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ENT Undergraduate ENT Undergraduate Lecture Lecture Mr Rejali ENT Consultant University Hospital, Coventry

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ENT Undergraduate Lecture. Mr Rejali ENT Consultant University Hospital, Coventry. Plan. 3 lecture: Otology Rhinology Head and Neck Practical session. Otology. Anatomy / Physiology History Examination Outer ear problems Middle Ear Problems Inner Ear Problems. - PowerPoint PPT Presentation

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Page 1: ENT Undergraduate Lecture

ENT Undergraduate LectureENT Undergraduate Lecture

Mr Rejali

ENT Consultant

University Hospital, Coventry

Page 2: ENT Undergraduate Lecture

PlanPlan

• 3 lecture:– Otology– Rhinology – Head and Neck– Practical session

Page 3: ENT Undergraduate Lecture

OtologyOtology

• Anatomy / Physiology

• History

• Examination

• Outer ear problems

• Middle Ear Problems

• Inner Ear Problems

Page 4: ENT Undergraduate Lecture

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

Page 5: ENT Undergraduate Lecture

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

Page 6: ENT Undergraduate Lecture

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

Page 7: ENT Undergraduate Lecture

Otology Anatomy Middle Ear 2Otology Anatomy Middle Ear 2

• Tympanic membrane• Right ear• Attic• Handle of malleus• Light reflex

Page 8: ENT Undergraduate Lecture

Otology Anatomy Middle Ear 3Otology Anatomy Middle Ear 3

• Eustachian tube equalises pressure between middle ear and atmosphere

Page 9: ENT Undergraduate Lecture

Otology Anatomy Inner Ear 1Otology Anatomy Inner Ear 1

• Cochlea – Hearing• Semicircular canal –

Angular acceleration• Vestibule – Linear

acceleration

Page 10: ENT Undergraduate Lecture

Otology Physiology CochleaOtology Physiology Cochlea

• Sound transmission through middle ear

• Oval - Round Window travelling wave.

• Tonotopic distribution of organ of corti

Page 11: ENT Undergraduate Lecture

Otology Physiology Vestibular Otology Physiology Vestibular FunctionFunction

• Macula in saccule and utricle - linear acceleration

• Crista in semi-circular canal – angular acceleration

Page 12: ENT Undergraduate Lecture

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

Page 13: ENT Undergraduate Lecture

Otology HistoryOtology History

• Inner ear:– Hearing loss

(sensoneural)– Vertigo– Tinnitus

Page 14: ENT Undergraduate Lecture

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

Page 15: ENT Undergraduate Lecture

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

Page 16: ENT Undergraduate Lecture

Otology DiagnosisOtology Diagnosis

• Surgical Sieve• Outer ear• Middle Ear• Inner Ear• Hearing loss

– Conductive– Sensoneural

Page 17: ENT Undergraduate Lecture

Otology InvestigationsOtology Investigations

• Pure Tone Audiogram• Tympanogram• CT• MRI

Page 18: ENT Undergraduate Lecture

Otology ManagementOtology Management

• Explanation• Advice• Medical• Surgical

Page 19: ENT Undergraduate Lecture

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

Page 20: ENT Undergraduate Lecture

Otology ExternalOtology External

• Pinna skin tumour

Page 21: ENT Undergraduate Lecture

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

Page 22: ENT Undergraduate Lecture

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

Page 23: ENT Undergraduate Lecture

Otology External Otology External

• Exostoses– Cold water swimmers

• Osteomas– Bening neoplasia

Page 24: ENT Undergraduate Lecture

Otology MiddleOtology Middle

• Tympanosclerosis– Previous infection or

trauma.– Usually of no

significance

Page 25: ENT Undergraduate Lecture

Otology MiddleOtology Middle

• Retracted tympanic mebrane– Often no treatment

needed– Differentiate from

perforation– Occasionally progress

to cholesteatoma

Page 26: ENT Undergraduate Lecture

Otology MiddleOtology Middle

• TM perforation• If dry may need no

treatment• If recurrent infection

can be repaired.

Page 27: ENT Undergraduate Lecture

Otology MiddleOtology Middle

• Acute otitis media– Pain– Hearing loss– Later otorrhea

Page 28: ENT Undergraduate Lecture

Acute Mastoiditis

• IV antibiotics

• Surgery

Page 29: ENT Undergraduate Lecture

Otology MiddleOtology Middle

• Otitis media with effusion – glue ear

• Middle ear fluide• Common in children• Hearing loss• Infection starts

process• Treatment

conservative, Grommets

Page 30: ENT Undergraduate Lecture

Otology MiddleOtology Middle

• Cholesteatoma

Page 31: ENT Undergraduate Lecture
Page 32: ENT Undergraduate Lecture

Otology Middle EarOtology Middle Ear

• Mastoid cavity

Page 33: ENT Undergraduate Lecture

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

Page 34: ENT Undergraduate Lecture

Otology Inner EarOtology Inner Ear

• Vertigo illusion of movement– Hallmark of vestibular

dysfunction– Rotary– Linear

Page 35: ENT Undergraduate Lecture

Otology Inner EarOtology Inner Ear

• Benign Paroxysmal Positional Vertigo

• Vestibular Neuronitis• Meniere's Disease• Recurrent

vestibulopathy• Differentiate from

central vestibular causes.

Page 36: ENT Undergraduate Lecture

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

Page 37: ENT Undergraduate Lecture

Otology Inner EarOtology Inner Ear

• Presbyacusis• Congenital Hearing

Loss

Page 38: ENT Undergraduate Lecture

Otology Inner EarOtology Inner Ear

• Tinnitus• Acoustic neuroma

Page 39: ENT Undergraduate Lecture

Facial PalsyFacial Palsy

• Upper vs Lower motor neurone pattern.

Page 40: ENT Undergraduate Lecture

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

Page 41: ENT Undergraduate Lecture

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)

Page 42: ENT Undergraduate Lecture

The End of Otology SectionThe End of Otology Section

Page 43: ENT Undergraduate Lecture

RhinologyRhinology

• Anatomy

• Physiology

• History

• Examination

• Pathology

Page 44: ENT Undergraduate Lecture

Rhinology Anatomy 1Rhinology Anatomy 1

• External• Internal

– Lateral wall– Medial wall

Page 45: ENT Undergraduate Lecture

Rhinology Anatomy 2Rhinology Anatomy 2

• Nasal septum– Little’s area– Epistaxis

Page 46: ENT Undergraduate Lecture

Rhinology Anatomy 3Rhinology Anatomy 3

• Paranasal Sinuses– Frontal– Maxillary– Ethmoid– Sphenoid

Page 47: ENT Undergraduate Lecture

Rhinology PhysiologyRhinology Physiology

• Nose– Warms, moisten– Filter– Mucociliary

• Sinuses– Function unknown

Page 48: ENT Undergraduate Lecture

Rhinology History Rhinology History

• Nasal obstruction• Anterior rhinorrhoea• Olfaction• Facial pain• Sneezing• Epistaxis

Page 49: ENT Undergraduate Lecture

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

Page 50: ENT Undergraduate Lecture

Rhinology InvestigationRhinology Investigation

• Allergy testing– IgE levels– RAST (Blood test)– Skin Prick Testing

• Plain X ray – inaccurate

• CT

Page 51: ENT Undergraduate Lecture

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

Page 52: ENT Undergraduate Lecture

Rhinology Allergic Rhinitis 2Rhinology Allergic Rhinitis 2

• Investigations– RAST test– Skin Prick test

Page 53: ENT Undergraduate Lecture

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

Page 54: ENT Undergraduate Lecture

Rhinology Deviated Nasal SeptumRhinology Deviated Nasal Septum

• Aetiology– Congenital– Traumatic

• Symptom– Nasal obstruction– Bilateral or Unilateral

• Sign• Treatment

– As for rhinitis– Surgery

Page 55: ENT Undergraduate Lecture

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

Page 56: ENT Undergraduate Lecture

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)

Page 57: ENT Undergraduate Lecture

Rhinology Nasal PolypsRhinology Nasal Polyps

• Aetiology– Not known

• Symptoms– Nasal Obstruction– Rhinorrhoea

• Treatment– Topical steroid

medication– Surgery

Page 58: ENT Undergraduate Lecture

Rhinology Sinusitis 1Rhinology Sinusitis 1

• Aetiology– Infective– Acute vs. Chronic

• Not all facial pain is sinusitis

• Symptoms– Facial pain– Nasal discharge– Nasal obstruction

• Signs

Page 59: ENT Undergraduate Lecture

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

Page 60: ENT Undergraduate Lecture

Rhinology Epistaxis 1Rhinology Epistaxis 1

• Aetiology– Idiopathic– Trauma– Tumours– (Coagulopathy)– (Hypertension)

• Treatment– First aid/Resusitation– Cautery– Nasal Packing

Page 61: ENT Undergraduate Lecture

Rhinology Epistaxis 2Rhinology Epistaxis 2

• Anaesthetise prior to cautery

Page 62: ENT Undergraduate Lecture

Rhinology Sino-nasal carcinomaRhinology Sino-nasal carcinomaand Nasopharyngeal Carcinomaand Nasopharyngeal Carcinoma

• Rare• Aetiology

– Wood dust– Nickel dust, Chromium

• Symptoms– Nasal obstruction– Scant regular epistaxis

Page 63: ENT Undergraduate Lecture

Rhinology Rhinology

• Ethmoiditis• ENT must be

involved.• Must be

admitted.• Potentially

serious.• Rx: ab, decong

+/- surg.

Page 64: ENT Undergraduate Lecture

Rhinology Nasal Fracture Septal Rhinology Nasal Fracture Septal HaematomaHaematoma

• Can be manipulated• Consider the rest of

head injury and facial skeleton

Page 65: ENT Undergraduate Lecture

Rhinology Nasal Fracture Septal Rhinology Nasal Fracture Septal HaematomaHaematoma

• Septal haematoma– Soft swelling– Must be drained within

12 hours

Page 66: ENT Undergraduate Lecture

End of Rhinology SectionEnd of Rhinology Section

Page 67: ENT Undergraduate Lecture

Laryngology (Mouth Pharynx Laryngology (Mouth Pharynx Larynx -Throat) SectionLarynx -Throat) Section

Page 68: ENT Undergraduate Lecture

LaryngologyLaryngology

• Anatomy• History• Examination• Investigations• Pathology

Page 69: ENT Undergraduate Lecture

Laryngology Anatomy 1Laryngology Anatomy 1

• Anatomy Mouth

Page 70: ENT Undergraduate Lecture

Laryngology Anatomy 2Laryngology Anatomy 2

• Anatomy Oropharynx

Page 71: ENT Undergraduate Lecture

Laryngology Anatomy 3Laryngology Anatomy 3

• Anatomy - Neck

Page 72: ENT Undergraduate Lecture

Laryngology Anatomy 4Laryngology Anatomy 4

Page 73: ENT Undergraduate Lecture

Laryngology History 1Laryngology History 1

• Dysphagia (wt loss)– Solid– Liquid

• Dysphonia• Neck pain• Referred otalgia• Haemoptysis• (Globus pharyngeus)

Page 74: ENT Undergraduate Lecture

Laryngology History 2Laryngology History 2

• Smoking • Alcohol

Page 75: ENT Undergraduate Lecture

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

Page 76: ENT Undergraduate Lecture

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

Page 77: ENT Undergraduate Lecture

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)

Page 78: ENT Undergraduate Lecture

Laryngology Examination 4Laryngology Examination 4

Page 79: ENT Undergraduate Lecture

Laryngology InvestigationsLaryngology Investigations

• Bloods– TFT– Ca– Thyroid antibodies

• FNA• CXR• USS Neck• CT• MRI

Page 80: ENT Undergraduate Lecture

Laryngology TonsillitisLaryngology Tonsillitis

• Sore throat• Pyrexia• White follicles on

tonsils• Penicillin• Recurrent episodes

treat with tonsillectomy

• (Glandular fever)

Page 81: ENT Undergraduate Lecture

Laryngology Quinsy (Peritonsiller Laryngology Quinsy (Peritonsiller abscess)abscess)

• Infection spreads to peritonsiller tissues and can form abscess

• Asymmetrical swelling• Treat with drainage +

antibiotics

Page 82: ENT Undergraduate Lecture

Laryngology AdenoidsLaryngology Adenoids

Page 83: ENT Undergraduate Lecture

Laryngology Laryngology Pharynxl/Larynx/Mouth CarcinomaPharynxl/Larynx/Mouth Carcinoma

Page 84: ENT Undergraduate Lecture

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

Page 85: ENT Undergraduate Lecture

Laryngology Neck lump Various Laryngology Neck lump Various “Benign”“Benign”

• Normal structures• Reactive lymph nodes• Mumps• Sebaceous cyst

Page 86: ENT Undergraduate Lecture

Laryngology Neck lump variousLaryngology Neck lump various

Page 87: ENT Undergraduate Lecture

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

Page 88: ENT Undergraduate Lecture

Laryngology Neck lump Salivary Laryngology Neck lump Salivary Gland NeoplasiaGland Neoplasia

• Parotid swellings– Mainly benign– Usually pleomorphic

salivary adenoma

• Submandibular gland– Usually inflammatory

Page 89: ENT Undergraduate Lecture

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

Page 90: ENT Undergraduate Lecture

Laryngology Neck lumps Branchial Laryngology Neck lumps Branchial CystCyst

• Congenital• Treatment excision

Page 91: ENT Undergraduate Lecture

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)

Page 92: ENT Undergraduate Lecture

Laryngology Neck lump TBLaryngology Neck lump TB

• Usually multiple nodes

• Cold abscess• If draining do so for

weeks

Page 93: ENT Undergraduate Lecture

Laryngology Larynx CarcinomaLaryngology Larynx Carcinoma

• Dysphonia / Hoarseness for >3 weeks

Page 94: ENT Undergraduate Lecture

Laryngology Larynx Reinke’s Laryngology Larynx Reinke’s OedemaOedema

• Smoking

Page 95: ENT Undergraduate Lecture

Laryngology Larynx Vocal Cord Laryngology Larynx Vocal Cord nodulesnodules

• Vocal cord nodules

Page 96: ENT Undergraduate Lecture

Laryngology DysphagiaLaryngology Dysphagia

• Liquid – neurological• Solid – mechanical

– Tumour– Pharyngeal pouch

(regurgitation)

Page 97: ENT Undergraduate Lecture

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

Page 98: ENT Undergraduate Lecture

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.

Page 99: ENT Undergraduate Lecture

Laryngology Larynx EpiglottitisLaryngology Larynx Epiglottitis

• 4 year old drooling toxic child

• Do nothing!• Get other people• Go to theatre

Page 100: ENT Undergraduate Lecture

Laryngology Acute Airway 1Laryngology Acute Airway 1

• Stridor.

• Tachopneic

• Cyanosis (very late sign)

• Acute– Foreign Bodies– Inflammatory Swelling

• Chronic– Tumour. Larynx Bronchous.

Page 101: ENT Undergraduate Lecture

Laryngology Acute Airway 2. Laryngology Acute Airway 2. First Aid. Choking. Foreign First Aid. Choking. Foreign

BodyBody

Baby and adult

Heimlich

Page 102: ENT Undergraduate Lecture

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

Page 103: ENT Undergraduate Lecture

Laryngology Acute Airway 5 Laryngology Acute Airway 5 TracheostomyTracheostomy

Identify cricothyroid membrane

Page 104: ENT Undergraduate Lecture

Laryngology Acute Airway 6 Laryngology Acute Airway 6 TracheostomyTracheostomy

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

Page 105: ENT Undergraduate Lecture

Laryngology Acute Airway 3. Laryngology Acute Airway 3. First Aid. Choking. Foreign First Aid. Choking. Foreign

Body. DogBody. Dog

Page 106: ENT Undergraduate Lecture

THE ENDTHE END

Questions?