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Key learning points on ENT




Key questions: Hearing problems

+ The prevalence of hearing impairment is around 53% of the population aged 71-80 years.

+ Assessment for any patient complaining of hearing loss consists of an otological history and examination.

+ A cochlear implant does not restore normal hearing levels but enables patients to acquire and understand spoken language.

+ Patients with an implant are at an increased risk of pneumococcal meningitis.

+ Deafness can be subdivided into pre-lingual and post-lingual.

+ The prevalence of tinnitus in patients with normal hearing is 15-35%.

+ The prevalence of tinnitus in patients with presbyacusis is 70%.

+ Hearing aids are the first-line treatment for patients with tinnitus and hearing loss. But their efficacy against tinnitus varies between individuals.

+ Induction loop systems work by transmitting a sound signal in the form of a magnetic field, which is picked up by the T setting on a hearing aid.

+ Childhood screening tests depend on the age of the child, their intellect and their motor ability.

+ Persistent glue ear can lead to hearing loss.

+ Children should usually be referred to the local community audiology service, not ENT.

+ Babies and young children can appear to startle and react to sounds even if they have significant hearing problems.

+ The parents of any baby who missed a hearing screen in hospital should be encouraged to be assessed as outpatients.

ENT emergencies in primary care

+ If the foreign body in the ear is an organic object, such as a living insect, mineral oil should be poured into the patient’s ear.

+ A patient with a watch battery in the ear should be urgently referred, but do not syringe.

+ Auricular haematoma should be suspected when there is a fluctuant swelling of the pinna, especially after trauma or sporting injury.

+ The most common organism causing perichondritis is Psuedomonas aeruginosa.

+ Sudden sensorineural hearing loss is usually a rapid-onset loss of significant hearing – 30 decibels or more below normal within 72 hours – and is labelled as being idiopathic in 60% of cases.

+ Tuning-fork tests should help to confirm sensorineural, rather than conductive, deafness.

+ Septal haematoma or a fractured orbital floor requires immediate referral.

+ Patients with epistaxis should be advised to pinch the nose firmly for 20 minutes with the head bent forwards.

+ The ‘parent’s kiss’ is successful in removing nasal foreign bodies in up to 80% of children.

+ Rhinosinusitis can spread locally to the orbit via the ethmoid sinuses.

+ Quinsy starts with unilateral sore throat with mild otalgia, and progresses to trismus, drooling of saliva and odynophagia.

+ In an emergency airway obstruction, the following can be administered: oxygen, nebulised adrenaline 5ml 1:1,000 and consider hydrocortisone IM.

Ten Top Tips: Otitis externa

+ Acute otitis media sometimes needs to be treated systemically, but otitis externa rarely does.

+ Rapid onset – usually within 48 hours – is characteristic of acute otitis externa.

+ Well over 90% of otitis externa is bacterial, usually Pseudomonas aeruginosa or Staphylococcus aureus.

+ Fungal infections are rarer and usually follow long antibiotic courses.

+ Irritants, including topical medications, earplugs or hearing aids, may be involved.

+ Patients with malignant otitis externa are typically elderly and diabetic with severe, unremitting otalgia, aural fullness, otorrhoea and hearing loss.

+ There is very little evidence to support the use of steroid-only drops for otitis externa.

+ There is evidence that up to 60% of people self-administering ear drops don’t do it properly.

+ Oral antibiotics are often prescribed inappropriately for otitis externa.

+ Mild to moderate pain usually responds well to paracetemol or an NSAID.

+ Recommendations to prevent acute otitis externa are aimed at keeping the ear canal dry.

+ If symptoms last beyond two weeks once treatment has started, it is classified as a treatment failure.

ENT malignancies

+ Men are twice as likely to be diagnosed with cancers of the nose and sinuses as women.

+ Early symptoms of cancer of the nose and sinuses are non-specific, so a high index of suspicion is needed.

+ Thyroid cancer is uncommon, but between 15-20% of the UK population have a palpable goitre, of which half are nodular.

+ Patients with nodules who have abnormal thyroid function tests should be referred non-urgently.

+ Thyroid cancer has an incidence in the UK of approximately 1,200 cases per year.

+ Oral cancer is the eighth most common cancer worldwide.

+ Red and white patches of the oral mucosa that are painful, swollen or bleeding require urgent referral.

+ Smoking and alcohol consumption are the most common aetiological factors in the development of mouth cancer.

+ Investigations for head and neck cancer in primary care are not recommended because they can delay referral.

+ Incidence of laryngeal cancer peaks in men aged 55-65.

+ The cardinal symptom of laryngeal cancer is progressive, continuous hoarseness.

+ Dual-modality treatment – either chemoradiation or surgery and post-operative radiotherapy – is commonly used in more advanced laryngeal cancer.

+ Salivary cancers are uncommon, comprising 3% of primary head and neck cancers in the UK.

+ Salivary cancer usually presents as lumps over the major salivary glands.

+ A salivary lump should be referred under the two-week rule.

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