Otolaryngology for Medical Students

Orientation, Goals, Tips and Key Topics

Itinerary

Welcome Otolaryngology Staff Tips and Resources MCQ Pre-Test The ENT History The head and neck exam Important ENT Topics

Otolaryngology Staff
Victoria Dr. D. MacRae - Peds/Otology Dr. M. Husein - Peds Dr. J. Yoo - H&N Dr. K. Fung - H&N Dr. J. Franklin H&N Dr. H. Lampe - H&N Dr. S. Sukerman - General University Dr. L. Parnes - Otology St. Josephs Dr. E. Wright - Rhinosinology Dr. V. Janzen - Rhinosinology Dr. C. Moore - Facial Plastics Dr. R. Ruby - Otology

Tips for ENT Rotation

Goal is to gain exposure to the breadth of ENT, not mastery of every subject Your personal objective should be to gain proficiency with ENT history and exam, and familiarity with a range of Primary Care ENT topics Review your 1st and 2nd year lecture notes, ENT for Primary Care text, emedicine, mdconsult Try to review appropriate lecture notes prior to related clinic/OR

The ENT History

Briefer than the Internal Medicine history (think surgical) Key points (especially important in ENT):

Smoking/alcohol history Numbers of infections (e.g. ear, sinus, throat) in last 1, 2, 3 yrs

previous treatments (e.g. which Abx and how recently)

Ears: hearing loss, pain, d/c, tinnitus, vertigo Previous ENT surgeries

The Head and Neck Exam

As with other specialties, the head and neck exam is to be used to supplement clinical information acquired from a detailed history Have an approachbe effective and make sure it can be replicated so as not to miss findings Most of all, practice, practice, practice

You wont know what is normal until you see it many times

The Ear - History

Otologic:

Nasal:

Hearing loss

Obstruction, discharge etc

Onset and rate of progression Otologic vs. referred Consistency?

Otalgia

Drugs:

Otorrhea

Ototoxic agents

Tinnitus Vertigo

Family History

Of hearing loss etc.

Differentiate from dizzyness

Noise exposure

The EAR - Examination

Inspect auricles and mastoid region

size, shape, symmetry, landmarks, color, position, deformities or lesions

Palpate auricles and mastoid

tenderness, swelling, nodules

The Tympanic Membrane

Inspect external auditory canal (with pneumatic otoscopy)

cerumen, color, lesions, d/c, foreign bodies

Inspect tympanic membrane

landmarks color, contour perforations, mobility all 4 quadrants

Examples of Abnormalities...

Normal Tympanic Membrane

Acute Otitis Media

Tympanosclerosis

Perforation with Tympanosclerosis

Osteoma

Otitis Externa

Cholesteatoma

The Ear Hearing Assessment

Formulation:
1.

Conductive Hearing Loss

Disease affecting outer/middle ear Disease affecting cochlea or CN VIII Disease involving both middle & inner ear

2.

Sensorineural Hearing Loss

3.

Mixed Hearing Loss

The Ear Hearing Assessment

Response to questions during history Response to a whispered voice Tuning fork air/bone conduction

Rinne (image above) Weber (image below)

Interpretation of Tuning Fork Test

Test Expected Findings CHL SNHL

Weber

No Lateralization

Lateralization to ear with loss Bone conduction better than air conduction (Rinne negative)

Lateralization to better hearing ear Air Conduction better than bone conduction

Rinne

Air Conduction better than bone conduction (Rinne positive)

The Audiogram -- the Basics

Bone conduction line Air conduction line Air-bone gap = conductive hearing loss Depressed bone conduction line = sensorineural loss

The Nose and Paranasal Sinuses History

Nasal

Sinuses

Rhinorrhea Nasal obstruction Sneezing Discharge Olfaction Allergies

Facial pain Dental pain Hearing loss Post nasal drip Olfaction Congestion Discharge

The Nose & Paranasal Sinuses Exam

Inspect the external nose

shape, size, color, nares

Palpate the ridge and soft tissues of the nose

tenderness, displacement cartilage/bone, masses

Evaluate patency of nares Inspect nasal mucosa and septum

color, alignment, discharge, swelling of turbinates, perforation

Inspect and palpate regions of the sinuses Flexible/Rigid Endoscopy

Sinusitis

Examples - Polyps

Septal Perforation

Nasopharyngeal Carcinoma

Upper Aerodigestive Tract - History

Oral Cavity/Oropharynx:

Hypopharynx/Larynx

Pain Bleeding Dysarthria Numbness/Dysgeusia Referred otalgia Dry mouth

Dysphonia Dysphagia Cough/hemoptysis Pain Shortness of breath Stridor Globus

Swallowing:

Dysphagia

Solids vs liquids

Odynophagia Aspiration Reflux

The Oral Cavity - Examination

Inspect lips and vermilion borders

symmetry, color, edema, surface abnormalities

Inspect and palpate gingiva

color, lesions, tenderness

Inspect teeth

occlusion, caries, loose or missing teeth

Inspect and palpate tongue and buccal mucosa

color, symmetry, swelling, ulcerations

Inspect palate, floor of mouth, uvula, tonsils, oropharynx

The Neck - Examination

Inspect the neck

symmetry, alignment of trachea, fullness, masses, webbing, skin folds, jugular vein distribution, carotid artery prominence

Evaluate range of motion of neck Palpate the neck

tracheal position, tracheal tug, movt hyoid bone and cartilages with swallowing

Lymph Node Groups

Palpate lymph nodes

size, consistency, tenderness, warmth, mobility

Pre-auricular Post-auricular Occipital Jugulodigastric Submental/submandibular Facial Anterior&Posterior Cervical Supraclavicular

The NECK

Palpate the thyroid gland

Size, shape, configuration, consistency, tenderness, nodules Examine on deglutition

The Larynx

Indirect laryngoscopy

hold pts tongue wrapped in guaze with one hand hold mirror in other hand against soft palate assess vocal cord mobility, lesions in region posterior pharyngeal wall, posterior cricoid region, piriform recesses vocal cord mobility and appearance arytenoid mucosa/cartilages, aryepiglottic folds epiglottis, valleculae, base of tongue

Direct laryngoscopy

Examples of Oral Cavity - Torus

Oral Cavity Traumatic Fibroma

Oral Cavity - Hemangioma

Oral Cavity - Papilloma

Oral Cavity - Squamous Cell Carcinoma

Leukoplakia

Examples - Hypopharynx/Larynx
Foreign Body (Fish Bone)

Vocal Cords

Cyst Papilloma

Nodule Polyp

Vocal Cord - SCC

Leukoplakia

Hypopharynx/Supraglottis

Pyriform Sinus Ca

Epiglottitis

Cranial Nerves

Examine cranial nerves II - XII Consider screening neurological exam in dizzy patients:

Mental Status Cranial Nerves Gross Motor Gross Sensory Reflexes Cerebellar Tests (Rhomberg, finger-to-nose, heel-shin, rapid alternating hand movements)

Common Topics in ENT

(based on the clerkship objectives)

Otitis Media and Otitis Externa Tinnitus and Hearing Loss Vertigo Facial Paralysis Epistaxis Acute and Chronic Sinusitis Obstructive Sleep Apnea Cancers of the Head and Neck

Otitis Media

Otitis Media

Most common disease diagnosed by clinicians Incidence rapidly increasing each year, almost 90% of kids have at least one bout by their 2nd b-day Presentation: fever, pain, irritability (in kids) also conductive HL, behavioural changes, otorrhea, anorexia, Organisms: Strep. Pneumoniae (40%) Haemophilus influenzae (25%) Moraxella catarrhalis (12%) Risk Factors: day-care, passive smoking, family history, non-breast fed, no vaccine

Otitis Media

Why?

Eustachian tube dysfunction in children skull)

(ie. Anatomy of infant

Treatment considerations: antibiotics for AOM, OME, RAOM

antbx 7-10 day regime vs 6-8 weeks role of tympanostomy tubes +/- adenotonsillectomy (see Bluestone figures)

When to refer

Otitis Media - complications

Features of high risk: neonate, immunocompromised state (diabetes, HIV, neutropenia) Symptoms of intracranial pathology:

fever, severe headache, meningeal signs, seizures

Symptoms of otologic pathology:

pain (retroorbital, mastoid), vertigo, SNHL, displaced pinna, cranial nerve 6,7,8

Otitis Media - complications

Otologic Mastoiditis/subperiostel abscess Petrous Apicitis Labyrinthitis Facial Paralysis Intracranial Meningitis Epidural abscess Sigmoid sinus thrombosis Brain abscess

Otitis Externa

Otitis Externa

Presentation: otalgia, fullness, pruritis, hearing loss Etiology: Otitis media, water exposure, canal trauma Organisms: pseudomonas, proteus, Staph, fungal Treatment:

Debridement ototopical agents (Ciprodex, Garasone, Sofracort) 3-7 days PO antibiotics if severe (cellulitis/nodes) analgesics water precautions, pt education

Tinnitus

Tinnitus - DDx

Presbycuisis - age-related sensorineural loss Cardiovascular dz - pulsatile Menieres - assocd w/ episodic vertigo, aural fullness, hearing loss Brain neoplasm - esp CPA tumors Trauma/noise - assocd w/ temporary hearing loss Psychosocial Dz - aural hallucinations, esp. Schiz Drug-induced - ASA most common, usually highpitched, reversible Otosclerosis - otospongiosis of cochlea, labyrinth Multiple Sclerosis

Hearing Loss

Hearing Loss

Conductive Hearing Loss

impedes amplification and/or transmission of sound to cochlea can involve external ear, EAC, TM, middle ear space, and/or contents

Sensorineural Hearing Loss

involves inner ear (i.e. cochlea), acoustic nerve, and/or central auditory pathways

Hearing Loss: DDx

Conductive

External Ear

Sensorineural

congenital atresia cerumen foreign body malformations infections neoplasms congenital effusions (serous OM) acute OM neoplasms otoclerosis TM perforation ossicular discontinuity tympanoscerosis otosclerosis ossicular fixation mastoiditis

congenital acquired

Middle Ear

presbycuisis noise-induced HL head trauma drug toxicity Menieres sudden SNHL tumor perilymphatic leak CNS disease (e.g. MS) labyrinthitis

Vertigo

Vertigo

false perception of movement important Qs: onset, duration, frequency, associated ear symptoms, positional triggers, hx ear dz/head trauma ENT exam, plus Hallpike maneuver, CN+cerebellar testing

Common Causes of Vertigo

Menieres Dz

episodes lasting mins-hrs roaring tinnitus, aural fullness, low-pitched hearing loss

Benign Paroxysmal Positional Vertigo (BPPV)

most common cause episodes lasting secs triggered by head movt +/- hx injury, infection

Labyrinthitis/Vestibular Neuronitis

Central

sudden onset lasts hrs, subsides over days hx viral infection

assocd other neuro S+S +/- LOC vascular temporal lobe cerebellar

Facial Paralysis

Acute Facial Paralysis

Recall/review anatomy of the facial nerve; its intra-extracranial components History: onset, duration, rate of progression, recurrence (Bells , MR syndrome) Associated symptoms: numbness middle and lower face, otalgia, hyperacusis, diminished tearing, taste alteration Bells; intense ear pain and vesicular eruption HZ infection Complete Head and Neck exam/ CN assessment, palpation of parotid gland and neck Facial palsy; complete vs incomplete, segmental vs uniform involvt, unilateral vs bilateral (<1%)

Acute Facial Paralysis: Investigations

CBC with diff and ESR Serum antibody tests; serum ANA and RF Electrophysiologic tests

nerve excitability test (NET) maximal stimulation test (MST) Electroneurography (ENoG) Electromyography (EMG)

CT, MRI+/- CXR

Acute Facial Paralysis Bells

Rapid onset palsy, minimal assoc symptoms, spontaneous recovery 1/3 pts develop only paresis, 95% total recovery 2/3 complete paralysis, facial tone/movt 85% in 3 wks; expect 3-6 months The longer the delay in recovery, the greater the liklihood of adverse sequelae ? HSV evidence for etiology

Acute Facial Paralysis Treatment

Treatment must be initiated promptly for maximal efficiency delay of > 3 days decreases efficiency Medical tx:

Prednisone 1mg/kg/day for 7-10 days Acyclovir 400mg po 5 times daily for 7 days

Surgical Tx:

Decompression (>90% degen on ENoG w/in 14 days onset + no voluntary motor unit potentials EMG)

Eye Care

avoid vents, liberal use of ophthalmic lubricants, shielded glasses Potential gold weight implants, canthoplasty, tarsorrhaphy for long term

Epistaxis

Epistaxis

Most common bleeding d/o of head and neck

Very common 60% incidence through ones life 10% seek medical attention; 6-10% ENT consult

Seasonal incidence Winter > Summer POTENTIALLY LIFE THREATENING Etiology consider local and systemic factors Site of bleed Anterior 90% Posterior 10%

Epistaxis first things first

History: side, duration, amount, temporal pattern, trauma PMHx: liver disease, coag d/o, family hx, HTN, previous epistaxis, nutrition Medications: ASA, NSAIDS, warfarin, heparin, chloramphenicol, dipyridamole Examination: - ABCs and vitals (orthostatics) - General exam (purpura, petechiae) - Nasal exam (head light, suction, decongest, determine bleeding site)

Epistaxis Acute Management

Reassure patient IV hydration depending on extent of bleed control HTN Bloodwork CBC, INR/PTT, Group and Cross Treatment - depends on etiology - those with systemic factors, conservative, noncauterizing, cartilage-sparing techniques for initial therapy correct coags, d/c meds

Epistaxis Acute Management

Anterior : localize bleed - silver-nitrate cautery - surgicel/oxycel (cellulose),gelfoam (gelatin) - anterior packing (merocel vs impreg guaze) - PO antibiotics with packing (TSS) Posterior: difficult to see etiology - posterior packing (foley/rockets/formal pack) - embolization - IMAX , ethmoid ligation - endoscopic cauterization Consider ENT referral if posterior pack required

Sinusitis

Sinusitis

Inflammation of mucosal lining of the sinuses Pathophysiology: patency of ostia function of cilia quality of nasal secretions Predisposing factors: local, regional, systemic Be aware of complications very serious GET CULTURE for diagnosis Treat for at least 10 days 3 weeks to prevent relapse

Sinusitis - Classification

Rhinosinusitis classified according to 5 axes: clinical presentation: acute, subacute, chronic sinus involved: ethmoids, maxillary, frontal, sphenoidpansinusitis causative organism: bacterial, viral, fungal, protozoan presence of complication: extrasinus extension modifying or aggravating factors: immunosuppression, diabetes, malnutrition, NG tube, IgG deficiency

Sinusitis - bacterial

Acute lasts 1 day 4 weeks - management antbx for at least 7 days post-sx - surgery rarely necessary complications Subacute lingers 4 weeks 3 months - inflammation still reversible med. managet Chronic - persisted disease > 3 months - generally irreversible damage to sinus drainage - surgical managet

Sinusitis

Viral sinusitis:

follows viral URI damage cilia from cilia ciliotoxins predisposes to bacterial sinusitis noninvasive (mycetoma, AFS) invasive ( fulminant FS, indolent) orbital intracranial need aggressive medical AND surgical tx

Fungal sinusitis:

Complications of sinusitis

Obstructive Sleep Apnea

Obstructive Sleep Apnea

repeated reductions/cessations in airflow, w/ apnea index >=5, respiratory disturbance index (RDI) of at least 10 on polysomnograph central apnea: absence of airflow assocd w/ lack of inspiratory effort Snoring: 28% of women, 44% of men aged 30-60 OSA: 9% of women, 24% of men (RDIs of 5 or higher)

OSA: Pathophysiology

tongue contacts the soft palate and posterior pharyngeal wall in the presence of lateral collapse of the pharynx, thus generating occlusion risk factors: obesity, redundant tissue in the neck, retrognathia, craniofacial anomalies Alcohol and other sedating medications may contribute

OSA Management

Investigations: Polysomnogram (Sleep Study) Treatment

Conservative Measures: weight loss, avoid sedatives, sleep on side Continuous Positive Airway Pressure (CPAP) Oral Appliance Surgery in select patients: Uvulopalatopharyngoplasty, septoplasty

Neoplasms of the Head and Neck

Neoplasms of the Head and Neck

6-8 % of all malignancies in the body historically M>F but ing in women due to smoking 90% Squamous Cell Ca

H&N Tumors: Risk Factors

Nose/Sinuses: asian descent, hardwood dust, nickel, chromium Lip: UV exposure, poor oral hygiene, smoking/EtOH Salivary Gland: smaller gland, risk malignant Oral Cavity: smoking, EtOH, poor oral hygiene, chronic dental irritation, betel nut chewing Pharynx: smoking, EtOH Thyroid: family history, radiation exposure

Peritonsillar Abscess

Common complication of tonsillitis in adolescents and young adults Symptoms: trismus, painful swelling in throat, dysphagia, odynophagia, fever, otalgia, hot potato voice Classic findings:

unilateral swelling peritonsillar region with bulging soft palate Deviation of midline of palate and uvula to contralateral side

Hx: sore throat > 5 days with ineffective antbx tx

Peritonsillar abscess

Management:

Clindamycin 300mg QID x 7 days + analgesics Needle aspiration and I&D (effective >90%) - risk of recurrence 10-15% - pts younger than 40 yrs with hx of recurrent tonsillitis @ greatest risk >2 bouts of peritonsillar abscess candidate for tonsillectomy Inability to swallow fluids, poor airway, immunosuppression, young patients may be factors for admission Tonsillectomy for some surgeons

Upper Airway Obstruction

Can present as a life-threatening hypoxemia and hypercapnia First priority is to establish airway; dont forget about the nasopharyngeal a/w Signs: inspiratory stridor (decreased intraluminal pressure compared to atmospheric pressure Bernouille principle Most important step in initial evaluation is determining whether an airway needs to be established immediately

Upper Airway Obstruction Diagnostics

History/Symptom Features
Severity of symptoms Hx tobacco/ETOH Fevers/chills/pain Recent neck/chest surgery Hx previous intubation Hx HTN or fam. Hx obstn Severe hoarseness

Considerations
? Immediate a/w ? Cancer in upper a/w ? Infection ? site RLN injury VC paralysis Post. Glottic closure or subglottic scar tissue angioedema Obstn @ glottic level

Upper A/W obstruction - Dx

Main points in hx: timing, age, PMHx, other systemic d/o, ability to sleep lying down Physical exam: pt may need antihistamines, epinephrine, steroids, antbx during dx evaluation Pulse oximetry demonstrates end-point obstn, no info during progression Hypercapnia, acidosis early signs of hypoventilation Agitation, cyanosis, resp effort on inspection Nasal flaring, neck retractions, accessory muscle use signs of fatigue; listen to chest for symmetry/noises

Upper A/W obstruction - Dx

Complete head and neck exam: nose, oral cavity, larynx highlight exam Radiology: may not be time for soft tissue lateral views, generally not great aid to dx

CT and MRI useful

Management related to diagnosis and urgency

Differential Diagnosis Upper A/W obstruction

MISI BOVO Malignant tumours (SCC, Adenoid cystic of trachea, thyroid Ca) Infections (Epiglottitis, supraglottitis, Tracheitis, cellulitis FOM
Lugwigs, Retropharyngeal abscess)

Subglottic stenosis (hemangioma, intubation) Inflammatory (GERD larygospasm, Angioedema) Benign tumours (recurrent papillomas, chondromas, lipomas,
fibromas) Body (Foreign)

Differential Diagnosis Upper A/W obstruction

Other Vocal Cord lesions (polyps, glottic webs) Vocal cord paralysis (recurrent nerve injury, systemic neurologic
disorder, idiopathic)

Other Vocal Cord Mobility D/O (cricoarytenoid joint fixation,

inspiratory adduction functional laryngospasm, scar tissue in interarytenoid region)

Angioedema

Presentation: acute painless mucosal edema - face, lips, tongue, larynx - airway obstruction 20% Etiology ACE Inhibitor sensitivity most common - see chart Treatment aggressive - high humidity oxygen, epinephrine, antihistamines, steroids - secure airway (observe, ET Tube, tracheotomy) - D/C ACE inhibitors and Med consult (HTN)

Temporal Bone Fractures

Blunt and penetrating trauma MVA, fall Three types : longitudinal, transverse, mixed Longitudinal: most common 70-80% - facial nerve injury 10-20% - ruptured TM, hemotympanum, CSF leak - persistent conductive HL (ossicular chain) Transverse: # usually involves bony labyrinth - profound SNHL - facial nerve injury (~ 50%) - CSF otorrhea/rhinorrhea, meningitis

Temporal Bone Fractures

Management: - trauma protocol ABCs, C-spine - Ear exam - Assess facial nerve early (immediate vs delayed) - Assess hearing Audiogram, tuning forks - Radiology Head CT (brain injury) + CT temporal bone windows

Temporal Bone Fractures

Treatment: immediate facial nerve paralysis OR to repair delayed FN paralysis observe, steroids, eye protection CSF leak conservative bed rest, >90% resolve in two weeks SNHL hearing aid conductive HL ossicular reconstruction vertigo tx symptomatically, Serc, Meclizine, PT

Nasal Fracture

Very common; most common facial fracture High index of suspicion for fracture - mechanism, appearance, epistaxis, obstruction Examine entire face (nose, orbit, zygoma, mandible) - instability, mobility, crepitation - septal hematoma, lacerations Facial x-rays variable reliability CT face indicated if other fractures present ENT REFERRAL - < 5 days for closed reduction - > 12 days for septorhinoplasty

Sudden Sensorineural Hearing Loss

Hearing Loss

sudden, usually unilateral no trauma history rapidly progressive (<3 days) Etiology Uncertain - Viral (30-50% assoc viral URTI) - see chart Associated Symptoms Aural fullness, tinnitus, vertigo

Sudden SNHL

Diagnostics: 90% no etiology found - normal P/E - Audiogram, ABR, Otoacoustic emission - Lab tests (see chart) - possible MRI with gadolinium (1-3% AN) Management: 2/3 recover spontaneously - Antiinflammatory steroids - vasodilators carbogen, histamine, papaverine - rheologic agents LMW dextrans, heparin - antivirals/diuretics/triiodobenzoic acid deriv - surgery Bottom line: EARLY REFERRAL