Ophthalmology and ENT — Ear, Nose and Throat, NMC MBBS licence examination syllabus (Nepal Medical Council).
The quiet child at the back of the class may not be inattentive. They may simply not be hearing you.
Most ENT presentations are common, self-limiting and unglamorous. Buried among them are a small number of conditions that destroy hearing, erode into the skull, or announce a curable cancer while it is still curable.
The clinical skill is not in managing the common things — it is in recognising the few that look like them.
Every hearing problem is one of two things, and the distinction decides everything that follows.
Conductive loss means sound cannot reach the cochlea. The cochlea works perfectly; the delivery system does not. Causes sit in the external or middle ear: wax, fluid behind the drum, a perforation, or a problem with the ossicles. Much of this is treatable, sometimes trivially.
Sensorineural loss means the cochlea or the auditory nerve cannot detect sound. Causes include ageing, noise exposure, certain drugs, and infection. This is usually permanent, and management is rehabilitation — hearing aids, communication strategies — rather than cure.
Two patterns should never be dismissed. Sudden sensorineural hearing loss — hearing lost over hours to days — is an emergency requiring same-day referral, because the window in which treatment may help is short and it closes. And unilateral hearing loss in an adult is never simply ageing: age-related loss is symmetrical, so a one-sided loss demands an explanation.These are routinely confused, and they need entirely different management.
Acute otitis media is an infected, painful middle ear — fever, severe earache, a distressed child. The important and counter-intuitive point is that most cases resolve without antibiotics, so adequate pain relief matters more than a prescription. Antibiotics are reserved for defined situations set out in national guidance.
Otitis media with effusion is fluid behind an intact drum without acute infection. It is painless. The child has no fever, does not complain, and simply does not hear well. Antibiotics do not help, because there is no acute infection to treat.
An ear that discharges for weeks or months is easy to treat as a nuisance and to manage with repeated courses of drops. Some chronic ear disease is exactly that. Some is not.
Cholesteatoma is the reason for caution. It is not a tumour, but it behaves destructively: it expands and erodes the bone it grows into. Since it sits in the temporal bone, what it erodes into includes the facial nerve, the inner ear, and ultimately the cranial cavity.
Hence the complications, which are serious and out of proportion to the innocuous-sounding symptom: facial palsy, vertigo, meningitis, brain abscess and lateral sinus thrombosis.
So the practical rule: a chronically discharging ear — particularly with offensive or blood-stained discharge — needs specialist assessment rather than another course of drops. The question is not how to dry the ear; it is what is causing the discharge. And headache, fever, vertigo or facial weakness in someone with a discharging ear is an emergency, because it suggests the disease has already left the middle ear.Most sore throats are viral and self-limiting, and antibiotics shorten symptoms very little while selecting resistance. The consultation is therefore mostly explanation — expected course, safety-net advice, and what would change your mind — as set out in the antimicrobial chapters.
But streptococcal throat infection is not ignored, and the reason is specific to settings like Nepal: its late complications. Rheumatic fever and post-streptococcal glomerulonephritis follow streptococcal infection after a latent interval, and rheumatic heart disease remains a leading cause of cardiac disease in young adults in South Asia. That risk is what justifies treating streptococcal throat infection where it is prevalent.
The features that make a sore throat urgent are about the airway and about deep infection, not about the severity of the pain:
Tonsillectomy criteria are deliberately not given here: they differ substantially between national guidelines and remain genuinely contested. Use the criteria your service applies.
This is short, and it is one of the highest-yield paragraphs in the chapter.
Persistent hoarseness needs the vocal cords examined. Laryngeal cancer is curable when caught small — and a changed voice is frequently its only early symptom. Risk rises with smoking and with alcohol, and disproportionately when the two are combined.
The failure mode is not ignorance but repetition: "it is probably laryngitis" is a reasonable first thought and a dangerous fourth one. Give it a defined period, and if the voice has not recovered, arrange examination rather than repeating the reassurance. Additional features — a neck lump, referred ear pain, difficulty swallowing, or weight loss — should sharply increase concern.Vertigo is not dizziness. Vertigo is an illusion of movement — the room spinning — and points to the vestibular system or its central connections. Lightheadedness on standing is a different symptom with cardiovascular causes. Asking the patient to describe the sensation without using the word "dizzy" separates them, and saves a great deal of misdirected investigation.
A unilateral nasal problem is different from a bilateral one. Bilateral nasal obstruction with sneezing and clear discharge is usually allergic or infective. Unilateral obstruction, unilateral bleeding, or a unilateral foul discharge is a different problem — in a child, most often a retained foreign body; in an adult, it requires examination to exclude a tumour.
No antibiotic regimens, audiometric thresholds, tonsillectomy criteria or referral time limits are quoted here — all are national guideline territory and some are genuinely contested. Use your local guidance.
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