ENT Flashcards
Function of the nasal cavity
= most superior part of the respiratory tract
- Warms and humidifies inspired air.
- Removes and traps pathogens and particulate matter from the inspired air.
- Responsible for sense of smell.
- Drains and clears the paranasal sinuses and lacrimal ducts.
Respiratory vs Olfactory regions of nasal cavity
Respiratory region = lined by a ciliated pseudostratified epithelium, interspersed with mucus-secreting goblet cells.
Olfactory region = located at the apex of the nasal cavity. It is lined by olfactory cells with olfactory receptors.
What are the nasal conchae?
= curved shelves of bone projecting out of the lateral walls of the nasal cavity.
They project into the nasal cavity, creating four pathways for the air to flow
What are the four pathways of air flow created by the nasal conchae?
- Inferior meatus – between the inferior concha and floor of the nasal cavity.
- Middle meatus – between the inferior and middle concha.
- Superior meatus – between the middle and superior concha.
- Spheno-ethmoidal recess – superiorly and posteriorly to the superior concha.
What is the aim of the nasal conchae creating different paths of air flow?
to increase the surface area of the nasal cavity
to disrupt the flow of air to make it turbulent (so that it spends longer in the nasal cavity).
What structures drain into the nasal cavity?
Paranasal sinuses - frontal, maxillary, ethmoidal, sphenoid
Nasolacrimal Duct
Auditory (Eustachian) tube
Cribriform Plate
Sphenopalatine foramen
Incisive canal
What is the purpose of the Auditory (Eustachian) tube opening into the nasal cavity?
Connects the middle ear to the nasopharynx (opens onto the lateral wall of the nasal cavity)
It allows the middle ear to equalise with the atmospheric air pressure.
What is a problem that can occur due to the Auditory (Eustachian) tube opening into the nasal cavity?
Provides means for infection to spread from the upper respiratory tract to the ear.
Incisive Canal of nasal cavity
Pathway between the nasal cavity and incisive fossa of the oral cavity.
Transmits the nasopalatine nerve and greater palatine artery.
Sphenopalatine foramen of nasal cavity
Located at the level of the superior meatus
Sphenopalatine artery, nasopalatine and superior nasal nerves pass through
Cribriform plate of nasal cavity
part of the ethmoid bone
forms a portion of the roof of the nasal cavity
contains very small perforations, allowing fibres of the olfactory nerve to enter and exit.
Arterial Supply of nasal cavity
Internal carotid branches:
- Anterior ethmoidal artery
- Posterior ethmoidal artery
External carotid branches:
- Sphenopalatine artery
- Greater palatine artery
- Superior labial artery
- Lateral nasal arteries
These arteries form anastomoses with each other, especially in the anterior portion of the nose.
Little’s / Kiesselbach’s area
An area in the anterior portion of the nose, where there are lots of anastomoses of arteries
common site for nosebleeds (~90% from this area)
Venous drainage of the nose
The veins of the nose tend to follow the arteries.
They drain into the pterygoid plexus, facial vein or cavernous sinus.
How can the innervation of the nose be divided?
Special = the ability of the nose to smell
General = sensory innervation
Special sensory innervation of the nose
OLFACTORY NERVE
The olfactory bulb lies on the superior surface of the cribriform plate
Branches of the olfactory nerve run through the cribriform plate to provide special sensory innervation to the nose.
General sensory innervation of the nose
Innervation to the septum and lateral walls is delivered by the nasopalatine nerve (branch of maxillary nerve) and the nasociliary nerve (branch of the ophthalmic nerve).
Innervation to the external skin of the nose is supplied by the trigeminal nerve.
Parts of the external ear
Auricle
External Acoustic Meatus
Tympanic Membrane
Auricle
Functions to capture and direct sound waves towards the external acoustic meatus.
A mostly cartilaginous structure:
=> Helix, anti-helix, concha, tragus, antitragus
External acoustic meatus
A sigmoid-shaped tube
=> Initially superoanterior, then superoposterior, then inferoanterior.
Extends from the deep part of the concha to the tympanic membrane.
External 1/3 formed by cartilage
Internal 2/3 formed by the temporal bone.
Tympanic Membrane
Connective tissue structure; covered with skin on the outside and a mucous membrane on the inside
Connected to the surrounding temporal bone by a fibrocartilaginous ring
On the inner surface, the handle of malleus attaches to the tympanic membrane, at the umbo
Vasculature of external ear
Supplied by branches of the external carotid artery:
- Posterior auricular artery
- Superficial temporal artery
- Occipital artery
- Maxillary artery (deep auricular branch) – supplies the deep aspect of the external acoustic meatus and tympanic membrane only.
Venous drainage is via veins following the arteries listed above
Sensory innervation of external ear
Greater auricular nerve (branch of the cervical plexus) – innervates the skin of the auricle
Lesser occipital nerve (branch of the cervical plexus) – innervates the skin of the auricle
Auriculotemporal nerve (branch of the mandibular nerve) – innervates the skin of the auricle and external auditory meatus.
Branches of the facial and vagus nerves – innervates the deeper aspect of the auricle and external auditory meatus
Why can some individuals complain of an involuntary cough when cleaning their ears?
due to stimulation of the auricular branch of the vagus nerve (the vagus nerve is also responsible for the cough reflex).
Lymphatic drainage of external ear
The lymphatic drainage of the external ear is to the superficial parotid, mastoid, upper deep cervical and superficial cervical nodes.
Middle Ear
Lies within the temporal bone
Extends from the tympanic membrane to the lateral wall of the inner ear.
Main function = to transmit vibrations from the tympanic membrane to the inner ear via the auditory ossicles.
Divided into two parts - Tympanic Cavity and Epitympanic Recess
Middle Ear - Tympanic Cavity
located medially to the tympanic membrane,
contains the 3 auditory ossicles
Middle Ear - Epitympanic Recess
a space superior to the tympanic cavity,
which lies next to the mastoid air cells
What are the bones of the middle ear?
- Malleus
- Incus
- Stapes
Middle Ear - Malleus
Attaches to the tympanic membrane, via the handle of malleus.
The head of the malleus lies in the epitympanic recess, where it articulates with the next auditory ossicle.
Middle Ear - Incus
Consists of a body and two limbs.
=> The body articulates with the malleus,
=> The short limb attaches to the posterior wall of the middle ear
=> The long limb articulates with the stapes
Middle Ear - Stapes
The smallest bone in the human body.
It joins the incus to the oval window of the inner ear.
It is stirrup-shaped, with a head, two limbs, and a base.
=> The head articulates with the incus, and the base joins the oval window.
Mastoid Air Cells
Located posterior to the epitympanic recess.
A collection of air-filled spaces in the mastoid process of the temporal bone.
The mastoid air cells act as a “buffer system” of air – releasing air into the tympanic cavity when the pressure is too low.
Middle Ear - Muscles
two muscles - serve a protective function
=> tensor tympani and stapedius
They contract in response to loud noise, inhibiting the vibrations of the malleus, incus and stapes, and reducing the transmission of sound to the inner ear.
Acoustic reflex
The contraction of the tensor tympani and stapedius in response to loud noise, inhibiting vibrations of the bones and thereby reducing transmission of sound to the inner ear.
Why are middle ear infections more common in children?
The auditory tube is shorter and straighter in children, so there is an easier pathway for a URTI to spread to the middle ear.
Inner Ear - contents, location, connections to middle ear
Houses the vestibulocochlear organs
Located within the petrous part of the temporal bone.
Has two openings into the middle ear – the oval window and the round window
What are the main functions of the inner ear?
- To convert mechanical signals from the middle ear into electrical signals, which can transfer information to the auditory pathway in the brain.
- To maintain balance by detecting position and motion
Bony Labyrinth of inner ear
= a series of bony cavities within the petrous part of the temporal bone.
It consists of three parts – the cochlea, vestibule and the three semi-circular canals.
Bony Labyrinth - Vestibule
Central part
Separated from the middle ear by the oval window.
Communicates anteriorly with the cochlea and posteriorly with the semi-circular canals.
Bony Labyrinth - Cochlea
Houses the cochlear duct of the membranous labyrinth
It twists upon itself around a central portion of bone (the modiolus), producing a cone shape.
Branches from the cochlear portion of the vestibulocochlear (CN VIII) nerve are found at the base of the modiolus.
The presence of the cochlear duct creates two perilymph-filled chambers above and below:
i. Scala vestibuli
ii. Scala tympani
Bony Labyrinth - Semi-circular Canals
There are 3 canals – anterior, lateral and posterior.
Contain the semi-circular ducts, which are responsible for balance (along with the utricle and saccule).
Inner Ear - Membranous Labyrinth
= a continuous system of ducts filled with endolymph.
It lies within the bony labyrinth, surrounded by perilymph.
It is composed of the cochlear duct, three semi-circular ducts, saccule and utricle.
Membranous Labyrinth - Cochlear Duct
Triangular shape
Separated from the scala vestibuli by Reissner’s membrane
Separated from the scala tympani by the basilar membrane
The basilar membrane houses the epithelial cells of hearing – the Organ of Corti.
Membranous Labyrinth - Saccule and Utricle
= Two membranous sacs located in the vestibule.
They are organs of balance – detect movement or acceleration of the head in the vertical and horizontal planes
=> The utricle receives the three semi-circular ducts.
=> The saccule receives the cochlear duct.
Endolymph drains from the saccule and utricle into the endolymphatic duct.
Membranous Labyrinth - semi-circular ducts
Located within the semi-circular canals
Upon movement of the head, the flow of endolymph within the ducts changes speed and/or direction.
Sensory receptors detect this change, and send signals to the brain, allowing for the processing of balance.
Inner Ear - innervation
Innervated by the vestibulocochlear nerve (CN VIII).
At the internal acoustic meatus it divides into the:
- Vestibular nerve – supplies the utricle, saccule and three semi-circular ducts.
- Cochlear nerve – supplies the receptors of the Organ of Corti
Bones of the neurocranium
Four singular bones centred on the midline (frontal, ethmoid, sphenoid, and occipital).
Two sets of bones occurring as bilateral pairs (temporal and parietal).
Bones of the viscerocranium (facial skeleton)
Three singular bones lying in the midline (mandible, ethmoid, and vomer)
Six paired bones occurring bilaterally (maxilla; inferior nasal concha [turbinate], zygomatic, palatine, nasal, and lacrimal bones).
Muscles of face
Occipitofrontalis
Obicularis Oculi
Obicularis Oris
Buccinator
Nose:
- Nasalis – transverse and alar parts
- Procerus
- Depressor septi nasi
Platysma
Sensory innervation of face
provided mainly by the trigeminal nerve (CN V) via the:
- The ophthalmic nerve (CN V1) – only sensory
- The maxillary nerve (CN V2) – only sensory
- The mandibular nerve (CN V3) – sensory and motor
Motor innervation of face
- Mandibular nerve (CN V3) – the muscles of mastication (masseter, temporal, medial and lateral pterygoids).
- Facial nerve (CN VII) – the muscles of facial expression.
Where does the facial nerve emerge from the cranium?
stylomastoid foramen
Superficial lymph nodes of head and neck
Receive lymph from the scalp, face and neck
- Submental
- Submandibular
- Superficial parotid/pre-auricular
- Mastoid / retroauricular
- Occipital
Deep (cervical) lymph nodes of head and neck
Receive all of the lymph from the head and neck – either directly or indirectly via the superficial lymph nodes.
They are organised into a vertical chain, located within close proximity to the IJV within the carotid sheath.
Parotid gland - location
enclosed within a tough fascial capsule – the parotid sheath
apex = posterior to the angle of the mandible base = related to the zygomatic arch
Parotid duct
The parotid duct passes horizontally from the anterior edge of the parotid gland.
At the anterior border of the masseter, it pierces the buccinator and enters the oral cavity through a small orifice opposite the second maxillary molar tooth.
Sensory innervation of the parotid sheath
greater auricular nerve (C2 and C3) provides sensory innervation to the parotid sheath and overlying skin.
Boundaries of anterior triangle of neck
- Superiorly – inferior border of the mandible (jawbone).
- Laterally – anterior border of the sternocleidomastoid.
- Medially – sagittal line down the midline of the neck.
suprahyoid muscles
located superiorly to hyoid bone:
Stylohyoid
Digastric
Mylohyoid
Geniohyoid
infrahyoid muscles
located inferiorly to hyoid bone:
Omohyoid
Sternohyoid
Thyrohyoid
Sternothyroid
Contents of carotid triangle
Common carotid artery (which bifurcates within the carotid triangle)
Carotid sinus
Internal jugular vein
Hypoglossal and vagus nerves.
Contents of submental triangle
the submental lymph nodes
=> filter lymph draining from the floor of the mouth and parts of the tongue.
Contents of submandibular triangle
- The submandibular gland (salivary), and lymph nodes.
- The facial artery and vein also pass through this area.
Boundaries of posterior triangle of neck
- Anterior – posterior border of the sternocleidomastoid.
- Posterior – anterior border of the trapezius muscle.
- Inferior – middle 1/3 of the clavicle
Contents of the posterior triangle of neck
- many muscles (including a number of vertebral muscles which are covered by the pre-vertebral fascia)
- the EJV
- the accessory nerve (CN XI)
- the cervical plexus
- the trunks of the brachial plexus
Path of the external jugular vein
Formed by the retromandibular and posterior auricular veins
Lies superficially, crosses SCM muscle to reach posterior triangle.
Within the posterior triangle, the EJV pierces the investing layer of fascia and empties into the subclavian vein.
What are the 3 main distinct features of the cervical vertebrae?
- Triangular vertebral foramen.
- Bifid spinous process – this is where the spinous process splits into two distally.
- Transverse foramina – holes in the transverse processes.
=> They give passage to the vertebral artery, vein and sympathetic nerves.
C-Spine - C1
= the atlas.
- Has no vertebral body and no spinous process.
- Has lateral masses which are connected by an anterior and posterior arch.
- Each lateral mass contains a superior articular facet (for articulation with occipital condyles), and an inferior articular facet (for articulation with C2).
- There is a transverse ligament of the atlas to secure the articulation with the dens of the axis.
C-spine - C2
= the axis.
- Has the dens/odontoid process, which extends superiorly to articulate with the anterior arch of the atlas, in doing so creating the medial atlanto-axial joint.
- The axis also contains superior articular facets, which articulate with the inferior articular facets of the atlas to form the two lateral atlanto-axial joints.
What and where is the pharynx?
a muscular tube that connects the oral and nasal cavity to the larynx and oesophagus.
It begins at the base of the skull and ends at the inferior border of the cricoid cartilage (C6).
Consists of:
- Nasopharynx
- Oropharynx
- Laryngopharynx
Nasopharynx - location, contents, function
• Located between between the base of the skull and the soft palate
• Performs a respiratory function by conditioning inspired air and propagating it to the larynx.
=> Lined with respiratory epithelium
• Contains the adenoid tonsils.
Oropharynx - location, contents, function
- Located between the soft palate and the superior border of the epiglottis
- Contains the posterior 1/3 of the tongue, the lingual tonsils, the palatine tonsils and superior pharyngeal constrictor muscle.
- Involved in the involuntary and voluntary phases of swallowing.
Laryngopharynx - location, contents
- Located between the superior border of the epiglottis and inferior border of the cricoid cartilage (C6)
- Continues inferiorly as the oesophagus
- Contains the middle and inferior pharyngeal constrictors
Waldeyer’s ring
= the ring of lymphoid tissue in the naso- and oropharynx
formed by the paired palatine tonsils, the adenoid tonsils and lingual tonsil.
Motor/sensory innervation of the pharynx
MOTOR
Most muscles are innervated by the vagus nerve (CN X).
the only exception being the stylopharyngeus (glossopharyngeal nerve).
SENSORY
Receives sensory innervation from the glossopharyngeal nerve (CN IX)
What are the two main groups of pharyngeal muscles?
CIRCULAR - contract sequentially from superior to inferior to constrict the lumen and propel the bolus of food.
LONGITUDINAL - act to shorten and widen the pharynx and elevate the larynx during swallowing
Circular pharyngeal muscles
Superior pharyngeal constrictor (oropharynx)
Middle pharyngeal constrictor (laryngopharynx)
Inferior pharyngeal constrictor (laryngopharynx)
Longitudinal pharyngeal muscles
Stylopharyngeus (styloid process to pharynx)
Palatopharyngeus (hard palate to pharynx)
Salpingopharyngeus (Eustachian tube to pharynx)
Vascular supply to the pharynx
ARTERIAL SUPPLY
via branches of the external carotid artery:
- Ascending pharyngeal artery
- Branches of the facial artery
- Branches of the lingual and maxillary arteries.
VENOUS DRAINAGE
Achieved by the pharyngeal venous plexus, which drains into the IJV.
Where is the Larynx?
- Suspended from hyoid bone
- Spans between C3 and C7
- Covered anteriorly by the infrahyoid muscles
- Covered laterally by the lobes of the thyroid gland.
Function of the larynx
Several important functions:
=> Phonation, cough reflex, protection of the lower respiratory tract.
Sections of the larynx
- Supraglottis – from the inferior surface of the epiglottis to the vestibular folds (false vocal cords).
- Glottis – contains vocal cords and 1cm below them.
- Subglottis – from inferior border of the glottis to the inferior border of the cricoid cartilage.
What epithelium is there in the larynx?
Lined by pseudostratified ciliated columnar epithelium.
An important exception to this is the true vocal cords, which are lined by a stratified squamous epithelium.
Vascular supply to the larynx
ARTERIAL SUPPLY
- Superior laryngeal artery (from the external carotid)
- Inferior laryngeal artery (from the thyrocervical trunk)
VENOUS DRAINAGE
- Superior laryngeal vein (=> IJV)
- Inferior laryngeal vein (=> left brachiocephalic vein )
Motor/Sensory innervation of larynx
via branches of the vagus nerve:
- Recurrent laryngeal nerve – provides sensory innervation to the infraglottis, and motor innervation to all the internal muscles of larynx (except the cricothyroid).
- Superior laryngeal nerve – the internal branch provides sensory innervation to the supraglottis, and the external branch provides motor innervation to the cricothyroid muscle.
Cartilages of larynx
UNPAIRED:
Thyroid
Cricoid
Epiglottis
PAIRED
Arytenoid
Corniculate
Cuneiform
What is Adam’s apple?
= laryngeal prominence of thyroid cartilage
where the two sheets of cartilage joints anteriorly
Cricoid cartilage
= a complete ring of hyaline cartilage, completely encircling the airway
Articulates with the paired arytenoid cartilages posteriorly and thyroid cartilage superiorly
Epiglottis
= a leaf-shaped plate of elastic cartilage
Marks the entrance to the larynx
During swallowing, the epiglottis flattens and moves posteriorly to close of the larynx and prevent aspiration.
What are the laryngeal folds?
- Vocal folds (= true vocal cords)
- Vestibular folds (= false vocal cords)
Vocal folds / true vocal cords
Abducted, adducted, relaxed and tensed under control of the muscles of phonation to control the pitch of the sound created.
Relatively avascular, appear white in colour
Space between the vocal folds is called the rima glottidis.
Vestibular folds / false vocal cords
Pink in colour
Act to provide protection to the larynx
Groups of muscles of the larynx
- External muscles
=> Act to elevate or depress the larynx during swallowing - Internal muscles.
=> Act to move the individual components of the larynx
=> Play a vital role in breathing and phonation.
Innervation of the intrinsic muscles of the larynx
All innervated by the inferior laryngeal nerve, which is the terminal branch of the recurrent laryngeal nerve
(except the cricothyroid – innervated by external branch of superior laryngeal nerve).
Thyroid gland - location and structure
Spans the C5-T1 vertebrae
Two lobes (left and right); connected by a central isthmus anteriorly.
Lobes are wrapped around the cricoid cartilage and superior rings of the trachea.
Located within the visceral compartment of the neck (along with the trachea, oesophagus and pharynx) which is bounded by the pre-tracheal fascia.
Thyroid gland - arterial supply
= two main arteries (and one additional one)
Superior thyroid artery
- 1st branch of the external carotid a.
Inferior thyroid artery
- Arises from the thyrocervical trunk (branch of subclavian a.)
(Thyroid ima artery)
- Only ~10% of people have this additional artery
- Arises from brachiocephalic trunk
Thyroid gland - venous drainage
Superior, middle, and inferior thyroid veins, which form a venous plexus around the thyroid gland.
Superior and middle veins drain into the IJV
Inferior vein drains into the brachiocephalic trunk.
Thyroid gland - innervation
Branches of sympathetic trunk
Thyroid gland - lymphatic drainage
To the paratracheal and deep cervical nodes.
Parathyroid Glands - location
Located on posterior aspect of thyroid gland (external to the thyroid but within the pretracheal fascia)
Most people have 4 parathyroid glands (although variation from 2-6 is common)
=> Superior – located in the middle of posterior border of each thyroid lobe.
=> Inferior – usually found near the inferior poles of the thyroid gland, but location is inconsistent (can be found as far inferiorly as superior mediastinum)
Cervical Plexus
Located in the posterior triangle of the neck, within the prevertebral layer of cervical fascia
Formed from the anterior rami of cervical spine nerves C1-C4
Muscular branches lie deep to sensory branches
Sensory branches of cervical plexus
Greater Auricular Nerve (C2 and C3) => external ear and skin over parotid gland
Transverse Cervical Nerve (C2 and C3) => anterior neck
Lesser occipital Nerve (C2) => posterosuperior scalp
Supraclavicular Nerves (C3 and C4) => skin overlying supraclavicular fossa
Stertor
= noisy breathing due to partial obstruction ABOVE the larynx (tonsils, adenoids, tongue, angioedema)
Stridor
= noisy breathing due to partial obstruction BELOW the larynx
NEEDS ENT REFERRAL.
Signs of severe airway obstruction
- Tracheal tug/recession
- Tachycardia
- Hypoxia
- Use of Accessory mm.
- Confusion
Differentials of stridor
CONGENITAL
Laryngomalacia
VC web / VC Palsy
Subglottic stenosis
ACQUIRED (acute) Laryngeal trauma Foreign body Croup Epiglottitis Allergic reaction
ACQUIRED (chronic) VC Palsy VC polyp/cyst Tumour Thyroid mass Subglottic stenosis
Laryngeal trauma - presentation and management
Stridor, neck bruising, surgical emphysema
Mx = intubation +/- tracheostomy
Foreign body in airway - presentation, Ix, Mx
Feel something “stick” in throat,
sharp pain,
cannot eat/drink/swallow saliva
Ix = lateral neck X-ray and CXR
Mx = flexiscope and removal
Management of Stridor
- Basic Hx and assess severity (cyanosis, RR, etc.)
- A-E assessment
- Secure Airway
Methods of securing airway in stridor
a. Endotracheal Tube = 1st line
b. Cricothyroidotomy
c. Tracheostomy
Cricothyroidotomy - method
Brown IV cannula through cricothyroid membrane & connect high flow O2
Incision in midline of cricothyroid membrane and insert ET tube with O2 bag
Tracheostomy - method and complications
Tube inserted between 2nd and 4th rings of cartilage
Complications = tube blockage, wound infection, pneumothorax
Indications for tracheostomy
Stridor,
Drain/prevent over-spilling of secretions,
Respiratory failure.
What is tonsillitis?
= an acute bacterial infection of the tonsils
Caused by:
- strep. pyogenes,
- staphylococci
- m. catarrhalis
Tonsilitis - symptoms
- Sore throat + odynophagia
- Pyrexia, malaise, etc.
- Lymphadenopathy
+/- pus on tonsils
Tonsilitis - Centor Score
(1 point each): C – absence of [C]ough E – tonsillar [E]xudate N – tender cervical [N]odes T - >38oC [T]emperature
If Score >3 = high chance of strep A and need ABX
Tonsilitis - complications
Peritonsillar abscess (quinsy) Deep neck space infection
Tonsilitis - management
IF UNILATERAL Sx => ENT Referral
Analgesia, fluids, soft food.
ABX – PO penicillin V (or clarithromycin if pen allergic)
Tonsillectomy if recurrent/complications
When is a tonsillectomy done?
Done if tonsilitis is recurrent/complications:
7x in 1 year 5x in each of 2 years 3x in each of 3 years 2 episodes of quinsy
Tonsillectomy - complications
1-2 weeks of pain post-op
Complications:
a. 1o post-op haemorrhage – needs surgery
b. 2o post-op haemorrhage – from infection => IV ABX
What is peritonsillar abscess / Quinsy?
= pus between the tonsil capsule and lateral pharyngeal wall
Caused by strep. pyogenes
Presentation of peritonsillar abscess / Quinsy
SYMPTOMS
- Sore throat, odynophagia, dysphagia
- Trismus
- “Hot potato voice” (muffled voice)
- Referred otalgia
SIGNS
- Usually unilateral (DDx = tumour)
- Unilateral swelling, LATERAL to tonsil.
- Deviated tonsil and uvula to opposite side.
What is trismus?
= restriction of the range of motion of the jaws
Management of peritonsillar abscess / quinsy
ENT referral
- Needle aspiration or incision & drainage
- IV ABX +/- steroids for swelling
- Analgesia, fluids, soft food.
What is infectious mononucleosis?
“glandular fever”
= EBV infection affecting LNs, tonsils and liver.
Infectious mononucleosis - symptoms
- Prodromal illness: fever, malaise
- Sore throat, dysphagia
- Cervical lymphadenopathy
- Abdo pain
- Hepatosplenomegaly (50%)
Infectious mononucleosis - investigations
FBC
LFT
Blood film
Monospot test
Infectious mononucleosis - management
Self-resolves in 2-4 weeks
Supportive Tx – analgesia, fluids
ABX ONLY if tonsilitis (but NOT amoxicillin)
Monitor LFTs
Advice
- Avoid intimate contact
- No contact sport => splenic rupture
- No alcohol => liver damage
What ABX should be avoided in a patient with glandular fever?
ABX are not routinely given as EBV is a virus
=> should only be given if there is evidence of bacterial tonsillitis
Avoid ampicillin and amoxicillin => rash
Pharyngitis - acute/chronic
- Acute:
Sudden-onset sore throat
Usually viral (rhinovirus, coronavirus, influenza, HSV, VZV)
May be bacterial (group A strep) - Chronic:
Long-standing sore throat
Specific (syphilis, TB, toxoplasmosis)
Non-specific (GORD, tobacco, chronic sinusitis).
Pharyngitis - management
fluids, analgesia,
gargle warm salty water.
What causes epiglottis?
H. influenzae
Epiglottitis - Sx
PHARYNX NORMAL O/E
Very sore throat + high fever
Dysphagia, drooling
Stridor
Epiglottitis - Mx
Immediate admission
Airway protection – intubation/tracheostomy
IV ABX and steroids
DO NOT TRY TO EXAMINE THROAT/MOUTH
How do deep neck space infections occur?
Due to spread of throat infections (pus/abscess) via para or retro-pharyngeal space.
Deep neck space infection - symptoms
Sore throat + odynophagia Dysphagia, drooling Fever Trismus Reduced neck movements “Hot potato voice”
Deep neck space infection - signs
Poor Head Movement
Neck mass
Septic
Deep neck space infection - investigations
CT – shows deep neck spaces
USS – shows abscesses
OPG – dental x-ray
Deep neck space infection - management
Emergency A - E Assessment
Airway protection
IV ABX
Surgical drainage
Deep neck space infection - complications
- Airway compromise
- Empyema
- Pneumonia
- Mediastinitis (50% mortality)
- Carotid artery erosion
Why can you get referred otalgia with a sore throat?
Ear has shared nerve supply with oro/laryngopharynx
Globus Pharyngeus
Painless sensation of “sticking” / lump in throat even when not swallowing
Causes – LP reflux, stress/anxiety, minor inflammation
Globus Pharyngeus - Mx
Must exclude pathologies like cancer
Mx –
Treat any underlying cause,
Avoid caffeine/smoking,
Sip icy sparkling water
Definition of sleep apnoea
30 or more episodes of cessation of breathing, each lasting at least 10 seconds, over a period of 7 hours of sleep
Sleep Apnoea Index
measures the number of episodes to determine the severity.
Causes of sleep apnoea
- OBSTRUCTIVE – due to upper airway collapse (decreased O2 causes reflex of waking slightly and taking deep breath).
- CENTRAL – fault with central respiratory drive (e.g. cerebral palsy, cognitive defect).
Risk factors for sleep apnoea
Old age Male Down’s Syndrome Sedatives OBESITY Smoking/alcohol Craniofacial abnormalities Neuromuscular Disease
Sleep apnoea - Sx
- Snoring/choking in sleep and witnessed apnoeas
- Restless/non-refreshing sleep
- Daytime sleepiness and decreased concentration
- Irritability and decreased libido
Kids – poor school performance
Babies – poor feeding as blocked nasal breathing.
Sleep apnoea - Ix
- History
- Examination – upper airway endoscopy
- Sleep Studies
- Measure pulse, ECG, O2 overnight
- Audio/video recording of sleep
- Polysomnography = gold-standard version
Sleep apnoea - Mx
- Lifestyle – weight loss, smoking/alcohol reduction
- Conservative – nasal splints/tape & jaw advancers
- Medical – CPAP via mask
=> Noisy and uncomfortable - Surgery – adenotonsillectomy, polypectomy, uvulopalatopharyngoplasty
Management of snoring
- Lifestyle – weight loss, smoking/alcohol reduction
2. Conservative – nasal splints/tape & jaw advancers
Major salivary glands
= 3 paired glands
- Parotid – serous
- Submandibular – mixed
- Sublingual – mucous
Why is the parotid gland painful if swollen?
it has a fibrous capsule which is painful if stretched
What is xerostomia?
What are some causes?
= dry mouth
Causes: • Depression/anxiety • Drugs – antimuscarinics/sympathomimetics • Radiotherapy to head/neck • Sjogren’s Syndrome
Sjogren’s Syndrome
= an autoimmune disorder of decreased saliva/mucous.
What is there increased risk of in people with Sjogren’s Syndrome?
increased risk of non-Hodgkin’s lymphoma.
Sjogren’s Syndrome - symptoms
DRY MOUTH + EYES (+ vagina)
Glossitis
+/- Parotid gland enlargement
Sjogren’s Syndrome - investigations
HLA, B8, DR2
Specific antigens – SSA, SSB
Labial biopsy = diagnostic
Sjogren’s Syndrome - management
Steroids
Artificial saliva/tears
(Parotidectomy if recurrent parotitis)
What is Sialadenitis?
What are the causes and risk factors?
= inflammation of salivary gland
Causes – infection, stones, malignancy
RFs – dehydration, poor oral hygiene, elderly.
Sialadenitis - Sx
Swollen, tender gland
+/- pus from duct
+/- fever and systemic Sx
Sialadenitis - Mx
Hydration & analgesia
High dose ABX +/- pus drainage
(Gland removal)
Parotitis
= inflammation of parotid gland
Causes:
- Infection (measles, mumps, HIV, TB, candidiasis)
- Sarcoid
- Drugs
Sialolithiasis
= Calculi in salivary glands
scialectasis
Dilation of salivary ducts
Sialolithiasis - Sx
Post-prandial swelling & pain
+/- palpable calculi in gland
Sialolithiasis - Ix
CT/X-ray
Sialogram
Sialolithiasis - Mx
Hydration & analgesia
Duct massage
Surgical stone removal (if necessary)
Non-salivary causes of facial swelling
Masseter hypertrophy Lymphadenopathy Dental infection/abscess Mastoiditis Cysts
Salivary causes of facial swelling
Sialadenitis
Sialolithiasis
Sjogren’s Syndrome
Neoplasm – benign/malignant
Process of normal voice production
= due to vocal cord vibration
Oscillation of VCs causes sound wave that resonates within vocal tract
Vowel production = vibration of OPEN VCs and mouth/tongue position
Consonant production = force air through narrowed VCs
Vocal cords - fundamental frequency (F0)
= PITCH (Hz)
Determined by density of vocal fold
Density altered by muscle contraction/relaxation
Higher density = lower frequency (e.g. males, Reinke oedema)
Vocal cords - Intensity/Pressure Level
= LOUDNESS (dB)
Determined by subglottic pressure
Pressure depends on degree of VC closure/length of closure
Lower pressure = weaker voice (e.g. recurrent laryngeal nerve palsy).
Dysphonia
= any voice impairment
Dysarthria
= reduced voice muscle coordination
Dysphasia
= receptive or comprehensive impairment
Structural/neoplastic causes of voice disorders
Malignant = Laryngeal Carcinoma
Benign – Polyp
Benign – Reinke’s Oedema
Laryngeal Carcinoma - causes
Causes = smoking, genetics, alcohol excess
Laryngeal Carcinoma - Presentation
Sx
= progressive hoarseness; +/- stridor, dysphagia, referred otalgia, cervical lymphadenopathy.
Signs
= irregular mass; leukoplakia/eythroplakia
Laryngeal Carcinoma - Mx
Mx = radiotherapy; surgical excision.
Vocal cord Polyp - cause and Sx
Causes = shouting
Sx = Husky (deeper) voice
Signs = smooth, grey swelling (usually UNILATERAL)
Vocal cord Polyp - Mx
= surgical excision; +/- medical Tx; +/- voice therapy
Reinke’s Oedema
= a collection of fluid in Reinke’s space
Causes = smoking, voice overuse, LP reflux
Reinke’s Oedema - Presentation
Sx = deep, gravelly voice
Signs = grey/red swelling (usually BILATERAL)
Reinke’s Oedema - Mx
Stop smoking/treat reflux;
Surgical reduction;
Voice therapy.
Reinke’s space
= a potential space between the vocal ligament and the overlying mucosa
Inflammatory causes of voice disorders
Laryngitis
Laryngopharyngeal Reflux
Laryngitis
= inflammation of the larynx
Cause = Bacterial / fungal / HPV
Sx:
• Hoarse/croaky/voice loss;
• Sore throat, odynophagia;
• URTI symptoms
Signs = erythematous, sloughy VCs
Laryngitis - Mx
Self-limiting
Voice rest,
Supportive - analgesia, fluids;
Steam inhalations
Laryngopharyngeal Reflux - Sx
Sx • Strained voice + decreased pitch range • Dysphagia & globus sensation • Cough and constant throat clearing • May NOT have any heartburn
Signs
• General erythema & oedema
Laryngopharyngeal Reflux - Mx
- Gaviscon & PPI
- Vocal hygiene
- Dietary advice – avoid fatty/fried food & caffeine
Neuromuscular causes of voice disorders
= recurrent laryngeal nerve palsy.
Muscle tension imbalance causes of voice disorders
= excessive tension of laryngeal muscles.
Recurrent laryngeal nerve palsy - causes
- Surgical trauma (e.g. thyroidectomy)
- Malignancy
- Idiopathic
- Neurological disorders
Recurrent laryngeal nerve palsy - Sx
- Weak, higher pitched voice
- Tires with prolonged use
- Choking on fluids
- Weak “bovine” cough
- Diplophonia (two tone voice)
Recurrent laryngeal nerve palsy - Ix
- Examination – listen to voice, head & neck exam, CNS exam
- CXR – to exclude mediastinal mass/pancoast tumour
- CT (skull base to mid-thorax) – check for lesions along nerve
- Barium swallow – if oesophageal lesion suspected
Recurrent laryngeal nerve palsy - Mx
Can just wait for spontaneous recovery
Voice therapy
VC medialisation – inject collagen/surgery
Excessive tension of laryngeal muscles - causes
- Stress/anxiety
- Following URTI
- Long-term ineffective voice use
- Compensation for underlying VC problem (e.g. cyst)
Excessive tension of laryngeal muscles - Sx
- Husky voice – worse with use
- Deeper or higher pitched than expected
- Unstable voice
- Sore throat
Excessive tension of laryngeal muscles - Mx
- Vocal hygiene – steam inhalations
- Lifestyle advice – avoid irritants (smoke, caffeine, spicy food)
- Voice therapy
Aims of voice therapy
Aims to restore voice, eliminate benign nodules and avoid further vocal problems.
Indications for voice therapy
LP reflux
Nodules, cysts, polyps
Muscle tension imbalance
Psychological voice problems
Components of voice therapy
Semi-occluded airflow exercises – reduce muscle straining
Efficient respiration
Voice resonance and projection
Advice on vocal hygiene – steam inhalations, avoid irritants, etc.
Types of head and neck malignancies
Aerodigestive tract (nasal/oral cavity, pharynx, larynx) = SCCs
Glands
Lymph nodes – lymphomas, secondary tumours
Thyroid = papillary, follicular, medullary, anaplastic
Skin = SCCs, BCCs, melanomas
Risk factors for head and neck cancers
Tobacco/alcohol (including chewing tobacco)
HPV 16 & 18
Occupation – woodwork, textiles, nickel
Leukoplakia
=> 1/3 become cancerous
Eythroplakia
=> ½ become cancerous
Leukoplakia
Grey/White patches in the mouth
Don’t come off when scraped
=> 1/3 become cancerous
Erythroplakia
Red patches in the mouth
Bleed easily if scraped
=> ½ become cancerous
2WW referral for ?head & neck malignancy
- Odynophagia/Dysphagia >3 weeks
- Hoarseness >3 weeks
- Persistent, unexplained neck lump >3 weeks
- Persistent mouth ulceration >3 weeks
- Leukoplakia/Eythroplakia
Signs of head & neck malignancy
- Persistent, unexplained neck lump >3 weeks *
- Persistent mouth ulceration >3 weeks *
- Leukoplakia/Eythroplakia *
- Bleeding in mouth/throat or haemoptysis
- General B symptoms – weight loss, night sweats, fever
Symptoms of head & neck malignancy
OFTEN UNILATERAL
- Odynophagia/Dysphagia >3 weeks *
- Hoarseness >3 weeks *
- Trismus
- Referred otalgia
- Dyspnoea/Stridor
Head & neck malignancy - investigations
History and Head/neck exam + flexible nasal endoscopy
Bloods – FBC, U&E, LFT, TFT, glucose, albumin
Assess nutritional status
Fine needle aspiration cytology (FNAC)
BIOPSY = DIAGNOSTIC
=> But avoid if possible as need a GA
CT/MRI of neck (for TNM staging)
CXR/CT chest (for TNM staging)
Glottic tumour
= most common head and neck cancer, and good prognosis
Hoarseness first, then odynophagia/stridor
Often no lymphadenopathy
Supra/subglottic tumour
= late presentation and poor prognosis
Odynophagia/stridor first, then hoarseness
Referred otalgia
Head & Neck cancer - management
Depends on TNM stage & age/health of patient.
MDT involvement.
- Surgery
- Neck dissection to remove LNs +/- SCM, IJV, SAN
- Laryngectomy - Radiotherapy/chemotherapy
- Transoral Laser Resection
What is a laryngectomy?
= “end tracheostomy”
Remove the larynx and bring airway to surface
Separated from the nose/mouth/oesophagus
Unlike tracheostomy where still have airway above tube
Laryngectomy - follow up
- Swallowing difficulties (SALT)
- Voice restoration (SALT)
Thyroid cancer - Sx
Neck lump, moves when swallow/tongue out
Hoarse voice / breathing difficulties
Thyroid cancer - Mx
Thyroidectomy
Neck dissection
+/- radioactive iodine
Causes of dysphagia
Structural changes – e.g. post-op
Obstructive – e.g. malignancy, pharyngeal pouch
Neurological – e.g. CVA/stroke
Muscular
Respiratory
Gastro-oesophageal – e.g. LP reflux/GORD
Signs/symptoms of dysphagia
Food/fluid pockets in mouth and/or “sticks” in throat
Aspiration => coughing, wheezing, recurrent chest infections
Dehydration
Weight loss
What should be done for a patient with unexplained dysphagia >3 weeks
2WW referral
Dysphagia - Ix
Video-fluoroscopy
Barium swallow
Endoscopy
Dysphagia - Mx
MDT management
Swallowing exercises Oral care – steam inhalations, artificial saliva Posture and positioning Adaptive equipment – cups/straws/ spoons Modified diet – pureed, thickeners
What is the most common cause of a neck lump?
Reactive Lymphadenopathy (caused by infection)
Head/Neck lump differentials - reactive lymphadenopathy
Enlarged LNs
Infective cause
Will have Hx of infective Sx
Head/Neck lump differentials - lymphadenopathy due to neoplasm
Lymphoma
Rubbery, painless lump
B-cell Sx
Head/Neck lump differentials - Thyroglossal cyst
Moves up with tongue protrusion
Common in <20 yo
Congenital neck lumps
Thyroglossal cyst
Cystic hygroma
Branchial cyst
Head/Neck lump differentials - Branchial cyst
Smooth, mobile, oval
Most commonly located along the anterior border and the upper 1/3 of SCM
Present in early adulthood
Head/Neck lump differentials - Cystic hygroma
Lymphatic lesion – soft, fluctuant, transilluminable
90% present <2 yo
Head/Neck lump differentials - neoplasm of salivary glands
Features depend on type
CN VII palsy if malignant
Head/Neck lump differentials - infection of salivary glands
Swollen & painful
Pain related to eating
Xerostomia & dry eyes
Head/Neck lump differentials - stone of salivary glands
Swollen & painful
Pain related to eating
Xerostomia & dry eyes
Head/Neck lump differentials - carotid aneurysm
Pulsatile, lateral mass
+/- dysphagia, hoarseness
Head/Neck lump differentials - Sebaceous cyst/lipoma
Soft, mobile
+/- pain
Excess wax - management
Wax softening drops – e.g. sodium bicarbonate/olive oil
Ear syringing
Outer ear foreign bodies - management
Wax hook/forceps/suction to remove FB
GA if uncooperative/deep in canal
What are contraindications to ear syringing?
grommets, perforation, otitis externa
Pinna haematoma
Blood collects between cartilage and perichondrium.
Caused by Trauma
Complications = Avascular necrosis & infection (= CAULIFLOWER EAR)
Management = immediate drainage.
What types of outer ear neoplasm are there?
Benign – papilloma or adenoma
Malignant – BCC or SCC
Otitis externa - signs and symptoms
= inflammation of the ear canal
Symptoms:
- Pain & swelling
- Itching
- Hearing loss
- Discharge (from middle ear through perforated TM)
Signs:
- Tender pinna/tragus
- Swollen/red canal
- TM not visible
Causes of otitis externa
Skin conditions (e.g. eczema, psoriasis)
Generalised skin infections (e.g. impetigo)
Localised skin infections (e.g. pseudomonas, S. aureus, candida)
Trauma/foreign bodies
Water exposure
Otitis externa - Mx
Mild/simple (TM visible)
• Analgesia and keep dry
• Topical ABX +/- steroid
Severe/complex (TM not visible/Tx resistant): => ENT referral • Microsuction • Pope wick & drops • PO ABX if pinna cellulitis
Differentials/complications of otitis externa
Necrotising OE Mastoiditis Pinna perichondritis Pinna cellulitis Middle ear infection (discharge but no canal swelling)
What is Necrotising OE?
= complication of Acute otitis externa (AOE) where the infection spreads to skull base.
Caused by pseudomonas aeruginosa.
Necrotising OE - signs
Severe pain – worse at night and when chewing
Nerve palsies – CN VII, IX, X, XI
Canal granulations
Necrotising OE - Mx
ENT referral
High dose IV ABX
CT/MRI
Acute otitis media with effusion (OME)
= “Glue Ear”
Symptoms:
- Middle ear fluid with no Sx of Infection (painless)
- Conductive hearing loss of 20-30 dB
- Speech delay/school problems
Acute otitis media with effusion - RFs
- Child
- Smoking
- Large adenoids
- Nasal abnormalities
Acute otitis media with effusion - cause
Cause = Eustachian tube dysfunction
Due to:
Nasal/sinus infection
Allergic response
Ciliary dysfunction
Acute otitis media with effusion - Mx
50% spontaneous resolution
If >3 months:
- Grommets – ventilate middle ear (pop out in 18 months)
- Hearing aids
Acute Suppurative Otitis Media (ASOM)
= acute infection of the middle ear
Causes – H. influenza (most common bacterial cause), S. pneumoniae, M. catarrhalis, RSV/rhinovirus
Acute Suppurative Otitis Media - signs and symptoms
Symptoms:
- PAIN! => crying/screaming child
- Fever / systemic upset
- Conductive hearing loss
- Otorrhoea (pus +/- blood) => if TM perforated, this relieves pain
Signs:
- Bulging TM
- TM perforation & pus/blood
Acute Suppurative Otitis Media - management
by GP:
- Analgesia & wait for resolution in 3-7 days
2. PO amoxicillin +/- steroid ear drops ONLY if: • <6 months old • <2 years with bilateral Sx • Risk of complications • Systemically very unwell
Acute Suppurative Otitis Media - complications
- Residual perforation/effusion (chronic SOM)
- Ossicle necrosis
- Tympanosclerosis
- Intracranial sepsis/meningitis
- Facial Palsy
- Labyrinthitis
- Mastoiditis
Mastoiditis - Sx and Mx
Otalgia, hearing loss, malaise/pyrexia, post-auricular swelling, pinna down & forwards.
Mx = ABX +/- surgery (ENT referral)
What is Chronic Suppurative Otitis Media?
Recurrent ASOM (>6 weeks) leading to damage of the TM.
Chronic Suppurative Otitis Media - Sx
Repeated ottorhoea
CHL – 10-20 dB or more
Chronic Suppurative Otitis Media - Mx
= ENT referral to assess possible complications:
Regular aural toilet
ABX + steroid ear drops
What is cholesteatoma?
= accumulation of keratinising squamous epithelium attracting anaerobic bacteria (pseudomonas aeruginosa).
Cholesteatoma - Sx and signs
FOUL SMELLING OTORRHOEA
Attic retraction & squamous debris
Conductive hearing loss
Cholesteatoma - Ix
CT/MRI
Cholesteatoma - Mx
ENT referral
Surgical removal of sac
Mastoidectomy if advanced disease
Cholesteatoma - complications
= due to erosion of bone & nearby structures:
- Facial nerve palsy
- Vertigo
- Intracranial sepsis
- Conductive HL
(FOUL OTORRHOEA + FN PALSY NEEDS ENT REFERRAL)
Tympanic Membrane perforation - causes
AOM Foreign bodies Head injury – temporal bone fracture Barotrauma Sudden increase in air pressure – e.g. loud noise/slap
Temporal bone fracture
Needs CT
20% transverse => sensorineural HL
80% longitudinal => conductive HL
Complications – TM perforation, CSF leak, bleed, FN palsy
Tympanic Membrane perforation - Sx
Conductive HL (10-20 dB) \+/- pain, tinnitus, vertigo
Tympanic Membrane perforation - Mx
Heals in 6 weeks
=> Keep dry & wait
GP follow up in 6 weeks
=> If not healed, then ENT referral
What is otosclerosis?
A familial condition where spongey bone forms around oval window, causing fusion with stapes.
Otosclerosis - Sx
Progressive, bilateral conductive HL
+/- tinnitus
Otosclerosis - Mx
Hearing aid
Stapedectomy
Middle ear neoplasms
- SCCs = malignant
- Bloody otorrhoea & deep pain
- May cause FN palsy - Glomus tumours (paraganglionic cells) = slow-growing and benign:
- Pulsatile tinnitus & CHL
- Pulsatile red mass behind eardrum
- May cause FN palsy or CN IX/XII paralysis
Process of hearing
Sound waves vibrate tympanic membrane => transmits to ossicles
Ossicles amplify & transmit to oval window
Pressure waves through perilymph vibrate tectorial membrane
Hair cells are moved against organ of corti and stimulate cochlear nerve
Signals carried to cortex
What is tinnitus?
= the perception of noise with no external stimuli
Due to incorrect information reaching the brain or incorrect processing in the brain
Causes of subjective / intrinsic tinnitus
= only heard by the patient
Idiopathic Drugs Trauma Presbycusis Labyrinthitis Meniere’s Vestibular schwannoma Otosclerosis
Causes of objective/extrinsic tinnitus
= heard by others as well
Palatal myoclonus
Insect in EAM
Vascular
Vascular tinnitus
= PULSATILE
AVM / glomus jugular tumour
Needs CT/MRI
Tinnitus - Mx
NO CURE => control symptoms
- Explain
- Incorrect information reaching the brain OR
- Incorrect processing in the brain - Masking:
- Radio/TV in background
- “Tinnitus maskers” – play noise into other ear - Counselling:
- CBT, mindfulness
- Tinnitus therapy – techniques to avoid stress response
- Support groups - Heading aids – if associated with SNHL
Unilateral SNHL - causes
Acoustic neuroma Trauma Vascular insult Post-labyrinthitis Otosclerosis Congenital
Bilateral SNHL - causes
Presbycusis Noise induced Metabolic Otosclerosis Congenital
Sudden onset SNHL - causes and Mx
Emergency => ENT Referral
Causes: • Meniere’s • Viral infection • Ototoxic drugs • Temporal bone fracture • Tumour (exclude acoustic neuroma with CT/MRI)
Management:
• ENT Referral
• PO Steroids ASAP! (prednisolone)
When is the prognosis of SNHL worse?
Prognosis = worse if there is also severe vertigo
Acoustic Neuroma - Sx
Tumour affects the IAM (containing CN VII and CN VIII) and if big then also the base of skull
Sx:
- Vertigo = Progressive and constant
- Facial palsies
- Headache
- Ataxia
- SNHL, Tinnitus
If tumour is large – can get trigeminal paraesthesia
Acoustic Neuroma - Ix
Must investigate for this with all unilateral SNHL
- Pure tone audiometry
- CT/MRI
Acoustic Neuroma - Mx
5% regress and 80% won’t grow – “watch and wait”
- Symptom management
~15% will grow
- Radiotherapy to prevent further growth
- Surgical excision (might end up with dead ear/no vestibular function/ facial nerve damage)
Noise-induced hearing loss - Cause and features
Caused by chronic loud noise exposure (initially reversible, but eventually permanent)
Features:
• SYMMETRICAL SNHL and tinnitus
• Dip at 4kHx on audiogram
Noise-induced hearing loss - Management
Prevention is key
Hearing aid
What is non-organic hearing loss?
= feigned loss of hearing to get compensation.
What is presbycusis?
= SNHL due to aging (>50 years), due to loss of outer hair cells of cochlea.
Presbycusis - features
Bilateral high frequency SNHL +/- tinnitus
Worse if background noise
Presbycusis - Ix
Hx and otoscopy
PTA / tympanogram
Presbycusis - Mx
Reassure – stress that low/mid frequency hearing is good, and decline is gradual
Hearing aid
Hearing tactics
What are “hearing tactics”
Facing speaker,
Decrease background noise,
Be open; tell others you have difficulty hearing.
Peripheral causes of vertigo
= ears, eyes, somatosensors
Labyrinthitis / Vestibular neuronitis Vestibular Migraine BPPV Meniere’s Ototoxic drugs
Non-vertigo causes of dizziness
Postural hypotension / vasovagal
Arrhythmias
Presbystasis (age-related dysfunction of the vestibular system)
What is labyrinthitis?
What are the symptoms?
Vertigo caused by inflammation of the VESTIBULOCOCHLEAR SYSTEM
Caused by URTI/AOM
Symptoms:
- Persistent vertigo (sudden onset, lasts days to weeks)
- N&V
- Nystagmus
- +/- SNHL
Labyrinthitis - Ix and Mx
Ix:
- ENT exam
- Pure Tone Audiometry
Mx:
= SUPPORTIVE
=> (Vestibular sedatives = SHORT TERM ONLY), Antiemetics, Bed rest
=> Vestibular rehabilitation – take away all vestibular sedatives so the system can recalibrate.
What is vestibular neuronitis?
Inflammation of VESTIBULAR NERVE, caused by viral infection.
Symptoms:
- Persistent vertigo (sudden onset, lasts days to weeks)
- N&V
- Nystagmus
- No ear Sx
Vestibular neuronitis - Ix and Mx
Investigations:
- ENT exam
- PTA
Management = supportive:
- (Vestibular sedatives), Antiemetics, Bed rest
- Vestibular rehabilitation – take away all vestibular sedatives so the system can recalibrate.
What is benign paroxysmal positional vertigo (BPPV)?
Vertigo caused by displaced semi-circular calculi
Occur either spontaneously or caused by head injury.
Vertigo is sudden and episodic (if head moved)
Lasts seconds – minutes
Symptoms:
- Positional vertigo
- Rotational Nystagmus
- NO EAR Sx
- +/- N&V
BPPV - Ix and Mx
Investigations:
- ENT Exam
- PTA
- Dix-Hallpike Manoeuvre
Management:
- Eply Manouvre
- Exercises to do at home
- Reassure – resolves in 12-18 months
Dix-Hallpike Manoeuvre
- Performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right.
- After waiting approximately 20-30 seconds, the patient is returned to the sitting position.
- The procedure is then repeated on the left side.
- If the test is positive, the patient will complain of VERTIGO and you should be able to directly observe NYSTAGMUS
What is Meniere’s Disease?
What are the key symptoms?
Occurs due to excess endolymph, cause is unknown.
Sudden onset and recurrent
Lasts 30-40 mins
Triad of Symptoms (occurring at the same time as vertigo): 1. Vertigo 2. Tinnitus 3. Low frequency SNHL (+/- aural fullness, +/- N&V)
Meniere’s Disease - Ix
Investigations:
- ENT exam
- PTA
- Romberg Test +ve (during attacks)
- CT/MRI to r/o neuroma
What is required for all facial palsies?
All facial palsies need a thorough ENT & neuro examination.
Facial palsy with sparing of frontalis
= UMN problem
Entire facial palsy
= LMN problem
Facial Palsy - Ix
Hx, ENT exam, neuro exam
PTA
Electroneuronography (= electrical stimulation of FN)
MRI/CT – if suspicious case
Facial Palsy Mx - eye care
Artificial tears,
Eye patch at night
Bell’s Palsy
Most common facial palsy.
Caused by viral infection of FN
Symptoms:
- Sudden onset (hours)
- Ipsilateral facial palsy (incl. frontalis)
- +/- pain
- No ear/CNS pathology
What conditions cause an increased risk for Bell’s palsy?
Increased risk in diabetes and pregnancy
Bell’s palsy - Mx
80% fully recover in 2 months
Mx:
- High dose PO steroids
- Eye care + analgesia
Ramsay Hunt Syndrome
Caused by HSV infection of facial nerve.
Symptoms:
- Ipsilateral facial palsy (incl. frontalis)
- Ear pain
- Vesicular rash in/on ear
- +/- SNHL, vertigo, tinnitus
Ramsay Hunt Syndrome - Mx
Palsy = irreversible
PO Acyclovir +/- corticosteroids
(unless systemically unwell, then IV acyclovir)
Eye care + analgesia
Causes of facial palsy in children
Congenital
Forceps delivery
Chickenpox
Acute OM
Red flags of facial palsy
Associated ear infection / foul otorrhoea => cholesteatoma
Progressive palsy / parotid mass => neoplasm
Associated neuro symptoms => CVA
Nasal Polyps
= grey/white, soft & mobile pedunculated swelling in nose/sinuses
Symptoms:
- Nasal obstruction
- Anosmia
- Rhinorrhoea
What should be considered with unilateral or bleeding nasal polyps?
RED FLAG => needs ENT referral
Nasal Polyps - associations
Cystic fibrosis
Infective sinusitis
Samter’s triad – polyp + asthma + aspirin sensitivity
Nasal Polyps - Ix
Anterior rhinoscopy – biopsy if suspicious
Nasal Polyps - Mx
Medical – antihistamines, steroid drops/spray, decongestants
Surgical – polypectomy (if significant blockage/red flag features)
Nasopharyngeal Carcinoma - RFs and Sx
= SCC
RFs – southern Chinese origin, EBV
Symptoms:
- Cervical lymphadenopathy
- Unilateral otalgia
- Unilateral OME
- Nasal obstruction
- CN palsies
Nasopharyngeal Carcinoma - Mx
CT & MRI
Radiotherapy
Surgery
What can tenderness on palpation of tragus / pinna indicate?
often tender in otitis externa
Things to cover in an ear history of presenting complaint
Hearing loss – when, progression, side
Otalgia / Pain – side, nature of pain
Otorrhoea / Discharge – nature (e.g. foul smelling, blood, CSF), side, duration
Tinnitus – pulsatile or not, severity, sleep, side
Vertigo / Dizziness – what they mean, duration, associated Sx
Facial Nerve Sx
Potential presenting nose complaints
What are red flags?
- Blockage
- Discharge
- Change in smell
- Facial Pain
- Bleeding
Red flags – numb face, neck lump, unilateral Sx, proptosis, diplopia, eye displacement.
How is an examination of the nose performed?
Inspection of outer nose
=> Front, side, top, bottom
Palpation
Anterior rhinoscopy
=> Use finger to lift up tip of nose
Nasal airway patency
=> Use a metal speculum to occlude one nostril gently from underneath.
How is an examination of the oral cavity performed?
General Inspection => Swelling on face Inspection of mouth - Lips - Gums and Teeth - Tongue – dorsum, sides, underneath - Buccal mucosa - Parotid duct
Inspect palate and uvula
- Use tongue depressor to gently depress the tongue
- Candidiasis/papilloma/ulceration
- Deviation of uvula
Inspect tonsils, pharyngeal arches
- Use tongue depressor to gently depress the tongue
Inspect floor of mouth:
- Assess for abnormalities of submandibular gland duct
- Assess for ulceration
Palpation:
- Palpate any identified lumps
- Palpate lateral walls for parotid gland and duct
- Palpate floor for submandibular gland and duct
How is an examination of the neck performed?
General inspection
Inspection:
- Lumps, Asymmetry, Scars, Skin changes
- Distended neck veins
Palpate:
- Lumps
- Trachea
- Carotid pulse (one side at a time)
Palpate Lymph Nodes systematically (anterior and posterior triangle)
If a neck lump is found, what should be done.
Inspection -
- ask the patient to swallow (+/- sip of water).
- Any lump attached to the pre-tracheal fascia will move upwards on swallowing – i.e. a thyroid lump or thyroglossal cyst
Palpation
=> Ix = USS
What are some ototoxic drugs?
Aminoglycosides (e.g. Gentamicin),
Furosemide,
Aspirin
A number of cytotoxic agents
Causes of epistaxis
Idiopathic or Nose-picking = most common
Trauma
Infection
Tumours
Features of posterior epistaxis
- Profuse
- Bilateral
- Failed anterior packing
Epistaxis - predisposing factors
- HTN
- Anticoagulants, NSAIDs, aspirin
- Coagulopathies
- Hereditary Haemorrhagic Telangiectasia
What should be considered with unilateral Epistaxis in adolescent boys?
consider juvenile angiofibroma (a nasopharyngeal tumour)
=> Needs CT and excision
Epistaxis - Mx
- First aid
- Resuscitation (if severe)
- Cauterisation (if anterior bleed)
=> Using silver nitrate or bipolar diathermy - Packing (anterior = 1st line, posterior if anterior fails)
- Sphenopalatine artery ligation
- Surgery – if cannot stop bleed
Epistaxis first aid
- Lean forward, pinch fleshy part – for 10 mins
- Apply ice to bridge of nose
- Avoid swallowing blood
Epistaxis - resuscitation
- Estimate blood loss, measure pulse/BP
- FBC, coag screen, G&S
- IV fluids if needed
Epistaxis - packing
Done if cannot visualise or cauterise bleed
NEED PROPHYLACTIC ABX
- First line – anterior packing
- Second line – posterior packing
Management of nose fracture
- Manage Epistaxis / acute problems
- MUST Rule out serious complications
- Clinic 5-7 days later
=> Assess bony nose injury once swelling has subsided - Manipulation of bony deformity (within 14 days of injury)
Nose fracture - serious complications to rule out
- Zygomatic/facial fracture – diplopia, facial numbness, trismus
- Head injury – LOC, N&V, amnesia, pupils
- CSF leak – unilateral, clear nasal discharge
- Obstructed airways
- Chest/abdo injuries
- Septal haematoma
what is the timeframe for manipulating the bony deformity of a nose fracture?
Must be done within 14 days of injury
Septal haematoma
= a bleed between the septum and perichondrium
Appears as bilateral red/purple bulge
Septal haematoma - complications
- Blocks nose and gets infected
* Necrosis and septal perforation
Septal haematoma - management
Immediate ENT referral
Surgical drainage & IV ABX
Septal perforation - causes
Usually Trauma/surgery
Also:
• Avascular necrosis (septal haematoma/cocaine use)
• Granulomatous infection (syphilis, TB, Wegener’s)
Septal perforation - symptoms
- Sense of nasal obstruction
- Whistling
- Crusting / bleeding
Septal perforation - management
- Douching and Vaseline
* Surgery
When should a FB in the nose be considered?
How is this managed?
Suspect in kids if unilateral offensive discharge (+/- epistaxis)
Management = removal with forceps/Johnson probe / suction
Acute rhinosinusitis
< 4 weeks
Subacute rhinosinusitis
4 - 12 weeks
Chronic rhinosinusitis
> 12 weeks
What is rhinosinusitis?
= inflammation of the nasal and sinus mucosa, causing URTI Sx for >10 days.
Risk factors for rhinosinusitis
- Polyps
- Deviated septum
- Dental infection
- Smoking
Rhinosinusitis - pathophysiology
Viral URTI causes hyperaemia & oedema of mucosa and increased secretions
Stagnant secretions become infected by bacteria
=> H. influenzae, Strep. pneumoniae
Rhinosinusitis - Sx
Mucopurulent rhinorrhoea
Nasal obstruction/congestion
Reduced smell/taste
Facial pain – over infected sinus, worse when bending forwards
Malaise/pyrexia
Rhinosinusitis - Ix
Anterior rhinoscopy – inflamed mucosa
Flexible Nasal Endoscopy – mucous in oropharynx
Rhinosinusitis - Mx
Conservative:
=> Simple analgesia, Steam inhalations, Nasal decongestants
Medical:
• Steroid nasal spray (e.g. beconase)
• Amoxicillin - only if severe pain/high fever/persistent Sx
Surgical (ENT referral):
• Maxillary sinus washout - only if progressive pain / complications
Rhinosinusitis - complications
Chronic sinusitis
Mucocele
Osteomyelitis
Intracranial problems (need CT) – meningitis, brain abscess
Facial cellulitis
Periorbital cellulitis
Facial Cellulitis - Sx, sources, Mx
Infection spreads to the skin of the face
Symptoms
=> Red, warm, painful skin
Sources:
- Orbital cellulitis
- Sinusitis
- Osteomyelitis
Management = high dose ABX + sinus drainage
What is mucocele?
A collection of sterile mucous in an obstructed sinus
Over years, increasing pressure causes sinus expansion
Mucocele - Sx and Mx
Symptoms:
- Eye displacement
- Visual problems
- Facial swelling
Management:
- Surgical sinus drainage
Periorbital cellulitis following sinus infection
Infection spreads into orbit (usually ethmoid sinus through ethmoid bone).
Symptoms:
- Unilateral eyelid swelling, pain, redness
- Blurred vision
- Fever, headaches, meningism, sepsis
Periorbital cellulitis - Mx
Urgent ENT referral and CT
High dose IV ABX
Nasal decongestant
Careful eye obs (for signs of abscess pressing on optic n.)
Chronic rhinosinusitis - pathophysiology
INFECTION – viral / bacterial (anaerobes, staph. aureus, gram -ve)
ALLERGENS – dust mites, pollen, animal hair
- Specifically known as allergic rhinitis
- Sneezing, itchy eyes, rhinorrhoea
Chronic rhinosinusitis - Sx
Nasal obstruction / congestion POST-NASAL DRIP – worse at night, morning cough to clear Reduced smell/taste or unpleasant smell Intermittent facial pain Crusting / bleeding
Chronic rhinosinusitis - Ix
Diagnosis based on Hx
Anterior rhinoscopy AND FNE / endoscopy
Chronic rhinosinusitis - Mx
Infection:
- Broad spectrum PO ABX (3+ weeks)
- Topical nasal steroids (2 months)
- Steroid nasal spray (after finishing drops)
- Nasal douching
Allergic:
- Avoid allergens
- Antihistamines
- PO steroids
If no improvement in 8 weeks
- ENT referral
- Confirm Dx and CT & surgery to clear drainage pathway
How is the best way to apply nasal steroid drops (e.g. betamethasone drops)?
applied with the head upside down over the edge of a bed.
Nasal douching
½ tsp salt, ½ tsp sugar, ½ tsp bicarb dissolved in boiling water
Draw up some with a syringe
Block one nostril with finger and sniff up mix with other nostril
Let it run out after
Important to do this BEFORE any nasal spray/drops (not after)
What is vertigo?
= abnormal sensation of movement with ROTATIONAL component / “room spinning”
Usually with nausea and vomiting.
Can be persistent or episodic
Central causes of vertigo
Involve brainstem
Space-occupying lesion Head injury Alcohol/drugs Degenerative disease (e.g. MS) Vascular ischaemia
what is an unlikely cause of vertigo with LOC / collapse ?
Unlikely to be a peripheral cause of vertigo (more likely to be central)
What are vestibular sedatives?
“Anti-dizziness” medications
prochlorperazine, cinnarizine, cyclizine, or promethazine
Given as a SHORT course - prolonged use may delay recovery
What is the difference between labyrinthitis and vestibular neuritis?
Both follow viral infection, BUT:
Vestibular neuronitis = inflammation of vestibular nerve (vertigo with no loss of hearing)
Labyrinthitis = inflammation of entire inner ear (vertigo with hearing often affected)
Meniere’s Disease - Mx
ENT Referral
Prevention = DIET – low salt/caffeine
Symptomatic Tx = Vestibular sedatives “anti-dizzy”, Antiemetics
MEDICAL
- Betahistine (1st line)
- Chemical labrinthectomy – intratympanic steroids, intratympanic gentamycin
(Surgical – surgical labyrinthectomy)
Reassurance and advice for Meniere’s disease
Advise that an acute attack of vertigo will normally settle within 24 hours in most people
Advise the person not to drive when they are feeling dizzy
Discuss reliable sources of information
Vestibular migraine - Sx
- Vertigo (tends to last minutes to hours)
- Possibly tinnitus
- Photophobia / Phonophobia / aura associated with vertigo is almost diagnostic.
- Sympathetic Sx – sweating, flushing
Vestibular migraine - Mx
Diet = 1st line – avoid 5C’s • Caffeine • Cheese • Chocolate • Claret (wine / alcohol) • Chinese food
Lifestyle – avoid too much/too little sleep and too much/too little fluids
(Medical – low dose antidepressants)
What is an acoustic neuroma?
= vestibular schwannoma
Compression of vestibular nerve due to benign tumour of the schwann cells of vestibular nerve.
Assessment of hearing
Hx
Otoscopy
Audiometric tests
Conductive hearing loss
= problem with the outer/middle ear
Bone conduction normal, reduced air conduction
Sensorineural hearing loss
= problem with the inner ear/ auditory nerve/ brain
Reduced air AND bone conduction
Mixed hearing loss
= CHL and SNHL
Decreased air conduction will be greater than decreased bone conduction
Limits with tuning fork tests
Just used for SCREENING
Cannot be performed on patient’s whose loss is too severe to be able to hear the tuning forks (512-Hz or 1024Hz )
Weber’s Test
- Strike the tuning fork and place it on the middle of the forehead.
- Note where the sound is best heard – the left ear, the right ear, or both equally.
Rinne’s Test
- Strike a tuning fork and place it 25mm from entrance to ear canal for 2-3 seconds
- Without delay, press the base of the tuning fork against the mastoid process for 2-3 seconds.
- Ask the patient which they heard louder
(2-3 second timing is important in order for the sound to not disappear and alter the results of the test.)
Normal Weber’s and Rinne’s
Weber’s - Central / no lateralisation
Rinne’s - Positive – AC > BC
Rinne’s test Positive
when AC > BC
Normal hearing or SNHL
SNHL - Weber’s and Rinne’s
Webers = Lateralises to the side with the better cochlea (i.e. opposite side to loss)
Rinnes = Positive – AC > BC
Why does weber’s test lateralise to the opposite side of SNHL?
Cochlear damage = no sound detection on that side
therefore sound lateralises to the better cochlea
CHL - Weber’s and Rinne’s
Weber’s = lateralises to the side with the greater conductive loss
Rinne’s = Negative – BC > AC
Rinne’s test Negative
when BC > AC
Conductive hearing loss
Why does weber’s test lateralise to the same side of CHL?
Distracting external sounds not heard, so sound from fork seems louder on that side
What is cross hearing?
When sound is applied to one ear, the opposite cochlea can be stimulated to varying degrees.
This occurs either by escaping sound travelling through air to the opposite ear, or via vibrations through the bone of the skull.
=> CAN GIVE A FALSE RINNE NEGATIVE
=> CAN AFFECT PTA RESULT
e.g. if the patient has a normal ear and a dead ear, audiological tests would result in a better threshold in the dead ear due to cross hearing.
FALSE rinne Negative
the tone may appear louder by bone due to cross hearing from the better ear
What is masking in audiology?
The process of artificially raising the hearing threshold of the non-test (better) ear, to get a more accurate result of the test ear’s hearing.
Pure Tone Audiometry
Use electrical equipment to control frequency and intensity of sound to quantify hearing loss.
Tests the range of speech frequency
Used for:
- Diagnosis
- Rehabilitation
- Monitoring hearing
When is monitoring of hearing required?
a. Patients working in high noise environments (annual screening)
b. Patients on ototoxic drugs
c. Pre- and post-surgery (e.g. grommets)
What ranges are tested in PTA?
Hearing is tested over the range of speech frequency – 250 Hz to 8000 Hz.
Bone conduction is tested over 500 to 4000Hz.
decibels normal hearing level
Normal hearing = 0 dB nHL
This means that the patient is able to hear the sound at an intensity that is 0 dB louder than a normal hearing person would be able to hear – i.e. it is the same as a normal hearing person.
35 dB nHL means that the patient is able to hear the sound at an intensity that is 35 dB LOUDER than a normal hearing person would be able to hear
Audiogram symbols - Air conduction
Right ear = O (red)
Left ear = X (blue)
Audiogram symbols - Bone conduction (not masked)
Right ear = Triangle (red)
Left ear = Triangle (blue)
Audiogram symbols - Bone conduction (masked)
Right ear = [ open bracket (red)
Left ear = ] close bracket (blue)
Audiogram symbols - Masking applied to air conduction, but no change in normal threshold
Right ear = half-coloured circle (red)
Left ear = half-coloured X (blue)
Audiogram symbols - Shadow response to masking
Right ear = coloured circle (red)
Left ear = coloured X (blue)
WHEN is masking applied to audiogram?
Used to prevent cross-hearing
Applied when:
- AC – 40dB or greater air to air difference (right vs. left)
- BC – 10dB or greater air to bone difference in the same ear (AC vs. BC)
Audiogram - normal hearing
Hearing level within normal threshold (-10 to 20)
Audiogram - SNHL
AC decreased and BC decreased
Bone/air gap <5-10 dB
Audiogram - CHL
AC decreased,
BC within normal range
(Bone/air gap >15 dB)
Audiogram - mixed HL
AC and BC both lower than normal range, but decrease is greater for AC
(Bone/air Gap >15 dB)
Tympanometry
= a test of middle ear function.
Measures sound compliance into the middle ear
Measured over a range of pressures (from negative to positive)
Information is plotted on a tympanogram.
Tympanometry - Normal range for Ear Canal Volume
0.6 – 2.5 mL
Tympanometry - Normal range for Middle Ear Pressure
+50 to -100 daPa
Tympanometry - Normal range for Compliance
0.3 – 1.6 mL
Tympanometry - TYPE A
Peak at atmospheric pressure (0daPa)
Normal compliance
Tympanometry - TYPE Ad
= Like Type A with taller peak
Increased Compliance:
- Healed TM perforation
- Retraction pocket
- Ossicle disarticulation
Tympanometry - TYPE As
= Like Type A with smaller peak
Decreased Compliance:
- TM scarring
- Fluid in middle ear
Tympanometry - TYPE B
= Flat line, no peak
No Peak Compliance
- Middle ear effusion / tumour
- TM perforation
- Grommet
Tympanometry - TYPE C
Type C
Peak in negative pressures
- Peak compliance at low frequency
- Eustachian tube dysfunction
Paediatric audiometry - timings
Newborn Hearing Screening Programme (NHSP)
=> within 5 weeks of birth (ideally before discharge)
Behavioural Observation Audiometry (BOA)
=> 0 – 6 months
Visual Reinforcement Audiometry (VRA)
=> 6 months – 3 years
Performance Test / Conditioned Play Audiometry (CPA)
=> 30+ months
Conventional Pure-tone Audiometry
=> 5+ years
Newborn Hearing Screening Programme
Offered to all babies within 5 weeks of birth
2 tests:
- Automated Otoacoustic emission (AOAE):
- Tests function of outer hair cells.
- If child fails 2 of these, then AABR is performed. - Automated Auditory Brainstem Response (AABR)
- Uses electrodes to monitor brain activity response to sound stimulus.
- Can be done at any age, but will often need to be sedated after 6 months.
Behavioural Observation Audiometry
Age 0 – 6 months
Observe the child in a normal (quiet) state and also during presentation of loud sound to see if there is any change in behaviour (e.g. startle, eye movement/widening, head turn, etc.)
Does not assess laterality.
Visual Reinforcement Audiometry
Age 6 months – 3 years.
Observation of conditioned response to sound stimulus (sound field or insert)
Child is conditioned to turn when sound is heard, during conditioning the child is provided with a visual reward (toy).
Performance Test / Conditioned Play Audiometry
From age 30+ months.
Performance test – child presented stimulus in sound field, plays a game with dropping men in a boat.
CPA = continuation from performance test, but with headphones to obtain more specific results for each ear.
What are the branches of the facial nerve?
” two zoologists butchered my cat”
Temporal Zygomatic Buccal Marginal Mandibular Cervical
What can cause gingival hyperplasia?
Drugs:
- phenytoin
- ciclosporin
- calcium channel blockers (especially nifedipine)
Other causes:
– Acute myeloid leukaemia
What is the most common bacterial cause of otitis media?
H. influenzae
