introduction to the assessment and management of ENT problems

1. ENT Problems

2. ENT Problems
Nasal problems: injury, epistaxis, foreign body, sinusitis
Throat / mouth: sore throat, foreign body, mouth wounds, dental abscess
Ear: Infections, foreign body.

3. Nasal Injury
• Think head injury (i.e. record neuro observations as per local policy)
• Often appear swollen and deformed
• Observe for septal haematoma (‘cherry’) refer to appropriate ENT care
pathway
• Control any epistaxis with simple pressure
• If clinically deformed refer for ENT opinion via booked appointment
system

4. Epistaxis
• Common in all age groups
• Triggers:
 Hypertension
 hayfever
 anticoagulants
 nasal polyps / pathology
• Patients often become faint.

5. Epistaxis
• Simple pressure measures initially (10 minutes squeezing nostrils)
• If vessels visible silver nitrate stick may be used to cauterise this
• Consider packing short or long term
• Intravenous fluids if shocked.

6. Foreign Bodies In The Nose
• Encourage blowing
• ‘Milk’ the soft tissue
• ‘Magic Kiss’ (Backlin 1995)
• Negative pressure - suction
• Angled forceps.

7. Magic Kiss
• Described by Backlin in 1995
• Easy technique for parents to try
• Foreign body in left nostril – occlude right nostril, parent blows sharply
into the child’s mouth. Positive pressure pushes the object out
• Repeat until successful or try alternatives.

8. Throat
Why do patients attend with throat problems?
• Pain
• Swelling
• Unable to swallow
• Direct trauma
• Foreign body.

9. Sore Throat
• Usually viral infection
• Feel glands: hard and tender signifies more severe
infection
• Any drooling, inability to swallow own saliva is significant
• Antibiotics rarely necessary.

10. Sore Throat - Treatment
• Aspirin gargle
• Simple analgesia paracetamol / ibuprofen
• Consider glandular fever in a teenager (if symptoms greater than one
week)
• Consider antibiotics if:
 history of fever
 swollen glands
 pus on tonsils.

11. Foreign Bodies In Throat
• Often fish bone
• Panic often ensues / airway risk is minimal
• Consider X-ray (if radio-opaque foreign body is suspected)
• There may be a ‘scratch sensation’
• Remove with magill forceps if visualised
• Consider need for ENT assessment / laryngoscopy in problematic
cases

12. Mouth / Lip Wounds
• Bitten tongue – very vascular
• Deep wounds may require closure
• Most wounds will heal in a few days even if large
• Wounds through vermillion border – most require plastics referral
• Oral hygiene advice.

13. Dental Problems
• Teeth which have been knocked out can be preserved in milk and
replaced in it’s cavity
• Dental pain: redness, swelling, local tooth decay
• Where systemic symptoms / excess pain exists: Antibiotics and
analgesia
 Flucloxacillin / metronidazole
• Refer to own dentist.

14. Ear Problems
Why do patients present with ear problems?
 Pain
 Discharge
 Hearing loss
 Foreign bodies
 Direct trauma.

15. The Anatomy Of The Ear
Using diagrams and/or models work through the anatomy of the ear and
adjoining structures

16. External Ear
Trauma:
• wounds can usually be closed by conventional methods (glue, suture)
• thorough cleansing if cartilage is involved
• blunt trauma can lead to haematoma
• remember permanent damage to the ear is always on show, so have a
low threshold for referral.

17. External Ear
Acute Otitis Externa:
• red and itchy / uncomfortable in external meatus
• unusual to see discharge (swab if present)
• worsens when ear wet – cotton wool with Vaseline to keep water out of
ear canal
• can use antibiotic drops (otosporin) or systemic antibiotics for seven
days.

18. External Ear
Foreign bodies:
• Often children or adults with special needs
• need to have good co-operation from the patient before attempting
removal, be aware of the dangers of rupturing tympanic membrane
• usually only one attempt before referring to ENT clinic for removal
• live insects need to be drowned with an oil based liquid

19. Foreign Bodies In The Ear
• Cotton bud is usually the culprit
• Visualise with auroscope
• Attempt removal using a loop / hook
• If a solid deep object e.g. marble - attempt removal with liquid if
eardrum intact
• If unsettled refer to next ENT clinic.

20. Middle Ear
Acute Otitis Media:
• mainly viral – 60% of patients pain free within 24 hours
• inflamed / red ear drum, slight hearing loss, possible perforation
• steam (shower / head over sink) improves eustachian blood flow and
symptoms
• antibiotics if under two otherwise simple analgesia.

21. Summary
• Common presentations
• In infection, antibiotics are restricted to severe cases
• Good advice is important.