Master ENT (Otorhinolaryngology)
for PLAB 1

Core Concepts

Otorhinolaryngology (ENT) encompasses conditions affecting the ear, nose, and throat, along with related structures of the head and neck. Key areas include hearing and balance, olfaction, phonation, swallowing, and airway management. Understanding the distinction between conductive (outer/middle ear) and sensorineural (inner ear/neural pathway) hearing loss is fundamental. Common presentations often involve infection, inflammation, or structural issues affecting these interlinked systems.

Clinical Presentation

• **Ear:**
  • **Otitis Media (Acute):** Ear pain (otalgia), fever, hearing loss, bulging red tympanic membrane (TM).
  • **Otitis Media with Effusion (OME)/Glue Ear:** Conductive hearing loss, 'blocked ear' sensation, often bilateral, TM dull/retracted with fluid level or bubbles.
  • **Otitis Externa:** Ear pain, discharge, itching, pain on tragal pressure/pinna movement, often history of swimming/trauma.
  • **Cholesteatoma:** Chronic, foul-smelling ear discharge, progressive conductive hearing loss, sometimes vertigo/facial weakness, white pearly mass on TM.
  • **Vertigo:** Dizziness, spinning sensation. Accompanied by nystagmus, nausea, vomiting. Causes: BPPV (short duration, head movements), Meniere's (triad of vertigo, tinnitus, sensorineural hearing loss, episodic), Vestibular Neuritis (acute severe vertigo, no hearing loss), Acoustic Neuroma (unilateral sensorineural hearing loss, tinnitus, balance issues, facial numbness).
  • **Tinnitus:** Ringing, buzzing, or hissing sound in the ear.
• **Nose:**
  • **Acute Rhinosinusitis:** Facial pain/pressure, nasal congestion, discharge (purulent if bacterial), reduced smell, fever. Viral > bacterial.
  • **Allergic Rhinitis:** Sneezing, rhinorrhoea, nasal congestion, itching (nose/eyes/palate), seasonal or perennial triggers.
  • **Epistaxis:** Nosebleed. Anterior (Little's area, common in children) vs. Posterior (often older adults, severe, may need packing).
  • **Nasal Polyps:** Chronic nasal obstruction, reduced sense of smell (anosmia), watery discharge, often associated with asthma/aspirin sensitivity.
• **Throat & Neck:**
  • **Acute Tonsillitis/Pharyngitis:** Sore throat, odynophagia (painful swallowing), fever, enlarged/red tonsils with exudates (bacterial), headache, malaise. Viral > bacterial.
  • **Peritonsillar Abscess (Quinsy):** Severe unilateral sore throat, trismus (difficulty opening mouth), 'hot potato voice', uvula deviation away from affected side.
  • **Epiglottitis (rare in adults):** Rapid onset severe sore throat, dysphagia, drooling, inspiratory stridor, tripoding position. Medical emergency.
  • **Laryngitis:** Hoarseness/loss of voice, sore throat, cough. Mostly viral.
  • **Neck Lumps:** May be inflammatory (lymphadenopathy), congenital (thyroglossal cyst, branchial cyst), benign (lipoma), or malignant (lymphoma, metastatic SCC from head & neck). Assess size, consistency, mobility, tenderness, associated symptoms.

Diagnosis (Gold Standard)

Primarily clinical: thorough history and focused examination. Otoscopy for ear conditions (TM appearance, mobility). Anterior rhinoscopy for nasal conditions. Oropharyngeal examination for throat conditions. Audiometry (pure tone and speech) differentiates conductive vs. sensorineural hearing loss. Tympanometry assesses middle ear function. Imaging (CT scan) for complicated sinusitis, cholesteatoma extension, or neck lumps (to characterise and stage). Flexible nasoendoscopy for chronic sinonasal disease, vocal cord pathology, or assessing upper aerodigestive tract for lumps/red flags.

Management (First Line)

• **Ear:**
  • **Acute Otitis Media:** Analgesia (paracetamol/ibuprofen), watchful waiting for 48-72h (most resolve spontaneously). Antibiotics for severe pain, <6 months, bilateral, immunocompromised, or no improvement. Amoxicillin first line.
  • **Otitis Media with Effusion:** Watchful waiting (most resolve within 3 months). Grommet insertion for persistent bilateral OME causing significant hearing loss/developmental delay >3 months.
  • **Otitis Externa:** Topical antibiotic ear drops (e.g., ciprofloxacin, gentamicin) +/- steroid. Keep ear dry.
  • **Cholesteatoma:** Surgical excision.
  • **BPPV:** Epley manoeuvre.
  • **Meniere's:** Dietary salt restriction, betahistine, vestibular suppressants (e.g., prochlorperazine) for acute attacks.
• **Nose:**
  • **Acute Rhinosinusitis:** Analgesia, saline nasal irrigation, intranasal steroids. Antibiotics (e.g., amoxicillin) if symptoms severe, prolonged (>10 days) or worsening.
  • **Allergic Rhinitis:** Intranasal corticosteroids (first line), oral antihistamines. Avoidance of triggers.
  • **Epistaxis:** First aid (lean forward, pinch soft part of nose for 10-15 mins). Cautery (silver nitrate) for visible anterior bleeders. Nasal packing for uncontrolled bleeds.
  • **Nasal Polyps:** Intranasal corticosteroids. Surgical polypectomy for persistent/large polyps.
• **Throat & Neck:**
  • **Acute Tonsillitis:** Analgesia, hydration. Antibiotics (phenoxymethylpenicillin or clarithromycin if penicillin allergic) if bacterial cause suspected (e.g., Centor score).
  • **Peritonsillar Abscess (Quinsy):** Incision and drainage (or aspiration), antibiotics (e.g., co-amoxiclav or clindamycin), analgesia.
  • **Epiglottitis:** IMMEDIATE airway management (intubation often required), IV antibiotics (e.g., ceftriaxone), IV steroids. DO NOT examine throat directly if high suspicion.
  • **Laryngitis:** Voice rest, hydration.

Exam Red Flags