OTOLARYNGOLOGY- HEAD AND
NECK SURGERY (ENT-HNS)
Year
3 Clinical Clerkship
CONTACT INFORMATION:
Clerkship Director: Dr. Kevin Fung
Room C3-100,
Phone: 685-8599
Fax: 685-8567
Email:
kevin.fung@lhsc.on.ca
Administrative Assistant: Ms. Angelika Edwards
LHSC-VH, Room
C3-107
Phone: 685-8500
ext. 55807
Fax: (519) 685-8468
Email: angelika.edwards@lhsc.on.ca
INTRODUCTION:
Otolaryngology is a surgical
subspecialty with tremendous breadth and depth.
Problems that affect
structures of the head and neck significantly impact patients’ function and
quality of life (e.g. smell, hearing, breathing, swallowing, phonation,
communication, aesthetics).
Our patient population
ranges from neonates to the elderly.
Clinical problems can be
life-threatening (e.g. airway obstruction), urgent (e.g. head and neck cancer),
and elective (e.g. cosmetic surgery).
Surgical procedures can
be intricate (e.g. paediatric airway surgery), technologically and anatomically
complex (e.g. endoscopic sinus surgery with 3D-image guidance), really small
(middle ear surgery), really large (head and neck cancer resection with free
flap reconstruction), creative (cosmetic surgery), and most of
all….rewarding.
BROAD AIMS OF THE ENT-HNS ROTATION:
The ENT-HNS clerkship
is designed to give life to the information acquired in the first 2 Preclinical
years of your Medical studies.
This material was
covered in:
- the ENT sections of the Meds I
and II Resp/Airways SDG
- the EAR section of the Neurosciences
SDG.
It also provides a
testing ground for those that may be interested in this surgical subspecialty.
Residency training in
Otolaryngology lasts 5 years and is direct-entry via CaRMS.
Skills in ENT-HNS are
also vital to those considering:
- Family Medicine
- Emergency Medicine
- Anaesthesia
- Pediatrics
Our rotation is designed
to expose the student to the broad spectrum of this surgical subspecialty. The
student will get an exposure to as many of the subspecialty areas within our
field as possible in a one week rotation. This may include:
- Pediatric Otolaryngology
- Otology-Neurotology
- Rhinology
- Head & Neck Surgical Oncology
- Head & Neck Reconstructive Surgery
- Laryngology
- Facial Plastic and Reconstructive Surgery.
ENT-HNS CLERKSHIP ROTATION:
(i)
Introductory ENT clerkship lecture
Skills objectives are covered in the
introductory clerkship lecture, which is given at 7am-8am on the first Monday
of your Medicine rotation.
Tentative dates for this lecture are:
·
September 11, 2006
·
December 4, 2006
·
March 5, 2007
·
June 4, 2007
(ii)
ENT clerkship rotation
This is a one week rotation within the Medicine block.
Although this rotation is in the Medicine Block, we are a
completely independent block with respect to clinical activity, teaching, and
evaluation.
Rotation logistics:
Students will experience both North end and the South end
rotations:
North End (LHSC –
South End (LHSC -
Drs. K. Fung, J. Franklin, M. Husein, H.
Lampe, D. MacRae and J. Yoo:
The rotation is subject to change depending on the availability of
consultants.
Morning rounds and on-call:
Students will arrange with the ENT-HNS residents to meet for
morning rounds, and if desired, take evening call.
Grand rounds:
Please check your schedule for the location of Grand Rounds which
takes place every Wednesday at 7:00 am during the academic year.
Resident lectures:
Friday afternoon has been left open to the students to choose
extra operating room or clinic time if they desire. The residents have their
own lecture series Friday afternoons so the student may check the topic and
decide whether this activity may be of interest to them.
REPORTING INSTRUCTIONS:
ORIENTATION is for all students rotating on the service whether they start
their rotation at London Health Sciences Centre or
You will have an introductory teaching session with an ENT
resident which will introduce you to the skills required to perform a thorough ENT
Head and Neck physical examination.
The schedule and reading materials for the week will be provided
at this time.
Date/Time: Orientation will take place on the first
Monday of the rotation at 8am unless it is a Statutory Holiday. Please
contact Mary Jayne Brown for your scheduling one week before your rotation if a
Statutory Holiday is indeed your first day on the service.
Location:
Questions the student may have regarding any aspect of the
rotation may then be brought forward to the resident or to the Undergraduate
Secretary in order to provide you with any assistance you may require before
your week begins.
OBJECTIVES:
General objective:
The clinical clerkship rotation allows the student to develop the
knowledge and skills in ENT-HNS that is required to fulfill the professional
responsibility of a generic physician.
As in other specialty
rotations, objectives can be classified into two types:
(i)
Skills objectives
(ii)
Knowledge objectives
The clerkship rotation is designed primarily to address the skills
objectives, since these are best acquired in the clinical setting, and
secondarily to address the knowledge objectives, which were
first introduced in the pre-clerkship lecture series. The student should be able to use this
rotation as a way to consolidate this knowledge in the context of clinical
scenarios.
SKILLS OBJECTIVES:
Ear
Otologic history taking
for common otologic problems:
(i)
ear discharge
(ii)
otalgia
(iii)
infant hearing loss
(iv)
adult hearing loss
(v)
dizziness
(vi)
facial weakness
Removal of ear wax
Otoscopy including
pneumatic otoscopy
Tuning fork tests
Interpretation of basic
audiogram (hearing test)
Otoneurologic
examination
Dix-Hallpike maneuver and the Particle Repositioning Maneuver
Cranial nerve examination
Cerebellar function
Nose and Paranasal Sinus
History taking for
common nasal problems:
(i)
nasal obstruction
(ii)
nasal discharge
(iii)
facial pain
(iv)
anosmia
(v)
epistaxis
Anterior rhinoscopy
Exposure to endoscopic
examination of the full nasal cavity
Identification of normal
structures within the nasal cavity
Examination of the
external nasal structures
General appreciation of
plain films and CT scans of the nose and paranasal sinuses
Oral Cavity
History taking for
common oral cavity problems:
(i)
sore mouth
(ii)
drooling
(iii)
salivary gland problems
(iv)
lip lesion
(v)
tongue mass
Examination of the oral
cavity including bimanual palpation
Identification of
salivary duct openings
Assessment of the
oropharynx
Pharynx and Larynx
History taking for
common throat problems:
(i)
sore throat
(ii)
foreign body sensation (globus)
(iii)
hoarseness
(iv)
sleep apnea
(v)
stridor
Examination of the
pharynx and larynx via mirror as well as an exposure to endoscopic examination
of these anatomical areas
Neck
History taking for
common neck/visceral problems
(i)
Thyroid nodule
(ii)
Neck mass
Examination of the head
and neck and its viscera
Appreciate normal
anatomy
Identification of the triangles in the neck
Identification of surface anatomy of normal anatomical structures,
such as the carotid artery, thyroid gland, salivary glands, laryngeal
structures
Observe the technique of
fine needle aspiration
KNOWLEDGE OBJECTIVES:
Ear Infection
The student should be
able to:
- demonstrate knowledge of the differential diagnosis of otorrhea
and otalgia (local and referred) with an emphasis on external otitis, acute
and chronic otitis media and their complications.
Hearing Loss / Tinnitus
The student should be
able to:
- show an understanding of the need for the early diagnosis
of hearing loss in infants, including the need for a high "index of
suspicion" (early warning signs) and the need for early audiologic testing
and habilitation. The protocol followed by the Universal Infant Hearing
Program should be known to you.
The student should be
able to:
- describe the common causes of conductive hearing loss
(external canal to the stapes footplate)
- develop a differential diagnosis of sensory neural hearing
loss (sudden VS gradual), appreciate the need for preventive measures in the
workplace (noise reduction) and the devises available for rehabilitation
(hearing aids/assistive devices)
- provide a working knowledge of tinnitus (subjective
and objective)
Vertigo
The student should be
able to:
- differentiate vestibular vertigo from other causes of
imbalance vertigo
- distinguish peripheral vs. central vertigo
- provide a DDx of vertigo with and without learning loss
- diagnose benign paroxysmal vertigo based on the history
and clinical findings
Facial Paralysis
The student should be
able to:
- differentiate peripheral vs. central paralysis show an
understanding of peripheral facial paralysis from an ENT-HNS perspective (ie.
intracranial, temporal bone, extratemporal)
UPPER RESPIRATORY TRACT
Nose and Paranasal
Sinuses
The student should be
able to:
- describe the functions of the nose (airway, mucociliary
system, warming and humidification)
- demonstrate knowledge of the DDx of nasal obstruction with
and without rhinitis
- recognize, investigate, and treat
acute sinusitis
- be aware of the indication for
referral in chronic sinusitis
- formulate an approach to a patient
with acute epistaxis (anterior and posterior)
Pharynx
The student should be
able to:
- demonstrate an understanding of obstructive sleep apnea.
Who is at risk? What are the symptoms
and the long term complications?
- describe the mechanisms that are in
place that allow one to maintain and protect the lower respiratory tract (ie.
DDx of aspiration)
- describe the signs and symptoms that
might arise due to the presence of an infection/mass lesion (structural
abnormality or loss of function, eg. Carcinoma of the tongue base) in this area
(ie. the effect on swallowing, breathing, phonation, pain, foreign body
sensation, odynophagia, referred otalgia)
Larynx and upper airway
The student should be
able to:
- describe the supraglottic region and understand that it
extends up into the pharyngeal airway and thus pathology in this region
presents in a way similar to other pharyngeal airway pathologies (see above)
- formulate a DDx for dysphonia
(hoarseness)
- demonstrate knowledge of the different
types of stridor that present from the different sites of the upper airway
- describe the acute management of upper
airway obstruction using positioning, artificial airways and tracheotomy
UPPER DIGESTIVE TRACT
Oral Cavity and Pharynx
The student should be
able to:
- outline the three phases of swallowing with emphasis on
the oro-pharyngeal phases for ENT purposes
- demonstrate a basic knowledge of dental abnormalities as
they might be included as the primary cause of oral symptoms and signs
- have knowledge of the DDx of mucosal lesions in the oral
cavity
- demonstrate knowledge of the differential diagnosis of
dysphagia
- show an understanding of the lymphatic drainage of the
oropharynx as a route of metastatic spread.
Salivary Glands
The student should be
able to:
- demonstrate a knowledge of the anatomy of the 3 major
salivary glands
discuss the DDx of salivary gland swelling (single gland
/ multiple glands)
NECK
Congenital Masses:
The student should know:
- the DDx of congenital lesions found in the neck (midline
and lateral) and have a knowledge of the pertinent embryology
Lymphatics:
The student should know:
- the anatomy (nomenclature) of the regional lymph nodes
- the importance of the regional lymphatic drainage and its
relevance in the DDx of
primary lymph node pathology
- other pathologic entities that might occupy a lymph node
- the importance of a thorough head and neck functional
inquiry in investigating a possible metastatic neck mass from a primary in the
upper aerodigestive tract (the functional inquiry often leads to the primary
site of pathology)
- risk factors in developing H&N malignancies
- general principles in the treatment of H&N squamous
cell malignancies and the multidisciplinary nature of H&N cancer treatment
- quality of life issues inherent in choosing or not
choosing different treatment modalities
Thyroid Viscera
The student should know:
- the anatomy of the thyroid gland
- DDx of a thyroid mass (functional vs.
neoplastic) for ENT emphasis on neoplastic thyroid abnormalities
EVALUATION:
How do I
pass?
(i)
full attendance at all your assigned rotations
(ii)
pass the MCQ exam
The MCQ
exam
This is a brief examination which
will cover material outlined in the objectives, and in your Meds-I and II
lectures pertinent to ENT (i.e. the ENT sections of the Meds I and II
Resp/Airways SDG, and the EAR section of the neurosciences SDG). Skills objectives are covered in the
introductory clerkship lecture, which is given on the first Monday of your
Medicine rotation, and is also posted online:
http://www.schulich.uwo.ca/ENT/
The exam is administered at noon on Friday.
Who
completes your evaluation?
During your week on ENT, the consultants and
residents who you spend time with will complete evaluations for you. All evaluations are reviewed and compiled by
the Undergraduate Director. Although the
rotation is pass/fail, evaluators are encouraged to provide narrative comments
for exceptional students. A blank form
is attached for your information.
Your evaluation of the ENT rotation is important
as well – your feedback is important to us.
If you have any particular concerns or specific suggestions, please feel
free to contact the Undergraduate Director – Dr. Kevin Fung
(kevin.fung@lhsc.on.ca).
ELECTIVES:
We
recognize that a one week rotation in ENT provides the student only with a
glimpse of this specialty, which is adequate for those considering primary care
specialties, but not enough for those who are seriously considering ENT as a
career. We therefore highly encourage
interested students to spend elective time on our rotation. Electives can be arranged through Ms. Angelika
Edwards (angelica.edwards@lhsc.on.ca).
The
Department of Otolaryngology
CLINICAL CLERK ASSESSMENT FORM
To be completed by _____________________________________________________
Student’s Name: _______________________________________________________
For dates: _______________________ to ________________________
Number of days absent from rotation (do not include vacation time): _________
Is the student’s behaviour consistent with the CMA Code of Ethics? Yes___ No ___
FINAL
EVALUATION: Pass _____ Fail _____
Comments: Provide further information as germane with respect to the student’s formative evaluation. Students may select a limited number of comments for inclusion on the Medical Student Record of Performance (Dean’s Letter).