ENT Flashcards
1
Q
What signs do you look for on examination of the ear?
A
- Pinna symmetry, deformity, scars, active infection
- Mastoid skin changes, scars
- Pre-auricular pits, sinuses
- Ear canal: pull back and up, look for wax swelling erythema, discharge FB bony swellings crust
- Tympanic membrane: colour (should be pearly grey-translucent), bulging (fluid level in OM), perforation, light reflex (absence/distortion-increase IE pressure), scarring, cholesteatoma in attic
2
Q
Explain the tuning fork tests
A
512Hz fork
- Rinne (ME function): hold by ear canal + then mastoid process. AC>BC is normal or SNHL [Rinne +], BC>AC is CHL [Rinne -]
- Weber (more sensitive): hold in centre of forehead. Normal=central, CHL=heard more in deafer ear, SNHL=heard more in better ear
3
Q
An elderly pt presents with hearing loss, but Webers + Rinnes tests are normal. Why?
A
Presbyacusis is commonest form of HL in old age. This is a symmetrical SNHL, so there is no discrepancy between the ears that can be picked up on these tests (even tho the hearing is reduced)
4
Q
Explain the pure tone audiometry tests
A
Subjective tests for each ear using headphones (AC) and small vibrating thing on MP (BC) where play signals of increasing frequency
Normal threshold os 0dB, shouldn’t go below 20. 1 line for BC and 1 for AC.
SNHL: AC + BC impaired
CHL: AC impaired
Mixed: both impaired, AC often worse
5
Q
What test is useful for otitis media with effusion?
A
Impedance audiometry - signal of known intensity fed into EAM, microphone measures reflected sound levels. If fluid in ME the curve is flattened
6
Q
How is hearing tested in young children/babies?
A
- Newborns: otoacoustic emission
- Evoked response audiometry: doesn’t need cooperation, objective test
- Distraction test: child will turn to a noise 6m-18m
- From 2y can do various tests involving cooperation, from 3-4y can do the headphone pure tone audiometry tests
7
Q
Describe the sensory supply to the pinna
A
Upper lateral-CN V3 (auriculotemporal n)
Lower lateral + posterior-C3 (greater auricular n)
Supero-medial-C2/3 (lesser occipital n)
EAM-CN X auricular branch
8
Q
Describe the anatomy of the external ear up to the tympanic membrane
A
- Pinna: cartilaginous, plus fatty lobule containing bvs
- EAM: lateral 1/3 cartilage, medial 2/3 temporal bone
- Tympanic membrane: skin on external side + mucus membrane internal, shallow cone shape, semi-translucent, moves by air vibrations. Innervated by auriculotemporal n (outer) and CN IX (inner)
9
Q
Tympanic membrane perforation
A
Direct/indirect trauma or otitis media –> acute pain, CHL (usually not severe), tinnitus, vertigo unusual, may bleed from the ear
Usually heal alone (precautions about water), don’t put anything in the ear, only give Abx if evidence of infection, should heal over 6-8w, if taking >6m may need myringoplasty to repair using graft of temporalis fascia
10
Q
Haemotympanum
A
Blood in the middle ear, often a/w temporal bone #, may cause CHL. TM dull with bluish tinge. Conservative management, may need drainage
11
Q
Otitis externa ‘swimmers ear’ cause + features
A
Inflammation of skin of EAM often by skin commensals (Strep, Staph, Pseudomonas or fungi). RF are moist/humid, eczema, cotton bud trauma
CF: painful discharging ear, muffled hearing, itching (CHL), discomfort from pressure on tragus, debris/oedema in canal, regional lymphadenopathy, cellulitis spreading beyond ear, fever (more severe features)
12
Q
Otitis externa management
A
- Severe (red oedematous canal, debris, CHL, DC, lymphadenopathy, cellulitis, fever) –> 7d topical Abx +/- topical steroid. If spreading - oral flucloxacillin
- Mild: pruritus, no deafness/discharge, mild discomfort –> topical acetic acid spray
- Swab if not responding
- Adv simple analgesia, avoid getting water in it + analgesia
13
Q
Chronic otitis externa
A
Usually b/l, painless, relapsing condition with thickened skin easily traumatised
Need to remove debris + keep dry
Abx drops not advised unless acute inflammation as they precipitate allergy and fungal infection
14
Q
Malignant otitis externa
A
Aggressive infection a/w DM and immunocompromise, in the soft tissues of the EAM and eventually cause osteomyelitis of temporal bone - Pseudomonas
Chronic ear DC, deep severe pain, CN palsies esp CN VII, temporal headaches
Do CT + isotope scanning
M: aural toilet, IV Abx (ciprofloxacin covers pseudomonas), may need debridement. There is a 10% mortality!
15
Q
Furunculosis
A
Hair follicle infection in EAM - severe throbbing pain, pyrexia then rupture of abscess
May need drainage
16
Q
Perichondritis
A
Cartilage infection from trauma or severe otitis externa
Swollen red pinna, oedema that may spread, pre-auricular LN
M: local astringents e.g. magnesium sulphate + systemic Abx (as cart damage irreversible)
17
Q
Herpes zoster oticus
A
aka Ramsay Hunt syndrome
Reactivation of VZV in facial nerve geniculate ganglion –> severe pain, vesicles in ear canal + pinna (may also be on anterior 2/3 tongue + soft palate), often facial palsy
Antivirals to prevent permanent CN VII damage + corticosteroids
18
Q
Exostosis
A
Repeated exposure to cold water + wind –> bony growth in EAM. Benign but causes CHL
19
Q
Give some common problems with the auricle
A
- Congenital deformities
- ‘Bat ears’ - usually b/l, surgery around age 7
- Pre-auricular sinus - embryological remnant with a small pit, may get infected and need excision of whole sinus tract
- Infections - erysipelas (strep infection, serpiginous edge, rapidly spreads), spread of OE
- Perichondritis - inflammation of perichondrium, diffusely swollen shiny painful ear, need Abx + astringents + analgesia to prevent cartilage necrosis (aka cauliflower ear)
- Auricular haematoma
- Skin problems e.g. dermatitis from jewellery/eardrops, eczema/psoriasis
20
Q
What is in ear wax?
A
Sebaceous material + products of ceruminous glands + hair + skin
21
Q
How and when should ear wax be removed?
A
- Ind: meatal occlusion, impaction, irritation, hearing loss, OE, based on clinical inspection
- Syringing (use water, don’t do if have ruptured TM), microsuction (better, done by ENT). May need to soften before
- Comps: incomplete removal, trauma to ear canal skin, TM perforation, vertigo
22
Q
Describe the anatomy of the middle ear
A
Between the TM + IE
- Pharyngotympanic (Eustachian tube) - equillibrilates pressure + ventilates + drains, linked to nasopharynx. Opens during swallowing
- Ossicles: malleus, incus and stapes (this articulates with oval window)
- Muscles: tensor tympani (reduce amplitude, CN V3), stapedius (pulls stapes to decrease oscillatory range, nerve from CN VII)
23
Q
Cause and features of acute otitis media
A
Usually resp pathogens as resp pseudo stratified columnar epithelium (e.g. S pneumonia, H influenza, Moraxella) and viruses- usually ET dysfunction
CF: ear pain, young child may pull ear, DC (then TM may rupture with pus into canal and pain settles), fever, bulging TM, tachycardia
24
Q
Management of acute otitis media
A
- Conservative with analgesia + nasal decongestants - majority, as most viral in origin
- Abx indications: sx not improving in 4d, systemically unwell (but not needing admission), immunosuppression, <2y with b/l AOM, TM perforation/discharge in canal
- Abx would be 5d of amoxicillin (or macrolide if allergy)
- Recurrent: grommets
25
What are the types of chronic otitis media?
* Actively discharging or inactive
* Mucosal - TM rupture doesn't heal after AOM. Active if perforation still discharging
* Squamous - keratinised squamous cells introduced into ME from retraction pocket/perforation. Active squamous disease is cholesteatoma, inactive squamous may develop into cholesteatoma in future
26
How is chronic otitis media managed?
* Cholesteatoma-surgical management +/- mastoidectomy
| * Mucosal disease-topical Abx + aural toilet
27
Extracranial complications of middle ear infections
* Mastoiditis: inflammation, severe pain, erythema, sagging of posterior ear canal, oedema, oedema pushed down + out (subperiosteal abscess), drum bulges/discharges, systemically unwell. M: IV Abx prolonged, if abscess mastoidectomy
* Facial paralysis from acute inflammation
* Labyrinthitis: dizziness, loss of balance, N+V, SNHL. High dose Abx to prevent Abx
28
Intracranial complications of middle ear infections
* Meningitis-often pneumococcal. Infection of IE, lateral sinus or direct extension
* Abscess-extradural, subdural, temporal lobe (HL, otorrhoea, signs of RICP or seizure), cerebellar (nystagmus, past pointing, ataxia, headache)
* Lateral sinus thrombosis
29
What is glue ear?
Otitis media with effusion. TM intact but fluid is in the ME, a/w ET dysfunction (abnormal ventilation-often an URTI). Peak 2-6y; if in adults check post-nasal space for tumours. RF are T21 + cleft palate.
CF: CHL (may present as speech delay, school issues, behavioural/balance problems), flat trace on tympanometry (immobile drum), effusion retracted eardrum + slightly yellow, not painful but can get infected causing AOM/recurrent otalgia
M: most settle in 3m, may need grommets for ventilation (tympanoplasty tubes, stay in place for up to 12m), +/- adenoidectomy and myringotomy to aspirate the fluid
30
Otosclerosis
Genetic + environmental factors, majority b/l, mature bone replaced by woven bone --> stapes becomes fixed to oval window --> can't move properly --> CHL. F>M, early adults usually, worse in pregnancy, often a FH (autosomal dominant)
CF: progressive CHL, tinnitus, initially hearing improves in noisy environments. May have pink hue to TM (Schwartze's sign/Flamingo tinge cos hyperaemia) but otherwise normal
-may also get tinnitus/vertigo but less common
M: hearing aid, stapedectomy (put in prosthesis, but risk complete HL from surgery)
31
Describe the anatomy of the inner ear
In the petrous part of the temporal bone
* Membranous labyrinth filled with endolymph, suspended in perilymph, contained within bony labyrinth
* Cochlea: shell shaped, hearing perception
* Vestibular system: 3 semi-circular canals which detect movement, utricle (hair cells point up to detect horizontal movement), saccule (hair cells point to side to detect vertical movement)
32
Outline sound perception
Vibrating TM --> ossicular chain --> oval window --> cochlear --> organ of Corti hair cells transform into electrical impulses --> depolarises fibres in CN VIII cochlear nerve --> transmitted to brain
33
Define vertigo
Hallucination of movement a/w a problem in the vestibular system
may have nystagmus as brainstem impulses to ocular muscles attempt to correct balance
34
What causes vertigo?
* central: stroke, migraine, neoplasia, demyelination, drugs
| * peripheral: BPPV, meniere's, vestibular neuronitis
35
How does vertigo present by pathology?
* Episodic + ear sx: migraine, Meniere’s disease
* Episodic, no ear sx: migraine, BPPV, TIA, epilepsy, arrhythmia, postural hypotension, cervical spondylosis
* Constant + ear sx: chronic otitis media with labyrinthine fistula, ototoxicity, acoustic neuroma
* Constant, no ear sx: MS, intracranial tumour, CV disease, degenerative disorder of vestibular labyrinth, hyperventilation, alcoholism
* Solitary acute attack + ear sx: viral infection (e.g. mumps, HZV), vascular occlusion, labyrinthine fistula, rond-window membrane rupture/head injury
- Solitary acute attack, no ear sx: acute labyrinthitis, vasovagal faint, vestibular neuronitis, trauma
36
What is BPPV?
Benign paroxysmal position vertigo - episodic vertigo that occurs with head movements esp when in bed, lasts a short time, can be v distressing
otoliths in the SCCs cause abnormal stimulation of hair cells giving hallucination of movement
usually spontaneous but may follow URTI/head injury/chronic otitis media
37
How do you diagnose and treat BPPV?
* Diagnosis: Dix-Hallpike test. Turn head to affected side and gently lower head below rest of body, see nystagmus but repeated testing abolishes the vertigo
* Epley manoeuvre: to 'reposition particles', series of controlled movements of head aiming to dislodge otoliths
38
What is Meniere's disease?
A rare problem with increased endolymph, occurs in clusters typically in 40-60yos
39
How does Meniere's disease present?
* Triad of vertigo (episodic, a/w N+V), deafness (SNHL, fluctuating then permanent), tinnitus
* Aural fullness sensation
* Nystagmus, positive Romberg test
* Attacks from a few hours to several days, common to vomit, usually u/l initially but may become b/l (if other ear is fine usually compensate)
* Over time dont get acute vertigo but may be generally unbalanced
40
How is Meniere's disease managed?
* Needs ENT to confirm diagnosis
* Explanation, most resolve in 5-10y but most left with some HL
* Diet: reduce salt, chocolate, alcohol, caffeine, Chinese food. do not smoke
* Medical: low dose thiazide diuretics (aim to reduce endolymph pressure), vestibular sedatives (e.g. prochlorperazine, cinnarizine) + anti-emetics for acute attacks; betahistine + vestibular rehab for acute attacks
* Surgical: grommets, dexamethasone ME injection, endolymphatic sac decompression, vestibular destruction (ME injection of gentamicin)
* Inform DVLA, stop driving until control satisfactory
41
What is myringitis bullosa?
Localised otitis externa on TM - blisters on TM/deep in the EAM - excruciating pain
Presumed to be viral
42
Cholesteatoma
Epithelium trapped in skull base causing local destruction
most common 10-20y, RF is cleft palate
p/w foul smelling discharge, hearing loss, invasion sx like vertigo/facial n palsy/cerebellopointine angle syndrome, attic crust in upper part of eardrum
may invade labyrinth causing a fistula connecting ME+IE-->balance disorders
also can cause HL, invasion of nerves
m-refer to ENT for removal
43
What may indicate previous grommet insertion?
Tympanosclerosis - white patches in TM
Doesn't impair healing
Chronic effusion + thinning of TM - retraction pocket -if ET chronically fails to function
44
Vestibular neuronitis
Inflammation in the inner ear causing severe incapacitating vertigo + N+V for several days, may have horizontal nystagmus. Otherwise no other sx
M: vestibular sedatives e.g. prochlorperazine (dont take after attack as delay recovery), IV fluids. Afterwards may have generalised unsteadiness for a few weeks, vestibular rehabilitation may help
45
Labyrinthitis
Infection in the vestibular labyrinth --> sudden onset vertigo, horizontal nystagmus, HL if cochlear involved, N+V
Improves after 24h as central compensation occurs
If b/l produces a bobbing oscillopsia (lose normal eye control)
46
How may you test the vestibular system?
* Test balance asking to walk like tightrope, heel toe, march on spot with eyes closed (turn towards side with issue as reduced proprioception)
* Positional test-sit up on couch then lie flat with head to one side + below horizontal, note vertigo + nystagmus. Implies peripheral cause
* Fistula test: compress tragus, causes feeling of imbalance
* Caloric test: nystagmus when irrigate ear canal with water
47
Tinnitus
Real/imagined noise in the ear, RF-long term high intensity noise exposure
* Subjective: presbyacusis, noise-induced, ototoxic drugs, Meniere's, wax, otosclerosis, ME effusion, head injury, labyrinthitis, vestibular schwannoma. Most common is a rushing/hissing/buzzing noise a/w SNHL
* Objective: maggots, TMJ/ET sounds, AV malformations (pulsatile sound), normal pulsatile noise of ICA (mostly heard at night)
M: reassure not serious, correct hearing deficit with hearing aid/surgery, tinnitus masking devices to mask white noise, may need psychotherapy if stress worsens it
48
Causes of otalgia
* Ear causes: otitis externa, furunculosis, malignant otitis externa, myringitis bullosa, perichondritis, AOM, acute otitic barotrauma, Ramsay Hunt syndrome, neoplasia
* Non-otological: referred pain. E.g. tonsillitis (CN IX), dental disease [impacted molars, malocclusion] or sinusitis (CN V), TMJ dysfunction (CN V), oesophageal (CN X), cervical spondylosis in elderly (CN2+3), referred from nasopharyngeal carcinoma
49
Causes of otorrhoea
* Watery: skin conditions of EAM, fungal growth, CSF leak from temporal # (rare)
* Purulent: acute otitis externa, furunculosis
* Mucoid: ME pathology. E.g. chronic suppurative otitis media with perforation [tubo-tympanic] (M aural toilet, topical steroid drops to dry the ears, sometimes use eye drops with ofloxacin/ciprofloxacin)
* Mucopurulent/bloody: trauma, AOM, ear carcinoma (rare)
* Foul smelling: chronic suppurative otitis media (atticoantral disease), a/w cholesteatoma
* Iatrogenic from surgically-created mastoid cavities
50
What are the functions of the facial nerve?
* Greater petrosal nerve - e.g. lacrimation
* Chorda tympani - taste anterior 2/3 tongue + sublingual + submandibular glands
* Stapedius nerve
* Then stylomastoid foramen, then branches to parotid gland and muscles of facial expression (To Zanzibar By MotorCar)
51
What may cause facial palsy?
* Intracranial: vestibular schwannoma, stroke, brainstem tumour
* Intratemporal: Bell's palsy, Ramsay Hunt syndrome, middle ear infection, trauma
* Extratemporal: parotid tumours
* Misc: sarcoidosis, polyneuritis
52
Bell's palsy
Idiopathic facial paralysis. Diagnosis of exclusion but commonest cause
CN VII palsy, pain around mastoid, HL, taste loss, hyperacusis
Start to recover in 3w, antivirals + steroids often given but evidence lacking
53
Causes of balance disorders
Can be from inputs ears/eyes/proprioception, cerebellum fine movement, cortex space position), labyrinths + central connections
* Ear causes: ME disease (OME, AOM, cholesteatoma), trauma (post-surgery or temporal #), BPPV, Meniere's disease, labyrinthitis, otosclerosis, ototoxic drugs, vestibular schwannomas
* Non-ear: NOT VERTIGO, lightheaded/dizziness. E.g. cervical spondylosis, ageing, migraine, TIAs, head injury, epilepsy, hyperventilation/anxiety (a/w tinnitus + tingling in hands + feet)
54
Pinna injuries
* Auricular haematoma: blunt trauma/shearing force - bleeding beneath perichondrium - stripped from cartilage - necrosis + scar formation - cauliflower ear. Need to aspirate haematoma + firm pressure dressing + Abx to prevent
* Lacerations: suture as good blood supply, trim exposed cartilage
* Keloid scars
* EAM injuries like from cleaning wax
55
Middle and inner ear injuries
* Perforated TM
* Blast injuries-explosion or ear slap, usually rupture TM, may damage cochlea causing SNHL+tinnitus, may be permanent
* Otitic barotrauma: esp when pressure rising e.g. descent in flight/Scuba. Otalgia, extravasation of blood into ME, haemotympanum
* Head injuries - temporal # can damage cochlea or labyrinth
* Surgical trauma
* Haemotympanum
56
Ear foreign bodies
May cause otalgia/otorrhoea
Removal: specialist, usually suction or syringing
57
What causes conductive hearing loss?
* Common: wax, AOM, OME, otosclerosis, perforated TM, otitis externa, foreign body
* Less common: ME trauma, congenital pathology like ossicle abnormalities, tumours
58
What causes sensorineural hearing loss?
* Common: presbyacusis, noise-induced, congenital (genetic, TORCH infection), neonatal jaundice/hypoxia/prematurity, childhood infections (measles, mumps, meningitis), drugs (quinine, aminoglycosides, aspirin)
* Less common: vestibular schwannoma, CNS disease like MS, hypothyroidism, Meniere's disease, perilymph fistula
59
What causes childhood deafness?
* OME (CHL, temporary)
* SNHL rare but usually permanent - 1/2 hereditary, others acquired in utero/early childhood e.g. meningitis or TORCH infections
RF: prematurity, low bw, perinatal hypoxia, chromosomal abnormalities, severe jaundice, FH of hereditary deafness, TORCH infections
60
How do hearing aids work?
Amplify sound from small microphone and fed into ear canal
* In cochlear SNHL they are intolerant to noise over a certain level so amplification is difficult
* Can have bone-anchored type e.g. due to shape of ear canal with titanium screw into temporal bone so sound transmitted directly by BC to the cochlea
* COchlear implantS: electrodes in cochlea stimulate auditory nerve, done for profound b/l deafness
61
What are the common ear drops we need to know about?
* Ceruminolytics: soften wax e.g. olive oil, sodium bicarbonate, glycerine. Many irritant so use for short periods
* Astringents: anti-inflammatory e.g. betamethasone, glycerine. When oedematous canal so reduce swelling so that Abx can work
* Antibacterial: usually aminoglycosides + anti-inflammatory. If ear drum is perforated use ciprofloxacin instead
* Anti-fungal e.g. clotrimazole, nystatin.
62
What drugs can cause tinnitus?
aspirin, alcohol, quinine, ototoxic combinations like aminoglycosdie + loop diuretic, some cytotoxics
63
Why can ageing cause balance disorders?
Multifactorial:
* Poor proprioception as reduced vision + hearing
* Cervical spondylosis
* Hypotension or arrhythmias
* Medication
Best to avoid vestibular sedatives as they suppress what's left of normal function
64
Why can cervical spondylosis cause balance disorders?
Arthritic - osteophytes - vertebrobasilar insufficiency, esp when hyperextend neck - transient cerebral ischaemia
M: neck physio, NSAIDs
65
Presbyacusis
Common cause of SNHL - progressive loss of sensitivity of cochlear hair cells, usually B/L, high frequency, difficulty following conversations. 2 hearing aids used
66
Sudden SNHL
Rare, thought to be viral/vascular (idiopathic)
Emergency: give steroids, refer to ENT asap, can try intra-tympanic steroids, pure tone audiometry, MRI head to rule out VS
67
Noise exposure
Common, from sudden or prolonged exposure - wooly hearing, tinnitus, SNHL worst in range 3000-6000Hz
Prevention- avoidance, ear defenders
M-hearing age
68
Perilymph fistula
Rare cause of SNHL due to a rupture of the round/oval window --> perilymph leakage --> SNHL
Usually a trigger like RICP e.g lifting something
69
Vestibular schwannoma
A tumour on the vestibular n (used to be called acoustic neuroma), located in the internal auditory meatus or cerebello-pontine angle. Usually u/l but in NF2 may be b/l
CF: progressive SNHL, imbalance, tinnitus, CN V encroachment (CP angle -- absent corneal reflex), if advanced can cause RICP/brainstem displacement , CN VII encroachment (facial palsy)
70
Outline the nasal anatomy
* External nose mostly cartilage, septal cartilage biggest, mucosal inside is ciliated columnar + olfactory, bony swellings are the turbinates (x3)
* Nasal cavity goes from nostrils to posterior nasal aperture (choana) which opens into nasopharynx. Related to anterior cranial fossa @ cribriform plate of ethmoid bone, sinuses, NP, ET, lacrimal apparatus + conjunctiva
* Conchae/turbinate: covered in MM, longest is inferior
* Meatuses: superior + inferior
* Innervation by CN V + CN I
71
Outline the para-nasal sinus anatomy
Air-filled extensions of the respiratory part of the nasal cavity lined with ciliated pseudo stratified columnar ep + goblet cells
* Frontal: drains into middle meatus, roof is floor of anterior cranial fossa + floor is roof of orbit
* Ethmoidal: into ethmoid bone, medial wall of orbit
* Sphenoidal: behind nose, close to CN II + ICA + pituitary gland + cavernous sinus
* Maxillary: bodies of maxilla, roots of upper teeth project into them so tooth infections can spread
72
How would you examine the nose?
Inspection external then internal with auriscope with large speculum, assess nasal airway, interior quite horizontal, look back not up, can see anterior septum + inferior turbinates (may look like a polyp, but turbinates v sensitive but polyps aren't [and are grey-translucent])
73
What may cause epistaxis?
* Local: idiopathic, traumatic, iatrogenic, FB, rhinitis, polyps, neoplastic (e.g. juvenile angiofibroma, pyogenic granuloma), cocaine (vasoconstrictor so repeat use causes obliteration of septum)
* Systemic: HTN, coagulopathies, HHT (esp elderly), anticoagulants, thrombocytopenia (eg ITP, leukaemia, Waldenstrom's macroglobulinaemia)
74
How do you manage epistaxis?
* ABCDE
* First aid: pinch soft part of nose, head forward, tell to spit out blood, lean forward, breathe through mouth
* Examine for source of bleed
* Gently remove clots + dried blood w suction
* Cautery with silver nitrate/bipolar diathermy, can use topical adrenaline before to vasoconstrict, topical anaesthetic
* Nasal packing if cautery fails or can't see source, anterior and if continuous posterior (may need GA, causes airway obstruction). Pack with ribbon gauze, nasal tampons or balloon
* Surgical ligation or radiological embolisation of the sphenopalatine a, or of the ECA as a last resort
75
Nasal foreign body
Usually in children, adults may have a rhinolith
* CF: u/l, v bad smell DC, may be blood-stained, excoriation around nostril
* Need to remove as may spread to sinus/meninges, inhale, septal perforation, button batteries may burn skin
* M: if v cooperative + can see may be able to use forceps otherwise GA
76
Nasal trauma
* Septal haematoma: sensation of obstruction most common sx, pain + rhinorrhoea, b/l red swelling arising from septum, boggy (whereas the septum is firm). Comp-irreversible necrosis due to pressure ischaemia causing sale nose deformity. M-surgical drainage, IV Abx
* CSF leak with base of skull # (rare)
77
Septal deviation
* Usually from trauma, may become more prominent in children who grow, or due to nasal surgery
* If marked can cause nasal obstruction, recurrent sinusitis from impaired ventilation, facial pain, psychological sx, otitis media as reduced equalisation of middle ear
* M: treat rhinitis, may opt to correct it as a septoplasty
78
Septal perforation
* Causes: surgery, trauma e.g. repeated picking, inhalation of fumes, cocaine, carinoma
* V hard to repair, nasal douching to reduce crusting, antiseptic cream
79
Saddle nose deformity
Cartilaginous septum necrosis due to trauma/untreated septal haematoma/chronic inflammation
Aesthetic deformity + nasal obstruction
M: difficult, extensive surgery
80
What infections may affect the nose?
* Acute coryza - discourage >5d of nasal decongestants
* Nasal vestibulitis - sore, fissure, crust. M-topical Abx/antiseptic ointment, look for foreign body
* Furunculosis: abscess in nasal hair follicle, rare but can lead to CST/meningitis. Tip of nose red + painful. Systemic abx +/- drainage
81
What are the complications of sinus surgery?
* Damage to orbit
| * Damage to anterior skull base
82
What is rhinosinusitis?
Inflammation of the nose + paranasal sinuses, characterised by 2 or more out of: nasal blockage, nasal discharge, facial pain/pressure, reduction in smell
Usually >1 sinus affected. May have endoscopic signs like polyps/mucopurulent DC/oedema or CT changes like mucosal changes
83
Acute rhinosinusitis
Lasts <12w and sx completely resolve
* Causes: viral (usually rhinovirus/influenza + resolves in 5d, due to oedema which reduces ventilation), or non-viral (>5d, usually a bacteria also invades like S pneumonia/Haemophilus or Moraxella or anaerobes)
* Predisposing factors: nasal obstruction like polyps, recent local infection, swimming/diving, smoking
* CF: obstruction, rhinorrhoea (thick purulent DC), congestion in nose/face, facial pain (maxillary-cheeks, ehtmoid/periorbital headahce/periorbital, sphenoid-deep headache), frontal pressure pain on bending forward, pyrexia, pus in nose, tender sinuses, tooth pain
* OTC management: analgesia, nasal decongesting vasoconstrictors (sparingly, not for >5d)
* NICE management: analgesia, intra-nasal steroids if sx >10d/severe; Abx if systemically unwell or co-morbidities (phenoxymethylpenicillin, or co-amoxiclav if v unwell); do NOT offer oral steroids/steam/antihistamines (unless also allergy)/mucolytics
* May need surgical drainage of an empyema
84
Chronic rhinosinusitis
12w without complete resolution of sx, +/- polyps
* Prediposed by allergy, infections, ciliary impairment e.g. CF, anatomical e.g. septal deviation, immunocompromised, irritants like smoking or dust, hormones like in pregnancy, trauma, FB presence, swimming
* M: usually no cure. Avoid allergens, nasal douching, antihistamines/topical nasal steroids/oral steroids if severe/oral Abx, surgical like nasal polypectomy, functional endoscopic sinus surgery
85
What are the complications of acute rhinosinusitis?
* Orbital cellulitis or abscess
* Meningitis, extradural or subdural abscess
* Cerebral abscess of frontal lobe - frontal sinus infection a/w headache + abnormal behaviour
* Osteomyelitis of the frontal bone - need intensive Abx + debridement
* Cavernous sinus thrombosis - rare, a/w proptosis, chemosis + ophthalmoplegia, facial oedema, photophobia, u/l CN palsies of III/IV/V/VI
* Mucocele - bony swelling as secretions accumulate
86
Nasal polyps
Close a/w CRS, polypoid swelling of nasal lining
* A/w late onset asthma, aspirin sensitivity, infective sinusitis, cystic fibrosis, Kartagener's syndrome, Churg-Strauss syndrome
* CF: nasal obstruction, rhinorrhoea, poor sense of taste + smell
* Seen as swollen oedematous nasal mucosa, obstructing nose, yellow-grey, smooth + moist, may be pedunculate, move on probing, insensitive (unlike the turbinates)
* Usually B/L - if U/L possibly neoplastic
* In chidden - need to rule out cystic fibrosis
* M: allergen avoidance, systemic/topical antihistamines, topical steroids, Abx if infected. If large may need polypectomy/functional endoscopic sinus surgery
If GP suspects polyps should refer to ENT
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Allergic rhinitis
IgE-mediated type I hypersensitivity in mucus membranes, strong a/w asthma. Seasonal hay fever or perennial
Allergic rhinitis according to impact on asthma is used to classify, based on severity + duration of sx
CF: nasal congestion, airflow obstruction, rhinorrhoea, sneezing, reduced smell, allergic crease from rubbing, red mucosa, mucoid DC.
May look into allergies but usually no ix needed
M: conservative, antihistmaines/topical steroid, immunotherapy
88
What are the causes of chronic rhinosinusitis?
* Allergic rhinitis
* Infectious rhinitis like hormonal, drug-induced like beta blockers
* Occupational from fumes
* Vasomotor
* Rhinitis medicaments - excessive decongestant use causes rebound congestion
* Atrophic - after surgery/radiotherapy, or Sjogren's syndrome
* Senile - ipratropium bromide spray often helps
89
Differentials for chronic rhinosinusitis and nasal polyps
* Adenoid hypertrophy
* Septal deviation
* Foreign body (esp in child with u/l CRS +dc)
* CF
* Primary ciliary dyskinesia
* Tumours
* CSF rhinorrhoea
90
What tumours may affect the nose/sinus areas?
Most are SCC
RF are tobacco, male, alcohol, exposure to hardwood resins (adenocarcinoma), southern China (nasopharyngeal carcinoma), EBV (nasopharyngeal carcinoma)
* Maxillary + ethmoid sinus carcinomas - bloody DC, u/l obstruction, facial swelling, epiphora, proptosis, diplopia, pain
* Osteatoma-benign bony tumours
91
What is the vascular supply to the nose?
* A+P ethmoidal a( from ophthalmic a), sphenopalatine + greater palatine a (from maxillary a), septal branch of superior labial a (from facial a)
* Little's area/Kiesselbach's plexus: v vascular bit on anterior septum, branches from ECA+ICA, anastomosis of the above 5 arteries
92
What are the layers of the neck?
* Superficial cervical fascia
* Deep cervical fascia - investing layer around whole neck, pre-tracheal layer (anterior only), pre-vertebral layer (laterally becomes axillary sheath)
* Retropharyngeal space: between pre-vertebral layer + fascia of pharynx, allows pharynx expansion when swallow, has LN in children so can get an infection that may spread to posterior mediastinum
93
Muscles of the H+N
* Neck: trapezius + SCM CN XI, platysma CN VII, infrahyoid + suprahyoid muscles
* Facial expression: CN VII, LPS CN III
* Mastication: CN V. Pterygoids, masseter, temporalis
94
Blood supply to the H+N
* ECA: facial, angular, nasal, maxillary, labial branches
* ICA: ophthalmic --> supraorbital + supratrochlear
Drained into facial vein - IJV - EJV - pterygoid venous plexus - cavernous sinus
95
What is in the anterior cervical triangle?
Things between head and thorax - hyoid muscles, CCA bifurcation, IJV, CN VII, IX, X, XI, XII
96
What is in the posterior cervical triangle?
Things that go between thorax and upper limb: omohyoid + scalene muscles, EJV, subclavian vein, CN XI, cervical plexus (inc phrenic nerve), trunks of the brachial plexus
97
What are the boundaries of the anterior + posterior cervical triangles?
* Anterior: medial=midline of neck, lateral=anterior border SCM, superior=lower mandible
* Posterior: anterior=posterior SCM, posterior=anterior trapezius, base=middle 1/3 of clavicle
98
Outline the lymphatics of the H+N
* Right side down to diaphragm drains to right lymphatic duct which goes into right subclavian vein
* Left side + right side below diaphragm drain to thoracic duct which goes into left subclavian vein
* Superficial LN: submandibular, submittal, pre-auricular, post-auricular, occipital, superficial anterior + posterior cervical chains
* Deep LN: drain the superficial LN. Jugulodiagstric (raised on tonsillitis), jugulo-omohyoid, supraclavicular (right mid-chest/oesophagus/lungs, left abdo + thorax [Virchow's node])
99
What is Waldeyer's ring?
Lymph tissue surrounding pharynx -lingual tonsil (posterior tongue base), palatine tonsils, tubal tonsils (where ETs open into nasopharynx), pharyngeal tonsil (adenoid, behind uvula)
100
Retropharyngeal abscess
Abscess in the retropharyngeal space - can spread to the mediastinum. Most common in young children post-URTI
CF: rigid neck, reluctance to move, systemically unwell, airway compromise, dysphagia/odynophagia, mediastinitis
Do CT neck
M: secure airway, IV Abx, incision + drainage
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Ludwig's angina
Cellulitis of the space between the floor of the mouth + mylohyoid. A/w dental infection or immunocompromise. Spreads in fascial spaces
CF: swelling floor of mouth, painful, protruding tongue, airway compromise, drooling
CT neck
M: secure airway, IV abx, drain collections
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Parapharyngeal abscess
Potential space between oropharynx + nasopharynx
CF: febrile illness, trismus, odynophagia, reduced neck movement, swelling in neck
Contains carotid sheath so risk comps
M: airway, IV Abx, surgical drainage
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Epiglottitis
Emergency, H influenza main cause, 2-6y commonest group (rare now cos of Hib vaccine)
Infection - epiglottitis - obstructs laryngeal inlet
CF: rapidly progressive stridor, drooling, pyrexia, pain, 'quack like' cough, child sits up + leans forward to ease airway
M: airway (do not examine-spasm), calm, theatre GA for intubation, IV Abx (amoxicillin)
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How would you differentiate the causes of a neck lump based on its location?
* Anterior to ear-parotid
* Angle of mandible-jugulodigastric node (pharynx, tonsils etc)
* Inferior mandible-submandibular gland
* Bifurcation of CCA-carotid body tumour or aneurysm
* Midline between hyoid bone + thyroid gland - thyroglossal cyst
* Anterior border of SCM - branchial cyst
* Thyroid - thyroid nodule
* Supraclavicular fossa - Virchow's node
105
How do you investigate neck lumps?
US-guided FNA
| unless pulsatile!
106
Outline the causes of neck lumps
* normal neck structures pt identifies e.g. C1 vertebra transverse process, hyoid bone, cricoid cartilage
* skin infections
* lymphadenopathy: inflammatory, post-inflammatory, malignant
* benign tumours like lipoma, fibroma. poorly defined asymptomatic soft masses deep to skin
* malignant primary tumours e.g. salivary gland
* lymphoma: rubbery, painless, rare phenomenon of pain on drinking alcohol
* thyroid lumps: nodule/diffuse, move upwards on swallowing, often nodules/cysts/follicular adenoma but may be cancer; may by hypo, hyper or euthyroid
* salivary gland lumps e.g. pleomorphic adenoma of parotid (benign), malignancy (e.g. pain, paraesthesia, facial palsy), calculi (causing swelling + tenderness esp on eating, may be infected), SG infection with mumps or S aureus, chronic inflammation e.g. Sjögrens syndrome
* congenital + developmental
* carotid body tumour or aneurysm-painless, slow-growing, pulsatile over carotid bifurcation, can move sideways but not vertically (don't move on swallowing)
* trauma: haematoma, surgical emphysema
* congenital + developmental tumours
* pharyngeal pouch: in older men, posteromedial herniation, usually not seen but if big lump that gurgles on palpation, dysphagia, regurgitation, aspiration, chronic cough
* cervical rib - F>M, 10% develop thoracic outlet syndrome. fibrous brand branches towards sternum, often b/l, excised if NV compromise
* epidermoid cyst: common due to proliferation of endometrial cells, usually asymptomatic, typically firm round nodules with a central puncture
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What are the causes of airway obstruction?
Any obstruction between the nose/oral cavity to the alveoli, partial more common + causes stridor, or complete (may be silent, rapidly fatal)
Causes: trauma, bleeding, pharyngeal infections (epiglottis, croup, diphtheria, Ludwig's angina), angioedema, laryngitis, epiglottis, intraluminal oedema e.g. croup, inhaled FB, b/l vocal cord paralysis
108
Paediatric causes of airway obstruction
* Supralaryngeal: choanal atresia (severe neonatal airway obstruction, relived on crying, surgery so can feed), micrognathia (e.g. Pierre Robin sequence or Treacher Collins syndrome, needs NP/oral airway), adenotonsillar hypertrophy (may cause OSA)
* Laryngo-tracheal causes: congenital like laryngomalacia/congenital subglottic stenosis/laryngeal wests, acquired like foreign body (obstructs mostly in expiration), croup/epiglottitis, subglottic stenosis, recurrent respiratory papillomatosis (from HPV 6/11 through birth canal, progressive hoarseness/aphonia)
109
How may airway obstruction present and how do you manage it?
CF: stridor, stertor (like snoring sound), confusion, high HR+RR, reducing GCS, IC+SC recession (esp babies as soft bones), accessory muscle use, tracheal tug (trachea moves down in neck during inspiration), cyanosis, exhaustion
M:
* clear airway
* inflate lungs
* alternative airway if needed: guedal (oral to keep tongue base forward in unconscious), endotracheal intubation, laryngeal mask airway (rests on laryngeal inlet to permit ventilation)
* supportive: O2, nebuliser adrenaline to open small airways, steroids to reduce oedema
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Neck trauma
* penetrating - can damage N/V/viscuses
* blunt from RTA, spots, strangulaion
* iatrogenic from long term ETT causing ischaemia/scarring, laryngeal stenosis
* inhaled fumes, corrosives
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What is the cavernous sinus?
A plexus of thin walled veins on the upper surface of sphenoid. Contains OTOM CAT:
* Lat wall S to I: Oculomotor n, Trochlear n, Ophthalmic n, Maxillary m
* Traversing: ICA, Abducens n
112
What is the cavernous sinus?
A plexus of thin walled veins on the upper surface of sphenoid. Contains OTOM CAT:
* Lat wall S to I: Oculomotor n, Trochlear n, Ophthalmic n, Maxillary m
* Traversing: ICA, Abducens n
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Reactive lymphadenopathy
Usually acute + painful
* Pharyngitis/tonsilitis with strep, s aureus, TB, EBV, HIV, parasitic, fungal
* connective tissue disease
* URTI, ear infection, headline, dental abscess, cat scratch disease
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Why may LN be persistently enlarged?
Often persist after URTI up to months, firm mobile non-tender and remain same size they are prob fine
* Refer if solitary, or sudden increase in size or parenteral anxiety
* In adults refer if remain enlarged after 2w unless clear h/o an infection
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Malignant lymphadenopathy
* LN mets: u/l progressive swelling of single/multiple nodes. Rubbery
* Leukaemia - generalised lymphadenopathy
* Lymphoma - painless rubbery lymphadenopathy often in posterior triangle
116
Congenital + developmental neck lumps
* Thyroglossal cyst: usually child, midline cystic lump nr hyoid bone, moves up when swallow/protrude tongue, may get infected
* Branchial cyst: usually late childhood/early adult, u/l painless slow-growing smooth fluctuant swellings, lateral neck, anterior triangle, superficial to SCM along line of deep cervical LN, contains cholesterol crystals, may get infected, no transillumination, no movement on swallowing, may have a fistula. May be excised or not
* Laryngocele: intermittent neck swelling, palpable on Valsalva manouevre
* Dermoid cyst: along lines of fusion e.g. under tongue
* Cystic hygroma/lymphangioma: soft fluctuant mass in posterior triangle or axilla, transilluminates, presents in infancy, contains lymph
* Haemangioma: compressible, appears bluish on overlying skin
* Lipoma: soft mobile lump in dermal layer
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What are the congenital causes of airway obstruction?
* Choanal atresia: failure of posterior canalisation so severe obstruction relieved on crying
* Jaw underdevelopment in syndromes meaning tongue displaced posteriorly e.g. Pierre-Robin (a/w cleft palate)
* Laryngomalacia-stridor starts soon after birth as collapse of soft laryngeal tissues on inspiration, resolves by 2y or may need excision of aryepiglottic folds
* Congenital subglottic stenosis @ level of cricoid cartilage (can also get this acquired from ETT ventilation)
* Laryngeal webs/cysts: webs usually anterior, cysts can be congenital/from ETT
* Tracheal compression from a vascular ring
* Tracheomalacia - soft tracheal cartilage, a/w prematurity
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Anatomy of the throat
* Oral cavity
* Pharynx: nasopharynx inc adenoids + ET opening, oropharynx up to superior epiglottis
* Larynx: protects trachea + bronchi, and produces voice. Multiple cartilages, main is thyroid cartilage (Adam's apple) which is inferiorly linked to the cricoid cartilage. Divided into supra glottis, glottis and sub glottis. True+false cords prevent food entering + also larynx elements when swallow to stop food going in. Cords produce phonatory sound, teeth tongue + lips make speech. Recurrent laryngeal nerves supplies the muscles except cricothyroid (superior laryngeal n)
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Lesions in the oral cavity causes
* Masses - tongue usually neoplastic, cystic lesion in SG
* Ulceration: malignant until proven otherwise, may be aphthous e.g. a/w Crohn's
* Haemorrhage: gum disease, malignancy, bleeding disorder
* Discolouration: potential for malignant transformation. white (leukoplakia) and red (erythroplakia) patches
Refer under 2ww. RF for cancer are age, smoker, heavy drinker, chew tobacco/betel nut
120
What causes gingival hyperplasia?
* AML
| * Drugs: phenytoin, ciclosporin, calcium channel blockers esp nifedipine
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Obstructive sleep apnoea
Complete obstruction of airway so pt wakes up to alter position, may be prolonged and cause hypoxaemia, repeated-poor sleep + strain on CV system (HTN, stroke, HF, pulmonary HTN).
Children main cause adenotonsillar hypertrophy, adult main cause obesity, worse with alcohol + smoking
Comps: poor work/school performance, relationship problems, daytime sleepiness, increased risk of RTAs, CV comps
Ix: BMI, TFT (hypothyroidism), CXR (obstruction), ECG (RV failure), sleep study
M:
* Adult: lifestyle, treat rhinitis, improve nasal calibre, CPAP via face mask/nasal prongs
* Children: treat rhinitis, refer to ENT may do adenotonsillectomy
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Snoring
Partial upper airway obstruction from anywhere between nose to larynx - occurs in sleep as pharyngeal muscles relax
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What are adenoids and why are they removed?
Lymphoid tissue in nasopharynx, regress between 7y-adolescence
* Repeated URTI - pathological hypertrophy + bacterial develop biofilm so hard to overcome
* CF: nasal obstruction, pharyngitis from mouth breathing, OSA, rhinosunsitis, recurrent URTIs, otitis media, hypo nasal quality to speech
* Consider adenoidectomy.
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Pharyngitis
Common usually due to virus and a/w ARS, causes dysphagia, malaise, hyperaemic mucosa, swelling + tender LN. May be chronic esp in smokers, mouth breathing, periodontal disease
M: analgesia, plenty of fluids, Abx if pus/severe pain on swallowing/prolonged unresponsive
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Tonsillitis
* Cause: typically virus (rhinovirus, adenovirus etc) then bacteria supervene (beta haemolytic strep, staph, strep pneumonia, h influenza)
* Rarer forms include infectious mononucleosis (EBV, severe membranous tonsillitis, marked nodal enlargement, lymphocytosis, a/w splenomegaly), diphtheria( v rare, grey tonsil membrane, pyrexia usually low), agranulocytosis (ulceration on tonsils + oral mucosa), HIV (pharyngitis + infective tonsillitis with opportunistic organisms like fungi)
* CF: pyrexia, dysphagia, tender cervical lymphadenopathy, odynophagia, trismus, foetor, otalgia, red swollen tonsils+/- exudate, headache, malaise
* M: depends on Fever-PAIN score, if Abx use phenoxymethylpenicillin for 10d/cefalor. Avoid amoxicillin/ampicilin as it its actually mono can cause a maculopapular rash
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Fever-PAIN score for tonsillitis
```
Give Abx if score is 4-5
Fever during previous 24h
Purulence on tonsils
Attend rapidly within 3d onset
Inflamed (severely inflamed tonsils)
No cough coryza (indicates less likely viral URTI)
```
127
Possible complications of tonsillitis
* AOM
* Peritonsillar abscess-pus within peri-tonsillar tissue but outside tonsil capsule. Pt systemically unwell, severe pain + otalgia, buccal mucosa often furred, reduced neck mobility, pain localises to one side, tonsil pushed down + medially, deviation of uvula. M: IV ABx + drainage, consider tonsillectomy when recovered
* Retropharyngeal abscess
* Parapharyngeal abscess
* Pneumonia
* Glomerulonephritis + rheumatic fever from strep tonsillitis - uncommon now
* Scarlet fever: streptococcal tonsillitis + punctate erythematous rash + strawberry tongue
128
Tonsillectomy
SIGN guidance: 7+ well documented adequately treated sore throats in preceding year/5 or more each year for 2y/3 or more each year for 3y; recurrent febrile convulsions due to tonsillitis; OSA/dysphagia from enlarged tonsils/peritonsillar abscess if other therapy not working
Post-op: adv normal eating to encourage sloughing, adequate analgesia + hydration, warn about norm appearance up to 2w, v v painful esp first 10d (increases in first 6d)
Comp: primary bleeding in first 24h needs return to theatre, or secondary usually due to infection which improves w IV ABx
129
Pharyngeal cancers
* Carcinoma: painful ulceration + induration of pharynx/tonsil, often earache/slight bleed
* Lymphoma: painless enlargement of affected tonsil
130
Pharyngeal pouch - hypopharyngeal diverticulum
Area without muscle between inferior constrictor + cricopharynxgeus - herniation can occur (Killian's dehiscence) - pouch.
Mostly affects older people
CF: discomfort, dysphagia, delayed regurgitation of food, aspiration pneumonia, gurgling noises on swallowing, halitosis. Almost never causes a neck lump!!
Ix: barium swallow
M: surgery if symptomatic to divide the wall + staple the edges
131
Globus pharyngeus
Sensation of lump in throat, often overcome by eating. Often have GORD, may worry about cancer which then aggravates it
M: ENT for reassurance, GORD antacids/PPI if features
132
What are the indications for tracheostomy?
* Relieve upper airway obstruction
* Protect the tracheobronchial tree e.g. in Guillain-Barre syndrome or a brainstem stroke
* Artificial ventilation - for long period, more comfortable than an ETT
133
What are the potential complications of tracheostomy?
Bleeding, pneumothorax, mediastinal emphysema, obstruction by secretion crusts, dislodgement of tube, surgical emphysema from positive pressure ventilation, perichondritis, sub glottic stenosis
134
Foreign bodies in the throat
May impact in pharynx, oesophagus, stomach. May lead to perforation, mediastinitis
CF: feeling of sharp scratch when swallow, odynophagia, dysphagia, may cause airway obstruction if bolus pressing on trachea
135
How may laryngeal lesions present?
* Hoarseness - nr vocal cord
* Aspiration - failure of laryngeal inlet to close on swallowing
* Stridor or tachypnoea from turbulent flow
136
Acute laryngitis
Affects adults, usually caused by an URTI virus and RF include overuse of voice/smoking/alcohol
CF: aphonia (whisper/lost voice), dysphonia (hoarse), cough, pain, stridor (rare)
137
Supraglottitis
Adult epiglottitis - seven pain, slower to develop than epiglottitis + resp obstruction less likely
138
Chronic laryngitis
RF: smoking, alcohol, habitual shouting, professional voice users
Chronic inflammation in laryngeal mucosa/muscle imbalance
CF: dysphonia, voice fatigues easily, discomfort, tendency to clear throat
M: voice rest, treat any infection, steam inhalation, stop smoking, voice therapy
139
Muscle tension dysphonia
This is when there is abnormal coordination of the intrinsic laryngeal muscles
* Spasmodic
* Functional: no apparent structural issue but abnormal voice
* Functional aphonia 'mutism' - may be psychological
Strain to produce good voice, tires easily
RF: URIT, GORD, excessive use, stressful life events
140
Vocal cord nodules
Singers/screamers nodules - from excessive use. Made of fibrous tissue, usually respond to rest +/- SALT
141
Inflammatory lesions in the larynx
Reinke's oedema, polyps, cysts, granulation tissue --> interfere with normal cord apposition so get hoarseness
142
Vocal cord paralysis
Usually U/L and p/w hoarse breathy voice as the cords cannot appose, if severe may get aspiration
Usually the result of left RLN palsy (as it has the longer course + goes around the aortic arch) - e.g. chest pathology like malignant mediastinal nodes, oesophageal or bronchial carcinoma, aortic aneurysm, chest/neck surgery
Either RLN can be damaged by thyroid surgery or H+N cancers
143
Recurrent laryngeal nerve palsy
Can be due to surgery or cancer of the thyroid, or a brainstem pathology
144
Sialdenitis
Usually acute inflammation of salivary gland
* RF: SG stones, reduced flow (dehydration, post-op, drugs), poor oral hygiene, exacerbation of chronic inflammation
* Mumps: usually parotid glands. Swollen + painful, low grade fever, malaise. Self limiting, can cause deafness/orchitis/encephalitis
* Acute suppurative parotitis: in immunocompromised, uncommon, Abx/drainage
* Acute sialadenitis: usually SM gland, infection from oral cavity tracts back/stone in duct. Five, painful swollen gland worse on eating. M: analgesia, fluids, may need Abx/drainage, remove stone after infection
145
Sialolithiasis
Stones in salivary duct cause pain + swelling - worse during meals
Mostly affect SM gland (e.g. stone in Wharton's duct which drains it) as this is where thickest mucus made, can get in parotid (e.g. Stenson's duct), v rare in SL
Ix: US or sialogram
M: small ones analgesia+hydration, otherwise may need radiological or surgical removal of the stones/gland
Comps: sialadenitis, abscess
146
Sjogren's syndrome
Autoimmune lymphocytic infiltrate into ductal tissue of secretory glands -- dry eyes, dry mouth, enlarged SG, higher risk lymphoma, keratoconjunctivitis sicca
Causes b/l, painless enlargmenet of the gland. Lymphocytic infiltrate. Supportive treatment
Primary or a/w CT disease like RA, 90% female
147
Salivary retention cysts
Mostly in floor of mouth, surgically removed
148
What is a permanent enlargement of a salivary gland?
cancer until proven otherwise
149
What might cause salivary gland hypertrophy that isn't cancer?
endocrine e.g. myxoedema
| drugs e.g. oral hypoglycaemics
150
Salivary gland tumours
* Benign: pleomorphic adenoma most common + usually parotid (slow growing, smooth, mobile), can become malignant but slow growth; also Warthin's tumour (multiple cysts + solid lymphoid tissue, typically elderly male)), haemangioma
* Malignant: adenoid cystic carcinoma (early perineural invasion), also other types
151
Sialorrhoea
Salivary overflow when can't control SM/SL glands - can cause eczema + soil clothes - hyoscine patches help reduce flow, sometimes botox
152
Effect of HIV on the parotid gland
Lymphoepithelial cysts - b/l, multi cystic, symmetrical parotid swelling. Low risk of malignant transformation so usually conservative
153
Sarcoidosis in the salivary glands
May affect parotid glands (b/l) with non-tender swelling, xerostomia
154
Epidemiology of H+N cancers
M:F 2:1, usually SCC, high mortality + debilitating treatments.
RF: alcohol, tobacco, betel nut chewing (oral cancer), Chinese ethnicity (NP carcinoma), oropharyngeal HPV, male, older, low SES
155
CF of H+N cancers
```
Dysphonia, dyspnoea- esp laryngeal
Dysphasia/odynophagia
Neck mass
Pain from site or referred otalgia
Bleeding fro nose/moiuth
Nasal blockage
Non-healing ulcer in mouth or tongue
```
156
Where do H+N cancers arise?
* Larynx: commonest site for SCC, commonest is glottic @ VC. Often need a total laryngectomy so then breathe through a laryngeal stoma + speak through valve
* Pharynx + oral cavity: less common + worse prognosis, nasopharyngeal mostly chinese men, oropharyngeal in tonsis, 'hypopharynx' esp poor prognosis. cf are dysphagia, hoarseness, non-healing ulcers, u/l nasal polyps
157
How to investigate thyroid nodules
FNA
Hemithyroidectomy if suspect follicular disease as DNA doesn't pick up
Lumpectomies don't give adequate margins
158
Non-neoplastic thyroid nodules
* Single nodules: colloid, cystic
| * Multinodular goitre: common, if typical appearance on US don't need FNA
159
Thyroid neoplasms
* Benign: follicular adenoma
* Malignant: papillary adenocarcinoma (70%, a/w younger pt or neck irradiation), follicular carcinoma (20%, mets to bones + lungs), medullary carcinoma (5%, of calcitonin secreting C-cells, typical in MEN so screen other organs), anaplastic carcinoma (5%, typically older pt, poor prognosis)
160
How are thyroid nodules managed?
* Non-neoplastic: conservative, unless causing sx or diagnostic uncertainty in which cause aim for hemithyroidectomy to reduce endocrine comps
* Neoplastic: adenoma hemi-thyroidectomy to confirm, for carcinoma total thyroidectomy +/-adjuvant radio-iodine therapy (for papillary + follicular carcinoma)
161
What are the complications of thyroid surgery?
* Haematomas: confined space so resp compromise can arise - need to immediately remove sutures
* Airway obstruction due to haemorrhage or RLN palsy
* VC palsy
* Hypocalcaemia from parathyroid gland damage/removal, can cause QTc prolongation
162
Differentials for facial pain
* Sinusitis: facial fullness + swelling, nasal discharge, pyrexia, cough from post-nasal drip
* Trigeminal neuralgia: u/l facial pain, brief electric shock-like pains that have abrupt onset + termination, may have triggers like emotion or light touch
* Cluster headache: pain 1/2 per day for between 15m-2h, clusters of 4-12w, intense pain around one eye a/w redness, lacrimation, lid swelling, nasal stuffiness
* Temporal arteritis
163
Black hairy tongue
May be brown, green, pink or black
* RF: poor oral hygiene, Abx, H+N radiation, HIV, IVDU
* Swab tongue to exclude candida - give topical antifungals
* M: tongue scraping
164
How do the vocal cords appear in respiration + phonation, in normal + paralytic states?
* Normal: open in resp, fully closed in phonation
* U/l paralysis, open in resp but not fully on one side, not fully closed on one side in speech
* B/L paralysis remain slightly open in respiration, fully closed in phonation
165
Scarlet fever
Reaction to toxins produced by group A beta haemolytic strep, most commonly 2-6y
* Typically high fever, malaise, headache, N+V, sore throat, strawberry tongue, fine punctate erythema on torso initially + flexors 'sandpaper' texture, children often flushed appearance with circumoral pallor, later get desquamation esp fingers/toes
* Take throat swab but start Abx empirically
* Pen V for 10d or azithromycin
* Notifiable disease
* May get comps - otitis media after 20d is most common, also acute glomerulonephritis, bacteraemia, nec fasc
166
What is a goitre?
Enlarged thyroid gland
| If big can compress airway + cause dysphagia
167
What is a thyroid nodule?
An abnormal mass in the thyroid, majority aren't true neoplasms but need to check fro neoplasia + functional nodules causing hyperthyroidism
168
Anterior vs posterior epistaxis
Anterior - visible source of bleeding, usually an insult to Kiesselbach's plexus
Posterior - more profuse, originate from deeper structures, more in elderly pt, higher risk of aspiration + airway comrpmosie
169
Naspharyngeal carcinoma
SCC of nasopharynx, rare except in people from Southern China, a/w EBV infection
CF: cervical lymphadenopathy, otalgia, u/l serous otitis media, nasal obstruction/discharge/epistaxis, CN palsies
Combined CT + MRI to image, radiotherapy 1st line treatment
