ear nose throat Flashcards
What are common problems?
EAR-
Otitis externa, Ramsey hunt syndrome, glue ear, AOM, COM, cholesteatoma, mastoiditis, balance
NOSE-
Epistaxis, rhinosinusitis, nasal carcinoma, facial pain
THROAT-
Tonsillitis, quinsy, glandular fever, epiglottitis, malignancy
What is the basic structure of the ear?
Cochlea and cochlear nerve- hearing
Semicircular canals and vestibular nerve- balance
Tympanic membrane aka ear drum
Bones- ossicles, malleus, incus, stapes
External auditory canal
Pinna/auricle- outer part of ear
How do you take an ear history?
Hearing loss- onset/rate if progression
Otalgia (pain)- referred?
Otorrhoea (drainage)- mucoid
Tinnitus- pulsatile
Vertigo
Nasal
Drug hx- ototoxic drugs
Family hx- hearing loss when you do
Noise exposure
What is perichondritis?
Skin and soft tissue infection of pinna
Due to trauma (piercings, burns etc)
Pseudomonas sp.
Tx= IV antibiotics, analgesia
What is otitis externa?
Inflam and infection of external auditory canal
Pseudomonas, staph aureus
Pain, discharge, pruritis, hearing loss
Tx= aural toilet, analgesia, topical antibiotics +/- packing
What is Ramsey Hunt syndrome?
Acute LMN facial palsy + ear pain + varicella like cutaneous lesions
Anastamotic communications may affect CN V, IX, X
Tx= oral steroids/antivirals, analgesia, eye care, topical emollients
What is otitis media w effusion/glue ear?
Persistent mucoid/serous middle ear effusion
3 months+
Due to mucus overproduction/under clearance
Dull gray/yellow tympanic membrane
Reduced mobility
Occasional bubbles
Asymptomatic, hearing loss, delayed speech, recurrent infection
Tx= monitor, Gromment insertion +/- adenoidectomy, hearing aid
What is acute otitis media?
A. Non suppurative
No effusion
B. Suppurative
W pus usually following URTI
Strep. pneumoniae, Haem. influenzae, Moraxella catarrhalis
Intracranial complications
- meningitis, abscess, lateral sinus thrombosis
Extracranial complications
-mastoiditis, petrositis, palsy, labyrinthitis, hearing loss, TM perforation
What is chronic otitis media?
Persistent/intermittent discharge through non intact TM
Tx= aural toilet, topical/oral antibiotics
What is cholesteatoma?
Destructive and expanding keratinised squamous cell debris
Congenital/acquired
Slow destruction of middle ear/surrounding tissue
Hearing loss, chronic ear discharge, vertigo, abscess formation
Tx= aural toilet, mastoid surgery
What is acute mastoiditis?
Infection of mastoid air cells as a complication of AOM
Mastoid tenderness, pyrexia
Oedema and erythema of post auricular soft tissue
Thickened hyperaemic TM
Tx= broad spectrum IV antibiotic, CT +/- cortical mastoidectomy
What is BPPV?
Benign paroxysmal positional vertigo
Brief intense episodes of rotary vertigo worsened by head movements
Misplaces otoconia in middle ear
Diagnose- Dix-Hallpike maneuver
Tx= Epley manoeuvre
What is Menieres?
Vertigo lasting mins to hours due to fluid imbalance
Tx= low salt diet, meds (Furosemide, Stemetil, Betahistine), grommets, labyrinthectomy
What is labyrinthitis/vestibular neuronitis?
Acute debilitating vertigo lasting days to weeks followed by recovery
Tx=supportive care followed by vestibular rehab
What is deafness?
3 million- impaired hearing
Conductive= impediment to passage of sound waves between external ear and footplate of stapes
Sensorineural= cochlea or cochlear nerve fault
How do you do an ear exam?
Intro
Consent
Explain
Use otoscope
Inspect ear
Free field hearing tests
Tuning fork tests
Cranial nerve exam
What is the the basic structure of the nose?
Frontal sinus, sphenoid sinus
Ethmoid, palatine and nasal bone
Septal and vomeronasal cartilage
Sup, Mid, Inf turbinates
Vestibule
Choana
Sella turcica
Cribriform plate of ethmoid bone
How can you take a history for the nose?
Rhinorrhea
Nasal obstruction
Sneezing
Discharge
Olfaction
Allergies
Facial/dental pain
Post nasal drip
Congestion
How do you do a nasal exam?
Anterior rhinoscopy (inspection, palpating of facial bones, speculum and head lamp to inspect vestibule to turbinates)
Rigid rhinoscopy
Flexible nasoendoscopy
What is epistaxis?
Idiopathic 85%
Coagulopathy, rhinitis, trauma
Drugs (aspirin, warfarin)
Chronic granulomatous disease (Wegners, Sarcoid)
Neoplastic (SCC, adenocarcinoma, juvenile angiofibroma)
Tx= ABCDE, cautery (AgNO3), packing, surgery, interventional radiology
What is Littles area?
Anastomoses of 5 arteries (LEGS)
Labial artery (ant and post)
Ethmoid artery
Greater palatine artery
Sphenopalatine artery
What are the different types of packing?
Balloon tamponade
Absorbable packs
Haemostatic packs
Posterior packs (foley catheter, rapid rhino, BIPP, Vaseline)
Flow seal
What is rhinosinusitis and nasal polyposis?
Inflam of nose and para nasal sinuses w 2 symptoms
Tx= nasal douching, topical steroids, antibiotics, FESS
What is nasal carcinoma?
1. Undifferentiated non keratinising SCC
- southern China, Hong Kong, EBV virus
2. Differentiated keratinising SCC
- smoking, alcohol, HPV
Epistaxis, nasal obstruction, middle ear effusion, CN palsies
Tx= staging, chemotherapy/radiotherapy/excisional surgery +/- neck dissection
How do you take a history for the throat?
Oral cavity- pain, bleeding, dysarthria, numbness, otalgia
Swallowing- dysphasia, odynophagia, aspiration, reflux, regurgitation
Hypopharynx and larynx- dysphonia, cough, haemoptysis, pain, dyspnoea, globus, stridor
What is tonsillitis?
Viral 50-80% (herpes simplex, adenovirus, rhinovirus, influenza, coronavirus, RSV, EBV)
Bacterial (B haemolytic strep, pneumococcus, H. influenza)
Tx= analgesia, antibiotics, fluids, antiseptic mouthwash
What is centor criteria?
Diagnoses presence of group A strep (is sore throat bacterial)
4 criteria
Modified- adds pts age
0-1 points- no antibiotics
2-3 points- throat culture, if +ve antibiotic
4-5 points- empirically w antibiotic
Most likely 5-15 yrs
What is quinsy?
Peritonsillar abscess in potential space between tonsilar capsule and pharyngeal muscle bed
Sore throat, dysphasia, hot potato voice, trismus, uvula deviation
Tx= drainage, tonsillitis tx
What is glandular fever?
EBV
Sore throat, fever, malaise, lethargy
Cervical lymphadenopathy, white film on tonsils, hepatosplenomegally
Tx= analgesia, steroids, +/- antibiotics, avoid contact sports 6 weeks
What are indications for tonsillectomy?
Recurrent bacterial tonsillitis
2 peritonsillar abscess
Suspected malignancy
Sleep disordered breathing/OSA
What is epiglottitis?
Life threatening inflam of the epiglottis +/- supraglottic tissue
Less common- Haemophilus influenza B vaccine
Dysphasia, drooling, dysphonia, fever, pooling of saliva
Tx= stay calm, don’t examine, adrenaline nebulisers, oxygen, steroids, antibiotics, intubation/tracheostomy
What is laryngeal carcinoma?
Nearly always SCC
Smoking, alcohol, HPV, 4:1 male to female
TNM staging
Tx= surgery/laser excision +/- radiotherapy +/- chemotherapy
What are anatomical considerations of the neck?
Prominent landmarks
Triangles of the neck
Carotid bulb
Lymphatic levels
What are the different lymphatic levels?
I- oral cavity, tongue, submandibular gland
II- oral cavity, oropharynx, tonsil, parotid gland
III- tonsil, larynx
IV- larynx, hypopharynx, upper oesophagus
V- nasopharyngeal, scalp
VI- thyroid gland
VII- thyroid gland, lung
What are general considerations?
Paeds and YA- 90% benign
>40 yrs- rule of 80s
What is deep neck space abscess?
Neglected quinsy can lead to this
Neck space- area enveloped in fascia
Infection can easily spread and compromise airway
What are different neck spaces?
Peritonsillar area
Parapharyngeal space- skull base to hyoid bone
Retropharyngeal space- skull base to T1-T2
Danger space- skull base to diaphragm
Prevertebral space- skull base to diaphragm
What is ludwigs angina?
Odontogenic infection spreads to suprahyoid spaces in FOM
Strep, staph, fusebacterium, actinomyces
Abscess displaces tongue- airway obstruction
Pain, trismus, drooling, fever, neck swelling
Blood tests, inflam markers, OPG
Tx= admit, secure airway, drain, remove affected teeth, IV antibiotics/steroid, rehydrate
What is acute viral parotitis?
Mild pain, swelling (90% bilateral), pyrexia
Due to paramyxovirus
Complications- meningoencephalitis, pancreatitis, orchitis, deafness
Tx= rehydrate, analgesia
What is acute bacterial parotitis?
Pain, swelling, pyrexia, dehydration
80% mortality if untx
Due to Staph aureus, anaerobes
Tx= antibiotics, rehydrate, analgesics, drain
What is ranula?
Painless masses
Mucus filled cyst arising from sublingual salivary glands
Tx= marsupialisation, gland excision, suture, sclerosis agent
What is lymphadenopathy?
Infective- increase in size of cervical lymph nodes in response
Neoplastic-
-lymphoma- haematological malignancy
-metastatic disease
How do you diagnose head and neck swelling?
Developmental time course
Associated symptoms (dysphagia, otalgia, voice)
Personal habits (tobacco, alcohol)
Previous irradiation, surgery
Complete exam
Emphasis on location, mobility and consistency
What are diagnostic tests?
Fine needle aspiration cytology
Needle core biopsy
Computed tomography- CT/PET (solid vs cyst, extent, vascularity)
MRI (better for upper neck and skull base, vascular delineation w infusion)
Ultrasonography (solid vs cyst, noninvasive)
Radionucleotide scanning (para/thyroid masses, FNAC prefer)
Should FNA or core needle biopsy be used?
FNA- gold standard in thyroid
Core- all other except vascular
FNA- small gauge, reduces bleeding, seeding of tumour not a concern
Core- bigger needle- better sample
What is the nodal mass work up in an adult?
12% cancer is asymptomatic cervical mass
90% of these SCC
Panendoscopy
Directed biopsy (mucosal lesions, areas of radiographic concern)
Open exicional biopsy (frozen section results)
What are examples of primary tumours?
Thyroid mass
Lymphoma
Salivary tumours
Lipoma
Carotid body and glomus tumours
Neurogenic tumours
What are thyroid masses?
Paeds- most common neoplastic, more boys, higher incidence of malignancy
Adults- more women, mostly benign
Why is FNAB the gold standard for thyroid masses?
Decreases no of pts w surgery
Increased no of malignant tumours found at surgery
Doubled no of cases followed up
Unsatisfactory aspirate- repeat in 1 month
What is lymphoma?
More common paeds- 80% of Hodgkins have neck mass
Lateral neck mass only, fever, hepatosplenomegaly, diffuse adenopathy
Open biopsy
Full work up- CT, bone marrow biopsy
What are salivary gland tumours?
Parotid 80% (80% benign), submandibular 15% (50%), sublingual 5% (20%)
Malignancy- rapid growth, skin fixation, cranial nerve palsy
FNAC- >90% accuracy
CT/MRI- deep lobe tumours, intra vs extra parotid
What is a carotid body tumour?
Rare in paeds
Pulsatile, compressible
Mobile medial/lateral
Clinical diagnose, CT/angiogram to confirm
Tx=irradiation, monitor, surgical resection
What is lipoma?
Soft ill defined mass
>35 yrs
Asymptomatic
Clinical diagnose/excise to confirm
What is a neurogenic tumour?
From neural crest
More in neurofibromatosis syndromes
Schwannoma most common in head and neck (sporadic, 20-50yrs, usually mid neck, medial tonsillar displacement, hoarseness, horners syndrome)
What are congenital and developmental masses?
Epidermal and sebaceous cysts (most common, older, clinical- elevation and movement of overlying skin, skin dimple/pore, confirmed by excisional biopsy)
Branchial cleft cysts (2nd cleft most common, older paeds/YAs often following URI, smooth fluctuant mass under SCM, control infection and excise, maybe parotidectomy if 1st cleft)
Thyroglossal duct cysts (most common congenital, usually midline inferior to hyoid, elevates on swallowing, surgical removal)
Vascular tumours (in 1st yr of life, CT/MRI, lymphangiomas unchange- excise, hemangiomas resolve- excise if rapid growth/thrombocytopenia w/o med therapy)
What is granulomatous lymphadenitis?
Weeks to months
Minimal systemic
TB, atypical TB, cat scratch fever, actinomycosis, sarcoidosis
Firm, fixed nose w injection of skin
TB- more common adults, posterior triangle nodes, rare, responds to anti TB, may excisional biopsy
Atypical TB- paeds, anterior triangle nodes, brawny skin, induration, pain, responds to complete excision/curettage
Cat scratch fever (Bartonella)- paeds, preauricular and submandibular nodes, spontaneous resolution +/- antibiotics
How do you do a neck exam?
Wash hands
Introduce
Consent
Adequate exposure
Look, feel, move
Look- scars, mass, voice, systemic, swallow water, protude tongue
Feel- lymph nodes, pre/post auricular, occipital, thyroid gland (swallow, protrude tongue)
Thank
Wash hands
Summarise findings
How should you assess a neck lump?
Size
Location
Consistency
Fluctuance
Pulsatility
Temp
Skin change
Relation to structures
Auscultation
What are red flags from lumps?
Raise suspicion of malignancy-
-hard fixed mass
->35 yrs
-hx of persistent hoarse voice/dysphagia
-trismus
-otalgia
How would you further assess for a neck mass?
Examine oral cavity, oropharynx, nasal cavity
USS lesion, MRI neck
FNAB
Thyroid status
How would you assess the thyroid status?
Observe pt
Inspect hands for clammy cold/irregular pulse
Inspect face for lid lag, exophthalmos
Assess lump
Feel for tracheal deviation
Percuss for retrosternal goitre
Auscultate for thyroid bruits
Assess reflexes
Inspect for pretibial myoxoedema
Assess for proximal muscle wasting
