Post on 26-Dec-2015
Mr D RejaliENT Consultant
UHCW
PlanENT HistoryENT ExamInvestigationManagementCases
HistorySymptom XDuration overall?Duration of each episode?Duration between episodes?
Time
Severityof Symptom X
History EarHearing lossDischargePainTinnitusVertigo
History NoseNasal obstructionAnterior rhinorrhoeaPosterior rhinorrhoea Olfaction/SmellFacial painSneezing“Epistaxis”
History Pharynx and LarynxDysphagia/OdynophagiaHoarseness (Dysphonia)Throat painReferred otalgiaHaemoptysisNeck lump“Globus”
History Neck LumpDurationPositionsFluctuation in size (minutes /hours / days)Associated symptoms:
Pain / TendernessHead and neck symptoms, such as throat pain,
otalgia, dysphagia and hoarsenessSymptoms of systemic illness, such as fever,
malaise, weight loss and night sweatsIf thyroid lump ask about dysthyroid symptoms
Examination of the earWash 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 noseWash 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 throatWash hands. Introduce yourself.Uncover everything above clavicleUsing pen-torch and tongue depressor:
Examine mouth, start from above.Examine oropharynx (esp. tonsil)
Palpate mouth and tongueAssess voice and coughAncillary exam: neck
Examination of NeckWash 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’dGo behind patientExamine lymph node groups: (my way):
Start Occipital/Post auricularWork down Post triangle to supraclavicular
area.Work up posterior border SCM.Jugulodiagastric node work down SCM to
suprasternal notch.
Examination of Neck cont’dWork 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 lumpNeck lump
Site, size and consistency.Attachment i.e. what layer is itSingle/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 lumpSurgical sieve or anatomical. Or mixture.Reactive lymphadenopathy / LymphomaMidline congenital/ developmental
Thyroglossal cystDermoid
Thyroid Salivary
ParotidSubmandibular
Differential diagnosis of neck lumpLateral lymphadenopathy
Benign/Acute reactive, Chronic inflammatoryMalignant
Primary Lymphoma Metastatic (Head and Neck Primary or Distant)
Lateral congenital/developmentalBranchial cyst, Lymphangioma
Supraclavicular malignant mass: Lung, GI, Testes.
Other
InvestigationFNA.(Beware pulsatile mass)Bloods:
FBCCXRCT/USS/MRI
InvestigationTargeted 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)
InvestigationTargeted investigations:
Salivary Parotid
Distinct: lump MRI Diffuse: Sjogren’s antibody, MRI
Submandibular Floor of mouth X-ray for stone.
InvestigationTargeted 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.
ManagementCongenital midline neck swelling
Thyroglossal cyst: Sistrunk procedureThyroid
If benign ?conservative.Excision biopsy; minimum lobectomy.?Total thyroidectomy in cancer.
ManagementSalivary
Submandibular If stone palpable in mouth local excision Inflammatory/suspicious: total excision.
Parotid Inflammatory: conservative. Neoplastic:
Benign superficial parotidectomy. Malignant total parotidectomy
ManagementLateral neck swelling:
Developmental: excisionMetastatic 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.
ManagementSupraclavicular 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
Left branchial cyst
14 year old boy 3 days painful bilateral neck swelling, sore throat
Tonsillitis
Left parotid pleomorphic
salivary adenoma
ThyroidMultinodular
Goitre
10 year old boy left neck swelling 3 months
Left submandibular gland infection
Atypical mycobacterium
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)
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
Deviate Nasal Septum
14 year old female bilateral blocked nose, runny nose and eyes and sneezing
Allergic Rhinitis
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
TreatmentAdmitAntibioticsCT ScanOccasionally
surgery
6 yr old. Left otalgia/swelling after URTI
MastoiditisTreatment
AdmitIV
antibioticsUsually
surgery
Left facial palsy:•Idiopathic (Bell’s
Palsy)•Other (eg parotid malignancy, ear,
CVA)
Acute AirwayStridor. TachopneicCyanosis (very late sign)Acute
Foreign BodiesInflammatory Swelling
ChronicTumour. Larynx Bronchous.
Baby and adult
Heimlich
TracheostomyIf first aid measure fail and patients life is in
danger consider tracheostomy (crico-thyroidotomy).
You will need:Scalpel/KnifeStraw/Pen with inner part removed/Paper
rolled up
Identify cricothyroid membrane
Horizontal cut. 2cm wide. Deep enough. Insert airway.