Ent: looking ahead

Edoardo Cervoni, M.D.
Ear Nose Throat Specialist

6th March 2013 GP Trainees - Education Centre, RPH

Discolosures
 Grant/Research Support: no disclosure
 Consultant: no disclosure
 Major Shareholder: Locumdoctor4u Ltd. (Locum and
Concierge Medical Services)
 I will not be discussing “off-label” uses of medications
or investigations


ENT Referrals
i. Most ENT referrals are linked to Audiological and Otological problems.

ii. Out of 271 consecutive referrals to the RHP ENT Department triaged
in 2011, 58% could be potentially managed in Primary Care.

CLPCT NHS Survey 2011 – E Cervoni


ENT Referrals
i. Snoring and sleep apnoea were relatively common reasons of referrals.
ii. In a rather significant proportion of cases, relevant information, with specific
reference to the physical examination, were missing.
iii. Among the referrals redirected to the GPwSI in ENT, deafness with wax,
epistaxis and blocked nose were the most common complaints.

6thCLPCT NHS Survey 2011 – E Cervoni
March 2013 GP Trainees - Education Centre, RPH

Conditions referred

Cervoni E - 2011


ENT Referral Pattern is changing

WHY?
Ageing – Sanitation -
Vaccinations

Demographics
 Lancashire residents grew during the decade to
2011 by 3%. There was a 5% fall in the number of 0
to 19 year olds, which was greater than the regional
decrease.
 There was a 12% growth in people 65+ years, which
was also above the regional average.
 The growth rate of the 65+ year olds was positive in
all districts except Blackpool and the greatest in
Chorley and West Lancashire.


 Sensory Presbycusis Metabolic Presbycusis
 High frequency down- Slowly progressive
sloping SNHL Flat audiogram
 Speech discrimination Good speech discrimination
remains good Atropy of stria vascularis
 Degeneration a basal
potion of Organ of Corti Conductive Presbycusis
(predominately outer Thickening of basilar membrane
hair cells) Gradual down-sloping high
 Neural presbycusis frequency hearing loss
 Flat audiogram
 Rapid hearing loss Progressive
 Poor speech Speech discrimination for similar
discrimination pure tone hearing is worse in older
 Loss of spiral ganglion
cells patients than younger patients


Treatments
 Repeat testing
 Assistive devices
 Vibrating alarm clocks
 Flashing telephone and door signalers
 Television listening systems
 Personal amplifiers
 Hearing aids
In U.S.A. an estimated 4.5 million hearing aid users , but
only 10-20% who could use them do and 12% of people
who have them don’t wear them.

Types of hearing aid circuitry
 Analog
 Digitally controlled analog
 Digital sound processing

 Body Aids
 Behind-the-ear (BTE)
 In-the-ear(ITE)
 In-the-canal(ITC)
 Completely-in-canal(CIC)

Dysphagia
 Phases of swallowing
 Oral (reduced facial muscle strength, decreased
masticatory strength, reduced tongue control,
missing dentition)
 Pharyngeal (delayed in elderly subjects,
decreased pharyngolaryngeal sensory
discrimination, abnormal UES function,
increased penetration and silent aspiration)
 Oesophageal ( decreased or absent secondary
peristalsis)


Evaluation
 History: Feeding problem vs. swallowing disorder
 Liquids vs. solids
 Globus, halitosis, wet vocal quality, reflux,
odynophagia, recurrent pneumonia, hoarseness,
dysarthria
 Physical Exam
 Oral cavity and upper aerodigestive tract, saliva
quality/dentition/dentures
 Neurological evaluation including arousal,
orientation, cognition, cranial nerves


Investigations
 Barium swallow (anatomic lesions)
 Modified barium swallow (dinamic view) of
swallowing from oral cavity to lower
esophageal sphincter)
 FEES – Functional endoscopic evaluation of
swallowing
 Videofluoroscopic swallowing study, or
VFSS test


Causes of dysphagia
 Stroke
 Neuromuscular disease - Parkinson’s disease (pill-
rolling tremor, bradykinesia, cog-wheeling
rigidity), Amyotrophic lateral sclerosis
 Medications (xerostomia, mental status change,
dyskinesia, GERD, esophagitis)
 Cricopharyngeus dysfunction (functional,
structural, “bar” on barium swallow)
 Zenker’s diverticulum (regurgitation)
 Neoplasms


Treatments
 Swallowing therapy
 Dietary modifications
 Rationalization of medications
 PEG
 Cricopharyngeal myotomy, Botox injection of
cricopharyngeal bar
 Surgical repair of Zenker’s (open vs. endoscopic)


Balance Disorders
 Difficulties with sensory function, central nervous
system integration, neuromuscular and skeletal
function
 30-50% persons 65 and older fall in a given year
 50% per year fall age 80 or older
 1% of falls suffer hip fractures, 5% some type of
fracture
 Roughly half of hip fractures are estimated to
never recover normal function again


Vestibular changes with age
 Termed presbystasis
 Loss of hair cells primarily in the ampulla
 Total number of vestibular nerve axons is 37% than
younger patients
 Loss of neurons in vestibular nuclei of 3% per decade
age 40-90
 Reduction in gain of VOR, smooth pursuit, increase in
saccade latencies
Postural stability: Sensory (visual, hearing, vestibular,
proprioceptive)/Musculoskeletal/Cognitive/Integrative
function

Other factors in balance disorders
 Cerebellar degeneration, Parkinson’s disease,
Huntington’s disease, vitamin B12 deficiency,
dementia, diabetic neuropathy, brain and spinal cord
tumors, postural hypotension, cerebrovascular disease,
atherosclerosis, musculoskeletal disease, metabolic
disorders, cardiovascular disorders, medications,
visual impairment


 History
 Dizziness, dysequilibrium, vertigo
 Onset, duration, frequency, severity, provocation,
associated symptoms, falls
 Medications, medical conditions
 Physical exam
 Examine sensory functions, posture, gait,
neurological function
 Adjunctive testing
 Audiogram, electronystagmography, MRI,
posturography


Treatments


Objective -Pulsatile tinnitus
 Arteriovenous  Cardiac murmurs
malformations  Pregnancy
 Vascular tumors  Anemia
 Venous hum  Thyrotoxicosis
 Atherosclerosis  Paget’s disease
 Ectopic carotid artery  Benign intracranial
 Persistent stapedial hypertension
artery
 Dehiscent jugular bulb
Idiopathic stapedial muscle spasm
 Vascular loops Palatal myoclonus
Patulous eustachian tube


Subjective tinnitus
 Presbycusis
 Noise exposure
 Meniere’s disease
 Otosclerosis
 Head trauma
 Acoustic neuroma
 Drugs
 Middle ear effusion
 TMJ problems
 Depression
 Hyperlipidemia
 Meningitis
 Syphilis


Treatments
 Multiple treatments  Reassurance
 Avoidance of dietary  White noise from
stimulants: coffee, tea, radio or home
cola, etc. masking machine
 Smoking cessation
 Avoid medications
known to cause tinnitus


Nasal Complaints
 Nasal obstruction
 Rhinorrhea
 Epistaxis
 Olfactory dysfunction


Causes
 Inflammation: decrease immune function, mucociliary
dysfunction, allergy, dehydration with thickening of
secretions
 Dystrophic changes: both atrophy of nasal mucosa and
increase in vasomotor rhinitis are common
 Neoplasia: nasal obstruction, pain, epistaxis, rhinorrhea
 Trauma: old traumas, previous surgery
 Endocrine-metabolic disorders: hypothyroidism, decreased
vitamin A and zinc
 Pharmacologic effects: diuretics, tricyclic antidepressants,
antihistamines


Voice changes
 Estimated 12% of the elderly have vocal dysfunction
 Fundamental frequency of the male voice tends to
increase with age
 Fundamental frequency in females decreases with age


Voice changes
 Common vocal cord findings
 Atrophy
 Bowed cords
 Oedema
 Loss of collagen and elastic fibers, decrease in
density of fibroblasts, atrophy of submucous
glands, fibrosis, disorganization of collagen fibers


Neurological disorders with voice changes
 Essential tremor
 Parkinson’s disease: low volume, breathy, and
monotonic
 Stroke
 Myasthenia gravis
 Amyotrophic lateral sclerosis


Treatments
 Speech therapy
 Medialization thyroplasty
 Diagnosis and treatment of underlying disorder


Cancer
 Squamous cell cancers
 Thyroid malignancies
 Well differentiated have worse course
 Anaplastic or undifferentiated more common
 Salivary gland malignancies
 Lymphomas


Laryngeal Cancer – UK


Cosmetics
 Elderly are leading more active lives for much longer
than in the past
 With the explosive growth of cosmetic facial plastic
surgery paired with the explosive growth of the elderly
population there will be many more “elderly” cosmetic
patients


 Skin- loss of tone, dynamic and static wrinkling,
thinning, pigmentary changes, gravitational
descent of soft tissues
 Chemical peel, laser resurfacing
 Botox injection
 Rhytidectomy
 Upper third-ptosis of eyebrows and forehead
 Direct brow lift
 Pretrichial/coronal/endoscopic


 Periorbital Region - lower eyelid laxity, prolapsed lacrimal gland, ptosis
(usually dermatochalasis)
 Dacryoadenopexy
 Lower lid shortening
 Upper/lower blepharoplasty
 Nose – tip ptosis from loss of attachments between upper and lower lateral
cartilages, loss of connections between medial crura and septum,
ligamentous connections between domes of lower lateral cartilages and
anterior septal angle
 Rhinoplasty-shorten lateral crura, place septal strut
 Lower third – loss of premental fat pad “witches chin”, cheiloptosis,
platysmal bands
 Genioplasty
 Lip-lift
 Plication, imbrication, suture suspension, Z-plasty of platysma


Conclusions
 With the expected explosive growth of the elderly
population, this group will become a larger proportion
of patients
 The otolaryngologist must consider the patient’s
health and well being as a whole especially in this
group of patients who often have multiple problems


1. Parham K, Lin FR, Coelho DH, Sataloff RT, Gates GA. Comprehensive Management of Presbycusis: Central and Peripheral. Otolaryngol
Head Neck Surg. 2013 Feb 8.
2. Creighton FX Jr, Poliashenko SM, Statham MM, Abramson P, Johns MM 3rd. The growing geriatric otolaryngology patient population: a
study of 131,700 new patient encounters. Laryngoscope. 2013 Jan;123(1):97-102.
3. Dagan E, Wolf M, Migirov LM. Why do geriatric patients attend otolaryngology emergency rooms? Isr Med Assoc J. 2012 Oct;14(10):633-
6.
4. Kumar S, Rout N, Kumari P, Dey B. The conceptions of hearing impairment, causes and its management: a train survey. Int J Pediatr
Otorhinolaryngol. 2012 Aug;76(8):1123-6. doi: 10.1016/j.ijporl.2012.04.014. Epub 2012 May 12.
5. Van Vuuren PA, Kagan SH, Chalian AA. Geriatric otolaryngology toolbox: what you and your nurse can do to improve outcomes for
older adults. Ear Nose Throat J. 2009 Oct;88(10):1162-8.
6. Chalian AA. Accomplishment and opportunity in geriatric otolaryngology. Ear Nose Throat J. 2009 Oct;88(10):1156-61.
7. Goldstein JC. The American Society of Geriatric Otolaryngology. Ear Nose Throat J. 2007 Dec;86(12):718-9.
8. Eibenstein A, Fioretti AB, Simaskou MN, Sucapane P, Mearelli S, Mina C, Amabile G, Fusetti M. Olfactory screening test in mild
cognitive impairment. Neurol Sci. 2005 Jul;26(3):156-60.
9. Bora H, Bandyopadhyay SN, Basu SK, Majhi PK. Geriatric problems in otolaryngology. J Indian Med Assoc. 2004 Jul;102(7):366, 368, 370.
Review.
10. Vaiman M, Eviatar E, Segal S. Surface electromyographic studies of swallowing in normal subjects: a review of 440 adults. Report 1.
Quantitative data: timing measures. Otolaryngol Head Neck Surg. 2004 Oct;131(4):548-55.
11. Belafsky PC, Postma GN, Amin MR, Koufman JA. Symptoms and findings of laryngopharyngeal reflux. Ear Nose Throat J. 2002 Sep;81(9
Suppl 2):10-3.
12. Sahoo GC. Gerontology in ENT (Geriatric Otolaryngology) - an over view. Indian J Otolaryngol Head Neck Surg. 2001 Oct;53(4):267-9.
13. Jiang RS, Hsu CY. Endoscopic sinus surgery for the treatment of chronic sinusitis in geriatric patients. Ear Nose Throat J. 2001
Apr;80(4):230-2.


Ent: looking ahead

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Ent: looking ahead

Similar to Ent: looking ahead (20)

Recently uploaded

Recently uploaded (20)

Ent: looking ahead