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Title: ENT lecture Notes
Description: A comprehensive and detailed set of notes covering all aspects of ENT medicine. Diagrams included to aid learning. Useful for medical students.
Description: A comprehensive and detailed set of notes covering all aspects of ENT medicine. Diagrams included to aid learning. Useful for medical students.
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ENT LECTURE NOTES
Anatomy of the ear
The ear is the organ that detects sound
...
The ear is part of the auditory (hearing) and vestibular (balance and body position)
system
...
The outer ear includes:
! Auricle (also called the pinna): helps direct sound (and imposes filtering) into the
ear canal to the tympanic membrane (eardrum)
...
! Ear canal (also called auditory canal and external acoustic meatus): the most
important part of the outer ear
...
The ear canal is an air filled
cavity
...
Excessive earwax may impede the passage of sound in the ear canal, causing conductive
hearing loss (very common cause!)
Middle ear
• The middle ear, is an air-‐filled cavity behind the tympanic membrane (TM), which includes:
! Inner tympanic membrane (TM)
! The three ear bones or ossicles: malleus (or hammer), incus (or anvil), and stapes
(or stirrup)
...
Important for mucus
drainage of the middle ear and pressure equalization
...
If
there is a pressure difference between the two compartments then a conductive
hearing loss will occur
...
The malleus has a long process (the manubrium) that is attached to the mobile portion of
the tympanic membrane
...
The
stapes is the smallest named bone in the human body
...
When the stapes footplate
pushes on the oval window, it causes movement of fluid within the cochlea (a portion of
the inner ear)
...
Lesions of this part of CN VII can therefore cause
hyperacusis (oversensitivity to certain sound)
...
In humans the middle ear (like the ear canal) is normally filled with air
...
The
Eustachian tube connects from the chamber of the middle ear to the back of the
nasopharynx
...
This allows air to flow into the middle ear and any mucus to flow out
...
Having equal air pressure on each side of
the eardrum, and the middle ear free of mucus, enables the eardrum to work and vibrate
properly, which is needed to hear properly
...
g
...
For example, during
ascent in an airplane, there is a decrease in cabin air pressure, leading to a relative increase
in the pressure of the middle ear
...
Pressure equalization during descent is
much more difficult
...
Thus, a
relative negative pressure develops in the middle ear that tends to lock the Eustachian tube
closed
...
If the tube is unable
to open due to a cold or chronic Eustachian tube dysfunction, the excess pressure can lead
to discomfort and barotrauma
...
“Air conduction” refers to the passage of sound from outside the body to the cochlear via
auditory canal (external auditory meatus), TM membrane, auricles and oval window
...
Abnormalities such as impacted ear-‐wax/cerumen (occlusion of the external ear canal), fixed
or missing ossicles, or holes in the tympanic membrane generally produce conductive
hearing loss
...
g
...
Tympanoplasty is the general name of the operation to repair the middle ear's tympanic
membrane and ossicles
...
Sometimes artificial ear bones are placed to substitute for damaged ones, or a
disrupted ossicular chain is rebuilt in order to conduct sound effectively
...
The bony labyrinth (osseous labyrinth) is the rigid outer wall of the
inner ear (formed from the temporal bone)
...
! Cochlea: dedicated to hearing; converting sound pressure patterns from the
outer/middle ear into electrochemical impulses which are passed on to the brain
via the cochlear nerve (branch of CN VIII the vestibulocochlear nerve)
•
•
•
•
•
•
•
! Three semicircular canals and vestibule: integral part of the vestibular system
which is dedicated to balance
...
CN VII (the facial nerve) also travels through the internal acoustic meatus (then travels to
face via stylomastoid foramen)
The cochlea is dedicated to hearing
...
Within the cochlea are three
fluid filled spaces: the scala tympani, the scala vestibuli and the scala media
...
The fluid inside this duct is moved, flowing against the receptor cells of the Organ of Corti
...
These stimulate the spiral ganglion, which sends information
through the cochlear branch of the CN VIII to the brainstem (cochlear nuclei of the medulla)
...
The semicircular canals help in both dynamic and static balance
...
Hair cells are also receptor cells involved in balance, although the hair cells of the auditory
and vestibular systems of the ear are not identical
...
Firing of vestibular
hair cells stimulates the vestibular portion of CN VIII
...
• The transverse temporal gyri (also called Heschl's gyri – he shall hear!) are found in the area
of primary auditory cortex
...
• Auditory information received by Hescls gyrus (auditory cortex) is bilateral receiving input
from both ears
...
Unilateral
hearing loss occurs due to a problem within the ear or CN VIII
...
The external ear functions to collect and amplify sound, which then gets
transmitted to the TM of the middle ear
...
• Middle ear: The tympanic membrane (TM), malleus, incus, and stapes composes the middle
ear
...
The
primary functionality of the middle ear is that of conduction and amplification of sound via
transference of sound waves in the air collected by the auricle to the fluid of the cochlea in
•
the inner ear
...
Inner ear (labyrinth): The inner ear contains the semicircular canals, vestibule, and cochlea
...
The labyrinthine cavity
functions to conduct sound information to the CNS as well as to assist in balance (by sending
information regarding body and head position to the CNS)
...
Otoendoscopy
• Diagnostic tool
• Can assist in surgery or other medical interventions
Ear disease: The 7 D’s
Problems of the ear include (the 7D’s):
• Deafness and hearing loss
• Discomfort (ear pain = otalgia) – always consider referred pain => full ENT history
• Discharge e
...
blood or CSF (tests +ve for glucose – can use urinalysis strip, halo sign)
• Dizziness (vertigo specificaly)
• Din Din (tinnitus)
• Destruction by disease e
...
Cholesteatoma e
...
FACIAL NERVE WEAKNESS (must assess for
in ear exam)
• Defective movement of face e
...
LMN facial palsy (can result due to pathology within the ear
as facial nerve (CN VII) travels through the internal acoustic meatus)
Deafness
• Deafness, hearing impairment, or hearing loss is a partial or total inability to hear
...
• Presbycusis = age-‐related hearing loss (cumulative effect of aging on hearing – degeneration
of hair cells)
...
NB: remember that presbyopia = age related hypermetropia (long sightedness)
...
There is a diagnosis to determine the severity of the hearing impairment, and it is measured
in decibels
...
There are a number of measures that can be taken to prevent hearing loss, but in some
cases it is impossible to reverse or prevent
...
However, some of
these technologies have caused controversy in the deaf community
...
Furthermore, a hearing impairment may exist in only one ear (unilateral)
or in both ears (bilateral)
...
• Conductive: A conductive hearing impairment is present when the sound is not reaching the
inner ear, the cochlea
...
g
...
g
...
Conductive hearing impairments are characterised by impaired air
conduction (AC) on tuning fork tests & audiometry e
...
BC>AC -‐ on audiometry this would
manifest normal BC with a decrease in AC curve
...
e
...
On Webbers, the sound will lateralise to affected ear
...
The most common reason for sensorineural
hearing impairment is damage to the hair cells (epithelial cells of organ of Corti) in the
cochlea (e
...
presbycusis)
...
On Rinnes we have +ve result (AC>BC), and on Webbers the sound lateralises to the
opposite ear
...
Chronic ear
infection (a fairly common diagnosis) can cause a defective ear drum or middle-‐ear ossicle
damage (conductive hearing loss) and also damage to the inner ear (sensorineural hearing
loss) resulting in mixed hearing loss
...
Cortical deafness is an auditory disorder where the patient is
unable to hear sounds but has no apparent damage to the anatomy of the human ear
...
In most instances, the cause is bilateral embolic
stroke to the area of Heschl's gyri
...
Patients with cortical
deafness cannot hear any sounds, that is, they are not aware of sounds including non-‐
speech, voices, and speech sounds
...
g
...
Therefore
deafness in one ear must require a bilateral lesion of the auditory cortex in the temporal
lobe
...
g
...
• Primary otalgia is ear pain that originates inside the ear
...
Referred otalgia is
common
...
It may be caused by several
other conditions, such as impacted teeth, sinus disease, inflamed tonsils, infections in the
nose and pharynx, throat cancer (never forget this), and occasionally as a sensory aura that
precedes a migraine
...
External ear pain may be:
• Mechanical: trauma, foreign bodies (e
...
hairs, insects or cotton buds)
• Infective (otitis externa): Staphylococcus reus, Pseudomonas, Candida, herpes zoster
Middle ear pain may be:
• Mechanical: barotrauma due to pressure changes (often iatrogenic), Eustachian tube
obstruction leading to acute otitis media
...
g
...
influenzae)
Inner ear pain
• Inner ear infections (labyrinthitis) may RARELEY cause otalgia
Secondary (referred) otalgia
The neuroanatomic basis of referred otalgia rests within one of five general neural pathways
...
Hence, pathology in other "non-‐ear" parts of the body innervated by these neural
pathways may refer pain to the ear
...
Oral cavity
carcinoma can also cause referred ear pain via this pathway
...
The trigeminal nerve supplies somatic sensory to the
face, oral cavities and nasal cavities
...
• Facial nerve (cranial nerve VII): This referred pain can come from the teeth, tongue, the
temporomandibular joint (due to its close relation to the ear canal), or the parotid gland
...
• Glossopharyngeal nerve (cranial nerve IX): This referred pain comes from the nasopharynx,
and oropharynx, and can be due to pharyngitis, pharyngeal ulceration, tonsillitis, or to
carcinoma of the oropharynx (base of tongue, soft palate, pharyngeal wall, tonsils)
...
In
addition it supplies visceral motor (general visceral efferent) which provides
parasympathetic innervation of the parotid gland, and, visceral sensory (general visceral
afferent) – carries visceral sensory information from the carotid sinus and carotid body
...
The vagus nerve supplies
motor parasympathetic fibers to all the organs except the suprarenal (adrenal) glands, from
the neck down to the splenic flexure of the colon
...
g
...
The vagus also carries sensation from the external auditory
meatus and tympanic membrane
...
• Second and third spinal segments, C2 and C3
...
Yet some patients will have a "psychogenic otalgia," and no
cause as to the pain in ears can be found (suggesting a psychosomatic origin)
...
Key point: when pt presents with an “ear” history we must take a full ENT history e
...
ear (5Ds),
nose (5Ss), and throat/larynx (hoarseness, dysphonia, pain, dysphagia, stridor, difficulties
breathing, problems with coughing) => this is very important as the pt with ear pain may actually
have a laryngeal cancer
...
Discharge (otorhhoea)
• Acute otitis media: acute middle ear infection – if TM ruptures
• Chronic otitis media: chronic middle ear infection – if TM ruptures
• CSF otorrhoea: cerebrospinal fluid (CSF) otorrhea is a rare, dangerous and potentially life
threatening occurrence for which the otolaryngologist is often consulted
...
Occurs due to leakage of cerebrospinal fluid (CSF) though the ear structures
...
Test +ve for glucose on urinalysis strips
...
Dizziness and vertigo
• Vertigo is a subtype of dizziness in which a patient inappropriately experiences the
perception of motion e
...
a sensation of spinning while stationary (or room spinning around
them)
• It is often associated with nausea and vomiting as well as a balance disorder, causing
difficulties standing or walking
...
g
...
• DON’T FORGET THAT VERTIGO CAN BE CENTRAL OR PERIPHERAL
Peripheral:
• Vertigo caused by problems with the inner ear or vestibular system (which is composed of
the semicircular canals, the vestibule (utricle and saccule), and the vestibular nerve) is
called "peripheral", "otologic" or "vestibular" vertigo
...
Other causes include Ménière's disease and
Labyrinthitis/vestibular neuritis
...
g
...
Central:
• Vertigo that arises from injury to the balance centers of the central nervous system (CNS),
often from a lesion in the brainstem or cerebellum (vertebrobasilar system – posterior
circulation)
• Generally associated with less prominent movement illusion and nausea than vertigo of
peripheral origin
...
• Vertebrobasilar insufficiency (VBI) refers to a temporary set of symptoms due to decreased
blood flow in the posterior circulation of the brain
...
Many causes including cervical
spodylosis (OA of cervical vertebrae) leading to vertebral artery compression
...
Din din (tinnitus)
• Tinnitus is the perception of sound within the human ear (e
...
ringing in the ears) when no
actual sound is present
...
• The noises of tinnitus may vary in pitch from low frequency to high frequency, they maybe
intermittent or permanent and they usually vary in the intensity of sound
...
• Tinnitus has sometimes been described as ‘the sound of silence' because all people, if they
are seated in a completely quiet soundproofed room, will hear a type of rushing or hissing
sound
...
Hearing words, songs or
voices is not included in the definition of tinnitus
...
Many many causes!
Defective facial movements
• Lower motor neurone palsy e
...
Facial nerve palsy
• Causes of facial nerve palsy include:
! Bell's palsy: Previously considered idiopathic, it has been recently linked to
herpes simplex infection
...
May
also present with pain, and dysfunction of other components of facial nerve (e
...
lacrimal gland and special sense of taste to the anterior 2/3rds of the tongue, as
well as hyperacusis due to dysfunction of stapedius muscle)
! Trauma: especially fractures of the temporal bone, may also cause acute facial
nerve paralysis
...
Patients present with facial
paralysis, ear pain, vesicles, sensorineural hearing loss, and vertigo
...
Antibiotics
are used to control the otitis media, and other options include a wide
myringotomy (an incision in the tympanic membrane) or decompression if the
patient does not improve
...
Once suspected, there should be immediate surgical exploration to
determine if a cholesteatoma has formed as this must be removed if present
...
Common culprits are facial neuromas, congenital
cholesteatomas, hemangiomas, acoustic neuromas, parotid gland neoplasms, or
metastases of other tumours
Destruction by disease: Cholesteatoma
• Cholesteatoma is a destructive and expanding growth (non malignant cyst) consisting of
keratinizing squamous epithelium (e
...
produces keratin) in the middle ear and/or mastoid
process
...
• Acquired cholesteatomas, which are more common, can be caused by pathological
alteration of the ear drum leading to accumulation of keratin within the middle ear
...
• The patient may commonly have clinical signs of conductive hearing loss (BC>AC)
...
• Both the acquired as well as the congenital types of the disease can affect the facial nerve
(e
...
causing facial muscle weakness) that extends from the brain to the face and passes
through the inner and middle ear and leaves at the anterior tip of the mastoid bone, and
then rises to the front of the ear and extends into the upper and lower face
...
• If a patient presents to a doctor with ear discharge and hearing loss, the doctor should
consider the patient to have cholesteatoma until the disease is definitely excluded
...
There can also
be facial nerve weakness
...
It can also
affect and erode (via the enzymes it produces) the thin bone structure that isolates the top
•
of the ear from the brain, as well as lay the covering of the brain open to infection with
serious complications (rarely even death due to brain abscess and septicaemia)
...
Signs
• On initial inspection, an ear canal full of discharge (otorrhoea) may be all that is visible
...
• Once the debris is cleared, cholesteatoma can give rise to a number of appearances
...
• If there is less inflammation, the cholesteatoma may present the appearance of 'semolina'
discharging from a defect in the tympanic membrane
...
• If the cholesteatoma has been dry, the cholesteatoma may present the appearance of 'wax
over the attic' (pars flaccida)
...
• Foul smelling
Otitis externa
• Otitis externa (also known as "external otitis" and "Swimmer's ear") is an inflammation of
the outer ear and external auditory meatus (ear canal)
...
The inflammation
can be secondary to dermatitis (eczema) with no microbial infection, or it can be caused by
active bacterial or fungal infection
...
Clinical features:
• Pain is the predominant complaint and the only symptom directly related to the severity of
acute external otitis
...
• Touching or moving the outer ear (pinna) increases the pain, and this manoeuvre on
physical exam is important in establishing the clinical diagnosis
...
The
ear canal may also appear eczema-‐like, with scaly shedding of skin
...
When enough swelling and
discharge in the ear canal is present to block the opening, external otitis may cause
temporary conductive hearing loss
...
Sometimes the diagnosis of external otitis is presumptive and return visits are required to
fully examine the ear
...
• In severe cases of external otitis, there may be swelling of the lymph node(s) directly around
the ear e
...
pre-‐auricular and post-‐auricular lymph nodes (always examine these in ear
exam)
• The diagnosis may be missed in most early cases because the examination of the ear, with
the exception of pain with manipulation, may be normal
...
As a
moderate or severe case of external otitis resolves, weeks may be required before the ear
canal again shows a normal amount of cerumen
...
• Even without exposure to water, the use of objects such as cotton swabs or other small
objects to clear the ear canal is enough to cause breaks in the skin, and allow the condition
to develop
...
g
...
• Candida albicans and Aspergillus species are the most common fungal pathogens
responsible for the condition
...
• Tx for bacterial if persistent/severe: Amoxicillin
Acute otitis media (AOM)
• Common in children, not adults
• Otitis media is the medical term for middle ear infection
• The common cause of all forms of otitis media is blockage of the Eustachian (auditory) tube
...
g
...
• Because of the blockage of the Eustachian tube, the air volume in the middle ear is trapped
and parts of it are slowly absorbed by the surrounding tissues, leading to a mild vacuum in
the middle ear (-‐ve pressure occurs if persists to OME)
...
In addition, the blockage prevents
drainage of mucus from the middle ear
...
In rare cases, however,
the virus that caused the initial upper respiratory tract infection can itself be identified as
the pathogen causing the infection in the middle ear
...
Ear infections are much more common in children because the Eustachian tube is
horizontal and shorter, making bacterial entry easier
...
Clinical features
• An integral symptom of acute otitis media is acute ear pain (otalgia)
• Other possible symptoms include fever, and irritability (in infants)
...
• To confirm the diagnosis, middle ear effusion and inflammation of the tympanic
membrane (eardrum) have to be identified; signs of these are fullness, bulging, cloudiness
and redness/inflammation of the eardrum angry looking)
• Viral otitis may also result in blisters on the external side of the tympanic membrane, which
is called bullous myringitis (myringa being Latin for tympanic membrane)
...
Also, an upset child's crying can cause the eardrum to look inflamed
due to distension of the small blood vessels on it, mimicking the redness associated with
otitis media
...
" In younger children — pulling, tugging, or rubbing of the ear, or non-‐specific
symptoms (such as fever, irritability, crying, poor feeding, restlessness at
night, cough, or rhinorrhoea)
...
• The diagnosis is strengthened by the presence of at least one of the following:
o Bulging of the tympanic membrane, with loss of normal landmarks
...
o Perforation of the tympanic membrane and/or discharge (otorrhoea) in the external
auditory canal
...
Otitis media with effusion (OME) – GLUE EAR
• Otitis media with effusion (OME) (also called glue ear) is simply a collection of fluid that
occurs within the middle ear space due to the negative pressure produced by altered
Eustachian tube function
...
• Otitis media with effusion (OME) does NOT usually present with otorrhoea as the TM
prevents any discharge from passing
...
• Fluid in the middle ear can cause conductive hearing impairment, but only when it
interferes with the normal vibration of the TM by sound waves
...
• Early-‐onset OME is associated with feeding while lying down, parental smoking, too short a
period of breastfeeding and greater amounts of time spent in group child care
• The TM is retracted due to the negative pressure
• OME = effusion of the middle ear that may be either mucoid or serous (serous otitis media)
• Key features:
! DULL TM
! Fluid levels
! Retracted
! Conducting HL
Chronic otitis media (COM)
• Chronic suppurative otitis media (CSOM) describes a perforated tympanic membrane (TM)
and active bacterial infection within the middle ear space resulting in persistent drainage
from the middle ear space for several weeks or more (i
...
lasting >6-‐12 wk)
...
g
...
This disease is much more common in persons with poor Eustachian tube
function
...
•
•
Chronic suppuration can occur with or without cholesteatoma, and the clinical history of
both conditions can be very similar
...
The chronically
draining ear in CSOM can be difficult to treat
...
Ossicle dysfunction and effusion causes conductive hearing loss
...
• Chronic otitis media can also lead to a cholesteatoma
...
It is
usually caused by repeated ear infections associated with poor Eustachian tube function
...
Eventually, it may erode into the inner ear and cause permanent
hearing loss or vertigo
...
In
some instances, cholesteatomas can expand up into the brain
...
Initially, this involves careful cleaning of the ear, antibiotics, and eardrops
...
This also can
act as a road map for surgery
...
• Not all dizziness is vertigo (indeed most will not be)
• Not all dizziness is otogenic (e
...
not all dizziness originates from ear pathology)
•
With regards to vertigo:
! Benign positional paroxysmal vertigo (BPPV) is very common and is relatively
easy to treat
! Ménière’s disease is uncommon
Definition of dizziness
• Dizziness is an impairment in spatial perception and stability
...
Always ask the patient to explain
what they mean by “dizzy” without using the word dizzy
...
Many
people find vertigo very disturbing and often report associated nausea and vomiting
...
Vertigo can be peripheral
(involvement of inner ear) or central (involvement of the CNS)
...
g
...
g
...
g
...
It is a diagnosis of exclusion and can
sometimes be brought about by hyperventilation
...
g
...
g
...
g
...
g
...
g
...
What exactly do they mean by
dizzy?
Physiology of balance
Equilibrioception or sense of balance is one of the physiological senses
...
Balance is the result of a number of body
systems working together:
• Eyes (visual system)
• Ears (vestibular system: semicircular canals and vestibular apparatus)
• Proprioception (the body's sense of where it is in space)
• Cerebellum and other regions of brain (integrate and process the information)
The vestibular system, the region of the inner ear where three semicircular canals converge, works
with the visual system to keep objects in focus when the head is moving
...
The muscles and joints and their proprioceptive sensors also work with the balance system to
maintain orientation or balance
...
Normal balance depends on
• Vestibular system:
! The semicircular canals (lateral, superior and posterior) system detects
rotational (circular) movements (dynamic)
...
! The utricle and the saccule (contained within vestibule) are parts of the
balancing apparatus (membranous labyrinth) located within the vestibule of the
bony labyrinth (inner ear)
...
g
...
The cerebellum also controls eye movements related to head
turning, hence why cerebellar dysfunction can result in nystagmus
Other centres of the brain
History
• WHAT EXACTLY DO YOU MEAN BY DIZZINESS? COULD YOU DESCRIBE IT FOR ME?
• SOCRATES
• Site: loss of balance on one side of body?
• Onset, duration, frequency, and evolution? -‐ Fast onset? Slow onset? How long does the
dizziness last? Frequency of attacks? Has it changed with time?
• Character – rotational, light headedness, loss of balance, blackouts etc etc
• Associated symptoms? -‐ Nausea? Vomiting? Headache? Any other neurological symptoms
e
...
loss of sensation, motor disturbance, headaches, seizures, visual changes? CV
systematic enquiry: palpitations, chest pain, SOB, PND, orthostatic dyspnoea
...
Examination
• Full ear examination including hearing and otoscopy: an otoscope or auriscope is a medical
device which is used to look into the ears
...
g
...
An ECG may also be prudent
Common causes of “dizziness”
• Postural dizziness: history e
...
dizzy when standing up -‐ assess BP lying/standing – many
factors contributing to postural hypotension (>20 SBP or >10 DBP drop on standing)
• Side effect of medication: DH (e
...
anti-‐HT): review medications
• Cardiogenic e
...
arrhythmia, structural heart disease – ECG and ECHO
• Anaemia (due to lack of O2 going to brain): perform FBC
• Hypoglycaemia (due to lack of glucose going to the brain): measure BM
• Psychogenic & interaction with imbalance
• Vertigo disorders (see below) – central or peripheral
FITS, FITS AND FUNNY TURNS: COVER NEURO, ENT, AND CV SYSTEMATIC ENQUIRY
Specific causes of vertigo
• Peripheral causes:
! Migrainous Vertigo (vertebrobasilar migraine)
! BPPV (benign positional paroxysmal vertigo)
! Ménière's Disease
! Vestibular neuronitis
! Labyrinthitis
• Central causes e
...
VBI, VB migraine, etc
Migraine associated vertigo
• Migraine affects as many as 15-‐20% of the general population, and it has been estimated
that about 25% of patients with migraine experience spontaneous attacks of vertigo and
ataxia
...
• Migraine however can be acepthalic!
Ménière's Disease
• Rare disorder of the inner ear that can affect hearing (cochlea) and balance (semicircular
canals, utricle and saccule) to a varying degree
• Ménière's disease is idiopathic, but it is believed to be linked to endolymphatic hydrops, an
excess of fluid in the inner ear
...
g
...
This gives rise to local vasodilation and
increased permeability, which can relieve the pressure of excess fluid in the inner ear
...
Unfortunately, because the inner ear deals with both balance and hearing, few surgeries guarantee
no hearing loss:
• Chemical labyrinthectomy with intratympanic gentamicin: an ototoxic drug (such as
gentamicin – more vestibular toxic rather than cochlear toxic) is injected into the middle ear
to "kill" the vestibular apparatus (while hopefully retaining hearing)
• Surgery
Benign positional paroxysmal vertigo (BPPV)
• Very common
• It is the commonest cause of vertigo on looking up
• BPPV is characterised by a positional trigger of the vertigo on:
! Looking up
! Turning in bed -‐ often worse to one side
! First lying down in bed at night
! On first getting out of bed in the morning
! Bending forward
! Rising from bending
! Moving head quickly – often only in one direction
• Brief episodes of vertigo (few seconds to several minutes)
...
• The spinning sensation (vertigo) experienced from BPPV is usually triggered by movement
of the head, will have a sudden onset, and can last anywhere from a few seconds to
several minutes
...
Many
patients are also capable of describing the exact head movements that provokes their
vertigo
• Nystagmus may also be present during vertigo spells
• It is important to remember that the DD includes vertebro-‐basilar insufficiency (VBI) and
Carotid Sinus Hypersensitivity
...
However, for a diagnosis of VBI we need other posterior circulation features
with the vertigo e
...
visual disturbance, diplopia, dysarthria, dystaxia, etc
...
Causes pre-‐syncope/syncope NOT vertigo
...
Typical trigger factors are
shaving, head turning, neck extension or tight collars
...
In patients with BPPV, the otoliths are dislodged from their usual position within
the utricle (vestibule) and migrate over time into one of the semicircular canals
...
Diagnostic tests
• Dix-‐Hallpike’s Test
• The roll test
Dix-‐Hallpike test
• The Dix-‐Hallpike test is a common test performed by examiners to determine whether the
posterior semicircular canal is involved
...
This test will reproduce vertigo
and nystagmus characteristic of posterior canal BPPV
...
30 seconds
• Results: In BPPV we classically get nystagmus + vertigo
• Condition may be bilateral
• NB: The test fatigues => much reduced or absent response on repetition
TEST FOR EACH SIDE e
...
45 degrees to right (to test for left BPPV) and 45 degrees to left (to test
for right BPPV)
...
• The roll test requires the patient to be in a supine position with his/her head in 20° of
cervical flexion
...
Management
• Epley Manoeuvre
• Semont Manoeuvre
• Brandt-‐Daroff Exercises
Epley manouvre
• The Epley maneuver or repositioning manoeuvre is a manoeuvre used to treat benign
paroxysmal positional vertigo (BPPV) of the posterior or anterior semicircular canals
...
• The exercise is a form of habituation exercise, designed to allow the patient to become
accustomed to the position which causes the vertigo symptoms
...
This may help you get over your vertigo sooner
...
In some cases, the labyrinth itself can also be inflamed
...
A theory gaining support is that a significant
proportion of cases are caused by a reactivation of herpes simplex virus that affects the
vestibular ganglion, vestibular nerve, labyrinth, or a combination of these
...
• Usually comes on suddenly and can cause other symptoms such as unsteadiness, nausea
and vomiting
• Prolonged vertigo (days to weeks)
• No associated tinnitus
• No associated hearing loss
• Probable viral aetiology
• May be viral prodromal (early) symptoms
Labyrinthitis
• Labyrinthitis is an inner ear infection/inflammation (infection of the labyrinth which hosts
the organs of balance and hearing)
...
•
•
•
•
•
•
•
•
•
Labyrinthitis can cause balance disorders, vertigo, SN hearing loss and tinnitus (use these
features to distinguish from vestibular neuronitis => vestibular neuronitis does not cause
hearing loss or tinnitus)
Prolonged vertigo (days)
May be associated tinnitus and/or hearing loss (in contrast to vestibular neuronitis)
Probable viral aetiology, however other causes such as bacterial, and inflammatory disorder
May be viral prodromal symptoms
Labyrinthitis is usually caused by a virus, but it can also arise from bacterial infection, head
injury, extreme stress, an allergy or as a reaction to medication
...
NB: The inner ear is consists of the bony labyrinth, a hollow cavity in the temporal bone of
the skull with a system of passages comprising two main functional parts:
! The cochlea, dedicated to hearing; converting sound pressure patterns from the
outer ear into electrochemical impulses which are passed on to the brain via the
auditory nerve
...
g
...
Vestibular rehabilitation
therapy (VRT) is a highly effective way to substantially reduce or eliminate residual dizziness
from labyrinthitis
...
Rehabilitation strategies most commonly
used are: gaze stability exercises -‐ moving the head from side to side while fixated on a
stationary object (aimed to restore the Vestibulo-‐ocular reflex)
...
A type
of schwannoma, this tumor arises from the Schwann cells responsible for the myelin sheath
that helps keep peripheral nerves insulated
• Can occur at the cerebellopotine angle (CPA) causing compression of the brain stem,
cerebellum, and other CN’s
• CN VIII involvement: The earliest symptoms of acoustic neuromas include ipsilateral
sensorineural hearing loss/deafness, disturbed sense of balance and altered gait, vertigo
with associated nausea and vomiting
•
•
•
•
•
•
•
Large tumors that compress the adjacent brainstem may affect other local cranial nerves
...
The glossopharyngeal and vagus nerves are uncommonly involved, but their involvement
may lead to altered gag or swallowing reflexes
...
Compression of cerebellum can cause ipsilateral ataxaia
Larger tumors may lead to increased intracranial pressure, with its associated symptoms
such as headache (often early morning exacerbated by lying down, coughing, and leaning
forward), vomiting, and altered consciousness
...
Remember we Ix SNHL with MRI (and Ix conducting HL with CT)
Summary
• Non-‐vestibular causes of vertigo and dizziness are important to consider e
...
syncope,
hypoglycaemia, anaemia, proprioception disorders, musculoskeletal problems, visual
problems, medications, BVI, and carotid hypersensitivity syndrome
• BPPV is very common and is associated with brief episodes (seconds to minutes) of
positional induced vertigo (with no associated hearing loss (HL), tinnitus or aural fullness)
• Ménière's Disease is rare and is associated with short periods (>20 mins to hours) of vertigo
which may be associated with low frequency SNHL (sensorineural hearing loss), tinnitus and
aural fullness
...
• Vestibular neuronitis results in a prolonged (days to weeks) state of vertigo with no
associated HL (hearing loss), tinnitus or aural fullness (because vestibular nerve is affected
and this only supplies the organs of balance, not hearing)
•
•
Labyrinthitis results in a prolonged (days to weeks) state of vertigo with associated SNHL and
tinnitus (as the whole labyrinthine is inflamed, and this structure contains both organs of
hearing and balance)
...
Blood supply from “donor area” is cut
off
...
This is similar to but different from a
graft, which does not have an intact blood supply and therefore relies on growth of new
blood vessels
...
For this reason, surgeons will analyse bone structure and facial features
carefully before discussing any possible improvements
...
A
key principle of facial proportion is based on the "golden proportion," a concept that has
long been recognized in architecture and art
...
Facial Plastic Surgery
• Rhinoplasty: plastic surgery procedure for correcting and reconstructing the form, restoring
the functions, and aesthetically enhancing the nose
...
• Mentoplasty: chin implants
• Face lift
• Blepharoplasty: plastic surgery operation for correcting defects, deformities, and
disfigurations of the eyelids; and for aesthetically modifying the eye region of the face
...
Minimizes scarring
...
Wound closure is performed with sutures (stitches), staples,
or adhesive tape
...
They are left open to allow the free drainage of exudate and the formation of
granulation tissue to fill the cavity left by dead or excised tissue
...
Surgeon may pack the wound with a gauze or use a drainage system
...
Healing process can be slow due to presence of
drainage from infection
...
Examples: gingivectomy, gingivoplasty,
tooth extraction sockets, poorly reduced fractures, burns, severe lacerations, pressure
ulcers
...
In some cases, the presence of a foreign body or infection may be
suspected, and these wounds are left open deliberately for several days until the potential
complication has resolved
...
Wound healing by this approach
is termed “healing by tertiary intention” or “delayed primary closure”, and is most
commonly used in surgical wounds complicated by infection
...
The wound is purposely left
open
...
• Skin grafts: blood supply from donor are is cut off
• Skin flaps: intact blood supply from donor area
Facial plastic surgery
• In facial plastic surgery most often our goal is patient rehabilitation not necessarily the
pursuit of beauty
HEAD AND NECK CANCER
• Head and neck cancer refers to a group of biologically similar cancers that start in the lip,
oral cavity (mouth), nasal cavity (inside the nose), paranasal sinuses, pharynx, and larynx
...
• Head and neck cancers often spread to the lymph nodes of the neck, and this is often the
first (and sometimes only) sign of the disease at the time of diagnosis
...
• Head and neck cancer is strongly associated with certain environmental and lifestyle risk
factors, including:
! Tobacco smoking
! Alcohol consumption
! UV light-‐ particularly oral
! Particular chemicals used in certain workplaces
! Certain strains of viruses such as human papillomavirus (HPV) and EBV
• Head and neck cancer is highly curable if detected early, usually with some form of surgery,
but radiation therapy may also play an important role, while chemotherapy is often
ineffective
...
The lump may be metastasis, primary tumour, swollen lymph nodes, thyroid
swelling, or a benign neck swelling
• Cancerous lumps are usually painless (painful lumps are usually due to infection)
• Cancerous lumps are usually stony hard and irregular in shape
• Source of cancer can be skin, lips, mouth, pharynx and larynx (voice box)
! Any changes in voice? Hoarseness is a red flag
...
! Difficulty breathing? Stridor is a red flag
...
g
...
Examination
• General exam
• Inspection of face
• Oral cavity: inspect the entire mouth (majority of oral cancers occurs on side of tongue or
underneath the tongue)
• Pharynx (nasopharynx, oropharynx, laryngopharynx)
• Neck
! Inspect for swellings/asymmetry
...
Inspect neck on
tongue protrusion
...
If suspect
lymphoma/haematological reason for lump => blood tests
...
• Radiology:
! Usually ultrasound – shape, consistency, morphology
...
! CT scan: very good for more bony soft tissue contrast e
...
tumor in mouth up
against mandible
...
CT also used for identifying
any other masses in the body
...
g
...
g
...
Incidence could be reduced
significantly due to vaccination (males & females)
Basic and clinical sciences
• Squamous cell carcinoma: Squamous cells are the epithelium (tissue layer) that is the
surface cells of much of the body
...
This is
the most common form of larynx and pharynx and oral cancers, accounting for over 90% of
throat cancer
...
• Be wary of left supraclavicular lymphadenopathy (Virchow’s nodes)
...
Virchows nodes
takes its supply from lymph vessels in the abdominal cavity
...
The finding of an enlarged, hard node (also referred to as Troisier's sign) has long
been regarded as strongly indicative of the presence of cancer in the abdomen, specifically
gastric cancer, that has spread through the lymph vessels
...
g
...
Also be aware of stridor which can occur due to
obstruction of upper airway
...
Salivary glands masses: majority are parotid or submandibular
...
This is useful for
establishing if a neck mass is the thyroid gland or not
...
This nerve innervates the lower eyelid,
upper lip, and part of the nasal vestibule and exits the infraorbital foramen of the maxilla
...
It can be associated with
trauma
...
• Failure to recognise septal hematomas, or treat in a timely fashion, can cause a saddle
nose deformity
• Septal haematoma may critically disfigure (e
...
saddle nose deformity) the patient and it
should always be ruled out
...
Large hematomas are drained
by an incision parallel to nasal floor
...
Nasal fracture
• Diagnosis is clinical: investigations are superfluous (not required)
• Clinical diagnosis is based on deviation
• The nasal bones should be assessed for asymmetry and mobility
...
• Assess breathing
• Review in ENT clinic 5-‐7 days post-‐injury
Clinical features
• Deformity / deviation
• Bruising
• Swelling
• Tenderness and pain
• Epistaxis
• Rhinorrhoea: Persistent watery mucus discharge from the nose (as in the common cold)
...
The typical history of a CSF leak is that of
clear, usually unilateral, watery discharge
...
Test any rhinorrhoea with dipsticks (CSF tests
positive for glucose, mucous does not)
• Difficulty breathing
Management:
• No intervention
• MUA (manipulation under anaesthetic) of the nose (LA/GA)
Complications:
•
•
•
Epistaxis: particularly anterior ethmoidal artery – make sure to assess pharynx for posterior
nasal bleeding
CSF rhinorrhoea (leak): This can have devastating complications in some patients, as the
communication between the nasal cavity and the cerebrospinal fluid and CNS can result in
bacterial infections of the CNS (e
...
meningitis and encephalitis) that can have catastrophic
effects on the patient
...
• This deformity, which is often referred to as cauliflower ear or wrestler’s ear is often
considered a badge of honor among wrestlers and rugby players
...
Management
The principle in the treatment is to remove blood collection
...
g
...
• A temporal bone fracture can involve none or all of these structures
...
• Air conduction uses the apparatus of the ear (pinna, eardrum and ossicles) to amplify and
direct the sound to the inner ear (cochlea)
• In contrast bone conduction bypasses some or all of these and allows the sound to be
transmitted directly to the inner ears albeit at a reduced amplitude
• Webber test: in patients with no hearing defects the sound should NOT be localized to either
ear (e
...
should be heard equally in both ears, or not heard at all)
• Rinne test: in patients with no hearing defects AC>BC in both ears i
...
+ve Rinnes (however
note that sensorineural loss can also result in AC>BC – as both AC and BC are equally
decreased maintaining there relative difference)
...
It can detect unilateral (one-‐sided)
conductive hearing loss (external/middle ear air hearing loss) and unilateral sensorineural
hearing loss (inner ear or neural hearing loss)
...
The patient is asked to report in which ear the sound is
heard louder
...
This finding is because the conduction problem of the external or middle
ear diminishes the conduction of sound through the external and middle ear (so that
ambient noise received by the affected ear is decreased), while the well-‐functioning inner
ear (cochlea) picks the sound up via the bones of the skull (bone conduction) causing it to be
perceived as a louder sound than in the normal ear (as sensed ambient noise is reduced in
defected ear)
...
This situation is because the affected ear is
less effective at picking up sound even if it is transmitted directly by bone conduction into
the inner ear
...
• If Weber lateralises (sound heard loudest) to the left => either conductive loss in left or
sensorineural loss in right (or combined losses)
• If Weber lateralises (sound heard loudest) to the right => either conductive loss in right or
sensorineural loss in left (or combined losses)
If Webber does not lateralise => could mean normal, or equal SNHL bilaterally, or equal
conducting HL bilaterally
• We need information from Rinnes test in both ears for further diagnostic information
Rinne test
• For the Rinne test, a vibrating tuning fork (typically 512 Hz) is placed initially on the mastoid
process (the flat one part side of the tuning fork) behind each ear until sound is no longer
heard
...
g
...
• The test can also be carried out by asking the patient if the sound is louder when placed
beside the ear canal (AC) compared to when the tuning fork end was placed against the skin
on top of the mastoid process behind the ear (BC)
...
• In conductive hearing loss, bone conduction is better than air (BC>AC) resulting in a
negative Rinne (abnormal result) in the affected ear
• In sensorineural hearing loss, both BC and AC equally depreciated, maintaining the relative
difference of air and bone conductions (AC>BC) e
...
a positive Rinnes (“normal”) result
• Rinne left BC>AC indicates conductive loss in left (Webber should lateralise to left as well)
• Rinne right BC>AC conductive loss in right (Webber should lateralise to right as well)
• Rinne AC>BC in both ears can indicate normal (Webber should not lateralise), or
sensorineural loss on left (Webber lateralises to right), or sensorineural loss on right
(Webber lateralises to left), or bilateral mild sensorineural loss (Webber without
lateralisation)
• Rinne both ears BC>AC indicates conductive loss in both ears (Webber does not lateralise) or
combined loss in both ears
• Note that the words positive and negative are used in a somewhat confusing fashion here,
as compared to their normal use in medical tests
...
In this case, that parameter
is whether air conduction (AC) is better than bone conduction (BC)
...
g
...
• The Rinne test is not reliable in distinguishing sensorineural and conductive loss,
particularly in mild sensorineural loss
...
Summary
•
•
•
•
•
•
Webber and Rinne test indications: Differentiate hearing loss cause between sensorineural
hearing Loss and conductive Hearing Loss
Preparation: tuning fork should be 512 Hz (preferred)
Rinne test:
• Technique: Assess differences between bone conduction and air conduction with
a 512 Hz tuning fork
• Normal: Air conduction (AC) is better than bone conduction (BC)
...
Referred to as a positive test
...
Referred to as "negative test"
Weber test:
! Technique: Tuning Fork (512 Hz) placed at midline forehead
! Normal: Sound conducts to both ears equally (or not heard at all)
! Abnormal: Sound lateralizes to one ear
! In conductive hearing loss the sound lateralises (is heard loudest) in the ear with
conductive hearing loss
! In sensorineural hearing loss the sound lateralises to the ear without
sensorineural hearing loss (normal ear)
Perform formal audiography (e
...
pure tone audiometry) in patients with hearing loss for
an accurate evaluation
Hearing Loss and deafness
• Conductive
• Sensorineural
• Mixed
• Central
Conductive hearing loss
Conductive hearing loss occurs when there is a problem conducting sound waves anywhere
along the route through the outer ear, tympanic membrane (eardrum), or middle ear
(ossicles)
...
This may be caused by a variety of problems including (work from superficial
to deep):
! Pinna deformity
! Narrowing of the ear canal
! Buildup of earwax (cerumen)
! AOE with pus in external auditory meatus
! Fluid in the middle ear e
...
OME
! TM problem: Punctured eardrum or poor mobility of TM in OME
! Fixation of the ossicles (as in the genetic condition otosclerosis)
...
g
...
• This type of hearing loss may occur in conjunction with sensorineural hearing loss or alone
...
In conductive hearing loss, bone conduction is better than air (BC>AC => negative
Rinne)
...
Its function is to transmit
sound from the air to the ossicles inside the middle ear, and then to the oval window in the
fluid-‐filled cochlea
...
The TM is watertight and airtight
...
g
...
g
...
g
...
Rare causing of hearing loss
...
•
Aetiology
•
•
•
•
•
•
•
•
Presbycusis -‐ is deafness due to loss of perception to high tones, mainly in the elderly
...
Presbycusis is hearing loss that occurs in the high frequency range (4000 Hz to
8000 Hz)
...
The normal hearing range is from 20 Hz to 20,000 Hz
...
g
...
Ménière's disease -‐ causes sensorineural hearing loss in the low frequency range (125 Hz to
1000 Hz)
...
Ototoxic drugs
o Aminoglycosides (most common cause; e
...
gentamicin)
o Loop diuretics (e
...
furosemide)
o Antimetabolites (e
...
methotrexate)
o Salicylates (e
...
aspirin)
Physical trauma -‐ either due to a fracture of the temporal bone affecting the cochlea and
middle ear, or a shearing injury affecting cranial nerve VIII
...
Patients with these tumors often have signs and symptoms corresponding to compression of
both nerves
...
Summary
• Most sensory hearing loss is due to poor hair cell function
...
There are both external causes of
damage, like noise trauma and infection, and intrinsic abnormalities (such as deafness
•
genes)
...
Prebycuss commonly occurs to age related degeneration of the Organ of corti =>
type of sensorineural hearing loss (particularly high frequencies)
Presbycusis and noise induced SN hearing loss are common causes of SN hearing loss
Audiometry (PTA)
• Gold standard for assessing HL
• The audiomtery graph plots the quietest sound heard (in decibels) as a function of frequency
– this demonstrated a graphical form of hearing loss
• Values > than 20db are significant e
...
sounds of greater than 20db which are not heard
• In conductive hearing loss (BC>AC) we would expect the AC hearing loss to be >20 db where
as BC will be normal (the AC line is below 20 and is much lower down than BC line)
• In contrast, in sensorineural hearing loss, both air and bone condition are decreased
proportionally resulting in values of hearing loss >20 for both BC and AC (the AC and BC lines
are in close proximity to each other, and both are below 20, BC>AC, both decreased equally)
• NB: In the first example below we have presbycusis which is a progressive bilateral
symmetrical age-‐related sensorineural hearing loss
...
Higher frequency
sounds are affected more
...
g
...
Continually reassess (ABCDE) – particularly after every intervention
CALL FOR HELP if compromised SEWS score
Secondary survey
• Top to toe examination
• Further Ix
• Zones of neck
• Bleeding/haematoma
• Aerodigestive injuries
• Neurological: power, tone, reflexes, sensation (upper and lower limbs)
Investigations
• Bloods: FBC, group and save (G&S) if <20% chance need of blood transfusion, or cross match
(XM) if >20% requirement
• Imaging: AP and lateral of neck (full body e
...
CT head, body, abdomen and pelvis may be
indicated depending on mechanism of injury)
• CXR: to assess for haemo-‐pneumothorax, surgical emphysema
• CT Angiogram: vascular, pseudoaneurysm, laryngeal, aerodigestive tract
• MRA (magnetic resonance angiograpy) if neurological symptoms
• NB: The aerodigestive tract= the combined organs and tissues of the respiratory tract and
the upper part of the digestive tract (including the lips, mouth, tongue, nose, throat, vocal
cords, and part of the esophagus and windpipe)
...
Classification:
• Le fort fracture I (horizontal): Fracture passes horizontally above teeth apices
• Le fort fracture II (pyramidal): Fracture of nasal bridge, through frontal processes of maxilla,
through lacrimal bone and inferior orbital floor, then through under the zygoma, across the
pterygomaxillary fissure, and through the pterygoid plates
...
Effectively separates the bones of face from the bones of cranium
...
The
amount of force impacted during a motor vehicle accident is much greater than Le Fort took
into consideration during his work in the late 19th century
...
History
• Site
• Onset, timing, evolution
• Character: mechanism of injury
• Associated symptoms:
! LOC (loss of consciousness) & confusion
! Bleeding
! Epistaxis
! N&V
! Neurological symptoms
• PMH
• DH and allergies
• FH
• SH
• Take a SAMPLE history in an acute scenario
Examination
• Vision -‐ VA
• Cranial nerves
• Dental occlusion
• Soft tissue swelling
• Bruising & haematoma
• Upper airway may be compromised
• Palpate: detect for bony irregularities, crepitus (e
...
due to SC emphysema), and sensory
disturbances
Investigations
• CT imaging of choice (imaging of choice in trauma)
• X-‐Ray of C-‐spine
Management
Surgery:
• Reduce fracture and fix
Orbit floor fractures (Blowout fracture)
• Second commonest midfacial fracture
• Can also result in impact injury to globe
• Occurs when external force is applied to the orbital cavity from an object whose diameter is
larger than that of the orbit (large enough not to penetrate globe)
• This results in the orbital contents being retropulsed and compressed
...
g upper cheek area
• Restriction of ocular movement in particular vertical eye movements => results in vertical
diplopia worse on vertical gaze
• Periorbital ecchymosis (also known as “racoon/panda eyes”) : severe black eye which is
sign of basal skull fracture,
• Oedema e
...
swollen lid
• Enopthalmos (posterior displacement of eyeball); in contrast to exopthalmos (proptosis) of
the eyes which is anterior displacement
...
Investigation
• CT Sinuses
• Tear drop sign: The floor of the orbit is the most common portion of the orbit to sustain
fracture
...
The
tear-‐drop represents the herniated orbital contents, periorbital fat and inferior rectus
muscle
...
DON’T NEED IMAGING
...
g
meningitis and abscess
! Penetrating neck injury => lots of important structures in the neck which can be
damaged
•
•
•
•
•
! Le Fort fractures
! Orbital injury
ATLS life support principles apply for management of trauma patient
Special considerations in injuries of head & neck
...
• Turbinates are composed of pseudostratified columnar, ciliated respiratory epithelium with
a thick, vascular, and erectile glandular tissue layer
• The sphenoid sinus drains its mucous into the sphenoethmoidal recess
• The frontal sinus, ethmoid air cells and maxillary sinus drain into the middle meatus
...
Stagnation of body fluids is a strong risk factor for infection
...
It sits on the vertical
bony plate known as the nasal septum, separating the nasal cavity into two bilateral and
symmetrical anatomical caves
...
g
...
g
...
g
...
e
...
g
...
Glandular fever is characterized by white membrane covering one or
both tonsils and hypersensitivity to ampicillin and amoxicillin (a diagnostic rash will occur)
DD:
• URTI viral infection
• Infectious mononucleosis (glandular fever)
• HIV
•
•
•
•
•
Peritonsilar abscess (quinsy) => surgical emergency => call ENT surgeon, SEPSIS 6, incision
and drainage, secure airway
Candida infection
Malignancy: lymphoma, leukemia, carcinoma
Diptheria (white throat)
Scarlet fever
Clinical features of tonsilits
Viral
• Malaise
• Sore throat (mild analgesia requirement)
• Fever
• Able to undertake near normal activity
• Possible lymphadenopathy (painless)
• Lasts 3-‐4 days
• Cough
Bacterial
• Systemic upset
• Fever
• Odynophagia (painful swallowing)
• Halitosis (unpleasant odour in breath)
• Unable to work / school
• Tonsillar exudate
• Painful lymphadenopathy
• Lasts approximately 1 week, and often requires antibiotics to settle
ALSO EXAMINE EARS FOR AOM AND RESP SYSTEM FOR ANY ASCENDING/DECSENDING INFECTION
...
Also examine the ears (for AOM – as this may alter
Mx) and examine respiratory system (for LRTI)
...
g
...
g
...
REMEMEBER TO TAKE A CONTACT HISTORY
Glandular Fever
• Also called Infectious mononeucleosis
• Caused by Ebstein-‐Barr virus (EBV)
Signs
• Gross tonsillar enlargement with white membranous exudate
• Marked cervical lymphadenopathy and generalised lymphadenopathy
• Palatal petechial haemorrhages
• Hepatosplenomegaly
• Flu like symptoms e
...
fever and fatigue
Diagnosis
• Atypical lymphocytes in peripheral blood
• Lymphocytosis (high LYM)
• Deranged LFT’S
• Heterophil AB tests:
! +ve Monospot
! +ve Paul-‐Bunnell test
•
! IgM => acute
...
Low CRP (<100) – viral infections tend not to cause a very high CRP
Management
• Symptomatic treatment e
...
paractaemol, NSAIDs, fluids, food and rest
• Advice about not doing certain sports or activities for a few months afterwards – due to
risk of splenic rupture
• Do NOT prescribe ampicillin or amoxicillin -‐ as can cause hypersensitive rash and allergic
reaction (a diagnostic generalised macular rash will result!)
• Antibiotics: Although antibiotics exert no antiviral action they may be indicated to treat
bacterial secondary infections of the throat, such as with Streptococcus (Strep throat)
...
g
...
g
...
• Non-‐neoplastic:
! Acute infective
! Chronic infective: tubercular tonsillitis, actinomycosis, and congenital syphilis
! Hypertrophy e
...
due to chronic infection
! Congenital: teratoma, hemangioma, lymphangioma, and cystic hygroma
...
• Otitis media with effusion (OME) and ear infections are connected in two ways:
! After most AOM ear infections have been treated, fluid (an effusion) remains in
the middle ear for a few days or weeks
...
Bacteria that are already inside the ear become trapped and
begin to grow
...
This is usually
due to swelling of the mucous membranes in the nasopharynx, which in turn can be caused by a viral
upper respiratory infection or by allergies
...
This happens when the pressure in this space,
known as the middle ear, is too low (-‐ve pressure) which occurs due to Eustachian tube
blockage
...
g
...
• A normal TM is translucent, which allows us to see some of the landmarks
...
Diagnosis of OME
• History
• Otoscopy => middle ear fluid (flud levels, loss of translucency), no signs of acute
inflammation, reduced TM mobility (due to fluid), TM retraction (due to –ve pressure), dull
grey TM
• Tuning fork tests => conductive hearing loss
• Audiometry
• Tympanometry
Investigations
• Age appropriate hearing assessment
• Audiometry
! PTA (pure tone audiometry): This is the same test as used on adults
...
Bone conduction can be tested if needed, to help diagnose a
conductive or mixed loss
...
Gold standard for assessing hearing loss
...
It provides a result of the
relationship of air pressure in the external ear canal to impedance of the tympanic
membrane and middle ear system
...
Treatment
• Watchful waiting
• Review at 3 months
! Otoscopy
! PTA (pure tone audiometry)
! Tympanometry
• Explanation
• If OME persistent for >3/12 months with symptoms (deafness/hearing loss, speech
problems or balance problems) => Refer
Referral
• Persistent (> 3 months) bilateral OME
• CHL (conductive hearing loss) >25dB
• Speech/language problems
• Developmental behavioral problems
Surgical management
• <3 years old => Grommets: A grommet is a very small tube that is inserted into the ear
through a small cut in their eardrum
...
Equilibrisation of pressure between external ear and middle
ear is important for air conduction
...
Then one can often see the tear in the drum, as well as the discharge in the outer ear
...
Summary
First lets get the terminology straight
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Middle
ear effusion is present in both otitis media with effusion (OME) and acute otitis media
(AOM)
• Otitis media with effusion: when fluid in the middle ear is not infected, the process is
referred to as otitis media with effusion (OME), which can also be called secretory, serous,
or nonsupparitive otitis media
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OME is by much more common that AOM
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A diagnosis of AOM requires
• Acute onset of signs and symptoms of middle ear inflammation and middle ear effusion
(MEE)
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g
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This happens when
the pressure in the middle ear is too low (-‐ve pressure) which often occurs In
OME due to Eustachian tube blockage
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Then one can often see the tear in the
drum, as well as the discharge in the outer ear
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OME versus AOM summary
Complications
• Complications of acute otitis media consists of perforation of the ear drum, infection of the
mastoid space behind the ear (mastoiditis), and more rarely intracranial complications can
occur, such as bacterial meningitis, brain abscess, or dural sinus thrombosis
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However, the evidence shows only a weak association between OME and delayed speech
and language development
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MICROBIOLOGY OF ENT INFECTIONS
• Infections of throat and pharynx
• Infections of middle ear (AOM)
• Infection of sinuses (sinusitis)
• Infection of outer ear (Otitis externa)
• Viral ENT infections
Sore throat
• Infections of throat and pharynx can cause sore throat
• Diagnosis: Take throat swab (often not required unless infection is serious, persistent or
patient is immunocompromised)
• VAST MAJORITY (OVER TWO THIRDS) ARE VIRAL (e
...
adenovirus) => DO NOT NEED
ANTIBIOTICS (use Centor criteria)
Bacterial sore throat
• The most common bacterial cause is Streptococcus pyogenes (also known as Group A
streptococcus GAS): a beta haemolytic (complete haemolysis) gram +ve Streptococcus
bacteria (blue gram stain with Strips/chains of cocci)
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• Clinical: Acute follicular tonsillitis (type of pharyngitis)
• Treatment: Calculate Centor score (tender anterior cervical lymphadenopathy, absence of
cough, fever, Tonsillar exudate) to help decide if likely to be bacterial or viral
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! Clarithromycin if penicillin allergy
! I
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g
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Believed to be caused by
antibody cross-‐reactivity that can involve the heart, joints, skin, and brain
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! Sydenham's chorea can occur to due basal ganglia involvement
Post Streptococcal Glomerulonephritis
! 1-‐3 weeks post sore throat
! Haematuria, albuminuria and oedema
! Nephritic syndrome
Diphtheria (white throat)
• Pathogen = Corynebacterium diphtheria
• Gram +ve aerobic bacilli
• Severe sore throat (pharyngitis) with a grey/white membrane across the pharynx
• The organism produces a potent exotoxin which is cardiotoxic and neurotoxic
• Can be fatal due to exotoxin effects
• Can also cause airway obstruction due to membrane obstruction
• Epidemiology : Rare, but increased in certain parts of the world e
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Russia
• Vaccine: the vaccine is made from a cell-‐free purified toxin extracted from a strain of C
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• Sinusitis can be due to infection, allergy, or autoimmune problems
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• It is a common condition
• If bacterial: similar range of organisms as in otitis media
! Streptococcus pneumonia (alpha/partial haemolytic)
! Streptococcus pyogenes (beta/complete haemolytic)
! Haemophilus influenza
Clinical features
• Headache
• Viral : mild discomfort/pain over frontal or maxillary sinuses due to congestion – pain often
worse on leaning forwards
Pain on palpation over sinuses
Secondary bacterial infection: severe pain and tenderness (behind sinuses) with purulent
nasal discharge
• Rhinorrhoea (runny nose) or blocked nose
• Fever
Treatment:
• Average length of illness is 2
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• Reserve antibiotics for severe/deteriorating cases of >10 days duration
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Particularly painful on manipulation of the auricle
(diagnostic criteria)
! There may be a discharge, or increased amounts of ear wax (cerumen)
! If the canal becomes blocked by swelling or secretions, hearing can be affected
(conductive hearing loss)
• Bacterial causes
! Pseudomonas aeruginosa (found in water)
! Staphylococcus aureus (inhabitant of skin flora)
! Proteus spp
• Fungal causes
! Aspergillus niger
! Candida albicans
• Management
! External otitis is often a self-‐limiting condition
! When external otitis is very mild, in its initial stages, simply refraining from
swimming or washing hair for a few days, and keeping all implements out of the
ear, usually results in resolution
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Some contain antibiotics (e
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amoxicillin), either antibacterial or antifungal, and others are simply designed to
mildly acidify the ear canal environment to discourage bacterial growth
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g
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Then treat depending on culture results
e
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topical clotrimazole (trade name canesten) for Aspergillus niger, along with
thorough aural toilet
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• Lethargy may last longer
•
•
•
•
•
•
Anaemia (auto-‐immune (AI) and treated with steroids)
Thrombocytopenia (AI, usually mild, may not require steroids)
Splenic rupture (rare)
Upper airway obstruction (occasionally needs steroids or even intubation)
Increased risk of lymphoma, especially in immunosuppressed
...
g
...
g
...
g
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• It is a painful infection that typically affects the fingers or thumbs
...
g
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Altered consciousness is the key characteristic of encephalitis
More advanced and serious symptoms include seizures or convulsions, tremors,
hallucinations, and memory problems
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g infants and young children)
• Diagnosis clinically or by PCR test of swab in viral transport medium
Hand, foot and mouth disease
• Also due to Coxsackie viruses (enteroviruses)
• Family outbreaks common
• Diagnosis clinically or by PCR test of swab in viral transport medium
• NB: In general, group A coxsackieviruses tend to infect the skin and mucous membranes,
causing herpangina, acute hemorrhagic conjunctivitis, and hand, foot, and mouth (HFM)
disease
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Coxsackie B infection of the heart can lead to
pericardial effusion
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g over the sinuses, ) – DON’T FORGET THIS
• Staxis – epistaxis (nose bleed)
Other secondary nasal symptoms:
• Sneezing
• Itch (pruritus)
• Crusting
• Nose bleed (epistaxis)
• Dry mouth (xerostomia)
• Sore throat
• Snoring
• Halitosis (bad breath)
• Loss of taste (ageusia)
Nose examination
• External appearance of the nose -‐ from the front, sides, top and bottom
! Scars
! Skin changes
! Asymmetry
• Use a thudichum speculum to look into the nose, or alternatively if not available use your
fingers/tweezers to hold up the nose and use an auroscope to inspect:
! The nasal vestibule
! The septum -‐ are there any polyps? Is there any deviation?
! The inferior tubinate on the lateral wall -‐ if pale and boggy, think of allergic
rhinitis
• Airway patency and nasal airflow: using a silver tongue depressor under the nose, look for
steaming up of the metal when the patient breathes out of the nose
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• The inflammation results in the generation of large amounts of mucus, commonly producing
a runny nose (rhinorrhoea), as well as a stuffy nose and post-‐nasal drip
...
g
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• The allergens may also affect the eyes, causing watery (epiphoria), reddened (forniceal
injection) or itchy eyes and puffiness around the eyes (allergic conjunctivitis)
• Allergic rhinitis occurs when an allergen such as pollen or dust is inhaled by an individual
with a sensitized immune system, triggering antibody (IgE) production
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When the mast cells are stimulated by
allergens => histamine (and other chemicals such as leukotriennes) are released
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Eosinophils also play a role in the inflammation
process
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Very sensitive individuals can experience
hives or other rashes
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g
...
g
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• Non-‐allergic rhinitis can be classified as either non-‐inflammatory or inflammatory rhinitis
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• The pathology of vasomotor rhinitis appears to involve neurogenic inflammation however it
is not yet very well understood
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They may be yellowish, grey
or pink in colour
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Nasal polyps can vary
greatly in size
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• Clinical features
! The most common symptoms they cause are a stuffy, runny nose
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! In most cases the cause is not known
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Due to gravity, this swelling hangs down (dependent oedema), forming the polyp
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! Polyps can also grow in the sinuses
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! Sometimes polyps block the drainage channel of the sinuses into the nose
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! Large polyps sometimes interfere with breathing at night and cause obstructive
sleep apnoea
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• Complications include sinusitis
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Common symptoms of rhinitis are a stuffy nose, runny nose, and post-‐nasal
drip
• Acute rhinosinusitis (also known as acute sinusitis) causes the cavities around your nasal
passages (sinuses) to become inflamed and swollen
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Much more serious than rhinitis and can go on to cause life threatening
complications
• Acute sinusitis is most often caused by the common cold (viral URTI)
• Other triggers include allergies, bacterial and fungal infections
...
g influenza viruses, rhionvirsues, human parainfluenza viruses, and human
respiratory syncytial virus
• If the infection is of bacterial origin, the most common causative agents are Streptococcus
pneumonia and Haemophilus influenza
Acute episodes of sinusitis can also result from fungal invasion
Clinical features of rhinosinusitis
• Facial pain over the sinuses (often worse on leaning forwards)
• Referred pain e
...
to earache, toothache, or headache
• Discharge
• Nasal blockage
• Runny nose (rhinorrohea)
Management of sinusitis
• Analgesics (paracaetamol +/-‐ NSAIDs)
• Decongestants (e
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pseudoephedrine => vasoconstricts => decrease mucous)
• If persisting (>10 days) / worsening then add an antibiotic (e
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Pencillin)
Complications (not common)
• Adenoiditis and laryngitis in children
• Orbital complications: orbital cellulitis and orbital abscess (medical emergencies)
• Intracranial complications: meningitis or abscess formation (medical emergencies)
• Osteomyelitis (medical emergency)
• Cavernous sinus thrombosis (medical emergency): can cause dysfunction of CN III, IV and VI
• Psychological problems associated with chronic pain and ill health
• Can evolve into chronic sinusitis (a sinus infection that lasts longer than 12 weeks is known
as chronic sinusitis)
•
Summary
Investigations
• Allergy testing for suspected allergic rhnitis: Skin prick testing: Offers fast results to assess
for type 1 HS (IgE mediated) allergies
• RAST can also be used for Ix type 1 allergies
• Identifying allergens is crucial for allergen avoidance
Management
Allergic rhinitis
Non-‐pharmaceutical
• Allergen/irritant avoidance
• House dust mite (HDM) limitation
• Change drug therapy
• Decrease alcohol intake
Pharmaceutical
• Stage 1: Antihistamine e
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cetirizine
• Stage 2: Topical nasal steroid e
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beclomethasone
• Stage 3: Antihistamine + topical steroid
• Adjuvant: Topical anticholinergic e
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ipratropium (decreases mucus secretion)
Nasal polyps
• Step 1 = topical steroid
• Step 2 = oral steroids
• Surgery if persistent
Infective rhinosinusitis
• Nasal decongestant (cause vasoconstriction in nose arterioles) e
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pseudoephedrine or
xylometazoline (otrivine)
• Analgesia e
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paracetamol +/-‐ NSAIDS
• Anti-‐pyretic: paracetamol
• Broad spectrum antibiotic? Only if severe or persistent (e
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> 10 days) => peniciilin
Nasal trauma
Nasal septal haematoma
• Nasal septal hematoma is a condition affecting the avascular nasal septum
• It can be associated with trauma
• Can cause “stuffy nose” e
...
nasal congestion
• Because the septal cartilage has no blood supply of its own and receives all of its nutrients
and oxygen from the perichondrium, an untreated septal hematoma may lead to destruction
of the septum (due to necrosis)
• Failure to recognise septal hematomas, or treat in a timely fashion, can cause a saddle nose
deformity (can also occur in Wegeners and syphilis)
• Immediate drainage is necessary
• Small hematomas can be aspirated with a wide-‐bore needle
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• Systemic antibiotics are given after the incision and drainage to prevent local infection
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g
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• Plain radiographs (single X-‐ray film): These are used in cases of suspected inhaled or
ingested radio-‐opaque foreign bodies e
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fishbones, coins etc
Barium Studies
• These usually involve the patient drinking a suspension of barium sulphate
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The scanner
produces a burst of radio signal (RF pulse), which energises the body’s protons
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The scanner listens for a return signal, produced by the protons
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The scanner
creates an image using the returned signal
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Fine needle aspiration
(FNA) biopsies are relatively atraumatic and can be undertaken at the time of the ultrasound
appointment
• FNAs are often performed in cases of: suspected lymph node malignancy, assesment of
masses in salivary glands and evaluation of thyroid lumps
• Can be misleading to evaluate lymph nodes on morphology (size and shape) alone
• If there is uncertainty, an US guided FNA can be performed
Thyroid masses
• Most are benign with hyperplastic nodules accounting for about 80% of thyroid lumps
• If in doubt perform an FNA
• Perform TFTs
• In cases of suspected malignancy it is important to assess the local lymph nodes e
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supraclavicular and cervical
• Remember that the anatomical location of the thyroid is at the bottom of the neck!
Imaging of deafness
•
As a rule of thumb
! MRI used in the imaging investigation of sensorineural deafness e
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due to
suspected vestibular schwannoma
! CT used in the investigation of conductive deafness e
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due to suspected
cholesteatoma
AIRWAY OBSTRUCTION
• Airway obstruction is a blockage of respiration in the airway
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However, some
specify that the glottis (vocal cords) is the defining line between the upper and lower
respiratory tracts; yet others make the line at the cricoid cartilage
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As such,
it has to be able to withstand suction pressures generated by the rhythmic contraction of
the diaphragm that sucks air into the lungs
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In
addition to rhythmic innervation from the respiratory center in the medulla oblongata, the
motor-‐neurons controlling the muscles also receive tonic innervation that sets a baseline
level of stiffness and size
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The vocal cords within the larynx form the boundary between
the upper and lower airways
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The vocal cords within the larynx form the boundary between the upper and lower
airways
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g
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• Stridor is a special type of wheeze
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• Stridor in the inspiratory phase is usually heard with obstruction in the upper airways, such
as the trachea, epiglottis, or larynx; because a block here means that no air may reach either
lung, this condition is a medical emergency
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• Stridor is usually heard on inspiration
• In contrast, a wheeze is a continuous, coarse, whistling sound produced in the respiratory
airways during breathing, often on expiration (as seen in obstructive lung disease)
...
Wheezing is commonly
experienced by persons with a lung disease; the most common cause of recurrent wheezing
is asthma attacks, though it can also be a symptom of lung cancer
...
If you narrow any part of airway => flow will break =>
increased resistance => decreased airflow
• Poiseuille's Law states that the resistance exerted by a tube is proportional to 1/r4
• Therefore if we ½ the diameter of the airway => we get a 16 times increase in resistance =>
16 times decrease in airflow (but an increase in velocity, remember)
• Bernoulli principle: when air flows through a tube, the pressure on the lateral wall drops
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g
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Therefore in laryngomalacia, inspiration can result in collapse of airways
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Some infants have feeding
difficulties related to this problem
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The vast majority, however, will only have stridor without other more
serious symptoms such as dyspnea (difficulty breathing)
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Infants may also have gastro-‐oesophageal reflux but they
are otherwise generally well, happy babies
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The abnormal sounds may best be heard just
above the sternal notch
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For example, one way to determine whether a person is sleeping is to listen to their
breathing -‐ once the person falls asleep, their breathing becomes noticeably louder
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This problem is
exacerbated in overweight people (increased BMI) when sleeping on the back, as extra fat
tissue may weigh down on the airway, closing it
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In some cases the sound may be soft, but in
other cases, it can be loud and unpleasant
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Increasing age also results in decreased toncitiy of muscles => increased incidence of snoring
with increase age
Snoring is a low pitched sound called stertor
This process can also lead to obstructive sleep apnoea
Major factors involved in snoring in adults
! Increased BMI
! Increased age
! Anatomical predisposition
! Relaxants such as alcohol or other drugs relaxing throat muscles
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Causes of upper airway obstruction: MANY CAUSES
• Adenotonsillar hypertrophy
• Allergic reactions in which the trachea or throat swell closed, including allergic reactions to a
bee sting, peanuts, antibiotics (in particular penicillin), and ACE inhibitors (angioneurotic
oedema) e
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anaphylaxis
• Burns (thermal) from breathing in smoke
• Cancers causing obstruction e
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pharynx, larynx, lungs, thyroid
• Congenital airway disorder e
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subglottic stenosis
• Chemical burns and reactions
• Croup (laryngotracheobronchitis): respiratory condition that is usually triggered by an acute
viral infection (often parainfluezae virus; respiratory syntactical virus is commonest cause
of bronchiolotits! Don’t get these mixed up) of the upper airway
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Give nebulised steroids and look
after airway
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Decrease consciousness (GCS < 8)
Epiglottitis (infection of the epiglottis) is not common now (due to HIB vaccination)
...
Foreign body aspiration (such as peanuts and other breathed-‐in foods, pieces of a balloon,
buttons, coins, and small toys)
Laryngomalacia
Laryngotracheal trauma (penetrating or blunt)
Neurological causes
Paralysis of the vocal cord or vocal fold: many causes including neoplasm,
neurodegenerative, neuromuscular or idiopathic pathology
Peritonsillar abscess (quinsy)
Pertussis (whooping cough)
Retropharyngeal abscess
Throat cancer
Tracheomalacia: condition characterized by flaccidity of the tracheal support cartilage which
leads to tracheal collapse especially when increased airflow is demanded
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g
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The condition typically lasts less than 60 seconds, and causes a
partial blocking of breathing in, while breathing out remains easier
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g
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Commonly
caused by GORD
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Some people
suffer from frequent laryngospasms, whether awake or asleep
...
Symptoms include:
• Agitation or fidgeting
• Coughing
• Choking
• Confusion
• Difficulty breathing
• Speech difficulties e
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unable to finish sentence
• Gasping for air
• Panic
• SOB
• Stridor
• Wheezing (more typical of lower airway obstruction)
Signs
• Decreased breath sounds in the lungs
• Rapid, shallow, or slowed breathing
• Stridor
• Changes in consciousness
• Cyanosis (end stage)
• Dysphagia (usually only occurs in laryngeal or oropharyngeal cancer)
• Tight neck muscles
• Sternal and intercostals recession
• Use of accessory respiratory muscles
Investigations
• Laryngoscopy
• Bronchoscopy
• X-‐rays
Treatment
• ABCDE
• Treatment depends on the cause and severity of the blockage
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• A tube may be inserted into the airway (endotracheal tube or nasotracheal tube)
...
• Sometimes an opening is made directly into the airway (tracheostomy or cricothyrotomy)
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The following methods may help
prevent a foreign body obstruction:
• Eat slowly and chew food completely
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• Keep small objects away from young children
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g
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• LRTI e
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pneumonia, bronchitis and bronchiolitis,
• Aspiration of foreign material: more often blocks the lumen of the right main bronchus as it
is slightly wider and more vertical
Management
• ABCDE
• Lower airway obstruction can be measured using spirometry
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g
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g
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g
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(Strep
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Understand the difference between otitis media and otitis externa and know which
organisms cause each of these
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Case 1
A mother brings her six-‐month-‐old baby to your GP surgery first thing one morning because the baby
has been awake since 2 a
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screaming with pain and refusing to sleep
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The baby had finally fallen asleep at 7 a
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,
exhausted, and when his mum picked him up to come to the surgery, she noticed some green
discharge on the pillow that appeared to have come from his right ear
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You take swabs from the ear canal for bacterial culture
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The film provided shows the Gram film appearance of this
organism
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pneumonia – alpha haemolytic
What condition is the baby suffering from?
Acute otitis media (suggestive by fever and cold)
What treatment would you recommend for his condition?
Can delay prescribing if >2 or not severe, most resolve within 4 days – 80% if viral
Ensure adequate analgesia
1st line is amoxillin, 40 mg/kg/day for 5 days – better absorbed systemically – can give a
paediatric suspension
Local isolates of this organism are usually sensitive to penicillin
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Case 2
A 19-‐year-‐old female medical student attends your GP surgery with a very sore throat which she has
had for the last 3 days
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She has cervical lymphadenopathy
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You take a
throat swab for bacterial culture and a full blood count to check her haemoglobin
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The
photograph shows a picture of her blood film, which shows large atypical lymphocytes
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He is otherwise well
...
The tympanic membrane
is intact and looks healthy
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The film provided shows a microscopic preparation of this
organism stained with lactophenol cotton blue
...
What condition does the patient have?
Otitis externa
Fungal infection – Aspergillus niger, grey/black patches of wax seen on examination
How has he acquired this infection?
Wet ears – spores land and grow
What treatment would you recommend?
Topical aural toilet to clean ear
Clotrimazole (Canesten)
Does this fungus ever become invasive in this type of patient?
Not in this type of patient, but can become invasive in elderly patients with diabetes
Name two other organisms that commonly cause otitis externa
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On examination, the throat is very red and inflamed with pus on the tonsils
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Her temperature is 38
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You take a throat swab for
bacterial culture and receive the report shown
...
What condition does the patient have?
Sore throat with red/inflamed pus on tonsils and fever – acute tonsillitis
Causal organism: S
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Use Centror criteria
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Penicllin V 1 g bd for 10 days, If severe give IV benzylpenicllin 1
...
On examination, the conjunctivae are
inflamed
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You take an eye swab and
send it for bacterial culture
...
What clinical condition does the baby have?
Conjunctivits
How has the baby acquired this infection?
Rubbing eyes
Name two organisms that cause this infection?
HIB: gram –ve cocci/bacilli that grows on chocolate (blood) agar plates
S aureus, N gonorrhoeae, Chlamydia (in neonate)
Other ages: S aureus, S pneumoniae
What treatment would you recommend?
Topical antibiotics: chloramphenicol qds
Name one rare but possible complication of giving this antibiotic (when given systemically)
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There is no history of any
injury but he is pyrexial at 38ºC
...
What is your working diagnosis?
Orbital cellultis – serious infection that is a MEDICAL EMERGENCY
Presents with fever, swollen eye and restricted movement
Proptosis (exophthalmos) – forward displacement of eye can occur
SIGHT THREATENING infection
What microbiological and non-‐microbiological investigations would you order and why?
CT scan to identify orbital abscesses
Try to get a swab of pus to culture
Which specialists would you ask for help?
Ophthalmology and microbiology
What treatment would you start?
Requires emergency drainage
Organisms: HIB, Staph, Strep, anaerobes
Antibiotics: Cefuroxime/Ceftriaxone IV + high dose Flucloxacillin + metronidazole
What complications may occur?
Loss of sight, abscess
Cavernous sinus thrombosis
Must know ENT conditions
• Rhinitis (both allergic and non-‐allergic types)
• Nasal trauma – exclude septal haematoma, DON’T image for fractures
• Acute and Chronic Sinusitis
• Presbycusis (age related SN hearing loss): cumulative effect of aging on hearing
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g
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HIGH FREQUENCY LOSS
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•
•
•
•
•
•
•
•
•
•
•
Vestibular schwannoma (acoustic neuroma): benign (non cancerous) primary intracranial
tumor of the myelin-‐forming cells of the vestibulocochlear nerve (8th cranial nerve)
...
Vestibular neuronitis: prolonged labyrnthitis (days – weeks), no SNHL, no tinnitus
Labyrinthitis: prolonged labyrnthitis (days – weeks), may have SNHL and tinnitus
Benign Positional Paroxysmal Vertigo: short attacks of vertigo (mins), no other symptoms,
may have nystagmus, Dx with Dix Hallpike, Tx with Epley manouvre
Ménière’s Disease: hour attackes of vertigo, aural fullness, SNHL, tinnitus
Laryngeal and Pharyngeal Cancer
Globus Pharyngeus: also known as globus sensation and commonly referred to as having a
"lump in one's throat" is the persistent sensation of having phlegm, a pill or some other sort
of obstruction in the throat when there is none
...
The "lump in the throat"
sensation that characterizes globus pharyngis is often caused by inflammation of one or
more parts of the throat, such as the larynx or hypopharynx, due to Cricopharyngeal Spasm,
gastrooesophageal reflux (GORD), Laryngopharyngeal reflux or esophageal dysmotility
...
e
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Other causes include oesophageal motility disorders
or hypertrophy of the base of the tongue
Vocal Nodules
Laryngeal Papillomatosis: Laryngeal papillomatosis is caused by HPV types 6 and 11, in which
benign tumors form on the larynx or other areas of the respiratory tract
...
Causes a progressive
hoarseness, or a strained or breathy voice
...
In babies and small children the symptoms include a weak
cry, trouble swallowing, noisy breathing, and chronic cough
...
It can also be seen in older patients,
especially those with neuromuscular conditions resulting in weakness of the muscles of the
throat
...
Snoring and Obstructive Sleep Apnoea (Adults and Paediatrics)
! In children adenotonsillar hypertrophy is major cause of snoring
! In adults increased BMI, increasing age and anatomical predisposition is the
major risk factors for snoring, sedative drugs and alcohol, muscle relaxants
Title: ENT lecture Notes
Description: A comprehensive and detailed set of notes covering all aspects of ENT medicine. Diagrams included to aid learning. Useful for medical students.
Description: A comprehensive and detailed set of notes covering all aspects of ENT medicine. Diagrams included to aid learning. Useful for medical students.