What are the key Ear, Nose, and Throat (ENT) topics for family physicians?

Key ENT Topics for Family Physicians

Acute Otitis Media (AOM)

Family physicians must master the stringent diagnostic criteria for AOM, which requires rapid onset of symptoms AND signs of middle ear inflammation (bulging tympanic membrane, otorrhea, or intense erythema), not just a red tympanic membrane alone. 1

Diagnostic Essentials

• Document three key elements: rapid onset within 48 hours, symptoms of ear pain/irritability, AND objective signs including middle ear effusion with bulging tympanic membrane 1
• Pneumatic otoscopy is essential—a red tympanic membrane without effusion does NOT constitute AOM 1
• Common pitfall: 24% of clinicians inappropriately prescribe antibiotics for symptomatic children with red tympanic membranes but no middle ear effusion 2

Management Algorithm

• Pain management is mandatory regardless of antibiotic decision 1
• For children ≥6 months with non-severe illness and certain diagnosis: observation for 48-72 hours is appropriate 1
• First-line antibiotic when indicated: amoxicillin for β-lactamase-negative organisms 3
• If no improvement by 48-72 hours, reassess for alternative diagnosis or treatment failure 1

Prevention Counseling

• Breastfeeding for ≥6 months reduces AOM incidence 1
• Avoid supine bottle feeding and reduce pacifier use after 6 months 1
• Modify daycare attendance patterns when feasible 1

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Otitis Media with Effusion (OME)

Watchful waiting for 3 months from diagnosis is the recommended first-line approach for children with OME who lack risk factors for developmental problems—antibiotics, antihistamines, and decongestants are NOT indicated. 1, 4, 5

Diagnostic Approach

• Use pneumatic otoscopy to document middle ear effusion 1, 4
• Obtain tympanometry if diagnosis uncertain after pneumatic otoscopy 1, 4
• Document laterality, duration, and associated symptoms at each visit 4

Risk Stratification

Identify children at increased risk requiring earlier intervention 1, 4:

• Permanent hearing loss independent of OME
• Speech/language delay or disorder
• Autism spectrum disorders
• Down syndrome or craniofacial disorders (60-85% prevalence of OME) 1
• Cleft palate
• Blindness or uncorrectable visual impairment
• Developmental delay

Management Protocol

• For children NOT at risk: watchful waiting for 3 months with re-evaluation every 3-6 months 1, 4, 5
• Obtain age-appropriate hearing test if OME persists ≥3 months or in any at-risk child 1, 4, 5
• Offer tympanostomy tubes if bilateral OME persists ≥3 months with documented hearing loss 4, 5
• For children ≥4 years requiring surgery: consider adenoidectomy in addition to tubes 5

Critical "Do Not" Recommendations

• Do NOT prescribe antibiotics for routine OME management 1, 4, 5
• Do NOT use antihistamines or decongestants—no proven efficacy 1, 4, 5
• Do NOT use intranasal or systemic steroids 1, 4, 5

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Acute Otitis Externa (AOE)

Topical antimicrobial therapy targeting Pseudomonas aeruginosa and Staphylococcus aureus is the cornerstone of AOE treatment, with adequate pain relief being equally essential. 1

Diagnostic Criteria

All three elements required 1:

1. Rapid onset (within 48 hours) in past 3 weeks
2. Symptoms: otalgia (often severe), itching, or fullness
3. Signs: tenderness of tragus/pinna OR diffuse ear canal edema/erythema

• Hallmark sign: intense tragal tenderness disproportionate to visual findings 1

Modifying Factors Assessment

Evaluate for conditions requiring modified management 1:

• Non-intact tympanic membrane or tympanostomy tube
• Diabetes mellitus
• Immunocompromised state
• Prior head/neck radiotherapy

Treatment Approach

• Topical antimicrobial drops are first-line (targeting P. aeruginosa and S. aureus) 1
• Analgesic treatment based on pain severity—this is a strong recommendation 1
• Systemic antibiotics reserved for patients with modifying factors 1
• Educate patients on proper ear drop administration 1

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Allergic Rhinitis

Diagnosis requires correlation between symptom history after allergen exposure and specific IgE testing—history and examination alone are suggestive but not confirmatory. 1

Clinical Clues Favoring Allergic Rhinitis

• Pruritus and sneezing (more common than in nonallergic rhinitis) 1
• Seasonal exacerbations 1
• Onset typically before age 20 years 1
• Associated conjunctival symptoms 1
• Family history of atopy 1

Red Flags for Alternative Diagnoses

• Isolated postnasal drainage (less likely allergic) 1
• Unilateral symptoms (suggests structural problem, polyp, foreign body, or tumor) 1
• Symptoms triggered only by strong odors (vasomotor rhinitis) 1
• Rhinorrhea only with eating (gustatory rhinitis) 1
• Chronic topical decongestant use (rhinitis medicamentosa) 1

Comprehensive History Elements

• Nature and duration of symptoms 1
• Seasonality patterns 1
• Environmental and occupational exposures 1
• Current/past medications and their effectiveness 1
• Impact on quality of life and sleep 1
• Comorbid conditions (asthma, sinusitis, otitis media) 1

Physical Examination Focus

• Nasal mucosa appearance 1
• Nasal passageway patency 1
• Unilateral vs bilateral findings 1
• Anatomical obstruction causes 1
• Quality and quantity of nasal discharge 1
• Ear, eye, throat, and lung examination 1

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Hearing Loss Evaluation in Children

Family physicians should maintain high suspicion for congenital hearing loss and understand the genetic evaluation pathway, as approximately 30% of cases have no obvious etiology on initial assessment. 1

Three-Generation Pedigree Assessment

Document 1:

• Consanguinity and paternity
• Hearing status of parents and siblings
• Ethnicity and country of origin
• Inheritance pattern (autosomal dominant, recessive, X-linked, mitochondrial)
• Audiometric characteristics in affected family members

Syndromic Features to Evaluate

• Visual: heterochromia irides, retinitis pigmentosa, early cataracts 1
• Craniofacial: preauricular pits, branchial cysts, cleft palate 1
• Cardiac: syncope, arrhythmia, prolonged QT interval 1
• Renal: hematuria, proteinuria, structural defects 1
• Integumentary: premature graying, white forelock, abnormal pigmentation 1
• Endocrine: thyromegaly, diabetes 1

Risk Factor History

• TORCH infections (toxoplasmosis, rubella, CMV, herpes) 1
• Meningitis 1
• ECMO therapy 1
• Hypoxia 1
• Prenatal alcohol exposure 1
• Ototoxic drug exposure 1

Testing Algorithm for Simplex Cases

• CMV testing should be performed early in infancy 1
• GJB2 (connexin 26) mutation screening by sequence analysis—negative result does not exclude genetic etiology 1

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When to Refer to ENT Specialist

Indications for Otolaryngology Referral 1

OME-specific referrals 1:

• OME persisting ≥4 months with hearing loss or symptoms
• Recurrent/persistent OME in at-risk children regardless of hearing
• Structural damage to tympanic membrane or middle ear
• Document: effusion duration, laterality, hearing test results, speech/language concerns, history of AOM 1

Rhinitis-specific referrals 1:

• Diagnosis uncertain after initial evaluation
• Symptoms refractory to empiric treatment
• Complications: recurrent sinusitis, nasal polyps, significant sleep disturbance
• Rhinitis medicamentosa
• Need for allergen identification and immunotherapy education
• Anatomic abnormalities requiring surgical correction

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Common Pitfalls to Avoid

• Over-diagnosing AOM: A red tympanic membrane alone without middle ear effusion is NOT AOM 1, 2
• Prescribing antibiotics for OME: No indication for routine use—contributes to resistance without benefit 1, 4, 5
• Failing to assess hearing: Must obtain hearing test if OME persists ≥3 months 1, 4, 5
• Using antihistamines/decongestants for OME: No efficacy demonstrated 1, 4, 5
• Inadequate pain management in AOM and AOE: Pain relief is as important as antimicrobial therapy 1
• Missing modifying factors in AOE: Diabetes, immunocompromise, and tympanic membrane perforation alter management 1
• Assuming nonallergic rhinitis without testing: Specific IgE testing required to confirm allergic rhinitis 1