ENT IN GENERAL PRACTICEA QUICK GUIDE TO MANAGING COMMON CONDITIONS

LT COL KABIR BAKSHICLASSIFIED SPECIALIST (ENT)

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?

ESSENTIAL EQUIPMENT

• OTOSCOPE• TORCH• TONGUE DEPRESSOR• THUDICUM NASAL

SPECULUM• ARTERY FORCEPS• JOBSON HORNE PROBE

OR EUSTACHIAN CATHETER

THE NORMAL EAR

DISORDERS OF THE PINNA

BAT EAR MICROTIA PREAURICUARTAGS

PREAURICULARSINUS

DIAGNOSIS : SPOT!TREATMENT: SURGERY

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

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

DISORDERS OF EAR CANAL

WAX EAR (RT) OTOMYCOSIS (LT)TREATMENT : WAX SOFTENING DROPSFOLLOWED BY SYRINGING AFTER ONE WEEK TREATMENT : ANTIFUNGAL EAR DROPS

CAUTION : ALL EAR DROPS ARE NOT EQUIVALENT!!!

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!

DISORDERS OF MIDDLE EARACUTE 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

DISORDERS OF MIDDLE EARSEROUS 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

DISORDERS OF MIDDLE EARCHRONIC 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

DISORDERS OF MIDDLE EAR

TYMPANOSCLEROSIS

Vs

OTOSCLEROSIS

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 AVAILABLEFREE OF COST TO SERVING PERS/DEPENDENTS AS WELL AS ECHS MEMBERS/ DEPENDENTSUPTO 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!

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

THE NOSE AND PARANASAL SINUSES

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

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

NASAL VESTIBULITIS

• STAPHYLOCOCCAL INFECTION OF NASAL HAIR FOLLICLES

• INVOLVES DANGER AREA OF FACE

• EXQUISITELY PAINFUL• TREATMENT

– INJECTABLE ANTIBIOTICS– ANALGESICS– TOPICAL ANTIBIOTIC CREAM

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

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!

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

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

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

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

THE THROAT

ACUTE TONSILLITIS

• PRESENTATION– PAINFUL SORE THROAT– FEVER– ODYNOPHAGIA– TONSILLAR SWELLING– LYMPHADENOPATHY

• MANAGEMENT– ANTIBIOTICS– ANALGESICS– SALT WATER GARGLES

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

CHRONIC TONSILLITIS

• PRESENTATION– RECURRENT ATTACKS OF ACUTE

TONSILLITIS – ERYTHEMA OF ANTERIOR PILLARS– TONSILS MAY SHOW VARYING

DEGREE OF ENLARGEMENT– JUGULODIGASTRIC

LYMPHADENOPATHY

• MANAGEMENT– TONSILLECTOMY

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!

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

RESOURCES• DISEASES OF EAR, NOSE AND THROAT 5TH

ED: PL DHINGRA. ELSEVIER INDIA– E VERSION AVAILABLE FROM

http://www.filefactory.com/file/cca0cf0/n/Diseases_of_Ear_Nose_and_Throat_5th_Pg.chm

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