Domain – Ear, nose, throat and oral health (guiding topics)

Assess and manage ear presentations:

• hearing loss:
  • from various causes (eg conductive and sensorineural loss, malignancy)
  • occupation-related
  • in children, including speech and developmental delay
• outer ear:
  • auricular disease (eg perichondritis)
  • canal disease (eg exostoses)
  • ear wax
  • otitis externa
  • foreign body
  • trauma
  • canal eczema
• middle ear disease
  • otitis media
  • tympanic perforation
  • bullous myringitis
  • other (eg otosclerosis)
  • labyrinthitis
  • Meniere’s disease
• referred pain/non-aural causes of ear pain:
  • dental problems (abscess, impacted molar)
  • temporomandibular joint syndrome
  • pharyngeal disorders (eg malignancy, foreign body)
  • carotidynia
  • cervical spine problems, including osteoarthritis and spondylosis
  • neurological problems (herpes zoster, trigeminal neuralgia, glossopharyngeal neuralgia)
  • Bell’s palsy
  • any cranial nerve lesion affecting nerves V, VII, IX or X
  • upper cervical lesions
• ear malignancies (eg acoustic neuroma, cholesteatoma)
• facial nerve paralysis (Bell’s palsy)
• vertiginous syndromes:
  • benign paroxysmal vertigo
  • chronic vertiginous syndrome (eg tinnitus, Meniere’s disease)
  • vestibular neuritis
• Ramsay Hunt syndrome.

Presentation	Clinical Assess	High Yield Features	Management
Hearing Loss
– Conductive & Sensorineural Loss	History, tuning fork tests, audiometry	Aetiology: Otosclerosis, noise exposure, aging, infections  Risk Factors: Loud noise exposure, age, infections  Signs/Symptoms: Decreased hearing, tinnitus, dizziness	Address underlying cause hearing aids surgery (e.g., stapedectomy for otosclerosis) cochlear implants for severe sensorineural loss
– Malignancy	History, otoscopic exam, biopsy, imaging	Aetiology: Primary or metastatic tumors Risk Factors: Smoking, chronic otitis media, radiation exposure Signs/Symptoms: Unilateral hearing loss, otalgia, otorrhea, facial nerve weakness	Surgical resection radiotherapy
– Occupational-Related	History, audiometry, noise exposure assessment	Aetiology: Prolonged exposure to loud noise  Risk Factors: Work in noisy environments  Signs/Symptoms: Progressive hearing loss, tinnitus	Hearing protection noise control measures regular hearing tests hearing aids
– In Children	History, developmental assessment, audiometry	Aetiology: Congenital, infections, ototoxic medications  Risk Factors: Family history, prematurity  Signs/Symptoms: Delayed speech and language development, inattentiveness	Treat underlying conditions (e.g., antibiotics for infections) Early intervention, speech therapy, hearing aids, cochlear implants
Outer Ear
– Auricular Disease	History, physical exam, culture	Aetiology: Trauma, infections (perichondritis)  Risk Factors: Piercings, surgery  Signs/Symptoms: Pain, redness, swelling, drainage	Flucloxacillin 500 mg orally, 6-hourly for 7-10 days Drainage of abscesses, wound care
– Canal Disease	History, otoscopic exam, imaging	Aetiology: Exostoses, infections, foreign bodies  Risk Factors: Cold water exposure (exostoses)  Signs/Symptoms: Hearing loss, pain, discharge	Ciprofloxacin eardrops 0.3%, 3 drops twice daily for 7 days (if infection present) Removal of exostoses or foreign bodies
– Ear Wax	History, otoscopic exam	Aetiology: Accumulation of cerumen  Risk Factors: Use of cotton swabs  Signs/Symptoms: Hearing loss, fullness in ear, tinnitus	Cerumenolytics (e.g., olive oil drops, sodium bicarbonate drops) Ear irrigation, manual removal
– Otitis Externa	History, otoscopic exam, culture	Aetiology: Bacterial, fungal infections  Risk Factors: Water exposure, trauma  Signs/Symptoms: Ear pain, itching, discharge, hearing loss	Topical ciprofloxacin 0.3% with hydrocortisone 1%, 3 drops twice daily for 7 days; oral flucloxacillin 500 mg 6-hourly for 7 days (if severe)  Keep ear dry pain management with NSAIDs
– Foreign Body	History, otoscopic exam	Aetiology: Insertion of objects  Risk Factors: Young children  Signs/Symptoms: Pain, discharge, hearing loss	Removal of foreign body, treat any secondary infection
– Trauma	History, physical and otoscopic exam, imaging	Aetiology: Blunt or penetrating trauma  Risk Factors: Accidents, assaults  Signs/Symptoms: Pain, bleeding, hearing loss, deformity
– Canal Eczema	History, physical exam	Aetiology: Allergic reactions, dermatitis  Risk Factors: Allergies, irritants  Signs/Symptoms: Itching, redness, flaking skin	Topical hydrocortisone 1% cream, apply twice daily
Middle Ear
– Otitis Media	History, otoscopic exam, tympanometry	Aetiology: Bacterial, viral infections  Risk Factors: Upper respiratory infections, allergies  Signs/Symptoms: Ear pain, fever, hearing loss, otorrhea	Pharmacological: Amoxicillin 500 mg orally, 8-hourly for 5-7 days (adults); 15 mg/kg/dose 8-hourly for 5-7 days (children)  Non-Pharmacological: Analgesics myringotomy with or without tube placement
– Tympanic Perforation	History, otoscopic exam, audiometry	Aetiology: Infection, trauma, barotrauma  Risk Factors: Chronic otitis media, trauma  Signs/Symptoms: Hearing loss, otorrhea, tinnitus	Pharmacological: None specific unless secondary infection (e.g., amoxicillin) Non-Pharmacological: Observation, surgical repair (tympanoplasty)
– Bullous Myringitis	History, otoscopic exam	Aetiology: Viral infections (e.g., Mycoplasma)  Risk Factors: Upper respiratory infections  Signs/Symptoms: Severe ear pain, bloody otorrhea, hearing loss	Pharmacological: Azithromycin 500 mg on day 1, then 250 mg daily for 4 days Non-Pharmacological: Pain management with NSAIDs
– Other (e.g., Otosclerosis)	History, otoscopic exam, audiometry	Aetiology: Abnormal bone growth  Risk Factors: Family history, age  Signs/Symptoms: Progressive conductive hearing loss, tinnitus	Hearing aids stapedectomy
– Labyrinthitis	History, physical exam, vestibular tests, audiometry	Aetiology: Viral or bacterial infections  Risk Factors: Recent upper respiratory infection  Signs/Symptoms: Vertigo, hearing loss, tinnitus, nausea, vomiting	Pharmacological: Prednisolone 1 mg/kg (max 60 mg) orally daily for 10-14 days if bacterial, amoxicillin/clavulanate 875/125 mg 12-hourly for 10-14 days  Non-Pharmacological: Bed rest, vestibular rehabilitation, hydration
– Meniere’s Disease	History, physical exam, audiometry, vestibular tests	Aetiology: Endolymphatic hydrops  Risk Factors: Genetic predisposition, autoimmune diseases  Signs/Symptoms: Episodic vertigo, fluctuating hearing loss, tinnitus, aural fullness	Pharmacological: Betahistine 16 mg three times daily diuretics (e.g., hydrochlorothiazide 25 mg daily)  Non-Pharmacological: Low-salt diet vestibular rehabilitation, intratympanic steroids or gentamicin surgery in refractory cases
Referred Pain and Aural Causes
– Dental Problems	History, dental exam, imaging	Aetiology: Abscess, impacted molar  Risk Factors: Poor oral hygiene, dental caries  Signs/Symptoms: Tooth pain, swelling, fever	Pharmacological: Amoxicillin 500 mg orally, 8-hourly for 5-7 days; metronidazole 400 mg 8-hourly for 5 days (if anaerobic infection suspected)  Non-Pharmacological: Dental treatment (extraction, drainage), pain management
– TMJ Syndrome	History, physical exam, imaging	Aetiology: Bruxism, arthritis  Risk Factors: Stress, jaw clenching  Signs/Symptoms: Jaw pain, clicking, limited mouth opening	Pharmacological: NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours), muscle relaxants (e.g., diazepam 2-5 mg at night)  Non-Pharmacological: Dental appliances, physical therapy, stress management
– Carotidynia	History, physical exam, imaging	Aetiology: Inflammation of the carotid artery Risk Factors: Unknown Signs/Symptoms: Neck pain, tenderness over carotid artery	Pharmacological: NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours), corticosteroids (e.g., prednisolone 20-40 mg daily for 7-10 days)
– Cervical Spine Problems	History, physical exam, imaging	Aetiology: Osteoarthritis, spondylosis  Risk Factors: Age, neck injury  Signs/Symptoms: Neck pain, radiating pain to the ear	Pharmacological: NSAIDs (e.g., ibuprofen 400 mg every 6-8 hours), muscle relaxants  Non-Pharmacological: Physical therapy, surgical intervention in severe cases
– Neurological Problems	History, physical exam, neurological exam, imaging	Aetiology: Herpes zoster, trigeminal neuralgia, glossopharyngeal neuralgia  Risk Factors: Viral infections, nerve compression  Signs/Symptoms: Sharp, stabbing pain, rash (in herpes zoster), nerve dysfunction	Pharmacological: Acyclovir 800 mg 5 times daily for 7 days (for herpes zoster); carbamazepine 100 mg twice daily, increase as needed for trigeminal neuralgia  Non-Pharmacological: Pain management, physical therapy
– Bell’s Palsy	History, physical exam, neurological exam	Aetiology: Idiopathic, viral infections (e.g., HSV)  Risk Factors: Recent viral illness  Signs/Symptoms: Unilateral facial paralysis, ear pain, altered taste	Pharmacological: Prednisolone 1 mg/kg (max 60 mg) daily for 10 days, valacyclovir 1000 mg 3 times daily for 7 days (if viral)  Non-Pharmacological: Eye care (artificial tears, eye patch) physical therapy
– Upper Cervical Lesions	History, physical exam, imaging	Aetiology: Trauma, tumors  Risk Factors: Injury, cancer  Signs/Symptoms: Neck pain, radiating pain to the ear, neurological deficits
Ear Cancers
– Acoustic Neuroma	History, audiometry, MRI	Aetiology: Benign tumor of the vestibulocochlear nerve  Risk Factors: Genetic predisposition (e.g., NF2)  Signs/Symptoms: Unilateral hearing loss, tinnitus, vertigo, facial numbness	Observation (for small, asymptomatic tumors) surgical removal stereotactic radiosurgery
– Cholesteatoma	History, otoscopic exam, CT scan	Aetiology: Abnormal skin growth in the middle ear  Risk Factors: Chronic otitis media  Signs/Symptoms: Hearing loss, ear discharge, ear fullness, dizziness	Pharmacological: Antibiotics for secondary infection (e.g., amoxicillin/clavulanate 875/125 mg 12-hourly for 7-10 days)  Non-Pharmacological: Surgical removal
Facial Nerve Paralysis
– Bell’s Palsy	History, physical exam, neurological exam	Aetiology: Idiopathic, viral infections (e.g., HSV)  Risk Factors: Recent viral illness  Signs/Symptoms: Unilateral facial paralysis, ear pain, altered taste	Pharmacological: Prednisolone 1 mg/kg (max 60 mg) daily for 10 days, valacyclovir 1000 mg 3 times daily for 7 days (if viral)  Non-Pharmacological: Eye care (artificial tears, eye patch), physical therapy
Vertigo Syndromes
– Benign Paroxysmal Vertigo	History, Dix-Hallpike test	Aetiology: Displacement of otoliths in the inner ear  Risk Factors: Age, head injury  Signs/Symptoms: Brief episodes of vertigo triggered by head movements	Epley maneuver Brandt-Daroff exercises
– Chronic Vertiginous Syndrome	History, physical exam, audiometry, vestibular tests	Aetiology: Meniere’s disease, vestibular migraine  Risk Factors: Genetic predisposition, stress  Signs/Symptoms: Persistent or recurrent vertigo, tinnitus, hearing loss	Pharmacological: Betahistine 16 mg three times daily (for Meniere’s); propranolol 40-80 mg twice daily (for vestibular migraine)  Non-Pharmacological: Vestibular rehabilitation, low-salt diet (for Meniere’s)
– Vestibular Neuritis	History, physical exam, vestibular tests, audiometry	Aetiology: Viral infection affecting the vestibular nerve  Risk Factors: Recent upper respiratory infection  Signs/Symptoms: Acute onset of vertigo, nausea, vomiting, no hearing loss	Pharmacological: Prednisolone 1 mg/kg (max 60 mg) daily for 10-14 days; antiemetics (e.g., prochlorperazine 5-10 mg 8-hourly)  Non-Pharmacological: Vestibular rehabilitation bed rest hydration
– Ramsay Hunt Syndrome	History, physical exam, neurological exam, viral testing	Aetiology: Reactivation of varicella-zoster virus in the geniculate ganglion  Risk Factors: Immunosuppression, age  Signs/Symptoms: Severe ear pain, vesicular rash around the ear, facial paralysis, hearing loss	Pharmacological: Acyclovir 800 mg 5 times daily for 7 days; prednisolone 1 mg/kg (max 60 mg) daily for 10 days Non-Pharmacological: Pain management, eye care, physical therapy

Assess and manage nose presentations:

• rhinitis, including allergic rhinitis
• sinusitis
• epistaxis
• nasal polyps
• foreign bodies.

Presentation	Clinical Assess	High Yield Features	Management
Rhinitis
– Allergic Rhinitis	History, physical exam, allergy testing	Aetiology: Allergens (pollen, dust mites, pet dander)  Risk Factors: Family history, atopy  Signs/Symptoms: Sneezing, nasal congestion, rhinorrhea, itching	Pharmacological: Antihistamines (e.g., cetirizine 10 mg daily), intranasal corticosteroids (e.g., fluticasone propionate 1-2 sprays per nostril daily), leukotriene receptor antagonists (e.g., montelukast 10 mg daily) Non-Pharmacological: Allergen avoidance, nasal irrigation
– Non-Allergic Rhinitis	History, physical exam	Aetiology: Irritants (smoke, pollution), hormonal changes, infections  Risk Factors: Exposure to irritants, hormonal changes (pregnancy)  Signs/Symptoms: Nasal congestion, rhinorrhea, postnasal drip	Pharmacological: Intranasal corticosteroids (e.g., fluticasone propionate 1-2 sprays per nostril daily) nasal decongestants (e.g., oxymetazoline 0.05% spray twice daily for short-term use) Non-Pharmacological: Avoidance of triggers, nasal irrigation
Sinisutis
– Acute Sinusitis	History, physical exam, nasal endoscopy, imaging	Aetiology: Bacterial (Streptococcus pneumoniae, Haemophilus influenzae), viral infections  Risk Factors: Recent upper respiratory infections, allergies  Signs/Symptoms: Facial pain/pressure, nasal congestion, purulent discharge, fever	Pharmacological: Amoxicillin/clavulanate 875/125 mg orally twice daily for 7-10 days (first-line), doxycycline 100 mg twice daily for 7-10 days (if penicillin allergic)  Non-Pharmacological: Saline nasal irrigation, steam inhalation, pain management with NSAIDs
– Chronic Sinusitis	History, physical exam, nasal endoscopy, imaging	Aetiology: Chronic inflammation, bacterial infections, fungal infections  Risk Factors: Nasal polyps, allergies, asthma  Signs/Symptoms: Nasal congestion, postnasal drip, facial pain/pressure, hyposmia	Pharmacological: Intranasal corticosteroids (e.g., fluticasone propionate 1-2 sprays per nostril daily) saline nasal irrigation, long-term antibiotics (e.g., doxycycline 100 mg daily for 3-6 weeks)  Non-Pharmacological: Functional endoscopic sinus surgery (FESS) if refractory
Epistaxis	History, physical exam, nasal endoscopy	Aetiology: Trauma, dry air, hypertension, anticoagulant use  Risk Factors: Nasal trauma, use of anticoagulants, bleeding disorders  Signs/Symptoms: Nosebleed (anterior or posterior), nasal congestion	Pharmacological: Topical vasoconstrictors (e.g., oxymetazoline 0.05% spray) tranexamic acid soaked in cotton (for anterior bleeds)  Non-Pharmacological: Direct pressure, nasal packing cauterization treatment of underlying conditions (e.g., hypertension control)
Nasal Polyps	History, physical exam, nasal endoscopy, imaging	Aetiology: Chronic inflammation (e.g., chronic rhinosinusitis), allergic rhinitis, asthma  Risk Factors: Asthma, aspirin sensitivity, cystic fibrosis  Signs/Symptoms: Nasal obstruction, anosmia, recurrent sinusitis	Pharmacological: Intranasal corticosteroids (e.g., mometasone furoate 2 sprays per nostril daily) short course of oral corticosteroids (e.g., prednisolone 30 mg daily for 5 days)  Non-Pharmacological: Endoscopic sinus surgery if refractory
Foreign Bodies	History, physical exam, nasal endoscopy	Aetiology: Insertion of objects (common in children)  Risk Factors: Young children  Signs/Symptoms: Unilateral nasal discharge, foul odor, nasal obstruction, epistaxis	Pharmacological: None unless secondary infection (then use antibiotics as appropriate)  Non-Pharmacological: Remove of foreign body (positive pressure technique, direct instrumentation), treat any secondary infection

Assess and manage oral presentations

• acute:
  • gingivitis
  • periodontitis
  • dental abscess
  • mouth ulcers (aphthous)
  • leucoplakia
  • lichen planus
  • angular cheilitis
  • tongue changes (eg smooth, geographical, sore tongue)
  • acute parotitis and salivary stones
  • acute manifestation of systemic disease (eg systemic lupus erythematosus)
• chronic:
  • oral mucosal lesions
    • benign ulcers
    • oral cancers (mouth, lip and tongue)
    • salivary gland tumours
  • xerostomia.

Presentation	Clinical Assess	High Yield Features	Management
Acute
– Gingivitis	History, physical exam, dental exam	Aetiology: Plaque accumulation, poor oral hygiene  Risk Factors: Smoking, diabetes, certain medications  Signs/Symptoms: Red, swollen gums, bleeding gums, bad breath	Pharmacological: Chlorhexidine mouthwash 0.2%, rinse twice daily for 1-2 weeks  Non-Pharmacological: Improved oral hygiene, professional dental cleaning
– Periodontitis	History, physical exam, dental exam, X-rays	Aetiology: Bacterial infection, progression from gingivitis  Risk Factors: Smoking, diabetes, genetic predisposition  Signs/Symptoms: Gum recession, pocket formation, tooth mobility, bad breath	Pharmacological: Systemic antibiotics if severe (e.g., amoxicillin 500 mg orally, 8-hourly for 7 days)  Non-Pharmacological: Scaling and root planing, improved oral hygiene, regular dental follow-up
– Dental Abscess	History, physical exam, dental exam, imaging	Aetiology: Bacterial infection  Risk Factors: Poor oral hygiene, untreated cavities, trauma  Signs/Symptoms: Severe toothache, swelling, fever, pus discharge	Pharmacological: Amoxicillin 500 mg orally, 8-hourly for 7 days; metronidazole 400 mg 8-hourly for 7 days if anaerobic infection suspected  Non-Pharmacological: Incision and drainage, root canal treatment, tooth extraction if necessary
– Mouth Ulcers (Aphthous)	History, physical exam	Aetiology: Unknown, possibly immune-mediated  Risk Factors: Stress, trauma, certain foods  Signs/Symptoms: Painful, recurrent ulcers on mucosal surfaces	Pharmacological: Topical corticosteroids (e.g., triamcinolone acetonide 0.1% paste), topical anesthetics (e.g., lidocaine gel)  Non-Pharmacological: Avoidance of trigger foods, good oral hygiene
– Leucoplakia	History, physical exam, biopsy	Aetiology: Chronic irritation, tobacco use  Risk Factors: Smoking, alcohol use, HPV infection  Signs/Symptoms: White patches on the oral mucosa that cannot be scraped off	Pharmacological: None specific  Non-Pharmacological: Smoking cessation, regular monitoring, biopsy of suspicious lesions
– Lichen Planus	History, physical exam, biopsy	Aetiology: Immune-mediated  Risk Factors: Hepatitis C infection, genetic predisposition  Signs/Symptoms: Lacy white patches, painful sores	Pharmacological: Topical corticosteroids (e.g., clobetasol propionate 0.05% gel), systemic corticosteroids for severe cases  Non-Pharmacological: Regular monitoring, good oral hygiene
– Angular Cheilitis	History, physical exam	Aetiology: Fungal (Candida), bacterial (Staphylococcus) infection  Risk Factors: Denture use, nutritional deficiencies  Signs/Symptoms: Cracks, redness, and soreness at the corners of the mouth	Pharmacological: Topical antifungal (e.g., miconazole cream), topical antibacterial (e.g., fusidic acid cream)  Non-Pharmacological: Address underlying causes improve oral hygiene use of emollients
– Tongue Changes	History, physical exam	Aetiology: Nutritional deficiencies, infections, systemic diseases  Risk Factors: Poor diet, underlying systemic conditions  Signs/Symptoms: Smooth tongue, geographic tongue, soreness	Pharmacological: Nutritional supplements (e.g., vitamin B12, iron) antifungal agents if candidiasis (e.g., nystatin oral suspension)  Non-Pharmacological: Address underlying cause dietary improvements good oral hygiene
– Acute Parotitis & Salivary Stones	History, physical exam, imaging	Aetiology: Bacterial infection, dehydration, ductal obstruction  Risk Factors: Reduced salivary flow, chronic illness  Signs/Symptoms: Swelling, pain, pus discharge (if infected), dry mouth	Pharmacological: Antibiotics for bacterial infection (e.g., amoxicillin/clavulanate 875/125 mg orally twice daily for 7-10 days)  Non-Pharmacological: Hydration, sialogogues (e.g., sour candies), massage, stone removal if necessary
– Systemic Disease Manifestation	History, physical exam, relevant systemic work-up	Aetiology: Systemic lupus erythematosus, other autoimmune diseases  Risk Factors: Genetic predisposition, known autoimmune conditions  Signs/Symptoms: Oral ulcers, other systemic symptoms (e.g., rash, arthritis)	Pharmacological: Immunosuppressive therapy (e.g., hydroxychloroquine for SLE), corticosteroids for severe flares  Non-Pharmacological: Regular monitoring, management of systemic disease, patient education
Chronic
– Oral Mucosal Lesions	History, physical exam, biopsy	Aetiology: Chronic irritation, autoimmune diseases  Risk Factors: Tobacco use, chronic trauma  Signs/Symptoms: Persistent lesions, may be white, red, or ulcerated	Pharmacological: Depends on underlying cause (e.g., topical corticosteroids for inflammatory lesions)  Non-Pharmacological: Regular monitoring, biopsy of suspicious lesions, smoking cessation
– Benign Ulcers	History, physical exam, biopsy	Aetiology: Trauma, infections  Risk Factors: Ill-fitting dentures, viral infections  Signs/Symptoms: Painful ulcers, usually resolve spontaneously	Pharmacological: Topical corticosteroids (e.g., triamcinolone acetonide 0.1% paste), topical anesthetics (e.g., lidocaine gel)  Non-Pharmacological: Address underlying cause, good oral hygiene
– Oral Cancers	History, physical exam, biopsy, imaging	Aetiology: Tobacco use, alcohol use, HPV infection  Risk Factors: Smoking, heavy alcohol use, HPV infection  Signs/Symptoms: Persistent sores, lumps, white or red patches, difficulty swallowing	Pharmacological: As per oncologist’s protocol (chemotherapy, targeted therapy)  Non-Pharmacological: Surgical resection, radiotherapy, regular follow-up
– Salivary Gland Tumours	History, physical exam, imaging, biopsy	Aetiology: Benign or malignant tumors  Risk Factors: Radiation exposure, genetic factors  Signs/Symptoms: Painless lump, facial nerve involvement (if malignant)	Pharmacological: As per oncologist’s protocol (chemotherapy for malignant tumors)  Non-Pharmacological: Surgical removal, radiotherapy if indicated
– Xerostomia	History, physical exam	Aetiology: Medications, systemic diseases (e.g., Sjögren’s syndrome), radiation therapy  Risk Factors: Use of anticholinergic drugs, autoimmune diseases  Signs/Symptoms: Dry mouth, difficulty swallowing, dental decay	Pharmacological: Saliva substitutes, pilocarpine 5 mg orally three times daily  Non-Pharmacological: Good oral hygiene, frequent sips of water, sugar-free chewing gum, avoid caffeine and alcohol, regular dental check-ups

Identify, and appropriately manage, ear, nose and throat emergencies:

• barotrauma
• sudden hearing loss
• tympanic perforation
• temporal bone fractures
• foreign bodies in ear
• mastoiditis
• epistaxis
• nasal trauma
  • septal haematoma
  • nasal fracture
• post-tonsillectomy bleed
• palatal/laryngeal trauma
• quinsy.

Condition	Clinical Features	Management
Barotrauma	– Ear pain, hearing loss, tinnitus, vertigo, sensation of fullness in the ear	Pharmacological:  – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day)  – Nasal decongestants: Oxymetazoline 0.05% spray twice daily for 3 days  Non-Pharmacological:  – Valsalva maneuver, avoid diving/flying until resolved, use of nasal decongestants before flying or diving, keep ear dry
Sudden Hearing Loss	– Rapid onset (within 72 hours) of unilateral hearing loss, tinnitus, ear fullness, dizziness	Pharmacological:  – Corticosteroids: Prednisolone 1 mg/kg (max 60 mg) orally daily for 1-2 weeks, tapering dose  – Antivirals if viral etiology suspected: Valacyclovir 1000 mg orally 3 times daily for 7 days  Non-Pharmacological:  – Urgent ENT referral, audiometry to confirm diagnosis, hyperbaric oxygen therapy (if available), keep ear dry, avoid water exposure
Tympanic Perforation	– Sudden ear pain, hearing loss, otorrhea, tinnitus, vertigo (if inner ear involved)	Pharmacological:  – Topical antibiotics if contaminated: Ciprofloxacin 0.3% ear drops, 3 drops twice daily for 7 days  Non-Pharmacological:  – Keep ear dry, avoid water exposure, ENT follow-up for potential surgical repair, avoid blowing nose forcefully, consider tympanoplasty if persistent perforation or significant hearing loss
Temporal Bone Fractures	– Hearing loss, vertigo, facial nerve paralysis, hemotympanum, Battle’s sign (bruising behind the ear)	Pharmacological:  – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day)  – Antibiotics if CSF leak present: Ceftriaxone 2 g IV daily  Non-Pharmacological:  – CT scan to assess fracture, urgent ENT referral, facial nerve monitoring, prevent CSF leak (bed rest, head elevation), avoid blowing nose forcefully, possible surgical intervention for facial nerve decompression, CSF leak repair
Foreign Bodies in Ear	– Ear pain, hearing loss, visible foreign object in ear canal	Pharmacological:  – None unless secondary infection (then use antibiotics as appropriate): Amoxicillin 500 mg orally, 8-hourly for 7 days  Non-Pharmacological:  – Removal under direct visualization (irrigation for non-organic objects, suction, instrumentation), ENT referral if difficult to remove or for potential complications (e.g., perforation, deep impaction), avoid using cotton swabs in the ear
Mastoiditis	– Ear pain, fever, postauricular swelling and tenderness, protruding auricle, otorrhea	Pharmacological:  – IV antibiotics: Ceftriaxone 1-2 g IV daily, add metronidazole 500 mg IV every 8 hours if anaerobic infection suspected  Non-Pharmacological:  – Urgent ENT referral, possible surgical drainage (mastoidectomy), CT scan of temporal bones to assess extent, myringotomy for culture and drainage, hospital admission for severe cases, pain management with paracetamol or ibuprofen
Epistaxis	– Anterior: bleeding from the nostril  – Posterior: bleeding into the throat, difficulty controlling bleeding	Pharmacological:  – Topical vasoconstrictors: Oxymetazoline 0.05% spray, 2 sprays per nostril  – Tranexamic acid 500 mg orally three times daily for 5 days (for severe cases)  Non-Pharmacological:  – Direct pressure to the nostrils (pinch the soft part of the nose for 10-15 minutes), nasal packing with vaseline gauze or nasal tampon, cauterization with silver nitrate sticks (if bleeding site identified), consider posterior packing or balloon catheter for posterior epistaxis, treat underlying conditions (e.g., hypertension control), avoid nose picking and blowing
Nasal Trauma	– Nasal deformity, swelling, bruising, epistaxis, nasal obstruction	Pharmacological:  – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day)  Non-Pharmacological:  – Ice packs to reduce swelling, closed reduction of nasal fracture (within 7-10 days if no septal hematoma), ENT referral if septal hematoma or significant deformity, avoid further trauma to the nose, head elevation to reduce swelling
Septal Haematoma	– Nasal obstruction, pain, swelling of the nasal septum, difficulty breathing through the nose	Pharmacological:  – Antibiotics to prevent abscess formation: Amoxicillin/clavulanate 875/125 mg orally twice daily for 7-10 days  Non-Pharmacological:  – Urgent drainage of the hematoma, anterior nasal packing to prevent re-accumulation, ENT referral for follow-up, ice packs to reduce swelling, avoid further trauma to the nose
Nasal Fracture	– Pain, nasal deformity, epistaxis, swelling, bruising	Pharmacological:  – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day)  Non-Pharmacological:  – Ice packs to reduce swelling, closed reduction of nasal fracture (within 7-10 days if no septal hematoma), ENT referral if septal hematoma or significant deformity, avoid further trauma to the nose, head elevation to reduce swelling
Post-Tonsillectomy Bleed	– Hemorrhage from tonsillar bed, may occur within 24 hours (primary) or 5-10 days post-op (secondary)	Pharmacological:  – None specific  Non-Pharmacological:  – Urgent ENT referral, apply direct pressure with gauze soaked in adrenaline (1:10,000), patient positioning (head forward to prevent aspiration), IV fluids for resuscitation, blood transfusion if significant blood loss, return to operating theatre for hemostasis if necessary, monitor for signs of hypovolemia (tachycardia, hypotension), hospital admission for observation
Palatal/Laryngeal Trauma	– Dysphagia, hoarseness, stridor, subcutaneous emphysema, visible wounds or hematoma in the oropharynx	Pharmacological:  – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day)  – Antibiotics if infection risk: Amoxicillin/clavulanate 875/125 mg orally twice daily for 7-10 days  Non-Pharmacological:  – Secure airway if compromised (intubation or tracheostomy), imaging (CT scan) to assess injury, urgent ENT referral, possible surgical intervention for repair, hospital admission for observation and airway management
Quinsy (Peritonsillar Abscess)	– Severe sore throat, dysphagia, trismus, “hot potato” voice, uvular deviation, swelling and redness of the soft palate	Pharmacological:  – IV antibiotics: Penicillin G 2-4 million units IV every 4 hours, Metronidazole 500 mg IV every 8 hours (if anaerobic infection suspected)  – Analgesics: Paracetamol 500-1000 mg orally every 4-6 hours (max 4 g/day), Ibuprofen 200-400 mg orally every 6-8 hours (max 1.2 g/day)  Non-Pharmacological:  – Needle aspiration or incision and drainage of the abscess, supportive care (hydration, pain management), ENT follow-up, consider tonsillectomy if recurrent, monitor for airway obstruction

This detailed table provides an overview of the clinical features and management of common ear, nose, and throat emergencies, including specific pharmacological and non-pharmacological management strategies according to Australian guidelines.

Competently carry out certain ear, nose and throat procedures:

• use of auroscope
• Weber and Rinne tests (demonstration and interpretation)
• removal of foreign bodies
• nasal packing
• ear wax removal (syringing versus suction)
• interpretation of audiograms
• demonstration of use of nasal sprays.

Weber and Rinne tests.

Test	Demonstration	Normal Result	Interpretation for Conductive Hearing Loss	Interpretation for Sensorineural Hearing Loss
Weber	1. Strike a tuning fork (512 Hz) and place its base on the midline of the patient’s skull or forehead. 2. Ask the patient where they hear the sound best: in the left ear, right ear, or equally in both ears.	Sound is heard equally in both ears.	Sound is heard louder in the affected ear (conductive hearing loss).	Sound is heard louder in the unaffected ear (sensorineural hearing loss).
Rinne	1. Strike a tuning fork (512 Hz) and place its base on the mastoid process behind the patient’s ear. 2. Ask the patient to tell you when they no longer hear the sound (bone conduction). 3. Move the tuning fork near the ear canal (air conduction) without touching it. 4. Ask the patient if they can hear the sound again and when they no longer hear it.	Air conduction (AC) is greater than bone conduction (BC). The patient hears the fork next to the ear longer than on the mastoid process (AC > BC).	Bone conduction is greater than air conduction in the affected ear (BC > AC).	Air conduction is greater than bone conduction, but both are reduced in the affected ear (AC > BC, but both diminished).

Notes:

• Weber Test: Helps differentiate between conductive and sensorineural hearing loss. The lateralization of sound indicates the type of hearing loss.
• Rinne Test: Compares air conduction and bone conduction of sound. Helps confirm the presence of conductive hearing loss when BC > AC.

Steps for Weber and Rinne Tests

Weber Test:

1. Explain the procedure to the patient.
2. Strike the tuning fork gently against your hand.
3. Place the base of the tuning fork on the midline of the patient’s skull or forehead.
4. Ask the patient where they hear the sound (left, right, or both equally).

Rinne Test:

1. Explain the procedure to the patient.
2. Strike the tuning fork gently against your hand.
3. Place the base of the tuning fork on the mastoid process behind one ear.
4. Ask the patient to tell you when they no longer hear the sound.
5. Immediately move the tuning fork to the front of the ear canal.
6. Ask the patient if they can hear the sound again and when they no longer hear it.

By following these steps and interpreting the results as shown in the table, you can accurately assess the type of hearing loss present in a patient.

Interpreting an audiogram

involves understanding the various components and how they relate to hearing loss. Here’s a step-by-step guide to interpreting an audiogram in table format.

Component	Description	Interpretation
Frequency (Hz)	X-axis on the audiogram, ranging from low frequencies (250 Hz) to high frequencies (8000 Hz).	Lower frequencies represent bass sounds (e.g., vowel sounds), and higher frequencies represent treble sounds (e.g., consonants like “s” and “th”).
Hearing Level (dB)	Y-axis on the audiogram, ranging from -10 dB to 120 dB. Lower numbers indicate softer sounds, and higher numbers indicate louder sounds.	The level at which a person can barely hear a tone. Normal hearing is between -10 dB and 20 dB. Values above 20 dB indicate some degree of hearing loss.
Air Conduction (AC)	Represented by circles (right ear) and Xs (left ear) connected by a line. Tested using headphones or ear inserts.	Measures the ability to hear sounds through the air. Poor AC thresholds indicate hearing loss, but further tests are needed to determine the type (conductive vs. sensorineural).
Bone Conduction (BC)	Represented by brackets (< or >) or sometimes arrows. Tested using a bone oscillator placed on the mastoid bone.	Measures the ability to hear sounds through bone vibrations. Poor BC thresholds with good AC thresholds indicate conductive hearing loss. Poor BC and AC thresholds indicate sensorineural hearing loss.
Air-Bone Gap	The difference between air conduction and bone conduction thresholds at the same frequency.	An air-bone gap greater than 10 dB indicates a conductive component to the hearing loss. If no gap exists, the hearing loss is sensorineural.
Speech Reception Threshold (SRT)	The lowest intensity level (dB) at which a person can correctly repeat 50% of common spondee words (two-syllable words with equal stress).	Should be consistent with the pure-tone average (PTA) of the thresholds at 500, 1000, and 2000 Hz. Significant differences might indicate non-organic hearing loss or a need for re-testing.
Word Recognition Score (WRS)	Percentage of words correctly repeated at a comfortable loudness level above the SRT.	High scores (90-100%) indicate good speech understanding, while lower scores suggest difficulties understanding speech, especially in background noise.

Interpreting Types of Hearing Loss

Type of Hearing Loss	Audiogram Pattern	Characteristics
Normal Hearing	AC and BC thresholds between -10 dB and 20 dB across all frequencies.	Indicates no significant hearing loss.
Conductive Hearing Loss	AC thresholds are elevated (worse) while BC thresholds are within normal limits, showing an air-bone gap.	Indicates an issue in the outer or middle ear, such as earwax blockage, otitis media, or otosclerosis.
Sensorineural Hearing Loss	Both AC and BC thresholds are elevated (worse) equally without an air-bone gap.	Indicates an issue in the inner ear or auditory nerve, such as presbycusis, noise exposure, or ototoxic medications.
Mixed Hearing Loss	Both AC and BC thresholds are elevated (worse), but there is a significant air-bone gap.	Indicates a combination of conductive and sensorineural components, such as chronic otitis media with presbycusis.

Steps to Interpret an Audiogram

1. Examine the Frequency (Hz):
   • Check the X-axis to see the range of frequencies tested (250 Hz to 8000 Hz).
2. Check the Hearing Level (dB):
   • Look at the Y-axis to understand the decibel levels (loudness) where thresholds are plotted.
3. Compare Air Conduction (AC) and Bone Conduction (BC) Thresholds:
   • Identify AC thresholds (circles for the right ear, Xs for the left ear).
   • Identify BC thresholds (brackets or arrows).
4. Analyze the Air-Bone Gap:
   • Determine if there is a gap between AC and BC thresholds. An air-bone gap greater than 10 dB suggests conductive hearing loss.
5. Review Speech Reception Threshold (SRT) and Word Recognition Score (WRS):
   • SRT should align with the pure-tone average (PTA).
   • WRS provides insight into the patient’s ability to understand speech.
6. Determine the Type and Degree of Hearing Loss:
   • Use the patterns in the thresholds to classify the hearing loss as normal, conductive, sensorineural, or mixed.
   • Assess the severity based on the decibel levels (mild, moderate, severe, profound).

By following these steps and using the table, you can systematically interpret an audiogram and identify the type and extent of hearing loss in a patient.

show me example chart of an audiogramChatGPT

Sure, here is an example of an audiogram chart to help visualize how audiograms are plotted and interpreted:

Example Audiogram Chart

Frequency (Hz)	250	500	1000	2000	4000	8000
Right Ear (AC)	10	15	20	25	30	35
Right Ear (BC)	10	15	20	25	30	35
Left Ear (AC)	10	20	25	30	35	40
Left Ear (BC)	10	20	25	30	35	40

Audiogram Interpretation

1. Right Ear:
   • Air Conduction (AC): Thresholds are between 10 dB and 35 dB.
   • Bone Conduction (BC): Thresholds are the same as AC (10 dB to 35 dB).
   • Interpretation: No air-bone gap. This indicates sensorineural hearing loss that is mild to moderate.
2. Left Ear:
   • Air Conduction (AC): Thresholds are between 10 dB and 40 dB.
   • Bone Conduction (BC): Thresholds are the same as AC (10 dB to 40 dB).
   • Interpretation: No air-bone gap. This indicates sensorineural hearing loss that is mild to moderate.

Degree of Hearing Loss (Example)

• Normal Hearing: -10 to 20 dB
• Mild Hearing Loss: 21 to 40 dB
• Moderate Hearing Loss: 41 to 55 dB
• Moderately Severe Hearing Loss: 56 to 70 dB
• Severe Hearing Loss: 71 to 90 dB
• Profound Hearing Loss: >90 dB

Example Audiogram Chart

Symbols Used:

• O: Right ear air conduction (AC)
• X: Left ear air conduction (AC)
• <: Right ear bone conduction (BC)
• >: Left ear bone conduction (BC)

Explanation:

• Right Ear (AC): Circles (O) are plotted at thresholds 10 dB, 15 dB, 20 dB, 25 dB, 30 dB, and 35 dB across different frequencies.
• Left Ear (AC): Crosses (X) are plotted at thresholds 10 dB, 20 dB, 25 dB, 30 dB, 35 dB, and 40 dB across different frequencies.
• Right Ear (BC): Brackets (<) could be plotted at the same points as AC for right ear if indicated.
• Left Ear (BC): Brackets (>) could be plotted at the same points as AC for left ear if indicated.

Example Interpretation

• Right Ear: Mild to moderate sensorineural hearing loss, as indicated by the O symbols ranging from 10 dB to 35 dB without any significant air-bone gap.
• Left Ear: Mild to moderate sensorineural hearing loss, as indicated by the X symbols ranging from 10 dB to 40 dB without any significant air-bone gap.

This graphical representation helps in quickly identifying the type and degree of hearing loss by visually inspecting the plotted points on the audiogram chart.