Ear Nose and throat Introduction with brief explanation

Ear Nose and throat

1. ENT Undergraduate Lecture

2. Plan 3 lecture: Otology Rhinology Head and Neck Practical session

3. Otology Anatomy / Physiology History Examination Outer ear problems Middle Ear Problems Inner Ear Problems

4. Otology 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

5. Otology 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

6. Otology 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

7. Otology Anatomy Middle Ear 2 Tympanic membrane Right ear Attic Handle of malleus Light reflex

8. Otology Anatomy Middle Ear 3 Eustachian tube equalises pressure between middle ear and atmosphere

9. Otology Anatomy Inner Ear 1 Cochlea – Hearing Semicircular canal – Angular acceleration Vestibule – Linear acceleration

10. Otology Physiology Cochlea Sound transmission through middle ear Oval - Round Window travelling wave. Tonotopic distribution of organ of corti

11. Otology Physiology Vestibular Function Macula in saccule and utricle - linear acceleration Crista in semi-circular canal – angular acceleration

12. Otology 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

13. Otology History Inner ear: Hearing loss (sensoneural) Vertigo Tinnitus

14. Otology 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

15. Tuning 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

16. Otology Diagnosis Surgical Sieve Outer ear Middle Ear Inner Ear Hearing loss Conductive Sensoneural

17. Otology Investigations Pure Tone Audiogram Tympanogram CT MRI

18. Otology Management Explanation Advice Medical Surgical

19. Haematoma/Seroma of Pinna Aspirate x2 (sterile conditions) Compression bandage Review in 24hrs If re-accumulate proceed to formal drainage and quilting stitch

20. Otology External Pinna skin tumour

21. Otitis 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

22. Otitis Externa Furuncle localised infection and pain put wick with 10% icthamol/glycerine Or incise and drain under local anaesthetic Furuncle/Abscess of Hair Follicle

23. Otology External Exostoses Cold water swimmers Osteomas Bening neoplasia

24. Otology Middle Tympanosclerosis Previous infection or trauma. Usually of no significance

25. Otology Middle Retracted tympanic mebrane Often no treatment needed Differentiate from perforation Occasionally progress to cholesteatoma

26. Otology Middle TM perforation If dry may need no treatment If recurrent infection can be repaired.

27. Otology Middle Acute otitis media Pain Hearing loss Later otorrhea

28. Acute Mastoiditis IV antibiotics Surgery

29. Otology Middle Otitis media with effusion – glue ear Middle ear fluide Common in children Hearing loss Infection starts process Treatment conservative, Grommets

30. Otology Middle Cholesteatoma

31. Otology Middle Ear Mastoid cavity

32. Otology 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

33. Otology Inner Ear Vertigo illusion of movement Hallmark of vestibular dysfunction Rotary Linear

34. Otology Inner Ear Benign Paroxysmal Positional Vertigo Vestibular Neuronitis Meniere's Disease Recurrent vestibulopathy Differentiate from central vestibular causes.

35. Vestibular signal balance Reduced or no signal Increased signal Menieres Vestibular Neuronitis Normal balanced input Brain will get used to new situation but not to a frequently changing one. Increased signal BPPV Pathological Left ear in this case

36. Otology Inner Ear Presbyacusis Congenital Hearing Loss

37. Otology Inner Ear Tinnitus Acoustic neuroma

38. Facial Palsy Upper vs Lower motor neurone pattern.

39. Facial 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

40. Facial 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)

41. The End of Otology Section

42. Rhinology Anatomy Physiology History Examination Pathology

43. Rhinology Anatomy 1 External Internal Lateral wall Medial wall

44. Rhinology Anatomy 2 Nasal septum Little’s area Epistaxis

45. Rhinology Anatomy 3 Paranasal Sinuses Frontal Maxillary Ethmoid Sphenoid

46. Rhinology Physiology Nose Warms, moisten Filter Mucociliary Sinuses Function unknown

47. Rhinology History Nasal obstruction Anterior rhinorrhoea Olfaction Facial pain Sneezing Epistaxis

48. Rhinology 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

49. Rhinology Investigation Allergy testing IgE levels RAST (Blood test) Skin Prick Testing Plain X ray – inaccurate CT

50. Rhinology 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

51. Rhinology Allergic Rhinitis 2 Investigations RAST test Skin Prick test

52. Rhinology Allergic Rhinitis 3 Treatment Allergen Avoidance Anti-histamine Topical Systemic Steroid Topical spray or Drops Oral (limited use) Leukotriene antagonist Immunotherapy

53. Rhinology Deviated Nasal Septum Aetiology Congenital Traumatic Symptom Nasal obstruction Bilateral or Unilateral Sign Treatment As for rhinitis Surgery

54. Rhinology Perforation of Nasal Septum 1 Aetiology Idiopathic Trauma Tumour Wegener’s/SLE Chromic/Sulphuric acid or Cocaine Symptoms Nasal obstruction Crusting Epistaxis

55. Rhinology Perforation of Nasal Septum 2 Treatment Exclude serious causes Treat as rhinitis Nasal douching Septal button Surgery (success poor)

56. Rhinology Nasal Polyps Aetiology Not known Symptoms Nasal Obstruction Rhinorrhoea Treatment Topical steroid medication Surgery

57. Rhinology Sinusitis 1 Aetiology Infective Acute vs. Chronic Not all facial pain is sinusitis Symptoms Facial pain Nasal discharge Nasal obstruction Signs

58. Rhinology 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 sinusitis It is a dental infection

59. Rhinology Epistaxis 1 Aetiology Idiopathic Trauma Tumours (Coagulopathy) (Hypertension) Treatment First aid/Resusitation Cautery Nasal Packing

60. Rhinology Epistaxis 2 Anaesthetise prior to cautery

61. Rhinology Sino-nasal carcinoma and Nasopharyngeal Carcinoma Rare Aetiology Wood dust Nickel dust, Chromium Symptoms Nasal obstruction Scant regular epistaxis

62. Rhinology Ethmoiditis ENT must be involved. Must be admitted. Potentially serious. Rx: ab, decong +/- surg.

63. Rhinology Nasal Fracture Septal Haematoma Can be manipulated Consider the rest of head injury and facial skeleton

64. Rhinology Nasal Fracture Septal Haematoma Septal haematoma Soft swelling Must be drained within 12 hours

65. End of Rhinology Section

66. Laryngology (Mouth Pharynx Larynx -Throat) Section

67. Laryngology Anatomy History Examination Investigations Pathology

68. Laryngology Anatomy 1 Anatomy Mouth

69. Laryngology Anatomy 2 Anatomy Oropharynx

70. Laryngology Anatomy 3 Anatomy - Neck

71. Laryngology Anatomy 4

72. Laryngology History 1 Dysphagia (wt loss) Solid Liquid Dysphonia Neck pain Referred otalgia Haemoptysis (Globus pharyngeus)

73. Laryngology History 2 Smoking Alcohol

74. Laryngology 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

75. Laryngology 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

76. Laryngology 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)

77. Laryngology Examination 4

78. Laryngology Investigations Bloods TFT Ca Thyroid antibodies FNA CXR USS Neck CT MRI

79. Laryngology Tonsillitis Sore throat Pyrexia White follicles on tonsils Penicillin Recurrent episodes treat with tonsillectomy (Glandular fever)

80. Laryngology Quinsy (Peritonsiller abscess) Infection spreads to peritonsiller tissues and can form abscess Asymmetrical swelling Treat with drainage + antibiotics

81. Laryngology Adenoids

82. Laryngology Pharynxl/Larynx/Mouth Carcinoma

83. Laryngology Pharynx Lymphoma No specific local symptoms B symptoms Mucosa usually not ulcerating Check other lymph groups (neck, axilla and inguinal) and spleen

84. Laryngology Neck lump Various “Benign” Normal structures Reactive lymph nodes Mumps Sebaceous cyst

85. Laryngology Neck lump various

86. Laryngology Neck lump Thyroid lump 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

87. Laryngology Neck lump Salivary Gland Neoplasia Parotid swellings Mainly benign Usually pleomorphic salivary adenoma Submandibular gland Usually inflammatory

88. Laryngology Neck lump Thyroglossal 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

89. Laryngology Neck lumps Branchial Cyst Congenital Treatment excision

90. Laryngology Neck lump Metastatic Neck Nodes Neoplasia Benign (very common) Malignant Primary Carcinoma Lymphoma (common) Secondary metastases (always consider this) Mouth Pharynx Larynx Infraclavicular (lung, breast, stomach)

91. Laryngology Neck lump TB Usually multiple nodes Cold abscess If draining do so for weeks

92. Laryngology Larynx Carcinoma Dysphonia / Hoarseness for >3 weeks

93. Laryngology Larynx Reinke’s Oedema Smoking

94. Laryngology Larynx Vocal Cord nodules Vocal cord nodules

95. Laryngology Dysphagia Liquid – neurological Solid – mechanical Tumour Pharyngeal pouch (regurgitation)

96. Laryngology 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

97. Laryngology Snoring Obstructive Sleep 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.

98. Laryngology Larynx Epiglottitis 4 year old drooling toxic child Do nothing! Get other people Go to theatre

99. Laryngology Acute Airway 1 Stridor. Tachopneic Cyanosis (very late sign) Acute Foreign Bodies Inflammatory Swelling Chronic Tumour. Larynx Bronchous.

100. Laryngology Acute Airway 2. First Aid. Choking. Foreign Body Baby and adult Heimlich

101. Laryngology Acute Airway 4 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

102. Laryngology Acute Airway 5 Tracheostomy Identify cricothyroid membrane

103. Laryngology Acute Airway 6 Tracheostomy Horizontal cut. 2cm wide. Deep enough. Insert airway.

104. Laryngology Acute Airway 3. First Aid. Choking. Foreign Body. Dog

105. THE END Questions?