ENT Flashcards
Name 3 symptoms of otitis externa
Otalgia, discharge, itchiness
Name 3 precipitating factors for Otitis externa
Excess canal moisture - 'swimmers ear' Trauma e.g. fingernails High humidity Absence of wax Hearing aids Narrow ear canal
What 2 organisms are chief causes of otitis externa?
Pseudomonas aeruginosa and s.aureus
Investigations and management for otitis externa
Swab any discharge
Topical antibiotics and steroid - e.g. gentamicin + hydrocortisone
Oral abx if systemically unwell (fluclox)
If otitis externa is persistent, unilateral, ?resistant to treatment what are you worried about?
Malignant otitis externa - particularly in diabetics/immunocompromised/elderly
Malignant SCC - biopsy
Name the 4 main causes of ear discharge, and describe how the discharge may differ with each cause
Otitis Externa - scanty discharge
Otitis Media - mucous
Cholesteatoma - offensive mucous discharge
CSF otorrhoea - following trauma, contains glucose or makes ‘halo’ sign on filter paper.
A 25 year old man presents to the GP with rapid onset of otalgia (within the last day) and discharge from the ear. He has been vomiting, and unable to eat in the last day and says he is much worse than he was last week when he had a ‘severe’ cold. His temperature is 37.9. What is the likely diagnosis
Otitis Media
Name the 3 common symptoms of otitis media
Otalgia, pyrexia, malaise/coryzal sx
3 common causative organisms of otitis media
Pneumococcus, Haemophilus, Moraxella
A mother bring her 1 year old into the GP as for the last day he has been feverish, tugging at his ear, irritable and not tolerating feeds. However, while in the waiting room she notices a snotty substance on his ear and he seems much more settled. What is the likely dx?
Otitis Media with tympanic membrane perforation - relieves the pressure lessening pain.
The parent of a 5 year old with AOM is insistent on his receiving abx, what is the rationale for when to give them? What would you give?
60% will self-resolve within 24h.
Indications - systemically unwell, perforation and/or discharge in canal, sx lasting >4/7 or not improving, immunocompromise.
PO 5/7 amoxicillin (erythromycin/clarithromycin if penicillin allergic)
Define chronic otitis media, name symptoms
Perforated TM accompanied by recurrent or persistent infection, causes otalgia, otorrhoea, aural fullness and hearing problems.
Complications of cholesteatoma
Meningitis, cerebral abscess, facial nerve palsy, hearing loss, mastoiditis
What are the 2 cardinal sx of cholesteatoma
offensive discharge and hearing loss
What is a cholesteatoma?
Non-cancerous growth of squamous epithelial cells trapped in the skull base causing local destruction. Seen most commonly in 10-20y/o. Risk factor = cleft palate.
What causes mastoiditis?
Middle ear inflammation causes destruction of air cells in the mastoid bone which can cause abscess formation.
symptoms of mastoiditis
otalgia, fever, swelling and redness behind the pinna, protruding auricle
How would you manage a patient with suspected mastoiditis who presents to you in GP
Immediate referral to hospital for IV antibiotics!
How would you manage a perforated tympanic membrane
Reassure that most perforated TM will self-resolve in 6-8 weeks, try and keep the ear dry and don’t insert anything into it.
Follow up in 6 weeks - not healed yet then refer to ENT
How would otitis media look on otoscopy?
TM bulging and erythematous, dilated circumferential vessels.
Is Otitis Media with Effusion more worrying in an adult or child? Why?
Adult. In adult should r/o postnasal space tumour. Kids - adenoids and narrow Eustachian tube make them more liable to effusion.
Risk factors for OME
Boy, downs syndrome, cleft palate, winter, atopy, child of a smoker, primary ciliary dyskinesia
What is the main presenting complaint for otitis media with effusion?
Hearing loss in kids - may have faltering school performance, poor listening/behaviour/speech/balance, inattention, language delays, ear infections/URTIs
What might you see on otoscopy of someone with otitis media with effusion?
Retracted or bulging TM, fluid level or bubbles behind it, can be dull, grey or yellow.
How would you manage a child with suspected otitis media with effusion?
refer for formal hearing tests and audiometry - pure tone testing and impedance tympanometry.
Usually self resolves - active observation of OME for 3 months (advice on how to minimise impact of hearing loss e.g. reduce background noise, sit at child level and give them simple instructions) then reassess, at which point a failure of improvement may ?grommets
Which tests does the universal newborn hearing screening utilise?
Otoacoustic emissions (measures peripheral auditory system function) Audiological brainstem response (measures auditory pathway from CN8 to lower brainstem)
A child of 8 months old requires hearing tests, what test would you use
Visually reinforced audiometry used from 6months to 2.5yrs
What are the important dangerous causes to exclude in unilateral sensorineural hearing loss
nasopharyngeal ca, acoustic neuroma and cholesteatoma
A 25 year old woman visits the ENT clinic complaining of hearing loss and tinnitus, and occasionally a bit of vertigo. She thinks her father may have had something similar and is worried that she is going deaf. She has no pain or discharge. PMH - 3 months postpartum (G1P1). PSH - C-section 3/12 ago. DHx - COCP, multivitamins.
What is the likely diagnosis?
Otosclerosis - autosomal dominant (father), accelerated by pregnancy, more common in females.
What treatment can be offered for otosclerosis?
Hearing aids or surgery - stapedectomy/stapedotomy (CI contralateral SNHL as risk of SNHL), cochlear implant if severe.
Range of normal hearing level and hearing loss categories
-10 to +25 Mild - 26-40 Moderate - 41-70 Severe - 70-90 Profound >90
Which ototoxic drugs are associated with permanent hearing loss?
Cisplatins and aminoglycosides e.g. gentamicin
Which ototoxic drugs are associated with tinnitus and reversible hearing loss?
NSAIDs, aspirin, loop diuretic, quinine and macrolides.
How may an acoustic neuroma (vestibular schwannoma) present? How would you investigate?
Progressive Ipsilateral tinnitus ± SNHL. If large can give ipsilateral cerebellar or RICP signs. Can cause neuropathies of CN 5,6,7. MRI.
Define benign paroxysmal positional vertigo and the underlying pathophysiology
Attacks of sudden onset episodes of rotational vertigo lasting around 30s on moving the head, commonly when turning over/getting out of bed. No persistent vertigo, changes in hearing or tinnitus, no nystagmus, no headache/ataxia/visual or sensory problems.
Due to the displacement of otoliths stimulating the semicircular canals.
What investigation is used to diagnose BPPV
Dix-Hallpike test
How is BPPV treated
Usually self-limiting, can utilise the Epley manoeuvre .
How does Meniere’s disease present?
Sudden attacks of vertigo lasting 2-4h and nystagmus, may be preceded by aural fullness and tinnitus. May see fluctuating SNHL.
How is Menieres disease treated?
Acutely - prochlorperazine
Prophylaxis - betahistine
How does vestibular neuronitis present?
recurrent vertigo attacks lasting hours or days, usually accompanied by horizontal nystagmus. May see nausea and vomiting. NO hearing loss or tinnitus.
a 45 year old man presents to his GP with unbearable vertigo which has persisted for the last 2 days
Hx - vertigo which is made worse by moving but was not triggered by it, N+V, tinnitus. Had an URTI last week for which he did not seek medical help.
O/E - horizontal nystagmus towards the R, Weber localises to the R, Rinne positive on the R and L (AC>BC).
What is the likely dx?
Viral labyrinthitis
- recent viral (?) URTI
- vertigo exacerbated by moving but not triggered by it (r/o BPPV)
- vertigo lasting 2 days - menieres tends to last a few hours, BPPV a few seconds
- Hearing loss and tinnitus - vestibular neuronitis affects vestibular nerve only, not labyrinth so would not expect hearing loss.
How would you differentiate a turbinate to a polyp
Turbinate tends to be pale, polyp pink
Turbinate sensitive to touch, polyp insensitive to gentle palpation
How would acute sinusitis present?
Thick purulent discharge, facial pain worse on leaning forward, nasal obstruction
How should acute sinusitis be managed?
usually self-limiting
<10 days or improving - analgesia ± nasal decongestants
10+ days = intranasal corticosteroids (mometasone) ± PO phenoxymethylpenicillin 5/7 (if systemically unwell or not improving after 2wks)
How would you expect a bacterial sinusitis to present vs viral?
Purulent discharge, double-sickening - usually see viral sinusitis appear to get better then it gets worse again with secondary bacterial infection
How should allergic rhinitis be managed?
Mild-moderate = oral or nasal antihistamines e.g. loratadine
Moderate-severe = intranasal corticosteroids e.g. mometasone
Life-event e.g. exams - consider short course PO prednisolone
Name some associations of nasal polyps
cystic fibrosis
infective sinusitis
Samters triad - aspirin sensitivity, asthma + nasal polyps
Kartageners syndrome and Churg-Strauss syndrome
A 60 year old man presents to his GP with rhinorrhoea and and reduced sense of smell which has become bothersome. O/E - polyp seen in left nostril,right nostril clear.
What is your next step in management?
2WW to ENT - unilateral polyp can be sign of lymphoma or nasopharyngeal cancer.
How would you treat someone with chronic rhino sinusitis with polyps
topical intranasal steroids to shrink polyps e.g. 2wks intranasal betamethasone followed by 3 months intranasal fluticasone
What symptoms/signs diagnose acute bacterial rhinosinusitis?
3+ of - discoloured discharge (with a unilateral predominance) and purulent secretion into nasal cavity, severe local pain (with unilateral predominance), fever >38, elevated ESR/CRP, double-sickening.
Common causative organisms of acute bacterial rhinosinusitis
H. influenzae and s.pneumonia, s.aureus and moraxella catarrhalis, fungal.
Management of acute rhinosinusitis
Most cases are self-limiting and will resolve in ~2wks - analgesia, nasal saline irrigation, intranasal decongestants.
Antibiotics if suspected bacterial - phenoxymethylpenicillin 5/7.
If recurrent would refer for imaging/surgery - CT paranasal sinuses, nasal endoscopy; advise smoking cessation.
Complications of rhinosinusitis
Orbital cellulitis/abscess, intracranial involvement (meningitis, encephalitis, abscess, CST), myocoeles -> pyocoeles, osteomyelitis.
A 25 year old male presents to A+E having sustained a punch to the nose which is now bleeding. O/E - R sided peri-orbital haematoma, epistaxis, nasal deformity. No battle sign, peri-orbital ecchymosis, not assessed CSF rhinorrhoea due to blood, no septal haematoma seen.
You suspect a broken nose, how will you manage this?
Manage epistaxis - lean forward and pinch soft part of nostrils for 15 minutes, if successful prescribe naseptin, still bleeding proceed to nasal packing/cautery
Close any skin injury
Analgesia and ice for pain and swelling
Reassess 5-7d post injury once swelling has resolved, if required can perform MUA 10-14d after injury
Describe assessment and management of epistaxis
Resuscitation if needed - hypotensive, dizzy on sitting. A-e assessment (iv access, o2 sats, monitor obs)
Hx - which side? hx trauma? how much blood lost over how long? PMH + warfarin use?
Pinch soft lower nose for 20 minutes, leaning forward and breathing through the mouth, use an ice pack on dorsum of nose.
Assess site of bleeding:
- Anterior Little’s area supplied by Kiesselbachs plexus - apply lidocaine spray/cottonball soaked in 1:200,000 adrenaline for 2 minutes. Nasal cautery if unilateral bleeding (both sides septum risks perforation). Does not work = anterior pack.
- Can’t see it - refer to ENT. May mx with posterior pack, examination under anaesthetic, endoscopic ligation of sphenopalatine artery in serious bleeds, or embolisation if life-threatening bleed but can cause stroke.
how may a septal haematoma present and how should it be managed?
hx some sort of trauma, feeling of nasal obstruction, rhinorrhoea, pain. O/E boggy red swelling arising bilaterally from the septum. Management - seen by ENT that day for surgical drainage (3-4 days can -> septal necrosis and saddle nose deformity)
What are the centor criteria?
Factors which indicate likelihood of streptococcal cause of acute tonsillitis. A score of 3+ support use of antibiotics - usually 10/7 PO phenoxymethylpenicillin. Presence of tonsillar exudate History of fever Tender anterior cervical lymphadenopathy Absence of cough
Complications of tonsillitis
Otitis Media, sinusitis, peritonsillar abscess, parapharyngeal abscess, Lemierre syndrome
A 25 year old woman presents to the GP with a sore throat and fever (38.1) which has lasted for 3 days, she has no cough and no exudate on her tonsils, and has no clinical lymphadenopathy. PMH - hyperthyroidism. DHx - NKDA, carbimazole.
What is your next step?
This patient needs a FBC as carbimazole can cause bone marrow suppression and subsequent neutropenia, in which case carbimazole should be stopped.
A 30 year old male arrives at A+E extremely worried that he has ‘meningitis’ - he presents with a widespread erythematous rash which came on that morning. O/E results of note: pyrexial (38.1), tender cervical lymphadenopathy. He went to the GP earlier this week where he was diagnosed with tonsillitis and is now on antibiotics.
What do you suspect is the pathology in this patient? Why?
A widespread rash could be meningococcal sepsis, and this could have occurred secondary to the primary infection.
However, the more likely explanation is that this patients ‘tonsillitis’ was in fact infectious mononucleosis - pyrexia, lymphadenopathy and pharyngitis caused by EBV and the antibiotics given were amoxicillin which causes a maculopapular rash.
How would you treat a patient with infectious mononucleosis? What advice would you give?
No specific treatment, advise supportive care of paracetamol or ibuprofen for fever and good fluid intake to prevent dehydration. IM can cause splenomegaly so avoid contact sports for 8 wks due to risk of splenic rupture.
A 3 year old boy is brought to the GP by his mother with an erythematous rash on his axilla, chest and behind his ears which appeared 1 day ago and a sore throat and fever which he has had for the last 3 days. O/E erythematous, pin-prick blanching rash which is rough to the touch, he is otherwise flushed in the face with circumoral pallor and a ‘strawberry’ tongue.
What is your suspected diagnosis?
Scarlet fever - reaction to erythrogenic toxins released by GAHS (usually s.pyogenes), peak incidence 4 (2-6). Commonly see a fever and sore throat lasting 1-2 days, followed by red pinprick blanching ‘sandpaper’ rash, strawberry tongue, facial flushing with circumoral pallor, malaise headache, N&V.
What is the management for scarlet fever inc back to school advice? Complications?
PO Penicillin V 10/7, back to school 24h after commencing abx, notifiable disease!
Most common complication is otitis media, can get rheumatic fever, acute glomerulonephritis, meningitis.
Indications for tonsillectomy
Recurrent sore throat is due to tonsillitis, which is disabling and prevents normal function.
At least 7 well documented clinically significant, treated episodes of sore throat in 1 yr, 5 episodes in each of the last 2, or 3 in the last 3.
a 14 year old girl is 12h post-tonsillectomy when nurses reports bleeding from her wound. What is your next step?
ENT assessment for immediate return to theatre (primary haemorrhage)
a 15 year old boy is brought to the GP 1 week post-tonsillectomy due to minimal bleeding from the surgical site. What is your next step?
Immediate admission to hospital for ENT assessment, IV antibiotics and observation.
define stridor
high pitched noise heard during inspiration due to partial obstruction at the level of the larynx or large airways
is stridor more common in adults or children?
Children - can be explained by pouseilles law whereby resistance varies inversely with the 4th power of the radius so narrowing of the already small airways causes massive increase in resistance. Hence obstruction happens faster and more dramatically.
signs of impending airway obstruction
stridor, dysphagia, drooling, pallor/cyanosis, use of accessory muscles of respiration and tracheal tug
causes of stridor
inflammation - CROUP, epiglottitis, laryngitis, anaphylaxis
Congenital - laryngomalacia, web/stenosis, vascular ring
trauma - chemical/thermal, from intubation
tumours - haemangiomas, papillomas
cardinal symptoms and signs of croup
stridor, barking cough ± resp distress due to upper airway obstruction, often worse at night.
how is croup graded
mild - occasional cough, no stridor
moderate - frequent cough, stridor at rest
severe - frequent cough, stridor at rest, respiratory distress
how is croup managed?
STAT PO dexamethasone 0.15mg/kg (emergency rx high flow O2 and nebulised adrenaline)
Admit if severe, or moderate but not settling, or if <6months, known anatomical abnormality or unsure dx
Advise parents it is self-limiting and usually resolves within 48h but safety net seek help if severe signs
causative organism of croup?
parainfluenza viruses
causative organism of acute epiglottitis
haemophilus influenza B
presentation of acute epiglottitis
classically children but now being seen more in adults due to vaccination programme against HiB Rapid onset - ENT emergency due to potential for airway obstruction Pyrexia and generally unwell Stridor Drooling and pooling of saliva Muffled voice or cry Sore throat without cough Adults - sore throat and odynophagia
Management of acute epiglottitis
Keep the patient calm by any means - crying can cause further oedema -> airway obstruction -> respiratory arrest.
DO NOT examine the throat, just call for ENT and anaesthetist immediately for laryngoscopy, intubation, dexamethasone and abx
Causes of hoarseness (dysphonia)
Laryngeal ca, laryngeal n palsy (e.g. lung / thyroid / oeseophagus ca, parathyroidectomy), laryngitis (viral, GORD, autoimmune e.g. RA), vocal cord nodules, Reinkes oedema.
How may a recurrent laryngeal nerve palsy present? How would you investigate this?
weak ‘breathy’ voice, repeated coughing/aspiration, exertional dyspnoea. If no recent surgery CXR, then if clear CT neck (base of skull -> hilum) ± US thyroid ± OGD
Causes of dysphagia
Extrinsic - compression from lymphadenopathy/lung ca/mediastinal mass, cervical spondylosis, IDA
Oesophageal wall - achalasia, diffuse oesophageal spasm, hypertensive LOS.
Intrinsic - tumours, strictures, oesophageal web, schatzki rings
neurological - CVA, Parkinson’s, MS, MG, brainstem pathology
How should dysphagia be investigated?
2WW referral for endoscopy - red flag sx if no assoc transitory odynophagia
What sx would indicate dysphagia to be malignant?
Constant or painful dysphagia
No impairment of fluid - ?stricture (benign or malignant)
anaemic, UEW, malaise etc.
Risk factors for oesophageal ca?
Smoking, alcohol intake, achalasia, Barretts oesophagus, tylosis, Plummer-Vinson synd
Symptoms of oesophageal ca
Dysphagia, weightloss, hoarseness, cough
How does a pharyngeal pouch develop?
Pharyngeal mucosa herniates through Killian’s dehiscence, an area of weakness, possibly due to incoordination of swallowing and increased pressure above the closed upper oesophageal sphincter.
symptoms/signs of a pharyngeal pouch
dysphagia with gurgling, regurgitation of undigested food, halitosis, lump in the neck, aspiration/pneumonia
how would you investigate ?pharyngeal pouch, then how is it treated
barium swallow
endoscopy to r/o malignancy within the pouch
endoscopic stapling of the wall dividing pouch from oesophagus
risk factors for head and neck ca
smoking, alcohol, vitamin A+C deficiency, HPV, GORD, deprivation
2ww referral for laryngeal cancer
45+ with persistent unexplained hoarseness OR unexplained lump in the neck
2ww referral for oral cancer
persistent unexplained lump in the neck or unexplained ulcer in oral cavity lasting >3wks
typical presentation of oropharyngeal ca and risk factors
older smoker with sore throat, sensation of a lump and referred otalgia. Risk factors - pipe smoking, tobacco chewing, HPV 16
typical presentation of laryngeal ca
older male smoker with progressive hoarseness, then stridor/dysphagia/odynophagia. May see haemoptysis or ear pain. Younger patients typically have HPV.
Which has the best prognosis:
A) Supraglottic laryngeal cancer
B) Glottic laryngeal cancer
C) Subglottic laryngeal cancer
B - causes hoarseness earlier and spread to nodes later
How is laryngeal cancer investigated
Laryngoscopy and biopsy, MRI staging, HPV test
How is laryngeal cancer treated
Small tumour = radiotherapy
Large = partial or total laryngectomy.
Causes of facial n palsy
UMN - Forehead sparing - stroke, SDH, SOL
LMN - not forehead sparing - infective (acute otitis media, cholesteatoma, HSV1, CMV, EBV1), parotid malignancy, trauma, iatrogenic, Bells Palsy (idiopathic).
How do you differentiate between UMN and LMN lesion in a facial palsy
Forehead sparing in UMN lesion due to dual innervation of the occipitofrontalis with branches from both ipsilateral and contralateral CN7 UMN.
Risk factors for Bells Palsy
Diabetes and pregnancy
treatment of bells palsy
reassure
eye care - may require lubricating drops, covering at night
present within 72h onset - PO prednisolone 25mg BD 10/7.
When should you refer Bells palsy to ENT?
Doubt about dx, recurrent or bilateral, failure to improve after 1 month.
A 45 year old man comes to the GP with a neck lump he is very worried about as he thinks it may be cancer. How many weeks should it be present before investigation should be considered?
> 3 weeks. Less than this is likely to be a reactive lymphadenopathy from a self limiting infection.
red flag sx of a neck lump
Hard and fixed
associated otalgia, dysphagia, stridor, hoarse voice
epistaxis or unilateral nasal congestion
UEW, night sweats, fever, rigors
cranial n palsy
kids - hx malignancy, supraclavicular mass, >2cm
A 39 year old woman comes to the GP with a lump in her neck, she reports no B sx, no changes in her voice, no difficulty or pain on swallowing. She has only recently noticed this lump which O/E is hard and fixed but not tender.
How would you investigate this neck lump?
USS neck lump ± fine needle aspiration.
Some dx do not need FNA, lymphoma - core bx preferable so would not undergo FNA.
What are the differential dx for a midline neck lump in someone:
A) under 20 yrs old
B) over 20 yrs old
A) dermoid or thyroglossal cyst
B) ?thyroid mass
How would you identify a thyroglossal cyst on clinical examination
Ask patient to protrude tongue and the cyst will move up
Differential dx for a submandibular neck lump
Reactive Lymphadenopathy
Malignant lymphadenopathy
TB, submandibular salivary stone, tumour or sialadenitis
What diagnosis would you want to rule out in someone with anterior triangle neck lump and splenomegaly?
Lymphoma
Anterior triangle neck lump found anterior to SCM in a 25 year old. Likely diagnosis?
Branchial cyst
What investigations would you perform on ?branchial cyst, what might you find?
US neck + FNA to rule out cystic mets from head and neck ca. Fluid contains cholesterol crystals
an 18 month old with a large, soft and fluctuant mass in the posterior triangle that transilluminates
Cystic hygromas - usually dx by 2 y/o, surgical excision or sclerotherapy
Sialadenitis most commonly affects which salivary gland
parotid
Sialadenitis is more commonly caused by bacteria or virus?
Virus
What is the most common cause of viral sialadenitis and where does it usually affect?
Mumps and parotid gland
What 2 diseases is chronic sialadenitis commonly associated with?
Sarcoidosis and Sjogrens syndrome.
How does mumps usually present?
Prodromal - low grade fever, headache, malaise
Bilateral gland swelling (can be unilateral)
Complications of mumps
Meningitis/encephalitis, deafness, pancreatitis, orchitis.
Investigations of sialadenitis
FBC, CRP, ESR, ?autoimmune screen, pus swabs if possible, blood culture if evidence of systemic involvement, viral serology if ?mumps
Management of sialadenitis
Good oral hygiene, fluid intake, analgesia, antibiotics if bacterial infection suspected, sialogogues such as lemon juice.
How does Sialolithiasis present?
Usually asymptomatic, if symptomatic get intermittent painful facial swelling during/after meals, stone may be palpable in floor of the mouth
Sialadenitis vs Sialolithiasis
Sialadenitis - prodromal sx malaise, headache and fever, bilateral swelling. More likely to affect parotid.
Sialolithiasis - only pain and swelling associated with eating. More likely to affect submandibular.
Mx sialolithiasis
good oral hydration, analgesia, good fluid intake, sialogogues such as lemon juice to promote saliva production.
What is the most common tumour affecting salivary glands
80% salivary gland tumours affect parotid, of which 80% are benign pleomorphic adenoma, of which 80% are in the superficial lobe.
Red flag sx for salivary gland tumour
hard fixed mass ± pain, overlying skin ulceration, lymphadenopathy, facial nerve palsy
Risk factors for salivary gland tumours
smoking, EBV, radiation, genetic alterations (p53 mutations)
How is suspected salivary gland tumour investigated?
Routine blood r/o infection - FBC, CRP, U+E
USS + FNA
Staging CT neck and thorax
How are most salivary gland tumours treated?
Excision
Radiotherapy can be used as an adjuvant or in non-resectable tumours.
Complications of salivary gland tumour excision surgery
Facial nerve palsy - can be transient facial n paresis which should resolve in 3-12 weeks, must include injury/sacrifice of facial n in consent.
Haematoma - can be rapidly expanding and cause airway obstruction
Late complications - Freys syndrome and salivary fistula
