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ENT & Maxillofacial Surgery Esika Peter University of Dundee Year 3Thanks to our partners!Learning Outcomes: • Outline the gross anatomy of the outer, inner and middle ear, with appreciation of the tympanic membrane • Understand the use of surgical management in patients with pathologies relating to the ear; includingbut not limited to: otitis media with effusion, auricular hematoma - “cauliflower ear”, tympanic membrane perforation • Recall the bony anatomy, function and divisions of the nasal cavity • Describe the different paranasal sinus’ as well as their importance in transsphenoidal surgery • Appreciate the anatomy and surgical relevance of Kiesselbach's plexus in managing epistaxis • Understand the mechanism of septal hematoma, as well as the surgical management and complications • Describe the anatomy and neurovascular supply of the major salivary glands in the face. • Understand the anatomy of the parotid gland, paying attention to the important anatomical relations - especially the facial nerve (CN 7) • Apply anatomical knowledge to the setting of ENT surgery; parotidectomy, salivary gland tumour resections (particularly pleomorphic adenoma)Learning Outcomes: • Outline the gross anatomy of the outer, inner and middle ear, with appreciation of the tympanic membrane • Understand the use of surgical management in patients with pathologies relating to the ear; includingbut not limited to: otitis media with effusion, auricular hematoma - “cauliflower ear”, tympanic membrane perforation • Recall the bony anatomy, function and divisions of the nasal cavity • Describe the different paranasal sinus’ as well as their importance in transsphenoidal surgery • Appreciate the anatomy and surgical relevance of Kiesselbach's plexus in managing epistaxis • Understand the mechanism of septal hematoma, as well as the surgical management and complications • Describe the anatomy and neurovascular supply of the major salivary glands in the face. • Understand the anatomy of the parotid gland, paying attention to the important anatomical relations - especially the facial nerve (CN 7) • Apply anatomical knowledge to the setting of ENT surgery; parotidectomy, salivary gland tumour resections (particularly pleomorphic adenoma)Anatomy of the Ear:Anatomy of the Tympanic Membrane : What is used to orientate if it is tympanic membrane of the right ear or left ear? • Cone of Light • Right ear – 5 o’clock • Left ear 7 o’clockOtitis Media with Effusion (aka Glue Ear): • Condition where fluid accumulates in the middle ear • More common in kids due to the anatomy of the Eustachian tube → peaks at 2 years of age • Kids have large adenoids blocking the Eustachian tube • It is the most common cause of hearing loss in kids and can predispose them to develop Acute Otitis Media • Risk Factors: • Male sex • Siblings with glue ear • Higher incidence in Winter and Spring → could be due to recurrent URTI • Bottle feeding in supine position • Day care attendance • Parental smoking • Craniofacial abnormalities → e.g. cleft palateOtitis Media with Effusion (aka Glue Ear): • Symptoms • Conductive hearing loss • This can lead to poor school performance, behavioural problems and speech delay • Ear-tugging in kids • Recurrent Acute Otitis Media Red Flags: • Signs • Unilateral glue ear • Weight loss, fever, night • Middle ear effusion → rarely may see bubbles behind the ear • Altered TM colour → dull sweats • Neck lumps • TM retraction • Unilateral epistaxis • Loss of light reflex • Unilateral nasal obstruction • Investigations • Otoscopy • Rinne + Weber → Bone conduction > Air conduction, Lateralises to the affected ear • Audiometry → Mild conductive hearing loss (20-40dB) • Tympanometry → Flat tracingOtitis Media with Effusion (aka Glue Ear): • Management • Watchful waiting for 3 months (as most cases resolve on their own) • During this period, it is essential to monitor the patient's symptoms and provide regular follow-up appointments to assess changes in hearing status • Monitoring should include two hearing tests using pure tone audiometry at least 3 months apart as well as tympanometry • Autoinflation/valsava manoeuvre • If resolution is not achieved within 3 months: • Non–surgical • Softband BAHA (bone anchored hearing aid) • Surgical • Myringotomy and grommet insertion → Grommets will fall out spontaneously within 6-12 months • NICE recommends > 3 months of bilateral OME and hearing level in better ear < 25-30dBHL • T-tubes • Adjuvant adenoidectomy is recommended for children > 4 years of agePerforated Tympanic Membrane • Causes • Infection → complication of OME • Iatrogenic • Barotrauma • Direct trauma • Signs and symptoms • Incidental • Otalgia • Otorrhoea • Conductive Hearing loss • Recurrent Otitis Media • Management • Small perforations tend to resolve spontaneously (90% of perforations heal within 6 weeks) • Advisable to avoid getting water into the ear during this time • Conservative: • Maintains strict water precautions. Consider hearing aids. • Surgical • If they have >3 infections per year, consider myringoplasty (repair of the ear drum). • The main aim of myringoplasty is to ensure the middle ear can be kept dryPinna Haematoma • Common injury caused by shearing forces applied to the auricle by trauma/direct blow to the external ear, mostly commonly seen in e.g. rugby players/ boxers • Trauma —> Shearing Forces —> Necrosis —> Fibrosis • Blood supply to the underlying cartilage can become impaired • If pinna haematomas are left untreated, due to the disrupted blood • Management supply, avascular necrosis of the pinna can occur • Need same day assessment by ENT • Incision and drainage of the • Subsequent fibrocartilage overgrowth can lead to a structural deformity - haematoma should be performed <24 ‘cauliflower ear’ hours to prevent cauliflower ears • Steps: • Investigations • LA —> Incision —> Evacuate • Usually clinical diagnosis → inspection / palpation of the ear haematoma —> Mattress sutures. • Otoscopy • Needle aspiration may be appropriate • Important to rule out TemporalBone Fracture for small haematomas • Hearing loss • Facial nerve injury/palsy • Battles sign (post auricular bleeding)Anatomy of the Nasal Cavity Functions of the nasal cavity • Warms and humidifies the inspired air • Removes and traps pathogens and particulate matter from the inspired air • Responsible for nose of smell • Drains and clears the paranasal sinuses and lacrimal ducts The paranasal sinuses are clinically relevant in transsphenoidal surgery (aka endoscopic trans- sphenoidal surgery (ETSS)) • The sphenoid bone shares a close anatomical relationship with the pituitary gland which sits in the sella turcica in the sphenoid bone. • The pituitary can be accessed surgically by passing instruments through the sphenoid bone and sinusAnatomy of the Kiesselbach’s Plexus (aka Little’s Area)Epistaxis • Causes • Trauma - Nose picking, nose blowing • Insertion of foreign objects • Fractures • Hypertension • Cocaine use • Bleeding disorders • Types • Anterior bleed • Posterior bleed Epistaxis • Management → always done in a stepwise approach • First aid measures • Pinching the fleshy anterior part of the nose, leaning forward, spitting out into a bowl, ice pack compression • On arrival to secondary care • Resuscitation if necessary → ABCDE approach • Arrest/slow flow (e.g. ice, topical vasoconstrictor) • Anterior rhinoscopy/nasal endoscopy to investigate source of bleeding • Direct therapy • Silver nitrate cautery if there is an identifiable anterior bleeding point • Indirect therapy • This includes nasal packs (e.g. rapid rhino) or Foley catheters to compress difficult to identify bleeding points (likely posterior) or heavy bleeding points • Surgery → if all other measures fail • Sphenopalatine artery ligation (endoscopic)Nasal septal haematoma • Important complication of nasal trauma that should always be looked for and ruled out • If it is left untreated irreversible septal necrosis due to decreased blood supply to septal cartilage may occur within 3-4 days which can in turn result in a saddle nose deformity • It is the development of a haematoma between the septal cartilage and the overlying perichondrium • It is often associated with trauma → A+E should rule out head trauma • Symptoms • Sensation of nasal obstruction • Pain • Signs • Bilateral red swellings arising from the nasal septum • While commonly it is bilateral it can also present unilaterally • Differentiated from deviated nasal septum by gentle probing • Septal haematomas → boggy feeling • Deviated septum → firm feeling • Management • Urgent surgical incision and drainage <24 hours • IV antibiotics (amoxicillin) • Splints / quilting suturesThe salivary glands Parotid gland • It is located superficial to the mandibular ramus • Blood supply: Posterior auricular and superficial temporal arteries • Venous drainage: retromandibular vein • Innervation: • Sensory: auriculotemporal nerve • Sympathetic: Superior cervical ganglion • Parasympathetic: CN IX -> otic ganglion -> auriculotemporal nerve (branch of CNV3) • Secretions transported to oral cavity via Stensens duct and opens into oral cavity at second upper molar • Has important anatomical relations that pass through the gland • Facial nerve (CN VII) • Gives rise to five terminal branches within the parotid (To Tanzibar By Motor Car) • Temporal • Zygomatic • Buccal • Mandibular • Cervical • These branches innervate the muscles of facial expression • External carotid artery • Retromandibular arteryThe salivary glands Sublingual gland • Smallest and the most deeply situated • It is located medially on the floor of the oral cavity underneath the tongue • Blood supply: Sublingual and submental arteries • Venous drainage: Sublingual and submental veins • Innervation: • Parasympathetic via chorda tympani (branch of CN VII) • Sympathetic: Superior cervical ganglion • Secretions transported to oral cavity via minor sublingual ducts (of Rivinus) which open out onto the sublingualfolds. Submandibular glands • It is located below and behind the ramus of the mandible • Blood supply: Submental and sublingual artery • Venous drainage: Facial and sublingual vein • Innervation: • Parasympathetic via chorda tympani (branch of CN VII) • Sympathetic: Superior cervical ganglion • Secretions transported to the oral cavity from small ducts (Rivinus’ ducts) to Bartholin’s duct to submandibular duct (Wharton’s duct) to sublingual papillae Salivary gland tumours • They are uncommon • Parotid tumours are the most common type, they tend to be benign • Pleomorphic adeoma are the most common type of bening tumours but they can transform to become malignant • Tumours of the submandibular and sublingual glands tend to be malignant • Clinical Features • ais the affected gland • Facial nerve palsy → associated with malignant parotid tumours • Investigations • US-FNA • Imaging → for staging • CT – local relations • MRI – deep lobe of parotid, relations with CN VII • Management • Surgical resection with superficial or total parotidectomy resection +/- cervical lymph node clearance +/- adjuvant radiotherapy • Usually in their early stages it is not possible to distinguish a benign tumour from a malignant one • There is a risk of malignant transformation of adenoma if left alone • Facial nerve, retromandibular vein and external carotid artery are at risk during a parotidectomy@supta_uk @SUPTAUK www.supta.uk