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MEDED FINALS LECTURE SERIES: ENT Dr Mahjabin K Chowdhury CONTENTS Otitis media, otitis externa, hearing loss, BPPV, 01 - EARS cholesteatoma, pinna haematoma, mastoiditis, vertigo conditions Epistaxis, sinusitis/periorbital cellulitis, foreign 02 - NOSE body, septam haematoma, polyp/mass, Tonsillitis/sore throat, quinsy, tonsillectomy, 03 - THROAT epiglottitis, head/neck cancers 04 - MISC Weber + Rinnes, audiology, tracheostomies + laryngectomies,EARS / OTOLOGYOtitis Media +/- effusion Infection of the middle ear Usually caused by strep pneumonia, haemophilus influenzae Sx: Pain Fever Flu prodome Change in hearing Pressure, popping sounds, loss of hearing, long hx => ?effusion RED FLAGS: glue ear in adult => ?Ca in post nasal spaceOtitis Media +/- effusion Ix: Bedside - obs, examination, otoscopy Can be febrile, children can be systemically unwell External ear should LOOK normal TM - bulging, erythematous, opaque/loss of cone of light If effusion => dull behind TM, fluid level, bubbles Bloods - FBC, U+E, CRPOtitis Media +/- effusion Acute otitis media OM with effusionOtitis Media +/- effusion Mx: Conservative: pain relief!! MediUsually co-amoxiclav PO 5-7d (clari if pen allergic)in <2yo, sx non resolving, TM perf Surgical: grommet insertion for glue earMastoiditis Infection of the mastoid air spaces of the temporal bone. Can be a complication of OM (usually in children). Sx: Boggy erythematous mastoid Pinna of ear pushed forward/outward Septic Ix + Mx to consider (senior led): Blood cultures, CT head/temporal bones, LP for meningitis NBM, if not improving => surgeryMastoiditisOtitis Externa Infection of external auditory canal (EAC). Commonly caused by pseudomonas. RFs: DIABETES, swimming/water sports, eczema/psoriasis, foreign body Sx: Discharge in ear canal, stenosed EAC Ix + Mx Examination + otoscopy Swabs, microsuctioning, Popewick insertion (if canal stenosed) Keep ear dry (Vaseline on cotton wool) Ciprofloxacin drops +/- dexamethasone (Cetraxal/cetraxal+)Otitis Externa RED FLAGS (admission, PO/IV abx considered): cranial nerve palsies (usually VII) pinna cellulitis complete EAC stenosis non-resolving OE despite tx Low threshold for concern if: immunocompromised, diabetic, >65yo => more likely to develop NECROTISING OE (osteomyelitis of temporal bone) Ix + Mx to consider (senior led): CT head/temporal bones, IV abx, prolonged abx course?Otomycosis Aka fungal OE (candida, aspergillus). Often due to prolonged ABX use. Sx: Similar to OE but exudate is more cottage cheese like, often with spores/black heads visible Previous/multiple recent OE episodes Mx: Clotrimazole drops (continue tx for 2 weeks post resolvement)Pinna haematoma Bleeding between perichondrium and cartilage. Risk of avascular necrosis to pinna Mx: Analgesia ABX if contaminated Aspirate/drain => refractory cases ?washout under GA Different ways to close (dental rolls, silastic splints, stitches)Cholesteotoma Keratinising squamous cell epithelium growth in middle ear Non cancerous but can invade local structures and/or cause ix Associated with cleft palate. Sx: Foul smelling discharge Unilateral CONDUCTIVE hearing loss Ix: otoscopy shows mass superiorly (attic) of ear canal near TM Mx: surgical removalCholesteotoma Pathophysiology: Cells originate from out TM surface Theory that -ve preassure from austacian tube dysfunction causes TM retraction. Proliferation of cells occurs in this pocket and damages surrounding tissues. Sx related to local invasion: Vertigo CN palsy Hearing loss from ossicle damageSudden hearing loss Unilateral and SENSORINEURAL Rule out hx of head trauma, recent ear surgery, otalgia, nystagmus, infectious symptoms Mx: Reducing dose of prednisolone (60mg 5d, reducing by 10mg daily henceforth) Audiology assessment (acutely and in 1-3 weeks post steroid) Intratympanic steroid injection if not improvement on audiogramBPPV One of the most common causes of vertigo - sensation of surroundings spinning whilst stationary Sx: Triggered by changes to head position 20-30s duration POSITIVE Dix-Hallpike manoeuvre Mx: Epley maneouvre (can require 2-3 attempts, successful in most cases) Vestibular rehabilitation exercises Vestibular neuronitis Inflammation of the NERVE often post Vertigo disorders viral ix Recurrent bouts of vertigo lasting hours +/- nystagmus Ix: HiNTS exam to differentiate from Meniere’s disease cause)ior circulatory stroke (Central Long term ear disorder due to Mx: vestibular exrcises, antihistamines build up of endolymph in labyrinth for mild relief, prochlorperazine (IM, buccal) if servere Sx: vertigo, hearing loss, fuFEBess in ear sensation Ix: audiology assessments serially Labarynthitis antihistamines, andort term Inflammation of the NERVE + prochlorperazine can be used VESTIBULAR organs => vertigo + hearing loss Can also have nystagmus LONG TERM Ix: W+R (sensorineural), HiNTS Mx: as above SHORT TERMAcoustic neuroma/ Vestibular schwannoma Benign tumour of schwann cells surrounding vestibularcochlear nerve. Hence sensorineural hearing loss + vertigo + fullness of ear Presents similar to Meniere’s but a slow growing tumour so managed as OP. Brain MRI confirms tumour. Mx: conservative or surgicalQUESTIONSQ1Q1 2021 WRITTEN PAPER 1 40F attends ENT OP clinic with a series of vertigo episodes spanning 3 years. Each episode is preceded by a feeling of fullness in her L ear. The attacks last for several hours and leave her with L sided tinnitus and deafness. She sometimes vomits during the attacks. An audiogram shows left sided sensorineural hearing loss. What is the likely diagnosis? a. BPPV b. Chronic labarynthitis c. Meniere’s disease d. Vestibulobasilar insufficiency e. Vestibular neuronitis Q2 2021 WRITTEN PAPER 1 40F attends ENT OP clinic with a series of vertigo episodes spanning 3 years. Each episode is preceded by a feeling of fullness in her L ear. The attacks last for several hours and leave her with L sided tinnitus and deafness. She sometimes vomits during the attacks. An audiogram shows left sided sensorineural hearing loss. What is the likely diagnosis? a. BPPV b. Chronic labarynthitis c. Meniere’s disease d. Vestibulobasilar insufficiency e. Vestibular neuronitis Q2Q3Q3NOSE / RHINOLOGYEpistaxis Aka ‘Little’s Area’Epistaxis: mx If first aid fails and bleeding point VISIBLE Numb with ‘blue spray’ (co-phenylcaine) If cBleeding into oropharynx still occurringng Silver nitrate stick to cauterise Naseptin cream (chlorhexadine + neomycin) POSTERIOR CAUTERY PACKING FIRST AID ANTERIOR PACKING ARTERY LIGRATION Pinch soft portion of nose for Bleeding after 24-48h pack insertion 20m continuously If first aid fails and bleeding point NOT VISIBLE SphenopalatSenior led decision most cases Suck on ice/ice pack locally Insert Rapid Rhino into nostril Spit out any blood in mouth Low threshhold for concern if known clotting disorder or on anticoagulants If packing needed, send for Hb, G+S, clotting if above applies, and get IV accessEpistaxis: mx POSTERIOR CAUTERY PACKING FIRST AID ANTERIOR ARTERY LIGRATION PACKINGNasal septal haematoma Bleeding between mucoperichondrium and nasal cartilage usually secondary to nasal trauma. Must be seen ASAP to prevent AVN developing. Sx: bilateral BOGGY FLUCTUANT swelling in nostrils medially Mx: I+D under GA. If nasal # present, see as OP in # clinic for manipulation under anaestheticSinusitis Inflammation of sinuses Sx: rhinorrhea, blocked nose, reduced sense of smell, pain on leaning forward, viral prodrome Mx: Analgesia Nasal steroid if sx >10d Short course 5-7d Otrivine (nasal decongestant, NICE reports limited evidence) Nasal douching Only consider ABX if long duration (>10d) or systemically unwellPeriorbital cellulitis Arises from trauma/bites (likely to be periorbital) or from sinusitis/frontoethmoidal sinus (likely to become orbital cellulitis). Sx: swollen orbital region, proptosis, pain on eye movement, diplopiaPeriorbital cellulitis Ix: Opthal for in depth eye examination Bloods (FBC, U+E, CRP, sepsis 6 if systemically unwell) CT orbits/sinuses to assess eye compromise CT Head - Low threshold if sx persist despite ABX or rise in inflam markers to assess for abscess formation Mx: IV ABX (should NOT be delayed for ix results) Nasal steroids and decongestants Supportive mxForeign Body Common in children, LDs, psychiatric patients Collateral history or witness Sx: unilteral nasal foul discharge, inhalation issues, see sooner if organic material or batteries Ix: thudicum + otoscope Mx: Mother’s kiss => removal under direct vision => removal under GAQUESTIONSQ4Q4Q5 v similar previous past paper Q! Q5Q6Q6THROAT / LARYNGOLOGYTonsillitis Inflammation of tonsils due to infection Typically viral (adenovirus, rhinovirus, influenza, EBV) but can be bacterial (strep. pyogenes, staph aureus) Sx: sore throat, malaise, change in voice, odynophagia/dysphagia, lymphadenopathy, trismus Ix: Throat exam (tonsil grading), neck exam, otoscopy Bloods (FBC, U+E, CRP, glandular fever screen) Mx: Conservative/analgesia (Difflam), ABX: Pen V (CENTOR or FeverPAIN) Admit if: unable to tolerate fluids, not improving on PO abx, ?quinsyTonsillitis Brodsky’s Tonsillar GradingQuinsy Aka peritonsillar abscess Sx: ASYMMETRICAL oropharynx, uvular deviation, “hot potato voice” Ix: same as tonsillitis Mx: I+D Analgesia (+ oromorph) IV dexamethasone (6.6mg STAT, for trismus esp)Tonsillectomy Requirements SIGN criteria for tonsillectomy 5+ episodes each year for 2 consecutive years 3+ episodes each year for 3 consecutive years 2+ quinsy everPost Tonsillectomy Bleed Main complication post-tonsillectomy. Secondary = later (more associated with infection, systemically unwell) 4-8% patients will have PTB. Small minority of these will end up in theatre to control haemorrhage (more likely in adults). Big bleeds can be preceded by small ‘herald’ bleed. Must be admitted + reviewed under ENT ALWAYS for 24-48h.Post Tonsillectomy Bleed Mx: A-E assessment If severe bleed or primary = BACK TO THEATRE ASAP IV wide bore access, FBC, coag, G+S, Adrenaline soaked gauze to stop bleeding when awaiting theatre. IV TXA H2O2 gargles + ice packs to back of neck Keep NBM until senior reviewed?? Normal post-tonsillectomy appearance - “slough”H+N Ca Pathway Laryngeal Ca Oral Ca Thyroid Ca 45 yo + Unexplained ulcer >3w Unexplained thyroid Unexplained neck lump lump Unexplained neck lump Unexplained pesistent Dentists to refer: hoarseness Oral cavity lump Red/white patch consistent with erythroplakia or erythroleukoplakiaH+N Ca Pathway Laryngeal Ca This would be investigated by ENT ! 45 yo + Oral would be maxfax (Trust dependant) and thyroid Unexplained neck lump would be endo surgery. Unexplained pesistent hoarseness Important to clarify symptoms that make larynx/pharynx more likely -> lack of thyroiditis symptoms, position of lump, RFs (smoking) First ix would be FNE to visualise then CT/MRI (senior led decision)Neck Lumps American Head and Neck Society (AHNS) Levels Level I Submental and submandibular triangles. The upper third of the sternomastoid above the level of the Level II hyoid bone. Level III The middle third of the sternomastoid between the level of the hyoid bone and the level of the cricoid cartilage The lower third of the sternomastoid beneath the level of the Level IV cricoid cartilage. Level V Posterior triangle Anterior compartment. Below the hyoid bone, between both Level VI common carotid arteries inferiorly down to the sternumNeck Lumps American Head and Neck Society (AHNS) Levels Submandibular gland infection/blockage (sialadenitis), dental Level I abscess, submandibular gland tumour. Level II Lymph node, parotid tail lump (usually benign), branchial cyst Level III Branchial cyst, lymph node Level IV Lymph node Level V Lymph node, cystic hygroma, lipoma Thyroid multinodular goitre/single nodule, thyroglossal duct Level VI cyst, dermoid cystIngested Foreign Body WHO takes care of this differs by trust! Sx in line with upper airway/oes -> ENT Sx in line with lower oes -> Upper GI RED FLAGS: Airway compromise, sharp item >5cm, battery ingestion (see below) IMMEDIATE removal as can cause burns, ulcers and perforation Swallow tea spoon of honey periodically to coat battery and prevent erosion Ix: A-E FNE to visualise location Lateral neck XR - cannot rule out FB if -ve, go off of sx. Mx: rigid oesophagoscopy/pharyngoscopyEpiglottitis Usual causative agents: HiB, Staph, Pneumococcus, Group B strep Sx: Fever, tripodding, drooling, accessory muscle use, laryngeal tenderness Mx: Emergency => ENT/anaesthetics to secure airway Stable => secure airway, access + cultures, IV abx and dex, r/vQUESTIONS 2022 WRITTEN PAPER 2 76F ate fish and chips 3 days ago. Presented to ENT on call from GP. Reports ongoing non-resolving throat pain and pain on swallowing. She has not coughed up any blood. Observations are all stable. Examination is unremarkable. What are your next steps? a. Neck USS b. Reassure and discharge home with safety netting c. XR Neck d. Laryngoscope e. MRI neck Q7 2022 WRITTEN PAPER 2 76F ate fish and chips 3 days ago. Presented to ENT on call from GP. Reports ongoing non-resolving throat pain and pain on swallowing. She has not coughed up any blood. Observations are all stable. Examination is unremarkable. What are your next steps? a. Neck USS b. Reassure and discharge home with safety netting c. XR Neck d. Laryngoscope e. MRI neck Q7Q8Q8Q9Q9MISCWeber’s + Rinne’s NB: “positive” Rinne’s = AC>BC AUDIOLOGY geekymedics.com/audiogram-interpretation/ Normal hearing O and X is R and L AIR conduction < and > is R and L BONE conduction AUDIOLOGY geekymedics.com/audiogram-interpretation/ Sensoineural hearing loss AUDIOLOGY geekymedics.com/audiogram-interpretation/ Conductive hearing loss AUDIOLOGY geekymedics.com/audiogram-interpretation/ PresbyacusisTrachy and LarysTrachy and Larys Indications: Upper airway obstruction Trauma to face/neck to preserve airway Indications: ITU >10d H+N Ca Percutaneous or surgical insertionTrachy and LarysTHANK YOU! Feedback is v much appreciated :) Any Qs, ask away