Introduction
A rotation in ear, nose, and throat (ENT) is becoming increasingly common in general practice specialty training and not before time, given the amount of GP consultations that relate to this specialty. This is an ideal opportunity to pick up knowledge and skills that will serve you well in day-to-day practice in your registrar year and beyond. You may even consider using this experience as a springboard to build a career as a GP with a special interest (GPwSI) in ENT. Either way, a rotation in ENT will likely be viewed favourably when looking for work.
It is important, then, to get the most out of your time in the specialty. Few trainees will have much experience in this area and this can be daunting initially. This article aims to give you a few pointers to help get you started as a GPwSI in ENT.
ENT doctors know you won't have had much exposure to their specialty, so they don't expect you to know it all on your first day, or your last day.
ENT doctors are generally a happy bunch, so don't be afraid to ask for help.
You will see a lot of ENT pathology in general practice, this attachment is valuable.
The nursing staff know a lot about ENT, use this resource.
Nasal packing for epistaxis should not be viewed as the definitive treatment; it is a holding measure.
Try to treat epistaxis first before resorting to packing. However, be aware that the patient can lose a lot of blood, so if need be, pack the nose.
Inserting nasal tampons is uncomfortable for the patient, Merocel® packs can be coated in Aquagel or Naseptin® and rhino packs should be soaked in sterile saline to make insertion easier. When inserting packs aim along the floor of the nose. Properly inserted packs will be flush with the alar margin and not look like walrus tusks.
You'll be amazed at what children will put up their nose. And how much of it they can get up there.
Unilateral nasal polyps should be treated with suspicion, biopsy may be required to exclude neoplasms.
Chronic sinusitis can cause meningitis and intracranial pathology: always look for signs of these.
Head and neck patients can get very sick very quickly, keep an eye on them.
Patients who have had a laryngectomy breath through their neck. Putting an oxygen mask on their face achieves nothing.
Speech and language therapists will become your good friends. Treat them with respect and they will make your life easier.
Get to know your local oral and maxillofacial surgical team, you will need them and they will need you.
Go to theatre, even if you have no wish to try your hand at operating. It is good to know what your patients will go through when you refer them.
Never skip breakfast, you may not get lunch.
Practice nasendoscopy on your colleagues.
Take neck lumps seriously.
The ear canal is sensitive: be careful with the micro-suction.
Don't give Augmentin® or amoxicillin to people with tonsillitis, it could be glandular fever and they could develop a rash.
Anyone being admitted with tonsillitis should get tested for glandular fever.
Don't interrupt a surgeon while they are dissecting something off the facial nerve.
Stridor = stay calm, implement appropriate first aid and initial treatment (oxygen, nebulised adrenaline, consider steroids and antibiotics) and seek senior help, both ENT and anaesthetics.
Make sure you know how to work and maintain the microscope, the bulb will always go when there is nobody else around.
Know where the endoscopes are kept out of hours and how to get access to them.
Know where the emergency tracheostomy kit is and how to get access to it out of hours.
If a patient has a sore throat and tender neck with a normal looking oropharynx, have a good look at their epiglottis (unless they are a child). Warning signs of epiglottitis include drooling, an unwell patient, and stridor.
Remember A comes first in ABC.
When removing foreign bodies from young children's ears or noses you will only get one good attempt. Tell the parents what you want them to do before you start, wrap the child firmly in a blanket and hide the big scary wax hook from sight. Beware of batteries or magnets as a foreign body, these must be removed as a matter of urgency.
Peri-orbital cellulitis is potentially life threatening and is a risk to the patient's vision. It is often secondary to acute sinus infection. Nasal decongestants, intravenous antibiotics, and ophthalmology visual assessment are necessary. The patient may require computed tomography and surgical drainage, so keep the patient nil by mouth until you have discussed the case with the senior on-call.
Dizzy patients can be fun and interesting, honest. Know the important things to ask and do a full neurological and vestibular exam. This skill will be invaluable in general practice.1
Romberg's test is a test of proprioception not vestibular function.
Warfarin, aspirin, and clopidogrel as a combination is a terrible combination and will wake you up at night.
Hoarseness should not be ignored and should be scoped.
In older diabetic patients (although not exclusively) with otitis externa, consider malignant otitis externa.
Although friendly and nice, ENT specialists are still surgeons, so if you do drive a nicer car than them keep it quiet (even if you are now broke).
There is a high volume of patients with a fast turnover. The ward clerk is a special person so get on their good side.
Enjoy yourself. It will be busy and daunting to start with but you'll get the hang of it.
Notes
Provenance
Freely submitted; not externally peer reviewed.
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- Received September 5, 2010.
- Accepted November 9, 2010.
- © British Journal of General Practice, May 2011