Disorders of the head and neck are some of the most common problems presenting to primary care physicians. Familiarity with the diagnosis and treatment of these disorders is essential to the comprehensive practice of Family Medicine.

Goals

1. Become familiar with the pathophysiology, diagnosis, and management of the most common disorders of the head and neck that present in primary care.

2. Become proficient in common and necessary ENT procedures.

3. Understand the indications for obtaining consultation with an otolaryngologist. Be capable of providing anticipatory guidance to the patient re: the referral and continue to act in the role as patient advocate throughout such consultations.

Objectives

For the ENT problems listed below, the resident will:

1. Take a pertinent history, and perform an appropriate physical exam utilizing proper equipment and procedures.

2. Devise a management and treatment plan, showing awareness of relevant pathophysiology, current treatment options and the correct use of necessary labs and tests.

3. Identify conditions or complications necessitating ENT referral.

Ears:

Dizziness/vertigo

Hearing Loss

Tinnitus

Otitis Externa

TM Perforation

Otitis with Persistent Effusion

Nose:

Epistaxis Sinusitis

Nasal Fracture

Rhinitis

Mouth & Throat:

Oral Lesions

Hoarseness

Stridor/Croup

Common HIV Oral Manifestations

Oropharyngeal Infections:

Tonsillitis, pharyngitis, stomatitis, herpangina

Neck:

Neck Mass Thyroid Nodule Epiglottis

TMJ Syndrome Sleep Apnea/Snoring Carotidynia

Salivary Gland Disease Facial Nerve Paralysis

Procedures

For the procedures listed below, the resident will: 1. Enumerate the indications, contraindications and complications 2. Demonstrate competent performance of those starred (*) 3 Describe the technique of those non-starred (participating as a clinical situation arises). *cerumen removal

*nasal cautery *wick insertion (otitis externa) *Pneumatic otoscopy

nasal packing (anterior) nasal packing (posterior) emergency cricothryrotomy removal Wharton’s duct calculus reduction of dislocated TMJ fiberoptic nasopharyngoscopy

Studies

Correctly interpret sinus x-rays, audiograms and tympanograms, and discuss how the abnormal findings impact management plans.

IV. Discuss the indications/contraindications of the following otolaryngology specialist procedures, demonstrating the resident’s appropriate role as a primary care patient advocate.

PE tube insertion Sinus surgical management Tonsillectomy Adenoidectomy

V. Describe the most common otolaryngological manifestations of HIV disease, and outline an approach to their management.

Methods

Pre-rotation Information: Prior to the rotation, the resident isto review goals and objectives, identify areas of interest and resident specific goals for the rotation, and receive reading materials.

Rotation: Outpatient focused 2 week rotation in the R 3 year, consisting of a total of 12 half-days in the offices of Otolaryngologists Dr’s. Hamill, Shrewsbury or Souliere. Whenever possible, the resident should be involved with the initial evaluation and examination of patients, presenting findings and discussing evaluation and management with the attending. Where feasible, necessary tests and procedures should be performed by the resident, under supervision of the attending. (See ENT resident memo for rotation details)

Lectures: Attend the following ENTdidactic conferences:

Dizzyness

ENT Pearls

Otitis Media/ with effusion

Sinusitis/rhinitis/epistaxis Hearing Loss/tinnitus

Workshops: Attend fiberoptic nasopharyngoscopy workshop:

Reading:

See reading list and syllabus - to be reviewed at pre-rotation briefing

Elective: The resident may choose to pursue additional ENT training at Madigan Army Medical Center, Department of Otolaryngology, specifically in regards to hands-on procedural experience such as fiberoptic nasopharyngoscopy, nasal packing, etc. Specific rotation times would be arranged individually.

Required Reading for Rotation

1.Common Problems of the Head and Neck Region- a manual and guide for mangement of diseases and injuries in head and neck surgery.

1. AAFP Monograph 242 — Common Ear, Nose and Throat Problems

2. Nasopharyngoscopy — a Self-Study Program for the Family Physician.

Other Optional Readings by Region

Starred (*) listings are in Syllabus Ear

OM/effusion (*)Managing OM with effusion in young children, Clinical Practice Guidelines, AFP vol 50, no.5, Oct. 1994.

Text of Otolaryngolgy, chap. 24, Diseases of the middle ear and mastoid.

Dizzyness (*)A practical approach to dizziness, Post. grad. med. Ruckenstein,M pg. 70-81

(*)Differential Dx and Management of the dizzy patient, Common Problems of the head & Neck., pg. 195

(*)The dizzy patient, Med Clin NA , vol.75, no6, Nov. 1991, pg. 1251

Hearing Loss

(*)Hearing Loss (a review article), NEJM, vol 329, no 15, Oct.7, 1993, pg.1092 .

Hearing Loss, Textbook of Otolaryngology, chap. 25, pg.368

Tinnitus

(*)Management of the patient with tinnitus, Med Clin NA, vol75,no6,Nov.1991,pg. 1225

Tinnitus, Textbook of Otolaryngology, chap. 26, pg. 394

Ear

Procedures

(*)An introduction to tympanometry, Am Fam Phy, 44:2113, 1991

(*)Proceedures for the Primary Care Physician

chap. 32 Tympanometry chap. 31 Cerumen Impaction Removal chap. 34 Removal of Foreign Body from the Ear and Nose

Nose

Epistaxis (*)Practical management of epistaxis, MedClin NA, vol75,no6,Nov,91, pg. 1311

(*)How to stop a nosebleed, Postgrad Med, vol 86, no4, Sept.15, 1989

(*)Management of anterior and post. epistaxis, Am Fam Phys, vol.43,no.6,June,1991, pg.2007

Sinusitis

(*)Does this patient have sinusitis? JAMA, vol.270,no.10,Sept.8,1993, pg.1242

(*)Sinusitis Common Problemss of the Head and Neck Region , pg. 41

Acute/chronic sinusitis ,Text of Otolaryngology, chap. 16, pg. 236

Rhinitis

(*)Allergic Rhinitis, Am Fam Phys., vol.51, no.4, March, 1995, pg. 837

(*)Evaluation of Nasal Obstruction, Common Probs of Head & Neck, pg. 75

Acute and Chronic Disease of the Nose, Text of Otolaryngology, chap. 15, pg.225.

Nasal Fracture

Management of Nasal Fractures, Manual of Otolaryngolgy, Pg. 33

Procedures (*)Procedures for Primary Care Physicians Chap. 39 Management of Epistaxispg. 342 Chap. 40 Flexible Fiberoptic Rhinolaryngoscopy

Throat/Neck

Neck Mass

(*)How to (and not to) manage a patient with a neck lump, Common Probs. Head & Neck Region, pg. 129

(*)Age: A clue in neck mass diagnosis., Pt. Care, Jan.15, 1990, pg. 38

Neck Masses, Text of Otolaryngology, chap. 7, pg. 247

Snoring/Sleep Apnea

(*)Snoring and obstructive sleep apnea, Med Clin NA, vol.75, no.6

(*)Snoring and sleep apnea, Common Probs Head & Neck, pg. 85

Hoarseness

(*)Hoarseness: Eval. & Therapy , Common Probs Head & Neck, pg. 49

(*)Diagnosis and treatment of hoarseness, The Practitioner, June,1994pg.474-478

Thyroid Mass

(*)Management of the patient with a thryroid mass, Common Probs Head & Neck,pg.151

TMJ Syndrome

(*)A common sense approach to TMJ pain, Pt Care, Sept.15,1988, pg. 57

Carotidynia

(*)Carotidynia, American Family Physician, vol.50, no.5, pg. 987

Tonsils and Adenoids

(*)Tonsils and adenoids: when is surgery indicated?, Common Probs Head & Neck, pg.97 Tonsils and Adenoids, Text of Otolaryngology, chap. 4, pg. 68

Salivary Glands

Salivary glands, Manual of Otolaryngology, chap. 6, pg. 215

Procedures

(*)Procedures for Primary Care Physicians chap. 41 Indirect laryngoscopy, pg. 260 chap. 43 Emergency cricothyrotomy, pg. 270 chap. 44 Reduction of dislocated TMJ, pg. 279

Misc.

HIV Disease

(*)Otolaryngological aspects of AIDS, Med Clin NA, vol.75, no.6, Nov.1991, pg.1389

Geriatrics

(*)Otolaryngolic problems in the elderly, Med Clin NA, pg. 1373

Evaluation

The standard rotation evaluation form is filled out by the attending physician at the conclusion of the rotation. In addition, the resident may meet with the faculty liaison for a post-rotation debriefing, to review resident performance, the accomplishment of curricular goals and objectives, and to outline any further experience the resident might require or desire.