5. ENT and General Practice

Question 1

List the ENT conditions studied, which can be adequately treated, unsupported, by a General Practitioner?

Answer 1

Wax
Uncomplicated OM (Acute and Chronic)
Simple URTI
Certain FB only
Minor Trauma

Question 2

List the conditions studied, which are best treated on an elective ENT basis?

Answer 2

Otitis Externa
Reluctant and Chronic Safe OM
Hoarseness and Dysphagia (>2weeks = laryngoscopy)
Neck Lumps
Chronic Adenotonsillar hypertrophy
Nasal Polyps

Question 3

List the conditions studied, which require urgent/emergency ENT intervention?

Answer 3

Complicated OM, sinusitis, URTI
Pediatric Upper Airway Problems
All Abscesses 
All Trauma
All FB
All tumours
Respiratory distress /stridor

Question 4

Distinguish between complicated and uncomplicated Otitis Media?

Answer 4

Complicated = OM from which complications have developed, e.g. Mastoiditis

Question 5

Distinguish between safe and unsafe chronic otitis media?

Answer 5

Safe = Perforation and can be managed by G.P.

Unsafe type = Kerattin formation in the attic region = ENT

Question 6

What should a G.P. Be conscious of in the patient with otitis externa?

Answer 6

Looking out for signs of squamous cell carcinoma (canal mass, pain, hearing loss)
They may try antibiotics to treat OE but referal to outpatient ENT is the usual.

Question 7

What intervention might be used in the context of stubborn wax impactation?

Answer 7

Micro Ear (Direct Vision and suction)

Question 8

From what locations does referred oltagia often orginate? For each explain why?

Answer 8

Temporal-Mandibular Joint (teeth grinding, due to stres)
Parotid
Dental (due to shared innervation of trigemial)
Cervical Spine (Disc Degeneration)
Tongue Base (Glossopharyngeal Nerve)

Question 9

What is the Ddx for presentation with loud tinnitus?

Answer 9

SNHL

Question 10

How is facial nerve palsy (Bells) diagnosed?

Answer 10

Diagnosis of exclusion?

Question 11

What constitutes “full facial palsy”?

Answer 11

All the facial muscles

Question 12

What conditions are important to rule out in facial palsy?

Answer 12

Tumour of the Pons
Tumour of the Parotid

Scan (including skull base)

Question 13

What is the usual course of a new bells palsy?

Answer 13

Most patients make a complete recovery?

Question 14

What are the complications of a bells palsy?

Answer 14

Eye (Exposure Keratisits)
Swallowing (buccal mouth control)
Taste disturbance

Question 15

What might be done by a G.P. to rule out viral involvement in Acute Otitis Media?

Answer 15

Hold of antibiotics for 24/Hrs

Question 16

What are some of the characteristic of Glue ear?

Answer 16

Common in children
Usually painless
Appearance extremely variable
Drum can be sucked in by negative pressure
Sometimes honey appearance, sometimes golden.

Question 17

What should be done before beginning ENT interventions for Glue Ear?

Answer 17

Must wait at least 3 month since 90% will resolve and 10% will not resolve w/o intervention.

Question 18

What is the treatment for Glue ear which has not resolved after 3 months?

Answer 18

Tube 9grommet) inserted, which ventilates the middle ear giving it time to recover
The grommet falls out after around 9 months as the tympanic membrane seals itself.
Do audiogram + tympanometry
In adults always check Nasopharynx for carcinoma (effusion)
Medical Therapy

Question 19

Distinguish between safe and unsafe Chronic Suppurative Otitis Media?

Answer 19

Perforation location…
Pars Tensa = Safe
Atticocoantral = Unsafe

Question 20

What are the characteristics of chronic suppurative otitis media?

Answer 20

Otorrhoea

Polyps and granulation tissue, bleeding on contact (unsafe)

Question 21

What is the Tx for chronic suppurative otitis media?

Answer 21

Aural Toiler
Surgery (repair of the ear drum) esp. if attic disease

(See flow chart)

Question 22

How should polyps in the nasal cavity be treated?

Answer 22

Polyps bilateral → GP (steroids) → ENT if necessary
Unilateral Polyps → Urgent ENT
Septal Problems → Elective ENT

Question 23

How should nasal trauma be treated?

Answer 23

The most minor might be treated by a G.P
Anything else ENT
In the case of a haemotoma must find or risk necrosis

Question 24

What is the treatment for acute sinusitis?

Answer 24

Give Augmentin/Cefuroxime

Nasal Drop Steroids

Question 25

What is the worry with infection of ethmoid sinus?

Answer 25

Spread to the eye.

Question 26

What are the 4 phases of sinusitis?

Answer 26

Inciting Phase
Ostial Obstruction
Bacterial Phase
Ostiomeatal COMPLEX

Question 27

Describe chandlers classification on the spread of sinusitis.

Answer 27

Orbital Cell
Post Septal Cell
Subperiosteal Abscess
Orbital Abscess
Cavernous Sinus Thrombosis

Question 28

Outline the 8 divisions of the oral cavity for the purposes of an oral examination

Answer 28

• Ventral and dorsal tongue
• Hard Palate
• Upper and lower alveolus
• Floor of mouth
• Lips
• Buccal mucosa

Question 29

Is peritonsillar abscess a form of tonsillitis?

Answer 29

A peritonsillar abscess (quinsy) is not a tonsillitis and is far more dangerous since can threaten the airway.
Uusally unilateral and there is swelling of the palate, complete distortion of the anatomy.
Treated with lancing with needle halfway between the uvula and the posterior molelar since you don’t want to hit the carotid which lies laterally.

Question 30

What drug is C/I in peritonsillar abscess and why?

Answer 30

Augmentin
Should be avoided in infectious mononucleosis as is suspected since the occurrence of a morbilliform rash has been associated with this condition following the use of amoxicillin.

Question 31

What are the indications for tonsillectomy?

Answer 31

Recurring definite tonsillitis (6py/4+attacks py for 2 years)
Quinsy (conservative = quinsey #2 )
Obstructive sleep apnoea (common in children as well)
Suspected malignancy.

Question 32

What are the potential complications of tonsillectomy?

Answer 32

Bleeding primary or secondary
Secondary usually one week post op
Always requires readmission
Often settles with conservative management

Question 33

Describe what is seen post-tonsillectomy?

Answer 33

Post tonsilectomey appearance
Prior to mucosalisation of the sloughs it will look pretty bad.
Eating and drinking helps to clear the debris

Question 34

What is the difference between snoring and OSA

Answer 34

Snoring = vibration of soft tissue structures located in the upper airway (soft palate, uvula, tongue base, nasopharynx) and usually occurs during inspiration.

Sleep Apnoea: It is characterised by loud snoring with periods of cessation of breathing lasting 10 seconds or more followed by gasping and choking. These episodes continue throughout the night.

Question 35

What is the Tx for obstructive sleep apnoea/snoring?

Answer 35

CPAP
Uvulopalatopharyngoplasty or UPPP
Laser assisted uvulopalatoplasty 
Adenotonsillectomy
Septoplasty