The role of the GP in the care of People with ENT and mouth problems
As a GP, your role is to:
- identify symptoms that fall within the range of normal or are caused by self-limiting conditions
- know the epidemiology of, and understand how to recognise, oral, head and neck cancers, including the risk factors, and identify unhealthy behaviour (such as smoking) as well as being able to refer appropriately
- ensure that a patient’s hearing impairment or deafness does not negatively impact on the communication between the patient and doctor
- promote the benefits of early intervention to ensure people who need hearing aids get the most out of them
- perform effective assessment, including conducting or interpreting more detailed tests (such as audiological tests, the Dix–Hallpike test) and treatment including procedures (for example, Epley manoeuvre) where indicated
- Demonstrate empathy and compassion towards patients with ENT symptoms that may prove difficult to manage (such as tinnitus, facial pain, unsteadiness, hearing loss).
Emerging issues in the care of people with ENT and mouth problems
- Guidelines for appropriate management are now widely available but not always used
- Management of patient expectations of the role of antibiotics and using an evidence-based approach to antibiotic prescribing
- Changes to smell and taste related to Covid-19 infection can be persistent and can have a significant effect on quality of life
- Covid-19 has brought extra communication challenges in healthcare settings for people with hearing impairment, due to increasing use of telephone and video consultations and use of face masks
- Head and neck cancer rates are increasing, and outcomes depend on early diagnosis
- High levels of undiagnosed hearing loss; many more people could benefit from hearing aids than are currently doing so
- E-cigarettes are being increasingly used to aid smoking cessation. Ongoing research into the safety of e-cigarettes and their use for smoking cessation is underway. As a GP you should be aware of the latest evidence and guidance on e-cigarettes, and smoking cessation more generally, and use your clinical judgement on an individual patient basis.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care prognosis.
Symptoms and signs
- Symptoms within the normal range that require no treatment, such as small neck lymph nodes in healthy children and ‘geographic tongue’
- Cough
- Deafness and the differentiation of types of hearing loss, including sudden hearing loss
- Dental problems and immediate necessary treatment (for example analgesia, antibiotics and signposting for definitive care)
- Disturbance of smell and taste
- Earache and discharge
- Epistaxis
- Facial dysfunction: sensory and motor
- Facial pain
- Head and neck lumps
- Hoarseness
- Jaw pain
- Rhinitis and nasal obstruction
- Salivation problems, including swelling and obstruction of glands, excessive and reduced salivation
- Sore throat and mouth
- Sore tongue and changes in taste
- Tinnitus
- Vertigo and dizziness
- Snoring and sleep apnoea
Common and important conditions
- Aesthetic and reconstructive surgery and botulinum toxin therapies
- Congenital abnormalities
- Cranial nerve disorders
- Disorders of the salivary glands
- Ear disorders: including otitis externa, otitis media with and without effusion, perforation of the ear drum, cholesteatoma and mastoiditis
- Emergency treatments such as tracheotomy
- Epidemiology of rarer but potentially serious conditions such as oral, head and neck cancer, taking into account risk factors and unhealthy behaviour
- Head and neck malignancies, including unidentified malignancies presenting with lymphadenopathy
- Hearing aids and cochlear implants, tinnitus maskers
- Hearing problems, including deafness tinnitus and associated speech or language disorders
- Increasing incidence of hearing loss in certain groups, such as people with a learning disability or dementia
- Nasal problems, including perennial and allergic rhinitis, postnasal drip, epistaxis and septal deviation
- Oral problems, including pain, infections, premalignant conditions and malignancies
- Sinus problems, including infection, polyps and allergic rhinosinusitis
- Throat problems such as infections, globus or gastroesophageal reflux causing a cough
- Tracheotomy management in primary care
- Vertigo: central (such as brainstem stroke) and peripheral (for example, benign paroxysmal positional vertigo, vestibular neuronitis, Ménière’s disease).
- Vocal disorders such as hoarseness, dysphonia and aphonia, and underlying causes (for example, vocal cord nodules, laryngeal nerve palsy)
Examinations and procedures
- Otoscopic appearances of the normal and abnormal ear
- Tests of hearing such as tympanometry, audiometry, tuning fork tests including the Weber and Rinne tests, neonatal and childhood screening tests
- Detailed tests where indicated (such as audiological tests and the Dix–Hallpike test to help diagnose benign paroxysmal positional vertigo (BPPV))
- Skills that can be used in primary care to effect a cure when indicated (such as the Epley manoeuvre)
Investigations
- Audiology testing
- X-ray, ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) scans
- Nasendoscopy
- Sleep studies
Service issues
- ENT, oral and facial symptoms may be manifestations of psychological distress, (such as globus pharyngeus, atypical facial pain, burning mouth syndrome)
- National paediatric screening programme for hearing loss; effects of ENT pathology on developmental delay (for example, ‘glue ear’ can impair a child’s learning)
- Pathology in other systems may lead to ENT-related symptoms, such as gastro-oesophageal reflux disease (GORD) and cerebrovascular accident (CVA)
- Systemic disease such as haematological, dermatological and gastrointestinal problems may present with oral symptoms (for example, glossitis caused by iron deficiency anaemia)
- Referral criteria and pathways for patients with dental or gingival problems to their general dental practitioner or local community dental services
- Access to specialist services in oral medicine or oral and maxillofacial surgery for patients with oral disease
- Referral criteria and local provision for ear wax removal
- The impact of hearing loss on quality of life, the relationship between hearing loss and other long-term conditions (such as dementia) and community and cultural attitudes to deafness
- The need to equip the primary care working environment to ensure people who are deaf, or have hearing loss or speech impairment, can contact and access GP services easily, and communicate effectively in waiting areas and consultation rooms
- Referral criteria and provision of services for patients with loss of smell or taste relating to Covid-19 or other causes
- Community-specific aspects of oromucosal disease related to lifestyle (such as chewing paan, tobacco, betel nut, khat/qat, or reverse smoking)
- Influence of socio-economic status (especially vulnerable populations such as homeless people) on rates of head and neck malignancy
- Highly specialised and regionally based services, such as the provision of cochlear implants
- Relevant local and national guidelines, including fast-track referral guidance for suspected cancer.
Case discussion
Mark Johnson is a 25-year-old solicitor who presents with persistent nasal obstruction, runny nose, watery eyes and regular sneezing. The problem is perennial and has been getting worse for years. He also has asthma. He has moved into a flat and has adopted a cat. The use of steroid sprays and antihistamines only marginally improves things, and he tells you he is ‘fed up’ with his symptoms and ‘something has to be done’. He requests an immediate referral to a specialist. Your examination reveals some form of swelling in the nose, more noticeable on the right than the left.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How do I feel when a patient says, ‘something has to be done’? Why is this patient presenting now? What do I think his ideas, concerns and expectations might be? |
An ethical approach This is about practicing ethically with integrity and a respect for equality and diversity. | When should I refer? Would my decision to refer change if the patient had private health insurance? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How do I feel about his demand for referral? How will I manage those feelings in the consultation? How might I deal with his frustrations and anger? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | How can I determine if Mark has been compliant with treatment? How effective is allergy testing (paper radioimmunosorbent test (PRIST), radioallergosorbent test (RAST) or skin tests)? What triggers his symptoms? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | How do I determine whether the swellings in the nose are nasal turbinates or polyps, or part of the normal nasal cycle? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How could the history help to determine the cause of his symptoms? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What are the options available in managing this patient in general practice? What is the optimal treatment (drug and dosage)? What are the current guidelines for reducing exposure to house dust mites? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | How might Mark’s asthma and nasal symptoms be linked? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | Who else might I involve in the management of this patient? If I refer him, what key features should go in the referral letter? Where can I direct Mark for further information about his condition? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | Do I have sufficient knowledge of nasal anatomy to allow me to detect any abnormality? If not, how could I improve my knowledge? What is the evidence for the effectiveness of common ENT treatments? What other resources do I need in my area? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How would I know from my information technology (IT) system whether Mark has had a recent asthma review? What recall systems are in place? How can I check how frequently Mark has been getting any repeat medications? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | How might these symptoms affect Mark’s ability to work and study, and his social life? What would I advise if he asks whether the cat could be contributing to his symptoms? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | What are the resource issues relating to providing care for allergies in the NHS? |
How to learn this area of practice
Work-based learning
As a GP registrar, you will find the frequency of ENT-related symptoms in primary care makes this the ideal environment for you to learn the basics of history-taking and examination (including identifying what is ‘normal’). It is not uncommon for a clinician (GP or other healthcare professional) to have developed additional expertise in ENT, and working alongside such an individual can be very beneficial. Local ENT departments are usually very willing to have GP registrars sitting in outpatient clinics, and taking time to arrange a regular session in such a clinic will provide you with invaluable experience. The experience will be enhanced if you can see patients initially and then discuss examination findings and potential management with your supervising colleague.
The extensive use of endoscopes and microscopes will greatly facilitate your understanding of ENT pathology. In both scenarios, always ask for feedback on cases and look to use structured assessment tools (available online) to document your learning. Make the most of opportunities to observe and discuss common conditions such as hearing loss with an audiologist or hearing therapist.
The frequency of common oral-related symptoms in primary care and the limited undergraduate training in this area make it worth your while attending specialist clinics in oral medicine and oral and maxillofacial surgery. In these clinics you will learn how to examine the mouth, recognise and provide initial management of common oral conditions, and appreciate the presenting features of oral cancer and precancerous lesions.
Self-directed learning
You can find an eLearning module relevant to this topic guide at elearning for healthcare and at RCGP eLearning.
It is not uncommon to come across friends and relatives with ENT conditions and this can give you an insight into the impact on quality of life of what may be regarded as ‘trivial conditions’. Examples include general upper respiratory tract infections, allergic and non-allergic rhinitis, snoring and deafness. Indeed, as a primary care physician it is essential that you understand the effect of a significant hearing loss on an individual’s way of life. It is also important that you understand its isolating effect and appreciate the statement that ‘blindness separates an individual from objects; deafness separates an individual from people’.
Learning with other healthcare professionals
As a GP registrar, gaining experience in other medical specialties will give you insight into dealing with common ENT and oral problems. In particular:
- Paediatrics – many children have ENT-related conditions that affect their general wellbeing and may compromise their education
- Medicine of the elderly – deafness and balance disorders are common
- Immunology – it is not uncommon for systemic allergy to present with symptoms and signs in the ear, nose, oral cavity or throat
- Dermatology – skin conditions affecting the face and scalp, and otitis externa, may present to skin specialists
- Respiratory medicine – both the upper and the lower airway often need to be treated together
- Oral medicine and oral and maxillofacial surgery – oral signs and symptoms may be a manifestation of underlying systemic disease
- Gastroenterology – for example, GORD that is causing coughing
- Hospital audiology clinics and hearing therapists
- Hearing loss clinics in the high street – these increase access to a range of services.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Hearing loss in adults and children
- Recognition of red flags in ENT
- Common ENT symptoms such as vertigo
Simulated Consultation Assessment (SCA)
- An older woman has severe shooting pains in her left lower jaw
- A hearing-impaired man has troublesome tinnitus interfering with his sleep and concentration
- A middle-aged woman has sudden-onset disabling rotational dizziness: examination expected
Workplace-based Assessment (WPBA)
- Log entry about the referral criteria for a child with recurrent tonsillitis and the evidence for tonsillectomy as an intervention
- Clinical examination and procedural skills (CEPS) on examining a patient with unilateral deafness and the interpretation of the results
- Consultation Observation Tool (COT) about a singer with persistent hoarseness (or, for example, a patient with persistent loss of taste and smell following a Covid-19 infection)