local Causes�������������������������������������������������������������������������������������������� 12
Otitis Externa ���������������������������������������������������������������������������������������������� 12
Acute Otitis Media�������������������������������������������������������������������������������������� 14
Consequences of Viral and Bacterial Otitis Media���������������������������������� 16
Ear Secretions���������������������������������������������������������������������������������������������� 18
Otitis Externa ������������������������������������������������������������������������������������������ 19
Middle Ear Pathology������������������������������������������������������������������������������ 19
Trauma or Foreign Body�������������������������������������������������������������������������� 19
xi
xii Contents
There are many well-documented consultation models such as Helman’s Folk Model
(1981), Pendleton et al. (1984), Neighbour (1987) and Calgary-Cambridge (1996) to
name but a few. Many of which, designed in Primary Care. The use of consultation
models helps to add structure to the consultation and ensure all relevant aspects are
explored. It is not the intention of this book to specify a preferred model or whether
a clinician devises their own model. However, there is a common factor in that all
models which includes presenting complaint, past medical history, drug history,
social history, examination, differential diagnosis, investigations and treatment.
ENT History
The clinician should ascertain a patient’s past medical history. This may help the
clinician determine if it is a recurring health problem. A history should include
allergies. This is especially important in ENT presentations. Any history of asthma
or respiratory conditions, neurology or rheumatology may also be significant.
Undertaking a past medical history may affect a patient’s treatment plan or options
for surgery and anaesthesia.
Drug History
Social History
Ototoxic
Anticoagulants
s
ug
Dr Affecting the vestibular system
Affecting BP
Alcohol
Smoking
Endocrinology
G
en Allergology
er
a lc
on Immunology
diti
ons
Cardiology
Mental Health
Rheumatology
Infectious diseases
References
The Ear
o torrhoea may indicate trauma. Likewise, patients with a mucous discharge may
have a perforated tympanic membrane and patients with a clear fluid following a
head or skull injury could have a CSF leak. A foul-smelling otorrhoea is character-
istic of cholesteatoma. However, there are other infections leading to extremely
malodorous ear secretion such as infection caused by Proteus. The history should
investigate any childhood illness, trauma, foreign bodies, respiratory symptoms,
any ENT surgery or excessive exposure to water e.g. swimmers. Associated symp-
toms such as hearing loss, tinnitus, pain, vertigo and facial palsy should also be
explored. Vertigo and facial palsy associated with otorrhoea require urgent
referral.
Patients complaining of ear noise (tinnitus) often indulge in a very detailed
description of what they hear. Most of this is useless in making the diagnosis.
Tinnitus has many causes, including hearing loss, loud noise exposure, head
injury or surgery and side effects of medications. Aspirin, NSAIDs, furosemide
and quinine have all been associated with tinnitus. The clinician should ascer-
tain the patient’s symptoms, whether they are experiencing a ringing, any aural
fullness, fluctuating hearing loss, vertigo, otalgia or vestibular symptoms.
However, it is important to recognize if the tinnitus is non-pulsating or pulsating
since the latter may occur with severe vascular tumours or malformations. Ear
popping and cracking are suggestive of Eustachian tube dysfunction, as it is a
feeling of pressure inside the ear. Subjects suffering from Ménière’s syndrome
may report a similar experience. Dizziness accounts for 2.5% of primary care
presentations and of which 50% of dizziness presentations have an ontological
cause. When obtaining the clinical history, the clinician should ascertain onset,
duration and associated symptoms. Hain (1997) suggests duration can help to
diagnose the complaint: BPPV (usually lasts seconds), TIA (minutes), Ménière’s
(hours), vestibular neuronitis (days) and ototoxins (years). Associated head
movement or change in head position, hearing disturbance, headache, cognitive
symptoms and stress are helpful to explore. If after picking up the history you
do not have a suspect, it is unlikely that diagnostic clinical examination and
further investigations may bring to fruitful results. The facial nerve is in close
anatomic relationship with the ear and it can be involved in its pathology.
Therefore, the patient may experience change in sense of taste or facial weak-
ness. The clinician should explore this, as the patient may fail to recognise the
link and its relevance (Fig. 2.1).
Ear Equipment
Otoscope
It is a fundamental tool that can be fitted with or without sliding lens (this allowing
the use of instruments such as the Jobson Horne for removal of earwax), and pneu-
matic pump for assessment of tympanic membrane mobility. Best visualisation of
the external auditory canal (EAC) is achieved positioning your head at the same
Ear Equipment 7
Aminoglicosides
Quinine
s Salicylates
r ug
D
Loop diuretics
Cisplatin
Erythromycin
Neurofibromatosis
ry
isto Deafness
lt h
Blood mi
Fa
Triggers Spontaneus
Fe Induced by stimulation
ve
r
Hypertermia
Hyperpyrexia
Ti Low
nn Pitch
itu
s High
Pulsation
Type
Non-pulsation
Severity
Fig. 2.2 Otoscope
level as the patient’s head. With the free hand, the clinician should straighten the
external auditory meatus (ear canal) by gently pulling the auricle upward and back-
ward in the adult and downwards and backwards in the child. The clinician should
choose the widest speculum that will comfortably fit into the patient’s ear, as this
would provide the best view of the ear structures. The clinician should choose the
largest speculum that will comfortably fit into the patient’s ear, as this would pro-
vide the best view of the ear structures (Fig. 2.2).
8 2 Otology
Tuning Forks
In ENT, tuning forks are used to assess hearing loss and ascertain whether the
hearing loss is conductive or sensorineural in nature. Each tuning fork carries a
number (128, 256, 512 and 1024 Hz.) This is the frequency at which the fork
vibrates.
Diapason at 512 Hz
The 512 Hz tuning fork is the most effective in the range of clinical diapasons avail-
able as the patient may not recognize a lower frequency (128, 256 Hz), and higher
frequencies have a shorter duration making the Rinne test difficult to perform. The
tuning fork may be made of steel or aluminium, the latter being a much cheaper
material, but is suitable to clinical use (Fig. 2.3).
The easiest and most useful hearing tests to perform are the Rinne and the
Weber test. The Rinne and Weber test are used to differentiate between
conductive hearing loss (CHL) and sensorineural hearing loss (SNHL). Both
should be carried out and the Rinne test should be done first. We shall address
the details of both tests in a separate section of this book dedicated to hearing
evaluation.
Frenzel Goggles
Ear Syringe
Ear syringing is the most common ENT procedure carried out in primary care. Its
purpose is the removal of cerumen. There are many types of ear syringe, including
metallic, glass or made of plastic and electric with automatic pressurization
(Propulse II.) The Medical Device Agency advocates the use of the Propulse II as
the safest device (Fig. 2.5).
10 2 Otology
Otological Examination
In addition to the clinical anamnesis we have described in the previous sections, the
complete otological examination comprises a physical examination and testing
which includes:
• Inspection
• Otoscopy
• Removal of cerumen if present
• Use of tuning forks
• Pneumatic otoscopy/“fistula test”
• Vestibular system assessment
• Cranial nerve exam
• Head and neck exam
It is common practice to examine the unaffected or least affected ear first. This
will set a baseline for the clinician to compare the other ear to. The clinician should
start by assessing the pinna, reviewing the skin around, behind and adjacent to it.
Evaluate for the presence of scars, as this may be significant in framing the clini-
cal scenario (Figs. 2.6 and 2.7).
The clinician should assess whether there is a deformity of the pinna, or any skin lesions.
The clinician should then assess the appearance of EAC. The otoscope is funda-
mental to this providing magnification and illumination. The otoscope will be used
in conjunction with a speculum of the largest size that can fit in the EAC of the
patient without causing discomfort. Pulling the pinna upwards and backwards
straightens the ear canal, and the clinician should assess:
• Normal findings such as hair, and cerumen
• Abnormal findings such as dry flaky skin suggestive of eczema, inflamed or
swollen ear canal, discharge, impacted cerumen or foreign body
• The appearance of tympanic membrane – this includes analysing the m obility of
the TM, any retraction pockets, the presence of keratinous a ccumulations, any
erosion of the ossicular chain, any perforations or scars (Fig. 2.8)
Temporal
fascia grafting
site
Retroauricular
approach
Retroauricular
approach
Grafting
site
Triangular fossa
Scaphoid fossa
Tragus
Concha cava
Antihelix
Antitragus
Lobule
Otalgia
Earache is a common presenting complaint in primary care. Often, but not always,
it is indicative of an ear infection. When the otoscopic examination is normal, the
ear pain is a referred pain. In addition, the healthcare professional has to be aware
that catarrhal otitis can lead to chronic acute otitis media and vice versa. When con-
sidering an ear infection, in conjunction with the clinical history, the diagnostic
elements illustrated in the following paragraphs are of extreme relevance.
• TMJ syndrome
• Cervical spondylosis
• Cancers of the throat, mouth and nasopharynx
• Odontogenic
In the following sections we shall explore the local causes of otalgia, whilst some
of the conditions causing referred otalgia will be discussed in other sections of the
book instead.
Local Causes
The main local causes of otalgia are trauma, or pathology of the pinna, otitis externa,
and otitis media.
Clinical Presentation
Otitis externa may be due to acute or chronic eczema, psoriasis, seborrhoeic derma-
titis, skin infection of the EAC or pinna.
Examination
• Itching and/or ear pain
• Watery secretion
• Some deafness, or blocked ear
• Pain that radiates towards neck and adenopathy
Clinical Management
• Antibiotic and topical steroid drops for 5 days
• Cream and/or antibiotic drops with steroid and gauze
• Ear swab for microbiological examination
• Diabetic control if applicable
• Consider shampooing
• Acetic acid in drops or spray
• Use of ear plugs to avoid water entering the ear canal
Key Points
Refer to a specialist if marked stenosis of the EAC, or in case of ear obstruction
due to exostosis of the EAC, keratin debris, facial cellulitis, persistent symp-
toms resistant to medical treatment, and infections interfering with the use of
hearing devices. Other causes of otitis externa are boils, which are very painful
especially to traction of the pinna; shingles; myringitis bullosa haemorrhagica;
and perichondritis, which require hospitalization for appropriate therapy.
Otitis Externa 13
RED FLAGS
Painless secretion
Key Points
Refer to the ENT specialist recurring otitis media if cause for concern for the
patient, family, or GP. Also refer to the ENT consultant if chronic otalgia,
recurrent or from otological causes.
• Admit for immediate specialist assessment, adults and children with acute com-
plications of acute otitis media such as meningitis, mastoiditis, or facial nerve
paralysis.
• Consider admitting patients who are systemically unwell.
• Consider admitting people with significant, persistent symptoms on high-dose
amoxicillin/clavulanic acid, or azithromycin.
Fig. 2.12 Myringosclerosis
Acute Otitis Media 17
Key Points
Acute otitis media in adults is uncommon in those subjects that have not been
already prone at a young age and as such it should be followed-up carefully.
Refer to specialist in the absence of a speedy resolution, or in case of
recurrence.
Any child younger than 2 years old that is unwell needs otoscopic
examination.
The level of concern of relatives often goes in parallel with the severity of the
ENT pathology.
Treating otitis media with analgesia for 24 h does not harm the patient’s
health.
An exudative otitis media in an adult without previous history of ontological
problems should trigger special attention.
A mastoid abscess should not be diagnosed in the presence of normal tym-
panic membrane, or almost normal.
A mastoiditis requires hospital admission if evidence of complications.
18 2 Otology
RED FLAGS
The presence of ear discharge is a common finding in general practice. The presence
of secretions in the EAC does challenge the clinician’s ability to visualize the tym-
panic membrane without the help of a suctioning device. As such, the clinician
should be particularly careful in their proposed management. In the presence of
history of ear surgery, or surgical incision, the patient should be referred to the ENT
specialist. Ear discharge, or otorrhoea, may be due to several causes, ranging from
an otitis externa to pathology of the middle ear.
Fig. 2.14 Otorrhoea
Management of Ear Secretions 19
Otitis Externa
We have already discussed otitis externa as being a cause of otalgia. In fact, earache
is the prominent feature of otitis externa and the presence of discharge in the absence
of pain should suggest the possibility of a perforated otitis media instead. Otitis
externa can be due to a variety of causes, including a trauma, boils, pseudomonas,
or rarely a neoplasm. The use of cotton buds is a common trigger of otitis externa.
Otitis externa is often associated with pruritus, sensation of ear fullness because of
the accumulations of keratin scales and exudate, and a slight hearing loss.
It can lead to ear discharge only in the presence of tympanic membrane perforation.
Pathologies of the middle ear that can cause discharge include the already discussed
AOM, chronic otitis media, some fractures of the temporal bone and granulations of
the tympanic membrane.
Clinical Management
• Antibiotic and topical steroid drops for 5 days.
• If the patient is diabetic, obtain an ear swab to exclude Pseudomonas aeruginosa
infection which, if present, would demand ENT referral.
• Suggest avoiding shampoo, conditioner, swimming, and sauna.
• Repeat otoscopic examination if the above measures do not bring benefit.
• In the presence of tight and swollen ear canal, use gauze or other guide.
• Analgesia.
• Oral antibiotics if adenopathy present.
• Anti-histamine if itching.
• If abundant keratin debris, refer to ENT? cholesteatoma.
20 2 Otology
RED FLAGS
Tympanic membrane perforations can be handled in the large part by primary care.
They occur when a hole or tear develops in the tympanic membrane.
These are divided into:
• Peripheral
• Of the attic
• Central
Fig. 2.15 Tympanic
perforation
Perforation of Tympanic Membrane 21
Key Points
Consider referring patient in case of:
• Recurring/persistent otorrhoea
• Otalgia resulting from secondary otitis externa
• Deafness
• Vertigo
• Persistent perforation
22 2 Otology
RED FLAGS
Headache
Vertigo
High fever
Fig. 2.16 Cholesteatoma
• Deafness
• Smelly otorrhoea
• Otalgia
• Facial nerve deficit
• Vertigo
• Mastoid abscess
• Meningitis
Examination
• The presence of cholesteatoma is typically suggested by the presence of abun-
dant keratinic debris with or without smelly discharge and tympanic mem-
brane perforation. The latter is most common, but it may not be present on
occasions such as in the case or a retraction pocket or a congenital
cholesteatoma.
Clinical Management
• The presence or suspect of cholesteatoma dictates ENT referral for further
management.
Child Deafness
If a parent suspects that his child has difficulty hearing, the GP should consider a
request for visiting an ENT specialist. In general, the perception of deafness in a
child indicates the presence of bilateral hearing loss. The first question to consider
is if deafness is associated with ear pain.
With Otalgia
Consider:
• Acute otitis media
• Upper respiratory tract infection
Without Otalgia
Consider:
• Earwax
• Bilateral exudative otitis media
24 2 Otology
• History of pre-, peri-, post-natal complications or that might suggest the pres-
ence of sensorineural hearing impairment
• History of meningitis, or severe rash
• History of head trauma
• Congenital malformations
Examination
• Presence of earwax: sodium bicarbonate 5% drops for 48–72 h, eventually fol-
lowed by irrigation of the EAC. However, this would not be advisable in the
young child.
• Glue ear which is very common and is determined by:
–– Vascularisation of the tympanic membrane
–– Golden colour of tympanic membrane
–– Absence of bright reflex triangle
–– Almost blue reflex of tympanic membrane
–– Presence of fluid, or air-water levels/bubbles behind an intact tympanic
membrane
–– Horizontal handle of the hammer
Clinical Management of Deafness with Otalgia
• Acetaminophen for 24 h in the presence of acute otitis media
• Symptoms lasting longer than 24h, 5 days of antibiotic therapy
• If the ear pain resolves but the deafness remains, treat as deafness without ear pain
• Note: Nasal drops don’t help
Clinical Management of Deafness Without Otalgia
• It is important to get a good clinical history from the relatives and clarify what,
when and how the suspect of deafness was established.
• Evaluate speech and the ability to read; in the event of a delay request ENT and
Paediatric assessment.
In the clinical management of “glue ear”, or chronic otitis media exudative,
consider:
• Otitis media and exudative otitis media can be linked to each other.
• In the case of a speech delay, refer to a specialist.
• In the absence of a delay in speech, observe for a couple of months before
referring.
• Lack of improvement after 2 weeks, should lead to referral.
• In the presence of auditory fluctuations, reviewing every 2 months.
• In older children, spontaneous resolution is more likely.
• Nasal drops, mucolytic and antibiotics should help.
Auditory assessment of a child can usually take place in a GP surgery using the
Leeds Picture Discrimination Cards and whispered voice a metre away.
• 0–3 years: refer
• 3–6 years: Leeds Picture Discrimination Cards
• 6 years: whispered voice
Hearing Tests 25
If parents believe that a child has hearing problems, refer. Always refer a child
with marked hearing loss even when this is possibly due to the presence of serous
otitis media, or glue ear.
RED FLAGS
Speech delay
Malformations
Adult Deafness
Usually, deafness in adulthood has a slow onset and evolution. It can be uni-/bilat-
eral, affecting the understanding of speech, especially on the phone and in noisy
environments.
Key anamnestic points
• Past medical history of ear surgery
• Infantile exanthema
• Head trauma
• Severe systemic diseases that have required the use of ototoxic medications
• History of occupational exposure to noise
• Hobbies such as hunting, or music
• Family history of deafness
• Diabetes
• Autoimmune disease
Hearing Tests
Rinne Test
The Rinne test is used to evaluate CHL. CHL occurs when there is a problem
conducting the sound waves to the inner ear anywhere along the route through the
outer ear, tympanic membrane, ossicular chain, up to the oval window (or fenstra
vesibuli). CHL may occur in conjunction with SNHL or in isolation. The Rinne
26 2 Otology
Fig. 2.17 Rinne
+
>
<
False
<
Neg CHL
SNHL
Fig. 2.18 Weber
Weber Test
The Weber test is used to detect either unilateral hearing loss of transmissive type or
unilateral sensorineural hearing loss (SNHL). When undertaking the Weber test, the
512 Hz diapason is placed in the centre of the patient’s forehead. Patients with uni-
lateral hearing loss (or predominantly unilateral) perceive the sound from the dis-
eased side if suffering from conductive hearing loss, or from the healthy side – or
less sick – if suffering from a perceptive hearing loss. In transmissive deafness, if
deafness is bilateral and there is a difference in the threshold between the two ears,
the sound will be lateralized in the worst ear; if deafness is symmetrical, to the cen-
tre (Fig. 2.18).
Ear Syringing
It is important that a comprehensive history has been undertaken before performing ear
irrigation to determine if there are any contraindications why it should not be performed.
28 2 Otology
Also an understanding of the basic anatomy of the ear is essential, so that the clinician
examining the patient understands what constitutes normal and when there are devia-
tions to this. Patients should be advised to use olive oil for at least 7 days, to soften the
wax prior to irrigation. The procedure for ear irrigation should follow the NHS
Modernisation Guidelines written by Harkin (2007) and is as follows.
• Explain the procedure to the patient, outlining risks associated with it such as
dizziness, perforation, otitis externa. If the patient is happy to proceed, gain con-
sent and document.
• Check whether the patient has had ear irrigation before.
• Sit the patient in a chair appropriate for the procedure with the ear to be irrigated
facing you.
• Inspect both ears with the otoscope.
• Place the protective cape and disposable towel in position, and ask the patient to
hold the receiver under the ear. It is advisable the patient tilt their head slightly
towards the affected side.
• Check your head light or mobile light is in place.
• Check the temperature of the water using a thermometer to approximately 37 °C.
• Remember any variation by more than a few degrees may cause the patient to
feel dizzy. If this occurs, stop irrigating, and ask the patient to fix his gaze on
some object for a few minutes until the dizziness passes.
• You should be sitting at the same level as the patient when carrying out this
procedure.
Use of an electronic syringe (Propulse II irrigator)
• Fill the reservoir of the Propulse II irrigator with warm water of 37 °C. Set the
pressure to minimum.
• Connect disposable jet tip applicator to the tubing of machine with firm push/
twist action. Push until click is felt.
• Direct the tip of the jet into the reservoir and switch on the machine for 10–20 s.
This distributes the water through the system to expel any trapped air or cold
water. This also enables the patient to accept the noise the machine makes.
• Gently pull the pinna upwards and outwards to straighten the meatus.
• Place the tip of the nozzle into the external auditory meatus entrance. Nothing
should be inserted into the ear further than the part that can be seen from the
outside. Inform the patient that you are about to begin and that they should make
you aware of any symptoms of pain, dizziness or nausea. Switch the machine on
(using either foot or hand control).
• Direct the stream of water onto the posterior wall of the canal (11 o’clock in the
right ear and 1 o’clock in the left ear). Increase the pressure switch as determined
by the aural condition. It is advisable that a maximum of two reservoirs of water
be used in any one irrigation procedure.
Hearing Tests 29
• If the clinician has not managed to remove the wax within 5 min of irrigation,
switch to the other ear if indicated; allow approximately 15 min before returning
to first ear.
• Periodically inspect the meatus with the otoscope and inspect the solution run-
ning into the receiver.
• After removal of the wax, ask the patient to dry mop the excess water from the
meatus. Dry mop excess water from meatus under direct vision because stagna-
tion of water and any abrasion of the skin during the procedure may predispose
the otitis externa to infection.
• Examine ear, both meatus and tympanic membrane, and refer to ENT if there is
severe inflammation or trauma. Record all findings and treatment in the patients’
notes.
NB: Irrigation should never cause pain. If the patient complains of pain – stop
immediately.
Contraindications
Precautions
• Tinnitus – people with troublesome tinnitus may notice that when the wax is
removed and their hearing improves the tinnitus may increase in severity; dis-
cuss the procedure with the patient in detail and document consent in patients’
records
• Healed perforation – discuss on an individual basis – consider referral for suction
removal
• Dizziness
30 2 Otology
Key Points
Consider referral if:
• Removing the earwax doesn’t solve the deafness
• Sudden onset of deafness in the absence of earwax
• Unilateral symptoms
• Other symptoms in addition to ear tinnitus
• Tympanic membrane abnormalities
RED FLAGS
• ENT departments
• Audiologists
• Special schools
• Adapted television and telephone
Vestibular System 31
Vestibular System
The use of Frenzel goggles may be particularly helpful to look and assess for the
presence of nystagmus. This may be spontaneous, gaze evoked, post-headshake,
positional, triggered by the Dix-Hallpike manoeuvre, by pneumatic otoscopy, or by
other techniques. Smooth pursuit, saccades, gait, and head-shaking nystagmus
should be assessed. The Romberg test, the Fukuda step test and the hyperventilation
test are also helpful.
Smooth Pursuit
Saccades
Head-Shaking Nystagmus
axis of rotation could be parallel to one of the semicircular lateral canals. HSN is
absent in normal subjects; hence its identification with Frenzel’s glasses in a dark
room or a video camera (videonystagmoscopy) can be helpful. In fact, passive head
shaking is an effective way of triggering nystagmus in patients with peripheral and
central vestibular lesions.
The Fukuda stepping test (FST) is another particularly useful test in the limited
space of a consulting room. In the FST, also known as Unterberger’s stepping test,
the patient is asked to walk in place with their eyes closed. There are two variants to
the test, with 50 and 100 steps, the latter being somewhat more sensitive. Abnormal
deviation towards the side of the lesion, that means >45° deviation, occurs in most
cases, but in about 1/4 of the patients this could be towards the intact side, and in
another 1/4 it can remain within the normal range. Hence, if the patient rotates to a
particular side they may have a labyrinthine lesion on that side, but this test should
not be used in isolation of other tests to diagnose lesions.
Hallpike Test
Also known as the Dix-Hallpike test, it is probably one of the most helpful test that
can be performed in primary care to make diagnosis of BPPV. The British Society of
Audiology (2014) suggests the clinician should begin by explaining the procedure to
the patient and demonstrating if necessary. Make sure the patient is aware that he/she
may experience vertigo with eventual nausea and/or vomiting, but that this is likely
to be short-lived. Also, the clinician should be aware of the absolute contraindica-
tions to the test; these are: recent cervical spine fracture, atlanto-axial subluxation,
cervical discopathy, confirmed vertebro-basilar insufficiency and recent neck trauma
that restricts torsional movements of the neck. The test is performed with the patient
sitting upright on the examination table, or on their bed during a home visit, with the
legs extended. The patient’s head is then rotated to one side by 45°. The examiner
helps the patient to lie down backwards quickly with the head held in 20° extension.
This extension may either be achieved by having the examiner supporting the head
as it hangs off the table/bed, or by placing a pillow under their upper back. The
patient must be reminded to keep the eyes open staring straight ahead, and endeav-
ouring to suppress blinks, as their eyes are then observed for about 45 s. There is a
characteristic 5–10 s period of latency prior to the onset of nystagmus. If rotational
nystagmus occurs then the test is considered positive for benign positional vertigo.
During a positive test, the fast phase of the rotatory nystagmus is towards the affected
ear, which is the ear closer to the ground. The direction of the fast phase is defined by
the rotation of the top of the eye, either clockwise or counter-clockwise.
Tinnitus 33
Key Points
• Good lighting
• Practice your technique
• Correct equipment
• Be methodical
Tinnitus
Subjective Tinnitus
It is more often associated with a sensory deficit. A disease of the middle ear that inhib-
its masking ambient sounds, such as an otitis media, can exacerbate it. Many adults are
extremely anxious about tinnitus. Often the patient fears a brain tumour causes tinnitus.
A reduction of the anxiety levels may be surely beneficial. When this is present, the
patient will probably be willing to have an MRI scan, but rather rarely this would bring
any valuable information. Many patients are aware of a certain level of deafness.
• Refer to a specialist if deafness has a social impact
• Refer if the tinnitus is unilateral
• If mild, reassure the patient about the benign nature of tinnitus
Objective Tinnitus
Objective tinnitus occurs when the examiner can hear it as well. Objective tinnitus
is rare and it demands further investigations via ENT referral.
Vertigo
The patient uses various terms to describe dizziness such as unsteadiness, light-
headedness, giddiness or vertigo. It is up to the clinician to determine if it is an
episode of true vertigo or not. Vertigo is a sensation of spinning and as such, to make
a diagnosis of vertigo, the patient needs to have experienced a rotational movement
34 2 Otology
Cardiovascular pathology
Rheumatological disease
High pitch
Tinnitus Neurological pathology
Low pitch
Infective disease
SNHL
Endocrinological pathology
Conductive Deafness
Immunological disease
Mixed General conditions
Depression
Purulent
Fear of serious disease
Acqueus Secretions Mental Health Anxiety
Hyperventilation
Serous Ear
Stress
Head
Surgical Positional
Ear
Accidental Trauma Objective Spontaneus
Acustic Provoked
Barotrauma Positional
Vertigo Fainting feeling Induced by physical exercis
Seconds
Palpitations
Minutes
Type Vomiting
Hours Subjective
Duration Duration
Days Headache
Severity
Absent Triggers
Spontaneus Confusion
Positional
Ear diseases
Gaze Triggered Nystagmus
Previous episodes
Induced by stimulation
Ototoxic
Drugs Hypotensive
Anamnesis
Affecting the vestibular system
Smoke, alcohol, abuse drugs
Jerk nystagmus
convergence-
retraction nystagmus
refers to the irregular
jerking of the eyes back
into the orbit during up-
ward gaze. It can indicate
midbrain tegmental dam-
age.
Downbeat nystagmus
refers to the irregular
downward jerking of the
eyes during downward
gaze. It can signal lower
medullary damage.
Vestibular nystagmus,
the horizontal or rotary
movement of the eyes,
suggests vestibular dis-
case or cochlear dysfunc-
tion.
Pendular nystagmus
Horizontal, or pendu-
lar, nystagmus refers to
oscillations of equal ve-
locity around a center
point. It can indicate con-
gential loss of visual acu-
ity or multiple sclerosis.
Vertical, or seesaw,
nystagmus is the rapid,
seesaw movement of the
eyes; on eye appears to
rise while the other ap-
pears to fall. It suggests
an optic chiasm lesion.
Objective Vertigo
Ménière’s Syndrome
This is probably diagnosed more often than it should be. It is an idiopathic disease
of the inner ear characterized by hearing loss, tinnitus and dizziness. Endolymphatic
hydrops, that is an increase of the inner ear fluids pressure, mostly sharp, is believed
to be responsible for the onset of the symptoms and signs.
Clinical Presentation
• Vertigo and nausea
• Hearing fluctuation with vertigo
• Feeling of ear fullness, or pressure
• Tinnitus
• Cluster episodes, of variable duration ranging from several hours to days
Ménière’s syndrome must be referred to a specialist for an appropriate diagnostic
and therapeutic management.
Clinical Management
• Medical: diuretics, hypo-saline diet, sedatives, anti-vertiginous, antiemetic, any
correction of metabolic dysfunctions and vasculopathy.
• Surgery: surgical therapy is indicated in those cases that do not benefit from
medical treatment. It can be divided into conservative and destructive: the latter
should be reserved for the terminal stages of the disease and unilateral forms.
The conservative treatment or functional treatment aims for the improvement of
the vestibular symptoms with hearing preservation: sacculotomy and endolym-
phatic shunt. The most radical intervention does not take into account the conse-
quences for the hearing, in an attempt to achieve the highest success rate: it
consists of the labyrinthectomy and in the section of the vestibular nerve.
Viral Labyrinthitis
Subjective Vertigo
Vertebrobasilar Insufficiency
Fistula Test
Key Points
Refer urgently to specialist in case of:
• Cholesteatoma
• Otorrhoea
• Deafness
• Facial paralysis
• Headaches and other neurological abnormalities
• Previous otological surgery
• Recent head injury
2 1 3 4
Patients suffering with BPPV experience short bursts of severe dizziness when they
move their head in certain directions.
Clinical Presentation
• Vertigo generally appears when the patient gets up from bed, or lies down; when
looking up to a shelf, or lacing shoes.
• Typically one side is affected and the patient learns to avoid this position, most
notably the recumbent on one side when in bed.
• Can be cured with appropriate clinical examination.
• Otoscopy is normal.
Clinical Management
• Reassure the patient
• Vestibular exercises (Fig. 2.21)
• Refer to a specialist if it does not resolve within 1 month
References
British Society of Audiology (2014) Recommended procedure for hallpike maneuver [online].
http://www.thebsa.org.uk/wp-content/uploads/2014/04/HM.pdf
Hain TC (1997) Approach to the Vertigo. In: Practical neurology. Lippincott-Raven, Philadelphia
Harkin H (2007) Ear care guidance from the NHS Modernisation Agency. NHS Modernisation,
London
Lemajic-Komazec S, Komazec Z (2006) Initial evaluation of vertigo. Med Pregl 59(11–12):
585–590
Chapter 3
Rhinology
The Nose
Degree
Laterality
Nasal obstruction
Duration
Duration Fever
Onset
Hyposmia
Change of voice Hyponasal
Anosmia
resonance
Olfaction changes
Change of taste Hypernasal
Trauma
Pain
Laterality Facial Surgical
Nose
Accidental
Headache
Unilateral Laterality Laterality
Bilateral Amount
Duration Nasal discharge
Serous Epistaxis Duration
Aqueous Type
Frequency Triggers
Purulent
Anticoagulants
Drugs
Blood stained Triggers
NSAIDs
General conditions
suspect sinusitis include pressure or pain in the patient’s cheeks or forehead, nasal
congestion, a sense of heaviness in the head heaviness and sometimes facial pain.
Determining the severity of the pain and the length of time a patient has experi-
enced the symptoms will establish appropriate management. If the sinusitis has
lasted up to 10 days it is likely to be viral. For symptoms lasting longer than 10 days
it is more likely to be a bacterial sinusitis. Symptoms lasting for more than 12 weeks
are suggestive of chronic sinusitis, and lasted >12 weeks is chronic sinusitis. Patients
may describe fever, purulent discharge, nasal obstruction, post-nasal drip, chronic
unproductive cough, malaise and facial pain.
Nasal voice may be distinguished in hyponasal and hypernasal speech, otherwise
respectively known as rhinolalia clausa and rhinolalia aperta. The first is typical of
nasal congestion, the latter of cleft palate and velopharyngeal insufficiency. The doc-
tor should be informed about the presence of defects of smell, such as loss of smell
(anosmia), its reduction (hyposmia), and unpleasant odours, particularly putrefactive
odours (cacosmia). A thorough patient history is essential in determining any olfac-
tory disorders such as sense of smell and sense of taste can often be confused by
patients. Patients may also present with hyposmia, which is partial loss of smell. The
clinician should ascertain the time the loss occurred and if there were any other con-
tributing factors, such as trauma or illness. Intra-nasal obstruction, allergic rhinitis,
head trauma and also type II diabetes and Alzheimer’s have been linked to anosmia.
Drug and alcohol history should be taken as long term alcohol misuse can lead to
anosmia. Certain medications such as metronidazole can also cause it (Fig. 3.1).
Nose Assessment
An otoscope can be used to make a rhinoscope with a wide speculum. The patient
should be asked to breathe with his mouth during the examination to prevent the
otoscope lens fogging during the procedure. The otoscope gives a good view of the
anterior nasal cavity (Fig. 3.2).
Nose Assessment 41
Silver nitrate sticks can be used for nasal cauterization to treat recurring nose bleeds.
Frequent nose bleeds are likely to be a result of an exposed blood vessel in the nasal
cavity; therefore cauterizing it may prevent further bleeding. Silver nitrate sticks
look like large matches and are dipped in water before being applied to the lesion
for a few seconds (Fig. 3.3).
42 3 Rhinology
Nose Inspection
• Symmetry
• Septal deviations
• Deformity of the nasal pyramid
• Patency of the nostrils
• Little’s area (varices, crusting, bleeding) (Figs. 3.4 and 3.5).
• Septal perforations
• Nasal vestibule
• Turbinates
• Osteo-meatal complex
• Injury or growths in the nasal cavity
Epistaxis
Epistaxis in the Child
Children tend to bleed from the nose more easily than adults and from the front of
the septum, otherwise known as Little or Valsalva area. Establishing the severity of
bleeding should take precedence over the history taking.
Epistaxis in the Child 43
Kiesselbach’s
plexus
Superior
labial artery
Greater
palatine artery
Clinical Presentation
The child may present with symptoms of a cold or as an exacerbation of allergic rhinitis.
In a child this may be accompanied by a foul-smelling discharge; this may indicate a
foreign body. Likewise a unilateral bleed or discharge may also indicate a foreign body.
Examination
• Look for foreign body
• Prodromal sign of exanthema
• Inflammation of nasal vestibule
• If appropriate, get child to blow nose; this will help to remove clots and give a
better view of the nasal cavity
• External nasal deformity
Clinical Management
• Anterior nasal bleeding can usually be stopped with a compression of the nos-
trils. At the same time, the child should bend the head forward.
• Cauterization of eventual varicosities of the Little’s area with silver nitrate fol-
lowed by application of antibiotic nasal cream, more often mupirocin or
chlorhexidine dihydrochloride 0.1% / neomycin sulphate 0.5%, for up to 10 days.
• If there is no obvious varicosity, or crusting, nasal topical antibiotic application
for a week, and control.
• In case of absence of a specific site of bleeding, consider a haemostatic disorder
and arrange further investigations to explore this possibility.
• For recurrent nosebleeds, refer to the specialist.
44 3 Rhinology
RED FLAGS
Signs of shock
Epistaxis in Adults
Clinical Presentation
Like children, establishing the severity of the bleed should take precedence over the
history taking. Once this has occurred it is important to establish whether the epi-
staxis is unilateral or bilateral. A good history should enquire about previous epi-
staxis, history of hypertension, other systemic diseases, family history or any
bruising. In adults, a medication review may prove helpful looking for anti-
coagulants, aspirin, NSAIDs and dipyridamole.
Examination
• Consider anterior nasal bleeding as in children. Approximately 90% of bleeds
are anterior in nature.
• Posterior nasal bleeding should be suspected when a specific point of bleeding is
not clearly identifiable, or stopped with the compression of the nostrils.
Posterior epistaxis is:
• More frequent in old age
• More severe when associated with hypertension
• May stop spontaneously, but is usually very copious
• Should be handled within the scope of first aid emergency ENT
Clinical Management
• Treat the anterior nasal bleeding as in children
• In case of posterior nasal bleeding
–– Check blood pressure
–– Refer to a specialist if recurring, or if associated with visible nasal lesion
Key Points
Check if the patient takes anticoagulants.
Check haematocrit and coagulation.
Consider angiofibroma in a young man with nasal obstruction. In this case,
refer to the specialist.
Allergic Rhinitis 45
RED FLAGS
Suspected shock
Nasal Obstruction
Nasal obstruction refers to the feeling of a reduction of nasal flow, uni- or bilateral.
It is generally divided into:
• Mucosal oedema due to:
–– Viral rhinitis
–– Allergic rhinitis
–– Vaso-motor rhinitis
–– Nasal polyps
• Septal deviation:
–– Post-traumatic
–– Idiopathic
–– Nasal valve insufficiency with collapse of one or both nostrils
• Rhino-pharyngeal obstruction due to:
–– Hypertrophy of adenoids
–– Polyp(s)
–– Neoplasm
Allergic Rhinitis
Often characterized by the presence of the triad: sneezing, aqueous nasal secretions
and itching of palate, eyes, nose and/or throat (Fig. 3.6).
46 3 Rhinology
Clinical Presentation
When taking the medical history, you should also look for data that can identify the
potential allergen(s) such as:
• Dust
• Pollens
• Feathers
• Mould
• Spore
• Animal dander
Examination
Typical findings at the clinical examination are:
• Oedema of the inferior turbinate
• Pale colour of the nasal mucosa
• Wet nasal mucosa
• Choanal space reduction
• Allergic dermatitis
Clinical Management
• Medicinal products for topical use.
• Steroids for nasal use. They are also available in aqueous forms that cause less
easily nasal bleeding.
• Allergen(s) avoidance.
• Anticholinergics for topical use if the rhinorrhoea is predominantly watery.
• In the case of cacosmia and facial pain, a study of the paranasal sinuses is essen-
tial before starting the steroid use.
Vasomotor Rhinitis 47
Clinical Presentation
Vasomotor rhinitis in many ways resembles allergic rhinitis, but it is not triggered
by an allergen and its cause is currently unknown. It can be exacerbated by:
• Perfumes
• Spray
• Air temperature changes
• Tobacco smoke or other irritants
In addition:
• There is not usually an associated itch
• The obstructed side is generally alternating
• Can co-exist with an allergic form
• Sometimes it is associated with puberty and hormonal changes
• Its onset may be associated with anxiety and frustration
• Watery nasal discharge is typical
48 3 Rhinology
Fig. 3.7 Vasomotor
rhinitis with watery
discharge
Examination
• Vasomotor rhinitis can be sub-classed as ‘runners’ that exhibit wet rhinorrhea
• Dry vasomotor rhinitis – with airflow resistance and nasal obstruction with lim-
ited rhinorrhea
Clinical Management
Clinical management mirrors that of allergic rhinitis. The distinction between aller-
gic rhinitis and vasomotor rhinitis may be clinically challenging and it is most often
dictated by history data rather than by the appearance of the nasal mucosa.
Clinical Presentation
Symptoms develop in a gradual, progressive way and are very often in the context
of an allergic rhinitis or vasomotor rhinitis. In addition, there is often a history of:
• Previous nasal polypectomy
• Decreased sense of smell
• Recurrent sinusitis
Examination
• Alterations in facial appearance
• Assess inferior turbinate, anterior septum and middle meatus
• Assess posterior wall for polyposis
• Undertake otoscopy – extensive polyposis can lead to Eustachian tube dysfunc-
tion and cause otitis media
Clinical Management
• In the case of mild symptoms, intra-nasal drops such as Beclomethasone should
be applied twice daily with the head in extended position.
Nasal Polyps 49
MT MT MT MT MT
IT IT IT IT IT
0 1 2 3 4
Fig. 3.8 Nasal polyposis and its grading (Lund and Mackay 1993)
Key Points
In the case of nasal polyps, one must always keep in mind that this is a recur-
rent disease, so the topical steroid therapy should be maintained.
RED FLAGS
Bloody discharge
Unilateral growth
Facial swelling
Allergy Testing
The allergy testing can be made via cutaneous stimulation, the patch and the prick
test, or via blood collection using the RAST test. The latter can be directly arranged
by GPs. The skin tests require the support of a Resuscitation Department and the
patient should stay in observation for a couple of hours. A referral should be
arranged, but the purpose of skin tests is limited and often impractical. Even from a
commercial point of view, the advantages are much reduced, and because of this it
is not easy to find the necessary kit. The RAST test (radio absorbent sensitivity test)
is easily obtainable, although expensive; it can be carried out on a sample of venous
blood.
Septal Deviation
Examination
• May be associated with deformity of the nasal pyramid.
• There may be a history of trauma of the nasal pyramid.
• Unilateral nasal obstruction is often present.
• There are often coexisting changes of the nasal mucosa, such as compensatory
hypertrophy of the turbinates.
Clinical Management
• Refer to a specialist if nasal obstruction is only due to septal deviation.
• In case of co-existence of rhinitis, treat the rhinitis first, and if that’s not enough,
refer to a specialist.
Nasopharyngeal Obstruction
Fig. 3.10 Adenoids
hypertrophy
• Post-surgical scarring
• Tumours
Examination
• Look for dysmorphic features
• Perform anterior rhinoscopy
• Assess oropharynx
• Both in adults and in children look for possible ear pathology
• Cervical lymph nodes: palpate for any inflammatory or neoplastic pathology
Clinical Management
• This highly depends on the cause of the obstruction. Referral to the ENT special-
ist is required and if the adenoids are deemed to be responsible for the obstruc-
tion, they may require adenoidectomy.
52 3 Rhinology
Sinusitis
Examination
• Rhinoscopy to ascertain the presence of nasal discharge
• Assess for fever
• Facial tenderness
Clinical Management
• In the event of Pott’s oedema, refer immediately to the ENT specialist
• Antibiotic therapy may be indicated if sinusitis does not respond to home reme-
dies or symptoms are severe
• Analgesia
Fig. 3.11 Purulent
sinusitis
Sinusitis 53
• Menthol/inhalations
• Refer to the specialist in case of non-resolution of symptoms
Recurring Rhinosinusitis
Examination
• A minimum mucosal thickening without hydro-air levels is common and not
necessarily pathological, and a diagnosis of rhinitis, rather than of sinusitis,
should be taken into account.
• Bone erosions are suggestive of neoplastic disease and require urgent specialist
clinical evaluation.
• Small cystic lesions of maxillary sinuses are common and do not require
treatment.
Clinical Management
• Imaging may help to assess the presence of chronic disease. GP may request
x-rays with chin-occipital view to evaluate the maxillary, frontal and ethmoid
sinuses.
• An acute exacerbation of a recurring form requires the use of metronidazole and
penicillin, or macrolide.
• Analgesia.
• Menthol/inhalations.
• In an allergic rhinitis, nasal steroid are useful.
• Nasal polyposis can respond to the nasal steroid spray or drops.
• Referring to a specialist is required in case of:
• Frequent recurrences
• Large nasal polyps
• Large septal deviation
• Suspect of neoplastic pathology
In the absence of radiographic abnormalities, diagnosis of sinusitis is highly
unlikely. The clinician should consider other possible causes of facial pain and in
particular the contact between nasal concha and septum.
Key Points
Rhinitis medicamentosa is a disease that results from prolonged use of decon-
gestants. If a patient presents with nasal obstruction and nasal mucosa oedema
after a period of prolonged use of decongestants, refer to a specialist as may
require surgical correction.
Unilateral nasal secretion in a child is believed to be due to the presence of
a foreign body until proven otherwise and it requires an urgent ENT referral.
Children are not prone to nasal polyps and their presence should trigger the
suspect of cystic fibrosis.
54 3 Rhinology
References
The Throat
Voice problems and sore throat are two of the most common complaints associated
with the throat, larynx and hypopharynx regions. Voice disorders should be distin-
guished in problems with the articulation of the voice, or dysarthria, and hoarseness,
or dysphonia, when there is a change in the quality of the voice instead.
Hoarseness is the most frequent among the two. It is important to determine if
hoarseness has been of a gradual onset or sudden onset. Gradual onset may be as a
result of smoking or drinking alcohol, whilst sudden onset may be as a result of an
infection or vocal abuse. Smoking and alcohol should be documented in all cases. A
patient’s occupation may provide vital information to the history, especially if they
use their voice in a professional way such as a singer. In these cases it is worth ask-
ing the patient if they have experienced a change in their pitch or abnormal pitch
range. The clinician should determine if their hoarseness is constant, or whether it
changes throughout the day. Any exposure to chemicals or corrosive substances
may also be important. Previous trauma, surgery or endotracheal intubation should
be ascertained. Patients may describe their voice disturbances as breathy, hoarse,
low-pitched, strained, and trembling or a feeling of vocal fatigue. Clinicians should
be aware that specific voice disturbances could help the focus on a differential diag-
nosis. For example, breathy complaints could indicate functional dysphonia, vocal
cord paralysis or abductor spasmodic dysphonia.
Dysarthria results from a neurological injury of the phonation system. As such,
the causes may be several, including multiple sclerosis, Parkinson’s disease,
Parkinson plus syndromes, stroke, motor neuron disease and others. A sore throat
itself is actually a symptom. Other common presenting symptoms include a feeling
of a lump in throat, mucus in the throat and general discomfort. Sore throat is usu-
ally caused by viral infection; however, the most common bacterial infection affect-
ing the throat is Group A beta-haemolytic streptococcus. The clinician should
ascertain the duration and severity of the symptoms, any dysphagia, rash or stridor,
Ageusia
Ulcerations
Parageusia
Oral Taste
Blisters muco
sa
Dysgeusia
Bullae
Hypogeusia
Referred
Pain Mouth Saliv Reduced
a
Local tenderness
Increased
Odynophagia
General conditions and
medications
whether the patient feels systemically unwell and whether there is the presence of
trismus. Associated symptoms may include malaise, headache, rhinitis, cough and
hoarseness. These symptoms are often benign in nature. However, can also be
symptoms of malignancy. Patients with acid reflux may present with throat prob-
lems. If this is linked with symptoms of dyspepsia or gastro-oesophageal reflux it
should be investigated (Fig. 4.1).
Tongue depressors, (Fig. 4.2) typically a disposable wooden spatula, are used to
depress the tongue to allow the clinician to inspect the patient’s mouth and throat
structures. Again an otoscope can be used as a torch to improve visualisation of the
mouth and throat. A clinician should always wear gloves when performing an oral
examination.
Sore Throat
It is a frequent symptom and often associated with viral upper respiratory tract
infection.
Pharyngitis
Clinical Presentation
• Sore throat or dryness of the throat
• Worse in the morning
• Absence of systemic impairment
• The patient may have sense of nasal obstruction especially at night
• Cold symptoms
–– Acutes
–– Chronic (Fig. 4.3)
Examination
• Check the nasal passages
• Check the sinuses
• Check oropharynx, mouth, and tonsils
• Assess cervical lymph nodes
Clinical Management
• Invite to stop smoking
• Advise to stop or reduce to recommended limits alcohol intake
• Refer to a specialist in case of failure to respond to previous approaches
Fig. 4.3 Chronic
pharyngitis
• Tobacco
• GORD
• Alcohol
• Occupational irritants
• Vocal abuse
• Venereal diseases
RED FLAGS
Unilaterality
Clinical Presentation
• Major general prostration
• Fever
• Cervical adenopathy
• Otalgia
• Halitosis
Sore Throat 59
Fig. 4.4 Bacterial
tonsillitis
Examination
The Centor criteria are particularly useful to corroborate the diagnostic suspect giv-
ing an indication of the likelihood of a sore throat being due to bacterial infection.
The criteria are:
• Tonsillar exudate
• Tender anterior cervical adenopathy
• Fever over 38 °C (100.5 °F) by history
• Absence of cough
If 3 or 4 of Centor criteria are met, the positive predictive value is 40–60%.
The absence of 3 or 4 of the Centor criteria has a fairly high negative predictive
value of 80%. Also of good clinical value is the streptococcal score card. This
gives an indication of the likelihood of a sore throat being due to infection with
group A beta-haemolytic streptococci (GABHS). The criteria are (Centor et al.
1981):
• Age 5–15 years
• Season (late autumn, winter, early spring)
• Fever (≥38.3 °C [≥101 °F])
• Cervical lymphadenopathy
• Pharyngeal erythema, oedema, or exudate
• No symptoms of a viral upper respiratory infection (conjunctivitis, rhinorrhoea,
or cough)
If 5 of the criteria are met, a positive culture for GABHS is predicted in 59% of
children; if 6 of the criteria are met, a positive culture is predicted in 75% of
children.
60 4 Laryngology
Peri-tonsillar Cellulitis
Peri-tonsillar Abscess
• The Monospot test or blood smear on a slide helps to confirm the diagnostic
suspect
• Supra-infection may require specific treatment
RED FLAGS
Quinsy/abscess
Meningism
62 4 Laryngology
Key Points
Refer to ENT asymmetrical swelling of tonsils, particularly if this is not asso-
ciated with acute inflammatory condition.
Ampicillin/amoxicillin should not be used in a suspected mononucleosis.
Recurrent pharyngitis in a debilitated and worsening patient requires blood
test to exclude hematologic pathology.
Hoarseness
Days
Weeks
ion
rat
Months
Du
Years
Dysphagia solid>fluids
ing
Swallow
Dysphagia solid<fluids
Cough History taking in
General conditions Dysphagia solid=fluids
neck & throat
Fever disease Pho Type
nati
on
Weight loss
Duration
Other pathologies and ory
medications i st Onset
lh
Pa
cia
in
So Referred Progression
Smoking
Local tenderness
Alcohol
Clinical Management
It depends on the cause. Referral to a specialist is often required to exclude neoplas-
tic pathology if hoarseness persists for more than 3 weeks.
• Restrict use of the voice (vocal cords rest)
• Analgesia
• Fumigation and vapours
• Refer to a specialist hoarseness persisting for more than 3 weeks to exclude neo-
plastic pathology, nodules, or polyps
• Chest x-rays
RED FLAGS
Pain
Dysphagia
Haemoptsis
Otalgia
Lump/neck mass
Dysphagia
Acute Dysphagia
Progressive Dysphagia
Other Causes
• Neurogenic dysphagia
• Connective tissue disorders such as systemic sclerosis
Globus Pharyngeus
Local/district examination:
• Angular cheilitis
• Glossitis
• Neck masses
• Masses of the oral cavity
• Movements of the tongue, palate and pharynx
• Sensory examination of mouth and pharynx
Clinical Management
The investigations should include:
• X-ray of the neck with side view
• Chest x-ray
• Barium
• Basic blood tests
In case of a suspect neurological disorder, refer immediately to a specialist.
RED FLAGS
Ear Pain
Sore Throat
Symptoms of lateralization
Persistent hoarseness
Snoring
Snoring is the snorting or rattling noise some people may do when breathing during
sleep. The noise comes from the vibration of the soft palate due to a turbulent air
flow. Also the vibration for the mouth tissues, nose and throat can contribute signifi-
cantly to its generation. Some people snore infrequently and the sound they make are
not particularly loud, while others may snore every night loudly enough to disturb
other people. From an anatomical point of view snoring is due to loss of tone of the
muscles of the soft palate, including those of the uvula, but there are many contribut-
ing factors to it, all of them contributing to the speed and turbulence of the air flow,
or the capacity of vibrating of the soft tissues of the upper aero-digestive tract.
66 4 Laryngology
Apnoea: snoring may be associated with apnoeic episodes. Few, short episodes of
apnoea may occur also in normal individuals, but apnoeic episodes that last more
than 10 s and ending with a loud snoring, or heave with awakening, often temporary
and partial, are suggestive of obstructive sleep apnoea syndrome (OSAS).
Epworth Sleeping Score: reference scale that makes possible to evaluate the
severity of daytime sleepiness. With a score 10 < ESS the OSAS is unlikely.
Sometimes children with OSAS may be hyperactive during the day (Fig. 4.7).
Examination
General examination
• Obesity
• Arterial hypertension
Localized/district examination
• Nasal obstruction
• Soft palate ptosis
• Short, large neck
• Mandibular retrognathism
• Hypertrophy of tonsils
• Hypertrophy of adenoids
• Hypertrophy of lingual tonsil
Clinical Management
• Weight loss.
• Smoking cessation.
• Avoid alcoholic drinks for 4 h before bedtime.
References 67
RED FLAGS
Daytime sleepiness
References
Little P, Gould C, Williamson I, et al. (1997) Reattendance and complications in a randomised trial
of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ
315:350–352
Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K (1981) The diagnosis of strep throat
in adults in the emergency room. Med Decis Making. 1(3):239–246
Chapter 5
Head and Neck
Any of the structures of the mouth may be involved in local disease or may be part of
wider systemic pathology. Therefore a thorough history is needed to determine
between the two. Certain symptoms such as xerostomia (dry mouth) should not be
considered in isolation. This may be as a result of drugs, gland dysfunction or diabe-
tes. Ulcerations of the oral mucosa could be as a result of local disease such as poor
dental hygiene, gingivitis or systemic illnesses including anaemia, AIDS or HIV. Any
ulceration that is red, white or pigmented lasting for longer than 3 weeks should be
investigated. Angular stomatitis and tongue/mouth soreness could be from a haema-
tological cause or iron deficiency. Any intraoral swellings that increase in size or pain
associated with eating are usually as a result of salivary gland pathology. Patients
who present with any lumps in the neck should be referred to an ENT specialist, so
that they can be appropriately investigated to determine if they are secondary lymph
nodes and the likely primary source. In patients presenting with a neck lump, it is
worth investigating any symptoms of the tongue, mouth, nose or throat as these may
identify the primary site. Enlarged lymph nodes may be a result of a previous infec-
tion, so the clinician should determine if the patient has had any recent illnesses or
infections. Symptoms associated with under-active or over-active thyroid should be
determined. Associated symptoms such as weight loss, night sweats and malaise are
suggestive of systemic diseases such as AIDS or lymphoma.
Neck Lump
All patients with an unexplained lump in neck that recently appeared, or a lump that
was not diagnosed before and has changed during a period from 3 to 6 weeks,
should be referred urgently to an ENT specialist.
Facial Palsy
The facial nerve controls the muscles of the facial expression and stapedius, the lac-
rimal and submandibular glands, and the sensory function of the anterior 2/3 of the
tongue. Hence, as well as facial droop, patients may present with drooling, hyperacu-
sis, altered taste, speech issues, earache, dry eye and reduced corneal reflex. Facial
palsy can be classified in central or peripheral. The two forms are differentiated clini-
cal examination since the facial motors nuclei are two, one top and one bottom bilat-
erally innervated that receives only a contra-lateral innervations. It follows that:
• Central facial palsy is incomplete, affecting only the lower half of the contra-
lateral face.
• Peripheral facial paralysis is complete and ipsilateral and its severity can be clas-
sified according to House and Brackmann (1985) (Fig. 5.1).
Herpes Zoster
Herpes affects the ear, mouth, pharynx and facial nerve. Even the acoustic nerve
may be affected and is otherwise known by the name of Ramsay-Hunt.
Clinical Presentation
• Ramsay-Hunt syndrome presents with severe otalgia Hunt JR (1907).
• Burning pain several hours before onset of typical herpetic blistering.
• Blistering rash will appear around the ear, face and sometimes in the oral
cavity.
• The syndrome generally causes more severe symptoms and has a worse progno-
sis than Bell’s palsy has. Even if the latter, of which the exact reasons remain
unclear, maybe likewise ascribed to herpetic infection.
• Accompanying vestibular symptoms such as vertigo, nausea and vomiting may
be present.
Facial Palsy 71
RED FLAGS
Suspect of stroke
Suspect of mastoiditis
Head trauma
Bell’s Palsy
RED FLAGS
Otitis media
Cholesteatoma
Parotid tumour
Bilateral onset
References 73
Other Causes
References
House JW, Brackmann DE (1985) Facial nerve grading system. Otorlaryngol Head Neck Surg
93(2):146–147
Hunt JR (1907) On herpetiform inflammation of the geniculate ganglion: a new syndrome and its
complications. Nerve Ment Dis 34:73
Chapter 6
Post-operative ORL
Adenoidectomy
After adenoidectomy, the patient may experience post-operative bleeding and pain.
Post-operative Bleeding
Bleeding after adenoidectomy surgery requires immediate hospitalization, with
posterior nasal tamponade, if necessary.
Post-operative Pain
It is in general minimal. If otalgia, perform otoscopy to exclude ear infection.
Trans-tympanic Tubes
Nasal Surgery
Pain
Generally present in post-transplantation, especially because of nasal swabs inserted
to prevent adhesions. In the absence of infection, use analgesia. In case of oedema
or infection, the patient should be admitted to hospital.
Post-operative Epistaxis
An epistaxis after nasal surgery should be sent to a specialist immediately although
a mupirocin cream like Naseptin can help.
Tonsillectomy
Post-operative Bleeding
Most often it occurs within the first 48 h. Generally, the patient is readmitted immedi-
ately, in case he had been already discharged. Minor bleeding can occur up to 10 days
after surgery and are most often caused by infection or detachment of granulation
tissue from the loggia of the tonsils. Hospital readmission is required (Fig. 6.2).
Post-operative Pain
Although the patient is discharged with analgesia, sore throat in the subsequent days
has to be expected and the patient may attend the GP surgery. It is on this occasion
that the GP may confuse the granulation tissue with pus and infection. It may
Oncology ORL 77
Fig. 6.2 Tonsillectomy
happen that the GP replaces an antibiotic that the ENT department initiated, assum-
ing that this was not working. In addition, we must be cautious in the use of soluble
aspirin for the risk of bleeding associated with NSAIDs. Paracetamol, codeine and
ibuprofen are all valuable alternatives.
It is helpful to assure patients and their relatives that within a couple of weeks the
situation will be resolved. As for the food, hard foods like nuts and chips should be
avoided in favour of a liquid or soft diet. Eating little and often can be beneficial.
Avoid a two-large-meals diet.
Oncology ORL
The request for an urgent ENT appointment is recommended whenever you suspect
a malignancy. Several signs and symptoms may be the trigger and they shall be
illustrated in the following paragraphs.
Hoarseness
If hoarseness persists for more than 3 weeks, particularly in smokers over 50 years
old and heavy drinkers, we recommend an urgent CXR. Patients with positive
results must be sent urgently to a team specialized in the management of lung can-
cer. Patients with a negative result must be sent urgently to a team that specializes
in cancer of the head and neck.
78 6 Post-operative ORL
Sore Throat
In patients with unilateral unexplained pain in the area of the head and neck for
more than 4 weeks, associated with ear pain (otalgia), but with normal otoscopy,
you should formulate a request for urgent ENT assessment.
Chapter 7
Pharmacology
Antibiotic Prescribing
Common Prescriptions
Rhinitis
Vertigo
Betahistine
Cinnarizine tablets (Stugeron)
Otitis Externa
Sore Throat/Mouth
Acute viral sore throat No antibiotic indicated Issue Use CENTOR to guide
Patient Information Leaflet diagnosis If 3 or 4 present
(PIL) on viral sore throats If treat as for bacterial sore
in doubt, use of deferred throat
prescription is an option N.B. If symptoms persist
refer to ENT
Acute laryngitis No antibiotic indicated Issue
Patient Information Leaflet
(PIL) on viral sore throats
Acute sinusitis Use symptomatic relief Avoid antibiotics as 80%
(analgesia) before resolve in 14 days without,
prescribing antibiotics and they only offer marginal
Amoxicillin 500mg tds for 7 benefit after 7 days
days or Doxycycline 200mg
stat. then 100mg od for 7
days in total (for children
Fig. 7.1 2016 Antimicrobial Guide and Management of Common Infections in Primary Care
(From the Pan Mersey Area Prescribing Committee NHS 2016)
Common Prescriptions 81
Immediate antibiotic
treatment should be Acute
(AOM) considered for
bilateral AOM in 3 episodes
in 6 months or >5 episodes in
12 months
Chronic otitis media Refer to ENT
Otitis externa First use aural toilet If cellulitis or disease
(if available) and analgesia. extending outside ear canal,
First line: Acetic acid 2% start oral antibiotics and
(EarCalm®) 1 spray tds for refer. In severe infection of
7 days. Second line: Neomycin the pinna, swab to exclude
sulphate with corticosteroid pseudomonas Caution:
and acetic acid (Otomize®) Topical neomycin has been
1 metered spray tds known to cause ototoxicity
Third line: Ciprofloxacin and must not be used if there
0.3% eye drops (Ciloxan) is a suspicion of ear drum
2 drops three times a day as perforation. See third line
ear drops for 7 days if: swelling recommendation (unlicensed
is so severe that topical indication)
treatment cannot be
administered in the form of a
spray or there is confirmed or
suspected tympanic
membrane perforation
Intermittent or prolonged
(>7 days) use should be
avoided in primary care.
For cellulitis or extensive
infection to outside ear canal:
Flucloxacillin 500mg qds for
5 days In penicillin allergy:
Clarithromycin 500mg bd for
5 days For fungal infections
use clotrimazole solution
1%, apply 2-3 times daily until
14 days after cure
Fig. 7.1 (continued)
82 7 Pharmacology
Glue Ear
Reference
Pan Mersey Area Prescribing Committee NHS (2016) Antimicrobial guide and management of
common infections in primary care 11–14
References
A H
Adenoidectomy, 51, 75 Halitosis, 58, 60
Adult deafness, 25 Hallpike test, 32–33
Allergic rhinitis, 40, 43, 45–48, 53 Head-shaking nystagmus, 31, 32
Hearing tests, 8, 25–30
Herpes zoster, 70–72
B Hoarseness, 2, 55, 56, 62–65, 77–78
Bell’s palsy, 70, 72
N
C Nasal obstruction, 39, 40, 44, 45, 47–50, 52,
Child deafness, 23 53, 57, 66
Nasal polyps, 45, 48–50, 53, 54
D
Dysphagia, 55, 62–64 O
Otalgia, 5, 6, 11–12, 15, 16, 19, 21, 23–25,
39, 58, 62, 70, 75, 78
E Otitis externa, 12–13, 18, 19, 28, 29, 73, 80,
Ear syringe, 9 81
Epistaxis, 2, 39, 42–44, 76 Otoscope, 6, 7, 10, 19, 28, 29, 37, 40, 41, 56,
71
F
Facial palsy, 6, 70–71 P
Fistula test, 10, 37–38 Pharyngitis, 57–58, 62
Frenzel goggles, 8, 9, 31
Fukuda stepping test (FST), 32
R
Recurring rhinosinusitis, 53–54
G Rhinitis, 45, 53, 56, 79
Globus pharyngeus, 64–65 Rhinosinusitis, 53–54
Glue ear, 24, 25, 82 Rinne, 8, 25–27, 30
T
Tinnitus, 2, 6, 19, 21, 22, 29–36, 70 W
Tonsillectomy, 76–77 Weber, 8, 27–30