1.Edoardo Cervoni, M.D. (T)GP & Ear Nose Throat Specialist Director: Locumdoctor4u Ltd.24 February 2014GP Trainees - Education Centre, RPH1

2. Discolosures Grant/Research Support: no disclosure Consultant: no disclosure Major Shareholder: Locumdoctor4u Ltd. I will not be discussing off-label uses of medicationsor investigations24 February 2014GP Trainees - Education Centre, RPH2 3. ENT Referrals i.Most ENT referrals are linked to Audiological and Otological problems.ii.Out of 271 consecutive referrals to the RHP ENT Department triaged in 2011, 58% could be potentially managed in Primary Care.CLPCT NHS Survey 2011 E Cervoni24 February 2014GP Trainees - Education Centre, RPH3 4. ENT Referrals i. ii.Snoring and sleep apnoea were relatively common reasons of referrals. In a rather significant proportion of cases, relevant information, with specific reference to the physical examination, were missing. iii. Among the referrals redirected to the GPwSI in ENT, deafness with wax, epistaxis and blocked nose were the most common complaints.CLPCT NHS Survey 2011 E Cervoni24 February 2014GP Trainees - Education Centre, RPH4 5. Conditions referredCervoni E - 201124 February 2014GP Trainees - Education Centre, RPH5 6. ENT Referral Pattern is changingWHY? Ageing Sanitation Vaccinations 24 February 2014GP Trainees - Education Centre, RPH6 7. Demographics Lancashire residents grew during the decade to 2011 by 3%. There was a 5% fall in the number of 0 to 19 year olds, which was greater than the regional decrease. There was a 12% growth in people 65+ years, which was also above the regional average. The growth rate of the 65+ year olds was positive inall districts except Blackpool and the greatest in Chorley and West Lancashire. 24 February 2014GP Trainees - Education Centre, RPH7 8. The Rise of Hearing Loss There are morethan 10 million people in the UK with some form of hearing loss, or one in six of the population. From the total 3.7 million are of working age (16 64) and 6.3 million are of retirement age (65+). 24 February 2014GP Trainees - Education Centre, RPH8 9. 24 February 2014GP Trainees - Education Centre, RPH# 10. Rinne Test24 February 2014GP Trainees - Education Centre, RPH10 11. Bing & Schwabach Test Bing test is a qualitative Schwabach test is a testtest of bilateral conductive involvement. Tragal compression to cause EAC obstruction when patient cannot hear any longer sound from mastoid. If tone caomes back, to be marked as negative.of air-conduction thresholds. The number of seconds is counted while the tone is still heard24 February 2014GP Trainees - Education Centre, RPH11 12. Spatial mapping In cases wheredisparities exist between hearing tresholds, the patients will typically gave difficulty finding midline. Binaural integration may be achieved.24 February 2014GP Trainees - Education Centre, RPH12 13. Sensory Presbycusis High frequency down-sloping SNHL Speech discrimination remains good Degeneration a basal potion of Organ of Corti (predominately outer hair cells) Neural presbycusis Flat audiogram Rapid hearing loss Poor speech discrimination Loss of spiral ganglion cells24 February 2014Metabolic Presbycusis Slowly progressive Flat audiogram Good speech discrimination Atrophy of stria vascularis Conductive Presbycusis Thickening of basilar membrane Gradual down-sloping high frequency hearing loss Progressive Speech discrimination for similar pure tone hearing is worse in older patients than younger patientsGP Trainees - Education Centre, RPH13 14. Treatments Repeat testing Assistive devices Vibrating alarm clocks Flashing telephone and door signalers Television listening systems Personal amplifiers Hearing aids In U.S.A. an estimated 4.5 million hearing aid users , but only 10-20% who could use them do and 12% of people who have them dont wear them. 24 February 2014GP Trainees - Education Centre, RPH14 15. Types of hearing aid circuitry Analog Digitally controlled analog Digital sound processing Body Aids Behind-the-ear (BTE) In-the-ear(ITE) In-the-canal(ITC) Completely-in-canal(CIC) 24 February 2014GP Trainees - Education Centre, RPH15 16. Objective -Pulsatile tinnitus Arteriovenous malformations (AVM) Vascular tumors Venous hum Atherosclerosis Ectopic carotid artery Persistent stapedial artery Dehiscent jugular bulb Vascular loops24 February 2014 Cardiac murmurs Pregnancy Anemia Thyrotoxicosis Pagets disease Benign intracranial hypertensionIdiopathic stapedial muscle spasm Palatal myoclonus Patulous eustachian tubeGP Trainees - Education Centre, RPH16 17. Subjective tinnitus Presbycusis Noise exposure Menieres disease Otosclerosis Head trauma Acoustic neuroma Drugs (i.e.: aspirin,quinine, AG, loop diuretics)24 February 2014 Middle ear effusion TMJ problems Depression Hyperlipidemia Meningitis Syphilis Foods (i.e.: caffeine,GP Trainees - Education Centre, RPHalcohol)17 18. Treatments Multiple treatments Reassurance Avoidance of dietary White noise fromstimulants: coffee, tea, cola, etc. Smoking cessation Avoid medications known to cause tinnitus24 February 2014GP Trainees - Education Centre, RPHradio or home masking machine18 19. Balance Disorders Difficulties with sensory function, central nervous system integration, neuromuscular and skeletal function 30-50% persons 65 and older fall in a given year 50% per year fall age 80 or older 1% of falls suffer hip fractures, 5% some type of fracture Roughly half of hip fractures are estimated to never recover normal function again 24 February 2014GP Trainees - Education Centre, RPH19 20. Vestibular changes with age Termed presbystasis Loss of hair cells primarily in the ampulla Total number of vestibular nerve axons is 37% thanyounger patients Loss of neurons in vestibular nuclei of 3% per decade age 40-90 Reduction in gain of VOR, smooth pursuit, increase in saccade latencies Postural stability: Sensory (visual, hearing, vestibular, proprioceptive)/Musculoskeletal/Cognitive/Integrative function 24 February 2014GP Trainees - Education Centre, RPH20 21. Non-labyrinthine balance disorders CEREBELLAR METABOLIC DEGENERATION PARKINSONS DISEASE HUNTINGTONS DISEASE SPINAL CORD TUMORS POSTURAL HYPOTENSION CEREBROVASCULAR DISEASE ATHEROSCLEROSIS MUSCULOSKELETAL DISEASE24 February 2014 GP Trainees - Education Centre, RPHDISORDERS CARDIOVASCULAR DISORDERS MEDICATIONS B12 DEFICIENCY DEMENTIA DIABETIC NEUROPATHY VISUAL IMPAIRMENT ALCOHOL 21 22. Vestibular system assessment History Dizziness, dysequilibrium, vertigo Onset, duration, frequency, severity, provocation,associated symptoms, falls Medications, medical conditions Physical exam Examine sensory functions, posture, gait, neurological function Adjunctive testing Audiogram, electronystagmography, MRI, posturography24 February 2014GP Trainees - Education Centre, RPH22 23. Treatments24 February 2014GP Trainees - Education Centre, RPH23 24. Nasal Complaints Nasal obstruction Rhinorrhea Epistaxis Olfactory dysfunction24 February 2014GP Trainees - Education Centre, RPH24 25. Causes Inflammation: decrease immune function, mucociliary dysfunction, allergy, dehydration with thickening of secretions Dystrophic changes: both atrophy of nasal mucosa and increase in vasomotor rhinitis are common Neoplasia: nasal obstruction, pain, epistaxis, rhinorrhea Trauma: old traumas, previous surgery Endocrine-metabolic disorders: hypothyroidism, decreased vitamin A and zinc Pharmacologic effects: diuretics, tricyclic antidepressants, antihistamines24 February 2014GP Trainees - Education Centre, RPH25 26. Dysphagia Phases of swallowing Oral (reduced facial muscle strength, decreased masticatory strength, reduced tongue control, missing dentition) Pharyngeal (delayed in elderly subjects, decreased pharyngolaryngeal sensory discrimination, abnormal UES function, increased penetration and silent aspiration) Oesophageal ( decreased or absent secondaryperistalsis)24 February 2014GP Trainees - Education Centre, RPH26 27. Evaluation History: Feeding problem vs. swallowing disorder Liquids vs. solids Globus, halitosis, wet vocal quality, reflux, odynophagia, recurrent pneumonia, hoarseness, dysarthria Physical Exam Oral cavity and upper aerodigestive tract, saliva quality/dentition/dentures Neurological evaluation including arousal, orientation, cognition, cranial nerves 24 February 2014GP Trainees - Education Centre, RPH27 28. Investigations Barium swallow (anatomic lesions) Modified barium swallow (dinamic view) ofswallowing from oral cavity to lower esophageal sphincter) FEES Functional endoscopic evaluation of swallowing Videofluoroscopic swallowing study, or VFSS test 24 February 2014GP Trainees - Education Centre, RPH28 29. Causes of dysphagia Stroke Neuromuscular disease - Parkinsons disease (pillrolling tremor, bradykinesia, cog-wheeling rigidity), Amyotrophic lateral sclerosis Medications (xerostomia, mental status change, dyskinesia, GERD, esophagitis) Cricopharyngeus dysfunction (functional, structural, bar on barium swallow) Zenkers diverticulum (regurgitation) Neoplasms 24 February 2014GP Trainees - Education Centre, RPH29 30. Treatments Swallowing therapy Dietary modifications Rationalization of medications PEG Cricopharyngeal myotomy, Botox injection of cricopharyngeal bar Surgical repair of Zenkers (open vs. endoscopic) Oesophageal stent24 February 2014GP Trainees - Education Centre, RPH30 31. Voice changes Estimated 12% of the elderly have vocal dysfunction Fundamental frequency of the male voice tends toincrease with age Fundamental frequency in females decreases with age24 February 2014GP Trainees - Education Centre, RPH31 32. Voice changes Common vocal cord findings Atrophy Bowed cords Oedema Loss of collagen and elastic fibers, decrease in density of fibroblasts, atrophy of submucous glands, fibrosis, disorganization of collagen fibers24 February 2014GP Trainees - Education Centre, RPH32 33. Neurological disorders with voice changes Essential tremor Parkinsons disease: low volume, breathy, andmonotonic Stroke Myasthenia gravis Amyotrophic lateral sclerosis24 February 2014GP Trainees - Education Centre, RPH33 34. Treatments Speech therapy Medialization thyroplasty Diagnosis and treatment of underlying disorder24 February 2014GP Trainees - Education Centre, RPH34 35. Head & Neck Cancers Squamous cell cancers Thyroid malignancies Well differentiated have worse course Anaplastic or undifferentiated more common Salivary gland malignancies Lymphomas24 February 2014GP Trainees - Education Centre, RPH35 36. Laryngeal Cancer UK24 February 2014GP Trainees - Education Centre, RPH36 37. Cosmetics Elderly are leading more active lives for much longerthan in the past With the explosive growth of cosmetic facial plastic surgery paired with the explosive growth of the elderly population there will be many more elderly cosmetic patients24 February 2014GP Trainees - Education Centre, RPH37 38. Face ageing Skin- loss of tone, dynamic and static wrinkling, thinning, pigmentary changes, gravitational descent of soft tissues Chemical peel, laser resurfacing Botox injection Rhytidectomy Upper third-ptosis of eyebrows and forehead Direct brow lift Pretrichial/coronal/endoscopic 24 February 2014GP Trainees - Education Centre, RPH38 39. Surgical correction Periorbital Region - lower eyelid laxity, prolapsed lacrimal gland, ptosis(usually dermatochalasis) Dacryoadenopexy Lower lid shortening Upper/lower blepharoplasty Nose tip ptosis from loss of attachments between upper and lower lateral cartilages, loss of connections between medial crura and septum, ligamentous connections between domes of lower lateral cartilages and anterior septal angle Rhinoplasty-shorten lateral crura, place septal strut Lower third loss of premental fat pad witches chin, cheiloptosis, platysmal bands Genioplasty Lip-lift Plication, imbrication, suture suspension, Z-plasty of platysma24 February 2014GP Trainees - Education Centre, RPH39 40. Conclusions With the expected explosive growth of the elderlypopulation, this group will become a larger proportion of patients The otolaryngologist must consider the patients health and well being as a whole especially in this group of patients who often have multiple problems24 February 2014GP Trainees - Education Centre, RPH40 41. 1.2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.Parham K, Lin FR, Coelho DH, Sataloff RT, Gates GA. Comprehensive Management of Presbycusis: Central and Peripheral. Otolaryngol Head Neck Surg. 2013 Feb 8. Creighton FX Jr, Poliashenko SM, Statham MM, Abramson P, Johns MM 3rd. The growing geriatric otolaryngology patient population: a study of 131,700 new patient encounters. Laryngoscope. 2013 Jan;123(1):97-102. Dagan E, Wolf M, Migirov LM. Why do geriatric patients attend otolaryngology emergency rooms? Isr Med Assoc J. 2012 Oct;14(10):6336. Kumar S, Rout N, Kumari P, Dey B. The conceptions of hearing impairment, causes and its management: a train survey. Int J Pediatr Otorhinolaryngol. 2012 Aug;76(8):1123-6. doi: 10.1016/j.ijporl.2012.04.014. Epub 2012 May 12. Van Vuuren PA, Kagan SH, Chalian AA. Geriatric otolaryngology toolbox: what you and your nurse can do to improve outcomes for older adults. Ear Nose Throat J. 2009 Oct;88(10):1162-8. Chalian AA. Accomplishment and opportunity in geriatric otolaryngology. Ear Nose Throat J. 2009 Oct;88(10):1156-61. Goldstein JC. The American Society of Geriatric Otolaryngology. Ear Nose Throat J. 2007 Dec;86(12):718-9. Eibenstein A, Fioretti AB, Simaskou MN, Sucapane P, Mearelli S, Mina C, Amabile G, Fusetti M. Olfactory screening test in mild cognitive impairment. Neurol Sci. 2005 Jul;26(3):156-60. Bora H, Bandyopadhyay SN, Basu SK, Majhi PK. Geriatric problems in otolaryngology. J Indian Med Assoc. 2004 Jul;102(7):366, 368, 370. Review. Vaiman M, Eviatar E, Segal S. Surface electromyographic studies of swallowing in normal subjects: a review of 440 adults. Report 1. Quantitative data: timing measures. Otolaryngol Head Neck Surg. 2004 Oct;131(4):548-55. Belafsky PC, Postma GN, Amin MR, Koufman JA. Symptoms and findings of laryngopharyngeal reflux. Ear Nose Throat J. 2002 Sep;81(9 Suppl 2):10-3. Sahoo GC. Gerontology in ENT (Geriatric Otolaryngology) - an over view. Indian J Otolaryngol Head Neck Surg. 2001 Oct;53(4):267-9. Jiang RS, Hsu CY. Endoscopic sinus surgery for the treatment of chronic sinusitis in geriatric patients. Ear Nose Throat J. 2001 Apr;80(4):230-2.24 February 2014GP Trainees - Education Centre, RPH41