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Core Concepts
ENT (Otorhinolaryngology) encompasses disorders of the Ear, Nose, Throat, and related Head & Neck structures. It governs crucial sensory functions (hearing, smell, taste, balance) and vital functions (breathing, swallowing, speech). Key physiological connections, such as the Eustachian tube (middle ear-nasopharynx) and paranasal sinuses (drainage into nasal cavity), are vital. Understanding the differentiation between conductive and sensorineural hearing loss (using Weber and Rinne tests) and various causes of vertigo is fundamental. Common pathogens include viruses (e.g., URI), bacteria (e.g., Otitis Media, Sinusitis, Streptococcal Pharyngitis), and fungi (e.g., Otitis Externa, particularly in immunocompromised patients).
Clinical Presentation
- Ear: Otalgia (earache), hearing loss (conductive or sensorineural), otorrhea (discharge), tinnitus (ringing), vertigo (spinning sensation), aural fullness, imbalance.
- Nose: Rhinorrhea (runny nose, clear or purulent), nasal congestion/obstruction, epistaxis (nosebleed), anosmia/hyposmia (smell disturbance), facial pain/pressure (sinusitis), post-nasal drip.
- Throat/Larynx: Sore throat (pharyngitis), dysphagia (difficulty swallowing), odynophagia (painful swallowing), hoarseness/dysphonia (voice change), cough, globus sensation (lump in throat), neck swelling/lump.
- Systemic: Fever, malaise, fatigue, unexplained weight loss (especially with neck masses).
Diagnosis (Gold Standard)
Ear:
- Otoscopy: Visual inspection of the tympanic membrane (e.g., AOM: bulging, red; OME: dull, retracted, fluid levels; OE: swollen canal, debris; TM perf: visible hole).
- Audiometry (Pure Tone/Speech): Quantifies hearing loss severity and differentiates conductive from sensorineural types.
- Tympanometry: Measures tympanic membrane compliance and assesses middle ear pressure and presence of fluid.
- Caloric Testing/Videonystagmography (VNG): Assesses vestibular (balance) function, crucial in vertigo workup.
- Anterior Rhinoscopy/Nasal Endoscopy: Visualizes the nasal cavity, septum, turbinates, polyps, and discharge characteristics.
- CT Paranasal Sinuses: Gold standard for diagnosing chronic sinusitis, assessing extent of disease, and pre-surgical planning for masses or polyps.
- Allergy Testing (Skin prick/IgE): Confirms specific allergens in allergic rhinitis.
- Oropharyngeal Exam: Direct visualization of tonsils, pharynx, and oral cavity.
- Flexible Nasopharyngolaryngoscopy: Essential for evaluating hoarseness, dysphagia, post-nasal drip, and examining the larynx and base of tongue.
- CT/MRI Head & Neck: Used for evaluating suspicious masses, deep space infections, or assessing tumor extent.
- Biopsy: Definitive diagnosis for any suspicious lesions, especially malignancy (e.g., Squamous Cell Carcinoma).
- Throat Swab (Rapid Strep Test/Culture): Confirms Group A Streptococcal Pharyngitis.
Management (First Line)
- Acute Otitis Media (AOM): Amoxicillin (high-dose) for 7-10 days. Watchful waiting for mild, uncomplicated cases in children >2 years.
- Otitis Media with Effusion (OME): Watchful waiting (3 months). Myringotomy with grommet insertion for persistent, symptomatic effusions.
- Acute Otitis Externa (OE): Topical antibiotic ear drops (e.g., Ciprofloxacin/Ofloxacin) ± steroid drops.
- Benign Paroxysmal Positional Vertigo (BPPV): Epley's maneuver.
- Impacted Cerumen: Cerumenolytics (e.g., mineral oil), ear irrigation, or manual removal.
- Allergic Rhinitis: Intranasal corticosteroids (e.g., Fluticasone), oral antihistamines.
- Acute Bacterial Rhinosinusitis: Amoxicillin-Clavulanate for 7-10 days. Symptomatic relief (nasal saline, decongestants) for viral cases.
- Epistaxis: Anterior nasal packing (Merocel, dissolvable packing), chemical (silver nitrate) or electrical cautery. Identify and treat underlying causes (e.g., hypertension).
- Acute Streptococcal Pharyngitis: Oral Penicillin V for 10 days (crucial for preventing Acute Rheumatic Fever).
- Acute Laryngitis: Voice rest, hydration, avoiding irritants.
- Peritonsillar Abscess (PTA): Incision & drainage (or needle aspiration), systemic antibiotics (e.g., Amoxicillin-Clavulanate).
- Gastroesophageal Reflux Disease (GERD) with ENT symptoms: Proton Pump Inhibitors (PPIs).
Exam Red Flags
- Unilateral symptoms: Persistent unilateral nasal obstruction/discharge, hearing loss, neck mass, or tonsil enlargement should raise suspicion for malignancy.
- Constitutional symptoms: Unexplained weight loss, night sweats, or persistent fever can indicate malignancy, chronic infection, or systemic disease.
- Airway compromise: Stridor, severe dysphagia, drooling, or a muffled voice are emergent signs (e.g., epiglottitis, deep neck space infection, foreign body, laryngeal tumor).
- Neurological signs: Facial weakness, severe persistent vertigo accompanied by other neurological deficits (e.g., stroke, acoustic neuroma) require urgent evaluation.
- Rapid progression: E.g., rapidly worsening facial or periorbital cellulitis.
- Persistent symptoms: Symptoms not responding to appropriate first-line therapy (e.g., chronic sinusitis, hoarseness >2-3 weeks, non-healing oral lesions).
- Bloody discharge: Unexplained bloody nasal discharge (especially unilateral) or bloody ear discharge without trauma warrants investigation.
- Severe pain out of proportion: E.g., necrotizing otitis externa in diabetic or immunocompromised patients.
- Orbital or intracranial signs: Proptosis, vision changes, severe headache, or altered mental status suggest complications of sinusitis or mastoiditis.
- Fixed, hard, or rapidly growing neck mass.
Sample Practice Questions
A 45-year-old male presents with a 6-month history of bilateral nasal obstruction, reduced sense of smell (anosmia), and persistent post-nasal drip. He occasionally experiences dull frontal headaches. He denies any history of allergy or epistaxis. On anterior rhinoscopy, multiple pale, glistening, grape-like masses are seen filling both nasal cavities. What is the most appropriate initial management approach for this patient?
A 5-year-old boy presents to the emergency department with a 3-day history of right ear pain, high-grade fever, and decreased hearing. His mother reports that the ear pain initially improved after a discharge from the ear, but now he has developed a tender, red, and swollen area behind his right ear, pushing the pinna forwards and downwards. On examination, the tympanic membrane is dull and bulging, and the post-auricular swelling is clearly visible. What is the most likely diagnosis?
A 45-year-old male presents to the emergency department with profuse bleeding from his right nostril for the past 30 minutes, which started spontaneously. He has a history of hypertension, for which he takes amlodipine. On examination, blood is seen actively dripping from the right anterior nostril. His blood pressure is 160/95 mmHg. What is the most appropriate initial step in the management of this patient's epistaxis, after ensuring airway patency and patient positioning?
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