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ENT Undergraduate LectureENT Undergraduate Lecture
Mr Rejali
ENT Consultant
University Hospital, Coventry
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PlanPlan
• 3 lecture:– Otology– Rhinology – Head and Neck– Practical session
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OtologyOtology
• Anatomy / Physiology
• History
• Examination
• Outer ear problems
• Middle Ear Problems
• Inner Ear Problems
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Otology Anatomy External Ear 1Otology Anatomy External Ear 1
• External– Pinna
• Skin• Cartilage
– External audiotary meatus (canal)
• Lateral/Outer 1/3 in cartilages and produce wax
• Medial 2/3 in bone and wax free
– Skin migration
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Otology Anatomy External Ear 2Otology Anatomy External Ear 2
• External auditory meatus/canal
• Ear wax (and hair) produced in outer 1/3 of ear canal
• Ear wax (cerumen) more soluble in water
• Rare cause of hearing loss unless impacted on to tympanic membrane or blocking canal completely and with a thickness of >2-m mm
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Otology Anatomy Middle Ear 1Otology Anatomy Middle Ear 1
• Air containing space in temporal bone.
• Three ossicles (Mallus, incus and stapes) transfer sound from air to inner ear fluids
• Common site of pathology
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Otology Anatomy Middle Ear 2Otology Anatomy Middle Ear 2
• Tympanic membrane• Right ear• Attic• Handle of malleus• Light reflex
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Otology Anatomy Middle Ear 3Otology Anatomy Middle Ear 3
• Eustachian tube equalises pressure between middle ear and atmosphere
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Otology Anatomy Inner Ear 1Otology Anatomy Inner Ear 1
• Cochlea – Hearing• Semicircular canal –
Angular acceleration• Vestibule – Linear
acceleration
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Otology Physiology CochleaOtology Physiology Cochlea
• Sound transmission through middle ear
• Oval - Round Window travelling wave.
• Tonotopic distribution of organ of corti
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Otology Physiology Vestibular Otology Physiology Vestibular FunctionFunction
• Macula in saccule and utricle - linear acceleration
• Crista in semi-circular canal – angular acceleration
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Otology HistoryOtology History
• Outer ear:– Pain– Discharge: scant,
serous– Hearing loss, late
• Middle ear:– Hearing loss
(conductive)– Discharge: moderate
mucoid– Pain
• In acute otitis media until tympanic membrane perforates
• Chronic otitis media only if complicated e.g. otitis externa or intracranial complications
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Otology HistoryOtology History
• Inner ear:– Hearing loss
(sensoneural)– Vertigo– Tinnitus
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Otology ExaminationOtology Examination
• Wash hands (MRSA)• Intro• Ask about tenderness• Which is better ear• Inspect pinna, mastoid
area• Otoscopy
– External auditory canal– Tympanic membrane
• Hearing test• Other test: cranial nerve
(esp VII), co-ordination and romberg
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Tuning Fork TestTuning Fork Test
• Rinne– Air conduction louder
than bone conduction
• Weber– Lateralises to side of
conductive loss and away from sensoneural hearing loss
• Clinical hearing test
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Otology DiagnosisOtology Diagnosis
• Surgical Sieve• Outer ear• Middle Ear• Inner Ear• Hearing loss
– Conductive– Sensoneural
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Otology InvestigationsOtology Investigations
• Pure Tone Audiogram• Tympanogram• CT• MRI
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Otology ManagementOtology Management
• Explanation• Advice• Medical• Surgical
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Haematoma/Seroma of PinnaHaematoma/Seroma of Pinna
• Aspirate x2 (sterile conditions)
• Compression bandage
• Review in 24hrs• If re-accumulate
proceed to formal drainage and quilting stitch
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Otology ExternalOtology External
• Pinna skin tumour
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Otitis ExternaOtitis Externa• Otitis Externa • Acute
– Painful– Serous discharge– Moist swollen canal– Tympanic membrane
intact– Pseudomonas aeroginosa– Treat topical toilet and
antibiotics
• Chronic– Eczema– Topical toilet and steroids
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Otitis ExternaOtitis Externa
• Furuncle localised infection and pain
• put wick with 10% icthamol/glycerine
• Or incise and drain under local anaesthetic
Furuncle/Abscess of Hair FollicleFuruncle/Abscess of Hair Follicle
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Otology External Otology External
• Exostoses– Cold water swimmers
• Osteomas– Bening neoplasia
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Otology MiddleOtology Middle
• Tympanosclerosis– Previous infection or
trauma.– Usually of no
significance
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Otology MiddleOtology Middle
• Retracted tympanic mebrane– Often no treatment
needed– Differentiate from
perforation– Occasionally progress
to cholesteatoma
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Otology MiddleOtology Middle
• TM perforation• If dry may need no
treatment• If recurrent infection
can be repaired.
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Otology MiddleOtology Middle
• Acute otitis media– Pain– Hearing loss– Later otorrhea
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Acute Mastoiditis
• IV antibiotics
• Surgery
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Otology MiddleOtology Middle
• Otitis media with effusion – glue ear
• Middle ear fluide• Common in children• Hearing loss• Infection starts
process• Treatment
conservative, Grommets
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Otology MiddleOtology Middle
• Cholesteatoma
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Otology Middle EarOtology Middle Ear
• Mastoid cavity
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Otology Inner EarOtology Inner Ear
• Balance: Balance is determined by a complex combination of inputs into the brain.
• These inputs are: – Vision – Proprioception (sensation
of position of joints) – Inner ear
• Integration by brain
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Otology Inner EarOtology Inner Ear
• Vertigo illusion of movement– Hallmark of vestibular
dysfunction– Rotary– Linear
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Otology Inner EarOtology Inner Ear
• Benign Paroxysmal Positional Vertigo
• Vestibular Neuronitis• Meniere's Disease• Recurrent
vestibulopathy• Differentiate from
central vestibular causes.
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Vestibular signal balanceVestibular signal balance
Reduced or no signalIncreased signal
MenieresVestibular Neuronitis
Normal balanced input
Brain will get used to new situation but not to a frequently
changing one.
Increased signal
BPPV
PathologicalLeft ear in this case
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Otology Inner EarOtology Inner Ear
• Presbyacusis• Congenital Hearing
Loss
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Otology Inner EarOtology Inner Ear
• Tinnitus• Acoustic neuroma
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Facial PalsyFacial Palsy
• Upper vs Lower motor neurone pattern.
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Facial PalsyFacial Palsy
• Not all are Idiopathic (Bells Palsy)– Assess other cranial nerves– Ear– Parotid
• Symptoms/signs which suggest other aetiology– Above exam +VE– Slow onset– Little, no or incomplete recovery
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Facial PalsyFacial Palsy
• Eye care. If concern d/w Ophthalmic team.– Tape eye closed at night after Lacrilube– Hypomellose eye drops PRN during day
• Steroids (Prednisolone 40mg od for one week) are indicated early in the course of the disease (less than 3 days) if there are no contraindications.
• Acyclovir if signs of herpes zoster infection (vesicles in TM or pharynx or palate. (400mg five times a day for 10 days)
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The End of Otology SectionThe End of Otology Section
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RhinologyRhinology
• Anatomy
• Physiology
• History
• Examination
• Pathology
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Rhinology Anatomy 1Rhinology Anatomy 1
• External• Internal
– Lateral wall– Medial wall
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Rhinology Anatomy 2Rhinology Anatomy 2
• Nasal septum– Little’s area– Epistaxis
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Rhinology Anatomy 3Rhinology Anatomy 3
• Paranasal Sinuses– Frontal– Maxillary– Ethmoid– Sphenoid
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Rhinology PhysiologyRhinology Physiology
• Nose– Warms, moisten– Filter– Mucociliary
• Sinuses– Function unknown
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Rhinology History Rhinology History
• Nasal obstruction• Anterior rhinorrhoea• Olfaction• Facial pain• Sneezing• Epistaxis
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Rhinology ExaminationRhinology Examination
• Examination– Inspect external nose– Palpate external nose– Evaluate nasal airway
• Steam pattern on metal tongue depressor
– Inspect nasal mucosa• Use otoscope• Lateral, medial
– Inspect palpate over sinuses
– Endoscopy – Olfaction
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Rhinology InvestigationRhinology Investigation
• Allergy testing– IgE levels– RAST (Blood test)– Skin Prick Testing
• Plain X ray – inaccurate
• CT
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Rhinology Allergic Rhinitis 1Rhinology Allergic Rhinitis 1
• IgE mediated allergic reaction– Seasonal/Hay fever,
allergy to pollen– Perennial – allergy to
House Dust Mite– Other: cat etc
• Nasal obstruction, sneezing, rhinorrhoea, eye symptoms
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Rhinology Allergic Rhinitis 2Rhinology Allergic Rhinitis 2
• Investigations– RAST test– Skin Prick test
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Rhinology Allergic Rhinitis 3Rhinology Allergic Rhinitis 3
• Treatment– Allergen Avoidance– Anti-histamine
• Topical • Systemic
– Steroid• Topical spray or Drops• Oral (limited use)
– Leukotriene antagonist– Immunotherapy
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Rhinology Deviated Nasal SeptumRhinology Deviated Nasal Septum
• Aetiology– Congenital– Traumatic
• Symptom– Nasal obstruction– Bilateral or Unilateral
• Sign• Treatment
– As for rhinitis– Surgery
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Rhinology Perforation of Nasal Rhinology Perforation of Nasal Septum 1Septum 1
• Aetiology– Idiopathic– Trauma– Tumour– Wegener’s/SLE– Chromic/Sulphuric
acid or Cocaine
• Symptoms– Nasal obstruction– Crusting– Epistaxis
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Rhinology Perforation of Nasal Rhinology Perforation of Nasal Septum 2Septum 2
• Treatment– Exclude serious
causes– Treat as rhinitis– Nasal douching– Septal button– Surgery (success
poor)
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Rhinology Nasal PolypsRhinology Nasal Polyps
• Aetiology– Not known
• Symptoms– Nasal Obstruction– Rhinorrhoea
• Treatment– Topical steroid
medication– Surgery
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Rhinology Sinusitis 1Rhinology Sinusitis 1
• Aetiology– Infective– Acute vs. Chronic
• Not all facial pain is sinusitis
• Symptoms– Facial pain– Nasal discharge– Nasal obstruction
• Signs
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Rhinology Sinusitis 2Rhinology Sinusitis 2
• Treatment– Acute
• Decongestants• Antibiotic
– Chronic• Topical steroid medication• (Antibiotics)
• Many patients with “sinusitis” have idiopathic facial pain syndrome
• Complication– Ethmoiditis– Common in children
This is not sinusitisIt is a dental infection
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Rhinology Epistaxis 1Rhinology Epistaxis 1
• Aetiology– Idiopathic– Trauma– Tumours– (Coagulopathy)– (Hypertension)
• Treatment– First aid/Resusitation– Cautery– Nasal Packing
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Rhinology Epistaxis 2Rhinology Epistaxis 2
• Anaesthetise prior to cautery
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Rhinology Sino-nasal carcinomaRhinology Sino-nasal carcinomaand Nasopharyngeal Carcinomaand Nasopharyngeal Carcinoma
• Rare• Aetiology
– Wood dust– Nickel dust, Chromium
• Symptoms– Nasal obstruction– Scant regular epistaxis
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Rhinology Rhinology
• Ethmoiditis• ENT must be
involved.• Must be
admitted.• Potentially
serious.• Rx: ab, decong
+/- surg.
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Rhinology Nasal Fracture Septal Rhinology Nasal Fracture Septal HaematomaHaematoma
• Can be manipulated• Consider the rest of
head injury and facial skeleton
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Rhinology Nasal Fracture Septal Rhinology Nasal Fracture Septal HaematomaHaematoma
• Septal haematoma– Soft swelling– Must be drained within
12 hours
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End of Rhinology SectionEnd of Rhinology Section
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Laryngology (Mouth Pharynx Laryngology (Mouth Pharynx Larynx -Throat) SectionLarynx -Throat) Section
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LaryngologyLaryngology
• Anatomy• History• Examination• Investigations• Pathology
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Laryngology Anatomy 1Laryngology Anatomy 1
• Anatomy Mouth
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Laryngology Anatomy 2Laryngology Anatomy 2
• Anatomy Oropharynx
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Laryngology Anatomy 3Laryngology Anatomy 3
• Anatomy - Neck
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Laryngology Anatomy 4Laryngology Anatomy 4
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Laryngology History 1Laryngology History 1
• Dysphagia (wt loss)– Solid– Liquid
• Dysphonia• Neck pain• Referred otalgia• Haemoptysis• (Globus pharyngeus)
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Laryngology History 2Laryngology History 2
• Smoking • Alcohol
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Laryngology Examination 1Laryngology Examination 1
• Mouth– Inspection
• Start from hard palate and work down• Hard Palate• Sup alveolar ridge• Sup bucco-alveolar sulcus• Buccal mucosa• Inf bucco-alveolar sulcus• Inferior alveolar ridge• Floor of mouth• Tongue
– Palpation of above (esp tonge and floor of mouth)– Listen to voice– Neck
• Neck
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Laryngology Examination 2Laryngology Examination 2
• Neck (have a system)– Intro– Ask about pain/tenderness– Exposure above clavicles– Inspect from front and side – Inspect while swallowing– Palpate from behind
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Laryngology Examination 3Laryngology Examination 3
• Neck (have a system)– Palpate from behind
• Start from mastoid• Down posterior triangle• Up posterior border of sternocleiodo-mastoid• Down ant border SCM• Work up ant triangle including thyroid (ask patient to swallow
when at thyroid)• Continue working up anterior triangle: feel laryngeal
cartilage, hyoid.• Sumandibular and submental area.• Finish with parotid and preauricular area.• If you did feel a lesion further local (percussion of sternum or
auscultation), regional & systemic examination may be needed (eg thyroid or other lymph node groups)
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Laryngology Examination 4Laryngology Examination 4
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Laryngology InvestigationsLaryngology Investigations
• Bloods– TFT– Ca– Thyroid antibodies
• FNA• CXR• USS Neck• CT• MRI
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Laryngology TonsillitisLaryngology Tonsillitis
• Sore throat• Pyrexia• White follicles on
tonsils• Penicillin• Recurrent episodes
treat with tonsillectomy
• (Glandular fever)
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Laryngology Quinsy (Peritonsiller Laryngology Quinsy (Peritonsiller abscess)abscess)
• Infection spreads to peritonsiller tissues and can form abscess
• Asymmetrical swelling• Treat with drainage +
antibiotics
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Laryngology AdenoidsLaryngology Adenoids
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Laryngology Laryngology Pharynxl/Larynx/Mouth CarcinomaPharynxl/Larynx/Mouth Carcinoma
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Laryngology Pharynx LymphomaLaryngology Pharynx Lymphoma
• No specific local symptoms
• B symptoms• Mucosa usually not
ulcerating • Check other lymph
groups (neck, axilla and inguinal) and spleen
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Laryngology Neck lump Various Laryngology Neck lump Various “Benign”“Benign”
• Normal structures• Reactive lymph nodes• Mumps• Sebaceous cyst
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Laryngology Neck lump variousLaryngology Neck lump various
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Laryngology Neck lump Thyroid Laryngology Neck lump Thyroid lumplump
• Thyroid lumps move with swallowing
• Benign– Multinodular goitre / Adenoma
• Malignant –thyroid– Dysphonia– Dysphagia– Metastases
• Ix– Bloods (TFT, Ca, Thyroid
Antibodies), FNA, USS/CT
• Rx– Conservative/Medical/Surgical
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Laryngology Neck lump Salivary Laryngology Neck lump Salivary Gland NeoplasiaGland Neoplasia
• Parotid swellings– Mainly benign– Usually pleomorphic
salivary adenoma
• Submandibular gland– Usually inflammatory
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Laryngology Neck lump Laryngology Neck lump Thyroglossal CystThyroglossal Cyst
• Thyroglossal cyst• Moves/tethered
with/to floor of mouth• Before removal check
to insure normal thyroid exists
• Diff diagnosis:– Dermoid– Lymph node– Sebaceous cyst
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Laryngology Neck lumps Branchial Laryngology Neck lumps Branchial CystCyst
• Congenital• Treatment excision
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Laryngology Neck lump Metastatic Laryngology Neck lump Metastatic Neck NodesNeck Nodes
• Neoplasia– Benign (very common)– Malignant
• Primary– Carcinoma– Lymphoma (common)
• Secondary metastases (always consider this)
– Mouth– Pharynx– Larynx– Infraclavicular (lung,
breast, stomach)
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Laryngology Neck lump TBLaryngology Neck lump TB
• Usually multiple nodes
• Cold abscess• If draining do so for
weeks
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Laryngology Larynx CarcinomaLaryngology Larynx Carcinoma
• Dysphonia / Hoarseness for >3 weeks
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Laryngology Larynx Reinke’s Laryngology Larynx Reinke’s OedemaOedema
• Smoking
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Laryngology Larynx Vocal Cord Laryngology Larynx Vocal Cord nodulesnodules
• Vocal cord nodules
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Laryngology DysphagiaLaryngology Dysphagia
• Liquid – neurological• Solid – mechanical
– Tumour– Pharyngeal pouch
(regurgitation)
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Laryngology DysphoniaLaryngology Dysphonia
• Dysphonia >3 weeks needs investigation• Risk for ca: smoker, drinker.• Other suspicious symptoms: wt loss ,
dysphagia.• Benign: Reinke’s Oedema, Nodules,
Inhaler laryngitis, Functional Dysphonia• Malignant: local (ca), distant bronchogenic
ca’ causing recurrent laryngeal nerve palsy
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Laryngology Snoring Obstructive Laryngology Snoring Obstructive Sleep ApnoeaSleep Apnoea
• Partial obstruction of airway– Snoring– High BMI– Pharyngeal– Nasal
• Recurrent obstruction to airway fragmenting sleep– Daytime somnolescence– Similar aetiology to snoring– Treatment: lifestyle, CPAP,
surgery.
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Laryngology Larynx EpiglottitisLaryngology Larynx Epiglottitis
• 4 year old drooling toxic child
• Do nothing!• Get other people• Go to theatre
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Laryngology Acute Airway 1Laryngology Acute Airway 1
• Stridor.
• Tachopneic
• Cyanosis (very late sign)
• Acute– Foreign Bodies– Inflammatory Swelling
• Chronic– Tumour. Larynx Bronchous.
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Laryngology Acute Airway 2. Laryngology Acute Airway 2. First Aid. Choking. Foreign First Aid. Choking. Foreign
BodyBody
Baby and adult
Heimlich
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Laryngology Acute Airway 4 Laryngology Acute Airway 4 TracheostomyTracheostomy
• If first aid measure fail and patients life is in danger consider tracheostomy (crico-thyroidotomy).
• You will need:– Scalpel/Knife– Straw/Pen with inner part removed/Paper
rolled up
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Laryngology Acute Airway 5 Laryngology Acute Airway 5 TracheostomyTracheostomy
Identify cricothyroid membrane
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Laryngology Acute Airway 6 Laryngology Acute Airway 6 TracheostomyTracheostomy
Horizontal cut. 2cm wide. Deep enough. Insert airway.
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Laryngology Acute Airway 3. Laryngology Acute Airway 3. First Aid. Choking. Foreign First Aid. Choking. Foreign
Body. DogBody. Dog
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THE ENDTHE END
Questions?