MODULE 1 · GDFM PROGRAMME

Nose and Throat Conditions

📅 🏛 College of Family Physicians Singapore

Learning Objectives

💎 Differentiate allergic vs vasomotor rhinitis and apply current treatment guidelines (ARIA 2024–25)
💎 Recognise and manage acute bacterial rhinosinusitis — know when to use antibiotics
💎 Approach epistaxis: distinguish anterior vs posterior bleeds and manage accordingly
💎 Identify red flags in hoarseness requiring urgent ENT referral
💎 Screen and manage obstructive sleep apnea in primary care, including newer therapies
💎 Evaluate a neck mass — differentiate infection, inflammation, and malignancy

💎 Allergic Rhinitis (AR): pale, grey, boggy mucosa — IgE-mediated, triggered by allergens (house dust mite, pollen)
💎 Vasomotor Rhinitis (VMR): beefy red turbinates — non-allergic triggers (temperature, smoke, irritants)
🚨 Rhinitis Medicamentosa: rebound swelling after >2 weeks of topical decongestant use — STOP the spray
💎 AR Classification: Intermittent (<4 days/wk, <4 wks) vs Persistent (>4 days/wk, >4 wks)
🚨 Red flags in children: unilateral symptoms, bloody discharge, CN signs → refer ENT

💎 First-line: Intranasal corticosteroid (INCS) — most effective single agent for AR
💎 Combination INCS + intranasal antihistamine (MP-AzeFlu / Dymista®) — superior to monotherapy for moderate-to-severe AR
💎 Oral antihistamines for breakthrough symptoms, especially ocular/cutaneous features
🚨 Avoid LTRAs (montelukast) as first-line in patients ≥15 yrs — less favourable benefit–risk profile
💎 Severe CRS with nasal polyps (CRSwNP): dupilumab (biologic) — refer for specialist assessment
💎 Immunotherapy (SCIT/SLIT) for moderate-to-severe AR poorly controlled by pharmacotherapy

💎 Diagnosis: ≥2 symptoms, one must be nasal blockage OR purulent discharge
💎 Viral ARS (<10 days): symptomatic treatment only — no antibiotics
🚨 ABRS suspected if: symptoms >10 days without improvement OR 'double worsening'
🚨 EPOS 2020: Consider ABRS if ≥3 of 5 — unilateral discharge, severe pain, fever ≥38°C, double sickening, raised CRP/ESR
💎 Even in ABRS: watchful waiting preferred for systemically well patients — antibiotics if unwell or risk factors
🚨 Refer to ED: periorbital cellulitis, diplopia, meningismus — complications of sinusitis

💎 Most bleeds: anterior, from Kiesselbach's plexus (Little's area) — venous in young, arterial in elderly
💎 First aid: pinch soft alar cartilage firmly, lean forward — hold for 10–15 minutes
🚨 Posterior epistaxis: blood drains down pharynx, source not visible anteriorly — urgent ENT referral
🚨 NPC red flags: epistaxis + unilateral hearing loss + neck mass + CN palsies → urgent workup
💎 Assess haemodynamic stability first — posterior bleeds can be profuse

🚨 REFER if hoarseness >2 weeks without apparent benign cause — rule out laryngeal carcinoma
💎 Key red flags: dysphagia, hemoptysis, otalgia — especially in smokers/heavy drinkers
💎 Vocal quality clues: breathiness → VC paralysis; worse in morning → LPR; worse later → myasthenia gravis
🚨 Do NOT prescribe antibiotics or corticosteroids for dysphonia without laryngoscopy
💎 Vocal hygiene: hydration, avoid irritants, voice rest — effective for benign lesions
💎 VC paralysis: unilateral = breathy weak voice; bilateral = adducted cords + compromised airway

💎 Most common site: tonsil (31.8%) → pain at jaw/upper neck
💎 Inspect systematically: tonsillar poles → tonsillo-lingual sulcus → valleculae
🚨 Button batteries = emergency — chemical necrosis within hours — immediate removal
💎 Laryngeal rocking test: pain on rocking thyroid cartilage → upper cervical esophagus impaction
🚨 Non-contrast CT neck if no FB seen on exam or lateral X-ray — CT has replaced barium swallow
🚨 Refer if: removal unsuccessful, rocking test positive, esophageal FB on imaging, chest pain/dysphagia

💎 Screen: loud snoring + witnessed apneas + EDS (ESS ≥10) — also fatigue/lack of energy
💎 Severity: mild AHI 5–14, moderate 15–29, severe ≥30 events/hour
💎 CPAP: first-line for moderate-to-severe OSA — pneumatic splint, reduces CV risk
💎 Oral appliances (MAD): alternative for mild-to-moderate OSA or CPAP-intolerant patients
🚨 Hypoglossal Nerve Stimulation (Inspire®): AHI 15–65, BMI <35, no complete concentric velum collapse on DISE
💎 Lifestyle: weight loss, positional therapy, avoid alcohol/sedatives before sleep

🚨 Assume malignant until proven otherwise: duration ≥2 weeks, firm/hard, fixed, non-tender, >1.5 cm
💎 Infection: tender, erythematous, warm, associated with URTI/dental — treat with amoxicillin-clavulanate
🚨 Partial/no response to antibiotics → must exclude malignancy — refer for FNA
💎 Midline mass that moves on swallowing or tongue protrusion → Thyroglossal Duct Cyst (TGDC)
💎 Lateral soft cystic mass ± discharge history → Branchial Cleft Cyst — FNA to exclude malignancy
💎 Ultrasound increasingly used as first-line imaging at point of referral before FNA

Key Point

💎 AR vs VMR: boggy pale mucosa vs beefy red — treat AR with INCS first; add MP-AzeFlu (Dymista) if insufficient

Key Point

💎 Sinusitis: antibiotics only for ABRS with systemic features — watchful waiting for most

Key Point

🚨 Epistaxis: pinch alae + lean forward; posterior bleed → urgent ENT

Key Point

🚨 Hoarseness >2 weeks = ENT referral to rule out malignancy

Key Point

💎 OSA: CPAP first-line; HNS (Inspire) for CPAP-intolerant (AHI 15–65, BMI <35)

Key Point

🚨 Neck mass: firm, non-tender, >2 weeks = malignant until proven otherwise → FNA

ARIA-EAACI Guidelines 2024–2025 Revision: Intranasal Treatments. Allergy. 2025. DOI:10.1111/all.70131
Rosenfeld RM et al. Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngol Head Neck Surg. 2015
Stachler RJ et al. Clinical Practice Guideline: Hoarseness (Dysphonia) Update. Otolaryngol HNS. 2018
Kapur VK et al. AASM Clinical Practice Guideline for Diagnostic Testing for Adult OSA. J Clin Sleep Med. 2017
AASM Manual for Scoring of Sleep and Associated Events, Version 3. AASM, 2023
Pynnonen MA et al. Clinical Practice Guideline: Evaluation of the Neck Mass in Adults. Otolaryngol HNS. 2017