PRACTICAL ENT FOR GENERAL PRACTITIONERS by Hisham S Khalil, MS, FRCS (ORL-HNS), MD, FHEA Consultant ENT Surgeon, Derriford Hospital, Plymouth Director of Clinical Studies and Inter-professional Learning, Plymouth University Peninsula School of Medicine Aristotle Poulios, MSc, MRCS, DO-HNS, FEB ORL-HNS Rhinology Fellow Derriford Hospital Plymouth Honorary University Fellow Plymouth University Peninsula School of Medicine Katarzyna Konieczny ENT Research Fellow Derriford Hospital Plymouth ISBN 978-0-9572477-2-7 1 © Copyright Khalil, 2014 Table of Contents INTRODUCTION ........................................................................................................................... 4 Clinical Skills .................................................................................................................................. 5 SECTION I THE EAR .................................................................................................................... 8 PERTINENT ANATOMY OF THE EAR .................................................................................. 8 PHYSIOLOGY OF HEARING ................................................................................................. 11 The External Auditory Canal and Auricle ............................................................................. 11 The Middle Ear Transformer Mechanism ............................................................................. 11 The Inner Ear ......................................................................................................................... 11 Central Auditory Processes ................................................................................................... 12 PHYSIOLOGY OF BALANCE ................................................................................................ 13 CLINICAL EXAMINATION OF THE EAR ............................................................................... 14 Otoscopy .................................................................................................................................... 14 Left Tympanic Membrane Right Tympanic Membrane ASSESSMENT OF HEARING ...... 14 I. Subjective Tests ..................................................................................................................... 15 A. Tuning Fork Test ............................................................................................................. 15 B. Free field Speech Tests .................................................................................................... 15 C. Pure Tone Audiometry (PTA) ......................................................................................... 16 D. Speech Audiometry ......................................................................................................... 16 Examples of PTA ................................................................................................................... 17 II. Objective Tests ..................................................................................................................... 19 A. Tympanometry ................................................................................................................. 19 B. Otoacoustic Emissions (OAEs) ......................................................................................... 20 C. Auditory Brainstem Evoked Responses (ABR) ................................................................ 21 HEARING ASSESSMENT IN CHILDREN ................................................................................ 23 Subjective Assessment of Hearing in Children ......................................................................... 23 Objective Assessment of Hearing in Children .......................................................................... 23 Other Tests ................................................................................................................................. 23 Magnetic Resonance Imaging (MRI) .................................................................................... 23 DISORDERS OF THE EAR ......................................................................................................... 25 Disorders of the External Ear .................................................................................................... 25 Impacted Wax ........................................................................................................................ 25 Auricular Haematoma ............................................................................................................ 25 Foreign Bodies ....................................................................................................................... 26 Otitis Externa ......................................................................................................................... 26 Necrotising (malignant) otitis externa ................................................................................... 28 Ramsay Hunt Syndrome ........................................................................................................ 28 Treatment of otitis externa ..................................................................................................... 28 Exostoses ............................................................................................................................... 28 Disorders of the Middle Ear ...................................................................................................... 29 Otitis Media ........................................................................................................................... 29 Otitis Media with Effusion (glue ear) .................................................................................... 29 Acute Suppurative Otitis Media ............................................................................................ 30 Chronic Suppurative Otitis Media ......................................................................................... 31 Otosclerosis ........................................................................................................................... 34 Middle Ear Tumours .............................................................................................................. 35 Disorders of the Inner Ear ......................................................................................................... 37 Presbycusis ............................................................................................................................ 37 2 Labyrinthitis ........................................................................................................................... 37 Benign Paroxysmal Positional Vertigo (BPPV) .................................................................... 37 Meniẻre’s Disease .................................................................................................................. 38 Ototoxicity ............................................................................................................................. 39 Acoustic Neuroma ................................................................................................................. 39 Noise Induced Hearing Loss .................................................................................................. 40 Facial Nerve Paralysis ............................................................................................................... 41 Causes of Hearing Loss ............................................................................................................ 44 Conductive Hearing Loss ...................................................................................................... 44 Sensorineural Hearing Loss ................................................................................................... 44 Mixed Hearing Loss .............................................................................................................. 45 Diagnostic Approach to Hearing Loss ....................................................................................... 46 Treatment of Hearing Loss ........................................................................................................ 47 Conventional Hearing Aids ................................................................................................... 47 Types of Hearing Aids ........................................................................................................... 47 Surgery for Hearing Loss ...................................................................................................... 48 Diagnostic Approach to Ear Discharge ..................................................................................... 51 Diagnostic Approach to Dizziness ............................................................................................ 51 Diagnostic Approach to Ear Ache ............................................................................................. 52 Recommended internet resources: ......................................................................................... 53 SECTION II ................................................................................................................................... 54 THE NOSE AND SINUSES ......................................................................................................... 54 PERTINENT ANATOMY OF THE NOSE AND