ENT inPrimary Care

A Concise Guide

Edoardo CervoniKim Leech

123

ENT in Primary Care

Edoardo Cervoni • Kim Leech

ENT in Primary Care

A Concise Guide

ISBN 978-3-319-51986-9 ISBN 978-3-319-51987-6 (eBook)DOI 10.1007/978-3-319-51987-6

Library of Congress Control Number: 2017935364

© Springer International Publishing AG 2017This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed.The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Printed on acid-free paper

This Springer imprint is published by Springer NatureThe registered company is Springer International Publishing AGThe registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Edoardo CervoniENT SpecialistCentral Park SurgeryLeylandLancashireUK

Kim LeechAdvanced Nurse PractitionerCentral Park SurgeryLeylandLancashireUK

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Preface

ENT disease represents a significant percentage of the day-to-day cases seen in primary care – approximately 1 in 4 consultations. Research suggests this figure is between 23% (Cross and Rimmer 2007) and 25% (Lloyd et al. 2014) of all primary care presen-tations. Unfortunately, the educational curriculum of the medical schools and family doctor/GP training programs do not parallel the high prevalence of ENT disease. As a result, health care professionals such as GPs and nurse practitioners (NPs) may refer many patients to secondary care with ENT problems when they could handle them in primary care. It is legitimate to assume that a better understanding of the clinical his-tory, clinical examination and accurate management of ENT disease might lead to a better management of the ENT patient and a reduction in the number of specialist appointments requested in general practice. This book is not a complete compendium of otolaryngology. Instead, it is intended to be a practical guide for the primary care provider. The topics covered are common and the ENT disease management is the one you would expect to take place in a primary care setting. The use of ENT diagnostic instrumentation refers to what should be available in any GP surgery. We think this book is a useful addition to the library of medical students, GPs in training, board certi-fied family physicians and NPs. Its format is simple and the text is minimal. The topics are organized in such a way as to highlight when a patient should be sent to a specialist immediately and when they can be efficiently managed in general practice.

Leyland, Lancashire, UK Edoardo CervoniLeyland, Lancashire, UK Kim Leech

References

1. Cross S, Rimmer M (2007) Nurse practitioner manual of clinical skills, 2nd edn. Elsevier, London

2. Lloyd S, Tan ZE, Taube MA, Doshi J (2014) Development of an ENT undergraduate curricu-lum using a Delphi survey. Clin Otolaryngol 39:281–288

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Acknowledgements

We would wish to personally thank the following people for their contributions to our inspiration and knowledge and other help in creating this book.

Dr. Cervoni would like to thank the many people who have brought him this far. They are his relatives, teachers, and colleagues he had the pleasure to work with over the years, but especially his very much loved children, Oliver Alessandro and Francesca, with the infinite love that they give every day.

Mrs. Kim Leech would like to acknowledge her parents, Mark and Brenda Jagger, for her upbringing, their support and encouragement, her husband, Ashley, for his continued support and constant belief and her beautiful daughter, Maddison.

Finally, we would like to thank the patients for their trust and for having shared their experience of living with the most diverse ENT pathologies.

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Abbreviations

AIDS Acquired immune deficiency syndromeAOM Acute otitis mediaBD Twice a dayBPPV Benign paroxysmal positional vertigoCHL Conductive hearing lossCSF Cerebrospinal fluidEAC External auditory canalENT Ears, nose and throatHIV Human immunodeficiency virusNSAID Nonsteroidal anti-inflammatory drugRAST Radioallergosorbent testSNHL Sensorineural hearing lossTDS Three times a dayTIA Transient ischaemic attackTMJ Temporomandibular joint

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Contents

1 ENTAnamnesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1The ENT Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

ENT History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1History of Presenting Complaint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Past Medical History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Drug History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Social History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Otology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Organ Targeted History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

The Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Ear Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Otoscope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Tuning Forks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Frenzel Goggles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Ear Syringe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Otological Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Otalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Causes of Referred Otalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Local Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Otitis Externa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Acute Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Consequences of Viral and Bacterial Otitis Media . . . . . . . . . . . . . . . . . 16Ear Secretions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Otitis Externa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Middle Ear Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Trauma or Foreign Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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Management of Ear Secretions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Perforation of Tympanic Membrane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Cholesteatoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Child Deafness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

With Otalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Without Otalgia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Adult Deafness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Hearing Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Rinne Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Weber Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Evaluation of Auditory Function by GP . . . . . . . . . . . . . . . . . . . . . . . . . 30Services for Patients with Hearing Loss . . . . . . . . . . . . . . . . . . . . . . . . . 30

Vestibular System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Smooth Pursuit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Saccades . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Head-Shaking Nystagmus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Fukuda Stepping Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Hallpike Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Tinnitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Subjective Tinnitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Objective Tinnitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Objective Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Subjective Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Fistula Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Benign Paroxysmal Positional Vertigo (BPPV) . . . . . . . . . . . . . . . . . . . 38

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

3 Rhinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39The Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Nose Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Dentist Mirror or a Cosmetic Mirror . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Silver Nitrate Sticks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Nose Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Epistaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Epistaxis in the Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Epistaxis in Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Nasal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Allergic Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45Vasomotor Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47Nasal Polyps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48Allergy Testing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Contents

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Septal Deviation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Inspiratory Nasal Valve Collapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Nasopharyngeal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Sinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Recurring Rhinosinusitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

4 Laryngology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55The Throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Mouth and Throat Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Sore Throat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Other Causes of Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Tonsillitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Hoarseness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Acute Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Progressive Dysphagia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Other Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Globus Pharyngeus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Snoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Key Anamnestic Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

5 HeadandNeck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69The Oral Cavity and the Neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Neck Lump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69Salivary Gland Lump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Facial Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Herpes Zoster . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Bell’s Palsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Other Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

6 Post-operativeORL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Adenoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Trans-tympanic Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Nasal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Tonsillectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Oncology ORL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Neoplastic Suspect in ENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

7 Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Antibiotic Prescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Common ENT Antibiotic Prescribing in Primary Care . . . . . . . . . . . . . 79

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Common Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79Vertigo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Otitis Externa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Sore Throat/Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80Glue Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

Reference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Contents

1© Springer International Publishing AG 2017 E. Cervoni, K. Leech, ENT in Primary Care, DOI 10.1007/978-3-319-51987-6_1

Chapter 1ENT Anamnesis

The ENT Consultation

There are many well-documented consultation models such as Helman’s Folk Model (1981), Pendleton et al. (1984), Neighbour (1987) and Calgary-Cambridge (1996) to name but a few. Many of which, designed in Primary Care. The use of consultation models helps to add structure to the consultation and ensure all relevant aspects are explored. It is not the intention of this book to specify a preferred model or whether a clinician devises their own model. However, there is a common factor in that all models which includes presenting complaint, past medical history, drug history, social history, examination, differential diagnosis, investigations and treatment.

�ENT�History

Undertaking an effective clinical history is an essential part of the ENT consultation, as it is with any aspect of medical practice. The content explored will vary from clinician to clinician and depend upon the patient’s past medical history, social history and drug history, as well as previous experiences. It is essential that the clinician has good com-munication skills, both verbal and non-verbal and may notice any cues given by the patient. Smith (2003) suggests that if the clinician listens to the patient, they will tell you the diagnosis. The information collected in the history will enable the clinician to target their questions to a certain line of enquiry and will guide the clinician to which investigations may be appropriate. During the history taking, the physician-patient relationship takes shape. It allows the clinician to get to know their patient, gain their confidence and trust and develop an understanding of any external influences that might affect their health. It also allows the clinician to explore the patient’s ideas, con-cerns and expectations. This is a crucial element of the clinical encounter for several reasons, including understanding of their condition and compliance to treatments.

2

�History�of�Presenting�Complaint

When a patient presents with an ENT complaint, it is important to ascertain factors such as onset, frequency and duration of symptoms, whether the patient has any other associated symptoms and what treatments, if any they have already tried. At this point, the physician should address questions specific to the system or systems. In relation to ENT, whether the patient has experienced any dizziness, congestion, decreased smell, hoarseness, odynophagia, swellings or lymphadenopathy, pain or discharge (to name a few ENT symptoms.) Corbridge (2011) suggests that, in gen-eral, unilateral symptoms should increase the clinician’s suspicion because most of the conditions that have serious consequences, such as tumours and cancers, are unilateral, at least initially.

�Past�Medical�History

The clinician should ascertain a patient’s past medical history. This may help the clinician determine if it is a recurring health problem. A history should include allergies. This is especially important in ENT presentations. Any history of asthma or respiratory conditions, neurology or rheumatology may also be significant. Undertaking a past medical history may affect a patient’s treatment plan or options for surgery and anaesthesia.

�Drug�History

Reviewing patient prescribed medications may alert a clinician to pre-existing ENT complaints or the presenting complaint may be because of a current medication. For example, a patient who presents with epistaxis who is prescribed apixaban or a patient presenting with hearing loss or tinnitus who is prescribed a macrolide or maybe quinine. A clinician should ascertain if the patient is taking any other medi-cations, prescribed, over-the-counter or otherwise obtained.

�Social�History

Many clinicians utilise physician-centred approaches to social history, which can be limiting to smoking, drinking alcohol and the use of drugs. However patient-centred approaches are often more in-depth and incorporate a wider range of social factors such as place of birth, qualifications/education, occupation, home environment, diet, exercise, sexual history, religion, tobacco, alcohol and drug use. In some cases, the details of the patient’s household may also be relevant (Fig. 1.1).

1 ENT Anamnesis

3

References

Corbridge RJ (2011) Essential ENT. 2nd edn. CRC Press, LondonHelman CG (1981) Disease versus illness in general practice. J R Coll Gen Pract 31:548–562Kurtz SM, Silverman JD (1996) The Calgary-Cambridge Referenced Observation Guides: an aid

to defining the curriculum and organising teaching in communication training programmes. Med Educ 30:83–89

Neighbour R (1987) The inner consultation. Lancaster, MTPPendleton D, Schofield T, Tate P, Havelock P (1984) The consultation: an approach to learning and

teaching. Oxford University Press, OxfordSmith R (2003) Thoughts for new medical students at a new medical school. BMJ.

327(7429):1430–1433

Past ENT history

Current ENT signs andsymptoms

ENT anamnesis

Social history

Ototoxic

Anticoagulants

Affecting the vestibular system

Affecting BP

Alcohol

Smoking

Occupation

Occupation

Hobbies

Endocrinology

Allergology

Drugs

General conditionsImmunology

Cardiology

Mental Health

Rheumatology

Infectious diseases

Noise exposure

Fig. 1.1 ENT anamnesis map

References

5© Springer International Publishing AG 2017 E. Cervoni, K. Leech, ENT in Primary Care, DOI 10.1007/978-3-319-51987-6_2

Chapter 2Otology

Organ Targeted History

The Ear

Hearing loss is a very common presenting symptom of ear disease. It is estimated that ten million people in the UK suffer with this complaint. Hearing loss can occur in the external, middle or inner ear and can be conductive, sensorineural in nature or both. The clinician should ask the patient how long they have been experiencing the symptoms, was it a sudden loss or gradual and whether it is unilateral or bilateral. Unilateral loss could indicate important pathology. Family history of hearing loss can be relevant, and gaining an understanding of any professional or recreational noise the patient has been exposed to could be significant. In a child, it is important to enquire about previous infections, trauma at birth or anoxia, and other medical conditions. Ear problems can very often result in otalgia (ear pain).

Due to the distribution of cranial nerves and shared innervations such as of tem-poromandibular joint, mouth, teeth, salivary glands and throat; otalgia can quite often be because of referred pain. Therefore, the clinician needs to determine if the pain is from a direct or a referred cause. The clinician should explore whether the pain is acute or chronic and whether it has been a recurrent problem. The patient may describe the pain as sharp, dull, a discomfort, a deep penetrating pain or diffuse ante-rior pain. The clinician should ascertain what the exacerbating and alleviating factors are and whether there are any associated symptoms such as fever, congestion, nasal or ear discharge, sinus pain or headaches. As mentioned, otalgia can be because of referred pain for example tonsillitis. Fifty percent of ear pain is from a dental or TMJ causes, therefore a comprehensive history should assess ear, dental, sinus, jaw, neck, tongue, mouth and neurological disorders that can affect the head and neck.

Otorrhoea is a common presentation in primary care, especially in children. The clinician should ask the patient about onset, duration, amount and quality of otorrhoea. A purulent discharge could indicate infection, whilst a blood-stained

6

otorrhoea may indicate trauma. Likewise, patients with a mucous discharge may have a perforated tympanic membrane and patients with a clear fluid following a head or skull injury could have a CSF leak. A foul-smelling otorrhoea is character-istic of cholesteatoma. However, there are other infections leading to extremely malodorous ear secretion such as infection caused by Proteus. The history should investigate any childhood illness, trauma, foreign bodies, respiratory symptoms, any ENT surgery or excessive exposure to water e.g. swimmers. Associated symp-toms such as hearing loss, tinnitus, pain, vertigo and facial palsy should also be explored. Vertigo and facial palsy associated with otorrhoea require urgent referral.

Patients complaining of ear noise (tinnitus) often indulge in a very detailed description of what they hear. Most of this is useless in making the diagnosis. Tinnitus has many causes, including hearing loss, loud noise exposure, head injury or surgery and side effects of medications. Aspirin, NSAIDs, furosemide and quinine have all been associated with tinnitus. The clinician should ascer-tain the patient’s symptoms, whether they are experiencing a ringing, any aural fullness, fluctuating hearing loss, vertigo, otalgia or vestibular symptoms. However, it is important to recognize if the tinnitus is non-pulsating or pulsating since the latter may occur with severe vascular tumours or malformations. Ear popping and cracking are suggestive of Eustachian tube dysfunction, as it is a feeling of pressure inside the ear. Subjects suffering from Ménière’s syndrome may report a similar experience. Dizziness accounts for 2.5% of primary care presentations and of which 50% of dizziness presentations have an ontological cause. When obtaining the clinical history, the clinician should ascertain onset, duration and associated symptoms. Hain (1997) suggests duration can help to diagnose the complaint: BPPV (usually lasts seconds), TIA (minutes), Ménière’s (hours), vestibular neuronitis (days) and ototoxins (years). Associated head movement or change in head position, hearing disturbance, headache, cognitive symptoms and stress are helpful to explore. If after picking up the history you do not have a suspect, it is unlikely that diagnostic clinical examination and further investigations may bring to fruitful results. The facial nerve is in close anatomic relationship with the ear and it can be involved in its pathology. Therefore, the patient may experience change in sense of taste or facial weak-ness. The clinician should explore this, as the patient may fail to recognise the link and its relevance (Fig. 2.1).

Ear Equipment

Otoscope

It is a fundamental tool that can be fitted with or without sliding lens (this allowing the use of instruments such as the Jobson Horne for removal of earwax), and pneu-matic pump for assessment of tympanic membrane mobility. Best visualisation of the external auditory canal (EAC) is achieved positioning your head at the same

2 Otology

7

level as the patient’s head. With the free hand, the clinician should straighten the external auditory meatus (ear canal) by gently pulling the auricle upward and back-ward in the adult and downwards and backwards in the child. The clinician should choose the widest speculum that will comfortably fit into the patient’s ear, as this would provide the best view of the ear structures. The clinician should choose the largest speculum that will comfortably fit into the patient’s ear, as this would pro-vide the best view of the ear structures (Fig. 2.2).

Aminoglicosides

Affecting the vestibular system

Quinine

Salicylates

Loop diuretics

Cisplatin

Erythromycin

Neurofibromatosis

Deafness

Referred

Otologicalanamnesis

Symmetry

Type if hearing loss

Blood

Aqueous

Serous

Purulent

Progression

Onset

Duration

Direct

Duration

Seconds

Days

Minutes

Hours

Positional

Spontaneus

Induced by stimulation

Triggers

Hypertermia

Hyperpyrexia

PitchLow

High

Pulsation

Non-pulsationType

Severity

Discharge Pain

Hearing Vertigo

Fever

Tinnitus

Familt history

Drugs

Fig. 2.1 Otological anamnesis map

Fig. 2.2 Otoscope

Ear Equipment

8

Tuning Forks

In ENT, tuning forks are used to assess hearing loss and ascertain whether the hearing loss is conductive or sensorineural in nature. Each tuning fork carries a number (128, 256, 512 and 1024  Hz.) This is the frequency at which the fork vibrates.

Diapason at 512 Hz

The 512 Hz tuning fork is the most effective in the range of clinical diapasons avail-able as the patient may not recognize a lower frequency (128, 256 Hz), and higher frequencies have a shorter duration making the Rinne test difficult to perform. The tuning fork may be made of steel or aluminium, the latter being a much cheaper material, but is suitable to clinical use (Fig. 2.3).

The easiest and most useful hearing tests to perform are the Rinne and the Weber test. The Rinne and Weber test are used to differentiate between conductive hearing loss (CHL) and sensorineural hearing loss (SNHL). Both should be carried out and the Rinne test should be done first. We shall address the details of both tests in a separate section of this book dedicated to hearing evaluation.

Frenzel Goggles

The Frenzel goggles are helpful to assess nystagmus, a condition of involuntary movement of the eyes, the assessment of which is often extremely helpful to diagnose pathologies affecting the vestibular system (Fig. 2.4).

Fig. 2.3 Tuning fork sets

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9

Ear Syringe

Ear syringing is the most common ENT procedure carried out in primary care. Its purpose is the removal of cerumen. There are many types of ear syringe, including metallic, glass or made of plastic and electric with automatic pressurization (Propulse II.) The Medical Device Agency advocates the use of the Propulse II as the safest device (Fig. 2.5).

Fig. 2.4 Frenzel goggles

Fig. 2.5 Electronic syringe

Otological Examination

10

Otological Examination

In addition to the clinical anamnesis we have described in the previous sections, the complete otological examination comprises a physical examination and testing which includes:

• Inspection• Otoscopy• Removal of cerumen if present• Use of tuning forks• Pneumatic otoscopy/“fistula test”• Vestibular system assessment• Cranial nerve exam• Head and neck exam

It is common practice to examine the unaffected or least affected ear first. This will set a baseline for the clinician to compare the other ear to. The clinician should start by assessing the pinna, reviewing the skin around, behind and adjacent to it.

Evaluate for the presence of scars, as this may be significant in framing the clini-cal scenario (Figs. 2.6 and 2.7).

The clinician should assess whether there is a deformity of the pinna, or any skin lesions.The clinician should then assess the appearance of EAC. The otoscope is funda-

mental to this providing magnification and illumination. The otoscope will be used in conjunction with a speculum of the largest size that can fit in the EAC of the patient without causing discomfort. Pulling the pinna upwards  and  backwards straightens the ear canal, and the clinician should assess:

• Normal findings such as hair, and cerumen• Abnormal findings such as dry flaky skin suggestive of eczema, inflamed or

swollen ear canal, discharge, impacted cerumen or foreign body• The appearance of tympanic membrane – this includes analysing the mobility of

the TM, any retraction pockets, the presence of keratinous accumulations, any erosion of the ossicular chain, any perforations or scars (Fig. 2.8)

Temporalfascia graftingsite

Graftingsite

Retroauricularapproach

Retroauricularapproach

Fig. 2.6 Surgical scars

2 Otology

11

Otalgia

Earache is a common presenting complaint in primary care. Often, but not always, it is indicative of an ear infection. When the otoscopic examination is normal, the ear pain is a referred pain. In addition, the healthcare professional has to be aware that catarrhal otitis can lead to chronic acute otitis media and vice versa. When con-sidering an ear infection, in conjunction with the clinical history, the diagnostic elements illustrated in the following paragraphs are of extreme relevance.

Causes of Referred Otalgia

There are several possible causes of otalgia. Among them are:

• Tonsillitis• Mononucleosis

Helix

Scaphoid fossa

Crura of antihelix

Concha cava

Antihelix

Antitragus

Lobule

Triangular fossa

Crus of helix

Tragus

Fig. 2.7 The ear

Fig. 2.8 Intact tympanic membrane

Causes of Referred Otalgia

12

• TMJ syndrome• Cervical spondylosis• Cancers of the throat, mouth and nasopharynx• Odontogenic

In the following sections we shall explore the local causes of otalgia, whilst some of the conditions causing referred otalgia will be discussed in other sections of the book instead.

Local Causes

The main local causes of otalgia are trauma, or pathology of the pinna, otitis externa, and otitis media.

Otitis Externa (Fig. 2.9)

Clinical PresentationOtitis externa may be due to acute or chronic eczema, psoriasis, seborrhoeic derma-titis, skin infection of the EAC or pinna.

Examination• Itching and/or ear pain• Watery secretion• Some deafness, or blocked ear• Pain that radiates towards neck and adenopathy

Clinical Management• Antibiotic and topical steroid drops for 5 days• Cream and/or antibiotic drops with steroid and gauze• Ear swab for microbiological examination• Diabetic control if applicable• Consider shampooing• Acetic acid in drops or spray• Use of ear plugs to avoid water entering the ear canal

Key PointsRefer to a specialist if marked stenosis of the EAC, or in case of ear obstruction due to exostosis of the EAC, keratin debris, facial cellulitis, persistent symp-toms resistant to medical treatment, and infections interfering with the use of hearing devices. Other causes of otitis externa are boils, which are very painful especially to traction of the pinna; shingles; myringitis bullosa haemorrhagica; and perichondritis, which require hospitalization for appropriate therapy.

2 Otology

13

RED FLAGS

Painless secretion

Pain which does not parallel clinical observation

Non resolving otalgia especially in the diabetic patient

Recurrent/Persistent unilateral infection

Facial nerve deficit

Fig. 2.9 Otitis externa

Otitis Externa

14

Acute Otitis Media

The acute otitis media, or AOM, may be viral or bacterial.

Viral Otitis Media (Fig. 2.10)

Clinical PresentationViral otitis media may be secondary to upper respiratory tract infection, there may be the absence of fever, or mildly raised temperature and one of both ears may be affected. Children may present in combination with vomiting and diarrhoea.

Examination• Hyperaemia of the handle of the hammer• Bubbles and fluid behind a tympanic membrane flushed, but intact• The absence or decrease of luminous triangle• Hypervascularisation of the tympanic membrane

Clinical Management• Acetaminophen during the 24 h, when the pain is more accenuated.• NSAIDs, such as ibuprofen, may be particularly helpful at night.• If the ear pain persists for more than 24  h, review pain control and

consider  antibiotic therapy, particularly if fever, age less than 3 years old, yellow tinged middle ear secretions, or perforation of the tympanic membrane.

• Check in 2 weeks to prevent relapse.

Fig. 2.10 Viral otitis media

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15

Acute Bacterial Otitis Media (Fig. 2.11)

Clinical PresentationPatients may present following a viral otitis media. It can be a complication of tonsillitis and be associated with a high fever. Vomiting may also be present. If a perforation is present, there may be a discharge of purulent fluid with or without blood, and pain.

Examination• Tympanic membrane is red and bulging• Central perforation with presence of pus• Haemorrhagic areas

Clinical Management• First-line treatment is ibuprofen or paracetamol. Observe. If no improvement

after 72 h, amoxicillin 500 mg tds for 5 days.• For people who are allergic to penicillin, prescribe a 5-day course of clarithro-

mycin bd.• Treat pain and fever with paracetamol or NSAID such as ibuprofen.• Admit for immediate paediatric assessment, any child younger than 3 months of

age with the presence of a temperature of 38 °C or more and any child 3–6 months of age with the presence of a temperature of 39 °C.

Key PointsRefer to the ENT specialist recurring otitis media if cause for concern for the patient, family, or GP. Also refer to the ENT consultant if chronic otalgia, recurrent or from otological causes.

Fig. 2.11 Acute bacterial otitis media

Acute Otitis Media

16

• Admit for immediate specialist assessment, adults and children with acute com-plications of acute otitis media such as meningitis, mastoiditis, or facial nerve paralysis.

• Consider admitting patients who are systemically unwell.• Consider admitting people with significant, persistent symptoms on high-dose

amoxicillin/clavulanic acid, or azithromycin.

Consequences of Viral and Bacterial Otitis Media

• Full resolution: no action to follow.• Persistent otalgia: refer to specialist.• Serous otitis media: if asymptomatic, observation; if painful or cause of deaf-

ness, refer to ENT.• If associated with acute tympanic membrane perforation, suggest avoiding the

entrance of water in the ear canal and review the patient in 1 month; refer to the specialist if the perforation has not closed.

• Myringosclerosis (white limestone plaques in the context of the tympanic membrane): no further action required unless this is associated with significant hearing loss. In that case, ENT referral is indicated (Fig. 2.12).

• Chronic tympanic perforation: ENT referral (Fig. 2.13).

Fig. 2.12 Myringosclerosis

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17

Key PointsAcute otitis media in adults is uncommon in those subjects that have not been already prone at a young age and as such it should be followed-up carefully. Refer to specialist in the absence of a speedy resolution, or in case of recurrence.Any child younger than 2  years old that is unwell needs otoscopic examination.The level of concern of relatives often goes in parallel with the severity of the ENT pathology.Treating otitis media with analgesia for 24 h does not harm the patient’s health.An exudative otitis media in an adult without previous history of ontological problems should trigger special attention.A mastoid abscess should not be diagnosed in the presence of normal tym-panic membrane, or almost normal.A mastoiditis requires hospital admission if evidence of complications.

Fig. 2.13 Chronic tympanic membrane perforation

Acute Otitis Media

18

RED FLAGS

Children < 3 monthes of age with a temperature > 38ºC

Children 3-6 months of age with a temperature > 39ºC

Swelling or pain to the mastoid process

Symptoms and signs suggestive of meningitis

Facial nerve deficit

Ear Secretions (Fig. 2.14)

The presence of ear discharge is a common finding in general practice. The presence of secretions in the EAC does challenge the clinician’s ability to visualize the tym-panic membrane without the help of a suctioning device. As such, the clinician should be particularly careful in their proposed management. In the presence of history of ear surgery, or surgical incision, the patient should be referred to the ENT specialist. Ear discharge, or otorrhoea, may be due to several causes, ranging from an otitis externa to pathology of the middle ear.

Fig. 2.14 Otorrhoea

2 Otology

19

Otitis Externa

We have already discussed otitis externa as being a cause of otalgia. In fact, earache is the prominent feature of otitis externa and the presence of discharge in the absence of pain should suggest the possibility of a perforated otitis media instead. Otitis externa can be due to a variety of causes, including a trauma, boils, pseudomonas, or rarely a neoplasm. The use of cotton buds is a common trigger of otitis externa. Otitis externa is often associated with pruritus, sensation of ear fullness because of the accumulations of keratin scales and exudate, and a slight hearing loss.

Middle Ear Pathology

It can lead to ear discharge only in the presence of tympanic membrane perforation. Pathologies of the middle ear that can cause discharge include the already discussed AOM, chronic otitis media, some fractures of the temporal bone and granulations of the tympanic membrane.

Trauma or Foreign Body

It is uncommon for a GP to see an ear trauma or a foreign object in the external auditory canal during surgery times. However, should this be the case, a referral to the local A&E Department is generally required. This may not be the case only if the GP can fully visualise the external and middle ear establishing the absence of lesions or foreign bodies. The presence of deafness, tinnitus, or vertigo should warrant further specialist assessment. A GP may also attempt removal of foreign objects by means of ear stringing, or using otoscope and Jobson Horn instrument.

Management of Ear Secretions

Clinical Management• Antibiotic and topical steroid drops for 5 days.• If the patient is diabetic, obtain an ear swab to exclude Pseudomonas aeruginosa

infection which, if present, would demand ENT referral.• Suggest avoiding shampoo, conditioner, swimming, and sauna.• Repeat otoscopic examination if the above measures do not bring benefit.• In the presence of tight and swollen ear canal, use gauze or other guide.• Analgesia.• Oral antibiotics if adenopathy present.• Anti-histamine if itching.• If abundant keratin debris, refer to ENT? cholesteatoma.

Management of Ear Secretions

20

RED FLAGS

Facial nerve injury or deficit of other cranial nerves

Vertigo suggestive of cholesteatoma

Foul-smelling secretion suggestive of cholesteatoma

Previous ontological surgery

Otorrhoea by cerebrospinal fluid leakage

Perforation of Tympanic Membrane (Fig. 2.15)

Tympanic membrane perforations can be handled in the large part by primary care. They occur when a hole or tear develops in the tympanic membrane.

These are divided into:

• Peripheral• Of the attic• Central

Fig. 2.15 Tympanic perforation

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21

Each type has different management plans.

Clinical Presentation• Otalgia• Discharge from the ear• Temperature of 38 °C or above• Tinnitus

Examination• Undertake otoscopy to identify a perforation with or without granulation

tissue• Look for retraction pockets and keratinic debris, which may hint the presence of

cholesteamtoma• Be alerted by foul-smelling debris or discharge, which may suggest Pseudomonas

or other bacterial infection

Clinical Management of Central Perforations• Prescription drops if secretions obscure the tympanic membrane. Most antibiotic

ear drops contain aminoglycosides that are ototoxic. They are often still pre-scribed by the ENT consultant, but in primary care the use of non-ototoxic drugs such as ofloxacin drops with or without topical steroid could be preferable. When the perforation is dry, observe and advise patient to avoid getting water in the entrance of the ear canal using cotton with wax or Vaseline.

• Pain relief such as paracetamol or ibuprofen.• Review the patient after 6 weeks.• Very often central perforations resolve spontaneously.

Clinical Management of Peripheral Perforations and Perforation of the Attic• All peripheral perforations and perforations of the attic require ENT referral in

view of the higher risk of chronic middle ear disease and in particular cholesteatoma.

Key PointsConsider referring patient in case of:

• Recurring/persistent otorrhoea• Otalgia resulting from secondary otitis externa• Deafness• Vertigo• Persistent perforation

Perforation of Tympanic Membrane

22

RED FLAGS

Facial nerve deficit

Headache

High fever

Vertigo

Cholesteatoma (Fig. 2.16)

Cholesteatoma is a less common finding in general practice. It occurs when a col-lection of cells grow on the inside of the ear drum. Left untreated, it can damage the structures of the middle ear and lead to deafness, ear infections, vertigo, tinnitus and facial nerve damage.

Clinical PresentationThe presence of symptoms and conditions that should trigger the suspect of choles-teatoma are:

Fig. 2.16 Cholesteatoma

2 Otology

23

• Deafness• Smelly otorrhoea• Otalgia• Facial nerve deficit• Vertigo• Mastoid abscess• Meningitis

Examination• The presence of cholesteatoma is typically suggested by the presence of abun-

dant keratinic debris with or without smelly discharge and tympanic mem-brane perforation. The latter is most common, but it may not be present on occasions such as in the case or a retraction pocket or a congenital cholesteatoma.

Clinical Management• The presence or suspect of cholesteatoma dictates ENT referral for further

management.

Child Deafness

If a parent suspects that his child has difficulty hearing, the GP should consider a request for visiting an ENT specialist. In general, the perception of deafness in a child indicates the presence of bilateral hearing loss. The first question to consider is if deafness is associated with ear pain.

With Otalgia

Consider:

• Acute otitis media• Upper respiratory tract infection

Without Otalgia

Consider:

• Earwax• Bilateral exudative otitis media

Child Deafness

24

• History of pre-, peri-, post-natal complications or that might suggest the pres-ence of sensorineural hearing impairment

• History of meningitis, or severe rash• History of head trauma• Congenital malformations

Examination• Presence of earwax: sodium bicarbonate 5% drops for 48–72 h, eventually fol-

lowed by irrigation of the EAC. However, this would not be advisable in the young child.

• Glue ear which is very common and is determined by:

– Vascularisation of the tympanic membrane – Golden colour of tympanic membrane – Absence of bright reflex triangle – Almost blue reflex of tympanic membrane – Presence of fluid, or air-water levels/bubbles behind an intact tympanic

membrane – Horizontal handle of the hammer

Clinical Management of Deafness with Otalgia• Acetaminophen for 24 h in the presence of acute otitis media• Symptoms lasting longer than 24h, 5 days of antibiotic therapy• If the ear pain resolves but the deafness remains, treat as deafness without ear pain• Note: Nasal drops don’t help

Clinical Management of Deafness Without Otalgia• It is important to get a good clinical history from the relatives and clarify what,

when and how the suspect of deafness was established.• Evaluate speech and the ability to read; in the event of a delay request ENT and

Paediatric assessment.

In the clinical management of “glue ear”, or chronic otitis media exudative, consider:

• Otitis media and exudative otitis media can be linked to each other.• In the case of a speech delay, refer to a specialist.• In the absence of a delay in speech, observe for a couple of months before

referring.• Lack of improvement after 2 weeks, should lead to referral.• In the presence of auditory fluctuations, reviewing every 2 months.• In older children, spontaneous resolution is more likely.• Nasal drops, mucolytic and antibiotics should help.

Auditory assessment of a child can usually take place in a GP surgery using the Leeds Picture Discrimination Cards and whispered voice a metre away.

• 0–3 years: refer• 3–6 years: Leeds Picture Discrimination Cards• 6 years: whispered voice

2 Otology

25

If parents believe that a child has hearing problems, refer. Always refer a child with marked hearing loss even when this is possibly due to the presence of serous otitis media, or glue ear.

RED FLAGS

Speech delay

Marked hearing loss

Malformations

Chronic ear discharge

Adult Deafness

Usually, deafness in adulthood has a slow onset and evolution. It can be uni-/bilat-eral, affecting the understanding of speech, especially on the phone and in noisy environments.

Key anamnestic points

• Past medical history of ear surgery• Infantile exanthema• Head trauma• Severe systemic diseases that have required the use of ototoxic medications• History of occupational exposure to noise• Hobbies such as hunting, or music• Family history of deafness• Diabetes• Autoimmune disease

Hearing Tests

Rinne Test

The Rinne test is used to evaluate CHL. CHL occurs when there is a problem conducting the sound waves to the inner ear anywhere along the route through the outer ear, tympanic membrane, ossicular chain, up to the oval window (or fenstra vesibuli). CHL may occur in conjunction with SNHL or in isolation. The Rinne

Hearing Tests

26

test is performed by placing a 512 Hz diapason to the patient’s mastoid bone. A person with intact hearing should be able to hear the tuning fork by air after he can no longer hear the sound through the bone. If the person being examined is not able to hear the tuning fork when it is quickly repositioned near to the external acoustic meatus that means his bone conduction is greater than the air conduction. In turn, this indicates that there is some kind of problem that inhibits the move-ment of sound waves to the cochlea (i.e. there is a hearing loss). In the case of hearing loss of a sensorineural type, the ability to perceive the diapason via con-duction through bone is also diminished, therefore the conduction of sound through the air will still be more effective (Fig. 2.17).

+

–

>

<

–

<

False

Fig. 2.17 Rinne

2 Otology

27

Weber Test

The Weber test is used to detect either unilateral hearing loss of transmissive type or unilateral sensorineural hearing loss (SNHL). When undertaking the Weber test, the 512 Hz diapason is placed in the centre of the patient’s forehead. Patients with uni-lateral hearing loss (or predominantly unilateral) perceive the sound from the dis-eased side if suffering from conductive hearing loss, or from the healthy side – or less sick – if suffering from a perceptive hearing loss. In transmissive deafness, if deafness is bilateral and there is a difference in the threshold between the two ears, the sound will be lateralized in the worst ear; if deafness is symmetrical, to the cen-tre (Fig. 2.18).

Obstruction of the Auditory Canal

• Benign lesion/exostoses of the EAC• Earwax

Exostoses are common is scuba divers and swimmers in cold waters. Their man-agement requires ENT referral. Wax can be removed by means of ear drops, such as sodium bicarbonate 3%, 3–4 drops to be applied for 3–4 days and to be followed, if necessary, by ear syringing.

Ear Syringing

Ear Irrigation Procedure

It is important that a comprehensive history has been undertaken before performing ear irrigation to determine if there are any contraindications why it should not be performed.

SNHLCHLNeg

Fig. 2.18 Weber

Hearing Tests

28

Also an understanding of the basic anatomy of the ear is essential, so that the clinician examining the patient understands what constitutes normal and when there are devia-tions to this. Patients should be advised to use olive oil for at least 7 days, to soften the wax prior to irrigation. The procedure for ear irrigation should follow the NHS Modernisation Guidelines written by Harkin (2007) and is as follows.

• Explain the procedure to the patient, outlining risks associated with it such as dizziness, perforation, otitis externa. If the patient is happy to proceed, gain con-sent and document.

• Check whether the patient has had ear irrigation before.• Sit the patient in a chair appropriate for the procedure with the ear to be irrigated

facing you.• Inspect both ears with the otoscope.• Place the protective cape and disposable towel in position, and ask the patient to

hold the receiver under the ear. It is advisable the patient tilt their head slightly towards the affected side.

• Check your head light or mobile light is in place.• Check the temperature of the water using a thermometer to approximately 37 °C.• Remember any variation by more than a few degrees may cause the patient to

feel dizzy. If this occurs, stop irrigating, and ask the patient to fix his gaze on some object for a few minutes until the dizziness passes.

• You should be sitting at the same level as the patient when carrying out this procedure.

Use of an electronic syringe (Propulse II irrigator)

• Fill the reservoir of the Propulse II irrigator with warm water of 37 °C. Set the pressure to minimum.

• Connect disposable jet tip applicator to the tubing of machine with firm push/twist action. Push until click is felt.

• Direct the tip of the jet into the reservoir and switch on the machine for 10–20 s. This distributes the water through the system to expel any trapped air or cold water. This also enables the patient to accept the noise the machine makes.

• Gently pull the pinna upwards and outwards to straighten the meatus.• Place the tip of the nozzle into the external auditory meatus entrance. Nothing

should be inserted into the ear further than the part that can be seen from the outside. Inform the patient that you are about to begin and that they should make you aware of any symptoms of pain, dizziness or nausea. Switch the machine on (using either foot or hand control).

• Direct the stream of water onto the posterior wall of the canal (11 o’clock in the right ear and 1 o’clock in the left ear). Increase the pressure switch as determined by the aural condition. It is advisable that a maximum of two reservoirs of water be used in any one irrigation procedure.

2 Otology

29

• If the clinician has not managed to remove the wax within 5 min of irrigation, switch to the other ear if indicated; allow approximately 15 min before returning to first ear.

• Periodically inspect the meatus with the otoscope and inspect the solution run-ning into the receiver.

• After removal of the wax, ask the patient to dry mop the excess water from the meatus. Dry mop excess water from meatus under direct vision because stagna-tion of water and any abrasion of the skin during the procedure may predispose the otitis externa to infection.

• Examine ear, both meatus and tympanic membrane, and refer to ENT if there is severe inflammation or trauma. Record all findings and treatment in the patients’ notes.

NB: Irrigation should never cause pain. If the patient complains of pain – stop immediately.

Contraindications

Irrigation should not be carried out when the patient:

• Has a history of a perforation or there is a history of mucous discharge in the last year

• Has had a history of middle ear infection in the last 6 weeks• Has had an untoward experience following this procedure in the past• Has had previous ear surgery• Has a grommet in place• Has evidence of otitis externa• The patient has a cleft palate (repaired or not)• Has epilepsy

Precautions

• Tinnitus – people with troublesome tinnitus may notice that when the wax is removed and their hearing improves the tinnitus may increase in severity; dis-cuss the procedure with the patient in detail and document consent in patients’ records

• Healed perforation – discuss on an individual basis – consider referral for suction removal

• Dizziness

Hearing Tests

30

Evaluation of Auditory Function by GP

• Whispered voice at 1 metre with contra lateral masking• Conversation at 1 metre with contra lateral compression of tragus• General conversation with lip masking• Test with the diapason: Weber and Rinne with 512 Hz tuning fork• Pure tone audiometry if available

RED FLAGS

Unilateral hearing loss

Sudden hearing loss

Deficits of cranial nerves

Services for Patients with Hearing Loss

• ENT departments• Audiologists• Special schools• Adapted television and telephone

Key PointsConsider referral if:

• Removing the earwax doesn’t solve the deafness• Sudden onset of deafness in the absence of earwax• Unilateral symptoms• Other symptoms in addition to ear tinnitus• Tympanic membrane abnormalities

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Vestibular System

The use of Frenzel goggles may be particularly helpful to look and assess for the presence of nystagmus. This may be spontaneous, gaze evoked, post-headshake, positional, triggered by the Dix-Hallpike manoeuvre, by pneumatic otoscopy, or by other techniques. Smooth pursuit, saccades, gait, and head-shaking nystagmus should be assessed. The Romberg test, the Fukuda step test and the hyperventilation test are also helpful.

Smooth Pursuit

Smooth pursuit is a movement of the eyes allowing us to follow a moving target. We can also shift the gaze voluntarily by means of saccadic eye movements. Pursuit is triggered by a moving visual signal and it would be very difficult, if possible, to be initiated in its absence. Smooth pursuit and saccades work together. If a target moves faster than 30°/s, the pursuit tends to require catch-up saccades. Smooth pursuit is asymmetric in so far that we are better at horizontal than vertical smooth pursuit, that is we can follow a moving target without making catch-up saccades horizontally rather than vertically. We are also better at downward rather than upward pursuit. Smooth pursuit may be affected by a variety of conditions as it requires the coordination of different brain areas also far away from each other.

Saccades

As briefly mentioned above, a saccade is quick, coordinated movement of both eyes between two positions of fixation in the same direction. Saccades are involved in fixation, rapid eye movement, and in the fast phase of optokinetic nystagmus.

Head-Shaking Nystagmus

Head-shaking nystagmus, or HSN, is a latent spontaneous vestibular nystagmus which can be provoked by rapid passive head shaking around a vertical axis. Typically HSN is triggered by means of horizontal sinusoidal head oscillations of 30° each side, for at least 20 cycles, and then abruptly interrupted. Ideally, the head of the subject should be 20° downward with respect to the vertical axis, so that the

Vestibular System

32

axis of rotation could be parallel to one of the semicircular lateral canals. HSN is absent in normal subjects; hence its identification with Frenzel’s glasses in a dark room or a video camera (videonystagmoscopy) can be helpful. In fact, passive head shaking is an effective way of triggering nystagmus in patients with peripheral and central vestibular lesions.

Fukuda Stepping Test

The Fukuda stepping test (FST) is another particularly useful test in the limited space of a consulting room. In the FST, also known as Unterberger’s stepping test, the patient is asked to walk in place with their eyes closed. There are two variants to the test, with 50 and 100 steps, the latter being somewhat more sensitive. Abnormal deviation towards the side of the lesion, that means >45° deviation, occurs in most cases, but in about 1/4 of the patients this could be towards the intact side, and in another 1/4 it can remain within the normal range. Hence, if the patient rotates to a particular side they may have a labyrinthine lesion on that side, but this test should not be used in isolation of other tests to diagnose lesions.

Hallpike Test

Also known as the Dix-Hallpike test, it is probably one of the most helpful test that can be performed in primary care to make diagnosis of BPPV. The British Society of Audiology (2014) suggests the clinician should begin by explaining the procedure to the patient and demonstrating if necessary. Make sure the patient is aware that he/she may experience vertigo with eventual nausea and/or vomiting, but that this is likely to be short-lived. Also, the clinician should be aware of the absolute contraindica-tions to the test; these are: recent cervical spine fracture, atlanto-axial subluxation, cervical discopathy, confirmed vertebro-basilar insufficiency and recent neck trauma that restricts torsional movements of the neck. The test is performed with the patient sitting upright on the examination table, or on their bed during a home visit, with the legs extended. The patient’s head is then rotated to one side by 45°. The examiner helps the patient to lie down backwards quickly with the head held in 20° extension. This extension may either be achieved by having the examiner supporting the head as it hangs off the table/bed, or by placing a pillow under their upper back. The patient must be reminded to keep the eyes open staring straight ahead, and endeav-ouring to suppress blinks, as their eyes are then observed for about 45 s. There is a characteristic 5–10 s period of latency prior to the onset of nystagmus. If rotational nystagmus occurs then the test is considered positive for benign positional vertigo. During a positive test, the fast phase of the rotatory nystagmus is towards the affected ear, which is the ear closer to the ground. The direction of the fast phase is defined by the rotation of the top of the eye, either clockwise or counter-clockwise.

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Tinnitus

Tinnitus is the hearing of sound when no external sound is present. It can be described in various ways, but most often as a whistle or hum, in the head; in some cases, the noise is described as pulsating and synchronized with the heartbeat.

Subjective Tinnitus

It is more often associated with a sensory deficit. A disease of the middle ear that inhib-its masking ambient sounds, such as an otitis media, can exacerbate it. Many adults are extremely anxious about tinnitus. Often the patient fears a brain tumour causes tinnitus. A reduction of the anxiety levels may be surely beneficial. When this is present, the patient will probably be willing to have an MRI scan, but rather rarely this would bring any valuable information. Many patients are aware of a certain level of deafness.

• Refer to a specialist if deafness has a social impact• Refer if the tinnitus is unilateral• If mild, reassure the patient about the benign nature of tinnitus

Objective Tinnitus

Objective tinnitus occurs when the examiner can hear it as well. Objective tinnitus is rare and it demands further investigations via ENT referral.

Vertigo

The patient uses various terms to describe dizziness such as unsteadiness, light- headedness, giddiness or vertigo. It is up to the clinician to determine if it is an episode of true vertigo or not. Vertigo is a sensation of spinning and as such, to make a diagnosis of vertigo, the patient needs to have experienced a rotational movement

Key Points• Good lighting• Practice your technique• Correct equipment• Be methodical

Tinnitus

34

of the surroundings clockwise or counter-clockwise, depending on the side being affected and the type of disorder. If the patient does not describe such roundabout experience, we cannot talk about vertigo (Fig. 2.19).

Lemajic-Komazec and Komazec (2006) suggest that balance control depends on receiving afferent sensory information from several sensory systems: vestibu-lar, optical and proprioceptive. Bioelectric signals, generated by endolymphatic fluid movements in the semicircular canals and in the otolithic apparatus, are transmitted via the vestibular nerve to the vestibular nucleus. All four vestibular nuclei, located bilaterally in medial longitudinal fasciculus, are connected with several central nervous system structures. These central nervous system structures are involved in maintaining visual fixation, spatial orientation and balance con-trol. Therefore, afferent signals balance disorders will lead to nystagmus that is an involuntary movement of the eyes.

Nystagmus due to peripheral lesions is conjugate nystagmus, because there is a bilateral central connection.

Lesions above the vestibular nuclei induce deficits in synchronization and conju-gation of eye movements, thus the nystagmus is dissociated.

In peripheral vestibular disorders, spontaneous nystagmus is rhythmic, associ-ated, horizontal-rotatory or horizontal, with vertigo which decreases with time, and harmonic signs. Harmonic signs are so called when their direction coincides with the slow phase of nystagmus.

High pitchTinnitus

General conditions

Objective

Type

Positional

Spontaneus

Provoked

Fainting feeling

Headache

Confusion

Ear diseases

Previous episodes

Ototoxic

Drugs HypotensiveAnamnesis

Affecting the vestibular system

Smoke, alcohol, abuse drugs

Positional

Induced by physical exercis

Palpitations

Vomiting

Duration

Severity

Triggers

Subjective

Deafness

Secretions

Trauma

Ear

Low pitch

SNHL

Conductive

Mixed

Purulent

Acqueus

Serous

Head

SurgicalEar

Accidental

Acustic

Barotrauma

Seconds

Minutes

Hours

Days

Absent

Spontaneus

Positional

Gaze Triggered

Induced by stimulation

Nystagmus

Duration

Vertigo

Mental Health Anxiety

Stress

Depression

Hyperventilation

Fear of serious disease

Immunological disease

Endocrinological pathology

Infective disease

Neurological pathology

Cardiovascular pathology

Rheumatological disease

Fig. 2.19 Vertigo mind map

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Spontaneous nystagmus in central vestibular lesions is severe, dissociated, hori-zontal, rotatory or vertical, without changes related to optical suppression; if ves-tibular symptoms are present, they are non-harmonic.

In central disorders, findings after peripheral, caloric stimulation – which can be carried out by a clinical audiologist – are either normal or pathological, with dysrhythmias and inhibition in pendular stimulation (Fig. 2.20).

Jerk nystagmusconvergence-retraction nystagmusrefers to the irregularjerking of the eyes backinto the orbit during up-ward gaze. It can indicatemidbrain tegmental dam-age.

Pendular nystagmusHorizontal, or pendu-lar, nystagmus refers to oscillations of equal ve-locity around a centerpoint. It can indicate con-gential loss of visual acu-ity or multiple sclerosis.

Downbeat nystagmusrefers to the irregulardownward jerking of theeyes during downwardgaze. It can signal lowermedullary damage.

Vestibular nystagmus,the horizontal or rotarymovement of the eyes,suggests vestibular dis-case or cochlear dysfunc-tion.

Vertical, or seesaw,nystagmus is the rapid,seesaw movement of theeyes; on eye appears torise while the other ap-pears to fall. It suggestsan optic chiasm lesion.

Fig. 2.20 Jerk vs. pendular nystagmus

Vertigo

36

Objective Vertigo

Ménière’s Syndrome

This is probably diagnosed more often than it should be. It is an idiopathic disease of the inner ear characterized by hearing loss, tinnitus and dizziness. Endolymphatic hydrops, that is an increase of the inner ear fluids pressure, mostly sharp, is believed to be responsible for the onset of the symptoms and signs.

Clinical Presentation• Vertigo and nausea• Hearing fluctuation with vertigo• Feeling of ear fullness, or pressure• Tinnitus• Cluster episodes, of variable duration ranging from several hours to days

Ménière’s syndrome must be referred to a specialist for an appropriate diagnostic and therapeutic management.

Clinical Management• Medical: diuretics, hypo-saline diet, sedatives, anti-vertiginous, antiemetic, any

correction of metabolic dysfunctions and vasculopathy.• Surgery: surgical therapy is indicated in those cases that do not benefit from

medical treatment. It can be divided into conservative and destructive: the latter should be reserved for the terminal stages of the disease and unilateral forms. The conservative treatment or functional treatment aims for the improvement of the vestibular symptoms with hearing preservation: sacculotomy and endolym-phatic shunt. The most radical intervention does not take into account the conse-quences for the hearing, in an attempt to achieve the highest success rate: it consists of the labyrinthectomy and in the section of the vestibular nerve.

Viral Labyrinthitis

It is characterized by the presence of:

• Recent viral upper respiratory tract infection• Accompanied by nausea and vomiting• Often lack of hearing impairment• Normal otoscopic examination• Beginning as vertigo then later changes into imbalance and resolves

Clinical Management• Reassure the patient that symptoms generally resolve within a few days, some-

times weeks, occasionally months• Use of vestibular suppressant if necessary• Vestibular physiotherapy• Refer to a specialist if symptoms persist for more than 6 weeks

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Subjective Vertigo

Vertebrobasilar Insufficiency

The diagnosis is suggested by:

• Association with the neck extension and rotation• Normal tympanic membrane• Association with cervical pain from spondylosis• May be associated with other diseases due to atherosclerosis• Occasional episodes of cerebral ischemia

Clinical Management• Cervical collar – rarely proposed nowadays• Lifestyle changes• Treatment of osteoarthritis

Fistula Test

In the case of a cholesteatoma with or without otorrhoea, you might encounter an erosion of lateral semi-circular canal. In the case of cholesteatoma and vertigo, fis-tula test can sometimes confirm the diagnosis. To perform the fistula test, you are squeezing the tragus with the finger, and the patient, in case of a positive test, expe-riences the presence of objective vertigo with nystagmus directed towards the oppo-site side. Alternatively, you can use the pneumatic otoscope to achieve the same objective.

Key PointsRefer urgently to specialist in case of:

• Cholesteatoma• Otorrhoea• Deafness• Facial paralysis• Headaches and other neurological abnormalities• Previous otological surgery• Recent head injury

Vertigo

38

Benign Paroxysmal Positional Vertigo (BPPV)

Patients suffering with BPPV experience short bursts of severe dizziness when they move their head in certain directions.

Clinical Presentation• Vertigo generally appears when the patient gets up from bed, or lies down; when

looking up to a shelf, or lacing shoes.• Typically one side is affected and the patient learns to avoid this position, most

notably the recumbent on one side when in bed.• Can be cured with appropriate clinical examination.• Otoscopy is normal.

Clinical Management• Reassure the patient• Vestibular exercises (Fig. 2.21)• Refer to a specialist if it does not resolve within 1 month

References

British Society of Audiology (2014) Recommended procedure for hallpike maneuver [online]. http://www.thebsa.org.uk/wp-content/uploads/2014/04/HM.pdf

Hain TC (1997) Approach to the Vertigo. In: Practical neurology. Lippincott-Raven, PhiladelphiaHarkin H (2007) Ear care guidance from the NHS Modernisation Agency. NHS Modernisation,

LondonLemajic-Komazec S, Komazec Z (2006) Initial evaluation of vertigo. Med Pregl 59(11–12):

585–590

2 1 43

Fig. 2.21 Vestibular exercises for BPPV

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39© Springer International Publishing AG 2017 E. Cervoni, K. Leech, ENT in Primary Care, DOI 10.1007/978-3-319-51987-6_3

Chapter 3Rhinology

The Nose

Undertaking a history of the nose should include questions aiming to establish whether any of its functions – smelling, conditioning, warming, humidification of inhaled air and voice resonance – is impaired or not. Change of airway resistance and sense of smell are key indicators of nasal pathology. Also common presenta-tions seen in primary care are rhinorrhoea, epistaxis, facial pain or sense of pressure, and a nasal voice. Rhinorrhoea is perhaps the most frequent sign reported and observed by the clinician when dealing with nasal problems. Like otorrhoea, the clinician should ascertain whether the discharge is watery, purulent, mucousy or blood stained as this will help determine the cause. Rhinorrhoea can be chronic, acute or recurrent; so gaining an understanding of the duration may be pertinent. The patient should be asked if it is linked to any allergies or whether it is seasonal. Associated symptoms that the patient may describe include watering eyes, itchy eyes, sore throat and facial pain or pressure.

Many patients complain of nasal obstruction. This can be unilateral or bilateral. The clinician should determine the duration it has been occurring for, whether it is constant, intermittent or related to seasons or allergies. Any associated symptoms should also be explored including facial pain, sneezing, headache, post-nasal drip, sore throat, otalgia and asthma. If a patient presents with epistaxis, the clinician must prioritise significant bleeding over undertaking a history. However, once the bleeding is controlled, then the clinician should enquire as to whether the epistaxis was unilateral or bilateral, anterior or posterior. Foreign bodies can lead to epistaxis and should be ruled out, especially in children. It is important to ask the patient if the bleed was spontaneous or post trauma. The onset, duration and recurrence are also of significance.

Associated symptoms should be reviewed along with medications prescribed and past medical history. For example, the patient may be prescribed anti- coagulants or suffer from hypertension or renal disease. Symptoms that may direct the clinician to

40

suspect sinusitis include pressure or pain in the patient’s cheeks or forehead, nasal congestion, a sense of heaviness in the head heaviness and sometimes facial pain.

Determining the severity of the pain and the length of time a patient has experi-enced the symptoms will establish appropriate management. If the sinusitis has lasted up to 10 days it is likely to be viral. For symptoms lasting longer than 10 days it is more likely to be a bacterial sinusitis. Symptoms lasting for more than 12 weeks are suggestive of chronic sinusitis, and lasted >12 weeks is chronic sinusitis. Patients may describe fever, purulent discharge, nasal obstruction, post-nasal drip, chronic unproductive cough, malaise and facial pain.

Nasal voice may be distinguished in hyponasal and hypernasal speech, otherwise respectively known as rhinolalia clausa and rhinolalia aperta. The first is typical of nasal congestion, the latter of cleft palate and velopharyngeal insufficiency. The doc-tor should be informed about the presence of defects of smell, such as loss of smell (anosmia), its reduction (hyposmia), and unpleasant odours, particularly putrefactive odours (cacosmia). A thorough patient history is essential in determining any olfac-tory disorders such as sense of smell and sense of taste can often be confused by patients. Patients may also present with hyposmia, which is partial loss of smell. The clinician should ascertain the time the loss occurred and if there were any other con-tributing factors, such as trauma or illness. Intra-nasal obstruction, allergic rhinitis, head trauma and also type II diabetes and Alzheimer’s have been linked to anosmia. Drug and alcohol history should be taken as long term alcohol misuse can lead to anosmia. Certain medications such as metronidazole can also cause it (Fig. 3.1).

Nose Assessment

An otoscope can be used to make a rhinoscope with a wide speculum. The patient should be asked to breathe with his mouth during the examination to prevent the otoscope lens fogging during the procedure. The otoscope gives a good view of the anterior nasal cavity (Fig. 3.2).

Degree

Duration Fever

Pain

Nose

Hyposmia

Anosmia

Change of taste

Facial

Headache

Laterality

Unilateral

Bilateral

Serous

Aqueous

Purulent

Blood stained

Type

Triggers

Duration

Laterality

Nasal discharge

Olfaction changes

Nasal obstructionLaterality

Duration

Onset

Hyponasal

Hypernasal

Change of voiceresonance

Trauma

Epistaxis

Surgical

Accidental

Laterality

Amount

Duration

Drugs

Frequency

General conditions

NSAIDs

Triggers

Anticoagulants

Fig. 3.1 Rhinological anamnesis mind map

3 Rhinology

41

Dentist Mirror or a Cosmetic Mirror

Useful to evaluate the nasal flow, particularly in newborns.

Silver Nitrate Sticks

Silver nitrate sticks can be used for nasal cauterization to treat recurring nose bleeds. Frequent nose bleeds are likely to be a result of an exposed blood vessel in the nasal cavity; therefore cauterizing it may prevent further bleeding. Silver nitrate sticks look like large matches and are dipped in water before being applied to the lesion for a few seconds (Fig. 3.3).

Fig. 3.2 Otoscope being used to perform nasal examination

Fig. 3.3 Silver nitrate sticks

Nose Assessment

42

Nose Inspection

• Symmetry• Septal deviations• Deformity of the nasal pyramid• Patency of the nostrils• Little’s area (varices, crusting, bleeding) (Figs. 3.4 and 3.5).• Septal perforations• Nasal vestibule• Turbinates• Osteo-meatal complex• Injury or growths in the nasal cavity

Epistaxis

Patients do often experience recurring spontaneous nasal bleeding, from one or both nostrils. Sometimes, the GP is called to deal with epistaxis at the surgery, but much more frequently this pathology is handled in the Emergency Room.

Epistaxis in the Child

Children tend to bleed from the nose more easily than adults and from the front of the septum, otherwise known as Little or Valsalva area. Establishing the severity of bleeding should take precedence over the history taking.

Fig. 3.4 Little’s area, otherwise known as Valsalva area

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Clinical PresentationThe child may present with symptoms of a cold or as an exacerbation of allergic rhinitis. In a child this may be accompanied by a foul-smelling discharge; this may indicate a foreign body. Likewise a unilateral bleed or discharge may also indicate a foreign body.

Examination• Look for foreign body• Prodromal sign of exanthema• Inflammation of nasal vestibule• If appropriate, get child to blow nose; this will help to remove clots and give a

better view of the nasal cavity• External nasal deformity

Clinical Management• Anterior nasal bleeding can usually be stopped with a compression of the nos-

trils. At the same time, the child should bend the head forward.• Cauterization of eventual varicosities of the Little’s area with silver nitrate fol-

lowed by application of antibiotic nasal cream, more often mupirocin or chlorhexidine dihydrochloride 0.1% / neomycin sulphate 0.5%, for up to 10 days.

• If there is no obvious varicosity, or crusting, nasal topical antibiotic application for a week, and control.

• In case of absence of a specific site of bleeding, consider a haemostatic disorder and arrange further investigations to explore this possibility.

• For recurrent nosebleeds, refer to the specialist.

Anterior ethmoid artery

Kiesselbach’splexus

Superiorlabial artery

Greaterpalatine artery

Posterior ethmoid artery

Sphenopalatine artery

Fig. 3.5 Vascularisation of the Little’s area

Epistaxis in the Child

44

RED FLAGS

Bleeding non resolving with direct pressure

Recurrent idiopathic epistaxis

Signs of shock

Epistaxis in Adults

Clinical PresentationLike children, establishing the severity of the bleed should take precedence over the history taking. Once this has occurred it is important to establish whether the epi-staxis is unilateral or bilateral. A good history should enquire about previous epi-staxis, history of hypertension, other systemic diseases, family history or any bruising. In adults, a medication review may prove helpful looking for anti- coagulants, aspirin, NSAIDs and dipyridamole.

Examination• Consider anterior nasal bleeding as in children. Approximately 90% of bleeds

are anterior in nature.• Posterior nasal bleeding should be suspected when a specific point of bleeding is

not clearly identifiable, or stopped with the compression of the nostrils.

Posterior epistaxis is:

• More frequent in old age• More severe when associated with hypertension• May stop spontaneously, but is usually very copious• Should be handled within the scope of first aid emergency ENT

Clinical Management• Treat the anterior nasal bleeding as in children• In case of posterior nasal bleeding

– Check blood pressure – Refer to a specialist if recurring, or if associated with visible nasal lesion

Key PointsCheck if the patient takes anticoagulants.

Check haematocrit and coagulation.Consider angiofibroma in a young man with nasal obstruction. In this case,

refer to the specialist.

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RED FLAGS

Bleeding not stopped by direct pressure

Suspected shock

Recurrent unilateral bleed

Associated symptoms such as facial pain, numbness ordiplopia

Anticoagulants or anything to suggest blood disorder

Nasal Obstruction

Nasal obstruction refers to the feeling of a reduction of nasal flow, uni- or bilateral. It is generally divided into:

• Mucosal oedema due to:

– Viral rhinitis – Allergic rhinitis – Vaso-motor rhinitis – Nasal polyps

• Septal deviation:

– Post-traumatic – Idiopathic – Nasal valve insufficiency with collapse of one or both nostrils

• Rhino-pharyngeal obstruction due to:

– Hypertrophy of adenoids – Polyp(s) – Neoplasm

Allergic Rhinitis

Often characterized by the presence of the triad: sneezing, aqueous nasal secretions and itching of palate, eyes, nose and/or throat (Fig. 3.6).

Allergic Rhinitis

46

Clinical PresentationWhen taking the medical history, you should also look for data that can identify the potential allergen(s) such as:

• Dust• Pollens• Feathers• Mould• Spore• Animal dander

ExaminationTypical findings at the clinical examination are:

• Oedema of the inferior turbinate• Pale colour of the nasal mucosa• Wet nasal mucosa• Choanal space reduction• Allergic dermatitis

Clinical Management• Medicinal products for topical use.• Steroids for nasal use. They are also available in aqueous forms that cause less

easily nasal bleeding.• Allergen(s) avoidance.• Anticholinergics for topical use if the rhinorrhoea is predominantly watery.• In the case of cacosmia and facial pain, a study of the paranasal sinuses is essen-

tial before starting the steroid use.

Fig. 3.6 Swollen inferior turbinate in allergic rhinitis

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• Oral therapy supports topical treatment. In case of nasal symptoms or persistence of non-nasal symptoms, their use is particularly recommended and relies on:

– Anti-histamine – Pseudo-ephedrine – Anti-histamine and sympathomimetics

• Inhalation therapy. Perhaps not as popular in the UK as it may be in the rest of Europe, it is based on the use of:

– Menthol – Steam – Eucalyptol

– Inhalations reduce pain in sinuses and reduce nasal obstruction most often, up to 2 h.

• Immunotherapy – This is still not widely available. Fujisawa (2015) suggests that to make the therapy more effective, it is preferable to start it as early as possible, hopefully in infancy. But it is still difficult at present because of relatively fre-quent adverse events and invasive manner of administering allergen extracts for young children. It would need a referral to an allergologist.

• Surgery – Surgical interventions aim to reduce the volume of the turbinate which is recommended when:

– Nasal obstruction is severe. – Medical treatment does not give good results. – Turbinate reduction improves airflow and the distribution of medicines for

topical use.

Vasomotor Rhinitis (Fig. 3.7)

Clinical PresentationVasomotor rhinitis in many ways resembles allergic rhinitis, but it is not triggered by an allergen and its cause is currently unknown. It can be exacerbated by:

• Perfumes• Spray• Air temperature changes• Tobacco smoke or other irritants

In addition:

• There is not usually an associated itch• The obstructed side is generally alternating• Can co-exist with an allergic form• Sometimes it is associated with puberty and hormonal changes• Its onset may be associated with anxiety and frustration• Watery nasal discharge is typical

Vasomotor Rhinitis

48

Examination• Vasomotor rhinitis can be sub-classed as ‘runners’ that exhibit wet rhinorrhea• Dry vasomotor rhinitis – with airflow resistance and nasal obstruction with lim-

ited rhinorrhea

Clinical ManagementClinical management mirrors that of allergic rhinitis. The distinction between aller-gic rhinitis and vasomotor rhinitis may be clinically challenging and it is most often dictated by history data rather than by the appearance of the nasal mucosa.

Nasal Polyps (Fig. 3.8)

Clinical PresentationSymptoms develop in a gradual, progressive way and are very often in the context of an allergic rhinitis or vasomotor rhinitis. In addition, there is often a history of:

• Previous nasal polypectomy• Decreased sense of smell• Recurrent sinusitis

Examination• Alterations in facial appearance• Assess inferior turbinate, anterior septum and middle meatus• Assess posterior wall for polyposis• Undertake otoscopy – extensive polyposis can lead to Eustachian tube dysfunc-

tion and cause otitis media

Clinical Management• In the case of mild symptoms, intra-nasal drops such as Beclomethasone should

be applied twice daily with the head in extended position.

Fig. 3.7 Vasomotor rhinitis with watery discharge

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49

• Alternatively, you can use a steroid spray.• An x-ray of the sinuses may be useful to detect possible hydro-air levels, but it is

nowadays rarely requested as CT and MRI scan are easily available and do offer significant diagnostic advantages.

• An oedema or thickening of the mucosa of the paranasal sinuses is acceptable, if minimal.

• We recommend smoking cessation.• ENT specialist advice should be sought when:

– Drug therapy does not produce acceptable results – Severe nasal obstruction – A neoplastic pathology is suspected due to the presence of unilateral polyp,

with or without nasal bleeding

0 1 3 42

MT MT MTMT MT

IT IT ITIT IT

Fig. 3.8 Nasal polyposis and its grading (Lund and Mackay 1993)

Key PointsIn the case of nasal polyps, one must always keep in mind that this is a recur-rent disease, so the topical steroid therapy should be maintained.

RED FLAGS

Bloody discharge

Unilateral growth

Facial swelling

Polyps in children could mean cystic fibrosis

Nasal Polyps

50

Allergy Testing

The allergy testing can be made via cutaneous stimulation, the patch and the prick test, or via blood collection using the RAST test. The latter can be directly arranged by GPs. The skin tests require the support of a Resuscitation Department and the patient should stay in observation for a couple of hours. A referral should be arranged, but the purpose of skin tests is limited and often impractical. Even from a commercial point of view, the advantages are much reduced, and because of this it is not easy to find the necessary kit. The RAST test (radio absorbent sensitivity test) is easily obtainable, although expensive; it can be carried out on a sample of venous blood.

Septal Deviation

Examination• May be associated with deformity of the nasal pyramid.• There may be a history of trauma of the nasal pyramid.• Unilateral nasal obstruction is often present.• There are often coexisting changes of the nasal mucosa, such as compensatory

hypertrophy of the turbinates.

Clinical Management• Refer to a specialist if nasal obstruction is only due to septal deviation.• In case of co-existence of rhinitis, treat the rhinitis first, and if that’s not enough,

refer to a specialist.

Inspiratory Nasal Valve Collapse

A certain degree of movement of the nostrils during inhalation is normal. However, a collapse of the nostril(s) is pathological and leading to nasal obstruction. In this case, the patient should be referred to an ENT specialist (Fig. 3.9).

Nasopharyngeal Obstruction

The causes of nasopharyngeal obstruction include:

• Hypertrophic adenoids in children (Fig. 3.10)• Antro-coanal polyps• Craniosynostosis

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• Post-surgical scarring• Tumours

Examination• Look for dysmorphic features• Perform anterior rhinoscopy• Assess oropharynx• Both in adults and in children look for possible ear pathology• Cervical lymph nodes: palpate for any inflammatory or neoplastic pathology

Clinical Management• This highly depends on the cause of the obstruction. Referral to the ENT special-

ist is required and if the adenoids are deemed to be responsible for the obstruc-tion, they may require adenoidectomy.

Fig. 3.9 Collapse of the nasal valve

Fig. 3.10 Adenoids hypertrophy

Sinusitis

52

Sinusitis

Sinusitis it is common presentation in primary care (Fig. 3.11).

Clinical PresentationThe following symptoms suggest the possibility of sinusitis:

• Cacosmia• Facial pain and tenderness of the maxillary and frontal sinuses• Nasal obstruction• Mucopurulent rhinorrhoea• Fever associated with symptoms listed above, peri-orbital oedema or swelling of

face (or Pott’s oedema) can occur as a complication of sinusitis but it is unusual with proper medical treatment

• Sensation of congestion of upper respiratory tract, head, and ears• Dizziness• Hyposmia

Examination• Rhinoscopy to ascertain the presence of nasal discharge• Assess for fever• Facial tenderness

Clinical Management• In the event of Pott’s oedema, refer immediately to the ENT specialist• Antibiotic therapy may be indicated if sinusitis does not respond to home reme-

dies or symptoms are severe• Analgesia

Fig. 3.11 Purulent sinusitis

3 Rhinology

53

• Menthol/inhalations• Refer to the specialist in case of non-resolution of symptoms

Recurring Rhinosinusitis

Examination• A minimum mucosal thickening without hydro-air levels is common and not

necessarily pathological, and a diagnosis of rhinitis, rather than of sinusitis, should be taken into account.

• Bone erosions are suggestive of neoplastic disease and require urgent specialist clinical evaluation.

• Small cystic lesions of maxillary sinuses are common and do not require treatment.

Clinical Management• Imaging may help to assess the presence of chronic disease. GP may request

x-rays with chin-occipital view to evaluate the maxillary, frontal and ethmoid sinuses.

• An acute exacerbation of a recurring form requires the use of metronidazole and penicillin, or macrolide.

• Analgesia.• Menthol/inhalations.• In an allergic rhinitis, nasal steroid are useful.• Nasal polyposis can respond to the nasal steroid spray or drops.• Referring to a specialist is required in case of:• Frequent recurrences• Large nasal polyps• Large septal deviation• Suspect of neoplastic pathology

In the absence of radiographic abnormalities, diagnosis of sinusitis is highly unlikely. The clinician should consider other possible causes of facial pain and in particular the contact between nasal concha and septum.

Key PointsRhinitis medicamentosa is a disease that results from prolonged use of decon-gestants. If a patient presents with nasal obstruction and nasal mucosa oedema after a period of prolonged use of decongestants, refer to a specialist as may require surgical correction.

Unilateral nasal secretion in a child is believed to be due to the presence of a foreign body until proven otherwise and it requires an urgent ENT referral.

Children are not prone to nasal polyps and their presence should trigger the suspect of cystic fibrosis.

Sinusitis

54

References

Fujisawa T (2015) Allergen immunotherapy in children. Arerugi 64:787–794Lund VJ, Mackay IS (1993) Staging in rhinosinusitus. Rhinology. 31:183–184

Patients from tropical regions, or sub-tropical, may take a couple of years before showing signs of dust allergy.

Nasal polyps should always trigger an ENT referral if unilateral.Steroid drops should be avoided in the long term in favour of spray.Remember nasal valve incompetence as a cause of nasal obstruction.Posterior nasal drainage is a nonspecific symptom.Facial oedema is always indicative of complications and the patient should

be referred to a specialist.Unilateral nasal bleeding with obstruction, or facial pain, should be sent to

a specialist with a suspect of neoplastic pathology.

3 Rhinology

55© Springer International Publishing AG 2017 E. Cervoni, K. Leech, ENT in Primary Care, DOI 10.1007/978-3-319-51987-6_4

Chapter 4Laryngology

The Throat

Voice problems and sore throat are two of the most common complaints associated with the throat, larynx and hypopharynx regions. Voice disorders should be distin-guished in problems with the articulation of the voice, or dysarthria, and hoarseness, or dysphonia, when there is a change in the quality of the voice instead.

Hoarseness is the most frequent among the two. It is important to determine if hoarseness has been of a gradual onset or sudden onset. Gradual onset may be as a result of smoking or drinking alcohol, whilst sudden onset may be as a result of an infection or vocal abuse. Smoking and alcohol should be documented in all cases. A patient’s occupation may provide vital information to the history, especially if they use their voice in a professional way such as a singer. In these cases it is worth ask-ing the patient if they have experienced a change in their pitch or abnormal pitch range. The clinician should determine if their hoarseness is constant, or whether it changes throughout the day. Any exposure to chemicals or corrosive substances may also be important. Previous trauma, surgery or endotracheal intubation should be ascertained. Patients may describe their voice disturbances as breathy, hoarse, low-pitched, strained, and trembling or a feeling of vocal fatigue. Clinicians should be aware that specific voice disturbances could help the focus on a differential diag-nosis. For example, breathy complaints could indicate functional dysphonia, vocal cord paralysis or abductor spasmodic dysphonia.

Dysarthria results from a neurological injury of the phonation system. As such, the causes may be several, including multiple sclerosis, Parkinson’s disease, Parkinson plus syndromes, stroke, motor neuron disease and others. A sore throat itself is actually a symptom. Other common presenting symptoms include a feeling of a lump in throat, mucus in the throat and general discomfort. Sore throat is usu-ally caused by viral infection; however, the most common bacterial infection affect-ing the throat is Group A beta-haemolytic streptococcus. The clinician should ascertain the duration and severity of the symptoms, any dysphagia, rash or stridor,

56

whether the patient feels systemically unwell and whether there is the presence of trismus. Associated symptoms may include malaise, headache, rhinitis, cough and hoarseness. These symptoms are often benign in nature. However, can also be symptoms of malignancy. Patients with acid reflux may present with throat prob-lems. If this is linked with symptoms of dyspepsia or gastro-oesophageal reflux it should be investigated (Fig. 4.1).

Mouth and Throat Assessment

Tongue depressors, (Fig. 4.2) typically a disposable wooden spatula, are used to depress the tongue to allow the clinician to inspect the patient’s mouth and throat structures. Again an otoscope can be used as a torch to improve visualisation of the mouth and throat. A clinician should always wear gloves when performing an oral examination.

Oral mucosa

Pain Mouth Saliva

Taste

Ageusia

Parageusia

Dysgeusia

Hypogeusia

Reduced

Increased

General conditions andmedications

Ulcerations

Blisters

Bullae

Referred

Local tenderness

Odynophagia

Fig. 4.1 Mouth anamnesis map

Fig. 4.2 Tongue depressor

4 Laryngology

57

Mouth, throat and neck examination

• Scars and nodularity• Symmetry of the face and lips• Speech quality• Teeth• Soft and hard palate• The oral mucosa and the retro-molar trigon• Palpation of the floor of the mouth, neck, and salivary glands

Sore Throat

It is a frequent symptom and often associated with viral upper respiratory tract infection.

Pharyngitis

Clinical Presentation• Sore throat or dryness of the throat• Worse in the morning• Absence of systemic impairment• The patient may have sense of nasal obstruction especially at night• Cold symptoms

– Acutes – Chronic (Fig. 4.3)

Examination• Check the nasal passages• Check the sinuses• Check oropharynx, mouth, and tonsils• Assess cervical lymph nodes

Clinical Management• Invite to stop smoking• Advise to stop or reduce to recommended limits alcohol intake• Refer to a specialist in case of failure to respond to previous approaches

Other Causes of Pharyngitis

• Iatrogenic, from prolonged use of antibiotics or topical steroid• Anti-inflammatory causing agranulocytosis• Dental caries

Sore Throat

58

• Tobacco• GORD• Alcohol• Occupational irritants• Vocal abuse• Venereal diseases

RED FLAGS

Presence of traces of blood

Smoker/ Age greater than 40 years

Unilaterality

Tonsillitis (Fig. 4.4)

Clinical Presentation• Major general prostration• Fever• Cervical adenopathy• Otalgia• Halitosis

Fig. 4.3 Chronic pharyngitis

4 Laryngology

59

ExaminationThe Centor criteria are particularly useful to corroborate the diagnostic suspect giv-ing an indication of the likelihood of a sore throat being due to bacterial infection. The criteria are:

• Tonsillar exudate• Tender anterior cervical adenopathy• Fever over 38 °C (100.5 °F) by history• Absence of cough

If 3 or 4 of Centor criteria are met, the positive predictive value is 40–60%. The absence of 3 or 4 of the Centor criteria has a fairly high negative predictive value of 80%. Also of good clinical value is the streptococcal score card. This gives an indication of the likelihood of a sore throat being due to infection with group A beta- haemolytic streptococci (GABHS). The criteria are (Centor et al. 1981):

• Age 5–15 years• Season (late autumn, winter, early spring)• Fever (≥38.3 °C [≥101 °F])• Cervical lymphadenopathy• Pharyngeal erythema, oedema, or exudate• No symptoms of a viral upper respiratory infection (conjunctivitis, rhinorrhoea,

or cough)

If 5 of the criteria are met, a positive culture for GABHS is predicted in 59% of children; if 6 of the criteria are met, a positive culture is predicted in 75% of children.

Fig. 4.4 Bacterial tonsillitis

Sore Throat

60

Peri-tonsillar Cellulitis

• Peri-tonsillar redness and oedema• Lock of the jaw, but not marked

Peri-tonsillar Abscess

• Evolution of peri-tonsillar cellulitis• Symptoms and signs of peri-tonsillar cellulitis• Lockjaw

ExaminationThe appearance of the tonsils between episodes of acute tonsillitis does not help much the diagnosis. At times, the tonsils are hypertrophic, sometimes to the point to cause snoring, or airway obstruction. In other cases, they may be cryptic. Some caseous material may be found in the cryptae of the tonsils, hinting chronic inflam-mation with dysfunctional tonsils. During periods of acute sore throat, in case of viral infection, you may observe:

• Redness and oropharyngeal mucosa and oedema with or without ulcerations

• In the case of unilateral ulceration of the pharynx, consider herpetic infection

• Petechiae of the palate• Oedema of the uvula• Cold sores of the nostril

In case of tonsillitis, you can demonstrate:

• Limited redness, swelling of the tonsils and of the tonsillar pillars• Pus in the tonsillar crypts• Halitosis• “Hot potato voice”• Redness of the face• Fever• Painful cervical adenopathy• General malaise

In the case of mononucleosis:

• Halitosis• “Hot potato voice”• Petechiae on the palate• Tonsils swollen with whitish patina• Fever• Adenopathy• Liver and spleen may be enlarged• Jaundice may be present• General malaise

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61

Clinical Management of Tonsillitis• In sore throats without lockjaw, or other complications, soluble aspirin is a good

option in the adult only. In children, paracetamol and ibuprofen should be preferred.• The majority of patients with sore throat may have already tried to manage their

disease for at least a day with analgesia before presenting to the family physician.• At this point, having made a diagnosis of tonsillitis, antibiotic therapy, preferably

with penicillin V, erythromycin, or clarithromycin, for 10 days rather than 5 or 7 days, is an option (Little et al. 1997).

• Refer to the specialist in case of recurrent tonsillitis requiring antibiotic therapy in line with local referring policy.

Clinical Management of Infectious Mononucleosis• Do not advise antibiotic therapy as this would not help.• It may require a prolonged period of rest.• Liver disease may occur, but often it is not clinically significant (Fig. 4.5).

• The Monospot test or blood smear on a slide helps to confirm the diagnostic suspect

• Supra-infection may require specific treatment

RED FLAGS

Trismus (reduced mouth opening)

Hot potato voice

Patients unable to swallow their own saliva or smallamounts of fluid

Quinsy/abscess

Meningism

Fig. 4.5 Glandular fever

Sore Throat

62

Hoarseness

An anomaly of the voice:

• Tone• Quality• Pitch• Volume

Hoarseness is often associated with upper respiratory tract infection in otherwise healthy individuals, and viral causes in most cases (Fig. 4.6).

Examination• Weight loss: report immediately to a specialist for suspect neoplastic pathology• Weight gain: investigation for suspect of myxoedema• Associated with dysphagia: refer immediately to exclude malignancy• Otalgia: can suggest neoplastic pathology• Cervical adenopathy: can indicate neoplastic pathology• History of bronchitis and sinusitis• History of dyspepsia and GORD• Chemical trauma or smoke• Vocal abuse

Key PointsRefer to ENT asymmetrical swelling of tonsils, particularly if this is not asso-ciated with acute inflammatory condition.

Ampicillin/amoxicillin should not be used in a suspected mononucleosis.Recurrent pharyngitis in a debilitated and worsening patient requires blood

test to exclude hematologic pathology.

Social

hist

ory

General conditions History taking inneck & throat

disease

Dur

atio

n

Phonation

Pain

Swallowing

Years

Months

Weeks

Days

Dysphagia solid>fluids

Dysphagia solid<fluids

Dysphagia solid=fluids

Type

Duration

Onset

ProgressionReferred

Local tenderness

Cough

Fever

Other pathologies andmedications

Weight loss

Smoking

Alcohol

Fig. 4.6 Laryngology map

4 Laryngology

63

Clinical ManagementIt depends on the cause. Referral to a specialist is often required to exclude neoplas-tic pathology if hoarseness persists for more than 3 weeks.

• Restrict use of the voice (vocal cords rest)• Analgesia• Fumigation and vapours• Refer to a specialist hoarseness persisting for more than 3 weeks to exclude neo-

plastic pathology, nodules, or polyps• Chest x-rays

RED FLAGS

Persistence over 3 weeks duration

Pain

Dysphagia

Haemoptsis

Otalgia

Lump/neck mass

Smoker/age greater than 40 years

Dysphagia

Dysphagia is defined as difficulty swallowing (aphagia is its extreme form when swallowing becomes impossible) of fluids, solids, or both.

Acute Dysphagia

The most common causes are:

• Supraglottic inflammation (epiglottitis); this condition requires immediate refer-ral to the ENT specialist.

• Tonsillitis that causes pain, obstruction, or both.• Tonsillar abscess, which demands urgent ENT referral with hospitalization.• Mononucleosis, which may require hospitalization for fluid and steroid therapy.• Foreign bodies tend to show up in emergency rooms rather than at GP Surgery.

In case of this suspect, refer to a specialist urgently.

Dysphagia

64

Progressive Dysphagia

This should always trigger the suspect of oesophageal or pharyngeal neoplastic pathology in particular when associated to:

• History of weight loss and fatigue• First to solids and then to both fluids and solids• Hoarseness

Cough when drinking may suggest the possibility of aspiration. Anamnestic data suggesting a benign cause of progressive dysphagia are:

• Regurgitation: a barium swallow allows you to confirm a pharyngeal or oesopha-geal diverticulum. Refer to the specialist.

• A history of GORD suggests the possibility of a stricture due to oesophageal mucosal ulceration. Even in this case, refer to the specialist.

Other Causes

• Neurogenic dysphagia• Connective tissue disorders such as systemic sclerosis

Globus Pharyngeus

The sense of obstruction in the throat is a functional problem and it is otherwise known as globus pharyngeus, or hystericus. The term ‘pseudo-dysphagia’ also describes adequately the problematic.

• The knot in the throat improves swallowing, but returns immediately after.• It is variable.• There are no signs of obstruction.• There is often anxiety.

The patient should be referred to the specialist for endoscopic evaluation.

ExaminationGeneral examination should be looking for abnormal findings such as:

• Pallor• Weight loss• Abdominal masses• Abnormal chest examination• Cranial nerve abnormalities

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65

Local/district examination:

• Angular cheilitis• Glossitis• Neck masses• Masses of the oral cavity• Movements of the tongue, palate and pharynx• Sensory examination of mouth and pharynx

Clinical ManagementThe investigations should include:

• X-ray of the neck with side view• Chest x-ray• Barium• Basic blood tests

In case of a suspect neurological disorder, refer immediately to a specialist.

RED FLAGS

Ear Pain

Sore Throat

Symptoms of lateralization

Persistent hoarseness

Snoring

Snoring is the snorting or rattling noise some people may do when breathing during sleep. The noise comes from the vibration of the soft palate due to a turbulent air flow. Also the vibration for the mouth tissues, nose and throat can contribute signifi-cantly to its generation. Some people snore infrequently and the sound they make are not particularly loud, while others may snore every night loudly enough to disturb other people. From an anatomical point of view snoring is due to loss of tone of the muscles of the soft palate, including those of the uvula, but there are many contribut-ing factors to it, all of them contributing to the speed and turbulence of the air flow, or the capacity of vibrating of the soft tissues of the upper aero-digestive tract.

Snoring

66

Key Anamnestic Points

Apnoea: snoring may be associated with apnoeic episodes. Few, short episodes of apnoea may occur also in normal individuals, but apnoeic episodes that last more than 10 s and ending with a loud snoring, or heave with awakening, often temporary and partial, are suggestive of obstructive sleep apnoea syndrome (OSAS).

Epworth Sleeping Score: reference scale that makes possible to evaluate the severity of daytime sleepiness. With a score 10 < ESS the OSAS is unlikely. Sometimes children with OSAS may be hyperactive during the day (Fig. 4.7).

ExaminationGeneral examination

• Obesity• Arterial hypertension

Localized/district examination

• Nasal obstruction• Soft palate ptosis• Short, large neck• Mandibular retrognathism• Hypertrophy of tonsils• Hypertrophy of adenoids• Hypertrophy of lingual tonsil

Clinical Management• Weight loss.• Smoking cessation.• Avoid alcoholic drinks for 4 h before bedtime.

Fig. 4.7 OSAS and sites of obstructions of the upper airways

4 Laryngology

67

• Do not use hypnotics, or muscle relaxers at night.• Trial of mandibular snore ban type pusher. Optionally, refer the patient for poly-

somographic studies. A respiratory physician may advise continuous positive airway pressure (CPAP).

CPAP is a small machine that delivers a constant and steady air pressure through a hose to a mask or nose piece. Remember to tell the patient it is its obligation to inform the Driving Vehicles Licensing Authority.

RED FLAGS

Daytime sleepiness

Sleep apnoea observed by another person

References

Little P, Gould C, Williamson I, et al. (1997) Reattendance and complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics. BMJ 315:350–352

Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K (1981) The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1(3):239–246

References

69© Springer International Publishing AG 2017 E. Cervoni, K. Leech, ENT in Primary Care, DOI 10.1007/978-3-319-51987-6_5

Chapter 5Head and Neck

The Oral Cavity and the Neck

Any of the structures of the mouth may be involved in local disease or may be part of wider systemic pathology. Therefore a thorough history is needed to determine between the two. Certain symptoms such as xerostomia (dry mouth) should not be considered in isolation. This may be as a result of drugs, gland dysfunction or diabe-tes. Ulcerations of the oral mucosa could be as a result of local disease such as poor dental hygiene, gingivitis or systemic illnesses including anaemia, AIDS or HIV. Any ulceration that is red, white or pigmented lasting for longer than 3 weeks should be investigated. Angular stomatitis and tongue/mouth soreness could be from a haema-tological cause or iron deficiency. Any intraoral swellings that increase in size or pain associated with eating are usually as a result of salivary gland pathology. Patients who present with any lumps in the neck should be referred to an ENT specialist, so that they can be appropriately investigated to determine if they are secondary lymph nodes and the likely primary source. In patients presenting with a neck lump, it is worth investigating any symptoms of the tongue, mouth, nose or throat as these may identify the primary site. Enlarged lymph nodes may be a result of a previous infec-tion, so the clinician should determine if the patient has had any recent illnesses or infections. Symptoms associated with under-active or over-active thyroid should be determined. Associated symptoms such as weight loss, night sweats and malaise are suggestive of systemic diseases such as AIDS or lymphoma.

Neck Lump

All patients with an unexplained lump in neck that recently appeared, or a lump that was not diagnosed before and has changed during a period from 3 to 6  weeks, should be referred urgently to an ENT specialist.

70

Salivary Gland Lump

Patients with persistent unexplained swelling of a parotid, sublingual, or subman-dibular gland should be referred urgently to ENT.

Facial Palsy

The facial nerve controls the muscles of the facial expression and stapedius, the lac-rimal and submandibular glands, and the sensory function of the anterior 2/3 of the tongue. Hence, as well as facial droop, patients may present with drooling, hyperacu-sis, altered taste, speech issues, earache, dry eye and reduced corneal reflex. Facial palsy can be classified in central or peripheral. The two forms are differentiated clini-cal examination since the facial motors nuclei are two, one top and one bottom bilat-erally innervated that receives only a contra-lateral innervations. It follows that:

• Central facial palsy is incomplete, affecting only the lower half of the contra- lateral face.

• Peripheral facial paralysis is complete and ipsilateral and its severity can be clas-sified according to House and Brackmann (1985) (Fig. 5.1).

Herpes Zoster

Herpes affects the ear, mouth, pharynx and facial nerve. Even the acoustic nerve may be affected and is otherwise known by the name of Ramsay-Hunt.

Clinical Presentation• Ramsay-Hunt syndrome presents with severe otalgia Hunt JR (1907).• Burning pain several hours before onset of typical herpetic blistering.• Blistering rash will appear around the ear, face and sometimes in the oral

cavity.• The syndrome generally causes more severe symptoms and has a worse progno-

sis than Bell’s palsy has. Even if the latter, of which the exact reasons remain unclear, maybe likewise ascribed to herpetic infection.

• Accompanying vestibular symptoms such as vertigo, nausea and vomiting may be present.

5 Head and Neck

71

• Hearing can be reduced, with or without tinnitus.• The eye and mouth may be affected; the latter with alteration to taste, known as

disgeusia.

Examination• Examination will demonstrate a vesicular rash• Examination of facial nerves• Assessment of taste• Otoscope and hearing assessment• Pain and/or paraesthesia• If the vestibular system is affected, vestibular testing would show a deficit on the

same side of the lesion.• Middle ear pathology – The involvement of the facial nucleus lower motor neu-

ron is associated with ipsilateral otorrhoea and/or cholesteatoma.• Post-traumatic causes – Most often occur in the emergency room while occa-

sionally patients seek advice from part of GP. In this case, the patient should be reported immediately to the specialist. They may be: a temporal bone fracture, post-surgical, sharp/blunt facial trauma, or a birth canal trauma

Clinical Management• Analgesics• Acyclovir (topical or oral) if onset of symptoms is within 48 h• Protection of the cornea• EMG evaluation

Fig. 5.1 Peripheral facial paralysis

Facial Palsy

72

RED FLAGS

Suspect of stroke

Suspect of mastoiditis

Head trauma

Severe otitis externa

Bell’s Palsy

Bell’s palsy is a diagnosis of exclusion.

Clinical Presentation Complete• Can be preceded by otalgia.• Often the patient is believed to have had a stroke.

Examination Complete• The sense of taste in the front 2/3 of the tongue is affected, and the patient may

have watery eye and reduced corneal reflex. However, their recovery is often faster than the recovery of the motor function.

Clinical Management• In 75% of the cases, it resolves within 3 weeks from the onset and the lack of a

resolution within that span of time should suggest a request for specialist visits.• ACTH and corticosteroids have not been confirmed as effective. However, it is

believed that steroid tablets such as prednisolone help to reduce inflammation and are normally taken for 10 days.

• The eye should be protected and artificial drops prescribed.• In the case of a suspicion of damage to the cornea, refer to ophthalmologist.• In the case of a slow recovery, suggest physiotherapy with transcutaneous elec-

trical stimulation.• Consider alternative diagnoses in case of multiple neuropathies.

RED FLAGS

Otitis media

Cholesteatoma

Parotid tumour

Malignant otitis externa

Bilateral onset

5 Head and Neck

73

Other Causes

Other causes may be an acoustic neuroma, a parotid gland malignancy, a malignant otitis externa or Lyme disease.

References

House JW, Brackmann DE (1985) Facial nerve grading system. Otorlaryngol Head Neck Surg 93(2):146–147

Hunt JR (1907) On herpetiform inflammation of the geniculate ganglion: a new syndrome and its complications. Nerve Ment Dis 34:73

References

75© Springer International Publishing AG 2017 E. Cervoni, K. Leech, ENT in Primary Care, DOI 10.1007/978-3-319-51987-6_6

Chapter 6Post-operative ORL

Adenoidectomy

After adenoidectomy, the patient may experience post-operative bleeding and pain.

Post-operative BleedingBleeding after adenoidectomy surgery requires immediate hospitalization, with posterior nasal tamponade, if necessary.

Post-operative PainIt is in general minimal. If otalgia, perform otoscopy to exclude ear infection.

Trans-tympanic Tubes

It is not uncommon for a GP to be consulted by parents alarmed by the appearance of ear discharge from the very same ear where a drainage tube, this being a grommet or a T-tube, had been positioned by the ENT specialist some weeks or months before. The discharge may follow an upper respiratory tract infection or a bath with subsequent infection due to contaminated water, for example, penetrated in the mid-dle ear. It is reasonable to suggest topical antibiotic therapy as eardrops, or an oral antibiotic. The GP should be mindful of the ototoxicity of the aminoglycosides usu-ally present in the eardrops. Eye drops with ofloxacin or ciprofloxacin may be very helpful in similar circumstances. There is no conclusive evidence that swimming is risky for the child with trans-tympanic drainage. It is preferable to avoid shampoo and conditioner in your ear (Fig. 6.1).

76

Nasal Surgery

PainGenerally present in post-transplantation, especially because of nasal swabs inserted to prevent adhesions. In the absence of infection, use analgesia. In case of oedema or infection, the patient should be admitted to hospital.

Post-operative EpistaxisAn epistaxis after nasal surgery should be sent to a specialist immediately although a mupirocin cream like Naseptin can help.

Tonsillectomy

Post-operative BleedingMost often it occurs within the first 48 h. Generally, the patient is readmitted immedi-ately, in case he had been already discharged. Minor bleeding can occur up to 10 days after surgery and are most often caused by infection or detachment of granulation tissue from the loggia of the tonsils. Hospital readmission is required (Fig. 6.2).

Post-operative PainAlthough the patient is discharged with analgesia, sore throat in the subsequent days has to be expected and the patient may attend the GP surgery. It is on this occasion that the GP may confuse the granulation tissue with pus and infection. It may

Fig. 6.1 Grommet in place

6 Post-operative ORL

77

happen that the GP replaces an antibiotic that the ENT department initiated, assum-ing that this was not working. In addition, we must be cautious in the use of soluble aspirin for the risk of bleeding associated with NSAIDs. Paracetamol, codeine and ibuprofen are all valuable alternatives.

It is helpful to assure patients and their relatives that within a couple of weeks the situation will be resolved. As for the food, hard foods like nuts and chips should be avoided in favour of a liquid or soft diet. Eating little and often can be beneficial. Avoid a two-large-meals diet.

Oncology ORL

Neoplastic Suspect in ENT

The request for an urgent ENT appointment is recommended whenever you suspect a malignancy. Several signs and symptoms may be the trigger and they shall be illustrated in the following paragraphs.

Hoarseness

If hoarseness persists for more than 3 weeks, particularly in smokers over 50 years old and heavy drinkers, we recommend an urgent CXR.  Patients with positive results must be sent urgently to a team specialized in the management of lung can-cer. Patients with a negative result must be sent urgently to a team that specializes in cancer of the head and neck.

Fig. 6.2 Tonsillectomy

Oncology ORL

78

Sore Throat

In patients with sore throat unexplained and persistent, it is recommended that a request for an urgent ENT assessment should be arranged.

Otalgia with Sore Throat or Neck

In patients with unilateral unexplained pain in the area of the head and neck for more than 4 weeks, associated with ear pain (otalgia), but with normal otoscopy, you should formulate a request for urgent ENT assessment.

6 Post-operative ORL

79© Springer International Publishing AG 2017 E. Cervoni, K. Leech, ENT in Primary Care, DOI 10.1007/978-3-319-51987-6_7

Chapter 7Pharmacology

Antibiotic Prescribing

When prescribing, or considering prescribing antibiotics, it is advisable to:

• Document the indication/rationale for antimicrobial therapy, including clinical criteria relevant to this.

• Review and document the patient’s allergy status.• Ensure the choice of antibiotic complies with the antibiotic guidelines whenever

possible and to keep a record of any clinical criteria relevant to the choice of agent.• Document a management plan including duration of the treatment or review

date.• Where relevant, consider drainage of pus or surgical debridement/removal of

foreign material. To this aim, immediate ENT referral may be required.

Common ENT Antibiotic Prescribing in Primary Care (Fig. 7.1)

Common Prescriptions

Rhinitis

Beclometasone nasal sprayBudesonide nasal spray (Rhinocort Aqua)Betamethasone nose drops (Betnesol, Vistamethasone)Ipratropium bromide 21 μg/metered spray (Rinatec)Xylometazoline hydrochloride 0.1% (Otrivine)Fluticasone propionate 50 μgAzelastine hydrochloride 137 μg/metered spray (Dymista)

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Fig. 7.1 2016 Antimicrobial Guide and Management of Common Infections in Primary Care (From the Pan Mersey Area Prescribing Committee NHS 2016)

Clinical diagnosis Treatment advice Comments and guidelinesfor lab testing

Acute sore throat Centor>3Phenoxymethylpenicillin500mg qds for 10 days Inpenicillin allergy:Clarithromycin 500mg bd for5 days

Centor score 3 or above treatwith antibiotics. < 3 noantibioticsTake a throat swab inpersistent infections lasting3-4 weeks (CKS). Treatmentadvice also applies to ScarletFever but for 10 days

Acute viral sore throat No antibiotic indicated IssuePatient Information Leaflet(PIL) on viral sore throats Ifin doubt, use of deferredprescription is an option

Use CENTOR to guidediagnosis If 3 or 4 presenttreat as for bacterial sorethroatN.B. If symptoms persistrefer to ENT

Acute laryngitis No antibiotic indicated IssuePatient Information Leaflet(PIL) on viral sore throats

Acute sinusitis Use symptomatic relief(analgesia) beforeprescribing antibioticsAmoxicillin 500mg tds for 7days or Doxycycline 200mgstat. then 100mg od for 7days in total (for children

Avoid antibiotics as 80%resolve in 14 days without,and they only offer marginalbenefit after 7 days

Vertigo

BetahistineCinnarizine tablets (Stugeron)

Otitis Externa

Clotrimazole for ear infections (Canesten)Betamethasone ear drops (Betnesol, Vistamethasone)Dexamethasone (as sodium metasulphobenzoate) 0.05%, framycetin sulphate 0.5%,

gramicidin 0.005%. (Sofradex)Dexamethasone 0.1%, neomycin sulphate 3250 units/mL, glacial acetic acid 2%

(Otomize)Ofloxacin 0.3% (Exocin)

Sore Throat/Mouth

Benzydamine spray (Difflam)Chlorhexidine mouthwash (Corsodyl)Mucoadhesive buccal tablets of hydrocortisone 2.5 mg (as sodium succinate)

7 Pharmacology

81

under 12 use clarithromycininstead of doxycycline) Forpersistent symptoms Co-amoxiclav 500/125mg tds for7 days

Chronic sinusitis Refer to ENT and treataccording to advice

Labyrinthitis Antibiotics not indicated Bacterial Parotid glandinfection (usuallyunilateral)

Flucloxacillin 500mg qds for7 days In penicillin allergy:Clindamicin 450mg qds for7 days

Ensure the patient is hydrated

Acute otitis media First line treatment isparacetamol or ibuprofen andobserve If no improvementafter 72 hours; Amoxicillin500mg tds: for 5 days Inpenicillin allergy:Clarithromycin 500mg bd for5 days

80% of cases will resolve in72 hours. If no vomiting andtemp < 38.5 use paracetamolor ibu profen.

If in doubt, use a delayedprescription.

Immediate antibiotictreatment should be Acute(AOM) considered forbilateral AOM in 3 episodesin 6 months or >5 episodes in12 months

Chronic otitis media Refer to ENT Otitis externa First use aural toilet

(if available) and analgesia.First line: Acetic acid 2%(EarCalm®) 1 spray tds for7 days. Second line: Neomycinsulphate with corticosteroidand acetic acid (Otomize®)1 metered spray tdsThird line: Ciprofloxacin0.3% eye drops (Ciloxan)2 drops three times a day asear drops for 7 days if: swellingis so severe that topicaltreatment cannot beadministered in the form of aspray or there is confirmed orsuspected tympanicmembrane perforationIntermittent or prolonged(>7 days) use should beavoided in primary care.For cellulitis or extensive

If cellulitis or diseaseextending outside ear canal,start oral antibiotics andrefer. In severe infection ofthe pinna, swab to excludepseudomonas Caution:Topical neomycin has beenknown to cause ototoxicityand must not be used if thereis a suspicion of ear drumperforation. See third linerecommendation (unlicensedindication)

infection to outside ear canal:Flucloxacillin 500mg qds for5 days In penicillin allergy:Clarithromycin 500mg bd for5 days For fungal infectionsuse clotrimazole solution1%, apply 2-3 times daily until14 days after cure

Fig. 7.1 (continued)

Common Prescriptions

82

Glue Ear

Autoinflation nasal balloon (Otovent)

Reference

Pan Mersey Area Prescribing Committee NHS (2016) Antimicrobial guide and management of common infections in primary care 11–14

7 Pharmacology

83© Springer International Publishing AG 2017 E. Cervoni, K. Leech, ENT in Primary Care, DOI 10.1007/978-3-319-51987-6

References

BMJ Best Practice (2016) Tonsilitis [online]. http://bestpractice.bmj.com/best-practice/mono-graph/598/diagnosis/criteria.html

British Society of Audiology (2014) Recommended procedure for Hallpike maneuver [online]. http://www.thebsa.org.uk/wp-content/uploads/2014/04/HM.pdf

Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K (1981) The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1(3):239–246

Corbridge RJ (2011) Essential ENT. 2nd edn. CRC Press, LondonCross S, Rimmer M (2007) Nurse practitioner manual of clinical skills, 2nd edn. Elsevier, LondonFujisawa T (2015) Allergen immunotherapy in children. Arerugi 64:787–794Hain TC (1997) Approach to the Vertigo. In: Practical neurology. Lippincott-Raven, PhilidelphiaHarkin H (2007) Ear care guidance from the NHS Modernisation Agency. NHS Modernisation,

LondonHelman CG (1981) Disease versus illness in general practice. J R Coll Gen Pract 31:548–562House JW, Brackmann DE (1985) Facial nerve grading system. Otorlaryngol Head Neck Surg

93(2):146–147Hunt JR (1907) On herpetiform inflammation of the geniculate ganglion: a new syndrome and its

complications. Nerve Ment Dis 34:73Kurtz SM, Silverman JD (1996) The Calgary-Cambridge Referenced Observation Guides: an aid

to defining the curriculum and organising teaching in communication training programmes. Med Educ 30:83–89

Lemajic-Komazec S, Komazec Z (2006) Initial evaluation of vertigo. Med Pregl 59(11–12):585–590Lloyd S, Tan ZE, Taube MA, Doshi J (2014) Development of an ENT undergraduate curriculum

using a Delphi survey. Clin Otolaryngol 39:281–288Neighbour R (1987) The inner consultation. Lancaster, MTPPan Mersey Area Prescribing Committee NHS (2016) Antimicrobial guide and management of

common infections in primary care 11–14Pendleton D, Schofield T, Tate P, Havelock P (1984) The consultation: an approach to learning and

teaching. Oxford University Press, OxfordSmith R (2003) Thoughts for new medical students at a new medical school. BMJ.

327(7429):1430–1433

85© Springer International Publishing AG 2017 E. Cervoni, K. Leech, ENT in Primary Care, DOI 10.1007/978-3-319-51987-6

AAdenoidectomy, 51, 75Adult deafness, 25Allergic rhinitis, 40, 43, 45–48, 53

BBell’s palsy, 70, 72

CChild deafness, 23

DDysphagia, 55, 62–64

EEar syringe, 9Epistaxis, 2, 39, 42–44, 76

FFacial palsy, 6, 70–71Fistula test, 10, 37–38Frenzel goggles, 8, 9, 31Fukuda stepping test (FST), 32

GGlobus pharyngeus, 64–65Glue ear, 24, 25, 82

HHalitosis, 58, 60Hallpike test, 32–33Head-shaking nystagmus, 31, 32Hearing tests, 8, 25–30Herpes zoster, 70–72Hoarseness, 2, 55, 56, 62–65, 77–78

NNasal obstruction, 39, 40, 44, 45, 47–50, 52,

53, 57, 66Nasal polyps, 45, 48–50, 53, 54

OOtalgia, 5, 6, 11–12, 15, 16, 19, 21, 23–25,

39, 58, 62, 70, 75, 78Otitis externa, 12–13, 18, 19, 28, 29, 73, 80,

81Otoscope, 6, 7, 10, 19, 28, 29, 37, 40, 41, 56,

71

PPharyngitis, 57–58, 62

RRecurring rhinosinusitis, 53–54Rhinitis, 45, 53, 56, 79Rhinosinusitis, 53–54Rinne, 8, 25–27, 30

Index

86

SSaccades, 31Septal deviation, 42, 45, 50, 53Sinusitis, 40, 48, 52–54, 62, 80, 81Smooth pursuit, 31Snoring, 60, 65–66Sore throat, 39, 55–62, 76, 78, 80–81

TTinnitus, 2, 6, 19, 21, 22, 29–36, 70Tonsillectomy, 76–77

Tonsillitis, 5, 11, 15, 58–63Trans-tympanic tubes, 75–76Tuning forks, 8, 9, 26, 30

VVasomotor rhinitis, 47–48Vertigo, 6, 19, 21, 22, 33–38, 70, 80

WWeber, 8, 27–30

Index