1. Mr D Rejali ENT Consultant UHCW

3. Plan
ENT History
ENT Exam
Investigation
Management
Cases

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

5. History Ear
Hearing loss
Discharge
Pain
Tinnitus
Vertigo

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

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

8. 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

9. 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.

10. 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

11. 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

12. 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.

13. 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.

14. 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.

16. 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)

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

18. 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

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

21. 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)

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

23. 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.

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

25. 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

26. 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.

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

28. Some cases

29. 50 yr female. 5 year swelling
Left parotid pleomorphic salivary adenoma

30. 40 year old female, 2 yr neck swelling
Multinodular
goitre

31. 20 year old male midline neck swelling 1 year
Thyroglossal
cyst

32. 20 year old male left neck swelling fluctuating over last 1 year
Left branchial cyst

33. 14 year old boy 3 days painful bilateral neck swelling, sore throat
Tonsillitis

34. 55 year old male 2 year history
Left parotid pleomorphic salivary adenoma

35. 50 year old female anterior neck swelling 10 years
Thyroid
Multinodular
Goitre

36. 10 year old boy left neck swelling 3 months
Left submandibular gland infection
Atypical mycobacterium

37. 70 year old male 3 months neck swelling
Malignant Lymphadenopathy

38. 15 year old male 7 days sore throat
Glandula fever /Infectious mononucleosis

39. 15 year old male 7 days sore throat worse left side
Quinsy / Peritonsillar
Abscess

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

41. 60 year old smoker with dysphagia, hoarsness and neck lump
Laryngeal Carcinoma

42. 78 year old male with dysphagia and regurgitation of food
Barium Swallow
Pharyngeal Pouch

43. 78 year old male with dysphagia/choking more for liquids since CVA
Barium Swallow
Neurological Dysphagia

44. 14 year old female bilateral blocked nose
Deviate Nasal Septum

45. 14 year old female bilateral blocked nose, runny nose and eyes and sneezing
Allergic Rhinitis

46. 44 year old female bilateral blocked nose, asthmatic
Nasal Polyps

47. 4 year old with pyrexia and otalgia
Acute Otitis Media

48. 4 year old with hearing loss
Otitis Media with effusion

49. 50 yr male intermittent discharge from ear
Left chronic otitis media / perforated ear drum

50. 45yr male smelly discharge constant for years
Chronic otitis media /Cholesteatoma

51. 50 Right Unilateral hearing loss and tinnitus for 4 years.
Acoustic Neuroma (Vestibular Schwannoma)

52. 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.

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

54. 6 yr 5 days ago URTI. 24hr left swollen eye
Periorbital cellulitis secondary to sinusitis
Treatment
Admit
Antibiotics
CT Scan
Occasionally surgery

55. 6 yr old. Left otalgia/swelling after URTI
Mastoiditis
Treatment
Admit
IV antibiotics
Usually surgery

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

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

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

59. 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

60. Tracheostomy
Identify cricothyroid membrane

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

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