Module 3D ENT - Lectures Flashcards
What is meant by amplitude and frequency?
- Amplitude (difference between the denser and less dense areas of air molecules) = loudness
- Frequency = the number of waves that pass in one second
–> 1 wave per second = 1 Hertz (Hz)
–> The greater the frequency, the higher the pitch.
What is sound measured in?
decibels (dB)
Ear anatomy
- The pinna is the outer fleshy part of the ear
- Sound waves travel down into the auditory canal until they reach the tympanic membrane
- The tympanic membrane moves in relation to the sound waves hitting it –> this moves the 3 bones within the middle ear –> which in turn moves the oval window which is attached to the cochlear
Middle ear anatomy
- what are the 3 bone structures called
- what holds these bone structures in place?
- The 3 bone structures within the middle ear are called the malleus, incus, and stapes –> held in place by the stabilising ligaments and two muscles (stapedius muscle and tensor tympani muscle)
Do the bones of the middle ear amplify the sound or the force against the oval window + why is this beneficial?
- The bones of the inner ear do no amplify the volume of the sound, they amplify the force
- There is a fluid-filled structure within the cochlear which requires more force as it is fluid not air
What is impedance matching in regards to the middle ear and sound?
Impedance matching allows vibration of the fluid in the inner ear –> sound can be transmitted directly to the cochlear through bone
What is the attenuation reflex in regards to sound and the middle ear?
- this describes the action of the two muscles (stapedius muscle and tensor tympani muscle) in response to a very loud sound
- the muscles help to stabilise the bone structures and in turn protects the cochlear from the loud sound
- it also acts to mask low frequency sounds in loud environments –> reducing background noise making speech easier to hear in noisy enivronments
Describe the travel of sound waves from initial entry to the round window
+ what is the round window?
- The sound waves pass through the aduitory canal, through the middle ear, and through to the cochlear
- They hit the oval window (where the stapes are) –> the waves then pass along through fluid called perilymph which goes all around the cochlear (over the top of the Organ of Corti) to the round window
- The round window is a membranous structure at the other end of the cochlear and basically just allows for the transmission of waves
Where does all of the ‘actual hearing’ take place within the ear + where are low/high frequency sounds heard
- The Organ of Corti
- High frequency sounds –> heard at the base
- Low frequency sounds –> heard near the helicotrema
Organ of Corti
- where does it sit
- what does it do in response to vibrations
- Organ of Corti sits in the middle of these two fluid-filled areas –> gets vibrated as the waves pass either side
- Genereates a nerve impulse in response to vibration of the basilar membrane
- Contains specialised cells called inner and outer hair cells
- Synapses with the spiral ganglion of Corti and then the cochlear nerve
. - Perilymph –> Na+ rich
- Endolymph –> K+ rich
What happens when the oval window is pushed in
- Pushing in of the oval window pushes perilymph into the scala vestibule
- The pressure change travels along the scala vestibule, through the helicotrema along the scala tympani and causes movement at the round window
- Causes non-rigid structures within the cochlear to move –> the basilar membrane moves
Organ of Corti - hair cells
- why are outer hair cells important
- The hair cells (inner and outer) are the structures that actually detect the movement of the basilar membrane
- Movement of the basilar membrane relative to the tectorial membrane –> results in displacement of the hair cells
- Inner hair cells are not attached to the tectorial membrane
- Outer hair cells are important for the amplification of sound
What ion is involved in depolarisation of inner ear hair cells?
Hair cells depolarise with K+, unlike nerve cells
Which inner ear hair cell type innervates the majority of spiral ganglion cells?
Inner hair cell
Outer hair cells are responsible for the amplification of sound –> what is the name of the protein which contracts and elongates to amplify sensitivity to sound waves?
Prestin
Auditory pathway –> which cranial nerve is involved?
Cranial nerve VIII (vestibulocochlear nerve)
Primary auditory cortex
- Primary auditory cortex is like a ‘piano’ –> damage to a part of it can knock out that frequency of sound
The Organ of Corti –> YouTube video
https://www.youtube.com/watch?v=bwCz3Q8y-PM
The vestibular system –> what is it?
- The vestibular system provides information on the spatial orientation and movement of the head and plays an essential role in regulating movement of the trunk and limbs as well as the maintenance of body posture
- In addition, afferent discharges from the vestibular organs influence reflex centres responsible for maintenance of a stable retinal image by controlling neck muscles and extraocular eye muscles
- Rotary movement of the head is detected by hair cells in the semicircular canals, while linear acceleration and the direction of gravity are detected by hair cells in the otolith organs
Inner ear anatomy
- In addition to the cochlear, there is the Otolith organs and the semicircular canals
What is Meniere’s disease?
- A transient condition that can last up to 3hrs
- Symptoms –> dizzy, unsteady, nauseous, ringing in ears, and a drop in hearing
- thought to be due to excessive secretion of endolymph with acute swelling in vestibular and cochlear duct –> self-limiting may be due to minor rupture relieving pressure
- Treatment –> betahistine, diuretics, corticosteroids, surgery
Inner ear –> Otolith organs
Inner ear –> semicircular canals
Vestibular nervous pathway
Vestibular-ocular reflex
The vestibular system endolymph motion –> YouTube video
https://www.youtube.com/watch?v=dSHnGO9qGsE
Benign paroxysmal positional vertigo
- Manoeuvre to diagnose (Dix-Hallpike manoeuvre) –> pt sat on bed, head tilted 45 degrees laterally and eyes facing you for 30 secs, then lower the patient horizontally flat keeping head in 45-degree position –> if pt has nystagmus then +ve test
(perform on both sides)
(video: https://www.youtube.com/watch?v=8RYB2QlO1N4 )
. - Common disorder of the inner ear
- Typically lasts a few seconds to a few minutes
- Thought to be caused by displaced otoconia
- Can be detected using the Dix-Hallpike maneuver
- Head tilting and rotating can reposition otoconia (Epley maneuver)
- Acute severe BPPV can be treated with antivertigo medication
Nystagmus
- Rhythmical, repetitive and involuntary movement of the eyes
- Multiple causes, congenital and acquired
- Semi-circular canals are stimulated while the head is not in motion
- Can be associated with vertigo
.
Video: https://www.youtube.com/watch?v=9LsHp-tgx8w
What is an audiogram?
An audiogram measured by an audiologist using an audiometer converts measured thresholds from absolute sound pressure level to a hearing threshold level relative to the normative population, thereby allowing direct reading of the loss in hearing sensitivity at each frequency relative to the normal population
Anatomy and Physiology of the Auditory system –> YouTube video
https://www.youtube.com/watch?v=A2Ee9VrDHh4
Which of the following best describes the middle ear ossicle attached to the tympanic membrane?
- Incus
- Malleus
- Stapes
Malleus
The cochlea’s 3 chambers are the scala vestibuli, scala media, and scala tympani. The scala vestibuli and scala tympani are filled with _____________ (similar to _____________ fluid).
- Endolymph (similar to intracellular fluid)
- Perilymph (similar to cerebrospinal fluid)
Perilymph (similar to cerebrospinal fluid)
Low-frequency sound causes which portion of the basilar membrane to vibrate to the greatest extent?
- Near oval window
- Middle portion
- Along entire length
- Near helicotrema
Near helicotrema
The otolith organs (utricle and saccule) are primarily involved in detecting which type of movement?
- Rotational movements
- Linear acceleration
- Sound waves
Linear acceleration
Which of the following cranial nerves is involved in transmitting sensory information from the vestibular system to the brain?
- Cranial nerve III (Oculomotor nerve)
- Cranial nerve IV (Trochlear nerve)
- Cranial nerve VI (Abducens nerve)
- Cranial nerve VIII (Vestibulocochlear nerve)
Cranial nerve VIII (Vestibulocochlear nerve)
Carotid sheath –> Axial view
Vagus nerve
- vagus nerve is the 10th cranial nerve –> provides motor supply to the muscles of swallow and speech
- also supplies parasympathetic fibres to all organs except the adrenal glands
- also supplies sensory fibres to the ear, throat, heart, lungs, abdomen, and taste
- one of the main branches is the recurrent laryngeal nerve which supplies all the muscles of the larynx
Facial nerve
- Facial nerve (7th cranial nerve) –> supplies all the muscles of facial expression
- 5 terminal branches –> temporal branch, zygomatic branch, buccal branch, marginal mandibular branch, and the cervical branch
Phrenic nerve?
- at risk during neck surgery
Accessory nerve
- 11th cranial nerve
- motor supply to sternocleidomasteoid and trapezius
- at risk during lymph node excision or neck dissection
Hypoglossal nerve
- 12th cranial nerve
- motor supply for all ipsilateral muscles of the tongue (except the palatoglossus muscle)
Cervical sympathetic trunk
- paired nerve bundle from skull to coccyx
- in neck embedded in posterior wall carotid sheath on prevertebral fascia
- 3 ganglia –> Superior (C2, C3), Middle (C6), and Inferior (1st rib)
- Injury can cause Horner’s syndrome –> ptosis, miosis, and anhidrosis
Thyroid –> arterial blood supply (2) + veins (3)
Arterial supply:
- superior thyroid artery (branch of external carotid artery)
- inferior thyroid artery (branch of thryocervical trunk)
.
Veins:
- Superior thyroid vein
- Middle thyroid vein
- Inferior thyroid vein
History for neck lump
Examination of neck lump
Thyroid examination video
https://www.youtube.com/watch?v=exGgjm55Stw
Why give a glass of water for the pt to swallow during a thyroid examination?
- a thyroid swelling will move up and down on swallowing because the thyroid gland is attached posteriorly to the cricoid and thyroid cartilages by a layer of pre-tracheal fascia called Berry’s ligament
(Note: lymph nodes do not move on swallowing)
Thyroglossal cyst
- most common congenital cyst in neck
- moves up and down on swallowing and tongue protrusion
- can be managed conservatively
Brachial cyst
- typically present with swelling arising deep to upper 1/3 of SCM
- may be infected at initial presentation with erythema/pain/temp.
- Investigate with USS fine needle aspiration and MRI to exclude a deep tract/sinus
- treatment with surgery as they may become recurrently infected
Carotid body tumour (paraganglioma)
- rare
- pulsatille lateral neck swelling at bifurcation of common carotid artery (possible bruit on auscultation)
- typically benign but some are malignant with metastases
- treatment with surgery or radiotherapy
Lyre’s sign
- splaying of the external and internal and external carotid arteries
Schwannomas
Salivary gland tumours
Recurrent salivary gland swellings
Parotid gland swelling
80% of tumours are within parotid gland
Alarming symptoms of a neck/facial lump suggesting malignancy
- Painful mass
- Rapidly increasing mass
- VII nerve weakness
- Lymph nodes
- Paraesthesia
- Trismus
Parotid SCC
Bilateral parotid swelling
Thyroid lumps
Aetiology of thyroid lumps
Alarm bells for thyroid cancer
- Family hx of thyroid cancer
- Hx of exposure to radiaiton
- <20 yrs or >70 yrs
- Male
- Lymph nodes palpable
- Vocal cord palsy
Investigations for thyroid nodules
- TFTs
- Thyroid USS +/- FNA (fine needle aspiration)
When to treat thyroid nodules
- C –> Cosmesis
- C –> Compression
- C –> Cancer
- C –> fear of ‘Cancer’
Sebaceous cyst
Lipoma
Lymphangioma
Main investigation for lymph nodes
USS FNA
- if lymphoma suspected –> USS core biopsy will diagnose and subtype
Reactive lymph nodes
lymph node abscess
Lymph node –> Atypical mycobacteria
TB neck
Other infected lymph node causes
Neck lumps –> Sarcoidosis
How many cranial nerves are there + functions
12 paired cranial nerves (PNS)
- Sensory (general or special)
- Motor
- Parasympathetic
12 cranial nerves names
How do lesions affecting cranial nerves (CN) present?
Most of the time will present with ipsilateral effects –> some may present with contralateral however
- generally cranial nerves do not decussate (cross-over)
What type of nerve fibres carry motor information from the CNS?
- efferent fibres
What type of nerve fibres carry sensory information from the internal and external environment (general and special senses)?
- afferent fibres
- General senses –> pain, pressure, touch, temperature, proprioception
- Special senses –> all carried in cranial nerves –> olfaction, vision, taste and hearing. and vestibular function
Cranial nerves can be organised on the basis of the functional components of each nerve:
1) General Somatic Afferent (GSA)
2) General Visceral Afferent (GVA)
3) General Visceral Efferent (GVE)
4) General Somatic Efferent (GSE)
All modalities of conscious sensation pass through a sequence of ______ neurones from peripheral receptor via the _______ to perception of sensation in the cerebral _______.
Except _____ projections which only consists of ___ neurones between receptor and cerebral cortex and does not primarily project via the _____.
All modalities of conscious sensation pass through a sequence of three neurones from peripheral receptor via the thalamus to perception of sensation in the cerebral cortex.
Except olfactory projections which only consists of two neurones between receptor and cerebral cortex and does not primarily project via the thalamus.
Parasympathetic and sympathetic efferent fibres pass through a sequence of _____ neurones between CNS and innervated structure.
Parasympathetic and sympathetic efferent fibres pass through a sequence of two neurones between CNS and innervated structure.
Where are cell bodies of first order neurone (preganglionic neurone) located?
brain or brainstem
Where are cell bodies of the second order neurone (postganglionic neurone) located?
in the periphery in an autonomic ganglion
What does the brainstem consist of?
- Mid-brain
- Ponjs
- Medulla Oblongata
Where do CN exit brainstem?
- CN III, IV –> Mid-brain
- CN V –> Pons
- CN VI, VII, VIII –> Ponto-medullary junction
- CN IX, X, XI (Cranial part), XII –> Medulla Oblongata
- CN XI (spinal part) –> C1 - 5
Which cranial nerves are from nuclei components of the forebrain and which are from cranial nerve nuclei in the brainstem?
- CN I and II are from nuclei components of the forebrain
- CN III-XII are from cranial nerve nuclei in the brainstem
Functions of the midbrain, pons, and medulla oblongata
Are sensory nerve nuclei usually located medially or laterally in the brainstem?
Laterally
- motor nuclei tend to be located more medially
Olfactory Nerve (CN I) –> function
Purely sensory – olfaction (smell)
What muscle does the trochlear nerve (CN IV) innervate?
Superior oblique muscle
What muscle does the abducens nerve (CN VI) innervate)?
Lateral rectus muscle
What are the 3 sensory divisions of the trigeminal nerve + which division do motor fibres only travel in?
- Ophthalmic
- Maxillary
- Mandibular –> motor fibres travel in the mandibular divison only
Vestibulocochlear Nerve (VIII) –> function
- Vestibular –> carries info regarding position and movement of head
- Cochlear –> carries auditory info
Glossopharyngeal Nerve (CN IX) –> what sensory area is supplied + which muscle is innervated by the motor component?
- Taste from posterior 1/3 of tongue
- Motor component arises from nucleus ambiguous –> innervates one muscle –> stylopharyngeus
Are the Accessory nerve (CN XI) and Hypoglossal nerve (XII) purely sensory or purely motor?
Purely motor
Motor functions of cranial nerves
Sensory functions of cranial nerves
Extradural haematoma
- ‘lemon-shaped’, more localised than subdural haematoma
- located between skull vault and dural layer
Subdural haematoma
- ‘banana shape’
Subarachnoid haemorrhage
How would an inflammatory neck swelling present and what is the main differential?
Atypical mycobacteria neck –> presentation, how is it transmitted, treatment options
- Symptoms –> painless, ‘cold abscess’, may be discharge
- Transmitted oral route from soil
- Initial treatment –> oral clarithromycin 6/52
- Surgery –> nodal excision or curettage
TB neck (aka. “scrofola”) –> presentation, at risk groups, investigations/diagnosis, treatment
- collar stud abscess, lymphadenopathy, lungs may be affected
- Risk groups –> immunocompromised (eg. HIV), developing countries (poverty)
- Dx –> FNA-cytology (granulomas), acid-fast bacilli, culture (mycobacterium), lymph node excision biopsy, Mantoux test
- Treatment (triple therapy) –> Rifampicin, Ethambutol, Isoniazid
Lymph node malignancy –> primary vs secondary
- Primary –> lymphoma (haem malignancy)
- Secondary –> squamous cell carcinoma (SCC)
Investigations for a neck lump
- USS fine needle aspiration –> non-lymphoma lymph node/thyroid/salivary gland swelling
- USS core biopsy –> lymph nodes (suspected lymphoma diagnosis)
Treatment options for head/neck cancer
MDT:
- Surgery
- Radiotherapy +/- chemotherapy –> chemo alone has no curative role
Deep neck space infections –> what are we worried about, presentation, treatment principles
- Potential airway compromise
- External erythema and significant neck swelling may present late –> may present with torticollis +/- sepsis in child
- Submandibular, retropharyngeal, parapharyngeal abscess
- Treatment principles –> stabilise airway/monitor FIRST (before imaging too), incision and drainage of abscess, IV antibx, monitor bloods after (FBC, ESR, CRP), and low-threshold to rescan +/- return to theatre
Ludwig’s angina –> what is it, most common aetiology, and treatment
- life-threatening cellulitis of the soft tissue involving the floor of the mouth and neck –> the infection is rapidly progressive, leading to potential airway obstruction
- Ludwig angina involves 3 compartments of the floor of the mouth: sublingual, submental, and submandibular
. - Aetiology –> dental infection
. - Treatment –> secure airway, IV antibx (broad-spectrum), surgical drainage is an option
–> IV steroids and nebulised adrenaline can also improve facial and airway oedema and antibx penetration
Audible breathing (aka. noisy breathing) is either referred to as stertor or stridor, what is meant by these terms?
- Stertor = “noisy breathing caused by partial obstruction of the respiratory tract above the larynx”
- Stridor = “noisy breathing caused by partial obstruction of the respiratory tract at or below the larynx”
(Stridor and stertor are sounds (signs) of airway narrowing and cold be a sign of impending airway obstruction)
What are some signs of impending airway obstruction?
- noisy breathing –> stertor or stridor
- increased resp. rate
- increased use of muscles (accessory, interstitial)
- tracheal tug
- difficulty in talking
- tachycardia
- sweating
- nasal flaring
- reduced resp. rate
- cyanosis, reduced GCS
- cardiorespiratory arrest
Management
- “open curtains” –> do nothing
Management
- “closed curtains” –> consider intubation
- “wardrobe obstructing curtains” –> consider surgical airway
Tracheostomy video
https://www.youtube.com/watch?v=d_5eKkwnIRs
Nasal structure –> split into 1/3’s
- Upper 1/3 –> bony
- Middle 1/3 –> upper lateral cartilage
- Lower 1/3 –> lower lateral cartilage (alar cartilage)
What are the turbinates within the nose made up of ?
Ciliated columnar epithelium
What are the 4 sinuses within the nose?
- Frontal
- Maxillary
- Anterior ethmoid
- Posterior ethmoid and sphenoid –> sits at the back, affected the least
Which arteries supply the nose?
- Internal and external carotid arteries
–> the carotid system anastamoses at ‘Little’s area’ –> this is where most nose bleeds occur
Nerve supply of the nose –> sensory
- Sensory supply is via the maxillary division of the trigeminal nerve
- The nasal vascular supply is controlled by sympathetic and parasympathetic NS
Functions of the nose
- Filtration of dust and pathogens and protection
- Olfaction (smelling)
- Humidification of inspired air and warming
- Reception and elimination of secretions from the nasal mucosa
- Vocal resonance
Aetiology of nose bleeds (epistaxis)
- Majority are idiopathic and self-limiting
- Trauma –> picking at nose
- Infection
- Neoplasia
- Foreign body
What are some general things that can exacerbate nose bleeds (epistaxis)?
- Hypertension
- Drugs (anticoagulants/Warfarin)
- Blood diseases (leukaemia)
- Hereditary haemorrhagic telangiectasia
Who should you not give naseptin to for epistaxis?
- ppl with peanut/soya allergy –> it contains peanuts
What substance is used for cautery in the treatment of epistaxis?
Silver nitrate
Where is the best place to apply pressure during a nose bleed + first aid measures
How would you assess blood loss in an active nose bleed?
- Record pulse and BP
- signs of shock –> pallor and sweating
- IV fluids
- FBC (Hb), clotting screen, and G+S
Controlling the bleeding in a nose bleed –> what can we do?
- First-aid measures to start with
- Nasal cautery –> silver nitrate
- Nasal packing –> Merocel (smear with Nasewptin cream before insertion to allow it to slide in more easily) –> once inserted you inject saline into it and it becomes larger and can absorb blood
- Surgery –> ligation of vessels –> sphenopalatine artery (last resort)
Septal haematoma –> what is it and treatment
- a rare but serious complication of nasal or facial trauma –> it refers to the collection of blood under the mucoperichondrium or mucoperiosteum of nasal septal cartilage or bone
- Need to drain hematoma otherwise septal perforation or nasal deformity will occur
Nasal fracture –> when do we reduce the deformity?
- at about 10 days
- too soon and there is still swelling
- too late and bony callus has formed
Mandibular fractures –> symptoms, investigations, treatment
- Usually presents from RTA or heavy knock to the face
- Symptoms –> severe trismus and possibly dental malocclusion
- Investigations –> X-rays highlight the fracture line
- treatment –> reduce and immobile the fracture for several weeks by wiring teeth together
Malar fractures –> presentation + which nerve may be damaged?
- Presentation –> following RTA or heavy knock to face, palpation of orbital rum will reveal a step
- Infraorbital nerve –> supplies big area over the cheek
Maxillary fractures –> what classification is used to categorise + presentation + treatment
- Le Fort I, II, and III
- Due to severe force such as RTA, may be life-threatening (often associated with other severe injuries)
- Requires reduction and splinting
Auricular haematoma (aka. “cauliflower ear”) –> presentation + treatment
- Occurs following blunt trauma –> typically rugby or boxing
- Simple aspiration or incision and drainage –> need to monitor to ensure haematoma does not re-accumulate
(if not treated properly then can get deformities eg. cauliflower ear)
Rhinophyma –> what is it?
- Due to overgrowth of sebaceous glands in tip of nose + often associated with rosacea
- Cosmetic but can also limit nasal airway
Facial pain aetiology
- Rhinological –> inflammation within nasal cavities or sinuses (note: chronic sinusitis is usually painless)
- Dental –> TMJ dysfunction, myofascial pain, dental disease
- Vascular –> migraine (unilateral), cluster headaches (unilateral or periorbital), temporal arteritis
- Neuralgia –> trigeminal (very painful), glossopharyngeal (pain on swallowing), post-herpetic
- Non-organic –> tension headache, atypical facial pain
Taste (gustation) –> five core modalities and taste zones
- Salt, sweet, sour, bitter, umami
What nerves supply the anterior 2/3 of tongue and posterior 1/3 of tongue?
- Anterior 2/3 –> chorda tympani branch leaves facial and joins lingual branch of V3 to supply ant. 2/3
- Posterior 1/3 –> glossopharyngeal nerve
Key rhinological symptoms/questions…
Definition of rhinitis
Rhinitis = an inflammatory disorder of the nasal mucosa characterised by two or more of the following symptoms:
- rhinorrhoea (anterior and/or posterior)
- blockage
- itching/sneezing
Two types of rhinitis
Allergic rhinitis and asthma share many common inflammatory processes –> what characterises these?
Eosinophil infiltration
Intermittent rhinitis VS persistent rhinitis (ARIA rhinitis classification)
History taking in pt with rhinitis –> key things to ask
- distinguish from other types of rhinitis or rhinosinusitis
- allergen contact –> pets, damp home, etc.
- seasonal vs perennial
- concurrent asthma
- paternal atopy
- drug hx –> eg. use of nasal sprays, beta-blockers
Investigations in a pt with rhinitis
- Endoscopic examination of nose
- Skin prick allergy tests or RAST
Acute rhinosinusitis –> timeline, symptoms, recurrent ABRS criteria
- 10 days to 12 weeks
- Symptoms –> nasal blockage, hyposmia (decreased sense of smell), mucopus discharge, facial pain/pressure
- Recurrent ABRS –> complete resolution between episodes but 12/52 per year
Key organisms involved in acute bacterial rhinosinusitis
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
Acute bacterial rhinosinusitis treatment
- Nasal steroids
- Nasal douching
- Decongestants –> topical +/- oral
- Co-amoxiclav 625mg tds for 2/52 or clarithromycin 500mg bd if penicillin allergy
Complications of sinusitis
- Mucucole/pyomucocoele formation –> mucosal cyst
- Osteomyelitis (Pott’s puffy tumour) –> tender forehead swelling with associated symptoms
- Periorbital cellulitis
- Silent sinus syndrome
- Meningitis
- Cranial nerve palsies
What is required for a diagnosis of chronic rhinosinusitis?
Chronic rhinosinusitis (CRS) –> what immune cells are involved (nasal polyps vs without nasal polyps)
- Nasal polyps –> TH2 mediated pathway
- Without nasal polyps –> TH1 mediated pathway
Most common bacterial flora found on CRS (chronic rhinosinusitis pts)
Staph. aureus
CRS (chronic rhinosinusitis) treatment
- Nasal douching for all
- With polyps –> topical steroids, spray, drops, prednisolone, doxycycline 3/52
- Without polyps –> nasal steroids, macrolide 12/52
- If this fails consider –> sinus surgery, biologics (dupilumab, mepolizumab)
“Allergic” fungal rhinosinusitis (AFRS)
Nasal obstruction differentials –> Bilateral vs Unilateral
- Usually bilateral –> rhinitis, rhinosinusitis
- Usually unilateral –> neoplasia, antro-choanal polyp, deviated nasal septum, foreign body
Facial pain
Red flag symptoms for sinonasal disorders
- Unilateral symptoms –> bleeding, crusting, cacosmia, blockage
- Orbital symptoms
- Neurological signs inc. CN palsies
- Severe frontal headaches
- Clear, watery rhinorrhoea, esp. unilateral
Smell and taste disorders
What is the role of the tendon of stapedius
- tenses when there is loud noise –> dampening movement of stapes bone and protecting the cochlear
Tuning fork –> what Hz is used
512Hz
Audiogram –> High tone deafness
- this is the type of deafness we see as we age
- Red + round = right ear (RRR)
- Blue + crosses = left ear
What is a BAHA (bone-anchored hearing aid)?
- a surgically implanted device that helps people with hearing loss hear better
- BAHAs are often used by people who can’t wear traditional hearing aids
Facial nerve anatomy
Facial parlaysis –> UMN (central) VS LMN (peripheral)
- UMN facial palsy (stroke) –> preservation of forehead and brow movements –> due to bilateral innervation centrally
- LMN/peripheral facial palsy (eg. tumour in parotid gland) –> entire side of face paralysed
Bell’s Palsy and cholesteatoma
- Bell’s Palsy –> idiopathic facial paralysis
- Cholesteatoma –> chronic disorder of the ear with infection and dead skin gathering within the middle ear and eroding bone locally –> this is also a cause of a facial paralysis
(therefore, a diagnosis of Bell’s palsy can only be made with confidence after ear drum has been inspected)
Ramsay Hunt Syndrome –> what is it
a rare neurological disorder that occurs when the varicella-zoster virus (VZV) reactivates and affects the facial nerve –> can cause facial paralysis
Examination of balance disorders
- Watch the pt walk in
- Romberg –> pt stood up with feet together and arms by side –> look for swaying (repeat with eyes closed)
- Unterberger
- Hallpike
- Check for postural BP change
- Rest of CNS exam may not help much
(Note: Hx is more useful than assessment)
BPPV (Benign Paroxysmal Positional Vertigo) –> what is it + diagnosis + management
- a common inner ear disorder that causes vertigo, dizziness, and other symptoms when you move your head
- Basically caused by an imbalance of crystals within the inner ear
- Episodic transient and positional
- +ve Hallpike test with rotating nystgamus
- Epley manouvre works well
Example: Fast-beating nystagmus to the right –> which ear is affected
left ear
Audiogram example
Air conduction hearing test
- Simply tests what sounds you can hear at different volume and pitch –> the results are recorded on an audiogram
- Can identify hearing loss, but doesn’t tell us what the issue is
Bone conduction hearing test
- By using vibrations, it goes straight to the cochlear (inner ear) –> bypasses outer and middle ear
- Therefore, can identify if there is an issue with the cochlear itself
Bone conduction hearing test –> example
- There is an issue with the cochlear itself –> the triangles represent the bone conduction test
- SNHL: ac=bc (inner ear problem)
Bone conduction hearing test –> example
- There is an air-bone gap –> this tells us that something in the outer or middle ear is stopping the sound from getting through to the cochlear
- Could just be wax in the ear, or could be perforation or infection
- CHL: bc<ac (middle ear problem)
Tympanometry –> what does it measure
Measures the change in compliance (movement) of the eardrum
Tympanometry classification
Peak classification
Newborn hearing screening
- (left) otoacoustic emission (OAE) test –> measures how well the inner ear responds to sound, and is often used to screen for hearing loss in infants and children
- (right) automated audiotry brainstem response (AABR) test –> tests auditory nerve function
Hearing aids
Digital Hearing Aids –> advantages
Vestibular function tests
- most commonly teste semicircular canal is the horizontal semicircular canal
Nystagmus
Vestibular assessment
- Hx gives most of info
Labelled tonsil anatomy –> Normal
Tonsilitis
Main function of tonsils and adenoids
Immunological function –> part of Waldyer’s ring
Why take tonsils and/or adenoids out?
- Recurrent tonsilitis/adenoiditis (?causing ear infections)
- Obstructive sleep apnoea syndrome
What causes tonsilitis?
- Viral
- Bacterial –> 15-40% are Strep)
Management of tonsilitis
- Conservative
- Antibiotics –> only if bacterial
- Tonsillectomy –> if 6/7 per year, or 3/4 per year over 2 years
What is Quinsy?
- Peritonsillar abscess causes by a bacterial infection –> tonsilitis progresses and causes an abscess to form
Adenoid anatomy
- If become enlarged then can block eustachian tube and cause issues with middle ear
Waldyer’s Ring
- A ring of tissue that helps protect against pathogens entering via the nose/mouth
Basics of hearing –> anatomy
Normal eardrum/tympanic membrane
Abnormal eardrum/tympanic membrane –> “glue ear” or otitis media with effusion
Abnormal eardrum/tympanic membrane –> acute otitis media causing eardrum to bulge
Why would we put grommets in a pt’s ear?
- Recurrent otitis media
- Persistent otitis media with effusion (glue ear)
How do grommets work in the ear?
Ventilates the middle ear
Congenital nasal –> Choanal atresia
- a congenital condition where the back of the nose does not form properly –> cartilage overgrowth or bony blockage
- if one side blocked then okay but if both blocked then serious
Lymphangioma of the tongue
uncommon, benign malformations of the lymphatic system that can occur anywhere on the skin and mucous membranes
Teratoma
- a rare type of germ cell tumor that may contain immature or fully formed tissue, including teeth, hair, bone and muscle
- contain cells from all 3 cell lines (mesoderm, endoderm, ectoderm)
Larynx anatomy
- Vocal cord
- False vocal cords (vestibular bands)
- Epiglottis
- Aryepiglottic fold
5.. Arytenoid process - ?
- Base of tongue
What is the abnormality?
Subglottic stenosis
- small lumen and a band of tissue
What is this abnormality?
- Recurrent laryngeal papillomatosis –> due to HPV
What is this abnormality?
Perforation of ear drum
What is this abnormality?
- Cholesteatoma –> infected skin cyst
- pearly white skin cyst behind the eardrum
Cochlear implantation
- consists of an internal and external part
- this device allows people with no ability to hear to hear sounds
Vertigo definition
a sensation of dizziness or abnormal motion resulting from a disorder of the sense of balance
Assessing the dizzy patient –> history
- Onset (first episode)
- Precipitating factors (eg. neck movements)
- Associated symptoms (eg. deafness, tinnitus)
- Frequency
- Duration
- PMH (trauma, surgical hx)
Presentation of dizziness –> differentials
Duration of dizziness attacks
Triggers of dizziness attacks
Examination and interpretation –> dizziness
Dix-Hallpike
Common peripheral vestibular disorders
- BPPV –> vertigo lasts seconds, nystagmus on Dix-Hallpike
- Menieres –> vertigo lasts hours, fluctuable hearing loss, tinnitus
- Vestibular neuritis –> acute vertigo lasting days, normal hearing and neuro exam
BPPV treatment
Epley manoeuvre –> canalolith repositioning manoeuvres
Vestibular rehabilitiation
- Central compensation
- Recalibratoin of vestibular reflexes
- Physio –> Cawthorne-Cooksey exercises (or Brant-Daroff exercise)
Main function of pinna
To collect sound –> large SA helps with this
Roles of outer ear, inner ear, and middle ear
Shape deformities of ear
- purely cosmetic –> hearing won’t be affected really
Microtia –> sizes of ear (grades)
- mainly cosmetic again
Preauricular sinus
Haematoma of the ear
treatment is drainage
Otitis externa and perichondritis
- infection of outer ear = otitis externa
- Otitis externa –> Staph. A or pseudomonas
- Perichondritis –> Pseudomonas
Acute otitis externa
Chronic otitis externa
Necrotising otitis externa
- Potentially life-threatening progressive infection of the external ear canal which may spread to cause osteomyelitis of the temporal bone and adjacent structures
- Symptoms –> night pain, not responding to usual treatment, immunocompromised, cranial nerve involvement
- Most common pathogen –> Pseudomonas aerogenosa
- Management –> CT temporal bone, long-term pseudomonas antibx
Risk factors for otitis externa (outer ear infections)
Otitis externa clinical signs and symptoms
- Top left –> inflamed
- Bottom left –> folliculitis
- Top right –> otomycosis (fungal ear infection)
- Bottom right –> necrotising otitis externa
Chronic otitis externa
- chronically inflamed skin
Treatment of otitis externa
- Avoiding ear infections –> avoid self-cleaning, water precautions, manage risk factors
. - Cleaning external auditory canal
- Analgesia
- Topical antibx +/- topical corticosteroid (7-14 days)
- Oral antibx if pt is immunocompromised or severe infection, or systemic infection
Acute otitis media
- the presence of inflammation in the middle ear cleft
- viral
- bacterial
Risk factors for middle ear infections (otitis media)
Presentation of otitis media
Ear ache, hearing loss, systemic signs
Treatment of otitis media
Surgical management for severe acute otitis media –> Myringotomy
Otitis media with effusion
Eustachian tube dysfunction or block
Images of fluid within middle ear (otitis media with effusion)
Management of otitis media
- Audiogram and tympanogram
- Conservative –> Otovent balloon, treat URI if present
- Surgical –> grommet +/- adenoidectomy
Chronic otitis media - mucosal
- Repeated acute otitis media prevents healing of the perforation –> persistent perforation
- Copious mucopurulent ear discharge + hearing loss
Chronic otitis media - squamous –> Cholesteotoma
Squamous epithelium in middle ear (build up)
Otosclerosis
- Stapes bone gets fixed –> therefore cannot vibrate
- Symptoms –> hearing loss
Meniere’s Disease –> symptoms
- Vertigo –> episodic lasting 20 min to 12hrs
- Hearing loss –> fluctuating
- Tinnitus –> pulsatile
Healthy inner ear VS Meniere’s disease
Treatment for Meniere’s disease
- Self-limiting
- Diet and lifestyle
- Medical –> diuretics, betahistine, intratympanic
- Surgical –> endolymphatic sac surgery
BPPV –> symptoms + diagnosis + treatment
- Symptoms –> vertigo on turning head in relation to gravity (turning while sleeping, looking up while taking book from shelf)
- Diagnosis –> Dix-Hallpike manoeuvre (vertigo can be elicited by movement)
- Treatment –> Epley manoeuvre (canalolith repositioning manoeuvre/exercise)
Labrynthitis/Vestibular neuritis
- Viral infection
- Vertigo lasts for days –> peaks and gradually subsides
- Diagnosis –> clinical, audiogram
- Treatment –> labrynthine sedative, steroids
Vestibular schwannomma
- Benign tumour arising from vestibular
- Constant, less severe, facial palsy, central signs
- Always MRI to check for tumours
Types of hearing loss –> Conductive VS Sensorineural
- Conductive –> issue with outer ear or middle ear
- Sensorineural –> issue with inner ear
Causes of hearing loss
Rinne’s Test
- Using a 512Hz tuning fork
- Initiate vibration and place on pt’s mastoid process of the tested ear
- Once pt cannot hear vibrations, move the tuning fork over ear and ask if pt can hear (air conduction)
- If bone conduction is greater than air conduction then suggests conductive hearing loss
- Note: air conduction should be greater than bone conduction so this would be normal or if Weber has detected a hearing loss then could be sensorineural
Weber Test
- Tells us which side hearing loss is, but use Rinne’s to distinguish whether conductive or sensorineural
- Sound lateralises towards conductive hearing loss
- Sound lateralises away from sensorineural hearing loss
