ENT

ENT Emergencies

Tonsillitis
- Inflammation of tonsils
- Dx:
1. FBC
2. Paul Bunnel Test (Heterophile Antibody Test)  rapid test for
mono
LFT
- Tx:
1. Broad spectrum antibiotics
2. Analgesia +/- steroid bolus

Quinsy (Peritonsillar Abscess)

- Abscess formation (filled with pus) due to infection behind the
tonsils
- Dx:
1. CT Scan
2. MRI
- Tx:
1. Antibiotics
2. Analgesia
- Trismus: during the physical examination, trismus (inability or
difficulty in opening the mouth) present because of inflammation of
the pharyngomaxillary space and pterygoid muscle

Epiglottis
- Causative organism:
1. Children (life threatening): H Influenzae type B
2. Adults (supraglottitis): broad range of respiratory pathogens
 Biphasic stridor seen in supraglottitis

- S+S: Epiglottitis Croup

1. Fever Cause Bacterial Viral
2. Recent URTI Age 1-5 years
3. Sitting forwards, drooling Obstruction Supraglottic Subglottic
4. Sore throat Fever High Low
5. Plummy voice Dysphagia Marked None
6. Dysphagia Drooling Present Minimal
Posture Sitting Recumbent
Toxaemia Mild – severe Mild
Cough None Barking,
brassy
Stridor Voice Muffled Hoarse
- High-pitched, wheezing RR Rapid Rapid
sound caused by Laryngeal Tender Non-tender
disrupted airflow Palpation
Clinical Course Rapid Longer
resolution resolution
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- Tx:
1. Oxygen
2. Adrenaline Nebulisers
3. Heliox
4. Steroids
5. Antibiotics
- Requires urgent ENT, Anaesthesia, and Paeds referral

Nasal Fracture
- Tx:
1. Exclude other max-fax fractures
2. Exclude CSF rhinorrhoea
3. Analgesia
- Referral needed if obvious deformity (after 5-7 days) or septal
haematoma

Epistaxis
- Children: recurrent self-limiting bleeds
o Risk factors: URTIs, digital trauma
- Adults:
o Traumatic
o Anterior bleed
 Little’s area
 Recurrent, self-limiting
o Posterior bleed
 Elderly
 Medical comorbidities (hypertension, aspirin, warfarin)
 More severe and require admission
- Tx:
o Resuscitate
o FBC, G&X match, Platelets
o BP, IV Line (Cautery)
o Nasal Packing  BIPP, Merocel, Rapid Rhino

Foreign Body in Nose

- Tx:
o One attempt at removal only
o Don’t use forceps for round objects
- Urgent ENT referral

Orbital Cellulitis
Chandler’s Classification – Orbital
- Tx:
Cellulitis
o Systemic
Grade Periorbital cellulitis (preseptal)
antibiotics
1
o Decongestants
Grade Orbital cellulitis (post septal)
o Analgesia
2
Grade Subperiosteal abscess
3
Grade Intraorbital abscess
4
Grade Cavernous sinus thrombosis
5
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- Urgent ophtho and ENT referral and CT sinuses

Otitis Externa
- Discharge, pain, hearing loss, itching
- Commonest organisms: S Aureus, Ps Aeruginosa, Proteus
- Predisposing factors: water, cotton buds, eczema
- Tx:
1. Topical antibiotics
2. Aural toilet
3. Analgesia

Acute Otitis Media

- S+S:
1. Pain
2. Discharge (otorrhea)
3. Hearing loss
- Tx:
1. Systemic antibiotics
2. Analgesia
3. Decongestants

Perichondrial Haematoma
- Tx:
1. Systemic antibiotics
2. Analgesia
- Urgent referral for incision and drainage

Facial Palsy
- UMN (forehead sparing): CVA, MS
- LMN (complete): Bell’s Palsy (idiopathic)

Intracranial Intratemporal Extracranial

Acoustic Trauma Trauma
Neuroma
Guillain Barre Acute Otitis Media Malignant parotid
tumour
Neurosarcoid Malignant Otitis
Externa
Glomus Ramsey-Hunt
- Tx: Tumour Syndrome
1. Lyme Disease SCC
Cholesteatoma
Prednisolone 30mg
2. Acyclovir 200mg 5x/day
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3. Hypromellose eye drops

4. Lacrilube ointment

- Urgent ENT review  red, bulging ear drum

- If poor eye closure  ophthalmology review

HPV

General Information
- Common Wart: HPV 1, 2
- Recurrent Respiratory Papillomatosis (benign form): HPV 6, 11
- Genital Warts: HPV 6, 11
- High Risk Strains: HPV 16, 18, 31, 33, 45, 52, 58

Effectiveness of Gardasil
- Over the last decade, impact of HPV vaccination in real-world
settings has become increasingly evident, especially among girls
vaccinated before HPV exposure in countries with high vaccine
uptake.
- The following maximal reductions in HPV infections and diseases
have been reported globally:
o ~ 90% for HPV 6/11/16/18 infection
o ~ 90% for genital warts
o ~ 45% for low-grade cytological cervical abnormalities
o ~ 85% for high-grade histologically proven cervical
abnormalities

Side Effects of Gardasil

1. Pain, redness, and/or swelling at site of injection
o Symptoms show immune response
2. Fainting  15 minutes post vaccination
3. Anaphylaxis (severe)
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Gender Neutral Vaccination

- Vaccinate boys!

Thyroid Cancer Management

Spectrum of Thyroid Disease

- Diagnosis of a papillary carcinoma is based on nuclear features:
o Ground glass orphan annie nuclei, longitudinal nuclear
grooves and nuclear inclusions
- Risk factor for papillary thyroid carcinoma:
o Ionizing radiation
- Treatment of choice for papillary thyroid carcinoma: thyroid
lobectomy

Trends in Thyroid Cancer

- Larger nodules = easy to diagnose  don’t miss many 5cm thyroid
cancers
- Smaller nodules (1cm, 1.2cm) these are the tumors driving the
increased incidence
- 87% from small tumors largely defined by non-clinical 
ultrasonography
- Cancers have always been there, but most are asymptomatic
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Overdiagnosis in Cancer
- Treating these cancers has no impact or effect for the patient
- Don’t prevent their symptoms, don’t prevent their death
- Treating these diseases is of no benefit and possibly harmful in
treating them

Prognostic Factors

Obstructive Sleep Apnea

Definitions
Sleep apnea: intermittent cessation of airflow at the nose and mouth
during sleep

Apneas: cessation of airflow at the nose and mouth of at least 10 s

duration
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Apnea-Hypopnea Index: number of apnea and hypopnea events per hour

of sleep
- Normal is < 5

Hypopnea: 30% reduction in airflow, with a concomitant 4% drop in

oxygen saturation

Snoring: vibration of respiratory structures and the resulting sound due to

obstructed air movement during breathing while sleeping

Types of Sleep Apnea

1. Central Sleep Apnea: neural drive to all respiratory muscles is
abolished
2. Obstructive Sleep Apnea: airflow ceases despite continuing
respiratory drive because of occlusion of the oropharyngeal airway

Prevalence
- 2% in middle-aged women
- 4% in middle-aged men

Pathophysiology

Causes of Adult Obstructive Sleep Apnea

1. Loss of muscle tone
2. Obesity
3. Old age
4. Conditions causing narrowing of the upper airway
5. Brain injury
6. Alcohol/ smoking/ medications
7. Craniofacial abnormalities
8. Genetics
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Signs and Symptoms

1. Daytime sleepiness
2. Snoring
3. Morning headaches
4. Awakening with a sensation of choking, gasping
5. Moodiness or irritability
6. Lack of concentration & Memory impairment
7. Decreased libido and impotence
8. Nocturia
9. History of hypertension, cardiovascular disease, cerebrovascular
disease & T2DM
10. Depression

Diagnosis
1. History
2. Clinical examination: BMI, neck circumstance, nasal and throat
examination, endoscopic exam with Muller manoeuvre
3. Epworth Sleepiness Scale: measure daytime sleepiness
4. Polysomnography: overnight sleep study with recordings of:
a. ECG, EEG, EOG, submental EMG
b. Movement of chest wall and airflow at the
mouth and nose
c. Arterial O2 saturation (finger/ear oximetry)
d. Heart rate
e. Apnea-Hypopnea Index 

Treatment Options
1. Lifestyle Modifications: weight, stop smoking and drinking, avoid
sedatives

2. Mandibular Advancement Device: dental appliance, used to treat

mild OSA

3. Continuous Positive Airway Pressure (CPAP): pneumatic splitting of

airway, used in moderate to severe OSA, possible side effects:
a. Mask discomfort
b. Nasal dryness or irritation
c. Difficulty breathing through your nose
d. Headaches and ear pain
e. Stomach pain and flatulence (wind)

4. Surgical Options:
a. Nasal surgery to restore patent nasal airway
b. Adenoidectomy & adenotonsillectomy
c. Palatal surgery: UPPP, LAUP
d. Hyoid Advancement
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e. Midline laser glossectomy

f. Maxillary/mandibular glossectomy
g. Tracheostomy

Paediatrics Obstructive Sleep Apnea

- 1-3% of all children, but up to 40% of those children that snore.
- Peak incidence 2-8 years (lymphoid tissue maximal size)

Natural History
1. Poor growth
a. GH secretion reduced in children with OSAS

2. Learning and Behavioral issues

a. Reduced academic performance
b. Hyperactivity Causes
c. Aggression 1. Adenotonsillar
d. Poor attention Hypertrophy
e. Reduced alertness 2. Obesity
3. Craniofacial
3. CVS/ Resp Complications Abnormalities
a. Pulmonary HTN/ cor 4. Storage
pulmonale Disorders 
b. LVH mucopolysacc
haridoses
Examination
History
1. General
1. Nighttime symptoms
a. Syndromes or structural
a. Snoring
abnormalities
b. Apneas
b. BMI
c. Nighttime sweats
2. Tonsil and adenoid size
d. Restless
a. Poor correlation
e. Enuresis
3. Nasal exam
2. Day time symptoms
a. Septal deviation, intranasal
a. Mouth breathing
masses, turbinate
b. Nasal obstruction/ hypo nasal
enlargement
speech
4. Oral cavity
a. Tongue size and motion
b. Pharyngeal dimensions

Treatment
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1. Conservative
a. CPAP/ BIPAP: useful prior to surgery if child unfit or if there is
a delay  poor compliance
b. Oral and nasal steroids: only helpful if an acute condition is
causing the OSAS (EBV)

2. Surgical
a. Adenotonsillectomy (1st line): curative (83%)  those with
severe OSAS may have residual symptoms but have
improvements on sleep study

b. Other
i. Tongue reduction for macroglossia
ii. Craniofacial surgery
1. Mandibular advancement
2. Midface distraction
3. Choanal atresia repair
Fundamental Skills

Otology
1. Inspection:
a. Postauricular (scars)
b. Congenital scars
c. Trauma
d. Lesions

Tips for Examination

- Ensure you have a well-rehearsed explanation of everything you plan
to do prior to commencing the test, which should include:
o Name of instrument in hand
o What it measures
o Discomfort level expected
o Where the instrument is going in relation to patient
o How long the exam could take
o If further instructions will be offered during the exam
o Ask patient if they understand, any questions, and if you may
proceed

Weber’s Test Interpretation

Symmetric Hearing: tone is heard centrally or bilaterally
- Conductive Hearing Loss: lateralizes to affected ear
- Sensorineural Hearing Loss: lateralizes to better-hearing ear
- AC is louder than BC: Rinne’s positive
o Normal ears and the vast majority of SNHL
- BC is louder than AC: Rinne’s negative
o Significant conductive element
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Rhinology
1. Inspection
a. Change in shape / contour of the nose
b. Deformities congenital / acquired if any
c. Presence of swelling  inflammatory, cysts, or tumors
d. Presence of ulceration  trauma / infective / neoplastic

Oral Cavity and Oropharynx

- Use head light and tongue depressor(s)
- Patient seated at the same level as examiner
- The patient's legs must be placed to one side of the examiner
- Remove dentures
- Use gloves to palpate mucosal lesions

Oral Cavity Subsites

- Oral exam must include examination of all 7 subsites:
1. Lips
2. Gingiva
3. Floor of mouth
4. Tongue
5. Buccal mucosa
6. Hard palate
7. Retromolar trigones
Otology and Lateral Skull Pathology

Outer Ear
1. Pinna Disorders (congenital): microtia, bat ear

2. Trauma: head injury, base of skull fracture, tympanic membrane

perforation, CSF otorrhoea, facial nerve function, cut wounds and
laceration, auricular hematoma  aspiration or I&D with
compression dressing

3. Wax: secreted from sebaceous and ceruminous glands in EAC

a. Contents: lipids, lysozymes, desquamous debris
b. Natural migration pattern and normal ear hygiene
c. Wax impaction treatment
i. Syringing
ii. Microsuction

4. Infections: otitis externa

a. Etiology
i. Water exposure d. Microbiology
ii. Scratching i. Pseudomonas
iii. Skin conditions aeruginosa
b. Symptoms ii. Staph
iii. Fungi (otomycosis)
e. Treatment – local
i. Topical
antibiotic/steroid
ii. Canal toilet
iii. Wick
f. Complications
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i. Pain on moving the pinna

ii. Discharge
iii. Itch
c. Signs
i. Red
ii. Edematous skin
iii. Debris
iv. Tympanic membrane intact

Necrotizing Otitis Externa

- Osteomyelitis and spread of infection along lateral skull base in
patients with DM or immunocompromised
- Microbiology
1. Pseudomonas aeruginosa
2. Staph, Aspergillus, Proteus (rare)
- S+S:
1. Severe Otalgia
2. Granulation tissue in EAC
3. Cranial nerve palsies
- Diagnosis:
1. CRP, ESR, FBC, Ear swab
2. CT Scan, MRI scan

Other Outer Ear Infections

1. Pinna Cellulitis: Staphylococcus, Streptococcus, Pseudomonas
2. Erysipelas: Group A β-haemolytic Streptococci
3. Relapsing polychondritis: autoimmune disease, treated with steroids
4. Herpes Zoster Oticus (Ramsay – Hunt Syndrome) discussed in CNVII
lecture

Middle Ear
1. Lateral Wall: tympanic membrane, Chorda Tympani
2. Medial Wall: promontory, oval & round Window, facial nerve, LSCC
3. Posterior Wall: entrance to mastoid, pyramid
4. Anterior: Eustachian tube, Carotid artery, Tensor Tympani
5. Roof: Tegmen Tympani
6. Floor: Jugular bulb, Carotid artery

Eustachian Tube Dysfunction

1. Predisposing factors
a. Craniofacial anomalies (cleft palatee)
b. Immuunodefiencies
c. Adenoidal enlargement
d. Nasal allergy
e. Parental smoking
f. Bottle feeding
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g. Day care attendance

2. Types:
a. Tympanic membrane retraction: superior portion of drum, pars
flaccida, into middle ear space
b. Acute otitis media
c. Otitis media with effusion (glue ear)
d. Chronic suppurative otitis media
e. Cholesteatoma

Acute Otitis Media

- Viral or bacterial (S. pneumonia, H. influenzae, M. catarrhalis)
- Most common age 3 months- 3 years
- S+S:
1. Pain, pyrexia, hearing loss < 3/52
2. Red bulging tympanic membrane with with middle ear fluid
3. Ear discharge improves the symptoms
4. Decreased TM movement on pneumatic otoscopy
- Treatment:
1. Conservative:
 Healthy children > 2 yrs consider observation x 72 h
with analgesic and antipyretic
2. Medical:
 Consider in children <2yrs, otorrhea, S+S of systemic
disease, high risk for complications
 Add antibiotics:
 1st line: amoxicillin 80-90mg/kg/day
 2nd line: (worsening symptoms after 2-3 days): co-
amoxiclav
 Penicillin allergy: clarithromycin, erythromycin
3. Surgical:
 For recurrent acute otitis media, consider grommet
(tubes) placement
 3 or more in 6 months
 4 or more in 12 months

Extracranial Intracranial
1. Tympanosclerosis 1. Meningitis
2. TM perforation (heal on its own in 2 weeks, occasionally 2. Extradural
associated with chronic otorrhea) abscess
3. Hearing Loss 3. Subdural
4. Mastoiditis & subperiosteal abscess abscess
5. Facial nerve paralysis 1% 4. Brain abscess
6. Petrositis (Gradenigo’s syndrome) 5. Sigmoid sinus
7. Labyrinthitis thrombophlebi
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8. Chronic suppurative otitis media tis

6. Otitis
Hydrocephalu
s
- Complications:

Mastoiditis
- Empyema in mastoid, sub-periosteal abscess
- S+S
1. Fever, ear pain, protruding pinna
2. Erythema of skin, tenderness +/- fluctuance over mastoid
- Diagnosis
1. Contrasted CT of temporal bone may indicate abscess
- Treatment
1. Initially IV antibiotics, then possible mastoidectomy and
grommet

Otitis Media with Effusion - OME (Glue Ear)

- Presence of fluid in middle ear, without S+S of infection
- Peak at 2yrs and 5yrs
- Otoscopy: dull TM, fluid level, immobile
- Commonest cause of hearing loss in children  30-40 dB conductive
hearing loss
- Antibiotics are not indicated
- Refer to ENT if present > 3 months for possible grommet

- Treatment:
1. Conservative
 Hearing aid
 Down Syndrome, cleft palate
2. Medical
 Auto inflation
3. Surgical
 Grommets  children with persistent bilateral OME over
a period of 3 months with a hearing level in the better
ear of 25–30 dBHL

- Complications: - If adult patient  recent

1. Tympanosclerosis origin and unilateral, should
2. Atelectasis prompt nasopharyngeal
3. Retraction pockets examination (with scope) to
4. Erosion of ossicles assess for pathology blocking
5. Cholesteatoma the eustachian tube
o Rule out early
nasopharyngeal
carcinoma
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Grommets Causes of Otorrhea

- Prevent negative middle ear pressure 1. Otitis externa:
- Last ~ 9 months then extrude on their own white cottage
- Inserted in the anterior inferior quadrant cheese like
- Indications: 2. Otitis media with
1. OME perforation: mucoid
2. Recurrent AOM 3. Trauma,
3. Complications of AOM Granulation Tissue,
- Complications: Neoplasm: blood
1. Discharge (50%) stained, clear fluid
2. Residual tympanic membrane - CSF
perforation (1-2%) 4. Cholesteatoma:
3. Tympanosclerosis (40%) foul smelling
otorrhea
Chronic Suppurative Otitis Media without
Cholesteatoma
- Discharging ear >3/12 in the presence of tympanic membrane
perforation  usually as a result of acute otitis media
- Symptoms: otorrhea, hearing loss (otalgia usually not a feature)
- Pathogens: P. aeruginosa, S aureus, Proteus
- Treatment:
1. Topical non ototoxic antibiotics  steroids drops
2. Surgical repair of tympanic membrane

Tympanoplasty
- Transcanal, endaural or post-auricular incision
- Temporalis fascia or tragal cartilage is harvested as a graft to serve
as scaffold for tympanic membrane (TM) regrowth
- Surgeon elevates the EAC skin and remnant TM to put graft medial
to TM, which is laid back down into position
- Waterproof ear until dressing comes out
- Avoid flying for 6 weeks
- Complications
1. Failure 10-15%
2. Chorda Tympani injury
3. Dizziness / tinnitus
4. Cholesteatoma
5. Hearing Loss

Chronic Suppurative Otitis Media w/ Cholesteatoma

- Benign keratinizing squamous cell epithelium in the middle ear
- Congenital Cholesteatoma: embryonic squamous epithelium trapped
in middle ear
- S+S:
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1. Foul-smelling chronic ear drainage (treat with antibiotic drops)

2. Hearing loss due to ossicular damage

- Treatment: - Treatment
1. Conservative Complications:
2. Surgical: Mastoidectomy 1. Facial
a. Remove disease in nerve
mastoid and middle ear injury
b. Repair ear drum (0.5%)
2. CSF
Paediatric ENT Leak,
meningiti
Otology s
Otoscopy
1. Glue ear 3. Hearing
1. Hearing loss
2. Acute otitis media loss,
2. Ear discharge
3. Acute mastoiditis vertigo,
3. Ear pain
4. Foreign body tinnitus
4. Vertigo
5. Hearing loss 4. Chorda
5. Lower motor
6. Prominent ears tympani
neuron facial injury
nerve palsy
Eustachian Tube Dysfunction 5. Recurren
6. Intra-cranial
- Common in children t
suppuration
- Recurrent URTI Choleste
(brain abscess, atoma
- ET tube shorter and
meningitis)
straighter
7. Febrile infants
- Large adenoids

GlueEar
- Chronic serous otitis media
- Fluid in the middle ear
- Commonest cause of hearing loss in children
- Otoscopy: retracted and dull tympanic membrane
- Predisposing Factors:
1. Developmental anatomy Prominent Ears
2. Adenoidal enlargement - Common
3. Nasal allergy cosmetic
4. Cleft palate deformity
5. Passive smoke inhalations 1. Absent
- Treatment: antihelix
1. If OME > 3 months: grommets 2. Deep
2. If recurrent: adenoidectomy concha
3. Protrudin
Acute Otitis Media g lobule
- Fluid in the middle ear, with signs + - Work-up: check
symptoms of an active infection hearing
- Treatment:
Pinnaplasty/Ot
oplasty
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- Bacterial (85%); Viral (15%): S. pneumonia, H. influenza, M.

catarrhalis
- S+S:
1. Pain, pyrexia
2. Red bulging tympanic membrane
- Treatment:
1. Antibiotic, analgesic, antipyretic

Acute Mastoiditis
- Complication of otitis media
- Empyema in mastoid, subperiosteal abscess
- S+S:
1. Otalgia, red, tender, post-auricular swelling, protruding
(proptotic) pinna
- Complications
1. Meningitis, subdural
2. Extradural temporal lobe abscess
- Treatment
1. IV antibiotics
2. Mastoidectomy
3. Grommet
Rhinology
1. Epistaxis
2. Rhinitis
3. Adenoidal hypertrophy
4. Sinusitis/Periorbital cellulitis
5. Foreign body
6. Choanal atresia

Epistaxis
- 90% - Little’s area/ Kiesselbach’s plexus
o Internal Carotid: ophthalmic artery  anterior and posterior
ethmoid arteries
o External Carotid: sphenopalatine artery, greater palatine
artery, superior labial artery, angular artery
- Causes:
o Nose picking/ digital trauma
o Allergic rhinitis
- Treatment: silver nitrate cautery
- Investigate if:
o Weight loss, easy bruising
o Unilateral epistaxis in adolescent male to rule out underlying
vascular tumor such as a JNA (Juvenile Nasopharyngeal
Angiofibroma)

Allergic Rhinitis
- Frequency: seasonal / perennial
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- Symptoms: congestion, rhinorrhea, atopic symptoms

- Exam: pale, swollen inferior turbinates, +/- polyps
- Identify antigens: skin prick tests or RAST (Radioallergosorbent test
check IgE)
- Treatment:
1. Avoid allergen
2. Topical or oral antihistamine
3. Nasal steroids
4. Immunotherapy

Adenoidal Hypertrophy
- Symptoms:
1. Nasal obstruction
2. Snoring
3. Sleep apnea
4. Glue ear
5. Recurrent otitis media
- Treatment
1. Surgical curettage

Paediatric Complications of Sinusitis

- Bacteremia via veins and bone (laminae papyracae)
- Orbital
- Intracranial
o Meningitis
o Extradural abscess
o Subdural abscess
o Intracerebral abscess
- Osteomyelitis
Orbital Complications
- Preceded by URTI - Chandler’s Classification
- Exam: 1. Pre-septal cellulitis
1. Lid swelling and 2. Orbital cellulitis
redness 3. Subperiosteal abscess
2. Impaired Eye opening 4. Orbital abscess
3. Proptosis 5. Cavernous sinus thrombosis
4. Ophthalmoplegia - Treatment:
5. Check vision / colour 1. IV Antibiotics
first to go 2. Nasal toilet (decongestants and
- Work-up: rinses)
1. CT of orbits and 3. If abscess, FESS +/- open
sinuses approach to decompress eye
2. May also need MRI
brain

Choanal Atresia
- Failure of canalization of the bucco-nasal membrane
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- Bilateral present at birth

- Babies are obligate nasal breathers for the first 3 months of life
- S+S: cyclical crying and cyanosis, inability to feed
- Diagnosis:
1. Fogging-metal spatula
2. Catheter / nasogastric tube
3. Fiberoptic scope
4. CT scan – bony or membranous/mixed
- Secure with oropharyngeal airway
- Associated with CHARGE
1. Coloboma, Heart anomalies, Atresia, Retardation, Genito-
urinary anomalies, Ear abnormalities

Oropharyngeal
1. Tonsillitis
2. Glandular fever
3. Quinsy
4. Tonsillectomy
5. Obstructive sleep apnea

Acute Tonsillitis
- Viral
1. Adenovirus, parainfluenza virus
2. S+S: mild sore throat, low grade fever, mild adenopathy

- Bacterial (20%)
1. S. pneumonia, H. influenza, M. Catarrhalis
2. Severe sore throat lasting > 48 hours
3. Dx: throat culture

- Treatment:
1. Analgesia, antipyretics, rehydration, rest
2. Antibiotics if bacterial
3. Amoxicillin +/- clavulanic acid

Glandular Fever
- Infectious mononucleosis aka “Mono”
- Epstein Barr virus
- History:
1. Acute sore throat and fever
2. Cervical lymphadenopathy
3. Grossly enlarged tonsils with grey slough
4. Rash with ampicillin
- Work-up
1. Hepatosplenomegaly
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2. Lymphocytosis, abnormal liver function tests

3. Positive monospot test/ IgM for EBV

Quinsy
- Peritonsillar abscess
- Pus collection between tonsillar capsule and the superior
constrictor muscle
- S+S:
1. Severe sore throat, dysphagia, odynophagia
2. Trismus
3. Hot potato voice
4. Referred pain to ear
- Bacteria: S. aureus, S. pneumonia, Bacteroides
- Treatment:
1. Admit, IV antibiotics and drainage of the abscess
2. If recurrent, strongly consider tonsillectomy

Tonsillectomy
- Indications: (SIGN guidelines)
1. Recurrent, disabling sore throats due to acute tonsillitis
2. 7 or more sore throats in the preceding year
3. 5 or more in each preceding 2 years
4. 3 or more in each preceding 3 years
- Obstructive sleep apnea
- Chronic tonsillitis
- Asymmetric Tonsils (Rule out Malignancy)
- Recurrent peritonsillar abscess
- Risks and complications
1. Bleeding which can be life-threatening, anesthetic risks,
dehydration, palatal dysfunction, scarring, voice changes,
velopharyngeal insufficiency or stenosis, post-obstructive
pulmonary edema
- Normal symptoms post tonsillectomy exam:
1. Eschar
2. Foul smelling
3. Mild palatal edema

Obstructive Sleep Apnea

- Cessation of breathing during sleep
- Upper airway obstruction
- Usually relieved by adenotonsillectomy in children

Neck/Airway
1. Epiglottitis
2. Neck masses
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3. Infective
4. Inflammatory
5. Congenital

Epiglottis
- Etiology: Group B Hemophilus influenza
- S+S:
1. Acutely unwell, febrile, drooling, won’t cough or swallow
2. Tripod position
- Treatment:
1. Don’t look in throat or distress child – (could obstruct/die)
2. Consult anesthetics, ENT, and ICU
3. Child requires management in ICU usually after intubation –
3rd generation cephalosporin

Infective / Inflammatory Mass

- Reactive lymphadenopathy
1. common in children
2. Infective site in pharynx, oral cavity or skin
3. Usually settles with no treatment or conventional antibiotics
- TB
1. Commonest in immunocompromised
2. Requires prolonged drug therapy
- Other
1. Cat scratch disease – B. hensellae
2. Toxoplasmosis
3. Actinomycosis

Congenital
- Lateral
o Branchial cleft cysts
- Midline
o Thyroglossal duct cyst
o Dermoid cyst
- Diffuse
o Lymphangioma / hemangioma

Thyroglossal Duct Cyst

- Etiology:
o Most common congenital midline neck mass
o Remnant of thyroid gland
o Attached to foramen caecum
- Exam: Elevates on tongue protrusion / swallowing
- Workup: ultrasound to ensure normal thyroid gland
- Treatment: Sistrunk operation (includes excision of central portion
hyoid) to completely excise tract and cyst
 ENT

Dermoid Cyst
- Ectodermal remnants
- Occur in region of branchial or thyroglossal cysts
- Deep to cervical fascia – not mobile
- Most often congenital, but may be acquired from puncture wound =
implantation dermoid
- Treatment: surgical excision

Lymphangioma / Haemangioma
- Congenital neck swellings
- Vascular malformations
- May be associated with oral / laryngeal hemangiomas
- Hemangiomas usually resolve of own accord
- Treat if develop airway problems
- May suddenly increase in size due to hemorrhage

Ear Nose Airway

- 3-4 year olds - 3-4 year olds - Toddlers
- beads, seeds - Beads, seeds - Cough and choking
- Very painful to remove - Usually can episode
- Usually require general anesthetic remove - Expiration and inspir
- No urgency unless button battery - - Risk of on x-ray
corrosive inhalation - Bronchoscopy and
- Urgent removal of foreign bo
Paediatric Foreign Bodies
 ENT

Rhinology, Nasal Obstruction, Sinusitis

Causes of Nasal Obstruction

Congenit Anatomical Inflammatory Neoplastic Foreign
al Body
1. Choan 1. Deviated septum 1. Polyps 1. Inverted
al 2. Turbinate 2. Sarcoid, Papilloma
atresi hypertrophy Wegener’s 2. SCC
a 3. Fractured nasal 3. Rhinosinusitis 3. JNA
bones 4. Allergic Rhinitis

Management of Nasal Obstruction

1. Full history / examination
2. Identify underlying cause / imaging
3. Often treat empirically
a. Nasal steroid spray
b. Nasal decongestant spray or drops
c. Antibiotics
4. Watch for unilateral or atypical symptoms
5. Determine degree of severity/effect on quality of life

Nasal Polyposis
- Incidence – 0.2-4%, general bilateral, most common in asthmatics
- Edematous mucosa of ethmoid sinuses, prolapses into nasal cavity
- Samter’s Triad:
1. Asthma
2. Nasal polyposis
3. Aspirin sensitivity
- Symptoms:
1. Nasal obstruction
2. Rhinorrhea
3. Sneezing
4. Anosmia
- Examination: pale, boggy, edematous mucosa
- Treatment:
1. Steroids
 Spray – 6 months
 Drops – 2-3/52
 Oral – 10 day reducing course
 ENT

2. Surgery
 Endoscopic Polypectomy (often in conjunction with
sinus surgery)
 Often recur after surgery

- Suspicious symptoms:
1. Unilateral blockage
Common Cause of
2. Unilateral epistaxis
Blockage/Discharge
3. Unilateral swelling
1. Rhinitis
4. Neck mass
2. Nasal polyps
5. Ear effusion
3. Sinusitis
6. Atypical pain
4. Septal
deviation

Unilateral Polyp
- Suspicious for tumor or fungal sinusitis
1. Most common tumor is “inverted papilloma,” which can
degenerate into SCC
2. Olfactory neuroblastoma
3. SCC
4. Meningocele Nasal Foreign Bodies
- Work-Up: - Unilateral
1. CT Sinus nasal
2. MRI brain/skull base if indicated obstruction
3. Biopsy - Unilateral
nasal
Choanal Atresia discharge
- Presents at birth  babies are obligate nose breathers for first 3
months
- Cyclical crying / cyanosis and inability to feed
- Diagnosis: test with catheter, observe mucus / fogging
- Fiberoptic nasal endoscopy, CT Scan
- Require secure oral airway / feeding / definitive procedure
- 50% associated with other abnormalities (CHARGE syndrome)

Pathophysiology of Sinusitis
1. Obstruction of sinus drainage (polyps, edema, structural)
2. Reduced mucociliary clearance
3. Mucous stasis
Infection
Osteomeatal Complex: area under middle turbinate, where ethmoidal,
maxillary and frontal sinuses drain
- Spectrum of sinusitis:
o Viral Rhinosinusitis
o Bacterial Rhinosinusitis
o Fungal sinusitis
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Causes of Sinusitis
Patient Factors Environmental Factors
1. Structural / Pathological 1. Allergens
abnormalities of nose - Food - alcohol,
- Polyps dyes
- Septal deviation - Pollen
- Nasal tumor 2. Smoke
2. Mucociliary clearance abnormality 3. Chemicals
- Cystic fibrosis 4. Fungi
- Immotile cilia 5. Medications
3. Immunodeficiency 6. Occupational
- HIV - Heat, dust,
chemicals
Acute
Viral Rhinosinusitis
- Underlying Pathophysiology:
o Infection, inflammation, mucosal swelling, increased mucous
production
- Common symptoms: low-grade fever, facial discomfort, purulent
nasal discharge
- Treatment: antipyretics, hydration, analgesics, decongestants
- Natural history: spontaneous resolution in 7-10 days
Symptoms of Rhinosinusitis
Bacterial Rhinosinusitis
Major Symptoms Minor Symptoms - Acute: < 12 weeks
1. Facial pain/ pressure 1. Cough with complete
2. Facial 2. Headache resolution of
congestion/fullness 3. Fever symptoms
3. Postnasal drip/ 4. Halitosis - Chronic: > 12 weeks
rhinorrhea 5. Dental pain without complete
4. Nasal obstruction 6. Ear pain/ resolution of
5. Olfactory Pressure symptoms
disturbance 7. Fatigue

Clinical Definition of Rhinosinusitis

1. Endoscopic signs of:
a. Nasal polyps and/or
b. Mucopurulent discharge primarily from middle meatus and/or
c. Edema/mucosal obstruction primarily in middle meatus
And/or
2. CT changes
a. Mucosal changes within the osteomeatal complex and/or
sinuses

Acute Bacterial Rhinosinusitis

- Pathophysiology:
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o Prolonged mucosal edema resulting in sinus obstruction and

retention of secretions with bacterial superinfection
- Duration
o Longer than 7-10 days or worsening after 5 days, less than 12
weeks
- Pathogens
o Streptococcus pneumoniae, Hemophilus influenzae, and
Moraxella catarrhalis
- When to get cultures:
o ICU or immunocompromised patients
o Children not responding to appropriate medical management
o Patients with complications of sinusitis
- Goals of Treatment:
o Control infection, reduce tissue edema
o Facilitate drainage, maintain patency of sinus openings
o Break the pathologic cycle leading to chronic sinusitis
- Treatment:
o 1st line: 10-14 days of Amoxicillin/Clarithromycin/Azithromycin
o 2nd line: Augmentin/Macrolides/Quinolones

o Adjunctive measures:
 Short-term topical decongestants, oral decongestants,
antipyretics, hydration, analgesics, mucolytics,
humidification, warm compresses
 For severe or recurrent cases: systemic steroids
 If concomitant allergy: nasal steroids, antihistamines
o Otolaryngology Referral:
 3-4 infections per year
 Infection that fails to improve after 2-3 weeks of
antibiotics
 Nasal polyposis on exam
 Complications of sinusitis

Chronic Sinusitis
- Chronic obstruction of sinuses, longer than 12 weeks
- Anaerobes, S. aureus
- Nasal obstruction, facial pressure, postnasal drip
- Allergy testing / avoidance if appropriate
- Need to out rule underlying abnormality
1. Polyp, tumor, septal deviation
- Treatment:
1. Eradicate infection
 Antibiotics
2. Treat underlying cause
 Correct septal deviation
 Remove nasal polyps
 Treat nasal allergy
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3. Reduce inflammation to improve sinus drainage

 Long term topical steroids/ oral steroids
- Complications:
1. Lower respiratory tract infection
2. Ear: AOM
3. Osteomyelitis: "Potts puffy tumor"
4. Orbital: preseptal cellulitis, orbital cellulitis, subperiosteal
abscess, orbital abscess, cavernous sinus thrombosis
5. Intracranial: meningitis, extra-dural abscess, sub dural
abscess, intra-cerebral abscess

Acute Frontal Sinusitis

- Frontal sinus lining contains veins that penetrate posterior table of
sinus, allowing organisms or infected clot to reach dura
o Meningitis or frontal lobe abscess may result
- Treatment of frontal sinusitis with air-fluid level on CT
o Aggressive antibiotic therapy to cover S. pneumoniae and H.
influenzae with CSF penetration
o Topical vasoconstriction to improve drainage
o Surgical drainage may be required to prevent sequelae

Acute Ethmoid Sinusitis

- Severe cases may result in orbital complications
- Commonest in children
- Preceded by URTI
- Redness & swelling of eyelids, +/- proptosis
- CT scan to out rule orbital abscess
- Orbital abscess requires surgical decompression to avoid optic
nerve damage

Intracranial Complications of Sinusitis

1. Meningitis
2. Abscess
a. Extradural
b. Subdural
c. Frontal lobe
3. Cavernous sinus thrombosis

Orbital Complications
- Chandler’s classification
1. Pre-septal cellulitis
2. 2: Orbital cellulitis
3. 3: Subperiosteal abscess
4. 4: Orbital abscess
5. 5: Cavernous sinus thrombosis
- Treatment:
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1. IV Antibiotics
2. Nasal toilet (decongestants and rinses)
3. If abscess, FESS +/- open approach to decompress eye

Functional Endoscopic Sinus Surgery (FESS)

- Unblock the osteomeatal complex and allow aeration and drainage
of the sinuses
- Performed under image-guidance
- Indications for surgery:
1. Sinusitis causing complications: meningitis, brain abscess,
subperiosteal orbital abscess
2. Cavernous sinus thrombosis
3. Fungal sinusitis
4. Neoplasm or suspected neoplasm

- Complications:
1. Nasal
 Epistaxis
 Infection
 Adhesions
 Hyposmia/Anosmia
2. Orbital
 Hematoma
 Optic nerve trauma
3. Intracranial
 CSF leak
 Meningitis

Allergic Rhinitis
- Iinflammation in nose when the immune system overreacts to
allergens in the air
- 10% - 30% of adults,40% of children
- Comorbidities: conjunctivitis, headaches, rhinosinusitis, and
asthma.
- Seasonal allergic rhinitis is caused by tree, grass, and weed pollens
- House dust mites are the most common cause of perennial allergic
rhinitis

- S+S:
1. Frequent sneezing
2. Itching
3. Nasal obstruction
4. Watery rhinorrhoea
5. conjunctival swelling & erythema, eyelid swelling, lower
eyelid venous stasis “allergic shiners"
6. swollen nasal turbinates
7. allergic salute
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- Diagnosis:
1. Serum-specific IgE
2. Skin prick testing

- Treatment:
1. Avoidance
2. Antihistamines
3. Steroids
4. Antileukotrienes
5. Immunotherapy

Vasomotor/Non-Allergic Rhinitis
- Hyperactive nasal mucosa
- Non–specific stimulus
- Patients complain of nasal blockage, clear discharge after irritant
exposure
- Red, boggy nasal mucosa
- Skin prick tests negative
- Diagnosis of exclusion
- Treatment:
o Medical  empiric
o Surgical  make more space
 ENT

History, Exam, and Anatomy of Otorhinolaryngology

Field of Otorhinolaryngology
3. Otology
4. Rhinology
5. Laryngology
6. Head and Neck Cancer
7. Paediatric ENT
8. Facial Plastic Surgery

History
1. Chief complaint
a. Location
b. Duration
c. Frequency
d. Quality
2. Aggravating and relieving factors
3. Associated symptoms
a. General: fevers, chills, cough, heartburn, dizziness, etc

ENT-Specific Associated Symptoms

Otologic: tinnitus, otalgia, otorrhea, hearing loss, vertigo
Facial: swelling, pain, numbness, cranial nerve dysfunction
Nasal: congestion, rhinorrhoea, post-nasal drip, epistaxis, impaired smell,
facial pain
- Unilateral symptoms / eye symptoms =
Sinus: pressure, pain
Throat: odynophagia, dysphagia, globus sensation, throat clearing
Larynx: vocal changes or weakness, hoarseness, stridor, dyspnoea
Neck: pain, lymphadenopathy, torticollis, dyspnoea

EAR
Examination of the Nose
1. Clean hands, introduction, consent, check for otalgia
2. Inspection: pinna, post and pre auricular area
3. Otoscopy: ear canal, tympanic membrane
4. Tuning fork tests
5. Whisper test

Otoscopy
 ENT

1. Hold otoscope correctly to improve view and avoid trauma

2. Assess the ear canal
3. Aim to see all 4 quadrants of the tympanic membrane
4. Examine eustachian tube function:
a. Valsalva  Limited by effusion, scarring, perforation, ET
dysfunction

Tympanic Membrane Perforation

1. Size: pinhole, small, large
2. Location: quadrant, central vs. marginal
3. Effusion: dry vs. wet

Weber’s Test Procedure

- Strike the fork and place the base on the forehead.
- Alternative locations: dorsum of the nose, upper incisor, chin
- Ask:
o If the sound is heard
o If it is heard in the middle of the head or in both ears equally,
towards the left or towards the right
- Interpretation:
o Symmetric hearing = normal
 Tone is heard centrally or bilaterally
o Conductive hearing loss
 Lateralizes to affected ear
o Sensorineural hearing loss
 Lateralizes to better-hearing ear

Rinne’s Test Procedure

1. Bone Conduction (BC): strike the fork and hold it so that the base is
pressed firmly against the mastoid, hold for 2 seconds
2. Air Conduction (AC): transfer fork placing tips of tines in line with
the axis of EAC, nearest tine should be approximately 2.5cm from
EAC
- Interpretation:
o AC is louder than BC: Rinne’s positive
 Normal ears and the vast majority of SNHL
o BC is louder than AC: Rinne’s negative
 Significant conductive element

Whisper Test (Clinical Test of Hearing)

- Stand arm’s length (60cm) behind the seated patient so they cannot
read your lips
- Rub tragus to mask non-tested ear
- Whisper bisyllabic numbers = 12dB
- Will need 2/3 correct
 ENT

- Fail  increase voice to conversational 50dB

- Fail  loud 75dB
- Fail  move closer 15 cm --- whisper 35dB
- Fail  conversational 55dB

RHINOLOGY
Examination of the Ear
- External Inspection: - Look for:
1. Bridge/Bony pyramid 1. Change in shape / contour of the
2. Dorsum/ nose
Cartilaginous 2. Deformities congenital / acquired
pyramid if any
3. Tip 3. Presence of swelling:
inflammatory, cysts, or tumours
Anterior Rhinoscopy 4. Presence of ulceration: trauma /
- Examination of the infective / neoplastic
vestibule
1. Septum
2. Inferior turbinate
3. Floor of the nose
- Use: Thudicum's speculum and Killian’s speculum.
- Assess: turbinate size, septal deviation, polyps, drainage, masses

ORAL CAVITY and OROPHARYNX

Mouth Examination
1. Use head light and tongue depressor(s)
2. Patient seated at the same level as examiner
3. The patient's legs must be placed to one side of the examiner
4. Remove dentures
5. Use gloves to palpate mucosal lesions

Oral Cavity Subsites

1. Buccal mucosa
2. Alveolar margins + gingiva upper
3. Alveolar margins + gingiva lower
4. Hard palate
5. Floor of mouth
6. Anterior 2/3 Tongue
7. Lips
8. Retromolar Trigones

NECK
1. Inspection
2. Palpation
a. Always ask for tenderness
b. Position head and neck in neutral position
c. Palpate from posterior
 ENT

d. Bimanual
e. Define the Lower Border of the Mandible
3. Auscultation (Lateral neck mass)
4. Trans illuminate (Lateral neck mass)
5. Percussion (Central neck mass)

Neck Lump
1. S: size, size, shape, surface (skin), surround (skin)
2. T: tender, transluminate, temperature
3. F: fluctuate, fixed, fields

PHARYNX
Flexible Laryngoscopy
1. Mucosal surfaces evaluated:
o Nasopharynx: eustachian tube openings, adenoid pad
o Oropharynx: posterior soft palate, tongue base, posterior and
lateral pharyngeal walls
o Hypopharynx: vallecula, epiglottis, and pyriform fossa
o Larynx: arytenoid cartilages, vocal folds (false and true), vocal
fold mobility: Glottis opens with inspiration (sniffing) and
closes for phonation

Airway Disease and Tracheostomy

Field of Otorhinolaryngology
1. Inspection
2. Assessment of Breathing:
o Signs of respiratory distress: nasal flaring /
retractions/grunting
3. Respiratory Rates
o New Born: 30-50
o Toddler: 20-40
o Adolescent: 15-25
o Adult: 12-15
4. Percussion
5. Auscultation
o Wheeze: audible vibrations of airflow restriction
o Stridor: neonate
 Inspiratory: supraglottic
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 Biphasic: glottic
 Expiratory: subglottic

Laryngeal Cancer
- Most common cancer of the upper aerodigestive tract  median age
at diagnosis: 65
- Risk factors:
o Prolonged use of tobacco and excessive alcohol
- Anatomical Subtypes:
o Glottic Cancer: 59%
 Grow slower & metastasize late
 Early disease matched with dysphonia and early
diagnosis
 Lesions limited to the true vocal cords (T1 and T2)
demonstrate a 5% incidence of cervical metastasis
o Supraglottic Cancer: 40%
 Early symptoms subtle, often ignored
 Few barriers to tumor spread
 Rich lymphatic drainage, often bilateral
 Lymph node metastases common
o Subglottic Cancer: 1%
 Up to 20% Pts develop a second primary

Advanced Disease (T3/T4) Treatment

1. Chemoradiotherapy (Organ Preservation) Indications for
a. Quality of voice, swallowing & airway Tracheostomy
b. Lack of trach or PEG 1. Burns
c. Absence of pain or discomfort 2. Airway
obstruction
2. For Laryngectomy (Organ Sacrifice) 3. Sleep apnea
a. Quality of swallowing
b. Speech rehabilitation Complications for
c. Psychosocial adjustment Tracheostomy
d. Lifestyle limitations 1. Death
2. Obstruction
3. Displacement
4. Bleeding
5. Subcutaneous
emphysema
Head and Neck Cancers
6. Pneumothorax
7. Fistula
Definitions
8. Tracheoesopha
Neoplasia: presence or formation of new, abnormal
geal
growth of tissue.
9. RLN damage
Dysplasia: neoplastic epithelium that remains confined within the
basement membrane of the epithelial surface within which it arose
 ENT

Cancer: abnormal cells that grow beyond their usual boundaries, and
which can then invade adjoining parts of the body and spread to other
organs (WHO definition)

Head and Neck Cancers

- Govern many of the 5 senses, swallowing, breathing,
communication, facial animation and aesthetics
- Loss of these functions can have a severe negative effect on patient
quality of life

Risk Factors
1. Irritation from rough teeth, fillings, or crowns, or ill-fitting dentures
that rub against your cheek or gum
2. Chronic smoking, pipe smoking, or other tobacco use
3. Sun exposure to the lips
4. Oral cancer (rare)
5. HIV or AIDS

Signs and Symptoms

1. Shortness of breath
2. Hoarseness
3. Difficulty swallowing
4. Painful swallowing
5. Persistent Pain
6. Bleeding
7. Ulceration – oral / skin
8. Lump/Mass lesion
9. Cervical lymphadenopathy  most important prognostic factor

Leucoplakia: areas of keratosis appear as firmly attached white patches

on the mucous membranes of the oral cavity
- 20-50% show evidence of dysplasia on presentation
- Malignant transformation 5 - 6.5%
- Erythroleukoplakia - 20% malignant transformation

Oral Cancer
- No significant improvement in survival over 50 years
- 'Depth of invasion’ key prognostic factor
o Any tumour with a depth over 3mm – prophylactic neck
dissection levels 1-4
 ENT

Skin Cancer
Melanoma Non-Melanoma
- 4% arise from melanocytes - 95% cure rate in early stages
denovo or from preexisting - BCC  80%
congenital, acquired or - SCC  16%
dysplastic nevus - Merkel cell- polyoma virus association

Basal Cell Carcinoma

- Tumors arise from the basal layer (deepest layer) of the epidermis
- 80% found on the H&N, rarely metastasizes
- Numerous subtypes
1. Nodular BCC
2. Classic BCC
- Jacobi ‘Rodent’ ulcer  large nodular bcc with central necrosis
- Cicatricial (Morpheaform) BCC  aggressive subtype
- Infiltrative BCC – aggressive BCC  deep infiltration
- Superficial BCC (Superficial multicentric)  trunk/erythematous
patch

Cutaneous Squamous Cell Carcinoma

- Site: ear or hair bearing lip
o >2cm tumor diameter
o >6mm depth
- Risk factors:
o Immunosuppression
o Chronic inflammation/previous burn

Non-Hodgkin’s Lymphoma
- Occur at any age and are often marked by lymph nodes that are
larger than normal, fever, night sweats and weight loss
- Most non-Hodgkin's lymphoma arises from B cells
- Subtypes of non-Hodgkin's lymphoma:
1. Diffuse large B-cell lymphoma
2. Follicular lymphoma
3. Mantle cell lymphoma
4. Burkitt lymphoma

Hodgkin’s Lymphoma
- Marked by the presence of Reed-Sternberg cell
- Risk factors:
o Infection with Epstein-Barr virus
o Age 15-35 and >55
o Male sex
o Positive family history
- Subtypes
o Nodular sclerosis Hodgkin's lymphoma
o Mixed cellularity Hodgkin's lymphoma
 ENT

o Lymphocyte-depleted Hodgkin's lymphoma

o Lymphocyte-rich classical Hodgkin's lymphoma
- Treatment:
o Radiotherapy
o Chemo +/- radiotherapy
- Recurrent disease: bone marrow transplant
Skull Base
1. SCC (70%): verrucous carcinoma, basaloid squamous cell
carcinoma, spindle cell carcinoma, and transitional or cylindrical
cell carcinoma
2. Adenoid Cystic
3. Adenocarcinoma
4. Malignant Melanoma
5. Sinonasal neuroendocrine tumours: ENB & Non ENB – (sinonasal
undifferentiated carcinoma (SNUC), neuroendocrine carcinoma
(NEC), and small cell carcinoma (SmCC)
6. Lymphoma
7. Sarcoma: chondrosarcomas, fibrosarcomas, leiomyosarcomas,
rhabdomyosarcomas, liposarcoma, malignant peripheral nerve-
sheath tumours
8. Metastatic disease: prostate, breast, kidney, lung, and thyroid

Aetiology
- SCC and adenocarcinoma are associated with exposure to nickel
dust, mustard gas, thorotrast, isopropyl oil, chromium, or
dichlorodiethyl sulphide
o Wood dust exposure, in particular, is found to increase the risk
of SCC 21 times and the risk of adenocarcinoma 874 times

Paranasal Sinus Cancer

- Rare, aggressive tumours that generally are diagnosed in an
advanced stage.
- Patients often symptom free until the tumour reaching a large size
with widespread destruction
- Treatment: surgery

Radiation
- Sinonasal and ventral skull base cancers encompass a variety of
rare “orphan” tumors
- Multimodality treatment with surgery and postoperative radiation
therapy is the standard paradigm.
- Advances including intensity-modulated radiation therapy and
charged particle therapy have allowed for improved oncologic
outcomes and reduced toxicity
- Radiation oncologists must balance target coverage and critical
structure dose to maximize tumor control while minimizing severe
toxicity
 ENT

Sinonasal and Ventral Skull Outcome

- Rare
- Overall survival  poor
- For most histologies, primary treatment with surgical resection with
or without adjuvant radiotherapy provides the best survival outcome

Neck Mass

History
6. Trauma
1. Age
7. Travel
2. Location / size / duration of neck mass
8. Smoking &
3. Occurrence of symptoms
ETOH
4. Acute symptoms- pain, sore throat, dysphagia,
9. Rt exposure
dysphonia
10. Assoc
5. Discharge sinus / fistula
medical
conditions
Examination
1. Anatomy
2. Otoscopy: sinus/fistula  branchial anomaly
3. Neck: lymphadenopathy
4. Salivary glands: chronic sialadenitis
5. Mucosal surfaces: oral / oropharynx / hypopharynx / larynx

Investigations
1. FBC 8. HIV
2. TFT 9. Blood cultures
3. Mono 10. PPD skin
4. Cat Scratch 11. Flexible
5. Toxicology endoscopy
6. LDH 12. U/S &
7. EBV FNAC
13. CT
Differential Scanning
More common in 14. Consider paediatrics, more common in
adults resp / ID /
medical
oncology /
hematology
consultations
 ENT

1. Inflammatory: self-limiting
a. Cervical adenitis: painful response to infection or
inflammation
b. Chronic sialadenitis: due to stones or duct stenosis can result
in gland hypertrophy and fibrosis

2. Infectious
4. Congenital: branchial
a. Bacterial and viral
anomalies & thyroglossal
b. Nodes become necrotic
duct cysts  check TFT
c. Staph & Strep frequently
a. Branchial Apparatus
polymicrobial
b. Branchial Anomaly
d. Typical & atypical mycobacterial
c. Lateral neck
infection  single node
d. Thyroid Embryology
e. HIV: especially adults
e. Thyroglossal duct
f. Cat Scratch: Bartonella Henselae
cyst
g. Toxoplasmosis
f. Central neck
h. Infectious Mononucleosis  EBV
mono test
i. Fungal: Actinomycosis

3. Neoplastic: benign and malignant

a. Benign: lipomas, haemangiomas, neuromas, fibromas
b. Malignant: SCC, ppapillary thyroid cancer, lymphoma, skin
cancer lymphatic metastases, RCC, breast cancer

Hearing Loss

History and Examination

1. Temporal features
5. Audiology
a. Acute/chronic
a. Pure tone audiometry:
b. Progressive/fluctuating
>4years old 
c. Sudden/gradual
performed in
2. Associated symptoms
soundproof booth
a. Tinnitus, vertigo, otalgia,
b. Play audiometry: 3-4
otorrhea
years
3. Establish level of handicap
c. Visual response
4. Clinical Examination
audiometry: 1-4years
a. Weber’s Test
d. Distraction testing
b. Rinne’s Test
c. Whisper Test

Hearing Assessment in Children

- Objective tests when audiometry is not possible
- Tympanometry: determine if middle ear effusion is present
- Oto-acoustic emissions (OAEs): assess integrity of outer hair cells
 ENT

- Brainstem Evoked Response (BSER): assess auditory pathways and

brainstem function in response to auditory stimuli (under GA or
sedation)

Pure Tone Audiogram

Threshold: softest sound you are able to hear
- Thresholds of 0-25 dB are considered normal
for adults
- X = left ear, O = right ear

Tympanometry
- Push air into sealed EAC to assess tympanic membrane mobility and
response to pressure changes in the EAC
- Used to detect middle ear fluid when the physical exam is unclear
- Type A: healthy tympanic membrane and middle ear
- Type B: “flat tympanogram” - fluid in ME (normal volume) or
tympanic membrane is perforated (high volume)
- Type C: high peak - negative ME pressure = ET dysfunction

Types of Hearing Loss

1. Conductive
a. External/middle ear  lateral to oval window
i. Causes in external ear: wax, otitis externa, atresia
ii. Causes in middle ear: ME effusion/retraction, tympanic
membrane perforation, cholesteatoma / retraction (destroys
ossicles), otosclerosis, tumor, trauma
b. Often reversible
c. Air conduction (AC): ability of external and middle ear to transmit
sound to cochlea
d. Bone conduction (BC): sensorineural only
e. Air-bone gap = conductive hearing loss
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2. Sensorineural
a. Inner ear/central  medial to oval window
b. Usually irreversible
c. Most common form in adults  b/c tthresholds fall below 20 dB
d. No gap between air conduction line and bone conduction line
e. Bilateral Causes: presbycusis (age), noise-induced, drug- induced
(ototoxicity), genetic, congenital
f. Unilateral Causes: acoustic neuroma, Meniere’s disease, late
otosclerosis, idiopathic sudden loss, trauma

3. Mixed
a. Unilateral, bilateral

Otosclerosis
1. Etiology: fixation of stapes footplate by immature new bone
2. Presentation:
a. Early: progressive conductive hearing loss, tinnitus (75%),
vertigo (25%)
b. Late: May affect cochlea causing sensorineural loss
c. F>M, pregnancy, 20s-30s
d. Positive family history (50%), AD with incomplete penetrance
e. Initially unilateral, may become bilateral (70%)
3. Treatment
a. Conservative: hearing Aid
b. Medical: fluoride
c. Surgical: stapedotomy / BAHA  risk of surgery = dead ear
i. BAHA: bone anchored hearing aids

Bone Anchored Hearing Aids

- Titanium screw inserted into skull directly stimulate cochlea
through bone conduction
- Indications
o Unilateral/bilateral conductive hearing loss with bone
conduction thresholds better than 65dB
o Inability to use conventional hearing aids (atresia, meatal
stenosis, infected mastoid cavities, otitis externa,
otosclerosis)
- Contraindications - Complications
o Skin condition of the scalp o Abutment infections,
o <5yrs of age granulation tissue
o Inability to clean abutment o Failure to osseointegrate
area

Presbycusis
- Age-related decrease in hearing
- Reduction in the number of spiral ganglion cells and hair cells
 ENT

- Initially affects high frequencies

- Bilateral and symmetrical
- Audiogram – ‘Ski slope’ curve
- If not symmetrical, needs MRI scan to rule out a tumor
- Treatment: hearing aid

Noise Induced Hearing Loss

- >8hrs of >85dB over several years or >180dB as a single sound
o Occupational noise
o Not wearing ear protection
o Target shooting
o iPods use
o Loud music exposure
o Power tools
- Usually a symmetric “noise notch” at ~4000 Hz
- Gradually spreads to speech frequencies (500-2000Hz)

Ototoxicity
1. Aminoglycosides: gentamycin, streptomycin, neomycin, tobramycin
2. Loop diuretics: furosemide – usually reversible
3. Salicylates: aspirin - reversible
4. Quinine (malaria)
5. Propranolol
6. Cisplatinum (chemotherapy): monitor hearing while on chemo,
inform risk
7. Others: erythromycin, vancomycin

Vestibular Schwannoma (Asymmetric Sensorineural Hearing Loss - SNHL)

- Benign, rare locally destructive growth of Schwann cells on superior
vestibular nerve in cerebellopontine angle (CPA) / internal auditory
meatus (IAM)
- Sporadic (95%) or Genetic (5%)  neurofibromatosis II
- S+S:
1. Unilateral sensorineural hearing loss, unilateral tinnitus,
vertigo
2. Large tumor may compress trigeminal, facial, potentially IX-XII
- Investigation:
1. All unilateral SNHL require MRI IAM to rule out acoustic
neuroma
2. MRI (T2 weighted with gadolinium)
- Treatment:
1. Conservative
2. Stereotactic Radiosurgery
3. Surgical

Meniere’s Disease (Asymmetric SNHL)

- Attacks of rotatory vertigo + tinnitus + aural fullness + SNHL
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- In early stages, hearing loss is fluctuating and usually low frequency

- In later stages, often get permanent SNHL
- 2nd ear may become affected

Sudden Sensorineural Hearing Loss

- Most common cause is idiopathic, but need to exclude other causes
- Less likely to recover if: elderly, vertigo, long history, raised ESR

- History: recent infection, trauma, ear surgery, medication

- Blood tests: FBC, ESR, glucose, cholesterol, TFT, ACE, ANCA,

autoantibodies, syphilis serology

- Diagnostics: MRI IAM

- Prognosis: 50% have spontaneous recovery

- Aetiology:
1. Idiopathic
2. Infection
 mumps, measles, rubella, Varicella-zoster, syphilis
 labyrinthitis, meningitis,
3. Trauma
 Temporal bone fracture, ear surgery, barotrauma,
acoustic trauma
4. Tumor
 Vestibular schwannoma
5. Autoimmune
 Wegener’s granulomatosis, Polyarteritis nodosa, Cogan’s
syndrome, relapsing polychondritis, SLE
6. Neurological
 MS
 CVA

- Treatment:
1. Hearing Aids
2. Oral steroids prednisolone 1mg/kg, reducing over 10-14/7
(start early)
3. Cochlear Implant: provides direct stimulation of cochlear
nerve
 In children, early implantation can be very helpful in
their language and social development
 ENT

Vestibular Disorders

Physiology of Vestibular Organ

- Vestibular system:
o 3x semicircular canals at right angles + 2x otolith organs
(utricle and saccule)
- SCC sense angular accelerations
- Otolithic organs sense linear acceleration
- Vestibulo–ocular reflex: maintain optical fixation during head
movement
- Vestibulospinal reflex: senses head movement and position relative
to gravity
- Central vestibular system: cerebellum, spinal cord, temporal lobe
cortex
- Orients head in space, detects motion to allow for positional
adjustments of eyes, head, and posture to maintain vision and
balance
- Semicircular canals detect angular acceleration (head rotation)
- Utricle + Saccule sensitive to linear accelerations (gravity, vehicle
motion)
- Movement of endolymph with movement, shifting of otoconia in
these organs stimulate hair cells
- Vestibulocochlear nerve transmits signals to the vestibular nuclei in
the brain stem

Balance
- Depends on: visual input (70%), proprioception (15%), vestibular
input (15%)

Definitions
Dizziness: vertigo, presyncope, disequilibrium, others
Vertigo: sensation of rotation of one's self or the surroundings when no
movement exists
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Disequilibrium: patient feels unsteady

Peripheral (ENT) Central (NOT ENT)
1. BPPV 1. Migrainous Vertigo History
2. Meniere’s 2. Brainstem - Is this vertigo or is it
Disease - TIA light headedness,
3. Labyrinthitis - Cerebellar CVA fainting, panic attack?
4. Acoustic - Chiari - Episodical/Constant
Neuroma Malformation - Duration/frequency of
- Multiple symptoms (seconds,
Sclerosis minutes, hours, days)
- Triggering factors
(rolling over in bed, URTI, head injury)
- Associated symptoms (headache, eye symptoms, palpitations, SOB,
black outs, N/V)
- Associated ear symptoms (hearing loss or tinnitus, ear pressure)
- Any other neurological
complaints
- Past cardiovascular, neurological,
ophthalmological,
rheumatological history
- New medications?

Examination
1. Otoscopy 1. Smooth Pursuit
2. Tuning forks 2. Head Trust
3. Fistula Test test – Vestibulo
ocular reflex
4. Cranial Nerve exam 4. Nystagmus
3. Pure tone
5. Cerebellar function audiogram
a. Past Pointing 5. Vestibular
b. Dysdiadochokinesia function tests
6.
7. MRI
GaitIAM and
6. Vestibular Brain
a. Unterberg test
b. Romberg test
c. Dix – Hallpike test

Vestibular Disorders

Peripheral vs. Central Vertigo – HiNTs Criteria

- Indications: acute vestibular dysfunction to evaluate for post
circulation CVA  needs nystagmus and active vertigo at time of
assessment
- Hi: head impulse: correcting saccades  peripheral vertigo
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- N: nystagmus: horizontal nystagmus  peripheral vertigo, vertical,

rotatoryor direction changing, nystagmus – central vertigo
- TS: Test of Skew (alternate eye cover test): vertical gaze
corrections – central vertigo
- Positive HiNTS criteria – at least 1 of 3 positive – suggestive of
cerebellar CVA
- Sensitivity 100%, Specificity 96%

Benign Paroxysmal Positional Vertigo (BPPV)

- Commonest cause of rotary vertigo
- Usually 40-60 year olds, common after head trauma
- Due to presence of debris in the posterior SCCs
- Symptoms:
o Movement of head → movement of debris → stimulates SCC →
vertigo for a few seconds
- Signs:
o Normal otoscopy and hearing
o Positive Dix Hallpike test
- Treatment:
o Epley’s manoeuvre

Meniere Disease
- Endolymphatic hydrops
- Pathophysiology:
1. Rupture theory, Chemical
theory
2. Vasospasm theory, Drainage
theory
3. Immunological theory
- Epidemiology:
1. male < female
2. 30-50 years old
3. 10 % familial
4. Usually unilateral, bilateral in 10-15%
- Symptoms
1. Aural Fullness
2. Vertigo
3. Tinnitus
4. Hearing loss
5. Nausea + Vomiting
6. Disequilibrium for a few days
- Signs:
1. Horizontal nystagmus
2. Fluctuating low frequency sensorineural hearing loss initially

- Investigations:
1. PTA
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2. Videonystagmography/calorics showing canal paresis

3. MRI IAM to exclude acoustic neuroma

- Treatment:
1. Conservative
 Dietary Changes, salt and fluid restriction
 Vestibular physiotherapy
 Hearing aids
2. Medical
 Loop diuretics (bendrofluazide)
 Improve middle ear blood flow (betahistine)
 Short term vestibular sedatives (prochlorperazine)
3. Surgical
 Intratympanic steroids injection
 Intratympanic gentamycin injection
 Endolymphatic sac surgery
 Endolymphatic sac decompression
 Vestibular neurectomy
 Labyrinthectomy

Labyrinthitis
- Viral or post viral inflammatory disorder
- Sudden onset of severe persistent vertigo in a previously well
patient with nausea, vomiting, ataxia
- Vertigo lasts for days
- Horizontal nystagmus, positive Romberg’s & Unterberg’s test
- Normal otoscopy and neurological examination
- Treatment:
1. Spontaneous recovery over 1-2 week due to central
compensation occurs
2. Vestibular rehabilitation to promote compensation.
3. Prochlorperazine for a few days
 ENT

Radiation Oncology

Risk Factors for Head and Neck Cancers

1. Smoking and excess alcohol associated with 80% of oropharyngeal
SCC
a. 20% are not related to smoking or drinking
2. HPV (high risk strains)  tonsil SCC
3. EBV  nasopharyngeal
4. Betel nut chewing
5. Post HSCT (hematopoietic stem cell transplant)
6. Leukoplakia  1/3 develop into cancer

Subtypes
1. Oral cavity: tongue, retromolar trigone/gum, buccal mucosa, hard
palate
2. Nasopharynx
3. Oropharynx: base of tongue and vallecula, tonsil, soft palate
4. Hypopharynx: pyriform sinuses, post cricoid, posterior pharyngeal
wall – tend to metastasize early due to extensive lymphatic supply
5. Larynx: glottis/supraglottis/subglottis
6. Nasal cavity and paranasal sinuses
7. Salivary glands: parotid, submandibular, sublingual
8. Mucosal melanoma
- 90% are squamous cell carcinoma, with the exception of salivary
gland where
adenocarcinoma is more
common

Work-Up and Staging

1. History and exam
2. EUA
3. CT, PET-CT and MRI
4. Biopsy
5. TNM classification
6. Histological grade – P16

Approach to Management
1. MDT
2. Stage
3. Performance status
4. Symptoms
5. Preservation of function following treatment
6. Patient preference

Generalizations of Management
1. Stage I or II: surgery alone or primary radical radiotherapy alone
 ENT

2. Stage III or IV: (extensive primary, regional metastases): surgery

and adjuvant radiotherapy or primary radiotherapy alone
- More recently, use of induction and concomitant chemotherapy

Surgery
- Resectability and distance from critical - Radiation induced
structures osteonecrosis of the jaw
- Aesthetics – surgery can be deforming - Pre radiotherapy dental
- Side effects of both surgery and review
radiotherapy: xerostomia, diction,
phonation, hoarseness, swallow
- Use of trachea and PEG tubes

Radiotherapy
- Aim: target tumour and preserve surrounding tissue
- Damaging the DNA within cancer cells and destroying their ability to
reproduce
- When damaged cancer cells are destroyed by radiation, body
eliminates them
- Normal cells can be affected by radiation, but they are able to repair
themselves
- Sometimes radiation therapy is the only treatment a patient needs
- Other times, it is combined with other treatments, like surgery and
chemotherapy
- 2/3 of all cancer patients will receive radiation therapy as part of
their treatment
- Radiosensitizers: Cisplatin, Cetuximab
- Duration:
o Radical: 70Gy/35♯  7 weeks of treatment
o Adjuvant: 60-66Gy/30-33♯
o Palliative: 30Gy/10#, 40Gy/15#

Radiotherapy Planning
1. SLT, dietician – PEG if baseline dysphagia
2. Dental review in dental hospital  extractions, stent
3. Mould room appointment for orbit
4. Planning CT in treatment position with orbit
5. Target definition/volume delineation
6. CT, PET, MRI
7. Planning  dosimetrist/physics
8. Treatment  LINAC, radiotherapist

Types of Radiation Therapy

- Specialized types of external beam radiation therapy
1. Three-dimensional conformal radiation therapy (3D-CRT)
 Uses CT or MRI scans to create a 3-D picture of tumor
 ENT

 Beams are precisely directed to avoid radiating normal

tissue
2. Intensity modulated radiation therapy (IMRT)
 Specialized form of 3D-CRT
 Radiation is broken into many “beamlets” and intensity
of each can be adjusted individually
- Palliative  simple parallel opposed fields

Indications for PORT

- Absolute indications
o Positive / close margins (< 5 mm)
o >1 LN positive
o Extra capsular extension (ECE)
o pT4 Disease
- Intermediate Risk Factors
o Lymphovascular Space Invasion (LVI +ve)
o Perineural Invasion (PNI +ve)
o pT3 Disease

Post-Operative Treatment
- Dose 60 GY/30 #
- Add Cisplatin chemotherapy if T4, node +, extra capsular extension,
positive margin
- Central structure  always use bilateral approach
- Angle down technique to avoid shoulders or IMRT
Oral Cavity
Unilateral Tumours Bilateral Tumours
- Well lateralised primary tumour: - Central tumour
 Oral tongue - Floor of mouth, soft
 Buccal mucosa palate, base of tongue
 RMT - Larynx, Hypopharynx,
 Tonsil Nasopharynx
- <1cm midline extension - Tumour extends
- N0, N1 and N2a nodal disease towards midline
- T1-2 disease - Bilateral LN + (N2c)
- More advanced disease can be treated if - Advanced disease
other criteria satisfied

Management of Oral Cavity Tumours

- Surgery and PORT
- Often combined Maxillofacial and Plastics approach for
reconstruction of mandible, flaps
- Radiotherapy to large area of oral cavity is poorly tolerated
especially when combined with chemotherapy
- Radiotherapy preferred if surgery would require removal of majority
of tongue  poor functional outcome or patient preference
 ENT

Laryngeal Subsites
1. Supraglottis
a. Epiglottis
b. Aryepiglottic folds
c. Arytenoids
d. Ventricles
e. False cords
2. Glottis: vocal cords
3. Subglottis: extends from 1 cm below the vocal cords to the lower
border of cricoid cartilage
- Larynx needed for: breathing, swallowing, eating, speaking

Management of Laryngeal Tumours

- Early laryngeal tumours: radiotherapy alone or laser surgery
- Advanced tumours: chemo / radiotherapy as laryngeal conservation
approach
- Laryngectomy: T4 (cartilage invasion), severe dysphagia and fixed
lymph nodes
- Majority of these require PORT

Facial Nerve Paralysis

Causes of Facial Nerve Paralysis

1. Idiopathic
a. Bell’s Palsy
b. Tx: steroids
c. Prognosis: 95%

2. Infection
a. Ramsey Hunt syndrome
b. Bacterial: AOM, Cholesteatoma,
Necrotizing OE, Lyme’s disease
c. Viral: Herpes Zoster Oticus/Ramsay-
Hunt Syndrome
d. Tx: steroids + antivirals
e. Prognosis: 25-50%
 ENT

3. Trauma
a. Iatrogenic during ear or parotid surgery, temporal bone
fractures
b. Tx: steroids +/- exploratory surgery
c. Prognosis: poor

4. Tumours
a. Parotid
b. Facial neuroma
c. Acoustic neuroma
d. Tx:
i. Benign: conservative, medical, surgery (parotidectomy,
mastoidectomy)
ii. Malignant: depends on histology and stage (MDT)
e. Prognosis: poor

5. Congenital
a. Möbius Syndrome

6. Other
a. Melkersson Rosenthal Syndrome

Facial Nerve Palsy Work Up

- Detailed History
- Test motor branches and
document grade of paralysis
- Examine
1. Otoscopy
2. Parotid gland
3. Other cranial nerves
4. Hearing

House Brackmann Scale (for the facial

nerve) 

Bell’s Palsy
- Idiopathic, acute unilateral facial nerve paralysis with onset in less
than 72 hours
- Diagnosis of exclusion
- 70% of facial nerve paralysis
- Recurrent in 10% of patients
- Usually complete spontaneous recovery:
o In >70% of cases with initial complete paralysis
o In >94% of cases with incomplete palsy
 ENT

Ramsay Hunt Syndrome

- Herpes zoster oticus
- LMN facial nerve palsy accompanied by severe pain and vesicles in
the external ear and occasionally sensorineural hearing loss
- Reactivation syndrome of herpes zoster in the geniculate ganglion
- Tx:
1. Early steroids
2. Analgesia
3. Antivirals
- Prognosis: poorer than Bell’s
- Residual neuralgia post viral infection

Temporal Bone Trauma

- Mechanisms of injury:
1. Fracture may transect or nerve
2. Distant fracture may cause delayed stretching or bruising
- Exam findings
1. Possible facial weakness
2. Battle’s sign
- Diagnosis: CT scan (temporal bone)
- Treatment:
1. Direct re-anastomosis or a graft
- Hearing may also be affected
1. Conductive (hemotympanum or ossicular discontinuity)
2. Sensorineural (VIIIth nerve damage)