Ear, nose, throat and oral health

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Ear, nose, throat (ENT) and oral conditions are common presentations in general practice, making up 3.6 out of every 100 consultations.1 In Australia, around 3.6 million people suffer from hearing loss and more than 1.3 million people live with a hearing condition that could have been prevented.2 Each year in Australia, more than 500 children are born with moderate to profound permanent hearing impairment.3 Hearing disorders are more common in men than women and the proportion of people with long-term hearing disorders increases with age.3 General practitioners (GPs) are well placed to screen for hearing loss across all demographics.

The most common ear disease affecting children in Australia is otitis media, presenting as a spectrum of disease from otitis effusions to chronic suppurative otitis media.4 Intervention prevents secondary hearing loss which has a significant impact on speech and language development and is a cause of behavioural issues, early school leaving, and limited employment options in later years.4 

The 2018–19 National Aboriginal and Torres Strait Islander Health Survey estimated 14% of Aboriginal and Torres Strait Islander peoples had a long-term ear or hearing problem.4,5 The proportion was the same for men and women, and similar for remote and non-remote areas.4,5 Aboriginal and Torres Strait Islander children have a higher rate of ear disease and associated hearing loss than non-Indigenous children.5 A number of initiatives co-designed with Aboriginal Community Controlled Health Services are in place to reduce the incidence of hearing loss and improve oral health status in Aboriginal and Torres Strait Islander patients.

ENT presentations such as vertigo may present with or without hearing loss and constitute approximately 54% of cases of dizziness.6 Other ENT presentations include acute or chronic nasal obstruction, allergies (allergic rhinitis) and sore throat.7 If not treated and managed, these can adversely affect quality of sleep resulting in daytime somnolence and fatigue.7 Approximately one-third of children aged five to 12 years will have an episode of sore throat each year, most cases are viral in origin, with 15–36% caused by bacteria, predominantly group A streptococcus (GAS).8 GPs are well positioned to manage such conditions and treat as per current guidelines.

Poor oral health and disease accounted for 4.5% of the burden of non-fatal disease in 2015, of which tooth decay, gum disease and tooth loss were the most common.9 Poor oral health affects chewing and swallowing, in turn affecting dietary intake and compromised nutrition.9 Poor oral health is associated with chronic diseases, including stroke and cardiovascular disease.10 It can also affect an individual’s appearance, self-esteem and self-confidence and their ability to talk and communicate effectively, thus impacting on social wellbeing and interpersonal relationships.10 GPs have a role in promoting good oral hygiene amongst patients and ensuring timely referral to appropriate oral and dental specialist services to avoid complications.

Head and neck cancer is the seventh most commonly diagnosed cancer in Australia, with the number of diagnosed cases doubling over the past 40 years and predicted to continue to increase.11 Smoking and alcohol are major risk factors accounting for 75% of the cases.11 GPs providing lifestyle modification advice and early detection can lead to increased survival rate.11

References
  1. Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2013 – 14. General practice series no. 36. Sydney: Sydney University Press, 2014. [Accessed 31 August 2021].
  2. Australian Government Department of Health. Ear health: Canberra: Commonwealth of Australia. [date unknown] [Accessed 16 September 2021].
  3. Australian Institute of Health and Welfare. Australia’s health 2016: Vision and Hearing Disorders. Australia’s health series no. 15. Cat. no. AUS 199. Canberra: AIHW, 2016 [Accessed 16 September 2021].
  4. Kong K, Lannigan FJ, Morris PS, Leach AJ, O'Leary SJ. Ear, nose and throat surgery: All you need to know about the surgical approach to the management of middle-ear effusions in Australian Indigenous and non-Indigenous children. J Paediatr Child Health 2017;53(11):1060–64.
  5. Australian Institute of Health and Welfare. Indigenous hearing health: Canberra: AIHW, 2020 [Accessed 16 September 2021].
  6. Dommaraju S, Perera E. An approach to vertigo in general practice. Aust Fam Physician 2016;45(4):190–94.
  7. Esmaili A, Acharya A. Clinical assessment, diagnosis and management of nasal obstruction. Aust Fam Physician 2017;46(7):499–503.
  8. Tran J, Danchin M, C Steer A, Pirotta M. Management of sore throat in primary care. Aust J Gen Pract 2018;47(7):485–89.
  9. Australian Institute of Health and Welfare. Oral health and dental care in Australia. Canberra: AIHW, 2021 [Accessed 16 September 2021].
  10. Lewis A, Wallace J, Deutsch A, King P. Improving the oral health of frail and functionally dependent elderly. Aust Dent J 2015;60(Suppl 1):95–105.
  11. Koh J, Walsh P, D'Costa I, Bhatti O. Head and neck squamous cell carcinoma survivorship care. Aust J Gen Pract 2019;48(12):846–48.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • effectively and appropriately communicate with patients with hearing loss and/or speech impairment in conjunction with their families and others involved in their care
1.1.1, 1.1.2, 1.1.3, 1.1.4, 1.2.1, AH1.3.1, 1.3.1, 1.3.2, 1.4.4
  • effectively communicate and establish a therapeutic relationship with parents/carers of Aboriginal and Torres Strait Islander children at risk of chronic ear disease
AH1.1.1, AH1.4.1, RH1.4.1, 1.4.4
  • conduct a consultation that provides continuity of care through timely referral and follow-up to prevent associated secondary conditions
1.4.2, RH1.4.1
  • discuss preventable causes of complications associated with such conditions including deafness, rheumatic disease, tooth loss and early detection of malignancy
1.2.1, 1.2.2, 1.2.3, 1.3.1, 1.3.2, 1.4.3, AH1.4.1, RH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • diagnose, treat and manage common ENT and oral presentations
2.1.1, 2.1.2, 2.1.3, 2.1.4, RH2.1.1, 2.3.4
  • identify and manage urgent ENT and oral presentations
2.1.1, 2.1.2, 2.1.3, 2.1.4, RH2.1.1, RH2.3.1, AH2.1.2
  • articulate the evidence base for prescribing pharmacological treatment and consider non-pharmacological options in management of common ENT and oral presentations
2.1.9
  • identify and screen for actual or potentially life-threatening conditions including quinsy and acute rheumatic fever
AH2.1.1, AH2.1.2, 2.1.3, RH2.1.1
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify, and advocate to remove barriers that have an impact on patients accessing timely optimal care to prevent sequelae
3.2.1, 3.2.2, 3.2.3, 3.2.4, AH3.2.2, RH3.2.1
  • discuss health inequalities in relation to common ENT and oral conditions
AH3.2.2, RH3.2.1, 3.2.3
  • describe opportunistic screening practices for patients at risk of hearing loss
3.1.1
  • promote the importance of good oral hygiene and its association with chronic illness and adequate nutrition
3.1.3, 3.1.4, 3.2.2, 3.2.3
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • demonstrate the ability to act in the patient’s best interest when antibiotics are requested inappropriately for conditions including childhood otitis media and acute sore throat
4.1.1, 4.4.2, AH4.2.1, 4.1.5
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • identify readily accessible evidence-based guidelines for pre-referral treatment and referral of common ENT and oral conditions
5.1.1, AH5.1.1, AH5.2.1, AH5.1.3
  • implement effective recall systems for monitoring conditions of the ear, nose, throat and mouth
5.1.1, 5.1.3

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Hearing loss affects both children and adults. It is important to assess hearing in patients presenting with conditions that may be associated with hearing loss, such as speech and behavioural concerns in a child, or adults presenting with an unsteady gait and tinnitus.
  2. Nasal obstructions are a common presentation in general practice; remember to examine the nasal cavity for evidence of any inflammatory changes suggestive of acute or chronic allergic rhinitis and screen for possible causes of obstructive sleep apnoea.
  3. Most ear and throat conditions in general practice present as ear pain or as a sore throat secondary to an upper respiratory tract infection, requiring rational prescribing of oral antibiotics. A careful throat examination needs to be conducted to avoid a missed diagnosis of an early quinsy that would require emergency management. Also consider the patient presenting with a persistent sore throat or with dysphonia, requiring further investigations and prompt referral to a non-GP specialist.
  4. Consider non-prescription medications (over-the-counter preparations) to help in the management of common ear, nose and throat conditions; for example, the use of sinus rinses in the management of sinusitis.
  5. Become familiar with common dental presentations, such as bleeding gums as a result of gum disease, or the patient presenting with severe dental pain after a tooth extraction as a result of a dry socket or acute infection.
  6. Always look at the tongue and buccal mucosa when carrying out an ear, nose and throat examination to look for any suspicious lesion in high-risk groups, for example, smokers.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Ear, nose, throat and oral health

Barbara, 71 years old, presents to you with her husband Peter with concerns about her hearing. Peter has noticed that she is unable to hear him, and he needs to yell for her to understand. Barbara thinks that her hearing is fine, and her husband tends to speak softly.

Questions for you to consider Clinical exam assessment area Domains

What communication strategies could you use to communicate if Barbara had hearing loss or hearing impairment?

What if Barbara was four years old and brought in by her parents with concerns about her hearing and speech development? How would you assess her hearing and speech during the consultation?

What if her parents thought she had an ear infection and asked you for antibiotics but you didn’t feel they were indicated – how would you explain your rationale for not prescribing them?

  1. Communication and consultation skills
1,2,5

What communication strategies could you use to communicate if Barbara had hearing loss or hearing impairment?

What if Barbara was four years old and brought in by her parents with concerns about her hearing and speech development? How would you assess her hearing and speech during the consultation?

What if her parents thought she had an ear infection and asked you for antibiotics but you didn’t feel they were indicated – how would you explain your rationale for not prescribing them?

  1. Clinical information gathering and interpretation
2   

What differential diagnoses would you consider with Barbara’s presentation, and what are the diagnoses not to miss? What investigations would you do to help confirm your most likely diagnosis?

What if Barbara was a 25-year-old pregnant lady presenting with hearing loss?

What if Barbara presented to you with hearing loss and an unsteady gait and tinnitus? What serious conditions should you not miss?

  1. Making a diagnosis, decision making and reasoning
2   

What is your approach to managing Barbara’s possible hearing loss?

What is your approach to managing a six-year-old child with a one-day history of a sore ear secondary to an upper respiratory tract infection? How can you rationalise your prescribing of oral antibiotics in children?

Would your management change for a child presenting with persistent otitis media or for a child from a vulnerable or high-risk population, for example, Aboriginal and Torres Strait Islander?

What would your approach be if Barbara had a persistent ear discharge? What other serious conditions should not be missed? What if she were a child? Would your approach to management change? When do you refer a patient with a perforated ear drum?

  1. Clinical management and therapeutic reasoning
2   

What are the specific risks of an elderly patient with hearing loss? What opportunistic screening strategies could you implement for hearing loss in older people?

What specific health concerns do you need to consider in adults or children in high-risk populations presenting with ear and throat complaints?

  1. Preventive and population health     
1,2,3

What if Barbara was 82 years old, deaf but refused to wear a hearing aid, and presented for a medical assessment to renew her driver license?

What if this was a 55-year-old truck driver who presented with poor sleep, snoring and tiredness?

  1. Professionalism
4   

What if this was a 54-year-old man working in a remote mining town presenting to you with hearing loss after working in a loud work environment?

  1. General practice systems and regulatory requirement
5   

What if Barbara’s hearing loss was contributed to by wax in her ear? What do you need to consider when getting consent from Barbara for an ear syringe?

What would your approach be for a five-year-old child who presents at the emergency department with a suspected foreign body in their ear?

  1. Procedural skills
2   

What if Barbara’s hearing loss was unilateral, what would your differential diagnoses be? How would you manage this consultation?

What if Barbara’s hearing loss was associated with persistent ear pain? How would you approach this?

  1. Managing uncertainty
2   

What if Barbara’s hearing loss was associated with vertigo, nausea and vomiting?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Identify what you find challenging about oral health presentations; for example, how do you manage an avulsed baby tooth or adult tooth? Review guidelines about how to manage these conditions. Consider spending some time with your local dentist.

  • What did you learn? How will this new information help you manage patients presenting with dental concerns, such as a toothache?
  • How might your management be different if you worked in a rural or remote location?  

Identify one of your patients who has had a hearing assessment. Review the office tests you could carry out during a consultation with a patient presenting with hearing loss. Review an audiogram and reflect on what you would expect to find on an audiogram.

  • Do the results of an audiogram correlate with your clinical findings?
  • Who is responsible for performing audiograms in your practice? Could you learn this skill?

Identify the clinical concerns in two patients (one child, one adult) who present with signs and symptoms of obstructive sleep apnoea secondary to nose and throat pathology.

  • When and how do you screen for sleep apnoea during a consultation?
  • When do you suspect a nose or throat pathology?
  • What guidelines or questionnaires do you need to be aware of to make an appropriate referral to a non-GP specialist?
  • What advice do you give to patients who drive private or commercial vehicles?
With a supervisor

Discuss the serious conditions that should not be missed in a patient presenting with an ear, nose, throat or oral health complaint.

  • What red flag signs and symptoms were you able to come up with?
  • Describe these possible presentations to your supervisor. Did they have any others?

Discuss how you would approach management of intra-oral swelling.

  • What feedback did your supervisor give you? Did they have any tips for management?
  • How might your management be impacted if you worked in a rural or remote location? What are your limitations? What are your local referral pathways?
  • What are the specific challenges for Aboriginal and Torres Strait Islander peoples seeking access to dental services?

Observe your supervisor inserting an ear wick.

  • What are the indications for an ear wick? What equipment do you need? What are the steps involved in the process? What general advice do you give to the patient? When would you remove an ear wick?
  • Is your supervisor willing to observe/help you practise this skill the next time either of you has an appropriate patient?
In a small group

Role-play how you might approach a patient with vertigo. Take turns demonstrating an appropriate clinical examination, including a dix-Hallpike manoeuvre.

  • What are the steps involved in carrying out a dix-Hallpike manoeuvre, and how would you explain the examination to a patient? Watch a YouTube video to further refine your clinical skills.
  • What are the common cause of vertigo, and how would you explain these to a patient?

Discuss case scenarios involving the role of oral antibiotics in the management of a sore throat. Discuss how you could rationalise your prescribing of oral antibiotics to patients.

  • What guidelines are available to manage sore throats in children and adults? Are there any guidelines for managing sore throats in high-risk/vulnerable groups such as Aboriginal and Torres Strait Islander peoples?
  • What clinical features do you look for to help with your decision? Would you do any investigations? If so, would the results influence your ongoing management?
With a friend or family member

Explain to a friend or family member the symptoms of benign paroxysmal positional vertigo and the exercises to help treat and manage it.

  • What educational leaflets or patient information sheets could you use to help with your explanation?
  • Did your friend or family member understand your explanation? Is there anything you could do differently?

Explain to a friend or family member what good dental hygiene is, and its role in avoiding dental caries and tooth decay.

  • Ask your friend or family member for feedback on how well you explained the importance of good oral hygiene. Will they change their dental hygiene practice? How could you motivate them to change their current habits?
  • Consider oral hygiene as part of your opportunistic preventive care. How could you incorporate it in your health check-up/assessment for patients of all ages?

Explain to a friend or family member how to use a nasal spray in allergic rhinitis.

  • What tools could you use to help with your explanation? How could you check whether they understood your advice?
  • Consider spending some time with your local pharmacist to discuss over-the-counter medications and preparations that may help in managing certain conditions.

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Have a structured approach to common ear, nose, throat and oral health presentations, including screening high-risk populations such as Aboriginal and Torres Strait Islander peoples.
  • Identify common ear, nose, throat and oral health conditions and manage them appropriately.
  • 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.
  • Assess and manage nose presentations:
    • rhinitis, including allergic rhinitis
    • sinusitis
    • epistaxis
    • nasal polyps
    • foreign bodies.
  • 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.
  •  Assess and manage throat presentations:
    • pharyngitis
    • tonsillitis
    • infectious mononucleosis (EBV)
    • hoarseness (dysphonia)
    • epiglottitis
    • foreign bodies
    • odynophagia
    • dysphagia
    • laryngopharyngeal reflux.
  • Identify, through history and examination, oral, head and neck cancer, and appropriately investigate and manage these.
  •  Identify and assess ear, nose, face and oral cavity structural abnormalities:
    • prominent ears
    • facial deformity
    • cleft lip and cleft palate
    • tongue-tie
    • pre-auricular sinus
    • brachial cyst.
  • 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.
  •  Identify, and appropriately manage, oral emergencies:
    • trauma such as management of avulsed, luxated or broken tooth
    • maxillofacial trauma
    • complication after dental procedures (eg acute infections).
  • 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.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
Articles on antibiotic prescribing for management of otitis media in children, hearing loss in elderly patients, and an overview of acute and chronic sinusitis. Common foreign objects, the associated anatomy and the instruments and indications for use. A framework for approaching and managing patients who present with olfactory impairments. Guidelines on causes, assessment, appropriate investigation and management of tinnitus. A framework for approaching patients with vertigo, and a suggested approach to the assessment of vertigo. Articles on surgical solutions to orofacial problems, dental abscess and common causes of swelling in the oral cavity. The causes, complications and management of a patient presenting with a dry mouth. Managing patients with dental infections who present to emergency departments or general practice surgeries. Presentations of dental-related trauma, and a brief management plan for each condition.
Online resources
This chapter in the Red book provides guidance on preventive activities for oral health.
  • The Royal Australian College of General Practitioners. Oral health
Chapter 8 in the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people provides guidance on preventive activities for oral health, including risk factors for dental disease.
  • National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners. Oral and dental health.
Educational information to help parents understand the management of common respiratory symptoms.
Learning activities
eLearning modules with case presentations to assess your clinical knowledge.
  • The Royal Australian College of General Practitioners gplearning activities:
    • Check, Unit 579, January – February 2021: Oral medicine
    • Check, Unit 573, July 2020: Ear, nose and throat
    • AJGP Clinical Challenge September 2020: Dentistry
    • Early childhood oral health: Case studies from general practice
    • Tempo module – Antibiotic use in children with acute otitis media
This webinar provides rural and remote GPs with the knowledge, confidence and resources to competently manage commonly presenting dental emergencies.
Other
The management of otitis media. The management of acute rhinosinusitis. The management of chronic rhinosinusitis. The management of a sore throat. Assessment and management of children presenting with acute otitis media. Assessment and management of children presenting with a sore throat.
This contextual unit relates to the other unit/s of:
The content of this unit can be applied to all aspects of general practice, so is relevant to all other units.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/ear-nose-throat-and-oral-health 23/05/2022