INTRODUCTION TO ENT ROTATION

Here are a few details on your upcoming ENT rotation.This is a two-week outpatient experience in a community ENT physician office, with a couple of choices for preceptors as discussed below.As a brief rotation, what you get out of the experience depends on efficiently using the reading and clinical time to accomplish the goals and objectives.

The ENT curriculum consists of the following:

1. ENT Office — depending on schedule and availability, your experience is in one or both of the following offices - Call the preceptor offices Now to confirm preceptor availability, then let Kary Trumble know what your schedule will be.

A. Charles Souliere, M. D. experienced and enthusiastic about teaching. He allows residents to see patients ahead of them, and does allow involvement in some procedures.

Address: 915 Sixth Avenue, Suite 1, Tacoma, WA.Telephone 627-6731/ 627-6734

B. Donald Shrewsbury, M. D. - Long time preceptor for this rotation, has a busy practice, is interested in teaching, this tends to be a somewhat more observational experience and answers questions usually towards the end of the day.

C. Nicholas Hamill, M.D. — Younger partner, very enthusiastic teacher, allows some hands on opportunities, gives our main lecture series.

Address: B2010 Allenmore Medical Center, 1901 South Union, Tacoma, WA. Telephone 627-4502.

Available Times in Office

Mornings 9 am - noon

Afternoons 1 - 5 PM

Mondays

Souliere or Hamill

Shrewsbury

Tuesdays

Hamill

Shrewsbury

Wednesdays

Shrewsbury

Hamill

Thursdays

Souliere

Souliere

Fridays

Shrewsbury

Hamill

For additional experience: C. Madigan ENT Residency Clinic - For those especially interested in getting extra opportunities to do flexible nasopharyngoscopy, I would suggest spending one or two half days at Madigan as an added experience, but not as the whole rotation.

Positives - More opportunities for hands-on procedures i.e. NP Scope. Has pediatric referral clinic Monday afternoon and Tumor clinic Tuesday morning.

Negatives - Lower volume, less bread and butter adult cases than community ENT offices.

Schedule: Clinic is available every day of the week except Wednesday afternoon. As above, Monday afternoons are Peds Referral clinic, Tuesday mornings are the Tumor clinic.

To arrange, call the chief resident at 968-2749 (Department Office)

1. ENT Self Test — You should answer all questions by the end of the 2 weeks What should you really get out of ENT? Enough to answer the questions posed in these case scenarios because these are the patients I guarantee you will see many times in your career as a family physician. Prepare now or learn later on on-the-job!

2. Fiberoptic Nasopharyngoscopy Module

Everyone should complete the NP procedure module, regardless of whether you plan to perform this procedure later in practice; working through the requirements of the module helps understand the anatomy of the nose and throat, and what your patients will experience at your consultant’s office.

This is a self-guided module found on the TFM curriculum web site:

http://faculty.washington.edu/dacosta/Procedures/np.html

1. Reading

Required: The following monographs will be loaned to you during the rotation - you can check them out from Kary Trumble. Please return them at the end of your rotation to avoid being charged for their replacement.

a. AAFP Monograph 242—Common Ear, Nose and Throat Problems: review this as a preparation for what the AAFP board exams are likely to ask you in the area of ENT.

b. Common Problems of the Head and Neck Region - another good text for more in depth explanations of common ENT problems.

c. Nasolaryngoscopy — A self-study program for the Family Physician.

The following case scenarios are common primary care ENT problems. Try to work through and answer them during the rotation using the reading and your preceptor as resources. Answers are available.

1. A 62 year old female presents to your office with a complaint of 3 to 4 days onset of “dizziness.” What are the differentiating features of the following important differential diagnoses in terms of history, physical exam in office testing?

Benign Positional Vertigo Meniere’s Disease TIA/CVA Cerebellar Dysfunction or Lesion Acoustic Neuroma

1. You see a 4 year old boy for his fourth Otitis Media episode this year, now three weeks after the most recent episode. Exam shows a persistently dull retracted tympanic membrane wihout redness or pain. The mother thinks this is way too many episodes and far too many antibiotics, asks you what your opinion is about “tubes” for the ear.

A) What are the treatment guidelines for Otitis Media with persistent effusion? B) Specifically, when are PE tubes indicated?

C) Families frequently ask you, the primary physician, about whether the ear can be gotten wet either in showering, bathing or swimming after PE tubes are put in . How do you advise them?

1. You are seeing a 40 year old hispanic farm worker who has had progressive “drooping” of the left side of his face over the last 1-2 days. He is petrified that his unilateral drooping face is a CVA like his mom had. What history and physical exams allow you to distinguish Bell’s Palsy from a stroke? What is your differential diagnosis of a unilateral 7th never paralysis?

A) After you’ve made your diagnosis of a 7th nerve palsy, what do you recommend for initial treatment?

B) Your patient wants to know what his chances are for recovery? How soon? Are there any tests you can do to get prognostic information about likelihood of complete recovery?

4) A worried mother brings in her 11 year old daughter to you “to finally get theses tonsils out.” She has had 3 to 4 “tonsil infections” per year but there are no documented episodes of strep positive cultures on the chart and no previous records are available.

On exam, her tonsils are quite large, nearly meeting midline but otherwise are unremarkable in appearance. This sullen, early adolescent rolls her eyes and appears healthy without any history of respiratory distress.

A) What are the accepted indications now for tonsillectomy?

B) Must you always take out the adenoids, since we always write “T and A”? What are the indications for adenoidectomy?

1. An eight-year-old boy is brought in by his mother because he can’t hear out of one ear. Two days ago, he and his buddy were goofing around and he sustained a slap injury to his ear with an open palm. Your exam confirms a tympanic membrane perforation. Upon hearing the diagnosis, the mother understandably wants to know:

A) What is the treatment for this?

B) How long should it take to heal?

C) What are the indications for ENT referral with this diagnosis?

1. A 15-year-old teenager is brought in unhappily to your urgent care after a fall doing her gymnastic routines where she struck her nose. The central nasal bridge is swollen. Dad wants you to “reduce the fracture right now so she won’t have any cosmetic defects.”

A) What must you absolutely check for now and should not miss on early exam with history of blunt nasal trauma?

B) How should you manage this acutely?

C) If the nose is broken, what is the definitive managment recommendations?

1. A 65-year-old farmer is in your next room at the request of his wife who is tired of his complaining of “that darn burnin ringing in my ears.” The wife is sure that you can fix it.

A) What is the differential diagnosis of tinnitus at this age?

B) How much of a workup do you need to convince you that it’s benign?

C) After you are sure that it is benign, what do you tell this man “and his long suffering wife” to do that might be helpful?

1. State the main differential diagnosis and workup for Epistaxis in the following patients:

A) A four-year-old with painless, gradually increasing episodes of profuse anterior epistaxis bilaterally.

B) A 22-year-old with episodic, small volume epistaxis, mainly on the right side with chronic sneezing and itchy eyes after moving to Washington State.

C) A 55 year old smoker with a new onset of posterior epistaxis that gags him, also notes a right ear that won’t pop for the last month as well.

1. A 32-year-old woman was found to have a small, painless thyroid nodule during routine exam. She is a non-smoker, has no throat or thyroid symptomes. Your third-year medical student wants to put a needle into it today.

A) What are the steps in evaluation of a painless thyroid nodule?

B) What about the suggestion of your medical student?

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.

1. A 62-year-old female presents to your office with a complaint of 3 to 4 days onset of “dizziness.” What are the differentiating features of the following important differential diagnoses in terms of history and physical exam in office testing?

A) Benign Positional Vertigo

B) Meniere’s Disease

C) TIA/CVA

D) Cerebellar Dysfunction or Lesion

E) Acoustic Neuroma

1. You see a 4-year-old boy for his fourth Otitis Media episode this year, now three weeks after the most recent episode. Exam shows a persistently dull, retracted tympanic membrane without redness or pain. The mother thinks this is way too many episodes and far too many antibiotics and asks you what your opinion is about “tubes” for the ear.

A) What are the treatment guidelines for Otitis Media with persistent effusion?

B) Specifically, when are PE tubes indicated?

C) Families frequently ask you, the primary physician, about whether the ear can be gotten wet either in showering, bathing or swimming after PE tubes are put in. How do you advise them?

1. You are seeing a 40-year-old hispanic farm worker who has had progressive “drooping” of the left side of his face over the last 1 - 2 days. He is petrified that his unilateral drooping face is a CVA like his mom had. What history and physical exams will allow you to distinguish Bell’s Palsy from a stroke?

A) What is your differential diagnosis of a unilateral 7th nerve paralysis?

B) After you have made your diagnosis of a 7th nerve palsy, what do you recommend for initial treatment?

C) Your patient wants to know what his chances are for recovery. How soon? Are there any tests you can do to get prognostic information about likelihood of complete recovery?

1. A worried mother brings in her 11-year-old daughter to you “to finally get these tonsils out.” She has had 3 to 4 “tonsil infections” per year but there are no documented episodes of strep-positive cultures on the chart and no previous records are available.

On exam, her tonsils are quite large, nearly meeting midline but otherwise are unremarkable in appearance. This sullen, early adolescent rolls her eyes and appears healthy without any history of respiratory distress.

A) What are the accepted indications now for tonsillectomy?

B) Must you always take out the adnoids, since we always write “T and A”? What are the indications for adenoidectomy?

1. An 8-year-old boy is brought in by his mother because he can’t hear out of one ear. Two days ago, he and his buddy were goofing around and he sustained a slap injury to his ear with an open palm. Your exam confirms a tympanic membrane perforation. Upon hearing the diagnosis, the mother understandably wants to know:

A) What is the treatment for this?

B) How long should it take to heal?

C) What are the indications for ENT referral with this diagnosis?

1. A 15-year-old teenager is brought in unhappily to your urgent care after a fall doing her gymnastic routines where she struck her nose. The central nasal bridge is swollen. Dad wants you to “reduce the fracture right now so she won’t have any cosmetic defects.”

A) What must you absolutely check for now and should not miss on early exam with history of blunt nasal trauma?

B) How should you manage this acutely?

C) If the nose is broken, what are the definitive management recommendations?

1. A 65-year-old farmer is in your next room at the request of his wife who is tired of his complaining of “that darn ringing in my ears.” The wife is sure that you can fix it.

A) What is the differential diagnosis of tinnitus at this age?

B) How much of a work-up do you need to convince you that it is benign?

C) After you are sure that it is benign, what do you tell this man and his “long-suffering wife” to do that might be helpful?

1. State the main differential diagnosis and work-up for Epistaxis in the following patients:

A) A four-year old with painless, gradually increasing episodes of profuse, anterior epistaxis bilaterally.

B) A 22-year-old with episodic small volume epistaxis mainly on the right side with chronic sneezing and itchy eyes after moving to Washington State.

C) A 55-year-old smoker with a new onset of posterior epistaxis that gags him, also notes a right ear that won’t pop for the last month.

1. A 32-year-old woman was found to have a small, painless thyroid nodule during routine exam. She is a non-smoker and has no throat or thyroid symptoms. Your third-year medical student wants to put a needle into it today.

A) What are the steps in evaluation of a pinless thyroid nodule?

B) What about the suggestion of your medical student?