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ENT (Head and Neck Pathology, Checklist, Otology, Laryngology, Rhinology) …

- - - - Inflammation of salivary gland
    - - Calcified mass in the gland
      - Causes
        
        Predispositions:
        
        Serous secretion
        
        Anatomy - antigravitaional
      - Treatment
        
        Antibiotics and fluids
        
        Sialendoscopy
        
        Gland excision
      - Site
        
        Most common submandibular
    - - Benign
        
        Pleomorphic Adenoma
        
        Does not present with facial palsy
        
        Warthin's tumour
      - Intermediate
        
        Mucoepidermoid
      - Malignant
        
        Adenoid cystic
        
        Acinic cell carcinoma
      - Location
        
        Parotid
        
        80:20 rule
        80% benign
        20% malignant
        
        Submandibular
        
        50:50
        
        Minor salivary gland
        
        20% benign
        80% malignant
  - - - Malignancy
        
        THY 4 and 5 - total thyroidectomy
        -THY 3 partial thyroidectomy, follow up if malignancy detected
        
        THY 3 + high AGES score - consider total Thyroidectomy
      - Hyperthyroid patients refractory to medical rx
        
        Graves
        
        PT rendered euthyroid by long term Tx with carbimazole
        
        Chronic use of Carbimazole can cause agronulocytosis
        
        Full thyroidectomy or radioactive iodine used
      - Large Multinodular Goitre causing compressive symptoms
      - Cosmesis (appearance)
    - - Thy 1 Inconclusive
      - Thy 2 Benign
      - Thy 3 Follicular pathology 80ben:20mal
      - Thy 4 Suspicious for malignancy
      - Thy 5 Malignant
    - - A. Age
        over 40 male
        over 45 female
      - G. Gender - Male
      - E. Extracapsular spread
      - S. Size greater than 4cm
      - Indicates those more likely to have malignant cancer
    - - GA
      - Infection
      - Haematoma
      - RLN damage
      - SLN damage
      - Hypothyroidism
      - Hypocalcaemia
    - - Papillary
        
        Most common
      - Follicular carcinoma
      - Medullary
        
        10%
        
        Aggressive
        Whole thyroid should be removed
      - Anaplastic
        
        5%
        
        Very poor prognosis
    - - Thyroid Function Tests (TFTs)
      - FNA Fine needle aspiration
        
        Gives THY stages
      - Ultrasound
        
        Differentiates solid vs cystic
        Cysts more likely benign
        
        Helps visualise size and regularity of margins
  - - - Indications
        
        Hypercalcemia
        
        Stones, bones, groans, pychic moans
      - Primary hyperparathyroidism Causes
        
        Benign adenoma
        
        Hyperplasia
        
        Malignancy
      - Complications
        
        GA
        
        Infection
        
        Haematoma
        
        RLN damage
        
        SLN damage
        
        Hypocalcaemia
        
        Hypoparathyroidis
    - - Indications
        
        Upper Airway Obstruction
        
        Assisted ventilation
        
        Bronchial toilet
        
        Trauma
        
        Elective
      - Percutaneius Versus Open TRacheostomy
        
        Open
        
        Patients with obesity
        
        Abnormal / poorly palpable midline neck anatomy
        
        Head and Neck Surgery
      - Compications
        
        GA
        
        Bleeding
        
        False passage
        
        Decannulation
        
        Tube obstruction
        
        Pneumothroax
        
        Tracheomalcia
        
        Treaceo-cutaneous fistula
        
        Dysphagia
    - - Emergency airway access
      - Advantaged
        
        Accessible, minimal dissection
        
        FAster than tracheostomy
        
        C-spine instability
      - Complications
    - - Surgery preferred to radio in
        
        children with thyroid cancer
        
        Women of childbearing age
        
        Ocular symptoms of hyperthyroidism
      - Complications
        
        Hoarseness
        
        SLN / RLN nerve damage
        
        Hypothyroidism
        
        Hypocalcaemia
        
        Thyroid haematoma
        
        Can become medical emergency
    - - Indications
        
        Prominauris
        
        Elective
      - Treat at age 4/5
        
        Must wear bandage for 2 weeks post op
        
        Low compliance in younger children
    - - Investigations
        
        AP and Lateral X-ray
    - - Complications
        
        3 Fs
        
        Facial neve
        
        Fistula
        
        Frey's syndrome
        
        GA / infx
        
        Recurrence
      - Indications
        
        Benign Tumours
        
        Pleomorphic adenoma
        
        Warthin's tumour
        
        Malignant Tumours
        
        Mucoepidermoid carinoma
        
        Adenoid cystic carcinoma
        
        Acinic cell carcinoma
        
        Mets
        
        Infx / Inflammation
        
        Chronic sialadenitis
        
        Obtructive
        
        Sialolithiathis
  - - - Oral cavity
      - Oropharynx - junction of hard and soft palate
      - Nasopharynx
      - Hypopharynx
        
        Piriform fossa
        
        Posterior pharyngeal wall
        
        Postcricoid
      - Larynx
    - - Smoking
      - Alcohol
      - HPV
        HPV likes the tonsil :)
      - Chemical Exposure
      - Plummer-Winson Syndrome
      - Epstein-Barr Virus
    - - Symptoms
        
        Odynophasia
        
        Unilateral otalgia
        
        Hoarseness - dysphonia
        
        Stridor
        
        Trismus - difficulty opening mouth
        
        Weight loss
        
        Sore Throat / Pain
        
        Dysphagia
      - Signs
        
        Peristent red/white patches which are swollen / painful/ bleeding oral cavity
        
        Oral ulceration
        
        Lateral neck mass
        
        Rapidly growing thyroid mass
        
        Cranial nerve palsy
        
        Unilateral ear effusion
        
        Assymmetric tonsils
  - - - Zone 1
        
        Highest Mortality
      - Zone 2
      - Zone 3
  - - - Most common congenital latera neck mass
      - Presentation
        
        Late 20s early 30s
      - Cause
        
        Failure of fusion of 2nd and 3rd branchial arches
      - Diagnosis
        
        Cholesterol granulomas on FNA
        
        Differential Diagnosis
        
        Mumps
        
        TB
        
        Lymphoma
        
        Dental abcess
      - Treatment
        
        Total surgical excision
      - Investigations
        
        Cholesterol granules on FNA
    - - Presentation
        
        Childhood - >50% before the age of12
        Ave age 6
      - Cause
        
        Congenital midline mass dur to the embryological remnant of the thyroglossal duct
      - Thyroglossal duct descends from the forament cecum of the tongue
        
        Cysts must be removed due to risk of infection, fistula, cancer
        
        Recurrence ~3% when hyoid removed
      - Treatment
        
        Sistrunk's Procedure
        
        Removal of middle portion of hyoid bone as well as cysts
      - Moves with tongue protrusion
      - Complications
        
        Infx
        
        Fistula
        
        Cancer
- - - - Peritonsillar Abscesses
        Complication of tonsilitis
      - Presentation
        
        Deviated uvula
        
        Trimus (can't open mouth)
        
        Very high temperature
      - Treatment
        
        Excise and drain
        
        Tonsillectomy in case of >2 quinsies
    - - Presentation
        
        Deafness with/ without Otorrhoea
      - Types
        
        Central
        
        Safe
        Heals by itself in 3 months
        
        Marginal
        
        Unsafe
        Extends to Annulus
      - Treatment
        
        Depends on age / Reaction to anaesthesia
        
        Tympanoplasty
    - - Presentation
        
        Itching
        
        Mucoid / watery otorhoea
      - Infection of the external ear
      - Causes
        
        90% bacterial
        Often pseudomonas
        
        10% fungal - candida 90%
        
        Staph. Aureus
      - Disease progression
        
        Tendancy to become chronic
        
        Malignant OE aggressive pseudomonas infection in immunocompromised patients
        
        ENT emergency
        
        50-80% mortalibity
      - Treatment
        
        6 weeks of IV antibiotics
    - - Abnormal Collection of keratinising squamous epithelium in the middle ear
      - Presentation
        
        Mucopurulent otorrheo
        
        Hearing loss
      - Classification
        
        Congenital
        
        Aquired
      - Risks
        
        PT with chronic Eustachian tube dysfuntion
        
        PT with middle ear issues leading to negative pressure
      - Disease Progression
        
        Negative pressure pulls pars flaccida into middle ear forming "attic pocket"
        
        Dead cells accumulate
      - Complications
        
        Facial nerve palsy
        
        Taste change
        
        Vertigo
      - Investigations
        
        CT
      - Treatment
        
        Mastoidectomy
        
        Clears out collections of cells
        
        Atticotomy
        
        If condition is caught early and has not progressed to mastoid air cells
    - - Presentation
        
        Ear pushed down and out with visible external swelling
        
        Otalgia
      - Treatment
        
        Excise and drain
        Give broad spectrum antibiotics
        
        Grommet
      - Complications
        
        Meningitis
        Thin tegmen tympani
        
        Inner ear damage
        
        Recurrnece
        
        Decreased hearing
        
        Intracranial complications
      - Infection of the mastoid bone
    - - Abnormal growth of bone in the middle ear
      - Epidemiology
        
        F:M 2:1
        
        0.5% of population
        
        More common in Caucasians
      - Risk Factors
        
        Childhood measles
      - Treatment
        
        Hearing Aid
        
        Stapedectomy
    - - >30dB loss over 3 contiguous audiometric frequencies
      - Hypothosised Causes
        
        Infection
        
        Autoimmune
        
        Ototoxic drugs
        
        Neoplasia
      - Treatment
        
        Steroids ASAP
      - Investigations
        
        MRI Scan to rule out acoustic neuroma
    - - DD
        
        Nasopharyngeal carcinoma in Chinese patients
  - - - Ear pain
      - 50% of patient have normal ears - referred pain from Teeth (paeds) or TMJ (Adults)
    - - Discharge
    - - Classification
        
        Conductive
        
        Sensorineural
    - - Perception of noise in the abscence of external stimuli
      - Epidemiology
        
        10% of adults have prolonged
        
        1% severly impacted
      - Investigations
        
        Scan when unilateral to rule out acoustic neuroma
        
        Slow growing benign tumour of Schwann cells surrounding CN8
      - Objective tinnitus
        
        PT hears objectively hear an extra sound within their head
    - - Subjective perception of rotation
      - Classification
        
        Peripheral
        
        Benign Positional Vertigo (BPV)
        
        Seconds
        
        2% chronic
        
        20% will suffer at some point in their life
        
        Onset ~ 50yrs
        
        Presentation
        
        No hearing loss
        
        Nausea
        
        Possible Causes
        
        Delay in movement of otoliths
        
        Diagnosis
        
        Dix-Hallpike manoeuvre
        
        Treatment
        
        Eply Manoeuvre
        Repositions free floating particles in semicircular canals
        
        Meniere's disease
        
        20min-hours
        
        40-60 yrs
        
        Genetic link - more endolymph production
        
        Presentation
        
        Episodic vertigo
        
        Tinnitus
        
        Hearing loss (low Hz sensorineural)
        
        Typical triad
        
        Treatment
        
        Severe cases: Gentamicin - ototoxic drug is injected into middle ear
        
        Acute Labyrinthitis
        
        Weeks - Months
        
        30-60 yrs
        
        Pt appears very unwell compared to other causes of vertigo
        
        Causes
        
        Viral / vestibular neurtitis
        
        Viral, bacterial, autoimmue
        
        Treatment
        
        Supportive therapy
        
        Bed rest
        
        Fluids
        
        Investigation
        
        MRI
        
        Balancing Monkey Acrobat
        BPV, Meniere's, Acute Labyrinthitis
        
        Central
    - - Causes
        
        KITTENS
        
        K
        
        Congenital
        
        I
        
        Idiopathic (Bell's)
        Infective (mumpes, herpes, Lyme's)
        Iatrogenic (Parotidectomy/ maistoidectomy)
        
        T
        
        Trauma
        
        T
        
        Toxins
        
        E
        
        Endocrine
        Diabetics
        
        N
        
        Neoplasia
        Neurological (stroke, TIA, MND)
        Neurogenic
        
        S
        
        Systemic
        
        Bonus ;)
        
        Cholesteatoma
      - Presentation
        
        Unilateral facial weakness
  - - - Indications
        
        Obstructive sleep apnoea (OSA)
        
        Cessation in breathing for >10 sec
        
        Recurrent Infection
        
        7 /year
        6/ year for 2 yeras
        5/year for 3 years
        
        Tonsillar Asymmetry
        
        Think lymphoma
        
        Tonsiliths
        
        Calcifications
        
        More than 2 quinsies
        
        Peritonsillar abscesses
      - Risks
        
        GA
        
        Infection
        
        Damage to teeth / tongue / TMJ due to Boyle-Davis gag
        
        Post op haemorrhage
    - - Indications
        
        Profound deafness
    - - Most common ENT surgical procedure
        
        Mainly paediatric due to horizontal Eustachian tube
        
        Occasionally done in adults in those with muffled hearing for weeks ater a cold etc
      - Indications
        
        Fluid in the middle ear 4/5 times in 6 months
      - First line Tx
        
        Sprays
        
        Drops
      - Complications
        
        Infection
        
        Mucopurulent ottorrhoea
        
        Tympanosclerosis
        
        Premature extrusion
        
        Repeat procedure in 20%
      - Site of insertion
        
        Anterior Inferior quadrant of tympanic membrane
    - - Indications
        
        Obstructive sleep apnoea
        Cessation in breathing for >10 sec
        
        Recurrent / presistent infection or recurrent adenoiditis
        
        Consider after muliple pairs of grommets
      - Enlarged adenoids block eusachian tube
        
        Does not cause immunological issues - remaining tissue compensates
    - - Procedure
        
        Temporal fascia, tragal cartilage or fat grafted into hole
      - Complications
        
        Failure
        
        Otorrhoea
        
        Tinnitus
        
        Vertigo
        
        chorda tympani damage - changes in taste, decreased hearing
  - - - A. Normal
      - B. Flat curve, indicates fluid or perforated eardrum
      - C. Negative pressuer
  - - - Pathology in the external canal or middle ear
      - Cause
        
        Wax in adults
        Fluid in children
    - - Hearling loss due to issues with CN8 or the cochlea
      - Causes
        
        Age related
      - Children present with slow speech
- - - - Causes
        
        KITTENS
        
        K. Congenital
        
        I. Infective / Iatrogenic / Idiopathic
        
        T. Trauma
        
        T. Toxins
        
        E. Endocrine - hypothyroidism
        
        N. Neoplasm
    - - Inspiratory
      - Expiratory
      - Biphasic
  - - - Epidemiology
        
        Benign common disorder
        
        2-4% of ENT referrals
      - Constant sensation of having obstruction in the throat
      - Generally resolves spontaneously
        
        Link to LPR or GERD, or anxiety
        
        Doesn't impair swallowing but can be irritating
        
        Local to C6
    - - Risks
        
        1 st born
        
        Vaginal delivery
      - Cause
        
        HPv 6 & 11
      - Juvenile v. Adult onset (JORRP/AORRP)
        JORRP more aggressive
      - Treatment
        
        Microdebridement
        Generally has to be repeated
        
        the removal of damaged tissue or foreign objects from a wound.
    - - Presentation
        
        Constant Throat clearing
        
        Irritation
        
        Hoarseness (dysphonia)
      - Treatement
        
        PPI
    - - Presentation
        
        Unwell children with expiratory stridor
        
        Reasonably well looking
        
        Slow onset
        
        Low grade fever
        
        Barking cough
        
        Hoarse
        
        Mild / moderate expiratory stridor
      - Steeple Sign :church:
        
        Differentiation from Epiglottitis
    - - Presentation
        
        Inspiratory stridor and can cause respiratory arrest
        
        Toxic looking
        
        Acute onset
        
        High temperature
        
        Minimal coughing
        
        Unable to speak
        
        Moderate / sevre inspiratry stridor
        
        Drooling and leaning forward
      - Medical Emergency
      - Thumb Sign :+1:
        
        Differentiates from Croup
    - - Presentation
        
        Paediatric hoarseness in children of school-going age
        M>F
      - Treatment
        
        Speech and Language therapy
  - - - Inspiratory
        
        Above level f vocal cords
      - Expiratory
        
        Wheeze
      - Biphasic
        
        Level of vocal cord
    - - Croup (Laryngotracheobronchitis)
      - Acute Epiglottitis
- - - - Leads to deformed looking nose and should be referred to ENT
        
        Swelling for 7 days post injury
        
        Do not leave suspected fracture untreated for >14 days - bone sets
      - Treatment
        
        Manipulation of nasal bones (MNB) under LA
      - Complication
    - - Potential complication of nasal fracture - Do not miss
        
        Mucoperichondrium seperates from skin and potential space fills with blood
      - Treatment
        
        Incise and Drain
        
        Broad spectrum antibiotics
      - Complications
        
        Saddle nose deformity
        
        Result of cartilage collapse
        
        Characteristic of GPA (Granulomatosis with polyangiitis)
    - - Presentation
        
        Often Asymptomatic
        
        Whistling sounds when breathing
      - Causes
        
        KITTENS
        
        K - Congential (not often)
        
        I - Infection (Infective Septal haematoma)
        Iatrogenic - septoplasty
        
        T - Trauma - digital
        
        T - Toxins (Cocaine)
        
        N - Neoplasia (mucosal melanoma)
        
        S - Systemic (Granulomatosis with polyangitis)
        
        PURRRRforation
      - Managment
        
        Septal button
    - - Formation of oedematous sinonasal mucosal growth which encroaches into the nostril
        Allergic aetiology
      - Grading
        
        1-3 based on size
      - Samter's Triad
        
        10% of people with nasal polyps also have asthma and aspirin sensitivity
      - Epidemiology
        
        1-5% of population
        
        More likely in allegeric pts g. Asthma
        
        Elderly
        
        Usually bilateral
      - Symptoms
        
        Congestion
        
        Mucopurulent discharge / rhinorrhoea
      - Treatment
        
        Reducing dose of oral steroids
        
        Risk of mania / modd swing
        Gasric symptoms - give PPI
        
        Surgical nasopolypectomy
      - Paediatric Polys
        
        Cystic fibrosis until prove otherwise
    - - Symptoms
        
        Facial pain and pressure
        
        Bilarteal nasal blockage
        
        Post nasal drip
        
        Mucopurulent Rhinorrhoea
        
        Anosmia / hyponosmia
        
        Cough
        
        Temperature
      - Management
        
        Consevative
        
        FESS
        Functional endoscopic sinus surgery
        
        CT first
        
        Delineate landmarks
        
        Objectives
        
        MMA
        Middle meatal antroscopy
        
        Complications
        
        GA / Bleeding / infx / adhesions
        
        Septal perforation
        
        Orbital damage
        
        CSF leak
        
        Need for revision
        
        Indications for FESS
        
        Chronic Rhinosinusitis
        
        Nasal polyposis
        
        Frontal mucocele
        
        Sinogenic tumours
        
        CSF leak
        
        Orbital decompression - Graves
        
        Epistaxis
        
        Trans-sphenoidal approach to pituitary
    - - Treatment
        
        IV antibiotics
      - Epidemiology
        
        Peak age 2 yrs
      - Chandler's Grade
        
        Pre-septal cellulitis
        
        Orbital cellulitis without abcess
        
        Subperiosteal abcess
        
        Intra-orbital abcess
        
        Cavernous sinus thrombosis
      - Complications
        
        Vision loss
        
        Abcess
        
        Cavernous sinus thrombosis
    - - Dual blood supply
        
        90% anterior
        
        10% population
        
        Littles area
      - Causes
        
        K - Congenital
        
        HHT
        
        Haemophilia
        
        vWD Von Willebrand's disease
        
        I - Immune
        
        Allergic rhinitis
        
        I - Idiopathic
        
        I - Iatrogenic
        
        FESS
        
        Septoplasty
        
        T - Traumatic
        
        T - Toxins
        
        Anticoagulation
        
        N - Neoplasia
        
        Scc
        
        Inv papilloma
        
        S - Systemic
        
        Coagulopathy
        
        Chronic granulomatous disease (sarcoid)
      - Treatment
        
        First aid
        
        Silver nitrate cautery
        
        Nasal Packing
        
        Merocel
        
        Rapid rhino
        
        BIPP Pack +/- balloon
        48-72 hrs
        
        Surgery - SphenoPalatine Aartery ligation / Embolisation
  - - - Nasal Discharge
      - Classification
        
        Mucopurulent
        
        Bilateral
        
        Polyps
        Chronic rhinosinitus
        
        Unilateral
        
        Paeds: Foreign Body
        
        Watery
        
        Unilateral
        
        Paeds: Rhinitis
        
        Bilatertal
        
        Cold
        Alllergic Rhinitis
        Paeds: Adenoiditis
    - - Unilateral
        
        Septal Deviation - septoplasty
    - - Cause
        
        Excess mucous produced by nasal mucosa
        Accumulates in throat and back of nose
    - - Partial / full loss of smell