ent undergraduate lecture mr rejali ent consultant university hospital, coventry

ENT Undergraduate LectureENT Undergraduate Lecture

Mr Rejali

ENT Consultant

University Hospital, Coventry

PlanPlan

• 3 lecture:– Otology– Rhinology – Head and Neck– Practical session

OtologyOtology

• Anatomy / Physiology

• History

• Examination

• Outer ear problems

• Middle Ear Problems

• Inner Ear Problems

Otology Anatomy External Ear 1Otology Anatomy External Ear 1

• External– 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 2Otology 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

http://en.wikipedia.org/wiki/Image:Ear-anatomy-text-small.png

Otology Anatomy Middle Ear 1Otology 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


• Tympanic membrane• Right ear• Attic• Handle of malleus• Light reflex


• Eustachian tube equalises pressure between middle ear and atmosphere

Otology Anatomy Inner Ear 1Otology Anatomy Inner Ear 1

• Cochlea – Hearing• Semicircular canal –

Angular acceleration• Vestibule – Linear

acceleration

Otology Physiology CochleaOtology Physiology Cochlea

• Sound transmission through middle ear

• Oval - Round Window travelling wave.

• Tonotopic distribution of organ of corti

Otology Physiology Vestibular Otology Physiology Vestibular FunctionFunction

• Macula in saccule and utricle - linear acceleration

• Crista in semi-circular canal – angular acceleration

Otology HistoryOtology History

• Outer 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 HistoryOtology History

• Inner ear:– Hearing loss

(sensoneural)– Vertigo– Tinnitus

Otology ExaminationOtology 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 TestTuning Fork Test

• Rinne– Air conduction louder

than bone conduction

• Weber– Lateralises to side of

conductive loss and away from sensoneural hearing loss

• Clinical hearing test

Otology DiagnosisOtology Diagnosis

• Surgical Sieve• Outer ear• Middle Ear• Inner Ear• Hearing loss

– Conductive– Sensoneural

Otology InvestigationsOtology Investigations

• Pure Tone Audiogram• Tympanogram• CT• MRI

Otology ManagementOtology Management

• Explanation• Advice• Medical• Surgical

Haematoma/Seroma of PinnaHaematoma/Seroma of Pinna

• Aspirate x2 (sterile conditions)

• Compression bandage

• Review in 24hrs• If re-accumulate

proceed to formal drainage and quilting stitch

Otology ExternalOtology External

• Pinna skin tumour

Otitis ExternaOtitis Externa• Otitis Externa • Acute

– Painful– Serous discharge– Moist swollen canal– Tympanic membrane

intact– Pseudomonas aeroginosa– Treat topical toilet and

antibiotics

• Chronic– Eczema– Topical toilet and steroids

Otitis ExternaOtitis Externa

• Furuncle localised infection and pain

• put wick with 10% icthamol/glycerine

• Or incise and drain under local anaesthetic

Furuncle/Abscess of Hair FollicleFuruncle/Abscess of Hair Follicle

Otology External Otology External

• Exostoses– Cold water swimmers

• Osteomas– Bening neoplasia

Otology MiddleOtology Middle

• Tympanosclerosis– Previous infection or

trauma.– Usually of no

significance


• Retracted tympanic mebrane– Often no treatment

needed– Differentiate from

perforation– Occasionally progress

to cholesteatoma


• TM perforation• If dry may need no

treatment• If recurrent infection

can be repaired.


• Acute otitis media– Pain– Hearing loss– Later otorrhea

Acute Mastoiditis

• IV antibiotics

• Surgery


• Otitis media with effusion – glue ear

• Middle ear fluide• Common in children• Hearing loss• Infection starts

process• Treatment

conservative, Grommets


• Cholesteatoma

Otology Middle EarOtology Middle Ear

• Mastoid cavity

Otology Inner EarOtology 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


• Vertigo illusion of movement– Hallmark of vestibular

dysfunction– Rotary– Linear


• Benign Paroxysmal Positional Vertigo

• Vestibular Neuronitis• Meniere's Disease• Recurrent

vestibulopathy• Differentiate from

central vestibular causes.

Vestibular signal balanceVestibular signal balance

Reduced or no signalIncreased signal

MenieresVestibular Neuronitis

Normal balanced input

Brain will get used to new situation but not to a frequently

changing one.

Increased signal

BPPV

PathologicalLeft ear in this case


• Presbyacusis• Congenital Hearing

Loss


• Tinnitus• Acoustic neuroma

Facial PalsyFacial Palsy

• Upper vs Lower motor neurone pattern.


• 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


• 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 SectionThe End of Otology Section

RhinologyRhinology

• Anatomy

• Physiology

• History

• Examination

• Pathology

Rhinology Anatomy 1Rhinology Anatomy 1

• External• Internal

– Lateral wall– Medial wall


• Nasal septum– Little’s area– Epistaxis


• Paranasal Sinuses– Frontal– Maxillary– Ethmoid– Sphenoid

Rhinology PhysiologyRhinology Physiology

• Nose– Warms, moisten– Filter– Mucociliary

• Sinuses– Function unknown

Rhinology History Rhinology History

• Nasal obstruction• Anterior rhinorrhoea• Olfaction• Facial pain• Sneezing• Epistaxis

Rhinology ExaminationRhinology Examination

• 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 InvestigationRhinology Investigation

• Allergy testing– IgE levels– RAST (Blood test)– Skin Prick Testing

• Plain X ray – inaccurate

• CT

Rhinology Allergic Rhinitis 1Rhinology 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


• Investigations– RAST test– Skin Prick test


• Treatment– Allergen Avoidance– Anti-histamine

• Topical • Systemic

– Steroid• Topical spray or Drops• Oral (limited use)

– Leukotriene antagonist– Immunotherapy

Rhinology Deviated Nasal SeptumRhinology Deviated Nasal Septum

• Aetiology– Congenital– Traumatic

• Symptom– Nasal obstruction– Bilateral or Unilateral

• Sign• Treatment

– As for rhinitis– Surgery

Rhinology Perforation of Nasal Rhinology Perforation of Nasal Septum 1Septum 1

• Aetiology– Idiopathic– Trauma– Tumour– Wegener’s/SLE– Chromic/Sulphuric

acid or Cocaine

• Symptoms– Nasal obstruction– Crusting– Epistaxis

Rhinology Perforation of Nasal Rhinology Perforation of Nasal Septum 2Septum 2

• Treatment– Exclude serious

causes– Treat as rhinitis– Nasal douching– Septal button– Surgery (success

poor)

Rhinology Nasal PolypsRhinology Nasal Polyps

• Aetiology– Not known

• Symptoms– Nasal Obstruction– Rhinorrhoea

• Treatment– Topical steroid

medication– Surgery

Rhinology Sinusitis 1Rhinology Sinusitis 1

• Aetiology– Infective– Acute vs. Chronic

• Not all facial pain is sinusitis

• Symptoms– Facial pain– Nasal discharge– Nasal obstruction

• Signs

Rhinology Sinusitis 2Rhinology 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 sinusitisIt is a dental infection

Rhinology Epistaxis 1Rhinology Epistaxis 1

• Aetiology– Idiopathic– Trauma– Tumours– (Coagulopathy)– (Hypertension)

• Treatment– First aid/Resusitation– Cautery– Nasal Packing

Rhinology Epistaxis 2Rhinology Epistaxis 2

• Anaesthetise prior to cautery

Rhinology Sino-nasal carcinomaRhinology Sino-nasal carcinomaand Nasopharyngeal Carcinomaand Nasopharyngeal Carcinoma

• Rare• Aetiology

– Wood dust– Nickel dust, Chromium

• Symptoms– Nasal obstruction– Scant regular epistaxis

Rhinology Rhinology

• Ethmoiditis• ENT must be

involved.• Must be

admitted.• Potentially

serious.• Rx: ab, decong

+/- surg.

Rhinology Nasal Fracture Septal Rhinology Nasal Fracture Septal HaematomaHaematoma

• Can be manipulated• Consider the rest of

head injury and facial skeleton

Rhinology Nasal Fracture Septal Rhinology Nasal Fracture Septal HaematomaHaematoma

• Septal haematoma– Soft swelling– Must be drained within

12 hours

End of Rhinology SectionEnd of Rhinology Section

Laryngology (Mouth Pharynx Laryngology (Mouth Pharynx Larynx -Throat) SectionLarynx -Throat) Section

LaryngologyLaryngology

• Anatomy• History• Examination• Investigations• Pathology

Laryngology Anatomy 1Laryngology Anatomy 1

• Anatomy Mouth


• Anatomy Oropharynx


• Anatomy - Neck

Laryngology History 1Laryngology History 1

• Dysphagia (wt loss)– Solid– Liquid

• Dysphonia• Neck pain• Referred otalgia• Haemoptysis• (Globus pharyngeus)

Laryngology History 2Laryngology History 2

• Smoking • Alcohol

Laryngology Examination 1Laryngology 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

• Neck


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


• 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 InvestigationsLaryngology Investigations

• Bloods– TFT– Ca– Thyroid antibodies

• FNA• CXR• USS Neck• CT• MRI

Laryngology TonsillitisLaryngology Tonsillitis

• Sore throat• Pyrexia• White follicles on

tonsils• Penicillin• Recurrent episodes

treat with tonsillectomy

• (Glandular fever)

Laryngology Quinsy (Peritonsiller Laryngology Quinsy (Peritonsiller abscess)abscess)

• Infection spreads to peritonsiller tissues and can form abscess

• Asymmetrical swelling• Treat with drainage +

antibiotics

Laryngology AdenoidsLaryngology Adenoids

Laryngology Laryngology Pharynxl/Larynx/Mouth CarcinomaPharynxl/Larynx/Mouth Carcinoma

Laryngology Pharynx LymphomaLaryngology 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 Laryngology Neck lump Various “Benign”“Benign”

• Normal structures• Reactive lymph nodes• Mumps• Sebaceous cyst

Laryngology Neck lump variousLaryngology Neck lump various

Laryngology Neck lump Thyroid Laryngology Neck lump Thyroid lumplump

• 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 Laryngology Neck lump Salivary Gland NeoplasiaGland Neoplasia

• Parotid swellings– Mainly benign– Usually pleomorphic

salivary adenoma

• Submandibular gland– Usually inflammatory

Laryngology Neck lump Laryngology Neck lump Thyroglossal CystThyroglossal Cyst

• 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 Laryngology Neck lumps Branchial CystCyst

• Congenital• Treatment excision

Laryngology Neck lump Metastatic Laryngology Neck lump Metastatic Neck NodesNeck 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 TBLaryngology Neck lump TB

• Usually multiple nodes

• Cold abscess• If draining do so for

weeks

Laryngology Larynx CarcinomaLaryngology Larynx Carcinoma

• Dysphonia / Hoarseness for >3 weeks

Laryngology Larynx Reinke’s Laryngology Larynx Reinke’s OedemaOedema

• Smoking

Laryngology Larynx Vocal Cord Laryngology Larynx Vocal Cord nodulesnodules

• Vocal cord nodules

Laryngology DysphagiaLaryngology Dysphagia

• Liquid – neurological• Solid – mechanical

– Tumour– Pharyngeal pouch

(regurgitation)

Laryngology DysphoniaLaryngology 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 Laryngology Snoring Obstructive Sleep ApnoeaSleep 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 EpiglottitisLaryngology Larynx Epiglottitis

• 4 year old drooling toxic child

• Do nothing!• Get other people• Go to theatre

Laryngology Acute Airway 1Laryngology Acute Airway 1

• Stridor.

• Tachopneic

• Cyanosis (very late sign)

• Acute– Foreign Bodies– Inflammatory Swelling

• Chronic– Tumour. Larynx Bronchous.

Laryngology Acute Airway 2. Laryngology Acute Airway 2. First Aid. Choking. Foreign First Aid. Choking. Foreign

BodyBody

Baby and adult

Heimlich

Laryngology Acute Airway 4 Laryngology Acute Airway 4 TracheostomyTracheostomy

• 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


Identify cricothyroid membrane


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

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

Body. DogBody. Dog

THE ENDTHE END

Questions?

ent undergraduate lecture mr rejali ent consultant university hospital, coventry

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