ENT Flashcards
Name 3 things to look for on inspection of the ear
Pre-auricular - scars (parathyroidectomy, middle ear surgery), swelling (infection, parotid tumour), erythema (infection), sinuses, pits, fistulae
Pinna - erythema and swelling (infection, haematoma), tenderness
Post-auricular - scars, painful swelling (mastoiditis, lymphadenitis)
What features of the tympanic membrane should be assessed on otoscopy?
Presence of light reflex
Colour - red (inflammation), white (sclerosis)
Position - retracted (cholesteatoma, infection), bulging (infection), perforation
Ossicles - visible malleus, incus and stapes or not
What is pneumatic otoscopy?
Otoscope with air tight seal and rubber bulb which allows pressure to be altered within the ear canal
If the patient can hear a whisper at 60cm during a free field hearing test, approximately how good is their hearing?
Better than 30dB
If the patient can hear a whisper at 60cm during a free field hearing test, approximately how good is their hearing?
Better than 30dB
What does Weber’s test show?
If sound is louder in one ear, there is a conductive hearing loss in that ear OR sensorineural hearing loss in the other ear (Rinne’s test will confirm which)
If a patient has a unilateral conductive hearing loss, the tuning fork sound will be heard louder in the deaf ear
If a patient has a unilateral sensorineural hearing loss, the tuning fork sound will be heard louder in the normal ear
What does Rinne’s test show?
If sound is louder via bone conduction, there is an external/middle ear disease affecting air conduction
How can the nose be anatomically divided to aid inspection?
Bony pyramid/upper 3rd
Cartilaginous pyramid/middle 3rd
Lobule/lower 3rd
How should the nose be inspected on examination?
Front - shape, deviation from midline, scars, skin changes
Side - bump, collapse, projection, rotation of tip (up or down)
Below - symmetry, deviations, scars
Give 3 things which may be seen on anterior rhinoscopy
Septal deviation Swelling (rhinitis causing enlarged inferior turbinates, oedema and clear rhinorrhoea) Septal perforations Prominent blood vessels Polyps in middle meatus
What is nasal misting?
Assess degree of misting on metal surface to check airflow and patency
What structures are found in the post-nasal space?
Adenoid pad
Fossa of Rosenmuller
Eustachian tube orifice
If a neck mass moves on swallowing, what does this suggest?
Thyroid origin (e.g. goitre, thyroglossal cyst)
If a neck mass moves on tongue protrusion, what does this suggest?
Thyroglossal cyst
What is Pemberton’s test?
Test for a retrosternal goitre that may obstruct
the thoracic outlet and superior vena cava
A positive sign is
congestion of facial/neck veins and hoarse voice upon raising the
arms
What is the blood supply of the external ear?
Auriculotemporal branch of superficial temporal artery
Posterior auricular branch of external carotid artery
What is a cauliflower ear?
Cartilage necrosis which occurs when cartilage is separated from overlying perichondrium (e.g. due to infection, blood, trauma) from which it derives nutrients
What part of the ear communicates with the nasopharynx via the Eustachian tube?
Middle ear
What is presbycusis?
Decreased ability to detect high pitched sounds with increasing age
What is a distinguishing feature of true vertigo?
Sensation of spinning and movement of surrounding environment
What are the 3 most common causes of vertigo originating from the labyrinth?
Benign paroxysmal positional vertigo
Vestibular neuritis
Meniere’s disease
What are the main signs/symptoms of BPPV?
Sudden onset
No hearing loss
Hallpike test positive
Rotary vertigo on moving head
What are the main signs/symptoms of Meniere’s disease?
Gradual onset Fluctuating hearing loss Rotary vertigo Tinnitus worse during episode Aural fullness before onset of vertigo
What are the main signs/symptoms of vestibular neuritis?
Sudden or gradual No hearing loss Rotary vertigo continuous for >24 hours Associated nausea and vomiting Confined to bed Several days/weeks to resolve
How can vertigo be investigated?
Full neurological examination Pure tone audiometry Dix-Hallpike test MRI Video head impulse testing
What might prompt an MRI of the internal auditory meatus for a patient with vertigo and why?
Asymmetrical sensorineural hearing loss - exclusion of an acoustic neuroma
How is BPPV treated?
Curative in 90% - Epley manoeuvre (repositioning of displaced otoconia crystals)
Persistent - Brandt-Daroff exercises
Resistant - surgical posterior semi-circular canal occlusion
How is vestibular neuritis treated?
Anti-emetics
How is Meniere’s disease treated?
Reduce pressure - low salt diet, betahistine, diuretics
Intratympanic injection of steroid or gentamicin
Surgical - saccus decompression, labyrinthectomy, vestibular nerve section
How is vestibular migraine treated?
Symptom diary to identify and avoid triggers
Migraine preventative medication
Give 3 causes of conductive hearing loss
Excessive earwax Otitis media with effusion Tympanic membrane perforation Otosclerosis Cholesteatoma
What are the signs/symptoms of excessive earwax causing conductive hearing loss and what investigations may be done?
Blocked feeling, wax on otoscopy
No additional investigations
What are the signs/symptoms of OME causing conductive hearing loss and what investigations may be done?
Popping/clicking, pressure, dull TM, fluid level/bubbles on otoscopy
Tympanogram - flat trace
What are the signs/symptoms of TM perforation causing conductive hearing loss and what investigations may be done?
Middle ear discharge (if infected), perforation seen on otoscopy
No additional investigations
What are the signs/symptoms of otosclerosis causing conductive hearing loss and what investigations may be done?
Unilateral or bilateral, often no signs, Schwartz sign (red TM due to vessel injection)
CT, pure tone audiometry (Carhart notch)
What are the signs/symptoms of cholesteatoma causing conductive hearing loss and what investigations may be done?
Chronic smelly discharge, deep retraction pocket with keratin collection
CT (extent of disease)
Give 3 causes of sensorineural hearing loss
Presbycusis Noise induced Vestibular schwannoma Complication of meningitis Acute sensorineural loss
What are the signs/symptoms of presbycusis causing sensorineural hearing loss and what investigations may be done?
Bilateral, gradual onset, normal otoscopy
Pure tone audiometry
What are the signs/symptoms of noise causing sensorineural hearing loss and what investigations may be done?
Tinnitus, normal otoscopy
Pure tone audiometry
What are the signs/symptoms of vestibular schwannoma causing sensorineural hearing loss and what investigations may be done?
Asymmetric loss, normal otoscopy
MRI
What are the signs/symptoms of meningitis causing sensorineural hearing loss and what investigations may be done?
History of meningitis, normal otoscopy
MRI (labyrinth obliteration)
What are the signs/symptoms of acute sensorineural loss causing sensorineural hearing loss and what investigations may be done?
Tinnitus, vertigo, normal otoscopy
MRI, autoimmune screen
How is hearing loss managed?
Audiological - hearing aids
Surgical - tympanoplasty (repair perforation), stapedectomy (sound transmission), bone anchored hearing aid (conductive), cochlear implantation (sensorineural), middle ear implant (conductive)
How is excessive earwax managed?
Topical eardrops (olive oil, sodium bicarbonate) - softens impaction
Microsuction - evacuate
Jobson Horne wax probe - coax out
Syringing - primary care
Define tinnitus
Perception of sound when no external sound is present; objective or subjective
What is tinnitus often associated with?
Hearing loss
What are the 2 types of tinnitus?
Non-pulsatile - false perception of sound; buzzing, high-pitched tone or clicking and popping
Pulsatile (4%) - noise synchronous with heartbeat due to turbulent blood flow; treatable
What investigations can be done for tinnitus?
MRI - if unilateral and hearing loss (acoustic neuroma)
MR/CT angiography - pulsatile
How is tinnitus managed?
Reassurance
Address any underlying cause
Behavioural therapy and tinnitus retraining therapy
Noise generator for sleep
Hearing aid for hearing loss may mask tinnitus
What is Bell’s palsy?
The most common type of facial nerve palsy which is idiopathic and a diagnosis of exclusion
Give 4 causes of facial nerve palsy, other than Bell’s palsy
Trauma - temporal bone fracture, surgical injury
Infection - Ramsay Hunt syndrome, otitis media
Neoplastic - parotid or temporal bone tumour
Congenital - CHARGE syndrome
Inflammatory - sarcoidosis, GBS, MS
Other - cerebrovascular
What are the signs/symptoms of a facial nerve palsy?
Dry painful eye (closure impaired)
Drooling and difficulty eating
Paralysis of 1 side of the face and drooping of the mouth
What should be done on examination of a facial nerve palsy?
Differentiate between UMN (forehead sparing) and LMN
Test facial nerve function
Otoscopy
Head and neck examination
What classification system can be used for assessment of facial nerve palsy?
House-Brackman grade
1-6 from normal to no movement
What are the complications of facial nerve palsy?
Corneal scarring -> blindness
Wasting of facial muscles
Synkinesis
Psychological disturbance
What investigations can be done for facial nerve palsy?
Pure tone audiometry - conductive hearing loss (cholesteatoma), asymmetrical sensorineural hearing loss (acoustic neuroma)
MRI - central cause
How is facial nerve palsy managed?
Eye care - artificial tears, tape eyelid shut, refer to ophthalmology
Medical (Bell’s/RHS) - oral steroids and antivirals within 48 hours
Surgical - facial nerve grafting, facial reanimation
Why can otalgia be more significant than at first glance?
Pain can be referred from elsewhere in the head or neck (CN 5, 7, 9, 10 and C2/C3 cervical nerves)
What are the signs/symptoms of acute otitis media?
Child with severe ear pain and preceding URTI
Erythema, bulging drum, febrile
What are the signs/symptoms of otitis externa?
Severe pain often with preceding itch and water contact
Tender, narrow EAM and mucopus
What are the signs/symptoms of necrotising otitis externa/skull base osteomyelitis?
Elderly with severe pain and diabetes/other cause of immunosuppression
Granulation on floor of canal +/- CN palsies
What are the signs/symptoms of TMJ dysfunction?
Pain anterior to tragus, worse on eating
Normal eardrum, tender over TMJ, misaligned/clicking bite
Give 3 possible causes of referred otalgia
CN 5 man - TMJ dysfunction, salivary gland pathology, dental abscess
CN 5 max - mucosal inflammation in sinuses
CN 9 - peritonsillar abscess, tonsillitis, oropharyngeal carcinoma
CN 10 - laryngeal cancer
C2/3 - cervical spondylosis
Name 3 bacteria which commonly cause a discharging ear infection
Pseudomonas aeruginosa Staphylococcus aureus Proteus Streptococcus pneumonia Haemophilus influenza Moraxella catarrhalis
What should be asked in the history of a patient with discharging ear?
Duration (chronic = cholesteatoma/COM) Associated otalgia, fever, systemic symptoms Hearing loss or dizziness Foreign body (children) Facial nerve palsy (COM) Trauma (CSF) Topical antibiotics (prolonged use)
Give 3 conditions in which otorrhoea occurs?
Otitis externa Acute otitis media +/- perforation NOE Cholesteatoma Trauma - CSF
What signs/symptoms would indicate AOM +/- perforation as a cause for otorrhoea?
Recent URTI
Deep severe ear pain preceding and improved by discharge
Mucoid ear discharge
What signs/symptoms would indicate COM as a cause for otorrhoea?
Itchy ear canal
Thin watery discharge
Canal may be completely occluded
What is otitis externa?
Inflammation of the auditory canal which can be acute or chronic
Give 3 risk factors for otitis externa
Swimming Warm/humid climate Eczema Diabetes Immunosuppression Trauma (cleaning, scratching) Hearing aids (reduced ventilation)
What is the most common organism causing otitis externa?
Bacterial - pseudomonas, staphylococcus (epidermidis, aureus)
Can also be fungal
Give 2 symptoms of otitis externa
Otalgia (on movement of pinna/jaw)
Pruritis
Discharge
Hearing loss
What can be seen on examination of otitis externa
Pain on moving pinna
Swelling, erythema and purulent discharge in external auditory meatus
Why should the tympanic membrane be examined for perforation in otitis externa?
May be secondary to otitis media
What are the complications of otitis externa?
Peri-auricular cellulitis
NOE
What investigations can be done for otitis externa?
Swab ear canal for microscopy and sensitivity
Urgent CT if NOE suspected
How is otitis externa managed?
Microsuction Topical antibiotic (ciprofloxacin) and steroid ear drops via Pope wick
How is necrotising otitis externa managed?
Admit for diabetic control, IV antibiotics and regular microsuction
What is acute otitis media?
Acute inflammation of the middle ear, usually due to infection
In what age group is acute otitis media most common?
Infants
What are the risk factors for acute otitis media?
Lack of breastfeeding Attending nursery Family history Age 6-18 months Exposure to smoking
What are the bacterial and viral causes of acute otitis media?
URTI
Viral infection - RSV, rhinovirus, enterovirus
Bacterial - streptococcus pneumoniae, haemophilus influenza
What are the symptoms of acute otitis media?
Infants - fever, ear pulling, irritability, vomiting
Children/adults - otalgia, fever, unwell, hearing loss, purulent discharge
What signs may be seen on examination of acute otitis media?
Bulging/injected TM
Perforation with purulent discharge
What are the complications of acute otitis media?
Tympanosclerosis (scarring) Hearing loss TM perforation Mastoiditis Labyrinthitis Facial nerve palsy Meningitis Intracranial abscess Lateral/cavernous sinus thrombosis Subdural empyema
What investigations may be done for acute otitis media?
Swab if discharging
CT/MRI if complications suspected
How is acute otitis media managed?
Analgesia (ibuprofen) and antipyretics (paracetamol)
Oral antibiotics if no improvement in 24-48 hours (10 day course of amoxicillin)
Still no improvement, switch to co-amoxiclav
What is otitis media with effusion?
Middle ear fluid without signs of infection
AKA glue ear
At what age is otitis media with effusion most common?
2 years and 5 years old
What causes otitis media with effusion?
Eustachian tube dysfunction
Why are children more likely to experience glue ear?
Their Eustachian tube is smaller and more horizontal, impairing middle ear ventilation
What conditions increase the risk of glue ear?
Cleft palate
Syndromic conditions affecting the face and skull base (e.g. Down’s syndrome)
Why should glue ear be treated with suspicion in adults?
Unilateral middle ear effusion may be due to nasopharyngeal tumour which blocks drainage of Eustachian tube
What are the symptoms of otitis media with effusion?
May be asymptomatic in infants - parents may notice hearing loss or behavioural problems
What signs may be present on examination of otitis media with effusion?
Poor speech development
Dull TM
Visible fluid level
Poor TM compliance on pneumatic otoscopy
What investigations can be done for otitis media with effusion?
Pure tone audiogram (conductive hearing loss)
Tympanometry (flat type b curve)
Flexible nasoendoscopy in adults (rule out tumour)
How is otitis media with effusion managed?
Watch and wait - 50% resolution in 3 months
Hearing aid
Myringotomy and ventilation tube insertion
Adenoidectomy
After how long does a Grommet normally extrude and what are its complications?
9 months
Tympanosclerosis and perforation
What are the 2 types of chronic otitis media?
Mucosal - TM perforation in presence of recurrent/persistent infection
Squamous - retraction of TM with keratin collection (cholesteatoma)
What causes (mucosal) chronic otitis media?
Chronic infection and perforation
Pseudomonas aeruginosa, staphylococcus aureus
What are the symptoms of (m) chronic otitis media?
Hearing loss
Otorrhoea
What signs may be seen on examination of (m) chronic otitis media?
Inactive - dry perforation
Active - wet perforation with inflammation, otorrhoea
What investigations can be done for (m) chronic otitis media?
PTA
Swab
How is (m) chronic otitis media managed?
Microsuction
Antibiotic and steroid ear drops
Myringoplasty
What is a cholesteatoma?
Accumulation of benign keratinising squamous cells in the middle ear which hyperproliferate and secrete enzymes which can be locally destructive
‘Skin in the wrong place’
What are the causes and pathophysiology of cholesteatoma?
Chronic childhood Eustachian tube dysfunction - causes TM retraction which obstructs keratin migration from TM to external canal
Congenital - persistent epithelial cells left in middle ear during embryological growth
What are the symptoms of cholesteatoma?
Persistent/recurrent ear discharge despite topical antibiotics
Unilateral hearing loss
What signs may be seen on examination of cholesteatoma?
Deep retraction pocket in TM with keratinous debris within
Granulations around margins with adjacent bony erosion
Discharge (if infected)
Congenital - TM intact but bulging with pearly white mass seen through TM
What investigations can be done for cholesteatoma?
PTA
CT temporal bone
How is cholesteatoma managed?
Surgical - remove cholesteatoma sac and repair TM and any bony defects; ossiculoplasty may be needed
What is rhinophyma?
The skin overlying the cartilaginous portion of the nose contains multiple pilosebaceous glands which can undergo hypertrophy to cause an enlarged, bulbous nose
What type of epithelium covers the turbinates in the nose?
Pseudostratified ciliated columnar epithelium
What arteries are involved in Little’s area?
Anterior ethmoidal
Sphenopalatine
Greater palatine
Superior labial
What are the key points to cover when taking a history from a patient with epistaxis?
Unilateral predominance - which nostril did it start from?
Anterior/posterior - running out the front or down the back of the throat
How frequent are episodes
Estimated blood loss (e.g. teaspoon, cupful)
PMH - HTN, cardiac, anti-coagulants, nasal surgery
Smoking, occupation, nut allergy
Management techniques usually/already used
Where is Little’s area found and what is the difference between it and Kiesselbach’s plexus?
Anterior part of the septum - anastomosis between branches of internal and external carotid arteries
They are the same thing
How is epistaxis managed non-surgically?
Initial - lean forward, pinch soft part of nose, ice to suck on/apply to forehead
Cautery with silver nitrate if ongoing
How is epistaxis managed surgically?
Endoscopic sphenopalatine artery ligation under general anaesthetic
What artery is likely to be damaged in traumatic epistaxis?
Anterior ethmoidal artery
What needs to be carefully considered when there is an acute traumatic injury of the nose?
Septal haematoma - starves septal cartilage of oxygen resulting in necrosis which leaves a saddle nose
Give 3 causes of nasal obstruction
Infection - rhinitis, rhinosinusitis
Allery - inflammation, polyps
Developmental - cleft lip
Traumatic - septal haematoma, perforation
Iatrogenic - adhesions, residual deformity
Drugs - decongestants, beta-blockers, OCP cocaine
Neoplastic - benign, malignant
Inflammatory - GPA, EPA, sarcoidosis, CF
When does a fractured nose need ENT assessment?
Swelling and bruising which may be obscuring deformity
Reviewed in 5-7 days to discuss manipulation
How is a septal haematoma managed?
Drainage in theatre
Prophylactic antibiotics
What is rhinitis?
Inflammation of the mucous membranes of the nose - allergic or non-allergic
What are the symptoms of rhinitis?
Nasal congestion Runny nose Itching Sneezing Post-nasal drip
What is rhinosinusitis?
Inflammation of the mucous membranes of the nose and paranasal sinuses
What are the symptoms of rhinosinusitis?
Runny nose Post-nasal drip Nasal congestion or obstruction Facial headache Reduction in sense of smell
How is acute rhinosinusitis defined according to symptoms?
Sudden onset of 2 or more symptoms, one of which should be nasal blockage/obstruction/congestion or nasal discharge
+/- facial pain/pressure
+/- reduction/loss of smell for <12 weeks
What are the bacterial and viral causes acute rhinosinusitis?
Viral most common - rhinovirus, coronavirus, parainfluenza, RSV
Bacterial - streptococcus pneumoniae, haemophilus influenzae
What are the symptoms of acute rhinosinusitis?
Nasal obstruction Coloured discharge Facial pain Reduced/absent smell Fever and malaise Deterioration after initial milder phase of illness (post-viral or bacterial)
What signs may be seen on examination of acute rhinosinusitis?
Facial tenderness
Anterior rhinoscopy - inflammation, discharge
Nasoendoscopy - pus from middle meatus
What are the complications of acute rhinosinusitis?
Meningitis Cavernous sinus thrombosis Intracranial abscess Osteomyelitis Orbital/pre-septal cellulitis Orbital abscess
How can acute rhinosinusitis be investigated?
Bloods - WCC, CRP, blood culture (very ill)
If not responding - swab, CT
How is acute rhinosinusitis managed?
<5 days and mild - analgesia, nasal saline irrigation, fluid rehydration, nasal decongestant (e.g. pseudo-ephedrine) for 1 week
Persistent >10 days or worsening after 5 days - topical nasal steroids
Severe - broad spectrum antibiotics for 7 days (e.g. amoxicillin), topical intranasal steroids
Recurrent/chronic - ENT referral for endoscopic sinus surgery
What is chronic rhinosinusitis?
Inflammation of nasal mucosa and paranasal sinuses for >12 weeks
With or without polyps
How is chronic rhinosinusitis defined according to symptoms?
2 or more symptoms - nasal blockage, discharge, facial pain, smell reduction
And either endoscopic signs of polyps/middle meatus oedema/mucopurulent discharge or CT mucosal changes of sinuses
How is chronic rhinosinusitis managed?
Non-operative - saline nasal irrigation, nasal decongestants, anti-histamines (if allergic), oral steroids (if polyps), topical steroids (without polyps), antibiotics
Operative - functional endoscopic sinus surgery
What are the most common malignant sino-nasal tumours?
Squamous cell carcinoma
Adenocarcinoma (wood workers)
Nasopharyngeal carcinomas
What is a cleft lip and palate?
A cleft is a gap/split in the upper lip and/or roof of the mouth (palate) resulting in an abnormal connection between the oral and nasal cavity
What is the difference in severity between a submucous cleft and a bilateral cleft lip and palate?
Submucous cleft - muscles of the soft palate don’t fully join; may be relatively asymptomatic
Bilateral cleft lip and palate - immediate concerns at birth regarding airway and feeding
Give 3 things likely to be affected in a patient with a cleft/lip palate
Feeding - failure to thrive
Otologic - glue ear
Speech/swallow - SLT needed
Cosmetic - correction of lip and nasal deformity within 1st year
Dental - restoration/prosthesis
Psychology, social work - counselling for parents
What can the tough fascia of the temporalis muscle be used for?
Perforated TM repair (myringoplasty)
At what level does the common carotid bifurcate? What is located here?
At the level of the superior border of the thyroid cartilage
Carotid sinus and carotid body
How can the internal carotid artery be distinguished from the external carotid artery in surgery?
Internal carotid artery has no branches
Which major salivary glands are mucous and which are serous?
Parotid - serous
Submandibular - both
Sublingual - mucous
Where do the parotid, submandibular and sublingual glands drain?
Parotid - opposite the 2nd upper molar (Stenson duct)
Submandibular - floor of oral cavity (Wharton’s duct)
Sublingual - submandibular duct and sublingual fold in oral cavity floor
What is the significance of the foramen caecum?
Represents the embryological site of the thyroid gland - lingual thyroid may present as a mass in this area if there is failed migration
What is Ludwig’s angina?
Necrotising cellulitis +/- abscess formation of the floor of the mouth which can extend into the neck and be caused by dental root abscesses
May cause life threatening airway obstruction due to swelling
What associated symptoms should be asked about in the history of a head/neck lump?
Pain Sore throat Difficulty swallowing Painful swallowing Breathing problems Coughs/colds Blood Weight change Ear pain Night sweats Fever Voice changes
Give 5 red flag ENT symptoms
Unexplained neck lump that changed over 3-6 weeks
Hoarse voice >3 weeks
New onset dysphagia
Unexplained persistent salivary gland swelling
Otalgia >4 weeks with normal otoscopy
Non-healing ulcer
White/red mouth/oropharynx lesion
Give 3 causes of a neck lump
Submandibular gland pathology Tooth abscess Parotid pathology Branchial cyst Lymphadenopathy Paragangliomas Thyroid goitre/nodule Thyroglossal cyst Dermoid cyst
What is a branchial cyst, how is it investigated and how is it managed?
A cavity that is a remnant from embryologic development, presenting as an upper neck mass in young adults
Investigations - neck USS and fine needle aspiration cytology
Management - surgical excision
What questions should be asked when taking a dysphagia history?
Level of dysphagia - pharynx, upper/mid/lower oesophagus
Solids, liquids, saliva
Associated - hoarseness, odynophagia, otalgia, regurgitation, GI bleeding, weight loss
Progression in symptoms
Risk factors for cancer - smoking, alcohol
Give 6 causes of dysphagia
Retrosternal goitre Thoracic aortic aneurysm Mediastinal mass Lung cancer Motility problem MND MS CVA Achalasia Oesophageal spasm Pharyngeal pouch Stricture Candidiasis Foreign body Oesophageal/pharyngeal cancer Oesophageal web
How can dysphagia be investigated?
FBC - Hb (anaemia) CXR CT/MRI neck Barium swallow Laryngoscopy and oesophagoscopy Video fluoroscopy
What is dysphonia?
Hoarseness
Altered vocal quality, pitch, loudness or vocal effort
Give 4 causes of hoarseness
Squamous cell carcinoma Vocal cord nodules/papillomas/cysts Vocal cord palsy Surgery Intubation Excessive use Hypothyroidism Laryngitis Candida Recurrent laryngeal nerve palsy Muscle tension dysphonia
How can hoarseness be investigated?
Flexible nasoendocopy examination of the larynx
Bloods - TFTs
Give 3 red flags for hoarseness
History of smoking and alcohol Concomitant neck mass Unexplained weight loss Associated - neurological symptoms, haemoptysis, dysphagia, odynophagia, otalgia Persistent and worsening hoarseness Immunocompromised patient
What is tonsillitis?
Infection of the palatine tonsils; bacterial or viral
What is the most common bacterial cause of tonsillitis?
Group A beta haemolytic streptococci
What are the signs/symptoms of tonsillitis?
Sore throat Odynophagia Dysphagia Earache Malaise and headache Pyrexia Swollen tonsils +/- exudate Thick voice Bilateral cervical lymphadenopathy
What is trismus and what does it indicate?
Reduced opening of the mouth Peritonsillar abscess (quinsy)
What are the complications of tonsillitis?
Peritonsillar abscess (quinsy) Parapharyngeal and retropharyngeal abscess (potentially life-threatening)
What investigations may be useful in tonsillitis?
FBC U&Es Glandular fever screen CRP Blood cultures (pyrexia)
How is tonsillitis managed?
Analgesia - paracetamol, ibuprofen Topical analgesia - difflam Fluid resuscitation Consider antibiotics Consider tonsillectomy
What criteria is used to determine if antibiotics should be given in tonsillitis?
Centor criteria
50% chance of tonsillitis being bacterial if 3 or more of: tonsillar exudate (pus), pyrexia, no cough, tender cervical lymph nodes
If a tonsillitis patient meets criteria for antibiotics, what should be given and how?
Penicillin V 500mg QDS for 10 days
Erythromycin if allergic
What medication should be avoided in tonsillitis and why?
Amoxicillin - causes a rash if the patient has glandular fever
What are the indications for tonsillectomy?
Sore throats are due to active tonsillitis
Episodes are disabling and prevent normal functioning
7 or more significant sore throats in a year OR 5 or more episodes in each of 2 years OR 3 or more episodes in each of 3 years
What is a pharyngeal pouch?
Out-pouching of the pharyngeal mucosa and submucosa at the oesophageal sphincter
AKA Zenker’s diverticulum
What are the signs and symptoms of a pharyngeal pouch?
May be asymptomatic Progressive dysphagia Sensation of lump in throat Regurgitation of undigested food Halitosis Recurrent chest infections (aspiration) Gurgling
How is a pharyngeal pouch investigated?
Barium swallow
Rigid oesophagoscopy to exclude carcinoma
How is a pharyngeal pouch managed?
Conservative if asymptomatic
Endoscopic/open stapling and division of muscles
What is globus pharyngeus?
Sensation of a lump, discomfort or foreign body in the throat without an obvious cause
Diagnosis of exclusion linked to stress/anxiety
How is globus pharyngeus investigated and managed?
Ix - flexible nasopharynolaryngoendoscopy, barium swallow, CT scan, upper GI endoscopy
Mx - reassurance, lifestyle advice, anti-reflux therapy
What symptoms are associated with globus pharyngeus?
Laryngopharyngeal reflux
Cricopharyngeal spasm
Oesophagitis
What are suspicious features for thyroid USS?
Solid hypoechogenic nodules with microcalcifications
Irregular margins
More tall than wide
Lymphadenopathy
Why might a hemithyroidectomy be done for diagnosis?
Fine needle aspiration cytology can diagnose papillary carcinoma but cannot distinguish between follicular adenoma (benign) and follicular carcinoma, so the whole nodule needs to be assessed via histology
What is a thyroglossal cyst?
Embryological remnant of thyroglossal tract during descent of
the thyroid from the foramen caecum at the tongue base
What are the signs and symptoms of a thyroglossal cyst?
Often asymptomatic
May enlarge with URTI
May become infected or form an abscess/discharging sinus
Palpable neck lump in the midline
Moves up on tongue protrusion and swallowing
How is a thyroglossal cyst investigated and managed?
Ix - USS +/- FNAC
Mx - only if recurrent infection; Sistrunk’s procedure (excision of cyst, tract and portion of hyoid bone)
What are the signs/symptoms of multinodular goitre?
Neck lump moves on swallowing
Multiple irregular nodules
Cosmetic deformity
Pressure changes (very large) - breathlessness, orthopnoea, dysphagia
Pain and swelling (rupture/haemorrhage)
Dullness on percussion of manubrium (retrosternal)
What are the complications of multinodular goitre?
Mass effect/compression
Cosmetic appearance
Nodule haemorrhage
Thyrotoxicosis
How is multinodular goitre investigated and managed?
Ix - TSH, T4, FBC, thyroid USS +/- FNAC, CT neck and chest
Mx - watch and wait, anti-thyroid drugs +/- beta-blockers if hyperthyroid, total thyroidectomy with replacement thyroxine/calcium if mass effect/cancer
What are the risk factors for thyroid cancer?
Female
Radiation exposure
Family history
What are the types of thyroid cancer, in order of prevalence?
Papillary Follicular Medullary Anaplastic Lymphoma
How are thyroid nodules classified?
THY classification 1 - non-diagnostic, lack of cellularity 2 - non-neoplastic 3 - follicular (needs resection) 4 - suspicious but non-diagnostic 5 - diagnostic of malignancy
How do papillary and follicular thyroid cancer differ on pathology?
Papillary - multifocal, Orphan-Annie nuclei, psammoma bodies, lymphatic invasion
Follicular - unifocal, encapsulated, haemorrhagic, invasive, Hurtle cells
How are papillary and follicular thyroid cancer managed and followed up?
Lobectomy/thyroidectomy Neck dissection Post-operative radio-iodine therapy Levothyroxine Follow up - thyroglobulin measurement (tumour marker) for 6 weeks at least and USS/FNAC if indicated
Where does medullary thyroid cancer arise?
Parafollicular/C cells of the thyroid
Give 2 inherited syndromes which can cause medullary thyroid cancer
Familial medullary thyroid cancer
MEN 2A
MEN 2B
How is medullary thyroid cancer investigated and managed?
Ix - USS and FNAC, tumour markers (calcitonin, carcinoembryonic antigen), genetic screening, 24 hour urine metanephrine (phaeochromocytoma)
Mx - total thyroidectomy and neck dissection, prophylactic surgery may be considered in MEN
Why is radio-iodine not used as a post-operative therapy for medullary thyroid cancer?
No iodine uptake - cancer is of neuroendocrine cells, not follicular cells
Give 3 features of anaplastic thyroid cancer
Rare Aggressive Undifferentiated Affects elderly Rapidly enlarging, bulky, hard mass over 2-3 months USS and core/open biopsy needed Poor prognosis Palliative care
Give 3 features of thyroid lymphoma
Rare Diffuse large B cell lymphoma Hashimoto's thyroiditis is a risk factor Compressive, rapidly enlarging goitre Core/open biopsy needed Treat with chemotherapy +/- radiotherapy
In which salivary gland/s do most tumours occur?
Parotid gland
Mostly benign
E.g. pleomorphic adenomas
In which salivary gland/s is malignancy more common?
Submandibular gland
Sublingual gland
E.g. mucoepidermoid carcinoma or skin metastases
What are the red flags of salivary gland tumours?
Hard Rapid growth Tender Infiltration of surrounding structures Overlying skin ulceration Facial weakness/palsy
Give 2 benign salivary gland tumours and 3 features of each
Benign pleomorphic adenoma - mostly parotid, painless, slow growing, retromandibular, 10% malignant transformation, surgical excision
Warthin’s tumour/adenolymphoma - can be bilateral, tail of parotid, elderly men, smokers, ovoid, mobile, fluctuant, surgical excision or conservative
Give 3 malignant salivary gland tumours and a feature of each
Mucoepidermoid tumour - most common cancer, parotidectomy
Acinic cell - parotid, 10% metastasise, parotidectomy
Adenoid cystic carcinoma - spreads along nerves with skip lesions, facial nerve often involved, parotidectomy
Lymphoma - NHL, increased risk if Sjogren’s
What is the most common cancer of the oral cavity?
Squamous cell carcinoma
What are the risk factors for oral cavity cancer?
Smoking Alcohol Betal nut (India) Chronic dental infection Immunosuppression
What are the signs/symptoms of oral cavity cancer?
Painless ulcer/lump (pain is a late sign)
Increasing size which can affect speech/swallowing
Discolouration
Erythematous velvety mucous membrane (erythroplakia) or white (leukoplakia) or mixed (speckled leukoplakia)
Lichen planus
Non-healing ulcer
Neck swelling (metastases)
What are the risk factors for carcinoma of the lip and how is it managed?
RFs - male, fair skin, old, sun exposure
Mx - excision and primary closure/skin flap reconstruction (size dependent)
Where is tongue cancer most likely to occur and how is it managed?
Lateral border of the anterior 2/3 of the tongue
Mx - surgical excision (small); resection, neck dissection, post-operative radiotherapy, chemotherapy, flap reconstruction (large)
What are the 3 subdivisions of the pharynx?
Nasopharynx
Oropharynx
Hypopharynx/Laryngopharynx
What are the risk factors for pharyngeal cancer?
Smoking Alcohol HPV (oropharynx) EBV (nasopharynx) Radiation
What are the risk factors for nasopharynx cancer?
South Asian
North Asian
EBV
What are the signs/symptoms of nasopharyngeal cancer?
Cervical lymphadenopathy
Ear pain, secretory otitis media, hearing loss, CN palsies
Epistaxis, discharge, changes in smell, nasal obstruction
Persistent unilateral otitis media with effusion and no preceding URTI
What is juvenile nasopharyngeal angiofibroma?
Epistaxis in a young adult due to a benign but locally invasive and highly vascular rare tumour of the lateral wall of the nose
How is nasopharyngeal cancer investigated and managed?
Ix - detailed head and neck exam, nasoendoscopy, formal biopsy, FNAC of neck nodes, MRI/CT
Mx - chemotherapy and radiotherapy
From what structures of the oropharynx can cancer arise and what is the most common type?
Tongue base, tonsils, tonsillar fossae
70% tonsillar carcinomas are squamous cell carcinomas
What are the risk factors for oropharynx cancer?
Smoking
Alcohol
HPV 16 and 18
What are the signs/symptoms of oropharynx cancer?
Painless unilateral tonsillar swelling History of throat discomfort with worsening dysphagia Referred otalgia (Arnold's nerve) Lump in throat sensation Cervical lymphadenopathy Trismus
How is oropharynx cancer investigated and managed?
Ix - head and neck exam, panendoscopy and biopsy, FNAC of neck nodes, MRI and CT
Mx - surgery +/- radiotherapy/chemotherapy
Where do most hypopharynx cancers arise?
Pyriform sinus
What are the signs/symptoms of hypopharynx cancer?
Cervical lymphadenopathy Pain from throat to ear Progressive difficulty with/painful swallowing Voice changes Paterson-Brown-Kelly syndrome
How is hypopharynx cancer investigated and managed?
Ix - endoscopy, biopsy, imaging, barium swallow, MRI, CT
Mx - surgery and radiotherapy (early) plus neoadjuvant chemotherapy (advanced)
What are the 3 divisions of the larynx?
Supraglottis
Glottis
Subglottis
What is the most common type of laryngeal cancer?
Glottic cancer - squamous cell
What are the risk factors for laryngeal cancer?
Male
Elderly
Smoking
Alcohol (cumulative)
What are the signs/symptoms of laryngeal cancer?
Hoarseness worsening over 6-12 weeks Noisy breathing/stridor Cough Haemoptysis Odynophagia Dysphagia Neck lymphadenopathy
How are laryngeal cancers investigated and managed?
Ix - full ENT exam, flexible nasoendoscopy, biopsy, CT, MRI
Mx - radiotherapy or endoscopic laser excision (small); chemoradiotherapy or laryngectomy with post-operative radiotherapy (large)
What is laryngopharyngeal reflux?
Group of upper respiratory tract symptoms secondary to irritation from gastric contents
What are the symptoms of laryngopharyngeal reflux?
Hoarseness Throat clearing Chronic cough Globus pharyngeus Dysphagia
How is laryngopharyngeal reflux diagnosed?
Reflux symptom index patient questionnaire score >13
Laryngoscopy
Reflux finding score >7
Transnasal oesophagoscopy
Gold standard - 24 hour dual probe pH manometry with intraluminal impedance studies
How is laryngopharyngeal reflux managed?
Lifestyle modification - avoid eating 3 hours before sleeping, smoking cessation, reduce alcohol intake, address obesity, avoid fizzy drinks, avoid throat clearing
Other - speech therapy, alginates, PPI, referral to gastro
What is obstructive sleep apnoea?
Apnoea (breath holding for >10 seconds leading to arousal from sleep) or hypopnea (reduced airflow with oxygen desaturation)
How is obstructive sleep apnoea severity classified?
Apnoea-hypopnoea index - mild (5-15), moderate (16-30), severe (>30)
What are the complications of obstructive sleep apnoea?
Neurocognitive impairment
T2DM
CVD - HTN, CAD, HF, stroke, pulmonary HTN
Increased mortality
What are the causes of obstructive sleep apnoea?
Children - large tonsils/adenoids, large tongue, muscle hypotonia (Down’s syndrome)
Adult - nasal obstruction (polyps), large tonsils, pharyngeal airway collapse (obesity)
What are the symptoms of obstructive sleep apnoea?
Witnessed breath holding/gasping/choking
Restlessness
Daytime sleepiness
Irritability
How is obstructive sleep apnoea diagnosed?
Detailed history ENT examination BMI, neck circumference Maxillofacial structures Nasopharyngolaryngoscopy Epworth sleepiness score (>10) Gold standard - noctunal polysomnography (airflow, oxygen saturation, ECG, EMG, EEG, body position)
How is obstructive sleep apnoea managed?
Lifestyle - weight loss, reduce alcohol, avoid sleeping supine
Interventions - nasal dilators, mandibular advancement device, CPAP
Treat nasal obstruction - intranasal steroids, decongestants, saline douches
Surgery - adenotonsillectomy (children), options for adults less effective
Give 2 causes of acute airway obstruction in adults
Infection - supraglottitis, deep neck space infection
Neoplastic - tongue base, oropharyngeal or laryngeal tumours
Give 2 causes of acute airway obstruction in children
Infection - croup, epiglottitis
Foreign body
Congenital - laryngomalacia, subglottic stenosis
What are the signs/symptoms of acute airway obstruction?
Dyspnoea Stridor/stertor/snuffle Change in voice Cough Tachypnoea Agitation Cyanosis Use of accessory muscles Wheeze Decreased breath sounds
What are the different types of stridor and what do they suggest?
Inspiratory - obstruction between glottis and supraglottis
Expiratory - obstruction below carina
Biphasic - obstruction between glottis/subglottis
What is the main complication of acute airway obstruction?
Respiratory arrest
How is acute airway obstruction managed?
Senior help early Oxygen/heliox Nasopharyngeal airway Nebulised adrenaline Nebulised/IV steroids Intubation Tracheostomy
Give a feature from each of history, examination and management of deep neck space infection (causing airway obstruction)
Hx - short onset; sore throat, odynophagia, voice change
Ex - septic, trismus, neck swelling, stridor
Mx - secure airway, broad spectrum antibiotics, drainage of collection
Give a feature from each of history, examination and management of laryngopharyngeal carcinoma (causing airway obstruction)
Hx - longer duration; sore throat, odynophagia, voice change, weight loss
Ex - cachexic, neck lymphadenopathy
Mx - secure airway, imaging, FNAC neck nodes, MDT discussion
Give a feature from each of history, examination and management of anaphyalxis (causing airway obstruction)
Hx - bee/insect sting, food trigger, known allergy
Ex - stridor, wheeze, respiratory distress, cyanosis, facial swelling
Mx - call anaesthetist, IM adrenaline, IV chlorphenamine, IV hydrocortisone, HDU/ICU
Give a feature from each of history, examination and management of epiglottitis (causing airway obstruction)
Hx - sore throat, severe odynophagia, dysphagia, fever, neck tenderness
Ex - do not agitate, drooling, tripod position, pyrexia, respiratory distress, tender over hyoid
Mx - senior help, secure airway in theatre, IV antibiotics, throat swab
What are the risk factors for/causes of epistaxis?
Trauma Foreign body Nasal spray Infection Previous surgery Drugs - warfarin, NOAC, cocaine coagulopathy Pregnancy HTN Alcohol Hereditary haemorrhagic telangiectasia
How is epistaxis managed by an ENT surgeon?
Examine for bleeding source with headlight and Thudicum’s - suction and adrenaline soaked cotton wool
Apply simple pressure for 10 minutes with head tilted forwards
Chemical cautery with silver nitrate
Get senior help early if this fails
Oxygen, suction, IV access, bloods, fluids
Anterior nasal packing
Posterior nasal packing
Surgery - ligation
Interventional radiology embolisation
Why should silver nitrate not be used bilaterally for cautery?
Risk of septal perforation
In what 2 situations is a foreign body more worrisome?
Inhaled into the airway
Button battery
What are the symptoms of foreign body in the nose?
Unilateral nasal discharge (may be offensive)
Nasal obstruction
Irritability
How is a foreign body in the nose managed?
Positive pressure via mouth
Earwax hook or alligator forceps may be used for extraction
Removal under GA
What are the symptoms of a foreign body in the ear?
Hearing loss
Discharge (may be offensive or contain blood)
How is a foreign body in the nose managed?
Removal - wax hook, alligator forceps, microsuction
What can cause a perforated TM?
Grommets
Infection - acute otitis media
Trauma - blow to ear, barotrauma
How does TM perforation present?
Ear pain when perforation occurs
Hearing loss
Recurrent discharge
How is a perforated TM managed?
Conservative - free of water, will heal in 6-8 weeks
Infected - antibiotic ear drops
Surgery - reconstruction
What types of foreign body in the pharynx or oesophagus need more urgent management?
Children - button battery (or coin, can look similar)
Adults - food bolus (if there are bones present)
What are the signs/symptoms of foreign body in the pharynx or oesophagus?
Adult - dysphagia, odynophagia, drooling
Children - non-specific, off their food, lethargic
How is a foreign body in the pharynx or oesophagus managed?
Remove batteries and food bolus with bone ASAP
Food bolus without bone - may pass spontaneously in night when muscle relaxes, can use hyoscine butylbromide to relax muscles
Surgery - upper rigid oesophagoscopy or OGD
In penetrating neck trauma, what are the zones the neck can be divided into? What important structures may be damaged in each?
Zone I - clavicle to cricoid; common carotid artery, internal jugular vein, trachea, oesophagus
Zone II - cricoid to angle of mandible; larynx, pharynx, common carotid artery, carotid bifurcation, internal jugular vein, CNs (accessory, vagus, hypoglossal)
Zone III - angle of mandible to skull base; internal carotid artery, skull base, CNs
How is penetrating neck trauma managed?
ATLS protocol
Secure airway - intubation, surgical (cricothyroidotomy or tracheostomy)
Imaging if stable - CT angiogram, CT head and neck
Surgical exploration if platysma breached
What drugs can be used in Meniere’s disease?
Prochlorperazine
Cinnarizine
Betahistine
Intratympanic dexamethasone/gentamicin
Why should prochlorpromazine not be given for >2 weeks in Meniere’s disease?
Prevents the brains central compensation which occurs naturally after an episode of labyrinthitis
What should be given post-cautery for 2 weeks to aid healing and what precaution should be taken?
Naseptin cream (chlorhexidine and neomycin) Cannot be used if the patient has a nut allergy
What are the 2 types of anterior packing?
Merocel nasal tampons (scaffold for clots)
Rapid rhino nasal packs (clot formation and pressure via internal balloon)
What should be done before interventions when managing an epistaxis where conservative management has failed?
Decongest and numb the nose - combined lignocaine and phenylephrine spray
What are the options for posterior nasal packing?
Foley urinary catheter - use balloon to occlude the post-nasal space with anterior ribbon gauze
Antero-posterior rapid rhino
Brighton epistaxis balloons
What does pure tone audiometry measure?
Evaluates the quietest sound which can be heard with each ear at various frequencies - the hearing threshold
What should the ears be examined for before PTA?
Foreign body
Obstructive wax
Active infection
What are normal hearing, mild loss, moderate loss, severe loss and profound loss defined as on PTA?
Normal hearing - 20dB or better Mild hearing loss - 21-40dB Moderate hearing loss - 41-70dB Severe hearing loss - 71-90dB Profound hearing loss - 90dB.
What is tympanometry?
Indirectly measures the “compliance” or freedom of movement of the middle ear structures
Sound transmission from the outer to the middle ear is optimal when the pressure in the ear canal matches the middle ear pressure
What do the results of a tympanogram show?
Type A describes a Normal tympanogram - The peak may be shallow indicating
stiffness of the drum (e.g ossicular fixation or tympanosclerosis) or
may be high indicating a flaccid ear drum (e.g ossicular
disarticulation)
Type B describes a flat or very low peak. This is typical of a middle
ear effusion. It can also be seen if there is an ear drum perforation
but the ear canal volume will be higher.
Type C shows low pressure in the middle ear and is seen in
Eustachian tube dysfunction.
How does newborn hearing screening work?
Outer hair cell vibrations can be detected in the external
auditory meatus as otoacoustic emissions and can be used as
an objective measure of cochlear function
Transient evoked otoacoustic emissions occur in response to
short stimulatory acoustic signals in the form of clicks or tone
bursts
Their presence usually indicates that the hearing threshold is
better than 40dB
What forms of hearing testing can be used as a child gets older?
Behavioural techniques - 0-6 months Distraction techniques - 6-18 months Visual reinforcement audiometry - 9-36 months Performance testing - 24-60 months PTA - >5 years
What is a tracheostomy and what are its indications?
Conduit from the skin of the neck to the trachea due to - real/anticipated airway obstruction, prolonged ventilation, pulmonary toilet (clearance of secretions)
What are the complications of a tracheostomy?
Immediate - haemorrhage, pneumothorax, air embolism, cardiac arrest, damage to structures (RLN)
Early - dislodgement, surgical emphysema, crusting, infection, tracheal necrosis, tracheoarterioal/oesophageal fistula, dysphagia
Late - tracheal stenosis, difficulty decannulating, tracheocutaneous fistula
What pieces of equipment should patients with a tracheostomy have?
2 spare tracheostomy tubes - same size and smaller size Tracheal dilator 10ml syringe Suction unit and catheter Gloves Forceps Lubrication
How do you resuscitate patients with a tracheostomy?
Give breaths through the tracheostomy, not the mouth
If no chest rise - suction the trach tube, change it if it is plugged/dislodged
What causes prominent/protruding ears?
Defect in part of the cartilage (gristle) of the ear
How are prominent ears managed?
Reassurance
Cartilage moulding devices (neonates)
Pinnaplasty (age 5-18)
What is sialadenitis?
Infection or inflammation of the salivary glands
What are the causes of sialadenitis?
Infection (e.g. mumps) Dehydration Autoimmune (e.g. Sjogren's) Stones Strictures
What are the symptoms of sialadenitis?
Pain Erythema Swelling (after eating) Fever Nasty taste in mouth
How is sialadenitis managed?
Advise to drink plenty of fluids, maintain good oral hygiene, massage glands and apply warm compress
Bacterial - antibiotics
Removal of stones and dilation of strictures
What is a salivary gland stricture?
Narrowing of the duct
How are salivary gland strictures managed?
Stretching/dilation of duct with endoscope or balloon under LA
How are salivary gland stones managed?
Small - removed by endoscope and wire basket under LA
Large - fragmented with wire drill/lithotripsy and then removed with wire basket
Very large/multiple - endoscope or gland preserving surgery
What is Reinke’s oedema?
Oedema within Reinke’s space in the vocal fold which increases mass and deepens the voice
How is Reinke’s oedema managed?
Smoking cessation
Anti-reflux therapy (PPI)
Persisting - superior chordotomy
What causes vocal cord nodules?
Inappropriate use of the voice causing strain and leading to trauma and formation of nodules which affect closure of vocal cords producing a change in voice
How are vocal cord nodules managed?
SLT - education on use of voice
Rarely need surgical intervention
How do patients with vocal cord palsy present and why?
Recent onset breathy voice which becomes tired with use - one vocal fold is immobile which allows air to escape
What should be ruled out when vocal cord palsy is suspected?
Sinister cause affecting recurrent laryngeal nerve
What additional imaging should be requested for vocal cord palsy based on its location?
Imaging for left palsy - skull base to upper chest
Imaging for right palsy - skull base to root of neck
How is vocal cord palsy managed?
SLT - compensation
Failure or malignant cause - injection thyroplasty to medialise immobile cord
What are Brandt-Daroff exercises?
Exercises to treat BPPV which can be done by patients at home
Involve rotating the head to 45 degree and lying on the opposite side for 30 seconds and then repeating on the other side (1 loop)
5 loops 3 times a day for 2 weeks
What is synkinesis?
Voluntary muscle movement causes the simultaneous involuntary contraction of other muscles
E.g. smiling inducing an involuntary contraction of the eye muscles, causing a person to squint when smiling
What is Paterson Brown Kelly syndrome?
A disorder marked by IDA anaemia and a web-like growth of membranes in the throat that makes swallowing difficult and may increase the risk of developing oesophageal cancer
AKA Plummer-Vinson syndrome and sideropaenic dysphagia
