Ent in General Practice

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A guide to the diagnosis and management of common ENT conditions. Produced for use in basic medical education.

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Ent in General Practice

  1. 1. ENT IN GENERAL PRACTICE A QUICK GUIDE TO MANAGING COMMON CONDITIONS LT COL KABIR BAKSHI CLASSIFIED SPECIALIST (ENT)
  2. 2. THE DILEMMA <ul><li>ENT IS A NICHE SPECIALITY YET MANY ENT CONDITONS ARE NOT UNCOMMON ! </li></ul><ul><ul><li>HOW TO DIAGNOSE? </li></ul></ul><ul><ul><li>HOW TO TREAT? </li></ul></ul><ul><ul><li>IS THIS CONDITION SERIOUS? </li></ul></ul><ul><ul><li>WHEN TO REFER? </li></ul></ul><ul><ul><li>WHEN TO WAIT? </li></ul></ul>
  3. 3. ESSENTIAL EQUIPMENT <ul><li>OTOSCOPE </li></ul><ul><li>TORCH </li></ul><ul><li>TONGUE DEPRESSOR </li></ul><ul><li>THUDICUM NASAL SPECULUM </li></ul><ul><li>ARTERY FORCEPS </li></ul><ul><li>JOBSON HORNE PROBE OR EUSTACHIAN CATHETER </li></ul>
  4. 4. THE NORMAL EAR
  5. 5. DISORDERS OF THE PINNA BAT EAR MICROTIA PREAURICUAR TAGS PREAURICULAR SINUS DIAGNOSIS : SPOT! TREATMENT: SURGERY
  6. 6. DISORDERS OF THE PINNA AURICULAR HEMATOMA KELOID <ul><li>DUE TO MINOR TRAUMA </li></ul><ul><li>COMMON IN WRESTLERS </li></ul><ul><li>TREATMENT : I & D </li></ul><ul><li>PRONE TO RECURRENCE </li></ul><ul><li>FOLLOWS TRAUMA/ PIERCING </li></ul><ul><li>TREATMENT : EXCISION </li></ul><ul><li>PRONE TO RECURRENCE </li></ul><ul><li>REQUIRES POSTOP INTRALESIONAL </li></ul><ul><li>STEROID INJECTION </li></ul>
  7. 7. DISORDERS OF EAR CANAL FURUNCULOSIS OF EAR CANAL (OTITIS EXTERNA) <ul><li>CAUSE : STREPTOCOCCAL / STAPHYLOCOCCAL INFECTION OF SKIN OF EAC </li></ul><ul><li>TREATMENT : ANTIBIOTICS, ANALGESICS </li></ul><ul><li>MAY BE ASSOCIATED WITH UNTREATED MIDDLE EAR INFECTION </li></ul>
  8. 8. DISORDERS OF EAR CANAL WAX EAR (RT) OTOMYCOSIS (LT) TREATMENT : WAX SOFTENING DROPS FOLLOWED BY SYRINGING AFTER ONE WEEK TREATMENT : ANTIFUNGAL EAR DROPS CAUTION : ALL EAR DROPS ARE NOT EQUIVALENT!!!
  9. 9. DISORDERS OF MIDDLE EAR <ul><li>TRAUMATIC PERFORATION </li></ul><ul><li>DIAGNOSIS </li></ul><ul><ul><li>HISTORY OF TRAUMA </li></ul></ul><ul><ul><li>RAGGED EDGES OF PERFORATION </li></ul></ul><ul><ul><li>FRESH BLEEDING </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>NO EAR DROPS </li></ul></ul><ul><ul><li>KEEP EAR DRY </li></ul></ul><ul><ul><li>ORAL ANTIBIOTICS, ANTIHISTAMINICS </li></ul></ul><ul><ul><li>REVIEW AFTER ONE MONTH </li></ul></ul><ul><li>IF DUE TO NOISE OF MIL WEAPONS… IT IS IMPULSE NOISE TRAUMA… INNER EAR NEEDS EVALUATION FOR NIHL! </li></ul>
  10. 10. DISORDERS OF MIDDLE EAR <ul><li>ACUTE SUPPURATIVE OTITIS MEDIA </li></ul><ul><li>STAGES </li></ul><ul><ul><li>TUBAL OCCLUSION </li></ul></ul><ul><ul><li>PRESUPPURATION </li></ul></ul><ul><ul><li>SUPPURATION </li></ul></ul><ul><ul><li>DISCHARGE/RESOLUTION/ COMPLICATIONS </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>ORAL ANTIBIOTICS </li></ul></ul><ul><ul><li>ANALGESICS </li></ul></ul><ul><ul><li>ANTIHISTAMINICS </li></ul></ul><ul><ul><li>NASAL DECONGESTANTS </li></ul></ul><ul><ul><li>FOLLOWUP </li></ul></ul><ul><li>SPECIAL CONSIDERATIONS </li></ul><ul><ul><li>ROLE OF EAR DROPS </li></ul></ul><ul><ul><li>MYRINGOTOMY </li></ul></ul>
  11. 11. DISORDERS OF MIDDLE EAR <ul><li>SEROUS OTITIS MEDIA (GLUE EAR/ OME) </li></ul><ul><li>SYMPTOMS </li></ul><ul><ul><li>INSIDIOUS ONSET, LONG STANDING CONDITON (3 MONTHS) </li></ul></ul><ul><ul><li>HEARING LOSS </li></ul></ul><ul><ul><li>OCCASSIONAL OTALGIA </li></ul></ul><ul><ul><li>BUBBLING SOUNDS, ECHO OF OWN VOICE </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>CORTICOSTEROID / ANTIHISTAMINIC NASAL SPRAYS </li></ul></ul><ul><ul><li>ORAL DECONGESTANTS / ANTIHISTAMINICS </li></ul></ul><ul><ul><li>CHEWING GUM, BLOWING BALLOONS </li></ul></ul><ul><ul><li>MYRINGOTOMY AND GROMMET INSERTION </li></ul></ul><ul><li>SPECIAL CONSIDERATIONS </li></ul><ul><ul><li>ROLE OF ADENOTONSILLECTOMY </li></ul></ul><ul><ul><li>ROLE OF TEMPORARY HEARING AID </li></ul></ul><ul><ul><li>DIFFERENTIATION FROM AOM WITH EFFUSION </li></ul></ul>
  12. 12. DISORDERS OF MIDDLE EAR <ul><li>CHRONIC OTITIS MEDIA </li></ul><ul><li>CLASSIFICATION </li></ul><ul><ul><li>MUCOSAL </li></ul></ul><ul><ul><ul><li>ACTIVE </li></ul></ul></ul><ul><ul><ul><li>INACTIVE </li></ul></ul></ul><ul><ul><li>SQUAMOUS </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>DRY THE EAR </li></ul></ul><ul><ul><ul><li>TOPICAL ANTIBIOTIC/ STEROID EAR DROPS </li></ul></ul></ul><ul><ul><ul><li>ORAL ANTIHISTAMINICS </li></ul></ul></ul><ul><ul><li>OPERATE THE EAR </li></ul></ul><ul><ul><ul><li>SAFE,DRY,FUNCTIONING EAR </li></ul></ul></ul><ul><li>SPECIAL CONSIDERATIONS </li></ul><ul><ul><li>COMPLICATIONS OF COM </li></ul></ul><ul><ul><li>RESULTS OF SURGERY </li></ul></ul><ul><ul><li>RESTORATION OF HEARING </li></ul></ul>
  13. 13. DISORDERS OF MIDDLE EAR <ul><li>TYMPANOSCLEROSIS </li></ul><ul><li>Vs </li></ul><ul><li>OTOSCLEROSIS </li></ul>
  14. 14. DISORDERS OF INNER EAR <ul><li>SENSORINEURAL HEARING LOSS </li></ul><ul><ul><li>SUDDEN </li></ul></ul><ul><ul><li>NOISE INDUCED </li></ul></ul><ul><ul><li>PRESBYACUSIS </li></ul></ul><ul><ul><li>UNILATERAL </li></ul></ul><ul><li>EMERGENCY Mx OF SUDDEN SNHL </li></ul><ul><ul><li>TAB PREDNISOLONE 60 mg/day </li></ul></ul><ul><ul><li>TAB ACYCLOVIR 400 mg 4 hrly </li></ul></ul><ul><ul><li>LOW MOLECULAR WEIGHT DEXTRAN (LOMODEX) 250 ml 12 hrly </li></ul></ul><ul><ul><li>TAB BETAHISTINE (VERTIN) 16 mg 8 hrly </li></ul></ul>ALL KINDS OF HEARING AIDS- ANALOGUE / DIGITAL, BODY WORN/ BTE/ CIC ARE AVAILABLE FREE OF COST TO SERVING PERS/DEPENDENTS AS WELL AS ECHS MEMBERS/ DEPENDENTS UPTO A COST OF RS 10,000/20,000/60,000 ONCE EVERY 5 YEARS ON PRESCRIPTION BY A SERVICE ENT SURGEON THROUGH CENTRALLY EMPANELLED SERVICE PROVIDERS MRI OTOLOGICAL EMERGENCY!
  15. 15. SYRINGING THE EAR <ul><li>USEFUL FOR WAX REMOVAL, FOREIGN BODY REMOVAL </li></ul><ul><li>USE 50 ml SYRINGE, LARGE BORE IV CANNULA </li></ul><ul><li>WATER AT BODY TEMPERATURE TO AVOID CALORIC EFFECT </li></ul><ul><li>COUNSEL PATIENT BEFOREHAND </li></ul><ul><li>AVOID OVERINSERTION </li></ul><ul><li>DIRECT FLOW TOWARDS OCCIPUT </li></ul><ul><li>USE A KIDNEY TRAY TO COLLECT WASTE WATER </li></ul>
  16. 16. THE NOSE AND PARANASAL SINUSES
  17. 17. DEVIATIONS OF NASAL FRAMEWORK <ul><li>DIFFERENTIATE BETWEEN </li></ul><ul><ul><li>EXTERNAL NASAL DEVIATIONS </li></ul></ul><ul><ul><li>SEPTAL DEVIATIONS </li></ul></ul><ul><ul><li>COMBINED DEVIATIONS </li></ul></ul><ul><li>IS THE DEVIATION RESPONSIBLE FOR THE SYMPTOMS? </li></ul><ul><ul><li>DIFFERENTIATE BETWEEN CONSTANT BLOCKAGE DUE TO DNS Vs SEASONAL OR INTERMITTENT BLOCKAGE DUE TO ALLERGY Vs ACUTE ONSET BLOCKAGE, HEADACHE AND FEVER DUE TO AC RHINOSINUSITIS </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>RHINOPLASTY, SEPTOPLASTY OR SEPTORHINOPLASTY </li></ul></ul>
  18. 18. NASAL BONE FRACTURE <ul><li>DOCUMENT NATURE OF TRAUMA </li></ul><ul><li>LOOK FOR ASSOCIATED MAXILLOFACIAL INJURIES AND INJURIES TO SKULL/SPINE/ CHEST/ EXTREMITIES </li></ul><ul><li>NEVER FORGET ABC OF TRAUMA MANAGEMENT! </li></ul><ul><li>RAISE AN MLC! </li></ul><ul><li>MANAGE NASAL BLEEDING … IF ACTIVE! </li></ul><ul><li>DISPLACED NASAL BONE FRACTURES LEAD TO COSMETIC DEFORMITY… THEY ARE REDUCED IN INITIAL 12 HRS OR AFTER 3 DAYS (UPTO 10 DAYS LATER) </li></ul><ul><li>IF LEFT UNTREATED, DISPLACED NASAL BONE FRACTURES HEAL IN 2-3 WEEKS LEADING TO COSMETIC DEFORMITY AND REQUIRING SEPTORHINOPLASTY AFTER 3 MONTHS </li></ul>
  19. 19. NASAL VESTIBULITIS <ul><li>STAPHYLOCOCCAL INFECTION OF NASAL HAIR FOLLICLES </li></ul><ul><li>INVOLVES DANGER AREA OF FACE </li></ul><ul><li>EXQUISITELY PAINFUL </li></ul><ul><li>TREATMENT </li></ul><ul><ul><li>INJECTABLE ANTIBIOTICS </li></ul></ul><ul><ul><li>ANALGESICS </li></ul></ul><ul><ul><li>TOPICAL ANTIBIOTIC CREAM </li></ul></ul>
  20. 20. INTRANASAL POLYPS <ul><li>DIFFERENTIATE HYPERTROPHIED INFERIOR TURBINATE FROM INTRANASAL POLYPS </li></ul><ul><li>ALLERGIC POLYPS ARE USUALLY BILATERAL, MULTIPLE, AND PALE </li></ul><ul><li>MEDICAL POLYPECTOMY </li></ul><ul><ul><li>SHORT COURSE ORAL STEROID </li></ul></ul><ul><ul><li>INTRANASAL CORTICOSTEROID SPRAY </li></ul></ul><ul><ul><li>ORAL ANTIHISTAMINICS </li></ul></ul><ul><li>SURGICAL MANAGEMENT : FESS </li></ul>
  21. 21. ALLERGIC RHINITIS <ul><li>DIAGNOSIS </li></ul><ul><ul><li>PAROXYSMAL SNEEZING, WATERY RHINORRHOEA,NASAL ITCHING AND STUFFINESS </li></ul></ul><ul><ul><li>SEASONAL OR PERENNIAL </li></ul></ul><ul><ul><li>GENETIC PREDISPOSITION </li></ul></ul><ul><ul><li>OFTEN ASSOC WITH OTHER ATOPIC MANIFESTATIONS IN EYE, EAR AND THROAT ,ALLERGIC POLYPS OR BRONCHIAL ASTHMA </li></ul></ul><ul><ul><li>MAY PROGRESS TO SINUSITIS IF UNTREATED </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>AVOIDANCE OF ALLERGEN </li></ul></ul><ul><ul><li>INTRANASAL CORTICOSTEROID/ ANTIHISTAMINE SPRAYS (FLUTICASONE / AZELASTINE) </li></ul></ul><ul><ul><li>ORAL ANTIHISTAMINICS (CETRIZINE/ FEXOFENADINE) </li></ul></ul><ul><ul><li>ORAL ANTI LEUKOTRIENE (MONTELEUKAST) </li></ul></ul><ul><li>SPECIAL CONSIDERATIONS </li></ul><ul><ul><li>AVOID USE OF TOPICAL DECONGESTANTS LIKE NASIVION/ OTRIVIN … RHINITIS MEDICAMENTOSA! </li></ul></ul><ul><ul><li>LIFELONG TREATMENT MAY BE REQUIRED! </li></ul></ul>
  22. 22. ACUTE SINUSITIS <ul><li>PRESENTATION </li></ul><ul><ul><li>ACUTE INFLAMMATION OF SINUS MUCOSA DUE TO INFECTION </li></ul></ul><ul><ul><li>FEVER, HEADACHE, PURULENT NASAL DISCHARGE, ERYTHEMA AND TENDERNESS OVER AFFECTED SINUSES </li></ul></ul><ul><li>TREATMENT </li></ul><ul><ul><li>ANTIBIOTICS </li></ul></ul><ul><ul><li>ANALGESICS </li></ul></ul><ul><ul><li>TOPICAL DECONGESTANTS </li></ul></ul><ul><ul><li>ANTIHISTAMINICS </li></ul></ul><ul><ul><li>STEAM INHALATION </li></ul></ul>
  23. 23. CHRONIC SINUSITIS AND FESS <ul><li>PRESENTATION </li></ul><ul><ul><li>CHRONICALLY IMPAIRED DRAINAGE OF SINUSES DUE TO INTERACTION OF BACTERIAL OR FUNGAL INFECTION, ALLERGY, ANATOMICAL ABNORMALITIES AND CILIARY DYSFUNCTION </li></ul></ul><ul><ul><li>HEADACHE, PURULENT NASAL DISCHARGE, NASAL STUFFINESS, ANOSMIA </li></ul></ul><ul><li>INVESTIGATIONS MUST INCLUDE SINUS CT SCAN </li></ul><ul><li>TREATMENT </li></ul><ul><ul><li>ONE MONTH TRIAL OF MEDICAL MANAGEMENT </li></ul></ul><ul><ul><li>FUNCTIONAL ENDOSCOPIC SINUS SURGERY </li></ul></ul>
  24. 24. EMERGENCY MANAGEMENT OF EPISTAXIS <ul><li>FIRST AID </li></ul><ul><ul><li>SIT THE PATIENT UPRIGHT AND PINCH THE NOSE (TROTTER’S METHOD) </li></ul></ul><ul><li>IF BLEEDING PERSISTS </li></ul><ul><ul><li>FOR POSTERIOR NASAL BLEEDING INFLATE A FOLEY’S CATHETER IN NASOPHARYNX </li></ul></ul><ul><ul><li>FOR ANTERIOR NASAL BLEEDING DO ANTERIOR NASAL PACKING WITH RIBBON GAUZE OR GELFOAM STRIPS </li></ul></ul><ul><li>IF BLEEDING STOPS SPONTANEOUSLY / MINOR BLEEDING </li></ul><ul><ul><li>DECONGESTANT DROPS, ANTIHISTAMINICS, ANTIBIOTICS </li></ul></ul><ul><li>IF ELDERLY PATIENT WITH HYPERTENSION </li></ul><ul><ul><li>CHECK BLOOD PRESSURE </li></ul></ul><ul><ul><li>ELICIT MEDICATION HISTORY </li></ul></ul><ul><ul><li>RESTART ANTIHYPERTENSIVES </li></ul></ul>
  25. 25. REMOVAL OF NASAL FOREIGN BODIES <ul><li>REMOVE UNDER VISION USING AN EUSTACHIAN CATHETER OR JOBSON HORNE PROBE </li></ul><ul><li>DO NOT PUSH THE FOREIGN BODY FURTHER INTO THE NASOPHARYNX </li></ul><ul><li>CONSIDER SEDATING OR RESTRAINING THE CHILD </li></ul>
  26. 26. THE THROAT
  27. 27. ACUTE TONSILLITIS <ul><li>PRESENTATION </li></ul><ul><ul><li>PAINFUL SORE THROAT </li></ul></ul><ul><ul><li>FEVER </li></ul></ul><ul><ul><li>ODYNOPHAGIA </li></ul></ul><ul><ul><li>TONSILLAR SWELLING </li></ul></ul><ul><ul><li>LYMPHADENOPATHY </li></ul></ul><ul><li>MANAGEMENT </li></ul><ul><ul><li>ANTIBIOTICS </li></ul></ul><ul><ul><li>ANALGESICS </li></ul></ul><ul><ul><li>SALT WATER GARGLES </li></ul></ul>
  28. 28. PERITONSILLAR ABSCESS <ul><li>PRESENTATION </li></ul><ul><ul><li>VERY PAINFUL SORE THROAT </li></ul></ul><ul><ul><li>HIGH FEVER </li></ul></ul><ul><ul><li>MARKED ODYNOPHAGIA – INABILITY TO SWALLOW SALIVA </li></ul></ul><ul><ul><li>HOT POTATO VOICE </li></ul></ul><ul><ul><li>TRISMUS </li></ul></ul><ul><ul><li>SWELLING OF SOFT PALATE, ANTERIOR PILLARS </li></ul></ul><ul><ul><li>TONSIL MAY OR MAY NOT BE ENLARGED </li></ul></ul><ul><ul><li>DEVIATION OF UVULA TO OPPOSITE SIDE </li></ul></ul><ul><ul><li>TORTICOLLIS </li></ul></ul><ul><ul><li>CERVICAL LYMPHADENOPATHY </li></ul></ul><ul><li>MANAGEMENT </li></ul><ul><ul><li>I & D </li></ul></ul><ul><ul><li>ANTIBIOTICS </li></ul></ul><ul><ul><li>ANALGESICS </li></ul></ul><ul><ul><li>SALT WATER GARGLES </li></ul></ul>
  29. 29. CHRONIC TONSILLITIS <ul><li>PRESENTATION </li></ul><ul><ul><li>RECURRENT ATTACKS OF ACUTE TONSILLITIS </li></ul></ul><ul><ul><li>ERYTHEMA OF ANTERIOR PILLARS </li></ul></ul><ul><ul><li>TONSILS MAY SHOW VARYING DEGREE OF ENLARGEMENT </li></ul></ul><ul><ul><li>JUGULODIGASTRIC LYMPHADENOPATHY </li></ul></ul><ul><li>MANAGEMENT </li></ul><ul><ul><li>TONSILLECTOMY </li></ul></ul>
  30. 30. FOREIGN BODY OESOPHAGUS <ul><li>PRESENTATION </li></ul><ul><ul><li>TYPICAL HISTORY OF INGESTION </li></ul></ul><ul><ul><li>DYSPHAGIA, DROOLING </li></ul></ul><ul><ul><li>BEWARE OF HOARSENESS, DYSPNOEA, STRIDOR … THESE MAY INDICATE FOREIGN BODY IN AIRWAY </li></ul></ul><ul><li>MANAGEMENT </li></ul><ul><ul><li>X RAY NECK, CHEST AP AND LATERAL </li></ul></ul><ul><ul><li>ASK FOR TIME OF LAST MEAL, DRINK </li></ul></ul><ul><ul><li>KEEP NIL ORALLY IF OPERATIVE INTERVENTION PLANNED </li></ul></ul><ul><ul><li>FISH BONES ARE USUALLY RADIOLUCENT, SMALL CHICKEN BONES MAY BE OBSCURED </li></ul></ul><ul><ul><li>OESOPHAGOSCOPY IS THE GOLD STANDARD INVESTIGATION </li></ul></ul><ul><ul><li>IF THE FB HAS REACHED THE STOMACH, IT WILL USUALLY PASS OUT WITHOUT DIFFICULTY! </li></ul></ul>
  31. 31. EMERGENCY AIRWAY MANAGEMENT <ul><li>FIRST CONSIDER </li></ul><ul><ul><li>JAW THRUST </li></ul></ul><ul><ul><li>OROPHARYNGEAL AIRWAY </li></ul></ul><ul><ul><li>AMBU BAG </li></ul></ul><ul><ul><li>INTUBATION </li></ul></ul><ul><ul><li>LARYNGEAL MASK AIRWAY </li></ul></ul><ul><li>TRACHEOSTOMY </li></ul><ul><ul><li>INVOLVES INCISION OF SKIN, SEPARATION OF STRAP MUSCLES, DIVISION OF THYROID ISTHMUS, OPENING OF TRACHEA AND FIXATION OF TRACHEOSTOMY TUBE </li></ul></ul><ul><ul><li>PLANNED PROCEEDURE TAKES MINIMUM 20 MIN – 1 HR </li></ul></ul><ul><li>CRICOTHYROTOMY </li></ul><ul><ul><li>PROVIDES INSTANT AIRWAY </li></ul></ul><ul><ul><li>REQUIRES NO SPECIAL TRAINING OR EQPT </li></ul></ul><ul><ul><li>OPENING MADE IN CRICO THYROID MEMBRANE </li></ul></ul>
  32. 32. RESOURCES <ul><li>DISEASES OF EAR, NOSE AND THROAT 5 TH ED: PL DHINGRA. ELSEVIER INDIA </li></ul><ul><ul><li>E VERSION AVAILABLE FROM http://www.filefactory.com/file/cca0cf0/n/Diseases_of_Ear_Nose_and_Throat_5th_Pg.chm </li></ul></ul><ul><li>THIS PRESENTATION IS AVAILABLE FROM </li></ul><ul><li>www.slideshare.net </li></ul><ul><li>CREATED UNDER CREATIVE COMMONS LICENCE FOR NON COMMERCIAL USE </li></ul><ul><li>ALL IMAGES DOWNLOADED FROM THE INTERNET AND COPYRIGHT OF ORIGINAL OWNERS! </li></ul>

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