Zaid Awad
MBChB MRCSEd MRCSEng DOHNS Specialty Registrar in Otolaryngology, Head and Neck Surgery, London
Imperial College Healthcare NHS Trust
Clinical Research Fellow Department of Surgery and Cancer
Imperial College of Science, Technology and Medicine, London
Acute Suppurate Otitis Media
Chronic Suppurative Otitis Media
Otitis Media with Effusion / Secretory Otitis Media
Adhesive Otitis Media
+/- Cholesteatoma
COMMON
NOT INFECTIVE
SELF LIMITING
Caused by ETD
(Eustacian tube dysfunction)
Negative MEP
Effusion of fluid in Middle ear
No pain, no fever, not unwell
Deafness, poor development of speech, behaviour
Cons / Medical / Surgical
Watch & wait
Hearing Aid
Ventilation tube
Effective
Compliance
NO ANTIBIOTICS
Perforation of TM
Follows a slow to heal ASOM
May be active or inactive
Safe / Unsafe perforation
Mucosal or cholesteatoma
Similar principles to cholesteatoma
safe
unsafe
What is it?
Keritinising squamous epithelium in middle ear cleft
How?
Congenital (rare)
Aquired - primary (retraction)
- secondary (implantation)
Skin migrates from umbo outwards across TM and out along canal
Pars flaccida
( 2 layers )
Pars tensa
( 3 layers)
Eustacian tube
dysfunction
Negative MEP
Retraction of pars
flaccida
RP fills with
debris
Infection
Erosion and
spread
Cholesteatoma
Same as ASOM + mastoiditis
But more insidious
Slow erosion more common
Conservative / medical / surgical
Conservative - microsuction, review
Medical – antibiotic drops
Surgical – cortical mastoidectomy
mastoidectomy
Conductive vs Sensorineural
Purple/green vs blue areas
Differentiate by tuning fork tests and tympanograms and Audiogram
Setup/physics
AC
BC
Masking
Sound has 2 components:
Frequency (pitch) cf. wavelength
Hz / kHz
Intensity (loudness) cf. amplitude
dB
Setup/physics
The cochlear does not hear all sounds equally at all frequencies
So, why does a normal PTA look like this?
Bone conduction
Used to prevent non-test ear hearing stimulus presented to test ear
Tympanometry
Measure of compliance of TM at varying pressures in EAM
Peak at 0dPa
Best movement of drum when no extra pressure on either side of TM
Peak at 0dPa, but unusually high
amplitude
? Ossicular disruption
Peak at 0dPa, but unusually low
amplitude
? Stapes fixation
No Peak
No best TM movement at any pressure
When tymp is flat,
usually means 1 of 3 things:
1. Artefact
2. Fluid in ME
3. Perforation
Look at EAM vol.
If large = perf
If normal = fluid
Peak at < 0dPa
Best movement of drum when no negative pressure in EAM thus middle ear pressure must be < atmospheric
Filtration (hairs/mucus/cilia)
Warming (30C)
Humidification
Olfaction
Vocal resonance
Bony upper 1/3
Cartilage lower 2/3 Alar
L Lat
U Lat
Septum
Turbinates (x3)
Ciliated epithelium
Sinus drainage to around middle turbinate
Anterior drain to middle meatus
Frontal
Maxillary
Ant Eth
Posterior drain superior meatus/sphenoethmoidal recess
Post Eth
Sphenoidal
Simple acute infective (=a cold)
Allergic (Mast cell degranulation): seasonal (pollen & spores) or perennial (dust mite, animal dander)
Treat with nasal steroids/antihistamines/ allergen avoidance
Intrinsic (10-15% population)
Obstruction
Vasodilatation
Oedema
sneezing
Imbalance of ANS supply to mucosa
PNS overrides SNS
watery rhinorrhoea
Medicamentosa
OTC decongestants are usually designed for short term use
Like heroin
Very difficult vicious circle to break free from
Inflammatory origin most common
neoplastic
CF
idiopathic
Aspirin/Asthma/Obstruction
Hx Ex Ix
Steroids/Surgery
Recurrence
Inflammation of the MM lining the paranasal sinuses
May be in conjunction with CAUSATIVE FACTOR
Medical Rx resolves most:
Analgesia
Decongestants
Steam
Antibiotics
Surgical Rx includes sinus washout
Retained secretions
blocked nose
frequent acute episodes
sinofacial pain
Take careful pain history before diagnosis
Visualise drainage system by CT
FESS
High incidence in those of Eastern origin
Hong Kong boat people (male)
Associated with:
Dried, salted, smoked fish
EBV
Genetic
Radiotherapy
Little place for surgery (not curative)
Very extensive anastamoses
Int Carotid & Ext Carotid branches
Ethmoidal arteries above MT
Sphenopalatine/Palatine/Labial below MT
Little’s Area
Kiesselbach’s plexus
Emergency talk
Congenital/Acquired
Deviated septum
Rhinitis
Polyps
Foreign body
Neoplasia
Collection of lymphoid tissue
Atrophies from age 6 to 12
If enlarged cause -nasal obstruction -Glue ear & recurrent
acute otitis externa -Snoring & sleep apnoea Adenoidectomy
curative
Aetiology: bacterial (Grp A Strep, Pneumococcus, Haemophilus); viral
Complications: Quinsy (peritonsilar abcess)
Treatment: penicillin
If multiple episodes (eg 6/yr) consider tonsillectomy
Swallowing: complex process.
Incidence: high in certain populations
Eg elderly , CVA, GORD
Associated with many different conditions.
Huge impact on QOL.
Important with relation to nutritional state.
May indicate sinister pathology.
Oral Preparatory
Oral
Pharyngeal
Oesophageal Duration & characteristics
of each phase depends on consistency and volume of food/drink taken.
Great majority= Squamous
Risk factors: smoking, alcohol
Location: majority on vocal folds
Presentation: hoarseness(followed by cough, irritation, referred otalgia, neck node)
Treatment: endoscopic removal, radiotherapy, laryngectomy
Lymphadenopathy
Thyroid/Parathyroid gland
Salivary Gland (parotid, submandibular…)
Thyro-glossal Cyst
Branchial Cyst
Carotid Body Tumour
Cystic Hygromata
Pharyngeal Pouch
Sterno-mastoid Tumour
Cervical Rib
NEOPLASTIC INFLAMMATORY
INFECTIVE
(TB/Syphilis)
ACUTE
Viral, Bacterial,
Fungal..
CHRONIC
NON-
INFECTIVE
(Sarcoid/
Rheumatoid)
BENIGN
MALIGNANT
PRIMARY
(Lymphoma
Sarcoma..)
SECONDARY
H&N and
visceral cancer
Patient age
Paediatric (0 – 15 years): 90% benign
Young adult (16 – 40 years): similar to paediatric
Late adult (>40 years): 12-20% malignant
Location
Congenital masses: consistent in location
Metastatic masses: key to primary lesion
Any solid asymmetric mass MUST be considered a metastatic neoplastic lesion until proven otherwise
Asymptomatic cervical mass – 12% risk of cancer
~ 80% of these are SCC
Ultrasonography
which can be used for Fine needle aspiration (FNAC)
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Most common congenital
neck mass
50% present < 20yrs
Midline (75%) or near
midline (25%)
Inferior to hyoid bone
(65%)
Elevates c protrusion of
tongue
Surgical removal
(Sistrunk)
Anterior border of
sternocleidomastoid
2nd-3rd decade
following URTI
PAROTID SWELLINGS:
INFECTIONS: mumps, bacteria
TUMOURS:
80% of all salivary gland tumours arise in parotid
80% of parotid tumours benign
Whereas 80% of other salivary tumours malignant
Parotidectomy and Malignant parotid tumours can cause VIIth palsy
From old…
References in Egyptian hieroglyphics refer
to its use 3500 BCE
Chevalier Jackson in the early 20th century
popularised its use in the mainstream
Elective
Most common + most fun
Horizontal incision
Emergency
Less common but more ‘exciting’
Vertical incision
Airway obstruction
eg. Tumour, bilateral vocal cord palsy
Ventilation
long term intubation
Dead space and secretions weaning from ventilator, chronic lung disease
Protection of airway eg. Chronic aspiration
Cuffed and uncuffed
Fenestrated and unfenestrated
Single and double lumen
Various diameters
To protect airway
To allow ventilation
Uncuffed Cuffed
Allow patient to ventilate past tube via upper airway
Allow speech
Double lumen allows easy cleaning
Single lumen has a greater internal diameter
Skin
Dissection
Separate straps
Divide thyroid isthmus
Window in trachea
Below 1st ring
Stitch in place Incision=ba
d
Hole=good