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Co Sponsored by
ENT for the PA-C 2015
Workshops
March 19, 2015
The Fairmont Newport Beach, California
UC Irvine
Sunil Verma, MD
Program Co-Director (AAOA-HNSF)
Marie Gilbert, PA-C, DFAAPA
Program Co Director (SPAO-HNS)
Jose C. Mercado, PA-C, MMS, DFAAPA
Workshop Director (SPAO-HNS)
Introduction
There are multiple methods and techniques available to
successfully complete all the topics presented in these
workshops. Some are based on patient request, available
equipment or supervising physician’s preference.
The goal of these workshop is to correctly demonstrate the
most common methods and give participants time for hands on
training.
Workshop topics have been selected based on relevancy,
practice need and audience requests from over seven years of
lecture series. This entire program has been reviewed and is
approved for a maximum of 28 earnable hours of AAPA clinical
Category I CME credit by the Physician Assistant Review Panel.
The activity was planned in accordance with AAPA’s CME
Standards for Live Programs and for Commercial Support of Live
Programs.
Table of Contents
Workshop Schedule……………………………………………
1
Airway Workshop –Advanced…………………………….
2
Audiology workshop…………………………………………..
10
ENT Procedures Workshop…………………………………
11
Flexible Fiberoptic Workshop –Basic………………….
19
Flexible Fiberoptic Workshop – Advanced………….
24
Otology Workshop – Basic………………………………….
30
Otology Workshop – Advanced………………………….
36
Vertigo Workshop………………………………………………
41
Recommended Reading……………………………………..
45
Workshop Schedule
Time
Workshop
Instructor
Location
7:30 a.m. -9:30 a.m.
Advanced Otology
Basic Flex Scope
Vertigo
Marovich/Clark
Grant
Valdez
TBD
10:00 a.m. to 12:00 p.m.
Audiology
Basic Flex Scope
Basic Otology
Advanced Otology
Advanced Flex Scope
ENT Procedures
Vertigo
TBD
Grant
Fichera
Marovich/Clark
Felter
Mercado
Valdez
TBD
Audiology
Basic Flex Scope
Basic Otology
Advanced Otology
Advanced Flex Scope
ENT Procedures
Vertigo
TBD
Grant
Fichera
Marovich/Clark
Felder
Mercado
Valdez
TBD
Audiology
Basic Flex Scope
Basic Otology
Advanced Otology
Advanced Flex Scope
ENT Procedures
Vertigo
Advanced Airway
TBD
Grant
Fichera
Marovich/Clark
Felder
Gilbert
Valdez
Mercado
Advanced Scopes
ENT Procedures
Advanced Airway
Felder
Gilbert
Mercado
1:00 p.m. – 3:00 p.m.
3:30 p.m. – 5:30 p.m.
6:00 p.m. – 8:00 p.m.
TBD
TBD
1
ENT for the PA-C
Presented by: Jose Mercado, PA-C
Airway workshop – Advanced
Learning objectives
Discuss and practice tracheostomy care techniques.
Discuss and practice management for tracheostomy airway obstruction.
Discuss and practice management for tracheostomy airway leaks.
Discuss and practice management for tracheostomy bleeding.
Discuss indications for and practice cricothyrotomy
2
Notes___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
3
Airway Scenarios
Attendees will rotate through 4 simulated
scenarios where they will be given a
patient and asked to perform corrective
measures.
• Scenario 1: 47 year old male with
respiratory failure status post
tracheostomy 8 days ago. Having
increased difficulty breathing.
• Scenario 2: 66 year old female with
respiratory failure, ventilator dependant
has developed a leak.
• Scenario 3: 59 year male with SCCA, left
tongue, status post tracheostomy
accidentally decanulated during patient
transport.
• Scenario 4: 44 year old male in acute
respiratory distress in ER unable to
intubate.
4
Task: Resolve Blocked Tracheostomy
Indications: Blocked or leaking tracheostomy tube, poor
saturation, etc
1. Explain Procedure. Monitor oxygen
saturation.
2. Check equipment, ensure cuff functions.
3. Position the patient supine with a
shoulder roll to hyperextend the neck and
bring tracheal orifice closer to surface.
4. Provide supplemental oxygen prior to
procedure.
5. Check inner cannula – most common
cause of obstruction – mucous plug.
A. Rinse - inner cannula with warm
saline.
B. Suction -use saline bullets and
suction.
6. Visualize distal end tracheostomy tube
with flexible fiberoptic endoscope
checking for granulation tissue.
Pearl - If unable to clear obstruction may
need to change trachoestomy tube.
Mercado 2013 ©
Mercado 2013 ©
Mercado 2013 ©
Mercado 2013 ©
Mercado 2013 ©
5
Task: Resolve Leaking Tracheostomy
Indications: Leaking tracheostomy tube, poor saturation, etc
1. Explain Procedure. Monitor oxygen
saturation.
2. Check cuff pressure.
•Defective cuff – ensure cuff has
enough air and is working.
3. If cuff is working and still have leak
consider
•Tracheomalacia.
•Fistula
4. Visualize distal end tracheostomy
tube with flexible fiberoptic
endoscope checking for granulation
tissue, etc.
5. Change tracheostomy tube (regular
to extra long tracheostomy tube or
vice versa).
Mercado 2013 ©
Mercado 2013 ©
Mercado 2013 ©
6
Task: Change Tracheostomy
Indications: for tracheostomy change include minimizing
risk of postoperative infection and granulation tissue
formation, verifying formation of a stable tract for
ancillary support staff, and downsizing the
tracheostomy tube if the patient is clinically improving.
Contraindications:
Changing a tracheostomy tube too soon after operation
(generally < 5 days) before tract has healed adequately,
increases the likelihood of entry into a false passage.
Performer inexperience and unavailability of staff
versed in airway management.
Extremely high ventilator settings, which increases the
risk of decannulation.
Patient noncooperation without ancillary support.
Complications: Although tracheostomy tube changes are
routinely performed, the procedure is not without
complications.
Minimize complications by understanding and
practicing procedure as well as anticipating potential
problems. In addition to oxygen, pulse oximeter and
suction, have basic emergency equipment at bedside,
such as a manual ventilator bag, 2 extra tracheostomy
tubes (same size as the trach and one smaller) and an
7
endotracheal tube with stylet.
Task: Change Tracheostomy
1. Explain Procedure. Monitor oxygen saturation.
2. Check equipment, ensure cuff functions.
3. Position the patient supine with a shoulder roll
to hyperextend the neck and bring tracheal
orifice closer to surface.
Mercado 2013 ©
4. Provide supplemental oxygen prior to
procedure.
5. Deflate cuff, suction and release ties. Ensure
tracheostomy is stabilized.
Mercado 2013 ©
6. Remove tracheostomy as patient coughs.
Mercado 2013 ©
7. Insert new tracheostomy with obturator within
lumen. (Rotate 90º from its
correct position, to engage the stoma. Then turn
the obturator back 90º to its correct position.)
8. Remove obturator and replace with inner
cannula. Inflate cuff if needed and secure
tracheostomy.
Mercado 2013 ©
Mercado 2013 ©
8
Task: Perform Cricothyrotomy
Indications: Temporary emergency airway when tracheal
intubation, face mask or laryngeal mask is not possible or
unsuccessful.
1. Explain Procedure. Locate
landmarks
Mercado 2013 ©
2. Make 1 inch vertical incision.
Mercado 2013 ©
3. Introduce catheter at 45° angle
and aspirate bubbles to verify
location.
4. Insert flexible guide wire
(Seldinger Technique).
Mercado 2013 ©
Mercado 2013 ©
5. Anchor guide wire and remove
catheter.
Mercado 2013 ©
6. Insert cricothyrotomy catheter.
Mercado 2013 ©
9
ENT for the PA-C
Presented by: Jen Repovsch, AuD
Audiology
- Recognize methodology of audiometric evaluation
- Recognize methodology of testing otoacoustic emissions (OAE)
- Perform audiometry, tympanometry and OAE testing on a simulated patient
10
ENT for the PA-C
Presented by: Jose Mercado, PA-C and Marie Gilbert, PA-C
ENT Procedures Workshop
Learning Objectives
Discuss indications for and practice removal nasal foreign body.
Discuss indications for and practice control anterior epistaxis.
Discuss indications for and practice control posterior epistaxis.
Discuss indications for and practice fine needle aspiration.
Discuss indications for and practice peritonsillar abscess drainage.
Discuss indications for drainage auricular hematoma and practice splinting.
11
Notes___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
12
Task: Removal Foreign Body Nose
Indications: Unilateral purulent nasal discharge
1.
Explain Procedure. Apply topical
anesthetic & decongestant
BILATERALLY.
Mercado 2013 ©
2.
Good visualization with use of
bright headlight & nasal
speculum.
Mercado 2013 ©
3.
4.
Alligator forceps should be used
to remove cloth, cotton, or paper.
Other hard FB are more easily
grasped using bayonet forceps,
Kelly clamps, or they may be
rolled out by getting behind it
using an ear curette, single skin
hook, or right angle ear hook
Perform flexible fiberoptic
endoscopy to check for infection,
bleeding and additional foreign
bodies.
Mercado 2011 ©
Mercado 2013 ©
13
Task: Control Anterior Epistaxis
Indications: Anterior persistent nosebleed in office
1. Apply direct manual pressure for at least 10
minutes.
2. Spray or apply topical anesthetic with
decongestant. Reapply direct manual
pressure an additional 10 minutes
Mercado 2011 ©
3. Once bleeding has subsided, identify site of
nosebleed
4. Control bleeding with silver nitrate
cauterization. (start from outside in)
Mercado 2011 ©
5. Lubricate naris with Vaseline or Neosporin
ointment. Keep cotton in nares for at least 1
hour to prevent staining
6. Let sit for 10-15 minutes to ensure
hemostasis is achieved.
Mercado 2011 ©
• Avoid sneezing, forceful nose blowing, nose
picking, etc.
• Follow up 2 weeks as re-cauterization may be
necessary.
Mercado 2011 ©
14
Task: Control Epistaxis
Indications: Persistent anterior or posterior nosebleed
despite cauterization
1. Thoroughly soak in sterile water for 30
seconds.
2. Insert nasal pack into the patient’s
nostril parallel to the septal floor, or
following along the superior aspect of
the hard palate, until the blue
indicator ring is inside the opening of
the nostril.
3. Using a 20 cc syringe, slowly inflate the
posterior (green stripe) balloon first
with air only inside the patient’s nose.
4. Inflate second balloon with air.
5.
Allow the patient to sit for 15-20
minutes prior to discharge. Swelling
in the nasal anatomy will reduce and
the balloons may need to be inflated
more to avoid movement of the
device. Don’t forget prophylaxis
antibiotics!
6. To remove packing, deflate balloons 4872 hours later.
15
Task: Fine Needle Aspiration
Indications: Obtain histopathologic diagnosis of suspected
neoplasms
1. Explain Procedure. Prepare
supplies
Mercado 2011 ©
2.
Palpate and identify mass or
lesion.
3.
Clean topically with alcohol.
4.
Stabilize the mass with nondominant hand. Insert needle
through the skin with a quick
motion.
Mercado 2011 ©
Mercado 2011 ©
5.
Transfer specimen to slides and
either fix or immediately
submerge in alcohol.
Mercado 2011 ©
16
Task: Drainage Peritonsillar Abscess
Indications: Drainage peritonsillar abscess >1cm.
1.
2.
Explain Procedure. Prepare
supplies and locate landmarks
Apply topical anesthetic, inject
local anesthetic.
3.
Insert large bore needle with
guard (optional) over area of
greatest fluctuance (imaging).
4.
Aspirate pus (release pressure
when with drawing).
Mercado 2011 ©
Mercado 2011 ©
Mercado 2011 ©
5.
Perform incision at the point of
maximum protrusion, usually
between the uvula and the
second upper molar tooth.
6.
Perform blunt dissection with
curved hemostat.
Treat with PCN based antibiotics and
oral steroids.
Mercado 2011 ©
17
Johnson RF, Stewart MG, Wright CG. An evidence-based review of the treatment of peritonsillar abscess. Otolaryngol Head Neck Surg. 2003;128(3):332–343
Task: Drain Auricular Hematoma
Indications: Drainage hematoma within 5-10 days to prevent
irreversible cartilage thickening.
1. Explain Procedure. Prepare supplies
2. Prepare 1/16inch thick Aquaplast by
making pattern on OPPOSITE ear.
3. Inject anesthesia (ring block).
Mercado 2013 ©
Mercado 2013 ©
4. Drain hematoma.
5. Immerse Aquaplast in hot water (160°F)
until it becomes transparent. Then mold
over site.
6.
Prepare non-adherent gauze pad or
petroleum gauze the shape of the
Aquaplast so they project 1-2 mm
BEYOND margins
7. After placement of gauze pads between
the splints and the skin surface secure
with two or three through and through
0 silk on a straight needle to snuggly
compress splint dressing to hematoma
in sandwich fashion.
Mercado 2013 ©
Mercado 2013 ©
Mercado 2013 ©
Mercado 2013 ©
Mercado 2013 ©
Mercado 2013 ©
18
ENT for the PA-C
Presented by: Grant Needham, PA-C
Flexible Fiberoptic Workshop – Basic
Learning objectives
Discuss normal anatomy visible via flexible fiberoptic nasopharyngoscopy
Practice the use of the flexible fiberoptic nasopharyngoscope on mannequins.
Practice the use of the flexible fiberoptic nasopharyngoscope on simulated patient
Understand and practice proper endoscope use and care.
Normal variants and abnormal findings will be discussed in Advanced Course.
19
Notes___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
20
Task: Practice indirect laryngoscopy
Indications: Asses vocal cords on mannequin and simulated
patient.
1. Explain Procedure. Prepare supplies
2. Position patient
3. Apply topical anesthetic soft palate.
Mercado 2013 ©
4. Stabilize tongue with non-dominant
hand.
5. Place warm dental mirror in the
back of the throat and angle it
down towards the larynx. Light can
be reflected downward and the
larynx can be seen in the mirror.
6. Indirect laryngoscopy can be quick
and gives a good three
dimensional view of the larynx in
true color.
Mirror Laryngoscopy, image is inverted.
21
Task: Practice flexible endoscopy
Indications: Flexible endoscopy is done when there may be a condition or disease
in the nose, sinuses or throat that is not adequately visualized on routine
examination.
Indications
History (one or more required)
1.
Persistent hoarseness.
2.
Suspected neoplasm of upper aerodigestive tract.
3.
Chronic cough.
4.
Chronic postnasal drainage.
5.
Recurrent epistaxis.
6.
Chronic rhinorrhea.
7.
Chronic nasal congestion or obstruction.
8.
Hemoptysis.
9.
Hemorrhage from throat.
10.
Throat pain.
11.
Otalgia.
12.
Airway obstruction.
13.
Dyspnea.
14.
Stridor.
15.
Dysphagia
16.
Head or neck masses—unknown primary tumor.
17.
Laryngeal injury—with hoarseness or airway obstruction.
18.
Chronic aspiration.
19.
Velopharyngeal incompetence.
20.
Suspected foreign body.
21.
Unilateral middle ear effusion.
22.
Obstructive sleep apnea or severe snoring.
Preoperative assessment of vocal cord function, eg, prior to thyroid surgery
23.
http://www.entnet.org/Practice/upload/LaryngoscopyNasopharyngoscopy-CI_May-2012.pdf
22
Task: Practice flexible endoscopy
1. Explain Procedure. Prepare
supplies.
2. Position patient.
3. Apply topical anesthetic &
decongestant nose.
Mercado 2011 ©
4. Perform flexible naso/laryngeal
endoscopy.
Mercado 2011 ©
5. Direct laryngoscopy provides
detail view of nasal passage
and vocal cord function.
Mercado 2011 ©
Mercado 2011 ©
6. Remove endosheath and
maintain clean technique.
Fiberoptic Laryngoscopy, image is true.
Mercado 2011 ©
23
ENT for the PA-C
Presented by: Marti Felter , PA-C
Flexible Fiberoptic Workshop – Advanced
Learning objectives
Identify normal anatomy, normal variants and abnormal findings visible via flexible fiberoptic
nasopharyngoscopy.
Understand indications and perform flexible and rigid scope examination adult.
Understand indications and perform flexible scope examination child/infant.
Perform intranasal culture and sinus debridement using rigid scope adult.
24
Notes___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
25
Task: Practice flexible endoscopy
Indications: Flexible endoscopy is done when there may be a condition or disease
in the nose, sinuses or throat that is not adequately visualized on routine
examination.
Indications
History (one or more required)
1.
Persistent hoarseness.
2.
Suspected neoplasm of upper aerodigestive tract.
3.
Chronic cough.
4.
Chronic postnasal drainage.
5.
Recurrent epistaxis.
6.
Chronic rhinorrhea.
7.
Chronic nasal congestion or obstruction.
8.
Hemoptysis.
9.
Hemorrhage from throat.
10.
Throat pain.
11.
Otalgia.
12.
Airway obstruction.
13.
Dyspnea.
14.
Stridor.
15.
Dysphagia
16.
Head or neck masses—unknown primary tumor.
17.
Laryngeal injury—with hoarseness or airway obstruction.
18.
Chronic aspiration.
19.
Velopharyngeal incompetence.
20.
Suspected foreign body.
21.
Unilateral middle ear effusion.
22.
Obstructive sleep apnea or severe snoring.
Preoperative assessment of vocal cord function, eg, prior to thyroid surgery
23.
http://www.entnet.org/Practice/upload/LaryngoscopyNasopharyngoscopy-CI_May-2012.pdf
26
Task: Practice flexible endoscopy
1. Explain Procedure. Prepare
supplies
2. Position patient
3. Apply topical anesthetic &
decongestant nose.
Mercado 2011 ©
4. Perform flexible naso/laryngeal
endoscopy
Mercado 2011 ©
5. Direct laryngoscopy provides
detail view of nasal passage
and vocal cord function.
Mercado 2011 ©
Mercado 2011 ©
6. Remove endosheath and
maintain clean technique.
Fiberoptic Laryngoscopy, image is true.
Mercado 2011 ©
27
Task: Practice flexible endoscopy child/infant
1. Explain Procedure. Prepare supplies.
2. Position patient papoose vs. cradle.
Mercado 2011 ©
3. Apply topical anesthetic &
decongestant nose.
Mercado 2013 ©
4. Perform flexible naso/laryngeal
endoscopy
Mercado 2013 ©
5. Direct laryngoscopy provides detail
view of nasal passage (choanal
atresia, adenoid hypertrophy,
laryngomalecia, subglottic stenosis
and vocal cord function.
6. Remove endosheath and maintain
clean technique.
Mercado 2013 ©
28
Task: Practice rigid nasal endoscopy
1. Explain Procedure. Prepare
supplies
2. Position patient
3. Apply topical anesthetic &
decongestant nose.
Mercado 2013 ©
4. Perform rigid nasal endoscopy
and sinus debridement.
Mercado 2013 ©
Patient
5. Perform rigid nasal endoscopy
and obtain culture.
Dr. Kevin Kavanaugh © www.entusa.com
Mannequin
Patient
Septum
6. Remove endosheath and
maintain clean technique.
Inferior
Turbinate
Septum
Inferior
Turbinate
29
ENT for the PA-C
Presented by: Jeff Fichera, PA-C, PhD
Otology Workshop – Basic
Learning objectives
- Discuss normal, normal variant and abnormal otologic conditions
- Demonstrate techniques for cerumen removal
- Demonstrate techniques for foreign body removal from ear
- Perform manual pneumatic otoscopy examination
30
Notes___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
31
Task: Removal cerumen impaction
1. Position Patient -Explain Procedure
2. Visualize Canal/Landmarks
3. Determine BEST Procedure -Remove Cerumen
4. Re-Inspect Ear
Mercado 2011 ©
Mercado 2011 ©
Modified semireclined position
allows visualization
of attic space.
Use largest size
speculum that fits &
place deep enough to
clear the hair-bearing
skin.
Mercado 2011 ©
Mercado 2011 ©
Suction
Curette
Mercado 2011 ©
Hold speculum
between first &
second finger to
retract the pinna up
& backward in an
adult .
Mercado 2011 ©
Alligator
Forceps
Mercado 2011 ©
Visualize
membrane and
identify
landmarks.
Mercado 2011 ©
Warm
Irrigation
32
Task: Removal foreign body ear
1. Explain Procedure. Prepare
supplies
2. Position patient
3. Foreign Bodies – eraser heads,
beads, cotton tips, bugs, etc…
removal requires direct
visualization prior to removal
either via warm irrigation or
instruments like an alligator
forceps, curette or suction.
Mercado 2011 ©
4. Drown insects with mineral oil
or lidocaine before attempting
removal.
5. Use warm water as cold water
may cause dizziness.
Mercado 2011 ©
33
Task: Distinguish OE from OM & AOM from SOM
Indication: using OtoSim distinguish types of ear
disease.
34
Task: Manual Pneumatic Otoscopy
Indication: Evaluate middle ear function.
1. Pull the ear upwards and
backwards to straighten the
canal before inserting
otoscope.
2. Insert the otoscope to a point
just beyond the protective hairs
in the ear canal. Use the largest
speculum that will fit
comfortably.
3. Anchor otoscope - hold the
otoscope with your thumb and
fingers so that your hand makes
contact with the patient.
Mercado 2011 ©
4. Insufflate with non-dominant
hand.
5. Observe movement of tympanic
membrane.
Mercado 2014 ©
35
ENT for the PA-C
Presented by: Ryan Marovich, PA-C and Andrew Clark, PA-C
Otology Workshop – Advanced
Learning objectives
Practice removing cerumen impaction under microscope
Practice myringotomy
Practice ventilation tube insertion
Practice intra-tympanic membrane injection
36
Notes___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
37
Task: Removal cerumen impaction under microscope
1. Position Patient/microscope -Explain Procedure
2. Visualize Canal/Landmarks
3. Determine BEST Procedure -Remove Cerumen
4. Re-Inspect Ear
Mercado 2013 ©
Mercado 2011 ©
Reclined position allows
visualization of attic
space with microscope.
Mercado 2011 ©
Visualize
membrane and
identify landmarks.
Use largest size
speculum that fits &
place deep enough to
clear the hair-bearing
skin.
Mercado 2011 ©
Hold speculum between
first & second finger to
retract the pinna up &
backward in an adult .
Mercado 2011 ©
Mercado 2011 ©
Mercado 2011 ©
Suction
Curette
Alligator
Forceps
38
Task: Perform myringotomy & ventilation tube insertion
1.
An operating microscope with a 250-mm lens is
brought into the field and focused on the
external auditory meatus.
2.
A speculum of a size appropriate for visualizing
the tympanic membrane) is placed into the
external auditory canal, and any cerumen is
removed so that the entire tympanic membrane
can be visualized.
3.
A horizontal incision is made in the
anteroinferior quadrant. It should be deep
enough to incise the eardrum but not so deep
that it injures the middle structures.
4.
The incision should be slightly smaller than the
diameter of the tube’s inner flange.
5.
Microsuction effusion with a 3, 5 or 7 French
Baron suction cannula.
6.
A ventilation tube is introduced by holding the
posterior surface of the inner flange with small
alligator forceps.
7.
If necessary, insertion is completed with a
curved or straight pick. Most tubes can be
inserted directly with small alligator forceps.
8.
Residual effusion or blood is aspirated.
9.
Otic antibiotic drops are instilled to reduce
bleeding and loosen any thickened secretions
that were not removed by suction
Mercado 2011 ©
Mercado 2011 ©
39
Task: Perform intratympanic injection
1. 1. Explain Procedure. Prepare
supplies. Allow the dexamethasone
to warm to room temperature (to
avoid dizziness).
2. Position patient
3. Apply anesthetic
Mercado 2013 ©
4. Make two small incisions - -one for
the injection and one for ventilation.
5. Inject the dexamethasone through
the posterior incision.
• Most patients begins with a single intratympanic injection of
dexamethasone (12 mg/ml).
•Follow up in 2-3 weeks. Repeat the injection at 6-8 weeks if
vertigo recurs.
40
ENT for the PA-C
Presented by: Mike Valdez, PA-C
Vertigo Workshop
Learning Objectives
Discuss and demonstrate vertigo examination;
Neurological examination
Rhomberg Test
Fukada Stepping Test
Dix-Hallpike
Demonstrate ENG/VNG.
Demonstrate and practice canalith repositioning
41
Notes___________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
42
Task: Perform Vertigo Physical Examination
1. Obtain detailed history
2. Physical examination
a. Neurological
examination (CNII-XII)
b. Rhomberg Test
c. Fukada Stepping Test
d. Dix-Hallpike
52
43
Task: Perform Canalith repositioning (Modified Eply
Maneuver )
Patient’s head is systematically
rotated so that the loose particles
slide out of the semicircular canal
and back into the utricle.
Mercado 2013©
1. If vertigo affects RIGHT ear, the
patient is brought to the head
hanging position with right ear
turned DOWNWARD.
Mercado 2013©
2. Move the head to end of table,
rotate head to the left with right
ear turned UPWARD.
3. Hold for 30 seconds, then roll
patient onto the left side while
clinician rotates head
LEFTWARD until the nose points
down to floor.
4. Hold position for 30 seconds.
Mercado 2013©
Mercado 2013©
5. Then patients returns to sitting
position with head facing left.
Mercado 2013©
44
Recommended Reading
1. Otolaryngology , A Surgical Notebook Lee / Toh ISBN 9781588903044
2. Color Atlas of ENT Diagnosis, Bull ISBN 9783131293954
3. ENT-Head and Neck Surgery: Essential Procedures, Theissing ISBN 9783131486219
4. Laryngeal Evaluation Indirect Laryngoscopy to High-Speed Digital Imaging, Kendall
ISBN 9781604062724
5. Differential Diagnosis in Otolaryngology Head and Neck Surgery, Stewart and Selesnick
ISBN 978-1-60406-051-5
6. Basic Otorhinolaryngology A Step-by-Step Learning Guide, Probst ISBN
9781588903372
7. The Audiogram Workbook, Hepfner ISBN 9780865777194
8. Imaging for Otolaryngologists, Dunnebier 9783131463319
Please visit
http://www.thieme.com/index.php?option=com_content&view=article&id=633&ca
tid=66&Itemid=90
For special discounts.
All workshops written by Jose C. Mercado, PA-C, MMS, DFAAPA
except “Audiogram Workshop”
54