Transcript Ent Undergraduate Lecture

ENT Undergraduate Lecture
Mr Rejali
ENT Consultant
University Hospital, Coventry
Plan
• 3 lecture:
– Otology
– Rhinology
– Head and Neck
– Practical session
Otology
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Anatomy / Physiology
History
Examination
Outer ear problems
Middle Ear Problems
Inner Ear Problems
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
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
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
Otology Anatomy Middle Ear 2
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Tympanic membrane
Right ear
Attic
Handle of malleus
Light reflex
Otology Anatomy Middle Ear 3
• Eustachian tube
equalises pressure
between middle ear
and atmosphere
Otology Anatomy Inner Ear 1
• Cochlea – Hearing
• Semicircular canal –
Angular acceleration
• Vestibule – Linear
acceleration
Otology Physiology Cochlea
• Sound transmission
through middle ear
• Oval - Round Window
travelling wave.
• Tonotopic distribution
of organ of corti
Otology Physiology Vestibular
Function
• Macula in saccule
and utricle - linear
acceleration
• Crista in semi-circular
canal – angular
acceleration
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
Otology History
• Inner ear:
– Hearing loss
(sensoneural)
– Vertigo
– Tinnitus
Otology Examination
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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 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 Diagnosis
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Surgical Sieve
Outer ear
Middle Ear
Inner Ear
Hearing loss
– Conductive
– Sensoneural
Otology Investigations
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Pure Tone Audiogram
Tympanogram
CT
MRI
Otology Management
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Explanation
Advice
Medical
Surgical
Haematoma/Seroma of Pinna
• Aspirate x2 (sterile
conditions)
• Compression
bandage
• Review in 24hrs
• If re-accumulate
proceed to formal
drainage and quilting
stitch
Otology External
• Pinna skin tumour
Otitis Externa
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Otitis Externa
Acute
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Painful
Serous discharge
Moist swollen canal
Tympanic membrane
intact
Pseudomonas aeroginosa
Treat topical toilet and
antibiotics
Chronic
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Eczema
Topical toilet and steroids
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
Otology External
• Exostoses
– Cold water swimmers
• Osteomas
– Bening neoplasia
Otology Middle
• Tympanosclerosis
– Previous infection or
trauma.
– Usually of no
significance
Otology Middle
• Retracted tympanic
mebrane
– Often no treatment
needed
– Differentiate from
perforation
– Occasionally progress
to cholesteatoma
Otology Middle
• TM perforation
• If dry may need no
treatment
• If recurrent infection
can be repaired.
Otology Middle
• Acute otitis media
– Pain
– Hearing loss
– Later otorrhea
Acute Mastoiditis
• IV antibiotics
• Surgery
Otology Middle
• Otitis media with
effusion – glue ear
• Middle ear fluide
• Common in children
• Hearing loss
• Infection starts
process
• Treatment
conservative,
Grommets
Otology Middle
• Cholesteatoma
Otology Middle Ear
• Mastoid cavity
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
Otology Inner Ear
• Vertigo illusion of
movement
– Hallmark of vestibular
dysfunction
– Rotary
– Linear
Otology Inner Ear
• Benign Paroxysmal
Positional Vertigo
• Vestibular Neuronitis
• Meniere's Disease
• Recurrent
vestibulopathy
• Differentiate from
central vestibular
causes.
Vestibular signal balance
Normal balanced input
Pathological
Left ear in
this case
Increased
Reduced
or
signal
nosignal
signal
Increased
Vestibular
Menieres
BPPVNeuronitis
Brain will get used to new
situation but not to a frequently
changing one.
Otology Inner Ear
• Presbyacusis
• Congenital Hearing
Loss
Otology Inner Ear
• Tinnitus
• Acoustic neuroma
Facial Palsy
• Upper vs Lower motor
neurone pattern.
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
Facial Palsy
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Eye care. If concern d/w Ophthalmic team.
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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 Section
Rhinology
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Anatomy
Physiology
History
Examination
Pathology
Rhinology Anatomy 1
• External
• Internal
– Lateral wall
– Medial wall
Rhinology Anatomy 2
• Nasal septum
– Little’s area
– Epistaxis
Rhinology Anatomy 3
• Paranasal Sinuses
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Frontal
Maxillary
Ethmoid
Sphenoid
Rhinology Physiology
• Nose
– Warms, moisten
– Filter
– Mucociliary
• Sinuses
– Function unknown
Rhinology History
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Nasal obstruction
Anterior rhinorrhoea
Olfaction
Facial pain
Sneezing
Epistaxis
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
Rhinology Investigation
• Allergy testing
– IgE levels
– RAST (Blood test)
– Skin Prick Testing
• Plain X ray –
inaccurate
• CT
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
Rhinology Allergic Rhinitis 2
• Investigations
– RAST test
– Skin Prick test
Rhinology Allergic Rhinitis 3
• Treatment
– Allergen Avoidance
– Anti-histamine
• Topical
• Systemic
– Steroid
• Topical spray or Drops
• Oral (limited use)
– Leukotriene antagonist
– Immunotherapy
Rhinology Deviated Nasal Septum
• Aetiology
– Congenital
– Traumatic
• Symptom
– Nasal obstruction
– Bilateral or Unilateral
• Sign
• Treatment
– As for rhinitis
– Surgery
Rhinology Perforation of Nasal
Septum 1
• Aetiology
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Idiopathic
Trauma
Tumour
Wegener’s/SLE
Chromic/Sulphuric
acid or Cocaine
• Symptoms
– Nasal obstruction
– Crusting
– Epistaxis
Rhinology Perforation of Nasal
Septum 2
• Treatment
– Exclude serious
causes
– Treat as rhinitis
– Nasal douching
– Septal button
– Surgery (success
poor)
Rhinology Nasal Polyps
• Aetiology
– Not known
• Symptoms
– Nasal Obstruction
– Rhinorrhoea
• Treatment
– Topical steroid
medication
– Surgery
Rhinology Sinusitis 1
• Aetiology
– Infective
– Acute vs. Chronic
• Not all facial pain is
sinusitis
• Symptoms
– Facial pain
– Nasal discharge
– Nasal obstruction
• Signs
This is not sinusitis
It is a dental infection
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
Rhinology Epistaxis 1
• Aetiology
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Idiopathic
Trauma
Tumours
(Coagulopathy)
(Hypertension)
• Treatment
– First aid/Resusitation
– Cautery
– Nasal Packing
Rhinology Epistaxis 2
• Anaesthetise prior to
cautery
Rhinology Sino-nasal carcinoma
and Nasopharyngeal Carcinoma
• Rare
• Aetiology
– Wood dust
– Nickel dust, Chromium
• Symptoms
– Nasal obstruction
– Scant regular epistaxis
Rhinology
• Ethmoiditis
• ENT must be
involved.
• Must be
admitted.
• Potentially
serious.
• Rx: ab, decong
+/- surg.
Rhinology Nasal Fracture Septal
Haematoma
• Can be manipulated
• Consider the rest of
head injury and facial
skeleton
Rhinology Nasal Fracture Septal
Haematoma
• Septal haematoma
– Soft swelling
– Must be drained within
12 hours
End of Rhinology Section
Laryngology (Mouth Pharynx
Larynx -Throat) Section
Laryngology
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Anatomy
History
Examination
Investigations
Pathology
Laryngology Anatomy 1
• Anatomy Mouth
Laryngology Anatomy 2
• Anatomy Oropharynx
Laryngology Anatomy 3
• Anatomy - Neck
Laryngology Anatomy 4
Laryngology History 1
• Dysphagia (wt loss)
– Solid
– Liquid
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Dysphonia
Neck pain
Referred otalgia
Haemoptysis
(Globus pharyngeus)
Laryngology History 2
• Smoking
• Alcohol
Laryngology Examination 1
• Mouth
– Inspection
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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 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 3
• Neck (have a system)
– Palpate from behind
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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 4
Laryngology Investigations
• Bloods
– TFT
– Ca
– Thyroid antibodies
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FNA
CXR
USS Neck
CT
MRI
Laryngology Tonsillitis
• Sore throat
• Pyrexia
• White follicles on
tonsils
• Penicillin
• Recurrent episodes
treat with
tonsillectomy
• (Glandular fever)
Laryngology Quinsy (Peritonsiller
abscess)
• Infection spreads to
peritonsiller tissues
and can form abscess
• Asymmetrical swelling
• Treat with drainage +
antibiotics
Laryngology Adenoids
Laryngology
Pharynxl/Larynx/Mouth Carcinoma
Laryngology 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
“Benign”
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Normal structures
Reactive lymph nodes
Mumps
Sebaceous cyst
Laryngology Neck lump various
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
Laryngology Neck lump Salivary
Gland Neoplasia
• Parotid swellings
– Mainly benign
– Usually pleomorphic
salivary adenoma
• Submandibular gland
– Usually inflammatory
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
Laryngology Neck lumps Branchial
Cyst
• Congenital
• Treatment excision
Laryngology Neck lump Metastatic
Neck Nodes
• Neoplasia
– Benign (very common)
– Malignant
• Primary
– Carcinoma
– Lymphoma (common)
• Secondary metastases
(always consider this)
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Mouth
Pharynx
Larynx
Infraclavicular (lung,
breast, stomach)
Laryngology Neck lump TB
• Usually multiple
nodes
• Cold abscess
• If draining do so for
weeks
Laryngology Larynx Carcinoma
• Dysphonia /
Hoarseness for >3
weeks
Laryngology Larynx Reinke’s
Oedema
• Smoking
Laryngology Larynx Vocal Cord
nodules
• Vocal cord nodules
Laryngology Dysphagia
• Liquid – neurological
• Solid – mechanical
– Tumour
– Pharyngeal pouch
(regurgitation)
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
Laryngology Snoring Obstructive
Sleep Apnoea
• Partial obstruction of
airway
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Snoring
High BMI
Pharyngeal
Nasal
• Recurrent obstruction to
airway fragmenting sleep
– Daytime somnolescence
– Similar aetiology to snoring
– Treatment: lifestyle, CPAP,
surgery.
Laryngology Larynx Epiglottitis
• 4 year old drooling
toxic child
• Do nothing!
• Get other people
• Go to theatre
Laryngology Acute Airway 1
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Stridor.
Tachopneic
Cyanosis (very late sign)
Acute
– Foreign Bodies
– Inflammatory Swelling
• Chronic
– Tumour. Larynx Bronchous.
Laryngology Acute Airway 2.
First Aid. Choking. Foreign
Body
Baby and adult
Heimlich
Laryngology Acute Airway 4
Tracheostomy
• If first aid measure fail and patients life is
in danger consider tracheostomy (cricothyroidotomy).
• You will need:
– Scalpel/Knife
– Straw/Pen with inner part removed/Paper
rolled up
Laryngology Acute Airway 5
Tracheostomy
Identify cricothyroid membrane
Laryngology Acute Airway 6
Tracheostomy
Horizontal cut. 2cm wide. Deep enough. Insert airway.
Laryngology Acute Airway 3.
First Aid. Choking. Foreign
Body. Dog
THE END
Questions?