mr d rejali ent consultant uhcw. plan ent history ent exam investigation management cases

Mr D RejaliENT Consultant

UHCW

PlanENT HistoryENT ExamInvestigationManagementCases

HistorySymptom XDuration overall?Duration of each episode?Duration between episodes?

Time

Severityof Symptom X

History EarHearing lossDischargePainTinnitusVertigo

History NoseNasal obstructionAnterior rhinorrhoeaPosterior rhinorrhoea Olfaction/SmellFacial painSneezing“Epistaxis”

History Pharynx and LarynxDysphagia/OdynophagiaHoarseness (Dysphonia)Throat painReferred otalgiaHaemoptysisNeck lump“Globus”

History Neck LumpDurationPositionsFluctuation in size (minutes /hours / days)Associated symptoms:

Pain / TendernessHead and neck symptoms, such as throat pain,

otalgia, dysphagia and hoarsenessSymptoms of systemic illness, such as fever,

malaise, weight loss and night sweatsIf thyroid lump ask about dysthyroid symptoms

Examination of the earWash hands. Introduce yourself.Ask which ear is worse, start with good

ear.Inspect outer ear.Examine with auriscope: canal, tympanic

membrane. Examine worse/symptomatic ear.Weber and Rinne test.Clinical hearing tests.Ancillary test: other cranial nerves, co-

ord, Romberg’s test.

Examination of the noseWash hands. Introduce yourself.Inspect external nose.Assess each nasal airway independently (eg

steam pattern on metal spatula).Using auriscope light:

Inspect nasal vestibule.Inspect septum, nasal cavity and lateral wall.

Ancillary examination: ears, mouth, oropharynx and neck

Examination of throatWash hands. Introduce yourself.Uncover everything above clavicleUsing pen-torch and tongue depressor:

Examine mouth, start from above.Examine oropharynx (esp. tonsil)

Palpate mouth and tongueAssess voice and coughAncillary exam: neck

Examination of NeckWash hands. Introduce yourself.Expose from clavicle up.Inspect from front and sides. Look for scars.Ask patient to swallow, look for any

movement of lumps.

Examination of Neck cont’dGo behind patientExamine lymph node groups: (my way):

Start Occipital/Post auricularWork down Post triangle to supraclavicular

area.Work up posterior border SCM.Jugulodiagastric node work down SCM to

suprasternal notch.

Examination of Neck cont’dWork up ant triangle including thyroid (ask

patient to swallow when at thyroid)Continue working up anterior triangle: feel

laryngeal cartilage, hyoid.Submandibular and submental area.Finish with parotid and preauricular area.If you did feel a lesion further local, regional &

systemic examination may be needed (eg thyroid (dysthyroid status) or other lymph node groups in axilla, groin and spleen), mouth, pharynx, ear & nose.

Examination of lumpNeck lump

Site, size and consistency.Attachment i.e. what layer is itSingle/multiple (Inflammatory)

Regional exam: Oral, nose, pharynx, larynx, facial nerve function if parotid.

Systemic exam: Thorax, Abdomen, Testes, (Thyroid, Signs of Dysthyroid function, Other Lymph node groups)

Differential diagnosis of neck lumpSurgical sieve or anatomical. Or mixture.Reactive lymphadenopathy / LymphomaMidline congenital/ developmental

Thyroglossal cystDermoid

Thyroid Salivary

ParotidSubmandibular

Differential diagnosis of neck lumpLateral lymphadenopathy

Benign/Acute reactive, Chronic inflammatoryMalignant

Primary Lymphoma Metastatic (Head and Neck Primary or Distant)

Lateral congenital/developmentalBranchial cyst, Lymphangioma

Supraclavicular malignant mass: Lung, GI, Testes.

Other

InvestigationFNA.(Beware pulsatile mass)Bloods:

FBCCXRCT/USS/MRI

InvestigationTargeted investigations:

Midline: Congenital/Thyroglossal cyst USS

Thyroid Bloods: Thyroid Function Tests (TFT),

Autoantibodies, Calcium Radiology: USS(+/-guided FNA) , (CT if concern

regarding malignancy/invasion of other tissues, Isotope scan if evidence of thyrotoxicosis)

InvestigationTargeted investigations:

Salivary Parotid

Distinct: lump MRI Diffuse: Sjogren’s antibody, MRI

Submandibular Floor of mouth X-ray for stone.

InvestigationTargeted investigations:

Lateral neck swelling. ?metastatic cancer Endoscopy find/look for and biopsy ?primary cancer If no primary on endoscopy and FNA does not

suggest metastatic node: excision biopsy.Supraclavicular malignant mass.

CT Thorax, Abdomen and pelvis Biopsy if best site for representative histology.

ManagementCongenital midline neck swelling

Thyroglossal cyst: Sistrunk procedureThyroid

If benign ?conservative.Excision biopsy; minimum lobectomy.?Total thyroidectomy in cancer.

ManagementSalivary

Submandibular If stone palpable in mouth local excision Inflammatory/suspicious: total excision.

Parotid Inflammatory: conservative. Neoplastic:

Benign superficial parotidectomy. Malignant total parotidectomy

ManagementLateral neck swelling:

Developmental: excisionMetastatic squamous cell carcinoma: (consider

primary) usually neck dissection.Lymphoma: medical via oncologist.Inflammatory: usually nothing but diagnosis

needed. If TB chemotherapy. If atypical mycobacterium excision may be required.

ManagementSupraclavicular malignant mass

Histology dependant Lymphoma Seminoma Squamous and Adenocarcinoma likely to be

palliative.

Some cases

50 yr female. 5 year swelling

Left parotid pleomorphic

salivary adenoma

40 year old female, 2 yr neck swelling

Multinodular goitre

20 year old male midline neck swelling 1 year

Thyroglossal cyst

Left branchial cyst

14 year old boy 3 days painful bilateral neck swelling, sore throat

Tonsillitis

Left parotid pleomorphic

salivary adenoma

ThyroidMultinodular

Goitre

10 year old boy left neck swelling 3 months

Left submandibular gland infection

Atypical mycobacterium

Malignant Lymphadenopathy

15 year old male 7 days sore throat

Glandula fever /Infectious

mononucleosis

15 year old male 7 days sore throat worse left side

Quinsy / Peritonsillar

Abscess

Right Oropharyngeal

carcinoma (tonsil)

Laryngeal Carcinoma

78 year old male with dysphagia and regurgitation of food

Barium Swallow

Pharyngeal Pouch

78 year old male with dysphagia/choking more for liquids since CVA

Barium Swallow

Neurological Dysphagia

Deviate Nasal Septum

14 year old female bilateral blocked nose, runny nose and eyes and sneezing

Allergic Rhinitis

Nasal Polyps

4 year old with pyrexia and otalgia

Acute Otitis Media

4 year old with hearing loss

Otitis Media with effusion

50 yr male intermittent discharge from ear

Left chronic otitis media /

perforated ear drum

45yr male smelly discharge constant for years

Chronic otitis media

/Cholesteatoma

50 Right Unilateral hearing loss and tinnitus for 4 years.

Acoustic Neuroma

(Vestibular Schwannoma)

Vestibular Schwannoma (Acoustic neuroma).

Benign schwannoma.Untreated some can

eventually cause brainstem compression and even death.

Treatment: can be monitored(if small), radiation treatment or surgery.

Unexplained asymmetrical/unilateral hearing loss or tinnitus require MRI scan brain/IAM

6 yr 5 days ago URTI. 24hr left swollen eye

Periorbital cellulitis secondary to sinusitis

TreatmentAdmitAntibioticsCT ScanOccasionally

surgery

6 yr old. Left otalgia/swelling after URTI

MastoiditisTreatment

AdmitIV

antibioticsUsually

surgery

Left facial palsy:•Idiopathic (Bell’s

Palsy)•Other (eg parotid malignancy, ear,

CVA)

Acute AirwayStridor. TachopneicCyanosis (very late sign)Acute

Foreign BodiesInflammatory Swelling

ChronicTumour. Larynx Bronchous.

Baby and adult

Heimlich

TracheostomyIf first aid measure fail and patients life is in

danger consider tracheostomy (crico-thyroidotomy).

You will need:Scalpel/KnifeStraw/Pen with inner part removed/Paper

rolled up

Identify cricothyroid membrane

Horizontal cut. 2cm wide. Deep enough. Insert airway.