nmrcgp for consultants

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ENT

This is what our GP trainees need to achieve during their time at your department. We've classified them under the six main compentency domains for general practice..

1. PRIMARY CARE MANAGEMENT

• Manage primary contact with patients who have an ENT or facial problem.
• Identify symptoms that within the range of normal and require no treatment e.g. cyclical blocking of nose, senile rhinorrhoea, small neck lymph nodes in well children.
• Explain the indications for appropriate referral to an ENT specialist e.g. recurrent tonsillitis (current guidelines are to refer if more than five attacks in two years or recurrent quinsy), Ear drum perforations (pars tensa are safe, whereas pars flaccida are unsafe).
• Identify where services are deficient or frequently have long waiting times for ENT surgery e.g. audiometry, hearing aids, cochlear implants.
• Describe arrangements for referral to specialist nurse services e.g. audiometry.

The knowledge base

Symptoms
• Hearing loss; ear wax, otalgia; discharging ear; dizziness; tinnitus; epistaxis; sore throat, hoarseness; dysphagia; croup; goitre, lymph nodes and other neck swellings; speech delay; foreign bodies; facial weakness

Common and/or important conditions
• Otitis media (suppurative/secretory); otitis externa; perforated tympanic membrane; cholesteatoma
• Vertigo; Ménière’s disease;
• Bell’s palsy; Tempero-mandibular pain, Trigeminal neuralgia
• Pharyngitis; tonsillitis; laryngitis; glandular fever; oral candida, herpes; salivary stones; GORD
• Infective and allergic rhinitis; sinusitis; nasal polyps
• Nasal fracture, haematoma auris
• Snoring and sleep apnoea
• Suspected Head and Neck Cancer:
• Unilateral hearing loss in the absence of external ear pathology or obvious cause

Investigation
• Otoscopy,
• Tuning fork tests
• Awareness of: pure tone threshold audiogram; speech audiometry, impedance tympanometry, auditory brainstem responses and otoacoustic emissions.
• Investigations may delay referral in suspected head and neck cancer (see Appendix 1)

Treatment
• Watchful waiting and use of delayed prescriptions
• Nasal cautery
• Fracture nose (need manipulation under anaesthetic within 2 weeks for optimum result)

Emergency care
• Septal haematoma
• Epistaxis
• Tonsillitis with Quinsy
• Otitis externa if extremely blocked or painful
• Foreign body
• Auricular haematoma or perichondritis

Prevention
• Screening for hearing impairment in adults and children
• Awareness of iatrogenic causes of ototoxicity

2. PERSON CENTRED CARE

• Describe strategies for communicating effectively with patients with hearing impairment and deafness e.g. remembering to face the patient and speaking clearly so that they can lipread.
• Demonstrate effective strategies for dealing with parental concerns regarding ENT conditions e.g. recurrent tonsillitis and glue ear.
• Empower patients to adopt self-treatment and coping strategies where possible e.g. hay fever, nosebleeds, dizziness, tinnitus.

3. PROBLEM SOLVING SKILLS

The knowledge base

Treatment
• Watchful waiting and use of delayed prescriptions
• Nasal cautery
• Fracture nose (need manipulation under anaesthetic within 2 weeks for optimum result)

Emergency care
• Septal haematoma
• Epistaxis
• Tonsillitis with Quinsy
• Otitis externa if extremely blocked or painful
• Foreign body
• Auricular haematoma or perichondritis

Prevention
• Screening for hearing impairment in adults and children
• Awareness of iatrogenic causes of ototoxicity

Specific problem-solving skills
• Utilise knowledge of the relative prevalence of ENT problems to assist diagnosis.
• Describe the alarm symptoms for head and neck cancer e.g. hoarseness persisting for more than 6 weeks, ulceration of oral mucosa persisting for more than 3 weeks.
• Demonstrate appropriate use of time as a diagnostic tool, including clear review procedures and safety netting.
• Understand the likely outcomes of tests e.g. ear swabs after multiple antibiotic courses always grow pseudomonas.

4. COMPREHENSIVE APPROACH

• Describe ENT presentations of systemic diseases e.g. GORD, CVA, AIDS
• Assess the likelihood of occupational exposure as a cause of ENT disease (e.g. industrial deafness).

5. COMMUNITY ORIENTATION

• Prioritise referrals accurately so people with minor conditions don’t compromise the care of those with more serious conditions
• Describe the national screening programme for hearing loss.
• Understand that certain services have limited availability e.g. Cochlear implants, digital hearing aids.
• Understand the legal implications of the Disability Discrimination Act 1995 including the need for 'reasonable adjustments' e.g., allowing more time for appointments or having a display board to announce the next appointment. They can also include providing communications support, such as a BSL/English interpreter or purchasing helpful equipment, such as a conversor and putting a prominent reminder on the jacket of a patient's notes or on the computer record to tell staff the patient is deaf.

6. HOLISTIC APPROACH

• Appreciate the impact of deafness on people’s lives. “Blindness separates people from things. Deafness separates people from people”
• Demonstrate awareness that certain ENT symptoms can indicate psychological distress e.g. globus – sensation of not swallowing in a patient who can swallow, the “dizzy” patient who can walk without difficulty.

All these 6 domains have a

7. Contextual Aspect

• Recognise that training in ENT problems has been very limited outside specialist programmes in the past, increasing the risk of inappropriate referrals and under-referral.

8. Attitudinal Aspect

• Ensure that a patient’s hearing impairment or deafness does not prejudice the information communicated or doctor’s attitude towards the patient.
• Demonstrate empathy and compassion towards patients with incurable disabling ENT conditions e.g. tinnitus.

9. Scientific Aspect

• Demonstrate a thorough knowledge of the scientific backgrounds of symptoms, diagnosis and treatment, particularly with respect to ENT interventions of dubious efficacy.
• Demonstrate an evidence based approach to antibiotic prescribing, to prevent the development of resistance e.g. otitis media.
• Understand and implement the key national guidelines that influence healthcare provision for ENT problems e.g. Prodigy.