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ENT and Ddx

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					ENT examination and Ddx of
Sore throat and hoarse voice
                            Teeth
   Hearing loss            Parotid
   Tinnitis                TMJ
   Vertigo                 Anterior tongue
   Localised symptoms      Oropharynx
   Trauma                  Tonsils
   Discharge               Base of tongue
   Foreign body            Larynx/laryngophary
   Pain/otalgia             nx
                            Oesophagus
                            Lymph
                            Cervical spine
   External ear                Tympanic
    › Irregularities             membrane
    › Tenderness                 › Using otoscope
    › Lymph nodes                › Entire TM cannot be
   Canal                            seen at once – view
                                     in quadrants
    ›   Wax
                                 ›   Colour
    ›   Localised swelling
                                 ›   Light reflex
    ›   Foreign body
                                 ›   Handle of malleus
    ›   Discharge
                                 ›   Shape
    ›   Straighten by
                                 ›   mobility
        traction on pinna
   Conductive                 Rinne
    › Outer or middle ear      Weber
    › Wax discharge,
      perforation of TM,
   Sensorineural
    › Defect of cochlea
      or auditory nerve
   Hereditary cause
   Obstruction                    Exterior
   Discharge                       › Skin
   Sneezing                        › Symmetry post trauma
   Pressure/pain                   › Periorbital swelling
   Ear symptoms                   Palpate nasal bones
   Smell abnormalities            Deviated septum
   Environmental exposure         Assess airway
   Autoimmune                     Sinus tenderness
   Allergy, asthma, allergic      Turbinates,
    rhinitis, atopy                Mucosa
                                   Little’s area
                                   Foreign body
   Lips
    › Cheilitis – inflammation      Glossoginival sulcus
       of lips
                                    Hard & soft palate and
   Parotid duct                     uvula
    › Stenson’s duct
                                    Tonsillar pillars
    › Oriface lateral to upper
       second molar                 Tonsils
   Teeth                              › Size (may be difficult to
                                           see in adults)
    › Real/false
                                       ›   Symmetry
    › Tap each tooth
       separately to elicit pain       ›   Colour
                                       ›   Membrane
   Gingiva (gums)
                                       ›   Ulceration
    › Inflammation
    › hypertrophy
                                      Floor of mouth
   Buccal (cheek) mucosa
   Tongue
   Floor of mouth
                                   Not to be missed
   Probability                     › Carcinoma
    › Viral URTI --> acute             Lung
        laryngitis                     Larynx

    ›   Non-specific irrative       › Imminent airway
        laryngitis                    obstruction
                                       Croup
    ›   Vocal abuse
                                       Acute epiglottitis
    ›   Nodules and polyps of
                                    › Rare infection
        chords
                                    › Foreign object
    ›   Phonaesthenia
                                    › Myaesthinia gravis
    ›   Acute tonsillitis
                                    › Motor neuron disease
                                   Darren Lockyer
   Pitfalls                    Masquerades
    › Toxic fumes
    › Vocal abuse                › Drugs
    › Benign vocal cord          › Smoking
        tumour
                                 › Hypothyroidism
    ›   GOR -->
        pharyngolaryngitis       › Acromegaly
    ›   Goitre
    ›   Dystonia
    ›   Physical trauma         Trying to tell me
    ›   Fungal infection         › Functional aphonia
    ›   Allergy                  › Functional stridor
    ›   Leucoplakia
 Diagnosis usually obvious from history
 Unusual hoarseness = hypothyroidism


   Investigations:
    ›   Thyroid function tests
    ›   CXR
    ›   Indirect laryngoscopy
    ›   Direct laryngoscopy
    ›   CT scan
         Suspected neoplasm/laryngeal trauma
   Probability                › Neoplasia
    › Streptococcal               Oropharynx
      tonsillitis                 Tongue

    › Chronic sinusitis with   › Blood dyscrasias
      post nasal drip          › Severe infections
                                  Acute epiglottitis
                                  Peritonsillar abscess
   Not to be missed               (quinsy)
    › CVS                         Pharyngeal abscess
       Angina                    Diphtheria
       MI                        HIV/AIDS
   Pitfalls                           ›   Systemic schlerosis
    ›   Foreign body                   ›   Sarcoidosis
    ›   EB mononucleosis               ›   Malignant grunuloma
    ›   Candida                        ›   TB
    ›   STIs                          Masquerades
         Gonococcal pharyngitis       › Depression
         HS II                             Significant association
         Syphilis                     › Diabetes (Candida)
    › Irritants                        › Drugs
    › Reflux oesophagitis -->          › Anaemia
      pharynolaryngitis
                                       › Thyroiditis
    › Chronic mouth
      breathing                        › Cervical spinal
                                         dysfunction
    › Aphthous ulceration
                                       › UTI
    › Thyroiditis
Oral thrush due to                                  Tonsillitis of Epstein-
Candida albicans                                    Barr mononucleosis




                     Acute follicular tonsillitis
                     from Strep. pyogenes

				
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posted:10/26/2011
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