Ent for the primary care provider.

Edoardo Cervoni, M.D.
(T)GP & Ear Nose Throat Specialist
Director: Locumdoctor4u Ltd.

24 February 2014

GP Trainees - Education Centre, RPH

1

Discolosures
 Grant/Research Support: no disclosure
 Consultant: no disclosure
 Major Shareholder: Locumdoctor4u Ltd.
 I will not be discussing “off-label” uses of medications

or investigations

24 February 2014


2

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

24 February 2014


3

ENT Referrals
i.
ii.

Snoring and sleep apnoea were relatively common reasons of referrals.
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.

CLPCT NHS Survey 2011 – E Cervoni

24 February 2014


4

Conditions referred

Cervoni E - 2011

24 February 2014


5

ENT Referral Pattern is changing

WHY?
Ageing – Sanitation Vaccinations
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6

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.
24 February 2014


7

The Rise of Hearing Loss
• There are more

than 10 million
people in the UK
with some form of
hearing loss, or one
in six of the
population.
• From the total 3.7
million are of
working age (16 –
64) and 6.3 million
are of retirement
age (65+).
24 February 2014


8

24 February 2014


‹#›

Rinne Test

24 February 2014


10

Bing & Schwabach Test
 Bing test is a qualitative

 Schwabach test is a test

test of bilateral
conductive involvement.
 Tragal compression to
cause EAC obstruction
when patient cannot
hear any longer sound
from mastoid.
 If tone caomes back, to
be marked as negative.

of air-conduction
thresholds.
 The number of seconds
is counted while the tone
is still heard

24 February 2014


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Spatial mapping
 In cases where

disparities exist between
hearing tresholds, the
patients will typically
gave difficulty finding
midline.
 Binaural integration may
be achieved.

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 Sensory Presbycusis
 High frequency down-

sloping SNHL
 Speech discrimination
remains good
 Degeneration a basal
potion of Organ of Corti
(predominately outer
hair cells)
 Neural presbycusis
 Flat audiogram
 Rapid hearing loss
 Poor speech
discrimination
 Loss of spiral ganglion
cells

24 February 2014

Metabolic Presbycusis
Slowly progressive
Flat audiogram
Good speech discrimination
Atrophy of stria vascularis
Conductive Presbycusis
Thickening of basilar membrane
Gradual down-sloping high
frequency hearing loss
Progressive
Speech discrimination for similar
pure tone hearing is worse in older
patients than younger patients


13

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.
24 February 2014


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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)
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Objective -Pulsatile tinnitus
 Arteriovenous








malformations (AVM)
Vascular tumors
Venous hum
Atherosclerosis
Ectopic carotid artery
Persistent stapedial
artery
Dehiscent jugular bulb
Vascular loops

24 February 2014








Cardiac murmurs
Pregnancy
Anemia
Thyrotoxicosis
Paget’s disease
Benign intracranial
hypertension

Idiopathic stapedial muscle spasm
Palatal myoclonus
Patulous eustachian tube


16

Subjective tinnitus
 Presbycusis
 Noise exposure
 Meniere’s disease
 Otosclerosis
 Head trauma
 Acoustic neuroma
 Drugs (i.e.: aspirin,

quinine, AG, loop
diuretics)

24 February 2014

 Middle ear effusion
 TMJ problems
 Depression
 Hyperlipidemia
 Meningitis
 Syphilis
 Foods (i.e.: caffeine,


alcohol)

17

Treatments
 Multiple treatments

 Reassurance

 Avoidance of dietary

 White noise from

stimulants: coffee, tea,
cola, etc.
 Smoking cessation
 Avoid medications
known to cause tinnitus

24 February 2014


radio or home
masking machine

18

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
24 February 2014


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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
24 February 2014


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Non-labyrinthine balance disorders
 CEREBELLAR

 METABOLIC












DEGENERATION
PARKINSON’S DISEASE
HUNTINGTON’S DISEASE
SPINAL CORD TUMORS
POSTURAL
HYPOTENSION
CEREBROVASCULAR
DISEASE
ATHEROSCLEROSIS
MUSCULOSKELETAL
DISEASE

24 February 2014









DISORDERS
CARDIOVASCULAR
DISORDERS
MEDICATIONS
B12 DEFICIENCY
DEMENTIA
DIABETIC
NEUROPATHY
VISUAL IMPAIRMENT
ALCOHOL
21

Vestibular system assessment
 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

24 February 2014


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Treatments

24 February 2014


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

24 February 2014


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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

24 February 2014


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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)

24 February 2014


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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
24 February 2014


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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
24 February 2014


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Causes of dysphagia
 Stroke
 Neuromuscular disease - Parkinson’s disease (pillrolling 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
24 February 2014


29

Treatments






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

24 February 2014


30

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

24 February 2014


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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

24 February 2014


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Neurological disorders with voice changes
 Essential tremor
 Parkinson’s disease: low volume, breathy, and

monotonic
 Stroke
 Myasthenia gravis
 Amyotrophic lateral sclerosis

24 February 2014


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

24 February 2014


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Head & Neck Cancers
 Squamous cell cancers
 Thyroid malignancies
 Well differentiated have worse course
 Anaplastic or undifferentiated more common
 Salivary gland malignancies
 Lymphomas

24 February 2014


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Laryngeal Cancer – UK

24 February 2014


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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

24 February 2014


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Face ageing
 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
24 February 2014


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Surgical correction
 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

24 February 2014


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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

24 February 2014


40

1.

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13.

Parham K, Lin FR, Coelho DH, Sataloff RT, Gates GA. Comprehensive Management of Presbycusis: Central and Peripheral. Otolaryngol
Head Neck Surg. 2013 Feb 8.
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.
Dagan E, Wolf M, Migirov LM. Why do geriatric patients attend otolaryngology emergency rooms? Isr Med Assoc J. 2012 Oct;14(10):6336.
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.
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.
Chalian AA. Accomplishment and opportunity in geriatric otolaryngology. Ear Nose Throat J. 2009 Oct;88(10):1156-61.
Goldstein JC. The American Society of Geriatric Otolaryngology. Ear Nose Throat J. 2007 Dec;86(12):718-9.
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.
Bora H, Bandyopadhyay SN, Basu SK, Majhi PK. Geriatric problems in otolaryngology. J Indian Med Assoc. 2004 Jul;102(7):366, 368, 370.
Review.
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.
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.
Sahoo GC. Gerontology in ENT (Geriatric Otolaryngology) - an over view. Indian J Otolaryngol Head Neck Surg. 2001 Oct;53(4):267-9.
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.

24 February 2014


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