A.

Background knowledge Write an inpatient consultation request and an outpatient referral to an otolaryngologist explaining the reasons for referral and level of urgency Be able to write a discharge letter to a general practitioner giving clear advice about the ongoing management of an ear disorder Recall the anatomy, physiology and function of the nose and paranasal sinuses. Recall the blood supply of the nose, with regard to potential sites of epistaxis. Recall the functional anatomy of the oral cavity, tonsils and adenoids, salivary glands, pharynx and larynx. Recall the physiology of the voice production, swallowing and airway functions. Recall the anatomy of the head and neck including lymphatics and thyroid glandShow student resources | View Communicate effectively with patients and parents about common ear conditions and their management. Recall the functional anatomy and relevant physiology of the pinna, external canal, tympanic membrane, middle ear structures, inner ear and balance organ.

The pain of ethmoidal sinusitis is what creates the sensation of pain behind the eyes. Maxillary sinus
Floor is formed by the alveolar process of the maxilla and is responsible for the toothache associated with maxillary sinusitis. Drains into the nasal cavity via the semilunar hiatus. Because this opening is found superiorly within the sinus, the maxillary sinus is particularly prone to infection.

Nasal cavity
Medial and lateral walls mucosa:
Submucosa = richly vascularised = is the site of epistaxis
Kiesselbachs plexus is located in the anterior/inferior quadrant of the nasal septum. It is a frequent site of nose bleeds.
Comprised of the following 4 arteries: - Anterior ethmoidal artery - Sphenopalatine artery: one of the terminal branches of the maxillary artery. Passes through the sphenopalatine foramen to enter the nasal cavity. - Superior labial artery - Greater palatine artery

Lateral Wall: formed by superior, middle and inferior nasal conchae

Conchae are bony processes that warm and humidify air during inhalation.

Nasopharynx
Nasopharynx is the portion of the airway between the skull base and the soft palate
Communicates with the nasal cavity via the choanae Its lateral and posterior walls are formed by the superior pharyngeal constrictor as well as the pharyngobasilar fascia. Pharyngeal tonsils are found in the nasopharynx and contain lymphoid tissue.
Pharyngeal tonsils can become enlarged, and are termed adenoids. Adenoids can obstruct nasopharynx and adenoidectomy is one of the most common pediatric surgeries performed.

The auditory tube opens into the lateral wall of the nasopharynx and connects the middle ear cavity with the posterior nasopharynx.
Respiratory infections can spread easily between the nasopharynx and the middle ear cavity via the auditory tube.

Nasopharyngeal carcinoma is a rare malignancy of the epithelium. It comprises ~1% of childhood malignancies and is strongly associated with EBV infection.

Oropharnyx and laryngopharynx

Oropharynx is the region of the pharynx adjacent to the oral cavity and extends from the soft palate to the epiglottis.
The posterior wall is formed by the pharyngeal constrictor muscles The palatine tonsils are found here in children (often involuted in adults). Contains the palatopharyngeal arches which extend from the soft palate to the lateral pharyngeal wall. Each arch is formed by the palatopharyngeus muscle. Contains palatoglossal arches which extend from the soft palate to the sides of the tongue. Each arch is formed by the palatoglossus muscle.

Laryngopharynx is the portion of the pharynx between the epiglottis and the esophagus.
Posterior wall is formed by the pharyngeal constrictor muscles The piriform recesses are found anteriorly and are a common site for food or foreign objects to become stuck.

Voice and swallowing

Innervations of larynx Internal branch of superior laryngeal nerve: sensory to larynx above cords External branch of superior laryngeal branch: motor to cricothyroid muscle Recurrent laryngeal nerve: all motor to larynx except for cricothyroid muscle; sensory to larynx below cords

 B. Ear disease ear infection (otitis externa/OE) and middle ear infection (acute Symptoms of ear disease otitis media/ AOM). Take a full and clinically relevant Outline the initial treatment for history, perform a basic physical each of the above conditions, examination (see below) and form a including pain relief reasonable differential diagnosis in patients presenting with: Foreign Body painful ear (otalgia) Understand that removal of a painless FB in the ear canal is discharging ear (otorrhoea) usually non urgent and best including bleeding from the ear performed by an experienced hearing loss (unilateral and doctor bilateral) Describe the immediate tinnitus management of a patient with a vertigo/dizziness live insect in the ear facial palsy Vertigo List the sites that share sensory List and understand the causes of innervation with the outer and middle vertigo and use history and ear and can therefore refer pain to the physical examination to arrive at a ear reasonable differential diagnosis Acute ear conditions Hearing Loss Explain the difference between Ear Infections conductive and sensorineural Describe the typical clinical hearing loss and provide examples presentation and key physical of common causes of each. findings that distinguish external

 Ear emergencies Explain why a haematoma of the pinna should be drained as an emergency Diagnose sudden sensorineural hearing loss; list the possible causes and outline the early management of this condition Describe the clinical features that would cause you to suspect a diagnosis of acute mastoiditis and outline the initial management of this condition Explain the importance of excluding a central cause of acute vertigo and describe features on history and examination that would cause you to suspect a central cause Paediatric ear disease Outline your understanding of how anatomical, physiological and immunological differences lead to different patterns of ear disease in adults and children Describe the symptoms, signs and otoscopic findings that would guide you in distinguishing between acute otitis media, middle ear effusion, glue ear, chronic suppurative otitis media,

outline the management of each condition Describe the potential complications of acute otitis media and of chronic suppurative otitis media Describe the considerations in the management of Otitis Media with Effusion (Glue ear) Describe the purpose and care of grommets (tympanostomy tubes) and the management of infected grommets Understand the importance of the safe use of ear drops in the presence of a non-intact ear drum Understand the pathogenesis, presentation and diagnosis of cholesteatoma (congenital and acquired) and the importance of early referral Discuss the importance of early detection of hearing loss in children Hearing loss in adults List and understand the causes of hearing loss and integrate history and physical examination to arrive

 at a reasonable differential diagnosis Explain the importance of further investigation and referral for asymmetric hearing loss Understand the pathogenesis, presentation and diagnosis of cholesteatoma and the importance of early referral Procedural skills

Take an ear swab for culture and sensitivity and interpret the results Interpret the basic features of an audiogram a Perform tympanometry and interpret the findings Examination of the ear

Perform a competent examination of the external and middle ear Syringe an ear safely when clinically Use an otoscope to identify the indicated clinical appearance of: Describe the safe management of normal structures, impacted ear wax wax Insert an ear wick when clinically common pathological conditions indicated including exostoses, otitis Perform Weber and Rinne tuning fork externa, middle ear effusion, tests to differentiate between acute otitis media, tympanic conductive and sensorineural hearing membrane perforation and loss foreign body Correctly use a pneumatic otoscope Use a pneumatic otoscope to assess Outline the principles involved in the mobility of the eardrum under removing a foreign body from the ear positive pressure canal Use a 512 Hz tuning fork to Investigations differentiate between conductive and

Otitis externa Pain worse by movement of auricle Otorrhea = sticky yellow purulent discharge (if wide meatus and no pain then chronic otitis!) Conductive hearing loss due to obstruction of external canal by swelling and purulent debris Post auricular lymphadenopathy Bacteria: pseudomonas aerugonisa, vulgaris, E.coli. S.auerus Fungus: candida, aspergilus niger RF: swimming, q tips, aggressive scratching, hearing aids, headphones Clean under magnification w/ irrigation, suction, dry swabbing If bacterial: antipseudoemonal otic drops (gentamicin, ciprofloxcilin + steroid + systemic antibiotic) DO NOT GIVE AMINOGLYCOSIDE

Otitis media NO pain w/ movement of auricle, but pain over mastoid process Otorrhea ONLY if tympanic membrane perforated TRIAD =FEVER, OTALGIA, CONDUCTIVING HEARIN GLOSS

Bacteria: s. Pneumo 35%, h influ 25%, m catarrahlis 10%, s. Aureus, anaerobes and gram neg if infants

Bottle feeding pacifier use, male, family history

Antibiotic 10 day course systemic antipyretcs/anelgesia = acetaminophen Decongestion for nasal congestion

If fungal = debridement and topical antifungals

Consider tympanastomy tubes for recurrent acute

Flavours of OE
Malignant otitis externa:: Osteomylitis of temporal bone
Presentation:
Refractory Otalgia + purulent otarrhea GRANULATION tissue on floor of auditoary canal

Demographic elderly diabetics, immunocompromised patients Etiology; very rare complications otitits externa esp if due to pseudomonas Complicaitons:
Lower cranial nerve palsy Systemic infection, death

Investigation: ct, hospital admission Tx = debridement iv antibiotics, hyperbaric O2

Acute ear conditions: foreign body

Basically dont try to get it out yourself, get an ENT consult Handling bugs in ear:

Acute ear conditions: hearing loss

Tinnitis ddx

Ear emergencies: hematoma of pinna

Due to trauma (rugby players, wrestlers, etc)
Shearing forces in anterior auricle causes separation of anterior auricular perichondrium form underlying tightly adherent cartilage Shearing of pericondral blood vessels and subsequent hematoma

Tx:
If w/in 7 days of trauma = drain under local anaesthesia , special surgical dressing and antibiotics to prevent infection Examine ear every 24 hours for several days. No aspirin, no nsaids, no anticoag If after 7 days then refer to surgical specialist for open surgical debridement

Why all this fuss? Complications:

Reaccumulation of hematoma Site infection = staph, psuedomonas, Chondirtis Scar formation = cauliflower ear.

Pt presents w/ painful ear

List the sites that share sensory innervation with the outer and middle ear and can therefore refer pain to the ear

Otalgia presentation a ddx

AND THE REFERRED PAIN

Referred pain to the ear

Referred Pain (from CN V, IX and X) - Ten T's + 2 Eustachian Tube TMJ Syndrome (pain in front of the ears) Trismus (spasm of masticator muscles; early symptom of tetanus) Teeth Tongue Tonsil (tonsillitis, tonsillar cancer, post-tonsillectomy) Tic (glossopharyngeal neura1gia) Throat (cancer oflarynx) Trachea (foreign body; tracheitis) Thyroiditis Ramsay Hunt syndrome (Geniculate Herpes) CN VII palsy (e.g. Bell's palsy)

Presentation: Discharging ear

Presentation: tinnitus

Presentation: vertigo/dizziness
Was the room spinning?
Is it central or peripheral?

Vertigo
Defn: illusion of rotational, linear or tilting movement of self or environment 1) Yes the room was spinning 2) Peripheral vs central aka inner ear or brainstem/cerebellum stimulation

Vertigo history is key!

4 aspects to ask about to different between 5 main ddx
Duration Hearing loss Tinnitis Aural fullness

A word about each ddx

Benign Paroxysmal positional vertigo: (most common cause)
Defn: acute attacks of transient vertigo lasting seconds to minutes initiatied by certain head positions + torsional nystgmus Eeiotlogy:
Canalithiasis = migration of free floating otolothis within endolymmph of semiciruclar canal Capulolithasis = otolith attached ot cupula of semiciruclar canal
Posterioral canal is affeted >90% of the time Both are usuall due to head injury, virla infec, deg disease, idiopathic.

Dx: hx and poistive dx hallpike manouvre Tx: will resolve spont, if pt is a bitch then do epley manovure, if that doesnt work then surgery w/ anti emetics for nausea/vomiting meanwhile.

Menieres disease (endolymphatic hydrops)

Defn: tinnitus + hearing loss + aural fullness + vertigo lasting minutes to hours Etiology: inadequate absorption leading to endolymphatic hydrops = over accumulation = dist0riton of membranous labrynth Epidemiology 40-60 Tx:
Bed rest, anti emetics, antivertigo medicaiton = beta histine. Long term: destroy vestibular end organ = gentamicin, can give betahistine prophylactically, consider surgery Monitorother ear as can happen bilaterally in 35% of cases

Vestibular neuronitis vs labrynthitis

Vestibular neuronitis Nausea + vertigo + imbalance Lasts days and residual imabalnace for days to weeks Viral infection, asso URTI symp w/ presentaiton; Diabetes, autoimmune Vestibular equivalent of bells Viral or bacterial Viral: rubella, CMV< mumps VZV Bact: S.pneumo, Ihinfluenxa, M.catarralis, Paeruginosa, Piribalis Complicaitons of acute and chornic otitis media, baceterali meningiits, cholesteatoma, temporal bone fracture Clnical features: Nausea + vertigo+ vomiting + itnnitus + unilateral hearing loss DO CT HEAD MUST RULE OUT MENINGITIS Labrynthitis (acute infection of ear) Vertigo + nausea+ tinnitus + unilateral hearing loss

Clinical features Nasuea + vertigo + imabalnce Irriative nystamus (towards offending ear acutley, away during convalescent phase)

Otitis media
Defn: inflammation of middle ear Etiology: 35% s.pneumo, 25% h.influ, 10% m catarrhalis
other
Anaerboes if newborn Gram negative if infant Viral
Barotrauma Adenoid hypertrophy Down sydnrome, = abnormal eustician tube

Systemic
Immuno supression (steroids, chemohterpay), diabetes, cystic fibrosis

Life style:
Bottle feeding, pacifier use Second hand smoke Crowded living condition,

Rf:
Anatomical
Eusticiantube dysfunc/obstriction:
URTI = swelling of tube mucosa Allergy same reason Chornic sinusitis = same reason Tumour = eg nasopharyngeal caricnoma

Other: male, family history

Basic mechanism
Block eusatchian tube -> Air absorbed in the middle ear -> negative pressure (an irritant to midle ear mucosa -> edema of mucosa with exudate/effusion -> infection of exudate from nasopharyngeal secretions

Presentation
Triad: Ear pain, fever (if young child), conductive hearing loss Infant:
Ear tugging, hearing loss, irritabilty, poor sleeping, anorexia

May present w/ complicaiton

VERY RARE TINNITUS, VERTIGO FACIAL NERVE PARALYSIS Otorrhea IF TM perforated Pain over mastoid process

Investigaitons

Tx
10 day course antibiotic:
Amoxicillin, if pencillin allergic macrolide If amoxiclin fials after 48 HOURS, then 2nd line: double dose, amoxicillin-clauvinic acid, cefuroxime, ceftixime

Symptomatic:
Antipyertic/analgeisc Decongestant

Prevention:
Parent educaiton Antibiotic prophylaxis: amoxicillin efective half theurapetic dose Pneumococal and influenza vaccine

When do you consider tympanostomy tube?

Lack of response (3/12) Persistent effusion 3/12 Recurrent episodes Bilateral hearing loss Chornic retration of tympanic membrane Any of hte ocmplicaitons of AOM on next slide

Taking care of grommets

Complications:
Early: extrusion, blockage, persistent otorrhea Late: myringoslceorsis, persistint TM perforaiton, cholesteatoma

Complications of acute ototis media

Ear related:
TM perforation Chronic suppearive OM Ossicular necrosis Cholesteatoma (intermediate step is OME) Persisting effusion

CNS
Meningiits Brain abcess Facial nerve paralysis

Other
Mastoiditis Labrynthitis Sigmoid sinus thrombophlebitis

Otitis media w/ effusion

Defn: presence of fluid in middle ear WITHOUTSIGNS OR SYMP OF EAR INFECTION Same rf as AOM Clinical features:
Fullness (blocked ear), hearing loss, could have pain but unlikely, Otoscopy findings:
Discoluraiton Meniscis fluid level behind TM Air bubbles IMMOBILITY = MOST RELIABLE FINDING

TX:
No statistical proof that antihistamines, decongestants, antibiotics clear disease Sx: myringotemy, ventilation tubes

Mastoiditis
Infection of mastoid air cells 2/52 after untreated or inadequately treated acute suppurative ottis media Etiology: same as AOM: S.pneumo, pyogenes, aurues, h.influ Classic triad: otorrhea, tenedneress to pressure over mastoid, retoraurtiuclar swelling w/ protuding ear Other: fever, hearing loss, TM preforaiton late Investigations: CT fluid in mastoid air cells, inturrpeiton of normal trabeculations of cells Tx: iv antibiotics w/ ventilation tubs and myringotomy
If fails after 48 hours then surgery If intracranial complications then surgery If discharge persisting for 4 weeks then surgery

Pediatrics: chornic supparative otitis media

Complications

Pediattifs: glue ear

Pediatrics: retracted ty mpanic membrane

Pediatrics and ear drops

Adult and child: cholestatoma and early referral

Defn:
Cyst Cyst = keratizing squamous peithlieum In middle ear, in mastoid and in temporal bone Can be congenital, can be acquired

Clnical features:
Progressive hearing loss = mainly conductive Otalgia, aural fullness, fever Hx of otitis media (Esp unilateral), Hx of ear surgery

O/E
Retraction pocket in TM Otosocpy: TM perforation, 'attic crust' - seen in the uppermost part of the ear drum Malodours unilateral otorrhea

Why is this a scary diseae?

Why is cholestatoma a scary disease?

Complications:
Conductive eharing loss Labrynthitis Temporal bone infection, mastoiditids Facial paralysis Meningitis Sigmoid sinus thromboiss Intracranial abcess!

Therefore must start investagions and tartment CT scan, audiogram, No conservative therapy mastoidiectomy +/-ossicular reconstruction

Congenital Small white pearl behind intact tympanic membrane Due to aberrant migration of external canal ectoderm during development No otitis media, no esutican tube dysfunc

Acquired TM not intact, retraction pockets or perforations Due to otitis media and chronic eustican tube dysfunc Chornic inflammatory process causing progressive destruction

Pediatrics early hearing loss

Impacted ear wax (most ocmmon cause of conductive hearing loss b/w 15-50 Ear wax: secretions from:
Ceruminous glands Pilos-sebacious glands Squamous of epithileium Dust Debri Narrow ear canals Hearing aids Cotton swab usage Osteomata

Rf of getting cerumn impaction:

Features: heairng loss, tinnitus, vertigo, otalgia, aural illnuess Tx: ear wax lytic drops aka ceruminolytic rdrops = bicarb solution olive oil, glycerine, syringe, manual debridement

Syrnage and ear and clinical indication

Syringing indications:
Totally occlusive cerumen w/ pain Decreasing hearing tinnitus

Syringing contraindications:
Must look at TM to see if its intact Only hearing ear Previous ear surgery

Ear wick

Webber and rinne

Pneumotic otoscope

Investigaitons: basic features of audogram

Investigaitons: tympanometry

Examination
Normal struct and pathological conditions w/ an otoscope Normal positive pressure mobility of ear drum

 Exostoses:
Bony proturbence in external auditory canal composed of lamellar bone Cold water swimming If large then can cause cirumen impaction or otitis externa No tx required.

C. Disease of the nose and paranasal sinuses Symptoms of disease of the nose and paranasal sinuses Take a full and clinically relevant history, including risk factors, paying particular attention to each of the following presenting symptoms:
obstruction (bilateral and unilateral) rhinorrhoea/ discharge post-nasal drip facial pain/ pressure/ congestion/ frontal headache anosmia/ hyposmia (reduced sense of smell)

closed-reduction procedure can be performed and describe the consequences of missing the window period

Foreign body
Outline the management of a patient presenting with a nasal foreign body Recognise that certain foreign bodies (eg watch batteries) require immediate removal and describe the consequences of delayed removal Recognise the symptoms and signs in a child that suggest a diagnosis of an unrecognised chronic nasal foreign body

Form a reasonable differential diagnosis for patients presenting with any of the symptoms listed above from history and physical examination Examination of the nose Perform a basic nasal examination using a torch or headlight and a nasal speculum Identify the clinical appearance of normal structures including the septum and turbinates, as well as common pathological conditions including septal deviation, allergic inferior turbinates and nasal polyps Emergencies Epistaxis
Perform an initial rapid assessment of estimated blood loss and severity of epistaxis. Initiate fluid resuscitation and immediate measures to control bleeding where necessary. Undertake a thorough history and clinical examination, paying particular attention to previous history, medications, hypertension, systemic conditions and suspicious features to determine an underlying diagnosis. Perform basic measures to control bleeding (nasal packing)

Common or important conditions Allergic Rhinitis

Outline the epidemiology, diagnostic tests and principles of management of allergic rhinitis. Outline the epidemiology, significance in terms of societal burden, diagnosis and principles of management of chronic rhinosinusitis and nasal polyps

Chronic Rhinosinusitis with/ without polyps

Septal deviation
Describe the symptoms of clinically significant septal deviation and turbinate hypertrophy and outline the management of these conditions

Fractured nose

Clinically assess a patient with a facial injury to distinguish between a simple fractured nose and a fractured nose associated with more complex facial injuries

Sinister pathology Apply this knowledge to differentiating benign nasal pathology from suspicious pathology Understand the significance of unilateral symptoms, risk factors and atypical presentations Investigations Describe the role of imaging, including CT scan, in the diagnosis and management of nose and sinus disorders. Show student resources | View Procedural skills Apply topical anaesthetic and vasoconstrictor spray to the nose Apply an anterior pack for epistaxis. (Advanced - Apply a posterior pack/ Dual-chamber balloon pack, perform cauterisation using silver nitrate)

Disease of nose and paransal sinus: obstruciton

Disease of nose and paransal sinus: rhinorrhea/discharge

Disease of nose and paransal sinus: post nasal drip

Disease of nose and paransal sinus: facial pain/pressure/congesiton/forntal ehadace

Rhinosinusitis
Etiology: Viral>bacterial difficult to diffrentiate. Investigations: clinical dx.
Bacterial rhinositis based on below
Presistent symp >10 days w/o improvement Severe symp fever>39 degrees celcius, purulent nasal dischare, facial pain > 3 days OR Worsening symp >5 days after initally improving viral upper resp infection

Role of imaging only to rule out complicaitons

Supparative complications = CT scan
If periorbital edema If vision abnormalities If altered mental status

X rays useless

Tx: amoxicllin-clauvulinc acid = covers strep pneumo and nontypeable HI. If symp dont improve 3 days after antibtiocs then do sinus pasipraiton to culture.

Disease of nose and paransal sinus: ansomina/hyposoma

Examination
Normal anatomy Septal deviation, allergic inferior turbinates, nasal polyps

Management epistaxis
Anatomy:
Littles area has the kiesselbacks plexus in the anterior portion of cartilaginous septum 4 (scorpio said 5) arteries anastomose at kiselbachs plexus

Etiology:
Most common is trauma (digital, foreign body, fractures (nasal and facial)) But a bigger list than that.

Management
1. 2. 3. 4. 5. 6. Investigations: CBC,PT/PTT, xray, CT if needed ABC Lean pt forward, constant firm pressure 20 min Assess blood loss: pulse, blood pressure, IV NS if needed Aspirate excess blood and clots if needed 4% topical lidogaine + decongesent If 5 failes, then cauterisation (should only be done on ne side) TO sound really smart, if the pt is adolscent male, and they have recurrent epistaxis, then consider juvenile nasopharyngeal angiofibroma most common benign tumour of nasopharynx.

Management: fractured nose

1120, plastric surgery 26

Mangement foreign body

Common coniditon: allergic rhinitis

Cmmon cnodition: chornic rhinositis

Common condition: spetal deviaiton.

Benign nasal pahtology vs suspicous pahtology

D. Throat, head and neck Symptoms

the throat

Post-tonsillectomy bleed
Assess and initially manage patients presenting with post-tonsillectomy bleeding Outline the principles of resuscitation and airway management in this clinical scenario

Take a full and clinically relevant history, including risk factors; perform a basic physical examination (see below); and form a reasonable differential diagnosis in patients presenting with: persistent mouth ulcers, sore throat, airway distress, globus/sensation of foreign body, dysphagia, odynophagia, hoarseness, neck lump Examination of the throat, head and neck Examine the oral cavity and tonsils, using a torch or headlight and tongue depressor or gauze, to identify the clinical appearance of normal structures and common or important pathological conditions including non-healing oral lesions, tonsillitis and quinsy Examine the neck and be familiar with the normal clinical appearance and palpation of normal structures and with common pathological conditions including enlarged lymph nodes and enlarged thyroid gland Acute conditions Tonsillitis/Quinsy
Differentiate between tonsillitis and quinsy and manage appropriately.
Take an appropriate history and examine a patient presenting with persisting hoarseness and explain the importance of specialist referral for hoarseness persisting for greater than 4 weeks

Common or important conditions Neck Lump

Take an appropriate history and perform a physical examination on a patient presenting with a neck lump Describe the clinical approach to the safe assessment, investigation and management of a patient presenting with a neck lump, drawing on your knowledge of the relevant anatomy.. Take an appropriate history and perform an examination in a patient presenting with a head and neck cancer in relation to risk factors and extent of spread Outline the initial investigations and the broad management of patients with head and neck cancer including the need for multidisciplinary care Take an appropriate history and perform an examination in a patient presenting with sleep disordered breathing (from snoring to obstructive sleep apnoea) Understand the important health consequences of obstructive sleep apnoea and broadly discuss management options Outline the clinical presentation, diagnosis and principles of management of laryngopharyngeal reflux

Head and Neck Cancer

Sleep Disordered Breathing

Laryngopharyngeal Reflux (LPR) Investigations Identify the key anatomical features on a normal lateral airway Xray Show student resources | View Procedural skills Remove an easily accessible fish bone from the throat.

Dysphonia/Hoarseness

Emergencies Management

Recognise that the management of life-threatening emergencies includes awareness of the limitations of your inexperience and the rapid mobilising of experienced staff. Describe the clinical features that would help you to differentiate between upper and lower airway obstruction Recognise the importance of early identification of patients with acute upper airway obstruction and of management that is appropriate to the most likely causes Anticipate and prepare for airway insertion before complete obstruction occurs Take an appropriate and history and perform an examination on a patient presenting with acute dysphagia and discuss initial investigations and management Assess and manage patients presenting with fish/chicken bones lodged in

Acute Upper Airway Obstruction

Acute dysphagia

Foreign body

Presentation: Persistent mouth ulcer

Presentaiton: sore throat/Odynophagia/globus

Pharyngitis: streptoccal, viral, Infecitous monolcuesus Tonsilitis Peritonsoler abcess Foreign body/trauma Leukemia Hodgkins disease

Presentation: airway distress

Stridor
note quality, timing body position important:
lying prone: subglottic hemangioma. double aortic arch lying supine: laryngomalacia. Glossoptosis

site of stenosis:
vocal cords or above: inspiratory stridor sub glottis and extrathoradc trachea: biphasic stridor distal tracheobronchial tree: expiratory stridor

indrawing sternal retractions use of accessory muscles of respiration tachypnea cyanosis altered LOC

Feeding Dlfftculty and Aspiration

supraglottic lesion laryngomalacia vocal cord paralysis post laryngeal cleft -+ aspiration pneumonia tracheoesophageal fistula

Respiratory Distress
nasal flaring supraclavicular and intercostal

Presentation Hoarseness
Ddx:
Acute laryngitis
Viral (influenza, adenovirus) bacterial, mechanical (oivce strain + submocsal hemorrhage + gocal cord edema)), enrivnoemntal fume inhalatnion

Chronic laryngits: chroinc voice strian, chorinc irritatinos = smoke, dust, cehmical fume, chornic alc use, GERD, znekers hiatous hernia, allergy hypohtyroidism, addisons
Must rule out malignancy if presents w/ dyshponia

Vocal cord polypos = benign tumour, voice strain, laryngeal irritatns (GERD, allergies, toabcco) Vocal cord nodules = usually seocndarhy to submucosal hemorhage or hyalinsaiton of nodules due to chornic voice abuse. Also urti, smokers, alc (hoarseness worst at end of day) Bneign larnyngeal pailloma: usually bceause of HPV hoarseness and airway obsturction, can undergo malignant transofmration
If pt is a smoker, and hoarseness presnt for more than 2 weeks MUST RULE OUT MALIGNANCY

Tonsillits/quinsy
NOT THE SAME THING!

Quinsy = PERITONSILLAR ABCESS

Defn: cellulitis of space behind tonsillar capsule extending onto soft palate leading to abcess Etiology: GAS 50%, s.pyogenes, s aureus, h.influ and anaerobes RF:
Previous acute tonsilitis spread into plane of tonsilar bed
Sore throat, dysphagia, odynophagia

o/e: tonsil might look normal, uvula deviated, edema of soft palate
Rarely involve CNV = increased salivaiton and trismus Dysphonia Ear pain Cervical lymphadneitis

Epidem: 15-30 Presentaiton:

Triad:
Trismus, ulnar deviation, hot potato voice

Tx:
Secure airway Surgical draingage w/ incision or needle aspiraiton followed by saline irrigation and iv pencillin G for 10 days Consider tonsillecotmy

hx
Fever, dehydraiton

Complications of quinsy
Aspiration pneumonia secondary to rupture of abcess Airway obstruction Lateral dissection into parapharyngeal and or carotid space Bacetermia because of lateral dissection into jugular vein Retropharyngeal abscess

Etiology:

GAS, HI, group G strepto Spneumo, Saureus, HI, m.catarrhalis EBV

Tonsillitis
Etiology: GAS 50%, s.pyogenes, s aureus, h.influ and anaerobes
Presentaiton: Triad: Trismus, ulnar deviation, hot potato voice

Presentation:
Hx:
Sore throat Dysphagia, odynophagia, trismus Malaise Otalgia

O/E

Tender cervical lymphadneopathy: submandibular, jugulodigastric Tonsils enlarged, inflammation eudates white follics hx Strawberry tongue, scarlet fever (if GAS) Patalal petecaie if EBV

Mangaement:
Swab, latex aggluitnation test, monspot (useless for <2 years) Tx: bed rest, soft diet, ample fouid, analgesics and antipyreitcs Antiobitcs only after swab (pencillin or amoxcillin 10 days)

Complication of tonsillitis
RHD Arthritis Scarlet fever Pertionsler abscess Deep enck space infeciotn Sepsis glomeruloneprhitis

Fever, dehydraiton Sore throat, dysphagia, odynophagia o/e: tonsil might look normal, uvula deviated, edema of soft palate Rarely involve CNV = increased salivation and trismus Dysphonia Ear pain Cervical lymphadneitis

Dysphonia/Hoarseness

Upper airway obstruction

Acute dysphagia

Foreign body
Most common cause of accidental death in children in Canada First step rule batteries out! Hx or o/e Depending how it got in --Ingested
usually stuck at cricopharyngeus coins, toys presents with drooling, dysphagia, stridor if very large

Aspirated usually stuck at right mainstem bronchus peanuts, carrot, apple core, popcorn, balloons Presentation:
stridor if lodged in trachea unilateral "asthma if bronchial, therefore often misdiagnosed as asthma if impacts to totally occlude airway: cough, lobar pneumonia, atelectasis, mediastinal shift, pneumothorax inspiration -expiration chest x-ray (if patient is stable) bronchoscopy and esophagoscopy with removal rapid onset, not necessarily febrile or elevated WBC

Diagnosis and Treatment

Post tonsilelcotmy bleed

Neck lump

Reactive lymphadenopathy By far the most common cause of neck swellings. There may be a history of local infection or a generalised viral illness Lymphoma Rubbery, painless lymphadenopathy The phenomenon of pain whilst drinking alcohol is very uncommon There may be associated night sweats and splenomegaly May be hypo-, eu- or hyperthyroid symptomatically Moves upwards on swallowing More common in patients < 20 years old Usually midline, between the isthmus of the thyroid and the hyoid bone Moves upwards with protrusion of the tongue May be painful if infected More common in older men Represents a posteromedial herniation between thyropharyngeus and cricopharyngeus muscles Usually not seen but if large then a midline lump in the neck that gurgles on palpation Typical symptoms are dysphagia, regurgitation, aspiration and chronic cough

Thyroid swelling Thyroglossal cyst

Pharyngeal pouch

Cystic hygroma

A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side Most are evident at birth, around 90% present before 2 years of age

Branchial cyst

An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx Develop due to failure of obliteration of the second branchial cleft in embryonic development Usually present in early adulthood

Cervical rib Carotid aneurysm

More common in adult females Around 10% develop thoracic outlet syndrome Pulsatile lateral neck mass which doesn't move on swallowing

Head and neck cancer

Sleep disorder breathing

Definition
comprises of a spectrum of sleeprelated breathing abnormalities ranging from snoring to

Clinical Features
heavy snoring, mouth breathing, pauses or apnea. enuresis, excessive daytime sleepiness,behaviouralJleaming problems, morning headache, failure to thrive

obstructive sleep apnea (OSA) Epidemiology

peak incidence between 2 and 8 Investigations years when tonsils and adenoids lexible nasopharyngoscopy for are the largest relative to assessment of nasopharynx and thepharyngeal airway adenoids Etiology polysomnography due to a combination of Treatment anatomic and neuromuscular surgical management 1st line: factors: adenotonsillectomy adenotonsillar hypertrophy nonsurgical: behavioural craniofacial abnormalities modification, CPAP neuromuscular hypotonia (i.e. cerebral palsy, Down syndrome) obesity

Laryngopharyngeal reflux
Laryngopharyngeal reflux (LPR),[1][2] also extraesophageal reflux disease (EERD)[3] refers to retrograde flow of gastric contents to the upper aerodigestive tract, which causes a variety of symptoms, such as cough, hoarseness, and asthma, among others. Patients who suffer from laryngopharyngeal reflux, or LPR, are more likely to experience symptoms as a result of stomach acid refluxing into the larynx. Extraesophageal symptoms are the result of exposure of the upper aerodigestive tract to the gastric juice. This causes a variety of symptoms, includinghoarseness, postnasal drip, sore throat, difficulty swallowing, indigestion, wheezing, chronic cough, globus pharyngis and chronic throat-clearing. Some people with LPR have heartburn, while others have little or none of this symptom. Dx:
As there are multiple potential etiologies for the respiratory and laryngeal symptoms, establishing LPR as the cause based on symptoms alone is unreliable. Laryngoscopic findings such as erythema, edema, laryngeal granulomas, and interarytenoid hypertrophy have been used to establish the diagnosis; but these findings are very nonspecific, and have been described in the majority of asymptomatic subjects undergoing laryngoscopy.[11] Response to acid-suppression therapy has been suggested as a diagnostic tool for confirming diagnosis of LPR, but studies have shown that the response to empirical trials of such therapy (as with proton-pump inhibitors) in these patients is often disappointing.

Xray of lateral airway

Summary
Ear
Swelling behind the ear = mastoiditis Haematomas of the pinna = drainage Otitis externa in immunocompromised patients = malignant OE Unilateral effusion in adult = nasopharyngeal mass Sudden hearing loss = urgent review Sudden vertigo in elderly = cerebellar CVA

Summary
Nose
Unilateral discharge = FB Battery = emergency Unilateral clear fluid = CSF Always image before biopsy in nose Unilateral mass + bleeding in young male = JNA - never biopsy Beware unilateral nasal mass

Summary
Throat
Airway - open, maintain, protect Airway FB until proven otherwise Oral swelling / infection = airway threat Unilateral Sore throat with asymmetrical tonsils = peritonsillar abscess Sick kid+ sore throat +drooling = epiglottitis = airway emergency Smoking + hoarseness = laryngeal cancer