ENT Undergraduate Lecture Mr Rejali ENT Consultant University Hospital, Coventry

Plan 3 lecture: Otology Rhinology Head and Neck Practical session

Otology Anatomy / Physiology History Examination Outer ear problems Middle Ear Problems Inner Ear Problems

Otology Anatomy External Ear 1 Pinna Skin Cartilage External audiotary meatus (canal) Lateral/Outer 1/3 in cartilages and produce wax Medial 2/3 in bone and wax free Skin migration

Otology Anatomy External Ear 2 External auditory meatus/canal Ear wax (and hair) produced in outer 1/3 of ear canal Ear wax (cerumen) more soluble in water Rare cause of hearing loss unless impacted on to tympanic membrane or blocking canal completely and with a thickness of >2-m mm

Otology Anatomy Middle Ear 1 Air containing space in temporal bone. Three ossicles (Mallus, incus and stapes) transfer sound from air to inner ear fluids Common site of pathology

Otology Anatomy Middle Ear 2 Tympanic membrane Right ear Attic Handle of malleus Light reflex

Otology Anatomy Middle Ear 3 Eustachian tube equalises pressure between middle ear and atmosphere

Otology Anatomy Inner Ear 1 Cochlea – Hearing Semicircular canal – Angular acceleration Vestibule – Linear acceleration

Otology Physiology Cochlea Sound transmission through middle ear Oval - Round Window travelling wave. Tonotopic distribution of organ of corti

Otology Physiology Vestibular Function Macula in saccule and utricle - linear acceleration Crista in semi-circular canal – angular acceleration

Otology History Outer ear: Middle ear: Pain Discharge: scant, serous Hearing loss, late Middle ear: Hearing loss (conductive) Discharge: moderate mucoid Pain In acute otitis media until tympanic membrane perforates Chronic otitis media only if complicated e.g. otitis externa or intracranial complications

Otology History Inner ear: Hearing loss (sensoneural) Vertigo Tinnitus

Otology Examination Wash hands (MRSA) Intro Ask about tenderness Which is better ear Inspect pinna, mastoid area Otoscopy External auditory canal Tympanic membrane Hearing test Other test: cranial nerve (esp VII), co-ordination and romberg

Tuning Fork Test Rinne Weber Clinical hearing test Air conduction louder than bone conduction Weber Lateralises to side of conductive loss and away from sensoneural hearing loss Clinical hearing test

Otology Diagnosis Surgical Sieve Outer ear Middle Ear Inner Ear Hearing loss Conductive Sensoneural

Otology Investigations Pure Tone Audiogram Tympanogram CT MRI

Otology Management Explanation Advice Medical Surgical

Haematoma/Seroma of Pinna Aspirate x2 (sterile conditions) Compression bandage Review in 24hrs If re-accumulate proceed to formal drainage and quilting stitch

Otology External Pinna skin tumour

Otitis Externa Otitis Externa Acute Chronic Painful Serous discharge Moist swollen canal Tympanic membrane intact Pseudomonas aeroginosa Treat topical toilet and antibiotics Chronic Eczema Topical toilet and steroids

Otitis Externa Furuncle localised infection and pain put wick with 10% icthamol/glycerine Or incise and drain under local anaesthetic Furuncle/Abscess of Hair Follicle

Otology External Exostoses Osteomas Cold water swimmers Bening neoplasia

Otology Middle Tympanosclerosis Previous infection or trauma. Usually of no significance

Otology Middle Retracted tympanic mebrane Often no treatment needed Differentiate from perforation Occasionally progress to cholesteatoma

Otology Middle TM perforation If dry may need no treatment If recurrent infection can be repaired.

Otology Middle Acute otitis media Pain Hearing loss Later otorrhea

Acute Mastoiditis IV antibiotics Surgery

Otology Middle Otitis media with effusion – glue ear Middle ear fluide Common in children Hearing loss Infection starts process Treatment conservative, Grommets

Otology Middle Cholesteatoma

Otology Middle Ear Mastoid cavity

Otology Inner Ear Balance:  Balance is determined by a complex combination of inputs into the brain.   These inputs are: Vision Proprioception (sensation of position of joints)   Inner ear Integration by brain

Otology Inner Ear Vertigo illusion of movement Hallmark of vestibular dysfunction Rotary Linear

Otology Inner Ear Benign Paroxysmal Positional Vertigo Vestibular Neuronitis Meniere's Disease Recurrent vestibulopathy Differentiate from central vestibular causes.

Vestibular signal balance Normal balanced input Pathological Left ear in this case Increased signal Reduced or no signal Increased signal Vestibular Neuronitis Menieres BPPV Brain will get used to new situation but not to a frequently changing one.

Otology Inner Ear Presbyacusis Congenital Hearing Loss

Otology Inner Ear Tinnitus Acoustic neuroma

Facial Palsy Upper vs Lower motor neurone pattern.

Facial Palsy Not all are Idiopathic (Bells Palsy) Assess other cranial nerves Ear Parotid Symptoms/signs which suggest other aetiology Above exam +VE Slow onset Little, no or incomplete recovery

Facial Palsy Eye care. If concern d/w Ophthalmic team. Tape eye closed at night after Lacrilube Hypomellose eye drops PRN during day Steroids (Prednisolone 40mg od for one week) are indicated early in the course of the disease (less than 3 days) if there are no contraindications. Acyclovir if signs of herpes zoster infection (vesicles in TM or pharynx or palate. (400mg five times a day for 10 days)

The End of Otology Section

Rhinology Anatomy Physiology History Examination Pathology

Rhinology Anatomy 1 External Internal Lateral wall Medial wall

Rhinology Anatomy 2 Nasal septum Little’s area Epistaxis

Rhinology Anatomy 3 Paranasal Sinuses Frontal Maxillary Ethmoid Sphenoid

Rhinology Physiology Nose Sinuses Warms, moisten Filter Mucociliary Function unknown

Rhinology History Nasal obstruction Anterior rhinorrhoea Olfaction Facial pain Sneezing Epistaxis

Rhinology Examination Inspect external nose Palpate external nose Evaluate nasal airway Steam pattern on metal tongue depressor Inspect nasal mucosa Use otoscope Lateral, medial Inspect palpate over sinuses Endoscopy Olfaction

Rhinology Investigation Allergy testing IgE levels RAST (Blood test) Skin Prick Testing Plain X ray – inaccurate CT

Rhinology Allergic Rhinitis 1 IgE mediated allergic reaction Seasonal/Hay fever, allergy to pollen Perennial – allergy to House Dust Mite Other: cat etc Nasal obstruction, sneezing, rhinorrhoea, eye symptoms

Rhinology Allergic Rhinitis 2 Investigations RAST test Skin Prick test

Rhinology Allergic Rhinitis 3 Treatment Allergen Avoidance Anti-histamine Topical Systemic Steroid Topical spray or Drops Oral (limited use) Leukotriene antagonist Immunotherapy

Rhinology Deviated Nasal Septum Aetiology Congenital Traumatic Symptom Nasal obstruction Bilateral or Unilateral Sign Treatment As for rhinitis Surgery

Rhinology Perforation of Nasal Septum 1 Aetiology Idiopathic Trauma Tumour Wegener’s/SLE Chromic/Sulphuric acid or Cocaine Symptoms Nasal obstruction Crusting Epistaxis

Rhinology Perforation of Nasal Septum 2 Treatment Exclude serious causes Treat as rhinitis Nasal douching Septal button Surgery (success poor)

Rhinology Nasal Polyps Aetiology Not known Symptoms Nasal Obstruction Rhinorrhoea Treatment Topical steroid medication Surgery

Rhinology Sinusitis 1 Aetiology Not all facial pain is sinusitis Infective Acute vs. Chronic Not all facial pain is sinusitis Symptoms Facial pain Nasal discharge Nasal obstruction Signs

Rhinology Sinusitis 2 Treatment Acute Decongestants Antibiotic Chronic Topical steroid medication (Antibiotics) Many patients with “sinusitis” have idiopathic facial pain syndrome Complication Ethmoiditis Common in children This is not sinusitis It is a dental infection

Rhinology Epistaxis 1 Aetiology Treatment Idiopathic Trauma Tumours (Coagulopathy) (Hypertension) Treatment First aid/Resusitation Cautery Nasal Packing

Rhinology Epistaxis 2 Anaesthetise prior to cautery

Rhinology Sino-nasal carcinoma and Nasopharyngeal Carcinoma Rare Aetiology Wood dust Nickel dust, Chromium Symptoms Nasal obstruction Scant regular epistaxis

Rhinology Ethmoiditis ENT must be involved. Must be admitted. Potentially serious. Rx: ab, decong +/- surg.

Rhinology Nasal Fracture Septal Haematoma Can be manipulated Consider the rest of head injury and facial skeleton

Rhinology Nasal Fracture Septal Haematoma Soft swelling Must be drained within 12 hours

End of Rhinology Section

Laryngology (Mouth Pharynx Larynx -Throat) Section

Laryngology Anatomy History Examination Investigations Pathology

Laryngology Anatomy 1 Anatomy Mouth

Laryngology Anatomy 2 Anatomy Oropharynx

Laryngology Anatomy 3 Anatomy - Neck

Laryngology Anatomy 4

Laryngology History 1 Dysphagia (wt loss) Dysphonia Neck pain Solid Liquid Dysphonia Neck pain Referred otalgia Haemoptysis (Globus pharyngeus)

Laryngology History 2 Smoking Alcohol

Laryngology Examination 1 Mouth Inspection Start from hard palate and work down Hard Palate Sup alveolar ridge Sup bucco-alveolar sulcus Buccal mucosa Inf bucco-alveolar sulcus Inferior alveolar ridge Floor of mouth Tongue Palpation of above (esp tonge and floor of mouth) Listen to voice Neck

Laryngology Examination 2 Neck (have a system) Intro Ask about pain/tenderness Exposure above clavicles Inspect from front and side Inspect while swallowing Palpate from behind

Laryngology Examination 3 Neck (have a system) Palpate from behind Start from mastoid Down posterior triangle Up posterior border of sternocleiodo-mastoid Down ant border SCM Work up ant triangle including thyroid (ask patient to swallow when at thyroid) Continue working up anterior triangle: feel laryngeal cartilage, hyoid. Sumandibular and submental area. Finish with parotid and preauricular area. If you did feel a lesion further local (percussion of sternum or auscultation), regional & systemic examination may be needed (eg thyroid or other lymph node groups)

Laryngology Examination 4

Laryngology Investigations Bloods TFT Ca Thyroid antibodies FNA CXR USS Neck CT MRI

Laryngology Tonsillitis Sore throat Pyrexia White follicles on tonsils Penicillin Recurrent episodes treat with tonsillectomy (Glandular fever)

Laryngology Quinsy (Peritonsiller abscess) Infection spreads to peritonsiller tissues and can form abscess Asymmetrical swelling Treat with drainage + antibiotics

Laryngology Adenoids

Laryngology Pharynxl/Larynx/Mouth Carcinoma

Laryngology Pharynx Lymphoma No specific local symptoms B symptoms Mucosa usually not ulcerating Check other lymph groups (neck, axilla and inguinal) and spleen

Laryngology Neck lump Various “Benign” Normal structures Reactive lymph nodes Mumps Sebaceous cyst

Laryngology Neck lump various

Laryngology Neck lump Thyroid lump Thyroid lumps move with swallowing Benign Multinodular goitre / Adenoma Malignant –thyroid Dysphonia Dysphagia Metastases Ix Bloods (TFT, Ca, Thyroid Antibodies), FNA, USS/CT Rx Conservative/Medical/Surgical

Laryngology Neck lump Salivary Gland Neoplasia Parotid swellings Mainly benign Usually pleomorphic salivary adenoma Submandibular gland Usually inflammatory

Laryngology Neck lump Thyroglossal Cyst Moves/tethered with/to floor of mouth Before removal check to insure normal thyroid exists Diff diagnosis: Dermoid Lymph node Sebaceous cyst

Laryngology Neck lumps Branchial Cyst Congenital Treatment excision

Laryngology Neck lump Metastatic Neck Nodes Neoplasia Benign (very common) Malignant Primary Carcinoma Lymphoma (common) Secondary metastases (always consider this) Mouth Pharynx Larynx Infraclavicular (lung, breast, stomach)

Laryngology Neck lump TB Usually multiple nodes Cold abscess If draining do so for weeks

Laryngology Larynx Carcinoma Dysphonia / Hoarseness for >3 weeks

Laryngology Larynx Reinke’s Oedema Smoking

Laryngology Larynx Vocal Cord nodules

Laryngology Dysphagia Liquid – neurological Solid – mechanical Tumour Pharyngeal pouch (regurgitation)

Laryngology Dysphonia Dysphonia >3 weeks needs investigation Risk for ca: smoker, drinker. Other suspicious symptoms: wt loss , dysphagia. Benign: Reinke’s Oedema, Nodules, Inhaler laryngitis, Functional Dysphonia Malignant: local (ca), distant bronchogenic ca’ causing recurrent laryngeal nerve palsy

Laryngology Snoring Obstructive Sleep Apnoea Partial obstruction of airway Snoring High BMI Pharyngeal Nasal Recurrent obstruction to airway fragmenting sleep Daytime somnolescence Similar aetiology to snoring Treatment: lifestyle, CPAP, surgery.

Laryngology Larynx Epiglottitis 4 year old drooling toxic child Do nothing! Get other people Go to theatre

Laryngology Acute Airway 1 Stridor. Tachopneic Cyanosis (very late sign) Acute Foreign Bodies Inflammatory Swelling Chronic Tumour. Larynx Bronchous.

Laryngology Acute Airway 2. First Aid. Choking. Foreign Body Baby and adult Heimlich

Laryngology Acute Airway 4 Tracheostomy If first aid measure fail and patients life is in danger consider tracheostomy (crico-thyroidotomy). You will need: Scalpel/Knife Straw/Pen with inner part removed/Paper rolled up

Laryngology Acute Airway 5 Tracheostomy Identify cricothyroid membrane

Laryngology Acute Airway 6 Tracheostomy Horizontal cut. 2cm wide. Deep enough. Insert airway.

Laryngology Acute Airway 3. First Aid. Choking. Foreign Body. Dog

THE END Questions?