ENT presentation Barbara Adams and Mike - PowerPoint Presentation

1. ENT presentationBarbara Adams and Mike Pointon

2. Aims and objectivesKnow how to assess and manage common ENT problems in primary careKnow about watchful waiting and use of delayed prescriptionsKnow how and when to refer to ENT secondary care for non-urgent referralsKnow about ENT emergencies and how to refer

3. Ear

4. Acute otitis media (AOM) definitionsAOM: Infection in middle ear, characterised by presence of middle ear effusion associated with acute onset of signs and symptoms of middle ear inflammationRecurrent AOM: ≥3 episodes in 6m or ≥4 in 1y with absence of middle ear disease between episodesPersistent AOM (treatment failure): symptoms persist after initial management (no antibiotics, delayed antibiotics or immediate antibiotic prescribing strategy) or symptoms worsening

5. AOM: causes & complicationsBacterial infection: most common- strep pneumoniae, h influenzae (only 10% due to type B and preventable by HIB vaccine), moraxella catarrhalisViral infection: most common- respiratory syncytial virus and rhinovirusComplications: hearing loss; chronic perforation and otorrhoea, CSOM, cholesteatoma, intracranial complications

6. AOM: diagnosisPresents with earache (!)In younger children-non specific symptoms, e.g rubbing ear, fever, irritability, crying, poor feeding, restlessness at night, cough, or rhinorrhoeaMastoiditisAOMAOM

7. AOM Differential diagnosesOther URTI: may be mild redness of TM, self limitingOtitis media with effusion (OME)/ glue ear: fluid in middle ear without signs of acute inflammation of TMCSOM: persistent inflammation and TM perforation with exudate >2-6w. May lead to . . . . . . Acute mastoiditis (rare)- swelling, tenderness and redness over mastoid bone, pinna pushed forwardBullous myringitis (rare)- haemorrhagic bullae on TM caused by Mycoplasma pneumoniae (90% spontaneous resolution)

8. Management of AOM: when to refer or admit?Advise a no antibiotic or delayed antibiotic strategy for most people with suspected AOM but:consider antibiotics in children < 3m, bilateral AOMsystemically unwellhigh risk of complications e.g. immunosuppression, CF.For all antibiotic prescribing strategies: inform patient average duration of illness for untreated AOM is 4 days. Admit: According to “Feverish illness in Children” NICE GuidanceAdults and children with suspected complications e.g. meningitis, mastoiditis, or facial paralysisAmoxicillin or Erythromycin

9. Follow up of AOMRoutine follow up not usually requiredFollow up if: symptoms worse or not settling within 4 daysotorrhoea persists >2wperforation if hearing loss persists in absence of pain or fever, ie OMERecurrent AOM: Second line co-amoxiclavhttp://guidance.nice.org.uk/CG47 Feverish illness in childrenhttp://guidance.nice.org.uk/CG69 Respiratory Tract Infections

10. Otitis media with effusion (OME) / Glue earDefinition: non-purulent collection of fluid in middle ear (must be > 2/52 after recent AOM to be classed as Glue ear)Causes:Eustachian tube dysfunction> 50% due to AOM especially in < 3 yrsOther: low grade bacterial/viral infections; gastric reflux; nasal allergies; adenoids or nasal polyps; CF; Down’sPressure changes e.g. with flying or scuba diving (adults)Symptoms: hearing loss absence of earache or systemic upset can present with problems of speech/language development, behaviour or social interaction

11. Otitis media with effusion

12. Other causes of hearing loss (or perceived loss)-Foreign body in EACperforated TMSNHLlistening problems inc ADHD and learning difficultyInitial management of OMEAsk about developmental delay or language difficultiesHearing testDrugs not recommended as OME usually self limiting but consider ICS if there is associated allergic rhinitis

13. Early intervention with grommets gives no benefit for long-term hearing, language and behaviour and increases risk of TM abnormalities. Subgroup with hearing loss > 25DB may benefit from early grommet insertion.

14. OME general advice:good prognosis, self-limiting and >90% get resolution within 6m; limited proven benefit from drugsOME in adults is unusual in adults and need referral to ENT (unilateral could mean nasopharyngeal ca)Grommets – general points:usually stop functioning after 10m approx 50% require reinsertion within 5y conductive deafness after extrusion improves slowlyComplications are otorrhoea, may need specialist input.most activities unaffected, i.e. can fly and swim but avoid immersion; re hearing loss should face child when speakingAdenoidectomy: is usually second line treatment for OME but no UK national guideline; conflicting evidence.No evidence for Tonsillectomy in OME

15. Chronic Suppurative Otitis Media (CSOM)Symptomspersistent painless otorrhoea >2w May be preceded by AOM, trauma and grommetsDifferentialsOE, FB, waxAssessmentExclude intracranial involvement, facial paralysis or mastoiditis- needs admissionotherwise routine referral

16. Otitis externa (OE)Inflammation of EACLocalised OE: folliculitis that can progress to a furuncleDiffuse OE: more widespread inflammation e.g. swimmers earOE defined as: acute if episode<3w; chronic if >3mMalignant OE: extends to mastoid and temporal bones resulting in osteitis. Typically in elderly diabetics. Suspect if pain seems disproportionate to clinical findings

17. Localised OECauses: usually infected hair root by staph aureusSymptoms: severe ear pain (compared to size of lesion); relief if furuncle bursts; hearing loss if EAC very swollenSigns: tiny red swelling in EAC (early); later has white or yellow pus-filled centre which can completely occlude EACManagement: analgesia; hot compress; antibiotic only if severe infection or high risk patient - flucloxacillin or erythromycinRefer: if needs I+D, no response to antibiotic or cellulitis spreading outside EAC

18. Acute diffuse OECauses: bacterial infection- pseudomonas or staph aureusseborrhoeic dermatitisfungal infection- usually candidacontact dermatitis - meds (sudden onset) or hearing aids/earplugs (insidious onset)Symptoms: any combination of ear pain, itch, discharge and hearing lossSigns: EAC and/or external ear are red, swollen or eczematousserous/purulent dischargeinflamed TM – may be difficult to visualisepain on moving ear or jawInvestigations: rarely useful but if treatment fails, send swab for bacterial and fungal culture

19. Management: Use topical ear preparation for 7 days; 2% acetic acid for mild casesantibiotic plus steroid e.g. Locorten-Vioform Gentisone HC (NB not if perforation)If wax/debris obstructing EAC or extensive swelling or cellulitisPope wickDry mopping (children)Microsuction (ENT PCC)Advise re prevention of OE: keep ears clean and dry; treat underlying eczema/psoriasisFailure of topical meds: review diagnosis/complianceconsider PO fluclox or erythromycin?fungal (spores in EAC)Swab and refer

20. Chronic OECauses: Secondary fungal infection- due to prolonged use of topical antibacterials or steroidsSeborrhoeic dermatitis; contact dermatitisSometimes no cause can be found for OESymptoms:mild discomfort; pain usually mildSigns:lack of ear wax; dry, hypertrophic skin leading to canal stenosis; pain on examAssess risk /precipitating factors; severity of symptoms; signs of fungal infection- whitish cotton-like strands in EAC, black or white balls of aspergillus. Look for signs of dermatitis, evidence of allergy (ear plugs etc) or focus of fungal infection elsewhere, e.g. Skin, nails, vagina- can cause 2’ inflammation EAC Investigations:only take swab for C+S if treatment fails as interpretation can be difficult: sensitivities are determined for systemic use and much higher concentrations can be achieved by topical use; organisms may be contaminants, usually fungal overgrowth after using antibacterial drops due to suppressed normal bacterial flora

21. Chronic OE Management:advise general measures as for acute diffuse OETreatment depends on cause - often requires more than one strategy:if fungal infection- top antifungal, refer if poor responseseborrhoeic dermatitis- antifungal and steroid combinedIf no cause evident- 7d course top steroid +/- acetic acid spray. If good response, may need to continue steroid but reduce potency/dose.If cannot be withdrawn after 2-3m, refer ENT. If poor response, try trial of top antifungalRefer ENT if contact sensitivity (re patch testing); if EAC occluded; if malignant OE suspected.

22. Foreign BodiesManagement depends on what it is:Batteries – immediate referral to ENTInert FB – e.g. retained grommet, beads, foam - not so urgentOrganic – e.g. food, insects. May cause infection therefore should be dealt with sooner. For insects – drown in olive oil first.Some FBs may resolve with syringing, but if not refer to PCCDo not attempt to remove under direct visualisation as more likely to cause harm

23. Nose

24. Anterior or Posterior – hx gives clues> 90% from Little’s Area Age gives clue – more likely posterior in ElderlyCause: Idiopathic, trauma (nose picking), dry mucosa, hypertension, coagulopathy, NSAID, Warfarin, tumourCAN BE FATAL!!!First Aid: Compression & IceEpistaxis

25. Avoid blowing their nose (1/52)Avoid hot drinks (1/52)Naseptin cream 1/52Admit: If cannot control, elderly, warfarinised, low platelets, recurrent excessive bleedingPCC: If not settling with conservative rxAgNO3 cautery – can be done in GPPacking, Electrocautery, Surgery (SPA ligation, ECA ligation, embolisation)

26.

27. Cautery: What you need:A good lightsourceNasal speculum (or large aural speculum)Lignocaine (with adrenalin)Cotton woolCautery sticks

28. Causative factors – allergic, viral, bacterial, fungal, autoimmune. Acute <12wks, Chronic >12wks, Recurrent (>4/yr)15% population. 6 million lost working days / yr in the UKPresents as “My cold won’t go away” – persistant symptoms of URTI, without improvement after 10-14 days or worsening after 5 daysMajor: Nasal congestion/obstructionPurulent dischargeLoss of smellFacial pain / ear pain or fullnessRhinosinusitis

29. Minor:Tenderness over sinus areaFeverHeadacheHalitosisFatigue / LethargyPost nasal dripWhat to exclude on examination:Periorbital swelling, extraocular muscle dysfunction, decreased VA or proptosisForeign bodiesConcomitant otitis media (in children)CNS complicationsPolypoid changes or deviated septumWhat to expect on examination:Erythema / swelling of nasal mucosaMucopurulent secretionsTenderness over sinuses

30. DifferentialsAllergic rhinitis (seasonal or perennial)Usually just nasal symptoms and usually persistentNasal FB – unilateral blockage or dischargeSinonasal tumour – chronic, unilateral blockage, discharge (bloody)Other causes of facial pain Tension HeadacheTMJ dysfunction or bruxismNeuropathicDental pain (hot/cold drinks, chewing)InvestigationsXrays / Bloods / Swabs = not required, only indicated if > 12 wks and failure to respond to Rx – will probably refer at that stage (rigid endoscopy / coronal CT / allergy testing)

31. Consider emergency admission to hospital if symptoms are accompanied by:Systemic illnessSwelling or cellulitis in faceSigns of CNS involvementOrbital involvementConsider urgent ENT referral if:Persistant unilateral symptoms such as (suspecting sinonasal tumour):Bloodstained dischargeNon-tender facial painFacial swellingUnilateral polypsConsider routine referral to ENT if:More than 3-4 episodes per year lasting > 10 days with no symptoms between episodes

32. Management of acute rhinosinusitis (guidelines on map of medicine) Viral is 200 times more common than bacterialViral URTI usually precedes bacterialBacterial usually has more severe and prolonged symptomsStrep pneumoniae, H. influenzae, Moraxella CatarrhalisFirst line :AmoxicillinDoxycycline, erythromycin, clarithromycin (pen allergic)Second Line:Co-amoxiclavAzithromycin (pen allergic)

33. More than 7 days Fewer than 7 daysConsider antibioticsAdvice on self-care measures-paracetamol or ibuprofen-intranasal decongestant (1 week max) +/- oral decongestant (limited evidence)-Saline douching-Warm face packs (5-10 mins, tds may help drainage)-Maintaining hydration & rest-(topical steroids if polypoid change)Follow up for complications, compliance, expect improvement after 72 hrs with first line AbxConsider change of ABxFollow up for complications & complianceRecurrent acute episodesLess than 6/52 between episodesMore than 6/52 between episodesUse second line antibioticsUse first line antibiotics

34. Management of chronic rhinosinusitis (referral toolkit)

35. Commonest in children aged 1-4Rare in adultsPotential risk to airwaySuspect if persistant unilateral symptoms of blockage or foul smelling dischargeUnless very easy to get at, and very compliant child, best not attempted in GP (sometimes only get one shot!)Nasal Foreign Bodies

36. Best viewed from above – looking at deviation of nasal bones – difficult if swollenExclude septal haematomaRequires immediate drainage to prevent abscess or permanent saddle nose deformityOtherwise refer to PCC for manipulation 7-10 days post injury. For old injuries routine ENT referralNasal Fracture

37. Nasal blockage will almost always be accompanied by snoringHave OSA in the back of your mindDefined as the presence of at least five obstructive events per hour during sleepFeaturesImpaired alertnessCognitive impairmentExcessive sleepiness (Epworth scale)Morning headaches Choking or SOB feeling at nightNocturiaUnrefreshing sleepSleep quality of partners affected (“does he stop breathing at night?”)Refer to Respiratory in the first instanceConsider OSA

38. Throat

39. Sore throat: causes Common infections:rhinovirus; coronovirus, parainfluenza virus; common cold (25% sore throats)GABHS causes 15-30% sore throats in children and 10% in adultsHerpes simplex virus type 1 (more rarely type 2) = 2%Epstein Barr virus: infectious mononucleosis (glandular fever)- <1%. Suspect IM if sore throat persists >2w - do FBC and IM screen.Non-infectious causes Physical irritationHayfeverStevens Johnson syndromeKawasaki diseaseOral mucositis 2’ chemo /radiotherapy

40. Sore throat: complicationsComplications of streptococcal pharyngitis are rare: Suppurative complications:OMacute sinusitisperitonsilar cellulitis / peritonsillar abscess (quinsy)Pharyngeal abscessRetropharyngeal abscess, more common in childrenNon suppurative complications are rare:rheumatic feverpost-streptococcal glomerulonephritisR sided quinsy showing displacement of uvula to L

41. Sore throat: when to referAdmit if stridor or respiratory difficultyTrismus, drooling, dysphagia.Dehydration /unable to take fluidsSevere suppurative complications, ie if abnormal throat swelling/suspected abscessSystemically unwell and at risk of immunosuppressionSuspect Kawasaki diseaseProfoundly unwell and cause unknown

42. Sore throat: management in primary careReassure sore throat usually self limiting and symptoms resolve within 3d in 40% cases, 1w in 85% (even if due to streptococcal infection)Advise see healthcare professional if symptoms do not improve, and urgently if breathing difficulties, stridor, drooling, muffled voice, severe pain, dysphagia or unable to take fluids or systemically illSymptoms of infectious mononucleosis usually resolve within 1-2w, mild cases within days. But lethargy continues for some time and rarely may continue for months or years. Advise re contact sport. Advise regular paracetamol, ibuprofen, fluids ++ but avoid hot drinks; saline mouthwashes; discuss role of antibioticsConsider delayed prescription or immediate antibiotics – use Centor scoring - Antibiotic regime: Prescribe phenoxymethylpenicillin for 10d; or erythromycin or clarithromycin for 5d. Avoid amoxicillin (EBV)

43. Indications for tonsillectomy for recurrent acute sore throatSore throats are due to acute tonsillitisEpisodes of sore throat are disabling and prevent normal functioningSeven or more well documented, clinically significant, adequately treated sore throats in the preceding year or Five or more such episodes in each of the preceding two years orThree or more such episodes in each of the preceding three yearsSIGN 2010, Management of sore throat and indications for tonsillectomy http://www.sign.ac.uk/pdf/qrg117.pdf

44. VertigoVertigo: ‘is a symptom and refers to a perception of spinning or rotation of the person or their surroundings in the absence of physical movement’Peripheral vertigo = labyrinthine causeBenign paroxysmal positional vertigo (BPPV)Vestibular neuronitis:Meniere’s disease:Central vertigo = cerebellar causeCommonMigraineUncommonstroke and TIA cerebellar tumouracoustic neuromaMS

45. Assessment of vertigoMost balance problems that present in primary care are not rotatory vertigo, but unsteadiness. A full time GP is likely to see 10-20 people with vertigo in 1yTo determine vertigo rather than dizziness, ask:“do you feel light-headed or do you see the world spin around you as if you had just got off a roundabout”about timing, duration, onset, frequency and severity of symptomsaggravating factors, e.g. head movementeffect on daily activitiesassociated symptoms: hearing loss, tinnitus (unilateral/bilateral), headache, diplopia, dysarthria /dysphagia, ataxia, nausea, vomiting

46. Assessment of vertigo: medical historyRecent URTI or ear infection suggests vestibular neuronitis or labyrinthitisMigraine: inc likelihood of migrainous vertigoHead trauma/ recent labyrinthitis: BPPVTrauma to ear: perilymph fistulaAnxiety or depression can worsen symptoms or cause feelings of lightheadedness (e.g. from hyperventilation)Acute alcohol intoxication can cause vertigoExaminationENT – incl. Weber and Rinnes testsFull Neuro incl cerebellar testing + gait. Particularly looking for nystagmus

47. Assessment of vertigo: specific testsRomberg’s test:identifies peripheral or central cause of vertigo (but not sensitive for differentiating between them)Ask patient to stand up straight, feet together, arms outstretched with eyes closed. If patient unable to keep balance- the test is positive (usually fall to side of lesion)A positive test suggests problem with proprioception or vestibular function. Hallpike manoeuvre:to confirm diagnosis of BPPV

48. Hallpike manoeuvre - demonstrationBe cautious with patients with neck or back pathology or carotid stenosis as manouvre involves turning and extending neck http://northerndoctor.com/2010/09/27/dizziness-dix-hallpike-and-the-epley-manoeuvre/Ask patient to:report any vertigo during testkeep eyes open and stare at examiner’s nosesit upright on couch, head turned 45’ to one sidelie them down rapidly until head extended 30’ over end of bed, one ear downward If neck problems- can be done without neck extensionobserve eyes closely for 30 sec for nystagmus- note type and directionsupport head in position and sit upRepeat with other sidetest is positive for BPPV if vertigo and nystagmus (torsional and beating towards ground) are present and nystagmus shows latency, fatigue and adaptation

49. Features of central causes of vertigosevere or prolonged new onset headachefocal neurological deficitscentral type nystagmus (vertical)excess nausea and vomitingprolonged severe imbalance (inability to stand up even with eyes open)

50. Features of peripheral causes of vertigoBPPV:vertigo induced by moving head positionepisodes last for secondsVestibular neuronitis and labyrinthitis:vertigo persists for days and improves with timeno hearing loss or tinnitus with vestibular neuronitisin labyrinthitis, sudden hearing loss with vertigo and tinnitus may be presentMeniere’s disease:ages 20-50y men> womenvertigo, not provoked by position changeepisodes last 30 min to several hourssymptoms of tinnitus, hearing loss and fullness in earmay be clusters of attacks and long remissions

51. Medication used in vertigoprochlorperazinecyclizinecinnarizinepromethazine

52. TinnitusUnwanted perception of sound within head, in absence of sound from external environmentCan be described as ringing, hissing, buzzing, roaring or humming. Classified as-Subjective tinnitus:sound only heard by patient; assoc with abnormalities of auditory systemObjective tinnitus:sound heard by patient and examiner; caused by physical abnormality that produces sound near or within ear

53. Disorders associated with subjective tinnitusTwo thirds people with tinnitus have disorder causing hearing loss; one third have idiopathic tinnitusMost commonly assoc with disorders causing sensorineural hearing loss (SNHL):age relatednoise inducedMeniere’s diseaseLess commonly assoc with disorders causing conductive hearing loss:impacted waxotosclerosis (rare)

54. Uncommonly, subjective tinnitus is associated with:Ototoxic drugsCytotoxic drugs (e.g. Cisplatin, methotrexate)Aminoglycosides (gentamicin)macrolides, quinine, aspirin, NSAIDs and loop diureticsEar infections: (OM, OME, CSOM)Neurological disorders: acoustic neuroma; schwannoma, MSMetabolic disorders: Hypothyroidism; diabetesPsychological disorders: anxiety and depressionTrauma

55. Disorders associated with objective tinnitusObjective tinnitus is very rareDue to:Vascular disorders:AVMs; vascular tumours;High output states:anaemia; thyrotoxicosis; Paget’s disease

56. Management of tinnitus in primary careAssess underlying causeRefer to ENT:All patients with objective tinnitusPatients with subjective tinnitus, following hearing test, who have associated SNHLTinnitus associated with conductive hearing loss when treatable causes not identified or managed in primary careTinnitus secondary to head or neck injuryTinnitus of uncertain causeTinnitus that is causing distress despite primary care management

57. Foreign BodiesFeeling of food (most commonly) stuck in throat / oesophagusIf complete dysphagia of acute onset, then very high chance of a FB obstructionIf delayed onset of FB sensation after eating, and mild symptoms, could simply be abrasion, symptoms will go in 48 hrs. Refer if not resolvedOesophageal food bolus: coke or pineapple juice, buscopan (IM) or GTN (SL) can help

58. Other

59. Lower motor neurone (involving forehead)Motor supply to the scalp, facial muscles & stapediusTaste to anterior 2/3 of the tongueVII nerve palsy

60. Possible causes:Traumaticfacial lacerations, blunt trauma ( BOS fracture), newborn paralysisNeoplasticparotid tumors, tumors of the external canal and middle ear, metastatic lesions, SCC, cholesteatoma, acoustic neuromaInfectiousherpes zoster oticus (Ramsey-Hunt syndrome), AOM, CSOM, malignant otitis externaIdiopathicBell's palsy although traditionally defined as idiopathic it is thought to be associated with herpes simplex virus type 1

61. Characteristics of a peripheral facial paralysis include:Motorunable to wrinkle foreheadunable to raise eyebrowunable to wrinkle nasolabial foldunable to purse lips or show teethinability to completely close eye(classified using House-Brackmann scale)Decreased taste sensationHyperacusisReduction of lacrimation

62. Need full head & neck examinationIf Ramsey-Hunt will give aciclovirAll will get steroids (40mg prednisolone daily)Eye taping at night and lacrilube if cannot close eyeReferral to PCCWill get hearing test on the day and subsequent follow up+/- Ophthalmology referralPrognosis depends on cause

63. Sialolithiasis (calculi)Sialadenitis (inflammation)AcuteChronicRecurrentTumoursOtherSalivary Gland Problems

64. ExaminationInspect the enlarged gland and all othersTender – Sialadenitis / SialolithiasisNon-Tender – TumourMore than one gland affected – autoimmune or viral (e.g. Mumps)Overlying inflammation might point towards infectionTest facial nerveInspect the oral cavity (bimanual)May be able to palpate a stoneMay be able to express pus from the duct

65. 80-95% in SMG, 5-20% in ParotidIntermittent pain and swelling at meal times.Acidic or spicy foods cause worse symptomsSwelling appears before, and persists after the painMost common in 3rd – 6th decadesVery rarely cause complete salivary obstructionSialolithiasis

66. Palpation of SMG SMG duct (Wharton’s) openingsStone inside duct opening

67. Opening of Parotid Duct (Stensen’s) Adjacent to maxillary 2nd molar

68. ManagementSour foods (sialogogues) to stimulate saliva flowMassaging the affected gland to promote saliva flowArtificial saliva products and/or frequent small drinksAntibiotics may be required for episodes of acute inflammation (see Sialadenitis)Refer if not settling

69. Most commonly affects the Parotid (Parotitis)Elderly, dehydrated, debilitatedPain & feverTender swelling with redness, may be purulent discharge from the ductSialadenitis

70. ManagementRehydrationStaph aureus is most common organismFlucloxacillinCo-amoxiclavRefer for admission if:Fails to improve after 5/7 ABxFacial nerve involvementRequiring IV fluids

71. ProphylaxisAdequate fluid intakeAvoidance of anticholinergicsGood oral hygiene (gargles etc)Stimulation of salivation e.g. gum chewingChronicUsually from partial duct obstructionReferRecurrentConsider swabbing any duct dischargeRefer

72. Usually more insidious onsetUsually painlessGoing to be referring under 2ww rules for neck lumpTumours

73. Autoimmune – Sjogren’sMetabolic – Myxoedema, DM, Cushing’s, Bulimia, Alcoholism, Cirrhosis, GoutDrug induced – OCP, CoproxamolViral – MumpsOther

74. Referrals(only 5 slides to go . . . . . . )

75. Same day – SHOPrimary Care Clinic - SHO2 week wait – faxedRoutine referrals – Voice/Balance/General/Thyroid/Oncology – written/C&BAudiology – written/C&BMicrosuction – written/C&BENT SHO through switchboard or bleep 585Ward 15 (Adults) or Ward 17/18 (Children)Referrals

76. Located in Head & Neck outpatients YDHAccessed through SHOAM & PM Mon, Tues, Thu, FriUsually will get appt within a week, sooner if clinical need. SHO led with support from Staff Grades / SpRHave access to audiometry on the dayPrimary Care Clinic

77. Otitis ExternaNasal FractureEpistaxisVII n palsyRecent parotid swelling (stones/infection)Sudden SNHLForeign bodiesSubmandibular swellings usually go via max facs to exclude dental abscess

78. NICE Guidance CG27 June 2005Refer urgently patients with:an unexplained lump in the neck, of recent onset, or a previously undiagnosed lump that has changed over a period of 3 to 6 weeksan unexplained persistent swelling in the parotid or submandibular glandan unexplained persistent sore or painful throatunilateral unexplained pain in the head and neck area for more than 4 weeks, associated with otalgia (ear ache) but a normal otoscopyunexplained ulceration of the oral mucosa or mass persisting for more than 3 weeks unexplained red and white patches (including suspected lichen planus) of the oral mucosa that are painful or swollen or bleedingFor patients with persistent symptoms or signs related to the oral cavity in whom a definitive diagnosis of a benign lesion cannot be made, refer or follow up until the symptoms and signs disappear. If the symptoms and signs have not disappeared after 6 weeks, make an urgent referral. Two-Week-Rule

79. Hoarseness > 3/52  CXR  ENT if NAD Refer urgently patients with a thyroid swelling associated with any of the following:a solitary nodule increasing in sizea history of neck irradiationa family history of an endocrine tumourunexplained hoarseness or voice changescervical lymphadenopathyvery young (pre-pubertal) patientpatient aged 65 years and older Do not delay referral with Ix (e.g. TFTs / USS)Request thyroid function tests in patients with a thyroid swelling without stridor or any of the features listed above. Refer patients with hyper-/hypo-thyroidism and an associated goitre, non-urgently, to an endocrinologist. Patients with goitre and normal thyroid function tests without any of the features listed above should be referred non-urgentlyhttp://guidance.nice.org.uk/CG27