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ENT for GPs: Your Essential Guide

From earwax to epiglottitis - because every GP needs to know when to worry and when to wax lyrical about wax removal

🥇 Tea-Friendly Learning 🥈 For GP Trainees Short on Time 🥉 Red Flag Focused

Last Updated: March 2026

Executive Summary: What You'll Master Today

Because you have 47 other things to do before lunch, and that's just the morning list

Quick Facts at a Glance:

1 in 3

Approximately 12 million UK adults affected

17.7%

Persistent tinnitus affects quality of life in 6% of adults

24-hour referral

Requires urgent ENT specialist assessment within 24 hours

80%

Most common reason for antibiotic prescription in children

📥 Downloads & Resources

Clinical reference materials and web resources for ENT in primary care

Downloads

path: EAR, NOSE & THROAT

Web Resources

RCGP ENT Curriculum Topic Guide ↗ Outlines what a GP trainee should know and do in ENT, covering red flags, common presentations, and learning suggestions aligned to WPBAs and AKT.
Hull University Teaching Hospitals — Primary Care ENT Guidance ↗ Pragmatic initial management of common ENT conditions agreed jointly by ENT specialists and primary care clinicians.
North West London ICB — ENT Primary Care Guidance ↗ Primary-care-oriented guidance and referral criteria for common ENT presentations from NW London ICB.
GIRFT ENT Referral Guidelines — Adults (PDF) ↗ National standardised referral pathways from primary care for adult ENT presentations, with suggested work-up and referral content guidance.
GIRFT ENT Referral Guidelines — Paediatrics (PDF) ↗ As above for children, with paediatric-specific indications, safety-netting advice, and clear referral criteria.
ENTSHO.com ↗ Concise on-call-style pages covering otitis externa/media, epistaxis, quinsy, stridor and more — practical management steps and red flags, very GP-usable.
ENT UK — Community & GP Resources ↗ Hosts clinical guidelines, patient leaflets, and the practical Official Handbook for Medical Students and Junior Doctors — useful for GP trainees.
ENT UK — GPwER Guidance (PDF) ↗ Knowledge, skills, and training expectations for GPs with an Extended Role in ENT — useful for those building a community ENT service.
ENT UK — "What Should a GP Learn About ENT?" (PDF) ↗ Core ENT knowledge and skills benchmarked for GPs — useful when planning GP training sessions or a self-study plan.

🧭 Quick Navigation

Jump directly to the section you need

Brainy Bites Data Gathering Diagnostic Approach Differential Diagnosis Common Conditions Red Flags Hearing Loss Types

🧠 Brainy Bites: Essential ENT Wisdom

The stuff seasoned GPs wish someone had told them sooner

💡

Always Check Hearing First - Whisper test from 2 metres. "Can you hear me whisper?" Document and compare to previous readings.

🎯

The 24-Hour Rule - Sudden sensorineural hearing loss = ENT emergency. Don't wait - refer within 24 hours or hearing may be permanently lost.

⚠️

Red Flag Triad - Drooling + Stridor + Can't swallow = Epiglottitis. Call 999, don't examine throat, get anaesthetist involved.

💊

FeverPAIN Score - Score ≥4 = 62-65% streptococcal infection. Give antibiotics immediately. Score 2-3 = delayed prescription.

🔄

BPPV Epley Manoeuvre - "Sit, turn head 45°, lie back quickly, wait 30s, turn 90° left, wait 30s, roll onto side." Cures 80% of posterior canal BPPV.

👂

Weber Test Memory Aid - "Weber goes to the Worse ear in conductive loss, but to the Better ear in sensorineural loss."

🎪

Quinsy Recognition - "Hot potato voice + trismus + uvula deviation = peritonsillar abscess. Same-day ENT referral for drainage."

🌊

Postnasal Drip Clue - "Chronic cough worse at night + throat clearing + sensation of mucus = think postnasal drip before prescribing another inhaler."

1️⃣ Data-Gathering & Examination Tips

Essential consultation frameworks and examination skills for primary care

Otoscopy

EAR

Equipment Required

Otoscope
Specula (various sizes)
Pneumatic attachment (optional)

Examination Steps

1 Explain procedure and gain consent

2 Select appropriate speculum size

3 Pull pinna up and back (adults) or down and back (children)

4 Insert speculum gently into external auditory canal

5 Inspect canal for wax, discharge, foreign body

6 Visualize tympanic membrane: colour, position, light reflex, perforation

7 Assess mobility with pneumatic otoscopy if available

Normal Findings

Pearly grey tympanic membrane
Cone of light at 5 o'clock (right) or 7 o'clock (left)
Visible malleus handle
Mobile membrane with pneumatic insufflation

Abnormal Findings

Red, bulging membrane (acute otitis media)
Retracted membrane with visible fluid level (otitis media with effusion)
Perforation
Cholesteatoma (white debris, attic perforation)
Wax impaction
Otitis externa (canal inflammation)

Rinne and Weber Tests

EAR

Equipment Required

512 Hz tuning fork

Examination Steps

1 Rinne Test: Strike tuning fork and place on mastoid process

2 Ask patient to indicate when sound stops

3 Immediately move fork to external auditory meatus

4 Ask if sound is still audible

5 Weber Test: Strike tuning fork and place on vertex/forehead

6 Ask patient where sound is heard (midline, left, or right)

Normal Findings

Rinne positive: Air conduction > bone conduction (AC>BC)
Weber: Sound heard equally in both ears (midline)

Abnormal Findings

Conductive loss: Rinne negative (BC>AC), Weber lateralizes to affected ear
Sensorineural loss: Rinne positive, Weber lateralizes to better ear
Mixed loss: Rinne may be negative, Weber lateralizes to better ear

Dix-Hallpike Test

EAR

Equipment Required

Examination couch
Frenzel glasses (optional)

Examination Steps

1 Explain procedure and warn of vertigo

2 Sit patient upright on couch

3 Turn head 45° to one side

4 Rapidly lower patient to supine with head extended 20° below horizontal

5 Observe eyes for nystagmus for 30-60 seconds

6 Return patient to sitting position

7 Repeat on opposite side

Normal Findings

No nystagmus
No vertigo

Abnormal Findings

BPPV: Rotatory nystagmus after 5-10 second latency
Nystagmus fatigues with repeated testing
Vertigo accompanies nystagmus
Central causes: Immediate nystagmus, no latency, no fatigue

Anterior Rhinoscopy

NOSE

Equipment Required

Thudichum nasal speculum
Light source
Decongestant spray (optional)

Examination Steps

1 Explain procedure

2 Tilt patient's head back slightly

3 Insert speculum into nostril vertically

4 Open blades gently in horizontal plane

5 Inspect nasal vestibule, septum, inferior turbinate

6 Look for polyps, discharge, mucosal changes

7 Repeat on opposite side

Normal Findings

Pink, moist mucosa
Midline septum
Visible inferior turbinate
No discharge or polyps

Abnormal Findings

Septal deviation
Nasal polyps (pale, grape-like)
Mucopurulent discharge (sinusitis)
Mucosal inflammation (rhinitis)
Epistaxis source
Foreign body

Throat Examination

THROAT

Equipment Required

Tongue depressor
Light source
Gloves

Examination Steps

1 Explain procedure

2 Ask patient to open mouth wide and say "Ahhh"

3 Inspect lips, teeth, gums, buccal mucosa

4 Use tongue depressor to visualize oropharynx

5 Assess tonsils: size, symmetry, exudate

6 Inspect soft palate and uvula

7 Look for posterior pharyngeal wall inflammation

Normal Findings

Pink, moist mucosa
Symmetrical tonsils
No exudate
Midline uvula
No ulceration

Abnormal Findings

Tonsillar exudate (bacterial tonsillitis)
Asymmetric tonsils (quinsy, malignancy)
Petechiae on palate (EBV)
Ulceration (aphthous, malignancy)
Candidiasis (white plaques)
Deviated uvula (quinsy)

Neck Examination

THROAT

Equipment Required

None required

Examination Steps

1 Inspect neck from front and sides

2 Palpate lymph node chains systematically

3 Submental, submandibular, jugular chain, posterior triangle, supraclavicular

4 Assess thyroid gland (ask patient to swallow)

5 Palpate for masses

6 Assess cranial nerve XII (tongue protrusion)

Normal Findings

No visible swelling
No palpable lymph nodes (or small, soft, mobile nodes)
Symmetrical neck movement

Abnormal Findings

Lymphadenopathy: size, consistency, mobility, tenderness
Thyroid enlargement
Neck mass (branchial cyst, thyroglossal cyst, malignancy)
Supraclavicular nodes (high risk of malignancy)

Diagnostic Approach by Presenting Complaint

Key History Questions

Onset and duration?
Unilateral or bilateral?
Associated hearing loss or discharge?
Recent URTI or swimming?
Pain on moving jaw or pulling pinna?
Systemic symptoms (fever)?

Examination Findings to Look For

Otoscopy: TM appearance, perforation, discharge
Pinna and canal examination
Mastoid tenderness
TMJ examination
Throat examination (referred pain)

Investigations

Usually clinical diagnosis
Swab if otorrhoea present
Imaging if mastoiditis suspected

Differential Diagnoses

Acute otitis media

Otitis externa

Referred pain (TMJ, dental, throat)

Mastoiditis

Cholesteatoma

Malignant otitis externa (diabetics)

Key History Questions

Sudden or gradual onset?
Unilateral or bilateral?
Associated tinnitus or vertigo?
Noise exposure history?
Family history of hearing loss?
Ototoxic medications?

Examination Findings to Look For

Otoscopy: wax, perforation, effusion
Rinne and Weber tests
Whispered voice test
Cranial nerve examination if unilateral

Investigations

Audiometry (pure tone and speech)
Tympanometry
MRI IAM if unilateral SNHL
Blood tests if sudden SNHL (FBC, ESR, glucose)

Differential Diagnoses

Wax impaction

Otitis media with effusion

Presbycusis

Noise-induced hearing loss

Acoustic neuroma

Ménière's disease

Sudden sensorineural hearing loss

Key History Questions

True vertigo (spinning) or dizziness?
Duration of episodes?
Triggers (head movement, position)?
Associated hearing loss or tinnitus?
Neurological symptoms?
Headache or visual disturbance?

Examination Findings to Look For

Dix-Hallpike test
Gait and Romberg test
Cranial nerve examination
Nystagmus assessment
Cardiovascular examination (postural BP)

Investigations

Usually clinical diagnosis for BPPV
Audiometry if Ménière's suspected
MRI brain if central cause suspected
ECG if cardiac cause suspected

Differential Diagnoses

BPPV

Vestibular neuronitis

Ménière's disease

Labyrinthitis

Posterior circulation stroke

Vestibular migraine

Orthostatic hypotension

Key History Questions

Unilateral or bilateral?
Constant or intermittent?
Associated rhinorrhoea or sneezing?
Seasonal variation?
Epistaxis or blood-stained discharge?
Facial pain or pressure?

Examination Findings to Look For

Anterior rhinoscopy
Assess for polyps, septal deviation
Facial tenderness (sinusitis)
Lymphadenopathy

Investigations

Usually clinical diagnosis
CT sinuses if chronic rhinosinusitis
Allergy testing if allergic rhinitis
Nasal endoscopy if unilateral symptoms

Differential Diagnoses

Allergic rhinitis

Chronic rhinosinusitis

Nasal polyps

Septal deviation

Adenoidal hypertrophy (children)

Nasal tumour (unilateral)

Key History Questions

Duration of symptoms?
Fever or systemic upset?
Difficulty swallowing or breathing?
Cough or coryzal symptoms?
Contact with streptococcal infection?
Immunization status (diphtheria)?

Examination Findings to Look For

Throat examination: tonsillar exudate, symmetry
Cervical lymphadenopathy
Temperature
Respiratory rate and effort
Trismus or drooling

Investigations

FeverPAIN or Centor score
Throat swab if recurrent
Monospot if EBV suspected
Imaging if quinsy suspected

Differential Diagnoses

Viral pharyngitis

Bacterial tonsillitis (Group A Strep)

Infectious mononucleosis (EBV)

Peritonsillar abscess (quinsy)

Epiglottitis

Diphtheria (rare)

Differential Diagnosis Framework

Systematic Approach to ENT Presentations

Organize your differential diagnosis by anatomical location and pathological process

Location	Inflammatory	Structural	Neoplastic
External Ear	Otitis externa, Perichondritis	Wax impaction, Foreign body	SCC, BCC
Middle Ear	AOM, OME, Mastoiditis	Cholesteatoma, Perforation	Glomus tumour
Inner Ear	Labyrinthitis, Vestibular neuronitis	BPPV, Ménière's	Acoustic neuroma
Nose/Sinuses	Rhinitis, Sinusitis	Polyps, Septal deviation	Nasal carcinoma
Throat	Pharyngitis, Tonsillitis, Quinsy	Tonsillar hypertrophy	Oropharyngeal carcinoma
Larynx	Laryngitis, Epiglottitis	Vocal cord nodules/polyps	Laryngeal carcinoma

Common ENT Conditions: Management Guide

Sore Throat, Tonsillitis & Quinsy

THROAT 1.2 million GP consultations/year in the UK

Clinical Features — Pharyngitis & Tonsillitis

Sore throat, odynophagia, fever
Viral cause in ~70% — coryzal symptoms, no exudate
Bacterial (Group A Strep) — tonsillar exudate, fever >38°C, no cough, lymphadenopathy
EBV (glandular fever) — splenomegaly, generalised lymphadenopathy, palatal petechiae
FeverPAIN score: Fever, Purulence, Attend rapidly (<3 days), Inflamed tonsils, No cough
Recurrent tonsillitis: ≥7 episodes/year, ≥5/year for 2 years, or ≥3/year for 3 years (Paradise criteria)

⚠️ Clinical Features — Quinsy (Peritonsillar Abscess)

Severe unilateral throat pain — dramatically worse than typical tonsillitis, often can barely swallow
"Hot potato" muffled voice — classic, immediately recognisable
Trismus (difficulty opening the mouth) — due to pterygoid muscle spasm
Uvular deviation away from the affected side — hallmark sign
Visible bulge of the soft palate and tonsil on the affected side, pushing the tonsil medially
Drooling (unable to swallow saliva), high fever, systemically unwell
Usually follows 4-7 days of worsening tonsillitis — patient feels "this is different, much worse"

The case for watchful waiting

Around 80% of sore throats are viral and self-limiting. Even when bacterial (Streptococcus pyogenes), the infection is often self-limiting and antibiotics shorten symptoms by only about half a day. Reserve antibiotics for higher FeverPAIN/Centor scores.

💬 What to say to patients / parents:

"Most sore throats settle within a week. Antibiotics only shorten things by about half a day. The throat is usually worst around day 3 or 4, then gradually improves day by day."

For parents: "If little Johnny had a twin and we gave Johnny antibiotics but nothing to the twin, they'd both usually be better by day 7. The antibiotic might just make Johnny better half a day earlier."

🦠 Classic viral clues

• Cough
• Coryza / runny nose
• Conjunctivitis
• Hoarseness
• Diarrhoea

🔴 Classic bacterial clues

• Fever
• Tonsillar exudate
• Tender anterior cervical lymphadenopathy
• Absence of cough

Immediate Management

Analgesia — paracetamol and ibuprofen regularly
Encourage fluids and rest
Calculate FeverPAIN or Centor score
If quinsy suspected — same-day ENT referral for incision & drainage

Primary Care Management — Pharyngitis/Tonsillitis

FeverPAIN 0-1: no antibiotics
FeverPAIN 2-3: delayed antibiotic prescription
FeverPAIN ≥4: phenoxymethylpenicillin 500mg QDS × 10 days (first-line)
Penicillin allergy: Clarithromycin 250mg twice daily × 5 days (adults)
Never give amoxicillin if EBV suspected — causes widespread maculopapular rash
Monospot test if EBV suspected — advise no contact sport for 3-4 weeks (splenic rupture risk)
Safety net: return if worsening, drooling, trismus, difficulty breathing or swallowing

⚠️ Why not amoxicillin?

1️⃣ Rash risk in EBV

Up to 90% of patients with infectious mononucleosis develop a widespread maculopapular rash if given amoxicillin. It's not a true allergy, but it's alarming for patients and creates lasting confusion about penicillin allergy. Phenoxymethylpenicillin carries far lower risk of triggering this reaction.

2️⃣ Antimicrobial stewardship

Phenoxymethylpenicillin is narrow-spectrum — it targets Streptococcus pyogenes (Group A strep) precisely. Amoxicillin is broader-spectrum, which promotes resistance and disrupts normal flora unnecessarily. Use the narrowest effective agent.

Quinsy — Management

Same-day ENT referral — incision and drainage (I&D) or aspiration under local anaesthetic
IV antibiotics and fluids if systemically unwell or unable to swallow
IV dexamethasone to reduce swelling and speed recovery
Interval tonsillectomy considered after second quinsy
Do NOT attempt to lance or examine aggressively in primary care

ENT Referral — Tonsillectomy

Paradise criteria met: ≥7 episodes in 1 year, OR ≥5/year for 2 years, OR ≥3/year for 3 years; each with fever >38.3°C, cervical lymphadenopathy, tonsillar exudate, or positive strep
Obstructive sleep apnoea from tonsillar hypertrophy
Recurrent quinsy — interval tonsillectomy
Unilateral tonsillar enlargement without infection — 2WW malignancy referral

NICE Guidance

NG84 — Sore throat: antimicrobial prescribing

Last updated: October 2017

Red Flags - Urgent Action Required

Hot potato voice + trismus + uvula deviation + visible palatal bulge = Quinsy — same-day ENT
Stridor or airway compromise — call 999 immediately, do not examine throat
Neck stiffness with sore throat — meningitis
Unilateral tonsillar enlargement without acute infection — malignancy, 2WW referral
Drooling with inability to swallow — airway at risk, emergency
Severe systemic sepsis — admit urgently
Epiglottitis — drooling, inspiratory stridor, unable to swallow, sitting forward, muffled voice: DO NOT EXAMINE THROAT, call 999, keep child calm
Respiratory distress or stridor — airway emergency, call 999
Severe dysphagia — unable to swallow saliva, drooling: admit urgently

Acute Otitis Media

EAR Prevalence: 80% of children by age 3

Clinical Features

Ear pain (otalgia)
Fever and systemic upset
Bulging, red tympanic membrane
Reduced hearing
Otorrhoea if perforation occurs

Immediate Management

Analgesia (paracetamol/ibuprofen)
Safety-netting advice

Primary Care Management

Watchful waiting for 72 hours in most cases
Delayed antibiotic prescription
Immediate antibiotics if: systemically unwell, <2 years with bilateral AOM, otorrhoea, immunocompromised
First-line: Amoxicillin 500mg three times daily × 5 days (adults; 7 days if severe)
Second-line / penicillin allergy: Clarithromycin 500mg twice daily × 5 days; or if treatment failure: Co-amoxiclav 500/125mg three times daily × 5–7 days

Specialist Referral Indications

Recurrent AOM (≥4 episodes in 6 months)
Persistent effusion >3 months
Complications (mastoiditis, intracranial)

NICE Guidance

Otitis media (acute): antimicrobial prescribing

Last updated: 29 March 2022

Red Flags - Urgent Action Required

Severe systemic infection
Mastoiditis (post-auricular swelling, tenderness)
Meningitis symptoms
Facial nerve palsy

Grommets in Children (Otitis Media with Effusion)

EAR Prevalence: 10–15% of children require grommets

Clinical Features

Conductive hearing loss, often bilateral
Speech and language delay in young children
Inattentiveness at school — often first noticed by teachers
Recurrent ear infections in some cases
Dull, retracted or fluid-filled tympanic membrane on otoscopy
Flat tympanogram (type B) on tympanometry
Hearing loss ≥25dB in better ear — threshold for intervention
OME persisting >3 months despite conservative management
Impact on speech, language, development or learning

Immediate Management

Reassurance — most cases resolve spontaneously within 3 months
Watchful waiting with hearing monitoring
Formal audiology referral — pure tone audiogram
Document any impact on learning, behaviour or development

Primary Care Management

Watchful waiting for 3 months before referral in most cases
Autoinflation (Otovent balloon) — encourage twice daily use
Treat any underlying allergic rhinitis contributing to Eustachian tube dysfunction
Refer to audiology for hearing assessment
Advise parents to minimise exposure to passive smoke

Specialist Referral Indications

Persistent bilateral OME >3 months with hearing loss
Speech, language or developmental concerns
Significant impact on quality of life or education
Recurrent AOM with effusion between episodes

NICE Guidance

NG91 — Otitis media with effusion

Last updated: November 2023

Red Flags - Urgent Action Required

Significant speech or language delay — urgent audiology referral
Suspected cholesteatoma — white debris, attic perforation
Unilateral OME in adults — must exclude nasopharyngeal carcinoma
Associated craniofacial abnormality (e.g. Down syndrome, cleft palate)
Frequent AOM causing significant morbidity — expedite ENT referral
Educational concerns raised by school or parents — prioritise referral

Chronic Suppurative Otitis Media (CSOM)

EAR Prevalence: 2-4% of population globally

Clinical Features

Chronic ear discharge >6 weeks
Through perforated tympanic membrane
Often painless (unlike acute otitis media)
May have conductive hearing loss
Offensive smell common

Immediate Management

Aural toilet (gentle cleaning/suction)
Keep ear dry - avoid water

Primary Care Management

First-line: Ciprofloxacin 0.3% ear drops — 4 drops into affected ear twice daily × 7 days (NICE first choice for perforated drum)
Second-line: Ofloxacin 0.3% ear drops — 10 drops into affected ear once daily × 7 days
7-14 days treatment
More effective than oral antibiotics
Review in 2 weeks

Specialist Referral Indications

No improvement after 4-6 weeks of treatment
Recurrent episodes despite treatment
Suspected cholesteatoma (foul smell, hearing loss)
Complications (facial nerve palsy, vertigo, headache)

Red Flags - Urgent Action Required

Facial nerve palsy
Vertigo or balance problems
Severe headache
Signs of intracranial complications

Vestibular Neuronitis vs Labyrinthitis

EAR Common causes of acute prolonged vertigo in primary care

👂 Vestibular Neuronitis

The vestibular nerve — the nerve that carries balance signals from the inner ear to the brain — becomes inflamed, usually after a viral illness. The cochlea (hearing part) is completely unaffected.

Think of it as the balance signal cable going down — the brain suddenly gets no balance input from one side, causing intense spinning vertigo. It's like pulling the plug on one side of a stereo balance system.

👉 Hearing is normal — the cochlear nerve is untouched.

🦠 Labyrinthitis

Inflammation spreads into the labyrinth itself — the fluid-filled bony structure that houses both the vestibular apparatus (balance) and the cochlea (hearing). Usually viral, occasionally bacterial (rare but serious).

Because both systems are involved, patients get vertigo and hearing loss. The vertigo is just as severe as vestibular neuronitis, but the added cochlear damage is the distinguishing feature.

👉 Hearing loss is present — this is the key difference.

	Vestibular Neuronitis	Labyrinthitis
Structures affected	Vestibular nerve only	Labyrinth (cochlea and vestibular apparatus)
Vertigo	Severe, constant, sudden onset	Severe, constant, sudden onset
Hearing loss	❌ None — hearing preserved	✅ Present — often significant
Tinnitus	Absent	Often present
Nystagmus	Horizontal, fast phase away from affected side	Horizontal, fast phase away from affected side
Preceding illness	Often post-viral URTI (presumed viral neuritis)	Often post-viral or during acute viral illness
Duration of acute phase	Days to 2–3 weeks of severe symptoms	Days to 2–3 weeks of severe symptoms
Full recovery	Weeks to months; most recover fully; some residual imbalance	Weeks to months; hearing loss may be permanent
HiNTS exam	Peripheral pattern (reassuring)	Peripheral pattern (reassuring)

🧠 The key differentiator

Hearing loss = Labyrinthitis. No hearing loss = Vestibular neuronitis. Both cause continuous severe vertigo lasting days — unlike BPPV (seconds) or Ménière's (hours). Both are peripheral vestibular disorders and should not show neurological signs.

The HINTS Examination

Use HINTS (Head impulse, Nystagmus, Test of Skew) in patients presenting with acute continuous vertigo with nystagmus within hours or days of onset to differentiate peripheral (e.g. vestibular neuritis) from central (e.g. posterior circulation stroke). Do not use for intermittent vertigo (e.g. BPPV).

✅ Reassuring — likely peripheral (e.g. vestibular neuritis)

Head impulse: Abnormal — catch-up saccade present (eyes lag then correct)
Nystagmus: Unidirectional horizontal — beats in one direction only
Test of Skew: No vertical skew — eyes stay level on alternate cover test

⚠️ Worrying — possible central cause (stroke/tumour) — needs imaging

Head impulse: Normal — no catch-up saccade (eyes stay on target despite head movement)
Nystagmus: Bidirectional or vertical — direction changes with gaze, or beats vertically
Test of Skew: Vertical skew present — one eye higher than the other on alternate cover

🧠 Memory aid — "HINTS to stroke": A normal head impulse test is the danger sign — it means the brainstem is not compensating, suggesting a central lesion. Think: "If the head impulse is normal, something is abnormally wrong."

HINTS Exam — Video 1 HINTS Exam — Video 2

📅 Recovery timeline (both conditions)

Day 1–3: Worst phase — severe constant vertigo, unable to stand or walk safely, nausea and vomiting
Day 3–7: Gradual improvement; vertigo less constant but still provoked by movement
Week 2–6: Central compensation begins; symptoms gradually resolve; imbalance improves
3–6 months: Most patients fully compensated; some have residual imbalance, especially in the elderly

Immediate Management

Reassure — benign peripheral vestibular disorder, will resolve
Advise bed rest during the acute phase (day 1–3); avoid driving
Hydration — IV fluids if unable to tolerate oral fluids due to vomiting
If labyrinthitis with significant hearing loss: urgent ENT referral to exclude sudden SNHL requiring steroids

Vestibular Sedatives — Short-term only (max 3–7 days)

⚠️ Use for symptom control in the acute phase only. Prolonged use suppresses vestibular compensation and delays recovery. Wean off as soon as tolerated — usually within 3–7 days.

First-line — antihistamine (vestibular sedative): Cinnarizine 30mg three times daily (unlicensed but widely used in UK practice); or Promethazine 25mg twice daily — max 7 days
Second-line — phenothiazine antiemetic: Prochlorperazine 3–6mg buccal (Buccastem) twice daily, or 5mg orally three times daily, or 12.5mg IM if vomiting severely — max 7 days
Alternative antiemetic: Metoclopramide 10mg three times daily (short-term); or Ondansetron 4–8mg twice daily for refractory nausea

Vestibular Rehabilitation

Encourage mobilisation as soon as tolerated — movement promotes vestibular compensation
Vestibular rehabilitation exercises (Cawthorne-Cooksey exercises) — begin once acute phase settles, usually week 2
Formal vestibular physiotherapy referral if symptoms persist beyond 6 weeks
AVOID prolonged vestibular sedatives — they impair central compensation

Specialist Referral Indications

Any associated hearing loss — ENT urgently (exclude sudden SNHL)
Neurological symptoms (diplopia, dysarthria, dysphagia, ataxia, facial palsy) — emergency neurology/stroke
Symptoms not improving after 6 weeks — ENT or neurology
Recurrent episodes — consider Ménière's disease, vestibular migraine
Diagnostic uncertainty — atypical nystagmus, no preceding viral illness

NICE Guidance

NICE CKS — Vertigo

Last reviewed: July 2023

Red Flags - Urgent Action Required

Neurological symptoms (diplopia, dysarthria, dysphagia, facial palsy, limb ataxia) — posterior circulation stroke until proven otherwise, emergency 999
Direction-changing nystagmus, vertical nystagmus, or nystagmus that does not suppress with fixation — central cause, urgent neurology
Severe headache with acute vertigo — subarachnoid haemorrhage or posterior fossa bleed
Associated hearing loss with acute vertigo — labyrinthitis; if sudden SNHL, urgent ENT for steroids within 2 weeks
Truncal ataxia — unable to sit unaided; suggests central pathology
New onset vertigo in patient with vascular risk factors (hypertension, diabetes, atrial fibrillation) — higher index of suspicion for posterior circulation stroke

Hayfever (Seasonal Allergic Rhinitis)

NOSE Affects ~20% of the UK population; peaks May–July

🌼 UK Pollen Season Calendar

🌳 Tree pollen

March – May

🌾 Grass pollen

May – July (peak)

🍂 Weed/mould

July – September

Clinical Features

Sneezing — often paroxysmal, triggered by pollen exposure
Clear watery rhinorrhoea
Nasal congestion and itching
Itchy, red, watery eyes (allergic conjunctivitis) — present in ~70% of cases
Itchy palate and throat
Reduced smell and taste during episodes
Fatigue — underappreciated; significantly impacts quality of life, school and work performance
Symptoms clearly seasonal — correlate with pollen count
Worsened by outdoor exposure, warm windy days, fresh-cut grass
Associated asthma: 30–40% of hayfever patients have asthma — always ask about chest symptoms

📊 Stepwise approach — match treatment to severity

Start 2 weeks before the anticipated season begins for best effect. Step up if symptoms not controlled after 2–4 weeks at each level.

Step 1 — Mild intermittent symptoms

Drug class: Non-sedating oral antihistamine
First-line: Cetirizine 10mg once daily — taken as needed or regularly during season (OTC, inexpensive, effective)
Alternative: Loratadine 10mg once daily (marginally less sedating than cetirizine in some patients)
Alternative: Fexofenadine 120mg once daily — truly non-sedating; useful for drivers, pilots, those operating machinery
Add: Topical antihistamine eye drops if conjunctivitis prominent — Sodium cromoglicate 2% eye drops 1–2 drops 4 times daily, or Azelastine 0.05% eye drops 1 drop twice daily

Step 2 — Moderate / persistent symptoms

Drug class: Intranasal corticosteroid (INCS) — most effective single treatment for nasal symptoms
First-line INCS: Fluticasone propionate 2 sprays (100 micrograms) per nostril once daily — start 2 weeks before season; continue throughout season
Alternative INCS: Mometasone furoate 2 sprays (100 micrograms) per nostril once daily — equivalent efficacy, slightly different particle size
Alternative INCS: Beclometasone dipropionate 2 sprays (100 micrograms) per nostril twice daily
Continue oral antihistamine alongside INCS if eye or skin symptoms persist
Drug class: Intranasal antihistamine (adjunct) — Azelastine 0.14% nasal spray 1 spray per nostril twice daily — fast-acting (15 min), useful for breakthrough symptoms

Step 3 — Severe / poorly controlled symptoms

Drug class: Combined intranasal antihistamine + corticosteroid
First-line combination: Azelastine / Fluticasone propionate (Dymista) 1 spray per nostril twice daily — more effective than either component alone; NICE-approved
Drug class: Leukotriene receptor antagonist — add if asthma coexists
Add-on for asthma + hayfever: Montelukast 10mg once daily at night — especially useful when both conditions co-exist
Nasal decongestant (short-term only): Xylometazoline 0.1% — 1–2 sprays per nostril up to 3 times daily, maximum 7 days. Do not exceed 7 days — risk of rhinitis medicamentosa (rebound congestion)

Step 4 — Very severe / debilitating / exam-season crisis

⚠️ For patients severely debilitated despite steps 1–3 — this includes students sitting important exams, those in high-performance occupations, or patients with uncontrolled symptoms. Oral corticosteroids should be a short-term rescue only.

Drug class: Short course oral corticosteroid
First-line oral steroid rescue: Prednisolone 20–25mg once daily in the morning × 5–7 days — for acute severe exacerbation or exam crisis; no taper needed for courses <2 weeks
Important: Avoid IM triamcinolone (Kenalog) injection — not recommended by BSACI/NICE due to risk of adrenal suppression, avascular necrosis of hip, and prolonged systemic steroid exposure. Oral prednisolone is safer and controllable
Drug class: Intranasal corticosteroid — escalated dose
Ensure Dymista is optimised (step 3) before prescribing oral steroids
Concurrent asthma flare: Review and step up inhaled corticosteroid therapy; refer to asthma nurse/GP asthma review if poorly controlled during season

Step 5 — Allergen immunotherapy (specialist)

Drug class: Allergen immunotherapy (subcutaneous or sublingual)
Sublingual immunotherapy (SLIT): Grazax (grass pollen) — 75,000 SQ-T grass allergen tablet dissolved under tongue once daily, started 4 months before season, continued for 3 years
Alternative SLIT: Actair or Staloral — taken daily, long-term (3 years minimum)
Refer to allergy clinic / immunologist for assessment — indicated for patients with confirmed grass or tree pollen allergy failing maximum pharmacotherapy
SLIT significantly reduces symptom burden and medication use; may modify disease course long-term

Non-pharmacological measures (reinforce at every step)

Check pollen count daily (Met Office app or BBC weather) — stay indoors on high-count days
Wear wraparound sunglasses outdoors
Shower and change clothes after being outdoors
Apply petroleum jelly (Vaseline) around nostrils to trap pollen
Keep car and house windows closed during peak pollen season
Avoid drying clothes outside when pollen count is high
Avoid cutting grass or being in freshly cut grass areas

NICE / BSACI Guidance

NICE CKS — Allergic rhinitis (including hayfever)

Last reviewed: July 2023

Red Flags — Investigate Further

Unilateral nasal symptoms — always investigate to exclude nasal polyp, foreign body or tumour
Blood-stained nasal discharge — malignancy or granulomatous disease (GPA/Wegener's)
Nasal polyps in a child — consider cystic fibrosis; refer for sweat test
Anosmia not recovering after season — may indicate chronic rhinosinusitis or nasal polyps
Hayfever symptoms out of season — reconsider; may be perennial rhinitis or other cause
Worsening asthma during pollen season — review asthma management; consider step-up
Suspected anaphylaxis to pollen (rare) — refer urgently to allergy clinic; prescribe adrenaline auto-injector

Allergic Rhinitis

NOSE Affects ~20% of the UK population

Clinical Features

Nasal congestion, clear rhinorrhoea, sneezing, nasal itch
Associated eye symptoms (allergic conjunctivitis) in 50%
Seasonal (hay fever) — tree pollen (Mar-May), grass pollen (May-Jul), mould (Jul-Oct)
Perennial — house dust mite, pet dander, mould
Pale, boggy, bluish nasal mucosa on rhinoscopy
Associated asthma, eczema, or food allergy in many patients

Immediate Management

Allergen avoidance advice
For mild/intermittent: non-sedating antihistamine — Cetirizine 10mg once daily, Loratadine 10mg once daily, or Fexofenadine 120mg once daily

Primary Care Management

First-line: Intranasal corticosteroid — Mometasone furoate 100 micrograms (2 sprays) per nostril once daily, or Fluticasone propionate 100 micrograms (2 sprays) per nostril once daily; start 2 weeks before pollen season for hay fever
Start 2 weeks before anticipated pollen season for hay fever
For breakthrough symptoms: Cetirizine 10mg once daily, Loratadine 10mg once daily, or Fexofenadine 120mg once daily
If poor response to monotherapy: Combined azelastine/fluticasone (Dymista) 1 spray per nostril twice daily
Saline nasal irrigation as adjunct
RAST/ELISA blood allergy testing or skin prick testing to identify allergens
Advise on pollen avoidance strategies during high-count days
If rhinitis coexists with asthma: Montelukast 10mg once daily at night (leukotriene receptor antagonist)

Specialist Referral Indications

Inadequate response after 2-3 months of optimal pharmacotherapy
Consideration for allergen immunotherapy (SCIT or SLIT)
Associated nasal polyps or chronic rhinosinusitis
Occupational rhinitis requiring investigation
Severe uncontrolled symptoms affecting quality of life

NICE Guidance

NICE CKS — Allergic rhinitis

Last updated: February 2023

Red Flags - Urgent Action Required

Unilateral symptoms — exclude nasal polyp, foreign body or tumour
Blood-stained discharge — malignancy or granulomatous disease
Anosmia — may indicate nasal polyps or serious underlying pathology
Facial pain with fever — complicated sinusitis or orbital cellulitis
Nasal polyps in a child — consider cystic fibrosis (refer for sweat test)

Postnasal Drip (Upper Airway Cough Syndrome)

NOSE Very common; one of the top 3 causes of chronic cough

Clinical Features

Chronic cough — worse at night and on waking
Sensation of mucus dripping down the back of the throat
Frequent throat clearing
Cobblestone appearance of posterior pharyngeal wall
Associated with allergic rhinitis, sinusitis or vasomotor rhinitis
Nasal discharge — clear (allergic/vasomotor) or purulent (infective)
Hoarse voice — from mucus irritating the larynx
Bad breath (halitosis)
Sore throat from constant mucus contact

Immediate Management

Identify and treat underlying cause
Intranasal saline irrigation — first-line symptomatic relief

Primary Care Management

First-line intranasal corticosteroid: Beclometasone dipropionate 100 micrograms (2 sprays) per nostril twice daily, or Mometasone furoate 100 micrograms (2 sprays) per nostril once daily — 4–6 week trial; if good response continue long-term
Second-line (or adjunct if allergic component): Cetirizine 10mg once daily, or Loratadine 10mg once daily
Avoid triggers — house dust mite reduction, pet allergen avoidance
Humidifier at night if dryness is a contributing factor
Avoid irritants: cigarette smoke, strong odours, chemical fumes
Short-term decongestant spray if acute exacerbation — max 7 days
Antibiotics only if bacterial sinusitis confirmed (purulent discharge >10 days)
Review response at 6-8 weeks; step up if partial response

Specialist Referral Indications

No response to 3 months of intranasal steroids
Unilateral symptoms — exclude polyp, tumour, or foreign body
Associated nasal polyps
Suspected chronic rhinosinusitis requiring CT or endoscopy

NICE Guidance

NICE CKS — Rhinitis

Last updated: March 2023

Red Flags - Urgent Action Required

Unilateral symptoms with blood-stained discharge — malignancy
Haemoptysis — urgent investigation required
Unexplained weight loss or night sweats — possible malignancy
Persistent hoarseness >3 weeks — laryngeal pathology, 2WW referral
Nasal obstruction with weight loss or cervical lymphadenopathy
Facial pain or swelling — complicated sinusitis

Benign Paroxysmal Positional Vertigo (BPPV)

EAR Most common cause of vertigo; lifetime prevalence ~2.4%

Clinical Features

Brief episodes of intense rotational vertigo (seconds to <1 minute)
Triggered by head position change — rolling over in bed, looking up, bending forward
No hearing loss or tinnitus
Positive Dix-Hallpike test: rotatory upbeat nystagmus, 5-10s latency, fatigues on repetition
Posterior semicircular canal most commonly affected (85-90%)
May follow head trauma, viral illness, or prolonged bed rest
Nausea is common; vomiting less so
Episodes typically cluster then resolve spontaneously over weeks

Immediate Management

Reassure — benign, self-limiting condition
Perform Dix-Hallpike test to confirm diagnosis before commencing Epley
Epley manoeuvre — 80% success rate after one treatment
Demonstrate and teach home Brandt-Daroff exercises

Primary Care Management

Perform Epley manoeuvre in clinic — can be repeated if needed
Advise driving restriction until symptoms resolve
Vestibular sedatives (prochlorperazine) not routinely recommended — may impair compensation
If nausea/vomiting severe: Prochlorperazine 3–6mg buccal tablet (Buccastem) twice daily, or 5mg orally three times daily — use for maximum 2 weeks only to avoid impairing vestibular compensation
Advise patient to avoid lying flat for 48 hours after Epley manoeuvre
Review in 4 weeks — most resolve; teach Brandt-Daroff if persisting

Specialist Referral Indications

Failed repeated Epley — consider horizontal canal BPPV variant
Atypical nystagmus (direction-changing, no latency, no fatigue) — central cause
Associated neurological symptoms — urgent
Recurrent BPPV — consider vestibular rehabilitation

NICE Guidance

NICE CKS — Vertigo

Last updated: July 2023

Red Flags - Urgent Action Required

Nystagmus without latency, no fatigability — central cause (stroke, tumour)
Associated diplopia, dysarthria, ataxia — posterior fossa stroke, emergency
New onset headache with vertigo — subarachnoid haemorrhage
Acute onset with unilateral hearing loss — labyrinthine infarction
Prolonged vertigo (>1 minute continuous) — not typical BPPV, consider central cause
Headache with new vertigo — possible subarachnoid haemorrhage
Vertical nystagmus — always central in origin, urgent neurology referral

Tinnitus

EAR Affects ~10% of adults; 1% report severely debilitating tinnitus

Clinical Features

Perception of sound in one or both ears without external source
Most commonly bilateral high-pitched ringing or buzzing
Usually associated with sensorineural hearing loss
Pulsatile tinnitus — synchronous with heartbeat; vascular cause until excluded
Unilateral tinnitus with hearing loss — acoustic neuroma until excluded
Common triggers: noise exposure, wax impaction, medication, stress, ototoxins
Significant impact on sleep, concentration, and mental health
Often worse in quiet environments — patients use background noise for relief
Character varies: ringing, buzzing, hissing, whistling or clicking

Immediate Management

Exclude reversible causes: wax, medication review, blood pressure
Reassure: tinnitus rarely indicates serious pathology in most patients

Primary Care Management

Otoscopy and check for wax — remove if present
Review medications for ototoxins (NSAIDs, loop diuretics, aminoglycosides, quinine)
Audiometry referral for full hearing assessment
Advise on sleep hygiene and sound therapy — white noise apps, bedside sound machines, radio at low volume
Tinnitus Retraining Therapy (TRT) or CBT for distressing tinnitus
Hearing aids if associated hearing loss — may also reduce tinnitus perception
Screen for anxiety and depression — comorbidity is common
British Tinnitus Association resources: www.tinnitus.org.uk

Specialist Referral Indications

Pulsatile tinnitus — urgent ENT for vascular imaging (MRI/MRA)
Unilateral tinnitus — ENT for MRI IAM to exclude acoustic neuroma
Associated sudden hearing loss — emergency ENT referral
Objective tinnitus (audible to examiner) — urgent ENT
Tinnitus not responding to primary care management at 3 months

NICE Guidance

NG155 — Tinnitus

Last updated: March 2020

Red Flags - Urgent Action Required

Pulsatile tinnitus — vascular pathology (glomus tumour, AV malformation, carotid stenosis)
Unilateral tinnitus with hearing loss — acoustic neuroma (MRI IAM)
Associated neurological symptoms — intracranial pathology
Objective tinnitus (heard by examiner) — vascular or palatal myoclonus
Sudden onset tinnitus — may indicate sudden SNHL, treat as ENT emergency

Hearing Loss

EAR 1 in 6 UK adults; 80% of over-70s have significant hearing loss

Clinical Features

Conductive or sensorineural — distinguish using Rinne and Weber tests
Difficulty hearing conversation, especially in background noise
Frequently asking others to repeat themselves
TV or radio volume increased — often first noticed by family
Social withdrawal, communication difficulties, low mood
Gradual bilateral high-frequency loss = presbycusis (most common cause)
Conductive loss: wax, OME, otosclerosis, perforation
Sensorineural loss: noise-induced, ototoxicity, acoustic neuroma, sudden SNHL
Unilateral SNHL with tinnitus — acoustic neuroma until proven otherwise
Sudden SNHL (>30dB over 3 frequencies in <72h) = ENT emergency

Immediate Management

If sudden SNHL: same-day ENT referral — if oral steroids started in primary care pending referral: Prednisolone 60mg once daily × 7 days then taper over 7 days (within 2 weeks of onset for benefit)
Wax impaction: olive oil drops for 2 weeks then irrigation if needed

Primary Care Management

Whisper test + otoscopy in all patients
Rinne and Weber tuning fork tests to classify type
Check for reversible causes: wax, OME, medication review (ototoxics)
Refer to audiology for pure tone audiogram
Adults >18 with bilateral SNHL: direct referral to NHS hearing aid services
Review ototoxic medications (aminoglycosides, loop diuretics, cisplatin)
Screen for depression — hearing loss significantly impacts mental health
Consider urgent 2WW referral if unilateral hearing loss with suspicious associated symptoms

Specialist Referral Indications

Sudden SNHL — same-day ENT (emergency)
Unilateral SNHL — ENT for MRI IAM to exclude acoustic neuroma
Conductive loss not explained by wax or OME
Children with any hearing loss — urgent audiology
Cochlear implant assessment if severe-to-profound bilateral SNHL
Asymmetric hearing loss or associated tinnitus

NICE Guidance

NG98 — Hearing loss in adults

Last updated: June 2018

Red Flags - Urgent Action Required

Sudden onset hearing loss <72 hours — ENT emergency, same-day referral
Unilateral hearing loss with tinnitus — acoustic neuroma (MRI IAM)
Hearing loss with facial palsy or vertigo
Blood-stained discharge with hearing loss — cholesteatoma or malignancy
Pulsatile tinnitus with hearing loss — vascular pathology, urgent ENT + imaging

👂 Conductive vs Sensorineural Hearing Loss

Master the Weber and Rinne tests - your tuning fork is your friend

Conductive Hearing Loss

Common Causes:

• Earwax impaction (most common)
• Otitis media (acute/chronic)
• Otosclerosis
• Perforated tympanic membrane
• Foreign body
• Ossicular chain disruption

Test Results:

Weber: Lateralises to affected ear
Rinne: Bone conduction > Air conduction (negative)

Sensorineural Hearing Loss

Common Causes:

• Age-related (presbycusis)
• Noise-induced
• Sudden sensorineural hearing loss
• Ototoxic medications
• Acoustic neuroma
• Meniere's disease

Test Results:

Weber: Lateralises to unaffected ear
Rinne: Air conduction > Bone conduction (positive)

How to Perform Weber & Rinne Tests

Weber Test:

1. Strike 512Hz tuning fork
2. Place on centre of forehead/vertex
3. Ask "Where do you hear the sound?"
4. Normal: heard centrally

Rinne Test:

1. Strike 512Hz tuning fork
2. Place on mastoid process
3. When sound stops, move to ear canal
4. Ask if they can still hear it
5. Normal: AC > BC (positive Rinne)

Memory Aid

"Weber goes to the Worse ear in conductive loss, but to the Better ear in sensorineural loss"

🌀 Epley-Hallpike Manoeuvre

Canalith Repositioning Procedure (CRP) - Step-by-step guide for BPPV treatment

Canalith Repositioning Procedure (CRP)

The Epley manoeuvre is the gold standard treatment for posterior canal BPPV, with an 80% success rate after a single treatment. This procedure repositions displaced otoconia (ear crystals) from the semicircular canals back to the utricle.

Epley Manoeuvre Step-by-Step Diagram - Canalith Repositioning Procedure

1 Starting Position

Sit with your head turned 45° toward the affected side. The patient should be sitting upright on the examination couch with legs extended.

2 Lie Back Position

Aided by your healthcare provider, lean back with one ear pointed toward the ground with your neck extended 10°-20°. The head should hang slightly off the edge of the couch. Wait 30 seconds or until vertigo subsides.

3 Turn Head to Opposite Side

Turn your head 90° toward the unaffected side. Keep your head in the extended position while turning. Wait another 30 seconds.

4 Roll to Side

Turn your head another 90° by rolling your body toward the unaffected side. You should now be lying on your side with your nose pointing downward at about 45°. Wait 30 seconds.

5 Return to Sitting

Sit up while keeping your head turned and neck flexed. Slowly return to an upright sitting position. The entire procedure takes about 2-3 minutes.

Clinical Tips

• Each position should be held for 30 seconds
• Vertigo and nystagmus are expected during the procedure
• Can be repeated if first attempt unsuccessful
• Success rate: 80% with single treatment

Post-Procedure Advice

• Avoid lying flat for 48 hours after treatment
• Sleep with head elevated (2 pillows)
• Avoid rapid head movements for 24 hours
• Symptoms may recur - teach patient home exercises

Requires immediate action within hours

🎆 You've Got This!

ENT presentations can be challenging, but with systematic assessment, knowledge of red flags, and appropriate use of resources, you can provide excellent patient care. Remember: when in doubt, seek senior advice or specialist input.

🛡️ Safety Net

Always provide clear safety-netting advice and ensure patients know when to seek urgent review.

📊 Evidence-Based

Use NICE CKS and local guidelines to support your clinical decisions and antimicrobial stewardship.

📚 Continuous Learning

Reflect on cases, seek feedback, and use every patient encounter as a learning opportunity.