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
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
Otology Anatomy Middle Ear 2Otology Anatomy Middle Ear 2
• Tympanic membrane• Right ear• Attic• Handle of malleus• Light reflex
Otology Anatomy Middle Ear 3Otology Anatomy Middle Ear 3
• 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
Otology MiddleOtology Middle
• Retracted tympanic mebrane– Often no treatment
needed– Differentiate from
perforation– Occasionally progress
to cholesteatoma
Otology MiddleOtology Middle
• TM perforation• If dry may need no
treatment• If recurrent infection
can be repaired.
Otology MiddleOtology Middle
• Acute otitis media– Pain– Hearing loss– Later otorrhea
Acute Mastoiditis
• IV antibiotics
• Surgery
Otology MiddleOtology Middle
• Otitis media with effusion – glue ear
• Middle ear fluide• Common in children• Hearing loss• Infection starts
process• Treatment
conservative, Grommets
Otology MiddleOtology Middle
• 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
Otology Inner EarOtology Inner Ear
• Vertigo illusion of movement– Hallmark of vestibular
dysfunction– Rotary– Linear
Otology Inner EarOtology Inner Ear
• 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
Otology Inner EarOtology Inner Ear
• Presbyacusis• Congenital Hearing
Loss
Otology Inner EarOtology Inner Ear
• Tinnitus• Acoustic neuroma
Facial PalsyFacial Palsy
• Upper vs Lower motor neurone pattern.
Facial PalsyFacial 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 PalsyFacial 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 SectionThe End of Otology Section
RhinologyRhinology
• Anatomy
• Physiology
• History
• Examination
• Pathology
Rhinology Anatomy 1Rhinology Anatomy 1
• External• Internal
– Lateral wall– Medial wall
Rhinology Anatomy 2Rhinology Anatomy 2
• Nasal septum– Little’s area– Epistaxis
Rhinology Anatomy 3Rhinology Anatomy 3
• 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
Rhinology Allergic Rhinitis 2Rhinology Allergic Rhinitis 2
• Investigations– RAST test– Skin Prick test
Rhinology Allergic Rhinitis 3Rhinology Allergic Rhinitis 3
• 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
Laryngology Anatomy 2Laryngology Anatomy 2
• Anatomy Oropharynx
Laryngology Anatomy 3Laryngology Anatomy 3
• Anatomy - Neck
Laryngology Anatomy 4Laryngology Anatomy 4
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
Laryngology Examination 2Laryngology 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 3Laryngology 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 4Laryngology Examination 4
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
Laryngology Acute Airway 5 Laryngology Acute Airway 5 TracheostomyTracheostomy
Identify cricothyroid membrane
Laryngology Acute Airway 6 Laryngology Acute Airway 6 TracheostomyTracheostomy
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
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