surgery - ENT presentations Flashcards
what is a facial palsy?
weakness or paralysis of the muscles of the face.
what are most facials palsy caused y?
what’s this called?
idiopathic
called bell’s palsy
what indicated UMN and LMN palsy?
forehead sparing = UMN palsy
forehead paralysis = LMN palsy.
what is Bell’s palsy?
idiopathic LMN facial palsy
diagnosis of exclusion
where does the facial nerve arise and travel to?
arises in the pons as separate sensory and motor roots
then travels in the internal acoustic meatus, very close to the inner ear.
when does the facial nerve roots fuse>
As they enter the facial canal - form single facial nerve before branching off
what are the branches of the facial nerve?
intracranial branches of the greater petrosal nerve
nerve to stapedius
chorda tympani
how does the facial nerve travel through the middle ear and where does it exit?
In the facial canal and then through the mastoid bone. Finally, it exits the cranium via the stylomastoid foramen
what are the first extra cranial branches of the facial nerve?
the posterior auricular nerve, nerve to digastrics, and nerve stylohyoid
what are the facial nerve branches in the parotid gland?
terminal branches of the Temporal, Zygomatic
Buccal
Marginal mandibular
Cervical branches.
what is the pathophysiology/RF for Bell’s palsy?
most common = viral origin eg HSV-1, CMV, EBV
less common = diabetes, pregnancy
features of Bell’s palsy?
painless unilateral LMN weakness of facial muscles
inability to close their eye (temporal and zygomatic branches)
Hyperacusis (nerve to stapedius)
Metallic taste (chorda tympani)
Reduced lacrimation (greater petrosal nerve)
how do you grade the severity of a facial palsy?
House-Brackmann classification
what is grade 1 facial palsy?
Normal facial function in all areas.
what is grade 2 facial palsy?
Mild Dysfunction
Slight weakness noticeable on close inspection; may have very slight synkinesis.
what is grade 3 facial palsy?
Moderate Dysfunction
Obvious, but not disfiguring, differences between 2 sides. Noticeable, but not severe, synkinesis or hemifacial spasm. Complete eye closure with effort.
what is grade 4 facial palsy?
Moderately Severe Dysfunction
Obvious weakness of disfiguring asymmetry, normal symmetry and tone at rest but unable to complete eye closure.
what is grade 5 facial palsy?
Severe Dysfunction
Only barely perceptible facial muscle motion, asymmetry at rest.
what is grade 6 facial palsy?
Complete paralysis
No movement
causes of UMN facial palsy?
how will they present?
stroke, subdural haematoma, multiple sclerosis, or neoplasm (e.g. a primary brain malignancy)
The will present with forehead sparing
other causes of LMN facial palsy?
Infective, such as acute otitis media, cholesteatoma, viral infection (including HSV-1, CMV, and EBV)
Neoplasm (e.g. parotid malignancy)
Trauma (e.g. temporal bone fracture) or iatrogenic (e.g. mastoid or parotid surgery)
what ix are carried out for Bell’s palsy?
diagnosed clinically
Serology for HSV-1 and VZV can be performed, yet will unlikely alter future management if detected. This is particularly relevant where vesicular pustules are evident.
mx for bell’s palsy?
Patient reassurance is essential as can return spontaneously to full function.
if presenting within 72hrs START ORAL STEROIDS
when is Bell’s palsy referred to surgery?
doubt over the diagnosis, recurrent or bilateral Bell’s palsy, or no sign of improvement after 1 month
what is dosing of steroids in Bell’s palsy?
Giving 25 mg twice daily for 10 days
OR
Giving 60 mg daily for five days followed by a daily reduction in dose of 10 mg
what are the surgical options for bell’s palsy?
Synkinesis could be treated with botox injections
persistent weakness can be treated with anterior belly of digastric transfer, fascia lata sling, or cross-facial nerve grafting
when is bell’s palsy referred to ophthalmology?
if the cornea remains exposed after attempting to close the eyelid (House Brackmann grade of IV or more).
poor prognosis in Bell’s palsy?
Complete palsy
No signs of recovery within 3 weeks
Age >60yrs
Associated pain
Ramsay Hunt syndrome
Associated hypertension, diabetes mellitus, or pregnancy
what is Ramsay-hunt syndrome?
Herpes Zoster oticus
a unilateral facial palsy caused by reactivation of varicella zoster virus from the geniculate nucleus, the nucelus of the facial nerve.
features of Ramsay hunt?
moderate to severe ear pain
develop into a facial palsy, accompanied by ipsilateral vertigo, hyperacusis, and tinnitus
Vesicles will be visible covering the concha, anterior ⅔ tongue, and / or the soft palate.
ix and mx of Ramsay hunt?
Diagnosis is clinical
prednisolone and acyclovir
complications of Ramsay hunt?
chronic tinnitus and vestibular dysfunction.
what is hoarse voice?
weak or altered voice.
TRUE VOCAL CORDS:
- function
- innervation
responsible for producing voice by being able to abduct and adduct
innervation from the recurrent laryngeal nerve and the external branch of superior laryngeal nerve.
what does the recurrent laryngeal nerve supply?
all the intrinsic muscles of the larynx, apart from the cricothyroid
ie lateral cricoarytenoid, posterior cricoarytenoid, transverse and oblique interarytenoid and thyroarytenoid
what innervates the cricothyroid?
external laryngeal nerve.
what does cricothyroid do?
increases the pitch of our voice.
1st ix for horse voice?
flexible nasal endoscopy (FNE) and Microlaryngobronchoscopy (MLB)
what does FNE do?
allows visualisation of the larynx and the vocal cords
can be performed in the outpatient clinic, with minimal preparation required.
what does MLB do?
allows for visualisation of the larynx, vocal cords, and bronchi
performed under general anaesthetic in theatres
allows for biopsies or treatment options too, such as microdebridement or laser excisions to be performed.
what additional ix for hoarse voice may be needed?
CT neck and chest (to assess for any lesion along the path of recurrent laryngeal nerve)
Video-stroboscopy is a useful diagnostic test in vocal cord dysfunction.
laryngeal electromyography (EMG, to distinguish between palsy from fixation, i.e. neural – paralysis, joint – fixation).
what are examples of benign laryngeal conditions?
vocal cord nodules
intercostal cysts
muscle tension dysphonia
vocal cord polyps
laryngeal papillmoas
laryngopharyngeal reflux
Reinke’s oedema
what are infection vocal cord conditions?
laryngitis
Supraglottitis and Epiglotittis
what are vocal cord nodules?
secondary to chronic phonotrauma (vocal abuse)
benign bilateral lesions at the junction between the anterior and middle 1/3 of the vocal folds due to strain
mx = voice therapy from the SALT team
what are intercostal cysts?
due to phonotrauma or blockage of mucous gland excretory duct
investigated with videostroboscopy
mx = voice therapy from the SALT team
what is muscle tension dysphonia?
caused by habitual misuse of the muscles of the larynx
hoarse voice that worsens at end of day or after prolonged use
dx = stroboscope
mx = voice therapy from the SALT team
what are vocal cord polyps?
unilateral benign lesions
mx = surgical excision to exclude malignancy
what are laryngeal papillomas?
benign lesions caused by HPV infection
if untreated can cause airway obstruction
mx = surgical excision, may need to be repeated due to recurrence
what is laryngopharyngeal reflux?
caused by acid reflux resulting in inflammation of the larynx
FNE will reveal interarytenoid oedema, oedematous vocal cords, or granulations of the vocal cord
mx = proton pump inhibitor (PPI) therapy ± H. Pylori eradication therapy
what is Reinke’s oedema?
oedema of the vocal folds
strongly linked to smoking
more common females
mx = Smoking cessation and voice therapy
what is laryngitis?
nflammation of the vocal cords, commonly following respiratory tract infections
FNE will reveal an acutely inflamed larynx
mx = conservative
what is Supraglottitis?
inflammation of the supraglottic structures, commonly after respiratory tract infections
FNE findings may show oedematous arytenoids
mx = abx
laryngeal cancers:
- histologically
- cause
- presentation
mostly SCC
assoc with HPV
present with hoarse voice, neck lump, dysphagia, weightless, otalgia
what causes recurrent laryngeal nerve palsy?
thyroid cancer, lung cancer, thoracic aortic aneurysm, multiple sclerosis (MS), or stroke
what are red flags for a neck lump - adults?
Hard, painful and fixed lump
Associated otalgia, dysphagia, stridor, or hoarse voice
Unilateral nasal symptoms such as epistaxis, discharge, or congestion
Unexplained weight loss, night sweats, or fever or rigors
Cranial nerve palsies
what are red flags for a neck lump - kids?
also include the presence of a supraclavicular mass, lumps larger than 2cm, and a previous history of malignancy.
ix for neck lump?
1st = USS +/- FNA
other = CT or MRI
what does USS do for neck lump?
characterisation of lymph nodes, salivary glands, vascular structures, and thyroid nodules
what is a cystic hygroma?
benign fluid-filled sac caused by a malformation of the lymphatic system
classically presents in the axilla or posterior triangle of the neck.
how do cystic hygromas present?
before aged two years
soft painless fluctuant masses that transilluminate
can grow large enough to cause airway obstruction or dysphagia
what congenital conditions can cystic hygroma be assoc with?
turner’s
mx of cystic hygroma?
leave alone
surgical excision
lymphatic sclerotherapy
what are carotid body tumours?
benign neuroendocrine tumours that arise from the paraganglion cells of the carotid body
how does a carotid body tumour present?
pulsatile painless neck lump, often with a bruit present on auscultation
slow growing
can compress surrounding cranial nerves, leading to palsies
cardiac arrhythmia
mx of carotid body tumour?
conservative
surgical excision
radiotherapy if unresectable
what is a thyroglossal cyst?
congenital fluid filled sac, commonly presenting in younger patients
what is the embryology of thyroid?
thyroid gland originates from the base of the tongue (foramen caecum), migrating down to its final position in the neck and connecting back to the tongue via the thyroglossal duct.
In normal development, this duct will obliterate
embryology of thyroglossal cyst?
portion of duct remains patent, creating cavities that may fill with fluid and be prone to infection
how do thyroglossal cysts present?
palpable painless midline mass
that move up with swallowing and protrusion of tongue
increase in size + painful when infected
mx of thyroglossal cyst?
surgical intervention with the modified Sistrunk procedure
what is the modified Sistrunk procedure?
central body of the hyoid bone is removed to allow complete removal of the entire thyroglossal tract
what must patients have before having surgical removal of thyroglossal cyst?
ultrasound scan of the neck to identify the thyroid gland pre-operatively, as the only functioning thyroid tissue may be attached to the cyst and risks getting excised during the procedure.
what is a branchial cyst?
congenital masses which arise in the lateral aspect of the neck, typically anterior to the sternocleidomastoid (SCM).
how do branchial cysts form?
During the fourth week of development, branchial clefts form ridges known as branchial arches, involved in the formation of a number of structures in the head and neck.
Incomplete obliteration of these clefts will result in the formation of branchial cysts.
how do branchial cysts present?
palpable masses anterior to SCM, typically unilateral
infected = increase in size and painful
Larger branchial cysts can result in dysphagia, dysphonia, and difficulty breathing.
mx of branchial cyst?
surgical excision (definitive) + USS/FNA prior
sclerotherapy
what is sudden sensorineural hearing loss?
sudden onset hearing loss
diagnosis of exclusion
unilateral, with around half of patients experiencing full restoration of hearing with 2 weeks.
RF for SSNHL?
increasing age
smoking
HTN
aetiology of SSNHL?
viral infection eg viral neuronitis
vascular impairment
autoimmune disorder
features of SSNHL?
acute onset of sensorineural hearing loss*, developing within 72hrs. This is often associated with tinnitus and vertigo.
no otorrhoea, otalgia, focal neurological deficit
ix for SSNHL?
Pure Tone Audiometry (PTA) and Tympanometry
bloods = FBC, ESR, autoantibody screen, coag screen, syphillis serology
what scan is done in SSNHL?
MRI or internal auditory meatus
mx of SSNHL?
high dose oral steroids
PPI
if no improvement - salvage intratympanic steroids
what is tinnitus?
perception of sound in the absence of an external auditory stimulus
e.g. ringing, buzzing, humming, whistling, or clicking
what is primary tinnitus?
no underlying cause is identified, often associated with sensorineural hearing loss
what is secondary tinnitus?
an underlying cause has been identified, often further sub-classified into subjective (only heard by the patient) or objective (also audible to the examiner)
causes of tinnitus?
important to check in tinnitus?
clarify certain features, including duration, character, symmetry, and associated symptoms (including hearing loss and focal neurology)
what examinations would you do in tinnitus?
On examination, otoscopy and audiometry are essential. Examine the cranial nerves and TMJ routinely for focal neurology.
Specifically, in pulsatile tinnitus, auscultation of the temporal bone with a stethoscope can identify a dual fistula in those with an underlying vascular malformation.
when is tinnitus otological emergency?
Sudden onset pulsatile tinnitus
Significant neurology
Severe vertigo
Secondary to head trauma
Unexplained sudden hearing loss
ix for tinnitus?
comprehensive audiological assessment - pure-tone audiometry (PTA) and tympanometry
non-urgent bloods = FBC, TFTs, lipid levels, and/or blood glucose (random or fasting)
when is imaging done in tinnitus?
persistent unilateral pulsatile tinnitus = contrast CT
persistent unilateral tinnitus with unilateral SSNHL = MRI internal acoustic meatus
mx of tinnitus?
conservative management and reassurance
Tinnitus retraining therapy (TRT) and cognitive behavioural therapy (CBT)
use of hearing aids
what is acoustic neuroma?
also termed vestibular schwannomas, are benign tumours that arise from the Schwann cells surrounding the vestibulocochlear nerve (CN VIII).
what is affected in acoustic neuroma?
The vestibular portion of the nerve is most commonly affected and account for 8% of all brain tumours (specifically 80% of tumours at the cerebellopontine angle)
where is the problem in acoustic neuroma - genetics?
abnormalities in tumour suppressor genes on chromosome p22.
Bilateral vestibular schwannomas are rare and often associated with neurofibromatosis type 2
features of acoustic neuroma?
progressive unilateral sensorineural hearing loss, tinnitus, and vertigo,
cranial nerve palsy, headaches, seizures and reduced consciousness
ix for acoustic neuroma?
MRI scan with contrast of the internal auditory meatus
mx of acoustic neuroma?
slow growing (2-3mm per year), therefore monitoring interval MRI scanning if small
Stereotactic radiosurgery
Surgical removal
what is Stereotactic radiosurgery?
focal collimation of gamma rays to slow or stop tumour growth. This method tends to produce good tumour control, with high rates of hearing and facial nerve preservation.
what is stridor?
noise made by turbulent flow of air being forced through narrowed upper airways
how does stridor happen?
stenosis in the supraglottic, glottic, subglottic, or tracheal level
how do you know the level of stridor ie inspiratory vs expiratory?
acute causes of stridor?
Foreign Body Inhalation, Epiglottitis, Laryngotracheobronchitis (Croup), Laryngitis, Anaphylaxis, and Neck Space Abscess
chronic causes of stridor?
Laryngomalacia, Subglottic Stenosis, Vocal Cord Paralysis, Subglottic Haemangioma, Respiratory Papillomatosis, Macroglossia or micrognathia, and Malignancy
what is Bernoulli principle?
states that an increase in the velocity of any fluid as it passes through a tube will cause a decrease in the linear pressure on the tube walls.
how does Bernoulli’s principle impact stridor?
as the airway begins to narrow and the velocity of air flow at the narrowing subsequently increases, the linear pressure exerted will decrease and causes a collapse of the airway, resulting in the transmitted airway sounds.
when does stridor become more concerning?
itself is a red flag
more concerning when sound decreases = patient more tired and less air shifted by lungs
what are important signs to look out for in stridor?
torticollis and trismus, inability to swallow and drooling, absence of a cough, cyanosis, evidence of systemic infection, or poor response to initial management.
ix of stridor?
clinical dx
secure the airway
non-emergency or chronic cases, visualisation of the upper airway will normally be done via fibreoptic nasal endoscopy
CT for abscess or malignancy
bronchoscopy for subglottic
acute mx of stridor?
what is Epiglottitis?
inflammation of the epiglottis and surrounding tissues, most commonly caused by H. Influenzae type B infections.
characteristic sign in epiglottis?
high-pitched stridor.
who does epiglottis affect?
children between 2-7 years
features of Epiglottitis?
sore throat, a fever, and dyspnoea, characteristically in the absence of a cough. Late signs of the condition if left untreated include drooling, dysphagia, and stridor.
The patient will look unwell and is classically seen, in late stages on the disease, sitting in the tripod position (to allow gravity to assist in keeping the airway open).
ix of epiglottitis?
urgent assessment by senior anaesthetist or ENT surgeon, in a HDU or ICU setting
immediate mx of Epiglottitis?
Nebulised adrenaline and IV dexamethasone
Blood and throat cultures
IV broad-spectrum antibiotics
Analgesia and IV fluids
mx after stabilisation in Epiglottitis?
xamination Under Anaesthesia (EUA) and intubation in theatre is required
fibreoptic nasal endoscopy can be attempted
Patients should be kept on intravenous antibiotics and steroids
Patient who have not been vaccinated should be given appropriate antibiotic prophylaxis.
what is laryngotracheobronchitis also known as?
CROUP
what is laryngotracheobronchitis/croup?
inflammation of the larynx, trachea, and bronchus, including the vocal cords
what is laryngotracheobronchitis/croup caused by + common organisms?
viral infection, common organisms including parainfluenza, influenza, RSV, and rhinovirus.
who is usually affected by laryngotracheobronchitis/croup?
6m to 2y
characteristic sign of laryngotracheobronchitis/croup?
barking cough
when is laryngotracheobronchitis/croup most common?
colder months ie winter
features of laryngotracheobronchitis/croup?
self-limiting illness, becoming worse within 48 hours and then gradually improving
preceded by an upper respiratory infection
dyspnoea and a characteristic barking cough, with potential fever.
Symptoms are usually worse at night.
how do you grade croup?
ix for croup?
do not require any investigations and can be made as a clinical diagnosis.
initial blood tests (FBC and CRP) for inflammatory makers
viral swabs
mx of croup?
oral dexamethasone (0.15mg/kg)
paracetamol and ibuprofen
IV fluids
when is hospital admission considered for croup?
mx in hospital for croup?
inhaled corticosteroids
nebulised adrenaline
In severe cases, intubation may be warranted.
what is vertigo?
hallucination of movement or spinning of the environment, often resulting in issues with balance.
how are causes of vertigo divided?
central vs otological
what are central causes of vertigo?
multiple sclerosis, posterior stroke, migraine, or intracranial space occupying lesion
what are otological causes of vertigo?
Benign Positional Paroxysmal Vertigo, Meniere’s Disease, and Vestibular Neuronitis
what is BPPV?
caused by the presence of canaliths in the semi-circular canal instead of the utricle
movement of the patient’s head will result movement of these crystals that cause an abnormal movement of endolymph, resulting in vertigo
RF for BPPV?
idiopathic mostly
head injury, previous history of labyrinthitis, and older patients
features of BPPV?
vertigo attacks last seconds
same head movement causing the onset of symptoms every time
nausea or vomiting
ix of BPPV?
Dix-Hallpike manoeuvre
a positive test invoking the symptoms and nystagmus
mx of BPPV?
Epley’s Manoeuvre
what advice should be given after doing Epley?
dvised not to drive, to keep sleep upright, not to bend down or look upwards for 48 hours
Resolution is not always complete
what is menieres disease?
disorder comprised with a triad of symptoms including vertigo, hearing loss, and tinnitus
pathophysiology of menieres?
an increase in endolymphatic pressure
Caused by dysfunctioning sodium channels, an osmotic gradient is subsequently set up that draws fluid into the endolymph, increasing the endolymphatic pressure to cause symptoms.
features of menieres?
severe paroxysmal vertigo, sensorineural hearing loss, and tinnitus
unilateral, lasting for minutes to hours, and usually resolve within 24 hours
repeated attacks
ix of menieres?
Otoscopy = normal ear drum
Audiometry = low frequency sensorineural hearing loss
Tympanometry = normal
mx menieres?
acute + chronic
acute:
- N+V = buccal or IM short course of prochlorperazine
chronic:
- lifestyle= reducing salt or avoiding chocolate and caffeine
- regular betahistine medication
- surgical intervention may be warranted
what are the surgical options for meniere’s?
intratympanic gentamicin injections, intratympanic steroid injections, endolymphatic sac destruction, or labyrinthectomy
what is vestibular neuronitis?
inflammation of the vestibular nerve, resulting in vertigo that typically lasts days but can last weeks to months
what causes vestibular neuronitis?
a viral infection
features of vestibular neuronitis?
sudden onset and severely incapacitating, nearly always associated with nausea and vomiting
ear drum will be normal and a horizontal nystagmus will be present when examining the eyes
ix of vestibular neuronitis?
acute = CT head or MRI
mx of vestibular neuronitis?
managed at home
vestibular sedatives
IV fluids
If there are persistent problems due to vestibular hypofunction, then the patient may require longer term vestibular rehabilitation via Cawthorne-Cooksey exercises.
