Mr D Rejali ENT Consultant UHCW

Plan ENT History ENT Exam Investigation Management Cases

History Symptom X Duration overall? Duration of each episode? Duration between episodes? Severity of Symptom X Time

History Ear Hearing loss Discharge Pain Tinnitus Vertigo

History Nose Nasal obstruction Anterior rhinorrhoea Posterior rhinorrhoea Olfaction/Smell Facial pain Sneezing “Epistaxis”

History Pharynx and Larynx Dysphagia/Odynophagia Hoarseness (Dysphonia) Throat pain Referred otalgia Haemoptysis Neck lump “Globus”

History Neck Lump Duration Positions Fluctuation in size (minutes /hours / days) Associated symptoms: Pain / Tenderness Head and neck symptoms, such as throat pain, otalgia, dysphagia and hoarseness Symptoms of systemic illness, such as fever, malaise, weight loss and night sweats If thyroid lump ask about dysthyroid symptoms

Examination of the ear Wash hands. Introduce yourself. Ask which ear is worse, start with good ear. Inspect outer ear. Examine with auriscope: canal, tympanic membrane. Examine worse/symptomatic ear. Weber and Rinne test. Clinical hearing tests. Ancillary test: other cranial nerves, co-ord, Romberg’s test.

Examination of the nose Wash hands. Introduce yourself. Inspect external nose. Assess each nasal airway independently (eg steam pattern on metal spatula). Using auriscope light: Inspect nasal vestibule. Inspect septum, nasal cavity and lateral wall. Ancillary examination: ears, mouth, oropharynx and neck

Examination of throat Wash hands. Introduce yourself. Uncover everything above clavicle Using pen-torch and tongue depressor: Examine mouth, start from above. Examine oropharynx (esp. tonsil) Palpate mouth and tongue Assess voice and cough Ancillary exam: neck

Examination of Neck Wash hands. Introduce yourself. Expose from clavicle up. Inspect from front and sides. Look for scars. Ask patient to swallow, look for any movement of lumps.

Examination of Neck cont’d Go behind patient Examine lymph node groups: (my way): Start Occipital/Post auricular Work down Post triangle to supraclavicular area. Work up posterior border SCM. Jugulodiagastric node work down SCM to suprasternal notch.

Examination of Neck cont’d Work up ant triangle including thyroid (ask patient to swallow when at thyroid) Continue working up anterior triangle: feel laryngeal cartilage, hyoid. Submandibular and submental area. Finish with parotid and preauricular area. If you did feel a lesion further local, regional & systemic examination may be needed (eg thyroid (dysthyroid status) or other lymph node groups in axilla, groin and spleen), mouth, pharynx, ear & nose.

Examination of lump Neck lump Site, size and consistency. Attachment i.e. what layer is it Single/multiple (Inflammatory) Regional exam: Oral, nose, pharynx, larynx, facial nerve function if parotid. Systemic exam: Thorax, Abdomen, Testes, (Thyroid, Signs of Dysthyroid function, Other Lymph node groups)

Differential diagnosis of neck lump Surgical sieve or anatomical. Or mixture. Reactive lymphadenopathy / Lymphoma Midline congenital/ developmental Thyroglossal cyst Dermoid Thyroid Salivary Parotid Submandibular

Differential diagnosis of neck lump Lateral lymphadenopathy Benign/Acute reactive, Chronic inflammatory Malignant Primary Lymphoma Metastatic (Head and Neck Primary or Distant) Lateral congenital/developmental Branchial cyst, Lymphangioma Supraclavicular malignant mass: Lung, GI, Testes. Other

Investigation FNA.(Beware pulsatile mass) Bloods: FBC CXR CT/USS/MRI

Investigation Targeted investigations: Midline: Congenital/Thyroglossal cyst USS Thyroid Bloods: Thyroid Function Tests (TFT), Autoantibodies, Calcium Radiology: USS(+/-guided FNA) , (CT if concern regarding malignancy/invasion of other tissues, Isotope scan if evidence of thyrotoxicosis)

Investigation Targeted investigations: Salivary Parotid Submandibular Distinct: lump MRI Diffuse: Sjogren’s antibody, MRI Submandibular Floor of mouth X-ray for stone.

Investigation Targeted investigations: Lateral neck swelling. ?metastatic cancer Endoscopy find/look for and biopsy ?primary cancer If no primary on endoscopy and FNA does not suggest metastatic node: excision biopsy. Supraclavicular malignant mass. CT Thorax, Abdomen and pelvis Biopsy if best site for representative histology.

Management Congenital midline neck swelling Thyroid Thyroglossal cyst: Sistrunk procedure Thyroid If benign ?conservative. Excision biopsy; minimum lobectomy. ?Total thyroidectomy in cancer.

Management Salivary Submandibular Parotid If stone palpable in mouth local excision Inflammatory/suspicious: total excision. Parotid Inflammatory: conservative. Neoplastic: Benign superficial parotidectomy. Malignant total parotidectomy

Management Lateral neck swelling: Developmental: excision Metastatic squamous cell carcinoma: (consider primary) usually neck dissection. Lymphoma: medical via oncologist. Inflammatory: usually nothing but diagnosis needed. If TB chemotherapy. If atypical mycobacterium excision may be required.

Management Supraclavicular malignant mass Histology dependant Lymphoma Seminoma Squamous and Adenocarcinoma likely to be palliative.

Some cases

50 yr female. 5 year swelling Left parotid pleomorphic salivary adenoma

40 year old female, 2 yr neck swelling Multinodular goitre

20 year old male midline neck swelling 1 year Thyroglossal cyst

20 year old male left neck swelling fluctuating over last 1 year Left branchial cyst

14 year old boy 3 days painful bilateral neck swelling, sore throat Tonsillitis

55 year old male 2 year history Left parotid pleomorphic salivary adenoma

50 year old female anterior neck swelling 10 years Thyroid Multinodular Goitre

10 year old boy left neck swelling 3 months Left submandibular gland infection Atypical mycobacterium

70 year old male 3 months neck swelling Malignant Lymphadenopathy

15 year old male 7 days sore throat Glandula fever /Infectious mononucleosis

15 year old male 7 days sore throat worse left side Quinsy / Peritonsillar Abscess

Right Oropharyngeal carcinoma (tonsil) 60 year old man, smoker and heavy drinker, right otalgia and some dysphagia Right Oropharyngeal carcinoma (tonsil)

60 year old smoker with dysphagia, hoarsness and neck lump Laryngeal Carcinoma

78 year old male with dysphagia and regurgitation of food Barium Swallow Pharyngeal Pouch

78 year old male with dysphagia/choking more for liquids since CVA Barium Swallow Neurological Dysphagia

14 year old female bilateral blocked nose Deviate Nasal Septum

14 year old female bilateral blocked nose, runny nose and eyes and sneezing Allergic Rhinitis

44 year old female bilateral blocked nose, asthmatic Nasal Polyps

4 year old with pyrexia and otalgia Acute Otitis Media

4 year old with hearing loss Otitis Media with effusion

50 yr male intermittent discharge from ear Left chronic otitis media / perforated ear drum

45yr male smelly discharge constant for years Chronic otitis media /Cholesteatoma

50 Right Unilateral hearing loss and tinnitus for 4 years. Acoustic Neuroma (Vestibular Schwannoma)

Vestibular Schwannoma (Acoustic neuroma). Benign schwannoma. Untreated some can eventually cause brainstem compression and even death. Treatment: can be monitored(if small), radiation treatment or surgery.

Unexplained asymmetrical/unilateral hearing loss or tinnitus require MRI scan brain/IAM

6 yr 5 days ago URTI. 24hr left swollen eye Periorbital cellulitis secondary to sinusitis Treatment Admit Antibiotics CT Scan Occasionally surgery

6 yr old. Left otalgia/swelling after URTI Mastoiditis Treatment Admit IV antibiotics Usually surgery

Idiopathic (Bell’s Palsy) Other (eg parotid malignancy, ear, CVA) Left facial palsy: Idiopathic (Bell’s Palsy) Other (eg parotid malignancy, ear, CVA)

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

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

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

Tracheostomy Identify cricothyroid membrane

Tracheostomy Horizontal cut. 2cm wide. Deep enough. Insert airway.

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