ENT

04/10/22 7:15 PM

1. Antibiotics
1. Phenoxymethylpenicillin
• Acute Bacterial Sinusitis
• Bacterial Tonsillitis (Streptococcus)
• Quinsy
2. Amoxicillin
• Bacterial Otitis Media (Streptococcus)
3. Gentamicin/Acetic Acid 2%/Hydrocortisone
• Otitis Externa
4. IV Ciprofloxacin
• Malignant Otitis Externa (Pseudomonas)
5. Flucloxacillin
• Ear Furuncle (Staph. Aureus)
6. Co-Amoxiclav
• Large Haematoma
• Unwell Acute Bacterial Sinusitis
7. Fluoroquinolones (Ciprofloxacin, Levofloxacin, Ofloxacin)
○ Perichondritis (Pseudomonas)

2. Nose
1. Epistaxis
○ "Initial" First Aid Measures
§ Lean Forward and Pinch soft cartilaginous part for 10-15 minutes
○ Bleeding stopped with First Aid Measures
§ Naseptin (Chlorhexidine + Neomycin)
○ Bleeding did not stop with First Aid Measures
1. Nasal Cautery- One Side First
□ If the bleeder can be identified + Facility available + Tolerated (Adult and Older children but not
younger children)
2. Nasal Packing
□ If Nasal Cautery is ineffective or bleeder cannot be identified
2. Foreign body in Nose of Infants
○ Toddler age (1-3 YO) + Unilateral nasal discharge (later on becomes foul-smelling) +NO cough or facial pain
○ In chronic sinusitis, there is usually cough, facial pain and the nasal discharge is usually B/L
3. Acute vs Chronic Sinusitis
○ Acute Sinusitis- <12 weeks, often follows common cold
○ Chronic Sinusitis- >12 weeks sinusitis
○ Ix- Most Appropriate- CT of Head and Sinuses
○ Rx
§ No role of ORAL decongestant (e.g. oral pseudoephedrine)
§ <10 days
□ Nasal decongestant containing ephedrine/ NASAL SALINE
® IMPORTANT- Nasal Ephedrine can cause HTN
□ PCM/Ibuprofen for fever and facial pain relief
§ >10 days
□ Nasal steroids for 14 days if symptoms>10 days without significant improvement
○ Suspecting Bacterial and Commencing Antibiotics
§ Complicated Sinusitis (systemically unwell patients with features such as Peri-orbital oedema or cellulitis or
displaced eyeball or diplopia)
§ Symptoms (All should be present)
□ > 10 days
□ Fever >38
□ Purulent Nasal Discharge
□ U/L pain
§ Rx
□ Phenoxymethylpenicillin
□ If very unwell- Co-amoxiclav
□ If penicillin allergic- Clarithromycin/ Doxycycline
4. Sinus Headache
○ Headache that worsens on bending the head forwards and in the early morning WITHOUT Nausea and Vomiting
○ Note
§ Headache that worsens on bending forwards
□ Without Nausea and Vomiting = Sinus Headache
□ With Nausea and Vomiting = Migraine (with aura and is much severe)
§ Idiopathic Intracranial Hypertension (IIH)
□ Occurs daily + Worse in the morning + Improves with standing + Obesity is a risk factor
® Ix- Lumbar Puncture
5. Nasal Septal Abscess
○ Fall on Nose + Nasal Pain and Tenderness + General Malaise + Fever
○ Nasal Septal Hematoma- Incision and Drainage
○ If no I&D- leads to Nasal Septal Abscess
6. Nasal Polyps
a. Samter's Triad- Asthma, Aspirin Sensitivity, Nasal Polyps {Aspirin-exacerbated respiratory disease (AERD)}
7. DVLA
○ DO NOT NEED TO INFORM
§ Pulmonary Embolism or DVT
○ Inform
§ TIA
□ Single TIA
® Stop car driving for at least 1 month
® Stop Lorry or Bus driving for 1 year
□ Inform DVLA
® Car + Multiple TIAs
® Lorry or Bus + Single TIA
§ Stroke
□ Do not Drive
□ Inform DVLA if
® Residual neurological symptoms 1 month after stroke such as
§ Visual field defects (hemianopia)
§ Cognitive defects
§ Impaired limb function
§ Epilepsy/ Seizure
□ Notify DVLA
® Car Driver- can drive again after 1-year of being seizure-free or >6 months of no seizure if
changed medication
® Lorry or Bus- can drive again after 10-year of being seizure-free without notification
§ OSA
□ Suspected/ Mild OSAS controlled within 3 months- Stop driving and Urgent referral to Sleep Clinic
□ Already Diagnosed Moderate/>3 months- Inform DVLA
§ Alzheimer's/ Dementia
□ Ask to inform DVLA>Refuse> Inform DVLA yourself
§ Diabetes + Insulin
§ Pacemaker
§ Glaucoma
8. OSA
○ Dx
§ Initial- Epworth Sleepiness Scale, Pulse Oximetry, Overnight study of breathing pattern
§ Gold Standard- Polysomnography
§ Rx
□ In Children- Refer to ENT Surgeon for Tonsillectomy (MCC include enlarged tonsils and adenoids)
® Note: Children with OSA may be active during daytime while adults may doze off
□ Conservative- eg. Weight reduction, reduce alcohol intake
□ CPAP- First line for moderate or severe OSA
9. Nasal Injury
○ Hx of Nose bleed + Vitals stable + No active bleeding + No CSF leakage + Skin over nose intact + Nose deviation to
right side
• Ix- Speculum examination of nasal cavity
§ This can show: Nasal haematoma, site of bleeding, septal deviation, septal perforation
10. Allergic Rhinitis
• Xylometazoline intranasally
§ However, this medical should not be used for >7 days
§ If used for >7 days, it can cause rebound nasal congestion
• Rhinitis Medicamentosa: Therefore, if the congestion still exists in a patient who used Xylometazoline for >7 days,
the first step is to:
○ Advice the patient to stop medication and to have a medicine-free interval
11. Narcolepsy
• CHESS
○ Cataplexy
○ Hallucination
○ Excessive Daytime Sleepiness
○ Sleep Paralysis
○ Sleep disruption

3. Mouth
1. White Oral Lesions
1. Oral Thrush
○ Immunosuppression (DM, Elderly, Smoking, Antibiotics, Steroids)
○ Candidiasis
○ Can be rubbed out
○ Angular Cheilitis
○ Rx
§ Stop smoking
§ Good inhaler techniques
§ Rinse mouth with "water" after use
§ Check adequate spacer techniques
§ 1st line- Miconazole gel> Nystatin suspension
§ Oral Fluconazole 50mg OD for 7 days or Fluconazole oral suspension
2. Leucoplakia
○ Smoking
○ Premalignant
○ Sharply well defined
○ Cannot be rubbed out
○ Ix
§ Stop Smoking
§ Biopsy
3. Lichen Planus- 4P on F + LP of buccal mucosa + Cannot be rubbed out easily
○ Where 4P- Pruritic, Purple, Papular, Polygonal rash on Flexor surfaces
○ L-Lacy Pattern on buccal mucosa
○ Also in stem- Fine white streaks overlying lesion with lacy pattern of buccal mucosa
○ Rx
§ Topical Steroids
§ Benzydamine mouthwash/spray
4. A newly formed ulcer on top of a previous Leucoplakia
○ Think- SCC "Squamous cell carcinoma"
2. Sialadenitis
○ Acute Sialadenitis- Dehydration (eg. post-op) (dehydration leads to overgrowth of oral flora and presents with
erythema, pain and tenderness)
○ Chronic Sialadenitis (Kuttner's Tumour)- Sialolithiasis (salivary stones) which leads to decreased salivary outflow
○ Features
○ Swelling in submandibular region which can become enormously enlarged
○ Swelling is more painful and prominent on chewing (this indicated obstruction due to salivary stones)
○ Tenderness and redness
○ Sour taste in the mouth (no saliva), dry mouth (no saliva)
○ Decreased mobility of jaw
○ Ix- USG> FNAC
○ Important DDx
○ Mikulicz Syndrome (Sarcoidosis)
§ Triad of
1) Symmetrical Enlargement of all Salivary glands (salivary + Parotid)
2) Narrowing of palpebral fissures due to enlargement of lacrimal glands
3) Parchment-like dryness of mouth
○ May occur secondary to Sarcoidosis, TB or Lymphoma

4. Throat
1. Neck Lumps
○ Lump that moves with tongue protrusion
§ Thyroglossal Cyst
□ because it is attached to the thyroglossal tract which attaches to the larynx by the Peritracheal Fascia
○ Lump that moves up with swallowing (and not tongue protrusion)
§ ?Goitre ?Large Thyroid Nodule
○ Fluctuant lump and trans-illuminates in the neck
§ Cystic Hygroma
○ Lump in anterolateral neck
§ Tonsillar carcinoma (elderly, smoking, progressive hoarseness of voice, dysphagia)
○ Lateral Neck Mass + Non-Translucent
§ Brachial Cyst
○ Lateral Neck Mass + Translucent
§ Lymphangioma
□ Lateral = along or near sternocleidomastoid muscle (SCM)
2. Plummer Vinson Syndrome
• Also called Paterson Kelly syndrome or Sideropenic Dysphagia
• Plummer Vinson was a PIG
○ Triad of:
1) Post-Cricoid Dysphagia - Painless, Intermittent Dysphagia (secondary to oesophageal webs)
2) Iron Deficiency Anaemia
3) Glossitis
○ Risk factor for Oropharyngeal Carcinoma
○ Common in Post-menopausal women
○ Rx- Iron supplementation and balloon dilatation of webs
3. Functional Dysphonia
○ Weak and altered voice in some occupations where there is voice overuse (eg. teachers, actors, singers,
commentators, etc.)

○ Voice disturbance in absence of any structural abnormality of the larynx and the cords
○ Do not be tricked by a Hx of a previous respiratory infection- Functional Dysphonia
○ If this weakness of voice occurs DURING the respiratory infection, the cause might be Laryngitis
4. Acute Tonsillitis
○ Centor Criteria For Bacterial Tonsillitis
§ 3 out of following 4 Centor Criteria raise the suspicion of Bacterial- Streptococcal Tonsillitis
□ Phenoxymethylpenicillin = Penicillin V
1) Fever > 38
2) Tender and Enlarged Anterior Cervical LNs
3) Tonsillar Exudates / Pus
4) NO associated cough
○ When is Tonsillectomy indicated?
§ Sleep Apnoea "New Update- Important"
§ SIGN Criteria- 7,10,9
□ >7 episodes of tonsillitis per year for 1 year
□ >5 episodes per year for 2 years (Total= 10)
□ >3 episodes per year for 3 years (Total= 9)
○ Complications
§ Primary bleeding (first 24 hrs)- Call ENT Surgeon "may require return to the theatre"
§ Secondary bleeding "or Reactive bleeding" (1-10 days post-op, usually after discharge)- Admit and give IV
Antibiotics
5. Benign Parotid Tumour
○ Most common type- Benign Pleomorphic Adenoma (or Benign Mixed Tumour)
○ Features
• Asymptomatic
• Solitary
• Painless
• Firm
• Mobile mas/swelling at the angle of the mandible
• Grows slowly
○ Rx- Superficial Parotidectomy or Enucleation
○ 2-10% risk of malignant transformation
6. Parotid Enlargement DDx
a. Sjogren Syndrome
§ Parotid Enlargement
§ Xerostomia (Dry mouth)
§ Keratoconjunctivitis Sicca (Dry eyes)
b. Mikulicz Syndrome
§ Parotid + Salivary Gland enlargement
§ Parchment-like dryness of mouth
§ Lacrimal gland enlargement
§ Causes
□ Sarcoidosis
□ TB
□ Lymphoma
c. Mumps
§ Parotitis
□ Otalgia on eating
§ Infectivity period
□ 7 days before and 9 days after (14-21 days)
§ Complication
□ Orchitis (4-5 days after parotitis)
d. Others
§ Parotitis
□ Painful, tender
§ Mandible/Parotid Cancer
□ Not Mobile
§ Benign Pleomorphic Adenoma
□ Firm, Painless BUT Mobile
§ Chronic Sialadenitis
□ Painful chewing + Sour mouth
□ Ix
® USG>FNAC
§ Heerfordt's Syndrome
□ Uveoparotid Fever (Uveitis + Parotid Enlargement + Fever)
7. Quinsy (Peritonsillar Abscess)
• Hx of Tonsillitis or Sore throat
• Red and inflamed bulge (or) swelling beside the tonsil (above and lateral to a tonsil) + Hx of Dysphagia and Sore
throat
• Presentation
1. Trismus (lockjaw = spasm of jaw muscles)
2. Dripping of saliva
3. Otalgia (as CN IX glossopharyngeal nerve supplies both ears and tonsils)
4. Hot potato voice
5. Uvular deviation
• Rx- IV Antibiotics (Penicillin V- Phenoxymethylpenicillin for Tonsillitis) with Incision and Drainage with Urgent
Admission
8. Mild Squamous Dysplasia of Larynx

• Hoarseness, White patch "Leucoplakia" over the Vocal Cords

• What to do Next?
• Advice the patient to STOP SMOKING
• + Observe and F/U (Risk of Malignancy- Laryngeal cancer)

5. Ear
1. Removal of Ear Foreign Body
1. Insect
• Initial step- KILL by Mineral Oil>Alcohol>Lidocaine 2%
• To REMOVE- Syringe it out by Water irrigation or Olive oil
2. Seeds (eg. beans, pea)
• "Rapid access" = Routine Referral
• Not urgent referral to ENT to remove it by suction with a catheter or by a hook
• Never irrigate or instil oil in case of organic matter (eg. seed, bean, pea) as it would swelling causing more
discomfort and difficulty to remove
3. Super Glue
• Manual removal in 1-2 days (after desquamation)
• Or: refer to ENT if ear drum in involved
4. Earwax build up
• few drops of olive oil to soften hard wax
5. Batteries
• Refer to ENT as they should be taken out within 24 hours
6. Any Spherical Object (eg. pencil rubber)
• Remove by hook
• Routine referral to ENT "not urgent referral"
7. Intellectually disabled person (eg. autistic child)
• Remove under General Anaesthesia by ENT
8. Remove Under GA if
• In Severe Pain
• Extremely restless
• Difficult to examine
• Referral to ENT
1. patient requires sedation
2. difficulty in removing foreign body
3. patient is uncooperative (eg. a person with autism, mental retardation, very young child to be cooperative)
4. TM is perforated
5. adhesive (eg. super glue) is in contact with TM
□ If none of above, refer to ENT with Routine referral only if no specific options
2. Ear Wax
1. Firstly- Ear drops for 3-5 days to soften wax and ease its removal
2. If persists- Ear irrigation
• If these two lines have been tried but symptoms (eg. hearing loss) persists, what should be done?
• In this case, one of 3 options is attempted:
1. Another course of 3-5 days ear drops
2. Initial water into the ear and irrigate after 15 minutes
3. Refer to ENT specialist
3. Rinne and Weber test
• Important- Do MRI if SNHL is suspected
• 512 Ghz Tuning fork is used
• Remember
○ AC>BC Normally/SNHL
○ BC>AC = CHL
○ Weber always lateralizes towards the better site (Opposite in SNHL and Same in CHL)
• Summary of results of Tests
○ BC>AC- CHL in the same side and Weber's test lateralises to same side in CHL
○ AC>BC (normal) or SNHL and Weber's test lateralises to other side in SNHL
4. Otitis Media
• Usually follows viral URTI (Tonsillitis)
• Otalgia>Itching
• Tympanic Membrane:
○ Erythematous Bulging TM
○ Absent light reflex
○ Red, Yellow or Cloudy
○ Bulging, or perforated, with or without purulent discharge
• Ruptured tympanic membrane alleviates the pain- Oral Amoxicillin for 5 days
• Bacterial (e.g. High fever, cervical LNP) or >3 days- Oral Amoxicillin for 5 days
○ If Allergic to Penicillin- Erythromycin or Clarithromycin
• Usually viral (requires analgesics and supportive treatment only)
• Commonest Organisms
○ RSV (Respiratory Syncytial Virus)
○ H. Influenza
○ Streptococcus Pneumoniae
○ Streptococcus Pyogenes
5. Otitis Externa
• Features
○ Hx of swimming, high humidity, Travel
○ + Painful ear
○ + Pus or serous fluid inside the ear canal
○ Tragal Tenderness
○ Itching>Otalgia
• Rx (Any of 1)
1. Acetic acid 2%
2. Topical Gentamicin + Hydrocortisone
3. Topical Gentamicin
□ Avoid Aminoglycoside (eg. Gentamicin) if there is tympanic membrane perforation as it is Ototoxic
® Ciprofloxacin drops should be used instead
6. Otitis Media vs Externa
• Itch f/b Pain- Otitis Externa
• Pain f/b discharge- Otitis Media
7. Otitis Media with Effusion
• Glue Ear
• BC>AC in both ears + Weber's does not lateralize + Child + Does not hear the teacher well in class = OME
• Commonest cause of Conductive hearing loss in Children (Otosclerosis is commonest cause of CHL in young adults
of age 15-45 YO)
• Tympanic membrane is either Retracted "more common" or Bulging
• Bluish grey, Dull or Yellow +/- Air-Fluid Level
• Signs to look for
• A child raises the TV volume up
• A child is doing poorly in school
• A child lacks concentration and is socially withdrawn
• Important: First, Refer them for Audiogram. "Audiogram will show conductive hearing loss more common B/L"
• Tympanometry- assesses the ability of eardrum to react to sound
• Rx
• First visit or recently diagnosed
○ Reassure and review in 3 months (as it can resolve spontaneously)
• If persists over 3 months and B/L
○ Grommets Insertion "i.e. surgery"
• If surgery is contraindicated or rejected
○ Ear aids
• Encourage parents to STOP SMOKING
8. Otosclerosis
• Commonest cause of Progressive CHL in Young adults (15-45 YO)
• Increased Stapes bony growth
• CHL (Low tone loss)
• Pregnancy accelerates the progression of otosclerosis
• Flamingo pink blush (Schwartz sign)
• Inability to hear Low frequency sounds. Therefore, raising the speaker's voice would allow the patient to hear better
(Inability to hear high-frequency sounds = Presbycusis)
• Hear better while in a noisy environment
• Rx- Stapedectomy or Stapedotomy with Prosthesis insertion
9. Otoscopy findings
1. OME- Bluish grey, or Yellow TM with an air fluid level
2. Otosclerosis- Flamingo pink blush (Schwartz sign)
3. Acute Suppurative OM- Cartwheel appearance of vessels
4. Tympanosclerosis- Chalky white patches on TM
5. Cholesteatoma- Pearly white mass behind TM
10. Cholesteatoma
• Acquired Cholesteatoma
• Keratinizing squamous epithelium-neither a cholesterol nor a tumour
• Pearly White Mass BEHIND the TM (remember, white chalky mass ON the TM- Tympanosclerosis)
• Chronic Foul-smelling purulent discharge (otorrhea)
• Canal filled with pus/ mucus/ granulation tissue
• Hx of recurrent Otitis Media
• Cholesteatoma is poorly responsive to antibiotics
• Conductive Hearing Loss
• Ix- Refer to ENT> CT scan
• Congenital Cholesteatoma
• same but presenting patient is a child (6 months - 5 years)
• Neither Hx of recurrent OM nor TM perforation
• Note
• Because of the ability of Cholesteatoma to erode and damage the adjacent structures, the presenting
symptoms may include facial paralysis, vertigo, headache besides deafness and earache
• Mx- Refer to ENT for consideration of surgical removal
11. Malignant Otitis Externa
• Cause- Pseudomonas
○ Features
§ Black colour skin near/in ear canal
§ Facial Palsy
§ Severe Pain in the ear
§ Purulent Foul Discharge
§ Conductive Hearing Loss
○ Risk factors- Immunocompromised, DM
○ Dx- CT Scan
○ Rx- Refer urgently to ENT/ IV Ciprofloxacin
12. Trauma to the Ear
○ Eg. During fight, slap to the ear
○ Intense Otalgia, Bleeding per ear, Tinnitus, temporary Decreased Hearing (conductive)
○ First Ix- Otoscopy (suspected perforated eardrum)
13. Hearing tests in Children
○ Mnemonic- OA Dil Vale CS Pelenge (6,18,24,48,60)
1. Below 6 Months
○ Otoacoustic Emissions (OAE)
○ Audiological Brainstem Responses (ABR)
2. 6-18 Months
○ Distraction Testing
3. 6-24 Months
○ Visual Reinforcement Audiometry (VRA)
4. 2-4 Years
○ Conditioned Response Audiometry (CRA) (or Conditioned Play Audiometry)
○ Speech Discrimination
5. 5 Years
○ Pure Tone Audiogram
14. Arrange/Refer for Hearing tests
1. Any parental concern about hearing loss at any time (despite previously normal hearing tests) "Important"
2. Professional (Doctor's) Concern
3. Temporal Bone Fracture
4. Bacterial Meningitis
5. Severe Unconjugated "Indirect" Hyperbilirubinemia (e.g. Gilbert Syndrome)
○ Hyperbilirubinemia (increased blood indirect bilirubin can cross the blood-brain barrier and deposit in the
auditory ventricular nucleus cells = SNHL)
6. Delayed speech and language milestones
15. Ear Furuncle
• Red, Painful, Tender, Hard Nodule in ear
• Cause- Staph Aureus
• Rx
○ Resolves
○ Flucloxacillin
○ I&D if large
16. Presbycusis
• Inability to hear HIGH-frequency sounds (Raising the voice would not improve hearing)
• Elderly
• Bilateral SNHL (Otosclerosis is CHL)
• "Don't shout I am not Deaf"
• Poor hearing especially in noisy environment
• Rx- B/L Digital Hearing Aids
17. Noise-Induced Hearing Loss
• Exposure to a loud sound
• Occupational noise- Occupational hearing loss
• B/L SNHL
• Cannot hear well in a large room when a number of people are talking simultaneously.
• Cannot understand the speech well while on the phone. He feels that sound is muffled
18. Large Haematoma
• Incision and Drainage + Prophylactic Oral Antibiotics (Co-Amoxicillin) for 1 week
• Injury to Ear pinna with intact TM and no large haematoma
• No further investigations
• Analgesics
• If left untreated (not drained early), necrosis may develop and affect the auricular cartilage leading to a persistent
deformity called "Cauliflower Ear"
19. Perichondritis

• Pseudomonas Aeruginosa
• Rx
○ Oral Fluoroquinolone- Ciprofloxacin, 91 emifloxacin (Factive), Levofloxacin (Levaquin), Moxifloxacin (Avelox)
and Ofloxacin (Floxin)
○ Sometimes with an aminoglycoside plus semisynthetic penicillin
○ If Abscess- I&D
20. Musical Ear Syndrome
• Non-Psychiatric Musical Auditory Hallucination
• Hearing music/sounds without external source (brain tries to fill the gaps of hearing loss with these musical sounds)
• Women>60 YO
• Does not hear voices or people talking (differentiate from Schizophrenia)
• Tinnitus and Hearing loss
• Aetiology unknown
• Ix- Pure Tone Audiometry
• Rx- No cure

6. Cancers
1. Oropharyngeal Cancer
○ Lump or Ulcer in mouth or throat
○ Referred Otalgia
○ Persistent sore throat and painful swallowing
○ Old and Smoker
○ Palpable, non-tender Cervical LNP
2. Tonsil Cancer
○ Elderly + Smoker + Dysphagia + U/L Ear Pain + U/L red lesion with central ulcer that bleeds on touch
○ Persistent sore throat (over weeks)
○ Progressive Hoarseness of voice
○ Dysphagia and Painful swallowing
○ Feeling of a persistent lump in throat
○ Palpable lump on anterolateral portion of neck
○ MCC- Squamous Cell Carcinoma (SCC)
○ Note- absence of LOW does not exclude tonsil cancer
○ Tonsillar cancer spreads to- Mandible
§ Pain throat + Trismus (spasm of jaw muscles, causing mouth to remain tightly closed)
§ Differential diagnosis- Quinsy (Peritonsillar abscess)
• Quinsy
® Hx of Tonsillitis or Sore throat + Red and inflamed bulge (or) swelling beside the tonsil (above
and lateral to a tonsil) + Hx of Dysphagia and Sore throat
® Symptoms- Trismus (Lockjaw) + Dripping of saliva + Otalgia + Hot potato voice + Uvular Deviation
® Rx- IV Abs + I&D after Urgent admission
3. Nasopharyngeal Cancer
○ Painless Cervical LN + Eustachian tube obstruction- Otitis media, Epistaxis, Nasal obstruction, CHL, Tinnitus
○ Risk factors- EBV (specific), Smoking, Alcohol
○ Mx- Urgent ENT referral (within 2 weeks), Biopsy (2 weeks), CT (staging)
• Note- EBV> Hodgkin's lymphoma, Nasopharyngeal carcinoma
4. Paranasal Sinus Cancer
• Pressure / pain / Tenderness / Swelling in the cheek, upper teeth
• Blood seen in the nasal discharge
• Nasal obstruction
• Hx of chronic sinusitis
• If obit is involved- Epiphora (excessive watering of the eye), Diplopia
5. Nasopharyngeal vs Paranasal Sinus Cancer
Nasopharyngeal Carcinoma Paranasal Sinus Carcinoma
Both will present with nasal obstruction and Both will present with nasal obstruction and epistaxis
epistaxis
Ear symptoms- Otitis media, CHL and tinnitus Eye symptoms- Epiphora, diplopia
May have a neck mass No neck mass

• Remember: Red Flag signs like U/L Obstruction or discharge warrant an urgent ENT referral (to rule out sinonasal
tumour)
6. Suspected Laryngeal Cancer Referral Pathway
• Appointment within 2 weeks) for aged 45 and over with:
§ Persistent unexplained hoarseness of voice (for >3 weeks)
or
§ An unexplained lump in the neck
7. Laryngeal Cancer
• Smoking + Hoarseness of voice + Dysphagia + Haemoptysis
• Risk factors
1. Smoking (main avoidable RF and number one cause of laryngeal cancer in UK)
2. Asbestos, formaldehyde
3. Poor fruit and vegetable diet
4. HPV 16- Oral, Pharyngeal, Laryngeal cancer

7. Vertigo
1. Sudden Falls
• Unconscious
1. Stokes Adam attack- Abnormal ECG
2. Hypoglycaemia
• Whipple's Triad- Low plasma glucose (usually <4) + Manifestations + If blood glucose is corrected- rapid
resolution of symptoms occur
3. Vasovagal attacks- Unconscious + Hx of prolonged standing, straining, pooping, heavy weight lifting or after
visual stimuli e.g. seeing blood, Usually a YOUNG FEMALE (with NO chest pain, palpitation and with Normal
ECG)
4. Epilepsy- Unconscious +/- Post-seizure confusion
• Conscious
1. Drop attacks- Sudden falls without losing consciousness (cauda equina or vertebrobasilar insufficiency)
2. Postural (Orthostatic) Hypotension- Hx of Polypharmacy, Addison's, Pheochromocytoma
• What to do?
§ Fbs
§ Bp
§ Ecg
2. Vertigo Differentials from ENT
BPPV Meniere's Disease Acoustic Neuroma Vestibular Labyrinthitis
neuritis
Sympto • Vertigo • DVT • DVT + CN Palsy ○ 3Vs ○ 3Vs
ms • +/- Fullness, Nausea and • +/- Pressure sensation in § Viral § Viral
Vomiting affected ear/ Headache URTI URTI
§ Vertigo § Vertigo
§ Vomiti § Vomiti
ng ng
○ Nystagmus ○ Hearing loss
(SNHL) /
Tinnitus
Duratio • Seconds to minutes • Minutes to Hours (2-3 hours) • Minutes to Hours (2-3 • Hours to days • Hours to days
n hours)
Factors • Triggered by • Not provoked by movements • Not provoked by • Aggravated/E • Aggravated/E
movement movements xacerbated xacerbated
by movement by movement
of head of head
Ix • Dix-Hallpike • Normal MRI • Order MRI • None • None
• "Dx by Dix" Cerebellopontine angle/ Cerebellopontine angle/
• Provokes Internal Auditory Meatus Internal Auditory Meatus
Nystagmus • Excludes Acoustic
Neuroma
Rx • Epley, not just PSCC • Zine Family • Prochlorperazine • Prochlorperaz Prochlorperazin
but SCC • Prochlorperazine ine e
§ "Apply Epley • Promethazine
for Rx" • Cyclizine
• Prochlorperazine
Prophyl • None • Betahistine • None • None • None
axis
Notes • Rotatory Nystagmus- • None • B/L Acoustic Neuroma • None • None
Posterior SCC seen in NF2
• Vertical Nystagmus-
Superior SCC
• Horizontal
Nystagmus- Lateral
SCC

8. Others
1. Mandibular Lumps and any Salivary Masses persisting for more than 1 month
• U/S Guided FNAC (eg. Free and mobile submandibular mass that grows rapidly with skin induration)
2. Injury to ear pinna with INTACT tympanic membrane
○ No further investigations (self-limiting)
• If Hematoma- refer to ENT for I&D
• If Painful- give analgesics
3. Oesophageal Candidiasis
• Dysphagia + Odynophagia
4. Laryngeal Candidiasis
• Hoarseness of Voice
• Inhaler use/ Steroids use
5. Temporomandibular Joint Disorder (TMJ Disorder)
• Pain in an Ear, Cheek, Mandible that increases on Chewing + Bruxism (Grinding of the teeth)
6. Buccal Ulcer with Palpable Cervical Nodes
• Squamous Cell Carcinoma
7. Hoarseness of voice- DDx
• Laryngeal ca (>3 weeks + Hx of smoking/HPV 16)
• Laryngeal candidiasis (Hx of steroid use)
• Tonsil Ca (with dysphagia, palpable lump, painful swallowing)
• Mild squamous dysplasia of larynx
• Anaphylaxis
• COPD
• U/L Injury to Recurrent Laryngeal Nerve
• About 18% of Lung cancer patients experience Hoarseness of voice due to compression of the tumour on the
recurrent laryngeal nerve