EAR, NOSE & THROAT NOTES

Written by: Amierah Nabillah Haji Othman

Sources: UCC 4th Year ENT Lecture Notes Oxford Handbook of Clinical Specialties (9th Edition)

EAR

1. INTRODUCTION: - Wash hands - Introduce yourself - Confirm patient details - Explain examination (Today Id like to examine your ears,

this will involve me having a look inside your ears using a special piece of equipment known as an otoscope. In addition Ill also be assessing your hearing using a number of different tests)

- Gain consent (Are you happy for me to go ahead) 2. GROSS HEARING ASSESSMENT:

- Ask the patient if they have noticed any change in their hearing recently. - Explain that youre going to say a word or number and youd like them to repeat it back to you. - To test:

o With your mouth approximately 15cm from the ear, whisper a number or word (e.g: 41 or chicken) o Mask the ear not being tested by rubbing the tragus o Ask the patient to repeat the number or word back to you o If the patient repeats the correct word or number, repeat the test at an arms length from the ear (normal hearing whisper heard at 60cm) o Assess the other ear in the same way

3. RINNES TEST:

- Air conduction (AC): o Tap a 512HZ tuning fork & place at the external auditory meatus o Ask: Can you hear it?

- Bone conduction (BC): o Move the tuning fork (whilst still vibrating), placing its base onto the mastoid process o Ask: Where is the sound louder? - In front of the ear (EAM) or behind it (mastoid process)

- Findings: o Normal = AC > BC (Rinnes positive) o SNHL = AC > BC (both air & bone conduction equally) o Conductive deafness = BC > AC (Rinnes negative)

4. WEBERS TEST: - Tap a 512HZ tuning fork & place in the midline of the forehead - Ask the patient: Where do you hear the sound? - Findings:

o Normal = sound is heard equally on both ears o SNHL = sound is heard louder on the side of the normal ear o Conductive deafness = sound is heard louder on the side of the affected ear

To recap Rinnes Webers Normal AC > BC (Rinnes positive) Equal on both ears SNHL AC > BC (both equally) Louder on normal ear Conductive BC > AC (Rinnes negative) Louder on affected ear

5. OTOSCOPY:

- Ask the patient if they have any ear discomfort (if so, examine the non-painful side first)

- Pinnae: o Scars:

! Postauricular: Mastoidectomy ! Endaural: Middle ear surgery

o Abnormalities: ! Perichondritis -> Cauliflower ear

- Ear canal / tympanic membrane: o Ensure the light is working on the otoscope o Apply a sterile speculum (the largest that will comfortably fit in the external auditory meatus) o To straighten the external auditory meatus, pull the pinna:

! Up & back (3 y/o and older) ! Down & back (< 3 y/o)

o Position otoscope at the external auditory meatus: ! Otoscope should be held in your right hand for the patients right ear and vice versa ! Hold the otoscope like a pencil and rest your hand against the patients cheek for stability ! Advance the otoscope under direct supervision

o Look for: ! Wax ! Swelling ! Erythema ! Discharge ! Foreign bodies

o Examine the tympanic membrane: ! Colour?: Pearly grey & translucent (normal) /

erythematous (inflammation) ! Erythema or bulging of the membrane?: Inspect

for a fluid level (e.g. otitis media) ! Perforation of the membrane?: Note the size and

site ! Light reflex (cone of light) present?: Absence /

distortion may indicate inner ear pressure (e.g. otitis media)

! Scarring of the membrane?: Tympanosclerosis (can result in significant hearing loss)

o Withdraw the otoscope carefully o Discard the otoscope speculum in a clinical bin

6. TO COMPLETE EXAMINATION:

- Thank patient - Wash hands - Summarise findings - Suggest further investigations (e.g. audiometry) Source: - Hearing/Ear examination (http://geekymedics.com/2015/03/28/hearing-ear-examination-osce-guide/)

2) OTALGIA 1. OTITIS EXTERNA (OE) Definition: - Inflammation of the outer ear and ear canal - Sometimes known as swimmers ear Risk factors/aetiology - Trauma (fingernails/cotton bud/keys) - Moisture (humid weather/swimming/bathing) - Skin conditions (eczema/psoriasis) - Absence of wax Organism: - Bacterial: Pseudomonas (chief), Staph - Fungal: Aspergillus, Candida - Viral: Herpes zoster/simplex Presentation: - Minimal ear discharge - Itch - Pain - Swelling - Tragal tenderness - Dulled hearing Complications: - Hearing loss - Canal stenosis Investigation: - Swab for C&S Management: - Aural toilet (microsuction) - Aural drops (antibiotics +/- corticosteroid) *pg 543 OHCS - Pope wick (if canal narrowed) - Analgesia Look out for: - Persistent unilateral OE in diabetics/immunosuppressed patients/elderly (at risk of malignant/necrotizing otitis externa) - Treatment resistant OE (sign of malignancy) 2. MALIGNANT/NECROTIZING OTITIS EXTERNA Definition: - An aggressive life threatening extension of OE leading to temporal bone destruction and base of skull osteomyelitis - This is not a type of cancer! Risk factors/aetiology: - Middle aged diabetics (90%) - Immunosuppression - Aural irrigation Organism: - Pseudomonas (chief) - Proteus - Kiebsella Presentation: - Similar to OE but more severe - Pain deep in ear (may be worse when moving head) - Ongoing purulent discharge - Cranial nerve palsy (trouble swallowing/facial weakness) Investigations: - Swab for C&S - Cranial nerve examination - CT/MRI

Management: - IV antibiotics (8 weeks) - Surgical debridement 3. PERICHONDRIAL HAEMATOMA Pathophysiology: - Blunt trauma causes haematoma between cartilage and perichondrium (which supplies nutrients) - Cartilage loses blood supply and becomes fibrosis - As a result, the cartilage regenerates in a haphazard manner giving characteristic deformity/redundant skin (cauliflower ear) - The ear may also become slightly pale due to reduced blood flow - Also known as: pinna/auricular haematoma Management: - Urgent referral after ear trauma - Drainage of haematoma - Pressure dressing with splints - Antibiotics 4. CHONDRODERMATITIS NODULARIS HELICIS (CNH) Definition: - Benign tender cartilaginous inflamed nodule dwelling on the upper helix or antihelix - Also known as: Winklers disease Risk factors/aetiology: - Poor blood flow from pressure (headphone users) - Vasoconstriction (from cold) Management: - Pressure-relieving methods/prosthesis - Avoid excessive exposure to the cold - Wide excision or deep shave (if not resolved) 5. TEMPOROMANDIBULAR (TMJ) DYSFUNCTION Definition: - Pain and dysfunction of muscles of mastication and the TMJ joints - A form of referred otalgia Risk factors/aetiology: - F>M (oestrogen-related?) - Malocclusion - Bruxism (teeth-grinding) - Stress Presentation: - Earache - Facial pain - Joint clicking/popping - Joint derangement - Joint tenderness (exacerbated by lateral movements of the open jaw or trigger points in the pterygoid) Management: - Analgesia - Occlusal splints - CBT - Physiotherapy - Acupuncture - Reconstructive surgery *Other causes of otalgia: Furunculosis/Bullous myringitis/Barotrauma/Referred pain *Auricular skin tumours: Benign: Keratoacanthoma/CNH Malignant: BCC/SCC/Melanoma

3) DISCHARGING EARS & OTITIS MEDIA Lets look at the character of the discharge (otorrhoea) - External ear:

o Scanty watery discharge (no mucinous gland!) o Blood (if theres trauma) o Liquid wax (if it leaks out)

- Middle ear: o Serosanguinous discharge (chronic granulation OM) o Offensive discharge (cholesteatoma)

- CSF otorrhoea (think of trauma!): o Halo sign on filter paper o Glucose or B2 (tau) transferrin present

1. OTITIS MEDIA WITH EFFUSION (OME) Definition: - Fluid in middle ear - Also known as: serous otitis media (SOM)/ secretory otitis media (SOM)/ glue ear Risk factors/aetiology: - Cleft palate - Downs syndrome - Cystic fibrosis - Primary ciliary dyskinesia - Children of smokers - Atopy - URTI - Oversized adenoids - Narrow nasopharyngeal dimensions - Post radiotherapy, e.g. nasopharyngeal carcinoma Pathophysiology: - Dysfunction of the Eustachian tube (due to any of the above) - Middle ear (connected with the nasopharynx via ET) which normally absorbs air, creates a negative pressure if ET blocked, thus interstitial fluid pulled in Presentation: - Hx:

o Poor listening o Poor speech/language delay o Hearing fluctuation (Ossicle function disrupted) o Ear infections/ URTI o Balance problems (LSCC exposed)

- Examination: o Variable (retracted/bulging drum) o Dull, grey or yellow o Superficial radial vessels o Decreased drum mobility

Investigations: - Audiogram (Conductive defects) - Tympanometry (Flat tympanogram- Type B) Management: - Usually resolves over time - Topical/systemic methods are NOT recommended! - Hearing aids: Bilateral OME and hearing loss if surgery contraindicated - Surgery

o Indication: ! Persistent bilateral OME (>3 months) ! Hearing level in better ear 3 years

o Grommets (complication: tympanosclerosis/ infection) preferred over T-tubes (complication: residual perforation) o +/- Adenoidectomy

2. ACUTE OTITIS MEDIA (AOM) Definition: - Middle ear inflammation (commonly after URTI) Organism: - Bacterial: Pneumococcus/Haemophilus/Moraxella - Viral: Rhinovirus Presentation: - Acute onset - Presence of fluid (otorrhoea) - Middle ear inflammation - Local symptoms (otalgia) - Systemic signs (fever/vomiting) - Age (6 months to 3 years) Management: - Analgesia - Antibiotics

o Not routinely prescribed as initial treatment, but if prescribed, a short course ~5 days (e.g. amoxicillin) o Consider age and severity

- Decongestants/antihistamines NOT recommended! Complications (if discharge persists): *slide 24 (Middle ear part 1) - Mastoiditis

o Definition: Middle ear inflammation leading to destruction of air cells in mastoid bone +/- abscess o RF: Withholding antibiotics in otitis media o Presentation: temperature, tender mastoid, protruding auricle o Investigation: CT o Management: IV antibiotics (e.g. ceftriaxone), myringotomy, grommet, mastoidectomy

- Facial nerve palsy - Labyrinthitis - Petrositis - Meningitis - Intracranial abscess ENT referral if: - > 4 episodes in 6 months - Complications arise Management: - Surgery (grommets +/- adenoidectomy) - Specific treatment for complicationsGROMMETS - Function:

o Ventilates & maintains pressure of middle ear (reduces risk of fluid build up) o Helps pus flow out if infection occurs

- Indications: o Recurrent otitis media (4-6 x per year) o OME > 3 months with hearing loss/speech delay o Complicated AOM o Eustachian tube dysfunction o Adenoidectomy on the second set of grommets if adenoids enlarged

- Procedure: o Placed in antero-inferior quadrant o Lasts ~ 6-12 months and falls out on its own

- Complications: o Bleeding o Perforated tympanic membrane o Otorrhoea o Infections o Further grommets

3. CHRONIC OTITIS MEDIA (COM) Types: - Without cholesteatoma (mucosal)

o Mucosa of middle ear is chronically inflamed and infected - Cholesteatoma (squamous)

o Squamous epithelium trapped within the temporal bone Presentation: - Hx:

o Hearing loss o Otorrhoea o Otalgia o Tinnitus o Vertigo o Nasal obstruction o Previous history of COM, tympanic membrane perforation or otologic surgery o *Urgent referral if theres progressive unilateral

hearing loss with chronic foul-smelling otorrhoea (suspect cholesteatoma)

- Examination: o Otomicroscopy o Posterosuperior retraction pocket with squamous epithelium o Granulation from diseased bone o Aural polyps o Pneumatic otoscopy (positive: suggests perilymphatic fistula) o Remember to take cultures!

Investigations: - Audiology (usually conductive loss & may vary greatly, confirm with tuning forks) - Imaging (CT temporal bone to evaluate extent of cholesteatoma Management: - Mucosal:

o Topical treatment (steroid/antibiotic drops) o Aural toilet o +/- Mastoid exploration

- Cholesteatoma: o Mastoid exploration o Removal of cholesteatoma

TYMPANIC MEMBRANE PERFORATION - Mostly occur with AOM - Risk factors/aetiology:

o Infection (fluid in middle ear) o Iatrogenic (grommets) o Trauma (explosion, instrumentation)

- Presentation: o Pain (usually transient) o Hearing loss o Bleeding o Tinnitus o Vertigo (rare)

- Management: o Leave alone (small usually heals, large dont, if in between, just wait and see!) o Waterproof o No antibiotics/drops o OPD in 8-12 weeks (if not healed, tympanoplasty)

TYMPANOSCLEROSIS - Definition:

o Calcification of tissues of the tympanic membrane and middle ear - Aetiology:

o Recurrent AOM o OME o Post grommet insertion

CHOLESTEATOMA - Pathophysiology:

o Stratified squamous epithelium (skin cyst) trapped in middle ear o Locally destructive around and beyond pars flaccida (places pressure on bone and secretes enzymes)

- Classification: *slide 4 (Middle ear part 2) o Congenital o Primary acquired o Secondary acquired

- Aetiology: o Peak age: 5-15 y/o

- Complications: o Hearing loss (CHL, SNHL) o Tinnitus o Perilymphatic fistula o Facial paralysis o Meningitis/brain abscess

4) HEARING LOSS

AUDIOMETRY Pure Tone Audiometry - Function:

o Quantifies hearing loss and determines nature o Subjective

- Standard measure - > 4 years can be tested - Procedure:

o Headphones deliver electronically generated tones at different strengths over frequencies of 250-8000 Hz in a sound-proofed room o The patient says when he hears sounds o The intensity is recorded in decibels (dB) by the tester as the AC threshold o BC threshold is obtained by using a transducer over the mastoid process o Masking (narrowband noise to the untested ear) prevents cross stimulation of the non-test ear

- Results:

Sensorineural Hearing Loss

Conductive Hearing Loss

Mixed Hearing Loss

Speech audiometry

- Function:

o Examines speech discrimination above threshold o Assesses disability o Predicts whether hearing aids would help

- Procedure: o Patient is asked to repeat words presented via headphones

ACOUSTIC IMPEDENCE AUDIOMETRY (TYMPANOMETRY) - Function:

o To test the condition of the middle ear by measuring the compliance of tympanic membrane o Objective

- Procedure: o The tympanometer is fitted into the ear o As the tympanometer continuously changes the pressure in the ear canal, a transmitter sends a sound to the drum o The wave that is reflected back is picked up by the microphone in the probe o The tympanometer measures the energy of the reflected sound

- Results:

Type A : Normal Type B : Fluid in ear or perforation Type C : Negative middle air pressure *Extra info: http://www.dilworth.co.nz/clinical-information-articles/guide-to-tympanometry-1

1) CONDUCTIVE HEARING LOSS Aetiology: - External canal obstruction

o Wax o OE o Atresia

- Tympanic membrane perforation o Trauma o Barotrauma o Infection

- Problems with ossicular chain o Otosclerosis o Infection o Trauma

- Inadequate ET ventilation o OME o Tumour in middle ear (glomus)

Management: - Find out cause and treat

2) SENSORINEURAL HEARING LOSS A) Sudden SNHL Definition: - > 30 dbHL in 3 contiguous pure tone frequencies over < 72 hours

Aetiology: - Infection (mumps/measles/meningitis/TB/syphilis) - Trauma (skull base fracture/ear surgery) - Tumour (Acoustic neuroma) - Autoimmune (Wegeners granulomatosis) - Multiple sclerosis - Idiopathic Investigations: - MRI to rule out tumour - Blood tests

o FBC o ESR o Glucose o ACE o ANCA o Auto-antibodies o Syphilis serology

Management: - Controversial! (Oral steroids/ vasodilator/ antivirals) Prognosis: - Better if early presentation - Negative prognostic factors:

o Age 65 y/o o ESR o Vertigo o Hearing loss in the opposite ear o Severe hearing loss o Long history

B) Gradual SNHL Site: - Bilateral:

o Presbyacusis (age) o Noise-induced o Drug-induced (ototoxicity)

- Unilateral: o Idiopathic/presbyacusis o Acoustic neuroma o Menieres disease o Late otosclerosis

Management: - Hearing aids

o Audio-amplification system o Types

! Behind ear ! In ear ! In canal ! BAHA (Bone anchored hearing aids)

Indications: conductive HL/ unilateral HL/ intolerance to ear level hearing aids/congenital malformations/single-sided deafness Contraindications: average bone threshold M o Pregnancy o Age 20-30 y/o

- Presentation: o Initially conductive HL, but may later affect cochlea causing SNHL o Initially unilateral, but may later become bilateral o Tinnitus o Mild, transient vertigo o Schwartz sign (pink tinge to TM) o Carharts notch (dip at 2kHz) at masked bone conduction

Left sided otosclerosis

- Management:

o Hearing aid o Surgery (risk of dead ear):

Stapedectomy (removing) Stapedotomy (drilling) Cochlear implant if severe

C) SNHL in children Aetiology: - Congenital

o AD o AR o X-linked

- Acquired o Antenatal:

! TORCH infections ! Drugs

o Perinatal: ! Hypoxia ! Trauma

o Neonatal: ! Congenital abnormalities ! Meningitis ! Convulsions ! Kernicterus ! Low birth weight ! Ototoxic drugs

Management: - Auditory rehabilitation

o Lip reading o Sign language o Environmental aids (special units in school/ visits from teachers of the deaf) o Hearing aids (if cochlear hair cells present) o Cochlear implants (if cochlear hair cells absent)

! Infants Profound bilateral SNHL No benefit from hearing aids No contraindications High motivation and appropriate expectations from family Earlier implantation if SNHL secondary to meningitis

! Children (and adults) Severe to profound bilateral SNHL No benefit from hearing aids Poor speech discrimination

5) TINNITUS Definition: - Perception of sound in the absence of auditory stimulation (usually age 50-60 y/o) Subjective tinnitus: - Local:

o Hearing loss o Presbyacusis o Noise-induced o Head injury o Otosclerosis/post-stapedectomy o Menieres disease o Acoustic neuroma o TMJ problems o Meningitis o Syphillis

- General: o Cardiovascular (HTN/anemia/heart failure

- Drugs: o Anti-inflammatory o Antibiotics o Antidepressants o Aspirin o Loop diuretics o Aminoglycosides o Quinine o Alcohol

- Psychological: o Divorce/retirement/etc

Objective (pulsatile) tinnitus: - AV malformations - Venous hum - Atherosclerosis - Ectopic carotid artery - Carotid stenosis - Carotid body tumours - Glomus tumours - Aneurysm - High CO states

o Pagets disease o Hyperthyroidism o Pregnancy o Anemia)

Investigations: - Hx:

o Character (Constant? Pulsatile?) o Alleviating/exacerbating factors o Otalgia o Hearing loss o Worse if isolated or depressed o Disturbs sleep o Drugs

- Examination/tests: o Otoscopy (patulous ET/myoclonus of tensor tympani) o Hearing/tuning fork test o BP & pulse o Audiometry o Tympanogram o MRI (to exclude acoustic neuroma) o Hb/ lipids

Management: - Treat underlying cause - Removal of cerumen - Masking devices - Hearing aids - Medication (Alprazolam/TCA) - Tinnitus retraining therapy (TRT)

PRESBYACUSIS - Definition:

o Age-related hearing loss from accumulated environmental noise toxicity - Presentation:

o Loss of high frequency sounds before 30 y/o o Progressive o Hearing most affected in the presence of background noise

- Management:

o Hearing aids

6) VERTIGO (VESTIBULAR) Definition: - Subjective sensation of self-motion when no-self motion is occurring/ the sensation of distorted self-motion during an otherwise normal head movement Vestibular causes of vertigo: - Peripheral

o Benign positional vertigo (seconds-minutes) o Menieres disease (hours) o Vestibular neuronitis (days) o Labirinthitis

- Central o Acoustic neuroma

Other causes of vertigo: - Multiple sclerosis - Head injury - Malignancy - Verterbral-basilar insufficiency - Arrhythmias - Hypotension - IHD - Migraine Diabetes - Medications

o Gentamicin (neuronitis) o Antihypertensives o Diuretics o Metronidazole o Sedatives o Alcohol

Presentation (Focusing on vestibular vertigo): - More severe compared to central vertigo - May be described as swaying, tilting, bobbing, bouncing, sliding - Accompanied by

o Nausea o Vomiting o Hearing loss o Tinnitus o Nystagmus (usually horizontal)

Examination: - ENT/Head and neck - Cranial nerves (Rinne & Weber) - Nystagmus - Rhombergs - Unterbergers - Hallpike manoeuvre Investigations: - Audiogram - Electronystagmography - Brainstem auditory evoked responses - Calorimetry (COWS) - CT/MRI 1) BENIGN POSITIONAL VERTIGO Presentation: - Attacks of sudden rotational vertigo lasting >30 sec provoked by head turning - Symptom free interval - +/- minor head injury Pathogenesis: - Displacement of otoconia in semicircular canals Diagnosis: - No persistent vertigo

- No speech/visual/motor/sensory problems - No tinnitus/headache/ataxia/facial numbness/dysphagia - Hallpike manoeuvre

o Latency (a few seconds) o Rotatary nystagmus (Geotropic) o Reversal upon return to upright position

Management: - Reassurance (usually self-limiting in months) - Precaution against heights (dangerous!) - Vestibular rehabituation exercises - Reduce alcohol intake - Epleys manoeuvre - Drugs:

o Histamine analogues (betahistine) o Vestibular sedatives (prochlorperazine) o Antidepressants

- Posterior semicircular canal denervation (last resort!) 2) MENIERES DISEASE Definition: - Dilatation of endolymphatic spaces of the membranous labyrinth - F>M - Age 35 y/o (peak) Presentation: - Vertigo for ~12h with prostration - Nausea/vomiting - Aural fullness - Uni/bilateral tinnitus - +/- SNHL (fluctuating) - Occurs in clusters (

4) LABIRINTHITIS Definition: - Inflammatory disease of inner ear of labyrinth Aetiology: - Viral: Rubella, CMV, Herpes zoster, mumps, measles - Bacterial: Secondary to meningitis, OM - Autoimmune: Wegener Granulomatosis, polyarteritis nodosa (uncommon) 5) ACOUSTIC NEUROMA Definition: - Tumours arising from schwann cells around vestibular or cochlear nerves that behave as space-occupying lesions - Also known as: Vestibular schwannoma Presentation: - Progressive unilateral tinnitus +/- SNHL - Headaches - Facial numbness (trigeminal compression) - Ipsilateral cerebellar signs/ Increased ICP signs - Vertigo (rare) Investigations: - Audiogram - MRI (especially in those with unilateral tinnitus/ deafness) Differential: - Meningioma Management: - Watch and wait - Surgery (difficult & often not needed, esp elderly) - Gamma knife surgery (to reduce neuroma volume) Follow up: - MRI (to detect expansion)

NOSE 1) HISTORY:

- Facial pain/ pressure - Obstruction/ snoring - Rhinorrhoea - Epistaxis - Itchy/sneezing - Taste/smell dysfunction - Eye symptoms 2) EXAMINATION:

- External abnormality - Anterior rhinoscopy - Septal deviation/ haematoma - Rigid nasendoscopy - Flexible nasendoscopy 3) INVESTIGATIONS:

- RAST (IgE) - Sweat test if appropriate - Photographs (for rhinoplasty) - CT sinues (for sinusitis/ nasal polyps/ orbital cellulitis) - MRI sinus/brain (tumour/ intracranial lesion) 1) RHINITIS Definition: - Inflammation in the nose and paranasal sinuses with more than two symptoms:

o Cardinal symptoms ! Nasal congestion ! Nasal discharge

o Other symptoms ! Facial pain ! Facial pressure ! Decreased olfaction ! Endoscopic signs of nasal polyps/mucus & pus discharged primarily from the sinus ! CT showing mucosal changes within the sinuses

Epidemiology: - Very common presentation to GP - 10-25% of certain populations (40% children) - Allergic and infective causes are most common - QoL impairment Other causes of NASAL CONGESTION: - Child:

o Big adenoids o Choanal atresia o Postnasal space tumour o Foreign body *Refer urgently if:

Unilateral obstruction +/- Foul bloody discharge

- Adult: o Deflected nasal septum o Granuloma (TB/syphilis/granulomatosis with polyangiitis/leprosy) o Topical vasoconstrictors o Tricyclics *Refer urgently if:

Unilateral obstruction Numbness Tooth loss Bleeding

1) ALLERGIC RHINITIS Definition: - Inflammation to the mucosal lining of the nose caused by inappropriate hypersensitivity reaction to an aeroallergen Aetiology: - Seasonal (outdoor allergens)

o Tree pollen o Grass pollen o Weed pollen

- Perennial (indoor allergens) o House dust mite faeces o Pets (dog/ cat/ horse) o Cockroaches o Moulds

Symptoms: - Nasal pruritus - Sneezing - Rhinorrhoea - Stuffiness/ nasal congestion - +/- hyposmia, altered taste Signs: - Swollen turbinates - Mucosa pale or mauve - Nasal polyps Pathophysiology: - IgE mediated inflammation to nasal mucosa from allergen exposure, causing inflammatory mediator release from mast cells Classification: - Intermittent: 4 weeks - If mild, none of the below, but if moderate-severe, more than one of:

o Sleep disturbance o Impaire work of school o Impaired daily activities o Troublesome symptoms

Investigations: - Skin prick test: look for wheal - Radio-allergoabsorbent test (RAST), if skin prick test C/I: measures antigen specific IgE - Intradermal testing Management: - Nasal saline irrigation - Nasal steroids (beclomethasone) - Antihistamines (loratadine) - Systemic decongestants (pseudoephedrine) *C/I in: HTN/ hyperthyroidism/ heart disease/ MAOI use - Anti-leukotriene agents (zafirlukast) - Immunotherapy *when medical treatment fails 2) NON-ALLERGIC RHINITIS Definition: - Rhinitis in the absence of an identifiable allergy, structural abnormality or sinus disease Occupational rhinitis: - Aetiology:

o Cigarette smoke o Chemicals/solvents o Metal salts o Latex o Glues o Wood dusts

Medication induced rhinitis: - Aetiology:

Rhinitis Medicamentosa: - Definition:

o A condition of rebound nasal congestion brought on by extended use of topical decongestant (e.g. phenylephrine) & certain oral medications (e.g. sympathomimetic amines) that constrict blood vessels in the lining of the nose - Pathophysiology:

o Nasal mucosa innervated by sympathetics mainly o NA stimulates Alpha 1 and 2 leading to vasoconstriction o Sympathomimetics produce vasoconstriction by endogenous release of NA o Prolonged use will lead to reduced presynaptic NA which in turn reduces alpha receptor sensitivity

- Treatment: o Dont take the meds longer than recommended o Gradual stopping of decongestant (introduce corticosteroid spray) o Warn of temporary worsening of symptoms!

Non-allergic rhinitis with eosinophilia syndrome (NARES): - Definition:

o A condition comprising of symptoms consistent with allergic rhinitis in which an absence of allergy has been demonstrated by allergen skin testing, and nasal cytology analysis demonstrates >25% eosinophils - Associated with Samters triad:

o Asthma o Aspirin and NSAID sensitivity o Nasal/ethmoidal polyposis

Hormonal: - Aetiology:

o Pregnancy o Puberty o Menstruation o ? Hypothyroidism

Vasomotor rhinitis (Idiopathic rhinitis) - A diagnosis of exclusion! Exclude:

o Positive allergy test o Smoking o Nasal polyps o Pregnancy o Medications affecting nasal functions o Beneficial effects of nasal corticosteroid sprays

- Consider also: o Structural abnormalities o Immunologic conditions

Wegeners granulomatosis Sarcoidosis Polychondritis Rheumatoid arthritis

o Infections (bacterial (TB)/HIV) o Foreign body o CSF (after head injury, + glucose) o Cystic fibrosis o Kartageners syndrome

2) SINUSITIS Definition: - Infection/inflammation of the nasal cavity and paranasal sinuses Differential diagnosis: - Migraine - TMJ dysfunction - Neuralgia - Cervical spine disease - Temporal arteritis - Herpes zoster Anatomy: - 4 sinuses: maxillary, frontal, ethmoid and sphenoid - Drain into the nasal cavity (lateral to the middle turbinate) - Lined by respiratory mucosa, with goblet cells and cilia - Osteomeatal complex (OMC) obstruction is critical in the development of sinusitis Classification: - Acute: 12 weeks Signs & symptoms: - Major:

o Facial pain /pressure Maxillary: at cheek or teeth Ethmoidal: between eyes Worse on bending *Percussion tenderness

o Nasal obstruction/congestion o Purulent rhinorrhea/post nasal drip

- Minor: o Halitosis o Ear pain / pressure / fullness o Anosmia/hyposmia o Headache o Fever

Viral sinusitis: - How to recognise:

o < 10 days post URTI - Pathophysiology:

o Virus causes mucosal oedema & decreased ciliary action, leading to mucous retention and secondary bacterial infection Bacterial sinusitis: - How to recognise:

o >10 days post URTI o Responds to antibiotics

- Aetiology: o Direct spread (dental root infection/swimming in infected water) o Odd anatomy (septal deviation/large ethmoidal bulla/ polyps/ large uncinate process) o ITU causes (mechanical ventilation/ recumbency/ use of nasogastric tube) o Systemic causes (Kartageners/ immunodeficiency) o Biofilms

- Organisms: o Staph aureus o Pseudomonas o Strep pneumonia o Haemophilus influenza o Moraxella catarrhalis o Fungi

Investigations: - CT

o Excellent visualisation o Consider for complicated acute sinusitis or chronic sinusitis preoperatively

- MRI o Rule out intracranial complication

- Plain x-ray/USS are useless! Management: - Analgesia (if painful) - Antipyretic (if feverish) - Decongestants (Antihistamines are NOT routinely used as they may thicken secretion & complicate drainage)) - Nasal saline irrigation - Antibiotics (amoxicillin/co-amoxiclav) Complications: - Acute local:

o Frontal (subperiosteal abscess) o Ethmoidal (orbital cellulitis/abscess/cavernous sinus thrombosis) o Maxillary (swollen cheek) o Sphenoidal (cavernous sinus thrombosis)

- Acute distal: o Intracranial (meningitis/ extradural or subdural abscess/ intracerebral abscess) o Septicemia o Toxic shock syndrome

- Chronic: o Mucocoele (chronic slowly expanding lesions of the sinuses that may erode bone) o Dental problems

- Orbital: o Orbital cellulitis *below

3) NASAL POLYPS Definition: - Polypoidal mass arising from the mucous membrane of the nose and paranasal sinuses Associations: - Asthma - Cystic fibrosis - Allergic rhinitis - Rhinosinusitis - Aspirin sensitivity - Primary ciliary dyskinesia Typical patient: - Male >40 y/o Sites: - Middle turbinates - Middle meatus - Ethmoids - Maxillary (If the polyp here prolapses and fills in nasopharynx, it is called: antrochoanal polyps) *Refer urgently if: Polyp causing unilateral obstruction (esp with pain or bleeding), and do biopsy! (Look at the ddx below) Differential diagnosis: - Juvenile nasopharyngeal angiofibroma - Nasopharyngeal carcinoma - Lymphoma - Inverting papilloma - Glioma - Neuroblastoma - Encephalocoele Symptoms: *depends on size of polyps - Nasal obstruction - Anosmia - Facial pain/ pressure - Rhinorrhoea - Snoring Signs: *upon anterior rhinoscopy/rigid nasendoscopy - Pale - Mobile - Insensitive to gentle palpation Investigations: - Allergy testing - Sweat test (Polyp in a child have to outrule CF) - RAST (IgE) - CT (Before the surgery) - MRI (If concerned about intracranial lesion extending into the nose) Management: - Corticosteroids

o Nasal drops (betamethasone) o Nasal sprays (beclomethasone) o Oral medication (presdnisolone)

- Surgical (If failed medical management) o Endoscopic sinus surgery o Risks:

! Bleeding (anterior ethmoid) ! Infection ! Orbital injury (medial rectus, globe, optic nerve) ! Intracranial injury (CSF leak)

o Post-op: ! Watch for bleeding ! Beclomethasone drops ! 0.9% saline douched/sniffed to relieve crusting

ORBITAL CELLULITIS *A medical emergency! - Pathophysiology:

o Lamina papyracea (paper thin bone) separates the ethmoid sinus from the orbit, allowing pus to track through it, causing: Proptosis (exophthalmos) Chemosis Periorbital oedema/ abscess Raised IOP leading to ischaemia of the optic nerve (colour vision goes first)

- Management: o Urgent ophthalmology and ENT opinion o CT sinus o MRI brain (if concerned about intracranial collection) o Broad spectrum antibiotics IV (e.g. cephalosporin, metronidazole o Topical decongestants (e.g. otrivine) o Surgical:

Aim to drain pus and ventilate sinuses Internal (endoscopic) or external approach

4) NASAL OBSTRUCTION Aetiology: - Anatomical

o Adenoid hypertrophy o Septal deviation/ haematoma/ perforation o Turbinate hypertrophy o Choanal atresia

- Mucosal o Allergic rhinitis o Non-allergic rhinitis o Sinusitis o Rhinitis medicamentosa o Nasal polyps o Neoplasms

5) NASAL TRAUMA Considerations: - Nasal bones - Nasal septum - Facial bones Examination: - GCS - Vital signs - Inspect

o Anterior rhinoscopy (for septal deviation/ abscess) o Eye movements

- Palpate o Nasal bones o Facial bones

Complications: - Cosmetic concerns - Functional concerns - Epistaxis - Septal haematoma/ abscess - Head injury/ LOC - Trapped inferior rectus muscle

Management: - Refer to ENT OPD 7 days post trauma - Reduce nasal bones if displaced (LA/GA) within 2 weeks post trauma as complete settling occurs at 3 weeks *Refer urgently if:

Septal haematoma Anterior ethmoidal artery bleed

CHOANAL ATRESIA - Definition:

o A congenital disorder where the back of the nasal passage (choana) is blocked, usually by abnormal bony or soft tissue due to failed recanalization of the nasal fossae during fetal development - Presentation:

o Unilateral Usually not detected until much later in life because baby manages to get along with only one nostril available for breathing

o Bilateral Life-threatening Neonates are obligate nasal breathers (they mainly use their nose to breathe)

- Management (of bilateral choanal atresia) o Airway maintenance o Nutrition (orogastric tube feeding) o Associated anomalies (ECG, renal USS) o Surgery (endoscopic/transpalatal approach)

- Associated conditions (CHARGE syndrome): o Coloboma o Heart defects o Atresia of the choanae o Retarded growth or development o Genitourinary abnormalities o Ear abnormalities

SEPTAL HAEMATOMA - Definition:

o Blood collection between cartilage and perichondrium and may form abscess (Mid-face is danger area as it has valve-less veins communicating intracranially) - Presentation:

o Soft, fluctuant & tender on palpation - Treatment:

o Drainage and packing o Antibiotics (to prevent septal abscess)

- Complications: o Septal perforation o Nasal collapse

SEPTAL PERFORATION - Aetiology:

o Post septal surgery o Trauma o Nose picking o Body piercings o Nasal prongs (O2 delivery) o Sniffing chrome salts/cocaine o Malignancies (e.g. BCC) o Nasal steroid/decongestant spray o Chronic mucosal inflammation/granuloma

- Presentation: o Irritates o Whistles o Crusts o Bleeds

- Treatment: o Rhinoplasty (as closure is usually hard) o Saline douche (for crust) o Silastic buttons to occlude the hole

CSF RHINORRHOEA - Pathophysiology:

o Ethmoid fractures disrupting dura and arachnoid can result in CSF leaks o If not associated with trauma, ask if its a tumour

- Investigations: o Lab glucose (+ for glucose) o Immunoelectrophoresis (B tau transferrin)

- Management: o Lumbar drain o Bedrest o Surgery often not needed o Antibiotics (for traumatic leaks)

6) EPISTAXIS (NOSEBLEED) History: - How long? - How much blood? (Quantity) - Ear/ nose/ throat symptoms? - Risk factors?

o Anticoagulation (warfarin/ aspirin/ Plavix) o Hypertension o Trauma o Neoplasia

! Benign (e.g. angiofibroma) ! Malignant (e.g. SCC)

o Thrombocytopenia o Dyscrasia/ haemophilia

Anatomy: - Blood supply to the nose

o Sphenopalatine artery (80%) o Anterior ethmoid artery (10%) o Posterior ethmoid artery (5%)

- Kiesselbachs plexus (Littles area) o Arterial anastomosis o Source of most bleeding!

MANAGEMENT First Aid: - Pinch nose (Littles area) for 15 minutes - Head forward (dont swallow blood) - Ice pack to the nape of the neck Hospital: - Resus: ABC

o Wide bore IV access o Bloods/ group and hold o Fluids o Control BP (? Address anti-coagulant effects)

Examination: - Anterior rhinoscopy (? Anterior bleed) - Oral cavity (? Posterior bleed) - Otoscopy (? OME indicating nasopharyngeal mass) - Head and neck (? Metastatic neck node) - Nasendoscopy (? Source, tumour) Managing the epistaxis - Topical lignocaine/adrenaline - Silver nitrate (AgNO3) cautery to Littles area - Nasal packing

o Merocel tampon o BIPP (bismuth iodoform paraffin paste) o Posterior balloon (if posterior bleed) * Packing a nose:

Go PARALLEL to the palate, NOT up towards the brain! Pack BIPP in layers standing along the floor of the nasal cavity Same as for passing an NG tube

- Surgery: o SPA ligation (through the nose) o AEA ligation (facial incision) o IMA ligation (through maxillary sinus) o ECA ligation (identify two branches first)

- Radiological embolization: o Can be lifesaving for bleeding not responding to surgical measures, but can cause stroke!

JUVENILE NASAL ANGIOFIBROMAS - Epidemiology:

o Young adolescent males - Presentation:

o Recurring epistaxis o Nasal obstruction

- Investigation: o Rigid nasendoscopy (To see mass in nose)

- Management: o Surgical incision

THROAT 1) HISTORY:

- Sore throat - Hoarseness - Dysphagia/ odynophagia - Stridor - Haemoptysis/ hematemesis - Cough - Oral ulceration - Neck lump 2) EXAMINATION:

- Entire oral cavity

o Lips o Buccal mucosa o Gingivo-alveolar sulcus o Dentition o Tongue o Floor of mouth o Palate o Uvula o Tonsils

- Waldeyers ring of lymphoid tissue o Pharyngeal tonsils (Adenoids) - Top o Palatine tonsils Sides o Lingual tonsils - Bottom

- Ulcer?/ Mass? - Palpate (bimanual for submandibular gland and parotid) - Lymph nodes

o Submental o Submandibular o Jugulo-digastric o Anterior/ posterior cervical o Pre- post auricular o Posterior triangle o Supraclavicular

3) INVESTIGATIONS:

- RAST (IgE) - Sweat test if appropriate - Photographs (for rhinoplasty) - CT sinues (for sinusitis/ nasal polyps/ orbital cellulitis) - MRI sinus/brain (tumour/ intracranial lesion) 1) TONSILS & ADENOIDS 1) OBSTRUCTIVE SLEEP APNOEA (OSA) Definition: - Apnoea = Cessation of airflow for 10 seconds - Hypopnoea = Continued breathing over 10 seconds but ventilation reduced by 50% during sleep Apnoea Hypopnoea Index (AHI): - Number of events of apnoea and hypopnoea per hour - Severity of OSA

o Mild: 5-14 o Moderate: 15-30 o Severe: >30

Complications: - Hypertension - CCF/Cor Pulmonale - Cardiac arrhythmias - Myocardial infarction - CVA - Diabetes - Depression - Road Traffic Accidents!!

Aetiology: - Central

o The nervous system fails to adequately control breathing, thus leading to irregular sleep patterns and decreased oxygen levels - Peripheral

o Negative thoracic pressure during inspiration causes collapse of upper airway structures leading to decreased oxygen levels Presentation: - Excessive daytime sleepiness - Impaired concentration - Snoring - Choking episodes during sleep - Witnessed apnoea - Restless sleep - Nocturia - Reduced libido Examination: - BMI - Neck circumference - Nasal obstruction - Small jaw - Large tongue - Large tonsils/ adenoids - Craniofacial abnormalities Investigations: - CXR (cardiomegaly) - ECH (arrythmias) - Polysomnography Management: - Behavioral

o Weight loss o Stop smoking o Reduce alcohol

- Non-surgical o CPAP

- Surgical o Adenotonsillectomy (cures 90% children) o Nasal surgery o Uvulopalatopharyngoplasty (UPPP) o Tracheostomy

2) TONSILLITIS Definition: - Infection of palatine tonsils (but may involve adenoids and lingual tonsils) +/- preceding URTI Presentation: - Sore throat - Lymphadenopathy Organisms: - Viral - Bacterial

o Group A or B Strep o Strep viridans o Staph aureus o Haemophilus influenza o Strep pneumonia o Moraxella catarrhalis o E. Coli

Differential diagnosis: - Epstein Barr virus - Agranulocytosis - Leukaemia - Scarlett fever, diphtheria Management: - Swab (OHCS mentions that swabbing is irrelevant and can lead to overdiagnosis) - Analgesia

o Paracetamol o Ibuprofen o Diclofenac if severe

- Antibiotics o Benzylpenicillin o Amoxicillin* o Coamoxyclavulinic acid* o Erythromycin *Not in mononucleosis

- Hospital referral if o Not eating/ drinking o Airway concerns o Peritonsillar abscess (Quinsy)

- Tonsillectomy if recurrent problem 3) PERITONSILLAR ABSCESS (QUINSY) Definition: - Tonsillitis that suppurates (collection of pus that forms around the tonsil) - If untreated, can spread through neck fascia, causing airway obstruction and aspiration of pus Presentation: - Trismus (unable to open mouth completely) - Severe sore throat - Hot potato voice (muffled voice) Examination: - Swelling of soft palate around tonsil - Uvular deviation - Tender cervical lymphadenopathy Management: - Analgesia - Antibiotics - Fluids - Aspiration and drainage under LA (Be careful as the carotid artery is nearby)

4) MONONUCLEOSIS (GLANDULAR FEVER) Epidemiology and Aetiology: - Young adults - Epstein Barr virus Presentation: - Sore throat - Generalised malaise - Altered voice Examination: - Membranous tonsillitis - Extensive lymphadenopathy - Hepatosplenomegaly Investigations: - FBC - Monospot (heterophil) test - LFT Management: - Benzyl penicillin +/- metronidazole - AVOID ampicillin/ amoxicillin antibiotics (leads to diffuse non-allergic rash) - Paracetamol (if LFTs are normal

TONSILLECTOMY - Indications:

o Absolute OSA Malignancy

o Relative Tonsillitis (5 or more episodes per year, for at least 2 years) Quinsy (2 episodes) Snoring Halitosis (food debris collecting within the crypts of the tonsils) Post transplant lymphoproliferative disorder

- Complications: o Bleeding

Reactionary (if clot displaced/ligature slipped) Primary (within the first 24 hours) Secondary (after the first 24 hours)

o Pain (adults > kids) NSAIDS, PCM, +/- codeine

o Pulmonary oedema (tonsillectomy for OSA) o Regrowth of lymphoid tissue o Death (1 in 20000)

- Management (of post tonsillectomy haemorrhage): o ABC o IV access o Bloods including GXM (cross matching) o Resuscitate with fluids (+/- bloods) o Cauterise tonsil fossa if possible o Cauterise under GA otherwise o IV antibiotics: Co-amoxiclav (if pyrexic/ neutrophilic/ elevated CRP)

- Blood volume recap o 1-6 years: 80 mls/kg o 10 years: 75 mls/kg o Adult: 70 mls/kg *So for a 20 kg 4 year old who bleeds, his total blood volume is approximately 1.6 litres

3) DEEP NECK SPACE INFECTIONS

Key Points: - Infection within the head and neck may suppurate - Pus can track along defined planes (between fascial sheaths) - Some planes extend down to diaphragm (danger space) - Swelling: airway compromise possible - Involvement of vessels: septic emboli Presentation: - Sore throat - Dysphagia / odynophagia - Neck pain / swelling - Otalgia (referred pain) - Respiratory distress / voice change - Fever / reduced PO intake / malaise (paediatric) Signs: - Trismus - Stridor / obstructive breathing - Reduced range of neck movement / torticollis - Neck mass (red, fluctuant, tender, hot) Aetiology: - Pharyngitis / tonsillitis - Odontogenic infection - Suppurative lymph node (esp. paeds) - IVDU (Intravenous drug user) - Trauma - Sialoadenitis - Microorganisms (Strep/ Staph/ Klebsiella/ Neisseria/ Bacteroides Management: - ABC - Secure airway if necessary (tracheostomy) - CT - IV antibiotics (augmentin / clindamycin) - Incision and drainage of pus (transoral or external) Complications: - Airway obstruction - Aspiration of pus - Sepsis - Mediastinitis (from retropharyngeal and danger spaces) - Carotid artery rupture

4) UPPER AERODIGESTIVE TRACT CONDITIONS 1) PHARYNGEAL POUCH (ZENKERS DIVERTICULUM) Presentation: - Dysphagia with gurgling - Regurgitation - Choking on swallowing - Halitosis Investigations: - Barium swallow - Endoscopy (can cause perforation when a pouch is unsuspected) Management: - Endoscopic stapling of pouch

o 15-20 minutes o Minimal morbidity o Can be repeated

- External division of pouch (Cricopharyngeal myotomy/ Transcervical diverticulectomy) o 2-3 hours o Significant morbidity o Not undertaken as often as stapling o Risk of mediastinitis

2) FOREIGN BODIES (RESPIRATORY TRACT) Epidemiology: - Peak incidence: 1-3 years - Most common cause of accidental death at home - Peanuts most common - Delays in diagnosis is common Types of foreign body: - Inorganic FB

o Usually plastic/ metals o Examples: Small parts from toys/ beads etc o Little reaction o Obstructive only o However, button batteries are corrosive!

- Organic FB o Examples: Food/ rubber/ wood/ sponge o Can induce marked inflammatory reaction o Granulations o Abscess o Haemoptysis

Presentation: - Silent period (delay) - Choking - Coughing (paroxysmal) - Wheezing - Pyrexia

o Unexplained o Persistent o Lobar pneumonia

Examination: - Reduced air entry (may be unilateral) - Atypical BS (audible click/ fluttering) - Wheeze (may be unilateral) - Atelectasis of lung & midline shift of mediastinum Management: - Airway assessment - Microlaryngoscopy &Bronchoscopy - Surgical airway (emergency only, and its rare!)

o Cricothyroudotomy o Tracheostomy

3) FOREIGN BODIES (OESOPHAGEAL) Common FB: - Meat bolus - Coins - Bones - Batteries (corrosive!)

o Risk of oesophageal perforation ! Mediastinitis >50% mortality

Management: - Soft food bolus

o Try muscle relaxant o Buscopan IM o Endoscopy

- Bone/ battery o Urgent oesophagoscopy (rigid/ flexible)

4) ANGIOEDEMA Pathophysiology: - Inflammation of venules in layers below the dermis - Vascular leakage mediated by histamine, serotonin & kinins Classification: - Allergy (shellfish/ nuts/ animal dander) - Drugs (contrast/ opiates/ ACE-I/ aspirin/ NSAIDS) - Hereditary (C1 esterase deficient or dysfunctional) Treatment: - Dexamethasone IC (8mg) - Piriton IV - SC adrenaline may be necessary - Anaesthetic intubation - Tracheostomy if airway occluded 5) LARYNGEAL PAPILLOMATOSIS Aetiology: - Benign tumours form on the larynx - Caused by HPV 6& 11 - Commonly found in children

o Direct transmission during vaginal delivery o C-secs in mothers with genital warts

Presentation: - Adults:

o Hoarseness o Strained/breathy voice o Breathing difficulties more common in children

- Babies and small children: o Weak cry o Trouble swallowing o Noisy breathing (may be a stridor) o Chronic cough

Management: - Surgical debulking - Intralesional cidofovir Prognosis: - Most resolve with repeated surgery - Can be fatal if disseminates to lungs

5) UPPER AIRWAY OBSTRUCTION 1) STRIDOR Definition: - Turbulent air flow through a narrowed airway (supraglottis/ glottis/ subglottis/ trachea) - Differentiate from STERTO = Low pitched snoring noise, generated at nasopharynx, oropharynx Classification: - Inspiratory: supraglottic - Expiratory: trachea - Biphasic: glottis/ subglottic History (Paediatric): - Onset/ duration - Pallor/cyanosis - Impact of position and feeding - Abnormal cry/ voice - Feeding difficulty/ failure to thrive - Perinatal hx (NICU/ traumatic birth) - Developmental hx Examination (Paediatric): - Vitals (sepsis?) - Altered level of consciousness - Accessory muscle use - Nasal flaring - Tracheal tug - Drooling - Altered cry or speech - Cutaneous haemangioma at beard area (capable of growing into the airway) - Neck mass - Auscultation of neck and chest Aetiology (Paediatric): - Congenital (laryngomalacia/ web stenosis/ vascular rings) - Inflammation (laryngitis/ epiglottitis/ laryngotracheobronchitis/ anaphylaxis) - Tumours (haemangiomas/ papillomas) - Trauma (thermal/ chemical/ intubation) - Misc (airway/ oesophageal foreign body/ vocal cord prolapse) 2) CROUP (LARYNGOTRACHEOBRONCHITIS) Definition: - Infection of the upper airway, generally in children, which obstructs breathing and causes characteristic barking cough Epidemiology: - Winter months - Parainfluenza virus (95%) - Peak 6-18 months old Presentation: - Gradual onset hoarseness - Barking cough - Biphasic stridor - Fever - +/- Cyanosis - CXR may show steeple sign of tapering trachea Management: - May require admission - Humidification - Oxygen - Steroids - Nebulised adrenaline - Intubate if deteriorate

VOCAL CORD LESIONS - Benign:

o Papilloma (90%)/ Polyps/ Reinkes oedema/ Adenoma/ Chondroma/ Hemangioma/ Lipoma/ Neurofibroma - Malignant:

o SCC (90%)/ Adenocarcinoma/ Adenoid cystic/ Muco-epidermoid

3) RETROPHARYNGEAL ABSCESS Definition: - Lymph nodes suppurate in the retropharynx Epidemiology: - Rare - Typical patient: child (1-3 years) Presentation: - Stiff, extended neck/ torticollis - Fails to eat or drink Investigation: - CT (diagnostic) - Lateral neck x-ray (soft tissue swelling) Management: - IV antibiotics - Surgical drainage (under GA and head down to prevent aspiration) 4) EPIGLOTTITIS Definition: - Infection of the epiglottitis and/ or supraglottic structures with potential for airway obstruction Epidemiology: - Rarer than croup but high mortality (Its an emergency as respiratory arrest can occur) Organisms: - Haemophilus influenza - Strep pyogenes Presentation: - History is often short - Septicemia is rapid - Cough is ABSENT - Others:

o Sore throat o Fever o Dyspnoea o Voice change o Dysphagia o Tender anterior neck +/- cellulitis o Hoarseness o Pharyngitis o Anterior neck nodes o Drooling (head forward, tongue out) o Prefers to sit

Management: - Take to ITU - Minimal handling- dont examine throat! (May cause respiratory arrest) - Caution with:

o Fibreoptic examination o Throat swab o Radiology

- Anaesthetic and ENT opinion - Secure airway in a controlled manner - Treat with IV (e.g. ceftriaxone, analgesia) - May require tracheostomy Differential diagnosis: - Laryngomalacia - Subglottic stenosis - Vocal cord palsy - Laryngeal papilloma

5) LARYNGOMALACIA Definition: - A main congenital anomaly of the larynx (60%) appearing within hours of birth (or up to a few months) Pathophysiology: - Soft laryngeal cartilages prolapse into airway on inspiration Presentation: - Stridor

o Onset after 6 weeks o More noticeable in certain positions, sleep, or if excited/ upset

- +/- Cyanosis - +/- Feeding difficulties Management: - Usually observe + reflux medications (in 85%, no treatment is needed and symptoms usually improve by 2 years old) - Aryepiglottoplasty/pexy (if failure to thrive) 6) SUBGLOTTIC STENOSIS (SGS) Definition: - Narrowing of the subglottic airway Types: - Congenital (if there is problems in the formation of the cartilage ring that make up the trachea) - Acquired (post intubation/ gastro-oesophageal reflux) Presentation: - Stridor - Dyspnoea - Difficulty feeding - Failure to thrive - Recurrent episodes of croup Management: - Dilatation - Laser division - Cricoid split/ laryngotracheal reconstruction - May need tracheostomy to secure airway at least temporarily 7) LARYNGEAL PARALYSIS Epidemiology: - 10% of all laryngeal lesions Aetiology: - Cardiovascular anomalies (including PDA ligation) - Birth trauma - Neurological (e.g. Arnold Chiari malformation) - Idiopathic Presentation/ Management: - Unilateral

o May manifest during the 1st few weeks of life with hoarse, breathy cry aggravated by agitation, feeding difficulties +/- aspiration o Supportive (most recover by 2-3 years)

- Bilateral o Inspiratory stridor at rest that worsens upon agitation +/- significant respiratory distress o May need urgent airway intervention (intubation, tracheotomy) +/- surgery

6) HOARSENESS (DYSPHONIA) Definition: - Difficulty producing sound with change in voice pitch or quality (breathy, scratchy, husky) History (Ask about): - Gastro-oesophageal reflux (GORD) - Dysphagia - Smoking (Hoarseness lasting >3 weeks in smoker, suspect larygngeal carcinoma- may be the only presentation!) - Stress - Singing/ shouting 1) REFLUX LARYNGITIS

Definition: - Chronic laryngeal sign associated with GORD Management: - PPI (BDS) for 2-4 months - +/- Surgical fundoplication 2) LARYNGITIS Definition: - Inflammation of the larynx - Usually viral and self-limiting, but there may be secondary infection with streps or staphs - Can be secondary to GORD or autoimmune disease Presentation: - Pain (hypopharyngeal/ dysphagia/ pain on phonation) - Hoarseness - Fever Management: - Supportive - If necessary, give penicillin (PO) for 1 week - Steam inhalation may help 3) REINKES OEDEMA Definition: - The swelling of the vocal cords due to oedema Aetiology: - Smoking - GORD - Hormonal changes (hypothyroidism) - Chronic voice abuse Management: - Laser therapy (if conservative management fails) 4) SINGERS NODULE Definition: - Fibrous nodules (often bilateral) at the junction of the anterior 1/3rd and posterior 2/3rd of the cords caused by vocal abuse - The junction is the middle of the membranous vocal folds (the posterior portion of the vocal fold is cartilage) and it may receive most contact injury during speech Presentation: - Hoarseness - Painful phonation - Frequent vocal breaks - Reduced vocal range Management: - Speech therapy (if used early) - Excision

ACUTE AIRWAY OBSTRUCTION MANAGEMENT IN ADULTS - Sit patient up - Oxygen - IV steroids - Nebulised adrenaline - Note O2 sats, RR, pulse, BP - Call anaesthetist, ENT doctor - If no relief, obtain an emergency airway

o Cricothyroidotomy Good quick access Neck extended Midline through cricothyroid membrane Kits available Limitations for long term use

o Tracheostomy Airway obstruction Pulmonary toilet Prolonged intubation Part of a head and neck procedure If the tube comes out

Anaesthesia to reintubate Reintroduce the trachea (Stay sutures) Cricothyroidotomy

- Take brief hx from relatives, keeping in view common causes of stridor o Inflammatory o Infective o Neoplastic o Autoimmune o Anaphylactic

- Do ABG if possible without causing delay or stress - When stridor improves, do a flexible nasendoscopy (ENT doctor) to visualise the airway to get an idea of the cause of the stridor - Get AP + lateral x-rays of neck and chest WHY IS THIS CHILD DROOLING? -

5) LARYNGEAL NERVE PALSY Anatomy/ pathophysiology: - The recurrent laryngeal nerve supplies the intrinsic muscles of the larynx (apart from the cricothyroideus, external branch of the superior laryngeal nerve) - It is responsible for the abduction and adduction of the vocal cord - It originates from the vagus nerve. It runs

o Left under the ligamentum arteriosum o Right under the subclavian artery o Turns back in a cephalic direction to run in the trachea-oesophageal groove

- In its passage between the cricoid and thyroid cartilages, it is vulnerable to compression from the cuff on an overinflated ET tube Presentation: - Hoarseness with a breathy voice & weak cough - Repeated coughing/ aspiration - Exertional dyspnoea Causes: - Cancer (30%)

o Laryngeal o Thyroid (Reversible in 35%) o Oesophageal o Hypopharynx o Bronchus o Malignant node

- Iatrogenic (25%), usually after o Parathyroidectomy o Oesophageal surgery o Pharyngeal pouch surgery

- Others: o CNS disease (polio/ syringomelia) o TB o Aortic aneurysm o Idiopathic (e.g. neurotropic virus)

Investigations: - CXR - Barium swallow - MRI - Panendoscopy Management: - The nerve may recover on its own - Voice therapy may be useful - If surgery is needed, the goal is to change the position of the paralyzed vocal cord to improve the voice, which can be done through

o Arytenoid adduction (stitches to move the vocal cord towards the middle of the airway) o Injections of collagen, Gelform, or another substance o Thyroplasty

- If both the left and right nerves are damaged, a tracheotomy may be needed to allow breathing, followed by another surgery later 6) OTHERS *OHCS Pg 568 - Functional disorders of speech articulation - Spasmodic dysphonia

DIFFERENTIAL DIAGNOSIS OF HOARSENESS Consider generalised infiltrating entities: - Hyperkeratosis (smoking/ alcohol abuse/ pollution) - Leukoplakia - Granulomata - Papilloma - Polyps - Cysts Less common causes: - Intrinsic (decreased lubrication/ laryngocoele/ Wegeners granulomatosis/ sarcoidosis/ TB/ syphilis) - Extrinsic (goitre/ carotid body tumours) - Neoplasia (Pancoast/ larynx or thymus cancer/ lymphoma/ glomus tympanicum tumour) - Toxic (vomit/ fumes) - Injury (arytenoid subluxation/ CVP lines) - Bacterial (Epiglottitis/ diphtheria/ abscess/ aortitis) - CNS (vagus lesion/ Gullian-Barre/ MG) - Endocrine (acromegaly/ addisons/ myxodema) Rarer causes: - Mycotic aneurysm - Subclavian aneurysm - Malformations - Mucormycosis/ fungi in HIV - Mucosal leishmaniasis - Hamartoma/ hemangioma - Angioneurotic oedema - Gouty cricoarytenoiditis - Behcets vasculitis - Chondrosarcoma - Relapsing polychondritis Emergency presentation: - Epiglottitis - Aortic dissection - Anaphylaxis - Acid/alkali ingestion - Trauma/ foreign body HOW SHOULD YOU TAKE CARE OF YOUR VOICE? - Dont whisper and dont shout! - Drink plenty of fluids (8 cups/day, but not tea, coffee, alcohol or cola) - Get plenty of Zzz - Avoid irritants (spicy food/ tobacco/ smoke/ dust/ alcohol/ aspirin gargles) - Avoid eating before sleeping (to prevent indigestion) - Humidify living area - Dont suck on medicated lozenges (numbs the throat and menthol is drying) *Chew gum instead - Steam inhalations when ill

7) NECK LUMPS History: - Onset/ duration - Systemic/ local symptoms - Rapid growth (? Malignant) - Maternal hx if infection - Trauma - Radiation (thyroid malignancy) - Family hx of neck masses - Cats, animals at home - Travel - Smoking/ drinking hx Examination: - Mass

o Site o Size o Shape o Surface o Edge o Consistency o Mobility o Tenderness o Skin changes

- Full ENT/ Head and Neck examination Differential diagnosis: - V : Vascular - I : Inflammatory - T : Traumatic - A : Autoimmune - M : Medication - I : Infective - N : Neoplastic - C : Congenital Neck masses more likely to be malignant if: - Supraclavicular/ posterior triangle - Fixed - Increased age - Generalised lymphadenopathy - >3cm in side - Hepatosplenomegaly Management: - Bloods

o FBC o ESR o Rapid strep test o LDH (lymphoma) o PPD (mycobacterial lymphadenitis) o Serology (EBV/ Toxo/ Bartonella/ CMV/ HIV/ Borellia)

- CXR (TB) - USS - CT/ MRI - ECG/ ECHO (Kawasaki) 1) PAEDIATRIC NECK LUMPS Epidemiology: - 90% children 4-8 years - Acute usually infective Differential Diagnosis (Elaboration in OHCS Pg 572): - Congenital:

o Midline ! Thyroglossal duct cyst ! Lymph node ! Thyroid ! Dermoid cyst ! Ranula

o Lateral ! Lymph node ! Branchial cyst ! Salivary gland ! Sebaceous cyst ! Hemangioma ! Lymphatic malformation ! Torticollis

- Acquired: o Infective

! Bacterial (strep/ staph/ TB/ Cat scratch/ Lyme disease/ Toxoplasmosis/ Brucellosis) ! Viral (EBV/ CMV/ Coxsackie/ Adenovirus) ! Fungal (Coccidiomycosis)

o Inflammatory ! Kawasaki/ Langerhans cell/ histiocytosis

o Medications ! Dilantin/ INH/ Immunisations (MMR/DTP)

o Vascular ! Lymphatic malformation/ hemangioma

2) ADULT NECK LUMPS Differential diagnosis: - The ddx mnemonic used for paediatric neck lumps can also be used for adults - The big difference is that neck lumps in adults are overall more likely to be neoplastic! - Benign:

o Lipoma o Sebaceous cyst o Hemangioma o Fibroma

- Malignant (primary or metastatic): o Upper aerodigestive tract cancer o Thyroid cancer o Salivary gland cancer o Skin cancer o Lymphoma

THYROGLOSSAL DUCT CYST Definition: - A fibrous cyst that forms in the neck from persistence of the portion of embryonic thyroglossal duct - Most common congenital abnormality of the neck - Classically at or below the hyoid Presentation: - Moves with tongue protrusion and swallowing - Some may have neck/throat pain/dysphagia Management: - Sistrunk procedure (Surgical resection of the duct to the base of the tongue and removal of the central portion of the hyoid bone) BRANCHIAL CYST Definition: - An epithelial cyst arising from the lateral part of the neck from a failure of obliteration of the second branchial cleft in embryonic development - Divided into 4 types (90% is Type II along the anterior border of SCM) Management: - Conservative (no treatment) - Surgical excision

8) HEAD & NECK SQUAMOUS CANCER (HNSCC)

Subdivisions of the head and neck (figure): - Nasopharynx

o Skull base to lower border of soft palate - Oral cavity

o Lips to circumvallate papillae - Oropharynx

o Lower border of soft palate to posterior tip of epiglottis o Posterior to circumvallate papillae

- Larynx o Supraglottis o Glottis o Subglottis

- Hypopharynx o Piriform fossae o Post cricoid region

- Cervical oesophagus

Lymph nodes levels in the neck (figure): - I : Midline to posterior digastric - II : Along IJV, skull base to hyoid - III : Along IJV, hyoid to cricoid - IV : Along IJV, cricoid to clavicle - V : Posterior SCM to anterior trapezius - VI : Between medial borders of carotid sheaths Lymph nodes in the neck: - I : Submental/ submandibular triangles, nodes - II : Jugulodigastric nodes - III : Nodes around carotid bifurcation - IV : Lower cerivical nodes - V : Supraclavicular and posterior triangle nodes Importance of lymph node levels in the neck: - Staging of SCC - Metastatic disease - Some tumours present with an enlarged node only

HNSCC in general Epidemiology: - 5-6% of all cancers - Overall 50% 5 year survival Aetiology: - Alcohol - Smoking/ chewing tobacco - Family hx - HPV 15-60% (oropharyngeal cancer) - Wood dust exposure - Betel nut - Nitrosamines - EBV (nasopharyngeal cancer) - Immunosuppression Investigations: - Panendoscopy and biopsy - FNA of neck node - Bloods: FBC/ U&E/ LFT/ Albumin/ Ca - CT with contrast (neck and chest) - MRI (neck) - PET scan Management: - MDT - Surgery

o Remove tumour o Neck dissection o Reconstruction

- Radiotherapy o Neck treatment

- Chemotherapy o Cisplatin, 5-FU

Surgical complications: - Breathing

o Stoma o Tracheostomy tube

- Swallowing o Aspiration o PEG feeding

- Cosmetic deformity o Scars o Radiation burns

- Speech o Post-laryngectomy (TOF valve, oesophageal speech, electrolarynx)

- Chyle leak - Fistulae Radiotherapy complications: - Skin burn - Mucositis

o Dry mouth o Odynophagia o Weight loss

- Osteroradionecrosis - Carcinogenesis - Secondary tumour

o Leukaemia - Injury to vital structures

o Brain o Eyes o Spinal cord

Chemotherapy complications: - Nephrotoxicity - Ototoxicity - Exacerbates the complications of radiotherapy - Cautious use in elderly, frail or very ill

1) NASOPHARYNGEAL CARCINOMA Epidemiology: - 25% of all cancers in China Aetiology/ Associations: - HLA A2 Allele - EBV - Tobacco, formaldehyde, wood dust exposure - Weaning on to salted fish (nitrosamines) Staging: - T1: Nasopharynx, oropharynx, nasal cavity - T2: Parapharyngeal extension - T3: Bony structures of skull base/ paranasal sinuses - T4: Intracranial, cranial nerves, hypopharynx, orbit, infratemporal fossa/ masticator space - N1: Unilateral cervical, unilateral or bilateral retropharyngeal nodes, above supraclavicular fossa, 6cm in the greatest dimension - N2: Bilateral cervical above supraclavicular fossa 6cm - N3: >6cm / N3b: Supraclavicular fossa Presentation: - Neck nodes (painless) - Nasal obstruction, bleeding - OME (Conductive deafness as Eustachian tube is affected) - Headaches - Cranial nerve palsies (not I, VII, VII) Investigations: - Endoscopy/biopsy - PCR (for EBV) - MRI staging Treatment: - Chemoradiation 2) ORAL CAVITY CANCER Aetiology/ Associations: - Tobacco - Alcohol - Betel nut chewing - Poor oral hygiene - Irritation by ill-fitting dentures - HPV Presentation: - Ulcer - Pain - Bleeding - Mass - Neck node - Leukoplakia/erythroplakia (take biopsy) Treatment: - Surgery:

o Maxillectomy o Mandibulectomy o Glosstectomy o Radical neck dissection o Mohs surgery o Combinational (e.g. glossectomy + laryngectomy)

- Radiotherapy +/- Chemotherapy 3) OROPHARYNGEAL CARCINOMA Epidemiology: - Male > Female = 5:1 - Typical older patient: Smoker - Typical younger patient: HPV

Presentation: - Sore throat - Voice change - Dysphagia/ odynophagia - Neck lump - Referred otalgia Treatment: - Surgery:

o Jejunal flaps o Tubed skin flaps o Gastric pull ups o Transoral laser o Robotic surgery o Partial laryngeal surgery

- Radiotherapy: o May be 1st line is T1 (2cm but

9) THYROID 1) GOITRE Definition: - Generalised enlargement of the thyroid gland Aetiology: - Sporadic (diffuse/ multinodular) - Physiological (pregnancy) - Autoimmune (Graves/ Hashimotos/ postpartum) - Thyroid cancer - Endemic goitre (iodine deficiency) - Dyshormonogenesis - Drug-induced - Inflammatory (de Quervains Riedels) Sporadic goitre: - Females > males - Pathogenesis:

o Early: Diffuse hypertrophy of follicular cells with colloid depletion o Late: Involution of epithelium with colloid accumulation o Focal hyperplasia/ variable involution (+/- haemorrhage, fibrosis, calcification) resulting in multinodular goitre (MNG) o MNG: nodules are demarcated but not encapsulated o Hyperplastic nodule: adenomatous, not neoplastic

2) ADENOMA Definition: - Benign neoplasm of follicular cells which is encapsulated and solitary (it is NOT premalignant and is difficult to distinguish adenoma from carcinoma on FNA) 3) THYROID NODULES Epidemiology: - Affects 10% of the population especially:

o Females o Elderly o Pregnancy o 50% are by the age of 50 y/o

- Overall: o 80% benign hyperplastic nodules o 15% benign adenomas o 5% carcinoma

Risk factors for MALIGNANT thyroid nodules: - Children - Male - Hx of prior neck irradiation* - Family hx of thyroid cancer* - Clinical features* (rapid growth/ RLN palsy/ fixed) - Solitary - Size > 4cm - Suspicious ultrasound features - Radioactive iodine (RAI) uptake: cold >> hot scans (functioning or hot nodules are rarely from cancer) - PET scans: FDG avid (FDG is an analogue of glucose, so anything that is metabolically active will have an uptake) *Very important questions to ask about in the history! Investigations: - Bloods: TFT (decreased TSH may indicate toxic nodule) - FNA:

o For all nodules >1 to 1.5 cm o Can diagnose malignancy o Cannot differentiate between follicular/ Hurthle cell adenomas from carcinomas (Thus need thyroid lobectomy)

- Ultrasound (FNA under ultrasound more accurate) - CT

o Retrosternal goitre o Noncontrast always for thyroid malignancy (iodine in contrast prevents use of radioactive iodine treatment as cancer treatment for 3 to 6 months!)

- MRI (alternative to CT) Indications for thyroid surgery: - FNA positive or suspicious for malignancy - FNA inconclusive (follicular adenoma) - High risk (elderly males/ children/ radiotherapy/ family hx) - Clinical suspicion - Compressive symptoms - Cosmetic concerns - Graves (failed medical treatment/ RAI contraindicated) 4) THYROID CANCER Epidemiology: - Differentiated (85-90%)

o Papillary carcinoma o Follicular carcinoma o Hurthle cell carcinoma

- Poorly differentiated (> M - Indolent disease - Risk factors (radiation esposure) - Histology (orphan Annie, psammoma bodies) - Often multicentric and bilateral - Lymph node involvement often wont affect prognosis if age 45 years - Male sex - Distant metastases - Size of primary tumour - Extrathyroid extension Treatment: - Surgery:

o Thyroid lobectomy (low risk patients) o Total thyroidectomy (higher risk patients)

! Risk of recurrence ! Complications from revision thyroid surgery ! Thyroglobulin as a tumour marker ! RAI use

o Neck dissection ! If pre/paratracheal nodes involved, may require more extensive neck dissection

- Radioactive iodine ablation: o Used to treat/ diagnose differentiated thyroid cancer o Smaller dose of radiation o For high risk patients/ those with local or distant mets o Not good for poorly differentiated malignancies

- TSH suppression is very important post-op - Thyroglobulin may be monitored - Repeat RAI uptake scan as necessary POORLY DIFFERENTIATED THYROID CANCER - Malignancy of follicular cell origin - Features between differentiated and anaplastic carcinoma - Contrast CT and PET best investigations - Not well detected or treated by RAI - Treat with external beam radiotherapy ANAPLASTIC THYROID CANCER - Poor prognosis (Most die within 6 months) - Stages as T4 - Rapid growth, local invasion - Avoid pre-emptive tracheostomy if possible MEDULLARY THYROID CANCER (MTC) - From parafollicular C-cells - RET proto-oncogene mutation - Sporadic (75%) - Familial (25%): MEN/ non-MEN - MEN IIa

o MTC o Primary hyperparathyroidism o Phaeochromocytoma

- MEN IIb o MTC (aggressive) o Phaeochromocytoma o Marfanoid features o Mucosal neuromas

- Treatment: o Genetic analysis o Urinary/plasma catecholamines o Calcitonin o Total thyroidectomy and neck dissection o Prophylactic thyroidectomy for MEN

! Before 5 years MEN IIa ! Before 5 months MEN IIb

THYROIDECTOMY Complications: - Scar - Infection - Haematoma* - Hypocalcemia* - Recurrent laryngeal nerve palsy (bilateral if total thyroidectomy) Management of haematoma post thyroidectomy: - Presentation:

o Neck swelling o Airway obstruction

- Call for help (ENT doctor/ anaesthesist) - Management (if the patient cant breathe):

o Open skin clips/ skin sutures o Open 2-3 layers of sutures which close the subcut tissues (first layer) and muscles (second layer) together o Stay in midline until you reach the clot or see the trachea, remove the clot o Bring to theatre (all the above done in ward) Continued

Management of hypocalcaemia post thyroidectomy: - Presentation:

o Pins/needles o Muscle cramps o Arrythmias

- Management: o Check Ca and albumin, ECG o To calculate corrected Ca:

Ca + {(40-albumin)x0.02} o If corrected Ca 1.8 but < 2.1:

If symptomatic, 10 mls of 10% Ca gluconate over 10 mins IV o If corrected Ca >2.1

No treatment o If patient is very symptomatic give Ca gluconate without waiting on the bloods o Repeat until symptoms abate

10) SALIVARY GLANDS Major salivary glands: - Parotid - Submandibular - Sublingual Minor salivary glands situated in: - Oral cavity - Oropharynx - Nasopharynx Parotid gland: - Serous - Produce 20% saliva - Extent: External auditory canal to angle of mandible - Divided into: superficial and deep lobes - Separated by CNVII (facial) - Tail of gland - Surrounded by fascia capsule - Stensons (parotid) duct pierces buccinators at 2nd molar Submandibular gland (SMG): - Serous + Mucous - Produce 65-70% saliva (eventhough its smaller than the parotid!) - Extent: Superior to digastric muscles - Whartons duct

o Exits medial surface o Between mylohyoid & hyoglossus o 5 cm in length o Lingual nerve and CNXII (hypoglossal)

Sublingual gland (SL): - Mucous - Produce 5% saliva - Extent: Between mylohyoid muscle and geniohyoid/genioglossus - The ductal system do not have intercalated ducts and usually do not have striated ducts either so they exit directly from 8-20 excretory glands Minor salivary glands: - 600-1000 - Simple ducts - Buccal, labial, palatal, lingual - Tumour sites: Palate, upper lip, check - Lingual & palatine nerves Functions of saliva: - Moistens oral mucosa - Moistens & cools food - Medium for dissolved food - Buffer (HCO3) - Digestion (Amylase/ Lipase) - Antibacterial (Lysozyme, IgA, Peroxidase, FLOW) - Mineralization - Protective Pellicle Important considerations in the examination: - Parotid swelling:

o CNVII document o Look in the oral cavity (Tonsil displaced medially from a deep lobe of parotid tumour?_ o Always examine the lymph nodes throughout the neck

DISORDERS OF SALIVARY GLANDS 1) SIALADENITIS Definition: - Inflammation of the salivary gland

Organisms - Viral

o Paramyxovirus (mumps) - Bacterial

o Staph aureus ! Acute suppurative parotitis ! Acute sialadenitis

Risk factors: - Dehydration - Diabetes mellitus - Sialolithiasis Presentation: - Pain/ tenderness - Temperature/ Fever - Facial swelling - Mass Management: - Medical

o IV antibiotics o Rehydration o Analgesics o Oral hygiene o Sialogogues

- Surgical o Incision and drainage

2) MUMPS Definition: - Epidemic parotitis, a viral disease caused by the mumps virus (paramyxovirus) - 2-3 weeks incubation period Presentation: - Prodrome

o Fever o Malaise

- Painful swelling in one or both glands Complications: - SNHL - Encephalitis - Sterility Treatment: - Empirical Prevention: - Vaccination CHRONIC INFLAMMATION OF SALIVARY GLANDS 1) SJOGRENS SYNDROME Definition: - A chronic systemic inflammatory disorder characterized by lymphocytic infiltrates in exocrine glands Presentation: - Oral symptoms:

o Dry mouth secondary candidiasis o Stomatitis o Glossitis o Dental caries

- Eye symptoms: o Keratoconjunctivitis sicca

- Salivary gland: o Subjective enlargement 40% o Clinical enlargement 20%

Findings: - Raised ESR - Rheumatoid factor (75-95%) - Antinuclear factor (68%) - Antithyroglobulin factor - 10-20% risk developing non-hodgkins lymphoma 2) SIALOLOTHIASIS Definition: - Salivary calculi Common site (Submandibular gland) - Mucoid, thick secretions - Duct orientated superiorly at orifice - Precipitation of salivary minerals - Alteration of salivary components Stasis of salivary flow Presentation: - Intermittent painful swelling - Associated with eating - +/- Secondary infection Examination: - Bimanual palpation - Stone visible? - Thick salivary secretions Investigations: - Radiology (Plain films, CT) - Bloods (Ca2+, PTH) Management: - Conservative:

o Sialogogues o Milking

- Surgical: o Dilatation of duct orifice o Excision of duct papillae o Exploration of duct and removal of stone o Excision of gland

SALIVARY GLAND NEOPLASMS Epidemiology: - Account for only 6% of head and neck cancers - Only 0.3% of all cancers - Proportion of malignant and benign varies with the gland of origin Presentation/ What to look out for: - Painless neck mass (parotid/ SMG/SL) - Oral cavity mass (minor salivary gland) - CNVII palsy (more likely malignant) - Pain - Growth rate - Fixation Examination: - Full ENT/ head and neck examination - Neck nodes present? - Flexible nasopharyngoscopy (very important for minor salivary gland lesions that may present innocuously, e.g. globus, throat pain) Investigations: - Fine needle aspirate:

o Accuracy = 84-97% o Sensitivity = 54-95% o Specificity = 86-100% o Safe, well tolerated

- Ultrasound (neck mass) - CT - MRI

BENIGN NEOPLASMS 1) PLEOMORPHIC ADENOMA Aetiology: - Most common of all salivary gland neoplasms

o 70% of parotid tumours o 50% of submandibular tumours o 45% of minor salivary gland tumours o 6% of sublingual tumours

- Age 40-60 y/o - F>M = 3-4:1 - Long-term risk of developing SCC! Presentation: - Slow growing painless mass

o Parotid: 90% in superficial lobe, most in tail of gland o Minor salivary gland: lateral palate, submucosal mass

Gross pathology: - Smooth - Well-demarcated - Solid - Cystic changes - Myxoid stroma Treatment: - Complete surgical excision - Parotidectomy with facial nerve preservation - Submandibular gland excision - Wide local excision of minor salivary gland - Avoid enucleation and tumour spill 2) WARTHINS TUMOUR (PAPILLARY CYSTADENOMA

LYMPHOMATOSUM) Aetiology: - 6-10% of parotid neoplasms - Older, Caucasian, males - 10% bilateral or multicentric - 3% with associated neoplasms Presentation: - Slow growing painless mass Gross pathology: - Encapsulated - Smooth/lobulated surface - Cystic spaces of variable size, with viscous fluid, shaggy epithelium - Solid areas with white nodules representing lymphoid follicles Treatment: - Surgical excision MALIGNANT NEOPLASMS 1) PLEOMORPHIC ADENOMA Aetiology: - Most common salivary gland malignancy - 5-9% salivary neoplasms - Parotid 45-70% of cases - Palate 18% - Age 30-80 y/o, peak around 50 y/o - F>M Presentation: - Low-grade: slow growing painless mass - High-grade: rapidly enlarging, +/- pain

- Minor salivary glands: may be mistaken for being benign or inflammatory process: o Hemangioma o Papilloma o Tori

Treatment: - Influenced by site, stage, grade - Stage 1 & II

o Wide local excision - Stage III & IV

o Radical excision o +/- Neck dissection o +/- Postoperative radiation therapy

2) ADENOID CYSTIC CARCINOMA Aetiology: - Overall 2nd most common malignancy - Most common in submandibular, sublingual and minor salivary glands - M>F Presentation: - Asymptomatic enlarging mass - Pain, paraesthesia, facial weakness, paralysis Treatment: - Complete local excision - Tendency for perineural invasion: facial nerve sacrifice - Postoperative radiotherapy Prognosis: - Local recurrence: 42% - Distant metastasis: lung - Indolent course:

o 5 year survival 75% o 20 year survival 13%

3) ACINIC CELL CARCINOMA Aetiology: - 2nd most common parotid and paediatric malignancy - 5th decade - F>M - Bilateral parotid disease in 3% Presentation: - Solitary, slow growing, often painless mass Treatment: - Complete local excision - Postoperative radiotherapy Prognosis: - 5 year survival 82% - 10 year survival 68% - 25 year survival 50% 4) CARCINOMA (EX: PLEOMORPHIC ADENOMA) Aetiology: - 2-4% of all salivary gland neoplasms - 4-6% of mixed tumours - Age 60-80 y/o - Parotid > submandibular > palate - Risk of malignant degeneration:

o 1.5% in first 5 years o 9.5% after 15 years

Presentation: - Long standing painless mass that undergoes sudden enlargement

Treatment: - Radical excision - Neck dissection (25% with lymph node involvement at presentation) - Postoperative XRT Prognosis: - Dependent upon stage and histology 5) SQUAMOUS CELL CARCINOMA Aetiology: - 1.6% of salivary gland neoplasms - Age 70-80 y/o - M>F = 2:1 - Must rule out:

o High-grade mucoepidermoid carcinoma o Metastatic SCC of intraglandular nodes o Direct extension of SCC

Treatment: - Radical excision - Neck dissection - Postoperative radiotherapy Prognosis: - 5-year survival 24% - 10-year survival 18%

COMPLICATIONS OF SALVARY SURGERY: - Parotidectomy:

o Scar (modified Blair incision) o Infection o Haematoma o Freys syndrome o Parasthesia of lobule o CNVII injury (transient up to 15%/ permanent

11) THE FACIAL NERVE Facial nerve distribution: - Motor root:

o Muscles of facial expression - Sensory root:

o External ear - Secremotor:

o Submandibular gland o Lacrimal gland

- Special taste: o Taste (chorda tympani)

FACIAL NERVE PALSY

Lesion: - Upper motor neuron:

o Upper facial muscles are partially spared Upper spares upper (e.g. patient can wrinkle their forehead unless there is bilateral lesion, and the sagging of the face seen with LMN is not as prominent) o Source:

! Brain/ brainstem - Lower motor neuron:

o Patient cant wrinkle forehead o Source:

! Cerebello-pontine angle ! Labyrinthine segment ! Geniculate segment ! Tympanomastoid segment ! Extracranial

Examination: - Ear (AOM?/ Cholesteatoma?) - Oral cavity (Ramsay Hunt?/ deep lobe mass?) - Head and neck (parotid mass?) - Muscles of facial expression - CN II and XII especially Rinne/Weber tests

House-Brackmann Grading of CNVII Palsy: - I : Normal movement - II : Slight asymmetry - III : Weak at rest, complete eye closure, synkinesis - IV : Incomplete eye closure, synkinesis - V : Flicker of movement - VI : No movement *Synkinesis = the development of linked or unwanted facial movements Investigations: - Audiogram - Electroneuronography (ENoG) and Electromyography (EMG) to aid in prognosis - +/- CT or MRI is not settling or recurring Aetiology: - Idiopathic:

o Bells Palsy (60-75%) - Infective/ Inflammatory:

o Chronic suppurative otitis media o HZV, HSV o Sarcoidosis o Lyme Disease (Borrelia) o TB o HIV o Botulinism

- Trauma: o Temporal bone fracture, surgery, forceps delivery

- Tumour: o Acoustic neuroma, glomus, parotid

- Other: o Metabolic (DM/ pregnancy) o Congenital (Mobius syndrome) o Neurological (Guillain-Barre syndrome)

Treatment: - Identify and treat specific cause:

o E.g. AOM, cholesteatoma, parotid mass - Bells Palsy:

o Protect Eye e.g. tape closed at night, sunglasses, lubricants o Steroids

- Temporal Bone trauma: o Decompress VII only if dead ear and complete palsy at time of trauma

- Post trauma / surgery: o Gold weights o Tarsorraphy o Slings

- Recurrent palsy/failure to improve: o Low threshold for MRI

1) BELLS PALSY Definition: - A disorder affecting the facial nerves causing weakness of the muscles usually on one side of the face - Viral prodrome - Diagnosis of exclusion! Presentation: - Rapid onset - Numbness/ pain in face, ear, neck - HSV in geniculate oedema > pressure Prognosis: - Recovery 3-6 weeks - 15% residual weakness - Recurrence 12%

2) RAMSEY HUNT SYNDROME Definition: - A herpes zoster virus infection of the geniculate ganglion of the facial nerve Presentation: - Painful vesicles Complications: - SNHL - Vertigo - Encephalitis Treatment: - Acyclovir - Strong analgesics 3) OTHER CAUSES - Acute Otitis Media:

o Children in particular o Facial nerve has no bony covering as it crosses middle ear in 25% people (Thus, inflammatory mediators irritate it!) o Treatment:

! Myringotomy ! Drainage of middle ear ! Grommets

- Chronic Otitis Media: o Cholesteatoma o Pressure, superimposed Infection o Treatment:

! Surgical removal of cholesteatoma - Parotid Tumour:

o Usually malignant if CNVII paralysis o Facial skin malignancy metastasising to intraparotid LNs o Following parotidectomy

- Facial trauma: o Injure branch directly

- Temporal bone fracture: o Longitudinal or transverse o Exploration if immediate & complete o CT Scan

- Surgical injury: o Acoustic neuroma surgery o Mastoid surgery, parotidectomy

THE END!