ent for general practitioner

1. ENT IN GENERAL PRACTICE
A QUICK GUIDE TO MANAGING COMMON CONDITIONS
V d prasanna kumar
CLASSIFIED SPECIALIST (ENT)

2. THE DILEMMA
ENT IS A NICHE SPECIALITY YET
MANY ENT CONDITONS ARE
NOT UNCOMMON !
– HOW TO DIAGNOSE?
– HOW TO TREAT?
– IS THIS CONDITION SERIOUS?
– WHEN TO REFER?
– WHEN TO WAIT?

3. ESSENTIAL EQUIPMENT
• OTOSCOPE
• TORCH
• TONGUE DEPRESSOR
• THUDICUM NASAL
SPECULUM
• ARTERY FORCEPS
• JOBSON HORNE PROBE
OR EUSTACHIAN
CATHETER

4. THE NORMAL EAR

5. DISORDERS OF THE PINNA
BAT EAR MICROTIA PREAURICUAR
TAGS
PREAURICULAR
SINUS
DIAGNOSIS : SPOT!
TREATMENT: SURGERY

6. DISORDERS OF THE PINNA
AURICULAR HEMATOMA KELOID
• DUE TO MINOR TRAUMA
• COMMON IN WRESTLERS
• TREATMENT : I & D
• PRONE TO RECURRENCE
• FOLLOWS TRAUMA/ PIERCING
• TREATMENT : EXCISION
• PRONE TO RECURRENCE
• REQUIRES POSTOP INTRALESIONAL
STEROID INJECTION

7. DISORDERS OF EAR CANAL
FURUNCULOSIS OF EAR CANAL (OTITIS EXTERNA)
• CAUSE : STREPTOCOCCAL / STAPHYLOCOCCAL INFECTION OF SKIN OF EAC
• TREATMENT : ANTIBIOTICS, ANALGESICS
• MAY BE ASSOCIATED WITH UNTREATED MIDDLE EAR INFECTION

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. DISORDERS OF MIDDLE EAR
TRAUMATIC PERFORATION
• DIAGNOSIS
– HISTORY OF TRAUMA
– RAGGED EDGES OF PERFORATION
– FRESH BLEEDING
• TREATMENT
– NO EAR DROPS
– KEEP EAR DRY
– ORAL ANTIBIOTICS, ANTIHISTAMINICS
– REVIEW AFTER ONE MONTH
• IF DUE TO NOISE OF MIL
WEAPONS… IT IS IMPULSE NOISE
TRAUMA… INNER EAR NEEDS
EVALUATION FOR NIHL!

10. DISORDERS OF MIDDLE EAR
ACUTE SUPPURATIVE OTITIS MEDIA
• STAGES
– TUBAL OCCLUSION
– PRESUPPURATION
– SUPPURATION
– DISCHARGE/RESOLUTION/ COMPLICATIONS
• TREATMENT
– ORAL ANTIBIOTICS
– ANALGESICS
– ANTIHISTAMINICS
– NASAL DECONGESTANTS
– FOLLOWUP
• SPECIAL CONSIDERATIONS
– ROLE OF EAR DROPS
– MYRINGOTOMY

11. DISORDERS OF MIDDLE EAR
SEROUS OTITIS MEDIA (GLUE EAR/
OME)
• SYMPTOMS
– INSIDIOUS ONSET, LONG STANDING
CONDITON (3 MONTHS)
– HEARING LOSS
– OCCASSIONAL OTALGIA
– BUBBLING SOUNDS, ECHO OF OWN VOICE
• TREATMENT
– CORTICOSTEROID / ANTIHISTAMINIC NASAL
SPRAYS
– ORAL DECONGESTANTS / ANTIHISTAMINICS
– CHEWING GUM, BLOWING BALLOONS
– MYRINGOTOMY AND GROMMET INSERTION
• SPECIAL CONSIDERATIONS
– ROLE OF ADENOTONSILLECTOMY
– ROLE OF TEMPORARY HEARING AID
– DIFFERENTIATION FROM AOM WITH
EFFUSION

12. DISORDERS OF MIDDLE EAR
CHRONIC OTITIS MEDIA
• CLASSIFICATION
– MUCOSAL
• ACTIVE
• INACTIVE
– SQUAMOUS
• TREATMENT
– DRY THE EAR
• TOPICAL ANTIBIOTIC/ STEROID EAR DROPS
• ORAL ANTIHISTAMINICS
– OPERATE THE EAR
• SAFE,DRY,FUNCTIONING EAR
• SPECIAL CONSIDERATIONS
– COMPLICATIONS OF COM
– RESULTS OF SURGERY
– RESTORATION OF HEARING

13. DISORDERS OF MIDDLE EAR
TYMPANOSCLEROSIS
Vs
OTOSCLEROSIS

14. DISORDERS OF INNER EAR
• SENSORINEURAL HEARING LOSS
– SUDDEN
– NOISE INDUCED
– PRESBYACUSIS
– UNILATERAL
• EMERGENCY Mx OF SUDDEN SNHL
– TAB PREDNISOLONE 60 mg/day
– TAB ACYCLOVIR 400 mg 4 hrly
– LOW MOLECULAR WEIGHT DEXTRAN
(LOMODEX) 250 ml 12 hrly
– TAB BETAHISTINE (VERTIN) 16 mg 8 hrly
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. SYRINGING THE EAR
• USEFUL FOR WAX REMOVAL,
FOREIGN BODY REMOVAL
• USE 50 ml SYRINGE, LARGE BORE IV
CANNULA
• WATER AT BODY TEMPERATURE TO
AVOID CALORIC EFFECT
• COUNSEL PATIENT BEFOREHAND
• AVOID OVERINSERTION
• DIRECT FLOW TOWARDS OCCIPUT
• USE A KIDNEY TRAY TO COLLECT
WASTE WATER

16. THE NOSE AND PARANASAL SINUSES

17. DEVIATIONS OF NASAL FRAMEWORK
• DIFFERENTIATE BETWEEN
– EXTERNAL NASAL DEVIATIONS
– SEPTAL DEVIATIONS
– COMBINED DEVIATIONS
• IS THE DEVIATION RESPONSIBLE
FOR THE SYMPTOMS?
– 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
• TREATMENT
– RHINOPLASTY, SEPTOPLASTY OR
SEPTORHINOPLASTY

18. NASAL BONE FRACTURE
• DOCUMENT NATURE OF TRAUMA
• LOOK FOR ASSOCIATED MAXILLOFACIAL
INJURIES AND INJURIES TO SKULL/SPINE/
CHEST/ EXTREMITIES
• NEVER FORGET ABC OF TRAUMA
MANAGEMENT!
• RAISE AN MLC!
• MANAGE NASAL BLEEDING … IF ACTIVE!
• DISPLACED NASAL BONE FRACTURES LEAD TO
COSMETIC DEFORMITY… THEY ARE REDUCED
IN INITIAL 12 HRS OR AFTER 3 DAYS (UPTO 10
DAYS LATER)
• IF LEFT UNTREATED, DISPLACED NASAL BONE
FRACTURES HEAL IN 2-3 WEEKS LEADING TO
COSMETIC DEFORMITY AND REQUIRING
SEPTORHINOPLASTY AFTER 3 MONTHS

19. NASAL VESTIBULITIS
• STAPHYLOCOCCAL INFECTION OF
NASAL HAIR FOLLICLES
• INVOLVES DANGER AREA OF FACE
• EXQUISITELY PAINFUL
• TREATMENT
– INJECTABLE ANTIBIOTICS
– ANALGESICS
– TOPICAL ANTIBIOTIC CREAM

20. INTRANASAL POLYPS
• DIFFERENTIATE HYPERTROPHIED
INFERIOR TURBINATE FROM
INTRANASAL POLYPS
• ALLERGIC POLYPS ARE USUALLY
BILATERAL, MULTIPLE, AND PALE
• MEDICAL POLYPECTOMY
– SHORT COURSE ORAL STEROID
– INTRANASAL CORTICOSTEROID SPRAY
– ORAL ANTIHISTAMINICS
• SURGICAL MANAGEMENT : FESS

21. ALLERGIC RHINITIS
• DIAGNOSIS
– PAROXYSMAL SNEEZING, WATERY
RHINORRHOEA,NASAL ITCHING AND STUFFINESS
– SEASONAL OR PERENNIAL
– GENETIC PREDISPOSITION
– OFTEN ASSOC WITH OTHER ATOPIC MANIFESTATIONS
IN EYE, EAR AND THROAT ,ALLERGIC POLYPS OR
BRONCHIAL ASTHMA
– MAY PROGRESS TO SINUSITIS IF UNTREATED
• TREATMENT
– AVOIDANCE OF ALLERGEN
– INTRANASAL CORTICOSTEROID/ ANTIHISTAMINE
SPRAYS (FLUTICASONE / AZELASTINE)
– ORAL ANTIHISTAMINICS (CETRIZINE/ FEXOFENADINE)
– ORAL ANTI LEUKOTRIENE (MONTELEUKAST)
• SPECIAL CONSIDERATIONS
– AVOID USE OF TOPICAL DECONGESTANTS LIKE NASIVION/
OTRIVIN … RHINITIS MEDICAMENTOSA!
– LIFELONG TREATMENT MAY BE REQUIRED!

22. ACUTE SINUSITIS
• PRESENTATION
– ACUTE INFLAMMATION OF SINUS
MUCOSA DUE TO INFECTION
– FEVER, HEADACHE, PURULENT NASAL
DISCHARGE, ERYTHEMA AND
TENDERNESS OVER AFFECTED SINUSES
• TREATMENT
– ANTIBIOTICS
– ANALGESICS
– TOPICAL DECONGESTANTS
– ANTIHISTAMINICS
– STEAM INHALATION

23. CHRONIC SINUSITIS AND FESS
• PRESENTATION
– CHRONICALLY IMPAIRED DRAINAGE
OF SINUSES DUE TO INTERACTION OF
BACTERIAL OR FUNGAL INFECTION,
ALLERGY, ANATOMICAL
ABNORMALITIES AND CILIARY
DYSFUNCTION
– HEADACHE, PURULENT NASAL
DISCHARGE, NASAL STUFFINESS,
ANOSMIA
• INVESTIGATIONS MUST INCLUDE
SINUS CT SCAN
• TREATMENT
– ONE MONTH TRIAL OF MEDICAL
MANAGEMENT
– FUNCTIONAL ENDOSCOPIC SINUS
SURGERY

24. EMERGENCY MANAGEMENT OF
EPISTAXIS
• FIRST AID
– SIT THE PATIENT UPRIGHT AND PINCH THE NOSE
(TROTTER’S METHOD)
• IF BLEEDING PERSISTS
– FOR POSTERIOR NASAL BLEEDING INFLATE A
FOLEY’S CATHETER IN NASOPHARYNX
– FOR ANTERIOR NASAL BLEEDING DO ANTERIOR
NASAL PACKING WITH RIBBON GAUZE OR
GELFOAM STRIPS
• IF BLEEDING STOPS SPONTANEOUSLY /
MINOR BLEEDING
– DECONGESTANT DROPS, ANTIHISTAMINICS,
ANTIBIOTICS
• IF ELDERLY PATIENT WITH HYPERTENSION
– CHECK BLOOD PRESSURE
– ELICIT MEDICATION HISTORY
– RESTART ANTIHYPERTENSIVES

25. REMOVAL OF NASAL FOREIGN BODIES
• REMOVE UNDER VISION USING
AN EUSTACHIAN CATHETER OR
JOBSON HORNE PROBE
• DO NOT PUSH THE FOREIGN
BODY FURTHER INTO THE
NASOPHARYNX
• CONSIDER SEDATING OR
RESTRAINING THE CHILD

26. THE THROAT

27. ACUTE TONSILLITIS
• PRESENTATION
– PAINFUL SORE THROAT
– FEVER
– ODYNOPHAGIA
– TONSILLAR SWELLING
– LYMPHADENOPATHY
• MANAGEMENT
– ANTIBIOTICS
– ANALGESICS
– SALT WATER GARGLES

28. PERITONSILLAR ABSCESS
• PRESENTATION
– VERY PAINFUL SORE THROAT
– HIGH FEVER
– MARKED ODYNOPHAGIA – INABILITY TO
SWALLOW SALIVA
– HOT POTATO VOICE
– TRISMUS
– SWELLING OF SOFT PALATE, ANTERIOR
PILLARS
– TONSIL MAY OR MAY NOT BE ENLARGED
– DEVIATION OF UVULA TO OPPOSITE SIDE
– TORTICOLLIS
– CERVICAL LYMPHADENOPATHY
• MANAGEMENT
– I & D
– ANTIBIOTICS
– ANALGESICS
– SALT WATER GARGLES

29. CHRONIC TONSILLITIS
• PRESENTATION
– RECURRENT ATTACKS OF ACUTE
TONSILLITIS
– ERYTHEMA OF ANTERIOR PILLARS
– TONSILS MAY SHOW VARYING
DEGREE OF ENLARGEMENT
– JUGULODIGASTRIC
LYMPHADENOPATHY
• MANAGEMENT
– TONSILLECTOMY

30. FOREIGN BODY OESOPHAGUS
• PRESENTATION
– TYPICAL HISTORY OF INGESTION
– DYSPHAGIA, DROOLING
– BEWARE OF HOARSENESS,
DYSPNOEA, STRIDOR … THESE MAY
INDICATE FOREIGN BODY IN AIRWAY
• MANAGEMENT
– X RAY NECK, CHEST AP AND LATERAL
– ASK FOR TIME OF LAST MEAL, DRINK
– KEEP NIL ORALLY IF OPERATIVE
INTERVENTION PLANNED
– FISH BONES ARE USUALLY
RADIOLUCENT, SMALL CHICKEN
BONES MAY BE OBSCURED
– OESOPHAGOSCOPY IS THE GOLD
STANDARD INVESTIGATION
– IF THE FB HAS REACHED THE
STOMACH, IT WILL USUALLY PASS
OUT WITHOUT DIFFICULTY!

31. EMERGENCY AIRWAY MANAGEMENT
• FIRST CONSIDER
– JAW THRUST
– OROPHARYNGEAL AIRWAY
– AMBU BAG
– INTUBATION
– LARYNGEAL MASK AIRWAY
• TRACHEOSTOMY
– INVOLVES INCISION OF SKIN, SEPARATION
OF STRAP MUSCLES, DIVISION OF THYROID
ISTHMUS, OPENING OF TRACHEA AND
FIXATION OF TRACHEOSTOMY TUBE
– PLANNED PROCEEDURE TAKES MINIMUM
20 MIN – 1 HR
• CRICOTHYROTOMY
– PROVIDES INSTANT AIRWAY
– REQUIRES NO SPECIAL TRAINING OR EQPT
– OPENING MADE IN CRICO THYROID
MEMBRANE

32. RESOURCES
• DISEASES OF EAR, NOSE AND THROAT 5TH
ED: PL DHINGRA. ELSEVIER INDIA
– E VERSION AVAILABLE FROM
http://www.filefactory.com/file/cca0cf0/n/Diseas
es_of_Ear_Nose_and_Throat_5th_Pg.chm
• THIS PRESENTATION IS AVAILABLE FROM
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OWNERS!